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Property Address: 18584 Troy Street NW,Elk River Inspector Initials/Date: RGP 11/30/15 <br /> 1. Impact on Public Health-Compliance component#1 of 5 <br /> Compliance criteria: Verification method(s): <br /> System discharge sewage to the ❑Yes O No O Searched for surface outlet <br /> ground surface. O Searched for seeping in yard/backup in home <br /> System discharge sewage to drain tile Dyes No ❑ Excessive ponding in soil system/D-boxes <br /> or surface waters. ❑ Homeowner testimony(See comments/Explanation) <br /> System cause sewage backup into Oyes O No ❑ "Black soil"above soil dispersal system <br /> dwelling or establishment. ❑ System requires"emergency"pumping <br /> Any"yes"answer above indicates the system is ❑ Performed dye test <br /> an imminent Threat to Public Health and Safety. ❑ Unable to verify(See comments/Explanation) <br /> ❑ 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, Oyes O No ❑ Probed tank(s)bottom <br /> cesspool,drywell,or leaching pit. O Examined construction records <br /> ❑ Examined Tank Integrity Form(Attach) <br /> See page pits meeting 7080.2550 may be ❑ Observed liquid level below operating depth <br /> compliant if allowed in local ordinance. ❑ Examined empty(pumped)tanks(s) <br /> ❑ Probed outside tank(s)for"black soil" <br /> Sewage tank(s)leak below their Oyes ONo ❑ Unable to verify(See Comments/Explanation) <br /> designed operating depth. ❑ Other methods not listed(See Comments/Explanation) <br /> If yes,which sewage tank(s)leaks: <br /> Any"yes"answer above indicates the <br /> system is Failing to Protect Groundwater. <br /> Comments/Explanation: <br /> probable cesspit,actual configuration unknown. <br /> 3.Other Compliance Conditions-Compliance components#3 of 5 <br /> a.Maintenance hole covers are damaged,cracked,unsecured,or appear to structurally unsound. <br /> Oyes* ONo ❑Unknown <br /> b.Other issues(electrical hazards,etc.)to immediately and adversly impact public health or safety. <br /> ❑Yes* ONo ❑Unknown <br /> *System is an imminent threat to public health and safety <br /> Explain: <br /> no visible manhole <br /> c.System is non-protective of ground water for conditions as determined by inspector. ❑Yes* 0 No <br /> *System is failing to protect groundwater <br /> Explain: <br /> 651.296.6300 800.657.3864 <br /> www.pca.state.mn.us TTY 651.282.5332 or Available in alternative formats <br /> wq-wwists4-31 1/24/12 800.657.3864 6 <br />