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Aug 2413 06:04p Joseph Olson 763-498-8290 p.6 <br /> Property address: 1925 W. Farm Road inspector initials/Date: 8/20/ <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the I ❑ Yes ❑ No 0 Searched for surface cutlet <br /> ground surface. f ❑ Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile ❑Yes ❑No El Excessive ponding in soil systemlD-boxes <br /> or surface waters. ; ❑ Homeowner testimony(See Comments/Explanation) <br /> ❑ "Black soir above soil dispersal system <br /> System cause sewage backup into 0 Yes ❑No ❑ System requires"emergency'pumping <br /> dwelling or establishment. <br /> • <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_ [] Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, I ❑Yes ®No El Probed tank(s)bottom <br /> cesspool, drywell, or leaching pit. I ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be El Examined Tank Integrity Form (Attach) <br /> compliant if allowed in local ordinance. j <br /> 0 Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑ Yes ® No <br /> designed operating depth. ® Examined empty(pumped)tanks(s) <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 /> On 8/20/12, Elmer J. Peterson Co. pumped septic tanks. See notes on attached tank report. <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. p Yes" E No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. El Yes* 0 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- ❑No <br /> *System is failing to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651.296-5300 • 800.657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq•wwists4-31 • 1/24/12 Page 2 of 3 <br />