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Home My WebLink AboutCONIFER HEIGHTS BLK 1 LT 18 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 ~ame 7~,"f'e-// /'~ ~,? ~ DISTANCES '72,,~:~"" //9~/,.-./ Or..~/.,o~ ,Dr, we ~J'O~ F~0M~"'"'""-~ SEPTIC ABSORPTION ~Udress TANK FIELD WELL Phonels) I Permit No. IND. of Bedrooms WELL / / LEGAL DESCRIPTION LOT LINE ~./ / I Co~/'~"~./' ,~,~' ~ ¢3' FOUNDATION ~ ' Township, Range, Section . AS-BUILT DIAGRAM (Show location of well, septic system, property lines, foundation, 7"/~./u ~ J"..~ ~ W/.'u ~/.k".~o ?--'"J'-/ d,veway, water bodies, eto. I TANKS [] SEPTIC [] HO~,.DING~''~' Manufacturer ~ gallons ~ L~ I Material~ No. of Compartments '"'- TYPE OF SYSTEM ZX-~,~,__ [] TRENCH [] BED ~ W. DRAIN [] OTHER e.'Y~'t'/L/~"/'~..~J'~_, .~,~.~',~'. - ~l'. ~"' Depth to pipe bottom from Total depth from original grade - 1 '/~e ~-'~ :ill added above original grade Gravel depth beneath pipe Gravel length LT/~-' / FI Gravel width.~'P'-J FT! /4 / J"'"',,\ Total absorption area Distance between lines ~ Number of lines fsoil rating Pipe material ~/~./.~/' ' WELLS__.._~.~ / / [] PRIVATE I-)~v) Classification ,A,B,C, ,,T.e~afl~ept h ] Cased to / / j~F'""?.~j FTI FT REMARKS: / ^ I. Inspect. ions Performed by: I / ~- ~ ~ cedily that this inspection was perlormed according to all . Health Department Approva Date 72-013 (3/85) ' 99507 L .,...~ .... Le~ga :1." ~::~ .d::~ d :L v :i s ;i. ,.'.:~r'~ ~ L, Ulq .t r" I=.1"~ I'"t~= t L'&I t S L.c~t.: !"~ a~.;:.t, i ,:::~r"~: :34 'l"c~wr~sh :i. p: :L~?,N Range:,: 3W ~....~::~'~'. S:i.:,.e:, 25350 (sq, ft., or'. ac:r. es) !'"tax [ii) (.:.:, d r'. c~cur~.::.. ',: "f'h :i. s Fx.:,:, r~ m :i. t ',: ~:?. Tc:,t a ! Cap e.c .t '~'.. y :', 4 B ]. o c: 1.:: ~, Stii:F::' ~ I C 'TAf'~II<: !'"1 i n :i. mum t. cd:.. a 1 sept. i c t an I.:: c: apac :i. 't. y: :L :~ ~:~5() ga '.1. 1 or"~s ,, Each sept. i c: JZ .:::i l] J :; 0]t..J!i~?,. I"t~f:~.'.,/E:'-,,:~t ], E,19 ,:':':/ '::i t, :':~'i'. C:~;]f'llj::p:'MPt, f]'IE'I"It.c~,, )'.i)E,;,pt.h t.(::)t.c,p of' sept:i.c rani.:: (s) < Zl-,O f' ,~.~,'..:.::, '!.'. f' ~::, (::j~.~. :i f' c.:.) !:~ i ri s u. ]..i:L't. i c)ri (::) v ~.:.:, r' t. ,::~"1J.:: ( !:; ) ,, ].' i\J:iiii'l"AL...J .... j:::'ji!i]::i: I!i:NG .[ I',Ilii:EF:~',S AF::'I:::'I::~:OVED DES I GN. t',IOT I. F::'Y DHHS PF':'. I OR 'T'O Ii:ACH :1: NSI:::'EC T' I ON. Igl::YT'li:i: COND I "1" I ON 1:::'01=~: SECOIxlI} CI.,..I.=.!:AN C)U 'f' I='OF:~ SEPT I C ft::::l',Jl< ,, 'TH :t: !S F:'I::RM ]: T :1: S :1: SSL.JI::D F::'[)F::: THIS E X :[ ST ]: I',IG 4 BEDt::::OC)M S :1: NGLE J:::~:':~t"l :J: C '? )C:) !,'.,J E::: I,... L :[ J'".J(:':') (::)J\JJ,,..]" AJ\J:(:) J:::: ×:J:::' :J: I::;:J::::!::i (.:)N :L (,::?, /:::!; 1/90 ,, :L,, :I: am fam:i.l:i, ar' with 'L. he:, r'equ:i, rement, s for' o n -. s: :L t. e) s(:?wer's and we:l.:t.~:::: as set ~'or'th by t.l"te:, J"lur'i:i.c:ipa].:i.t.y c)~' Al"~chor'a{:]e) (MOA) ~:i.n(::J t. he St~J~.t(,:~ (])~' 2, ]: ::,J :L :L '.I. :J.l']~::t..::;~].]. t.h(-:+) ::::::::::::::::::::::: iii ac:c:c)r~clanc:e:,wit. l"i a:t.]. MOA ::::::::::::::::::::: al'Icj 3,, :!: wi'.l. 1 .:aclh(::,r~(::.:, t.c) a:l.:L MOA anti Stat, e (::)f' Alasl.::a r'(::)(::jL.~:Lr~el:ler')ts fop t.h(:.~ set d:Lst, anc:e:,s fp<::)m any ex:st.:Lng ~,.~:e:l.:l., ~gast. ewat. er' disposal system (::)r~ pul:)l~.c: :l:: (.):.:, b~ (,:.:.:, P a g (:.:.) S y S t. G:,) m (::) I'] t h i J~:i c) p a ri y ~:~ cJ ...] a (:: e n t c:) I" 1'] (,D a p b y ], (:)t.. <'::~ :J ::::. c) L,~F~cJ(:.:.:'P::~'~,,~:::I"~d '{',, J"/ ~:: t, t.J"~(:/:' :::::::::::::::::::::::::: of t. he t.c)t.a], sy.::~t,(.::,:,~:l :L::: .:J. bec!r',c~(::)ms and ~::l'"J'~.~,' Eq"i].~/:~.P~]E'iJtG::,f'it. w:LI:L r. equ:i.r.,:.::.> ar'~ aclctit, iol"ia], per'.m:J.t., <Cb,.u'"~cq.:..,r'; T ::::::::::::::::::::::::: .... WR :1: GH'I' .J .......... :..c.:... L. (:.~'~,' :'. DATE:" ALASKA enulRonmenTAL COFITROL $1 RUICI $, IrlC. t~nqineeri.~l $ I~nuironrnenlal $1udies SPECIFICATIONS FOR A FIVE-WIDE WASTBWATER TREATMENT SYSTEM LEGAL DESCRIPTION: LOT 18, BLOCK 1, CONIFER HEIGHTS SUBD. 1.0 GENERAL 1.1 The Drawings, sheets 1 thru 4, shall be a part of this specification. 1.2 All materials and workmanship shall meet the requirements of the Municipality of Anchorage, Department of Health ~ Human Services (DHHS), the conditions of the permit, and all applicable rules and regulations currently in effect. 1.3 All elevations and depths are advisory and are to be verified or modified in the field by a DHHS approved Inspector. 1.4 It is the responsibility of the property owner or Installer to adhere to approved designs for installation, to maintain the specified separation distances, and to have the appropriate inspections. 1.5 It Is the responsibility of the property owner or installer to report to the engineer any observed conditions which would put the system In violation of state or Municipal regulations. 1.6 If the installation is not inspected by an AECS engineer, AECS will not be responsible for the installed system. An engineer at AECS should be consulted prior to construction, to determine the number of inspections that will be required and to explain what these inspections will involve. 2.0 SEPTIC SYSTEM 2.1 The existing septic tank may be used, if it meets the capaclty requirements for the residence and the approval of DHHS. Older systems may need tank Integrity verified. If not, then specifications 2.2 through 2.6 apply. 2.2 The septic tank shall be a UPC-approved two-compartment tank, constructed of 12 gauge steel with bttumasttc coating, set level on undisturbed soil and insulated with overlying layer of 2 inch burial type polystyrene. 