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Property address: , kr tip✓ _{,f ' ,1 � (MI Inspectorinitiais/Date: <br />1. Impact on Public Health —Compliance component #1 of 5 <br />System discharge sewage to the I ❑ Yes ❑ No <br />ground surface. <br />System discharge sewage to drain tile 1 ❑ Yes ❑ No <br />System cause sewage backup intoI ElYes El No <br />dwelling or establishment. <br />Any "yes" answer above indicates the system Is <br />an imminent Threat to Public Health and Safety. <br />Comments/Explanation: <br />2. Tank Integrity —Compliance component #2 of 5 <br />System consists of a seepage pit, ❑ Yes ❑ No <br />cesspool, drywell, or leaching pit. <br />Seepage pits meeting 7080.2550 maybe <br />Sewage tank(s) leak below their I ❑ Yes ❑ No <br />If yes, which sewage tank(s) leaks: <br />Any "yes" answer above Indicates the <br />system is Failing to Protect Groundwater. <br />Comments/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 Comments/Explanation) <br />❑ "Black soil" above soil dispersal system <br />❑ System requires "emergency" pumping <br />❑ Performed dye test <br />❑ Unable to verify (See Comments/Explanation) <br />❑ Other methods not listed (See Comments/Explanation) <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 />ID Examined empty (pumped) tanks(s) <br />❑ probed outside tank(s) for "black soil' <br />❑ Unable to verify (See Commonts/Explanation) <br />❑ Other methods not listed (See CommenivExplana6on) <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* ❑ No ❑ Unknown <br />b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety. p Yes" OW ❑ 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 falling to protect groundwater <br />Explain: <br />www.pca.state.mn.us • 651-296.6300 • 800-657.3864 M 651-282-5332 or 800-657-3864 • Available in attemative formats <br />wq-wwists4-31 • 1124112 Page 2 of 3 <br />