Name: Address: City/State Phone: *Please include the Commercial/Industrial/Other Establishment Sheet with permit

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1 DODGE COUNTY SEPTIC SYSTEM PERMIT APPLICATION 721 Main St N, Dept.123, Mantorville, MN Phone: PERMIT # Date Rec d Amt Rec d OFFICE USE ONLY: Installer Sheet Design Sheet Homeowner Signature MPCA Design Forms Applicable Fees Com/Ind Sheet CONTACT INFORMATION Property Owner: Date: Site Address: Phone: Mailing Address: Parcel ID#: Subdivision: Lot: Block: INSTALLER Name: Address: City/State Phone: Septic Type: New Construction Replacement Tank(s) Only Holding Tank Standard System: Trenches Bed At-Grade Mound Other; Seeding / Sod to be done by: Homeowner Installer Yes No System will be constructed according to the approved septic system design created by a MPCA Certified Designer. If the property is located within the city of Mantorville; City needs to sign off on permit City of Mantorville Permit Approval: Yes No Signature OWNER PROVIDED INFORMATION The Building Is: Proposed Existing Type(s) of Use: Residential Commercial* Other* *Please include the Commercial/Industrial/Other Establishment Sheet with permit Residential: Number of Bedrooms Basement Finished Yes No Home Extended Business (specify) Daycare (specify) Water Using Devices Garbage Disposal Dishwasher Large Bathtub/Jacuzzi (check all that apply) Water Softener Clothes Washer Hot Tub Daycare Sewage Ejector or Grinder Pump Property Lines: Determined & Approved by Property Owner Approximate Property Lines Surveyed & Staked (Check all that apply) Property Owner Signature I hereby certify that I have read this application and verify that all information is true and correct. Property Owners Printed Name Property Owners Signature Date Installer Signature I hereby certify with my signature as the installer, that the materials; including sand, rock, and soil, design of equipment, construction and workmanship will meet state and county code requirements to the best of my knowledge. I agree to indemnify and save Dodge County harmless from all losses, damages, costs and charges that may be incurred by the County because of my failure to conform to and comply with the provision of the Dodge County Septic and Wastewater Treatment Ordinance. Signature Date License# Expires_ Application Approved / / Approval Sent / / Application Denied / /

2 DODGE COUNTY SEPTIC PERMIT APPLICATION CONTINUED; DESIGN SHEET Property Owner: Address Site Evaluator: Phone # Property/Site Information: Proposed Drainfield area Roped or Flagged Soil Borings/Percolation holes Staked & Labeled Shore land Area Floodplain Flood Elevation Data Attached Proposed Septic System Meets All Setbacks Well Casing Depth: Well Info Source: Soils Information: Depth to Mottled Soil Depth to Bedrock Depth to Standing Water Recommended Drainfield Depth Average Perc Rate in Drainfield Area Required Attachments: Site Drawing for Designated & Alternative Drainfield Areas Soil Texture at Recommended Drainfield Depth Soil Structure at Recommended Drainfield Depth Soil Color (Hue/Value/Chroma) 3 Above Mottling Soil Sizing Factor at recommended Depth Percent Slope at Recommended Drainfield Area Percolation Test Results AND/OR Soil Observation Logs* *At least two soil borings are required for the designated area, one boring required for alternative Drainfield area. The most restrictive boring within the primary site must be verified by Dodge County before permit submittal. I hereby certify with my signature as the site evaluator, that all soil and setback data for this design are true and correct to the best of my knowledge. I agree to indemnify and save Dodge County harmless from all losses, damages, costs and charges that may be incurred by the County because of my failure to conform to and comply with the provision of the Dodge County Septic Ordinance Chapter 21 and MN Rules Chapter Signature License Number Date SEPTIC SYSTEM DESIGN Designer Name Phone# Required Attachments: Worksheets, Attach all Applicable Worksheets Mound / At-Grade / Trench / Bed Design Worksheets Pressure Distribution Worksheets Pump Size Calculations & Worksheet Pump Tank Worksheet Complete Site Map Signed Operating Permit Obtained from Dodge County Design Flow: Number of Bedrooms, Projected Daily Flow (gpd), Type of Home (I-IV), _Classification of Dwelling (I-IV) Yes No Garbage Disposal Existing/Proposed Yes No Ejector or Grinder Pump Existing/Proposed Yes No Effluent Screen Yes No Alarm Alarm Location: Tanks: (For holding tanks, fill out Holding Tank Sheet) # of Septic Tanks Volume of Each Tank,, Volume of Pump Tank Reserve Capacity Combo Tank Size Existing Tank: Volume COC on File Watertight Meets 7080 & Co. Ordinance Alternative System: Alternative System; (List Type of System) Drainfield; Trench Bed At-Grade Mound Treatment Level Penetration into Native Soil ; Type of Media Used ; Time Dosed Yes No I hereby certify with my signature as the designer, that all soil and setback data and design criteria for this design are true and correct to the best of my knowledge. I agree to indemnify and save Dodge County harmless from all losses, damages, costs and charges that may be incurred by the County because of my failure to conform to and comply with the provision of the Dodge County Septic Ordinance Chapter 21 and MN Rules Chapter Signature License Number Date

