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DEPARTMENT Gi- HEALTH AND ENVIRONMENTAL F ra'lT" E.+-:1" I ONa
825 'i_' STREET, ANCHORAGE'AI''.. 9-'4501
AF'F'L €-:1 iNaT E.L: ha I Na R I N hIER ':its WE.I.-!_5L_.EY CT
1 `GAL_ L_SHANE Bl LEE: ESTATE"-'--, LOT SIZE
44_4:i_ j.
84100 SiT!UARE FEET
MINIMUM DISTANCE BETWEEN A WELL. AND ANY ON—SITE SEkIA+3E DI'_;F'€:`€:SAL_
100 FEET FOR A PRIVATE WELL OR 200 FEET FOR H F'UE:I-. I C WELL.WE:L_L. L.061�, ARE F:E€;!UTRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN =:ii
OF THE WELL COMPLETION.
:_,i-`E€�;IFTC:AT'TONa=; AND CONSTRUCTION DIAGRAMS ARE AVAILABLE 1.0 INSURE PROF'EF:
I Na';TAL.LAT :L Oill.
�., A.�_ 0,,.0 a. `N - "°<"° � � _. :j- I1r-a �" 6:= 6 d4= (D e PIS FEE. °-0 E . F F° � �` 6 -6 � ^1 � = o u=" Li FEE
1.: I Af°t FAMILIAR WITH THE REQUIREMENTS .. FOR ON—ITE SEWERS ANC, WELLS AS SET.
FI]F.TH BIT' THE N' UN IC:IF'ALATY OF ANCHORAGE.
T WILL ISN•a�;T'ALL THE :::;9Y' TEI' l IN ACCORDANCE E WITH THE CODES.
S.
APPLICANT EDWIN �-J NaNaER
:i:'=;' ;LIE I? E:`r'_—... _'._.-__..._l�/1�.�!-____._...__._L)€=1 T E.------�___. .•.._--_
411..
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services Ak
On -Site Services Section RECEIVED
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
DEC 2 0 1993
CERTIFICATE OF HEALTH AUTHORITY iviurt.c..l E;+tcOQ1 age
APPROVAL FOR A SINGLE FAMILY DWELLING Dept. Hcaith v. Human Se:-v.ces
Parcel I.D. # (71 �- HAA # gA:`00777
1. GENERAL INFORMATION
Complete legal description LoF9� II (GcGc 1 Shane Gee Es/a/-hs
Location (site address or directions) e6,Y d Ti any C(/�-ct r -
Property owner
Kean Su tlrvan
Day phone
3yy -ro7S
y
Mailing address
6GY0 T1 ��un� Cc rc to
AAchopgrae, hk
99507
Lending agencySeC-t
-b
Day phone
S6Z-5 6 z6
Mailing address
5-60 E 3 et r" f}Ue.
r4Ac-h0�2c2. A -k
99.SG3
Agent McYr;z
Tuf-fer°W Jcctv tuht/-e
Co Day phone
76z'3IS-/
Address 3 Za r c " S t. A -A chow e A -k '?9,5_03
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
V
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
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA 921
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 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 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 regulations in effect on the date of this inspection.
Name of Firm Fla F fwq Techn rca. f Servi c.et Phone Sys- 13
Address I gS30 Echo Sf,, A/7Ch o�agPr �� 995-/C
Engineer's signature °�� !%t{i�+p— Date D-ec 201, 1993
6. DHHS SIGNATURE
Approved for
_ Disapproved.
Am
14,. lee •e e11 p1��^t ��`.
Al
It 1 1
y\.�".��',`iy,,.
1 p Y f1♦ f
r1:'�� � X7!•1 � p
i�u aepaeasas16 e1e011prf pi v,p Y�
b{�V �IOSO• •• -p�11 Pq1"i
THEODO;<E F. D1, RE
? n ,
C[
3 bedrooms.
