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Property address: /9$7 63 t y/ /4[.. /etkl, Inspector initials/Date: ,e, VV.V <br /> 1. Impact on Public Health— Compliance component#1 of 5 <br /> Corn I liance criteria: Verification method(s): <br /> Searched for surface outlet <br /> System discharge sewage to the ❑Yes No <br /> 'round surface. arched for seeping in yard/backup in home <br /> System discharge sewage to drain tile ❑Yes KNo ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup into ❑Yes 4FNo ❑ System requires"emergency'pumping <br /> dwelling or establishment. <br /> ❑ Performed dye test <br /> Any"yes"answer above indicates the system is ❑ 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 8 �i <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes ❑ No ❑ Probed tank(s)bottom <br /> cesspool,drywell, or leaching pit. ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> compliant if allowed in local ordinance. <br /> _ ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their Li Yes L l No ❑ Examined empty(pumped)tanks(s) • <br /> designed operating depth. <br /> If yes, which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> ❑ 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 /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked, unsecured,or appear to structurally unsound. ❑Yes* ❑No ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑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 ❑Yes* ❑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 /> Pnon 7 of 3 <br />