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. � 05/01/2014 07:03 9528733112 PAGE 02/a4 <br /> Prop�rty address: 125�xolden View Drive• Lang Lake __^ Inspector fnitials/Date: J5 � 5/1/��1a _ <br /> (mm/ddly}ryyJ <br /> 1. Impact on Public Health—Compliance component #1 of 5 <br /> Com lianc�cri#�ria: . Verlfication method(s): <br /> System dischargas sewage to the ❑Yes �No � Searched for surface outlet <br /> round surf2�Ce. �Searched for seepfng in yardlbackup in home <br /> System dfscharges sewage to drain ❑Yes �Nv d Excesslve ponding in soil system/D-boxes <br /> tile or sur�ace waters. � Homeowner testimony(See Comme»ts/Exp�anafron) <br /> System causes sewage backup into ❑Yes �$1 No ❑"Black soil"above soil dispersai system <br /> dwelling or esiablishment. I 0 System requires"emergenc�'pumping <br /> Any""yes"a�nswer above indicafes the 0 Per�armed dye test <br /> sysfem is en imminent threat to public ❑ Unable to verify(See Gomments/�xp�anatfon} <br /> f�ealth and safety. ❑Other methods not lisied (See Gomments/Explanatron) <br /> Com mentsJ�xplanation: <br /> 2. Yank Inte�rity—Compiiance component #2 of 5 <br /> Complpance criteria: verification method{s}: <br /> System consists of a seepage pit, ❑Yes �Na ❑ Probed tank(s)bottom <br /> cesspofll,drywell,or leaching pit. ❑ �xamined canstructlon records <br /> Seepage prfs mesting 7080.2550 may be �ExBmined Tank Integrity Form (AttaChj <br /> compliant iP allowed ln Jocaf ordinartCe, <br /> "'— ""— �Observed liquid le�el below operating dep#h <br /> Sewage tank(s}IQak below their ❑Yes � No <br /> deslgned operating depth. � �xamined empty(pumped)tanks(s) � <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black sal" <br /> ' � Unable to verify(See Comments/�zplanailon) <br /> Arry "yes"�nswer above indicates the <br /> system is fsiling to prot�ct gro�►ndwater. ❑Othsr methods not�isted (see comments/�xplanatlon) <br /> Gommpnts/Explanatlon. � <br /> 3. Other Compliance Cond3tions�-Compliance component#3 of 5 <br /> a. Maintenance hole Covers are damaged,cracked,unsecurad,or appear to be struoturally unsound. ❑Yes" �No ❑Unknown <br /> b_ bther issues(elechf�alltazards,er�.)to immecfiat9ly and adversely impact public health or safety. �Yas° �I No ❑unknown <br /> *System fs an imminent thres!to AuWic health and safety. <br /> Expla�n: <br /> c. System is non-protective o4 ground waCer far other condit{ons as determined by inspector. ❑Yes' �No <br /> "System!s falling ro protect grou�ndwater. <br /> Explain; <br /> www.pCa_state.mn.us • 651•Z96•6300 . 800-657-386A • TTY 651-ZSZ-533�,or 800-657-3864 • Avaitabte in alternative formais <br /> wq-wwts[s4-3T • 3J 161 fz Poge 2 of 3 <br />