HomeMy WebLinkAboutDEL'S LT 3Lot 3
#015-492-03
Municipality of Anchorage
® Development Services Department
Building Safety Division
On-Site Water and Wastewater Program, 4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507 Page Of
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: OSP I U 0 9(a PID Number: O i S- y I Z- o3
Name' Marfl rV Bowe
Wastewater System: [:]New Upgrade
Address: ++,
624o c, tlz A✓�
ABSORPTION FIELD
Phone: Number of Bedrooms:
❑ Deep Trench Shallow Trench 0 Bed 0 Mound 0 Other:
LEGAL DESCRIPTION
Soil Rating: -*
CJ• 8 T GPWf
Total Depth from original grace:
9.2 Ft.
Block: Lot: SubdMsion-_ 7�
3 l/E Ll5
Depth to pi o ginal grace:
�•Z Ft.
Gravel depth beneath pipe: 2
Ft.
Township: Range: Section:
Fill added above odshal grade:
O
Gravel Length: 1�
4Z 4
I Ft.
Ft.
Well: 4 i5�in
El New Upgrade
Grovel width:
Ft.
Number of lines:
2
Distance between lines:
ID Ft.
Classification(Private, B, C):
Told Depth:
Cased to:
Total abso n/ar�ea:
Pe
Pipe Material:b ,t ��^^
F910 P ASrA 303
Ft.
Ft
Driller.
Date Drilled:
Static Water Level:
Installer:Date
Af Ilom6 EerviGeo
Installed:
+IS —• 1I
Ft
Yield:
Pump Set al:
Casing Height Above Ground:
TANK
GPM
FL
Ft.
SEPARATION DISTANCES
OSeptic ❑ Holding ❑ S.T.E.P. ❑ Other:
To
Septic
Absorption
Lift
Holding
ublic/Private
ManufacWrer.1
AnCb01'4 TA
capacity:
Gat. I000
From
Tank
Field
Station
Tank
Sewer Line
e 11
Well
100'+
1001+
,t
NIA
NAlA
ZS[1-
Material:
ee
Number of Compa%amens:
`._
Surface Water
jp0i+
I001+
NIA
/VIA
LIFT STATION
Lot Lim
5 (+
1.5
NIA
NIA
Gal.
anufacturer:
Foundation
51 �
10 t i.
N I A
l
rVIA
'Pump on"level at:
in.
"Pump off lave[ at:
in.
High water alarm at:
in.
NIA
/1
N]A
Pump Make & Ma
Electrical Inspections performed by:
Curtain Drain
5l) {
� So i'
Remi°
£xis in •Se b(_ s s�ewt AaQoneJ
BENCH MARK
Location and Descdptbn:
Gr Se 6
M Re Mire .+�eh%
Assumed Elevation:
(
I�e jr L
I VV Ft.
b LAP. SPv2� l4n(1 Dates: 1s 5 /
Engin 'S'Stamp
� \�\\
Inspections performed :
p P Y
!I
2nd '�' T !j.
/`V... •..q
Development Services Department Approval
9T
Conditional Approval Date:
/
tP?
. .
RS E. PURKLAND•.
'� 1f15 0
Reviewed and approved by: Date:
(Rer. 04106)
SWING TIES
A
8
s. r. C.O. C
27'
23.5'
s. r. C.O. D
225'
28.5'
DBL C.O. £
20'
31'
OF. C.O. F
48'
39.5'
DF. C.O. G
55'
78'
DF. MT. H
57'
78.5'
OF. C.O. l
64'
54'
DF. MT. J 65.5' 81.5'
E
INV. ELEV.
20' GVL
�i EUV. 86.8'
1 Y
S*
G
PEI
BENCH MARK O A"
25 0 25 50 75 100 125 150
SCALE., 1' = 50 FT
ELEV 96.3'
92.6'
=INV. ELEV. 89.9' 1000 GALLON
Gft SEPTIC TANK
ELEV. 87.8'
�} H2O ELEV. 82.8'
B.O.H. ELEV. 77'
NOTE. THIS IS NOT A SURVEYED PLAT. WELL & SEPTIC
LOCATIONS TAKEN FROM ON-SITE WATER AND WASTE WATER
DEPARTMENT DOCUM£NTAWN. ALL LOCATIONS SHOWN ARE
APPROXIMATE.
FLEV. 926'
00♦.,n Nob.. %50
" �i~•♦
BENCH MARK OARAGE SLAB ���� ��„w;♦♦
ASSUMED ELEVATION 100'
SPORKLAND ENGINEERING DEL'S LOT 3 SEPTIC SYSTEM ASBUILT
20W 1K 9. A NUE JIM BOWS DATE.' AUGUST 9, 2011
ANCH(907) 279-J9l9 6740 E. 71Z AVE., ANCHORAGE, AK 99316 SH££T.• 1/J 01F/D:26JO
PERMIT #67111084 PID # 015-492-03 DELSL3D2.DVG
ZOT
4
R . utton ' o
LSl}92
PROFESSION PL �' sem•
Lot -5 , Block —
De/s SubdUsion —
Anchorage Recording District, Alaska
OT SURVEY CERTIFICATION
E //2 td AV NUE
S 89. 59 00"E o
T•• �• 1605.00'
SEariC s.6I00) < I
r0
402
SHEO- .
ti
GARAGE
Or
40° 28'
�E
0� .Wru
G i6
LOT
KENNEL 0 2
25s O
J
I49, 4/3
I
�•.STEEL RA/L CORRAL
— -----165•00
(77-275)
I hereby cortity that i have surveyed the property shown and described
hereon, and that the Improvements situated thereon are within the prop-
erty lines and do not overlap or encroach on adjacent property and that
no improvements on adjacent property overlap or encroach on the premises
In question and that then are no roadways, utility line, or other visible
easements M said property except as Indicated hereon.
