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Property address: aC 0 F(144\ Inspectorinitials/Date: J 1-.t-1°1 <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: • Verification method(s): <br /> System discharge sewage to the ❑Yes 1E1 No 0 Searched for surface outlet <br /> _ground surface. El Searched for seeping In yard/backup In hon 1J• J <br /> System discharge sewage to drain tile 0 Yes El No MI Excessive ponding in Boll aystem/D-voxes YS <br /> or surface waters. ] Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup Into 0 Yes ® 'Slack soil'above soil dispersal system •. <br /> dwelling or establishment. ❑ System requires'emergency'pumping <br /> ❑ Performed dye test <br /> Any"yes"answer above Indicates the system is 0 Unable to verify(See Comments xplanation) <br /> an imminent Threat to Public Health and Safety. Ei Other methods not listed <br /> Comments/Explanation: 519 n n�c )-�� A'C Comments/Explanation) <br /> • <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: . Verification method(s): • <br /> System consists of a seepage p0, ❑Yes 0 No 0 Probed tank(s)bottom <br /> •cesspool,drywall,or leaching pit. 0 Examined construcflon records <br /> Seepage pita meeting 7080?2550 may be ❑ EitamIntegrityForm ined Tank (Attach) <br /> compliant if Awed In local ordinance. <br /> 0 Observed liquid level below operating depth <br /> Sewage tank(s)leak below their 0 Yes El No <br /> designed operating depth. 0 Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: 0 Probed outside tank(s)for"black soil" <br /> • <br /> An D Unable to verify(See Comma <br /> y "Yes"answer above lndfcates thents/L�xp/anation) <br /> system Is Falling to Protect Groundwater. ❑other methods not listed(See Comments Explenettan) <br /> Comments/Explanation: • <br /> • <br /> • <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ©Yea* ®No ❑Unknown <br /> b. Other issues(eledidrical hazard%em.)to immediately and adversely impact Public health or safety. ❑Yes' p No 0 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 ll yes' 0 No <br /> *System Is falling to protect groundsveter <br /> Explain: pea-1 3tiSV i 5,0.43.-v 0 voo-) swS .- -<a oS wic,.�S <br /> 1-4¢ Svre-ctire.,►-s\,. <br /> WWW.pca.state.mn.us • 651.296.6300 • 800.6571.3864 TTY 651.282.5332 or 800-657-3864 . Available in alternative formats <br /> mu-wwists4.31 o 1124112 <br />