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HomeMy WebLinkAboutWildwood Resort_16000360209004_Septic System Permits_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 Pi>.. — Owner Card — Owner ; 9 TTYfX"<V 911 ^0 Permit No.,LEGAL Date DESCRIPTION AND UDr-aYLKh3 6 / X feLOCATION TWP NameLake Classtf.Sec.TWP RangeLake No. Lake Name IDENTIFICATION: Please Print All Information. FirstInitial Milling Address —No. Street, City and State Aiuu jLko Zip No.Tel. No.Last Name AWi -OWNER f)A i y\SEWAGE SYSTEM INSTALLER Name. This System will be ready for inspection on., 19. This space for office use only 19 M Date Rec'd Owner or Agent SignaturePhone Call Rec'd ByTime Rec'd NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD 3 TOGIs.Sq. Ft.Sq. Ft.Capacity I Di^y____ J 0 0Ft.Ft.Ft.Distance from nearest well 1 Ft.Ft.Ft.Distance from lake or stream MlFt.Ft.Ft.Distance from occupied building Ft.Distance from property line 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 ,JV1 By It.I......PERCOLATION TEST DATA:Date of First Test ...... 19 Rate 1st Test Taken 2.&..I0.M(Date of Second Test 19 Rate f\ First Test -I- 2nd Test 2 Rate2nd Test Taken 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 inature Permission is hereby granted to the above named applicant to perform the wdfk describecTin the above statement. This permit is granted upon express condition that the person to whom it is granted, and his agents, employees and workman shalPponform 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 motk is not commenced within six (6) months.fmit Permit: i Issued Date: trShoreland ManaTOrpent Office Fee $Surcharge $ /^rr^ f).Comments: JTsyjQ-L yi\o^a VlCTO* LUtiPCtK ft CO . PDlHtCftt fCftSuS tk^cft "7^ i Form No. MKL-0771-003 158906 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 V'i' te — Office V low — Inspector Ph.. Card — Owner S Owner 0N \ t L'Permit No.,LEGAL Date DESCRIPTION AND LOCATION Lake No.Lake Name Lake Classif.Sec.TWP TWP NameRange IDENTIFICATION: Please Print All Information. Last Name Initial Mailling Address —No. Street, City and State Zip No.First 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 Time Rec'd Phone Call Rec'd By Owner or Agent Signature NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD GIs.Sq. Ft.Capacity Sq. Ft. Ft.Ft.Ft.Distance from nearest well Ft.Distance from lake or stream Ft.Ft. Distance from occupied building Ft.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 ,JVI By :PERCOLATION TEST DATA:Date of First Test 19 Rate 19....RateDate of Second Test 1st Test Taken By *2!First Test ■H 2nd Test 2 Rate2nd Test Taken By The undersigned hereby makes application for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work inAgreement; strict accordance with ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn­ esota Department of Health. Applicant agrees that plot plan, sketches and specifications submitted herewith and which are approved by Shoreland Management Offi­ cial shall become a part of the permit. Applicant further agrees that no part of the system shall be covered until it has been inspected and accepted. It shall be the responsibility of the applicant for the permit to notify the County Shoreland Management that the job is ready for inspection. (Call or use attached mailer notice.) Dated Signature Permission is hereby granted to the above named appiicant 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: Issued Date: Shoreland Management Office p 7 >;Fee $Surcharge $ hloaSdT7Comments:. > ' • .-V L Form No. MKL-0771-003 @ VICT»R UIHDtIN ■ CO.. OO.NTCOl. OtOCUO FM.L0. M.MH 158906 .i ’'’'I ■ 1 7 INSPECTION RESULTS t 4Inspector must make all measurements SEWAGE DISPOSAL SYSTEM STATISTICS SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORYActualShould be Should be Actual Should beActual / SP S FCapacityGIs.S FGIs.S F S F /Oo^ F r)t F Distance from Nearest Well 75 50 F FF F F Distance from Lake or Stream F FF F F ok 20Distance from Occupied Building 10 20FFF F F F odL FDistance from Property Line 10 10 10FFF F F Distance from Bottom to Water Table 4 4FFF FF ML l!)Inspector's Comments: V / « r Tt) 47t?jw (Lxi, a rt.