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North Central Camp Cherith_08000120081003_Septic System Permits_
wmP ^ Otter Tail County CV\o 1/1 '^f'Land & Resource Management Subsurface Sewage Treatment System Inspection FormOTTER TAIL COUNTY - MINNESOTA Property ID No.r> 9fociS\'2JDD9.\f\Y^Permit No.□ Non-Shoreland III VCity/Twp.Installer/MPCA #MPCA Type I II ^^f3^ound^^^^placement □ Other□ New □ Repair Type of System □ Trench □ Pressure Bed □ At-Grade Soil Treatment Area InspectionTank Inspection Other Inspection:Final Inspection Dat Inspector specter Corrections Y /NCorrections Corrections Y Corrections2 TREATMENT MEDIA MOUNDS/AT-GRADE K ^^ound 0Percent SlopeTREATMENT MEDIA Drainfield Rock O Registered Treatment Media □ At-Grade Sand Below Bed on Upslope Side(in):Bed Length(ft)i^^Registered Treatment Media:Bed Width(ft): Downslope(ft); | Upslope(ft): |IV^ISEWAGE/HOLDING TANKS Sideslope(ft): 4\UY\Manufactuer Model No.iCapacity (Gallons)Rock Below Pipe(in): □ New □ Existing □ Combo PRESSURE DISTRIBUTION1st Tank: I Lateral Spacing(ft^ Lateral Dia(in)□ New □ Existing □ Combo Number of Laterals:/2nd Tank: Perforation Spacing(ft)^^0"□ New □ Existing □ Combo Perforation Dia(in)Cleanouts:Pump Tank TRENCHES/PRESSURE BEDS PUMP INFO g Pump Trench _ Pressure ^ Bed□ Drop Box End Fed □ Dist Box □ Gravity Pump Manufacturer/Model No: Rock Below Pipe(in)^^l^Eyent Counter □ Run-Time Clock□ Drop Box Center Fed □ 6 □ 12 □ 18 □ 24 Flow Measurement Reading: SETBACKST,Ta Tj T4 TsTrench Depth (in) Dwelling Non-Dwelling Building(s) to tanks(ft) Duelling Non-DwellingIL'^ IP'S)T,TjTrench Length (ft)Ts T4 Ts Building(s) to STA(ft) 1?^We"(s)Tr Ts Ts TioTrench Depth (in) Surface water(ft)Sensitive Well — Trench LengtfT(ft)Property lines(ft) |(JTsTrTsTsT,o BluffRoad R.O.W. r'Sh 3(p-^Depth of Restriction(in):Depth of System(in):Vertical Separation Provided(in):7-1Bed Width(ft):Bed Length(ft):Pressure Bed Dimensions (io^mComments: Final Inspects SignatureSSTS Inspection Form 04*28>2020 PT-873169 • Victor l^nd^ Co, Printers - Fergus Falls, MN • 1-800-346-4870 'I'll \ ( On'S\-n;l/t■W'l53bOtter Tail County Land & Resource Management Subsurface Sewage Treatment System Inspection Form (\\\ OTTER TAIL COUNTY - MINNESOTA Address Property ID No.Permit No.□ Non-Shoreland 12 CityfTwp. /III \ IV V Installer/MPCA #MPCA Type I II\ ,Ef Mound□ Repair □ ^Replacement □ Other□ New Type of System □ Trench □ Pressure Bed □ At-Grade Soil Treatment Area InspectionTank Inspection Other Inspection: Final Inspection trispector )\Date//,..J\cMHh.Date Date Inspector Inspector•;"Ai \Corrections Y N Corrections Y N ;Corrections Y N Corrections Y N ;/ TREATMENT MEDIA MOUNDS/AT-GRADE 0Mound13, Drainfield RockTREATMENT MEDIA Percent Slope□ Registered Treatment Media □ At-Grade Sand Below Bed on Upslope - Side(in):3c...Registered Treatment Media:Bed Width{fl):} Bed Length(ft): ■ .- "1 Upslope(ft);Downslope(ft):; Sideslope(ft):SEWAGE/tHIOLDING TANKS i T\ '3//'Rock Below Pipe(in): y,Capacity (Gallons) Manufactuer Model No.'N. ' iV''1st Tank:PRESSURE DISTRIBUTION□ New □ Existing □ Combo □ New □ Existing □ Combo2nd Tank:Number of Laterais: Lateral Spacing(ft)Lateral Dia(in) □ New □ Existing □ Combo Perforation Dia(in) Perforation Spacing(ft)Pump Tank Cleanouts: Y N oou TRENCHES/PRESSURE BEDS PUMP INFO □ Pump Trench Pressure r□ Drop Box End Fed □ Dist Box □ Gravity □Pump Manufacturer/Model No:Bed Rock Below Pipe(in)Event Counter □ Run-Time Clock□ Drop Box Center Fed □ 6 □ 12 □ 18 □ 24 Flow Measurement Reading: Ti SETBACKSTrench Depth (in)Tj Tj T4 Ts Dwelling Non-Owellin^-Dwelting Non-Dwelling Building(s)totanks(ft)Building(s) to STA(ft)Trench Length (ft)T,Ta T3 T4 Ts Well(s)TeTrench Depth (in)Tr Ts Ts T,o Surface water(ft)Sensitive Well ! Trench Length (ft)Property lines(ft) 1TeTrTe Te T,o BluffRoad R.O.W. Vertical Separation Provided(in):Depth of Restriction(in): • Depth of System(in):Bed Width(fl):Bed Length(fl):Pressure Bed Dimensions b 13 - ' Kr ! rV I i IComments:i . n VA.A/ r Final Inspector \ p- I Signature Al l!)' ASSTS Inspection Form 04*28-2020 T PT-873169 • Victor Lund^W) Co., Printers • Fergus Falls, MN • 1-800-346-4870 Department of LAND AND RESOURCE MANAGEMENT OTTER TAIL COUNTY Government services Center 540 West Fir Avenue - Fergus Falxs MN 56537 Phone: 218 - 998 - 8095 otter Tail County Website: www.ottertailcountvmn.us OTTCR TflII \ AS-BUILT REPORT SUBSURFACE SEWAGE TREATMENT SYSTEM SITE/OWNER INFORMATION Site Address Property ID# Mail CityProperty Owner Mail State/ZipMailing Address SSTS CONTRACTOR INFORMATION MPCA License #Installation Business Certified Individual on Job Date of Installation SYSTEM INFORMATION TANK 1 TANK 2□ Registered Tank □ Registered Tank ManufacturerManufacturer Model NumberModel Number gallons Liquid Capacity gallonsLiquid Capacity Date of ManufactureDate of