HomeMy WebLinkAboutMOUNTAIN PARK ESTATES #2 BLK 4 LT 19 SUBMJ .
Municipality of Anchorage
Community Development Department MAY1 A ege 1 3
On-Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907)343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP131145 PID Number: 017-023-19 ❑ New ❑✓ Upgrade
Name:
Gary & Donna Russell ABSORPTION FIELD
Address
❑ Deep Trench ❑✓ Shallow Trench ❑ Bed ❑✓ Mound
12941 Lupine Road [' Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
4 6 GPD/SF 1.0 Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot 0.5 Ft. 0•5Ft.
Mountain Park Estates#2 4 19 Fill added above original grade Gravel length
Township Range Section 2.0 Ft. 20.0 Ft.
Gravel width Beds:Number of Lines Distance between lines
SEPARATION DISTANCES 5Ft. N/A N/A Ft.
To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist.between trenches
Tank Field Lift Station Tank Line 100 2 1
From Ft N/a Ft.
Well 104.1 129.1 116.3 N/A 81 TANK ❑Septic El S.T.E.P. 0 Holding ❑Other
Manufacturer Capacity
Surface Water 100+ 100+ 100+ N/A Anchorage Tank/Orenco 1500Ga1.
Material Number of compartments
Lot Line 48.0 17.2 51.0 N/A Steel 2
NA
Foundation 17.0 52.2 27.0 N/A LIFT STATION
Manufacturer Capacity
Curtain Drain N/A N/A N/A N/A Orenco 500 Gal.
Remarks Pump on level at Pump off level at High water alarm at
43 in. 401n. 45 in.
Pump make and model Electrical Inspections performed by
P2005
PIPE MATERIAL House to tank 3034 Tank td 3034
Installer drainfiel
A+ Home Services Drainfield 3034 CO/MT 3034
Inspector Pannone Engineering Services BENCH MARK (Assumed elevation) 100ft
Inspections, Location and description
dates: 1 7/9/13 2nd 7/10/13
3rd 7/11/13 4th Corner of house trim.
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp
` �
Conditional Approval: Date '"C. ' OF•AC �l
k
,� • St.ik
\1'>j"j c- \ -b wu,u-rci Wcvo Co bj MeW o‘-‘ t ..Meveri•F. 15a'nriorae E 81_49 S
0
51i�i/1�1 . i 43s•. D16s
Approved keittUILA (vt.t.o- / J Date 5/2(///I kk '. a?o clsg-
Cict,�,d Sorb \\\
Inspection Report_1-1-12.doc
I L I \ 1 4
A B
T1 34.4 23.9 0`/
LS1 42.0 26.6 e�/
LS2 45.4 29.4 WELL (E) 3 \
. \
/
M1 64,7 67.7
4 4'
M2 53.4 67.7 --"--'4, 3
/ ri / \4,
MSM-~M� W
1 /
es 41
\ ? . V 510 45
N
f
,. ,/ \
WELL (E) \ 3 \ _ ►,
•
-
v -. 47 _ 4- 4
- N� w/4 3 ! 1 /
w—� w
WELL (E) 10' UTILITY ESM v ..
0
z 129.1 b i \
I o DRIVEWAY ATH-1 tt
J 104.1 .. M2 M1 App NEW DRAIN FIELD W�
lip, T1 _ -, 20.OLF x 5.0'W x 0.5'ED x 1.0'TD
4 BR G . '� WI 2' SAND
•
Iv B
HOUSE s, ,0 ,ro0 I I 6
1.4}. / S2 \ 1 1
w��w`W/ L T 19 S1 DRAIN FIELD (E)
\\------ IN FAILURE N
,1, 41 ' REUSE AS RESERVE 1
U \ t1
�iv M M....---..— SM �/ .\\. 1I /
N`' W--.._._w..—..—.—VI 41 V 1{
\ \ er
� � NEW 1500g S.T.E,P. TANK
\ r W/ AX20 POD AND I 7
AUX PUMP VAULT `T �\
ABANDONED EXISTING
SEPTIC TANK AND LIFT J h,
STATION PER CODE /
7 _
3
WELL E �
\ UL
e„..„.„7_ 1
3 ''M—M—�M� z ..
