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Property address: 645 Femdale Road,Orono,MN Inspector initials/Date: �� <br /> (mm/dd/YYNY) <br /> 1. impact on Pubtic Hea(th—Compliance component#1 of 5 <br /> Com liance criteria: Verification method(s): <br /> System discharges sewage to the ❑Yes �No � Searched for surface outlet <br /> round surface. � Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑Yes �No ❑ Excess{ve ponding in sal system/D-boxes <br /> tile or surface waters. <br /> ❑ Homeowner testimony(See Comments/Explanation) <br /> System causes sewage backup into ❑Yes � No ❑"Black soil"above soil dispersal system <br /> dwelling or establishment. <br /> ❑ System requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminent threat to public ❑ Unable to verify(See CommentsiExplana6on) <br /> health and safety. <br /> ❑Other methods not listed(See Comments/Explanation) <br /> Com ments/Explanation: <br /> 2. Tank Integrity—Compliance 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. <br /> ❑Examined construction records <br /> Seepage pits meefing 7080.2550 may be ❑Examined Tank Integrity Form(Attach) <br /> com /iant if al/owed in loca/ordinance. <br /> ❑Observed liquid level below operating depth <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 /> AI1y "yes"answer above indicafes fhe ❑ Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. ❑Other methods not listed(See Comments✓Exp/anation) <br /> Com ments/Explanation: <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsea�red,or appear to be structurally unsound. ❑Yes" �No ❑Unknown <br /> b. Other issues(electrica�hazards,et�.)to immediately and adversely impad public health or safety. ❑Yes* �No ❑Unknown <br /> `System is an imminent threat 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 protect groundwater. <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-Z82-5332 or 800-657-3864 • Available tn altemative formats <br /> wq-wwists4-316 • 6/4/14 Poge 2 of 3 <br />