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Jun 07 2016 07:47AM HP FaxRusty Olson 7634988290 page 6 <br /> Property address�� 1260 French Creek Dnve _ _ inspector initials/Dete: 5/8l16 <br /> 1. Impact on Pub(tt Health—Compliance component#1 of 5 <br /> Compliance criteria• Verefication methocf(s): <br /> System discharge sewage to the � ❑Yes ❑No ❑ Seerched for surface outlet <br /> �raund surface. ❑ Searched for seeping in yard/bad�up in home <br /> 5ystem discharge sewa8e to drain tile ❑Ye$ p� � �ceS3Ne ponding in soN system/D-bpxes <br /> or surface waters. ❑ HOmeownertesfimony(See Comments/Eacplanetlon) <br /> System cause sewage backup into i ❑Yes ❑ No � �Black soil"above sal dispersal system <br /> dwelling orestabfishment. ❑ System requires'emergenc�'pumping <br /> Any"yes'•answarabove indicates the aysiem is ❑ Performed dye iest <br /> an/mminent Thr�eat[o Public Hoa/th and Safety, � Uneble to verify(See Cornment✓Explanation) <br /> ❑ Other methods no1 listed(5ea CommentslExplanstion) <br /> Co mmentslExp lanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance crlteria: Verification method(s); <br /> System consisis of a seepage pit, ?[]Yes �No ❑ Probed tank(s)bottom <br /> cesspool,dryuvell,or leaching pit. � <br /> i ❑ Examined consiruction reoordg <br /> S�pag�e pits moefing 7p80.255p may be ❑ Examined 7ank fntegrily Form(Attach) <br /> complient rf a!lowetl m loCaJ oRlinance. <br /> Sewage iank(s)leak below their ❑ ��►'�ed liquid level bebw operating depth <br /> ( ❑Yes �No <br /> designed operatin depth. �_ � Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(sj leaks ,` ❑ P"obed outside tank(s)for"black soil° <br /> Any "yes"answer above indicates the � U�bJe to verify(See Comments/Expfanation) <br /> system is Failing ta Protect Groundwater. ❑Other methods noi listed{See Comments/ExpJanation) <br /> Go m ments/F�lanatlon: <br /> On 5/BI16,Elmer J. Peterson Co. pumped septic tanks. <br /> 3. Other Compliance Conditions—Compi�ance comp�nent#3 of 5 <br /> a. lNaintenance hole covers are damageq,r,raci�ed,�n�red,or appear to stn,cturaily unsound. ❑Yes� ❑t,� ❑Unknown <br /> b. �ther issues(etec�ric8�hazartis,e��p�immediately and adversely impact public heatth pr safety p yes* p No ❑Unknown <br /> "System is an immlrtenr fhrast f�public heald�and safety <br /> Explain: <br /> c. System is non-pmt�ctive of ground water for other condi�ons as detarmined by inspector ❑Yes• ❑No <br /> 'SYs�is fail/n9�Prof�eeef groundwater <br /> Expiain: <br /> www.pca.state.mn.us . 6S7•29b-6300 • 800-657-3864 . TTY 651-282-5332 or 800-657-3864 • availahle in altemative formats <br /> wq•wwisfs4•3f . 1114/12 <br /> T..------ ��2�3 <br />