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Irequest.pdf https://word-view.officeapps.live.com/wv/WordViewer/request.pdf?F... <br /> r=roperty address 432� �'��ppewa Lane vrono, MN 55�5� Inspector initialsr�aie ��d ; "ur?8/2r�1� <br /> _ irnm;dd/YYYY.� <br /> 1 . Impact on Pub(ic Hea(th— Compliance component#1 of 5 <br /> Compliance criter�a: _ Verification method�s): <br /> System discharges sewaqe to the ; ❑Yes � No U Searched tor surface outlet <br /> yround su�face. ___ ' � Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑Yes � No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surFace waters. _ ❑ Homeowner testimony(See CommentsiExpiana6on) <br /> System causes sewage backup into ❑ Yes � No ❑ "Black soil"above soil dispersai system <br /> dvrelfing or estabiishment. <br /> _ __ _ ❑ System requires"emergency"pumping <br /> Any"yes"ansWer ahove indicates ihe ❑ Perfo�med dye test <br /> system is an imminent threaf to public ❑ Unable to verify(See Comments/Explanation) <br /> /1@c'i/fh cil�d Saf@rJ/. ❑ Other methods not listed (See Cvmmenis/Explanatron) <br /> Com ments/Explanation: <br /> System causes sewage backup into home not confirmed. Nome is vacant. <br /> 2. Tank Integrity—Compiiance component#2 of 5 <br /> Com�liance criteria: Verification method{s): <br /> System consists of a seepaye pit, []Yes � No ❑ Probed tank(s)bottom <br /> cesspool,drywell, or leach�ng pit. ❑ Exam�ned construction records <br /> Seepaqe prts meeting 7G80.2550 may be ❑ Examined Tank Integnty Form(Attach) <br /> compliant ff a!lowed rn 1oc:a!ordinarx,r. _ <br /> — — -- ❑ Observed liquid level below operating depth <br /> Sewage tank(s) leak Celow their ❑ Yes � No � Examined empty(pumped)tanks(s) <br /> designed operating depth. <br /> I If yes,which sewage tank(s) feaks: i ❑ Probed outside tank(s)for �black soil" <br /> ❑ Unable to venFy(See Comrnents/ExplanaUon) <br /> Any "yes"answer above indicates the <br /> sysfem is failing to pratect groundwater. ❑ otner methods not��sted�see com�e��r�rEX��Bnar�on� <br /> CommentslExplanation: <br /> Tanks pumped by others tank integrity appears sound. <br /> 3. Other Compliance ConditionS—Compliance component#3 of 5 <br /> a Maintenance hole .overs are damaged.cracked unsecured,or appear to be stnicturally unsound. ❑Yes` �No �Unknawn <br /> b. Other issues�e�ectr�ca�nazards.etc.)to immediaiely and adversely impact public health or safery. ❑Yes` � No ❑ Unknown <br /> *Sysfem is an imminent ihreaf to public healih and safety. <br /> Explain: <br /> c. System fs non-protedive of ground water for other canditions as determined by inspector. ❑Yes' � No <br /> `System is faifing to protect groundwater. <br /> Explain: <br /> _ _ _ __ <br /> ,4ww.pca.s.atc.mn.us • b`.�1 296-G300 • 800-657-386a • 'T"651-282-53;2 0-8Q0-657-?Str'! • Avai(ahi��n a;tc�r;�at�vc•�o�r��a�� <br /> 4 of 7 «;,-�;sts4 3t • 3i 16!t2 3/25/�b��3�5:�12'PM <br /> ��:�«-wi5:5-� s� • .�. .� ,� <br /> 5 of 7 3/25/2013 6:12 PM <br />