HomeMy WebLinkAboutMaple Lane Resort_41000030015006_Septic System Permits_CERTIFICATE OF APPROVAL
SEWAGE SYSTEM
HO mm TMK’iw
(i-#i 22nd yp.cp.mhpj!This certificate has been issued this
to certify that the sewage system installed as per sewage permit number indicated below has been approved for use
day of
Ki by Otter Tail County-, Minnesota.
m
w- ■
The premises covered by this certificate are legally described as:
56-191 '
56-13S
tlfdcULOA
Twp. Name GJJi and3513339Twp.Lake No.Sec.Range
mh..
■W/
m.3.
Maplt Lane. R.ti>ofit
[ion. CamppAi ^J,2,3 £ 4}
•M<
Judd VnungOwner: Namek]!
Rtn,UJnJng^ MMAddress
5658SZip No.
M7562 ■TnPermit No. SP
Signed by:.
Malcolm K. Lee. Land & Resource Management Administrator
Otter Tail County, MinnesotaMKL-0987001
243.984 — Victor Lundeen Co.. Printers. Fergus Falls, Minnesota
SHORELAND MANAGEMENT — COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 • Fergus Falls, MN 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
White — Office
Yellow — Inspector
Pink — Owner
15L3lPermit No,Pi £ LmeLEGAL
DESCRIPTION
AND
- 13^
Lake No.
£. 3r^r~Li^ ST-WHAZr
'■jllQAfjpBA3^ / AlLOCATION
Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and StateLast Name First Initial Zip No.Tel. No.
O'tArY Q fZr I Vi’YirV-s-'T\AO£>OWNER
1^1-HiX)
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
itNUMBER OF BEDROOMS;ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT.DRAIN FIELD
IdXOOEl GIs.Capacity fq. Ft.Sri. Ft.
So Ft.Ft.Ft.Distance from nearest well
75 Ft.Distance from lake or stream Ft.Ft.
lo Ft.Distance from occupied building Ft.Ft.
toDistance from property line Ft.Ft.Ft.
Ft.Distance from bottom to Water Table Ft.Ft.
AH distances are shortest distance between nearest points
i-icPLiO/rYC ~TYitv'l<0rV(^RECORD OF TESTS:
Inspection was made/on
PERCOLATION TEST DATA:Date/of First Test
Date of Second Test
1st Test Tak^ By
First Test72nd Tes|t Taken By
Agreement:
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.
I understand that I have been granted a sewage system site permit in accordance with
the requirements of the Shoreland Management Ordinance of Otter Tall County. I ^
understand I must contact my township in order to determine whether or not any addi-
tional permits are required by the township for my proposed project.
s.„ /Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permSTts-graated 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 jDtter 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.
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
Signaftire
Permit:
3 -Issued Date:
Shoreland Management Office0,0, GOFee $_jj Rec #
/ , -a. 3 j- y (4 H~r x;-Comments:
7^7
Form No. MKL-032085 237.443 — Victor Lundeen Co.. Printers. Fergus Falls. Minnesota
•y
-iSHORELAND MANAGEMENT — COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 • Fergus Falls, MN 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
jWhite — Office
Yellow — Inspector
Pink — Owner
wr I
i
Permit No. ~7 S(o ^
ALEGAL
'ssoeoDESCRIPTION 1
1AND
rv i v/'i I.
e. tir^TTLr’.t - iisT go '2a3^ 2 <LOCATION
Lake No.Lake Classif.Sec.TWP TWP NameLake Name Range
IDENTIFICATION; Please Print All Information.
Mailing Address — No. Street, City and State Zip No.Tel. No.Last Name First Initial
KLi V'ir^nVGj OilIV C 'ryyVOWNER
Tiiaa?
}Aao~SEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for Inspection 19.on.
This space for office use only
mry^ Call FLU
•ita Re<
19 ,M
Dat Rac'd Pho Rac'd By Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
i ’Sq. Ft.GIs.Sq. Ft.Capacity i
iFt.Ft.Ft.Distance from nearest well
75 Ft.Ft.Distance from lake or stream Ft.
I/O Ft.Distance from occupied building Ft.Ft.
