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Property address: O.'57 y:4 iv Inspector initials/Date: 4.`&0' 3-3,-Y7 <br /> 1. impact on Public Health—compliance component#1 of 5 . <br /> Com•Bance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes ®No 0 Searched for Surface outlet <br /> •round surface. • Searched for seeping in yanUbac up in home 3 <br /> • it emissive In <br /> System tem discharge sewage to drain the ❑Yes a Na ponding soil systemlO-boxes iJt� <br /> • sdwaters. 0 Homeowner testimony(See Comment 1Thcpianalion) <br /> sInto 0 Yes ® I soa"above soli dispersal system 4.1 <br /> System cause sewage backup y7 <br /> dwelling or edabtshrnent. ® reams"e" g° 'pumping 3.1.0 <br /> ❑ Performed <br /> Any"yea"answer above Indicates tine system Isttodye test <br /> 0 Unable verify(ass Con►naer,faerprar,attar,) <br /> an Imminent Threat to Public Health and Safoily. p Other methods not listed(See Comrgenta+Explar adrm) <br /> Comments/Explanation: <br /> • <br /> 2. Tank Integrity--Compliance component#2 of 5 • <br /> Compliance criteria: ,. .Verification nurthod(s): <br /> • <br /> System consists of a seepage pit, 0 Yes ❑No . 0 Probed tanks)bottom <br /> cesspool,drywall,or leaching pit. ❑. Ertamined corstructbn records <br /> Seepage pita meeting 7080.2560 may be • ❑ Examined Tank integrity Form(Attach) <br /> complyi stowed in loyal arirmr ee. <br /> Observed liquid <br /> Sewage tank(s)leak tallow their ❑Yee 0 Na IDlevel below operating depth <br /> designed operatic doh. 0 Examined empty(pumped)tanks(s) <br /> If yes,which sewage tanks)leaks: 0 Probed outside tank(s)for"black sail' <br /> Any"yelp answer above indicates the ❑ Unable to verify(Sea m rpia aria) <br /> system is Failing to Protect Groundwater. ❑Other Methods not fisted(See Com mentsExplanesson) <br /> Comments/Explanation: • <br /> Se-6 -OrtA 11.1-4(444.04 f.e.fipotpco *PfX0ig5cog 60 9 <br /> • <br /> 3. Other Compliance Conditions--Compliance component S3 of 5 <br /> a. Maintenance hole covers am damaged,yuan,unsewed;or <br /> to y tusarutd. ©Yee )♦No ❑Unknown <br /> b. Other issues(eaoalael hazards,era.)to inanedietely raid*dainty knpact pUbb health or Safety. 0 yes* ■No 0 Unknown <br /> *System is an imminent!beet to pubba health and meaty <br /> Win: <br /> c. System Is non-protective of Wound water for other yrs es detenrb,ad by Inspector Ci Yes ■No <br /> *System Is filling to protect <br /> Explain: • <br /> • <br /> Vtftglaktittalik5 5111%415 i1106144 s . 71!j. " or • Available in alternative formats <br /> ew..wwlrte/.7! . 117.41 el <br />