HomeMy WebLinkAboutISTS Record
-
,.,\,
.-
d'"
,..;;.. SCOl''Il GOlWl'N',.MINN4S0T A.
APPLICATION FOR INDIVIDUAL SEWAGE TREATMENT SYSTEM (ISTS) PERMIT
'I
,
~ .
(Not~]Illi;ant: o?~" out shaded section below) / / cj '7
Twp~tv') * I orH ' Date Received If; - I {p - ..;;.
ProjectAddres~ /."5 ::z./~ J . Hen,i/no ('.r'r Pennit# -7..~ A-2<..--'
City/Zip l=>'- 'J Receipt # 2-f.r?-=~
Site Evaluator Installer Fee ."', <:; 0.0 ()
Septic Tank Size as per design submitted and approved I dCr> --+ It) 0(:) Receipt Code ":;])?)
Pump Tank Size as per design submitted and approved '.. I?,\ :' New ISTS Replacement K
Drainfield Size as per design submitted and approved (below) Percolation Rates /5 1"5'. Zc,
( Number of Potential Be&:-ooms' -5
/i,,--]... <:~,.(,,,,,,,, kJL:t JS'I (.,,'~ \ .\'-!- I'{" ....f .-n< k Depth to Restricting Layer I~j
APPLlCANT.FDiliOUTINFORM1\-~O~SID\D~;~()NLY .'
Applicant mt'~.QJ CA~ Phone(H)~...fih~~{"'~ (W) IAI.)- ~fli}../_<t"'t
Appiicant Mail Address ~ b I H{:nf\ l1'\h CJ\ tv. ~ City ~~ Stale 1-4.. I Zip ~ :rD~
Owner (if different)
Owner Maij Address
Phone (H).
City
(W)
State
Zip
Parcel Number Sect. --"'- S~vision Name (ifapplicable) Lot #_ Block #_
SoilleSts and a design of the ISTS meetjog MinD.Cba;ter 7080 standards must acc6!1l}lii,ily;~;~pplic8tion.
'.'.' ':,::./,. "..:"<r"/%0~0'!::>';\ ",/:,;.;;'
Appli~ hereby agrees thaI, upon issiIancCl ofthiS~t;::llIl,'WOrk shall be done and:lill:~1!'i.Cd~,~ in compliance with Slale Rules
and. any applicable township, city, and county ordinanCes;i,;The,applicant must also enSunnlilit'tbCSCOtt County E.~, :.." ........ ,,".~J Health Dept. is
notified ofanY'l~ illstallation by 9:00 a.m. Ofthe:lIl[~;:';~__;:on is requested. <; .;,\\
Applic8ntSiPature m r /\ ^^ ........S~:;;..,.:::z~~';~;...U-()~
TOWNSHIP OR CITY USE ONLY
.___of________
Recommend Approval
Recommend Disapproval
and Permit complies with the Wetland Conservation Act
Signature of Township or City Clerk (or representative)
Date
.---------------- COUNTY USE ONLY
ISTS Setbacks~iUilding: (tanks))) (drainfield) du Lake/CreeklWetland - Wells <;t; + 10' to Lot Line or ROW/Easement.
Approved + Denied By Scott County Environmental Health, subject to existing regulations and the following conditions:
1. Verify and maintain all required setbacks and elevations.
2. Protect (fence oft) the primary and alternate drainfield locations while any building construction activity is occurring
on the site and maintain fencing or some other approved barrier if the drainfield could be damaged after inst8l1ation.
3. Install rock bed on contour and maintain at least 36 inches between the rock bed and the water tablelmottling.
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 valid 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 ofthe final Department arr- _,ed design.
9. Nonresidential ISTS shall include a water meter and, if a dosing device is used, an electrical event counter.
Signature
.
r t1 ~ ~ c/ fc. n= /
Date (<J//,f ~ 3
White - County Yellow - Township Pink - Applicant Gold - Township
~OLOING TANK(S) I~r New
LiqUid Capacity I .\..>.1J
Tank Manufacturer tJ r
Baffle Type: ~ Fiberglass Sanltary-T C~
No. of Inspe&oN rifles -=1 4" ~
No. & Diam. of Manhole Access I \~. 'I I.
