HomeMy WebLinkAboutCamp Joy_56000140104000_Septic System Permits_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 — Onice
Yettow — Inspector
Pink — Owner
! \) 01 6<j( r
Un ....^ ^
Permit No.C/V^LEGAL
DESCRIPTION
Parcel Numberf ct
AND
1‘i liS Hi ucKeLOCATION
Lake No.Lake Classif.Lake Name Sec.Range TWP NameTWP
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and StateLast Name_____________ ________ _________
4.1.
/iFirst Initial Zip No.Tel. No.
OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for inspection on... 19.
This space for office use only
19 .M
Date Rec'd Time Rec'd Phone Call Rec'd By
NUMBER OF BEDROOMS: \40uSEESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
Sq. Ft.GIs.Capacity Sq. Ft.
/CO60Ft.Ft.Ft.Distance from nearest well
SOsoFt.Distance from lake or stream Ft.Ft.
!0 Ft.Distance from occupied building Ft.Ft.
(OloDistance from property line Ft.Ft.Ft.
3Ft.Distance from bottom to Water Table Ft.Ft.
AH distances are shortest distance between nearest points
S-ll ll.h.lPERCOLATION TEST DATA:Date of First Test 19 Rate
‘IIDate of Second Test 19 , Rate
1st Test Tal By
2 .....................................................First Test + 2nd Test
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.
Signature ^
I understand that I have been granted a sewage system site permit in accordance with
the requirements of the Shoreland Management Ordinance of Otter Tail County. I
understand I must contact my township in order to determine whether or not any adSf^
tional permits are required by the township for my proposed project.
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 -yoid if work is not commenced within six (6) months.
Permit;
5 ao - Y/Issued Date:
Land A Resource Management Office
Fee $Rec #
Comments:
J'.:
Form No MKL 082090 253,056 — Victor Lundeon Co., Printers, Fergus Falls, Minnesota
Jf5fCLiVCrO^^^HpRELAND MANAGEMENT — COUNTY OF OTTER TAIL
^t>£> COUNTY COURT HOUSE
Phone 218-739-2271 • Fergus Falls, MN 56537t ^APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
White — Office
Yeilow — Inspector
Pink — OwnerbV^,
PI U I V ^ fH
p Un Ip “
Permit No.LEGALs
! DESCRIPTION 0/I-Parcel Number
AND Ii
5’
lAS:LOCATION
Lake No. Lake Classif.Lake Name Sec.TWP TWP NameRangei
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Tel. No.Last Name ,First Initial Zip No.
I—JcOWNER
a/cSEWAGE
SYSTEM
INSTALLER
Name.
YJ 3 ,^/y)
IL /-oof^
/-/ 0
7" //This System will be ready for inspection on., 19.
This space for office use only
7- )0 .19 .M
Date Rec'd Time Rec'd Phone Call Rec'd By
NUMBER OF BEDROOMS;ESTIMATED COST;
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
Sq. Ft.
jr:>o
so
'Xo^^o GIs.Capacity Sq. Ft.
Ft.Ft.Ft.Distance from nearest well
Ft.Distance from lake or stream Ft.Ft.
ID xoDistance from occupied building Ft.Ft.Ft.
iO10Distance from property line Ft.Ft.Ft.
3Ft.Distance from bottom to Water Table Ft. Ft.
AH distances are shortest distance between nearest points
♦J--'/PERCOLATION TEST DATA;
/)cua7 Date of First Test ■i19
. 19
, Rate
Sll a1 I 3Date of Second Test , Rate
1st Test Tal By
±.l2a.3('
First Test + 2nd Test72nd 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 spiecifications 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 inspacted and accepted. It shall be the
responsibility of the applicant for the parmit to notify the County Shoreland Management that the job is ready for inspection.
;
;
Signature r
I understand that I have been granted a sewage system site permit in accordance with
the requirements of the Shoreland Management Ordinance of Otter Tail County. I
understand I must contact niy township In order to determine whether or not any acW*
tionai permits are required by the township for my proposed project.
