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HomeMy WebLinkAboutSCIMITAR #2 BLK 2 LT 28� o )I -w-w I sel-�Ic� MUNICIPALITY OF ANCHORAGE t j DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 826 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME � [PHONE EW,411-w Iq TT -.JIB ❑UPGRADE MAILING ADDRESS _ /�3c x /9 LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS DISTANCE TO: Well > Jn(l Absorptionarea �5 / Dwelling ' PERMIT"NO. U Y �e)l 1 <" - F- Z 0.a Manufacturer di✓� r' r %e !s ; ��_ > Material ; ,z_. � pass No. of compartments W F- ,-/f,._�c N Liq. capacity in gallons `r -�0 IF HOMEMADE: Inside length Width Liquid depth IJ �' DISTANCE TO: Well z.�- Dwelling _.,e., PERMIT NO. 2 Z Fa- Manufacturer Material Liquid capacity in gallons 0 x DISTANCE TO: Well Foundatjgn Nearest loi((� in% , PERMITNO..� _-.. LU a z No. of lings Length of each line Total length of lines Trench width Distance betty en lines P Z w / _ i •Q inches /✓ /f' NTop of tile to finish grade Material beneath tile Total effective absorption area o 4 r inches 31'6 ✓G-, Length Width Depth PERMIT NO. w (7 oar w� Type of crib Crib diameter Crib depth _ Total effective absorption area LU DISTANCE TO: Well Building foundation Nearest lot line _j Class Depth Driller Distance to lot line PERMIT NO. J DISTANCE T0: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS ,/."/li,,(, 2/LII/n/ /"'i1'4 SOIL TEST RATING _ INSTALLER I/�L lit REMARKS I z OF Az - ,(�j. p°°cD•e ono .® eni ° 1°° G^OD u• •Y • ® ^, Earl P. I. -Ills � ;�j'D°° NO. 1745-E e �I. — i 0 alp °ROFESSIO LEGAL APPROVED DATE i 7 � /').f 11"2 fP— 'i/7A1 ICIPA1. OF ANCHORAGI? rrtifirb Ddifing/ IFILE .,'C:TION �! by �' ' A & L DRILLING COPAN JAN �'�0 BOX 97, EAGLE RIVER, ALASKA 99577 • TELEPHONE 694-2588 E,C,;Erl 11 _ED' OWNER OF LAND ADDRESS_ _' % I - `F / . STATIC LEVEL OF WATER FT. LEGAL DESCRIPTIONL __ -_ %` ` " •' % DRAW DOWN F"f. --_ r_ DATE - Started v Ended i` ' ` _ GALS. PER HR - PERMIT NUMBER KIND OF CASING ' DEPTH OF WELL '- KIND OF FORMATION: i From Ft. to = Ft. G+ r ,;',' .._1 From Ft. to Ft. From Ft. to Ft __ From Ft. to Ft. From Ft. to Ft. Ft. _ f__ r " From From .-_-_Ft. to_ Ft. - - From Ft. to _Ft. Ft. From Ft. to Ft. Fronr Ft. to_ From Ft. to %'-' Ft %fr`=• l -- .-. From _ _Ft Ft. From From Ft. to % i'` Ft From Ft. to---Ft--- o FtFromm From. Ft. to '.ZFt. i := l c. "- From FMW1_CIPALITYFq),P ANCHORAGE -_---- __ DEPT. OF HEALTHY -- - From Ft. to Ft ! __ f� i ,,:_ r _; , " From _ FtEtV RONMEN[PQI. PROTECTION From Ft. to Ft. 3� �, .�' _ �'_- From Ft. to rFI �y nno� From - Ft. to .� � ? Ft �i - /Jn /" f-�lrt.. = J - From -Ft. to-----1177Ft. I� - ----- From; Ft. to `��� Ft. ��' <4<<� . �` Frain Ft. to �r �t�= _ From Ft. to. % , Ft % = rl ` �� `�'; _' `'ter ' From to--Ft.-- o_ Ft.From -Ft. Froml' ; Ft. to _ 1 '" ` Ft. From Ft. to_ -Ft. From Ft. to Ft. From—. Ft. to Ft. From Ft. to From From Ft. to _Ft. Ft. From Ft. to Ft. MISCL. INFORMATION: r. From _Ft. to_ Ft. From Ft. to_ -Ft. From Ft. to__. Ft. From Ft. to Ft. Fronr Ft. to_ -Ft. DRILLER'S NAME TYPE OF SOlL H8SORBTICIA SYSTEM ISTRENCH MRXIMUM NUMBER OF BEDRO0MS � I SOlL RHTING (SQ FT/8R)= 85 THE REQUIRED SIZE OF THE SUIL 1:18SORPTlO11 .1 SYSTEM IS: ��-o l�. g � �=, . � 11 V::-lp ��������� �;:;: -': 0 ��;i 11 it 171 Iwo I E 1. . TO K 1"" -1 $-1 . = wb; THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE BETWEEN THE SURFHCE 11" THE GROUND RND THE BID TT0M OF THE EXCHVRTION (IN FEET) THERE IS NO SET 1, 11 FOR TRENCHES THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRHVEL BETWE£N THE OUTFHLL PIPE RND TH£ BOTTOM OF THE EXCHVHTlON (IN FEET), out F1 TO U 1 IN FE I J AN TH Box I - X 42 - w- Vol NO 0< K3 :17 & FIT= ���!!.:wlil ����, ijm F, , '11 :�l:� �:: PERM\T HPPLlNMI HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTHLLHTlON INSPECT[ONS OF HNY WELLS f TO THIS PROPERTY HND THE NUM8ER OF RESIDENCES THHT THE WELL WILL SERVE, �~~— �0-113 C R! > 1 140 G" FA BE QlF X Ff by YN WWI Q 47 Tot AD! 11 .... '10����� -~'— BHCKFILL7NG OF HNY SYSTEM WITHOUT FINHL INSPECTION HNT�, RPPROVHL BY TUIS DEPHRTMENT WILL BE SU8JECT TO PROSECUTIONL ���1-0 : 4 -1 - HN&I ilk TOM5 TO 1H ED TH M FA 17: 13 -�; m!