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� w <br /> Property address: ,�,���j^ �!�J'�� /� V� � inspector initials/Date: < < � �a <br /> , 1. Impact on Public Health-Compliance component#1 of 5 <br /> Com liance criteria: V�.e,/rification method�s): <br /> System discharge sewage to the ❑Yes 0 No �L'�f,/5earched for surface ouUet <br /> round surface. pd 5earched for�seeping�in yard/badcup in home <br /> System discharge sewage to drain tife ❑Yes �o � ����ve panding in soil system/D-boxes <br /> or surfac:e waters. ❑ Homeowner testimony(See Canments�€xplanabon) <br /> System cause sewage backup iMo ❑Yes �o ❑ "Black soil°above sal dispersel system <br /> dwelling or establishment. ❑ System requires eme�c�'pumping <br /> � Any"ye�s"answer abo've lndJcates the�ystem is � Performed dye test <br /> ❑ Unable to verify(See Comm�pfanetion) <br /> an lmmjnent Threat to Publ�C Health and Safety. � p�,er methods�ot�isted�see con,men�xp��r,� <br /> CommentslExplanation: <br /> 2. Tdnk Integi'ity—Compliance component#2 of 5 " <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 construdion records <br /> Seepage pits�meeHng 7080.2550 may be ❑ Examined Tank IMegrity Form(Attaad�) <br /> com ►ant if allowed in loca/ordlnance. <br /> Sewage tank(s)leak below their ❑Yes ❑No ❑ Observed liquid levei below opei�ating depth � <br /> desi ned o ratln d th. ❑ Examined empty(pumped)tanks(s) � <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black sal" <br /> ❑ Unable to verify(SeeCommentslExplanatlon) <br /> Any"yes"answer above inalicates the �Other methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <br /> Comments/F�cplanation: A,}'��t.e.i+i�i <br /> �� <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cradced,unsecured,or appear to strudurally unsound. ❑Yes' ❑No ❑Unknown <br /> b. Other issues(elecbrk�lhazeids,etc.j to immediately and adversely impad public health or safety. ❑Y�' ❑No p Unknoam <br /> *System!s an imminent threaf to publfc health and safeiy <br /> Explain: <br /> c. System is nor�pro�eetiue of grourid wa�r for other conditions as determined by inspedor ❑Yes" O No <br /> *System is faiNng fio protec!groundwater <br /> Explain: <br /> www.pea.state.mn.us '•- 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-65.7-3864 • Available in altemative formats <br /> : _ _ :... . <br /> _ _ <br /> wq-wwist34-31 � i/24/12 -- - . - . Page 2 of 3 <br />