HomeMy WebLinkAboutTwin Lake Landing_02000180128001_Septic System Permits_r.'-'
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Otter Tail County
Land & Resource Management
Subsurface Sewage Treatment System Inspection FormOTTER TAILCOUNTY-MINNESOTA
02oooi?ori*ooiAddressProperty ID No.Permit No.□ Non-Shoreland
oCity/Twp.Installer/MPCA #MPCA Type VIIIIIIV
□ New □ Repair Replacement □ Other Type of System Trench □ Pressure Bed □ Mound □ At-Grade
Soil Treatment Area
InspectionTank inspection Other inspection:Final Inspection
y Date lnspector0-p InspectorInspector□ate Inspector Date i-
f.;Corrections Y N Corrections Corrections Y N Corrections
TREATMENT MEDIA MOUNDS/AT-GRADE
Registered Treatment Media Percent SlopeTREATMENT MEDIA □ Drainfield Rock □ Mound □ At-Grade
f+cc Sand Below Bed on Upslope Side(in):Registered Treatment Media:Bed Width(fl):Bed Length(ft):
Downslope(ft):Upslope(ft): Sideslope(ft):
Capacity
(Gallons)
Manufactuer
Model No.
Rock Below Pipe(in):
PRESSURE DISTRIBUTION□ New □ Existing □ Combo1st Tank:
□ New □ Existing □ Combo Number of Laterals:Lateral Spacing(ft)2nd Tank: Lateral Dia(in)
□ New □ Existing □ Combo Perforation Dia(in) Perforation Spacing(ft)Pump Tank Cleanouts: Y N
VioV \nste\lfd iW!TRENCHES/PRESSURE BEDS P INFO■r
0□ Pump
T rench
Pressure^ Drop Box End Fed W Dist Box ^ Gravity □Pump Manufacturer/Model No:Bed
Rock Below Pipe(in)□ Drop Box Center Fed □ 6 □ 12 □ 18 □ 24 Flow Measurement Reading:□ Event Counter □ Run-Time Clock
SETBACKS3o"3^"3^"Trench Depth (in)T,T3 T4 V Ts3^
Dwelling Non-Dwelling Dwelling Non-Owelling^>70'^02 \Trench Length (ft)Building(s) to tanks(ft)Building(s) to STA(ft)
Surface water(ft)Te Ty Ts Ts TioTrench Depth (in)Well(s)Sensitive Well •
50''/Te IP(^Trench Length (ft)T7 Te Te T,o Property lines(ft)BluffRoad R.O.W.
/ ./
Depth of Restriction(in):Depth of System(in):Vertical Separation Provided(in):Bed Width(ft):Bed Length(ft):Pressure Bed Dimensions
Comments:
—>Final Inspector
Signature9 y
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SSTS Inspection Form 04-28-2020
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PT-873169 • Victor Lundeen Co., Printers • Fergus Falls, MN • 1 •800-346-4870
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CERTIFICATE OF COMPLIANCE
fell SEWAGE SYSTEM M-*i
1i9_llJanuoAif22nd \day of_This certificate has been issued thisii!Mto certify compliance with regulations of Shoreland Management Ordinance, Otter Tail County, Minnesota..1iiThe premises covered by this certificate are legally described as:
1knoh.Range 40Twp. 134
kU oi G. L. I, S oi Hwy (3.9 Ac.)
E i, SE i (27.9 Ac.)
Sec.__U.m-Twp. Name.Lake No.1
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mLul/cAn Eo6toAyOwner: Name.
mSauk Cznttig., Hinnuota910 A6h. St.Address.is
5637SZip No.
7Q9S /■Permit No. SP_
Signed by:
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Malcolm K. Lee, Shoreland Administrator
Otter Tail County, Minnesota
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MKL-0871-009
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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 — Olfice
Yellow — Inspector
Pink — Owner
Permit No.,(fulLEGAL
DESCRIPTION
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AND
LOCATION
LaRe No.Lake Name Lake Claseif.Sec.TWP TWP NameRange
IDENTIFICATION: Please Print All Information.
