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Home My WebLink AboutShady Grove Resort_53000260162000_Septic System Permits_Department of ■ t LAND AND RESOURCE MANAGEMENT OTTER TAIL COUNTY Government Services Center • 540 West Fir Fergus Falls, MN 56537 Ph: 218-998-8095 Otter Tail County’s Website: www.co.ottertail.mn.us Tv September 12, 2005 r. Wesley & Theresa Jeltema 35671 Rush Lake Loop Ottertail, MN 56571 V .1 /■ '■ i'- RE:Sewage Treatment System Servicing Tax Parcel Number 53000990337000 & 53000990338000 & 53000260162000 Described as Lots 3 & 4 of Snodgrass Basswood Grove and Pt GL 1 Com NW Cor GL 1..., Section 26 and 27 of Rush Lake Township, Rush Lake (56-141) r ;I. L- i As of September 2, 2005, the sewage treatment system (Sewage Treatment Installation Permit #17726) servicing your property was determined to be in compliance with the provisions of the Sanitation Code of Otter Tail County for a 16 Rental Cabins, 2 Owner’s Dwellings, 1 Laundry Facility and 1 Fish Cleaning House. If you have any questions regarding this matter, please contact our office. ' • r ■ • Sincereiy,i. 1 •; i Wayne Roisum Inspector i f' II/- i r ^APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM LAND & RESOURCE MANAGEMENT, OTTER TAIL COUNTY (218-998-8095) GOVERNMENT SERVICES CENTER, 540 WEST FIR, FERGUS FALLS, MN 56537 www.co.otter-tail.mn.us WHITE - Office YELLOW- L&R Inspector PINK - Owner/ Contractor (after issue) / '7 -7APPLICATION MUST BE COMPLETE IN ORDER TO BE PROCESSED Permit No. SECTION-.- LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER CLASS TWPNO.RANGE TWP NAME fl US A /jr&0 PARCEL NUMBER (S) OF PROPERTY BEING SERVICED E-911 ADDRESS OR DIRECTIONS FROM NEAREST PUBLIC ROAD 3-0 00- LEGAL DESCRIPTION Last Name First Initial Mailing Address Daytime Phone No. ^ t\Ccol-y 3 S~ ^Lc-J Lcx^/Ce_Property Owner Contractor - Lie. #‘TC ^ THIS SPACE FOR OFFICE USE ONLY AM. >• This System will be ready for inspection on.the year of P.M..at. A.M. P.M. Date Received Time Received L&R Officiai SEWAGE TREATMENT SYSTEM DESIGN DATA • AS SHOWN ON DRAWINGTYPE OF INSTALLATION (CIRCLE ONE) TANK DRAINFIELD 4 Ft' .Size Is. New System (20) Trench, Rock (21 )j.Trench, Gravelless (22) Trench, Chamber (23) Bed (24) Mound (25) At Grade Add-On/ Replacement (32) Tank, Septic (^Tank, Lift Trench, Rock (3^ Trench, Gravelless (36) Trench, Chamber (37) Bed (38) Mound (39) At Grade (40) Combination V.Setback to nearest well Ft. Ft.7^0 tnSetback to OHWL (lake &/or river)Ft.Ft. Setback to wetland Ft.Ft. S70Setback to dwelling Ft.Ft.Collector System (26) Trench, Rock (27) Trench, Gravelless ' (28) Trench, Chamber (29) Bed (30) Mound (31) At Grade Setback to non-dwelling Ft. Ft. yoSetback to nearest property line Ft.Ft.Other (41) Tank, Holding (42) Outhouse (43) Sewer Line (44) Performance (45) Miscellaneous Setback to road right-of-way Ft. Ft. 3Elevation above restrictive layer Ft. Ft. ALL DISTANCES ARE SHORTEST DISTANCE BETWEEN NEAREST POINTS. DEPTH OF WATER WELL # BEDROOMS.ABSORPTION AREA FOR MOUNDS 'mGARBAGE DISP. Y ABATEMENT Y f.Ft^EFFLUENT DISTRIBUTION ( ) Gravity ( ) Pressure HOLDING TANK MONITOR/ DISPOSAL CONTRACT ( )Yes ( ) 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 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 valid for a period of six (6) months. /60. ^JDate:Permit Fee $ Signature of Property Owner/Agent for Owner5^/ ? 7 rDate:Rec. No. Lan(j & Resource Management Office !/61 Comments: Form No. BK — 0203-003 315,609 • Victor Lundeen Co.. Printers • Fergus Falls, Minnesota APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM LAND & RESOURCE MANAGEMENT, OTTER TAIL COUNTY (218-998-8095)/f/C GOVERNMENT SERVICES CENTER, 540 WEST FIR, FERGUS FALLS, MN 56; www.co.otter-tail.mn.us WH/TE - Office YELLOW - L & R Inspector PINK - Owner / Contractor (after issue) /-fn Or.APPLICATION MUST BE COMPLETE IN ORDER TO BE PROCESSED Permit No. LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER CLASS SECTION TWP NO.RANGE TWP NAME j\ u ^ A <7 5 !A>3^GO j 7 Cy / PARCEL NUMBER (S) OF PROPERTY BEING SERVICED E-911 ADDRESS OR DIRECTIONS FROM NEAREST PUBLIC ROAD I 5 3-000 - ‘^1 LEGAL DESCRIPTION [k\ ^/C^ 'oc’C.-frzo)/e Last Name First Initial Mailing Address Daytime Phone No. ^Xq_c.(.3 ^ J ^ La /<3i Gap 7Y) ^ ~7 } Property Owner 2 JOto p / / •i rL iTe Z'ul^ <yf\h/} ^ (3 Ci-C/ ^Contractor Lie.# \ \ THIS SPACE FOR OFFICE USE ONLY IS-'a f A.M. ► This System will be ready for inspection on_the year of P.M. Date Received /6 A.M. P.M. Time Received L & R Official SEWAGE TREATMENT SYSTEM DESIGN DATA - AS SHOWN ON DRAWINGTYPE OF INSTALLATION (CIRCLE ONE) TANK DRAINFIELD ^^Is.3 S'00 f FI*SizeAdd-On/New System (20) Trench, Rock (21) Trench, Gravelless (22) Trench, Chamber (23) Bed (24) Mound (25) At Grade Replacement (32) Tank, Septic ^ Tank, L Trench '^S) Trench, Gravelless (36) Trench, Chamber (37) Bed (38) Mound (39) At Grade (40) Combination Setback to nearest well Ft. Ft. Lift Setback to OHWL (lake &/or river)in.Ft.Ft., Rock Setback to wetland Ft. Ft. noSetback to dwelling Ft.Ft.Collector System (26) Trench, Rock (27) Trench, Gravelless (28) Trench, Chamber (29) Bed (30) Mound (31) At Grade Setback to non-dwelling Ft. Ft. Setback to nearest property line Ft. Ft.Other (41) Tank, Holding (42) Outhouse (43) Sewer Line (44) Performance (45) Miscellaneous Setback to road right-of-way Ft.Ft. 3Elevation above restrictive layer Ft. Ft. ALL DISTANCES ARE SHORTEST DISTANCE BETWEEN NEAREST POINTS. DEPTH OF WATER WELL #BEDROOMS ----ABSORPTION AREA FOR MOUNDS GARBAGE DISP. Y ^ ABATEMENT Y /fN'Ft^EFFLUENT DISTRIBUTION ( ) Gravity ( ) Pressure HOLDING TANK MONITOR/ DISPOSAL CONTRACT ( )Yes ( ) 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 tor 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. -///;'Date:Permit Fee $i Signature of Property tor Owner •yf ?r3/! >Date:Rec. No.; Lan6 & Resource Management Office V i 1/0/3-nn /-.y~i / /Comments:y'' C--■t ArForm No. BK — 0203-003 315,609 • Victor Lundeon Co.. Printers • Fergus Falls. Minnesota SEWAGE TREATMENT SYSTEM PERMIT INSPECTION RESULTS Inspector must make all measurements HOLDING SEPTIC TANK OUTHOUSEDRAINFIELDLIFT TANKCATEGORY /To/ Capacity FT2 FT2GLS.GLS. FT FT FTSetback from Nearest Well Setback from Buried Water Suction Pipe FT FT FT FT Setback from Buried Pipe Distributing Water Under Pressure FT FT FT FT FTSetback from OHWL (lake &/or river)FT FT FT FTSetback from Setback from Wetland FT FT FT FTSetback from Dwelling FT FT FT /O^ FTSetback from Non-Dwelling FT FT FT /Of FTSetback from Nearest Property Line FT FT FT /O-f FTSetback from Right-of-Way FT FT FT ^f ftElevation above Restrictive Layer FT FT FT Holding Tank/Lift Alarm YES NO Old System Pumped & Destroyed YES NO SEPTIC TANKtS)FILTER Sewer Line to Well Separation DRAINFIELD CALCULATION / ? Fh y FTMinimumActual# Tanks Installed □ YESManuf, .ft^□ NO FT 20Model # MOUND CALCULATION MOUND /AT-GRADE ROCK REDUCTION Inspector’s Comments: ABSORBTION AREA inchesRock trenches with of rock under pipe for .