HomeMy WebLinkAboutSpruce Lodge_56000110076000_Septic System Permits_SEWAGE SYSTEM ABATEMENT NOTICE
LAND & RESOURCE MANAGEMENTCOUNTY OF OTTER TAIL
COURTHOUSE, FERGUS FALLS, MN 56537
(218) 739-2271
Lake Number: (56- 3 85) Lake Name; STAR
FLOYD F & RUTH FELTON
RR 1 BOX 364
DENT, MN 56528 9724
You are hereby notified that the sewage system which you maintain on the
following described property:
'
UNPLATTED
LOT 3 EX PLATTED & EX TR
Sec:Tv7p;Range:14 135 041
Parcel Number:GIS #:56000140097000
is.-not constructed and/or located in accordance with minimum standards of
the Shoreland Management Ordinance of Otter Tail County.
Please be advised that you must correct this situation within 30 days... You
should contact this office in order to determine what corrections and
permits are required prior to complying with this notification.
(iMuk eC o rj? €
'Land$ & Resource Management Official - Dated 7/2
^00
:
-}
'
STATE OF MINNESOTA )
)ss. AFFIDAVIT OF SERVICE BY MAIL
COUNTY OF OTTER TAIL)
Mavis Samuelson, of the City of Fergus Falls, County of Otter Tail, in the State of
Minnesota, being duly sworn, says that on the July 25, 2000 she seiwed the annexed:
ABATEMENT
On the following person, by mailing a copy thereof, enclosed in an envelope, postage, -
prepaid, and by depositing same in the post office at Fergus Falls, Minnesota, directed to ^
said person at the following address:.->'1 .
i
FLOYD & RUTH FELTON
RR#1 BOX 364
DENT MN 56528-9724
i
;
Mavis Samuelson
Land 86 Resource Managerrient Official 1--
■t.
Subscribed and sworn to before me this
A 6^in the year of 9,000day of
;>Ai y SI I 9^00SMy Commission Expires'
;.;e'C0S
JOYCE LTHOMPSON
NOTARY PUBtlC-MINNESOTA
My Commission Expires JAN. 31,2005IM
.'f'
ForniLtrs-CertifiedMailingMS
Cv
FIELD NOTES
LAKE NO.: 56-DATELAKE NAME:
Parcel No.:LEGAL DESCRIPTION FIRE NO.:
fc
Sfrvot tol^< (p/a'F
Cc’ij-e
I>€w-f H isl
. OWNERS, NAME AND ADDRESS:
SLSXl
Comments:
SEPARATION DISTANCES(IN FEET)
SEWER LINE TANK ABSORPTION AREA OUTHOUSE
^0V-
WELL..,
. OHWL
LOT LINE
DWELLING
NON DWELLING
GROUND ELEVATION @
REASON(S) FOR ABATEMENT:
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CERTIFICATE OF APPROVAL
SEWAGE SYSTEM
jt)
m'i 19 94December19th
ll
This 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 WJ-M,
i Is
WM
The premises covered by this certificate are legally described as:iiTwp. Name Stor LakeRange 41Twp. 13511Lake No. 56-3R5 Sec.miBI
GL 3 ___
Spruce Lodge iM}Mif.*
1k]-Eel toil,- FLnyd
205 Reno Ave
Owner: Name
mi P fe:)Canby, PINAddress
55220Zip No.
Permit No. .SP 994?
Signed by:
Land & Resource Management Official
Otter Tail County. Minnesota
A
MKL-0987001
ft
•>A
JT-263191 Victor Lundeen Co., Printers, Fergus Falls, Minnesota
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
AND
LOCATION
SECTION TWfijNAMELAKE NUMBER LAKE/RIVER NAME LAKE/RIVER
CLASS^
&D
TWP. NO.RANGE
J&aJ /BS//4^/
FIRE OR LAKE ASSOCIATION NUMBERPARCEL NUMBER(S)- Ol)l)- /! -do'7^-oOO^ 6(^- Od-3-d(0o/^o/
IDENTIFICATION: Please Print All Information
Zip CodeMailing Address — No. Street, City and StateFirst Telephone No.Last Name Initial
Property
Owner
Sewage
SystemInstaller
Name
A.M.
P.M.This System will be ready for inspection on., 19.at
^ 6This space for office use oniy
NUMBER OF BEDROOMS:
A.M.
P.M19 (^ ) NOGARBAGE DISPOSAL: ( ) YESTime Rec’d Phone Call Rec'd ByDate Rec’d
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM TANK DRAIN FIELD( ) Holding tank (Alarm Required)
( ^ ) Septic tank
'K>
//23 sq R/y)oo GIS.Capacity
eo/Mn^'60 Ft.Distance from nearest wellDrain field
( ) Standard ( ) Bed ( Trench
{ ) Modified
( ) Mound
30 Ft.Ft.Distance from iake or stream 30
/O^r^O/O Ft.Ft.Distance from building
/oFt.Ft.Distance from property line
EFFLUENT DISTRIBUTION
( )() Gravity
( ) Pressure
Distance from bottom to Water Table Ft.Ft.
All distances are shortest distance between nearest points
WATER WELL DEPTH:,.
