HomeMy WebLinkAboutCozy Cove Resort_14000990550000_Septic System Permits_CERTIFICATE OF APPROVAL
SEWAGE SYSTEM
SEPTIC TANK & LIFTm:972l5tFebruarymThis certificate has been issued this
to certify that the sewage system installed as per sewage permit number indicated below has been approved for use
by Otter Tail County, Minnesota.
day of 19
mi
il The premises covered by this certificate are legally described as:
DEAD LAKE1354056-343 02Lake No.Sec.Twp.Range Twp. Namem
COZY COVE SUBDlVIBIOM-HEINRICtl B
OUTLOT A lMs;
m
BENSON. GARY D S< PATRICIA AOwner: Name
RR 2 BOX 934. DENT, NNAddress fM1m:56530Zip No.
10901Pennit No. SP
Signed by:T
Land & Resource Management Official
Otter Tail County, Minnesota
il
MKL-0987001
m
JT 279005 Victor Lnndem Co.. PriiUm, Fergus Ftlls.Minnewtt
OTTER TAIL COUNTY LAND & RESOURCE MANAGEMENT
121 W. JUNIUS, FERGUS FALLS, MN 56537 (218) 739-2271
August 7, 2002
Gary D & Patricia A Benson
PO Box 97
Dent MN 56528-0097
RE: Sewage System Servicing Cozy Cove Resort, Cozy Cove Subd-
Heinrich Beach, Marion Lake (56-243)
Dear Mr. & Ms. Benson,
Our records indicate that the sewage system installed on the
above mentioned property was considered to be in compliance with
the provisions of the Sanitation Code of Otter Tail County in
effect at the time of installation.
Since this is the case, we would still consider this sewage
system as being in compliance with our current Sanitation Code
requirements. Should this sewage system malfunction, it would
have to be repaired or replaced in conformance with the
provisions of the Sanitation Code in effect at the time of
failure.
If you have any questions regarding this matter, please contact
our office.
Kyle Westergard
Inspector
KWW/jlt
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
S'- 3o
WHITE — Office
Yellow — Inspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone:(218)739-2271 - FERGUS FALLS, MN 56537
/0?0 /
C,o'^~j cSu
LEGAL Permit No.
DESCRIPTION fX'I Abatement: ( ) Yes
" ^cC\. eg.
NoAND, (/t 'T ,c^
LOCATION Oc^ [-A~
LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER
CLASS .
SECTION TWP. NO.RANGE TWP NAME
oxexoPARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
/^y~OS~fO-Oao
IDENTIFICATION: Please Print All Information
Mailing Address — No. Street, City and StateLast Name First Initial Zip Code Telephone No.
Aj a/____
Property
Owner
7fc^Le^ fcL-<-X. By)CSewage
System
Installer
Name
A.M.
This System will be ready for inspection on P.M., 19-at
This space for office use only ^ 'YNUMBER OF BEDROOMS:
A.M.
P.M19 GARBAGE DISPOSAL: ( ) YES { ) NODate Rec'd Time Rec'd Phone Call Rec'd By
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
(^) Septic tank
(No Lift station (Alarm required)
(' ) Drain field
) Trenches
( ) Bed
) Mound
( ) Outhouse
( ) Sewer line
TANK DRAIN FIELD/rrrroA ACapacityGIs.Sq Ft.
eOODistance from nearest well Ft.Ft.
tXODistance from lake or stream Ft. Ft.(
/ODistance from building Ft. Ft.
(
yoDistance from property line Ft. Ft.
Distance from bottom to Water Table Ft. Ft.
EFFLUENT DISTRIBUTION
( ) Gravity
( ) Pressure
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:
WATER WELL DEPTH /0 110
Perc Tester.Date of Perc Test
Rate of 1 St 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 submitted herewith and which are approved by Shoreland Management Officical 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 responsibilty of the applicant for
the permit to notify the County Shoreland Management that the job is readwjor inspection.
^ 9-DATE:
Signature NNs,
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 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.