� ��� 1J..����� VI2 Steven A. Johnson ;3ox 76 Chugiak, Alaska 99567 Phone: 688-3085 Soils Log Percolation Test Performed for L. i VL0`-T L a S Ove �^ Date Legal Description LQ �- ��} �3I Ocd1C d� �� n.� -6, Test Pit Location b Ito � _ �� '9 �rejYVI CL(, 0 r — rv�+2/6Jt;u 2 - (� 13nLuv\ 1H 6 12 14 16 6w W i � bov�dem �O s� mi 1/\O C jc,ti e -y l C� dc- Total depth this test feet AVERAGE ABSORPTION AREA REQUIRED FROM SOILS LOG = ___1-)1,.ft.2/bdrm. DATE NET TIME(Min.) NET DROP In. PERQ RATE(Min/in) Percolation rate Signed minutes/inch I I .� i f. 1 .1 1 A j All" !dkNkRAUN M I if r'i IJ L666ti6h (,t Ito, 'd 'fl It JI: Malhhg ."d ill4Pi If Leh I ng 'IIJa IML If 1 .1 h gtl S6 ddi 16 Address Unless 6the4ilie'r6i If NUMOMOF BEDR I 17, ;T' sll 3. VIA EWSI jj If rid!4 IT fill IN IL �1�- Y,40114 q It �1. ? I !I! it V-5 N c If ! A W;lit t I � 1l TI 4. TYPE OF V it" n' I V t it q 1, 1 k ; I if it i,Noldir Xlj FI" N0 TE: If comMun I� attesting tc 72-023 (NV. 1 /91) Pl MOA�N2i" Ill ' Vf l"i if I jj Vf f" If "T rry,, It LING 2 .''bay phOHO Oay, phone T f -6; If "pay phone If is il a ter nfir-mati, iI t sc t r �i i a�rl Ill: 1 {' •'' h(,r! 1111, i1A l(G%'}� 9P�i ((�Y 1±{6�'Ip! tsi I1..� I , :� II{ MP�I�'tl '' '� � a $: 1 V STFEWNT..OF INSPEC 11 ,, ,, 1. IU}, 1{I! , {I j t 5 1 1 1Ir j I I 11 rfl I. lfi i'll 1 , 1„ I I � {�'1 , A ( l N ii r �• � A !d � I � ( J I 'I�U'41 { l+ii�� l 1 1 ! I, � I�e1 1- , "Ii I i --. , As oertifi��h 7Y`rrly seal Oil KO f ��V�IIdtlan'da ahoW�t �q14w, I verify that my,,, 11 f i � I I .L3 (I.x.' r,l,:�l{"�rI1n+5ip�11�L. . f'l,� y�� l° `Invest( a gf;this H©alt `, Y f' P pt o Oat '6n-site water Supply! l p I tlya t, I' '1, I�rft 1+'111 -' �'„I 3'!�� VI� i f'i� j-T?7�Y}{'I�t li�{ jl l��{�i��Yi�j�i �?�i rl; , I I `{ it i' , and7or wastawater'dis Qs$ $, jpry�]� 1}(A 1014 }tl pqp ( for the number of bedrooms 111411) /I J'�I ) 'lu>,.1 Ay 1Sill II1 U��)1'tl+l p,'If�A._a}�I u1�19t"I rl I %lAYf}+rt6'{�'tII�L�411i I' ).. ,T.;' i(1 i; '.;' + and }��J�qq! f structure Indio p p[ }per 1 K ap a 61 formpppt) n obtained from a I'{ l ip Zo F �y 1'411 rY g11��1�iY ��FQ'{b, i11C'{Ivl'1�'{1l�FIIII I �I , J, ii�{ k, l I I I I i, 3 4he'on site"water I, f` , C I, i the Mujr�'ICipplity,of Anohora Irp�}Qr f Y ! Y�si atl n p„ d`�rlspegtion, �r1fi�141 l f�,i �,i :Ina '151 J1,1; .111 .,, ,, lil,(� �l( 15.1j1,�I��II L��`f�'13��i1-'i!t J,+I'I Iti �t/}ii�{I{,1 {�II!:'il I,.i. II' I, r I lif, 11 z ,a supply an it wastewater;d( j[¢� I •� (c �1I 'rI�'c�k rj� Municipal and State codes, ail 1. SI �}to { �, Si RI'IiS� '! 1'.I- I 1 1:111J?II•'I" i 1111' '��I, i I:'111�1�'ll l i=1'1'1 ��j Iill �li,Ie.'' I �I 1,, .ii ' 1 1 Vii" ;+' rdinan and re ulatlons e . 1} a i s pc l l f1rY 1 1 t 9 11 l II. f' el J L, �I i ll,i{S.l�i(�.�r 1 tem}' 11E?:.SIaP 1 ,i '1 � 6�l l�b � � Q��7'�.i 91lie:. 14{b,r r } r Na , ir1,431 ) n n!�li.,'4Y 11Gdl1 ... I f-:fl 1. Ir t ;714,1 �JI IIA y.I 1-.ini 7l �yM'��I F1I i I I' ill 1 11 �, rQ6q11.1704 �,�,�I'ftIY!�►�1',, ���,��,1,,�;�l�l��lkl��t;V����}';i'�ll�:,1 ��rra���r1u,, 'i I�_ h�� ,! {( l e r 1, f j i I r a 1, t , ,. I lI 7 1 i ire. 1 I'd I � r l J �@1�pI II l� J I{ { + (1i1�1�� {pi' I i f �I Ilii il. � I ��i 'l�h !",���111�til If�1�1 �' }r 1 IIS% � 9^� ! � 0 fffii r I 16F Engin aignature �+i' �'�.� ,1� ru-� ,FIS tf{Ipate___I �}ss++11{:�{, ' 1" '�:. i Y ' ' )'' ) 1, +`.I t � �1�( y, II . 1 ' 11�1i { tr- f !; �p � 1 sl 1 ,i i,I�11I 1111 If li�•i! , I � IiI i i I I I:.i I '�I t e% f F'(�II.I:,1 I t :. r I l l 1 f I I f �I,. , 11.1, I II a 1 b u II ; HL!I ° yy d II jj �• �5 , a�iil 111 , f •. ,. f , i 1, , - i� 4 ��1i Y'r �'iI 6^�I(I�I' 111 1l��II'll�. N�r]tr,i IC.: II ilii � �� 1 � I1 .In ial I. il✓� Ili I,If ja1l / { I I Init jl 4P', i+.{!I.{ P ainl Ill r # I i� , ,j 1, r I I�•. ��I. 11 I I.. { I , , 1 ,11(<� ,1 71:1 ,, � t�(� it 11.�w1 f "). �Q it , rl', 1 1 1 1 111,1 I, i� i l l7 t r- fif 1711 i 9dj f( 1 @Nllt11""fa ���� j l i?•j i 41 P J I{It {r ,/Iy,!'e �>l. 'r, :. �{ 111'11 ),I'd l y} 1 1 { , l I'll � I i11t ri�d� , i , f 1 I7 � I' • I �� ,! a i 4 �.• J i I{ ii I��' �(c�.'rl �� , f71 I i14� I l l i r, a f i' i ySy r r I• PPP l{ II rl =1' r I I�f •%. tl I.. ', }1. �;.4%Ik P:nnll �Il 'l+I+hllYlli n!j-jrrJ ..ry.. rt ,h, I,IJ� `-Is- ,.