/ .."--- \4•/,, R
/ \
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NOTES: „,���\\ Dote
PANNONE ENG SVC LLC of A�•wl 1/3/2014
RECORD DRAWING P.O. BOX 100217 ANCHORAGE, )K 99510 ,c� :4
�, '• s.79.�!i Scale
PHONE (907) 272-8218 FAX (907 272-8211 *co-...9TM #, 1°-50'
e, • • 0IP.I.D. NO
MOUNTAIN PARK ESTATES #2, BLOCK 4, LOT 1 - 017-023-19
GARY & DONNA RUSSELL i Steven.R.. ann'ORe �'pERMIT NO.
r . CE 8149 j OSP131145
12941 LUPINE ROAD � �s • •��
PLAN ANCHORAGE, AK 99516 �ikkj- •ANN...-:4"orTs = Sheet 3
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION WAS INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE
STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON—SITE
WASTEWATER DISPOSAL SYSTEMS.
3. SCOPE OF WORK: INSTALLED NEW 1500g S.T.E.P. TANK WITH AX20 POD AND AUXILIARY PUMP VAULT. INSTALLED DRAIN
FIELD
4. GROUNDWATER WAS ENCOUNTERED AT A DEPTH OF 5 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL TEST
HOLE. AN APPARENT WATER TABLE WAS NOT OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 5 FEET BELOW
EXISTING GRADE.
RIGID INSULATION
FILTER FABRIC
1.25"0 DRAIN PIPE
TS&V W/)b"HOLES DRILLED 18"O.C.
5.0' DRAIN ROCK 6"ABOVE PIPE INV
101.5 3
TH-1 X2.0 —_1
. _
1.D OR -9998.55 _ 1.0 ,,
GM 4.0 :,_
\ DRAIN ROCK
-5.0 GM/ `2.0'SAND
-70 SM
SECTION
I-
0
w
RIGID INSULATION
m m
0 _I cc cc FILTER FABRIC
~ ~ DRAIN ROCK 6"ABOVE PIPE INV
0 0 o a z z
p Z a M 1.25"0 DRAIN PIPE
IA a W/)b"HOLES DRILLED 18"O.C.
o o L 10...
J Q
Ar
( it
----l— ss.s— � —_
4.098.5'
_____L_ 96.5-
DRAIN ROCK
sa.V 1500 g S.T.E.P. 2.0'SAND
TANK(P)WI
AX20 POD
PROFILE
ABBREVIATIONS
CU COPPER
DESIGN PARAMETERS DIP DUCTILE IRON PIPE
PRIMARY/RESERVE SEPTIC SYSTEM TH TEST HOLE
LEGEND NO. BEDROOM: 4 (600 gpd) FC FOUNDATION CLEAN OUT
- w w WATER LINE/ TANK SIZE: 1500g S.T.E.P. TANK T# TANK CLEAN OUT NO.
WELL RADIUS W/ AX20 POD C# CLEAN OUT NO.
PERC RATE = <1 MPI M# MONITOR TUBE NO.
ss NEW SEPTIC SOIL RATING: 6 GPD/SF u 4ES R.I. RIGID INSULATION
AREA ROD: 100 SF I.,• -c (' OCO DOUBLE CLEAN OUT
SYS. TYPE:DE SF__
0.5' E.D. DV DIVERTER VALVE
MIN LENGTH: 20.0 LF FS FLOW SPLITTER
USED: BFG BELOW FINISH GRADE
20 LF X 5' WIDE, 0.5' E.D., 1.0' TD OG ORIGINAL GRADE
WITH 2.0' SAND FG FINISH GRADE
D�77��TOOTAL77ARRE�EA: 11000T SF TS&V TOPSOIL & VEGETATE
NOTES: PA1 NO E ENG SVC, LLC �_1QF411 k Dote
1/3/2014
RECORD DRAWING P.O. BOX 100217 ANCHORAGE, AK 99510 ~'�� '4 1
� "• s- `+ Scale
PHONE (907) 272-8218 FAX (907) 272-8211 01---7,04`. .•
�. 9
-)0' • TH *4, NTS
"'
MOUNTAIN PARK ESTATES #2, BLOCK 4, LOT ' ••• OPID
..D. S
NO
GARY & DONNA RUSSELL
�I'•• teveCER8149 n • % PERMITNO.
