HomeMy WebLinkAboutKimp's Kamp_14000080067004_Septic System Permits_Wl|C|l^Otter Tail County
Land & Resource Management
Subsurface Sewage Treatment System Inspection FormOTTER TAIL
COUNTY ■ MINNESOTA
Add res '””'"*iM?boofiOCT7ojO 20:‘il nPermit No.□ Non-Shoreland
(9„\\}/vi5Afv\ ^ HICityrrwp.Installer/MPCA#MPCA Type VIIIIV
>v□ New □ Repair Replacement □ Other Type of System □ Pressure Bedench □ Mound □ At-Grade
Soil Treatment Area
InspectionTank Inspection Other Inspection:Final Inspection
.3^ .°^£iI»toInspectorDate I _Ui < IPOO Inspector Inspector Inspector
'iY 0Corrections Corrections Corrections Corrections
TREATMENT MEDIA MOUNDS/AT-GRADE
Percent SiopeTREATMENT MEDIA □ Drainfield Rock egistered T reatment Media □ Mound
Sand Below Bed on Upslope Slde(in):Registered Treatment Media:Bed Width(ft):Bed LengthftQ:
SEWAGE/HOLDING TANKS Downslope(ft):Upslope(ft). Sidesiope(ft):
Capacity
(Gaiions)
Manufactuer
Model No.
Rock Below Pipe(in):
PRESSURE DISTRIBUTION1st Tank:□ New □ Existing Combo
f''^^ombo
'Tiater^ Spacing(ft)□ New □ Existing Number of Laterals:2nd Tank: Lateral Dia(in)i-
Perforation Spaaftg(ft)
-A \Vf30 □ New □ Existing Perforation Dia(in)Pump Tank ombo Cleanouts: Y N
TRENCHES/PRESSURE BEDS PUMP INFO
'A;Pump
Trench
Pressure
□ Drop Box End Fed □ Dist Box □Gravity Pump Manufacturer/Model No:Bed
X. ^ztiyent Counter □ Run-Time ClockRock Below Pipe(in)□ Drop Box Center Fed □ 6 □ 12 DIB □ 24 Flow Measurement Reading:
SETBACKSTrench Depth (in)
Dwelling Non-Dwelling Dwelling Non-Dwellingllr.r.'l'v?TO 53 'VjTrench Length (ft)Tj T3 Building(s) to tanks(ft) Building(s) to STA(ft)
Surface water(ft) |Q^IkIVTrench Depth (in)Te T7 Ts T9 T,o Sensitive WellWell(s)
e Trench Length (ft)T7 T»T9 T,o\P0 Property lines(ft)BluffRoad R.O.W.
Depth of G
Restriction (in):.v
/ / Depth of ^ —3
"V System(in): L- |Vertical Separatiori-
Provided(in): ^
6V(V3fU- ______________
Bed Width(ft):Bed Length(ft):Pressure Bed Dimensions
IQ’jpQfll
(5S?(^cjC) ^
Final Inspector
SignatureSSTS Inspection Form 04-28-2020
PT-873169 ■ Victor Lum !^., Printers • Fergus Falls, MN • 1-800-346-4870
1
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m Compliance Inspection FormMinnesota Pollution
Control Agency
520 Lafayette Road North
SL Paul MN 55155-4194
Existing Subsurface Sewage Treatment Systems (SSTS)
Doc Type: Compliance and Enforoement
For local tracking purposes:Inspection results based on Minnesota PoDution Control Agency (MPCA)
requirements and attached forms - additbnal local requirements may also apply.
Submit completed form to Local Unit of Government (LUG) and system owner
within 15 days
System Status
ivstem status-on-data-fmm/dd/yyyY): 10/22/201 fi
^ Compliant - Certificate of Compliance
(Valid for 3 years from report date, unless shorter time
frame outlined in Local Ordinance.)
Q Noncompliant- Notice of Noncompliance
(See Upgrade Requirements on page 3.)
Reason(s) for noncompliance (check all applicable)
D Impact on Public Health (Compliance Component #1)- Imminent threat to public health and safety
D Other Compliance Corbitions (CompliarKe 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
D Soil Separation (Compliance Component #4) - Failing to protect groundwater
□ Operating permit/monitoring plan requirements (Compliance Component US) - Noncompliant
Property Information
Property address: 38267 White Haven Rd Dent, MN 56528
Property owner: John Kimple, Kimps Kamp Resort
Parcel ID# or SecTTwp/Range: 14000990282000 & 14000080072000
Reason for inspection: permit_______________
Ovmer’s phone: 218-298-2716
or
Owner’s representative:
Local regulatory authority: Land & Resource Management
Brief system description: three 800 gallon tanks. 20 x 100 gravity bed
Comments or recommendations:
Representative phone: _______________
Regulatory authority phone: 218-998-8095
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: Wayne Johnson Certification number: C2520______
License number 901________
Phone number; 218-863-3373
Business name: Super Septic & Excavation
Inspector signature:
Necessary or Loc^ly ftequired Attachments
E System/As-built drawing^ Soil boring logs
□ Other information (list):
^ Forms per local ordinance
www.pca.state.mn.us • 651-296-6300 • 800-657-3864
wq-ww1sts4-31 • 3/16/12
TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
Poye 1 of 3
Inspector initials/Date;Property address; 38267 White Haven Rd Dent, MN 56528
1. Impact on Public Health - Compliance component #1 of 5
Compliance criteria:Verification method(s):
'^^earched for surface outlet
(^ Searched for seeping in yard/backup in home
□ Excessive ponding in soil system/D-boxes
Q Homeowner testimony (See Comments/Exf^enation)
□ “Black soil" above soil dispersal system
□ System requires “emergency” pumping
□ Performed dye test
D Unable to verify (See Comments/Explanation)
Q Other methods not listed fSee <^mments/Explanation)
□ Yes ^ NoSystem discharges sewage to the
ground surface.______________!
