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Home My WebLink AboutRAVEN WOODS BLK 1 LT 5P-avenwoods Block 1 Lot 5 #015-232-11 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion?;;<HV No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. 015 232 11 RAVEN WOODS 1 5 BINDER JOHN R III & KIA D LIVING TRUST 6246 TRAPPERS TRAIL ROAD ANCHORAGE, AK 99516-2405 04 05 2023 186 STA-RITE / CENTRIPRO L7P4EHL-06 / M10432/100C313 1.00 15 MARTINSON PELLETS ANCHORAGE WELL & PUMP SERVICE 7640 KING STREET ANCHORAGE AK 99518 Municipality of Anchorage Pageof3 DEPARTMENT OF HEALTH ANDUMAN SERVICES ENVIRONMENTAL SERVIC S DIVISION P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On-Site WastTater Disposal System and/or Well Inspection Report Permit Number. : " 0 o t 1 Z PID Number: olS— Z3Z = 1 D Wastewater System: O New ji'upgrade 6eRT Aep TAiiiscaLLA A°°'°'"_ AHS ABSORPTION FIELD A9151f K w Phone:345 _ ,' 571 7( No. of Bedrooms: 44 O Deep Trench Shallow Trench O Bed O Mound O Other LEGAL DESCRIPTION s°II a.°n0 0. 5 Total Depth lromoriginalgnA (or OEB PD1S Ft Lot r Block: Subdivision: Depth to pipe bottom liom original grog: Gravel depth Death pipe ' 7 A Woc).Ls Ft. Ft. Township: -� Range: Section: Fill added above original glide: 1+ vel length, e%'� ILO 1. F . O• Ft. WELL• Gravel width: rs Number of lines: Dutanw Nt.eenW ' 7 Ft Ft Clauihcatwn (Pnvate. A.B,C): Total Depth: Cased To: Total absorption area: Pipe material: f'fdl� P F Ft. OO O Ft. T O- 034 Driller. D SMbC Water Level: Installer.1t 11o `_J A g Date Installed: ,$'S/94 Ft. 7C YMId: tamp Set at casting Magri Above Ground: TANK GPM Ft. Ft. SEPARATION DISTANCES prSeptiC 0Holding OS.T.E.P. To li AewrPuon Lm Hold'nq k/Private ManAufacturer. �� Capacity In gallons: From Tanh F,Nd station Tanks;. aewa U_ It A64 weo- — — ZSIt Material: S CeEt- Number of Compartments: Ioeti IOolt wai`� IGot+ eon+ -- — — LIFT STATION �� Size In 9 snufacturer. LineIbl+ _ 'Pump on' level at: 'P High water atarrn at Foundation'-- CurtainNG rV �� Pump Ele Tical lnspednsioperformed by: Drain BENCH MARK Remarks: Lior, 1.tsu M u /I To 7 C F?E.� v6FE Location and Description: 'tom = Too of WtI4PsLj S &. tc rLe o T lie ot_fl SFS nC+ *�Ft Assumed Elevation: ENG AL 0 Al �P� • � ;4s yl� r 1 11LA6KA tN.Re/-�- WrbteuL�Tet .'49r .......e ... Coa�daYArirS lr+c, Dates:, lz d Inspections performed by: l �!�'?'�, ,. . . 2n 8 ' 4 ; JAMES P. YALUAMS 3r.A I i •. N0.9608 Department of Healt lid H rvic approval Ij'�,yFo.:, c.E 7n - - Reviewed and approved by: DaRA te: 72-013 (Ray. "l) 40A 25 PERM•T'NUAS-BUILT DRAWING PARCEL m NUMBER: SW980112 112 - 015-232-11 NOTE: ALL SWING -TIES ARE SCALED MEASUREMENTS TAKEN FROM AN AS -BUILT SURVEY DONE BY WILLIAM D. FLEMING ALASKA WATER AND WASTEWATER CONSULTANTS, INC. 7320 E. CHESTER HOGHTS CIRCLE. ANCHORAGE. AK 68504 PHONE. (907) 337-6179/FA%: (907) 338-3246 l aP� res PSQa AL DESCRIVIION: .: A9YO RAVENWOODS SUBDIVISION. LOT 5, BLOCK 1 ..........L OF WORK: /IwM AA .. AS -BUILT OF SEPTIC SYSTEM UPGRADE f/ y (SY James P. W81 YAHLD FOR: PHONE NUMULN: i •. CE -9608 ROBERT AND MARCELLA DRAGNICH 345-7571 00:� •... L: 3r7AwN BY: NAUt: %1%'*QP• ..••t• 9�19�98 J.L.M. 1 = 40' 2 OF 3 �oFa \ G REVISED. LOCATION NOTE: TH/JLOCATION SHOWN DESIGN PLAN WAS APPROXIMATE NEW 1250 GALLON fX�C I SEPTIC TANK C ` INSTALLED FLOW DIVIDER (FD2) 0BLI D91_2 INSTALLED FLOW DMDER (FDI) CO2 1 i C04 CO l?.N/z `� I I �GT3 CO MT4��' C07 INSTALLED FLOW DMOFR (FD3) FCO ST154. z r i 1 Coe #Hi1 DELI a 1 OBL2 W I CO ill FD 1 .rte FD2 d I F03 168 1 EW DRAINFIELDS C01 I CO2 198 I MT1 175 1 CO3 168 C04 1 L---------------------------------------- MT2 1 79 COS 17 10' UTILITY EASEMENT NOTE: ALL SWING -TIES ARE SCALED MEASUREMENTS TAKEN FROM AN AS -BUILT SURVEY DONE BY WILLIAM D. FLEMING ALASKA WATER AND WASTEWATER CONSULTANTS, INC. 7320 E. CHESTER HOGHTS CIRCLE. ANCHORAGE. AK 68504 PHONE. (907) 337-6179/FA%: (907) 338-3246 l aP� res PSQa AL DESCRIVIION: .: A9YO RAVENWOODS SUBDIVISION. LOT 5, BLOCK 1 ..........L OF WORK: /IwM AA .. AS -BUILT OF SEPTIC SYSTEM UPGRADE f/ y (SY James P. W81 YAHLD FOR: PHONE NUMULN: i •. CE -9608 ROBERT AND MARCELLA DRAGNICH 345-7571 00:� •... L: 3r7AwN BY: NAUt: %1%'*QP• ..