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Oct, 22, 2012 11 : 14AM No, 1004 P, 5 <br /> Properiy addreas: Inspector initlafs/pate: <br /> 1. (mpclG� on PUb��C HeBlth--Compliance Component#1 of 5 <br /> Com Ilance criteria: Veriticatlon method(g): <br /> Systam discharge sewege to 1he CI Yes �No ❑ Searrhed for surFace outiet <br /> round surface_ � Searched for seeping�in yerd/backup In homel�0 <br /> System discharge sewage to d�afn iile []Yes �No� � ��g$�ve ponding in soll system/D-boxes 1�D <br /> or surf�ce wsters, ❑ Homeowner t�stlmony(See Comments/E+cplenaHon) <br /> System cause sewage backup into ❑Yes �No � �B�a�soil"above soil diapersal system �Q <br /> dwelling or esteblishment_ ❑ System requires'emergenc�'pumping <br /> ❑ Perfonned dye test <br /> Any"yes"answer above Indlcates!he system ts ❑ Unable to verify(See Comments�Eacp/enetion) <br /> an Imminent Threet to Publlc Hewlth and Safety. [] Q{her methods not Ileted(5ee Commenfs/ExplenationJ <br /> CommentslE�cplanation: <br /> 2. Tallk 111tegl'ity—Campliance component#2 of 5 <br /> Com Ilance crite�ia: VerHlcation method(s): <br /> System cflnsists of a seepege pit, ❑Yes �No ❑ Probad ta�k(s)bottom <br /> cssspool,drywell,or leeching pit. <br /> ❑ Examined canstrudion records <br /> 5eepape pNs meeting ro80.2350 mey as ❑ Examined Tank(ntegrity Fortn(Attach) <br /> com lient if ellowed In locel ortllnanoe. <br /> Sewage tank(s)leak below their ❑Yes �No � Observed Ilquid level below operating depth <br /> desi ned o eratln de th. � F�camined empty(pumped)tanks(s) <br /> If yes,which sewa0e tank(s)leaks: ❑ Probed outslde tank(s)for'black soll" <br /> Any "yes"answer ebove indlcates fhe ❑ Unable to verlfy(See Comments/Explena6on) <br /> system is Failing to Protecf Groundwater. ��her methods not listed(Sae comrnenfs/Exp�anation) <br /> CommenislExplenetion: <br /> 5�,�i I�'���ru�r� �t�►�1 Y� �� `�'� � c�'� 1��������r.. 5�1er�':.. <br /> t.� d�'�. �1 �Gi�G�Q�l���.1�? <br /> 3. Other Complian�e Corld�tions—Compliance component#3 of 5 <br /> a. Mainten8nc8 hdle oovers ane damayed,Cradced,unsecured,orappear to stn�cturally unsound. ❑Yes" �No Q Unknown <br /> b. Other issues(elecvica/in�za►Us,etc.)to imrnedietely snd adversely impact public health or sefety_ ❑Yes'� �No ❑Unknown <br /> *Sysbem!s en Imminent tl�reat tio publlc health and aafety <br /> Explain: <br /> c. Syatam is non-protective of ground watser for other oondi4vns as detertnlned by inspector []Yea• �No <br /> 'Syst�em fs falling tn proG�ct groundwat�er <br /> Explain: <br />