Conditional approval for
Additional Comments
aUTIC
bedrooms, with the following stipulations:
Date _Z—I�7
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 issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rov. 1/91) Back MOA M21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: 1-9, r3 I., Shane keg_ Esf Parcel 1. D. 0/4 - o6 / — �6
A. Well Data
Well type Pr rya f e If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
Date completed 12/26/78 Driller Penn Terrey
Total depth 0' Cased to 60 ' Casing height i6,
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump levet€.
Y
FROM WELL LOG
/25/78
if'
1D
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Wires properly protected (Y/N)
AT INSPECTION
Z (
193 MUNICIPALITY OF ANCHOKAGE
ENVIRONMENTAL SER`/ICES DIVISION
1 H'
1,r:', 2 ' 1993
.p.m. 6. a + g.p.m.
3y' RECEIVED
; On adjacent lots
Absorption field on lot N.A. ; On adjacent lots &I.A.
Public sewer main 63. Public sewer manhole/cleanout los '
Sewer service line 7 29 ' Petroleum tank N ao e s eeo�
1�5ecue.Y (Actin in '77-s�/�acc/ion oCrs%incp ceial /�/@ �irne of rnsfur�cvf«�
WATER SAMPLE RESULTS:
Coliform O ro( /IOC mZE Nitrate o 3Other bacteria G cal /100m -e
Date of sample: 12 / I / 9 3, Collected by: r= /at e Tech Svc
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts(Y/N)
High water alarm (Y/N)
Date of pumping
Tank size
Foundation cleanout (Y/N)
Compartments
Depression (Y/N)
tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot On adjacent lots
To property line AUS0010n 11@10
Surface water/drainage
Foundation
water mainfservice line
72-026(3/93)• Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons —Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at "Pump off" Level at
High water alarm level
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed
Length
Total absorption area
Width
Soil rating (GPD/Ft)
Gravel thickness
Cleanout present (Y/N)
_System type _
Total depth
Depression over field (Y/N)
Date of adequacy test _Results (pass/fail)
Water level in absorption field before test _ After test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
On adjacent lots
Cutbank
for
If yes, give date
Property line
To existing or abandoned system on lot
Water main/service line
Surface water _Driveway, parking/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
Bedrooms
I certify that t have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection
HAA Fee $ OD
Date of Payment /,A- (�)/- �)-3
Receipt Number
72-026 (3/93)' Back
Waiver Fee $
Date of Payment
Receipt Number
ry
N rz A
„ °..
Signaturef /fi
r.
tl y:; nQao4 t%wA9R6 P+f ;>0°- sv ij
Engineer's Name
-Tb eo reo,-e ! • 1 -to o re-
�1. °�adn2e oceeo0°Oo9 s°6 °°°°)y
Date r 2a
Ig9 3
i ;eouo;: r. r :UU, E
:.✓,..01)
1.7
HAA Fee $ OD
Date of Payment /,A- (�)/- �)-3
Receipt Number
72-026 (3/93)' Back
Waiver Fee $
Date of Payment
Receipt Number
0
NORTHERN
TESTING
LABORATORIES,INC.
3330 INDUSTRIAL AVENUE
FAIRBANKS, ALASKA 99701
907-456-3116
2505 FAIRBANKS ST.
ANCHORAGE, ALASKA 99503
907-277-8378
Flattop Technical Services
14530 Echo St.
Anchorage AK 99516
Attn: Ted Moore
Our Lab #:
Location/Project:
Your Sample ID:
Sample Matrix:
Comments:
Method Parameter
EPA 300.0 Nitrate -N
F131623
911 Shane Lee Est.
Water
l/"�/ V V
Reported By: Patrici' A. Woody
Senior Chemist
Report Date: 12/07/93
Date Arrived: 12/02/93
Date Sampled: 12/01/93
Time Sampled: 1215
Collected By: TM
MDL = Method Detection
Limit
* Flag Definitions
B = Below Regulatory Min.
H = Above Regulatory Max.
Date Date
Units Results * MDL Prepared Analyzed
--------------------------------------------------
mg/l 0.31 0.15 12/06/93
I
f
NORTHERN TESTING IIAB®R� DRIES, INC.
