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SKY RANCH ESTATES #1 BLK 4 LT 5
Permit Number: Tax Code Number: On -Site Wastewater Disposal System Permit OSP161255 01530107000 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 Work Type: Septic Upgrade Permit Effective Dates: September 20, 2016 to September 20, 2017 Design Engineer: CREWDSON ENGINEERING, LLC Subdivision: SKY RANCH ESTATES #1 Site Legal Address: SKY RANCH ESTATES #1 BLK 4 LT 5 G:2737 Owner/Address: HOLLAND EVAN B & JUDY D 5531 WHISPERING SPRUCE DRIVE ANCHORAGE AK 995162312 e.I)arnneIII Site Mailing Address: 5531 WHISPERING SPRUCE DR, Anchorage Lot Size in Sq Ft: 13475 Total Bedrooms: 4 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. Special Provisions: 1. Construction may proceed at your own risk before the 7 day water monitoring is complete. < )OA611- t'_C, Please submit stamped and signed results with the As -built Inspection Report. If the results require a design change, construction of the system will stop pending On -Site review and approval. L:= TS Maintenance Agreement is to be submitted with the IR. 4- /01-27116 co'I'tvf Co -411 1017-016CC) 10 2 s�/6 C �� _LLL r y s re n -, ti se j . Received Issued By: Date: Date: Municipality of Anchorage P.O. Box 196650 0 4700 Elmore Road Anchorage Alaska 99519-6650 0 (907) 343-7904 o Fax (9071 343aa Development Services Division On -Site Water and Wastewater Program * ** * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSVI61122 COSA#: Permit#:OSP161255 PID#: 015-301.07 Legal Description: Sky Ranch Estates #1 B4 L5 Engineer: Crewdson Engineering Applicant: Evan and Judy Holland Your request for a waiver of the required 100 feet horizontal separation from the absorption field to the private well has been approved. The approved separation distance is 95.0 feet. This waiver approval applies to the proposed and existing absorption field only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. ❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected adjacent property. ® Adjacent properties are not affected by this waiver. ............................................................................... Waiver is Granted: X Waiver is not Granted: Date: 11� Approved by: t� ................................................N: :: v.iie **** VARIANCE/WAIVER REVIEW **** 4 MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERP Parcel I.D. 015-301-07 Property owner(s) Evan Holland Day phone 907-748-4908 Mailing address Site address 5531 Whispering Spruce Drive Legal description (Sub'd., Block & Lot) Sky Ranch Estates #1 B4 L5 Legal description (Township, Range & Section) Lot Size 13,475ff Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field Initial ❑ Single Family (SF) x❑ (w/wo ADU) Septic Tank Upgrade X❑ Duplex (D) F-1Holding Tank ❑ Renewal F-1 Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the,a�bove information is correct. I further certify that this is in accordance with applicable Muni6ipal Codes. (Signat6r of property owner or authorized agent) Permit/Rush Fees: a115- -#3..9 Waiver Fees: ( (2 $ Date of Payment: 14�0//(Date of Payment: /o%h6 Receipt Number: ON -M? 03-L- 0 Receipt Numbe r: 053766 Permit No. Ll 5&& IA5_5 Waiver No.��f ) 6 N? -2 Permit App__- Civil & Environmental Engineering October 23, 2016 Municipality of Anchorage On-site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99519-6650 Attention: On-site Engineer Reference: Sky Ranch Estates q1, Block 4, Lot 5 Change Order AWWTS o #z James "Jay" Crewdson, P.E. Email: CELLC.1@outlook.com Cell/Text: (907) 280-9493 Fax: (907) 688-2295 A large number of buried logs/stumps were discovered near the northeast corner of the property during construction of the drainfield. Due to this discovery and the much less area remaining to locate a new drainfield, we are requesting a design change to use an Advanced Wastewater Treatment System (AWWTS). Due to the cold weather and the need to finish the ongoing construction as soon as possible, we are also requesting the owner's AWWTS Maintenance Agreement be allowed to be submitted with the Inspection Report prior to final operational approval. Please feel free to contact me if you have any questions. Thanks, James Jay' Crewdson, P.E. PO Box 671389 • 18368 Amonson Road • Chugiak, Alaska 99567 Civil & Environmental Engineering October 19, 2016 Municipality of Anchorage On-site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99519-6650 Attention: On-site Engineer James "Jay" Crewdson, P.E. Email: CELLC.1@outlook.com Cell/Text: (907) 280-9493 Fax: (907) 688-2295 Reference: Sky Ranch Estates #1, Block 4, Lot 5 Change Order 1: Revised Septic Permit Application OS�/61a SS Drainfield Added The owner of the subject property would like to replace the two existing septic tanks (1973 concrete 1000 - gallon and 1980 steel 500 -gallon) with one new 1250 -gallon septic tank and install a new 4 bedroom drainfield using conventional treatment. The existing septic tanks will be decommissioned in accordance with the code. The proposed septic tank and drainfield will be installed per the Septic Design Plan View (page 1 of 1). As designed, the proposed upgrade has no conflicts and will satisfy all code requirements. Due to freezing weather and the need to get the exposed excavation finished, we are asking to proceed at our own risk without 7 -day groundwater monitoring. Other nearby local test holes (attached) are reporting no groundwater and the 18 -foot deep onsite groundwater monitor has been dry for two days. Please feel free to contact me if you have any questions. Thanks, James " y" Crewdson, P.E. PO Box 671389 • 18368 Amonson Road • Chugiak, Alaska 99567 Crewdson Engineering,_ LLC Civil & Environmental Engineering October 19, 2016 Municipality of Anchorage On-site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99519-6650 Attention: On-site Engineer Reference: Sky Ranch Estates #1, Block 4, Lot 5 Waiver Request Well to Drainfields James "Jay" Crewdson, P.E. Email: CELLC.1@outlook.com Cell/Text: (907) 280-9493 Fax: (907) 688-2295 The existing crib drainfield was installed in 1973 and then an add-on trench was installed in 1980 to increase the number of bedrooms the system could be approved for. The approved inspection report for the add-on trench shows the drainfield is at least 100 feet from the well serving the subject property. During the site investigation associated with septic tank upgrade OSP161255, the sump standpipe at the end of the add-on trench was found to be approximately 99 feet from the well, which puts the side of the 3 -foot wide trench (per On-site records) approximately 97.5 feet from the well if the sump was installed in the middle of the trench as shown in the records. The proposed drainfield can be shown on paper that it will fit without a waiver. To get it to fit, it has been located: 1 -foot from a utility easement, 11 -feet from a property line, and 16 -feet (minimum required) from the existing drainfield. Given the situation outlined above, the following waivers are being requested: 1. 