Laserfiche WebLink
Property address: i S O SZ- 2 y-N v . Oft. A cAz, ¶Z*z insjsec for Initials/Date: O,i ct (o <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com.Bance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes ❑No 0 Searched for surface outlet <br /> _round surface. ® Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile ❑Yes 0 Na Excessive ponding in soli system/ID-boxes No <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanatloen) <br /> System cause sewage backup into ❑Yes 0 Na 0 "Black soil"above soil dispersal system <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/Explenatlon) <br /> an imminent Threat to Public Health and Safety. o Other methods not listed(See CommentslExpienatiim) <br /> Comments/Explanation: • <br /> • <br /> . <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, 0 Yes 0 No 0 Probed tank(s)bottom <br /> •cesspool,drywall,or leaching pit. 0 Exartined construction records <br /> Seepage pits meeting 7080 2550 may be 0 Ertamined Tank integrity Form(Atter,) <br /> compliant f alkn ed in local ordinance. <br /> Sewage tank(s)leek below their ❑Yes ❑No 0 Observed liquid level below operating depth <br /> designed operating depth.designed empty(pumped)tanks(s) <br /> if yes,which sewage tank(s)leaks: 0 Probed outside tank(s)for'black soir <br /> Any"yea"answer above Indicates the 0 Unable to verify(See comments�xp/areeuorr) <br /> system Is Failing to Protect Groundwater. • ❑Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: . <br /> k9goviocz ' ' . <br /> • <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" 0 No ❑Unknown <br /> b. Other issues(eted>icei hazards,etc.)to immecfrately and adversely impact public health or safety. ❑Yes* 0 No 0 Unknown <br /> 'System is an imminent threat to public health and safety <br /> Explain: <br /> • <br /> c. System is non-protective of ground water for other conditions as determined by inspector Q Yes* 0 No <br /> 'System is felling to protectgroundwreter <br /> Explain: <br /> • <br /> WwVl.pca.State.mll.us • 651.296.6300 ® 800457.3864 • TTY 651.282.5332 or 800-657-3864 • Available in aitematfve formats <br /> wa-wwfsts4.31 • 1/24/12 <br />