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Feb 29 2016 05:06PM HP FaxRusty Olson 7634988290 page 3 <br /> Property address: 1185WYndamere Road.,Orono MN Inspector initials/Date: J.0.2/25116 <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 the � E]Yes ®Na <br /> ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. <br /> [I Homeowner testimony(See Comments/Explanation) <br /> [I "Black soil"above soil dispersal system <br /> System cause sewage backup into El Yes ®No <br /> dwelling or establishment. [I System requires"emergency"pumping <br /> ElAny"yes"answer above Indicates the system is <br /> an Imminent Threat to Public Health and Safety. ❑ Unable too verify(See Comments/Explanation) <br /> dye test <br /> Unable <br /> ❑ Other methods not listed(See Comments/Explanation) <br /> Com ments/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 ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> compliant if allowed in local craYnence. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes ®No ❑ Examined empty(pumped)tanks(s) <br /> designed operafina depth. <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> I <br /> Any"yes"answer above inahcates the ElUnable to verify(See CommentarExplanation) <br /> system is Failing to Protect Groundwater. ®Other methods not listed (See CommentslExplanation) <br /> Comments/Explanation: <br /> Elmer J Peterson pumped the tanks on 2/25/16 <br /> 3. other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covens are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes• E No ❑Unknown <br /> b. Other issues(elecaical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes' END ❑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• E No <br /> *System is failing to protect groundweew <br /> Explain: <br /> www.pca.state.mn.us • 651.296-6300 • 8OD-657-3864 TTY 651-282-5332 or 800.657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1124112 Page 2 of 3 <br />