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Home My WebLink AboutRush Lake Resort_53000230140001_Septic System Permits_\'i-' w*'^74^CERTIFICATE OF COMPUANCE SEWAGE SYSTEM Mtm... <SF-’S 61i^a & Jw-%tej «•pw,1911J anuary3rdThis certificate has been issued this day of. mWM to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.; '0M Mti P'€^ mmmmm fmWMm '"'I iSSis The premises covered by this certificate are legally described as: Twp. 135 Rash LakeRange 39Sec 23 Twp. Name.Lake No. Mielkes Modern Cabins Resort •; w pi piiaip' Mielkes Modern CabinsOwner: Name. Richville, MinnesotaAddress. 56576Zip No. 351Permit No. SP_'I' Signed by:. Malcolm K. Lee, Shoreland Adminislrator Otter Tail County, MinnesotaONE SYSTEM ONLYMKL-0871-0097,-i U&'m 159035 ‘ 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 Yellow Pink — Owaer Card -t Owuer Office Inspector /5? e //e j^3 /3S- -39 Permit No.,LEGAL Date DESCRIPTION AND 3^-/7/ K..cL UAiPLOCATION Lake Classif.Sec.Lake No. Lake Name TWP Range TWP Name IDENTIFICATION; Please Print All Information. Mailling Address —No. Street, City and StateInitial Zip No.Tel. No.Last Name First /V^rLo^nOWNER SEWAGE SYSTEM INSTALLER Name This System will be ready for inspection on., 19. This space for office use only .19 ,M Date Rec'd Phone Call Rec'd ByTime Rec'd Owner or Agent Signature ^ aery SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PIT, SEPTIC TANK ■^~Z> Ft- DRAIN FIELD sg. Ft.GIs.Iq. Ft.Capacity s~n -t Ft.Ft.Distance from nearest well Ft.Ft.cToy- Ft.Distance from lake or stream /O ^ Ft.Ft.Ft.Distance from occupied building /O Ft.Distance from property line Ft.Ft. U-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. 19.....Rate .1Date of Second Test 1st Test Ta n By /r t 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.) CfDated Signature Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota. This permit may be revoked at any time upon violation of any said ordinance. NOTE: Permit void if work is not commenced within six (6) months. Permit; ^//> Issued Date: ^^-'^''^''^^horeland Management Office SI ov 6^0Fee S Surcharge $ Comments:. !06'~ Form No. MKL-0771-003 viCToa luhdKh » CS . aaiaTca* rc««us racLt. 158906 ^ iX3Xl,^3!^ Ok i-o J^siAe. "Po/Zo^A^ i/w^ ^AdfiVt iCy/-c^ <^-Z7-9Z, Zc. S'l-aijid 'UicJ' Ke^ roL^ r-tsa^ ^0^ hJi cl h».c/ h&vicjJrCT /'k -t^firnri \/jt,,^iXa^ Qj^LfC^ <s>^S ca^ /^ “ cl !3 T^olcI r<C^ / A cus M Qoi €r'r^y th*^S Oi/yy Jn^s lhc^/u% Ok tZf 1^ htlrry^s Oi^ ^ Sys Arf'vv j /l Icl \y/ i^t// h&- //. /^ .OK p: r^vvt^x>^^7o SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone 218-739-2271 - Fergus Falls, Mn. 56537 APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM White — Office Yellow — Inspector Pink — Owr^r Card — Owner Permit No.,LEGAL Date DESCRIPTION AND LOCATION Lake Classif.Sec.TWP TWP NameLake Name RangeLake No. IDENTIFICATION: Please Print All Information. Tel. No.Mailling Address —No. Street, City and State Zip No.First InitialLast Name OWNER SEWAGE SYSTEM INSTALLER Name OlTI/72This System will be ready for inspection on., 19. This space for office use only 19 ,M Phone Cal! Rec'd ByDate Rec'd Time Rec'd Owner or Agent Signature SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PITSEPTIC TANK DRAIN FIELD GIs.Sq. Ft.Sq. Ft.Capacity Ft.Ft. Ft.Distance from nearest well Ft. Ft. Ft.Distance from lake or stream Ft.Ft.Ft.Distance from occupied building Distance from property line Ft. Ft. Ft. Ft.Ft. Ft.Distance from bottom to Water Table AH distances are shortest distance between nearest points RECORD OF TESTS: Inspection was made on ., 19 , Time 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 2 Rate2nd Test Taken By Agreement: strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn esota Department of Health. Applicant agrees that plot plan, sketches and specifications submitted herewith and which are approved by Shoreland Management Offi cial shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the responsibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection. (Call or use attached mailer notice.) The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in Dated Signature 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:. CERTIFICATE ISSL'ED Form No. MKL-0771-003 viCToi LuNCtCH a CQ . rf*«us fall* ..158906 INSPECTION RESULTS Inspector must make all measurements SEWAGE DISPOSAL SYSTEM STATISTICS SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY Actual Should be Actual Should be Actual Should be Capacity GIs.GIs.S F S F S F S F bk FDistance from Nearest Well F 75F F 50F F Distance from Lake or Stream F F F F F F Distance from Occupied Building 10 20 20FFF!F F F Distance from Property Line 10 10F 10FFFF F Distance from Bottom to Water Table 