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Home My WebLink AboutKNIK HEIGHTS BLK J LT 1On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water& Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP161071 Tax Code Number: 01823223000 Work Type: Septic Upgrade Permit Effective Dates: April 28, 2016 to April 28, 2017 Design Engineer: PANNONE ENGINEERING SERVICE Subdivision: KNIK HEIGHTS Site Legal Address: KNIK HEIGHTS BLK JILT 1 G:2936 Owner/Address: PIERCE ROBERT CHARLES & EILEEN A 13345 RIDGEWOOD CIRCLE ANCHORAGE AK 995162940 Site Mailing Address: 13345 RIDGEWOOD CIR, Anchorage Lot Size in Sq Ft: 22400 Total Bedrooms: 3 This permit is for the construction of: Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Receiv( Issued Q MUNICIPALITY OF ANCHORAGE (a� APF? 1 2016 Community Development Department Development Services Division 6 On -Site Water & Wastewater Program Phone: 907-343-799 Fax: 907-343-7997 ON-SITE SEWERIWELL PERMIT APPLICATION Parcel I.D. 018-232-23 Property owner(s) Robert Pierce Day phone Mailing address 13345 Ridgewood Circle, Anchorage AK 99516 Site address 13345 Ridgewood Circle, Anchorage AK 99516 Legal description (Sub'd., Block & Lot) KNIK HEIGHTS BLOCK J LOT 1 Legal description (Township, Range & Section) Lot Size 22,400 So. Ft. APPLICATION IS FOR: (® all that apply) Absorption Field ❑X Septic Tank ❑X Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms 3 APPLICATION IS AN: TYPE OF DWELLING: Initial ❑ Single Family (SF) ❑X Receipt Number: OOb(AG (w/wo ADU) Upgrade ❑X Duplex (D) ❑ Renewal F-1 Multiple Dwellings ❑ (SF and/or D) THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. property owner or autnorized agent) Permit/Rush Fees: Jam` Waiver Fees: Date of Payment: 1-190-1(0 Date of Payment: Receipt Number: OOb(AG Receipt Number: Permit No. 05010.1 b1 1 Waiver No. Permit App__- : Pannone Engineering Services LLC Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve0i)aneneak.com April 27, 2016 Subject: KNIK HEIGHTS BLOCK J LOT 1 Septic System Upgrade Permit Request Design Narrative This is a design narrative for a permit to install an upgrade septic system to be issued for this property. The proposed system will serve an existing three (3) bedroom house. Currently the lot is developed. The existing tank and existing drain field is in failure. The existing drain field will be re -used as a reserve. The system will utilize a new 10002 septic tank and new conventional drain field. This lot bnd the surrounding lots are served by private wells. There are no wells within 100' of the proposed septic system 1. Soils. One test hole was performed in the vicinity of this system by Pannone Engineering Services in April 2016, and groundwater was monitored for at least seven days. Ground water was not observed to a depth of 14.0' below the surface in the test hole monitor tube in April 2016. Bedrock was not encountered in the test hole. Based on the results of the percolation tests and overall soils appearance; an application rate of 1.2 gallons/day/square was used for a conventional wastewater system in the area of these test holes. 2. Soil Absorption System Design. a. See Sheet 1 of the design package. 3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain field. The proposed drain field upgrade will maintain at least 100 feet from all surface water and drainage ditches. 4. Topography: The existing topography for the majority of the property is level with slight slopes from the east to the west at approximately 2%-4% in the area of the septic system. There are no steep slopes within 50' of the proposed drain field. The proposed drain field will maintain 50' separation all steep slopes. S. Drawing Markings: The Drawings are marked "For MoA Review Only'. When written notification that the review is complete and that there are no further comments is received from MoA On -Site Department, the note will be removed and "Issued for Construction" drawings will be issued. The proposed installation will not affect the future development of this or the surrounding lots. Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 Physical: 332 East Manor, Anchorage, AK 99501 Telephone: (907) 272-8218 FAX: (907) 272-8211 / WELL E RIDGEWOOD CIRCL \ W — W SEPTIC AREA 40LFx5.0'Wx4ffE.D., 5.5T.D. W/ 2" RIGID INSULATION, CO & MT SEP AT ENDS OF FIELD �AR Q w SEPTIC > / N\-� nn AREA Q o REMOVE 10OOg EPTIC TANK IAW MOA CODE(E) INSTALL NEW 1000g SEPTIC TANK(P), 3BR 3BR i W/ DCO & DV AFTER TANK VERIFY INTEGRITY OF LINE TO FC \ UtJ I ESmt�_ — WELL —-- — — --— WELL E iw 3 NOTES: PAMONE ENG SVC, LW FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 AS RESERVE \ KNIK HEIGHTS BLOCK J LOT 1 DRAWN JRL ROBERT PIERCE 13345 RIDGEWOOD CIRCLE SITE PLAN ANCHORAGE, AK 99516 CE 8149 I K z z 04/27/2016 Scale k 1"=50' P.I.D. NO - • 018-232-23 9 PERMIT NO. i OSPI61071 Sheet 1 OF 4 SECTION 1000 g SEPTIC TANK (P) PROFILE DESIGN PARAMETERS TEST HOLE PRIMARY SEPTIC SYSTEM PROPOSED J EXISTING TANK SIZE: 1000g ao s s SOIL RATING: 1.2 GPD/SF - > AREA ROD: 375 SF - Qo0 - 0 ; MIN LENGTH: 38 LF - WELL RADIUS USE: 40LFx5.0'Wx4.0' E.D., 5.5' TD oW TOTAL AREA: 200 SF (380 SF EQUIV) m PMNONE ENG SVC, LLC FOR CONSTRUCTION �U w w PHONE (907) 272-8218 FAX (907) 272-8211 U U �jjj o FILTER FABRIC EL.. 10 n n jaj Ian I I o a �r BRAIN ROCK 6" ABOVE PIPE INV ',4" m DRAIN PIPE 1000 g SEPTIC TANK (P) PROFILE DESIGN PARAMETERS TEST HOLE PRIMARY SEPTIC SYSTEM PROPOSED NO. BEDROOM: 3(450 gpd) EXISTING TANK SIZE: 1000g CLEAN OUT NO. -PERC RATE: 1.66 MPI _ MONITOR TUBE NO. SOIL RATING: 1.2 GPD/SF - TYPICAL AREA ROD: 375 SF - REDUCTION FACTOR: 0.5 - SYS. TYPE: WIDE TRENCH 4.0'ED WATER LINE / MIN LENGTH: 38 LF - WELL RADIUS USE: 40LFx5.0'Wx4.0' E.D., 5.5' TD NEW SEPTIC TOTAL AREA: 200 SF (380 SF EQUIV) NOTES: PMNONE ENG SVC, LLC FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 KNIK HEIGHTS BLOCK J LOT 1 DRAWN JRL ROBERT PIERCE 13345 RIDGEWOOD CIRCLE SITE PLAN ANCHORAGE, AK 99516 61110100 ABBREVIATIONS TH TEST HOLE (P) PROPOSED (E) EXISTING CO CLEAN OUT NO. MT _ MONITOR TUBE NO. TYP TYPICAL 04/27/2016 Scale CE `8149....T. & IPERMIT NO T 2 OF SOILS LOG — PERCOLATION TEST SLOPE SITE P j w W I 5\ 7i 13 14 WAS GROUND WATER BOH ENCOUNTERED? N DATE PERFORMED: 04APR16 IF YES, AT WHAT DEPTH? —0—' DEPTH TO WATER AFTER MONITORING? — DRY — DATE: 11APR2016 WATER READING DATE TEST HOLE 1 NET TIME FILL FILL 1 1 04APR16 OR ORGANICS 2 6.260" 2 3 8.72 MIN Orange/Brown 6.000" 1.45 GP Silty SAND & 4 6.260" GRAVEL w/ 4 1406 Cobbles 5 DRY 6.000" 1.62 6 1407 6.260" 7 6 1417 j 9.98 MIN I s 1 6.000" 1.fi6 9 GRAY Silty 10 GP SAND & GRAVEL 11 12 SOILS LOG — PERCOLATION TEST SLOPE SITE P j w W I 5\ 7i 13 14 WAS GROUND WATER BOH ENCOUNTERED? N DATE PERFORMED: 04APR16 IF YES, AT WHAT DEPTH? —0—' DEPTH TO WATER AFTER MONITORING? — DRY — DATE: 11APR2016 WATER READING DATE a 1 \M\ SFD3BRL N\ SBD SLOPE TH 1 SOIL TEST RESULTS/ANALYSIS • PERCOLATION RATE 1.66(minlinch) (Hydrologic Soils Group: HSG A) • -PERC HOLE DIAMETER 6" • TEST RUN BETWEEN 4FTAND5FT. • TEST RUN FOR OVER AN HOUR, LAST -THREE READINGS PROVIDED. COMMENTS: Test hole excavated by A+ HOME SERVICES. Test Hole was presoaked before Perc test. PERFORMED BY: Joseph Lawendowski. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. NOTES: PANNONE ENG SVC, LLC UCTION P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 KNIK HEIGHTS BLOCK J LOT 1 DRAWN JRL ROBERT PIERCE 13345 RIDGEWOOD CIRCLE SITE PLAN ANCHORAGE, AK 99516 CE 8149 Date 04/27/2016 Scale NTS P.I.D. NO 018-232-23 DERMIT NO. OSP161071 3 OF a CLOCK NET TIME LEVEL READING NET DROP (MPI) 1 04APR16 1348 6.260" 2 1356 8.72 MIN DRY 6.000" 1.45 3 1357 6.260" 4 1406 9.72 MIN DRY 6.000" 1.62 5 1407 6.260" 6 1417 j 9.98 MIN I DRY 1 6.000" 1.fi6 a 1 \M\ SFD3BRL N\ SBD SLOPE TH 1 SOIL TEST RESULTS/ANALYSIS • PERCOLATION RATE 1.66(minlinch) (Hydrologic Soils Group: HSG A) • -PERC HOLE DIAMETER 6" • TEST RUN BETWEEN 4FTAND5FT. • TEST RUN FOR OVER AN HOUR, LAST -THREE READINGS PROVIDED. COMMENTS: Test hole excavated by A+ HOME SERVICES. Test Hole was presoaked before Perc test. PERFORMED BY: Joseph Lawendowski. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. NOTES: PANNONE ENG SVC, LLC UCTION P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 KNIK HEIGHTS BLOCK J LOT 1 DRAWN JRL ROBERT PIERCE 13345 RIDGEWOOD CIRCLE SITE PLAN ANCHORAGE, AK 99516 CE 8149 Date 04/27/2016 Scale NTS P.I.D. NO 018-232-23 DERMIT NO. OSP161071 3 OF a SPECIAL PROVISIONS TO SPECIFICATIONS 1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON—SITE WASTEWATER DISPOSAL SYSTEMS AND AND IN ACCORDANCE WITH AMC 15.65 AND 15.55. 2. SCOPE OF WORK: INSTALL NEW 1000g SEPTIC TANK, AND SOIL ABSORPTION SYSTEM. 3. GROUNDWATER WAS NOT ENCOUNTERED TO A DEPTH OF 14 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL TEST HOLE. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 14 FEET BELOW EXISTING GRADE NOTIFY THE ENGINEER IMMEDIATELY. 4. THE CONTRACTOR (BOTH WELL AND SEPTIC SYSTEM CONTRACTORS) SHALL HAVE ANY WELL LOCATION AND SEPTIC LOCATION STAKED AND ANY LOT LINE AND WELL RADIUS SHOWN ON THE PLAN WITHIN 30 FEET OF THE PROPOSED SYSTEM STAKED BY A REGISTERED LAND SURVEYOR BEFORE STARTING THE WORK. 5. THE CONTRACTOR IS RESPONSIBLE FOR ALL R.O.W. AND OTHER REQUIRED PERMITS, OTHER THAN THE ATTACHED. 6. THE CONTRACTOR SHALL CALL FOR LOCATING OF ALL BURIED UTILITIES. 7. THE CONTRACTOR SHALL PROVIDE 24 HOUR NOTICE TO THE ENGINEER PRIOR TO START OF WORK. ALL SURVEYING AND LOCATES SHALL BE IN PLACE PRIOR TO NOTIFYING THE ENGINEER. 8. THE CONTRACTOR SHALL NOTIFY THE ENGINEER OF ANY DISCREPANCY BETWEEN THE APPROVED DRAWINGS AND SITE CONDITIONS/LIMITATIONS POTENTIALLY CAUSING THE NEED TO MODIFY THE DESIGN. 9. AT THE COMPLETION OF THE WORK, THE CONTRACTOR SHALL SUBMIT RED—LINE AS—BUILT DRAWINGS TO THE ENGINEER. THE RED—LINES SHALL INCLUDE PIPE LENGTHS, ORIGINAL GROUND ELEVATIONS, PIPE ELEVATIONS, AND _. TANK ELEVATIONS. 10. THE CONTRACTOR SHALL PROVIDE PHOTOGRAPHS OF THE SYSTEM INSTALLATION TO INCLUDE BOTTOM OF EXCAVATION, TOP OF PIPE WITH CLEAN—OUTS AND MONITOR TUBES INSTALLED, INSTALLED TANK AND FINAL GRADING. 1 1. THE CONTRACTOR PROVIDED DATA (UPON WHICH THIS RECORD DRAWING IS BASED) APPEARS TO REPRESENT THE PROJECT AS CONSTRUCTED. THIS DATA IN CONJUNCTION WITH THE PERIODIC FIELD OBSERVATIONS BY THE ENGINEER (OR HIS DESIGNEE) AS REQUIRED BY AMC 15.65 DOES NOT GUARANTEE THAT THERE ARE NO HIDDEN DEFECTS BY THE CONTRACTOR. 12. THE CONTRACTOR SHALL SIGN THE FOLLOWING: I CERTIFY THAT ALL WORK WAS PERFORMED IN ACCORDANCE WITH THE APPEND PERMIT, AND ANY AND ALL CHANGE ORDERS, AND THAT THE AS—BUILT REDLINES ARE TRUE AND ACCURATE REPRESENTATION OF THE PROJECT AS CONSTRUCTED. - CONTRACTOR: BY: TITLE: NOTES: PA O0�4 ENG 9955110C PHONE (907) 272-8218 FAX (907) 272-8211 '�' p' � �C, *� * .... ... .. .... even nnone CE 8149 ,(} jj f�aY Date 04/27/2016 016 FOR CONSTRUCT ON Scale NTS eNTS KNIK HEIGHTS BLOCK J LOT 1' ROBERT PIERCE 13345 RIDGEWOOD CIRCLE ANCHORAGE, AK 99516 P.I.D. NO 018-232-23 PERMIT NO. osPlslo7l DRAWN JRL SITE PLAN Sheet 4 OF MUNICIPALITY OF ANCHORAGE r DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION Il ENVIRONMENTAL ENGINEERING DIVISION 825 L Street -Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL_ SYSTEM AND/OR WELL INSPECTION REPORT NAMEW W�- - ❑ UPGRADE MAILING ADDRESS LEGAL DESCRIPTION _. l 8�ocl� `f � -/!Y,f -- — NO. OF BROOMS LOCATION }!�� ,,/ Well Absorption area Dwelling PERMIT NO. DISTANCE TO: �/ U — t-' 2 0.Q Manufacturer Material ��//' / �J No. of compartments — N Liq. capacity in gallons IF HOMEMADE: Inside length Width �^ Liquid depth CI K7 W DISTANCE TO: Well Duelling PERMIT NO, U Q Manufacturer Material Liquid capacity in gallons X b p UJ 2 DISTANCE TO: Well _ Foundation �-74 Nearest lot line PERMIT NO — L Z 6- 2 w No. of lines Length of eaacc�h line Total length f lines Trench wi Itl Distance between Imes F•ett� N A — Top of file to finish grade Material beneath rile inches Total effective absorp area Length � INidth � Depth PERMIT NO. w — U Q F Type of crib — Crib diameter Crib depth — Total effective absorption area a� w Well Building foundation rn DISTANCE TO: J Class Depth Driller Nearest Distance lot line to lot lire PERMIT NO. w Building Foundation Sewer line DISTANCE TO: Septic. tank Absorption area(s) OTHER PIPE MATERIALS -- SOIL TEST RATING INSTALLER REMARKS — --- -- OF 30 lot �g - ZIP 6 ODDO ama WOO n-- �- earth ®. p _ Qn 4064-E-0 APPROVED DAIE[/j,J LEGAL d P1 U