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HomeMy WebLinkAboutRustling Leaf Resort_35000180171000_Septic System Permits_.t ^ /t V Vi UVi vteir Minnesota Pollution Control Agency 520 Lafayette Road North SLPaul.MN 55155-4194 Compliance Inspection Form Existing Subsurface Sewage Treatment Systems (SSTS) Doc Type: Compliance and Enforcement For local tracking purposes;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 System StatusitSystem status on date (mm/dd/yyyy): 10/4/2018 ^ Compliant - Certificate of Compliance (Valid for 3 years from report date, unless shorter time frame outlined in Local Ordinance.) [H Noncompliant- Notice of Noncompliance (See Upgrade Requirements on page 3.)I Reason(s) for noncompliance (check all applicable) □ Impact on Public Health (Compliance Component #1) - Imminent threat to public health and safety D Other Compliance Conditions (Compliance Component #3) - Imminent threat to public health and safety □ Tank Integrity (Compliance Component #2} - Failing to protect groundwater CD 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: 31488 cove Rd Ottertail mn. Property owner: Diane Peycke_____________ Parcel ID# or Sec/Twp/Range: 3500018017000 _______________Reason for inspection: bldg permit Owner’s phone: or Representative phone: _________________ Regulatory authority phone: 218/998/8095 Brief system description: 1- system with house and 2 cabins 2-1000 gal septic tanks and bed type drainfield_________ Comments or recommendations: Owner’s representative: ______ Local regulatory authority: Otc 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: Brian Brogard Business name: Brogard Plumbing Inspector signature: Certification number: 603_________ License number: 1332________ Phone number: 218/579/0469 Necessary or Locally Required^ttachments Q System/As-built drawingO Soil boring logs □ Other information (list): □ 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 Property address: 31488 cove Rd Otterlail mn.Inspector initials/Date: brb | 10/4/2018 (mm/dd/yyyy) 1. Impact on Public Health - Compliance component #1 of 5 Compliance criteria:Verification method(s): El Searched for surface outlet E Searched for seeping in yard/backup in home Q Excessive ponding in soil system/D-boxes □ Homeowner testimony fSee Comments/Explanation) □ “Black soil” above soil dispersal system D System requires “emergency” pumping □ Performed dye test |~| Unable to verify (See Comments/Explanation) r~l Other methods not listed (See Comments/Explanation) □ Yes E NoSystem discharges sewage to the ground surface.______________ □ Yes E NoSystem discharges sewage to drain tile or surface waters. □ Yes ENoSystem causes sewage backup into dwelling or establishment. Any “yes” answer above indicates the system is an imminent threat to public health and safety. Comments/Explanation: 2. Tank Integrity - Compliance component #2 of 5 Compliance criteria:Verification method(s): E Probed tank(s) bottom El Examined construction records □ Examined Tank Integrity Form (Attach) □ Observed liquid level below operating depth □ Examined empty (pumped) tanks(s) □ Probed outside tank(s) for “black soil” □ Unable to verify (See Comments/Explanation) □ Other methods not listed (See Comments/Explanation) □ Yes ENoSystem consists of a seepage pit, cesspool, drywell, or leaching pit. Seepage pits meeting 7080.2550 may be compliant if allowed in local ordinance. □ Yes E NoSewage 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. CommentsyExplanation: 2-1000 gal lampy