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• <br /> Property address: 755 Ferndale Road Inspector initials/Date: 6/16/170 <br /> 1. Impact on Public Health —Compliance component#1 of 5 <br /> Com•liance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes ® No ❑ Searched for surface outlet <br /> 'round surface. ❑ Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile CI Yes ® No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. CIHomeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into CI Yes ® No ❑ "Black soil"above soil dispersal system <br /> dwelling or establishment. ❑ System requires"emergency"pumping <br /> ❑ 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 Safety. ® Other methods not listed (See Comments/Explanation) <br /> Comments/Explanation: <br /> New System <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, drywell, or leaching pit. ❑ Examined construction records <br /> Seepage pits meeting 7080.2550 maybe ❑ 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 /> CIExamined empty(pumped)tanks(s) <br /> desi•ned o•eratin• death. <br /> If yes,which sewage tank(s) leaks: ❑ Probed outside tank(s)for"black soil" <br /> El 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 /> Comments/Explanation: <br /> New System <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* ® No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. 0 Yes* ® No 0 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* ® 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 />