HomeMy WebLinkAboutGeorge Gerlach Et Al_56000990356000_Septic System Permits_Department of
LAND AND RESOURCE MANAGEMENT
OTTER TAIL COUNTY
Government services Center - 540 West Fir
Fergus Falls. MN 56537
Ph: 218-9S8-SOS5
OTTER Tail County's Website: www.co.otter-tail.mn.us 0 2 20/5
Otter Tail County Compliance Inspection Form AddenduWNo&FseoupQg
This form is a required attachment to MPCA Compliance Inspection Form for all Existing Subsurface Sewage
Treatment Systems in Otter Tail County as of June 1,2011.
Property Information
S^OOO^^Ol^7Qoo/^oob/^oO
Township; 5\4ar
(Sgofy f^grl<^cir\
Property Address: 'Ill'll Rc^y Tr|. MV S^S
Reason for Inspection: F^rmi' 4"
Number of Bedrooms:
In Shoreland Area?
Lake/River Name, Number, & Class
OTTCR TRK
e o
Parcel Number;
Section:
Property Owner Name(s);
:z □Yes No
System Compliance Status; ^ Compliant
^ Non-Compliant
XDoes the soil treatment area have less than 3 feet of vertical separation?
Is the septic tank located less than 50 feet from any well?
Is the soil treatment area located less than 50 feet from any deep well?
Is the soil treatment area located less than 100 feet from any shallow well?
Does any part of the septic system fail to meet the minimum OHWL setback
requirements for the public water classification?
Yes No
XYes No
XYes No
XYes No
XYes No
'Yes" indicates that the system is failing to protect ground water
and is noncompliant. If "Yes", describe the condition noted:
Required Attachments: System drawing to scale on next page.
Completed MPCA Compliance Inspection
I hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of
future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system,
inadequate maintenance, or future water usage.
Name;Phil Stoll
Certification Number;7526
Business License Name & Number;
Signature;
Stoll Inspections 2982
^-?HSDate;
Excel/Compliance Form forOTC 1/15/2014 Page 1 of 2
Otter Tail County Compliance Inspection Form Addendum (cont.)
*yiQ loooJ^iGOOI ^OQParcel Number: _
Date & Initial: ^C>\\
System Drawing
The system drawing must be to scale and include all septic/holding/lift tanks, drainfields, wells within 100 feet of system (indicate depth of
weils), dwelling and non-dwelling structures, lot lines, road right-of-ways, easements, OHWLs, wetlands, and topographic features (i.e. bluffs).
^5'
•s5
Cgry^j^ljc.'^ceAdditional Comments:»A
Excel/Compliance Form for OTC 1/15/2014 Page 2 of 2
Compliance Inspection FormMinnesota Pollution
Control Agency
520 Lafayette Road North
St. Paul, MN 55155-4194
Existing Subsurface Sewage Treatment Systems (SSTS)
Doc Type: Compliance and Enforcement
For local tracking purposes:Inspection results based on Minnesota Pollution Control Agency (MPCA)
requirements and attached forms - additional local requirements may also apply.
Submit completed form to Local Unit of Government (LUG) and system owner
within 15 days
System Status
System status on date (mm/dd/yyyy): 8/31/2015
O Noncompliant - Notice of Noncompliance
(See Upgrade Requirements on page 3.)
^ Compliant - Certificate of Compliance
(Valid for 3 years from report date, unless shorter time
frame outlined in Local Ordinance.)
Reason(s) for noncompliance (check all applicable)
□ Impact on Public Health (Compliance Component #1) - Imminent threat to public health and safety
□ Other Compliance Conditions (Compliance Component #3) - Imminent threat to public health and safety
□ Tank Integrity (Compliance Component #2) - Failing to protect groundwater
□ Other Compliance Conditions (Compliance Component #3) - Failing to protect groundwater
□ Soil Separation (Compliance Component #4) - Failing to protect groundwater
□ Operating permit/monitoring plan requirements (Compliance Component #5) - Noncompliant
Property Information
Property address: 31179 Star Bay Trail, Dent MN 56528
Property owner: George Gerlach__________________
Parcel ID# or Sec/Twp/Range: 56000990357000-6000-5000
______________Reason for inspection: Permit_________
______________ Owner’s phone:
or
Representative phone: _______________
Regulatory authority phone: 218-998-8095______
Brief system description: 1000 gal, concrete tank +1000 gal, concrete tank to 500 gal. Lift to 900 sq. ft. Pressure Bed. 20* x 45'
Comments or recommendations:
Owner’s representative: _______________
Local regulatory authority: Ottertail County
Certification
/ hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No
determination of Mure system performance has been nor can be made due to unknown conditions during system construction,
possible abuse of the system, inadequate maintenance, or future water usage.
