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� ' Property address: Inspector initials/Date: 1. Impact on Public Health—Compliance component#1 of 5 Com liance criteria: _ Veri�cation method�s): System discharge sewage to the ❑Yes ❑No ❑ Searched for surface outlet round surface. ❑ Searched for seeping in yard/badcup in home ❑ Excessive ponding in soil system/D-boxes System discharge sewage to drain tile ❑Yes ❑No � Homeowner testimony(See CommentsiExplanation) or surface waters. ❑ "Black soil"above soil dispersa)system System cause sewage backup into ❑Yes ❑ No � System requires"emergency"pumping dwelling or establishment. ❑ PerFormed dye test Any"yes"answer above indicates the system is ❑ Unable to veriTy(See Comments/Explanation) an lmminent Threat to Public Health and Safety. ❑ Other methods not listed(See Comments/Explanation) Com ments/Explanation: 2. Ta11k Integ�ity—Compliance component#2 of 5 Com liance criteria: Verification method(s): System consists of a seepage pit, ❑Yes ❑ No ❑ Probed tank(s)bottom cesspool,drywell,or leaching pit. ❑ Examined construction records Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) com liant if aUowed in loca!ordinance. ❑ Observed liquid level below operating depth Sewage tank(s)leak below their ❑Yes ❑No � Examined empty(pumped)tanks(s) desi ned o eratin de th. ❑ Probed outside tank(s)for"black soil" If yes,which sewage tank(s)leaks: � _ ❑ Unable to venfy(See Comments/Explanation) Any"yes"answer above indicates the ❑Other methods not listed(See Comments/Explanation) system is Failing to Protect Groundwater. Com ments/Explanation: 3. Othe�COmplldnCe Conditio115—Compliance component#3 of 5 a. Maintenance hole covers are damaged,cracked,unsecured,or appear to strudurally unsound. ❑Yes* ❑No ❑Unknown b. Other issues(electrical hazards,etc.)to immediately and adversey impact public heafth or safery. ❑Yes* ❑No ❑unknovm '`System is an imminenf threat to public health and safety Explain: c. System is non-protective of ground water fo�other conditions as determined by inspector ❑Yes` ❑No •System is failing to protect groundwater Explain: www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4-31 • 1/24/12 Page 2 of 3