2.3 The septic tank shall be a minimum of 5 feet from 3.0 2.4 2.5 2.6 2.7 the house foundation, and a minimum of 5 feet from the absorption area. The septic tank and drainfteld shall be a mlnimum of 100 feet from any private well or body of water, 150 feet from Class "C" wells, and 200 feet from Class "A" or "B" wells, unless otherwise specified. Less than the required separation distance must have prior approval or waiver by Alaska Department of Environmental Conservation (ADEC). Piping shall be fitted with a mechanical watertight calder coupling of the inlet and outlet of the septic tank. Piping shall be 4 inch ASTM D-3034 or cast iron, sloped a minimum of 1/4 inch per foot from the house to the tank and 1/8 inch per foot from the tank to the trench. Cleanouts shall be installed as designated, capped with air-tight rain caps (Jim Caps or equivalent), and extend a minimum of i feet above ground level. If a lift station Is required, It shall be a combination lift station septic tank per Anchorage Tank and Welding, Inc. using an ORENCO lift station design. Specifications and design drawings are on file with the Municipality and with the engineer. DRAINPIELD 3.1 The gravel for the dratnfield shall be 0.5 to 2.5 inch, screened rock with less than 3 percent passing the No. 200 sieve. All substitutes must have prior DHHS approval. 3.2 The bottom and side of the excavation shall be raked with the backhoe blade to ensure that It has not been compacted during excavation. The bottom elevation shall be level. 3.3 Monitor standpipes(s) shall be placed as shown In the drawings, and shall be rtgld PVC ASTM D-3034. or 4 Inch cast iron. The section shown with holes may be drilled 0.5 inch holes on the 6 Inch centers on opposite sides of the pipe, or a regular section of perforated sewer pipe, clamped to a solid section, with either a no-hub coupling or a solvent joint. The perforated section of the monitor tube shall be located in gravel only. A 4.0 3.4 3.5 3.6 3.7 rubber rain cap (Jim Cap or equivalent) shall be placed over the top of the pipe. The distribution pipe shall be 4 inch rigid PVC with a minimum crush strength of 1500 pounds or equal. If the system is a pressure distribution system see Section 5.0. All distribution pipes shall be laid level. If the final grade of the dratnfleld is less than 4 feet from the gravel,, insulation is required using burial type polystyrene rigid board insulation. There shall be 1 inch of insulation for every foot of soil less than the required 4 feet of cover, but there must be at least 18 inches of soil cover even though insulation is used. The solid pipe extending from the septlc tank or lift station to the dratnfield shall also have a minimum of 4 feet of cover or an equivalent layer of insulation to prevent freezing of the llne. Filter fabric is required on top of rock. It is recommended that the area excavated and the area in the vicinity of the dralnfield shall be planted with a white clover, red fescue mix, or with Kentucky bluegrass. INSPECTIONS 4.1 A minimum of three inspections are required for installation of the trench. The first inspection will be of the excavation to verify that the installation will be in the proper soil. 4.2 The second inspection will be after placement of the gravel, monitor standpipe(s) and distribution pipe to verify proper installation before backfill. 4.3 The third inspection will be after final backfill, 'grading and seeding to ensure that adequate soil cover has been proved over the drainfield. 4.4 The inspection of the septic tank can be incorporated with any one of the above listed inspections. 4.5 The lift station will require either an MOA electrical Inspection or certification by a licensed electrician depending on whether the building code applies to this part of the city. 5.0 PRESSURE DISTRIBUTION SYSTEM 5.1 The lateral and header pipes are to be Schedule 40 PVC or ABS in the sizes indicated on the drawings. 5.2 The laterals are to be. level within plus or ntnus 1 inch. 5.3 Ail joints are to be solvent welded. 5.4 There shall be 2 inches of rock over the top of the headers and laterals. 5.5 The holes in the pipe are to be properly sized and spaced. 5.6 5.7 The holes shall be clean with nO cuttings still attached to the pipe or left free inside the pipe. Holes may be reverse beveled if it does not increase the outside hole size. ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. ! 200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 SHEE,,~O / CHECKED BY DATE. SCALE ..I n 0 Ill 7 '4:4 rj H H H fl H < , "": E' A 2:~'/,f ,~ ,u "r certify ~hat I have s~ryeyed th~ following described prope~=y, Lot 18 Block 1 'Conifer Heights Subdivision, Anchorage Recording Preoinc~, Alaska, an~ improvements situated thereon are wi=h£n the property lines and do not overlap or encroach on the property 1-ying adjacent thereto, that no improvements on propert? lying adjacen: thereto encroach on the p~emi~ss..in question a~d that there are no roadways, t=ansmission lines or other visiblc easements on said property except as indicated hereon- Dated. at Anchorage, Alaska this .. ;~;~ "r/,_.M day of PERFORMED FOR: LEGAL DESCRIPTION: 2 --3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST /~,.~Township, Range, Section: ~"'/,,2/L) SLOPE S~TE PLAN WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? p_ E Depth to Water After Monitoring? ,DP,~ Date: ~'-~/o~J/ / Reading Date Gross Net Depth t~ ~' Net Time Time Water (~f~) Drop COMMENTS PERCOLATION RATE ~>' (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ,'"~ FT AND y FT PERFORMED BY: t~' /~'~,'/~/ ~ I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THiS DATE. DATE: C~/~_.