HomeMy WebLinkAboutLeuthner_57000020018011_Shoreland Permits_OTTER TAIL COUNTY
Grade & Fill Permit #
I S
(kPROPERTY OWNER
TWP. NAME
p-r _______
LAKE NO. 'Vg^ SEC.CO
LEGAL DESCRIPTION:
WORK AUTHORIZED LyCir Vow
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NOTE: This card shall be placed in a conspicuous place not more than 4 feet above grade on the premises on which work
is to be done, & shall be maintained there until completion of such work. NOTIFY LAND & RESOURCE MANAGEMENT,
218-998-8095 WHEN AUTHORIZED WORK HAS BEEN COMPLETED.
C^r\rA.vVvKW^Sw^>S»Ol ■
1. EARTHMOVING SHALL BE DONE BETWEEN
2. Entire area shall be stabilized within 10 days of completion of any earthmoving.
3. Owner is legally responsible for all surface water drainage that may occur.
' n4. No fill shall enter or be taken from the beds of public water without a valid permit from the
MN Department of Natural Resources.
5. If the terms of this permit are violated, the entire permit may be revoked and the owner may
be subject to legal prosecution.
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/
APPLICATION FOR GRADE & FILL PERMIT ’
LAND & RESOURCE MANAGEMENT, COUNTY OF OTTER TAIL
GOVERNMENT SERVICES CENTER, 540 WEST FIR, FERGUS FALLS, MN 56537
218-998-8095
www.co.otter-tail.mn.us
Permit No.PLEASE PRINT OR TYPE ALL INFORMATION
LAKE/RIVER #LAKE/RIVER NAME LAKE/RIVER
CLASS
SECTION TWP. NO.RANGE TWP NAME
si^-sn'd Lc<.-V UovVCiL 0 3 I SIN qiuJ
PROPERTY (E-911) ADDRESS 'PARCEL NUMBER(S)
^afBTrr^ g7ooOo;;C)c>)8b)i ______
e'/cyCov- sAC PT C-L 8CLEGAL DESCRIPTION O
F>Cr A 5 7
Last Name First Initial Mailinq Address DAYTIME Phone No.
Property
CAv\fi>tL>ruoc>.c ri 7^9 VOwner
Contractor
Name C»V/\V 1^ \ Ooct-^VVXC ViiO eB
es-QHLie. #
Date Stamp
NOTES: 1. The lotlines and project area(s) must be staked.
2. If project disturbs more than 1 acre of land you
are required to obtain a General Storm Water
Permit from the MPCA.
L&R Initial
PROJECT REQUEST (You may use the grid on back for required scale drawing):
* /DESCRIBE YOUR PROJECT(S): 77)/£>cit'dt w
n~V Vo C V-lCvV <0*^ Vd._____
0-* > V\^\ \?^^^^ru \
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i^Va^ Vv(x\-C Q-V -VVx, c AccAvVrvvc
DETAILED INFORMATION:
AREA TO BE CUT/EXCAVATED:R~ - 27 =Yds^FT~T FI. X
Length Width Ave. Depth
Yds^WALK-OUT BASEMENT PROJECTS: a-
(Outside of the building foundation)
Ft V Ft. X Ft. - 27 =
Length Width Ave. Depth
835^'4fL X \3 0 Yds^AREA TO BE FILLED/LEVELED;Ft. X Ft. - 27 =
Length Width Ave. Depth
^•33Yds^TOTAL EARTHMOVING REQUESTED =
BACKFILL AT FOUNDATION:Ft.Ft.
Max. Depth Distance From Foundation
CULVERT:If Yes, must indicate size and location on drawing.
Yes No SCANNEDIMPERVIOUS SURFACE:%
7-/- /P>
£ATURE OF PROPERTY OWNIR/AGENT FOR OWNER DATE RECEIPT NUMBER
BKO
The scale drawing must be a signed drawing which includes and identifies a graphic scale (feet), all existing and/or proposed structures, septic tanks,
drainfields, lotlines, road right-of-ways, easements, OHWLs, wells, wetlands, topographic features (i.e. bluffs), and onsite impervious surface dalculations,V
Scale
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3^5.195 • VtctCH Lundeen Co. Pfiniofs • Fergus Falls, MN • l-800-3*i6-4870
APPLBCATBON FOBS SB¥E PEISRIBBT
LAND & RESOURCE MANAGEMENT, OTTER TAIL COUNTY (218-998-8095)
121 W. JUNIUS AVE. SUITE 130, FERGUS FALLS, MN 56537
www.co.otter-tail.mn.us
WHITE - Office .
GOLDENROD - Inspector
YELLOW - Owner (after issue)
PINK - Assessor
7Permit No.PLEASE PRINT OR TYPE ALL INFORMATION
TWP NO.RANGE TWP NAMELAKE/RIVER
CLASS
SECTIONLAKE/RIVER NAMELAKE / RIVER NO.
g) L-ost>041j2-p 12^302-
property (E-911) ADDRESSPARCEL NUMBER (S)
3noooo'2-oo\so \ \22306-SS-Otu-
LEGAL DESCRIPTION
Lob& P\MeA
Daytime Phone No.First Initial Mailing AddressLast Name
22 306-330V AuP, [JU^rA/(A)oa^^
nr\2?o^ 33rjT/v- Ava/^ u iAdrA/u)d>d, m/O
Property
Owner €p3I-22^4
"TlAi&iAataLSContractor
Name
Lie.#
ONSITE SEWAGE
TREATMENT SYSTEM
^ Permit No. /g
ONSITE WATER SUPPLY
(\4i(iividual ( ) Public ( ) None
NOTE: MN Rules Chpl. 4725 (MN Well
Code) requires a 3’ (minimum) structure
setback to a well.
J^OPOSED PROJECT (please circle the appropriate number)
n^^New Dwelling( 2 ) Add’n to Dwelling
( 5 ) RCU/Year_____
( 7 ) Add’n To Non-Dwelling ( 8 ) Storage Structure
(10) Other.
( 3 ) 'Replacement Dwelling
( 6 ) Detached Garage
(9) W.O.A.S.
(4 ) MHA'R.( ) OTLSD * This permit is only valid after verification
from the O.T.LS.D. that a conforming
sewage system will be installed to service
this lot contact Rollie Mann at 864-5533.'Existing Dwelling to be removed before.
CHARACTERISTICS OF PROPOSED W.O.A.S.
(WATER ORIENTED ACCESSORY STRUCTURE)CHARACTERISTICS OF PROPOSED NON-DWELLING
Outside
Dimension
CHARACTERISTICS OF PROPOSED DWELLING
Outside _ ^Dimension 6 ^ Ft. x ^ o Ft."
s,,R._Li£!d. O)
Setback to Lotline 33 Ft. & ^ / Ft."
Setback to Right of Way I GO Ft."
Setback to Ordinary High Water Level VI Q Ft.
Elevation Above Ordinary High Water Level I 3 Ft.
Setback to Septic Tank 30 Ft.
Setback to Drainfield 23 Ft.
Setback to Bluff *^/A- Ft.
Maximum Proposed Height I ^ Ft.
^ Yes
Outside
DimensionFt. X Ft."Ft. X
Sq. Ft.
Setback to Lotline___
Setback to Right of Way
Setback to Ordinary High Water Level __
Elevation Above Ordinary High Water Level
Setback to Septic^nk__
Setback to Dr^field____
Setback \oJo\uW_______
Maximunft Proposed Height
Bathroim Proposed ( ) Yes ( ) No
Sq. Ft.
Setback to Lotline ___
Setback to Right of Way
Setback to Ordinary High Wal^r Level __
Elevation Above Ordinar^igh Water Level
Setback to Septic TanK
Setback to Drainfi|?(d____
Setback to Bluf/_______
Maximum ^posed Height
( ) Boathouse
( ) Gazebo
Ft."Ft."R.&,
Ft."Ft."
Ft.Ft.
Ft.Ft.
Ft.Ft.
Ft.Ft.
Ft.Ft.Ndi'Basement
Walkout Basement v— \ Yes
Total Bedrooms -3 ^
Ft.Ft.No
\( ) Screen Porch
( ) Storage Structure
**Project/Lotlines/Right-of-ways Must be Staked Onsite Prior to Appliontipn /ihripfctic
□ 20 Cubic Yards or Less ' Coble Yards - 299 Cubic Yards' □ 300 Cubic Yards or More'
.Xr- O ^ P ptyr O v-'
' 1-1% lo"-i c\x-(3 rc iVKv- <:?L-Vv-v^ .J
Water Frontage * ' P_________Ft. Bluff____Yes W No
Must Include on scale drawing
Permit may be required
Topographical Alteration / Earthmovinq
□ None ^ 4y FTT7CHARACTERISTICS OF LOT;
34M V (oLot Area.
z.023j(/00 X 100 =,%Impervious Surface Ratio:Impen/ious Surface RatioTotal Lot Area (FT^)Total Impervious Surface Onsite (FT^)
THIS IS A SITE PERMIT ONLY AND DOES NOT CONSTITUTE A BUILDING PERMIT AS SET FORTH IN CHAPTER 16, MINNESOTA STATE STATUTES.
Agreement: I hereby certify that the information contained herein is correct and agree to do the proposed work in accordance with the description above set forth
and according to the provisions of the Ordinances of Otter Tail County, Minnesota. I further agree that any plans and specifications submitted herewith shall become
a part of this permit application. I also understand that this permit is valid for a period of six (6) months.
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
condition that the person to whom it is granted, and his agent, employees and workmen shall conform In all respects to the Ordinances of Otter Tail County,
Minnesota. This permit may be revoked at any time upon violation of said Ordinances. ^
I understand that it is my responsibiiity to inform the Land & Resource Management office^fnee the lonstructed.
V- 7-0 3
y- 7- g >
Date:
f Property OwnerSigm
Date:
Land & Resource Management Office[^\3Q.qo RECEIPT NO. 'illPERMIT FEE $PROJECT(S) TOTAL SQ.FT.,
Comments:»•__________ _______________ ^ ^rfL|>^v'liVrA (^lO-fO-QZ-'^
vieMT-'
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313,012 • Vidor Lundeen Co., Printers • Fergus Falls, MinnesotaForm No. BK — 0203-0501
5- lU^o3
APPLICATION FOR SITE PERMIT
LAND & RESOURCE MANAGEMENT, OTTER TAIL COUNTY (218-998-8095) ^
121 W. JUNIUS AVE. SUITE 130, FERGUS FALLS, MN 56537
www.co.otter-tail.mn.us
WHITE-Office
GOLDENROD - Inspector
YELLOW- - Owner (after issue)
PINK - Assessor of-
:>oio 7Permit No.PLEASE PRINT OR TYPE ALL INFORMATION
RANGE TWPNAMESECTIONTWP NO.LAKE/RIVER
CLASSLAKE / RIVER NO.LAKE/RIVER NAME
L 0 --.t D 13 3■2-
PROPERTY (E-911) ADDRESSPARCEL NUMBER (S)
s •_
LEGAL DESCRIPTION
Let C tyi PUi^^eA C\v^r{ ty
Daytime Phone No.Initial Mailing AddressFirstLast Name
A\/y ((l^Arvu)a><^,
At/’'-(- S2» ^Property
Owner LrtAlV v\rtr ~T\a owv; s 6
io8^\' I u 1-. \a^_^ E-Contractor
Name
Lie.#I AeA)
ONSITE SEWAGE
TREATMENT SYSTEM
ONSITE WATER SUPPLY
(\/individual ( ) Public ( ) None
NOTE: MN Rules Chpt. 4725 (MN Well
Code) requires a 3’ (minimum) structure
setback to a well.
PROPOSED PROJECT (please circle the appropriate number)
( (1 ),'New Dwelling (2 ) Add’n to Dwelling
(4) MHA'R.
(7) Add’n To Non-Dweliing (8) Storage Structure
(10) Other,
(3) 'Replacement Dwelling
(6) Detached Garage
(9) W.O.A.S.