Manufacture Maximum Depth Allowed ftMaximum Depth Allowed ft Actual Depth Buried ftActual Depth Buried ft TANKS PUMP TANK□ Registered Tank □ Registered Tank ManufacturerManufacturer Model NumberModel Number Liquid Capacitygallons gallonsLiquid Capacity Date of ManufactureDate of Manufacture ftMaximum Depth Allowed ft Maximum Depth Allowed ftftActual Depth BuriedActual Depth Buried DRAINFIELD SPECS PRESSURE DISTRIBUTION SPECS Number of Laterals□ Distribution Box □ Pressurized Trenches□ Drop Box Perforation DiameterNumber of Trenches in ftTotal Lineal Feet of Trenches ft Perforation Spacing ftDepth of Trenches from Grade Lateral Spacingin Clean-Outs Installed at End LateralsTotal Area Installed sq ft PUMP INFORMATIONPRESSURE BED SPECS ManufacturerBed Length & Width X Model NumberDepth of Bed from Grade:in MOUND/AT-GRADE SPECS TREATMENT MEDIA Bed Length & Width X □ Drainfieid Rock □ Registered Treatment Media in Treatment MediaSand Below Bed (Upslope Side) ftDownslope Berm Width CERTIFICATION I hereby certify that the system at the above referenced address was installed according to the Otter Tail County Sanitation Code and Minnesota Rules, Chapter 7080-7083. Installer Signature DateInstallerMPCA Lie# V i ^'loO'»i g^v ! n.I Department of w LAND AND RESOURCE MANAGEMENT OTTER TAIL COUNTY Government Services Center 540 West Fir Avenue - Fergus Falls MN 56537 Phone: 218- 998 - 8095 otter Tail County Website: www.ottertailcountvmn.us OTrcRTmi AS-BUlLT REPORT SUBSURFACE SEWAGE TREATMENT SYSTEM SITE/OWNER INFORMATION Site Address Property ID# Mail CityProperty Owner Mail State/ZipMailing Address SSTS CONTRACTOR INFORMATION Installation Business MPCA License # Date of InstallationCertified Individual on Job SYSTEM INFORMATION TANKl TANK 2□ Registered Tank □ Registered Tank ManufacturerManufacturer Model NumberModel Number Liquid CapacityLiquid Capacity gallons gallons Date of ManufactureDate of Manufacture ftMaximum Depth Allowed ft Maximum Depth Allowed ft Actual Depth Buried ftActual Depth Buried TANKS PUMP TANK□ Registered Tank □ Registered Tank Manufacturer Manufacturer Model NumberModel Number Liquid Capacity gallonsLiquid Capacity gallons Date of ManufactureDate of Manufacture Maximum Depth Allowed ftftMaximum Depth Allowed Actual Depth Buried Actual Depth Buried ftft PRESSURE DISTRIBUTION SPECSDRAINFIELD SPECS Number of Laterals□ Distribution Box □ Pressurized Trenches□ Drop Box Number of Trenches Perforation Diameter in Perforation Spacing ftTotal Lineal Feet of Trenches ft ftDepth of Trenches from Grade Lateral Spacingin Clean-Outs Installed at End Lateralssq ftTotal Area Installed PRESSURE BED SPECS PUMP INFORMATION ManufacturerBed Length & Width X Model NumberDepth of Bed from Grade:in MOUND/AT-GRADE SPECS TREATMENT MEDIA Bed Length & Width □ Drainfieid RockX □ Registered Treatment Media in Treatment MediaSand Below Bed (Upslope Side) Downslope Berm Width ft CERTIFICATION I hereby certify that the system at the above referenced address was installed according to the Otter Tail County Sanitation Code and Minnesota Rules, Chapter 7080-7083. Installer SignatureInstaller DateMPCA Lie# i"i. •; : ; •. _i^;\o 5?k •, 'Q •T''Cp^ >-^v ^ - 1'M ! :-,oo o .A ./ \0 I Department of w LAND AND RESOURCE MANAGEMENT OTTER TAIL COUNTY Government Services Center 540 West Fir Avenue - Fergus Falxs MN 56537 Phone: 218 - 998 - 8095 otter Tail County Website: www.ottertailcountvmn.us AS-BUILT REPORT SUBSURFACE SEWAGE TREATMENT SYSTEM SITE/OWNER INFORMATION Property Owner ( ^ i Qcxx<i vvi _____ SSTS CONTRACTOR fNFORMATION Property ID# Qf^ cVQvyQ I 2.U Q & .. PCSite Address Mail City ~L rviWjMail State/ZipMailing Address mm^mmunnInstallation Business 6^-^ V '-5' ^MPCA License # _______ of Installation ^§Certified Individual on Job Date SYSTEM INFORMATION TANK2TANK!□ Registered Tank □ Registered Tank ManufacturerManufacturer Model NumberModel Number gallons Liquid Capacity gallonsLiquid Capacity Date of ManufactureDate of Manufacture ftftMaximum Depth AllowedMaximum Depth Allowed ft ftActual Depth Buried pump tank . Manufacturer Actual Depth Buried Manufacturer Model NumberModel Number gallonsgallonsLiquid CapacityLiquid Capacity Date of ManufactureDate of Manufacture ftMaximum Depth AllowedMaximum Depth Allowed ft ftActual Depth Buried ft Actual Depth Buried PRESSURE DISTRIBUTION SPECSDRAINFtELD SPECS Number of Laterals□ Drop Box □ Distribution Box Number of Trenches^N. □ Pressurized Trenches 'MPerforation Diameter in ftftPerforation SpacingTotal Lineal Feet of Trenches ftLateral SpacingDepth of Trenches from Gra in Clean-Outs Installed at End LateralsTotal Area Installed sq ft f r -.t PUMPINFORIVIATlPRESSURE BED SPECS ManufacturerBed Length & Width X Depth of Bed from Grade: 'Model Number 'V\i*^IQ|in MOUND/AT-GRADE SPECS TREATMENT MEDIAr--if '-Q^Drainfield Rock^ i 27 □ Registered Treatment MediaBed Length & Width X in Treatment MediaSand Below Bed (Upslope Side) 0^'\ Vc ^ftDownslope Berm Width CERTIFICATION I hereby certify that the system at the above referenced address was installed according to the Otter Tail County Sanitation Code and Minnesota Rules, Chapter 7080-7083..