Easements of record other than thoN shown an
the plot of record are not shown hereon unless,
otherwise noted.
LEGEND
0 Bross or Aluminum capped monument recovered
o Iron pipe and/or rebor recovered.
❑ 2 x 2 hub & took recovered
• 5/Sax 30" rebar set this survey
—i Fence Line (Approx. Location)
Scale /„•4,y Date Prepared by: R. L. BUTTON
07-25-11 Registered Lond Surveyor
°
(907)279-6200 5/9 W. Eighth Ave. Anchorage Aiosko 9950/
Ref. 2� F. B. No. / OOH Property of:
C�//77 B O We
On -Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSP111086
Tax Code Number: 01549203000
Work Type: Septic Upgrade
Permit Effective Dates: June 09, 2011 to June 08, 2012
Design Engineer: FLATTOP TECHNICAL SERVICES
Subdivision: DEL'S
Site Legal Address: DEL'S LT 3 G:2638
Owner/Address: BOWE MARILYN S &
JAMES STANLEY SR 6240 E 112TH AVE ANCHORAGE AK 995161824
Site Mailing Address: 6240 E 112TH AVE, Anchorage Lot Size in Sq Ft:
Total Bedrooms:
This permit is for the construction of:
49413
3
Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater
Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80).
3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By: VJ �` -�_ Date: 0/' C9 / I
i
i
Issued By: __ �' , zDate:
Municipality of Anchorage
P.O. Box 196650 • 4700 Elmore Road
Anchorage, Alaska 99519-6650 s (907) 343-7904 • Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Department
On -Site Water and Wastewater Program
NO
�enr S'
t
n
N
Department
* * * * VARIANCE/WAIVER REVIEW * * * *
Waiver#: OSP111087 COSA#: Permit#:OSP111086
PID#: 015-492-03
Legal Description: Del's Lot 3
Engineer: Flattop Technical Services
Applicant: Jim Bowe
Your request for a waiver of the required 10 feet horizontal separation from the absorption field
to the property line has been approved. The approved separation distance is 2.0 feet.
This waiver approval applies to the proposed absorption field only. Any future upgrade to the
on-site wastewater disposal system will require all separation distances be met or another
approval from this department.
...............................................................................
Waiver is Granted: X Waiver is not Granted:
Date: Approved by:
Name of Review$
Rec#: 01504C Amount: $200.00 Date Paid: 5/31/11
**** VARIAN C E/WAIVER REVIEW ****
On -Site Water & Wastewater Program
Mayor Dan Sullivan
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. Ot ,5-- M9 2 -0 3
Phone: 907-343-7904
Fax: 907-343-7997
Property owner(s) ."I( " GC_ cv 0 Day phone 3 Yd- 1'90G
Mailing address 6/2YG i 11Z I" +tee /}rC4o,-e45K7 +It 915th'
Site address Sa.►+�► __ __
Legal description (Sub'd., Block & Lot) 4e, 0�- 3,, D e t r S I -D
Legal description (Township, Range & Section)
Lot Size
Sq. Ft.
THIS APPLICATION IS FOR:
(M all that apply)
Absorption Field hA
Septic Tank
19
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
Number of Bedrooms 3—
THIS APPLICATION IS AN:
Initial
❑
Upgrade
N
Renewal
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Alla w 2. o ' A "f L, h'-<
I certify that the above information is correct. I further certify that this application is being made
for a Single Family Dwelling and is in accordance with applicable Municipal Codes.
Z 21„t
(Signature of property owner or authorized agent)
Permit/Rush Fees: 53G
Date of Payment: 5
Receipt Number: D
Permit No. (�7 5 n ( S
GABuilding\On Site\Forms\Client Forms\Permit App_010411.doc
Waiver Fees: 2.Cc'
Date of Payment:�,�°
Receipt Number:
-
Waiver No.
