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a <br /> Property address: 2160 6th Ave North,Long Lake Inspedor ini6als/Date: JS I 7/26/2017 � <br /> (mMdd/yyyy) <br /> 1. Impatt on Public Health—Compliance component#1 of 5 <br /> Com liance crite�ia: Verificatfon method(s): <br /> System discharges sewage to the ❑Yes �No �Sea�ched for surface outiet <br /> �ound surFace. �Sea�ched fo�seeping in yard/backup in home <br /> System discharges sewage to drain ❑Yes �No ❑ Excessive ponding in soii system/D-boxes <br /> tile or surFace waters. ❑ Homeowner testimony(See Comments/Exp/enation) <br /> System causes sewage badcup into ❑Yes �No ❑°Black soil"above soil dispersal system <br /> dwelling or establishmerrt. <br /> ❑System requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminent threat to public ❑Unable to verify(See Comments�xp/anahon) <br /> health and safety. ❑Other methods not listed(See Comments/Explanation) <br /> CommentslExplanation: <br /> 2. Tank Inte�grity—Compliance component#2 of 5 <br /> Com liance crite�ia: Verificatfon method(s): <br /> System consists of a seepage pit, �Yes ❑No ❑Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> �Examined construction records <br /> Seepege pits meeBng 7080.2550 may be ❑Examined Tank Integrity Fortn(Attech) <br /> com Ilant!f allowed in/oca!ordinanoe. <br /> Sewage tank(s)leak below their �Yes ❑No �Observed liquid level below operating depth <br /> designed operating depth. ❑Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑Probed outside tank(s)for"black soil" <br /> Any"yes"answer above indicates the ❑ Unable to verify(See Comments/Exp/anstlon) <br /> system is failing to protect groundwater. ❑�er methods not listed(See Comments/Exp/anation) <br /> Comments/Explanation: <br /> accoMing to records tanks�re installed in 1966 and have not been updated <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Mairrtenance hole oovers are damaged,cracked,unsecuned,or appear to be shuchirally unsound. ❑Yes* �No ❑Unknawm <br /> b. Other i�ues(ete�x�ical hazards,etc.)to immediately and adversely impad public health or safety. ❑Yes' �No p unkna�m <br /> "System is an Imminent threat to publlc health and safety. <br /> Explain: <br /> a System is non-protec�ive of g�nd water for�conditions as determined by inspector. p Yes• �No <br /> 'System is/aflfng 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 altemative formats <br /> wq-wwlsts4-31 • 3/16/12 Aage 2 of 3 <br />