Pol X Q 1:W=o L.. 1: W "o I CT H Fil 141 min 1-11 -1 fit Q Ch EH DEPHRTMENT O. 1EHLTH HND ENVIRONMENTHL F /TECTION 825 'L' STREET/ HNCHORHGE. HK99501 264�4720 ��R_ 6 Pr_4 �J� 1" Ei7i- E 11 - 11�� PERMIT NO. ( 8106]6 ) HPPLICAM STEWHRT BHRWcS CIR. P.H ]:',R]-.8895 LOCHTION RIDGEWOOD CIRCLE LEGHL L1 8J KNIK HTS. LOT SIZE 20000 SQUARE FEET TYPE OF SOIL HBSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBTR OF BEDF! OOMS� ] SOIL RHTING (SQ FT/BR)� 175 THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS: �BEE ��11- A �� PA 0:1 W 1-1 -to A: Q ��Q "W" RE: L.. �RE. 1=1 -V M = 71 THE 1 DIMENSION IS THE LENCiTH (IN FEET) OF THE TRENCH OR INFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE BETWEEN THE SURFHCE OF THE GROUND HND THE BOTTOM OF THE EXCHVHTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFHLL PIPE HND THE BOTTUM OF THE EXCHVHTION (IN FEET). �1",�11�.j 9 -IS, �;; 1 If H - �1�7_1 C.E'H C1 II:::*".ii L_ H__ Y:-*-n�� PERMIT RPPLICHNT HAS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE INSTHLLHTION INSPECTlONS OF HNY HDJHCENT TO THIS PROPERTY HND THE NUMBER OF RESIDENCES TMHT THE WEE -LL WILL SERVE ��is ��... F, 1. r"D f1_11 IEEE' ��E�u BHCKFILLING OF HNY SYSTEM WITHOUT FINHL INSPECTION HND HPPROVHL BY THIS DEPHRTMENT WILL BE SUBJECT TO PROSECUTION MINIMUM DISTHNCE BETWLEEN H WELL HND HNY CIA -SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVHTE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTHNCE FROM H PRIVATE WELL TO H PRIVATE SEWEER LINE IS 25 FEET HND TO H COMMUNITY SEWER LINE IS 75 FEET, WELL LOGS HRE REQUIRED HND MUST BE RETURNED TO THE DEPHRTMENT WITHIN ]0 �HYS OF THE WELL COMPLETION OTHER REQUIREMENTS MHY HPPLY. SPECIFICHTIONS HND CONSTRUCTION DIHGRHMS HRE HVHILHBLE TO INSURE PROPER INSTHLLHTION Q K Fit 1-1 1. W ��1�F._.: C_,:- EHE": P-9 13 Ell 15". �� _1_. I CERTIFY THHT 1: I HM FHMILIHR WITH THE FOR ON-SITE SEWERS AND WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORT1GE. 2: I WILL INSTHLL THE SYSTEM lN HCCORDHNCE WITH THE CODES ]� I UNDERSTHND THHT THE ON-SITE SEWER SYSTEM MAY IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS. offuum HPPLICHNT STEWFIRT BHRDES ISSUED BY _~..~~DHTE _. t?r, I--Pv i4"' !070-10 AND ii'r}SFrr�,di��l1i �ttr:tTF;s'i #ts�6 _ C .. ' .." 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It� Illi` 'aT�:l•Iri�, i sa,;`i�cs�.� f ? lot. c3'�,i�A..}�.__`'.`S° jl � l�F 7' a...� Y.f if A7 l\' �"^�;1�«•Il �% _~I� /� `I/I Ir � I1 �!I,.��...:+�„ ) .., � UJ 11 L 12 L / b 5'� CUN;UI_ I II 1,1 0 cx,i , l 3 /S -/.5G a oox a7c-1.1, srnrr uouTc. n ANC11'')?W.r, nl-A;,l<'A 91107 PHONE 3n4-7071 SOILS LOG Performed for �- i\Ao-,i Location NocV e .,vsw isce o�ti� S']Je Soil Type � 0 5 M 2 5w� 6 Nater Level 1'emar.ks J c 10 L 12 v M 14 - �w • �s 16 ' 18 v,.. ..20 Total Depth of Excavatio Groundwater (X) Not Reached Depth, if Reached Classificaeion Method �) Visual ( ) Sieve Analysis SoNol s,l brown (C) _ Sv✓`nd-�-j y�r�u [ I - u�w�/ S O %a J�s atM . (i-12' ) Gvo.-.gel J G�-ea.v�, so�w�, �135 �- IS•/ �S Material at Total. Depth Bedrock (X) NOL Peached Depth, if Reached MUNICIPALITY OF ANCHORAGE DEPT. OF i z' ENVIRONNiENIA.L ;'-CTIONQQ Cary F. Player, Consulting, Geologist O O O O O O O O O O O O l a] Ml k3 �3 ! 3 !•3 �3 H rel �3 ; 3 0:0: O O O O O O ,� O O O O Z/1 F" N : y � ' N N :ct o w :m o ! rt i:r,' a :w ND :y � ;rt ll N m 01 Yy-1 r=i N o co J � rn V } WWIW rt 'N :N In m car ;� O m :a AMA :N ;a O a O ^ Ic-\ /O yO H N N N N Q 'O V -W N: O :ln O CO V O : 1�0 W : N J ' N : N iln :V W .N ?O Vi i0 i Co V i O :O to : co :N i W :U) co n 'W ' O 'O ? td O 'y a a wC wC Iri i a C r� C R.ID N :O H N C w :w N :C C iN iN O O O O O O O O O O O O l a] Ml k3 �3 ! 3 !•3 �3 H rel �3 ; 3 0:0: O O O O O O ,� O O O O Z/1 F" N : y � ' N N :ct o w :m o ! rt i:r,' a :w ND :y � ;rt ll N J m 01 0 r=i N o co J � rn � } WWIW rt 'N :N In m car ;� O m :a AMA :N ;a a in ^ Ic-\ J m 01 0 N o co J � f-. } WWIW m car � m AMA 0 a ^ Ic-\ 01 N J � f-. } MUNICIPALITY OF ANCHORAGE G Z ,1 DEPARTMENT OF HEALTH AND ENVIRONMENTAL PRO i'ECTION I o DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL !�I Dias OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date "��3�rO 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) 4a� Bi�-oc2- J, �1je-" 6(7s 5'Aet0Pr 2'iiz� 2,3 w Location (address or directions) 9 /.6�3�5 Xlc("euea� _ (b) Applicant Name / ts. lt/Siern� Telephone: Home � '�f�0� Business Applicant Address /,33¢5 L' 51& (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer ❑ ; Other (explain); - (d) Lending Institution Telephone — Address (e) Real Estate Company and Agent Address Telephone - (f)- Mail the HAA to the following address. 2. TYPE OF RESIDE E �j Single -Family Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well lit Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE D OSAL 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(M84) 5. ENGINEERING FIRM PROVIDIN%. ,NSPECTIONS, TESTS, FILE SEARCH, DA,,. 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. �J Name of Firm �d �1- /-'dd��%�er ° Telephone 3��F44f� Address zoa 66 SE'S Date 4Zi3,Arr C: T %. a J. Corwin o` �1":, °e o. CE -6233 �,'3 �•zy/,/�� Engigd,errs Seal �+°< ��' •tee, '., �-� 6. DHEP APPROVAL Approved for bedrooms by ' Date Approved— Disapproved Conditional Terms of Conditional Approval dhe� 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. Page 2 of 2 72-025 (11,84) MUNICIPALITY OF ANCHORAGE (MOA) -� HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-•4720 Legal Description: Z-6� J3CVC C J 1'�/w/4 /1L /O/; 's A. WELL DATA Well Classification P�'/V54 Z If A, E3, C, D.E.C. Approved (Y/N) AlIj; 41 Well Log Present (Y/N) t L-5 Date Completed (��/d'/ Yield 54 Total Depth 3- c' — Cased to 170 Depth of Grouting 1V0A,1C_ Static Water Level ✓tea — Pump Set At— 4,0/✓ Casing Height Above Ground — Z -v Sanitary Seal on Casing (Y/N) A -S Electrical Wiring in Conduit (Y/N) Separation Distances from Well: Depression Around Wellhead (Y/N) To Septic/Holding Tank on Lot .t On Adjoining Lots To Nearest Edge of Absorption Field on Lot — �oora ; On Adjoining Lots — To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments + coir! Gtl� i 1--O / IL 1t/'o1v4_To Nearest Public Sewer r � d'JE To Nearest Sewer Service Line on Lot k7p �(/� ; Date — Y AJ9 B. SEPTIC/HOLDING TANK DATA Date Installed Jul-, 19R/ Size /000 674C. No. of Compartments Standpipes (Y/N) _��:k Air -tight Caps (Y/N) V&� — Foundation Cleanout (Y//N) le� _ Depression over Tank (Y/N) _ �o Date Last Pumped / %ZC 7 Pumping/Maintenance Contract on File (Y/N) A" _ ; for — /�4 Holding Tank High -Water Alarm (Y/N) _ &A - Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: / To Water -Supply Well To Building Foundation i To Property Line _ %'5 To Disposal Field To Water Main/Service Line — �U� %� To Stream, Pond, Lake, or Major Drainage Course //o IV(_ - Comments Page 1 of 2 79_n9ai1 1/ani C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /7 Type of System Design ��/ Date Installed / ?16 / Length of Field 0 Width of Field �Depth of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test 1S'&G Gravel Bed Thickness — Standpipes Present (Y/N) Date of Last Adequacy Test/ Separation Distance from Absorption Field: To Water -Supply Well /00 (� To Property Line le / to To Building Foundation nnn�� 25-/1- To Existing or Abandoned System on AX' Lot ; On Adjoining Lots 30/ i To Water Main/Service Line /0 14 To Cutbank (if present) X&il/- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/ "Pump On" Level at "P ff" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) ENineer's Seal Comments % 3 roo ** ChecAthack ting Against HAA Request *' I certify , v rified, or conformed to all MO/A� amend HAA guidelines in effect on the date of this inspection. /-ZeComoa Signed Datey MOA No.f�%'�7 Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) Yfuc J. CoMir) o c/mac/5zsa �• `� � ``!?ram" "��T��•� 'rr.l�l ENineer's Seal % 3 Yfuc J. CoMir) o c/mac/5zsa �• `� � ``!?ram" "��T��•� 'rr.l�l _ - - __. _ _ _ J. � -. .- - .-r. �v.rv. u.nvf. �rcn>2-sMrM �k 1'tMt'![•ea•m_rY�r�±r��, sr ce. x� e m .�- INVOICE / AIpJ 021943 0070c;oog SEWER AND DRAIN ",4co" Cfo '%aauGlea CLEANING SERVICE ?