�II r-F�n� 1.�1t{1r li dl�ll �aa i I �} N;S�+) il� I•� 'q� 1 (, It1° 1' r F: u i , .- r� :'I y 11 I �r � I (I I I�•1 , i, 1� 1. i I:;i � In ql4 qrn (e�rrNula �.ew 'i i" v r M t S iii (1'r' I ( Il 11 I I d Lo 'ROBERT Q,.-COWAN w ♦� 1,6:(IaJI; DHMS{SIGNATURE{.3f1,1, i I F,{II e, I �.,k Ili I I 41 II t l�I� {1 1Jrn _ 1afpllNlPN�a Iii , f 1 r li il, i - 1111( .! a,)�i)i;i'I/ Ir }I ,JJ ,,,, 11>•h.>:,a,;I-11,11Approved.for _k a rQQms II;H,�1I111',- II 1„i Ilf ��a F 95�4� 1 5''I 11 ,7T,i 1 a'IN {' 1 �y'1 {Ii q-�!' 3 ,17,_1( I,-`�, r {,., �I �•yti.� .,�c I 1 rIJ l c 1 I III 711,it1{+!1 . F 11 '�4 N� �{I ,f1 lin I IILI ''jf� filil �Aiq I. 1I a M1LV, ( if,dx d 1 l-.I it ' .! i 11 ,6' lei*1r-tl", A �ISapprOVed I rlaj't II Mdtj f v,i+li�rN k{ i 1111 illg; iql an �Ji IIHII}p. }l, I' In 1 I Y ;���' l i I_ �f; I I , !i,� �, J�� , , Il g I ,{' ( f s (sll �i { f ,� ,I ,Il r {1 I f 1 1 .q 1 II ,.? ar i f {i'r 111f 11{I fl II �� ��I ���iL 3i , I III � e ,�� fl 1141. 1:. 1,, �i Ili R, �"11'1 r I , '-, �) 1, ��N ltlt ) ll ' Conditional approVal}fgn ill e�rooms,iwlth�lthelfollowing stipuletlons: 1 li+ i I t ri{ �,I l,e-�•�: f vI 1'I I I„i �,-�_.__ ' 11�', •�' ''1 .Il:�.il Ull, 1. ,r li ( 1 ,_L i �r1 I fl •:f ' , I C. , i){Jri� � r1r 111(1-il:v i Ila f� f ill 1 !�_�� . r it , I !t: -SI 1111r !,�`i� r4alllb ((l II It , ILl i ;I Ii'i 1 i 1 t I t f� ` •It F l �.-{ d 1F•{dNJ,,f.{ I �� I,,,, >,,;. � I1�i{ f;• {i��Sg111GG1�i1 ,y , , ,: If• ( '. I, 7[ 'i4 I � Additlon�� �gmments ii y .,� - �!, r♦/ sl! i s }1 I I (I r 114 ! Y` ��'. - I4 !s 'j; /I 1I�p�9] )h)},` i{{,- frti,,.� l•I��ir�l���1�ji 71 I�II I 1' �'I V 1 (`•'11 tSlin'r `r,•. It {•e I I 1 } 9�yrtx l 1 rrdil ,1 i ! ,I, 1 f- ' 1 W l 1 1� 7= I .111•�� { ,+ -1' �i 1), i { r {' fi, , i'�� r. � ' l IJ *��A{.,ll rlE li � I'F 11 ,} •�i.i; ll�' Iia f I'r���il' }i ��'¢�F�S it �� Il f �i1 YI �1���4' + 1 i'1 {., .��'• a r4 l�al h..1��fI ' ,t lk Ia. i{{jl �L�t Ix'�i r�Fi1 ,ilA', a(Ii JM iitw Itis .tp{��rl ilq {j�t �1 7 Al 1 i 1�, I f �1� 11 4l P i J a 1 {, ��r�), ` �.i•I } �� N. 'hld 63 n€ - 15 , +'f>. Il!".+ r ),j3`T 31t'1 a�11111 ti IJ i 'I it%r1i If}aM 411' r,l i _;The Muhldp' Nifty}qf Anchorage Deplaj411�16p�1 � h1slth'and;f1urnan, Hn{lces�(phjNS):issues Health Authority 1 ;;, { 1,;'Approval C nlflcatos based only Upo�T7th' s prosentatiogs;'g�Yen i P ragPaph 5 above by a0ndependent I 'I 1 :I. ,� Slll N< { r{,J('}}fg , i-. rlkAf �5 I 1 v {I r. ( f -. professional engineer registered in the $kl�t At �la�k� r[hH pji�MS does th�s as a courtesy to purchasers of homes and their lending Institutions in ordergl�lsfyilt}{(�;federal+fid stata (qulrements, Employees 9f DHMS do not ;cpnduc `In§pactions or analyze da�a I�q�r ;k1 a (flc te,l'; issued; Thg unicipality of Anchorage is not '1 ��•,- } (� IL}i113'S'if '(�l•lr l[tl5 }I,respQnsibla°fori errors'or omissions irk Q I @I enginapk'8 yygr e .e 1111 f �rryr, 1 }iI il. f, 1' 11,r io INP ip I'1 i( i , { ! 1�•1 I N} {1 I ff { I,i9,i ?PPT 1 k YI t{ ItI lr I_:�I 9 111 11J1 ,n, 11 li7-0'�S IRW 1/911IrOKIiM0A III{ �� N21 r:{1yl I ! I, t { fF o A I _ YI �t ' I � •,, r , Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L- TT Z-5 F-A.,.te-'Z S( -L /--A , ro t'.z Parcel I.D. A. Well Data Well type P2 a A -S- If A, B, or C, attach ADEC letter. ADEC water system number ~I/A Log present &N) _ _^Date completed _ ! 7%8 Driller 4�(,/It Total depth Cased to -5-3 / a � Casing height � /2- Sanitary seal ON) _ Wires properly protected„(9i'N) FROM WELL LOG Date of test 117 8 Static water level 2-1 C•ap PI Well flow2 9.p -M. Pump levell L)11— SEPARATION DISTANCES FROM WELL TO: Septic/hekkng tank on lot / o o Absorption field on lot / o� Public sewer main - °i AT INSPECTION 239 t `; I�� tTj JJ T71 �s ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Sewer service line _ 17- s r d Petroleum tank WATER SAMPLE RESULTS: Coliform !a0 rf- 00 �2s i F Nitrate a // Other bacteria O Date of sample: Collected by: B. SEPTIC/HOLOMG TANK DATA ? Z Date installed / 9 7 8 Tank size / v o v Compartments_ 7- Cleanouts OW Foundation cleanout (XINp _Depression (YKE4)/1___ High water