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• <br /> Property address: 1 1 Inspector initials/Date: ' <br /> 1. impact on Public Health-Compliance component#1 of 5 <br /> Com•fiance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes i No ❑ Searched for surface outlet <br /> round discharge <br /> . 0 Searched for seeping In yard/backup in home <br /> System discharge=image to drain tie 0 Yes No 0 Excessiveponding in soil system/D-boxee <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> (: "Black soir above soil dispersal system ; ,; <br /> System cause sewage backup into 0 Yes ❑No 0 System requires'emergency'pumping • <br /> dwelling or establishment. <br /> 0 <br /> Any"yes"answer above indicates the system IsUnablee ttoblo dye test <br /> 0 verify(See Commentsexplanatlon) <br /> an imminent Threat to Public Health and Safety. 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 0 No 0 Probed tank(s)bottom <br /> •cesspool,drywall,or leaching pit. 0 Examined construction records <br /> Seepage pits meeting 7080.2550 may be EXamlned Tank Integrity Form(Attach) <br /> compliant if allowed In local ordlnarrce. <br /> 0 Observed liquid level below operating depth <br /> Sewage tank(s)leak below their 0 Yes 0 No g <br /> 0 <br /> designed operating depth. Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: 0 Probed outside tank(s)for black soli' <br /> Any"yes"answer above indicates the ❑ Unable to verify(See Comments/Explanation) <br /> system is Falling to Protect Groundwater. 0 Other methods not listed(See Comments/F cpienatton) <br /> Comments/Explanation: • • <br /> • <br /> • <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged cradced,unsecured,or appear to st�uraly unsound. 0 Yes* <br /> ' in No ❑Unknown <br /> b. Other issues(elechtcal hazards,etc.)to Immediately and adversely impact public health or safety. 0 Yee 13 No 0 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 i <br /> *System is falling to y inspector ❑Yes' No <br /> n9 protect <br /> Explain: <br /> www.pca.state.mn.u'; • 651.296.6300 o 800.657.3864 e • TTY 651.282.5332 or 800.657.3864 i Available in alternative formats <br /> wo-mosts4-31 • 1/24/12 <br />