-■7 - rysi Installer Signature DateInstallerMPCA Lie# CHRONOLOGY REGARDING THE SEWAGE SYSTEM INSPECTION PROGRAM Primary Owner North Central Camp Cherith Inc Alternate Owner Lake 56-538 Schrams 08000120081003Parcel No 32884 Camp Cherith RdGIS Address Date of Compliant Letter Date of Non-Compliant Letter Date Abatement Notice Date to County Attorney Date Initial Response (owner) Date Resolved Comments: Chronology Sewage System Inspection Program 1-2012 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 07/23/2012 North Central Camp Cherith Inc Attn Ann Wellmann Po Box 127 Circle Pines MN 55014 0127 RE: Primary Owner North Central Camp Cherith Inc Result of Onsite Sewage System Inspection, Compliant Parcel(s) 08000120081003 Lake Name Schrams Lake/River No 56-538 Dear North Central Camp Cherith Inc As part of Otter Tail County’s ongoing Sewage System Inspection Program, our Office inspected your sewer system located at 32884 CAMP CHERITH RD on 6/6/2012. At that time we found that your sewage system located at 32884 CAMP CHERITH RD was compliant with the Sanitation code of Otter Tail County. If you have any questions regarding this inspection, please contact our Office at 218-998- 8095. Sincerely George Hausske Inspector Michael Douglas Inspector SCANNED SEWAGE SYSTEM INSPECTION PROGRAM FIELD NOTES Schrams LAKE NO 56-538 LAKE CLASS NELAKE NAME 32884 CAMP CHERITH RD MAPARCEL NO 08000120081003 SECTION NOTOWNSHIPCandor Township 12 PROPERTY OWNER North Central Camp Cherith Inc TAXPAYER North Central Camp Cherith Inc Attn Ann Wellmann Po Box 127 Circle Pines MN 55014 0127 ONSITE INSPECTION FINDINGS - SKETCH ON BACK: Septic Tank/Drainfield Cesspool Porta Potty Holding Tank Leaching Pit Sink Drain Seepage Pit Surface Discharge Outhouse Drywell Straight Pipe Primitive Dwelling SEPARATION / SETBACK DISTANCES (in feet): TANK ABSORPTION AREA OUTHOUSE OHWL RESTRICTIVE LAYER WELL ONSITE INSPECTION RESULTS: COMPLIANT (Send Compliant Letter) IMMINENT THREAT TO PUBLIC SAFETY OR HEALTH (Send 10 Day Abatement Notice) NON-COMPLIANT (Send Non-Compliant Letter) REVISIT NO FURTHER ACTION NECESSARY COMMENTS: / (A^liy ‘ Dite,SCANNEDInspector’s Signature(s^ Existing File:Yes No Sewage System Inspection Program - Field Notes Form 6-1-2011 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 05/07/2012 North Gentral Camp Cherith Inc Attn AmyWellmann Po Box 127 Circle Pines Mn 55014 0127 RE: Onsite Sewage System Inspections Parcel 08000120081003 Lake 56-538 Schrams Dear North Central Camp Cherith Inc: As part of Otter Tail County’s oncM^affort to County Board of Commissioners^sm existing septic systems for com order to complete this process, year in which an area of^^3ountyl It appears your propert^^ included in the area that will be inspected in 2012. Since this is the case, please be info^igd that^arting June 6, 2012 Inspectors from our Office will be checking existing septic s^^^^your area. lerve and enhance water quality, the ^d our^ice to conduct onsite inspections of nee wifwhe Sanitation Code of Otter Tail County. In ^p wa^reated (July 10, 2008) which identifies the inspected. Should a non-compliant septic system be discovered, our Office will contact the property owner and inform them of the need for their septic system to be brought into compliance with the provisions of our Sanitation Code. If you have any questions regarding this matter, please contact our Office (218-998-8095). Sincerely, Scott Ellingson Inspector Department of LAND & RESOURCE MANAGEMENT COUNTY OF OTTER TAIL Phone 218-739-2271 Court House Fergus Falls, Minnesota 56537 tvJune 14, 1993 ^vOi-r (f I Margie Glllee 910 E. 3rd St. St. Paul, HN SS106 RE: Sevage System, North Central Caap Cherith, Inc Schraas Lake (56-538).• P Ms. Gilles, I aa writing you in regards to the failed septic system on Camp Cherith. understand that you have replaced Hr. Naaktgeboren as the Caap Board Chairperson and are therefore the person I should contact concerning this problem. I As you probably know, Caap Cherith experienced a major sever system failure during July of 1992. Apparently Hr Mark Ronnlng reached an agreement with Mr. Naaktegeboren or yourself allowing you until the start of use of Camp Cherith in 1993 to correct this problem. This letter is to inform you that this system must be corrected, you have until the start of use of Camp Cherith in 1993 or July 1, 1993 to have this problem corrected, which ever is sooner. Therefore If you have any questions, (739-2271 Ext. 226). at the Land & Resource Officeplease contact