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May 05 2015 03:14PM HP FaxRusty Olson 7634988290 page 6 <br /> Property address 3420 High Lane __ _ _ _ _ Inspedor initialsJnate: 4l2M1 __ <br /> 1, ImpaGt On Publit Health--Compiiance component#1 of 5 <br /> Compliance criteria: � Verification method[s): <br /> System discharfle sewage to the I ❑Yes ❑No ❑ Searched for surface outkt <br /> ground surface. ❑ Searched for seeping�tt yard/backup in home <br /> ❑ Excessive ponding in soil systemlD-boxes <br /> System disCharge sewage to drain tile ❑Yes ❑No � Homeowner testimony(See Canmerns/Explenetion) <br /> or suriace waiers. <br /> System cause sewage backup into ❑Yes ❑No � "Bladc sal"above sail dispersal system <br /> dwelling orestablishment. ❑ System requires'emergenc�'pumping <br /> - ❑ Perfomied dye lest <br /> Any"yes"snswerabove indicate�s the system is ❑ Unable to veriiy(See CammernsiFcplanatio�) <br /> an/mminent Threat tc Pt�blic He.alth and Safety. ❑ p�er methods not listed(See Comments/Explanetion) <br /> C om m en tslExpta n ati an: <br /> 2. Tdnk Int2��ty—Compliance cornponent#2 of 5 <br /> GomPliance criteria: ___� Yerificativn method(s�: <br /> System consisis of a seepage pit. ❑Yes �No ❑ Probed tank(s}bottom <br /> cesspoot,dryweA,or leaching pit. I <br /> ❑ F�camined cons0uction records <br /> Seepege pits meeCng 7080 2554 may be ' ❑ E�carnined Tank Integrity Forrn(Attsch) <br /> compliant if aQowed in bcal adirtanCs. <br /> - - - -- ❑ Qbserved liquid level below operating depth <br /> Sewage tank{s}leak below their ❑Yes � No � �amined empty(pumped)tanks(s) <br /> -signed operatinq depth. <br /> yes,which sewage tank(s)Isaks: ❑ P��outside tank(s)for"black soil" <br /> r;ny"yes"answer abova indicates fhe � Unable to V@rify(See Comments/Erplana6bn) <br /> system is Failing to Protect Groundwater. ❑Other methods not listed{See Comments/�xplenation) <br /> Commertts/Explanation: <br /> On 4l24115,Efiner J. Peterson Co.pumped septic tanks. <br /> 3. (3ther ComplidnCe Conditiotts—Compliance componerrt#3 of 5 <br /> a. Maintenance hole oovers are damaged,cracked,unsecured,or appear to stn,�cturaqy unsound. ❑Yes' ❑No ❑Unknown <br /> b. Other issues(electr�cal hazaros,e�.)to immediately and adversefy impad public heaRh or safety. ❑Yes` ❑No ❑Unlcnown <br /> ;System ia an immin�ent�reat to publiC healttr end safety <br /> Exp�ain: <br /> c. System is non-protecti�e of grrwnd water for other condi�ons as determir�ed by inspecxor p Yes' C]No <br /> `Syst�errr is failing to proued�oundwarter <br /> Explain: <br /> www.pcastate.mn.us • 651-296-6300 . 800-657-3864 • M 651-282-533Z ar 80�657-3864 - Available in altemative forrnau <br /> wq•wwis[s4-3f . I/Z4I11 Page2oJ3 <br />