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Property address: 4645 Bayside Rd Orono,MN Inspector initials/Date: 4-1 <br /> oZ 71 <br /> IF (mm/dd4Wy) <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharges sewage to the ❑Yes ®No ®Searched for surface outlet <br /> round surface. ®Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑Yes ®No ❑Excessive ponding in sal system/D-boxes <br /> file or surface waters. ❑Homeowner testimony(See CommentsiExplanation) <br /> System causes sewage backup into ❑Yes ®No ❑"Black soil"above soil dispersal system <br /> dwelling or establishment. <br /> [ISystem requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑Performed dye test <br /> system is an imminent threat to public ❑ Unable to verify(See CommenwExpianation) <br /> health and safety. <br /> ❑Other methods not listed(See CommentslExplanation) <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 ❑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: ❑Probed outside tank(s)for"black soil" <br /> Any"yes"answer above indicates the ❑ Unable to verify(See CommentsExplanation) <br /> system is failing to protect groundwater. ❑Other methods not listed(See Comments/Explanation) <br /> CommentalExplanation: <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes* ®No ❑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 groundwater for other conditions as determined by inspector. ❑Yes* ®No <br /> *System/s falling to protect groundwater. <br /> Explain: <br /> www.pca.state.mn.us • 651-2%-6300 • 800-657-3864 TTY 651-282-5332 or Soo-657-3864 • Available in altemattve formats <br /> wq-wwlsts4-31b • 614114 <br /> Page 2of3 <br />