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HomeMy WebLinkAboutPeterson Pelican Lake HOL_17000991130000_Septic System Permits_g-W) DISTRICT COURT SEVENTH JUDICIAL DISTRICT COURT FILE NO.: 733. PROSECUTOR FILE NO.: 17M-59E FILED mar - 6 2017 offlffiswaSTATE OF MINNESOTA COUNTY OF OTTER TAIL ppf'A \%'''rxb\i State of Minnesota, Plaintiff, COMPLAINT- SUMMONSV. Peterson Pelican Lake Hoi LLC 2544 32nd Street S Fargo, ND 58103 Defendant The Complainant, being duly sworn, makes complaint to the above-named Court and states that there is probable cause to believe that the Defendant committed the following offense(s): Failure to Comply With Abatement Notice 0TCSM042.; 56.0060(4) (♦•♦No MOC Code assigned**^) (♦♦♦No ICR Code assigned^^*) 0-90 days and/or $ 1,000 fine Count: I In Violation of; MCX:: ICR: Penalty: On or about 2/17/2017, within the Coun^ of Otter Tail, one Peterson Pelican Lake Hoi LLC, the defendant, did fail to upgrade, replace, or properly abandon within the time period established by the Office of Land and Resource Maiuigement, the non-compliant sewage system on the property. RECEIVED MAK li s 2017 LAND&RESOUeCE t ■* PAGE 2 STATEMENT OF PROBABLE CAUSE Complainant is a duly acting and appointed law enforcement officer with the County of Otter Tail, Minnesota, who received information regarding the below-described offense. On November 14,2013, Stoll Inspections visited the property located at 23451 Fish Lake Lane, Dunn Township, Otter Tail County, for the purposes of a sewage system inspection. The property failed that inspection. On December 6,2013, Scott Ellingson with the Otter Tail County Land and Resource Management Office sent the then property owner. Bell State Bank and Trust, a non-compliance letter citing the foiled inspection with instructions to contact the Land and Resource Management OfHce by January 6,2014. No action was taken. On April 5,2016, Alex Kvidt with the Land and Resource Management Office sent the property’s current owner, PETERSON PELICAN LAKE HOL LLC, DEFENDANT herein, a non-compliance letter citing the failed inspection with instructions to contact the Land and Resource Management Office by May 5,2016. No action was taken. On January 9,2017, Mr. Kvidt sent the DEFENDANT a certified letter containing a sewage system abatement notice instructing the DEFENDANT the property must be fixed by February IS, 2017. That letter was signed and returned to the Land and Resource Office by Hillary Preson. No action was taken. PLEASE TAKE NOTICE; Pursuant to Minn. Stat. 609.49., intentional failure to appear for duly scheduled court appearances may result in additional criminal charges, and in addition to any arrest warrant that may otherwise be issued by the Court. PAGE 3 Complainant requests that Defendant, subject to bail or conditions of release, be: (1) Arrested or other lawful steps be taken to obtain Defendant's appearance in court; or (2) Detained, if already in custody, pending further proceedings; and that said Defendant otherwise be dealt with according to law. COMPLAINANT'S NAML:COMPLAINANT'S SIGNATURE; Subscribed and sworn to before the undersigned this «^? day of ,2017. AMY JO BUSkO i: Notary Publlc-MInnesota Coinmlsdcin Expiras Jan 31, a020; i' SIGNATURE:NAME/TITLE: /\aA^ c. 0 Being authorized to prosecute the offenses charged, I approve this complaint. PROSECUTING ATTORNEY’S SIGNATURE; Jacob James Thomason 0395701 Assistant County Attorney 121 W. Junius Fergus Falls, MN 56537 (218) 998-8417 ^ inDate: PASE4 Court File Number: nNDlNG OF PROBABLE CAUSE From the above sworn facts, and any supporting affidavits or supplemental sworn te^mony, 1, the Issuing Officer, have determined that probable cause exists to support, subject to bail or conditions of release where applicable. Defendant's arrest or other lawful steps to be taken to obtain Defendant's appearance in court, or Defendant's detention, if already in custody, pending further (Hoceedings. Defendant is therefore charged with the above>stated ofFense(s). X SUMMONS THEREFORE, YOU THE ABOVE-NAMED DEFENDANT, ARE HEREBY SUMMONED to appear on the / day of l^vri 1 20 H at ^'/’S before the above-named court at 121 West Junius Fergus Fall^VdN to answer this complaint __WARRANT To the Sheriff of the above-named county; or other person authorized to execute this warrant I hereby order, in die name of the State of Minnesota, that the above-nam^ Defendant be apprehended and arrested without delay and brought promptly before the above-named court (if in session), and if not, before a Judge or Judicial Officer of such court without unnecessary delay, and in any event not later thu 36 hours after the arrest or as soon as such Judge or Judicial Officer is available to be deah widi according to law. Exteute in Border StatesExecute Nationwide___Execute In MNOnty __ORDER OF DETENTION Since the above-named Defendant is already in custody, I hereby order, subject to bail or conditions of release, that the above-named Defendant continue to be detained pending further proceedings. Bail: Conditions of Release: sworn to, te issued by the undersigned Judicial Officer thisThis coinpiaint, duly subscribed and.20 Lrf SIGNATURE:JUDICIAL OFFICER: .. ^ _______i23d:NAME: TITLE; Sworn testimony has been given before the Judicial Officer by the following witnesses: Clerk's Signature or File Stanq>:COUNTY OF OTTER TAIL STATE OF MINNESOTA State of Minnesota Plaintiff,REnms OF SERVICE thereby Certify and Return that Ihaveeerveda copy Summons upon the Dsfendant(s) herein-named Signature cf Authorised San/iee Agent: VS. Peterson Pelican Lake Hoi LLC Defendant. i •i PAGE 5 DEFENDANT FACT SBQSET cither i)OBs: Race/Ethnidty: CD): ' Alias Information:: Fingerprinted: Handgun Permit: Location ofVioiation: Driver’s license #: Accident Type:’ •:License Plate BAC Status: BAG Level: I •V .i I r. I PAGE 6 V Statute and Offense Grid ■'V-; Coant: 1 MOC GOC RptCtrlAgnqp RptCtrltflLeveJStatute #/Dcter aad SapCt Statute Type OfTensc Date 2/I7/20I7 ore SMO 4:2.; 56.0060 (4)* MistL Failure (0 Comply With Abatement Notice NoneI Ordinance e* i i_ OTTER TAIL COUNTY LAND & RESOURCE MANAGEMENT PUBUC WORKS DIVISION W/WV.CO.OTTER-TAJL MN.US9TTCRTft;i GOVERNMENT SERVICES CENTER 540 WEST FIR AVENUE FERGUS FALLS, MN 56537 218-998-8095 FAX: 218-998-8112 7/21/2017 Peterson Pelican Lake Hoi Lie 2544 32nd St S Fargo ND 58103 7846 RE: Primary Owner: Peterson Pelican Lake Hoi Lie Sewage Treatment System Servicing Tax Parcel Number: 17000991130000 Described as:Sec 17 Twp Dunn Township Sect-17 Twp-137 Range-042 INWOOD BEACH 3RD ADDN RES BLK2 #1130 1119 & Lake: 56-768 Fish As of 07/20/2017 the holding tank (Sewage Treatment Installation Permit # 24761 servicing your property was determined to be in compliance with the provisions of the Sanitation Code of Otter Tail County. Please be advised that this certification is only valid for five years from the date of this mailing 7/20/2022. If you have any questions regarding this matter, please contact our office. Sincerely, Alexander Kvidt Inspector I APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM LAND & RESOURCE MANAGEMENT GOVERNMENT SERVICES CENTER, 540 WEST FIR, FERGUS FALLS, MN^537 218-998-8095 www.co.otter-tail.mn.use 1 • -a ►t 7^:)o-/9 OTTER Tflll WHITE - Office YELLOW -L&R Inspector PINK - owner / Contractor (after issue)couATT-aiinffOTa !APPLICATION MUST BE COMPLETED IN ORDER TO BE PROCESSED iPermit No.i LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER CLASS SECTION TWP NO.RANGE TWP NAME nh T . V'-^ L rc i:.-uno .<PARCEL NUMBER (S) OF PROPERTY BEING SERVICED E-911 ADDRESS OR DIRECTIONS FROM NEAREST PUBLIC ROAD .9.?. Mil • \ i -oco - I -1 o' coo LEGAL DESCRIPTION T:» n iL cx: \ c. 'r>, Re-C. Pa V«L' ^ > I It I Q H 9' 5r:>. - or.xv :^r c\i^c\r\n I c? be PcTrv> Lix rl Last Name First Initial Mailing Address Daytime Phone No. Pe te V '■: r- (\ Pp, [ u' n r\ t a \ t aCMR oV. R fa vacProperty Owner Ocel3S::Htl Lie,.7C I-3(r/-- 3 tCOI-fC\y (xTi' lotr \ V t V \ r aoc_______ ' \-9lfu-g ( U !-UaM', k luot-y i?rif.!ir\C i TiV 'i Contractor Lie.