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May 02 2015 09:44AM HP FaxRusty Olson 7634988290 page 3 <br /> Property add ss _180 Biq Island Orono,MN _ InspectorinitialslDate: J.O.4/26115 <br /> 1. Impe t OIl Publ1C Hedlth—Compliance component#1 of 5 <br /> Com iance criteria: Verification method�s): <br /> Systern discharge sewage to the '�� ❑Yes � No � Searched for surface outlet <br /> round urface. � Searched fnr seeping in yardlbackup in home <br /> _-- �_ _. <br /> [ ❑ Excessive ponding in soi!systemlD-boxes <br /> System discharge sewage to drain tile ! ❑Yes �No <br /> or surf e waters. I ❑ Homeowner testimony(See Comments/Explanation) <br /> ❑ "Black soil"above soil dispersal system <br /> Syslem cause sewage backup in;o ; ❑Yes � No ❑ System requires"emergency'pumping <br /> dwellin or establishment. <br /> — ❑ PerFormed dye test <br /> Any"�es"answer above indicates the system is ❑ Unable to verify(See Commsnts/Explanation) <br /> a�t/m inent Threat to Public Health and Safety. ❑ pther methods not listed (See Comments/Explanatior�) <br /> Comm ntslExplanation: <br /> 2. Tank:Inte�rity—Compliance component#2 of 5 <br /> Com iance criteria: Verification metfiad(sj: <br /> Syste consists of a seepage pit, i ❑ Yes � No � Probed tank(s)bottom <br /> cesspo I,drywell,or leaching pit. ', � Examined construction records <br /> Seepag pifs meeting 7080 2550 may be ❑ Examined Tank Integriiy Form(Attar.h) <br /> complia t if alfowed in local ordrnance. <br /> ---– ❑ Observed liquid level below operating depth <br /> Sewag tank(s) leak below their ; ❑Yes � No <br /> desi n d o eratin de th. ❑ Examined empty(pumped) tanks(s} <br /> If yes, hich sewage tank(s)leaks: ' ❑ Probed outside tank(s)for"black soil" <br /> -�' --_ __— --- <br /> Unable to verify(See Comments�cplenatr'on) <br /> Any �/eS"answer a6ove indicates the ❑ pther methods not listed (5ee CommentslExplanation) <br /> syste is Failing to P�otect Grourrdwater. <br /> Comm nls/Explanation: <br /> 3. Othe Comp lidnCe COrlditi0n5—Compliance component#3 of 5 <br /> a Mai��ienance hoie covers are damaged,cracked,unsecured,o�appear to structurally unsound. ❑Yes" �No ❑UnknoHm <br /> b. Oth�r issues(elechical hazards,etc.}to immediately and adversely impact public health or safety. ❑Yes* �No ❑Unknown <br /> "S tem is an imminent threat to public health and safery <br /> Ex lain: <br /> c Sysjtem+s non-protective of ground waterfor other conditions as determined by inspector ❑Yes" �No <br /> *S tem is failing to protect groundwater <br /> Ex lain: <br /> www.pca.stat .mn.us • 651-296-6300 • 800�657•386a • TTY 651-282-5332 or 800•657-3864 � Available in altemat've formats <br /> wq-wwists4-3�' • 1/24/12 Page 2 of 3 <br />