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L <br /> Property address: 1270 French Creek Dnve.,Orono, MN ______ Inspector initials/Date: J.O.01/09h4 <br /> 1, tmpaCt On PubliC Health—Compliance companent#1 of 5 <br /> Compliance criteria: ----- --- Verif'�cation method(sy: <br /> System discharge sewage to the ❑Yes �No � ����for surface outlet <br /> _ round surtace. _____ _ � Searched fw 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. _ I ❑ Homeowner testittlony(See Comments/Exptanafion) <br /> S stem cause sewa e backu mto � �g�����abave soit dispersa!system <br /> Y 9 P� ❑Yes �No � System requires"emergency"pumping <br /> dwelling or estabtishmerrt. <br /> ❑ Pertormed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to veriry�see comments�icp�anar�on) <br /> an tmminent Threat to Publfc Hea/th and Safety. ❑ Other methods not listed(See CommentsiEarplanation) <br /> Comments/Expfanation: <br /> 2. Tdt7k (Rt2g�lty—Compliance component#2 of 5 <br /> Com�liance 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 /> I ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be + ❑ Examined Tank Integrity Form(Attach) <br /> Complranf if el/owed in loca!ordinanc�. � <br /> � ❑ Observed liquid leve!below operating depth <br /> Sewage tank(s)leak below their ; ❑Yes � No <br /> designed operatin9 dePth__ �_ � Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: i ❑ Probed outside tank{s)for"black soil" <br /> -- ❑ Unable to veI'ify(See Comments/Explanation) <br /> Any "yes"answer above lndicates the �pther methods not listed(See Comments/6cplanation) <br /> system Is Failing to Protect Groundwater. <br /> Comments/Explanation: <br /> Elmer J Peterson pumped the tanks on 12/27/13 <br /> 3. Other Compliante Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to struduraHy unsound. ❑Yes* �No O Unknown <br /> b. Other issues(s�ecfica�hazards,etc.)to immediately and adversely impad public health or safety. ❑Yes' �No p Unknawn <br /> "System is an imminent thr+aat to pubfic health and safety <br /> Explain: <br /> c. System is non-protective of g�nd water for other conditions as determined by inspector ❑Yes` �No <br /> *Syst�em is failing M protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651-296-63� • 800-657-3864 • TTY 651-282-5332 or 800-657•3864 • Avaitable in alternative formau <br /> wq-wwists4-3i • 1/24/12 Fage 2 of 3 <br />