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HomeMy WebLinkAboutTIMBERLUX #1 BLK B LT 7AN k tic Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~L'Jcl~O~°l PID Number: O1~ 2-HOG Nam.: KELSO~' )~AVJlD ¢ ~A Wastewater System: D New ~Upgrade Address: ~00 ~B~IT C~ ~0. ~¢/~ ABSORPTION FIELD Phone: ~- ~ ~ No. of Bedrooms: ~ ~eep Trench O Shallow Trench D Bed ~ Mound D Other LEGAL DESCRIPTION soi, Rating: Total Depth fro~ original grade: ~.~ GPD/Sq. Ft ~,~ t Lot: ~ Block:~~B~L~Subdiv~i°n: ~ ( ~epthtopipeboHomfromoriginalgrade:~,~ Ft Graveldepth ~eath pipe Ft. Township: ~ I Range: ISection: ~ Fill added above original grade: Gravel length: H ~ t WELL: ~ w[~J~New ~ ~,~r~ Upgrade iravelwidth: ~.5' Ft. II ~ Ft. 1~4T~ Ft Ft. ~O Y,e,d: ,~m~S~: ~ C~i,~ ~,h~*b0~ ~o~d: TANK SEPARATION DISTANCES a s~pt~ ~ Holding ~S.T.E.P. S~,~c~/oo'~/oo'~ ~ ~ ~ LIFT STATION Line 7~~ Io~ ~ / ~ ~ ' [~ Foundation ~' ~' ~' ~ ~ 'Pump °n" 'eve' at: I"Pump°ff"~evelat IHigh wa~er a'arm at: ~. Remarks: BENCH MARK Inspections performed~4 E,¢, .i,,, Leap .~, N~.,~ Dates: 1st ~gl~ River, Alaska g95~ 2nd. Department of Health and Human Se~ices approval Reviewed and approved by: Date'./2 -/~ -?~ "~- 72-013 (Rev. 9/91) MOA 25 Permit No. SW950501 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O, Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report LOT 7A, 13LOCK 13, TIMBERLUX S/D #1 01827106 Legal Description: PID No.: ST1 ST2 MT1 FINAL GRADE ~ ~ ~ /--108.{ · 1500 GAL. . $.T.E P, SYST ]M 105.6'~ 99.6'-- ~ · 94.0' WA ~ER FOUND 9- [9-95  FCO 41 ' 24' ST1 57' ST2 62' 40' MH 63' 42' ~ MT1 99' 28' 12/05/1995 ~:52 AND S EHG!HEERING PAGE 01 Lo~lttion (addti~! oh ~ow~ ANCHORAGE ALAS~ S~e el e~g-~ep~ o~ Date of com~letio~ ~'~ 2J ~ELL DRY ~ROUIED gro~ Sorface ~ 2 TO~ 4~ COBBLES AND SOUL oE~S ~TO ~ ~,~_~ 83 ,-- ~" 8 ?_TO_.~ ~-97 TO-.-4115___ .... TO, ~__ -- ---.-._TO . _TO._____~_ --__TO____ 1-CUSTOMER ID:O gCl 19'95 8:18 No.O01 P.02 PAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P~O. BOX 196650~ 825 "L~' STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW950301 DESIGN ENGINEER:S & S ENGINEERING O~NER NAME:KELSOE DAVID W & JULIA K O~NER ADDRESS:4700 RABBIT CREEK RD ANCHORAGE, ALASKA 99516 DATE ISSUED: 9/28/95 EXPIRATION DATE: PARCEL ID:01827106 LEGAL DESCRIPTION: TIMBERLUX #1 BLK B LT 7A LOT SIZE: 40000 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM 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 (iSAACS0) . 3. THE ENGINEER MUST NOTIFY DEHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. 1 OF 9/28/96 SPECIAL PROVISIONS: RECEIVED BY:.~~Y / ROBERT C. COWAN, R E, ROBERTA, SHAFER, RE. September 18, 1995 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 S~'VER & WATER iNSPECTION ENGtNEERINGSTUDIES ANC~ REPOFCrS WELL INSPECTION & FLOWTEST SITE PLANS ROAO DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 7A, Block B, Timberlux S/D ~1 Request you issue a permit to drill a well and upgrade the septic system serving the four bedroom house on the referenced property. We also request a separation distance waiver of &O feet to the cutbank south of the proposed system. A test hole was excavated and a percolation test performed in the area of the proposed upgrade. The approximate location of the test hole is located on the attached site plan. At the time of excavation water was encountered at fifteen feet in the test hole and after seven day ground water monitoring, water was found at ~o,~r~ feet. Attached is the proposed upgrade design. We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. Enclosure 17034 NORTH EAGLE RIVER LOOP SUITE 204 EAGLE RIVER, ALASKA 99577 ,~ = 50' SITE PLAN UPGRADE <~c ,.~.T.S.~^~ '~" I DETAIL I~ o Development Services Department Phone: 907-343-7904 4n -Site Water & Wastewater Section \� _ -/� Fax: 907-343-7997 Pump Installation Log VTell Drilling Permit Number: Date of Issue: - - Parcel Identification Number: Legal Description Block Lot Property Owner Fume & Address: TMLA_ 911— AG—Z4 Pump Installation Date: Pump Intake Depth Below Top of Well Casing: SS- feet Pump Manufacturer's Name: Pump Model: AO Purnp Site: �( hp Pitless Adapter Burial Depth: feet Pitless Adapter Manufacturer's name: Pitless Adapter Installer: Well Disinfected Upon Co etion? k yes ❑ No Method of Disinfection: Comments: Pump Installer Name: ANCHORAGE WELL & PUMP SERVICE 7640 King Street Anchorage, AK 99518 Company: PH: (907) 243-0740 Mailing Address: City: State: zip: Attention: The pump installer shall provide a.pump installation log, to On-site within 30 days of pump installation. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: D~V ~ 0 j.~*/~ ,, ~'~1~_ LEGAL DESCRIPTION: T/~O/~,~,~ ~_~/ )~' J'/~&'~ DATE PERFORMED:' Township, Range, Se~ion: 1 2 3 4 5- 7 8 9 10 11 12 13 14 15 16 17- 18- 19- 20- WAS GROUND WATER ENCOUNTERED7 IF YES, ATWHAT ) ~ O DEPTH? p E SLOPE SITE PLAN Depth Io Water ADer , // Monitoring? / ¢¢ Dale: ~ q/q3~ Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~" ~ {minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND ~ FT COMMENTS 0d~ ~ ,~ "~' ~%//_.~ ~) E~, " - ---~ ...... ~ ~ t ~ SPERFORMEDIN 72~008 (Rev. 4/~) ~a~e Rt~r, Ale~a ~  t " 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 PHONE ,~] NEW LEGAL DESCRIPTION ~ J A~sorption 8feb D~elling PE~IT NO. ~ Manufacturer ~r~e ~ Material ~t~ [ No. ofcom~ments Eiq. capaci~n ~l~s IF HOME.DE: ,ns~ Width Liquid depth ~ uOZ ~ DISTANCE TO: WOII~ /~ Dwelling PERMIT NO. O Z ~ Manufacturer Material Liquid capacity in gallons ~ Well Foundation ~. Nearestlotline ~5~ PERMITNO. ~Oq ~3 ~ DISTANCE TO: I O~ e No. of lines i Length of each lines Total length of Hne~ ~ Trench wiO~ ~ Diszance between lines ~ TOp of t'la tO finish ~rade ~1 ~ 'riches Total effective a o aroa Lon~th ~idth Depth PEBMIT ~0. ~ ~ Type of crib [~ Crib diameter Crib depth Total effective absorption area ~ WelJ Building foundation Nearest ]et line ~ DISTANCE TO: ~ 3~ Depth Driller Distance to lot~e~ PERMITNO.~O~~ 9~STA~CE TO:~.i~di.g fou.a~ Se~r ~in~ ¢ ~ Sep~io t~,~ +1 ~ ~ Absorption ~ f 0 ~ OTHER PIPE MATERIALS SOl L TEBT flATIN~ INSTALLER ~ ~, ~ ( 72~)13 (Rev, PERMIT NO. MLINI[:IPALITY DEPARTMENT~825 HELL ( ?80423 RPPLICRNT DA¥ID KELSOE LOCBTION RABBIT CREEK ROAD OF 8NC:HCIRRGE HERLTH AMI) EN'qIRONMENTRLi~'.OTECTION ~ STREET, 8NCHORAGE, RK. 9~D1 224-4720 ON--S I TE SEWER 303i WEST 4~D RPT #2 PERt'I I T LEGBL L 78 BLOCK "B" TIMBERLUX SUB. LOT SIZE 44i~3 Sg~LBRE FEET TYPE OF SOIL 8BSORBTION SYSTEM IS~ TRENCH MAXI~'IUM NUMBER OF BEDROOMS = 3 SOIL RATING (SQ FT?BR>= THE REQUIRED SIZE OF THE SOIL 8BSORPTION SYSTEM IS: C'EPTH= 8 LENGTH---- 51 G R F~'-ZEL DEPTH= 4. 5 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRBINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFBCE OF THE GROUND AND THE BOTTOM OF THE E~CBVRTION (IN FEET>. THERE IS NO SET WIDTH FOR TRENCHES. THE GRBVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE 8ND THE BOTTOM OF THE E~CBVBTION (IN FEET>. REL-4LI I RED SEPT I C TR~HK S I ZE= 1000 GI-]LL~31'-.IS PERMIT RPPLICANT HRS THE RESPONSIBILITY TO INFORM THIS DEPBRTMENT DURING THE INSTALLRTION INSPECTIONS OF RNY WELLS ADJACENT TO THIS PROPERTY 8ND THE NUMBER OF RESIDENCES THAT THE WELL WILL SER~'E. T~O (: 2 ) I NSPEC:T IONS RRE REQU I RED BRCKFILLING OF RNY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS DEPBRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL RND RNY ON-SITE SEWBGE DISPOSBL SYSTEM IS 100 FEET FOR 8 PRIVBTE WELb OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MBY 8PPLY~ SPECIFICRTIONS 8ND CONSTRUCTION DIBGRRMS 8RE 8VBILABLE TO INSURE PROPER INSTBLLBTION. PERt1 I T EXP I RES DECEMBER 3:1.. 1'_-::~?:3 I CERTIFY THRT 1: I 8M FRMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY THE MUNICIPBLITY OF RNCHORBGE. 2: I WILL INSTRLL THE SYSTEM IN 8CCORDRNCE WITH THE CODES. -~: I UNDERSTRND THAT THE ON-SITE SEWER SYSTEM MBY REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THBN 3 BEDROOMS. SIGNED: .... .................... APPLICANT DA~/~D KELSOE .., ._ /-- , Hay 18, 1978 R&M No. 851118 Mr. Dave Kelsoe 3031 West 43rd, Apartment 2 Anchorage, Alaska 99503 Subject: Soil Investigation for Sanitary Sewer System, Lot 7A, Block B, Timberlux Subdivision, Anchorage, Alaska Dear Mr. Kelsoe: At your request of May 15, 1978, we conducted a subsurface soils investi- gation at the proposed location of the sanitary sewer system on the subject lot. The investigation complied with those procedures required by the Municipality of Anchorage Department of Health and Environmental Protection. This investigation, which was accomplished on May 18, 1978, consisted of a test hole excavated to a depth of 15 feet below the existing ground surface. The test hole was sited according to your instructions and its location is shown in attached Drawing A-01. Excavation was accomplished with a backhoe. A sample was taken at the depths shown on the soils log in Drawing A-01. The sample will be held in storage at our lab for approximately six months. In addition, all material excavated was continuously monitored by an experienced engineering geologist. The topography at the excavation site is generally gently-sloping. At the time of the investigation the site had original vegetation consisting of spruce and mosses. The top of the test hole was located at original ground surface. The soils encountered in the excavation are shown in the test hole log in Drawing A-O1. This log displays specific conditions encountered at the test location. However, subsurface conditions may vary in other parts of the lot without any apparent surficial evidence of the change. Groundwater was not encountered. Bedrock was not encountered. At the time the hole was excavated seasonal frost was not present. Permafrost was not encountered. Based on the visual classification of the soil and the requirements set forth by the Muncipality of Anchorage, a percolation test was not necessary within the test hole on the subject lot. May 18, 1978 Mr. Dave Kelsoe Page -2- We appreciated this opportunity to be of service to you. Please contact us if you have any questions concerning this letter or if we can be of addi- tional service. Very truly yours, R&M CONSULTANTS, INC. Lynne Kosikowski Staff Geologist Jim McCaslin Brown, Ph.D. Project Manager Ji~:LK/kah BORING NUMBER 1 Date Completed:5-18-78 LOCATION SKETCH No Scale ~ ~.~ o4~'~ so~L DESC.,PT,ON ~ ~ ORG~IC ~TE~ 0.75' _ :do' · ~.o'., Light Brown, Dry, Medium Dense ~:,? 3.01 ~BIT C~EK ROAD ~.~ s~ G~ 3.5' -- ~..~ S~DY G~B ~/SO~ COBB~S ~o~' Occasional Boulder LOT 7A ~2~ Grayish-brown, D~ to Slightly ~.~o. i'~ ~ist, Medi~ Dense to Dense IO '~'~ NOT[; DISTANCES SHOWN ARE ~PPROXlMATE AND HAVE NOT BEEN MEASURED aY SURVEYING METHODS, :.~.t~'"~ EXPLANATION ~'.'o >?:.. ~ ORGANIC MATERIAL ;G~' ~11 L~ffle Visible Ice 0:10' Vx -- ~-o'~ SS,72,5Z 1°/o,85.9 pcf -15. 15.0 ' TD ~ SA~LWR -- 12.0' After Boring TYPICAL SOILS LOG ~ SAMPLER TYPE SYMBOLS ~ OR~ANIC SOiL SYMBOLS [ CDWN.,~ 1 ~ =, .~ C K O. ~j~.Y~. R&M CONSULTANTS, C~L'~ ~;ov~ l/ SOILS LOG Lot 7A, Block B Timberlux Subdivision Anchorage, Alaska /""°J'"°' 851118~ [DWG, NO. A-01 ,J " DRILLING LOG David 'Kelsoe " Use of Well Location (address of: Township, Range, Section, if known; or distance,main read LO~'~ 7A Block B T~mberlmx Subdfvision?~n?noro~e ?{]:-S~e o~ c~g Depth of ~oIe 270 'feet Case~¢o ....87.10 fee~ ,~" Static water level ~0 ft. z(above) (below) land surface. Finish of well (check one) *ope~ end (~m--); ': ..; .'. ,.-.-: Scmen( ); Perforated ( xX '-~ )' -~-.:?":: ?, .':--'"' ,:.? - _.'~r'./ :Describe screen or perforation ? shot p,~rFnrnt{nns; F~om -:'Well pumping test at 3 gallons per ~)'; (minute) for ! hours with '~io"' ftc: . of drawdown from static level. ~ : %:~: Date of completm~ 8/2 ~/, ,3 .~ - WELL Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness E:c!~ tin~, well -- TO. Bedrock, zht ~ra~ TO TO TO- MUNICIPALITY OF ANCHORAGE 0 �, 11 Development Services DepartmentPhone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 018-271-06 Legal description TIMBERLUX #1 BLK B LT 7A Site address 4700 Rabbit Creek Rd Current property owner(s) Mize Expiration Date: 2► �Z X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: 0 Original Certificate Date: 2/21/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory X Absorption Field Advisory Nitrate Advisory Tank Age Advisory X Arsenic Advisory Other COSA Approval_June 2022 MMHMIP UTY OF AiqcHORAGE Development Services Department =7 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 018-271-06 Complete legal description Timberlux Block B Lot 7A Location (site address) 4700 Rabbit Creek RD. Current property owner(s) ,Joshua & Samantha Mi .e Day phone 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: [fl Private Well—❑ -Private Well serving -2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ® Water Storage *2 Private Wells 4. TYPE OF WASTEWATER DISPOSAL: © Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ® Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 27 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed kZ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ 5Waiver Fee $ Date of Payment 0/h � ()Qat Date of Payment COSA # �SC��7i �� Waiver # COSA Application—June 2022 Legal Description: Timberlux 91 Block B Lot 7A Parcel ID: 018-271-06 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA 0 Well log is filed with Onsite (or attached) Well production at time of test0.i0/0.529pm Date drilled * _Total depth 270/405 ft Water storage tank volume 1000 gallons Cased to 87/98 ft Well disinfected for coliform test? ❑ Yes Q No ❑✓ Sanitary seal is functioning correctly 91 Coliform bacteria is Negative © Wires are properly protected Nitrate mg/L 0 Nitrate less than MRL (ND) Casing height (above ground) 31/25 in Arsenic ug/L Q Arsenic less than MRL (ND) Date of flow test for COSH 8/29/22 Collected by Amterra Consulting Static water level at beginning of test 61/61 ft. Date 8/24/22 Es i'rt- o 2,/2(2 02� Comments * 2 wells on lot (N well) 8/25/1978 (S well) 11/9/1995 B. TANK DATA C. LIFT STATION --- ---Measured operating -fluid level in septic -tank 42"--- - n Required maintenance completed Date of pumping 9/15/22 Age of lift station 27 years ❑ Required maintenance completed, if AWWTS Lift station material Steel Comments: Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 16/16/1995 0 ALL standpipes present per record drawing Total measured depth from grade 8.2 ft (max) Measured depth to pipe invert from grade ft (min) J❑ N/A - pressurized field. ❑ Per record drawings, field is insulated. ❑ Monitor tubes go to bottom of effective. If not, state depth into effective 4.7 ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: COSA Checklist—June 2022 Adequacy test date 8/29/22 Results 0 Pass Fluid depth prior to test 28 in Water added 600 gal New fluid depth 50 in Elapsed time G00 min Final fluid depth 28 in Absorption rate 600 gpd FIELD STATUS - POST RECOVERY Effective depth (per record drawings) 72 in Effective depth used 43 in Effective depth remaining 29 in E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' ✓❑ Yes if No Community Sewer Manhole/Cleanout > 100' ✓❑ Yes if No ft ✓❑ Yes if No ft Neighboring Tank > 100' ✓❑ Yes if No ft Private Sewer/Septic Line > 25' Q Yes if No ft Absorption Field on Lot > 100' 7 Yes if No ft Holding Tank > 100' Q Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' 0 Yes if No ft 0 Yes if No ft ft If tank or field is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' © Yes if No ft 0 Yes if No ft ❑ N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' ✓❑ Yes if No ft Surface Water > 100' 0 Yes if No ft Tank to Property Line > 5' n Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' ❑✓ Yes if No ft Private Wells > 100' Q Yes if No ft Water Main > 10' ✓❑ Yes if No ft Community Wells > 200' © Yes if No ft Water Service Line > 10' © Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Areterra Consultin Engineer's Printed Name Kenneth Duffus Engineer's Comments: This investigation was completed in compliance with ADEC and NIDA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The now and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. COSA Checklist June 2022 Phone (907)-696-6111 Date ll` —z MUNICIPALITY" "ANCHORAGE Development Service! � Department Phone: 907-3e70N. On -Sita Water & Wasi Dwater Section Fax: 907_34'r7997 Lift StationIPUrnp Vault Maintenance.Log Owner&/7� �-o'/ �e,,� Street Address Phone&)(,,`'! Legal PID___ -Sludge level __Linclhes -Pumping: required y?t- 6_0D, -Pumping completed Pump basket cleanec -Effluent filter cleaned -Control floats cleanecProper float settings confirmed -Operation satisfactory -Dedicated electrical a arm circuit r -�­+, no o -Audible and visual alarm inside dwelling -Alarm system operatirr at 6--V6 0- t�stfqqtpry -Ground water intrusio i at riser to tank connection ri, 6 -Ground water intrusic i around pipe penetrations ores -Weep hole functional nn -Manhole lid: Furictic�naf Insulated Properly Secured All manufacturer required inspections and maintenance completect-, Y_Q s 1 110 Comments: ................... I.— ...... ­__ ...... - ....... ........ ....................... ......... ........... ........ .............. ......... ...... .............. ....... .......... . ....... ...... ....................... .......... !NV, f Technician LL.L �c Date of maintenance," Conipany Signature V Date Septic Tank Advisory Certificate of On -Site Systems Approval #OSC 221456 Subdivision: Timberlux #1 Block B lot 7A Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this COSA / property is 27 years old. A leaking septic tank may be a source of contamination to the aquifer. Typical replacement costs range from $15,000 to $117,000 This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of a 16 -year-old septic tank in failure and should be replaced. Mailing Address P ,O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www. ci. anchorage. ak. us (907) 343-7904 Water Well Advisory Certificate of On -Site Systems Approval (COSA) # OSC221456 During a recent COSA on-site inspection and test of the potable water supply well on -Block B, Lot 7A of Timberlux# 1 subdivision, the well's productivity was determined to be .62 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 4 -bedroom residence is .41 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. MUNICIPALITY OF Development Services Department On -Site Water & Wastewater Section I;�>tll�iyE:l�xIIQiI:1 EPLANS ANCHORAGE Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: �,^ Complete legal description TIMBERLUX #1 -BLOCK B, LOT 7A Location (site address) 4700 RABBIT CREEK ROAD, ANCHORAGE, AK 99516 Current property owner(s) WARD & SANDY HEPPER Day pRhone Mailing address 4700 RABBIT CREEK ROAD, ANCHORAGE, AK 99516 Real estate agent 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS 4. TYPE OF WATER SUPPLY: Private Well Water Storage Community Well Public Water System 2 (413R SEPTIC) Day phone t 1 TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Holding Tank. ❑ ❑ Community ❑ ❑ Public Sewer.. ❑ Waiver request for: .i Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: t. COSA Fee $ S'S Waiver Fee $ Date of Payment 31rglao,;L/o Receipt Number Q oQ /2y Date of Payment Receipt Number COSA # 05 C 2011&3 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY ANCHORAGE AK 99516 Engineer's Printed Name CURTIS HUFFMAN PE Date 3/18/2020 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, ���►�®���1. local soil characteristics, groundwater levels that may fluctuate during the year, quality of ! ® 1�1 construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to ���• • • • �" �! these various and dynamic characteristics and are outside the control of the evaluator of the /" Q,1 •• •;� (% well and septic system. Therefore, any estimate of how long a system will function satisfactory; TH : • • ••. for current or future occupants or guarantee that no unseen encroachments, deficiencies or • • discrepancies exist can be given by First Water Consulting & FWfS . l .... ........ 