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Property address: 1925 Fox Street,Wayzata, MN Inspector initials/Date 11;151201 <br /> 1. Impact on Public Health — Compliance component #1 of 5 _ <br /> Compliance criteria: Verification method(s): <br /> System discharges sewage to the ❑ Yes ® No ® Searched for surface outlet <br /> ground surface. ® Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑ Yes ® No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters. <br /> ❑ Homeowner testimony(See Comrnents�Ext7lena�+ons <br /> System causes sewage backup into ❑ Yes ® No ❑ "Black soil'above soil dispersal system <br /> dwelling or establishment. <br /> ❑ System requires'emergency" pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminent threat to public ❑ unable to verify(See Comments/Explanation' <br /> health and safety. ❑ Other methods not listed (See Cornments/Exolanahon; <br /> Comments/Explanation: <br /> 2. Tank Integrity— Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit. ❑ Yes ❑ No ❑ Probed tank(s)bottom <br /> cesspool, drywell, or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meeting 7080 2550 may be ❑ Examined Tank Integrity Form (Attacf)) <br /> compliant if allowed in local ordinance. <br /> El Observed liquid level below operating de,�tth <br /> Sewage tank(s) leak below their ❑ Yes ❑ No <br /> designed operating depth. <br /> F1 Examined empty(pumped)tanks(s) <br /> If yes.. which sewage tank(s)leaks: EI Probed outside tank(s)for"black soil" <br /> Any "yes"answer above indicates the ❑ unable to verify(see Comments/Explanat+on' <br /> system is failing to protect groundwater. ® other methods not listed (See CommentsExpl ario'.­, <br /> Comments/Explanation: <br /> See attached Sewage Tank Complinace Certification completed by others. <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 _ <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes* ®No O o,,, <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* ® Nf ❑ <br /> *System is 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 failing to protect groundwater. <br /> Explain: <br /> www.pca.stat.e.mn-,:s 651-296-6300 800-657-3864 TTY 651-282 5332 or 800-657-3864 Available in al.tc r:,i,. 0 <br /> wq-wwists4.31 • 3;'!6112 <br />