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Home My WebLink AboutMOUNTAIN SHADOWS BLK 1 LT 5Mountain Shadows Block 1 Lot 5 #017-401-13 --7 Lot 6 Lot 7 10' UTILITY EASEMENTS S 00'01'00"E\ 8.00' PLOT PLAN AS BUILT —x— SCALE _1N= 40' GRID _ SW 2841 Project No. 20-239 R1 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associafes, inC (907) 522-6476 Phone (907) 522-4625 Fax 4=1OF Professional Land Surveyors ken0longsurvey.com A jonothon0longsurvey.com I hereby certify that I have surveyed the following described property: LOT 5, BLOCK 1, MOUNTAIN SHADOWS SUBDIVISION (PLAT No. 71-168) Anchorage Recording District, Alaska, and that the Improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no Improvements on the property lying adjacent thereto encroach on the surveyed promises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the Day of of Anchorage, Alaska It Is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plot. AECC963 Municipality of Anchorage Development Services Department Building Safety Division ,`? - On -Site Water and Wastewater Program, 4700 Bragaw St. P.O. Boz 196650 Anchorage, AK 99519-6650 Page 2 of 2 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number. SLVO 7 0 / 3 9 PID Number: 017 - 10/ Name ,To 11n Pope Wastewater System: ❑ New ❑'Upgrade Ada.ss IZ500 ,lermne Rol Nnclt 99s-16 ABSORPTION FIELD Nes d B.d o s O D•so Trends g Snal" Tram O Bed O Mona O DB,sr LEGAL DESCRIPTION Bat Rang 1 2 Ta.DeOnkornwgn"9,,,, • GPDfft' 9.0 + SQAV( Ft. Blpol Ld Subdinswn -/ I /rOrCAkc'n S!1GNG Gal DMn ro qW Donom hatn orgnY paw 2•S Ft. G," dep, usnenn p.M �'� Toenanp Range swan Fe baled above "" paaa Fi Grbret Long, 0-S Ft. 36'•r?6r = 7 Ft. Well:❑ Upgrade • EFVST ❑New rade Gne'oi �n Na Bones Dmbnce beraeen ares Ftnat Clessmrat. (Pmw.. A. B. C) Tar Dep, Cased le Tout Wwrptwn ar.b Papa Male I'C rf Fo. Ft .SBU Ff D.iw Dae DMied static Waw LerM Mesta Dais nstrmed Ft At- Bane Eewtcw 8/1/ZOO7 Yrd Pump Seta Gang He gM Above Cr GPM Ft. Ft TANK SEPARATION DISTANCES 0 Septic ❑ Holding ❑ S.T.E.P. ❑ Other. To Septic Absorption Litt Holding ubc PnvateA--a` spray From Tank Field Station Tank Sewer Line Anelnpl-Q a iUh t,— ►OopGa was— 101, 134 r — 7 2S' M.twW Sl-ee l " 2.np. m.ma sulboa Wats y 1w • ?,�, _ _ LIFT STATION N. /y.. La Lw I S t i 0 1 '�• Grw aures Fouwwton n IG' 7 O Punp on NMp Or a NM H9n rats aw,a in n in Curran Drrn _ _ — Pump Mars a Modes Eiocu" napectwn, P.dan.d by R.marks New h'c }vnk tnr.lol4d w 2' BENCH MARK r r JGtien '/v Giv fate e,,orc. Suri Lorcet. and Dswtpmn QbJ_�rrn0/-Cor`ner 0-.rn & NLAI cerncr W e� tiF. 13411 Zwo valve ( kr funW$ leraYm he rnrloltr of w,- 100'0 FL pitow Tc+/4 rY 1'e conn tC'/Zu� is G"'r T�•nfri /Fe K+der G(r'rri gAx"ieM ots/egaw/e /y. ' P Engineefs Stamp Inspections performed by:F(a f/p/, i ecli S -c Dates: 1' '7/3//,07 2nd &/1 / c Development Services Department Approval ••• a:r. &i Conditional Approval Date: --�� i" a' ; 9TH �".� *11 4. ... ............•••••.ib« . THEODORE F. ILOORE !' CE -3589 and by: v-0 Reviewed approved ate: z 'q1 , •' 5• 54 5' 1. P.01 . ..� Municipality of Anchorage Development Services Department 0witding Safety Otvisian - F Onsm On -Site Water and Wastewater Program, 47CO Bra9aw St P.O. Box 196850 Anchorage, AK 99519.850 Page'2 Of Z www.d.anchorage.ak.os (907)14104 79 N a -SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number. tV07 G 9 PID Number. of 7 - of - I N.n. Torn Pu Wastewater System: []New' @'Upgrade A�wr.aa 'Zbr'd Tiann� Rol /InsLJ 9!s 16 ABSORPTION FIELD PnM. rrrw a a«la.nl •314: -SSSS O o..o tr . g at~ Tw eh a e.n o .wu e a an«. LEGAL DESCRIPTION t.2 o'••• a,a, a•eM1r.an cJronP 9.0 t Sano( rt. I em 61n Gf�C.Cv D«JPigPW palam pan a.gnr tr.ea: '2.1 r/..a OaPr. 4.ra.rp tlP. .S!1 Ta...c'a Ilanpe fi.a.n ti. fe.aw. m... anantl ar.5a. U•S Cnw Ltlpp t' Well: 6yur ❑New El Upgrade sG C*16ft.� 11n.a. A9. Cr TNS own c...ea tr. tapepww.n r.a 15l n 610 P[rf 0 + . 5,«n:—W. L..tl' tra mawA 1- L) - 3o S M )V 4n - r/ t Fl cava ,1 ' /'�* /7vmC St/✓r Car pr..,Nilr¢ &�I�ZGp 7 °..•4 Sar Cana -9"Apt.. Crwn w n. Ft TANK SEPARATION DISTANCES ® Septic ❑ HoIcing ❑ S.T E.P. ❑ Other. To from Septic Tank Ab40rptior FkW Litt Station Voicing Tank titwPMate Saver line r}n CNOrd •%twn L:• P )GG(J CM. Wan loll I ise _ > ZS rtltlW SI -«l w.a.a arp«tnyrya. 