HomeMy WebLinkAboutSAND LAKE #1 LT 3AOnsite File
MUNICIPALITY OF ANCHORAGE %icnt
On -Site Water & Wastewater Program �o S�
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 ,� v
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http://www.muni.org/onsite '
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On -Site Wastewater Disposal System Permit
Permit Number: OSP231103 Effective Date: 5/24/2023
Work Type: SepticTank Upgrade Expiration Date: 5/23/2024
Tax Code Number: 01111131000
Site Legal Address: SAND LAKE #1 LT 3A G:
Site Mailing Address: 5007 W 80TH AVE, Anchorage
Owner: REIFEL SAUNDRA & Lot Size in Sq Ft: 25342
Design Engineer: FORGE ENGINEERING Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions:
j 1. The record Drawing is to accurately show the field as a 12' by 47' bed.
2. Prior to tank installation, determine the edge of the bed to ensure that the 5' tank to field separation is
met.
Ree-eiv_edZ-y:
Issued By:�����
Date:
Date: �Zl (/� -;
MUNICIPALITY OF ANCHORAGE
4�
Community Development DepartmentPhone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 011-111-31
Property owner(s) Sunny Reifel
Mailing address 5007 W 80th, Anchorage, AK 99502
Site address 5007 W 80th
Day phone 206-909-5344
Legal description (Sub'd., Block & Lot) Sand Lake #1 Lot 3A
Legal description (Township, Range & Section)
Lot Size 25,342 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑ Single Family (SF) ❑X
(w/wo ADU)
Septic Tank
❑X
Upgrade I -Xi .
Duplex ❑
(D)
Holding Tank
ElRenewal
El
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 7 2
Date of Payment:
Receipt Number: Oyn73D
Permit No. _ c� S P Z 3 1( o .3
Permit App_'-:- ,'-..:c
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
May 5, 2023
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Sand Lake #1 Lot 3A - 5007 W 80th
Septic system design
Dear On-Site Services Engineer:
The owner of the above lot has a septic tank that has reached its end of useful life, we are submitting
this permit application for its replacement. The attached site plan identifies the location of the
home as well as the wells and septic location. No conflicts exist between this proposed system and
any other wells or septic system, whether on this lot or adjacent lots. We are replacing the septic
tank with a larger 1,500-gallon septic tank.
The new septic tank will be a minimum of 100’ from all wells and surface water. Please refer to
the attached plan for the septic design. If this design is followed, there will be no adverse impacts
to adjacent properties.
Sincerely,
Benjamin Schiller, PE
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231103, Deb Wockenfuss, 05/24/23
Benjamin Schiller
CE 12592REGISTEREDPROFESSION A L E N GINEER
1"=50'
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
SAND LAKE #1, LOT 3A
FEET
0 50 100
3-BDRM HOME
SEPTIC PLAN
5/5/23
SAND LAKE
WEST 80th AVE
GARAGE
DECK
DOCK
10' T&E EASEMENT
DECOMMISSION EXISTING
1000-GAL SEPTIC TANK
NEW 1500-GAL
SEPTIC TANK
FCO
2CO
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231103, Deb Wockenfuss, 05/24/23
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
I' ENVIRONMENTAL ENGINEERING DIVISION
*0
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
NEW
s�3raXlj BRIAN W. HALL
❑UPGRADE
MAILING ADDRESS
o bre ee
LEGAL DESCRIPTION
A, X:�, 4.
LOCATION
NO. OF BEDROOMS
1:
DISTANCE TO:
Well /
Absorption ^rea
Dwelling .3 /
PER ITN
Uy
E- Z
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Manufacturer ^•����' %%
PL
Materia f
No. of compartments
P
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5,4/
Liq. capacity in gallons
O
IF HOMEMADE:
Inside length
Width
Liquid depth
0
DISTANCE TO:
Well
Dwelling
PERMIT NO.
