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Property address: 560 Kokesh Fartn Road Orono MN inspector initis�IDate: J.0.6�2/17 <br /> 1. Impact on Public Health—Compiiance component�t1 of 5 <br /> Compllence criteM�: VeriNcaticn method(s): <br /> System discharge sewage to the � ❑Yes �No � ����$urFace outlet <br /> ground surfaoe. � Searchad for seeping in yard/badcup in home <br /> System disd�arge sewage to drain tile ❑Yes �No � ���rye ponding in soil system/D-box� <br /> or surfat�e waters. ❑ Homeowner teatimony(See CommentadExpanatiart) <br /> System cause sewage backup into ❑Yes �No � °Bladc soil"above soii dispersal sysfiem <br /> c!v►relling or establishment � ❑ System requires'emergency"pumping <br /> ❑ PerFormed dye test <br /> Any"yes"anawer abave Ind/cat�as the system/a ❑ Unabie to veriry(see cann�renrs�caenaann) <br /> an Imm/nent Threat to Public Haal�r snd Salet�r. ❑ pthe�m�ods not listed(Sse Cornme�ta�F rpranatron) <br /> CommentslExplanatiorr <br /> 2. Tank Integrlty—Compliance cbmponent#2 of 5 <br /> Complianc�criteria: Veri�catian method(sj: <br /> System�r�isis of a seepage pit, � ❑Yes �No � Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit• � Exsmined construdi�records <br /> SeepeQe plts+�eHrtg 7o8o•2s50 may be ❑ Examined Tank Integrity Form(Attedr) <br /> oomdlant if aAlow�d in bcN o►dine�. <br /> ❑ Obsenred liquid level below operating depth <br /> Sewago tank(s}leak below their ❑Ycs �No <br /> designed oPeretin9 dePth. ❑ Examined emPtY(Pumped)tanks(s) <br /> If yes,which sewage tank{s)leaka: � ❑ Probed outside tank(s)for"black soil" <br /> Any`yres"a�swer above ina�cates the ❑ Unabie ta verify(See Ca»ments/�xplanation) <br /> system is Failfn�to Protect Groe�ndwater; ���'°ds not iiatea�see comme�r�p+s,�►/ <br /> Comments/Explanation: <br /> Peterson Company pumped the tanks. <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. MaiMeneu�oe t�ale covets are tl�amaged,cxac�c�,unsecured,or appear to stttx:turaity unsau�d. �Y�' �No ❑Unkno�nm <br /> b. Othef isa�(elecxrtca►hssmds,e�.)to imrrrediatey and adve�y impad public heaith or safety. O Y�* �I�b p U�cnam <br /> "�ys�rn is an�nmlm�►►t threat to pubiic/w�itl►and sahty <br /> F�cplain: <br /> c. System is r�-protedive of g�rxt wafier for�conditions as dedertniried by inapecdor ❑Yas• �No <br /> '�yst�rn is faiNn��o p�t,�ur►ahv�r <br /> Explain: <br /> www.pca.stats.mn.us • 65�-296-6300 • 800-657-3864 • TTY 651-2$2�5332 or 800-657-38ba • Available in attemative formats <br /> wq-wwists�-31 • 1124/t2 Poge 2 of 3 <br />