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Property address: 4040 Watertown Road Inspector initials/Date: 11/3/17 <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> Compliance c • — Verification <br /> System discharge sewage 0 Yes ❑No 0 Sea"• . . surface outlet <br /> _ground surface. _ __ P deed for seeping in yard/badcup in home <br /> System discharge sewage to drain tile II . ❑No 0 Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> SystemDeux sewage backup info i es ❑No 0 'Black soir above soil dispersal system <br /> dwelling or establishment le System requires"emergency'pumping <br /> II • . ed dye test <br /> Any"yes"answer • indicates the system is 0 Un: <br /> •an imminent T t to Public Health and Safety. w (See Comments/Explanation) <br /> Comments/Explanation)❑ Other me• ... ... listed(See Comrrrenta/Explanation) <br /> Comments!Explanalion: <br /> 2. Tank Integrity-Compliance component#2 of 5 <br /> Compliance criteria: Verification methodis): <br /> System consists of a seepage pit, (❑Yes ®No 0 Probed tank(s)bottom <br /> cesspool,drywall,or leaching pit. 0 Examined construction records <br /> Seepage pas meeting 7080.2550 may be 0 Examined Tank Integrity Form(Attach) <br /> compliant it allowed h local ordinance. <br /> Sewage tank(s)leak below their i ❑Yes ®No 0 Observed liquid level below operating depth <br /> ® <br /> designed operating depth. I Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: 0 Probed outside tank(s)for`black soil" <br /> 0 Unable to verify(See Comments/Explanation) <br /> Any"yes"answer above indicates the <br /> system is Falling to Protect Groundwater. ❑osier methods not listed(See CorrxnentslExp/anatron) <br /> Comments/Explanation: <br /> On 11/3/17,Elmer J.Peterson Co.pumped tanks. <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance - ... era are damaged,cracked,unsecured,or appear to structurally unsound. 0 Yes' <br /> 0 No ❑Unknown <br /> b. Other issues(etecbica/ :,. . to immediately and adversely impact public _` . ❑Yes` 0 No 0 Unknown <br /> 'System is an imminent threat to.,,, health and safety <br /> Explain: <br /> c. System Is non-protective• ., •water for other Conditions as determi ❑Yes ❑No <br /> 'System is groundwater <br /> Explal ' <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • _ ----..----.._— ts <br /> TTY 651-282.5332 or 800.657-3Available in alternative formats <br /> wq•wwists4.31 • 1124/12 <br /> Page 2of3 <br />