HomeMy WebLinkAboutOak Park Resort_8005781_Septic System Permits_CERTIFICATE OF APPROVAL
SEWAGE SYSTEM
iS
i
[S-J iw19 H31 ST DECEMBERday ofThis certificate has been issued this
to certify that the sewage system installed as per sewage permit number indicated below has been approved for use
m.by Otter Tail County, Minnesota.
w.The premises covered by this certificate are legally described as:
%Range 3 9 Twp. Name N I D A R 0 STwp. 13^56-238 Sec. _6Lake No.I)
6 132 39 16.06
PART 6L 5 COM NE COR GL 8 S 491'
7o DEG 811* TO BG N 7o DEG E 8
N 491• S 86 DEG W 1292' S 66' E
S 396' TO LAKE SELY ALONG LAKE Tm
'1WiWd
SuANSQM. JAMES H. & THERESA E.Owner: Name
Rg? ROX 6ft^ riTTHERALL^ MNAddress%
56524Zip No.
K:-1^8888Permit No. SP 'PSigned by:
Linui & Resource Management Official
Otter Tail County, MinnesotaMKL-0987001
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25.1,617 Vicior l.untlccn Co. I’riiiUTs. I crgii.s l iill.s, Mmucsoiii
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
Parcel Number
AND
Q /3^- 39 IfCj f toLOCATION
TWP NameLake No.Lake Name Lake Clastif.Sac.TWP Range
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Tel. No.Zip No.Last Name First Initial
C^\ j-hh ^ ^ 1 i
N'SoOWNER
\54L-JO V Jr i TSEWAGE
SYSTEM
INSTALLER
Name,
This System will be ready for inspection on., 19.
This space for office use only
19_____.M
Date Rec'd Time Rec'd Phone Call Rec'd By
NUMBER OF BEDROOMS: -3ESTIMATED COST;
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
Gis.Capacity . Ft.Sq. Ft.
^o/raoFt.Ft.Ft.Distance from nearest well
75^vrFt.Distance from lake or stream Ft.Ft.
/oDistance from occupied building
Distance from property line
Ft. Ft.Ft.
/Q/o Ft.Ft.Ft.
N
3Ft.''Distance from bottom to Water Table Ft.Ft.
AH distances are shortest distance between nearest points
.S5PERCOLATION TEST DATA:Date of First Test 19 Rate
19..?./- 7- 77 Date of Second Test , Rate
1st Test'Taken By >N
L2..Z4First Test + 2nd Test .L .....I.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.
I understand that I have been granted a sewage system site permit in accordance with
the requirements of the Shoreland Management Ordinance of Otter Tail County. I
understand I must contact my township in order to determine whether or not any addi
tional permits are required by the township for my proposed project.
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE: Permit void if work is not commenced within six (6) months.
Permit:
Land & Resource ManagemSu
Issued Date:
Office
Fee $Rec #
Comments:
Fomn No MKL 082090 253,056 — Victor Lundeen 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
Yeflow — Inspector
Pink — Owner
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OPi^ 'pP’S-k
Permit No.LEGAL /i\^t^onn- 6(£>-oo6Z- on^eso^rDESCRIPTION
Parcel Number■
AND
rc-O-ik cJ '-H-PZ. ^n KIToeoiLOCATIONc r <7
Lake Classif.Lake No. Lake Name TWP NameSec.TWP Range
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and StateFirst Zip No,Last Name Initial Tel. No.
So y COC iOWNER
^O/nLUJl C-Z 'i-^K-Pva / /rn N
Uo v ^ l4*-nri fSEWAGE
SYSTEM
INSTALLER
Name,
I
■V i9ji: -JiL^/o-rThis System will be ready for inspection on.
This space for office use only
ft
Date Rec'd Time Rec'Phone Call Rec'd By
•NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
Sq/Ft.^COO GIs.Capacity Sq. Ft.
7 S~<^//arjs~o Ft.Ft.Ft.Distance from nearest well
75'75"Ft.Distance from lake or stream Ft.Ft.
f'C zoDistance from occupied building Ft.Ft.Ft.
/o /o>Distance from property line Ft.Ft.Ft.
J1Distance from bottom to Water Table Ft.Ft.Ft.