Inspector name: Phil Stoll
Business name: Stoll Inspections
Inspector signature:
Certification number: 7526_______
License number: 2982_______
Phone number: 218-839-1849
Necessary or Locally Required Attachments
□ System/As-built drawingS Soil boring logs
□ Other information (list):
E Forms per local ordinance
www.pca.state.mn.us • 651-296-6300 • 800-657-3864
wq-wwists4-31 • 3/16/12
TTY 651 -282-5332 or 800-657-3864 • Available in alternative formats
Pose 1 of 3
Inspector initials/Date; PJS | 8/31/2015Property address: 31179 Star Bay Trail, Dent MN 56528
(mm/dd/yyyy)
1 ♦ Impact on Public Health - Compliance component #1 of 5 >:
Verification method(s):
^ Searched for surface outlet
^ Searched for seeping in yard/backup in home
□ Excessive ponding in soil system/D-boxes
Q Homeowner testimony fSee Comments/Explanation)
□ “Black soil” above soil dispersal system
□ System requires “emergency” pumping
□ Performed dye test
C] Unable to verify (See Comments/Explanation)
□ Other methods not listed fSee Comments/Explanation)
Compiiance criteria:
□ Yes S NoSystem discharges sewage to the
ground surface.____________.
System discharges sewage to drain
tile or surface waters.
□ Yes S No
□ Yes S NoSystem causes sewage backup Into
dwelling or establishment.
Any “yes” answer above indicates the
system is an imminent threat to public
health and safety.
Comments/Explanation:
2. Tank Integrity - Compliance component #2 of 5
Verification method(s):
S Probed tank(s) bottom
^ Examined construction records
□ Examined Tank Integrity Form (Attach)
□ Obsen/ed liquid level below operating depth
□ Examined empty (pumped) tanks(s)
S Probed outside tank(s) for “black soil”
□ Unable to verify (See Comments/Explanation)
□ Other methods not listed (See Comments/Explanation)
Compiiance criteria:
□ Yes S NoSystem consists of a seepage pit,
cesspool, drywell, or leaching pit.
Seepage pits meeting 7080.2550 may be
compliant if aliowed in iocai ordinance.
Sewage tank(s) leak below their
designed operating depth.
If yes, which sewage tank(s) leaks:
□ Yes Kl No
Any “yes” answer above indicates the
system is failing to protect groundwater.
Comments/Explanation:
3» 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* 0 No □ Unknown
*System is an imminent threat to pubiic heaith and safety.
Explain:
c. System is non-protective of ground water for other conditions as determined by inspector. □ Yes* S No
*System is faiiing to protect groundwater.
Explain:
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wq-vmists4-31 • 3116/12
Inspector initials/Date: PJS | 8/13/2015Property address: 31179 Star Bay Trail, Dent MN 56528
(mm/dd/yyyy)
4. Soil Separation - Compliance component #4 of 5
□ UnknownDate of installation: 10/4/2000
(mm/dd/yyyy)
Shoreland/Wellhead protection/Food beverage ^ yes □ No lodging? ^ ^
Verification method(s):
Soil observation does not expire. Previous soil
observations by two independent parties are sufficient,
unless site conditions have been altered or local
requirements differ.
0 Conducted soil observation(s) (Attach boring logs)
Q Two previous verifications (Attach boring logs)
□ Not applicable (Holding tank(s), no drainfield)
Q Unable to verify (See Comments/Explanation)
O Other (See Comments/Explanation)
Compliance criteria:____________
For systems built prior to April 1, 1996, and
not located in Shoreland or Wellhead
Protection Area or not serving a food,
beverage or lodging establishment:
Drainfield has at least a two-foot vertical
separation distance from periodically
saturated soil or bedrock.