(Rev. 1/11)
FLATTOP TECHNICAL SERVICES
CIVIL & ENVIRONMENTAL ENGINEERING * ENERGY CONSERVATION & ANALYSIS
TED MOORE, P.E. 14530 ECHO CANYON ROAD
PH./FAX: (907)345-1355 ANCHORAGE, AK 99516
E -Mail: tgmoore@gci.net May 31, 2011
M.O.A. DSD
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sirs:
The purpose of this letter is to provide the required design narrative in support of our application for a
permit to upgrade the wastewater disposal system serving the existing 3 -bedroom residence on Lot 3 of
Del's S/D. The existing soil absorption presently appears to be operating in a surcharged condition. A
site plan, design drawings and specifications and soils log are enclosed for your review. We are also
requesting a lot line waiver allowing the proposed bed to be located as close as 2 feet from the north
property line abutting East 112th Avenue right-of-way. This waiver is necessary to allow sufficient
room for the proposed system to be constructed. Because this is a road right of way, granting the
requested waiver will have no impact on future upgrades to wastewater disposal systems on adjoining
properties. Therefore, we feel that the requested waiver ought to be able to be granted.
Test hole #1 was dug on 5/23/11 to evaluate soil conditions relevant to the design of the soil absorption
system upgrade. A preliminary test hole excavated to the west of TH#1 encountered the remains of an
old stump burial site in the area shown on the site plan. Approximately 5 feet of fill has been placed on
this portion of the lot, which obscures the original contours of the land, so the alignment of the proposed
soil absorption system is based on an extrapolation of the contours from land adjacent to the filled area.
In test hole #1 the apparent original ground was encountered at a depth of 5 feet. Below the typical
organic layer and shallow loam strata a dry, gray silty sand stratum was encountered at a depth of 6.5
feet. Below 12 feet the stratum gradually becomes siltier and damper with lenses of blue clay below 16
feet. Although no free groundwater was observed at the time the test hole was excavated, groundwater
did show up in the monitor tube within the first couple of days, and the highest groundwater depth
observed during the monitoring period was 13.5 feet below ground level. Because the test hole was dug,
and groundwater monitoring conducted, during spring breakup (when the highest groundwater levels are
typically observed), we feel that maintaining a 4 -foot separation from the highest observed groundwater
(i.e. 9.5 feet below ground level) is appropriate.
A percolation test conducted between 7.5 and 8.0 feet below ground level in the silty sandy gravel
stratum resulted in a percolation rate of 1.2 minutes per inch. Because this measured percolation rate
was faster than expected based on visual evaluation of the stratum, the proposed design is based on a
more conservative 0.8 gpd/sq. ft. /day.
The proposed upgrade design is for a 5 -foot wide drainfield with 2.0 feet of sewer gravel under the
distribution pipe. Using 0.8 gpd/sq. ft. /day, the length of a standard 5 -foot wide drainfield would be (3
x 150)/0.8/5 = 113 lineal feet. With 2.0 feet of gravel under the distribution pipe, the length reduction
factor (as described in the wastewater ordinance) would be 0.7 — giving a total required drainfield length
of 80 feet. The proposed drainfield is conservatively sized to have a total length of 88 feet. Because
the required drainfield length necessitates that it be constructed in two parallel segments, we have
positioned the second segment 6" lower than the first to correspond to the apparent difference in the
original ground level. We have also incorporated a 3" high "bump" in the line connecting the two
drainfields to ensure that the first one is fully utilized before spilling over into the second.
Given the foregoing waiver analysis, the proposed upgrade is not expected to have any significant
impact on present or future water supply and wastewater disposal systems serving adjacent properties,
nor will it have any significant impact on reserved space -surface and subsurface, or on drainage.
Please give me a call at 345-1355 if you have any questions on this submittal.
Sincerely,
Ted Moore, P.E.
Flattop 2echnacalServices
14530 Echo Canyon 4Z94 Anchorage, 4R 99516
('hone (907) 345-1355
Lot 3, Del's S/D
6240 East 112th Avenue
Wastewater disposal system upgrade
Specifications
1.0 General:
1.1 The scope of the project consists of decommissioning and replacing an existing 1000 -gallon
septic tank and constructing two 5 -foot wide soil absorption drainfields with a combined length of 88
feet and having a total of 2.5 feet of sewer gravel (2.0 feet below the horizontal distribution pipe).
1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor
deviations from these drawings may be allowed or required by the engineer conducting the inspections.
All construction procedures and material specifications shall conform to Municipal and State
requirements. All separation distances shall be in conformance with Municipal requirements, unless
specifically waived.
1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work
around any buried utilities.
1.4 Unless agreed otherwise, the contractor shall be responsible for any tree clearing and
grubbing necessary to complete the project.
1.5 The contractor shall provide adequate cover material and rough grading over all system
components to ensure that proper drainage is achieved after settlement and that there are no residual
depressions. Insofar as possible the contractor shall minimize damage to trees and existing lawn areas.
1.6 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading
after the soil is compacted, and seeding all areas disturbed by the construction.
2.0 Septic Tank:
2.1 The existing 1000 -gallon, steel septic tank shall be properly decommissioned per code.
2.2 A new 1000 -gallon Municipally approved septic tank shall be installed in approximately
the same location, with care taken to ensure that it is outside the 100 foot radius around the well.
2.3 All pipe connections to the tank shall be equipped with waterproof mechanical couplings.
2.4 A double cleanout shall be installed in the discharge line downstream of the septic tank.
3.0 Soil absorption system:
3.1 The soil absorption bed shall be constructed by excavating two 5 -foot wide drainfields with
a combined length of 88 feet with depths of 9.0 feet and 9.5 feet below present ground level, as shown
on the site plan and design drawings.
