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HomeMy WebLinkAboutDAWN VILLAGE BLK 2 LT 11Drawn VI'O I I age Block 2 Lot 11 #014-061-49 A~CNOi~G(. AL~mI.A W SUBSURFACE EXPLORATION ~ifl Rep~ of Operations 22V TIME DISTRIBUTION HOURS RiG HOURS CASING LOG to. SOILS LOG ~,~- Yater levelt DRILLER, Ic) feet. Sa~, gravel and some :ocka. l~o ~ater. Tight ~ clay inter~d~ ~th g~vel ~ SOL~ ~CkSe Va~r ~a~ng ~d ~d ~vel. Production~ 12 gallo~a per minute. INSPECTOR __ ,, C v.A.� IVE A Y i TE STATE pC • RN A� , 7176 [AST 73110 AV[NU[ ANCHORAGE. ALASKA 69707 SUBSURFACE EXPLORATION Shift Report of Operations rEDERSON CMISTRIICTIONI I11C- PRO,CCT Dawn Subdivision, Lot 111 Block 2 1, ORN [R 6" Domestic Well S. TVP[OF CKPLOVIATION 22W f. CONTRACTOR WFSTER"I STATES ASSOCIATES (DVI►M(N7 NAM[ 22 NOL[ NO. A. CONTRACT NO. S. SURFACE [L[VATION M[ATN [R D[PTN•\C6/N fNIIT OCPTN•[NO SNIIT O[PTN ORILLCO.r. S. P[RMIIROfT [N COUNI[R[DI FROM TO 7. MATER L[V[L DAT[ 6 SHIFT �• TIME DISTRIBUTION HOURS DRILLER ��� CNV RN GRILL • Herb Johnson ROTAR7 GRILL FIS"IN6 PULL CASINO •OOM TRUCK STANDBY 1 ' NEL►[R TRUCK -- WELDING $URGING . PUMPING .nn e I nr. RIG'HOURS &AMPLC NO. DEPTHS TV SAMPLC S MATERIALS AND REMARKS NO. L[MGTN NOTA L LCNGTN /ROM TO 1 10'1 i 10'11 0 39 Sad, gravel and some rocks. No water. 2 715 8144 39 86 Tight sandy clay interbedded with gravel r 3-8'1 7'2i somc rocks, 4 710 X11124 739'1 86 93 Water bearing sand and gravel., 5 1104 6 5'1" 449211 7 8'6" 521811 8 8'6 6112" 9 C3—„'67'5" 10 6'11 71 « 7494- 1 II lz 515" 1 8619" « P2 1 Ta 9111 octn I Water levels 19 feet. rroductiont 12 gallons ver minute. !' P. tjUNXC::T.t• nL—XTY OFF t-jNClns-j- F:i0E: ' DEPARTMENT OF HEALTH RNG EtJVIP.OFIF1EtdTRL FROTECTIOtI 2516 E. TUDOR RD.. RNCHORAGE, AK. 99007 276-222.1 t•IELI- PERM X -r PERMIT NO. C 77022 APPLICANT PETERSON CONSTRUCTION SRA BOX 1718X 344-86: LOCATION TESHCRP ST LEGAL L11 82 DR14H VILLAGE LOT SIZE 10000 SQUARE F MINII0.►N DISTANCE BETWEEN A 14ELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE I•JELL OR 200 FEET FOR A PUBLIC WELL. WELL LOGS APE REQUIRED AND 11UST BE RETURNED TO THE DEPARTMENT HITHIIJ 30 DR% OF THE WELL COMPLETION. iSPECIFICATIONS MID CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. ! PERM X -I- ", AL -I [> F=OM OI'JE YL'FtR I' Mol" "-'SUE I CERTIFY THAT 1: I RI•I FAMILIAR. WITH THE REQUIREMENTS FOR 014 -SITE SEWERS R11D WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL I1•ISTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. .. t. — . — ----- SIGNED: -APPLICANT PETERSON CONSTRUCTION ISSUEI> 13Y --- r ---=-----------DATE-- i � 1-x n U 0GOW r. PT S•3203 allru W ✓T SCT 02 aN.t C40u40 6 '-waS? 10.7j7 f0 FT M 9YN•36•( M•- [1Q.M $3 FT. �9i 79'Qs I -- wur..n• us( .1,. 4 £ 9.+91 SOFT w 3 s•-e.9s.so.rT « • (� 1 f.7S?S.. r f Q I :1 it •.99+ SOIL I.9Z��3c( us s3 'S((MOMO7[i 6 • I 1.730 s0 FT ,j'�Sfii_� _- 1, ..',• 1,120 iO /T •'� 11►149rj.•! • 1+i is t0�1lTILiTY 4 ;� EASEMENTS 8,7112 SO 11 1 :-+A 9119•s2'1e't 4• 0V N p• v N S-1 03 3 1 PT S•3203 allru W ✓T SCT 02 aN.t C40u40 6 '-waS? 10.7j7 f0 FT M 9YN•36•( M•- [1Q.M $3 FT. �9i 79'Qs I -- wur..n• us( .1,. 4 £ 9.+91 SOFT w 3 s•-e.9s.so.rT « • (� 1 f.7S?S.. r f Q I :1 it •.99+ SOIL I.9Z��3c( us s3 'S((MOMO7[i 6 • I 1.730 s0 FT ,j'�Sfii_� _- 1, ..',• 1,120 iO /T •'� 11►149rj.•! • 1+i is 4 ;� 8,7112 SO 11 1 :-+A 9119•s2'1e't 4• :3 C 9,2[7 So IT f UST 134119 i 2 -` 1 / I v , .1 IT N i It •ALUM. (�► wC". ..;'name fA0U40 tas7 = �F b S 9.2&2 SOFT SEE I Ix i`f uua [ 12005 rn4 ' car 1 INSET W 7 _ r 8 W!. g 434 It v�'i .a. Im L eus4te J ~I: I tp It c. iv"s O \ 5-723+ •°I S.4.0 to FT.71.2 i3 i 21 . 9.972 SOFT iy LOT .t I S 10900 0 Sul �19.ri—..90.. „ ) S-3134 I97s 23I n .�r WEST 32976 "' • ,Y • �— 1 = ". „ M (6ot�se f ©[a7.� mp) 17000 • BLM 79 Te N 5# P1— 131908(meo9) RASPBERRY ROAD v 1 LEG ND Set this survey Found Des:rlption wK/,GM•,IFil'dCI W/ Alum cap set fish%/pvmt. SURVEYOR'S CERTIFICAT s^=� Pro;_ ii. -n 1, EARLKQRYNTA Municipality of Anchorage • j Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw, Street P.O. Box 196650 Anchorage, AK 99519-665001A, www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. 