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� <br /> 08/19/2014 15:49 9528733112 PAGE 02/64 <br /> Property address: 760 DlckeV Lake Drive,Orono ' Inapector initialsJl7ate: JS � 8/14J2014 <br /> (mm/dd/yyyyJ <br /> 1. Innpatt on Public Health — Compliance component#1 of 5 <br /> Com Ilance crlterla: Verfficat�on method(s): <br /> System discharges 5ewage to the ❑Yes � No �Searched for surface vutlpt <br /> round surf�Ce. �Searched for seeping in yard/backup in hpme <br /> System dlscharges sewage to drain [�Yes � No ❑ Exc�Ssive ponding in soif system/D-boxes <br /> tlle or aurface waters. � <br /> ❑ Homeown�r testimpny(se�ck�mmancs�Fxp�anation) <br /> System Causes sewage backup into ❑Yes � No ❑"Black soil"abo�e soil dispersal system <br /> dwefling or establishment. <br /> ❑System requires"emergency"pumping <br /> Any"yes"answ�r above indicafes fhe ❑ Pertormea aye test <br /> system is�n fmm�nenf thre�f to public �']Unabte to verify (Sae Comments/Explanatr'on) <br /> healih and safety. � Other method5 nOt IiSted (See Comments/Explenetion) <br /> Commen tslExpl enatian: <br /> 2. Tank Inte�rity—Compliance component#Q of 5 <br /> Cam Ilanae orlteria: Verifpc�fiion methad(s): <br /> 3ystem cOnsists of a seepage pft, ❑Yes � No ❑ Probed tank{s}bottom <br /> C6sspool,drywell,or leaching pit. <br /> ��x�mined construction records <br /> Ssepage pfts meeting To80.26s0 may be ❑Examined Tank Intagrity F�rm (Attactr) <br /> COm 11Er7f ff allowed In local ofdl»anCe. <br /> Sewage t2nk(S)I�ak helow their I ❑Yes � No ❑Observed liquid level below operating depth <br /> designed operating depth. � Examined empry(pumped)tenks{s) <br /> If yes,which 5ewage t2nk(s}leaks: f ❑ Probed outsfde tank(s)For"black soil" <br /> /�f1y "yes"answ�r sbova fndfcates the ❑ Unable to verlfy(S��Commants/EkplanafionJ <br /> S�/S�@R7!S f811!!1g t0 p1'Ot@C��f OlJ17C�Wa�/. ❑ �her methQds not listed (See Comments/Explan�tion) <br /> Comme nts/�xpl anation: <br /> 3. O�her Compliance Conditians--Compliance component#3 of 5 <br /> a. Maintenance h01e covgrs ara damaged,cracked,unsecured,or appear to be s#ructurally unsound. ❑Yes" �No ❑Unknawn <br /> b. OCher issues(e%ctricar nazaals,etc.)to immediately�nd adversaly impact publlc health or safety_ ❑Yes' �No ❑unknawn <br /> 'S�rstem is an imm;rrenr lhreat te publlc heslth and safpty. <br /> Explain: <br /> c_ System is non-protective oF gr�und water for other conditions as determined by inspectar. ❑Yes" �No <br /> 'Syst�m fs taTlfrtg tb prot9ct groundwater. <br /> ExplaOn: <br /> www.pca.state.mn.us • 651•�,9b•630Q • 800-657-3664 . TTY 651�282-5332 or 800-657-3864 - Ava4lable in alCemative formats <br /> wq•wwists4•31 • 3/16/1Z Page 1 of 3 <br />