.^/g//3.3
/OO
PERCOLATION TEST DATA: Date of First Test Rate, 19.
Date of Second Test Rate19'yi
1st JP^st Taken By /O. o
2nd Test Taken w
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 tor
the permit to notify the County Shoreland Management that the job is ready for inspection.
'6DATE:
Signature
Permit: Permission is hereby granted to the above named applicant to perform the work described in the above statement. This pehfiit is granted upon express condition
that the person to whom it is granted, and his agent, employees and workmen shall conform in all respe
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. , —
the Ordinance of Otter Tail County, Minnesota.
Issued Date:
Land & R^urce Management OfficeCO/mw36Rec #____Fee $.
}
Comments:
Form No. BK-0993-003 268,559 - Victor Lundeen Co.. Printers - Fergus Falls. MN • 800-346-4870
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
'T
IVH/rS — Off/ce
/e0OM' Inspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone:(218)739-2271 - FERGUS FALLS, MN 56537
1
Permit No.LEGAL
& LSDESCRIPTION
» » # ♦AND
LPCATION
LAKE/RIVER NAME SECTIONLAKE NUMBER LAKE/RIVER
CLASS_
RANGETWP. NO.TWP NAME
y-Ia/O G>D //
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
5^- / / /)-
IDENTIFICATION: Please Print All Information
Mailing Address — No. Street, City and Slate Zip CodeLast Name First Initial Telephone No.
)<■^63 •' / /ZV.Property
Owner
7Sewage
System
Installer
jyn-^rjName
m ------- I
„ h:50'Iz^^.M.
This System will be ready for inspection on..M., 19.
This space for office use <s:, )o NUMBER OF BEDROOMS:3-J-)P.M.) YES (V ) NOGARBAGE DISPOSAL: (Pti6ne<5all Rec’d ByTime Rac'dDate Rec’d 7
SEWAGE TREATMENT SYSTEM DATA: MINIMUM REQUIREMENTSTYPE OF SEWAGE SYSTEM
( ) Holding tank (Alarm Required)DRAIN FIELDTANK
(J1 Sq Ft./7)7)7)GIs.Capacity( ^) Septic tank
60/y)n^a/)Distance from nearest well Ft.Drain field
( ) Standard ( ) Bed ( ^) Trench
( ) Modified
( ) Mound
7
Distance from lake or stream Ft. Ft.
/o Ft.Distance from building Ft.
7
m.Ft.Distance from property line Ft.
EFFLUENT DISTRIBUTION
( ^) Gravity
( ) Pressure
^ Ft.Distance from bottom to Water Table Ft.
All distances are shortest distance between nearest points
WATER WELL DEPTH:
.'ddujycl3cp
9^
/n.n
d /.3 /^ 3 /d /PERCOLATION TEST DATA: Date of First Test Rate, 19
Date of Second Test Rate, 19/1st Tpst Taken By JAA/3). o = ^3-3 =First Test + 2nd Test Rate22nd Test Taken
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.
y/ ' ' ^yV7 LzDATE;______________________________________ _______:
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 respecte to the Ordinance of Otter Tail County, Minnesota. This permit may be revoked at any time upon violation of any said ordinances. i j
NOTE: Permit void If work is not commenced within six (6) months. \/
y v / 7/ S'O/Issued Date;
Land & Resource Management Office35^myRec #,
c y.'.'■ // > rf J
Fee $.J
A A")/ 1(03^2d. Ai /drdAk-—&Comments:
Form No. BK-0993-003 268,559 - Vidor Lundoen Co., PrirMra • Forgus FaRs, MN • 800-346-4870
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK DRAIN FIELDCATEGORYActualMinimumMinimumActual
SFCapacityGLS.SFGLS.
FTDistance from Nearest Well FT FT50 FT
Distance from Buried Water Suction Pipe FTFT FTFT5050
Distance from Buried Pipe Distributing Water Under Pressure (FT FT FT FT10 10
-fcj£0.|-FT /So ftDistance from Lake or River (OHWL)FT FT
ft 10/20 FTFTDistance from Nearest Building 10 FT
TC> ft iO__ftDistance from Nearest Property Line FT FT10 10
3Distance from Bottom to Water Table FT FT FTFT3
YES NOHolding Tank/Lift Alarm
Sewer Line to Well Separation DRAINFIELD CALCULATIONINTERPRETATION
OF ABBREVIATIONS
GLS. = Gallons
SF = Square Feet
FT = Linear Feet
5V5SActualMinimum
FTX .FT
FT /36<P'20 FT SF
yc-5,¥Inspector’s Comments:
0~5^"
SKETCH:
\!\i\
Inspector’s Signature
<r-1
Date of Inspection
Time of Inspection
i
t*
D U^HA^LSjli.UU
KjOOi^\tii-U.
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■ '^>f tl£i
ITT
f 21SS02(^ VICTOR LUNOEEN CO.. PRIHTERB. FCROUS FALLS.MKL-087V,-:028 / '.T >'WINN,
PERCOLATION TEST DATA
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, Minnesota 56537■
Ph. No.
