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Jun to iY ue;Jup 763-21 •-1X9y p 2 <br /> L . , <br /> Properly sddtess: $D Inspector iniliaIsMate: Io= <br /> 1. Impact on Public Neakh—Compliance component#1 of 5 <br /> CornaMawnoe criteria, iVecifle.atton trlethed(s): <br /> System discharge sewage to the U Yes IN No ES Sewched for surface outlet <br /> ground audfaae. 19 Sawcnsa t`a;seeping in ya,-&bW up in homes <br /> SyvWn discharge sew®ge a drag his Yes 01 No EMeasive oondN it soil sys*r%V,4 t yes <br /> or surface waters. Nomea w arwrtimony;See ct>Irinw fteexpwww;,I <br /> System Cause _ ❑ 40ledc as:"above soil oisoarsal systerr. <br /> sewage backup into i ❑Yes �No <br /> dwelling or Mablishment ❑ System muires'eme-gerr-'run-ping <br /> • El ?erfarrtted aye tees <br /> Any"S+ea'snswerr ef�oew NJd/eatas:lie oyatem/s Q UnOtle to verly(See Cammenre&plernrnonr <br /> an l►nminvnt ThMW to Arbl/c NadMt and Salary. p Mer rrsittods nor listed(Sas Oam n#a SA rpWM"i <br /> Comini ntslExplanation: <br /> 2. Tank Integrity—Compliance component 42 or F� <br /> Complance cHtwis: Verification rivAhod(s): <br /> System colnialb of a seepage ph. ❑Yes 0 No ® Probed ranks)bodom <br /> cesspool.drywer,or 1escHng pit Examined wrs'ructk)v^mnr, <br /> seepewplts/lr env?M2330 maybe Q Ekarrined Iwk integrity Form'A.rwo) <br /> r Mwlowodin Mg owe• IX_ <br /> Sewage lank(s)lank below their ❑Yes 10 No Observed liquid level Calow eprarating daptl <br /> i <br /> A" oneratirrB death. I 0 Examured er•+pty;puviped)tene*a) <br /> M yes,which sewage tank(s)leaks: ❑ Probed milside tank(s)for`oledr Soil- <br /> 0 ilnaole to verity!Sas Cawmwdsjirdan+Aiorr; <br /> Any Ryas"answer above indl eetes rhe <br /> syMM is Failing to Pmiteet Oroundw"W ❑Osher molwds not asked(sne Cwrrwrrs--xpuwrapoN <br /> CommentdExplanetion: _..._.... <br /> 3. Other Comphar>Iee Conditions—Compliance component#3 of 5 <br /> a- Maintenance hole oovers are damaged,cracked, unsaaued,or appear to alni turally unsound. O YeE• X.No O Unknowr. <br /> b. Other testes Meda*Mum*ex.)b irontadwt*end adversely impact pubik:r!ealh or aatellr, p res- )04o O unknom <br /> Sysasm is en Imminwrt thre.r to vubft health and aafrty <br /> Explain: <br /> a S tem is of d water <br /> tr+ r�peta�ea e� ter etherstMMlons aw retarrnrr>w by irnpeacr L]Ytee• �I No <br /> 'System i$faft Ito P wt 9rwndMAsW <br /> Explain: <br /> Mw.v.pcastate.mn.us 6S1 X296-b3pp 800.657-316/ - TTY 651-tL2.53�2 0•fBOO.667.38W -�Avaittbse in a:0eiracive tor»�aw <br /> w4-ww1sW-31 . 1/24112 <br />