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Property address: 2400 Woodhaven Drive inspector initis s/Date: 727/12 <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 ❑No 0 Searched for surface outlet <br /> ground surface 0 Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile 0 Yes 0 No 0 ve ponding in soil system/D bones <br /> or surface waters. ❑ Homeownertestimony(See CommentsiExplanaeon) <br /> System cause sewage backup into ; 0 Yes 0 No CI "Black soil'above soil dispersal system <br /> dwelling or establishment ❑ System requires`emergency pumping <br /> ❑ Performed dye test <br /> Any"yes"answer above incicates the system is 0 Unable to verify(See Comments/aplanatron) <br /> an Imminent Threat to Public Health and Safety- ❑ Other methods not listed(See Commentsr5xplanadon) <br /> Convnents/Fxplantion: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit0 Yes ®No 0 Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit <br /> ❑ Examined construction records <br /> Seepage pits meeffng7080.2550 maybe 0 Examined Tank Integrity Form(Attach) <br /> compliant if:Bowed in focal ordinance. _ <br /> Sewage tank(s)leak below their ❑Yes ❑ Observed liquid level below operating depth <br /> designed operating depth. 0No ® EnMined empty(pumped)tanks(s) <br /> if yes,which sewagetank(s)leaks: ❑ Probed outside tank(s)for black soil' <br /> Any"yes"answer above indicates the ❑ Unable to verify(See CommerrtvExplanaffon) <br /> system is Failing to Protect Groundwater. ❑other methods not listed(See Comments/Fxplanabon) <br /> Comments/Explanation: <br /> On 727/12, Elmer J.Peterson Co.pumped the septic tanks. No cracks or water leaks at that time. <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> • <br /> a Maintenance hole covers are damaged,cracked-unsecured or appear to structurally unsound. ❑Yep' 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 to public health and safety <br /> blain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector 0 Yes' ❑No <br /> -system is failing to protect groundwater <br /> Explain: <br /> www-pcastate.nvtus • 651-296-6300 . 800-657-3864 • TTY 651-282-5332 or 800-857-3864 • Available in alba-native fomlars <br /> wq-wwists4-31 • 1/24/12 <br /> Paget of <br />