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, <br /> Property address 4755 Bayside Road, Orono MN 55359 Inspector initials/Dat�:�U) 7/10/2014 <br /> __._ (mmiddiYYYY) <br /> r� <br /> 1 . Impact an Public Hea(th — Compliance component #1 of 5 <br /> CompEiance criteria: Verification method(s): <br /> System discharges sewage to the ❑ Yes � No ❑ Searched for surface outlet <br /> grou�d surface. � Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑ Yes � No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters. ❑ Homeowner testimony(See Commenrs/Explanation) <br /> System causes sewage backup into ❑ Yes � No ❑ "Black soil° above soil dispersal system <br /> dwelling or establishment. <br /> ___ ❑ System requires "emergency" pumping <br /> Any "yes"answer abave indicafes the ❑ Performed dye test <br /> sysfem is an imminent threat to pubfic ❑ unabie to�er�ty�s�P commenrs,�ExP+�nar�on� <br /> health and safefy. <br /> � Other methods not listed (See CommentslExplanation) <br /> Comments/Explanation: <br /> Performed a hydraulic test by dosing the septic system via water ran from the house and the pump. No evidence of any <br /> hydraulic issues. <br /> 2. Tank inte�rity— Compliance component #2 of 5 <br /> Compiiance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑ Yes � No ❑ Probed tank(s) bottom <br /> cesspool, dryweil, or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meetrng 7080.2550 may be ❑ Examined Tank Integrity Form (Attach) <br /> Contpliant if allowed in focal o�dinance. <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 /> -- _ <br /> A�7y "yes"af7SW@I"abOV@ I!]dlCafG'S fh@ ❑ Unable to verify(See Comments,�Expianation) <br /> SySt@m is fHiling to�JI'�tECt C�COUI7dWat@!". ❑ Other methods not listed (See Comments/Expfanation) <br /> Comments/Explanation: <br /> 3. Othet' CompliallCe COndltions—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. Qther issues(electrica!hazards, etc.)to immediately end adversely impact public health or safety. ❑Yes* � No ❑ Unknown <br /> *Sysfam is an irrrminent 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 protectgroundwater. <br /> Explain: <br /> _ <br /> _._ ___ <br /> __ <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Availabte in alternative formats <br /> wq-wwists4-37 • 3/16/72 Page 2 of 3 <br />