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Property address: 14308 70th street SW,Cokato MN 55321 Inspector initials/Date: tk J 1/21/2015 <br /> (min'd4NYy) <br /> 1. Impact on Public Health—Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharges sewage to the 0 Yes No 0 Searched for surface outlet <br /> ground surface. !31 Searched for seeping in yard/backup in home <br /> System discharges sewage to drain 0 Yes ►'w4 No 0 Excessive ponding in soil system/D-boxes <br /> the or surface waters. <br /> -- _. 0 Homeowner testimony(See Comments/Explanation) <br /> System causes sewage backup into 0 Yes ®No 0"Black soil'above soil dispersal system <br /> dwelling or establishment. <br /> 0 System requires"emergency"pumping <br /> Any"yes"answer above indicates the ❑ Performed dye test <br /> system is an imminent threat to public 0 Unable to verify(See Comments/Explanation) <br /> health and safety. <br /> — 0 Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> 2. Tank Integrity—Compliance component#2 of 5 <br /> Compliance criteria: Verification method(s): <br /> System consists of a seepage pit, 0 Yes 0 No 0 Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. <br /> 0 Examined construction records <br /> Seepage pits meeting 7080.2550 maybe <br /> compliant if allowed in local ordinance i ❑ Examined Tank Integrity Form(Attach) <br /> Sewage tank(s)leak below their 0 Yes 0 No ❑Observed liquid level below operating depth <br /> designed operating depth. 0 Examined empty(pumped)tanks(s) <br /> 0 Probed outside tank(s)yes,which sewage tank(s)leaks: ( )for"black soil <br /> Any "yes"answer above indicates the 0 Unable to verify(See Comments/Explanation) <br /> system is failing to protect groundwater. 0 Other methods not listed(See Comments/Explanation) <br /> Comments/Explanation: <br /> tank location is unknown <br /> 3. Other Compliance Conditions—Compliance component#3 of 5 <br /> a. Maintenance hole covers are damaged,cracked,unsecured,or appear to be structurally unsound. 0 Yes* E No 0 Unknown <br /> b. Other issues(electrical hazards,etc.)to immediately and adversely impact public health or safety. 0 Yes* 0 No 0 Unknown <br /> *System is an imminent threat to public health and safely. <br /> Explain: <br /> c. System is non-protective of ground water for other conditions as determined by inspector. 0 Yes* 0 No <br /> *System is failing to protect groundwater. <br /> Explain: <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TiY 651.282.5332 or 800-657-3864 • Available in alternative formats <br /> wq-wwists4-31b • 6/4/14 Page 2 of 3 <br />