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Mar 17 2017 09:55AM HP FaxRusty Olson 7634988290 page 3 <br /> Property addres5: 1003 Cox Farm Road,Orono MN Inspec�or inEtials/Date� J. �.3l10/17 <br /> 1. lmpact on PubliC Heaith—Cornpliance component#1 of 5 <br /> Compliance crlteria: VerEficatlon methad(s): <br /> System discharge sewage to the � ❑Yes �No � Searched for surfaoe ouflet <br /> ground surface. � Searched for seeping in yardlbackup in home <br /> System discharge sevrage to drain tile i ❑Yes � No ❑ �cessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See CommentsiExplanation) <br /> System cause sewage backup into � ❑Yes �No � 9g�adc soil'a6ove soil dispersal system <br /> I ❑ System requires"emergency'pumping <br /> dwelling or establishment. ; <br /> An " s"answer above indicates the s stem is � Qerformed dye test <br /> Y Ye Y ❑ Unable io verify(See Comments/ExF.vanation) <br /> an lmminent Thrieat to Pub!!c Health and Safety. ❑ Other methods not listed(see comments�Ex�fenatlon) <br /> CammerrtslExplanaaon: <br /> 2. Tank Integrity—Comptiance component#2 of 5 <br /> Com iiance criteria: Verif�catlon method(s): <br /> System cc�nsists of a seepage pit, , ❑Yes �No ❑ Probed lank(s)bottom <br /> cesspool,drywell,or I�ching pit. j ❑ Examined constn�ction records <br /> � <br /> Seepage pits meet;ng 7080.255o mey be � ❑ Examined Tank Ir�tegrity Form(Aaach) <br /> com iant if aNawed!n focaf orrlinanee. <br /> Sewage tank(s)ieak below their ❑Yes � Na � Observecl liquid level below operating depth <br /> designed operating depth. ❑ Examined empiy(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: i ❑ Probed outside tank{s}for"bladc sail" <br /> ❑ Unable to vetify(See Commer►ts/Explanatlon) <br /> Any"yes"answer above indlcate�s the �Other methods not lisbed(See Comnrents/Expianation) <br /> system is Farling to Protect G�oundwater. <br /> Co mments/Explanation: <br /> Peterson Company pumped the tanks. <br /> 3. Other Complidnce Conditions—Campliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecx�red,or appearto sGvdurally unsound. ❑Yea" �No p Unknawn <br /> b. Ottter issues(elecbical harards,etc.)to immediately and adversely impad public healfh or safety. ❑Yes' �No � Unknawn <br /> "Systam!s an la►minent threat to publlc heafd�and safety <br /> Explain: <br /> c. System is non-protedive of ground water ior other oonditions as determined by inspector O Yes` �No <br /> •SysDem is fai!!ng tn protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651•296-6300 • 800-65T-3664 . TTY 651-282-5332 or 806-657-3864 • Avaitable in altemative formats <br /> wq-wwists4-3i . 1l241!2 Poge 2 of 3 <br />