�awa t/cc �aai.c" P.O. BOX 112688 PHONE 345-2513 ANCHORAGE, ALASKA 99511-2686 . P I sq Job Address )All - -tiAl l,',:,MANa II I1Mfa :111 DAYti fa v?f I1 fly'(/}�(7vJ� 30T0_ROOTER SERVICE CALL HRS. @_ ----- STEAM THAWING HRS. (a — MIP CHARGE...--------_.---------HRS------fes --------- OVERTIMECHARGE _HRS. QD — ADDITIONAL LABOR CHARGE-------a,p------- - -------------- PUMPING SERVICE IVZZ (GAL) HRS @ � HYDRO -JET SERVICE FIRS -- MATERIALS — -- -- connn TM14 INVnICF iOTAL TOTAL FOOTAGE CLEANED OR THAWED_—.._BLADESUSED I_ PROBABLE CAUSE OF STOP 3` j V' V v' LINE CLEANED ------- --- 0 JOB NOT GUARANTEED FOR FOLLOWING REASON WORK ACCEPTED BY — CHEMICAL & GEOLOGICAL LABORATORIES OFf1LASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID N 92-0040440 IABOR.TORIE ANALYSIS REPORT BY SAMPLE for Work Order # 6034 Date Report Printed: APR 12 88 @ 09:03 Client Sample ID:BACKYARD WELL PWSID :UA Collected @ hrs. Received APR 8 B8 @ 13:15 hrs. Preserved with :NONE Analysis Completed :APR 8 88 Laboratory Supervisor STEPHEN C. EDE Released By : C�'-.r(�/� Special Instruct: Chemlab Ref #: 9617 Lab Smpl ID: 1 Matrix: Water Client Name CORWIN & ASSOC Client Acct CORWINP P .0. # NONE REC D Rey # Ordered By Send Reports to: I)CORWIN & ASSOC 2) Allowable Parameter Tested Result/Units Method Limits NITRATE -N 0.39 my/l EPA 353.2 10 Sample ROUTINE SAMPLE Remarks: 1 Tests Performed See Special Instructions Above UA=Unavallabie ND= None Detected See Sample Remarks Above NA- Not Analyzed LT=Less Than, GT=Greater Than MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTI-I AUTHORITY APPROVAL CERTIFICATE 1 I. General Information Application Date I? s ��mq (a) Legal. Description (include lot, block, subdivision, section, totownship,�range) �TL ,.— .� - ! L ia. I` �.o.^• o.`_. ��., _' {s. �4q� �A .r..� •.�� .,�,_.a._ . Location (address or directions) (b) Applicants Name_mnlHome Business_ Applicants AddressT L4 KLC (c) Applicant is (check one) Lend Buyer . ; Other M (,expl (d) Lending Institution Address ..Insti"tution ;'-Otmer(bdOmier ; Telephone (e) Real Estate Co. &Agent AC=VL1p",�f F�.?�m.� T1:.M Vie! Address < J' Nk)y_7j rx.2_ ` ___,LL ! � , Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single --Family j Multi—Family Number of Bedrooms 3. Water Suy Individual Well r Community 1-1 Other (describe)_ Public M Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting 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 I of 2] Amount: y0 a -^ [Page 1 of 21 2-15-84 ea_r�®sem b..s b a.� W , , uvacxan nspecrions, 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 onsite 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 regula- tions in effect on the date of this inspection. Name of Firm % ja; _ '[> � �� Telephone_M -- Ldq/ Address i sA:�4 Date f;;i (ENGINEER SEAL) 6o DHEP Approval is -^ , v. 222 - [_ Approved for '� 64 JUNE 2a, 1ji1 A PP #� bedrooms BY hirt��. � ,% Date° Approved Disapproved Conditional Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DI:IEP) ISSUES HEALTH AUTIiORITY 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 INSTITUTIONS 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•x84 03AHD3c MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) �86' CHECKLIST - FEBRUARY 1984 NC IKWOad IViN]WNoa]AN3 q HIIV]H do 'LACI.`.— A. WELL DATA Legal Description . .�.� _......., we. Well Classification_ J>el VArt* If A, B. or C. D.E.C. Approved(YM) W Well Log Present (Y/N) Y _ Date Completed 6/.218'% " Yield xy Total Depth r'p Cased to /70Depth of Grouting /yc9N L Static Water Level (Gp t Pump Set At 601%i Casing Height Above Ground 42,11 le Sanitary Seal on Casing (Y/N) y Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N).j�L Separation Distances from Voll: To Septic/Holding Tank on Lot 1004 On Adjoining Lots 156 To Nearest Edge of Absorption Field on Lot 100 ; On Adjoining Lots (3d `I' To Nearest Public Sewer Line NONLE To Nearest Public Sewer Cleanout/Manhole pAlE To Nearest Sewer Service Line on Lot Ja f Water Sample Collected By I- -e- Date— Water SP Comments B. SEPTIC/HOLDING TANK DATA Date Installed? I� 191 Size ID&O No. of Compartments Tt.&o _ Standpipes (Y/N) !