0I —D6I -14 1 COSA# Oma( 0 41-5-�-I 1. GENERAL INFORMATION Expiration Date: 3 — a Cl — O Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address DAWN VILLAGE S/D• BLOCK 2. LOT 11 6611 TESHLAR DRNE • ANCHORAGE, AK • 99507 WALTER HOLBROOK Day phone 8834 JEWEL TERRACE SURE B • ANCHORAGE. AK • 99502 Day phone BETHANY STAMPER W/ COLDWELL BANKER BEST Day phone 265-9169 3000 C STREET • ANCHORAGE. AK • 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well N Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site ❑ Individual Holding tank ❑ Community On-site ❑ 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. I further verify that based on the information obtained from the Municipality of Anchorage riles 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 Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineers Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance ofthe system under the conditions encountered at the time of the lost, and separation distances measured to readily idontifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater 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 the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the sole benefit of the ownerlisted above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE l� Approved for Disapproved. Conditional approval for Attachments: COSA Checklist Septic System Advisory Well Flow Advisory bedrooms. CI 337-6179 Date ( Z1 Z2 J *� 4 y �0 orness.' E— 53 :O ro/esato�°oo �400o P��tY OF'gN . J= �•• • O ON-SITE • c�'� •c WATER AND ; Ms WASTEWATER : PROGRAM ' O bedrooms, with the flowing stipulations: '•, �_ ., • • ,. • � ���� Arsenic Advisory Maintenance Agreements Supplemental Engineers Report Nitrate Advisory Other By: tRm. 11105) Original Certificate Date: 1.2 - o fl —09 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) 343.7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: DAWN VILLAGE S/D; BLOCK 2, LOT 11 Parcel to: D I q ^ 1) G 1— y I WELL DATA Well type PRIVATE If A. B, or C provide PWSID# NIA Well Log (Y/N) YES Date completed 1/18/1977 Sanitary seal (YIN) YES Wires property protected (Y/N) -_ Total depth 95 ft. Cased to 95 ft. Casing height (above ground) 12+ FROM WELL LOG AT INSPECTION Date of test 1/18/1977 12/10/2009 Static water level 19 ft. 10 ft. Well production 12 g.p.m. .... _ . _. _ . 10.2 g.p.m... WATER SAMPLE RESULTS: Coliform colonies/100 ml. Nitrate�.�%g./L. Other bacteria colonies/100 Arsenic: hlnug./L. Date of sample: 12/10/200 Collected by: GEG Ltd. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size gal. Number of Compartments _ Foundation cleanout (YIN)— Depression over tank (YIN)— Date YIN)_Date of pumping Pumper ABSORPTION FIELD DATA Date installed Soil rating (g.p.dJfeor ft'/bd System type Length ft. Width ft. Gravel below pipe Total depth - ft. Eft. absorptio a_ ft' Monitoring lube_ Depression over field_ Date of adequacy test Results (Pass/Fail) For_bedroc Fluid depth i�abso n field beforetest_in. Wateradded_gal. New depth Elapsed n. Final fluid depth _ in. Absorption tato >= g. A y rejuvenation treatment (past 12 me.) (Y/N & type) If yes, give date Date installed Cleanouts (Y/N) _ High water alarm D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN) "Pump on" level at in. "Pump off" leve High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A On adjacent lots N/A Absorption field on lot N/A On adjacent lots N/A Public sewer main *45'+ Sewer/septic service line Animal containment areas 50'+ Public sewer manhole/cleanout 50'+ Holding tank N/A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption Water main Wells on adjacent lots Water service SEPARATION DISTANCE FROM ABSORPTION Property line Water service F. COMMENTS *PER EXISTING G. ENGINEER'S CERTIFICATION Surface TO: Water main Surface water Driveway, parking/vehicle storage Wells on adjacent lots I certify that I have determined through field inspections and 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 Date 12-1Z2/09 ,, 0, COSA Fee S 1 �r Date of Payment 09 Receipt Number 3 5 3N 0 (Rev. 11105) Waiver Fee $ Date of Payment Receipt Number SGS ReLM 