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Property address: 4565 Bayside Road Inspector initials/Date: JS 1 5/28/2020 <br />(mm/dd/yyyy) <br />1. Impact on Public Health — Compliance component #1 of 5 <br />System discharges sewage to the I ❑ Yes ® No <br />discharges sewage to drain I ❑ Yes ® No <br />System causes sewage backup into ❑ Yes ® No <br />dwelling or establishment. <br />Any "yes" answer above indicates the <br />system is an imminent threat to public <br />health and safety. <br />Com ments/Explanation: <br />2. Tank Integrity— Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, ❑ Yes ® No <br />cesspool, drywell, or leaching pit. <br />Seepage pits meeting 7080.2550 may be <br />compliant f allowed in local ordinance. <br />Sewage tank(s) leak below their ❑ Yes ® No <br />designed operating depth. <br />If yes, which sewage tank(s) leaks: <br />Any "yes" answer above indicates the <br />System is failing to protect groundwater. <br />Com ments/Explanation: <br />Verification method(s): <br />® Searched for surface outlet <br />® Searched for seeping in yard/backup in home <br />❑ Excessive ponding in soil system/D-boxes <br />❑ Homeowner testimony (See CommentsrExplanation) <br />❑ "Black soil" above soil dispersal system <br />❑ System requires "emergency' pumping <br />❑ Performed dye test <br />❑ Unable to verify (See CommentsrExplanation) <br />❑ Other methods not listed (See CommentsrExplanation) <br />Verification method(s): <br />® Probed tank(s) bottom <br />® Examined construction records <br />❑ Examined Tank Integrity Form (Attach) <br />❑ Observed liquid level below operating depth <br />® Examined empty (pumped) tanks(s) <br />❑ Probed outside tank(s) for "black soil" <br />❑ Unable to verify (See Comments/Explanation) <br />❑ Other methods not listed (See CommentsrExplanation) <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 ❑ Unknown <br />b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety. ❑ Yes* ® No ❑ Unknown <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.state.mn.us • 651-296-6300 • 800.657-3864 <br />wq-wwists4-31 • 3/16/12 <br />• TTY 651-282.5332 or 800-657-3864 <br />• Available in altemative formats <br />Page 2 of <br />