HomeMy WebLinkAboutHeavenly Days Resort_35000230205001_Septic System Permits_Department of
LAND AND RESOURCE MANAGEMENT received
APR 3 0 2014
land & RESOURCE
OTTER TAIL COUNTY
Government Services Center - 540 West Fir
Fergus Falls, MN 56537
PH; 218-998-8095
Otter Tail County’s Website: www.co.otter-tail.mn.us
Otter Tail County Compliance Inspection Form Addendum
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
Parcel Number;
Township: Lm'fi Lake________^3Section:
Property Owner Name(s): Lours
Property Address: />fA/5^sS7
Reason for Inspection: ___________
Number of Bedrooms: V
In Shoreland Area? No
Lake/River Name, Number, & Class (if applicable): Sh/Z/S Lec^1^
r^nK^ompliant
System Compliance Status: (circle on
Yes
Yes /@)
Yes
Does 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? Yes /(N^
Does any part of the septic system fail to meet the minimum OHWL setback
requirements for the public water classification?
Yes /(^)
"Yes" indicates that the system is failing to protect ground water
and is noncompliant. If "Yes", describe the condition noted:
srfzt^rO^
Required Attachments: System drawing to scale on next page.
Completed MPCA Compliance Inspection form, 1/24/12
1 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: gob ^o\Ce<___________
Certification Number:
Business License Name & Number: B0W9 Cen/7/P^.-e
Signature: QJtjLg Date:
Excel/Compliance Form for OTC 2/29/2012 Page 1 of 2
Otter Tail County Compliance Inspection Form Addendum (cont.)
Date & Initial:Parcel Number: '?S^oO'^'^OO.oG'C>00 1
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 wells), dwelling and non-dwelling structures, lot lines, road right-of-ways, easements, OHWLs, wetlands, and
topographic features (i.e. bluffs).
a
\
):U
&
0
Additional Comments:
Page 2 of 2Excel/Compliance Form forOTC 2/29/2012
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): V" ^
□ 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
Parcel ID#orSec/Twp/Range: S~’33 'R (3'B^
Reason for inspection:
Owner’s phone:
Property Information
Property address: 30(3 59
Property owner:
or
Owner’s representative: Representative phone:
Local regulatory authority: Regulatory authority phone: 99^^ 8095'
Brief system description: /51PO Conr ho
Comments or recommendations:
Certification
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.
Inspector name: _
Business name: _
Inspector signature:
^6 fee. ^Certification number: C 3397
License number:
Phone number: 5/^ ^^3
V
’C S-etri/ZC-^Id)
Necessary or Locally Required Attachments
O System/As-built drawingS Soil boring logs
□ Other information (list):
Q Forms per local ordinance
www.pca.state.mn.us • 651-296-6300 • 800-657-3864
wq-wwists4-31 • 3116112
TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
Page 1 of 3
M<S33^QQ99 CoiCi^i'V /Vt f-)f Inspector initials/Date:fi^|\ | 9~~ 30~~
' (mm/dd/yyyy)
Property address;
1. Impact on Public Health - Compliance component #1 of 5
Compliance criteria:Verification method(s):
0 Searched for surface outlet
S Searched for seeping in yard/backup in home
□ Excessive ponding in soil system/D-boxes
□ Homeowner testimony (See Comments/Explanation)
□ “Black soil” above soil dispersal system
D System requires “emergency” pumping
□ Performed dye test
Q Unable to verify fSee Comments/Explanation)
□ Other methods not listed (See Comments/Explanation)
□ Yes NoSystem discharges sewage to the
ground surface.______________
□ Yes BNoSystem discharges sewage to drain
tile or surface waters.
□ Yes El 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
Compliance criteria:Verification method(s):
S Probed tank(s) bottom
B Examined construction records
□ Examined Tank Integrity Form (Attach)
□ Observed liquid level below operating depth
B Examined empty (pumped) tanks(s)
□ Probed outside tank(s) for “black soil”
□ Unable to verify (See Comments/Explanation)
□ Other methods not listed (See Comments/Explanation)
□ Yes ONoSystem consists of a seepage pit,
cesspool, drywell, or leaching pit.