Sincerely, George Hausske Inspector Hark Ronnlng, County Health Inspector Fred Naaktgeboren, 608 2nd St. S cc: Buffalo, HN 55313• P mis SHORELAND MANAGEMENT ORDINANCE — SUBDIVISION CONTROL ORDINANCE RIGHT-OF-WAY SETBACK ORDINANCE — SEWAGE SYSTEM CLEANERS ORDINANCE RECORDER, OTTER TAIL COUNTY PLANNING COMMISSION /of /OTTER TAIL COUNTY DEPARTMENT OF PUBLIC HEALTH DIVISION OF ENVIRONMENTAL HEALTH FERGUS FALLS. MN 56537 739-2271, Ext. 290 Page Date LODGING ESTABLISHMENT INSPECTION REPORT Time: '/leSS-2^ S7-S}HjdC LICENSEE ADDRESS CITY OR TOVyiSHIP y LICENSE NO. 7 3 T3/ BUSINES POSTED UNITS/ROOMS PH ITEMS MARKED AND ORDERS WRITTEN BELOW MUST BE COMPLIED WITH BY DATE INDICATED ITEM WT.REQUIREMENTS ITEM WT.REQUIREMENTS ITEM WT.REQUIREMENTS BUILDING REQUIREMENTS ROOM FURNISHINGS INSECT. RODENT 2 I Clean good repairGood repair, maintained21 315 Prevent entrance Professional ext. 28 TOILETS, SHOWERS 2 Health, safety, comfort4 16 Provided each floor or room2 529 Evidence present PERSONAL HEALTH FLOORS 317 One toilet and lav/10 One tub or shower/20 5 Handwashing practices30 3 2 Construction, clean, good repair Communicable disease231 18 Doors self-closing Rooms ventilated CLEANLINESS1 WALLS, CEILINGS 3 Clean - free of rubbish, litter32 2 Clean, good repair proper construction 4 19 Clean, good repair Signs posted 2 FIRE PROTECTION SCREENING WATER SUPPLY Fire escapes accessible, good repair 33 5 2 Doors, windows, openings screened. Other methods 20 Safe source7 21 Hot water temp. 130° F.Exit signs4 HAND WASHING Extinguishers present Annually chargedLIGHTING, VENTILATION 22 Hot and cold / or equipment 1 6 2 Adequate lighting Egress from sleeping 7 Ventilation, make-up1 23 Towels / hand dryers Smoke detectors1 air GUEST ROOM UTENSILS Other 8 Heaters vented4 24 Multi-use, stored, washed properly, equipment PLUMBING________ 2 I Installed, maintained 2 SPACE REQUIREMENTS 34 9 5 70 ft° - 60 ft° - 400 ft°Single service, stored, dispensed 5 Cross connections25135 10 3 ft. bed separation ICE DISPENSING1 11 2 At least 50% above gr.WASTE DISPOSAL 36 3 Proper dispensing £6 7 /Sewage in accordance with — M.P.C.A. Rules BEDDING - LINEN 3 MCIAA37 12 2 Provided Good repair, clean13 2 Garbage and refuse Containers - storage area OTHER38 Changed between142 27 3 NOTE: PLANS AND SPECIFICATIONS MUST BE SUBMITTED FOR REVIEW AND APPROVED PRIOR TO BEGINNING ANY NEW CONSTRUCTION. REMODELING, OR ALTERATIONS TO THE PREMISES OR ITS FACILITIES. ITEM REMARKS AND ORDERS !S Signatures RATING SCORE ROSS. FIRE CODE VIOLATIONS RECEIV PUBLIC HEALTH rSANITARIAN Distribution: White-Agency Yellow-EstablishmentOTH 0019 Nelson Bros. Printing, Inc., Fergus Palls. MN Department of LAND & RESOURCE MANAGEMENT COUNTY OF OTTER TAIL Phone 218-739-2271 Court House Fergus Falls, Minnesota 56537 (o~ 0^,July 20, 1992 North Central Camp Cherlth, Inc. 3200 129th Lane NW Coon Rapids, HN 55448 RE: Septic System, Schrams Lake (58-538). Dear Sir: On July 17, 1992 I visited North Central Camp Cherlth, Schrams Lake In Otter Tall County Minnesota. Inc. located on My visit vas prompted by Mr. Mark Ronnlng, Health Inspector. failure vas In progress at Camp Cherlth. the Otter Tall County Public Running advised me that a serious septic systemMr. My visit confirmed that the dralnfield portion of this septic system vas discharging sevage to the ground surface In fairly large amounts. After my visit to the camp, I again talked to Mr. Ronnlng. he considers this a very serious problem. He told me that In this regard and somevhat contrary to vhat I Indicated to the people I spoke vlth onsite, I feel that our office should hold you to the August 1, 1992 deadline for fixing the septic system that vas mandated by the Health Department. Sincerely, George Hausske Inspector mgb SHORELAND MANAGEMENT ORDINANCE — SUBDIVISION CONTROL ORDINANCE RIGHT-OF-WAY SETBACK ORDINANCE - SEWAGE SYSTEM CLEANERS ORDINANCE RECORDER, OTTER TAIL COUNTY PLANNING COMMISSION OCT 3 g 1,992 Camp Cher af^ Pionttr C/uSjt> 1%;^ ^.c^'^- / •'t^ •^'X ^^<*‘—»''-~^b/ ^!^er£^ /9fy_ JL jzixr~ ^i^'^L.^f-yaaXX ^zL^^-dr'y^ueC'— OTTER TAIL COUNTY DEPARTMENT OF PUBLIC HEALTH DIVISION OF ENVIRONMENTAL HEALTH COURTHOUSE FERGUS FALLS, MINNESOTA 56537 Page of LODGING ESTABLISHMENT INSPECTION REPORT O 7~Date / S Z-\ ir No. ^ City/T^wn^ip ORDERS WRITTEN BELOW MUST BE COMPLIED WITH BY DATE INDICATED P- o._C>23r County /l/,C//a^ao/CLicensee ITEM REMARKS AND ORDERS c. -U<1UI / 7 3TuA 9Z. / P \ gf CZ-C——«X. <_ ^ /Z C? 7~~ C-i ^ ^ ..-■g—>-c«-a.