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Jun 28 2015 03:47PM HP FaxRusty Olson 7634988290 page 3 <br /> Property address; ±! REF Text114 l'MERGEFORMAT2790 SilverUew Inspedor initialsiDate: J. O.6l28/15 <br /> 1. Impact on Public Health—Comp�iance component�t� ot 5 <br /> Complfance c�iteria: Verification method(s): <br /> System discharge sewage to the � ❑Yes �No � Searched for surfaoe outlet <br /> ground surface. i � Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile � ❑Yes � No � �cessive ponding in soil system/D-boxes <br /> or surtace waters. L ❑ Homeowner testimony(See Commenrs�ExplenaUon) <br /> S stem cause sewa e backu mto I ❑ "glack soil"above soil dispersal system <br /> Y g p� ❑Yes �Np ❑ System requires"emergency"pumping <br /> dwelling or establishment. � <br /> ❑ Pertormed dye test <br /> Any"yes"answer above Jnd/cates ihe system is ❑ Unable to verify(see CommentsiE'xplanation) <br /> an lmminent Threat to Public Health arrd Safety, � pther methods not listed(See Comments/ExpJanaUon) <br /> Com memslExplanation: <br /> 2. Td11k Integ�ity—Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s�: <br /> System consists of a seepage pit, i ❑Yes � No ❑ Probed tank(s)battom <br /> cesspool,drywell,or leaching pit. � � Examined construction records <br /> Seepage pits meeting 7080.2550 may be ; <br /> co l�ant if aJlowed in loca!ordinance. ❑ Examined Tank Integrity Form(Attach) <br /> ❑ Observed liquid level befow operating depth <br /> Sewage tank(s)leak below their ❑Yes �No <br /> designed operatinq depth. � ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s}leaks: � ❑ Probed outside tank(s)for"black soil" <br /> /�fly"yes"answer above indicates the ❑ Unable to verify(See Comments/Explanatron} <br /> system is Falling to Profect Groundwater. �Other methods not listed (See Comments�Exp/anation) <br /> Comments/Exp la nation: <br /> City Records <br /> 3. OthEr CompllanCe Conditio�l5—Compliance component#3 of 5 <br /> a. Maintenanee hole covers are damaged,cradced, unsecured,or appear bo structurally unsound. ❑Yes• �roo ❑unknown <br /> b. Other issues(elechi�cai hazerds,etc.)to immedialely and adversely impact public health or safety. ❑Yes' �No ❑Unknown <br /> *5ystem is an imminen!thr�at to puWic healtfi and safery <br /> Explain: <br /> c. System is non-protective of ground water for other corxlitions as determined by inspector p ves� �No <br /> "System is failing to protect groundwatei <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 860-657-3664 • TTY 651-282-5332 or 800-657•3864 . Available in alternative formats <br /> wq•wwisrs4-3f • 1/24/12 <br /> PaRe 2 of 3 <br />