□ Yes ^NoSystem discharges sewage to drain
tile or surface waters.!□ Yes ^§.JJoSystem causes sevirage backup into
dwelling or establishment.
Any “yes" answer above indicates the
system is an imminent threat to public
health and safety.V.
Comm.nWE«planatlon: ^
r■t-
2, Tank Integrity - Compliance component #2 of 5
Compliance criteria:Verification method(s):
^^J’robed tank(s) bottom
^5N&(amined construction records
□ Examined Tank Integrity Form (Attach)
□ Observed liquid level below operating depth
^^riExamined empty (pumped) tanks(s)
□ Probed outside tank(s) for “black soil”
. □ Unable to verify (See Comments/Exptanahon)
□ Other methods not listed (See Comments/Explanation)
□ Yes ^ NoSystem consists of a seepage pit,
cesspool, drywell, or leaching pit.
Seepage pits meeting 7080.2550 may be
compliant if allowed in local ordinance.
■
□ Yes ^ 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/Explahation:
1
3. Other CotnpHance 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 (eledrical hazards, etc.) to immediately and adversely impact public health or safety.
*System is an imminent threat to pubiic heaith and safety.
Explain:
□ Yes* H No □ Unknown
!
c. System is non-protective of ground waterfor other conditions as determined by inspector. □ Yes* IS No
*System is faiiing to protect groundwater.
Explain:
TTY 651-2S2-5332 or 800-657-38&4 • Available in alternative formats
Page 2 of 3
www.pca.state.mn.us • 651-296-6300 • 800-657-3864
wq-wwists4-31 • 3/16/12
Inspector initials/Date: I /0.Property address; 38267 White Haven Rd Dent, MN 56528
4. Soil Separation - Compliance component #4 of 5
Date of installation:
(mm/dd/yyyy)
Shoreland/Wellhead protection/Food beverage lodging?
Compliance criteria:_____________
□ Unknown Verification method(s):
Soil observation does not expire. Previous soil
obsen/ations by two independent parties are sufficient,
unless site conditions have been altered or local
requirements differ.
Conducted soil observation(s) (Attach boring logs)
□ Two previous verifications (Attach boring logs)
[U Not applicable (Holding tank(s), no drainfield)
[H Unable to verify (See Comments/Explanation)
D Other (See Comments/Explanation)
^Yes □ No
□ 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:
Drainfield has at least a two-foot vertical
separation distance from periodically
saturated soil or bedrock. ______
Yes □ NoNon-performance systems built April 1,
1996, or later or k>r 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.*
Comments/Explanation:
Boring Log
0-14 sandy Loam 10yr3/2
14-40 loamy sand 10yr4/3
40 - 72 sand 10yr5/4
□ Yes □ No“Experimenter, “Other", or “Performance”
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.
Indicate depths or elevations
36A. Bottom of distribution media
+72B. Periodically saturated soil/bedrock
+36C. System separation
36D. Required compliance separation*
*May be reduced up to 15 percent if allovired 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 n No If “yes”, A below is required
□ Yes □ 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 sechon does not need to be completed.
Compliance criteria
a. Operating Permit number __________________
Have the Operating Permit requirements been met?□ Yes □ No
b. Is the required nitrogen BMP in place and properly functioning?□ Yes □ No
Any “no” answer indicates Noncompliance.
Upgrade Requirements (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 this notice or within a shorter period if required by local ordinance. If the systerri 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 stria. 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.
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
Page 3 of 3
Department of
LAND AND RESOURCE MANAGEMENT
OTTER TAIL COUNTY
Government services center - 540 westt fir
Fergus Fall^, MN 1^6537
PH: 218-998-S08S
OTTER Tail County's website: www.co.otter-tau.mnais
OTJCRTflll
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
14000990282000Parcel Number;
Township:
Property Owner Name(s); John Kimple
Property Address;
Reason for Inspection: Sale of Property
Number of Bedrooms; 24
08Dead Lake Section:
Yaquina Bay Rd
0 □In Shoreland Area?
Lake/River Name, Number, & Class Dead Lake 56-383 NE
Yes No
^^ompliant
I I Non-Compliant
System Compliance Status:
"XInoDoes the soil treatment area have less than 3 feet of vertical seperation?
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
4: No
^’No
3no
Yes
Yes
Yes
"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: Wayne Johnson________
Certification Number; C2520
Business License Name & Number; Super Septic & Excavation
Signature;
#901
Date:
Excel/Compllance Fonri for OTC 4/30/2014 Page 1 of 2
otter Tail County Compliance inspection Form Addendum (cont.)
14000990282000Parcel Number;
Date & Initial:
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).
Additional Comments:
Excel/Compliance Form for OTC 04/30/2014 Page 2 of 2
r 'S'i
7 2^»3;<t(lf Z-:,6 iflfi
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APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
WHITE — Office
Yellow — Irlspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone:(218)739-2271 - FERGUS FALLS, MN 56537
linojLEGALPermit No.
DESCRIPTION 5O^Q UI^Oj Abatement: ( ) Yes ( ) NoAND
LOCATION
""WLAKE NUMBER LAKE/RIVER NAME LAKE/RIVER SECTION RANGETWP. NO.
fo
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
/ ■-'OJ- J ‘j—CXX)
IDENTIFICATION: Please Print All Information
Mailing Address — No. Stre^, City and State
3ii
^'>Ln. a/0
La^Name _____________ ______ First .! Initial Zip Code Telephone No.
Property
Owner
(\ciA\ fcl/(
Sewage
System
Installer
Name
A.M.
