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07/28/2015 9 : 17AM FA'/, f�0002/0004 <br /> • I <br /> Property address: 710 Blg Island,Orono,MN 55331 Inspector initialslDate: JS 7/27/2015 '' <br /> (mm/dd/YYYY) — <br /> 1. tmpact oh Publi� Health —Compliance component#1 of 5 <br /> Compllance criteria: _ Verification method(S): <br /> 5ystem discharges sewage to the ❑Yes �fVo �Searched for sutface outfet <br /> ground surtace. �Searched for saeping fn yard/backup in hame <br /> System discharges sewage to drain ❑Yes �No ❑Excessive ponding in soil systemJD-boxes <br /> tile or surface waters. <br /> ❑Homeowner testlmony(5ea CommentslExplanafJon): <br /> System causes sewege backup into ❑Yes �C] No ❑"Biack so1P'above soii dispersal system <br /> dwelling or esta6lishment. <br /> ❑System requires"emergency"pumping <br /> Any"yes"answer above indicat�es the [�Performed dye test <br /> sysiem fs art imminent threa!to publlc ❑U118b1e to vgrlfy(Sec Comments/Explanation) <br /> healfh dlid Safety. ❑Other methods not listed (Scs Comments/Explanat�on) <br /> Comments/�xplanation: <br /> 2. Tank Integrft --Compliance component#2 vf 5 I <br /> Compliance criterie: Verlflcation method(s): <br /> System consists of a seepage plt, ❑Yes 0 No ❑Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. � <br /> �EXamined GOnSt1'Uotion racords <br /> Seepage pits meeting 7080.2550 mAy be � <br /> compliant!t aUowed in local ordinance. ❑Examined Tank Integrity Form(Attach) <br /> Sewage tank(s)leak below their ❑Yes �No �Observed liqufd level below operating depth I <br /> designed operating depth. ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: �Probed ovtslde tank(s)for"black soil" <br /> Any"yes"answer above indicates fhe ❑U�,able to verify(Sae Comments/Explanation) ! <br /> syst�em is failing to profect groundwater. ❑Other methods not listed (See Comments/Explanation) <br /> CommentslExplanation: <br /> 3. Other Com 11dt1[e Cond1�10f15—Compliance component#3 of 5 <br /> a. Malntensnce hole eovers arE damac�ed,cracked,unsecured,or appear to be st�ueturally unsound. Q Yes" �No ❑Unknown <br /> b. Other issues(electrica!hazards,etc.)to Immediately and adversely impact public health or safely. Q Yes" �No ❑Unknown <br /> *System is an imminent threat to publlc hea/th and safety, i <br /> Explain: <br /> c- System is non-proteclfve of ground water for other conditfdns as deternlfned by inspgCtor. ❑Yes^ �No I <br /> "Sysiem is fail;ng to protecf groundwater. <br /> Explain: � <br /> www_pca.state.mn.us • 651-Z96-6300 � 890-657-3864 . TTY 651-282-533z vr 800-657-38G4 • Available in alternative formats <br /> wq-wwists4-31 . 3/16/1� <br /> Poge2of3 <br /> � <br />