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� Property address: 2555 Fox Street, Orono, MN 55391 Inspector initials/Date:``��_ Z=� r�'L <br /> 1. Impact on PubliC Health —Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes � No ❑ Searched for surface outlet <br /> round surface. ❑ Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile ❑Yes � No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into ❑Yes � No � �Black soil"above soil dispersal system <br /> dwelling or establishment. ❑ System requires"emergency'pumping <br /> — -- ❑ Performed dye test <br /> Any"yes"answer above indicates the system is <br /> ❑ Unable to verify(See Comments/Explanation) <br /> an lmminent Threat to Public Health and Safety. <br /> _ ___ __ ___ ❑ Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tdnk Integrity—Compliance component#2 of 5 <br /> Compliance criteria_ _ Verification method(s): <br /> System consists of a seepage pit, I ❑Yes � No � Probed tank(s)bottom <br /> cesspool, drywell, or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form (Attach) <br /> compliant if allowed in local ordinance. <br /> � Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes � No � Examined empty(pumped)tanks(s) <br /> designed operating depth. <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> — ❑ Unable to verify(See Comments/Explanation) <br /> Any "yes"answer above indicates the <br /> system is Failing to Protect Groundwater. ❑ Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> Tanks passed inspection. Recommend to have tanks pumped every 2 years. <br /> 3. Other ConlplldnCe COndltiOnS—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes* � No p Unknown <br /> b. Other issues(elect�ical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* �No ❑ Unknown <br /> *System is an imminent threat to public hea/th 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 /> ------- _--- ---------------— ------------ <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 Page 2 of 4 <br />