► This System will be ready for inspection on , 19.P.M.at
This space for office use oniy ^ O 3—NUMBER OF BEDROOMS:
A.M.
19 P.M GARBAGE DISPOSAL: { ) YES ( ) NODate Rec’d Time Rec’d Phone Call Rec'd By
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTS,TYPE OF SEWAGE SYSTEM
J^^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.
50Distance from nearest well Ft. Ft.
100Distance from lake or stream Ft.Ft.(
/QDistance from building Ft.Ft.
10Distance 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____
Perc Tester.Date of [St.
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 ready for inspection.
uyi/ifDATE:
Signature
Permit: Permission is hereby granted to the above named applicant to perform the work described iri 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 noLcommenced within six (6) months.
Issued Date:
,
Try nn ^ ^ ^
yg.iM-C-1 t- io(\\rd0Plk
Land & Resource Management Office
Rec #.Fee $.
Comments:
277.212 • Victor Lundeen Co.. Printers • Fergus Falls. MinnoostaBK 079B-003
■i
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM i•?1WHITE — Off/C^
Yellow — Inspector *■
Pink — Owner
1LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone: (218) 739-2271 - FERGUS FALLS, MN 56537
Permit --------J
LEGAL
DESCRIPTION 5o^a iA{<^cu Abatement: ( ) Yes ( ) NoAND
LOCATION
LAKE NUMBER LAKE/RIVER NAME
iMqS
LAKE/RIVER
2'
SECTION TWP. NO.RANGE TWP NAME r U hi--.1f'r foL■) ■
I
L PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER2
-coo\
IDENTIFICATION: Please Print All Information
Last Name First Initial Mailing Address — No. Street, City and State 5/t Zip Code Telephone No.
!Cl I HfL VProperty
Owner ^/0 L
-5 <:(
/\Cl.V\Sewage
System
Installer
/Name U)
I J%
A.M.JO- /y-7This System will be ready for inspection on., 19.P.M.at zz/This space for office use oniy
NUMBER OF BEDROOMS;'7Z.A.M./P.M
GARBAGE DISPOSAL; ( ) YES ( ) NODate Rec'd Time Rec’d Phone Call Rec'd By
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
tank (Alarm Requii^)
( ) Septic tank
( ) Lift Station (Alarm required)
( ) Drain field
( ) Trenches
( ) Bed
( ) Mound
( ) Outhouse
( ) Sewer line
, . TANK
U (J:0Q
DRAIN FIELD
Capacity GIs.Sq Ft.c
Distance from nearest well Ft.Ft.
TY mDistance from lake or stream Ft. Ft.
nDistance from building Ft.Ft.
10Distance from property line Ft.Ft.
Distance from bottom to Water Table Ft.Ft.
\EFFLUENT DISTRIBUTION
( ) Gravity
( ) Pressure
VAll distances are shortest distance between nearest points \
PERCOLATION TEST DATA:
WATER WELL DEPJ^ ^___
(JlAj
i
Perc Tester,■jDate of Perc Test_
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 for inspection.
/-<•" ; ,U -;<r'DATE:JjZI//Signature
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. Tllis 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.!?i
/
1
/Issued Date:4-
A I CO' Rom oh wo
• f Land & Resource Management Office
\Fee $.Rec if.i.-' iT Y IO-.?-‘i-|IComments:T1 IM5--f-Mfhi 1
\, V ■
H-f4
277.212 • Victor Lurtdeen Co.. Printers • Fergus Falls. MinneostaBK 0795-003
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
r
DRAIN FIELDHOLDING
SEPTIC TANK LIFT TANKCATEGORY Actual Minimum
c^'ty^j^Ls.SF SFGLS.Capacity
FT FTDistance from Nearest Well FT FT
Distance from Buried
Water Suction Pipe FTFTFTFT50
Distance from Buried Pipe
Distributing Water Under Pressure FTFT10FTFT
FTFT FTFTDistance from Lake or River (OHWL)
10/20 FTFT FTFTDistance from Nearest Building
ZZ FTFT10FTFTDistance from Nearest Property Line
FTFT3FTFTDistance from Bottom to Water Table
NOHolding Tank/Lift Alarm
NOOld System Pumped & Destroyed
DRAINFIELD CALCULATIONSewer Line to Well SeparationINTERPRETATION
OF ABBREVIATIONS
GLS. = Gallons
SF = Square Feet
FT = Linear Feet
MinimumActual
FTX
FT 20 FT SF
Inspector’s Comments:
SKETCH:/firt
s/
>t//-
Inspector's Signature
M- /V-V?
Date of inspection
/laT)
nme of Inspection
AIR TEST CERTIFICATION
On %r i(j, /9^n (date), an air test of the sewer line installed under
for __________Sewage Disposal System Permit Number ///^ Qi
(owner), on la/Zs>
line held
(lake/river) was made. At that time, the sewer
pounds per square inch for cZ^ minutes.
4
X ^cY /c/,9-Installer's Signa;Kjre License No.Date
System design must be to scale and must include the proposed location of the sewage system, 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/jnch(es) equalsScale:.grid(s) equals feet, or
SIGNATURE:SUBMITTED BY:f
FIRM NAME: —
ADDRESS: ___________
DATE:
7^MPCA LICENSE #:
LICENSE CATEGORY:
I ('7) / 000
<n
WtLV
V - • 4
281.183 • Victor Lundten Co.. Priftt«f> • Fergus Fells. MN • 1-800*346-4870BK - 0496 - 029
SITE DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, MN 56537
OWMER:
LAST NAME
Qo/- </C(eO
FIRST MIDDLE TELEPHONE NUMBER
ADDRESS:
STATE
5>
STR./RT CITY ZIP CODE
jQ<r*z/
LAKE/RIVER NO.LAKE NAME SEC.TWP.RANGE TWP. NAME
LEGAL DESCRIPTIOM:SOIL BORING LOG
^ LohT- GIkD-
/V geo 9fr -
PARCEL NUMBER
COLOR &
MUNSELL NO.
