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Nov 30 2015 07:27PM HP FaxRusty Olson 7634988290 <br />page 3 <br />Property address: 1580 Sixth Ave. N Orono MN Inspector Inhials/Date: J. 0. 11130M 5 <br />1. Impact on Public Health —Compliance component #1 of 5 <br />Compliance criteria: <br />System discharge sewage to the ❑ Yes ® No <br />round surface, <br />System discharge sewage to drain the i ❑ Yes ® No <br />or ce surfawaters, <br />System cause sewage backup into j ❑ 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 />CommentslExplanation: <br />2. Tank integrity— Compliance component #2 of 5 <br />Compliance criteria: _ <br />System consists of a seepage pit, ❑ Yes ® No <br />cesspool, drywell, or leaching pit <br />Seepepe pits meeting 7080.2550 maybe <br />_comptient 1fallov4d in local ordinance <br />Sewage tank(s) leak below their ❑ Yes ® No <br />designed operating depth <br />If yes, which sewage tank(s) leaks: <br />Any "yes" answer above indicates the <br />system iS Failing to Protect Groundwater. <br />Comment&Expianaton: <br />See tank report <br />Verificatlon method(s); <br />® Searched for surface outlet <br />® Searched for seeping in yardibackup in home <br />❑ Excessive ponding in soil syatem/D-boxes <br />❑ Homeowner testimony (See Comments/ExplanetW) <br />❑ "Black soil" above soil dispersal system <br />❑ System requires "emergency pumping <br />❑ Performed dye test <br />❑ Unable to verify (See CommentsFxp/enaUon) <br />❑ Other methods not listed (See CommenrsiExplanation) <br />Verification method(s): <br />❑ Probed tank(s) bottom <br />❑ Examined construction records <br />❑ Examined Tank Integrity Form (Attach) <br />❑ Observed Ilquid level below operating depth <br />❑ Examined empty (pumped) tanks(s) <br />❑ Probed outside tank(s) for "black soli" <br />❑ Unable to verify (See Comments/Explanation) <br />® Other methods not listed (See Commenr&iExpianarion) <br />3. Other Compliance Conditions — Compliance component #3 of 5 <br />a. Maintenance hole covers are damaged, cracked, unsecured, or aPPWrto structurally unsound. ❑ Yee• ®No ❑ Linknovm <br />b. Other issues (Mbcfta/hazards, etc.) to immediately and adversely impact pubic health or safety. ❑ Yes• ®No ❑ Unknown 'System Is nn imminent thrust to public health and safety <br />Explain: <br />C. System is non -protective of ground waber for other conditions as determined by Inspector ED Yes' IS No <br />System is falling to protect groundwater <br />Explain: <br />www.pca.state.mn.us • 651.296.6300 • 800.657.3864 TTY 651.282.5332 or til)0.657.3864 . Available in alternative formats <br />wq•ww1sts4.31 • 1124112 <br />Page 2 of.3 <br />