□ Yes □ No
I Vt.
E Yes □ No Comments/Explanation:Non-performance systems built April 1,
1996, or later or for non-performance
systems located in Shoreland or Wellhead
Protection Areas or serving a food,
beverage, or lodging establishment:
Drainfield has a three-foot vertical
separation distance from periodically
saturated soil or bedrock.*
H|4 Wi
0^10 Y
□ Yes □ No Indicate depths or elevations“Experimental’’, “Othef, or “Perfonvance"
systems built under pre-2008 Rules; Type IV
or V systems built under 2008 Rules (7080.
2350 or 7080.2400 (Advanced Inspector
License required)
Drainfield meets the designed vertical
separation distance from periodically
saturated soil or bedrock.
26"A. Bottom of distribution media
>62"B. Periodically saturated soil/bedrock
>36"C. System separation
36"D. Required compliance separation*
"May be reduced up to 15 percent if allowed by Local
Ordinance.Any “no” answer above indicates the system is
faiiing to protect groundwater.
5. Operating Permit and Nitrogen BMP* - Compliance component #5 of 5 ^ Not applicable
□ Yes S No If “yes”, A below is required
□ Yes S No If “yes”, B below is required
Is the system operated under an Operating Permit?
Is the system required to employ a Nitrogen BMP?
BMP = Best Management Practice(s) specified in the system design
If the answer to both questions is “no”, this section does not need to be compieted.
Compliance criteria
a. Operating Permit number;
Have the Operating Permit requirements beeti^niet?
b. Is the required nitrogen BMP injiace and properly functioning?
Any “no” answer indicates Noncompliance.
□ Yes □ No
□ Yes □ No
Upgrade Requirements (Minn. Slat §115.55) An imminent threat to public health and safety (ITPHS) must be upgraded, replaced, or its use
discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance. If the system Is failing to protect
ground water, the system must be upgraded, replaced, or its use discontinued within the time required by local ordinance. If an existing system
is not failing as defined in law, and has at least two feet of design soil separation, then the system need not be upgraded, repaired, replaced, or
Its use discontinued, notwithstanding any local ordinance that is more strict This provision does not apply to systems in shoreland areas, Wellhead Protection Areas, or those us^ in connection with food, beverage, and lodging establishments as defined in law.
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wq-wwists4-31 • 3/16/12
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CERTIFICATE OF APPROVAL
SEWAGE SYSTEM
i*COLLECTOR SYSTEM
J'/This certifies that as of the 12th of February, 2001, the sewage treatment
system serving the following described property is compliant with the
provisions of the Sanitation Code of Otter Tail County.WM
LOTS 3,4 & 5 BLK 2
PEACH'S SHADY SHORE mM
iM
d
Parcel Number(s): 56000990355000,0356000 & 0357000
Section: 03 Township: 135 Range: 041 Township Name: STAR LAKE
Lake Number: 56-385 Lake Name: STAR
mCurrent Property Owner: GEORGE J GERLACH ET AL
Number of Bedrooms: 7 (3 DWELLINGS-2 W/3BR & 1 W/IBR)M.
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284.709 * Viciof Lundeen Co.. Ptimers * Fergus Falls. MN ■ 1-800-346-4670
RECc?VED
February 7,2001 FEB 1 2 2001
Pat LAND & RESOURCE
Land and Resource Management
121 West Junius
Suite 130
Feigus Falls, MN 56537
Dear Pat,
I am writing to respond to your telephone call of today regarding our lake property on Star Lake, Dent MN in
Ottertail County. We have three cabins located on lots 1,2,3,4,and 5 of Peach’s Shady Shores Addition on Star
Lake. You requested to know the number of bedrooms in each cabin. You requested this information to
determine if the sewer system we had installed at the county’s direction last summer was sized correcdy. You
asked that I provide my response in writing for your file.
The cabin located on lot 2 is a three-bedroom cabin with one bathroom. The cabin located on lot 3 is a three-
bedroom cabin with one bathroom. And, the cabin located on lot 5 is a one-bedroom cabin with no running
water, no bathroom, and no permanent electrical hookup We use it occasionally as a guest-house. When it is
used, they need to use the bathroom in one of the other cabins.
