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Nov 11 2016 09:11 AM HP FaxRusty Olson 7634988290 page 15 <br /> _r� <br /> Property addreas: fp45 Brown Road S Inspector mitialsrDate: 10/2M16 / <br /> 1. Impact 011 Publit Fledlth-Compliance component#1 �f 5 <br /> Complfancs critena: _ Verificatfon mothod�s): <br /> T- ' <br /> SyBtem diachn�ge aewafle to ehe_i❑Yes p No � ���•a��surfaee o�tiel <br /> �round sudace. ❑ Seaictied tor Secpirtg jn yardlbackup in home <br /> System diccharge saweQe to drain tile �Yes C'No � ��r61Ye ponding in aoil ayabarrdD-bo,es <br /> or surfaoe we.ers. _ , � ❑ Homeawner Destlmony(Ses Cbmmsn:a�p�aneb'on) <br /> System cause sewage baCkup'vrip ❑y� ❑No C1 'BlecN soil"nbove soil dispersai systam <br /> c�+rellingorestaWishment. ` ❑ System�uires'emergency�pumping <br /> Any"yes"anawar abovo indio�tea tha ayatsrtt is G Pe�famed dye test <br /> an(mmJnent Throst to p11b�/c HealU�end Saf�a[y. ❑ uneble to verity(see c�mments�rprenanon/ <br /> _ ❑ Other methods not listed(Sae Commenrs/Explenebon) <br /> CommeMs/E�cp lanatlon: <br /> 2. Tdr1k Integrity-Complianoe cornponent#2 of 5 <br /> _Co�nCe criiaria: _ Verlfkation m�thod�s�: <br /> &ystcm consists of a seepage pit, � Q Yea �No ❑ ProDed tank(sJ bottom <br /> cesspod.QryweJl,or Ieaching pit. <br /> �, Exarnjned mng�rudion records <br /> Se9pepe piGc maating 7080.2650 mey 6e ❑ E�mtningd Tank I nteg�ity FOrttt(Attacn) <br /> complient if e!lowealn bca+oMinarx�e. <br /> 9e�^iege tartk(s)leak balow iheir ± � ❑ �b�rved tiquid Ieve1 below operating depth <br /> ❑Y@s �No <br /> designed operaHng depth, � Fxaminetl emAH(P�mPed;tanks(s) <br /> If yes,which sewage tank(s}leaks: � � Probed ouL4ide tank(a)fpr`black saf" <br /> Any`•yes"anaw9r above indi ates the Q Unable ta veriry�see canmoms�pr�na��a,1 <br /> system is Fsi!►ng to Profect Groandwatar. ❑��methods not listed(See Carrm�enty6cpbneWnl <br /> CommentrJE�lBnafion: <br /> On 10124/16.Elmer J.Peterson Co.pumped m�ka. <br /> 3. Othe�COt11PI�df1Ce COr1dlt�OnS—Compliance component#3 oF 5 <br /> a. Malntenence hde mvers are dameged�cracksd�unsecured,or appear h�strt�chxaNy ur�sound. ,'�Yee' ❑N a ❑UNenown <br /> b. Other igg�g(elac4Ycml harartis,e�.)to irmwdigtby and adYereely impact public health or Safery. ❑Yes' ❑Na ❑Unknovm <br /> 'systan is an immin�+r!Nww2 to pubNc hwVaf and safely <br /> E7�lain: <br /> c. Syetem is nor►protedive of ground vre4er(or othar ooMitlwis ee tlelerminetl by inspeUor ❑Yes' ❑No <br /> "SY����N�►g io P�oEect groundwretcr <br /> Exptein: <br /> www.pca.su[e.mn.us • 65t-2%-6300 • 800-657-]864 . 7TY657-2ffi-5331ordd7-657�3gy1 • Availa6leinaltemativeformats <br /> w4-�sts43� . �/24I72 <br /> Acqe 7 of 3 <br />