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Oct 10 14 12:07p Joseph Olson 763-498-8290 p.3 <br /> Propsrty address: 2655 Counfryside Drive W., Orono,MN � Inspector initialslDate: J. O. 10/07/9� <br /> 1, frtlpaCt o� PUbIiC Hedith —Compliance component#1 of 5 <br /> Compliance criteria: _ ` Verff�catior�rnethod{s�: <br /> System discharge sewage to the � ❑Yes 0 Na I� Searched for surface ouUet <br /> ground surface. _ � Searched for seepiRg in yard/backup in home <br /> System discharge sewage io drain tile Q Yes �No ❑ Excessive ponding in soPl system/D-boxes <br /> or surface waters. _ ❑ Nomeowner testirnony(See CommentsiExpla�ationj <br /> System cause sewage backup into ❑Yes �No � �glack soil'ahove sail dispersai system <br /> dwelling or establishment. , ❑ System requfres"emergenc�'pumping <br /> - - -- ❑ Performed dye test <br /> AAy"ye,s"answer above indicafes the system is ❑ Unable to verify(See Comments/Fxplanation) <br /> an lmminent Threat to P�blic Hea/th a»d Satety. <br /> --- _____ ❑ Other methods not listed(See Comments/Fxplanahbn) <br /> Com ments/F�cplanati on: <br /> 2. Tdnk Itltegrlty—CompJiance component#2 of 5 <br /> _Compliance criteria: __ _ _ _ Verification method(s): <br /> System coRsists of a seepage pit, �Yes B;No � Probed tank(s) bottom <br /> cesspool, drywell, or leaching pit. I <br /> � Examined construction records <br /> Seepaye pits meeting 7080.2550 may be ' ❑ Exarnined Tank Integrity Forrn(Ad'ach) <br /> complianY if aJlowed in hxaf orrlrnance. <br /> ❑ Observed liquid leyel below operating depth <br /> Sewage tank(s) leak betow their ❑Yes ,� No <br /> desi ned o eratin de th. ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: I ❑ Probed oulside tank(s)for"black soi!" <br /> Any"yes"a11SW�.'r BL}OVE 1lIC/fCBt@5 fI1@ ❑ Unable to verify(See Comments/ExplanaL'on) <br /> system is Fai�ing to Protect Groundwater. ❑�her methods not listed (See CommerrtsiExplana�ion) <br /> C om menis�Explanati an: <br /> 3. Other Campliance Conditions—Cflmpliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes* � No ❑Unknow� <br /> b. Other issues(eiecbicalhazards,etc.)to immediately and adversely impaci public health or safety_ ❑Yes" �No ❑Unknavn <br /> `Systern rs an immirrenf ttr�at to public healNe and safety <br /> Explain: <br /> c. System is non-protec[ive of ground water for other conditions as deiermined by inspector ❑Yes' �No <br /> 'System fs failing to protect groundwater <br /> Escplain: <br /> v,nwv.pca.state.mn.us - 651-29b•6300 - 800-657-3864 . TrY 651-282-5332 or 800-b57•3864 • Available in alLernative formats <br /> wq-wwiscs4-3i . 1124/?2 Page 2 of 3 <br />