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HomeMy WebLinkAboutPROSPECT HEIGHTS #1 BLK 5 LT 12AProspect Heights #I Lot 12A A 6 01 114—o G�, it c- I i-EEIALIC ov�lv C, W ck L-1 CJ 7- L V VLI) rr 6-1 Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 1 ON -SITE WASTEWATER INSPECTION REPORT Permit Number: _OSP231173 PID Number: 015-091-4000 Dwelling: N Single Family (SF) El with ADU r_1 Duplex (D) R Two Single Family Project: R New RN Upgrade Name Oscar Nolan ABSORPTION FIELD R Deep Trench R Wide Trench [I Bed [I Mound Site Address 9501 Buddy Werner Drive, Anchorage, AK 99507 El Other Phone Number of Bedrooms Soil Rating Total depth from original grade I THREE (3) GPD/SFJ Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Prospect Heights Addn. #1 BLK 5 LT 12 Fill added above original grade Ft. Gravel length Ft. Township Range Section Sec. 13, T1 2N, R3W, S.M. Alaska Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well >1 00' TANK 9 Septic [] S.T.E.P. E] Holding [I Other Manufacturer GREER Capacity 1,250 Gal. Surface Water >1 00, Material Number of compartments Lot Line >51 NA PLASTIC Two (2) Foundation >5' LIFT STATION Manufacturer Capacity Remarks EXISTING TANK ABANDONED PER MOA CODE REQUIREMENTS Gal. Tank installed 5'+ to existing field and lot line. Alarm location Electrical installed by PIPE MATERIAL House to tank D3034 Tank to D3034 drainfield Installer TURNAGAIN ARM CONSTRUCTION LLC. Drainfield COIMT D3034 Inspector GABRIEL THOMAS BENCH MARK (Assumed elevation) 100 ft Inspection 1s, 8/22/23 9/1/23 dates: 2 nd Location and description 3 d 4 th Concrete slab corner (13) ON -SITE WATER AND WASTEWATER SECTION APPROVAL Conditional Approval: Date OF. Aw co *.-'49 T—H .......... Gabriel Thomas N0101 h", 3505 law, 'aw — Septic System Approved Date ZS Note: this approval does not include 40 \. PROFESSION — well permit requiremnts. t Kev uotvz/ its) 24.4' 52.5' 24.4' 52.5' 4.0'x7.0' CA NTILEVER 2.0' CA NT. ELEC.G AS T W O STORY RESIDENCE 12'x24'SHED 4.0' CA NTILEVER B A RRIER RxR TIE METAL CASINGBELOW GRADE/ LEGEND FOUND 5/8" REBAR, NO CAP EDGE OF GRAVEL DECK CONCRETE CHAIN-LINK FENCE OVERHEAD UTILITIES POWER POLE RECORD DATA PER PLAT #74-227 SEPTIC PIPE WELL SEPTIC TANK LID SATELLITE DISH TIMBERLINE SURVEYING AND MAPPING 17035 BARONOFF AVE EAGLE RIVER, AK 99577 907-242-5320 ryan@timberlinealaska.com FILE NO.: 25.045 SCALE: 1" = 40 FEET DATE: 3/21/2025 SHEET: 1 of 1 MOA GRID: SW2441 SCALE: 1" = 40 FEET(11"x17") 40'0' 80' AS-BUILT OF: ADDRESS: 9501 BUDDY WERNER DR, ANCHORAGE, AK LOCATED IN: ANCHORAGE RECORDING DISTRICT LOT 12A, BLOCK 5PROSPECT HEIGHTS SUBD.ADDN. #1, PLAT #74-227 PID: 015-091-40000 PERMIT: OSP231173 FROM HOUSE INSTALLED DOUBLE CLEANOUTS ♦A 4 FEET COVER & INSULATION BOARD C1\ C2 ^ I C^ INSTALLED DOUBLE CLEANOUTS C4 /Cs FINISHED DV ORIGINAL INSULATION BOARD(2) 91.32 91.29 NEW 1,250 GAL. 90.32 HDPE SEPTIC TANK 90.12 INVERT AT INLET I J INVERT AT OUTLET CAST IRON VALVE BOX SCALE: NOT TO SCALE CONNECTED TGEXISTING PIPING CONNECTED TO EXISTING ORAINFIELDS AS -BUILT: PROFILE CS INSTALLED BETWEEN WESTERN FIELD AND DV 100' WELL RADIUS PROPERTY LINE PER MOA WETLAND MAPPING, APPROXIMATE LOCATION OF OPEN CHANNEL, SEE NARRATIVE 00 0J 1 EXISTING SEPTIC AREA 1 \ I � - I Xzt�LL 100' WELL I 0.5' PER PERMIT SW060101 RADIUS x __-WATER LINE \ EXISTING FIELDS (REMISED) INSTALLED NEW 1,250—GAL. -----------_ TANK WITH OVER 5' MINIMUM -----____-_ SEPARATION FROM DRAIN - "RAVEL ---i___ FIELD AND PROPERTY LINE ------__ ------------- VEL DRIVEWAY- i \ -iDIV ,'DIED IN NEW TANK A� 6 al �.� DIVERTER VALVE (DV) \ I LD TANK ABANDONED OIN PLACE SWING TIES - I A. _g ' / NEW LINES & FITTINGS 1 76.8' 61.3' INSTALLED PER CODE 2 75.8' 60.4' R 74.3' 59.1' 3 70.2' 55.6' 4 69.2' 54.9' 5 68.5' 4.2' 6 60.1' 47.5' V 61 5' 49 2' SWING TIE POINTS EXISTING SEPTIC AREA 0' 40' 80' SCALE: 1" = 40 FEET OF. Ai, AkqS TH Gabriel Thomas I �c� V 8505 �`�� RO01 fESS10Ne.,.i�'� 18.1, LOCATION OF RAISED FLOWER — BED AND LANDSCAPING E—GRADED NFIKING AREA TO PREVENT PARYQNG ON TANK i EXISTING 38R HOUSE PROSPECT HEIGHTS ADDN. #1 BLOCK 5, LOT 12A PERMIT NUMBER: OSP231173 PID NUMBER: 015-091-40000 BENCH MARK LOCATION: CONCRETE SLAB CORNER AT POINT "B" ASSUMED BENCH MARK ELEVATION: 100' AS -BUILT: PLAN prepared For. OSCAR NOLAN PROSPECT HEIGHTS ADDN. #1 BLOCK 5, LOT 12A ANCHORAGE, ALASKA 'repored By: GABRIEL THOMAS, PE 12633 GLEN ALPS ROAD ANCHORAGE, ALASKA ---___....... _._....__.._...__—.._...._....T _ DWG, AS -BUILT RECORD DRAWING DRAWN ®Y: 'AS SHOWD1___ GKT DESIGNED BY. 9KT MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP231173 Work Type: SepticTank Upgrade Tax Code Number: 01509140000 Site Legal Address: PROSPECT HEIGHTS #1 BLK 5 LT 12A G:2441 Site Mailing Address: 9501 BUDDY WERNER DR, Anchorage Owner: NOLAN OSGAR Design Engineer: Thomas Gabriel This permit is for the construction of: Effective Date: Expiration Date Q f Department Lot Size in Sq Ft: Total Bedrooms: 7/10/2023 7/9/2024 50473 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall 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 shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the. same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: • The tank is to be protected with a permanent barrier to prevent vehicles from parking or driving over the tank. The record drawing is to show and label the barrier. -R�ed= y: �Z ✓i" j fo 11 am,,, e it Issued By: Date: Date: /� 2 3 MUHMPAUTY OF AHCHORQOE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTICIWELL PERMIT APPLICATION Parcel I.D. 015-091-40000 Property owner(s) Osgar Nolan Day phone 907.346.3696 Mailing address 9501 Buddy Werner Drive, Anchorage, AK 99507 Site address 9501 Buddy Werner Drive, Anchorage, AK 99507 Legal description (Sub'd., Block & Lot) PROSPECT HEIGHTS #1, BLK 5 LT 12A Legal description (Township, Range & Section) Sec. 13, T12N, R3W, S. M. Alaska. Lot Size 50,473 Sq. Ft. Number of Bedrooms Three (3) APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) Q (w/wo ADU) Septic Tank Q Upgrade 0 Duplex (D) ❑ Holding Tank ElRenewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: N/A Distance: N/A I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property'oWner or authorized Permit/Rush Fees: $ Z Z 5 Waiver Fees: Date of Payment: Receipt Number: Permit No. l)S 2 l 3 j Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc July 7, 2023 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Section 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: PROSPECT HEIGHTS #1 BLOCK 5, LOT 12A To Whom It May Concern: I am writing to request a permit to install a new septic tank for the residence located at Prospect Heights #1 Block 5, Lot 12A. This proposed system upgrade will replace the existing septic tank that services the properties three-bedroom residence. The existing 1,000 -gallon tank appears to be compromised. The proposed replacement tank will be 1,250 -gallons, which exceeds the minimum 1,000 -gallon tank size required for a three-bedroom residence; however, this will not change the permitted usage of the residence at this time. Effluent from the proposed tank will tie into the existing absorption field. The property has an existing, private water well located on the western side of the lot, over 100 feet from the proposed septic tank location. The surrounding lots are also serviced by private water systems, which are all over 100 feet from the proposed tank location. The proposed design will not impact the aforementioned properties septic or water systems nor will it conflict with any neighboring water wells or wastewater disposal systems. Per the Municipality of Anchorage (MOA) Wetlands Mapping database, there is an "open channel' within the vicinity of the tank as illustrated on the drawing. However, as defined by AMC 15.65, this natural depression, or open channel, does not contain surface water nor is it cataloged as a wetland area. The installation of this proposed septic tank complies with MOA codes and the drainage flowing onto and off the property will not adversely affect the performance of the proposed wastewater system, or neighboring systems. The proposed septic tank will not change the general slope of the area nor will ponding and/or concentration of surface runoff result from this installation. If you have any questions, or require additional information, please let me know. Sincerely, — Z�4 �_/ �_ Gabriel K. Thomas, P.E. 907-317-8970 �.� PER A WETLAND MAPPING APPROXIMATE i ,qA J LOCATION SOF OPEN CHANNEL, SEE NARRATIVE i meq- 100' WELL IZ-2 RADIUS NOTE: Q ` WELL RADI IS APPROXIMATE VERIFY/STAKE ALL WELLS ARE 100'+ FROM PROPOSED TANK LOCATION PROPERTY LINE--' � EXISTING DOUBLE FLOW _ SPLITTER 1/4 & 3/4 EXISTING SEPTIC AREA NEW TANK MUST MAINTAIN 5' MINIMUM --� SEPARATION FROM DRAIN ! FIELD AND PROPERTY LINE u 100' WELL i 0.5' PER PERMIT SW060101 RADIUS I EXISTING FIELD 1,250 -GAL TANK _ WATER LINE TO BE USED TO BE INSTALLED ---------------- \ CODE, INSTALL iPER WITH 4+COVER ------- _ f OR USE INSULATION ------ - DOUBLE CLEANOUTSDC TO BE INSTALLED (2X) TIE IN NEW TANK TO i� INSTALL RAISED FLOWER \` �'�F�qY `` EXISTING SYSTEM AT �� ro' ,�' .� REVDENT/PARKINSG ONTANK EXISTING DIVERTER VALVE (DV) -- ' I i PARKING AREA 1,000 GAL. TANK �.� TO BE DECOMMISONED PER CODE �� I ------ _ _,_ _ - ' INSTALL NEW LINES & FITTINGS _ AS REQUIRED, PER CODE EXISTING 3BR HOUS TIE INTO EXISTING PLUMBING SWING TIE POINTS 18.1' C,OF Al PROSPECT HEIGHTS ADDN. #1 TH * BLOCK 5, LOT 12A �o�9)�� • • • • EXISTING SEPTIC AREA OQ ��'`� ........����... O�i.�OO�ty Gabriel Thomas _1N1/.1 8505 / / / c�lF'�Fp : ''•��Np�.`����� 100' WELL ROFESSIO �' RADIUS 0' 40' 80' TANK REPLACEMENT DEIGN SCALE: 1" = 40 FEET LOT 12A9 BLOCK 5 NOTES PROSPECT HEIGHTS ADDN. #1 PLAT #74-227 1. LOTS SERVED BY PRIVATE WATER ADDRESS: 9501 BUDDY WERNER DR ANCHORAGE, AK 99516 X SYSTEM. NO WELLS WITHIN 100' OF PROPOSED SYSTEM IMPROVEMENTS. MOA PARCEL: 015091-40 PERMIT NO.: VERIFY SETBACKS IN THE FIELD. GABRIEL K THOMAS, P.E. DRAWN BY: G.T. 2. PREVENT AND PROTECT AGAINST VEHICLES PARKING ON OR NEAR 12633 GLENN ALPS ROAD FILE NO.: 02 NEW TANK INSTALLATION ANCHORAGE, AK 99516 SCALE: 1" = 40' 907-317-8970 DATE: 7/7/2023 LOCATION thomasengineering@gmail.com SHEET: 1 of 1 Municipality of Anchorage Development Services Department `¢ 1\ Building Safety Division On-Site Water and Wastewater Program, 4700 Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 Page 1 of 3 ' www.ci.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: SW060101 PID Number: 015-091.40 Znneth & Dana Spadafora Wastewater System: ❑ New ® Upgrade TrOl Buddy Werner Dr. Anch. AK 99516 ABSORPTION FIELD Phan.: Nurtbr of 346-1340 :1 ® Dsp Troan a Sh.11ow Tasrw, D e.a 0 Mauna 0 of «: LEGAL DESCRIPTION Soi Ft" Tool DpN lean "q groes: 0.6 GPDFI' 717 Ft. Bloch: Lot: 8ubaM : Dean b pW bonam ham apNY prose: Gr. Mpn b~h pps: 5 12A Prospect Heights No.1 212 Ft. 515 Ft Ta ip: Range: S.cean: FeaeeW oflginwprWN: G,. L.npm: 1.511.5 Ft. 57120 Ft. Well: El New ❑Upgrade cr. Wwam: Nu G of1Yasa: DM.na.a...n1....: 3 Ft. 1 2 13 Fl CIa.Wbratan (Pmsts, A B. q: T" D.ph: Gose b: T" sb.orpa Woo, Pip. Mat": Exist' Private Ft. Ft. 750 Ft 3034 PVC Dr41.r Dns D.1w: Sona W W.r Level: r"bor: DM. Imwba. FL A+ Home Services 6/912006 YasW: Pump sW W: C..np H"M Above Caro : TANK GPM FL FL SEPARATION DISTANCES ❑ Septic ❑ Holding ❑ S.T.E.P. ❑ Other: To Septic Absorption On Holding ublltlPrivateI' '.. ty- From Tank Field Station Tank Sewer Une EXIStrg I Gal. WWI 177.8 136 100+ Mat.W: Concrete Number W Coff* n W: sua.a.ww. 100+ 100+ LIFT STATION Line 20.6 0.5 .. .m paws. GW FwMwion 31.8 46.8 'Puny on' rwl u: 'Parry W Nr.l at Mph .1w a.. at N N. N. Cuaain D,an 50+ 50+ Purrp Malas a Moesl Elocmaal N.pn pert by: R Request Lot Ilne Waiver to 0.5 Feel Tank exposed and verified to BENCH MARK be in good shape with no leaks. l.oa.ban Ww 0.".: Garage Slab A.aam.a bv.lron. 100.0 FL Engineer's Stamp Inspections performed by: PANNONE ENG. SVC, LLC Dates: 1" 61912006 z^° 61912006.gip, • OF �� •,............. ..;�•,• Development Services Department Approval . �.•' ry •••• •°; �I Conditional Approval Date: i E 4 T� :, . .................T.....00 �rggg.