HomeMy WebLinkAboutHolly's Resort_02000990330000_Septic System Permits_SHORELAIMD MANAGEMENT - COUNTY OF OTTER TAIL *
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APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
White - Office
Yellow — Inspector
Pink — Owner
Card — Owner
COUNTY COURT HOUSE
Phone 218-739-2271 - Fergus Falls, Mn. 565
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Permit No.,LEGAL
Date
DESCRIPTION
AND
^ p 2jl /f o /?,LOCATION
Lake Classif.Sec.TWP Range TWP NameLake NameLake No.
IDENTIFICATION: Please Print All Information.
Mailling Address —No. Street, City and State Zip No,Tel. No.First Initial;t Name
FjtjjtiAoOWNER
SEWAGE
SYSTEM
INSTALLER
Name.
1^ This System will be ready for inspection ., 19.on.
This space for office use only
19 M
Phone Call Rac'd ByDate Rec'd Time Rec'd Owner or Agent Signature
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PITSEPTIC TANK DRAIN FIELD
1^00 GIs.^ 3q- Ft.Sq. Ft.Capacity
Y-5^0^ Ft.roFt.Ft.Distance from nearest well
>r 0Ft.Ft.Ft.Distance from lake or stream
l^L Ft.Ft.Ft.Distance from occupied building
t / PDistance from property line Ft.Ft. Ft.
r Ft.Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on ,, 19., Time ,JVI By
2..i./.PERCOLATION TEST DATA:Date of First Test 19
, 19...7..'^...,
Rate
/Date of Second Test Rate
LI .(2.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 iob is ready for inspectio lall or use attached mailer notice.)
il.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.
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
// / /^ 22.tK.Issued Date:
ihoreland Management Officj
- yo /l/y- T?T. DO >Fee $Surcharge $
Comments:
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Form No. MKL-0771-003 IS8906
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