HomeMy WebLinkAboutMOUNTAIN PARK ESTATES #2 BLK 3 LT 8%1,o
f_.~ MUNICIPALITY OF ANCHORAGE
, '' ' DE ,:{TMENT OF HEALTH AND HUMAN SER ES
·" ~ Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Subdivision
Township. Range, Section
AS-BUILT DIAGRAM (Show Iocanon of well, septic system, property lines, loundahon,
TANKS
,~¢~EPTIC XiSTi G HOLDING
Manul~cturer Capacdy m gallons
Material No of Compadments
TYPE OF SYSTEM L~
~th to p~pe bottom from Total depth from original grade
Fill added above orig,nal grade Gravel depth beneat~ pipe 1{ ;~ ~ ~'1 6: ~ - /
~i lengJh ,)~ Gravel w'~h J
Total absorpt ....... Distance bet .... lines /O' '! J
· z / WELLS
Classd~cabon (A,B,C~ Total Depth Cased to
ET
'~ ' { Scale:
~ ENGI ' ' 'S SEAL
Municipal and S a e oui ems' ' : / , ~'
Health DepaAment Approval: (/ Date: r~
72-013 (3/85)
M U N Z C Z P A L i T Y 0 F' A N C H 0 R A G E
De. pantment. Df' Health .:.." Human Services
8,~5 L. Street, Anchor'aqe, Alaska 99501
0 N - S I T E S E W E R P E R M I T
Date Issue:d: .... /=:?/88
Up g r. ade
Engineer Designed
[)wr'~er' Name~ ALASKA I.S.A,, FEDERAL. CREDIT' UNION
Ownep A.'.::ldr-ess,". I:::'~ 0, BOX 196613
ANCHORAGE, AK 99519-6613
[}ay Phor~e:
786-2.887
Pal"cci. I d :; 0 ;L7-022-~0
Lot Legal: Subdivision: MOUNTAIN F'ARK EST ~2 Lot: 8
Section: 26 ]"ownsh:i.p: 12N Range: 3W
L. et Size 19S00 (sq,, ft. or acr'es)
Max Bedrooms: 'T'his Pe['mit: :3 Total Capacity: 3
B 1 oc: k -" 3
SEPTIC TANI..'.:: M:Lnimum total septic tank' capacity: ].,000 gallons. Each septic
tank must have a{ least ,'~ compap{ments. Depth to top o~' septic tank(s) :: 4.0
f'eet requ:i.r, es :Lnsulation over tank(s).
INFORM D.H.H,,S. PRIOR 'TO .~ST & 2!NI) INSPECTIONS BY ENGINEER,
AF:'TEF:~ OFFICE I"'tOLIRS CALl_. :].':43-4681 AIND LEAVE A MESSAGE
CONSTRUC'T' Ir""ER EN[~INEERS AT'TACH.FD AF:'PR[]VED DESIGN
THI,S F:'EF~MIT EXPIRES 1.7./:31/88
TH]:S PERMIT FOR A SINGLE FAMILY RESIDENCE GNL. Y
IF
I CEF;."T I t:::Y ]"HAT :"
1,, I am familiar with the r'ec:luiremen'~..s ~'of on,-~:i, te sewer'~ and wel].s as se'L
~orth by '!:.he Munic:i. pa].ity of Arichorage (MOA) and the State of A].asl.::a.
2,. I will install the system in acc:ordance with a].l MOA cedes and regulatior'~s,
and in compliance with the design cPitePia of th:i.s pePmit,
:3. :1: will adhere to a].l MOA and State o¢ Aiaska requirements for' the set back
d:[stanc:es Crom any existing well., wast. ewateP disposal system er' public
sewerage system en this op any adjacent op n~aPby lot.
4. I understand Chat this pePmit is va. lid For' a m~ximum oF 3 bedrooms.
also undePstand ~hat the capacity of the total sysCem is :3 bedpoems and
, any er~].argemerr~ill r-equi~an additional per. mit.
