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. Property address: 4440 Bayside Road,Orono Inspedor initialsJDate: JS I 5/30/2017 <br /> (+nm/dd/YYYYI <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com Ilance criterla: Veriflcation msthod(s): <br /> System discharges sewage to the ❑Yes �No �Searched for surface outlst <br /> round surFaoe. �Searc�ed for seeping in yard/badcup in home <br /> System discharges sewage to drain ❑Yes � No ❑E�ccessive ponding in soil system/D-boxes <br /> tile or surface waters. <br /> ❑Homeov►mer testimony(See Comments/Explanation) <br /> System causes sewage backup into ❑Yes �No ❑"Bladc soil"above soil dispersal system <br /> dwelling or establishment. <br /> ❑System requires"emergency°pumping <br /> Any"yes"answer above Indlcates the ❑ Per�or,ned c�re tesc <br /> system is an lmminent threat to pubUc ❑ Unable to verify(See Comments/Explanatlon) <br /> health and safety. <br /> ❑Other methods not listed(See Comments/Explanstlon) <br /> Comme�rts/Explanallon: <br /> 2. T�tnk(ntegrity—Compliance 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 /> cesspool,dryvrell,or leaching pit. <br /> � Examined construction records <br /> SeepagAs pits meet/ng 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> com isnt if aHowed in loca/adinance. <br /> Sewage tank(s)leak below their ❑Yes � No ��bserved Bquid level below opereting 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 indfcafes the ❑ Unable to verify(See Comments/Ezplanationj <br /> system is failing to protect groundwater. ❑otner metnods not iis�ed�ses co►„menrs��anatron� <br /> Comments/Explanadon: <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be stnacturally unsound. ❑Yes* �No ❑unknown <br /> b. Other issues(eledmc�hazarcls,etc.)to imrnediately and adversely imped public heatth a'safety. ❑Yes" �No p UNcnowm <br /> "Sysiem!s an Imminent flrreat to puWlc health and safety. <br /> Explain: <br /> a System is r�on-protedive of ground water for other condipons as determined by inspector. p Yes• �No <br /> 'System is falHng to pr+�t�ctgrnundwat�er. <br /> Explain: <br /> www.pcastate.mn.us • 651-296-6300 • 800-657-3864 • TTY b51-282-5332 or�0-657-3864 • Available in altemative formats <br /> wq-wwlsts4-31 • 3/16/f2 PQge 2 of 3 <br />