••t• 9�19�98 J.L.M. 1 = 40' 2 OF 3 �oFa P W, AS -BUILT DRAWING 015 NUMBER: ID NUMBER: I SW980112 015-232-11 fRA GRAa I"& GV. a FM GIX1E 101.1+ -T x101.1+ 101.44.- .PROFILE 01.1+- PROFILE AS -BUILT DRAWING N.T.S. ALASKA WATER AND WASTEWATER CONSULTANTS, INC. P� OaF�0�4 7320 E CHESTER HEIGHTS CIRCLE. ANCHORAGE. AK 98504 PHONC (907) 337-6179/FAX: (907) 336-3246 •. .5�� aCAL OLSCNIPIION: �•49 • 9 RAVENWOODS SUBDIVISION; LOT 5, BLOCK 1, ;... ,. • :YNL OF WONK: PROFILE AS -BUILT OF SEPTIC SYSTEM UPGRADE Q• • •..................••• James P.''Wllliams; ,IHLPANLD FON: PHONL NUMHLN: i '•. CE -9608 ROBERT AND MARCELLA DRAGNICH 345-7571 QDOA� ' • :' ,r' �d JAIL 9/19/98 J.L.M. JNAWN UY: Snit N.T.S. rA4;L:3 OF 3 D�•�dp�ots�eW�d�°o MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ►a'.uu Pm PAGE 1 O �/�1' 1 1 V `�• ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW980112 DESIGN ENGINEER:ALASKA WATER & WASTEWATER SERVICES OWNER NAME:DRAGNICH ROBERT G & MARCELLA A OWNER ADDRESS:6246 TRAPPERS TRAIL RD ANCHORAGE, ALASKA 99516 PARCEL ID:01523211 LEGAL DESCRIPTION: RAVEN WOODS BLK 1 IT 5 LOT SIZE: 78408 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1 2 3 4 i DATE ISSUED: 5/13/98 EXPIRATION DATE: 5/13/99 THE ATTACHED APPROVED DESIGN. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING THE FOLLOWING SPECIAL PROVISIONS. SPECIAL RECEIVED ISSUED B DATE • 11 r7 DATE:,7 SIJ ! 8 Alaska Water & Wastewater 7320 East Chester Heights Circle — Anchorage — Alaska 99504 (907) 337-6179 — Fax (907) 338-3246 Consulting Engineers April 24, 1998 Municipality of Anchorage Department of Health & Human Services Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Septic Upgrade Design for Lot 5, Block 1, Raven Woods Subdivision. To whom it may concern: The existing 4 bedroom house is served by a private septic system and well. The existing trench is encroaching groundwater and must be upgraded. Three test holes were excavated to the west of the existing septic system. Comments regarding the proposed upgrade design are summarized as follows: 1. SOILS: Attached are the soil logs which shows the soil profile, and the percolation test results. The area around test hole 43 will be used for the proposed upgrade. The soils in test hole #3 below the organics are primarily silty sand with silt lenses and some gravel (SM/ML) to a depth of 6 feet. At a depth of 6 feet the soils transition to silt with silty sand pockets through -out with light gravel (MUSM) to a depth of 13 feet (bottom of test hole). No groundwater was encountered during the excavation of the test hole. On 4/23/98, the monitoring tube was checked and groundwater was found to be at 10.5 feet. Two soil percolation tests were performed, one at 3 feet to 3.5 feet which perked out at a rate of 20 minutes./inch and one at 6 feet to 6.5 feet which perked out at a rate of 48 minuternch. 2. TRENCH DESIGN: a. Percolation Rate: 48 minutestinch b. Allowable Application Rate: 0.45 gallons/day/ft2 c. Number of Bedrooms: 4 d. Design Flow: 600 gallons per day e. Minimum Absorption Area: 1334 ft2 f. Effective Depth: 4feet g. Reduction Factor = 0.50 h. Width: 5 feet (min.) i. Minimum Length: 4 - 40 feet long each = 160 feet total length j. Effective absorption area= 1600 ft2 (>1350 ft2 OK) k. Maximum depth = 6 feet 3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed upgrade. 4. TOPOGRAPHY: Beginning at the southwest property comer, the lot slopes downward from south to northwest at a average grade of approximately four percent. There are no slope concerns (see attached topography site plan). I am unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact me at 337-6179, or 244-9612. Thank you for your assistance. A Sincerely, Jeffry 41 Ga*i�ss, P.E.; LOS ,w0pp5 510 Rj,VEN �0t bwp0 5 510 \\ RAVEN tslX A 0 `oj 2W0p05 R;VEN E0� VI0�p5 510 i i • p , RAVEN s,jaeAM 0 ---------------- r--------------- , , , , , , c9m � na O 50 w00p5As101 RAIN 4 I LOt '.p005 5J0 R�,VEN GRIZZLY AVE. Ot 9. 06DS SIO A. R� EN WD EOlNAW06DS I j 5, 9105 510 ,N00 SITE PLAN: LOT 5, BLOCK 1, RAVEN WOODS SUBDIVISION PREPARED FOR, ROB DRAGNICH PREPARED BY, ALASKA WATER 6 WASTEWATER DATE, 4/24/98 DRAWN, J.L.M. SCALEi 1' = 100' ............ 0 •J a A. G ess.•• —7953 4 4ed spy0 �r,fe�_ eeW—� a •NOTE, THE CONTRACTOR SHALL HAVE THE NORTH AND VEST PROPERTY LINE ADJACENT TO THE PROPOSED SEPTIC UPGRADE FLAGGED BY A REGISTERED LAND SURVEYOR PRIOR TO CONSTRUCTION. WELL arD TFT�WAv PROPOSEDDTIC TMIDK ;GA� �Sj�NM I INSTALL DBL CO h USE I C u �L F NO — •L1T— —C/0 \ C/O C/O ill-r.M THB]� MT —C/0 4THtt EXISTING SEPTIC SYSTEM TO I C/o - BE ADAM COMPLETELY 1NSTALL FLOW SPLITTERS V/ 4• RISER STANDPIPES TH41+ H I PROPOSED O FOOT VIDE TRENCHES u5a III T N WITH A OTA LENGTH 160 FE ET.INSTALL - 40 F®T LONG EACH 6 FOOT DEEP (MAX.)WITH { OF SEVER OOLIISA TRENCHES TO W TOUIL �I I I SO' UTILITY EASEMENT NS AL FLpy SpLTT��pS GRADE VITH 41 RISER STANDPIPES IGINAL GRAVE M /0 C T /p C/0 MT Y MiN. 6' D �� , i t,C.'IN �z -INSU.ATIDN 4' EF ECTIVE SULA i:k'� 10' MIN 10' NTH 30' MIN. 4- MIN TO GROUNDVATER 6' MIN TO IMPERMEABLE SOILS PROFILE DRAWING .� p NTS. WELL AND SEPTIC DESIGN, LOT 5, BLOCK 1, RAVEN WOODS S/D = A PREPARED FOR, ROB DRAGNICH e r Ca •• SS.- PREPARED S;PREPARED BY, ALASKA WATER L WASTEWATER ��+'• C 7953 \a: DATE, 4/24/98 DRAWN BY, J.L.M. SCALE, 1' = 50' 0 "S/D RAVz EN O ?by- e Municipality of Anchorage j :45 DEPARTMENT OF HEALTH & HUMAN SERVICES / . ... 825 "L" Street, Anchorage, Alaska 99502-0650 , SOILS LOG — PERCOLATION TEST F� R-06 ,, \\9 PERFORMED FOR: 2oB �P.d6r.�IGN DATE PEi11l LEGAL DESCRIPTION: LS, Ins Township, Range, Section: DEPTH L� 1 2 I MLr— Sit_7 "'Awry S 3 *v LeNsGs 1_:I, TI /NEO D&jZ 4 pcns6n. w/ Pe 6- 8 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS PERFORMED BY, ACCOROANCEV 72-" (Rev. 4/85) M('&SNL — WE-' SLOPE 3'%-% OF qy N ; ES P. WiLLIAMS :,4 N0.9608 SITE PLAN SEAL) WAS GROUND WATER — I.i -I'le SILL ENCOUNTERED] o" L"�CwKr SJ17y Saw P„usrl sP°Ca S 6- IF YES. AT WHAT ss, O DEPTH? V P Cilaring? Wber Atur I I1� O`1 .TS� b. S D7te: 23 S.O.N. ALL STATE AND MUNICIPAL PERCOLATION RATE'• "i_ (minutminChh)�`PERC HOLE DIAMETER _ TEST RUN BETWEEN FT AND FT ;ti rttn FMt6 G - . _ 1 CERTIFY THAT TRIS TEST WAS PERFORMED IN DELINES M EFFECT ON THIS DATE. DATE PERFORMED FOR LEGAL DESCRIPTION: WTH IF"'I'l-I OM, 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS PERFORMED BY ACCORDANCE% 72-008 (Rev. 4/85) C Municipality o1 Anchorage * ,491 DEPARTMENT OF HEALTH & HUMAN SERVICES•• •••�• 825 "L" Street, Anchorage. Alaska 99502-0650 SOILS LOG — PERCOLATION TEST s •. 208 D�sbnllcl+IE L� op• I p DATE Uei y Sr c1 )S I� J�j Ev Township. Range. Section: It �• * � W27N.? AMM L (` / (MEO pnvSg-) M' -1-9A _ MnINLy SILT g().iL, W/V,AT7"6Q facel OF WAS GRO ENCOUNI IF VES, A DEPTH? Depth to Witt Monitoring? )F AMl tWEER'SSEAL) . too. 1..... e..... . i P. WILLIAMS 10.9608 �Qe Reading Date Gross Time Net Time Depth to Water Net Drop o } rRC lh c eSwrso 1;w r? PNw ♦ fry 115' S.0 �s yrJ S,ay APDfbo. I. If 'Sol 3onrw y.. AV Hxo c 10 `110 M -C �IZD Tr PJ11 O r •' •}t60 36 y" t N 101 aoM,. ti e t o�/w 6.. r!ol 70„•. �:31 3o t• S �/s %s PERCOLATION RATE 40 *f (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN •S—SO FT AND .S -r1.0 FT lire AAA—I.