95 -feet between the well and the existing drainfield. This will both revise On -site's records to be showing the correct distance and also allow that distance to be approved as -is. 2. 95 -feet between the well and the proposed drainfield. This will give the contractor more space to work with in trying to get the drainfield to fit. It will only be used if current unknowns come to light that force the proposed and permitted location to be revised. Justification for the waiver. 1. The reduced separation has been in existence for 36 years with no apparent problems. �. j If"��1� . Subject well: "0" mg/L in 1988 1 Y'� Lb. Lot 6 well (43' from subject well): 0.25 mg/Lin 1997 2. Any septic system overflows would flow away from the well. 3. The house is in between the drainfields and well. PO Box 671389 • 18368 Amonson Road • Chugiak, Alaska 99567 Page 2 of 2 October 19, 2016 Sky Ranch Estates #1, Block 4, lot 5 4. Alpine Drilling flow tested the 248 -foot deep well in 1988. At that time, it had a static water level 180 -feet, which equates to a pressure head of 68 -feet (29 psi). This shows the aquifer is confined and as such is very unlikely to become polluted from sources in the local area. 5. The existing septic tanks were waived at 85 -feet from the same well in 1988 by Dan Roth with no apparent impact to the well. Please feel free to contact me if you have any questions. Thanks, James "]z UrA nes A. Crewdson .10 1 Q5 17(G . �aC��i' ,LLC 7q PO Box 671389 • 18368 Amonson Road • Chugiak, Alaska 99567 LEGEND COMMUNITY WATER ON NORTH COMMUNITY WATER ON NORTH SIDE OF PROPERTY SIDE OF PROPERTY _ I P II rIL I I EASE MEN r _ COMit 2 - - - - CO2 SHED MR SEPTIC O T C °O V Orb ST2 CRIB AND LOT4 TRENCH (E) (E) existing GPD - gallons per day (P) proposed IAW - in accordance with BEG - below EG JV - Jandy valve BOH - bottom of hole MPI - minute per inch CO - cleanout MT - monitor tube DC - double cleanout PV - pump vault DWY - driveway SF - square foot DV - diverter valve SFH - single family home EG - existing ground ST - septic tank cleanout FC - foundation cleanout TM - treatment module FG - finish grade Crewdson Engineering, LLC 'W�!'d Civil & Environmental Engineering lion 671389 Chu,ak AK 99567 • cello@o,A ok CEIVTexL 907-289-9493 • Fax :907-688-2295 v DECOM TWO SEPTIC TANKS SPO IAW CODE JDWY 3BEDROOM WELL (E) O T12N R3W SEC 22 NE4NE4SE4 ZONING: PLI if .4, LAND USE VACANT CLASS'. RESIDENTIAL OWNER: MOA NO WELLS WITHIN 200OF THE PROPOSED SEPTIC SYSTEM F Z TRENCHAND F% CRIB (E) IFZ- LOT 6 I 100' WELL RADIUS 3 BEDROOM SFH I I I I WELL (E) O NOTE: DESIGN REQUIREMENTS 1. ALL PROPERTY LINES, EASEMENTS AND WELL RADII TH1: 24 -MPI. BOH 20', DRY WITHIN 20 FEET OF THE PROPOSED SEPTIC SYSTEM TH2 8 -MPI, BOH T, DRY SHALL BE FLAGGED PRIOR TO CONSTRUCTION BEDROOMS: 4 2. PROVIDE ADDITIONAL 120V -20A CIRCUIT AT PUMP CAT -III APPL. RATE. 4 GPDISF VAULT FOR OPTIONAL FUTURE AIR PUMP. AREA. 150 SF Sky Ranch Estates #1, Block 4, Lot 5 Septic Design Plan View Change Order 2 Prepared for. Evan Holland Date. 10-24-16 Permit. OSP161255 Page. 1 of 1 DEEP TRENCH: LENGTH: 20' EFFECTIVE DEPTH: 5' TOTAL DEPTH: 9'MIN - 14'MAX 1250 -GAL SEPTIC TANK 500 -GAL PUMP VAULT AEROCELL CAT -III TREATMENT • • '� • James A. CrewdsonC11527 .- : r k PROFESSIONaV��� ALLC #112279 ALL '_ Municipality of Anchorage r6n Development Services Department i Cj ,• Building Safety Division 00 .�. On -Site Water and Wastewater Program .4.1 *'?, 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www. ci. a n ch o rao e. a k. us (907) 343-7904•, Soils Log - Percolation Test 'tI1&`i Performed For: Evan Holland Date Performed: 10 -18 -IE Legal Description: Sky Ranch Est #1, B4, L5 Township, Range, Section: J /'7 Slope Site Plan J � Depth OG 1- 2- 3 C" L 4- 5- 6- 7- 8- 9- 11- 12- 13- 1 1 1 1 1 COMMENTS PevC 4014 PROBE© - - io-414(o WAS GROUND WATER No ENCOUNTERED? S IF YES, AT WHAT DEPTH? L Depth to Water After I� e Ur P Monitoring? ✓ E Pr e I PERCOLATION RATE �JL (minuteslnw) PERC HOLE DIAMETER 6 t TEST RUN BETWEEN 6 FT AND FT PERFORMED BY: CreWdson Engineering LLC I James Crewdson CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 10-18-16 Performed For: Legal Description: Ha Depth 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. c i. a n c h o ra o e. a k. u s (907)343-7904 RLLC _�`) 49 Soils Log -Percolation Test Evan Holland Date Performed 10 -18 - Sky Ranch Est #1, B4, L5 Township, Range, Section: 1_ vv 2- 3- 4- 5- 6- - 3 4- 5- 6 �i' 1 Pe r 0- 7- 8- 9- 10- 11- 12- 13-, 16 78- 9- 10- 11- 12- 13- 16 17 18 19 COMMENTS WAS GROUNDWATER ENCOUNTERED? s IF YES, AT WHAT DEPTH?T� L Depth to Water After f,�{ o F Monitori � E ,If1 �V� Date: o�/WChrn�'o� A. Crewdson 011527 ,`���i PERCOLATION RATE F'? (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND --;Z FT PERFORMED BY: Crewdson Engineering LLC I James Crewdson CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 10-18-16 ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT BETWEEN MUNICIPALITY OF ANCHORAGE H Evan & Judy Holland THIS MAINTENANCE AND REPAIR AGREEMENT made and entered into as of this Day of of 20, by and between herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY." In consideration of the mutual covenants contained herein, the parties to this Maintenance and Repair Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. Municipality grants permission to Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as Cat -III Aerocell located at (legal description). Sky Ranch Estates #l, Block 4, Lot 5 2. Definitions. Alteration. Any change to the design or function of an AWWTS that includes the installation or removal of any parts, components or pieces not included in the original construction permit and design. Certificate of On -Site Systems Approval (COSA). An approval by the Municipality of existing water and wastewater disposal systems given at the time of property sale and title transfer in accordance with Anchorage Municipal Code (hereinafter, "AMC") 15.65. These approvals certify that the systems are adequate for the homes that they support and meet the codes that were in place at the time of system construction. Damage. Any man-made or natural change in a system that would inhibit the system from performing as designed. Maintenance and Repair. The scheduled and as needed replacement of existing parts, components and pieces of an AWWTS that were included in the original design which would allow the AWWTS to continue to perform as designed. Permit. An On -Site Wastewater Disposal Permit as required by AMC 15.65 to construct and operate an AWWTS. 