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Property address: 4565 Bayside Road �rono ArfN _ _____ Inspector initials/tlate: J. O.9/17/14 <br /> 1. 11'1'1pdCt o� PUbIiC �-le8lth—Compffance component#1 of 5 <br /> Campliance creteria; --,- _---- Ver�cation method(sf: <br /> Sysfem discharge sewage to the ❑Yes �No � Searched for surface outiet <br /> �round surface. i � Searched for seeping in yard/backup in home <br /> ___.------ -• <br /> �__.. <br /> System discharge sewage to drain tite � [)Yes �No ❑ Exaessive ponding in soil systerND-boxes <br /> or surface waters_ [� Homeowner testimony(See Comments/Explanation) <br /> Sysfem cause sewage backup into ❑Yes � ��B�ack soit"above soil dispersal system <br /> dwelling or establishmenf. ; <br /> ��O ❑ System requires"emergency°pumping <br /> - ❑ Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verify�See CommerrtsrExplanation) <br /> an lmminent Threat to Public Heaffh and Safety. <br /> ---- __ ______ ❑ Other methods not listed(See Comments/Explanation) <br /> CommentsJExplanation: <br /> 2. Tdt1k It1t�t'lty—Compliance cornponent#2 of 5 <br /> Compliance criteria: __ Verification m�thod(s); <br /> System consists of a seepage pit, i Q Yes <br /> cess ool,d j ��O � Probed tank(s)bottom <br /> p rywelf,or leaching pit. � Examin�d constructian records <br /> Seepage pits meeting 7080.2550 may be ; ❑ Examined Tank Integrity Form(Attach) <br /> _com�fiant if atlowed in local ordinance. '; <br /> ❑ C3bserved iiquid level below operating depth <br /> Sewage tank(s1 leak below their � ❑Yes <br /> � No <br /> ue��yr�:.��,rarufi„ �� th. � ❑ Euamii�ed empry(pumped)tanks(s) <br /> -�-—�-----_____�._t <br /> !f yes,which sewage tank{s)leaks: � ❑ Probed outside tank(sj for"black soil" <br /> - -----------------___....__.__ _ _ L.______. ❑ Unable to verify(See Commenfs/Explane6on) <br /> �11y "yes"answer abave indicates fhe �Other methods not listed(5ee CommentsfExplanation) <br /> sysfem is Failing to Protect Graundwater. <br /> Comments/Explanation_ <br /> 3. Qther Complian�e Conditions—Comp�iance component#3 of 5 <br /> a. Mai�tenance hole covers art damaged,cracked,unsecured,oc appear to struchrrally unsauncf. ❑Yes" �No p Unknown <br /> b. Other issues(e�ectricat hazards,etc.}to immediateiy and adversely impact public healfh or safety. ❑Yes* �No ❑Unknown <br /> '`Syst+em is an imminent tfrr�at fo pub/ic hea/th and safety <br /> E�cpiain_ <br /> c. System is non-protedive of ground water for other condi6ons�determined by inspector ❑Yes- �No <br /> '`S�rstem is failiag to protect�roundwaisr <br /> E�cplain: <br /> ----__. __-- <br /> www.pca.state.mn.us • 651-Z96-63QQ • 8d0•557-38b�4 • TTY 653-282-5332 or 800-657-3864 • Avaitabie in attemative formats <br /> wq-wwists4-3f . t/24/i� Page 2 af 3 <br />