� j '.Steven k. Ponnone i Abse. +tor( Fir1d P f 1 /!/p7 Reviewed and approved by: Date: ♦ CT': ♦ No. C 81 �1� �?�10�2 '�'� y-"f—,— r0 • a>taa�-ESS„U��� PERMIT NO:SW060101 RECORD DRAWING WASTEWATER DISPOSAL SYSTEM LOT 12A BLOCK 5 PROSPECT HEIGHTS #1 a rk -41/ Y \ oy o� oQ QUO ELECTRIC -1 GAS LINE JO WELL P.I.D. NO: 015-091-40 --- !s^� TH11 1 .8 W 10% + ExISTO FItLO, / TO BE REUSED -- EM -roIM CONCRETE SE TANK VERFIE INTEGRITY CO A B T1 53.0 42.4 DV 57.7 47.3 Et 72.3 62.6 EXIsrG E2 105.197.5 SEPTIC DC 72.2 58.7 AREA- FS1 73.3 59.5 FS2 75.8 62.L - - ---C14-90.1 75.3 M1.1 90.2 75.4 C1.2 130.1 119.7 EXISTG WELL RADIUS 11011.2 130.8 120.5 / M- C2-1 77A 63.6 M2.1 85.8 73.2 C2.2 89.6 78.3 fox 13.0 INSTALLED DOUBLE ROW SPLITTER TO SPLIT FLOW 1N a 3148 DOUBLE CLEAN. (BALL TYPE) EXISTG3BR HOUSE 12AvaQ 0 Qip K JQ OA --Z Qg40 r rpQ' OQ / \ Q4Q- / NOTES: 3) Maintain IV separation to all PERC RATE:16-30 MPI e0 ♦ 1) All work shall be performed In lot lines and proposed water APPLICATION RATE: 250 SFBR OF 94 accordance with AMC15.65. lines. 0.6 GPD/SF Gj�p'•��••"'••••••,•••• �� 2) Materials used shall be in 4) Lots served by private water 3 BR HOUSE #0 deed M system. No wells within 100' of REQ'450g GPD DESIGN FLOW accordance with those s C A� M •••••�•';'� �4 AMC15.65, Wastewater Disposal. proposed system. EO'D AREA: 750 SF - 5' WIDE TRENCH CE 8146 828107 KENNETH AND DANA SPADAFORA 9501 BUDDY WERNER DRIVE .�� ANCHORAGE, AK 99516 6S1� (907) 346.1340 75 LF x 5 ED. 2-S' WIDE, r TO PANNONE ENG. SVC, LLC P. O. BOX 102954 ANCHORAGE, ALASKA 99510 227-3522 P. 272-8218 Fax PLAN + • /~ EXISTG WELL RADIUS EXISrG 1 SEPTIC IELL AREA PROPOSED UPGRADE SAS. 2 TRENCHES 1057LF a SWM TED. r TD 1 G 20LFx3Wx 5` ED. r TD --- !s^� TH11 1 .8 W 10% + ExISTO FItLO, / TO BE REUSED -- EM -roIM CONCRETE SE TANK VERFIE INTEGRITY CO A B T1 53.0 42.4 DV 57.7 47.3 Et 72.3 62.6 EXIsrG E2 105.197.5 SEPTIC DC 72.2 58.7 AREA- FS1 73.3 59.5 FS2 75.8 62.L - - ---C14-90.1 75.3 M1.1 90.2 75.4 C1.2 130.1 119.7 EXISTG WELL RADIUS 11011.2 130.8 120.5 / M- C2-1 77A 63.6 M2.1 85.8 73.2 C2.2 89.6 78.3 fox 13.0 INSTALLED DOUBLE ROW SPLITTER TO SPLIT FLOW 1N a 3148 DOUBLE CLEAN. (BALL TYPE) EXISTG3BR HOUSE 12AvaQ 0 Qip K JQ OA --Z Qg40 r rpQ' OQ / \ Q4Q- / NOTES: 3) Maintain IV separation to all PERC RATE:16-30 MPI e0 ♦ 1) All work shall be performed In lot lines and proposed water APPLICATION RATE: 250 SFBR OF 94 accordance with AMC15.65. lines. 0.6 GPD/SF Gj�p'•��••"'••••••,•••• �� 2) Materials used shall be in 4) Lots served by private water 3 BR HOUSE #0 deed M system. No wells within 100' of REQ'450g GPD DESIGN FLOW accordance with those s C A� M •••••�•';'� �4 AMC15.65, Wastewater Disposal. proposed system. EO'D AREA: 750 SF - 5' WIDE TRENCH CE 8146 828107 KENNETH AND DANA SPADAFORA 9501 BUDDY WERNER DRIVE .�� ANCHORAGE, AK 99516 6S1� (907) 346.1340 75 LF x 5 ED. 2-S' WIDE, r TO PANNONE ENG. SVC, LLC P. O. BOX 102954 ANCHORAGE, ALASKA 99510 227-3522 P. 272-8218 Fax PLAN PERMIT NO: SW060101 RECORD DRAWING DETAILS P.I.D.NO: 015-09110 WASTEWATER DISPOSAL SYSTEM LOT 12A BLOCK 5 PROSPECT HEIGHTS N1 M3 LV t 38fLL wmL 9 h/ 1•i w 1A m 0 � 0 pJp b @ O 2 w E yy YUU z l S ~ Z " W E o r171.7 rrrrr . aeCIN3 LVLL U 7777 O W uoav3o U) O_ t „ r 2 Ls .� vnmdS lJ i 6 �b as u omv N q t 318(1[10 3AWAe3183N0 —j t l gNV31� Z F~ m $' tno Hr3lo g � .............., � Nouwwwi • 49 TM .....i •� .. ........ .... . •PREPARED FOR: 0 "' : "' " """' . PANNONE ENG. SVC, LLC Steven R. Pannone KENNETH AND DANASPADAFORA P.O. BOX 102954 ' CE 8149 8501 BUDDY WERNER DRNE ANCHORAGE, ALASKA 99510 #� 10/16,D7 ,.•'�� ANCHORAGE. AK 99516 ;�.� (907) 346-1340 227-3522 P. 272-8218 Fax 4t) tilt :'�� DATE: 11-01-06 DETAILS SCALE: NTS Pannone Engineering Seruices, LLC P.O. Box 102954 Consulting Engineers Anchorage, Alaska, 99510 (907) 272-8218 (907) 272-8211 Fax November 7, 2006 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program 4700 S. Bragaw Street P. O. Box 196650 Anchorage, Alaska 99519 Subject: Lot 12A, Block 5 Prospect Heights Lot Line Waiver Request Gentlemen: I am writing to request a lot line waiver be granted for the above referenced property. The drain field needed to be moved to the north due the presence of a gas line and electric line in the upgrade location. The new drain field is located 0.5 feet off the north property line. The neighboring septic system is located greater than 50 feet away. Granting this waiver will not affect the upgrade of the neighboring system to the north when it is necessary. If you have any questions or concerns, please contact me at 227-3522 or 272-8218. Sincerely, Steven R. Pannone, P.E. Civil Engineer Attachments: WAIVER FEE: 1-46 PAYMENT DATE: It 10 RECEIPT4: C:\Work\Letters\12A 5 Prospect Hts.002.doc ((C�' Municipality of Anchorage C(1. Da 1%6R)-Anchum•. \Inslul !MLiI!F(i(ii(1.471M11ilmow Mmd 10, 011im 0X17)343-14:Mll • Fam (lM)71343-K1X) hllp://n,�,c.numLar�; Mayor Mark Begich Development Services Departinent November 7, 2007 Steve Pannone Pannone Engineering P.O. Box 102954 Anchorage, AK 99510 Subject: Waiver Request for Prospect Heights #1, Block 5 Lot 12A Waiver Request WR#: 070059 Parcel ID # 015-09140 SW060101 Dear Steve Pannone: ru• n t .Q Department 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 0.5 foot. This waiver approval applies to the existing absorption field to property line separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, ()w Gt)Cc'c — Deb Wockenfuss Civil Engineer On -Site Water & Wastewater Program Community, Security, Prosperity Municipality of Anchorage / Development Services Department r Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchoragc.ak.us (907)343-7904 Waiver Review Worksheet WR#:070059 PID#:015-091-40 HA/Permit# SW060101 Date Received: November 7, 2007 Legal Description: Prospect Heights #1, Block 5 Lot 12A Engineer. Steve Pannone Pannone Engineering P.O. Box 102954 Anchorage, AK 99510 Applicant: Ken Spadafora Waiver Requested: .5' lot line waiver Criteria: Geology A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: Points: ,..............a.........................................................