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• <br /> Property address: 7,f3t.) ! (4- ( (41; Inspector initials/Dat � 1J'~1 q <br /> (mm/dd/yyyy) <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharges sewage to the 0 Yes 0 No ❑ Searched for surface outlet <br /> around surface. 0 Searched for seeping in yard/backup in home <br /> System discharges sewage to drain 0 Yes ❑ No 0 Excessive ponding in soil system/D-boxes <br /> tile or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> System causes sewage backup into 0 Yes 0 No 0"Black soil"above soil dispersal system <br /> dwelling or establishment. <br /> 0 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 Comments/Explanation) <br /> health and safety. <br /> 0 Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Com•liance criteria: Verification method(s): <br /> System consists of a seepage pit, 0 Yes eIgNo 0 Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> 0 Examined construction records <br /> Seepage pits meeting 7080.2550 maybe 0 Examined Tank Integrity Form(Attach) <br /> corn.liant if allowed In local ordinance. <br /> Sewage tank(s)leak below their ❑Yes No <br /> 0 Observed liquid level below operating depth <br /> designed operating depth. examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: 0 Probed outside tank(s)for"black soil" <br /> Any "yes"answer above indicates the 0 Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater, 0 Other methods not listed(See Comments/Explanation) /� <br /> , <br /> Comments/Explanation: --'42 c2�1a.� ,vjL � (4'S'- '' f'�r1Cee:1'°,uF'S'/ )-94 �d e5" <br /> Business Name: Kothrade Sewer,Water&Excavating, Inc. <br /> Business Address: 12059 Whitetail Ln, Hanover,MN 55341 <br /> Business Phone:763-498-8702 rc' <br /> Company Representative: Larry Bursch MPCA#:0192/9199 Signatu =01" <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes* 0 No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* ❑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. ❑Yes" 0 No <br /> *System is failing to protect groundwater <br /> www.pcastate.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Availabte in alternative formats <br /> wn.wwietc4.71h . h/4/14 <br /> Pnno of A <br />