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Property address: 1101 Willowbrook Drive.,Orono,MN Inspector initials/Date: J. 0.4/22117 <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the j LiYes Ej No ® Searched for surface outlet <br /> ground surface. ® Searched for seeping in yard/backup in home <br /> 0 Excessive ponding in soil system/D-boxes <br /> System discharge sewage to drain tile 0 Yes ®No <br /> 0 Homeowner testimony(See Comments/Explanation) <br /> or surface waters. <br /> System cause sewage backup into 0 Yes 0.14 No <br /> ❑ "Black soil"above soil dispersal system <br /> dwelling or establishment. ❑ 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. ❑ 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 0 No 0 Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. 0 Examined construction records <br /> Seepage pits meeting 7080.2550 may be 0 Examined Tank Integrity Form(Attach) <br /> compliant if allowed in local ordinance. <br /> 0 Observed liquid level below operating depth <br /> Sewage tank(s)leak below their 0 Yes 0 No 0 Examined empty(pumped)tanks(s) <br /> _designed operating depth. <br /> If yes,which sewage tank(s)leaks: i 0 Probed outside tank(s)for"black soil" <br /> ❑ Unable to verify(See Comments/Explanation) <br /> Any "yes"answer above indicates the ►�� Other methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <br /> Comments/Explanation: <br /> Peterson Company pumped the tanks. <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. 0 Yes* ®No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. 0 Yee ®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 0 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 • 1124/12 <br />