3. Term. The term of this Maintenance and Repair Agreement shall begin on the date of approval by the Municipality to operate the installed system or issuance of a COSA, and shall continue while the AWWTS is in use or is operational or until the property is sold or title is transferred by the owner and a new COSA is issued to the new owner or transferee of the property. 4. Alterations, Installation and Removal of Additional Equipment. Prior to performing any alterations to an AWWTS, the owner agrees to obtain an On-site Wastewater Disposal Permit from the Municipality in accordance with AMC 15.65. 5. Maintenance and Repairs. A. Throughout the term of this Maintenance and Repair Agreement, the Owner shall maintain their AWWTS in a satisfactory condition capable of producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. The owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the municipality and the manufacturer of the AWWTS for the entire term of the AWWTS. In addition, it shall be the responsibility of the Owner during the term of this Maintenance and Repair Agreement, and any renewals thereof, at the owner's sole expense, to pay for any and all: (1) repair(s), (2) maintenance, (3) adjustment(s), (4) replacement costs, and (5) inspection costs. B. Owner agrees to comply with all applicable ordinance, laws, regulations, rules and orders for the AWWTS. C. Upon request by the Municipality, the owner agrees to provide the Municipality a written schedule of routine maintenance and repairs which have been performed on the system. When a record of maintenance is documented and maintained by the system vendor, the owner agrees to allow the Municipality access to this information. D. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60 for improper discharge. E. Owner agrees that only maintenance and repair personnel approved by the Municipality will inspect and make any necessary maintenance, repairs or permitted alterations to the system. F. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS upon 24 hours written notice. G. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. H. Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the Owner's AWWTS. I. Owner agrees to provide and maintain a telephone connection to the AWWTS as required by the AWWTS approval. 6. Nonwaiver. The failure of either party at any time to enforce a provision of this Maintenance and Repair Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Maintenance and Repair Agreement or any part hereof, or the right of such parry thereafter to enforce each and every provision hereof. 7. Amendment. A. This Maintenance and Repair Agreement shall only be amended, modified or changed by a writing, executed by authorized representatives of the parties, with the same formality that this Maintenance and Repair Agreement was executed with, and such writing shall be attached to this Maintenance and Repair Agreement as an amendment. B. For the purposes of any amendment modification or change to the terms and conditions of this agreement, the only authorized representatives of the parties are: a. Owner: Evan or Judy Holland b. Municipality: Director, Community Development or designated authority C. Any attempt to amend, modify, or change this contract by either an unauthorized representative or unauthorized means shall be void. 8. Jurisdiction: Choice of Law. Any civil action arising from this Maintenance and Repair Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Maintenance and Repair Agreement. 9. Severabill Any provisions of this Maintenance and Repair Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Maintenance and Repair Agreement. OWNER: By: I (signature) Date: l!i ✓�r��% Ag a' (print name) STATE OF ALASKA ) ) ss. THIRD JUDICIAL DISTRICT ) The foreg 'nPP,instrument was ackn wledged before me this �� day of°J RUw� 20INOTARY L(Gty� LIC FOR ALASKA Commission expires: Chlq = iNOTARY '., PUBLIC;`* 1101 IIp\P��Q\ MUNICIPALITY: By: (signature) Date: �Q Z 7 6 (print name) Title: 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 -j 'f 7''7 3KLICE IVE1) JUN 20 2000 MUNUPALITY OF ANCHORAGE WWMENTAL SERVICES DIVI° CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # O t S - 307 - O 7 HAA # X4600o (o d 1. GENERAL INFORMATION 2. 3. 4. Complete legal description L vt S 13�ock 5� SkY RQ -ch Csl�-A<r 1;12 Location (site address or directions) S"3f -S lure Dr ! % e Property owner RtcyavrX phX11it Rocj�Day phone 26r-o.7y3 Mailing address 16DG� Uitn� Sri. >rwe I+mcA&rezAk-yz Lending agency un kn ac..i, Day phone Mailing address Agent None - /=S 6� Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site '✓ Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(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 furtherverify 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 72'c4n1'« / phone 3 yS-i3s's Address / 41,5'30 C—cl,o AcA0�-e-r94' L 9� 9S � Engineer's signature o1✓/� I- Date Tu��- le 2-000 6. DHHS SIGNATURE A v Approved for Disapproved. _4 bedrooms. Conditional approval for Additional Comments v. J�:r' alai pe eileteo 'LL I eP r=000ee oc.00ee�ev teettto`.-. :5 ............. 1®r1CCD0 E if. =A P bedrooms, with the following stipulations: Date (P+2-�--d 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. 7M25(Rev.1/91) Back MOAN21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description:S/5X lia�ch ArA#/ Parcel I.D.: 0(s -3'01-e527 A. WELL DATA Well type Priv a f -C If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well production I Date completed 1973 e' Cased to S y,9' Casing height (above ground) 2' FROM WELL LOG WATER SAMPLE RESULTS: Wires properly protected (Y/N) r AT INSPECTION g.p.m. `'/.9 Y g.p.m. Coliform 0 cr>(anj<!/Ivvml- Nitrate 0.590 7/-6 Otherbacteria Nv.,e re/9c�r/e-( Date of sample: 5-/Zs/2000 Collectedby: Tec/in,cw/ Serw'cer B. SEPTIC/HOLDING TANK DATA 7 / rY / eru y 00�7 / Y Date installed 10/z9/73 Tank size oNumber of Compartments �_ Cleanouts (Y/N)_y Y ver'Fled c(eanauf inr,� r�nc�ence Foundation cleanout (YIN) N Depression (Y/N) N High water alarm (Y/N) N• A. DateofPumping S/3i (oU Pumper Nor �-61anoi MjJ y C. ABSORPTION FIELD DATA 7/ 1 H/ So 2 S-0 a'l3c(r 7 reh�h Date installed to/ 29 ('73 Soil rating (g.p.d./ft2 or ft2/bdrm) 2 2-6 System type l 2S' 3' 8' Length18' Width 17' Gravel thickness below pipe 9' Total depth 3S' Effective absorption area 630 0' Monitoring Tube present (YIN) Y Depression over field (YIN) N Date of adequacy test SY 2S / 00 Results (Pass/Fail) Petrf For y bedrooms 9,5 2E. 7S- Fluid sFluid depth in absorption field before test (in.); 7 7 " Immediately afterG33 gal. water added (in.): J1?" 