2 5nrvow > lam' > rte+ - - LIFT STATION N Cr faKiA•1 t 2 a � G a — _ •P,no «i MMM 'rarb ar Mvtl M. M.,'tl wEM e«T r C.n.n Oran ,- _ � .. Pu,.e a••"• a •a°••, eMarrr n.ar:.an. qbn... q a«M,aa N e w i.'t it n k n.r.1 "har w 2' BENCH MARK r ro( Fc. e. wJ It, au Iwee f>, f+u a.1 acran.n. .a.p.a, Go 1-&m oA c -00 -AW- ir.m ur!Y LAI' r✓nt+• Li4,rl 24q Vbl✓t Jru/.e//.x,! � 11�� 4!/! ' /74L4lC e, I la t.. 14• F.4re, ✓t conn tC}we h ra^r M•,tti 0rrya,.0 s.pht /ante w«ri /* R 44 .n.c(• Inspections performed by: _ r to Ko/+ / eeb SVC Dates: 1" '7 /3 / /0 7 Engineers Stapp / 10 Development Services Department Approva�' r ! $'4.a Conditional Approval Date: ...�• ,. 0.........9............5.. p �.....�iA::'.1�.:.......a : T:!CJGOkE P. "0091 Reviewed and approved by: Date: �'•. s/�( •� do W:•r r3u, ••,..• • r.c,'.. PERMIT NO: SW070139 PID NO: 017-401-13 SWING TIES: FROM: COR. "A" COR. "B" COR. "C" TO: S.T. C.O. "D" 14.5' 34' S.T. C.O. "E" 20' 38, DBL. C.O. "F" 2T 40' B. R. VALVE "G" 23' 41' TR. C.O. *H" all 34' TR. M.T. "1" 90, 75' D.F. C.O. "J" 96, as, D.F. M.T. "W so, 78' D.F. C.O. "L" 74' 7T D.F. C.O. "M" 101' 101, D.F. M.T. "N" 91, 95, D.F. C.O. "0" 86' 95, lots*** :THEODORE F. AAOORE CE -35E9 TEST HOLE #1 BOTTOM @ 66.1. MAX WATER @ 69.1' 3.0' SOIL COVER "J" .M. I T.H. NEW 1000 -GAL . #2 SEPTIC TANK \ PAGE 2 OF 2 'F- 77.T L INV. 75.3' ELEV. 77.2' 4.7 ELEV. 74 EV 76.2 7 ELL EVV . 74.1: TWO (2) 38* LONG x 5' WIDE D S INFIEL�D w. 0.6'- 1.0* SAND & C.S'GVL UNDER DIST. PIPES R 100' 2 NEW 38 -FOOT LONG x 5 -FOOT WIDE SOIL ABSORPTION DRAINFIELDS w. 0.6' -1.0' SAND & 0.5* GVL UNDER DIST. PIPES PLAN LAN VIEW SCALE: I" = 30' 7' SOIL COVER RIGID INS. INVJJ1000 -GALLON" SEPTIC TANK INV. 90.81 of A CROSS-SECTION VIEW NOT TO SCALE MUNICIPALI7YOFANCHORAGE Development Services Department 1 On -Site Water 8 Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 \�\� (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Permit Number: SW070139 Legal Description: MOUNTAIN SHADOWS BLK 1 LT 5 Design Engineer: 0019 FLATTOP TECHNICAL SERVICES Owner Name: JOHN POPE Owner Address: 12800 JEANNE RD ANCHORAGE. AK 99516-3346 Date Issued: Jul 03, 2007 Expiration Date: Jul 02, 2008 Parcel ID: 017401-13 Site Address: 012800 JEANNE RD Lot Size: 22245 SO. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: Disposal Field ❑,/ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specked in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72 ) and Drinking Water Regulations (18AAC80 ). 3, The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours). ( Not required for a Water Supply Permit only). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. -ANY PORTION OF HORIZONTAL PIPE UNDER THE DRIVEWAY NEEDS TO BE INSULATED. Received By. �Zlwt— Issued By. _j tfJ' — Date: 7 /// /C>;7 Date: 3 0-1 Municipality of Anchorage . Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 ON-SITE SEPTIC/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING ZD Parcel I.D. 011 - L'iDi- 13 Property owner(s) 7c, n Egg s Day phoneS- Mailing address 12- Ttanno 8 �y A-neAo ave Zip Code 99s', Site address S —Zip Code Legal description (Sub'd, Block & Lot) 1-1/ Jr. C/o C t- S ' /I. n lel SA`-/ -,, -r'/1 Legal description (Township, Section & Range) Lot Size �� 7 N� Sq. Ft. THIS APPLICATION IS FOR (®all that apply) Absorption Field Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms THIS APPLICATION IS AN: Initial ❑ Upgrade Renewal ❑ I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: �/6U = Waiver Fees: Date of Payment: 6 / i c / y7 Receipt Number: (Rev. 11/05) Date of Payment: Receipt Number: c T a r: �FLAy 'TOP TECHNICAL SERVICES-. /q'- .i..�i\�V{II�,�M.V •tiV1M �� \.Y� R �+•. .:.