Mailing Address:Owner:
^0 5anr irst Zip No.StateSt. & No.M4ddleLast Name
De<;nriptinn-^^X^ ,2 0^TWP NAME
/cjTa/"
T3SJ/
RANGETWP.SEC.NAMELAKE OR RIVER NO.
TEST HOLE NO. 2TEST HOLE NO. 1
2H Depth to Bottom of Hole inches; Diameter of Hole JnchesDepth To Bottom of Hole.inches; Diameter of Hole inches
j>/ctv£k
Depth, Inches Soil Texture 2i 19_^Soil TextureDepth, Inches 195^Date.Date
'TSy/i c.'/Tcnn
do,, 7~>,
0- O I ..d-X' .
a 4
Percolation
Test By___:
Percolation
Test Bv .n- :?.i f4.UJ T7T'0^'y J3,Firm
Name.FirmName.CC
DTO/ /3,rr LUCC
'h
, -r^.r:2-nILIAddress.QC Address
<
0 COOtter Tail County License No.Otter Tail County License No..H
coUJMeasure
ment,
inches
Time
Intervals
minutes
Drop in
water level, inches
Percolation
rate minutes
per inch
H Time
Interval,
minutes
Measure
ment
inches
Drop in
water level, inches
Percolation
rate minutes
per inch
Remarks:Time Remarks:TimeO05I-^///if''//Q ' d 0
0
p; r//
3; ^__
7: ^ d
3UO__.
P^/I Vy ljp_2^1p/)
7:0/
0,)'lS /d_J2idd.i\ I')/
Ed/Pi.uJx<
/ Vc,Oi /?5/-d ^fuacj//l£Lfr /'o//Pfi .P'y'//7:0 /ZL
6</C)0/16 ZX ^ /„i //_7 / y //
W'.iXM:m
/r.' •
<
’a
^ See Booklet, "How to Run a Percolation
v'V.yZT.cst" by Agriculture Ext. Service, Un. of MN.“
Percolation rate =.minutes per inch *minutes per inchPercolation rate =
t
:
//^<s
I * *
APPLICATION FOR PERMIT TO INSTALL SEWAGE TREATMENT SYSTEM
WHITE — Office
Yelhw — Inspector
Pink — Owner
LAND & RESOURCE MANAGEMENT
OTTER TAIL COUNTY COURT HOUSE
Phone:(218)739-2271 - FERGUS FALLS, MN 56537
X^cZ /I5AILEGALPermit No.
DESCRIPTION
)Yee (^NoAbatement: (AND
LOCATION
LAKE NUMBER LAKE/RIVER NAME LAKE/RIVER
CLASS .
SECTION TWP. NO.RANGE WP NAME
I5SGrS- \<4'
PARCEL NUMBER(S)FIRE OR LAKE ASSOCIATION NUMBER
IDENTIFICATION: Please Print All Information
Last Name First Initial Mailing Address — No. Street, City and State Telephone No,Zip Code. (ZiJLO'________Property
Owner
Sewage
System
Installer
Name
A.M.
This System wilt be ready for inspection on.P.M., 19.at
This space for oHica u«a only ANUMBER OF BEDROOMS;AM.
19 P.M..
) YES NOGARBAGE DISPOSAL: (Date 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
( ) Bed
( ) Mound
( ) Outhouse
( ) Sewer line
TANK DRAIN FIELD
rP(/976nCapacity
SoDistance from nearest well
SO ■Distance from lake or stream Ft.
/o/r^nDistance from building m_^
/aDistance from property line Ft.Ft.
3__Distance from bottom to Water Table Ft.
EFFLUENT DISTRIBUTION
{)() Gravity
( ) Pressure
All distances are shortest distance between nearest points
PERCOLATION TEST DATA:
WATER WELL DEPTH
Muif Qj}JiaLaL ^
yo/rshs[ere Tester.Dale of Perc Test
Rate of 1st 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 Tai). 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 pad
of the permit. Applicant further agrees that no part of the system shall be covered ugt^t has been inspected and accepted. It shall be the responsibilty of the applicant for
the permit to notify the County Shoreland Management that the |ob is ready for i ✓:tion.
/?e^tr ?DATE:.
^igrxettjrffl /
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
thaF 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.
lOZ/fp /9(fIssued Date:
Land A Resedfee Management Office36®________________fO ^
%- -IrcuSuQ A-L M'n^. //U.
Fee $.Rec #
Comments:
277,212 • VieiAf lundMn Co. rrinian • Forgui Falli. Minnooit*BK 0796-003
-|i|;
; ■ I ,System design must be to scale and must include the proposed location of the sewage system, all
I I i existing/proposed buildings, property lines, the ordinary high water level of the water body and all water
I wells within 150’ of the sewage system ■ M ■ I Cl'
■ t >•.-! -I r.
IT':
i
f ;GRID PLOT PLAN
/___inch(es) equals feet SKETCHING FORMScale:..grid(s) equals feet, or
icV\ r- ^
^A^ Jy A ]SUBMITTED BY:
FIRM NAME:
SIGNATURE:
DATEr’117; I I' TT 'P'' 'address;/^-a j mpca license =?•
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MINNESOTA DEPARTMENT OF HEALTH
Section of Hotels, Resorts and Restaurants
717 Delowore S.E., Minneapolis, Minn. 55440
PUBLIC HEALTH and SAFETY INSPECTION RECORD
DATE/
OTNERP.O.
