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Property address: 2690 Fox St Orono,MN Inspedor initialslDate:�,�I Iv"'ou�C� <br /> (i►►►►✓dd/YYYYI <br /> 1. Impact on Public Health—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/badcup in home <br /> System discharges sewage to drain ❑Yes �No ❑Excessive ponding in soil system/D-boxes <br /> tile or surface waters. ❑Homeowner testimony(See Comments/Explanation) <br /> System causes sewage backup into ❑Yes �No ❑`glack 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 imminerrt threat to public ❑Unable to verify(See Comments/Explanation) <br /> hea/th and safety. <br /> ❑Other methods not listed(See Comments/Explanation) <br /> Comments/ExplanaUon: <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. ❑Examined construction records <br /> Seepage pits mee6ng 7080.2550 may be ❑Examined Tank Integrity Form(Attach) <br /> com iant if allowed in loca!ordinance. <br /> ❑Observed liquid le�el 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 soil" <br /> Any"yes"answer above indicates the ❑ Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. ❑��r methods not listed(See Comments/Explanation) <br /> Com ments/Explanati on: <br /> 3 Other Compliance Conditions—comp�iance component#3 of s <br /> a. Maintenance ho�e covers are damaged,cracked,unsecured,or appear to be stn.icturalty unsound. ❑Yes" �No ❑Unknown <br /> b. Other issues(elechical heza�ds,et�.)to immediately and adversely impad public heatth or safety. ❑Yes* �No ❑UMcnown <br /> "Sysi�em is an imminent fhreat to pub►fc health and safety. <br /> Explain: <br /> a System is non-protedive of ground water for other conditions as detertnined by inspector. p Yes• �No <br /> *System is failing to protecf groundwat�er: <br /> Exptain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 65t-28Z-5332 or SW-65T-3864 • Availab[e in altemative famats <br /> wq-wwists4-31 • 3/16/11 Poge I of 3 <br />