alarm (YIW_ /J _Alarm tested (Y/N) ' X14 _ Date of pumping _ 2 - zo - 9.s` _Pumper ..7T_ nam Pj -J4 SEPARATION DISTANCES FROM SEPTIC/HOL-BiNG TANK TO: Well(s) on lot t Q o ' — _On adjacent lots I oc� ` 4- Foundation I To property line �o ` Absorption field?' Water main/service line (�' Surface water/drainage I aC) � 4- 72-026(3Is3)•Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION 91STWCE FROM LIFT STATION TO: on lot On adjacent lots D. ABSORPTION FIELD DATA at Surface water Date installed I `I -I a Soil rating (GPD/Ftz) _ BS �� X, _System type _T,2e 1 c si Length 3 i Total absorption area Width -3-15- Gravel thickness '3/o Cleanout present ()N) Total depth 9' Depression over field (Y/D J Date of adequacy test 2 - / - 9s Result as ail) �ft SS for _ 3 Bedrooms Water level in absorption field before test 0 " After test _ b " Peroxide treatment (past 12 months) (Yo /J; n)F ��„lohf� If yes, give date _ �t1i1 SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /6)0 1+ -- To building foundation On adjacent lots moi -I - On adjacent lots _(oo ` '1 - i4 - Property line /01 4- 16 1o To existing or abandoned system on lot "1� —Cutbank '`r 4 Water main/service line_14 Surface water /,)0 r'L Driveway, parking/vehicle storage area _ S Curtain drain ^� E. ENGINEER'S CERTIFICATION I certify that / have checked, verified, or conformed to a# MOA and HAA guidelines in effect on tip„ate of this inspection. � 0. i, �' �V �...•....... Signature Engineer's Name a.2 r C_ rt EJ'2� / t� -r?� �S, RO-ERT C. CO':IAN Date �(S �� <;� .� CE - 8801 HAA Fee $ -1[0, Waiver Fee $ Date of Payment Date of Payment Receipt Number ��� % o2 -S �rf Receipt Number_ 72-026 (3/93)' Back MUNICIPALITY OP' ANCHORAGE M E M O R A N D U M NATER WELL ADVISORY HEALTH AUTHORITY APPROVAL N0. HA950156 During a recent- Health Authority Approval on-site inspection and test of ttie potable water supply well on Lot 28 Block 2 of Scimitar $2 Subdivision, the well's productivity was determined to be 0.5 gallons pea: minute. The minimum well productivity required by this Department (AMC 1.5. 55) for a Three(3)bedroom residence is 0.3 gallons per minute. Although the subject well currently exceeds this minimum requirement-, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. 05/01/95 15:38 COMMERCIAL TESTING 4 9076941211 ME Environmental Services Inc. ZtL Laboratory Division 90 CT&E Rei.N 95,1594-1 Laboratory Analysis Report Matrix WATP•R Client Sample ID L28 BLK2 SCIMITAR 02 NO.349 P02 Released Sample Remarks: SAMPLE COLLECTED BY; IIA, QC Allowable Icxr- Anal Parameter Reeulta 414a1 Unite method Limits Date Date Init -------------------------------------------- --"-------------`•- --10, 04/28/95 CMR Nitrate -14 0.11 my/L. EPA 353-1 —� t tl yvY2=PvnIC�=VYC=.D 6 w ^�6�=+ 6 w tl� D VA Unavailable See Special Inetructione Above NA a Not Analyzed xw See Sample Remarks Abov® IT = Less Than Undetected, RepOrCed, value is the practical quautif/cation limit. GT = Greater That) Secondary dilution. m _200 W. Potter Drive, Anchorage, AK 99518-1605 — Tel: (907) 562-2343 Fax: (907) 561-5301 rNVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA. FLORIDA, ILLINOIS, MARYLAND. MICHIGAN, MISSOURI. NEW JERSEY, OHIO, WEST VIRGINIA WORK Order 14204 client Name S & 9 $NGINBERING Printed Date 05/01/95 @ 15:26 hra- Ordered By BOB COWAN Collected Date 04/26/95 cd 11:00 hYs- Project Name Received Date 04/27/95 t 10:00 hra- Project# PWSID VA Technical Director STEPHEN C. ED Released Sample Remarks: SAMPLE COLLECTED BY; IIA, QC Allowable Icxr- Anal Parameter Reeulta 414a1 Unite method Limits Date Date Init -------------------------------------------- --"-------------`•- --10, 04/28/95 CMR Nitrate -14 0.11 my/L. EPA 353-1 —� t tl yvY2=PvnIC�=VYC=.D 6 w ^�6�=+ 6 w tl� D VA Unavailable See Special Inetructione Above NA a Not Analyzed xw See Sample Remarks Abov® IT = Less Than Undetected, RepOrCed, value is the practical quautif/cation limit. GT = Greater That) Secondary dilution. m _200 W. Potter Drive, Anchorage, AK 99518-1605 — Tel: (907) 562-2343 Fax: (907) 561-5301 rNVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA. FLORIDA, ILLINOIS, MARYLAND. MICHIGAN, MISSOURI. NEW