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, Property address: 4785 Creekwood Trail,Orono MfV Inspector initials/Date: J.O.4/23/13 <br /> 1. Impact on PubliC Health—Compliance camponent#1 of 5 <br /> Com Ifance criterla: Verification method(s): <br /> System discharge sewage to the ❑Yes �No � Searched for surface autlet <br /> round surface. � Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile ❑Yes �No � ��ssive pond(ng in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explenation) <br /> ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup into ❑Yes �No ❑ System requires"emergenc�°pumping <br /> dwelling or establishment. ❑ PerFormed dye test <br /> Any"yes"answer above lndlcates the system is ❑ Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safety. ❑ Olher methods not listed(See Comments/ExplanaUon) <br /> Comments/Expianation: I <br /> 2. Tank Integr"ity—Compliance component#2 of 5 i <br /> i, <br /> Compliance criteria: Verification method(s): � <br /> System consists of a seepage pit, ❑Yes �No ❑ Probed tank(s)bottom t <br /> cesspool,drywell,or leaching pit. ' <br /> ❑ Examined construction records <br /> i <br /> Seepege pits meebng 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) I <br /> oom liant if sllowed in loca!orclinance. <br /> ❑ Observed liquid level below operating depth � <br /> Sewage tank(s)leak below their ❑Yes �No � Examined emQty(pumped)tanks(s) ' <br /> desf ned o eratin de th. i <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil' <br /> Any"yes"answer above indicates the ❑ Unable to verify(See CommentsiE�cplanation) � <br /> system!s Failing to Protect Groundwafer. �Other methods not listed(See Comments/Explanation) �� <br /> Comments/Explanation: � <br /> 3. Other COmpllanCe COndltio115—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes* �No ❑Unknown I <br /> b. Other issues(elecbical hazarrls,etc.)to immediately and adversely impact public health or safety. O Yes' �No p Unknown ' <br /> *System!s an lmminent threat to publTc health and safety <br /> Explain: <br /> c. System is non-protective of ground water for other oonditions as determined by inspector ❑Yes' �No <br /> 'System is fa111ng to protect groundwater <br /> Explain: <br /> I <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3664 • TTY 651-282-5332 or 800-657-3864 • Availabie in altemative formats <br /> wq•wwists4-31 • i/24/12 Page 2 of 3 <br />