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Nov 12 2015 0924PM HP FaxRusty Olson 7634988290 page 6 <br /> Property address: 2995 Deer Run Tra!I _ __ fnspedar initials/Date: 10/27/15 � <br /> 1. Impact on PUbtic Hedlth—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> Syslem tlischarge sewage to the ! ❑Yes ❑No ❑ Searched for surface outlet <br /> round surface. ❑ Searched forseeping in yard/backup in home <br /> Systern discharge sewage to drain tile ❑Yes ❑No <br /> ❑ Excessive ponding in sail systemiD-boxes <br /> o�surfaoe waters. ❑ Homeowner testimony(See CommantslExplane6on) <br /> ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup inlo ❑Yes ❑ No <br /> dwetling or esIablishment. L � System requires"emergenc�'pumping <br /> - ❑ Performed dye te5t <br /> Any"yes"anawar above indicates the system is ❑ Unable to verify(Sea Comments�,cp�snation� <br /> an 1►nminenf ThrAat to Public Healih and Safety. ❑ Other methods not listed (see comments/Exp�anation� <br /> C omments/Explanation: <br /> 2. Ta�k Infiegr'�ty—Compliance component#2 of 5 <br /> Compliance crlterla: Verification method(s): <br /> System consists of a seepage pit, �Q Yes �No ❑ �'robed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> ❑ Examined construdion records <br /> Seapege piLs meaGng 7080.2550 rrrey he ❑ Examined 7ank Integrity Form(Attach) <br /> compliant if afbwed in local ordinance. <br /> - ❑ Observed liquid level below operating depth <br /> Sewsge tank(s)leak below their � ❑Yes �N� � Examined empty(pumped}tanks(s) <br /> designed operatin de th. <br /> li yes,which sewage tank(s}(eaks: ❑ Probed outside tank(s)for"black soi!" <br /> ❑ Unable 10 venfy(See Commanfs/�xplanatbn) <br /> Any ��yes"answer above indicates fhe �pther methods not liSted(See Cwnmenls/Explenation) <br /> sysfiem is Failing to Protect Groundwate� <br /> Comments/Explanation: <br /> On 10/27115,Elmer J.Peterson Co.pumped septic tar�ks. <br /> 3. Oth@I'COR1pl1e711Ce C011ditiorl5—Compliance component#3 of 5 <br /> a. MaiMenar�ce hote covers are damaged,cracked,�secvred,or appear to sVucturaNy unsound. ❑Yes• ❑No ❑Unknown <br /> b. Other issues(elechice7 hazaris,efc.)to immediately and adversey impac3 public health or safety ❑Yas• ❑No ❑Unknown <br /> `S�siern is an/mminerrt threaf!v pub!!c health and safety <br /> Explain: <br /> C. System is non-protective of ground water for ofher condi6ons as detertnined by inspec�or C Yes• ❑No <br /> "System is failing Eo protec!groundwatei <br /> Explain: <br /> www.pca,sta[e.mn.us • 651•296•b300 . 800-657�38ba . 'TY 651-282•5332 or 8A0-657-3864 . Available in altemative fwmats <br /> wq•wwists4-31 . 1/24/12 Page 2 of 3 <br />