HomeMy WebLinkAboutMCMAHON #2 BLK 11 LT 3A-1McMahon #2
Lot 3 A -1
#017-362-32
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JAN $ 8 2013
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Municipality of Anchorage
Community Development Department Page 1 of 3
On -Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-.7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP101254
PID Number: 017-362-32 ❑ New ❑� Upgrade
Name:
Lia Mattice
ABSORPTION FIELD
❑ Deep Trench ❑✓ Shallow Trench ❑ Bed ❑ Mound
Address
13060 Killey Street Anchorage, AK 99516
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
1.2 GPD/sF
9.7 Ft,
LEGAL DESCRIPTION
Depth to pipe invert from original gradeGravel
5.7 Ft.
depth beneath pipe
4.0 Ft.
Subdivision
Block Lot
McMahon No. 2
11 3A1
Fill added above original grade
0-1 Ft.
Gravel length
38 Ft.
Township Range Section
Gravel width
5Ft.
Beds: Number of Lines
Distance between lines
I Ft.
SEPARATION DISTANCES
TO
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
380One
Flz
Ft.
Well
>100'
>100'
N/A
N/A
>25'
TANK ❑+ Septic ❑ S.T.E.P. []Holding ❑Other
Manufacturer
Anchorage Tank
Capacity
1,000GaI.
Surface Water
>100'
>100'
N/A
N/A
Material
Number of compartments
Lot Line
>5'
>10'
N/A
N/A
Steel
Two
NA
--
Foundation
>5'
>10'
NIA
N/A
LIFT STATION
Manufacturer
Capacity.
Curtain Drain
None
Noted
- -
Gal.
Remarks
Pump on level at
Pump off level at
in.
High water alarm at
- In.
Pump. make and model
Electrical Inspections performedby
Installer
PIPEMATERIAL Housetotank D30Tank to
34 -.. drainfleld . D3034 -
PCN Inc.
Drainfield HDPE CO/MT D3634
Inspector A. Harala
BENCH MARK (Assumed elevation) 100.Oft
Inspection 1=� 3/17/11
dates: 2 3/17/11
Location and description - -
3" 3/18/11 41h
Lower Level Concrete Slab.
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
to
OF
Conditional Approval:
Date
4�
of 67..
* 491 .
�... N. • •s
/1.. :NH.0 •
a. %• MrCHAEI E. ANDERSON.: w
cam••.
� CE 4381
Approved
Date - -
'��I�
\�S;e
....y............ -r-. �.-,-p 1.1v v
DEVEOPMENT SERVICES DEPARTMENT Page 2 of 3
4700 Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
Permit No.: OSP101254 On -Site Wastewater Disposal System or Well Inspection Report PID No. 017-362-32
N89'53'00"E 190.00
I MCMAHON SUBDIVISION NO. 2
I LOT 3, BLOCK 11
I 43,700 S.F.
I I I
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I1.
B
S1
61.8' 61.0'
I
I
I
S265.4'
66.3' o
C4
80.5' 79.4 M
C5
51.8' 73.7' cv
M1
53.7' 71.6'
I
I
I
NOTE:
3
Second Well on Lot
00
I
I
Decommissioned in Accordance
0
with Municipal Code.
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-Existing
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Three
wen®
E
Bedroom
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a
Home
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Paved Lj
FCO
Driveway
Existing Septic Tank
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Disposed in Accordance -
With Municipal Code.
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---
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L--
---`
--
10' Utility Easement
N89'53'00"E
190.00
Existing
Absorption Trench
�1
Remains
in Tact for Possible
-
�. ......
•••••.,,
����•
�'�'
LEGEND
Reuse.
' •
SV —
Septic Vent
ff
CO —
MT —Monitor
Clean Out
Tube
PLAN
AS -BUILT
�.49th%"
10�c1 �j. .....� ��J�� Q."
f C``'
FCO
— Foundation
Clean
Out
,`-°`^rI
0 ; MICHAEL E. ANDERSON
�1
DV —
Diverter Valve
Existing
SCALE
1" = 30'
J,'., No. CE -4_381 •° �
��j�•./.,;i8.(l..••�4
E:]—
❑ —
Proposed
�0FES510�Pi��
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Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number: OSP101254 PID No. 017-362-32
103.5
U tocli U U
qGrade
inGallon
Tank96.9
_ Q
U F U
102.1 103.1
4Finished Grade
inal Ground__.__._____--._.__ _GeotextileFabric_
96.5 Drainfield Rock 96.5
92.4 �— 86.1
38' (Trench Length)
O'xE OF .<q�!
...... ,...49th...�...-..�.........p.:......
i.......................:°:`....`..
.......AEL E. ANDERSON :I
PROFILE AS-BUILT -,MICHAEL E.
