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Property address: \*ot,V 0)-5, Inspector initials/Date: ] c21-A s-,y <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Corn•Bance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes No 0 Searched for surface outlet <br /> around surface, 3 Searched for seeping in yard/backup In homeNO <br /> System discharge sewage to drain tile 0 Yes si No si <br /> Excessive ponding in soil system/D-boxes?uO <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> Yes 11 No 'Black soil"above soil dispersal system 140System cause sewage backup Into <br /> dwelling or establishment. ❑ System requires emergency'pumping <br /> ❑ Performed dye test <br /> Any"yes"answer above Indicates the system Is <br /> an Imminent Threat to Public Health and Safety. 0 Unable to verify(See Comments/Explanation) <br /> 0 Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Corn•fiance criteria: Verification method(s): <br /> System consists of a seepage pit, 0 Yes 0 No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> 0 Examined construction records <br /> Seepage pits meeting 7080.2550 maybe 0 Examined Tank Integrity Form(Attach) <br /> corn.lent if allowed In local ordinance. <br /> Sewage tank(s)leak below their ❑ Observed liquid level below operating depth <br /> ❑Yes 0 No 0Examined empty(pumped)tanks(s) <br /> designed o•eratideath. <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 <br /> ❑Other methods not listed(See Comments/Explanauon) <br /> system Is Falling to Protect Groundwater. <br /> Comments/Explanation: <br /> cDe I <br /> k°0(4)00"C) , » - i).t ,:1t."*C 4,0-64 <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear.to structurally unsound. 0 Yes* ®No ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. 0 Yes' ®No 0 Unknown <br /> "System/s 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 falling to protect groundwater <br /> Explain: <br /> Yrifff,QCd•Ittlte,mil,US i 651496.6300 800.657.3864 • TTY 651.282.5332 or 800.657.3864 • Available in alternative formats <br /> wq•wwlsts4.31 • 1/24/12 <br /> • <br />