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Oct. 31. 2013 12: 03PM No, 2113 P. 10 <br /> Properly address: 9'0142pd j I in.speGtorin;tialelDate l /0 -,34)-(3 <br /> (i►iddYYYY) <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com•fiance criteria: Verification methed(s): <br /> System discharges sewage to the ❑Yes ❑No 0 Searched for surface outlet <br /> round surface. u Searched for seeping In yardlbackup In home <br /> System discharges Sewage to drain 0 Yes. ❑No 0 Excessive ponding In soil systecrdp-boxes <br /> the • surface waters. ❑Homeowner testimony(See Co mnentr✓Exprananort) <br /> System causes sewage backup Into ❑Yes ❑NO 0'glad(soil'above soli dispersal system , <br /> dwelling or establishment. <br /> El System requires`emergency pumping <br /> .Any"yes"answer above_Indicates the []Performed dye test , <br /> system is an imminent threat to public O Unable to verify(see Commentsii=xplanation) <br /> health and safety. <br /> ❑Other methods not listed(See Commenra/erplanaion) <br /> ComMentslF.xptanetion: <br /> 2. Tank Int ty—Com fiance component#2 of 5 <br /> coin•fiance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes P.11140 ❑Probed tank(s)bottom <br /> cesspool,drywall,or leaching pit_ 0 Examined Construction records <br /> Seepage elm meeting 7080.2550=V be 0 Examined Tank Integrity Form Wash) <br /> •• ,., • Y'aimed InIO Jordkwi . <br /> Sewage tank(s)leak below their El YesVo 0 Observed liquid level below operating depth <br /> designed operating depth. // examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: Q Probed outside tank(s)for'black soft <br /> Any"yes"answer above indicates the <br /> 0 Unable to verity(See ) <br /> system is failing to protect groundwater. 0 other methods not listed(See O crunenie/Explana ) <br /> CommentelElrpLanation: f E <br /> F C. 1 sonal j, made.-f1 e, obse,Nolions-, 1n-IcA Ye4Kii.o ,c.- coflc IJSiar) l <br /> -111t- a�bp\)e. Cpm 1 artet,JCom or�e.rri- l of- 5 c2 4k-} Art Cof f ems-(. <br /> Nf1�16' A�rct �J�3f.,rs P CE TIr~Ic)-Tice' <br /> est Cornl : „ ', _ , c rr,cl-a�Xt.+ , InL yti► Cf4% •Di�� — <br /> 3. Other ante Con'� ons—Compliance corn..neat#3 of 5 ' or- r <br /> a. Maintenance hole covers are damaged,sacked,unsecured,or appear to be lAnXtVraly wand. 0 Yen" 0 No 0 Unknown <br /> b. Other issues(elscaicel hard;alt)to Immediately end adversely impact public health or safety. 0 Yes' ❑Nn ❑Unknown <br /> *System loan imminent threat to public health and safety. <br /> Explain: <br /> a System is non-protective of ground water for other conditions as determined by inspector. 0 Yes- 0 No <br /> 'System is falfng to protect groundwater; <br /> Explain: <br /> www.pca.state.inn.us - 651-296.4300 • 800.657.3864 - TTY 651.282-5332 or 800-657-3864 • Available in alternative format, <br /> we-wwlsts4-31 • 3/16112 Page 2 of 3 <br />