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Jul 25 2012 3; O1PM No 0718 P, 5 <br /> Property ad'dress: I I a� �� �d¢.. ��.J� Inspeotorinitials/Date: � �-1'b�)Z <br /> 1. Impact on Pubtic Health—Compliance component#1 of 5 <br /> Com Ilance criteria: Veriflcation method(s�: <br /> System dfacharge sewage to ihe []Yes �No ❑ Sean�'�ed for surfaoe outlet <br /> round surface. � Searched for seepin�in yardJbadwp in home No <br /> System discharge sewage to drain tile �Yes �No � �8sive ponding in soll system/D-bo�ces NO <br /> or surface wate�s. ❑ Homeovmer tesbmony(See Comnrent�IF cplenehar� <br /> � `Black soil"above soil dispenet sys#em N 0 <br /> Syatem cause sewa�e badap into ❑Yes �No ❑ System�equires"emerge�c�pumping <br /> dwelling or estsblishmerrt. <br /> ❑ Performed dye test <br /> Any"yrs"answer above Indlca�es the system is ❑ Uneble to verify(See Commenta�Exp/eneNor� <br /> an Imm/nant Threat!�Pub//c Heelah and Safety. � Other methods not listed(See comment�lExpranetfion) <br /> CommentslExplanadon: s����� �L��� �� <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Com lianae criterla: '�a��Ga 5-a 3�1'2, Veriflcatlon method(s): <br /> System consists of a seepage pit, ❑Yes @�No 0 Probed tank(s)bottom <br /> cesspooi,drywell,o�laadting pit. ❑ Examined oonatruafion records <br /> Seepepe pr�s meeth+g 7080.2550 mey be ❑ Examined Tank In�egrity Fortn(Attach) <br /> oom �nt if ellow�ed in laael adl�er►oa. <br /> ❑ Oba¢rved Uquid level below operating deplh <br /> Sewage tank(s)leak below ihelr [�Yes �I'No � �mined empiy(pumpe�tanks(s) <br /> desi ned o ratin de th. <br /> If yes,which sewape tank(s)leaks: � P�obed outside tank(s)for black soil" <br /> Any"y�s"answer above indicales the ❑�Unab�to verify(See Canmenb�c�enadon) <br /> system/s Failing to Prot�ect Croundwat�er. ❑�er methods not listed(See cammen�s�cpr.naaanJ <br /> CommentslE�lanalion: <br /> . ' . , � �-� . . <br /> � . • . , '. • . <br /> 3. Other Compliance Conditions--Compliance component�3 of 5 <br /> a. Maintsnsnoe hole oove�s are denteged,credced.un.sewred,or appea�I�o st�duraUy unsound. p Yes• ��vo ❑Unknown <br /> 6. Olher issues(elw�iical hezerd�e�c.)�o immedla�tely and edve►sely impad publiC health o�setety. p res' ■No ❑UnlanoHrt� <br /> �'Sys�am!s en lmminent thraat io publ�h�lth and safely <br /> Explein: <br /> c. Syslem is non-pr+ctective of gcound wdter for oiher oondftlons as dete�mined by inspe�tor p Yea' �No <br /> "System!s Palung b pr�ect q�undwo�tar <br /> Explain: <br /> --- •-- --. . —. .-• ------- --- •----.. . .. ... . .. . . , .. ... <br />