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HomeMy WebLinkAboutSCHROEDER EAST BLK 1 LT 17:5111) MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program POBox 1S0GoO 47U0Elmore Road Anchorage, Alaska S8519'G65O P -7904 Fax. (907)343'7S97 On -Site Wastewater Disposal System Permit Permit Number: OSP221385 Effective Date: 1020/2022 Work Type: Septic Upgrade Expiration Date: 10/20/2023 Tax Code Number: 05006307000 ' Site Legal Address: SCHROEOEF<EAST BILK 1LT17 G:0352 Site Mailing Address: 17531 3ANTAyNAR|ADR, Eagle River Owner: �OO�E�ARRYL Lot Size .inSqFt: 22380 Design Engineer: ARC TERRA CONSULTING INC Total Bedrooms: 3 This permit is for the construction of: 21 Disposal Field 2 Septic Tank El Holding Tank [] Privy [] Private Well [] Water Storage All construction shall 6einaccordance 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 (18/V\C8O) 3 The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65.ProvidanoUfioationbycalling (SO7)343-7QU4(24/7). 4� From October 15toApril 15.msubsurface soil absorption system under constructionduring freezing weather shall beeither: a. Opened and Closed onthe same day, or b. Covered, sealed, and heated to prevent freezing ��/�_ � �� �� �� /��� / f2- /�_/� �0���� Received By: Issued By: MUNICIPALITY. F ANCHORAGE Development Services Department `° Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTICM/ELL PERMIT APPLICATION Parcel I.D. 050-063-07 Property owner(s) Berry & Gale Moore Day phone _ Mailing address. 17531 Santa Maria Dr. Eagle River, AK Site address 17531 Santa Maria Dr. Eagle River, AK Legal description (Sub'd., Block & Lot) Schroeder East Block 1 Lot 17 Legal description (Township, Range & Section) Lot Size 22,380 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: 0 all that apply) Absorption Field ® Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank X❑ Upgrade 7X Duplex (D) ElHolding Tank ElRenewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. Dea. Duffus (Signatu're of property owner or authorized agent) Permit/Rush Fees: Jg5� Waiver Fees: Date of Payment:,3/� _ Date of Payment:.. Receipt Number: & 0 7 Receipt Number: Permit No. -65P 9 a_l 215- -- Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\FormsUient FormsTermit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221385, Deb Wockenfuss, 10/20/22 A TRCERR A A TRCERR A C O NSULT I N G ,I N C . Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221385, Deb Wockenfuss, 10/20/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221385, Deb Wockenfuss, 10/20/22 �Ir Lot 13 � I 10' UTILITY + EASEMENTS � !I �p S f Lot 14 / h CHAIN-LINK FENCE Lot 17 22.380 S.F. 12.3'x10.2' SHED §1 8.1'x12.0' SHED CHAIN-LINK FENCE Lot 16 ` WOODEN FENCE Lot 18 r 1 ! 30.0' GRAVEL 1 1 %$ DD' WIRE FENCE 12.1'x12.0' :.- GREENHOUSE Nt �� rp �SEPTIC---_ ' PIPES 2 10 82, C: o VO O 4z - ASPHALT CV - 1/' 4q 4Z .>► A 5.0'x5.0' A) ?22, ti DECK nD � v WELL V. (DECOMMISSIONED) /` / C NOTE: THE LOT IS SERVED BY A / COMMUNITY WATER SYSTEM. PLOT PLAN ___ AS BUILT _x_ SCALE _1-=40' _ GRID _ NW 0352__ Project No. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone Qo�d�p (907) 522-4625 Fax Q O F A Professional Land Surveyors anathan surveyuryy.com I hereby certify that I have surveyed the following described property: D� RSUBDIVISION — EAST ADDITION PLAT No. 71-298 p 49TH �9*0 LOT 17, BLOCK 1, SCHROEDE ( } Anchorage Recording District, Alaska, and that the Improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that ,y no Improvements on the property lying adjacent thereto encroach on the surveyed �/'� KEIdNE. ... N .. premises and that there are no roadways, transmission fines or other visible a �^o `�2G easements on said property except as indicated hereon. s b 'L Q ����Fo' A-�02. yJOO Dated this the +i2Day of w_GT�r>L' =, �? at Anchorage, Alaska �44ROF,CSSIONA1. �a It is the responsibility of the owner to determine the existence of any easements, 044000a4 covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 MUNICIPALITY OF ANCHORAGE ®� DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION s 825 I_ Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL. SYSTEM AND/OR WELL INSPECTION REPORT NAME- 1_`-i►e' - - PHONE Sg'.3 I_ [J UPGRADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS 3 QManufacturer Nf L.) Well + Absorption area Dwelling DISTANCE TO:-y�(�(',y -- - n - O©Cl Q J��� J Material V /oJ �Liq. capacity in gallonsIF HOMEMADE: Inside length Width DISTANCE I'0: Dwelling _ PERMIT NO. 9/O 9 3 -- No. of compartments Liquid depth PERMIT NO. C)? Q 3. E - Manufacturer Material Liquid capacity in gallons p ag w DISTANCE TO: Well Foundation Nearest lot line PERMIT NO. °� k Z w __ No, of lines L ngth of each line Total length of lines t Trench width inches _ Distance between lines y p Top of tile to finish grade pp , S W Material beneath the , 1p inches Total effective absorption area w Length lNidth � - � Depth PERMIT NO. �. Q F- G- a W W Type of crib— -Crib DISTANCE TO: diameter Crib depth Total -effective absorption area----- _ Nearest lot line Well Building foundation Class Depth Driller Distance to lot line PERMIT NO. UUa DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER LEGAL - PIPE MATERIALS I SOIL TEST RATI NG I -�•JC..JJ - INSTALLER REMARKS _ -- a I � I APPROV ED_�� �-_�A/T/E �� `f THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS: Lou ������ MIT ���j (21 W 1-1 = -Q (Foil F-` F:`11 "%-' E"l L_ E'N F--" 1", F4 =­-: � THE 01 owl al - OR DRHINFIELD. M 8.5 P-4 1 C: 3: V` U 3: W DEPARTMENT 6� HEHLTH Q Fo­ ���t-A �C3 E"E. HND ENVIRONMENTHL �/.OTECTION / r+/ OR PIT IS THE DISTHNCE BETWEEN THE SURFHCE 825 'L' STREET, ANCHORAGE, H 9501 BOTTOM OF THE EXCHYHTION (IN FEET). 264 0 VH I" V F-2 FE P-4 (0 1-1 W 1 EN W 1-1 �� ME -1 IE'l 9 E__ L_ L... F --'R P-4 �r..s I -V E.'-. F.E. a 'A EE, ���Vl I T_ PERMIT NO. ( 810]9] ) OUTFHLL PIPE HND THE BOTTOM OF THE EXCHVHTION (IN FEET). APPLICHPAT KEITH L NELSON SR BOX 2708 I'S 88-�017�� LOCHTION E. F!, ,u:�umx�� LEGAL B1 SCHROEDER EH -ST LOT SIZE SQUHRE FEET TYPE OF SOIL HBSORPTION SYSTEMISDRHI�FIELD MHXIMUM NUMBER OF BEDROOMS SOIL RATING (SQ FT/BR)­: �J 85 THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS: Lou ������ MIT ���j (21 W 1-1 = -Q (Foil F-` F:`11 "%-' E"l L_ E'N F--" 1", F4 =­-: � THE LENGTH DIMEN!"AON IS THE LEMMA (IH WET) OF THE TRENCH OR DRHINFIELD. THE D[,`.PTH OF H TRENCH OR PIT IS THE DISTHNCE BETWEEN THE SURFHCE OF THE GROUND HND THE BOTTOM OF THE EXCHYHTION (IN FEET). VH I" V F-2 FE P-4 (0 1-1 W 1 EN W 1-1 �� ME -1 IE'l F�- EE EFE T` THE GRHVEL DEPTH IS THE MINIMUM C)EPTH OF GRAVEL BETWEEN THE OUTFHLL PIPE HND THE BOTTOM OF THE EXCHVHTION (IN FEET). 