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May 0812 04;13p 763-213-0695 p.2 <br /> � <br /> Prope address: j � , ' <br /> � �• ���/1� Inspector initialslDate: - " f�- <br /> 9. Impact on Public Nealth—Compiia�ce component#1 of S <br /> Com liance c�iteria: Verification method{s): <br /> System discharge sewage to the ❑Y� ��{o ,� Searched for surface outlel <br /> _ground surface, � Searched f�or seeping in yard/bacJcup in home <br /> System discharge sewage to drain 61e ❑Yes �No E��ve ponding in sal system/aboxes <br /> or surface waters. (�I Homeowner testimony(See ConvReMsjEx�naii�n� <br /> System cause sewage backup irrto �y� � Mo � �B��k soil'above soil dispersal system � <br /> dwe�ling or esfablishmenk SYsten'►►equires°emergenc�'pumping � <br /> Any"yes"answer above indicates the system is � Pe��d dye test <br /> an/mminent Threat#o Public Healtf�and Safety, ❑ Unable tu veriry(See Comments/Exp/anst;oy <br /> ❑ Other methods not listeal(See Carrunents/Explanation� <br /> Commerrts/Explanatron: <br /> �'U�"� ,�a��/,F- ��- �°`�"�' <br /> 2. Tank Integrity—Compliance c�mponent#2 oP 5 <br /> Com liance crite�ta: Verfication method(s): <br /> Sysiem aonsists of a seepage pit, ❑Yes � No Q Probed tank(s)bottorn <br /> cesspool,drywell,or legching pit. � Examined construction recorcls <br /> SeePage p�ts meel�g 7080 2550 may be <br /> �f���n��� � Examined Tank Integ�ity Fortn{A�ach) <br /> � Observed liquid level below operadng depth <br /> Sewage tank(sj leak below their ❑Yes �'j No <br /> des' ned o ratin d fh, � �xa�'uned ernpiy(pumped)tanks(s) <br /> If yes,which sewage tank(s)leeks: � Probed au�s�de tank(s)for"black soil' <br /> Any `�res"answer above in�cates the ❑ Unable to verify(Ses Cormnents�Exp�arraaon) <br /> systerr� is Failing to Profiect Groundwater, ❑ �r methods r�ot Nsted(See Comments/Explanatlon) <br /> Comments/Explanation: <br /> 3. Other CompliarKe Conditions—Compliance component#3 of 5 <br /> a Maintenance hde covers are damaged,cracked.unsecured,or appear to stn�tu�apy urtspund. ❑Yes` Q No f��r�c�,ouv„ <br /> b. Other issues(e�tricai hazards,ee�)to immediately and adverseiy impact public health or safety. ❑ves� ❑ No ��nw,a,,,n <br /> �ysoem rs anlmmin�nt thieet to public he�andsa�y <br /> Explain: <br /> c. Sysbem is reon-Pratectiv+e af ground waier for ather condidons as de�eirnirled by i15peCtOf ❑Yes' No <br /> *syste,n is fa,r►ng t�o praGe�ct sv�oandrraCe. � <br /> Expfa9n: <br /> I <br /> www.pta.state.mn.us • 651-296-6300 • 800-657-3864 • 'I'Ty(�51-2ffi-5��9 nr RM.F57_�picd _ �.,.�.,��_� .,._.__..... , . <br />