1096527001 Client Name Gayness Engineering Group, Ltd Printed Datefrime Project Namc/N Dawn Village B2,LI I Collected Dste/Time Client Sample ID Dawn Village B2,LI I Received Datelrime Dlatri: Drinking Water Technical Director Sample Remarks: 1222/2009 9:45 12/092009 16:00 12/092009 16:15 Stephen C. Ede Allowable Prep Analysis Parameter Results POL Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 u8/L EP200.8 C (<10) 12/17/091221/09 NRB Waters Department Total Nitrate/Nitritc-N 0.223 0.100 Microbiology Laboratory Colony Count 0 Total Coliform 0 Fecal Coliform 0 mg/L SM204500NO3-F B (<10) coVI00mL SM209222B col/100mL SM209222B col/100mL SM209222B A (<200) A (<I) A (<1) 12/11/09 R3T 12/09/09 DLC 12/09/09 DLC 12/09/09 DLC ■SEC -29-2009 02:54A FROM: i ■ ■ f AAROW PUMP & WE11 SERVICE, LLC P.O. Box 110496 Anchorage, AK 99511 Office: (907) 346.9355 • Fax (907) 333-8976 Eagle River: (907) 622-9335 I CUSTOMER G r2 r .4 IA e, L n ra "q o T0:3383246 P.1 UNWOOC N° 68551• JOB SITE 7 EIMER i %1 L J L J WELLDEP awl OMMA UTED PUMP OEM aKESPEne0N OUANTITY • DESCRIPTION PRICE AMOUNT u.,f-/%o V, 60 y 9�owd4; f 4 W2 eo'eQKdut7 o K Vl.e- ' tti o COK U p ou SC LABOR HOURS RATE AMOUNT TOTAL MATERIAL TOTAL LABOR Q(� WORK ORDEREDBY DATE COMP. TOTAL LABOR PAY THIS AMOUNT ' Thank You SIGNATURE (I Horeby Acknowledge the Satisfactory Completion of the Above Described Work and agree that If above work Is not paid for In 90 days 1 agreo to allow Aarow Pump d Well Service, LLC. the right to remove unpaid for equipment and charge for labor already performed 8 labor to remove unpaid for equipment) TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF tb% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS. Municipality of Anchorage ; •• -� Development Services Department Building Safety Division • Onsite Water ti Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage. AK 99519519 N-6650 ��JJ??'' www.muni.orglonsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. ly-�i" Ln COSA# �lOn�1 �g 1. GENERAL INFORMATION Expiration Date: Complete legal description DAWN VILLAGE SUBDIVISION• BLOCK 2 LOT 11 Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address 6611 TESHLAR CIRCLE • ANCHORAGE AK 99507 HUNTER GREENUF Day phone c/o AGENT 200 W 34TH AVENUE #391 ' ANCHORAGE AK 99503 Day phone GARY COX w/ aloskopropertybuyer.com Day phone 727-4779 ow Atlexamy unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well O Individual On-site 11Individual ❑❑ Water Storage Individual Holding tank Community Class Well ❑ Community On-site N Public Water System ❑ Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite 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. 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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 a ANCHORAGE. AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date t Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, odppp conscientious engineering anaWs of the system In accordance with ADEC and MOA . oocpF q DSD Guidelines & Regulations. The reported results described the performance of the pP 4. • ""' system under the conditions encountered at the time of the test, and separation s distances measured to readily IdentaWe features. The operational fife of all wells and septic systems depend on the local sols condition, groundwaferlavelsfhat may 9 fluctuate Burin the 0• """' ' ' ........ • • ..... g year, and the water usage ofthe family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that Q r Game s! there are no hidden defects or encroachments. GEG, LTD. can therefore not provide OQ a CE— 3 ` any warranty or future estimate of how long the system will continue to meet the 04's Nd� operational requirements of the ADEC or MOA DSD. The content of this report Is for �� ^sy t . ) µ r o the sole benefit of the owner listed above. Any reliance upon or use of this report by any 00 Pref eoelo�e� other person or party Is not authorized nor will it confer any legal right whatsoever. D�VOoo�� 5. DSD SIGNATURE Approved for bedrooms. Disapproved. \�kd\�y OFrf � Conditional approval for bedrooms, with the tllowing stipulatiQ�',• •' •"• •,h'p��i� .