AH distances are shortest distance between nearest points I
V .::b y\-Os)"i'i ? a■.j i-'■i
1
^ Rate\.■ TPERCOLATION TEST DATA:Date of First Test 19
Urr^d ■ 77 , <9 7/. ■■Date of Second Test Rate
1st Test Taken By cxn %. 8(5 L<qA %e > s First Test + 2nd Test /j
aRate2nd Test Taken By 1
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.
-3
I understand that I have been granted a sewage system site permit in accordance with
the requirements of the Shoreland Management Ordinance of Otter Tail County. I
understand I must contact my township in order to determine whether or not any addi
tional permits are required by the township for my proposed project.17 Signature ‘I
■jPermission 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;
■is
7iI V/Sor4/ 9-9 f I,--;0_____
Land & Resource Management Office
\7Issued Date;4
.7Jd0923%Fee $Rec #7
\rrir~\Comments::
.7^ Form No MKL 082090 253,056 — Victor Lundeen Co., Printers, Fergus Falls, Minnesota
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INSPECTION RESULTS
Inspector must make all measurements
(,r'mounti S/'^ns^vySEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYActualShould Be Actual Should Be Should BeActual
Capacity ISooGIs.GIs.S F S F S F S F
/go^I
Axj-Joo FDistance from Nearest Well F F F F F
/ZfX)Distance from Lake or Stream F Jo!»-3ooFFF F F
IS
Distance from Occupied Building /OffFFFF F><0 F
y-/dDistance from Property Line F F F F F F
r-Distance from Bottom to Water Table 3 3FFFFF F
Q t'O -^yst<,ws ei ^s4-rry».df
Inspector’s Comments: ____________________
yw y (T^ To^y
Date of lns\ection.V
1’.
Time of Inspecnqn
INTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
F = Linear Feet
Job Title
MKL ' 032085 • Backer Agency
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GRID PLOT ^AN SKETCHING FORM — (Musi Be To Scale)
feet / inchesScalp: Each grid equais
9-/^!
Dated:19
Signature \
Please sketch your lot indicating setbacks from road right-of-way, iake and sideyard for each buiiding currently
on lot and any proposed structures.
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PERCOLATION TEST DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
OWNER:
FIRST TELEPHONE NUMBERLAST NAME MIDDLE
ADDRESS:
CITYSTR./RT.STATE ZIP CODE
SEC.LAKE/RIVER NO.LAKE NAME TWP.RANGE TWP. NAME
LEGAL DESCRIPTION:
PARCEL NUMBER
FIRE NUMBER NUMBER/BEDROOMS
— TWO TESTS ARE REQUIRED —
TEST HOLE NO. 1 TEST HOLE NO. 2/<3
Diameter of Hole ^_________inches^//Z.
C Co
Depth To Bottom of Hole inches;Depth To Bottom of Hole Diameter of Holeinches;inches
Date
Depth. Inches Soil Texture Soil Texture
Date 19
Depth. Inches
0-/h Percolation
Test By _
Firm
Name _____
Percolation
Test By____
Firm
Name ____
/, Co
//- ‘Ao
A/6 ^//P-
Address Address
Otter Tail County
License No.
Otter Tail County
License No.
PERC TEST # 1 PERC TEST # 2
INTERVAL n^ONUTBft W/WATER DROP PERC RATETIME TIME
INTERVAL IKflNllTBS^WATER DEPTH WATER DROP PERC RATEII
"nMA * PROP regC~
START /START./m 71-
TIME INTERVAL IMINUTBSl yOl^DBPTH WATER DROP PERC RATE PERC RAT^TIME INTERVAL rMINUTBS)WATER
: DEPTH
W.
WATER DROP
..IL.
ftREFILL REFILL /Jmv
INTERVAL nbllNUTBS)WATER DEFTH WATER DROP PERC RATETIME TIME INTERVAL (TMINtnESI W^TER DEPTH WATER PROP PERC RATEREFILLREFILL/^2.^ / . *7o
TIME SrOP ff&RC
'jm .1.II.
