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' May, 14, 2013 10: 12aN1 No. 1696 P, 6 <br /> " Prop�rty�ddress: a.13S 4o�.tiy„� �,�t,. �� lnspectorinitfalSlDate: 'S` S'11-)4j <br /> 1. IrTlpdCf On PubliC HEdlth—Compliance component#1 of 5 <br /> Cem IEance cr�terfa: Verificatlon method(s): <br /> System discharge sewege to the �Yea �No 0 5earched for surface outlet <br /> round surface. � Searched for seeping fn yard/badcup in home►�d <br /> System dlscharge sewage to draln tlle �]Yes ❑fVp � ��ss�ve ponding in soll system/D-boxes �o <br /> or surfaCe waters. ❑ Homeowner testlmony(See CommentslExplanatron) <br /> System cause sewage backup into ❑YAs � �����soil"above soif disparsaf system �o <br /> ��0 [] SysEem requlres"emQrgenc�'pumping <br /> dwelling or establlshment. 0 performed dye tast <br /> Any"yes"answer above Indlcates the system fs [J Unable to verify(See comments/Explenation) <br /> an lmminen#Threat to Publlc Hea/th and Safety. p Other methods not Ilsted(see Gomments�xplanatro�� <br /> Comments/Explanatloro: <br /> 2. TBnk Itttegrity—Campliance component#2 of 5 <br /> Com Ilance criterla: Verlflcatfon methad(ffi): <br /> System conslats of a seepage plt, ❑Yes ❑Na �] Probed tank(s)bottom <br /> cesspool,drywell,or leachiog pit. . <br /> ❑ Examirted canstructlon records <br /> Seepage pits meeNng 7060.2550 may be (� Examined Tenk Integrity Form(Attach) <br /> com lrant if a!lowed In local ordlnance. <br /> p Observed liquld level balow opereting dapth <br /> Sewage tank(s)lsak below thelr 0 Yes []IVp [J �amined empiy(pumped t$nks(s) <br /> desi ned o eratin de th. � <br /> If yes,which sewage tank(s)leeks: ❑ Probed outside tank(s)for'bfack soi!" <br /> Any "}res"answer above Indicafes the ❑ Unable to Verify(See Comments/Explansffon) <br /> system Is Failing tv Protect aroundwater. ❑�her m�thods not listed(See Commen�s/L�xplan�tlon) <br /> CommentsJF�tplanatipn' <br /> ��-�/ 'Q'���'(�r� '��'f►1� 1 ti���'r V�"� �a'�'� "' f3°S 5 �Ms�,�� <br /> � <br /> 1��-v��r <br /> 3. OCEIeI'COCtlplidllC@ COndikl4nS�Camplfance component#3 of 5 <br /> a. Maintenance hole cov��+s are damaged,cracked,unsecured,or eppear to struduralfy unsourtd. (]Yas' �No ❑Unknown <br /> b. Other issues(eled�k�l hexa,ds,atc.)to Immedie#e1y and adversely impact public heaRh or safery. {]Yes" �No (�Unknown <br /> '`Syst�m!s an immJnent thraat to publlc healdr snd safery <br /> Explain: <br /> c. System is npR-protedive of ground v�tter for other�pndiUons es determined by inspector �]Yes- �Na <br /> 'System rs fa1ling to p►oGgCtg►+Dundwatel <br /> Explaln: <br /> www.pca.state.mn.us . 651-296-63Q0 • 80Q-657-3864 • TFY 651•282-533�or 8OQ-657-3864 • Availab(e in altemattve formats <br /> wo•wwlsts4-3f . i/1�J/1� . <br />