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Property address: 3285 Graham Hill Road _ Inspector initials/Date: 11/29/17 <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the • 0 Yes 0 No 0 Searched for surface outlet <br /> ground surface. 0 Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile ❑Yes 0 No <br /> 0 Excessive ponding in soil system/D-boxes <br /> or surface waters. i ❑ Homeowner testimony(See Comrnents/Explanabon) <br /> "Bla--- <br /> so <br /> di <br /> ystem <br /> System cause sewage backup into 0 Yes ❑No soil"above encal pumping <br /> dwelling or establishment. 0 System requires"emergency pumping <br /> 1 ❑ Performed dye test <br /> Any"yes"answer above indicates the system is ❑ Unable to verify(See Comments/Explanation) <br /> an imminent Threat to Public Health and Safely. 0 Other methods not listed(See Comments Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes ®No ❑ Probed tank(s)bottom <br /> cesspool,drywall,or leaching pit. 0 Examined construction records <br /> Seepage pits meeting 7080.2550 may be 0 Examined Tank integrity Form(Attach) <br /> compliant if Mowed in kcal ordinance. <br /> 0 Observed liquid level below operating depth <br /> Sewage tank(s)leak below their ❑Yes ®No <br /> designed operating depth. ® Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: 0 Probed outside tank(s)for'black soil" <br /> 0 Unable to verify(See Comments/Explanation) <br /> Any"yes"answer above indicates the ❑Other methods not listed(See Comments/Explanation) <br /> system is Failing to Protect Groundwater. <br /> Commenls/Expl a nation: <br /> On 11/29/17,Elmer J.Peterson Co.pumped tanks. <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. 0 Yes' 0 No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. 0 Yes" 0 No ❑Unknown <br /> 'System is an imminent threat to public health and safety <br /> Explain. <br /> c- System is non-protective of ground water for other conditions as determined by inspector 0 Yes- 0 No <br /> 'System is failing to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31 • 1/24/12 Page 2 of 3 <br />