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� d3/15/2016 12 : 24PM FA� 9528733112 f�0002/0004 <br /> Property address: 515 Ferndale Rd North,Wayzata, Mn 55391 _ lnspector initialslDate- JS � 3/10/2016 <br /> (mm/dd/yYYYI —. <br /> 1. Impact on Public Heafth—Complianee component#1 of 5 <br /> Compliance criteria: VerificatiQn method(s): <br /> System diseharges 5ewaga to the ❑Yes � No � Searched far surFace outlet <br /> _ground surFace. _ � Searched for seeping in yard/backup in home <br /> Systertt diScharges sewage to drain ❑Ye5 � No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters. ❑ Nomeowner testimany(SAe Comr�ents✓Explanatiun) <br /> System causes sewage backup into ❑Yes � No ❑"Black soil"above soll dlspersal system <br /> dwelling or es[ablishmenf. <br /> — - �System requires"emergency'pumping <br /> Any"yes"answer above Indicates the ❑ Perf4rmed dye tesE <br /> system �s an imminenf threat to public ❑ Unable to verify(Sea Comments/Explanation) <br /> /I@a/l�] �nd Saf@fy. ❑Other methods not Ilsted (See Corrrmenfs/Explanation) <br /> Cvmm�ntsl�xplanatlon: <br /> 2. Tank Integrity—Compliance component#2 of� <br /> Compllance criteria: _ Verification method(s): <br /> System consists of a seepsge pit, ❑ Yes �No ❑Probed tank(s)bottom <br /> cesspool,drywell, or le�ching pit. <br /> ��xamined construction records <br /> SeepAc�e pits meefing 7080.2550 may be 0 Examin�d Tank Integnty Form (Attach) <br /> com Ilan(!f aflqwed in local oMinance. <br /> Sewage tank(s)leak below thoir [] Yes � No ❑ Observed Ilqufd level belaw operating depth <br /> designed operating depth. � �xamined empiy(pumped)tanks(s) <br /> If yes,which sawage tank(s)teaks: I ❑ Probed outside tank(s)for"black soil" <br /> Any "yes"enSWer�boVe 117diCates fh2 ❑ Unable to verlfy(5ee Commenls/E'xplanation) <br /> system,Is failing to protec#groundwafer. 0 pther methods not�isted �sse comrnenrs/�xpian�son� <br /> CommentslExplanativn: <br /> 3. Other Campliance Conditions—Compliance component#3 of 5 <br /> a. Malntenance hole covers ar�damac�ed,cracked,unsecured,or appear to be structurally unsound. ❑Yes"' �No ❑Unknown <br /> b. dther issues (el�cfrical hazards,etc.)to immediately and adversely impaet public health or safery. ❑Yes' �No ❑Unknovm <br /> �`Sysi�em is an imm/nent throat fa public health and safety. <br /> �xplai n: <br /> a Systerr�is non-protective of ground water for other conditions as dateRnined by inspector_ [�Yes* �No <br /> "'System is falling ro proteci graundtvater. <br /> �xplai n: <br /> www.pca.state.mn.us • 659-296•63Q0 • 800-657-3864 . 7TY 651-Z82-5332 pr 8pQ-657-3864 - AvailabEe in alterrtatfve formats <br /> wq-wwrsts4-31 • 3/76/12 <br /> Page 2 of 3 <br />