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Home My WebLink AboutMOUNTAIN PARK ESTATES #2 BLK 4 LT 23Mountain Park states lock 4 Lot 23 · ! 7-023 -23 Municipality of'Anchorage · Development Services Department :~ [~: Building Safety Division On-Site Water and Wastewater Program, 4700 S. Bragaw SL '~ ~" P.O. Box 196650 Anchorage, AK 99519-6650 Page ~ of3 www. ci.anchorage.ak.us (907)343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: -~ ~ Ot'/L~]~'-'~ ~ PID Number: 017- 0~-3 - .a.~: 5+~ %/g'/~ T}'"o"~ Wastewater System: [] New ~'Upgmde ~ Ruling: ' Grav~ Leng~ Numl3~L~llnes: I I:X.~ance be~-n aries: SEPARATION DISTANCES : ~'seplic [] Hokl'mg [] S.T.F_P. [] Other:. To Sepl~c Absorption Uff Holding =ubr~'Private Tank Field Station Tank Sew~'Une ~?'/I~/' ~' Ig',,~ c.~. S.r~=W,,., I1~/4-''Jogs- IO0[P ~ /i LIFT STATION ~o - ' ( J ,It/'~ ~l Assumea ~evauon: E_n,~~ 6 "'~-'~L ROBERT C COWAN Development Services Depart roval ', ~,. x ,..~.- .8o, PERm? NO. SW040025 PACE 2 OF 5 Municipo, ti-I: oF Anchoroae DEPARTMENT OF HEA::[_THAND HUPIAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.D. Box 196650 e Anchor'o. ge, Ato. sko 99519-6650·Tetephone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LECAL LOT 23, BLOCK 4, MOUNTAIN PARK EST. #2 P.I.D. NO. 017-02.3-23 I I LOT 24i , , EXIS'nNO ,. ~ I I ',.-C, ~ , ~-~_~_ N/BM \.. I~1 =~111 I E I '~, /". k.~ ~ i ~ ~ST~ -- "~~ ~ 5~ / ~ . I ~ ~ AREA MT~ MT2i I /LOT ss ,, ,~/ ~ ~ ~ ~ .... -~- ,. &~/ J x -. ~.~ ,,~ ..... · ....... ~.~=~ ~7 / ~ C AREA ~ / ~F~."~z % .-'.,'., ~"~Z .~.~ L U T ~ 1 . ' ~ ,~(~C~; / PERMIT NO. SW040025 PAGE 3 OF 3 Municip. a[i-l:¥ oF Anchoraoe DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.D. Box 196650 eAnchorage, Ataska 99519-6650e Telephone'. 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 2,3, BLOCK 4, MOUNTAIN PARK EST. #2 P,I.D. NO. 017--02.3--23 FINAL GRADE~sT1 ST2 C~O1 x-- 89.2' MT1 MT2 98.4' % 95.1' -~ MT1 = 91.2'-'// MT3 MT4 /- 98.1' 97'5'-X fl y 98.0' / /,,'-FINAL GRADE N I II - DISTRIBUTION PIPE~ MTB = ~1.1~ A B FCO *2.0' 23.5' ST1 54.5' 15.0' ST2 38.5' 14.5' TMT 31.5' 18.0' MH 43.0' 15.0' MT1 82.0' 76.0' MT2 82.0' 91.0' MT3 63.5' 59.0' MT4 68.0' 82.0' MT5 101.5' 72.0' MT6 80.0' 62.0' MT7 93.5' 61.0' MT8 67.0' 46.0' HOUSE OFFSET MT5 MT6 MT7 MT8 N L J It/ /FINAL GRADEX 97.0' 94.8'-~DISTRIBUTION PIPE~L s~~ 94.8' 9o.8'-'/ ,'"--MT6 = 90.8' ./ '"'--MT6 = 90.7' MT7 = 90.8'-' WATER FOUND ® 84.2' 82.2' B.O.H. N. T. S. ....~.~-.. .... ~%~- ~...'~'~ [ .... ~.~y~,-~ ............... ,~..~ ~ ................... ~ ~ ~ ROBERT C. COWAN ~,~-~ PAGE ZNSpECTZON: VOZCE 343-8300 ZFIspEC'rzoNi FAX (9071249;7777/. "'" '.ZflFOi'a43-Tg6Z ' · Add raa~ 1'2821 LUPINE RD :' BK 4 LT 23" . ... 'SUbdlviEl°n .......... #2 ' .: ..' Comm'enlz'or Dlrectlon~ "... . ',~ .......... MOUNTAIN pARK ESTATES '2nepection. RetroElectri=l.. ~'L.~ : Rein~pecfion N NO NONCOMPLIANCE OBSERVED , .. [] coRRECTIONS ESSEN'i'r. AL AS EXPLAINED BELOW .":':.':t :-:-.,. ':' '" [] WILL RE-EXAMINE AT NEXT- [] DO NOT CONCEAL'UNTIL REINSPECTION INSPECrION COMHENTS: (for Inspector use' only) .! Date:. MUNICIPALITY OF ANCHORAGE Development Services Department On-Site Wate~ & Wa~tewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343.7904 '5 ¢r ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Feb 24, 2004 Expiration Date: Feb 23, 2005 Permit Number: SW040025 Parcel ID: 017-O23-23 Legal Description: iMOUNTAIN PARKESTATES f~2 BLK..4 LTi i23./ Design Engineer: 0003 S & S Engineering Site Address: 012821 LUPINE RD Owner Name: Steven Trott Lot Size: 20130 SQ. FT. Owner Address: 12821 LUPINE ROAD Total Bedrooms: 4 Permit Bedrooms: 4 ANCHORAGE, AK 99516-3226 This permit is for the construction of: [~] Disposal Field r-~ Septic Tank [] Holding Tank [~ Privy r-] Private Well Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 ON-::SITE SEWER/WELL PERMIT APP~.jCATION FOR A SINGLE FAMILY DWELLING Parcel I.D. o/7 - 03-.3 Permit Number SW_..