Seepage pits meeting 7080.2550 may be
compliant if allowed in local ordinance.
□ Yes I^NoSewage tank(s) leak below their
designed operating depth.
If yes, which sewage tank(s) leaks;
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* S No □ Unknown
b. Other issues (electn'cal hazards, etc.) to immediately and adversely impact public health or safety. □ Yes* 0 No □ Unknown
*System is an imminent threat to public health and safety.
Explain:
c. System is non-protective of ground water for other conditions as determined by inspector. □ Yes* 0 No
*System is failing to protect groundwater.
Explain;
www.pca.state.mn.us • 651-296-6300 • 800-657-3864
wq-wwistsA-31 • 3/16/12
TTY 651 -282-5332 or 800-657-3864 • Available in alternative formats
Poge 2 of 3
(I/I
Property address; S'OS^ A\/^ ^ Inspector initials/Date: \
' ^ ^ (mm/dd/yyyy)
5.f4. Soil Separation - Compliance component #4 of 5 ,>
Date of installatiori; //O '"^^97 □ Unknown
(mm/dd/yyyy)
Shoreiand/Wellhead prbtection/Food beverage lodging? I
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.
H Conducted soil observation(s) (Attach boring logs)
D Two previous verifications (Attach boring logs)
E] Not applicable (Holding tank(s), no drainfield)
n Unable to verify (See Comments/Explanation)
□ Other (See Comments/Explanation)
a!
□ Yes S No
Compliance criteria:
□ Yes □ NoFor 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:
1
Drainfield has at least a two-foot vertical
separation distance from periodically
saturated soil or bedrock.
oiackComments/Explanation: 0~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:I
Drainfield has a three^foot vertical
separation distance from periodically
saturated soil or bedrock.*
^Yes □ No
<’ ■
■:
“Experimental”, “Other", or “Performance"
systems built under pie-2008 Rules; Type IV
or V systems built under 2008 Rules (7080.
2350 or 7080.2400 (Advanced Inspector
License required) j
It
Drainfield meets the designed vertical
separation distance from periodically
saturated soil or bedrock.
□ Yes □ No Indicate depths or elevations
) ^ a loov'g.A, Bottom of distribution media
B. Periodically saturated soil/bedrock
C. System separation
/
D. Required compliance separation*
Any “no” answer above indicates the system is
failing to protect groundwater.
*May be reduced up to 15 percent if allowed by Local
Ordinance.
■i
5. Operating Permit and Nitrogen BMP* - Compliance component #5 of 5 IS Not applicable
'iIs the system operated under an Operating Permit?
'IIs the system required to employ a Nitrogen BMP?
BMP = Best f/lanagement Practice(s) specified in,the system design
fi
If the answer tojboth-questions is “no”, this section does not need to be completed.
I
Compliance criteria
□ Yes □ No If “yes”, A below is required
□ Yes □ No If “yes”, B below is required
a. Operating Permit number. _____________________
Have the Operating Permit requirements been met?□ Yes □ No
b. Is the required nitrogen BMP in place and properly functioning?
Any “no” answer indicates Noncompliance.
□ Yes □ No
■V
:1
Upgrade Requirernents (Minn. Stat. § 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 ihis 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 used in connection with food, beverage, and lodging establishments as defined in law.
651-296-6300 . 800-657-3864www.pca.state.mn.us •
wq-wwists4-31 • 3/16/12
TTY 651 -282-5332 or 800-657-3864 • Available in alternative formats
Page 3 of 3
..
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
WHITE — Office ■
Yellow — Inspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone:(218)739-2271 - FERGUS FALLS, MN 56537
TU)i5 5’-' ^ Tt
Go S
Permit No.LEGAL
DESCRIPTION Abatement; (AND
LOCATION
SECTIONLAKE NUMBER LAKE/RIVER NAME LAKE/RIVER RANGETWP. NO.TWP NAME
^3)
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
-13'C><^5-oiT) -f >95'- oo /
IDENTIFICATION: Please Print All Information
Mailin^Address — No.rstreel, City and StateLast Name First Irtltial Zip Code Telephone No.