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.• -Ia
6.g- go - ■?/Issued Date:
Land & Resource Management Office
Fee $Rec #
Comments:
■ ,1
» ;Form No. MKL 082090 253.056 — Victor Lundoen Co., Printers, Fergus Fails, Minnesota
1.1,1 "IP
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYActualShould Be Actual Should Be Actual Should Be
X-is«»UA Cvt.iCapacityQls.GIs.S F S F S F S F
CO lO(*Distance from Nearest Well F F F F F F
MLDistance from Lake or Stream F F F F F F
•H+doDistance from Occupied Building 10 F F F F F F
F^rFayDistance from Property Line F F F F F F
3r^Distance from Bottom to Water Table 3 3FFFFF F
LAl^eInspector’s Comments:
f Ho c(ps-<SO
'i lK‘-
<
^(yudtr
I
Date of Inspection.
Time of Inspection
1
■I
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
F = Linear Feet
' Job Title
MKL • 032085 > Back«r Agency
♦(\%
As
215S02@
VICTOR LUNOEEN CO.. PRINTERS. FERGUS FALLS. UINN.PERCOLATION TEST DATAMKL -0871 -028
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, Minnesota 56537 Ph. No.
Mailing Address:Owner:
Last Zip No.StateCityMnddleSt. & No.First
Legal
Description:
5Tce^ Acc//^U±5’7^^
TWP NAMERANGETWP.SEC.NAMELAKE OR RIVER NO.
TEST HOLE NO. 2TEST HOLE NO. 1
Cp30 Depth to Bottom of Hole inches; Diameter of Hole jnchesDepth To Bottom of Hole Diameter of Holeinches; inches
11/>7/2y JLDepth, inches Soil Texture 19_£/Soil TextureDepth. Inches/r>/Qu DDate Date 19
^ ~ (dO' ^
f) ~ Ir)
c-/Jo /n </^i
X)an /A n
/?6V J2 in________
Percolation
Test By____
Percolation
Test By .f k.'lxQLUFirm
Name.F irm Name,QC
fM'f M rv fD7o/f/? ^ ! /!/!)( All n______
jOa/tT,
LU
oc
UJAddress.Addresscr<
)^(e//OGf to
Otter Tail Countv License No.,Otter Tail County License No_HCOLUMeasure
ment,
inches
Time
Intervals
minutes
Drop in
water level, inches
Percolation
rate minutes
per inch
H Time
Interval,
minutes
Percolation
rate minutes
per inch
Measure
ment
inches
Drop in
water level, inches
Remarks:Remarks:Time TimeogI-L /!/ /!-T///11//-• 2o
. ./.U.1P-
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n i
jusn
UUd.
11.JlL3l_
nil
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^ I.^'5 1 ef/)/
, / UIaqua21)! :i/O ' 02.?/d hntlj n//J Jon/ '»
IX-See Booklet, "How to Run a Percolation
Test" by Agriculture Ext. Service, Un. of MN,
Percolation rate =.minutes per inch minutes per inchPercolation rate
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CERTIFICATE OF COMPLIANCE
gW‘^m
Pmpi
WM
m
SEWAGE SYSTEM
'O
ic«i
"£!.W
28th day of_19___22This certificate has been issued this November
to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.I«i
m The premises covered by this certificate are legally described as:Wm
it-d Pmpim- ■■ -WJ
rm
i»-sf
Lake No. 56-385 Sec. 11-lA Twp. 135 Twp. Name.Range_lil.T.alfe
M Lots 15-19 of Elysium Park and Lots 1-6 1st Addition to Elysium Park
M&
m&mmm
piCamp Joy (Star T.ake R'lhle r.amp)Owner: Name.
•s 1*11Address.Dent jM-f rmesota
pfe Zip No.56528
1 Permit No. SP_2679
Signed by:_^&Malcolm K. Lee, Shoreland Administrator
Otter Tail County, Minnesota
MKL-087 1-009
m
VTMSit.y
159035 i.uiiocei
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
W te — Office
> low — Inspector
Pli.. — Owner
Card — Owner
Permit No.,LEGAL
DateUMrsDESCRIPTION
AND
(f,J> /JstT 4/ol^ ^k<yiLOCATION ,56- 3^$^
TWP NameLake Classif.Sec.TWPLake No. Lake Name Range
IDENTIFICATION: Please Print All Information.
Mailling Address —No. Street, City and State Zip No.Tel. No.First InitialLast Name
OWNER
)
SEWAGE
SYSTEM
INSTALLER
Name
This System will be ready for inspection on., 19.
