The URL can be used to link to this page

Home My WebLink AboutSAND LAKE #2 BLK 6 LT 23Sand Lake #2 Block 6 Lot 23 #011-133-14 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION l� ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME7v %/ Gp /V sem' P ONE NEW ❑ UPGRADE MAILING ADDRESS 3�� LEGAL DESCRIPTION- L2- �� /�� r v LOCATION NO. OF BEDROOMS +_y ,r / LCD k Well Absorption area / �I g, I D7 PERMIT NO�/ D / DISTANCE TO: DIS07— / ..tJ - U Y a Q Manufacturer �L Material ,� No. of compartments wF rn Liq. cap ac'ty�ng�l� s IF HOMEMADE: Inside length �N ttSS�� Width Liquid dept ell Dwelling PERMIT NO. DISTANCE TO: J Z Liquid capacity in gallons =ZH Manufacturer Material p Well y0 Foundation a A 1 O Nearest lot line/ l v/ PERMIT NO. J y w JLL z DISTANCE TO: % / „J • No. of lines Length of each lint' Total length of line Trench width Distance between Ines _ z inches F' CL cc t- Top of the to finish grade 1 Material beneath the / � D // inches Total effective absorption area O Length Width Depth PERMIT NO. Lu QI— Type of crib ib d' eter Crib depth Total effective absorption area as w W Building foundation Nearest lot line y DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. J dAT� J w Building foundation Sewer line Septic tank Absorption area(s) DISTANCE TO: OTHER PIPE MATERIALSt:- - -- -- _ 72- SOIL TEST RATING _Y - Fo INSTALLER �/ REMARKS Q -- ef — L i O 4144 qo_ APPROVED DATE LEGAL 721613 (Rev. 3/78) ' ^ .�~ �,/�.�� DEPHR..T H AND ENVIR8NMENTHL��~.OTECTION ..STREET, ' ^ 825 /L' ANCHORAGE/ HK. 99501 " _-� _� 264�4720 � �\ �~^/ �� _�� I� /l J" PERMIT NO. ( 81061] HPPLICHNT T & T CONST. CC]. SRH BOX,40]5~H ]4��--2670 LOCATION 8214D & WILCOX LOT SIZE 6750 SQUARE FEE"T LEGHL L23 B6 SAND LAKE #2 TYPE OF SOIL- ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = _3 SOIL RATING (SQ FT. -,BR):--, THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: 142 r l[- F1 uviR E-:: L_ EZ F --'r VA� THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIEU}. THE DEPTH OF 8 TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE QF 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). ��EE EF_ ��Ir C�* �n r -'l 2!: E7 A- A: B e:� I -El 973i FU L- Cp�� PERMIT HPPLICHNT 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. �� K_-- -IF T F-' BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY 8N -SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM APUBLIC NELL 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. TURNED TO THE DEPARTMENT WITHI�� '_30 DHy�� WELL LOGS ARE REQUIRED AND MUST BE RETURNED OF THE WELL COMPLETION. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE OTHER ��EQUIREMENTS APPLY. . AVAILABLE TO INSURE PROPER INSTALLATION. ��11 _F 3`1 " �� I CERTIFY THAI' 1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON --SITE SEWERS HND WELLS AS SET FORTH By THE MUNICIPALITY OF ANCHORAGE. NCE WITH THE CQDES 2: I WILL INSTALL THE SYSTEM IN 8CCQRBMS9STEM MAY REQUIRE ENLARGEMENT IF THE ]� I UNDERSTAND THHT THE ON-SITE SEWER RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS. SIGNED: HOIL 8. T C.0 -ST. CO. V4.0 ISSUED B �� MUNICIPALITY OF ANCHORAGE �..e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST Jr SOILS LOG ❑ PERCOLATION TEST PERFORMED FOR: ' Ai'( Z2se'-'L ' ,,11 DATE PERFORMED: LEGAL DESCRIPTION: t c1 21 ljlac`k6 Su?.YtY. Iak f/ Z DEPTH - SLOPE SITE PLAN�.'