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Jun 07 2016 07:47AM HP FaxRusty Olson 7634988290 page 3 <br /> Property address: 1260 French Creek Circie.,Orono, MN Inspector initialsJDate: J O. S116l16 <br /> 1. ImpdCt Or1 PubliC Hedlth—Cornpliance component#1 of 5 <br /> Compliance criteria:_ __ Verification method(s): <br /> System discharge se�rvage to the � ❑Yes � No � 5earched for surface outlet <br /> rg ound surface. ; � Searched for seeping in yardlbackup in home <br /> Sysiem discharge sewage to drain tile I ❑Yes � Nv � �xcessive ponding in soil systemlD-boxes <br /> or surtace waters. ' ❑ Homeowner testimony(See Commenfsl�xplanation) <br /> � ❑ "Black soil°above soil dispersal system <br /> System cause sewage backup into ❑Yes � No ❑ System requires"emergency°pumping <br /> dwelling or establishment. <br /> Any"yes"answer above indicates the sysfem is � Performed dye test <br /> an Imminent Threaf to Public Health and Safety. ❑ UnBble t0 vefify(5ee Comments/Explanation) <br /> �__ __ ___ ❑ Other methods not listed{See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tdl1k 111t2g1'lty—Compliance component#2 of 5 <br /> Com liance criteria: _ Veriflcation method(s): <br /> System consists of a seepage pit, j ❑Yes g No ❑ Probed tank(s)bottom <br /> cesspool, drywell,or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Exarnined Tank Integrity Form (A!tach) <br /> complrant if alJowed in loca!ordinance. <br /> ❑ �bserved liquid level below operating deplh <br /> Sewage tank(s)leak belaw their I ❑Yes � No ❑ Examined empty(pumped)tanks(s) <br /> designed operaling depth. <br /> If yes,which sewage tank(s)leaks� ❑ Probed outside tank{s)for"black soil" <br /> ❑ Unable io vefify(5ee Comments✓ExpJanation) <br /> Any "yes"answer above indicates the <br /> system is Failing to Profect Groundwater. �Olher methods not Eisted(See Comments/Explenation) <br /> Co mments/Explanatian: <br /> Peterson Company pumped the tanks. <br /> 3. Other ComplianCe Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked, unsec�red,or appear to strudurally unsound. ❑Yes' � No ❑ unknavn <br /> b. Other issues(electrical hazards,ecc.)to immedietely and adversely impact public health or safety. ❑Yes" � No O 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 co�ditions as determined by inspedor []ves^ � No <br /> 'System is failing to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651-296•6300 • 800-657-3864 • TTY 651-282-5332 or 800-657•3864 . Available in atterna[ive tormats <br /> wq-wwistsl-31 . 1/24!12 PQge 2 of 3 <br />