This space for office use only
,19 ,M
Date Rec'd Owner or Agent SignatureTime Rec'd Phone Call Rec'd By
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:2SEPTIC TANK SEEPAGE PIT DRAIN FIELD
s/i^<X>0 GIs./2 C O sq- Ft-Ft.Capacity
Ft.Ft.Ft.Distance from nearest well
Ft.Ft.Ft.Distance from lake or stream
fO '^OFt.Ft.Distance from occupied building Ft.
/ODistance from property line Ft.Ft.Ft.
tlFt.Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19,.........jVI By
/.
PERCOLATION TEST DATA:Date of First Test , Rate
Date of Second Test /.Rate
1st Test Taken By
,Z0 2L_/First Test -I- 2nd Test 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 specif ications 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.)
\3/c-? 7Dated,-‘C.—•**•■^1- -1 -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 cornmenced within six (6) months.,1
y2Issued Date:
Shoreland Management Office
STT^j-otj.
Fee $Surcharge $■7^
Comments:.
iO_77'Ml
Form No. MKL-0771*(^ VICT«» UlMtCCH k ea.. aaiMTiaa. riaaus r«LLa. m>mn 158906
1SHORELAND 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,
I Permit No.,Ic O Avxc, o ‘LEGAL 0 yu. ,0 /' P - •-? t //Date
DESCRIPTION
(iff »•AND
r-I ; rillLOCATION
Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
Last Name First Initial Mailling Address —No. Street, City and State Zip No.Tel. No.
1-'>OWNER • r
/■ t-.
SEWAGE
SYSTEM
INSTALLER
Name,
This System will be ready for inspection on.19.
This space for office use only
\
19 .M
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signa^ture
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
/ a GIs.Sq. Ft.Capacity ‘y Sq. Ft.
Ft.Ft. Ft.Distance from nearest well
/Ft.Distance from lake or stream Ft.Ft.
Ft.Distance from occupied building Ft.Ft.
Distance from property line Ft.Ft.■)Ft.
■ iS'Ft.Ft.Distance from bottom to Water Table Ft.
AH distances are shortest distance between nearest points
;RECORD OF TESTS:
i
iInspection was made on 19 .. , Time
...
,JV1 By
t
.LPERCOLATION TEST DATA:Date of First Test , 19 . Rate
/Date of Second Test 19 Rate"
1st Test Taken By
/First Test -I- 2nd Test 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.)
Dated
Signature
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.
Permit:
li ■•7
Issued Date:
Shoreland Management Office
c y)Fee $Surcharge $'i
>/I
CERTiFICATEComments:.
¥) ' <■ . (/ U
Form No. MKL-0771-003
VICTOk UtOBICII t CO.. FIIMTCaO, PCOOUS r*LL0. HIMN
158906
■1'^M'-r
INSPECTION RESULTS «
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORYActualShould be Actual Should be Actual Should be
Capacity GIs. GIs.S F S F S F S F
Distance from Nearest Well 75 50FF F F F F
Distance from Lake or Stream F F F F F F
Distance from Occupied Building 201020FFFFF F
Distance from Property Line 10 10 10FF F F F F
Distance from Bottom to Water Table 4 4FFF F F F
Inspector's Comments:
:
/
/
Date of Inspection 19____
Time of Inspection,,M
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF - Square Feet
F * Linear Feet
Job Title
. . ’ iQ:; «Agency
MKL-0771-003-Backer
-‘- v ••#it
!
)
.li.
PERCOLATION TEST DATA Price $1.00 per pad.
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537 Ph. No.Owner:Mailing Address:
^-Ct /Vc —Xp y_• Last ^Name First Middle St. & No.City State Zip No.Legal
Description:6 fQ
LAKE OR RIVER NO.NAME SEC.TWP.RANGE TWP NAME
TEST HOLE NO. 2TEST HOLE NO. 1
Depth To Bottom of Hole.Depth to Bottom of Holeinches; Diameter of Hole inches; Diameter of Hole.inches Jnches
- H 197^Depth, Inches Soil Texture Depth. Inches Soil TextureDate Date
Lctccri.'^i
------------------------------- PercolationTest By____
6 7^^'(D- R
(Zoo^ f 'f'o i~
Percolation
Test By___Sn^lCtaclC Q
LUFirm
Name.OC Firm
Name.IDA/:ACaI C Ol
QC
LUAddress.QC Address<J7 /3 7 /WOtter Tail County License No..Otter Tail County License No^HwLUMeasurement,
Inches Depth in Water
Level, Inches
Measurement,
Inches Depth in Water
Level. Inches
Time Remarks Time Remarks
On •'£% /
I/\2S 0aa0/Af./y,/h ALlKI '36
/a
O L: 7?o llp a // ZT
r 'L
it fdc20/ 37 100..VD
/. rg>
z./: V7 0
/{c r./6£0^J050
/
CO
0
/:o000 lucJC£0 Z1
6 <PcWcTTclTj^/ 8 •'UC,ll_A -. /o a:))
r c R r - I (lafc^ I. G /a ;a3mpI
MKL-0871-028
See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn.
