HomeMy WebLinkAboutRegnbue Haven Resort_12000310216000_Septic System Permits_JPUT ........
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APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
LAND & RESOURCE MANAGEMENTOTTER TAIL COUNTY COURT HOUSE
121 W. JUNIUS AVE. • SUITE 130
Phone:(218)739-2271 • FERGUS FALLS, MN 56537
WHITE - Office
YELLOW-L & R Inspector
PINK - Owner / Contractor
/^/S-2LAPPLICATION MUST BE COMPLETE IN ORDER TO BE PROCESSED Permit No.t
LAKE NUMBER LAKE/RIVER NAME SECTIONLAKE/RIVER
CLASS TWP NO.RANGE TWP NAME
1^7 TJK Co/eussJ/0/G5%-/JO S D
PARCEL NUMBER (S) OF PROPERTY BEING SERVICED E-911 ADDRESS
Coo 3 / 0^1 (p Ooo Co. /i-Lu^ p
LEGAL DESCRIPTION
i-Dr J i sA/i 77^ SyC jPS
rLast Name First Initial Mailing Address Daytime Phone No.
^/7Z5'0 Tn ■ Huj y PProperty
Owner
B j-i oContractor
Lie.#/ L>(u2
A.M.
► This System will be ready for inspection on.the year of .P.M..at.
This space for office use only
.AM. P.M.
Date Received Time Received L & R Official
SEWAGE TREATMENT SYSTEM DESIGN DATATYPE OF INSTALLATION
(CIRCLE ONE)
TANK DRAINFIELD
Ft"Size GIs.Add-On/
Replacement
(32) Tank, Septic ■WS^ank, Lift
^) Trench, Rock
(35) Trench, Gravelless
(36) Trench, Chamber
(37) Bed
(38) Mound
(39) At Grade
(40) Combination
New System
(20) Trench, Rock
(21) Trench, Gravelless
(22) Trench, Chamber
(23) Bed
(24) Mound
(25) At Grade
Setback to nearest well Ft.Ft.
¥Setback to OHWL (lake &/or river)Ft. Ft.
Setback to wetland Ft.Ft.
Setback to dwelling Ft.Ft.Collector System
(26) Trench, Rock
(27) Trench, Gravelless
(28) Trench, Chamber
(29) Bed
(30) Mound
(30) At Grade
VSetback to non-dwelling Ft.Ft.
Setback to nearest property line Ft. Ft.Other
(41) Tank, Holding
(42) Outhouse "fief^ewer Line
(44) Performance
(45) Warrantied
(46) Miscellaneous
Setback to road right-of-way Ft.Ft.
Elevation above restrictive layer Ft.Ft.
ALL DISTANCES ARE SHORTEST DISTANCE BETWEEN NEAREST POINTS.
DEPTH OF WATER WELL #B£QTO0MS
GARBA&E'D1§R Y / N
ABATEMENT Y>N-
ABSORRRON AREA FOR MOUNDS
Ft^EFFLUENTDISTRIBUTION
( ) Gravity
( ^ Pressure
HOLDING TANK MONITOR/
DISPOSAL CONTRACT
p><^Yes J
( ) No-L&R Can Not Process
Designer
Designer Lie. #__
PERCOLATION
TEST DATA
Date of Test Highest Rate
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 accordance 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 instaliation is
ready for inspection.
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express con
dition that the person to whom it is granted, and his agent, empioyees 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: This permit is valid for a period of six (6) months.
A copy of the final Inspection Report will serve as the Certificate of Compliance for approved Installations.
^OO
—Date:Permit Fee $
Signature of Property Qwner/Agent for Owner
Date: . S QJ-Rec. No.<1
Land a Raaource Management Office
Comments:
Form No. BK — 0201-003 304.4S5 • Victor Lundeen Co., Prinlors • Porgus Falls, Minnesota
1.
