HomeMy WebLinkAboutMecklenburg_10000120082001_Septic System Permits_7'5S'
Minnesota Pollution
Control Agency
520 Lafayette Road North
St. Paul, MN 55155-4194
Compliance Inspection Form
Existing Subsurface Sewage Treatment Systems (SSTS)
Doc Type: Compliance and Enforcement
For local trackir^5C®Pl?S])
OCT 0 2 2015
-------resource
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
(0- ISSystem status on date (mm/dd/yyyy):
S Compliant - Certificate of Compliance
(Valid for 3 years from report date, unless shorter time
frame outlined in Local Ordinance.)
Q Noncompliant - Notice of Noncompliance
(See Upgrade Requirements on page 3.)
Reason(s) for noncompliance (check all applicable)
□ Impact on Public Health (Compliance Component #1) - Imminent threat to public health and safety
□ Other Compliance Conditions (Compliance Component U3) - Imminent threat to public health and safety
□ Tank Integrity (Compliance Component #2) - Failing to protect groundwater
□ Other Compliance Conditions (Compliance Component #3) - Failing to protect groundwater
□ Soil Separation (Compliance Component #4) - Failing to protect groundwater
□ Operating permit/monitoring plan requirements (Compliance Component #5) - Noncompliant
^QsJci€tiC-€
Property Information
Property address: 39 ^ VJl
Property owner:
Parcel ID# or Sec/Twp/Range: ^ ~ 106 0 C )
/^Reason for inspection: OLan'^t'
Owner’s phone:
C/ni
or
Owner’s representative:
Local regulatory authority:
Brief system description:
Comments or recommendations;
Representative phone:
LanJ¥^F<;oUrii-e ^yj<(v/l^Qqu\atory authority phone;
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:(^<^5 ^B9 7Certification number:
License number: /9 39
Phone number:
Business name: CrTf-i/tc'-P
Inspector signature: ______
Necessary or Locally Required Attachments
@ System/As-built drawingB^Soil boring logs
n Other information (list):
0 Forms per local ordinance
www.pca.state.mn.us • 651-296-6300 • 800-657-3864
wq-vAvists4-31b • 6/4114
TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
PoQe 1 of 3
i
3^ Cj rfflgyg/l l a, tCf |Pc(. /V/U-5^^Vnspector initials/Date: ^QlS
^ " ’ ' (mm/dd/yyyy)Property address;
1. Impact on Public Health - Compliance component #1 of 5
Compliance criteria: Verification method(s):
0tSearched for surface outlet
0. Searched for seeping in yard/backup in home
D Excessive ponding in soil system/D-boxes
n Homeowner testimony (See Comments/Explanation)
□ “Black soil" above soil dispersal system
D System requires “emergency” pumping
□ Performed dye test
D Unable to verify (See Comments/Explanation)
D Other methods not listed (See Comments/Explanation)
D Yes S3 NoSystem discharges sewage to the
ground surface.______________
□ Yes 0 NoSystem discharges sewage to drain
tile or surface waters.
□ Yes 0 NoSystem causes sewage backup into
dwelling or establishment.
Any “yes” answer above indicates the
system is an imminent threat to public
health and safety.
Comments/Explanation;
2. Tank Integrity - Compliance component #2 of 5
Verification method(s):
0 Probed tank(s) bottom
S Examined construction records
□ Examined Tank Integrity Form (Attach)
□ Observed liquid level below operating depth
S Examined empty (pumped) tanks(s)
n Probed outside tank(s) for “black soil"
Q Unable to verify (See Comments/Explanation)
D Other methods not listed (See Comments/Explanation)
Compliance criteria:
□ Yes 0 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:
3. Other Compliance Conditions - Compliance component #3 of 5
a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. □ Yes* * B No □ Unknown
□ Yes* 0 No □ Unknownb. Other issues (electrical hazards, etc.) to immediately and adversely impact public health or safety.
*System is an imminent threat to public health and safety.
Explain:
c. System is non-protective of ground water for other conditions as detennined by inspector. □ Yes* 0 No
*System is failing 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
i
Property address; SBS^V Inspector initials/Date: 10" 3- ^ C>^5~
(mm/dd/yyyy)
i
4. Soil Separation - Compliance component #4 of 5
Date of installation: IQ- □ Unknown
(mm/dd/yyyy)
Shoreiand/Wellhead protection/Food beverage
lodging?
Compliance criteria: _____________
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.
0- Conducted.soil observation(s) (Attach boring logs)
□ Two previous verifications (Attach boring logs)
O Not applicable (Holding tanl<(s), no drainfield)
n Unable to verify ("See Comments/Explanation)
nH Other ("See Comments/Explanation) -
0Yes □ 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.
:?/ t/eviH
-y5> cjf^y^sh
K 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:
O-^if
□ Yes □ No“Experimental", “Other", or "Performance"
systems built under pre-2008 Rules; Type IV
or V systems built under 2008 Rules (7080.
2350 or 7080.2400 (Advanced Inspector
License required)
Drainfield meets the designed vertical
separation distance from periodically
saturated soil or bedrock.
Indicate depths or elevations
A. Bottom of distribution media
B. Periodicaliy saturated soil/bedrock
3/C. System separation
3'
D. Required compliance separation*
Any ‘‘no’’ answer above indicates the system is
failing to protect groundwater.
’May be reduced up to 15 percent if allowed by Local
Ordinance.
5. Operating Permit and Nitrogen BMP* - Compliance component #5 of 5 ^Not applicable
□ 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 functioninq?
Any “no” answer indicates Noncompiiance.
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.
vAvw.pea.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864
wq-Wwists4-31b • 6/4/14
• Available in alternative formats
Paqe 3 of 3
Department of
LAND AND RESOURCE MANAGEMENT
OTTER TAIL COUNTY
Government Services Center - 540 West Fir
Fergus Fauus, MN 56537
PH: 218-998-S095
OTTER Tail County’s Website: www.co.otter-tail.mn.us
Otter Tail County Compliance Inspection Form Addendum
This form is a required attachment to MPCA Compliance Inspection Form for all Existing Subsurface Sewage
Treatment Systems in Otter Tail County as of June 1,2011.
Property Information
Parcel Number:
Township: cMhfrall
Property Owner Name(s): b oh /V ) /Vi ckkmhu _____________
Property Address: 393^^1^ rail/
Reason for Inspection:
Number of Bedrooms: 3 '
In Shoreland Area?
Lake/River Name, Number, & Class
Section:
Yes0 □No
System Compliance Status; >^,Compliant
iNon-Compliant
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?
Yes No
Yes ^No
Yes No
XYes No
XYes No
"Yes" indicates that the system is failing to protect ground water
and is noncompliant. If "Yes", describe the condition noted; .
Required Attachments: System drawing to scale on next page.
Completed MPCA Compliance Inspection
I hereDy certity that all tne necessary
information has been gathered to determine
the compliance status of this system. No
Sol <^kcsName;
Certification Number; ^39 7
Business License Name & Number; 3^rl/ic-e t> 1
Signature;Date;
Excel/Compliance Form for OTC 1/15/2014 Page 1 of 2
otter Tail County Compliance Inspection Form Addendum (cont.|
Parcel Number: /.^oO^QoO t
Date & Initial: tD-D'-’3i0i^6ARSystem Drawing
The system drawing must be to scale and include all septic/holding/lift tanks, drainnelds, 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). yK
/,
r
0
,0^
1
Additional Comments:
Page 2 of 2Excel/Compliance Form for OTC 1/15/2014
Minnesota Pollution
Control Agency
520 Lafayette Road North
St. Paul, MN 55155-4194
Compliance Inspection Form
Existing Subsurface Sewage Treatment Systems (SSTS)
Doc Type: Compliance and Enforcement
For local tracki
OCT 0 2 2015
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
LAND & RESOURCE
System Status
System status on date (mm/dd/yyyy): /6~ o
Compliant - Certificate of Compliance
(Valid for 3 years from report date, unless shorter time
frame outlined in Local Ordinance.)
