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• ,�«y, 14. 2013 10, �3AM No. 1696 P, 9 <br /> Property address:�?��D�j,(� �Tl�'��✓�U -- _ Inspector initiels/Date; �,��__�__.___.. <br /> . (mmlddyyyyl <br /> 1. Impact on Pub[ir Healxh�-ComplVance component#1 of 5 <br /> Compliance criteria; Verliicatian method(�), <br /> System diSCharges seW�ge to ihe [�Yes ❑NO ❑Searched for surfece out3et <br /> r_q pund surface.__ ❑Searched for seeping En yard/backup in home <br /> System dis�harges sewege to drain i ❑Yes �No [�ExceS5lVe ponding(n.sail syslem/D-boxes <br /> kfle or surface walers, ❑Momeowner testimony(Ses Gomments/Explanetion) <br /> 5ystam causes sewaga backup into �Yes ❑No ❑"61ack soil`above soii dispersal system <br /> dwellirig or esteblishment. ❑Sysiem requlres"emergency"pumping <br /> Any"yes"answer above Ir�dicates the ❑P�rTormed dye test � <br /> system is an imm/nent threac to publlc �UnablB to V9rify(Sea Comments/Explenetlon) <br /> health and safefy. -- ❑Other methode not listed(See Comments/Explenatlon) <br /> Commentsl�xplanatlon: <br /> ��k �� �.� a � sC�n�.f � �� �sr��. r, <br /> � . ,oa.� . ,,►,;`��I� °—�,�� <br /> 2. Tank In'�egrity—Campliance component#2 ofi 5 <br /> Com liance criteria: Verlficatlon method(s): <br /> System conslsts of a seepage pit, ❑Yes �No ❑Probed fank(s)bottom <br /> cesspool,drywell,or leeching pil. ❑Examin�d construction records <br /> Saep�ge plts meeUng 7080.25s0 may ba ❑�xamin9d T�nk Integ�ity Form �AttBch) <br /> �ompfian!if allowed in(ocal ordfiance, _ _ <br /> �ObservBd liquid level below opareting depth <br /> Sewage tank(s)Isak below thelr �Yes �No <br /> designed opera6ng depth. �Examined empty(pumped)t8nk5(s) <br /> If yes,whlch sewage tank(s)leaks: �Probad outside tank(s)for"bleck soiP' <br /> Any "yes"answer above Indlcates the ❑Unab�e to verify(Se�Comments�xp�aneuon) <br /> system fs fa1ling to protec!groundwater, C�Other methods not listed(Sae commen�s�ExpienaUon) <br /> Comments/Explanat(on; <br /> 1 ce,t}; `�nA�- � �e,�s�nal� mar.l.t`� ob5e�rva}�on5,in�u4+�-k�.-�-+o�s,� �ohcl�sto�s -� `-i� <br /> a�pov2.��M I+anCe Cowlpov�ari� �Z o-� .� a' `�'�U�`� aY� C4Yf�CG~r. <br /> �AME: �,a�r� �urSt,� [�'RTI�IC/�tTV01�1 '� ' �•`y%!C"� <br /> �av51WE55 NftME � �r Se.vaen cr Extrn�c�kin M1�C 'F� �: O1 � <br /> 3. Other Compliance Cpnditio�ls•—com Ifance r.amponent#3 of 5 s - ��.,r.+�. <br /> a. Maintenanca holg c+�vers are damaged,GtadcOd,unsecured,or appear to be structuraliy unsound, �Yes' [a No ❑Unknawn <br /> b, �ther iasues{slectrtce!hatarcrs,etc.)to Immediately and adVersely impaCt public health or safety. ❑Yes' ❑No Q Unknown <br /> '5yafem fs an Imminent threat fo pubdc haalth ard safsfy. <br /> Explaln; <br /> c. System�s non-protective o!ground water Sor other condiUons as de�ermined by inspector, p Yes' �J No <br /> `System!s}'a(Iing to protectgroundwater, <br /> Expla(n; <br /> vnvw,pca.state.mn,us � 654�296-63U0 • SUo-657-3864 � TTY 851•282•5332 or 8oD-657-3864 . Ayailable in alternative farmats <br /> wq-wwfstsq•31 • 3/16/12 p°se Z°f 3 <br />