HomeMy WebLinkAboutISTS Permit
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SCOTT OUNTY, MINNESOTA
APPLICATION FOR INDIVIDUA SEWAGE TREATMENT SYSTEM (ISTS) PERMIT
(Note to Appl~nt: only fill out the are,ll.in box belyJ
Twp/City (. \-4t o(~, ."-V- t""l::.c..:._ Date Received -1/1: IS
Project Addres~ J -1:J~ S ' ~ju vI i'~ / V '" Permit # e:lf, -/1 - t:R~,-
City/Zip -/1, iY Lc, 1:...-,. " Receipt # . a'7 'fr I
Site Evaluator fuVt1V1ru) 'Installer (//,...,/;rrc, Fee ,fbr. 6) .
Septic Tank Size as per design submitted arid approved I Sb<) - k r7 Receipt Code ;-U.3-
Pump Tank Size as per design submitted and approved -~t /-:"",./ A'ru s-_ A~_4 New~TS. Replacement 'X
Drainfield Size as per design submitted and approved (beloW) Percolation Rat~ I( /3,. /1 /
j Number of Potential Bedroom' ,-:S
1l!:J 'X<;/o '~~/.f,e ' .;2d 'X ~5-' S,..."Ii...re/,...Itr_jl-b.... Depth to Restricting Layer .;>y"
APPlic~t (___~ D
Applicant Mail Address
Owner (if different)
Owner Mail Address
Parcel Number
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A~~CANT FILL OUT INFORMATION IN THIS BOX ONLY
~.Q\.., Phone (H) - (WiiV7.o5-:;;-;::>
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I -.;.. 7! ~/' .... . -: L- City / ,. v-state_ Zip 5'"' -.; "' ."L
17.a,,;, ,/ /..() /q..... LA Jl. Phone (H) (W)
.~ ) ~) ~ 1 Jl1d(lJ..... Li<2W' City 171- Sta~ZipCS-::;: '7 :J
Sect_ Subdivision Name (if applicable) Lot # _ Block #
Soil tests and a design of the ISTS meeting Minn. Chapter 7080 standards must accompany this application.
Applicant hereby agrees that, upon issuance of this permit. all work shall be done and all 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 a.79>f th y t e ins t~n is requested.
Applicant Signature Y PL.. " , .', Date 7//".p/Q-r-
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Recommend Approval
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TOWNSHIP OR CITY USE ONLY ----------------------------------------------
Recommend Disapproval
and Permit ~~lies with the Wetland Conservation Act
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Signature of Township or City Clerk (or representative)
Date
------------------------------------------------------ COUNTY USE ONL Y:,.-~----------------------------------------------------
ISTS Setbacks: Building: (tanks)...f.L. (drainfield) ~d Lake/Creek/Wetland~ Wells .sa . +10' to Lot Line or ROW/Easement.
Ar r' _ " .ll X Denieil
By Scott County Environmental Health, subject to existing regnlations and the following conditious:
1. Verify and maintain all required setbacks ~d elevations.
2. Protect (fence oft) the primary aud 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 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, y Z. '.'
6. Sod or seed the area as soon as possible upon completion to prevent soil erosion and damage to the drainfieId (foJ?l:de season
installations, My 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 used, an electrical event counter.
