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Property address: 215 Hollander Road Inspector initials/Date: RLP � 11/10/2016 <br /> (mm/dd/yyyy) <br /> 1. Impact on Public Health— Compliance component#1 of 5 <br /> Com liance criteria: Veri�cation method(s): <br /> System discharges sewage to the ❑Yes � No ❑ Searched for surface outlet <br /> round surface. ❑ Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑Yes � No ❑ Excessive ponding in soil system/D-boxes <br /> tile or surface waters. <br /> ❑ Homeowner testimony(See Comments/Explanation) <br /> System causes sewage backup into ❑Yes � No ❑"Black soil°above soil dispersal system <br /> dwelling or establishment. <br /> ❑ System requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminent threat to public ❑ Unable to verify(See Comments/Explanation) <br /> hea/th and safety. ❑Other methods not listed(See Comments/Explanation) <br /> Com ments/Explanation: <br /> New installation <br /> 2. Tank Integrity— Compliance component#2 of 5 <br /> Com liance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes � No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 may be ❑ Examined Tank Integrity Form(Attach) <br /> com liant if allowed in local ordinance. <br /> Sewage tank(s)leak below their ❑Yes � No � Observed liquid level below operating depth <br /> designed operating depth. ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> Any "yes"answer above indicates the ❑ Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. ❑ Other methods not listed(See Comments/Explanation) <br /> Com ments/Explanation: <br /> New installation of tanks <br /> 3. Other COmplianCe ConditiOns—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. ❑Yes* �No ❑Unknown <br /> b. Other issues(electrical hazarcls,etc.)to immediatety and adversely impact public health or safety. ❑Yes" �No ❑Unknown <br /> "System is an imminent threat to public healUi and safety. <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector. ❑Yes* �No <br /> *System is failing to protect groundwater. <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TT1f 651-282-5332 or 800-657-3864 • Available in altemative formats <br /> wq-wwists4-316 • 6/4/14 Poge 2 of 3 <br />