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Apr 291411:14a Joseph Olson 763-498-8290 p.7 <br /> !� <br /> Prbperfy address: _30 Oro�o�rcnard Road _ lnspsctor initialsl�ate: 21'14i14 ' <br /> �....�--"�.,......__- •�- <br /> 1. Impact on Pt�blic Heatth—Compliance cornponent#1 of 5 <br /> Com�l'�ance criteria: __ �_ Verification rnethod(sj: <br /> System discharge sewage to the , ❑Yes ❑ No 0 �arc{�ed for surface autlet <br /> _grouncf surtace. _ ! _ � ❑ Searched forseeping in yard/backup in home <br /> System discharge sewege to dr�in tile I [-',�Yes ❑1Vo � �cessive pondJng in soil systernlD-boxes <br /> or sutface v�aters. ❑ Homeownertestimony(See CommenrsiEzp►ertadon) <br /> S stem cause sewa e backu tnto � ❑ 'B�ack soi!"above soil dispersal system <br /> Y 9 A' ; ❑:'es p No <br /> dwelling or establishment ��� ❑ System requires"er�ergency"pump�ng <br /> ❑ Perforrr�ed dye test <br /> Any"yss"answerabove ir�aricates the system is � Unable to verify(See Comma <br /> nts�Explanafion) <br /> an lmminerrt Threa#to Public Heafth and Safety. � ptfter methods not listed.,'See Commen�xpianatior) <br /> Comments/Ex��anation: <br /> 2. Tat�k Integrity—Comp�iance component#2 of 5 <br /> Cocr�pHance criteria: Veri�ication method(sy: <br /> System consists of a seepage plt, ��Yes �No [I Probed tankts)bottom <br /> cesspool, drywell,or Isac�ing pit. <br /> � ❑ Examined canstructio:r records <br /> Sesoage piTs meeting 7080.2350 may be ' <br /> ❑ ExamEned Tank Integrity Form(Anach� <br /> compkaRf ital►owed in foca!orWnance. <br /> -- ❑ Observed liquid level below operating depth <br /> Sevrage tank(s)leak below their ; ❑Yes �Na <br /> desi�e�ratir►g depth. � Exarnin�er►Zpty(pumped)hanks(s} <br /> If yes,which sewage tank(s)leaks: ; Q Probed outside tank(s�far"black so�l" <br /> Any"yeS"aliSN�f abOV�JIIdiCe�23 thB � Q �nable to verify�See Commentsi�xplanatianl <br /> system is Fail�ng t�Prateci Groundwater. ���r m�hods not listed(See Comments/Explanahon� <br /> CommentslExplan a6on_ <br /> Or�2l14/14,Elmer J. Petersoa i,o. pumped septic tanks. See notes on attached tank report. <br /> 3, �het'COmp[i8l1ce Conditiot�s—CompEiance component#3 of 5 <br /> a. PJlaintenar,ce hde oovers are damaged,ca-ac�ced, unsecured,or app�rto structuraUy utssound. ❑Yes" ❑No ❑Unawwn <br /> b. ather issues(elecv+ca/hazarols,etc.)to irrxnediately and adversely impact public heatth or safety. p Yes" p No ❑unknavn <br /> "Sysiem is an immi»er�f N�t fo�aublic health and safety <br /> Explain: <br /> a System is non-protective of ground water for other conditions as determirred by inspectar ❑Yes• p ho <br /> 'System is failiag to pr�obect groundwaler <br /> �xpiain: <br /> www.pca.state.mn.s,rs • G51-255-b306 . 800-657-3864 • 31Y651-282-5332 or 800-657-3864 . Avaiiabte in alternative Eormats <br /> wq-wwists9-3J • i/Z9l12 ��2�3 <br />