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Aug 28 2015 09:18AM HP FaxRusty Olson 7634988290 page 3 <br /> Property address� 795 Ferndale Road N,Orono,MN Inspector initialslDate: J.O.8l25115 <br /> 1. ImpBct on Public He�lth—Compliance component#1 of 5 <br /> Comptiance criteria: Verification method(s�: <br /> System discharge sewage to the I ❑Yes �No � Searched for surface outlet <br /> ground surface. � Searched for seeping in yard/backup in home <br /> —+----- � ❑ Excessive ponding in soil systemlD-boxes <br /> System discharge sewage to drain tile , ❑Yes �No <br /> cr surface water5. ❑ Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup inio � ❑Yes �No � "Black soil" above soil dispersal systern <br /> dwell�ng or establishment. ❑ System requires"emergency'pumping <br /> — ❑ Periormed dye test <br /> Any"yes"answer above indicates the sysfem is ❑ Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Pu6lic Health and Safety. ❑ Other methods not listed rsee comme�r�Xprar,at�o�1 <br /> Co m mentslExpl a nation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: ____` Verification method{s): <br /> System consists of a seepage pit, ; ❑Yes �No ❑ Probed tank(s) bottom <br /> cesspool,drywell, or leaching pit. j <br /> ❑ Examined construction records <br /> SeepAge pits meeting 7080.2550 may be ❑ Examined Tank Integrity�orm (Allach) <br /> compliant if aUowed m local ordinance. I <br /> - - - — ❑ Observed liquid level below operating depth <br /> 5ewage tank(s)leak below their I ❑Yes �No <br /> designed o�erating depth. �� ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s) leaks: ❑ Probed outside tank(s)for°black soil" <br /> Any "yeS"answer a6ove indicates the ❑ Unable to verify(See Comments/Fxplanatron) <br /> system !s Faifing fo Protect Groundwater. � Other methods not listed(See Comments/Explanation) <br /> CommentslExplanation: <br /> Peterson company pumped the tanks <br /> 3. Other COmpliaRCe COrldit10t1S—Compliance component#3 of 5 <br /> a. Maintenance hole co�ers ane damaged,cracked, unsecured,or appear to structurally unsound. ❑Yes* �nlo ❑ Unknown <br /> b. Other issues(electrical hazarcis,etc.)to immediately and adversely impact 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 waier for other conditions as determineo by inspecior ❑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 800-657-3864 . Available in alternative formats <br /> wq•wwists4•31 • 1/24/12 Page2of3 <br />