The cabins on lots 2 and 3 are serviced by a deep well (about 50 ft) located on the line between lots 4 and 5.
It is my understanding from both the well contractor (Antonson Well Drilling) and the sewer contractor (Dan
Barry Excavating) that all the minimum set back, distance requirements and regulations were met
It is also my understanding that aU this work had to be and was permitted and inspected by your office. It is
disconcerting that there were unanswered questions at this late date after the work is completed and the
contractors paid.
I hope this information is what you needed to complete yoiu: file. If you require more information or have
more questions, feel free to call
Sincerely,
George Gerlach
(jCdcuA ^ kc,
^ ^ ^
I
Minnesota Well and Boring
Sealing No.
Minnesota Unique Well No.
or W-series No.
Uank I net kncwi^
MINNESOTA DEPARTMENT OF HEALTH H 171557WELL OR BORING LOCATION WELL AND BORING SEALING RECORDCounty Name
Townstu^Tjame
r ^ -C,
Minnesota Statutes. Chapter 1031. I
Township No Range No Section No Fraction ism ■* ig ) Date Sealed Dale Well or Boring ConsiructeO
3_\3'IkI W/H
Numerical Street Address or Fire Number and City of Well or Boring Location VDepth Before Sealing Original DepthU~i__^
Show exact location of w'ell or boring
in section grid with 'X'
y I ^
Skefch^map of well or boring
location, showing property
lines, roads, and buildings
f-
AQUIFER(S)
I Single Aquifer Q MuHiaquiter
ELL/BORING
Water Supply Well D Monit. Well
Env Borehole D Other___
STATIC WATER LEVEL
D Measured EstimatedT
h-//ft D below D above land surfacePL-"T"”1 CASING TYPE(S)T a o
1 ( / L^^U. I ^
w
H Steel G Plastic Q Tile Q Other
CASINQ(S)
Diameter Depth
C2_ K.2J- t.Set in oversize hole'’Annular space initially grouted?
D Yes D No Q Unknown
-/ [ilSh/□ Yes □ Noin from1 mH»
G Yes G No G UnknownG Yes □ Noin fromPROPERTY OWNER S NAME ft.to
r --------------------------------------------------Propel owneiis rr\aiiing address if different than well location address irKlicated above.Q No Q UnknownG Yes□ Yes □ Noin. from ft.to
SCREEWOPEN HOLE
/
Screen from ft. Open Hole from ft.to to
OBSTRUCTIONS
Q Rods/Drop Pipe □ Check Valve(s) □ Debris □ FillWELL OWNER'S NAME ^^^^Obstruction
WeH owr>er'$ mailir>g addreM if different than property owner's address indicated above Type of Obstructions (Describe)
Obstructions removed? D Yes Q No Describe
PUMP
Type
G Removed Not Present G OtherHARDNESS OF FORMATtONGEOLOGICAL MATERIAL COLOR TOFROM
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS. OR CASING AND BORE HOLE:
□ No Annular Space Exists
□ Annular space grouted with tremie pipe
□ Casing PorforationMemovak
If rtot known, irxlicata estimated formation log from nearby well or boring.
Q RemovedG Perforatedin. from to ft.
D Perforated Q Removedin. from ft.to
Type of perforatr
D Other
(One bag of cement ■ 94 lbs., one bag of bentonite « 50 fbs.)GROUTING MATERIAL(S)
to P / ft.
Grouting Material from yards bags
from ft.10 yards bags
from ft.to yards bags
from ft.to yards bags
REMARKS. SOURCE OF DATA. DIFRCULTIES IN SEALING OTHER WELLS AND BORINGS i
Other unsealed and unused well or boring on property,? G Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or bonr>g was sealed in accordar>ce with Minnesota Rules. Chapter 4725 The information contained m this report is
true to the best of my knowledge.C\£ .
Contractor Busirtes^Nama \r-H»gistratK>n tiio.