~_O_,~=__~- Mailing address (1) L p;¢e ¢o d Mailing address (2)~,~¢~ej ~ Zip Code Legal description (Section. Township & Range) Lot Size "~0! t~¢ Acre~ Number of Bedrooms THIS APPLICATION IS FOR: Sewer Only Sewer and Well Sewer Upgrade THIS PROPERTY CONTAINS: Hot Tub Swimming Pool Therapy Pool E] Well Only E] El Water Storage [] E] Jacuzzi E] Water Softening Unit I certify that the above information is correct. I further certify that this application is being re. add. for a Single Family Dwelling and is in accordance with applicable Municipal Codes. S &S ENGINEERING ~--~Z~/'~_~ 17034 E,gl. River Loop Road No. 204 F_~.=le ~lv~r: Alaska 99577 (Signature of property owner or authorized agent) Permit Fees: !"1 f, O. ,o Date of Payment: O~ ~'¥o7 .. ~...~ Receipt Number: (Rev. 12100) Waiver Fees: Date of Payment: Receipt Number: meemnq ROBERT C. COWAN, P.E. February 16, 2004 CML ENGINEERS (907) 694-2979 ' FAX (907) 694o1211 SEWER & WATER MAiN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WEII INSPECTION & FLOWTEST $ffEPLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTEWATER ~SPOS~L $~STEM DESIGN MUNICIPALITY OF ANCHORAGE Development Services Department P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Lot 23, Block 4, Mountain Park Estates #2 It is requested that you issue a permit to install a septic system upgrade to serve the existing four bedroom dwelling on the referenced property. Also request a lot line waiver of zero feet from the south property. A test hole was excavated and a percolation test performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation 2/6/04, water was found at 11.5 feet. After monitoring, ground water was found at 11.5 feet. We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent properties. If you require additional information, please contact us. Sincerely, Rcccojj Enclosure 17034 NORTH EAGLE RIVER LOOP ° SUITE204 ° EAGLE RIVER, ALASKA 99577 10' UTILITY EASEMENT 1" - 40' DESIGN SITE-PLAN SCALE i ~ o z~ ~DECK ,'/ ~ ~ Z~ 0~ ' 0 ....... ~ t ~-> __ __ __~ _~ ...... -, ...... ~-u-~-'- M_'m ~ ~ m ~t~ / t / Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage. AK 99519-6650 www. ci.anchoraqe.ak.us (907) 343-79O4 Soils Log - Percolation Test Performed For: ..~' 'j~_. V {~. "J"'/'~ O 3- 'T' Date Performed: Legal Description: LOT' ;~ '5 01,~ ~ I"~¢,.',..m4 ~,,~ j~,~lc Cr~5 ?. ~r~'ownship, Range, Section: 10- 11- 12- 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS Slope Site Plan WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water After Monitoring? Reading Date Gross Time Net Time Depth to Water Net Drop r~~ ~/do¢ o - ~-" - 3'o 3o ~,.,.' ~' '/:~" '/~" 3o - ~'/~" - ~O 3o .,~ ~ ~" '/~" ~o 30 ~.~ ~ =/s" '/~" PERCOLATION RATE (30 minutes/inch) PERC HOLE DIAMETER .( TEST RUN BETWEEN ~ FT AND ~ FT S & $ ENGINEERING PERFORMED BY: ,,..,~,~ ~- , ,.. · J CERTIFY THAT THIS TEST/WAS IN AI~.-C~A-~T"~-~!~L~A~L~k~j~jlPAL ~UID~LINES IN EFFECT ON THIS DATE. DATE: .~O//~,/O PERFORMED -F.~iI6 Rl¥~,'Alaska 99577 SEWER&WATER MAJN EXTENSIONS SEWER & WATER INSPECTION ENCdNEERING STUOIES AND REPORTS WELL INSPECTION & FLOW TEST srrE PLANS SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECI~ONS ON SITE WA~TEWATER DiSPOSAL$~TEM DE. SION ROBERT C. COWAN, RE. ROBERTA. SHAFER, P.E. REFERENCE: GENERAL: 1. ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS Lot 23, Block 4, Mountain Park Estates #2 February 16, 2004 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 The scope of this project includes the installation of a 1300 gallon HDPE septic tank, a pump basin, and a pressurized drainfield to serve the existing four bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, MuniciPal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: o A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP * SUITE 204 * EAGLE RIVER, ALASKA 99577, Page 2 Lot 23, Block 4, Mountain Park Estates #2 Febma~7 16, 2004 4. .5. 6. Septic tanks installed with less than 4 fi. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the holes faced downward. The distribution piping is to be of PVC (ASTM D3034 or equal). All joints are to be solvent cemented. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of rotor (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the. gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIMUM MATERIAL SPECIFICATIONS: 1. Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. Page 3 Lot 23, Block 4, Mountain Park Estates fY2 FebnJary 16, 2004 The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fired with watertight couplings (Caulder, Femco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. o All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. 7. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements, Which ever specifications applies. Page 4 Lot 23, Block 4, Mountain Par~ Estates #2 February 16, 2004 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. o The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. Permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR / INSTALLER Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 WR#: .040010 PID#: 017-023-23 Date Received: 212212004 Waiver Review Worksheet HA#: .~ Permitg: .5'WO 40 O2.~-- Legal Description: Mountain Park Estates #2 Block 4 Lot 23 Engineer: S & S Enqlneerin.q 17034 Eaqle River Loop Road #204 Applicant: Steve Trott Waiver Requested: 0 Foot Lot Line Waiver separation distance from Absorption Field to Property Line Criteria: Geology Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: m mmmm m m m mm m m m mm m m m m m m mm m m mmm m mm m m m m m mm m m m mmm mmm mmmmmm m m m mmmm m m mmm m m m m m m m m m m mm mmm m m m mm m m mm l Waiver is Granted: X' Waiver is not Granted: List Conditions or Reasons for above: 5 ~ 1~_ /~ /~) C/',.~'~C'~.~ ~/~'~(~ Date: 2/~-4/0~' By: .~/~* Name of Reviewer mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Rec#: 48407 Amount: $175.00 Date Paid: 2~23~2004 Municipality of Anchorage Mark Begich, Mayor Building Safety Division P.O. Box 196650 · 4700 Bragaw Street Anchorage, Alaska 99519-6650 · (907) 343-8301o Fax (907) 343-8200 http://wx~av, muni.org 2/22/04 Robert C Cowan S & S Engineering 17034 N Eagle River Loop, Ste 204 Eagle River, AK 99577 Subject: Waiver Request for Mountain Park Estates #2 Block 4 Lot 23 Waiver Request #WR040010 Parcel ID #017-023-23 Dear Mr. Cowan: Your request for a waiver of the required 10 feet horizontal separation from the absorption field to property line has been approved. The approved separation distance is 0 feet. This waiver approval applies to the existing absorption field to property line separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Daniel J. Roth Civil Engineer On-Site Water & Wastewater Program ~~ 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 PHONE I ~NEW '-~ ~. ~,~_.. l~.)~,~, ~ ~-~2 ~ ~ ~ UPGRADE MAI LING ADDRESS LEGAL DESCRIPTION Well Absorption area Dwelling PERMIT NO. ~ ~ DISTANCE TO: ~ 0 0 ~ ~ ~0 ~ ~z Manufacturer ~ ~ Material~ N°' of compartments Liq'~ ~ocapacityingall°ns iFHOME~DE: Inside length ~ Width ~ ~ Liquid depth O Z ~ Manufacturer~ ~ Material Liquid capacity in gallons ~ Well Foundation Nearest lot line PERMIT NO. ~ ~ ~ DISTANCE TO: ~ ~ --~~ ~ .o. of lines X Length of each line Total length,o~li:es Trench width Distance between lines ~ , ~8 ~ ~ ~/~ ~ ~ inches AC ~ ~~ Top of tile to finish grade ~l ~ U Material beneath tile ~ t~ Total effective absorption area ~ ~ O inches 5~ ~ Length Width Depth PERMIT NO. ~ ~ Type of Crib diameter Crib depth Total effective absorption area m ell Building foundation Nearest lot line ~ DISTANCE TO: ~ Class ~ ~ Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER SOIL TEST RATING ~ REMARKS .... ~ .... ,, ~ ,, t~ ,, t .... ~ . __ DATE LEGAL 72-0 [Rev. 3/78) DRILLING, INC. DRILLING LOG Well Owner ~' ~ ~; F,, ','~!?'.!.??.~,U Use of Well 'lk' '~ Location (address of: Township, Range, Section, if known; or distance main road Size of casing '-; Depth of Hole ~.~-~) feet Cased to [t)~ feet Static water level j :i.li ft. (~ib6~) (below) land surface. Finish of well (check one) Screen ( ); Perforated ( ). Describe .screen'.or perforation Well pumping test at :) gallons per of drawdo~n from static level. ' '~,/,'(A//9 'Date of completio~ open end ( ,,';'.. ' ); :',ft. WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness /~ :' TO TO TO TO TO TO TO TO __TO TO TO N%~r~%L Certif/ed Con~ractor 3- CONTRACTOR F'ERMIT NO. FFFLI.HNF [:,ICK WRIGHT LOCFIT I ON MT. PFIRKir__-,, i ' LEGAL L2~ B~ M'F. PR~:K EST 2 C, EPRRTMENT OF HERLTH FtND ENViF,:ONMENTRL PROTECTION ~j_ ~\~-~ ,_,~._,m'": ' L' STREET., FlNCHORFIGE., 264 -4 ," ,.'. ') SRR BU,..., LOT =, I ~.E ,~L.1EtO~ SLT.!UI "-' ' ' A ~'"-" ' I-': TRENL':H T"~,'F'E OF SOIL RE,:,JF-BII.N :~-_~rErl MIR:;.;;IMLIM NUMBER OF E:EDROOMS = 'qnlL RATING THE REQUIRED SIZE OF THE SOIL HB:,ORF[IDN :~_TEtl I_.. THE LENGTH DIMENSION IS THE LENGTH <IN FEET) OF THE 'FRENCH OR DRRINF'IELD. TFIE DEPTH OF FI TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFFtCE (:IF THE: GROUND FIND'THE BOTTOM OF THE EXCRVRTION (IN FEET::,. THERE IS NO SET WIDTH FOR TRENCHES. "['HE GRFIVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTF'RLL PIPE RND THE BOTTOM OF THE E~',CRVRTION (IN FEET). PERMIT RPPLIC:RNT HR:, THE F..E_FUN_,IE, ILI T~ TO INFLRM THIS [EFHF.'.FHENT DURING THE INSTRLLRTION IN_FEL. TION-,':' ~ ~ OF FINY WELLS FID.TRF:ENT. _ TO THIS PR. EF'ERTY FIND THE NUMBER OF RESIDENCES THRT THE WELL WILL :,EF..,E. E,H_.KFILLIN~ [if RNY :,t_,TEM WITHOUT FINRL INSPECTION FIND FIPPROVRL BY THIS .... ""' ' _-,UBJE_.T TO F'ROSEZJTION DEFHF..THENT WILL BE '- ' '" .MINIMUM DISTRNCE BETWEEN R WELL FIND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS :LOE~ FEET FOR Ft PRIVRTE' WEL. L.~ OR :LSE~ TO 20L'-~ FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL NELL LOGS FIRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 3:E~ DR"r'S OF "['HE WELL COMPLETION. OTHER REQUIREMENTS HRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS FiRE RVBILFIBLE TO INSURE PROPER INSTFILLRTION. F'F_~ F-:t-"l ][ T F= :~-:P Z F:ES [:,EC:EI"IE:ER -~_:::L., 1:~";~-~---: I CERTIFY TttFIT 1: I R!l FRMILtFiR WITH THE REQUIREMENTS FOR ON-SITE SENERS 8ND WELLS RS SET FORTH BY THE MUNICIPRLIT¥ OF RNCHORFiGE. 2: I MILL INSTRLL THE S'~'STEM IN FICCORDFINCE WITH THE CODES. i:':: I UN[:,ERSTRND THFiT THE ON-SITE SEHER SYSTEM MFiY REQUIRE ENLFiRGEMENT IF THE RESIDENCE IS REMO[:,EL. ED TO INCLUDE MORE THFiN 4 BEDROOMS. R~'F L I CFINT [)ICK P~..' I GHT / MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-550, Anchorage, Alaska 99502 276°2225 SOILS LOG- PERCOLATION TEST ~SOI LS LOG [] PERCOLATION TEST PERFORMED FOR: · EGAL DESCR,PT,ON: 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O D^TE P~..ORM.O: G ' I b, ?~ COMMENTS ~ ~t' y WAS GROUND WATER ENCOUNTERED? PER.ORMED ~: c~ ~ ~OS T' IF YES, AT WHAT DEPTH? SLOPE SITE PLAN Gross Net Depth to Net Readln~ Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT 72-008 (7/76) 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. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 017-023-23 GENERAL INFORMATION Complete legal descriptiOn Location (site address) COSA# 0 C-Iil99 Expiration Date: / MOUNTAIN PaRk ESTATES #2 BLOCK 4 LOT 23 12821 LUPINE, ANCHORAGE, AK 99516 Current Property owner(s) MARK SWANSON Day phone 345-8187 Mailing address Lending agency Day phone Mailing address Real. Estate Agent Mailing Address Unless otherwise ~equested, COSA will be held by DSD for pickup. NUMBER OF BEDROOMS: 4 Day phone TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class __ Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] ' Individual On-site [] [] Individual Holding Tank [] [] Community On-site [] [] Public Sewer [] I The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 Guidelin~es for this application, shows that the on-site Water supply and/or wastewater disposal system is (are) safe, fdnctional and adequate for the number of.bedrooms and type of structure indicated herein. I further vedfy that I~ase, d On the information obtained from the Municipality of Anchorage files and from my investigation and inspectiOns, 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 Spurkland Enginneering Address 203 W. 15th Ave., Ste 202, Anchorage, AK 99501 Engineer's Printed Name Lars Spurkland Phone 279-3916 Date OCT. 17. 2011 DSD SIGNATURE L,,,'// Approved for L.jL Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory (Rev. 11/05) X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: /' O - / '7 - / / Municipality of Anchorage Development Services Department Building Safety Division OmSite Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Descr:iption: WELL DATA Well type ~T. Date completed ?-IZO{'~1 Total depth ~.'~ ft. ~~n [~a~, C5¥~{~Z. $11<q Lo{ Z3 ,ParcellD: OI~--OZ3-0Z.~ IfA, B, or C provide PWSID # -- Sanitary seal (Y/N) ~ Cased to 100 ft. Well Log (Y/N) '~/ Wires properly protected (Y/N) Casing height (above ground) in. Date of test FROM WELL LOG Static water level ft. Well production ~,- g.p.m. WATER SAMPLE RESULTs: 'Coliform. A/'cfi', colonies/100 mL Nitrate 0tL%~ mg/L Arsenic: gO ug/L date of sample: ~JlZ(~ JJ SEPTIC/HOLDING TANK DATA ' / Tank Type/Material Jg~%l~t(:[ ~).l~.5{ic~/, Tank size J~01~ gal. 'Number of Compartments ~. Foundation cleanout (y/N)"~ Depression over tank (Y/N) ,A//' AT INSPECTION Collected by: Cleanouts(Y/N) ' ~ · ~ High water alarm (Y/N) /~ Date of pumping ~'~.'~.O~t Pumper /~+ ~f~. ~'~'tliC.6 C. ABSO~ION FIELD DATA Dateins~lled 4, 1o ~,' so,, (~r~lbd~) O,~S -~'~ , ~TG' rating Leng~ ~ ~ ~ . Width 5 ff. Total depth ~,~ ff. Eft. abso~tion area l~b0 ~ Monitoring tube Date of adequacy test ~l~iJ Results (Pass/Fail) ~5~ Fluid depth in absorption field before test ~ in. Elapsed Time: {~0 min. Final fluid depth ~ Any rejuvenation treatment (past 12 mo.) ~/N & ~pe) System type OPkl~ Gravel below pipe /'/ ft. "/ Depression over field Water added ~00 gal. _ in. Absorption rate >= N'Otl¢.. ~ If yes, give date For ~ bedrooms New depth l0 in. ~00 g.p.d. D. LIFT STATION Date installed 3I1~.I[I "Pump on" level at q~ in. Datum ~,~1, E. SEPAI~TION DISTANCES Size in gallons "Pump off" level at .51,5 Cycles tested in. Manhole/Access (Y/N) Y High water alarm level at qq,.