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Nov 12 2015 09:26PM HP FaxRusty Olson 7634988290 page 13 <br /> Property address: 3085 Watertown Road inspector initialsfDate: 9130/15 <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 file Cl Yes Cl No ❑ Excessive ponding in soli system/D-boxes <br /> gr surface waters. ❑ Homeowner testimony(See Corrwmnt&Explanstion) <br /> System cause sewage backup Into i ❑Yes ❑ 'Black soil"above soil dispersal system❑No ❑ <br /> dwelling or establishment. System requires'emergency" pumping <br /> ❑ Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verify(See Cwnment&,FxP wation) <br /> an Imminent Threat to Public Health and Safety. ❑ Other methods not listed(See CommosiExpienation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification nWhod(s): <br /> System consists of a seepage pit, ❑Yes ®No ❑ Probed tank(s)bottom <br /> cesspool,drywall,or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pitsmeating 7080.2550 may be ❑ Examined Tank Integrity Fort(Attach) <br /> compliant 9 e00wed in food ordinance. <br /> � ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes ®No ® Examined err�ty(pumped) s <br /> designed.o atin de ped tanks( ) <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 Comrnsnw&pianedon) <br /> system is Failing to Protect Groundwater. ❑ �methods not listed(See ComrnentslExplenetbn) <br /> Commerds/Explanation: <br /> On 9130/15,Elmer J.Peterson Co.pumped septic tanks. <br /> I Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Ye®* ❑No ❑Unkrawn <br /> b. Other issues(electrirat heron etc.)to immediately and adversely impact public health or safety. ❑Yes* ❑No ❑Unknown <br /> *8ystlern is an knrnfrrent thr9st to public MmM and sa ty <br /> Explain: <br /> Q System is rion-prolletdive of ground water for other conditions as determined by inspector ❑Yes- ❑No <br /> *System is ldtAng to Protect grcundwww <br /> Explain: <br /> www.pca.state.mn.us . 651-2%-6300 800 657 3864 TTY 651-2132-5332 or a00-657-3a64 . Available in alternative formats <br /> cup-wwfsts4-3f • 1124112 Page 2 of 3 <br />