•V'V }'Y-i�'�. CML E ENVIRONMENTAL ENGINEERING - ENERGY CONSERVATION & ANALYSIS TED MOORE, P.E. PH.IFAX: (907)345-1355 E -Mail: tgmoore@gcl.net M.O.A. DSD P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: June 25, 2007 14530 ECHO CANYON ROAD ANCHORAGE:, AK 99516 The purpose of this letter is to provide the required design narrative in support of our application for a permit to upgrade the wastewater disposal facilities on Lot 5, Block 1, Mountain Shadows S/D, located at 12800 Jeanne Road. Soils logs, perc test results, a site plan, design drawings and specifications are enclosed for your review. The proposed system will be constructed between test holes # 1 and 42. As can b: seen From th, soil logs, the native material between 2.5 feet and 8 feet below ground level is a somewhat silly gravelly sand with a measured perc rate of slightly over 1 minute per inch. Groundwater was observed as shallow as 7.0 feet. Using the soil application rate of 1.2 gpd/sq. ft. specified in the wastewater ordinance, this 3 - bedroom residence requires a total absorption area of (3 x 150)/1.2 = 375 square feet. The two (2) proposed 38 -foot long by 5 -foot wide soil absorption drainfields have a total absorption area cf 380 square feet. The use of 0.5 feet of coarse imported sand under the drainfields should help its longevity. The topography of the lot in the area of proposed construction slopes downwards towards the south and west at approximately 15%. The soil absorption system will be near the west edge of the lot to avoid a large area of fill material created for the driveway. The proposed project will have no significant impact on present or future water supply and wastewater disposal systems serving adjacent properties, nor will it have any significant impact on reserved space -surface and subsurface, or on drainage. Please give me a call at 345-1355 if you have any questions on this submittal. Sincerely, Ted Moore, P.E. TALISMAN ROAD ABANDON EXISTING 1000 -GALLON SEPTIC TANK (PER CODE) --- ----- ---------- - - - - -- I -- WELL � i 5} � LOT 6 J SEPTIC ; I' AREA ; 0 0 CONSTRUCT TWO (2) ro 38' LONG x 5' WIDE SOIL ABS. DRAINFIELDS w. 0.5' SAND & 0.5' GVL. ---BELOW DIST. PIPES , , LOT 7 , SEPTIC ; AREA i 0 0 0 r NO WELL WITHIN 100 FEET INSTALL DBL. C.O. 114STALL IIEVV ' PLUS *BULL RUN' 1000 -GALLON I DIVERTER VALVE SEPTIC TANK -I I �a T.H. , IOD% R , , SEPTIC SYSTEM 0 LOT 4 i THEODORE F. MOORE •.• CE - 3589 11 o to ss1=lf4 LOT 5 BLOCK 1 r HOUSE \ , R=100' ----_ - WELL— , , , , , LOT 6, BLOCK 1, MOUNTAIN SHADOWS SID SEPTIC SYSTEM UPGRADE SITE PLAN FLATTOP TECINICAL SERVICES 1 INCH = 5C FEET 14530 ECI IO CANYON ROAD DRAWN BY TFM ANCHORAGE, ALASKA 99516 J'JN=, 2007 7. NOTE: THIS IS NOT A SUR\#EY=D PU,T. ALL LOCATIONS SHOWN ARE APPROXIMF.TE. BDRM ; HOUSE IY I i m WELL 1 100 — �p I \ HOUSE \ , R=100' ----_ - WELL— , , , , , LOT 6, BLOCK 1, MOUNTAIN SHADOWS SID SEPTIC SYSTEM UPGRADE SITE PLAN FLATTOP TECINICAL SERVICES 1 INCH = 5C FEET 14530 ECI IO CANYON ROAD DRAWN BY TFM ANCHORAGE, ALASKA 99516 J'JN=, 2007 7. NOTE: THIS IS NOT A SUR\#EY=D PU,T. ALL LOCATIONS SHOWN ARE APPROXIMF.TE. 4• DIA. CONSTRUCT TWO (2) 38 -FOOT L04G F-810 x 5' WIDE SOIL ABSORPTION TRENCF PERF. PIPE w. 0.5' SAND 5 0.5' GVL. UNDER DIST. C.O. �- (TYP�� 5 PLAN VIEW I 38 SCALE: 1" =10' two 3.5 1 At CLEANOUT �"�• ' •• �I+ ••''.`Y MONITORTUBE� �••!•••••••••••••••••••_• MOUND BACKFILL 2' ORIGINAL FILTER FP CE. F. ADORE �— 2" RIGID INSULATION 5 15 �'\1-4-F-810PERF. PIPE I 5� 12" to 2 1/2" SEWER GRAVEL CCARSE PIT RUN SAND LOT 5, BLOCK 1, MOUNTAIN SHADOWS SID CROSS-SECTION "A - All SEPTIC SYSTEM UPGRADE: SCALE: 1" = 5' - 0" PLAN AND CROSS-SECTION FLATTOPTECIINICALSERVICES SCALE: AS SHOWN 14530 ECHO CANYON ROAD DRAWN BY: TFNI ANCIIORAGE, AK, 99516 JUNE. 2007 FLATTOP TECHNICAL SERVICES 14330 ECHO ST. ANCHORAGE, ALASKA 99516 TEST HOLE # 1 SOILS LOG — PERCOLATION TEST LEGAL DESCRIPTION: _Lot 5, Block. 1, Mountain Shadows S/D-- DATEPERFORMED: -June 8,2007_--_--_-----._._.--_ PERFORMED FOR:., -_John Pope DEPTH (feet) 1 2 3 ` 4 5 6 7- a- 9- 10- 12 6-910- 12 13 14-1 15 16 � I 17-1 I 18 I i 19 i 20 1 COMMENTS: 4�;....... 'e, o w' S THEODORE F. LSOORE Cl:.3589 so SLOPE STE FLAN PL SM Reddish sandy loam 11 I I LH• �� N�^s I 2 '" I i31usE 23 r10°�� OUSE' —(�fir Q r� URNS -: SP Somewhat silty gravelly sand 15% 53 6 ,ori I i 21 !Y —%+ - LOT5 BLOCK 1 ! T.H. r% Waterseeps #1 �,,� ; I � i ML Gravelly silt :------------�-...._..................._._..__... _: Depth to Groundwater I Date I B.H. I 0%-,� `--Seeps- 6/8/07 � 1C0%�r- i Water08.0'6115/07---SLOPE Clock Net Time - Percometer Net Drop 1 Date Reading Time (mm�1es) ' Reeding (inch s) G76/8 i-12 Presoak--� -- -4 27 112 rr 1'" Resoak= �. -- - • -- - 271/2 -- -- 4---- -- - -S _ --231133.35 3/8 1 #1 - 11:3835-"- 5 -183!8 5 -'Add water_— -- - 11:39 25 -I - 23 3/8 f - -#2 - 1144:25 I 5 16 314 45/8 Add water -_ 1111:45:05--"'23 3/8 #3 11:50:05-7- 5 16 3/4 '4 5/3 i PERCOLATION RATE 1+ _ (minutesfinch) PERC HOLE DIAMETER 6" TEST RUN BETWEEN 3.5 FT AND 4.0 FT PERFORMED BY FLATTOP TECHNICAL SERVICES. I,. �j�.yls.