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• <br /> Property address. 2120 Carriage Lane Orono Inspector initials/Date: JS 111/2/2017 <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 0 Yes ® No ® Searched for surface outlet <br /> _ground surface. <br /> ® Searched for seeping in yard/backup in home <br /> System discharges sewage to drain 0 Yes ® No 0 Excessive ponding in soil system/D-boxes <br /> tile or surface waters. <br /> 0 Homeowner testimony (See Comments/Explanation) <br /> System causes sewage backup into ❑ Yes ® No 0 "Black soil"above soil dispersal s stem <br /> dwelling or establishment. P Y <br /> ❑ System requires"emergency" pumping <br /> Any"yes"answer above indicates the 0 Performed dye test <br /> system is an imminent threat to public <br /> health and safety. 0 Unable to verify(See Comments/Explanation) <br /> 0 Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity— Compliance component#2 of 5 <br /> Compliance criteria: <br /> Verification method(s): <br /> System consists of a seepage pit, 0 Yes ® No ® Probed tank(s)bottom <br /> cesspool, drywell, or leaching pit. <br /> ® Examined construction records <br /> Seepage pits meeting 7080.2550 may be <br /> compliant if allowed in local ordinance. ❑ Examined Tank Integrity Form(Attach) <br /> Sewage tank(s)leak below their 0 Yes ® No ❑ Observed liquid level below operating depth <br /> designed operating depth. ® Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> 0 <br /> Any "yes"answer above indicates the Unable to verify(See Comments/Explanation) <br /> 0Other methods not listed (See Comments/Explanation) <br /> system is falling to protect groundwater. <br /> Comments/Explanation: <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. 0 Yes* ®No 0 Unknown <br /> b. Other issues(electrical hazards.etc.)to immediately and adversely impact public health or safety. 0 Yes* ®No p Unknown <br /> *System is an imminent threat to public health and safety. <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector. 0 Yes* ® No <br /> *System is failing to protect groundwater. <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 <br /> • TTY 651-282-5332 or 800.657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 3/16/12 <br /> Page 2 of 3 <br />