X 10/DEC 1 2 2000 -j-f License or
\
land & fD-.:rJoRCE /^jufhon/ad ifuire’Date
(II
f '-y.■i-. ,Ja )Ptiame of Person Seating WeH or BoringH171557local COPV
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
Sealing No
Minnesota Unique No
or W-series No
(Leave tXank ■( not known)
H 156898WELL OR BORING LOCATION WELL AND BORING SEALING RECORDCounty Name ^
'(yl- hr : I Minnesota Statutes, Chapter 1031
Township Name Township No.Range No Section No Fraction (sm Ig )
... !•
Date Sealed Date Well or Boring Constructed
/oL ^ Ih'lL '
Numencal Street Address or Fire Number and City of Well or Boring Location
L ~ I I h' ■, . hikiL Depth Before Sealing Original Depth
Sketch map of well or boring
location, showing property
lines, roads, and buildings.
STATIC WATER LEVELShow exact location of well or boring
in section gnd with 'XV
AOUIFER(S)
[J Single Aquifer Q Multiaquifer
Q Measured ^^siimatedWELL-BORING
Q Water Supply Well CD Monit Well
Q Env. Bore Hole Q Other____ft ^s.^low G above land surface
T CASING TYPE(S)W
--i-^ Steel Q Plastic □ Tile Q Other
....t-CASING
Diameter Depth Set m oversize hole‘s Annuaiar space initially grouted'^
□ Yes □ No □ Unknown
S (2.h □ Yes □ Noin. from ft.to1
G No G UnknownG YesQ Yes □ Noin. from ft.toPROPERTY OWNER S NAMECut/- \ t h2r .Q Yes Q No Q Unknown□ Yes □ NoProperty owrtei't mailing address if different than wen location address indicaied above in. from ftto
f it h!
SCREEN/OPEN HOLE
G -'V/
^ f ft. Open Hole fromScreen from to ft.to
OBSTRUCTIONS
O Rods/Drop Pipe D Chock Valve(s) D Debris Q Fill ObstructionWELL OWNER’S NAME
WeH owner's rnaikr>g address if different than property owr>er’$ address indicated above.Type of Obstructions (Describe)_________________
Obstructions removed? □ Yes D No Describe
PUMP
Type----------
D Removed ^N^ot Present Q OtherHARDNESS OF FORMATIONGEOLOGICAL MATERIAL COLOR FROM TO
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS. OR CASING AND BORE HOLE:
EH No Annular Space Exists
[H Annular space grouted with tremie pipe
1 n Casing Perforation/Remwa!
If not known, ktdicate estimated formation log from r>aart>y well or boring
G Perforated Q Removedin. from ft.to
G Perforated O Removedin. from ft.to
Type of perfor^
Q Other
Z GROUTING MATERIAL($)
/Ji' k I, i 0Grouting Material It.bagsto __yardszl/'^l ft.from yards bagsto
ft.yards bagsto
from ft.to yards bags
REMARKS. SOURCE OF DATA. DIFFICULTIES IN 8EAUNQ OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? O Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules. Chapter 4725. The information contained in this report is
true to the best of my knowledge.
DfC 1 2 2000 \A/(ll jyM,
License or Regrafraaon Aio.Contractor BusinessWeme .oland & RESOUiRCE \
~yiutpOfU»d Repraseqtt^.^ignatun
J /'n/'i'i !■
Date
H 153898 Name o/ Parson Sealing Wat or Boring
LOCALCOPY
8/98 RHF-nid.'td-na
Co
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
121 W. JUNIUS AVE. • SUITE 130
Phone:(218) 739-2271 • FERGUS FALLS, MN 56537
WHITE - Office
YELLOW -L&R Inspector
PINK - Owner / Contactor
/3 7 ¥3Permit No.PLEASE PRINT OR TYPE ALL INFORMATION
TWP NAMERANGELAKE/RIVER
CLASS
SECTION TWP NO.LAKE/RIVER NAMELAKE NUMBER
3S' I 3O r/E-911 ADDRESSPARCEL NUMBER (S)
/c /'T-ooc
LEGAL DESCRIPTION^^ ^ '7S- ^
Daytime Phone No.Initial Mailing AddressLast Name First
Property
Owner
PA/^ 6A^A^Contractor
Lie.#2----6ra-^
A.M.
PM.., the year of .at.>• This System will be ready for inspection on.
This space for office use oniy
A.M. P.M.