� J/_ k—. -CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 101/ 2-r14" _ ti aF(`arra FLATTOP TECHNICAL SERVICES `a . I ,.l�7m 14530 ECHO ST. ANCHORAGE, ALASKA 99516L'p9TH ,13 TEST HOLE # 2 SOILS LOG -PERCOLATION TEST r...........•••••••••••i•..p Si ♦....... •. ••• .•,�. LEGAL DESCRIPTION: Lot 5, Block 1, Mountain Shadows S/Drj THEODORE F. AAOORe; JU DATE PERFORMED: _-June 8, 2007.- ?`,- PERFORMED FOR: John Pape _-------------'- ---'- '-.---------- _.-. r�4i•�1an.r,'f:; T DEPTH .,.:,-.x, SLOPE S TE FLAN I _ Pt (feet) ------ - - So% + 2 SM Reddish sandy loam N i ; H. _ 12 3 - - 23 �,oa'?,OUSE' 4 i i SP Somewhat silty gravelly sand DRIVE i 5 15°k 53 r,on I I 21 6 ' I I- —}� LOTS j BLOCK 1 ! seeps Water y°°• 7 - 41 T.H. j #1 6 j 9 ML Gravelly silt I L 10-. �_. ..._... . - _.. ., Depth to Gioundwater Date' _0'11_ tt B.H. Seeps @ 7.0` - 6/8/07 j Water 7'-,9"-_-_x6/15/07__BLOPE12 ' 13 .i I_. _ _ _, l_ _ _ _. 14' -.Clock Net Time Percometer Net Drop ' Date Reading Time (minutes) Reeding (Inches) -------_� —...-------.. _ .,.._... 15 I 6/8._=_12" Presoak _ _ _ .. ;.._ 2718 _ _. . i 12"-Resoak -- 1— .. __ . _ 2712 12 1010 _ 23 3/8 18:/4_ ..-__ 4SIE -. j Add water }_1215 40 _._ _ _ 23 3/e n' I #2 5 1813/16 49116 .. C Add water 12-21 _7 7 _ 23 3/8 i #3 _,_ ,12 26 10. I 5 - _. 187/8 . _ 4 12 _ 19 Ii 20'I - PERCOLATION RATE -1+_ _ (minutesfinch) PERC HOLE DLWETER _ 6'. _ TEST RUN BETWEEN 3.25 FT AND 3.75 FT COMMENTS: PERFORMED BY FLATTOP TECHNICAL SERVICES. 1, ��.. %Lw.K._ CERTIFY THAT THIS TEST WA.: PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 21'/O) e-Mttop 7echnicaf Services 14530 Echo Canyon 9j9a,4Anchorage, AX 99516 Thone (907) 345-1355 Lot 5, Block 1, Mountain Shadows SID 12800 Jeanne Road Wastewater disposal system upgrade Specifications 1.0 General: 1.1 The scope of the project consists of abandoning an existing septic tank and installing a new 1000 -gallon septic tank that discharges effluent into 2 new 5 -foot wide by 38 -foot long soil absorption drainfields that are underlain by 0.5 feet of pit -run sand. 1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor deviations from these drawings may be allowed or required by the engineer conducting the in::pections. All construction procedures and material specifications shall conform to Municipal and State requirements. All separation distances shall be in conformance with Municipal requirements, unless specifically waived. 1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work around any buried utilities. 1.4 Unless agreed otherwise, the contractor shall be responsible for any tree clearing and grubbing necessary to complete the project. Prior to the start of excavation, the contrictir shall cut down and remove the branches of all trees larger than 6 inches in diameter and neatly stack th:se trees outside the construction area. 1.5 The contractor shall provide adequate cover material and rough grading over all system components to ensure that proper drainage is achieved after settlement and that there are no residual depressions. Insofar as possible the contractor shall minimize damage to trees and existing lawn areas. 1.6 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after the soil is compacted, as well as placement of topsoil and reseeding all areas disturbed by the construction. 2.0 Septic Tank: 2.1 The existing 1000 -gallon steel septic tank shall be properly abandoned by thoroughly pumping, removing its top and backfilling with soil. 2.2 The new 1000 -gallon, 2 compartment septic tank shall be Municipally approved aid shall be set level on undisturbed soil. Each compartment shall be equipped with a watertight manhole cover and a 4" cleanout. If the tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial type, rigid insulation. The existing soil absorption trench shall be retained for future use by switching a "Bull Run" diverter valve. 