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Mallard Bay Resort_41000030019002_Septic System Permits_
OTTER TAIL COUNTY LAND & RESOURCE MANAGEMENTPUBLIC WORKS DIVISION 'JVWJV CO OTTER-TAIL MN US9mRTii|i GOVERNMENT SERVICES CENTER 540 WEST RR AVENUE FERGUS FALLS. MN 56537 218-998-8095 FAX; 218-998-8112 5/3/2018 Robert & Anita Meisenheimer 21244 Greenhead Dr Clitherall MN 56524 9656 RE: Sewage Treatment System Servicing Tax Parcel Number; 41000030019007 Described as:Sec 03 Twp Nidaros Township Sect-03 Twp-132 Range-039 PART GL 8 COM SW COR SEC 3 S 87 DEG E 1246' N 38 DEG E Lake: As of 05/02/2018 the septic tank (Sewage Treatment Installation Permit # 24903) servicing your property was determined to be in compliance with the provisions of the Sanitation Code of Otter Tail County for a 3 bedroom home. Please be advised that this certification is only valid for five years from the date of this inspection 5/2/2023 If you have any questions regarding this matter, please contact our office. Sincerely, Alexander Kvidt Inspector 9f APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM LAND & RESOURCE MANAGEMENT ^jSpVERNMENT SERVICES CENTER, 540 WEST FIR, FERGUS FALLS, MN 56537 218-998-8095 www.co.otter-tail.mn.us OTTCR Tflll WHITE - Office YELLOW -L&R Inspector PINK - Owner / Contractor (after issue)coiMiTY-ainncioTii APPLICATION MUST BE COMPLETED IN ORDER TO BE PROCESSED Permit No. LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER CLASS SECTION TWP NO.RANGE TWP NAME ' cl a YoS3^(333R/ PARCEL NUMBER (S) OF PROPERTY BEING SERVICED E-911 ADDRESS OR DIRECTIONS FROM NEAREST PUBLIC ROAD cP/PVV G?reenlfieac| ^(OQOO 300 \ ^ 03~1 \r. LEGAL DESCRIPTION TLA 6l3 SU Cdy- S«C 5 SCDV>r\> « Last Name First Initial Mailing Address Daytime Phone No. na(<i4Pr^(l MA/ /^eis^v^hfciiT^er 'RobeA ^Property Owner Brgyrgt Plum biVi^ HecriiV^ at'-d , Xyic. T.o.Contractor Lie.*^ . A/Yi13305U>S^I THIS SPACE FOR OFFICE USE ONLY A.M. >• This System will be ready for inspection on , the year of P.M.at A.M. P.M. Date Received Time Received L&R Official TYPE OF NSTALLATION (circle one)SEWAGE TREATMENT SYSTEM DESIGN DATA AS SHOWN ON DRAWINGResidential (A) New4BbReplacement IQ Add on Collector Other Est. (D) New (E) Replacement (F) Add on (G) New (H) Replacement (I) Add on Soil Treatment Area Tank LiftDesign Flow (Gallons/Day) (J) 0 qK> 1 — 2,499 (L) 2,500 — 4,999 (M) 5,000 — 10,000 Effluent Distribution fvj ) Gravity ( ) Pressure / giF GIs Ft.)|QQlDSize / te)'Setback To Nearest WellType I Type II Ft.Ft. f(20) Trench, Rock (27) Rapidly Permeable m' Ft"Setback To OHWL Ft.Ft.(21) Trench, Gravelless (28) Flood Plain (22) Trench, Chamber (29) Privies Ft.Ft. Ft.Setback To Bluff(23) Bed (30) Flolding Tank (Contract Required) 4 (24) Mound Ft. Ft.Setback To Dwelling (25) At Grade Type III iSetback To Non-Dwelling So' Ft'-(26) Greywater (31) Other/Problem Soils/<12" Soil Ft. Ft. (J3^ank Only__________ (35) Other Depth of Type IV /Setback To Nearest Lot Line (5o'^Ft^Ft.Ft.(32) Public Domain & Proprietary Technologies 7Setback To Road Right-Of-Way Ft. Ft.Type VtaTotal # Bedrooms ^(33) Performance 7Elevation Above Restrictive Layer ^Ft.Ft.Ft.Garbage Disposal Y /Abatement Y / cO PERC TEST DATA ^ico-K fill 39>oCj<;oDesigner 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 accor dance 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 condition 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; I.This permit is valid for a period of six (6) months. 2.This permit does not include the building sewer (sewer line). License #Date of Test Highest Rate Sigr^Bture of ^operty Owner/J^ 115'.303 nDate:Permit Fee $ ent for Owner %Y]LDate:Rec. No.Libd Resource yenTOffiam Comments:^ C^i>hpl/Ct<Hc(L Date Stamp tjw^rCiu^JL. fii^ l)if\ Form No. BK — 04-2014-06 ' J L&R Initial . 357,243 • Victor Lundeen Co., Printers • Fergus Falls, Minnesota APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTE LAND & RESOURCE MANAGEMENT GOVERNMENT SERVICES CENTER, 540 WEST FIR, FERGUS FALLS, MN 56537 218-998-8095 www.co.otter-tail.mn.us OTTER TRII - Office YELLOW -L&R Inspector PINK - Owner / Contractor (after issue)eOUflTY-ailllCIOTR APPLICATION MUST BE COMPLETED IN ORDER TO BE PROCESSED Permit No. LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER CLASS SECTION TWP NO.RANGE TWP NAME A'>davo531313:2n/ PARCEL NUMBER (S) OF PROPERTY BEING SERVICED E-911 ADDRESS OR DIRECTIONS FROM NEAREST PUBLIC ROAD ■; / P V G * ^ ‘ I‘ti (A.dH {300130^^ 1 N.yv. LEGAL DESCRIPTION ^ (:.L SUJ Cor S€C 5 S• •COV>Yi I Ic/!Last Name First Initial Mailing Address Daytime Phone No.'1 i) G^-Hura(( MA Property Owner W.-iC “' ^ /2/v4u/y}f.i‘5 j'.y^ lif.i i- —Plun.Lutt Lkoiui^x a*xi__C: n.<:aL.a'\i Ui Ji ■p >,• «Contractor Lic.«Mirvtc.ry)/v miai'll iI35JJ zif^m-OLao5Lg6 I/ THIS SPACE FOR OFFICE USE ONLY 11 ■T)^>■ This System will be ready for Inspection on , the year of P.M.at. ^\\ h%Date'Received 4’- M^& R Official A.M. Time Received TYPE OF NSTALLATION (circle one)SEWAGE TREATMENT SYSTEM DESIGN DATA AS SHOWN ON DRAWINGResidential (A) New (B) Replacement (C) Add on Collector Other Est. (D) New (E) Replacement (F) Add on (G) New (H) Replacement (I) Add on Soil Treatment Area Tank LiftDesign Flow (Gallons/Day) (J) 0 Effluent Distribution (... ) Gravity ( ) PressureiS. 1 — 2,499 2,500 — 4,999 (M) 5,000 — 10,000 GIs'^'GIs Ft.Size Setback To Nearest Well Ft.'^'Type I Type II Ft.Ft.iu.(20) Trench, Rock (27) Rapidly Permeable ' Ft.'-Setback To OHWL Ft.Ft.(21) Trench, Gravelless (28) Flood Plain i: (22) Trench, Chamber (29) Privies Ft.Ft.Ft.Setback To Bluff(23) Bed (30) Holding Tank (Contract Required)(24) Mound Ft.Ft.Setback To Dwelling (25) At Grade Type III Setback To Non-Dwelling(26) Greywater (31) Other/Problem Soils/<12" Soil < Ft.V Ft.Ft.■So (34)J-ank Only Type IV Setback To Nearest Lot Line ,i Ft Ft.Ft.(32) Public Domain & Proprietary Technologies(35) Other V Setback To Road Right-Of-WayDepth of Well Ft.V Ft. Ft.Type V Total # Bedrooms (33) Performance Elevation Above Restrictive Layer ___ Ft.Ft.Ft.Abatement Y / N Garbage Disposal Y / N-. PERC TEST DATA 39 H(■ Designer 3 ^ ‘ Agreement; The undersigned hereby makes appiication for permit to install, alter, repair or extend Sewage Treatment System herein specified, agreeing to do ail such work in strict accor dance with Sanitation Code of Otter Taii County, Minnesota. Appiicant 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 shali 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 condition 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. License #Date of Test ■jHighest Rate■f i NOTE: I.This permit is valid for a period of six (6) months. 