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.� <br /> Propaart�;address: 755 Femdal Rd.N Orono,Mn Inspector initials/Date:� 11/02/2015 <br /> (►m►✓dd/YYYY) <br /> 1. Impact on Pubtit Health—Compliance component#1 of 5 ' � <br /> Com liance crtteria: Verification rr�ethod(s): �� <br /> System discha�ges sewage to the ❑Yes �No ❑�������� <br /> round surface. �Searched for seeping in yardlbadcup in home <br /> System discharges sewage to drain ❑Yes � No ❑F,ccessive ponding in soil systertVD-boxes <br /> tile or surfaoe waters. ❑Homeovmer testimony(See Commerrts/Explanatia�) <br /> System causes sewage badcup iMo ❑Yes � No ❑"Biadc soiP above soil dispersal system <br /> dwelling or establishmerrt. <br /> ❑System requires"emergerxy"pumping <br /> Any"yes"answer above indicates the ❑Pe��� <br /> system is an imminent thr�eat to public ❑unabte to verity�see comme,►rs�aa►,eno�►� <br /> hea/th and safety. <br /> ❑Other methods not listed(See Com►ner►tslFxp�anetion) <br /> Comments/E�lanation: <br /> 2. Tank Integrity—Comptiance component#2 of 5 <br /> Com tiance criteria: Verfication method(s}: <br /> System consists of a seepage pit, ❑Yes �No ❑Probed tank(s)bot�om <br /> «�sspool,drywvell,or leaching pit. <br /> ❑Examined oonstrudion records <br /> �P89'e Pr��b�9��•2��Y� ❑ Examined Tank Integrtty Form(Atted►) <br /> iant if aHowed in local ordineitce. <br /> Sewage tank(s)leak below their ❑Yes �No �Observed liquid level belaw operating depth <br /> designed operating depth. � Examined empty(pumped}tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑Probed outside tank(s)for'bladc soil' <br /> Any`�res"answer above indicates the ❑ Unable to verity(See CanmentsiF�cp►enstior,) <br /> system is failing t�n protect groundwater. ��'"�1Ods"°t�t`�d�se�co�e"rs�"�ra"�°"� <br /> Comments/Explanation: <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. MaiMenanoe hole aovers are damaged,cradced.uruecured,or appear b�be strix�uraNy unsound. ❑Yes' �No ❑Unkr►awn <br /> b. Olher issues(e�ecbir,al haze►ti�e�-)�o irtrned�atelY and aci�'erselY�P�P��heafth or safety. ❑Yes' �t�o �Urrcnown <br /> 'System is an imminer►t ttereet bn puWic healtl�and safety. <br /> Explain: <br /> c. S�rstem is non-probedive of ground wa6er for olt�aor�di�ia�s as deteRnined bY ir�spedor- ❑Yes' �No <br /> �ystem is fsiling t�protect groundwrat�er. <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TfY 651-282-5332 or 80a�657-3864 • Available in altemative formats <br /> . . . _.. ,,,,.. Page2of3 <br />