LICENSEE
address
ADDRESS
P.O.
Nf). OF EMPLOYEESBUSINESS NAME
Lie NO. //' POSTED CABINS yNO. OF; BEDS_____. SLEEPING ROOMS.,, UNITS
Mobile UoTie Park and/or Recreational Campin/s .Area Sices,TYPE OF BUSINESS
ORDERS WRITTEN BELOW MUST BE COMPLIED WITH BY DATE INDICATED
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WELL - SEWER DIAGRAM
Received by ^ ~ ~f/
COI4PLIANCE PREVIOUS O
DI.STRICT OFFirP-S 1, i^er'.i.-^ii 7.S5o820i 2. W.nkato (.i«')-r.0251 .1. Rochester
(285-0178) 4. Uuiuih U2J-4f,42! a. Marshal! i537 7151) 6. MpC (29(. 5.>.'>5!
7. Fergus Falls {7.36-692:) 8. St. Cloud 125.5-42 IM
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CERTIFICATE OF COMPLIANCE
SEWAGE SYSTEM5tVHOLVJMG TANK
^ Mi
15 th day nf JanuoAi^19ilThis certificate has been issued this&
to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.
The premises covered by this certificate are legally described as:
:!StaA Lake.m 56-3S5 Sec.JlA.Twp. Jll Range ^^Twp. Name.Lake No.
Gov. Lot 3 zxctpt that pant hejioXoion.e. plotted cu, SptLucc Lodge..V' •
IV
Vtotjd FeZtonm.Owner:Name.
Canbd, HcnneAota205 R&no Ave.A d dress.
Zip No S6220
6S06Permit No. SP_
Signed by:.
M2colm K. Lee, Shoreland Administrator
Otter Tail County, Minnesota
MKL-087 1-009
159035 tmKi tLi.1, HIM
1>
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 — Owner
/or S a-rccpr nfit pprpr Permit No..LEGAL
DESCRIPTION
AND
/V /rg<LOCATION
TWP NameLake No. Lake Name Lake Classif.Sec.TWP Range
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Zip No.Tel. No.InitialLast Name First
P’loyd -.Ao^■V P hTwOWNER
Rau kofL,SEWAGE
SYSTEM
INSTALLER
Name.
T/j/s 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 Signa^ture
NUMBER OF BEDROOMS;ESTIMATED COST:
i iOSEWAGE DISPOSAL SYSTEM DATA:KSEEPAGE PITANK DRAIN FIELD
\ Sq. Ft.X1600GIs.Sq. Ft.Capacity
Ft.Ft.Ft.Distance from nearest well
6D Ft.Distance from lake or stream Ft.Ft.
I n Ft.Distance from occupied building Ft.Ft.
m Ft.Distance from property line Ft.
UboFt.Ft.Distance from bottom to Water Table FtS
AH distances are shortest distance between nearest points
I^Q—RECORD OF TESTS:
Inspection was made on , Time .JM 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
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.
A i \Dated
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:
^ I /V^A^ \Q^(nIssued Date:■1 l:
Shoreland Management Office
Rec #
^__IrlpUtD.Comments:8lodn ‘€
Form No. MKL-032085 225239 — Victor Lindeen Co.. Printers, Fergus FaQs,
' V
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
mne — offic*
Yelfow — Inspector
Pink — Owner
(i>0U d -G/Cf"/)/
. 0 ^ TD ftTLC
Permit No.
LEGAL //
DESCRIPTION
AND
S/ //S.-T-.LOCATION
TWP NameLake Classif.TWP RangeSec.Lake No.Lake Name
IDENTIFICATION; Please Print All Information.
Mailing Address — No. Street, City and State Tel. No.Zip No.InitialFirstLast Name
OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
WooThis System will be ready for inspection on., 19.
This space for offjtbs use only J
fXV -1
Owner or Agent Signe^tureDate Rac'd Time Rec'd Phone Call Rec'd By
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
iDistance from property line I L. Ft.Ft. Ft.
l.k:Ft.Ft. Ft.Distance from bottom to Water Table
All distances are shortest distance between nearest points
1^RECORD OF TESTS:WoT LA i-1 li: Osl-
Inspection was made on ., 19., Time ,M By
PERCOLATION TEST DATA:Date of First Test ., 19
. 19
, Rate
Date of Second Test Rate
1st Test Taken By
First Test + 2nd Test '2'Rate2nd Teat 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.
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 16) months.
Wi•\-OilIssued Date:
Shorelend Management Office
■. ?Fee $Rec #! ■■/A/InnJTArOlA\' /c//A-V^Comments:
Form No. MKL-03208S 225239 — Vcw LundHn Co.. PrWn. Forgus Fab. MN
“s. ' V. \ 'm
n‘ ■, V / M
i; NVvUlo.'^ ~o.
