A. GENERAL PROPERTY INFORMATION. Applicant s name Day Phone Installer Name Send permit to installer. B. PROPERTY DESCRIPTION

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1 Lake County Planning & Zoning 601 Third Avenue Two Harbors, MN (218) LAKE COUNTY SUBSURFACE SEWAGE TREATMENT SYSTEM APPLICATION INCLUDE FEE WITH APPLICATION New Septic System: $200 Tank replacement Only: $75 Non-commercial Septic System Repair or Expansion: $75 Commercial/Cluster System: $500 Commercial Septic System Repair: $250 After the Fact Fee: $800 INCOMPLETE APPLICATIONS WILL BE RETURNED! A. GENERAL PROPERTY INFORMATION Permit # Assessor Inspector: Fogelberg Runnberg Note to Installers: A 24 hr. septic inspection notice is required. Electrical Inspector: Richard Rue Bruce Bonicatto Applicant s name Day Phone Installer Name Send permit to installer. Complete Mailing Address Property Address (if other than mailing) Installer Address Phone Number B. PROPERTY DESCRIPTION Section Township Range Township Name Acreage Parcel Code # (REQUIRED) Quarter Section/Legal Description Lake/River Name Nearest Road Access Lot Dimensions Existing Land Use Width ft. ft. Property Land Features Non-shoreland North Shore Management Zone Wetland Present Shoreland/Shoreland Zone (within 1000 of lake or 300 of river) Lake Superior Erosion Hazard Area Bluff Present Lake/River frontage: feet of frontage C. SINGLE FAMILY RESIDENTIAL or COMMERCIAL/CLUSTER SYSTEM Please Specify: New System Holding Tank Only Repair of Existing System (Repair of SP# ) Expansion of Existing System (Expansion of SP# ) Commercial/Cluster System Water Use - Classification: Type I Other (specify & justify) System designed for # bedrooms # of bathrooms served by system #/Type Water Using Devises GPD Garbage Disposal? Yes No Sump Pump Yes No Foundation drain separate from system? Yes No Well Information: MN Unique Well # (if known) Well Casing Length Septic Tanks: (Sizing Calculations MUST be submitted) NUMBER OF NEW TANKS TO BE INSTALLED (DESCRIBE BELOW) Tank Liquid Pump Chamber Pump Alarm Size Capacity Capacity Size (Y/N) DESCRIBE EXISTING TANKS Tank Liquid Pump Chamber Pump Alarm Size Capacity Capacity Size (Y/N) NEW TOTAL # OF TANKS ON SITE: (# SHOULD INCLUDE NEW TANKS INSTALLED)

2 DRAINFIELD DESIGN (ALL SYSTEMS) Method used to determine type of system: Excavation Soil Evaluation Perc Test Designer License # (if other than installer) Treatment System (Calculations MUST be submitted) Trench Circle one: Drop Box Pressurized Distribution Box Other System Dimensions: Total trench length # of trenches Ind. Trench length Trench Width Area between trenches of trench of rock Trench rock cover material Dept of Cover Soil Diameter of pipe Diameter of emitter holes Distance between holes Mound Circle one: Gravity Pressurized At Grade system Other System Dimensions: Rock Bed length Rock Bed width Drainfield Cover Type Base length Base width Downslope width holes Total length of pipe Diameter of pipe Diameter of emitter of sand layer: inches Type of Sand: (Circle one) Washed Pit Run Accessories Sand filter Peat Filter Water Meter Other Experimental System Yes No If yes, Type of Experimental System: Experimental system release form signed Yes No (All applicants, fill out sketch plan on attached) As property owner, I declare I have reviewed the above application and declare the information provided to be correct. I further understand my responsibility to minimize water use and to have the septic tank(s) inspected and normally cleaned at lease once every three years to minimize the solids accumulation (retaining proper receipts is suggested.) SIGNATURE OF OWNER DATE As designing/installing contractor, I declare that all materials, design, construction and workmanship will be supplied in accordance with Minnesota Rules Chapter 7080 and the Standards adopted by Lake County. The permit placard must be posted at the work site during construction. IF any modification is proposed, approval of Lake County Land Use Office shall be obtained before initiation. I shall notify the Lake County Land Use office one work day preceding the day inspection/s are desired, providing the permit number and directions to the site. SIGNATURE OF DESIGNER* PHONE NUMBER DESIGNER LICENSE # DATE SIGNATURE OF INSTALLER *(REQUIRED if different than designer) INSTALLER LICENSE # DATE OFFICE USE ONLY Permit # Issued by: Receipt # Date of issue: Fee Paid: SS Owner s Guide Given REMARKS: THIS PERMIT EXPIRES ONE YEAR AFTER DATE OF ISSUE

3 As-built must be submitted to inspector prior to completion of final inspection. Application is incomplete without adequate, signed sketch plan. Sketching Form Permit #: The purpose of the sketch is to graphically illustrate the information included in your application. Please include the dimensions of all structures, present and proposed, well, septic systems, and distances to property lines, roadways, lakes, rivers and streams. The following items must be included and listed in the boxes below: Location of Location of Distance to Name of wetlands areas of vegetation removal and grading road centerline abutting property owners driveway property lines (size and shape of parcel) shoreline or rear yard adjacent roads access road (labeled) well/septic system & expansion side property lines all other structures (yours and neighbors) well, septic & drain fields I certify that the separation distances on this sketch plan are to the best of my knowledge true and correct. Signature of Designer** Print Name of Designer Date Signature of Installer** (REQUIRED if different than designer) Print Name of Installer Date Signature of Property Owner Print Name of Property Owner Date

4 Sketching Form (Sample Sketch) The purpose of the sketch is to graphically illustrate the information included in your application. I certify that the separation distances on this sketch plan are to the best of my knowledge true and correct. The following items must be included: (See example sketch on back) Location of: Distance to: Signature of Applicant JOHN DOE Print Name of Applicant wells/septic system & expansion road centerline (yours and neighbors) shoreline or rear yard North arrow side property lines driveway well, septic & drainfield access road (labeled) areas of vegetation removal & grading property lines (size and shape of parcel A:\septic ISTSapp.wpd Disk 5 November 2000

5 LAKE COUNTY SITE / SOIL EVALUATION FORM Property Owner Date Property address or location Parcel # Section Township Range Lot Check all that apply: Shoreland Dwelling New Existing Food, Beverage, Lodging est. Administrative Subdivision Evaluation Plat Evaluation For Administrative Subdivision or Plat, complete a Site/Soil Evaluation Form for each lot. Lot # / parcel this evaluation applies to: GENERAL SITE INFORMATION Soils disturbed or compacted? Vegetation Type (select one): Wet Dry Unknown Type of observation: Probe Pit Boring Drainage (select one): Good Fair Poor Ponding Flooding Slope: % Slope Form: Drainage solutions or? Well casing depth (from well log): Benchmark location: CONCLUSIONS FROM SOIL EVALUATION to standing water: inches to saturated soil or mottling: inches to Bedrock: inches Maximum depth to bottom of system (trenches): inches Soil sizing factor (SSF): gpd/ft² Minimum fill under rock cell (mound/at-grade): inches Linear loading rate (LLR): gpd/ft Site is suitable for: Trench Bed Mound At-Grade Other Boring 1 SOIL BORING LOGS Boring 2 I hereby certify that I have completed this work in accordance with applicable ordinances, rules and laws. Name of Evaluator PCA License # Signature Date

6 SOIL BORING LOGS Boring 3 Boring 4 Boring 5 Texture Color Structure Consistence Redoximorphic Texture: (sand, sandy loam, silt, clay, etc) Colors: from Munsell soil book Structure: (granular, platy, blocky, prismatic, single grain) and is it (weak, moderate, strong) Consistence: (loose, friable, firm, very firm) I hereby certify that I have completed this work in accordance with applicable ordinances, rules and laws. Name of Evaluator PCA License # Signature Date