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Property address: 2740 Deer Run Trail East Inspector initials/Date: RLP � 8/20/2015 <br /> (mm/dd/yyyy) <br /> 1. Impact on Public Health — Compliance component #1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharges sewage to the � ❑ Yes � No ❑ Searched for surface outlet <br /> ground surface. ___ � ❑ Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑ Yes � No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters. <br /> — ❑ Homeowner testimony(See Comments/Explanation) <br /> System causes sewage backup into ' ❑ Yes � No ❑ "Black soiP'above soil dispersal system <br /> dwelling or establishment. � <br /> -- -- ❑ System requires"emergency° pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminent threat to public <br /> ❑ Unable to verify(See Comments/Explanation) <br /> health and safety. <br /> ❑ Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> Replacement of mound only <br /> 2. Tank Integrity— Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, i ❑ Yes � No ❑ Probed tank(s) bottom <br /> cesspool, drywell, or leaching pit. <br /> j ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be I ❑ Examined Tank Integrity Form (Attach) <br /> compliant if allowed in local ordinance. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s) leak below their I ❑ Yes � No <br /> designed operating depth. ❑ Examined empty(pumped)tanks(s) <br /> If yes, which sewage tank(s) leaks: ❑ Probed outside tank(s)for"black soil" <br /> Al1y "y@S"answer above indicates the ❑ Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. ❑ Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> Verified by pumping contractor <br /> 3. Other COmplidnCe COnditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked, unsecured, or appear to be structurally unsound. p Yes* �No ❑ Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes'` � No ❑ Unknown <br /> *System is an imminent threat to public hea/th and safety. <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector. ❑Yes" �No <br /> *System is failing to protect groundwater. <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31b • 6/4/14 Page 2 of 3 <br />