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Property address: Lk d c o'- (4.45-Ors..-1644Fz. inspector Initials/Date: 7-3)-1S- <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Com fiance 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 t40 <br /> • System discharge sewage to drain tile 0 Yes §1 No l Excessive ponding in soil system/0-bootee NO <br /> or surface ❑ Homeowner testimony(See Com nentaexplanation) <br /> System cause sewage backup into ❑Yes ®No ® 'Black soir above soil dispersal system%n <br /> dwelling or establishment. 0 requires emergency'pumping <br /> 0 Performed dye test <br /> Any"yes"answer above Indicates the system Is U <br /> an Imminent Threat to Public Health and Safety. ❑ Unable to verify(See Comments/Explanation) <br /> ❑ Other methods not listed(See Comments/alienation) <br /> Comments/Explanation: <br /> 2. Tank Integrity-Compliance component#2 of 5 <br /> • <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pft, 0 Yes 0 No 0 Probed tank(s)bottom <br /> •cesspool,drywelt,or leaching pit. 0 Examined construction tion records <br /> Seepage pi meeting 7080.2550 may be 0 Examined Tank Integrity Form(Attach) <br /> compliant stowed Inlocal . ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their 0 Yes ❑No 0 Examined empty(pumped)tanks(s) <br /> designed operating depth. <br /> if yes,which sewage tank(s)leaks: 0 Probed outside tank(s)for`black soir <br /> Any"yes"answer above!na®cates the • <br /> ❑ Unable to verity(See Carurrerrta�xpd�atlon) <br /> system is Falling to Protect Groundwater. ❑Other methods not Hated(See Gbnrmsnfta/ExplanaSOrr) <br /> Commentt/Explanation: • <br /> Se-t. OriVer040 4.11r,..1* f-eP 'S' <br /> 3. Other Compliance Conditions-Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. J Yss* ®No p Unknown <br /> b. Other issues(elecbibet hazards,etc.)to immediately and adversely impact public health or safety. 0 Yes* No ❑Unknown <br /> 'System is an Imminent threat to public health and safety <br /> Explain: <br /> c. System Is of ground water for other conditions as determined by Inspector ❑Yes* It No <br /> *System is failing to protectgroundwator <br /> Explain: <br /> • <br /> www.pca.state.mn.us • 651.296.6300 • 800457-3864 • • TR 651.282.5332 or 800657 3864 • Available in alternative formats <br /> wq wwlsW-3! • 1/24/12 <br />