—I iw AwsFNt6 SO" I I ' I CERTIFY THAT 74S TEST WAS PERFORMED IN ALLSTATE AND MUNICIPAL GUIDELINE 1 EFFECT ON THIS DATE. DATE `�� 0*7 124=0L'P1:1.1 LEGAL 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Municipality of Anchorage DEPARTMENT OF HEALTH 8 HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST ^/flog ONIGhF o DATE ION: l�Rlll=NWaLX�S phi Lsr p� Township, Range, Section: SLOPE SAA1/111L — &/-ZyS14,w a'SIt.7 LF,NSES # So� 6RPWCL. /AVSM - StL.-r "'Act'p STD Pot:t67s TNem'Go•OL'T L U/LXKT GWEL WAS GROUND WATER i1\_ ENCOUNTERED? f W , S IF VES, AT WHAT L DEPTH? O %O,S E N m Depth Water t�L Z.O.R.1�Monitoring? toOri ly,�? .ut SeWILL101S :• N0.9508 SEAL) V --Eat:. f{ Reading Date Gross Time Net Time Depth ae►oa Water Net Drop M 10 N . � of oAa/ S' 4 3/ IT r—gy 3-3•s u (N :0z o A4 tN yy) or I' 5: 6z 30 A•VP N/i" 1%" COMMENTS •""',I WIDE WLJ PERFORMED ALL STATE AND MUNICIPAL 72 -WS (Rev. 4/85) 11�a PERCOLATION RATE i8� � e+� (minutevinch) PERC HOLE DIAMETER TEST RUN BETWEEN 6 { 6.5 FT AND 3 i 3•f r F,:.1a,K� I "11 p^ s F ' '"� CERTIFY THAT THIS TEST WAS PERFORMED IN IN EFFECT ON THIS DATE. DATE — i , MUNICIPALITY OF ANCHORAGE \\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION ^' 825 L Street • Anchorage, Alaska 99501 Telephone 264A720 ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAMEPHONE Ro bark D n ii 333-1'740 '1 ❑ UPGRADE /Gh MAILIN DPLEIS Miles /'� V/"l i�nGl� r 171<171<1�950y ( LEGAL DESCRIPTION LO -r 5- LOCATION.�� NO. OF BEDROOMS 1r'2t�t�►�E� Well Absorption area / Dwelling , PERMIT N D DISTANCE TO: t`J /Z , . %? S v _Y 2Q w� Manufacturer C-2 Material STQE No, of compartments r2- Liq. capacity in gallons I IF HOMEMADE: Inside length Width Liquid depth 17- 15 fj Y DISTANCE TO: Well Dwelling PERMIT NO. -10Z _? Manufacturer Material Liquid capacity in gallons O W= DISTANCE TO: Well Foundation Nearest lot line PERMIT NO. J LL Z No. of lines Length of each Ike Total length of lines Trench width Distance between lines f? W I 7 S inches Top the to finish Material beneath Total f- of grade -, file all ective,bZ tion area o t inches C`�1 Length Width Depth PERMIT NO. W l7 a F Type of crib Crib diameter Crib depth Total affective absorption area W 1 DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. J W i DISTANCE TO: Building foundation Sewer line Septic tank Absorption area Is) OTHER PIPE MATERIALS cRsr SOIL TEST RATING 07-7- INSTALLER X'pk' PE Fy.C. - REMARKS G p 1 O N 7/ I t �1 I APPROVED DATE LEGAL 9)21183 RuenWOC6 sib L0-1 5, Plk I _ 72-013 (Rev. 9/781 t-lUrJ I C Ir~ F=iL_I TY OF= Fir.FC,F�FZF10E DEPARTMENT HEALTH AND ENVIRONMENTAL EOTECTION 825 'L' STP.EET, ANCHORAGE, AK. 99601 264-4720 ' LJEL_L- FAr4E> ON-SITE SEF4Ef2 F7EF ZP1 I T PERMIT NO. C 830503 ) APPLICANT MARCELLA/ROBERT DRAGNICY 8461 MILES COURT ANCHORAGE 995Y'333-1707 LOCATION LEGAL L5B1 RAVENWOODS LOT SIZE 999999 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FTIBR)= 225 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: E>EP'TF-F= 12 LENGTH= !T;-7 (:3FRnVE:L_. COEF:l'TH= S THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DP,AINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN 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 CIN FEET). FREQU I FREF> TFir-JK SIZE= 12,SQ (3nLLF-Or-4S PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. --- TWO < 2 ] I rJSF�EGT I QNS nFRE Fz>aQU I FIEF? --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY OM -SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE I5 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F>E=&P1 I T EXP' I FSES D>ECEMFIEFZ X11 1'x ED 3'. I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED A• "Awash V4. 0 APPLICANT MARCELLAMBERT DRRGNICH ISSUED BY Za (-NIUNICIPALITY OF ANCHORAGE f DEPARTML,.T OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION ,I 825 L. Strut, Ancnap-. Alrk. 99601 2844720 TEST a. SOILS LOG — PERCOLATION TEST o67� �r4,y oicLlPERFORMED: PERFORMED FOR:. ADATE _�J/`r LEGAL DESCRIPTION: 46 -el 9,4 ✓LXI W 00 (--) -� DEPTH SLOPE -1 T��/�IpE k$2 oe4 1 (FEET) O=C) I^T ^J) C S � 71 2- 1 I - 3 5 some SAND 6- L E LE 7 8 9 10 11 `-12 13 14 15 18 17-1 Ise OF A 18 7 ;� 19 201 NO.1732•E ♦_ -- June 22,1968 COMME 0 mmmmlammmmmi WASGROUNDWATER S ENCOUNTERED? L O P IF YES, AT WHAT E DEPTH? C P ? 1 R.Wi,q 0.t• Torr T,t� Whiteto r Not Dino 5-13- 5-14 24►+ - 5 5-14 r, 5-14 ¢h 48M 2�w+ '75/a 1 It PERCOLATION RATE 2. dninumflnd,l O TEST RUN BETWEEN FT AND 5� FT c. 2 p PERFORMED BY. 6 a N S I C NC% YIVG CERTIFIED BT 77-008 Ir.. rql i DATE: 5 -141 --sl • �' M -W DRILLING, Inc. ` P.O. Box 10-378 • 10300 Old Seward Highway _ (907) 3498535 ANCHORAGE, ALASKA 99511 DRILLING LOG Well Owner I'MIiT DRMTTai Use of Well Ikx'estic Location (address of: Township, Range, Section, if known; or distance main road Tnt 9 Rlnntk 1 P nx +coda Size of casing Err Depth of Hole 200 feet Cased to 198.80 feet Static water level 165 ft. (9BNv6)'% (below) land surface. Finish of well (check one) open end ( ); Screen ( );` Perforated ( ). Describe screen or perforation hone Well pumping test at 4 gallons per (hour) (minute) for---J---hours with 1001", It: of drawdown -from static level. Date of completion Jul ALtpvst 1, 1983 WELL LOG Depth In feet from ground surface Give details of formations penetrated, size of material, color and hardness 0 TO 2 Casin7 stic],W 2 TO 3 Overbuy iai 3 TO30 Bxtxjn silty gravel 30 TO 125 Brum silty sand with pra, eA 125 TO 140 Brm:n silty elm, and gravel 140 TO 180 Gray silty clig with gravel (clrm) 180 TO 195 Gray clay end p riml Q� TOS_ Watnrbcarin- ffrvel TO TO TO TO TO TO TO r to No's. , tractorn+. alt 3—CONTRACTOR Municipality of Anchorage -- Development Services Department =` Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Boz 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us� (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-232-11 COSA# t O1 1nC 1. GENERAL INFORMATION Expiration Date: Complete legal description RAVEN WOODS S/D; BLOCK 1, LOT 5 Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address 6246 TRAPPERS TRAIL ROAD, ANCHORAGE, AK, 99516 BUD & LEE ANN FACKRELL Day phone 6246 TRAPPERS TRAIL ROAD, ANCHORAGE, AK, 99516 Day phone DAR WALDEN W/ KELLER WILLIAMS Day phone 223-1188 865-6500 101 W. BENSON BLVD, #503, ANCHORAGE, AK, 99503 Unless otherwise. requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site 0 Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site 1 ❑ 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 samples. (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. 1 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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date Engineer's Comments In conducting this evaluation, GEG, LtD. attempted to provide a thorough, the in ADEC MOA 0oo��4p� 4 OF k conscientious engineering analysis of system accordance with and DSD Guidelines & Regulations. The reported results described the performance of the o A`. 4 '` • " % . sOp system unde- the conditions encountered at the time of the test, and separation OQQ distances measured to readily identifiable features. The operational life of all wells and QD* ;' T.��Q septic systems depend on the local soils condition, groundwater levels that may Q • : • • • • fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test O..... .. ........ results do not guarantee future performance of the system, nor do they guarantee that Op '. f y A. orness.- there are no hidden defects or encroachments. GEG, LTD. can therefore not provide future how long the to the Q m C 7 53 u p �Q sfP ' -� . •' any warranty or estimate of system will continue meet �� (,y c�c�0 Q�Qea operational requirements of the ADEC or MOA DSD. The content of this report is for r'ro f the sole benefit of the owner listed above. Any reliance upon or use of this report by any. es sio��q� ��DO000 other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE`\\`�Q �(`{ OF &6+ 11 f/ Approved for bedrooms. J ON-SITE Disapproved. : � WATER AND Conditional approval for bedrooms, with the following stipulations: WASTEWATER PROGRAM �%au „89R �i� l Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: — -7— 1 Z (Rev. 11105) Municipality of Anchorage • '� Development Services Department Building Safety Division Onsite Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: RAVEN WOODS S/D; BLOCK 1, LOT 5 Parcel ID: 015-232-11 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N A Date completed 8/1/1983 Sanitary seal (Y/N) YES Total depth 200 ft. Cased to 198.8 ft. FROM WELL LOG Date of test 8/1/1983 Static water level 165 ft. Well production 4 — 9 -p.m - WATER SAMPLE RESULTS: Coliform (0 colonies/100 ml. Arsenic: Wug./L. B. SEPTIC/HOLDING TANK DATA Nitrate N_mg./L. Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 7/24/2012 171 ft. 5.04+ g,p.m, Date of sample: 7/24/2012 Tank Type/Material SEPTIC/STEEL Tank size 1250 gal. Number of Compartments E Collected by: GEG, Ltd. Date installed 8/12-18/1998 Cleanouts (Y/N) YES Foundation cleanout (YIN) YES Depression over tank (Y/N)1 N4 High water alarm (Y/N) N/A Date of pumping Pumper '6 % % IOV17 [1 . Se./ U 1'( 4e S C. ABSORPTION FIELD DATA Date installed 8/12-16/98 Soil rating .p.d./ r ft2/bdrm) 0.45 System type MULTIPLE TRENCH 4 ® 40' Length 160 TOTAL ft. Width 5 ft. Gravel below pipe 4 ft. *7.5/7.8 Total depth *7.1/7.3 ft. Eff. absorption area 1600 ft2 Monitoring tube YES Depression over field NO Date of adequacy test **7/24-25/2012 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 28 in. Water added 600 gal. New depth 34 in. Elapsed Time: 775 min. Final fluid depth24 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date **HOUSE WAS VACANT AT TIME OF TEST. SEPTIC SYSTEM WAS PRE—SOAKED W/ 2000 GALLONS (DISTRIBUTED TO ALL 4 TRENCHES) PRIOR TO TEST. TESTED NORTHERN MIDDLE TRENCH ONLY. OTHER TRENCHES HAD LESS THAN 2" LIQUID IN THEM FOLLOWING THE PRE—SOAK. D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. "Pump off' level —I . . High water alarm level at Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankitft station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Sewer /septic service line 25'+ Public sewer manhole/cleanout N/A Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and,; ? 4 1 .'.T* review of Municipal records that the above systems are in ...... ' .... ........ "' ... . conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS QQ 9 CE -79 3 I2 m� Date 7�3t o��4neap i31(�0�0�0 COSA Fee S `t qo� o Date of Payment 81 r hp Receipt Number G ,?3O36 (Rev. 11105) Waiver Fee $ Date of Payment Receipt Number Cr• E /\ Municipality of Anchorage • Development Services Department Building Safety Division Onsite Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 9951M650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. INrl-a3p-II COSA# I.IIJ��io75� Expiration Date: 1. GENERAL INFORMATION Complete legal description Lot 5 Block 1 Ravenwoods Location (site address) 6246 Trappers Trail Road, Anchorage. Ak 99516 Current Property owner(s) Robert Dragnich Day phone 564-3766 Mailing address 6246 Trappers Trail Road, Anchorage, AK 99516 Lending agency Day phone Mailing address I I Real Estate Agent _Barbara RamsevlDynamic Properties Day phone 261-7553 Mailing Address 3111 C Street Anchorage, AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On Systems Approval-(COSA}based-only-upon-the-representations-given-in-paragraph// 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 Onsite 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 Pannone Engineering Services LLC Phone 272-8218 Address P.O. Box 102954 Anchorage AK 99510 Engineer's Printed Name G. Scoff Crowther Date `�Ilq b - Engineers Comments: In conducting an adequacy test, l attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines !@. Regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guaranteo'that there arc fats or encroachments. PES can therefore not provide any wartanty for future performance nor give anytistimate �,I�h ) will continue to meet the operational requirements of the MOA DSD. The content of this report is fof 'he 1flCorpefliY above. Any reliance upon or use of this report by any other person or party is not authorized nor will it ionf afry al right w socY;' S. DSD SIGNATURE .,,. 1,e Approved for 4 bedrooms. Disapproved. ats. aeon cRowrtjz Conditional approval for bedrooms, with the folio c u�attons): off., P>1�f'ES3tOt1a�� COSA Checklist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report By; Original Certificate Date: m« nAst Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 3437904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST I Legal Description: Lot 5 Block 1 Ravenwoods Parcel ID: O /.J ;. '6�4— it A. WELL DATA Well type P If A, B, or C provide PWSID e Date completed 811tI983 Sanitary seal (YIN) Y Total depth _X&_11. Cased to 198.8 ft. FROM WELL LOG Date of test 8nn983 Static water level 185 ft. Well production 4.0 g.p.m. WATER SAMPLE RESULTS: Coliform V colonies/100 mL Nitrate "() mg/L Arsenic: ','51 & mg/l Date of sample: OnOM6 B. SEPTICIHOLDING TANK DATA Well Log (Y/N) Y Wires properly protected (Y/N)_ I Casing height (above ground) 24+ in. AT INSPECTION 8n812008 187 ft. 3.5 9.p -m. Other bacteria ` f =colonies/100 mL I Collected by: Laura Pannone Tank Type/Material Anchoreae Tank Steel Date installed en211998 Tank aim 1250 gal. Number of Compartments j Cieanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (YIN) WA Date of pumping 8/220008 Pumper A+ Home Services C. ABSORPTION FIELD DATA Date installed 811711998 Soil rating (g.p.d./fte or fe/bdrm) 0.45 System type Shallow Trench Length 180' ft. Width S ft. Gravel below pipe 4 ft. Total depth 7.1to7 S ft. Eft. absorption area URfte Monitoring tube Y Depression over field N Date of adequacy test 811812008 Results (Pass/Fail) Paas For 4 bedrooms Fluid depth in absorption field before test N91S.5 in. Water addedW gal. New depth'21.5111, in. Elapsed Time: 11 min. Final fluid depth = in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Absorption rate >= 800+ g.p.d. i If yes, give date D. LIFT STATIola--,-. Date installed 'Pump on' level at _ in. Datum Cycles E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: in. Manhole/Access (Y/N) _ High water alarm level at Meets alarm 6 dimuit requirements? In. Septic tankAift station on lot 100+ On adjacent lots 100+ Absorption field on lot 100+ On adjacent lots 100► Public sewer main 100+ Public sewer manhole/cleanout 100+ Sewer /septic service line 25+ Holding tank 100+ Animal containment areas 100+ Manure/animal excrete storage areas 100+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO Building foundation 10+ Property line 10+ Absorption field 50+ Water main 100+ Water service line 25+ Surface water 100► Wells on adjacent lots 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 50+ Water