�o Air -tight Caps (Y/N) > Foundation Cleanout (Y/N) Depression over Tank (Y/N) N Date Last Pumped 'k-13195 Pumping/Maintenance Contract on File (Y/N) M,a4 ; for N/A Holding Tank High -Water Alarm (Y/N) IV/,y Temporary Holding Tank Permit (Y/N) tyl^ Separation Distances from Septic/Holding Tank: To Water -Supply TAbll /Do To Building Foundation 10 To Property Line Irk To Disposal Field - 1D1 To Water Main/Service Line 10+ To Stream, Pond, Lake, or Major Drainage Course N 0 N [_ Comments Receipt # 3,22 65 7 _ Date Paid: _J_tE;.,q5 Amount: —yoc* [Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 1-75 Type of System Design --,f, ta Date Installed 7/111,g/ Length of Field 0 Width of Field NO Depth of Field Gravel Bed Thickness Square Feet of Absorption Area 5 4.0 Standpipes Present (Y/N) O N S _ Depression over Field (YIN) N Date of Last Adequacy Test IlLf/* s Results of Last Adequacy Test Pgtsg i m Separation Distance from Absorption Field: To Water -Supply T\b ll ! o o 'f To Property Lire to Ap To Building Foundation 95 To Existing or Abandoned System on Lot N D N E 1 On Adjoining Lots N5? 30 To Water Main/Service Line 1 b '- To Cutbank (if present) N ON L To Stream/Pond/Lake/or Major Drainage Course 1\1 O N �= To Driveway, Parking Area, or Vehicle Storage Area 51 Comments D. LIFT STATION N O N t^ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes Comments Dimensions Manhole/Access (YM) "Pump Off" Level at Vent Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conform d to all MOA HAA Guidelines in effect on the date of this inspection.% % Signed Date !/ 2.Zl � a_ Company MOA No. 9 yS (`-Q l / Y.B1/d5/s [Page 2 of 21 n _9.0 M C Ai �`�..��°'• e• ori ,��. y, a ��(/f{,,y/J • • rSE • e Yee ;i` 2225-F UNE 25, 1971 , 2-15-a4 P O n E 1P VIN W I�lr�1U�,I �a o o ANCHORAGE, ALASKA 203 W. '15tb V I x99501 CONSULTING ENGINEER TELEPHONE: (907) 279.3916 PETE JARRET HERITAGE INVESTMENT 207 E. NORTHERN LIGHTS BLVD. ANCHORAGE, ALASKA 99503 JANUARY 22,1985 S E P T I C S Y S T E M A D E Q U A C Y T E S T LEGAL: LOT 1, BLOCK J, KNIK HEIGHTS LOCATION: 13345 RIDGEWOOD CIRCLE OWNER: EDWARD ORTEGUS RESIDENCE: THREE BEDROON, SINGLE FAMILY WATER SYSTEM: ON SITE WELL SEPTIC SYSTEM: FROM MUNICIPAL RECORDS: TANK: 1000 gal. Greer. Steel ABSORPTION SYSTEM: Trench ABSORPTION AREA: 560 sq. ft. SOIL RATING: 175 INSTALLATION DATE: July 1981 DATE OF PUMPING: January 21, 1985 DATE OF TEST: January 21, 1985 TEST PROCEDURE: Tank was pumped and water added to the sump of the trench at a steady rate of 7 gallons per minute. The water level in the sump was monitored and the following readings taken: Water Volume Gal. -0- 100 200 300 450 Water Depth In. 48 53 56 58 60 After 24 hours the water level was checked. The level was 36 inches. TEST RESULT: This system absorbed more than 450 gallons of water in a 24 hour period. The Municipal requirement is that 150 gallons per bedroom must be absorbed in a 24 hour period. Thio' system surpasses this requirement. Tobben Spurkland P.E. Pete Jarret Heritage Investments Lot 1, Block J Knik Heights Jan. 22, 1985 Page two The operational life of all septic systems depends on the local soil conditions, groundwater levels that may fluc- tuate during the year, and the water usage of ,; ;•°• %`a the family being sereved by the system. These Fpi ,:' , conditions are outside the control of the `.••• evaluator of this septic system. We can there- fore not give any estimate of how long the ��,^`• t'�. 2225-E system will continue to meet the operational a� :' 1 NE 25, 1911 requirements of the Municipality and State. 203 10 o �'r A �GD�NU a, ND® VQ�Q AN HORAGE,VALASKAIT o99501 CONSULTING ENGINEER TELEPHONE: (907) 279.3916 PETE JARRET HERITAGE INVESTMENTS 207 E. NORTHERN LIGHTS BLVD. ANCHORAGE, ALASKA 99503 JANUARY 21, 1985 R E S I D E N T I A L W E L L I N S P E C T I O N LEGAL: LOT 1, BLOCK J, KNIK HEIGHTS LOCATION: 13345 RIDGEWOOD CIRCLE OWNER: EDWARD ORTEGUS TYPE OF WELL: RESIDENTIAL, SINGLE FAMILY WELL LOG AVAILABLE: YES INSTALLATION REQUIREMENTS MET:YES WELL YIELD FROM WELL LOG: 5 GPM PUMP YIELD: 7 GPM DATE OF INSPECTION: JANUARY 21, 1985 TEST PROCEDURE: WELL WAS PUMPED AT A STEADY RA'Z'E OF 7 GALLONS PER MINUTE FOR 65 MINUTES. DURING THAT TIME 450 GALLONS WAS DELIVERED. TEST FOR COLIFORMS: TEST WAS PERFORMED JAN. 18, 1985. TEST WAS NEGATIVE. TEST RESULT: � 4s °p - i.