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Feb 29 2016 05:06PM HP FaxRusty Olson 7634988290 page 6 <br /> Property address: 1185 WyndmWe Road <br /> Inspector initiate/pate: 22611 g <br /> 1, Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification mealod(s): <br /> System discharge sewage to the 12 Yes ❑No ❑ Searched for surface outlet <br /> _Jround surface. ❑ Searched for seeping In yard/backup in home <br /> System discharge sewage to drain 1119 ❑Yes ❑No ❑ Excessive ponding In soU system/D-boxes <br /> or surface waters. ❑ HOmeOwnef testimony(See��WlanaBan) <br /> System cause sewage backup into ❑Yes ❑ ❑ •Biadc sole atxrre Soil dispersal system <br /> dweIling or establishment. ❑ System requires"emergency pumping <br /> Any"Yes"answer above indicates the sysftm s ❑ Performed dye test <br /> an Imminent Thr"t to pub/k Hea/tJh and Safety, ❑ Unable to verity flee Cornrwn(VExplenaVM) <br /> ❑ <br /> Commerrts�anation: Other methods not Hated(see Commer►ts/ExpranaWn) <br /> 2. Tank Integrity—Compliance compOnent#2 of 5 <br /> Com Illance criteria: Viiwftadon method(&): <br /> System consists ora seepage 70t �Yes ❑ Probed tank(&)bottom <br /> cesspool,drywell,or leaching <br /> ❑ Examined oonatrucfiori records <br /> Seepage Ars 11ee6M 7080.2460»ley be <br /> cont lent 4 albwed in local ordnarm, ❑ Examined Tank Integrity Form(Attach) <br /> Sewage teink(s)leak below their [111 Yes ®Ivo 11 Observed liquid level below operating depth <br /> designed o h. ® Examined empty(pumped)tanks(.) <br /> If yes,which sewage tanks)leaks: ❑ Probed outside tank(s)for"black soil" <br /> Any "�W„answer above indicates the ❑ Unable to verity(see Ca,enta�Exp/anarlon) <br /> system is Fairing tO Prott+ct Groundwater. ❑Other methods not listed(See Cor mentwaplaneaon) <br /> Comments/Explanation: <br /> On 2/25/16,Elmer J.Peterson Co.pumped septic tanks. <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Mair*ermnoe hole covets are damaged,cracked,unsecured,or appear to structurally ur>sound. ❑Yes* <br /> ❑No ❑Unknown <br /> b, Other issues <br /> is an lit"MkMVt 911110W to P r Y and Impact public heath or safety. ❑Y.s` [3 [3[3 UNcnown <br /> uWJc lisattlr and aadety <br /> Explain. <br /> C. System is non-protective of ground water for other conditions as demd by Inspector ❑Yes• ❑No <br /> 'SyBterrt is f"np to probed 9youndMeter <br /> Explain: <br /> v;ww•Pca-state-mn.us • 651-296-6300 800-657-3864 TTY 651.282-5332 ora00.657-3864 . Available to altemattve formats <br /> vr'Q-wwis&+31 . 1124112 <br /> Page 2 of 3 <br />