No. 8. l;Ieight of Manhole Risers \)l It .,
\ SCOTT COUNTY ...... 't"""i
tNOIVIOUAL SEWAGE TREATMENT SYSTEM INSPECTION FORM-
~Twp. frcrL...kt> Inspection Dates 1-7'01 ! ')Pi~~i:~O.).,3-4').!"
Owner AT ( ;.., e 1 :-o.r r Installed for (#BEl,drm Dr gpd) j Busllndiv :r
Project Address 15-..",1 11"v.t"" ",f Designer. l5('1t,,,,, _Installer kl''1l..p--:-.,
City VI.- J 0 NEW ~REPLACE 0 REPAIR 0 ADDITTON
SETBACKS:"Il' tf'RE.!lLC.I,jE8>BED OR GRAVELLESS LEACHFIE':9~
Buildings to Tank ;) ..1 ~6~-' concrete!<llJ,aS.liV
Buildings to Orainfield ?;. U Trench Depth J 0 Width ] {,.
Well(s) setback 50' or 100' not installed Trench Lengths S"U -' r
Lake!CreeklWetland - Trench Bottom Level
Property Line(s) ,"".... Trench Spacina ')<:p ;,." Ji,.I
Drainfield Rock Below Pipe I ).
or Size oJ..Gravel!ess Pipe
Actual! wected.Depth of Backfill
Absorption Area: Square Feet
Lineal Feet
.
I
,.
ves I no
o Existing
I... .
..(5(,)
Mt>,UND OR ATGRADE:
Percent Slope
qike Width up
Drainfield Rock Below Pipe
Inches of Sand Below Rock
Perforation Size & Spac'
Pipe Size and Spac' ,
Dimensions of k Bed
Dimensions and Base
Depth of nal Cover
~%
down /'" side
./ inches
upslope_downslope
PUMP INFO:
Liqu id Capacity
Tank Manufacturer
No. 8. Height of Risers
Pump Manuf. 8. Model No.
Horsepower GPM
Feet of Head installed or as per design
Cycles Per Day Installed or as per design
Gallons Per Cycle il'~talled or as per design
Size of Discharge Line y't 1.5" 1,2"
Type of Electrical Hookup post & box by tank
Alarm Location qarage I basement
Alarm: Tank Alert I Level Alarm I Other
Cycle Counter & Water Meter (Commercial)
10aO
iY,P
I .~ 'T iJ.:!'
~xisting
ALTERNATE SITE AVAILABLE
ENV HL TH APPROVED DESIGN ON SITE
ALTERNATIVE I EXPERIMENTA'r SYSTEM:
T1pe \
v'~-1 I 00
~ '~;;~ i'f -,; "'
91~J,
-..J. r/ r
rd
Yo'
~ee Notes added to Design Drawing
__Drawing of System Below
--
)'0'
'",- 50 I
~\)\
! \ 1
Iv
.,
Inspector Comments: Divert ail surface waterawav from or around drainfield area. Sod or seed as soon as Dossible
to Dreventsoll erosion. 7/.;~ ",,,,.,( ~y ).V,;;f"....... ^o f>v"",,p w., s ',~,5t--;i1J'J
Corrective Action Reouired:
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 Individual/Community
Sewage ~~eatment System _~r~ance No.4.
"'{~;~ /~wr
Installation Inspector's ~~~at~~e
l ."
"'--''''j
FINAL COVER Inseecler "
t,
I ht?:...~ byy, certify, as the installer, that the following tank openings were or will be constructed to be
wa ~ht; inlet. outlet, Jnspection pipes and the access to the maintenance hole. including risers.
.1.H (Installer Initials)
F4rthermore. I hereby certify, as the installer, th e individual sewage treatment system was or will
beinstaUed in accordance with the Sc Co I vidual/..9.ommunity.Sewage Treatment System
Ordinance No.4. I agree to indemnify!a say ounty haff!!!ess1tbm all loss. damages, costs,
and charges that may be incurred by t~e oun ause of m';t,.ffillure to conform to and comply with
the provisions of this Ordinance. /1'"
,,\ .
t '.-/' .....t, Installer's SJcmature
. \
Thi~ystem is d in compliance 0 not In complian~ith the' t County Individual/Community Sewage Treatment
System-Drdinance No.4, therefore, this document is a ~ Certificate of Compliance 0 Notice of Noncompliance.
White ~ County <rellow ~ Owner Pink -Installer
, ,