HomeMy WebLinkAbout17000990956000_Variances_07-12-1999I OFFICE OF COUNTY RECORDER
I OTTER TAIL MINNESOTA
i I hereby certify that
I this instrument #
; was filed/recorded in this office
j for record on the __L5_day of
Lj^Metcalf, CounW Recorder
' Dggjjty
8S0^70
Wend) by: J
.recording feeP
.well certificate
/
THE ABOVE SPACE IS RESERVED FOR THE COUNTY RECORDER
APPLICATION FOR VARIANCE
COUNTY OF OTTER TAIL
COURTHOUSE, FERGUS FALLS, MN 56537
(218) 739 -2271
*** COMPLETE THIS APPLICATION IN BLACK INK***
Receipt Number
DAYTIME PHONE S’7/
tuf^^oLE Aid. S5-2I/
_________LAKE CLASS G>D
Application Fee
'i%aiaAal'ImoAt <itdjL
So f^cHBArh c,,
Lr/^B NdfLihl-
LAKE NUMBEi^57g ^
PROPERTY OWNER
ADDRESS
F^XicRhl kfikBLAKE NAME
Di^NN w
TOWNSHIP =#^/37 RANGE ^TOWNSHIP NAME DUNN#9SECTION
^ »3ro//y" OOP - OOC^ '-D- NUMBERPARCEL NUMBER
S£c-fthhJ
Aof-^ f^^oURH B£RoJ^ 9bL\cr,4
) iMih/^sscrh^—
LEGAL DESCRIPTION
Lpthe
TYPE OF VARIANCE REQUESTED (Please Check)
structure Size____Sewage System SubdivisionStructure Setback Ciuster Misc.
^ECIFY VARIANCE REQUESTED ^(q 93 F-f fh/L
fi'eUjr Ou(~h^iA o/^
(Zs ^ /ZsfiiLU /TeoiA^
^Spf-.o D^nh'i-Pi&L.^ CM.LV£^fi
i UNDERSTAND THAT I HAVE APPLiED FOR A VARIANCE FROM THE REQUIREMENTS OF THE SHORELAND
MANAGEMENT ORDINANCeSUBDIVISION CONTROLS ORDINANCE OF OTTER TAIL COUNTY.
I ALSO UNDERSTAND THAT OTHER PERMITS MAY BE REQUIRED, IT IS MY RESPONSIBILITY TO
CONTACLLAND & RESOURCE MANAGEMENT REGARDING THIS MATTER.
^ DATE
/
signature of property owner
APPLICANT MUST BE PRESENT AT THE HEARING
(Applicant Will Receive Notification As To The Date/Time Of Hearing)
~D A/yi/ 7^/^
Augui^^iS'^^9'9^
Page 11 /
11 -57 75^
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'r,m?Accepted By Land & Resource L & R Official/Dat
Time d:3o/9 99Date Of Hearing /7«i^/S.
Motion
Marshal Smart - Approved as requested.
Motion was made by Cecil Femling, second by David Holmgren and unanimously carried, to approve a variance to |
install a septic tank and a lift station sewage pump for a drain field within the road right-of-way on Lot 29, a variance to
install a pressure sewage line, underjFish Lake Way a township road, from the septic tank to the drain field and a
variance to install a septic drain field ^within the cul-de-sac of Fish Lake Way. It was noted that the installation of the
proposed system had been prepared by a licensed installer and that it was an improvement over the existing systern. Hardship is a very small lot. ! i
j
Chairrn^n/Otte/Tail County, Board of<Adjustment
Permi^) required from I Land & Resource Management
Yes (Contact Land & Resource Management)
No
Copy of Application Mailed to Applicant And the MN DNR
bk 0198-001
Minnesota291.306 • Victoi Lundeen Co.. Piinters • Fergus Falls.
o. i p,
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM ^
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone; (218) 739-2271 - FERGUS FALLS, MN 56537
WHITE —Office
YELLOW — LS R Inspector
PINK — Owner/Contractor
)6eM^LEGAL Permit No.
DESCRIPTION
)Yes (y<4NoAbatement: (AND
LOCATION
LAKE NUMBER LAKE/RtVER NAME lAKE/RIVER
7a I ^
SECTION TWP. NO.RANGE TWP NAME
■I)UA/U
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
OOO /
/
IDENTIFICATION; Please Print All Information
Last Name First Initial Mailing Address — No, Street, City and State Zip Code Teiephone No.7t/- 4^7^ 4^Ai A/M'/;7Property
Owner
/L
%//lAl 55!i/J
I //MJ ^6,/A /L' V-#/ i—.Sewage
System
Installer §Name 7/
, O , (sr-T—y' J7.State Lie.«
A.M.