7- A’i-Issued Date:
Land & Resource Management Office
.•?o Rec #.Fee $.
Ok A/rA'ks P-./6 - ^ Cr — DP / SComments:
277,212 • Victor Lundeen Co,, Printers • Fergus Falls. MinnoostaBK 0795-003
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
I
WHITE — Office
Yellow — Inspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone: (218) 739-2271 - FERGUS FALLS, MN 56537
/090 /
Coiyc 'LEGAL Permit No.'Z'Po/L
Cx)^'-jCoo€ Su k)C^'
^ VDESCRIPTIONy NoAbatement: ( ) Yes
' t cC\ PSAND
ce.LOCATION ^
LAKE NUMBER LAKEIRIVER NAME SECTIONLAKE/RIVER
CLASS TWP. NO.RANGE TWP NAME
jOfanr ox noO 0
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
IDENTIFICATION: Please Print All Information
Last Name First Initial Mailing Address — No. Street, City and State Telephone No.Zip Code
fhc A ^
OexO' ___
Property
Owner
/fc(c^ j/a^O fvSewage
System
Installer
Name
A-)o^c!vv,^
45-:bO ,.M.l
«•This System will be ready for inspection on , 19.P.M,at
This space for office use only NUMBER OF BEDROOMS: V
8'^ocj ^%5-.30 19 GARBAGE DISPOSAL: ( ) YES ( ) NODate Rec’d Time Rec’d Phone Call Rec'd By
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
(^) Septic tank
Lift station (Alarm required)
) Drain field
( ) Trenches
( ) Bed
( ) Mound
( ) Outhouse
( ) Sewer line
TANK DRAIN FIELD
/>Capacity GIs.Sq Ft.or Q
r )5(3Distance from nearest well Ft. Ft.-r<^
roDistance from lake or stream Ft. Ft.
Distance from building JO Ft.Ft.
5Distance from property line Ft.Ft.
Distance from bottom to Water Table •Ft.Ft.
EFFLUENT DISTRIBUTION
( ) Gravity
( ) Pressure
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:
WATER WELL DEPTH
I)) I ^t
Perc Tester.Date of Perc Test7^
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 submitted herewith and which are approved by Shoreland Management Officical 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 responsibilty of the applicant for
the permit to notify the County Shoreland Management that the job is ready fpr inspection.f ()\
DATE:
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 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.
? •> fCIssued Date:
Land & Resource Management Office
JLFee $.Rec #_
-ic' As:7^Comments:
^ n r/f;U^-^ o77-'
/ i y y T
277.212 * Victor Lundeen Co . Printers • Fergus Falls. MinneostaBK 079B-003
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS •*e'
DRAIN FIELDHOLDING
SEPTIC TANK LIFT TANKCATEGORY Actual Minimum
JO&O GLS.GLS.SF SFCapacity
"h 1<S ^ FT FT FTDistance from Nearest Well FT
Distance from Buried
Water Suction Pipe jvoUS'
So'
FT 50 FT-j- S‘ 0- ft FT
Distance from Buried Pipe Distributing Water Under Pressure FT FTFT10FT
^ !&V FT FT FTDistance from Lake or River (OHWL)FT
10/20 FTFT FTFTDistance from Nearest Building /5
2.e> FT FTFT FT 10^ Distance from Nearest Property Line
HO
FT FTFTFT3Distance from Bottom to Water Table
NO•Hotding Tank/Lift Alarm
YES NOOld System Pumped & Destroyed Y *-
DRAINFIELD CALCULATIONSewer Line to Well SeparationINTERPRETATION
OF ABBREVIATIONS
GLS. = Gallons
SF = Square Feet
FT = Linear Feet
Actual Minimum
FTX
^ S'O FT FT20 SF
Inspector’s Comments:J U
Cj’tl^ i-t !»r<,sSuAA^jLj
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SKETCH:
<6 -L.lUir A^f-c eriP^A.
XJ- i S
.y.
/2
Inspector's Signature JO
Date of Inspection
I2-.63.