1: W 1=1 p"I V` "'EH"; 1: W Q A IF, 120 I -DI �F,�§ I_ L_ C) PA SE,;; PERPIT APPLICANT HAS; THE TO INFORM THIS DEPHRTMENT DURING THE PNSTHLLHTION INSPECTIONS OF HNY WELLS RDJHCENT TO THIS PROPERTY HND THE NUMBER OF RESIDENCES THAT THE WELL WILL SEF'.'VE. ��.. Y 14 cin 12 on" A ����E� C-:7" I r,11 S5 low Q E. V Q Gh 1.1 1 04;;". E.EE E." - ---_ BRG1-`FTLLT1',1G OF ANY SYSTEM WITHOUT FINAL INSPECTION HND HPPRiDVAL BY THIS DEPARTMENT WILL E:E SUBJECT TO PRiDSEcUTION. MINIMUM DISTHNCE BETWEEN R WELL AND ANY ON-SITE SEWHGE DISPOE; HL SYSTEM 11-; 100 FEET FOR H PRIVHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM R PRIVATE WELL TO H PRIVRTE SEWER LINE IS 25 FEET HND TO A COMMUNITY SEWER LINE IS 75 FEET. F.I[ELL LOGS FIRE': REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]0 DHYS OF THE WE11. C011PLE7I0N. C)THER MHY APPLY. HND CONSTRUCTION DIHGRHMS ARE HVHILHfi-LE TO INSURE PP!OPER INSTHLLHTION. FO" EH A M 1 7' T �E : C- E: r-1 FT E07 fit A ft.' A 154 En T- I CEF,!TIFY THFil 1: I HM FHMILIFIR WITH 1 -1 -JE FOR FINE*, WELLS HS SET FORTH BY THE MUNICIPHLITY CDF ANCHORAGE. 2: I UI ... L THE SYSTEM IN HCCORClANCE WITH THE CODES. ]� I THHT THE ON—SITE SEWER SYSTEM MHY REQUIRE ENLHRGEMENT IF' THE: RL,:SID�NCI,.- IS REMODELED TO INCLUDE Mi -DRE THAN r3EDROCD1T.-];. SIGNED ....... HPPLICHNT KEITH L NELSON ...... ~~�~~.DHTE~~.`J /'�J�.�/��� V4.0 A 1 izE � "91 t A HE ol, F 1 lip! 1 Ai- gaggs"! SMRA ilo! I F151flo f)fP9:Q;fQ! FQ, My juf"3111 " if[ Ql� 1011 J- a I I OYU 10 off; MIMI —6 R 157101111 two 11 r 1 �,� [it fill W 14,11 tf 07MM-N sl�5� 1- rim -tv ;I P, - -'j flip XQUQ11 iQj jr! G T PER Y 71 AKU 1 le" as 0-11AW 11 A oil PMM Zvi Awcm -z7yq j Fv- 1 T QW P; sm -Taw if! 1 NT, R Fl, F FY l 1 i'l 1 s i N, 1 j 1 lip, u ; 1 Yno a to 14 {4'414 T( V f so, A 1 izE � "91 t A HE ol, F 1 lip! 1 ilo! I F151flo f)fP9:Q;fQ! FQ, My juf"3111 " if[ Ql� off; MIMI —6 R 157101111 two 11 r 1 �,� [it AwYn 07MM-N sl�5� -tv ;I P, - -'j flip XQUQ11 iQj jr! 11 -f -M 71 lv, oil F T IDN rV15 1 2� -z7yq j Fv- 1 -+ Ql 1- 5 1_1 P -A 1 P; I wwrif 1 YiN 1. 1 if! 1 NT, R Fl, F FY l 1 i'l 1 s i N, 1 j 1 lip, u ; IM 111 of J17- f ;wv: Kv- 11 1 Tin. ;f 1. d' AY rks w t ri vis i s v I r 1H, f i ON PPY 7r H` W" , A 01300 1 fit virrartau,, Cr?"i Fw_ T 115M Ff hPA 1 1 =r . n Opp, 0i f 7011 1 FS P-__ !,us -01 10 An vWfi7 i AMP3 Fuss- lc I [V H�D -o "s r to 1 ppA r0t,"' _C ;j 1111, it f 1 WFIJ P" A 1440 1 QTQ P. yn WOO ?1141 whu AQ: CVIBIWANY Wo WAT to! 1KTIOWNW, it, 1; i� 'PI poly 1"Mr. -WOUS r Y -N Wo F SQ.-- 1 1 no wj - Olt tn I-- 1 1 WMAHR tit 01 �Hll 1, ;.­F;jw?4 T 1 Al 1 1 141i i i xjc; rot i rim- 3 ; QAA&F&HMN MAP 10c M A! 11, only WAMA7 01- W 10511-1- 1 4 &Y 4 UP F D 1 f! 1 W �!