<OWner) AL_ASKA U..~.A. FEDERAL [',REDIT LINION
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL
To~K,.nship, Range, Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT ~._.~__ O
DEPTH? p
E
Oeplh to Water. A, fler. , ,-L '~/~,,5' *'
72-008 (Rev. 4/85)
Gross Net Depth to Net
Reading Date
Time Time Water Drop
! ~//~/,:~¢:-zz/,,~,:;z io ,,~ .... ~-o/'..4~ .04
~- " ~:.¢~7~:d~ 1o,~,'~ ,~'o /.4¢ ..o4
~ " ~:x~y?,:~~ lo,~,'~ .-;o/,4~ . e4
PERCOLATION RATE '~'-~ . (minutes/inch} PERC HOLE DIAMETER
TEST RUN BETWEEN '4-' FT AND ,~: FT
i
I
I P~ELL
I ,
·LoT 8'
IoZ' /
HO~E ,, .-
/~,,,;~E~WER SYSTE~o~LO~TION' P,~o~
NORTH JE~y ~3 OETEE~IHEO ~Y U3E OF CLOTH TAPE
."Z
PROTECTION
6 ]988
~& 8s$o¢iate$,inc. MUNICIPALITY OF ANCRORAGH
DEPT. OF HEALTH &
Consulting Engineers ENVIRONMENTAL PROTECTION,
1000 E. Dimond Blvd. · Suite 205 · Anchorage, Alaska 99515 · (907) 522-1311
J U N 1. 3 1988
June 13, 1988
Dan Roth
On-Site Services
Municipality of Anchorage
Department of Health and Human Services
825 L Street, 5th Floor
Anchorage, Alaska 99501
SUBJECT: LOT 8, BLK. 3, MOUNTAIN PARK ESTATES #2
RECEIVED
Dear Mr. Roth
This letter is in response to our phone conversation on June
10, 1988. During the construction of the new septic system on
the above referenced project, no evidence of a spur line coming
off of the main trench was encountered.
The as-built of the existing system on file with the M.O.A.
does not show the dimensions of where the spur lines are
located. The southern edge of the new bed system was
excavated, and no sign of the spur line trench was visible.
The new bed system was installed as per our as-built submitted
on June 7, 1988. If you have any additional questions please
contact our office.
Sincerely,
CORWIN & ASSOCIATES, INC.
Jerry Kress
JK/ck
) MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAl. PROTECTION
ENVIRONMENTAl. ENGINEERING DIVISION
825 [. Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAl._ SYSTEM AND/OR WELL INSPECTION REPORT
NAME IPHONE I .~NEW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION ~ P NO, OF BEDROOMS
Well Absor0tion~rea
DISTANCE TO: I~T
Material - No. of compartments
~<~ZH Manufacturer ~ ~
m Uq. caOacitg in ~aHons Inside Ion~th Width ~iqui0 dopth
/~O O IF HOME.DE: ....
~ ~ DISTANCE TO: Well Dwelling PERMIT NO,
O ~ ~ Manufacturer Material ~ Liquid capacity in gallons
Nearest lot Hne PERMIT NO.
~ Well Foundation
--~ i~2 lO.,'~O ~ ~ inches
~ Top of tile to finish grade Material beneath tile Total effective absorption area
~ ~
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
m ~ell Buil~in~ ~oundation ~earest lot line
m DISTANCE TO:
~ Class Depth Driller Distance to I~t line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
Ovc
SOiL TEST RATING
INSTAELER
~EMA~K8
. b~ .
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
LOCRT i. ON
L_EGF!L. LE', EC¢ i'IT p,k: E:~E;".F'~t!:2'. LOT SIZE
T"¢F'E OF SOIL ;RE',SOF..:F'T:i:Oi'..t SY'STEH IS: [:,RRINFF[ELD
i"iFP:;iPIUH hP.JFIBEFt OF E:EDROOHS =' 3: SOiL RRTiNG (SQ F'i",..-'E',R)'.~:
THE [~:E(;¢LJZFtED SiZE OF' THE SOiL RBSORF'TIEU'-,I SWSTEH
'T'HE.: LENGTH L-:,iHENSION iS THE LENGTF! ,::Zi'.,i FEET) OF THE 'TF;~ENC:H OFf: DF:FtINFiELD.
THE DEPTH OF R 'T'F~:ENC,~4 Cfi,:.: F'iT IS ThlE DISTFINCE E~ET!.,.IEEi'-,! THE SLIRFF!CE OF THE
GRC~L!i'.,iD Ri'.,!D 'IT'HE: I.:.?OT'IT'Oi',! OF' THE EXCF'¢v'RTZOi'q (~I'-,I FEET::,.
