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Mar 28 2017 1022AM HP FaxRusty Olson 7634988290 page 6 <br /> , Pr�7eRy eddross: 1905 County Rond E Inspecbor initielWate: _3I20l17 _ <br /> � <br /> f, Impatt on Public Heakh—Compt�nce component�t�ot 5 <br /> Compiiencs criesria: YNII1c�tlon method�s�: <br /> SystBm dieChe�ge eewage M fhe ❑Yes ❑No ❑ �rched for aurTxe ouUet <br /> �round eurfece. ❑ $�arched for seepk�g in yardlpackap in tqme <br /> System dicctwryo sewaee to drain tila ❑Yee ❑No ❑ �we ponding In soil syatenVOfiooces <br /> Or wfiaco watsra. ❑ HomeoMiefa►ta�tlm�Ml(bYe Comm�nk/E,cplerNNon) <br /> Syatem cauae sewipa bx#up Irrto ❑Yp ❑No � �81ad�wiP abov9 6a1 tllepefW syMem <br /> tlwalling or Ea�abAshmenl. � �°m�Oa���a'^m'"Q <br /> ❑ Peifortned dye tast <br /> Any�yae"d►awvr abow frrdlcatas tM ayatam[s ❑ Unable fo vaify{see commenrmErpa�oru <br /> ����t���p�f����S��• ❑ Othar methoda not Itsted(See Conrnenfs/EKpfarraHonj <br /> CommaMslExplenation: <br /> 2. Tank Integrity—Compllance component iR2 ot 5 <br /> cam Isnce erita�la: --- VoNlic�tlon mathod(i): <br /> Systwn catelats of a seepe9e Pi►. ❑Yes �No ❑ Probed tank(s)bot6om <br /> eesspool,dryweA,or Isaching pR, ❑ �minetl o�onstrudfpn reCords <br /> S�epeD°pMs'ro°6rg�Dd02SSpm°Yb° ❑ ExaminstlTanklMegAtyForm(Alteeh) <br /> can�P1!urt N�nowdln lbal ordw+ano�. _. ❑ Obeerved Ipuld level below operaUnp dePth <br /> Sewegs tar+k(s}leak below their ❑Yes �No � �����1e��s� <br /> desianetl cperatiny depth, <br /> If yes,which sewage tank{s)leeks: _.__ ❑ Probsd oulside lank(s)kr"bladc toiP <br /> -- ❑ U11ib18 to veAf�'(Sea Qxnmente�Explanatvn) <br /> My«yYS••sAswer above indk+rNs fhe ❑ou�«men�ods na��stee(see cemn»nla�xplaneud,) <br /> system Js FailJnB to Protec!Groundwat�u: <br /> CommemtlE�Isr�etbrc <br /> On 3l20M7,ElmerJ.Peterson Co.pumpe�itev�ka. <br /> 3. Other CompNan�Condittons—com�ianoe componenc rq ot5 <br /> e. Meir�ta�ance Ible�eis are damegsd.aeelted.urueared�a apFwar m sbuchirely urwound. �ves' Q No ❑Unknown <br /> b. O1her fstues{suancdhara�,Ne.)to irmiediably and advaraely impact pub�FNaIM oraabty. ❑Yes• ❑No ❑Unbwwn <br /> 'Sysam b�n Ynmlrwnt tlnart to publlc hoaMh n►d snMy <br /> Explafn: <br /> c SyaEem h non-prolee�Ne of qarnd wa�r tor olher cmditione ae detenrined bY inapedor ❑Ya' ❑No <br /> 'Sf�an ia/alfing to pret�clQ/aredwal�r <br /> E�Iak►; <br /> www.pa.uate.mn,u: • 651-2%-6300 . 60a657•386a . TTY641-282-5337or8W-557•)86a . AvaMableNallemaWaformab <br /> , wq•ww�ts�)1 . 7/24!)1 P68eioj7 <br />