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Oct 1,0 14 12:08p Joseph Olson 763-498-8290 p.5 <br /> Property address: _2655 Countryside Drive W Inspector inikfalslDate= 1017/1d <br /> '�. Impdc# Otl PUbI�C HE'dlth—Campliance component#� of 5 <br /> Compliance criter�a: _ Verifrcation method�s): <br /> System discharge sewage to the � �Yes ❑No Q Searched for surface outlet <br /> grovnd surface. _� I ` ❑ Searched for seeping in yardlbacicup in home <br /> System discharge se�,vage fo drain tile � ❑Yes ❑No ❑ Excessive ponding in soil systemlD-bwces <br /> or surtace waters. � ❑ Homeowrter testimony(5ee Comments/E�cplanation} <br /> System quse sewa e backu nto ❑ °B!ack soil'above soit dispersal system <br /> 9 pi I 0 Yes ❑No <br /> dwelling or establishment. �� ❑ System requires"emergenc�'pumping <br /> ❑ Performed dye test <br /> Any°°yes"answer above indicates the systern is � �jng�j�e to verify(See Comments�Expfanatfon) <br /> an Imminent Threat to Public Healfh and Safety. ❑ �her methods not i�sted (see commencs�XprB,�adon) <br /> Com m sntslF�1 a na ti o n: <br /> 2. Tank tnte�rity—Compliance component#2 0€5 <br /> Compliance_criteria: ��� Verification metFtod(sj: <br /> Sysfem consists of a seepage pii, i ❑Yes � No ❑ Probed tank(s)botfom <br /> cesspool,cirywell, or leaching pit. <br /> ❑ Examined cQnstruction records <br /> Seepage pits meeung 7080_2550 may be � F�camined Tank Iniegrity Form{Attach) <br /> com �ant if aflowed in foca!orJinanca. _I <br /> ❑ Observed iiquid fevel befaw operating depth <br /> Sewage tank(s)leak befow their ; (-'� Yes �No <br /> designed operating depth. � � Examined empiy(pumped}tanks(s) <br /> ( --- - <br /> If yes,which sewage tank(s) leaks: i ❑ Probed outside tank(s)for"black soil' <br /> ❑ Unable to veriiy(Ses Commenis�Explanation} <br /> Any"yes"answer above indicates the <br /> system is Failing ta Protect Groundwater: Q Qther methods not fisted(See CommentsiExplanaGon) <br /> C omments/Explanatfon: <br /> On 10/7/14,Elmer J.Peterson Co.pumped tanks_ See notes on adaehed tank repoR. <br /> 3. Other Compliance Conditions—Compi�ance component#3 of 5 <br /> a_ Maintenance hole covers are damageci,cracked,unsecured,or appear to siruCturaEly unsound. ❑Yes' ❑No ❑Unknawn <br /> b. Otherissues(elecfricalhazards,et�.)to immecfiately and adversely impact public health orsafety. ❑Yes• ❑No ❑Unknown <br /> '$ystem is an imminer�t threat ta public health and safiety <br /> Explain: <br /> c. System�s non-protedive of ground water for other conditions as dekermined by inspector p Yes" ❑No <br /> *System is failing to protectgroa»afwater <br /> Explain: <br /> www.pcastate.mn.us . 651-296-630p • 800-657-3864 • T7Y 65f-282-5332 or 8D0-657-3864 • Available in aEtemative formats <br /> wq-wwists4-31 . 7/1d/i2 Page 2 uf 3 <br />