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. Property address: 4440_Bayside Road,Orono Inspedor initiais/Date: JS � 5/30l2017 <br /> (mMddVyyyy) <br /> 1. Impact on Public Heatth—Compliance component#1 of 5 <br /> Com Ilance criteria: Veriflcation method(s): <br /> System discharges sewage to the ❑Yes �No �Searched for surFace ouHet <br /> round surfeoe. �Searched for seeping in yard/badcup in home <br /> System discharges sewage to drain ❑Yes � No ❑Faccessive ponding in sflil system/D-boxes <br /> tile or surface waters. <br /> ❑ Homeowner testimony(See Comrrrents/Explanation) <br /> System causes sewage badcup into ❑Yes � No ❑"Bladc soil"above soil dispersal system <br /> dwelling or establishment. <br /> ❑System requires"emergency"pumping <br /> Afly"yes"answer above indlcates the ❑ PerFormed dye test <br /> system is an Immfnent threat to pubUc ❑ Unabls to verify(See Comments/Fxp/anaHon) <br /> health and safety. ❑Other methods not listed(See Comments/Facplanation) <br /> Commerrts/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Com liancs criteria: VeM�ication method(s): <br /> System consists of a seepage pit, ❑Yes �No ❑ Probed tank(s)bottom <br /> cesspool,dryv+�ll,or leaching pit. <br /> � Examined construction records <br /> Seepage plts meeung 7oso.255o may be ❑ Examined Tank Integrity Form(Attach) <br /> com iant if aMowed!n loca!ordinance. <br /> Sewage tank(s)leak below their ❑Yes �No ��bserved liquid level below operating depth <br /> designed operating depth. � Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"bladc soil` <br /> Any "yes"answer above indfcat��s the ❑ Unable to verify(See Comments/Ex�anat�on) <br /> system is failing to protect groundwater. ❑Other methads not listed(See Comrrrents/Explenatlon) <br /> Comments/Explanatlon: <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. MaiMenance hole covers are damaged,cxacked,unsecured,or appear to be stnicturally unsound. ❑Y�* �No ❑Unknowm <br /> b. Other iasues(elecbiic�l hazerds,etc.)to immediately and adversely impad public heatth or safety. O Yes* �No ❑UNcnown <br /> "Syst�em!a an lmminent threat to puWlc health and safety. <br /> Explain: <br /> c. System is non-protedive of ground water for other oonditions as determined by inspedor. ❑Yes' �No <br /> *Syat�em fs fal!!ng io protectgroundwater. <br /> Exptain: <br /> www.pca.state.mn.us • 65t-296-6300 • 800-657-3864 • TTY 651-282-g332 or�0-657-3864 • Available in altemative formau <br /> wq-wwtsts4-31 • 3/16/f2 PQge 2 of 3 <br />