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
LAND & RESOURCE MANAGEMENTOTTER TAIL COUNTY COURT HOUSE ^
121 W. JUNIUS AVE. • SUITE 130
Phone:(218)739-2271 • FERGUS FALLS, MN^537 ,
WHITE - Office
YELLOW - L&R Inspector
PINK - Owner / ContractorI.
e\AAPPLICATION MUST BE COMPLETE IN ORDER TO BE PROCESSED Permit No.
c
LAKE NUMBER LAKeRIVER NAME SECTIONLAKE/RIVER
CLASS TWP NO.RANI TWP/NAME1-
,3/130/T. P/f^e\ S'L-Bo 0D Oje^-issld
Co. //ccv fr
PARCEL NUMBER (S) OF PROPERTY BEING SERVICED E-911 ADDRESS
Ooo 3 f o<^/ G (Do o
LEGAL DESCRIPTION
J-or'■
Last Name First Initial Mailing Address Daytime Phone No.'fcj,Property
Ownerr 'XO X 4 r 7. ?
_____________________________
Contractor
Lie. ft
rV
A.M.
>■ This System will be ready for inspection on.the year of
This space for office use only
//oo57^/0 /A.M. P.M.Ef Date Received Time Received L&R Official
SEWAGE TREATMENT SYSTEM DESIGN DATASTYPE OF INSTALLATION
(CIRCLE ONE)
t TANK DRAINFIELD
f Ft"t Size GIs.Add-On/
Replacement
(32) Tank, Septic
T^CTank, Lift (^4) Trench, Rock
(35) Trench, Graveiless
(36) Trench, Chamber
(37) Bed
(38) Mound
New System
(20) Trench, Rock
(21) Trench, Gravelless
(22) Trench, Chamber
(23) Bed
(24) Mound
(25) At Grade
Setback to nearest well Ft.Ft.
Setback to OHWL (lake &/or river)Ft.Ft.e;
Setback to wetland Ft.Ft.
1
Setba^ to dwelling
-ti------------------------------------
Setba^o non-dwelling
Ft.Ft.Collector System
(26) Trench, Rock
(27) Trench, Gravelless
(28) Trench, Chamber
(29) Bed
(30) Mound
(30) At Grade
/
(39) At Grade , \ ( 1
(40) CombinatiOT \w 1/Ft. Ft.
* ^^^«f6ack to nearest property line Ft. Ft.Other
(41) Tank, Holding
(42) Outhouse
T^St^Sewer Line
(44) Performance
(45) Warrantied
(46) Miscellaneous
Setback to road right-of-way Ft. Ft.
Elevation above restrictive layer Ft. Ft.
ALL DISTANCES ARE SHORTEST DISTANCE BETWEEN NEAREST POINTS.
DEPTH OF WATER WELL # BEDROOMS.ABSORPTION AREA FOR MOUNDS
GARBAGE DISR Y / N
ABATEMENT Y7T+Ft^EFFLUENT
DISTRIBUTION
( ) Gravity
( ^Pressure
HOLDING TANK MONITOR/
DISPOSAL CONTRACT
pAYes D
( ) No-L&R Can Not Process
Designer__D:
Designer Lie. #
!
I
i
PERCOLATION
TEST DATA
Date of Test Highest Rate
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 accordance 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.
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express con
dition that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the Sanitation Code of Otter Tail County,
Minnesota. This permit may be revoked at any time upon violation of the Sanitation Code.
NOTE: This permit is vaiid for a period of six (6) months.
A copy of the final Inspection Report will serve as the Certificate of Compliance for approved installations.
->4 /00
S-a —Date: 4^/ CY /V Permit Fee $■ \
Signature of Property ^ner/Agent for Owner
/yjs j-9Date: S ^/O /3P Rec. No.--C
Land S Resource Management Office
Comments:
Form No. BK — 0201-003 304.46S • Victor Lundson Co., Printers • Fergus Falls. MinnesotaL
SEWAGE TREATMENT SYSTEM PERMIT INSPECTION RESULTS
Inspector must make all measurements
HOLDING
SEPTIC TANK DRAINFIELD OUTHOUSELIFT TANKCATEGORY
gl|.Capacity FT2GLS.
