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Apr 17 15 09:40a Joseph Olson 763-498-8290 p.3 <br /> Property address: 2785 White Oak Circle, Orono,MN _ Inspector initials/Date: J.0.4/17115 <br /> Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the I ❑Yes <br /> Z No ® Searched for surface outlet <br /> ground surface. ® Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile 0 Yes ® No D Excessive ponding in soil system/D boxes <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into ❑Yes ® No 0 "Black soil"above soil dispersal system <br /> dwelling or establishment. 0 System requires"emergency'pumping <br /> 0 Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safety. 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, ❑Yes Z 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 /> ❑ 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: D Probed outside tank(s)for"black soir <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 /> Com m entsfExplan ation: <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 ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑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* ®No <br /> *System is failing to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1124117 <br /> Page 2of3 <br />