Property address: Inspector initials/Date: | (mm/dd/yyyy) Impact on Public Health – Compliance component #1 of 5 Compliance criteria: Verification method(s): Searched for surface outlet System discharges sewage to the Yes No ground surface. Searched for seeping in yard/backup in home System discharges sewage to drain Yes No Excessive ponding in soil system/D-boxes tile or surface waters. Homeowner testimony (See Comments/Explanation) System causes sewage backup into Yes No soil” above soil dispersal system “Black dwelling or establishment. System requires pumping “emergency” Any answer above indicates the “yes” Performed dye test system is an imminent threat to public Unable to verify (See Comments/Explanation) health and safety. Other methods not listed (See Comments/Explanation) Comments/Explanation: Tank Integrity Compliance component #2 of 5 – Compliance criteria: Verification method(s): System consists of a seepage pit, Yes No Probed tank(s) bottom cesspool, drywell, or leaching pit. Examined construction records Seepage pits meeting 7080.2550 may be Examined Tank Integrity Form (Attach) compliant if allowed in local ordinance. Observed liquid level below operating depth Sewage tank(s) leak below their Yes No Examined empty (pumped) tanks(s) designed operating depth. Probed outside tank(s) for soil” If yes, which sewage tank(s) leaks: Unable to verify (See Comments/Explanation) Any answer above indicates the “yes” Other methods not listed (See Comments/Explanation) system is failing to protect groundwater. Comments/Explanation: Other Compliance Conditions – Compliance component #3 of 5 a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. Yes* No Unknown b. Other issues to immediately and adversely impact public health or safety. (electrical hazards, etc.) Yes* No Unknown *System is an imminent threat to public health and safety. Explain: c. System is non-protective of ground water for other conditions as determined by inspector . Yes* No *System is failing to protect groundwater. Explain:
Property address: Inspector initials/Date: | (mm/dd/yyyy) Impact on Public Health – Compliance component #1 of 5 Compliance criteria: Verification method(s): System discharges sewage to the ground surface. Yes No Searched for surface outlet Searched for seeping in yard/backup in home Excessive ponding in soil system/D-boxes Homeowner testimony (See Comments/Explanation) “Black soil” above soil dispersal system System requires “emergency” pumping Performed dye test Unable to verify (See Comments/Explanation) Other methods not listed (See Comments/Explanation) System discharges sewage to drain tile or surface waters. Yes No System causes sewage backup into dwelling or establishment. Yes No Any “yes” answer above indicates the system is an imminent threat to public health and safety. Comments/Explanation: Tank Integrity – Compliance component #2 of 5 Compliance criteria: Verification method(s): System consists of a seepage pit, cesspool, drywell, or leaching pit. Seepage pits meeting 7080.2550 may be compliant if allowed in local ordinance. Yes No Probed tank(s) bottom Examined construction records Examined Tank Integrity Form (Attach) Observed liquid level below operating depth Examined empty (pumped) tanks(s) Probed outside tank(s) for soil” Unable to verify (See Comments/Explanation) Other methods not listed (See Comments/Explanation) Sewage tank(s) leak below their designed operating depth. Yes No If yes, which sewage tank(s) leaks: Any “yes” answer above indicates the system is failing to protect groundwater. Comments/Explanation: Other Compliance Conditions – Compliance component #3 of 5 a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. Yes* No Unknown b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety. Yes* No Unknown *System is an imminent threat to public health and safety. Explain: c. System is non-protective of ground water for other conditions as determined by inspector . Yes* No *System is failing to protect groundwater. Explain: