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Property address: / 0 G 2 <br /> LA �k71' �..J <br /> Inspector initials/Date: Z _ ( <br /> (mm/dd/yyyy) <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 Comments/Explanation) <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. <br /> ❑Other methods not listed(See Comments/Explanation) <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 "Jo ❑ 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(Attach) <br /> compliant if allowed in local ordinance. <br /> ❑Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes 1151allo Examined emptyum <br /> designed operating depth. (p ped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s) for"black soil" <br /> Any "yes"answer above indicates the 111 Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. ❑ Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: /.)t) li�� ) 17-2,.Lik 10,) c) i- <br /> Business Name: Kothrade Sewer,Water&Excavating, Inc. <br /> Business Address: 12059 Whitetail Ln, Hanover,MN 55341 <br /> Business Phone:763-498-8702 _ <br /> Company Representative: Larry Bursch MPCA#:0192/9199 Signature:;;-- ZeizZ „ � <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* 0 No ❑Unknown <br /> b. Oilier issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes* ❑No 0 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 /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31b • 6/4/14 Page 2 of 4 <br />