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Property address: 350 N.Arm Lane Inspector initials/Date: 1/30/18 <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes 0 No 0 Searched for surface outlet <br /> ground surface. 0 Searched for seeping in yard/backup in home <br /> 0 Excessive ponding in soil system/D-boxes <br /> System discharge sewage to drain tile 0 Yes 0 No <br /> 0 Homeowner testimony(See Comments/Explanation) <br /> or surface waters. y C ) <br /> System cause sewage backup into ❑Yes 0 No 0 'Black soil"above soil dispersal system <br /> dwelling or establishment. ❑ System requires"emergency"pumping <br /> ❑ Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safety. <br /> 0 Other methods not listed(See Comments/Explanation) <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, ❑Yes ®No ❑ Probed tank(s)bottom <br /> cesspool,drywall,or leaching pit. <br /> 0 Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> compliant Hallowed in local ordinance. <br /> Sewage tank(s)leak below their ❑Yes ®No 0 Observed liquid level below operating depth <br /> designed operating depth. ® Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: <br /> 0 Probed outside tank(s)for'black soil" <br /> — ❑ Unable to verify(See Comments/Explanation) <br /> Any"yes"answer above indicates the ❑Other methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <br /> Comments/Explanation: <br /> On 1/30/18,Elmer J.Peterson Co.pumped tanks. <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 0 Unknown <br /> b. Other Issues(eledncai hazards,etc.)to immediately and adversely impact public health or safety 0 Yes' ❑No U 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 0 Yes* ❑No <br /> 'System is failing to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800.657-3864 • Available in alternative formats <br /> wq-wwlsts4.31 • 1/24/12 Page 2 of 3 <br />