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� // � � '"` ! <br /> ���CC.��,I(_ � ���z�2G�-Y� �'�v <br /> Propeny address: 1205 French Creek Drive,Way2ata MN 55391 inspector initials/Date: L8 47-49-2015 <br /> 1. Impact ort Public Hea[th—Compliance component#1 of 5 <br /> Com liance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes ❑No ❑ Searched for surface outtet <br /> round surface. ❑ Searched for seeping in yardlbackup in home <br /> System discharge sewage to drain 61e ❑Yes ❑No � �cessive ponding in soil systemiD-boxes <br /> or surface waters. ❑ Homeowner testimony(See CommentsiExpranation� <br /> System cause sewage backup i�to ❑Yes ❑No � �glack soii"above soit dispersat system <br /> dweqing or establishment. ❑ System requires"emargency"pumping <br /> ❑ Per�ormed dye test <br /> Any"yss"arrswer above indlcates the sysfem is ❑ Unable to vetify(See Comments/Explanation) <br /> an lmmineni Threat to Pubtic Health and Safety. <br /> ❑ Other methods not listed(See Commenis/Explanation) <br /> Comments/F�cptanation: <br /> 2. Tank lntegrity—Compliance component#2 of 5 <br /> Com liance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes �JVo ❑ Probed tank(s)bottom <br /> cesspool,drywetl,or teaching pit. � ❑ Examined canstruction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Fonn(Attach) <br /> com lianrifatlowedin rocarordinance. [] Observed liquid tevet below operating depth <br /> Sewage tank(s)leak below their ❑Yes (�No <br /> desi ned o ratin de th. � - � �xamined empty(pumped)tanks(s) <br /> tf yes,which sewage tank(s}leaks: ❑ Probed outside tank(s}for"black soil' <br /> Any "yes"answer above indicafes the ❑ Unable to verify{See Comments/Explanation) <br /> system is Failing fo Protect Groundwater. ❑Other methods not Iisted;Ses Commants/Explanatrorr) <br /> Comments/Explanation: ,�- /j�j0 ��(. �G J kr l3�;��r s t a (�l u c e - Ta.:�/cs ,`�J <br /> SCt'�:S�Gc:.'t"Orl,� COni�l�i'�dnJ. <br /> ! <br /> Business Name: Kothrade Sewer,Water,Excavating,Inc <br /> Business Address: 12059 Whitetait Ln,Hanover MN 55341 <br /> Business Phone: 763.498.8702 <br /> Company Representative: Larry Bursch MPCA#: 0192/9199 Signature• �,c� l �zc-L• <br /> 3. Othe� ComplldnCe Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. p Yes' p No ❑Unknown <br /> b. Other issues(etectricat hazards,ete.}to immediately and adversely impact public health or safety. ❑Yes' ❑No ❑Unscnown <br /> *System is an immfnent threat to publfc health and safety <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector p Yes' ❑No <br /> 'System is failing to protect ground�+vater <br /> www.pca.state.mn.us • 651-29b-6300 • 800-657-38b4 • T7Y 651-282-5332 or 800-657-386A • Available in altemative formats <br /> wq•wwists4•31 • t l2d/t2 Page 2 of 9 <br />