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• <br /> Property address: 9 9 0 0. S 1=+'Q' C s _.. <br /> Inspector initials/Date: •�-� .�' �--�<- �<� <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Corn•!lance criteria: Verification method(e): • <br /> System discharge sewage to the 0 Yes ❑No 0 Searched for surface outlet <br /> round surface. li Searched for seeping in yard/backup In home' <br /> System discharge sewage to drain tile 0 Yes 0 No ra Excessive ponding in soil system/D-boxes <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> El "Black soil'above soil dispersal system <br /> • <br /> System cause sewage backup into 0 Yes dwelling or establishment. 0 No lI System requires"emergency'pumping <br /> ia <br /> Any"yes"answer above Indicates the system is 0 Performed dye test <br /> an Imminent Threat to Public Health and Safety. ❑ Unable to verify►(See CanmentsiExp/eneoron) <br /> Comma ❑ Other methods not listed(See Comments/Explanation) <br /> nts/Expianation: • <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,dryw ell,or leaching pit. <br /> Seepage pits meeting 7080.2550 may be ❑ Examined construction records <br /> compliant If allowed In local ordinance, ❑ Examined Tank integrity Form(Attach) <br /> 0 Observed liquid level below operating depth <br /> Sewage tank(s)leak below their 0 Yes 0 No <br /> designed operating depth. 0 Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for'black soil' <br /> Unable to verify(See Comments/Explanation) <br /> Any"yes"answer above Indicates the ❑ ) <br /> system Is Falling to Protect Groundwater. 0 Other methods not!kited(See Conrmerrfs/Explanatlon) <br /> Commentif/Explanation: <br /> • <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structural! <br /> b. Other issues(electrical hazards,etc.)to Immediately andy ❑Yes 0 No ❑;J�� <br /> System is an Imminent threat to public health and impact p health or safety. El Yes* ❑No ❑Unknown <br /> Explain: <br /> c. *System Is System n-prove of ground water for other txmdtions as determined by inspector p Yes• ii No <br /> ng to protect groundwe er <br /> Explain: <br /> www.pca.State.mn.us " 651.296.6300 0 800.657.3864 " • lY 651.282.5332 or 800-657.3864 " Available in alternative formats <br /> wo-wwlsts4.31 0 1 1241 12 <br />