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1. Impact on Public Health-Compliance component to of 5 <br /> . , - criteria: Verification method(s): <br /> to the ❑Yes No g Seardied for surface outlet <br /> System discharge sewage ® Searched for seeping in yard/backup m home <br /> Systemsyst <br /> discharge sewage to drain tie ❑Yes VI No ❑ HonlExceeonte poeatkn n cod e'Co astses€xp <br /> p f-Iocneo�Kner te�nornir rte° i1 <br /> or surface w `Blast sol"above mor tispwsal System <br /> ,{� <br /> today sewageay into Q Yes No System requires- wY PWB V ;444 <br /> dMrtea ng or edablishment Performed dye test <br /> Any"yes"answer above indicates the system is 0 Unable to verily(see ) <br /> an Imminent Throat to Public Health and Safety. ❑ other methods not hated(Sae ) <br /> 2. Tank integrity-Com ante component#Z of 5 <br /> C. . „ criteria: Verification method(s): <br /> of a seepage pt, Pg Yes ❑No 0 Probed tank(s)button <br /> • .c.--/=11t, teething,or teething pit ❑ mined construction`records <br /> . meeting 70602550 may be , ❑ Examined Tank Integrity Form(mach) <br /> tallowed kr Io colon ranee. Q Observed squid level below operating depot <br /> Sewage tanks)le.41:below their NI Yes ❑No Q F-Xamined erne y(pumped)tanks(s) <br /> designed operating depth. 0 Probed outside tanks)for"black soil <br /> N yes.which sewage tank(s)teaks —•*...... [0 Unable to verity(Sea Commentsflaplanattovn) . <br /> My'Vss°answer above indicates the 0 Other methods not fisted(See ) <br /> system is FaNing to Protect Groundwater_ <br /> C°MMentSdr7lare:.', d Wilt bile-4X L?4°C"CZ <br /> 3. Other Compliance Conditions-compliance component#3 of 5 <br /> a. nAalotenanCe Me oo,re.*are dammed,cracked,unsecured,or-eppear 10 structural!),unsound. $Yate CI wo ©Unknown► <br /> b. other iseuea(sWecbts►heturds,add.)to i m eclietety and adversely irreaeot pubic heath or safety. 0 Yea' gi No 0 tlrictiown <br /> *system le an public hearth and sate(y <br /> Explain: atrfi-e--"-aCiAtZ <br /> c System ie non potecawe of ground welter for other conditions as detemarted by inspector 1°'!Yes• ❑No <br /> 'System is failing epet ms,vQta,r n <br /> Exptadn CPV-e,- A //' <br /> 720 Tatetitarl—N <br /> www.pCa_state.nn_us • 651-296.6300 - als667-3M64 • m eel 2a2-5332 or MOO.657-304 • Avaltil a in alternative formats <br /> wq-wwfsts4-31 • t/24/12 Poe 2 of 3 <br />