Mailing Address — No, Street, City and State Zip No.Tel. No.First InitialLast Name
Cl~9 (o FY-. HOWNER
S CAwk^ m tsj
I
i:y (^ 6-h 0SEWAGE
SYSTEM
INSTALLER
r rName.
This System will be ready for inspection on... 19.
This space for office use only
19
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature
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1 - I ft ^ P +■ -r I
NUMBER OF BEDROOMS;ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
2-0 rYtO Sq. Ft.Gis.Capacity Sol Ft.
/ooFt.Ft.Ft.Distance from nearest well
■7r Ft.Distance from lake or stream Ft.Ft.
'2-0(O Ft.Distance from occupied building Ft.Ft.
JO i_oDistance from property line Ft.Ft.Ft.
3Ft.Distance from bottom to Water Table Ft.Ft.
AH distances are shortest distance between nearest pcfints
RECORD OF TESTS:
Inspection was made on 19 , Time ,JVI By
2.,I.£Lr....I:Z..
l£...PERCOLATION TEST DATA:Date of First Test 19
. 19....?^.
Rate
1ft Tett Taken By 11/)l ' '
3.Date of Second Test Rate
2.’^3 . ^3First Test + 2nd Test 22nd Test Taken By 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 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 joblis ready for inspection.
6^ 3 X nature JDated
Sig
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 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:
Shorelend Managemenf OfficeO 0 jTCoCo/2cFee $Rec #
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Form No. MKL-032085
225239 — Victor Lundnn Co., PrMirt. Firgw FMi. MN
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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
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•
White — Office
Yellow — Inspector
Pink — Owner
. /: ^
.1Permit No..
'It Vf f
LEGAL /|-Lu
IDESCRIPTION I ~J
AND
-t-i . K'rLOCATION
Lake Classif.TWP NameLake No. Lake Name Sec.TWP Range
IDENTIFICATION: Please Print All Information.
Mailing Address — No. Street, City and State Zip No.Tel. No.First InitialLast Name
OWNER
SEWAGE
SYSTEM
INSTALLER
Name.
f (c)li(-
C/XJL^This System will be ready for inspection on... 19.
This space for office use only
11 .i"Phone Call Rec'd ByDate Rec'd Time Rec'd Owner or Agent Slgna^ture b't'.
I"' i
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.Ft.Distance from lake or stream Ft.
Ft.Distance from occupied building Ft.Ft.
Distance 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
'~o 2.^PERCOLATION TEST DATA:Date of First Test . 19
, 19
, Rate■U,
3'f. / ’i f! '.LDate of Second Test Rate
1st Test Taken By '3 3 (
Rata
First Test + 2nd Test 12nd 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 app>roved by Shoreland Management Offi
cial shall become a p>art 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.
The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in
6Dated.
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 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 (61 months.
IIssued Date:
Shoreland Man
CERTFee $Rec #
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Form No. MKL-032065
225239 — Victor Lunctoon Co.. Printers, Fergus Fals, MN
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INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEPTIC TANK SEEPAGE PIT DRAIN FIELDCATEGORYShould BeActual Should BeActual Actual Should Be
%010 TBSLCapacityGIs.GIs.S F S F S F S F
/^001SIDistance from Nearest Well F F F FFF
I 7^Distance from Lake or Stream F F F F FF
I F?(J/ (7Distance from Occupied Building F F F F F F
3 F
Distance from Property Line F F F FlO F
, »3Distance from Bottom to Water Table F F F F
Qg4t,
5^'5^3
Inspector’s Comments:
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Date of Inspection
1-Time of Inspection
Signature of InspectoraINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF = Square Feet
F = Linear Feet
Job Title
MKL • 032085 • Backer Agency
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vicTo* LUNaetN CO.. ntiNTCRt. reiteus falls, uihn.PERCOLATION TEST DATAMKL -0871 -028
LAND AND RESOURCE MANAGEMENT
Otter Tail County
Fergus Falls, Minnesota 56537
Mailing Address:Owner:
ft #'9^Fo 5 e >
Zip No.StateCityFirstSt. & No.MiddleLast Name ____
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Legal
Description;
TWP NAMELAKE OR RIVER NO.