~/'/~ O f 72-008 (Rev. 4/85) i MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME IPHONE 7~a~ ~'NEW LEGAL DESCRIPTION LOCATION P~ 0 "~ DISTANCE TO: Iwell ~OOv Xbsorptionarea~ Dwelling q / PERMITNO~~[~g ~ Z Manufacturer ~. ~ Ma~ No. of c~artments Liq. capgci~ i~al~ns Inside length Width Liquid depth / ~ IF HOMEMADE: .~ _ _ ~ ~ DIST~TO:~~ ~Well Dwelling PERMIT NO. O Z ~ ~acturer ~~~ ~ ~ ~ Well Foundation Nearest lot line PERMIT NO. of ea~line, Tota~ length of Ii Trench ~o. of I~S s ~idt~¢ Distance bet ~ Top of tile to finish graOe ~'~ 7 Material beneath~ie g ' - inches Total effective abs~9tio~ r~ 3 / o Length Width Depth PERMIT NO. ~ Typ~~Crib~r ~th ~effec~area __ ~~ ~ ~ Buildin~dation ~ear~ liae ~ . ~ Depth Driller Distance to, IFc~ . PERMIT NO~ ~ DISTANCE TO: Building founda~on~j~ Sewer line ~ Septic tank ~/O~ Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING ~ - INSTALLER ~ - . REMARKS ~'~ [ ~ ~ ~ ~ APPROVED ~~~ DATE LEGAL ~~~ 72-01~ 825 PERMIT NO. ( ~005~ ) r.lLIr-J I C:IPRLIT'T" C~F R[-JC:HORR~SE DEPARTMENT ~- HEALTH AND ENVIRONMENTAL "~OTECTION STREET, RNCHORAGE, AK. 264-4720 I)f-J--SITE SELLER APPLICANT SAMUEL P. HILL SAR BOX 2072-H 99507 LOCATION LEGAL ~.ii,i-i~i~ ~ LOT SI ZE TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MRXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SO FT/BR)= THE REQUIRED SIZE OF 349-4747 _?.0000 SQURRE FEET THE SOIL RBSORPT~ SYSTEM IS' [)EPTH= 12 LEt~GTH= ~ [:,EPTH= /'[) I]RR~/EL THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION <IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE 8ND THE BOTTOM OF THE EXCAVATION (IN FEET). RE,_--iI. LI I RE[':-. SEPT I C: TRI'41<:. S I ZE= :1.250 GRLLOI%IS PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. Tl4Cm <2) INSPECTIONS ARE REQLIIREC, BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM R PUBLIC NELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. NELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. PERr~ I T E:¢P I RES DECEMBER 31.. :1_9:=-:0 I CERTIFY THAT i: I 8M FAMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED: RPPLICRNT SRMUEL P. HILL I::.:.UED BY ............. DRTE_-~.r-~,~,.--Q~ ..... V4. 0 """ I. ! E L_ L F! r-.I I::, PERM!T HO. ( ::' :'F'LICRNT '~" ~. ~ ']lC~ T I OH CF'E OF ':i:l'3IL H[:,.z,L~FPTICIN _, .r --, T [:.l'l I$' :~;..::II"11_.1I'1 t'.iLII'IE:EF: OF E:EDROOM':-., = ~ [:,EF'RRTIdENT or- HERL. TH RN[:' ENV IF:ONMENT[~L Pc.:OTEC:T ION STREET., ~NCHORRGE., RK. ~ :[ 264-4720 C~ r-4 .-- S I T' E :5 E 1...1 EFt F' E R Pl I T LO-r S I ZE ~ 00-z~O '~::OURPE FEE']' SL-.I I L F:P3'T I HG ,': Si] F T,"E:P 7:, = ~ ~0 THE I_EI'.~GTH [:,IHENSIOr~ IS THE LENGTH <IN FEET.'., OF THE I"REi'-,4]:H C;I;: DRF!INFIEL[:'. THE [:,EF']'H OF FI TRENC:H OR PIT IS THE [:,[S?,~I"IC'E 8ETHEEH ]'HE SIJF:FFtCE OF THE (JRf'~UI'.I[:, Ri'.IC, THE E~OTTOH OF THE E,.-:,_.FIvHTION (IN FEET:, THERE IS NO '_--,E! HIlt, TH FOR TRENCHES THE ~RFI,,,EL [:,EPTH IS THE MINIMUM DEPTH OF GRFiVEL E:ETHEEI'.,I THE nLrTFFILL PIPE RtlD THE 80'TTr3M C;F THE ~.._..-,_.nvn/lCll"J <IN FEET/' ;F:t,I[T RPF'LICFff,IT FIRS THE RESPOt.~SIBILIT'¢ T() INFOF.:M THIS DEF'F~RTMEt'.,rI' [:,UF'Ii'a] THE ,I::,THLLRTIC'IH'- " II'.,I%F'EC:TIOI"~ OF FINY HELL'--, F:IC:,JFtC:E. HT TO THIS FF.LIFEF. T~ AH[:, THE .IME',ER OF FtESIC, ENCES THFIT THE HELL HILL SERVE. '1- ! -.1C~ ,-'. 2 .-':, I I'-t '_=:.. F' E Ct.- T' I L-'~ !'-I '-;E; Ft F: E3 I:.~: E C::.~ IJ Z F.: EE [.'.':, iF'.KF ILL I I"a] OF RH'¢ ,_,, _ TEH 14 [ THOLIT F I t'.,IF{L I r. ISPEC:T I OH RN[', FtPF'F'i'iS,'FtL E"¢ l H ! ~F'FIR TMEHT 14 t L.L E:E '.::LtE:..!EC:T TO PROSEC:LIT ! ON. 't.lIrffl_ll',l [:,ISTfiI',ICE E:ETWEEN R HELL RH[':, Rl'.~"r' ON-SITE SEHRG[:. C:,ISF'OSRL ?¢:ST'Erq ~0 FEET F'OF: Fw F'RIVRTE HELL OF' 150 TO ':::00 FEET FF.:OI'~ R F'UE:LIC HELL -'0~ THE TYF'E OF F'L1E:LI(: :HIHUH [:,[~T~NC:E FROH F~ F'RIVF~TE HELL TO ~ F'RI'v'RTE SEHEF: [_.I[~E IS 25 FEET ~ F~ COMr, IUNIT'T' SEi, IE~; [_IHE IS 75 FEET ]_t LOGS RRE- REOL, IRE[:, RNC, MIJC~T [~:E F:CTLtRt~E[) TO THE C:,EF'FiF?THEHT H[THIH ?0 THE HETL.L C:OMF'LETIOH 'HEFt F:EC~I.tlF:EMEN]"'~: MRY RF'F'LY fi:F'EE:TFIC'RTIOHS RND C:ONSTRI. iCTION [)IFaGF:F~HS ~fiF:E .'F~II_flBLE TO [t.~:~I.IFiE PROPER It~%Tfa!._LFtTIOtl CEF:TfF'¢ THHT I Rt.1 F:,~:~HILIRR NiTH 'THE REQLilREMEI',~TS FOR L-~I'-~-SI'FE SEHEF:S RH[:, HELLS AS-; SEf iR'tH DY THE HUH ~ C: I F'Fit_ I TY OF RHC:HOF:RGE. I HILL. II'-tSTRL..L. THE SYSTEM IH FIL-:COFi:['*RHCE I,II'TH THE Ii:ODES. I IJrIC, EF'STFtt.4C, THAT THE OH-SITE SEI4Et~: SYSTEM I'tF-~Y PEC~UIRE Et'.ILFIF:GEP1ENT IF THE 'ZIE:,Et. IE:E IS FTEHOE:,ELED TO I I-IC:LUE:,E HOY, E THRt'I ~ f-~ F'F'L I ',,,',l. 0 R. J. Kramer SRA Box 77-L Anchorage, AK 99507 August 12, 1980 Mr. Sam Hill Design in Wood Ltd. SRA 2072-H Anchoraqe, AK 99507 REF: Test hole and soil log report for Sanitary System, Lot 18, Block 1 Conifer Heights Subdivision Dear Mr. Hill: I am submitting herein the boring logs and comments regarding soil conditions encountered at the referenced site. This investigation was performed in accordance with your request of August 9, 1980, and those procedures outlined in the Manual of Septic-Tank Practice, and a study of On-Site Sewage Disposal system in the Greater Anchorage Area Borough, Anchorage, Alaska. A single test hole was excavated within the Lot 18 area for the purpose of defining the general subsurface ~oil conditions and performing percolation test for the proposed sanitary system. The location of the test hole is shown on Drawing 1. Excavation was performed with a JD540 with a 16 foot backhoe. Test hole was excavated down to 16' below the ground surface. A soil log was prepared and soil identified using the Unified Soil Classification System. The soil was classified as ML gravelly sandy silt from 0.5' to 6.5' level and ML sandy silt from 6.5 level to 16.0 level. These classificaitons did require a percolation test. Ground water was not encountered in the test hole. The recommended Absorption Capacity is 270 square feet per bedroom based on a Percolation Test. Should you have any questions, please contact me. Very truly yours, R. J. Kramer MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ,,~ SOILS LOG ,¢..