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Property address: 1000 Cox Farm Road, Long Lake, MN 65356 <br />1. Impact on Public Health —Compliance component #1 of 5 <br />ComRliknice criteria: <br />System discharge sewage to the ❑ Yes ® No <br />_ground surface._ T <br />System discharge sewage to drain the ❑ Yes I 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 Threat to Public Health and Safety. <br />CommentslExplanation: <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 />Seepage pits meeting 7080.2560 may be <br />compliant if allowed in local ordinance <br />Sewage lank(s) leak below their I ❑ Yes ® No <br />_designed operating depth. _ <br />If yes, which sewage tank(s) teaks: <br />Any "yes" answer above indicates the <br />system is Failing to Protect Groundwater. <br />Comments/Explanation: <br />Tanks were pumped at time of inspection <br />Inspertor initialslDate: 5-12-14 RK <br />Verification method(s): <br />® Searched for surface outiet <br />® Searched for seeping in yardibackup in home <br />❑ Excessive ponding in soi) systemlD-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 Cnmments/Fxpianation) <br />❑ 01her methods not listed (see Ccmmenis/Explanation) <br />Verification method(s): <br />Probed tank(s) bottom <br />❑ Examined construction records <br />❑ Examined Tank Integrity Form (attach) <br />❑ Observed liquid level below operating depth <br />D4 Examined empty (pumped) tanks(s) <br />❑ Probed outside tank(s) for black soil" <br />❑ Unable to verify (See Comment.vFxpianation) <br />❑ Gther methods not listed (See CammentslExplanation) <br />3. Other Compliance Conditions —Compliance component #3 of 5 <br />a. Maintenance hoie covers are damaged, cracked, unsecured, or appear to structurally unsound. ❑ Yes' 0 No ❑ Unknown <br />b. Other issues (erectrfcalhazards, 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 groundwater for other conditions as determined by inspector ❑ Yes' ® No <br />"System is failing to protect groundwater <br />Explain: <br />wwy+-pra.state.mn.us 651-296-6300 800-657-3864 TTY 651-282.5332 or 800-657-386d - Available in alternative formats <br />wq-wwists4.31 • f124112 Page 2 of 3 <br />0 <br />