tank 3. Other Compliance Conditions - Compliance component #3 of 5 a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. □ Yes* S No □ Unknown b. Other issues fe/scfnca/ha2arc(s, efc.) to immediately and adversely impact public health or safety. □ Yes* H 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* S No ^System is failing to protect groundwater. Explain; TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 2 of 3 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31b • 6/4/14 Property address: 31488 cove Rd Ottertail mn.Inspector initials/Date: brfa | 10/4/2018 (mm/dd/yyyy) 4. Soil Separation - Compliance component #4 of 5 Date of installation: 6/6/1983 (mm/dd/yyyy) ShorelandA/Vellhead protection/Food beverage lodging? Compliance criteria:______________ □ 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. E Conducted soil observation(s) (Attach boring logs) □ Two previous verifications (Mach boring logs) □ Not applicable (Holding tank(s), no drainfteld) d Unable to verify (See Comments/Explanation) Q Other (See Comments/Explanation) □ Yes □ No D Yes O NoFor 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. S Yes □ 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: Loam0-22 10yr2-2 loamy sand 10yr3-4 Frialbe sand lOyr 4/3 loose 22-28 28-36 36-82 sand lOyr 4/4 loose □ 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. Indicate depths or elevations 32A. Bottom of distribution media 84B. Periodically saturated soil/bedrock 52C. System separation 36D. Required compliance separation* *May be reduced up to 15 percent if allowed by Local Ordinance. i Any “no" answer above indicates the system is failing to protect groundwater. 5. Operating Permit and Nitrogen BMP* - Compliance component #5 of 5 ^ Not applicable I □ Yes □ No If “yes”, A below is required □ Yes □ 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? □ Yes □ No □ Yes □ Nob. Is the required nitrogen BMP in place and properly functioning? Any “no" answer indicates Noncompiiance. 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 locai 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. TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 3 of 3 www.pca.state.mn.us • 651-296-6300 wq-wwists4-31b • 6/4/14 800-657-3864 #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;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 System Status System status on date (mm/dd/yyyy): 10/4/2018 ^ Compliant - Certificate of Compliance (Valid for 3 years from report date, unless shorter time frame outlined in Local Ordinance.) Q Noncompliant - Notice of Noncompliance (See Upgrade Requirements on page 3.) Reason(s) for noncompliance (check all applicable) □ 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} - Faiiing to protect groundwater □ Other Compliance Conditions (Compliance Component #3) - Failing to protect groundwater Q Soil Separation (Compliance Component #4) - Failing to protect groundwater □ Operating penmit/monitoring plan requirements (Compliance Component #5) - Noncompliant Property Information Property address: 31488 cove Rd Ottertail mn. Property owner; Diane Peycke ________ Parcel ID# or Sec/Twp/Range: 35000180171000 _______________ Reason for inspection: bldg permit _______________ Owner’s phone: _________________ or Representative phone: _________________ Regulatory authority phone; 218/998/8095 Owner’s representative: ______ Local regulatory authority: Otc Brief system description: 2-standard septic tank, with trench type drainfield Comments or recommendations: Certification / hereby certify that all the necessary information has been gathered to determine the compliance status of this system. No detennination 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; Brian Brogard Certification number: 603_________ License number: 1332________ Phone number; 218/579/0469 Business name; Brogard Plumbing Inspector signature; - Necessary or Locally Required'Attachments □ System/As-built drawing □ Forms per local ordinance□ Soil boring logs □ Other information (list): TTY 651-282-5332 or 800-657-3864 • Available in alternative formats Page 1 of 3 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwi5ts4-31b • 6/4/14 Property address: 31488 cove Rd Ottertail mn.Inspector initials/Date: brb | 10/4/2018 (mm/dd/yyyy) 1 ■ Impact on Public Health - Compliance component #1 of 5 Compliance criteria:Verification method(s): E Searched for surface outlet Searched for seeping in yard/backup in home □ Excessive ponding in soil system/D-boxes D Homeowner testimony (See Comments/Explanation) □ "Black soil" above soil dispersal system □ System requires “emergency” pumping □ Performed dye test □ Unable to verify (See Comments/Explanation) r~l Other methods not listed (See Comments/Explanation) □ Yes S NoSystem discharges sewage to the ground surface.________________ □ Yes S NoSystem discharges sewage to drain tile or surface waters. □ Yes S NoSystem causes sewage backup Into dwelling or establishment. Any “yes” answer above indicates the system is an imminent threat to pubiic heaith and safety. Comments/Explanation; 2. Tank Integrity - Compliance component #2 of 5 Compliance criteria:Verification method(s): El Probed tank(s) bottom D Examined construction records □ Examined Tank Integrity Form (Attach) □ Observed liquid level below operating depth □ Examined empty (pumped) tanks(s) □ Probed outside tank(s) for “black soil” D Unable to verify (See Comments/Explanation) CD Other methods not listed (See Comments/Explanation) □ Yes H NoSystem consists of a seepage pit, cesspool, drywell, or leaching pit. Seepage pits meeting 7060.2550 may be compliant if allowed in local ordinance. □ Yes S NoSewage tank(s) leak below their designed operating depth. If yes, which sewage tank(s) leaks: Any “yes" answer above indicates the system is faiiing to protect groundwater. Comments/Explanation: 1000 gal lampy tank < I 3. Other Compliance Conditions - Compliance component #3 of 5 a. Maintenance hole covers are damaged, cracked, unsecured, or appear to be structurally unsound. □ Yes* * S No □ Unknown b. Other issues ('e/ecteaZ/jazards, eto.) to immediately and adversely impact public health or safety. □ Yes* IEI No □ Unknown *System is an imminent threat to pubiic health and safety. Explain: c. System is non-protective of ground water for other conditions as determined by inspector. □ Yes* El No ‘System is failing to protect groundwater. Explain; TTY 651-282-5332 or 800-657-3864 • Availabte in alternative formats Rase 2 of 3 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31b • 6/4/14 Property address: 31488 cove Rd Ottertail mn.Inspector initials/Date: brb I 10/4/2018 (mm/dd/yyyy) 4. Soli Separation - Compliance component #4 of 5 Date of installation: 6/6/1983 (mm/dd/yyyy) ShorelandAIVellhead protection/Food beverage lodging? Compliance criteria:______________ □ 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. S Conducted soil observalion(s) (Attach boring logs) □ Two previous verifications [Attach boring logs) Q Not applicable (Holding tank(s), no drainfield) r~l Unable to verify (See Comments/Explanetion) r~l Other /See Comments/Explanation) □ Yes □ No D Yes D NoFor 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. S Yes □ 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: 0-22 22-30 loam 30-36 36-82 sand 10yr 2-2 10yr3-4 Frialbe loamy sand lOyr 4/3 loose 10yr4/4 loose Loam □ 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) Drainfieid meets the designed vertical separation distance from periodically saturated soil or bedrock. Indicate depths or elevations 32A. Bottom of distribution media 72B. Periodically saturated soil/bedrock 40C. System separation D. Required compliance separation* 36 *May be reduced up to 15 percent if ailowed by Local Ordinance. Any “no" answer above indicates the system is failing to protect groundwater. 1^ Not applicable5. Operating Permit and Nitrogen BMP* - Compliance component #5 of 5 □ Yes □ No If “yes”, A below is required D Yes □ 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? □ Yes □ No □ Yes □ Nob. Is the required nitrogen BMP in place and properly functioning? Any “no" answer indicates Noncompliance. Upgrade Requirements (Minn. Stat. § 115.55) An imminent threat to pubtic heatth and safety (tTPHS) must be upgraded, replaced, or its use discontinued within ten months of receipt of this notice or within a shorter period if required by iocai ordinance, if the system is faiting to protect ground water, the system must be upgraded, reptaced, or its use discontinued within the time required by iocai 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 Pose 3 of 3 wv/w.pca.state.mn.us • 651-296-6300 • 800-657-3864 wq-wwists4-31b • 6/4/14 ■I 1 Page 3 of 3Rapidly-changing content, accuracy is NOT guaranteed QsNEW SIMPLE SEARCH Back to Home Page ©Copyright 2001- 2018 County o( Otter Tall, Minnesota. U.S.A. All Rights Reserved. This web site Is maintained by Otter Tail County . http://\vww.otlertailcounty.us/ez/publicparcel_full.php?PIN=35000170170000 10/4/2018 W;% Im.V:/;fi /-1^ mCERTIFICATE OF COMPLIANCE iii !ESEWAGE SYSTEM i!!& if^M; ! 79___S329thVdcmb^day of_This certificate has been issued thismi VK*‘ '^'to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.■f m-The premises covered by this certificate are legally described as:If# Le.a.1 LaiizTwp. 134 Range 3SLake No. 56-114 Sec. 1 7 Twp. Name. wmm.W 7/3 0|5 GL 4 Ex. Ttiacti {LzadgA'-i Ruokt).Ims/N1 W0 £ ■ sr-I ’Rndnofj I ondptjA____________________________________ 7 7 74 2nd Stfizzt SouthweLit, Wadena, Minnesota Owner: Name. WmAddress.% mm-I Zip No 564S2r (%577S7 «1^Permit No. SP_ Mjucolm K. Lee, Shoreland Administrator Otter Tail County, Minnesota Signed by:. MKL-0871-009 '■'I'l r rja \.w - «■.g-«I; n/NT ®159035 4 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-Offic* Ye//ow — inspector Pink — Owner Cord— Owner ^1-Permit No., LEGAL DESCRIPTION AND n /3V 3^UJ^ LFi^pLOCATION TWP NameTWPRangeLake Classif.Sec.Lake No. Lake Name IDENTIFICATION: Please Print All Information. Tel. No.Zip No.Mailling Address —No. Street, City and StateFirstInitialLast Name 111 '-I 3 n/O 3 I_____S_uJ_Li= ripensOWNER /nn/ T SEWAGE SYSTEM INSTALLER Name. This System will be ready for inspection , 19.on. This space for office use only 19 .M Owner or Agent SignatureDate Rac'd Time Rec'd Phone Call Rec'd By NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PITSEPTIC TANK DRAIN FIELD ^ ^ ^ Sq. Ft.GIs.Sq. Ft.Capacity j fypoFt. Ft.Ft.Distance from nearest well IS Ft.Ft. Ft.Distance from lake or stream \0 .SiOFt.Ft.Ft.Distance from occupied building iO Ft.Distance from property line Ft.Ft. 3 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 .....3.3,PERCOLATION TEST DATA:Date of First Test , 19 , Rate /. 