Time of Inspection
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Dent. Mn
4-r GOVT LOTS H- & 5 Sec 2 Twp 135$T —r-"-' i-rK-H-;-9
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NOT DRAWN TO. SCALE 7-BRA IN FSLD'WILL DT orrT7'I 1 t3^V above water table .(Vertical)^ -^7 -- SEPTIC. TANKS SEALED UNITS'\<EII.T:!‘a 900 GALLONS V 7^-DRAIN FIELD c
H I>niiICATES PROPOSED 3E'.^IER LINES V-; -i-
;.^|4^;;i9-TOTAL-BEDROOMS TO SERVICE J69—,"ri U.74“;-LL-^j-------
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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
79<yfPermit No.LEGAL
do 2. ^CoveDESCRIPTION
AND
z 13^^ vmo LXi- OLOCATION
Lake No.Lake Name Lake Cia&sif.Sec.TWP TWP NameRange
IDENTIFICATION: Please Print All Information.
Majljing Address — No. Street, City and State
Z Bex 9
Last Name Initial Tel. No.First Zip No.
/OWNER
Ve^r^T'. m V ■I^c^p>a\\f t >^C a-SEWAGE
SYSTEM
INSTALLER r '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 Signature
NUMBER OF BEDROOMS; 3ESTIMATED COST;
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
JOOC GIs.Sq.y^t.Capacity ^ Sq. Ft.
ITT0^Ft.Ft.Distance from nearest well
Ft.Distance from lake or stream Ft.Ft.
Distance from occupied building Ft.Ft.Ft.
/aDistance from property line Ft.Ft.Ft.
7, I ^ Ft. a
AH distances are shortest distance between neared points
Distance from bottom to Water Table Ft.Ft.
RECORD OF TESTS:
Inspection was made on 19 . Time JVI By.
PERCOLATION TEST DATA:Date of First Test . 19 , Rate
Da l6ri3Test 19 , Rate
1st Test Taken By
First Test + 2nd Test
Tak^ By 2 Rate2nd Test
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.
I understand that I have been granted a sewage system site permit in accordance with
the requirements of the Shoreland Management Ordinance of Otter Taii County. I
understand i must contact my township in order to determine whether or not any addi
tional permits are required by the township for my proposed project.
i—
SignaVure
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.
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
I - 19 S'?VJ2-3P
Shoreland Managemenf^ice
Issued Date:
Fee $Rec #
I ^'iZL oComments:
Form No. MKL-032085 237,443 — Victctr Lundeen Co.. Printers, Fergus Falls. Minnesota
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
Permit No..LEGAL
(Zo 2. ^Oo vCDESCRIPTION
AND
) 3ST 7^LXM/J IM(v OLOCATION
Lake No. Lake Classif.Lake Name Sec.TWP Range TWP Name
IDENTIFICATION; Please Print All Information.
Malijng Address — No, Street, City and StateLast Name First Initial Zip No.Tel. No.
Bej!sc ^iT, o X q 5 y'//CPOWNER
Dt.-r'jZ, m r\J ■s ^ cy ,'TL
5\f < >' CSEWAGE
SYSTEM
INSTALLER
/ •Name.
If JtPThis System will be ready for inspection on., 19
This space for office use only
/7pS.19
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature
NUMBER OF BEDROOMS: 3ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT i^DRAIN FIELD
\GIs.Capacity Sq.
1 )Ft.Ft. Ft.Distance from nearest well r
70 Ft.Distance from lake or stream Ft.Ft.
/7 Ft.Distance from occupied building Ft. Ft.
Distance from property line Ft.Ft.Ft.(
//Ft.Distance from bottom to Water Table Ft.Ft.
AH distances are shortest distance between nearest points
RECORD OF TESTS;
Inspection was made on 19 , Time M By
... I
PERCOLATION TEST DATA:Date of First Test 19 Rate
Date of Second test 19 Rate
1st Test Taken By
First Test + 2nd Test 22nd Test Taltfen By Rate
The undersigned herieby 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.
