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• <br /> • Property address: Inspector Initials/Date: <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com•fiance criteria: Verification method(e): <br /> System discharge sewage to the ❑Yes 13 tido 0 Searched for surface outlet <br /> ...round surface. In Searched for seeping in yard/backup in home <br /> System discharge sewage to drain the ❑Yes t3 No ® Exoesalve ponding in soil systerNp-boxes <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> System cause sewage bacwp into ❑ye6 ❑ -Black soil above soil dispersal system <br /> dwelling or establishment. ®No ❑ System requires"emergency"pumping <br /> ❑ Performed dye test <br /> Any"yes"answer above Indicates the system Is 0 Unable to verify(See CommentsWExpienation) <br /> an Imminent Threat to Public Health and Safety. 0 Other methods not listed(See Commenta/Explenation) <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 0 No 0 Probed tank(s)bottom <br /> cesspool,drywall,or leading pit. 0 Examined construction records <br /> Seepage pits meeting 7080.2550 may be 0 Examined Tank Integrity Form(Attach) <br /> compliant if allowed in local ordinance. <br /> Sewage tank(s)leak below their <br /> 0 Observed liquid level below operating depth <br /> designed operating depth. ❑Yes 0 No 0 Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: 0 Probed outside tanks)for"black soir <br /> Any"yea"answer above In•r`ccates the 0 Unable to verify(See Comments• <br /> +Ekplanatiar) <br /> system Is Falling to Protect Groundwater. ID Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: • <br /> c,e-td kr' "7 'i'' ol's- ` ' • <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,Cr appear to structurally unsound. ❑Yes• <br /> IN No El Unknown <br /> b. Other issues(elect♦lbai hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes' as No ❑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 ❑Yes` ( No <br /> 'System Is falling to protect groundwater <br /> Explain: <br /> • <br /> wolm ca,state.mrt.us a 651.296-630(1 657.3864 a TTY 651.282.5332 or 800.657-3864 6 Available in alternative formats <br /> wa-wwtsts4-31 • 1/24112 <br />