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Property address: 710 Big Island, Orono Inspector initials/Date: PJB � 06/24/2016 (mm/dd/yyyy) 1. Impact on Public Health— Compliance component#1 of 5 Com liance criteria: Verification method(s): System discharges sewage to the ❑Yes � No � Searched for surface outlet round surface. � Searched for seeping in yard/backup in home System discharges sewage to drain ❑ Yes � No ❑ Excessive ponding in soil system/D-boxes tile or surface waters. ' ❑ Homeowner testimony(See Comments/Explanation) System causes sewage backup into I ❑Yes � No ❑ "Black soiP'above soil dispersal system dwelling or establishment. ❑ System requires"emergency° pumping Any"yes"answer above indicates the ❑ Performed dye test system is an imminent threat to public ❑ Unable to verify(See Comments/Explanation) health and safety. � Other methods not listed (See Comments/Explanation) Comments/Explanation: System is well built and appears to be functyioning properly. 2. Tank Integrity— Compliance component#2 of 5 Compliance criteria: _ Verification method(s): System consists of a seepage pit, ❑ Yes � No � Probed tank(s) bottom cesspool, drywell, or leaching pit. � Examined construction records Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form (Attach) compliant if allowed in local ordinance. ❑ Observed liquid level below operating depth Sewage tank(s) leak below their ❑Yes � No designed operating depth. ❑ Examined empty(pumped)tanks(s) If yes,which sewage tank(s) leaks: ❑ Probed outside tank(s)for"black soil" Any "yes"answer above indicates the ❑ Unable t0 verify(See Comments/Explanation) system is failing to protect groundwater. � Other methods not listed (See Comments/Explanation) Comments/Explanation: Tanks were tested using a recording Datalogger with no loss of volume in a static tank test. 3. Other ComplidnCe Conditions—Compliance component#3 of 5 a. Maintenance hole covers are damaged,cracked, unsecured,or appear to be structurally unsound. ❑Yes* � No ❑ Unknown b. Other issues(electncal hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes' � No ❑ Unknown *System is an imminent threat to public health and safety. Explain: c. System is non-protective of ground water for other conditions as determined by inspector. ❑Yes` �No 'System is failing to protect groundwater. Explain: www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4-316 • 6/4/14 Page 2 of 3