L&R OfficialTime ReceivedDate Received
SEWAGE TREATMENT SYSTEM DATA; MINIMUM REQUIREMENTSTYPE OF INSTALLATION('^^ystem DRAINFIELDTANK
^7/<77, 00 o GIs.Size( 2 ) Holding Tank (Alarm Required)
Q3<(Septic Tank
pi^Lift Station (Alarm Required)
rainfield
( A ) Trenches, Rock
( C ) Trenches, Graveless ( D ) Mound
( E ) Trenches, Chamber ( F ) At-grade '^^^Collector
^ ( 7 )^uthouse
( 8 ) Greywater System
( 9 ) Sewer Line
( 10 ) Performance
(11) Other
Ft.Setback to nearest well
OHWL river, wetland)Ft.Ft.Setback to
730/ O Ft.Ft.Setback to dwelling
Ft.Ft.Setback to non-dwelling
Ft.Ft.Setback to property line
Ft.Ft.Elevation above water table (OHWL)NA:z# Bedrooms
Garb. Disp. Y
Abatem^^fT"^ N z Ft.NA Ft.Depth to restrictive layer in soil
ABSORPTION AREA FOR MOUNDS/JffrG^ADES
(ATTACH DESIGNJfliDRKSlHEETS)
( ) GravityEFFLUENT
DISTRIBUTION
Ft^WATER WELL DEPTH HOLDING TANK
MONITOR/DISPOSAI RACT
Designer
Designer Lie. # f'
PERCOLATION
TEST DATA( )Y^
No - L & R Can Not Process f/^T/oo Highest RateDate of Test
Agreement: The undersigned hereby makes application for permit to instail, alter, repair or extend Sewage Treatment System herein specified, agreeing to do all
such work in strict accordance with Sanitation Code of Otter Tail County, Minnesota. Applicant agrees that the Site Data Worksheet submitted herewith and which is
approved by a Land & Resource Management 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 approved for use. If shall be the responsibility of the applicant for the permit to notify Land & Resource Management that the installation is
ready for inspection.
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 Sanitation Code of Otter Tail County,
Minnesota. This permit may be revoked at any time upon violation of the Sanitation Code.
NOTE: This permit is vaiid for a period of six (6) months.
yes'/ a
Date:
oi Property Qyffiweiy^g/Mt for OwnerSigi
Date:
Land & Resource Management Office-3^r-PERMIT FEE $RECEIPT NO.
Comments:
Form No. BK — 1099-003 301,772 • Victor Lundeen Co.. Printers • Fergus Falls. MN • 1-800-3^6-4870
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
121 W. JUNIUS AVE. • SUITE 130
Phone: (218) 739-2271 • FERGUS FALLS, MN 56537
WHITE - Office
YELLOW- L & R Inspector
Pif'JK - Owner / Contactor
/Permit No. f ^PLEASE PRINT OR TYPE ALL INFORMATION
TWP NAMELAKE/RIVER
CLASS
SECTION TWP NO.
/Jr
RANGELAKE NUMBER LAKE/RIVER NAME
3 V/O
E-911 ADDRESSPARCEL NUMBER (S)
OOPOAT ) -Quo) P
LEGAL DESCRIPTION
/-crSt-7. X r' /
Daytime Phone No.Mailing AddressLast Name First Initial
yjc// c7 c o/<^Qy / < /Ju /Uf_________Property
Owner
3'^^ z V
p! ^ \ PP~~Contractor
Lie.#0
y -zy-2
the year of at>• This System will be ready for inspection on.
This space for office use only /O/B/dO.
