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Jan 09 2017 01:07PM HP FaxRusty Olson 7634988290 page 3 <br /> Property address: 2705 White Oak Circle.,Orono, MN Inspector initials/Date: J. 0. 1/06/17 <br /> 1. 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 ❑Yes No® <br /> CI Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup into ❑Yes ® No ❑ System requires"emergency"pumping <br /> dwelling or establishment. ❑ Performed dye test <br /> Any"yes"answer above indicates the system is 0 Una ble 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 ® 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 /> Sewage tank(s)leak below their ❑Yes ® No Ci Observed liquid level below operating depth <br /> designed operating depth. ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ED Probed outside tank(s)for"black soir <br /> „ <br /> Cl Unable to verify(See Comments/Explanation) <br /> "yes"yes answer above indicates the ❑Other methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <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 D Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* ®No ❑ 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 • 1/24112 Page 2 of 3 <br />