HomeMy WebLinkAboutMOUNTAIN PARK ESTATES #2 BLK 5 LT 11MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
Municipality of Anchorage Page / of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: '~ ~ c[-~:)~.~ I PID Number: C'~/rT- O~ ~ '-
Name: -~O~ ~. ~U~~ Wastewater System: D New ~ Upgrade
Address: I~ ]~O ~[~ ~( ABSORPTION'FIELD
Phone' ' NO. of Bedsores: M~'Other
~l~ ,t ~ ~/~ ~ Deep Trench ~ Shallow Trench ~Bed ~
LEGAL DESCRIPTION so, Rating: Total ~original grade:
GPD/Sq. Ft.
Lot: Block: Subdivision: . Depth 1o pipe bottom from original grade: ~e[ depth beneath pipe
Township: /~ ~ Range: ~ ~ Section; /~' Fill added above original ~ Ft. Gravel length: Ft.
WELL: ~ New ~ Upgrade, Gravelwidth: ~ Number of lines: aistance between lines:
Ft. Ft.
Classification (Private, A,B,C): Total Dep~ ~ased To: Total ~n area: Pipe material:
~ Ft. Ft, SQ. Ft.
Driller: ~ Date Drilled: Static Water Level:Ft.~f~ler: Date installed:
yi.~M PumpSetat: Ft. Casing Height Above Grou;~: /TANK
SEPARATION DISTANCES [:.'Septic ~Holding B S.T.E.P.
Manuf c,.rer~..~ ~ Capacity in gallons:
TO Septic Absorption Lifl Holding ~ublic/Private
From Tank Field Station Tank Sewer Lines
~ Material: i Number of Compartments:
Well ~0~ -~ {0~ ~ ~d~/
Surface ~
Water ~ / o¢¢ ~ LIFT STATION
Lot .~ 5~~ ~ Size in gallons: Manufacturer:
Line ~
Foundation ~ ~ .~ ~ ~ ~ ~ "Pump on" level at: /~ff~el at: High water alarm at:
CurtainDrain ~ ~ ~ ~ ~ p~. Electrical Inspections performed by:
Remarksf~~ ¢ %UCV ~¢F,~ BENCH MARK
~_~ ~O~ ~' Location and Description:
Assumed Elevation: ~[,
Inspections performed by: ~*. ' '~¢ Dates: lst~-/~"%~ ~ L~¢~..~&~
Department of Health and Human Services approval ,,,:4~,~ ~ "¢[.~.¢:~¢~.,-
Reviewed and approved by: ,~~ ~ Date: /¢-~
72-013 (Rev. 9/91) MOA 25
Per.mit N'o. SW9.50221 Page 1 of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone:545-¥744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description T. 12 N, R. 5 W, SEC 15 SM AK. PID No: 017-02.3-55
LOT 1 1, BLOCK 5 MT. PARK ESTATES NO. 2
LOT 10
BL~ 5
LOOA~ON OF N~ ~ ~
.......... ~ LOT 11 ~
~ BLK 5
ASBUILT
LOT 1 2
~LK ,5
HOLDING TANK P~N VIEW
~. CO~1~ClO8 ~0 ~R~ ~oo' u~u. s[~to~ ~ ~ ' Car~
mOM A~OINING WELLS PRIOR TO EX~VATION ~ ~ ~ C~Z63~3
Permit No. SW950221 2. of 2
Municipality of Anchorage
DEPARTMENT OF- HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone:545-4744
On-Site Wastewa~:er Disposal System and/or Well Inspection Report
Legal Description T. 12 N, R. 3 W, SEC 15 SM AK. PlD No: 017-023-55
LOT 11, BLOCK 5 MT. PARK ESTATES NO. 2
~d 102.9
% C.O.
LOT 11
0
ASBU LT
SITE MAP
~....' '....f~
~ ..' ~ '-.~
MT 1 ~ I~ ~ .' Oarl),8. ~rJ
" , , ,?~; . . .
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW930221
DESIGN ENGINEER:ARCTIC SLOPE CONSULTING GROUP
OWNER NAME:RUSSELL JOHN C &
OWNER ADDRESS:13120 LUPINE RD
ANCHORAGE AK 99518
PAGE 1 OF
DATE ISSUED: 7/15/93
EXPIRATION DATE: 7/15/94
PARCEL ID:01702335
LEGAL DESCRIPTION: MOUNTAIN PARK ESTATES #2 BLK
5 LT 11
LOT SIZE: 19800 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
HOLDING TANK 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 343-4329 OR 343-4681 AFTER BUSINESS HOURS
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:
PERMIT IS FOR INSTALLATION OF 2,000 GALLON HOLDING TANK.
