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Last Resort_22000110087001_Septic System Permits_
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM LAND & RESOURCE MANAGEMENTOTTER 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 \3WPLEASE PRINT OR TYPE ALL INFORMATION Permit No. LAKE NUMBER LAKBRIVER NAME LAKE/RIVER CLASS SECTION TWP NO.R.ANGE TWP NAME 13/Rh%-m IILn PARCEL NUMBER (S)E-911 ADDRESS ^ODOI\00%1 CO ( LEGAL DESCRIPTION 17. A-c Last Name First Initial Mailing Address Daytime Phone No./%X ^ ^ gTedProperty Owner ujaI>S!,X>. 5%0'y AI S-hnlifHContractor Lie.#/OVQ AM. > This System will be ready for inspection on_the year of ,PM..at. This space for office use only .A.M. P.M. Date Received Time Received L & R Official SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF INSTALLATION TANK DRAINFIELD( 1 ) System loco wSizeGIs.( 2 ) Holding Tank (Alarm Required) ( 3 ) Septic Tank ( 4 ) Lift Station (Alarm Required) Drainfield Trenches, Roc Setback to nearest well Ft.Ft. Setback to OHWL (lake &/or river)Ft.Ft.75fSO( B ) Seepage Bed ( C ) Trenches, Graveless ( D ) Mound ( E ) Trenches, Chamber ( F ) At-Grade ( 6 ) Collector ( 7 ) Outhouse ( 8 ) Greywater System ( 9 ) Sewer Line ( 10) Performance (11) Other Setback to wetland Ft.Ft. Setback to dwelling Ft. Ft.ZIP lOSetback to non-dwelling Ft. Ft. [0Setback to property line Ft. Ft. 3Elevation above water table (OHWL)Ft. Ft. All distances are shortest distance between nearest points ABSORSION AREA FOR MOUNDS(')() GravityEFFLUENT DISTRIBUTION .Ft^( ) PressureWATER WELL DEPTH HOLDING TANK MONITOR/DISPOSAL CONTRACT Designer____ Designer Lie. # PERCOLATION TEST DATAl>-e-cP ( )Yes ( ) No - L & R Can Not Process Date of Test Highest Rate 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. Date: Signal^e a Property Owrv^/Agentlor Owner Date: l^fiffla & Resource Mana^ment Office l3og'g'$PERMIT FEE $RECEIPT NO. A(U Ar-^A 'X't> 5^ ^ 3e>o re>cK rt^c/ucfipn Comments: Form No. BK — 1099-003 300.815 • Victor Lundeen Co.. Printers • Fergus Falls. MN • 1-800-346-4870 APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM LAND & RESOURCE MANAGEMENT OTTER TAIL COUNTY COURT HOUSE121 W. JUNIUS AVE. • SUITE 130 mWOIOPO Phone: (218) 739-2271 • FERGUS FALLS, MN 5653^^^*^^^ WHITE - Office YELLOW -L&R Inspector PINK - Owner / Contactor I37'/,<PPLEASE PRINT OR TYPE ALL INFORMATION Permit No. LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER CLASS TWP NO.SECTION R,<\NGE TWP NAME ^/3 (r l i Z ^OTiYi{ 9PARCEL NUMBER (S)E-911 ADDRESS 1 X^COal\oo%l OO f LEGAL DESCRIPTION i S Las*^-T^ lnitiaP"*..a - MoilinQ AddressLast Name First Daytime Phone No. /%!rzProperty Owner A.'’< M.D.u..’ A L i A I unContractor Lie.#\oro A.M. ► This System will be ready tor inspection on.PM.the year of .at. This space for office use only A.M. P.M. L&R OfficialDate Received Time Received SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF INSTALLATION TANK . DRAINFIELD( 1 ) System ( 2 ) Holding Tank (Alarm Required) ( 3 ) Septic Tank ( 4 ) Lift Station (Alarm Required) Drainfield ((^Trenches, Rock ( B ) Seepage Bed ( C ) Trenches, Graveless ( D ) Mound ( E ) Trenches, Chamber ( F ) At-Grade (6) Collector (7 ) Outhouse ( 8 ) Greywater System ( 9 ) Sewer Line (10) Performance ( 11 ) Other Ft"GIs.Size Xpoo Ft.Setback to nearest well Ft. Ft.Ft.Setback to OHWL (lake &/or river)75YZp Ft.Ft.Setback to wetland Ft.Ft.Setback to dwelling :70 )0 Ft.Ft.Setback to non-dwelling \0 Ft.Ft.Setback to property line 3 Ft.Elevation above water table (OHWL)Ft. All distances are shortest distance between nearest points