/
Distance from property line iO Ft.Ft. Ft.
/Ft.Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
fnY G ~T~Y)iO
............... 19/
RECORD OF TESTS:/VcTT/
/
Inspection was made/6n , Time M By
/
PERCOLATION T£ST DATA:Date,of First Test , 19/y
C^e of Second Test 19
1st Test TakeW By //
First Test + 2nd Test.,3
TesV' Taken By 2 Rate2nd
/
Agreement:
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.
I understand that I have been granted a sewage system 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 addi
tional permits are required by the township for my proposed project.
.................■
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.
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
Signature
Permit:
a - 5Issued Date:
Shoreland Management Office
2o-ooFee $Rec #
I 3 J- 7 P4 Hl~ 'TG-Comments:t
i
iForm No. MKL-032085 237,443 — Victor Lundeen Co., Printers. Fergus Falls, Minnesota
. .:
i
s^y^ C ^INSPECTION RESULTS
Inspector must make all measurementsi
U ■
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYActualShould Be Actual Should Be Actual Should Be
1.0 1-900Capacity Qls.GIs.SF S F S F S FWv
rDistance from Nearest Well 5^ 5 F F F F FF
Distance from Lake or Stream F F F F F F
VDistance from Occupied Building F/o F F F FF
Distance from Property Line F F F F F F)o
Distance from Bottom to Water Table 3 3FF F F F F
51
i' ><L Ov y 0«V^J
Inspector’s Comments: V>oo^-U(:::g> ^
I
9KDate of Inspection.19
IT.'' MS'Time of Inspection M
Signature o^nspector
INTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
S^are Feet
Linear Feet
Job Title
AgeiKy
&
f• •,* -
;
i
L ----
;A*^vy;Sr.'rMt:e|; fibwfrn»*nt. U«t JnU««;t3) £n Sjftftton-tjur€» .-(SJv-.Township On* .Hundred
j~BoftlnpiaiL ai o point-Cholng ,the ncnter of the Towatblp Stood] lococod North'
3>.{>1 loot frost tho,tlortbssst cprosr of Lot 2 In RUJIANS HMLC
.«, plot cm ncord at tha'IbMnty. Becor^r'nOftiee; ' . ‘v :. ' •".Va'
{•;•/'.J.^fbeoce Korth 37 0.3’*^’ East hh.U.foH nore or'less .to the North .
"=Woa ®* sold Section-3l' ;' v.';.’-. :>V-; 'Sooth- 89®-4r43" -East ',»Mt .feet. •oA^or " thssrL<a-;igts s<l««-„'. . .-;,.ic;',--I
i^Vri'1f-^:-? 'V-3*>en*S'S««lhaastsrl)r along the lisks appro*tisiteiy itO fact to :
■‘"•'-'L .''_* point located East 1131.86-feet froa the saidspolnt of beginning; .-,. --■V'-jK^?- -:>i!j :thenc*. south'21®32*15" West 102^(10 feet to jtbs cec^er of s-creek;
^ ®®^^******^^^'*^®"S eireek, ccntaf{ine<'hpyTSXinatetp ^’7'
'ai;;.,.490 feet to the cenfer of the township road;, .'S^ . ■ - ..-'. i
' Thenc* North 77-17*16^ Neat V7J.32 feet along the toadfv ,.- Thence North 69®Q9*OV Neat. 387.06 feet along the road; V . ^
j thence North 60®37'*0" «*« 244.73 feat .to.the polnc of V- ' '-
■g'Sy^^r-^ttOgsidbirWth .s part 'of-Cow Lot Three (3) In Section Thirty Eire V - '
Vt Toroahfp One HtsHlrcd Thirty Throe (133) North. Range “Thirty Nine (39) n
’T/Tt:■'-*• Waat, Otter-.Tall Count*, MtnfMiota. deaerlbad aa follows} s
^:^^j!!^'CMneiiclnA at> the Nertheeet.earner of ^ot 2 Vn. HOtMANS H^CB •
r:' -on record »t the Counftj Jtecor4e7ft Offfee’i theiwe Horth Z8 12*40*' Eeet _ •• ^ -WiOK fefC o» «n-extension'the SouthcTly eeld Lot 2 j thence -V-jV"-*
3> 03*45*' jEeet 82o68 feef. sere or leee-to the South .line of said .s; •■ <
n.'T;;.>‘:',9»^;‘''.'8ahct«i 33 and. the point .of' becj'nm'inr; ‘ • •'v.'-*'"'''i: - '•
north'37^03* *4"._.Edal'-"SW .feet."*iA or Xaag. thjho odge '.; . '
Eaat Battla Lakai .- '/r'C-'x .--V'*.:^. 'I ..;;.. Vj.V; A v:-:;
•“j-.Li;-.J^^.-:;/',-^ TIioiica Southealtarly plpng tha Uk*'spproaliaataty STO.
