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Property address: �� i /,,^u��u�k ��4�.( D�O''° Inspector initials/Dat I05 <br /> (mnHdd�yyyy) <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharges sewage to the ❑Yes (:] No ❑ Searched for surface outlet <br /> round surface. ❑ Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑Yes ❑ No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters. ❑ Homeowner testimony(See Commentvuxplenation) <br /> System causes sewage backup into ❑Yes ❑ No ❑"Black soil"above soil dispersal system <br /> dwelling or establishment. <br /> ❑ System requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminent threat to public ❑ Unable to verify(See Commentvrxplanabon) <br /> health and safety. ❑Other methods not listed(See Comments;Explanatbn) <br /> Com ments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes allo ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Fort(Attach) <br /> compliant it allowed in local ordinance. <br /> Sewage tank(s)leak below their [I Yes Jallo ❑Observed liquid level below operating depth <br /> designed operating depth. Examined empty(pumped)tanks(s) <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 CornmenisoExplena6m) <br /> system is failing to protect groundwater. ❑Other methods not listed(See CommentwExplanabon) <br /> Comments/Explanation: <br /> �aksorvully mak -+ane obsGtJa+ions in}u�ie -E-io,�s,ter- Loncl�s�a,� -�1' <br /> " 1�,u abo�Q_ Corvti�l�a�1Ce, Co►'►��o>1en->�- Z of rj cr ti� 1 G�Z Co{f2CJ <br /> C69TI FI014 10 AJ <br /> -�vs l ILSs M Avt- l�o- },� K�c , ,%-6- \kc}; , I r>L AA PC i4 0 i Z <br /> 3. Other Compliance ConGttions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes' ❑No ❑Unknown <br /> b. Other issues(elecbical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* ❑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 • 3116112 Page 2 of 3 <br />