01
ij.'' ^o’ty.CERTIFICATE OF COMPLIANCE
wSEWAGE SYSTEMSI
iW#i§i4
mhi WMfel30th19 74DecemberThis certificate has been issued this day of
to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.SfiS«
tel
The premises covered by this certificate are legally described as:
Lake No. 5^~365 . Sec. lUl^ri
Pi
|i
II6r4latelpa
/"wp. 13^Range Ul Twp. Name Star Lake
fl^tel
teli*tew
Camp Joy Bible Camp
Star Lake Bible Camp Assn.Owner: Name.
mm Mm
m-m
Dent. Minnesota *^6^28Address.
m Zip No.
1039Permit No. SP_G 1'yb
Signed by:.*Malcolm K. Lee, Shoreland Administrator
Otter Tail County, Minnesota
MKL-087 1-009
I
..•s<
®(59035 'ticTo* (.ukodii ( CO. MikTcng, rcneui rAiLi. uii*
SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 - Fergus Falls, Mn. 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTFM
White — Office
Yellow — InspectorPink — Owner
Card — Owner
/c? y9^ l> y 1^, U-f ^Permit No..cLEGAL
Date
DESCRIPTION
AND
S 7h ^ Lc, A-ia p N i^r HILOCATION
Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
Initial Mailling Address —No. Street, City and StateLast Name First Zip No.Tel. No.
>^~rloikjt 0] (^Lfi C(!L^/yj 1^OWNER
S o >
SEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for inspection on., 19.
This space for office use only
19
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signa^ture
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
/So O 0 Sq. Ft.\GIs.Sq. Ft.Capacity
<fO'^Ft.Ft.Ft.Distance from nearest well
TOFt.Ft.Distance from lake or stream Ft.
L£l Ft.Distance from occupied building Ft.Ft.
ULDistance from property line Ft.Ft.Ft.
Ft.Ft.Distance from bottom to Water Table Ft.
AH distances are shortest distance between nearest joints
RECORD OF TESTS:
Inspection was made on 19,, Time JVI By,
.l.±,.1.1...I.L.PERCOLATION TEST DATA:Date of First Test , 19
, 19
Rate
L2-Date of Second Test Rate
1st Test Taken By
IIIFirst Test + 2nd Test
Ra2nd 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.)
C,- f If - T-/Dated
Permit:
condition that the person to whom it is granted, and his agents, employees and workmen shall conjfjrm 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.
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
G - 7 1Issued Date:
loreland Management O/fice
»<ro5" > (yoFee $Surcharge $
Comments:.
fOO ro
Form No. MKL-0771-003 I .I...1S8906VICTCa LUMfiCtN i 60..
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
V'!' te — Office
V low — Inspector
Pii.. — Owner
Card — Owner
Kilriv/xia10
Permit No.,//^LEGAL
Date
DESCRIPTION
AND
//'LOCATION
Lake No.Lake Name Lake Classif.Sec.TWP TWP NameRange
IDENTIFICATION: Please Print All Information.
Last Name First Initial Mailling Address —No. Street, City and State Zip No.Tel. No.
OWNER
SEWAGE
SYSTEM
INSTALLER
Name
/c
C ' T f ,„?) J: »«-/*..
11 ^ «>/»>*!This System will be ready for inspection on., 19
This space for office use only
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signa^ture
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
GIs.Capacity Sq. Ft.Sq. Ft.
Ft.Ft.Ft.Distance from nearest well
1Ft.Distance from lake or stream Ft.Ft.
Distance from occupied building Ft.Ft.Ft.
Distance from property line Ft.Ft.Ft.
Distance from bottom to Water Table Ft.Ft.Ft.
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19,, Time ,JVI By
PERCOLATION TEST DATA:Date of First Test ,, 19 . Rate•M
r
Date of Second Test 19 Rate
1st Test Taken By
First Test -I- 2nd Test 22nd Test Taken By Rate
Agreement:
strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn-
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.)