.'-^'S.^aht -to the South Mho"df soU Section 35i-' ‘•.-A,,-:r.;
-acrea-WM'-olr. '
\ (3) of HOUlMS M*fLE LANE 8IACN, a plattod Subdfvlalon of i
' of Covernneot Lot Three (3) In Section .Three (3), Township One Hundred
V thirty Two tl32) North, Haage Thirty Nine (34) Nest, Otter Tall County, Nlnne.
^^^-r-a..-ihoea. <m. f f la-tn. the; Occar Tail Copncy Racardara Of flee. .
7'.
:• ‘y
■.- ^-
' -■•' r
r»>i,Vi> • poini iocitid £»»t 1131.86 fcec Iron tlv
,th«nc*. south':i 52'15'' W«it 101.00 feti ti
' 8aiitln*««t«rly «lonB raid crerlt, c»i
north'e*V'0>” f«et al
. -S'! ':'js-vv;;
«rtth .1 p»lrt ef CovcrhMit^ Let Thrat (3 . ; ;:r . |i^§jfe(35>,.,Whtp,0« »undr.8 thlrty^^hra, 1)33) .
> ■ v' ?“’■ “““3""'' ‘
i* :i ,ift'
■ ' ■■ ^ racord at tlw Count} Sacoil'darA'bltict)'
'iv’-W'/>'v‘
Ai.>.•r
’ ’ /// ' ■
'fSm
A>W.*
» -
*r \
^ X W ^ V ■ ,
.':
I
J f /J /I.9 ■I :)l A: ' 0 .I^ u? I I'■ ^ .-M
■ A .'•.
\'i
c' f"-/,'■' '66^01'faac oh an tatahaion a^ tha Soiiclirrly'Jlii
I 35..in* tha point .Of ba^ 1 Wih|^,
Tltanca Horth'31*dS'*4" ta'at '^"io faa,t nori-i
• !IP \ 'it ''
* ■ irZ^ Cy "/fcy$ -JaJ:A
■.i
J iN
I / ' '-—^^ . k--’W^'^Sf^/.'I'-'of'Eaat fcattlO Lakat(^)A|4v€/f ' 'VV,'i,'.'.’ ■ V>'?' 'v. jrj.-’. '3^ SoutheaitarJjr along ihO laka ipproa
^4.' • ■ • ' ' •:'■ ■■ - 8af»a thirep:,»iha. 1393 t
'. .■ Ayr'-'
III
8 ■:i
■ \y '
r-iy \r-..>• V-:4-\d\!'- /3,0A ■
/'a;/'■
/BKA(
t'i
,!R
.!
i
yp>j‘
Mf :
t
il ^-!I» «i • ■ V?»’•■
? h".'
[' V^ ’ »
V.M •-
k;■rf ■{ '
tv
r'‘_
. 1 v'■■
)
i\' \i
n;.n
Ayh Ay' '{i,'
r’
V
SHORELAIMD MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 - Fergus Falls, Mn. 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
Vif ite - Offica
y low — Inspector Pii..
Card
Owner
Owner
^ e. ^ ^ 0 r'Permit No.,LEGAL
Date
DESCRIPTION
AND
rj-/3^ E- UaT~r/4^J r /:}:> j? C-ITPLOCATION
Lake No. Lake Classif.Sec.TWP NameLake Name TWP Range
IDENTIFICATION: Please Print All Information.
