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Property address: inspector irutiaM/Datie: I <br /> (nsNddyYYY) <br /> 1 impact on Public Health—Com�liance oomponer�t#1 of 5 <br /> Com liance criteria: Verfication method(s): <br /> System discharges sewage�the ❑Yes �No Q�Searched for surface outlet <br /> round surFace. (�Searched for seeping in yardibadcup in home <br /> System discharges sewa9e to drain �Yes �No ❑Eucessive por�ding in soil systerrUD-boxes <br /> tile or surface wate►s. j$I Homeo�rner testimony(Ses Conunents/E�cplar�tionJ <br /> System causes sewage badcuP irrto ❑Yes �No ❑aB��-above sal dispersal system <br /> dwelling or estabfishment <br /> ❑System require.s'emer9enc�'Pumpin9 <br /> Any"yes"answer above inarcates tt�e ❑Pertormed ciye test <br /> system is an imminent ihreat t�puWic ❑Unable to verify(See Can►r►ents/�xP1a�'on) <br /> health and safety. p other meinods rwt�isted(see comrnenrs/Exdanatio�) <br /> Comments/Exp�a�ratlor►= <br /> Z. Tank Int ri —Com iance com nerrt#2 of 5 <br /> Com liance criteria: Verification method(s): <br /> System oonsists of a seepage Pit. ❑Yes �No ❑Probed tank(s)bottom <br /> oesspool.dMnrell.or I�ching pit• ❑Examined construc�ion rec;or'ds <br /> Seapege pits meeting 7080.2550 may be ❑Examined Tank Irrtegrity Form(Attgch) <br /> r,wn ' nt if aHowed in bca/o�narres. (�p��liquid level below operatin9 dePth <br /> Sewage tank(s)leak below their ❑Yes Y.�J No ��m�����umped)tanks(s) <br /> designed operatin9 dep�thh• ❑Probed outside tank(s)for`bladc saP <br /> If yes,which sewa9e tank(s)leaks_ <br /> qR},`�res"answer above indicates the <br /> ❑Urrab�e to verity lsee comr►rentslExp/snatipnl <br /> system is failiny ir�protect groundwater. C7 other metnods not iisted fs�co►,►�.►«v��) <br /> Comments/Explanatia�: �D t'u„'� .�pSP t l� �ll�.� C,�l�t b.l,� <br /> 3. Other Com tiance Gonditior�s—Com � c�m t�3 of 5 <br /> a M�ritenar�ce t�ole cavers�dama�.c�dced,ur�aued..ar.a��.be struc�ua�Y��''�- ❑Yes* �I No�UNmown <br /> b Other issues(electri�l haza'�etc-)to immedrately and adverselY�mPact Iwb��Ith or safety. ❑Yes` �No 0 Unla�own <br /> . *System is an immi►�t threat to publJc l�ealtl�and s�etY- <br /> Explain: <br /> � �t���ve of grax�d water�or ottier flor�tions as debenrrr�ed bY v�spec'�ar• ❑Yes- �No <br /> *Syst+e�n is fail"mg�n pr�sCt9rot►►�h�t� <br /> TiY 651-282-5332�800-657-3864 • Available in atte�mative formats <br /> v,,v,,w.pca-state.mn.us • 651-2%-6300 • 800-657-3864 • page Z of 4 <br /> wq-wwisCs4-316 • 6/4/14 ----_-----_- _ <br />