�ed`Ap-- 5'7^�L) fF rFT 1 f^ S 6 A or 2 0 3 Comm Date Gross Time Net Time Depth to Water Net Drop 6 0 5 & C 6 m c 7 r' 8 ° c s i 6 T 9 r cs 10 0 ©` 11 � t✓i C+'ar� a 00 jiv ) 12 13- 3 s � 15- 15 16- 16 17 17 e b 18- 81920 R 19- 20- COMM WAS GROUND WATER Alb ENCOUNTERED? IF YES, AT WHAT DEPTH? L 6'Y Gr7F Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT PERFORMED BY: 13A ILS,, a CERTIFIEDBY: 72-008 (6/79) DATE:,_7 —7 -$`iii Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program , IT' 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. o f r - 17 3 - / Y COSA # OR 0177 Expiration Date: - 17- O 9 1. GENERAL INFORMATION Complete legal description tiP 23 19/oete 6. Sand 1%* .e S/D # Z Location (site address) & Z Z 2 Lv% / cn x Sf . Current Property owner(s) Toe t Dauu.n Fttr ile y Day phone 9S 2 - 35'0,9 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address _B2.7-2. w.lce x Sst� Ar g hk '?'?So 2 Day phone An6f"OtZJY4rX es _0 Re /lux Day phone 2S7-Cyr6f 110 w 349 1+4.14 Sk.k laa A&c 99Sa3 Unless otherwise requested, COSA will be held by DSD for pickup. Irl tare to // An, - if/ e+ a @ 25'7 -ov6S 2. NUMBER OF BEDROOMS: 3 when COXA it fltaoty 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual On-site Individual Water Storage ❑ Individual Holding Tank ❑ Community Class C Well 19 Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 Flcrf/oe Tsr<i.r %rte SPrv.w Phone 3 YS—)3s'r Address )Y -C36 ecAep 6:tApon i�( A++ctie��oG� 99Si� Engineer's Printed Name Date _t% Ztne 1f 2t 2000 S: f ; 4 0.0...446006 5. DSD SIGNATURE 61 i n'20DGRE F. YOORE�- i ^°, . C1-3569 s. c _� Approved for _ 3 bedrooms. ;. G ° °� . S \.t. 01. Disapproved. ,`7fi"*:s =. Mr"• Conditional approval for bedrooms, with the following stipulations: ... .• ONSITE Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: Co ' % %' )Rw 11105) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519.6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lo f 23, i D. LIFT STATION N• h. Date installed 'Pump on' level at _ in. Datum E. SEPARATION DISTANCES Size in gallons Manhole/Access (YIN) 'Pump off" level at_ in. High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: N. A• L Cl.cusr "C" ccell rt on laF Z -Y, Septic tank/lift station on tot Absorption field on lot Public sewer main Sewer /septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank Animal containment areas Manure/animal excrete storage areas _ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation = t0' Property line fU' Absorption field b Water main SU' Water service line > 9,o ' Surface water > tao Wells on adjacent lots tp8� iw "f 2Z — Rppp,s..eof ve a wrj 9 Yq0 69 f 2Y — APppo ~e ✓da AO LY wcaewr 1/27 /B L SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 6r Building foundation 2B' Water main_? d'o ' Water Service line 7> So' Surface water > 100' Driveway, parking/vehicle storage �> to f Curtain drain Non• f ten Wells on adjacent lots —m2L> tco' F. COMMENTS .1G A1ilCa/ on a/epp'CWo� t he 1+vf0//a_/70n ✓wpoef. t'4/6/S/aJ 0i%tax./ W61•ntr &A tw•f/?inL G. ENGINEER'S CERTIFICATION