J(7Z
= z
ManufacturerMaterial
Liquid capacity in gallons
=
LU
DISTANCE TO:
Well
Foundation
Nearest lot line
PERMIT NO.
J LL Z
Z w
No. of lines
Length of each line
Total len t lines
Trench widt
Distance betweef lines
�
�of
inches
mH
Top of tile to finish r de /
Material beneath tile
Total effective absorption area
-W—/
❑
6
Z inches
5 1 .0
w
Length
Width
Depth
PERMIT NO.
dI—
wa
Type of crib -.
Crib diameter
Crib depth
Total effective absorption area
Lu
h
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
C / -f o)y5.4e
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SOI L TEST RATI NG
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INSTALLER
5• r �, -4-
REMARKS
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APPROVED DATE LEGAL r ,
�U r-4 I C- I F:"F-i I_ I CH Fr' ���OD F,.- F --i Ca V-7
,
DEPARTMENT O'�9EHLTH AND ENVIRONMENTAL r'lTECTION
825 'L STREET, ANCHORAGE, HK. 99 .1.
264-1720
. t'J I- COLNI- I -F ����� �����
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PERMIT N[\ ( 810483"> �
APPLICANT BRIAN W HALL 3704 IOWA DR 26] 81]5
LOCQTION 5007 W80TH
�>
LEGAL L4 SAND LAKE SBD \ LOT SIZE 15400 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = ] SOIL RATING (SQ FT/BR)=: 125
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
��F"-" 7' I -I= �-2L ��P-4 8:3 _r " r-'- ;2 4- ��FLO V E: I_ �7'"I-il� �
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELC\
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
����j 1 F;-" El r_� c- --- F --"-T- 3: c- ���lr-j V., �k D- a2l B D- 93i Fl 9 p CH "!E;
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES 'THAT THE WELL WILL SERVE
�III ED F F=7 97-- -F I CH r-4 SE; F-1 R? I= CA k-1 I F-_"EE.U.a
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION HND APPROVAL. BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]0 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F.0 T-8 I -r F=' 3: R* E-7 !ErE 0 IFE 1-1 E=_. F= FR 2: --p- 1_ "-=-a E3 :JL
I CERTIFY THAT
1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS.
SIGNED:
APPLICANT BRIAN J HAI
ISSUED B ` DHTE 45V4.0
SOILS LOG
- /�nctiuieatlr /✓iar/tq �'����
// MUNICIPALITY OF ANCHORAGE
• ae DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED T FOR: i;R {KN' 1kA LL DATE PERFORMED: 6I21IB
CA
LEGAL DESCRIPTION: LT I'SAND I,.•.•Ay a t' I
F ILLDZ SLOPE SITE PLAN
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IF YES, AT WHAT
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Date
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Time
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Net
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+ J NE 25, 1971 ••• ;ate
®SFS 'GN`AqF s PERCOLATION RATE
X7170 XI.il�' TEST RUN BETWEEN
PERFORMED BY: ,. CERTIFIED BY:
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— FT
DATE: 5
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Municipality of Anchorage ' Gi
On-Site Water and Wastewater Program 4'
(907) 343-7904 °i SA E "�.
T Y
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 011-111-31 Expiration Date: l d-1 J
1. GENERAL INFORMATION
Complete legal description SAND LAKE#1 LOT 3A
Location (site address) 5007 W 80TH AVENUE,ANCHORAGE,AK 99502
Current Property owner(s) BRIAN W. HALL Day phone
Mailing address 5007 W 80TH AVENUE,ANCHORAGE,AK 99502
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Individual
Individual Well ® Holding Tank ❑
Individual Water Storage ❑ Community ❑
Community Class_Well ❑ Public Sewer ❑
Public Water System ❑
Waiver/Variance request for: Distance:
Received by: 4:20,f4Date: 7- /Y—/E
COSA to be released to the engineer,unless othe 14-d-sted by the engineer.