JERSEY, OHIO, WEST VIRGINIA Municipality of Anchorage MEMORANDUM 'ro: DHHS Accounting & Budget From: On -Site Services, DHHS Date: March 28, 1995 Subject: Request for Refund - Account #2570-9426 Please make the necessary arrangements for the following refund. The engineering firm withdraw the request for a Conditional Health Authority. Please refund the $300.00 HAA fee and send to the address listed below. Thank you. S & S Engineering 17034 North Eagle River Loop Road, Suite 204 Eagle River, AK 99577 Legal Property Description: Lot 28, Blk 2, Scimitar #2 Kathy Bouschor On -Site Services cc: File Receipt # 833-00712 Amount: $ 300.00 Account # 2570-9426 Municipality of Anchorage • DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Services Division Telephone: 343-4744 A. ON-SITE SERVICES FEE DOCUMENTATION Date Paid: �� Permit Number: Name of Payer- Name 9n Check) f3 , Receipt #: Mailing Address:,(Off of Description(s): Type of Payment: (Indicate Amount Paid) C/ 0 %JAL Health Authority: Excavator Permit: _ Sewer & Well Permit: _ Engineer Permit: _ Well Permit:-/). _ Pumper Permit: — Sewer Permit: Well Driller Permit:. Copy Request: Tank Manufacturer: (Waste Treatment) 72-034 (Rev. 10/87) DISTRIBUTION: 7�Za. 4,z) OS -00712 heck #:�7�� WAIVERS: Lot Line: Well to Tank: Well to Field Field to Surface Water Tank to Surface Water WHITE—MASTER FILE CANARY—PROGRAM FILE FYM nc 15, 1995 ROBERT C. COWAN, P.E. ROBERTA. SHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 I IEAI.THAUTHOP-'• Lucy Fou4t APPROVALS P.O. Box 670896 WASTEWATER Chugiak, AK 99567 DISPOSAL SYSTEM REFERENCE; Lot 28; Btock 2; Scimitar 02 SEWER&WATER MAIN EXTENSIONS Dear M4. Fotut, Our request 6or a Cond Banat Heatth Authority Approvat (HAA) on .the SEWERBNMTER re6ereneed property ha,6 been rejected by .the Mun.ieipa ity 06 Anchorage INSPECTION �1 _ (MVA) Vepartment 06 Heatth and Human Service,6 ('UHHS). We requested the "eonditionaZ approvat" based upon public water being connected to .the home no .eater than 15 September, 1995 and upon the 6aet that your request was based upon a re6inanee as opposed to a )wase 06 the home. ENGINEERING STUDIES AND REPORTS It .is aunt understanding that .the project to extend pubti.e water to yolt subdivizion and a subsequent connect to your. home is not pltuentty planned jolt con.6truciion .this year. Cultitent status o6 .the project at Anchorage Waste Water Ut-i e ity (AWWU) .indicates that Ata4ha WELL INSPECTION Pubtic Utit ty Commi44tion (APUC) approva.2 o6 .the voting method .i6 not &FLOW TEST expected untie .the end o6 May. 16 the approvat .i4 not obtained anew vote witt have to be taken be6ore the project can continue. Under the best scena)Lio we wowed a.6sume the APUC wilt approve the project ata it is currently e,6tabti,6hed and that the A4semb.ty witt set up the SITE PLANS d 6t,%ict by the end o6 June. This would mean the dez.ign, eoutAucti.on ptau and 4pecij.ieations witt not be heady be.6ore September o6 1996 which wiU delay con.6tLuetion untie May o6 1996 at the eaictiest. ROAD DESIGN Band upon this information, the Heatth Department .is not witting to i44ue. a HAA until they have a more 6-vun commitment 6rom AWWU. 16 you with to proceed with your re6inanc%ng, Jim Cro64 at the DHHS would be witting to di-6cus6 the .6itu.a#,ion with your .loan ob6.icer and perhaps a SOILTEST resotuti.on eoutd be reached that wilt 4atis6y all concerned. The MOA has indicated that they witt 4e6und the HAA bee that we paid .in yowt .interest, there6ore a corrected bitting if, a%i:.:r::.ed. PERCOLATION TEST p When we may be o6 6urtha 4erv,ice ptea4e contact us. Si ere2y, STRUCTURAL& MECHANICAL INSPECTIONS A. SHAFER, P.E. 17034 NnRTH FArI F RIVER I nnP . RI IITF 9nn . ❑Ar1 r GIVCP AI A0VA nnw� RA g ONSITE ENCLOSURE WASTEWATER DISPOSAL SYSTEM DESIGN 17034 NnRTH FArI F RIVER I nnP . RI IITF 9nn . ❑Ar1 r GIVCP AI A0VA nnw� o Municipality of Anchorage REQUEST FOR VOUCHER CHECK FROM: Dept. of Health & Human Services (DEPARTMENT) TO: MUNICIPAL CONTROLLER DATE: March 28, 1995 la g7d77 _ THIS SECTION FOR ACCOUNTS PAYABLE USE ONLY —� 7099 VOUCHER NO. PAYMENT DT. V VENDOR