4 4FFFFF F Inspector's Comments: \hZxt/ — r . : V >/ ■ AJ^{ tpS. ^JryjAy«s,P>v aO^ KaJ.C-X>^ r)o> 4Date of Inspection vTuX—ImTime of Inspection. \/y^0 fPy Signature/Of InspectorINTERPRETATION OF ABBREVIATIONS GIs = Gallons SF “ Square Feet * Linear Feet Job TitleF AgencyMKL-0771-003-Backer ,v'- » N J PERCOLATION TEST DATA Price $ 1.00 per pad.Q SHORELAND MANAGEMENT OTTER TAIL COUNTY Fergus Falls, Minnesota 56537 Ph. No. Owner:Mailing Address: Zip No.Last Name First StateMiddleSt. & No.City Legal Description: TWP NAMESEC.TWP.RANGENAMELAKE OR RIVER NO. TEST HOLE NO. 2TEST HOLE NO. 1 3 ^3 ^k.Depth to Bottom of Hole inches; Diameter of Hole inchesDepth To Bottom of Hole.inches; Diameter of Hole inches OlA__i9_2_?7Depth, Inches Soil Texture Depth. Inches Soil Texture 19DateDatec 4tLL 2^-r— Sr-Percolation Test By____ Percolation Test By .a L om It-FirmName.FirmName.CC DaUJ a: -Z'LUAddress.CC Address < cnOtter Tail County License No..Otter Tail County License No..H LUMeasurement, Inches Depth in Water Level, Inches Measurement, Inches Depth in Water Level. Inches h-Time Remarks Time Remarks o5 -k t:o32. ^ o ' ^h- 31 '■ to ter f -f -f-/tici' dt^-iAl3Z (LXU1>-M 73----------! L I 3 CO -L^iHtc.■f' / ✓<3^; i-2 MKL-0871 -028159179 ®V<CT«* LUHOCCM 4 CO . FRINTIM. Ftusua FALL*. See Booklet, "How to Run a Percolation Test" by Agriculture Ext Service, Un. of Minn. Department of LAND AND RESOURCE MANAGEMENT R-CEIVED SEP 1 8 2013 OTTER TAIL COUNTY Government Services Center - 540 West Fir Fergus Falls, MN 56537 PH: 218-99S-8095 Otter Tail County's Website: www.co.otter-tail.mn.us LAN'D 8. RES0URC5’ 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 May 1,2011. Property Information Parcel Number: __________ Property Owner Name(s): KevA Property Address: 3LN(j> Reason for Inspection:__ Number of Bedrooms: |( In Shoreland Area? No Lake/River Name, Number, & Class (if applicable): inspection Results k (oice ^ yUN SZ-S~7/ 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? Yes Yes Yes Is the soil treatment area located less than 100 feet from any shallow well? Yes !c^ 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, Pages 1 through 8, revision dated 4/24/09 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. System Compliance Statu^s<^ompliant^ Non-uompii^t(Circle one) ■i.- i t m 'w Name: Certification Number: :iivnsBusiness License Name & Number:__ Signature:Date: Page 1 of 2Excel/Compliance Form for OTC 2/23/2011 Otter Tail County Compliance Inspection Form Addendum (cont.) Property Information Parcel Number: S3cWOZ3DI^ OOP I Property Owner Name(s): 01^^ _________ Property Address: yviig 5fcs~7l 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). Additional Comments: 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 mainten Name: Certification Number: Business License Name & Number:_^ Signature: ^e, or future,water usage,Til sUJ ^ V Ef Date: Page 2 of 2Excel/Compliance Form for OTC 2/23/2011 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 Instructions on page 6 Summary Form (Completed form must be submitted to the local unit of government within 15 days.) Parcel number; 53000230140001 For Local Tracking Purposes:System status: S Compliant □ Noncompliant (based on all compliance requirements) Property Information Property owner name(s): Ken Olson____________________ Property address: 36146 Rush Lake Loop, Ottertail, MN 56571 Property owner address (if different): County: Ottertail_________ Date system constructed: _? Property owner phone: Permitting authority; Ottertail County ____Reason for inspection: Permit System Description Brief system description: 500 lift to approximately 2 1000 gal, concrete tanks to drainfield bed area, Number of bedrooms; 11 Design flow rate:Local permit number: Is the system; In Shoreland area? An U.S. Environmental Protection Agency (EPA) Class V Injection Well? □ Yes ^ No □ Yes S No13 Yes □ No In Wellhead Protection Area? System serving a Minnesota Department of Heath (MDH) licensed facility?□ Yes 3 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): 3 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 9/5/2016 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__ _____________ Business license natrj^nd number: Stoll Inspections Name of local unit OT^va'nment^ ^4__________ Signature ____________ Certification number. L2982 or Date: 9/5/13 Required Attachments S Hydraulic Performance S Soil Boring Logs O System drawing/As-bui(t 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. □ Operating Permit Form (if applicable)I3 Tank Integrity ^ Soil Separation TTY 651-282-5332 or 800-657-3864800-657-3864 rnative formats Page 1 of 8 651-296-6300www.pca.state.mn.us • wq-wwists4-31 • 4/24/09 System status: ^ Compliant □ Noncompliant (as determined by this form)53000230140001Parcel number: Hydraulic Performance and Other Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #1 of 4 Date of observation: 9/5/13 This form expires upon next inspection or in three years, whichever occurs first: 9/5/16 Reason for observation: Permit Verification Method*; (Optional) (Check the appropriate box) S Searched for surface outlet □ Performed hydraulic test E Searched for seeping in yard □ Checked for backup in home □ Excessive ponding in soil system/D-boxes S Homeowner testimony Q Examined for surging in tank □ “Black soil” above soil dispersal system □ System requires “emergency" pumping □ Performed dye test □ aher:______________________ 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 ^ No hie^r surface waters?______________ Does 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 13 No □ Yes 3 No □ Yes 3 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): Ken Olson Property address: 36146 Ru^ Lake Loop, Ottertail, MN 56571 Property owner’s address (if different); 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 StqN_____________________________ Business license nam^nd number. Stoll Inspections Name of local unityO'^o'^rnmjmf^/______________ Signature: _______________ or Date: 9/5/13 TTY 651 -282-5332 or 800-657-3864 • Available in alternative formats Page 2 of 8 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31 • 4/24/09 System status: ^ Compliant Q Noncompliant (as determined by this form) Parcel number: 53000230140001 Soil Separation Compliance and Other Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #3 of 4 Date of observation: 9/5/13___________ This information on this form does not expire. Reason for observation: Permit 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? Verification Method**: (Optional) (Check the appropriate box) S Conducted soil observation(s) (attach boring logs) □ Two previous verifications (attach boring logs) n Other:____ □ 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 □ 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?* Any “no" answer indicates that the system is falling to protect ground water. * 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 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): Ken Olson Property address: 36146 Rush Lake Loop, Ottertail, MN 56571 Property owner’s address (if different): 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 Certification number: L2982 Business license na'P® number: Stoll Inspections Name of locai unit /f g9^emafem//y_______________ Signature: or Date: 9/5/13 www.pca.state.mn.us • 651-296-6300 wq-wwists4-31 • 4/24/09 800-657-3864 TTY 651 -282-5332 or 800-657-3864 . Available in alternative formats Page 4 of 8 System status: S Compliant □ Noncompliant (as determined by this form)53000230140001Parcel number: Tank Integrity and Safety Compliance - Compliance Inspection Form for Existing SSTS Compliance Issue #2 of 4 Date of observation: 9/5/13____________ This form expires on (three years): 9/5/16 Reason for observation: Permit 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" Q Pressure/vacuum check □ Other:_________________ Compliance questions/criteria: (Required) (Chieckthe appropriate box)___________________________ Does the system consist of a seepage pit*, □ Yes [3 No cesspool, drywell, or leaching pit? Do any sewage tank(s) leak below their □ Yes 13 No designed operating depth? 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* 13 No n 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 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); Ken Olson____________________ Property address: 36146 Rush Lake Loop, Ottertail, MN 56571 Property owner's address (if different): County: Ottert^l Property owner phone: / hereby certify that i personally made the observations, interpretations, and conciusions reported on this form and that they are correct. Certification number: L2982Name: Phil Stoll Business license nam^nd numi^r: Stoll Inspections Name of local unit 6f/ovafnmeniE^//^ or Date: 9/5/13 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 • !, « Site Sketch: Ke Code:Name: LcJu x*iS □g>3_g 0 N.H i>e PffC^ Soil Boring O^R^: Locate each bating ontfaeio^abcn^ indicate on tbgil^oftiicoohjinn •fee soil texture, stnictuie, color, depth of esdidiffineDt soil evidence of nootding, bedxodk and standing-water. Also indicate if the xoatsiiiBl is filL lOv^r BR.#BR# z'* 3/z / *» 3C» % s*^ 7«'' RECORDDEEIH OFMC«lLlKe. 5KA8CmffiCKmm(AS D5IERMINH)USlNGmMDNmcM ORABOVE LINES >v (kfw<u>(rxvtcg.. &0N Corameab: WltBtneels u be cotnpleted to brii« the iboYc system htto conidanceiffinsd notio campikace? met palstf^fttgjiterthMiBpt.tlao'. S/IV97