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04/22/2016 11 :48AM FAX 9528733112 f�0002/0004 <br /> . � <br /> Property address- 1820 Fox Street Orano,Mn 55391 Inspeotor initials/Date: JS � 4/21/2016 <br /> (mm/dd/yyyy) <br /> 1. Impact on Public Nealth—Compliance compone�t#'! of 5 <br /> Compfiance criteria: _ Verifi�atlon methad(s): <br /> System discharges sewage to the ❑Yes � No �Searched for surtace outlet <br /> c.�round surtace. ❑Searched for seeping in yard/backup in home <br /> System discharges sewage ta draln �Yes � No ❑ Excessive ponding in soll system/D-boxes <br /> tile or surhace waters. <br /> 0 Homeownef testlrttony(See Commenfs/ExplanaHen) <br /> System causes sewage backup into ❑Yes �No ❑°Black sofl"abovQ soil dlspersal system <br /> dweliing or establishment. � <br /> []System requlres"emergency"pumping <br /> Any"yes"answer above indlcates the 0 Perform�d dye test <br /> system is an Imminent fhreat to publ;c <br /> health and safefy. ❑ Unabte to veriTy(seB commenrs�Explanation) <br /> _ ❑Othef ine[hods not listed(Sae Comments/ExplanationJ <br /> Commentsl�xpianation: <br /> 2. Tank inte rity—CQm liance component#2 of 5 <br /> Gompllance criterla: Verlflcation method(s): <br /> System conslsts of a seepage pit, ❑Yes �No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. (� Examined construction recards <br /> Seapage pits meeting�o8p.2550 may be <br /> com l;ant if aUowcd in loca!ordlnance_ ❑ Examined Tank Integflty FOrrn(AtfAch) <br /> Sewage tank(s)leak balow their �y� ❑�bserved liquid level below operating depfh <br /> designed operating depth. �N� pty(pumped)tanks(s) <br /> �]C Examined em <br /> If yes,which sewaga tank(s)leaks� ' ❑ Probed autside tenk(s)fqr"black soil" <br /> 1411J/ `�)/eS"answer above indiCates the ❑ Unablg to Verify(Sae Comm@nts/Explanatron) <br /> sysf�m is failing fo prot�ect groundwa#er. ❑ ather methods noi Iisted(3ee Commenra/�xpJanatlon) <br /> Camments/ExpEanatlon: <br /> 3. Othef C0111plianGe Conditi0115—Compliance component#3 of 5 <br /> a. Mainfenance hole wvers are damaged,cr�eked,unSeCllred,or appear to be structurally unspund. O Yes" �No p Unknown <br /> b. Other issues(elac�e�hazards,er�.)to Immediatefy and adversely Impact public health or safety, p ve9* 1�No ❑unknown <br /> *S�rstem/s an imminenf th�at to public health and safety. <br /> Explain: <br /> c. System is non-proteCtive of ground water for other Conditions as determined by inspecfpr, p Yes^ �No <br /> *System is faAfng to proteCt groundwater. <br /> Explain: <br /> www.pcastate.mn.us • 651-z9b-6300 • 800•657-3864 . TTY 651•282-5332 or 9Do-657-3864 • Available In alternative formais <br /> wq-wwists4-31 . 3/16/12 <br /> Pnge2of3 <br />