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Jul 28 2016 10:OOPM HP FaxRusty Olson 7634988290 page 3 <br /> � <br /> Property address: 2940 Fox Street,Orono,MN __ Inspector initials/pate: J.O.7/d8/16 <br /> 1. ImPdCt 0� PubliC Hedlth—Compfiance component#1 of 5 <br /> Com liance criteria: _ __ Verification method(s): <br /> System discharge sewage to the ; ❑Yes � No � Searched for surFace outlet <br /> ground _s_urface, j � Searched for seeping in yard/backup in horne <br /> System discharge sewage to drain tile ' ❑Yes � No ❑ �cessive ponding in soil system/D-boxes <br /> or suriace waters. � ❑ Homeowner testimony(See Comments✓Explanetion) <br /> ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup into ❑Yes � No ❑ System requires"emergency'pumping <br /> dweflmg or establishment. I ❑ Pe rforme d dye te s t <br /> Any"yes"answer ab�ve indlcafes!he system is ❑ Unable to verify(See Commentsi�xp�anation) <br /> an lmminent Threat to Public Health and 5afety. ❑ Other methods not listed (See Comments/Explanation) <br /> CommentslExpla nation: <br /> 2. Tank Integrlty— Compliance component#2 of 5 <br /> _Compliance criteria: _ Verificatlon method(sE: <br /> Systern consists of a seepage pit, ❑Yes �No � Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> � Examined construction records <br /> Seepags pits mesting 7Q80.2550 may be ❑ Examined Tank Iniegrity Form(Attach) <br /> compliant if allowed in loca/ortiinance. <br /> ❑ Obseroed liquid level below operating depth <br /> Sewage cank(s}leak below their � ❑Yes � No � Examined empty(pumped)tanks(s) <br /> desi ned o eratin de th. <br /> ' _ _ _____ _ <br /> If yes,which sewage tank(s) leaks: ❑ Probed outside tank{s)for"black soil' <br /> A�1y "yes"answer above indicates the ❑ Unable to verify(see Comments�xp�anation} <br /> sysfem is Failing to Protect Groundwater. ❑ocner mett,ods not iisted �see commer,cs�Xpre�srro�� <br /> Comments/Explanation: <br /> 3. �ther Compliance Conditions —Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked, unsecured,or appear to structurally unsound. ❑Yes" �No ❑�lnknown <br /> b. Other issues(eiectricarhazarrls,etc.)to immediately and adversely impact public health or safety. i]Yes` �No ❑Unknown <br /> 'System is an imminent threaf to public health and safety <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector ❑Yes` �No <br /> 'System is failing to protectgroundwater <br /> Explain: <br /> www.pca.state.mn.us • 651-296•6300 • 800•657-3864 . TTY 651•282•5332 or 800•657•38Q4 . Available in alternative formats <br /> wq•wwists4•31 • 1/24/1? Page 2 aj 3 <br />