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Property address: f Z q� F�f��� C'��G`< A�--, Inspector initials/Date: ��{�_�l� <br /> 1 a Impa�t ot� Public Health—Compliance component#1 of 5 <br /> Com iiance criteria: Verification r�ethod(s): <br /> System discharge sewage to the ❑Yes �No � Searched for surface outlet <br /> ground surface. [�]'�Searched for•seeping in yard/backup in home <br /> — ❑ Excessive ponding in soil systemlD-boxes <br /> System discharge sewage to drain tile ❑Yes �No <br /> or surFace waters. ❑ Homeowner testimony(See Comments/ExpJanation) <br /> ,� ❑ "Black soil"above soil dispersal system <br /> System cause sewage backup into ❑Yes � �lo [] System requires"emergenc�'pumping <br /> dwelling or establishment. ❑ Performed dye test <br /> �4�►y"yes"answer above ino�icates th�sysfem is ❑ Unable to verify(See CommentsiExplanation) <br /> an Immiltenf ThPea1 to Pu�blic Heaffh and Safety. ❑ Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2 Tdnk Integ�'ity—Compliance component#2 of 5 ,(jy �u ,�.._���,` _ _ <br /> Com lianee criteria: Verification rnethod(s): <br /> System consists of a seepage pit, ❑Yes ❑ No ❑ Prob�d tank(s) bott�m <br /> cesspool,drywell, or leaching pit. I ❑ Examined construction records <br /> Seepage pitsmeeting?08Q.255Qm.aybe ❑ Examined Tank Integri'ty ru�iu(Httacii) <br /> complianf if allowed in local ordinance. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes ❑ No ❑ Examined empty(pumped)tanks(s) <br /> desi ned o eratin de th. <br /> If yes, which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> _ - ❑ Unable to verify(See Comments/ExplanationJ <br /> Any "yes"ansv�er a,bove indicages the <br /> ❑Other methods not listed (See Comments/Explanation) <br /> syster� is Fail►ng �o Protect Grou�edvvager, <br /> Comments/Explanation: <br /> 3 o Oth��' COB'�p�te��1Ce COI1d�$1o�15—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. ❑Yes* ❑No O Unknown <br /> b. Other issues(electrical hazards,etc:)to immediately and adversely impact public health or safety. ❑Yes" ❑No ❑Unknown <br /> "Sysfem is an imminenf threaf fo public health and safefy <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector ❑Yes" ❑No <br /> *System is fiailing to protect groundwater <br /> Explain: <br />