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� Oct. 12, 2012 10: 16AM No. 0962 P, 4 <br /> Property address: 2�S").O �0��r..�'��� S�v�- 'C�'. ' Inspector lnitlals/Date: ���,a �c�-� -)-� <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com liance criteria: Verlilcatlon method(s): <br /> System discharge sewage to 1he �Yea ❑N� ❑ Searclied for surta�outlet <br /> round surfac�. � Searchad tor seeping in yardibadcup in home`��'`�� <br /> System discharge sewege to drain tile ❑Yes 0 No �� �ceeeive ponding in sal syatem/D-boxea �(�6 S <br /> o�surface waters_ ❑ Homeawner tesUmony(See GbmmentsiExp�anallon� <br /> , � 'BIaGc soil"above soll dispersal system��'����'�. - <br /> System cause sewage backup into ❑Yes � No ❑ System requires'emergency�'pumping <br /> dwelling or esisblishment. <br /> ❑ Perfurtned dye test <br /> Any"yes"answer aborra indlc�ttes the system is ❑ UnBble to verify(See Commenls/ExplenafionJ <br /> an Imminent Threat to Publlc Health and Safety. ❑ Othe�methods not Ilsted(See Comments/�cplenetion) <br /> Comments/ExplanaUon: ��t'��b�"::�a ►:, '���.1�,.�.,� — ,;�,��� ���-s��4�����, �1��,e��.J�:: <br /> i �p�,��. f 1'���•S� °l 4��� <`.,�" �"•1�11i. �,1..�aU 51�y ��0•� 'C'1�����k��,� I �.\5i��.1�a �-}�I Ifi�C'.aJx'. <br /> 0 y�b��.;�ot�,. <br /> � . <br /> M�-G��,�... o� .S. Kc��c-w� ��.���r�vas.���.,c���t�. ����rac,►r�,G`t,�.�',,�1:9�t�, v�"� <br /> � <br /> �. Tank Integl'1ty—Cvmpliance component#2 of 5 �'�� �� w.�;�:�:, ti.�� ���y����;;���x�:�., <br /> � .�_________ <br /> ICom liance crlteria: Verification method(s): <br /> � System consists ofi a seepage pii, ❑Yes ❑No ❑ Probed tank(s)bottom <br /> , cesspool,drywell,or leaching piL ❑ Exemined const�udion recar+ds <br /> ,I Seepeqe p!(s meeflna 7060.2550 may be ❑ Examined Tank Inbegnly Form(At6ach) <br /> I com liant if allowed in locel ovdin�nce. <br /> p Observed liquiC level below operating depth <br /> Sewage tank(s)leak below their ❑Yes ❑ No [� ��mined empry(pumped)ianks(s) <br /> desi ned o eratln de th. <br /> If yes,whlch sewsee tank(s)leaks: ❑ Probed outside tank(s)for`black soil" <br /> �] U08ble{o ve�fy(See Comments/Explanalion) <br /> Any "yes"answer above lndlcates!he ❑pther methods not Ifsted (See Comments/Explenatlon) <br /> system �s Failing to Protect Groundwat�er. <br /> � Comments/E�cplanatian: <br /> �j(��i ���`t1�,��(I "�9 'S,Or�I� 11����%'�^'b"�"{ 'P-�@�� <br /> 3. Other Compiiance Condltions�Compliance component�i3 of 5 <br /> e. Malntenanc9 hole oove�s al�demeged,crack,ed,unseatred,or appear to strudutally unsaund. p Yes• F]No ❑Unknown <br /> b. Other issues(elect�cal heza►ds,ete.)to immediately and edversety impact public heafth or safety. L�Yes' 0 No 0 Unknown <br /> "System Jls an Imminent threat!o publlc health and safety <br /> Explain: <br /> c. System is non-protedive of ground waler for other oonditions as detsrmined by inspedor [�Yes• �No <br /> "Sysiem is falling i+o proCect groundwaier <br /> Explain: <br />