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Necessary or Locally Required Attachments <br /> ®Soil boring logs El System/As-built drawing ❑ Forms per local ordinance <br /> ❑Other information(list): <br /> Property address: 20 Wear Lane S Orono,MN Inspector initials/Date: ( 4/28/2015 <br /> (mm/dd/yyyy) <br /> 1. Impact on Public Health- Compliance component#1 of 5 <br /> Compliance criteria Verification method(s): <br /> System discharges sewage to the 0 Yes El No El Searched for surface outlet <br /> ground surface ►� Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑Yes ®No LI Excessive ponding in soil system/D-boxes <br /> tile or surface waters ®Homeowner testimony(See Comments/Explanation) <br /> System causes sewage backup into ❑Yes ® No ❑"Black soil'above soil dispersal system <br /> dwelling or establishment. <br /> ...__.._........._.............._. ❑System requires"emergency"pumping <br /> Any"yes"answer above indicates the 0 Performed dye test <br /> system is an imminent threat to public 0 Unable to verify(See Comments/Explanation) <br /> health and safety. <br /> 0 Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity-Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, 0 Yes ® No 0 Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> ❑Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑Examined Tank Integrity Form(Attach) <br /> compliant if allowed in local ordinance, <br /> El. <br /> Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes ►Zi No <br /> ®Examined empty(pumped)tanks(s) <br /> designed operating depth. <br /> If yes,which sewage tank(s)leaks: ❑Probed outside tank(s)for"black soil' <br /> ID <br /> Any"yes"answer above indicates the Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. ❑Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> Tank pumped and verified by Duanes Septic Service. <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. 0 Yes` tEl No 0 unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. 0 Yes* ►! No 0 Unknown <br /> *System is an imminent threat to public health and safety. <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector. ®Yes" 0 No <br /> *System is failing to protect groundwater. <br /> www.pca.state.mn.us • 651-246-6300 • 800-657-3864 - TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31b - 6l4/14 Page 2 of 4 <br />