□ Noncompliant - Notice of Noncompliance
(See Upgrade Requirements on page 3.)
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
□ 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
S /VcbU on system
Property Information Parcel id# or Sec/Tw^Range: 0 !
Property address: 3*^ 8for inspection:
Property owner: Donle-I C. k If y\ t>\^V Owner's phone:0or
Owner’s representative:Representative phone:
Local regulatory authority; Wfeegulatory authority phone: 7^}'^ 99^
Brief system description: 5~ l^ok I ^ > I ^Ot> CjQ//cm in
Comments or recommendations: . i * /I I d
■f-s S'
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: _
Business name: _
Inspector signature:
Certification number: y
License number:___D_J___
Phone number: 2>(8'
Necessary or Locally Required Attachments
0 System/As-built drawing0,Soil boring logs
□ Other information (list);
0-Forms per local ordinance
www.pca.state.mn.us • 651-296-6300 • 800-657-3864
wq-wwists4-31b • 6/4/14
TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
Pfloe 1 of 3
3'^ ^^I^Ctl'hl^\allUk^^o( CI/'fy)f‘rll/L/^\/< Inspector initials/Date: ^A(\\ /<5^
7 ' (mm/dd/yyyy)
Property address:
1. Impact on Public Health - Compliance component #1 of 5
Compliance criteria: Verification method(s):
l^-Searched for surface outlet
^ Searched for seeping in yard/backup in home
n Excessive ponding in soil system/D-boxes
□ Homeowner testimony (See Comments/Explanation)
n “Black soil’’ above soil dispersal system
□ System requires “emergency” pumping
D Performed dye test
□ Unable to verify (See Comments/Explanation)
Q Other methods not listed (See Comments/Explanation)
n Yes 0 NoSystem discharges sewage to the
ground surface.______________
□ Yes S NoSystem discharges sewage to drain
tile or surface waters.
□ Yes NoSystem causes sewage backup into
dwelling 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
Verification method(s):
0 Probed tank(s) bottom
^Examined construction records
n Examined Tank Integrity Form (Attach)
n Observed liquid level below operating depth
S-Examined empty (pumped) tanks(s)
□ Probed outside tank(s) for “black soil”
O Unable to verify (See Comments/Explanation)
D Other methods not listed (See Comments/Explanation)
Compliance criteria:
□ Yes 0 No,System consists of a seepage pit,
cesspool, drywell, or leaching pit.
Seepage pits meeting 7080.2550 may be
compliant ifailowed in iocai ordinance.
□ Yes 0 NoSewage tank(s) leak 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:
3. Other Compliance Conditions - Compliance component #3 of 5
a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. □ Yes* * 0 No □ Unknown
b. Other issues (electrical 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* SNo
*System is failing to protect groundwater.
Explain:
TTY 651-282-5332 or 800-657-3864 « Available in alternative formats
Page 2 of 3
800-657-3864651-296-6300www.pca.state.mn.us
wq-wwists4-31b • 614/14
C[I'l'hPrQlllakp Cl/j'h^railf.y01)1 i^^^\nsoecXor initials/Oate: ^OfS'
^ (mm/dd/yyyy)
Property address:
4\ Soil Separation - Compliance component #4 of 5
Date of installation:
Gsu •! olvt *A A V'fcoi'r/5 (mm/dd/yyyy)
Shoreland/Wellhead protection/Food beverage
lodging?
Compliance criteria:_____________
S Unknown Verification method(s):
Soil observation does not expire. Previous soil
obsen/ations by two independent parties are sufficient,
unless site conditions have been altered or local
requirements differ.
0 Conducted soil observation(s) (Attach boring logs)
SYes □ 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.
□ Two previous verifications {Attach boring logs)
□ Not applicable (Holding tank(s), no drainfield)
□ Unable to verify (See Comments/Explanation)
□ Other (See Comments/Explanation)o-
H-'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;
□ Yes □ No“Experimental", “Other", or “Performance"
systems built under pre-2008 Rules; Type IV
or V systems built under 2008 Rules (7080.
2350 or 7080.2400 (Advanced Inspector
License required)
Drainfield meets the designed vertical
separation distance from periodically
saturated soil or bedrock.
Indicate depths or elevations
A. Bottom of distribution media
B. Periodically saturated soil/bedrock
3:C. System separation
3'D. Required compliance separation*
*May be reduced up to 15 percent if allowed by Local
Ordinance.
Any “no” answer above indicates the system is
failing to protect groundwater.
5. Operating Permit and,Nitrogen BMP* - Compliance component #5 of 5 ^ Not applicable
□ 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.
v/ww.pea.state.mn.us- • 651-296-6300 • 800-657-3864
wq-wwists4-31b • 614/14
TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
Paqe 3 of 3
Department of
LAND AND RESOURCE MANAGEMENT
OTTER TAIL COUNTY
Government Services Center - 540 West Fir
Fergus Falls, MN 56537
PH: 218-998-8095
Otter Tail County’s Website: www.co.otter-tail.mn.us
Otter Tail County Compliance Inspection Form Addendum
This form is a required attachment to MPCA Compliance Inspection Form for all Existing Subsurface Sewage
Treatment Systems in Otter Tail County as of June 1,2011.
Property Information
Parcel Number: ~ /5i960 l-^0(D £ f
Township: C/T-fhei^ II
Property Owner Name(s): C. Meakkp^but
Property Address:
Reason for Inspection: ^ ~
Number of Bedrooms:
Section:
in.Yes| No| IIn Shoreland Area?
Lake/River Name, Number, & Class
System Compliance Status: ^ Compliant
Non-Compliant
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?
X NoYes
NoYes
Yes No
NoYes
>C NoYes
"Yes" indicates that the system is failing to protect ground water
and is noncompliant. If "Yes", describe the condition noted:
Required Attachments: System drawing to scale on next page.
Completed MPCA Compliance Inspection
1 hereby certity that all the necessary
information has been gathered to determine
the compliance status of this system. No
Rob (goIcesName;
Certification Number:
Business License Name & Number:
Signature:
0oi>3 O!
Date:
Excel/Compliance Form forOTC 1/15/2014 Page 1 of 2
otter Tail County Compliance inspection Form Addendum (cont),
Parcel Number: fr IMO (
Date & Initial: U> ~%0i^
System Drawing
The system drawing must be to scale and include all septic/holding/lift tanks, drainnelds, 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).
/I"
Additional Comments:
Page 2 of 2Excel/Compliance Form for OTC 1/15/2014
bv •**>. ^
m UWl)?^immIts
m t''I
m
mw/a CERTIFICATE OF APPROVAL
SEWAGE SYSTEM &'
u mThis Certificate has been issued this 26th of October, 1999 , to certify
that the sewage system installed as per Sewage Treatment System Permit
Number 13135 has been approved for use by Otter Tail County, Minnesota.
ft#
sma'
The property served by this Sewage System is legally described as:
UNPLATTED
PT GL 2; BG 1386.02' S FR NW
CR; S 300' E 140' N 300' W
140' TO BG.
Parcel Number(s): 10000120082001
Section: 12 Township: 132 Range: 040 Township Name: CLITHERALL TOWNSHIP
Lake/River Number: 56-238 Lake/River Name: CLITHERXll
ii
7.M
I'lKi
I
m SiCurrent Property Owner: RODNEY H & NANCY L NELSON
Number of Bedrooms: 3
rs
Land Sc Resource Management Official
mm-
3 V.ki;
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miI
mmi EH,
iyi
.¥-\
284.709 • Viciot Lundoan Co.. Ptintets • Fergus Falls. MN • 1-800-346-4870
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM- 0
LAND & RESOURCE MANAGEMENTOTTER TAIL COUNTY COURT HOUSE
Phone: (218) 739-2271 - FERGUS FALLS, MN 56537
WHITE—Office
YELLOW — L&R Inspector
/ PINK — Owner/Coritractor
/3/MS ffi. -
S3CO' e /‘^O' MSOO' UJ
LEGAL Permit No.
