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May 24 2015 04:15PM HP FaxRusty Olson 7634988290 page 6 <br /> �' <br /> Property address; 1250 French Creek Drive __ Inspedor initials/Date: 5l18/1_ _ <br /> 1. ImpaCt on PubHc Heatth—Comp�iance component#� oF 5 <br /> Compliance criteria• __ _ _ Ve�fication methai(s): <br /> System disoharge sewage to the j ❑ Yes ❑ No ❑ Searched for surface outlet <br /> �round surfaoe. _ � _ _ ❑ Searched for seeping in yard/badcup ln home <br /> ❑ Excessive ponding in soil system�D-boxes <br /> 5ystem discharge sewa�e to drain tile � ❑Yes ❑ No � t.�pmeowner testimony(See Commerrts�Explen�ation) <br /> or surface waters. 1 <br /> -- - .�_ -- ❑ "BYack so�'above soil dispersal systern <br /> System cause sewage badcup into ❑Yes ❑No � gygtem requires"emergenc,y' pumping <br /> dwelling or esiablishment. mm , y ❑ Performed dye test <br /> q17y`�yg�g"gffgW@/8bpt�9 indlc�Rs the syStem 1s ❑ Unable ro verify{5ee C�mn+enrsrF�planeeion) <br /> an/mminer►t'rhroat to Publlc Heafth and Safety. ❑ pther methods no1 listed{See Ganment�✓ErptenatronJ <br /> Co m menta/E�laneiion: <br /> 2. Td11k 1�t�lty—Compliance component#2 of 5 <br /> Compliance criteria: _ _ __ Verlflcation melfiodls): <br /> 5ysbem consists of a seepage pit, ❑Yes �No ❑ �robed tank(s)bottom <br /> cesspool,drywell,or leaching pit. I ❑ Examined construction r�ecords <br /> $eepage prts meebng 7080.2550 may be ❑ Examined Tenk Ir�egrity Form(Attach) <br /> compuant rf al�owed in�ocal wdrnanca. � Observed liquid level below operating depih <br /> Sewage tank(�}leak below their ❑Yes � No � �mined empiy(pumped)tanks(s) <br /> If_ igned operatrng depth. <br /> des <br /> - - - ._._. <br /> yes,whiCh sewage tank(s)leaks: I ❑ Prabsd outside tank(s)far"btack soil <br /> — - ---- — -- ❑ Unable to venfy(See CommentsiExplenatia�) <br /> Any`yes"answer above indicates the �p�er methoqs not listed(Sea Commenrs�Enplanario») <br /> system is Failing to Protect Groundwater.� <br /> CommentslExplanation: <br /> On 5/18/15,Elmer J. Peterson Co.pumped septic tanks. <br /> 3. Other Compliance Conditlons—comp�;a�ce component#3 of 5 <br /> a. Mairitenanoe hole covers era damsged,cradced,unseca,red,Or eppear to Structurdlly unsound. ❑Yes" p No ❑Unknown <br /> b, Qther issues(elec�ic-,a/hezertfa,e�c.)to immediatefy and adversely impact pubdc heatth or safery. ❑Yea• ❑No ❑Unknown <br /> 'Sysiem is an imminent threa!to pubkc heelth artd aafa[y <br /> Explain: <br /> c, System is non�rote��ve of gramd water tor otF�canditions as detennined by inspedor p Yes" ❑No <br /> •Syst�rn!s failing to pro6aci grottndw�ater <br /> Explain: <br /> www.pca.state.mn.us • 651•29d-6300 • 800-657-3864 • lTl'651-282-5332 or 800•657-3864 � Availabte fn altemative tormats <br /> wq-wrris W-31 • 1!?4!f 1 Paqe 2 oJ 3 <br />