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''P-TEST HOLE NO. 1 TEST HOLE NO. 2
c3/6Diameter of HoieJ_____^
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O/Depth to Bottom of Hole inches; Diameter of Hole InchesDepth To Bottom of Hole inches;inches
,4iEDepth, inches Soil Texture Soil TextureDepth, Inches Date
rppSA-^'dI O '£ 3P.1 I.
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\}Percolation
Test By____
ercolation
Test Bv^ ^tL-AcXjWFirmName cr F irm Name.
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lUAddress.QC Address
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Otter Tail County License No..Otter Tail County License No..Hc/>LUMeasure
ment,
inches
Drop in
water level, inches
Time
Intervals
minutes
Percolation
rate minutes
per inch
H Time
Interval,
minutes
Measure
ment
inches
Percolation
rate minutes
per Inch
Drop In
water level, inches
Remarks:Remarks:Time Timeo
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See Booklet, "How td Run a Percolation
Test" by Agriculture Ext. Service, Un. of MN.
Percolation rate *.minutes per inch minutes per inchPercolation rate »
L
/fe^inches GRID PLOT PLAN SKETCHING FORMScale: Each grid equals
4 - - Pd 1.Dated:Signature
Please sketch your lot indicating setbacks from road right-of-way, lake and sideyard for each building currently
on lot and any proposed structures.
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ABATEMENT NOTICE
Shoreland Management
COUNTY OF OTTER TAIL
Court House
Fergus Falls, Minn. 56537
ZSth JuZy 86Dated this..day of.19
LuveAnt foitoATo.
910 A6h StAZiitAddress.
City and State.Sauk Ce.nZtLZ, MN 56378Zip Code.
the, ^ewagz' You are hereby notified that.
Which you maintain at (Legal Description and Location) - Plus Fire No.
Tulin Lake Landing - NUi G.L. I S Huiy S 3.9 Ac
in E 1/2 SE 1/4 27.9 Ac
134Tulin LakeA 1W 18 knoh4056-382
RangeClass.Sec.Twp.Lake Name Twp. NameLake No.
conitAucted and/oK locatedis not.
in accordance with minimum standards of the Otter Tail County, Minnesota Shoreland Management Ordinance.
You are hereby ordered to abate the above described condition within.^__days from this date. If you fail to
correct the above defect you may be subject to a fine, imprisomfi^t or injunction proceedings.
Shoreland ManageTfTSnt Official \\/V>^
PROOF OF SERVICE
State of Minnesota
County of Otter Tail
Fergus Falls, Minnesota 56537
The above notice and order was served by me on._______________ 19__, by handing a copy thereof
fthe (owner-occupant-agent) of the above describedto
premises. *By posting a copy thereof upon the above described premises.
Otter Tail County Sheriff Department
*Strike out words that do not apply.
CC: Otter Tail County Attorney
MKL.03 72-036-01
J20522®'''**”LundMn O' C«., Printara, Parfu* Falla, Minn.
^ SENDER; CompItM ittfm 1,2.3 and 4.
Put vour address in the "RETURN TO" space on the
reverse side. Failure to do this will prevent this card from
being returned to you. The return receipt fee will provide
you the name of the person delivered to and the date of
delivery. For additional fees the following services are
available. Consult postmaster for fees and check box(es)
for service(s) requested.
1. iH Show to whom, date and address of delivery.
2. ED Restricted Delivery.
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3. Article Addressed to;
LuveAne. Fo4^eA
910 Ash St.
Saak CzYVtAZ, MN 5637S
4. Type of Service:
□ Registered □ Insured
Certified □ COD
□ Express Mail
Article Number
P557 606 iJ97
Always obtain signature of addressee or agent and
DATE DELIVERED.
