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Property address: �-,Wim L/ -�� � Inspector initials/Date:' "�� C/ ' •�6 �y <br />- — - <br />1. Impact on Public Health —Compliance component #1 of 5 <br />Compliance criteria: <br />System discharge sewage to the ❑ Yea ❑ No <br />ground surface. <br />System discharge sewage to drain file ❑ Yes ❑ No <br />or surface waters. <br />System cause sewage backup into ❑ Yes ❑ No <br />dwelling or establishment <br />Any "yes" answer above indicates the system is <br />an Imminent rhreat to Public Health and Safety. <br />CommarblExplanation: <br />2. Tank Integrity -Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, ❑ Yes ® No <br />cesspool, drywell, or leaching pit. <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 CommentOFxplanation) <br />❑ 'Black soil" above soil dispersal system <br />❑ System requires "emergency" pumping <br />❑ Performed dye test <br />❑ Unable to verify (See Comments/Expianation) <br />❑ Other methods not listed (See Comments/Explanatton) <br />Verification method(s): <br />❑ Probed tank(s) bottom <br />❑ Examined construction records <br />Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form (Attach) <br />compliant if allowed in total ordinance. <br />❑ Observed liquid level below operating depth <br />Sewage tank(s) leak below their ❑ Yes No �r <br />designed operatin th. Examined empty (pumped) tanks(s) <br />If yes, which sewage tank(s) leaks: ❑ Probed outside tank(s) for `black soil" <br />❑ Unable to verify (See Comments/Explanation) <br />Any `yes" answer above indicates the ❑ Other methods not listed (See Comments/Explanation) <br />_system is Failing to Protect Groundwater. <br />Comments/Explanation: /-toxo /- /65v forrabu 7-4AAr. 1050 iaNk_ tS +-1.< P,,r•+ p `rc,4- <br />'&4ift ;„t p&oe. <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: Lany Bursch MPCA #: 0192/9199 Signatww� <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 (electri_-a .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 />www.pes.state.mn.us 651-296-63W BOO.657.3864 TTY 651-282-5332 or 800.657-3864 Available in alternative formats <br />w4-wwlsts4-31 • 1124/12 <br />Page 2 of 4 <br />