~ Meets alarm & circuit requirements? ,,, in. SEPARATION DISTANCES FROM WELL ON LOT TO: SePtic tank/lift station on lot Absorption field on lot 100 Public sewer main Sewer./septic service line Animal containment areas On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank /V/,~, Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5I+ Property line .~ ~ 4- Absorption field Water main /~//~ Water service line t Surface water I Wells on adjacent lots 100 '} 5':+ Property line Water Service line JO I~. curtain drain SD + ~,O SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: ~' ~ Y( Building foundation )O I /V,/,/jt ~' Water main Surface water J DO'f- (j~',O.~ Driveway. parking/vehicle storage Wells on adjacent lots' /00 F. COMMENTS I 25 * G. ENGINEER'S CERTIFICA'IION ,,.,~.. ,~_, .O. ~. ,A..~,~.~t ~, · ' ~'~.'' "-..e ~I I certify that l have determined through field inspections and ~ o~." ~ '"?.~. ~, review of Municipal records that the above systems am in l? '~ % conformance with MOA COSA guidelines in effect on this date. ~ '] ~'- ' . , ,(;~'[~ ~ ~'J'" ~"~ . ~ Engineer's Printed Name LAIT,~ ~..~'/~U/Zk~. ~14D ~J~' '~SP~'~ - % COSA Fee $ ~t (~ ~.~ L~ G.y.~~ Waiver Fee $ Date of Payment Receipt Number O~LD_O:. ~ Date of Payment Receipt Number (Rev. 4/10) Municipality of Anchorage DeveloPment Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw SL ' P.O, Box 196650 Anchorage, AK 99519-6650 www. ci.anchorage.ak, us (907) 343-7904 Parcel I.D. O I ? - o~ .3 - ~L 3 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Expiration Date: ~ - ..~ L? - O ~ GENERAL INFORMATION Complete legal description LO 3- Locat. io..n .(~!te' .a. ddre.~s.or directions) cu'h'eht"PrS~3'e~ty'ov~ner(s) ~ 7-g, V ¢ Mailing address Lending agency TRO~-T Day phone Day phone Mailing address Real Estate Agent p/{o~., c ~, ~100 Mailing Address ,~ ~,o t c, Y '/', ~ ,4~" c I-/. ubless Otherwise requested, HAA will be held by DSD for pickup. 'NUMBER OF BEDROOMS: Day phone TYPE oF WATER SUPPLY: Individual Well Individual Water Storage Community Class . Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer [] F1 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health .Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and'may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid ~vater. samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Municipality or Anchoragei Development SerVices Department: Building Safety Division ' on-site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.chanchorage.~,r,.u s (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Lega,llDescription: L o"r' ~, ~ A. 'WELL !DATA !'Iota! depth '~'~-O ft. ; :, Date Of test i 'static water level ~.': ~ ,4 ,uro,,,uc,,on , : ;' WATER SAMPLE RESULTS: · :, Coliform col0niesll00 mi. : '~ s~gJI Ar . B: :SEpTIC/HOLDING TANK DATA /~ LO Crc ~ If A, B, or C pro:vide PWSID # Sanitary seal (~1',1) Cased to IOo+ft. FROMWELL LOG ~ ) o 5"- ft. ~ g.pm. Nitrate 19. ~loqt mg./i. Date of sv. mple: a/6/o q Weli Log(~) 'YE.J' Wires properly protected (~N) Casing height (above ground) ! ,3- J~ in.. AT INSPECTION i/ loq /' ~,S~ ft. g.p.m. i Tar{l~ Type/Material :5'ig/~7'.