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Nov, 6, 2 12 12;47PM No, 1056 P, 4 <br /> • Properlyadd : a0�d0 5�0��.�►s�' 'p� Inspectorinitials/Date: C��!� � a,�s�1�-.. <br /> 1. lmpac on Publ�c Health—Compliance component#1 of 5 <br /> Com II nce arite�a: Verlfication method(s); <br /> System ischa�ga sewage t�the ❑Yes �No ❑ Searched ior surFaoe ou0et <br /> round s rface_ I� Searched�or seeping in yerd/badwp in home f�� <br /> System tscharge sewage to drain Ule ❑Yes ❑No d �Ssive ponding in sofl systemlD-boxes <br /> n�surfa weters. Dry Homeowner tostimoriy(see Commentsl�c�enation) <br /> u �Bl�ck solP above soil dispersal system <br /> System use sewage backup into ❑Yes ❑No ❑ System requires'emergenc�'pumping <br /> dwelling establishment. � <br /> Any" "answar above indlcates the system is � P°�O�'"�dye test <br /> an Imm t Th�eat to Publlc Hea/th and Safety. � Uneble to verlfy(See Canmants�xp/enerio►,) <br /> ❑ Oq�er methods nat Usted(See Comments/�xpJeneNon) <br /> Comme Exp�anation: N o�S�' F•m�P'�'� �(o o �F`��� �f� �poC?�• ¢04�.: -�..���r,�r�l�:r:� <br /> 2. Tank I tegrity—Compliance component#2 of 5 �(�,a, � � �� <br /> Com li nce cHte�i�: VeNBcativn metbod�s): <br /> System nsiats of a soepage pit, ❑Yes ❑No ❑ Probed tank(s)botlom <br /> cesspool dtywell,or Iesching pit <br /> ❑ Examined oonstruction reCords <br /> Seepage ' meeting T090.2550 may be ❑ Examl�ed Tank I�tegrity Fom�(Aaach) <br /> lian! allowed'm local oNl�ence. <br /> Sewage nk(s)leak below their ❑Yes ❑No � ���liquid leve!below operating depth <br /> desi ned o ratin de th, ❑ E�camined empty(pumped)tenks(s) <br /> If yes, h sewage tank(s)leaks: ❑ Probe�outslde tank(s)for"bladc soil" <br /> Any'� "answer above incNcates the ❑ Unable to veriy(See Comment�zpuenstion) <br /> syste /s Falling to Protect GrouRdwater. ❑�her methods not 1i61,ed(See Commenfsl�xpleneE;o„� <br /> Comm lanetion' <br /> �� ���-�'4�'���-��a�.-�-��r������ <br /> 3. Other cmpliance Conditions-Compiiance component�13 of 5 <br /> e. hol�covers are damaged,cradced,unsewred,or appear bo strueturelly unsound. ❑Yee` �No ❑Unkrrown <br /> b. Other es(e�rir,alha�ard�edc.)to imrrre�atehr and adv�impac�publlc heatth or sefety, p Yes' �No O Un�own <br /> *S !s an immineri!thraat�o ptrWic health snd sa�ety <br /> Explal : <br /> c. Sys is non-protective of grou�d water for other c�ndfions as deEemiined by inspector Q Yea• �No <br /> '� is falong b probect groun�tsr <br /> Explei <br /> ..........�....►.... ... .r. nn. •�m n.u� .■....•. �.�...�' ��� ��•� --- -----. . . . <br />