^!7 l C^-fi~T. ]/ ^ Z-'____________________________________________ i Rating Score Received by Public Health Sanitariaj r REPORT OTTER TAIL COUNTY DEPARTMENT OF PUBLIC HEALTH DIVISION OF ENVIRONMENTAL HEALTH FERGUS FALLS. MN 56537 739-2271, Ext. 290 / of.1 Page C Date: LODGING ESTABLISHMENT INSPECfTION Time: /’^ C O ADDRESS CITY OR TOWNSHI^C^CrSn—/Ly' L\_^I BUSINESS NAME / . LICENSE NO.UNITS/ROOMSPOSTED PHONE 19//CO gar" 3 3 Y-i-// r<-f ITEMS MARKED AND ORDERS WRITTEN BELOW MUST BE COMPLIED WITH BY DATE INDICATED ITEM WT.REQUIREMENTS ITEM WT.REQUIREMENTS REQUIREMENTSITEM WT. BUILDING REQUIREMENTS ROOM FURNISHINGS INSECT, RODENT I 2 j Good repair, maintained 2 j Clean good repair1 3 Prevent entrance Professionai ext. 15 28 TOILETS, SHOWERSI 2 4 health, safety, comfort 16 2 Provided each floor or room 29 5 : Evidence present PERSONAL HEALTH FLOORS 5 Handwashing practices3One toilet and Iav/10 One tub or shower/20 17 30 2 Construction, clean, good repair3 2 Communicable disease31 Doors self-closing Rooms ventilated 18 CLEANLINESS1 WALLS, CEILINGS Clean - free of rubbish, litter323 2 Clean, good repair proper construction 4 2 Clean, good repair Signs posted FIRE PROTECTION SCREENING WATER SUPPLY 33 Fire escapes accessible, good repair52 j Goors, windows, —[openings screened. Other methods 20 ! 7 ^Safe source PoiSoA-' S 21 I 4 Hot water temp. 130° F.; Exit signsIHAND WASHING Extinguishers present LIGHTING, VENTILATION 22 Hot and cold / or equipment - Annually charged1 j Egj;ess from sleeping6 2 Adequate lighting 7 Ventilation, make-up1 Towels / hand dryers23 Smoke detectors1 air GUEST ROOM UTENSILS ’ Other 8 Heaters vented4 Multi-use, stored, washed properly, equipment 24 2 PLUMBING .^ 34^1 mil 2 ; i Installed, maintained 35 ! 5 Cross connections .^SPACE REQUIREMENTS 9 ^5 iJO ft^ - 60 ft' ■ 400 ft'Single service, stored, dispensed 25 1 1 I 3 ft. bed separation10 ICE DISPENSING 2 I At least 50% above gr.3 I Proper dispensing11WASTE DISPOSAL 36 / 26 7 l^ewage in accordance with -------[m.P.C.A, Rules 3 jMCIAABEDDING • LINEN 37 I2Provided12 [OTHERGood repair, clean132 Garbage and refuse Containers - storage area 38 !Changed between214 27 3 NOTE: PLANS AND SPECIFICATIONS MUST BE SUBMITTED FOR REVIEW AND APPROVED PRIOR TO BEGINNING ANY NEW CONSTRUCTION. REMODELING, OR ALTERATIONS TO THE PREMISES OR ITS FACILITIES. ITEM REMARKS AND ORDERS ^__/ ^^^^ r. ^ fZ^ ~~ ^ 3^ MY //, 9 Signatures YoP' M Lu-/f -20 ■ J RATING SCORE POSS. FIRE CODE VIOLATIONS RECEIVED BY PUBLIC HEALTH SANITARIAN Distribution: White-Agency Yellow-EstablishmentOTH 0019 Nelson Bros. Pnnitng, Inc.. Fergus Falls. MN p e-/^ <!>( d. | ^^ f T C 'i^9i-x\\^^ (Q A :z-o 30 CjYf\r) ■ZGOO JJJ^ 30 75" 6/50 7^^ (t I O J i~> -fTif/U If/C^ ' ~2GO a , __/.07 Y . 63ifZ_ /3700 ^ Z5' '"H'qTc ■Pf; n Q y S' Ocv^y Catnap ru? tl A //3q p<i°fk P /3 ^ 1^ t, <A «^y /c^a/.G7 p<^/t . :i^ 2^'3 D w \+'K/ c ")Acr A ©.“^Y ( 3o vv-» ^3 'z.C,^S~C'^f 7. Xl-^'2^ 6/ 009^ ArrL-lCAINl MUM UtL rKUMlIM A1 HtAKlINU TO WHOM IT MAY CONCERN;Gofiman Tomihlp I OttdA T<uZ County Htghway Vzpt. County CouAtkou&z FzAgu6 FaJLU, MW 56537 ; has made application to the Otter Tail County Planning Commission for a Conditional Use Permit as per requirements of the Otter Tail County Shoreland Management Ordinance. The Otter Tail County AugiiAtPlanning Commission will assemble for this hearing on 19_B1 Place CnmmJ\Alnv)oh' A Pnnm^ Cnnhf Fersus Falls, Minnesota. This notice is to advise you that you may attend the above hearing and express your views on the Time 7:00 2J\i. Conditional Use requested. The property concerned in the application is legally described as: Twp. Name.Lake No.S£=TXTSL— Sec. 7 Q Twp. 137 Range.GonmanIQ. Otd.pti. TaJf tjJooti Class ACLake Name:.Fire No. WEi, SzctLon 79, T137N, R39W THE CONDITIONAL USE REQUESTED IS: Rzplacz dzif(iiznt TownAklp BtUdgz Mo. 147S ovzA thz OttzA. TauZ RfvzA coLth 2 LLnzA 0^ 72’ x 10' pAzzau>t concAztz box. cuZvzAti, M-vtk znd AzctionA, zorutthuct apptiocLzkzA to zuZvzAtA and fitpAap znd Azcttom. AppfioxMnatzty 1,350 zubtc yoAcU oi cZzan ittt jJoA zoyu>tnuztlon ojJ tka> bhtdgz tLzplaczmznt pEOjZct utttl bz placzd bzZoM thz OfidLincdiy Htgh WatzA Elzvatton. SEWAGE SYSTEM7 17th DecemberThis 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 by Otter Tail County, Minnesota.? Vie premises covered by this certificate are legally described as:m m CandorRange 41Twp. 13711Lake No. 36-538 Sec.Twp. Name m ii North Central Camp Cherithm 7. North Central Camp CherithOwner: Name Address 18605 50th PI North Plymouth. MNiii mn 55447Zip No. Permit No. SP 5-4 JT'263191 Victor Lundecn Co., Printers, Fergus Falls, Minnesota r SHORELAND MANAGEMENT — COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone: (218) 739-2271 • FERGUS FALLS, MN 56537 APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM WHITE — Office Yellow — Inspector Pink — Owner Iuj'6- Nu>fi( + --------j, —I — SUf'/'j lujet-K to done Wff/'u LEGAL Permit No. DESCRIPTION AND LOCATION LAKE/RIVER NAME SECTIONLAKE NUMBER LAKE/RIVER CLASS TWP RANGE TWP NAME Of^-OOU-C^-OO^t-O^O ^^^/'Oo/.Coo^f OOJ-hCV^)r^-ccjo /3y PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER IDENTIFICATION: Please