_ Ut .: Hlilo_,,r�� s M to MRAT ; r+ r w W Y 4� vYi < Y co Q W w A Ix m m 3 a .tea ° ® a Y y ♦ w a J a v Q a c� z a U 1� w W >Cq i i cc �s w Nm x ry W U LL p d c� 0 Q A h Y. 0 a vYi < Y co Q W A w A Ix 3 .tea a w O w Q Z F x w i i i (z ry p d c� A A Y. A A � .tea ua Q A F x w i i i p d 3 A A MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE ,l 1. General Information Application Date 17m 14-84 (a) Legal Description (include lot, block, subdivision, section, township, range) L r f-6 1oadl Pir ash S )l� % /Siy 2 & u) :3: /yl . Location (address or directions) K c���� z914 i (b) Applicants Name s pj15'otj Tele phone e home Business S;7 2414 Applicants Addres (c:) Applicant is (check one) Lending Institution Owne /builder ; Buyer = ; Other = (explain);��� (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent1LL:TOP __ "o kt.5®") �. Address 94) (0 f� 00.1 vjsrn Telephone 34'6 zboo (f) Mail the HAA to the following address: nC?�A)I 1 V1cnD O`��iJE'/ 2. Type of Residence r Single -Family Multi -Family Other (describe) _ Number of Bedrooms 3. Water Supply - Individual Well IM Community Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite Public Community 7-7 Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 21 { 5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is 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 in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm COK)S i (JCS' *� =.lq rneierS. l✓)c Telephone _? 6zoop Address22 I �Q u eyJ1 aie- Date �✓ �� 1`l(� O('G L'� 9� ;: �� L°�S•n� �ft r, (ENGINEER SEAL) 6. DHEP Approval Approved for ",& bedrooms Approved -;-� Disapproved Terms of Conditional Approval .a R ev By K/ Date^ Conditional CAUTION THE INNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE: OF .ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. TIME MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THF PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEAL'T'H AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1.984 Legal Description: 1. C",-., ;aec NIAL ION .JA N 7 198E) Well Classification ?1R)VKFE If A, B. or C, D.E.C. Approved(Y/N) —_ Well Log Present (Y/N) Y� Date Completed V_98 1 — Yield 2.� Total Depth 4� I Cased to 24iaeA,a� Depth of Grouting C* Static Water Level —� Pump Set At S4(.1 Casing Height Above Ground _ 18*1 Sanitary Seal on Casing (Y/N)y Electrical Wiring in Conduit (Y/ ) Depression Around Welllead Separation Distances from Voll: To Septic/Holding Tank on Lot 1(DO+ On Adjoining Lots 1004 - To Nearest Edge of Absorption Field on Lot 14:0+�; Or. Adjoining Lots 10c9�--� To Nearest Public Sewer Line _ IoO+ To Nearest Public Sewer CN A Cleanout/Manhole 100+ To Nearest Sewer Service Line on Lot Water Sample Collected ByL2.wCJ��+''.�o- -_, Date Water Sample Test Results _=�'�sSe-D Comrrnnts PIMP-LoAVceVST 1584 4_ -Ow ?C -KF ZMerV $y et w) L L) p� nn LtV G C.0 , AJG1> �9-84 ((�0A,- rrA c-" 6 B. SEPTIC/HOLDING 'LANK DATA Date Installed -rvJ� 81 _ size )oc�®� No. of Compartments Standpipes (Y/N) I Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) N __ Date Last Pumped iZG L 84- Pumping/Maintenance 4Pumping/Mainterance Contract on File (Y/N)Nt(_ for,— Holding Tank High -Water Alarm (Y/N) U/� Temporary Holding Tank Permit (Y,/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well 100 14- To Building Foundation_ I`a' To Property Line �— 15� To Disposal Field To Water Mair./Service Line To stream, Pond, -Lake, or Major Drainage Course Receipt # Date Paid: Amount:k, i- xi (Page 1 of 21 2-15-II4 C. ABSORPTION FIELD DATA o e� Spa-,� NSI C -LI Soils Rating in Absorption Strata %b r. Type of System Design i� Date Installed ZyyuL'l 8� ($I- 0395) Length of Field Width of Field _ d"(�'Depth of Field Gravel Bed Thickness 3 __ Square Feet of Absorption Area _ Standpipes Present (Y/N) Depression over Field (Y/N) (J _ Ikate of Last Adequacy Test ��- Results of Last Adequacy Test �DaTAuP.TS -�bC, 3.3-DetA k1O\YKK Separation Distance from Absorption Field: (! .Ic.