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Sep 30 2016 06:06AM HP FaxRusty OLson 7634988290 page 3 <br />, ' <br /> Property eddress: 280 Hollander Road, Orono, MN tnspectar inilialslDate: J.O.9/02116 <br /> 1. ImpdCt on PubliC He8tth—Compliance component#1 of 5 <br /> Compliance criteria: Verification mathod�s): <br /> System discharge sewage to ihe , ❑Yes � No � �arched for surtace outlet <br /> ground surFace. � Searched for seepi ng in yard/badcup in home <br /> System discharge sewage to drain tile ' ❑Yes � No � ��ssive ponding in soil sys6ern/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See CommentsiExplenallon) <br /> System cause sewage backup into ; ❑Yes �No � "Black soil"above soil disparsal system <br /> dwelling or establishment. � ❑ System requires"emergenc�/'pumping <br /> ' ❑ Performed dye test <br /> Any"yes"answer above indicates the system!s ❑ Unable to verify(See CommentsiExplanahon) <br /> an Jmm/nent Threat to Publlc Healih and Safety. ❑ pther method5 not listed(See CommentslExplanation) <br /> Com ments/Expla nation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Com Ifance criteria: Verification method(s): <br /> System conslsts of a seepage pit, ❑Yes �No ❑ Probed tank(s)bottom <br /> cesspoal,drywell,or leaching pit. ; ❑ Examined construction records <br /> Seepege pits meeting 7080.2550 may be , ❑ Examined Tank lntegrity Form(AttachJ <br /> compliant if allowed in locel ondinsn�ce. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their , ❑Yes �No ❑ Examined empty(purnped)tanks(s) <br /> desi ned o ra6n de th, <br /> If yes,which sewage tank(s)leaks: j ❑ Probed outside tank(s)for"black soil" <br /> ❑ Undble to velify(Sse Commerrts/Explanatton) <br /> Any"yes"answer a6ove indicates the �pther methods not listed(See Comments�xp�anstion) <br /> system is Failing to Protect Groundwater. <br /> Commerrts/Explanation: <br /> Peterson Campany Pumped the tanks. <br /> 3. Other Cornpliance Conditions —Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked, unsecured,or appear to stn,duratly unsound, ❑Yes* �No ❑unknown <br /> b. other issues(eJectrica!hazerxis,etc.)to immediately and adversely impad public heallh or safety. ❑Yes" �No ❑Unknown <br /> "Syslem is an imminent ti►reat to pubJic health and safety <br /> Explain: <br /> c. System is non-protective of ground wat�rfor other conditions as detertniried by inspedor ❑Yes• �No <br /> *Systpm is lailing to prot�ect groundyvater <br /> Explain: <br /> www.pca.state.mn,us • 65f-296•6300 • 800-657-3864 • T7Y 651-282-5332 or 800�657•3864 • Available in altemative formats <br /> wq-wwists4-31 • 1124!!2 Page 2 of 3 <br />