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• Property address: 1101 Willowbrook Drive Inspector initials/Dale: 4118/17 <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> _Compliance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes 0 No ❑ Searched fix surface outlet <br /> round surface. ❑ Searched for seeping in yardlbackuP in home <br /> System discharge sewage to drain tib ❑Yes 0 No <br /> 0 Excessive ponding in soil system/D-boxes <br /> or surface water. ❑ Homeowner testimony(See CormrentsiEspianation) <br /> System cause sewage backup into ❑yes ❑No 0 "Slack soir above SCA digs/arse'system <br /> dwelling or ee ewhment 0 System requires'emergency pumping <br /> Any"yes"answer above Ind chi atm the system Is 0 Pew dye test <br /> an Imminent Threat to Public Health and Safety. ❑ Unable to odty(See Comments/Explanation) <br /> 0 Other methods not listed(See CommenGyExAtarratlon) <br /> Comments/Explanation. <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification <br /> metltod(a): <br /> System consists of a seepage Pit, ! 0 Yes ®No 0 Probed tank(s)bottom <br /> cesspool,drywall,or leeching pit. <br /> pitsSeepage meeting 7080.2550 they be ❑ Examined crortatruction records <br /> compliant it/Mowed in local onlMence. ❑ Examined Tank Integrity Forth(Mach) <br /> Sewage terhk(s)look below their ❑Yet ®No 0 Observed liquid level below operating depth <br /> ® <br /> designed 0 eratinst deuN►.. Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leeks: 0 Probed outside tanks)for'black soir <br /> Any ares"answer above Indicates the 0 Unable to verify(see comments xplanaaon) <br /> 0 Other methods not listed(see Cornmentt/Expiansson/ <br /> system is Falling to Prosect Groundwater. <br /> Comments/Explanation: <br /> On 4/18/17,Elmer J.Peterson Co.pumped tanks. <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured.or appear <br /> to structurally unsound. 0 Yes* ❑No 0 Unknown <br /> b. Other issues(electrical hazards etc)to immediately and adversely impact public health or safety. 0 Yes' 0 No 0 Unknown <br /> "System is an Imminent threat topubac health and safety <br /> Explain: <br /> c. System is non-protective of ground water for other cot/Mons as determined by inspector 0 Yes' 0 No <br /> 'System Is falling toprotect groundwater <br /> Explain: <br /> WW•pca.state.mn.us - 651-296-6300 • 900-657.3964 • TTY 651-282-5332 or 800-657-3864 • Avaltabte in attemative formats <br /> wq-wwists4.3/ • 1/24117 <br /> Page 2of3 <br />