Arse per, tame- fTlec- r w. �y tu�'var w, Srylftc /'•/'u aardloP I certify that I have determined through field inspections and ��' pccRe review of Municipal records that the above systems are in a.004'p' aCe 44 conformance with MOA COSA guidelines in effect on this date. �� t Engineer's Printed Name Theo o65.r F. r•fo0,7—, Date Jctnr 1 200 9 of� COSA Fee $ A/90 =`- Date of Payment Receipt Number. (Rev. 11105) C•nrwdion .e F/ ChveC tr sol/ 1z/3'/mss ahw.rcP l pneo e,l/ lorq jro� •tSH e,aT P., s. L ? os44 Waiver Fee $ tl 'r.t'•. CL �SG9 /cs9 ' Date of Payment Receipt Number SCS Ref# 1092181001 Client Name Flattop Technical Srv. Project Name/# 123;B6; Sand lake #2 Client Sample 11) 123;B6; Sand Lake 42 hlatrix Drinking Water PWSID 218660 Sample Remarks: Printed Date/1'ime Collected Date/Fime Received Date/Time Technical Director 06/03/2009 14:25 05/22/2009 12:50 05/222009 13:20 Stephen C. Ede Allowable Prep Analysis Parameter Results PQI. Units Method Container ID Limits Date Date Init Metals by ICP/M3 Arsenic 29.9 • 5.00 ug/l. CP200.8 C (<10) 05/29/09 06/01/09 NRB Waters Department Total Nitratc/Nitritc-N Microbiology Laboratory Colony Count Total Coliform Fccal Coliform ND 0.100 mF/L SM204500NO3-F 11 (<10) 06/01/09 JD!. 2 col/100mL SM209222B A (Q00) 05/22109 DLC 0 coVI00ml- SM209222B A (<I) 05/22/09 DLC 0 coVl00ml. SM20922211 A (<I) 05/22/09 DIX Municipality of Anchorage ., '•iii- fat • Development Services Department , Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Arsenic Advisory Certificate of On -Site Systems Approval # 090177 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 6, Lot 23 of Sand Lake #2 Subdivision. This inspection revealed an arsenic concentration of 29.9 micrograms per liter (ug/L) for the property's well water sample. 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.or /off nsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. o� Municipality of Anchorage s o, Development Services Department Building Safety Division - On -Site Water and Wastewater Program - 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www. ci. a n ch o ra g e. a k. u s (907)343.7904 CFRTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 011-133-14 HAA Expiration Date: -3 — D — O 4L 1. GENERAL INFORMATION Complete legal description Tnr23- Block 6; Sandi-ake Subdivision #7 Location (site address or directions) 8222 Wilcox St. Current Propertyowner(s) Gary Rodgers Day phone 243-7415 Mailing address Box 574,:645 G St. #100 Anchorage. AK 99501-3471 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address held by DSD for /��, 1 r�� 03 Unless otherwise requested, HAA will be pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: - Individual Well ❑ Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class C Well Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties seed by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new ureter sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 Health Authority 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 numbef 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 S & S Engineering Phone 694-2979 Address 17034 N. Eagle River Loop Ste.204 Eagle River, AK 995577 Engineer's Printed Name Robert