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Nov 0613 06:50p 763-213-0695 p.2 <br /> Co� fiance cr�er"ra: � Ver�9cation rne�rod(s�: <br /> , Sys#em d�e sewage to the ❑Yes �No �Seard�ed for surFaoe ouNet ` <br /> round surface. � Seardied fnrjseepn9�Y�P in home <br /> System disc�arge sewag�to drairt�le � ❑Yes �No ❑ Excessive pa�diAg in soil systertUD-booces <br /> or surFaoe wafers. Hameo+emer testrnony�Se�e ' ) <br /> {7� [�'Black so�'above sa'f d�persal system <br /> System cause ae�iage badoup iri6o ❑Yes P'�--NO �( �em�1����9�1�Pu�9� <br /> dwefGng or estabC�nent � <br /> Any"yes"answerabove indicafes ffie sysf+esm is . �-P�oaned tiye test _ . <br /> en lmminerrt Tlrreat to PubNc HealEf�and Saf+e�jr. ❑ Ur�able#o verify(See � <br /> ❑ Other rt�ttl0ds�Ot fested(See Cornm�ntslBrpJana[ion) <br /> CommentsiEx�ianatim: � � <br /> � Tank Inte�ity—Compfiance oomponerrt�2 of 5 � - , <br /> Com ance pitar#at- - Yerification metl�od(s): <br /> System c�ns�sts aFf a seepa9e Qit. Q Yes �No .0 Probed tank(s)bottom <br /> cesspool,dryweN.ar�fiing pit � �. � Examfrted oo�sUuction r�eootds - <br /> Seepag+epits meeGig 708Q25S0 meYbe � � Eacamined Tank infiegrsty Form(Attadi) <br /> ' ,fsMowedinlocalaer�►m�ae. • <br /> Sewage ta�k(s)leak below i�eF ❑Yes �No ; � Observed�q�Ptl►{P��P�?�p���� _ . <br /> desi ned ' d - - �� <br /> If yes,which�ewage tarrc(aj i�ks: ❑ Probed outside tantc(s)for"bladc soil' � • <br /> Any'Sres"answer above in�cates the � tfnati�e to veriiy�s�c�or,».,�e�aon� . <br /> syst+em is Failing t+o Prote�Groundwater. _ O other metnods not�ed(see co�r,e.,cs�xpra►r�onl - <br /> cor�ur�er�lEx�r�a�ion: . . _ <br /> � Other Campliar�ce Conditions—Comp�ance component#3 af 5 <br /> �. . . <br /> a Mairstenar�ce frofe covefs ane damaged,cxadaed,un�eared.or apF�ear fiu strtod�alh►ur�owid- �Yes' �No ❑Unknanm <br /> b. Other i�(elecerar�tiazeras,�c.j eo inrr�ategr and ad�rsely imp�ct pubr�c t�eallh or safety. �res' �No ❑udoiown <br /> "5ysfem�s a.,i�m,er►rttireat t+o put�i'ic heafth and�fetyr - . <br /> . 6cpEain: . <br /> c. Sy�em is non-�ve of ground wa6erfior o�er oondi�ans as detertnined by ins�+or Q Yes' �No <br /> 'SSast+em Is fa�Ting fo p�►o�ect g�aundw�i� , - . <br /> E�lain: � <br /> iww.pra.stat��an.us '► 651-296-630q • 800-657-3864 1'TY 651-2�-5332 or 800-657=3864 • Avaitable in alDernative tormats <br /> �•wwrsa�.�t - rtz4�iz _- __.._ ._:_—_ . _-- � � - <br /> _- _: <br /> -..:._ . <br /> f <br /> I <br /> � • <br /> ? <br />