ABSORfflON AREA FOR MOUNDS('^ Gravity ( ) Pressure EFFLUENT DISTRIBUTION Ft^HOLDING TANK MONITOR/DISPOSAL CONTRACT WATER WELL DEPTH Designer____ Designer Lie. #. PERCOLATION TEST DATAP( )Yes ( ) No - L & R Can Not Process Highest 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 ali 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. Signature of Properly Owr^r/Agent1or O Date: wner \6'Date:j Lartd & Resource Mana^ment Office 13o ^ SPERMIT FEE $RECEIPT NO. A (Ij A. r t AComments: (SpS “ i'prk Aot- r L>c/uf_________________ ? (:>00 ft - lOPO^' ^ Irp’t ^'j '\o'h ^ 3oo iri u)J ^ I// t -p 4' r /^l.AtK '' 300.815 • Victor Lundeen Co . Punters • Fergus Falls. MN • 1-800-346-4870Form No. BK — 1099-003 SEWAGE TREATMENT SYSTEM PERMIT INSPECTION RESULTS Inspector must make all measurements HOLDING SEPTIC TANK DRAINFIELD OUTHOUSELIFT TANKCATEGORY Capacity FT2FT2GLS.GLS. Setback from Nearest Well FT FT FT Setback from Buried Water Suction Pipe FT FT FT Setback from Buried Pipe Distributing Water Under Pressure FT FT FT Setback from Lake, Wetland or River (OHWL)FT FT FT Setback from Dwelling FT FT FT Setback from Non-Dwelling FT FT FT Setback form Nearest Property Line FT FT FT Elevation from Bottom to Water Table / Restrictive Layer FT FT FT FT Holding Tank/Lift Alarm YES NO Old System Pumped & Destroyed YES NO SEPTIC TANK Sewer Line to Well SeparationFILTER DRAINFIELD CALCULATION Actual Minimum Manuf.□ YES FTX Model #□ NO FT 20 MOUND CALCULATION ROCK REDUCTION Inspector’s Comments:,ABSORBTION AREA Rock trenches with inches Ft. X of rock under pipe for .% Ft2 DF.reduction / equivalent to SKETCH: Print Inspector's Name Inspector's Signature Date / Time of Inspection □ Installation Approved L & R Official Initial/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, wetlands and all water wells within 150' of the sewage system. GRID PLOT PLAN feet SKETCHING FORMfeet, or__L inch(es) equalsScale:..grid(s) equals SUBMITTED BY./ll/'eii) FIRM NAMEiSraa ADDRESS: SIGNATURE:/A LCJ^.DATE:/Q— ^C>c>6 fi 1 fi w\ MaJ A MPCA LICENSE #: .3 LICENSE CATEGORY:, R^s o p.f- %% lOOO tf , f-= 3&cJ'- h ~ il7S' 7 s''f ?S' IS-'qI tcP+-% .k iaJ^t /^>oo fr OHw rci<zk '/C^ .4. JL, ^JfCL- ^4- 295.213 • Viciot Lundeen Co Primers • Fergus Falls. MN • 1-800-346-4870BK - 0496 — 029 SITE DATA ' ^ LAND AND RESOURCE MANAGEMENT Otter Tail County Fergus Falls, MN 56537 OWNER: TELEPHONE NUMBERMIDDLEFIRSTLAST NAME ADDRESS: i ■ZIP CODESTATE-CITYSTR./RT RANGE TWP. NAMESEC. TWP.LAKE NAMELAKE/RIVER NO. S LEGAL DESCRIPTION:SOIL BORING LOG Date. COLOR & MUNSELL NO. DEPTH (INCHES)STRUCTURETEXTURE BLOCKY PLATY PRISMATIC NONEPARCEL NUMBER BLOCKY PLATY PRISMATIC NONE FIRE NUMBER NUMBER OF BEDROOMS BLOCKY PLATY PRISMATIC NONE GARBAGE DISPOSAL: YES NO ft.WELL CASING DEPTH;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 ft.DEPTH OF BORING:. PERC TEST #2PERC TEST # 1 - TWO TESTS ARE REQUIRED - PERC RATEWATER DROPINTERVAL (MINUTES)WATER DEPTHTIMEWATER DEPTH WATER DROP PERC RATEINTERVAL (MINUTES)TIME STARTSTART PERCTIMEDROPPERCTIMEDROP PERC RATEWATER DROPWATER DEPTHTIMEINTERVAL (MINUTES!WATER DROP PERC RATEINTERVAL (MINUTES)WATER DEPTHTIME REFILLREFILL DROP PERCTIMEPERCTIMEDROP PERC RATEWATER DEPTH WATER DROPINTERVAL (MINUTES)PERC RATE TIMEWATER DEPTH WATER DROPINTERVAL (MINUTES)TIME REFILLREFILL PERCTIMEDROPPERCDROPTIME PERC RATEWATER DROPINTERVAL (MINUTES)WATER DEPTHTIMEWATER DROP PERC RATEWATER DEPTHTIMEINTERVAL (MINUTES)REFILLREFILL PERCTIMEDROPDROPPERCTIME PERC RATEWATER DEPTH WATER DROPINTERVAL (MINUTES)PERC RATE TIMEWATER DEPTH WATER DROPINTERVAL (MINUTES)TIME .REFILLREFILL PERCTIMEDROPPERCTIMEDROP PERC RATEWATER DROPWATER DEPTHPERC RATE TIME INTERVAL (MINUTES)WATER DROPINTERVAL (MINUTES)WATER DEPTHTIME REFILLREFILL DROP PERCTIMEDROPPERCTIME WATER DROP PERC RATEWATER DEPTHINTERVAL (MINUTES)WATER DROP PERC RATE TIMEWATER DEPTHTIMEINTERVAL (MINUTES)REFILLREFILL PERCTIMEDROPTIMEDROPPERC PERC RATEWATER DROPWATER DEPTHPERC RATE TIME INTERVAL (MINUTES)WATER DROPINTERVAL (MINUTES)WATER DEPTHTIME REFILLREFILL PERCDROPTIMEPERCTIMEDROP PROPOSED DESIGN: PRESSURE DIST..GRAVITY DIST,ATGRADE.MOUND.HOLDING TANKTRENCHBED. SPECIFY:.OUTHOUSE.OTHER.SEWER LINE. SYSTEM DEStGN ON BACK Minnesota Department of Health Division of Environmental Health Engineering Unit 121 East Seventh Place, Suite 220 P.O. Box 64975 St. Paul, Minnesota 55164-0975 HE-01422^a (T/9$t/ s (651) 215-0836 On-Stte Sewage Treatment Plan Review Application On-site sewage treatment plans must be submitted for all projects other than 1-. 2-, and 3-unit residential buildings. Some county offices may review sewage treatment plans if a written agreement has been estab lished between the Minnesota Health Department and the county. If you have any questions regarding where to submit plans or what is required for a plan review, please call 651/215r0836 and ask to speak to a public health engineer. Project Infornrtationa ^Project Name___j^ci ____________ City/Township I 'Z Project Street Address _______A/^lo ^^2^ sType or print the following information.r f ________________I nr. <TL riass 'JUij If the street address is unknown, provide the distance and direction to the project from dosest road intersection. County YES NO □ ^ □ . m Is the project inside the city limits? is the on-site system for a new project or building? Will a garbage disposal discharge to the system? Will a restaurant or food service discharge to the system? , □ □ If yes, is serviceware □ disposable or □ washable and reusable. If a well is present: Distance between the well and the drain field:___ Distance between the well and the septic tank: _ / JtQ / 5*0 Septic System Designer Name License No. Address .7ji City )r\^ r yL______ State Phone ^ ^~S~/OO Project Owner 9ii 'A b l icT- Qcu^s^. OQQqO: Name Address \wLpct»^ .City '?6L State z,n J-4.S3WPhone .(area cotie) (area code)\*Plans must be signed by the septic system designer. Provide the following information in addition to this application form: □ A Site plan— Show the distances from the septic tank and drainfield to the following: wells, buildings, sur face waters, property lines, parking lots, driveways, or any other significant features on the property." The site -.■■i.j .".iplan must show the soil boring and percolation test locations.'iiL;□ Details of the trenches, bed, or mound — Show a cross-sectional view of the trench, bed, or mound. -Indicate the type of material (sand, &il, of rock) andthe depth of each layer in the drainfield. Provide a - detailed plan showing the overall dimensions and features of the drainfield. Indicate the distances between drairifieid'pi^, the pipe sizes, and the locations of perforations in the pipe. □ Soil boring and percolation test data — Provide copies of actual field test results. Please turn page over and complete the back. ) Bed or Trench ConstructiowfFlow Rate Calculations Pow rate calculations should be determined using the tables provided in the Minnesota On-site Sewage Treatment Manual. Flow rate based on: (check one and pmvide number ct urko) □ Number of customers___ 37 .01 ;V. Length of trenches o' beds .pS'Width of trenches or beds (trenches, t.5-~3 feel) (bads, 3-25 teeiy~ Number of trenches oir beds 1.’, ■(people) Number of employees Depth of trenches or beds__ (to inches minimum, 64 inches maximum) (peopio)Cinches) □ Maximum seating capacity Depth of rock below drainfield pipe (6-24 inches) Depth of rock above drainfield pipe (at least 2 inches) . Depth of backfill above rock 3^^ (seats) (inches)□ Building square footage (square feel) . □ Other Cinches) (number and units)(I.e., campsites, mobile homes, etc.) Maxirtium daily flow rate (inches)(6-36 inches) ^ Type and size of pipe Type of distribution (check one): Gravity |S Pressure □ (gallons per day) Average daily flow rate (gallons per day) Hours per dayDays of use per year * Filter material must be a durable nonwoven geotex tile cover which allows passage of water.Soil Data Soil percolation rate_______ (provide a copy of the soil percolation test) Soil sizing factor___________ (minutes per inch) At-Grade Mound or Mound Construction Data (square feet per galion) Depth from surface to restricting layer (provide a copy at the soil boring) Type of restricting laverl (mottled soil, bedrock, or water table) (inches)'I Length of rock bed (too feet maximum) Width of rock bed _ (10 feet maximum) Upslope dike width (feel) Percent slope of natural grade S TeSJ ^ V Septic Tanks Number of septic tank(s) (feet) / Downslope dike width (feet) Size of septic tank(s)Linear Loading Rate_________ (at-grade systems only) Depth of sand fill____________ (at least 12 inches) Depth of rock below pipes____ (at least 9 inches) Depth of rock above pipes • (at least 2 inches) (gallons)(2-8 gpdm)'•h Number of compartments in each tank___ Will sewage be pumped to the septic tank(s)? (inches) YES □ NO a (inches) Other Tanks or Components Lift station tank capacity______________ (inches) Cover over the rock (at least 12* center and 6* at side)(side)(center)(gallons) Type and size of pipeNumber of lift station pumps (sae)(type) Slope of sides of mound (3:1 maximum) Filter material must be a durable nonwoven geotex tile cover which allows passage of water. ^:umber of drop bokes ‘ *Number of distribution boxes V System design must be to scale and mustTihcliJde|tRrpropdsedIdcetitfni ofjthe^sraBS feVstem, "all existing/proposed buildings, pr6|:iert{^ iihesj ^he‘ordinal-yi-liigh-wkteHel/^l 'of thel wdt^r bod^, vvedands and all water wells within 150' of the sewage system.II GRIDRtOtPLAN feet SKETCHING TORM I!I IScale:grid(s) equals feet, or Jhchi es) equalsi I \L!I !!I 1 I ; \ , ^ 44|^-l-bAT(E; 71^1 i/y);4.in/ £>AAr /\i)^ IT^lskiLyi i SjGtoURSUBMITTED BY:I I U /J7FIRM NAME: MPCA LICENSE J^: SE CATEGORY: ---------1-------h - ! 1 i - i 1 r rADDRESS: I. Ii 2^i ilCEK ■ i/I II-I I [ -!-! ; I I ’ I I I :l;1 I[i I i ! I i 1 !I :r r;(N- ‘ 1w I 1 i L.i 1 !P ;1^jbo^j . I !(5!/4!f!'O-'Ii 1\t (I !IrI 1 ■ I I < 1I ij i it:_t I I I :I1I i;(IJf%^6 I ; Ir'-1i 0j!1 ! i“ 1- ■ f !.J-1 N J L:!!-I I I ; ' ! i I I i I Ir i-'n-rt : j i I I! i ', I IiIi—-I i nI- M --!_|i /T 0I t «i i'rTrvri'^i. . > : L . . ! : I I. L ; L.i I J II L-.!I * 1'1 I i + i I ’ i ■ 'rH ' " TO I Ii! !I ' i I i - r r-;- '-It;II!:f rri r1 i III iI I !i -i-r I I M m I)”r !i IIl-i-it]\L“vr;I 11:1!-I ! ::i 'l i .ti.1 i1Ii*#«- LiliidzLi:', FallL MN •1-800-3^4870• 1 Co.. PrintersBK - 0496 - 029 Fergus295.21:Victor Lurideen 1 t i ■ 1'lI -- —iT-'-.-’l-v • ■ -Aisivi-ci:.'&v..: - ^SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone 218-739-2271 - Fergus Falls, Mn. 56537 APPLICATION FOR PERMIT TO INSTALL SEWAGE D/SPOSAL SYSTEM Wh/il-Offin Y0IIOW - IrupKtor Pink - Owrw Cord—Own*f Permit No., sLEGAL DESCRIPTION AND Clt<cdkdiLL 45-/jfALOCATION 'n TWP NameSac.TWP RangeLake Classif.Lake No. Lake N IDENTIFICATION; Please Print All Information. Tel. No.Zip No.Mailling Address —No. Street, City and StateInitialFirstLast Name O__________^OlCljru!