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Property eddre�s: 3��� �,►�1Q���.,►.�• tj.�,.r.�. p Q,d;�v .� Inspector inlUalalDate: ��,d-1 ''' <br /> 1. lmpact on Public Heaith-Compitance component#1 of 5 <br /> .. Com ifancs c�iterla: Variftcatlan m�thod(s): <br /> System discharge aewage tu the ❑Yes �No � ��r eurface ouUet <br /> round surface. � Searched for seeping in yardlbadcup ln home nlo <br /> System diacharge sawage to drain t�e ❑Yes �Na �I �zo�sive pondtng in so(I systam/0-boues 1.�4 <br /> or surtaoe waters. D Homeo�mer tesNmony($ee comment�EicpianaHon) <br /> System cause sgwage badcup lr�tc ❑Yes �No � ���S°��0�8011 dispersal system �.10 <br /> dwelfing or establishn�nt. ❑ System requlres"emergencyl'pumptng <br /> ❑ Performed dye test <br /> Any'•yes„anawer above/ndicai�s ths system is ❑ Unsbte to verify(See Coniment�i6rplansllon) <br /> an!mminenf Tftreat tia Publ(c Ne�tlth and Safety. 0 p��methods not fiated(see Comments�F rpla,reato„) <br /> Commentsf�xplaneUon: , . <br /> 2. Tank Integt"ity--Comp�iance component#2 of 5 � <br /> Coni liance crlterta: ,. Veriflcatiort method{s); . <br /> System oonslsts of a aee�a6e Pit, ❑Yes ❑No ❑ Probed t�nk(s)bottom <br /> �c�sPool.dryweil,o�leadiln9 P�. . ❑ E.xamined construcdon records <br /> See�e pRs mee�rtq T080.765o mey be ❑ Exatt�lcted Tartk I�agcity Fo�n(attach) <br /> c�mm lfsnt,�aUowed!n loca!a�lner�e. <br /> ❑ �bserved lEguid fe�rel below opera�ng depth <br /> Sewage tank(s)leak below thelr ❑Yes ❑No � �i�� u�t <br /> desi ned ratin de th. PiY(P i�t�nks(s) <br /> Ef yes.which sewage tarik(s)feaks: ❑ Probed outside tank(s}for`bladc soil' <br /> I1ny"yes"answerabove ina�catea the . . O U�le to veMy(see commer,ts�xp�enauon� <br /> aystem Is Falling to Protecf Groundwefer. . ❑Other methods not fisted(See comments�xplenatton) <br /> CommentsJExplanaSon: ' • <br /> S�i�/ 1�'�'��L1�,k� '�,Ckf�111�, 11.t�'���r,�`'� . '���'� -��`(�1��'�'�'bw'�� � <br /> 3. Other Comptlance Conditions—Compii�nce campanent#3 of 5 <br /> a. Mair�enanos hole oovecs are dart�ged�cxedced.un�mad,oc�tc�ra0y unso�nd. D Yes• �►ao I�un�oMm <br /> b. Other issues(elecbical hazerd�,eb.}b�h�eE�ly 8nd adveisely MpBd pubNC h�dlt oT Sa�etyl. �]Yes" ■No ❑Unia�own <br /> *System Is an Unminer�t th►est to pubJk haaffh and sal�ty <br /> ��; �i���C4-1 t.�. �fL¢�A�S� - . <br /> c. Systiem is nori�rotedi�re of ground waterfor o�her t�iats as de�emdned by t�pec�or ❑Yes" ■Mo <br /> 'Syale►n/a fi1IORg�0 p/vmCtQ�ulwd�t�F . <br /> Explafn: <br /> � Www�pc��state�ilul�us � 651•z9b�b300 � 800�651�3864 � � TTY b31•281•5332 Or�65�•3864 • Ava��abte�altemative farmats <br /> wq-wwlstsf-3i • 1/24/12 <br />