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Property address: 225 Old Crystal Bay Road S., Orono, MN <br />1. Impact on Public Health - Compliance component #1 of 5 <br />Compliance criteria: <br />System discharge sewage to the ❑ Yes ® No <br />ground surface. <br />System discharge sewage to drain tile ❑ Yes ® No <br />or surface waters- - — -- — -- — - — <br />System cause sewage backup into ❑ Yes ® No <br />dwelling or establishment. <br />Any "yes" answer above indicates the system is <br />an Imminent Threat to Public Health and Safety. <br />Comments/Explanation: <br />2. Tank Integrity —Compliance component #2 of 5 <br />_Compliance criteria: <br />System consists of a seepage pit, ❑ Yes [K No <br />cesspool, drywell, or leaching pit. <br />Seepage pits meeting 7080.2550 may be <br />compliant_if allowed in local ordinance. <br />Sewage tank(s) leak below their ❑ Yes ® No <br />designed operating doth. _ <br />If yes, which sewage tank(s) leaks: <br />Any "yes" answer above indicates the - - <br />system is Failing to Protect Groundwater. <br />Comments/Explanation: <br />The tanks are to be abandoned. <br />Inspector initials/Date: J. O. 7120115 <br />Verification method(s): <br />Searched for surface outlet <br />® Searched for seeping in yard/backup in home <br />❑ Excessive ponding in soil systemlD-boxes <br />❑ Homeowner testimony (See CommentslExplanation) <br />❑ "Black soil" above soil dispersal system <br />❑ System requires "emergency" pumping <br />❑ Performed dye test <br />❑ Unable to verify (See CommentslExplanation) <br />❑ Other methods not listed (See CommentslExplanation) <br />Verification method(s): <br />® Probed tank(s) bottom <br />Examined construction records <br />❑ Examined Tank Integrity Form (Attach) <br />❑ Observed liquid level below operating depth <br />❑ Examined empty (pumped) tanks(s) <br />❑ Probed outside tank(s) for "black soil' <br />❑ Unable to verify (See Comments/Explanation) <br />❑ Other methods not listed (See CommentslExplanation) <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 (electricalhazards, etc.) to immediately and adversely impact public health or safety. ❑ Yes* E 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 651-2.96-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Availabte in alternative formats <br />wq-wwists4-31 • 1124112 <br />Pa?e2of3 <br />