�•� To Water -Supply ill _ �� _ To Property Line To Building Foundation 7z's! To Existing or Abandoned System on J* Lot N A _; on Adjoining Lots 751 To Water Main/Service Line N P� _ To Cutbank(if present) W) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments 1U909MAMQJ L>ArA ;?Oe- eX\!srrNy- �!IeLp -TAKEN PzolA FE2v�Ir INS P6csn L -0J ON FI t -d' e D. LIFT STATION NA Date Installed Dinensions Size in Gallons _ Manhole/Access (Y/N) �y "Pump On" Level at "Pump Off" Level at High Water Alarm Level at ,— Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes(YM) Comments__— ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conforrred to all MOA HAA Gu d2tin fi�"t% effect on the date of this inspection. Signed e-. _$-n�F,�o Date Company e s V - aJL, MOA Nom& 4--OZ3 KB1 /d5/s ,1 ,f„ �. z (Page 2 of 21 !' 2-15•-84 5. LEGAL DESCRIPTION DATE RECEIVED INSPECTION APPOINTMENTS 81arz<JG4 d TIME TIME TIME Ac . (D �Q p C \ro DATE / DATE DATE i0 -Y\ -Y,\ INSPECTOR 4 ` �4^C4 INSPECTOt\�J �} \ INSPECTOR 1 MUNICIPALITY OF ANCHORAGE t��I I IPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTENSg1EPT. & OF HEALTH 825 L Street . Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION • ENVIRONMENTAL SANITATION DIVISION OCT 13 1Y81 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEVRERILV�� DIRECTIONS: Complete all parts on page 1. Incomplete requests will not he processed. Please allow ten (10) daysfor processing. 1. PROPERTYOWNE PHONE I ', IVe,l`5ell 1/1 624-1-1,124<1 MAIL-ING ADDRESS 5T RT $ #/ ,via WIa4,'a ter- Cv%1 PROPERTY RESIDENT (If different from above) PHONE e-- a/� NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION T PHONE MAILING ADDRESS 4. REALTOR/AGENT PHONE MAILING ADDRESS - 5. LEGAL DESCRIPTION JL 81arz<JG4 d in a 14 e P 16757 STREET LOCATION 6. TYPE NUMBER OF,BEDROOMSS 7ESIDENCE 0 One ❑ Four ❑ Other SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY pd Three ❑ Six 7. WATERS PPLY 10 INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE ISPOSAL SYSTEM i INDIVIDUAL/ON-SITE** (5I _YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) /' ,a n,n 140., ;;/741 THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE D SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE 4�]� /THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY f�INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified___ PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED - 3. SEWAGE DISPOSAL SYSTEM QfNDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED t INSTALLER 1` ❑Septic Tank�r ❑ Holding Tank Size: is If Tank is homemade give dimensions: SOILS RATING / TYPE OF TANK - _ MANUFACTURER TOTAL ABSORPTION AREA MATERIAL C! 4. DISTANCES WELL TO: Septic/Holding Tank Absorption AreaSewer Line Nearest Lot Line _ Absorption Area to nearest Lot Line - ' 5. COMMENTS Ih�'APPROVED FOR <S BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) . ❑ DISAPPROVED DATE _ BY ,a n,n 140., ;;/741