Laserfiche WebLink
. � ,- , , <br /> � Property address: �J�/� �7t�,�/ �Cl2 �/¢-ss Inspector initials/Date• 7� � �i r� <br /> ` <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com liance criteria: Ver'fication method(s): <br /> System discharge sewage to the ❑Yes No ���earched for surFace outlet <br /> round surface. L�(Searched for�seeping in yard/backup in home <br /> System discharge sewage to drain tile ❑Yes �/No � ��ssive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testlmony(See CommentsiExplanatlon) <br /> ❑ "Black soil"above soil dispers�l system <br /> System cause sewage backup into ❑Yes No � � <br /> dwelling or establishment. ❑ System requires emergenc� pumping <br /> , � ❑ Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verify(See Comments/Explanadon) <br /> an/mminent Threat to Public Health and Safety. <br /> ❑ Other methods flot listed(See Comments/Expfanation) <br /> Comments/Explanation: <br /> 2. T'ank Inte�►t'lty—Compliance component#2 of 5 �y /�ii.•...•�trJG,p, ` <br /> Com liance criteria: Verification method(s): <br /> System consisEs of a seepage pit, ❑Yes ❑ No � Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. ❑ 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 /> ❑ Observed liquid level below operating depth � <br /> Sewage tank(s)leak below their ❑Yes ❑ No . <br /> desi ned o eratin de th. ❑ Examined empty(pumped)tanks(sj <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil" <br /> A17y "yes"answer above indicates the ❑ Unable to verify(see Comments/Explanation) <br /> SySfern IS F�%l►ng$O Pl'OteCf GI'Oundwater ❑Other methods not listed(See Comments�Explanation) <br /> C omments/Explanation: <br /> 3< OthG I'GOII'Ip11a11Ce COtldl$iOns—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked, unsecured,or appear to structurally unsound. ❑Yes* ❑No ❑Unknown <br /> b. Other issues(electrical hazards,etc:)to immediately and adversely impact public health or safety. ❑Yes* ❑No ❑Unknown <br /> �Sys#em is an imminenf threaf to public healfh and safety <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspedor ❑Yes" ❑No <br /> *System is failing to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us � 651-296-6300 a 800-657-3864 � TTY 651-282-5332 or 800-65.7-3864 � Available in alternative formats <br /> _ <br /> _ _ _ _ _ . . — - - Page2of3 _ <br /> _ . .._.._e �• I/7Al{'] . . . <br />