\ k. c____________ StS (i^c\t \/) 0 ks?Li>Xy t <1 (r ^ A Date of Inspection .19___ Time of Inspection.M Q Signature of InspectorINTERPRETATION OF ABBREVIATIONS Git - Gallons SF “ Square Feet F “ Linear Feet Job Title AgencyMKL-0771-003-Backer '■h ■ •» ' y.‘-y. * L ; * TO BE COMPLETHD BY PERSON INSTALLING SYSTEM i hereby attest, thav, ^ or familiar vuth the minimum standards required by the OTTER TAIL COUNTY SHUREL/’]«U N3ANAGEMENT ORDINANCE regarding sewage systems and that above system in accordance with those standards. “the Legal Description: J57License No. OwnersNflame Sign'ature of Installer D&te of Installation Date Please return when completed to Shoreland Management Zoning Office - Court House, Fergus Falls, Minnesota 56537. PERCOLATION TEST DATA SHORELAND MANAGEMENT OTTER TAIL COUNTY Fergus Falls, Minnesota 56537 yy 3Ph. No. Mailing Address:iwner: LISPS'ZL^[C FjtoLast Name Middle St. & No.City State Zip No.Legal Description: LAKE OR RIVER NO.SEC.NAME TWP.RANGE TWP NAME TEST HOLE NO. 2TEST HOLE NO. 1 4 4:? 0 3 4Depth to Bottom of HoleDepth To Bottom of Hole, inches; Diameter of Hole.Jnchesinches; Diameter of Hole inches ODepth, Inches Soil Texture Depth. Inches Soil TextureDate.Date 3 3 4Percolation Test By____ Percolation Test Bv .7OatFirmName.GC Firm Name.DOLU QC V.I-VLU Address.CC Address < COOtter Tail County License No..Otter Tail County License No..COLUMeasurement, Inches Drop in Water -Level. lr>ches Drop in Water Level. Inches H Measurement, InchesTimeRemarksTime Remarks o 7 ? 4L9^UL7- ly % 7: v47'¥y / 7 7:.X 7‘.^37 9 Hr9: C 3:zt\ X ) 3Ci©‘=1 -y1 / y ^ y/ c/i -‘ii 183818 ®MKL-0871-028 VICT8B i-wagcca «iBTiBt rcB«u8 ria.k.8. m See Booklet/'How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn. ir. ^ ^ /icoJ^ C&i S/V7/; jU^ /7d^' J/o ' 7th 3 ^ ' J ^ ST ^ 3 6, 7(oG ' jU -^, £fK'c3y-^ % SHOP ELAND MANAGEMENT - COUNTY OF OTTER TAIL COUNTY COURT HOUSE Phone 218-739-2271 - Fergus Falls, Mn. 56537 APPLICATION FOR PERMIT TO INSTALL SEWAGE DISPOSAL SYSTEM te — Otfice V low — Inspector Pli.. Card — Owner Owner ;* ■■V Permit No,LEGAL Date DESCRIPTION AND LOCATION Lake No.Lake CJassTT; See.Lake Name TWP Range TWP Name IDENTIFICATION; Please Print All Information. /Mailling Address —No. Strfe»t< City and StateLast Name First Initial 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 Time Rec'd Phone Call Rec'd By Owner or Agent Signature NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD GIs.Capacity Sq. Ft.Sq. Ft. Ft.Ft.Ft.Distance from nearest well Ft.Distance from lake or stream Ft.Ft. Ft.Distance from occupied buildinq Ft.Ft. \ Distance from property line Ft.Ft.Ft. \Ft.Ft.Distance from bottom to Wati Ft.Table AH f^tances are shdftest distance between nearest points RECORD OF TESTS: Inspection was made on ., 19 , Time M By PERCOLATION TEST DATA:Data of First Test , 19 , Rate Date of Second Test 19 ,, Rate 1st Test Taken By First Tel -I- 2nd Test 2 Rate2nd Test Taken By \ \ The undersigned hereby makes applicJ^tion for permit to install or extend Sewage Disposal System herein specified, agreeing to do all such work in strict accordance w|jh ordinances of the County of Otter Tail, Minnesota and Minnesota Individual Sewage Disposal Code Minimum Standards set forth by Minn­ esota Department of ffealttj. Applicant agrees that plot wan, sketches and specifications submitted herewith and which are approved by Shoreland Management Offi­ cial shall become a part of the-tjermit. 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.) Agreement; 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 Cr rnty 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; k 1 Issued Date: Shoreland Management Office /Fee $Surcharge $ 1■f ') !Comments:.