DEPTH
(INCHES)TEXTURE STRUCTURE
BLOCKY
PLATY
PRISMATIC
NONEtBLOCKY
PLATY
PRISMATIC
NONE
FIRE NUMBER
NUMBER OF BEDROOMS BLOCKY
PLATY
PRISMATIC
NONE
GARBAGE DISPOSAL; YES NO
WELL CASING DEPTH:ft.
BLOCKY
PLATY
PRISMATIC
NONE
FLOODPLAIN: YES NO
VEGETATION: AQUATIC TERRESTRIAL
BLOCKY
PLATY
PRISMATIC
NONE
SLOPE AT INSTALLATION SITE:%
TYPE OF OBSERVATION: Probe Pit Boring
PARENT MATERIAL: Till Outwash Loess Bedrock Alluvium COMMENTS:.
ORIGINAL SOIL:Yes No
COMPACTED SOIL: Yes No
DEPTH OF BORING:.ft.
PERC TEST #1 PERC TEST #2- TWO TESTS ARE REQUIRED -
WATER DEPTHTIMEINTERVAL (MINUTES)WATER DROP PERC RATE TIME INTERVAL (MINUTESI WATER DEPTH WATER DROP PERC RATESTARTSTART
TIME DROP PERC TIME DROP PERCTIMEINTERVAL (MINUTES)WATER DEPTH WATER DROP PERC RATE TIME INTERVAL (MINUTESI WATER DEPTH WATER DROP PERC RATEREFILLREFILL
TIME DROP PERC TIME PERCDROPTIMEINTERVAL (MINUTESI WATER DEPTH WATER DROP PERC RATE TIME INTERVAL (MINUTESI WATER DEPTH WATER DROP PERC RATEREFILLREFILL
TIME DROP PERC TIME DROP PERCTIMEINTERVAL (MINUTESI WATER DEPTH WATER DROP PERC RATE TIME INTERVAL (MINUTES)WATER DROPWATER DEPTH PERC RATEREFiaREFILL
TIME DROP PERC TIME PERCDROPTIMEINTERVAL (MINUTES)WATER DEPTH WATER DROP PERC RATE TIME INTERVAL (MINUTES)WATER DEPTH WATER DROP PERC RATEREFiaREFILL
TIME DROP PERC TIME DROP PERC
INTERVAL (MINUTES!WATER DEPTH WATER DROP PERC RATE TIME INTERVAL (MINUTESI WATER DEPTH WATER DROP PERC RATEREFILLREFIU
---- =TIME DROP PERC TIME DROP PERCTIMEINTERVAL (MINUTES)WATER DEPTH WATER DROP-PERC RATE TIME INTERVAL (MINUTES)WATER DEPTH WATER DROP PERC RATEREFILLREFILL
TIME DROP PERC TIME DROP PERCTIMEINTERVAL (MINUTES)WATER DEPTH WATER DROP PERC RATE TIME INTERVAL (MINUTESI WATER DEPTH WATER DROP PERC RATEREFILLREFia
TIME DROP PERC jTIMEDROPPERC
PROPOSED DESIGN:
TRENCH.BED.ATGRADE.MOUND HOLDING TANK GRAVITY DIST..PRESSURE DIST.
SEWER LINE.OUTHOUSE.OTHER.SPECIFY:.
— SYSTEM DESIGN ON BACK —
s
*
FIELD NOTES
LAKE NO.: 56- 383 DATELAKE NAME: DEAD
FIRE NO.:Parcel No.: 14000990299000LEGAL DESCRIPTION
YAQUINA BAY
LOT 5 BLK 2 i
OWNERS NAME AND ADDRESS:
FLUTO, RICHARD
FLUTO, DONNA
317 WEBSTER ST
LISBON, ND 58054
Comments:
SEPARATION DISTANCES(IN FEET)
ABSORPTION AREA OUTHOUSETANKSEWER LINE
?IWELL
(ISOHWL
o}<LOT LINE
^6DWELLING
NON DWELLING
s-c>'GROUND ELEVATION @
REASON(S) FOR ABATEMENT:
?■') I ^
A-
A U/H Lyt^ C^nruA^c^
Sep 14AA-
f "Z- C' p ^
50 *w
0fjp''
/t^3 < ISO
SKETCH ON BACK...
Inspector's Signature(s)
^ 103^
ih-
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FIELD NOTES
DATELAKE NO.; 56- 383LAKE NAME: DEAD
FIRE NO.:Parcel No.: 14000990282000
g OC? 7A OCrO
LEGAL DESCRIPTION
OL
/6s ^YAQUINA BAY
LOTS 1 THRU 13 BLK 1
/-3 s)k,-2.
OWNERS NAME AND ADDRESS:
KIMPLE, JAMES
KIMPLE, JOHN
RIDGEROAD
(9li
hcLr‘^s A
/df>r<vT.
MONMOUTH JUNCTI
J ^'-1Cononents:
cy
SEPARATION DISTANCES(IN FEET)
OUTHOUSEABSORPTION AREATANKSEWER LINE
WELL
OHWL
LOT LINE
DWELLING
NON DWELLING
GROUND ELEVATION §
REASON(S) FOR ABATEMENT:
SKETCH ON BACK...
Inspector's Signature(s)
SHORELAND MANAGEMENT — COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 • Fergus Falls, MN 56537
APPLICATtON FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
Whit9 — OMc*
Yellow — Inapeelof Pink — Owner
7^
Permit No,
L«k9 No. Lake Name
LEGAL
DESCRIPTION
H W 't i
Mo/' 3rs €>F utAND
cP (f ^A/£.LOCATION
Sec.TWP NameLake Clattif.TWP Range
IDENTIFICATION: Pleate Print All Information.
