HomeMy WebLinkAboutWoodlawn Resort_29000060050000_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
White - Office
Yellow — Inspector
Pink — Owner
Card — Owner
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Permit No..LEGAL
Date4-DESCRIPTION
AND
6/ a mc^7 ^ C\iiD Cp rvi ZLOCATION( r^o
Lake No.Lake Name Lake Classif.Sec.TWP Range TWP Name
IDENTIFICATION: Please Print All Information.
Last Name__________________________a First______Initial Mailling Address —No. Street, Cityjnd StateZip No. Tel, No.
ite.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:-\L}Tu^\ ..
DRAIN FIELD
SEWAGE DISPOSAL SYSTEM DATA:
SEPTIC T.^K 3IICPAOE PtT
32-6^OQ-
/5~5-:^0Ft.
'IS-ZO.
GIs.Capacity Sq. Ft.
/ Th^Ft.Distance from nearest well
J 0 o I f)bFt.Ft.Distance from lake or stream Ft.
/r 2=^>6Ft.Ft.Distance from occupied building Ft.
"4-0Distance from property line Ft.Ft.Ft.
Ft.Ft.Ft.Distance from bottom to Water Table AH distances are shortest^stance between nearest points
RECORD OF TESTS:
Inspection was made on 19 , Time ,M By
11...PERCOLATION TEST DATA:Date of First Test , 19 Rate
. 19.7....sf..
Ll.1..y..3^Z.
Date of Second Test Rate
1st Test Taken By l-CG L....L.LIIFirst Test -I- 2nd Test
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.)
Kula, V\Dated
Signature
Permit:
condition that the person to whom it is granted, and his agents, employees and workmen shall confo
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. /
Permission is hereby granted to the above named applicant to perform the work described in the above statement. This permit is granted upon express
in all respects to ordinan^SfoTStter Tail County Minnesota.
/ X- 7 //nLlIssued Date:.ManagementSjind
W </
Ob - TgFee $Surcharge $
^ Ap U (f^O SComments:.
Form No. MKL-0771-003 vicTca kuaatCN • ce.. Miauat. riacus r»i.k.a. «i«tt.l5S906
-Tot' \\ASPCc;f-(0/i.
H:00SHORELAND 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
Yeilow — Inspector
Pink — Owner
Card ^ Owner
I /'■ ' Q ' U I fC"/ o f Permit No.,11 oLEGAL
Date
/ i , 2 /DESCRIPTION n
AND
r6/0 j “An <tLOCATION c
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.7 f ,L ' POWNERL> '
t
SEWAGE
SYSTEM
INSTALLER
rName,
■3/d0 6Tk79This System will be ready for inspection on., 19.
This space for office use only
Rf iii .^py/y’SJ9J/ '7j(] m-S'19
Date Rac'd Time Rac'd Phone Call Rac'd By Owner or Agent Signa,ture
NUMBER OF BEDROOMS:ESTIMATED COST;
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGETITSEPTIC TANK DRAIN FIELD
f '/ 7;GIs.Capacity Sq. Ft.Sq. Ft.
7
y ' Ft.Ft.Ft.Distance from nearest well
)Ft.Ft.Distance from lake or stream Ft.
J J /I yDistance from occupied building Ft.Ft.Ft./T "9X
Distance from property line 9 (JFt.Ft.Ft.
T
H LFt.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 JVI By
V 'n .LLk / ^
(/:j ■PERCOLATION TEST DATA:Date of First Test 19
, 192..^,
. Rate
:I
Date of Second Test...,
,• [ (
, Rate
1st Test Taken By /(■ c?First Test ■F 2nd Test„„"i 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
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.!• •'I;(■ /91i
Issued Date:
Shoreland Management Office
Fee $Surcharge $
—rssu&J—
<7 if.-:'rI\A Ia yA,.' iA. \ aComments:.
1
■i
Form No. MKL-0771-003 vieroi LUNOctM « c».. orimu**. p(t«ui mimh.158906
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORYActualShould be Actual Should be Actual Should be
Capacity GIs.GIs.S F S FS F S F
FDistance from Nearest Well 75 50
F F F F F
too pDistance from Lake or Stream F F F F F
F
goo F
Distance from Occupied Building 201020F F F F F
Joo’^Distance from Property Line 10 10 10FFFF F
-cO F ■ 4Distance from Bottom to Water Table 4F F F F F
Inspector's Comments:
14-ab:z.^\4Date of Inspection
3 1____MTime of Inspection,/i. .) A A'4 r\
(
Slgnatu^ of InspectorINTERPRETATION
OF ABBREVIATIONS
GIs - Gallons
SF = Square Feet
“ Linear Feet
If
Job TitleF
S 'Agency‘MKL-0771.003-Backer
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ibio o /r^
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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
Yellow — Inspector
Pink — Owner
Card — Owner
I r—i / 6S' t.Permit No../ 6'l-,' o f
LEGAL
lyDate/)
-•2 /DESCRIPTION / i £ £ 'ir^PlJrAND
r/6f i ) }f(LOCATION
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.
s.J - OA !
■ cOWNER^ L' '
SEWAGE
SYSTEM
INSTALLER
Name,
/ 9This System will be ready for inspection on.3,, 19.