• / C / -i . I Form No. MKL-0771-003 ....158906 vicTAt umtccii « c>.. MiMTtn. rinaua ru.L*. INSPECTION RESULTS 4 Inspector must make all measurements > SEWAGE DISPOSAL SYSTEM STATISTICS SEEPAGE PIT DRAIN FIELDSEPTIC TANKCATEGORY Should beActualActualShould be Actual Should be Capacity GIs.GIs.s F SF S FS F Distance from Nearest Well 5075 FF F F F F Distance from Lake or Stream FF F F F F 20Distance from Occupied Building 10 20 F F FFFF 10 10Distance from Property Line 10FFF FFF 4 4Distance from Bottom to Water Table F FFFFF Inspector's Comments: 4 Date of Inspection 19___ Time of Inspection,M Signature of InspectorINTERPRETATION OF ABBREVIATIONS GIs « Gallons SF “ Square Feet “ Linear Feet Job Title F Agency MKL-0771-003-Backer ■■y■L 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 Pl».. — Owner Card — Owner 3/yfc9Permit No.W C7 SM2lLEGAL Date DESCRIPTION AND ko 3G j3Q V/LOCATION Lake Classif.Sec.TWP Range TWP NameLake No.Lake Name IDENTIFICATION; Please Print All Information. Zip No.Tel. No.Mailling Address —No. Street, City and StateFirstInitialLast Name U -L /fUnOWNER7^ SEWAGE SYSTEM INSTALLER Name. This System will be ready for inspection on., 19. This space for office use only 19 Date Rec'd Owner or Agent SignatureTime Rec'd Phone Call Rec'd By NUMBER OF BEDROOMS:ESTIMATED COST; SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD /OOP GIs.Sq. Ft.Sq. Ft.Capacity t Sv Ft.Ft. Ft.Distance from nearest well ■73 Ft.Ft.Ft.Distance from lake or stream /O^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 , 19 > Rate Date of Second Test , Rate 1st Test Taken By First Test Test-I- 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.) 44Dated Signature Permit: condition that the person to whom it is granted, and his agents, employees and workmen sl^all con’^orm in all respects t^ oiNjinances 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 woiirdfescribed in the above ement. This permit is granted upon express Issued Date: Shoreland Manageii’?3/ fc- 73<^~ g 9 2,2_ Fee $.Surcharge $ (X\ V AComments:. @ viCT»» kuaacCH • e»-. PttaTcn. riHau*158906Form No. MKL-0771-003i T SHORELAND MANAGEMENT - GOUNTY OF OTTER TAIL COUNTY SQURT HOUSE Phone 218-739-2271 - Fergus FallsTWn. 56537 APPLICATION FOR PERMIT TO INSTALL SEI/VA^ DISPOSAL SYSTEM ? W :te — Office V low Pi».. - Card - — InspectorOwner Owner -rr i / C-' 'Permit No.(/Li . NLEGAL Date j DESCRIPTION AND LOCATION Lake No.Lake Name Lake Classif.Sec.TWP TWP NameRange IDENTIFICATION: Please Print All Information. Initial Mailling Address —No. Street, City and State Zip No.Tel. No.Last Name First OWNER SEWAGE SYSTEM INSTALLER Name. Th/s 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 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.Distance from lake or stream Ft. Ft.Ft.Distance from occupied buildinq Ft. Distance from property line Ft.Ft.Ft. Ft.Ft.Ft.Distance from bottom to Water Table All 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 F 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 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. (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 1H 9 '< ! T- < '•Fee $Surcharge $ Wo cEgy -ii Comments:. jk Form No. MKL-0771-003 1S8906 vierga lumsccm 4 eo.. aiiHTiat. riasut r«Lki. r ■ •K 4. INSPECTION RESULTS Inspector must make all measurements i SYSTEM STATISTICS SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORY Should beActualShould be Should be ActualActual Capacity GIs.S F S FGIs.S F S F Distance from Nearest Well 5075FF F FF F Distance from Lake or Stream F FFF F F 20Distance from Occupied Building 10 20F FF F FF Distance from Property Line 10 10 10FF F FF F 4Distance from Bottom to Water Table 4FF F F F F Inspector'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 k A ’£^es / CERTIFICATE OF COMPLIANCE SEWAGE SYSTEM HOLDING TANK((■i E 79__Z1day of April to certify compliance with regulations of Shoreland Management Ordinance, Otler Tail County, Minnesota. 