3.2 The bottom of the each excavation should be level at the indicated depths.
3.3 A total of 2.5 feet of washed sewer gravel shall be placed on top of the sand with the
perforated distribution pipes laid level such that the pipe inverts are no less than 2.0 feet above the
bottom of the sewer gravel. The non -perforated pipe connecting the two drainfields shall incorporate a
3 -inch "bump" to ensure that the first drainfield is completely filled before flowing into the second.
3.4 The distribution pipes shall be 4" diameter ASTM F-810 or D-3034 perforated pipe.
Monitor tubes and cleanouts shall be of 4" diameter and installed in the locations shown on the design
drawings. The portion of the monitor tube extending through the sewer gravel shall be perforated.
3.5 Approved filter fabric shall be placed over the entire top surface of the sewer gravel, prior to
backfill.
3.6 The backfill shall be mounded a minimum of 6 inches above original ground level.
3.7 Unless specifically agreed otherwise the homeowner shall be responsible for arranging to
have the site finish graded after the backfill material has stabilized, and for placement of adequate seed
to promote rapid revegetation.
4.0 Inspections:
4.1 A minimum of 4 engineering inspections will be required during the course of the project:
(1) initial stakeout with the contractor to establish the location of the system and to discuss the plans,
specifications and construction procedures, (2) after the native material has been excavated to expose the
infiltrative surface to ensure that it conforms with the soil test information, (3) after the sewer gravel is
in place and the distribution pipes have been laid and connected up to the septic tank, but prior to
placement of filter fabric, and (4) after rough backfill and grading is complete. The septic tank
installation inspection shall be in conjunction with one of the other listed inspections.
4.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far
in advance to ensure the availability of the engineer.
�
LOT 5,BLOCK *
SOUTH LAKEWOOD HILLS #1 \ °`
LOT 6, BLOCK 4
SOUTH LAKEWOOD HILLS #1
EAST 112thAVENUE
4 5w----
10 %
50% `STLIMP%PTIC
2% BANK "AREA
6'HIGH'-,,---,,-',51
/SYSTEM
FILL Exim_
H11-AREACONSTRUCT
TWO 2') 5--WIDEHORIZONTAL
DISTRIBUTION PIPES
AW AV
THEODORE F. MOORE
CE - 3589
ABANDON EXISTING
SOIL ABSORPTION TRENCH
42
"All
46
T
m
5
—CLEANOUT—
MONITOR TUBE—
OUND BACKFILL 6"
7.5
9.5 FILTER
FABRIC
i�
5 10
3" "BUMP" IN LINE /
CONNECTING DRAINFIELDS
CROSS-SECTION "A - A"
SCALE: 1" = 6'
PLAN VIEW
SCALE 1" =10'
CONSTRUCT TWO NEW 5 -FOOT WIDE
SOIL ABSORPTION DRAINFIELDS with
2.0 SEWER GRAVEL (2.5' TOTAL DEPTH)
UNDER DISTRIBUTION PIPES
TOTAL LENGTH = 88' (46'+ 42')
4" PERF PIPE
�— (D-3034 orF-810)
..A.. DBL. /
C.O.
FROM
EXISTING
FDN. C.O.
7
E']
DECOMMISSION EXISTING
1000 -GALLON SEPTIC TANK
AND REPLACE WITH NEW
1000 -GALLON SEPTIC TANK
-dow OF
Ar Ar A Te
32
.*�.4 ......®..........
jo
sTHEODORE F. MOORE
•: �i�
+® s• ",, CE -_3589 ® mcg'
AV
01 P, k
!%rOfess%O`.
,®ls®
ORIGINAL GROUND
5 2.5' WASHED SEWER GRAVEL
(2.0' BELOW DIST. PIPE)
LOT 3 DEL'S S/D
SEPTIC SYSTEM UPGRADE
PLAN AND CROSS-SECTION
FLATTOP TECHNICAL SERVICES SCALE: AS SHOWN
14530 ECHO CANYON ROAD DRAWN BY: TFM
ANCHORAGE, AK, 99516 MAY, 2011
FLATTOP TECHNICAL SERVICES
14530 ECHO CANYON ROAD
ANCHORAGE, ALASKA 99516
TEST HOLE #1 SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: Lot 3. Del's S/D
DATE PERFORMED: --MV 2-3 2Q11 _
Clock
Time
PERFORMED FOR: Jim Bowe
Percometer
Reading
DEPTH Pt
(feet)
SLOPE
10%
2
3
4
5
5.5'
6
6.5'
7
8
9
10
11
12
13
14
15
16
17
18
19
19.25'
20
GM Silty gravel fill material
Pt. Original ground topsoil
SM Reddish silty loam
GM Gray silty sandy gravel
Dry, loose
Indistinct transition
GM Gray silty gravel
Damp
ML Gravelly silt with
clumps of "blue clay"
B.H.
SITE PLAN
Depth to Groundwater I Date
Date Reading
Clock
Time
Net Time
(minutes)
Percometer
Reading
Net Drop
(inches)
12 -
273/8
12" Re -soak
2734
12" Re -soak
_
_
22 1/2
Add water & start
2:0555
#1
2:1 U5
5
173/8
4-5/8
Add water
2:12:45
22
#2
2:17:45
5
175/8
4 3/8
Add water
2:19:45
22 1
#3
2:24:45
5
173/4 1
41/4 1
I
_
_
i
I
PERCOLATION RATE 1.2 (minutes/inch) PERC HOLE DIAMETER 6"
TEST RUN BETWEEN 7.5 FT AND 8,0 FT
COMMENTS: The measured perc rate was faster than expected based on visual evaluation of the stratum. Recommend use of 0.8 gpd/sq. ft.
A preliminary test hole excavated to the west of TH #1 encountered the remains of an old stump burial site as shown.
PERFORMED BY FLATTOP TECHNICAL SERVICES. IT,— CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: X/ 3 1 / I/
/ MUNICIPALITY OF ANCHORAGE
\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
j 825 L Street - Anchorage, Alaska 99501 Telephone 264.4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME ,..
'AttS...
PHONE
LE'NEW
❑ UPGRADE
MAILING ADDRESS c
S .2,S- S
LEGAL DESCRIPTION
LOCATION Ave_
1\1T`
NO. OF BEDROOMS
3
U Y
DISTANCE TO:
Well
�j
Absorption area
Dwelling
PERMIT NO.
_
d 2
W a
~
Manufacturer
Material
No, of compartments
N
Liq. capacity in gallons
OOO
IF HOMEMADE:
inside length
Width
Liquid depth
6 Y
JD2
DISTANCE TO:
Well
Dwelling
PERMIT NO.
_ F
Manufacturer
Material
Liquid capacity in gallons
D
W =
DISTANCE TO:
Well �/OD
Foundation
Nearest lot line
PERMIT NO.
.W.I ME
f ?
No. Of lines
Length of each line
Total length of lines
Trench width
Inches
Distance between lines
CI_
0
Top of the to finish grade r /
ZaL 3
Material beneath the r
(p inches
Total effective absorption area
/
W
C7
Length
Width
Depth
PERMIT NO.
d H
Wd
Type of crib
Crib diameter
Crib depth
Total effective absorption area
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption areas)
OTHER
PIPE MATERIALS
O irl4
SOI L T EST RATING
a.o 0
INSTALLER
REMARKS
i
APPHOVED DATE LEGAL
'�)C L L 8-14-12f
72-013 (Rev. 3178)
wzmm
Dox 13Gfi, Swivn ROUTE A ANcxxoRAGEq ALASKA 00 502
344-7719
SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF 176 feet.
DRILLED AT THE RATE OF $20.00 PER FOOT.
PROPERTY OWNER
&A.
Steve
Pi4a
345-1901
LOCATION OF WELL
SITE
Lt.
3 au.
sub.
DELI S
DRILLER 91t• 7aq ¢, B03e
WELL LOG:
0-----12' g ue t. 20% •Dandy. cta y.
12----36' Ctay. tatth. 35% Vmuet.
36----50' Katdpan. R cemented gAavet.
50----92' 91 vet tatth 30;5 4V ty. 4andly clay.
92---159' P=vet. At,o a 4tity wet atmj. Sdtt4 wateAytetd at 159 feet.
759--175' Tine .Dandy. gAave•t. 20;5 etay. A wet mate&iat Vtetdinq •Dome wateA.
175--176' R q.00d etean eom4e. Vmuet ptoduc iq 15 9PR tattJt 50 feet of- wa,t.eA
.atan.dinq oft Gahan.. 3/4 !lo-LDe Subm.eAAZ&Ce. puap ohoudd Ge dn,•tatted flue feet,
04 bottom..
Co,jt of D44t-iaq: $20.00 X 176 feet: 83520.00 t
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF
THANK YOU VERY MUCH.
53520.00
BERNIE CLAUS OF RAMPART DRILLING WORKS
DATE RIaAch 20•th.l 1981
SERVICE CHARGE OP IY.% PER MONTH WILL BE ASSESSED ON PAST DUE ACCOUNTS.
t
• M!JtJ I C I RL I TY OF' nr4l=HPFR_FI0E �1
. DEPARTMENT HEALTH AND ENVIRONMENTAL OTECTION niL..K�61
825 'L' STREET, ANCHORAGE, AK. 99501
264-4720
LJELFL f4t4O Otd—SITE SEWER F•ERM I T PERMIT NO. C 810264 Ltl�s�_
APPLICANT STEVE PISA SRA BOX 475-5 M/At6�,
LOCATION 112TH. AVE
LEGAL LOT 3 DEL SUB LOT SIZE 45000 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH cl Wo
z AlY
MAXIMUM NUMBER. OF BEDROOMS = 3 SOIL RATING CSO FT/BR)=
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: PfG
OErF`TH= 12 LEttiFGTH= 150 GRFI%v'EL OEF'TH= S
THE LENGTH DIMENSION IS THE LENGTH (IF! FEET> OF THE TRENCH OR DRAINFIELD.
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).