Print All Information Last Name First Mailing Address — No. Street. City and State________________L N0 fi^r'di Mh Initial Zip Code Telephone No. (LAt1f> Ck-tr,H[%3:2<70 -Property Owner dOON He I Hc6jSewage System instaiier Name A.M. ► This System will be ready for inspection on P.M., 19.at / /lee for )l/o This space for office use only NUMBER OF BEDROOMS: A.M. P.M19 GARBAGE DISPOSAL: ( ) YES () NODate Rec’d Time Rec'd Phone Call Rec’d By Capacity ^ EWAGE DISPOSAL SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM ( ) Holding tank (Septic ( Drain field ( ) Standard ( ) Bed Trench ( ) Modified ( ) Mound TANK DRAIN FIELD GIs.Ft.tank SODistance from nearest well Ft.Ft. £C>Distance from lake or stream Ft.Ft. 3kODistance from building 10 Ft.Ft. 10 /ODistance from property line Ft.Ft. EFFLUENT DISTRIBUTION ( 3^) Gravity (' ) Pressure 3Distance from bottom to Water Table Ft.Ft. All distances are shortest distance between nearest points WATER WELL DEPTH: :x?^3PERCOLATION TEST DATA: Date of First Test J.st Test Taken By --< , 19 Rate ^3Date of Second Test Rate, 19 = _tlFirst 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 re for inspection. DATE: Sigrfature Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express condition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the 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. y' Issued Date: Land & Resource Management Office Sized Ly hASeJ hO rAHferj. AyrU Cnferi'A AhI 4bir 0.4 e -foh ___________ 3^.00Fee $.Rec # 1Comments: ic ^ I4-!c>t0 CA Form No. BK - 0292-003 260,771 — Victor Lundeen Co.. Printers, Fergus Falls, Minnesota I v.V-'- ->^ ••I 1^1- trp-'J^ 914^ SHORELAND MANAGEMENT — tJOUNTY 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 Nr)',i 5WLUofIc. to 6e done p'a, LEGAL Permit No. DESCRIPTION 5 fillIM~1^ ^2/^ AND 1^1 ^-h^3 . iLOCATION LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER CLASS SECTION TWP RANGE TWP NAME (LAddof'II -Dot ( Oo-^ ^-OO^Arj)^ ho / I3'7 PARCEL NUMBER(S) nO(r IRE OR LAKE ASSOCIATION NUMBER f I—7 IDENTIFICATION: Please Print All Information Last Name Telephone No. *First Mailing Address — No. Street. City and State-PM- B C:<T-M^ Soth PD Yl 4^-^-rj fnrrh)^ Initial Zip Code He I hlc6) Property Owner spm-rf e>e^ Sewage System Installer Name A.M. This System will be ready for inspection on., 19.P.M.at A, Qi2ee jor }^q This space for office use only NUMBER OF BEDROOMS: A.M. 19 P.M NOGARBAGE DISPOSAL: ( ) YES (Date Rec'd Time Rec'd Phone Call Rec'd By EWAGE DISPOSAL SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM ( ) Flolding tank ( )(^) Septic ( Drain field ( ) Standard ( ) Bed (^) Trench ( ) Modified ) Mound TANK DRAIN FIELD Vfe7i^Capacity GIs.tank SODistance from nearest well Ft.Ft. SDDistance from lake or stream Ft.Ft. XODistance from building m Ft.Ft. ( 10 10Distance from property line Ft.Ft. EFFLUENT DISTRIBUTION ( V) Gravity ( ) Pressure 3Distance from bottom to Water Table Ft.Ft. All distances are shortest distance between nearest points WATER WELL DEPTH: PERCOLATION TEST DATA: Date of First Test . 19 Rate')Wl. .(H Test Taken By Af?Date of Second Test Rate. 19 = -toFirst Test + 2nd Test 2nd Test Taken By 2 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 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. 6- ^3 /■.. .- -T- DATE: S/grTature Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express condition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the 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(II 3ky 5ilcJ Ly 176^, hA^^J ho rAHf><rrS c (yyr\< ^LniDfie C r-t f €r/ A And -kloU) pa- Cop VA e ^'OabJ Ut Fee a; ^H.OO Rec ft. ■ jfComments:it ^ n Aj? (/ Form No. BK — 0292-003 260.771 — Victor Lundeen Co.. Printers, Fergus Falls, Minnesota i 4 4 INSPECTION RESULTS Inspector must make all measurements ^ SEWAGE DISPOSAL SYSTEM STATISTICS /SEPTIC TANK DRAIN FIELD ActualCATEGORY Minimum Actui Minimum ,yGLS.SFCapacityGLS.SF O_^Distance from Nearest Well FT FT FT50/ Distance from Buried Water Suction Pipe FT FT FT50FT50 Distance from Buried Pipe Distributing Water Under Pressure FT FT FT FT1010 f FTScO -h FTDistance from Lake or River (OHWL)FTFT ^Distance from Nearest Building FT FT10FT20 /O^ t'/OH h FTDistance from Nearest Property Line FT FT 10 FT10 6 /- FTFT FTDistance from Bottom to Water Table FT 3 Sewer Line to Well Separation DRAINFIELD CALCULATIONINTERPRETATION OF ABBREVIATIONS GLS. = Gallons SF = Square Feet FT = Linear Feet ■>Actual Minimum FTX FT FT20 SF ^ p f e.e'V'V Inspector’s Comments: T.