Mailing Address — No. Street, City and StateFirst Zip No,Tel. No.InitialLast Nameg
OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for inspection on... 19.
This space for office use only
,19_____.M
Date Rac'd Time Rac'd Phone Call Rec'd By Owner or Agent Signature
3NUMBER OF BEDROOMS:ESTIMATED COST;
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIEI D
3?VCapacityGIs.Sq. Ft.Sq. Ft.
50 Ft.Ft.Ft.Distance from nearest well
iro Ft.Distance from lake or stream Ft.Ft.
10 ‘:iDDistance from occupied building Ft.Ft.Ft.
IP 10Distance from property line Ft.Ft.Ft.
7Ft.Distance from bottom to Water Table Ft.Ft.
AH distances are shortest distance between nearest points
I
RECORD OF TESTS:
1Inspection was made on 19,, Time .....jVI By
19
19..5...™...
I
JA.LPERCOLAJTON T^ DATA:/III. ,Date of First Test IRate,
i£..:.AP..Date of Second Test Rate,
1»t Tet^Tekan By L.k£An 3 10First Test + 2nd Test i2nd Test Taken By Rata
Agreamant: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 Minn
esota Department of Health. Applicant agrees that plot plan, sketches and specifications submitted herewith and which are approved by Shoretand 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 therob is ready for insp^tjon.
Dated.
Signature'' *
Permit: Permission is hereby ^^anted 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 workrrwn 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 rwt commerKed within six |6I months.
^-A|- srTIssued Date:
Shot^enti Uenegement Office
Fee $Rec #
Corjlments:I ^ {-j. TA
y
Form No. MKL-0320eS
225239 — Mew Lmtm C».. PMm. Fei|w F*. M
\
' ■ V'INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYActualShould Be Actual Actual Should BeShould Be
Capacity GIs. GIs.S F S F S F S F
Distance from Nearest Well FF F F FF
Distance from Lake or Stream F F F F FF
Distance from,Occupied Building F F F F F F
Distance from Property Line FF F FFF
Distance from Bottom to Water Table 3 3FFFF F F
Inspector's Comments:
f{
f Si:I
:{
5^r<5
<,/19Date of Inspection
li?0Time of Inspection M
Signature ot InspectorINTERPRETATION
OF ABBREVIATIONS
GIs » Gallons
SF = Square Feet
F = Linear Feel
Job Title
i
MKL • 03208$ • Backer Agency
V,
-
-r fT k
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY
FERGUS FALLS. MINN.
1MKL-0871-030
- , r File Opening Date 19?^L.
:
Special U» ( ) Use DescriptioaSubdivision File ( )Subdivision Name.Individual File ( )
Name of Applicant:.
~ L^Nwtw
Address:.
^ St. * No. CHvk} (3'T fhJ
Sm ______ Tiiim Banna ' Tma — -
Zip No.PhO€M No.
MiddNrim
P&>JLegal De^ptoj 5^--5?3
gji rimTu^snraix-I -L. Mp -PAJ^ GJ..^. /Crr*
2
^tMpS ■■
fw ”
fi'O BUILDING PERMITS I VARIANCES ON RUM DINf; PFRMITS
Otp NotWodKflno JudotmoitRwultiAopl. Pits H—fina D«t»DmWQ.
I H
iO SEWAGE SYSTEM PERMITS
!xOyV<^ n^XjLylHL^ y2yny2J-'cfy
^ PJL%xl G-U .2
txC?w COL^ / (f, ^
bata Om ifNpaetad tPurpoaaNO.
I
0 SPECIAL USE PERMITS
Haartnf Oat*COMMENTS SeCTApplication Data
i
Accompanying Documents Filed in Cabinet No..
■j -!
:'
' NOTE: O 0 See enclosed Inspectors Copy of Permit Application. 0 Seee 4
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
miu — omce
Yellow — Inspector
Pink — Owner 7hO *
Permit No.
I2-~I( ~9l-
*5(7^ lyJY
LEGAL
DESCRIPTION
ts ■Of-<yiAND
LOCATION
TWP NameLake Clauif.Sec.TWPLake No.Lake Name Range
IDENTIFICATION: Please Print All Information.
Mailing 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
3NUMBER OF BEDROOMS;ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PITSEPTIC TANK DRAIN FIELD
Sq. Ft.3?yGIs.Sq. Ft.Capacity
50 Ft.Ft.Ft.Distance from nearest well
iroFt.Ft.Ft.Distance from lake or stream
10 2.0Ft.Distance from occupied building Ft.Ft.
lO 10Distance from property line Ft.Ft.Ft.
7Ft.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 By
91 1:A£.2sA0...PERCOLAJipN T^ DATA:
Aul /lU,.
Date of First Test ,, 19
, 19
, Rate
^1Date of Second Test Rate
1ft Test^aken By
.L„.4£iU3 ?6First Test + 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 tbe^b is ready for inspection.
g'-AI -il
' ' Signature^
Dated
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
Issued Date;
Shoreland Management Office
Fee $Rec #
/QJU} f iJ. V yiUpY -Comments:
Q7
Form No. MKL-032085 225239 — \^r LindMfl Co., Printore. Forgus Fals. MN
h.
iISHORELAND MANAGEMENT — COUNTY OF OTTER TAIL -
COUNTY COURT HOUSE
Phone 218-739-2271 • Fergus Falls, MN 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
i i
White — Office
Yellow — Inspector
Pink — Owner
kf
7E
7)
Permit No._1
LEGAL
DESCRIPTION
H tKi^ II-//-<^1 Ctjfxjucr^ DF(yi
Dt.J A/f.
ct ^o-v^AND
7
S- .^35TWP
LOCATION
t:■el
TWP Name(•FlangeLake Classif.Lake No.Lake Name Sec.
