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Property address: �� �/•� � (.� lA TZ Inspector initials/Date: <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> —Compliance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes [ No VY Searched for surface outlet <br /> round surface. JR Searched for seeping in yard/backup in home <br /> E] Excessive ponding in soil system/D-boxes <br /> System discharge sewage to drain the E]Yes IQNo <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> ❑ "Black soil'above soil dispersal system <br /> System cause sewage backup into ❑Yes M No ❑ System requires"emergency"pumping <br /> dwelling or establishment. ❑ Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safety. ❑ Other methods not listed(See CommentsEExplanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance.criteria:Sr_ ,-K-.4jk Verification method(s): <br /> System consists of a seepage pit, ❑Yes No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be �°Examined Tank Integrity Form(Attach) <br /> compliant if allowed in local ordinance. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes No ❑ Examined empty(pumped)tanks(s) <br /> designed operating depth. <br /> ❑ Probed outside tank(s)for"black soil" <br /> If yes,which sewage tank(s)leaks: <br /> ❑ Unable to verify(See Comments/Explanation) <br /> Any "yes"answer above indicates the ❑Other methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <br /> Comments/Explanation: <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes* *o ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* V No ❑Unknown <br /> *System is an imminent threat to public health and safety <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector ❑Yes* No <br /> *System is failing to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1124112 Page 2 of 3 <br />