3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 •FAX 456-3125
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 - (907) 277-8378 • FAX 274-9645
,I
DRINKING WATER ANALYSIS REPORT FOR TOTAL COLIFORM BACTERIA
Flattop Technical Service Public Water System I.D.#
14530 Echo St.
Anchorage, AK 99516 Date Received: 12/01/93 Time Received: 12:00
Date Analyzed: 12/01/93 Time Analyzed: 16:00
Date Reported: 12/06/93 Time Reported: 08:43
Next Sample Due:
Collected by: TM
Sample Type:
Routine
Method of Analysis:
Membrane Filtration
Comments:
Comments:
S
= Satisfactory
U
= Unsatisfactory
POS
= Positive Test Result
ND
= None Detected
TNTC
= Too Numerous To Count (>200 Colonies)
CG
= Confluent Growth
HSM
= Heavy Sediment Masking, Results May
Not Be Reliable
SA
= Sample Age >30 Hours But <48 Hours,
Results May Not Be Reliable
Old
= Sample Age >48 Hours, Too Old For
Analysis
R
= Resample Required
NT
= No Test
* # Colonies/100 m1 ** # Colonies/ml
Sample Sample Total* Fecal* Other* HPC**
Location Date Time Lab# Coliform Coliform Bacteria Result Comments
---------------------------------------------------------------------------------------------
1 911 Shane Lee Est 12/01/93 12:15 AB2629 0 NT 0 NT S
MUNICIPALITY OF ANCHORAGE
• Department of Health & Human Services M
DIVISION OF ENVIRONMENTAL SERVICES •}�
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # C_) 1 i-1 — I0Lo l —(,oS HAA #1r,1
-'-'a
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
L9 R( SHANE Li5e, ESC 7Arts
Location (address or directions)
6640 TIFFANY TERRACE
(b) Property owner M IM I STIL 50N Telephone: (home) 349-29ol Business
Mailing Address GOO TIFFANY TERRACE I ANCO.
(c) Lending Institution N• B A Telephone 2 76- /1 3Z
Mailing Address INOR-Tt16Rr4 LTS I- Ch S -r. 99S03
(d) Real Estate Company and Agent E R.A PROFESS1o/JAL L ARRY ROSS
Address 2-702 GAM 3 E LL
Telephone 278 - 277!0
(e) Mail the HAA to the following address: (or check here 2', if hold for pick up.)
List contact person and day phone number below:
TED MOORE" / CHRIS A ttARA
3 �{S- 13SS
2. TYPE OF RESIDENCE
Single -Family i� Number of bedrooms 3
3. WATER SUPPLY
Individual Well �( Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ❑ Publicx Community ❑ Holding Tank ❑
Note_ If co.r,r ""ity .r 11 system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
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 regulations in effect on the date of this inspection.
Name of Firm FL A7TOP -TEC N . :SVCS . Telephone 14S- 1355
Address ILf53D EC Ha SI 4NC�. FSK
Date Tan e Y, 0 9O
6. DHHS APPROVAL
Approved for _ bedrooms by
Approved Disapproved
Terms of Conditional Approval
OF A
g ..........................