PERC rath
TIME INTERVAL IX^nNlfTBST WATER I«PTH WATER DROP IT MB INTERVAL (MINinESl >ATER DEPTH WAimPROP PERC RATEREFILL//REFILL I . .4,7
TTMH DROP PERC
Sf * / ^6^
TIME ^ DROP WJZ.u
INTERVAL fMTNUTBS)WATER DEPTH WATER DROP PERC RATETIIME TIKg INTERVAL (MINinESl WATER DEPTH WATER DROP PERC RATEREFILLREFILL
■P •f
*llMM DROP PERC TlMti DROPINTPIVALIMTNVTES)WATER DEPTH WATER DROP PERC RATETIME TIME INTERVAL IMTNtnEST WATER DEPTH WATER PROP PERC RATEREFILLREFILL
TTME” DROP PERC TTRE” CROP" PERC
INTERVAL (MINUTBST PERC RATETIMEWATER DEPTH WATER PROP INTERVAL (MINUTESTTIME WATER DEPTH WATER PROP PERC RATEREFILLREFILL
r
T2SE~ DROP PERC TIME DROP PERCTIMEINTERVAL IMTNUTESI WATER DEPTH WATTODROP PERC RATE TIME INTERVAL (MINUTES)WATER DEPTH WATER PROP PERC RATEREFILLREFILL
r
TIME DROP PERC TIME DROP PERC
COMMENTS/CALCULA TIONS:
MKL — 0390 - 005 250,815 — Vidor Lundeen Co., Printers, Fergus Falls, Minnesota
GRID PLOT PLAN SKETCHING FORM — (Must Be To Scale)
feet / inches 1Scale: Each grid equals
»• m 4-
Dated:19 i
Signature \ 4
Please sketch your lot indicating setbacks from road right-of-way, lake and sideyard for each building currently ^
on lot and any proposed structures. ------------------------------------------
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PERCOLATION TEST DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, MN 56537
OWNER;
FIRST MIDDLE TELEPHONE NUMBERLAST NAME
ADDRESS:
CITY STATE ZIP CODESTR./RT.
SEC.LAKE/RIVER NO.LAKE NAME TWP.RANGE TWP. NAME
LEGAL DESCRIPTION:
PARCEL NUMBER
EIRE NUMBER N UMBER/BEDROOMS
— TWO TESTS ARE REQUIRED —
8'^TEST HOLE NO. 2TEST HOLE NO. 1
oDiameter of Hole ^Depth To Bottom of Hole inches: Diameter of Hole,inches Depth To Bottom of Hole inches:inches
9//t^^ /
_________ 19Date19Depth, Inches Soil Texture DateDepth. Inches Soil TextureC o ZhyJ0-^Percolation
Test By _
Firm
Name ___
/' C <3 L>/g ZlJ Percolation
Test By___
Firm
Name ___
Szfz^r?
Address Address
Otter Tail County
License No.Otter Tail County
License No.
PERC TEST # 1 PERC TEST # 2
PrrenVALfMIWllTBtt w/ATgR PePTH WATER I»OPTIME PERC RATE TIME INTERVAL fMPIUTES)WATER DEPTH35"
WATER OP
PERC RATESTART/START
-—7/
PnERVAL<MlNl/TES>
REFILL
WATER DROPTIMEWATTOPgmi PERC RATE TIME INTBtVAL Q»flNinESI
m.
WATER DROP PERC RATEREFILL/L
INTERVAL (MINUTES)
izm:.
WATER DROP PERC RATETIME TIME INTERVAL IMINirrSSl DEPTH WATER DROP PERC RATE/5-5; ) ..92^
TIMB DROP PERC
REFILL REFILL /. .ys'TIME bROP P6rc
.1
INTERVAL (Mpurrea WiOER DEPTH WATER DROP PERC RATETIME TIME INTERVAL fMINlJTHSl WATER DR«»PERC RATEREFILLi3 . / .
TTME ^ bROP PBB.C
REFILL /93,7-TKCff’ DROP
INTERVAL (MINUTERTIME WATER DEPTH WAIERDROP PERC RATE TIME INTERVAL (MINirtBR WATER DEPTH WATER DROP PERC RATSREFILLREFILL
T
'IIMM' bROP PERC '/TMM' bkop PERC
INTERVAL (MINUTER WATER DEPTH WATER INIOP PERC RATETIME TIME INTERVAL (MINUTES)water DEPTH WATER DROP PERC RATS
REFILL REFILL
DROP PERC *nMJ£i DROP PBRC
INTERVAL (MINUTER WATER 1>EPTH PERC RATETIMEWATTODROP TIME INTERVAL (MINUTER WATER DEPTH WATER MtOP PERC RATSREFILLREFILL
4 4-'flMU DROP PERC 1'IkU^ DROP PERC
INTERVAL (MINUTERTIME WATER DEPTH WATER DROP PERC RATE TIME
INTERVAL (MINUTER WATER DEPTH WAIERDROP PERC RATEREFILLREFILL
^DROP *PERCTIME TIME * DROP PERC
COMMENTS/CALCULA TIONS:
MKL — 0390 - 005 250,815 — Victor Lundeen Co., Printers, Fergus Falls, Minnesota
A\
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
Yeiiow — Inspector
Pink — Owner
'p^e.lc
Permit No.LEGAL
so e IDESCRIPTION Parcel Number
AND
C-i ' I <l Y d Pz.
He
LOCATION
Lake Classif.Lake No.Lake Name Sec.TWP TWP Nameange
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Zip No.Tel. No.First InitialLast Name
So -y( CSsVv//' M .->0 -J I >V-iOWNER
<s/ ] 1 YY) f\liL! 6V 14' rv 'zi ^ rg kc'4“SEWAGE
SYSTEM
INSTALLER
Name.7
This System will be ready for inspection on.19.
This space for office use only
.19 M
Date Rec'd Time Rac'd Phone Call Rec'd By
IS- ■NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
/ Sq. Ft.GIs.Capacity Ft.
Ft.Ft.Ft.Distance from nearest well
75*7:5'Ft.Distance from lake or stream Ft.Ft.
Ft.Distance from occupied building Ft.Ft.
/O foDistance from property line Ft.Ft.Ft.
3.Ft.Distance from bottom to Water Table Ft.Ft.
AH distances are shortest distance between nearest points
PERCOLATION TEST DATA:Date of First Test 19
. 19.....*^./....
Rate
Irt Test^ Taken By
It mci < t sKe'*
Date of Second Test Rate
■ &D3K.S-..ZL^..&First Test + 2nd Test
2nd Test Taken By Rate
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.
I understand that I have been granted a sewage system site permit in accordance with
the requirements of the Shoreland Management Ordinance of Otter Tail County. I
understand I must contact my township in order to determine whether or not any addi
tional permits are required by the township for my proposed project.
//'3
Signature
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE: Permit void if work is not commenced within six (6) months.
Land & Hesource Management Office
Issued Date:
9'?3>
<• v/.S rtrs
Fee $
Comments:
Rec #
Form No. MKL 082090 253,056 — Victor LunOeen Co., Printers. Fergus Falls, Minnesota
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V
^ ‘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
I
While — Office
Yeilow — Inspector
Pink — Owner I t-
l\1. i
r.Permit No.I JLEGAL . .J
^6 -0O6S-0/'?Of^lcffDESCRIPTIONr Parcel NumberrIAND
^7^ I ’/"/•'> r q ( (!3Z^ 39 //LOCATION
Lake Classif.Lake No.Lake Name TWP NameSec.TWP Range
I IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Zip No.Tel. No.Last Name First InitialI e**- -2. Rr/v LO
q / o 1 ( pn -r^
tJOWNER'f
\!L-j o'y J! )-l<L y^cf ^ ^^UiA~TSEWAGE
SYSTEM
I INSTALLER
Name.;
••;
■J
' J'This System will be ready for inspection on.19__
This space for office use bnly ,3
ri/Q~ \
Date Rec'd Time Rec'd Phone Call Rec'd By J Jp«5fNUMBER OF BEDROOMS; ^3ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
V SIS'..../ arK:? Gis.Capacity Ft.jSq. Ft.\
\^o/r<xQFt., Ft.Ft.;Distance from nearest well 1i\75^Distance from Take or str^m ''-^..■+-•7:rFt.Ft. Ft.L T \fo 20Distance from occupied building Ft.Ft.Ft./
7 /G/ODistance from property line ~Ft.Ft.Ft.