# i; 9 THIS SPACE FOR OFFICE USE ONLY n\2o 7s:kn t'2-.Sb rtii► This System will be ready for inspection on , the year of I'Z'SD-1120)A.M Date Received Time Received L&R Official TYPE OF NSTALLATION (circle one)SEWAGE TREATMENT SYSTEM DESIGN DATA AS SHOWN ON DRAWINGResidential (A) New . (B) Replacement (C) Add on Collector Other Est. (D) New (E) Replacement (F) Add on (G) New (H) Replacement (I) Add on Soil Treatment Area Tank LiftDesign Flow (Gallons/Day) (J) 0 0<) 1 — 2,499 (L) 2,500 — 4,999 (M) 5,000 — 10,000 Effluent Distribution ( ) Gravity ( ) Pressure \GIs GIs Ft.Size Setback To Nearest WellType I Type II Ft.Ft.Ft.1 (20) Trench, Rock (27) Rapidly Permeable T GR Ft.Setback To OHWL Ft.Ft.(21) Trench, Gravelless (28) Flood Plain \5^ (22) Trench, Chamber (29) Privies t-J Ft.Ft.Ft.Setback To Bluff(23) Bed (30) Flolding Tank (Contract Required)T(24) Mound ^ Ft.Ft. Ft.Setback To Dwelling \\I (25) At Grade Type III 4 Setback To Non-Dwelling h-(26) Greywater (31) Other/Problem Soils/<12" Soil Ft.Ft.tOG Type IV(34) Tank Only Setback To Nearest Lot Line ft-Ft.R.i’,X)l(32) Public Domain & Proprietary Technologies(35) Other Setback To Road Right-Of-Way IDepth of Well Ft.Ft.Type V i 4-Total # Bedrooms (33) Performance uElevation Above Restrictive Layer Ft-,FAFt.Abatement Y / N Garbage Disposal Y / N PERC TEST DATA k)V3License # ' -'Designer Agreement: The undersigned hereby makes application for permit to install, alter, repair or extend Sewage Treatment System herein specified, agreeing to do all such work in strict accor­ dance with Sanitation Code of Otter Tail County, Minnesota. Applicant agrees that the Site Data Worksheet submitted herewith and which is approved by a Land & Resource Management Official shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and approved for use. It shall be the responsibility of the applicant for the permit to notify Land & Resource Management that the installation is ready for inspection. Date of Test Highest Ratets. ■i Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express condition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the Sanitation Code of Otter Tail County, Minnesota. This permit may be revoked at any time upon violation of the Sanitation Code, NOTE: I.This permit is valid for a period of six (6) months. 2.This permit does not Include the building sewer (sewer line). C)L)I1 15 -■Date:Permit Fee $ S/gnature of Property Owrier/A^nt for Owner ^ n- nn no.G ^'1 -90UA' ■IDate:Rec.V,: Land S Resource Managemen^Cfficial IComments: ! i i Form No. BK — 04-2014-06 . 357,243 • Victor Lundeen Co., Printers • Fergus Falls. Minnesota 1 SEWAGE TREATMENT SYSTEM PERMIT INSPECTION RESULTS STA (Soil Treatimnt Ana) OUTHOUSE TRENCH REDUCTIONHOLDING SEPTIC TANK LIFT TANKCATEGORY I1U0C>Rock trenches^inchesCapacityFT2GLS.GLS. 19)^ ft of sidewall for %FT FTSetback from Nearest Well ufltl6nTeqi^lent to tt“redSetback from Burled Water Suction Pipe FT FT Setback from Buried Pipe Distributing Water Under Pressure ITA CALCULATION fS«/ Treatment Area^mi FT FT FT Setback from OHWL (lake &/or river)FT FT Ft.Ft; Setback from Bluff FT FT FT 1^'Setback from Dwelling FT FT FT MOUND / AT-GRADE 55"' FT ypCK BEDSetback from Non-Dwelling FT FT |006 - FTSetback from Nearest Property Line FT FT Ft. P-o’-Setback from Right-of-Way FT FT FT Ft* TElevation above Restrictive Layer FT FT FT SAtiDJN=MeaN©^=^=.FtINSTALLERS COMMENTS SEPTIC TANK(s)Holding Tank / Lift Alarm IpYES □ NO # Tanks InstaliedYES □ NOOld System Pumped & Destroyed Weep-Heles^ _ Manuf.Lateral Pipe SizeNumber of Laterals #IN f(f6Q LrModel #Perforation Spacing IN FILTERS □ YESGallons Per MinutePUMPS Feel olW-fInspector's Comments: Sketch: 7-jw? Time As of was found to be compliant with the provisions of the Sanitation Code of Otter Tail County. the above described sewage system installation Date Initial / L & R Official 4ti Land & Resource Management Official Form No. BK — 04-2014-06 357,243 • Victor Lurt<}t«n Co.. Prirttort • Fergus Falls, Minnesota OTTER TAIL COUNTY LAND & RESOURCE MANAGEMENT PUBLIC WORKS DIVISION WAW.CO.OTTER-TAIL MN.USQTreRTflJt GOVERNMENT SERVICES CENTER 540 WEST FIR AVENUE FERGUS FALLS, MN 56537 *• 218-998-8095 FAX. 218-998-8112 2/15/2017 Peterson Pelican Lake Hoi Lie 2544 32nd St S Fargo ND 58103 7846 RE: PIN: 17000991130000 Described as:Sec 17 Sect-17 Twp-137 Range-042 INWOOD BEACH 3RD ADDN RES BLK2 #1130 1119 & Twp Dunn Township Lake: 56-768 Fish You are hereby notified that you have violated the Shoreland Management Ordinance of Otter Tail County, Minnesota pursuant to MINN. STATUTES CHART. 394 AND SEC. 103F.201 THROUGH 103F.221. The nature of the violation is as follows: OTC SMO 56.0060 Subp 4 Failure to comply with an abatement notice. This violation referred to the Otter Tail County Attorney’s Office for legal action. Alexander Kvidt Land & Resource Management Official '■'ID > STATE OF MINNESOTA ) )ss. AFFIDAVIT OF SERVICE BY MAIL COUNTY OF OTTER TAIL) Alexander Kvidt Minnesota, being duly sworn, says that on the 2/17/2017 she/he served the annexed; of the City of Fergus Falls, County of Otter Tail, in the State of VIOLATION On the following person(s), by mailing a copy thereof, enclosed in an envelope, postage prepaid, and by depositing same in the post office at Fergus Falls, Minnesota, directed to said person(s) at the following address: Peterson Pelican Lake Flol Lie 2544 32nd St S Fargo ND 58103 7846 Alexander Kvidt Land & Resource Management Official Subscribed and sworn to before me this February 17, 2017 kNotary/’ublic My Commission expires 1/31/2020 AMY JO BUSKO Publlc-Minnesota ! '' Expire* Jan 31, 2020Vi«^/VVVVVvvnpVvv»vvwvvvvvvwww'i V Wuiivh.U 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 12/06/2013 Bell State Bank & Tst 51 Broadway Fargo ND 58102 4991 RE: Primary Owner Bell State Bank & Tst Result of Onsite Sewage System Inspection, Non-Compliant Parcel(s) 17000991130000 Lake Name Fish Lake No 56-768 Class GD Dear Bell State Bank & Tst: As part of Otter Tail County’s ongoing Sewage System Inspection Program, our Office inspected your sewer system located at 23451 FISH LAKE LN on 11/14/2013 At that time, we found your sewage system to be non-compliant for the following reason(s): Failed compliance inspection Please contact our Office by 01/06/2014, at 218-998-8095, so that this matter can hopefully be resolved. Sincerely, Scott Ellingson Inspector Department of LAND AND RESOURCE MANAGEMENT OTTER TAIL COUNTY Govcrnmcnt Services Center - 540 West Fir Fergus Facls. MN 56537 PH: 218-998-6005 Otter Ta*. County's Website: www.co.otter-tail.mn.us RECEIVED JUN 1 6 2015 LAND & RESOmCE OTTCRTnil 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: pOUD9*?/1 Z^OoO -f HooP I^0l'l7£vo Township: L>uv>n_______________ Property Owner Name(s): Property Address: PtlIx LtJ ^tkce^ fftti Reason for Inspection: Number of Bedrooms: In Shoreland Area? Lake/River Name, Number, & Class Section: /7 S □Yes No System Compliance Staty^^ ^UllipildMl^ Non-Compliant 0Does 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 Yes Yes Yes No No No 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 hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system, inadequate maintenance, or future water usage. Name; Phiistoii Certification Number: 7520 Business License Name & Number: Signature: Stoll Inspections 29^ / 0/ n Date; Page 1 of 2Excel/Comptiance Fomi for OTC 1/15/2014 Otter Tail County Compliance Inspection Form Addendum (cont.) Compliance Inspection FormMinnesota Pollution Control Agency 520 Lafayette Road North St. Paul, MN 55155-4194 Existing Subsurface Sewage Treatment Systems (SSTS) Doc Type: Compliance and Enforcement Instructions on page 6 Summary Form (Completed form must be submitted to the local unit of government within 15 days.) Parcel number: 17000991129000&17000170232000 System status: □ Compliant S Noncompliant (based on all compliance requirements) For Local Tracking Purposes: Property Information Property owner name(s): Bell State Bank & Trust Property address: 23471 Fish Lake Lane, Pelican Rapids, MN 56572_______ Property owner address (if different): 409^heyenne St. West Fargo, ND 58078 County: Ottertail Date system constructed: 1982 Property owner phone: Permitting authority: Ottertail County ____Reason for inspection: Sale System Description Brief system description: 750 gal. Concrete Tank to 381 Sq. Ft. rock ^nd trench drainfield Local permit number: 4920____ Is the system: In Shoreland area? An U.S. Environmental Protection Agency (EPA) Class V Injection Well? □ Yes S No Compliance Status (Based on state requirements - additional local requirements may also apply.) Based on the information gathered and reported on attached forms, the compliance status of this system is (check one): □ Certificate of Compliance - valid until (3 years from date of report): S Notice of Noncompliance - For Noncompliant systems: The reason for noncompliance is: Soil Separation ________________________________ This noncompliant system is classified as (check one below): □ Imminent threat to public health & safety [3 Failing to protect ground water □ Not in compliance with operating permit Number of bedrooms: 2 Design flow rate: S Yes □ No □ Yes E NoIn Wellhead Protection Area? System serving a Minnesota Department of Heath (MDH) licensed facility?