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Property address: 2555 Fox Strset,Orono Inspector initials/Date: JS I �2J2017 <br /> (mMdd/yyyy) <br /> 1. lmpact on Public Health—;Compiiance component#1 of 5 <br /> Com Ilance ariteria: Verification method(s): <br /> System discharges sewage to the ' ❑Yes �No �Seardied for surface outlet <br /> round surface. �Searched for seeping in yard/backup in home <br /> System di;,charges sewage to drain ❑Yes �No ❑Excessive ponding in soil system/D-boxes <br /> tile or surface waters. ❑Homeowner testimony(See Canments/Expfanador►) <br /> System causes sewage backup into ❑Yes �No ❑"Black soil"above soil dispersal system <br /> dwelling or establishment. <br /> ❑System requires"emergency°pumping <br /> Any"yes"answer above inqlicates the ❑PerFormed dye test <br /> system is an imminent thre�t to publ/c ❑Unabie to verify(See CommentsiExplsnatfon) <br /> health and safety. ❑ptt1e��,�s not iisted�see�menr�xpre,►at�on� <br /> Comments/Explanatlon: <br /> 2. Tank Integrity—Complianc� component#2 of 5 <br /> Com liance criteria: VeMfication method(s): <br /> System consists of a seepage pit, ❑Yes �No �Probed tank(s)bottom <br /> cesspoof,drywell,or leaching pit. ' �Examined construction records <br /> Seepage pits mseting 7080.2550 may be i ❑Examined Tank Integr(ty Form(At�ch) <br /> c�m lfant if allowed fn local o►clinertce. ' <br /> Sewage tank(s)leak below their ❑Yes �No ❑Observed liquid level below operating depth <br /> designed operating depth. ❑E�camined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)Isaks: ❑Probed outside tank(s}for"black soil" <br /> Any"yes"answer above indlcates the O Unable to verify(see Commenrs�xp�anatton) <br /> systoem fs fal/►ng to protect groundwater. ❑�er methods t�t listed(See CommentslExplenation) <br /> Comments/Explanatlon: <br /> 3. Other Comptiance Condltions—compiiance component#3 of 5 <br /> a. Maintenar�ce hole covers are damaged,cxacked,unsea�red,w appear to be structurally unsound. ❑Yes* �No ❑Urdcnown <br /> b. Other issues(elec�rica/hazerds,ei�.}to immedia#ely and adversely impad publ�health o�safety. ❑Yes* �Na p Unknown <br /> "`System is an imminerrt�reat dp public heafdr and saiety. <br /> Explaln: <br /> c. System is non-protedive of graand water for other ounditiais as determined by inspeaor. ❑Yes• �No <br /> �System fa fallfng to proUecf groyndwal�er. <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-2$2-5332 or 800-657-3864 • Available in aitemative formats <br /> wq-wwlsts4-31 • 3/16112 PQge 2 of 3 <br />