3 Date of Evaluation: SEPTIC SYSTEM SITE PLAN DRAWING REQUIRED INFORMATION: Designated and alternate drainfield areas All required setbacks as listed below Soil borings and perc test locations Percent and direction of slope Buried water pipes within 50 of proposed ISTS Location of all buildings Lakes, Rivers, Streams, Wetlands Lot dimensions & property lines identified Location of water wells, buried pipes, Location of all easements Type of vegetation at site Evidence of disturbed or compacted soil Yes No Setbacks (minimum distance identified in parentheses) this must be filled out by designer Building to tank (10 ft) Water line (10 ft) Building to drainfield (20 ft) Property boundary (10 ft) Type of Well (cased sandpoint dug ) Road right-of-way(s) 10 ft) Drainfield Absorption area to Well River or stream (75 ft) Well to tank (septic/holding/pump) 50 ft Well to buried sewer line (50 ft/20-50 ft air tested) Show access route for tank maintenance on diagram Please draw map to scale or dimension or attach another map of your choice N

4 DODGE COUNTY SEPTIC PERMIT APPLICATION CONTINUED; HOLDING TANK SHEET Property Owner: Parcel ID#: Designer Name: Property Owner Install Yes No Projected Daily Flow (gpd) Number of Septic Tanks, volume of Each Tank,. Is the Holding Tank for;(check all that apply) Dwelling (home) Shed Employees* Business* Other*;(specify) *property owner to fill out and sign Commercial/Industrial/Other Establishment Sheet Proposed Holding Tank Meets all Setbacks Yes No Site Map Attached Yes No Holding Tanks must have an alarm, the alarm must identify when the holding tank is at 75% capacity Holding tanks may require an operating permit and pumping agreement. I hereby certify with my signature as the designer, that all soil and setback data and design criteria for this design are true and correct to the best of my knowledge. I agree to indemnify and save Dodge County harmless from all losses, damages, costs and charges that may be incurred by the County because of my failure to conform to and comply with the provision of the Dodge County Septic Ordinance Chapter 21 and MN Rules Chapter Signature License # Date Property Owner Tank Install Property owner to sign below only if this Holding Tank will be installed by property owner I hereby certify with my signature as the property owner, that all information provided is true and correct to the best of my knowledge. I agree to indemnify and save Dodge County harmless from all losses, damages, costs and charges that may be incurred by the County because of my failure to conform to and comply with the provision of the Dodge County Septic Ordinance Chapter 21 and Minnesota Rules Chapter I agree to install the septic holding tank according to Minnesota Rules Chapter Property Owner Signature Date

5 Dodge County COMMERCIAL / INDUSTRIAL / OTHER ESTABLISHMENTS SHEET Building Information: The Building Is: Proposed Existing The Building Is Used For: Primary and Secondary soil dispersal (Drainfield) areas are to be secure using snow fence or caution tape prior to septic permit approval and are to be maintained until construction of the soil dispersal area. _Number of Employees _Number of Shifts Per Day _Number of Days Open/Week _Number of Hours Employees Work Per Shift _Maximum Number of Clients/Day Yes No Business Open to Public, Customers, or Clients Submittal of a completed Class V Inventory Sheet required for systems serving 20 or more persons per day. Property Lines: Check all that apply Daycare Cafeteria Water Used in Manufacturing Produce High Strength Waste Water Softener Showers Restaurant/Kitchen Other (Specify Below) Specify Other _ Determined & Approved by Property Owner Approximate Property Lines Surveyed Clearly Visible Any changes made to this document must be made by the property owner prior to the submission of the permit application. Any changes that occur during the construction of the septic system must be submitted in writing to the Dodge County SSTS Program Manager and the Certified Designer listed on the Design Sheet for approval, prior to the issuance of a Certificate Of Compliance. Yes I hereby certify that the information I have provided is correct. Property Owner s Printed Name Property Owner s Signature Date No

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