3rui/Ln Date of Second Test 19 , Rate 1st Test Taken By // l\/r /^S,<...33First Test -I- 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 $ Comments:. Form No. MKL 0771-003 @lvltw lATTlE LAKI. MI)«4{SOTA • • 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 S F S F S F Distance from Nearest Well 5075FFFF F F Distance from Lake or Stream F F F F F F 20Distance from Occupied Building 10 20FFFFF F Distance from Property Line 10 10 10FFFFF F Distance from Bottom to Water Table 33F F F F F F Inspector's Comments: I Date of Inspection 19___ Time of Inspection^M Signature of InspectorINTERPRETATION OF ABBREVIATIONS GIs » Gallons SF = Square Feet F = Linear Feet Job Title AgencyMKL-0771-003-Backer r A N.»• cySHORELAND MANAGEMENT - COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone 218-739-2271 - Fergus Falls, Mn. 56537 APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM Wh/f» — Yellow — Inspector Pink — Owner Grd—Owner /-■n--Permit No.,LEGAL • IDESCRIPTION 1AND LOCATION TWP NameTWPRangeLake No. Lake Classif.Sec.Lake Name IDENTIFICATION; Please Print All Information. Zip No.Tel. No.Mailling Address —No. Street, City and StateLast Name First Initial OWNER SEWAGE SYSTEM INSTALLER Name This System will be ready for inspection on., 19 This space for office use only $3 A.. flvvVVi.19 Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD GIs.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 ,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 S 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 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. 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 $3 3^ ^ ssu*:<r»cert IF \( T CERTIFICATI !Comments:.L .V- Form No. MKL-0771-003 [Review battle lake. Minnesota k\ , / 'it 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 /*&-fDistance from Nearest Well F75 50 F F F F F Distance from Lake or Stream F/OQ-^F F F F F /o ^3^ FDistance from Occupied Building 10 20 20F F F F F OK FDistance from Property Line 10 10OH 10FFFF F ^i>FDistance from Bottom to Water Table 33FFFF F IInspector's Comments:____0^ Ccut ^ 2- 'Z CjyO ^ UU\ t ; /kujA 4 <vA c^-Lcy&JlSUt^ V ■ ?0 ~ t/0 f^ ^ 5^0c4c Date of Inspection 19___ S/q / ^ ?Time of Inspection.M y CJO ^ ^ L~ i Signature of InspectorINTERPRETATION OF ABBREVIATIONS GIs » Gallons SF “ Square Feet P « Linear Feet •<v Job Title AgencyMKL>0771.003-Backer .-.Lv.&S 'p/\2 {Jyt-JL^C, — O-ytP /tj6vJXs-P 'KSlu S'O'ria. / fy ^ ^umj2- fiju- y • * >. ■ -. : f CVU -■ ■ TIPi ”i , -,.J • .» SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone 218-739-2271 - Fergus Falls, Mn. 56537 APPLICATION FOR PERMIT TO INSTALL SEI/VAGE DISPOSAL SYSTEM Wh/f» —Offic* Ymihw — Inspector Pi'nk — Oiivner Cord—Owner (S' L.t u '/3 GillcrPermit No., LEGAL DESCRIPTION AND n !3i _M.KiOLOCATION TWP NameRangeSec.TWPLake Classif.Lake No.Lake Name IDENTIFICATION: Please Print All Information. Tel. No.Zip No.Mailling Address —No. Street, City and StateInitialFirstLast Name ///7 l/wti Ste ^uJOWNER Uy o/£h^ SEWAGE SYSTEM INSTALLER Name. Th/s System will be ready for inspection on... 19. This space for office use only V.M19 or Agent SignatureOwnDate Rec'd Phone Call Rec'd ByTime Rec'd Y ~ " r - — J. ^ (,/.)