HomeMy WebLinkAboutRogness_38000130092002_Septic System Permits_„ Minnesota Pollution
Control Agency
520 Lafayette Road North
St. Paul, MN 55155-4194
Compliance Inspection Form
Existing Subsurface Sewage Treatment Systems (SSTS)
Doc Type: Compliance and Enforcement
For local tracking purposes;
^ received
Inspection results based on Minnesota Pollution Control Agency (MPCA)
requirements and attached forms - additional local requirements may also apply.
Submit completed form to Local Unit of Government (LUG) and system owner
within 15 days 0'
land & RESOURCE
System Status
System status on date (mm/dd/yyyy): 9/3/2014
O Noncompliant- Notice of Noncompliance
(See Upgrade Requirements on page 3.)
1^ Compliant - Certificate of Compliance
(Valid for 3 years from report date, unless shorter time
frame outlined in Local Ordinance.)
Reason(s) for noncompliance (check all applicable)
D Impact on Public Health (Compliance Component #1) - Imminent threat to public health and safety
□ Other Compliance Conditions (Compliance Component #3) - Imminent threat to public health and safety
□ Tank Integrity (Compliance Component #2) - Failing to protect groundwater
□ Other Compliance Conditions (Compliance Component #3) - Failing to protect groundwater
□ Soil Separation (Compliance Component #4) - Failing to protect groundwater
□ Operating permit/monitoring plan requirements (Compliance Component #5) - Noncompliant
Property Information
Property address: 33659 Pickeral View Dr, Richville, MN 56576
Property owner: Margaret Rogness__ _
Parcel ID# or Sec/Twp/Range: 38000120084001
Reason for inspection: Transfer of ownership
Owner’s phone:________________________4or
Owner's representative: ^e Rogness
Local regulatory authority: Ottertail Co Land and Resource Dept
Brief system description: 2 septic tanks, lift, drainfield trenches (gravelless pipe)
Comments or recommendations:
Old cesspool/seepage tank still on property. Suggested it be destroyed/filled. Joe Rogness agreed and had plans in place to make
that happen.
Representative phone: 612-770-9526
Regulatory authority phone; 218-998-8095
\
Certification
/ hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No
determination of future system performance has been nor can be made due to unknown conditions during system construction,
possible abuse of the system, inadequate maintenance, or future water usage.
Inspector name; Bill Schueller
Business name: Schuellet!s Septic Solutions
Inspector signature:
Certification number: ^3332
License number:
Phone number:'.
Necessary or Locally Required Attachments
^ System/As-built drawing^ Soil boring logs
□ Other information (list):
S Forms per local ordinance
www.pca.state.mn.us • 651-296-6300 • 800-657-3864
wq-wwists4-31b • 6/4/14
TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
Page 1 of 3
Inspector initials/Date: BJS | 8/18/2014Property address: 33659 Pickeral View Dr, Richville, MN 56576
(mm/dd/yyyy)
1. Impact on Public Health - Compliance component #1 of 5
Verification method(s):
S Searched for surface outlet
^ Searched for seeping in yard/backup in home
Q Excessive ponding in soil system/D-boxes
D Homeowner testimony fSee Comments/Explanation)
□ “Black soil” above soil dispersal system
Q System requires “emergency” pumping
□ Performed dye test
D Unable to verify (See Comments/Explanation)
□ Other methods not listed (See Comments/Explanation)
Compliance criteria:
System discharges sewage to the
ground surface. __
System discharges sewage to drain
Jile or surface waters.
System causes sewage backup into
dwelling or establishment.
Any “yes” answer above indicates the
system is an imminent threat to public
health and safety.
Comments/Expianation:
□ Yes S No
□ Yes S No
□ Yes S No
2. Tank Integrity - Compliance component #2 of 5
Verification method(s):
S Probed tank(s) bottom
^ Examined construction records
□ Examined Tank Integrity Form (Attach)
O Observed liquid level below operating depth
K Examined empty (pumped) tanks(s)
□ Probed outside tank(s) for “black soil”
□ Unable to verify (See Comments/Explanation)
n Other methods not listed (See Comments/Explanation)
Compliance criteria: ___
System consists of a seepage pit,
cesspool, drywell, or leaching pit.
Seepage pits meeting 7080.2550 may be
compliant if allowed m local ordinance.__
Sewage tank(s) leak below their
designed operating depth.