THE GF.':R',,,'EL DEF'Tid IS THE HINIHU!'"! [:,EF"i"H (::iF' GRR',,,'EL. BETHEEN THE OLtTI:TRL. L F'IF'E
i::~!'.,li::, THE: f3OTTOH OF' THE E:XC:F!',,,'RT!O!'-,I ,::):N FEET).
· P!:q~'i'4'l, ..... , .... .... FiF'F'I ................. '[ "FIFFi" i...l,¢:i:i~; 'J-HE -..__,,l:;'~':":'~:'r'"'~-i'::"r F'T.,,, ._, ,. _, .~ ,_ ~'r'"'-',, TO INFOF.':H '1"HZ':; ",E'PF:IP:"I"HFN'F [:,!..IR- 'Z ,L~ -' THE
.,Ti'";"T'.: I I ~"F'r "j"l_.:_.., ,,...._:,, .,. :[i'.,!';:F'F'i'"TT '"1'.~i':: OF F:iN'Y' ,.,.i~':,~., ....... "'- FIE:',:fFICENT "FO THIS P,~RIT:)F'ERT'T' FIIqD THE
."~L ."E:i ER OF: FtE':211 [:'ENCEtL:; ".LLIFq'' THE !..E'L L !.'.il L..L SF:,~:',,,'E.
E:F!(::i':::FZL. LIN!3 OF FhN':"::,'F:,I~,'-' '"'"~""~i ........ i'.!iTHIT:)UT F'TNFI! ,.T'I'::'F:'~'""FTi~!~'"i--' ...... · , .]. t:''J ', i',[~- i:~F'PPq","RL. .... FPy'
E:'EFI::iFdTHEf'~!T i'J:IT LL BE S L!ELiEIT3'F TO F'RCP--::;E(.':iJT i
HiH!!"iUH DiSTF!!'.,!CE BET'iqEEN Fi i4EL_L. FH'.~[> FiN'¢ ON-SiTE SE!.4FIGE
':IT.OE~ FEET FOR F! F'RZ'v'F:ITE NELL OR :[.[3ei 'Ti::) 2Ei~3 FEET FR:Of'! IT:i PUBLIC .klEL. L. t)EF'Et'-,![:,ZNG
LiF'Oi'.,i 'TIDE '!"?F'E OF PUE',LL,"C HELIT ....
HIN):HIT..~H DZST!hF.iCE.:: i::'I~:ELH F:! F'F;'.]:'v'FiTE i4EITJ_ TO Fi F'I:;~:I'v'F!TE SE:i.,.IER' L. tI'.,!E ZS 2.5 FEEE'T' RN!3,
TO F:i C,OHHLIi'.,!.[T'.r' SEHER L~.NE iS 7D F:E:ET.
14EL. L LOGS Fi'RE F:EELi.i(F..:ED RND HITJST BE RE'FLiF.'.i'-,tED T'O T'F!E DEPFffe. TifiEI'..!T !4:ITT,~-ItI'.,I
OF' THE: !4ELL COI"iPL.ETiON.
CYTHE:R i:;~:EIT;!U ! I:-:.':EHEi'.,FFS
F:P,,,'R ]: L. RE~LE TO i NSI.jF..'.E PF.:OF'ER Z NSTRL..IT_I::iT ]: O!'.,t.
i CEF:TiF'"r' THWT
::L: i Fid I:':'F:i!"I:[L):RR FilTH THE REi~;:¢JZF:EHEf,FTS FOR ON-SI'TE '.E;E[,!E[RS FIND i4EL.LS RS SET
F'OF;FFH F3'¢ TFIE HLiN ;[ C l F'F~L Z'T"¢ OF FiHCFiORf:iGE.
2: :[ HiL. L. Zh!STIaL. L THE S'.~.'STEH ):N FaCC:OFtDFINIT:)[~; !.,.!:[TH "f'FIE CO[:,ES.