%Ft. X .ft^ DF.reduction / equivalent toFt2 iSKETCH: A 4 91^ i 7 ---------- C^-7'CX IGOO lUlo Infial/L & FI OfficialTimeDate the above described sewage system installation was found to be compliant with the provisions of the SanitationAs of Code of Otter Tail County. A Land & Resource Management Official \ CERTinCATE OF APPROVAL SEWAGE SYSTEM mDRAIN FTEI..D 21st 97FebruaryThis certificate has been issued this to certify that the sewage system installed as per sewage permit number indicated below has been approved for use by Otter Tail County, Minnesota. day of 19 Si' m The premises covered by this certificate are legally described as: 13556-141 27 Range Name RUSH LAKEs,.Lake No.Sec.Twp. mSNODGRASS' BASSWOOD GROVE LOT 2ii M m''1HOWE, DALE WMOwner: Name mi tiSHADY GROVE RESORT, OTTERTAIL. HNAddressk'.p!56571Zip No. 11012Permit No. SP Signed by: ^ Ouer Tail County. MinnesotaMKL-0987001 HaSi JT 279005 Victor Lundeen Co.. Printen, Fergus Fall*, Minnc»oli y 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 S/?4c//DESCRIPTION Abatement AND LOCATION SECTION RANGELAKE/RIVER CLASS TWP NAMELAKE NUMBER LAKE/RIVER NAME TWP. NO. 3? ^yf/6p FIRE OR LAKE ASSOCIATION NUMBER I ^1 I3S&.0 PARCEL NUMBER(S) IDENTIFICATION: Please Print All Information Zip Code Telephone No.First Initial Mailing Address — No. Street, City and StateLast Name Property Owner rlt hoUPAl4Sewage System Installer Name A.M. ► This System will be ready for inspection on P.M., 19-at This space for office use oniy NUMBER OF BEDROOMS: —- A.M. P.M19 GARBAGE DISPOSAL: ( ) YES ( NOTime Rec'd Phone Call Rec'd ByDate Rec’d SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM ( ) Holding tank (Alarm Required) ( ) Septic tank ( ) Lift station (Alarm required) ( ^) Drain field ( ) Trenches ( X) Bed ( ) Mound ( ) Outhouse ( ) Sewer line TANK DRAIN FIELD 3 ^C)OSqR.Capacity GIs. Y Distance from nearest well Ft. Ft. Distance from lake or stream Ft. Ft. Distance from building Ft.Ft.c-,5loDDistance from property line (0Ft.Ft. 3Distance from bottom to Water Table Ft. Ft. EFFLUENT DISTRIBUTION ( ) Gravity ) Pressure All distances are shortest distance between nearest points WATER WELL DEPTH PERCOLATION TEST DATA: Perc Tester.Date of Perc Test Rate of 1 St 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 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 r^dy for inspection. fo/l^/ UDATE: Signature Permit: Permission is hereby granted to the above named applicant to perform the work described in the above staterhent. 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. Lj iX. (rff.Issued Date: Land & Resource Management Office ______Fee $.Rec #. Comments: 277,212 • Victor Lundeen Co.. Printers • Fergus Falls. MinnoostaBK 0795-003 ■1 . APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM ;?WHITE — Office Yellow — Inspector Pink — Owner LAND & RESOURCE MANAGEMENT OTTER TAIL COUNTY 03URT HOUSE Phone: (218) 739-2271 - FERGUS FALLS, WIN 56537 1101^Permit No.LEGAL DESCRIPTION )Yes (V)N0Abatement AND LOCATION SECTION RANGELAKE/RIVER CLASS TWP NAMELAKE NUMBER LAKE/RIVER NAME twpTnoT 3? I I /rhpSC-IHI I 77 ns6^ FIRE OR LAKE ASSOCIATION NUMBERPARCEL NUMBER(S) i IDENTIFICATION: Please Print All Information .3 Mailing Address — No. Street, City and State Telephone No.Last Name First Initial Zip Code •/ ncO ■< P<4/-g ^/3C %Property Owner / -/ / .mhJ C CT7/ r/c (r^oUJAHSewage System Installer Name y3 /6 ^A.M. This System will be ready for inspection on., 19.at This space for office use only NUMBER OF BEDROOMS:t-/3 <CXiO P.M19 GARBAGE DISPOSAL: ( ) YES ( >C) NODate Rec'd Time Rec'd Phone Call Rec'd By SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM ( ) Holding tank (Alarm Required) ( ) Septic tank ( ) Lift station (Alarm required) Drain field ( ) Trenches ( X) Bed ( ) Mound ( ) Outhouse ( ) Sewer line TANK DRAIN FIELD 3, Ft-Capacity GIs. Distance from nearest well Ft.Ft. Distance from lake or stream . I Ft.Ft.5q/ ' 4'Distance from building Ft.Ft. tDistance from property line Ft.Ft.