REGlU I REO SEF•T I C TFiMK 0-131== 1000 GALLQtdS
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 !JILL SERVE.
--- TL401 <2> FARE FZEG!U I REO ---
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND•"APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-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 IS 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}ERM I T EXP' I RES OECEMB'ER :T1, AL1?S1
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 S0{ IEP. SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCODEU-7RE THAN 3 BEDROOMS.
II II l(�� //
SIGNED
APPLICANT STEVE
ISSUEBY !Y7� do t'"'' 52-------- DATEGF�=vv=f,! V4. 0
Municipality
of
Anchorage
n
825 "L" STREET
ANCHORAGE, ALASKA 99501
(907) 264-4111
GEORGE M. SULLIVAN,
MAYOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
December 31, 1980
Steve Pisa
Star Route A Box 475-S
Anchorage, Alaska 99507
Permit # 800616
Subject: Lot 3 Del Subdivision
A permit issued by this department for well and/or sewer
system has expired as of this date.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log should be sent
to this department to document the installation date.
If an engineer inspected the installation of the on-site
sewer system, please have them send us the as-builts for
our files.
If there are any further questions, please call this
office at 264-4720.
Sincere,A4
`
Les N.
Buchholz, R.S.
Senior
Environmental cialist
LNB/ljw
enc: Copy of Permit
SWP/057
0
MUr4 I C I PF3L I -rke OF' F3 r4 CHORF3GE
DEPARTMENT f"' HEALTH AND ENVIRONMENTALf'40TECTION
825 STREET, ANCHORAGE. AK. 9_ 31
.; + 264-4720
WELL nN1> OM—S I TE SELJER PERrl I T
PERMIT NO. C 800616 >
APPLICANT STEVE PIZA SRA BOX 475-5
LOCATION LOT 3 DEL
LEGAL PLOT 3 DEC SUBDIVISION; LOT SIZE 45000 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING CSO FT/BR)= 200
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DEPTH= 7LO� L_aNO-r"= SO GRF=fVFZ _ F>EPTH= 5
THE LENGTH DIMENSION IS THE LENGTH (IFJ FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IFJ FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MIFJIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATION CIN FEET).
REGtiU I REFI SEPT I C -rn"K S I c E= 1'00110 '3F=1L_LOtJS
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.
--- TLJO C ZZ ? I "SPECT I OMS FIRE RE:QU I RE[a
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-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.
MIFJIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 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.
PERMIT EXP I RES [7ECEMJ3ER 31� 1.S=I8l+
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 IM ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT TH FJ -S E SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODE D IF UDE MORE THAN 3 BEDROOMS.
SIGNED: ----- - ---- -------------------------
AP _ C N ;� .VE PIZA
ISSUED BY ------- L JL`L__I 11 -`1 („LUL41___DATE_Lv_./- _=e lCJSL V4.0
Movembar 29, 1975
Paul G. Hansen, P.E.
2526 East L•3th Avenue
Anchorage, Alaska 99507
Mir. Ken Del Monico
Star Route "A" Box 26
Anchorage, Alaska 99507
SOILS EXPLORATION AND PERCOLATIOi1 TESTS
PROPOSED DEL'S SUBDIVISION, LOTS 2, 3, 4
NEAR O'1-1.4LLEY SCHOOL, AaCHOr.-AC'c, ALASX.1
In accordance with your request, soils exploration and percolation testing
for on-site sewage disposal were performed on the three proposed lots.
Drilling was performed on October 6, 1975 by Denali Drilling, Inc. of.
Anchorage employing a B-50 Fiobile drill and consisted of three 20 -ft.
test holes; logging and percolation testing were performed by myself
in accordance with the United Soil Classification System. the Soil Triangle,
and the "Manual of Septic -Tank Practice". Soils arere described and classified
in the field by means of numerous grab samples.
Logs of test holes are found on Sheet 1; percolation test results are
on Sheets 2 and 3. Test hole locations have been plo�pted on your proposed
subdivision plat..
The property has very satisfactory drainage to the northwest, arith a
maximum relief of about 60 feet throughout the three lots. No standing
water was noted. Numerous large spruce and birch trees, up to 15 inches
in diameter, were observed.
In general, the soils consisted of sand, silty sand, sandy silt, and
gravelly sandy silt (SP, Sli, 11L) of medium density. Graval and small
cobbles were occasionally encountered. A crater table was encountered
in Test Hole 13 (Lot 4) only, at a dapth of 11 feet. For this reason,
no percolation test was performed in T.11. 3; ho,:rever, if necessary, an
on-site sewage disposal system could be located in the southern half
of Lot 4, at a higher elevation, where the anter table is expected to
be at a greater depth. T.11. 2 started to slough during the percolation
test, giving erratic results, so another test was perforrcd in an adjacent
1test hole (2A) with a standpipe. Test holes were filled with water and
saturated for at least 24 hours prior.to percolation testing. The tato
percolation tests yielded plarcolation rates of about 9 minutes/inch,
3-1/2 to 4 hours after the tests began, corresponding to ahout 160 square
feet of absorption area re Broom. The test hole logs arould
suggest a value of abou 200 square feet.
