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• <br /> Property address: 850 Old Crustal Say Road inspector Initials/Date: 7!21117 y; <br /> 1. Impact on Public Health—Complance component#1 of 5 <br /> Convihetce criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes 0 No 0 Searched for surface outlet <br /> ground surface. 0 Searched for seeping In yard/backup In home <br /> System dbdmege sewage to drain the ❑Yes 0 No 0 Excessive ponding in soil syaMrtW-bootee <br /> or surface oaten. ❑ homeowner testimony(See ComentaaplanetIonj <br /> p •31adr nor above sop dispersal system <br /> System causer sewage backup into ❑Yes 0 No ❑ System requires'emerperwY pumping <br /> dwelling or establishment0 Performed dye lest <br /> Any'"yes"answer above inScalaa the system Is ❑ tie to vertfy(See ) <br /> an hnminarnt Threat to Public Hotta and Staf4W. 0 Other methods not Meted(See <br /> 2. Tank integrity—Compliance component#2 of 5 <br /> Compliance criteria: _ Verification method(s): <br /> System consist ala seepage pit, ❑Yes ®No 0 Probed tardc(s)bottom <br /> cesspool,drywall,or leeching pit. ❑ Examined co otrudlon records <br /> &wale pea twitting 70802550 ntay be 0 Examined Tank Integrity Fonn(Asad►) <br /> aor toArr+GJf arwarvs dare non orrd wxae. <br /> 0 Observed liquid level below operating depth <br /> Sewage tanks)Mak below their ❑Yes 0-4 No E Examined empty(p tanks(s) <br /> designed accreting depth. <br /> 0 Probed outside tanks)for blade son <br /> If Yes,which swage tallMai beaks: 0 Unable to verify(see <br /> Any"`yore'answer above indicates the ❑cream methods not listed Me* <br /> system Is Falling to Protect Groundwater. <br /> On 2/21117,Einer J.Peterson Co.pumped tanks. <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenaroe hole cream am damaged,cranked.u seaasd,or appear to etrudundly rewound. ❑Yes' ❑Na 0 Unknown <br /> b. Other Issues(e/eurroanew*eau)to krenedlntely and adversely Impact pubic health or safety. O Yea' 0 No 0 tMrmonw <br /> 'System Is enImminent Onset tepet*heathandsalely <br /> : <br /> a System is non-protective of ground water for other candid ons as determined by Inspector ❑Yee* ❑No <br /> 'Systemk Mirotoprotetgeomrrh <br /> Explain: <br /> www.pp.state.mr.us • 681-296.6300 • 900-657-3864 • TTY 651.282-5332 or 800.657-3564 • Available in alternative famine <br /> wq-wwMMta4-31 • 1124112 pop 2 of 3 <br />