COSA Fee $ 45? Co Waiver Fee $
Date of Payment ? ��( Date of Payment
Receipt NumberO1/4;°D- Receipt Number
COSA# cfe.,1r13 Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING,INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD.,EAGLE RIVER,AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 6/23/18
THIS COSA DOCUMENT CANNOT BE USED TO TRANSFER TITLE UNLESS ALL VENDORS(ENGINEERING,SURVEYING,CONTRACTORS,ETC...ASSOCIATED
WITH THIS COSA ARE PAID IN FULL AT OR BEFORE CLOSING. Engineer's Comments: This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested.
The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface,changes inland use,
local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the
system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function
satisfactory for current or future occupants or can ArcTerra guarantee that no unseen �� .\Nok `
encroachments,deficiencies or discrepancies exist. . OF A `
irr����� AL;
V1 <7
/ k A •
6. DSD SIGNATURE i--AUM`—;� �e
r0 System#1 Approved for 3 bedrooms. + KENn'ETH M.o lie ,
uue�I /
/
System #2 Approved for bedrooms. `r�F c�
Disapproved. \``-11b2.-
/ Conditional approval for bedrooms, with the following stipulations:
v ' " k '( .
cQ1,)
Li){ (2:
r.- „ 4.,.4.4.,4 4 t ,.
d (if c.( 07 ,.. L.,.
�� ON-SITE *7
WATER AND R‘
WASTEWATER c
7) PROGRAM U
rt:
------� v
t w_ Original Certificate Date: 7- l�-to
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advi
Septic System Advisory Arse ' Advisory
Well Flow Advisory Othe \( .C- M t.124�
COSA blue sheet 7010-12.doc
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system _
Certificate of On-Site Systems Approval Checklist
Legal Description: SAND LAKE#1 LOT 3A Parcel ID: 011-111-31
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 6/27/1981 Sanitary seal (Y/N)Y Wires properly protected (Y/N) Y
Total depth 156 ft. Cased to 156 ft. Casing height(above ground) 18+ in.
FROM WELL LOG AT INSPECTION
Date of test 6/27/81 10-13-2017
Static water level 63 ft. 54 ft.
Well production 20+ g.p.m. 5.7 g.p.m.
WATER SAMPLE RESULTS:
Coliform 'N/`EG 2 colonies/100 mL Nitrate mg/L
Arsenic: t 't'3 ug/L Date of sample: 6/22/2018 Collected by: ARCTERRA
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL Date installed 7-11-1981
Tank size 1000 gal. Number of Compartments 2 Cleanouts(Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N
Date of pumping 10.11.2017 Pumper Northland Pum in
C. ABSORPTION FIELD DATA
Date installed 7/11/1981 Soil rating (g.p.d./ft2 or ft2/bdrm) 125 System type SHALLOW TRENCH
Length 47 ft. Width 12 ft. Gravel below pipe 1 ft.
Total depth 13.3 ft. (Measured 10/13/17) Eff. absorption area 564 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 10-13-2017 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 490 gal. New depth 0 in.
Elapsed Time: 1 min. Final fluid depth 0 in. Absorption rate >=450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &type) N If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 100'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water 100'+ Driveway,parking/vehicle storage 10'+
Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 100'+
F. COMMENTS
Although,the steel septic tank is significantly past average life expectancy the fluid levels appear to be normal and tank operating
adequately based on pumping and observations.
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in conformance
with MOA COSA guidelines in effect on this date. i�" OF AZA '
Engineer's Printed Name KENNETH M.DUFFUS 1 -7 `
Date 6123/2018 4 i TH
COSA canary sheet_2-6-15.doc KENNETH . par 4.
Air
Nik.".`ESS1* o
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT • `!r 907-343-7904
On-Site Water and Wastewater Section `' j` Fax: 343-7997
www.muni.org/onsite
Septic Tank Advisory
Certificate of On-Site Systems Approval # OSC181322
Subdivision: Sand Lake #2 , Lot: 3A
The septic tank for this property is 37 years old. The average life for a steel septic
tank is 20 years. Typical replacement costs range from $6,000 to $9,000.
