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Property address: 4720 NORTH ARM DRIVE WEST,ORONO Inspector initials/Date:�� 10/15/2012 <br /> - — __ _-- - <br /> (mm/dd/yyyy) <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharges sewage to the ,� ❑Yes �No �Searched for surface outlet <br /> ground surface. _ �Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑Yes �No ❑Excessive ponding in soil system/D-boxes <br /> tile or surface waters. <br /> ------ - - --- - ❑ Homeowner testimony(See Comments/Explana6on) <br /> System causes sewage backup into ❑Yes � No ❑"Black soil"above soil dispersal system <br /> dwelling or establishment. <br /> ❑System requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminent threat to public ❑ Unable to verify(See Comments/Explanation) <br /> hea/th and safety. <br /> __ _ ❑ Other methods not listed(See Comments/Exp/anation) <br /> Com mentslExplanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, � ❑Yes � No � Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. � <br /> � Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank(ntegrity Fotm(AttachJ <br /> compliant if allowed in loca/ordinance. _ <br /> Sewage tank(s)leak below their I �Yes ❑ No �Observed liquid level below operating depth <br /> designed operating depth. ❑Examined empry(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: <br /> i �Probed outside tank(s)for`black soil° <br /> A»y "yes"allswel'abOVe iRdlCates the ❑ Unable to verify(See CommentsiEzplanation) <br /> system is failing to protect groundwater. ❑Other methods not listed(See Comments/Explanation) <br /> Comments/Expla nation: <br /> LIQUID LEVEL 1N FIRST TWO TANKS IS BELOW NORMA�LEVEL-TANKS LIKELY LEAKING <br /> 3. Oth2�C0111p1tatlCe COrldttlOnS—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes* �No ❑Unknown <br /> b. Other issues(e/ectrica/hazards,etc.)to immediately and adversefy impad public health or safety. ❑Yes' �No ❑Unknown <br /> *System is an imminent threat to public hea/th and safety. <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspedor. p Yes• �No <br /> *System is failing to protectgroundwater. <br /> Explain: <br /> www.pca_state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Availabte in altemative formats <br /> wo-wwtsts4•31 • 3/16/12 Poge Z of 3 <br />