^SoJc nOWNER fYLvx 5*-/ ;SEWAGE SYSTEM INSTALLER <XYV-nName. This System will be ready for inspection on.19, This space for office use only .M,19 Owner or Agent SignaturePhone Call Rec'd ByDate Rec'd Time Rec'd 6NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PITSEPTIC TANK DRAIN FIELD UjA45 0 0 Gis.Sq. Ft.Sq. F/.Capacity d ^ //O d57)Ft. Ft.Ft.Distance from nearest well Id 55Ft.Ft.Ft.Distance from lake or stream °? 610Ft. Ft.Ft.Distance from occupied building /oJoFt.Ft.Ft.Distance from property line Ft.Ft.Ft.Distance from bottom to Water Table AH distances are shortest distance between nearest points RECORD OF TESTS: ., 19,Inspection was made on , Time ..........JVI By ,, 19 ....C^r ,Z.l:J.dPERCOLATION TEST DATA:Date of First Test Rate ,Z(%Uj2-rK S T'TJiJicinry-^Date of Second Test 19 , Rate 1st Test Taken By 11 /% First Test -I- 2nd Test Ra2nd Test Taken Bv 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 Tall, 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.) 9- V 'yC}0LA5rz:95Dated Signature Permission is hereby granted to the above named applicant to perform the work described In the above statement. This permit is granted upon expressPermit; condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota. This permit may be revoked at any time upon violation of any said ordinance. NOTE; Permit void if work is not commenced within six (6) months. issued Date: Shoreland Management Office AFee $ Comments:. Form No. MKL-0771-003 [^VIEW lATTlI LAKC, MiNNC$OTA J ✓ INSPECTION RESULTS Inspector must make all measurements SEWAGE DISPOSAL SYSTEM STATISTICS DRAIN FIELDSEEPAGE PITSEPTIC TANKCATEGORYActualShould be Actual Should be Actual Should be Capacity GIs.GIs.S F SF S F SF Distance from Nearest Well 75 50FFFFF F Distance from Lake or Stream 1 FFFFF F Distance from Occupied Building 2010 20FFFFF F Distance from Property Line 10 10 10FFFF F F Distance from Bottom to Water Table 33FFFFF F Inspector's Comments: ; Date of Inspection 19___ Time of Inspection.^M Signature of InspectorINTERPRETATION OF ABBREVIATIONS GIs = Gallons SF = Square Feet F » Linear Feet* Job Title Agency MKL-0771-00 3-Backer I ?• .•I ; I 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 Whlw-Offira Y^tlow — Inapecfof Pink — Owner Card —Owner Permit No.. LEGAL cMi3DESCRIPTION AND LOCATION TWP NameSec.TWP RangeLake Classif.Lake NameLake No. IDENTIFICATION: Please Print All Information. Zip No.Tel. No.Mailling Address —No. Street, City and StateInitialFirstLast Name OWNER SEWAGE SYSTEM INSTALLER Name. ^2 3-‘ This System will be ready for inspection on.. 19 This space for office use only 3- Owner or Agent SignatureDate Rec'd Time Rec'd Phone Call Rec'd By NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PITSEPTIC TANK DRAIN FIELD Sq. Ft.Sq. Ft.GIs.Capacity Ft. Ft.Ft.Distance from nearest well Ft. Ft.Ft.Distance from lake or stream Ft. Ft. Ft.Distance from occupied building Ft.Distance from property line 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 Rate Date of Second Test 19 ., Rate 1st Test Taken By First 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 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 $Not E RTIFlCvATF ISSUeD Comments:. - # Form No. MKL-0771*003 [^(VIEW ftAtUE UKI, MINNESOTA INSPECTION RESULTS Inspector must make all measurements SEWAGE DISPOSAL SYSTEM STATISTICS SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORY Actual Should be Actual Should be Should beActual uisSii'isCapacityGIs.GIs.S F S F S F ^0Distance from Nearest Well 75 50FFFF F 75 7S75* Flg_Distance from Lake or Stream F F F F 2fl FLADistance from Occupied Building 2010 20FFFF F TDistance from Property Line d10 10FFFF F 3 .Distance from Bottom to Water Table 33FFFF F Inspector's Comments: / ___sO^ lam n If 1 ^ ZlO 19J^Date of Inspection 3-Time of Inspection. r3K Signature of InspectorINTERPRETATION OF ABBREVIATIONS GIs ■■ Gallons SF = Square Feet F = Linear Feet Job Title AgencyMKL-0771-003-Backer 3' ^ /* <ti I . . I !•. \ 0.^I PERCOLATION TEST DATA SHORELAND MANAGEMENT OTTER TAIL COUNTY Fergus Falls, Minnesota 56537 Ph. No. Owner:Mailing Address: Last Name Middle St. & No.State Zip No.City Legal Description: LAKE OR RIVER NO.SEC.NAME TWP.RANGE TWP NAME TEST HOLE NO. 2TEST HOLE NO. 1 ItLK'UL Depth to Bottom of Hole Inches; Diameter of Hole inchesDepth To Bottom of Hole,inches; Diameter of Hole inches nOL. f>-Depth, Inches Soil Texture Soil TextureDepth, InchesDate19i Date 19 nSaauu -CU^y 6"LPercolation Test By____ Percolation Test Bv .2-I)22oLU //Firm Name.QC FirmName.z>oLU cc PJ^.JLU Address.CC Address < COOtter Tail County License No..Otter Tail County License No.^I-COlUMeasurement, Inches Drop In Water ■Lev#l. Ipches Drop in Water Level. Indies Measurement, Inches HTimeRemarks Time Remarks O% JA-o ^ 1' I jx- D-L •:IL- .5'/ /X-S'L /^. - /.5l '!%'■ ‘4 b >■ £f /3'I' 7TI >/>/¥ IhL / '/4 /^/y IxLn 1HJL w.w2i:5If'U±V £T-JpG 7 I MKL-0871-028183818 ®fiCToa uiaSfia • e« . a*i«ni rM.1 See Booklet/'How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn. L. 1S9035 r 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 OfficS InspectcvW te V low Pli.. — Owner Card — OwnW Permit No. ^ ^ V ^ Date ah'f'LEGAL DESCRIPTION AND Lake Ciassif. n ViL-jryyLOCATIONLake^ame Lake No.Sec.TWP Range TWP Name IDENTIFICATION: Please Print All Information. Last Name First Initial Mailling Address —No. Street, City and State Zip No.Tel. No.po bn: /7OWNER 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 3NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD /poo GIs.C7e Sq 0/ao Capacity Sq. Ft.. Ft. Ft.Ft.Ft.Distance from nearest well y 0 Ft.Distance from lake or stream Ft.Ft. SUbroDistance from occupied building Ft.Ft.Ft. /oDistance from property line Ft.Ft.t. Ft.Distance from bottom to Water Table Ft.Ft. AH distances are shortest distance between nearest points RECORD OF TESTS: Inspection was made on 19 , Time ,JVI By r...3 PERCOLATION TEST DATA:Date of First Test , 19 Rate s-k.L..Date of Second Test 19 Rateu\^ 1st Test Taken By \ V 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.) Signature s/Dated 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 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. / Issued Date: Shoreland Management Fee $*11111 Inn gr $ _______i cn\ j/ljucComments:. Form No. MKL-0771-003 viCToi lukrccm « CO., ooiiinao. ritous rALLi himm.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'" te V low — I Pi... Ca^d - Offices nspector *nerOwner a Permit No.,/LEGAL Date DESCRIPTION O AND LOCATION Lake No.Lake Name Lake Classif.Sec.TWP TWP NameRange IDENTIFICATION: Please Print All Information. Last Name Initial Mailling Address —No, Street, City and StateFirst 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 Rec'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.