If yes, which sewage tank(s) leaks:
Any “yes” answer above indicates the
system is failing to protect groundwater.
Comments/Explanation:
□ Yes E No
□ Yes E No
3. Other Compliance Conditions - Compliance component #3 of 5
a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. □ Yes* H No □ Unknown
b. Other issues (electncal hazards, etc.) to immediately and adversely impact public health or safety. □ Yes* E No □ Unknown
*System is an imminent threat to public health and safety.
Explain:
c. System is non-protective of ground water for other conditions as determined by inspector. □ Yes* ^ No
*System is failing to protect groundwater.
Explain:SCANNED
651-296-6300 • 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
Page 2 of 3
www.pca.state.mn.us •
wq-wwists4-31b • 6/4/14
Property address: 33659 Pickeral View Dr, Richville, MN 56576 Inspector initials/Date:1 9/3/2014
(mm/dd/yyyy)
4. Soil Separation - Compliance component #4 of 5
Date of installation: 4/21/1994
(mm/dd/yyyy)
Shoreland/Wellhead protection/Food beverage
lodging?
Compliance criteria: __
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:
Drainfield has at least a two-foot vertical
separation distance from periodically
saturated soil or bedrock.
O Unknown Verification method(s):
Soil observation does not expire. Previous soil
observations by two independent parties are sufficient,
unless site conditions have been altered or local
requirements differ.
^ Conducted soil observation(s) (Attach boring logs)
D Two previous verifications (Attach boring logs)
r~l Not applicable (Holding tank(s), no drainfield)
□ Unable to verify fSee Comments/Explanation)
r~l Other (See Comments/Explanation)
S Yes □ No
□ Yes □ No
S Yes D NoNon-performance systems built April 1,
1996, or later or for non-performance
systems located in Shoreland or Wellhead
Protection Areas or serving a food,
beverage, or lodging establishment:
Drainfield has a three-foot vertical
separation distance from periodically
saturated soil or bedrock.*
Comments/Explanation:
Soil Boring:
0-5 Sandy Loam 10yr 3/1
5-8 Sandy Loam 10yr 3/4
5-80 Coarse sand 10yr 4/4-6Z4
□ Yes □ No“Experimental", “Other", or “Performance"
systems built under pre-2008 Rules; Type IV
or V systems built under 2008 Rules (7080.
2350 or 7080.2400 (Advanced Inspector
License required)
Drainfield meets the designed vertical
separation distance from periodically
saturated soil or bedrock.
Any “no” answer above indicates the system is
failing to protect groundwater.
Indicate depUis or elevations
40A. Bottom of distribution media
80+B. Periodically saturated soil/bedrock
C. System separation ____40
D. Required compliance separation* 36
‘May be reduced up to 15 percent if allowed by Local
Ordinance.
5. Operating Permit and Nitrogen BMP* - Compliance component #5 of 5 ^ Not applicable
□ Yes □ No If “yes”, A below is required
D Yes D No If “yes”, B below is required
Is the system operated under an Operating Permit?
Is the system required to employ a Nitrogen BMP?
BMP = Best Management Practice(s) specified in the system design
If the answer to both questions is “no”, this section does not need to be completed.
Compliance criteria
a. Operating Permit number: ______
Have the Operating Permit requirements been met? ____
b. Is the required nitrogen BMP in place and properly functioning?
Any “no” answer indicates Noncompliance.
□ Yes □ No
□ Yes □ No
Upgrade Requirements (Minn. Stat § 115.55) An imminent threat to public health and safety (ITPHS) must be upgraded, replaced, or its use discontinued within ten months of receipt of this notice or within a shorter period if required by local ordinance. If thd^^terru:
ground water, the system must be upgraded, replaced, or its use discontinued within the time required by local ordirianeq. Ip
is not failing as defined in law, and has at least two feet of design soil separation, then the system need not be upgraped,^ rafi
its use discontinued, notwithstanding any local ordinance that is more strict. This provision does not apply to systemsTn shoreland areas,
Wellhead Protection Areas, or those used in connection with food, beverage, and lodging establishments as defined in law.
wvw.pea.state.mn.us • 651-296-6300 • 800-657-3864
wq-wwists4-31b • 614114
TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
Page 3 of 3
Department of
LAND AND RESOURCE MANAGEMENT
OTTER TAIL COUNTY
Government Services Center - 540 West Fir
Fergus Fall^. MN 56537
PH: 21S-99S-S095
Otter Tail County's Website; www.co.ottcr-taii..mn.us
OTTjERTflIl
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: 38000120084001_______________
Township: Maine____________________________
Property Owner Name(s): Margaret Rogness___________________
Property Address: 33659 Plckeral view or, Richvllle, MN 56576
Reason for Inspection. Transfer of ownership
Number of Bedrooms: 9
Section:12
□Yes[^In Shoreland Area?
