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• Property address: ►l 3 0 oA.,d 9-7o Inspector initials/Date: 4 (o-to-j�j <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com•Mance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes No 0 Searched for surface outlet <br /> •round surface. ® Searched for seeping in yard/backup in home`s <br /> System discharge sewage to drain the ❑Yes ®No Excessive ponding in soil system/D-boxes <br /> or surface waters. 0 Homeowner testimony(See Comments/Explanation) <br /> System cause sewage backup into Yes ®No ®Black soil above soil dispersal systems <br /> dwelling or establishment ❑ System requires'emergency pumping <br /> 0 Un <br /> Any"yes"answer above Indicates the system Is <br /> CI Unaablblee ttoo d dye test <br /> verify(See Comments/Explanation) <br /> an imminent Threat to Public Health and Safety. ❑ Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity-Compliance component#2 of 5 <br /> Com•Mance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes 0 No 0 Probed tank(s)bottom <br /> cesspool,drywall,or leaching pit. 0 Examined construction records <br /> Seepage pits meeting 7080.2550 may be 0 Examined Tank Integrity Form(Attach) <br /> corn. ant if allowed in local ordinance. <br /> Sewage tank(s)leak below their ❑Yes 0 No ❑ Observed liquid level below operating depth <br /> desi•ned o.-ratine de.th. ❑ Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for"black soil' <br /> Any"yes"answer above Indicates the ❑ Unable to verify(See Comments/Explanation) <br /> system Is Falling to Protect Groundwater ❑Other methods not listed(See Comments/Exptenatbn) <br /> Comments/Explanation:^ // <br /> Wl// v-< ) 't'Q�� 11.1 S i -1 gr-e-Qi.1 -f+ c-5 >ao-s'llas?i v` <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 falling to protect groundwater <br /> Explain: <br /> www.pca.state.mn.us • 651-196-6300 • 800.657.3864 • TTY 651.282.5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwlsts4-31 • 1/24112 <br />