~ ~.( PERCOLATION TEST PERFORMED FOR: LEGAL DEscRIPTION: Z<~)'~- 1 2 3 4 8 9 10 11 13 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? SITE PLAN WO S L O P E 14 15 16 17 18 19 2O COMMENTS Reading Date Gross Net Depth to Net Time Time Water Drop ~ ,,. ~,~-7 .~.~. ~,, ~ ,, ~ ~.'1. I ~ /~,.5" ~.~" .~ ~.'~-o ) ~ i~,~" I, ~-" PERCOLATION RATE -~'~ (minutes/inch) TEST RUN TWEEN <:~ FT AND ~ FT 72-008 (6~79) * Fou~ ) 5c~c~-: /"= 4-0' 'oo~) Lo~- /5- 9'? MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # OI ~'- O'~3 - .~' ! 1. GENERAL INFORMATION Complete legal description Lot 18; Block ": HAA # Conifer Heights Location (site address or directions) 7721 Port Orford Drive Anchoraqe, AK Property owner Mailing address Deborah Richards 7721~Port Orford Drive Day phone 346-1843 Anchorage, AK 99516 Lending agency ..~ Mailing address Day phone Agent, Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 ~ TYPE OF WATER SuppLy: Individual well xxx Community well Public water 'NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 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. S & S ENGINEERING Name of Firm I."C34-=,~;=. ~,wr" Loop -.eau' .o" .~''zv,~ Phone Add tess 99577 Eagle RJve~,/~ska Engineer's signature ~. ~/ tZ ~_,~,--. Date DHHS SIGNATURE Approved for Disapproved. Conditional approval for concentrat~mn ~ 6.15 mE~1. More information on nitrates DHHS, 343-/:7/:/:. bedrooms. bedrooms, with the following stipulatiOns: Note: The well for this property meets existing State and Municipal Codes. There are nitrates present. It is suggested that periodic testin~ be performed to insure the wells continued suitability. Current nitrate EPA m~w4mllm ~n~Pn~t4~ ~8 ]0.~ ~g/], is available from the On-site Services Program, By: /~'/~&~"-'-'-~---C /~'~ Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutiOns in order to satisfy certain federal and state requirements. Employees of DHH$ 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-O25(Rev. 1/91) Back MOA#21 MUNICIPALITY OF ANCHL.)RAC~- ENVIRONMENTAL SERVICES DIVISION blunicipality of Anchorage 0CT27 19g?{~) DEPARTMENT OFHE,~,I~TH & HUMAN SERVICES Environmental Services Division R E C E ! V E ~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: Health Authority Approval Checklist ~.~,. v co,,~..e~ /+TS Parcel I.D.: {g I E' -- 0°1 3 -- S" i A. WELL DATA VV"ell type ?/~ ~'4 4 ~' e. If A, B, or C, attach ADEC letter. ADEC water system number Log present (~/N) "~ ~ '~' Date completed Total clepth ~, ;), '5 Cased to ~/o- + Sanitary seal (~N) ~/(' '~ Casing height (above ground) Wires properly protected ~N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform C~ FROM WELL LOG Nitrate Date of sample: ,/0/ ~-~ B. SEPTIC/HOLDING TANK DATA g.p.m. Collected by: AT INSPECTION / g.p.m. Other bacteria $ & S ENGINEERING Eagle River, Alaska 99577 Date installed c~/~/ ~'0 Tanksize 13..s-o Number of Compartments ~'- Cleanouts(~/N) Foundation cleanout {~N) ¥ e-)" Depression (Y~ ~' ~ High water alarm (Y,~. ~v o Date of Pumping ~/I '/ / '~ 7 Pumper / ~' ,9 ~ ¢ J' C. ABSORPTION FIELD D/!~TA0 Date.installed fl / ~.e / q 0 Length H ~' ' Width t3 Soil rating (g.p.d./ff= or fff/bdrm) } 5' J System type , ~ ' Gravel thickness below pipe 3. ~ Total depth Effective absorption area q Date of adequacy test I o / · k / q 7 Results (Pass/Fail) P 4- s J For Fluid depth in absorption field before test (in.); b 4. ¥ Immediately after ~4~ gal. water added (in.): Fluid depth ~ ~/a (ins) Minutes later: 30 Absorption rate = GoO "t- g.p.d. Monitoring Tube present [~N) ¥ ~'Depression over field (Y/I~ H 0 bedrooms I/ Peroxide treatment (past 1~2 months) (Y/N)~v0,''~ 7~-026 (Rev. 3/g6)* If yes, give date o ~-~: B~Lce ,/ ~R.4~( D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) ~.~"'"'"'-'~ "Pump off" level at* High water alarm level at* ~ *Datum Cyc~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line I )oo + On adjacent lots ! t 0 o ~ On adjacent lots ~ / ~r Public sewer manhole/cleanout "~ ~ f '~'~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~ t ~ Property line Absorption field Water main/service line lO/~- Surface water/drainage / o 0 ~+ Wells on adjacent lots Ioo /,J.-. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line I o / '/" / Building foundation 1 o 4- Water main/service line Surface water I o 0 ~ Driveway, parking/vehicle storage area Curtain drain ~,, 0 ~ ~. ~: ," ~ '~' ~ Wells on adjacent lots t 0 0 F, ENGINEER'S CERTIFICATION Engineer's Name Date I certify that I have determined thru. field inspections and in conformance with MOA HAA guidelines in effect on this date. 1'¢ x C . review of Municipal reco,~"'~Ea~~s are 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 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. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot Location (site address or directions) 7721 Port Orford Anchorage, AK ProPerty owner Mailing address Lending agency Mailing address Thomas Blakcn~y 7721 Port Orford Day phone Anchorage, AK Day phone Agent Ol~r2o~. Sah~osst~J.n/ REMAX ANCHORAGE Address 2600 Cordova St. #I00 Anchoraq~, Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 --v TYPE OF WATER SUPPLY: Individual well ×XX NOTE: Day phone 257-0106 AK 99503 Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: XXX Individual on-site Holding tank Community on-site _. Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the M~nicipality 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. Engineer's signature Phone Date ' ~///~- DHHS SIGNATURE ~ Approved fOr Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: By: AdditionalComments Note: The State and Municipal Codes. There are nitrates present. It is ....................... the continued suitability. Nitrate concentration is 4.3 mg/1. EPA ~~m Cuncunt~tiun i~ 10.0. rog/1. 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 courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lo?- [ ~ I~L~ / ~o/~/Fe'-i'~. HT'$~/-)Parcel I.D. A. WELL DATA Well type Log present ~N) Total depth Sanitary seal If A, B, or C, attach ADEC letter. Date completed Cased to Date of test Static water level Well flow Pump level FROM WELL LOG /.5- SEPARATION DISTANCES FROM WELL TO: Septic/imm~i~tank on lot .//~-~ ~) Absorption field on lot Public sewer main Sewer service line '~5 Wires properly protected ~)N) g.p.m. ADEC water system number /f-////'~ ?/11/ga Driller --%~/'/~(=~/J r~o$. PlelCC/tvL5 Casing height /~- '~ AT INSPECTION ~;:~ - ~' l /z / ""' g.p.m ~ ~ oO ; On adjacent lots ; On adjacent lots /0o ?- Public sewer manhole/cleanout Petroleum tank .~6 WATER SAMPLE RESULTS: Coliform ~)//0~>/~ ~ Date of sample: C.~/~-/~ ~ Nitrate Collected by: Other bacteria Date installed ?/Z. CleanoutsON) ??5_5' High water alarm (Y(~ ateo, um ,n Tank size / 2_-3"<~ Compartments Foundation cleanout(~N) .'7"~ . Depression (Y/~._)~ Aiarm tested (Y/N) /,~'//,/r Pumper ,~'"~' Hot'~ g' SEPARATION DISTANCES FROM SEPTIC/~B~J~"-I'ANK TO: Well(s) on lot /00 ' · On adjacent lots To propertyline :~'~' / Cbsorption field "'/~ Surface water/drainage /oW/cT /°/'~ Foundation ~ Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION /~JO/,J&~ Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) ; "Pump on" level at '~el at High water alarm level ~les tested Meets MOA electrical codes (Y/N) SEPARATION DISTAN¢.B-F'R~M LIFT STATION TO: Well on.J~~ Surface water On adjacent lots D. ABSORPTION FIELD DATA (-}~IGI~J¢~5~E /'0// . . ~ ?0 1~ / Date installed ~/Z~ /Zo/~O Sollratlng ~ ~( Width Length ~ ~ Gravel thiokne~, ~ ' System typ~"~/I/..5~ Total depth Total absorption area Depression over field (Y/(~ Results(~ail) Peroxide treatment (past 12 months) (Y/N) Cleanouts present ~'N) Date of adequacy test for 4 /-tjC.t.d fJ If yes, give date bedrooms SEPARATION DISTANCE FRgM ABSORPTION FIELD TO: Well on lot !/4/' On adjacent lots //~ ~'~ Property line /~ /' TO building foundation ~ O! /(.///t~ TO existing or abandoned system on lot On adjacent lots ~--~(--~ ~ Cutbank /c]o~Ae'-JE~J~' Watermain/service line ~----~' ¢ Surface water Driveway, parking/vehicle storage area '%"-J'(--~ ' Curtain drain /L)oxJ~ E. ENGINEER'S CERTIFICATION n fo~~ I certify that I have checked, verified, or co A and HAA guidelines in effect on the date of this inspection, . Signature__ Engineer's Name Eagle River, Alaska ~*'~ ;: .',~,..';,~.~,, ......... ;~~~,, HAA Fee $ / 7 Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING (r'~/~c-_ O?J~-,.I"/ HAA# //~,~L.'~O~ ~'-~'~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address~.r 'd,i.rec, tions),' (b) Properfy'o~'t~'r".:!.;/~'.~i¢'// A)F,,//47z Telephone '(home) ~'P3'".4~2J~ Business '.",-". ,.¢¢: Mailing Address' , . · , (c) Lending Institution : '~ Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here J~, 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 ~' 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-site,Ji~. Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 · ~po~ sjeeu!l~ue I8UO!SSejoJd eql u! suo!ss!~uo Jo sJo~e Joj elq!suodse~ lou s! e§eJoqou¥ jo ~l!led!o!un~ @qJ. 'penss! s! el~o!jBJeo e eJojeq e~ep eZ~leUe ~o suo!loedsu! lonpuoo lou op SHHQ jo see~oldLU3 's~ue~ueJ!nbeJ elm, s pu~ I~Jepet u!~peo ~js!l~s o~ JepJo u! suop, nl!lsu! ~u!puel J!eq], puc seuJoq jo sJes~qoJnd ol XselJnoo ~ s~ s!ql seop SHHQ eq/ '~tSel¥ jo e],elS eql u! peJe~,s!§eJ ~eeu!§ue leUO!SSejoJd luepuedepu! u~ ~q e^oq~ S qde~Se~ed u! UeA!§ suop,~luese~deJ eql uodn XlUO peseq pm, eo!j!Jeo le^o~ddv Xlpoqlnv qlleeH senss! (SHHQ) seo!^~eS UeLUnH puc qllee, H jo lueLmAedeo e6e~oqouv ~o ~!led!o!unlAI eq.L penuT~uOO s,II~ ~q~ e~nsuT o~ p~o~z@d ~q 6UT~S~:'OTPoTz~d~'~q~ pe3s~BBns sT gI 'gues~ad seg~Tu s~ e~qL 'sepQ~ i~dToTunM pu~ ~S BuT~sTx~ s~m X3~do~d sTq~ ~o~ II~ ~qL ~:~oN leAo~ddv leUOp,!puoo ;o SLUJe.I. leUOp,!puoo peAoJddes!cI 'x~ peAoJdd¥' .~ JO~ PoAoJddV 'lVAOblddV SHHa '9 A. WELL D/~ Well Classification MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: /- Well Log Present QN) Date Completed Total Depth ~.Z.~ "Cased to'~ Z25 Depth of Grouting u,~ ~_~.,,e0 If A, B, C, D.E.C. Approved (Y/N) ~/fl/~"O Yield ,.~ 7 ¢/~.~'~ ,.~/~ Static Water Level /~ · Casing Height Above Ground Electrical Wiring in Conduit ~N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by ,~, Water Sample Test Results Comments ~.9,,¢' ? ! /~' Pump Set At Sanitary Seal on Casing (~N) Depression Around Wellhead (Y/~ ;On Adjoining Lots ,,,)/P~ //'/ / ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ,'~'"',,~ ;Date B. SEPTIC/HOLDING TANK DATA Date Installed ~'b~'//ff'~ Size Standpipes ~)N) ''~ Depression over Tank (Y/([~ I Z..~O No. of Compartments Air-tight Caps ~N) Foundation Cleanout Date Last Pumped ~/1¢',~ Pumping/Maintenance Contact on File (Y/N) ~J,/'~ ; for ,~)//,R HoldingTa~r~k High~.Water~Alarm (Y/N) .,'d/bt Temporary Holding Tank Permit (Y/N) SEPARATION'D~I$TANcEs. FROM SEPTIC/HOLDING TANK: To Building Foundation ,'? '/ To ~Vater,-~uppty,,W, ff]'~;j'. ./,0/ To Prope~ty, Lir3e,- .... 5'"[ / To Wate~'Main/~erv~ce;'Lid~:~ - ) ~.c' / To Stream,-Pond, LaEe or.M~jor Drainage Course Comments ,~-.e/' ~' To Disposal Field 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ?,/~-~/.