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
esota
Dated
' Signature
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.
Permit:
Issued Date:
Shoreland Management Office
S7 "a‘-!Fee $Surcharge $certificate issuzr
Comments:.
ILL /
Form No. MKL-0771-003 i.158906vieroa mNoctH a ea..
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY
Should be Actual Should beActualShould beActual
SFCapacityGIs.GIs.s F S FS F
lotj FDistance from Nearest Well 5075F F F FF
'iv tDistance from Lake or Stream F F F F F F
F 20Distance from Occupied Building 10 20LHF FF F F
F10Distance from Property Line 10 10FF F F F
i4 4Distance from Bottom to Water Table /fFFF F F
/^KL. ^hx c
/ t rJL ^ .
Inspector's Comments:
I, t-rTiU.C U
b A-<> /L-Ct.^ <~LSLJi.
r
! ^19^Date of Inspection
Time of Inspection.M
V/ signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs ™ Gallons
SF * Square Feet
F =• Linear Feet
■I
/
Job Title
Agency
MKL-0771*003-Backer
♦ ^
:!''fST§ii’T.«rdbV »kV•: 11 ILii l"s3' Jsic’niawfitiptK»
s'i;*r--i{5't'i3. Timv.iti iy UK* OTTBH TAIL C.-.DM: m ‘ie^-w. KwJ.Tv-f'MiNr 'XVOI^JANCE Tf^gat^ini
t--:'--9.$,^ sy-..ir.M i feri Ci.:v. X t.'yii- Tn'St^.Jl'jd the
above sysoaffi in aociirTci^JiC'^- 'wbith those standards.
';»
Legal Description;
License No.
STgnatufe of”
j^te
InstallerO' C./„?cDate of Installation /?7y
Please return when completed to Shoreland Management Zoning Office -
Court House, Fergus Palls, Minnesota 56537.
TO BE CO‘i 'iD EV' XOLAIion TESIER
1 hereby atL^sc cha'. I atr, familiar with
the minimum scaudalds required by the
OTTER TAIL COUNTS SH'JRELAND ^lANAOEMENT
ORDINANCE repardlnp, sewap;e systems and
that the land elevation where soil absorption
portion of sewage system will be installed
in not less than six (6) feet above the
high water level of the lake, stream or
flowage involvede
Legal Description:
CAMP JOY BIBIE CAMP
Sec 14 Star Lake Twp
CAMP JOY BIBLE CAMP
of^^^rcolator TesterOwners Name Sig^a
Jun ml7^Star Lake 56-385
Lake Name Dated
Please return when completed to Land and Resource Management Office,
Court House, Fergus Falls, Minnesota
percolation test results»
56537.Attach a copy of the
MKL-0574-045
PERCOLATION TEST DATA Price $ 1.00 per pad.
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537 Ph. No.
Owner:Mailing Address:
CAMP JOY BIBI£ CAMP Dent Mn
Last Name First Middle St. & No.State Zip No.City
Legal
Description:56-385 Star 14 41W135 Star Lake
LAKE OR RIVER NO.SEC. TWP.TWP NAMENAMERANGE
TEST HOLE NO. 2TEST HOLE NO. 1
c.Depth to Bottom of Hole inches; Diameter of Hole JnchesDepth To Bottom of Hole,inches: Diameter of Hole inches
ly i9_ZirSoil TextureDepth, Inches Depth, Inches Soil TextureDate19 Date
/-Percolati
Test Bv_
Percolation
Test By .‘S. J. Elfert clSc, yjrJ,/O ^Q
UJFirm
Name,
Firm
Name.QC
D
oLU
cc
LU
Address.GC Address
<
toOtter Tall County License No..Otter Tail County License No^I-coLUMeasurement,
Inches Depth in Water
Level, Inches
H Depth In Water
Level, Inches
Measurement,
InchesTimeRemarksTime Remarks
O
I / 33^'
/ 3z<6
///-33d,/ f/o
f/.33y /3
/ 3
/>"
2o ^
/3^o ly 7
/ f ^3>/•yr^Z-/L
2.^ ^/Z/S'iL L±
/ z /V
7-S z- //y
Hi
PERCOUTION RATE * 10 x lli «r 1 Min/Inch
MKL-0871-028159179 ®vicTo* LUMOCCN » CO . rftiHTciit. rc*«u» rm.i.s.
See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn.