12-06-19 Septic Compliance Form - Laserfiche WebLink

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, Property address: 1510 Green Trees -Road— Inspector initials/Date: - 10123/19 1. Impact on Public Health — Compliance component #1 of 5 Compliance criteria: _ Verification method(s): System discharge sewage to the ❑ Yes ❑ No ❑ Searched for surface outlet around surface. ❑ Searched for seeping in yardibackup in home System discharge sewage to drain tile ❑ Yes ❑ No El Excessive ponding in soil systemlD-boxes or surface waters. [ Homeowner testimony (See CommentslExplanation) System � ❑ "Black soil" above soil dispersal system cause sewage backup into ❑Yes ❑ No y g p ❑ System requires "emergency" pumping dwelling or establishment. -- ---- - ❑ Performed dye test Any "yes" answer above indicates the system is ❑ Unable to verify (See CommentslExplanation) an Imminent Threat to Public Health and Safety. ❑ Other methods not listed (See CommentslExplanation) CommentslExplanation: 2. Tank Integrity -Compliance component #2 of 5 Compliance criteria: Verification method(s): System consists of a seepage pit, ❑ Yes No ❑ Probed tank(s) bottom cesspool, drywell, or leaching pit. ❑ Examined construction records Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form (Attach) compliant it allowed in local ordinance. ❑ Observed liquid level below operating depth Sewage tank(s) leak below their ❑ Yes No ® Examined empty (pumped) tanks(s) designed operating dem If yes, which sewage tank(s) leaks: El Probed outside tank(s) for "black soil" E] Unable to verify {see Comments/Explanation} Any "yes" answer above indicates the ❑Other methods not listed (See CommentslExplanation) system is Failing to Protect Groundwater. CommentslExplanation: On 10123119, Elmer J. Peterson Co. pumped tanks. 3. Other Compliance Conditions —Compliance component #3 of 5 a. Maintenance hole covers are damaged, cracked, unsecured, or appear to structurally unsound. ❑ Yes` ❑ No ❑ Unknown b. Other issues (electricalhazards, etc.) to immediately and adversely impact public health or safety. ❑ Yes"` ❑ No 1] Unknown 'System is an imminent threat to public health and safety Explain: c. System is non -protective of ground water for other conditions as determined by inspector ❑ Yes- ❑ No *System is failing to protect groundwater Explain: www.pca.state.mn.u5 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 Available in alternative formats wq-wwists4-31 • 1124112 Page 2 of 3