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Property address: 1200 Phillips Dr.Orono Mn 55356 Inspector initials/Date: JS � 7/28/2016 .._. __ . ___....__ __.______ __.____._ _ _ _. (mm/dd/YYYY) 1. Impact on PubliC Health—Compliance component#1 of 5 Compliance criteria: Verification method(s): _ __. _ System discharges sewage to the ❑ Yes � No � Searched for surface outlet ground surface. ___ � Searched for seeping in yard/backup in home .__._. System discharges sewage to drain ❑ Yes � No ❑ Excessive ponding in soil system/D-boxes tile or surface waters. __ ❑ Homeowner testimony(See CommenrsiExp�anatron) System causes sewage backup into ❑ Yes � No ❑ ��Black soii"above soil dispersai system dwelling or establishment. ____. _ ----._ _.....__ _.__ _ _.. ____-- --___ ..... __ ❑ System requires"emergency"pumping Any"yes"answer above indicates the ❑ Performed dye test system is an imminent threat to public ❑ Unable to verify(See Comments/Explanation) health and safety. _.. ___ __,, __ ❑ Other methods not listed (SQe Comments/Explanarion) __ _ Comments/Explanati on: 2. Tank Integrity—Compliance component#2 of 5 Compliance criteria: Verification method(sj: _ _ _. _ _ System consists of a seepage pit, ❑ Yes � No ❑ Probed tank(s)bottom cesspool, drywell,or leaching pit. � Examined construction records Seepage pits meeting 7080.2550 may be compliant iiallowed rn toca!ordinartce. ❑ Examined Tank Integrity Form (Artacn) ____ __ _ . _ _ ❑ Observed liquid levet below operating depth Sewage tank(s)leak below their ❑ Yes � No designed operating depth. � Examined empty(pumped)tanks(s} If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" _.__..._ _ _ ___ _ Any "yes"answer above indicates the nab�e to verify�see comme�:sieXpianarron� system is failing to protect groundwater. ❑ Other methods not listed (See Comments/Explanation) __._ _ ---.._ _. __.._... ___._._ _._.__. _.._ Com ments/Explanation: 3. Othe�Co111p11d�Ce Collditi011s—Compliance component#3 of 5 a. Maintenance hole covers are damagerl,cracked.unsecured,or appear to be structurafly unsound. ❑Yes' �No ❑Unknown b. Other issues(e�ectricai hazards.etc.)to immediately and adversely impact public health or safety, p Yes' �No ❑Unknown *System is an imminent threat to public hea/th and safety. Explain: c. System is non-protective of ground water for other conditions as determined by inspector. p Yes• �No *System is faiung to protect groundwater. Explain: _ _ __ _ __ ___ www.pca.scate.mn.us • 651•296•6300 • 800-657•3864 • TTY 651-282•5332 or 8�-657-3864 • Availabte in alternative formats wq-wwis[s4-31 • 3116/12 Page 2 of 3