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Property address: 888 Dakota Ave -Orono Inspector initials/pate: JS � 5/21/2014 <br /> (mm/dd/yyyy) <br /> 1 . Impact on Public Health — Compliance component #1 of 5 <br /> Compliance criteria: Verification method(sj: <br /> System discharges sewage to the ❑Yes � No � Searched for surface outlet <br /> _ground surface. � Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑ Yes � No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters. , <br /> ❑ Homeowner testimony (See Comments/Explanation) <br /> System causes sewage backup into �rn�Yes � No ❑ "Black soil"above soil dispersal system <br /> dwelling or esiablishment. <br /> ---- ❑ System requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminenf threat to public ❑ Unable to verify (See Comments/Explanation) <br /> health and safefy. <br /> _ ❑ Other methods nOt listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Inte�rity— Campliance component #2 of 5 <br /> _ Com liance criteria: Verification method(s}: <br /> System consists of a seepage pit, ❑Yes � No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. � Examined construction records <br /> Seepage prts meeting 7080.2550 may be ❑ Examined Tank Integrity Form (Anach) <br /> compliant i(allowed in local ordinance. <br /> ❑ Observed liquid level below operating d�pth <br /> Sewage tank(s)leak below their ❑ Yes � No <br /> designed operating depth. � Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s) leaks: ❑ Probed outside tank{s)for"black soif' <br /> AfT y "yes"answer above indicates the ❑ Unab(e to verify(See CommentslExp�ana[ion) <br /> system is failing to protect groundwater. ❑ C)ther methods not listed (See Comments/Explanatton) <br /> Com mentslExplanation: <br /> 3. Othel" COmpli8nC2 COtlditiOtlS— Compliance component #3 of 5 <br /> a. Maintenance hole covers are damaged,cracked, unsecured,or appear to be structurally unsound. ❑Yes' �No ❑Unknown <br /> b. Other issues (electrical hazards, etc.)to immediately and adversely impact public health or safety. ❑Yes` �No ❑Unknown <br /> rSysfem is an imminent fhreat to pubtic health and safety. <br /> Expiain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector. Q Yes' �No <br /> �System is failing to protect grourrdwater. <br /> Expiain: <br /> www.pca.staCe.mn.us • 651•296-6300 • 800•657•3864 • TTY 651•282-5332 or So0-657-3864 • Available in altemative formats <br /> wq-wwists4-3t • 3/16/!2 Page 2 of 3 <br />