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Property2ddr�ss: �D ��U..�R'�� �P.o <br /> �nepector i�ttiatslDate:���'l�, <br /> '(. Impact an Publlc Heaith—Compliance component#1 of 5 <br /> Compilance criterla: Verfflcatton method(8): <br /> System discharge sewage to the ❑Yes �No ❑ Searched for surtace outlet <br /> round surface. � Searched#or seep(ng in yardibackup in home N� <br /> System discharge sewage to drain tile ❑Yes (]No � ��g$�e ponding in soii system/0•boxesµ� <br /> or sur�tace"'are�g' ❑ Homeowner testimon <br /> Y(See Commanfs/�kpianaHon) <br /> System cause sewage beckup into � Q Yes (�No � �Biack soil"above soli d;spersai system�.1c� <br /> dweiling or establishment. ,(] System requires'emergency pumping <br /> AnY"Yes"answer abova fndtcafes fhe system/s � P�rfO�ed dye test <br /> an lmminenf Threat to Publlc Healfh and Safety. � �nable to verify(5ee Comrr�entyExp�eRatJon) <br /> . ❑ Other methoda not ilstad(See Comments/E�rpienatlon) <br /> Comments/Expfanaflon: !-1va5 c% �iw�Q-�� <br /> 2. Tattk Itltegrfty—Compliance component#2 of 5 • <br /> Compllartca cdteria�_ <br /> System consists of a seepage plt, �erlticatton method(s): <br /> cesspool,dryweil,or feachfng pit. �YeS �N0 � P�Obed tank(s)bottom <br /> Seepape pttsmeaNnp7080.25SOmaybe 0 �emfned ppnstnJctloll recpr�g <br /> can !larrt Hailawed In tocalorrlinence. ❑ Examined Tank lntegrity Form(qttach) <br /> Sawage tank(s)leak beluw thelr �YeS �Ha � flbserved Iiquld fevet below opereting depth <br /> desinned operatinq de th. � Examlrted em <br /> !f yes,which sewa e teak s leaks: PtY(Pumped)tanks(s) <br /> 8 {) ❑ Probed ouis(de tank(s)fo�"black so(I' <br /> Any��yeg��anSWer aboYB IDdIC8tes fh8 I� Unable to vsrify(See Comments�ExplanaUon) <br /> sysfem/s Falling fo Protect Qroundwafer. ❑other methods not I(sted�see co,r,menrs�Xaenseon� <br /> CommentetExplanaUon: �✓fi�l�, Lfr�4�F►N� ti,Qaass� ,aip.S .(.t�,v� <br /> cofsv_.�� �4-+�wit3�.iu� �-5 h�tir.��, �e qfC� Ft�wt'4Go <br /> . . . , 'GQJJSG�WjJ��o'lJ�}\%�..U�.o-15°f1r <br /> 3. Other Comp(iance Conditions—Compifanca component#3 ot 5 <br /> a. Maintenancs hole cove�s are demaged,pg�,u�red,or appear.to stnxYurapy unaour�d. ❑yey+ <br /> nx u �No ❑Unknown <br /> b. Other issues(elecaicalharerds,etc.)to immedlatety ehd advpiselY hnPeat public health ot sa{ety. ❑Yey �No ❑Unknown <br /> "System is an imminent lhreat to publlc heslfh and saWty <br /> Expiain: <br /> c, System is non•protedlve ot ground water{or ower��yons as determined yy t�spe�o� p Y�, ��o <br /> 'Sysfem Is IaJling to protect qroundwater <br /> Explain: � <br /> 1'tYtW�QCd,St8tt,11111,US � b51•296�6300 � 800�651•3964 • � TTY b51-282.5332 or 800�b57•3864 • Avai(able in altemative formats <br /> vw+-�.nuieled.Qi . IHir�v <br /> I <br /> i <br /> I <br /> � <br /> � <br /> I <br /> � <br /> I <br /> i <br /> i <br />