>tt»jtance 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.Distance from bottom to Water Table Ft.Ft. AH distances are shortest distance between nearest points RECORD OF TESTS: Inspection was made on 19 , Time ,M By 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 $ 1 rf/ Comments:. CERT . O O Form No. MKL-0771-003 yicTsu waBiiN « e«.. ,158906•ni 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 S FCapacityyor<ry So'^ GIs.GIs.S F S F S FJT Distance from Nearest Well f F 75F 50FF F /OofDistance from Lake or Stream /*00 T FFFFF F 5-^Distance from Occupied Building 10 2020FFFFF F /'Of- p/o TDistance from Property Line 10 10 10FFFF F FDistance from Bottom to Water Table 4 4FFFF F Inspector's Comments: ;r- / <S'Date of Inspection 19__^ Time of Inspection M SignatuE^e of InspectorINTERPRETATION OF ABBREVIATIONS GIs ■■ Gallons SF • Square Feet F “ Linear Feet / Job Title AgencyMKL-0771-003-Backer •- ' <.■ 'v’r e PERCOLATION TEST DATA Price $1.00 per pad. SHORELAND MANAGEMENT OTTER TAIL COUNTY Fergus Falls, Minnesota 56537 Ph. No.Owner:Mailing Address: 5oxi /A i Kifd State Zip No.Last Name First Middle CityLegal Description:f c-NAMELAKE OR RIVER NO.SEC.TWP.RANGE TWP NAME TEST HOLE NO. 2TEST HOLE NO. 1 zDepth To Bottom of Hole.Depth to Bottom of Hole inches; Diameter of Hole.inches;Diameter of Hole Jnchesinches if-yDepth, Inches Soil Texture Depth. Inches Soil TextureDate19 Date 19.(Itk Percolation Test By____ Percolation Test By____Jo OLUFirmName.QC OLU GC LUAddress.GC Address < (/>Otter Tail County License No.Otter Tail County License No^l-C/3LUMeasurement, t nches Depth in Water Level, Inches I-Measurement, Inches Depth in Water Level. Inches Time Remarks Time Remarks*o ■V r,SrgI-L//3 ' M Si d 5 Q(/ 4.UP f '5 6 V .5^ /AT7 M Vvf±!Arr/ 9 W ir / Ah{l Lm0~o'N I/'//AS r^C. 2 MKL-0871-028 Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn. 183-81& @EVKW lATUf LAKI MINNfSOTA r i V- O C2O - t i1 »N ^ , • • ^ ^ it • • ■:«• *'J V ■ ■ ?^s,W,tc --’ U CERTIFICATE OF COMPLIANCE S,SEWAGE SYSTEM K. mi:S i #'tlUthNovemberI9JI ftV?jiili mm This certificate has been issued this day of.Hi Mto certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota. The premises covered by this certificate are legally described as: Range ^3 . A-./•CfiPl3in mM Lake No.^^LlI31l Twp 13UN ElizabethSec._ll.Twp. Name.Wf: wLast Resort aramm{ IV. :s : ,i>1 !»'i Harry MathesonIMOwner: Name. aSI Address Breckerridge , Minnesota :f0fmw& m 56520Zip No.m • > ■'ife m852Permit No. SP_ MalcoW K. Lee, Shoreland Administrator Otter Tail County, Minnesota 'Lc.Signed by:. iMKL-0871-009 l'' "1 *15^\v sirwf JO A ?i ®159035 •'=' \V- 'j SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone 218-739-2271 - Fergus Falls, Mn. 56537 APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM White - Office Yellow — Inspector Pink — Owner Card*— Owner Permit No.,:5o rLEGAL Date DESCRIPTION AND LOCATION jStZZ. Lake NLake No.Lake Classif.Sec.TWP Range TWP Name IDENTIFICATION: Please Print All Information. Initial Mailling Address —No. Street, City and StateLast Name First Zip No.Tel. No. 0M.ciSiO-rxOWNER _____£7 kr^ ol yV^ 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 GIs.S(/Ft.Sq. Ft.Capacity Ft.Ft.Ft.Distance from nearest well Ft.Ft.Distance from lake or stream Ft. o^CJFt.Ft.Distance from occupied building Ft. /ODistance from property line Ft.fLO.Ft.Ft. £F^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 '£....£.2... ..........JVI By............ ., 19 .... Rate. , 19....?;.3...... Rate Lt/..PERCOLATION TEST DATA: /^re»c A. Sr* /________________ Date of First Test ,z.Date of Second Test 1st Test Taken By =L±//1 First Test -I- 2nd 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 inspection. (Call or use attached mailer notice.) /mj.. fsJDated 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 // Oo/o Issued Date: Shoreland Management Office jLo/rFee $_u^_L Surcharge $ QorJj-----y. AComments:.atO—* Form No. MKL-0771-003 ©,158906 VICT»« IWMKIN 4 c«.. pa>art*4. rc««u4 r«„Lf. SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone 218-739-2271 - Fergus Falls, Mn. 56537 APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM White * Office Yellow “ Inspector Pink — Owner Carc^ — Owner -)a-Permit No...5CV rLEGAL /-T\Date DESCRIPTION AND •'/LOCATION r -V* C.' Lake Classif.Sec.TWP Range TWP NameLake No.Lake Name IDENTIFICATION: Please Print All Information. Initial Mailling Address —No. Street, City and State Zip No.Tel. No.FirstLast Name OWNER /r A < Ari. ~i T'/ ' t\ SEWAGE SYSTEM INSTALLER Name. // 1 0 /Q. M.Thh System will be ready for inspection , 19.on. This space for office use only ,M.19 Phone Call Rac'd ByDate Rec'd Time Rec'd Owner or Agent Signature NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PITSEPTIC TANK DRAIN FIELD 2LLGIs.Sq. Ft.Sq. Ft.Capacity Ft. Ft. Ft.Distance from nearest well Ft.Ft. Ft.Distance from lake or stream Ft.Ft.Ft.Distance from occupied building Ft.Ft.Ft.Distance from property line Ft. Ft. Ft.Distance from bottom to Water Table AH distances are shortest distance between nearest points RECORD OF TESTS: 19 , Time ,JVI ByInspection was made on ,/ V■' 3PERCOLATION TEST DATA:Date of First Test . 19 , Rate /'3 ..y .19....;;.'JDate of Second Test Rate 1st Test Taken By /, 7 /./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. AppI leant 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.) /.'Ly(ADated 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 (6) months. Permit: /y // //Issued Date:. Shorelary^Management Office Surcharge $Fee $_.1 £i I7,tro V i/ f~yrytjL)Comments:.---'n arA'l : /1 /N ^ vicTea ui«»icN 4 e*.. pwiina*. rcaaus facL*. mimn 158906^Form No. MKL-0771-003 «• INSPECTION RESULTS r Inspector must make all measurements•: SEWAGE DISPOSAL SYSTEM STATISTICS SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY Actual Should be Actual Should be Actual Should be e%O0Capacity 7^0 SFGIs.GIs.S F S F SF Distance from Nearest Well 5 50FFFF F Distance from Lake or Stream F F F F F cS^ ^ FDistance from Occupied Building 201020FFF F F Distance from Property Line 10 10 10F/fPT FF F F F FDistance from Bottom to Water Table 4 4FFFF F / Inspector's Comments: 30 X /Date of Inspection, A/o :qoTime of Inspection,M Signature of InspectorINTERPRETATION OF ABBREVIATIONS GIs ■* Gallons SF * Square Feet =■ Linear Feet Job TitleF AgencyMKL-0771-003-Backer X ■ ■ s;.. >V PERCOLATION TEST DATA Price $1.00 per pad. SHORELAND MANAGEMENT OTTER TAIL COUNTY Fergus Falls, Minnesota 56537 i Ph. No.Owner:Mailing Address:* ^ < ytj y - 4^StateFirstMiddleSt. & No.City Zip No.Legal L LuRUDescription; ^ ^ lakeWriver no.NAME TWP.RANGE TWP NAME 4 a/:, l/I.As'Li TEST HOLE NO. 2TEST HOLE NO. 1 d Depth to Bottom of Hole 4^Depth To Bottom of Hole.inches; Diameter of Hole inches; Diameter of Hole.Jnchesinches Depth, inches Soil Texture Depth, Inches Soil Texture d— *li Vd^colation ^ , Test By------L----<L ^ -/ifPercolation Test By Q yfl *HI7Firm Name CjUCC Firm Name. aUJCC LU TOtter Tail County License No. Address.CC Address < CO7^Ott^1-V Measureme Inches COLUMeasurement, Inches Depth in Water Level, Inches H Depth in Water Level. Inches Time Remarks Time Remarks o /j3:yg MJ6 5/A I- I'/J V1 / X /a ^ JJL 6iA‘X %3^M±_ /a /Si- /;jo :Z j:: / / M MKL-0871-028 See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn.