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� Property address: 575 Kokesk Farm Rt>ad Orono MN inspector initials/Date: J.0.5/04/17 <br /> 1. Impact on Pubti� Health—Compiiance component#� of 5 <br /> Gom�liance criteri�: Ver�cation meth�l(a): <br /> System discharge sewage to the ! ❑Yes � No � Searched for surfacs outiet <br /> ground surFace. � Searc�ed for seeping in yard/backup in home <br /> System discharge sewage to drain tile ' ❑Yes � No a �0��e ponding in soil systerrW-boxes <br /> or surface weters. ❑ Homeowner testimony(see Ca,►ments/Explanation) <br /> _ ..._.._....... <br /> System cause sewage badcup into ; ❑Yes � Na ❑ �s�adc soil"above soil dispersal system <br /> dweiling or estabiishment. ❑ System requi�es"emergency"pumping <br /> ❑ Perfortned dye t�st <br /> A»y"yes"answ+er abave indicates the sys#em Is ❑ Unable to verify(Sse Comments/Facp►onation) <br /> an/mminent Threat to Publfc Health and Ssfeiy. � pt►ter rnethods not listed(S�Comments/Explanation) <br /> Commen4s/E�cplanation: <br /> 2. Tank Integrity—Compiiancs comRonent#2 of 5 <br /> Compiiance criteria: Vs�cation method(s): <br /> System consists of a seepage pit, '; ❑Yes � No � Probed tank(s)bottom <br /> cesspooi,dryweli,or leaching pit. � Examined construc�ion rec�rds <br /> Seepagre pits meetir�7080.2550 mey be ❑ Examined Tank(ntegrity Form(Attach) <br /> com�ieni ii auawed i»locel or�fnance. ` <br /> Sewage tank(s)teak betqw their 7 ❑Yes � No � Observed liquid levei below operating depth <br /> designed operating depth. ❑ Examined empry(pumped)tanks(s) <br /> If yes,v�ich sewage tank(s)leaks: ❑ Probed outside tank(s)for"bladc soil" <br /> ❑ Unab�to verify(See CommentslExptanation) <br /> ar,y "yes"answer above indicatss the [�pther methods not listed(See Comrnants/Exptanation) <br /> system is Failing fo Protect Gr+oundwater. <br /> Comme��lanation: <br /> The tanks were pumped on 11/16/15. I opened the the tanks and the liquid level was at the operating level and the baffels <br /> were in place. <br /> 3. Other Comptiance Conditions—Compliance compcment#3 of 5 <br /> a. Maintenance ho�c�vers ar�damaged,cx�dced,unsecured,or appear to strudurally ur�sound. ❑Y�" �No ❑Unknown <br /> b. Othe�issues(e/ec�ric�deza,rts a�.)fio immediately and adversely ir»pad pubi�heal�o�safety. O Yes" �No ❑Unknown <br /> �ystem!s an immin�►t threat in pubric heat�h and�+ <br /> Exptain: <br /> c. System is non-protective of ground wa�r fa�t�r cbnditi�s�c�tertnined by inspedor 0 Yes• �No <br /> "Systern►s failinQ to pro�sct grouRah�ler <br /> Explain: <br /> www.pca.state.mn.us • 651•29b-6300 • 800-657-3864 • T7Y 651-282•5332 or 800-657-3864 • Availabie i�aEternative formats <br /> wa-wwists4-3f . 1/24/1� _ _ __ <br />