DESCRIPTION ) Yes { 3^ ) NoAbatement: (AND
LOCATION
LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER SECTION TWP. NO.RANGE TWP NAME
/3A ^ C£d/(ujJl^
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
/nmlOENTIRCATION: Please Print All InformaUon
Last Name Mailing Address — No. Street, City and Slate________First Initial Zip Code Telephone No.
Property '
Owner yi
y^y y^r!hk/i'a y^.^2Az/yh^ I.
Sewage
System
. Installer
Name
/State Lie. If
A.M.
; > This System will be ready for inspection on.the year of .PM..at.
This space for office use only 3NUMBER OF BEDROOMS:
A.M.(^)NO.PM.GARBAGE DISPOSAL: ( )YESPhone Call Rec'd By^_Date Rec’d Year of Time Rec'd
/ TYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
( L-»^eptic tank
( : . ) Lift station (Alarm Required)
( |^^)^'6rainfiel^
^^^^nches
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTS
DRAINFIELDTANK
J.
60//OO/y>ooCapacity GIs.
Distance from nearest well Ft.Ft.
7£75Distance from lake, wetland or river (OHWL)Ft.Ft.'(
( )Bed
( ) Mound *
) Outhouse
) Sewer line
10Distance from dwelling Ft.Ft.
/o mDistance from non-dwelling Ft.Ft.(
(10 Ft.Distance from property line
EFFLU^T DISTRIBUTION
( ) Pressure
3.Distance from bottom to Water Table Ft.Ft.(
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:WATER WELX DEPTH
* ABSORBTION AREA FOR MOUNDS
;C
Perc Tester .Date of Perc Test
.ft2
^ Average RateRate of 1 St Test Rate of 2nd Test
AgrMment:.The undersigned hereby makes application for permit to instali or extend Sewage Disposai System herein specified, agreeing to do all such work in
strict accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota
. Department of Health. Applicant agrees that plot plan sketches and specifications submitted herewith and which are approved by Shbreland 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 accepted. It shall be the respon
sibility of the applicant for the permit to notify the County Shoreland Management that th^ob is ready for inspection.
fm-cA' -i.IQ-DATE:
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 con
dition that the person to .whom it is granted, and his agent, employees and workmen shall conform in all respects to the Ordinance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances.
NOTE: Permit void if work is not commenced within six (6) months.
k Issued Date:
/ Land & Resource Management Office
Fee $.
Comments:
BK 0795-003 291,095 * Victor Lundeen Co.. Printers ■ Fergus Falls. Minnesota
s
• APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone: (218) 739-2271 - FERGUS FALLS, MN 56537
WHITE —Office
YELLOW — L&R Inspector
PINK — Owner / Contractor
At S'S FH AJF rtf'll ■
5 300' £ m' M300' UJ/^O't)S^
Of / - // /-j > /I A J ^
/ 7LEGALPermit No.
DESCRIPTION ( /)N0Abatement; ( ) YesAND
LOCATION
LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER SECTION TWP. NO.RANGE TWP NAME
- ^5/ (tlkiMAiM. M b /SA 4^/I
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
J A
IDENTIFICATION: PleaM Print All Information
Last Name First Initial Mailing Address — No. Street, City and State Zip Code Telephone No.
kfa/A a/il a U £/,F/Property
Owner /7?AJ A/F A A A A/5;?
Sewage
System
Installer
Name
A'Y/ ^Ja '/ /vO' YFa’/' FaState Lie. If > ■£ ^
A ArA F/(?AA J'L !
► This System will be ready for inspection on.the year of
This space for office use only 2NUMBER OF BEDROOMS:
<Y>GARBAGE DISPOSAL: ( )YES NO
Date Rec'd Year of Tune Rec'd Phone
TYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
( lF) Septic tank
) Lift station (Alarm Required)
( ^^FfTifa\n\\e\6
( (y) Trenches
( )Bed
( ) Mound *
( ) Outhouse
) Sewer line
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTS
TANK DRAINFIELD
■/// Ft“Capacity ; GIs.
{
Distance from nearest well Ft.Ft.
Distance from lake, wetland or river (OHWL)Ft. Ft./
Distance from dwelling Ft. Ft.
Distance from non-dwelling Ft.Ft.
(Distance from property line Ft.Ft.
EFFLUENT DISTRIBUTION
( ) Gravity
( ) Pressure
Distance from bottom to Water Table Ft.Ft.
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:WATER WELL DEPTH
' AL.
* ABSORBTION AREA FOR MOUNDS
Perc Tester <kf A -/ /r ■_Date of Perc Test■C,
.ft2
Rate of 1st Test Rate of 2nd Test Average Rate_
Agreement: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
strict accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota
Department of Health. Applicant agrees that plot plan sketches and specifications submitted herewith and which are approved by Shoreland management 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 accepted. It shall be the respon
sibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection.
DATE;^ A-\ ■'i
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 con
dition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the Ordinance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances.
NOTE; Permit void if work is not commenced within six (6) months.
..Issued Date:
Land & Resource Management Officei
Jfirtrnu tr irr ‘Fee $.Rec #
/f
Comments:_::C.
BK 0795^)03 291.095 • Victor iLindeen Co. Prirttars ■ Fergus Fells. Mirtrtesota
/
;4INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
IWLUnUG
SEPTIC TANK
DRAINFIELDLIFT TANKCATEGORY Actual Minimum
Capacity )06(^CftHAS GLS.GL 3.FT*FT*
Distance from Nearest Well ■TS~ FT FT
5-y ft
S~o FT
Distance from Buried
Water Suction Pipe FT 50
Distance from Buried Pipe
Distributing Water Under Pressure jg(f ^FTFT 10
Distance from Lake, Wetland or River (OHWL)
FT '7^ ftFTFT
Distance from Dwelling BoFTFT FT 10/20
Distance from Non-Dwelling ff— ft -h- ft ;oFT
Distance form Nearest Property Line FT FT FT 10
Distance from Bottom to Water Table ftFT FT 3
Holding Tank/Lift Alarm N<
(yp>Old System Pumped & Destroyed NO
Sewer Line to Well Separation DRAINFIELD CALCULATIONINTERPRETATION
OF ABBREVIATIONS
GLS. = Gallons
FT* = Square Feet
FT = Linear Feet
Actual Minimum J21FTX
^ FT .ft*20
MOUND CALCULATION ROCK REDUCTION//Inspector’s Comments: ^ f ^
ABSORBTION Aj
Rock trem with inches
^Ft. X
of rock under pipe for
.Ft2
reduction / equivalent to
ISKETCH:
Print Inspector's Na
/Vy<^/yf
inspector's Signature
Date / Time of Inspection
System'design must be to scale and must include the proposed location of the sewage system, all
existing/proposed buildings, property lines, the ordinary high water level of the water body, wetlands
and all water wells within 150' of the sewage system.
GRID PLOT PLAN
feet SKETCHING FORMi__grid(s) equals ^ feet, or inch(es) equalsScale:
SUBMITTED BY:
FIRM NAME: Stf^ice
6oX ______
SIGNATURE:
DATE: /O - 0-99
MPCA LICENSE #: !9S9ADDRESS:
Ibesij n&ir ^vi n SX'5'S~|LICENSE CATEGORY:.1
|N|
i0"^PwJt Gr''
V
N
V 296.213 • Victoi Lundeen Co Pnntsfs • Fergus Falls. MN • 1-800-346-4870BK 0496 — 029
'I:SBTE DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, MN 56537
OWNER:
//(Re>c(i^e.hJ^ho]n
MIDDLE TELEPHONE NUMBERFIRSTLAST NAME
ADDRESS:
d i-et^a /////tZ ST6
CITY STATE ZIP CODESTR./RT
C ! i // //C. / ff'kejra//i/0
RANGE TWP. NAMESEC. TWP.LAKE/RIVER NO.LAKE NAME
LEGAL DESCRIPTIOIM:SOIL BORING LOG — Date.(A/4..fKrr.c-iz:(Cf^ s 300'' E I ?o dC-
R-!00(do/^o^XOo /
COLOR &
MUNSELL NO.