23" Fluid depth 1 2' (ins) Minutes later: 2 2 Absorption rate = > GGD g.p.d. Peroxide treatment (past 12 months) (Y/N) NonL Gcnaw, If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION N, A . Date installed Manhole/Access (Y/N) _ High water alarm level at* _ Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: wolu�r Itfu~C `//t57/66 Septic/holding tank on lot 6S' On adjacent lots toa Absorption field on lot Public sewer main ION' Sewer /septic service line 7 2,s On adjacent lots > 100 ' Public sewer manhole/cleanout N• 14. Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: N, Foundation 12' Property line — Z67' Absorption field r to' _ Water main/service line > to' Surface water/drainage > too ' Wells on adjacent lots > rc<:�; ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line r 11, Building foundation - / h' , Water main/service line Surface water > /o o ' Driveway, parking/vehicle storage area > 367 ' Curtain drain NonC Se Pr) Wells on adjacent lots > too ' F. ENGINEER'S CERTIFICATION l certify that I have determined thru field inspections and review of Municipal records fha top ol�bve,systems are in conformance with MOA HAA guidelines in effect on this date. , r J 2ne, ,� ° Signature sbae e aauu°n em000b{ Engineer's Name Theo ado e�e Date June 1,5- 2000 wruo;r. i .00aE ° Cf. 5J ov HAA Fee $ 36>0 ^ Waiver Fee $ Date of Payment U Z L) Date of Payment Receipt Number b _S 3 2- Receipt Number 72-026 (Rev. 3/96)* A��L CT&E Environmental Services Inc. t--'� cr>000000�0000�o��inou000coon CT&E Ref.# 1002500001 Client PO# Pre -Paid Colis/NO3 Client Name Flattop Technical Srv. Printed Date/Time 06/01/2000 11:25 Project Name/# L5, 134, Sky Ranch Est. #1 Collected Date/Time 05/25/2000 12:30 Client Sample ID L5, 134, Sky Ranch Est #1 Received Date/Time 05/25/2000 15:30 Matrix Drinking Water Technical Director Stephen C. Ede Ordered By Released By PWSID 0 Sample Remarks: ALLowabLe Prep Analysis Parameter Results POL Units Method Limits Date Date Init WATERS DEPT Nitrate -N 0.590 0.500 mg/L EPA 300.0 10 max 05/25/00 SCL MICRO LABORATORY Total Coliform 0 coL/100mL SM18 92228 05/25/00 JOT CT&E Environmental Services Inc. Laboratory Division Drinking Water Analysis Report for Total Coliform Bacteria READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE MUST BE COMPLETED BY WA PUBLIC WATER SYSTEM ID# X PRIVATE WATER SYSTEM .x Send Results �,, Send Invoice /ischnrta+/ 1`e�,liev water System Nameycompany Name Contact Name Results may be unreliable. Sample too long in transit. Phone Number Fax Number l y s-3 r/ F tis St. • Number of colonle-1100-1 Mailing Address - Date Received: AnCAej t E 9S l City Stale ZiP Cotla State Send Results Send Invoice Company Name Conlacl Name Mailing Address City Stale Zip Code SAMPLE DATE: D S 2 S O Month ` Day Year SAMPLE TYPE: yRoutine Treated Water Repeat Sample y; Untreated Water (refer to lab nor_ ) Special Purpose - Time Collected Location Collected from: Collected: by (initial): L Sc 13 Y S br 3A 11, Elf• #/ 12 3U PH TFrY rswnrcotnt nriCel WATER AN MMO-MUG Result: Total Coliform Membrane Filter: Direct Count Verification: LTB Fecal Coliform Confirmation: Final Membrane Filt"suit Reported By: Comments: BGS 1 chili 200W. Potter Drive Anchorage, AK 99518-1605 Tel: (907) 562-2343 Fax: (907) 561-5301 Ana Is shows this Water SAMPLE to be: Satisfactory Result* Analyst —I Unsatisfactory I® Sample over 30 hours old.- Results may be unreliable. Sample too long in transit. Sample should not be over 48 hrs old for analysis to indicate reliable results. Please send a new sample via special delivery mail. • Number of colonle-1100-1 5^ J Date Received: Time Received: Analysis Began: l�O�� - Filter Analytical Method: Membrane MMO-MUG Lab Ref No. Date: Time: Client notified of unsatisfactory results: Phone Date: E. Coli _ Colonies/100ml COLIFORM Spoke with Time: Fax fax TNTC =Too Numerous to Count OB =Other Bacteria Coliform/100ml Dater Time: I5LlQ hrs ANION 9GS Member of the SGS Group (Societe Generale de Surveillance) Result* Analyst I® 611jank You • Number of colonle-1100-1 Sent to ADEC: ANC FBK JUN Date: Time: Client notified of unsatisfactory results: Phone Date: E. Coli _ Colonies/100ml COLIFORM Spoke with Time: Fax fax TNTC =Too Numerous to Count OB =Other Bacteria Coliform/100ml Dater Time: I5LlQ hrs ANION 9GS Member of the SGS Group (Societe Generale de Surveillance) MUNICIPALITY OF ANCHORAGE �^ DEPARTMENT OF HGALTI-I & GiNVIRONMENIT711. PROTECTION I� _ ENVIRONMENTAL_ ENGINEERING DIVISION \ 325 LStreet - Anchorage, Alaska 99501Telephone 264-4720�= ON-SITF SEINAGE DISPOSAL_ SYSTEM AND/OR VUL.1_ INSP CTiON REPORT NAME r PI -ZONE ❑NEW ) - � (L ---- - •� C�' 4 1OPGRADE b MAILINADD RE. LEGAL DESCRIPTION LOCATION UNO. OF BEDROOMS Welltion Dnelling PERT NO. DISTANCE TO: _('nn_ l © 9�`Zz F- Z Manufacturer MatOri I Noof compartments W _ w r Liq. capaci y in gallons IF HOMEMADE Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. O Z Q 2 F - Manufacture is `�- - i capacity m _ — -._ q w y Well Foundation Nearest lot Ii q Y s PERMIT N ' i DISTANCE TO: U. z -Zw No. of lines Length of each line Total length of lines Wench width Distance betw on lines 0[����-- --- �,�——�.._._ ���Inches p Top of the to finish grade pk Material beneath tile �! �r Total effectit as orlioAl area Length Width Depth^� PERMIT NO. In 41-- Type of crib rib dia tei Crib 013th _utaI e i tive absoipvon area LU Well Building foundation Nearest lot line DISTANCE TO: _ J J Class o� Depth �_ m fo n� Driller _ Seg r line Distance to Int line Septic ' PERMIT NO. A i TANCE TO. OTHER - PIPE MATERIALS— l'D V\ SOIL TEST RATING _ `� p� • `U INSTALLER (� / S r,, LVI 'e SDYI '�1'lT�✓ISC. —1 iii - - REMARKS oe `/ y^� U It� �� V L � I �: L.� / c r e' DATE LEGAL APPROVED / 72-013 (Rev. 3P18) V P11 IJ 1 C::'• 1, �--4 V-9 F-0 JEE, C :1.0TECT I ON •d 1" HEAL.TH AND S -AA- ll-..'EEJ-, A N C H (J R A F3 E.- AK. 9�-, jil TYP"E OF:, SOU. SYSTEPI IS: TREI,-,ICH MAXII-1LIM NUMBEf,: OF-- M: . . DROCXTM; = 1 SOIL. RAllhIG FTel--:R,:,,l= 250 THF- RE(:WIFJc: t ..'.-IZE FIF:' "F HE 5011- ABSORP"I"ION SYSTEPI I-: IEE'. F7' -11"" 11-11 ... . ....... 17'9 N C-1 n -w," F- 'A C'n EE, lf=^ 7" 1-1 E 1.4 IEE U P, (3 P -m Ffl EL' R=-,, E ---..P, P-11 1 '"1 ... 01 P E R i, I I I' Il Ll TREt-IGH OR DRAII'-JF'IEI 1). THE DE: " PTH OF" A "i'RENCH R PIT IS THE DI,CE- "I"ANBETWEE-J.-I OC' THE SURFACE OF' THE L 0 C f-1 "I'l 11 1 N( SF-,RUCE S. R. A. BM -14 J.628-1) tl THI:-'.'RE U. --:GAL. L. F5 B 4 RANCH L.Ct"I" SIZE J. C"421 c! IARE F."EET TYP"E OF:, SOU. SYSTEPI IS: TREI,-,ICH MAXII-1LIM NUMBEf,: OF-- M: . . DROCXTM; = 1 SOIL. RAllhIG FTel--:R,:,,l= 250 THF- RE(:WIFJc: t ..'.-IZE FIF:' "F HE 5011- ABSORP"I"ION SYSTEPI I-: IEE'. F7' -11"" 11-11 ... . ....... 17'9 N C-1 n -w," F- 'A C'n EE, lf=^ 7" 1-1 IJ:.:PAGTH D11,10-ISION .15 THE I-EN13TH (IN F'EE"[') OF THE TREt-IGH OR DRAII'-JF'IEI 1). THE DE: " PTH OF" A "i'RENCH R PIT IS THE DI,CE- "I"ANBETWEE-J.