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Clay County Planning and Environmental Programs Environmental Health Services 715 North 11th Street, Suite 303 Moorhead, MN 56560 (218) 299-5004 11/2025 Septic Application – Compliance/ Installation For a Compliance Inspection, fill out pages 1 and 2. Applicant ☐ Applicant Same as Owner Name Phone # Email Owner Fee $150 Name Phone # Email Property Address Parcel # City, State, Zip Mailing Address City, State, Zip House Information Year Constructed # of Bedrooms # of Bathrooms Square Footage Well Depth Water Using Appliances (check all that apply) ☐ Water Softener ☐ Washing Machine ☐ Dishwasher ☐ Grinder/ Ejector ☐ Garbage Disposal ☐ Sump Pump ---PAGE BREAK--- 11/2025 COMPLIANCE INSPECTION Reason for Inspection ☐ Home Sale ☐ Building Permit in Shoreland Clay County Sewer Code 6-1-10 : It is the responsibility of the seller to provide to the buyer a copy of the certification inspection indicating whether the system is in compliance or noncompliance prior to closing on an agreement to sell or transfer real property. During the period between November 1 and April 30, a request for a certification inspection must be submitted to the Clay County Environmental Services Division office prior to closing on an agreement to sell or transfer real property and the associated inspection completed by July 1. In accordance with this code, realtor contact information is required to ensure proper communication with the buyer of a property for future scheduling and completion of inspection. Realtor Information Name Phone # Email In the past two years, have any of the following occurred? ☐ Backing up into the house via toilets, showers, wash tubs, drains? ☐ Septic tank overflowing to ground surface? ☐ Moist, mushy ground or effluent surfacing along the drainfield? When was the septic tank and/or lift station last pumped? Does the homeowner, realtor, or other representative wish to be present at the time of inspection? If yes, Name Phone I hereby certify the above information to be correct and accurate to the best of my knowledge, and that I do not hold Clay County or its employees responsible for any damages, costs or claims resulting from any approvals, judgements, opinions, or findings issued upon completion of this inspection. PROPERTY OWNER OR REPRESENTATIVE DATE ---PAGE BREAK--- 11/2025 INSTALLATION (If you are applying for a Compliance Inspection, skip this section) SYSTEM SPECIFICATIONS Tanks ☐ Septic Tank ☐ Pump Tank ☐ Holding Tank ☐ Other Number of Tanks Tank #1 size Tank #2 size Tank #3 size Soil Treatment Area ☐ Rock Trench ☐ Chamber Trench ☐ Low-Profile ☐ Standard ☐ High-Capacity ☐ Seepage Bed ☐ Pressure Bed ☐ At-Grade ☐ Mound ☐ Other Sq. Foot of STA Installer License # Septic System ☐ New ☐ Remodel Shoreland – Is the property in the shoreland from a lake (1000 ft) or river (300 ft)? ☐ Yes ☐ No Lake/ Stream Name Classification ---PAGE BREAK--- 11/2025 Agreement: The undersigned hereby applies for permit to install, alter, or repair the sewage treatment system herein specified, agreeing to do all such work in strict accordance with the ordinances of Clay County and the State of Minnesota. APPLICANT FURTHER AGREES TO ATTACH RELEVANT PLANS, PLOTS, SKETCHES, AND SPECIFICATIONS, AND THEY SHALL BECOME PART OF THE PERMIT AND ANY VARIATION FROM THESE PLANS WITHOUT WRITTEN PERMISSION FROM PERMITTING AUTHORITY SHALL INVALIDATE SAID PERMIT. Policy: Issuance of permits, approval by inspection, nor any other approval and/or certification of compliance issued or requested shall be construed to represent a guarantee or warranty of a sewage treatment system’s operation or effectiveness of that treatment. ALL APPLICATIONS FOR PERMITS MUST BE ACCOMPANIED BY COMPLETE SITE EVALUATION DATA AS DEEMED RELEVANT BY PERMITTING AUTHORITY. Installer is responsible for notification for system inspection at least 24 hours prior to system being covered. It is the responsibility of the installer to meet all setbacks and requirements of the code and provide Clay County Environmental Health with a design of the system before the system is installed. I have read and agree to the conditions as specified above. Signature of Applicant Date Note: Application must be filled out in its entirety before a permit is issued. Make checks payable to Clay County Treasurer.