[0 3Distance from bottom to Water Table Ft.Ft. EFFLUENT DISTRIBUTION ( ) Gravity (')C) Pressure All distances are shortest distance between nearest points PERCOLATION TEST DATA: WATER WELL DEPTH Perc Tester.Date of Perc Test Rate 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 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 r^dy 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■7^p i Jr U.iZ Ip Fee $.Rec #.fj !oca-'ifon <D. -j._Q V! ■///r'-.n / U/t /I■ ; 277.212 • Victor Lundeen Co.. Printers * Fergus Falls. MinneostaBK 0795-003 -----!•IJ :Wk' "JWW ^ ‘ INSPECTION RESULTS Inspector must make all measurements SEWAGE DISPOSAL SYSTEM STATISTICS DRAIN FIELDHOLDING SEPTIC TANK LIFT TANKCATEGORY Actual Minimum SFCapacityGLS. GLS.SF ^ / FT {CrQ f- ftDistance from Nearest Well FT FT Distance from Buried Water Suction Pipe FT FT FT 50 FT Distance from Buried Pipe Distributing Water Under Pressure FT FT FT FT10 FT FTDistance from Lake or River (OHWL)FT FT I 0 ft 10/20 FTDistance from Nearest Building FT pO ft/sDistance from Nearest Property Line FT FTFT10 3. y ftDistance from Bottom to Water Table FT FT FT3 /^ES NOHolding Tank/Lift Alarm NOOld System Pumped & Destroyed Sewer Line to Well Separation DRAINFIELD CALCULATIONINTERPRETATION OF ABBREVIATIONS GLS. = Gallons SF = Square Feet FT = Linear Feet Actual Minimum 81-r rrFTX FT 20 FT SF Inspector’s Comments: ■ ^ SKETCH:n nr ,4 I/' c ____ Inspector's Signature vile of Inspection ~ , L-i'V‘tc I <rzrz?A3a Time of inspection GRID PLOT PLAN feet SKETCHING FORMinch(es) equalsfeet, orgrid(s) equalsScale: / W ..19Dated:SignatureX ' •' Please sketch your lot indicating setbacks from road right-of-way, lake and side^rd for each building currently on lot and any i^oposed structures./ iz / 7 r —, 0'^vN'4T7 \\\}\\\ \\■^;l u. \\ \\\>»r-'(1! I 1'tv itS i5, ,!; I'2T“‘ c.M£,,y 0]\1i 1 ■r.;? ;jRECEIVED JUN 1 2 1996 tAND&RWURCf /4wx<f, ■f/■JT* CTX. /^/yo^ 278.428 • Victor Lundeen Co. Printers • Fergus Falls. MN • 1-80D348-4870 S m TWN. msammsm^g&;mXx P1*4 ^1 \ clW CERTIFICATE OF COMPLIANCE SEWAGE SYSTEM m iiffi13 2lt.tb }9-Xlday nf ,T?^rmp-pyThis certificate has been issued this iito certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota. The premises covered by this certificate are legally described as:itLake No. Sec. 26 Twp. 135 pa W) m Range Twp. Name Rn<^h T.Pikft Shady Gy-’ove Rescpt Wy.m mm Owner: Name. wi fm|s»ii 7 m R F Dj Ottfir•hfl'il j T41\TAddress. m 56571Zip No. 2119Permit No. SP_ m Signed by:. Malcolm K. Lee, Shoreland Administrator Otter Tail County, Minnesota ............ MKL-087 1-009 cVt/X" @ 1S9035 vi::o» tuHBCCi » eo. ft»:us f«LLs. JIlU minnesota department of health 717 s.e. delaware st. minneapolis 55440(m Decembw 7* 1976 Mr* <3wan Secman Himeaota 36571 Jear Mr* Stosfssant Vie ar« anolosing a copy of our report covarias an aacankination of plans and spacificarions on a savMga disposal systsw for ^<ty Orova assort*Ottartall County* Rusik lake T«m)ihip» the plana and specif ioations appear to b« in getierat eonfoisaity' with the standards of this r>aparttBant* ^Then the pro4aot is ooB^leted* please conmmicate with Hr* Richard 8anitariaa in our t^rest Central district office* in Fergus Falls* in order that be tsey make final inspection* A sat of tius identified plans and