> This System will be ready for Inspection on.the year of PM..at.
This space for office use only NUMBER OF BEDROOMS:
A.M.
( X ) NORM.GARBAGE DISPOSAL: ( ) YESDate Rec'd Year of Time Rec’d Phone Can Rec'd By
TYPE OF SEWAGE SYSTEM
( ) Holding tank (Aiarm Required)
( Septic tank
station (Alarm Required)
(Drainfield
( ) Trenches
(;><JBed
( ) Mound *
( ) Outhouse
( ) Sewer line
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTS
.3»CTANK DRAINFIELD
r Ft^/OouCapacity GIs.
Distance from nearest well Ft.Ft.
Distance from lake, wetland or river (OHWL)Ft.Ft.
Distance from dwelling Ft.-2o Ft./O
Distance from non-dwelling Ft.Ft.
Distance from property tine Ft.Ft./aEFFLUENT DISTRIBUTION
( ) Gravity
('y'') Pressure
Distance from bottom to Water Table Ft.Ft.
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:WATER WELL DEPTH
/7o
* ABSORBTION AREA FOR MOUNDS (/uo-f
CPerc Tester .Date of Perc Test
,ft2
LfA /A/VRate of 1 st Test Average RateRate of 2nd Test
Agreement: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
strict accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota
Department of Health. Applicant agrees that plot plan sketches and specifications submitted herewith and which are approved by Shoreland ipariagement Official
shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. H shall be the respon
sibility of the applicant for the permit to notify the County Shoreland Management that the job isjeady for inspection.
DATE;iA A.
SignaWre
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express con
dition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the Ordinance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances.
NOTE: Permit void if work is not commenced within six (6) months.
3
1
i/o/zz/ff -AiIssued Date;
Land & ^^seOrce ManagemenI Office
iRec# 2^ \ /%ISFee $.IComments 2/^Uj-7^/■-.. %49
291.095 • Victor LurMjeen Co. Printers • Fergus Falls. MinnesotaBK 079&003
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
DRAINFIELDHOLDING
SEPTIC TANK LIFT TANKCATEGORY Actual Minimum
7^.Capacity
GLS.FT2GLS.FT2
Distance from Nearest Well I QT J) pjFT FT
Distance from Buried
Water Suction Pipe FT FT FT 50
Distance from Buried Pipe
Distributing Water Under Pressure FT FT FT 10
Distance from Lake, Wetland or River (OHWL)
FT FT
/fft) f FTDistance from Dwelling
FT FT 10/20
Distance from Non-Dwelling
FT FT FT
Distance form Nearest Property Line
/ O'i' FT
FT FT 10____n;
Distance from Bottom to Water Table FT FT FT3
/Holding Tank/Lift Alarm YES NO
Old System Pumped & Destroyed YES NO
Sewer Line to Well Separation DRAINFIELD CALCULATIONINTERPRETATION
OF ABBREVIATIONS
GLS. = Gallons
FT^ = Square Feet
FT = Linear Feet
Actual Minimum
.FTX
.ft^FT FT20
MOUND CALCULATION ROCK REDUCTIONInspector’s Comments:
ABSORBTION AREA1^ 1 Rock trenches with inches
■CLj O ^ ^ V)t/L ! ^Ft. X
of rock under pipe for .%
.Ft2
DF.reduction / equivalent to
SKETCH:
Vo/
Prmt Inspector’s Name
Inspector's Signature
Date / Time of Inspection
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone: (218) 739-2271 - FERGUS FALLS, MN 56537
WHITE —Office
YELLOW —L&R Inspector
PINK — Owner/Contmctor
HIM-L£GAL Permit No.
DESCRIPTION )Yes (y^NoAbatement: (AND
LOCATION
LAKE NUMBER UKE/RIVER NAME LAKE/RIVERCLASS SECTION TWP. NO.RANGE TWP NAME
1 121
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
n-md-39-o^ sL -/
IDENTIFICATION; Please Print All Information
Last Name FirstInitial IMailing Address — No. Street, City and State ______________ Zip Code 1
Ml aJ /y^/.o
it n. /f}A! 5S^W I
Telephone No.
-JlMs
25'IJ
Property
Owner 1 z
/?7A)Sewage
System
Installer
Name
I o <- 2^y7astate Lie.»
A.M.
