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Prop�rty addra�ss: A Inspector inkfais/Date: !� _ <br /> 4S-31v-1 i.} <br /> 1. 1mpdCt on PubliG Hedlth—Compliance component#1 of 5 <br /> � <br /> Com Iiance criteria: Ver cation method(a): <br /> Syatem dlacherge aewage to fhe ❑Yea �No ❑ �ed fof surfece ouGet <br /> Qround surface. � earc.hed for see <br /> ping fn yardlbadcup in home a30 <br /> System discharge sewage to draln tile �Yes �No � $�e Ponding in soii system/p.boxes�.10 <br /> or surface waters. ❑ om6owner testlmony(Sea CommentsiEzpla»aym) <br /> Syatem cause sewape backup(nto ' ❑y� �No � lack so�'at�ove eoli dispersal system�ao <br /> dweiltng or establishment. ❑ tem requirea'emergenc�'pumping <br /> Any"yes"snswer above lndicates the system is � 8���teat <br /> an fmminenf Threaf to Public Health and Safety. � n�e to vedfy�see comme�,taipcp�e„auon� <br /> , � er methods not Usted(see Con,me„rs�xpte„auo„� <br /> CommentslExplanaUon: . <br /> . I <br /> 2. Tank Intt��ity—Compliance component#2 of 5 ' . <br /> Com Itance criterfa: .. Ver cation method(s); <br /> System coits(sts af a seepepe P�, ❑Yes ❑P!o ❑ robed tank s bottom <br /> cesspoot,dryweif,or leaching plt. �} <br /> ❑ miRed cons4vctlon reopMs <br /> SeeFe08 P/tr meetlnq 7080.2550 maybe ❑ ' ined Tank Irt <br /> com eM if allo»red in bce/oidMance. te$rity Fo[m(,qttacry� <br /> Sewape tank(s)leak below their ❑Yes ❑No � b$erved 1(quid level below operating depth <br /> designed operating de th. ❑ Ined empty(pumped)tAnks(s)� <br /> If yes,whlch sewage tank{s)teeks: ❑ mbed outaida tank(s)for'black soG' <br /> anY"yes"answer above/ndlcates fhe � +��e�vertiy�see comn,ant��anarron� <br /> sysfem is Falling!o Protect Groundwater, � 0 �me��Gseecs rsee c«nme„fs�xaa�q <br /> Comments/Explanation: <br /> S�-Fi ►�'f��'�'r.1?r� -SvkNrF� �t�t��C�'►�"� �' � Q�r�C�gor.� �u <br /> 3. Other Compliance Conditions—Compllance component�Ki 5 <br /> a. Maintenance hole cove�s are dameged,aadced,unaecur��ar appear.to . <br /> - Y unsound. ❑Yes �1�0 ❑uNa�ow� <br /> b. Other issues(e/erxn�osl hazer�ts eto.)to lmmedieteiy end edverseA!irtlPed p tlb heaRh or <br /> '�ystem/s an/mminanf thraai to pub/k hae18�and safety ��• ❑Y°s' �B No ❑Uoknawn <br /> Expiein: <br /> c. Syatem is non-proteethre of ground water for other Conc�tlans as de�rtn <br /> `SYstem is felAn9�Pro�9�undwater bY InsPeccor ❑Ye�• ■No <br /> Explatn: <br /> WWW,pGd�fdCe,II1i1�U5 � 651•Z9�6300 � 800�657•3�i4 � 11Y 651•282•S3 ar 800•657d864 . Avai[abte tn altemative fainats <br /> wq-wwfsfs4•31 • 1/2�/f2 <br />