RECEIVED BY:
ISSUED
DATE:
DATE:
ENGINEERS · ARCHITECTS · SCIENTISTS · SURVEYORS
July 9, 1993
Ms. Susan Oswald
Department of Health and Human Services
825 L Street
Anchorage, AK 99501
Re: Mountain Park Estates; Lot 11, Block 5
Holding Tank Installation
Dear Ms. Oswald:
This letter is in regard to our recently completed septic system design attempt on the above
referenced lot and our determination that no on-site system can be installed on the lot meeting
MOA regulations.
The existing system has failed many times in the last four years. The system was tested by a
professional engineer and did not pass required absorption volume requirements. Perk tests
performed in the areas adjacent to the existing field and in areas on the lot that are outside of
the on-site and adjacent lot well setback radius' produced results that do not allow systems to
be installed. See previously submitted perc test results and the lot diagram.
Based on site conditions; a lot size of +20,000 SF, tight soils, seasonally high perched
groundwater table, and the location of existing wells near the lot, it is my opinion that no septic
system can be constructed meeting MOA requirements on the lot.
Yours very truly,
CD~~eering
CSM:CC: 11100026.056
301 ARCTIC SLOPE AVENUE, SUITE 200 · ANCHORAGE, ALASKA 99518-3035
(907) 349-5148 · FAX (907) 349-4213
ENGINEERS · ARCHITECTS · SCIENTISIS · SURVEYORS
June 23, 1993
Ms. Susan Oswald
Department of Health and Human Services
825 L Street
Anchorage, AK 99501
Re: Mountain Park Estates; Lot 11, Block 5
Holding Tank Installation
Dear Ms. Oswald:
On June 6, 1993 three perk tests were performed on Lot 11, Block 5 Mountain Park Estates.
Poor tight soils with clay were encountered in all areas. It is our conclusion that there is not
sufficient area with acceptable soil to install an on-site septic system. We are requesting a 2000
gallon holding tank permit at this time.
The existing system will be abandon in place.
1)
A new 2000 gallon holding tank with high water alarm will be placed where the existing
tank is.
2) A 6" riser a minimum of 12" above grade will be installed.
3) An electrical permit will be required.
V~y~ours,
pCar.ey S~-roject ~ng~E'
CSM:KL:CC: 1110-0026.056
301 ARCTIC SLOPE AVENUE, SUITE 200 · ANCHORAGE, ALASKA 99518-3035
(907) 349-5148 · FAX (907) 349 4213
·Per. r~it No. Page 1 of 1
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone:345-474~
On-Site Wastewater Disposal System end/or Well Inspection Report
Legal Description T. 12 N, R. 5 W, SEC 15 SM AK. PID No: 017 023-55
LOT 11, BLOCK 5 MT. PARK ESTATES NO. 2
LOT 10
~l 5 BLK 5
HOLDING TANK P~N VIEW
1" =50'
NOTES
1. 2000 GALLON MIN. HOLDING TANK.
WI~ HIOH WATER A~RM REQUIRED,
2. ELECTRIC~ PERMIT REQUIRED.
~. DIS~RBED AR~ SHALL BE SEEDED TO ~N~ ¢ OF ~/ ~lllI
7. ~L CONSTRUCTION SHALL CONFORM TO M.OA.
~ mU.H.S. ST*.9~ S~EC~mCAT~O~S.
SOILS LOG - PERCOLATION TV~ -~T ~
~ DAT~ PR~FORA{~D. --~-~~-'-L~-'2~
SLOPE CONSULTING GROUP, INC.
Architects · ~s · ~urVeyOrS
9-
lO-
ll-
12-
13-
14-
16-
17-
18-
$-
4-
5-
SLOPE
,I
S
WAS GROUND W~-g,~,,t,~ ~ L
I~ y'f.S, AT WHAT DP-~'~ H? -- p
Monitoring? Dam _
Re. ad~g
,2 .'/o
pLAN
_//..~/~ ,, 3~ ~ /z)/F VF :/?
