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' Properly address: 70 My�Uewood Rd. U�apec�o�initla�ID�e: 6/242015 <br /> (nu►udidyyyy) <br /> _1. Impact on Public Health—Compqanoe component#1 af 5 <br /> Com nce c�itKia: Vs�iAcatloe meq�od(s): <br /> Sy�em dis�a�9es a�va9e to the ❑Yes �No ❑Searched ior a�faoe oultet <br /> t�ound sutfaae. �Seard�ed ior seeping in pardlb�dwp�home <br /> SY��a��ewage!�drain ❑Yes �No ❑E�ooeseiMe pond'nq in ad sysEerND-bo�aes <br /> tlle or surface waters. ❑Homeow�t�monY lSee ) <br /> System causes sewage bedcup mb �Yes �No ❑'Bisck so�'�re soi dispe�l sYsOem <br /> dw�eiNng or e�st�nent. ❑��u�`�,Y P�P��9 <br /> �Y"Y'�"a��above IndC�tlte ❑Pert�ormed dye test <br /> Syal�llf�s�I im/AIIf6illt!h/ast tn p(/b/iC ❑Urfable to v�erify(see J <br /> he�s![h and aaf fety. ❑other melhods rwt liated(Sse comn►s�,r�Exp�►�n1 <br /> Commsnb/Explanetlon: <br /> 2. Tank Integrity—Compliance componerrt#2 af 5 <br /> Com lance c�ibria• Verfflcatlon nisthod(s�: <br /> sytscern c�ons�ts of a aeepage ait. ❑Yes �Wo p Probea taNc(s)bollom <br /> �.�,a��8 P�- ❑Exami�d oon�at� <br /> SeePeg�v+da�e�q 7aBo.25`o may as ❑Enamined Tank IMegrity Fam(a[ted►) <br /> �abwedln lbcelorrllner�oe. <br /> ❑Obsenrod�iqtNd le�lel belOw cp�dePlh <br /> Sewage tank(s)I�k belaw tl�eir ❑Yes �No ���Ph��(s) <br /> ��9 dePih• <br /> ff yea,which sewage taMc(s)I�ks: ❑Probed outside tank(s)for'blad�soiP <br /> any"y�s"anawer above Indreatea n�e ❑Ur�e to v�e�►(sss co�►►�p�,sero�) <br /> sygtiem Is fallJng�o pro�ect�Oundw�at�►. O ou,er malhods rat r�ea�ses carr�n►snr�xp�ro►►J <br /> CommenWE�l�nnion: <br /> All taNts hav�e 24'manhols oo�ers to grade and'utlst and oullet b�flles intsd. <br /> 3. Other CompNance CondiHons—Comp�anoe oomponent�3 0�5 <br /> a Maintenanoe hols oovsis are d�r�aged�aadaed.unsecuned or appear b be�u�xaiy uneound. ❑Yes' �No ❑urrcnow� <br /> b. Olher�(els�k�l1�ela.)b imned�aoeh►and adMarsdY irr�pect Pubic heallh or seifely. ❑Ye� �Nb p lMla�own <br /> 'Systwn ls an lmm�rNnt�b publl�I�sltl�ar�d�►. <br /> ��: <br /> a SYslem is�an-Pnolec,'tiMe d grou�d waler for dher oondibons as delemwied by irro�ecfor. ❑Yea• �No <br /> ������ <br /> Explain: <br /> www.pca.staGe.mn.us • 651-296-6300 • 500-667-3d64 • TTY 661-2�-533Z or s00�667-3t64 • Available in alterr�aNve formats <br /> wq-wwlsW-3f6 • 6/�/14 Fbge 2 of 3 <br />