2.3 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The waste line from the residence to the septic tank shall have a minimum slope of 1/4"' per foot, and the waste line between the tank and the soil absorption system shall have a minimum slope of 1/8" per foot. A cleanout shall be installed 1 - 4 feet from the building foundation, and a double cleanout shall be installed within 5 feet downstream of the septic tank. A "Bull Run" diverter valve shall be installad downstream of the double cleanout allowing future switching back to the present trench, as desired. 3.0 Soil absorption drainfields: 3.1 The new soil absorption drainfields shall be constructed by creating two (2) 38 -foot long by 5 -foot wide excavations to a depth of 3.5 feet below ground level on the uphill side of the excavations. The long axis of the excavations shall parallel existing contours of the ground. 3.2 The bottom of the excavations shall be level. Any compacted or smeared surfaces shall be raked to allow proper infiltration. 0.5 feet of coarse pit -run filter sand shall be placed in the bottom of the excavations to create a level surface no deeper than 3.0 feet below grade. 3.3 A total of 1.0 feet of washed sewer gravel shall be placed on top of the sand with the perforated distribution pipes laid level such that the pipe inverts are no less than 0.5 feet above: the bottom of the sewer gravel. Special care shall be paid to ensure that the server gravel is clear. 3.4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the local: ons shomm on the design drawings. The portion of the monitor tube extending through the sewer gravel shall be perforated. A 6" high "bump" shall be installed in the line connecting the two drainfields to easure that the upper drainfield is completely filled prior to effluent overflowing into the lower drainfield 3.5 Approved filter fabric shall be placed over the entire top surface of the sewer gmv:l. A minimum of 3 feet of soil cover is to be placed over the filter fabric. 3.6 The top surface of the cover material shall be raised a minimum of 6 inches higher than the surrounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill slopes shall be no steeper than 3:1. 3.7 Unless specifically agreed otherwise the homeowner shall be responsible for arranging to have the site finish graded after the backfill material has stabilized, and for placement of adeq iate topsoil and seed to promote rapid revegetation of all areas disturbed by the construction. 4.0 Inspections: 4.1 A total of 5 engineering inspections will be required during the course of the proj.:ct: (1) initial stakeout with the contractor to establish the location of the system and to discuss the plans, specifications and construction procedures, (2) after the native material has been excavated to expose the infiltrative surface to ensure that it is at the right elevation, and conforms with the soil test information, (3) after the sand has been placed to bring the surface up to the proper elevation, (4) after the sewer gravel is in place and the distribution pipes have been laid and connected tip to the septic tank. but prior to placement of insulation or filter fabric, and (5) after rough backfill and grading is complete. The septic tank requires one inspection after it is set level and the piping connected, but prior to backfill. This inspection may be incorporated with any of the above inspections. 4.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in advance to ensure the availability of the engineer. GREr ANCHORAGE AREA BOF `H Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION_ REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME_ t MAILING ADDRESS��-�-- - PHONE LOCATION .p-�-�'t�t�li - 1 _LEGAL CSESCRIPTION_/-= SEPTIC TANK: DISTANCE NUMBER OF FROM WELL �a — MANUFACTURER ti MATERIAL__-_ COMPARTMENTS std - INSIDE LENGTH INSIDE WIDTH _ LIQUID DEPTH LIQUID CAPACITY le''ee7'GALLONS. TILE DRAIN FIELD: / r / TOTAL LENGT,,/H/ / DISTANCE FROM WELL /'A -FOUNDATION t/moi_.-_NEAREST LOT LINE �'�=�_Y OF LINES 7f7 NUMBER OF LINES DISTANCE BETWEEN LINES TRENCH WIDTHJ7 IN. TOTAL EFFECTIVE ABSORPTION AREA SQ. FT. LENGTH OF EACH LINE / PEPTH OF FILTER q/r DEPTH: TOP OF TILE TO FINISH GRADE a� MATERIAL BENEATH TILE __`5 N. A OV TLE 6 —IN. WELL: /% TYPE___��L_ '"�� - CONSTRUCTION 6 ��'�, ____ DEPTH_DISTANCE FROM: BUILDING NEAREST FOUNDATION _ LOT LINE CESSPOOL OTHER SOURCES APPROVED - __- _ DISAPPROVED DISTANCES: -- - INSTALLED BY: SEWER LINE DEPTH: PIPE MATERIAL: /� • - - LOT SLOPE: (-- ta� REMARKS: Form EQ -032 NEAREST SEPTIC SEEPAGE SEWER LINE TANK- SYSTEM_ REMARKS �A -K p,-3 qj DIAGRAM OF SYST f L,k r U 7� 'F- app DATE /v "Zj APPROVED G.A.A.B. SEP -04-2007 0925 M -VV DRILLING, Inc. P.O. Box 4.1224 • 1310C International Airport Road _ YLI ANCHORAGE. ALAS " RAGE, ALASKA 99509 'v 7 DRILLING LOG wen P.02 I -.