{'ladOProperty
Owner 4 MaJ 1
(Sewage
System
Installer
Name
A.M.
This System will be ready for inspection on , 19.P.M.at
2This space for office use oniy
NUMBER OF BEDROOMS:
A.M.
19 P.M GARBAGE DISPOSAL: ( ) YES ( V) 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)
r> ) Drain field
TANK
m
lELD
l,&vDCapacity GIs.Sq Ft.
So .sv/mDistance from nearest well Ft.Ft.
71Distance from lake or stream Ft.Ft.a( ) Trenches
Bed
Mound
( ) Outhouse
( ) Sewer line
/5440Distance from building Ft. Ft.
10 LDistance from property line Ft. Ft.
Distance from bottom to Water Table ft.Ft.
EFFLUENT DISTRIBUTION
( ^ Gravity
(/T^essure
WATER VfeLL DEPTH
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:
Perc Tester,Date of Perc Test,
LiLiRate 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 ready for inspection.
^7DATE:VSig^uri
Permit: Permission is hereby granted to the above named applicant fo 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.
Issued Date:
I Land & Resource Management Office35^Fee $,Rec #.
Comments:
277,212 • Victor Lundeen Co.. Printers • Fergus Falls. MinneostaBK 0795-003
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM, ^ o «?1
^ ,4.
LAND & RESOURCE MANAGEMENT /yOTTER TAIL COUNTY COURT HOUSE (
Phone: (218) 739-2271 - FERGUS FALLS, MN 56537 W
WHITf — Office
Yellow — Inspector
Pink — Owner ’
khl 5 :5"^ Ft
fees
Permit No.LEGAL
x‘ 'JDESCRIPTION
Abatement: (AND 30 V U'LOCATION
LAKE/RIVER NAME
ied\
SECTIONLAKE NUMBER LAKE/RIVER
CL^S>
RANGETWP. NO.TWP NAME (73 IiH^dc U j L~.t
i.
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER-{ Joy 00 I
IDENTIFICATION; Please Print All Information
Last Name First initiai Mailing Address — Npj Street, City and StateIU'UiUlv Zip Code Telephone No.
u IProperty
Owner
i t ■i
"Y s I
Sewage
System
Installer
Name
5
A.M.yp-z-z -97This System will be ready for inspection on.. 19.P.M.at
tThis space for office use only
NUMBER OF BEDROOMS:
IZA.M.
\ ./P.M GARBAGE DISPOSAL: () YES ( y ) 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
(yd) Lift station (Alarm required)
( ) Drain field
( ) Trenches
( ) Bed
(J) Mound
( ) Outhouse
( ) Sewer line
TANK DRAIN FIELD
7 X Sq Ft.
of J--------
I-Capacity GIs.I -
5T>Distance from nearest well Ft.
iDistance from lake or stream Ft.Ft."7
tm70Distance from building Ft.Ft.
1LiDistance from property line Ft.Ft.J
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
!)
Jk. y/dh ojt 7 I ^-^17Perc Tester.Date of Perc Test.
i ■VIki!Rate of 1st Test Rate of 2nd Test Average Rate i
Agreement; The undersigned hereby makes appiication for permit to instaii or extend Sewage Disposai 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 for inspection.
/' ,/" / -7.. -77ZDATE:
Signaiufh
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.
