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Property address: 525 Femdale Road N,Orono Inspector iniaals/Date: JS I 5/10/2017 <br /> (rr►m/dt!lYYYYJ <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com liance cHteria: Verification method�s): <br /> System discharges sewage to the ❑Yes �No ���ed for surFace ouUet <br /> round surface. �Searched for seeping in yard/badcup in home <br /> System discharges sewage to drain ❑Yes �No ❑ Excessive ponding in soil system/D-boxes <br /> �le or surfaae weters. <br /> ❑ HomeoHmer testimony(See Comments/Exp/anatl�on) <br /> System causes sewage badcup iMo ❑Yes �No ❑"Bladc soil"above soil dispersal system <br /> dweiling or establishment. <br /> ❑System requires°emergency"pumping <br /> Any"yes"answer above indfcates the ❑ Performed dye test <br /> system is an imminer�t threat to public ❑Unable to verify(See Comments/Explanation) <br /> hea/th and safety. ❑Other me�ods not listed(See CommantsiF�cplanat/on) <br /> Comments/Explanatlon: <br /> 2. Tank Integrity—Gompliance component#2 of 5 <br /> Com Ilance crlteMa: Verification method(s): <br /> System oonsists of a seepage pit, �Yes ❑ No �Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> ❑ Examined constnaction recorcls <br /> Seepage pits meedng 7080.2550 may be ❑ Examined Tank Integrity Form(Att�h) <br /> com !ar►t if aJbwed in loca/wdlnance. <br /> Sewage tank(s)leak below their �Yes ❑ No �Observed liquid level below operating depth <br /> designed operating depth. ��mined empry(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"bl�ck soil" <br /> Any"yes"answer above indicates the ❑ Unable to verify(See Comments/Explanadon) <br /> system is falNng to protect 8roundwate►: �a�r methods not listed(See Comme►tts/Explanetion) <br /> Commerhs/Explanation: <br /> Labeled as concrete block tanks on aty inventory record <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Mafr�tenance hole covers are damaged,cracked,unsecured,or appear to be stn�rally unsound. ❑Yes" �No ❑Unkrawn <br /> b. Otl�issues(e/echlcal hazaRfs,etc.)to immediately and adversely impact public health or safety. ❑Yes" �No p Unknown <br /> '�ystem!s an lmmir�ent threat to public hea/th end saf�ety. <br /> Explain: <br /> c. System is norrprotedive of ground water irn other conditions as determined by insp�tor. ❑Yes• �No <br /> '�ystem!s falNng ta prot�ect groundwat�er. <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 8�-657-3864 • TTY 651•282-5332 or 800-657-3864 • Available in altemative farmats <br /> wq-wwists4-31 • 3/!6/12 Poge 2 of 3 <br />