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. <br /> Property address: 2450 CounN Rd.8 lnspedor tniC�lslDate: I 7/8/2013 <br /> (mrt�Hd�yYYY) <br /> 1. Impact on Pubtic Health—Compliance component#1 of 5 <br /> Compllanca crlteHa: Verification method(s): <br /> System d{scharges sewege to the ❑Yes �No ❑Searched for s�tace outlet <br /> round surfece. �Searched for seeping tn ysrdlbackup in hane <br /> Syatem diecharges sewage w drein ❑Yes �No ❑Excesslve pondinp in soil systemlD-boxes <br /> tYe or eurfaoe WBtefs. ❑HOmeowne�Mst&t►ony(3es Onmmenfs�xp/snsUw�) <br /> Syatem causes sewage badcup Inlo ❑Yes �No ❑�glack soiP above sal dfspersal system <br /> dweAing or estebNshment. ❑System r ulrea`em <br /> �i ��Y'P�►�P��9 <br /> Any"yes"answer above lntllcates the ❑Pe�formed dye test <br /> system Is an lmminent threat to publlc ❑uneble to vertty�ses canmenre�xpr�eaonJ <br /> heslth and s9fefy. ❑other r�thods not Ifeted(sb�commer►fa/Fxp/eneHon) <br /> CommenWExplanatlon:� <br /> 2. Tank integrity—Compliance component#2 of 5 � <br /> Com Uance criteris: Verif(caHon ma�od�s): <br /> System consists ot a seepage P�, ❑Yes �I No ❑Probed lank(s)bottom <br /> . cesspool,drywell.or leaching pil ❑Exeurdned onnsvuctlon rec�ds <br /> Seap�e�ts meeHny 70Ao.2660 rraY bs ❑Examined Tank lirtegri(y Fonn(A�ch) <br /> ue�d M bea!orWnenoe. ❑Obeervad Ilquld level belaw operatlng depth <br /> SeWrage tenk(s)leak beto�v their ❑Yea �No <br /> de�gned opereUng depth. �Exsmined empty(pumPe�tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑Probed outalde iardc(s)for'black soiP <br /> My"yes"answer above/ndlcafea fhe ❑unab�e to ve�ily(see cammenta�c�en�on� <br /> system is 1a1/In8 to protect groundwater. ❑�ar methoda not Iiated(sss ) <br /> CommentslExpbnadon: <br /> 3. Other Comptlance Conditions—comp6ance componer�#3 of 5 <br /> a. Maintenanoe hole covere ere dameged�cxacked�unaerxirod,or appear io be ahuchxary unaourxl. D Ys" �No 0 Unlmown <br /> b. Other fseuea(e�f huarda elo.)to immetfli�ely and adve�elY irt�ad P�Nc ttealth or ea(�y. p Yes• �No O uNmown <br /> "Sysfe�n la an G►mtinent threat to pubHc hee/tl►and salf�q. , <br /> Expl�fn: <br /> c. System is non-proteclive of groimd water for other can�dons�determined by hepedor. p Yes• �No <br /> • 'System!s falllnp to procsct yroundwrter. <br /> Explain: <br /> www.pca.#ate.mn.ix • 651•296-6300 • 800-657-3864 • TTY 651•282•5332 or l00�667-33Si64 • Available 1n eltemaHve fortnats <br /> wq•wwlttaF31 • 3/16/12 � PogP 2 of 3 <br />