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. ' Property address: C,5 �t7LJd��,/1�� b � Inspector iniUaleJDate: tF-'o1g—ti 3 <br /> 1. ImpatE on Public Hedlth—Compliance component#1 of 5 <br /> Com Iiance criteria: Verification method(s): <br /> System dischsrge sewege to the ❑Yes �No ❑ �erched for surfece outlet <br /> round surface. � Searched for seeping in yrardlbadcup in home 1,1A <br /> S�stem discharpe sewage to drain tile ❑Yes ❑No � ���Ponding fn sofl systeml0.boxes <br /> or surface waters. ❑ Homeowner testimony(See Comments�Fxplenatior,)laa <br /> System cause sewage badcup into ❑Yes �No � �B18�s°Y ab°ve soi�dispersal system 1.10 <br /> dwelling or establishmer►t ❑ SYS��quires"emergency'pumping <br /> Any"yes"artswer above Jnd/cates the system ts � Pe���test <br /> an/mminent Threat to Publlc Health and Safety. ❑ Unable to verify(Sae Comments/Exp/anaUon) <br /> ❑ Other methods not Itsted(See Canments/Exp�enaUon) <br /> CornmentaJE�lanaUon: <br /> 2. TBnk integrity—Compliance component#2 of 5 <br /> Compliance criteria: __ Veriticatlon method(s): <br /> System oonsiats of a seepage pit, ❑Yes ❑No ❑ Probed tank(s)bottom <br /> cesspoot,drywell,or ieachi�g pit. <br /> ❑ Examined construction reco�ds <br /> Seepape pits meeHny 7080.2550 may be ❑ Examined Tank Integrity Fotm(Ntach) <br /> oan ieM if allowed rn bcaf ordlnenae. <br /> Sewage tank(s)Ieak below their ❑Yes ❑No � Observed I(quid level below operating depth <br /> desi ned o ral(n de th. ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outsfde tank(s)for"bladc aoU' <br /> ❑ Unable to verify(See Commer�fs/Explenatlon) <br /> Any'�res"ansWer above Indicates the ` �p�ryer meti�ods not Itsted(See CommentsiE,rplanetion) <br /> system is Fa!!/ng to Protect Groundwater. <br /> Comments/Explanation: <br /> S�� �C�(���rGq �S��a� �N�t�-t��( 4-�?�'�' -T�a+�.�� ,��,►s���c,t� <br /> 3. Othe�COmplidllt@ Co�dltio�s—Compliance component#3 of 5 <br /> a. Maintenance hole oovers are damaged,cradced,unsecured,or appear to sUuc;turapy unsound. Q Yes• �No ❑unknown <br /> b. Other issues(elecMrrN hazards,efc.)to immediet@ly and edversely impect pubGC healfh of 8afety. ❑Yes' �No p Unknown <br /> �ystgm is an lmmlrtenf fhreat to puWlc hea/th snd safety <br /> E�lein: <br /> c. System is non-protadive of ground water for other conditions as determined by inspector ❑Yes• ■No <br /> 'System is falUng to protectgnwndwater <br /> Explain: <br /> www.pca.scace.mn.us • 651-296•6300 • 800•657-3864 • TTY 651•282•5332 or 800�657•3864 . Avaitable 6�altsmattve formats <br /> »,�•�+5w-s� . rnair� , <br />