i / /
A.M.IfficialTime ReceivedDate Received
SEWAGE TREATMENT SYSTEM DATA; MINIMUM REQUIREMENTSTYPE OF INSTALLATION DRAINFIELDTANK(r System
O Ft"GIs.Size{ 2 ) Holding Tank (Alarm Required)
Septic Tank
(^ Lift Station (Alarm Required)
(,9^)^ Drainfield
( A ) Trenches, Rock
r o Ft. Ft.Setback to nearest well
u/ V . -
Setback to OHWL (flake, river, wetland)Ft.Ft.r^o
/ A f .M f
■^B) Seepage Bed
( C ) Trenches, Graveless ( D ) Mound
/ C Z Ft.Ft.Setback to dwelling
Ft.Ft.Setback to non-dwelling
,( E ) Trenches, Chamber ( F ) At-grade
yA) Collector
‘ ( 7 ) Outhouse
( 8 ) Greywater System
( 9 ) Sewer Line
(10) Performance
(11) Other
Ft.Ft.Setback to property line
Ft.Ft.Elevation above water table (OHWL)NA
# Bedrooms
Garb. Disp^.X.,A4SJ
Abatement YZ N z Ft.Ft.NADepth to restrictive layer in soil
ABSORPTION AREA FOR MOUNDS / AT-GRADES
(AHACH DESIGN WORKSHEETS)
( ) Gravity
^>4 Pressure
EFFLUENT
DISTRIBUTION
.Ft^WATER WELL DEPTH HOLDING TANK
MONITOR/DISPOSAL CONTRACT
( )Yes - ' ^
No - L & R Can Not Process
Designer
Designer Lie. #
PERCOLATION
TEST DATA
f/2 / DHighest RateDate of Test
Agreement: The undersigned hereby makes application for permit to install, alter, repair or extend Sewage Treatment System herein specified, agreeing to do all
such work in strict accordance with Sanitation Code of Otter Tail County, Minnesota. Applicant agrees that the Site Data Worksheet submitted herewith and which is
approved by a Land & Resource Management 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 approved for use. It shall be the responsibility of the applicant for the permit to notify Land & Resource Management that the installation is
ready for inspection.
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 Sanitation Code of Otter Tail County,
Minnesota. This permit may be revoked at any time upon violation of the Sanitation Code.
NOTE; This permit is vaiid for a period of six (6) months.
2Date:
/Signatare of Property Oirfnwer/Ag^t for Owner
Date:
Manfgement OfficeLand & Resource
/^ 7^JPERMIT FEE $RECEIPT NO. _/
Comments:
orm No. BK — 1099-003 301.772 • Victor Lundeen Co.. Printers • Fergus Fells, MN • 1-800-346-4870
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SEWAGE TREATMENT SYSTEM PERMIT
INSPECTION RESULTS
Inspector must make all measurements
HOLDING
SEPTIC TANK OUTHOUSEDRAINFIELDLIFT TANKCATEGORY
/oe>o//odOCapacity Sox>9dd FT2FT2GLS.GLS.
^160 O FTSetback from Nearest Well '/'<o O ft 4- jOX) ft
Setback from Buried
Water Suction Pipe FT FT FT
Setback from Buried Pipe
Distributing Water Under Pressure 4 icro ^FT FT
4d0 Ah ifO ftSetback from Lake, Wetland or River OHWL 4-60 ft ■4~Ca O pq-
noUsil FTSetback from Dwelling -Hoc ftFT
Setback from Non-Dwelling FT FT FT
. FT pj
leis ^ J"3
Setback form Nearest Property Line FT
-F /■Elevation from Bottom to Water Table / Restrictive Layer FT FT FT FT
kiMdtns^ank/Uft-Atarm-NO I
Old System Pumped & Destroyed NO
SEPTIC TANK Sewer Line to Well Separation DRAINFIELD CALCULATIONFILTER
Actual Minimum VsManuf._
Model #
□ YES FTX
9DOFT20
MOUND CALCULATION
MOUND /AT-GRADE ROCK REDUCTIONInspector’s Comments:
Rr LeAyL fL-iy
CAicS .VcM (o ^
ABSORBTION AREA Rock trenches with inches
Ft. X of rock under pipe for .%
Ft2 DRreduction / equivalent tolA
pte/u UJS^ '/h" ^of€Ji 9 ‘
4i-.^AcJLi- -y'VS?
SKETCH:S ruy^S ^
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ICOO^A
E-€)tOOOj ^ Aoo Print Inspector's Name'■¥
i'y
t/crQ
A 4t4
Inspector's Signature
'1
trail Date / Time of InspectionIf***'
p;l ItT 1 □ Installation Approveda:4
L & R Official Initial / Date
SITE DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, MN 56537
OWMER:
FIRSf ' \)~MIDDLE TELEPHONE NUMBERLAST NAME
ADDRESS:
CITY ZIP CODESTATESTR./RT.
g»- ) 54ar L«k(,
LAKE/RIVER NO. ^ LAKE NAME
3 S''Afjr /_a/^
SEC.TWP RANGE TWP NAME
LEGAL DESCRIPTION:SOIL BORING LOG — Date
^
SZ ■'000 ^^9
COLOR &
MUNSELL NO.