C. Cowan Date 7 1s-10.3 OF �; ROBERT C. COWAN �N 5. DSD SIGNATURE ''l�`c�s CE -8801 `- ��3bedrooms. t+tZF!' •... '•'�= Approved for Disapproved. layitro"� Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Vru Lmr\ fiIVU urn TRAfATr-P� PROGRAM Maintenance Agreements Supplemental Engineer's Report Other WI By: Original Certificate Date: la -10-03 (Rev 01102) Municipality of Anchorage Development Services Department Building Safety Division �— On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ,e7/ 23/- �t,,, 6. SOIW01.4gr S/7 Parcel lD:O//-1.33"/4 A. WELL DATA&o Well type it If A. B, or C provide PWSID # G Well Log (YIN) y�S Date completed _J Sanitary seal /ftL. YIN) Wires properly protected (Y/N) Total depth ft. Cased toCasing height (ab a ground) In. FROM WELL LOGAT INSPECT N Date oftestStatic ater level ft. Well roduction 9•P•m• 9-p•m- WATER SAMPLE RESULTS: Coliform O colonies/100 ml. Nitrate 0- 1 mg.A. Other bacteria 0 colonies/100 ml. Arsenic: = mgA. Date of sample: /IIa(o/e3 Collected by: Sf 5 E.vri.re vG. B. SEPTIC/HOLDING TANK DATA Tank Type/Material -5'oPr L I *rxrL Date installed / S r Tank size 1000 gal. Number of Compartments Z Cleanouts (YM) Y Foundation cleanout (YIN) _Y_ Depression over tank (YIN) A/ High water alarm (Y/N) Date of pumping / D Pumper C. ABSORPTION FIELD DATA Date installed I 1 Soil rating (g.p.dJft=o<ZDh)�2 System type LE1t/alfi Length 22 ft. Width / 1 * ft. Gravel below pipe /O ft. Total depth ft. Eff. absorption area 440 ft' Monitoring tube _ Depression over field W Date of adequacy test It 17,0 103 Results (Pass/Fail) PLe,!; For S bedrooms Fluid depth in absorption field before test _Q_ in. Water added gal. New depth in. Elapsed Time: / 0 min. Final fluid depth Jo_ in. Absorption rate >= 45rV g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Z If yes, give date D. LIFT STATION Date installed Q 'Pump on" level at in. Datum E. SEPARATION DISTANCES Size in gallons 'Pump off" levet at _in. Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift-statton on lot Absorption field on lot Public sewer main Sewer /septic service line r Manhole/Access (Y/N) High water alarm level at in. Meets alarm 8 circuit requirements? N/A �qss C u/FtL On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HGLDfNG TANK ON LOT TO: Building foundation t Property line5 ' Absorption field S t� Water main I D + Water service line 1 D �4- Surface water I 00 t F Wells on adjacent lots 96; , TD Lo r Z Zile !00 t Ya L07- 2-4` SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: i Property line 10 Building foundation /0" Water main Water Service line f0 4 Surface water /00 r+ Driveway, parkirg/vehicle storage Curtain drain AI AiFA JOWA/ Wells on adjacent lots /00 f - F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in p conformance with MOA HAA guidelines in effect on this date. �/1 Co wq,✓ � .T..µ Engineer's Printed Name /C O6EA� C . �lj t ROBERT T C COWAN C� Date 1 d 5 os .. HAA Fee S 3 7 Y- ro Date of Payment Receipt Number (Rev. 12101) Waiver Fee $ Date of Payment Receipt Number fLttr','Jlil„�3I-�icl:•',...�re€if.T.w l.• r.;:e.l R..I.a �y �.. a::+ 1' �_�-. ...L...:-lC^�(:+'G�.'�'�'T•-Yv+•L.r:J:.'�''(JCC:: �V.r. t.'•Yir'�: .•.v.:� . ^ w�•y!. . d.. •r. iw• •.