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vyOlclil UIJL,Ic tyc•7T.,YYQy C.U.)USI LI 1 OJ LJ •'J <br /> . _Around surface. ❑ Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile ❑Yes ❑ No <br /> ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Hgmeowner testimony(See Comments/Explanation) <br /> ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup into 0 Yes ❑No 0 System requires"emergency"pumping <br /> dwelling or establishment. ❑ Performed dye test <br /> Any"yes"answer above indicates the system is 0 Unable to verify(See Comments/Explanation) <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, 0 Yes ® No 0 Probed tank(s)bottom <br /> cesspool, drywell,or leaching pit. ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> compliant if allowed in local ordinance. <br /> `—� 0 Observed liquid level below operating depth <br /> Sewage tank(s)leak below their f ❑Yes ®No ® Examined empty(pumped)tanks(s) <br /> designed operating depth. <br /> If yes,which sewage tank(s)leaks: <br /> 0 Probed outside tank(s)for"black soil" <br /> ❑ Unable to verify <br /> Any "yes"answer above indicates the (See Comments/Explanation) <br /> system is Failing to Protect Groundwater. ❑Other methods not listed(See Comments/Explanation) <br /> comments/Explanation: <br /> On 5/4/18, 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 ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* ❑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 inspector ❑Yes* 0 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-wwists4.31 • 1/24/12 Page 2 of 3 <br />