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Oct. 31. 2013 12: 03PM No. 2113 P. 6 <br /> property address: a O WOc i �_� � W v Inspectorinitials/Date. <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the , ❑Yes No ❑ Searched for surface outlet <br /> ground surface. le Searched for seeping in yard/backup in home 14,0 <br /> System discharge sewage to drain dile ❑Yes No Ili,Excessive pending in soil systemfD-boxes -4 <br /> or surface waters. CI Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into ❑Yes ® •Black soil"above soil dispersal system 140 <br /> No 0 System requires"emergency"pumping <br /> dwelling or establishment. <br /> Performed dye test <br /> Any"yes"answer above indicates the system Is El Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safety- <br /> El Other methods not listed(See Comments+t"xplanatlon) <br /> Comments/Explanation; <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Com'Iiance criteria: Verification method(s): <br /> System consists of a seepage pit, (LI Yes 0 No © Probed tank(s)bottom <br /> cesspool,drywall,or leaching pit. <br /> 0 Examined construction records <br /> Seepage pits meeting 7080.2550 maybe C] Examined Tank Integrity Form(Attach) <br /> compliant if allowed in local ordinance, <br /> Sewage tank(s)leak below theirEl Observed liquid level below operating depth <br /> 0 Yes LI No El Examined emptyum <br /> designed oseratin! de.th, (pumped)tanks(s) <br /> If yes,which sewage tank(s)Leaks: D Probed outside tank(s)for"black soil" <br /> Any "yes"answer above indicates the (] Unable to verify(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. ether methods not listed(See CommenfsiExptanatlon) <br /> Comments/Explanation: <br /> �i''i�C/ r{�1 l✓�t '�tiQ S�l't; 1),1 � G b�-�. <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 <br /> RI No ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to Immediately and adversely impact public health or safety. ❑Yes" gi No ❑Unknown <br /> "System N an imminent threat to public health and safety <br /> Explain: <br /> c. System is non-protective of ground water for other tvondltions as determined by inspector ❑Yes• Er No <br /> 'System is falling to protect groundwater <br /> Explain: <br /> www.pca.state.mn,us • 651.296.6300 • 800.657.3864 • 1TY 651-282-5332 or 800.657.3864 • Available in alternative formats <br /> wq-wwists4.31 • 1124112 <br />