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Minnesota Pollution Compliance Inspection Form <br /> Control Agency Existing Subsurface Sewage Treatment Systems(SSTS) <br /> 520 Lafayette Road North Doc Type:Compliance and Enforcement <br /> St Paul,MN 55155-4194 <br /> Instructions:Inspection results based on Minnesota Pollution Control Agency(MPCA) For local tracking purposes: <br /> requirements and attached forms-additional local requirements may also apply. <br /> Submit completed form to Local Unit of Government(LUG)and system owner <br /> within 15 days. <br /> System Status <br /> System status on date(mm/dd/yyyy): 11/30/2015 <br /> ❑ Compliant-Certificate of Compliance 0 Noncompliant-Notice of Noncompliance <br /> (Valid for 3 years from report date,unless shorter time (See Upgrade Requirements on page 3) <br /> frame outlined in Local Ordinance) <br /> Reason(s)for noncompliance(check all applicable) <br /> ❑ Impact on Public Health(Compliance Component#1)-Imminent Threat to public health and safety <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Imminent threat to public health and safety <br /> p Tank Integrity(Compliance Compenant#2)-Failing to protect groundwater <br /> ❑ Other Compliance Conditions(Compliance Component#3)-Failing to protect groundwater <br /> p Soil Separation(Compliance Component#4)-Failing to protect groundwater <br /> ❑ Operating permit/monitoring plan requirements(Compliance Compenent#5)-Noncompliant <br /> Property Information Parcel ID#or Sec/Twp/Range: 75-131-2415 <br /> Property Address: 18584 Troy Street NW,Elk River Reason for inspection: Owner's Request <br /> Property Owner: Sherburne County Owner's Phone: (763)274-0925 <br /> or <br /> Owner's Representative: 0 Representative Phone: - <br /> Local regulatory authority: City of Elk River Regulatory authority phone: (763)635-1070 <br /> Brief system description: unknown configuration,no records available,did not find by probe. <br /> Comments or recommendations: <br /> replace system.Shallow well too close to septic area,install deep well. <br /> Very close to the Elk River Flood plain <br /> Certification <br /> I hereby certify that all necessary information has been gathered to determine the compliance status of this system.No <br /> determination of future system performance has been nor can be made due to unknown conditions during system construction, <br /> possible abuse of the system,inadequate maintenance,or future water usage. <br /> Inspector Name: Robert Polgreen Certification number: 9037 <br /> Business Name: Steinbrecher Companies,Inc. License number: L2851 <br /> Inspector Signature: �! � Phone number:(763)274-0925 <br /> Necessary or Locally Required Attachments <br /> • Soil boring logs 0 System/As-built drawing ❑ Forms per local ordinance <br /> O Other information(list): cover page,aerial photo <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 />