NO. REFERENCE NO. INVOICE DATE INVOICE NO. DESC I I I LLnTi = CHECK NO. CHECK DATE PREP APPA 1. REQUEST THAT A MUNICIPALITY OF ANCHORAGE CHECK BE ISSUED TO: Name S & S Engineering Address 17034 North Eagle River Loop Road, Suite 204 Eagle River, AK 99577 2. THIS PAYMENT IS FOR THE FOLLOWING (SUBSTANTIATION ATTACHED): Engineering firm withdrew request for Conditional Health Authority which was based on public water being connected to the home no later than 9/15/95. Project to extend public water to subdivision is not currently planned for 1995. (Lot 28, Block 2, Scimitar #2) 3. DISPOSITION OF CHECK: (1) IX MAIL TO PAYEE (2) ❑ MAIL TO PAYEE W/ATTACHMENT (3) ❑ NOTIFY PAYEE TO PICKUP IN TREASURY Phone No.: 4. ACCOUNTS TO BE CHARGED: ITEM 5. TOTAL AMOUNT OF CHECK 6. SIGNATURE$ 4V('lEim�plo�y'eev-UX I D Phone Na. 7. INSTRUCTIONS AUTHORIZED USE ONLY (6) 0 NOTIFY DEPARTMENT EMPLOYEE WHEN CHECK IS READY IN FINANCE Name: Org. No.: Phone No.: _ Approving Authority a. To be used only when payment cannot be made by purchase order, travel expense report, travel authorization or petty cash. b. Must be approved by department head unless approval authority is delegated in accordance with Policy and Procedure 24-7. c. Retain carbon copy for your file. 40-001 (Rev. 2/91) MOA #15 1 1 IIN MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES p1p� Division of Environmental Services��'"° On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAK41LY DWELLING Parcel I.D. # / — / 3 Y,6 HAP. #P — 111A" ' GO' f i 1. GENERAL INFORMATION Complete legal description Lot 28; IJLOcf 2; Sc..imm,itan #2 Location (site address or directions) 20087 Ty_&c i Chuaiak, AK Property owner Lucy Foust Day phone 688-3990 Lending agency _ o_ Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. M 2. NUMBER OF BEDROOMS: 31 o z_ t'7 1 M n U) D 3. TYPE OF WATER SUPPLY: 12 -N 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX Holding tank Community on-site �w Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Re. 1/91) Front MOA 7121 Individual well XXX " v c5 n Z Community well R v, In x C Public water N O NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX Holding tank Community on-site �w Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Re. 1/91) Front MOA 7121 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown( below, I verily that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and typeof structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my invest!gation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Warne of Firm c 8 Q EN ERiNG — Phone cl I Address 17034 Eagle R ve 7Lo p Ro d Kivor c Q ' Engineer's signature �.w DateA� REQUEST YOU ISSUE A CONDITIONAL HEALTH AUTHORITY APPROVAL. PUBLIC NATER TO BE HOOKED UP NO LATER THAN 15, SEPTEMBER, 1995. y 0P /-1:0�hS e: )i t� R0BEP.T C. C0NAN i J 6. ®HHS SIGNATURE 'd`<u;' CE -8801 Approved for bedrooms. Disapproved. Conditional approval for __ bedrooms, with the following stipulations: Additional Comments By: — Date NbTIC The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issuad. The Municipality of Anchorage is not responsible for errors or omissions in the prolassw.ra„ er,;,nar's work. 72-025 (Rev. 1/91) Back MOA x27 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lt>,t" 24'� f2a--2 SctaA Parcel 1. D. C) s�l—)3)—r/6 A. Well Data Well type A, B, or C, attach ADFO Int+pr AnFr` NratPr cvcfnm r"1!-^.1-r'r_ f�l� Log presentQY N) Date completed � `17 Total depth b' Cased to 3 \ ON Casing height 2� _ Sanitary seal (i I) `f Wires properly protected(t N) WATER SAMPLE RESULTS Coliform Nitrate O,\�1_ _Other bacteria O Date of sample: 2--\ct —cis Collected by: S A S L_r�� g__ . B. SEPTIC/HOLDING TANK DATA Date installed k9,1'79 Tank size t pap _Compartments f CleanoutsDN) 4 Foundation cleanout (Y& t-�_ Depression (Y}6P rL High water alarm (YW. rA Alarm tested (Y/N) �1.a Date of pumpingPumper StZ U[✓(Pr��i SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot kOC> On adjacent lots � do 1 Foundation i e \�- To property line _ \C> t� Absorption field S1 Water main/service line la Surface water/drainage to t.