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Property address: A a S d ,o Lg..:(ys' .-(64„( inspector initials/Date: r7 <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> Corn•liance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes 'No 0 Searched for surface outlet <br /> 'round surface. ® Searched for seeping in yard/backup in home Ho <br /> System discharge sewage to drain tile ❑Yes ( No RI Excessive ponding in soil system/D-boxes ud <br /> or surface waters. <br /> 0 Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into ❑Yes ®`No <br /> 111 <br /> 'Black soil"above soil dispersal system uo <br /> dwelling or establishment. ❑ System requires'emergency'pumping <br /> Any"yes"answer above Indicates the system is ❑ Performed dye test <br /> an imminent Threat to Public Health and Safety. ❑ Unable to verify(See Comments/Explanation) <br /> 0 Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: ,S 1,101- r t.1 S <br /> 2. Tank Integrity-Compliance component#2 of 5 <br /> Compliance criteria: . Verification method(s): <br /> System consists of a seepage pit, 0 Yes 0 No 0 Probed tank(s)bottom <br /> cesspool,dryweil,or leaching pit. <br /> Seepage pits meeting 7080.2550 may be El Examined construction records <br /> compliant If allowed in local ordinance. 0 Examined Tank Integrity Form(Attach) <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their 0 'es 0 No <br /> designed operating depth. 0 Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: 0 Probed outside tank(s)for"black soil" <br /> ❑ unable to verify(See Comments/Explanation) <br /> Any"yes"answer above indicates the <br /> 0Other methods not listed(See Comments/Explanation) <br /> system Is Failing to Protect Groundwater. <br /> Comments/Explanation: <br /> • <br /> `( A4.}::=)Us1—SAuW%\' 4 y'1‘..A.., vs) s'1\ Sully g -�Clx ✓a�SA3�c�v1-3r��r ` i,. <br /> ¢ 9tu c,�v�nQI, FJC�e <br /> 3. Other Compliance (Conditions-Colmpliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appearto structurally unsound. 0 Yes* is No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. 0 Yes* i 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 ❑Yes* 18 No <br /> *System Is falling to protect groundwater <br /> Explain: <br /> www.pcastate.mn,us • 651.296.6300 • 800-65M864 • • TTY 651.282.5332 or 800.657-3864 • Available in alternative formats <br /> wo-wwists4-31 . 1/74/17 <br />