□ Yes ^ No Certification / hereby certify that all the necessary infomnation has been gathered to determine the compliance status of this system. No determination of future system performance has been nor can be made due to unknown conditions during system construction, possible abuse of the system, inadequate maintenance, or future water usage. Name: Phil Stoll_________ _________ Business license name and number: Stoll Insjsections Name of local unit of government: ______ Signature: Certification number: L2982 or Date: 11/14/13 Required Attachments ^ Hydraulic Performance S Soil Boring Logs D System drawing/As-built drawing □ Any local requirements that are different from what is required on this form □ Other information (list):__________________________ _____ ______________ Upgrade Requirements (derived from 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. K Tank Integrity S Soil Separation □ Operating Permit Form (if applicable) www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31 • 4/24/09 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 1 of 8 r System status: □ Compliant ^ Noncompliant (as determined by this form) Parcel number:17000991129000&17000170232000 Hydraulic Performance and Other Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #1 of 4 Date of observation: 11/14/13 This form expires upon next inspection or in three years, whichever occurs first: Reason for obsenration: Sale Compliance questions/criteria: (Required) (Check the appropriate box)_________ Verification Method*: (Optional) (Check the appropriate box) ^ Searched for surface outlet □ Performed hydraulic test S Searched for seeping in yard □ Checked for backup in home □ Excessive ponding in soil system/D-boxes [3 Homeowner testimony □ Examined for surging in tank G “Black soil” above soil dispersal system □ System requires “emergency” pumping □ Performed dye test □ Other: ___________________________ □ Yes G NoDoes the system discharge sewage to the ground surface?____________________ □ Yes S NoDoes the system discharge sewage to drain tile or surface waters? □ Yes G NoDoes the system cause sewage backup into dwelling or establishment?_______ □ Yes G NoDo other situations exist that have the potential to immediately and adversely impact or threaten public health or safety (electrical, unsafe covers, etc.)?_______ Any “yes” answer indicates that the system is an imminent threat to pubiic heaith and safety. G Yes □ NoDoes the system pose a threat to ground water for any conditions deemed non- protective as determined by the inspector? “Yes” indicates that the system is fading to protect ground water. If “yes”, describe the condition noted: Saturated soil at 40 Inches * No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this detenvination. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency’s (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Obsen/ations, interpretations, and conclusions rhust be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Bell State Bank & Trust_______________ Property address: 23471 Fish Lake Lane, Pelican Rapids, MN 56572 Property owner’s address (if different): 409 Sheyenne St. West Fargo, ND 58078 County: Ottertail Property owner phone: / hereby certify that I personally made the observations, interpretations, and conclusions reported on this fomn and that they are correct.[ Name: Phil Stoll Certification number: L2982 Business license name and number: Stoll Inspections Name of local unit of government: ________________ Signature: ___________________________________ or Date: 711/14/13 651-296-6300 • 800-657-3864 . TTY 651-282-5332 or 800-657-3864, • Available in alternative formatswww.pca.state.mn.us • wq-wwists4-31 • 4/24109 System status: ^ Compliant □ Nohcompliant (as determined by this form) Parcel number: 17000991129000&17000170232000 Tank Integrity and Safety Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #2 of 4 Date of obsen/ation: 11/14/13 This form expires pn (three years): 11/14/16 Reason for observation: Sale Compliance questions/criteria: (Required) (Check the appropriate box)_________ Verification Method**: (Optional) (Check the appropriate box) S Probed tank bottom □ Observed low liquid level ^ Examined construction records □ Examined empty (pumped) tank S Probed outside tank for "black soil” □ Pressure/vacuum check □ Other: _____________________ □ Yes S NoDoes the system consist of a seepage pit*, cesspool, drywell, or leaching pit?_______ □ Yes ^ NoDo any sewage tank(s) leak below their designed operating depth?__________■ i If yes, identify which sewage tank leaks. Any "yes” answer indicates that the system is faiiing to protect groundwater. * Seepage pits meeting 7080.2550 may be compliant if allowed in ordinance by local permitting authority. ** No standard protocol exists. This list is not exhaustive, in sequential order, nor does It indicate which combinations are necessary to make this determination. i; Safety Check □ Yes* El No El Yes □ No* El No □ Yes* El No 1. Are maintenance hole covers damaged, cracked, or appeared to be structurally unsound? 2. Were maintenance hole covers replaced in a secured manner (e.g., screws replaced)? 3. Was secondary access restraint present (safety pan, second cover, or safety netting) - highly recommended. □ Yes 4. Are other safety/health issue present? Explain: _________________________________________ *System is an imminent threat to pubiic heaith and safety. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency’s (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector, maintainer, or senrice provider. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Bell State Bank & Trust_______________ Property address: 23471 Fish Lake Lane, Pelican Rapids, MN 56572 Property owner’s address (if different): 409 Sheyenne St. West Fargo, ND 58078 County: Ottertail Property owner phone: / hereby certify that I personally made the observations, interpretations, and conclusions reported on this fomn and that they are correct. Name: Phil Stoll Certification number: L2982 Business license name and number: Stoll Inspections Name of local unit of government: ________________ Signature: ___________________________________ or Date: 11/14/13 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31 • 4/24/09 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 3 of 8 System status: □ Compliant ^ Noncxjmpliant (as determined by this fomn) Parcel number:17000991129000&17000170232000 Soil Separation Compliance and Other Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #3 of 4 Date of observation: 11/14/13_________ This information on this form does not expire. Reason for observation: Sale Verification Method**: (Optional) (Check the appropriate box) ^ Conducted soil observation(s) (attach boring logs) □ Two previous verifications (attach boring logs) □ Other: _________________________________ Compiiance questions/criteria: (Required) (Check the appropriate box)______________ For 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: Does the system have at least a two-foot vertical separation distance from periodically saturated soil or bedrock?