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Property address: 485 Stubbs Bay Road N <br />Inspector initials/Date: 7/23/19 <br />1. Impact on Public Health — Compliance component #1 of 5 <br />System discharge sewage to theJ ElYes El No <br />,round surface, j <br />System discharge sewage to drain the I ❑ Yes ❑ No <br />System cause sewage backup into( ❑ Yes 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 />t-om fiance criteria: _ <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 ❑ 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 />Comments/Explanation: <br />On 7/23/19, Elmer J. Peterson Co. pumped tanks. <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 CommentalExplanation) <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 />® 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 Comments/Explanation) <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. ❑ Yes* [:]No 0 Unknown <br />*System is an imminent threat to public health and safety <br />Explain: <br />c. System is non -protective of groundwater for other conditions as determined by inspector ❑ Yes• ❑ No <br />*System is failing to protect groundwater <br />Explain: <br />•_..••.N�a.bLa.CJIII I.U5 657-Ly6-6JUU 800-657.3864 TTY 651-282-5332 or 800-657-3864 Available in alternative formats <br />wq-wwists4-31 • 1124112 <br />Paw 2of3 <br />