DEPTH
(INCHES)STRUCTURETEXTURE
BLOCKY
PLATY
PRISMATIC
NONE
0 'S tf t^ck '■J
LoCfi^S Wc k
PARCEL NUMBER
L J3SD BLOCKY
PLATY
PRISMATIC
NONE
5 o 7 B i'O iVvnOlc.FIRE NUMBER I2 -■isr
aNUMBER OF BEDROOMS BLOCKY
PLATY
PRISMATIC
NONE
.S a i^c( v'.'^0-LO 1GARBAGE DISPOSAL; YES Brou/'mCl^ft.WELL CASING DEPTH:BLOCKY
PLATY
PRISMATIC
NONE
YESFLOODPLAIN;
VEGETATION: AQUATIC TERRESTRIAL
BLOCKY
PLATY
PRISMATIC
NONE
4^%SLOPE AT INSTALLATION SITE:
(I^Borin^TYPE OF OBSERVATION: Probe Pit
(®PARENT MATERIAL;/Outwash Loess Bedrock Alluvium COMMENTS:.
No
COMPACTED SOIL: Yes
ORIGINAL SOIL:
r___ft.DEPTH OF BORING:.
PERC TEST #2PERC TEST # 1 - TWO TESTS ARE REQUIRED -
PERC RATEINTERVAL (MINUTES)WATER DEPTH WATER DROPPERC RATE TIMEWATER DROPINTERVAL (MINUTES)WATER DEPTHTIME
STARTSTART
---r"I3^
DROP PERCTIMETIMEDROPPERC
WATER DROP PERC RATEINTERVAL (MINUTES)WATER DEPTHPERC RATE TIMEWATER DROPINTERVAL (MINUTES)WATER DEPTHTIME
REFILLREFILL /I/I ::y.Kz::II.L
TIME * DROP PERCTIMEDROP .PERC
PERC RATEWATER DEPTH WATER DROPPERC RATE TIME INTERVAL (MINUTES)WATER DROPWATER DEPTHTIMEINTERVAL (MINUTES)REFILLREFILL ;///j /i7J.^07 =PERCTIMEDROPTIMEDROPPERC
PERC RATEWATER DROPINTERVAL (MINUTES!WATER DEPTHPERC RATE TIMEWATER DROPINTERVAL (MINUTES)WATER DEPTHTIME
RyiLLREFILL I -L^±-I/JLK15~gF?:PERCTIMEDROPTIMEDROPPERC
PERC RATEWATER DEPTH WATER DROPINTERVAL (MINUTES)WATER DROP PERC RATE TIMEINTERVAL (MINUTES)WATER DEPTHTIME
. REFILLREFia /1I f ^ s ____^I7 TIME DROP PERCTIMEDROPPERC
PERC RATEWATER DEPTH WATER DROPINTERVAL (MINUTES)WATER DROP PERC RATE TIMEINTERVAL (MINUTES)WATER DEPTHTIME
REFILLREFiafbL1 iiTiis::5~ -1lUoWo^-U-r -•PERCTIMEDROPTIMEDROPPERC
PERC RATEWATER DEPTH WATER DROPPERC RATE INTERVAL (MINUTES!WATER DROP TIMEINTERVAL (MINUTES)WATER DEPTHTIME
REFILLREFILL
i 2ZZ i 72ki_L !PERCTIMEDROPTIMEDROPPERC
WATER DROP PERC RATEWATER DEPTHINTERVAL (MINUTES)WATER DROP PERC RATE TIMEINTERVAL (MINUTES)WATER DEPTHTIME
REFILLREFILL f• ^ v5~-/1 ilyjjBE::?7X.3.3*PERC-TIME DROPTIMEDROPPERC
PROPOSED DESIGN:
TRENCH BED.GRAVITY DIST. PRESSURE DIST..MOUND.HOLDING TANK.ATGRADE.
OTHER.SPECIFY:______________
— SYSTEM DESIOM ON BACK —
OUTHOUSE.SEWER LINE.
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone: (218) 739-2271 - FERGUS FALLS, MN 56537
WHITE — OMice
YELLOW — Inspector
PINK — Owner
Le't ^/ZZOQLEGALPermit No.
DESCRIPTION
Abatement: ( ) Yes ( X) NoAND
LOCATION
LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER SECTION TWP. NO.RANGE TWP NAME
HO/3 2-/2-
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
/ C ~ o eo - / ^
IDENTIFICATION: Please Print All Information
Last Name First Mailing Address — No. Street. City and StateInitial Zip Code Telepnone No.
2 gor>^ A-Property
Owner t
n/i^
Sewage
System
Installer
t/^. ^ j Ji.'t' \f A. eX-PName
State Lie. #
A.M.
>■ This System will be ready for inspectior) on the year of P.M..at.
This space tor office use oniy NUMBER OF BEDROOMS:
A.M.
PM.GARBAGE DISPOSAL: ( ) YES ( )NODate Rac'd Year of Time Rec'd Phone Call Rec’d By
TYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
( ) Septic tank
( ) Lift station (Alarm Required)
( ) Drainfield
( ) Trenches
( ) Bed
( ) Mound
( ) Outhouse
(^<3 Sewer line
EFFLUENT DISTRIBUTION
( ) Gravity
( ) Pressure
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTS
TANK DRAINFIELD
Capacity GIs.
Distance from nearest well Ft.Ft.
r
Distance from lake or stream Ft.
7‘fDistance from dwelling Ft.
Distance frorri non-dwelling Ft.
Distance from property line Ft. Ft.
Distance from bottom to Water Table Ft. Ft.
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:WATER WELL DEPTH
Perc Tester Date of Perc Test
Rate of 1 st Test Rate of 2nd Test Average Rate
Agreement: The undersigned hereby makes application tor permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
strict accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota
submitted herewith and which are approved by Shoreland management Official ,
the systprtt shall be covered until it has been inspected and accepted. It shall be the respon-
letsepTmt that the job is ready for inspection.
Department of Health. Applicant agrees that plot plan sketches and spedjicati
shall become a part of the permit. Applicant further agrees that no patf
sibility of the applicant for the permit to notify the County Shorel^tid M
DATE:
rlure
Permit: Permission is hereby granted to the above named applic^t to perform the work described in the above statement. This permit is granted upon express con
dition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the Ordinance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances.
NOTE: Permit void if work is not commenced within six (6) months.
Issued Date:
Land & Resource Management Office
Fee $Rec #
■clJU.Comments:
BK 0795-003 291.095 • Vir;lf)i Liituli.'un Co, Ptiiiluis • fi ft)iib rally Minfi.’Sf(I:i
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
LAND & RESOURCE MANAGEMENTOTTER TAIL COUNTY COURT HOUSE
Phone: (218) 739-2271 - FERGUS FALLS, MN 56537
WHITE — Office
YELLOW — Inspector
PINK — Owner
Loi ^
^ tAh 6
IS
/zzooLEGALr 5 Permit No.
DESCRIPTION Li^.Abatement: ( ) Yes ( X)NoAND
■^oLOCATION
LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER
CLASS
SECTION TWP. NO.RANGE TWP NAME
)11 CA^ / /VOVPJ3 2^5-^ - ^ i 7 /z^PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
/^ ~ o oo ~ /2 -OO ' oo L 13 9 O
IDENTIFICATION: Please Print All Information
Last Name Mailing Address — No. Street, City and StaleFirstInitial Zip Code Telephone No.
N-cistn^U 2 7^ / /-f<3 ‘y~s^Property
Owner y-9 o
Sewage
System
Installer
i/v t/ AName
State Lie. #
>77^. /V► This System will be ready for inspection on.the year of .at.
