HomeMy WebLinkAboutSEPTIC TANK REPLACEMENT 1
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y � # � SCOTT COUNTY, MINNESOTA _., � � �.� � --�� � ° (__ � ` � � �� '� `�
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APPLICATION FOR INDIVIDUAL SEWAGE TREATMENT SYSTEM (ISTS) PERMIT �
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(Note to Applicant: only fill out the area in box below) }�'`� °' �� L ���� �' ��� ��
Twp/City t ' `- Date Received � ' � ���' ` � C-
Project Address � �; ��I c.,. r...t c � -i � , < <'� � ,� '� -+- }= � Pernut # ' 1-� l� t U �:, 7 `� i � l
City/Zip � - ° � � � � � � � � _ Receipt # � Z � �
Site Evaluator Installer Fee �� L- �.� , t��_)
Septic Tank Size as per design submitted and approved .��� � i Receipt Code
Pump Tank Size as per design submitted and approved New ISTS Replacement v
Drainfield Size as per design submitted and approved (below) Percolation Rates 1 .
Number of Potential Bedrooms T�
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Depth to Restricting Layer
� APPLICANT FILL OUT INFORMA THIS BOX ONLY � a-tv •,.► e�
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Applicant V • G /���Cc IS �11� .,� lr �E� Phone (H) �„�� "�- / (W) o� �
Applicant Mail Address / U 7 � 1 `�l �l` 7 i n �k � s '�" ��• � , Ciry �"�` � d P � �tate � � � Zip �� 7.� "
Owner (if different) Phone (H) (W)
Owner Mail Address Ciry State Zip
Parcel Number a1�N "" C) 7'� d� �'Sect Subdivision Name (if applicable) Lot # Block #
Soil tests and a design of the ISTS meeting Minn. Chapter 7080 standards must accompany this application.
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Applicant hereby agrees that, upon issuance of this permit, a11 work shall be done and a11 materials used shall be in compliance with State Rules
and any applicable township, city, and county ordinances. The applicant must also ensure that the Scott County Environmental Health Dept. is
notified of any ISTS installation by 9:00 .. of ay the inspection is requested.
Applicant Signature r� Date ? l t� "�[�
--------------------------------------------- TOWNSHIP OR CITY USE ONLY ----------------------------------------------
Recommend Approval Recommend Disapproval and Pernut complies with the Wetland Conservation Act '
5ignature of Township or City Clerk (or representative) Date
------------------------------------------------------ COUNTY USE ONLY -------------------------------------------------------
ISTS Setbacks: Building: (tanks)� (drainfield) I:ake/Creek/Wetland Wells� +10' to Lot Line or ROW/Easement.
Approved� Denied By Scott County Environmental Health, subject to ea�sting regulations and the following conditions:
1. Verify and mau►tain all required setbacks and elevations. ,
2. Protect (fence oft� the primary and alternate drain�eld locations while any building construction activity is cecurring on the
site and maintain fencing or some other approved barrier if the drainfield could be �damaged after installation. .�
3. Install rcek 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 surfaee 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 of the final Department approved design.
9. Nonresidential ISTS shall include a water meter and, if a dosing device is us d, an electrical event counter.
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Signature _ — Cl Date �/'— �l�"/d
White - County Yellow - Township Pink - Applicant F°""#»2'
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' SCOTT COUNTY ,��'�:.. r .:>; �* , � � �� 4 � ';� ' , ;", �
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SUBSURFACE SEWAGE TREATMENT SYSTEM IIVSPECTION FORM . �;
City/Twp. i.���� 4_ i�' Inspection Dates _£ F�.,=� �� ��_,� / Perm,it No. j,'� a�,-1.� '°� ��:;]
Owner � �i� � Installed for_(#Bedrm or gpd) �;� Business/Indiv
Project Ac�dress '-d ,�' `�;� i'� ; � �,; ti:t r- �-t, ,, a : r t , � Designer : �� °, - s .�' y .' � ' ' ,
� .,-� Installer .� :,�:!1_�.:. ��;,�; �:� ,.,:, , ,
C�tY !"��� � E �`' •� : ❑ NEW � REPLACE ❑ REPAIR ❑ ADDITION -'
SETBACKS: TRENCHES, BEI�OR GRAVELLESS LEACHFIELD:
Buildings to Tank l�f Drop box �`�� conc�ete / plastic
Buildings to Drainfield Trench Depth , Width
Well(s) setback 50' or 100' not installed Trench Lengths '�
Distance to Lake Creek Wetland Trench Bottom Level _ Yes � No
Property Line(s) Trench Spacing
Drainfield Rock Below Pipe
SEPTIC/HOLDiNG TANK(S): New ❑ Existing or Size of Gravelless Pipe
Liquid Capacity ��r';,c a� �� G3 A,� �•��> _� Actual / Expected Depth of Bac I
Tank Manufacturer ,�r n�� -�- �'C�a� � Absorption Area: Square Feet
Baffle Type: i pl��'i'��"berglass Sanitary-T Concrete Lineal Feet
Ido. of Inspection Pipes �--�- 4" / 6" diam.
No. & Height of Manhole Risers��� "'�� �`f. ��. PUMP INFQ
Top of Tank insulated if �2 ft.: Y� ffluE ent Filter: Y/�l► Liquid Capa�it�
Connections: ���, Tank Manufact er new / exis'ting
No. 8� Height of�i�ers �
MOUND OR AT,�RADE: Pump Manuf. & Mo I No.
Percent Slope `- % Horsepower GPM
Dike Width t� down side Feet of Head � installed or as per design
Drainfield Rock Below '� inches Cycles Per Day d Installed or as per design
Inches of Sand Below Ro�1�, upslope downslope Galfons Per Cycle lnstalled or as per design
Perforation Size & Spacing �°�, Size of Discharge Line 1.5" / 2"
K Pipe Size and Spacing "�, Type of Electrical Hookup � post & box by tank
Dimensions of Rock Bed Alarm Location garaga / basement
Dimensions of Sand Base . Alarm: Tank Alert / Level Alarm / Other
Water Meter: Yes / No Cycle Counter: Yes / No
Depth of Final Cover
Manhole/Risers to Surface: Yes / No Registered Product Name
System Type: II 111 IV V Alarm: Yes / No
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� Notes / Corrective Action Required: Divert surfac,e water around drainfield. Sod or seed ASAP to,_,prevent soil erosion. `
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I hereby certify that based on this inspection and the information I hereby certify, as the installer, that the subsurface sewage treatment system
submitted by the site evaluator/designer, the subsurface sewage was or will be installed in accordance with the Scott County Subsurface
treatment system appears to be in compliance with the Scott County Sewage Treatment System (SSTS) Ordinance No. 4. I understand and
Subsurface5ewag� •Treatmgrtt Sys�em Ordinance No. 4. accept the fln¢ings by the inspector and a e to comply with all requirements
' to finish or co ct the SSTS �ns as ritten on this inspection report..
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Installation InspectoPs Signature �' � ��
� Installer's Sig ture
FINAL COVER Ins ctor "'� °
This system is M1 in compliance ❑ not in compliance with the Scott County SubsurFace Sewage Treatment System
Ordinance No. , therefore, this document is a� Certi�cate of Compliance ❑ Notice of Noncompliance.
White - County Yellow - Owner Pink — Instalter �����