This advisory must be attached to all copies of the subject Certificate of On-Site
Systems Approval.
This is an example of what the metal of a 30 year old steel tank MAY look like.
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Mailing Address:P.O.Box 196650*Anchorage,Alaska 99519-6650*www.muni.org
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT i` . [' '; 907-343-7904
On-Site Water and Wastewater Section Fax: 343-7997
www.muni.org/onsite
Arsenic Advisory'
Certificate of On-Site Systems Approval # OSC181322
Subdivision: Sand Lake #2, Lot 3A
A water sample revealed an arsenic concentration of 44.3 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. information on arsenic is available from the On-Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-Site
Systems Approval.
Mailing Address: P.O. Box 196650 *Anchorage,Alaska 99519-6650 * www.muni.org
SAND LAKE
DOCK
EXISTING SHORELINE .
PLATTED SHORELINE i — c 1
N84'37'24' 105.45'
(N84'34'16"E 105.38' R)
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•
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N89'58'S1"W 104.85'
(N89'59'00"W 104.92' R)
0
to
W 80TH AVE
ANCHORAGE RECORDING DISTRICT,ALASKA
AS-BUILT OF:
SAND LAKE SUBDIVISION NO.1 0 =FND 5/8"REBAR
LOT 3A PLAT 2001-85
SURVEY CERTIFICATE:I,John L.Schuller,Have conducted a <\.. -:*C OF A��` y. LAND
4.
physical survey of this property as shown on this drawing and that the / ''" `. 11 A4. .`O G
improvements situated hereon are within the property lines and no �01ts�`' � 1 f
enchroachments exist other than noted.Under no circumstance should / : 49T i .. 1, os' ��•��
any information on this drawing be used for construction of fences, .�+as N. 1.
r4
structures,improvements,or for establishing boundary lines. , �// Kms- U • r''
EXCLUSION NOTES:It is the owners responsibility to determine to P" ‘....c,.., n
the existence of any easements,covenants,or restrictions which '.J HN L. SCHULLER: / = �,�
do not appear on the recorded subdivision plat. SI1/4ke'„.../0
' LS-10408 .I'vol 'i••••,....4.0.—
WORK ORDER NUMBER: acre SCALE: EMAIL •
' gJj� 1831 Talkeetna Street
OCT 25, 2017 1""30'
' '11'�,ai Anchorage, Alaska 99508
17—052 °R"""BN°Cam er ORO Mrs BO°c/PAGE: �ztofess.ono� ��� (907) 227-1455 office
JLS 2224 170165 �\\��`�� (907) 274-4992 fax
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Time
Time
e
Date
Date
Date s�
e /'r3 v
Inspector
Inspector
Inspector
Comments
Conditional Approval
A;u nrovnd BedroomIt s
Date Sewer Installed
Permit No.
Septic Tank Size
Holding Tank Size
Soils Rating
Well To Absorption Area
Well Log Received
1s�
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner
rl an W. Iia I I
hone
Mailing Address
P.O. Bax 8295 Anchorage AK 99508
J02%0
Buyer
Address
Lending Institution
First Nationalan
Phone
Address
Realty Co. & Agent
Phone
Address
Legal Description
tot 4 SandLake No.
Street Location
5007 tJ 80th Ave
of
TypeResidence
Single Family
three
❑ Multiple Family
No. of Bedrooms
❑ Other
WatK Supply
❑ Individual
ATTACH WELL LOG. A well log is required for all wells drilled since June
❑ Community
1975. For wells drilled prior to that date, give well depth (attach log if
❑ Public Utility
available.
Sewa�gge Disposal
1d
981
- Individual
Year Individual Installed:
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST.ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.