•.•./.•• ••• •r•..�+.M••h•rrK fA�•: •••.t:.-•irY�.K�CMI!•AM!1•q.1.11W'MMi'Ya.C:...•.vhSlI.r ..•.: ..r •,w., .-..16.1(1".(1 Li J PIPIs) 4 W4,&. AoA{,n Ts T•/aJ � Dl:A..Ir.4 o Y S� S A"�t. 1• .. . •-. � ls.lS�o3 � '• j • C141f Mir ••P•e+•'-r+t+Ilc..d n>..pn r ,49TH J Scala. „• D, Drovn byr. REJ OnvT wT•a•RrfY tnl•e"0 ...H u .. ............ �nMMVOdrnCWoe"d. •yGf_+�+ Da1C$.rrvei�' G+CCAad ¢- aof.rrvnfelro ......r Itar. 12. 81. br: REJ .ro•w.w+f a'w•n''f DRD• ��•,..•.t. Ja,-M. M. • • Dote Oram a•+n+Loea.r.•uos tv I Grid' p•1rI'IM1h Wq.m O.41M1 4 • •, 4121 5 Mar -13, 1981 2224 N.M81-008 lrf•fbf meet -o n, 4+•1+1 `�+�••a,.••+•�'a r La Oal Descripikin Lot 23, 6iock 6. Sand Lake #2 •n as e•m•r•, falrcl 411 \ -� • �• + �" J • • ilrj• 1 1L .Ia• t - iI ' fit N • :ail :S• • .iJ 11•fJ +('l •i •r SURVET TYPE o PLOT PLAN ❑ LOT SURVEY ❑ R[CEATIFICATION AS -BUILT u • 1"..1.00"t.e1+T of INV W114or or o."ff, pnor io LEGEND hub Q fork- foUnd O set • toWfacior+, to IV•df pratraltd ►.ad•"a areas rttanre iron rebcr -found 0 set e 10 Ir4r11.d goat owa •W -If, eowrru.as end w 41916."4(18 iron pipe •found O set o Ir4 40111K, of any f4mm"11. cv-f +tl Of /NI/rc M"f "IC11 eo" doo"t on 1M I•eodfd ■.odomon plat• Dross CPA alum Cop - -found & -found set set (}�[ V I<LY $11rYey Cerflfltdion ,b•�-\ .:;t7 �C•.O. •�•ALgS�+ Prepared MARK 'INC. *17 11W lranlw• Vr-4P I�r W" W4 a.Qlfi•d rrf0\oro fVM 111 ,� ' •.,.r ••J • �.. A ,BENCH Profesrlonol Land Survevors ••P•e+•'-r+t+Ilc..d n>..pn r ,49TH J Scala. „• D, Drovn byr. REJ OnvT wT•a•RrfY tnl•e"0 ...H u .. ............ �nMMVOdrnCWoe"d. •yGf_+�+ Da1C$.rrvei�' G+CCAad ¢- aof.rrvnfelro ......r Itar. 12. 81. br: REJ .ro•w.w+f a'w•n''f DRD• ��•,..•.t. Ja,-M. M. • • Dote Oram a•+n+Loea.r.•uos tv I Grid' p•1rI'IM1h Wq.m O.41M1 4 • •, 4121 5 Mar -13, 1981 2224 N.M81-008 lrf•fbf meet -o n, 4+•1+1 `�+�••a,.••+•�'a r La Oal Descripikin Lot 23, 6iock 6. Sand Lake #2 •n as e•m•r•, falrcl 411 \ -� • 72023 (3182) APPLI( NT FILLS OUT OF FLK NAI VIYLi Time Phone Property Owner �fl x o 3 '-4 Zip Code a Mailing Address Date ,;'Buyer iJnAy Date Date o � Zip Code G/"�istJ �- Address Lending Institution i1 �� s rt /11,4 k I 4 A Phone Address ' 7nj - J- x <�%JS d .� Zip Code Phone Realty Co. R Agent No N C Zip Code Address Legal Description ,�// 17()/dGk 6 �fl ,23 - 'CONDITIONS OF APPROVAL lLO Street Location 1A)1' ( ) CONDITIONAL PPPRROVAL' Type of Residence DATE I �iSingle Family ❑ Multiple Family No. of Bedrooms Soils Rating ❑ Other to Tank Septic Tank Size ' 71'(� IJ Water Supply ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. ❑ Individual El - For wells drilled prior to that date, give well depth (attach log if available). Community ❑ Public Utility - Sewer Disposal Year Individual Installed: Individual When Connected to Public Utility: ❑ Public Utility ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEST BEFORE PROCESSING CAN BE INITIATED. 72023 (3182) Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: - 'CONDITIONS OF APPROVAL ( APPROVED BEDROOMS ( ) DISAPPROVED - ( ) CONDITIONAL PPPRROVAL' DATE I BY: Date Sewer Installed Well To Absorption Area Well Log Received Soils Rating U -- (0Well to Tank Septic Tank Size ' 71'(� IJ 72023 (3182)