- i SKETCH: ^ \ ^ tnsp^tor s Signature //-n-n 3 Date of inspection /5 30 Time of Inspection INSPECTION RESULTS Inspector must make all measurements SEWAGE DISPOSAL SYSTEM STATISTIC: \septiq.jAnk DRAIN FIELD CATEGORY Actual Minimum Actual Minimum Capacity GiS.GLS.SF SF 1 Distance from Nearest Well FT FT50 FT FT Distance from Buried Water Suction Pipe FT FT FT50 FT 50 Distance from Buried Pipe Distributing Water Under Pressure FTFT FT10FT10 ftDistance from Lake or River (OHWL)FT FT FT / 0Distance from Nearest Building FTFT FT FT1020 ftDistance from Nearest Property Line FT FT FT1010 Distance from Bottom to Water Table FTFT FT FT3 Sewer Line to Well Separation DRAINFIELD CALCULATIONINTERPRETATION OF ABBREVIATIONS GLS. = Gallons SF = Square Feet FT = Linear Feet Actual Minimum FTX FT FT FT20 SF Inspector’s Comments: 7ll.1. \\ SKETCH: \ 1 ! Inspector's Signature It- ' Date ol Inspection I XrO Time of Inspection ■T ♦ 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 — Ollice Yellow — Inspector Pink — Owner Permit No.LEGAL DESCRIPTION AND LOCATION LAKE/RIVER NAME LAKE/RIVER CLASS SECTIONLAKE NUMBER TWP RANGE TWP NAME FIRE OR LAKE ASSOCIATION NUMBERPARCEL NUMBER(S) IDENTIFICATION: Please Print All Information Zip CodeInitialMailing Address — No. Street, City and Slate Telephone No.Last Name First Property Owner Sewage System Installer Name ! A.M. ^ This System will be ready for inspection on P.M.19.at This space lor office use only NUMBER OF BEDROOMS: A.M. P.M19 GARBAGE DISPOSAL: ( ) YES ( ) NODate Rec'd Time Rec’d Phone Call Rec'd By SEWAGE DISPOSAL SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM ( ) Holding tank ( ) Septic tank ( ) Drain field ( ) Standard ( ) Bed ( ) Trench ( ) Modified ( ) Mound DRAIN FIELDTANK A'p-7-r 96 p'Capacity GIs.i1 iDistance from nearest well Ft.Ft. Distance from lake or stream Ft.Ft. Distance from building Ft. Ft.i 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 WATER WELL DEPTH: I PERCOLATION TEST DATA: Date of First Test Rate, 19 ; Date of Second Test Rate. 19 1st Test Taken By First Test + 2nd Test 1 Rate22nd 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.: IDATE: ISignature Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express condition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the 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 ft. Comments:i i Form No. BK — 0292-003 260,771 — Vidor Lundeen Co.. Printers, Fergus Falls. Minnesota feet/inchesScale: Each grid equals GRID PLOT PLAN SKETCHING FORM Dated:19 Signature Please sketch your lot indicating setbacks from road right-of-way, lake and sideyard for each building currently on lot and any proposed structures. t:r:Tj z. -vO O ' s: C 2: ... •, ■ • > a:Ort-\ ZL ^ (- r-of r1--0>ti I'r\1 r'U] o La)> >■ -V ^-s \T X > > \p^ 7^ o> o *~'hx X7 VOr rr C7 r 215987®VICTOK LUNOCEN CO.. PRINTEM. EEXeuS FALLS. UtMN.MKL-0871-029 cH-X 4 "'TS , o W "“ » — 1^ ^ Ac^S p 3c? *\ftos Ppar/3 r 2'S0<7 V ^ % *?3\2.0i /A p *./ S o/> Zg '7'P c:?i^ nJXC— \ jj :Z-^X ^ / o-r-trV^ xfX ^>7 3XXG. ^ Vo i j V. .0 XO l\ zoo 7S %■ 3 ir<3 p; w ^r ■ZS3D y. 2 -^ SC2£> X. Z.2- 4 1^ A!7 -/- / f ^ _ 3 i-as n GRID PLOT PLAN SKETCHING FORM — (Must Be To Scale) feet/inchesScale: Each grid equals // r Dated:19 Signature Please sketch your lot indicating setbacks from road right-of-way, lake and sideyard for each building currently on lot and any proposed structures. i 4 ! i f-J. (ii I t ! I ' I ^1i ; i i : ; ,/lOf 1: ;;; j- -i .1 - —I • \ « r. ‘Ji. yWJ- 1 1 r'-: PERCOLATION TEST DATA LAND AND RESOURCE MANAGEMENT Otter Tail County Fergus Falls, MN 56537OWNER: ' FIRST TELEPHONE NUMBERMIDDLELAST NAME ADDRESS: CITY STATE ZIP CODESTR./RT. SEC.RANGE TWP. NAMELAKE/RIVER NO.TWP.LAKE NAME LEGAL DESCRIPTION: PARCEL NUMBER NUMBER/BEDROOMSFIRE NUMBER — TWO TESTS ARE REQUIRED — TEST HOLE NO. 2TEST HOLE NO. 1 k>3n.inches; Diameter of HoleDepth To Bottom of Hole inches Depth To Bottom of Hole inches; Diameter of Hole inches Date/lu.^u.sF *-/ 19 Percolation i ^ Test By Firm Name Date 5/Soil TextureDepth, Inches Depth. Inches Soil Texture io <4 i QiH ■20V Sodj ; ^ V 7 i\\ik) ShS’7> __________ Address Address ^ Otter Tail County License No. Otter Tail County License No. PERC TEST # 2PERC TEST # 1 tNTHtVAL(MIWtnrBy>WATER DEPTH WATER DROP percratb TIME INTHRVALfMIHUTBSyTIME WtfER DEPTH WATER DROP PERORATE ictn^START START Ll/i,4DR^*^ PBRCi..2r.30...-S-a...-1-1 T'ilMU INTERVAL nxpgnHa WATER DROP PERORATE TIME PERORATETIMEWATER DEPTH INTERVAL (MINUTES)WATER DEPTH WATER DROP(o\(ry /I-L2J /O'.rz llLZZZ REFILL REFILL .I'M.ilH--.3.0 WATER DROP PERORATE INTERVAL iMiNuren WATER DEPTH TIME INTERVAL IM1NinHS>WATER DEPTH WATER DROPTIME PERORATE isMi IS jiASS REFILL REFILLJ.7y.>X‘4-.3fs.