~ ~ (mlau~.s/inch) PERC HOLE D~ ~ --
P~CO~ON ~ ~ ~
. ~ ~ ,~ !~' ~' -~ ~'~ ~. ~,,. '//
I ~ - ~
ALL STATE AND ~UN[C~,~ Gu~ELIN~ IN EF~ ON ~]s ~c' ~
SOILS LOG - PERCOLATION TEST
~G~ D~ON: -' '
DEPTH
4-
5-
6-
7-
9-
10-
12-
13-
].4-
16-
19-
20-
SLOPE
Reading
Dat~
Oms~ Ncr Dep~ to Net
· Tim~ 'l'uno Water Dr~p
pERcOLATION . (minutes/inch) PERC HOLE D
co~E~S - ~ ~ U ~
LIN~ 1N,~n~n~NCE ~H ALL 5TAT~ A~u · EFFE~ ON ~IS DATE. DATE: ~
S
WAS GROUND WATI~ /~ L
ENCO~? O
IF Y~r.,S, AT WHAT DEPTIt? __ p
I~pth to Water Ai~r E
Monitorln~? Da~ __
N
ARCTIC SLOPE C0NSULT[NG GROUP, INC.
Engineers · Archi[acts - Scientists · Surveyors
· SOILS LOG - PERCOLATION TEST
SLOPE
$-
9-
'2,
WAS GROUND WAT~.,~ S
ENCOU~D? ~ L
0
IF YES, AT WHAT DEPTH? p
Depth to Water kt~r E
Monitoring? Dat~
PLAN
f
N
S6-Lz
Gros~ Net Depth to Net
Reading Dat~ Time Time Water . Drop
//..~ ,., ~ ~ ~"
13-
14-
15-
17-
18-
19-
20-
' PERCOLATION lUTE /, ~,'7.~ (mlautcainch) pr=ac ~OLE
- , C.T. THAT THIS. T'T
ACCO~CE ~H ALL STATE AND MUNIC~ GU~ELIN~ IN EF c } '
' i~ 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
NAME PHONE [~NEW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION__ NO. OF BEDROOMS
Z
Well Absorption area Dwelling PERMIT NO.
/
DISTANCE TO:
~ ~ Manufacturer~¢ ~~ Material~ ~ N°' of compartments
Liq. capacity in ~allons Inside length Width Liquid depth
/~ IF HOMEMADE:
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ = DISTANCE TO: Well //~ Foundation ~ / Nearest Iot/~line -/ PER~ ~ ¢~
--~ -- ~ Length of eaAhT~ fl'ine Total length of liRes Trench~th/ Distance between~ 'lines
J ~ Z No. of lines 7~ z inches Total effectiv~t,
~ Top of ti~ ,o finish grade/ Material beneath tile
~,¢ ~ ~ ~ inches
Lenoth Width D~pth PErMiT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank ..~ Absorption area(si
OTHER (~'
PIPE MATERIALS
SOIL TEST RATING ~ ~ I
INSTALLER
REMARKS ~ ~ -'
'l
72-013 (~ev. 3/78)
KEN'S COMPANY
WATER WELL D ILLINg
PUMP SALES & SERVICE . ~..i
(907) 243-7893 - . - 3163 LINDEN DRIVI~-.
JOHNSON
~e~ ~. '. '~'~:~'- :~-'. ' -'"~:'---., "-: ':" ' ;;~:
4 ft. ~o 18 ft,: Bro~ ~ilt
18 ft. to 25 ft. Gravel & b~ s[l~ ( drills ope~.) - .
45 ft, to .60 ft. - 'Graveli& ~ay silt.,f~m .-~
74.6 ft, to 7~ ft, Weep~d. ~-12ft..overnite,',bail~ dry no reoov.
90 ft. to 94 ft, Rock Slab~ fra~t~ed } "' ., '! "-.':~ -.--.
94 ft. to 100 ft. Bm sad t t~avel (weeps) low hd.,dirty
100 ft. to 106 fit. Gravel & bm silt '-
106 ft. to t08 ft, Same,., wepps.-, low he~d,}ails
108 ft. to I14 ft, Co,se ~avel tba silt (tltt).. :' ~:; [~ ,- -
114 to 114.6 f~. S~e but weeped tn 12
114.6 to 128 ft'. ' gravel & brn silt
128 to 135 ft. S~.~e with more brn slit
135 to 155 ft. Hard pan -
165 to 179
179 to 186 ft.
186 to 194 ft.
194 to 195
195 to 21~ ftc
215 to 223 ft.
223 to 225 ft.
Med. gravel & brn silt
Clay '
Gravel & brn silt
Nard pan
Same'but weeped In 1~ ft. overnite, bails dry.
Course gravel & brn silt, weeps, low head.
Same, but dry.