First Mailling Address —No. Street, City and State Zip No.Tel. No.Last Name Initial
iE // n l^)^OWNER
SEWAGE
SYSTEM
INSTALLER
^ .i QL'-^ ^
<^1 I y)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 Slgna.ture
NUMBER OF BEDROOMS; X Cub,ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
7^^YKsTlnq /0OT>7rpp£-?.?c-GIs.Capacity Sq. Ft.Sq. Ft.
5^Ft.Ft.Ft.Distance from nearest well
rT'i'Ft.Distance from lake or stream Ft.Ft.
V-'XO/EE! -y (r Ft.Distance from occupied building Ft.Ft.
. V./oDistance from property line /DFt.Ft.Ft.
t El.Ft.Ft.Distance from bottom to Water Table Ft.
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19 , Time M By
1.0... 197...Z...
, i9..‘:::;>...7..,
/PERCOLATION TEST DATA:Date of First Test Rate
\1~ r YL- L \ I Z.l.h.Date of Second Test Rate
1st Test Taken ByI f /I '■1First Test -I- 2nd Test 2 Rate2nd Test Taken By
Agreement:
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.)
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
' SignatureDated
Permit: Permission is hereby granted to the above named applicant to perform the work desgrlbed in the above statefnent. 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 i^ork is not commenced within six (6) months.I!1-1u 1,/W V./Issued Date:
Management Of^eShoreland
rr/fFee $Surcharge $
^c^aL>inS ~ H S - ^[) H • AfPComments:.
'-trs f -V
Form No. MKL-0771-003 .158906
VICTOt kUHOCCN t eo.. PDlHTIIII. fllltUS rALLI.
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
Y? te - Office
V low — Inspector Pi...
Card — Owner
Owner
Permit No.LEGAL
Date
DESCRIPTION
AND
LOCATION
Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
IVIailling Address —No. Street, City and State Zip No.Tel. No.InitialLast Name First
OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
>7 "^'^00^ 1)10}
This System will be ready for inspection on.. 197
This space for office use only
,19
Date Rec'd Time Rec'd Phone Caii Rec'd By Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
GIs.Sq. Ft.Capacity Sq. Ft.
Ft.Ft.Ft.Distance from nearest well
Ft.Ft.Distance from lake or stream Ft.
Ft.Distance from occupied building Ft.Ft.
Distance from property line Ft.Ft.Ft.
Ft.Ft.Distance from bottom to Water Table Ft.
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19,, Time ,JVI By
PERCOLATION TEST DATA:Date of First Test . 19 , Rate
Date of Second Test 19 , Rate
1st Test Taken By
First Test + 2nd Test 2'Rate2nd Test Taken By
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work inAgreement;
strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn
esota Department of Health. Applicant agrees that plot plan, sketches and specifications submitted herewith and which are approved by Shoreland Management Offi
cial shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the
responsibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection. (Call or use attached mailer notice.)
Dated
Signature
Permit:Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE: Permit void if work is not commenced within six (6) months.
Issued Date:
Shoreland Management Office
Fee $Surcharge $.•Vk.',
Comments:.
A. 158906Form No. MKL-0771-003 VICTOR UIOOEOH 0 CO . OOlOTIOO. FT*
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY
Actual Should be Actual Should be Actual Should be
Capacity GIs.GIs.s F S F S F SF
Distance from Nearest Well 75F F 50FFF F
Distance from Lake or Stream F F F F F F
Distance from Occupied Building 10 2020F F F F F F
Distance from Property Line 10 10 10FFFFF F
Distance from Bottom to Water Table 4 4FFF F F F
Inspector's Comments:
*Jono ^ - II- 7/
Date of Inspection 19.
Time of Inspection,M
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs ° Gallons
SF * Square Feet
■ Linear Feet
Job TitleF
AgencyMKL-0771.003-Backer
• J
159035 V'CTO* LUNDCCN t CO. MiHTfRI. PCa«U« P*LL*. MIIW
SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 - Fergus Falls, Mn. 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
W to
V low — Inspector Pli..
