HomeMy WebLinkAboutISTS Permit
t' ""':~"7J SCOTT COUNTY, MIJ~NES9T,;\
APPLICATION FOR INDIVIDUAL SEWAGE TREATMENT SYSTEM (ISTS) PERMIT
(Note to Applicaj/t: only fill pnt shaded sel;tion below) / /
Twp/Clty A-,'rt r /~ 1-" {'I Date Received 9 '11'<5.~
Project Address </..7 10 loV,,~" C;;;: . \ C' Permit # .-z.b' - P, -l.(
City/Zip P t: 0 r l -.Iei Receipt #
Site Evaluator ~ ,III. Installer,f All. Fee ? 0-, ".,
Septic Tank Size as per design submitted and approved I )":OV.. Receipt Code:7..l" n-.le.
Pump Tank Size as per design submitted and approved I ~" 0 , - New ISTS /j\ cz, Replacement X
Drainfield Size as per design submitted and approved (below) Percolation R<<\es - /' /3 I ~
J f Number of Potential Bedrooms ~
I "II 1-,,, ,,&, t J- .,) t I- .... Depth to Restricting Layer -"'0 ""'.ff-/, "t
:' b,uvpcrtO"l'
APPLICANT FILL OU'NNFORMATION INSHADED'AREA ONLY .
Applicant h.17 ~ k II ~ 5' Phone(H) 1"f,f;;. -
ApplicantMailAddress4<l '00 1.40 ,5f tJ k Cit/Pk'lO State(J)A{c,.zi[$jIP12
Owner,(ifdillhent)
Owner Mail Address
Phone(H)
Lot#_BI,*~~
Parcel Number
City
SeJ;t._ S~i()nN~(ifappliC8bie)
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"",,'CF',VO"
SoilleslS and a design of the ISTS meeting MinD. Chapter 7080 s:.....h..J.I must accompany this appli~~;; : .:i~l::,'
"",,/i"', . ',.: .... .*~., . ....,' " .. .,,':H:'''.ii~I'-0-,~_~':::5' _ ,-:"':"'>"'"-,0';
Applicant liereby agrees thaI, upon ~()fthis permi~ all work Shlill be done and a!b:::,~~,';~~~iii.llbe in COl1IPli~1!iIiStiitiRules
and any applicable township, city;,'!II4'~unty Ordinancesb 1'be:applicant must also enll1ir!=jltillt'tIie Scott County Enviroliiii#lllllcHealthDept. is
::::f;;: ~1a11~Ofthei};~j-;Onis requested...,,,~~,~,,%y~,,, DateY;/d.~:/~~"
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.--- TOWNSHIP OR CITY USE ONLY
Recommend Approval
Recommend Disapproval
and Permit complies with the Wetland Conservation Act
Signature of Township or City Clerk (or representative)
Date
ISTS Setbacks: Building: (tanks)
Approved ~enied
.--------- COUNTY USE ONLY
/ r
(0 (drainfield)2- 0 Lake/Creek/Wetland
f
;-v l Wells)'{} + 10' to Lot Line or ROW/Easement.
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By Scott Connty Environmental Health, subject to existing regnIations and the following conditions:
I. Verify and maintain all required setbacks and elevations.
2. Protect (fence oft) the primary and alternate drainfield locations while any bnilding constrnction 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 contour 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 npon completion to prevent soil erosion and damage to the drainfield (for late
season installations, hay or straw can be substituted nntil 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 of the final Department approved design.
9. Nonresidential ISTS shall inclnde a water meter and, if a dosing device is used, an electrical event connter.
Signature
~~d~
White - Connty Yellow - Township
Date 9 ~ / J- ()::
::;...'
Pink - Applicant Gold - Township
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. " seatt CO~~;""'~~ 0 ~. ~1"" ;.J
INDIVIOUAL SEWAGE~'TREA[ME;Nit~S1iM INSP'ECTlON FORM
&trWf'J,~""'.J#~ " '"'' '1I1$pectiQl1J:;l~tes C},-U --a:3>1 Permit~o, "1..r~I~).("
~r pi~..k 10<1 . ' lh$lalledf~:~rgpd)_'" Bustlndiv_
ProjeclAddress 1;/:11. 11''''?''Jr(:,~''' Design., t:; Ins~r~~, t4Pc
City I (If'\.'~t....~ '", o NEW REPlACE 0 R AIR [JAODl1'lON
~~=~~ank " ,~(, .... ~:~~~e~. BED OR GRAVELLE S ~~~f~7~
BUildjn9~ to Dralnfield ' e.. rt I 'l." T~h ~p.th I;> I' 'Width:1 J. "
Well(s) setliaek 50' or 1QO' SJ'V notlnsfall!ld Trem;hlEirlgths ' ~ l( .<;r-7r.