-I OC' THE SURFACE OF' THE AND "I"HE E:011"Cll,-1 C'if::' THE E'o-'XAlvlATlON CIN FEE"['X THI:-'.'RE IS NO WIC11"l-I FC)R TRENCHES. G'RA%-EL DEPTH IS TI -IE MINIMI -Ill DEPTH CiF UP.AVEL.. BF.':TkIE:'EN THE OUTFAL.L. F'IF'E" ANL.'i TldE:. BOTTOfl OF" THE E,'-CAVAT' ION <11,.J FEE-i':"I"). ! F-lG'-'ff U.1 I IF CZ., I E -E' F I I LE". �54 10 0 Z� C� F--fi L-- I— CH APPI-IGFIN]" HAS THE RESPONSIBIL.ITY "I -Ci INF'CIRM THIS E-EPARTIlENT CWRING ']"HE IN' lk,4`.;PECTION OF.-. ANY WEL15 ADJACENT TO THIS AND THE NljI,Il3E-::F--' OF RESIDEhICES TI-IFIT THE WELL. WILL. SEW.,E. BACF.-J-71I.-LING OF ANY SYS, -TEM 141THOUT FINAL. INSPECTION AND flPPRCllylAI- BY Tm,-�'; WILL BE SLIEUECT TO PROi SECUJ'ION. MININUIll DIS"I'ANCE BETkIEP.-I A I.kIELL AND ANY ON-S;ITE SF-':WAC3'*E DISf-"OSAL- SY'-::;"fT-7M IS .L( -`j0 F'EET FCiR A PRIVATE 1,10J.- OR lF.50 TO 200 F -E ET F--RO[el A PUBL.IC WELL- C-EF",EI,-JrlJJ--IG UPCII'l "I"IdE TYPE CiF PUBUC I'll N1111LIM DISTAI'4CE FRC)IeI F-1 PRI's ,IHTE WELL TO A PRIVATE SEWER I - INE IS 25 F:`EET ANI. 10 rl SEWER I -111E IS 75 FEET. "I"HL 7R REQUI.'REMENTS MAY APPL.Y. SPECIF"ICATIONS AND U"NSTRI-10"Flstd DIACMAMS ARE AVA I I AB17E TC'l INSURE PT'51TAL.UITION. J.* 1- 1, E:- K-7: JE -7-J,-1 Eo EE F� ::N_ . - I C E, F.", I' I F -Y T1 IAA 1: 1. AM F'AMIL-' AP, WITH THE FPEQUIREIlEhITS F:'OR ON-SITE -JERS BIT "I'I-IE 11UNICIPALITY OF' AP.-ICHORAGE. 2: 1 WILL THE S`P'STEI'l IN ACA.l*ORDANC:E I.-JITH Tl --IE C, -ODES. C 'N ",, SYSTEM MAY REIDUIRE .1 TI-IF11" JTIE j -SITE 'SEW RF--,..:-IDENC".E IS TO INCL.UDIH 1,10RE "I"HAN 4 BEDROOPIS. APPL I CANI' ESCIN ENT. . . ... LlE ISS'IL) BY—.— AND 14EUS AS SE -T. ENLARGEIlEP-4-r IF' I.M. 121 GRF �ER ANCHORAGE AREA B0' 'UGH � Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSA _SYSTEM NAME- '"" MAILING ADDRESS% � 0 �'1 7 PHONE •-� � �� � LOCATION- LEGAL DESCRIPTIONC�/'�/rk'`LJLC`'�, SEPTIC TANK: DISTANCE I C�'O l �' NUMBER OF FROM WELLFACT URER _ f�-MATERIAL s%LfiY!' COMPARTMENTS INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY` oo C) GALLONS. SEEPAGE PIT: J NUMBER OF PITS DIAMETER OR WIDTH / / LENGTH /� DEPTH ( I // �� C J LINING MATERIAL C �C -CRIB SI!X�� DIAMETER_DEPTH DISTANCE FROM: WELL/ /1 2_U�R2(j't,,(k"(--! TOTAL EFFECTIVE l `J BUILDING FOUNDATION_, NEAREST LOT LINE��) ''. ABSORPTION AREA (WALL AREA) (_- , � SQ. FT. ADDITIONAL ABSORPTION WELL: , C-e—i (tRQ Z' TYPE CONSTRUCTION BUILDING NEAREST FOUNDATION LOT LINE CESSPOOL OTHERSOURCES APPROVED DISAPPROVED DISTANCES: INSTALLED BY: (lz -C- )-It _(.JZ , PIPE MATERIAL:( Z ' kQ, LOT SLOPE: REMARKS: Req item %s granted upon distarnce reA qui rmmom-1 ei sp .r-0 f Ad__ -on l be permit. Specifally in que'sLi the seepage pit and building FormUmr�+MA911n DEPTH DISTANCE FROM: NEAREST SEPTIC SEEPAGE SEWER LINE -,TANK -,SYSTEM _ REMA DIAGRAM OF SYSTEM I 1 u] I� 6 0- I I DATEC�I,1�/ /i %_5 APPROVED<�// C�'<,ii r'G<<cr r •a G.A.A.B. / J 3 0 fl /r - GREATER ANCHORAGE AREA BOROUGH J6Du PERMIT NO, DEPARTMENT OF ENVIRONMF,NTAL. QUALITY€ 3330 "C" STRF_ET ANCHORAGE, ALASKA 99503 TELEPHONE 2.74-4561 SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT NAME OF APPLICANT �� L ---MAILING ADDRESS��`J/' _ G - PHONE -L- INSTALLATION LOCATION LEGAL DESCRIPTION --- INSTALLATION OF. SEPTIC l'ANI! _ L� SEEPAGE PIT----.---. DRAIN FIELD -- OTHER TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH --- - TO BE INSTALLED BY --- SOIL TEST RESUI_TS';2—d�-X��e--- ✓-���'� TEI1-115 PE:RMI-V 1S NOT VAI -I(2 WITHOUT 301 Ti;�T e1 COMPLETION DATE ANTICIPATED _ / .'7-_? - .---- FINAL. INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUTFINAL INSPGCT'ION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT'ro PROSECUTION. SEPTIC TANK SIZE'TYPE =/ "- SEEPAGE AREA SIZE: j L' /TYPE PIIINIMUM DISTANCES, RFOUIRA=MF_NTS FOUNDATION TO SEPTIC TANK s' FOUNDATION TO SEEPAGE PIT-------, DRAIN FIELD !~ _ SEPTIC TANK TO SEEPAGE PIT WALL J / SEPTIC TANK "�_-- SEEPAGE PIT -�-` DRAIN FIELD _ TO NEAREST LOT LINE. /LJ `J /L/�------. WELL TO SEPTIC TANK —. SEEPAGE PIT DRAIN FIELD .— ALSO CONSIDER AREA WELLS. / WATER MAIN TO SEPTIC TANK 1� -. SEEPAGE PIT DRAIN FIELD -. SEPTIC TANK, _lzzoJG-. SEEPAGE PIT //21-1) DRAIN FIELD I'D RIVER. LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. A INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVrL I3ACKF ILL CONFORM TO E30ROUGH REGULATIONS REGARDING INSTALLATION. G.A.A.B. OR LICENSED DESIGNER I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS N ACCORDANCE WITH SAID CODE. SCJ/�J DATE APPLICANT'S SIGNATU FORM NO. EQ -016 GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVJROiNP/1FN1 A1. QUALITY Case # 3330 "C" Street (ANCHORAGE, ALASKA 9950; Performed For MR. JAMES BROWN_ Dated Performed OCT 46_,1973 Legal Description: Lot_--5L�K ReNakI FST This Form Reports Soils Log x _ _ _Percolation Test - Soil Test Aust Be Logged To 4' Below Proposed Seepage System - Depth Feet Soil Characteristics 1�- 1 SApIW. DY OVERBURDEN WITHGRAVEL 2- 3- 4 —4 — GM SILTY SANDY GRAVEL 5-- 6 __._-_-__-+ _- 7----A,-_^^/---Gw WELL GRADED SAND AND GRAVE 8-- 9 --- 9-GM 1 0 -- 1 1-- ------ 1 2-- -- f--- 13— ML SILT, FINE SAND MIX 14— _er-Encountered? Na If Yes, At What Depth? N/At Reading I Date I Gross Time I Net Time i Dhpth to H2O Net Drop I' I ! J Percolation Rate _ Minu;:(, - Proposed Installation; Ser-i;a Pit X Drain Field Depth of Int et Aasi.0y - -- D;:rth 1:o Bottom of Pit or Trench 13� COMMENTS: REOOMMEND_-,ABOUT 228 SWUARE_FEET OF PIT SURFACE PER BEDROOM. Test: Performed BY Irate Certified BY �_ ___ �32r Da1:0 : 10-16-73 r � , a��E- Reading I Date I Gross Time I Net Time i Dhpth to H2O Net Drop I' I ! J Percolation Rate _ Minu;:(, - Proposed Installation; Ser-i;a Pit X Drain Field Depth of Int et Aasi.0y - -- D;:rth 1:o Bottom of Pit or Trench 13� COMMENTS: REOOMMEND_-,ABOUT 228 SWUARE_FEET OF PIT SURFACE PER BEDROOM. Test: Performed BY Irate Certified BY �_ ___ �32r Da1:0 : 10-16-73 r Am.; Arnni P.j. Oon UK I Lot 1 , W lock i ob, Won 'IV L 1. In I n i Sol A r WSW, Q. ;.I: A Q. v V Q it Al OK 1Wpop _1 1m. wn j.,aw nln WAINq at it AU 1,1!n rl'"w J! I! 'IV" IL 0 pip" William 0. lumew lnvivow-M! Loutrul officur 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 1. GENERAL INFORMATII (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (inclu e lot, block, / subdivision, section, township, range) 1 i3L �3C .N!Z- K Location (address or directions) (b) Property Owner /4�FG Telephone: Home Business 7_76— Mailing Address (c) Lending Institution eZ1 ' 11' 2r1 627 %G�1 i Telephone Mailing Address (d) Real Estate Company and Agent r�7Gr�� i�lh'Sf�TieS Address �&vv 14 3 T 5& 1 yl-' � o� Telephone 5-64 - 7e,' 3 (e) Mail the HAA to the followina address: or: Check hereif hold for pick up. List contact person and day phone number below. 