IDENTIFICATION: Please Print All Information.
Mailing Address - No. Street, City and State Zip No.Tel. No.First InitialLajSt Name
OWNER
i
IV
)lu . / ^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 Signature
NUMBER OF BEDROOMS;ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
3? 7'GIs.Sq. Ft.Sq. Ft.Capacity
Ft.Ft.Ft.Distance from nearest well
I ro lJFt.Ft.Ft.Distance from lake or stream 1
I 0 Ft.Distance from occupied building Ft.Ft.
IP iODistance from property line Ft.Ft.Ft.
3 \ Ft.Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
RECORD OF TESTS;
fInspection was made on ,, 19 , Time ,JVI By I
P6....:.AP..
.L.LL
..LL
= 3
PERCOLAi;iON TEST DATA:Date of First Test , 19 , Rate
At 19.“if....?.Date of Second Test Rate!
TesJ-Taken By1st
J hFirst 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.
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 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 I6) months.
Permit:
'rrlC^.Issued Date:
Shoreland Management Office
Fee $Rec #
f,Cornments:f iF7 —^] t/
f-;r :
Form No. MKL-032065 225239 — Victor Luncteen Co., Printers, Fergus PaRs. MN
T*’’1
ii
s
■ •
I .,. r;■.
t■ j •'! (-I 1
^ • r-^ I INSPECTION RESULTS
Inspector must make all measurements
•y
■j -
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYShould BeActual Should BeActual Should BeActual
Capacity GIs.GIs.S F S F S F S F
Distance from Nearest Weil F F F F FF
Distance from Lake or Stream F F F F F F
Distance from Occupied Building F F F F F F
Distance from Property Line F F F F FF
Distance from Bottom to Water Table 3 3FFFFF F
<:) k \O%'40 - JLAInspector’s Comments:
t f/f 9LVI
'Mlv i
0/
I
<
Date of Inspection 19
Time of Inspection M I
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
F = Linear Feet
Job Title
MKL - 032085 - Backer Agency
rw
H
SHORELAND MANAGEMENT — COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 • Fergus Falls, WIN 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
mite — OflSee Yellow — Inspector Pink — Owner
^ (J ^ (y ■ C. ^
9—(jF~ Je^^(
H 61k z ycxoMAjicLBc^
13r ^
*Sec. TWP
Permit No.,LEGAL
9-09.9F- 660i»teur<i <*■DESCRIPTION
AND
1^-387 l)F/f J NO iA/<'efyjygLOCATION
TWP NameLake Classif.RangeLake No.Lake Name
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Tel. No.Zip No.First InitialLast Name
ICi’Npk CTnli NOWNER
C fy-OCOAthlSEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for inspection on.19.
This space for office use oniy
.19 .M
Owner or Agent SignatureDate Rec'd Phone Cali Rec'd ByTime Rec'd
NUMBER OF BEDROOMS;ESTIMATED COST:
EESEWAGE DISPOSAL SYSTEM DATA:J.
^PTIC TANK-SEEPAGE PIT DRAIN FIELD
loop GIs.Sq. Ft.Sq. Ft.Capacity
SO Ft.Ft. Ft.Distance from nearest well
150 Ft.Ft. Ft.Distance from lake or stream
7L2.Ft.Ft. Ft.Distance from occupied building
73Distance from property line Ft.Ft.Ft.
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
PERC II. ATI ON TEST DATA:Date of First Test
Date of Second Test
1st Test Taken By
First Test + 2nlT Test 2 Rato2nd 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 i lection.
/,/
Dated ---Si^ature
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 Minni jota.
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<?-3XX^Fee $Rec #
Comments:+
Form No. MKL-032085 225239 — Victor Lundeen Co . Printers, Fergus Ftfs, MN
ri-.
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
1Whita — Office
Yellow — Inspector Pink — Owner
i
1
6^00jpM-tr—
Or- to: /<y«/
Y Sik z
;Permit No.LEGAL
li/-060^^-000
DESCRIPTION
AND
\)FAci Wo, t:"LOCATION
TWP NameLake Classif.Sec.TWPLake No.Lake Name Range
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Tel. No.Zip No,First InitialLast Name
■1 oL NfULI NOWNER
I ■K iSEWAGE
SYSTEM
INSTALLER
Ic r. kv A NjName.
W .\.L/This System will be ready for inspection on., 19.
TThis space for office use only
Phone C^l
19^ ?> ' IF?.M'2.
Dere Rec'y Rec'd By Owner or Agent SignatureTime Rec'd
NUMBER OF BEDROOMS;ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PIT-SEPTIC TANK DRAIN FIELD
/ ic 'U GIs.Sq. Ft.Sq. Ft.Capacity
\so rFt. Ft.Ft.Distance from nearest well
ISODistance from lake or stream Ft.Ft.Ft.
/ Q ■ . • . Ft.■■ Ft.■ Ft.Distance from occupied building I ’
Distance from property line Ft,Ft.Ft.
Ft.Ft.Ft.Distance from bottom to Water Table
All distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19 , Time.M By
/PERCOLATION TEST DATA:Date of First Test 19....R
Date of Second Test 19 Rate
1st Test Taken By \
+ 2r^ TestFirst Test 2 Rate2nd Test Taken By /I»•
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.
2.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 inform in ^11 respects to ordinances of Otter Tail County Minne^ta.
This permit may be revoked at any time upon violation of any said ordinance. f * •
NOTE: Permit void if work is not commenced within six (6) months.
J-7"/ •Issued Date:o
Shoreland Management OfficeOS'xo 1 rFee $Rec #f «„7.