Z;: ;[ i..!NDE:EST!::iF,I[) THFCF 'T'HE ON'-'S];TE SEI.,.iEIE: S"r'STEH ldF:i"¢ REC!IT.iZF~:E ENL!:FIF'.GEHEF,FF iF THE
i:RESZDENCE iS F:EHODE:L. ED TO ZNE:L.L!DE HORE "FHFIN 3 E',EDRCH3P1S.
/d'i" "" ~' ~ . ' "'""
qT':iP.F',. 'ZP',cV /'h,, ~, ', ;~ ' //;:. ?.:,,' ~ )z CD :
RPF'L. ICF!NT' ': "¢"P ~' .' ":~'F .*.'"~'Fi '"'r',l :".' ,~ . _ ' .
E',h-'. ......... ~: ........ L .................................. ~; ................................ F:,H'T'E'
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS' LOG- PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
1
2
3-
4
5
6
7
8
9
lO
11
12--
13
14
15
16
17
18-
19-
20-
COMMENTS
PERFORMED BY:
SLOPE SITE PLAN
gl ~_o~
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
S
Gross Net Depth to Net
.Reading Date
Time Time Water Drop
PERCOLATION RATE Y¢~ (minutes/inch)
TEST RUN BETWEEN Ct ¢-- FT'AND '5'~ '>~ FT
CERTIFIED BY: TE: ?"~/f~,t~'-? .
72L008 (6/79)
Drilling Contractor 2. :2,.'/'/~, ~'~ ~),. ~., ~. . P~ ..
Mailing Address
Property Owner
Mailing Address
Location of well site: Lot ~3 Rlk ~
Depth Jn Footage 2,~0 Te.c4. Diameter of C~si~g
74---75' CouA.~c ,.'%c;tzcA,
1_30-170' ~v,~.t~;L tt~.i.~ 307 c.~>'.
1£0-270~ /~ ,~eA. Zz~.emZ'.cm~ .Oe~_,.'~.oc,l:.. 50 w'aX.e& p,cod, u,c~c.Lon, un.L,LL 240 ~ce2., arJ..U~, a
Under Certification That ~ Log Is Tn~e and Cop'reef
,?um~.~t. 7.3-~;., 195.9
Date
Log Service Fee
· ~,;~ ~i~::::'.:,:~;~:;'::!";~, :' , .:':';: MUNIC!pALIT¥ OF ANCH0 ,;:'' ';.
~ : ,'.-~'?~" :i~: D'~RTMENT OF HEALTH AND ENviRoNMENTAL PROTECTION
" : '"" ':~ 'b~ i:~S'P~C~i°~' 'FOR HEALTH ~UT~Ri~:'APpR°vAE
;onser~ation~!
Page I of 2
72-025 (11/84)
)(
,JO ~LJj Jl~LJJ sMOJ. JS
A. WELL DATA
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
C o m m e n ts~¢~" ~, ,~L,'CI~,--~
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
Legal Description:
Lo't-- 8;./ 'b, tor
Well Classification t~/~"~'--~'4'~'~ If A, B, C, D.E.C. Approved (Y/N) ~ / A-
Well Log Present (Y/N) LI~ Date Completed ~'/~ ~ /~¢~ 0 Yield
Total Depth ~Z--~¢_~ O Cased to '7_.-~ ~O Depth of Grouting ~'"~/,'~
Static Water Level ~- O'"7 Pump Set At ~..~-~'~ O t ,-~--~.~
Casing Height Above Ground [ ~( 1 Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) V Depression Around Wellhead (Y/N) ~'~
Separation Distances from Well:
To Septic/Holding Tank on Lot (~"~ O[ ''~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot [ OO~ ; On Adjoining Lots
To Nearest Public Sewer Line jk,.~.~/~.~_ /St' To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
B, SEPTIC/HOLDING TANK DATA
Date Installed ~/"~/~d:~2-,-Size I. ~:)O 0 NO. of Compartments
Standpipes (Y/N) kT~ Air-tight Caps (Y/N) L~ Foundation Cleanout
Depression over Tank (Y/N) ~ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ~///~. ,'for
To Property Line
To Water Main/Service Line
Course
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
TO Water-Supply Well [ ~
Temporary Holding Tank Permit (Y/N)
TO Building Foundation ~
To Disposal Field ~-~ !