This space for office use only NUMBER OF BEDROOMS:
/bate Rec’d * 'fea/of Time Rec’d 'GARBAGE DISPOSAL: ( ) YES ( )NO
Phone Call Rec'd By
TYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
) Septic tank
) Lift station (Alarm Required)
( ) Drainfield
( ) Trenches
( ) Bed
( ) Mound
^ ) Outhouse
(^j^ri') Sewer line
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTS
TANK DRAINFIELD
i(Capacity GIs.
(
Distance from nearest well Ft.Ft.
Distance from lake or stream Ft. Ft.
Distance from dwelling Ft.
L
rDistance from non-dwelling H.Ft.(uDistance from property line Ft.Ft.
EFFLUENT DISTRIBUTION
( ) Gravity
( ) Pressure
Distance from bottom to Water Table Ft.Ft.
All distances are shortest distance between nearest points
[PERCOLATION TEST DATA:WATER WELL DEPTH
7 i. /-i■ ia
AI Perc Tester Date of Perc Testi
i
Rate of 1 St Test Rate of 2nd Test Average Rate
Agreement: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
strict accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota
Department of Health. Applicant agrees that plot plan sketches and specifications submitted herewith and which are approved by Shoreland management Official
shall become a part of the permit. Applicant further agrees that no part Of the systern shall be covered until it has been inspected and accepted. It shall be the respon
sibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection.
___________________
DATE:
' §ip)^ture
Permit: Permission is hereby granted to the above named applicaht to perform the work described in the above statement. This permit is granted upon express con
dition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the Ordinance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances.
NOTE: Permit void if work is not commenced within six (6) months.
Issued Date:
Land & Resource Management OfficeJ
Fee $Rec#
^ ///^
^ c^-cComments:__£2
BK 0795-003 291095 • Viriot LuixItHtn Lo. PriniKis • Fi-rgiis Falls. Mimwsoia
r
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
ORAINFIELDHOLDING
SEPTIC TANK LIFT TANKCATEGORY Actual Minimum
Capacity FT=^GLS.FT 2GLS.
Distance from Nearest Well FT FF FT
Distance from Buried
Water Suction Pipe FT FT FT FT50
Distance from Buried Pipe
Distributing Water Under Pressure FT FT FT FT10
Distance from Lake or River (OHWL)FT FT FT FT
Distance from Dwelling
FT FT FT 10/20 FT
Distance from Noh-Dwelling FT FT FT FT
Distance form Nearest Property Line FT FT FT 10 FT
Distance from Bottom to Water Table FT FT FT FT3
Holding Tank/Lift Alarm YES NO
Old System Pumped & Destroyed YES NO
ORAINFIELD CALCULATIONSewer Line to Well SeparationINTERPRETATION
OF ABBREVIATIONS
GLS. = Gallons
FT^ = Square Feet
FT = Linear Feet
Actual Minimum
FTFTX
bo*FT FT20
ROCK REDUCTION
Inspector’s Comments:
inchesRock trenches with
of rock under pipe for .%
DF.reduction / equivalent to
SKETCH:
*
Inspector's Signature
Dale of Inspection
\Time ol Inspection
r;.'V.
«)
i
lE#•wii
■."i .K L
Tk ■•- i-//7lE//%/i it /S 7/Z^LlJ-tut /7I /
f 7^■iEBa!aa^:iiiii /
5?z JpL7zy?\K 7)V X ziVW zN
>T / /V_i_I//V •
i//4-1
2;/7/
0 CO 0 0 fi /V'/0 s /
//
/7ir-
/1^7
/f /1?/ar /\*72^£iz-.7/77<iv T\'L
AI^K 3jZ./<t^T I
s 5,^'^7 A'Jl''Ai7t'L
S.
^35?:!
!
-~^-A T*:
«
i'APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
WHITE — Office
Yellow — Inspector
Pink — Owner »
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone:(218)739-2271 - FERGUS FALLS. MN 56537
Permit No.pr oF CL "XLEGAL
DESCRIPTION
AND
LOCATION
RANGE TWP NAMESECTIONTWP. NO.LAKE/RIVER
CLASS .Ai) /A
LAKE/RIVER NAMELAKE NUMBER
S Id /Z X Vo c c
FIRE OR LAKE ASSOCIATION NUMBERPARCEL NUMBER(S)
10 - OCO -/^ -ooSS-OO /Ll^Bo
IDENTIFICATION: Please Print All Information
Zip Code Telephone No.Mailing Address — No. Street. City and StateFirst InitialLast Name___________ ____________
^l7 ______9-^Property
Owner Ol^f
In ho tF %)Sewage
System
Installer
Name
A.M.
^ This System will be ready for inspection on P.M., 19-at
This space for office use only
NUMBER OF BEDROOMS:
A.M.
P.M19 GARBAGE DISPOSAL: ( ) YES ( ) NOPhone Call Rec'd ByTime Rec'dDate Rec'd
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
( ) Septic tank
( ) Lift station
( ) Drain field
( ) Standard ( ) Bed ( ) Trench
( ) Modified
( ) Mound
( ) Outhouse
DRAIN FIELDTANK
GIs.Sq Ft.Capacity
Ft.Distance from nearest well
to Ft.Ft.Distance from lake or stream
Ft.Distance from building
Ft.Ft.Distance from property line
Ft.Distance from bottom to Water Table Ft.
EFFLUENT DISTRIBUTION
( ) Gravity
( ) Pressure
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:
WATER WELL DEPTH
60- '
ik\//VPerc Tester,Date of Perc Test
Rate of 1 st Test Rate of 2nd Test Average Rate
Agreement: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in strict
accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota Department
of Health. Applicant agrees that plot plan sketches and specifications submitted herewith and which are approved by Shoreland Management Officical shall become a part
of the permit. Applicant further agrees that no part of the syste
tfte permit to notify the County Shoreland Management that^e job is readyfor inspection
ail be c6^«red until it has been inspected and accepted. It shall be the responsibilty of the applicant for
DATE:/signature
piCant to perform the work described in the above statement. This permit is granted upon express condition
cts to the Ordinance of Otter Tail County, Minnesota.
rPermit: Permission is hereby granted to the above named ap
that the person to whom it is granted, and his agent, employees and workmen shall conform in ajLre
This permit may be revoked at any time upon violation of any said ordinances.
NOTE: Permit void if work is not commenced within six (6) months.
5-So '^5Issued Date:
Land &^R^g^prde Management Office
5S —//9C/?3Fee $.Rec #.
Comments:
272.058 • Victor Lundeen Co.. Printers, Fergus Falls, MinnesotaFosto No. BK-0894-003
■f. ^ ^F\.
. ‘ APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
WHITE — owes
Yellow — Inspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone:(218)739-2271 - FERGUS FALLS, MN 56537
/05X^Pt of cTA X . .Permit No.LEGAL
DESCRIPTION
AND
LOCATION
LAKE NUMBER LAKE/RIVER NAME SECTION RANGELAKE/RIVER
CLASS . /Ifi.h
TWP. NO.TWP NAME
C/^;7>fe-jeA<;c VO r c
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
10 - ooQ -/5 -ao83-oo/L/^50
IDENTIFICATION: Please Print All Information
Last Name First Initial Mailing Address — No. Street, City and State Zip Code Telephone No.a)Cl Sa/\)j ^obajTv IZZ StOJr _______Property
Owner Ol^f
i 7*
Sewage
System
Installer
Name
7
This System will be ready for inspection on at
This space for office use only
NUMBER OF BEDROOMS;
AM.
19 P.M.,GARBAGE DISPOSAL: ( ) YES ( ) NOPhpne CalUlec'd ByDate Rec’d Time Rec'd
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
( ) Septic tank
( ) Lift Station
( ) Drain field
( ) Standard ( ) Bed ( ) Trench
( ) Modified
( ) Mound
( ) Outhouse
TANK DRAIN FIELD
Capacity GIs.Sq Ft.
7^Distance from nearest well Ft.
tDistance from lake or stream Ft.
Distance from building Ft.
Distance from property line Ft.Ft.