'^ '• .. OSP131145
12941 LUPINE ROAD cs•.
DESIGN DETAILS ANCHORAGE, AK 99516 tll%, 0FE=== Sheet 3
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
,LEGAL DESCRIPTION
DISTANCE TO: LI I W~llV(~:~: Absorption area.~.~
Manufacturer
Liq. capacity in gallon IF HOMEMADE: {'~/(~e length
DISTANCE TO: Well l ~ 'Dwelling
Manufacturer ~'~
Wall
DISTANCE TO:
N o. of lines~.._ Length
~ of tile to finish grade
Length Width
DISTANCE TO:
DISTANCE TO: '
Well
Depth
Building foundation
PHONE
UPGRADE
NO, OF BEDROOMS
Dwelling i01~! PERMIT NO~.~ ~:~O q 1~._.~
W dthJ Liquid depth
PERMIT NO,
Liquid capacity in gallons
aista"7/l " . "nes
~ ~ inches Total effective2gp~n area
PERMIT NO.
Total effective absorption area
Foundation
Material
Nearest lot line ~(~
Trench w dtb ~n~hes
Material beneath tile
Depth
Crib depth
Building foundation
Driller
Sewer line
Nearest lot line
Distance to lot line
Septic tank
PERM,T NO,-'-/
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTAELER ~
APPROVED
72-013 {Rev. 3/~)
DATE LEGAL
PERMIT NI3.
RF'F'L I CRN'r
LOCRT I ON
LEGFIL
D I CE WR I GHT
[)~'.RRM OUN
LT. t9 BK. 4. MTN PK.
EST.
_-,RR B,:s. :L .... ¢-R FINCH
=,~. [., LOT SIZE
"--- -' - IS
T'¢PE CIF SOIL RE,_,UF. BTIUN SYSTEM : TRENCH
BE[. RI.IUf 1_, = 4
MR>::IMUM NUMBER OF
2000E] L='-,,!URRE FEEl'
RHT I N -~ FT,." E:F.: ) =
SI]ilL " P ('Si). :~-:~..=.
THE REQUIRED SIZE CIF THE SOIL RBSORPTION =,TzTEfl IS:
[:,EF']-H= 5 LE f-~,]iT H= .... 4 8 F: Fi'-.-' E L [":. f£ F'-I- F'-I = ---~'
THE LENGTH DIMENSION IS. THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUND RND THE BOTTOM OF THE E>~CR'v'RTION (IN FEET').
]'HERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRL. L PIPE
RND THE BOT'rOM OF ]"HE E,"z, CRVRTION (IN FEET).
PERMIT RF'PLII]:RNT HFIS THE F..E:,PON=,IE, ILITr TO INFORM ]"HIS DEPRRTMENT [:,URING 'THE
INSTRL. LATION INSPECTIONS OF RN'¢ WELL--, ADJACENT TO THIS r~:_rrcl~../'r FIND THE
NUMBER OF F..E--,IDEN_.E=. THRT THE WELL WILL SERVE.
-r ~--I Ca .:-" '--: ]:
Z :I ~%I_-";F'E,-_':T ][ C,f-.IS RF-':E F..'E,':-,I ! I F-.'E[.":.
'- I ...... ' '1- ' E'"r'
BFICKFILLII'.IG OF RNY S'T'STEM WITHCIUT FINRL IN:.FE_.rION RN[:, HPFR_ ~HL , THIS
[:,EPFIRTMENT WILL BE SUB.TECT TO PROSECUTION.
MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTE}I IS
tOE~ FEET FOR R PRIVRTE WELL.; OR
15E~ TO ~C40 FEET FROM B PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL..
WELL LOGS RRE REI..'..'UIRE[:, RND MUST BE RETLIRNED TO THE DEPRRTMENT WITHIN ]:0
OF ]'HE WELL COMPLETION.
OTHER RECJ. UIREMENTS MR'¢ RPPL,'¢, SPECIFICRTIONS RND CONSTRI.JCTION DIFIORRI'IS RRE
RVRILRBL. E TO INSURE PROPER INSTFILLRTION.