□ Yes □ No For non-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: Does the system have a three-foot vertical separation distance from periodically saturated soil or bedrock?* Soil observation does not expire. Previous observations by two independent parties are sufficient, unless site conditions have been altered. □ Yes I^No For reduced separation distance systems (i.e., “performance” systems under old 7080.0179 or Type IV or V system under new 7080. 2350 or 7080.2400): Does the system meet the designed vertical separation distance from periodically saturated soil or bedrock?* * May be reduced by up to 15 percent if allowed in local ordinance. ** No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this determination.□ Yes □ No Any “no” answer indicates that the system is suing to protect ground water. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency’s (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector or designer. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Bell State Bank & Trust Property address: 23471 Fish Lake Lane, Pelican Rapids, MN 56572_________ Property owner’s address (if different): 409 Sheyenne St. West Fargo, ND 58078 County: Ottertail Property owner phone: / hereby certify that I personally made the observations, interpretations, and conclusions reported on this fomn and that they are correct Name: Phil Stoll Certification number: L2982 Business license name and number: Stoll Inspections Name of local unit of government: ________________ Signature: ___________________________________ or Date: 11/14/13 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-v/wists4-31 • 4124109 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Poge 4 of 8 System status: □ Compliant □ Noncompliant (as determined by this form)17000991129000&17000170232000Parcel number; Operating Permit Compliance and Nitrogen BMP Compliance - Compliance Inspection Form for Existing SSTS Compliance issue #4 of 4 Applicability: Is the system operated under an Operating Permit? □ Yes O No If “yes”, then complete item A, below Is the system required to employ a nitrogen BMP? O Yes □ No If “yes”, then complete item B, below If the answer to both questions is “no", then this form does not need to be completed. Compliance questions/criteria: (Required) (Check the appropriate box) A. For systems with operating permits: Has all the required monitoring and maintenance taken place and does the monitoring indicate compliance with the permit thresholds? D Yes □ No B. For a system that has a required nitrogen reducing BMP and does not have an operating permit; Is the nitrogen BMP in-place and appears to be properly operating? □ Yes □ No Any "no” answers indicates noncompliance Date of observation: __ Operating permit number; This form expires upon next inspection or in three years, whichever occurs first: Reason for observation; Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA). Compliance Inspection Fonn for Existing Subsurface Sewage Treatment Systems. Observations, interpretations and conclusions must be completed by an advanced inspector, service provider, or maintainer (maintainer for holding tanks only). Completed form must be submitted to the local unit of government within 15 days. Property owner name(s); Bell State Bank & Trust_______________ Property address: 23471 Fish Lake Lane, Pelican Rapids. MN 56572 Property owner's address (if different); 409 Sheyenne St. West Fargo, ND 58078 County; Ottertail Property owner phone; I hereby certify that I personally made the observations, interpretations and conclusions reported on this form and that they are correct Name; Phil Stoll Certification number; L2982 Business license name and number: Stoll Inspections Name of local unit of government:________________ Signature: __________________________________ or Date: 11/14/13 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31 • 4/24/09 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Poye 5 of 8 lams ’.BQp-tiflwqwTtgfasi”* ■' ' ; “ »i(?h,e J''’S j'^-’W"''^ j'-'^ KO^QSWHO^OOS^mJT { szKnsADey j-'S '> j,-'^. j^y ■1 ,'-•■riJI %. ’ ^! #¥8siraa SI afeaipitt oqv 'steteSoTOGBis |»B ^i{^s!ss^aaii^fft0 ^sdifimossnai^ggHMpaajpDipSs^p ^iop» 'Vat^ViWiXiS ‘aattpsa. ^ngn^nimip^aipjn-pi^gipmfltnMgm'iaAOtpifaniiaqigognnbqipBaagaatyT sSawoffBog I \.-iN ”■>r-i1 \ \\,\ /{/>\u iffLJ \/\,?,1 <.!i y /\ \'f!,y' n\r-1.LJ • - ■f -y' i ■ - J hh OJOLi r 40/:?9)79?^i2£liZ££l o'oy I { I I TTr*'I.."!’’A r 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. \ \ \ \ I \^CdO OCLi "ZOoCo 4^^ V-CiXp<3U \^0DO[10Z3>2i0fo(^ nocx>‘i'nii www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31 • 4124/09 TTY 651-282-5332 or 800-657-3864 ♦ Available in alternative formats Department of LAND AND RESOURCE MANAGEMENT <^fC0 2 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 2013^Nd 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 Humber!^ 1700099//3cocoi no^52coo4 Section: \~J noLizcci^ Township: ~C>av^r> 13~7__________ Property Owner Name(s):~ ____________ Property Address: 23V & / filL UU , PJ.Tjuk sz.s^7z- Reason for Inspection: ________________ Number of Bedrooms: 2- (^e^No / \9 0009^11In Shoreland Area? Lake/River Name, Number, & Class (if applicable):M System Compliance Status: (circle one) Compl|ani._— ^^on^bom^pliant 3 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? Yes /QsipJ) Ye^^^ o Yes Yes Does any part of the septic system fail to meet the minimum OHWL setback requirements for the public water classification? "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 form, 1/24/12 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. pit /Name: Certification Number: Business License Name & Number: ~ . Signature:Date: Page 1 of 2Excel/Compliance Form for OTC 2/29/2012 otter Tail County Compliance Inspection Form Addendum (cont.) Date & Initial:Parcel Number:/■7<X}099//^nnrX'^ ^ ?‘^I(I90G0 R9IIZ9000 ^ /7QP3=P0OO f HbDXiDOi^ System Drawing The system drawing must be to scale and include all septic/holding/lift tanks, drainfields, wells within 100 feet of system (indicate depth of wells), dwelling and non-dwelling structures, lot lines, road right-of-ways, easements, OHWLs, wetlands, and topographic features (i.e. bluffs). I VVO C UCc — /:y CCAiiiSu atodl unkhf\~ Cf)mpl lani" "/o SDII ^Additional Comments: Page 2 of 2Excel/Compliance Form for OTC 2/29/2012 Compliance Inspection FormMinnesota Pollution Control Agency 520 Lafayette Road North SL Paul, MN 55155-4194 Existing Subsurface Sewage Treatment Systems (SSTS) Doc Type: Compliance and Enforcement Instructions on page 6 Summary Form (Completed form must be submitted to the local unit of government \within 15 days.) Parcel number: 17000991130000 System status: □ Compliant S Noncompliant (based on all compliance requirements) For Local Tracking Purposes: Property Information Property owner name(s): ^ell State Bank & Trust Property address: 23451 Fi^ Lake Lane, Pelican Rapids, MN 56572 Property owner address (if different): 409 Sheyenne St. West Fargo, NO 58078 County. Ottertall Date system constructed: 1982 Property owner phone. Permitting authority: Ottertail County ____Reason for inspection: Sale System Description Brief system description: 750 gal. Concrete Tank to 381 Sq. Ft. rock and trench drainfleld Number of bedrooms: 2 Design flow rate:Local permit number: 4920 Is the system: In Shoreland area? An U.S. Environmental Protection Agency (EPA) Class V Injection Well? □ Yes ^ No □ Yes S NoE Yes □ No In Wellhead Protection Area? System serving a Minnesota Department of Heath (MDH) licensed facility?