HomeMy WebLinkAboutISTS PERMIT 28-B-25
~ SCOTT COUNTY, MINNESOTA
APPLICATION FOR INDIVIDUAL SEWAGE TREATMENT SYSTEM (ISTS) PERMIT
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(Note to Applicant: only fill out the area in box below)
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Project Address Ii )fC f - ~'l.... '.).'
City/Zip .r'; i." (.. k,_ 1-'..; '?,] -,
Site Evaluator Installer
Septic Tank Size as per design submitted and approved I 5(:) 0
Pump Tank Size as per design submitted and approved / y, ':;>( )
Drainfield Size as per design submitted and approved (below)
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Date Received Y. /(;
Permit #I-~; ~ I> ;1 ':;
Receipt #~4 y..." '-I
Fee {();2C'- C'(_)
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Receipt Code '>0.:./
New ISTS_ Replacement 'I
Percolation Rates :? -; I ;:y. 7,3. ~
Number of Potential Bedrooms I '-I
Depth to Restricting Layer I!PIII
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APPLICANT FILL OUT INFORMATION IN THIS BOX ONLY
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Applicant ....j ,c. ( /.''1 /"::-:' ! i (1 /(.j' "/ .,.J
Applicant Mail Address / /0 ~ c) /Yi (? (I &, [/';'. ..,/-€-'
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Phone (H)/:';;~ lit/I- (, 715 (w)'?5.) L/t,/j""cJj3 "
City tf;:/p /~/r;,~ State,M,v Zip 5' 5 ~ 7 A-
Owner (if different)
Owner Mail Address
Phone (H)
City
Sect_ Subdivision Name (if applicable)
(W)
State_ Zip
Parcel Number
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 install~ion by 9:00 a.m. of the day the-mspection is requested.
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Applicant Signature \'.,,;/,:I>n-1.--<::1 /./ ,'/ ""~ .c..,..- Date '"II /0/', 7
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TOWNSIIIJ> OFt CIT1r USE ON~1r ----------------------------------------------
Recommend Approval
Recommend Disapproval
and Permit complies with the Wetland Conservation Act
Signature of Township or City Clerk (or representative)
Date
------------------------------------------------------ COUNT1r USE ONLY -------------------------------------------------------
ISTS Setbacks: )3uilding: (tanks)~ (drainfield)~ Lake/Creek/Wetland-=-- Wells So :10' to Lot Line or ROW/Easement.
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Approved~ Denied_ By Scott County Environmental Health, subject to existing regulations and the following conditions:
(i)rerify 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 installation.
3. Install rock bed on contour and maintain at least 36 inches between the rock bec:l and the water table/mottling.
4. Protect sewer lines and system from freezing. . -J
5. Divert surface water away from or around the drainfield area~ I I
6. Sod or seed the area as soon as possible upon completion to prevent soil erosion aJ1(ldamage to the drainfield (for late season
installations, hay or straw c~n be substituJed unfil sodd~~g or ~ding can be done in the spring).
7. This permit is valid for 12 .honths~trOIfl t~aat'e iss~([ / . "
8. The property owner (or aP.Plican~ if ~ttfiren~ f!,'(llUi~ property owner) is responsible for assuring that the Installer receives a
copy of the final D~partm~IltJlPP'toVert design. ,I
9. Nonresidential ISTS shall include a water meter and, if a dosing device is used, an elecJr~vent counter.
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White. County
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Yellow. Township
Date
Pink. Applicant
S/ /p" //0 7-
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Signature
Form #1121
SCOTT COUNTY
SEWAGE TREATMENT SYSTEM INSPECTION FORM
~//..y/o "7 /:s-/ /'?/o 7' Permit No. ;;>~4'''< J-:-
Installed for (#Bedrm or ~pd) ~ Busines~/Indiv
Designer M. crJ..s.,~ Installer -1!!!f6MI ~_
D NEW ~EPL. ACE D REPAIR D ADDITION t:..I.
.~~ .liiIt 4,. ~/,feJ.,A:Jo.-/~. ~
~~ GRM'E~......~~ LEACHFIEL~'
Drop box -. concrete / plastic
Trench Depth "'/8'" Width /;;?'
Trench Lengths ~';1 ;'
Trench Bottom Level ,/'
Trench Spacing
Drainfield Rock Below Pipe ~ ,..
or Size of Gravelless Pipe
Actual / ~d Depth of Backfill ~ "f.zP'
Absorption Area: Square Feet ~ ..".. e rr-
Lineal Feet
I).' 7< ~J( I ;;Z 50
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SETBACKS:
Buildings to Tank
Buildings to Drainfield OZt;,. ,
Well(s) setback 50' or 100' .> St;::J , not installed
Distance to Lake Creek Wetland
Property Line(s) Ie) /
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SEPTIC/HOLDING TANK(S) ~ew
Liquid Capacity t SC'o--...<c
Tank Manufacturer <ire'
Baffle Type:~ Fiberglass Sanitary-T Concrete
No. of Inspection Pipes 3 ,K4"~'
No. & Diam, of Manhole Access .7 ,x;< q'
No. & Height of Manl).ole Risers ;;l. Xr20 ('
Connections: ,./
o Existing
MOUND OR A TGRADE:
Percent Slope ..-- %
Dike Width - up down side
Drainfield Rock Below Pipe t, tl inches
Inches of Sand Below Rock ~upslope-=-downslope
Perforation Size & Spacing jr',;3.< .3 '
Pipe Size and Spacing IJf~' .;?-V'
Dimensions of Rock Bed h:Z t X'.y-;l"
Dimensions of Sand Base -
Depth of Final Cover
ALTERNATE SITE AVAILABLE
ENV HL TH APPROVED DESIGN ONSITE
_ See Notes added to Design Drawing or
_ Drawing of System Below
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PUMP INFO:
Liquid Capacity
Tank Manufacturer dA
No. & Height of Risers I X ;lo II
~~~~~~ne~f. & Mj?;1 No. ~:t~ .~~
Feet of Head insta
Cycles Per Day
Gallons Per Cycle
Size of Discharge Line
Type of Electrical Hookup
Alarm Lo g rag
Alar . Tank Alert Level Alarm / Other
Cycle Coun er & Water Meter (Commercial)
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WIW/ existing
d r as
lied or as
Alternative / Experimental System / Pretreatment:
Type
Pretreatment Alarm
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Inspector Comments: The top of all tanks must be installed 4 feet or less below final qrade (unless exempted bv
Inspector). Divert surface water away from or around drainfield area. Sod or seed ASAP to prevent soil erosion.
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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
Individu ommunity Sewage Tre System Ordinance NO.4.
I hereby certify, as the installer, that the individual sewage treatment system
was or will be installed in accordance with the Scott County Individual /
Community Sewage Treatment ystem dinance NO.4. I understand and
accept the findin b e in or nd gree to comply with all requirements
to I' 0 tel S lIa n written on this inspection report.
This system is ~compliance 0 not in compliance with the Scott County Individual/Community Sewage Treatment
System Ordinance No.4, therefore, this document is ~.eertificate of Compliance 0 Notice of Noncompliance.