-,y t f.ocaUon (address of: Township, Range, SecUon, if known; or distance main roar] Size o1 eassing i —Depth lof Hole,i 24 . feet Cased to 1 feet of Well Dom Static water level 20 ft (AWK14) (below) land surface. Finish of well (check one) open end ( X ); Screen ( ): Pezf,rated ( ). Describe screen or perto�ation None Well pumping test a* 2 gallons per (MM) (minute) for -1 --hours with LQ 4*. of drawdown from static level. Date o1 completion 18 .tune 75 WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness 0 ,1.0 2 Fill 2 TO 11 9 8 9 To 14 14 TO 15 15 To 150 To— Pro- -TO- -TO- -TO- -TO- -TO- -TO— To- Silty OTOTOTOTOTOTOTO Silty Gravel Sand Weathered Bedrock Bedrocks ra ailtstone err illitea small water seaps n fractures 14 -150. M n 0 CerEfiwe Nos. 814 dr 913 0 2 — STATE TOTAL. P.02 NAME OF APPLICA INSTALLATION LOCATION LEGAL DESCRIPTION GRE, ANCHORAGE AREA Orli DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET -ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 0�0- SEWAGE DISPOSAL SYSTEM ---APPLICATION AND PERMIT INSTALLATION OF: SEPTIC TANK MAILING SEEPAGE PIT PERMIT NO zl-gl f, i PHONE DRAIN FIELD OTHER TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGHTO E INST�+LLED BY SOIL TEST RESULTS �0 �I �1/ fe� �NO i:: T b ERMIT 15 N07 VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC, TANK SIZE SE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK / FOUNDATION TO SEEPAGE PIT [DRAIN P*CL-M SEPTIC TANK TO T' WALL SEPTIC TANK SEEPAGE PIT _� DRAIN F12t'U'- TO NEAREST LOT LINE. WELL TO SEPTIC TANK SEEPAGE PIT DRAIN FIELD ,l ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK SEEPAGE PIT DRAIN FIELD , SEPTIC TANK, �) SEEPAGE PIT �v / DRAIN FI E L D �G+ TO RIVER. LAKE. STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED :TOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. l GRAVEL 13ACKFILLAZ CONFORM TO BOROUAGFi REGULATIONS REGARDING INSTALLATION TYPE l.� DIAGRAM OF SYSTEM c-�1' c��f�t� I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA DESCRIB D SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE _ �`�„ APPLICANT'S SIGNATURE P�R NO. 1.0-01 6 E UGH ORDINANCE NO. 28-68 AND THAT THE ABOVE f NAME OF APPLICANT GREATER, ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT PERMIT NO. r!Z MAN-ING AD4RESS--_. -PHONE _ INSTALLATION LOCATION —^'/ LEGAL DESCRIPTION INSTALLATION OF: SEPTIC TANK _ c) SEEPAGE PIT I �✓` DRAIN FIELD ._---___ OTHER TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH __ __ __ TO BE INSTALLED BY SOIL TEST RESULTS ^""�`"�"� �'�-^ __ NOTE; 'I"HIS PERMIT IS NOT VALID IMIYHOUT SOIL LEST COMPLETION DA"fl_ ANTICIPATED FINAL INSPE"CT'ION: 2.4 HOUR NOTICE. REQUIRED. BACKFILLING OF' ANY SYSTr-M WITHOUT FINAL INSPLCTION BY THE DEPARTMENT 01 ENVIRONMENTAI.. QUALITY AUTHORITY WILL BF_ SUBJE(. f I O PROSLCU"f 10N. SEPTIC TANK SIZE _ fYPE _ __ SEEPAGE AREA SIZE __ TYPE MINIMUM DISYANCK'S, RUQU1RFMENTS FOUNDATION TO SEPTIC TANK -5-'-.- G`-' I FOUNDATION TO SEEPAGE_ Pil' /d DRAIN FIELD � r -I SEPTIC TANK "f0 SEEPAGE PITWALL / `d _ ''T / I SEPTIC TANK -2 I SEEPAGE PIT —(. l� , DRAIN FIELD -_—_ TO NEAREST LOT LINE. WELL TO SEPTIC TANK _ _ SEEPAGE PIT _— DRAIN FIEI..D ___- - ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK --_---, SEEPAGE Pll' - DRAIN FIELD _ I SEPTIC TANK, `_�iSEEPAGE PI'f ' OJ DRAIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVAI"ION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRI"IGHT REMOVABLE CAPS. GRAVEL 13ACKFILL CONFORM TO BOROUGH REGULATIONS REGA INC INSTALLATI OIJ. G.A.A.B. OR -ltiM1X I/n V LICENSED /. e ^q^ . 1 0 wk" , o iAc*.vmm OF' sys,mm I CERT"IPY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 2868 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. r - DATE' CD APPLICANT'S SIGNATURE c.