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May 05 2015 03:14PM HP FaxRusty Olson 7634988290 page 3 <br /> 'roperty address: 3420 High Lane,Orono,MN _ Inspector initialslDate: J. 0. 5l05/15 <br /> 9. IfTt�dCt 011 PUbIiC Hedlth —Compfiance camponent#1 of 5 <br /> Compliance crite�ia: T Verification method(s): <br /> System discharge sewage to the ' ❑Yes � No � Searched for surface outlet <br /> �round surface. i � Searched for seeping in yard/backup in home <br /> ❑ Excessive ponding in soil systemlD-boxes <br /> System discharge sewage to drain tile I ] Yes � Na <br /> Of SUrtaCe waters. � ❑ Homeowner testimony(See CommentslExplanation) <br /> -- - ❑ "Black soiP'above soil dispersal system <br /> System cause sewage backup into ❑Yes � No <br /> dwelling or establishment. ❑ System requires"emergency"pumping <br /> ---- ---- ❑ Performed dye test <br /> Any"yes"answer above i»dicates the sysfem is ❑ Unable to verify(See Commenis/Ekplanation) <br /> an/mminent Threat to Public Health and Safety. ❑ Other methoos not liste[f(See Comments/Explanah'on) <br /> Comments/Explanation: <br /> 2, Tank Integrity—Compliance component#2 of 5 <br /> Compllance crlterla:_ 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 meeting 7G80.2550 may be i ❑ Examined Tank Integrity Form (Attach) <br /> complianf if allowed in local ordinance. I <br /> — ❑ Observed liquid level below operating deptn <br /> Sewage tank(s)leak below their � ❑ Yes � No <br /> designed operating depih. ❑ Examined empty(pumped)tBnkS(s) <br /> If yes, which sewage tank(s) leaks � ❑ Proned outs�de tank(s)for"black soil" <br /> ❑ Unable to verify(See Comments/Explanation) <br /> Any "yPS"answer abave indicates the ❑ pther methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <br /> Co m m ents/Expla nation: <br /> Peterson Company pumped the tanks <br /> 3. Oth@Y COmplidnCe COnditi0115—Compliance component#3 of 5 <br /> a. Maintenance hole covers are darnaged,cracked, unsecured,or appear to strudurally unsound. ❑Yes* �1 No ❑Unknown <br /> b. Other issues(electricalhazards,etc.)to immediately and adversely impact public health or safety. 0 Yes" �fVo ❑Unknown <br /> '`System is an imminent threat to public health and safety <br /> Explain: <br /> a System is non-protective of ground water forother conditiors as deterrnined by inspector �Yes' �No <br /> •System is failing to protectgraundwater <br /> Explain: <br /> www.pca.s[ate.mn.us • 551-296-6300 • 800-657-3864 . TTY 651-Z8Z•5332 or 800-657•3864 � Available in alternative formats <br /> wq-wwis[s4-3f • 1l24/11 Po,ge 2 of 3 <br />