2.This permit does not Include the building sewer (sewer line). ^ ''y • I y' ■ [ I, I I3^3- I iDate:Permit Fee $lA. Signature of Property Owner/Agent for Owner\\ ■ \I-'Date;Rec. No.,La^d if Resource Mane^emSiit^i^lar ^ zt.....3 'v CComments: V- n i^ ll r, It Tt f f'------Cdmpl ICi r.'Ttr' s4;1 Fdtm No. BX — 04-2014-Oti fwiloy iwi 357,243 ■ Victor Lundeen Co.. Printers • Fergus Falls. Minnesota f SEWAGE TREATMENT SYSTEM PERMIT INSPECTION RESULTS STA (Soil Treatment Area) OUTHOUSE HOLDING SEPTIC TANK TRENCH REDUCTIONLIFT TANKCATEGORY ^ariSK-v at/ Capacity Roal^^nches with of sidewall reductjialW equivalent t! inches1006 Q*-s.FT2GLS. %FTSetback from Nearest Well FT FT Setback from Buried Water Suction Pipe ft2FTFTFT Setback from Buried Pipe Distributing Water Under Pressure STA CALCULATION Treatment Area)FT FT FT VSetback from OHWL (lake &/or river)FT FT FT Ft. Setback from Bluff FT FT FT Setback from Dwelling FTIfl FT FT MOUND / AT-GRADE ^“"^PCK BEDy^^0Setback from Non-Dwelling FT FT FT Setback from Nearest Property Line FT FT FT Ft. Setback from Right-of-Way FT FT FT FP Elevation above Restrictive Layer FT FT FT SANeiirBrOUN&r^z=ss=..INSTALLERS COMMENTS SEPTIC TANK(s)Holding Tank / Lift Alarm , □ YES NO ( # Tanks InstalledOld System Pumped & Destroyed l^YES □ NO W( Manuf.Number of INiai Model #P°rfffr"‘*mp .Snaring Ft,Perforation Diameter Size IN □ YES ^NOFILTERSPUMPSGflllP"*^ D^r minute Inspector's Comments: Sketch: & i>10.1 lazo C'l‘t(IITC , the above described sewage system installationAs of was found to be compliant with the provisions of the Sanitation Code of Otter Tail CountynTimeInitial / L S R OfficialDate J Land fi Resource Management Official RteraForm No. BK — 04-2014-06 357,243 • Victor Lundoon Co., Printors • Forgu* Fells, Minnesota ... PARCEL ilOCX30 3<X>\9 0=>1SKETCH OF PROPERTY Please sketch all structures and septic systCTis on the pcopaty; Include setbadts and wells within 100 fe^ of the propoty. SEpnc iNsagscnONAPP YEAR .3017 SCp'l^f 54mavV 12JD AI3& liL j"I V\e«A 4t 3, 1,2. - ^ 3,4 li 5,|p,n ' ^3-50 JOSo\ +k, bSZ kvi'l/ he- coirv.rt.0*^ 1>uaI Ai4- p*w*^p^Cabi *^5 _ AsSb'A Cables 1,000 Land & Resource Management Otter Tail County Government Services Center, 540 W Fir Fergus Falls, MN 56537 arreRTAii 218-998-8095 wwwxo.otter-tail.mn.us FAX; 218-998-8112 SITE DATA WORKSHEET Property Information: Lake I River Number Lake / River Name Lake/River Class Section Township Name Nidaros56-191 Stuart RD 3 Parcel Number(s)Property’s E-911 Address 21244 Greenhead Dr.41000030019007 Property Owner Information: Name(s): Robert & Anita Meisenheimer Mailing Address; 21244 Greenhead Dr. Clitherall, MN 56524-9656 Designer information: Name: Scott Ellingson MPCA License Number: 3947 Advanced DesignerFirm Name: Scott's Septic Services, LLC License Category: Mailing Address: 201 Meadow Circle Ashby, MN 56309 (218) 205-1667E-Mail Address: scottsseptic@outlook.com Phone Number; Sewage Treatment System Design Information: Number of Bedrooms: 3 I'/ ji-y Garbage Disposal: Yes [2 No Well: Casing Depth: |47.00~~| Ft. Sewer Line Separation: [ Floodplain: Ft. I I Yes NoIT] NO Bluff:Yes [^Terrestrial Slope at Installation Site: lO.O 1^% Type of Observation: Probe []]] Pit __Boring I Till Outwash Vegetation;Aquatic I [AlluviumI I BedrockLoessParent Material: Original Soil: [^ Yes No Compacted Soil; Yes No Depth of Boring (to T or restrictive layer); 1 Ifl I I In. Signature of Licensed'Designer (J LR: Oiline Permitting Forms 2016; Site Data Worksheet Fillabie 03-09-2016 08/22/2017 Dale Land & Resource Management GSC, 540 W Fir, Fergus Falls. MN 56537 OTTtRTaii 218-998*8095: Website; www.co.ottertaii.mn.us • ••ITT •■•■tieTa ' Subsurface Sewage Treatment System Management Plan Sewage Treatment System Permit Number: Property Information: Lake / River ClassLake / River Number Lake / River Name Section Township Name NidarosStuartRD56-191 3 Property’s E-911 AddressParcel Number(s) 21244 Greenhead Dr.41000030019007 Property Owner Robert & Anita Meisenheimer This management plan will identify the operation and maintenance activities necessary to ensure long-term performance of your septic system. Some of these activities must be performed by you, the homeowner. Other tasks must be performed by a licensed septic service provider. Homeowner’s Management Tasks - Should Be Checked Every 6 months: Leaks - Check (look, listen) for leaks in toilets and dripping faucets. Repair leaks promptly. Surfacing sewage - Regularly check for wet or spongy soil around your soil treatment area. Effluent filter (if applicable) - Inspect and clean twice a year or more. Pump Tank Alarms - Alarm signals when there is a problem. Contact a service provider any time an alarm signals. Holding Tank Alarms - Can be either an electronic or a manual float, when activated, service (pumping) is required. Event counter or water meter (if applicable) - Record your water use. Vegetative Cover- Establish and maintain a vegetative cover over the sewage system. Professional’s (Licensed Septic Service Provider) Management Tasks - Should Be Checked Every 24 Months (2 Years): ^ Check to make sure tank is not leaking. ^ Check and clean the in-tank effluent filter. ^ Check the sludge/scum layer levels in all septic tanks. ~ Recommend if tank should be pumped. Check inlet and outlet baffles. ~ Check the drainfield effluent levels in the rock layer. ^ Check the pump and alarm system functions. Check wiring for corrosion and function. ^ Provide homeowner with list of results and any action to be taken. Check inspection pipe caps (replace as necessary). T Check manhole cover (accessibility, security, or damage). I understand it is my responsibility to properly operate and maintain the sewage treatment system on this property in accordance with this Subsurface Sewage Treatment System Management Plan. 08/15/2017Property Owner; DateSignature The following link will provide information from the University of Minnesota, regarding a Septic System Owner’s Guide: httD://www.extension.umn.edu/environmentyhousina-technoloav/moisture-manaQement/seDtic-svstem-owner-quide/ LR: Onlirre Pennitling Forms 2016: SSTSManasemem Plan FiUaWe 07-27-2016 OTTER TAIL COUNTY LAND & RESOURCE MANAGEMENT PUBUC WORKS DIVISION WWW.CO OTTER-TAIL MN US GOVERNMENT SERVICES CENTER 540 WEST RR AVENUE FERGUS FALLS, MN 56537 218-998-8095 FAX; 218-998-8112 5/3/2018 Robert & Anita Meisenheimer 21244 Greenhead Dr ClitheralIMN 56524 9656 RE; Sewage Treatment System Servicing Tax Parcel Number; 41000030019007 Described as;Sec 03 Sect-03 Twp-132 Range-039 PART GL 8 COM SW COR SEC 3 S 87 DEG E 1246' N 38 DEG E Twp Nidaros Township Lake; As of 05/02/2018 the septic tanks (Sewage Treatment Installation Permit # 24902) servicing your property was determined to be in compliance with the provisions of the Sanitation Code of Otter Tail County for a 15 bedroom resort. Please be advised that this certification is only valid for five years from the date of this inspection 5/2/2023 If you have any questions regarding this matter, please contact our office. Sincerely, Alexander Kvidt Inspector APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM LAND & RESOURCE MANAGEMENT ^ GOVERNMENT SERVICES CENTER, 540 WEST FIR, FERGUS FALLS, MN 56537 218-998-8095 www.co.otter-tail.mn.useSCANNEDOTTCR TRIl WHITE - Office YELLOW - L & R Inspector PINK - Owner / Contractor (after issue)COVATY-MIAnilOTi APPLICATION MUST BE COMPLETED IN ORDER TO BE PROCESSED Permit No. 7LAKE NUMBER , LAKE/RIVER NAME HI stuari LAKE/RIVER CLASS SECTION TWP NO.' RANGE TWP NAME/v/ 3 Z)/i^aYCiS3^133. PARCEL NUMBER (S) OF PROPERTY BEING SERVICEDH/oOOcD3 00\^ OO'^ y E-911 ADDRESS OR DIRECTIONS FROM NEAREST PUBLIC ROAD 'hr. ^ LEGAL DESCRIPTION /T/ G>L *3 5uj sec 3 3 • 1 t Last Name First Initial Mailing Address Daytime Phone No. Properly Owner omeff 'Pturv.biHfj fterA4|'iA,^ ^ OtTc]^ £noavoi'ti'wQ . TTiac. ' 7o. 35(o VI r\ > Contractor Lie.*MW3+13331 S'toS'gl THIS SPACE FOR OFFICE USE ONLY A.M. ► This System will be ready for inspection on , the year of P.M.at A.M. P.M. Date Received Time Received L & R Official TYPE OF NSTALLATION (CIRCLE ONE)SEWAGE TREATMENT SYSTEM DESIGN DATA AS SHOWN ON DRAWINGResidential (A) New (B) Replacement (C) Add on Collector Other Est./ (D) New (E) Replacement (F) Add on (G) New*=g)5Replacemenf (I) Add on t/ Tank Lift /j>950W3. f f i - V Treatment AreaI Design Flow (Gallons/Day) (J) 0 Effluent Distribution ) Gravity ( ) Pressure I I1 — 2,499 2,500 — 4,999 (M) 5,000—10,000 i(f2.3 Ft.7Size /ySetback To Nearest Well FtY'Type I Type II Ft.Ft.U3(20) Trench, Rock (27) Rapidly Permeable 73o’ Ft.'-Setback To OHWL Ft. Ft.(21) Trench, Gravelless (28) Flood Plain (22) Trench, Chamber (29) Privies — Ft.Ft. Ft.Setback To Bluff(23) Bed (30) Holding Tank (Contract Required) /yf v'(24) Mound 15'. 13 Ft.Ft.Ft.Setback To Dwelling (25) At Grade Type III f- loo' Ft.'/Setback To Non-Dwelling id R*(26) Greywater (31) Other/Problem Soils/<12” Soil Ft. ( ^jSTj^nk Only (35) Other Well y Type IV 7ISetback To Nearest Lot Line S'O Ft.v Ft.