U7A
Issued Date;
(50 Land & Resource Management Office
1Fee $.Rec #,
Comments:r
/1 4-
277.212 • Victor Lundeert Co.. Printers • Fergus Fells. MinneosiaBK 0796-003
J
r7 IT
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
9-
DRAIN FIELDHOLDING
SEPTIC TANK LIFT TANKCATEGORY Actual Minimum
j& GLS.5~ox> SFGLS.Capacity SF
/^r ft /&0 FTFT FTDistance from Nearest Well
Distance from Buried Water Suction Pipe FT FTFTFT50
Distance from Buried Pipe
Distributing Water Under Pressure FT FTFTFT10
1X5FT FT FTDistance from Lake or River (OHWL)FT
/r ft 10/20 FTFT FTDistance from Nearest Building
^ f FT FT FTFT10Distance from Nearest Property Line
L.3J5 FTFT FTDistance from Bottom to Water Tabie
3* "'5" 7^ T<x^/fES '/NOHolding Tank/Lift Alarm
/6^,NOOld System Pumped & Destroyed
DRAINFIELD CALCULATIONSewer Line to Well SeparationINTERPRETATION
OF ABBREVIATIONS
GLS. = Gallons
SF = Square Feet
FT = Linear Feet
FTXMinimumActuai
FTFT20 SF
Inspector’s Comments:
i
J
i
i
7
SKETCH:
hAJSP^
Inspector’s Signature
Date of Inspection
p-rtb
\Time oi InspectionRaasi'i;,. .. -V'-. •' /.
«
. S \JK^s^v*.ricr.■’.'•»a?1
"i?
'/j'li
CERTIFICATE OF APPROVAL
SEWAGE SYSTEM
'VP;p}^
fe-.W/
This Certificate has been issued this 2nd of December, 1997
certify that the sewage system installed as per Sewage Treatment System
Permit Number 11724 has been approved for use by Otter Tail County,
Minnesota.
, to m1mm*mm&m.t miM-t-The property served by this Sewage System is legally described as;¥1 ft
p;Lots 5 & 6 ex tr
Pt. GL 5
Section 23 - Leaf Lake Township
Section 23 - Leaf Lake Township
iMtimim'ASHimiR-
mParcel N\amber(^) : 35000230205000 35000230205001
Section; 23 Township; 134 Range; 038 Township Name; LEAF LAKE TOWNSHIP
Lake N\unber; 56-116 Lake Name; E LEAF
nmm m4if-;,5f ■; I
w.«
Current Property Owner; JACK L THOMPSON ET AL TRUSTEE
Number of Bedrooms; 4m
ma?
Land & Resource Management Official
Ti lA
mm
284.709 ■ Victor Lundoon Co. Printers * Fergus Falls. MN • 1-800-346-4670
SITE DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, MN 56537
OWNER:V
T r> n 0 /)/
LAST NAME FIRST MIDDLE TELEPHONE NUMBERi
ADDRESS:
Si S7JUBfifAl/A/ ^
^ CITYClR
STR./RT STATE ZIP CODEs^Asr~
LAKE NAME
/3/ Af l/Yh^uuLAKE/RIVER NO.SEC.TWP.RANGE TWP. NAME
LEGAL DESCRIPTION:SOIL BORING LOG
color;^
MUNSELL NO.
DEPTH
(INCHES)TEXTURE STRUCTURE
/sWS^5^/0 ''BLOCKY
PLATYS -^o o 6 ^ ^ 0 S e c9 c)THJM&'f 7i^'^iTS£SS.mePARCEL NUMBER
Lu rr/^ %01 AC/i' J/^Af BLOCKY
PLMYFIRE NUMBER .«giy^fu>
NUMBER OF BEDROOMS BLOCKY
PLATY
mSMATICIyyGARBAGE DISPOSAL: YES-
/Co 'plb Sf NON!iWELL CASING DEPTH:t.
block:\PLFLOODPLAIN; YES ttSMATIC
NONEVEGETATION: AQUATIC TERRESTRIAL
BLOCKY
PLATY
PRISMATIC
: . r'v NONE
SLOPE AT INSTALLATION SITE: 0 ^%
■J
TYPE OF OBSERVATION: Probe Pit i
f
PARENT MATERIAL: Till
No
-COMPACTED'SOILr^iYes
DEPTH OF BORING: / 'X-
Outwash Loess Bedrock Alluvium COMMENTS:,’i •
ORIGINAL SOIL:
ft.
