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�' -, � Property address: 1205 French Creek Drive __ Inspector initials/Date: RLF I 10/06/2015 (mm/dd/yyyy) 1. Impact on Public Health — Compliance component#1 of 5 Compliance criteria: Verification method(s): System discharges sewage to the ❑Yes � No ❑ Searched for surface outlet ground surface. __ __ ____ , _ __ ___ __ ❑ Searched for seeping in yard/backup in home System discharges sewage to drain ❑Yes � No ❑ Excessive ponding in soil system/D-boxes tile or surface waters. ❑ Homeowner testimony(See CommentslExplanation) System causes sewage backup into ❑ Yes � No ❑ "Black soil"above soil dispersal system dwelling or establishment - --- -- --- -- ❑ System requires"emergency° pumping Any"yes"answer above indicates the ❑ Performed dye test system is an imminent threat to public ❑ Unable to verify(See Comments/Explanation) health and safety. ❑ Other methods not listed (See Comments/Explanation) Comments/Explanation: Replacement system Type I Pressure Bed 2. Tank Integrity— Compliance component#2 of 5 Compliance criteria: Verification method(s): System consists of a seepage pit, ❑ Yes � No ❑ Probed tank(s) bottom cesspool, drywell, or leaching pit. ❑ Examined construction records Seepage pits meeting 7080.2550 may be compliant if allowed in local ordinance. ❑ Examined Tank Integrity Form (Attach) Sewage tank(s) leak below their ❑ Yes � No � Observed liquid level below operating depth designed operating depth. I ❑ Examined empty(pumped)tanks(s) If yes,which sewage tank(s) leaks: �, ❑ Probed outside tank(s)for°black soiP' Al1y "yes"answer above indicates the ❑ Unable to verify(See Comments/Explanation) system is failing to protect groundwater. ❑ Other methods not listed (See Comments/Explanation) Comments/Explanation: Existing tanks inspected and passed by pumping contractor 3. Other COmplianCe COnditiOns—Compliance component#3 of 5 a. Maintenance hole covers are damaged,cracked, unsecured,or appear to be structurally unsound. ❑Yes" � No ❑ Unknown b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. ❑Yes" �No ❑Unknown *System is an imminent threat to public hea/th and safety. Explain: c. System is non-protective of ground water for other conditions as determined by inspector. ❑Yes" � No *System is failing to protect groundwater. Explain: www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-wwists4-31b • 6/4/14 Page 2 of 3