(32) Public Domain & Proprietary Technologies / Setback To Road Right-Of-Way /oo"^ Fty IOO+ Ft.'^Ft.Type V Total It Bedrooms )5 (33) Performance Elevation Above Restrictive Layer Ft.Ft.Ft.Y / S)Garbage Disposal Y / CH)Abatement PERC TEST DATA / 3<^H1Designer 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 accor dance 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 condition 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; I.This permit is valid for a period of six (6) months. 2.This permit does not inciude the buiiding sewer (sewer iine). License #Date of Test Highest Rate 3igrh(ure of Property Owne/ZAyenY forP^er /75.Date:Permit Fee $ . ^ fliitC W (MRvif/ Vlli tst) Ifffi ^ >pJ<L Date:Rec. No.. Mi'S)ate StampComments: V~ Pi/a f -p-' 357,243 • Victor Lundeen Printers • Fergus Falls. Minnesota lllitiul . 17. Form No. BK 04-2014-06 r APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM LAND & RESOURCE MANAGEMENT NT SERVICES CENTER, 540 WEST FIR, FERGUS FALLS, MN 56537 218-998-8095 www.co.otter-tail.mn.us GOVERNJJ^ S~-:2~/r /^IC OTTER Tflil Vi/H\JE - Office YELLOW -L&R Inspector PINK - Owner / Contractor (after issue)COUHTT-BItilfOTN APPLICATION MUST BE COMPLETED IN ORDER TO BE PROCESSED Permit No. V,LAKE NUMBER LAKBRIVER NAME LAKE/RIVER CLASS SECTION TWP NO.RANGE TWPNAME>/i/x/s/v/v/S4uar f 3 /Vi Ja^ o<,!fLi 33 PARCEL NUMBER (S) OF PROPERTY BEING SERVICED E-911 ADDRESS OR DIRECTIONS FROM NEAREST PUBLIC ROAD -1 la A30 3 (DO 1^001 y I>r , ^,1 f ■ Daytime Phone No. LEGAL DESCRIPTION /(_ 0 CJKn 5Uj Lov 5€.(' 3 5: ‘'/"i c’- « I Last Name First Initial Mailing Address I tjUxt k)x/ 13.4 M---^,br t [ I _____ Property Owner ^J-tt Sgnivt'.•I ! mtv'5 •Jfe/Y-V IT 3y I'l ii-g4j.,Contractor Lie.#3Li >ft Lu^u 0^4—L KCg \Ot S'. \ .r ITS ) t ^<1111550 2Jk -rjno THIS SPACE FOR OFFICE USE ONLY 01?.II‘00 ^>■ This System wilt be ready for inspection on , the year of at ‘511 h%43a/3;2e?&>A.M. Date Received Time Received L&R Official TYPE OF NSTALLATION (circle one)SEWAGE TREATMENT SYSTEM DESIGN DATA AS SHOWN ON DRAWINGResidential (A) New (B) Replacement (C) Add on Collector Other Est. (D) New (E) Replacement i/ (F) Add on (G) New c(H) Replacement (1) Add on .^1 Soil' Treatment Area Tank LiftDesign Flow (Gallons/Day) (J) 0 (K) 1 — 2,499 (L) 2,500 — 4,999 (M) 5,000— 10,000 Effluent Distribution ( •-.) Gravity ( ) Pressure / V fVcts'P.3* • 5 LI Ft.Size 'n .p;) *>o VSetback To Nearest WellType I Type II Ftv Ft.Ft.It ?iO(20) Trench, Rock (27) Rapidly Permeable V3 X Ft.vSetback To OHWL Ft.Ft.(21) Trench, Gravelless (28) Flood Plain la (22) Trench, Chamber (29) Privies Ft.Ft.Ft.Setback To Bluff(23) Bed (30) Holding Tank (Contract Required)(24) Mound fO ^ ^ Ft.^^Ft.Setback To Dwelling * >3(25) At Grade Type III 7Setback To Non-Dwelling ' Ft.v(26) Greywater ' Ft.^(31) Other/Problem Soils/<12" Soil Ft.• cx:''/O/ Type IV(34) Tank Only v /Setback To Nearest Lot Line 1 -t Ft. »Ft.v Ft.:vO(32) Public Domain & Proprietary Technologies }oo(35) Other Setback To Road Right-Of-Way Ftv r Ft.'-Ft.Type V i:o a.} Total H Bedrooms (33) Performance Elevation Above Restrictive Layer Ft.Ft.Ft.Abatement Y / N-Garbage Disposal Y / ^ hh PERC TEST DATA VDesigner /oV r~ ‘ j ■ t-, 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 accor- ■ 1 dance 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 appiicant 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 condition 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. 39 W -1License #Date of Test Highest Rate ■i 'iNOTE: I.This permit is valid for a period of six (6) months. 2.This permit does not include the building sewer (sewer line).1 1hVB-D3Date:Permit Fee $ Signature of Properly Owner/Agent for pwqer ^ \y U 1.'N ■ 1'kn -Date:Rec. No.. 4Comments: / / 3"; »■'*»' / ^ - // 7^ 7 - ^.J /r ^ J- /,<■/■ /■6? n,,/ 'tIi/jjI. < ^ ■'OO- w wkI. 357,243 ■ Victor Lundeen Qp., Printers • Fergus Palis, Minnesota \Form No. BK — 04-2014-06 -I'i 1 «SEWAGE TREATMENT SYSTEM PERMIT INSPECTION RESULTS STA (Soil Treatment Area) OUTHOUSE HOLDING SEPTIC TANK TRENCH REDUCTIONLIFT TANKCATEGORY Rock treridieSTtith^inchesGLS.FT^ of sidewall for %FTSetback from Nearest Well FT FT ujjgpn'fequivalent to Setback from Buried Water Suction Pipe redu \2FTFT Setback from Buried Pipe Distributing Water Under Pressure STA CALCULATION (Soil Treatment10FTFT FT Setback from OHWL (lake &/or river)FT FT Ft. Setback from Bluff FT FT FT FP/ Setback from Dwelling FT FT MOUND / AT-GRADE BEDSetback from Non-Dwelling FT FT <5T ft Setback from Nearest Property Line FT FT FT Lt. Setback from Right-of-Way FT FT FP Elevation above Restrictive Layer FT FT FT SAND IN ID FtINSTALLERS COMMENTS SEPTIC TANK(s)Holding Tank / Lift Alarm '^YES g NO t It Tanks InstalledOld System Pumped & Destroyed □ NO Wejp=H©tes= ^Sb__ Manuf.Number of Laterals #IN Model #Perforation Si Perforation Diameter Sf INrTT FILTERS HYES-Galinng Ppr MiniitpPUMPS r0(il of TulatTIDoa' Inspector's Comments: Sketch: ^'1'll'M * * Time As of the above described sewage system installation was found to be compliant with the provisions of the Sanitation Code of Otter Tail County.Initial/Li ft OfficialDate mLand & Resource Management Official r Form No. BK — 04-2014-06 M.357.243 • Victor Lundeen Co., Prlntort • Forgut Falls, Minnasota PARCEL ^1 POOP goo \c\qo1SKETCH OF PROPERTY SEPTIC INSBJECnON ^on ;• APPPlease sketch all structures and septic systems on the property; Include setbacks and wells within 100 feet of the property.YEAR 50.-W S4uA,yV Ri> 2 VoisAS <90 iVlitte - oto^i ~nn\/ ^ U 8, l,^ “ ^ 5,4 - 5", Ip 1*^ ' J.3.50 uooJOSa i.w Hodi-ffi totVji’oS Cabins (pS2 ccmrt.0^ A14- i ii3i5b'-a ^obCob!*^s Mou»L hCttO Land & Resource Management Otter Tail County Government Services Center, 540 W Fir Fergus Falls, MN 56537 9TTCRTHII 218-998-8095 www.co.otter-tail.mn.us FAX; 218-998-8112 SITE DATA WORKSHEET Property Information: SectionLake / River Numtier Lake / River Name Stuart Lake / River Class Township Name Nidaros56-191 RD 3 Parcel Numberts) Property’s E-911 Address 41000030019007 21244 Greenhead Dr. Property Owner Information: Name(s); Robert & Anita Meisenheimer Mailing Address: 21244 Greenhead Dr. Clitherall, MN 56524-9656 Designer Information: Name: Scott Ellingson L MPCA License Number: 3947 Advanced DesignerFirm Name: Scott's Septic Services, LLC License Category; Mailing Address: 201 Meadow Circle Ashby, MN 56309 (218) 205-1667E-Mail Address: scottsseptic@outlook.com Phone Number: Sewage Treatment System Design Information: Number of Bedrooms; [1§ Garbage Disposal; Yes No ^ Well: Casing Depth:|47.00 iFf*^ Sewer Line Separation; [ Floodplain: Yes Vegetation: Aquatic ^ Terrestrial Slope at Installation Site: lO.O % Type of Observation; | | Probe I I Pit Boring I Till Outwash Original Soil: Yes No Compacted Soil: Yes [2 No Depth of Boring (to T or restrictive layer);. ]fl □ Yes |7]no0NoBluff; I I Bedrock I [AlluviumLoessParent Material; In.Ft. 08/22/2017 Signature of Licensed Designer ^Date LR; Orpine Penrotting Fcrms 2016; Site Data Worksheet FillaWe 03-09-2016 OSTP Basic Pump Selection Design Worksheet University OF Minnesota Minnesota Pollution Control Agency 1. PUMP CAPACITY V 04.20.2016Project ID; Pumping to Gravity or Pressure Distribution:Gravity / 30.01. If pumping to gravity enter the gallon per minute of the pump:GPM (10 - 45 gpmj 2. If pumping to a pressunzed distribution system:GPM Demand Dosing Soil Treatment3. Enter pump description: Soil treetmeni system I A po«ni of discharge 12. HEAD REQUIREMENTS 10A. Elevation Difference between pump and point of discharge: ft'viwfi: m w« nl*1p*p* B. Distribution Head Loss:5 ft ft (due to special equipment, etc.)C. Additional Head Loss: Table I.Frictlon Loss in Plastic Pipe per 100ft Distribution