71�t'n TYPE OF RESIDENCE Single -Family Number of Bedrooms _ 3 3. WATER SUPPLY Individual Well o 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 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 (Rev 81W Front A. WELL DATA 31 G; � I/ o MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 Legal Description: "7_15- AeCK 4 S � eel i Ud k';1 ed SES Well Classification �l�/✓%r TE If A, B, C, D.E.C. Approved (Y/N) 1"tI4 Well Log Present Y Date Com/pI ted &A,eW 4'dA1 —.Yield 7•� QPM Total Depth Y $' Cased to GO Z7y Depth of Grouting SIA Static Water Level a /Co•s Pump Set At 00 zo8r 0 Casing Height Above Ground / Sanitary Seal on Casing 0N) Electrical Wiring in ConduitON) Depression Around Wellhead (Y(V Separation Distances from Well: r � To Septic/Holding Tank on Lot �' 95' On Adjoining Lots �J r /� To Nearest Edge of Absorption Field on Lot /0T On Adjoining Lots — 0� To Nearest Public Sewer LineW To Nearest Public Sewer s Cleanout/Manhole wd To Nearest Sewer Service Line on Lot 5, Water Sample Collected by ,d ei d, tyln( ; Date 3 Water Sample Test Results /3fle % '-'&- Al/Te 4-70— —&- Comments A) !'ER i4or-m rA d,eutaeS WeRTa ?' yEA,wRt' 76 STtiJAPIPC, 13, SEPTIC/HOLDING TANK DATA iao-a-y-73 �ao� Date Installed �-�O Size aO0 No. of Compartments Standpipes()N) Air -tight Caps 0Y N) Foundation Cleanout (Ye Depression over Tank (Y.119 Date Last Pumped 3 �� �8 /SAAe_S Pumping/Maintenance Contract on File(Y/N) WIA for 14-IA Holding Tank High -Water Alarm (Y/N) r°/ Temporary Holding Tank Permit (Y/N') Separation Distances from Septic/Holding Tank: To Water -Supply Well To Property Line To Building Foundation To Disposal Field , To Water Main/Service Line /D fi To Stream, Pond, Lake, or Major Drainage Course Comments �1wR�'y sTAs�Ay/�i�. Page 1 of 2 72-026 (Ppv 81661 Front 4i Tom Fink, Mayor Municipality Of Anchorage, Department of Health and Human Services dhh5 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 April 15, 1988 Alan C. Wien Engineering Technician Alaska Environmental Control Services, Inc. 1200 West 33rd Avenue, Suite B Anchorage, Alaska 99503 Subject: Waiver Request For Lot 5 Block 4 Sky Ranch Estates Subdivision #1, Waiver Request Number WR88-014 Dear Mr. Wien: Your request for waiver of the required 100 foot separation of two septic tanks to a private well has been approved. The waived separation distance is 85 feet. During the well flow test, approximately 1725 gallons of water was pumped from the well over a period of four hours. The drawdown of the static water level during this period was six inches with an instant recovery when the test was finished. This indicates the aquifer supplying the well water is under pressure and confined. This along with the water well test report stating that the well has casing 248 feet deep to the aquifer indicates that it will be highly unlikely any surface contaminants will enter this well. This approval applies to the existing separation of septic tanks to well only. Any future upgrade to either will require all separation distances be met or another approval from this department. Sincerely, p Daniel J. Roth Civil Engineer On -Site Services cc: Gus Andress, P.E., Manager On -Site services/Water Quality Programs A EC 5 ALASKA MUIROnUTAL COnTROL SRUS, IX Q Engineering & Enuironmental Studies March 13. 1988 Municipality of Anchorage Department of health & Human Services 825 L Street Anchorage, AK. 99501 Re: Lot 5, Block 4, Sky Ranch Estates Subdivision-1j) On 3/9/88, a Health Authority Inspection was performed. The separai:i_on distance from the well to the original 1,000 gallon septic tank cl.eanont pipe is 85 feet. From the well to the additional 500 gallon tank cleanout pipe is 89 feet. The well was not in when the original tank was installed. There is no well log available. The attached drillers report shows total depth and casing to 248 feet. Static water level is 180.5 feet. A 4 hour well flow test was performed on 3/17/88 showing a flow rate of 7.5 gpm with a total drawdown of 0.5 feet. The septic tanks are downslope from the well with the house between the two. Water samples taken 3/9/88 are satisfactory. we request that you grant the appropriate waiver from well to septic tanks. I,: you have any questions, please call. Approved by: 0 A4 w' ^'°••e ee� • mi7 • �ooe esee eeef.feeenoko�' ee� eoo e.e �"ee oaod • LE Y C. REM, JR. g e CE -22;1`e a' Sincerely, ��� /I Alan C. Wien Engineering Technician 1200 West 33rd Ruenue, Suite B • Rnchoroge. Aloska 99503 9 (907) 561.5040 WAT . NELL - TEST PUMP RE. JRT Conducted by Owner dress _ Well Location Well Information: Ttl. Dopthe2i�/ ._Depth of CasingP_.�Screen From To -- Casing SizeSc�reon Dlam Screen Slot Remarks LJ �Z Pump Information: Intake Deptfra�Pump Size �L - S i /ut �✓tcJ Ir Line Depth l Static Water Levoll "S Fi~ PAv. Disch rgo s _GPM, Max. Drawdown Pump On: Time �� ��� Date .3 /ump OIL 'dam Time Date - —/ 'Z [IWATER PIEZO FLOW WATER PIEZO FLOW TIME I REMARKS TIME REMARKS LEVEL TUBE GPM LEVEL TUBE GPM 1'�' t'vy)hn /ZZ II. 1 1 1 1 Lot, ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561.5040 407-5' JOB SHEET NO. OF / / W ��N j[ CALCULATED BY DATE % CHECKED BY DATE SCALE- ZU CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562.2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE fox Work Order # 5559 Date Report Printed: MAR 14 88 @ 15:49 Client Sample ID:LS, B4 SKY RANCH ESTATES Client Name AECS PWSID :UA Client Acct ARECSRP Collected MAR 9 80 @ 13:40 hrs. P.O.# NONE REC D Received MAR 10 88 @ 11:00 his. Req # Preserved with :NONE Ordered By Analysis Completed :MAR 11 88 Send Reports to: Laboratory Supervisor STEPHEN C. EDE 1)AECS Released By G -�� 2) .............................................................................................. Special Instruct: Chomlab Ref #: 9335 Lab Smpl ID: 1 Matrix: Water Parameter Tested Result/Units ------------------------------------------------------------------------- NITRATE-N ND(0.10) mg/l Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY A. WEIN Method ------------ EPA 353.2 Allowable Limits ----------------- 10 .............................................................................................................. 1 Tests Performed Soo Special Instructions Above UA -Unavailable ND- None Detected Soo Sample Remarks Above NA- Not Analyzed LT -Loss Than, GT -Greater Than AK,�cs P -,P CHEMICAL & GEOLOGICAL LABORATORIES OT ALASKA, INC. 0 TELEPHONE (907) 562-2343 5633 B Streeti; I _ � i Anchorage, Alaska 99518 {V U �^*T°^°° Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY 11 PUBLIC WATER SYSTEM I.D.