Lake/River Name, Number, & Class
No
Pickeral 56-475 RD
System Compliance Status: ^ Compliant
Non-Com pliant
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
Yes
Yes
X No
X No
X No
Yes X 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 ali 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:Bill Schueller
Certification Number:C3332
Business License Name & Number:Schuelleks Septic Solutions LLfi L2945
Signature:Date:9/3/2014
Excel/Compliance Form for OTC 4/30/2014 Page 1 of 2
SCANNED
otter Tail County Compliance Inspection Form Addendum (cont.)
Parcel Number:
Date & Initial:9/3/2014
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).
0
^0
/ \\
5:5
's:
On
/^Ad
Q rA/Jfc
ix
Additional Comments:
A/^-T '71? ______
Excel/Compliance Form for OTC 04/30/2014 Page 2 of 2
SCANNED
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
WHITE — Office .
Yellow — Inspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone:(218)739-2271 - FERGUS FALLS, MN 56537
Permit No.LEGAL
DESCRIPTION GLleAND
LOCATION
SECTIONLAKE/RIVER RANGE TWP NAMELAKE NUMBER TWP. NO.CL
FIRE OR LAKE ASSOCIATION NUMBERPARCEL NUMBER(S)
SfS-ow- /;?- ooi^-dOO
IDENTIFICATION: Please Print All Information
Mailing Address — No. Street, City and State Zip Code Telephone No.InitialLasU^ame_____________________/ First
Property
Owner /S'&637f)AjLA- \/)rjAA
Sewage
System
Installer
Name
A.M.
P.M.This System will be ready for Inspection on , 19-at
This space for office use oniy
NUMBER OF BEDROOMS:
A.M.
(X) NOP.M19 GARBAGE DISPOSAL: ( ) YESPhone Call Rec’d ByTime Rec'dDate Rec’d
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
DRAIN FIELDTANK
( ) Holding tank (Al^m Required)
Septic tank-:jfe'^-^4^
) Drain field ^ ‘
3m>o GIs.Capacity Ft.
Ft.Distance from nearest well t.
) Standard ( ) Bed ) Trench 2£.(Ft. Ft.Distance from lake or stream • ■ft/ii
21( ) Modified
( ) Mound
Ft.Distance from building Ft.L
[0_Ft. Ft.Distance from property line
EFFLUENT DISTRIBUTION
( ) Gravity
( ) Pressure
7 .5Distance from bottom to Water Table Ft. Ft.
All distances are shortest distance between nearest points
WATER WELL DEPTH:
^-27/)PER^i^ATION TEST DATA: Date of First Test , 19 Rate
Date of Second Test , 19 Rate
1st)fe^Taken By < /+ 2nd TestFirst Test Rate22nd Test Takm By
Agreement: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in strict
accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota Department
of Health. Applicant agrees that plot plan sketches and specifications submitted herewith and which are approved by Shoreland Management Officical shall become a part
of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the responsibilty of the applicant for
the permit to notify the County Shoreland Management that the job is ready for inspection.
DATE:
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.
Issued Date:
Land <& Resource Management Office
Fee $.Rec #,
nJ yyytJ£Comments^
Form No. BK-0993-003 266,559 • Victor Lundeen Co., Printers • Fergus Falls, MN - 600-346-4670
!
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
WHITB — Office .
Yellow — Inspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone: (218) 739-2271 - FERGUS FALLS, MN 56537
Permit No.LEGAL
DESCRIPTION
AND
LOCATION
LAKE/RIVER NAME SECTIONLAKE NUMBER LAKE/RIVER
CLASS, -1kb
RANGE TWP NAMETWP. NO.
cAijcajU
PARCEL NUMBER(S) FIRE OR LAKE ASSOCIATION NUMBER
3-000- /a- oo?<j-dOO<S>
IDENTIFICATION: Please Print All Information
Mailing Address — No. Street, City and Slate Zip CodeLast Name Initial Telephone No./, FirstKjj^JIIa^sLL WfjProperty
Owner /
f ■ ■ ■' ■ ™ ^ - - 1 - - - - - - r %.rt
Sewage
System
Installer
/Name y
}xoo^a;i\3>o1/A.M.ty_This System will be ready for inspection on 19.P.M.at
This space for office use only ClNUMBER OF BEDROOMS:
A.M.(I (X)19 P.M..GARBAGE DISPOSAL: ( ) YESPhone Call Rec^ ByDate Rec'd Time Rec’d
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
DRAIN FIELDTANK( ) Holding tank (Al^rm Required) >
Septic ^
) Drain field o ^
( ) Standard ( ) Bed ) Trench
( ) Modified
( ) Mound
\3 AO A GIs.Capacity
/.Ft.Distance from nearest well .W//AO
I 2JLDistance from lake or stream • /
Distance from building
Ft. Ft.
Ft.Ft.
$T3 /o%Ft. Ft.Distance from property line
EFFLUENT DISTRIBUTION
( ) Gravity
( ) Pressure
7Distance from bottom to Water Table Ft. Ft.
All distances are shortest distance between nearest points
WATER WELL DEPTH:
-/
07^7 Xq
O ^0)
RatePERCOLATION TEST DATA: Date of First Test . 19
cTO
1st Te^Yaken By
Date of Second Test , 19 Rate
c^. O > /
■ y2nd Test Take^By First Test + 2nd Test Rate2
Agreement: The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in strict
accordance with Ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minnesota Department
of Health. Applicant agrees that plot plan sketches and specifications submitted herewith and which are approved by Shoreland Management Officical shall become a part
of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the responsibilty of the applicant for
the permit to notify the County Shoreland Management that the job is ready for inspection.
A''■JAyOe^.DATE:
7)Sigr}ature
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.(/
'Mb/ yy /Issued Date:
Land & Resource Management Office^"1
Rec #Fee $.j.
ya^L CO ■ T^c 77 l-ytJComments:7
FonnNo. BK-0993-003 268^ - Vk:torLundMnCo.. Printera • Fergus FaNs. MN • 800-346-4670
/■.1
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK DRAIN FIELD
CATEGORY Actual MinimumMinimumActuai
SF SFCapacityGLS. GLS.(P~
777P -h/OO FT -f/Q<9 FT FTDistance from Nearest Well 50 FT
Distance from Buried
Water Suction Pipe FTFTFT FT 5050
Distance from Buried Pipe
Distributing Water Under Pressure FTFT FT10FT 10
FT / ftDistance from Lake or River (OHWL)FTFT
90 //2- n-10/20 FTFTDistance from Nearest Building 10 FT
ftFT FTDistance from Nearest Property Line 10 FT 10
f>tr G-.& ■
ft ^ ft FTDistance from Bottom to Water Table ^FT 3
YES NOHolding Tank/Lift Alarm
DRAINFIELD CALCULATIONSewer Line to Well SeparationINTERPRETATiON
OF ABBREVIATiONS
GLS. = Gallons
SF = Square Feet
FT = Linear Feet
Actual Minimum y FTX
!?^0O■i' fOO FT FT20 SF
tnJ. /
fi»l^ , )al<x. ct. Joe^o.^ '4'^
Inspector’s Comments:oe*>€S
^tS i^a4*,r
/A»Si3^o'J,v3 txxv« n y9ra VI << <«; o^.^4
fkVif,
SKETCH:
Pm* £^AsUnis "^62^3
/ ■'V)^
fi. - 3 * isojt
>IV y / , •L*. /!/a r A./; cA /
X I%t 34
V %
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K\7 I.
o\ot,ery^
-T4 o-‘^ L?f^
/J6 iJltl j
s !£>0
Inspector’s Signature
9-gLi-99
Date ot Inspection
!2'.00
Time of Inspection
I
i
• GRID PLOT PLAN SKETCHING FORM — (Must Be To Scale)
^ (fe^Scale: Each grid equals inches
V/ao / »Dated:
Signature
Please sketch your lot indicating setbacks from road right-of-way, take and sideyard for each buiiding currently
on lot and any proposed structures.A/ O
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;PERCOLATION TEST DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, MN 56537
OWNER;
7
LAST NAME T
/w-^v
TELEPHONE NUMBERMIDDLEFIRST
ADDRESS:
ftSTR./RT.ZIP CODESTATECITY
iQi J3 V v/
TWP. NAMERANGESECTWP.LAKE NAMELAKE/RIVER NO.
