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� � <br /> Property address: 4380 County Road 6 Long Lake MN inspector initials/Date: I <br /> (n►m/dtVYYYY) � <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com liance criteria• Verification method(s): <br /> System discharges sewage to the ❑Yes � No �Searched for surFace outlet <br /> round surFace. �Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑Yes �No ❑Excessive ponding in soil systeMD-boxes <br /> tile or surfac�e waters. ❑ Homeowner testimony(See CommentslExpJanation) <br /> System causes sewage backup into ❑Yes � No ❑"Biadc soil"above soil dispersal system <br /> dweiling or establishment. <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 verity(See Comments/Exp►anation) <br /> healfh and safety. ❑pther methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Com liance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes �No �Probed ta�k(s)bottom <br /> cesspool,drywe{I,or leaching pit. �Examined�nstnaction records <br /> Seepage pirs rr►eeting 7080.2550 may be ❑Examined Tank Integrity Form(Attach) <br /> «�m liant if apowed in local ordinance. <br /> ❑Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes � No <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`�es"answer above in�cates the ❑ Unable to verify(See CommentsiExplanation) <br /> system is failing to protect groundwrater. ❑aher methods not listed(See CommentslExplanation) <br /> Com m enta/Explanation: <br /> 3. Other Compliance Conditions—comp�iance component#3 of 5 <br /> a. Maintenance hole c�vers a�e damaged,cradced,unsecxu�,or appear to be structurally unsound. ❑Yes' �No p Unknown <br /> b. Other issues(ele�recal hazards,etc.)to immediately and adversely impad public heaRh or safety. p Yes' �No p Unknown <br /> *Sysfem is an imminent threat to puWic heslth and safety. <br /> Explain: <br /> c. System is non-protective of ground water for other condfions as detertnined by in�pedor. p Yes• �No <br /> *System is failing 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-wwists4-31 • 3/16/12 Page 2 of 3 <br />