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May. 14. 2012 12: 39PM No. 0472 P. 4 <br /> Property address: 4 g O C-[AA 4cc pp. Inspector initials/Date: 44. 4,}1- p . <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> Corn•Nance criteria: Verification method(s): <br /> System discharge sewage to the 0 Yes IN No 0 Searched for surface outlet <br /> •round surface, IN Searched for seeping in yard/backup In home f•Z <br /> oe Excessive <br /> System discharge sewage to drain tile 0 Yes ®No pondirg in soil 8ystemlD-boxes MO <br /> or surface waters. 0 Homeowner testimony(See CommentsfExptanatlon) <br /> System cause sewage backupinto 'Brack soil'above soil dispersal system 1.O <br /> dwelling or establishment. 0Yes No 0 System requires"emergency pumping <br /> „ <br /> 0 Performed dye test <br /> "yes"yes answer above indicates the system is 0 Unable to 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•!lance criteria: Verification method(s): <br /> System consists of a seepage pit, ❑Yes ®No ❑ 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 /> «• ,iant if allowed in local ordinance. <br /> ❑ Observed liquid level below operating depth <br /> Sewage tank(s)leak below their 0 Yes ',5. No <br /> deli•ned o•eretin d: i tih. Examined empty(pumped)tanks(s) <br /> If yes,which sewage tank(s)leaks: ❑ Probed outside tank(s)for'black soli" <br /> Any`fires"answer above Indicates the ❑ Unable to verify(See Comments/Explanation) <br /> system is Falling to Protect Groundwater. ID Other methods not listed(See Gbmments/E,rplanation) <br /> Comments/Explanation: <br /> • <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' ii No ❑Unknown <br /> b. Other issues(electrical hazards,etc.)to Immediately and adversely impact public health or safety. ❑Yes* R 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 ❑Yes' i No <br /> 'System is falling to protect groundwater <br /> Explain: <br /> %maim•,nee"fefs inn - ACA r1,1t i7M MA♦rf gni« ew..••. ..••.. M ._ .____.. <br />