-3-c^-4-7 WATER DROP PERORATE INTERVAL <MINUTBS>WATER DEPTH TIMEHME INTERVAL rMPorraa WATER DEPTH WATER DROP PERC RATHREFILLREFILL 4 4 YIMU' DROP PBRC TTMB DROP PBRC INTERVAL IMINtHTO WATER DEPTH WATER DROP reRCRATB TIME INTERVAL (MINUTBSy WATER DEPTH WATER DROPTIKC PBRC RATE REFILL REFILL T •P 'lIMli DROP PERC 'riMM DROP Ptoc PERC RATEINTHIVAL(MTNl/rBS>WATER DEPTH WATER DROP TIME INTERVAL <MTNUTBS>water DEPTH WATER PROPTIME PERC RATEREFILLREFILL +4> ‘FiMM DROP PERC TIMM DROP PBRC INTERVAL IMINIITSP WATER DROP reRCRATB TIME INTERVAL IMPfUTBSIWATER DEPTHTIME WATER DEPTH WATER PROP PERC RATEREFILLREFILL i T 'flKtti” DROP ^kRC YIMU DROP ^Mr^reRCRATB TIMEINTERVAL (MTNinESI WATER DEPTH WATER PROP INTERVAL IMlNinESITIME WATER DEPTH WATER DROP PERC RATE REFILL REFILL T TTMM” DROP PERC TIME DROP PBRC nCOMMENTS/CALCULA TIONS: MKL — 0390 - 005 250,815 — Victor Lundeen Co.. Printers. Fergus Falls. Minnesota 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 *White - Office ^ Vellow — Inspector Owner Owner Pink Card /63^.^ •¥-Permit No.,LEGAL Date DESCRIPTION AND do/ir/t^ r-Sr^na/y\S iTj yyLOCATION RaLake No.Lake Name Lake Classif.Sec.TWP TWP Namenge IDENTIFICATION: Please Print All Information. Zip No.Mailling Address —No. Street, City and State Tel. No.First InitialLast Name r COWNER rV /tin rPSEWAGE SYSTEM INSTALLER OSName, This System will be ready for inspection on., 19. This space for office use only 19 .M Phone Call Rec'd ByDate Rec'd Time Rec'd Owner or Agent Signature /4> d__ SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PITSEPTIC TANK DRAIN FIELD GIs.Sq/Ft.Iq. Ft,Capacity Ft.Ft. Ft.Distance from nearest well .^(3 i~ Ft.Ft. Ft.Distance from lake or stream /O i- Ft.Ft.Ft.Distance from occupied building /O -h Ft.Distance from property line Ft.Ft. 7Ft.Ft.Ft.Distance from bottom to Water Table AH distances are shortest distance between nearest joints No f^rc..RECORD OF TESTS: Inspection was made on 19 , Time ,JV1 By PERCOLATION TEST DATA:Date of First Test ,, 19 , Rate Date of Second Test , 19 , Rate 1st Test Taken By First Test + 2yd Tesi 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.) VDated 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; MlIssued Date: Shoreland Management OfficeS'O Fee $Surcharge $ Comments:, VICTAH UtHDCCN • CO.. POrHttAI riOOuS «tOH 158906Form No. MKL-0771-003 r SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone 218-739-2271 - Fergus Falls, Mn. 56537 APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM White — Office Yeilow — Inspector Pink — Owner Card — Owner Permit No.,LEGAL Date DESCRIPTION AND LOCATION Lake Classif.Sec.TWPLake No.Lake Name Range TWP Name IDENTIFICATION: Please Print All Information. Mailling Address —No, Street, City and State Zip No.Tel. No.InitialFirstLast Name OWNER SEWAGE SYSTEM INSTALLER Name This System will be ready for inspection on., 19. This space for office use only .M19 Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PIT DRAIN FIELD GIs.Sq. Ft.Sq. Ft.Capacity Ft.Ft. Ft.Distance from nearest well Ft.Ft.Ft.Distance from lake or stream Ft. Ft.Ft.Distance from occupied building Distance from property line Ft.Ft.Ft. Ft.Ft.Ft.Distance from bottom to Water Table AH distances are shortest distance between nearest points RECORD OF TESTS: Inspection was made on 19 , Time JVI By PERCOLATION TEST DATA:Date of First Test 19 t Rate Date of Second Test 19 , Rate 1st Test Taken By First Test -t- 2nd Test 2 Rate2nd Test Taken By The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work inAgreement: strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn esota Department of Health. Applicant agrees that plot plan, sketches and specifications submitted herewith and which are approved by Shoreland Management Offi cial shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the responsibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection. (Call or use attached mailer notice.) Dated Signature Permit: condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota. This permit may be revoked at any time upon violation of any said ordinance. NOTE: Permit void if work is not commenced within six (6) months. Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express Issued Date: Shoreland Management Office Fee $Surcharge $ Comments;. M^TCAlLEDFOR INSFECi 158906 vieren luhsicii « co.. paiMteat. rttsua rw.L*. winhForm No. MKL-0771-003 'S'- V. INSPECTION RESULTS Inspector must make all measurements SEWAGE DISPOSAL SYSTEM STATISTICS SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORYActualShould be Actual Should be Actual Should be Capacity GIs.GIs.S F S F S F SF Distance from Nearest Well 75F 50FFFF F Distance from Lake or Stream F F F F F F Distance from Occupied Building 201020FFFF F F Distance from Property Line 10 10 10FFFFF F Distance from Bottom to Water Table 4 4FFFF F F Inspector's Comments: •■j .»'■ 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 > y/4-g</;U.S. DEPARTMENT OP AGRICULTURE DATE REFERENCE SLIP 7/ .. .3' : I I ACTION I I NOTE AND RETURN I I PER PHONE CALL I I RECOMMENDATION • Q REPLY FOR SIGNATURE OF I I RETURNED I I APPROVAL 1 I I AS REQUESTED I I FOR COMMENTo2l S 'O 7 r'y o7!^(V// (y/pY (7Z/ SI INFORMATIONS V5'6? 7S'0 73'O'? 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