specifications Is also enclosed* If 3rou have any <[ucetion8 in regard te the information ccntained in this report* please contact Hr* Faul fanegoi of this office* fours very traly# Charles F* Settle* Chief'Section of Cenerai Smrirooaimtal Engineering Enolosurc eCk Hal via ^iSsCknnss* c/o Oven Stoeimon Shorelend Hsnagsraont Office an equal opportunity employer ! IMINN]i;SOT.A DEPAH'I'MENT QF KSALTIi Division of Environmental Health IREFOET OK PLANS i iPlans and Specifications on Sewage Disposal System for Shady Grove Resort Location_ Lohe Township (near Otr.ertail)Date Examined 'oecembcr 6. 1.975 Prep;ared and submitted by Melvin McGowan c/o Owen Stoi-mian, R^F.D, Orcertail. Mimiescta Date Received__November 19, 1976 Plan Pile Noo A-1418 CX'mership -Oven .fr.ovman, R^F.Dcy Outerfcail, Minnesota Scope - Tills report includes the design of the sanitary features of a. sev:nge disposal system,. Type - Sanitaryo Designed to collect and treat domestic sewage and basement drainage onlyv Storm-water comiectioris should not be made.. Treatment - (1) 4725 gallon septic tank Final Disposal - 3350 square feet absorption areay 4 feet minimum above the water table. Recormiiendcjtions - Soil absorption tj’pe sev/age disposal systems are considered a temporary method of disposal suitable only until .such time as arrangements can be made to con nect to a community sev/erage system,, If the system fails before a connection can be made, the plumbing fixtures should not be used until additional soil absorption capacity can be provided. Connection should be inade to the municipal sev/erage system as soon as it becomes available. I'niet and ovVL-..*.efr. manho3.ee for the .septic tank sJ/al't bo provided, lewage di.sposal construction shall comply to recoarTiendaLion of the Minne.sota State Healtn Department. i 2, Conclusion These plans and specifications are in genera.l accordance with the requirements of the Minnesota Department of Health, and are recommended for approval with the under standing as stated in the preceding pavagj.-aphs, and with the usual reservations as stated on tiie appended sheet entitled, "Information Relative to Plan Examination." OPaul T, Panagos Public healo'n Engineer Seer.ion o.f General Environmental Engineering Approved: C3iarica P. Set(:.3.e, C3/ifcf Section of Genera]. Snqinoerino 5 fCEMESOTA DEPARTME2JT OF HEALTH Division of Environmental Health Information Relative to Plan Examination The examination of plans and specifications for water supply and sewerage systems (Regulation MD 136(a)), plumbing systems (Regulation JIHD 139(a.)(l)), and swimming pools (Regulation MHD litl(c)), is made to provide information concerning the sanitary features of projects presented for consideration in accordance with the above regulations of the State Board of Health. The approval of such plans is given upon the supposition that the survey and other data on.which the design is based are correct, and that necessary legal authority has been obtained to construct the project. The responsibility for the design of structural features and the efficiency of equipment must be tahen by the engineer or architect who designs the project. Water supply plans are examined with regard to the location, construction and operational features of the design and maintenance of all parts of the system which may affect the safety and sanitary quality of the water. Examination is based on the standards of this Department. Plans of sewage disposal systems considered by this Department are limited to those systems that can utilize soil absorption. They