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Page 2 of 3 <br />Property address: Inspector initials/Date: <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 <br />ground surface. <br /> Yes No 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 />System discharges sewage to drain <br />tile or surface waters. <br /> Yes No <br />System causes sewage backup into <br />dwelling or establishment. <br /> Yes No <br />Any “yes” answer above indicates the <br />system is an imminent threat to public <br />health and safety. <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, <br />cesspool, drywell, or leaching pit. <br />Seepage pits meeting 7080.2550 may be <br />compliant if allowed in local ordinance. <br /> Yes No 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 />Sewage tank(s) leak below their <br />designed operating depth. <br /> 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 />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 />X <br />X <br />X <br />X <br />V <br />Inspected installation of new tanks <br />X <br />X <br />X <br />730 Gander Road RLP 09/23/2020 <br />New installation