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63/04/2015 13:58 9528733112 PAGE 02/64 <br /> Property address: 2515 Country Side Drive-Or�no Inspector initialslDate. JS 3/3/2015 <br /> (mm/dd�yyyyJ <br /> 1. Impact on Public Health—Compliance component #1 of 5 <br /> Complfanae criter�a: , Verlfication rr�ethod(s): <br /> System dfscharges sewage to ihe ❑Yes � No �Searched?or surface outlet <br /> �ground surface. � Searched for seeping in yard/backup in home <br /> System discharges sewage to drain []Yes � No ❑ Excessiva ponding in sail system/D-box�s <br /> tile or surface waters_ �Homeowner t�stimony (See Gommenrs/�xplananon) <br /> System aauses sewage backup into ❑Yes � No �"Black soiP'above soil dispersal syst�m <br /> dwelling or establishm9nt. ❑System requires"emergency"pumping <br /> A�ty"yes"answer sbove indiCetes fhe Q Performed dye test <br /> syst�m is an fmmin�nt threat to publiC ❑ �nable to verify(See comments/Exp�anarron) <br /> heaJih�rtd sa�ety. <br /> ❑Other Methads not listed (See Comme»ts/Explanatlon) <br /> Comm�nis/Explanatlan� <br /> 2. Tank Integrity-� Compliance component#2 of 5 <br /> Com liance cri#eri�: Yeriticatipn m�thod(s); <br /> System consists af a seepage pit, ❑Yes � No � Probed tank(s)bottom <br /> cesspool,drywell, or leaching pi#. <br /> ❑ Examined constructlon records <br /> Seepage prts meeting 708q.255o may be ❑ Examined Tank Integrity Form (Attach) <br /> Com liant If allowed in loC&J ordl�ance_ <br /> ❑Observed flquid le�el belaw operatfng depth <br /> Sewage tank(S)leak below their ❑ Yes � N� �Examin�d empty(pumped)tanks(s) <br /> designed vperating depth. � <br /> If yes,which sewage tank(s)I�aks: I ❑ Probed outside t8nk(s)for°black soif" <br /> �I7}I ")/195"answer above indfcafes the �Unable to verify(See Camments/Explanafion) <br /> system is fairing�to prot�ct groundwater. ❑�th�r mQ#hods noi Ilsted (See Gomments/Expl�rfetion) <br /> Cor�ments/Explan etf o n: <br /> 3. Other Corllplian�e Cvnditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are darnaged,crackad,unsecured,or appear to be structurally unsound. ❑Yes" �No ❑Unknown <br /> b_ Other issues(e�ectrical hazards,etc.)to immed�ately and adversely impact public heafth or safety. ❑Yes'` �No [] Unknovm <br /> *&ystem Fs an fmminent thr�at ro puWlc health and safety. <br /> Explain: <br /> c. System is non•protgctive of ground waterfor other condltions as determined by inspectar. [a Y�s• �No <br /> "�yst�m fs laUfrtg ta protect groundwater <br /> Explain: <br /> wv�nv.pcascace.mn.us • 651-z96•6300 • 500-657-3864 • TTY 651-282-5332 or BOQ-&57•3864 � dvaiiabEe in altemative fOrmatS <br /> wq-wwfsts4-31 - 31'16/12 Page Y oj 3 <br />