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Property address: 180 North Shore Drive Inspector initials/Date: 8/21/19 le° <br /> • Impact on Public Health-Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes ❑ No 0 Searched for surface outlet <br /> ground surface. ❑ Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile ❑Yes ❑ No CI Excessive ponding in sail system/D-boxes <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup into ❑Yes ❑ No 0 System requires"emergency"pumping <br /> dwelling or establishment. <br /> ❑ Performed dye test <br /> Any"yes"answer above indicates the system is 0 Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safety. 0 Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity-Compliance component#2 of 5 <br /> Com•Hance criteria: Verification method(s): <br /> System consists of a seepage pit, 0 Yes ®No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be 0 Examined Tank Integrity Form(Attach) <br /> corn•tient if allowed in local ordinance. <br /> 0 Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes ®No ® Examined empty(pumped)tanks(s) <br /> desi•ned o.-ratin• de.th. <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> 0 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 /> On 8/21/19, Elmer J.Peterson Co.pumped tanks. <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. 0 Yes* El No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. 0 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 0 Yes* 0 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 • 1/24112 Page 2 of 3 <br />