•NUMBER OF BEDROOMS; \ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PITSEPTIC TANK DRAIN FIELD 1,1^1 Sq. Ft.2.000 GIs.Sq. Ft.Capacity /tooGOFt.Ft.Ft.Distance from nearest well 7£7S'Ft.Ft. Ft.Distance from lake or stream 10 2^Ft. Ft.Ft.Distance from occupied building 10Ft. Ft.Distance from property line Ft. 3 Ft.Ft.Ft.Distance from bottom to Water Table AH distances are shortest distance between nearest points RECORD OF TESTS: Inspection was made on ,JVI By 13.. 19...^3___ 19,, Time .y..:....a2?.. PERCOLATION TEST DATA:Date of First Test Rate,, 19 ...1.2,Dat-3 of Second Test , Rate 1st Test Taken By / < f,/ <A 2-37 Ldl! G , G1First Test -t 2nd Test "i 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.) C'ihndJ/, /:- 3 -<F3Dated ,1 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 £-3. -•S3 Issued Date: Shoreland Management Office ooFee $ Comments:. ~PC£- £/C' Form No. MKL-0771-003 [^(VIEW BATTLE LAKE. MINNESOTA I 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 Distance from Nearest Well .5075FF F F F F Distance from Lake or Stream F F F F F F Distance from Occupied Building 2010 20FF F F F F , Distance from Property Line 1010 10FFF F F F Distance from Bottom to Water Table 33FFFFF F Inspector's Comments: Date of Inspection 19___ Time of Inspection,M Signature of InspectorINTERPRETATION OF ABBREVIATIONS GIs B Gallons SF = Square Feet » Linear Feet Job Title . F AgencyMKL-0771-003-Backer ■ t Vr C ^ 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 Whife —y*»ow—Inspector Pink — Owner Owtrf —Owner Permit No., LEGAL <2.DESCRIPTION AND LOCATION TWP NameRangeSec.TWPLake Claasif.Lake No. Lake Name IDENTIFICATION: Please Print All Information. Tel. No.Zip No.IVIailling Address —No. Street, City and StateInitialFirstLast Name OWNER SEWAGE SYSTEM INSTALLER Name. This S/stem will be ready for inspection , 19.on. This space for office use only .19 .M Owner or Agent SignaturePhone Call Rec'd ByDate Rec'd Time Rec'd NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEEPAGE PIT DRAIN FIELDSEPTIC TANK Sq. Ft.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 Ft.Ft.Ft.Distance from property line Ft.Ft.Ft.Distance from bottom to Water Table AH distances are shortest distance between nearest points RECORD OF TESTS: ,, 19 , Time M ByInspection was made on , RatePERCOLATION TEST DATA:Date of First Test 19 Date of Second Test 19 , Rate 1st Test Taken By First Test -H 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 Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon expressPermit: condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota. This permit may be revoked at any time upon violation of any said ordinance. NOTE: Permit void if work is not commenced within six (6) months. Issued Date: Shoreland Management Office Fee $ CETRTlFir/Tr SSU’-l Comments;. Form No. MKL-0771-003 (Review BATUC LAKC. MINNtSOTA V •* I ,\ INSPECTION RESULTS Inspector must make all measurements SEWAGE DISPOSAL SYSTEM STATISTICS SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY Actual Should be Actual Should be Should be O SF ctual Capacity /OOP GIs.GIs.S F SF S F Distance from Nearest Well 75 50J ov ypFFFF F Distance from Lake or Stream /oo r FFFFF F I'oO ^ FDistance from Occupied Building 2010 20FFFF F Distance from Property Line /O Q >S' O ^ F10 10 10FFFF F - JOF^Distance from Bottom to Water Table 33FFFF F Inspector's Comments Co 0 ci/.S 'O-fl- 3/^9 ~ B//0,^ s-J bO 'Vq //CO M Date of Inspection Time of Inspection. y- 7 Signature of InspectorINTERPRETATION OF ABBREVIATIONS Git - Gallons SF “ Square Feet F ” Linear Feet Job Title AgencyMKL-0771.003-Backer VS -7 8 A \v^ Ko0 +V) \^ V-v ^ u 0 ^ -4.I L 0 V\L' ^ IS 2 S'6 !11 -Lo l_Lc«s Lsi.o^cJii^ ljla^ Rb S'l ^ II IS )cl^ J(joo£^&- ('^ aispy c_c.l<5 ^ys'^.oiM j 5c/0O X/(2.r ^a>- /t> ~f /fia -/ c^./Qg)^LK 'h 9>)^1>S10^ oirLiVa ^a ^ ?JW- /;?