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Ma r. 28, 2013 1 :45.��'6b � No, 1514 P, 4 <br /> . �'�_� � <br /> � Proqerty add�e�ss: o�sLt��-'��'+� �-��� �ns � <br /> _ pector Iniiials/f�ate: 5�;� -� � <br /> 1. Impatt on PubliC Health--Compliance companent#1 of 5 <br /> Com li�hce criterEs: Veriflcatton method(�): <br /> Systam dischar�e sewage to Uie []Yee �No ❑ Searched fo�8urface.outl8t <br /> round surFace. � Searched fnr seeping In yardJbackup In homa►s� <br /> System dlscharge sewaqe to drain tile p Yes �No � ��$gFve ponding in soil syatem/D-bvxe�.►cj <br /> o�surfac�waters, [] Momeownet tesGmony(See Gommenfs/�cplanetion) <br /> $ystam CBuse sewa e backu �nto. � "BfaGc soif"above soil dispersa!system�.(� <br /> dwelling ar establish ent. p ❑Yea �No d System r�qu(res"amgrgenc�'pumping <br /> ❑ Performed dye test <br /> Any"yes"answ�r�bove lndlcates the syat�m is ❑ U�aple ko verify(See CommentslExplanatlon) <br /> an Imminent Thnaat to Publ►c Health and$afety. Q Othef inethpds not I{sted(5ee CqmmenfslExplanatlonJ <br /> Commentsl�xplanation: , <br /> Z. T�nk Integrftiy—Compliance compon�nt#2 of 5 <br /> Com Ifance criterta: Verification method(s): <br /> System consists of a seepage pit, �]Yea ❑No ❑ Probed tank(s)bottom <br /> cesspool,drywall,or leeching pit. <br /> - �,] Examined oonstrudlon records <br /> SeepeQe plfs meeting 7080.255Q may be ❑ �mined Taqk Entegfity Fom1(Attech) <br /> Com lfant H aUowgd in locel ar!lrl8nce. <br /> Sewa e t8nk s Iqak below their I� Obse►ved Ilquid levef below operating depth <br /> 9 ( ) C]1'es []Na ❑ ��mined empty(Pumped)t�nks(s) <br /> desi ned o eratin de th. <br /> IF yee,whlch sewage tank(s)leaks: � Probed outslde tank(s)for"blaGc soll" <br /> Any"yes"answer above indlcates the C7 Unable to verliy(Sea Commenfs/F.xplanatfon) <br /> system!s Falljng fa Protect Groundwater. d�her methods not iis#ed(SBe Comments�xplanetlon) <br /> CommentslEuplanatfpn: <br /> �a�� ���rGy�� �S��a� �i�� ��'���� ��P� �� �,�r���! �.o . <br /> 3, pther Compliance Conditfons-�Compllance c,omponent#3 of 5 <br /> a. Maintenanca hole covers are demag�d,cradced,un�ecured,nr appe&r to stnx:tural►y uneound. ❑Y�s• �No ❑Unknawn <br /> b. Other Issues(el�hazanis,efc,)to immedlately and 8dversefy Impact public heallh or safely. ❑Yes' �No �]Unknown <br /> �Sy�dem Is an!mminent th�at b publlc hee7th ahd safety <br /> Explaln: <br /> c. Sy�tem is non-protective of ground water for other Conditions�s determined by Inspedor ❑Yes• �No <br /> 'Speiem/s falling to protect g►+aundw�ster <br /> Explsin: <br /> www.pca.state.mn,us • 651•246•6j00 � BOQ-b57�3864 • TTY 651•z81•5332 Or 8�D-b57•3864 + Avaiiable in gtfemative formats <br /> wq-wwl:rsa-3f . illq�r2 <br /> � <br />