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Property address: y�,`-L� L��'(�S=Y�-�,c�J��,� Inspector initials/Date: �'�=� lG�—JQ/-/;.'._ 1. Impdtt ott Publit Health—Compliance component#1 of 5 Com liance criteria: Verification method(s�: System discharge sewage to the ❑Yes �No ❑ Searched for surface outlet round surface. � Searched for seeping in yard/backup in home� System discharge sewage to drain tile ❑Yes �No � ��ssive ponding in sal system/D-boxes �� or surface waters. ❑ Homeowner testimony(See CommentsiExplanaHon) System cause sewage backup into ❑Yes � No � �Black soil"above soil dispersal system �p dwelling or establishment. ❑ System requires"emergency'pumping ❑ Performed dye test Any"yes"answer above indicates the system is ❑ Unable to verify(See Comments/Explanation) an Imminent Threat to Public Health and Safety. ❑ Other methods not listed(see CommentsiFcplana6on) Com ments/Explanation: 2. TBnk 111tegrity—Compliance component#2 of 5 Com liance criteria: Verification method(s): System consists of a seepage pit, ❑Yes ❑No ❑ Probed tank(s)bottom cesspool,drywell,or leaching pit. ❑ Examined construction records Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) com liant if allowed in loca!ordinance. ❑ Observed liquid level below operating depth Sewage tank(s) leak below their ❑Yes ❑ No desi ned o eratin de th. ❑ Examined empty(pumped)tanks(s) If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" Any "yes"answer above indicates the ❑ Unable to verify(See Comments/Explanation) system Is Failing to Protect Groundwater. ❑Other methods not listed�see commenrs�cp�anat�o�� Comments/Expla nation: 5�'.�i +�-j'rC vSr[.�� 5�+,.a� 1 t��-S'�',�;.�t,.t-C�( ��'� 3. Other Comptiance Conditions—Compliance component#3 of 5 a. Maintenance hole covers are damaged,cradced,unsecured,or appear to strudurally unsound. ❑Yes' �No ❑Unknown b. Other issues(electrical hazards,etc.)to immediately and adversety impact public health or safety. ❑Yes* �No ❑Unknown *System is an imminent threat to puWic health and safety Explain: c. System is non-protective of ground water for other conditions as determined by inspedor ❑Yes• �No *System is falling to prodect groundwater Explain: www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651•282-5332 or 800-657-3864 • Avaitable in altemative formats wq-wwists4-31 • 1/24/12