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Feb 0713 09:10a ' Joseph Olson 763-498-8290 p.6
<br /> Property address: 65 Stubbs Bay Road lnspecboi iriitialslDate: 4l23/12
<br /> 1. Impact ot� Public Health—Compliance cor�ponent#1 of�
<br /> Com liance criteria: Venfication methodts):
<br /> System discharge sewage to the �Yes � No ❑ Searohed far surtace out3et
<br /> araund sufidce. ❑ Searched far seeping in yardbackup in home
<br /> 5ystem discharge s$wage bo drain file ❑Yes (� No � ��ive ponding in soil system/D-boxes
<br /> or surtace waters. ( C Homeowner testimony(seB commerxs/Eupranad�on)
<br /> �"" - "" [! '6tack soil"above soi!dispersal system
<br /> 5ystem caus�sewage backup into ❑Yes Q No [] System requires'emergency'pumping
<br /> dwelling or establishmer�k.
<br /> ❑ PerFormed dye test
<br /> My"yes"answer atrove indreates the system is ❑ Unable to verify(see Comme►rts/Ezplanahon�
<br /> an lmrnineht Threat to Public Health and Safiety. ❑ Other methods not listed (See CommanGs�Explanation)
<br /> Comm ents/Exp la na3io n:
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<br /> 2. Tank Integrity—Compliance componeni�2 of 5
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<br /> COfTI 118t1Ce C�@r11: �/@�tf1CA#IOiI 113E�hdd(S): �
<br /> fiy$tem consists of a seep�ge'pit, ❑Yps � No , , ❑ Probed tank(s)bottom
<br /> . - .cesspoal, drywell, or leaching pit: ---� . -❑ Examined construction reaords ..� .
<br /> aeapage plts mee�ing�paQ.2550 maybe I 0. Examined�ank Integ�ity Form(Attach)
<br /> com�pNant if aAowed in locST"ond�iance. -
<br /> �.. ,���t r,�.�,. , � �bserved(i�uid I�ve!bebw operating depth
<br /> Sewwage tank(s)leak below their ❑Yes �No � ��i�ed'empty(pumped)tanks(s)�
<br /> ' n de th: _ ,
<br /> desi ned o rab n� ;���C'�or'black soiP
<br /> lf yes,,�WhiCh'sLwage���5rrk( � I��: . [] Uro ble t utstde tenl� s)'mrnernsl�xplartation)' : �
<br /> qny ,yes� artswoer abov�indicates the �
<br /> s m�s Fa'm'` P��OfECf GrOUAdwBi'�I. C3 �her methods not[istedLfSae comn►erttsl'Explsnetion)
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<br /> �oa�c�ments/Eacplanation.;resuE� „ . .. , st��r: , �.� ,..,T , .�� ,� xF,. • . ,,,
<br /> 0r�+i123l12,'E(rrierU:'�Pe�tirsdrr Co. pumped septiS#Anks. All 3 manholes are coveted with 4-6 inches of wopd chips., No; ;,.
<br /> cracks or vira�ter feaks af thai time: -
<br /> ��'Fr,�7 _ _� : i�s rt:r� �
<br /> 3. Other CornplianCe Co�d�tions—Compliance component#3 of 5
<br /> a. Maintenance hole covers are darr�aged,cxscked,unsecured,ar appear to struduralty unsound. ❑Ye�' �No p Unknohm
<br /> `'" _.b. :t�ther is'su�t�lsc6i�iazte�ds.'_�tc�)to�mrneSiiaketY and�dve[�IY.im ct �blic health or saf_ .L�Yes* _QNo,_ ❑Unknown_.
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<br /> ""S�+�stem is an immin�r►t threaf to pvblic hea/fih and safefy
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<br /> c. S�stem r5.non rQ+tachv,e�f ground water ior other conditions as determined by ins ector ❑�Yes" ��p No �
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<br /> S��emis.f8l7N1 `to grou►�dweter KI r,', ,..
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<br /> ���3e mn ps��.,• � 1-296-63D0 • 800-657-3864 • . 332 or 800-b57-386•F • Available in alternative formats
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<br /> TfY 651-28 -
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<br /> . , � , pl¢ye 2 of 3
<br /> i • 1/24/'12 c `h�f. ;r,. . •
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