•.• •♦ •• a°ti4 �. No 2225-E: lU lb, 1971 E ;• rye[ ,•.• The Municipal requirement for well flow is 150 gallons of water per bedroom per 24 hours.This well surpasses this requirement. The assessment of the condition of this well applies only to the conditions as of this date. The flow rate of the well may change due to subsurface conditions that may not be observed from the surface, and changes in land use and other factors that may impact, the conditions of the aquifer feeding the well. Time APPLIC JT FILLS OUT UPPER HAL )NLY Propert, Owner -:;.a __ kj, Aj Phone Mailing Address 'j '�� i il��_-�. Zip Code ) Date Date Date Buyer Inspector Inspector Address Inspector Zip Code Lending Institution Phone Address Field Notes: O v Zip Code Realty Co. & Agent ,,-� ," q Phone MAY ECEIVED (3 ) APPROVED BEDROOMS Address ( ) DISAPPROVED Zip Code ( ) CONDITIONAL APPROVAL' Legal Description'., j Street Location ? 'r�—�<'3a�T-� �'-� EST-iIVl{X. Type of Residence _ R Ingle Family -"- Septic Tank Size /tic`/L_% 11 Multiple Family No. of Bedrooms— edrooms❑ ElOther Water Supply 1 C ClArtdividual _ �� .� ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975. ❑ Community For wells drilled prior to that date, give well depth (attach log if available). O Public Utility Sewer Disposal EYfndividual Year Individual Installed: ' � El Public Utility When Connected to Public Utility ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time I Date Date Date Dat — �-.C? 3 C, --Df Cl Inspector Inspector Inspector Inspect r Field Notes: O v MUNICIPALITY OF ANCHORAGE DEPT. OF H- A.LTH P,. ENVIRONMENTAL PROTECTION MAY ECEIVED (3 ) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE CA -_ �. - �•} Soils Rating Date Sewer Installed Well To Absorption AreaWell Log Received '•:y''t�-...- ' Well to Tank �(.:.� Septic Tank Size /tic`/L_% 72023 (3182) D T 5. LEGAL DESCRIPTION DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME 6. TYPE OF RESIDENCE �DL °e X00 � O DATE DATE - DATE - ❑ Two CI Five ❑ MULTIPLE FAMILY -1-2 l INSPECTOR INSPECTOR INSPECTOR ��)) ��11 P\RAGE * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY MUNICIPALITY ❑ PUBLIC UTILITY DEPT. OF HEALTH & MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL PROTE❑ION 825 L Street - Anchorage, Alaska 99501 - p r,- /r'tt 1.1981 [II J L/ I;7 %%I ENVIRONMENTAL SANITATION DIVISION RECEIVED F Telephone 264.4720 G�1 IC D NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10)daysfor processing. 1. PROPERTY OWNER vOA,2T2t�}�5� - PHONE MAILING ADDRESS 5l31 ;ice �C}?i=.2 C'�rZ f\Nc.4luPiaC�c - 1�C` PROPERTY RESIDENT (If different from above)q' - PHONE - - L YiN1bL_ �-W _ _ _E)•a_ z� w15tu� --- - 2. 13UYER '5A �' PHONE MAILING ADDRESS - - -- - 3. LENDING INSTITUTION' � PHONE AV,`1 s �T iytu�1 Z'7(a 8180 MAILING ADDRESS 12 �t(ZPocZ� - H t l'—F N"iceLz_ rJG o�z� 4. REALTOR/AGENT �1V �iONE MAILING ADDRESS - - - 5. LEGAL DESCRIPTION L i b a i�1.r> tc_ STREET LOCATION _UTS 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS ®^ ❑ One ❑ Four ❑ Other SINGLE FAMILY ❑ Two CI Five ❑ MULTIPLE FAMILY ;&�- Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* * 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 UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM- t-_ INDIVIDUAL/ON-SITE** 19?)) _YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) � - THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE Ll PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED 10 - INSTALLER ❑Septic Tank or ❑ Holding Tank Size: I OD6 If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS APPROVED FORy BEDROOMS L_I CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY u ij-'Culsljjelr ilf I U tH chorviriv , 1; n I I i C2 C t 1 Id 110 WIN: I Its f0c Uh, ilulivi,111j,j TIMICIr and w;jf:fj,. revivo. i_j ry 11lu tOP CQ tl]Q yy], I (1,11;i IQ Suplivil thM. it is vattal: higim. "rhe" at -'j-)1 f {,t:t:l. )1 or !At aroilliel tKi W!] t,-. 5:711 nuncio to) MUICACT wil:tl sO tiait it: gjrnqlq m: tha we 'Ale"I'll (Nishin nowls ,51MV�� 'IYoun'! 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