23rdThis certificate has been issued this m ■M m aThe premises covered by this certificate are legally described as:r' Lake No. 56-522 Sec. 36 Twp. 136 Twp. Name Doram ii Wildwood Resort ik 'iU P, » ^iM m.i Owner: Name Ray Wendi- w.Adrlress Ttp-nt-^ M^nriPigntn 56528Zip No.m Permit No. SP. Signed by:. colm K. Lee, Shoieland Administrator 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 Ph.. Card Owner Owner A cP(a/ i 19 o2 Vo2XPermit No..LEGAL Date DESCRIPTION AND 0>orc{3 G iJC V/LOCATION Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name IDENTIFICATION; Please Print All Information. Last Name First Initial Mailling Address —No. Street, City and State Zip No.Tel. No. r.iOJL /nrs ■Uy P r\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 Time Rec'd Phone Call Rec'd By Owner or Agent Slgna:ture NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT RAIN FIE^ /Sq.J 00 0 GIs.S/ Ft.Capacity Ft. 7Ft.Ft.Ft.Distance from nearest well 3S.Ft.Distance from lake or stream Ft.Ft. f-lA Ft.Distance from occupied building Ft.Ft. -fJODistance from property line Ft.Ft.Ft. Ft.Distance from bottom to Water Table Ft. AH distances are shortest distance between nearest pbints RECORD OF TESTS:1Inspection 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 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 -7 7Dated Permit; condition that the person to whom it is granted, and his agents, employees and workmen shall cc^forln in all respects to ordinance of Otter Tail County Minnesota. This permit may be revoked at any time upon violation of any said ordinance. I \ NOTE; Permit void if work is not commenced within six (6) months. 1 \ /O Permission is hereby granted to the above named applicant to perform the work de;in the above statement. This permit is granted upon express *-/ Issued Date:. Shcveland Management Office4 JFee $Surcharge $ Comments:. Form No. MKL-0771-003 VICTP* UIdBItH 4 C».. *BI«t(*B M««US FM.LB ..Nk 158906 f 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.. Card — Owner , Owner Permit No.,LEGAL Date & DESCRIPTION vrAND LOCATION Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name IDENTIFICATION; Please Print All Information. Last Name initiaiFirst Mailiing Address —No. Street, City and State Zip No.Tei. No. 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 NUMBER OF BEDROOMS:ESTIMATED COST: SEWAGE DISPOSAL SYSTEM DATA: SEPTIC TANK SEEPAGE PIT DRAIN FIELD Capacity GIs.Sq. Ft.Sq. Ft. Ft.Ft.Ft.Distance from nearest well Distance from lake or stream Ft.Ft.Ft. Distance from occupied building Ft.Ft.Ft. Distance from property line Ft.Ft.Ft. Distance from bottom to Water Table Ft.Ft.Ft. AH distances are shortest distance between nearest points RECORD OF TESTS: Inspection was made on 19 , Time ,JVI By PERCOLATION TEST DATA:Date of First Test , 19 . Rate Date of Second Test 19 , Rate 1st Test Taken By First Test + 2nd Test 2 Rate2nd Tost Taken By The undersigned hereby makes appiication for permit to instail 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 job is ready for inspection. (Call or use attached mailer notice.) Agreement: 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; Issued Date: Shoreland Management Office Fee $Surcfiarge $ Comments:.c. Form No. MKL-0771-003 >... 158906viCTOt uiHecca a co.. Minna*. rca«u» '*ll8 } INSPECTION RESULTS * Inspector must make all measurements SEWAGE DISPOSAL SYSTEM STATISTICS h(o^ SEEPAGE PITSEPTfe-TANK DRAIN FIELDCATEGORY Actual Should be Actual Should be Actual Should be Capacity GIs.GIs.S F SF S F S F /0<y^Distance from Nearest Well 75F 50F F F F F Distance from Lake or Stream ro<i F F F F F F 21Distance from Occupied Building 10 2020FFFF F F /OfDistance from Property Line 10 10 10FFFFF F Distance from Bottom to Water Table 4 4FFFFF F Inspector's Comments: . ,9^Date of Inspection Time of Inspection .M ir ^nature o/InspectorINTERPRETATION OF ABBREVIATIONS GIs “ Gallons SF * Square Feet “ Linear Feet Job TitleF AgencyMKL-0771.003-Backer ' f T,/ i - *. ■ A