Distance from bottom to Water Table
N
7Ft. ^Ft. Ft.
AH distances are shortest distance between nearest points A
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1/t; 'i >r V \9//x 'i
s8sPERCOLATION TEST DATA:Date of First Je^ ....
Date of Second Test
i, 19 ..ILA-tyX-r .
1st Test^aken By JfXT>\
. tell ■1^7Rate
v-:
First Te?t....
■3=....24Rate
+ 2nd Test .<22nd 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.
’
\ understand that I have been granted a sewage system site permit in accordance with ^ /f } yt »
tional permits are required by the township tor my proposed project. <7^Sigftatdre' ' —'
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. 3
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.
I iV--i
IPermit;
Managemet^0Issued Date:
Land & Resource Managem Office
Fee $Rec #
.1Comments:
^ ■'Form No. MKL 062090 253,056 — Victor Lundeen Co.. Printers. Fergus Falls, Minnesota
*: -m-' ^ ■ - ..v . ,i ft ap..v.. j.... s ...w
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Of b-<^l<»w al4\jf^'\^ •,r HiCj' i-0 fZ, lo^
• V7^Y*-y
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'•s'INSPECTION RESULTS
) .'■
Inspector must make all measurements i
(j, wVw
SEWAGE DISPOSAL SYSTEM STATISTICS
l0*-y<^O t»QufvO
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYActualShould Be Actual Should Be Actual Should Be
Capacity p r«- jX )2SQ S FGIs.GIs.SF SF S F
rs'Distance from Nearest Well /oo F F F F F F
f+Distance from Lake or Stream Zoo 200FFFF F F
r37Distance from Occupied Building F F F F F F
73'/oDistance from Property Line F F F F F F
Distance from Bottom to Water Table 3 3FFFFF F
4*L-loy'Jl W sLo"f Si■r \VWA
OCO Sy«-l-*.yv> d tc
Inspector’s Comments: _______
rnOUiyJ Sys^e^
<n-^ “HrwC O-A
(a<(r*y=
loo^
zi
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Z/'v
yo- ff -Date of Inspection 19
3\<4^V •Time of Inspection M
Signature of lri^)ectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
F = Linear Feet
Job Title
MKL • 032085 • Backer Agency
<a 4- 4-v^Lf'' pe.r P< p r ^ trt
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UHIU KLUI PLAN I UHINU PUHM — (MUSt UO lO iiCalB}
feet/inches 1 ! ' , ! M >
i
iScale: Esch grid equsis
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^ ^ •—19 Q/.,4^Dated:
Please sketch your lot Indicating setbacks from road right-of-way, lake and ald^yard
on lot and any proposed structures. : I! i I
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!I - ><CERTIFICATE OF COMPLIANCE■1 -SSEWAGE SYSTEM
Ei FOR MOBILE HOME PERMIT ^ 5953
!?^.|(i £ji
7 2Th Janu(VU'’19 S4This certificate has been issued this day of_!m/AI :^3Jto certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.V
SfitiySpi i
3i
The premises covered by this certificate are legally described as:m«I
m:NfdaAOi,132 Range 39Sec___d Twp.Twp. \zme.Lake No.
■;
1Pt. o{i GL S, Oak PoAk ReLOAt
mMII
1i Lpp EpckmanMtlAOwner: Name.h m1
(-1 RJt., 2, Box bb. C£Uzt.h.PAaLZ. Mfnnej>ota.Address.i
-M■j Zip No 56524'I
n 'MfIElPermit No. SP_Fid?
m]Signed by:.
Malcolm K. Lee, SL-areland Administrator
Otter Tail Counts. >[innesotaJ;T
mmMKL-0871-009
k
«fe wIV .V-'/I >Szt*rfmLL
I
159035
^ f s J
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
Ye//ow — Inspector
Pink — Owner
Card — Owner
S'/s' o_Permit No.,
LEGAL
DESCRIPTION
AND
65 - ^ D _Ce 39LOCATION
Lake Classif.TWP NameSec.TWP RangeLake' Name. Lake No. .
IDENTIFICATION: Please Print All Information.