'rO*' ' ■>•'
!■{:r'
i;
•1
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYShould Be Should BeShould Be ActualActual Actual
1-I)L Y /5C»/yc^oCapacity S FGIs. GIs.S F S FS F
#£0Distance from Nearest Well FFFF F F
r(9Distance from Lake or Stream F F F F F F
iqL lq_Distance from Occupied Building FFFFFF
OK
(ODistance from Property Line F FFFF F
3 3Distance from Bottom to Water Table F FF FFF
V Sv,Inspector’s Comments:
,r ;yc s>
/•Cr-7^C
sC .1Date of Inspection 19
MTime of Inspection
U^,ture of Inspector
INTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feel^
F = Linear Fe^
- L
Job Title
• ,:r.i
! W.
, t} ■ •
L ;
MKL - 03208$ • Mcker Agency
;r ■'I
'V
‘tv
A ■
r:-m'
. : v:;
This certificate has been issued this_1
jo, certify compliance with regulations of Shoreland Management Ordinance, Otter Tail.County^ Minnesota.
Qth _ day of.Jnmjflpy '1910^.■S'..;;
The premises covered by this certificate are legally described as::
. r~«-:56-38^Ih 135 Star Lake
'■j- - .
'V'
‘■•T
■ ■ ■
I
/I'
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
JWhIte - Qffice
Yellow — Inspe^ctor
— OwnerCard — Owner
y (X^ 5~
Q>/YPermit No.,LEGAL iS-'y - 7 ?Date
DESCRIPTION
AND
JTtK // _12£' STfctr letQ-DLOCATIONr
Lake No. Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
First Initial Mailling Address —No. Street, City and StateLast Name Zip No.Tel. No.
Mtu0 uyOWNER
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 Rac'd ByTime Rec'd Owner or Agent Signa^ture
JNUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
^ 3 Osq. Ft.GIs.Sq. Ft.Capacity
■/v
Ft.Ft.Ft.Distance from nearest well
7^Ft.Distance from lake or stream Ft.Ft.
7 oFt.Distance from occupied building Ft.Ft.
AADistance from property line Ft.Ft.Ft.
Ft.Ft.Distance from bottom to Water Table Ft.
All distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19.,, Time ,JVI By
L.z...k..
..L-.A
21...PERCOLATION TEST DATA:Date of First Test 19
, 19
Rate
1st Te^ Taken By ff
u/Date of Second Test Rate
..Q.1.0First 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. (Call or use attached mailer notice.)
6-7- ^ ?Dated .0--f J.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
^ 'PiIssued Date:
Shoreland Management Office
. rpFee $Surcharge $I
\Comments:.
Form No. MKL-0771-003 158906
vieren lumoich « co.. oxaTcua. rtaou* r«t.La. maa
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
>Vtl1te - pffice
Yellow InspectorPirtk — Owner*
Card — Owhfer
M
\
■■
^ r / '/• ^
Permit No.,LEGAL
p Date
DESCRIPTION
AND
< -o r i a/'/ /:?5" ^0LOCATION
Lake No. Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
First Initial Mailling Address —No. Street, City and StateLast Name Zip No.Tel. No.
y ! { v L q’^U iL V: / ,> r-1 'I Q !}.^ <>c<’OWNER -f-
SEWAGE
SYSTEM
INSTALLER
Name,
/.
This System will be ready for inspection on.19.
This space for office use only
19 .M
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature
7NUMBER OF BEDROOMS:ESTIMATED COST;
SEWAGE DISPOSAL SYSTEM DATA:
_________,f POP
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
GIs.Capacity Sq. Ft.; !-^Sq. Ft.
y 7 Ft.Ft.Ft.Distance from nearest well ■)
j
Ft.Distance from lake or stream Ft.Ft.
Distance from occupied building Ft.Ft.Ft,
Distance from property line Ft.Ft.Ft.
i ■'Ft.Distance from bottom to Water Table Ft.Ft.
AH distances are shortest distance between nearest points
j
RECORD OF TESTS:
Inspection was made on „ 19 , Time JVI By i
...72 0
c " ^PERCOLATION TEST DATA:Date of First Test 19
/ 19
. Rate
21...(:> ' (>"^Date of Second Test Rate■V
/r-'1st Test Taken By
■'/OVFirst Test -I- 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
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:
, , f ^ V.Issued Date:
■ Shoreland Manageipient Office
r,Fee $Surcharge $
/V‘ />' 2. 'LV'y ,t .A4^4--^'/Comments:.I;
v~ruI1
Form No. MKL-0771-003 VICT9I LuneccN i CO . PiiKTcaa. rc*«ut hikh.158906 J
(y 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 75F 50FFFF F
Distance from Lake or Stream F F F F F
0 VDistance from Occupied Building 201020FFFF F
Distance from Property Line 10 10 10FFFFF F
Distance from Bottom to Water Table 4 4FFFFF F
Inspector's Comments:T
Date of Inspection
Time of Inspection,
V Slgnature^f InspectorINTERPRETATION
OF ABBREVIATIONS
GIs » Gallons
SF = Square Feet
“ Linear Feet
Job TitleF
Agency
M KL-0771-00 3-Backer
j
<T-T
1
*!•:
.*i-.,.>itu-------
■ jrL Vc ^ : ;v ... ^
• ■0
PERCOLATION TEST DATA Price $1.00 per pad.
