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Property address: 4245 ChFppewa Lane Inspector fnitlalslDate: 5/25l16 <br /> ' 1. 3mpac#on Public Nedtth—Compliarsce camponent#t of 5 <br /> _Compliance criteria: � Verification method(s): <br /> System discharge sewaga tolhe ❑Yes []No ❑ Searched for surface ouUet <br /> round surfaoe, ❑ SearChed tor seepfng in yardJbactcup in horrte <br /> Syetem discharge sewage to drafn file []Yes ❑No � ��eive ponding in soil systertUD-boxes <br /> or surface waters. ❑ Homeowner testimony(See Oommenla/ExpleneHon) <br /> System ceuse sewage badcnp into Q Yes ❑No � �$���SOiP above sop cGs�,�eraaE system <br /> dwelling or establishment. 0 SysEem requlres'emerger�'pumpi� <br /> ❑ Perfartned dye test <br /> Any Nyes"answer above indlcates the system!s � Unable to verify(See Commenls�Explenatran) <br /> an lmmi»errt Threat to Publ/c Heatth and Safety. ❑ Other methods not Itstetl(Sse Commer�tssiEzp�anaaorr) <br /> Commenls/E�lanation: <br /> 2. i'ank integCity—Compliance componenE#2 of 5 <br /> ComplEance criteria: Verlftcatfoh mefhod{s}: <br /> System consists of a seepege pft, ❑Yes Q�P!o ❑ Prohed tank{s)bottom <br /> cesspoW.dryweli,ar leaching pit ❑ Examined oonstructlnn records <br /> Seepape pifs meefing 7080.2550 mey be ❑ E.Xamtned TanK Integtiry Fomt(AaachJ <br /> cbmp7ient ri allow�ed fn foca!ordinence. <br /> Sewage tank(s)leak below thei� I]Yes �No� � ODserved{iqnid level 6elaw operating depEh <br /> desi ned ratin de th � Examined ampty{pumped)tanks(s) <br /> 1f yes,which sewaga tank(sj leaks: � Probed outalde tank(s)tor'bfack soH° <br /> Any"yes"answer above)ndlcates fhe ❑ unanee ro verify�sea commen�p�„aao„� <br /> system Js Pallingr to Pmtecf Groundwater. �Ofher methods not 6sted(Sea CommantslExpJanatlon} <br /> Comments/Exptanation: <br /> On 5125l18,Elmer J.Peterson Co.pumped septic tanks. <br /> 3. Other Compl�ance Conditions—Compliance component�3 of 5 <br /> ; a. N�ir�enance tafe oovers are damaged.cradced,unsecured,or appear to sUucfurelly unsoured. O Yes" p No ❑Unkno`m <br /> b. Otherissues(efectr;r.etdazards,etcJ to Immediately and adversely impact pub�e heaHh a safety. ❑Yes` ❑No Q Unknown <br /> �yafem!s en imminent threat fo pabl7c health and safaty <br /> Explain: <br /> c. S�rstem is nort-prbtective t�f ground waUer for oiher oopditfons as determ]ned by inspector p Yes• ❑No <br /> `SYste�++k fallJng to protect grouadwater <br /> Exptain: <br /> ; <br /> ; <br /> � <br /> www.pca.state.mn.us - 651-2%-6300 . 800-657-3664 . TTY651d82-5332orB00�65�-9864 • AyaltableinaltemacFneformats <br /> �wwtsts4•3f - lIZ41 t2 <br /> P4ge 2 of 3 <br />