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' Prop�rfy�ddre�ss: a��k �. "�,-5�S � � , ina�tot tn€u�isrogte: � <br /> . ��' � ���" <br /> � 1. Impact on Pub[ic Hea[th--Compiiance camponent#1 of 5 <br /> � Corn liance crlteria: Ve:tficatloR method(s); <br /> Systam disct�arge sewage#o the ❑y98 �N� ❑ Searcfted fior surtace autfet <br /> round sur�ace. �} Searched for seeping En ysrd/bac�cup in home� <br /> System discharge sewage to drain iiie � ❑Yes ❑.Ho � ��sshre ponding In soll systemlD-boxss 4�1,� <br /> or surface waters. ❑ Homeowner;eetlmony�See CommentslFxplanaHon) <br /> System Cause sewage beckup Into ' (�YeS ��o � 'Black so11"above soil d{spersal system µd <br /> dwelling or es#ablishment. � d System requires"emergency pumpjn9 <br /> Any�tyes"answer abovs Indlcates the systetn ls � PBriarmed dye tes# <br /> an lmmJr�enf Threat to Pub!!c.Healfh and Safety. C1 Uneble ta verify(&ee comme„ts��,cplan��on) <br /> . ❑ Other methods not IEsted (See Commants/�cplenation) <br /> CommentslExplanatlon: . � <br /> 2. Tanfc lnte�rity—Compfiance companent#2 of 5 � <br /> Com fiance crtteria: .. Verlficatiot� metho8 s ; <br /> 5ystem consfsts of a seepage pit, ❑Yes �oN t j <br /> �cesspool,dryweil,or leaching p1t. � pro���nk($)botfom <br /> Ssepepe p#smeeting 7080.2550mey6e ❑ �amined Constructfon re�orrts <br /> com Ilant If allo ed in iacal ordl�arrce, CJ �mined Tank Integ�ity�orm{qtfgch) <br /> Sewage tank(s)(eak befow their [�YeS ❑�o � Observed!(qt�ld Eevel below operating �ep� <br /> desi ned o eretin de th. CI ExamEned em <br /> (f yes,whfch sews e tank s leaks: Pty�P�mPed}t�nks(s) <br /> g � ) ❑ Probed outstde t�ttk{s)for`blsck soil" <br /> Any "yes°�answer above lndlcates the Cl una�ie�to veriiy�see comments�z�anarron� <br /> sYstem Is Faflfng fo Protect Groundwafer. , D Other methods not��s#ed ESQa CommBnts�Explanatton� <br /> Commentsl�xplanatlon: . ' <br /> 5�� {���rt�,��s ��4�� �t���.���{ '�'-�Q�7'-�S' �� �� �,�s��c.� <br /> 3. Ot�er Comp[iance Cond�tions�-Complfance component#3 ot 5 <br /> a. Maintenancs hole cove�s are dameged,cracked,urtse�,or <br /> ' ePPBar.tO StrUCturAtly Uns0urla. ❑Yes" �+y No ❑Unknown <br /> b. Other fssues(elec�iica/hasarrf�eM.)to immed(ately attd adverselY lmpact pUblic heallh or safety. ❑Yes* �No ❑ Unlcnown <br /> #SYstem Is an Imm/n�nt lhneat to pubpc hralth aitd saf�ty <br /> Explain; <br /> c. System is non-protec�ive oi g�ound yvater far other Condttlons as determir�d by inspector ❑Yes• ��o <br /> *System Is fa!ling to protect groundwater <br /> �xplain: . . <br /> � �+�c�n,pca,state,mn,us � 651�246�6344 � 800�6�7�3ab� � � �TTY 651•282-5332 ar 806-657•3s�a . �va;������� ,�.,.�._�:..-t-_--.. <br /> wn.w..d�MA_�t . �i�i�•n <br />