Signature
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~~te - County Yellow - Township Pink - Applicant
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Form #1121
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SCOTT COUNTY
INDIVIDUAL SEWAGE TREATMENT SYSTEM INSPECTION FORM
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CitylTwp. fl,,,,"
Owner
Project Address
City
LGf",
Inspection Dates
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SETBACKS:
Buildings to Tank If')
Buildings to Drainfield ,<,-.2'
Well(s) setback 50' or 100' --t:.o'.;
Distance to Lake Creek
Property Line(s) /7'
SEPTIC/HOLDING TANK(S) IKNew 0 Existing
Liquid Capacity /,.,,.,,., .r t'SGe' JC ;;;;'e/4ru
Tank Manufacturer /Z /'
Baffle Type: Plastic Fiberglass Sanitary-T Concrete
No. of Inspection Pipes 3 4" /Cu - m~tD,
No. & Diam. of Manhole Access _, ".2y" 3x li::
No. & Height of Manhole Risers I x.:?o/''' 3x;;,-,,"
Connections:
not installed
Wetland -
MOUND OR ATGRADE:
Percent Slope 7?f %
Dike Width ? up 8 down .2..., side
Drainfield Rack Below Pipe 9"# inches
Inches of Sand Below Rock ..L..t..upslope~downslope
Perforation Size & Spacing. Y.,; :? '
Pipe Size and Spacina 1"2 '"I'd v
Dimensions of Rock Bed /6 ')("/'o '
Dimensions of Sand Base ,21' Y ~.,s-'
Depth of Final Cover I If "7;,1 12" J /<"~J
ALTERNATE SITE AVAILABLE
ENV HL TH APPROVED DESIGN ON SITE
_ See Notes added to Design Drawing or
_ Drawing of Syst -,m Belo N Well
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7/.< jZ/o.s.-/ 7b9 Permit No. ii'G .-:f-..;S-
Installed for (~~edrm or@pd)" Business/lndlv
Designer _I'J../V: 6.,:,.. Installer _kl.......:...:-r-
o NEW 0 REPLACE 0 REPAIR O'ADDfTION
~ENCHES, BED OR GRAVELLESS LEACHFIELD:
Dr~x concrete / plastic
Trench Depth.... Width
Trench Lengths ......___
Trench Bottom Level
Trench Spacina
Drainfield Rock Below Pipe
or Size of Gravelless Pipe
Actual/ Expected Depth of Backfill
Absorption Area: Square Feet
Lineal Feet
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yes / no
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PUMP INFO:
Liquid Capacity ,~~ ~ I .$. i,./,. ~p /Sdo-:Ie..
Tank Manufacturer - .:J 4,0 ""!JJ!I>/ existing
No. & Height of Risers , t!f 7y"
Pump Manuf. & M.adel No. ~'/c
Horsepower h GPM ,,29.1"'...._
Feet of Head 1>'/' illll'T]jllf'd or as bar deSlglf-,
Cycles Per Day ~ or e< oer d~
Gallons Per Cycle ~nr a~- per ~
Size of Discharge Line 1.5" /(2
Type of Electrical Hookup post & box by tank
Alarm Location qarage / basement
Alarm:Q;l!ITll<Alert aevel Alarm / Other
Cycle Caunier & Water Meter (Commercial)
Alternative / Experimental System / Pretreatment:
Type
Pretreatment Alarm
N
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~.k tb"
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Inspector ::omment '.; tOD of at tanks must be installe~ 4 feet or less below final arade 'unless exe~Dted bv
InsDectorl. Divert !...llice ,,,",,,,, ~Wa\' from or around dralnfield area. Sod or seed ASAP to Drevent sOil erosion.
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
Individuall munlty Sewage Treatment System Ordinance NO.4,
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Installation ~-Signature .
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FINAL COVER Inspecta
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1 hereby ce 'N, as the ifist~r, ~. t the Individual sewage tre alment system
was or wi! e 'nstalled in ae r I~ce with the Scott County Individual!
Commun' Sage Treatm n ~ystem Ordinance No.;- 1.'JWerstand and
accept t e find ngs by the! p d 0 comply with all requirements
to finish or c~._ eet the 1ST 1 I tI n s written on this inspection report.
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I " tafr's signature \J
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This system is;gHn compliance 0 not in complian~ith the Scott County Individual/Community Sewage Treatment
System Ordinance No.4, therefore, this document is a?J Certificate of Compliance 0 Notice of Noncompliance.
White - County
Yellow - Owner
Pink - Installer
Form'1122