1 rf FTSetback from Nearest Well FT FT FT
Setback from Buried
Water Suction Pipe FT FT FT FT
Setback from Buried Pipe
Distributing Water Under Pressure FT FT FT FT
7/r-tSetback from OHWL (lake &/or river)FT FT FT FT
Setback from Setback from Wetland FT FT FT FT
} 0Setback from Dwelling FT FT FT FT
Setback from Non-Dwelling FT FT FT FT
Setback from Nearest Property Line FT FT FT FT
7mSetback from Right-of-Way FT FT FT FT
Elevation above Restrictive Layer FT FT FT FT
Holding Tank/Lift Alarm NO
Old System Pumped & Destroyed y YES NO
SEPTIC TANK FILTER Sewer Line to Well Separation DRAINFIELD CALCULATION
Actual Minimum
Manuf.□ YES ,FTX',Z>fs LModel #.ft^□ NO FT 20
MOUND CALCULATION
MOUND /AT-GRADE ROCK REDUCTION
Inspector’s Comments:,
ABSORBTION AREA Rock trenches with inches
of rock under pipe for .%Ft. X
r DF.reduction / equivalent toFt2
SKETCH:
i
5V
V
cl , the Sewage Treatment System
serving the previously described property is approved for use.
Lsnd-& Resource Management OfficialA £6-^/i
CERTIFICATE OF APPROVAL
SEWAGE SYSTEM
December15thThis certificate has been issued this day of
to certify that the sewage system installed as per sewage permit number indicated below has been approved for use
by Otter Tail County, Minnesota.
The premises covered by this certificate are legally described as:
Twp. Name CORLISSLake No.Twp. 1375A-130 Sec. 31 Range 38m
31 137 38
PART GL 3 COM NW COR LOT 1WilLEWIS WARD MARTIN'S PERFECT
BEACH S 497' S 51 DEG W 80' TO17
m BG N 30 DEG W 339. 18' TO POINT
m Owner: Name I AWRFNr.F A K I FNORA FHAUFR.
mi.Address RR 1 nny i.^c>. pfrham. mn
Zip No.!^A!o73?■ -
Permit No. SP 1 nAnA
Signed by:
Land & Resource Management OfTIcial
Otter Tail County. MinnesotaMKL-0987001
gS
Wi-'iXj x tel
JT 279005 Victor Lundeen Co.. Printers. Fergus Fells. MiimesoU
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
WHITE — Office
Yellow — Inspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone:(218)739-2271 - FERGUS FALLS, MN 56537
/ 6 /O y/ /o f y/I/I 7^/■i-/ i-
K.
Permit No.LEGAL O
DESCRIPTION
C /^ / /AND
LOCATION
TWP NAMERANGESECTIONLAKE/RIVER
CLASS TWP. NO.LAKE/RIVER NAMELAKE NUMBER
ni3l7^-no l/^.,
PARCEL NUMBER(S) ' 7
C, c r ^ ^C D.
FIRE OR LAKE ASSOCIATION NUMBER
U-€00 ~i I 0//ir^ GdO
IDENTIFICATION: Please Print All Information
Zip CodeMailing Address — No. Street, City and State Telephone No.InitialLast Name First
.A #*->. /i'T .
_________________________________
Property
Owner
D/yf/ SCSewage
System
Installer
Name
SCS/
A.M.
P.M.. 19.This System will be ready for inspection on at
This space for office use only
NUMBER OF BEDROOMS:
A.M.