Distance from bottom to Water Table Ft. Ft.
EFFLUENT DISTRIBUTION
( ) Gravity
( ) Pressure
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:
WATER WELL DEPTH
6c-'- /S ' btV?
Perc Tester.Date of Perc Test
Rate of 1st Test Rate of 2nd Test Average Rate
Agreennent: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in strict
accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota Department
of Health. Applicant agrees that plot plan sketches and specifications submitted herewith and which are approved by Shoreland Management Officical shall become a part
of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the responsibilty of the applicant for
the permit to notify the County Shoreland Management that the job is ready/for inspection.
^^ignature ^ ^
DATE:
Permit; Permission is hereby granted to the above named apiSttcant 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 M respects to the Ordnance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances. ___________
NOTE: Permit void If work is not commenced within six (6) months. yyy y J
I
5 - ' ^^5 yIssued Date:
Land &^^apree Manage25"-ment OWce//94V?3Fee $.Rec #.
Comments:
I
272.858 - Victor Lundeon Co.. Printers. Fergus Falls. MinriesotaForm No. BK-08S4-003
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
4
< * -
DRAIN FIELDSEPTIC TANKCATEGORYActualMinimum Actual Minimum
Capacity SFGLS. GLS. SF
Distance from Nearest Well FT FT FT FT50
Distance from Buried
Water Suction Pipe FT FT 50 FTFT50
Distance from Buried Pipe
Distributing Water Under Pressure FT FT FT 10 FT10
FTDistance from Lake or River (OHWL)FT FT FT
10/20 FTFTDistance from Nearest Building FT 10 FT
FT FTFTFT10Distance from Nearest Property Line 10
FTFTDistance from Bottom to Water Table FT FT 3
YES NOHolding Tank/Lift Alarm
DRAINFIELD CALCULATIONSewer Line to Well SeparationINTERPRETATION
OF ABBREVIATIONS
GLS. = Gallons
SF = Square Feet
FT = Linear Feet
MinimumActual
FTX
FTFT20 SF
euC<lA r r<rc/Inspector’s Comments:
SKETCH:
I 1
DSte oFInspection
Time of Inspection
7^
3Lis:t T4m:(i-
\
#<?>1 k &■c )
<7:
,41 r*^7^VK A"J^'eTViy
■■ J \>/yC7 IoN(Io,h-^:>
W 0
i:
-3?.■J>t:
0 N^,r
a c
/\
3 ► r^^<C§:>>z.T■i^
(S'_ .■j^5?:5:^1^w5;t*r '‘■“’ (bc/a0oc^(^oIA^
\i+(
’ 1^
?i_>»
C^
SEWAGE SYSTEM
Wn NOVEMBER19THThis certificate has been issued this day of
to certify that the sewage system installed as per sewage permit number indicated below has been approved for use
mmi by Otter Tail County, Minnesota.
%m The premises covered by this certificate are legally described as:^1.
CLITHERALLRangeTwp. ^ ^125 6-23 3Lake No.Sec.Twp. Name
mi 12 132 40 20.43
ii LOT 2 EX TRS
«; $
NELSON/ ICNE L. / ET. AL.4'i Owner: Name
m R#2 BOX 43/ CLITHERALL/ MNAddressii 56524Zip No.
9136Permit No. SP
Signed by:
L;ind & Resource Management OITlcial
Otter Tail County. MinnesotaMKL-098700!
r
JT-263191 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
^ ^ ^ k { ts Permit No.LEGAL
DESCRIPTION
AND
LOCATION
SECTIONLAKE NUMBER LAKE/RIVER NAME LAKE/RIVER
CLASS ^JtU? /?-
TWP RANGE TWP NAME
Cl,
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
I US O/o 0 <%P" /y daO
IDENTIFICATION: Please Print All Information
Last Name First Mailing Address — No. Street, City and StateInitial Zip Code Telephone No.
5<y/U Xqaj eProperty
Owner
C ^ J ^•
OcL'-E J ^ etc HSewage
System
Installer uName I Y<- »
A.M.
This System will be ready for inspection on , 19.P.M.at
This space for office use only JONUMBER OF BEDROOMS:
A.M.
P.M..19 ) YES ( X ) NOGARBAGE DISPOSAL: (Date Rec’d Time Rec’d Phone Call Rec'd By
SEWAGE DISPOSAL SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
( ) Holding tank
( ^ ) Septic tank
( J^) Drain field
( ) Standard ( ) Bed (^) Trench
( ) Modified
( ) Mound
^___________t __________TANK
I600
DRAIN FIELD
|X^6 sq FtCapacityGIs.
66Distance from nearest well Ft.
^6Distance from lake or stream Ft.
■^4- ioinDistance from building Ft.
JODistance from property line Ft.
EFFLUENT DISTRIBUTION
(^ Gravity
{ ) Pressure
3Distance from bottom to Water Table Ft.
All distances are shortest distance between nearest points
WATER WELL DEPTH:
/PERCOI/TION TEST DATA: Date of First Test , 19 Rate
LIVDate of Second Test . 19 Rate
///First Test -F 2nd Test
2 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 Minnesota Department
of Health. Applicant agrees that plot plan sketches and specifications submitted herewith and which are approved by Shoreland Management Officical shall become a part
of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the responsibilty of the applicant for
the permit to notify the County Shoreland Management that the job is ready for inspection.
Permit: Permission is hereby granted to the above named applicant to perform the worlj 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 Ordinance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances.
NOTE: Permit void if work is not commenced within six (6) months.
DATE:
Issued Date:
L^bo 4 Resource Management Office^b.QO
^ f~0 L OjXyC ^ o Aj ^ __Q_
jQjjtJh )Ojp3Tj
n p4XA.
Fee $Rec #,
Comments: ■
rrD. '2
Form No. BK — 0292-003 260,771 — Victor Lundeen Co., Printers. Fergus FaJIs, Minnesota
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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
>■
Permit No.LEGAL
DESCRIPTION
AND
LOCATION
SECTIONLAKE NUMBER LAKE/RIVER NAME LAKE/RIVER
CLASS
TWP RANGE TWP NAME
!%
PARCEL NUMBER(S) FIRE OR LAKE ASSOCIATION NUMBER
/ /ZS~o/O-0<S’6^ /i -QQ gr-2-6a0 \
IDENTIFICATION: Please Print All Information
Initial Mailing Address — No. Street, City and State Zip CodeLast Name First Telephone No.
5cj Aj J2nAJ €Property
Owner ^ ^r /C-e> r- C J ^«
OcL'^ J /S^ ici~Sewage
System
Installer
ilName ( A- ^
A.M.
This System will be ready for inspection on , 19-P.M.at
This space for office use oniy JONUMBER OF BEDROOMS:
A.M.
19 P.M (X)NOGARBAGE DISPOSAL: ( ) YESDate Rec'd Phone Call Rec'd ByTime Rec'd
SEWAGE DISPOSAL SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
( ) Holding tank
( ^) Septic tank
<X>
TANK DRAIN FIELD
/AV5J,Capacity GIs.
‘^honidFt.Distance from nearest well Ft.Drain field
( ) Standard ( ) Bed Trench
( ) Modified
( ) Mound
^76 35Distance from lake or stream Ft.Ft.
IdDistance from building Ft.Ft.
/O10Distance from property line Ft.Ft.
EFFLUENT DISTRIBUTION
( Gravity
( ) Pressure
JDistance from bottom to Water Table Ft.Ft.
All distances are shortest distance between nearest points
WATER WELL DEPTH:
fPERCOl^TION TEST DATA; Date of First Test _
Date of Second Test
. 19.Rate
L</2/, 19 RateL
1st Test Talsen By ///AtoFirst Test ■E 2nd Test
2 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 Minnesota Department
of Health. Applicant agrees that plot plan sketches and specifications submitted herewith and which are approved by Shoreland Management Officical shall become a part
of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the responsibilty of the applicant for
the permit to notify the County Shoreland Management that the job is ready for inspection.