I understand that I have been granted a sewage system site permit in accordance with
the requirements of the Shoreland Management Ordinance of Otter Taii County, i
understand i must contact my township in order to determine whether or not any addi
tional permits are required by the township for my proposed project.
.,3 -
Signature
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.
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
r rIssued Date:V
Shoreland Management b${C0
oco •Fee $C--Rec #_;
^ Or (a \y\ -p'r df (kiq-7 3 7 I z tI s IComments:
Form No. MKL-032085 237,443 — Victor Lundeen Co., Printers, Fergus Falls, Minnesota
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
1
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYActualShould Be Actual Should Be Should BeActual
\Capacity /goo GIs.GIs.S Fr-S F S F S F
70^Distance from Nearest Well F F F F F F
4-ISC)Distance from Lake or Stream F F F F F F
n VDistance from Occupied Building F F F F F F
/LhDistance from Property Line F F F F F F
Distance from Bottom to Water Table 3 3FFFFF F
Inspector’s Comments:
r a-l- ('i^,f ?
19 ^ 'Date of Inspection.
2 i o oTime of Inspection M
-I
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
F = Linear Feet
Job Title
• I
MKL ' 032085 • Backer Agency
..
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CERTIFICATE OF COMPLIANCE
SEWAGE SYSTEM i#;m i„„>-tpf./KiCSt-
lilth / 9-714.r/j/s certificate has been issued this day of:i Janus py-
&♦ Jto certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.l^-
r>Hi.
rThe premises covered by this certificate are legally described as:V
&Lake No. 56-2U3 Twp. 135 Range UOSec___1 Dead Lake!■■Twp. Name.
p£/
p!»,#
i ‘*1^
Cozy Cove Resort
G.L. I4 & 5
S-7.m
rf
Michael MitchellW-M)Owner: Name.
w•W.
€1 Route #1, Box ^6, Dent, MinnesotaAddress.mi Wi
-trW^6^?8Zip No.i&.&%
Malcolm K. Lee, Shoreland Administrator
861|Permit No. SP_
Signed by:.tOtter Tail County, Minnesota
m MKL-087 1-009'7
®159035 '"^19* tukOltii 4 ce. MiNTCM. rckou* «im
%
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
Yelow — Inspector
Pink — Owner fcard — Owner
Co^y Coi/<- R
(^L- ‘tfT S'^c/
■re<^ OT Permit No..LEGAL
/bDate
DESCRIPTION
AND
I— J3-£ ^0 Lo5^'*'2. v/3 r (\LOCATION
Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
First Initial Mailling Address ;^No- Street, City and State_______________A I i9v n ^Last Name Zip No.Tel. No./K] /ic^ae j
OWNER
SEWAGE
SYSTEM
INSTALLER
Name /VI C
This System will be ready for inspection on.19.
This space for office use oniy
19 ,M
Date Rac'd Time Rac'd Phone Call Rac'd By Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
^SCQ GIs.'^10 0 Sq. Ft.Sq. Ft.Capacity
T'5~0 Ft.Ft.Ft.Distance from nearest well
f^5* Ft.iTVDistance from lake or stream Ft.Ft.
2-0 Ft.*T~t)Distance from occupied building Ft.Ft.
/ bDistance from property line Ft.Ft.Ft.
/OFt.Ft.Distance from bottom to Water Table Ft.
All distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19 , Time ,M By
L19 2.^.....
. 19
PERCOLATION TEST DATA: Date of First Test.....Rate
Q.
nest Taken By
2.1....IS'-'Date of Second Test Rate
1st
_P //First Test + 2nd Test y' =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 sUaT^be covered uri>i
responsibility of the applicant for the permit to notify the County Shoreland Management tiwt thajob is re
^as been inspected and accepted. It shall be the
for inspection. (Call or use attached mailer notice.)
/ f -J-l.--? 3,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 expressPermit:
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.