F EEE. tl~ ]- E:=<F' · F.:E2; [:,EC:Et'IE:EF-: _:-1. :~_9 7'='
I CERT IF'T' THR'r
1:' IRM FRMILIRR WITH THE F.:EQLIIREMENTS FOR ON-.:%ITE SEWERS RND 1.4ELLS R'_-T, SET
FORTH B'¢ THE MUNICIPRLIT'T' i]F RNCHORRGE.
~.: I WiLL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
· ',: I UNDEF..=,THN[., THRT THE oN-_,ITE SEWER SYSTEM MR'¢ REi.T.!UIRE ENLRRGEMENT IF THE
-' '- '~" i ..... Fq,"-
REz, I[EN_.E IS F.:EMCIDELE[:, TI] INCLUDE MOIRE THFtN 4 E, EDF.,jI_I'i:,.
-/½/p ' / '
RF'PE'IC:RNT [)IE:K"WF..IGN/T
I SSLIED B'¢ ............ [:,RTE_ '~ - ',/'.% k:
,~:'~%~ ~ "~ ~ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-550, Anchorage, Alaska 99502 276-222'[
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
DATE PERFORMED:
LEGAL DESCRIPTION: ~-- i ~ ~ ~ ~[ T I~1/-, (~ ST,
1
2
3
4-
5-
6-
7-
8
9
10
11
12
13
14
15
16
17-
18-
19-
20-
COMMENTS
SLOPE
SITE PLAN
I' ii
GROUND WATER
WAS
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
FT AND
DATE:
PERFORMED BY: C~ ~'-~L'}~'~
(minutes/inch)
__ FT
CERTIFIED BY-~ ~ ~'~'~
72-008 (7/76)
Yield: 12 G2N
P.O Box i0-5t6
99911
Rick Mystrom,
Mayor
Mnn c paH of Anchor e
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
http://www.ci.anchorage.ak, us
343-4744
June 8, 1998
Gary J & Donna L Russell
12941 Lupine Road
Anbhor~ge, Alaska 99516 3226
Subject: Lot 19 Block 4 Mountain Park Estates Subdivision #2
Permit #SW970121, PID #017-023-19
The subject permit, issued June 5, 1997 by this office for a
single family well and/or on-site wastewater system, has
expired as of June 5, 1998.
A new permit must be obtained from this office for a well
and/or on-site wastewater system NOT installed by the
expiration date.
If you have drilled the well, a well log must be sent to
this office for documentation of the installation and to
close the permit.
If a licensed Professional Engineer has inspected the
installation of the on-site wastewater system, the original
as-built inspection report must be sent to this office for
review, approval and documentation. Ail inspection reports
must be submitted within 30 days of construction completion.
When applying for a new permit, the fees are: $320.00 for an
on-site wastewater permit; $120.00 for a well permit and
$440.00 for a combined on-site wastewater and well permit.
If you have any questions, please call this office at 343-4744.
jm~~,ely'
J~meS~ogramCr~aSnS'ageP~E'
On-site Services
enc: Copy of Permit
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW970121
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:RUSSELL GARY J & DONNA L
OWNER ADDRESS:12941 LUPINE RD
ANCHORAGE, ALASKA 99516
DATE ISSUED: 6/05/97
EXPIRATION DATE: 6/05/98
PARCEL ID:01702319
LEGAL DESCRIPTION:
MOUNTAIN PARK ESTATES #2 BLK
4 LT 19
LOT SIZE: 20130 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS
RECEIVED BY'. ~a'~~/~
DATE:
I Ilere~y ~erilry Ih~I . ~urv~y of Lot . I~ ..... Bluuk I~_ ..................
. .~.~., ~.~ .... e ~ ~ .....................................
that tho Improvemonls situetod thereon are within the property lihes and
do eot overlap or encroeoh on tho properly lying adjacent thereto, that no
improvements on property lying adjacent thereto encroach On the premises
in question and thaL there are no roadways, tr6nsmlsslon line~ or other
visible easements on gaid properly except as Indicated I1oreon, It Is the
fesponsibiJitY ~f the ~wner to determine the existence of B~y easemenls,
ouvenants, or restrlalion~ which do not appeer on tl~e recorded subdivision
plal. Under no circumstances should any dale hereon be used for
consirucllon or lot establisl~ing boundary or fence lines.