•C� ITE WATERATER PROGRA Attachments: / X11111 U 11111 COSA Checklist Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Reort Nitrate Advisory Other By: (Rw. 11NS) Original Certificate Date: _40 off_ Municipality of Anchorage Development ServiceS Department Building Safety Division ,.' ... On -Site Water 6 Wastewater Program 4700 Bregaw Street P.O. Box 196650 Anchorage, AK 995196650 www.muni.orgionsite (907)343.7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: DAWN WLLAGE SUBDIVISION; BLOCK 2 LOT 11 Parcel ID: A. WELL DATA Wen type PRIVATE If A, B, or C provide PWSID# N A Well Log (YIN) YES Date completed 1 /18/1977 Sanitary seal (YIN) YES Wires properly Protected (YIN) YES Total depth 95 ft. Cased to 95 ft. Casing height (above ground) 12+ In. FROM WELL LOG AT INSPECTION Date of test 1977 9/28/2006 Static water level 19 ft. 23 ft. Well production 12 g,p.m. 7.59 g.p.m. WATER SAMPLE RESULTS: Coliform _0_ colonies/100 ml. Nitrate N_ mg./L. Other bacteria _n oolonies/100 mi. 11/g/2006 AARROW PUMP AND WELL Arsenic: _ND-ug•/L• Date of sample: 9 2 2006 Collected by: GEG. Ltd. B. SEPTICIHOLDING TANK DATA PUBLIC SEWER Tank Type/Material Date installed Tank size gal. Number of Compartments _ s (Y/N) Foundation cleanout (YIN) _ D ver tank (Y/N) _ High water alarm (Y/N) Date Pumper C. ABSORPTION FIELD DATA PUBLIC SEWER Date installed Soil rating (g.p.d.lft'or ftlbdrm) _ System type Length ft. Width ft. Gravel bet ft• Total depth ft. Eff. absorption area _ fe Monitoring to _ Depression over field Date of adequacy test Results all For bedrooms Fluid depth in absorption field be _ in. Water added _gal. New depth _in. Elapsed Tune: Final ftuid depth _ in. Absorption rat >= g.p.d. J A venation treatment (past 12 mo.) (Y/N & type) If yes. give date I r D. LIFT STATION Date installed Size in gallons Manhole/Access "Pump on" level at _in. 'Pump off" Ie High water alarm level at in. Datu Cycles tested Meets alar & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A On adjacent lots N/A Absorption field on lot — N/A Public sewer main '45' Sewer /septic service tine +k 10'+ On adjacent lots N/A Public sewer manhole/cleanout 50'+ Holding tank N/A Animal containment areas 100'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: PUBLIC SEWED Building foundation Property line Absorption field — Water main Wells Water Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: PUBLIC SEWER Property line Building foundation Water main Water service line Surface waterriveway, parking/vehide storage Cud— Wells on adjacent lots F. COMMENTS I *PER WRM960067 + If Or -A tcs[ of:.( G. ENGINEER'S CERTIFICATION I cer* that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSH guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date 11 m u rab COSA Fee S y30. coo Waiver Fee $ _ Date of payment 1T��0 G Date of Payment Receipt Number l2�+_� (a Receipt Number, (Rev. 11105) ............. A ey G ess.: p C9-7 3,de� Nov 08 06 11:3921 __.,.. 0 AV, S89`-:r7'z0"E ^ So.00 C ki —r\ I Ur TELE 3 ELEG Es,nr - �t �'6sfl�c � rP � R i ✓ E _ P.2 Aaaaai Kart oowllna 156" L is the responsibility of the owner to dc1cmil a the mA� existence of any casements, covenants or restrictions c 1 Under no eircumsuneea should any data Dereon De 36` � r MFra wa Hie I � n 0 U used 6r construction or for establishing boundary or ASBUILT t n 45.t.4. Re So - �t �'6sfl�c � rP � R i ✓ E _ P.2 Aaaaai Kart oowllna 156" L is the responsibility of the owner to dc1cmil a the — �-�- `'•��- f � existence of any casements, covenants or restrictions which do not appear on the recorded subdivision plat 1 Under no eircumsuneea should any data Dereon De used 6r construction or for establishing boundary or ASBUILT Fi1SFlytt?IIS OF RECORD, OTHER THAN THOSE farce fines. The surveyor takes responsibility for the SHOWN ON THE RECORDED PIAT, ARE NOT initial transaction only. SHOWN HEREON. 1.ES'aEMR LOT // at.vs.n ic.� 7�.Z29 0BRASS CAP MONUMENT O IRON PIPE (PLAT NO.: • REBAR CORNER FOUND ANCHORAGE RECORDING DISTRICT p ItUB ANDTACK PREPARED BY: (907) S48 '054 WLING Bc ASSOCIA Fes: $y8-oBGf CQ 348—°roes P.O.BOX110029 ANCHORAGE, AK 99511-0029 REVISIONS DATE BY DATE: BY: SCALE: ,: r WORKORDEA: FIELD BOOK: GR1DN0: i/ oc-T''9rA / -30 �ats.5 �rR2.