P.M19 GARBAGE DISPOSAL: ( ) YES ( ^) NO
Phone Call Rec'd ByDate Rec'd Time Rec’d
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
) Septic tank
(;0 Lift station
(^‘) Drain field
( ) Standard (Bed ( ) Trench
( ) Modified
(yQ Mound
( ) Outhouse
DRAIN FIELDTANK
Sq/dVO frcr li.GIs.Ft.Capacity
/O //c^VFt. Ft.Distance from nearest well
t^O Ft.Ft.Distance from lake or stream
Ft.Ft.Distance from building
/OJSLFt.Ft.Distance from property line
3Distance from bottom to Water Table Ft.Ft.
EFFLUENT DISTRIBUTION All distances are shortest distance between nearest points
( ) Gravity
(V) Pressure PERCOLATION TEST DATA:
WATER WELL DEPTH
A./■/- iM^Perc Tester,Date of Perc Test
LasRate of 1st Test Rate of 2nd Test Average Rate
Agreement: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in strict
accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota Department
of Health. Applicant agrees that piot plan sketches and specifications submitted herewith and which are approved by Shoreland Management Officical shall become a part
of the permit. Applicant further agrees that no part of the system shall be cove
the permit to notify the County Shoreland Management that the job is ready/or Inspection.until it has been inspected and accepted. It shall be the responsibilty of the applicant for
DATE:
Signature
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express condition
that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the Ordinance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances.
NOTE: Permit void If work is not commenced within six (6) months.
-? r//'??Issued Date:
Land & Resource Management Office eT# DJj/p
——- 22m—
Fee $.Rec #.
/7ursfN-O'jl i e y-dfci- / S', eComments:
tOS/y-L T .X-L’
5.
272.858 - Victor Lundeen Co.. Printers, Fergus Falls. MinrtesotaForm No. BK-08S4-003
' • “i
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM,
WHITE — Office
Yellow — Inspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone: (218) 739-2271 - FERGUS FALLS, MN 56537
/ o^o y/Z./I/ILEGAL O '
DESCRIPTION s 't=i (Pi/■
£ / yAND
LOCATION
I
RMieE■-LAKE/RIVER
_ CLASSI/?,. /‘^/CD.
PARCEL NUMBER(S) 7
jj COO 1) Oj/l^
SECTIONLAKE/RIVER NAME TWP NAMELAKE NUMBER TWP. NO.
1313l Cor I SS
FIRE OR LAKE ASSOCIATIOJ UMB
V (I
/^•nn 5-5DIDENTIFICATION: Please Print All Information
,JrSilial Mailing Address — No. Street, City and Stale Zip Ngde Telephone No.Last Name First
/,^rry__/ Y/g__2tL rJ /.LJ.i/C - y 7ybu c /"Property
Owner azM
Sewage
System
Installer
Ueme/j/lj/ _S C //^r /:>
S<^S/ /S/S-7170/
s y;/ -30This System will be ready for inspection on . 19.at
FThis space for office use only
NUMBER OF BEDROOMS:
IA.M.((-30-P.M GARBAGE DISPOSAL: (' ) YES ( ^) NO
Time Rec'd Phone Call Rec'd ByDate Rec'd
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)
(. ) Septic tank
( V ) Lift station
( - ) Drain field
( ) Standard (X)Bed ( ) Trench
( ) Modified
( X) Mound
( ) Outhouse
_________TANK
/doo/r.cx' /J. 3 /
DRAIN FIELD
SqCapacityGIs.Ft.
Ft. Ft.Distance from nearest well Vo
5050 Ft.Distance from lake or stream Ft.
/4/Distance from building Ft.Ft.U/JO
/oDistance from property line Ft./o Ft.
3Distance from bottom to Water Table Ft. Ft.
EFFLUENT DISTRIBUTION
( ) Gravity
(y) Pressure
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:
WATER WELL DEPTH
Perc Tester.Date of Perc Test
t.n\aiRate of 1st Test Rate of 2nd Test Average Rate
Agreement: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in strict
accordance with Ordinances of the County of Otter Tail, Minnesota and Minn^pta Individu^Sewage Qjsposal Code Minimum Standards set forth by Minnesota Department
of Health. Applicant agrees that plot plan sketches and specifications subnlf^d herewith i^d^hich 4|e approved by Shoreland Management Officical shall become a part
of the permit. Applicant further agrees that no part of the system shall be covefed until it haSbeen inspected and accepted. It shall be the responsibilty of the applicant for
the permit to notify the County Shoreland Management that the job is ready/or Inspection.
