HomeMy WebLinkAboutISTS Permit & Inspection Form
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(Note to Applicant: only fill out the area in bo below)
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Proje~t Address --:;2 I I ' CA.. Vc:: C C\.,C... t (
City/Zip"~ . l:. S~'(")'IL~~ li
Site Evaluator & ~ IIlftaller
Septic Tank Size as per design submitted and approved I SdC>- ~C
Pump Tank Size as per design submitted and approved /0<00 -.1*
Drainfield Size as per design submitted and approved (below)
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'''~,~.~, . ~.... SCOTT €OUNTV'; MI~NESOTA'~', .,
APPLICATION FOR INDIVIDUAL SEWAGE TREATMENT SYSTEM (ISTS) PERMIT
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Date Received f.o. 2 <..0 - 0 '9
Permit #\'~-( F\ - ~~ h-
Receipt # 'tic
Fee I.oc.. S '-) C.J
Receipt Code $fj l
New ISTS_ Replacement ........--
Percolation Rates 2(;,. 7~.?~ ~ ~'"
Number of Potential Bedroo~s .y'
Depth to Restricting Layer ~ 'J '"
/;>~d
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~/ 'k 6 ~ ( S4ltAe>I?6r::~~
) APPLICANT FILL OUl; lNFORMATION IN THIS BOX ONLY
Applicant K>e l' t 1j d~ /1 z- -' ../. . Phone (H) ~. 53 op (W) ,-/03' 0 79 <7
Applicant Mail Address 37> 7 ') mCU S(!it~t?", City ~~ Sta~l!L. Zip 5~.5~ -3 ? 9'
Owner (if different) Phone (H) (W),
Owner Mail Address City
Parcel Numbe;LS~9 31 co2 ~\Sect_ Subdivision Name (if applicable)
State~Zip
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Lot #_ Block #_
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Soil tests and a design of the ISTS meeting Minn. Chapter 7080 standards\must accompan~..tfi1s application.
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Applicant hereby agrees that, ~p6n issu ce of this permit, all work shall be do~ and a!~..rriaterials used shall be in compliance with State Rules
and any applicable townshi~city, an ounty ordinances. The licant must als\' ~psUre that the Scott County Environmental Health Dept. is
notified of any ISTS inst~ation b :00 a.m. of the day th . pection'
Applicant Signature;;' \ Dateh ' ) t. ~ 0 Cf
1r()WNS~IJ><>R CITY US~ON~Y ----------------------------------------------
Recommend Approval
Recommend Disapproval
and Permit co lies with the Wetland Conservation Act
Signature of Township or City Clerk (or represl?ntative)
Date
------------------------------------------------------ COUNTY USE ON~Y ---- --------------------------------------------------
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ISTS Setbacks: Buildi~g: (tankS)~ (drainfield)~ Lake/creek/Wetlan. Well +10' to Lot Line or ROW/Easement.
Approved--X- Denied~By Scott County Environmental Health, subject to existi~~ regulations and the following conditions:
,,"r"~i: Verify and maintain altrequired setbacks and elevations.
2. Protect (fence oft) t~ primary and alternate drainfield locations while any building coI\struction activity is occurring on the
site and maintain fencing or some other approved barrier if the drainfield could be damaged after installation.
3. Install rock bed on contouf and maintain at least 36 inches between the rock bed and the water table/mottling.
4. Protect sewer lines and system from freezing.
5. Divert surface water away from or around the drainfield area.
6. Sod or seed the area as soon as possible upon completion to prevent soil erosion and damage to the drainfield (for late season
installations, hay,or straw can be substituted until sodding or seeding can be done in the spring).
7. This permit is v~Hd for 12 months from the date issued.
8. The property owner (or applicant, if different from the property owner) is responsible for assuring that the Installer receives a
copy of the final Department approved design.
