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11/05/2015 12:23PM FAX �0002/0004
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<br /> Proparty address: 425 Ferndale Road North Orono Inspector initials7Date: JS 1:1/4/2015' 'I , ��i �
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<br /> 1. lmp�tt on Public Health-�Compliance component#1 of 5 �
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<br /> COmpliance criteria: Verification method(s): - � '�' '`��'�� �
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<br /> �;;; ,. System discharges s�wage to the ❑Yes � No �Searched for surFace outlet ' �,
<br /> groun�tl surfaca. � S82rched for seeping Icl yardlbackup in hame I
<br /> � System discharges sewage to drain ❑Yes 0 No ❑ Excessive ponding in spil system/D-boxes::
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<br /> tile or�surface waters. _ Homeowne ,' � ��'
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<br /> ; System caus6s sewage backup into [�Yes � No ❑°Black soil"above soil dispersai system � �� '�� E�.;�;,
<br /> dwelfingorestablishment. ' ; �,
<br /> • � ❑System requires"emergency"pumping
<br /> � Any"yes"answer above indicates the ' �
<br /> sys#em !s an imminent threat to public ❑PerFormed dye test
<br /> healfh and safe#y. ❑ Unabl�to verify(See comments/Explanetion). _ , .
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<br /> _ � Other methods not listed(See Comments/F�cplanefion)'•�.-' :'.'_ , ' i
<br /> CommentS/Explanation: ., I
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<br /> ?`- � 2. T�11k (ntegrity— Compliance component#2 of 5 ` '
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<br /> Complianee criteria: _ Verification method(s): ' � �,�
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<br /> Systerrt consists of a seepage pit, ❑Yes �(Vo � Probed tank(s)bottom , �b�+.,� rs�; I'
<br /> cesspoo l, drywe l 1,p�162c hi�g pi t. ❑ Examined CpnstCuction records �i k�,} �i
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<br /> �.��� . Seepage pits me�fing 7080.2550 mey 6e ❑ E x a m i n e d T a n k I n t e g r i t y F o r m(A t t a a h) � ��
<br /> compllanf if el/owed in local orqinance, ;
<br /> • Sewa e tank s leak below their ❑ Observed liquid level belaw operating depth ,; �, ��: �
<br /> g ( ) ❑Yes � No _ � �,.
<br /> desigrled operating depth. �Examined empty(pumped)tanks(s) '`: � �,� �';�3r
<br /> If yes,which sewage tank(s)leaks: ❑ Probgd outside tank(s)for"black soil' ��
<br /> � '' - ❑ Unable to venfy(se�Comments✓Exp/enetion)
<br /> ' � ` Any ,"yes"answer above indica#es the '
<br /> system !s failing to proi�ect groundwater_ ❑Other methods not listed(See Comments�Explanetron) �` � '
<br /> CommentslExplanation: ,;- �`� `
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<br /> 3. Othe��ComplianC� COndltlOns—Compliance component#3 of 5
<br /> a. Mainfenance hole covers are damaged,crecked,unsecured,or appear to be structurally unsound. ❑Yes` �No ❑�Unknown � ' i
<br /> b. Other issues(e�ec�icalhazanfs,etc.)to immedistely and adversely impact public heaRh o�safety. ❑Yes* �No �UnknoWn'�_;'�; ;
<br /> "Sysdem is an imminent threat to public health and safety. y ,€a� (� i, '
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<br /> c. System is non-protective of ground weter fpr pthef oonditions as deferrnfned by inspector. ❑Yes� �No. . ; ;.
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<br /> =System is failing fo protectgrou»dwater. ' ' ` ::'' I
<br /> , H�plain: ��
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<br /> j : www.pca.state.mn.us . 651-296-63U0 • B00-657-3864 . TfY 651•282-5332 or 8Uo-657-3864 . Available irr altemative formats
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