'D.ted al A,,cborage, Alaska, this ...... 3 I ......... day oi .....~ U~.~ ......
~. ~3 .....
o6oi Buddy Wom~r Dr.
346-2000 694-909g ~
MUNICIPALITY OF ANCHORAGE
' : DE` ITMENT OF HEALTH AND HUMAN sERk
',, Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
mine DISTANCES
Ad~s~ - [ TANK FIELD WELL
Phone(s) Permit No. No. ol rooms
Lot J Bock ~ ~Subdiwsion -
Township, Range, Section ~
YZ ~' rtz ~ :~~ ~ S-BUl[TDIAG.AM(Showlocationolwell. septicsyste~.properlylmes, foundahon.
Fill added above orig,nal grade ~ ~~ ~ ~~
· otal absorpho~area ~ Distance between lines -- ~~
Numberolhne - I~,~n5 . P,pemateria ~ ..~:.
PRIVATE. ~ OTHER (Identifv) ~
Classdlcabon (A,B.C) Total Depth ET Cased to
}~7 ~ Depa~ment Approval: Date:
LEGEND
Primary monument recovered'
· Iron pipe and/or r~bar recovered
0 ~/8"z .~O~rebor se! thl~ #urvey
r
pREpARED FOR: ,rx~ tILX_~// /~-.~--,,~(d.~ P--
DRWN BY: J4.'5~c DATE: SCALE: I~ 30' ~HEETNO. of
CHCKD BY:~3C~ W.O, NO.
I hereby certify that on a¢ou~oto survey of tho
following described property-
was made on II/~/~ and that
implements sltuat~d thereon ora wIph[o tho
prop~y l[n~s and do not overlap or
on ~ property lylng~d]ac~t tho~, t~t no
improv~m~nm ~ propo~y lying adjacent
onc~a~h on tho premiss [o ~o~[on and
iod[ootod hereon.
~tod at ~cborago, AIa~a~ tht~ doy, oI
P~P~EO BY
CORWIN ~ ~OClATES
B~DG. B, SUITE II
A~CHOPAG6~ ALASKA 99~15
(907) ~4~- 4~40
Permit No.~r--~.~,-;?M~--/ Page ~-- of ~
' Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 ·Anchorage, Alaska 99519-6650 · Telephone: 343-47&4
On-Site Wastewater Disposal System and/or Welt Inspection Report
Legal Description: ~-_~i~r- ~_ ~-~ PID No.
WELL
(:4
/
?
... OF 4 t
-~.. ......
~ ~-:.' ~'..'Y~l,
S C A L E 1 "-4 O' ' ~x JAMES U. WmmT.4~ ~
._~-+' MUNICIPALITY OF ANCHOR E C O
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT, OF HEALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION..,~
{ ENVIRONMENTAL ENGINEERING DIVISION OCT 1 9 1978
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing.
PBOPE~TY ~ESI~ENT (if differen~ from 8bove) PHONE
PHONE
DRESS
3. LENDING INSTITUTION J PHONE
MAILING
· ~ALTOR~GENT PHONE
MAI LING AD ~R ESS
5. LEGAL DESCRIPTION
6. TYP~/OF RESIDENCE
(~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOM~.
[] One ~ Four
[] Two I--I Five
[] Three [] Six
[] Other
7. WATER
[~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISPOSAL SYSTEM
~INDIVI DUAL/ON-SITE~
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prio~r to that date, give well
depth (attach log if available.)
**If individual/on-site, give installation date 0,~ ~¢~ .
If system is over two (2) years old an adeq~uacy~test is required
by this Department.
72-010(3/78)
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
:' THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] iNDiviDUAL DEPTH OF wELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] I NDI VI DUAL/ON ~SITE DATE INSTALLED
[]PUBLIC UTILITY ~'~ ")8
Connection Verified INSTALLER
[]Septic Tank or []Ho~ding Tank
Size: Ic~'~:::) If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANU FACTUR E~..w~..
TOTAL ABSORPTION AREA MATERIAL ~e Sewer ]
4. DISTANCES Septic/Holdin a Line Nearest Lot Line
WELLTO:
Absorption Area to nearest Lot Line
5, COMMENTS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY
LEGAL DESCRIPTION
72-010 (Rev. 3/78)