are examined with regard to the features of design which concern location, construction, operation and maintenance of the system and vrhich may affect the public health. The examination is based upon information contained in the bulletins entitled, "Tentative Standards for Design of Small Sewage Works," July 1962, and the recommended "Ordinance and Code Regulating Individual Sewage Disposal System," 1971. Plans on plimbing systems are examined only insofar as the provisions of the Minnesota Plumbing Code apply. Swimming pool plans are examined with regard to the features of location and design which may affect the safety and sanitary quality of the water for public bathing. The examination is based upon Regulation MHD lUl, Public Swimming Pools. The State Board of Health reserves the right to withdraw its approval of plans if construction of the project is not undertaken within a period of two years. The fact that plans have been approved by the State Board of Health does not necessarily mean that recommendations for alterations or additions may not be offered at some later time when changed conditions or advanced knowledge make icprovements necessary. SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone 218-739-2271 - Fergus Falls, Mn. 56537 APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM W :te — Office V low — Inspector Pli.. 4— Owner CarQ — Owner A (9 Y Permit No.,LEGAL /0/'f/7tDate DESCRIPTION AND Ci D ■7(e 39ttj:* Lake Name LOCATION Lake No.Lake Claasif.Sec.TWP Range TWP Name IDENTIFICATION: Please Print All Information. Zip No.Tel. No.Last Name First Initial Mailling Address —No. Street, City and State A> rD o(3 \a^ iOWNER ./hcgSEWAGE 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 A NUMBER OF BEDROOMS: j 2_ C ^ gent Signature r « 0 S■ yESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD ‘■Inx.r 3 JtoGIs.Sq. Ft.Capacity Sq. Ft. I n 0 Ft.Ft.Ft.Distance from nearest well H d 0 Ft.Ft.Distance from lake or stream Ft. ■yrtJ-0 Ft.Distance from occupied building Ft.Ft. 7^roCADistance from property line________ Distance from bottom to Water Table Ft.Ft.Ft. Ft.Ft.Ft. AH distances are shortest distance between nearest pdints RECORD OF TESTS: Inspection was made on 19,, Time ,JVI By I2h.I oli blihb.PERCO ON TEST DATA:Date of First Test 19 Rate / Date of Second Test --------- First Test , 19...Rate ISt /.1.i + 2nd Test 1 Rate2nq [Test TakMi By The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do alt 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 Defjartment 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 the4eb is ready forinspection :all or use attached mailer notice.) Mhh/oDated 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 eonform in all respects to ordir^ces 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. h hi/?y /HIssued Date: loreland Management 0f|fce /JL j V VICTOR LWMDCCM t CO . MiHTIM. ,EMU, ^L, HINO 158906 ^^ ^ Fee $Surcharge $ Comments:. Form No. MKL-0771-003 SHORELAND MANAGEMENT - COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone 218-739-2271 - Fergus Falls, Mn. 56537 ' APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM W ;te — ^Offj^e V low — Inspector Ph.. 4 Owner Card ■»- Owner c i/■ o Permit No../ LEGAL Date DESCRIPTION AND LOCATION Lake No.Sec.TWP NameLake Name Lake ClassIf.TWP Range IDENTIFICATION: Please Print All Information. Mailling Address —No. Street, City and State Zip No,Tel. No.Last Name First Initial OWNER SEWAGE SYSTEM INSTALLER Name. 1^ This System will be ready for inspection 19.on. This space for office use only 19 Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signa.ture NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD GIs.Sq. Ft.Capacity Sq. Ft. Ft.Ft.Ft.Distance from nearest well Ft.Distance from lake or stream Ft. Ft. Ft.Distance from occupied building Ft.Ft. Qtstance from property line Ft.Ft.Ft. Ft.Distance from bottom to Water Table Ft.Ft. 