Head Loss Pipe Diameter (inches)Flow Rate (GPM)Gravity Distribution = Oft 21.51.251 Pressure Distribution based on Minimum Average Head Value on Pressure Distribution Worksheet: 0.39.1 3.1 1.310 1.8 0.412.8 4.312 Distribution Head LossIVMnimum Average Head 0.617.0 5.7 2.414 1ft 5ft 0.721.8 3.07.316 2ft 6ft 0.93.89.118 5ft lOft 1.14.62011.1 1.76.916.825 9.723.530.2.0D. 1. Supply Pipe Diameten in 3.212.935 1202. Supply Pipe Length:ft 16.5 4.140 5.020.545 E. Friction Loss in Plastic Pipe per 100ft from Table I:6.150y7.355ft per 100ft of pipe F. Determine Equivalent Pipe Lensth from pump discharge to soil dispersal area discharge point. Estimate by adding 25% to supply pipe length for fitting loss. Supply Pipe Length (D.2) X 1.25 = Equivalent Pipe Length 2.37Friction Loss =8.660 10.065 11.470 13.075 16.485 150.0 ft120ftX 1.25 20.195 G. Calculate Supply Friction Loss by multiplying Friction Loss Per 100ft (Line E) by the Equivalent Pipe Length (Line F) and divide by 100. Supply Friction Loss = 3.6 ft150.0 ft 1002.37 ft per 100ft X H. Total Head requirement is the sum of the Elevation Difference (Line A), the Distribution Head Loss (Line B), Additional Head Loss (Line C), and the Supply Friction Loss (Line G ) 18.63.6 ftft -5.0 ft +ft10.0 ft +4- X3. PUMP SELECTION 18.630.0 feet of total head.A pump must be selected to deliver at least GPM (Line 1 or Line 2) with at least Comments: Need Dual Alternating pumps. OSTP Pump Tank Design Worksheet (Demand Dose)University OF MinnesotaMinnesota Pollutlan Control Agency DETERMINE TANK CAPACITY AND DIMENSIONS Project ID:V 04.20.2016 22501. A. Design Flow (Destsn Sum. 1 A):GPD v/[500 650B. Min. required pump tank capacity:Gal C.Reconvnended pump tank capacity:Gal 7 7Thelen's 2250-22. A. Tank Manufacturer:B. Tank Model: y Note: Design calculations are based on this specific tank. Substituting a different tank mode! will change the pump float or timer settings. Contact designer If changes are necessary. 652C. Capacity from manufacturer:Gallons 15.1 Gallons per inch0. Gallons per inch from manufacturer: 43.5E. Liquid depth of tank from manufacturer:inches DETERMINE DOSING VOLUME 3 Calculate Volume to Cover Pump (The inlet of the pump must be at least 4-inches from the bottom of the pump tank & 2 inches of water covering the pump is recommended) (Pump and block height + 2 inches) X Gallons Per Inch (2Cor3E) ______________ in -t- 2 inches) X 27115.1 Gallons16Gallons Per Inch(S 4 Minimum Delivered Volume = 4 X Volume of Distribution Piping: - Line 17 of the Pressure Distribution or Line 11 of Non-level 5 Calculate Maximum Pumpout Volume (25% of Design Row) GPD X Gallons (minimum dose) 7 563 Gallons (maximum dose)0.252250Design Row:S 7150 Gallons6 Select a pumpout volume that meets both Minimum and Maximum:Volume of Liquid in Pipe7 Calculate Doses Per Day = Design Row t Delivered Volume sigal =gpdT 15150 Doses2250 Liquid Per Foot (Gallons) Pipe Diameter (inches) 8 Calculate Drainback:/ 2 inchesDiameter of Supply Pipe =A. 0.0451120feetLength of Supply Pipe >B. 0.0781.25 Gallons/ft0.170Volume of Liquid Per Lineal Foot of Pipe = Drainback = Length of Supply Pipe X Volume of Liquid Per Lineal Foot of Pipe gal/ft = C.1.5 0.110 D.^o.i7o_;>2 20.4 Gallonsft X 0.170120 0.3803 9. Total Dosing Volume = Delivered Volume plus Drainback gal = 0.6614 170 Gallonsgal + 10. Minimum Alarm Volume * Depth of alarm (2 or 3 inches) X gallons per inch of tank 20.4150 30.1gal/in =Gallonsin X 15.12 DEMAND DOSE FLOAT SETTINGS 11. Calculate Float Separation Distance using Dosing Volume. Total Dosing Volume /Gallons Per Inch 170 gal T 12. Measuring from bottom of tank: A. Distance to set Pump Off Float = Pump + block height + 2 inches v// \Inche^/11.315.1 gal/in =\A \Inches for Dose: 11.3 in “L \ in ” ~182in =Inchesin -r16 Alarm Depth Pump On Pump Off 31.3 30.1 Gal29.3 inB. Distance to set Pump On Float=Distance to Set Pump-Off Float + Float Separation Distance 170 Gal2918.0 in11.3in +in =Inches18 I \271 GalC. Distance to set Alarm Float = Distance to set Pump-On Float * Alarm Depth (2-3 inches) in + ') 312.0 Inchesin =29 \ m Land & Resource Management GSC, 540 W Fir, Fergus Falls, MN 56537 218-998-8095; Website: www.co.ottertail.mn.us Subsurface Sewage Treatment System Management Plan Sewage Treatment System Permit Number pq Property Information: Lake / River Class Section Township Name Nidaros Lake! River Number Lake / River Name Stuart RD56-191 3 Property’s E-911 AddressParcel Number(s) 21244 Greenhead Dr.41000030019007 Property Owner Robert & Anita Meisenheimer This management plan will identify the operation and maintenance activities necessary to ensure long-term performance of your septic system. Some of these activities must be performed by you, the homeowner. Other tasks must be performed by a licensed septic service provider. Homeowner’s Management Tasks - Should Be Checked Every 6 months: Leaks - Check (look, listen) for leaks in toilets and dripping faucets. Repair leaks promptly. Surfacing sewage - Regularly check for wet or spongy soil around your soil treatment area. Effluent filter (if applicable) - Inspect and clean twice a year or more. Pump Tank Alarms - Alarm signals when there is a problem. Contact a service provider any time an alarm signals. Holding Tank Alarms - Can be either an electronic or a manual float, when activated, service (pumping) is required. Event counter or water meter (if applicable) - Record your water use. Vegetative Cover- Establish and maintain a vegetative cover over the sewage system. Professional’s (Licensed Septic Service Provider) Management Tasks - Should Be Checked Every 24 Months (2 Years): I] Check to make sure tank is not leaking. ^ Check and clean the in-tank effluent filter. ~ Check the sludge/scum layer levels in all septic tanks. ^ Recommend if tank should be pumped. ^ Check inlet and outlet baffles. ~ Check the drainfield effluent levels in the rock layer. Check the pump and alarm system functions. Check wiring for corrosion and function. ^ Provide homeowner with list of results and any action to be taken. “ Check inspection pipe caps (replace as necessary). ^ Check manhole cover (accessibility, security, or damage). I understand it is my responsibility to properly operate and maintain the sewage treatment system on this property in accordance with this Subsurface Sewage Treatment System Management Plan. 08/15/2017Property Owner: DateSignature The following link will provide information from the University of Minnesota, regarding a Septic System Owner’s Guide: httD://www.extension. umn.edu/environment/housinQ-technoloav/moisture-manaaement/seDtic-svstem-owner-quide/ LR; OnWne PermtWng Forms 2016 SSTS Management Plan FtllaWe 07-27-2016 Department of LAND AND RESOURCE MANAGEMENT OTTER TAIL COUNTY GOVCRNMCNT SERVICES CENTER - 540 WEST FIR FERGUS Pauls, MN 56537 PH: 2ie-908-a095 OTTER TAH. COUNTY’S WEBSITE; WWW.CO.OTTER-TAH..MN.USqmRTfiji otter Tail County Compliance Inspection Form Addendum SOUINED This form is a required attachment to MPCA Compliance Inspection Form for ail Existing Subsurface Sewage Treatment Systems in Otter Tail County as of June 1, 2011. Property Information Parcel Number: |41000030019007 Township; Nidaros Property Owner Name(s): Robert & Anita Meisenheimer Property Address: 21244 Greenhead Dr. Reason for Inspection: [owners Request Number of Bedrooms: fis Section; 3 Yes /In Shoreland Area? Lake/River Name, Number, & Class Istuart, 56-i9i, rd No System Compliance Status:r/1Compliant r/lNon-Compliant /NoDoes the soil treatment area have less than 3 feet of vertical separation? Is the septic tank located less than 50 feet from any well? Is the soil treatment area located less than 50 feet from any deep well? Is the soil treatment area located less than 100 feet from any shallow well? Does any part of the septic system fail to meet the minimum OHWL setback requirements for the public water classification? Yes / NoYes NoYes Yes /No /NoYes 'Yes" indicates that the system is failing to protect ground water and is noncompliant. If ’Yes", describe the condition noted:ItCabins System All Tanks FAILS block J Drain Field PASSES 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: Scott Ellingson Certification Number: [8571 Business License Name & Number: j Scott’s Septic Services, LLC 3947 Signature:Date: 08/15/2017 Page 1 of 2Excel/Compfiance Form for OTC 1/15/2014 Otter Tail County Compliance Inspection Form Addendum (cont) ’r Parcel Number: 4100003001900? Date & Initial: 08/15/2017 System Drawing ■ iThe system drawing which includes and identifies a graphic scale in feet or indicates all setback distances, all septic/holding/lift tanks, dtainfields, 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). Excel/Compiianoe Form for OTC 4/14/2017 Page 2 of 2 ' ;?