@ Waiver Is Granted: X Waiver is not Granted. List Conditions or Reasons for above: Date: 1117127_ By:DebDeb Wockenfuss Name of Reviewer .......................................... a...a.............. Manassas&... Rec#: JIM Amount $M Date Paid: 111712007 MUNICIPALITY OFANCHORAGE Development Services Department \� On -Site Water d Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: May 19, 2006 Expiration Date: May 19, 2007 Permit Number: SWO60101 Parcel ID: 015-091-40 Legal Description: PROSPECT HEIGHTS #1 BLK 5 LT 12A Design Engineer: 0062 PANNONE ENGINEERING SERVI( Site Address: 009501 BUDDY WERNER DR Owner Name: KEN SPADAFORA Lot Size: 50473 SO. FT. Owner Address: 9501 BUDDY WERNER DRIVE Total Bedrooms: 3 Permit Bedrooms: 3 ANCHORAGE. AK 99516-1048 This permit is for the construction of: ❑✓ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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 engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received BY Date: Issued By: fy J Date: 52, ri cL Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, Alaska 99519-6650 www.muni.org/onsite (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 015.091.40 Property owner(s) Ken Spadafora Day phone 346.1340 Mailing address9501 Buddy Werner Drive, Anch, AK Zip Code 99516 Site address 9501 Buddy Werner Drive Zip Code 99516 Legal description (Sub'd., Block & Lot) _Lot 12A. Block 5 Prospect Healohts No.1 Legal description (Township, Range & Section) Lot Size 50,473 Sq. Ft. THIS APPLICATION IS FOR (® all that apply): Absorption Field Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms 3 THIS APPLICATION IS AN: Initial ❑ Upgrade JR Renewal ❑ 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. Pannone LLC (Signature of property owner or authorized agent) Permit/Rush Fees: 4 -IVU Waiver Fees: Date of Payment: 7 / ( y l4 Date of Payment: Receipt Number: !/'* �G W Receipt Number: (Rev. 11/05) Pannone Engineering Services, LLC P.O. Box 102954 Consulting Engineers Anchorage, Alaska, 99510 (907) 272-8218 (907) 272-8218 Fax May 10, 2006 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program 4700 S. Bragaw Street P. O. Box 196650 Anchorage, Alaska 99519 Subject: Lot 12A, Block 5 Prospect Heights Septic System Upgrade Permit Request Gentlemen: I am writing to request a permit to construct an upgraded septic system be issued for this property. The proposed systems will serve an existing three-bedroom house. The existing well is located in the western side of the lot, over 100 feet from the proposed septic system location. The surrounding lots are served by private water systems and are over 100 feet from the proposed soil absorption system. 1. Soils. See the attached soils log. Ground water was monitored for seven days through the May high ground water period. Ground water was encountered in the test hole at a depth of eleven feet after the water -monitoring period. Bedrock was not encountered in the test hole. It is my opinion that the overall soils appearance of the soils, an application rate of 0.6 gallons/day/square feet should be used using a conventional treatment system. 2. Trench Design. a. Percolation Rate: b. Application Rate: c. Number of Bedrooms: d. Design Flow: e. Min. Absorption Area: L Total depth: g. Effective Depth: h. Width: L Reduction Factor: j. Minimum Length: k. Design Length: 1. Effective Absorption Area: m. Septic Tank Size: C:\Work\Letters\12A 5 Prospect Hts.001.doc 15-30 Min Per Inch 0.6 gpdpsf 3 450 gallons per day 750 sf 7 feet 5 feet 2-3 feet 0.0 75 feet 75 feet 750 sf 1000 gallon if required Cont'd on page 2 Page 2 3. Surface Water: There is no surface water within 100 feet of the proposed system. The proposed systems will maintain at least 100 feet from all surface water and drainage ditches. 4. Topography: The average topography in the area of the proposed septic system is approximately 10 percent. The proposed system will be installed on the northern portion of the lot adjacent to the north property line. The proposed installation will not affect the future development of the surrounding or existing lots. There are no wells or septic systems within 100 feet of the proposed septic location. The existing septic tank is constructed of concrete. It will be exposed and the integrity of the tank verified. If you have any questions or concerns, please contact me at 227-3522 or 272-8218. Sincerely, `.% even R. Pannone, P.E. Civil Engineer ; M. • ... &"' Attachments:Pl- CE 8140 C:\WORK\LETTERS\12A 5 PROSPECT HTS.001.DOC even K. rnnnone:•&us PERMITNO: DESIGN DRAWING ' WASTEWATER DISPOSAL SYSTEM LOT 12A BLOCK 5 PROSPECT HEIGHTS #1 P.I.D. N0: 015-091.40 I� \ ' ' Exlsrc wBLLRADIus EXISTG SEPTIC \ 1 AREA 10.0 135.4 10% �134.5—4 0% �� i- • • EXIST IELD / TO BE REUSE �•>EXISTM 10000RETE SEFTC /NK VERFITY /INTEGRITY JJJ SEPTIC AREA PROPOSED UPGRADE SAS, 2 TRENCHES 1@57LF x 3Wx 5 ED, r TD 1 Q 2DLFx3Wx 5' ED, r TD 10.0 INSTALL DOUBLE FLOW SPUTTER TO MADE FLOW 1/4 a 3/4. ml43ii7 EXiSTG 38R HOUSE 12A EXISTG WELL RADIUS • hp �h NOTES: 3) Maintain 10'separation to all pERC RATE: 16.30 MPI ,, 1) All work shall be performed In lot lines and proposed water APPLICATION RATE: 250 SFBR OF tai accordance with AMC15.65. lines. 0.6 GPDISF i��P ••............... 1� 3 BR HOUSE Gj..•'•• �� 2) Materials used shall be In 4) Lots served by private water 450q GPD DESIGN FLOW All accordance with those specified In system. No wells within 1 00' of REO'D AREA: 750 SF -- d3. ` •••••• ; AMC15.65, Wastewater Disposal. proposed system. 5' WIDE TRENCH Steven FOR: KENNETH AND DANA SPADAFORA 9501 BUDDY WERNER DRIVE ANCHORAGE, AK 99516 (907) 346.1340 75 LF x 5 ED, 2-3' WIDE, r TO PANNONE ENG. SVC, LLC P. O. BOX 102954 ANCHORAGE, ALASKA 99510 227-3522 P, 272-8218 Fax PLAN PERMIT NO: DESIGN DRAWING DETAILS WASTEWATER DISPOSAL SYSTEM LOT 12A BLOCK 5 PROSPECT HEIGHTS #1 P.I.D.NO: 015-091-40 1I101f, 31� A ^ 03 T 3en1 WbN011 . .. ci u. 60 i; IL E w' c mui r5`p W Z!}���i n o ^ � -rG t Vr;Ai+�; •1;,�s.4 Lu J 013 HOV3 tY •iBfII r LL WLW,MI 0 N W'^ N L;J co D_ r to FF r3urlasMov 3110 r1valo _ S�liAY3iY3Me uwrN3ia Y 2 F~ ulo Nv3'u y OF •.�P(E A........• co • ••... ♦ ,nC N3 49 TM ♦ �..... i. ............:t..... ♦ i ♦ PREPARED FOR: PANNONE ENG. SVC, LLC ♦ Steven R. Pannone ♦♦ :.• = KENNETH AND DANA SPADAFORA P. O. BOX 102954 ♦ CE 8149 • lQ• '`�.• 9501 BUDDY WERNER DRIVE ANCHORAGE, AK 99516 ANCHORAGE, ALASKA 99510 #fit (907) 345-1340 227-3522 P, 272.8218 Fax \0 Sisk DATE: 5-10-08 DETAILS SCALE: NTS SOILS LOG - PERCOLATION TEST �.�p.�i PANNONE ENGINEERING SERVICES � pj•, .............. P.O. BOX 102954 fir' 49 TTM ti �.....: ..........',.....� ANCHORAGE, AK 99510 0 ' (907) 272-8218; .... ...... ................. Steven R. Pannone •��� PERFORMED FOR: ',' ,,.,�E 6149 Kenneth and Dana Spada,ora DATE PERFORMED: 05.03-06 �4"6p;'(.;.C2�S� 0..e•�'',��� LEGAL DESCRIPTION: 12A Block 5 Prospect Heights Al 44•',1a01sS% '�. _Lot TEST HOLE 1 OR Or°aniW Root SLOPE �artE PtIW Masa ML Brown Sins 2 i 1 3- 4 4— Silty Gavel to Poorly Graded 5 Gravels MSA 3$ MSA e TEST HOLE (� GM/ 7 GP j a ° 12A 10 12 �•— —•� ,9 GP/ Gray SILT w/ •� GM Peebles. Dry WAS GROUND WATER SLOPE 14 ENCOUNTERED? No 15 BOH IF YES, AT WHAT DEPTH? Seeps 0 •11 TEST MOLE 18 n DEPTH WATER AFTER MONITORING? •11 to DATE: 05-10-06 ,9 CLOCK WATER READING GATE TIME NET TIME LEVEL NET DROP READING 20 1 OS -03-O6 77:37 771e 2 1207 JO MIN J 11/03 7207 � 21164 72]7 70 MIN 3711 711e 5 72 J7 2 - e 7.07 JOMnI 31M PEROLATION RATE 27 (minAnch) PERC HOLE DIAMETER 6 inches TEST RUN BETWEEN 5 FT AND 6 FT COMMENTS: Test hole excavated by A+ Home Services. Test Hole was presoaked before pert test PERFORMED BY: Steven R. Pannone,P.E. 1 CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST 71A, SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTh OF Drilled at The rate of ~76eO0 PEr FOOT. #l~. 16qiZT~ g..q.C. SOl2 $44-0817 PROPERTY OWNER 254 LOCATION OF WELL SITE WELL LOg: 79--704~ t~ z~ MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL P2OTECTiON ~AY :1 3 Co,o,~ of ~aA/.A~w~: 250 feeA i2o Ow;tee f.o* ge_,bL Sea,L. $4 O00e O0 COST INCLUDES ALL LABOR AND MATERIAL For COMPLETION OF SAID DRILLING. WRITE CHECK PaYAble TO RAMPART DRILLING WORKS for THE SUM Of f/4000. O0 THANK YOU VERY MUCH. BERNIE CLAUS OF RAMPART DRILLING WORKS SERVICE CHARGE O F I%o~ PER MONTh WILl B~ A~B O~ PA~T DII~~AEC~HNT~ ~ SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF DRILLED AT THE RATE OF $~8.00 PER FOOT. PROPERTY OWNER ~- Hs~: LOCATION OF WELL SITE DRILLER ~e~e C~ms 530 Feet, DEPT. OF HEALTH & ~//orks e ENVIRONMENTAL PF;OTECTION WELL LOg: 0 ..... ~_g' Silty gr~ve! w4_th !981 ~3 .... 69~ Clay with a f~w ineh~ of g~avel on top of bed_~oek at 69 f~t~. T~ee~ 23~1' Sign~ of a d~n E~an,,l~w rock. Wet but not wate~ ~uctive.. 24i..46~ S~enta~ rock. 460--467' A d~n ~r~ula~ rock pr~uc~g a sma~ ~o~t of water, 467--520' S~ent~ rock~ 520--523' Wet granular rock pr~uc~ small ~o~t of water. ~23-=530' Sed~ent~ rock~ 300 feet of water st~ing off bottom at X,6 gals per foot. However pr~uction of well ~y on~ be aro~ 200 gals per day ~th a possible ~crease in ~e~ to 300 GPD. It was ~parts dec. ion to dr~ from 430 to 530 at no c~rge to ~. Wilson~ A~o, -~th $77~,00 ~vest~ by ~. ~on, ~part ~iHing ~rks feels that more water may be ne~ed. ~ the ~t~e ~ at that t~e ~ ~ill ~other well ~ a location chosen by ~. Wilson. At NO ~arge COSTINCLUDES ALL LABOR AND MATER[AL FOR COMPLETION OF SAID DRILLING. $~8x~0~ ~7~.oo w~rs CHECK PAYAS~E TO RAMPART OR~LUNe WORKS FOR THE SUM OF ~0.00 THANK YOU VS~Y MUCH. BERNIE CLAMS O~ RAMPART DRILLING WOR~S SERVICE CHARGE O~ .. ,. GREA.,.:R ANCHORAGE AREA BOR, ]GH '~' O Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE pJ"'OF' FROM WELL /04¢)1 MANUFACTURER ~"~,q/~'~,/~O'~(2'.-MATERIAL C0/~¢---("~-¢~t-'~ NUMBER OF COMPARTMENTS INSIDE LENGTH ~ INSIDE WIDTH ~ LIQUID DEPTH -'""-'- LIQUID CAPACITY//~GALLONS. DISTANCE FROM WELL NUMBER OF LINES ABSORPTION AREA { FOUNDATION ¢~ ~ / DISTANCE BETWEEN LINES WL~--O SQ. FT. LENGTH OF EACH LINE ~ / NEAREST LOT LINE%'1/___~. ! TOTAL LENGT ,....~ kcHq/c- OF LINES ~/~ TRENCH WIDTH ~ N TOTAL EFFECTIVE DEPTH: TOP OF TILE TO FINISH GRADE '~3 / DEPTH OF FILTER MATERIAL BENEATH TILE ~/--~./ IN. ABOVE TILE L/ IN. BUILDING FOUNDATION__ CESSPOOL APPROVED CONSTRUCTION 6[/ ~__~./'g ,¢ J"/L),~ DEPTH DISTANCE FROM: NEAREST NEAREST ~ ( SEPTIC /~<C) [ SEEPAGE LOT LINE SEWER LINE¢ . TANK , SYSTEM OTHER SOURCES INSTALLED BY: SEWER LINE DEPTH: DIAGRAM OF SYSTEM TYPE OF SOIL ABSOR.'BTION SYSTEM IS: TRENCH ttA};Tf'ILIP1 NUMBER OF BEDROOMS = 3 SOIL EATING (Sr, FT:'BR)= 150 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: L.-EF''T H= 1C1 ILEr-4o-rH= 17iE'F=i%:'EL_ C•EF: F• -r Fl= :' THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DR.'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). t=_Ei-1 IJ I F:ECti E•EF'T I r-T'F-Ir-JK' c I =E= :JL C_i17-4 0 C�nLLv=i rJ - --------- F -'I Ar 1 A ------- -^r E .. F A MAIN ENANCE - - • r - Flna2E IL Ai+"-Grrrrr i -'''TPM Puri �flG 4'ftll t1R" r•r �i for - - - _ ---------------------------------------- --- TLJCI i ' ] I r•a-P EC:'T I Cir -J'= i=i 1--."E=- F:EiT!U I --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWE 100 FEET FOR A PRIVATE WELL LOGS ARE REQUIRED OF THE WELL COMPLETION OTHER RE[aUIP,EMENTS MAY AVAILABLE TO INSURE PR: =N A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM Imo• WELL OR 200 FEET FOR A PUBLIC WELL. AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS APPLY. SPECIFICATION, AND CONSTRUCTION DIAGRAMS ARE JPER INSTALLATION. F'EF[L•1 I -F E: F' I F-: E ---:E: CrECEt•1E=EE' - 1s 3-j r 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 CODE':. _. I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. SIGNED:_---'��- APPLICANT HANK. WILSOP ISSUED BY V3. 0 9•�A/Y1 t11JtJ 1 �_ I�HL I T4' C, F= Ht-:� :F?K� lF"H1�E r DEPARTMENT HEALTH HNC? ENVIRONMENTAL OTECTION /o aQ-��% /Lil 825 'L' STREET, ANCHORAGE, AK •_+'+501 ' 279-2511 o O tn! E t_ t_ F=1 r-•! C• IJ r -•J —=. I T E -• E t•J E F� F• E F_ L'1 I TO& PERHIT NO. C 77437 ) APPLICANT HANK. WILSON SRA BOX cO 344-0817 LOCATION SUDUY WERNER, DR. LEGAL LOT 12A BLK 5 PROSPECT HGTS # LOT SIZE 54450 SQUARE FEET TYPE OF SOIL ABSOR.'BTION SYSTEM IS: TRENCH ttA};Tf'ILIP1 NUMBER OF BEDROOMS = 3 SOIL EATING (Sr, FT:'BR)= 150 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: L.