LEGAL DESCRIPTION:
PARCEL NUMBER
9NUMBER/BEDROOMSFIRE NUMBER
— TWO TESTS ARE REQUIRED —
TEST HOLE NO. 2TEST HOLE NO. 1
Diameter of Holeinches;inches Depth To Bottom of Holeinches; Diameter of HoleDepth To Bottom of Hole
Soil TextureDepth. Inches Depth, Inches Soil Texture
Pop Sdi'u
/-//> %/ PAa/\o- g pp 3q/CI-IOlPercolation
Test By
Firm
Name
Percolation
Test By
Firm
Name
/VaZ/-9
'Po P(L/ ----^ P L__
Address Address
Otter Tail CountyOtter Tail County
License No.License No.
il/)P 3 7 PERC TEST # 2PERC TEST # 1
PERC RATE JUfi-PTTBRVALfMIMUTBS)
WATER DEPTHPnERVALftCNUTSaWATER DEPTH WATER DROP WATER DROP PERC RATETIME
m Tl„::e.H
PERC RATE
&
WATER DROP INTERVAL <M1WI/TTO WATER Water dropINTERVAL (MINUTEST Water depthTIME y PERC RATE
REFILLREFILL
iO.^
Trtvffl • bft61» WSRg:10-
WATER DROP PERC RATE TIME INTERVAL IMINl/TBS^WATERINTERVAL IMlNtnEST WATER DEPTH WATER DROP PERC RATETIME
W-IS X.REFILLREFILL
lA -U-
PERC RATE TIME WATER DEPTHWATER DEPTH WATER DROP INTERVAL fMiNirrHm WATER DROP PERORATETIMEINTERVAL (MINUTTO
REFILL REFILL
«i
nKffl* CROP" PBRC 11MU' DROP PBRC
WATER DROP PERC RATE TIME INTERVAL fMlNUTBSI water depthINTERVAL (MPn/TBS)WATER DEPTH WAlTODRiy reRC RATETIME
REFILLREFILL
T ■f
'lTK5E~ DROP PERC 'nMB DROP" PERC
PERC RATE TIME IKTgtVALfMINUTBftINTERVAL <MTNI/TBST WATER DROP WATER DEPTH WATER DROPWATTO DEPTH PERORATETIME
REFILLREFILL
TTOB“ DROP" PERC *nMti DROP PERC
PERC RATE TIME INTERVAL (MINUTES)INTERVAL (MINUTES)WATER DROP WiOER DEPTHWATERDEPTH WATER DROP PERC RATETIME
REFILLREFILL
T 4
TIME DROP PBRC YlMli' DROP* i>BRC
PERC RATE TIMEWATER DROP INTERVAL (MINUTES)WATERDEPTHINTERVAL (MINUTES)
REFILL
Water depth WATER DROP PERC RATETIME
REFILL
T
time” DROP PBRC TIME DROP PBRC
COMMENTS/CALCULA TIONS:
MKL — 0390 - 005 250,815 — Victor Lundeen Co.. Printers, Fergus Falls, Minnesota
*#
'4
CERTIFICATE OF APPROVAL
SEWAGE SYSTEMft g
HOLDING TANK
1 7TH Ipi79 MFEBRUARYday ofThis certificate has been issued this
to certify that the sewage system installed as per sewage permit number indicated below has been approved for usey-
m by Otter Tail County, Minnesota.
■.ms.The premises covered by this certificate are legally described as:
Range Twp. Name ^ ^ -Twp. 156-475 Sec. _LlALake No.
12 134 41 7.2
PT GL 6 9G 1649.95' W OF
SE COR SEC 12/ W 204.77'/
N 3 deg 5 313'/ N 11 DEG fc
TO L</ ELY 200' ON LK/ S
m%
PQGNESS# GLENN D. % YVONNE&m.Owner: Name
FERGO? FALL3/ i^NAddress
m 56537 E.vJZip No.
7?41Permit No. SP Is Vi
Signed by:
Malralm K. Lee. Land & Resource Management Administrator
Oner Tail County, MinnesotaMKL-0987001
If.
.«
237.987 — Victor Lundeen Co., Printers. Fergus Falls. Minneaoo
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 — Ottice Yellow — Inspector Pink — Owner
I
C.O'Z, *5-2- C 12.
