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Property address: 405 Old Crystal Bay Rd S,Orono MN 55391 Inspector initials/Date: _LB 07-20-2015 <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com•ilance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes ❑No 0 Searched for surface outlet <br /> Around surface. 0 Searched for seeping In yard/backup In home <br /> System discharge sewage to drain tile ❑Yes ❑No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into ❑Yes ❑No ❑ `Black soil"above soil dispersal system <br /> dwelling or establishment. ❑ System requires"emergency'pumping <br /> ❑ Performed dye test <br /> Any"yes"answer above indicates the system is 0 Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safety. [J 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, 0 Yes VkNo ❑ 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 /> corn.'ant if allowed in local ordinance. • <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their 0 Yes 1;4 No ►:I Examined empty(pumped)tanks(s) <br /> designed operating de.th. _ <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> Any"yes"answer above indicates the 0 Unable to verify(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. L ❑Other methods not listed(See Comments/Explanation)�1 <br /> Comments/Explanation: Soy � t '4s)t _r n�R %li$il 141. putro p`�'a - ,t Hr; '}cro -.. )6009 a ( <br /> Business Name: Kothrade Sewer,Water,Excavating,Inc <br /> Business Address: 12059 Whitetail Ln,Hanover MN 55341 ,- <br /> Business Phone: 763.498.8702 <br /> Company Representative: Larry Bursch MPCA#: 0192/9199 Signature "g,r <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" 0 No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. 0 Yes" 0 No 0 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" 0 No <br /> *System is failing to protect groundwater <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-wwlsts4-31 • 1/24112 Page 2 of 4 <br />