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Apr 20 15 06:18p Joseph Olson 763-498-8290 p.14 <br /> Property address: 2785 White Oak Circle,Orono, MN Inspector initials/Date: J.0.4/17115 <br /> 7. Impact on Public Health-Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes ® No ® Searched for surface outlet <br /> ground surface. ® Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile D Yes ®No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backupinto 0 "Black soil"above soil dispersal system <br /> Y g ❑Yes ®No ❑ System requires"emergency"pumping <br /> dwelling or establishment. <br /> ❑ Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verily(See Comments/Explanation) <br /> an imminent Threat to Public Health and Safety- <br /> ❑ 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 El No ❑ 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 /> D Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑ Yes ® No <br /> designed operating depth. ® Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s) leaks: ❑ Probed outside tank(s)for'black soil" <br /> Any"yes"answer above indicates the ElUnable to verify(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. 0 Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes* ®No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. El 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 p Yes' ®No <br /> *System is failing to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • BOO-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-3 r • 1/24112 Page 2 of 3 <br />