�nr.n tir. cn-nlu Depth Feet Feet 2 , 3 .,� 12 - 13 -- 14 - Was ground water encountered? �j If yes, at what depth? Reading GREATER ANCHORAGE AREA BOROUr'' Gross Time `e Net Time Depth to Water apartment of Environmental Quo 3330 C Street \, Anchorage, Alaska 99503 SOILS I_,OG - PEROLATION TEST Performed for _3 ,�� _1-J�t ti � _ - -^ Date Performedy Legal Description: -- This form reports:" Soils log--�__ -- - Percolation -'test Depth Feet Feet 2 , 3 .,� 12 - 13 -- 14 - Was ground water encountered? �j If yes, at what depth? Reading Date Gross Time `e Net Time Depth to Water Net Drop _ .,� 12 - 13 -- 14 - Was ground water encountered? �j If yes, at what depth? Reading Date Gross Time `e Net Time Depth to Water Net Drop _ i,ercoiation rate minute. Proposed installation: Seepage Pit _ Drain Field n0pth of Inlet; Depth to hoUoni of pi t or trench - -- - - -- _ — 00111UlTS : - - -. J Performed By: ��i� �`--=� ��z��i� Certified By: _ -- EQ -040 (6/74) Date - --- 6 "'o no Municipality of Anchorage .� Development Services Department . Building Safety Division On -Site Water and Wastewater Program , A , r 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. O r 7- Yat - 13 COSA # 1) 0 5 3 Expiration Date: % a - 14 - Q-7 1. GENERAL INFORMATION Complete legal description Lo l-.�-. a I&Cie I. jwcauo b,;, ShkdG Cu Sin Location (site address) 1'2900 JAGnne fi #f Current Property owner(s) J o4 n Pop a Day phone 3 ws-- d47r, - Mailing address - - ---Lending agency Mailing address Real Estate Agent Mailing Address 1 2BGd �%¢tinnt /� y �}nc%u� cvgP. A 99.5/x{ v _ri . -r- Dayphone ve 9FephonThu FS PC/ Day phone Unless otherwise requested, COSA will be held by DSD for pickup. ptr ec, l/ Xzo h n P e e 3 ys' -dis-'e 2. NUMBER OF BEDROOMS: 3 token carA �Qay ��- 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding Tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Onsite Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of Onsite Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation, based on procedures outlined In the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the lime of Installation. Name of Firm F1//on Tsc4Aieg/ (7erv«v Phone Address 11S34; 1=c4o banyA- eA 99s el Engineer's Printed Name i baa"ea'e 1=. rrc,a-e Date 2S eV"I-t 2C'07 tea; �49imd Z • ,� 9 ,7 5. DSD SIGNATURE` . "ODORE F. kooRP I - r:j 'S CE -3587 NO Approved for _3 bedrooms. '''`, �•.. /� Disapproved. Conditional approval for _--bedrooms, ___bedrooms, with the following stipulations:__... .. Attachments: COSA Checklist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory _�_ Other BY OJZ t7O'�' Original Certificate Date: — e2 (Rev flN5) Municipality of Anchorage8011 • Development Services Department Building Safety Division" On -Site Water & Wastewater Program '" ° ` ° 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: 1_x? F S Q /e, c k J , /7 J-n-CA&O/a cw SUS Parcel ID: D / 7 - VV/ - /_7 A. WELL DATA Well type _-fv t If A. B, or C provide PW SID # Date completed 6 /18/ 7y Sanitary seal (Y/N) Y Total depth ISO ft. Cased to n15 ** f. ftk FROM WELL LOG Date of test S / 16 / 75 Static water level 20 ft. Well production 2 g.p.m. WATER SAMPLE RESULTS: Coliform O colonies/100mL Nitrate S97 mg/L Arsenic: <.f ppb dale of sample: 8 /ly /G7 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SPn 1-i c 1S/ -eel Tank size 16100 gal. Number of Compartments 2 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) t Z in. AT INSPECTION 8/ IS -/o7 'f• YS g.p.m. Other bacteria _� colonies/100 mL Collected by: F/crfioo Toch Svc Date installed 8/ ( /07 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (YIN) AN. A. Date of pumping 0-4 (N cw) Pumper t-1 - A C. ABSORPTION FIELD DATA Date installed a 7 Soilrating (g.p.d./ft'orfe/bdrm) 1. "fir Systemtype S'-K-�� d��nF�•lo( i Length 3S'+3b'�76f1. Width S ft. Gravel below pipe 0-S' ft. Total depth 3.0 ft. Eff. absorption area3&., fe Monitoring tube Y Depression over field Al Date of adequacy test P. A. C N e Results (Pass/Fail) ?ply For 2 bedrooms Fluid depth in absorption field before test U in. Water added 41 gal. New depth_6 in. Elapsed Time: O min. Final fluid depth o in. Absorption rate >= Y So g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date N. A, D. LIFT STATION N• �• Date installed `Pump on' level at _ in. Datum Size in gallons `Pump off" level at _ in. Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 161" Absorption field on lot 136 Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots > Fuc, On adjacent lots > 100 in. Public sewer main N• A. Public sewer manholelcleanout N• A. Sewer /septic service line > ZS Holding lank N• A% Animal containment areas N• A• Manure/animal excrete storage areas N• A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 12' Property line IS- Absorption field 70 r Water main ti - A. Water service line > to' Surface water > 100 Wells on adjacent lots > (o0 ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 101 Building foundation 70' Water main N•14 Water Service line - 7 10' Surface water > (00' Driveway, parking/vehicle storage > 3o Curtain drain N• A. Wells on adjacent lots > (0o' F. COMMENTS G. ENGINEER'S CERTIFICATION +`• :� .• •,cs' b I certify that 1 have determined through yield inspections and n i; Cr,9TH4 review of Municipal records that the above systems are in •.....•••....A ......O.D. P, conformance with MOA COSA guidelines in effect on this date. ,,.., , ,,,,,�.•,,,,,,,,,, Engineer's Printed Name ev e,& re F. 1`7aa,C ,w 7H''0" ORE F. #4OORe : f ', .�' CE -3589 $ 9 Date260 7 r: +.: ,''•.....Z° feat, a . Art COSA Fee $ Date of Payment Receipt Number 9g3(o� f (Rev. 11105) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage • �' Development Services Department j Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 070353 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 1, Lot 5 of Mountain Shadows subdivision. This inspection revealed a nitrate concentration of 5.97 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. PLOT PLAN _ ASBUILT SCALE 12-10 GRID 2541 Project No. O1I-1la2 Lang & Associates, Inc. 11500 Daryl Avenue, Anchorage, Alaska 99515 907 522-6476 Phone 4040 Registered Land Surveyors 9073 522-4625 Fax OF A O 0p I hereby certify that I haw surveyed the following described property �•'" 'QSQ taT g, t>L4>C---t, Wu-rplp SPAC'OWS d5'LAt'DIVISION (PLDT Anchorage Recording District. Alaska, and that the Improvemshhts stivatod thereon are within the property lines and do not encroach onto the properly....... er adjacent thereto, that no Improvements on the property lying adjacent thereto encroach on the surveyed premises and that then are no roadways, transmission lines or other visible easements on sold property except as Indicated hereon. ' "' • r . KENNETH 0. LAN Dated this the ?+L Day of lk"6TUIT at Anchorage. Alaska Qti '•., L,_- ?� 2 It Is the responsibllity of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. &v isLeb S6 Mai 1:dnfirm lb- `79 9 MUNI. CHORALE ALITY OF ANCHORAGE ALITY Op p DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTW4 OF HEALTH a`- -.- - - 625-L Street 0 PT - Anchorage, Alaska 99501 ENTAL PROTECTION • ENV' 'ONM /Y) fW ENVIRONMENTALe DIVISION , g 2 2 A978 be- 2 4 E72ING Telepho t �(�S REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEMIRIf I(1bLIUfO DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. r 1. PROPERTY O ER� 1 ' /t 'S%i 'HONE— kN N E , ` 1. V I IVGi�/l� J M (LING ADDRESS PROPERTY RESIDENT (If different fr99m above) PHONE ''E R �i( N Ncl f �� CQ rcr o r1 w l m 4c�Ae L 2. BUYER c— PHONE MAILING ADDRESS — 3, LENDING INSTITUTION PHONE MAILING ADDRESS 4. REALTOR/AGENT ��— PH E MAILING ADDRESS 6. LEGAL DESCRIPTION ; fMT,° S'H Ptzow S' 5% 1y/X/OA7 STREET LOCATION JEANNIe, irc� "1 'S' 111 / v APE n 2 ;rC (oi+l G11 h i�iIcAAr H�Ft^i'12 6. TYPE OF RESIDENCE SINGLE FAMILY v NUMBER OF BEDROOMS �I' 2 ❑ One ED Four Other fy ❑ Two ❑ Five ❑ MULTIPLE FAMILY `--- ❑ Three ❑ Six 7. WATER SUPPLY "— INDIVIDUAL* * ATTACK WELL LOG. A well log is required for all wells drilled 0 COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) QEP7W !' O F j" S. SEWAGE DISPOSAL SYSTEM E �— INDJVIDUAL/ON-SITE:*`' **If individual/on-site, give installation date_ R y 7C ❑ PUBLIC UTILITY If systern is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. m THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE El PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: 10C)© If Tank is homemade give dimensions: SOILS RATING - - e TYPE OF TANK MANUFACTURER TOTAL ABSORPT10N AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS le APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE /0l6 7 BY (Tale) LEGAL DESCRIPTION 72-010 (Rev. 3/78)