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Prop�riyaddre�ss: �.�i7� 5�,.���� f..�-:; UspedorinNtals�IDate: �-s�' �-)��-�� <br /> 1. impact on Public Health—compliance componer�tt#1 of s <br /> � Com liance aritaria: VerHicat�on met�od(s): <br /> syatem disduuge sdwege to the p Yes �No ❑ �ed for aurtaoe outlet <br /> round surface. ■ 3�rc.hed ior sa�ing in yaMlbadcup In home lso <br /> System dischsrge sswage to�ain�ta ❑Yes �No ■ E�easnrs por�!!ng M soil syatemlD-b000es r►fl <br /> ar surface wats�. � ❑ Momeawner testlmor�y(S`as Comments�Expla»aNa,1 <br /> � 'BNick soiP'a�+te sofl d[Spereal aystem f� <br /> System cause sewa�e t�aadwp inb ❑Yss �Na [� �m requfres"emer9�Y PumPj�9 <br /> dwetlinp or estabHshment .❑ Pertortned dye test <br /> Any"yes"anawer abo�re Indlca�es t�ro ay�rrr 1a ❑ �,����y���,1 <br /> en lmmlr�ent Thr+eat te Publlc Ha�Hh�ufd Saf�ty. p p��s����ntsv�xpls� <br /> Commerrts/ExplanaHon: • . <br /> 2. Tank tntegrity—Cflmpliance component�2 of 5 � <br /> Com llanca c�[te�la: .. Ve�on method(s�}; , <br /> system oonststs of a seep�gs v�� l7 Yes Q tVo . � Probed tanlc(s)bo�rn <br /> �cesspoot,d�,or leac�pit. . []� E�aart�ined aonshuc�t reao�da <br /> se�a�ae�,n�er�reso.2�so,�,aay�ds C! Examu�ed 7an�c ir�gdty Fam�,a�aca�r� <br /> com nt l�asow�d Nt lxal ae�a►tce. ❑ Obeerv�ed 1) ld i�bebw <br /> Sewage tsnk(s)�k belo�w theM ❑Yes ❑No � ��ng�� <br /> dest ned o ratin d ❑ �xami�ed empiy(pumped)#enks(s) <br /> lf yes.whfc�sswe�e tank{s)leaks: ❑ P�o�de tank(s)for"blacic soEC' <br /> Any"�rea"answer above tnc�ca�es the . � urrebee to ver�y�s�ee car,�n[a�ic�reRaaar,� <br /> system is FafJing t�o Prot�ect Ground'wa[+sr. . O other methods nat nsted�se cx�mrnenca�c�ra„auor,� <br /> Comme�f#tJExplanatlon: • <br /> S�-�i 1�'��r��.�r�CJ 'Stt�FN+� IN'��%'�-1''�"� '�►��'� -'� ��%'��yv� • dc� � <br /> 3. Other Compliar�ce Conditions—Compt�rtrtc»e oanponent#3 of 5 <br /> a. Msi�roenar�oe hole ooMeca aro dam��credaed.wreepngd�a'�ppe�r��napY uneour�. ❑Yee' �IVo ❑urdcnown <br /> b. OlEter is6ue8(efs�elh�aert7s,e�a.)�o MRI�I t�d adveraeh/hrtpac�PubliC healF�t or 8s[eiy. �Yas" �NO 0 Unknam <br /> "Sys�em la an hnminosffhrwt b publk f�dd►�d�ahfy <br /> Explain: <br /> C. SyBbe�n��9diVe of�ound vvater tor Other'��defi�nec!Mr�pector ❑Yss' l�l�o <br /> �Ya�wn!s!l�1dn��a prolect�ndNa� • <br /> Facplsin: . <br /> � www.pca.stas�.mn.us • 651�Z96�63�0 � eoo�66�•3e6a • • rnt b5s•2�!•5332 ar a00�7�3eia • availabte�atcen�atwe fom,ats <br /> wq wwlslxl-3t • lI21/f2 � <br />