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i <br /> i <br /> � <br /> , Property address: 29(3 Hotlanderl Road Orona,MN Inspector initials/Date: 61'"��� <br /> , (n►mldd�l'YYY) <br /> 1. Impact on Public He;alth—Compliance component#1 of 5 <br /> Cbrtt liance criteria: I VerificatIon method(s): <br /> System discharges sewage;to the ❑Yes � No �Searched for surface outlet <br /> round surface. �Searched for seeping in yard/backup-in'home <br /> System discharges sewage;to drain ❑Yes �No ❑;Excessive pondirig in soil system/D-boxes <br /> tife or surface waters. � ❑Homeowner testimony(See Comments/ExptanaGon) <br /> System causes sewage backup into ❑Yes �No ❑"Bladc soil"above soil dispersai system <br /> dwelling or establishment. ; ' <br /> ❑System requires�emergency'pumping <br /> Any"yes"answer above indicates the ❑performed dye test <br /> SySfe/Xf%S aR%1l1R3%R@I'�t�'hf�f I'O pUbl%C ❑Unable to verifjr(See Comments/�icplanafion) <br /> health and safety: ❑other methods not listed(see Commenrs/Exp►anarion) ' <br /> Comments/Explanation: i <br /> 2. 'Tank lntegrity—Com�liance componeni#2 of 5 <br /> Com liance criteria: - ` Ver�cation method(s):, <br /> ; <br /> System cansis#s of a seepage pit, ❑Yes �No ❑Probed tank(s)boitom <br /> cesspool,drywelt,or leachinq pit. �Examined construction records <br /> Seepage pits meeting 7080.255p may be ❑�mined Tank Integrity Form:(Attach) <br /> com liant if aUowed in local ordihance. <br /> Sewage#ank(s)leak below t�eir ❑Yes �No ��bserved iiquid levef below operating depth <br /> designed operating depth. ; ❑�amined empty(pumped)tanks(s) <br /> ff yes,which sewage#an[c(s);leaks: ❑Probed outside tank(s}for"black soil" <br /> Any"yes"answer abqve indicates the O��bie to veriry'�see eomments�pr8na�on� <br /> system is failing to pr'ptect groundwater. �other metnods not��sted�see comme►�rs�Pra►,anon� <br /> CommentslExplanation: ; <br /> used camera to view upper tank and baffle conditions <br /> , <br /> 3. Other Compliance,Cqnditions—comp�iance component#3 ot s ` <br /> a. hAaintenance hole oovers are damaged,craeked,unsecured;or appear to be strudurally unsound. p Yes* �No ❑Unknown <br /> � <br /> b. Other issues(electrical ha�arcls,et�.)to immediate{y and adversely irnpact pubGc heatth or safety. p Yes* �No ❑Unknown <br /> *Systiem is an imminen�threat to public healfh and safety. <br /> Exptain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector. p Yes* �'No <br /> *System is fallfng bo prr�Uecf gr+�trnahv�eter. <br /> ; <br /> Exptaln: <br /> ; <br /> www.pca.state,mn.us � b51 296-¢300 • SDO-657-3864 • TFY 65f-282-5332or 800-657-3864 • Avaflabie in altemative formats <br /> kvq-wwists4-31b • 6/4/14 Page 2 of 3 <br />