□ Yes S No Compliance Status (Based on state requirements - additional local requirements may also apply.) Based on the information gathered and reported on attached forms, the compliance status of this system is (check one): □ Certificate of Compliance - valid until (3 years from date of report): S Notice of Noncompliance - For Noncompliant systems: The reason for noncompliance is: Soil Seperation This noncompliant system is ciassified as (check one below): □ Imminent threat to public health & safety |3 Failing to protect ground water □ Not in compliance with operating permit 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. Name: Phil Stoll Business license name and number: StoN Inspections Name of local unit/etAovernmef^ / signature: Certification number: L2982 or Date: 11/14/13 Required Attachments 13 Hydraulic Performance ^ Soil Boring Logs □ System drawing/As-bui(t drawing O other information (list):_ Upgrade Requirements (derived from Minn. Stat. §115.55) An imminent threat to pubiic heaith 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 iodging estabiishments as defined in iaw. □ Operating Permit Form (if applicabl lEl Soil Separation vi Vru'iii O Any local requirements that are different from what is requtrgd on this form Tank Integrity ED TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 1 of 8 800-657-3864651-296-6300www.pca.state.mn.us • wq-wwists4-31 • 4/24/09 System status: □ Compliant ^ Noncompliant (as determined by this form) 17000991130000Parcel number: Hydraulic Performance and Other Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #1 of 4 Date of observation: 11/14/13 This form expires upon next inspection or in three years, whichever occurs first: Reason for observation: Sale Verification Method*: (Optional) (Check the appropriate box) H Searched for surface outlet □ Performed hydraulic test S Searched for seeping in yard □ Checked for backup in home □ Excessive ponding in soil system/D-boxes S Homeowner testimony □ Examined for surging in tank □ “Black soil" above soil dispersal system □ System requires “emergency” pumping □ Performed dye test □ Other; ___________________________ Compliance questions/criteria: (Required) __ (Check the appropriate box)______________________ Does the system discharge sewage to the □ Yes I3 No ground surface? _ __ Does the system discharge sewage to drain □ Yes ^ No tile or surface waters? □ Yes 13 NoDoes the system cause sewage backup into dwelling or establishment? ___ Do other situations exist that have the potential to immediately and adversely impact or threaten public health or safety (electrical, unsafe covers, etc.)? Any “yes” answer indicates that the system is an imminent threat to public health and safety. □ Yes 3 No 3 Yes □ NoDoes the system pose a threat to ground water for any conditions deemed non- protective as determitied by the inspector? "Vies" indicates that the system is faiiing to protect ground water. If “yes”, describe the condition noted: * No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this determination. Saturated soil at 40 Inches Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency’s (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Bell State Bank & Trust__ __ Property address: 23451 Fish Lake Lane, Pelican Rapids, MN 56572 Property owner's address (if different): 409 Sheyenne St. West Fargo, ND 58078 County: Ottertail Property owner phone. I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Certification number: L2982Name: Phil Stoll Business license name and number: Stoll Inspections Name of local unlt^f^i^^m^^^^^^^ or Date: 11/14/13Signature: e TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Pose 2 of 8651-296-6300 • 800-657-3864www.pca.state.mn.us wq-wwists4-31 • 4/24/09 System status: S Compliant □ Noncompliant (as determined by this form)17000991130000Parcel number: Tank Integrity and Safety Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #2 of 4 Date of observation: 11/14/13 __ _ __ This form expires on (three years): 11/14/16 Reason for observation: Sale Verification Method**: (Optional) (Check the appropriate box) S Probed tank bottom Q Observed low liquid level S Examined construction records Q Examined empty (pumped) tank S Probed outside tank for "black soil" O Pressure/vacuum check □ Other:__________________ Compliance questions/criteria: (Required) (Check the appropriate box) Does the system consist of a seepage pit*, cesspool, drywell, or leaching pit? __ Do any sewage tank(s) leak below their designed operating depth?___ ______ If yes, identify which sewage tank leaks. _ _______ __ Any “yes" answer indicates that the system is faiiing to protect ground water. □ Yes 13 No □ Yes 13 No * Seepage pits meeting 7080.2550 may be compliant if allowed in ordinance by local permitting authority. ** No standard protocol exists. This list is not exhaustive, in sequential order, nor does It indicate which combinations are necessary to make this determination. Safety Check □ Yes* 3 No 3 Yes □ No* 3 No □ Yes* 3 No 1. Are maintenance hole covers damaged, cracked, or appeared to be structurally unsound? 2. Were maintenance hole covers replaced in a secured manner (e.g., screws replaced)? 3. Was secondary access restraint present (safety pan, second cover, or safety netting) - highly recommended. □ Yes 4. Are other safety/health issue present? Explain: _______ ________ *System is an imminent threat to public health and safety. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector, maintainer, or service provider. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Bell State Bank & Trust________________________ Property address: 23451 Fish Lake Lane, Pelican Rapids, MN 56572 409 Sheyenne St. West Fargo, ND 58078 _________ Property owner phone: Property owner’s address (if different): County: Ottertail_____________ / hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Certification number: L2982Name: Phil Stoll__ ___________________ Business license name and number: Stoll Inspections Name of local unit oj ^verpmen^/ ____________ Signature: ____Date: 11/14/13 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 3 of 8 651-296-6300 • 800-657-3864www.pca.state.mn.us • wq-wwists4-31 • 4/24/09 System status: □ Compliant ^ Noncompliant (as determined by this form) Parcel number:17000991130000 Soil Separation Compliance and Other Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #3 of 4 Date of observation: 11/14/13 This information on this form does not expire. Reason for observation: Sale Compliance questions/criteria; (Required) (Check the appropriate box) __ _ _____ For 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: Does the system have at least a two-foot vertical separation distance from periodically saturated soil or bedrock? __ _______ For non-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: Does the system have a three-foot vertical separation distance from periodically saturated soil or bedrock?*________ For reduced separation distance systems (i.e., “performance” systems under old 7080.0179 or Type IV or V system under new 7080, 2350 or 7080.2400): Does the system meet the designed vertical separation distance from periodically saturated soil or bedrock?*_______________________ Any “no" answer indicates that the system is faiiing to protect ground water. Verification Method**: (Optional) (Check the appropriate box) S Conducted soil observation(s) (attach boring logs) □ Two previous verifications (attach boring logs) □ Other: □ Yes □ No Soil observation does not expire. Previous observations by two independent parties are sufficient, unless site conditions have been altered. □ Yes ^ No * May be reduced by up to 15 percent if allowed In local ordinance. ** No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this determination.□ Yes n No Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector or designer. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Bell State Bank & Trust __ __ Property address: 23451 Fish Lake Lane, Pelican Rapids, MN 56572 ______ Property owner's address (if different): 409 Sheyenne St. West Fargo, ND 58078 County: Ottertail Property owner phone; I hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Certification number: L2982Phil StollName: Business license name and number: Stoll Inspections Name of local univoflfaov^nmenlfy ^ /7 or Date: 11/T4^^ Signature: TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 4 of 8 651-296-6300 • 800-657-3864www.pca.state.mn.us • wq-wwist$4-31 • 4/24/09 I 7 0^0 \70 t3 zcoio \~ICC0 \7073 2^^00 \~}0CC I|7 ‘icoo l7 I' I ^<^00 \im^^{\\iacaD Site Sicetdk: ^c|! S'fe-'k. irvuit SeCodK ^I~S^ l»jU LtiwV^ _.\ \2 VSoilBoifia^OBR#): LocateeaeiibariDgon'dKiniqiaboTC.ihdKBiecnitbei^ihtofAecaluiim.