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1. Impact on Public Health - Compliance component #1 of 5 <br />System discharges sewage to the ground surface I ❑ Yes' <br />sewage to drain tile or <br />waters <br />❑ Yes - <br />P -1 No <br />O No <br />System causes sewage backup into dwelling or <br />establishment ❑ Yes* 2 No <br />Any "yes" answer above indicates that the system is an <br />imminent threat to public health and safety. <br />Describe verification methods and results: <br />no <br />Z. Tank Integrity - Compliance component #2 of 5 <br />Compliance Criteria: <br />System consists of seepage pit, <br />El Yes* I] No <br />cesspool, drywall, or leaching pit <br />Sewage tank(s) leak below their <br />❑ Yes* 2 No <br />designed operating depth. <br />If yes, which sewage tank(s) leaks: <br />Any "yes" answer above indicates that the system is <br />failing to protect groundwater. <br />Describe verification methods and results: <br />Attached supporting documentation: <br />❑ Other <br />❑ Not applicable <br />nrwcneu suppon:mg oocumenzation: <br />❑ Empty tank(s) viewed by inspector <br />Name of maintenance business: Elmer J Peterson <br />License number of maintenance business: L219 <br />Date of maintenance (mm/dd/yyyy): 7/3/2019 <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mm/dd/yyyy): <br />(must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 B (1)) <br />❑ Tank is Noncompliant <br />(pumping not necessary— explain below) <br />❑ Other: <br />Visually inspected tanks, probed tank bottoms. First tank has 1.5' of scum and 3" sludge, recommend pumping tanks this summer. <br />vropeny address: aoa amoos bay nd iv, Orono ann t)wbb <br />Business Name: Ingleside Engineering & Constuction, Inc. Date: 3/1/2022 <br />(mm/dd/yyyy) <br />wq-wwists4-31c • 7/12/21 • wviw. pca.state.mn.us • Available In alternative formats • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 Page 2 of 4 <br />