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Prop�tty addre�ss:• - y�a�►S� ��-,�G.� 1.s� Inspec#or tniUals/Date: � 1 t�y 3-1 tic <br /> 1. lmpact on Publlc Nealth—comptlar�ce campane�t#9 of 5 <br /> Com ifance cnteNa: � Verificatton methad(s): <br /> System disct�asge sewage to the ❑Yes �iJo ❑ �����r surface outlet <br /> raund surface. � Seardted for saeping in yardlbackup in home 1.Lp <br /> 5ystem dischargQ sewage to draSn lile ❑Yes �No �'���B����g irt soii systemlD-boxes f�p <br /> qr surface waters. ❑ NOmBOVme�testitYlohy(S�e Commanfs✓F.xplanafion) <br /> Syatem cause sewage backup into [j Y� �Q � "�lack soi!"above sail dispersal system�lJ <br /> dwelling or establishment. � ❑ �ygtem�equt�es'smergenc�'pumping <br /> ❑ Petformed dye feat <br /> Any"yes"answer above�ndlcates the system is ❑ Unabte to vetify(Ses Cor►iments/�7cplanadon) <br /> an lmminent Threat to Public Neaiflr and Safety. [� Ot�18r m8thpd9 hot 118l8d(See Commants/�xpfanedort) <br /> Gommenfs/Explanatlor�: : . , <br /> 2. Tank Integrfty--Compliance component#2 of 5 ' . <br /> Cam ilanae cflter3a: .. .Ve�Eficatiot�method(sj: . <br /> System conslsfs of a seepaga plt, ❑Yes ❑No . ❑ Probed tank{s)�ttom <br /> cesspooi,drywefl,or leactttng Pft• . <br /> C�• ExamEned oonstruc�ion�ecords <br /> Seepage p�s rneafJnQ 7Q80.2550 mey be � ❑ E,X�mined Tartk Inte <br /> corn llant if aqowed!n lacal ortifrrence. g[ity FoRn(Attach) <br /> Sewage tank(s)leek betow thetr d y� ��o ❑ Obsetved lEqutd feve!below opeta6ng depth <br /> desi ned o aratln de th. ❑ �mined empty(puMpec�t�nks(s) <br /> !f yes,which sewage tank{s)leaks: ❑ Probed outs(de tank(s)for'black so(t' <br /> Ali . ❑ Unable fo vetify(See Comments�Ex <br /> y rry�.,,��SW�r a6ove lndlcates the Planatfon) <br /> systsm is Fatlfng to Protec#Grtiundwafer. . CJ Other methods not listed(See Commenis�F�cplanafton) <br /> Commente/E�cplanetfan: • � <br /> S�� ��C�u�� �,��a�; ��a�C�t���� _ '�-�'� ������d� a0 � <br /> 3. Other Compltance Gonditions—Complla�nce component#3 of�5 <br /> a. Mainfenance hole cavers a�e damaged,cractc�d�ut�e��"pr��������u�� ❑Yes' <br /> ' �No ❑tlnknown� <br /> b. Other issues(elsctricalhazard�,ee�.}to Imrnedietbiy�nd adveisety Impact p€�bqa heafth or saf <br /> �Sysi�em!s an Tmmfna�nt thr�t to publlc healfh and ssl�ty �• ❑Y�• �Hfl ❑Unknown <br /> Explain: . � , . <br /> c. System is non-protedlve o#ground water for other mndi�ons as dete�mined by inspec�or Q Yes• ,��o <br /> *System!s falling M ptntect grotrndwater• � . • <br /> Expfain: . <br /> `�►����������� � ���`�.9�`�1� � �'��7�3� � • ��'����•5��2 0{'��5�•�� • �Yat�a��e�t altentat�te 4aimatr <br /> wq•ww/sW-3f • !/24/f? <br />