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Property address: 2, (oo► O C SAX V.A-),4 Inspector initials/Date: � %o--1- as <br />(mm/dd/yyyy) <br />1. Impact on Public Health — Compliance component #1 of 5 <br />Hance cri <br />System discharges sewage to the I ❑ Yes OR No <br />System discharges sewage to drain ❑ Yes H No <br />tile or surface waters. <br />System causes sewage backup into (❑ Yes Q 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 />Comments/Explanation: <br />Verification method(s); <br />❑ Searched for surface outlet <br />Searched for seeping in yard/backup in home 1.,1C <br />Excessive ponding in soil system/D-boxes �_W <br />❑ Homeowner testimony (See Commentwaxplana(lon) <br />"Black soil" above soil dispersal system 140 <br />❑ System requires "emergency" pumping <br />❑ Performed dye test <br />❑ Unable to verify (See Comments/Explanation) <br />❑ Other methods not listed (See Comments/Explanaton) <br />_2. Tank Integrity — Compliance component#2 of 5 _ <br />Com liance criteria: <br />System consists of a seepage pit, ❑ Yes ❑ No <br />cesspool, dryweil, or leaching pit. <br />Seepage pits meeting 7080.2550 may be <br />compliant it 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 />Camments/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 />❑ Examined empty (pumped) tanks(s) <br />❑ Probed outside tank(s) for "black soil" <br />❑ Unable to verify (See Comm ents/Explanation) <br />❑ Other methods not listed (See Comments/Explanation) <br />L <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. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety. ❑ Yes* p No p 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 . <br />*System is failing to protect groundwater. <br />Explain: <br />www.pca.state,mn.us - 651-296-6300 800-657-3864 TTY 651.282-5332 or 800-657-3864 <br />wq-wwists4.31b • 614114 <br />❑ Yes* lid No <br />• Available in alternative formats <br />