Zip No.Tel. No.Mailling Address —No. Street, City and StateFirstInitialLast Name
ySoAT' (oj2.OWNER
SEWAGE
SYSTEM
INSTALLER
TlA1Name.
This System will be ready for inspection on., 19.
;This space for office use only
19
Owner or Agent SignatureDate Rec'd Time Rec'd Phone Call Rec'd By
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PITSEPTIC TANK DRAIN FIELD
MA 6/)^ Sq.Ft.GIs.Sq. F/.Capacity
Ft.Ft. Ft.Distance from nearest well
Ft.Ft.Ft.Distance from lake or stream
6^1 Ft.Ft. Ft.Distance from occupied building
/5>Ft.Distance from property line Ft.Ft.
Ft. Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
RECORD OF TESTS:
, TimeInspection was made on 19 M By
.1^..r;.Z<s2Lrrr:r^ 19 IPERCOLATION TEST DATA:Date of First Test Rate
/Date of Second Test 19 , Rate
By1st Test Ta
/I IFirst Test -I- 2nd Test 2 Rate :2nd 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.)
Signature-isDated
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE: Permit void if work is not commenced within six (6) months.
Issued Date:
Shoreland Management Office
/O ■Fee $
Comments:.
Form No. MKL 0771-003 [Review baiue lake, Minnesota
♦ .•r ■.. ■'T' ^'''""
V
4
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYActualShould be Actual Should be Actual Should be
Capacity GIs.GIs.s F S F S F S F
Distance from Nearest Well 75 50FFFFF F
Distance from Lake or Stream F F F F F F
Distance from Occupied Building 2010 20FFFF F F
Distance from Property Line 10 10 10FFFFF F
Distance from Bottom to Water Table 33FFFFF F
Inspector's Comments:
Date of Inspection 19___
Time of Inspection M
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs * Gallons
SF “ Square Feet
F • Linear Feet
:
Job Title
Agency
M KL-0771-003> Backer
r ■>>
;>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
wh«»-omc*
Y«ffow — Inspector
Pink — Owner
Cord — Owner
/Permit No..
LEGAL
DESCRIPTION
AND
LOCATION
TWP NameTWPRangeSec.Lake Classif.Lake NameLake No.
IDENTIFICATION: Please Print All Information.
Tel. No.Zip No,Mailling Address —No. Street, City and StateInitialFirstLast Name
OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
/ '00 p/>919This System will be ready for inspection on.
This space for office use only
19
Owner or Agent SignaturePhone Call Rec'd ByDate Rec'd Time Rec'd
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PIT DRAIN FIELDSEPTIC TANK
Sq. Ft.Sq. Ft.GIs.Capacity
Ft. Ft.Ft.Distance from nearest well
Ft.Ft. Ft.Distance from lake or stream
Ft.Ft. Ft.Distance from occupied building
Ft.Ft. Ft.Distance from property line
Ft.Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
RECORD OF TESTS:
19., Time M ByInspection was made on
Date of First Test 19 RatePERCOLATION TEST DATA:
, RateDate of Second Test 19
1st Test Taken By
+ 2nd TestFirst Test Rate
2nd 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
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon expressPermit:
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE: Permit void if work is not commenced within six (6) months.
Issued Date:
Shoreland Management Office
Fee $
sUe§'CERTIMC aTl i 3
Comments:.
Form No. MKL-0771-003 @CVIEW lAint LAKI. MiMNISOTA
4
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORY
Actual Should be Actual Should be Actual Should be
> SSO ^oo\Oa>Capacity GIs.GIs.S F S F S F
FDistance from Nearest Well 75 50FFFF F
7^OS 2£fDistance from Lake or Stream F F F F F
w pDistance from Occupied Building 010 20FFF F
IZ> FDistance from Property Line 10 1 10FFFF F
3Distance from Bottom to Water Table 33FFF,F F F
Inspector’s Comments;
4- nog XZif
' XJ2>‘C2o-n^
L "oi<^,1-*- I
-fi /
A.
^ r-
V“ 2S ,19_S^Date of Inspection,
//:j^MTime of Inspection.
-cj/r
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs ~ Gallons
SF “ Square Feet
F “ Linear Feet
Job Title
AgencyMKL-0771-003-Backer
o.