H 20 came in 6~ ft. over nits .. bails dry
no recovery
Water bearing F~g .. 16 ftc hea~,l.~PM dirty
0vernite static ~ ft. Bailes dry'at 1gpm.
Glacial' till -
225 to 238 ft.
238 ft. to 239 ft.
239 ft.. to 248 ft.
2~ ft. to 252 ft. FraCtured rocE; Water_ bearlng~
.~/.~j~ Static'water level '~.~/ff (~8 ft. )
~ Test balled at 8 GP~ ~ -
Drawdo~ 6 ~* ~k~.~
ood recovery
Bottom stable
C18a~i &clear
Set 'pump a~ 252 ftc +-
PERMIT NO.
DEPRRTMENT OF' HERL_'TH FtN[:, ENVIRONMENTRL PF.'.CrTECTION
825 "'L'" STREET., F{NCHORRGE., BK. 995E~
264-47'2C~
810646 )
RPPL. IE:RNT GREG M. BFINKS 1625 F~LDER
L. OCFI'F ! ON LUPINE: ST.
L. EGRL LOT :L2L BLK 2 MT PRRK EST. ~2
LOT SIZE
279-8:L72
2.01_],':C~ SQURF.:E FEET
TYPE OF SOIL RBSORF'TION S'-r'STEM IS: TRENCH
MFIXIMUM NLIMBER OF BEDROOMS
SOIL RFITING (SQ FT,/BR)= 250
THE REQUIRED SIZE OF' THE SOIL RBSORPTION S'¢STEM IS:
[:,Em TH == :!. ~_--1_~ L E i'-,~ ~5: 'T H .... '?'5 r3 F-: F~ %-" El' L_ [:, E-] F' "F 1,-4 ==: (7
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR [:,RRINFIEL[:,.
THE DEPTH OF R TRENCH. OR PIT IS 'THE [:,ISTRNCE BETWEEN THE SURF'RCE OF ]'HE
GROUND RND THE BOTTOM OF THE E',:.::CF¢¢RTION (IN FEET).
THERE IS NO SET !.4IDTH FOR TRENCHES.
]'HE GRSVEL DEPTH IS THE MINIMUM DEPTH OF' GRF4',,,'EL BETHEEN THE OUTF'BLL PIPE
F~ND THE BOTTOM OF THE EXCR'-v'RTION (IN FEET).
PERMIT RPPLICFfN. T fIRS THE RESF'ONSIBILIT¥ TO INFORM THIS DEPRRTMENT DIJRING THE
INSTFtLLFtTION INSPECTIONS OF FIN'-? HELLS RD..TFtC:ENT '1'0 THIS PROPERT"r' RND THE
NUMBER OF RESI[:,ENCES THRT THE WELL HILL SERVE.
....... ]" ~-,._~ El ':; 2 ) I l'-~ '--=; F" E] C: T' :[ El f-,!.E; RF..':E F.L' E] C::-..~ L! Z F:E[:
BRCKFILLING OF FIN"? SYSTEM HITHOUT FINFIL INSPECTION RND FtPPROVFtL B'¥' THIS
DEPFtRTMENT HILL BE SUBJ'ECT TO PROSECUTION.
MINIMUM DISTRNCE BETHEEN R F.IELL RND RN"r' ON-SITE SENRGE DISPOSRL SYSTEM 125
18¢ FEET FOR Fl PRI'¢FITE HELL OR i5C1 TO 2ClO FEET FROM R PUBLIC HELL DEF'ENDING
UPON THE TYPE OF PUBLIC HELL
MINIMUM DISTRNCE FROM Ft PRIVFtTE HELL TO 8 PRIV.RTE SEHER LINE IS 25 FEE']' FIN[:'
TO Ft COMMLINIT"r' SEHER LINE IS 75 FEET.
HELL LOGS FIRE REQUIRED AND MUSI' BE RETURNE[:' TO ]'HE [:'EPRRTMENT HITHIN
OF :"FIE HELL COMPLETION.
OTHER REL.]UIREMENT':; MFtY RPF'L¥. SF'ECIF'ICRTIONS RND CON':;TRUCTION DIRGRFtMS RRE
RVRILRBLE TO INSLIRE F'ROPER INSTFtLLRTION.
t CERTIFY THRT
1: ! FIM FRMILIRR WITH '['HE REQUIF.:EMENTS FOR ON-SITE ?,ENERS RN[:, NELLS F~S SET
FORTH B'¢ THE MUNICIPRLIT'-? OF F4NCHORFIGE.
