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Property address: Lot 1, Block 1 White Oak Funk Add.., Orono, MN Inspector initials/Date: J. O. 8/16/16 <br /> 1. Impact on Public Health -Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes ® No ® Searched for surface outlet <br /> ground surface. ® Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile CIYes ® No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. CIHomeowner testimony(See Comments/Explanation) <br /> CI "Black soil'above soil dispersal system <br /> System cause sewage backup into ❑ Yes ® No <br /> dwelling or establishment. ❑ System requires"emergency"pumping <br /> ❑ 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. <br /> ❑ 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 ❑ Probed tank(s)bottom <br /> cesspool,drywell, or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may lye ❑ Examined Tank Integrity Form (Attach) <br /> compliant if allowed in local ordinance. <br /> — ❑ Observed liquid level below operating depth <br /> Sewage tank(s) leak below their ❑Yes ❑ No <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 /> Any "yes"answer above indicates the 1=1Unable to verify(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. ® Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> New tanks will be installed when the house is built. <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes* ®No 0 Unknown <br /> b. Other issues(electrical hazards,etc)to immediately and adversely impact public health or safety. 0 Yes* ®No ❑Unknown <br /> *System is an imminent threat tp 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 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1/24/12 Page 2 of 3 <br />