# ��� II Anal is shows this Water SAMPLE to be: PRIVATE WATER SYSTEM Name Phone No. /coo of 3 ,r— r3 Mailing Address City Stale Zip Code SAMPLE DATE: rJ CI HE Mo. Day Year SAMPLE TYPE: `Q Routine ❑ Check Sample (for routine sample with lab ret. no. ) ❑ Treated Water ❑ Special Purpose Untreated Water SAMPLE Time Collected NO. LOCATION I Collected BSy Satisfactory ❑ Unsatisfactory ❑ Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received rioo Analytical Method: Membrane Filter * No. of colonies/100 ml. Lab Ret. No. Result* NMI Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD ���V READ INSTRUCTIONS Membrane Filter: Direct Count CollformM00ml BEFORE Verification: LTB BGB COLLECTINGSAMPLE Final Membrane FII r R Sul 0 ��� Coilform1100ml Xr Reported By D to wig Time: l5'G� a.m. i p.m. TNTC Too Numberous T69Count ki. OB = Other Bacteria PART 1 Z. RFMA II`IDFR r'^! : °'7! ..A0; INSPECTION APPOINTMENTS���� 1-6 7- a 86 4 DATE RECEIVED TIME TIME TIME DATE DATE DATE SINGLE FAMILY ❑ One EJ Four ❑ Other ❑ MULTIPLE FAMILY INSPECTOR INSPECTOR�J�J� INSPECT(? INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled \A ll T �\A MUNICIPALITY OF ANCHORAGE DEPT Of LI; I DEPARTMENT OF HEALTH &ENVIRONMENTAL PROTECTIONVIRONNT7L r:,i�CfION 6 825 L Street - Anchorage, Alaska 99501 • [:n.r1Y 1 1980 ENVIRONMENTAL SANITATION DIVISION Telephone 264.4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRE( NS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. - 1. PROPERTYOWNER PHONE J� L NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. MAILINGADDRESS _-S kA 649x PROPERTY RESIDENT (If different from above) - - PHONE 2. BUYER ,! 'A ekELZ ' d . Ley/� f 34 9E i /34 MAILING ADDRESS 94 o ROVENA 3. LENDING INSTITUTION PHONE Al-ASAA 6c/ -/L MAILING ADDRESS 4. REALTOR/AGENT N010 -C, PHONE - MAILING ADDRESS 5. LEGAL DESCRIPTION ,-5 K Y RAI(f.'f-1 G57A72S5 it / 1-6 7- a 86 4 STREET LOCATION &3/ 1L)1-e1iV,7 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS SINGLE FAMILY ❑ One EJ Four ❑ Other ❑ MULTIPLE FAMILY ❑ Two ❑ Five 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 UTI LITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM - - �` INDIVIDUAL/ON-SITE** 71 '—YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. S4� May 5, 19,010 L, Lolqli x Roue -e A i'm AtWhOrziriolt AlaS%zi '-) 9 5 0 7 S" C'G i bot Block 4 Sky R"alloll Al)provvd. Cor v Ill: f -0 in(IiViduzil Eiowt?r alill wator f-acilitio'- CiAlk 1.10t. b0i,11 . . 'til Luc E0.1-lowiliq 11,1VO, -006ul 410 Thr -4 water ajjajy�,;j.!3 report b<, from 5G33 SLr(,-ctr -Cox- Our rav-iQw. (2) tanj- pli-r-.11,led wi-th P, roccipt01:11-vljjttel. t Llliu of-tice. All DK-li'-.Fqt:[Okcy LooL 50 P()r-COMWd Oa Vie. will (loter.nine, !Jl� �Alc-, of 1)1'. 1.VCtte S _po rl .0 L'Jul't no -A"; to bc! Bubmitited to d(!par.b.-ilon.l.. Eor ()tl.r. ravlclvl. 11C j T1c r< CIX -0- aiiy ploame- ca.11 thi,,3 264-47 0. "Amoorel RO I),' :r- 17- C. IT) r fkt -L A 10 1R(T11jw - ccAlaska Sabool -,Pqjj.oyao_,,� (,r,d, union .E, d 3500 Mllflc 3 reit 99. 0 3 CHEMICAL LABORATORIES u. ALASKA, INC. TELEPHONE (907)•279.4014 ANCHORAGE INDUSTRIAL_ CENTER _"ti 274.3364 5633 8 Street Vf �eeoamm�ice Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY WATER SYSTEM: Analysis shows this Water SAMPLE to be: I.D. NO. SAMPLE TYPE: ❑ Routine ❑ Check Sample (for routine sample with lab ref. no -- t ❑ Treated Water ❑ Special Purpose ❑ Untreated Water SAMPLE NO. I LOCATION t L 2 ( 3 II h Il 5 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Time Collected Collected By ❑. Satisfactory ❑ Unsatisfactory ❑ Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Date Received Time Received Analytical Method: ❑ Fermentation Tube El Membrane Filter Lab Ref. No. i Water System Name L-� Phone No. Mailing Address City SAMPLE DATE: mm I I J Mo. mm I I J Day State Zip Code Year SAMPLE TYPE: ❑ Routine ❑ Check Sample (for routine sample with lab ref. no -- t ❑ Treated Water ❑ Special Purpose ❑ Untreated Water SAMPLE NO. I LOCATION t L 2 ( 3 II h Il 5 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Time Collected Collected By ❑. Satisfactory ❑ Unsatisfactory ❑ Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Date Received Time Received Analytical Method: ❑ Fermentation Tube El Membrane Filter Lab Ref. No. Result* Analyst L-� CZ7 L-� •Noof colonies/100 ml. or No. of Positive portions. 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1970 Date Collected Source a.m. Date Received Time Received p.m. Lab. No. Presumptive l0mI lean loml I lOml 10ml T 2.0m1oaml 24 Hours Confirmator 24 Hours :Multiple Tube Report: Membrane Filter: Direct Count Verification: LTB Final Membrane Filter Results_ Reported By Broth 24 hours: _Broth 48 hours: 10ml Tubes Posltive/Total 10ml Portions Collform/100ml _BGB Collform/100ml Date Time: - a.m. p.m. AS I 1011 Orca Street chorage, Alaska 99501 (907) 278-1915 i May 81 1980 ASI No. 00580 Mrs. Debera Reiley SRA Box 1624-T Anchorage, Alaska 99507 Re: Adequacy Test for Existing Septic System on Lot 5, Block 4, Sky Ranch Estates Unit No. 1. Dear Mrs. Reiley: At your request our office conducted a percolation adequacy test on your existing septic system at the above -referenced location during the period May 3 to 5, 1980. You reported that your septic system consists of a 1000 -gallon septic tank and a log crib seepage pit. The septic tank had not been pumped prior to the percolation test. Since the 3 -bedroom house had been occupied up to the time of the test, a normal degree of saturation within the leach field is assumed. In accordance with the Anchorage Municipal Code, Chapter 15.65, Waste Water Disposal Regulations, any on-site sewage disposal system "shall have adequate capacity to properly dispose of the maximum daily sewage flow." The maximum daily flow is computed at 75 gallons per capita -day (gcpd). Since "the population of dwellings shall be estimated at two persons per sleeping room," the maximum daily sewage flow for your 3 -bedroom house is 450 gallons per day (gpd). To test the soil absorption capacity as well as the surge capability of your system, 140percent of the maximum daily flow or 650 gallons of clear water was added in 50 -gallon increments to the seepage pit. The water was obtained from your on-site private well at its maximum sustained rate of 2bout4 gallons per minute (gpm). The liquid levels were monitored closely to detect any backup in the septic system. Mrs. Debera Reiley Pray 8, 1980 Page -2- The attached Table of Test Data represents the depths of liquid in the septic tank and seepage pit, and the quan- tities of water added. The septic tank was determined to be 8.20 feet deep (bottom of tank to ground surface) with an initial depth of 3.90 feet in the tank. The seepage pit was measured to be 12.9 feet deep with an initial depth of3.5 feet. Ground elevation at the septic tank standpipe is approximately 0.5 feet above the seepage pit standpipe. The attached Summary of Test