PERC TEST #2PERC TEST # 1 - TWO TESTS ARE REQUIRED -
PERC RATEWATER DROPWATER DEPTH
TIME INTERVAL (MINUTES)WATER DEPTHPERC RATETIMEINTERVAL (MINUTES)WATER DROP^//g?START
..Aio?...k /j±a^-ijA3fc ^ i?-15.—A-TIME DROP PERCPERCTIMEDROP
WATER DROP PERC RATEINTERVAL (MINUTES)WATER DEPTHTIMEWATER DROP PERC RATETIMEINTERVAL (MINUTES)WATER DEPTH
tn
REFILLREFILL
^RO^P PERC^ME DROP PERC
.Aiif...x-I eTIME
PERC RATEWATER DEPTH WATER DROPTIMEINTERVAL (MINUTES)WATER DROP PERC RATETIMEINTERVAL (MINUTES)WATER DEPTH -7.^.f y-k-i.REFILLREFILL cy.fSJyO
E DROP PERC
= h S3t--tot TIMEPERCTIMEDROP
WATER DROP PERC RATEWATER DEPTHTIMEINTERVAL (MINUTES!WATER DROP PERC RATETIMEINTERVAL (MINUTES)WATER DEPTHHU Jj4..
—^-4^-61 H.i REFILLREFILL y -fuk
drop" PERC
^ '(>C= f/S
drop PERC
^;<fr 4ASA TIMETIME
WATER DEPTH WATER DROP PERC RATEINTERVAL (MINUTES)TIMEWATER DEPTH WATER DROP PERC RATETIMEINTERVAL (MINUTES!
----7-4-11^/5 3 REFILLREFIU4^-W’7.' D$' 0It PERCTIMEDROPTIME
WATER DROP PERC RATEWATER DEPTHINTERVAL (MINUTES)TIME WATER DROP PERC RATE TIMEINTERVAL (MINUTES)WATER DEPTH
-----7--^.
->/oS t! c y REFILLREFILL
r- ^p 7 CsitJukio...JJAl.\TIME DROP PERC
WATER DROP PERC RATEINTERVAL (MINUTES)WATER DEPTHPERC RATE TIMEWATER DROP-TIME INTERVAL (MINUTES)WATER DEPTH
watIr def^h
7ZiLlS.y.'i>Jus.REFILL /ok/ 7i^ /. Vi
TIME * DROP PERC
A^i ----7-4-TIME DROP PERC
WATER DROP PERC HATEINTERVAL (MINUTES)WATER DEPTHPERC RATE TIMEWATER DROPTIMEINTERVAL (MINUTES)REFIUREFIU
PERCTIMEDROPDROPPERCTIME
PROPOSED DESIGN:
PRESSURE DIST,GRAVITY DIST.HOLDING TANK.fATGRADE.MOUND.TRENCH
SPECIFY:.OTHER.OUTHOUSE.SEWER LINE.
— SYSTEM DESIGN ON BACK —
System design must be to scale and must include the proposed location of the sewage ^^ysteET, all
existing/proposed buildings, property lines, the ordinary high water level of the water body and all water
wells within 150' of the sewage system.
GRID PLOT PLAN
feet SKETCHING FORM/__grid(s) equals ^Jnch(es) equalsfeet, orScale:
SIGNATURE:SUBMITTED BY:
7-DATE:FIRM NAME:
/ ^^63 f MPCA LICENSE #:ADDRESS:
U-—■
/
LICENSE CATEGORY:.
\
\
<9
■ : '
i>
i-
■n
%
^ V
f CP t5^
—-
vn
1
11c
>1>>
N V sr \nN
____!-
>)\[
'T ■'
<
* ^ JL--------f4
/. i
yUP/L^
vn
\)
V IV'*'V
V •
• 1-800-346-4870BK— 0496— 029
0
PERCOLATION TEST DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, MN 56537
OWNER:
TELEPHONE NUMBERFIRSTMIDDLELAST NAME
ADDRESS:
CITY STATE ZIP CODESTR./RT.