5. Signature - AddresseeOOXsm6. Signature-U Agentu)d X
8. Addressee's Address fOM Y if requested and fee paid)
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RECEIPT FOR CERTIFIED MAIL
NO INSURANCE COVERAGE PROVIDED
NOT FOR INTERNATIONAL MAIL
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P.O., State and ZIP CodeSaak CentAe, MM 5637SP
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Certified Fee•k
Speciai Deiivery Fee
Restricted Deiivery Fee
Return Receipt Showing to whom and Date Deiivered
CMCOo>Return receipt showing to whom,
Date, and Address of Deiivery
.□TOTAL Postage and Fees $
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SENDER INSTBUCnONS
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apaea balew.
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a Attach to front of articia R apaaa parmka.
otharwiaa affix to back of articla.
• Endoraa attMa *Hotum RoMipt RagMiatad**
adlaoant to numbar._______
PENALTT POn PRIVATE
USE. $300
RETURN
or R.D. No.)
(City, State, and ZIP Coda)
&
FIELD NOTES
'TUJJa/DATElake hap
FIRE NO.____________
LEGAL DECRIPTION OF LOT;
LAKE NO.
P^U C>-C.' ( ^ ^ t-kADy 4- S.? 4c.
63?!?' aJI ,
JjA^r^WNERS NAME A CcU?gy^/j€ HtS Vf .4^1-----------------------------------------------------
^ ^4?^ /g_ lr~A-U^^ __^(cSp^l^
1/^ TYPE OF SEWAGE SYSTEM (Inspector’s Comments) (jlQ ^tJ\
SaiAI^ CjC^UTi^ I fi^/U
SEPARATION DISTANCES - FEET
Soil Disposal AreaSeptic TankCategory
Well -
Lake -
Lot Line -
Occupied Building -
k (.80Elevation of Area
BF.ARON SYSTEM WAS ABATED;^ a
TTUOLtu. TAat-
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1 SKETCH OF LOT ON BACK
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r«CERTIFICATE OF COMPLIANCEK>
SEWAGE SYSTEM■
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!9 7h ■7th Januaryday of_This certificate has been issued this
• -.r^'mm:-mjr-to certify compliance with regidations of Shoreland Management Ordinance, Otter Tail County, Minnesota.
;■';■ ■ The premises covered by this certificate are legally described as:
'■ * r. ■ ...-.■
fake No 56-382 Sec I8 Twp. 13U Range Ul Twp. Name Amor
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DM¥M"Erickson's Twin Lakes Landing
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fM Mrs. Henry EricksonOwner: Name.
Address Battle Lake, Minnesota
Ri•f
Zip No.
m.
Malcolm K. Lee, Shoreland Administrator
Otter Tail County, Minnesota
Permit No. SP_
Signed by:.
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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
Yeliow — InspectorPink — OwnerCard — Owngr
2^f 6lJ I rv Permit No.,LEGAL /> tDate
DESCRIPTION
AND
/?.LOCATION
Lake No. Lake Name Lake Classif.Sec.Range TWP Name
IDENTIFICATION: Please Print All Information.
Last Name First Initial Mailling Address —No. Street, City and State Zip No.Tel. No.
OWNER
/
SEWAGE
SYSTEM
INSTALLER
Name.
This System will be ready for inspection on.19.
This space for office use only
19 ,M
Date Rec'd Phone Call Rec'd ByTime Rec'd Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT D^^^FIELD
Sq. Ft.
5~0
//OO
__511Capacity Sq./Ft.
Ft.Ft.Ft.Distance from nearest well
^5'Ft.Distance from lake or stream Ft.Ft.
Ft.Distance from occupied building Ft.Ft.
7Distance from property line Ft.Ft./O Ft.ZjOl 7 VFt.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.............
19 ...>.■3:... Rate.
, 19„...?,3...-. Rale
/c>PERCOLATION TEST DATA:
£7t<L..
Date of First Test
Date of Second Test^ f/M.
1st Test Taki By
72./< t IFirst 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.)
n/C>Dated -F-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
/q /p* ^/OIssued Date:
Shoreland Management Office
.4- 00Fee S O.Vo ZfVSurcharge $
Ad/Comments:.
Form No. MKL-0771-003 158906
vierei lumdiin t eo.. p«uitc*i. rcR«u» «iaa
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 — InspectorPink — Owner
Card — Owne^
y{'/o i''r' 5£ r, c K ''oC>--n s /Permit No.,LEGAL
/ y 3DateC\DESCRIPTION
AND
)9LOCATION
Lake Classif.Sec.TWP RangeLake No.Lake Name TWP Name
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
M19
Date Rec'd Time Rec'd Phone Call Rac'd By Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST:
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.Distance from occupied building Ft.
GDistance 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 By
PERCOLATION TEST DATA:Date of First Test 19
, 19....Rate
Rate
Date of Second Test
1st Test Taken By
//First Test -I- 2nd Test S
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.)
V,, < .Dated
Signature
i___
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 $
y /I /fV>Comments:.
A 'lO Ii/C>//
Form No. MKL-0771-003 VICTO* LUHBEEN A CS.. PKIDTEPI. EEKAUS SALLA. yiHH.158906
i ^ -
INSPECTION RESULTS
Inspector must make all measurements
:'ini'll
SEWAGE DISPOSAL SYSTEM STATISTICS..i
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORYActualShould be tCtual Should be Actual Should be
//^FCapacityGIs.s F s F
Distance from Nearest Well 7 ^’on ^ FF 50,F F F
FDistance from Lake or Stream F F F F F
2D1.Distance from Occupied Building 10 2010FFFF F
FDistance from Property Line 10 1 10FFF F
Distance from Bottom to Water Table 4 4FF F F F F
V
Inspector's Comments:
)\o
in.
h.I/nJCtI
.19^”^
Date of Inspection
A' /O^Time of Inspection
^y)<s -
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF * Square Feet
* Linear Feet
Job TitleF
Agency
MKL-0771-003-Backer
.iT
ct .7 >
PERCOLATION TEST DATA Price $1.00 per pad.
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537
Owner:Mailing Address:
Last Name Middle St. & No.Legal
Description:MY
LAKE OR RIVER NO.NAME SEC. TWP.RANGE TWP NAME
TEST HOLE NO. 2TEST HOLE NO. 1
Depth to Bottom of Hole inches; Diameter of Hole InchesDepth To Bottom of Hole,inches; Diameter of Hole inches
Depth, Inches Soil Texture Depth. Inches il Texture Date
C?::>haU<PJ
Cb--/Percolatioi
Test By__Kta ~LUFirm
Name.CC Firm
Name.D
--------------- nr
oiU
Tspjf^yy.Address.Address
ZIA COOtter Tail County License No..Otter Tail County License No..H-coLUMeasurement,
Inches Depth in Water
Level, Inches
H Measurement,
Inches Depth in Water
Level, Inches
Time Remarks Time Remarks
I As-s-
d?.-u I (
sS4cO : rs-
c^ :
^\QST'
r^:/0
77W lOP
V^/kr^ y
2
MKL-0871-028
See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn.
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 — Office
Yellow — InspectorPink — Owner
Card — Owne4
% / /? ^
Permit No.,cV • y~^LEGAL
Date
DESCRIPTION
AND
11. V/ _ALOCATION/>7or
Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
InitialLast Name First Mailling Address —No^^Street, City and State_______
Ly /9.
Zip No,Tel. No.
OWNER
£t'y~>r\C^SEWAGE
SYSTEM
INSTALLER
/ V. ^/nName
This System will be ready for inspection on.,, 19.
This space for office use only
19
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC TANK SEEPAGE PIT DRAIN FIELD
Sq. Ft.
2yC> ^Sq. Ft.GIs.Capacity
75~Ft.T Ft.Ft.Distance from nearest well
<0 ':p5~ i~ Ft.Ft,
Jin r Ft.
t- Ft.
Ft.Distance from lake or stream
Jin Ft.Distance from occupied building Ft.
Distance from property line /n -A Ft.Ft.
V Ft.V ^Ft.Distance from bottom to Water Table Ft.
AH distances are shortest distance between nearest points
RECORD OF TESTS:
Inspection was made on 19 , Time M By
/PERCOLATION TEST DATA:
Its: y____________
1st T«t Tak^ By
f^o^ry
^r\ By
Date of First Test ,, 19 Rate J
>//x , i9....7p2f...,IDate of Second Test Rate
.//IFirst Test -I- 2nd Test 2 Rate2nd Test Tak
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.)
^/.2/ J70.Dated TSignatLre
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
■cZ.--------Fee $Surcharge $
/70
Comments:.
Form No. MKL-0771-003 158906
vicToa uiMecch t e«.. patHUai. ria«u» ru.i.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
Card — Ownef
Permit No.
LEGAL
Date
DESCRIPTION
AND
LOCATION
Lake Classif.Sec.TWP TWP NameLake Name RangeLake No.
IDENTIFICATION; Please Print All Information.
IVIailling 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
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature
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 -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:.
AM&-CERTinCATE JSStlED 158906Form No. MKL-0771-003 nai. rE«<us falls.
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORYActualShould be Actual ActualShould be Should be
Capacity GIs.GIs.S F SF SFS F
Distance from Nearest Well 75 50.F F F F F F
Distance from Lake or Stream F F F F F F
Distance from Occupied Building 201020FFFFF F
Distance from Property Line 10 10 10FFF F F F
Distance from Bottom to Water Table 4 4FFFFF F
_'fhInspector's Comments:
Date of Inspection 19___
Time of Inspection M
Signature of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs = Gallons
SF “ Square Feet
" Linear Feet
Job TitleF
AgencyMKL-0771-003-Backer
I.
■: -i
PERCOLATION TEST DATA Price $ 1.00 per pad.
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537
Mailing Address:
Ph. No.
Owner:
y -//c/l.iifiZ’c” :■ '•
Last Name First Zip No.Middle St. & No.City State
A/hoRLegal
Description:i9 HIrc-.'Aj
SEC. TWP.RANGE TWP NAMELAKE OR RIVER NO.NAME
o?0
TEST HOLE NO. 2TEST HOLE NO. 1
k-03Q Depth to Bottom of Hole inches; Diameter of Hoie jnchesDepth To Bottom of Hole,Diameter of Holeinches;inches
P Z2_i97SZ2_19JZ2Soil TextureDepth, Inches Depth. Inches Soil Texture Date _1Date
Ir"o- I aO ^Percolation
Test By____
Percolation
Test Bv ,n- ?>:;iKO' .3^\v C LaUJFirmName.Firm
Name.CC
3
oLU
oc
________
Uf£.____
Address.Address
<
CO
Otter Tail County License No..Otter Tail County License No..h-c/)uMeasurement,
Inches Depth in Water
Level, inches
H Measurement,
inches Depth in Water
Level. InchesTimeRemarksTime Remarks
o /^//z/^///±L % 7 c
I 6^f>^
/Tfh\
n 5Q Pm
06 7 MI f
M5ZZTmm-39 ^
3 Q
/3lZmT /ay/(5 i?^..py^AZSSZ77Tgjz:t/7-^
pLUJfl7^.
Z7/^'c r. .(y <LiX~/
KjZp.yyi./"V yJPCyJ<^~z_/(/
Z 7
/pA c f
/^ yj }Asl ZI2 MKL-0871-028159179 ®vicTo* cuHbCCN t CO . ^MiNTtaa. rtaeus rAcci. h'nn
See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn.