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Property address: 825 Old Crystal Bay Road S.,Orono,MN Inspector initials/Date: J.O. 11/26/17 <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes ®No ® Searched for surface outlet <br /> end surface. ® Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile 0 Yes ®No 0 Excessive ponding in soil system/D-boxes <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> System cause sewagebackupinto -f 0 'Black soil"above soil dispersal system <br /> Y0 Yes ®No <br /> dwelling or establishment. ❑ System requires"emergency"pumping <br /> 0 Performed dye test <br /> Any"yes"answer above Indicates the system is ❑ Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safety. 0 Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity-Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes ®No 0 Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> 0 Examined construction records <br /> Seepage pits meeting 7080!2550 may be ' 0 Examined Tank Integrity Form(Attach) <br /> cwnDliant it shower in/oeai ordinance <br /> 0 Observed liquid level below operating depth <br /> Sewage tank(s)leak below their 0 Yes ®No 0 Examined empty(pumped)tanks(s) <br /> designed operating depth. <br /> It yes,which sewage tank(s)leaks 0 Probed outside lank(s)for"black soil" <br /> 0 Unable to verify(See Comments/Explanation) <br /> Any "yes"answer above indicates the ®Other methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <br /> Comments/Explanation: <br /> Peterson Company pumped the tanks. <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to 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' (D No ❑ 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 falling to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651.296-6300 • 800-657.3864 • TTY 651-282.5332 or 800-657-3864 • Available in alternative formats <br /> wq-rhvists4-31 • 1/24/12 <br /> Page 2 of 3 <br />