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05/22/2613 08: 45 9528733112 PAGE 02/04 <br /> t <br /> Property address: .1380 FrenCh Creek Dr. _ Inspector initialslfJate: JS j 5/1712013 _ <br /> (mm/dd/YYYY) <br /> 1. Impact on Public Health— Compliance component#1 of 5 <br /> Co�liance cr�teria: _ Veriflcation method(s). <br /> System discharges sewage to the i ❑Yes � No <br /> �j Searched for surf�ce outlet <br /> __ground surface. . . _ � Searched for seeping in yard/b�ckup in home <br /> System discharges sewage ta drain [�Yes � Np 0 Excessive ponding in soil systemlD-boxes <br /> tile or surface waters. — ❑Homeowner testimony (See commentsiExplanation) <br /> System causes sewage backup inta ❑ Yes � No ❑"Black soil"above soil dispersal system <br /> dwelling or establishment. — [] Systerr�requires"ernergency"pumping <br /> Any"yes"answer above indicates the ❑ Pertormed dye test <br /> system is an immirre,�t threat to public Q Unable to verify(See commen�s�XnraRetlon) <br /> h�31th and Safety. ❑ Other methods not listed(See Comments/Explanefr'on) <br /> CommentslExplanation: <br /> �. Tank Integrity— Compliance companent#2 of 5 <br /> Com�ance criteria: Verification method(s): <br /> . __ <br /> System consists of a seepage pit, Q Yes �No (�Probed tank(s) bottom <br /> Cesspool,drywell, or leaching pit. � �xamined construction records <br /> Seepage pits meer�ng 7080.2550 may he ❑ Examined Tank Integrity Form (Attach) <br /> Cprnpllant if s!lowed in�CCaI QrrJrnance, _ ,_ _._ <br /> — - ❑ pbserved liquid level below operating depth <br /> 5ewag�#ank(s)leak below their ❑Yes � No � �xamined empty(pumped)tanks(s) <br /> designed operating depth. <br /> If yes,whlch sewage tank(s} leaks; ❑ Probed outside tank(s)fnr"black soil" <br /> ❑ Unable to verify(S�e Gommenfs/Exp�anAtion) <br /> Any "yes"answer abave fndicates t�hQ <br /> system►is failing to protect groundwater. � Othe�methods not listed �see Commen�s�Expienar�on) <br /> Com mentslExplanation: <br /> 3. Qther Compliance Conditions�Campliance c�mponent#3 of 5 <br /> a, Maintenance hole oovers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes" �No ❑Unknown <br /> b. 4ther issues(elecnicaf hazards,e1�.)to immediately and adversely impact public hQalth or safety, p Yes' �No p unknown <br /> "'System/s an imminent threa!to public health and saf�ty. <br /> Exptain: <br /> c. Systern is non-protective�f ground w2ter far ather wnditions as determined by inspector. p Yes" �No <br /> 'System is faAing to prvtect groundwater. <br /> Explain: <br /> _ <br /> . <br /> www.pca.s[ate,mn.us • 651•296-fi3Q0 • 800•657•3864 • TTY 651•282-5332 or 800-657•3864 • Availdble in alternative formats <br /> wq-wwls[s4-3� - 3!�6/92 Page 2 of 3 <br />