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Pro�rty address: 103 Manar Cirde Orono,MM _ Inspedor initials/Date: J. O.5/02/1�' � <br /> 1, Impact on Public Health–Compiiancs component#1 of 5 <br /> Complis�ncs criteria: Verification method(s): <br /> -�---- — <br /> System discharge sewage to the ; ❑Yes �No � ���'�d for surtac�outiet <br /> ground surface. ; � Sea�ched for seeping in yard/badcup in home <br /> System discharge sewage to drain tile : ❑Yes �No � ��sive ponding in soil system/DWboxes <br /> or surface waters. ___ � ❑ Homeormer testimony(58e CanmentsiExQlanetla►) <br /> System cause sewage badcup into ; ❑Yes �No � B�s°i��above soil dispe�sal system <br /> dwelling ar establishment. � ❑ System requires"emergency"pumping <br /> ` ❑ PelfOmt@d dye teSt <br /> Any"yes"answer abave 3ndfcatas the system is ❑ Unable to vetify(See Comrrwents/Explsnetron) <br /> an tmmine»t Thr�at to Public keaith end Safety. � pt����$not listed(See Comrr�nts/Exp/anation) <br /> Comments/Explanatian: <br /> 2. Ta11k Integt'ity–Compliance component#2 of 5 <br /> Compliance criteria: � Verificatian method(s): <br /> System consists of a seepage pit, � ❑Yes �No � Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. � <br /> , � Examined construdion records <br /> Seepege p�ts msetir�7080.2550 msy be I ❑ E�mined Tank Infegrity Form(Atted,) <br /> cor»pliant if altowed!n bca!ort�"irta�. � <br /> Sewage tank(s)leak below their � ; ❑Yes �No � Observed liquid level below operating depth <br /> designed operating dePth. ' ❑ Examined empty{pumped)tar�k$(s) <br /> � � ❑ Probed outside tank(s)for"black soil" <br /> If yes,which sewage tank(s}baks: � <br /> D Unable to verify(ses comments/Fxptenation) <br /> Any"ye.s"answer above lndicates the ❑p�er methods not tisted(See Camments/Explanation) <br /> system is Fa1/!ng to Protect Groundwater. <br /> Comments/E�lanation: <br /> 3. Other Compliance Conditions—Comp�iance component#3 of 5 <br /> a. Mairrtenanoe hole oovers are dama�d.craciced,unsecured.cK appear to strtxturally unsound. p Yes* �No ❑Unknav�m <br /> b. Other issues(etecxrkaJ haze►ds.ehc.}to immediateiy and adversely impad pu�ic healtl�o�safety. Q Yes" �Na ❑un�cna�un <br /> *Sys�em is an lmminent�rnat in pu�Jfc h�al�h and�a/ety <br /> Explain: <br /> c. System is non-pro�ecxive of grour�d water for att�er cor�iti�s as determined by inspec;tor p Yes" �No <br /> "'Sysiwt►fs falH�tg t+o prptect qnpundwaby <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 80Q-657-3864 • TTY 651-2$2-533?or 800-657-3864 • Avaitabte in attemative formats <br /> wq-wwfsts4•31 • i/24/12 � ^-- ^ -- <br />