PERCOLA TION TEST DA TA
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537 Ph. No.
Owner:Mailing Address:
/?/: a.St. & No.Last Name First Zip Nc/.Middle City State
Desnriptinn; ~ ^__________
LAKE OR RIVER NO.
r/i!L.J/XJiA O' j''r.Oc>tS^
NAME TWP.RANGE TWP NAME
Sc--e/o-^i~ -^(OO
TEST HOLE NO. 2TEST HOLE NO. 1
6>1H_Depth to Bottom of Hole.inches; Diameter of Hole.Depth To Bottom of Hole.Jnchesinches; Diameter of Hole inches
Depth, Inches Soil Texture Date /Ay.-"' y': / ^19^Depth, Inches Soil Texture 19 %3.Date
.5^/1 J,r> - ;?/>o -Percolation
Test By____
Percolation
Test Bv .aLUFirm
Name.^j-y.-rr'u
y A' y</ I r
cc FirmName.s_3 //oLU
o:
LUAddress.OC Address
<
^ '1^CO
Otter Tail County License No..Otter Tail County License No..H
coLU
Drop In Water
Levi. iTtches
Measurement,
Inches Drop In Water
Level. Inclias
Measurement,
Inches
HTimeRemarks Time Remarks
O/c ^J^;//
i/j //
■-/>/
0 6
a: y o ¥y //^/////o ■p4 /
Z±—4^/ 2r.
d' .^r)
4/.' 2. /
a: .2!
A
/--////f ’-AJ /
/j: ? O /)''u: ?/7
“T
wfk/ /’ d
IfdP
/}zi t ■f4A
183818 ®MKL-0871-028
wtCT«8 LuaBCCa 4 ed •m
See Booklet/'How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn.
/ST7
SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 - Fergus Falls, Mn. 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
W ;te — Offi»a • • «
V low
Pii.. -
Card -
— InspactorOwnerOwner
/?C Permit No..LEGAL
Date
DESCRIPTION
AND
4 MU33-LOCATION
TWP NameLake No.Lake Name Lake Classif.Sec.RangeTWP
IDENTIFICATION: Please Print All Information.
Mailling Address —No. Street, City and State Zip No.Tel. No.Last Name First Initial
11to f~- I 1 ^ 1/OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
Th/s System will be ready for inspection on., 19.
This space for office use oniy
.19 .M
Date Rac'd Time Rac'd Phone Call Rac'd By Owner or Agent Signature
/~/o /rl i rtf i F BEDROOMS:ESTIMATED COST:
3SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
GIs.'q. Ft.Capacity »q. Ft.
Ft.Ft.Ft.Distance from nearest well S-Q
Ft.Distance from lake or stream Ft.Ft.Z5Z
Ft.Distance from occupied building Ft.Ft.
Distance from property line Ft.Ft.Ft./ n 7Ft. Ft.Distance from bottom to Water Table Ft.
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on ,, 19 , Time .JVI B
PERCOLATION TEST DATA:Date of First Test 19 > Rate
Date of Second Ti 19 , Rate
1ft Test Taken By
First Test -I- 2nd Test ■2'Rate2nd Test Taken ry
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 re ifor inspection. (Call or use attached mailer notice.)
/ASignatim
Dated
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE: Permit void if work is not commenced within six (6) months.
Shoreland Management Office C/
Issued Date:
.4=0
Fee Surcharge $
(Comments:.
Form No. MKL-0771-003 vicTa* LuaDCtN • ca . eiuiTtaa. rtaaus r*LLt •■■■ 158906
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
W :te — Officp V low — InspectoiT Pii..
Card
Owner
Owner
Permit No..LEGAL
Date
DESCRIPTION
AND
LOCATION
Lake Classif.Sec.TWP NameLake No.Lake Name TWP Range
IDENTIFICATION; Please Print All Information.
Zip No.Tel. No.First Initial Mailling Address —No. Street, City and StateLast Name
OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for inspection on., 19.
This space for office use only
.19 .M
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
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.