//) ~ ^ 6 -7 ?
r. 0 0
0.^Issued Date:4“
Shoreland Managemgifn Office
• rz)
7 It
Fee $Surcharge $
MuU Pel J-e rComments:.>lr\ i A <>
Form No. MKL-0771-003 @ viCTO* umetcn » c«..,m»lSS906
PERCOLATION TEST DATA Price $1.00 per pad.
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537 Ph. No.
Owner:/y) irc/frS^Li-,
7 Last Name
Mailing Address:
/h Pi^o ^1 -By ^6?/y
First Zip No.Middle St. & No.City State
Legal
Description:L /3S"
SEC. TWP.TWP NAMENAMERANGELAKE OR RIVER NO.
^oat lo-r ^
TEST HOLE NO. 2TEST HOLE NO. 1
3 C>
Depth to Bottom of Hole inches; Diameter of Hole.inchesDepth To Bottom of Hole,inches; Diameter of Hole inches
- .2.^/e> -23 2^Depth, Inches Soil Texture Soli TextureDepth, InchesDate.19 19>ate
/ - />^J -/^Percolatio
Test By__
Percolation
Test By .b r^'3C/V 'dC //LUFirmName.Firm
Name.
CC
DaLU
IT
Tt/^A LU-Address.GC Address2<
if)Otter Tail County License No..Otter Tail County License No..HcoLUMeasurement,
Inches Depth in Water
Level, Inches
Measurement,
Inches
H Depth in Water
Level. Inches
Time Remarks Time Remarks
O
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See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn.
MKL-0871-028i«gi79 ®riCTo* LuNee<N « CO pmiiTia*. rc««us rAi.i.o. hh>«.
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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
f^nk — Owner Card Owner
V ;r ^ /C o ^ y ^ t.
Gc- ^ ^ r
f" C 0 / ''Permit No..LEGAL ? r/C'/b ^« c Date/DESCRIPTION
AND
/•\6-J JJ /n-L /' ,•LOCATION /jr
Lake Classif.Sec.Lake No. Lake Name TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
First Initial Mailling Address —No. Street, City and State Zip No.Tel. No.Last Name
//V .i h''OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for inspection , 19.on.
This space for office use only
,M.19
Date Rec'd Phone Call Rec'd ByTime Rec'd Owner or Agent Signa;ture
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PITSEPTIC TANK DRAIN FIELD
L ,i ■> yj 6' 6' GIs.a Sq. Ft.Sq. Ft.Capacity
7't-Ft.Ft.Ft.Distance from nearest well
f
b\Ft.Ft.i Ft.Distance from lake or stream
Ft.Distance from occupied building Ft.Ft.
Distance from property line Ft. Ft.Ft.
Ft.Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
tRECORD OF TESTS:i
Inspection was made on ..... 19
f U ' 5“
, Time ,JVI By j
j/PERCOLATION TEST DATA:Date of First Test , 19
. i9...yy
, Rate !
/Date of Second Test , Rate
1st Test Taken By
/!/iFirst 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
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.
' -- ; c
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
Issued Date;
Shoreland Management Office
^ 0I '0 r G b' 0 0 pjiFee $Surcharge $
i./>// o<•C <?.Comments:,i ]■CERTIFICATE__■'i
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I158906Form No. MKL-0771-003 viCToa LUHficCN t eo . fumtim. rinvus f*ll8. himii
INSPECTION RESULTS
Inspector must make all measurements
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is
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY
Actual Should be Actual Should be Actual Should be
Capacity 9dn GIs.GIs.S F F S F
50Distance from Nearest Well 2^13aFF F F
Distance from Lake or Stream F F F F F
Distance from Occupied Building ^4-f10 20
n
F F F F
Distance from Property Line 10 F 10FFF F
Distance from Bottom to Water Table 4FFFF F
Inspector's Comments:
/
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/
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/4 19_2JDate of Inspection
3’ :oaTime of Inspection,i
rjfA 0-j/>\r
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
» Linear Feet
Job TitleF
Agency
M KL-0771-003-Backer
T
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