~ Width of Field : /~/ ,~/,~J Type of System Design Length of Field ~,~',~ Depth of Field /~lJ~J:~? Gravel Bed Thickness /~) Square Feet of Absortion Area /~'~:)., /-7/ / ? Statndpipes Present Depression over Field (Y/¢ Date of Last Adequacy Test Results of Last Adequacy Test ..2Y'~?,~¢).- -5~?.r'~/-¢~ /¢-~,/¢J. SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area / //~/ / TO Property Line ¢/~'.,, ~-~'/ / _~_/ ,., 7~ To Existing or Abandoned System on ; On Adjoining Lots .~ ~ Z-J"- ~ To Cutback (if present) Comments Dimen/ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at A/ Vent (Y/N) Tested for Meets MOA Electrical~) Comments Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have check§d, verified, or conformed to all MOA and HAA guidetines~f~_~b~he date of this Comp n - /) Date Receipt No. ~- Date of Payment Amount: $ Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Sack Page 2 of 2 MUNICIPALITY OF ANCHORAGE ~ f ~ DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 18 Block 1 Conifer Heights Subdivision Location (address or directions) 7721 Port Orford (b) Property Owner Terrell Wright Mailing Address Telephone: Home 346-3252 Business 265-6936 (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the fotlowinc] address: or: Check here I--], if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family:[~ Number of Bedrooms Four(4) WATER SUPPLY Individual Well E~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite Dx 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. Page 1 of 2 72-025 fRev 8/86~ Front 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. Name of Firm Bevan Engineering Telephone 522-1383 Address Box 112852, Anchorage Date Engineer's Seal Note: Recommend installation of cleanout for second compartment of septic tank. Estimated cost of this installation is $200.00 DHHS APPROVAL Approved for four(4) bedroomsby ~ ~' ~~ Approved XXXXXXXXXXXX Disapproved Conditional Date March 19, 1987 Terms of Conditional Approval 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 courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 fRev 8/86/ Back MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date -"~-//~- ~.~ GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property Owner _/~'f,/"~'/"/' /~-/~/~'~_,,t5/'-,~' Telephone: Home Mailing Address " Business 2'~'.¢'- ~'¢..~- (c) Lending Institution """ ',', Telephone Mailing Address ~' (d) Real Estate Company and Agent Address Telephone Mail the HAA to the followin(~ address: or: Check here [-I, if hold for pick up. List contact person .and davy phone number below. (e) TYPE OF RESIDENCE Single-Family/~/ Number of Bedrooms WATER SUPPLY Individual Well~J~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite/~ 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. Page 1 of 2 72-025 fRev 8/861 Front 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, t 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 ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ,~'~-,,"~z'~",,~ _ Telephone Address ~"~'o~ ,/'/.~,~' .~"~.-.,'"~' d' Date -"~-//- DHHS APPROVAL Approved for --~,--/- ~"~) bedrooms by ~/~ ~;1' Approved Disapproved Terms of Conditional Approval ~c~.-~'~- ~," Date '""~'~ fi- ~ ~ Conditional 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 courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-o25 fRev 8/861 Back BEVAN ENGINEERING June 8, 1987 Municipality of Anchorage Department of Health & Environmental Protection 825 "L" Street Anchorage, Alaska 99501 P.O. Box 112852 Anchorage, AK 995 ! ! (9O7) 522-t383 ~," .'NICIPALITY OF ANCHORAGE DIFpT OF HEALTH & ENV R,',gr,iMFNTAL PROTECTION JUN 8 lg87 RECEIVED Re : Terrell Wright Health Authority Approval (HAA) Application Lot 18 Blk 1 Conifer Heights Subd. Gentlemen : On February 28, 1987 I submitted a Health Authority Application to your for the referenced property. On the HAA Checklist I recommended that the owner locate the second standpipe on the septic tank after breakup. This recommendation was based upon my concern that the second chamber of the tank contained a large amount of sludge. The original pumping receipt showed that only 900 gallons out of 1250 had been extracted~by the pumper. Since that time Mr. Wright has had his tank pumped again and backflushed. The second pumper had a more powerful pump and was able to pull a heavy bottom deposit out of the tank. The working volume of the tank is now up to the intended 1250 gallons. Since the septic asbuilt only shows a single tank standpipe and since the installation of a second pipe would require the partial disassembly of Mr. Wright's deck, I request that the conditional on the second standpipe be removed from Mr. Wright's Health Authority. Sincerely, Hugh R. Bevan P.E. 87207-ws MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Prope.y Owner ~r~/ Mailing ~'ddress. .. (c) Lending Institution *_. Telephone Mailing Address Telephone: Home '~"¢ Business (d) R~aI.Es,tate C,o?,pany and Agent Address Telephone. (e) Mail tl~'e HAAto the~followin~ address: or: Check here r-l, if hold for pick up. List contact perso.n ~and day phone number below. TYPE OF RESIDENCE Single-Family/~ Number of Bedrooms WATER SUPPLY Individual Well~ Community [] Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite/~ 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. Page I of 2 72-025 fRev 8/86~ Front 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 flies 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 ~,.~J/"~"";'~.~/,~ Telephone Address Date ~'-~'~'- DHHS APPROVAL Approved for "~'"'¢' ~/~ bedrooms by ~ /~2' '~'/e'~ Date Approved Disapproved Conditional Terms of Conditional Approval ,~E....~,~,,, 1~'/.~ /o ~.~.