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� <br /> � f � <br /> Property address: 3(�.,5�� �� � � Inspector initials/Date: O',� <br /> 1. Impact on Publie Health—Compliance component#1 of 5 <br /> Com liance criteria: Ver' cation method(s): <br /> System discharge sewage to the ❑Yes [�No S rched for surface outlet <br /> round surface. Searched for�seeping in yard/badcup in home <br /> System discharge sewage to drain tile ❑Yes �No � ��ssive pa�ding in soil system/D-�xes <br /> or surFace waters. ❑ Homeowner testimony(See Comments/�xplanatlon) <br /> ❑ "Black soil"above sal dispers�l system <br /> System cause sewage backup into ❑Yes No � System requires"emergenc}r'pumping <br /> dwelling or establishment. <br /> . � ❑ Pertormed dye test <br /> Any"yes"answer aboVe indicatas fhe�ysfem is ❑ Unable to verify(See CommentslExplanallon) <br /> an/mminent Threat to Public Health and Safefy. � p�er methods Flot listed(See Commer►t�xp/anation) <br /> Comments/Explanation: <br /> 2o Tar1k Inte�rity—Compliance component#2 of 5 �j,y �� �--.�o� ` <br /> �— <br /> Com liance criteria: Verification 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 /> seepage nits�meeting 7o8n 255n mey be ❑ Examined Tank Integrity Form(A:taah; <br /> r,omnliant if allowed in local orrlinance. <br /> ❑ Observed liquid level below operating depth � <br /> Sewage tank(s)leak below their ❑Yes ❑ No � Examined empty(pumped)tanks(s) � <br /> desi ned o eratin de th. <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> ❑ Unable to veliiy(See Comments/Explanation) <br /> Any "yes"�rlswer abOve indl'Cates#he � pther methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater <br /> Comments/Explanation: <br /> 3 a Oth�1'GOIllplldnCG COndltiOP15—Compliance component#3 of 5 <br /> a. Maintenance hofe covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes* ❑No ❑Unknown <br /> b. Other issues(electricalhazarris,etc:)to immediately and adversely impact public heafth or safety. ❑Yes" ❑No ❑Unknown <br /> "System is an imminent threaf to public health and safety <br /> Explain: <br /> c. System is non-protedive of ground water for other conditions as deterrnined by inspector ❑Yes" ❑No <br /> *System is failing 4o proi+2ct groundwater <br /> Explain: <br />