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537
Ph. No.Owner:Mailing Address:
STKBHL.01^re. DP?5Last Name First Middle St. & No.City State Zip No.Legal
Description;
LAKE OR RIVER NO.NAME SEC.TWP.RANGE TWP NAME
UrIv K } RE>Le,'iB PFA. ! M LyJ ms o
TEST HOLE NO. 2TEST HOLE NO. 1
lB.Diameter of Hole___CDepth To Bottom of Hole,Depth to Bottom of Holeinches;inches; Diameter of Holeinches inches
73Depth, Inches Soil Texture Date Cl^19^Depth, Inches 4 -Soil Texture19 Date
I !/3 URC.K Lop/<f)"' /^C' n If
Percolation
Test By____CO Percolation
Test By____iij>' i%"- ^9"//If f f ! tQ n
LU -----------------------7 V'^ L.Lq^Firm
Name.FirmName.13 -tC.LB-/OLUDC
A{^(/LUAddress.OC Address<
cnOtter Tail County License No.Otter Tail County License No.Hc/}
OeiBth i
LUMeasurement,
Inches in Water
Level, Inches
I-Measurement,
Inches in Water
Level, Inches
Time Remarks Time Remarks
oP iLL^ 0
I ^
2kl h- ! L.I—
'Ll /IC LLRX/ UJB'uj e I-u7>CyVv cL^Lr
L% P ■nJ6L ____T H b.____1.0^/? y 7*0
Tho > ) o j/'i lO P TicS I
^ i o u
t-8
H-qL 1^1 i/y7/ 0 fLLO
x55lV/^^ ^
3o ^ -L O
I—__________________
*2.0 /kAj>^ 'psfl
30 '4^
10 V 3t>i55‘/‘V t/v (Lo
30^
Sow
Hi y-v■ 30
J/0 c^ --/o
%
, Un. of Minn.
9W33f D■30 MKL-0871 -028
See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service03/
SOIL ABSORPTION SYSTEM WORKSHEET
Ovmer Name:
Average Percolation Rate
Number Bedrooms
7.Critical Slope
sq. ft.Bedroom Absorption Area:
X Number of Bedrooms v-3
Sq. feet required
Septic Tank Requirements in Gallon Capacity
750 Gals.2 Bedrooms or less
c 900 Gals.3 Bedrooms
1,000 Gals.4 Bedrooms
For each additional bedroom add 250 Gals.
Percolation Rate Per BedroomPercolation Rate Per Bedroom
19817701
20218852
206191003
210204115
214215125
218226135
222714023
226248150
230251609
2341652610
2382717011
2422817512
2462913 180 250^185 3014 a3004515190b3306019416
a Unsuitable for seepage pits
b Unsuitable for absorption system
CERTIFICATE OF COMPLIANCE
SEWAGE SYSTEM
TWO SYSTEMS ONLYmm
This certificate has been issued this day of.Januarv3xd11
to certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.
The premises covered by this certificate are legally described as:
56-385 Sec.JA Twp. 135Lake No.Range_AL Twp. Name Star Lakam
S15
Govt. Lot 3 except that part heretofore
platted as Spruce LodgeI*•
Owner:Name.Ernest J. ?^^reh^nuC4-J
Address Spii T.ndgPj ncntj M^nnegntnriire
WK - A Zip No 56528&
Permit No. SP_119 and 17
SHORELAIMD 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 — Of,fice
Yellow — Inspector
Pink — OwnerCard — Owner
/^6Permit No.,
LEGAL 'i' ^/9'?Date
DESCRIPTION
AND
/•-fLOCATION fyy
Lake Classif.Sec.TWP Range TWP NameLake NameLake No.
IDENTIFICATION: Please Print All Information.
Zip No.Tel. No.Mailling Address —No. Street, City and StateFirstInitialLast Name
75>-)^v,.ST5-7/-OWNER
SEWAGE
SYSTEM
INSTALLER
Name,
This System will be ready for inspection on., 19.
This space for office use only
,M19
Phone Call Rec'd ByDate Rec'd Time Rec'd Owner or Agent Signature
sr^ -j ‘
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PITSEPTIC TANK DRAIN FIELD
O a GIs.Sq. Ft.Sq. Ft.Capacity
?/■Ft. Ft.Distance from nearest well
7/^7n/ Ft.Ft.Ft.Distance from lake or stream
>Xr Ft.Ft.Ft.Distance from occupied building
/ d Ft./ iDistance from property line Ft. Ft.
C Ft.Ft.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
RECORD OF TESTS:
,, 19Inspection was made on , Time M By
/ I„ 19 2.%....,
. 19..Zu....
PERCOLATION TEST DATA:Date of First Test Rate
YDate of Second Test Rate Tf
K LL Katemr..X.First Test........./.-. t"-.....2nd Test
22nd 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 Indiyidual 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. ICall or use attached mailer notice.)
X X‘"'Xr)
Signature //yPermit: 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.