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19 , Time .JVI By
PERCOLATION TEST DATA:Date of First Test ,, 19 , Rate
Date of Second Test 19 , Rate
1st Test Taken By
First Test -I- 2nd Test
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:
Shoreland Management Office
Fee $Surcharge $
nIOT called FOR INSPECT
Comments:.
Form No. MKL-0771-003 VICTOI LUNfiCCN k CO.. MlNUai. rkCLt. hihm.158906
.4•*
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
t
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY
Should 4>eActualShould be Actual Should be Actual
Capacity GIs.GIs.s F s F S F SF
Distance from Nearest Well F 75FF F F F
Distance from Lake or Stream F F F F F F
Distance from Occupied Building 10 2020FFFFF F
Distance from Property Line 10 10 10FF F F F F
Distance from Bottom to Water Table 4 4FF F F F F
Inspector's Comments:
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
V
i •
FIELD NOTES
£/t<lLL /i - 9/DATELAKE NAME
LAKE NO.FIRE NO. ^
LEGAL DBSCRIPTON OF LOT:
^//-OnD-^(o~ oo^)i-6\7
Oo3i PolJ( /C.OL>cAji^
'Ti/ljbtu' ^ Etnx-^‘ v:p(s
6-/3a-3^PARCEL NO.
^I y lA y 3v\j^/!, i^ c-<^^ 'TpuyiM-^ £,<SuA/-K^"S^Sry\ f
or^
OWNERS NAME »vv»iz-a—
OWNERS ADDRESS
/// //: f I :/ / [fJ/3 & o;? />t
TYPE OF SEWAGE SYSTEM (INSPECTOR'S COMMENTS):
SEPARATION DISTANCES (IN FEET):
SEPTIC TANK ISOIL DISPOSAL AREA
WELL
LAKE
LOT LINE
OCCUPIED BUILDING
ELEVATION OF THE AREA
REASON SYSTEM WAS ABATED:CT^\) a£JL V "tcXylA<^ i
clUL 'V lAJiy^^yx^
3) aXL y-< Iso' UJ'ei£
X) i ^ O 9~C
QJL^■P'
5)
SKETCH OF LOT/ON BACK
L
4^qo
■N\/
-\■ A-\
-h
/s?'^7\
<-0^\1 OS''c4
^ O A /K/ «r
x:3*
& ^ I hcjU
oyioo^\___
0 Oi/^4^^03^i/~
p
/o'
FIELD NOTES
DATELAKE NAME
* ^ 3 -^tcLrt-n^FIRE NOLAKE NO.
LEGAL DESCRIPTON OF LOT:
^J-QOd ' 0^- dOS? - 0/7PARCEL NO.^-f5X-3^
RjoA>cnpt~ JC, OG ^cyuiyj_
<h &riA^tds
/-/, j MX S^>lra^ £,
A?
OWNERS NAME OA*UyV
OWNERS ADDRESS
TYPE OF SEWAGE SYSTEM (INSPECTOR'S OOMMBNTS):
^0’^ Q- ^ ^ /~o i ”
/ ^^^ S ^ tk^/< <Lo^ ^ A*tT*l^...£g.<7^^
l>-c£^Mj-t yvi^Mr tie^<s
r
ti 6*e
SEPARATION DISTANCES (IN FEET):
SEPTIC TANK SOIL DISPOSAL AREA
(y33<A.S J<c /50 sijxa^ISO^
oM. tnrt/^ !
WELL
LAKE
LOT LINE A/a
OtiX >^44. i O
Jj^ iL^. C '
OCCUPIED BUILDING
ELEVATION OF THE AREA
REASON SYSTEM WAS ABATED:
l) oXL ibuytk^ .^JJL^cJ^ SbuiAf tiiti,
2^ oJX lA/ttG^wJiMi^ t^^ks U/rx^^
aJlM 'tiXyVtk^
/-/ (S C> Xo 6<ACiC^
/O^
SKETCH OF LOT/ON BACK
i/\^-u^f»
\^o
;frcUUM^
Ljd\
&IsUA
C)-f^lOL^
£S ^
■/\
cJ^Joo'Cdi^'y,
s
I
{?-%l/<^d\
7
fir^Qjjft^\JU^
Sltxtk
■j-i>^l<
Saf-I- 3cr^l>1J
^5"
iSf^
e^'
/
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