//^c>c^ /OC'O 'Uq^Aoli'xO X''^ /^o J 5<pO S^y X'tfttM 2 S;3«- X ^ faU-f /ooo^Y98'i/ L-l< fOi>/’ ,_/O 50/i£»(- 5b«lc5 I 6Ct- Si h^(/~ ^ChtK -2^^^ ^cx:^ ^2!?> & i i. •A *■ ir ! S'y s '^'<-^/ 3 p ^ ' •’J sS^ f (j^2-t ^ £ <X c_ ^^ ^ ^ l-\. >-xl^ C? '■r t C.'tjj /\jj'-<-^ L-tVv4;SCv S I CM, »' > ^ 1^ ('o<^ f h <i ^ -ji^ —c'^y) M «. "l «-t5'coi^i'l ^^—4. ^0., _L^ /Xjl>»-..vx.,jJGL^1.-C c' I *A « ^1 CjM./ Sji/O. t. "f I — l-^O T'^^J^♦^ciJ^ C ,Vf'< r-------^ 0 e<Lff 1 o Lj^ I.'S yi ^4S^'cw i I; ;i ^ i-' ; •r-1 ...A .. ! .. Lf^^€SX)-<V r )A c/ibtV(Oabi^ foo. y Ct^b,r\J /W»,/ I AJo.J iJuA Ppc (4- 4<rS^ tOa 0-f^t-»/' G)rJ^ l/^zyrj3 Oi^ 4A^V Clc\^ c^m> H, S TKij FicVJ p. C9h\t\^ ltOi.3 ^A 4kti fUii^e Str^k>y'^ 7Z'4a?7 jki> -Cccl-c^ XO P" D ! I 1 J I : I I 1- t ^ t i !i I i I'!I ■ *:i ^ II.ii !i ■Ah'i i; I ;T -r|-t • :it' 1 I * + •1 i 1 ] t " 1- ■ -r—^i 1 ► 1W11^I --r: i-t-rt 00. ^PERCOLATION TEST DATA Price $ 1.00 per pad. SHORELAND MANAGEMENT OTTER TAIL COUNTY Fergus Falls, Minnesota 56537 Mailing Address: • U ///V - ^UkL S frSij}, J^/U4 Ph. No.Owner; Rs /Fg o/v£ 'Y Ah).Last Name First Middle St. & No.City State Zip No.Legal Description: LAKE OR ffivER NO. U)^sf to ^r~^, c n NAME TWP.RANGE TWP NAME TEST HOLE NO. 2TEST HOLE NO. 1 /rCl'3?Depth To Bottom of Hole,Depth to Bottom of Holeinches; Diameter of Hole inches; Diameter of Hole Jnchesinches P ? IQ C/i/fS 4-__________ %/ ^3-Depth, Inches Soil Texture 19Depth, Inches Soil TextureDate DateJ//fl/fOrjA ~DuJ~irl/udA Dr^h f I O /cP "Percolation Test By___ Percolation Test By____Q UJFirm Name.cr Firm Name.D aUJ cca r?W lYli PaUJAddress.QC Address< «/)Otter Tail County License No,.Otter Tail County License No,„I-coUJMeasurement. Inches Depth in Water Level, Inches Measurement, Inches Depth in Water Level. Inches Time Remarks Time Remarks O 4^jd-:^ JO' hZ /n: R-7 ~Fik lS!'(h 0^/o:h^JC'iA ID r / />: i4 ? LO' C J d ;z^'( M'■p jni'T 3 D Ct ^l/rOO Zuio:i^ i/:ol //:ooir.o^ lU^/r.n) jjJ-JiX :jUi^ //. do b-)•r/DAt-LU;S’It ICE n.Q-yLl P\ MKL-0871-028183-818 See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn. (^EVIfW SATUi LAKE MINNESOTA fa-i PERCOLATION TEST DATA f^ice W p^rISHORELAIMD MANAGEMENT OTTER TAIL COUNTY Fergus Falls, Minnesota 56537 e\veorec Ph. No.Owner:Mailing Address:I ^E^Fir j/N~^ r^nc\ sh. S.u^. _u>id£no^mioL e LQi»\i e /r.vkg Last Name Middle St. & No.City State Zip No. Description; t^Lo ~*■L. C^c0[ SI \jTWP NAME r:>l LAKE OR RIVER NO.NAME SEC. TWP.RANGE TEST HOLE NO. 2TEST HOLE NO. 1 lx n//32l A.S2-Depth To Bottom of Hole,Depth to Bottom of Hole inches; Diameter of Hole.inches; Diameter of Hole inchesinches ^ A oir\ j-______ Depth, Inches ,9^Soil Texture Depth. Inches Soil TextureDate Date32^^20 a/// ■D CsLaS. ,^ " h, y<" jK -l-r, ^-7 Percolation Test By____ Percolation Test By____Li^iai/r\ / ■r-h-JOjj t' IFirm ame FirmName.^/?N OLUGC LUAddress.GC Address < COOtter Tail County License No..Otter Tail County License No_HcoLUMeasurement. Inches Depth in Water Level, Inches I-Measurement, Inches Depth in Water Level. Inches Time Remarks Time Remarks of -' P<9 9:,)l5:z I- 9/cP^9/r^Ll/ ^ kI //■. 30 7 Lm.1^-21C- tLI9<H<^ 9>:>'9 2!LS13.I SiAL 7(Z 2 /"i:: %3U Ov-«^n"/0^\o9 I ■MD ■0mp>m IQ a A 2"L MKL-0871-028183-818 See Booklet. "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn. [^EVIIW BATTlf lAKi MINNESOTA