Results indicates that the liquid level in the seepage pit at the beginning of testing on Day 2 fell to 0.2 feet above its initial static level on Day 1, during a recovery period of 24 hours. On Day 3, the level had fallen to 0,2 feet above its static level on Day 2, during a recovery period of 24 hours. The level in the seepage pit at its highest level during the test (4.25 feet) was approximately 4.1 feet below the liquid level in the septic tank. Based on two days of testing, an average percolation rate for your existing septic system of approximately 535 gpd is indicated. Since an on-site sewage disposal system for a-3=t7'edroom dwelling must be capable of disposing of 450 gallons of sewage per day, your septic system appears to be functioning satisfactorily at this time. Many factors affect the operation of a soil absorption type of sewage disposal system. Soil type, groundwater depth, age and history of maintenance of the system, and types of waste are a few. This test has been performed in an attempt to determine actual soil absorption capabilities of your septic system under normal useage by considering the degree of saturation of the leach field and surge loads that might be imposed on the system. This test can only evaluate appar- ent performance at a given point in time, and cannot deter- mine either the condition of the leach field, seepage pit or other components of the septic ystem, or the depth of the water table. We appreciate the opportunity given to perform this adequacy test. If you have any questions regarding this test, please contact this office. Very truly yours, ALASKA SOILS INVESTIGATIONS Stephen D. Shroder, P.E. Project Manager OF �Zo e e 00 e 0n` tla e0 ��� i,{,i eyyJJ� ' 00 °YE9 dtivSDC'Aa a ee°p'y� p b aephen D. Shrndpp : 4CIZ 4148 - C \' Mrs. Debora Rei -ley May 8, 1980 Page -3- Wtr Added, Seepage Pit Rise in Seepage Pit Rise in Septic Tank Gallons Wtr Added per Ft of Rise (gal/ft) ASI No. 00580 SUMMARY OF TLST RI -SULTS ygal. 650 ygal. Day 3 650 1.1 ft. 1.25 ft. Recovery Time between Test (Hours) Drop in Pit during Recovery Average Rate of Fell (ft/hr) Average Absorption Rate (gal/day) -0- -0- 590 520 24 hr. 24 hr. 0.9 ft. 1.05 ft. 0.04 0.04 ft/hr ft/hr 530 345 gal/day gal/day Adequacy Test for F.:isting Septic System Owner: Richard and Debera Reil ey - Project No.-00-5-80- Address: o.00580Address: SRA 1624-T Anchorage, Alaska 99507 Legal Description: Lot 5, Block 4, Sky Ranch Estates Unite No. 1 Components of Septic Sys tem: —1000-qa1. Septic Tank; 8' x 8' Log_ Crib _ Number of Bedrooms: 3 Occupied prior to test: Yes X No How long vacant: NA.-------. Last pumped:_Never pumped_ ^y Test performed by: Shrader _ Water meter/S.N 5/8" Neptune Tnitial Static Levels: Septic Tank -3.9' _I Seepage Pit 3.5' T E3T DATA Time _ Liquid Depth, -ft Water — Added, gal - — Meter Reading, gal --- - — I'emarks Septic Tank T Seepage Pit 12_ 22pm 3 . 9 5 _ 3_ �'- _ -_--0_ 197277 Begin Test 12:45 3.75' 90 19,367 1:00 3.8' 3.85' 60 19,427 1:12 3.9' 50 19,477 1:25 3.8' 4.0' 50 19,527 1:38 - 4 . 1 ' 50 19,577 1_50 3.8' 4.2' 50 19,627 2_03 4.3' 50 19,677 2:17 3.8' 4.35' 50 19,727 2:31 4.4' 50 199777 2:48 3.8' 4-5' 80 19,857 2:53 4.5 20 19,877 ---- 3:08 3.8' 4.6' 50 19,927 Stop Test 650 gal 650 gal 12:35pm 3.8' 3.7' -0- 19,927 heck Level; tart Test 1-2-L-42——_— _8' 50 _ 19.977 -- /4/80 12:59 3.8' _ 3.85' 50 _ 20,027 —--- CV,ner: Richard and Debera Re.iley ------------_--- --_-- — Project No. 00580 T -,gal inscription: Lot 5 Block 4, Sky Ranch Estates Unit No. 1 TVEST DATA (Cont'd) -----Liqu:Deptt WaterTime Septic Tank Seepage Pit Added, gal Reading, ----�_.—_—__ g, gal Remarks ---- -- _ _ 203027 -- Teter Readin 1:12pm 3.8- 3.95'-- —.-1---- 20,077 1:37 _—.— — -- 4 . 1 ' 50 20,177 - — --- ------ 1:49 3.8' 4.2' -- ---- -- -- ----- — --- -- 5 0 2 0, 2 2 7 _2-01 — —4.3 5O -2D,277 ------ — 2:14 3.8' 4.45' 50 20,327 --------- 2:26 -- 4.55' 50 20,377 2:39 3.8' — 4.61— 50 20,427 -- — 2:51 ---� -50 - -- - -----2Oi�17 3:04 _ 3.81- -- —_4.8' 50 20,5L7 -- 3:17 3.8 --- 4_95' Stop Test ---- --- _--- 5 Q— 2.0 5 7 7 5/ 4/ 8 0 -- --- -- 650 oal 650 clal 12:2DPrn 6.45 3 39 heck Levels --- -0- -� 5/5/80 Ls�34 5e,pPwal es !. C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata T50Type of System Design et b i 7-'eaw'd Date Installed r9-18 1041-73 TROJ4 744_go I Length of Field ck18 1 TRSNtI/ 7,5 Width of Field cKfd 17 TRO e4 3 ' Depth of Field «I'6 13 rpeAlcd /L/ Gravel Bed Thickness CPA 9 � TQe?oell 3 � Square Feet of Absorption Area Depression over Field (Y/�1 Results of Last Adequacy Test 30 Standpipes Present (9N) Date of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well /O1 I To Property Line le d To Building Foundation __ / S To Existing or Abandoned System on Lot alo7- oa/ &6larc7 On Adjoining Lots /0,1- To O/1-To Water Main/Service Line /6 f To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course /moo fi To Driveway, Parking Area, or Vehicle Storage Area /o /^f Comments D. LIFT STATION DSlalled _ Size in Gallons 1� "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent (Y/N) ng Cycles during Adequacy Test. Meets MOA I certify that I ha he eddve fied, or conformed to all MOA,a%d HAA guidelines in effect on the date of this inspection. Signed _ Date �--4' 'ff Company AECg �iMOA No. lc� Receipt No. �'° �'C; °°•°•°°°°.9 &4_ Date of Payment— GL /'tea° YFy m? 4 Amount: $ / �U V 10,•00•• o•• •oo 0000°o•• D i eal o LER C. REID, JR. ° Page 2 of 2, rP 14` APrOIOSSIQVal , 72-026(Rev8/861 1311k tS 3� 5'el ,W6Y e57-- 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. / Name of Firm /`r C� Telephoone .5- -5-o ro Address /7.tro l�i. �� ��✓LS- 5ef ,*L/eW, viK p f so3 Date J- J yr'� w W 'W OF A4 w 4. 6. DHHS APPROVAL �/� Approved for -�_ bedrooms by �C Date 4 -14-168 Approved x Disapproved Conditional Terms of Conditional Approval CAUTION ru 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 (Rev 8/W Back 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY NUMBER OF BEDROOMS 1. TYPE OF RESIDENCE ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY ❑ TWO ❑ FOUR ❑ SIX PERMIT NUMBER 2. WATER SUPPLY DEPTH OF WELL ❑ INDIVIDUAL ❑ COMMUNITY DATE DRILLED ❑ PUBLIC UTILITY RECEIVED ems Connection Verified__LOG 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER ❑INDIVIDUAL/ON -SITE DAT_ INSTALLED ❑PUBLIC UTILITY 1 INSTALLER ��SS Connection Verified _. ❑ Septic Tank or ❑ Holding Tankx--- SOILS RATING. Size: i Q ® 0If Tank is homemade give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL Septic/Holding Tank Absorptio Area Sewer Line Nearest Lot Line Q. DISTANCES WELL T0: Absorption Area to nearest Lot Line 5. COMMENTS l� APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter m s c mp1q certificate) kD` q. DISAPPRED �j� DATE " �.� BY ...ice. 72-010 (Rev. 6/79)