► This System will be ready for inspection on.the year of PM..at.
This space tor office use only NUMBER OF BEDROOMS:
A.M.(^)NO.RM.GARBAGE DISPOSAL: ( ) YESDate Rac'd Tima Rac’dYear of Phona Call Rac’d By
TYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
(;7S-Septic tank
(y^ Lift station (Alarm Required)
(y^Drainfield
( ) Trenches
J^Bed
( ) Mound *
( ) Outhouse
) Sewer line
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTS
TANK DRAINFIELD
Ft'/OoaCapacity GIs.
i~oDistance from nearest well Ft.Ft.
Distance from lake, wetland or river (OHWL)Ft.Ft.
Distance from dwelling Ft. Ft./o
/ODistance from non-dwelling Ft. Ft.
(Distance from property line Ft.Ft.r^O
EFFLUENT DISTRIBUTION
( ) Gravity
Pressure
Distance from bottom to Water Table Ft. Ft.
All distances are shortest distance between nearest [mints
PERCOLATION TEST DATA:WATER WELL DEPTH .
O oLu/rP
* ABSORBTION AREA FOR MOUNDS
Perc Tester Date of Perc Test
,ft2
Uh_Rate of 1st Test Rate of 2nd Test Average Rate.
Agreement: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
strict accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota
Department of Health. Applicant agrees that plot plan sketches and specifications subrrwtted herewith and which are apprarod by Shoreland management Official shall become a part of the permit. Applicant further agrees that no part of the system shauWcovered uptilk>r^ been iri^Ki^ted and accepted. j( shall be the respon
sibility of the applicant for the permit to notify the County Shoreland Management tijatjire job ^nspectiony^ y y
/o//^/7f 2DATE:
r' /
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express con
dition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the Ordinance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances.
NOTE: Permit void if work is not commenced within six (6) months.
/o//z/ff
Landi
Issued Date:
rce Management Office
/fa J2-r/
7fZ_ ,21Fee $.Rec #
Comments.
A
291.095 • Yctor Lundaen Co. Primars • FarQus Falls. MirtnasotaBK 0795-003
PERCOLATION TEST DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, MN 56537
t 1
OWNER;i
LAST ^XME MIDDLE TELEPHONE NUMBER
ADDRESS:
STR./RT.CITY STATE ZIP CODE
LAKE/RIVER NO.LAKE NAME SEC.TIVP.RANGE TWP. NAME
LEGALDESCRIPTION:
PARCEL NUMBER
4^NUMBER/BEDROOMSFIRE NUMBER
— TWO TESTS ARE REQUIRED —
TEST HOLE NO. I TEST HOLE NO. 2
^ inches;Deplh To BoUom of Hole^_A\^5 Diameler of Holeinches;Oiaincter of Hole inches Depth To BoUom of Hole inches
19Depth, Inches Soil Texture Dale Soil Texture Date 19Deptlt, Inches
0-2S
_____
LcAIA lC»4MPercolation
lest By _
rirm
Name’
Percolation/^
N™e tEXaJ‘^Ht7
-770
Address Address
OUer^uil CUTIMty
License No.
0lter t^gr>ty •
License No. _Tin
PEKC I KS I # I PERC 1 ES I # 2
pnBtvALiMimrrBSj WATER DROPTIMEWA11□JL PERCRAIB TIME interval rMiwirras)WATER DCmt WATER DROP PERC RATE
JiP.!'.1..;^-}^iSTART
Tuag~ • ggSF PBRg-r START
TuaH~ gnop pfeiie~...to.UL7 —ijC?.
INTERVALfMPnJTBST water DEPTHio‘* r WATER DROP PERC RATE JU INTERVAL fMPrUTBSI PERC RATEWater DEPTH WATER DRpP
mlo , p.Tf.
TIKOI" ^ DROP" PHRg~
. REPILL REFILL ft-.■Id ..iQ......
