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Property address. 300 Stubbs Bay Road N Inspector initials/Date: 5/14/1 <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes ❑No 0 Searched for surface cutlet <br /> ground surface. 0 Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile i 0 Yes 0 No 17] Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> - ---"- -"- 0 "Black soil"above soil dispersal system <br /> System cause sewage backup into 0 Yes 0 No <br /> dwelling or establishment. 0 System requires"emergency"pumping <br /> 0 Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safety. ❑ Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity-Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, I 0 Yes ®No 0 Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. ❑ Examined construction records <br /> Seepage p/ts meeting 7080.2550 may be 0 Examined Tank Integrity Form(Attach) <br /> compliant if allowed in local ordinance. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes ®No ® Examined empty(pumped)tanks(s) <br /> designed operating depth._ <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> —1 ❑ Unable to verify(See Comments/Explanation) <br /> Any"yes"answer above indicates the <br /> 0 Other methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <br /> Comments/Explanation: <br /> On 5/14/18,Elmer J.Peterson Co.pumped tanks. <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes" ❑No El Unknown <br /> b. Other issues(elec Tical hazards,etc.)to immediately and adversely impact public health or safety. 0 Yes' ❑No 0 Unknown <br /> *System is an imminent threat to public health and safety <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector ❑Yes' 0 No <br /> 'System is falling 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 alternative formats <br /> wq-wwtsts4.31 • 1/24112 Page 2 of 3 <br />