(^,) Permit No.
{ ) OTLSD * This permit is ortiy vaiid after verification
from the O.T.L.S.D. that a conforming
sewage system vrilt be instaiied to service
this ht contact Roiiie Mann at 864-5533.
{5) RCU/Year.
'Existing Dwelling to be removed before.
CHARACTERISTICS OF PROPOSED W.O.A.S.
(WATER ORIENTED ACCESSORY STRUCTURE)
Outside
Dimension
CHARACTERISTICS OF PROPOSED NON-DWELLING
Outside
Dimension
CHARACTERISTICS OF PROPOSED DWELLING
Outside
Dimension
Sq. Ft. )
Setback to Lotline Ft. &
Setback to Right of Way i ‘~7 J ^ ^ Ft.”
Setback to Ordinary High Water Levei 11 Ft.
Elevation Above Ordinary High Water Level I Ft.
Setback to Septic Tank
Setback to Drainfield Ft.
Setback to Bluff Ft.
Maximum Proposed Height I ^ Ft.
Basement
Walkout Basement
Total Bedrooms
Ft. X Ft.”Ft. X F).”
Ft.”, •Ft. X
Sq. Ft.
Setback to Lotline ___
Setback to Right of Way
Setback to Ordinary High, Water Level __
Elevation Above Ordinary High Water Level
/Setback to Septic.Tank__
Setback to Drpinfield____
Setback to Bluff_______
Maximum Proposed Height
Bathroom Proposed ( ) Yes ( ) No
Sq.Ft.
Setback to Lotline___
Setback to Right of Way
Setback to Ordinary High Water Level __
Elevation Above Ordinary High Water Level
Setback to Septic Tank__
Setback to Drainfield____
Setback to Bluff_______
Maximum Proposed Height
( ) Boathouse
( ) Gazebo
/Ft.”Ft.”Ft. 8r.l Ft.”
Ft.”_Ft.”
Ft.Ft.
Ft.’oO Ft.Ft.
Ft.Ft.
Ft.Ft.
Ft.Ft.N</v/Yes Ft.Ft.A/Yes No
\( ) Screen Porch
( ) Storage Structure
"Project/Lotlines/RIght-of-ways Must be Staked Onsite Prior to Application / Inspection
a#'^21 Cubic Yards j 299 Cubic Yards' □ 3^ Cubic Yards or More* _____________________________________
4^—0S ^3 K35 ■J'e Vfvi Vd kS Fo
T
I > 0 Ft. Bluff Yes y/No eX4^- 9'ill <Jl ;
Von/ a "l 'P t" sw o-f '
______ X100 =
Must include on scale drawing
Permit may be required
Topographical Alteration / Earthmovinq
□ None □ 20 Cubic Yards or Less *
CHARACTERISTICS OF LOT:
f\( vf SSerFF.r,Water FrontageLot Area.I
T n ( i fil/- ( b/Aifn =• OZ
Impervious Surface Ratio 'Impervious Surface Ratio:0
Total Lot Area (FT^)Total Impervious Surface Onsite (FT^)
THIS IS A SITE PERMIT ONLY AND DOES NOT CONSTITUTE A BUILDING PERMIT AS SET FORTH IN CHAPTER 16, MINNESOTA STATE STATUTES.
Agreement: I hereby certify that the information contained herein is correct and agree to do the proposed work in accordance with the description above set forth
anr» according to the provisions of the Ordinances of Otter Tail County, Minnesota. I further agree that any plans and specifications submitted herewith shall become
a part of this permit appiication. I also understand that this permit is valid tor a period of six (6) months.
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
condition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the Ordinances of Otter Tail County,
Minnesota. This permit may be revoked at any time upon violation of said Ordinances.
I understand that it is my responsibility to inform the Land & Resource Management office once the building footings have been constructed.
f"* / - " ' A r ' \ I '' /
f —
A
- \y ,7-C )1Date:
Signatufje of Property Owner
Lend & Resource Management Office
Lf- 7-Date:
1 //\ 9 0 . oo RECEIPT NO.PERMIT FEE $PR0JECT(S)T0TAL SQ.FT.