INTERVAL fMINUTBST
REFILL
WATER DEPTH water drop PERC RATE ,I«MP INrERVALnmHUTES)water DEPTH ■>ATERDRpP PERORATE-J-Q“sH:'U27 REFILL-It)-.m".lO-
INTERVAL (MlNUnSSj WATER DROP FERCRATH Tli^INTERVAL IMlNtJTBS)WATER DEPTHTIMEwater DEPTH WATER DROP PERC RATH
REFILL REFILL
7IRm~'^D1U5P' "PBRg"TiMIr- ^ dr6p PtiRc
FERCRATE TIME INTERVAL IMlNinESI WATER DEPTHINTERVAL (MINITTES)WATER DEPTH WATER DROP WAITODROP FERCRATH
REFILLREFILL
miir vmp " r erc~~mig~'*‘gifgp'"pkRe-
PERC RATE TIME interval fMIWUTBSlINTERVAL (MINOIBSl WATER DCPni WATER DROP water DHPTHTIME water DROP PERORATE
REFILLREFILL
**Tirar DRUP' PERC'TIRE DROP Perc
interval fMIWUIBSl FERCRATE INTERVAL fMtWinEy>TTMB WATER DEPIH WATER DROP TIME WATER DEPTH WATER DROP PERORATE
REFILL REFILL
•flMii ^ bkop PtUiC rTIME DRbh
INTERVAL 04TNtnE$T water drop PERORATE TIME interval fMINUTBflTIMEWATER DEPTH WATER DEPTH WATER DROP ,PERORATE
REFILL REFILL
TlHB~^BRgP ~PBItC^'riMB~^r>ftgi> ~PBne~
COMMENTS/CA ECU LA TIOl^S:
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250,615 — Victor Lundeon Co.. Printers. Fergus Falls. Minnesota;MKL — 0390 - 005
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rUiUULAHUN test data
LAND AND RESOURCE MANAGEMENT
oiler Tail County
Fergus Falls, MN 56537
I '
OWNER;
LAST NAME MIDDLE TELEPHONE NUMBER ■;
ADDRESS:
Sil&HKDcTIll- MUlLt A/S/it/ff Mhl. 'SS'3-1/
siR./n). (rn' T" state ' zip code
- 786 P^iCoh->l Uh-k£ 7 /37
LAKE/RIPER NO. LAKE NAME TWP^ RANGE
7^^ ^£rcyfl^-:^cf
U,c>i~ l~/9^E-
Li j //L( —
S' lj-oo(\- o95'(p -mn
PARCEL NUMBER^ ^3(pl _Sl______
f/«£ NUMBER NUMBER/BEDROUMS
TWP. NAME
LEGAL DESCRIPTION:
— rwo TESrS are REgUIREU —
TES r HOLE NO. I TEST HOLE NO. 2
^ inches;
Depth To Bottom of Mole Oiitnicler of Mole 5
Diameter of Mole
inches;
..inches Depth To Bottom of Mole inch'
2-^ J'jHE:-19 CJ4 ^9^
Depth, Inches Soil Texture Date .Depth, Inches DaleSoil Texture
0-2J o LchMLoAIAI’cicolntion
I cst By _ _
rinnN:imc
Pcrcolntiotii
Test By___\
rirni
Name
ji____
C
(^.0. ^ci2-
-770
^)Mg| 'hiV<.'nm>(.y- ‘"j T.—x
License No, / / _________________
Aiklicss Address
OlIrH’^Tiit Ctjniity
License No.
imlKC I KS I n I FERC I ES I n 2
-JjyiSLMULVALfMlNUinS) WAI _WAieiU?BCC____w/
IJ4 aa»TART r f TART
rruic ^ih"
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TIME INtPrVALtMINlMim -JBMgSggJIL. . _5»]nsJOR.Ot!INlERVALfMPnnBSt WAiEp pBpni FERC RATE^AIBR DROP
&w..mIm:'.lo . V‘if. I*i4
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. RRriLL R^ILL.iJd....I
IHniHVAl.lMINUlB»l
RRFILL
^Ainw DErht
.sA“..■ _____________
INTER VAI WAT1 W/
liiT R8PILL
la-toll>7
IHtERVAL(MlNUIB5j iXRCRAlB INTBRV>a{MlNmB3T WAJBR PERTH WATER PROP PERC RATHWA3BWt>BriH _WA1IJPJ^0P____TTMB
RePILLnepiLL
iiMH * CUSP "fnrtc
__________rrjCRAiB
'tiAijB" ^ PROP' Pflkfc
water PROP INTERVAt.(MtmnBSI WATER DBP1H WATER PftOP PERC RATHIN IERVAL (MtWm BSJ WATER PCPniTIME
RBPILLRBP1LL
mtn. "rF.iic
______njc RA1R
TlHr'^CIUjr'fERC"
INTERVAL (MIHOTHSITIME
water pcpniINTERVAL (MINUIHS)WATBR PROP WATER DROP PERC RATEwater DOriHTIME
RDFILLRBPILL
TiTir. '^'Dttop "fp,nc~T[CTr*PBnP~*PEIlC'~
wtiB&SRQE_INTERVAL (MINUTEST
iHmRVAi.(MiNuins)
PERC RAIE TIME WATER PgRTHTTMBWATER DEIMtl WATER DROP PERC RATE
RBPILL RBPILL
•ru.uj‘ crop ~f pjc 'i-
TIKIH* BROir fERC"TIMB INTERVALfMmUIBSl_WATHRDEPni ■ WATBR DItOP_rERCRATE WATER DEPm WATER PROP .PERORATE
RBPILLREFILL
Tmg~ ^ PRgr ~f B«c~[iMB~^prop ~rmic~
COMMENTS/CALCULATIONS:
\ ■