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026 fRev 8/86~ Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~¢~/~-~ / ~:~::~
Width of Field ')~ ~_lq~,¢~
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot ~
To Water Main/Service Line :~ ~_~.~ I
To Stream/Pond/Lake/or Major Drainage Course
Type of System Design
Length of Field '7~"\. _~--'
Depth of Field
Gravel Bed Thickness
To Driveway, Parking Area, ~,~ehicle Si~rage ~'rea
Comments
Standpipes Present (Y/N)
Date of Last Adequacy Test '~-
f
To Property Line
To Existing or Abandoned System on
;On Adjoining Lots ~tJ/A
To Cutbank (if present)
f
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Manhole/Access (Y/N)
~6%,Pump Off" Level at
SdS, Vent (Y/N)
Pumping C~es during Adequacy Test. Meets MOA
/
** Check PCrrr~tted Bedr¢o~m Rating Against HAA Request **
I certify thCt ~'t'/~v~/~ ec,k~d,.~erified, or conformed to all MO~ an~ HAA guidelines in effect on the date of this inspection.
Compare ~/~'* ~, MOA ,o. ~ --~' S _
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
ineer's Seal
72-026 fRev 8/86) Back
.
SEWER SYSTEM LOCATION PLAN',
~ ~ -..~ ~.~ 3ECTION/TOWNSHIP/RAHG[
~-~:.:-~.~.,~,.~',~'.,'~--,,.'-'~':-~'.'"'"""'"':"~ ....... ~'"'""'""':"~':~'~:':':~'~':~ NOT BY SURYEYING TECHN[0UE~.
~. .. ~ ~ ,,,..,~,=~.,:~-~.,~.-.~.,- ~ .~, -
;.. ~ :..'.';:' :':~'t%'::..,;~., ..;.,, ,.::Z-~ ~ ~ '~-'', , '-'" "-'"" ..... r~' Y'
3OND BEAM
FRAMING -
INSULATION
SHEETROCK --
STRUCT. FINAL
OTHER
MUNICIPALITY OF ANCHORAGE, BUILDING SAFETY DIVISION
3500 EAST TUDOR ROAD ......
NSPECTIONS (9071 563-3464 . . · .. . .. , ' iNFORMATION'(907) 786-821!
FOOTING [] ELEG. TEMP. ~: ~ ..PLBG'uRDGR}-: , ~
ELEC, SERV CE~'~ ~LBG''RdUGH -' ' ~
~ ELEC. FINAL~;~;'~GAS '~'" .' ' ' '.~
~ OTHER ~ ' MECHANICAL.-- ''"~ '
: " MECH, FINA~
[] FIRE FINAL [-1. PLBG FINAL:': ':. [] -
[] ZONING E]? 'OTHER- []
ESSENTIAL Ag
,EXPLAINED BELOW ~' '
,NO NONCOMPLIANCE OBSERVED [] CORREOTIONS
[] WILL REEXAMINE AT NEXT INSPEC:TION -: E~:'~:?~'(~'c~I'~cE'A'L-UN'clI~'REiNSPECTED
COMMENTS . :. · .
INSPECTOR
WHEN CORRECTIONS ARE MADE, PLEASE CALL I~OR INSPECTION
DO NOT REMOVE THIS NOTICE
84-002 [Rev. 11/87) _ .
! .o..os'r ,. ^ co.s.,cuous pL^c~ · · · o · · · · o- ·
~ 24 HOUR NOTICE IS REQUIRED FOR INSPECTION SERVICE
,'~.'~' ~: ,ELECTRICAL
APPLICATION AND PERMIT
~ BUILDING SAFETY DIVISION
"~-~" ~U~,C,PAL,TY OE~C"O~ '~. ~ ~0. E
-~,;tNT~ATI~ ~ PHONE 78~ ~: INSPECTION 56~
~.)._ Su~ ELECTRICAL PERMIT FEES N0. ~ FEE
TOTAL FEE
APPROVED
&
BY
SIGNATURE OF PERMI~EE OR AGENT
84-009(Rev. 2/85)
POST THiS COPY
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
FEDERAL TAX ID # 92-0040440
RE?OP, T BY SklqPLg for Work Order ~ ~$00
Client Sample ID:L3, BI, HIDEAWAY LAKE SUBD.