-EF''T H= 1C1 ILEr-4o-rH= 17iE'F=i%:'EL_ C•EF: F• -r Fl= :' THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DR.'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). t=_Ei-1 IJ I F:ECti E•EF'T I r-T'F-Ir-JK' c I =E= :JL C_i17-4 0 C�nLLv=i rJ - --------- F -'I Ar 1 A ------- -^r E .. F A MAIN ENANCE - - • r - Flna2E IL Ai+"-Grrrrr i -'''TPM Puri �flG 4'ftll t1R" r•r �i for - - - _ ---------------------------------------- --- TLJCI i ' ] I r•a-P EC:'T I Cir -J'= i=i 1--."E=- F:EiT!U I --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWE 100 FEET FOR A PRIVATE WELL LOGS ARE REQUIRED OF THE WELL COMPLETION OTHER RE[aUIP,EMENTS MAY AVAILABLE TO INSURE PR: =N A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM Imo• WELL OR 200 FEET FOR A PUBLIC WELL. AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS APPLY. SPECIFICATION, AND CONSTRUCTION DIAGRAMS ARE JPER INSTALLATION. F'EF[L•1 I -F E: F' I F-: E ---:E: CrECEt•1E=EE' - 1s 3-j r 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 CODE':. _. I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. SIGNED:_---'��- APPLICANT HANK. WILSOP ISSUED BY V3. 0 uepartment oI Health and Envi~'onmental Protection ' ' Anchorage, Alaska 99507 SIIII~S l J)(; I'EI~()I,A'I'I()N TI.iST Performed For ~-[ ~ i cS o ~ lhis f ~, - ...................... . ..................... orm reporto. 5o~ls lo9 ~ Percolation [cst ' ' .............. Dep th Feet 1 -.____o ~ C7/~ i c a;/"$ ~ cvs " 11- "~ 12- ; 13. - Nas' §round wa~er encountered? .~_/~_c.'~_ ....... If yes, at wi,aL Reading . .Date Gross Time Net Time Uepth to Water Net i)rop rate ........ ' . 'Proposed installa~:~h':"g~,~:gc Pit brain I-icld ~, I~cpU~ of Inlet ................. . Ilcpt~C~b"bb'[~b~n"b'F"pi t ur ir(tach .............................. . COHH[NI5: .. ........... - .......................... :' EQ-.04O (6/74) Up(Z,,, &k N/) acppyo,k 'I ,�. Q� , `VowI�) of rnCLI� boxt.o �-• 3 - Ll -A!> • Municipality of Anchorage • '1 On-Site Water and Wastewater Program Lai (907) 343-7904 SAFETY Certificate of On-Site Systems Approval 015-091-40 Parcel I.D. Expiration Date: £ (? 1. GENERAL INFORMATION Complete legal description Prospect Heights #1 Block 5 Lot 12A Location (site address) 9501 Buddy Werner Dr. Current Property owner(s) Spadafora, Kenneth & Dana Day phone Mailing address 9501 Buddy Werner Dr. Real Estate Agent Day phone 2. TYPE OF DWELLING: 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 El Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by:0' I g ! r,( I Date: o f `f7 COSA to be released to the engineer. nless otherwise reques i, by the engineer. • COSA Fee $ �`J O Waiver Fee $ Date of Payment 9127/i ' Date of Payment Receipt Number (9-CI 3 g Receipt Number COSA# OC (c ( 113� 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. 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. In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA guidelines and 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 guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 745-8200 Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R Pannone Date 8/24/2018 OF AL'4slk 6. DSD SIGNATURE • . .••. / � .. ( System #1 Approved for bedrooms %Sleven R.'Pannone .•. CE-8149 System#2 Approved for bedrooms �� ��,•, • � Disapproved ),fN0FES540NA�4�,r Conditional approval for bedrooms, with the following stipulations: 1 ONS keel r !T !/1/ FR } /YOnLv1/47- .71Y 4�v FR R'14 c\c B / Original Certificate Date: The Municipality of Anchorage 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 Other COSA blue sheet S , c Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE If more than 1 septic systec J@9At3tEti1Wund,09/05118 COSA Checklist# ' of 2 Structure served by this system 2 Certificate of On-Site Systems Approval Checklist • Legal Description: Prospect Heights #1 B5 L12A Parcel ID:015-091-40 A. WELL DATA Well type Private If A, B, or C provide PWSID# Well Log (YIN) Y Date completed 8/5/1979 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 254 ft. Cased to 254 ft. Casing height(above ground) 20 in. FROM WELL LOG AT INSPECTION Date of test 8/5/1979 8/20/2018 Static water level 90 ft. 118.2 ft. Well production 8-10 g.p.m. 5.7 g.p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/100 mL Nitrate ND mg/L Arsenic ND ug/L Date of sample: 8/20/2018 Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/ Concrete Date installed 6/30/1977 Tank size 1000 gal Number of Compartments 2 Cleanouts(Y/N) Y Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N/A Date of pumping 8/9/2018 Pumper Northland Pumping Services, Inc. C. ABSORPTION FIELD DATA Date installed 6/9/2007 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.6 GPD/SF System type Deep Trench Length 57/20 ft. Width 3 ft. Gravel below pipe 5/5 ft. Total depth 7/7 ft. Eff. absorption area 750 ft2 Monitoring tube Y Depression over field N Date of adequacy test 8/20/2018 Results(Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 48/48 in.. Water added 450 gal. New depth 64/64 in • Elapsed Time: 1440 min. Final fluid depth 48/48 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment(past 12 mo.) (Y/N &type) N If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN) "Pump on"level at in. "Pump off level at in. High water alarm level at in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100+ On adjacent lots 100+ Absorption field on lot 1 00+ On adjacent lots 100+ Public sewer main 75+ Public sewer manhole/cleanout 100+ Sewer/septic service line 25+ Holding tank 100+ Animal containment areas 50+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10+ Property line 10+ Absorption field 5+ Water main 10+ Water service line 10+ Surface water 100+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 0.5* Building foundation 10+ Water main 10+ Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS *Waiver on file, WR#070059 Field is 99% used. Switched diverter valve to '77 field. Field cleaned and allowed to rest. G. ENGINEER'S CERTIFICATION • �da�0� 7. OF qF A�.,gskki I certify that I have determined through field inspections and ,o.'P• review of Municipal records that the above systems are in 0* 49 TH j\ -.