Card
Office
Owner
Owner
mo
5
Permit No.LEGAL
<a-Date
DESCRIPTION
&cxjgcU,AND
i? bLOCATION
Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
Tel. No.Mailling Address —No. Street, City and State Zip No.Last Name First Initial
(5^0 ^ l'V\ ■1Vv-)CL^v—OWNER
f~/ ■Ovoy->jo>-iSEWAGE
SYSTEM
INSTALLER f!Name.
This System will be ready for inspection on., 19.
This space for office use oniy
19 M
Date Rec'd Time Rec'd Phone Call Rac'd By Owner or Agent Slgnaiture
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
/OOO GIs.Sq. Ft.Capacity Sq. Ft.
Ft.Ft.Ft.Distance from nearest well
Ft.Distance from lake or stream Ft.Ft.
Ft.Distance from occupied building Ft.Ft.
Distance from property iine 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 , Rate
Date of Second Test 19 , Rate
1st Test Taken By
First Test + 2nd Test
Rate2nd Test Taken By
Agreement:
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.)
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
c6'^ -Dated
^ Signature
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.
...0a'-.5 -t/y\ O'Issued Date:
loreland Management Office
ooFee $Surcharge $
Comments:.
—
f\cb^>c<>
vicToa uineccM a ee . *ai«Tca«. rcaaus rM.La. M>aa 158906Form No. MKL-0771-003
1 SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 - Fergus Falls, Mn. 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
\W to — Office V low — Inspector Pi...
Card — Owner
Owner
Permit No..LEGAL
Date
DESCRIPTION
AND
LOCATION
Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
Last Name InitialFirst Mailling Address —No. Street, City and State Zip No.Tel. No.
OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for inspection on.f)ooy^S'll , 19
(ciThis space for office use only
-7^0
19 .M
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
GIs.Capacity Sq. Ft.Sq. Ft.
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.
Distance from bottom to Water Table Ft.Ft.Ft.
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19,, Time ,JVI By
PERCOLATION TEST DATA:Date of First Test 19 , Rate
Date of Second Test 19 , Rate
1st Test Taken By
First Test -I- 2nd Test "H2nd Test Taken By Rate
Agreement: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by 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. This permit is granted upon express
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE: Permit void if work is not commenced within six (6) months.
Permit:
Issued Date:
Shoreland Management Office
Fee $Surcharge $oeht issued
Comments:.
15890^Form No. MKL-0771-003 vicTot uineccH • co.. a«iNua«. rc
T^-y: ■
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORY
Actual Should be Actual Should be Actual Should be
Capacity GIs.GIs.s F s F S F S F
Distance from Nearest Well 75FF 50FFF F
Distance from Lake or Stream F F F F F F
Distance from Occupied Building 10 2020FFFFF F
Distance from Property Line 10 10 10FFFFF F
Distance from Bottom to Water Table 4 4FFFFF F
ojInspector's Comments:
w
19^Z£?Date of Inspection.
0*5. iC'Time of Inspection,.M
IV.
7 ,
nature ot Inspector /
17INTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
F = Linear Feet
Job Title
Agency
M KL-0771.003-Backer
PERCOLATION TEST DATA Price $ 1.00 per pad.
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537
Ph. No.Owner:Mailing Address:
Last Name First Middle St. & No.Zip No.
LAKE OR RIVER NO. NAME
Legal
Description:
RANGEtwp:
ATEST HOLE NO. 2TEST HOLE NO. 1
Depth To Bottom of Hole,Depth to Bottom of Hole inches; Diameter of Holeinches;Diameter of Hole Jnchesinches
19T2
t p
Depth, Inches Soil Texture Depth, Inches Soil TextureDate;Date 19_____
i
Percolation
Test By___.>« ■ PercolationynQ
UJ
'I FirmName,GC FirmT/Name______________-tZ)
aLUOC
UJAddress.QC Address
<
CO
Otter Tail County License No.Otter Tail County License No„h-COLUMeasurement,
Inches Depth in Water
Level, Inches
H Measurement,
I nches
Depth in Water
Level, Inches
Time Remarks Time Remarks
o6i5 Ath-6.4,/
/a f<
/
4uf/
L -5-^4.//
f
f 7/
z
MKL-0871-028
See Booklet, "How to Run a Percolation Test" by Agriculture Ext Service, Un. of Minn.