DEPTH
(INCHES)TEXTURE STRUCTURE
iC^ y BLOCKY
PLATY
PRISMATICM-Ooo
Wz.PARCEL NUMBER
BLOCKY
PLATY
PRISNI^IC(NOI^>aiFIRE NUMBER
~7NUMBER OF BEDROOMS BLOCKY
PLATY
PRISMATICGARBAGE DISPOSAL: YES
ft.WELL CASING DEPTH:BLOCKY
PLATY
PRISMATIC
NONE
FLOODPLAIN: YES
VEGETATION: AQUATIC ERRESTRIAI
BLOCKY
PLATY
PRISMATIC
NONE
%SLOPE AT INSTALLATION SITE:
TYPE OF OBSERVATION: Probe Pit
s>PARENT MATERIAL:Outwash Loess Bedrock Alluvium COMMENTS:,
(9ORIGINAL SOIL:No
COMPACTED SOIL: Yes
DEPTH OF BORING:ft.
PERC TEST #2PERC TEST # 1 - TWO TESTS ARE REQUIRED -
INTERVAL (MINUTES)WATER DEPTH WATER DROP PERC RATEWATER DROP TIMEINTERVAL (MINUTES)WATER DEPTH PERC RATETIME
1151?l.-z-T
TIME DROP PERC
STARTSTART.1 u-.S’S o.TIME PERCDROP
WATER DROPINTERVAL (MINUTES)WATER DEPTH PERC RATEWATER DROPTIMEINTERVAL (MINUTES)WATER DEPTH PERC RATE 7 1REFILLREFILL
DROP PERC
7.
TIME gROP
£E?-Ltn-ifj PERCTIME
WATER DEPTH WATER DROP PERC RATETIMEINTERVAL (MINUTES)WATER DROP PERC RATETIMEINTERVAL (MINUTES)WATER DEPTH ilLL ....uyxfell,REFIU
TIME DROP PiRC TIME * DROP PERC
REFILL
15
WATER DEPTH WATER DROP PERC RATETIMEINTERVAL (MINUTES!WATER DROP PERC RATETIMEINTERVAL (MINUTES)WATER DEPTH
WVREFILLREFILL
TIME DROP PERC
INTERVAL (MINUTES)ERC RATE WATER DROP PERC RATETIMEWATER DEPTHWATER DROPTIMEINTERVAL (MINUTES)WATER DEPTH REFILLREFILL
TIME
TIME PERCDROPTIME^ERCDROP WATER^gROP PERC RATEINTERVAL (MINUTES)WATER DEPTHWATER DROP :RC RATEINTERVAL (MINUTES)WATER DEPTHTIME
REFILLREFia
TIME DROP PERCTIMEDROP»ERC
INTERVAL (MtNUTESi- ..^MWffgTTDEPTH WATER DROP PERC RATEWATER DROP PERC RATE TIMEINTERVAL (MINUTES)WATER DEPTHTIME
.LREFILL
TIME DROP PERCTIMEDROPPERC
WATER DROP PERC RATETIMEINTERVAL (MINUTES)WATER DEPTHINTERVAL (MINUTES)WATER DEPTH WATER DROP PERC RATETIME
REFILLREFILL
TIME PERCDROPTIMEDROPPERC
PROPOSED DESIGN:
X 7^PRESSURE DISTGRAVITY DIST..MOUND.HOLDING TANK.TRENCH.ATGRADE.BED.
SPECIFY:______________
— SYSTEM DESIGN ON BACK —
OTHER.SEWER LINE.OUTHOUSE.
-V
Systemrdesign rmust be to scaleran-d]^must~include~itherpropo^ed~rocatibhlorthe[s^ag^^ existl^/prpfposed-bu i Id i ng p ro|^tY|-l i the-pr|dinar'y- h|i^h -wat^-level-pf -the- wat^bpp^wlet a^^
and alljvWter v^ir^withirT lSQ' d!f ithe~^wage, system. |~ T
all
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inch(Ws)Tequals fe'ef SKETeH NG FORWi:odgrid(s)Sea equalse:I 1sS£C f
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