*-0, conformance with MOA COSA guidelines in effect on this date. 0-•••••• � Engineer's Printed Name Steven Pannone :Steven R .Tonne �� Date 8/24/2018 r¢l� �.. CE-8149 / 1>�1 o®a St� ,r COSA canary sheet_2-6-15.00c If more than 1 septic system is on the lot: COSA Checklist# 2 of 2 Structure served by this system . i Certificate of On-Site Systems Approval Checklist Legal Description: Prospect Heights #1 B5 L12A Parcel ID:015-09140 A. WELL DATA Well type If A, B, or C provide PWSID# Well Log (Y/N) Date completed_ Sanitary seal (Y/N) Wires properly protected (Y/N) Total depth ft. Cased to ft. Casing height(above ground) in. FROM WELL LOG AT INSPECTION Date of test Static water level ft. ft. Well production g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Arsenic ug/L Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA • Tank Type/Material Date installed Tank size gal. Number of Compartments Cleanouts(Y/N) Foundation cleanout(Y/N) Depression over tank (Y/N) High water alarm (Y/N) Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed 6/30/77 Soil rating (g.p.d./ft2 or ft2/bdrm) 150 SF/BDRM System type Deep Trench Length 36 ft. Width 3 ft. Gravel below pipe_ 7+ ft. Total depth 10 +/ ft. Eff. absorption area 450 ft2 Monitoring tube_ Y Depression over field N Date of adequacy test 820/2018 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth 8 in. Elapsed Time: 120 min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d. N Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date • D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on"level at in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer/septic service line Holding tank Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10+ Property line 10+ Absorption field 5+ Water main 10+ Water service line 10+ Surface water 100+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water main 10+ Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS DV switched to this field a week before test. G. ENGINEER'S CERTIFICATION .4.:1-7c .OF ACS\� ` I certify that I have determined through field inspections and r'''4... 4` 9 review of Municipal records that the above systems are in pr.* ;• •_TH /\ ••*�� conformance with MOA COSA guidelines in effect on this date. .•••• ` •'. Engineer's Printed Name Steven Pannone 9 •Sieven R. Pannone 8/24/20186 CE-8149 /kiwi' Date � � 4(b• 1 °FESS% COSA canary sheet_2-6-15.doc Pannone Engineering Services LLc Steven R. Pannone, Principal Registered Professional Engineer E-mail:steve@panengak.com September 1, 2018 Subject: Prospect Heights#1, Block 5, Lot 12A Tank in Driveway I am writing to document the tank in the driveway at the above property. The tank was installed in June of 1977 and is constructed on reinforced concrete. The lid is six inches thick (verified recently when the baffle was inspected and repaired) and is in good shape with no signs of cracking or deterioration. The tank has 80 inches of cover, which will dissipate any wheel loading to virtually nothing (doing the math: 80 inches extended out at a 1:1 will produce an effective loading area of160 square inches per inch of load. If the load is 150 psi, the effective load on the tank is less than 1 pound. ) This concrete tank has been in service for over forty years. It is structurally sound and will continue to support wheel loadings under this driveway for years to come. If you have any questions or concerns, please contact me at 907.745.8200. Sincerely, Steven R. Pannone, P.E. Owner/Civil Engineer •���� O' 44- ,b • ♦�•;Steven R. Ponnone: .. ♦�! fye. 874Q � . ' 417 •441,rD • Mailing: P.O. Box 1807 Palmer, AK 99645 Telephone: (907) 745-8200 FAX: (907) 745-8201 Date: 8/1/2018 Reference: 9501 Buddy Werner Dr., Anchorage, AK Municipality of Anchorage, This letter is to inform you that we have never experienced any freezing of our septic system or tank the entire time we have lived in this house. We moved into this house in April of 1994 and have lived here full time since then. Kenneth Spadafora kspada@gci.net 907-440-1567 I 401 -P•Illm. II C.,4‘C) .1 \ --------I - --------. \Pk I \ N „v"' +\0 vi ryM' 7 S 5 58'11'58'E 372.73' ...01 t AP 30.00' N 33'50'00.E \ 'n 29.12' \ �eek N _ S ... c05 .. .. 24.5 79 J, • RAVEL.DRK � • CI' • [ w w W cn G . 9 + DO ' J W v F U) ct 1tri go; •h h H N N �. 0‘5'4. LG� �� r O P W P (P �� c00 ilii Z Rye n W \o� 'V� ID M Jai 4( V) I4 ai o / $ 1 / N 58'11'58`W 372.72' I I \,at CD 1 1 / 1.5P I / tat PLOT PLAN AS BUILT X SCALE 1" = 40' GRID SW 2441 Project No. — 18-329/A1 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates , inc . (907) 522-6476 Phone 907 522-4625 Fax Tc ooProfessional Land Surveyors kenOlangsurvey.com 4o F 'g . XIA JonathanOlangsurvey.com O '954 I hereby certify that I have surveyed the following described property: if Lot 12A, Block 5, PROSPECT HEIGHTS SUBD. ADDN. #1 (Plat No. 74-227) Q * 4 J A,4 N: '. O Anchorage Recording District, Alaska, and that the improvements situated thereon are 0"" """ ) 0 within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed �O..•.•KE . ETH G. •LAN . ..� premises and that there are no roadways, transmission lines or other visible O<^�, % / o� • easements on said property except as indicated hereon. Q 04(e ••• 4Q 4`411,•0 4 ••.Ls-520 o Dated this the Day of S�'�� •4""",v , at Anchorage, Alaska ,o ......• foo ` �4RO�SSI0NAL'� It is the responsibility of the owner to determine the existence of any easements, O�ODOo�` " covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 MUNICIPALITY OF ANCHORAGE 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.# ["'/ \(3--("1°~ / - L4('"~ HAA# 1. GENERAL INFORMATION Complete legal description L4:~'F iSA. Location (site address or directions) c~'OI (3U~'7' bd~___~foF__z~_ p~E~,,/~__ Property owner ,~'-'~ ¢~¢~L~ ¢F/ ~, ~(~'1~_ ~'t'L~V{~ ¢X%~ctO Day phone Mailing address °t%t'~\ ~L'~x,A,-~,~ ~,~,%S,'~,,~r~ ~--'~A~.~_~' Day phone Lending agency Mailing address Agent ~tE-t'~ Address ~¥t4Aw~t c- Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Day phone Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 {Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm P ~ I_ CLD~c~JL-'f-i ~E~ DHHS SIGNATURE Approved for '~/4--~/,) bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does th is as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a oertificate is issued. The Munioipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-0'25 (Rev. 1/91) Back MOA #21 C? 3090 ® Municipality of Anchorage aim Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LOT 12 A 6LcU-- 5 Parcel I.D. 5� p oSPacT _(C�r St A. Well Data Well type INDIVIDUAL.- If A, B, or C, attach ADEC letter. ADEC water system number /�, Log present (Y/N) Y£S© Date completed AA ' 5, 1979© Driller 9A W1 PA12T DQ(LL I V6t W04K- `=, Total depth 254© Cased to 254 © Casing height U Sanitary seal (YM) Yt:s Wires properly protected (Y/N) YI=S FROM WELL LOG Date of test 13 - S-'1 9© Static water level go, 2 Well flow 9-10 © g.p.m. Pump Ieveil 244 2 AT INSPECTION 10-I(o-�►3 0 UNICIPALIIY OF ANCHUKAtit IIS.S ENVIRONMENTAL SERVICES DIVISION •s g-p•6CT 2 E 1993 a�a RECEIVED SEPARATION DISTANCES FROM WELL TO: Septictholding tank on lot 180" + (D : On adjacent lots Absorption field on lot IS& + G) ; On adjacent lots (ZO1'`IU 120' + Public sewer main N/A Public sewer manhole/cleanout N/A Sewer service line NIA, Petroleumtank OW&V+r— 1WOKAAIreo nwMF- WATER SAMPLE RESULTS: Coliform O(a) Nitrate • I 0 � Other bacteria C�oo Dateofsample: 10 -IS -G30 Collected by: MAIzIL t<RIGKS6-J B. SEPTICIHOLDING TANK DATA 2 Date Installed Tank size l o00 © Compartments 2 Cleanouts (Y/N) 14 OQ.IV%UJAY Foundation cleanout (Y/NJ N0 C© Depression (Y/N) 90 � High water alarm (Y/N) Alarm tested (Y/N) Date of pumping I O `1- R 3 Pumper l�.l.tl t Stt w ��'S p2A1� SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Weli(s) on lot t&)14- O On adjacent lots 1101 + 0 Foundation 3S " To property line *SD'± 0 Absorption field I5 t Water main/service line NIA Surface water/drainage NWS MEAiv4EOl o6ScAVsrO BY D4/ Io- Ib -93 CONTINUED ON BACK PAGE 72-02e(=)•Front0 FR -0w, Ciµ+IS F(L.FS O Str ATr^f_kl� WATE0— SA qLZ k£Sut?S C. LIFT STATION Date installed Manufacturer Sae in gallons Manhole/Access (Y/N) Vent (Y/N) 1 High water alarm level _ "Pump on" level at Meets MOA electrical codes (YM) 'Pump off" Level at Cycles tested 93ogp SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed �-30--17 (D Soil rating (GPD/Ft') I CPD /S F (D System type 't-Rf,acf4 12) r Length 7:? oU Width 3r 0 Gravel thickness g 9� 0 Total depth 10 ± Total absorption area '450 (1) Cleanout present (Y/N) �t-S-, 63vQr>`0 Depression over field (YM) ND O Date of adequacy test 10-1 -9 3 (2) Results (passltall) PASS CC) for 1 3 Bedrooms Water level in absorption field before test '7511 O 1After test 7 Eu d Peroxide treatment (past 12 months) (Y/N) CW)yrP— yj0'c^TVS 4D l0 if yes, give date WWAa SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ,d + (D On adjacent lots 1101+ Property line I S To building foundation 47 O To existing or abandoned system on lot NIA On adjacent lots 1 10 Cutbank ✓J/A Water main/service line N/A Surface water KWF- d Driveway, parkingNehicle storage area 0'0 Curtain drain N /A E. ENGINEER'S CERTIFICATION I certify thatihaw, checked, verified, or conformed to all MOA and NAA Signature Engineers Name e 4.44 V Date !G -a a- u HAA Fee $ '� U O Waiver Fee $ Date of Payment /" ag-9z Date of Payment Receipt Number 45'i161 IO 8 44 Receipt Number w�EsS�kEolo Stevco 'BY arr ro-I(.-93 72-o26(M'Back 0 FRo— 1)t1-45 FILES his inspection. INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME TIME DATE" DATE DATE INSPECTOR _ INSPECTOR S -�� C L INSPECTO P-RSINGLE FAMILY ❑ Other ❑ MULTIPLE FAMILY MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTloQEPT. OF HEALTH & 825 LStreet- Anchorage. Alaska 9BFA1 ENVIRONMENTAL P.OTECFION ENVIRONMENTAL SANITATION DIVISION MAY 13 1981 *\'w Telephone 264-4720 DD�(('' ��[[ jj�� REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWBii�FU11fIQ DIRECTIONS: Complete ell parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days far processing. 1. PROPERTYOWNER PHONE /-/. /-/ S- / 7 MAILING ADDRESS `n ZO&O i4 NC/f ff/G y'4So7 PROPERTY RESIDENT III different from above) PHONE 1L/o /vE T. BUYER PH N Fivti/S /rlC.$TAS MAILING ADDRESS Z7J-4S5 / S¢L .17' .Sup �� /t� 3. LENDING INSTITUTIoON PHONE Aon-,�4s �vErr�c rol✓ PH ¢_7��� MAILING ADDRESS f ¢ ¢lam 08ar 7 as S f 13G !/T] 4. REALTOR/AGENT / PHONE LCX) flEAG7Z)/ZS �� LujCSot/ 27� 9S9/ MAILING ADDRESS -f 0 66 0 Jr/ 5. LEGAL ON DESCRIPTI e,07- / Z q STREET LOCATION liao0 I cvE K/-" 6. TYPE OFF RESIDENCE NUMBER OF,BEDROOMS ❑ One ❑ Four P-RSINGLE FAMILY ❑ Other ❑ MULTIPLE FAMILY 0 �1:1 Five LLLd�— Thhrere e ❑ Six 7. WATER SUPPLY 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.) S. SEWAGE DISPOSAL SYSTEM CO--'INDIVIDUAL/ON-SITE" /y !7 YEAR ONSITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY %f:�/S SiS710E M 1111?S /L/E(/E2 436:E0 U51ED 7/y 6; #00JE A-"e✓E2 'dd ERS NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72.0101RW. 9PIn1 �. •,i0 a cic C. 0' ti Q� yrs J" CIA,.u, lJ THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE r-I THREE [] FIVE E~ OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED ~( ~ 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED [PUBLIC UTI LITY ~ '-q"~ Connection Verified INSTALLER .[~Septic T_~nk or [] Holding Tank Size:''-~[ ~(-~QJ~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURE~~~, TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line Nearest Lot Line WELL TO: 1 Absorption Area to nearest Lot Line 5. COMMENTS [[],~APPROV ED FOR .'~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) ~ DISAPPROVED DATE BY l~