~__ 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 courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 fRev 8/861 Back WELL DATA MUN . src~:~TY OF ANCHORAGE (MOA) ~N¥~O~ HEALTH AUTHORITY APPROVAL (HAA) [~TCHECKLIST - FEBRUARY 1984 ~R 3 2~-4744 RtC[~[O LegalDescription:~/~ ~ Well Classification ,./~/~'~ ~ Well Log Present (Y/N) Total Depth Z'.~' 3 Cased to -,~'~ Static Water Level /,~c/~,., ~ ,,.~,¢~,,~., Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E.C. Approved'(Y/N) Date Completed -~"'/'"'- ,~' Yield Depth of Grouting ~.~ Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Nearest Edge of Absorption Field on Lot ,,/'¢ ~' -~ To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by To Nearest Sewer Service Line on Lot ,,'~'~'~'~",=~'-, ' Date ~--Z' 7- ~' · On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Water Sample Test Results Comments SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Size'~ '~.,/~"'/~/¢~¢'~/No. of Compartments Air-tight Caps (Y/N) Y Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ,,/~":' ''~ To Property Line ~',,~ To Water Main/Service Line Course ~.~ Foundation Cleanout (Y/N) ,,~ Date Last Pumped ~-/~ ~ , for ~ Temporary Holding Tank Permit (Y/N) --"-' To Building Foundation ~'~ To Disposal Field ~ To Stream, Pond, Lake, or Major Drainage Page 1..of 2 72-026 (Rev, 8/861Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field '~'~/'~/" Type of System Design '-/~-'~¢ Length of Field ~/ Depth of Field .';//~--~"~,'~'~/. ~-'~ .' Gravel Bed Thickness /'~'~ Standpipes Present (Y/N) /V' Date of Last Adequacy Test Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line /<~ ~' To Existing or Abandoned System on ; On Adjoining Lots /c~ ~ To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that~.e~c~e.~d, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ';;"~'. ~~ Date '~- ~--~- ~,~' Company '~ ' ~J-'~ Receipt No. Date of Payment ~ - ~ .- ~7 Amount: $ Page 2 of 2 72-026 fRev 8/86/ Back BEVAN ENGINEERING Approved Well & Septic Engineers P.O. Box 112852 Anchorage, AK 99511 (907) 522-1383 (907) 258-0584 March 2, 198'7 Munic:i, pality cfi: Anchorage Departmer~t o.F I-.tea].tln & Environmental F'ro'bect. ion 825 "1...." Str'eet Anchorage~ A].aska 995~:l IRe ,',' 'l"err'ell Wr':i. ght Health Au'~.hc)r'ity Apprc:~val (HAA) Application Lot :L8 Blk :1. Corli.J:er H~ic.]ht.s Ger~t 1 emen During the per"iod .J:rom F'ebruary 26 ta I::'ebruary 28, 198'7 we per.J:ormed reseat'ch, site inves'bi(.:jat, ion.s, well. ~:low test:Lng and absorpt:i, on .J:ield te.sting I:~ursuant. to Hea].tl"~ Aut. hc:}r':i.'by Appr"oval c:}n the abave re.t:erenced ].at. We per.Formed a well .~:].ow test. anc:l ,Found the well produc::tion to be 6.2 ga].lorls per" mil"lLv~:.(:~ (gpm) . "l"h:i. s exceeds i:he r"equi r'ed i:l,, 4167 gpJn .I;ar' a 4 I:)ec:lr'o(~m hc:>me. We took a water" sample .For Co].i.Form analys].s ar'id the resu].ts wer"e negative. We per".~ormed an adequacy test on t. he sept:Lc system and determ:Lned t. hat. it absorbed at a rat'e o.F 638 gallons per (day (gpd). This exc:eeds the 6~]~1.;~ gpd re. qu:i. red Yar a 4 bedroom hame,, The septic tanl.:: was pumped prev:Lc)usly al]d t. he w:)lume c.~.~: record is :1.251]] gallons. '1"o c:)ur knc;w].edge all o.( t. he in¥ormatian request, ecl c:~r'l t. he HAA Cl"~ecklist' and Applic:atiorl has been asseml]led. We are subm:i.t, ting this data to you ,For your" r"ev].ew. F."lease (:::c)ntac:'~ us i'~ we: can provide any acldit.:Lc~nal 'i.n¥or'mat.:i.c.~r'~,, At'~:achment s : HAA Appl:i. cati HAA []hec:klist Sewer' As'""bui ].t Or"igir'lal Sc:)i].s Inves'~iga'bi~rl Or i g i rial To'l:al Coil.Form Analysis Sept:i.e. F:'umping Rece:~ pt cc Terrel]. Wright 872~F7.....ws HOME SERVICES 15900 Francesca Drive Anchorage, Alaska 99516 345-1890 or 345-2444 INVOICE CUSTOMER · Terrell & ~/Iona Wright 7721 Port Orford Block / LOt /~ DATE DESCRIPTION AMOUNT .....:.? :?..' .... ' T~AL . . REMARK. .... · ~.:~ ~ PROBLEM AREA--CALL FOR MORE INFORMATION ~ NEEDS ~ BE DONE AGAIN IN ~MONTHS . / D Good Shape ~Sludge buildup on bottom D Floater on top D Jim cap missing or D Cut standpipe to 1' above ground D Needs Septictrine needs replacing ~ ...... . ......... --PLEASE PAY FROM THIS INVOICE-- 1. General Information Application Date / (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicants Address (c) Applicant is (check one) Lending Institution ~--~ (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address (f) Telephone Mail the HAA to the following address: 2. T_~e of Residence Single-Pamily~ Number of Bedrooms 3o Water Su_~ply- Individual Well~ Multi'Family~--~ Other (describe) Community ~ Public ~_~ Note: If community well system, must have written confirmation from the State Depar'tment of Environmental Conservation attesting to the legality and status. 4. Sewage Di_s_posal Onsite ~ 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° [Page 1 of 2] 5. Ensineerin$__~rm Providing Inspections ~ Tests~ _ As certified by my seal affixed hereto and as f the va i ion d verify 'ghat my investigation of this Health Authority Approval sho~ 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 Mu.micipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or w~stewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. -' Name of Firm Address bedrooms Disapproved DHEP Approval Approved for -7' Approved Telephone e Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSI/ES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 INSTITUTION~ IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. 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. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 ao MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Well Classification ~z~6~a- ~ Well Log Present (Y/N) y Total Dspth ~ / Cased to Static Water Level ~ MUNtCIPADTY OF ANCHORAG2 DEPT. OF rIF:ALT,Xl & J t 5 1985' Legal Description: If A, B, c~ C~ D.E.C. Approved(Y/N) Date Completed ~/~ _ Yield --- DaDth of G~outing Casing Height Above Ground Electrical Wiring in Conduit (Y/N) ~ Sepsration Distances f=cm Well: To Septic/Holding Tank on Lot /00+ ,, Sanitary Seal on Casing (Y/N) Y Dap=ession A~ound Wellhea~ ; On Adjoining Lots To Nearest Edge of Absc=ption Field on Lot ~9~- To Nearest Public Sewer Line 4//~ To Nearest Public Se~r Cleanout/Manhole ~//~ To Nearest Se~s~ Service Line on LOt Water Sample Collected By ~/. ~ · ~ Date ~/__~/~_~_~ water s le Test sults Ccearents ; On Adjoining Lots loc + B. SEPTIC/HOLDING TANK DATA / Date Installed $/~o Size 12~ ~4z No. of Ccmpa=tmsnts Standpipes (Y/N) ~ Air-tight caps (Y/N) ~ Foundation Cleanout (Y/N) Dsp=ession ove~ Tank (Y/N) A/ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) -- ; ~or~ Holding Tank High-Water Alarm (Y/N) -- Temporary Holding Tank Permit (Y/N) Separation Distances fzcm Se9tic/Holding Tank: To Water-Supply Well /00~- To Building Foundation To Property Line To Water Main/Se=vice Line Course Ccn~ents To Disposal Field ~ ~ / To St=earn, Pond, Lake, c~ Major Drainage Receipt % ~0~'~ ~5~ Date Paid: ]~~-~ Amount: ~ .~- [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD D~TA Soils Rating in Abso~tion Strata Date .Installed ~/~o Length of Field ! Width of Field ~ ' Type of System Design Depth of Field /2_- I ~ z Gravel Bed Thickness /~' Standpipes Ihtesent (Y/N) Date of Last Adsquacy Test Square Feet of Absorption A~ea . /280 Depression over Field (Y/N.) A/ Results of Last Adequacy Test Separation Distance f~cm A~sc~ption Field: To Water-Supply Well /sds- To P~ope~ty Line To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/c~ Majo~ D~ainage Course To D~iveway, Pa~king A~ea, o~ Vehicle Stc~age Area ~ :Z~' TO Existing o~ Abandoned System cn ; On Adjoining Lots ~//9 . To Cutbank(if p~esent) Comments Date Installed Size in Gallons "Pum~ On" Level at High Water Alarm Level at Tested fo= Ele~ical Codas(Y/N) Cc~ments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) I~ing Cycles du~ing A~equacy Test. Wsets MOA ** ** Check Permitted Bed~oo~ Rating Against HAA Request I certify that I have checked, verified, c~. ~onfc~d to all MOA HAA Guidelines in effect on the date of_~is ~ctic~. Signed , . c any , KB1/d5/s [Page 2 of 2] / MOA No. 2-15-84 BESSE, E & POTTS January 15, 1985 Municipality of Anchorage Depar~nent of Health and Environmental Protection 825 "L" Street Anchorage, AK 99501 Att.n: Keith Bandt Re: Adequacy Test - Conifer Heights Subdivision Lot 18, Block 1, Anchorage Dear Mr. Bandt, On January 14, 1985, the referenced on-site lot septic tank was pumped out and approximately 1000 gallons were recovered. The same day 650 gallons were loaded into the on-site leach field and it was found to be adequate. Sincerely, Robert P. Wessels Engineer RPW/lbs ENGINEERING, PLANNING, SURVEYING 2220 E. 88th Ave./Anchorage, Alaska 99507/Telephone 907-349-6451/344-1352 "Providing a quality personalized service to those building Alaska's future" Location: BF~kSE, EPPS & P(YFTS 2220 EAST 88 AVenUE AN~K~AGE, AK 99507 (~7) 349-6451 WATER ~ELL TEST Subdivision: Block: Address: ~ 73 1 ~*~ O~;~&2 d Tester: Initial Reading on Meter: /o, '5. ,o ~o GALLONS TIME GPM A VOLUME , TOTAL VOLUME /n: &~ 5.3 7~o Production Rate: ~-2_ GPM 24-Hour Capacity --- Gallons CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.. TELEPHONE (907) 562.2343 ANCHORAGE INDUSTRIAL CENTER 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER Water Systen~Name'/'/- / Phone No. ciw State Mo. Day Year Zip Code SAMPLE TYPE: [Routine Check Sample (for routine sample with lab ref, no, [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. 2 LOCATION Tim Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ,~Satisfacto~ I'-] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send riew sample via special delivery mail. Date Received /- I Time Received Analytical Method: [] Fermentation Tube [] Membrane Filter Lab Ref. No. Result* Analyst I rT3_ I FTq I Frq I Fr~ eNO. ol colomel/100 mi. or No. of PoIilI'~I porllonl, oe4 a~o (b) Rev. BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter:. Direct Count Verification: LTB Final Membrane Filter Results RepoSed By - BGB Date Time: TNTC = Too Numerous To Count CoilformllO0ml CoilformllOOml DATE RECEIVED DEPARTMENT OF HEAL~ & ENVIRONMENTAL PROTECTIO~EPT. OF l lEALTH & 825 L Street- Anchorage, Alaska 99501 ENVIRONMENTAL P~OTECTION ENVIRONMENTAL SANITATION DIVISION ¢,10V 5 1980 Telephone 264-4720 DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing, 1. PROPERTY OWNER j PHONE MAI~ING ADDRESS PROPERTY RESIDENT (If different from above) [' PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDINGINSTITUTION ~0~ PHONE MAILING ADDRESS 4. REALTOR/AGENT PHONE MAILING ADDRESS LEGAL DESCRIPTION STI~ EET'LOCATION 6. TYPE OF REj~IDENCE ~SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOj~ [] One ~J Four [] [] Two [] Five [] Three [] Six Other 7. WATER SU/PPLY [~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTI LITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM /_-~1 N DI VI DUAL/ON-SITE** [] PUBLIC UTILITY / ~ ~) YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVI DUAL/ON -SITE []PUBLIC UTILITY Connection Verified I--ISeptic Tank or [] Holding Tank Size: ( .~-0 If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line NUMBER OFBEDROOMS [] ONE [] TWO [] THREE [] FIVE [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING MANUFACTURER ~ MATERIAL Septic/Holding Tank IAbsorption Area ISewer Line [] OTHER INearest Lot Line 5. COMMENTS BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) DATE [] DISAPPROVED 72-010 (Rev. 6/79)