> t / i } >l CC^£&i-/Dated /
Issued Date:X Shoreland Management Office
Fee $ C.Surcharge $
Comments:,
@ VICTS* UIBOItN 4 C*.. PBIHTC44. FCBtUt rM.L«. Ml..158906Form 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 SEI/VAGE DISPOSAL SYSTEM
White — Office
Y^low — Inspector Pink
Car^ — Owner
Owner
Permit No..LEGAL
Date
DESCRIPTION
AND
LOCATION
TWP TWP NameLake Classif.Sec.RangeLake No. Lake Name
IDENTIFICATION; Please Print All Information.
Zip No.Tel. No.Mailling Address —No. Street, City and StateFirstInitialLast Name
OWNER
SEWAGE
SYSTEM
INSTALLER
Name
, 19This System will be ready for inspection on.±5This space for office use only
J(-P ' .*) M.19
Date Rec'd Phone Call Rec'd By Owner or Agent SignatureTime Rec'd
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:
19,Inspection was made on , Time ,JVI By
PERCOLATION TEST DATA:Date of First Test , 19 , Rate
Date of Second Test 19 ., Rate
1st Test Taken By
First Test -F 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, sketchesand specifications submitted herewith and which are approved by Shoreland Management Offi
cial shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the
responsibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection. (Call or use attached mailer notice.)
Dated
Signature
Permit;
condition that the person to whom it is granted, and his agents, employees and workmen shall conform in all respects to ordinances of Otter Tail County Minnesota.
This permit may be revoked at any time upon violation of any said ordinance.
NOTE; Permit void if work is not commenced within six (6) months.
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
Issued Date:
Shoreland Management Office
Fee $Surcharge $
Comments:.
CERTlFICAfE ISSUED
VICTOR LURBCEN « CO . RRIRTIRO. rCflOuS TM.LB.
158906Form No. MKL-0771-003
4
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORY
Actual Should be Actual Should be Actual Should be
tooo ).57 Q SFCapacityGIs.GIs.S F S F S F
hO fDistance from Nearest Well F 75FF F 50 F
Distance from Lake or Stream F F F F F F
Distance from Occupied Building 10 20 20FFFFF F
V(0-F /0^FDistance from Property Line 10 110FF10FFFM
Distance from Bottom to Water Table 4 4FFFF Ft
Inspector's Comments;
;
in UmDate of Inspection
Time of Inspection M
A'?i
y
77 Signature of Insp^c^rINTERPRETATION
OF ABBREVIATIONS
GIs <= Gallons
SF = Square Feet
F ■ Linear Feet
Job Title
Agency
M KL-0771-003- Backer
»
PERCOLATION TEST DATA Price $1.00 per pad.
SHORELAIMD MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537 Ph. No.
Owner:Mailing Address:
Last Name First Zip No.Middle St. & No.City State
Legal
Description:
SEC.LAKE OR RIVER NO.NAME TWP.RANGE TWP NAME
TEST HOLE NO. 2TEST HOLE NO. 1
///fitDepth to Bottom of Hole Inches; Diameter of Hole JnchesDepth To Bottom of Hole,inches; Diameter of Hole inches
V/, p ^^Z2=Depth, Inches Soil Texture;,Depth. Inches Soil TextureDate.DateITT6I' ^CLPercolation
Test By.
Percolation
JJLt' bin
zbii U<:-
/ j (\ :^;2rQUJ
£FirmName.QC
DOLU
GC
LUAddress.CC Address./<
CO
Otter Tail County License No..Otter Tail County License No..I-coLUMeasurement,
Inches Depth in Water
Level, Inches
h-Measurement,
Inches Depth in Water
Level. Inches
Time Remarks Time Remarks
O uJaiii1', 6b
g Zfl
/.'AG 5I-T7/// /24.34/ ' ^6 Ik 44dl_kmUAA 2_in 7/^0
-JKM.
jf):co
jlldd
im t f2h^
toys.a. ^,40 TIM r:7 ^ A5'cA g y
Tim iTTl
4- kh
25143-V) 6
Utk TZA214Ul2i77-06 U 'WM-2 4 ^L_4 MKL-0871-028159t79 ®j VICTOD t.JHDUN 4 £0 rCRSuS '**-11*
See Booklet, "How to Run a Percolation Test" by Agriculture Ext Service, Un. of Minn, fj),
*l»>«J5L .4 •MUSSuB6uS', '■a
CERTIFICATE OF COMPLIANCE
SEWAGE SYSTEM
TWO SYSTEMS ONLY
f
19 73This certificate has been issued this day of.January2xd
.Mto certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota.
The premises covered by this certificate are legally described as:
56-385 Sec. Ik.Twp. 135 Ra«ge__AL Twp. Name Star LakeLake No.
iIsGovt. Lot 3 except that part heretofore
platted as Spruce Lodge M
W'
m■
Owner: Name.Froest ,T. S^reh^o^J
mAddress.^priirp T.rifSgpj Ppnf, ^^^nnpgr>^^ni9
Zip No 56528 -tn-.
M/Permit No. SP 119 and 1 ?n
Signed by:.
Malcolm K. Lee, Shoreland Administrator Otter Tail County, Minnesota
MKL-087 1-009
PW
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
Office
“ I InspectorVU iPinkV o
'*
/ LR...