Comments:I
t ♦
5*.■arr^
Form No, MKLe32085 * * Ik- ■«225239 Victor Lundeen Co.. Printers, Fergus Falls. MN
11 jfppii^ .vipiiipp ii« Piv.'Jii^^ iifi'Mi iiHfi.pfK . iiiph "w m MffFTFT
•\.
.1
’ •-.
"S-
/
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYXActualShould Be Actual Should Be Should BeActual
\0COCapacity GIs.GIs.S F S F S FS F
Distance from Nearest Well F F F F F F
lSa“Distance from Lake or Stream F F FF F F
Sis'Distance from Occupied Buiiding F F F F F F
Distance from Property Line F F F F F F
3 3Distance from Bottom to Water Table F F F FF F
*\y\ >pa.s%.ww»^Inspector’s Comments:V'
«•»
oLJ> Sy^TgK/N fv\vAS"V‘ fCTwevcO oyI ^v-D ^vxtrA.'Q. -^VtA'V 4*~^
bA.‘V»t *.Ctt-T 4*1-^
7-3~g<oDate of Inspection 19
It‘.MoTime of Inspection M
Itm
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
F = Linear Feet
Job roe
MKL - 0320S5 - Backer Agency
w
vt
DIVERSIFIED PIPING, INC.*
670 Hamel Road
Hamel, MN 55340
Phone: (612) 478-2111
Minn. Watts: 1-800-362-3524
=
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!
+
i
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i
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6:- -_a,a^..\'* \r4fjy^tj Tr. i
•*'fEileen h Ci4.1ia.C J K'.inplf
CST^
e’
G'*'
1
Ic®:><E-.*/S!S«i*£l'«3 «u «!r•i*71 ;*•;Oi Vi ■nS '71
>i;^ ^K4M.iV»■*?’9 ^V>58%
E 0'^rv'vo.a-?#
^ , n# « - • •
\ *"*<]71 '^M 4VI43QVlS'JUS:Xa j S» / ^«'A a>c ■5;«E^'V .0 s.66•'A«.^\v. j»5 <4(1
:< k'-'
‘^VtV 3$.7
/2e9*ie^--'
tt'\A\h/i<>'YAQUINA BAY
-----------
":;Taa ;?■
^r\'i>r -v:'I ~~1.Is le.,afi >e ^u.0 _. 11*
-"-T3.4 s
^ 0>W<wJ
Ads’
tA* f"■««
4 ^4 J- '
LAKE
! •< |>«rifi Hv
K«/Bf,hl B s>M r.M^ 4k A»''1K
S. 1/2 SEC. 8N. 1/2 SEC. 17 a4 ■
- -".dl
-rf*
,v
X ‘
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T^/< / c Co/j > 5//C ^
/V ^
PERCOLATION TEST DATAMKL -0871 -028
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, Minnesota
Mailing Address:
56537 Ph. No.
Owner:
Zip No.StateCitySt. & No.Middle
NAME
FirstLast Name p€Ac/Legal
Description:
TWP NAMETWP.RANGESEC.LAKE OR RIVER NO.
TEST HOLE NO. 2TEST HOLE NO. 1
6 "✓ ♦111 A / sDepth to Bottom of Hole inches; Diameter of Hole.inchesDepth To Bottom of Hole,inches; Diameter of Hole inches
-Depth, Inches Soil Texture Soil TextureDepth, Inches uDateDate
If" J ( ’k 'L 0 A-rlr-Percolation
Test By____
Percolation
Test By ^ _/QLU /\\* dcJ.//C>0{T^Firm
Name.
Firm
Name.QC•//I(DoUJ
DC
^ / . Al pimAddress.QC Address
<
CO
Otter Tail County License No..Otter Tail County License No..toLUMeasure
ment,inches
Drop in
water level, inches
Percolation
rate minutes
per inch
Time
Intervals
minutes
Percolation
rate minutes
per inch
Time
Interval,
minutes
Measure
ment
inches
Drop in
water level, inches
Remarks:Remarks:Time TimeO§
H
1 h.2^I'-M//;
! ! <ro
I •' Tt.
111 I <T(2 I (/O 3^^4. CC-772-S^
Z-2.Z.LJM-3^/c?to
Uaii/i 7 .' Q 7 2-71/y
3//V
ai-av.
2 |u 4 /G»2gi ' 7
2_ 7 /
See Booklet, "How to Run a Percolation
Test" by Agriculture Ext. Service, Un. of MN
Percolation rate minutes per inchminutes per inch Percolation rate =
11
!I
I
i!1
Ci cvo:
‘^m.MmmfkB^MA0MAM *
'^^iii^^my-----------------
mu0MW^
wS'm<0m0i%»«v#ySS5^S,^E
|te.„
WSsi
fes
/??
rIt
!|
■ i‘r^ „.CERTIFICATE OF COMPLIANCE
SEWAGE SYSTEM
«
>1 iSft
m
■4i 9 thT/z/s certificate has been issued this day of.19 7fiHpr.pmhpr
.%1
I*teaia«C-A
to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.
WM
-- . . •■V— A
The premises covered by this certificate are legally described as:t
wm56-383 5ec. __8 Twp 135 Range JiQ_Twp. Name.Lake No.Dpar! T atfP
ia7.80 ac strip adjacent to Lots 1-13 Block 1 and
Lots 1-2-3, Blk 2 Yaquina Bay
Kimps Kamp Resort
h K 5^JKj'lf
JSte-4
mkj
IIlilil
§>m
Owner: Name.Freda KiTCpIp
Address.R ,__1, Denl-j M-innaant-a
Zip No.56528
IP?
Malcolm K. Lee, Shoreland Administrator
Otter Tail County, Minnesota
Permit No. SP_209a
Signed by:.