Signature^ ^ r
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express condition
that the person to whom it is granted, and his agent, employees and workmen shall conform in all respects to the Ordinance of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of any said ordinances.
NOTE: Permit void if work is not commenced within six (6) months.
//-/F-yxDATE:
// 7; - ?YIssued Date:
Land & Resource Management Office3S, -Fee $._ Rec #
7rK.<f( Qr^.e l/0fi_r /7 r>ofUrComments:Ou \ €V'
f
//!
“
272.858 • Victor Lundeen Co.. Printers. Fergus Falls. MinnesotaForm Mo. BK-0894.003
------TT—-
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK DRAIN FIELD
CATEGORY Actual MinimumMinimumActual
/Q SF(GLS.Capacity SFGLS.
^3 (e(D n-FTDistance from Nearest Well FT FT50
Distance from Buried
Water Suction Pipe FTFTFT FT 5050
Distance from Buried Pipe
Distributing Water Under Pressure FTFTFT FT 1010
FTlaX> f FT FTDistance from Lake or River (OHWL)FT
6,0 FT
FT
10/20 FTFT10FTDistance from Nearest Building
/OFT FTDistance from Nearest Property Line 10
tS'jl 3FT FTDistance from Bottom to Water Table FT 3J1 /cy^7-YES NOHolding Tank/Lift Alarm
DRAINFIELD CALCULATIONSewer Line to Well SeparationINTERPRETATION
OF ABBREVIATIONS
GLS. = Gallons
SF = Square Feet
FT = Linear Feet
Actual Minimum
FT
6 FT 20 FT SF
IInspector’s Comments:
loco*
i «. C, e_'Nv »
SKETCH
y
SWL4>
Inspector's Signature
//Jo-‘5-/
Date of Inspection
^600/XcrC
Time of Inspection
AIR TEST CEBTZFZCATIOil
On C- /J - y i''
Dlflpoaal Syatn Pffrplt Huabar O Y
Ovnvr)p on
ilnov held _
(Date)p an air toet of the never line InatBlled under Seoage
^ / Y /A W 6
(Lake/Rlver) vae nade. At that tinof the sever
: for
IS'r cpounds per square inch for.ulnutes.B »
Lloenee Nuaber DateInstaller's Signature
A42991
I
GRID PLOT PLAN SKETCHING FORM — (Must Be To Scale)
Scale: Each grid equals feet / inchei
ui-!
Dated:19 Signature
Please sketch your lot indicating setbacks from road right-of-way, lake and sideyard for each building currently
on lot and any proposed structures.
LAk<^i P'P—d tUk!
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PERCOLATION TEST DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, MN 56537
OWNER:
LAS^NAME L A.77^0
TELEPHONE NUMBER±J-ct f r MIDDLEFIRST
ADDRESS:
LAKEji,
Ain,
STATE
XI TWP. NAMERANGESEC.AMELAKE/RIVER NO.
LEGAL DESCRIPTION:/^ / A 0 1^/) I)
^! T of
JD OOP 1! o^/U 000
PARCEL NUMBER
<L-no
ft p
J 221994 pi
, i,Ax^.gs§§yiis^
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NUMBER/BEDROOMSFIRE NUMBER
— TWO TESTS ARE REQUIRED —
TEST HOLE NO. 2TEST HOLE NO.2IP inchesinches; Diameter of Hole _Depth To Bottom of Holeinches; Diameter of Hole.inchesDepth To Bottom of Hole
H-n-iP-
___
rA iJ>/C4 / d-
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19 19Date DateSoil Texture Soil TextureDepth. InchesDepth. Inches
Percolation
Test By
Firm
Name
Percolation
Test By____
Firm
Name ____
Address Address
Otter Tail County
License No.