/)
DATE:fcSignaitjfe
Permit: Permission is hereby granted to the above named applicant to perform the worV 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 Ordinance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances.
NOTE: Permit void if work is not commenced within six (6) months.
5-'^& -Issued Date:
Land S Resource Management Officelew Tin 9.Fee $.Rec #_
-f /o- Z’7 O Onx)__________(57^ jQ/jJh Xfl f rJj <r o ^ ~? O/ TComments:
y yTzl^/ iJ Y ? /j p/,
:)DP dyT'T/uZt ^1/r 1 J
■ V ¥Form No. BK -- 0292-003 260.771 Victor Lundeen Co.. Printers. Fergus Falls. Minnesota
■/
■ ^■■ *
TTi,
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
420
SEPTIC TANK DRAIN FIELDCATEGORYActualMinimumActualMinimum
Z- oo S -/ZGC, ^ SFCapacityGLS.3e>ot3 GLS.SF
2^iDistance from Nearest Well FT FTI Zo 50 FT
Distance from Buried
Water Suction Pipe ate FT FT FT50 FT50
Distance from Buried Pipe
Distributing Water Under Pressure ok FT FT FT1010
/300^ FT3) 0*0Distance from Lake or River (OHWL)FT FT FT
\32-Distance from Nearest Building FT FT FT FT1020
/4-Distance from Nearest Property Line FT FT FT FT/o 10 100
Distance from Bottom to Water Table FT FTFT 3 FT
Sewer Line to Well Separation DRAINFIELD CALCULATIONINTERPRETATION
OF ABBREVIATIONS
GLS. = Gallons
SF = Square Feet
FT = Linear Feet
(Actual Minimum 0 Csj)FTX(S S lo" -(pO FT FT20 SF
Inspector's Comments:
SKETCH:
Inspector's Signature
/ m fcs.
Dale of Inspection
i Time of Inspection
Vt-ci^yrry d,Sct~(pT/(P^\
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To-TAt^
A/y?<Jcy /. /OeLCixj
GRID PLOT PLAN SKETCHING FORM — (Must Be To Scale)
Scale: Each grid equals feet/inches
indicating setbacks from road right-of-way, lake and sideyard for each building currently ^tppdsed structures. I
Dated:
Signature
Please sketc
on lot and any
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PERCOLATION TEST DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, MN 56537
OWNER:
FIRSTLAST NAME MIDDLE TELEPHONE NUMBER
ADDRESS:
C ////if m//
STR./RT.CITY STATE ZIP CODE
/'L i-/0
LAKE NAME SECLAKE/RIVER NO.TWP.RANGE TWP. NAME
LEGAL DESCRIPTION:
PARCEL NUMBER
to
FIRE NUMBER NUMBER/BEDROOMS
— TWO TESTS ARE REQUIRED —
TEST HOLE NO.TEST HOLE NO. 2
4 LDepth To Bottom of Hole inches; Diameter of Hole.inches Depth To Bottom of Hole inches; Diameter of Hole inches
<r~ 3/Date 19Depth. Inches Soil Texture 19Soil Texture DateDepth. Inches
ercolation
esc By
Firm
Name
Brsk
S^n ni~fa'f'IOio
/ 'Bor /90
//f
ercolation
est By
Firm
Name
tPc/C€S
S'a rtetfro n\
- S^SS'l /-/■eAddress#/f7Address
Otter Tail County
License No.Otter Tail County
License No.H3 HA
PERC TEST # 1 PERC TEST # 2
WAjTHRDBrTHIWTEirVALrMPnJTBgJ PERCItATBWATTODROP TIMB IHTBItVAl/fc^twirrwai WATTODBPTH WATBRMtOP tCRATB
START START
r V'nMU~ DROP PfeRc THCIB" DROP pfaRCWlOgRPePTHTTI»g pnrBRVALQ»iimrrB«>
REFILL
reRCRATB TIME IKTHRVALn>aWUTRS>WiOTRDROP FBRCRATH
w •nsL-
REFILL7^I 'nKig~~p^5P~"ff6g~
WATER DEPTH PERC RATEINTERVAL OtilMUTBSy WATER DROP TIME INTERVAL /MlNtriEft wAwy 9CTTT1 WATER PERC RATE7VI.REFILL REFILLa I . a
TIM^ PftOP l^BRC
.2Wlt1M2.1
WitfER DEPTH FERCRATBINTERVAL OOWyTlirf WATER DROP
AdL
IKTERVALrMtwimw WlflER DEPTH WATER DR4 PERC RATEREFILLREFILL/ * ( . I
'HMB d1R5> ^brc
f7MJo.j.
TiMB“ bkop PUItC
WAIER DEPTHTilINTERVAL (vmnrrBRi reRCRATE _T1ME
7WWATER DROP INTERVAL IMPH/TEft WATER DEPTH WATER DROP PERC RATE
REFr REFILL/ J .JI -—TGK-I..Jl.7V9 * ^‘lulirflMit drop” ^ERc ClROP
WATER DEPTH reRCRATBTIMEINTEI^ALtMimnES^WAIERDROP TIME INTERVAL IMTNUTEt^WATER DEPTH WAIERDROP
PERC RATE2H17WREFILLREFILLII//TWflT^bROi*^"pB^ePERC
WATER DEPTH PERC RATETIMEINTBRVALIMINUTHa TIME IWTERMU.IMDIinES>
WATER DEOP PERC RATE
REFILL REFILL
rflMB" dTOF PBRC TtME”" DROP PERCTIMEINTERVAL IMTNUTgg^WA1 PERC RATEDEPTHWATER DEOF TTMB INTERVAL WATER DEPTH PERC RATEREFILLREFILL
**TIME DROP ^BRC 'TTOB” DROP PEAc>c
COMMENTS/CALCULA TIONS:
1$
/
MKL — 0390 - 005 250,815 — Victor Lundeen Co.. Printers, Fergus Falls. Minnesota
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flBLD NOTES
DATSUKI NAHI
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LBOM. DB8CRIFT0M OF LOT I
-/BX - 9d/0-6OO - Z2, - i)DSX-PAECXL NO.
6-1 ^
MJburA ^ L /^L
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ONMBRS NAMB
OHNBRS ADDBKSS
. P>?%S^5X^/
TtPI OF SWAOB BTBTBM (IMSPBCTOR«8 COMMENTS);
/ S-&6u^ 2^*vt /t ~sp
SBPABATION DISTANCKS (IN PBBT);
(XLtrUt^ H/dU.
2.^'
SEPTIC TANK
WELL
LAKE
<9kLOT LIMB
OCCUPIKD BUILDING
BLBVATION OF TUB AREA
reason SYSTBM MAS ABATEDt
A Ou^//x 'T^o c/of-e. yi> ou^// /'f /s
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NOTES REGARDING
lONE L. NELSON ET AL
CLITHERALL LAKE (56-238)
by
Pat Eckert, Inspector
Mike Douglas & I were onsite for Sewage System
Field notes show a travel trailer and four (4) mobile
August 13, 1991 -
Abatement Survey,
homes onsite.
June 25. 1992 -Per Sewage System Permit #9136 inspection copy, Tim
Griep indicates a mobile home in the travel trailer location.
August 26, 1 992 - Certificate of Title, 1973 Glenbrook mobile home,
owner being Rodney Nelson. Sold on May 1, 1993 to Denise Blaskowski.
Seller was Rodney Nelson.
August 14, 1996 - Certificate of Title, 1 973 Glenbrook mobile home, owner
being Emil Salvog.
Mobil Homes Record and Appraisal Card - obtained copy form Assessor's
Office on August 12, 1997. Per Melanie Swanson (Assessor's Office) a
record is started when a mobile home is moved into a township. Record
begins in 1993 which indicates a 1973 Glenbrook, 14' x 60' mobile home
was placed onsite in 1992.
Note from Assessor's files - On May 6, Emil Salvog stated that the roof had
caved in on mobile home on March 22nd. They will be getting a new one.