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4eR.l(-l50'fc>W?P I
25O.01S Victor Lundeen Co.. Printers, Fergus Fells. Minnesotai;MKL — 0390 - 005 i::1I,:/
^ ofTioH TO
Ifli
Wayne Olson, SupervisorDUNN TOWNSHIPMerle Miller
Chairman
Bob Dalman, Supervisor
Judy Sumpter, Clerk
R R 3 Boz 193
Pelican Rapids, Minnesota 66572
Carla Johnson, Treasurer
July 12, 1999
Land & Resource Management
Otter Tail County Courthouse
Fergus Falls, Mn 56537
RE: Robert SmartHoward Wergeland David Ramage
Gentlemen:
Dunn Township has no objections, to the above named
property owners on Pelican Lake, from boring under the
Township road so they can put their drain fields in the
center of the culdesac adjacent to their properties.
Township, also has no objection to giving the road bed right-
of-way for their tanks.
Dunn
Sincerely,
Judy Sumpter
Dunn Township Clerk
X
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3
~4CERTIFICATE OF COMPLIANCE
m
f.SEWAGE SYSTEM 'e,X‘»5
rWrcPI
&
ft*tei
:^4p
16th JanuaryThis certificate has been issued this day of.19 75'•^2%■.
MM to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.
The premises covered by this certificate are legally described as:
Lake No. 56-786 Sec. 3.Twp.121 Range_Ji2.Twp. Name.Huna
W
HLot 29 of Provan Beach
11Mm
Jll&
waOwner: Name M.G. Smart
m A ddress.103 S 3rd St., Monrhaatl, Mlnnpsnt^
IS 56560Zip No.
1061Permit No. SP_
Signed by:.
Malcolm K. Lee, Shoreland Administrator Otter Tail County, Minnesota M
m
MKL-087 t-009
m ®159035 '''6^®* Lu»BCt«i 1 to. p*iiTC»*. re«cu« f»u« yiv«i
r SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 — Fergus Falls, Mn. 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOHAL HYSiTFM
White — Office—inspector
Pink
Card
Owner
Owner
Ic- ^ ?
j /O !^ CO (_) C
•O/n /Permit No..hLEGAL<//y 'JDate
DESCRIPTION
AND
/ -U.
—«77xi-9LOCATION
^ -y n
Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
Last Name First Initial Mallling Address —No. Street, City and State Zip No. Tel. No.
./
■ <■■)OWNER
J r I'y
SEWAGE
SYSTEM
INSTALLER
Name,
i
This System will be ready for inspection on.19.;
This space for office use only -I
i
].19 M iDate Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST:—
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
Ft.? GIs.Capacity Sq. Ft.
-5C?~oFt.Ft.Ft.Distance from nearest well y
?5"Ft.Distance from lake or stream Ft.Ft./
Ft.Distance from occupied building Ft.Ft.
■'/o /ODistance from property line Ft.Ft.Ft.
•/LLFt.Ft.Distance from bottom to Water Table Ft.
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on ,, 19 , Time .M By
/PERCOLATION TEST DATA:Date of First Test 19 Rate
I jDate of Second Test 19....Rate
/1st Test Taken By
//First Test + 2nd Test ,/j.
Rate2nd Test Taken By
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work inAgreement;
strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn
esota Department of Health. Applicant agrees that plot plan, sketches and specifications submitted herewith and which are approved by Shoreland Management Offi
cial shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the
responsibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection. (Call or use attached mailer notice.)
Dated
Signature
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE: Permit void if work is not commenced within six (6) months.■1f/
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Issued Date;
Shoreland Management Office(T'O
Fee S •Surcharge $T
Comments:.