MKL-087,-009
................................................ ...............................................
py
0
®159035 '"eff* LunotiN 4 eo. rtmu* fiLL*. «>■<■
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
V lo(w Insp'bctor Pii..
Card
Office
Owner
Owner
Permit No.LEGAL
LU/r>ao Date
DESCRIPTION
AND
(Vfs- It Pr QoLOCATION
Lake No.Lake Name Lake Classif.Sec.TWP TWP NameRange
IDENTIFICATION: Please Print All Information.
Last Name First Initial Maiding Address —No. Street, City and State Zip No.Tel. No.1C\ fP-P M>i ■PI p! -POWNER
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 Signature
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
IJ JO Sq. Ft.^ -9ooo^ 3fc<a9Gis.Iq. Ft.Capacity
Ft.Ft.Ft.Distance from nearest well
I TP /JT>Ft.Distance from lake or stream Ft.Ft.
/O^Ft.Distance from occupied building Ft.Ft.
/o<Distance from property line Ft.Ft.Ft.
¥Ft.Distance from bottom to Water Table Ft.Ft.
AH distances are shortest distance between nearest poin
RECORD OF TESTS:
Inspection was made on .. 19 , Time JVl By
/.PERCOLATION TEST DATA: Date of First Test „ 19
, 19
. Rate
Date of Second Test Rate
1st :ei [7 /■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 untiljt has been inspected and accepted. It shall be the
responsibility of the applicant for the permit to notify the County Shoreland Management that theJob is read ir inspecfion. (Ci use attached mailer notice.)
<2
Dated tr Signatun
Permit: Permission is hereby granted to the above named applicant to perform the work dgecribed in the above rtatement. This permit is granted upon express
condition that the person to whom it is granted, and his agents, employees and workmen shall/Jon/Form in all respectsflo 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 npt commenced within six (6) months.
Issued Date:
Shoreland Managatnent Office
Pi 0Fee $A Surcharge $ax
.cyPsI- q~? njlolnComments:.
Form No. MKL-0771-003 vicToa LUHedH a ca.. aaianaa. Ptaaut SM.t.a. Hiaa.158906
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 low —Inspector
Owner
Owner 7Pli..
Card
Permit No.,LEGAL
Date
DESCRIPTION
AND
LOCATION
Leke No.Leke Classif.Lake Name TWPSec.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.
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 Rac'd By Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST;
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
GIs.Sq. Ft.Capacity 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.
Ft.Ft.Distance from bottom to Water Table 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
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
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
Issued Date:
Shoreland Management Office
Fee $Surcharge $
CERTl'^l^.ATE ISSUEDComnnents:.
viCTOi uiaeccN * m.. pdihtcm. rcittus fM.i.1.
,158906Form No. MKL-0771-003
9 • • •
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY
Actual Should be Actual Should be Actual Should be
Capacity GIs.GIs.S'F S F SFf
FDistance from Nearest Well 75FF 50FF F
istDistance from Lake or Stream ;F F F F F
/VLfU)Distance from Occupied Building 10 2020FFFF F
■r-I
FrDistance from Property Line 10 10 10FFFF F
^1Distance from Bottom to Water Table 4 4FFFFF F
c (-P p ^Inspector's Comments: ^ ^ X ^
r p 0 1
. i]
..g A
7
7^
0.1^-- //L-/>
Date of Inspection .19___
Time of Inspection,M
fnature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs » Gallons
SF “ Square Feet
* Linear Feet
Job TitleF
AgencyMKL-0771-003-Backer
7-/7'^ 1
B>il5 X ^00 - X 1^3 ^
C*^ sf 1 l^c( r 2oSfos^'(n7
TZ
^ ^ ■>» J ’ •
PERCOLATION TEST DATA Price $ 1.00 per pad.
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537A/f’S F/A^pLc.Ph. No.
Owner;Mailing Address:
/I
Last Name First Middle Zip No.St. & No.StateCity
Legal
Description:-3^ /Vt~ Dt/^^
SEC.LAKE OR RIVER NO.
Paired aj
NAME TWP.RANGE TWP NAME
^^rc E V^’PI^S-e^//y
Fr/fcc/yyp rrc XL
TEST HOLE NO. 1 TEST HOLE NO. 2
L3^Depth to Bottom of Hole inches; Diameter of Hole inchesDepth To Bottom of Hole.inches; Diameter of Hole inches
>'Y
Percolation
2LDepth, Inches Soil Texture Depth, Inches Soil TextureDate19 Date^c-V/Vv’J^/<^C. c>^u/Percolation
Test Bv^j/P-r^P n r^P>/V- 3 / y -Q
LU
Firm
Name.OC FirmName.3aLUCC
lUiHtv'Address.OC Address
<
COOtter Tail County License No..Otter Tail County License No^I-coLUMeasurement,
Inches Depth in Water
Level, Inches
Measurement,
InchesI-Depth in Water
Level. Inches
Time Remarks Time Remarks
O3/ "r’ g / 7 ezj-2.ji~/
C} <Jy ^//T /r
y^ ' S' y y<:■ ^ I i >
7^/ -> '^5^ y V
■7 73 -id ZL2.^ -0^1 ^
/J>/3 /c^g'fx J-/J / ^
rPi/ ^o 9 JL/77■7 ^ yjlr >/c ^ro //A
/C CO Ld/ e> £>c X- / '7dL\d 1'^-I ^/1C VII ^ I c 4-
______________________^1/ '
PQ/Cd/: ^k’/P / /hy/y'
159179 ®MKL-0871-028
«<cro* i.oNOt(H 1 CO ppik'cai rcasjs fails w<«h
See Booklet, "How to Run a Percolation Test" by Agriculture Ext Service, Un. of Minn.