� 2034 SGS RtEN Client Name Project Name/11 Client Sample ID Matrix Sample Remarks: 1065841001 Garness Engineering Group, Ltd. Lt 11 Bk 2 Dawn Village Lt I I Dk2 Dawn Village Drinking Water All Dates/fimes arc Alaska Standard Time Printed Date/time 10/052006 15:36 Collected Daterrime 09282006 8:30 Received Date/Time 09282006 10:10 Technical Director Stephen C. Ede Allowable Prep Analysis Parameter Results POL Units Method Container ID Limits Date Date [nit Metals by ICY/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 0929/06 10/03/06 WAW Waters Department Nitrate -N ND 0.100 mg/L EPA 353.2 0 (<10) 0929106 ALR Microbiology Laboratory Total Coliform 99 O0. No Coli col/IOOmL SN1209222B A (<1) 0928/06 TLF MUNICIPALITY OF ANCHORAGE . • I z DEPARTMENT OF. HEALTH & HUMAN SERVICES 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 FAMILY DWELLING Parcel I.D. p c 1+i — O b I — J1 °I HAA M Q CNSf` Lt ?�`1 1. GENERAL INFORMATION Complete legal description Le 7- t 1 13.,c c.e Z D.4 ta.v vd "o cc S/r Location (site address or directions) 6 G r i r Esw"A& D n, A.f C�//c /Z -1 C� c7o7 Property owner c:u",¢U. rre_ .4 hA c- C A e. E ,r Day phone -32 7 Mailing address 6,(11 r•ESHc..rA 0.4. A,� r, .4K ey9•S-•c Lending agency Day phone Mailing address Agent A M,,1t CNrcJ — Re."AX Day phone JS7 —c1s3 " Address Unless otherwise requested. HAA will be held for pickup.. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well x Community well Public water NOTE: It 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 , 1 Community on-site Public sewer K NOTE: If community wastewater system,provide written confirmation from State ADEC attesting to the legality and status of system. 124251p +.tA11 troll ►1OA021 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below; ) 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. l 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. S i S ENGINEERING phone Cif y '>-,i7 Name of Firm Vom E8,14 Eagt* River, Alaska 99S77� Address Engineer's signature 6. DHHS SIGNATURE _Y Approved for ___ bedrooms. Date le lls-1 9c Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Y The Munlcipality 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 es a ccurtesyto purchasersof homes and theirfending 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. n�pM.wn 5. 4wrn 8 Legal Description: A. WELL DATA — - — I.YX CWAUn OF ANQvX4a EN WOMMDrUI UWM pryW Municipality of Anchorage OCT 16 1996 DEPARTMENT OF HEALTH & HUMAN SERVICESR C Environmental Services Division C U VE L Street, Room 502 • Anchorage, Alaska 99501 • (907)'343-47 Ir Health Authority Approval Checklist 9 Wen type Pk s %4 r C 11 A, 8, or C, attach ADEC letter. Log presets) Y t S Date completed _ Total depth 9 3 r Cased to 9S - Sanitary seal 6IN) I Y t s 8. Date of test Static water level Well production FROM WELL LOG 10c Iq. 1 3 g.p.m. _ Parcel I.D.' ADEC water system number 4V IK _ Casing height (above ground) _ Wires properly protected $/N) Y[ S AT INSPECTION folt?�46 g.p n i Y A49r.1.cr40 aY pomea PLr.v WATER SAMPLE RESULTS: 1 O Nitrate 0.) Other bacteriawform.a Date of sample: a/ ?< /LL. Collected by. S 3 S ENGINEERING i We Rlwr, Alaska 99577 SEPTIGHOLDIN11TANK DATA f✓ 14 p a t, S E wt•.•e- Date installed I Tank size Number of Compartments nouts (YIN)— Foundation deanoirt (YM) High water alarm (YM) Data.o • ng Pumper i C. ABSORPTION FIELD DATA Date Installed I Soil rating (g p d.HN or ftYbdrm) Syr -tom type Length I Widttn Gravel thickness below pipe Eftectiw absorption area Monitoring Tube presen Depression over field (YIN) Date of adequacy Fluid depth In abs Fluid depth_G For beds test pn.): lmmedtately after_ gal. water added (In.): (ins) Minutes later. Absorption rate = a.p.d. (past 12 months) (YN it yes, glue data D. UFT STATION Date Installed Manhole/Access (Y/N) High water alarm level at' Cycles E. SEPARATION DISTANCES *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Size in gallons Septic/holdng tank on lot N 14 On adjacent lots Absorption Geld on lotg' /'f On adjacent lots 'Pump off' level at* Public sewer main 11 S Public sewer manhole/cleanout _ i Sewer /septic service line ax Litt station N A /A sc ' SEPARATION DISTANCES FROM SEPTIQN=INGTANK ON LOTTO: H/A PVAu$ c S L C,rt+ Foundation Property line Absorption Water main/service line Surtace water/drainage SEPARATION DISTANCE FROM ABSORPTION FI LOTTO: Property line Sudace water adjacent lots foundation Water maintservice One Driveway, parkingMehicie storage area drain Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that ! have defenr*W Mw field fnspecdons and review of Munk#W racords thatop In oonrortnarmce ,,��iiff Qui fines In effect on Ws date. yqP/'•�, Signature Engineers Name IQiBG•tr- C- C�.vAr • T�,•,' i166iQT G COWAN Date f0 /is/9G 4, ��y c. -COOL d, HAA Fee 3 --n, o6 r 01) Waiver Fee S ?C70.0 4z Date of Payment 10/6 l'9 Date of Payment A b Recoipt Number XZ7 41 2�jY3 % Receipt Number AL, ME Environmental Services Inc. Laboratory Division roei�coscs�movecos�cccs0006ccomes000sooerce. 200 W. Potter Drive Anchorage. AK 99518.1605 Tet: (W7) 562.2343 Fax: (907) 561.5301 CT&ERer.A 965419001 S & S Engineering Client POA Printed DatelTlme 1011419609:36 Client Name Project NamelA N/A Collected Datt/Time 10108/96 08:45 Client Sample 1D Lot 11 Blk2 Dawn Village S/D Director: then C 6 1 e Technicaeivedl Technical Director.(SAteph/en—C/. Ede hialrix By Drinking Water C Ordered 0 Released By J�'" — PIVSID anlple K matks: Oaraxter Ritrate•R Total coltions N N N Allowable Prep Analysis Results POL Units Method Limits Date Date int 0.100 U 0.100 atl/L SM18 4500-103F 0 0 col/10001 SM18 92228 110/08/96 EME 10/08/96 TALI S IS*%SGS Member of the SGS Group (SOci414GWraledaSurveitlanee) v FNVIRnNMFNTAI. FACILRIES IN ALASKA. CALIFORNIA. FLORIDA ILLINOIS. MARYLAND. MICHIGAN. MISSOURI. NEW JERSEY. OHIO. (NEST MR Municipality of Anchorage , Department of Health and Human Services 4 825 "l.' Street Fickh"tMM, p.o. Box 196650 Anchorage, Alaska 99519.6650 Mayor October 25,1996 Robert C. Cowan, PX- -S & S Engineering 17034 Eagle River Loop Road Suite 204 Eagle River, Alaska 99577 Subject: Waiver Request for Lot 11 Block 2 Dawn Village Subdivision Waiver Request NWR960057, PID X1014-061.49, 4HM60457 Dear Mr. Cowan: Your request for a waiver of the required 50 foot horizontal separation of a private well to a community sewer line has been approved. The approved separation distance is 45 feet. This waiver approval applies to the existing well and community sewer line only. Any future upgrade will require all separation distances be met or another approval from this department. If (here are any further questions or concerns regarding this waiver, please call our office at3434744. Sincerely,�']`�- Daniel J. Roth Civil Engineer On-site Services DJR11jm:Green y: w -� ._rIUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WRI UR96006of PIDI 014-061-49 HAI EA960457 Permit I Date Received: October 16, 1996 Legal Description: Lot 11 Block 2 Dawn Village Subdivision Engineer: Robert C. Cowan, P.E., S 6 S Engineering 17034 Eagle River Loop Road, Suite 204, Eagle River, Alaska 99577 Applicant: Charlotte/Hack Creen • rr«rr« Waiver Requested: Private well on property to the community sewer line of 45 feet. Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation a oau' rrr r^� VfR REQarsr FoR tar wBlvEj? REQuEsr N4,kOER tiVR9`0067 F Pw#Wr- Ilm? I?Ef"Esr FoR F1?1v/f%E I-EL4 704SEwrR L/tit=_ OF ¢f strz- l.r,vE D.4*— Z',(/ 711E U/C/Nt77 or Mr SKBTECr Pic"iKF SEw£R L/N E w/►S t'oA1sT/P R! nv Et6Kr mw Dutr&E ,ZROW PI>E WOW 7TlF_' TotaT3 •ar�p /� +SlEsTaS Cot/cRETr 73 /rrtKR� RGir�R•3T L E.9k/a4r• 77411 pn-s 714 iONSTRIltrtb.v M67 -K1/; OF M& r//k6 t__XEN y/£LLf :-E�tE k�✓e�v .s►60� 77 -[A -T- t. 09 -LV B e TO CL.OS[, t,., ELL. p,#r.+— rllr' Suorecr wrcL aws DR/LCEo IN 1977. R r T"iJ 7-1.,,* E TIME SEPI4t?r►-r/o/v REQutt¢LA4Ear3 APR 9 wept 2-0 /ktrt-/c rE•-��P LINE R� M/},vllOLE Prier &PM .J0PxC 7NERC I}RE t-F_LL Gobs Fo^ rF{,£ SunRou+Lp/NG L917'7 f}S 9-16LL Me! StcOrECr- RLL T/{E aELL LGGl /NO/CI}7F� lavJ•srr•vr rrnn77P OF SNBSctRf� :%'6 1L j /�' Tu F i¢RC.