�W •._ `:...:....d......... Engineer's Seal
THEODORE F. MOORE j• if
z, • CE - 3589 w`
e�
04 1
X68lmlgl
_SaH KI Sm i r+f
Conditional
CAUTION
Date 6 P C Go
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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 order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections"
ornnalyze data before a certificate is issued. The Municipality of Anchorage is not responsible fore rrors or omissions
in the orotmional I?noinel?r's work
72-025 (Rev. 7/88) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
• C4tghwitg b'pproval (HAA) i
MUNI pgl�y=S-WEB'pI0ARY 1984 _
'0NME 343-4744
MA 41990 Legal Description: L.9 gl SNANC LEE CSIA773-
A. WELL DATA E C E I V C
Well Classification PRIVAT& If A, B, C, D.E.C. Approved (Y/N) N,A--
Well Log Present (Y/N) YES Date Completed 2-128178 Yield
Total Depth ��Cased to � Depth of Grouting N096'
Static Water Level 35 Pump Set At UNKNownt
Casing Height Above Ground l2° t Sanitary Seal on Casing (Y/N) r
Electrical Wiring in Conduit (Y/N) to Depression Around Wellhead (Y/N) NO
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot 90g1 ; On Adjoining Lots N04
To Nearest Edge of Absorption Field on Lot RONe ; On Adjoining Lots N096'
7r
To Nearest Public Sewer Line IIS To Nearest Public Sewer Cleanout/Manhole //g
To Nearest Sewer Service Line on Lot L9
Water Sample Collected by FLATTOP TECH. Svcs ; Date S122�90
Water Sample Test Results Sctfrs - 0 Co(uforH /toom-e <o• / 7a nrArw/-e -N
Comments Duv'fl wed Flclw 14&f o/) 5-130 /94 Sklacty .4um4f5y Of c.�er-
IYM !a/IoAJ waker ed- Me enagfmur, oKmn ouf�uf of S.6S�f M cotes cw(
�� v
Aa Meaj,4raMe cQrawduwn - 1A he acnn�
B. SEPTIC/HOLDING TANK DATA NDKE
Date Installed
Standpipes (Y/N)
Size No. of Compartments
Depression over Tank (Y/N)
Air -tight Caps (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High -Water Alarm (Y/N)
Foundation Cleanout (Y/N)
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
To Building Foundation
To Disposal Field
Comments Rr7rdenCe Cownectr�Z k he wcc s7eu.arr
72-026 (Rev. 7/88) Front Page 1. of 2.
C. ABSORPTION FIELD DATA NO Nt
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
__ Depth of Field
Gravel Bed Thickness
Statndpipes Present(Y/N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Property Line
; On Adjoining Lots
To Stream, Pond, Lake, or Major Drainage Course
To Existing or Abandoned System on
To Cutback (if present)
To Driveway, Parking Area, or Vehicle Storage Area
Comments oeydencP C-onnec— e. -C- Y(o hlx.�a-� el'
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Check Permitted Bedroom Rating Against HAA Request"
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
I certify that
I have checked, verified, or conformed to
all MOA and HAA g.4kgq,ifi in effect on the date of this
inspection.
OF At�¢�
Signed
IA, �
—°
Company
F(c�ffchnic�c/ Serv�cPi
oP Te
4 P'�o �T,; ° y
Date
7 /90
°Y(°°°°°•°°•°°°•••••..t:�•0 Engineer's Seal
MOA No.
�e•THEODORE F. MOORE
u Y°°• CE - 35139
��
Receipt No.
p
7 �'7 ��
Receipt No.
Date of Payment�P "—V 5;o
Amount: $ w OD
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
IN
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET • ANCHORAGE, ALASKA 99518 • TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT BY SAMPLE for block Ordez 2.1910
Date Report hinted; MAY 25 90 ? 11:08
Clierh 2a;vple ID:L9 Bl SHANE LEE EST OUT5iDE HA, Client Nam^ FLATTOP TECH111CAL SPIV
YWSID :UA Client acct YLATTOT
Colleoied 11AY 22 90 � 14:45 ift s. P.O.r NONE RECEIVED
Received 14AY 22 90 0 1.5:30 hrs. Req N
Presex:,ed with :AS REQUIRED Ordered By : TED ?BOORS
analysis Completed :MY 23 90 Semi Repo-ltc to:
Labm:atocv Supervisot :STEPHEN C. EDE i)ELATTOP TECHNICAL SRV
Released By
Sneair�l
instruct:
Cherllab Ref 4: 901480 Lab Smpl ID: 3 Matiix: WATER
Parametcr Tested Result Units
-------- --------------------------
NITRATE -F; 1I1)(0.1G} ir�g/1
Sari+nle ROUTINE SAPITLE. SA11PLE COLLECTED BY ". MOORE.
Remak.