A? / T
Permit No.,LEGAL
Date
/DESCRIPTION
AND
/Sr- //rz-:^fjr js.LOCATION
TWP NameLake No. Lake Classif.Sec.TWP RangeLake Name
IDENTIFICATION: Please Print All Information.
Initial Mailling Address —No. Street, City and State Zip No.Tel. No.FirstLast Name
jC/C/ZatsT -JST/£ //A ^OWNER
/Pataca-,Pit-
S^g: MSEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for inspection , 19.on.
This space for office use only
M,19
Phone Call Rec'd ByDate Rec'd Time Rec'd Owner or Agent Signature
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
Sq. Ft.a GIs.Sq. Ft.Capacity
Zi'S.Ft.Ft.Ft.2a.Distance from nearest well
4^^-y Ft.Ft. Ft.Distance from lake or stream s'
;? o Ft.Ft.">x/Ft.Distance from occupied building
/ Ft./-/Distance from property line Ft.Ft.
/ O Ft.y oFt.Ft.Distance from bottom to Water Table
AH distances are shortest distance between nearest points
RECORD OF TESTS:
., 19Inspection was made on , Time ,JVI By
19 A..hr..
, 19...Z.;?h.... Rate
PERCOLATION TEST DATA:Date of First Test Rate
,sr’.Date of Second Test
y 1st Test By
IFirst Test...../i-f 2nd Test
Rate2nd Tesi aken 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.)// j yj
A / i 1 L-Dated 7 7^Z
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.
JUjU<z1
Shoreland Management Office ^Issued Date;
Fee $Surcharge $
Comments:.
viCToa uiHeeCH a e«.. aamTcat. rca«us raLkS
158906Form No. MKL-07V1-003
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
- Office
'Veli°™ ~ liwpector Pink^
Car”-'9w^ '■
Permit No.,LEGAL
Date
DESCRIPTION
AND
LOCATION
Lake Name Lake Ctassif.Sec.TWP Range TWP NameLake No.
IDENTIFICATION: Please Print All Information.
Mailling Address —No. Street, City and State Zip No.Tel. No.First InitialLast Name
OWNER
SEWAGE
SYSTEM
INSTALLER
Name,
This System will be ready for inspection on., 19.
This space for office use only
19 It J
Phone Call Rec'd By Owner or Agent SignatureDate Rec'd Time Rec'd
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:
,, 19 , TimeInspection was made on JVI 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
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:.
CERTfFfCATE iSSUED
VICTO* LUOBCCN I CO.. •RINtCa*. rtOflUS FALL*
158906Form No. MKL-0771-003
< >
,
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY
Should beActual Actual Should be Actual Should be
Capacity GIs.GIs.S F S F S F S F
Distance from Nearest Well F 75 50FFFF F
Distance from Lake or Stream F F F F F F
Distance from Occupied Building 10 2020FFFFF F
Distance from Property Line 10 10 10FFFFF F
Distance from Bottom to Water Table 4 4FFFFF F
Inspector's Comment I
T-
Date of Inspection .19___
Time of Inspection,.M
/SignatureyOfy/nspectorINTERPRETATION
OF ABBREVIATIONS
GIs - Gallons
SF “ Square Feet
* Linear Feet
Job TitleF
Agency
MKL-077 l-003-6acker
->:
1
)
PERCOLATION TEST DATA-
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537
Mailing Address:
Price $ 1.00 per pad.
Ph.' No.Owner:
Last Name First Middle St. & No.City State Zip No.Legal .
Description:O^- Z' /^
LAKE OR RIVER NO.NAME SEC.TWP.RANGE TWP NAME
TEST HOLE NO. 2TEST HOLE NO. 1
//■ /!4.Depth To Bottom of Hole,Depth to Bottom of Ho1e_;inches;inches; Diameter of HoleDiameter of Hole jnchesinches
2J=Depth, Inches Soil Texture/)
Jx A
Soir.TextureDepth, InchesDate Ai^19 DateT77h G 0Percolation
Test By____
Percolation
Test Bv .V if. ah''Q
I' r.iu> AiAit-1 LU
£FirmName CC Firm
Name.ax.')D7/
amcc
7^^
LUAddress.a:/Address
<
cnOtter Tail County License No.,Otter Tail County License No..HinLUMeasurement,
Inches Depth in Water
Level, Inches
1-Measurement,
I nches
Depth in Water
Level, Inches
Time Remarks Time Remarks
O!ililAA IMf66i-T7/ // '.3^Vk Ik
u
ITJMI
9 J'i,mx-/ :.^6
Ilk '~T79/0 0
.3-.00 £fj 6 lb
zA-IWI zSJl
3- 0 0 x^(U±'
' i Jiff
'X Ui *9 ^0
U): 00itJC
IIICH
^ .Jok IMli^
iK
3-V)A
IxW
1IMM 7 /
• y'JW!6M Uki0 7^'Z
159179 ®MKL-0871-028
Service, Un. of Minn.
) ^icTe* luxDUH « £0.. »«>uT(*i, rtaogs »>•••■.XLg-uj3tM- I k> ^43l4.See Booklet, "How to Run a Percolation Test" by Agriculture Ext /93L .1