This space for office use only
II'll19
Date Rec'd Time Rec'd Phone Call Rec'd By Owner or Agent Signature
NUMBER OF BEDROOMS:ESTIMATED COST:
SEWAGE DISPOSAL SYSTEM DATA:
SEEPAGE PITSEPTIC TANK DRAIN FIELD
1 O Sq. Ft.IV)i'Ziil ■^Sq. Ft.GIs.Capacity /
-7 •' y (j! II - Ft.Ft.Ft.Distance from nearest well
iyo! ClFt.Distance from lake or stream Ft.Ft.
J Ft.Distance from occupied building Ft.Ft.a-'
. “>•Distance from property line 1 (}Ft.Ft.Ft.
H- CFt.Ft.Distance from bottom to Water Table Ft.i :
All distances are shortest distance between nearest points
;
RECORD OF TESTS:
iInspection was made on 19,, Time ,M By
f\ip/V :■L, 19 I...
, 19 3..h
PERCOLATION TEST.DATA:Date of First Test , Rate
1 ! • ip 6L,:f
Date of Second Test , Rate
1st Test Taken By ' i h 'A. ■■?,?VO 'vjFirst 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.)
IDated
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 (6) months.
I,
I\V ' /
■1-- '•n1"7
ti/' >-f 'Issued Date:,y
Shoreland Management Offlce^
!Fee $Surcharge $z_
T I ' r-4^‘Lx 6- f Tj iA '■ OComments:.
1
Form No. MKL-0771-003 .158906
VICTOt U.neC(N k ee.. PMNTIM. FIHSUS rALLl.
INSPECTION RESULTS
Inspector must make all measurements
SEWAGE DISPOSAL SYSTEM STATISTICS
SEEPAGE PITSEPTIC TANK DRAIN FIELDCATEGORYActualShould be Actual Should be Actual Should be
Capacity GIs.GIs.S F S F S F S F
}0^ FDistance from Nearest Well 75 50F F F F F
too pDistance from Lake or Stream F F F F F
h O F
QQO F
Distance from Occupied Building 10 2020FFFF F
Distance from Property Line 10 10 10FFFF F
^ r- 4Distance from Bottom to Water Table 4FFF F F
Inspector's Comments:
14___19:2.'-(InspectionDate of
I____MTime of Inspection,//AZ'
I t
Slgnatu^ of Inspector f.INTERPRETATION
OF ABBREVIATIONS
GIs Gallons
SF = Square Feet
F * Linear Feet
Job Title
AgencyMKL-0771-003-Backer
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PERCOLATION TEST DATA Price $ 1.00 per pad.
SHORELAND MANAGEMENT
OTTER TAIL COUNTY
Fergus Falls, Minnesota 56537 Ph. No. Y ~ X ?
Owner:Mailing Address:
estiw At Cx S1,3^IX
Last Name First
Pi 4 -V
Middle St. & No.Zip No.City State
Legal
Description;,- ,9 V c » *P I Y V AAIr* .-
LAKE OR RIVER NO.SEC.TWP.NAME RANGE TWP NAME
TEST HOLE NO. 2TEST HOLE NO. 1
111^<13Depth to Bottom of Hole inches; Diameter of Hole inchesDepth To Bottom of Hole,inches; Diameter of Hole inches
Date <1. ^L J/___19 .'2.^Depth, Inches Soil Texture Depth. Inches Soil TextureDate.19.
P^y. cyo • J ^in ,.vPercolation fj
^ T^t Bv
/!/Percolation
Jest Bv_^_
f
/'j -•4t^. -K> -Q L#* I z* ^7 JjlLU
/' t If'C-'Firm
Name.CC FirmName.D1.'WaLU
CC
'M7^C'l t.- i t"- j ^LU
t j »;Address.CC Address
<0 \'y D s ' '^C/5Otter Tail County License No.,Otter Tail County License No«,HCOlUMeasurement,
Inches Depth in Water
Level, Inches
H Measurement,
Inches Depth in Water
Level, Inches
Time Remarks Time Remarks
o
_ 3 t ,7/ 7
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y! / CP
y:
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7 .'■’3
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MKL-0871-028159179 ®ViCTflH LuNfiCtM t ee . PRiHTCAt. Ft»«US FALL!.
See Booklet, "How to Run a Percolation Test" by Agriculture Ext. Service, Un. of Minn.
TO BE CO’ieLETED BY PEECOLATTON TESTER
1 hereby attest that I am familiar with
the minimum standards required by the
OTTER TAIL COUNTY SHORELAND T'IAI'IAOEMENT
ORDINANCE repardinp, sewape systems and
that the land elevation vxhere soil absorption
portion of sewape system will be Installed
in not less than six (6) feet above the
hiph water level of the lake
flowape involved.
stream or
Lepal Description:
t"
Owners Name Signature of Percolator Tester
^ _ y/ , 7 :Y■/?i A/V C. H g;
Lake Name Dated
Please return when completed to Land and Resource Management Office,
Court House, Fergus Falls, Minnesota
percolation test results.
56537.Attach a copy of the
!KL-0574-045