• .r .; Minnesota Pollution Control Agency 520 Lafayette Road North SLPauLMN 55155-4194 Compliance Inspection Form Existing Subsurface Sewage Treatment Systems (SSTS) Doc Type: Compliance and Enforcement For local tracking purposes:Inspection results based on Minnesota Pollution Control Agency (MPCA) requirements and attached forms - additional local requirements may also apply. Submit completed form to Local Unit of Government (LUG) and system owner within 15 days System Status System status on date (mm/dd/yyyy): 8/15/2017 ^ Noncompiiant - Notice of Noncompliance (See Upgrade Requirements on page 3.) ^ Compliant - Certificate of Compliance (Valid for 3 years from report date, unless shorter time frame outlined in Local Ordinance.) Reason(s) for noncompliance (check all applicable) □ Impact on Public Health (Compliance Component #t)~ Imminent threat to public health and safety □ Other Compliance Conditions (Compliance Component #3) - Imminent threat to public health and safety S Tank Integrity (Compliance Component §2) - Failing to protect groundwater □ Other Compliance Conditions (Compliance Component #3) - Failing to protect groundwater □ Soil Separation (Compliance Component #4) - Failing to protect groundwater D Operating permit/monitoring plan requirements (Compliance Component ftS) - Noncompiiant Property Information Property address: 21244 Greenhead Dr. Property owner: Robert & Anita Meisenheimer Parcel ID# or Sec/Twp/Range: 41000030019007________ _____________ Reason for inspection: Owners Request _____________ Owner’s phone: ___________________ or Representative phone: _______________ Regulatory authority phone: 218-998-8095 Owner’s representative: _______________ Local regulatory authority: Ottertail County Brief system description: Block Septic tanks to block lift tank to big gravity bed Comments or recommendations: All cabin septic tanks and lift tank FAILS Cabin Drain Field PASSES Certification / 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: Scott Ellingson ________ Business name: Scott's Septic Services, LLC Inspector signature: Certification number: 8571_______ License number: 3947_______ Phone number: 218-205-1667 Necessary or Locally Required Attachments □ System/As-built drawing ^ Forms per local ordinance□ Soil boring logs □ Other information (list): TTY 651 -282-5332 or 800-657-3864 • Available in alternative formats Page 1 of 3 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31b • 6/4/14 1 Inspector initials/Date: | 8/15/2017Property address: 21244 Greenhead Dr. (mm/dd/yyyy) 1. Impact on Public Health - Compliance component #1 of 5 Compliance criteria:Verification method(s): S Searched for surface outlet ^ Searched for seeping in yard/backup in home □ Excessive ponding in soil system/D-boxes □ Homeowner testimony (See Comments/Explanation) □ “Black soil” above soil dispersal system □ System requires “emergency” pumping □ Performed dye test n Unable to verify fSee Comments/Explanalion) Q Other methods not listed (See Comments/Explanation) □ Yes El NoSystem discharges sewage to the ground surface.______________ □ Yes I3 NoSystem discharges sewage to drain tile or surface waters. ________ System causes sewage backup into dwelling or establishment. □ Yes S No Any “yes” answer above indicates the system is an imminent threat to pubiic health and safety. Comments/Explanation: 2. Tank Integrity - Compliance component #2 of 5 Verification method(s): ^ Probed tank(s) bottom ^ Examined construction records O Examined Tank Integrity Form (Attach). □ Observed liquid level below operating depth □ Examined empty (pumped) tanks(s) □ Probed outside tank(s) for “black soil” Q Unable to verify (See Comments/Explanation) Other methods not listed (See Comments/Explanation) Compiiance criteria: S 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/Explanation: Owner told me they are block systems from 70's. He help work on them. s- 3. .Other Compliance Conditions - Compliance component #3 of 5 a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. D Yes* I3 No □ Unknown- b. Other issues (elearical hazards, etc.) to immediately and adversely impact public health or safety. □ Yes* 0 No □ Unknown *System is an Imminent threat to public health and safety. Explain: c. System is non-protective of ground water for other conditions as determined by inspector. □ Yes* B No *System Is falling to protwt groundwater. Explain: TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 2 of 3 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 ' wq-wwists4-31b • 6141 !4 Inspector initials/Date: 8/15/2017Property address; 21244 Greenhead Dr, (mm/dd/yyyy) 4, Soil Separation - Compliance component #4 of 5 Date of installation: 8/4/1979 (mm/dd/yyyy) Shoreland/Wellhead protection/Food beverage lodging? Compliance criteria:_____________ O Unknown Verification method(s): Soil observation does not expire. Previous soil observations by two independent parties are sufficient, unless site conditions have been altered or local requirements differ. H Conducted soil observation(s) (Attach boring logs) □ Two previous verifications {Attach boring logs) O Not applicable (Holding tank(s), no drainfietd) D Unable to verify (See Comments/Explanation) □ Other (See Comments/Explanation) E 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.________________ E Yes □ NoNon-performance systems built April 1, 1996, or later or for non-performance systems located in Shoreland or Wellhead Protection Areas or serving a food, beverage, or lodging establishment: Drainfield has a three-foot vertical separation distance from periodically saturated soil or bedrock.* Comments/Explanation: 0'-23" 10yr2/1 SL 23"-28" lOyr 3/3 SL 28"58" lOyr 4/6 S 58"-84"10yr6/6CS 0^v/ indicate depths or elevations□ Yes □ No“ExperimentaT, “Other”, or “Performance" systems built under pre-2008 Rules; Type IV or V systems built under2008 Rules (7080. 2350 or 7080.2400 (Advanced Inspector License required) Drainfield meets the designed vertical separation distance from periodically saturated soil or bedrock. 48"A. Bottom of distribution media 84"B. Periodically saturated soil/bedrock 36"C. System separation 36"D. Required compliance separation* "May be reduced up to 15 percent if allowed by Local Ordinance.Any “no” answer above indicates the system is faiiing to protect groundwater. ^ Not applicable5. Operating Permit and Nitrogen BMP* - Compliance component #5 of 5 □ Yes □ 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 section does not need to be completed. Compliance criteria a. Operating Permit number: _____________________ Have the Operating Permit requirements been met? □ Yes □ No □ Yes □ Nob. Is the required nitrogen BMP in place and properly functioning? Any “no” answer indicates Noncompiiance. Upgrade Requirements (Minn. Stat. § 115.55) An imminent threat to pubiic 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 ordinarxx. If the system is failing to protect ground water, the system must be upgraded, replaced, or its use discontinued within the time required by local ordinance. If an existing system is not failing as defined in law, and has at least two feet of design soil separation, then the system need not be upgraded, repaired, replaced, or its use discontinued, notwithstanding any local ordinance that is more strict. This provision does nof apply to systems in shoreland areas. Wellhead Protection Areas, or tht^e used in connection with food, beverage, and lodging establishments as defined in law. TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 3 of 3 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31b • 6/4/14 X'l’’-''* • - V _ ' - '■'I--■"■ ■■ -*-^ ,••'■' • '• s.'--' :■;•• '^m U.mmimE? fe~rv:s^^.iSgws£a pis:“/• ■ :■.■• ■ 'fy r' }J '■^' ■ ' i' ^ ' 1 1LIkw mm-.^H:gmm 1mp ^rntmM & i¥l-*v^ !7^<5r.#6^' +• •~\Li-ij-i: Wl*< w^swsgm^iSSy:: mmm:^Ste ■& mmK',2f kL.?• lifSiBiiEr 1 '<m■ '. ‘L •' P@SW v^*'' ftr:fM'j^ -V li ''"'y: y'-yL.'; /. :-L >■;: ■ yy «s M;-- : r]i^'r' ;-r '*.v7 A’. .■?'r-.I; |;'V ■s-> I ' ’r ejS»53i•■- lA pafifgEipfeS&^i^^^5Lp«>8-g^ .... .. ...^.s?: 7T l:r^y^afeSMfe^isa y ig*h m:m....„ ,. 4-:/r;-' 3.' ?;■ -■ ■ •^«.mi-:MyV L k:>yr: » ' r yj7-.-T^mm>,. T.-,-, •-•. j: clJ*- ' . >' . 5 sV.L1<■ih>>1S m mS:J-'f mm amM E \t^.’TSi Si Sf Deportment of LAND AND RESOURCE MANAGEMENT OTTER TAIL COUNTY GOVCRNMENT SCRVtCCS CCNTCR - tSAO WEST FM Fergus Faul^, mn 56537 Ph: 21S-008-a005 OTTER Tab. COUNTY’S WEBSITE: WWW.CO.OTTER-TAILJMN.US otter Tail County Compliance Inspection Form Addendum This form is a required attachment to MPCA Compliance Inspection Form for all Existing Subsurface Se^ge Treatment Systems in Otter Tail County as of June 1, 2011. SCANNEDProperty Information Parcel Number: 41000030019007 Township: Nidaros Property Owner Name(s): Robert & Anita Meisenhelmer Property Address: 21244 Greenhead Dr. Reason for Inspection: jowner Request Number of Bedrooms: [3 / In Shoreland Area? Lake/River Name, Number, & Class Section: 3 Yes Stuart, 56-191, RD No iSystem Compliance Status:Compliant Non-Compliant _/NoYes Yes Yes Does the soil treatment area have less than 3 feet of vertical separation? Is the septic tank located less than 50 feet from any well? Is the soil treatment area located less than 50 feet from any deep well? Is the soil treatment area located less than 100 feet from any shallow well? Does any part of the septic system fail to meet the minimum OHWL setback requirements for the public water classification? £No £No /NoYes /NoYes "Yes" indicates that the system is failing to protect ground water and is noncompliant. If ’Yes", describe the condition noted:House System Tank Fails Block Tank Drain Field Passes See attached well sealing record ( 20* of blue clay) Well 47’ deep ok'd by MNDH 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 perfonnance 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: Scott Ellingson Certification Number: 8571 Business License Name & Number: Scott's Septic Services, LLC 3947 Signature: ______________Date: 08/15/2017 Page 1 of 2Excel/Compiiance ForniforOTC 1/15/2014 Otter Tail County Compliance Inspection Form Addendum (cont) Parcel Number; 41000030019007 Date & Initial; 08/22/2017 gc- System Drawing The system drawing which includes and identifies a graphic scale in feet or indicates all setback distances, all septic/hokting/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). L LL "Dwt II xo S*)alloI» -1^iv-e I)o|0 MluP, t44looIco'’ \ 771/Vr TAILSAdditional Comments; 'r^raiA '4 Page 2 of 2Excel/Compliance Form for OTC 4/14/2017 Minnesota Pollution Control Agency S20 Lafayette Road North St Paul, MN 55155-4194 Compliance Inspection Form Existing Subsurface Sewage Treatment Systems (SSTS) Doc Type: Compliance and Enforcement For local tracking purposes:Inspection results based on Minnesota Pollution Control Agency (MPCA) requirements and attached forms - additional local requirements may also apply. Submit completed form to Local Unit of Government (LUG) and system owner within 15 days System Status System status on date (mm/dd/yyyy): 8/15/2017 ^ Noncompliant - Notice of Noncompliance (See Upgrade Requirements on page 3.) ^ Compliant - Certificate of Compiiance (Valid for 3 years from report date, unless shorter time frame outlined in Local Ordinance.) Reason(s) for noncompliance (check all applicable) □ Impact on Public Health (Compliance Component #1)- Imminent threat to public health and safety □ Other Compliance Conditions (Compliance Component #3) - Imminent threat to public health and safety S Tank Integrity (Compliance Component #2) - Failing to protect groundwater □ Other Compliance Conditions (Compliance Component #3) - Failing to protect groundwater □ Soil Separation (Compliance Component #4) - Failing to protect groundwater □ Operating permit/monitoring plan requirements (Compliance Component #5) - Noncompliant Property Information Property address; 21244 Greenhead Dr._____ Property owner: Robert & Anita Meisenheimer Parcel ID# or Sec/Twp/Range; 41000030019007________ _____________ Reason for inspection: Owners Request _____________ Owner's phone: ___________________ or Representative phone: _______________ Regulatory authority phone: 218-998-8095 Owner’s representative: _______________ Local regulatory authority; Ottertail County Brief system description: Comments or recommendations: Septic tank FAILS Drain field PASSES \/ See attached well record Block septic tank to/gravity bed v 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: Scott Ellingson__________ Business name: Scott’s Septic Services, LLC Inspector signature; Certification number; 8571_______ License number: 3947_______ Phone number: 218-205-1667 Necessary or Locally Required Attachments □ Soil boring logs □ Other information (list): Forms per local ordinance□ System/As-built drawing TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 1 of 3 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31b • 6/4/14 Property address: 21244 Greenhead Dr.Inspector initials/Date: 8/22/2017 (mm/ckl/yyyy) 1. Impact on Public Health - Compliance component #1 of 5 Compliance criteria:Veritic^oh method(s):' S Searched for surface outlet Searched for seeping in yard/backup in home m Excessive ponding in soil system/D-boxes □ Homeowner testimony (See Comments/Explanation) □ “Blagk soil” above soil dispersal system □ System requires “emergency” pumping □ Performed dye test □ Unable to verify (See Comments/Explanation) □ Other methods not listed (See Comments/Explanation) □ Yes S NoSystem discharges sewage to the ground surface.______________ □ Yes S NoSystem discharges sewage to drain tiie or surface waters._________ □ Yes El NoSystem causes sewage backup into dweiling or establishment. Any “yes” answer above indicates the system is an imminent threat to pubiic heaith and safety. Comments/Explanation: 2. Tank Integrity - Compliance component #2 of 5 Veriftcation method(s): 0 Probed tank(s) bottom El Examined construction records □ Examined Tank Integrity Form (Attach) □ Observed liquid level below operating depth □ Examined empty (pumped) tanks(s) □ Probed outside tank(s) for “black soil” Q Unable to verify (See Comments/Explanation) 13 Other methods not listed (See Comments/Explanation) Compliance criteria; 3 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. E Yes □ NoSewage tank(s) teak below their designed operating depth. If yes, which sewage tank(s) leaks: Any “yes” answer above indicates the system is faiiing to protect groundwater. Comments/Explanation: Owner told me they are block system from 70's. He help work on them. 3. Other Compliance Conditions - Compliance component #3 of 5 a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. □ Yes* S No □ Unknown b. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety. □ Yes* IS No □ Unknown *System is an imminent threat to pubiic health and safety. Explain: c. System is non-protective of ground water for other conditions as determined by inspector. DYes* IS No "System is faiiing to protect groundwater. Explain: TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 2 of 3 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31b • 6/4/14 Inspector initials/Date:^(^^ 8/15/2017Property address: 21244 Greenhead Dr. (mm/dd/yyyy) 4. Soil Separation - Compliance component #4 of 5 □ UnknownDate of installation: 8/14/1979 (mm/dd/yyyy) Shoreland/Wellhead protectlon/Food beverage ^ yes D No lodging? Verification method(s): Soil observation does not expire. Previous soil observations by two independent parties are sufficient, unless site coriditions have been altered or local requirements differ. S Conducted soil observation(s) (Attach boring logs) □ Two previous verifications {Attach boring logs) D Not applicable (Holding tank(s), no drainfield) □ Unable to verify (See Comments/Explanation) Q Other (See Comments/Explanation) Compliance criteria: O 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.________________ El Yes □ NoNon-performance systems built April 1, 1996, or later or for non-performance systems located in Shoreland or Wellhead Protection Areas or serving a food, beverage, or lodging establishment: Drainfield has a three-foot vertical separation distance from periodically saturated soil or bedrock.* Comments/Explanation: 0"-10"10yr2/1 SL 10"-25"10yr4/4SL 25"-45" lOyr 6/4 S 45"-84" lOyr 4/6 CS v/ □ Yes □ No indicate depths or elevations A. Bottom of distribution media______ “Experimental", “Other" or “Performance" systems built under pre-2008 Rules; Type IV or V systems built under2008 Rules (7080. 2350 or 7080.2400 (Advanced Inspector License required) Drainfield meets the designed vertical separation distance from periodically saturated soil or bedrock. 48" 84"B. Periodically saturated soil/bedrock 36’C. System separation 36’D. Required compliance separation* ’May be reduced up to 15 percent if allowed 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 1^ Not applicabte □ Yes □ 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 section does not need to be completed. Compliance criteria a. Operating Permit number: _____________________ Have the Operating Permit requirements been met? □ Yes □ No □ Yes □ Nob. Is the required nitrogen BMP in place and properly functioning? 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 system is failing to protect ground water, the system must be upgraded, replaced, or its use discontinued within the time required by local ordinance. If an existing system is not failing as defined in law, and has at least two feet of design soil separation, then the system need not be upgraded, repaired, replaced, or its use discontinued, notwithstanding any local ordinance that is more strict. This provision does not apply to systems in shoreland areas. Wellhead Protection Areas, or those used in connection with food, beverage, and lodging establishments as defined in law. TTY 651 -282-5332 or 800-657-3864 • Available in alternative formats Page 3 of 3 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31b • 6/4/14 r^yn^r ;fe.x.:^s.:;-.r jy ■»V^(t,„^ ■ ’■VT'”' .-'i^aii' ■ •■ ■ ■ • , '- ,’-V— '‘-i’l" ‘6T^JoaBf , f-.^'Vo^?'.''■' '.I".'. I ^ ^ u, :'■;i‘Cy'^;-i[i'u'’>^‘y'!u'.l^r •- % ................. r :l.". ... ,. ,^v (iSJJfeiUw'S.„„ ^.sctnWwK'j'; tiweiMl/. ■ ■ . T .„ . y . -S'- ' ■<’ A; •?> ‘J r' i. •titlll, >u/' ■ ■".. ~ i’irf *1.; ;-', |-" f. j-.v u ml: \LotlTiimt#,I fe';;,:f;: '• ;< ^ . "•' •i'-V.,; •" -■> ■ ■■. ■ ■.' - , ■». / .u • f- ; ■'•-v;:,iC r*'t ij‘ o::r i*nto,:TT vc^'iny ■;- L,-.: iBilkck ,■,rv A ,r^ te;- ;.'.i:^ .-.Softiii.L~: rr.''5 ;.M':!■ ‘r--" ?>Xt® ?Tt -■y; i •=j^Ml'M]1|0, ;::i. fl ^ -y".•-■4cf: ■ ;.5-,..4 - : -V- ■'■,fe.4^.-4~ ; f:^ "V-^.i r- :::a'-,->£y 44^'J ^^''-^ > ": f ‘'.r,r>v' mmM . ' 4 ?■' '■■*'’m\iri, -f •'■ , ‘.?v;•‘ ■;-■ .... -■ '■ 7' S.ci, ;>V. V..r;: \ ■>t-: ilESSBiE-ySSlS • >•l:"' i '■i , ! *^i > •i .1'.,.£7'J'-» * •*5<‘ ..5ii. 7, •* ry'ri;^',r’, i itisfexxsyxstot l« SlSsiS^BF^S* S? 3Sk2Se£2£s^ - >(5fc,.' :"'-.7,i,•;':: feX__^■ •ij,: < .v'ar -ti i. ■■• ‘■■-■^ ^i?:p m©jSRr-’. IMMMmM ;i\ ;■■ 3rS *:'.^‘4'^'Sr 2i-.. -.j«>V:. , ;rfx;'';:-4 1: j &i b:! (Si>c-i >.1 ' 7 Sf $4 iftwSS'iSiiKiafe i-;-l#i|w4®iS^^SSv 1 -frO?ii ;,rrr;.-.7|7:^ ‘s ft-. -.7 c.''.;. J ^74 f i^77l i-'^9Mmw:h ■e y ~:A ■•^4 7 ■' '7 ^;V 'r :^:k j :x. s: &fe-, »r;J r.'' ^ \ A\'yp-kV?3. (/t- J?.^ u fA. CERTIFICATE OF COMPLIANCE;^i SEWAGE SYSTEM HOUSE ONLY m?: PmThis certificate has been issued this 17 th 19 80day of_January 73 S#at?V ^7 m to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.iSSl U The premises covered by this certificate are legally described as:tecLake No. 56-191 Sec._1 Twp. 13?Range 3.9 Twp. Name.N1 H a rn t; mMallard Bay Resort Pt. of G.L. 8 in Bk 105 Pg 875 ex trs. 569* on lake as rec. si H Owner: Name.Bob Meisenheimer mSi AClitherallf MN 56534A ddress. ■A® Zip No. Permit No. SP 38 26 ptpf.Signed by:_ I NIalcolin K. Lee, Shoreland Administrator Otter Ta.il County, Minnesota MKL-0b7 1-009-IV s ^ s... IS ®159035 •ic’9* 4 eo. 'f»:L'i '*1.11 «ii'» » . *. 3S _s 3e as ix\.nV /sammM \ w l\'^bJ; CERTIFICATE OF COMPLIANCE SEWAGE SYSTEM RESORT Wa p m17th/9_82This certificate has been issued this day of.May to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota. fP /i^ 7t The premises covered by this certificate are legally described as:i?yi -iiW/!'9m-M56-191 Sec___3 132Lake No.Range 39Twp.Twp. Name. Ni'daros i;m; Mallard Bay Resort Pt. of G.L, 8 BK 105 Pg 875 ex trs. 569' on Ik as rec. in ) /*1EI milc•t=Bob MeisenheimerOwner: Name. W/ Clitherall, MinnesotaAddress. 56524Zip No. 3826Permit No. SP_ Signed by :. mM^coim K. Lee, Shoreland Administrator Otter Tail County, Minnesota ^'*rj mMKL-0871-009 / MW' 159035 vamn « <•. matt**, mmm ruu. bm 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 OfficeV'' :te V -low — Inspector Ph.. Card Owner ’Owner Permit No., LEGAL DatePi-, 5 . A. S' Uk. DESCRIPTION AND /3'^ V)£>(o~ /9 ( .S^XjuucuCfcLOCATION Range TWP NameLake Classif.Sec.TWPLake No.Lake Name IDENTIFICATION: Please Print All Information. Tel. No.Zip No.Mailling Address —No. Street, City and StateFirstInitialLast 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 Time Rec'd Phone Call Rec'd By Owner or Agent Signature NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PITSEPTIC bl^Q.S> ISO^ 32SO qoO TANK DRAIN FIELD 11 GIs.Sq. Ft.Sq. Ft.Capacity h! ouKo 6d //o^Ft.Ft. Ft.Distance from nearest well /'J/I Ft.Ft. Ft.Distance from lake or stream /o Ft.Ft.Ft.Distance from occupied building /ODistance from property line Ft.Ft.Ft. 4Ft.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 ....1.%..PERCOLATION TEST DATA:Date of First Test Rate, 19 ...2y4- rp l<ihCt A-i f 1st Test Taken^^y I ^\Date of Second Test 19 Rate 2 ¥First Test -I- 2nd Test Rate2nd Test Taken By 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 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 jgtuis ready for irispection7(Call or us/attached mailer notice.) 7- 77Dated 7 Signafure 7' L 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. 4sIssued Date: Shorelarrd Management OfficeSOOC.75Fee $_£Surcharge $+ .'jcinr> /VTComments:. (7) ^ Cj^a Vicroa LUMOttk 4 CO., paiertel. rtacus rjiiLI. winn.1]^S706 I C^jrtA ____/ °‘YTfForm No. MKL-0771-00/7^ Cr fiT RjI4a^s e — f\j*T ir^ y^rj 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 'T W te — Office V low Inspector Pli.. Card Owner Owner OLo • Permit No.LEGAL DateLtA, 5^ B-k \oC Q(o^' 0^DESCRIPTION /r\k5 .AND .,/■ r; .V 13::}■3,LOCATION Lake Name TWP NameLake No.Lake Classif.Sec.TWP Range IDENTIFICATION: Please Print All Information. Mailling Address —No. Street, City and State Zip No.Tel. No.Last Name First Initial OWNER erSEWAGE SYSTEM INSTALLER Name. . 