Mr. Ken Del Monico
November 29, 1975
Page 2
In my opinion, the three lots appear satisfactory for the proposed
development, in terms of surface drainage, foundation soils, and on-
site sewage disposal.
Or L.
PAUL G. HANSEN, P.E. p,C,;�;;i�r;l y *��
PGH:sh :....,f..../......:-r..v..
R. ; PAUL G. HANSEN ' N!+
Enclosures �rOT7; 3710-E �Alv-"J
ri
Test {tole 1
TEST 11OLE LOGS
Location: Lot 2
Elevation: 6841
Water Table While Drilling`- None
Water Table 24 (lours After Drilling - Hone
Depth
0 to 6"
6" to 4'
4' to 12'
12' to 20'
Test Hole 2
Description
Brown Organ
S'l-i tyic Cover
Brown, Fl, Sandy_ Gravel, CM
Brown, NFS, dry to damp, —fine to medium Sand, SP
with frequent gravel and cobbles, (maxirun size 4")
Brown, F2, moist Silt Sand, SM (possibly 1.11),with random fine grave
Location: Lot 3
Elevation: 680±
Water Table While Drilling - None
Water Table 24 flours After Drilling - None
Depth Description
0 to 6" Brown Organic CoverO 0
6" to 3' Brown, moist, F2 Silty Sand, S11 `y
3' to 6' Brown, moist, F4 SangLSilt, ML -z-7 's
6' to 20' Brown, moist -damp, F2, Nonplastic Silty Sand, SM
with random fine to medium Gravel T 8 , TO, and 13-1/2 - 14'.
Test Hole 3 h 9-j' C- c D
Location: Lot 4
Elevation: 662±
4later Table 1•lhile Drilling - 12'7
'Water Table 60 (lours After Drilling
Depth Description
0 to 4" Browd Or anic Cover
4" to 2' Brown, f'4, •ret, nonplastic fine Sandy Silt, NL
2' to 4' Brown, F4, Gravelly Sandy Silt, ML, Maxinum Size
4' to 7-1/2 Brown, F2, moistSim fine Sand with random fine gravel, SM
7-1/2' to 12' Brown, F2, moist Silty fine - Iledium Sand, SM, possibly SP
121.:to.15' Brom, F2, wet Silt_v Sand, S41 with random fine gravel maximum
size - 1/2"
15' to 20' Brom, F4, wet Gravelly Sand Silt, ML with 10 to 20% Gravel
7leA Hole I.. A
.. .. ._
....... .. ............ .: ......_ Se ure ��vd Lr. UC�U�P-r•7�I%J ...
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�%' 3S : P14
_ :3. hr : _..:.
3..2''.
: 33-
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73 „
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-
41
6 •
STATEMENT OF QUALIFICATION
PAUL G. HANSEN, P.E.
EDUCATION: Geological Engineer (Geol.E.), Colorado School of Mins, 1968
MSE, Soil Engineering, Princeton University, 1969
Doctoral work, 1970
EXPERIENCE: Soil Mechanics & Foundation Engineering, Alaska Testlab
(ACLW, later DMIL Engineers) 1970 - 1974
REGISTRATION: Civil Engineer 3710-E, State of Alaska
CY
(-, &,KD
CiAlt? Vo,
Q V /Ob' n_Ious l —
1� °'J
l�� t
Z 4pGE B`' Z
• '� Municipality of Anchorage
On -Site Water and Wastewater Program '
(907) 343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 015-492-03 Expiration Date:
1. GENERAL INFORMATION
Complete legal description DEL'S LOT 3
Location (site address) 6240 E. 112TH AVE., ANCHORAGE, AK 99516
Current Property owner(s) JAMES BOWE Day phone 406-323-1473
Mailing address
KEVIN BARRETT 250-7509
Real Estate Agent Day phone
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual
0
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
WaiverNariance request for: NONE
_
Distance: ---
J
Received by x , , tut � u Date: I I 12-
COSA to be releasedTo the a gi eer, unless otherwise requested by the engineer.
COSA Fee $ pp Waiver Fee $
Date of Payment 1 to 1.a C ky, Date of Payment
Receipt Number fb'5" �C7 G Receipt Number
COSA# OSC12,15510 Waiver#
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,
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 SPURKLAND ENGINEERING Phone 279-3916
Address 203 W. 25TH AVE.,STE.202A, ANCHORAGE, AK 99501
Engineer's Printed Name LARS SPURKLAND
6. DSD SIGNATURE
—Z System #1 Approved for 3 bedrooms
System #2 Approved for _ bedrooms
Disapproved
Conditional approval for bedrooms, with the
Date 11/5/12
F Al
elf
dlowir�dstratifa'rorrs`P��
By: �1�/�i� �/ g e� Original Certificate Date: f �i 2
f /�
Thenicip ty ge Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA). based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work. _
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory_
Well Flow Advisory
COSA blue sheet S , c
Other
If more than 1 septic system is on the lot:
COSA Checklist # 1 of 1
Structure served by this system 1
Certificate of On -Site Systems Approval Checklist
Legal Description: DEL'S LOT 3
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID #
Date completed 3/20/81 Sanitary seal (Y/N) Y
Total depth 178 ft. Cased to 176 ft.
FROM WELL LOG
Date of test 3/20/81
Static water level 125
Well production 15
WATER SAMPLE RESULTS:
ft.
aM
Coliform NEG colonies/100 mL Nitrate ND mg/L
Arsenic 10.4 ug/L Date of sample: 10/19/12
B. SEPTICIHOLDING TANK DATA
Parcel ID: 015-492-03
Well Log (Y/N) Y
Wires properly protected (YIN) Y
Casing height (above ground) >12 in.
AT INSPECTION
10/25/12
133
3.0
ft.
1
Collected by: ANSON MOXNESS
Tank Type/Material SEPTIC/STEEL Date installed 7/5/11
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (YIN) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping NEW Pumper HOUSE VACANT SINCE SYSTEM INSTALLED
C. ABSORPTION FIELD DATA
Date installed 7/5111 Soil rating (g.p.d.lft2 or fe/bdrm) 0.6 System type 5 -WIDE
Length 42 & 47 ft. Width 5 ft. Gravel below pipe 2 ft.
Total depth 9'2 ft. Eff. absorption area 636 ft2 Monitoring tube Y Depression over field N
Date of adequacy test NEW Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption field before test in. Water added gal. New depth — in.
Elapsed Time: min. Final fluid depth _ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons -
"Pump on" level at in. "Pump off' level at _
Datum Cycles tested ---
E.
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tankilift station on lot >100,
Absorption field on lot '100'
Public sewer main NA
Sewer /septic service line '25
Animal containment areas >50,
Manhole/Access (Y/N) --
in.
in. High water alarm level at -
Meets alarm & circuit requirements? _
On adjacent lots '100'
On adjacent lots '100'
Public sewer manhole/cleanout NA
Holding tank NA
Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5 Property line 'S
Water main NA Water service line '10'
Wells on adjacent lots '100'
ABSORPTION FIELD ON LOT TO:
Property line 1 Building foundation >10,
Water Service line '10 Surface water >100 (N.O.)
Curtain drain >50' (N.O.) Wells on adjacent lots >100'
F. COMMENTS
`WAIVER ON FILE
G. ENGINEER'S CERTIFICATION
I certify that 1 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 LARS SPURKAND
Date 10/25/12
COSA brown sheet 10-10-12.doc
Absorption field's
Surface water '100' (N.O.)
Water main NA
Driveway, parking/vehicle storage 1fl
( U 1 00 C�
in.
Municipality of Anchorage
Community Development Department
Development Services Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
Arsenic Advisory
Certificate of On -Site Systems Approval # 121510
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
3 of Del's Subdivision. This inspection revealed an arsenic concentration of
10.4 micrograms per liter (ug/L) for the property's well water sample. The
Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems.
While private wells are not subject to this regulation, EPA standards are
based on existing health information and can therefore be used to gauge the
relative quality of water from private wells. Information on arsenic is
available from the On -Site Water and Wastewater Program website
(www.muni.or /og nsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
us
5. LEGAL CRIPTION
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME
TIME
TIME
' Ac14 (An
DATE
❑ One ❑ Four ❑ Other
DATE
DA E
❑ MULTIPLE FAMILY
Three ❑ Six
7. WATER SUPPLY
INSPECTOR
' ATTACH WELL LOG. A well log is required for all wells drilled
INSPECTOR
INSPECTOR
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
t
It INDIVIDUAL/ON-SITE"
MUNICIPALITY Or A t,,-,'�-
❑ PUBLICUTILITY
MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH a
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTL6NIRONM:NTAL P"OTfCTION
825 L Street - Anchorage, Alaska 89501
•
1
OCT 21 1981
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-1720 1 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. PR�E TYOWNER
/
PHONE
355—/4d/
MAILINGADDR SS
—
PROPEERRTT� RESIDENT lit different from above)
PHONE
�Y)
2 BUYER�
�
NE
�
� L
�PH
MAILING ADDRESS
-
/O D
3. LENDING INSTITUTION
PHONE
..>ry
aaG -G o0
MAILING ADDRESS
4. RE OR/AGENT
r
PHONE
MAILING ADDRESS
15'7'7 "C -"
us
5. LEGAL CRIPTION
3 ,
STREET LOCATION
LIN //2±�-
6. TYPE OF RESIDENCE
NUMBER OF,BEDROOMS
SINGLE FAMILY
❑ One ❑ Four ❑ Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
Three ❑ Six
7. WATER SUPPLY
E�5- INDIVIDUAL-
' ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
It INDIVIDUAL/ON-SITE"
1PF1 YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLICUTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72010 (Rev. 6/79)
/ THIS SIDE FOR OFFICIAL USE ONLY - .
1. TYPE OF RESIDENCE
❑ SINGLEFAMILY"
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS '
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY -
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON-SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATEINSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: /Dot% If Tank is homemade
give dimensions:
SOILS RATING
Z pp -
TYPEOFTANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
w
Seer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
&--APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY
c
72010 I Rev. 6/79)