7 yComments:lO~IQyQg\> ^
VICAat'-
ky .Vrfi
!
\i '-i \
'f313,012 • Victor Lundeon Co., Printers • Fergus Falls. MinnesotaForm No. BK — 0203-0501
SITE PERMIT
INSPECTION RESULTS
Inspector must make all measurements and computations
Ft.Ft.Structure Set Back from Ordinary High Water Level //o
Ft.Ft.Structure Set Back from Top of Bluff
Ft.Ft.Structure Set Back from Road Right of Way
Ft.Ft.Ft.&Ft.&Structure Set Back from Lot Lines
Ft.Structure Height
Ft.Ft.Structure Set Back from Septic Tank
J2,<J 'i~-Ft.Ft.Structure Set Back from Drainfield
Elevation Of Lowest Floor Above Ordinary
High Water Level Ft.Ft.
Land Slope at Building Site %%
P ^ ] nikyti
Me i
Inspector’s Comments / Sketch:
0
7 r
r
3
Oafe of Inspection
Time of Inspection
Ly^[oiect Approved
Date / Initial
‘1
On<S ,grid(s) equalsScale:feet, or Jnch(es) equals feet
Please use this sheet for the required scale drawing of your proposal. Be sure to include lot dimension, water
frontage, and setbacks from RW, lake, lot lines, sewage system, top of bluff, existing structures and all imper
vious surface.
Required impervious surface coverage calculation (See definition in Shoreland Management Ordinance)
-^jLpOO ‘ 11.(o2.lzy
Total Lot Area
(FT2)
.02 2-X 100 =%4-
Total Impervious
Surface Onsite
(FT2)A
'H^ropos>f‘ci 3
- yv^Ohi\-€^\iO\ pcMrv), V\o^C^
0^^<so
p-
i\
/
/
/
5tiop /
\'Z00S'i'f-t
Or /
/
/
^'t! U i-t
DatedSignature
BK — 0500 — 029 304.678 * Victor Lundeen Co.. Printors * Forgu3 Falls. MN • t-800-346-4870
GRADE & FILL APPLICATION
COUNTY OF OTTER TAIL - LAND & RESOURCE MANAGEMENT
121 W JUNIUS SUITE 130, FERGUS FALLS, MN 56537 218-998-8095
Otter Tail County’s Website: www.co.ottertail.mn.us
PERMIT NO.Application Fee
Receipt Number
PROPERTY OWNER ^
MAILING ADDRESS O'? S
CITY, STATE, ZIP U/^o6^ujg<>0 1 7
LAKE NO. 3'^ 375 CLASS £0
DAYTIME PHONE NUMBER
LAKE NAME S-r
PARCEL NUMBER(S) 57 OOQO J. OQ/f^Of<
SECTION OX
LEGAL DESCRIPTION Lo'T 8 By Pla.T'TS^ /£v
TWP NAME
-rtl:E-911 PROPERTY ADDRESS ^7^^^U/^O ili-Lu oQ O
INATURE OR PROPERTY OWNER/AGENT FOR OWNER DATE
0
DATEL&R Official
DESCRIPTION PROJECT REQUEST BELOW (Provide Scale Drawing On Back)
iOO floO-i^oO3oOTOTAL CUBIC YARDS
i
C-C/
?yr. 7ir-(o-
- I.
4-
(fV'v
BK05/00 311,493 • Victor Lurtdeen Co.. Printers • Fergus Falls, MN • 1-600-346-4870
on«r>Scale;.grid(s) equals feet, or Jnch(es) equals feet
Please use this sheet for the required scale drawing of your proposal. Be sure to include lot dimension, water
frontage, and setbacks from RW, lake, lot lines, sewage system, top of bluff, existing structures and all imper
vious surface.
Required impervious surface coverage calculation (See definition in Shoreland Management Ordinance)
^}(pOO 4-
Total Lot Area
.02 X100= Z-.%
Total Impervious
Surface Onsite
(FT2)
\0jLc^ yvtobl'itS
jit-f -f'loM -c<so
'jk" if^ 'f
P-[0./
CoHi^f^OM L
m6X|4rflVl^
6tiop
te
Signature Dated
BK—Q5Q0 —029 304,678 ■ Victoi lundeen CoT • Fergus Fails. MN • 1-800-346-4B70
White - Office Yellow
Pink -
Gotdenrod — Inspector
SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone: (218) 739 -2271 — Fergus Falls, Minnesota 56537
APPLICATION FOR SITE PERMIT
— Owner Asse&fd^
Permit No.,LEGAL
DESCRIPTION
AND
LOCATION
TWP Name *'eo 2_pz 3±[Pi L O'S /
Sec.TWPLake Classif.RangeLake No.Lake Name
IDENTIFICATION: Please Print Ail Information
First Tel. No.Zip No.Mailing Address— No. Street, City and StateInitialLast Name
3. X («? y\Nf\CTtP^Owner
O''^Oee.wooo rJ/
NameContractor
Architect Name.
NON-RESIDENTIAl, PROPOSED USE:
S,ecit..
0 4 V h
TYPE OF IMPROVEMENT:RESIDENTIAL PROPOSED USE:
( Building
( ) Alteration
( .) One Family Dwelling
( ) Multiple Dwelling Units
\T^her
( )Other (Size
IESTIMATED COST OF IMPROVEMENT $
DIMENSIONS:PRINCIPAL TYPE OF FRAME: TYPE OF SEWAGE DISPOSAL:
( ) Public
(\/^ndividual Septic Tank, etc.
WATER SUPPLY:
( ) Public
( VKTndividual Well
( ) Yes (Vf^o( ) Masonry
( j^i^ood Frame
( ) Structural Steel
( ) Other — Specify
1Basement:
Stories above basement:
Sq. feet (outside dimension!
Bedrooms
LZ-..9.Q.
Batnt ..TT".!..,
/CHARACTERISTICS:/7 f3 feet.Maximum depth of lot feet.Water frontage issquare feet.Lot Area is
feet. (Building Line)Building set back from high water mark is.
Land height above high water mark at building line is.....rrP..feet ■2^
feet.Building set back from^tate highway rightpf way
Side yard is .../...fr:............... and..............
feet — from road right of way is
feet.
.feet from septic tank (Sewage System Permit must be obtained before installation).
feet from soil absorption system (Sewage System Permit must be obtained before installation).
Structure will be located
Structure will be located
Agreement: I hereby certify that the information contained herein is correct and agree to do the proposed work in accordance with the description above set
forth and according to the provisions of the ordinances of Otter Tail County, Minnesota. I further agree that any plans'and specifications submitted herewith
shall become a part of this permit application. I also understand that this permit is valid for a period of six (6) months.
THIS IS A SITE PERMIT ONL Y AND DOES NOT CONSTITUTE A BUILDING PERMIT AS SET FORTH IN CHAPTER 16, MINNESOTA STA TE STA TUTES.
I understand that I have been granted a site permit in accordance with the requirements of the Shoreland Management Ordinance of Otter Tail County. I understand
I must contact my township in order to determine whether or not any additional permits are required by the township for my proposed project.
Signature of Owner
tilDated.
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon thePermit:
express condition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the ordinances of Otter Tail
County, Minnesota. This permit may be revoked at any time upon violation of said ordinances.
3l- ?1Dated
Shoreland Managemel tcial
Permit Fee $.Receipt No.
(yS'P \py Try.I - r fqlComments:A-
Form No. MKL-0286-019 229971(g)
VICTOR LUNOGEN CO.. PRINTERS. FERGUS FALLS. MINN.
White — Office
Yellow — Owner
Pink — Assesscrr*
Goldenrod — Inspector
SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone: (218) 739 -2271 — Fergus Falls, Minnesota 56537
APPLICATION FOR SITE PERMIT
//'? i't d A Permit No..LEGAL
ifiy PeDESCRIPTION s o ej
AND
LOCATION
4? D '•4r <-/ /L, L T , T V iy f \...
TWP NameTWP RangeLake Classif.Sec.Lake NameLake No.
tPENTIFICATION: Please Print AH Information
Zip No.Tel. No.Mailing Address— No. Street, City and StateInitialLast Name First
PS 0 {V 1■ \\,/ V \ »Owner
JI'rA i
NameContractor
Architect Name,
NON-RESIDENTIAl, PROPOSED USE:
n t ij i- o>L.
TYPE OF IjVIPROVEMENT:
(\>^ew Building
( ) Alteration
( ) Other_____________
RESIDENTIAL PROPOSED USE:
( ) One Family Dwelling
( ) Multiple Dwelling
( ,r6ther
Specify:
£>.-' J'■ VUnitsIf/y^(/io . Z' V I ''■J— SSize
ESTIMATED COST OF IMPROVEMENT $
DIMENSIONS:PRINCIPAL TYPE OF FRAME: TYPE OF SEWAGE DISPOSAL:
( ) Public
('./l^lndividual Septic Tank, etc.
WATER SUPPLY:
( ) Public
( vKlndividual Well
V/'^o
( ) Yes( ) Masonry
( j).tA/ood Frame c-t-
( ) Structural Steel
{ ) Other — Specify
/Basement:
Stories above basement:
Sq. feet (outside dimension)
Bedrooms .rrrcv
LZ.£.0_,
Bathr'.'Tn'...
/CHARACTERISTICS: j/ ' /
Lot Area is ......J..r /feet.Maximum depth of lot feet.Water frontage is/.J (Jsquare feet.
Building set back from high water mark is.
Land height above high water mark at building line is
feet. (Building Line)
feet
.feet.Building set back from State highway right pf way
and...../.
feet — from road right of way is
.............feet.
.feet from septic tank (Sewage System Permit must be obtained before installation).
feet from soil absorption system (Sewage System Permit must be obtained before installation).
Side yard is
Structure will be located
Structure will be located
Agreement: I hereby certify that the information contained herein is correct and agree to do the proposed work in accordance with the description above set
forth and according to the provisions of the ordinances of Otter Tail County, Minnesota. I further agree that any plans and specifications submitted herewith
shall become a part of this permit application. I also understand that this permit is valid for a period of six (6) months.
THIS IS A SITE PERMIT ONL Y AND DOES NOT CONSTITUTE A BUILDING PERMIT AS SET FORTH IN CHAPTER 16, MINNESOTA STA TE STA TUTES.
I understand that I have been granted a site permit in accordance with the requirements of the Shoreland Management Ordinance of Otter Tail County. I understand
I must contact my township in order to determine whether or not any additional permits are required by the township for my proposed project.
i 7 /Dated.
Signature of Owner
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon thePermit:
express condition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the ordinances of Otter Tail
County, Minnesota. This permit may be revoked at any time upon violation of said ordinances.
i!II -I KDated
Shoreland Management Official
Permit Fee $ ■-7’'Receipt No.
■
I ■^ / C]h'/ mk'.( ^ •V J f.£21 u UComments:/
Form No. MKL-0286-019 229971®
VICTOR LliNOEEN CO.. PRINTERS. FERGUS FALLS. MINN.
N.
INSPECTOR'S CHECK LIST
Make all measurements and computations
i'
ACTUAL
IS jr MINIMUM Shall Be 4,Sq. Ft,
Lot Area (Square feet)Sq. Ft Sq. Ft.
Water Frontage Ft.Ft.
^oO~ Ft.Building Set Back from High Water Mark Ft.
Building Set Back from State Highway Ft.50 Ft.
7iT'Building Set Back from Street or Road Ft.40 Ft.
1Side Yard 'Z-cfzr &Ft.&Ft.
a<Rear Yard Ft.Ft.
Occupied Building to Septic Tank Ft.10 Ft.
Occupied Building to Absorption System Ft.20 Ft.
Elevation at Building Line above
High Water Mark_____________/-2^ 7 3 O’ Ft.3 Ft.
4 0Inspector's Comments:
^-kiXWZ
Inspector's Signature
1 \ Wv
Title
Inspection
Dated -- ,9
Agency
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