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Property address: 625 Spnng Hiii Road,arono�_MN Inspador initials/D�ts: J.0_3l12/17 <br /> 1, ImpaCt on Public Heelth—Compliance component#1 of 5 <br /> Compliance criteria: Ysriflaation method(s): <br /> System discharge sewage to the ❑Yes �No � Seer�ched for surface outlet <br /> ground swface. � Sea�ed for seeping in yard/badcup in home <br /> System discharge sewage to drain tile i ❑Yes �No � �cessive ponding in soil system/D-boxes <br /> or surface waters. ' ❑ Homeowner testimcx►y(See Comments/�'xplanat;a►) <br /> ' "' ❑ "Biadc soii"above sal dispersai system <br /> 5ystem cause sewage backup into ' ❑Yes � No � <br /> dwelling or establishment. ❑ System requires"emergency pumping <br /> --- ❑ Rerformed dye test <br /> Any"yes"answer abave/nd►caies the system la ❑ Unabls t0 verify(See GammenfslExp/anatfon) <br /> an Immina►t Threat to Pubpc Hea/th and Satety. ❑ Other methods not listec!(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Ta11k 111t@g�ity—Compliance component#2 of 5 <br /> Complfance criteria: Verification method(s): <br /> _._ _....______ �_�..._.� <br /> System cansists of a seepeqe pit, ` ❑Yes �No ❑ Probed tank(s)bottom <br /> cesspool,drywelf,o�leaching pit. ; � Exami�ed co�strudion records <br /> Seepege pits meeting 7060.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> c�mAliant rf alloa�ed in.bca!ordinarrc:e. <br /> - - ' ----- ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes �No <br /> designed operatin de h. ❑ �mined empty(pumped)tanks(s) <br /> �._�__---;— --....------- <br /> If yes,which sewage tank(s)leaks: ', ❑ Probed outside tank(s)for"btack sal" <br /> Any"yea"snsw�r above Indfcafea the ' ❑ Unable to verify(See Comments/Explartadon) <br /> system is Faftfng to Protec!Groundwater. �aner metnc�ds not rstea�see com,nenrsrEx�enar�on� <br /> CommentslExplanaUon: <br /> Previous septic cert.and aty records <br /> 3. Other Compliance Canditions—comp�iance component#3 of 5 <br /> a. Maintenance hole oovers are damaged,cradced,uns�ured,or appear to strudurally unsound. p Yes" �No ❑Unknowm <br /> b. Other issues(e/ecdica►heza�ats,eec.)to immediately a��dversely impad public heatth or safety. ❑Yes` �No ❑UnknaMm <br /> *Sysiem fs an lmminent threat to puWie Mea/Eh and ssfsty <br /> E�lain: <br /> a System is non-protedive of ground water for other conditions as determined by inspedor p Yes' �No <br /> *Syabem is fell/ny Go pmtectgroundwatar <br /> Explain: <br /> ___.......�. .._ _._............... ..._._._. <br /> �.__........._._ __._.._.._.— - <br /> www.pcastate.mn.us • 651-2%-6300 • 800-657-38b4 • TTY b51•2$2-5332 or 800-G5T-3864 • Available in attemative formats <br /> wq-wwls[s4-31 • 1/24/12 Poge 2 of 3 <br />