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P�`op8rty address: 1250 Lyman AvB. _ __ I►SSpACtor initials/Date: 2/7/'I <br /> 1. Impact on Pub(ic Heaith—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes ❑No ❑ 9earched for surFace ouElet <br /> �round surFace. L7 Sea�ched for seeping in yardJbackup In home <br /> System discharge sewage to drafn tile ❑Yes ❑No ❑ Excessive ponding in soii systemlD-boxes <br /> or surface waters. ❑ Homeowner tesiimony(See Comments/Explanation) <br /> System ceuse sewag�baokup into ❑Yes ❑No . � �Bleak soil"above soil dispersal system <br /> dwefl(ng or establlshment. ❑ System requires'emergency'pumping <br /> ❑ PerFormed dye test <br /> Any"yes"answer above indlcates the sysfern Is ❑ Unable to verify(See Commenfs�ExpfanaHoy <br /> an Imminent Threat to Aublic Health and 3afety. � pther methods not listed(Sea Comments/ExpfaneHon) <br /> Comments/Expla nation: <br /> 2: Tank integrity—�ompifance component#�of 5 <br /> Compliance criteria: Verification method(s}: @ <br /> System consists ofa seepage pit, ❑Yes �No ❑ Probed tank(sj battom <br /> cesspoot,drywell,or leaching pit ❑ Facamined construction records <br /> Seepaqe pRs meeting 7080.2550 meybe ❑ F�camined Tank Integlity Form(Attach) <br /> com lant!/allowedlnloca/oro�lnance. <br /> i ❑ Observed liquid level below operadng depth <br /> Sewage tank(s)leak below their ' ❑Yes �No � Exemined empty(pumped)tanks(s) <br /> dest ned o eratin de th. <br /> If yes,whlch sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soll' <br /> Any"yes"answer above lndlcafes fhe ❑ Unabfe to verify(5ee Comments/ExplanaBon) <br /> system fs Falling to Protect Grounaluvster. ❑Other methods not Ifsted(See Commants/Explanadon) <br /> Comments/Expianation: <br /> On 2/7l94,Elmer J.Peterson Co,pumped septic tanks. See notes ot1 attached tank report. <br /> 3. Other CompRience Conditions—Compltance component#s of 5 <br /> a. Maintenance hole covers are dameged,cracked,unsecured,or appear to structurally unsound. O Yes" ❑No Ia Unknown <br /> b. Other I9sues(e/ecGfca/hazerds,etc.}to Immedfately and edversely impaCt public health or safety. p Yes" ❑No ❑Unknown <br /> *Sysfem!s an lmminanf thnaa;fo publfc health and aafety <br /> Explain: <br /> o. System is non-prote�five of ground water for other oondmons as determined by inspector ❑Yes• p t�o <br /> •5ysfem ts fa113ng to protect grounafwater <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 80U-657-3864 • ?lY 651-282-5332 or 8Q0•657•3864 • Avatlable in alternative formats <br /> wq•wwists4-31 � i/24h2 Page 2 af 3 <br />