LakelCreek!Wetland ' , Tt.llI.1~ B~ Level ~ no
Property Line(s) " I rr J'- ,Trlth~ ;~!lj;ling , '- 'I +n ~. r l:-
. ,'" ", .1\ Dr.llIf~d~~low Pi"e ' '" I
SEPTICIHOLOING T AN~S) tti New 0 I':xlstlng., or $)~e 9feraYitlless Plp~
liquid Capacity , I rut) - ~ ~ Actual t.Ex ectad l;lepth I;tBackfill 0 I!
Tank Manufacturer '-, "j;I , 'AbBorption,: SquerelIteel ,$p,-,.-- f-r c.
aaffleType: Plastic Flberg'Iap saMi.tary-T"c~. ,Ie ,. ..;~ Llhealff'ei! H/r- I.', H-
No. of Inspection PIpe!; 7 '\{ 4./j! IItm, '.; , .
No. & DUIIl'i , of Manholtl AccellS 'l- Y 7," r . ' IIIIJMP IN'$;: ;' ,.' ,
No, & HelghtQf Manholel'tisers "2.... t..,r h- \O~L.iqU",ld. C a"' Il)q/~'" , .
Tank M4r\, cturer. l'. t' IfiJllf t eldsting
NO, & H'~Jg of Risers ; r:... I "
% Pumj1l ~nff. & Mooel Nl>, (? 0 p ( U M' II) c G
~lde HorsepowEif v 1- ' GPM "L!,' .
,Felli of H~ ! /, ' installed or as per tlesign
Cyeles Perpay .'{ -' :1< Installed or as per Qeslgn
iSallqns Pet Cycle , fJ (/ ins\a!lled or as. per c1eslgn
$~.of Oi' !'ge Line . ' '" ...u: ra:;,
'type of E . rieal Hooku~ ' p~nr~nk
AJlrltl 1.0 ' '\llerage;; ~~.m"!!i
Alarm:, A !'Leve'Alarm t OthElr< .
eyel" Co. er & Waler ~e/' (Commercial)
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A4'TERN~t.lve t exPJ;f\IMENTAL SYSTEM:
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Inspector c','omm ents :DhId all surlaell mr .ailf:oWwm orar.o L1'~d~~' I. d a~..SdcIl 011 seed as sarin as ~lb".,
',"" ',:'",._ ,,",-,_..,,"i. ""'_ ,:,', :,;$,;_,," "". ",~~:",,; ,.~.' -,"",', :..,~,_, -:. :. 'l" ' ~"_'
top""""'" 5c1l1".r.o&lon. " .'" .' " , .
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there!))< cwtlly Ihst~"ed OIllhl$ln$peeUOn "J h~~'e;erlIlY'''I''''lnllall'', ~I tie ~Q 1an~'OP<llll"'$ Wilt. Of will be tonstrut/ied 10 ~,
an<! the I~ $\lbn\r~!Id by thUll., ~~ 1IIle!, "!IlIst. Jn$l*lIIonPl~iri;f. eoce$8lO th_ malllle"'mee holt. InelUliil!lg rI..-s.
eva!iJa\Qf~r, lhe IndMdllaI S8W8llJl ~ . (l~r"lnltJaI.) . , ., '
11_8(1\ SlIS/lIInOll~tobe"ln eam~QeI '. . ' '.;, "",
t~he~ _',t~:O'!d=:':~4' = ::'{:':~I=:~nderfta$th~f~':~~~~7t:;s: ~~i::~~~~t.~:E:$'
" ), lIndC!\8~.;lltel~Yb.jneutred.j)y.~4: i>f.y~re 0' to8l'l<<eom1iy"'wtth
1~ nll1's~sSlgnal\Jre the provlelou cflhl$ Ordinance, '1 ,,_ ~ /"../. I' ~>(-"
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FINAL COYB\ tn$lleetor ' , . 1 ~ inaia!re,. Slonetu..e; "" '
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This $y!l.temls 0 In compliance 0 n~ In 1l000plllll'lI;Je withlhe~tt C~nty lndlvldualfCommunity Stwage Treajment
g)-stem Ordinance No, 4, therefore, this QQlll,lmimt Is Il 0 Certlflc.Ut of ei>mpllance Cl Notice of Noncompllarlce.
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WhIle. ColJiIty Yellow .,OW~er Pink -!""!ailer