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� <br /> Property address: _��� � _ �.,k< .�. �./�l� vh, Inspector initials/Date: ��_��,tr}�T <br /> 1 o ImpdCt o►� PUbIiC Healfih— Compliance component#1 of 5 <br /> Compliance criteria: Ve ication method(s): <br /> 5ystem discharge sewage to the ❑Yes No ��earched for surface outlet <br /> round surface. LJ 5earched for seeping in yard/backup in home <br /> System discharge sewage to drain tile ❑ Yes dNo ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments/Explanation) <br /> ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup into ❑Yes � No <br /> dwelling or establishment. ❑ System requires"emergency"pumping <br /> __� - - ❑ Performed dye test <br /> Any"yes"answer aboVe indicates fihe system is ❑ Unable to verify(See Comments/Explanation) <br /> an Imminent Threat to Public Health and Safefy. ❑ Other methods not listed (see Comments/�irp�anation) <br /> Comments>Explanation: <br /> Za Tdnk Integt'ity—Compliance component#2 of 5 ,g��✓�,�,,.,,p�.,V � <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes ❑ No � Probed tank(s) bottom <br /> cesspool, drywell, or leaching pit. ❑ Examined construction records <br /> Seepage pits meevng iU&U.2550 may be ❑ Examined Tank Integ�ity Form(A(tach,; <br /> compliant if allowed in local ordinance. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s) leak below their ❑Yes ❑ No <br /> desi ned o eratin de th. ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s) leaks: ❑ Probed outside tank(s)for"black soil" <br /> ❑ Unable to verify(5ee Comments/Explanatron) <br /> �ll7y "y@S"al7SWLP abOVe II1dICat�S fhC ❑ Other methods not listed (See Comments/Explanation) <br /> systeret es Failing fo Protect Grounclwater <br /> Comments/Explanation: <br /> 3 o Oth�r CO�1'lplia�ICe COiid�$1of�5—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes'` ❑No ❑Unknown <br /> b. Other issues(electrical hazards,etc:)to immediately and adversefy impact public health or safety. ❑Yes" ❑No ❑Unknown <br /> *Sysfem is an imminenf threaf to public health and safefy <br /> Explain: <br /> c. System is non-protective of ground water for other condifions as deterrnined by inspector ❑Yes" p No <br /> *System is failing to protecf groundwater <br /> Explain: <br /> www.pca.state.mn.us � 651-296-6340 a 800-657-3864 � TTY 651-282-5332 or 800-657-3864 = Available in alternative formats <br /> wq-wwists4-31 � 1/24/12 - Page 2 of 3 <br />