} OJc r-r+E s-"orEc7—fir LL, T KC iRc00H/v��' SUOSuKF+¢LE sort_ /s T�dl-rr Sar wn-e xOck -wit JAI. 7wovif N/GN 1'Rvl�ti/NL SI4A�0 � 6R/}t/6L f/s 0 tl irCr�srTFR�D, ALL ME rr,+r/L �-Yt7"G/z L EvEtT p4e 19-teu trcR% AMr 11 Co�vpl"rp f+eo^ tN2FistE iIvTAMI�NT/O/1/ t'. rFIE PoMe4r g_A_7WR 041&41 eQ, REcE�r rr>�reR t .uPcEr /. p/t�7 po jy#crr)eta fl?ESENr- Ap,0 NO tvtrRarer PErr"'r'""'r• . or It. . .. .P.0 0, '>. Com. IL . Po Al 7-s 1 w�r�a rgr�ce . .. ?G g --01L SoRBr/oN .M I :zq (74J �9 I ER�uEAD/L1rY 2.274) i✓►3TE N LF RI�DIfvi I fl SSaHE fOnrsE?V/Yri✓E Q� 2.9 i OI712 2f 20 61?:fA,o roTRL /5.7 roAla us/oN i fjLJHa4(,N THE POIVrS ls=RE /Y/iv/Msur NAX" /G 6Y vlRTae rx� Me u.VF /N QNtrT/aN /s putTitE tl�o✓ Aro f.�L�ren / 1�S9ESrus Cav[IQ6TE AND aEe.t Sg'+rL£J SWV.&. +ue 'ff4a7r-Vii- oR ivlrRirres VErcCT/f6ptr... GR otouT' �. w�✓ESE', r-� 014.1-CXoI-x ) R09ERTC. CowAl ROSERTA. SHAFE October 14, 1996 CMLFNGINEEM (907)694.2979 FAX (907) 694.1211 RECEIVED OCT 16 1996 ncran„wr am Municipality of Anchorage APPAOL+ DEPARTMENT OF HEALTH AND HCMAN SERVICES MurilCipality of Anchorage 825 "L" Street DePt Health & Human Services P.O. Box 196650 Anchorage, AK 99519 SEWERSWATER &WHE Q"IDI'd REFERENCE: Lot 11; Block 2; Dawn Village Subdivision Request you issue a -Health Authority Approval on the referenced property and grant a waiver for the horizontal separation distance SEWCRSWAr[R ►aPErno.+ between the private well and the community sewer line at 45 ft. The is 50 ft. due to the date these water an required separation distance facilities were installed. The manholes are at more than 50 ft. sewer from the well. END,fERHGSTLMS The mitigating factors involved which support the issuance of the AMWEPOM waiver are as follows: 1. Well logs in the vicinity show sand and gravel which would provide WELL94PECTICN treatment and confining clay before any released sewage could and at around 80 ft. deep. &RavtaT reach water bearing sand gravel 2. The topography in the area is relatively flat with a slight slope to the northeast. This would increase the horizontal distance S,TE'wa that contamination would have to travel (see topo). 3. Water samples from the well are satisfactory (attached). rlwa=IGN 4. Wells serving other properties throughout the neighborhood have been placed at similar distances from the sewer line. With no well water related health problems reported, this would appear to be an acceptable practice for the area. soaTTST We, therefore recon -.mend a waiver for the separation distance between the well and sewer line. PEFC ATna, TEST If you require additional information, please contact us. Sincerely, rsuc MCWV.C4 L NS►ECT10,T4 twEe " . Robert C. Cowan, P.E. ROC/gk CH LTE ENCLOSURES WASTEWATER Cr.P0tALSMTEA/ CESF.N 17MI AM1PiTH FAM F RMFR 1 ODV • fl m'F 9n4 • FAM F EWER. ALASKA 07577 1" = 30' SITE PLAN O O I I i x d I r � h I 1 E I I I i x . to I h 1 I O i co I I I I I i h 1 O i co = X 0— C= Nz 0 H r I- 0 to R� 51 ' APPLIC~NT FILLS OUT UPPER HAI" -)ONLY Dien%JJ .-Owner In n i kne _ 1 f+fr a C -g ) zip Coda Date M�(ng Address n per.{r ILk/\ Date Buyer Merck i7rep n , ` ;..1..•I g • r. ,hr .21p Code e 570 -7 Address .. // / p Unding Institution � `„+�� �J�—,;,,.a„ nh Cf /7e'�,Me' Plum. Inspector Zip cod. Address v �a• r Phone // Realty, Co. & Agent Zip Code Address Legal Description. - �� ) ��OrrGk a f D..,• ^ V logeE �J ijJlSeti+ Street Lo"Ven (0 + h �A/l.. rt nfJ-.+,n • �) Type of Residence Singla Family O MuRiPle Family No. of Bedrooms O Other Water Supply ATTACH WELL L00. A wait lop Is leQulred for ail wells drlled sloe. Jv l Individual'LJ For wells drilled Prior to that data. give well depth (attach Iog If avaoabte). Community O Public Utility Sawer Disposal O Individual Year Installed: Cornual Public LAolly Wnan Comseted to PuDIIC 1Jtiitty. 1 Holding Tank NOTE THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Tema Time kne _ Time Date Date Date Date Inspector • Inspector Inspector Inspector �_`- 1C1D:'Ji t� s - Field Notes: Nye• (.