main 100+ Water Service line 25+ Surface water 100+ Driveway, parkingivehide storage 100+ Curtain drain None Observed Wells on adjacent lots 100+ F. COMMENTS G. ENGINEER'S CERTIFICATION yt.P` ^• . I certify that I have determined through field inspections and �C review of Munlapal records that the above systems are in W , conformance with MOA COSH guidelines in effect on this date. " Engineer's Printed Name O. Seoft Crowther. P.E. ''A 0. �1 J, Date 7111N,�h 6491�: COSA Fee $ " V Date of Payment j U Receipt Number. G $ 5 & U (Rev. 11ft) Waiver Fee $ Date of Payment Receipt Number, sus SGS Ref. #: Client Name: Project Name: Client Sample ID: Matrix: PWSID 1064840 Pannone Engineering Ravenwoods, L5, B1 Ravenwoods, L5, B1 Drinking Water SGS Environmental Services Inc 200 W. Potter Drive Anchorage, AK 99518 Tel: (907) 562-2343 Fax: (907) 561-5301 All dates/times are Alaska Standard Time Printed Date/rime: 08/30/06 Collected Date/rime: 08/18/06 Received Date/rime: 08/18/06 Technical Director. Steohen Ei 16:50 11:30 11:55 Allowable Prep Analysis Parameter Results POL Units Method Limits Date I Date Init Bacteria 0.00 9222B 08/18/06 08/18/06 tlf Nitrate ND 0.10 mg/L EPA 300.0 10.00 08/18/06 08/18/06 alr Arsenic 5.16 5.00 ug/L 200.8 10.00 08/22/06 0823/06 mh I I 1 v O 1 � 1 x •lM 1 1 Q 1 p 1 1 1 g I I I 1 1 1 1 1 1 1 1 1 I 1 N 00"00.00"W 107.74' W O TRAPPERS TRAIL m BASIS 167.74 (REC) N 00000'00'E 167.62' (M) _ n 10' UTLITY EASEMENT 1---------------------- -----K v 1 1 � O 0 1 1 O 1 W D'/ 1 1 O O O 0 1 r Q O 1 0 1 0 .c D o �• � u' 1 O O ao o'er o I 1 1 1 O 0 O \ ° 1 C Y O 1 N N O 1 1 N �P - m m I 6`A a m u 1 Hu � D _ 1 OI m In D 1 cl n N �1 1 r• 1 z 41 1 1 ° -A m N i CP A mI '' N n i I p y M4 = I `b I I 1 v O 1 � 1 x •lM 1 1 Q 1 p 1 1 1 g I I I 1 1 1 1 1 1 1 1 1 I 1 N 00"00.00"W 107.74' W O TRAPPERS TRAIL PA I.V'- �I m OI' 151 O b9'ZL£ `a � m mr n 0 0 v !X o.M W D'/ 0 OD z r Q O 0 1 0 .c D o �• � u' ao o'er o ° C Y O 1 N N O C - m m x n n a m u — � D m n m n z ° .Z1 Z N n p y =i O aD, ~ n O r � Z E -. N 1 > m w � a v :D PA I.V'- �I m OI' 151 O b9'ZL£ `a � m v o o c 9's: n 0 0 !X o.M 0 0 1 0 .c D o �• � u' ao o'er o ° C Y O 1 N N O C p n n a m u o w ° N n y ~ n O r � C N q E -. N 1 > PA I.V'- �I m OI' 151 O b9'ZL£ `a � APPLIC--�'JT FILLS OUT UPPER HAL^ONLY ce be o l c �e( Property Owner �� / f / -rG ,� (�tJ /� C T r ? C Date Phone Malling Address n ? YM N�F'%1 GG Zip Code '-VL �� 333 -,gyp%% Bayer C'o-Dr-F45/-3/cN Inspector inspector Address /tI./ et !1 11 ,C Zip Code 9 95'23 Inspector Lending Institution //! � PgCyT-vr Phone Address / �_-/) �/ Zip Code /%S"p/ /izG�Gp/ �-7 -7V- Fleetly Co. & Agent Phone Address Zip Code moi- . �[ C.O• Owl •/-25-7 Legal Description L'3L oc% / /?^V --,J W UO A Street Location Type of Residence IR Single Family 'CONDITIONS OF APPROVAL ( ( DISAPPROVED ❑ Multiple Family No. of Bedroom� PPR_OVAAL ( 1 CONDITIONAL APPROVAL- ❑ Other DATE GATE � � �Q Water Supply Individual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. Community For wells drilled prior to that dale• give well depth (attach log If available). ❑ Public Utility ;?-- 2- /- gle.? I Well to Tank Sewer Disposal R3 FC Individual Year Individual Installed: ❑ Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RECUEST BEFORE PROCESSING CAN BE INITIATED. . Time Timeme ce be o l c �e( Time c.aC Date Date Date _ C 0 Dar - ^ (] ( �j Inspector inspector Ins D for Inspector Field Notes: /l Ya 'Iy3�g`� moi- . �[ C.O• Owl •/-25-7 �OL'A r ( APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ( DISAPPROVED PPR_OVAAL ( 1 CONDITIONAL APPROVAL- DATE GATE � � �Q Solis Rating Date Sewer Installed Well To Absorption Area //�'�" Well Log Received / 2-2-S ;?-- 2- /- gle.? I Well to Tank /d:.p Septic Tank Size / 724231