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Mar 17 2017 09:55AM HP FaxRusty Olson 7634988290 page 6 <br /> PropertY addre�: 1003 Cox Farm Road ,�/ <br /> _,� InepectorinfidalDets; 3l10l17 Y <br /> � <br /> 1. Impaft on Pubtic Health-Camp�iance component�1 of 5 <br /> CompNance crlterla: __ _� VerRicatbn method(a): <br /> Syatem dieeherge sewape to the ' �Yes ❑No ❑ ���aurface outlet <br /> gro�nd surfeoe. ' ❑ Seardled forse <br /> ePirtg�yard/badcup in home <br /> 9ysarm WschaiQe aewape to drain tile 0 esY []ryp ❑ Exoesaive ponding in soii system/D-no�aes <br /> ar surtaca waters. � ❑ Horneowner�stimony rsaer commenlyF,rpbn�'o„� <br /> Syatem cause sevrega baqcup Irrto ❑Yes ❑No � �Bteck sal'above soil dispenal sysiem <br /> dweYing w estabGahmeM. ❑ Syslem requies'emer9m�Y'P���6 <br /> ARy•�yes•�1v�alarabara h►nllcaios tha ❑ Pertorrnad dya teat <br /> an In►minerK Threat to Pubflc Pla�lEh and Safoty. ❑ uneb�e to verily(see Comment�rpronaua�) <br /> _ _ ❑Otllermdthads not listed(See Commenr�Expranruon) <br /> �ann�ent�lE�IanaUon: <br /> 2. Tank I�tegr�ty-Comp�iance component�a ot 5 <br /> Complianr.e criterla_ Verificatlan method�a►: <br /> Syscem consists of a seepapa pit, � ❑Yea �No O Probed tanlc(s)ootmm <br /> wsspuW,drywell,or leaohing pit. � <br /> � Examvied constr�tion records <br /> seena9ePds meaHnp 7080.z55omeyee ❑ F�nined Tank Inteyrity Form tANach1 <br /> carr er+rMaBbunedln loeslc+rdrrwnca. <br /> Sativpge tank(s)leak below lheir ��'ed Iiquiu level below pperadag tlepth <br /> dqs'�eci operatir� de�. __��Ya �No � Examined emPty(P�+�+Pedl tanks(a) <br /> IF yes,whlch sgwgpe tenk(a)leake: ' ❑ Probed autsids tank(s)for"W��^ <br /> �4ny"y�ea"anawe�abovo indlcaMs the � ❑ u"'b1°iO"�"�'��OfY"B^�"�a�� <br /> system is Fa1!!ng t�o Protoct Groundwater. ❑omer metnoda not 6srad�sea cane�,�Xpe�onj <br /> CommentalExPlertatbn_ � <br /> On 3/1p/17,EMerJ.P�tarson Co.pumpsd tanks. <br /> 3. Other Comptiance Conditions-Campl�ance component�a ot 5 <br /> a. MefntenarK�Fwl�cove�s ero�ma9ad,etacked.unBEared,or apr,ear eo sau�n,ra�y unsound. ❑v�s• ❑ra Q una�, <br /> b. Othet iesuet(sacMcalha:aMs.e1cJ b immedietely andadveieeN�P�P�bGC heaflh or safety. ❑Yr• ❑No ❑Unknown <br /> 'Systwn ls+n iaxninant tlnoat t0 pubRchaaJtl►and safehr <br /> F�rpleln� <br /> c. SY���1-MO�dILe Of growtd wat8f kf oth9r O�rldib011s ae delEftl'Uned by irtBp�C6Df ❑Y�' �No <br /> 'Syslem IS(QIIi►rg[p p/ipLiCi Sjl(WI�dW��N <br /> Ezplaln: <br /> www.pa.�t�ce.mn.us . 65�-296-6300 - 800-657-3864 . TTY 651•2523332 or QOp65�-3861 . Availebie 6n alte�7ative fortnats <br /> wq•wwists4•31 • f/7�/12 <br /> Paqe t of) <br />