Aliowabls
tfetlaoG Li.ruits
EPA 353.2 10
1 Tests Performed See Special Instructions Above UA=Unavailable
ND- N.n. D.tected See Jample Ra.&Kks AbUve
ii,A` Ilei ba..1'pea LT-imo Th'All, GT -Greater. 'Ehnn
APPLV'ANT FILLS
OUT UPPER HA-- % ONLY
Property Owner` r;� ti: <� ! ��
Phone
Mailing Address
q
Zip Code
Buyer
Address f�i;? r /''t��` �>;'J c .�j f'" Zip Code � l . J.>
Lending Institution 40
l
Phone
Inspector
Inspector
Address G f / !,� `%/C
/9�C Zip Code
Realty Co. & Agent{ -
Phone
4X //%%
APR 191`9 821
Address /!
Zip Code
'CONDITIONS OF APPROVAL
Legal Description [(i j %-/�.�i'vi� /�=c' /��<4flr�%�-)
Street Location
( ) CONDITIONAL APPROVAL'
•,
DATE — 3
BY: V
Type of Residence
Soils Rating
�irfgle Family !�
Well To Absorption Area
%❑ Multiple Family No. of Bedrooms—
Septic Tank Size
❑ Other
Water Supply
�ndividual
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
❑ Community
For wells drilled prior to that date, give well depth (attach log if available).
❑ Public Utility
Sewer Disposal
❑ Individual
Year Individual Installed:
\IZ Public Utility
When Connected to Public Utility: % T
�'L7 Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY
EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
LI- l �n t \s
Inspector
Inspector
Inspector
Inspector
Field Notes:
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
APR 191`9 821
RECEIVED
(3) APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
•,
DATE — 3
BY: V
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
Septic Tank Size
Well to Tank
72023 (3182)
1. 3d
kA - 11-1`
MUNICIPALITY OF ANCHORAGE
Al
5. LEGAL DESCRIPTION
3e! MUNICIPALITY OF ANCHORAGE ENVIRONVEN1TAL 11.'-'i`-CTION
'
STREET LOCATION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
'19-1
•
825 L Street - Anchorage, Alaska 99501 APR 9
6. TYPE OF RESIDENCE
ENVIRONMETeI NTAL ENGINEERING DIVISION
phone 264 4720 RECEIVED
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. POPERTYOWNER
❑ ThreLp ❑ Six vires
PHONE
I
-LU'0�"
"o ro rf'1 o A) e—
MAILIN - ADDRESS
-
o ku�"kq
❑ PUBLIC UTILITY
-11-5
PROPERTY RESIDENT (If different from above) -
PHONE
2. BUY
**If individual/on-site, give installation date .
PHONE
�
PUBLIC UTILITY
by this Department.
MAILING ADDRESS
3. LEN ING INSTIION
PHH��ONE
'
cz C c�
MAILING ADDRESS
' "
-
7Da CiN� ,moi C�
4. REA1 TOR/AGENT
— cla 'I
PHONE
MAILING APDRESS
n
q1 i
isdai -3
Al
5. LEGAL DESCRIPTION
STREET LOCATION
0
2�tJLo C�
6. TYPE OF RESIDENCE
NUMBER OF BEDROOMS -
❑ One E] Four E]Other
C4 SINGLE FAMILY
GAJ Two Five
❑ MULTIPLE FAMILY
❑ ThreLp ❑ Six vires
7. WATER SUPPLY
DR] 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.) RQ�1
8. SEWAGE DISPOSAL SYSTEM
❑ INDIVIDUAL/ON-SITE'*
**If individual/on-site, give installation date .
If system is over two (2) years old an adequacy test is required
PUBLIC UTILITY
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
INSPECTION APPOINTMENTS
DATE RECEIVED _.
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
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
EJ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATEINSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
-Size: _ If Tank is homemade
give dimensions:
SOILS RATING
TYPE OFTANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
11�I�APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY IT' )
LEGAL DESCRIPTION
72-Ul0 (Rev. 3/78)