Otter Tail County
License No.
PERC TEST # 2PERC TEST # 1
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CERTIFICATE OF COMPLIANCE
SEWAGE SYSTEM
HOLVJNG TANK miLM<J9llJanuoAtf22nd mday of_This certificate has been issued this
to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.
¥'IThe premises covered by this certificate are legally described as:
Range r.mCofdLLi>i>Twp. ^56-730 5ec___^SI Twp. Name.Lake No./<
i Att that pt. 0^ G.L. 3
Ely oi S.A.R., tu. [{^ohmeAly Rainbow Beach RcdOAt]MM§■
mmKenneth KadlngOwner: Name.
w.R R 7 Box SO PeAham, MinnesotaAddress.I
56573Zip No.
m7205Permit No. SP_
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
mite — Office
Yetlow — Inspector
Pink — Owner
aPermit No.,
LEGAL
SA A . ^ yfDESCRIPTION
AND
c^.IL LIlSLzIAjS)LOCATION
TWP NameTWPLake Classif.Sec. RangeLake No.Lake Name
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Tel. No.Zip No.InitialFirstLast 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 Owner or Agent Signa^tureTime Rec'd Phone Call Rec'd 8y
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PIT DRAIN FIELD
Sq. Ft.T / .--e/3 GIs.Sq. Ft.Capacity A./1
■t ■f
lo Ft.Ft.Ft.Distance from nearest well t!Xcr^/- Ft.Ft.Ft.Distance from lake or stream
Ft.Ft.Ft.y c/Distance from occupied building
Distance from property line Ft.Ft.Ft.
Ft.Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19 , Time ,M By
PERCOLATION TEST DATA:Date of First Test 19 . Rate
Date of Second Ti 19 Rate
Itt Test Taken By
FirstyTest + 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.
la'iSDated
X 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.
Shorefend Menegement Office
ya-j-j /TryIssued Date;.L' .t
Fee $ cP (/.Rec #
Ayr .q,.Comments: /'^LJLi.
Form No. MKL-032085 225239 — Vidor Lundom Co.. PrMars. Fergus Fals. MN
■r •m’'.
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 —OtHcB
Yellow — Inspe^orPink — Owner
•]Permit No../1LEGALi/■
DESCRIPTION
<. t-tAND4'S A
LOCATION yf
TWP NameTWPLake Classif.Sec.RangeLake No.Lake Name
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Zip No.Tel. No.First InitialLast Name
RR I ___
_______P^hdyyv) kJjL^Ayy\
OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
I ^^ '(OO i '2 O
This System will be ready for inspection on., 19.
This space for office use only
/il-L J± ??;/r M
Date Rec'd Owner or Agent SignatureTime Rec'd Phone Call Rec'd By
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
Sq. Ft.GIs.Sq. Ft.Capacity
Ft.Ft.Ft.Distance from nearest well
Ft.Ft.Ft.Distance from lake or stream
Ft.Ft. Ft.Distance from occupied building
Distance from property line Ft.Ft.Ft.
Ft.Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
\RECORD OF TESTS:
Inspection was made on 19,, Time ,M By
PERCOLATION TEST DATA:Date of First Test 19 , Rateteej
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 inspect^ 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.
Dated
Signature
Permit; Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE: Permit void if work is not commenced within six (6) months.