>CL APPROVED BEDROOMS i ) DISAPPROVED ( 1 CONOITIONALAPPSOV DATE/ Soles Ratlno I Dais Sewer Installed MUMCIPAUTY OF ANCHOPAI DEPT. On I'S'lTH ). ENYIRJ:u.U;iA.1..0 _CTIC ! :6 2 8 1963 -CONDITIONS OF APPROVAL Well To Absorption Area I Well Loo Received 1". March 4, 1903 tlichael P. McNichols 6611 Teshlar Dr. Anchorage, AT 99507 Subject: Lot 11 Block 2 DaWn Village Subdivision 0 LLX9. Approval for the individual acwer and Water facilities cannot be granted until the following itens have been completed: C The top or the Well casing should be scaled no that it is V/< stater tight. o The water analysis report ncedr. to be cubnitted to this office from the Chen Lab, 5633 D Street, for our review. Plcase notify this Departnent for a reinspection %then the noted ted. if discrepancien have pleacebcall een ct1liscoffice at 264-4720. here are any 264-4720. Sincerely, Jin Roberts Associate nnvironnental Specialist Snl36/p/F.1 INSPECTOR INSPECTO • ser ' w MUNICIPALITY OF ANCHORAGE DEPT. OF IiEALTH S . �'• DEPARTMENT OF HEALTH 6 ENVIRONMENTAL PROTECTItWRO MENTAL F«OTECTION 1125LStr«t.Andta".AlaWa"Sol \�. �V ENVIRONMENTAL SANITATION DIVISION iLt�R2i� �98� �1 i Telephone Z6 Aj 0 'RECE1 ED Y REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete oil parts om page 1. Incomplete nqu"U will not be processed. Please allow tam 1101 days for processing. 1. PROt!ERTY OWNER PHONE r r r MAILING ADDRESS PROPERTY RESIDENT lit dillaremt from above PHONE =BUYER • 1 PHONt_JWjoy MAI LING ADOPIM L 3. 1 I U N 7INQ PHONE 1-1-7 MAILING ADORESS ✓ ' a. R ALTOR/AGENT M N MAILING ADDRESS tK SINGLE FAMILY C3 One C3 Four C3 other_ C3 Two 13 Five E3 MULTIPLE FAMILY Three C3 six 7. WATEgUPPLY INDIVIDUAL' 'ATTACH WELL LOG. A weft log Is requires for all COMMUNITY .r... •._.. -- ,_- THIS SIDE FOR OFFICIAL USE ONLY. 1. TYPE OF RESIDENCE NUMBER O� 7 ❑ SINGLE FAMILY ❑ ONE ❑ THREE ❑ MULTIPLE FAMILY ❑ TWO 2. WATER SUPPLY PERMIT NUMBER ❑ INDIVIDUAL DEPTH OF WELL ❑ COMMUNITY DATE DRILLED ❑ PUBLICUTILITY Connection Verified LOG RECEIVED - 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAUONSITE. , ❑PUBLIC UTILITY Connection Verified ❑SepticTankor ❑HoldingTank Size: If Tank Is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 5. TO: ❑ FOUR ❑ .•Y (a APPROVED FOR BEDROOMS [1 CONDITIONAL APPROVAL (letter must accompany certificate) .-Q DISAPPROVED it MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH i ENVIRONMENTAL PROTECTION CS L Street. Anchorage, A&UM SIMM • ENVIRONMENTAL ENGINEERING DIVISION Telephone 264+1720 t j REGUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES OIRECTIONSr Complen e11 pent on pees t.InaeeipMte 1eWr'+wlo net be preeraed. PIM" e11" ten 1101 eeye for promarog. (1 t. PIT OWNER PH E LOf.: I£OFIRS�rJ 7 y671r IUA Eas 49? - 50y li /8X IC. JTy 7 L LSOALDEE IL /I IJ /) ^— DA w /" � • STR� TTwflON f YEf N LA D i • - - 0. TY►E OP REEIOlNCE NUMBEATiTMROOMS ❑ One ❑ Four ❑ Otho SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY C Three ❑ Six 7. f1ATCR RIPPLY 1 INDIVIDUAL' ' ATTACH WELL LOG. A well top is required for all veils drilled COMMUNITY since June 1976. For wells drilled prior to that data, give well ❑ PUBLIC UTILITY depth lattach log if aveilabis-1 6 SEIRAOE OtSPOSAL SYSTSM ❑ INOIVIDUAL/ON-SITE" �'lf Indivsystem Isoversite, give ears old date if system Is over two (2) Peen old an adequacy Int Is rewired PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. i THIS SIDE FOR OFFICIAL USE ONL.., INSPECTION APPOINTMENTS DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: NUMBER OF BEDROOMS 1. TYPE OF RESIDENCE ❑ ONE THREE ❑ FIVE ❑ OTHER SINGLE FAMILY ❑ MULTIPLE FAMILY ❑ TWO ❑ FOUR ❑ SIX PERMIT NUMBER 2. WATER SUPPLY INDIVIDUAL DEPTH OF WELL ❑ COMMUNITY DATE DRILLED ❑ PUBLICUTILITY LOG RECEIVED Connection Verified 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER DA7EINSTALLED eDIVIDUAL/ONSITE PUBLIC UTILITY Connection Verified INSTALLS ❑SepticTankor ❑HoldingTatk SOILS RATING Size: 11 Tuck is homemade give dimanslons• TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septi Ho dine Tank AEwrVtkon rw ower kM aaraat t m WELLTO: AMorption Area to rwrat Lot Lim 5. COMMENTS (d EnAPPROVED FOR 3 BEDROOMS ❑ CONDITIONAL APPROVAL flatter must accompany certificate) ❑ DISAPPROVED DATE I SY {Tidal s- Q�-V I e