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Property address: _1250 Lyman Ave.,Orono�MN Inspector initials/Date: J.O.02/07/14 <br /> 1. Impact on Pubiic Health—Compliance component#1 of 5 <br /> Com Ilance criteria: Verificatfon method(s): <br /> 5ystem discharge sewage to the ❑Yes �No � Searched for surface outlet <br /> round surface. � Searched for seeping in yard/badcup in home <br /> System diacharge sewage to drain tile ❑Yes �No ❑ Excessive ponding in soil system/D-boxes <br /> or surtaoe waters. ❑ Homeownar testlmony(See CommenlsiExplanat�on) <br /> ❑ 'Black soll"above soil dispersal system <br /> System ceuse sewage backup into ❑Yes �No ❑ System requires"emergency°pumping <br /> dwelling or establishment. ❑ perFormed dye test <br /> Any"yes"answer above fnd/cates fhe sysfem Is ❑ Uneble to verify(See CommentsiE'xplanaUon) <br /> an Imm/nent Threat fo Pub/Ic Healfh and Safety, ❑ Other methods not listed(see commenta�xp�enetron) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Com ilance criterla: Veriflcation method(s): <br /> System consists of a seepage pit, ❑Yes �No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. ❑ Examined construction records • <br /> Seepage plts meeting 7080.2550 may be ❑ EXamfned Tenk Integriiy Folm(Attach) <br /> com !lant if allowed!n loca!ordinance. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes �No � E�mined empty(pumped)tanks(s) <br /> desi ned o eratin de th. <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soiP <br /> Any"yes"answer above indicates the ❑ Unable to verify(See Comments/Explanatlon) <br /> system is Fal!ing fa Profect Croundwater, �Other methods not listed(See Comments/ExplanaUon) <br /> Comments/Expla nation: <br /> E�mer J Peterson pumped the tanks on 2/07/14 <br /> 3. Other Comp(iance Condittons—Compliance component#3 of 5 � <br /> a. Maintenence hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes* �No p Unknown <br /> b. Other issues(elec�ical hazards,etc.)to immediately and adversely Impact public heakh or safety. ❑Yes* �No ❑Unknown <br /> `System!s an/mminent threat to publfc hea/th and safety <br /> Explain: <br /> c. System is non-protecHve of ground water for other condlaons as determined by inspector ❑Yes• �No <br /> *System is fal!!ng to protecf groundwater <br /> , Explain: <br /> www.pca.state.mn.us • 657-296•6300 • 800-657-3864 • TTY 651-262-5332 or 800-657-3864 • Availabte tn attemative formats <br /> wq•wwlsts4-31 • 1/24/12 Pwge 2 af 3 <br />