Issued Date:
Shoreland Management Office
Fee $Rec #
/Comments:
- •a.,.-" ■ '
Form No. MKL-032065 225239 — Viclor Lindm Co.. PrvMrs. Ftrgus Fall. MN
f
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYShould BeShould BeActualShould Be Actual ActualCl !d>0 d i
Capacity f I') / L^<Av^fy
Distance from Nearest Well
^SOO S FS FGIs.GIs.S F S F
+-FFFFFF
+-)ooDistance from Lake or Stream F FFFFF
Distance from Occupied Building F F FF F F
16^Distance from Property Line F F FFFF
3 3Distance from Bottom to Water Table FFF FFF
Inspector’s Comments:
OVN \p\ ''<r^4r- Y^c/WvV^ ysJL_
______'l lA ^ ^ 'g -^\\\ -L Sy V\v^
I
M-iu19Date of Inspection
3'.ocy MTime of Inspection
Cpg fcfrr\
Signature of Inspector
INTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
F = Linear Feet
¥
Job Title
MKL • 032085 • Backer Agency
A'^
9- Qu a ^
Q.O
SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 — Fergus Falls, Mn. 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
White ^ Office
Yellow — JnspectorPink
Card — Owner
Owner
Permit No.,LEGAL
Date
DESCRIPTION
AND
Lake No. ^ Lake Name
3/ 131 5f CmLOCATION
Lake Classif.Sec,TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
Mailling Address —No. Street, City and StateFirstInitiai Zip No.Tel. No.Last Name
l\i~i £/U)OWNER
r<uX-ii miL.$(=673
SEWAGE
SYSTEM
INSTALLER
Name,
This System will be ready for inspection ., 19.on.
This space for office use only
.19
Phone Call Rec'd ByDate Rec'd Time Rec'd Owner or Agent Signa^ture
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
/GIs.Sq. Ft.Sq. Ft.Capacity
50 Ft.1 ^ K Ft.Ft.Distance from nearest well
5^ Ft.Ft.Ft.Distance from lake or stream
/Q Ft.Ft.Ft.Distance from occupied building
JO 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:
Inspection was made on 7'Time ,JVI By
PERCOLATION TEST DATA:Date of Firj 19
. 19
, Rate1st
late of Second Test , Rate
1st Test Taken By
First Test -I- 2nd Test s;"i RateTaken By2nd
The undersigned hereby makes application for permit to instali 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.)
L - 3 3-7^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
9r ^ A CVor.U' ^'h-1^Issued Date:
Shoreland Management Officer50>Fee $Surcharge $
Comments:.
Form No. MKL-0771-003 158906
VICTO* LVMBEEH t «».. PRIMTCRB. riHVUI rALI.8.
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 - o’ffic8
Yellow^ —, Jnspector
Pink Owner
C^d Owner
5Permit No..LEGAL
Date
DESCRIPTION
AND
V ■*. /LOCATION I
Lake No. Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
InitialFirst Mailling Address —No, Street, City and StateLast Name Zip No.Tel. No.
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 Signajture
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PITSEPTIC TANK DRAIN FIELD
1 GIs.Sq. Ft.Sq. Ft.Capacity \
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
Date of First- Test....
Date of Second Test
PERCOLATION TEST DATA:, 19 , Rate
19 , Rate
1st Test Taken By
First Test + 2nd Test
Rate2nd Test Taken By
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work 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 $
NOT CALLED FOR INSPECTComments:.
iForm No. MKL-0771-003 ViCTen LUMQCCH » CO.. eaiNTCM. rtoaus rktLa.
158906
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORYActualShould be Actual Should be Actual Should be
Capacity GIs.GIs.S F SF 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 201020FFFF F F
Distance from Property Line 10 10 10F F F F F F
Distance from Bottom to Water Table 4 4FFFFF F
Inspector's Comments:
A
Date of Inspection 19.
Time of Inspection M
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF - Square Feet
F * Linear Feet
Job Title
- -
n
r. iL.. '
> HT
Agency-r MKL-0771.003-Backer
^ ■ i
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GRID PLOT PLAN SKETCHING FORM».feet/inches.Scale: Each grid equals
Application for Building Permit Dated
Application for Sewage System Permit Dated
Building Permit Number_________________
Applicant agrees that this plot plan is a part of application (s) indicated above.
.1
.19.
19
Sewage System Permit Number.
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