> 72-026(3/93)`Front CONTINUED ON BACK PAGE- FROiui WELL LOG AT INSPECTION Date of test Static water level 2 -IJ n Well flow 2S ��P L -n g.p.m. ( m v D ti Mcn C Pump Ievell w < z n SEPARATION DISTANCES FROM WELL TO: !"9�1 0 o� Septic/holding tank on lot On adjacent lots tom �� Z5 �� u Absorption field on lot oL;) ; On adjacent lots l 0 �� '� Public sewer main P- Public sewer manhole/cleanout /a Sewer service line �� Petroleum tank '2-s- , k WATER SAMPLE RESULTS Coliform Nitrate O,\�1_ _Other bacteria O Date of sample: 2--\ct —cis Collected by: S A S L_r�� g__ . B. SEPTIC/HOLDING TANK DATA Date installed k9,1'79 Tank size t pap _Compartments f CleanoutsDN) 4 Foundation cleanout (Y& t-�_ Depression (Y}6P rL High water alarm (YW. rA Alarm tested (Y/N) �1.a Date of pumpingPumper StZ U[✓(Pr��i SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot kOC> On adjacent lots � do 1 Foundation i e \�- To property line _ \C> t� Absorption field S1 Water main/service line la Surface water/drainage to t.> 72-026(3/93)`Front CONTINUED ON BACK PAGE- C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Manufacturer Manhole/Access (Y/N) "Pump on" level at Meets MOA electrical codes (Y/N) es tested SEPARATION DISTANCE FROM LIFT STATION TO: on lot D. ABSORPTION FIELD DATA Date installed On adjacent lots at Surface water Soil rating (GPD/Ft2) ! 4 [/�(— System type Length 1-51 Width 315- Gravel thickness _ 1 Total depth ' Total absorption area _ 3 t o Cleanout presentQN) _ _ Depression over field (Y(Q Date of adequacy test Results, ssAail) PA -Ss for, 3 Bedroor Water level in absorption field before test O After test _ Peroxide treatment (past 12 months) (l ��b� �E IL�a i hl _If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot_ 10 0 4 On adjacent lots 100 lProperty line 6 r To building foundation /C) To exiting or abandoned system on lot On adjacent lots lh Cutbank /� Water main/service line /0 Surface water /Do (� Driveway, parking/vehicle storage area s' ± Curtain drain E. ENGINEER'S CERTIFICATION 1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in Signature Engineer's Name C e0 tvy Date 2 3 /0/ 5— HAA Fee $ .1(y. � �J Date of Payment Receipt Number O 72-026 (3/93)' Back �: "ti �, C.... � I of this inspection. ROBERT -C.COW.AN •���F� VTti C[-8II01 Waiver Fee $ Date of Payment Receipt Number ". , i, i f. Time Time Time "time Date APPLIC AT FILLS OUT UPPER HA"! ONLY � jroperty Owner Inspector Inspector Phone Mailing Address Inspector Field Notes: :.:. Zip Code Buyer MAY 2 3 1983 Address - --==« '- Zip Code Lending Institution ( \r) APPROVED BEDROOMS, ` ., ( ) DISAPPROVED Phone Address DATE Zip Code Realty Co. & Agent -. j . , , - Phone Address Septic Tank Size (0 0 0 Zip Code. - Legal Description Street Location Type of Residence q- Single Family ❑ Multiple Family No. of Bedrooms_ ❑ Other ` Water Supply , ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. ITIndividual For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility Sewer Disposal F,1 -Individual Year Individual Installed:_ % 1 ❑ Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED: Time Time Time "time Date Date Date Inspector Inspector Inspector Inspector Field Notes: /% MAY 2 3 1983 tell "Municipality of Anchorage" I)eDf ^X ( \r) APPROVED BEDROOMS, ` 'CONDITIONS OF APPROVAL EnVfl"QnBlentpi Protection" ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE BY: Soils Rating Date Sewer I t�lied `(,f( Well To Absorption Area Well Log Received Septic Tank Size (0 0 0 L Well to Tank ALASKA bOlnOnMenTAL COnTROL ShuUS, InC. Cngineering S enuironmenlal Studies MUNICIPAUt( OF ANCHOPAGE DEPT. OF HGA.LTtI t: ENVIROVk,�ENIAL PROTECTION ECIN ED JUNE 2 1983 CURT CARLEY REMAX ANCHORAGE AK 99501 SELLER — CANNON BUYER—FOUST SUBDIVISION—SEMITAR #2 BLOCK -2 LOT -28 SG1'-�,)ti C)C.. ADEQUACY TEST FOR SEWER SYSTEM THE 'TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 310 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 520 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 1000 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 3 BEDROOM HOME. THE SEPTIC TANK WAS PUMPED ON 6/2/83 . SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1000 IS ADEQUATE FOR THIS 3 BEDROOM HOUSE. 