He will call us when new one is put in. Just looking now. On May 20,
1997, Mr. Salvog called. He will be mailing copy of the title. New mobile
home is a 1997 Friendship, 16' x 66'.
August 11,1997 - Rodney Nelson came to our office. He asked what was
needed to put an addition on a mobile home. After determining this was on
a cluster, I said it would take a Site Permit and a Conditional Use Permit. He
asked how another mobile home was placed onsite this last Spring/Summer
with out going through the Planning Commission for a Conditional Use
Permit. I looked in the property's lake file. I did not find any Site or
Conditional Use Permits for that mobile home. I told him it appears that it
was done illegally. I gave him a Conditional Use Permit Application and told
him to talk with Bill Kalar. Since there was already a new mobile home
placed onsite with out a Conditional Use Permit, he would have to go
through the Planning Commission anyway. He will call Bill and set up an
appointment.
notes
lone Nelson (56-238)
Page 2
• r
August 13, 1997 - Emil Salvog came into our office. He said "A-1 Mobile
Home" from Minneapolis, placed the unit onsite in April or May.
* Mobile Home place onsite in 1991 or 1992 without a Site or Conditional
Use Permit. It replaced a travel trailer.
* New mobile home onsite in 1997 without a Site or Conditional Use Permit.
New unit is larger than unit form 1991/1992.
I
i
I
i
CERTIFICATE OF COMPLIANCE
SEWAGE SYSTEM
I20 th /9 81day nf March7’/2/s certificate has been issued thismi
r^'to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.g %
a?
6.
m-The premises covered by this certificate are legally described as:
56-238 Sec___11 Twp. 112Lake No.40 Twp. Name ClltherallRange.W2 iM
m Lot 2 Ex Sis A, B, C, D, E & H Ex W 16 rd
of E^ plus Wly 29.5’ of SL H, E, & So. 128.28’ of
SL C ex tracts
iM
5^’ *,; -S3
S-Tas?Owner: Name.lone L. Nelson#■;
Address.Clltherall, KN
W -W56524Zip No.
Permit No. SP.4058
Signed by:
Malcol K. Lee, Shoreland Administrator
159035 4
SHORELAND MANAGEMENT - COUNTY OF Ul itn
COUNTY COURT HOUSE
Phone 218-739-2271 - Fergus Falls, Mn. 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
11\\k
V^' te — Office <
\ Jqw — Inspectoj;
Pli.. — pwner Card Owner
Permit No.cP Y 5LEGAL
Date
DESCRIPTION
AND
-33,^ CJ/J'AsAad PD lA. /33\2kLOCATION
Lake No.Lake Name Lake Classif.Sec.TWP TWP NameRange
IDENTIFICATION:Please Print All Information.
Last Name Initial Mailling Address —No. Street, City and StateFirst Zip No.Tel. No.
C/Pitorilf . m toOAhiTy^AOWNERX,T
;)SEWAGE
SYSTEM
INSTALLER
Name.! it
This System will be ready for inspection on.., 19.
This space for office use only
.19 .M
Date Rac'd Time Rec'd Phone Call Rec'd By Owner or Agent Slgna:ture
9NUMBER OF BEDROOMS;ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
~7SO Gis.77^7) Qsp. Ft.Capacity Sq. Ft.
So Ft.5TJ Ft.Ft.Distance from nearest well
7.^ Ft.Distance from lake or stream Ft.Ft.
/Or.
in Ft.
P)0Distance from occupied building Ft.Ft.
LaDistance from property line Ft.Ft.
i' 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 .
19 .2.0...,
. 19...£...Q
,2<..£PERCOLATION TEST DATA:Date of First Test Rate
/Did'-O aDate of Second Test Rate
1st Test Taken
.aFirst Test + 2nd Test
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 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^ ready for inspection. (Call or use attached mailer notice )
3 tp^JLvury\
^ 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 (61 months.
Agreement:
Dated
Permit:
/n-nn-L-nIssued Date:-si
Shoreland Management Office
SOsFee $Surcharge $
Comments:.
Form No. MKL-0771-003 vicToa tuHSCCa 4 c» . aamuat. rcatut rALLi
158906
SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 - Fergus Falls, Mn. 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
r ■V'' te - Officel
^ l?W — Inspector Pii..' —j Owner
Card — Owner
Pl MS U'L 'ia Permit No..or £
a^/. S'
^.x T'PS.
LEGAL ~rr DateIDESCRIPTION0 r
AND
LOCATION
Lake No,Lake Name Lake Classif.Sec.Range TWP NameTWP
IDENTIFICATION: Please Print All Information.
First Mailling Address —No. Street, City and State Tel. No.Last Name Initial Zip No.
OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
7-a ■■ 3^toThis System will be ready for inspection on., 19.
This space for office use only
] iO fji19
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.
Ft.Distance from bottom to Water Table Ft. Ft.
All 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 ot Second Test 19 , Rate
1st Test Taken By
First 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
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:
Management Office
rs&- 9V5VFee $Surcharge $
Comments:.
Form No. MKL-0771-003 vicrea LuHoecH • co . primtcis. rtaeus
158906
• 1\
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORYActualShould be Actual Should be Actual Should be
7^0CapacityGIs.GIs.S F S F S F
"75Distance from Nearest Well F 75F 50FF F
95 25Distance from Lake or Stream F F F F F
Oo pDistance from Occupied Building 10 2020FFF F
FiODistance from Property Line 10 10 10FFFF F
'=UDistance from Bottom to Water Table 4 4FFFF F
Inspector's Comments:c ^
^5^ nQO
O ML
1- jO 19^Date of lnsp>ection
to: loTime of Inspection,
6^Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs " Gallons
SF ■ Square Feet
* Linear Feet
Job TitleF
Agency
M KL-0771-003-Backer
-■?!
1!r.-'V:.1
/•
i AIR TEST CERTIFICATIOHi
(Date), an air teat of the eever line installed under SevageOn
C7
for CDlspoaal System Permit Number
(!?/At that tl«e, the sever(Lake/River) vas made.Ovner), on
pounds per square inch for minutes.line held
I
Date
-^1
License NumberInstaller's Signature
042991
f
FIBLD NOTES
DATElake NANI
EIRE NO.LAXI NO.
LEGAL DESCRIPTON OE LOT:
10-OOP - )2 -Dc>2^-00!
60 )3SG' S PR
C / Vd ' 3
i;i-J 32-^0
lyp I ^o' ^ ,
PARCEL NO.
Ph (^k :
CR j S 3<^<s>'y
Pi ff ^ Pc LCMt y0UMIR8 NAME
Pa~tLl/IX lAj.OWNERS ADDRESS ’4y%M
52. S■1
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TYPE OE SWAQE 8TSTB< (INSPICTOR'S 00MNENT8) t
SEPARATION DISTANCES (IN EEBT);
SEPTIC TANK SOIL DISPOSAL AREA
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OCCUPIED BUILDING
ELBVATION OE THE AREA
reason SYSTW was ABATED!
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PERCOLATION TEST DATA Price $1.00 per pad.
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537 Ph. No.Owner:Mailing Address:
Last Name Middle St. & No.Legal
Description:Z£R^GE
LAKE OR RIVER NO.NAME SEC.TWP.TWP NAME
TEST HOLE NO. 2TEST HOLE NO. 1
L‘illDepth to Bottom of HoleDepth To Bottom of Hole.inches; Diameter of Holeinches;Diameter of JnchesinchesfSoilDepth, Inches Sjjil/7extu>^
Mil Depth, Incheslate Date
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Percolation
Test Bv /
Percolation
Test By /Q yj
fm. £:LUFirmName.OC Firm
Name,'A.ID(oZLLUOC
UJAddress.OC Address
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CO
Otter Tall County License No.Otter Tail County License No_HCOLUMeasurement,
I nches
Depth in Water
Level, Inches
H Measurement,
I nches
Depth in Water
Level. Inches
Time Remarks Time Remarks
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MKL-0871-028
See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn.