HomeMy WebLinkAboutELDON BLK 2 LT 4Eldon Block 2 Lot 4 #016-202-29 Lot 03 Used for Septic System Municipality of Anchorage On -Site Water and Wastewater Program - (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT 0 5 P ) g) 000 0� — Z 2— 2 Permit Number: PID Number: Dwelling: LJ✓ Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ❑ Upgrade Name: Cj'�V�f.� ABSORPTION FIELD ❑Deep Trench ❑Shallow Trench Bed ❑Mound Address V El Other Phone Number of Bedrooms Soil Rating Total depth from ongi I grade _ Z 5 GPD/SF I ` Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade N•l 1' Yl Ft. Gravel depth beneath pipe Ft. Subdivision i1� Block Ir G y L N Z length Fill added bove original grade 4"4 Gravel Township Range Section •Z Ft. Ft. Gravel width 14 FL Beds: Number of Lines .J Distance between lines 1 3 Ll n Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches I From Tank Field Tank Line FP Ft. Well 105- TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Gal. Surface Water 1001- Material Number of compartments Lot Line. NA Foundation7,� LIFT STATION Manufacturer Capacity Gal. Curtain Drain N Remark4kwe use.�e � � L.� 4 Pump on level at in. Pump off level at in. High water alarm at in. tvl f' Vhf 7�✓' S ft.�'I '-�'( /� I �N ft'' 1�o fu( P.t�7 nl5 q hri5crgpi' y� Pump make and model Electrical Inspections performed by /I/r� f �' r fa/ 44 Z_ 2- / Installer— Gt$ +;r,o- e'— PIPE MATERIAL House to tank Tankto drainfield S"1 fa ,�N Drainfield 303 y. CO/MT o 3Ll Inspector !) A/'Ap Q_ 1Ti�/ito(-y BENCH MARK (Assumed elevation) /00 !!—Oft Inspection to fl ' /S 2"a ,��,.•, 1'3 Location and description // /!� 6� I'r'r 6H�/� �11t. ��1 6� 3m 41h COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engmeq{g St2mpt ( '4 Conditional Approval: Date SANDOR MANYOU .:1 ^, C -8.67 : �-= Approve�60 44 Date Inspection Rep _-1-12.doc •x'1111 r o C) r¢ ti 118* : • ��Gs r � 1 1 ---I--------- I I 0£ m 00'066 M,6,b0.00N — — —N �\ r. '•+.fit 'ark..}� ,� {q,'. �yrg¢.at; !. on `l o .a a�5."•�'�}�'" 1:'c . {' .ri+9�' ° nfa m I O ocz IL s'r IN•. o I Q o LO 2 --- J -' ro LLI o'n a in Z J us i m '001\ ci _O J O r00[=N io 00'066 M.9 kVO.00N / £ N 16 Ln J u � a 4 N N Q 0 ow>�V< ) Np Q V i' Z WdNZ O ei yM a�a W NaU 5.Z !✓TI�!I' u in 0 00 E ll W j :'y���+II W Z O Lj LLJ I-00 W W ZZ � �� •`" ��O U7 �'O ¢J Ij�•' �z(Wj �d10 L- F- w II Z O K 3 M m Co C,� CL 0 £Z �' t N � co M! N O Y O 0 m � N Ob Lo N C O O'8Z U) w O you 0 N � I I o Z c `00 -� a w H U U) to t \\ 00'061. M.S ktOo00N VOQz I N ZO N N Q N p U W M > Q a W N m O N p N >O J mm N Z W F� O LN 0 m J 0 M o m w r- O r Ln O 0 W � M 7 V ((00 (( W M m coTco!CIZ15r) N O (D O O N N M I M M M M M N L> (D f-_ 00 0) O ll W j :'y���+II W Z O Lj LLJ I-00 W W ZZ � �� •`" ��O U7 �'O ¢J Ij�•' �z(Wj �d10 L- F- w II Z O K 3 M m Co C,� CL 0 £Z �' t N � co M! N O Y O 0 m � N Ob Lo N C O O'8Z U) w O you 0 N � I I o Z c `00 -� a w H U U) to t \\ 00'061. M.S ktOo00N VOQz I N ZO N N Q N p U W M > Q a W N m O N p N >O J mm N Z W F� O LN 0 m J ,5' 1-4, \ � k /r C) b2 / • rm� :\x�� )§ § 00 . < \ low' 1|11i � 1-4, \ � k /r C) b2 / • rm� :\x�� $ )§ § 00 . < \ $ � 2 --- E---- _� 22 \\ ( / • rm� :\x�� a )§ § 00 . < \ $ !d Ia § ( !" a )§ § $ � 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: OSP151000 Tax Code Number: 01620228000 Work Type: Septic Upgrade Permit Effective Dates: January 09, 2015 to January 09, 2016 Design Engineer: MANYOKY%SANDOR Subdivision: ELDON Site Legal Address: ELDON BILK 2 LT 3 G:2731 Owner/Address: ANDERSON STEVEN D 620 BILL STREET ANCHORAGE AK 995153429 Site Mailing Address: This permit is for the construction of: Y Disposal Field N Septic Tank Lot Size in Sq Ft: 11400 Total Bedrooms: 2 N Holding Tank N Privy N Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received Issued By zdtv 1'� I - (q- / �- MUNICIPALITY OF Community Development Department Development Services Division On -Site Water & Wastewater Program Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D.' 7,0 Z — 2 C � Z (T Property owner(s) g -E z e L1 1) Au dso M go k q Day phone I(% ' 3 4 g Mailing address It .4 Site address % ,R 1?!' I I1 s � Legal description (Sub'd., Block &Lot)Lo k e f Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 2,05 134157 01/06/15 11:13AM A94 ll^ll/Septic Systeme $569.00 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: ([D all that apply) Absorption Field Initial ❑ Single Family (SF) Septic Tank ElUpgrade (w/wo ADU) ® Holding Tank ❑ Renewal Duplex (D) El❑ Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal C des. (Signature of property owner or authorized agent) Permit/Rush Fees: 5^�O% �� Waiver Fees: Date of Payment: S Date of Payment: Receipt Number: �T 4�/qReceipt Number: Permit No. 10610!5!006 Waiver No. Permit App_9-1-12.doc ILHAAS & ASSOCIATES, INC. CIVIL ENGINEERING CONSULTANTS MATERIALS TESTING • ENVIRONMENTAL SERVICES January 5, 2015 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 Ehnore Road Anchorage, AK 99516-6650 Re: Block 2, Lots 3&4 Eldon Subdivision Onsite Septic Improvements Dear Onsite Services Engineer Steven D. Anderson, the owner of Lots 3 and 4, Block 2, Eldon Subdivision would like to upgrade his existing septic system in order to serve his two- bedroom home located at 620 Bill Street. We are therefore requesting that a permit be issued for the upgrade of this septic system. On December 29 2014 we excavated down to the septic tank 24" diameter manhole cover to inspect the integrity of the existing 1250 gallon septic tank. The tank showed only minor corrosion inside and the outside protective coating was still intact. The attached design documents identify the location and configuration of the existing and proposed septic system improvements. The existing five-foot wide shallow trench (167SF) would be connected to the new drain field 192SF). The combined effective absorption are of 359SF is adequate for the 2 bedroom private residence. The site plan also locates the existing wells on adjacent lots. No conflicts exist between the proposed septic system addition and the wells on this lot, or the nearby lots. Protective radii are depicted for the neighboring wells. Drainage arrows indicate the current drainage patterns which will be restored after construction. The available area on Lots 3 and 4 is limited for placement of the new septic system addition, due to the surrounding well locations. The test holes, which were excavated on 12-22-2014, indicated loose gray poorly graded sand with some silt and gravel (SP) to a depth of 12 feet. The percolation rate of the sand was determined to be 1.7 minutes per inch. 3900 E. 112TH Avenue•Anchorage, Alaska 99516•TEL (907)349-8799.FAX (907)349- 8791*haas@gci.net The existing ground surface on the lots slopes slightly to the southwest in the area of the proposed absorption bed. The bed would be placed parallel to the contours of the existing ground surface. A minimum of 100 feet distance would be maintained between the proposed septic system and surrounding wells and from any surface water in the area. This system, if constructed as designed, would have very little or no adverse effect on the nearby wells, septic systems, or reserve space. If you have any questions, please call me at 907-947-3499. Sincerely, Sa tky. P.E. Civil Engineer 7/.' .............. SM................ I OR MAWYOKY A. CE -8447 .'ffA 1� . - 1 LU .. w CO EL �''�• '� .. • in � L 1� Ifl I'' . `~�■ i� cr�, ZWO -CN Illiiry0 < ui �i"a� ' fly �i� • • .• = . 1�i I ■ ■ • ..� .. .l wMWIX IIIIII���- ilJ�1� f�l� j Im • �t l Wo Cl DER LU VJML�li, 4�1w1 • i , LL• 0 J 0 N 0 0 0 N I — -------- I I pyL N I I I J 0 N 0 0 0 N 00'066 MAkt,0v00N pyL N g U W M a P: ::E N m ti 0 2 {� •.''A��:: •C Lj fi W R N Z O m 0 H N��9Z a, 04 " /j\✓ / o 08Z inrc M aeus c IN E jI� Oi � W 001=8 o I\ 00'066 M..9kt,0o00N I \ N I J 0 N 0 0 0 N pyL N g U W M a P: ::E N m ti 0 2 {� •.''A��:: •C Lj U W R N Z O m R H N��9Z a, O m � $} uj §� / ' � � \/k °41 / � §� ,L ! + , Ne . }f § / ;r CD §/§ LLI Ln } �04 $} @ � 2 §� / ' � � \/k / � §� )\\ ! — — — , Ne . }f § / ;r CD §/§ LLI Ln C) @ � 2 §� / � � / � §� — — — 02 §/§ I \ � ƒ | 2 §� / � � HAAS & ASSOCIATES, IN( Civil Engineering Consultants 3940 E, 112th Avenue ANCHORAGE, ALASKA 99516 haas@gci.net TEL• (947) 349.3799 FAX: (947) 3A }� ..47; a .. 1.. x 5+ et u 5 ��► G rVUP�rl X, Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program .4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.ci.anchorage.ak. us (907) 343-7904 Soils Log - Percolation Test i z Performed For: S'+eve 1.2)) �`` ( ) H 11 CX L1� i yQ L t Date Performed: Z 2 2 4/ Legal Description: '&,K Z (iyJ t7> L ! Township, Range, Section: TN k--1 Depth �('�Cui)cs (Ilqj p S t 17- 18- 19- 20 - C-rCLAw Lc)o(�e Pool(A) G'rzydd d CS�j wig s; WAS GROUND WATER ^ O ENCOUNTERED? A s IF YES, AT WHAT DEPTH? L Depth to Water After p Monitoring? E Date: 1L' L% - Reading Date - Gross Time Net Time Depth to Water Net Drop l Iz /O:oog e- z/I --li L if /©° 1d d 3 If 167:?w 10 W�ti 6,0 y it f,0 o 0 't'; V1 6 0 orf PERCOLATION RATE r "_�_. (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND___#_FT rr at� COMMENTS � ��/'I-e'I-e- 4'/r'fI'l-L t/ it Oii. PERFORMED BY:" -u"`- hC�i/jl./(,(j�Lry I 4 0 CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STA E AND MUNICIPAL GUIDELINES IN EFFEC ON HIS DATE. DATE: t�+t� ke 0_(2"o Municipality of Anchorage Development Services Department Building Safety Division r On -Site Water and Wastewater Program ..4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.ci. anchoraoe.ak.us (907) 343-7904 Soils Log - Percolation Test Performed For:t � `' �L� t✓1 ) H fX-Q �CyQ" Date Performed: Legal Description: -b(, f, Z l .J e �:, y Township, Range, Section: /V #t 2, Depth 0Y'got'41ic - v9_ (Feet) L�✓LVlvt4r,&L 2- 3- i�oo S"_ Gr TOL 4 d 5- a'_ �poC�1 tci LI - 1 l� 15- 1 COMMENTS WAS GROUND WATER J ENCOUNTERED? 7 I 5 IF YES, AT WHAT DEPTH?_ L n Depth to Water After P Monitoring? E Date: Z ^ 2 C�jy Reading Date Gross Time Net Time Depth to Water Net Drop J 12--22 Z 1t0: �5 /ani �tl SII 3 I t %oS Lt) y li ' 15 to S it °•Z� PERCOLATION RATE 1 / (mmuteMnch) �P•ERC HOLE DIAMETER TEST RUN BETWEEN �: jr`—FT AND ,e�� FT 4,;_ t, „ — _2�'N PERFORMED BY: J,Tyt/�iL �Jy-,�1�%��I ERTIFY THAT THIS TEST WAS /' PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFF�DTHIS DATE. DATE: / Z � Z -Z — / 7 i .�t9"�uvrF!�3A({ T'3lz Ks!1�1�-1 V 't`..�.L.,. �.. .i ...r.. ,.�.�..�....o.. _ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name L- 9//�!` C d DISTANCES FROM TO SEPTIC TANK ABSORPTION FIELD WELL Address -f'-Z0 r 3Y fhe ffncidr e 17"k tf"2 WELL LOT LINE 7.S" 107' /5 - — Phone(s) Sire lYbn Permit No. No. of Bedrooms LEGAL DESCRIPTION Lot , r F.� Block +n Subdivisio Mon FOUNDATION Jg ZY/ Township, Range, Section % N k-14 57rj "mZd eZ o:.f (• A&BUILT DIAGRAM (Show location of well, septic system, property lines, foundation, driveway, water bodies, etc.) TANKS SEPTIC/Z& ❑ HOLDING f' IZ Manufacturer cera e Capacity in gallons I /2S -'r' Material Sve-/ No. of Compartments 7 - 3 t tl 0 '4 TYPE OF SYSTEM TYPE ❑ TRENCH ❑ BED W. DRAIN ❑ OTHERjt Depth to pipe bottom from original grade ,`lJ FT Total depth from original grade 7's- FTSDFill 14 , d / /b' r llei v u added above original grade FT Gravel depth beneath pipe r �% FT Gravel length is, FT Gravel width S-& FT Total absorption area ��% SO FT Distance between lines Al/d1 FT F ... 3 p i / Q B a i yl 1 Number of lines Soil rating Pipe material C -L 90 Installer 41' Lo&- Date Installed ' �ea q COrLl �i�o 9//3 — 9 2J - WELLS PRIVATE ❑ OTHER (Identifvl Classification (A,B,C) Total Depth Cased to I a pf-lu /o/ FT 2 FT Installer Date Instance: N REMARKS: , 5'ySaleA,r �i fu/asy W z"d.�cl 6urra/y CT g,• tiler C/aft, O/d /3rvk4Crrby 44,9-ded . S"t/S/dn /raker Scale: firs ! Inspections Performed by: '�idn sr �J�Ld.siC B7 S3,nd Sf0 u9'.l rvy /i'� OwE �p..+� �.,f'2:.i �'CCr �O:1y / are: Ivc J' l,.�e , b✓+tl� Serx�aPGf.. O/c/ tC/ /O/'Y/g% F 4' I / ` k�'e,c certify that this inspection was performed according to all Municipal and State guidelines in ellecl on this dddaatteeldly/r7' /n Health Department Approval: ----`^ "^� Dater z-uf� (mde) ENGINEER'S SEAL - From : DEAN CONST. Nov.20.1989 08:17 PM ♦ri��.� �rf tI s w r OF ANCIdORAGE, BUILDING 3500 EAST T��U�O^�OR ggqp'j0 Ll , 1404 , L�`!'Y' .0 it.{?Y+ NAME —/ Ei�DA LO_T_/,.�'" ,. eLCCK J ... SU6o�V. 04-00 PERMIT Nb(:6 96 ! PHONE C IV DATE L�..1s FOOTING ❑ CLEO. TEMP, FOUNDATION' _..— ❑ ELEC. SERVICE BOND BEAM [I FLED, ROUGH FRAMING -- ❑ ELEC, FINAL INSULATION CJ OTHER — SHEETROCK ❑� STRUCT. FINAL ❑ FIRE FINAL --- OTHER ❑ ZONING _— 4 ❑ FLOG, UNOGR. ..�...,,_ ❑ PLSG. ROUGH � I GA$ TEMP, ----- 9 GAS L] MECHANICAL �.. MECH. FINAL I ❑ PLBG. FINAL I ❑ OTHER N0 NONCOMPLIANCE 0DOtAVE0 U OORRECTIONS WENTIAL AS 9XPLAINED 6ELOW G WILL REEXAMINE AT NEXT INSPECTION O DO NOT CONCCAI4,VNTIL REINSPECTED COMMENTS .. y.,adaM.,,u+XwwL.lwuW�' �w , INSPECTOR VJFIEN CORRECTIONS ARE MADE. PLEASE CALL FOR INSPECTION—,-- NSPECTION_,- 6t-OOP lhw,tv67) ..,.. .�_..........�.�::°'�.', ;�' ,.. P01 �1UNIClPALITY OF A14C110RAGE Department of Health & Human Services 825 i Street, Anchorage, Alaska 99501 343-4720 ON - SITE SEWER P E R M I Permit Number: 890178 Upgrade {`W9(3do/~l{} Date Issued: 08/25/89 Engineer Designed Owner Name: A H F C Owner Address: 520 E. 34TH ANCHORAE)E, AK 99503 Parcel Id: 016-202-29 Lot Legal: Nubdivisions ELDON Lot: 4ockr`� '��ekt�ir/n: 19 Township: 12N angec 3W` SEE PERMIT 890178 FOR WELL ON LOT 3 Lot Size 22800 (sq.ft" or acres) T Day Phone: 561-1900 Max Bedrooms: This Permit: 1 Total Capacity: 1 SEPTIC TANK: Minimum total septic tank capacity: 1,000 gallons" Each septic tank must have at least 2 compartments. Depth to top of septic tank(s) < 4^0 feet requires insulation over tank(s)" PERMIT EXPIRES DECEMBER 31, 1989 ` NOTIFY DHHS OF INSPECTIONS AT 343~4744 OR 343~4681. WELL Om THIS LOTMUST BE ABANDONED PRIOR TO FINAL APPROVAL OF SYSTEM" I CERTIFY THAT: 1" I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska" 2. I will install the systemin accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. 4^ I understand that this permit is valid for a maximum of 1 bedrooms. I also understand that the capacity of the total system is 1 bedrooms and any enlargement will require n additional permit" Signed: DATE: ----------------------- ------- ~_~~'________., (Owner) A H F C Issued By: DATE: --------------------------- ^ ---- 9 __- l�,'\a A~-�\ 011A Jci A �^ �4LCS �6\ ` � ]L«y/�j(L" � ��m~ � �a �-� � \~/�- \ �� __0� � � ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 JOs GoT 3 � Al E2-b� SHEET NO.a OF S CALCULATED BY ll •/E� DATE a CHECKED BY DATE LASKA ENVIRONMENTAL ,DB Lois 3� dLne�C 2 t CONTROL SERVICES, INC. s-1200 West 33rd Avenue, Suite B SHEET NO. Z` of ANCHORAGE, ALASKA 99503 (907).561-5040 bcnLcuuTED Br /[�� r�D.AAI CHECKED BYy"/�' V DAl 0 dmcrm,a ®iK. uom, wa ou�i. J QU [— Z SSnn Z Z Z H00 " J HHZ w - 'a o Z LU IL IL J W I— HHJ O H ODW o walQ- H> Q m ❑ W ❑ tH- tan a Z > W ❑ C]Q H �F m m❑ao W � m Z w3 ❑ H ui QJ Z� If) 00 iu a y O o} I— Z Z [n Q m ZW F QZ ❑ ❑ Y m OJ N CU a H �- � U In r, I ❑ w 'V\ ❑ m C7 '� S m O° p0 Og H Z CD H LL O IL H ` H w O 0 LL w H ❑ ❑ QO wa N F Z m m a LL U) Q Q Q w O Hf H o0 o O °N op a� � v ❑ o m N Ir Q i W No O a — — T u R °o°° i 00 w H m O I 8�0 a a O O O O O w 8 ° 4° H Z I I I I X. H W I F- O ° Jz�� QH WU 2:W Z U OH (0 3 O Qua o �U a H Z cn JIL W Q Q QO Z m ❑0 QZu . , m H J O J (n N N QU U a HM ❑ cn U J W Y F- L) Q O 1 U Q O Q O Z U ¢� Q Y X W W Z W t0 3 J Q WW U F H H� ,IJP �fl fl IL � -n ❑ W W J OO�O9 c V N ❑ H 3 n a IL W �I Q y Y f9 U H Z Q 0 O I m Wa H N F Fi Q O H WO—' ,q Q W U a I W OZ N W ❑QH LL 11 LL H}F QH W Q W N OFQ WF - O J a H O U (E) -:)d7 ❑ 3 a U W=OZ HCc m J 3 Q Q NaH W W W ❑ H F. 7 nnnn N z OH 7❑ 12 N H Z N F= H H J ❑ V❑ Q ❑ ¢ ❑ H Z LL D IE w ❑ F- O H Z O H Q Q Z Q O W > O ❑ Q CE F H H U Q 3 X O H W Z ❑ N al Q N W J U W J y < z J Z z N �H Odea H Q Z a y —I F-- z W(n W ° Z W W w z m Q H F j H I m in �Z N > Ln H ¢ IL > WW N i ZW W H In W W W f ED � Qp z`t N aQ� ❑ m o �1 m J❑ a i m m H QU m u ❑ J w 0 a c� w ¢ = w in a U H H J z a a H w LL H ¢ 3 J N m O J W X w W w v 0 w v a IL ° a rn — I �o �o H .J 0O U J H pCIL 60 H ¢ V V J ¢ U o IL ¢ H W H p W Y Zm p Q w 00 U H Q WEq N av w a� a m w v r O Y •• tt 4'*'E y:04 49tH e Municipality of Anchorage ;•DEPARTMENT OF HEALTH & HUMAN SERVI825 "L" Street, Anchorage, Alaska 99502-0650SOILS LOG — PERCOLATION TEST� ^ -%I PERFORMED FOR: 7eHA'k A< 14fw/�7G DATE LEGAL DESCRIPTION: 4070 3 P9( BUX7— g5?Ayk% Township, Range, Section: DEPTH (FEET) 1 oL- 2 3 r�r, 5/{s/D� bRA✓EL 44000 5- ,�, 6 , � .. 7 �r CPAVEu� SArJD ' 0 10- A /S 11 11 ;. 2 12- 13 13- 14- 141516 15- 16-1 17- 18- 19- 20- COMMENTS 7181920 COMMENTS SLOPE WAS GROUND WATER ENCOUNTERED? A S IF YES, AT WHAT L O DEPTH? P E Depth to Water Atter_! Monitoring? _ Date: ••• 4NEER'S SEAL) � 9 i Zil- REID, •.'JR.� !251 ce ••�`i 5A�,� iMED: / 2 J X31J see /9 Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN (minutes/inch) PERC HOLE DIAMETER FT AND FT PERFORMED BY: L% I IiLG---'_+ ��� CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) EER'S SEAL) e Municipality of Anchorage ' co DEPARTMENT OF HEALTH & HUMAN SERVICES or*. .. 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST �� ��• C. RECD, JR „.p PERFORMED FOR: / � DAT LEGAL DESCRIPTION: `3r4zr, gi� Township, Range, Section: Tiznl ,Eiw1 fEd- �9 DEPTH SLOPE SITE PLAN 1 MLZ 2- 3- 4- 5- 6- 7- 8 3456 7 8 9 10 ;. i 11 12 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS 3141516171s1920 COMMENTS S, (?kVmu� JAY& /SSE- 043 In% sl1r i WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT L DEPTH? O P E Depth to Water After XO L-. [ Te 7#0/ Monitoring) Dale: PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER / TEST RUN BETWEEN FT AND FT /SEhPtvat4 �Yaie Z ?r3 7Z . PERFORMED BY: AEeG5 A' iJ1,F I ' A—� CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) v WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological & Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either to, Ib or Ic.) A.D.L. No. la. Borough Subdivision Lot e, Block Ib. 1/4 qtrs. Section No. Township No Range E❑ Meridian Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL: Address: Street Address and Area of Well Location 2. WELL LOG Feet Below g, WELL DEPTH: (final) 5. DATE OF COMPLETION Surface �— Material Type Top Bottom ;�,., 6, C] Cable tool E]Rotary C] Driven ❑Dug r.,? ❑ Auger ❑ Jetted ❑ Bored ❑ Other: 7. USE: .❑ Domestic ❑ Public Supply ❑ Industry ❑ Irriq aft on ❑ Recha rqc ❑ Commerical f ElTect Well E] Other: ./ �r ! ; C:' S. CASING: ❑ Threaded ❑ Welded diam. -'min. to ft. Depth Weight_ tbs./ft. diam. in. to ,f ft. Depth Stickup it. 9. FINISH OF WELL; Type:- Diameter " Slot/Mesh Size: Length: Set between ft. and !F/ ft. Backfilling Gravel pack 7 10. STATICWATER LEVEL7 ft. ❑ Above or ❑• Below land surface Date Equipment used: - II . PUMPING LEVEL below land surface and YIELD s (; ft. afterhra. pumping_ g. P. - .mft.after _hrs. pumpingg.p.m. ft. after 12.13ROUTING Well Grouted: ❑ Yes C] No Material: ❑ Neat Cement ❑ Other: P�t� NEP�S �O M pEPt Pt 13, PUMP: (if available) HP ENt Length of Drop Pipe ft. capacity g. p. m. ❑ Subm. ❑ Jet ❑ Centrifical ❑ Other E<Jv) ,ry 3.�j 19. REMARKS: 16, WATER WELL CONTRACTORS CERTIFICATION: 15, Wafer Temperature ❑ F ❑ C _° This well was drilled under my jurisdiction and this report is true to the.besi of my knowledge and belief; 1 Registered Business Name - Controcf License Number 9 Address: ! r' { c �] / Signed: / Date 1' Authorized' Representative - Form 02-WWR (11/81) Copy Distribution: WHITE - State DGGS, PINK -Driller, CANARY- Customer l°I U N 1: C, T P A L- :L "EY O f= A N C H O R A (:i E Department- of Health & Human Services 025 I_. Street, Anchorage, Alaska 99501. =:43-4720 0 N -- S I 'T E Permit. Numbers 890179 Upgrade Date Issued'„' 08/25/89 Owner Name: A H F C Owner Address: 520 E :4TH ANCHORAGE, MK 99503 W E L.. L P E R M I T �LJL�99C 1J-7 9 Parcel. I d : 016-202-28 Lot Legal: Subdivisions EL-.E:)I:lN Lot: 3 Blacks 2 Section: 1.9 Township: 12N Ranges 3W .SEE PERMIT L196179 L...ot. Size 22800 (sq,ft. or acres) M<am Bedrooms: This Permit: I Total. Capacity: J. Day Phone: 561.-1900 WE:I._L..: Log must- be submitted to Municipality of Anchorage Department of Health and Human Services within 30 clays of well. completion. PERMIT EXPIRES DECEMBER 31., 1.4135' SEE. PERMIT E90178 FOR SEWER PERMIT. HOUSE IS ON LOT 4. E CERTIFY THAT. 1.. I am familiar with the requirements for on' --site sewers and wells as set.. forth by the Municipality of Anchorage (MOA) and the State of Ala=ska. 2. I will inst..al.l the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 3. 1 will adhere to all MOA and State of Alaska requirements for the =.set back distances from any existing well, wastewater disposal system or public sewerage system on this or any ad,jacent or nearby lot, 4. 1 understand that this permit is valid for a maximum of I bedrooms. also understand that the capacity of the total system is I. bedrooms and any enlargement will regt.ire an additional. permit. � q Signed: 4- - /for -f DATE - (Owner ) ATE: (Owner) Issued Dys R H F C E)R..L.F:: ..'/ ■ GTER ANCHORAGE AREA BORH HEALTH DEPARTMENT NO 783 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEMMAILING /,J NAME.__/I_�.z_Mew A?(/ ADD E S &X /4tS ,Sl/r7eydll PHON ems"' K' SEPTIC TANK: NUMBER OF / DISTANCE FROM WELL �3`/ MATERIALSTFf` COMPARTMENTS .s�i5'C� SiFF�. CCL d //t^liI_S LIQUID LIQUID CAPACITY h/fC GALLONS. INSIDE LENGTH INSIDE WIDTH DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS OUTSIDE DIAMETER OR WIDTH 4 LENGTH—/ DEPTH, LINING MATERIAL `T�O r.DISTANCE FROM WELL %',l ,BUILDING FOUNDATION ��/ NEAREST LOT LINE ) %6' ALI . TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) - SQ. FT. TILE DRAIN FIELD: DISTANCE FROM TOTAL LENGTH NEAREST LOT LINE , OF LINES— NUMBER OF LINES.zf DISTANCE BETWEEN LINES �11� TRENCH WIDTH IIbKTOTAL EFFECTIVE AREA SQ. FT. LENGTH OF EACH DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE WELL:7 TYPE �l /_-�- DEPTH C1Z , BUILDING FOUNDATION.—SAMPLE NEAREST // _ NEAREST _ , SEPTIC �L� / SEEPAGE 5-J OTHER LOT LINE 1 f� L , SEWER LINE , TANK / SYSTEM CESSPOOL s , SOURCES_ DIAGRAM OF SYSTEM DATE `5// / APPROVED G9 -a -L GI?JL� HEA AUMORRY 31° GREVER ANCHORAGE AREA BOUGH yyy�y���///www DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. 3500 TUDOR ROAD POUCH 6-650 ANCHORAGE. ALASKA 99502 TELEPHONE 279-8686 SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT NAME OF APPLICANT Ti� 60"a- MAILING ADDRESS e!&�Z e® PHONE uG� INSTALLATION LOCATION Vie, : r ,�ol� '-f �� 9ys � 3 7egr LEGAL DESCRIPTION INSTALLATION OF: SEPTIC TANK �'SEEPAGE PIT a DRAIN /FIELD y�, OTHER , TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH TO BE INSTALLED BY ✓�'�/� C iL _L 1G//G so1L rssr RESULTS C:✓��/ii<%ii!✓ NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE / TYPE MINIMUM DISTANCES, f 15. G - dr -l. mIGE9a9111Pive�N. 0 "vwvW .4411* - Gtr./ SEEPAGE AREA SIZE � �P%� �yTY/PEy�Q`/A*'' i'l/VT C� .N 3 /�/ ✓Z- /� 5 1atl le ^=DIA4GRAM OF SYSTEM 110-1 FOUNDATION TO SEEPAGE PIT C�v6) , , DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL . SEPTIC TANK J , SEEPAGE PIT DRAIN FIELD TO NEAREST LOT LINE. �l / WELL TO SEPTIC TANK . SEEPAGE PIT GRAIN FIELD ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK ,�� ,SEEPAGE PIT DRAIN FIELD ^— �E / SEPTIC TANK, SEEPAGE PIT DRAIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. HEALTH AUTHORITY OR LICENSED DESIGNER I CERTIFY THAT 1 AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 2868 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. //q/ /''/♦DIY/�/� DATE �/� �� APPLICANT'S SIGNATURE( ® 'y Municipality of Anchorage e a On -Site Water and Wastewater Prograrrl (907)343-7904 Certificate of On -Site Systems Approval Parcel I.D. _ /t e , _ 2 2 6Z� Expiration Date: 9. GENERAL INFORMATION Complete legal description 3�a c�2 Location (site address) (vZ o Will Aw d" - ) AV— q q 5-15' Current Property owner(s) 5 kOr11 b Avicler$un Day phone Mailing address 6„ rG Vi ll 5 � &Ci'. -yr;! f AI'6 Real Estate Agent ],V k n t O 4;) e -Z- Day phone 2. TYPE OF DWELLING:, E' Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System rl Waiver/Variance request for. TYPE OF WASTEWATER DISPOSAL: Individual Holding Tank ❑ Community ❑ Public Sewer ❑ uu � COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ A COO Waiver Fee $ Date of Payment••�,,t L5 Date of Payment Receipt Number -�W� p�� Receipt Number COSk# Waiver# 6. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below; I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information - obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are)"in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm �� /� S fr [- l(f 4L i -r L_ Phone qf�— 3 y Address 3 6-/ v' � (� �) Z rt-+ A,;-(_ Engineer's Printed Name ,S} f� i7a iZ �``} tl j'v Date �a Z 6. DSD SIGNATURE System #1 Approved for '59— bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the following stipulations: '? 3 _ ) Original Certificate Date: r3. � The unicipality of Anchorage DevelopmentServicesDivision (DSD) issues Certificates of On -Site Systems Approval (COSH) based only v on 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 f c - If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: L! Stet ?2t I c 2' (�/ (v Zo L _Z c� ParcellD: q A. WELL DATA \ —o( CI Well type If A, B, or C provide PWSID # Date completed —I �� — Sanitary seal (Y/N) Total depth �ft. Cased to 0 FROM WELL LOG q (r Date of test ) — [ Q , Static water level fL Well production 2i O g,p,m, WATER SAMPLE RESULTS: v Coliform �yM �l colonies/100 mL Il � Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) �7,0 in. AT INSPECTION 11—I� - /y* ft. -* g.p.m. * 4? n e r 6,ev r vu�3-s Nitrate ( mg/L c.. Arsenic ug/L Date of sample: �i B. SEPTIC/HOLDING TANK DATA / Tank Type/Material Tank size / 2_S_r gal. Number of Compartments 2, Collected by. p,c,c ,T � N I- k Date installed q— 1 I '/ b K"9N Cleanouts (YIN) 07-tc- /Y �0 Fo\na¢Lh I_^..Jfl{ N/AI\ l n. ressio e� a ,V/ _ V^.r "" "'^ • l % =i '-'-U'r' "^' i u_.• tank t 1 N) High waici aiorni Date of pumping (2 2 —/ / Pumper �TG 6ee�7--i - 13, I< f 4' n ri / w/1 n l+ Vp� C. ABSORPTION FIELD DAT Date installed I Soil rating (g.p.d./ftz or ft2/bdrm) �5 J System type 5 Length IS ft. Width I �N _ ft. gavel below pipe eft. Total depth 4 > ft. Eff. absorption area( (0 7, ft Monitoring tube Depression over e d Date of adequacy test — 1 ' Results (Pass/Fail) For � droo Fluid depth in absorption field before test J 3 1 i P p in. n Water added. / gal. • New depth in. Elapsed Time: .� 00 min. Final fluid depth N p in. Absorption rate >_ g.p. ,TQ Any rejuvenation treatment (Past 12 mo.) (Y/N & Noe) If yes give date �Jo- wi Ne., -v D. LIFT STATION ' Date installed q'ZS . �7Size in gallons ( ZSb Manhole/Access (YIN) c� Pump on" level at �,5 _ in. "Pump off" level at I/Z in. High water alarm level at in. Datum 6� t+1 L S Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: i Septic tank/lift station on lot ®1 D Absorption field on lot`I 0 "I Public sewer main / hv t//]- Sewer /septic service line Animal containment areas /— On adjacent lots On adjacent lots i Public sewer manhole/cleanout Holding tank MIA- Manure/animal excrete storage areas NA SEPTICIHOLDING TANK ON LOT TO: Z5 1 Building foundation �O Property line ` Absorption field Water main U 14 f Water service line y Surface water Wells on adjacent lots oLO I +- ABSORPTION FIELD ON LOT TO: r /J Property line Building foundation a Water main jJ i tJ Water Service line Surface water (�� t Driveway, parking/vehicle storage l y i Curtain drain _ Wells on adjacent lots /00 F. C01MIME!"ITIS 51-I - �)y®* 1��u� h-71- oP11 � C- I -I3 -rs— G. ENGINEER'S CERTIFICATION I certify that t 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. U �r tit 1 AI �� U" 1 ��i��C5TAIVI S= Engineer's Printed Name rT Date SIRti _ �jD — o� 5 COSA brown sheet_10-10-12.doc Municipality of Anchorage E �u Community Development Department Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Arsenic Advisory Certificate of On -Site Systems Approval # OSC151043 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 2, Lot 4 of Eldon Subdivision. This inspection revealed an arsenic concentration of 19.5 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Information on arsenic is available from the On -Site Water and Wastewater Program website ()Kww.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. . GENIC&ENVIRtTNMENi`ALEN3GIFl RS'. x-=.:a .,. ::a:„ 2+" 9 / Well I 0 / I BLOCK 1 I Lot 10 I Lot 11I o Well I I � BILL St. / N89055'45"E coM 60.00 601100 Lot 13 Lot 12 / LOT 3 OWell 24.0 fence Garage 24.0 --0--- IF Utility Easement j \ 8181L O /M yvell BLOCK 2 O O O O Lot 5 LO T Scale: 1'=4 link fence 60.00 RECERTIFI D 2-04-2015 60.00 N89055'45"E AS -BUILT NO CORNERS ET THIS DATE :10us e \ I hereby certify that I have performed a Mortgagee's inspection over property line '�� QF `1 of the following described property: i ots 3 & 4 Block 2 ELDON SUBDIVISION �P' • � Anchorage ecor mg Precinct,as a, an a e j' 49th 9 #4 improvements situated thereon are within the property lines �' .' • • ••• * � and do not overlap or encroach on the property lying Note: No wells found on Lot 2, Block 2 / , .. .. .. • adjacent thereto, that no improvements on the property lying or Lot 11, Block 1. 007epk ,� ¢ y % adjacent thereto encroach on the premises in question and 0 •,Fred WC, I . ... ,• a. / that there are no roadways, transmission lines or other • visible easements on said property except as indicated sit 3255 — S • • �� hereon. qFa . • , • oy Dated at Anchorage, Alaska • • • • a this 8th day of December ,2014 EASEMENTS OF RECORD, OTHER THAN 1 1 woFessloaaL THOSE SHOWN ON THE RECORDED 1 \\\�� FRED ers and Ar ASSOCIATES PLAT ARE NOT SHOWN HEREON. Z -4- ($ Engineers and Surveyors Fb05-7, pg59 BE (907-248-1666) 100' Well Radius ° , S ptic vents r m e Se tic 3 nts Test Hol Wood r t. wall / Se 'c vent. O Window wel LIdec Lot 2 g.7 35.5 16.3 0 1 Story Frame House o ( —shed c6 N with Basement N I�'Jf O o 36.3 ° 00 15.5 a ., .- .. ..:.. . ' Sun Z deck yona ret. wale LOT 3 OWell 24.0 fence Garage 24.0 --0--- IF Utility Easement j \ 8181L O /M yvell BLOCK 2 O O O O Lot 5 LO T Scale: 1'=4 link fence 60.00 RECERTIFI D 2-04-2015 60.00 N89055'45"E AS -BUILT NO CORNERS ET THIS DATE :10us e \ I hereby certify that I have performed a Mortgagee's inspection over property line '�� QF `1 of the following described property: i ots 3 & 4 Block 2 ELDON SUBDIVISION �P' • � Anchorage ecor mg Precinct,as a, an a e j' 49th 9 #4 improvements situated thereon are within the property lines �' .' • • ••• * � and do not overlap or encroach on the property lying Note: No wells found on Lot 2, Block 2 / , .. .. .. • adjacent thereto, that no improvements on the property lying or Lot 11, Block 1. 007epk ,� ¢ y % adjacent thereto encroach on the premises in question and 0 •,Fred WC, I . ... ,• a. / that there are no roadways, transmission lines or other • visible easements on said property except as indicated sit 3255 — S • • �� hereon. qFa . • , • oy Dated at Anchorage, Alaska • • • • a this 8th day of December ,2014 EASEMENTS OF RECORD, OTHER THAN 1 1 woFessloaaL THOSE SHOWN ON THE RECORDED 1 \\\�� FRED ers and Ar ASSOCIATES PLAT ARE NOT SHOWN HEREON. Z -4- ($ Engineers and Surveyors Fb05-7, pg59 BE (907-248-1666) MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section CIMS P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I. D. # 014a26 e9 "V 1. GENERAL INFORMATION / �I / , Complete legal description Lot `f &loc j �, Z =-Voy & /V, Location (site address or directions) &W 81// Sf AgC7 19k 99515 Property owner Jo- h17 /v1+6[1&t7C Day phone %344'-e499 Mailing address 620 91116 finc. Ak 99515 Lending agency 1767ne %1iu/ ZG / Day phone Mailing address II Agent — /l7 = i a 1'er Day phone 338-i? 2. Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site X 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(R".1191) Front MOA1121 i' 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 5KLH Consujt nts Phone 344 --709(0 Address Engineer's signature 6. DHHS SIGNATURE . y._ Approved for bedrooms. Disapproved. Conditional approval for Additional Comments M Date 7 -?-,7-97 bedrooms, with the following stipulations: Date J --S-17 CAUTION 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 this as a courtesyto purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025(Pe.1/91) Back MOAM21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist / Legal Description: 4. rhf and 4 Bl xk ? Clr)on Parcel I.D.:_7 r' ?0 A. WELL DATA Well type t' it t If A, B, or C, attach ADEC letter. ADEC water system number Log present(Y/N) Date completed 9-19-94) Total depth Cased to 97' Casing height (above ground) 3 I Sanitary seal (Y/N) Date of test Static water level Well production FROM WELL LOG 9 i19- 89 WATER SAMPLE RESULTS: Coliform 24 Wires properly protected (Y/N) AT INSPECTION 7-22J7 .o ac -5"- 0, 24 g.p.m. '4n.m. Nitrate o. l Other bacteria 0 Date of sample: q-22-9719--14-97 Collected by: B. SEPTIC/HOLDING TANK DATA (.SEE 'D' ALSO, S. TC•P. sv..5 —rcH) Date installed 9-25-89 Tank size �5s� Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (YM) 7 Depression (Y/N) A_ High water alarm (Y/N) Y Date of Pumping 12--31-% Pumper /l/U/Wi/a/1 C. ABSORPTION FIELD DATA Date installed 4'2,.') 8 `� Soil rating (g.p.d./ft2 o ft2/bdr ) /`5� System type i 5-Lul(7P. r r Length l Width S; Gravel thickness below pipe 4 Total depth Effective absorption area ✓a% Monitoring Tube present (Y/N)Y Depression over field (YM) Ali Date of adequacy test 7-2Z 97 Results (Pass/Fail) PUSS' For bedrooms Fluid depth in absorption field before test (in.); U Immediately after250 gal. water added (in.): Fluid depth Q (ins) Minutes later: AM Absorption rate = %L54__1 a.p.d. Peroxide treatment (past 12 months) (YM) 72-026 (Rev. 3/96)` If yes, give date /U4 D. LIFT STATION Date installed 7-25 • F 51 Size in gallons 2,5-r Manhole/Access (Y/N) "Pump on" level at* 3,7 t "Pump off" level at* -3. L High water alarm level at*—,-? e5 *Datum 13L"/'i`LM11�i/)/7 Cycles tested choobdl' E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO r Septic/holding tank on lot 104 On adjacent lots Norte- wi m;l) /00 Absorption field on lot 10p, On adjacent lots Alawf wt Mil) /00 � Public sewer main A&n c Public sewer manhole/cleanout / ne, Sewer /septic service line A/oY)P. Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation /2 Property line Absorption field Move Water main/service line hhwe Surface water/drainage G.ath,n Wells on adjacent lots /1wne_ uiii in /4) / 0,p SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line .3qI Building foundation Z 3 Water main/service line ddYlC. Surface water Al(me Lo fIi Jn /610 , Driveway, parking/vehicle storage area Curtain drain /1ltme Wells on adjacent lots Move it!/1621/1 /Oto " F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records that-ttre abovW,systems are in conformance with MOA HAA guidelines in effect on this date. Signature Engineer's Name -Sft?LeA C, lile4 Sled Date 6197 14vol- HAA Fee $O n Waiver Fee $ Date of Payment R a — 7 Date of Payment Receipt Number � 60 S Y/4 Receipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHORAGE • ie Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 0/6 z0zx 14449, 0"/o/ Parcel I.D. # c/ HAA # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) /. `/ i 7 L -7o/1. S✓ 1, i iz .v h 'rU s/ �? Location (address or.dt(ectiong)- .< (b) Property owner r��N� Telephone: (home) Businessa Mailing Address OZ '� 3yif �.�� A,d 4� (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent PC r 2Y rrV'0''-f4' eS. Address Telephone (e) Mail the HAA to the following address: (or check here ❑, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single -Family Number of bedrooms 3. WATER SUPPLY Individual Well W Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-sitot Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Pagel of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and asof the validation date shown below, I verifythat my investigation of this Health Authority Approval 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 Ac7r S _x�,L Telephone --2 Address _P%;4 �y pc -1 fr AzcG rrze -74J Date 6. DHHS APPROVAL rJ Approved for �(� bedrooms by , Date// -29-9 Approved Disapproved Conditional Terms of Conditional Approval CAUTION The Municipality of Anchorage Departmentof Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above byan independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 19ev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE ENVIR LSERMtIBltf I36WTY OF ANCHORAGE (MOA) • Health Authority Approval (HAA) 01989 CHECKLIST - FEBRUARY 1984 343-4744 RECEIVED Legal Description: `% i3Z E /4"I /L. sl' /2 3 4' IU 6/d zn,2 fl7Y A. WELL DATA Well Classification Jar 1 0 *' If A, B, C, D.E.C. Approved (Y/N) J14 Well Log Present�,WN) Date Completed Yield Total Depth /L' / Cased to Depth of Grouting / Static Water Level . y Pump Set At Casing Height Above Ground �Z Sanitary Seal on Casing/N) Electrical Wiring in Conduit/N) SEPARATION DISTANCES FROM WELL: Depression Around Wellhead (Y/PQ) To Septic/Holding Tank on Lot /40 ;On Adjoining Lots ala o To Nearest Edge of Absorption Field on Lot On Adjoining Lots /C+F To Nearest Public Sewer Line >/cc r To Nearest Public Sewer Cleanout/Manhole >/00/ To Nearest Sewer Service Line on Lot A)/.4 Water Sample Collected by L . lar ; Date / -/z6r/ Water Sample Test Results oz. f. Ci ti•*2A.P: IV.0, tel) Comments B. SEPTIC/HOLDING TANK DATA Date Installed zss Size /-ST No. of Compartments Standpipes 67N) Air -tight Caps &/N) 0 - Foundation Foundation Cleanout&Y/N) Depression over Tank (Y/q Date Last Pumped Ns'j Pumping/Maintenance Contact on File (Y/N) AJ/A- ; for W14 Holding Tank High-Waterf 01rrh. (Y/N) Temporary Holding Tank Permit (Y/N) 1v1.0' SEPARATION DISTANCES FRC PC PEPTIC/HOLDING TANK: /0 To Water -Supply Well �,� :ki�PJ`, To Building Foundation � To Property Line 7 C/ To Disposal Field To Water Main/Service Llne > zo r To Stream, Pond, take or Major Drainage Course > Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata SSL Type of System Design /� ,df: /�ra.e. fa/✓ Date Installed �/�, cs�rLength of Field / Width of Field Depth of Field — --h- -5 7 Gravel Bed Thickness Square Feet of Absortion Area Depression over Field (Y6 Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: _ Statndpipes PresentMN) Date of Last Adequacy Test To Water -Supply Well /p > / To Property Line /S--/ To Building Foundation Z -Y r To Existing or Abandoned System on Lot To Water Main/Service Line :-? z - / On Adjoining Lots 5--0 t ' To Cutback (if present) ^J To Stream, Pond, Lake, or Major Drainage Course > ie e� ' To Driveway, Parking Area, or Vehicle Storage Area 761 Comments D. LIFT STATION Date Installed 9A rysq Dimensions � Z JT' Size in Gallons / z.gz' Manhole/Accessel ) "Pump On" Level at /fresef L '0.4c4 %k "Pump Off' Level at 'ef'F-s High Water Alarm Level at pt.,E sI -f 14 4 Tz• E . Vent K)N) Tested for Ni /1- Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes ON) Comments 4, JirifS'i`:�7o,i [S-�n�<'�^r.? y,��.-� o� Sz,;a�z! %,_�,.f, %N/'�z-,'�%f' On /0� 1,-1''I Mn 4 IDHSS "Check Permitted Bedroom Rating Against HAA Request" I certify that I have checked, verified, or conformed to all MOA and HAA guideliillw L% ffect on the date of this tion. FAe •�4Signed ••��•'-a� '• 5 ' <Company T _ ngineer's Seal Date Idlfll,�- % % 6 MOA No. R Y C. REID, JR. �`,•, CE -2251 •.•��w e� ®L•s•....a •• t�Qo`I £S 3 ® �s//professlm�n� i4... Receipt No. � � ��� Receipt No. ra.asn.*`a r Date of Payment ZD `/ �J Waiver Fee: $ Amount: $ /—/0, on Date of Payment 72-026 (ReV. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name,J/ Z- Telephone: Home 34` 6__m— Business Applicant Address ;Do. &x /116907 44r.k �SJ� (c) Applicant is (check one): Lending Institution ; Owner/builder ❑ ; Buyer ❑ ; Other ❑ (explain), . (d) Lending Institution Telephone Address (e) Real Estate Company and Agent _/�J2tJY,l/bSf (iJ�Ilc07 lCec�% �S l�T2 Cs0 ea7 Address ' -_`z� Telephone aiq (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family iX Multi -Family ❑ Other Number of Bedrooms WATER SUPPLY Indnldunl W�II ( Conmllundy ❑ Public ❑ Nigh" II CE�mllllli11t4 1A -ill `:1'�,t t`n 1, R1U1 hdA`(` V1 tlt tion i :`ntil tllAtii�n h �1n1 ih<� � �i; 11 t� 1�01�;711n10n1 �`t I nA Ii.�n nlPl11:11 t�,�h;.,� � t' .�n tkea+na 1" 1110 100;rllty ;Ind M;1tu9. 4 SEWAGE DISPOSAL Lln;ito 0 Public i.] Cotll nmlity LJ 1 ielkhna tnnk ❑ NOT) Itcori1nW1lIYwall;t moni,IiiIRth�IvoNIittoIIcollIIIItidtlonItontIIw,IitMitNhI)attIIIIIIt0LIlyIIiliiIIwI1RlllSII" lA-ailnll (litcvltflll) to thn lojit lfty and notur-1. 5. , ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 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. I a Name of Firm Address Date 6. DIIEP APPROVAL Approved for Q� Approved v 16. Telephone ... loo bedroom by .._._— �v' Date Disapxved __ _ Con�4nal _ Terms of Conditional Approval CAUTION Engineer's Seal The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 MUNICIPALITY OF ANCHO • • DEPT. OF HEALTH 8, RAGE MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) }(j 2 3 CHECKLIST - FEBRUARY 1984 264-4720 RECEIVED Legal Description: " 31t 81ac k 2 E�oa! v6d A. WELL DATA Well Classification IRfOAk' If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) A/ Date Completed /4i/ Yield 5npr„ Total Depth _44—W Casj�d to _ Depth of Grouting Static Water Level "-i _ Pump Set At-L)AIMam" Casing Height Above Ground .3D a Sanitary Seal on Casing (Y/N) %! Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N).. Separation Distances from Well: V 9�1+4 To Septic/Holding Tank on Lot ", a O"n Adjoining Lots To Nearest Edge of Absorption Field on Lot_ On Adjoining Lots 6 o7eaE To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole j To Nearest Sewer Service Line on Lot Water Sample Collected by J, ; Date 18-22-8.6 Water Sample Test Results `-""�' �' �` �fa�.f 4?/$o/85- Alor/5.�t. Comments aF P1*56s GNR13 Jawcfas � �ei+,ns Pix,n; Lkl� Cermc& recvpi" Q.�I - ?-,p 8S B. SEPTIC/HOLDING TANK DATA Date Installed Size GO QAAJ No. of Compartments 0 Standpipes (Y/N) —__ Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Depression over Tank (Y/N) Al Date Last Pumped e_J& -8$' Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well ?O v To Property Line To Water Main/Service Line Course -'- Comments t Page -1 of 2 72-026(11184) for Temporary Holding Tank Permit (Y/N) To Building Foundation 8 44 To Disposal Field 31 To Stream, Pond, Lake, or Major Drainage D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) — "Pump Off"fit ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) Cycles during Adequacy Test. Meets MOA Icertifyth Ihavec cke verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. SignedDate _ 0 -%N -ML !J Company MOA No. 8E- Receipt S'POF 441,i Date o� f Payment ��"`h`� ++p��..•••••••.• $ 4ti(w-4w*:yam` •°'� Amount: ` ,r: Engineer's Seal Page 2 of 2 72-026 (11,94) C. ABSORPTION FIELD DATA , Soils Rating in Absorption Strata `s/'L ` &_;& %w4rype of System Design 02Q18 Date Installed 7-lS—'71 Length of Field Width of Field Depth Depth of Field Gravel Bed Thickness *�4 Square Feet of Absorption Area Standpipes Present(Y/N) Depression over Field (Y/N) Al Date of Last Adequacy Test Results of Last Adequacy Test _ SA-�-�StAc'�aRy - %W (cS CtCtJ4 tl4w g,7fnreci Separation Distance from Antion Field rN 9 n J To Water -Supply Well !`N To Property Line !":si To Building Foundation To Existing or Abandoned System on Lot On Adjoining Lots To Water Main/Service Line To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area 170 Comments dE GAA$ 14SAec_ 164 46p 0t4 I CL�ed 7-15-471 D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) — "Pump Off"fit ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) Cycles during Adequacy Test. Meets MOA Icertifyth Ihavec cke verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. SignedDate _ 0 -%N -ML !J Company MOA No. 8E- Receipt S'POF 441,i Date o� f Payment ��"`h`� ++p��..•••••••.• $ 4ti(w-4w*:yam` •°'� Amount: ` ,r: Engineer's Seal Page 2 of 2 72-026 (11,94) � Municipality P.O. BOX 6650 y ANCHORAGE. ALASKA 99502-0£50 o 7� (907) 264-4111 Anchorage,r,CV, I cs i DEPARTMENT OF HEALTH 8 HUMAN SERVICES September 19, 1985 Tony D. Barter, P.E. Barter and Associatees 10461 Hampton Drive Anchorage, Alaska 99516 Subject: Waiver Request WR85-030, Lots 3, 4 Block 2 Eldon Subdivision Dear Mr. Barter: This Department has reviewed your request for a waiver of the separation distance requirement between the well and absorption field on the subject lot. This requirement has hereby been waived for the existing system only. Future upgrades must meet separation distance requirements at the time of upgrade. This waiver is valid for a one bedroom single family dwelling only. The separation distance between the well on Lots 3, 4 and the absorption field on Lot 5 was determined to meet the 100 foot separation requirement. A waiver for this distance is therefore not required. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/ljw 0 To: un cipality of Anchorage Pouch 6-650 :anchorage, Alaska 99502-0650 Ref.: Bot 3 and 4 Eldon Subdivision Dear Sir: 0 August 29, 1985 Barter c: associates Tony D. Barter, P 10461 :ampton Drive Anchorage, Alaska 99516 Two waivers are being requested by this letter. The first request is in regards to clarifying separation distances for an existing system on the subject property to an upgraded system on lot 5. In light of the fact that a separate waiver is being reauested concurrently by the owners of lot 5 for the same conditions I'll only add the following: 1. from the well on hot 4 to the absorption field of lot 5 the terrain slopes away from the well on a average negative 1095 slope. 2. The absorption field of lot 5 was upgraded in the fall of 1981 at which point the encroachment came into existence. 3. The initial water sample of Lot 4 was free of cleriform, although other bacteria. was present. Therefore, the well was clorinated on August 28th and resampled on august 29th. The second waiver is being requested for the absorption field of the subject property to the well of the same. According to Gu`- reports dated July 15, 1971 and June 7, 1979, this distance is 95 feet. Presently there is not a standpipe present to verify this distance. ?o upgrades are expected as a result of a recent adequacy test, Z8-21-85). From this, I would conclude that the system has been operating satisfactorily for the number of bedrooms reported and no apparent health hazard exists. Si cerel(��1 Tony 4 88Barter, P.E. TDB/kb MUNICIPALITY OF ANCHORAGE DEPT.:... , DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOPYI � '-'I ION 825 L Street - Anchorage, Alaska 99501 ,&/, -AY g ) ENVIRONMENTAL ENGINEERING DIVISION \\ J NUMBER OF BEDROOMS 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 processed. Please allow ten (10) days far processing. - 1. PROPERTY OWNER YiL' I Ilk ❑ Three ❑ Six PHONE er;� ',,' t I INDIVIDUAL* ���d/ 7 oq v MAILING ADDRESS since June 1975. For wells drilled prior to that date, give well PROPERTY RESIDENT (if different from above) PHONE 2. BUYER /2 PHONE MAILING ADDRESS ❑ 3. LENDING INSTITUTION PUBLIC UTILITY PHONE 2 MAILING ADDRES 4. REALTOR/AGENT PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION /s ,&/, 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS SINGLE FAMILY ❑ One ❑ Four ❑ Other Two ❑ Five ❑ MULTIPLE FAMILY Ilk ❑ Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* *ATTACH WELL LOG. Awell 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.) W2 �. S. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE** / **If individual/on-site, give installation date ! 9%,1 ❑ If system is over two (2) years old an adequacy test is required PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED .- 1 TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLICUTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM OINDIVIDUAL/ON-SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: 101100 If Tank is homemade give dimensions: SOILS RATING I TYPE OF TANK MANUFACTURER K./V/ �1 TOTAL ABSORPTION AREA MATERIAL / N 4. DISTANCES WELLTO: Septic/Holding Tank LO L Absorptionl(A✓r_eaWf"•" Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS �APPROVEDFOR 3 BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE �—? _�5 BY (Title) 1.9 LEGAL DESCRIPTION 72-010 (Rev. 3/78)