SEC.RANGE TWP. NAMELAKE/RIVER NO.LAKE NAME TWP.
LEGAL DESCRIPTION:
PARCEL NUMBER
FIRE NUMBER NUMBER/BEDROOMS
— TWO TESTS ARE REQUIRED —
TEST HOLE NO. 1 TEST HOLE NO. 2
Depth To Bottom of Hole inches; Diameter of Hole inches Depth To Bottom of Hole Diameter of Holeinches;inches
Depth, Inches Date 19
Soil Texture DateDepth. Inches Soil Texture 19
Percolation
Test By _
Firm
Name _____
Percolation
Test By____
Firm
Name ____
Address Address
Otter Tail County
License No.
Otter Tail County
License No.
PERC TEST # 1 PERC TEST # 2
TIME IKTERVAL(MmirrBa Water depth Water drop PERC RATE pMB
ms INTERVAL fMINirrBS>Water depth WATER DROP PERORATE
SL2?..S.S...1 S_^s %■
9^10 4-PERC
TIME INTERVAL flt<lNUTES>WATER DEPTH WATER DROP PERC RATE pME INTERVALrMTNUTByi
PERC RATEwater DEPTH WlOERDROP
“7 o ...1ST-.(REFILL REFILL£}ai.57^ A%L<4.Sz.U-Vr nTTIMB“ " bEdP FHKC~*
INTERVAL IMINITTBS)WATER DEPTHTIKffi WATER DROP PERC RATE TIME INTERVAL fMINUTBS)
WAT^MPTH WATTODROP PERORATE
3-f> --isJf-fREFILLREFILL,gL?.?.DROP I^RC
ji fLeS4TlKiti
TIME INTERVAL (MINUTES)Water depth WATER DROP PERORATE TIME INTERVAL (MINUTES)WATER EgPTH WATER DROP PERC RATEfi_oA fULW.^cC
TIMB ' 5kdP PERC
REFILL
^ DROP PERC
>0 iJ/.L...T
TIME .j INTERVAL (MINUTES)WATER DEPTH WATER DROP TCRCRATB TIME INTERVAL (MINUTES)WATER DEPTH WATER DROP PERC RATE?il3.3.P -fk^•3RE REFILL
DROP reRfc ^ DROP
fJ-kX J 0 }0
TlMli'PtRt
INTERVAL (MINUTES)TIME WATCT DEPTH WATER DROP PERC RATE INTERVAL (MINUTES)TIME Water depth WATER DROP PERC RATEW5T
fhLS<fUg .lU 3 5.-^.zREFILL
bito^ pBftir
Yd AgZ JioH
TIME P£ftC
t 0*flMB
INTERVAL (MPOffES)TIME WATER DEPTH WATER DROP PERC RATE TIME INTERVAL (MINUTES)water DEPTH WATER DR«»PERC RATE
ris>fiSA ..St.i.l..3.0 j^.REFILLS.ll'fr.REFILL /o.c/.rii
TIME " DROP l^ERCTIMfi ' DROP PERC
fO T
TIME INTERVAL (MINUTES)WATER DEPTH WATER DROP PERC RATE TIME INTERVAL (MINUTES)WATER DEPTH WATER DRCT*PERC RATEREFILLREFILL
^ DROP ”pErCTIME TIME • Drop pepc
COMMENTS/CA L CULA TIONS:
/
MKL — 0390 - 005 250,815 — Victor Lundeen Co., Printers, Fergus Falls, Minnesota
GRID PLOT PLAN SKETCHING FORM — (Must Be To Scale)
feet/ inches/ Scale: Each grid equais I
IDated:19 I Signature
Please sketch your lot indicating setbacks from road right-of-way, iake and sideyard for each buiiding currentiy
on iot and any proposed structures.
.1
. !
:; '
•\ ;r •
■>
!
:i
‘ :
iiI
•I
!
/