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• <br /> Propertyaddre+ss: ) cor•-y<0g) _ InspectorInitials/Date: 5 a <br /> i. Impact on Public Health-Compliance component#1 of 5 <br /> Com liance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes f;: No ❑ Searched for surface outlet <br /> r round surface. Z Searched for seeping in <br /> A 9 yard/backup in home`�v <br /> System discharge sewage to drain tile ❑Yes m No I Excessive ponding in soil system/D-boxes s) <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into 0 Yes ® "Bleck soil"above soil dispersal system <br /> dwelling or establishment ®No 0 System requires"emergency'pumping <br /> Any"yes"answer above Indicates the system is 0 Performed dye test <br /> an imminent Threat to Public Health and Safety. 0 Unable to verify(See Comments/Explanation)y. <br /> 0 Other methods not listed(See CommernsrExplanetion) <br /> Comments/Explanation: • <br /> 's�\`. �u c,� s.{5'e,.l <br /> � �'�1 ti •O•cz-e),'" ¢0%�Y t?GC;' Fv4 <br /> ►Jv 4Jl� »v P4- ') ✓, ,, <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,drywall,or leaching pit <br /> 0 Examined construction records <br /> Seepage pits meeting 7080.2550 may be <br /> compliant If allowed In local ordinance. ❑ i`xamined Tank integrity Form(Attach) <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(a)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: 0 Probed outside tank(s)for"black soil" <br /> Any"yea"answer abode indicates the 0 Unable to verify(See Comments�rpranatteorr) <br /> 0 Other methods not listed(See Comments/Explanation) <br /> system/s Falling to Protect Groundwater, <br /> Comments/Explanation: • <br /> • <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,crnac�ked,unsecured,or appear to structurally unsound. 0 Yes <br /> b. Other issues(elec iiral hazards,etc.)to Immediately and " 0 No ❑Unknown <br /> *System Is an imminent threat to public health ander public health or safety, ❑Yes° l Na p unknown <br /> Explain: • <br /> • <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 /> www.m.Statl?.trltl.u5 s 6M-296-6300 0 000.657.31 o • TTY 651.232.5332 or M657-3864 657-3864 c Available in alternative formats <br /> wa-wwists4.31 ° 1/24/12 <br />