^soil texture, structure, color, dugrtfa of each dMBterent soilcfvfcieuc* ofmotdlng, bedrodc sod stjsnding'water. Also suScaiB if ^ vatesdal is £HL BEiif8R# JO'' V/c/cif^l HO RBCORDimH OFMOrnSto. mcmBmWAER(ASDEBaao1BDt)SBiGlHBM!a«,CMBCX3B ORBBEIBDCKONA30VELINES , —----------------1- I I 'iiir --------- --------,,. — '^p/u iL'-y-tff (X <a;. ccUk^xCti mel pnls»'«iasjiBv\bishop3.dM'- 6/18OT , SCANNED 2^^^6hkaS poAc^\S ^ ^ n Department of ' ^ ^ ‘ ^ n ^ ^ LAND AND RESOURCE MANAGEMENT ' " RSCQv^^ ^ 2 2013 otter Tall County Compliance Inspection Form Addendum L 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 Tliis 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. ooQ Parcel Nurnben Property Information f7oz)on^tmeco 'Ti-jfiff/y {ea.dcjah) Township; Property Owner Name(s): g^vviic i-~~|vx6E Property Address^. ziH's'y ThlLL ^ Reason for Inspection: il30 Section: 17 Number of Bedrooms: @)In Shoreland Area? Lake/River Name, Number, & Class (if applicable); No f System Compliance Status: (circle oneyCompliant^ ^~Non-Com^iant 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? 3- 1000 I©Yes Yes Yes "Yes" indicates that the system is failing to protect ground water and is noncompliant. If ’Yes", describe the condition noted: Repuired Attachments: System drawing to scale on next page. Completed MPCA Compliance Inspection form, 1/24/12 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. <g#scAK:;:Dpk i sfetfName: Certification Number: Business License Name & Number: "S-lad Signature; ______u.Date: Excei/Compliance Form (or OTC 2/29/2012 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. \ \ \ [ { 0 KlCZi 4^^ •V-CiX \']00On0tI>2DO(^ \~}OCV Q(3«) <11111 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31 • 4/24/09 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Compliance Inspection FormMinnesota Pollution Control Agency 520 Lafayette Road North St. Paul, MN 55155-4194 Existing Subsurface Sewage Treatment Systems (SSTS) Doc Type: Compliance and Enforcement Instructions on page 6 Summary Form (Completed form must be submitted to the local unit of government within 15 days.) Parcel number: System status: S Compliant □ Noncompliant (based on all compliance requirements) 17000991119000&17000991130000&17000170232006 For Local Tracking Purposes: Property Information Property owner name(s): Bell State Bank & Trust Property address: 23451 Fish Lake Lane, Pelican Rapids, MN 56572_______ Property owner address (if different): 409 Sheyenne St. West Fargo, ND 58078 County: _pttertai[ Date system constructed: 1976 Property owner phone: Permitting authority: Ottertail County Reason for inspection: Sale System Description Brief system description: 3-1000 gal Holding Tanks Local permit number: 2250_____ Is the system: In Shoreland area? An U.S. Environmental Protection Agency (EPA) Class V Injection Well? Q Yes I3 No Number of bedrooms: 6 Design flow rate: S Yes □ No □ Yes S NoIn Wellhead Protection Area? System serving a Minnesota Department of Heath (MDH) licensed facility? Complianc© Status (Based on state requirements - additional local requirements may also apply.) Based on the information gathered and reported on attached forms, the compliance status of this system is (check one): S Certificate of Compliance - valid until (3 years from date of report): □ Notice of Noncompliance - For Noncompliant systems: The reason for noncompliance is. This noncompliant system is classified as (check one below): □ Imminent threat to public health & safety □ Failing to protect ground water □ Not in compliance with operating permit □ Yes SNo 11/14/2016 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. Name: Phil Stoll Certification number: L2982 Business license name and number: _Stoll Inspections Name of local unit of government: Signature:_______________ or Date: 11/14/13 Required Attachments S Hydraulic Performance □ Soil Boring Logs □ System drawing/As-built drawing □ Any local requirements that are different from what is required on this form □ Other information (list):________ ___________ ______ ______________________ Upgrade Requirements (derived from 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, S Tank Integrity □ Soil Separation □ Operating Permit Form (if applicable) www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31 • 4/24/09 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Parcel number: 17000991119000&17000991130000&17000170232006 System status: S Compliant □ Noncompliant (as determined by this form) Hydraulic Performance and Other Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #1 of 4 Date of obsen/ation: 11/14/13 This form expires upon next inspection or in three years, whichever occurs first: 11/14/16 Reason for observation: Sale Compliance questions/criteria: (Required) (Check the appropriate box)____________ _______ Does the system discharge sewage to the □ Yes S No ground surface? Does the system discharge sewage to drain □ Yes S No tile or surface waters? Verification Method*: (Optional) (Check the appropriate box) 0 Searched for surface outlet Q Performed hydraulic test 13 Searched for seeping in yard □ Checked for backup in home Q Excessive ponding in soil system/D-boxes □ Homeowner testimony □ Examined for surging in tank □ “Black soil” above soil dispersal system □ System requires “emergency” pumping O Performed dye test □ Other: _________ □ Yes SNoDoes the system cause sewage backup into dwelling or e^blishment?_______ Do other situations exist that have the potential to immediately and adversely impact or threaten public health or safety (electrical, unsafe covers, etc.)?_______ Any "yes" answer indicates that the system is an imminent threat to pubiic health and safety. □ Yes □ No □ Yes □ NoDoes the system pose a threat to ground water for any conditions deemed non- protective as determined by the inspector? “Yes” indicates that the system is failing to protect ground water. If “yes”, describe the condition noted: * No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this determination. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency’s (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Bell State Bank & Trust_______________________ Property address: 23451 Fish Lake Lane, Pelican Rapids, MN 56572 Property owner’s address (if different): 409 Sheyenne St. VVest^argo, Np 58078 Property owner phone:County: Ottertail / hereby certify that I personally made the obsen/ations, interpretations, and conclusions reported on this form and that they are correct Name: ^hil Stoll_________________________ Business license name and number: Stoll Inspections Name of local unit of gc^mment: //^ ^__________ Signature: _______ Certification number: L2982 or Date: 11/14/13 vww.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31 • 4/24/09 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Parcel number: 17000991119000&17000991130000&17000170232006 System status: ^ Compliant O Noncompliant (as determined by this form) Tank Integrity and Safety Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #2 of 4 Date of obsen/ation: 11/14/13 _ This form expires on (three years); 11/14/16 Reason for observation; Sale Compliance questions/criteria: (Required) (Check the appropriate box)________________________ Does the system consist of a seepage pit*, D Yes ^ No resspoql, drywell, or leaching pit? ___________________ Do any sewage tank(s) leak below their □ Yes E No designed operating depth? __________________ If yes, identify which sewage tank leaks. __ _____________ Any “yes" answer indicates that the system is faiiing to protect ground water. Verification Method**: (Optional) (Check the appropriate box) ^ Probed tank bottom □ Observed low liquid level ^ Examined construction records □ Examined empty (pumped) tank S Probed outside tank for “black soil” D Pressure/vacuum check □ Other: _________________ * Seepage pits meeting 7080.2550 may be compliant if allowed in ordinance by local permitting authority. ** No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this determination. Safety Check □ Yes* El No E Yes □ No* El No □ Yes* S No 1. Are maintenance hole covers damaged, cracked, or appeared to be structurally unsound? 2. Were maintenance hole covers replaced in a secured manner (e.g., screws replaced)? 