PC GLu <Permit No.,^ ^ S<5LEGAL
V/PO
DESCRIPTION
AND
;z ynLOCATION
Lake Cla&sif.TWP NameLake No. Lake Name Sec.TWP Range
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Tel. No.Zip No.First InitialLast Name
(jCgA/ D0OWNER
r?Cv/ / y -SSEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for inspection on., 19.
This space for office use only
_19
Date Rec'd Phone Call Rec'd By Owner or Agent Signa^tureTime Rec'd
O' 6e.s T^/aNUMBER OF BEDROOMS:ESTIMATED COST:/
L ryl a/ ^
-GEPTtC TANK
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PIT-----DRAIN FIELD
3)0 oo GIs.Sq. Ft.Sq. Ft.Capacity
Ft.Ft.Ft.Distance from nearest well
7^Ft.Ft.Ft.Distance from lake or stream
Ft.Ft.Ft.Distance from occupied buildinq
Distance from property line Ft.Ft.Ft.
Ft.Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
nTcttRECORD OF TESTS:
Inspection was made on 19 , Time jVl By
PERCOLATION TEST DATA: Date of First Test , 19 , Rate
Date of Second Test 19 , Rate
1st Test Taken By 1
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.!1
/- IG> - 21L.XDated
;
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 Dtter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE: Permit void if work is not commenced within six (6) months.
Permit:
I
] Ayv-v^
' shoreland Management d4ce
Issued Date:
a>
D/oy 'f^ a ^
Fee $Rec #
I
^ ^1 v^SComments:
Form No. MKL-032085 225239 — Victor Lundeen Co.. Printers, Fergus Falls. MN
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SHORELAND MANAGEMENT — COUNTY OF OTTER TAIL
COUNTY COURT HOUSE
Phone 218-739-2271 • Fergus Falls, MN 56537
APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM
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White — Ofhc6
Yellow — Inspector
Pink — Owner
fPr GLu Permit No.,Vj 0 ^LEGAL
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DESCRIPTION
AND
iiD yv^ (X- f t\f £f yt(} 70 /LOCATION
Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Zip No,Last Name First Initial Tel. No.
1.K ( ■ '/) i.|i:, mx^K- A/ ' SOWNER
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SEWAGE
SYSTEM
INSTALLER
/ y ^t-7 /( KName.T
^7This System will be ready for inspection on... 19.
This space for office use only
J' PG >19 .M
Date Rec'd Time Rec'd Phone Call Rec'd 6y Owner or Agent Signature
f 6e.NUMBER OF BEDROOMS:ESTIMATED COST:,S ' C\ /
SEWAGE DISPOSAL SYSTEM DATA:12.
SEPTIC TANK SEEPAGE PIT -y- DRAIN FIELD
3.000 GIs.Capacity Sq. Ft.Sq. Ft.
S O'Ft.Ft.Ft.Distance from nearest well 1
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i7<Ft.Distance from lake or stream Ft.Ft.
lO Ft.Distance from occupied building Ft.Ft.
/'ODistance from property line Ft.Ft.Ft.
Distance from bottom to Water Table Ft.Ft.Ft.
AH distances are shortest distance between nearest points
rRECORD OF TESTS:\ •
Inspection was made on 19,, Time M By
PERCOLATION TEST DATA:Date of First Test 19 . Rate
Date of Second Test 19 Rate
1st Test Taken By
First Test + 2nd Test 22nd Test Taken By Rate
Agreement:
strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn-
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.
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
esota
!\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.
/•-4 /Issued Date:aShoreland Man}igeS^nt Office
7a 'XRec # 70Fee $
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kAv-.< >7Comments:\
Form No. MKL-032085
225239 — Victor LimlMn Co.. Printers, Fergus FaUs. MN
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INSPECTION RESULTS
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Inspector must make all measurements5. i\
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYActualShould Be Should BeActual Should BeActual %
l-/^00 - I-I3S^Capacity Qls. Qls.S F S F S F S F
mDistance from Nearest Well F F F F F F
Distance from Lake or Stream F F F F F F
I"7Distance from Occupied Building F F F F F F
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7^Distance from Property Line F F F F F F
Distance from Bottom to Water Table 3 3FFFFF F
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OV>A
V.WNInspector’s Comments:Va
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9HDate of Inspection.1
Time of Inspection M
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Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
F = Linear Feet
Job Title
MKL - 032085 - Btciwr Agency