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� <br /> Prop�fty address: 3010 Somerset Lane Inspector Initials/Date I . 7/24/2018 <br /> (mm/dd/yyyy) <br /> 1. Impact on Public Health - Compliance component#1 of 5 <br /> Compliance Criteria: Verification method(s) <br /> System discharges sewage to the ,, � Searched for surface outlet <br /> ground surface � Yes � No <br /> ❑ Searched for seeping in yard/backup into home <br /> System discharges sewage to drain � ,, ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters Yes ❑ No <br /> ❑ Homeowner testimony(See Comments/Explanation) <br /> System causes sewage backup into � Yes � No � "Black soil"above soil dispersal system <br /> dwelling or establishment <br /> ❑ System requires"emergency"pumping <br /> Any"yes"answer above indicates that the system ❑ Performed dye test <br /> is an imminent threat to public hea/th and safety. p Unable to verify(See Comments/Explanation) <br /> ❑ Other methods not listed(See Comments/Explanation) <br /> Comments/Expl an ation: <br /> New installation <br /> 2. Tank Integrity- Compliance component#2 of 5 <br /> Compliance Criteria: Verification method(s) <br /> System consists of seepage pit, � Yes � No � Probed tank(s)bottom. <br /> cesspool,drywell,or leaching pit � Examined construction records <br /> Seepage pRs meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> compliant if ellowed in local ordinance <br /> � Observed liquid level below operating depth <br /> Sewage tank(s)leak below their � Yes � No ❑ Examined empty(pumped)tank(s) <br /> designed operating depth. � Probed outside tank(s)for"black soil" <br /> If yes,which sewage tank(s)leaks: � Unable to verify(See Comments/Explanation) <br /> Any "yes"answer above indicates that the system � Other methods not listed (See Comments/Explanation) <br /> is failing to protect groundwater. <br /> Comments/Explanati on: <br /> Tank integrity verified by pumping contractor <br /> 3. Other Compliance Conditions - Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound ❑Yes* �No ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safery ❑Yes* �No ❑Unknown <br /> •System is an imminent threat to public health and safety. <br /> Explain: <br /> c. System is non protective of groundwater for other conditions as determined by the inspector DYes" �No <br /> *System is failing to protect groundwater <br /> Explain: <br /> wq-wwists4-31c • 6/4/14 • www.pca.state.mn.us •Available in altemative formats • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 Page 2 0/3 <br />