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i <br /> Property address: 160 TMfula Trail Inspector initials/Date: 6/4/18 <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 ❑ Searched for surface outlet <br /> _ground surface. __ i ❑ Searched for seeping in yard/backup in home <br /> System discharge sewage to drain We ❑Yes ❑No ❑ Excessive ponding In soil systemlD-boxes <br /> or surface waters. ❑ Homeowner testimony(See Commente/Expwmtion) <br /> ❑ 'Black soil"above sail dispersal system <br /> System cause <br /> sewage backup into ❑Yea ❑No ❑ System requires"emergency pumping <br /> dwelling or establishment. ❑ Performed dye test <br /> Any yae"answer above Indicates the system is ❑ Unable to verify(See CommenrstExpranation) <br /> an Imminent Threat to Public Health and Safety. ❑ Other methods not listed(See Commentw&pranet on) <br /> CommentLIEVlanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Complier criteria: Verification method(s): <br /> System consists of a seepage pit, I ❑Yes ®No ❑ Probed tank(s)bottom <br /> cesspool,drywall,or leaching pit. ❑ Examined construction records <br /> Seepage pits meeting 7080.2650 may be ❑ Examined Tank Integrity Form(Attach) <br /> —COV-. if allowed in local ordinpnoe: <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes ®No ® Examined empty(pumped)tanks(s) <br /> defined operating depth. <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for'black soil" <br /> Any"yes"answer above Indicates the ❑ Unable to verify(See Comments/Expran&0on) <br /> system is Failing to Protect Groundwater. ❑Other methods not listed(See CommerNyExptanetbn) <br /> Comments/Explanation: <br /> On 6/4/18,Elmer J.Peterson Co.pumped tanks. <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Malntenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes• ❑No ❑Unknown <br /> b. Other issues(eleksrtcd hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes` ❑No ❑Unk own <br /> 'System is an imminent tlueat to public health end safety <br /> Explain: <br /> c. System is hon-protective of groundwater for other conditions as determined by Inspector ❑Yes' ❑No <br /> 'System Is loping 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 • Avallabte in altemattve formats <br /> wq-wwfsts4-31 • 1/24112 Page 2 of 3 <br />