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 -I- 2nd Test 2 Rate2nd Test Taken By The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work inAgreement: strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn esota Department of Health. Applicant agrees that plot plan, sketches and specifications submitted herewith and which are approved by Shoreland Management Offi cial shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the responsibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection. (Call or use attached mailer notice.) Dated Signature Permission is hereby granted to the above named applicant to perform the wjS^(^Uribed in the above statement. This p>ermit is granted cj^w^l^^n sh Permit: condition that the person to whom it is granted, and his agents, employees an upon express all conform in all respects to ordinances of Otter Tail County Minnesota. This permit may be revoked at any time upon violation of any said ordijjiince NOTE: Permit void if work is not commenced within six (6) rnonIttX V * Issued Date: Shoreland Management Office Fee $Surcharge $ Comments:. Form No. MKL-0771-003 ,n.i .... ISS906VICT»* LUMtEEtl 4 M.. ■ ^INSPECTION RESULTS i Inspector must make all measurements SEWAGE DISPOSAL SYSTEM STATISTICS SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY beActualShould be Actual Should beActual Capacity GIs.GIs.F SF S F Distance from Nearest Well 75F F 50FF F 0ypoDistance from Lake or Stream F F F F JDistance from Occupied Building 10 2020FFJ.F F F10Distance from Property Line 10 10 10F F 'F F F /Distance from Bottom to Water Table 4 4FFF F 3 3 f y -f t Jo _______ Inspector's Comments: Oi 3.>- ^^0,) - O' V. Y IC=5^ Date of Inspection .19___7 Time of Inspection,M Signature of InspectorINTERPRETATION OF ABBREVIATIONS GIs ^ Gallons SF = Square Feet = Linear Feet / Job TitleF AgencyM KL-0771-003- Backer PERCOLATION TEST DATA Price $ 1.00 per pad. SHORELAND MANAGEMENT OTTER TAIL COUNTY Fergus Falls, Minnesota 56537 Ph. No. Owner:Mailing Address: GHOViii Rc^SORT - Owen Gtowman RFD 1 Ottertail Mn Last Name First Middle St. & No.Zip No.City State Legal Description: GD LAKE OR RIVER NO. 26Rush Lake 135N 39W Rush Lake SEC.TWP.NAME RANGE TWP NAME Parcel in Sec 26 twp 135N abutting Rush Lake 10T}T^^'^ T f! Bll /S /2r=V '■ TEST HOLE NO. 2TEST HOLE NO. 1 26 66Depth to Bottom of Hole inches; Diameter of Hole.JnchesDepth To Bottom of Hole.inches;Diameter of Hole inches Octobey l6 it>JZ6 Oct 16Depth, Inches Soil Texture Depth, Inches Soil TextureDate.Date Lgam1-10 1-9 LoamPercolation S*<J* Lifert Test By________________________ Percolation Test Bv .10-24 Q-P6Sand SandQ LUFirmName.IT Firm Name.3O LUQC Perham, Mn LUAddress.CC Address < Otter Tail County License No..Otter Tail County License No..I-coLUMeasurement, Inches Depth in Water Level, Inches Measurement, Inches H Depth in Water Level, Inches Time Remarks Time Remarks O 37 ^5I- .3 / ^3-a -/ 3 jS3 t /3,i Zy -¥4 '/ 3/i 3l- ^3-7 3 / 3^ 7l^cS' J3S -/L//0 r I ^/ / V 2 > y-"*23'> 3 / ^ /¥93r 34I/ V >- 7XS 3^ - /^3y', /2JZ AV; PERCOLATION RATE = ~o“X 4 ''/V / Min/inchor 159179 ®MKL-0871-028 vide* i.o»ect«i * CO rt»eus r*cL» See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn.