HomeMy WebLinkAboutSwan Lake Club_13000190112000 _ 18402_Shoreland Permits_B-receivedHITF^-Office ,
GOLDENROp - Inspector
YELLOW - Owner (after issue)
PINK - Assessor
APPLICATION FOR SITE PERMIT
LAND & RESOURCE MANAGEMENT, COUNTY OF OTTER TAIL
GOVERNMENT SERVICES CENTER. 540 WEST FIR, FERGUS FALLS, MN 56537
218-998-8095 REC'EIVED LAND & RESOURCE
M 1 3 2011
www.co.otter-tail.mn.us
iUl > 2 2011PLEASE PRINT OR TYPE ALL INFORMATION Permit No.
'lake/river name 77 LAKE/RIVER /
CLASS \JLAKE / RIVER NO. ,V SECTION
Tiawe:
TWP NAME
.Sv.J'AfJ f-P
7PARCEL NUMBER (S)PROPERTY (E-911) ADDRESS 7\'bOOO\^0[\'7 OOD l?H0'V tiJTelLfttetJ
7LEGAL DESCRIPTION
LcT 3 of KmU 06ST
Last Name First Initial Mailing Address Daytime Phone No.
hlZ'LlJ'llOif
\[.AA A\b.
lr\v\L. ^CtO.r
Property
Owner ^iyu\ \ C hjL
^7 i^\d\(yjvd
ifiij c. -fUf___^Contractor
Name
Lie. # ^
PROPOSED PROJECT (please circle the appropriate number)
( 2 j Add'n to Dwelling
( 5) RCUA'ear_____
(8) Storage Structure
ONSITE WATER SUPPLY
Individual ( ) Public ( ) None
NOTE: MN Rules Chpt. 4725 (MN Well
Code) requires a 3’ (minimum) structure
setback to a well.
ONSITE SEWAGE
TREATMENT SYSTEMU() New Dwelling
i4 ) MH/YR
( 7 ) Add'n To Non-Dwelling
(10 ) Non-Conf. Replacement (identify) _
^^^Other (identify)______________
''*E)usting Dwelling to be removed prior to.
( 3) 'Replacement Dwelling
( 6) Attached / Detached Garage
1W.O.A.S.V'■57^1 OiPermit No.
( ) OTWMD 'Must have Sewage System Approval
from OTWMD prior to issuing Site Permit
Contact Rollie Mann at 218-864-5533snv*rA
J.CHARACTERISTICS OF PROPOSED W.O.A.S.
(WATER ORIENTED ACCESSORY STWCTURE)
Outside
DimensionFt. xJn."
CHARACTERISTICS OF PROPOSED DWELLING
(Must Include Attached Garage) /
Outside Dimension___
Sq. Ft.
Setback to Lotline ___
Setback to Right of Way
Setback to Ordinary High W^r Level ___
Elevation Above Ordinary ^h Water Level
Setback to Septic Tank /
Setback to Draintield /
Setback to Bluff /
Total Bedrooms,/_______
Maximum Prosed Height
RoofCh^e( )Yes ( ) No
Basept^t ( ) Yes ( ) No
Walkout Basement ( ) Yes (side profile required) ( ) No
' (((CHARACTERISTICS OF PROPOSED NON-DWELLING
Outside I 'y I
Dimension ^ Ft. x S Ft.** ''
Sq. Ft.
Setback to Lotline Ft. &
Setback to Right of Way i
PI Setback to Ordinary High Water Level t iO Ft.
Elevation Above Ordinary High Water Level, / t- Ft)
Setback to Septic Tank
Setback to Drainfield / 2-0
Setback to Bluff /
Maximum Proposed Height
Roof Change ( ) Yes (V) h
'' >
Bathroom Proposed ( ) Yes (
Ft. X Ft.**
yiZ?J Sq. Ft.
Setback to Lotline ___
Setback to Right of Way
Setback to Ordinary HigtyWater Level __
Elevation Above Ordinary High Water Level
Setback to Septicylank
Setback to Dr^field _
Setback to Bluff_____
FT&Ft.**Ft.Ft.**Ft.**
Ft.**
Ft.
Ft.Ft.
Ft.Ft.Ft.
Ft.
Ft.Ft.
MaximuijrProposed Height
( ) Brethouse
( ) (Jazebo
Ft.
( ) Screen Porch
( ) Storage Structure
**Project/Lotlines/Right-of-ways Must be Staked Onsite Prior to Application / Inspection
Topographical Alteration / Earthmovinq
None □ 20 Cubic Yards or Less * □ 21 Cubic Yards - 299 Cubic Yards*
* Must include on scale drawing,
additional Permit may be required.J □ 300 Cubic Yards or More*
CHARACTERISTICS OF LOT;
'1
-------l So. Ft.Bluff ()/) Yes ( )NoLot Area,Water Frontage Ft.7
-f / If c»t7
Tolaf Lot Area (FTj)Impervious Surface Ratio:X100 =.%Total Impervious Surface Onsite (FT^)Impervious Surface Ratio
THIS IS A SITE PERMIT ONLY AND DOES NOT CONSTITUTE A BUILDING PERMIT AS SET FORTH IN CHAPTER 16, MINNESOTA STATE STATUTES.
Agreement; i hereby certify that the information contained herein is correct and agree to do the proposed work in accordance with the description above set forth
and according to the provisions of the Ordinances of Otter Tail County, Minnesota. I further agree that any plans and specifications submitted herewith shall become
a part of this permit application. I also understand that this permit is valid for a period of six (6) months.
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 Ordinances of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of said Ordinances.
I understand that it is my responsibility to inform the Land & Resource Management office once the building footings have been constructed.
Lh lOjlDate:
Signature of Properly Owner/Agent for Owner
VodMTevaDate:
Land & Re^ogree Management Office^t> g-f*PERMIT FEE $ /7-j"PROJECT(S) TOTAL SQ.FT.RECEIPT NO.
Comments:
Form No. BK — 1003-0407 329.562 • Victor Lundeen Co., Printers • Fergus Falls. Minnesota
' L !~Jfi/HITE - Office
GOLDE^RQD - Inspector
YELLOW - Owner (after issue)
PINK - Assessor
APPLICATION FOR SITE PERMIT
LAND & RESOURCE MANAGEMENT, COUNTY OF OTTER TAIL
GOVERNMENT SERVICES CENTER, 540 WEST FIR. FERGUS FALLS, MN 56537
218-998-8095
www.co.otter-tail.mn.us
PLEASE PRINT OR TYPE ALL INFORMATION Permit No.
V’ LAKBRIVER NAME , yLAKE / RIVER NO.LAKE/RIVER
CLASS
SECTION TWPNO.RANGE TWP NAMEuVy •;Sj
t.-'ll)!f-L?15
PARCEL NUMBER (S)PROPERTY (E-911) ADDRESSyi'Hcv tiJTslLftteJ Let'll'1\'>)000[^0\\T!OOD •V
LEGAL DESCRIPTION
;3 Of oy Ucf](T Ll' T
/I
Last Name First Irtitial Mailing Address Daytime Phone No.
>\,cU /\\b.
^cior
Property
Owner /^m-^\Ciix)h y
;y/y ., /■ ^
- y —(-------
Contractor
Name
Lie. # ,
~
,ra—f--.[.H
PROPOSED PROJECT (please circle the appropriate number)
(2 j Add’n to Dwelling
(5) RCUYear_____
(7 ) Add'n To Non-Dwelling (8) Storage Structure
(10.) Non-Conf. Replacement (identify).
/l1),Other (identify)______________
r 'Existing Dwelling to be removed prior to
ONSITE WATER SUPPLY
iX ) Individual ( ) Public ( ) None
NOTE: MN Rules Chpt, 4725 (MN Well
Code) requires a 3’ (minimum) structure
setback to a well.
ONSITE SEWAGE
TREATMENT SYSTEM
■ 'gnCN) New Dwelling ( 3) 'Replacement Dwelling
( 6) Attached / Detached Garage
(i(9)'W.0.A.S.
(4) MHA'R (V) Permit No.
( ) OTWMD 'Must have Sewage System Approval
from OTWMD prior to issuing Site Permit.
Contact Rotlie Mann at 218-864-5533
i
i
3av'vA)
CHARACTERISTICS OF PROPOSED W.O.A.S.
(WATER ORIENTED ACCESSORY STRUCTURE)
Outside
Dimension
CHARACTERISTICS OF PROPOSED DWELUNG
(Must Include Attached Garage)
Outside Dimension___
Sq. Ft.I
i Setback to Lotline___
' Setback to Right of Way
Setback to Ordinary High Water Level ___
Elevation Above Ordinary High Water Level
: Setback to Septic Tank__
: Setback to Drainfield ___
Setback to Bluff '
, Total Bedrooms________
Maximum Proposed Height
5 Roof Change ( ) Yes ( ) No
I Basement ( ) Yes ( ) No
Walkout Basement ( ) Yes (side profile required) ( ) No
-CHARACTERISTICS OF PROPOSED NON-DWELUNG
Outside
Dimension r ?Ft."Ft. XFt. XX Ft.”;Ft. X .-Ft."
HV JSq. Ft.
Setback to Lotline : i? Ft. &
Setback to Right of Way I S ^ Ft.
Setback to Ordinary High Water Level / 3 0 Ft.
Elevation Above Ordinary High Water Level . /T- Ft.
Setback to Septic Tank ■ S ^ Ft.
Setback to Drainfield / pt.
’ - \JSetback to Bluff i 0 Ft.
Maximum Proposed Height
Roof Change ( ) Yes (^) No , .
Bathroom Proposed ( ) Yes (V) No ' ’ /
/1.0 Sq.Ft.
Setback to Lotline ________
Setback to Right of Way y Ft."
Setback to Ordinary High Water Level __
Elevation Above Ordinary High Water Level
Setback to Septic Tank__
Setback to Dranfield____
Setback to Bluff________
Maximurn Proposed Height
( ) Boathouse
( ) Gazebo
**Project/Lotlines/Right-of-ways Must be Staked Onsite Prior to Application / Inspection
Ft;&Ft."■iFt."Pf.&Ft."Ft."x/
Ft.
Ft.Ft.
Ft.'J Ft.
’iFt.J /Ft.■^1Ft.
Ft./Ft.tFt./^ R.Ii
,11 V Ft.
( ) Screen Porch
( ) Storage Structure
I•;
1t
^Topographical Alteration / Earthmovino
^ None □ 20 Cubic Yards or Less *
CHARACTERiSTiCS OF LOT:
* Must include on scale drawing,
additional Permit may be required.□ 21 Cubic Yards - 299 Cubic Yards*□ 300 Cubic Yards or More*
s Bluff (/X) Yes ( )No
= (' '
Lot Area. Sq. Ft.Water Frontage .Ft.
»I
Impervious Surface Ratio:X100 =.%Total Impenrious Surface Onsite (FT!)Total Lot Area (FT!)Impervious Surface Ratio
t
i THIS IS A SITE PERMIT ONLY AND DOES NOT CONSTITUTE A BUILDING PERMIT AS SET FORTH IN CHAPTER 16, MINNESOTA STATE STATUTES.
Agreement: i hereby certify that the information contained herein is correct and agree to do the proposed work in accordance with the description above set forth
and according to the provisions of the Ordinances of Otter Tail County, Minnesota. I further agree that any plans and specifications submitted herewith shall become
a part of this permit application. I also understand that this permit is valid for a period of six (6) months.
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 Ordinances of Otter Tail County, Minnesota.
This permit may be revoked at any time upon violation of said Ordinances.
I understand that it is my responsibiiity to inform the Land & Resource Management office once the buiiding footings have been constructed.\
________ /? ,
Signature of Property Owner/A^nt for Qwner
V V' „...
Land & Res^rce Management (Office1
K.!.r. / / .- Date:
7j
•- ;\i.' cr'‘x,:v f,,.' ,r )'-J'------DDate:
PROJECT(S) TOTAL SQ.FT.,PERMIT FEE $RECEIPT NO.
A C tW-11 Arc c/( (v/4 7c /. ik ^/ok 'Comments:
I[\
A329,582 • Victor Lundeen Co., Printers • Fergus Falls. MinnesotForm No. BK — 1003-0407
SITE PERMIT
INSPECTION RESULTS
Inspector must make alt measurements and computations
Structure Set Back from Ordinary High Water Level Ft.Ft.
Structure Set Back from Top of Bluff Ft. Ft.
Structure Set Back from Road Right of Way Ft.Ft.75-^
^ / Ft. & Sti Ft.Structure Set Back from Lot Lines Ft.&Ft.
e 7Structure Height Ft.Ft.
Structure Set Back from Septic Tank Ft.Ft.
Structure Set Back from Drainfield Ft.Ft.
Elevation Of Lowest Floor Above Ordinary
High Water Level Ft.Ft.
Land Slope at Building Site % %
Inspector’s Comments / Sketch:
C\)
: VL
/
InspectoTssi^atur^^^,^
Date of Inspection
/
Time of Inspection
Q^^roject Approved
Date / Initial
/ //2 Acr0 Pare*/
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LEGAL DESCRPnON <n’
'.\h
A/ of Goftnmont Lot Thrtt (J), txetpf 0 strtn omf oat-/to£ ff ^2) Acftt tract cotirt/t</to on* Ca^tr
Nhttttt 391 k fotatAp Out Httot-t^ Thirty-tto 3J2i North, of Poiyt Forty-two (42! Wtst.
Togtrfhtr. with Ntaf part of Gororamtfif Lot thrta (J). an^ that part of N>o Northtast Oworftr of tho
Sotfhoast Oworftr aim Stetion fwontyfoiir (24). fenshp out fmii'td and thirty-two 322} North ,Panyt
^orty-N)rt* (4J) Woxt. Offtr fa/ Comt\f UmAmwntf> —
~--lm
^•rrv^
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Cofoor of J ) of Oorormool Lot 3' ■ :
•f-
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RECeVHD
{ 'i 'mi)SCALE DRAWING FORM!
i.
Lhui Cuaik^j!.n. ■ 2 Oli lALL-jLJ<bb< JURC'E T
Tax Parcel Number(s)
The scale drawing must be a signed drawing which includes and identifies a graphic scale^^fe^, all existing ah^^proposed structures, septic
tanks, drainfields, lotlines, road right-of-ways, easements, OHWLs, wells, wetlands, topographic features (i.e. bluffs), and onsite impervious surface
calculations.■f
I" ^ m \\
Scale
3^3 %
impervious Surface Ratio
(Must Complete Worksheet On Other Side)
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G Rlwh :DatSignature of Propi rty Owner
338^596 • Victo Lund«en Co, Priryers • Fergus liaUs. MN ♦ 1-800-346-4870BK —0909 .. (...
IMPERVIOUS SURFACE CALCULATION WORKSHEET:
List of Onsite (Existing and Proposed) Impervious Surfaces (must be shown on scale drawing):
Ft2Structure(s):/
M cnyo Ft2Deck(s):1
Ft2Driveway(s):
jN)0K)tC Ft2Patio(s):
R2Sidewalk(s):
VQO Ft2Stairway(s):
Ft2Retaining Wall(s):
Ft2Landscaping;
(Plastic Barrier)
Other:Ft2
Ft2TOTAL IMPERVIOUS SURFACE:1
} cro^ (TtD Ft2LOT AREA:
01 m .%X100 =
IMPERVIOUS SURFACE RATIOLOT AREATOTAL IMPERVIOUS SURFACE
\
t Pre-Application Site Inspection Request
Twp NameLake/River Class SectionLake / River No. Lake / River Name
D AMC lllC
l?Hov Uvv\-^
I-333J
Xu)(\k L(\t^^8/1
Property (E-911) AddressParcel(?) Nc.
SvA^i Cu'Ai
Property Owner Information:
Name's):
\L>^\ A''/-Address:
$U 7At(L^ 5'flOS"
ok (^ll^
Type of Request:
Verify SetbackBluff:Stake SetbackDetermination
\\
Verify SetbackOHWL:Stake SetbackDetermination
Stringtest:Determination
Non-Conforming Repair or Replacement Structure:Confirm Consistency With Existing Structure
Miscellaneous:_____________________________
Describe Request: Wa uouta LUfe To
g:L£cT'KVo^ hiehv i;ft/)iilK 1ttC W-o-AJ. ___________
A scale drawing must accompany Pre-Application Site Inspection Request
& request must be staked onsite
A fUfc£.fAW/V/V (a/D HL
h ]\
Property dwner
M-n- you
Date
mReceived By;DateLand & Resource Management staff
INSPECTION COMPLETED (Inspection must be done wi)hin 10 days of receipt):
It
inspectorDate Property Owner NotifiedDate Onsite
(Inspector must provide site drawing or field notes on other side.)
mbowman Application & Forms Pre-Application Site Insp Request Form10/1/07
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