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Proparlyaddreas: 41 Ti ,n4 ills bQy)G� Inapedoriniflala/nete: Fyy—�g <br />1. Impact on public Health—Compliance comporient#t of 5 <br />System discharge sewage to theI ❑Yes ®No <br />ground surtace <br />System discharge sewage to drain fila El Yea gi No <br />System cause sewage backup Into 10 Yes ®No <br />Any "yea" answer above Indicates theay$bm la <br />an Imminent Threat to public Nona and S . <br />Comments/Explanation: <br />2. Tank Integrity—Compianca camponent#2 of 5 <br />System consists of a seepage pk,I ❑ Yea ❑ No <br />cesspool, drywall, or leaching pk. <br />task below their I ❑ Yes ❑ No <br />If yes, which sewage tanks) isaks:--F— <br />Any'WS" answer above lnalcates the <br />ayatem 1s Falling to protect Groundwater. <br />Commentd(Expiamflon: <br />StZ, Ao�*Vo'Im4 G <br />Verification method(s): <br />❑ Searched for surface outlet <br />® Searched for seeping in yardlbagrup In home` <br />M Excessive ponding in soil eyawmnlbox¢e', <br />❑ Homeowner testimony (See O=,ssnra/Expianetbn) <br />M 'Black coir above soli dispersal system - <br />❑ System requires 'emergency" pumping <br />❑ Performed dye test <br />❑ Unable to verify (see commenis/Ekp/ens ten) <br />❑ Other methods not listed (See comM nn,,Expleneson) <br />Verification method($): <br />❑ Probed tank(s) bottom <br />❑ E)mmined construction records <br />❑ Examined Tank Integrity Porrn (Adam) <br />❑ Observed liquid level below operating depth <br />❑ Examined empty (pumped) tanks(s) <br />❑ Probed outside tank(a) for -black soil' <br />❑ Unable to verify (See Commentwap/anayon) <br />❑ Other methods not 5sted (See ComMnfs,Explenatron) <br />3. Other Compliance Conditions — Compliance component #3 of 5 <br />a. Maintenance hole commare damaged, oadwd,unsecured, drapPesrbetructumpy unaoiaid. ❑Yee• <br />ecfn'cflr INN* ❑ Unkn m <br />b. Other Issues <br />(sl hexads, etc.) to Immediately and sdversey. bnpscl publio heash or sefety. ❑ Yes• ®No ❑ Unbn <br />'Sysbm is an ImminmtthrWbPubik hmith mdaeaiy <br />Explaln: <br />a System is nor protwft of ground water faroher condaonc ae datem*md by mapector ❑ Yes^ ❑ No <br />'Syatambatgngroproasctgroundwabr <br />Explain: <br />WJlW.pU.Stete.mn.gs a 659.29b6355 . 5U6657dt64 .. TTP 65t.2112.Ma' <br />wo•wwlsts0.31 . 1124112 8gF657•3864 a Available N altemadve fminats <br />