6. DSD SIGNATURE (� :• • Curtis Huffman �� �°F�; • CE 128991 0�* System #1 Approved for bedrooms islF�• •l1a/2oza •��� _Y_ �l Essin�P�.� System #2 Approved for bedrooms F°pROFESSO �����- Disapproved Conditional approval for bedrooms, with the following stipulations: By: ( V�-�. l _ Original Certificate Date: -- 2-�--Z CD 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 fl i Legal Description: TIMBERLUX #1 BLOCK B LOT 7A Parcel ID: 018-271-06 If more than 1 septic system on lot: COSA Checklist # _of A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 8/25/1978 (N WELL) & 11/9/1995 (S WELL) Total depth 270 / 405 ft Cased to 87 / 98 ft (INTO BEDROCK) ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA 3/18/2020 Static water level at beginning of test 72 / 68 ft. Well production at time of test 0.34+ / 0.48 Qpm Comments B. TANK DATA Age of tank(s) 24.5 years Tank type/material STEP / STEEL Measured operating fluid level in septic tank 43" ® Standpipes/foundation cleanout per record drawing Date of pumping 3/17/2020 D. ABSORPTION FIELD DATA Which system tested (date installed) 10/10/1995 ® ALL standpipes present per record drawing Total measured depth from grade 8 ft (max) Measured depth to pipe invert from grade _ft (min) ® N/A — pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective *4_5' Structure served by this system _ Water storage tank volume 1000 gallons Well disinfected for coliform test? ❑ Yes ® Nc ® Coliform bacteria is Negative Nitrate mg/L ® Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) Collected by Fw�cS Date of Sample 3/19/2020 - C. LIFT STATION ® Required maintenance completed Age of lift station 24.5 years Lift station material STEEL Comments: See attached MOA advisory. Adequacy test date 1/20/2020 Results Z. Pass For 4 bedrooms Fluid depth prior to test 0 in Water added 870 gal New depth 41 in Elapsed time 360 min ® Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 600 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) If yes, enter date Gallons introduced gallons FWC5 Comments/Deficiencies: *Assumed per visual observations and existing docs IR. .: E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ® Yes if No ft Wells on Adjacent Lots: Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' ® Yes if No _ ft Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' Surface Water > 100' ® Yes Animal Containment > 50' ® Yes if No ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ft ft ft ft ft ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No _ Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No —ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No —ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS *Absorption field is along edge / under driveway with no known issues. G. ENGINEER'S CERTIFICATION I certify that l 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. Or—w . i . ..%--.z ..... urtis Huffman f % CE 128991 •��@,�� ft ft ZD r, N \ N w \ o 0 Lot 9A 2.0• . 6.2' CANT RABBIT CREEK ROAD WE.p/E: [VE 13/E 0/E WE /E 0!E -- W \ N . 35.4 a u '4'i SEPTIC 5.4 / \ PIPES Lot 7A 40,000 s.f. PER MUNICIPAL RECORDS — M60— MEANDER LINE PER MUNI GIS ........... MANHOLE Lot 5a Lot 7 NOTE: DRIVEWAY LOCATION IS APPROXIMATE DUE TO SNOW COVER. PLOT PLAN _ AS BUILT —XL SCALE 1" —=40' GRID SW 3136 Project No. 20-112/R1 _ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone ooO�OpO (907) 522-4625 Fax ,moo F A Opp Professional Land Surveyors kenOlongsurvey.com o (( // jonafhanOlongsurvey.com DOP �! """' `:,9S4�4o I hereby certify that i have surveyed the following described property �'� Lot 7A, Block B. Unit No. 1, TIMBERLUX SUBDIVISION (Plat No. 64-75) v * ..49TH ' �f=4p Seward Recording District, Alaska, and that the improvements situated thereon ore within �' "' • • •' •' • •' L the property lines and do not encroach onto the property adjacent thereto, that no Q � improvements on the property lying adjacent thereto encroach on the surveyed premises Q� KEN tTTH .; ....0 G and that there are no roadways, transmission lines or other visible , o G 2te easements on sold property except as Indicated hereon. Qa 0 o LS -520.• Dated this the L,16, Day of i`/1.nEktA at Anchorage, Alaska 444QgR0'1z3510NP"-�Q� It Is the responsibility of the owner to determine the existence of any easements, �Opppooc covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 Well Water Advisory Certificate of On -Site Systems Approval # OSC201103 Subdivision: Timberlux#1 BLK B Lot 7A 907-343-7904 Fax: 343-7997 This well's productivity was determined to be .82 gallons per minute. The minimum well productivity required under (AMC 15.55) for a 2 -bedroom residence is .21 gallons per minute or 150 gallons per day per bedroom. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non- critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. Mailing Address ,PCl Box 196650 * Rncorage, Alaska 99519 6650 *�uvuvW muni org am"" Septic Tank Advisory Certificate of On -Site Systems Approval #OSC201103 Subdivision: Timberlux #1 BLK B Lot 7A Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 24.5 years old. Typical replacement costs range from $8,000 to $11,000. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 20 year old steel tank MAY look like. 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 Parcel I.D. # el ~- .~'~ / 1. GENERAL INFORMATION · Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING - Eocatzon~(site address or directions) ~ .. - --,----, - ---..P~3nerl'v'°wn~'r ~ ¢~ O ~ ;' ~ $~ ~ Day phone ..... M~aili ress';; -- c..,. Lendzng agency ,*' Day phone ~' Mailino addr~/~. · Address :~ tt 1- c 5'7'. e ,4-,~ c go,4,; c ~ ~'~2,.¢~,unle-ss-othe-rwise' ~'~qoested,,IdAA Will be held forPickup.' ~ 2.'., NUMBER OF BEDROOMS:~ · ............ ........ :: .... · - :-': Pubric ~vater NOTE:If community well system, provide written con.firmat, ion from State ADEC attest- ing to the legality and status of system.- - ~,__. 'I ~ ' 4. TYPE OF WASTEWATER DISPOSAL: . tank ,, ,,, ,' ~1 ·- , · Holding .-~ . . . .: .... ~ ,:-.- .~ ?/,~ , ity Commun on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. Se Name of Firm s & S ENGINEERING 17034 Eagle River Loop Read No. 204 Add ress F~,.I~ giver. Alaska 99S7~I' . Engineer's signature ~ .~~- ~ ~ 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 mves.ti_gation and inspection~ the on-site water supply and/or wastewater disposal system is in compliance with ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Phone (~ c/,./. 3. ~/'7 ~) Date 6. '~:': DHHS SIGNATURE ...... :""~'~'~. .... ......... "- Disapproved,'=:?: ....................................., , ~. ..-' ...... -:',--~ Condtona approval for ': ...... :bedrooms. with. the fottowm Additional Comments ' % · B~'~:'~'~ ~/..~ --., Date / 2 - /4 - ;';I :~; ~a?}~pe ~f~r a go :, yD euP;oT;:t r:fp rH:~l: th~:dn sH~i vm:nn inSe~irC:;m((pDhH 5H Sa)b Io~eU ebSy "~a?nhoeA~ethn;:nWt -~ _._~.,.o~,,,,o~ ,~.,,h~er ~:~nismred in the State of Alsska. The DHHS doee this ss a courtesy to purchasers of homes an~ thc'ir len~' {~h~ nstitutions'm orderto satisfy certain federal and state requ~rernents, Employees of DH HS do. not conduct inspec[[ons or analyze data before a certificate is issued. The Municipality of Anct~crage ~s noJ responsible for errors or omissions in the professional engineer's work. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501e (907) 343-4744 Health Authority Approval Checklist Legal Description: Lo'r -TA~ 'gt.oe.~..'E,) ~'~'~$~,0~-~/Dg*[Parcel I.D.: A. WELL DATA Well type pR ~z £ Log present ¢')N) "/ff i Date completed Total depth ~ o ~ Cased to o/ g Sanitary seal ~q) Y ~: J If A, B, or C. attach ADEC letter. ADEC water system number Casing height (above ground) Wires properly protected (6~/N) Date of test Static water level Well production FROM WELL LOG AT INSPECTION l g.p.m. O. G . g.p.m WATER SAMPLE RESULTS: ¢LO 2. ,v~.~ Coliform 0 ,/ o Nitrate 0 Date of sample: h/! 5-/~ J- 4~ ~. t/~ / '5'3-' Collected by: B. SEPTIC/HOLDING TANK DATA o. / Other bacteria o / o 17034 Eagle River Loop Road Eagle River, Alaaka 99577 Date installed lo -Io -q~ Tank size V~OO Number of Compartments ~1. Cleanouts ~)N) Foundation cleanout ~)'N) c/~$ Depression (Yt~ F/e:, High water alarm ~qq) Date of Pumping ~ ¥~.-r,~,'- Pumper C. ABSORPTION FIELD DATA Date installed IO - I o -q,-~ Soil rating ~r fl:/bdrm) ~.'Z System B'pe Length t._) ~ t , , Width 3.~ Gravel thickness below pipe ~ Total depth Effective absorption area (o 5/]~ Monitoring Tube present~N) ~t'~o Depression over field (Y~ ~',/c~ Date of adequacy test ~/e~ ".~-*m'.~- Results (Pass/Fail) -- For ~ bedrooms Fluid depth in absorption field before test (in.); Fhdd depth .(ins.) Minutes later: Immediately after ~al. water added (in.): Absorption rate = g.p.d. <>' t7 c Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date D. LIFT STATION Date installed ~o - to Manhole/Access ~ High water alarm level Cycles tested ~ Size in gallons "Pump on" level at* ~ % "Pump olT' level at* *Datum 15oyroz,,- o~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: (~holding tank on lot ! o 0 ~ ~ .; On adjacent lots Absorption field on lot ! o o f q'- _; On adjacent lots Public sewer main tv [ ,~ Public sewer manhole/cleanout Sewer/septic service line ~ S- / q'- Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~ ~' Property line '7 ~ Absorption field Water main/service line to ,'- Surface water/drainage_ too 4- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Bmlding foundation '7 ~ ~ Water main/service line /o t Surface water ldo ~ Driveway, parking/vehicle storage area Curtain drain ~'os..t~ ~.r, to~o,,.' Wells on adjacent lots ldo t* Properly line F. ENGINEER'S CERTIFICATION I certify that I have determined thrufield inspections and review of Municipal records that~,,~_ i~tems are in conformance with. MOA HAA gu.~delines in effect on this date. HAA Fee $ ~ ~D ~ ~ W~ver Fcc $ Dam of Payment /~ - ~ 7~ Date of Payment Receipt Number /~[ ~ ~9 Receipt Number Rev. 8/95 DSS: ~.wk.doc MUNICIPALITY OF ANOHORA~E DEPT. OF ~ :.',LT~! &  DEPARTMENT OF HEALTH ~ ENVIRONMENTAL PROTECTI~VLRONMENTAL [:[O] ECTION 825 L Street - Anchorage, Alaska 99S01 AUG 1 6 i979 E~VIRO~ENTAL E~61~[ERIN6 BlVlIIO~ REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND 8EWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER MAILING ADDRESS PROPERTY RESIDENT (If different from above~ 2. BUYER PHONE PHONE PHONE MAILING A[~DRESS 3, LENDING INST. ITUTION MAILING ADDRESS &~.:J~>' ,~;, 4. REALTOR/AGENT MAILING/~DDR ESS PHONE PHONE 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 Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well ~depth (attach Icg if available.) **If individual/on-site, give installation date ~-/J'- ,~,~. 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. 724)10(3/78) 4~,~ THIS SIDE FOR OFFICIAL USE DATE RECEIVED I NSPECTI ON APPOINTMENTS TIME TIME TiME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS -[;E] SINGLE FAMILY [] ONE ~] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY ~1 ~ INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTI LITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER ~[] I N DIVI DUAL/ON -SITE DATE INSTALLED [] PUBLIC UTI LITY C~ _ Connection Verified INSTALLER ~]Septic Tank or []Holding Tank ', o,~ L'-~ '~ ~ t t Size: I £'¥-')kr'~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line WELL TO: I~~ Absorption Area to nearest Lot Line 5. COMMENTS PPROVEDFOR BEDROOMS [] CONDITIONAL APPR'"OVAL (letter must accompa~ertificate) [~'~ DISAPPROVED ~ DATE i,-f .Y (Title ' / LEGAL DESCRIPTION 72-010 (Rev. 3/78)