3. Was secondary access restraint present (safety pan, second cover, or safety netting) - highly recommended. □ Yes 4. Are other safety/health issue present? Explain;__________________________________________ *System is an imminent threat to pubiic heaith and safety. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency’s (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector, maintainer, or service provider. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Bell State Bank & Trust Property address: 23451 Fish Lake Lajie, Pelican Rapids, MN 56572 Property owner’s address (if different): 409 Sheyenne St. West Fargo, ND 58078 County: Ottertail Property owner phone; / hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct Name: Phil Stoll_____________________________ Business license name and number: Stoll Inspections Name of local unit of goveny^mh Signature: _________ Certification number: L2982 or V Date: 11/14/13 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31 • 4/24/09 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats i7ft£;0 \ 5 200L> n teen'll 1! ^{'iCO BeCode 17060^^''^^030____Bci i S'^'k D.-wttl4. 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' otVC(v K-r:i §§N- ■ 4,''C.J CO■jS-IK;Jw 5O/or^^0 3.790- '^’4. />I "'W.i)50''* .;45Vr>0‘m\c^sy 1700 1129000v "■■V. r ^0 V-d \w\N*"W.\ i\(RisERVE r VAo' 17006^113000) RESERVE 2 \\i lA) OJ \\'7>. \\''4.-\\\\ \_„JV___'-'■—('5*^ki\-i-L-uROW ,'ii._36£^_ ''•7 '• ;V„J'--.IV. ■'T '•:-.v.K/^'W.••'i. -j;.. >170.0.011023200.6.,,.'oo;17000170232000-'-rY-'-T--~—' 00’j'TVX-i. ......... 17000991727000.c.Ti-''""' r For REFERENCE purposes only, THIS IS FDTA LEGAroOCCMENi: TueltoTil'2013 05:2! ^ &u')ol,>yj5, s^^■cS u^U<.Jj\^ap^ra!C. /d^a.h'c.%0. guaranteed. : Department of LAND AND RESOURCE MANAGEMENT Of c 0 2 20t3 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: r70I)Q^^tl (90CO Township: Property Owner Name(s):~^ij ScijJl Property Address: 2^41 i Reason for Inspection: Number of Bedrooms: Section: 17 7 In Shoreland Area? Lake/River Name, Number, & Class (if applicable): No System Compliance Status: (circle onej^^^Compliant^ ^Non-Cornpliant 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? 3'(0oo[^oU»V^ I Yes Yes Imo Yes /No Yes Yes "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 form, 1/24/12 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. <^SCAfJ!rLDPL( sfe(/Name: Certification Number: Business License Name & Number: Signature: ,s. Date: Page 1 of 2Excel/Compliance Form for OTC 2/29/2012 otter Tail County Compliance Inspection Form Addendum (cont.) Date & Initial: l)lNjl'3> I7ooo9^//jooc)0 /700017cq^^oou Parcel Number:/7noC:)99///9nfK:)f- The system drawing must be to scale and include all septic/holding/lift tanks, drainfields, wells within 100 feet of system (indicate depth of wells), dwelling and non-dwelling structures, lot lines, road right-of-ways, easements, OHWLs, wetlands, and topographic features (i.e. bluffs). _ - -t i tJo' I -3 (9 I ft-sJ*! Ln ^ Lo-ir^\ — CU)ryiyo//Ony3 ' ICtjO gpj ^o/g//> ijAdditional Comments: Page 2 of 2Excel/Compliance Form for OTC 2/29/2012 Compliance Inspection FormMinnesota Pollution Control Agency 520 Lafayette Road North St Paul, MN 55155-4194 Existing Subsurface Sewage Treatment Systems (SSTS) Doc Type: Compliance and Enforcement Instructions on page 6 SuiniTiary Form (Completed form must be submitted to the local unit of government within 15 days.) Parcel number: 17000991119000___________________ System status: ^ Compliant □ Noncompliant (based on all compliance requirements) For Local Tracking Purposes: Property Information Property owner name(s): Bell State Bank & Trust Property address: 23471 Fish Lake Lane, Pelican Rapids, MN 56572________ Property owner address (if different): 409 Sheyenne St. West Fargo, NO 58078 County. ^tterta[(___________ Date system constructed: 1976 Property owner phone: Permitting authority; Ottertail County ____Reason for inspection: Sale System Description Brief system description: 3-1000 gal Holding Tanks Local permit number: 2250 Is the system: In Shoreland area? An U S. Environmental Protection Agency (EPA) Class V Injection Well? □ Yes ^ No Number of bedrooms: Design flow rate: □ Yes B No^ Yes □ No In Wellhead Protection Area? System serving a Minnesota Department of Heath (MDH) licensed facility?□ Yes ^ No Compliance Status (Based on state requirements - additional local requirements may also apply.) Based on the information gathered and reported on attached forms, the compliance status of this system is (check one): ^ Certificate of Compliance - valid until (3 years from date of report): O Notice of Noncompliance - For Noncompliant systems: The reason for noncompliance is: This noncompliant system is classified as (check one below): □ Imminent threat to public health & safety □ Failing to protect ground water □ Not in compliance with operating permit 11/14/2016 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. Name: Phil Stoll Business license name and number: Stoll Inspections Name of local unit/flgovernmeifi/ /J signature: _ Z Required Attachments K Hydraulic Performance □ Soil Boring Logs □ System drawing/As-built drawing □ Any local requirements that are different from what is required on this form O other information (list): ___ ______________________ Certification number: L2982 or Date: 11/14/13 □ Operating Permit Form (if applicable)13 Tank Integrity □ Soil Separation ^ * B * ■ r-'Upgrade Requirements (derived from Minn. Stat. §115.55) An imminent threat to public health and safety'<(ITPHS)<fhust be upgraded, replaced, or its use discontinued within ten months of receipt of this notice or within a shorter period if required>byloeei vrmnince. If the system is failing to protect ground water, the system must be upgraded, replaced, or its use discontinued within the time required by local ordinance. If an existing system is not failing as defined in law. and has at least two feet of design soil separation, then the system need not be upgraded, repaired, replaced, or its use discontinued, notwithstanding any local ordinance that is more strict. This provision does not apply to systems In shoreland areas. Wellhead Protection Areas, or those used in connection with food, beverage, and lodging establishments as defined in law. TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Pa$e 1 of 8 800-657-3864651-296-6300www.pca.state.mn.us wq-wwists4-31 • 4/24/09 System status: ^ Compliant □ Noncompliant (as determined by this form) 17000991119000Parcel number: Hydraulic Performance and Other Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #1 of 4 Date of observation: 11/14/13 This form expires upon next inspection or in three years, whichever occurs first: 11/14/16 Reason for observation: Sale Verification Method*: (Optional) (Check the appropriate box) ^ Searched for surface outlet Q Performed hydraulic test ^ Searched for seeping in yard □ Checked for backup in home □ Excessive ponding in soil system/D-boxes □ Homeowner testimony □ Examined for surging in tank Q “Black soil” above soil dispersal system Q System requires “emergency” pumping □ Performed dye test □ Other:______________________ Compliance questions/criteria: (Required) __(Check the appropriate box) ^ Does the system discharge sewage to the □ Yes H No ground surface?___ ______________________ Does the system discharge sewage to drain □ Yes El No tile or surface waters? □ Yes E NoDoes the system cause sewage backup jiTto^dwejling or establishment? ___ Do other situations exist that have the potential to immediately and adversely impact or threaten public health or safety (electrical, unsafe covers^etc.)? Any “yes” answer indicates that the system is an imminent threat to public health and safety. □ Yes E No 1 □ Yes El NoDoes the system pose a threat to ground water for any conditions deemed non- protective as determined by the inspector? “Yes” indicates that the system is faiiing to protect ground water. If "yes”, describe the condition noted: * No standard protocol exists. This list is not exhaustive, in sequential order, nor does it indicate which combinations are necessary to make this determination. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Bell State Banl^S Trust Property address: 23471 Fish Lake Lane, Pelican Rapids, MN 56572 Property owner's address (if different): 409 Sheyenne St. West Fargo, ND 58078 County: Ottertail Property owner phone: / hereby certify that I personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Certification number: L2982Name: Phil Stoll_____________________________ Business license name and number. Stoll Inspections Name of local ______________ Signature __________ or __ . Date:n 11/14/13 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Paje 2 of 8 651-296-6300 • 800-657-3864www.pca.state.mn.us • wq-wwists4-31 • 4/24/09 System status: ^ Compliant □ Noncompliant (as determined by this form) Parcel number; 17000991119000 Tank Integrity and Safety Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #2 of 4 Date of observation: 11/14/^___________ This form expires on (three years): 11/14/16 Reason for observation: Sale Verification Method**: (Optional) (Check the appropriate box) ^ Probed tank bottom Q Observed low liquid level H Examined construction records □ Examined empty (pumped) tank S Probed outside tank for “black soil" □ Pressure/vacuum check □ Other:____________________ Compliance questions/criteria: (Required) (Check the appropriate box)_________________________ Does the system consist of a seepage pit*, □ Yes ^ No cesspool, dryvyell, or leachinj pit?____ Do any sewage tank(s) leak below their designed operating depth?__________ □ Yes 13 No If yes, identify which sewage tank leaks. Any “yes” answer indicates that the system is faiiing to protect ground water. * Seepage pits meeting 7080.2550 may be compliant if allowed in ordinance by local permitting authority. " No standard protocol exists. This list Is not exhaustive, in sequential order, nor does It indicate which combinations are necessary to make this determination. Safety Check □ Yes* 3 No 3 Yes □ No* 3 No □ Yes* 3 No 1. Are maintenance hole covers damaged, cracked, or appeared to be structurally unsound? 2. Were maintenance hole covers replaced in a secured manner (e.g., screws replaced)? 3. Was secondary access restraint present (safety pan, second cover, or safety netting) - highly recommended. □ Yes 4. Are other safety/health issue present? Explain: __________ *System is an imminent threat to public health and safety. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency’s (MPCA) Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems. Observations, interpretations, and conclusions must be completed by an inspector, maintainer, or service provider. Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): Bell State Bank & Trust _____________ Property address: 23471 Fish Lake Lane, Pelican Rapids, MN ^^2 Property owner’s address (if different): 409 Sheyenne St. West Fargo, ND 58078 County: ^ttertail Property owner phone: / hereby certify that 1 personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Certification number:Phil StollName: Business license n^e and number: Stoll Inspections or Name of local ui goyeri Date: 11/14/13Signature: TTY 651 -282-5332 or 800-657-3864 • Available in alternative formats Page 3 of 8 651-296-6300 • 800-657-3864www.pca.state.mn.us • wq-wwists4-31 • 4/24/09 17 000 no4 3 2004> 17 000^^ Il2‘|000 17 OCD^'^ l' I 7000 RnOfe- SteSbMdi: Pi'S^ Uji< Lu-v^ 1z ^SailBoiinp(KR#): Locate esciibanBgoa1faein^dKi^.iiidicatB<m&ei^itofftB caIunm.tb£ soil ttxiure, structure, coUh-, depth of eadidlfSnrwit soil typ^ evidence of mottling, bedrodk aad standing Tvato. Also nid&»te if is £IL BR.#SR# IffiCOM>imB OifcfiXriLatCL SBABCMAlliMHWAIBR^ti DSIBRiaiB)tBffiGraMDNaBLLCaL(&B0GK3 08.®8DC& ONAaaVELiNES . .{-joLliVui l^o(C!>U.’trvTLCffiraeatK WMneedniabecoinrirlHttohriBgftftihotattfcutfaM^flimuJite^gB—rfMTfhf:"^***^ met pnlsiff<iiia2_dav\bIsbBp3.riM'> 6/18/97 > 5.0. ^1F/, Lh CERTIFICATE OF COMPLIANCE m SEWAGE SYSTEM m .)HOLDING TANKS -aThis certificate has been issued this day of.19 7ft27 th March mmw^mmto certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.‘31 #1m The premises covered by this certificate are legally described as:rm Lake No. 56-768 Sec. 17 Twp. 137 Range 42•V-. ‘si',1; &Lot 1 Inwood Beach Third Addn.S' mm 53 fiPifcjDoyle KargelOwner: Name. R. 3. Box 139^ Pelican Rapids. MinnesotaAddress. M urn56572Zip No.wm mm-Permit No. SP_2258 Signed by:. Malcolm K. Lee, Shoreland Administrator Otter Tail County, Minnesota *MKL-087 1-009 m PT-g •M 159035 VICTOR LUNDtCN 4 CO. PRIRURS. rCRCUa r>LL0. UIlKI 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 ite — #Office V low — Inspector Pli.. Card — “Owner Owner 0 a 9 T'0 r Permit No___LEGAL 7(^Date DESCRIPTION AND eh 17 137 ii _h76j>LOCATION TWP NameLake Classif.Sec.TWP RangeLake No. Lake Name IDENTIFICATION: Please Print All Information. Zip No.Tel. No.Mailling Address —No. Street, City and State ,_____£ ? j/iV /i? f I Cdil —^ > Last Name First Initial 7 Vo V / -£KarOWNER SEWAGE SYSTEM INSTALLER Name. This System will be ready for inspection on., 19. This space for office use only 19 .M 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 3-/boo GIs.Sq. Ft.Sq. Ft.Capacity £7)Ft.Ft.Ft.Distance from nearest well Ft.Ft.Ft.Distance from lake or stream 'T-lA Ft.Ft.Ft.Distance from occupied building 'EJJLDistance from property line Ft.-Ft. Ft. Ft.Ft.Ft.Distance from bottom to Water Table AH distances are shortest distance between nearest points 7m7RECORD OF TESTS: uInspection was made on ' 19 , Time .jVI By PERCOLATION TEST DATA:Date of First Test , 19 . Rate Date of Second Test 19 , Rate•: 1st Test Taken By First Test + 2nd Test 2 Rate2nd Test Taken By The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work inAgreement; strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn­ esota Department of Health. Applicant agrees that plot plan, sketches and specifications submitted herewith and which are approved by Shoreland Management Offi­ cial shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the responsibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection. (Call or use attached mailer notice.) i P':Dated Aignature 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 conforn\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 js not commenced within six (6) months. Permit: ./'i nissued Date: Shpreland Management Ofjrici 5 \JFee $Surcharge $ Comments:. iiVICTOI LUMDttN 4 CO.. etlMTC**. rCKSUS rucLI. Mika 158906Form No. MKL-0771-003 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 — Office X low —'inspector Ph.. — Owner Card OvAiner a Permit No.. if yvUAPrsJ- (XAk/^'^3 -4^ /LEGAL Date DESCRIPTION AND LOCATION Lake No. Lake Name Lake Clatsif.Sec.TWP Range TWP Name IDENTIFICATION: Please Print All Information. Last Name First Initial Mailling Address —No. Street, City and State Tel. No.Zip No. OWNER SEWAGE SYSTEM INSTALLER Name. ^ ^ 19-^^ This System will be ready for inspection on. j ,'0OThis space for office use only r\A I '' (7 Cj .M Date Rec'd Time Rec'd Phone Cali Rec'd By Owner or Agent Signa.ture NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD GIs.Sq. Ft.Capacity Sq. Ft. Ft.Ft.Ft.Distance from nearest well Ft.Ft.Distance from lake or stream Ft. Ft.Distance from occupied building Ft.Ft. Distance from property line Ft.Ft.Ft. Ft.Ft.Distance from bottom to Water Table Ft. AH distances are shortest distance between nearest points RECORD OF TESTS: Inspection was made on 19,, Time JVI By PERCOLATION TEST DATA:Date of First Test , 19 , Rate Date of Second Test 19 , Rate 1st Test Taken By First Test -I- 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:. Form No. MKL-0771-003 vteTot kUMBKH t c« . attiUTca*. Fca«us raLL* y.N.lS8906 i * INSPECTION RESULTS » '■ iV.. 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 SF Distance from Nearest Well F 75F F 50FF F Distance from Lake or Stream F F F F F F Distance from Occupied Building 10 2020FFFF F F Distance from Property Line 10 10 10FFFFF F Distance from Bottom to Water Table 4 4FFFFF F /oir /0 K LDInspector's Comments: fe 0- LSV < 7s nc K ^ C:k V-70VA '■‘i G-'5o ■77 iDate of Inspection 19!___ ■1 Z^///Time of Inspection.M A Signature of lns|^6torINTERPRETATION OF ABBREVIATIONS GIs = Gallons SF = Square Feet F “ Linear Feet Job Title AgencyMKL>0771-003-Backer i j