�
No Scale ��10+l,.ZS.L.•• �i�
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: OSP101254
Tax Code Number: 01736232000
Work Type: Septic Upgrade
Permit Effective Dates: November 03, 2010 to November 03, 2011
Design Engineer: ANDERSON ENGINEERING
Subdivision: MCMAHON #2
Site Legal Address: MCMAHON #2 BLK 11 LT 3A-1 G:2835
Owner/Address: MATTICE DONALD E & LIA
13060 KILLEY STREET ANCHORAGE AK 995162866
Site Mailing Address: 13060 KILLEY ST, Anchorage Lot Size in Sq Ft:
Total Bedrooms:
This permit is for the construction of:
43700
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.
2/d I/ i I
oC01
1 -P -
Received
Issued By
olf jwr'X ''t 1d.
PW
Date: 11"3 -10
Date:
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
�Sf")qyi131, �; (-1
Parcel I.D. 017-362-32
Property owner(s) Lia Mattice Day phone
Mailing address 13060 Killey Street Anchorage, AK
Site address 13060 Killey Street Anchorage, AK
ip Code 99516
ip Code 99516
Legal description (Sub'd., Block & Lot) McMahon Subdivision No. 2, Block 11, Lot 3A-1
Legal description (Township, Range & Section)
Lot Size 43,700
Sq. Ft. Number of Bedrooms Three (3)
THIS APPLICATION IS FOR (® all that apply)
Absorption Field
0
Septic Tank
0
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
THIS APPLICATION IS AN:
Initial
❑
Upgrade
0
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.
(Signature of property owner or authorized agent)
Permit/Rush Fees: Waiver Fees:
Date of Payment: /0P Ll Date of Payment:
Receipt Number: t Receipt Number:
(Rev. 11/05)
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
October 26, 2010
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 Elmore Road
Anchorage, AK 99519-6650
Subject: Lot 3A-1, Block 11, McMahon Subdivision No. 2
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The existing absorption system on the subject lot has failed and must be upgraded. We
are therefore requesting a permit be issued for the upgrade of the septic system to
accommodate the three-bedroom home on the lot. The attached Site Plan and backup
documentation identify the location and configuration of the existing and proposed
septic system. The existing 1,250 Gallon Septic Tank will be replaced with a new 1,000
Gallon Septic Tank. The existing tank will be decommissioned in accordance with
Municipal Code. The existing absorption trench will be left intact and tied to the new
system with a flow diverter valve. Also identified on the plans are the locations of the
existing well on this and adjacent lots and adjacent septic systems. No conflicts exist
between the proposed septic system and the wells on this or adjacent lots. A second
abandoned well is also located on this lot. It will be decommissioned in accordance
with Municipal Code as part of this project. Protective radii are shown to the adjacent
wells. Drainage arrows are shown indicating the current drainage patterns. The
drainage patterns will be maintained after construction.
A test hole was recently placed on the lot which indicated Gravel with Silt and Sand
(GM/GW). The percolation test performed on the underlying material resulted in an
absorption rate of 4 minutes per inch. We have designed the new trench to be within
the 30' radius of the location of the test hole with an application rate of 1.2 gallons per
date per square foot. We are proposing to place a 38' long trench by 5' wide with a 4'
effective depth. The total depth of the system will be 8.5' with the distribution line at
4.5' below the existing surface. A minimum of 3' of fill will be placed over the new
absorption trench and 4' over the new septic tank.
Lot 3A-1, Block 11, McMahon No. 2
November 2, 2010
Page Two
The ground surface on the lot slopes slightly to the southeast in the area of the
absorption trenches. The trenches will be placed parallel to the contours of the ground
as much as possible and in conformance with design criteria. A minimum of 100' will be
maintained between all components of the septic system and the proposed well and
from any surface water in the area.
If the system is constructed in accordance with our design the following statements
apply:
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
;•• 49th_•°.
MICHAEL E. ANDERSON Z;I•• NO. CE -4381 Zai
��TFQF *1.... J...... • FC�4W
TAIGA DRIVE
1 A-1 1 0 2
O
Existing
1 � Well
0
18 17
A-1 Existing O
Well
XX
AKULA DRIVE
3A-1
City Water
and Sewer
w 10
Existlling 1 2
We
J
J
Y
All � �1
49th .
................................................
MICHAEL E. ANDERSON
% No. CE 4381 ' =i
�.pROFESS\Pi��•
A-1
Existing
Well
AREA MAP
SCALE 1" = 100'
7
LEYDEN DRIVE
101
LEGEND
N89°53'00"E 190.00
MCMAHON SUBDIVISION NO. 2
LOT 3, BLOCK 11
43,700 S.F. /
\
\\ NOTE:
No Areas of Excessive Slope
or Surface Water are Within
100' of Any Part of the New
Septic System.
1
1
I
I
I
d
"I
of
38' Long x 5' Wide
I
x 4 Effective Depth
I Abs rption Trench
I
1
Co \
MT \\
Place New 1,000
5� Septic Tank, and
Tank 'Cleanouts.
i
CO
Th ree
Bedroom
Home
lion
Post
07
0
0
i�
0
0
0
z
Decommission
Existing Well in
Existing Accordance With
Well Municipal Code
w
Paved W
Driveway
07
FtJ
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L I I Y
N
Dispose of Exist" g Tank
— Dv In Accordance With
\�s Municipal Code.
THA
�J L-- """-----------
10' Utility Easement
SV —
Septic Vent
CO —
Clean Out
E
Monitor Tube
a
— Foundation Clean Out
DV —
Diverter Valve
O
�N
o
LEGEND
N89°53'00"E 190.00
MCMAHON SUBDIVISION NO. 2
LOT 3, BLOCK 11
43,700 S.F. /
\
\\ NOTE:
No Areas of Excessive Slope
or Surface Water are Within
100' of Any Part of the New
Septic System.
1
1
I
I
I
d
"I
of
38' Long x 5' Wide
I
x 4 Effective Depth
I Abs rption Trench
I
1
Co \
MT \\
Place New 1,000
5� Septic Tank, and
Tank 'Cleanouts.
i
CO
Th ree
Bedroom
Home
lion
Post
07
0
0
i�
0
0
0
z
Decommission
Existing Well in
Existing Accordance With
Well Municipal Code
w
Paved W
Driveway
07
FtJ
_I
L I I Y
N
Dispose of Exist" g Tank
— Dv In Accordance With
\�s Municipal Code.
THA
�J L-- """-----------
10' Utility Easement
SV —
Septic Vent
CO —
Clean Out
MT —
Monitor Tube
FCO
— Foundation Clean Out
DV —
Diverter Valve
❑ — Existing
❑ — Proposed
N89.53'00"E 190.00 NOTE
100' Well Radius to be
Staked by a Registered
Land Surveyor Prior to
Construction.
SITE PLAN
SCALE 1 " = 30'
'
49th
y -,
MICHAEL E. ANDERSON
#-�( No. CE -4381 -*Q
i
••����,pROFESS��Pi• ••
LOT 3A-1, BLOCK 11, MCMAHON
SUBDIVISION, ADDN. NO. 2
DESIGN FACTORS: SYSTEM REQUIREMENTS
Three Bedroom Home 5' Wide Trench System
Perc. Rate: 1-5 Min./Inch 1,000 Gallon Septic Tank
Application Rate: 1.2 GPD/SF 4' Drainfield Rock
3 Bedrooms X 150 GPD/1.2 GPD/SF (Application Rate) = 375 SF Absorption Area
375 SF/5 SF/LF-.5 (Red. Factor) = 37.5 LF Trench Length
THEREFORE: Construct a 38' Long x 5' Wide x 4' Effective Depth Absorption Trench at the
Location Shown. Flow Line Elevation in Trench to be 4'6" Below Original Ground Surface. Total Depth
to be 8.5' Below Existing Ground. Provide 4' Cover Over Septic Tank and 3' Cover Over Absorption
Trench. Place a Flow Diverter Valve to Tie in Existing Trench.
4'0" Natural
Backfill
6"
\O
4'0"
5'
Geotextile
Fabric
4" Perforated
PVC (Holes Down)
Drainfield Rock
TYPICAL 5' WIDE TRENCH SECTION
(NO SCALE)
NOTE: Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 4' Separation From Groundwater.
Minimum 100' Separation From Wells in the Area.
Minimum 100' Separation From Surface Water or Streams.
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
4700 BRAGAW STREET ANCHORAGE, AK 99519-6650
DEPTH
(feet)
1-
2-
3-
4-
5-
6-
7-
8-
9-
10-
11
12-
13-
14-
15-
16-
17-
18-
19-
20 -
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION: LOT 3, BLOCK 11, MCMAHON SUB. No. 2
PERFORMED FOR: L I A M ATT I CE
DATE: 10/31/2010 PROJECT No.:
PARCEL ID#: TECHNICIAN: A. HARALA
TEST HOLE A I
OB/OG
d
a
SILTY GRAVEL
d WITH SAND
d_ GM
V
.d
d
WELL GRADED GRAVEL
GW
a
d
SLOPE
N
0
SITE PLAN
SEE SITE PLAN
WAS GROUND WATER ENCOUNTERED? No
IF YES @ WHAT DEPTH? S
DEPTH OF WATER AFTER MONITORING: NONE LO 2%
d DATE OF MONITORING: 11/2/2010
a
_ •n
a
d
BOH @ 16'
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DEPTH To
WATER
(INCHES)
NET DROP
(INCHES)
TEST HOLE PRESOAKED PRIOR TO TESTING:
10/31
1
1:14/1:24
10
1.63"/4.25"
2.62"
2
1:25/1:35
10
1.50"/4.00"
2.50"
3
1:36/1:46
10
1.75"/4.00"
2.25"
4
1:47/1:57
10
1.50"/3.75"
2.25"
5
1:58/2:08
1 10
1.63"/4.13"
2.50"
6
2:09/2:19
10
1.63"/4.13"
2.50"
PERCOLATION RATE: 4.0 (MIN/INCH) PERC. HOLE DIA. -E-(INCHES)
TEST RUN BETWEEN: 5.5 FT. and 6.5 FT.
COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST.
TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE: 111212010
t ? MUNICIPALITY OF ANCHORAGE .
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage. Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME .
[] UPGRADE
LOCATION / NO, OF BEDROOMS
- ' Absorption area Dwelling PERMI~ ~
~ DISTAN~ TO: Well/~ i /~O f C~ [
~Z< Manufacturer~. '~ ~ No. of compartments ~
~ ~ Liq, capacity in gallons Inside length Liquid depth
/~O IF HOMEMADE:
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O Z ~ Manufacturer Materia~ Liquid capacity in gagons
;~ O ~ DISTANCE TO: We~ [ Founda~ ¢~ Nearest lot I~ / PERMIT NO.
Length of each lin~ Total lengt hwJd~
~-- No. of lines / *¢ ' h~i. Trenc~' inches Distance between lines
" .~ Top of tile to finish grade., Material beneath tile~._...~ inches Total effective ~s~n area
Length Width Depth PERMIT NO.
~ ~ Type of crib ~ Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth DriJler Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(a)
~ DISTANCE TO:
OTHER.,t ~r~
PIPE MATERIALS ~ ~5 ~O~ ~/.
SOIL tES~ RATI~
INSTALLER ~
REMARKS ~
APPROVED / DATE LEGAL.
::i: ]: f::ihi F:'F:IHXI.XF[R N Z'FH THE F::E:QUZF::?"~E:N'!":'~; F:'O~::: ON.-:::;Z'T'E :~:;!::!,.~i::::F::::i. Fihi';::, FiEL..L:::i: .,'-:~; :~::E'T'
!::"OF::'!"i-i E','.~' "ii-~ .fdUF,i Z C '~ !::'i:::i~.. :i. '?4 Cq:
;:::: :? i-,.! ): L.L. :i: N::;T!qLL. %'.-.![:: :::?.:.'~;'i"EP! ]: f.,! F:C:COF:DF:i.~CE N Z TH THE
::::: :( L.!F,!F:,?:::..':~:::i;TF:N[:, ThiFF!' 'THF: O?+.-S):TE ::':::?::!,.!E:F: %VTT¢:!'q ?':.h::!"v' !:~:Ei:.:!i..~):F:E:
)( ']:};::; [ iii:}'{':, !~¢.:.< d, '~ ' .................. [L3'T'F;'.. _ -
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99502 '276~2221'
SOILS LOG- PERCOLATION TEST
SOl LS LOG
PERCOLATION
TEST
PERFORMED FOR: ~ ~-~ ]~"! ~'~
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
SITE PLAN
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
E ~
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
{minutes/inch)
TEST RUN BETWEEN
f
FT AND FT
CERTIFIED BY:
72-008 (7/76)
~o ~o
''~ ~" (J ' DEPT. OF-/'i~ALTH &
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL ?~;OTECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
~ ~/~ 825LStroet-Anohorage, Alaska 99501 Fff[3 1 lgTg
~ ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720 RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be proce~ed. Please allow ten (10) days for processing.
1. PRO~RTY OWNER ~ J PHONE
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
MAILING ADDRESS
MAILING ADD~ESS
4. REALTOR/AGENT ~ PHONE
I
MAILING A~D~SS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One [] Four
[] Two [] Five
~ Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.} /~DFL~ /371 '/~)~ J~P ~
**If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
I THIS SIDE FOR OFFICIAL USE ONLY ' ,, "' ~"'
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
'ONE ~ THREE [] FIVE E~] OTHER
SINGLE
FAMILY
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER '
2. WATER SUPPLY ~,~ ~),~(A,(~
~ INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRI LL~'ED
[] pUBLIC UTILITY
Connection Verified LOG RECEIVED~,~Ii~/~ ~ ~n'~)
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
~ INDIVl DUAL/ON -SITE DATE INSTALLED
Connection Verified INSTALLER
~Septic Tank or E~ Holding Tank ~'~ ~.~.~
Size: I~'~ If Tank is homemade SOILS RA~'~ING ,
give dimensions: ) ~'~.
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/HoldingTank. Absorption Area ISewer Line Nearest Lot Line
I
Absorption Area to nearest Lot Line
5, COMMENTS
I~"'APPROV ED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
LEGAL DESCRIPTION
72-010 (Rev, 3/78)