HomeMy WebLinkAboutISTS Permit
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" "". I . SCOTT COUNTY, MINNESOTA
APPLICATION FOR INDIVIDUAL SEWAGE TREATMENT SYSTEM PERMIT
-----,,;:r----------- COUNTY USE ONLY ----------------
,
",/VI Date Received C;" :;? C. 9",_
Twp/City SI!~JttJ(, LI4K..G Permit number ~ <..;. ~11'/.3-//
Project~ddressl I -t'~,r-~ 4:.PI9' C:IIli:C~~ Receipt.Jjll.lmber I", {W
City r~/(J~ t.l!/J(E",. Zip 5S.37Z- Fee q' .3ol'
Percolation Rates F~ 6~ 3 Depth to Restricting Layer '7'2 ~
Minimum ~'1!l'1 ~ '1000 gallon septic tank No, Potential Bedrooms .3
Recommend i 500 -'2 <- oallon septic tank Garbage disposal yes" no ~
/ tx:?O gallon pump tank New Repair X
Drainfield Requirement: Minimum I~~E gEl); /2" X 5""0 I
Recommended
54mc
K I "J" PER.~
Site Evaluator
5~/EK'~
On-site System Installer
- - - - - - - - - - - APPLICANT FILL OUT INFORMATION BELOW - - - - - - - - - --
ownerV?n~rro/ [lye, t,Ot\fUIJ Phone (Home) ryvork) <ltj)- t-J7/!J
Address I 7 I 7 -3 ::L oIf.
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City ,n ;. I D J t /1 k
State 4h!- Zip c:, :.:,-2, 1l
'project Legal Desc,
Parcel number
See
Lot
Block
Subdivision Name
'. A design of the Sewage Treatment system must accompany this application. Please contact the Environmental Health Office
for a complete list of items required for permit approval.
Applicant hereby agrees that, upon issuance of this permit, all work shall be done and all materials used shall be in
compliance with any ~,~able tOW~Ship~ty, and coun~dina,nces.
APplic:nt Signature 7//~~,1-, llJ, /t:~_____ ~ Date 0/ d t) 1 {,
- - - - - - - - - - - - - - TOWNSHIP OR CITY USE ONLY - - - - - - - - - - - - --
Are@'re any wetlands on property? _Yes _No Will any wetlands be impacted by proposed project? Yes No
Wetland Replacement Plan attached? _Yes ~No LGU Exemption # Please attach copy of exemption.
Recommend: Approval Disapproval
Signature of TownshiJ;l or City Clerk Date
Setbacks-:- BUild'n~s ZCJr- -Road/? RAttfOL~~~sUS~gflll Y ~.iFreek/Wetland IS U"-Wells- ,c;-tJ T
Approved X Denied _ By Scott County Environ']?ental Health, su ject to exi~ting regulations and t~e following
conditions: 1:'1/57/"'1, 1/1,111;::5 Mtl6T &:: rG(""~ 1- SX/lI11N)5/) To t/ERIFY IP:
Us.elJ~ - IF eXI5Tlvfr. TANI'S /f.e'c l)ET~"'IIUb.7;) tl/f..Jt(Se?1~ l/1,cy
MUt7; f,c Colll1~ If r///t;D ~ AJc'-<J T/ltfJ<S 1A)"37/f14t;t> ~ ()~7)I#J'/~a;;--
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SignatureC~~ /. Date i-2LJ-rft:, .
White - County Yellow - Township Pink - Applicant Gold - Township
01670-2818(9-94 5C)