J1
Form No. MKL-0771-003 @ e«.. MittTca*. rcMus mikn.158906vtCToa LuaaccN k
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INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORYActualShould be Actual Actual Should beShould be
Capacity GIs. GIs.S F S F S F S F
Distance from Nearest Well 75 50FFFFF F
Distance from Lake or Stream F F F F F F
20Distance from Occupied Building 10 20FFF F F F
Distance from Property Line 10 10 10FFFF F F
4 4Distance from Bottom to Water Table F F F F F F
Inspector's Comments:
QZ
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/
Date of Inspection 19___
Time of Inspection,M
Signature of inspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
» Linear Feet
Job TitleF
AgencyQt: --■ .0!vMKL-0771-003-Backer
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SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 - Fergus Falls, Mn. 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
White - Office
Yellow — Inspector.
Pink — Owner
Card — Owner
Permit No.LEGAL
Date<'0 ODESCRIPTION
AND
G-OLOCATION
Lake No.Lake Name Lake Classif.Range TWP Name
IDENTIFICATION: Please Print All Information.
Last Name First Initial Mailling Address —No. Street, City and State Zip No.Tel. No.5 3^^ ^C>-.OWNER
SEWAGE
SYSTEM
INSTALLER
Name,
This System will be ready for inspection .. 19.on.
This space for office use only
.19 ,M
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
Sq. Ft.>^C~) GIs.r Ft.Capacity
Ft.ST)SOFt.Ft.Distance from nearest well
?:Ft.Ft.Distance from lake or stream Ft.
Ft.Distance from occupied building Ft.Ft.
/o jD/oDistance from property line Ft.Ft.Ft.
i4Ft.Ft.Distance from bottom to Water Table Ft.
AH distances are shortest distance between nearest^fioints
RECORD OF TESTS:
Inspection was made on ,, 19 , Time ,JV1 By
/PERCOLATION TEST DATA:Date of First Test 19
, 19...?..'
Rate
fDate of Second Test Rate
1st Test Taken B
-Lt ;First Test + 2nd Test S
2'Rate2nd Test Taken By
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work inAgreement:
strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn
esota Department of Health. Applicant agrees that plot plan, sketches and specifications submitted herewith and which are approved by Shoreland Management Offi
cial shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the
responsibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection. (Call or use attached mailer notice.)
Signature
Dated
Permit:
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance. /)NOTE: Permit void if work is not commenced within six (6) months. / y ! /) T)
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
c y yy K
Issued Date:i
eland Management Office, sro
Fee $Surcharge $
Comments:.
Vietft* LUNDII* 4 CO.. PlUITtat. FCMUl FALL*. MIMN 15S906Form No. MKL-0771-003
TO BE COMPLETED BY PERSON INSTALLING SYSTEM
I hereby attest that I am familiar with the
minimum standards required by the OTTER TAIL
COUNTY SHORELAND MANAGEMENT ORDINANCE regarding
sewage systems and that I have installed the
above system in accordance with those standards.
uf (lL'^c.®
Legal Description;^ « c ^
License No.
Owners Name
Signature of Installer2^
7Date of Installation (/-r>- C
Date
Please return when completed to Shoreland Management Zoning Office
Court House, Fergus Falls, Minnesota 56537
PERCOLATION TEST DATA Price $ 1.00 per pad.
SHORELAIMD MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537
Ph. No.Owner:Mailing Address:
S A? -r X 5kJ Ll- f^OoH OMA Aj//ua/>
Last Name First Middle St. & No.City Zip No.State
Legal
Description:2 Gh rvryPb L/C/f
NAME
LoT ^ ^
/3 7 HX
LAKE OR RIVER NO.SEC.TWP.RANGE TWP NAME
r^fSr^cHp y\<pj
TEST HOLE NO. 2TEST HOLE NO. 1
3 LDepth to Bottom of HoleDepth To Bottom of Hole.inches; Diameter of Hole.inchesInches;Diameter of Hole inches
.3/ 7¥7^Depth, Inches Soil Texture Depth, Inches Soil TextureDate Date 191QjUt jXikJrL>“Percolation
Test By____
Percolation
Test By____36 "30 "o
PJJ^ fLUFirm
Name.OC Firm
Name,ZD
aLU
Address.Address
COOtter Tail County License No..Otter Tail County License No^HCOLUMeasurement,
Inches Depth In Water
Level, Inches
I-Measurement,
Inches Depth In Water
Level, Inches
Time Remarks Time Remarks
o 9:/'79: /3
?: 20
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9 :
M9 "0LI (S.S'
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MKL-0871-028
See Booklet, "How to Run a Percolation Test" by Agriculture Ext Service, Un. of Minn.