<-. // _/4 D__PE. ,. Tadk Size I 3 0 0 gal. ' Number of Compartments FoUndation c!eanout (~q) Y~'J Depression over tank (Y~ ~° Da~6 of pumping ~ [~ - /'~ ~''''/ Pumper , ',:~ , , C. iABSORPTION FIELD DATA :' "" r t%drm) ; Da~ iastalled '~ Soil rating i', ~ : Leh~th/'~ 3 ~,: I ~ [ ft. Width .7.o.~l~0epth. ~ ft.~ Eft. absorption erea t ~ ~0 ft~ Monitoring tube Dat~ ~o~ adequacy test ~ ]~- ~ ~ ~ Results (~ass/Fail) ,FI0!d.depth in absorptioa field before test in. Water a0ded ~ ElaPsed Time: ;min. Final fkdd~Absorption rate >= ' 1; ' e : :An9 rejuve I & type) If yes, 9ive date. Other bacteria 0 colonies/100 S & S ENGINEERING Collected by: Eagle River, Alaska 99577 Date installed "5 Cleanouts(~) High water alarm (Y/N) 5//4,- t,o ~.,' O,, ~5" System type ft. Gravel below pipe q ... ft.' Depression over field ~' 0 For L/ bedrooms. in. g.p.d.. 16:37 FAX ~002/002 ,30' I N 8§'56'06" W 185.00' 7.~ ~=.,;.=. (~c.o. '1 ~.~. ~clo. ' DRI~WAV I~ 82.1' - I Z H~ ~DA~ ~ '23 7.o. l~j' ' ~C.O. L~GEHD N 89'56'06" W x 10' UTILITY EASEMENT · I~c.q. 1'5'1~.o. []c.o. ,.,7 C~An~ UN~ ASBUILT SURVEY .--x~.-"' '~'.'.?,s'Z',, ..- '.*,, ~, · /./ . H: \620400'\SUR V~_..Y~620 e,-^SB T. DWC SE'~ CLEAN OUT EDGE OF' A~ALT ~,' TAU:'BLo~<' ,ZT,.Js. NC WAU. I hereby cer'Ufy that an accurate survey of the improvements on the follow{rig described property. ~T 23 ~'~ M~T~ P~ ~A~,'~~. ~ wa~ mode on. March 16, 2004 ~d that safd ~mprov~en~ eituat~ ~er~n are wi~ ~e:~e~y I~es and do not o~rl~p ~ en~ on ~e p~y I~ng ad]a~nt th~eto' and ~at no improv~ I~ng ad~c~t ~eto,~=oa~ on ~e promises ~n. qu~Uon, ~c~t ~ sho~, and that ~e ~e no ~e or pla~ed r~dwa~, ~~on fines ar a~er ea~ e~t as sha~ It is the r~one~Mlty of ~e owner to dete~ine the e~etence of any eaeeman~, fight-of--way, covenants, ar ~ictlone which do not app~r ~ ~e ~b~on plaC Und~ no ~r~m~ ~anc~ ~ould any data h~ be =used f~ ~nst~ctl~n or ~r eeta~is~g bounda~ ar fen~ lln~ bP~ RCH DATE 3/16/04 C~. RCH SCN-E 1-___30, 1 ~< F.B. 250 d~Bf 620a~00 ~ ~ ~ P-561 ~ 2~ II I 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 2/25/85 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 23, Block 4, Mtn° Park Estates #2; Sec. 26, TWN 12N, R3W Location(addressordirections) 12821 Lupine Road - Off Dearmoun (b) Applicant Name Bill Westbrooke Telephone: Home 345-6257 Applicant Address 7150 Rabbit Creek Road Business Same (c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain); Sellar (d) Lending Institution ~'~'¢t-~/¢z:/~./~-~-f Address ~)' ~' /~ Real Estate Company and Agent (e) Address ~ ~ ~ ~/~~ r (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family [] Multi-Family [] Number of Bedrooms 3 Other WATER SUPPLY Individual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation aitesting to the legality and status. 4. 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-o25 (11/84) 5.. ENGINEERING FIRM PROVIOING 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. z7b Engineer's Seal DHEP APPROVAL Approved for Approved Terms of Conditional Approval CAUTION 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. Paqe 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 MUNICIPALIVf OF AB,,'CROR,AG~ DEPL OF HF:ALTil & [NVIRONMENTAL PP3 1L~CI'ION l,,'¢,, 0 q 1986 28..4,2° R E C E IV E D Legal Description: Lot 23, Blk 4, Mtn, Park Estates #2 Sec 26, TWN i2N, R3W WELL DATA Well Classification Well Log Present (Y/N) Total Depth 220 ' Static Water Level 105 ' Casing Height Above Ground 24" Electrical Wiring in Conduit (Y/N) L/C/ If A, B, C, D.E.c. Approved (Y/N) / ~///' 2/20/79 ¥ Date Completed Yield Cased to 100 '+ Depth of Grouting (1979) (118' ~985) PumpSetAt Not Known Sanitary Seal on Casing (Y/N) ¥ Depression Around Wellhead (Y/N) Y 2 GPM Y N 100'+ 100'+ Separation Distances from Well: To Septic/Holding Tank on Lot 100' ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot 105 ' ; On Adjoining Lots To Nearest Public:Sewer Line None ±n Area To Nearest Public Sewer Cleanout/Manhole None in Area To Nearest Sewer Service Line on Lot Water Sample Collected by QUADRA - Wayne McFadden ; Date Water Sample Test Results Passed Comments We[1 passed 'drawdo~cn test; 2/22/85. 85' B. SEPTIC/HOLDING TANK DATA Date Installed 1978 Size 1250 Gal. No. of Compartments 2 Standpipes (Y/N) Y Air-tight Caps (Y/N) Y Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) N Date Last Pumped 2/21/85 Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High-Water Alarm (Y/N) N/A Temporary Holding Tank Permit (Y/N) N/A Separation Distances from Septic/Holding Tank: 100' 47' 40' To Water-Supply Well To Property Line To Water Main/Service Line Course To Building Foundation 22 ' To Disposal Field 5 ' To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 1978 Width of Field 3' Square Feet of Absorption Area .50/4 Depression over Field (Y/N) N Results of Last Adequacy Test Passed 125 Type of System Design Length of Field t22~ Depth of Field 6 ~ Gravel Bed Thickness 2 ~ Standpipes Present (Y/N) Date of Last Adequacy Test Trench Y 2/22/85 Separation Distance from Absorption Field: To Water-Sup'ply Well 105 ' To Building Foundation 15' Lot None To Water Main/Service Line 45 ' To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course None To Driveway, Parking Area, or Vehicle Storage Area 95 ' Comments Absorption Field Passed 2/22/85 To Property Line 10' To Existing or Abandoned System on ; On Adjoining Lots 100~+ None D. LIFT STATION Date Installed N/A 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 Bequest ** I certify that [ have checked, verified, or conformed to a.~ll M CA and HAA guidelines in effect on the date of this inspection. Sign ed ~'~,f,~ Company~v~ ~/~' MOANo. ~ ~- J~ Receipt No. '~'~-~ ~ ~ :::'"~"" '~~* : Date of Payment ,'¢~-*" "' ~7~ 0%%~q¢~-,: Engineer's Seal Amount: $ ~. Page 2 of 2 MUNICIPALITY OF A.bLCJ;J R'AG"E MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL DEPARTMENT OF HEALTH & ENVIRONMENTAL PRoTEcTION 825 LStreet-Anchora~e, Alaska 99501 AP~ ~ 7 ENVIRONMENTALENGINEERINGDIVISION Telephone 264-4720 C ~ J V REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES PI RECTI ONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PRO ERTY WNER PROPERTY RESIDENT (If different from above) / PHONE PHONE 2~ B~YE. /~ ~ MAILING A~RESS MAILING ADDB~88 4. REALTOR/AGeNT , ~ ' ~ I PHONE ~ILING ADD~ESS 5. LEGAL DESCRIPTION [] One ~ Four ~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six [] Other 7. WATER SUPPLY ~ INDIVI DUAL* ' ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) a. SEWAGE DISPOSAL SYSTEM **If individual/on-site, give installation date ~,-- /~. /~ INDIVIDUAL/ON-SITE** If system is over two (2) years old an adequac~'~est is required [] PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME T]ME DATE DATE DATE I NSP ECTOR INSPECTOR INSPECTOR DIRECTIONS: 1, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDI VI DUAL/ON -SITE DATE INSTALLED [~] PUBLIC UTi LiTY Connection Verified INSTALLER []Septic Tank or [--I Holding Tank Size: J~,.=~:~) If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS ~ APPROVED FOR z~ BEDROOMS ~ CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev, 3/78)