7 A f� a i [y i 1 Ai•r° �e•gise..e`�e.n ea..ei. e.�ei S-. ..r.... earn• a•+ <r. Lero Reid, Jr. •\ ;� �• o. 2231-E ,• C� c+ 9e'ee Z, Ail 1200 West 33rd Auenue. Suite B • Anchorage. Alaska 99503 • (1907) 276-1361 t ' --� — DATM RECEIVED INSPECTION APPOINTMENTS t, TIM _E TIME - TIE Tulwar _ DATE n v DATE DATE [g7 SINGLE FAMILY ❑ One ❑ Four ❑ Other INSPECT t INSPECTC1%, -- `CQ7� �— --� '-HORAGE DEPT. O. r' '- ' :' MUNICIPALITY OF ANCHORAGE ENVIROIVP; E T,, t r;:cTiON DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 * ATTACH WELL LOG. A well log is required for all wells drilled ENVIRONMENTAL SANITATION DIVISION Telephone 264.4720 RECEIVE -11) REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE Paul E. and Amy L. Prove 688-9225 MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE NHN Tulwar Chuu iak, Alaska NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. _ 2. BUYER — PHONE UNKNOWN; Seller leaving state and all Dauer wp-nL ' 11 hp MAILING ADDRESS handled byagent. 3. LENDING INSTITUTION �PHONE UNKNOWN MAILING ADDRESS 4. REALTOR/AGENT — —e PHONE TARGET INC., REALTORS/Jim Morrill 277-0551 MAILING ADDRESS _ 1021 tl. 251LLAyenu Anchorage, Alaska 99503 5. LEGAL DESCRIPTION Lot 28, Bleck 2, Scimitar 112 STREET LOCATION Tulwar _ 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS [g7 SINGLE FAMILY ❑ One ❑ Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY K7 Three ❑ Six 7. WATER SUPPLY l� 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 DISPOSAL SYSTEM — ® INDIVIDUAL/ON-SITE** p y / ! r,YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. —0 ✓. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY — ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER — DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON-SITE ❑PUBLIC UTILITY Connection Verified = PERMIT NUMBER DATEINSTALLED ' o,oi Al INSTALLER ❑Septic Tank or ❑ Holding Tank Size: If Tank is homemade give dimensions: _ SOILS RATING 0� S _ TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL - 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line -77 Lot Line Absorption Area to nearest Lot Line 5. COMMENTS V�--APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE / BY (L. V" -P— 72-010 (Rev. 6/79) Imo. - �• ^--mss- --�, - �Am�i�l�L�rl[_�TI:�AIJ2.V r�� �rz�p_LM I M"l r MUNICIPALITY OF ANCHORAGE DEPT C g< ✓IP,:)i i N rAL r : DEPARTMENT OF HEALTH &ENVIRONMENTAL PROTECTIONP.C1 ION - 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DI RECTI ONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10). days for processing. 1. PROPERTYOWNER l / -PHONE. ADDRESS f%t/ /�F�S -CGd9 �� C i�llSo�✓ Jk 702 MAI LING ADDRESS 0 PROPERTY RESIDENT (If different fro above PHONE — se cf 2. BUYER > PHONE �/ 4 - - UolL,v C s" a a—%F�T cL f, J MAILING ADDRESS 3. LENDING INSTITUTION FN�U�_YJ�. MAILING ADDRESS--— _ n. REALTOR /AGENT / ' '� �j'P1 ONE'— /�.� FAQ L- 9s 5 g' MAILING ADDRESS 5. LEGAL DESCRIPTION — - ^—� 6�IL 2 STI TREELOCATION N 77 8. TYPE OF RESIDENCENUMBER OF BEDROOMS '�— ,51. SINGLE FAMILY ❑ One ❑ Four ❑ Other ❑ MULTIPLE FAMILY ❑ -- Two 1:1 Five J] Three [jSiX 7. WATER SUPPLY— —"— — --- INDIVIDUAL* *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975, For wells drilledpriorto that date, give well ❑ PUBLIC UTILITY 8. SEWAGE depth (attach log if available.) / �� -- Aell " Ly�~ ���� DISPOSAL SYSTEM--- --- 7—• INDIVIDUAL/ON-SITE** **If individual/on-site, give installation date ❑ PUBLIC UTILITY If system is over two (2) years old an adequacy test is required —p by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) —�'— --- -- THIS SIDE FOR OFFICIAL USE ONLY m - DATE RECEIVED^� INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY^ ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified___ PERMIT NUMBER 'a DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED r INSTALLER -- J ❑ Septic Tank or ❑ Holding Tank Size: 000 If Tank is homemade give dimensions: SOILS RATING - TYPE OF TANK -- MANUFACTURER f TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line - - - 5. COMMENTS W-- APPROVED FOR _ BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 1 Rev. 3/781