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f <br /> P rtY P , } ry <br /> Pro e address: _2915_Somerset Lane __ _ Ins ector initials/Date: __7/30/18 /' _ <br /> 1. Impact on Public Hedlth—Compliance component#1 of 5 <br /> Compliance criteria: 1 Verifica6on method�s): <br /> System discharge sewage fo the I �Yes ❑No ❑ Searched for surface outlet <br /> ground surface. � ❑ Searched for seepmg in yard/backup in home <br /> ---__— <br /> System discharye sewage to drain tile ' ❑Yes ❑No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner tesdmony(See Comments�cp�anation) <br /> System cause sewage backup into ❑Yes ❑No � �Black soil"above soii dispersal system <br /> dwelling or establishment. ❑ System requires'emergenc�pumping <br /> ----- ❑ PeAormed dye tesl <br /> Any"yes"answer above indicates the system is ❑ Unabte to verify�see canmentsFxaenetan� <br /> 8n Imminent Threat to Public Nealth and Safety. ❑ Other methods not listed(See Comments�Explanation) <br /> CommentslExplanation: <br /> 2. Tdnk Integtity—Compliance component#2 of 5 <br /> Compliance criteria: Veriflcation method(s): <br /> System consisis of a seepage pil, ❑Yes �No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. ❑ Examined oonstrudion records <br /> Seepeqe pts meeting 7080.2550may be ❑ Examined Tank Integrity Form(Attech) <br /> compliant il ellowed in local ordinence. � Observed liquid levei below opefating depth <br /> Sewage tank(s)leak below their ❑Yes �No <br /> _designed operating depth. � �mined emply(pumped)tanks(s) <br /> -` — "— ❑ Probed outside tank(s)for'black soif' <br /> If yes,which sewage tank(s)leaks: � <br /> Arty"yes"answer above indicates the ❑ Unable to veriiy(See commem�xpienanav,) <br /> sysfem is Failing to Pratect Groundwater. ❑Other methods not listed(See CommentsiExplanadon) <br /> Comments/Explanation: <br /> On 7/30/18,Elmer J.Peterson Co.pumped tanks. <br /> 3. Other Compliance Gonditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to slruduraly unsound. ❑Ves' ❑No ❑Unknown <br /> b. Other issues(eiecfricel n�e�ds,etc.)to immediately and adversely inpad public heatth or safety. p Yes` ❑No ❑Unknown <br /> 'System is an imminent threat to pt�bfic health and safety <br /> F�cplain: <br /> c. System is non-protective of ground water tor other conditions as detertnined by inspector ❑ves• p No <br /> 'System!s/alling to piotoct groundwater <br /> Explain: <br /> _ _..____ - - <br /> --..__ _-- <br /> www.pcastate.mn.us • 657-296-6300 • 800-657-38N • TTY 65i-282-5332 or 800-657-3864 • Avatlabte in altemative formats <br /> wq•wwfsts4•31 • 7/24!12 Poge 2 0/3 <br />