EWSID :UA
Collected ~{A¥ 23 88 ~ h~s.
Receive6 ~[[¥ 23 8~ @ 14:10 ~hr~.
Preserved with :NOME
Client Acer : CORWIN?
P.O.~ NONE REC~D
Req ~
Ordered By : JERRY
Analysis Completed :}~A¥ 25 88 Send Repsrts to:
Laboxstorv SupervisOr, :S~EPHEN C. EDE !)CORWiN & ASSOC
Released By : X,~c~_~_;Zz-- 2[)
/
Special
Instruct:
Che;~ab Re~ ~: ii20 Lab Smpl iD: 2 Matrix: Water
kilowab!e
?eram~ter Tested 5esulz/Units }~ethed L~m~ts
NITRATE-N 3.1 m9/i EPA 353.2 10
Sampie 50UTINE SAMPLE.
Remarks: SA}~PL[ COLLECTED ~Y J. KRESS.
! Tsst~ Performed See Special insrructlsns ~bove UA.,Unavailab!e
ND- None Detected "See Sample Remarks ~boYe
}IA- Not Ana!yze~ LT*Lees Then, GT-Greeter Than
./~~'l~ CHEMICAL & GEl OGICAL LABORATORIES OF ALASKA, INC.
TELEPHON (907) 562-2343 5633 B Street '
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
[] PUBLIC WATER SYSTEM I.D.#
[] PRIVATE WATER SYSTEM
Name
/woo ~-. 'D//]/cfo~,/D
Mailing Address.
Phone No.
City State
Mo. Day Year
Zip Code
SAMPLE TYPE:
J~-. Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
_) [] Treated Water
[] Untreated Water
SAMPLE
NO. . LOCATION , '
/-oT '~ f~L~ /
3 l
4 l
5 l
Time Collected
Collected By
I //:~¢.,~ J.
TO BE COMPLETED BY LABORATORY
Anal/vsis shows this Water SAMPLE to be:
[i~/Sati~factory
[] 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 delivew mail.
Date Received
Time Received
Analytical Method:
/5//0
Membrane Filter
* No. of colonies/100 mi.
Lab Ref. No. Result*
I//.~o"- ~ I-D1
I FTq
F-FI
F-F1
Analyst
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS Membrane Filter, Direct Count
BEFORE
COLLECTING SAMPLE
Coilform/100ml
Verification: LTl]_
Fin a ' M em brane~ltet ~u~?//
TNTC = Too Numberous ~o Coun
OB = Other Bacteria :
BGB
Coilform/lOOml
PART 1
OF Z REMAINDER TO FOLLOW
APPL/ NT FLEES OUT UPPER HA ONLY
'l~ro*~erty 0wner,~,.~,,,L.L,.~.~t~ T~>~ ~,~ ~,,~,,j..~......¢, ~.~ ~~.~ Phone
Buyer ~.~%~
Address Zip Code ~
Lending Institution ~ ~~ ~~ Phone
Address ~AI~, ~= ~~ ZipCode d~5 o ~
Phone
Realty Co. & A~nt t~J~
Address Zip Code
LegalDescription ~ ~ ~~ ~ ~~~ ~ ~T,~
Type of Resi~nce
~ Single Family
~ Multiple Family No. of Bedroo~ ~
~ Other
Water Supply
Individual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth {attach log
if
available).
~ Public Utility
Sewer Disposal
Year Individual Installed: ~ ~C~¢~
Individual
Public Utility When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
inspector Insp~tor Insp~tor Inspirer
Field Notes: , · ~ ~
~ ~ P~OTECflON
RE6EIVEB
BEDROOMS ~~ *coNDITIoNS OF APPROVAL
(
Soils ~atino Dato ~wer Installod Woll 1o ~Bsorption ~roa ~ell ko~ ~ecoive~
~--q ~ Well ,o Tank Septic T~k Size
72-023 (3182)
ABSOR N S E
PLAN VIEW
SITE PLAN
NAIVE BACKFILL~
b
2% _
UNDISTURBED EARTH
SECTION
500 GAL
DTI001t26'
ON-SITE
SEWAGE DISPOSAL SYSTEM
FOR LOT 8 BLK 3 MOUNTAIN PARK ESTATE