9. Nonresidential ISTS shall include a water meter and, if a dosing device is used, an electrical event counter.
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Signature
Date
Pink - Applicant
7-/3~of
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Form #1121
SCOTT COUNTY
INDIVIDUAL SEWAGE TREATMENT SYSTEM INSPECTION FORM
City/Twp."~1W l a.,~
Owner
Project Address 3~ lYJo~hc:;;t{
City 'Pr> IJY La e-
Inspection Dates
SETBACKS:
Buildings to Tank J I
Buildings to Draintield ~
Well(s) setback 50' or 100' in;;}. not installed
Distance to Lake Creek - Wetland
Property Line(s) IS
SEPTIC/HOLDING TANK(S) 0 New 0 Existing
\-:;oC> Liquid Capacity ISOO
Tank Manufacturer lui~r'
Baffle Type: Plastic Fiberglass Sanitary-T Concrete
No. of Inspection Pipes -"-- 4" / 6" diam.
No. & Diam. of Manhole Access 3~
No. & Height of Manhole Risers .5 xa3
Connections:
MOUND OR A TGRADE:
~~~~~ %
~i~ 3'Wike Width ~ up ~(p down 'X. side
I Draintield Rock Below Pipe 7'/1 inches
~ Inches of Sand Below ROCk~uPslope_downslope
'1/$1-$ Perforation Size & spac~ ~ ~
1-ft. Pipe Size and Spacing 7/7. .33
/O}l~C> Dimensions of Rock Bed /1:) XsD
Dimensions of Sand Base
Depth of Final Cover
ALTERNATE SITE AVAILABLE
ENV HL TH APPROVED DESIGN ONSITE
_ See Notes added to Design Drawing or
_ Drawing of System Below
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:r'..;2~ '1 / ~- 3- () Cf Permit No. :pfltjq- Wcf'1
I stalled for ~rm or gpd) Y Business/lndiv
Designer I"') Installer /1Jtt.Ki/JltU-n-,
o NEW 0 REPLACE 0 REPAIR' D ADDITION
S, BED OR GRAVELLESS LEACHFIELD:
concrete / plastic
Width
TRENC
Drop box
Trench Depth
Trench Lengths
Trench Bottom Le
Trench Spacing
Draintield Rock Below ipe
or Size of Gravelless PI
Actual/Expected Depth 0 ackfill
Absorption Area: Square Feet
Lineal Feet
yes I no
PUMP INFO:
l00uLiquid Capacity rucl
Tank Manufacturer }Ji~.el/
No. & Height of Risers yt{" I
new I existing
Pump Manuf. & Mo ""R;;S'I
Horsepower '3lr
Feet of Head
Cycles Per Day
Gallons Per Cycle
Size of Discharge Line
Type of Electrical Hookup os & box b k
Alarm Location a-h';' -?1 YVlJv1 garage I basement
Alarm: Tank Alert / Levei7Alarm / Other~("'l:..
Cycle Counter & Water Meter (Commercial -
Alternative / Experimental System / Pretreatment:
Type
Pretreatment Alarm
N
Ii-o u..& Q.-
...
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Inspector Comments: The top of all tanks must be installed 4 feet or less below final arade (unless exempted bv
Inspector). Divert surface water away from or around drainfield area. Sod or seed ASAP to prevent soil erosion.
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..1=M1Iu.,Lld 1N~,/I~!u(lY1 IN i -P n-uu pumf' /7.P~oIea/ ~ a~cefmt7e/~ ,i).ff~. ~ /I~ fJ'V~r rzud...o(
Corrective Action Required:
I hereby certify that based on this Inspection and the Information
submitted by the site evaluator/designer, the individual sewage
treatment system appears to be in compliance with the Scott County
Indivldua ommu~Treatment System Ordinance No.4.
In alia on Inspector's Signature
I hereby certify, as the Installer, that the individual sewage treatment system
was or will be installed In accordance with the Scott County Individual/
Community Sewage Treatment System Ordinance No.4. I understand and
accept the findings by the Inspector and agree to comply with all requirements
to finis r correct the ISTS on as written on this Inspection report.
This system is in compliance 0 not in complianc~ith the Scott County Individual/Community Sewage Treatment
System Ordinan e No.4, therefore, this document is a Lf\ Certificate of Compliance 0 Notice of Noncompliance.
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