19^This SKSfem will be rehdy for inspection on. This space for office dise only Date Rec'd' ^k'~25 Time Rec'c/Phone Call Rec'd By Owner or Agent Signa^ture .) NUMBER OF BEDROOMS;ESTIMATED COST:. Cl SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD GIs.Sq. Ft.Sq. Ft.Capacity Ft.Ft.Ft.\Distance from nearest well Ft.Distance from lake or stream Ft.Ft. Distance from occupied building Ft.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 Rate19 , i9..rz..k«Date of Second Test Rate 1st Test Taken By First Test -I- 2nd Test Rate2nd 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 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 Permission is hereby granted to the above named applicant to perform the work described in the above statement. Thi^^iit 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 ordintu^^^rDtter 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. / ) ,7 \ Permit: i ! erend Management Office Issued Date: Fee $" 4Surcharge $ Comments:. -•'t Form No. MKL-0771-003 vicToa uiaacen 4 co . primtc**. rf««ua riu.Li h>hh.158906 INSPECTION RESULTS ' Inspector must make all measurements . . £?' SEWAGE DISPOSAL SYSTEM STATISTICS SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY Actual Should be Actual Should be Actual Should be7^ SFCapacityGIs.GIs.S F SF T / 25 75%Distance from Nearest Well f/75FF F F Distance from Lake or Stream fte>F F F F 20^4MlADistance from Occupied Building ,F^10 20FFF F FeC 10Distance from Property Line 10 10FFF F s.TfiDistance from Bottom to Water Table 4FFA F I ^ iaJx2jl /wT --------Inspector's Comments; zIT"* -<JL_ ^ ::iB 3 - y ~^lyw-g •^3 1/ -f- cc^cr^1QI ^11 f* Date of Inspection 19 Z_MTime of Inspection. Signature of InspectorINTERPRETATION OF ABBREVIATIONS GIs *“ Gallons SF * Square Feet “ Linear Feet Job TitleF AgencyMKL-0771.003-Backer C-aJ^ r ; I :* ! I *. GRID PLOT PLAN SKETCHING FORMfeet/inches.Scale: Each grid equals 19Application for Building Permit Dated 19Application for Sewage System Permit Dated Sewage System Permit Number.Building Permit Number Applicant agrees that this plot plan is a part of application (s) indicated above. 19,Dated.Signature On this form make a drawing of your lot. Indicate all present buildings with solid lines and all proposed buildings or additions with dotted lines. Also indicate in feet; lake setback, side yard setback end rear yard setback. i Vi .i ! ' ^ i :I i 1 . 1 c:> 6T I ! I I ! I ,( 4 -Lj j I i-.j-i I M i I 1 I 1 -I 4- i I i ; ' r"\. I Xf-—^ s / a y 6-T 'v'c~ Retail I / /O 7f ‘=0 -! / o c? b) (R> ^ o o lo '-^^'\^'Y\r~ <3L,/v-_^ 1^ /.j~er- / ^ <5> Z^^~eT- <sr^^>-ts<>-»^JZ-i2e/^ f / A- ^ S''7 -Vv^ ( 1^^ ^s~ As- >. «' ' r. ■f- A- JO^ 7 -T /;2.^ V ^ <=irf{ Q, 'r 1/prc^&. ht s ,y^ cthc>tiz. I Of/e^ - 2 d ^ A! ^ ~ ■/'^£) *«• ctj c- / — J ^ c> 7/ ^o' TP (>^ilf i -y PERCOLATION TEST DATA SHORELAND MANAGEMENT OTTER TAIL COUNTY Fergus Falls, Minnesota 56537 // / ■ .L J /icsi sci-i es>o y Ph. No. Owner:Mailing Address:// e.CZ'I(IkKt^^ ^MTddle C lasstast Name fc^Rrst 'S/Hczy St. & No. 2 City State Zip No.Legal Description: //^1 y ^e> 3jj LAKE OR RIVER NO.//^ f uO Ki P \r J^/<i L ■2^ io 2> ycat^i, SEC. , TWP, ^ RANGE /^/ tz,// ^ 3 NAME TWP NAME<-'9 £. — fd-/o /7/^y? ,2, — /i? e-o4 ^ ^ 0 Ce-> <£✓ *-7//// •-?z^/- /.: /• €_■//^ o “t. TEST HOLE NO. 1 Os> /-/'^ ^ E>y(‘CE>ts>TEST HOLE NO. 2 y t-yZ-dy/4^Depth to Bottom of Hole inches; Diameter of Hole.inchesDepth To Bottom of Hole.inches; Diameter of Hole inches ^ C, /f\/^/V ITDepth, inches Soil Texture Depth, Inches Soil TextureDate.Date 19 J, /(O - L 00-1-L ^ a 4.*^Percolation Test By____ Percolation Test Bv__y c./^"/'S'/’o *•; f ^z>V ^ / E !Z~ ^ ‘-Z1 ^ '4-\Z~ H ^Firm Name.Firm Name.c ,D 5 «? >v c/<-£✓/ oLU GC Ti.-'/lU4fAddress.GC Address < r(/)Otter Tail County License No..Otter Tail County License No.I-05 LU Drop In Water Level., Incites Measurement, Inches Drop In Water -Level. iTWhes Measurement, Inches I-Time Remarks Time Remarks o Jr2.)y I/O 2-to y /' /1-^/V 7 ?«•r 3 *4 'Tf I /3?/ V3, O 3 ^3 . O g./C. -i'dg 2-'?7 2., O7 S’/HO, >S'% fl y 2..J, ^/-5?3.’u t., O //< S't A O0 1^zV’.3 5.HiJ 2.-^AA,0ooA /,C>/.1LU>o sA ^ /, o>/7, ^______________/_____/. _________2,^ /4i/s ^ 2^ /^ / c-.// '•r- f MKL-0871-028183818 ®VICT08 LU88C1B ■ CO.. g8l*Tt*t. rCtfUl r«.L8. MIMM.- • •>See Booklet, "How to Run a Percolation Test" by Agriculture Ext.. Service, Un. o f Minn. \WATERWELLRECORD7f'tf7:±ks-!t iTi^v^i.Tp n7ji^' fa 9 *j>i iiK. .1 1.1 l)i<roii.>n Hum Kuj.i inu tkccChink nr St(e9r Addreu and CiCy uT Wet] Liicaiioo !jor Water Saxiplf Minnesota Staruiet I ifiA.O!-.US Township Numhci Kan|c Number Seciion No.J. ('KOHLH l Y OWNtR S NAMKi% '/. %WES£.SjJ. J j >tuJL a/ Skeicb mail uf well location Mallard Bay Resort Clitherall, Minn. w Addrc^k Ihd 4 WLLL ULHIH (compleied)Date of Cumplecion 8=30=7747Addilion Nante_ 1.n. 4CH Kcvetic tL3 I >r iven ioOdui C'liblv KiiilEwUloi k Numhef 2DMoIIov. ruj sDAit ft[Z] Mured iDT H mi.bCDjeiu'd '*Q 1’iiv.ef Auger:x Lot Number 6. USK 2^3 Uoiiu-'iiii 4[Z]l’ublu Supply 7C] Indu&liy sCZ) Commercial S \ mi S^Municipal b(~l Air < ■rlllcJllMI 2C3 Irrigaiiiio HAKHNi-bS 01 lOKMAIlONhOHMAIlON LlXl col OR EHOM JO .'! 1 K-vl Well 7. CASINt;HUCIIT: Abovr/1 MOLL 1>IAM55mBjir.iileU sQwdJcd 1Soft0BlackTop Soil Clay / jG.,...II. V.. ^ No _____41HardYellow Orivc Sboc'Jd ]4 II ___in lo______ft.Weight Ihr./n 204HardYellow m. to______n.Sand It Weight Ihr./rt. _____\\\. to______ft. .ibi.;tt. "h~ CKl'l N4020Med.Blue ir ii|ic.i liiilcJohnson____I' Stainless Steel Clay tl. to n.Make l:uH- Sflnd type 1>M.4-4740Soft T2) GreyX4-eofL4Ai^Stoi/C?au/e Length^7713 nrriNCS; Set between ft- and ft. mid It. S I A 11C W A H H l.KVl.L 8=30=7/16 laud suiface Oahovc Date Measured 10. PUMl'INC i.LVLl. (below land lurtjce)14127 ft. after hn. pumping hia. punipingIt. altri n. WLl.L IILAU COMPLKTION adapter iQ basement uffael jOai leaAl 12" above Kiade 1 2. Well grouted? QVek Cu. Yds. lO Ncut Cement 2O Ueiilonite jD Depth: from ft. 10 n. ft. to •ft. Id. Nearest aounek of poauble contaniiiialion SewerNorth75.feet .direction type vXl n.iDWell disinfected upon Completion? 14. PUMP 8=30-77 Dale installed O Not installedAermotor S15I2 -Ji 50Manulai'luicrs Name i;23HModel Number HP Voltsa1X12aft- capacityLength of drop pipe g.p.m. GalvanizedMaterial of drop pipe3&jQl. S. Turbino sOKeupritceiingType;Suhmcikitilc 4C3cenuifugal2l_Jiel I*. WATLK WLLL CONTKAC lOR’S CEKTII-ICATION This well was drilled under my jurisdiclton and this report b true (o the best of my knowledge and belief. Robertson Well Drilling-26.14.4 Licasate BuMneu Namt ^ Lkenat iVo. , I^nn. 56309------------ AutTioriied Repieacniative Use a aerond Uttas, (/needed. I ft. KLMAHKS. LLtVATION.SOUKCbOK DATA. elC-AshbyAddress 9-/0-17 Daig _ SI(om1 8=30=77Paul Harvego Data Name of DrillerIMPORTANT: FILE WITH DEED - WELL OWNER COPY 5/74 30M 7/76 30M I . k.*-: • C GRID PLOT PLAN SKETCHING FORM.feet/inches.' Scale: Each grid equals .19.Application for Building Permit Dated 19Application for Sewage System Permit Dated Sewage System Permit Number.Building Permit Number. Applicant agrees that this plot plan is a part of application (s) indicated above. 19,Dated. S Ignatu re On this form make a drawing of your lot. Indicate all present buildings with solid lines and all proposed buildings or additions with dotted lines. Also indicate in feet; lake setback, side yard setback and rear yard setback. // fi >I .<2://!\-------/.// 2- / O / 12 !‘/ ./3 -r‘/3.^ i /// f i // / / I / ! _.1501O4 ®CL-0871-029 LuaBtlM B'ce.. rettus r.iL«. ■<«.. VICTOB