;-2: I HILL INSTFILL THE SYSTEM IN RCCORDRNCE ~4ITH 'THE CODES.
3: I UNDEF.'STFIND THFtT THE ON-SITE SEHER S'-?STEM MR'¢ REQUIRE ENLFIRGEMENT IF THE
RESIDENCE IS REMODELED 'TO INE:LUDE MORE THRN .7-< BEDROOMS.
V4. 0
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6-
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
, : SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
Lo. //,
SILT
ML
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SLOPE
SITE PLAN
s
L
O
P
E
Gross Net Depth to Net
Reading Date Time Time Water Drop
/~¢~ 1,2-5 70 /~
~ / ~ ;~ / ~ o '~ / ~ /
No. 2225-E
PERCOLATION RATE - (minutes/inehl
TEST RUN BETWEEN */ , FT AND ~/~ FT
PERFORMED BY:
72-008 (6/79)
DevelopmentMUMUPAUTY OF ANCHORAGE
`F -j /
Services Department �Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approva
Parcel I.D. 017-023-35
1. GENERAL INFORMATION
Expiration Date: 1-/-lT - 2-0Z /
#2 B
Park E
P
arEst �
Complete legal description MountainLL11
Location (site address) 13120 Lupine Road
Current property owner(s) Ryan & Heather Mathias Day phone
Mailing address
Real estate agent Day phone
2. TYPE OF DWELLING:
❑ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ S�So o Waiver Fee $
Date of Payment y' Z Date of Payment
Receipt Number (% qS Cl7I Receipt Number
COSA# -� 2-11 (91..q Waiver #
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, 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 time of installation.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA
COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time
of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on
the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not
guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot
provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole
benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly
recommends buyers hire their own engineer to evaluate this report.
Name of Firm Pannone Engineering Services
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R. Pannone P.E.
DSD SIGNATURE
— Y System #1 Approved for _�/_ bedrooms
System #2 Approved for bedrooms
Disapproved
Phone (907) 745-8200
Date
Conditional approval for bedrooms, with the following stipulations:
/ f /
Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate -Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: Mountain Park Estates #2 B5 L11
If more than 1 septic system on lot: COSA Checklist # 1 of 1
A. WELL DATA
0 Well log is filed with Onsite (or attached)
Date drilled 1981
Total depth 252 ft
Cased to 40+ ft
0 Sanitary seal is functioning correctly
0 Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 1/6/21
Static water level at beginning of test 161.4 ft.
Comments
B. TANK DATA
Age of tank(s) 15 years
Tank type/material Steel
Measured operating fluid level in septic tank
0 Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA Mounded Bed
Which system tested (date installed) 6/29/05
0 ALL standpipes present per record drawing
Total measured depth from grade 3.1 ft (max)
Measured depth to pipe invert from grade ft (niin)
0 N/A — pressurized field
0 Monitor tubes go to bottom of effective. If not, state
depth into effective
0 Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
Parcel ID: 017-023-35
Structure served by this system 1
Well production at time of test 2.37 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ❑✓ No
0 Coliform bacteria is Negative
Nitrate 8.42 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L 0 Arsenic less than MRL (ND)
Collected by PES
Date of Sample i812021
C. LIFT STATION
❑ Required maintenance completed
Age of lift station 15 years
Lift station material Steel
Comments:
Adequacy test date 1131202'
Results ED Pass For 4 bedrooms
Fluid depth prior to test 0 in
Water added 600 gal
New depth 0 in
Elapsed time 260 min
Final fluid depth 0 in
Absorption rate 1600 gpd
Any rejuvenation treatment (past 12 months) No
If yes, enter date
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
121
Yes
Community Sewer Manhole/Cleanout > 100'
C]✓ Yes
if No
ft
,/ Yes
if No ft
Neighboring Tank > 100' 0 Yes
if No
ft
Private Sewer/Septic Line > 25' EZI Yes
if No ft
Absorption Field on Lot > 100' M Yes
if No
ft
Holding Tank > 100' Yes
if No ft
Neighboring Absorption Fields > 100'
171 Yes if No ft
Water Main > 10'
Animal Containment > 50' Yes
if No ft
ED Yes
if No
ft
n Yes if No ft
Water Service Line > 10'
0
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway comment below
Community Sewer Main > 75' IZI Yes
if No
ft
✓0 Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
121
Yes
if No
ft
Surface Water > 100'
® Yes if No ft
Property Line > 5'✓0
Yes
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
F/
Yes
if No
ft
Private Wells > 100'
171 Yes if No ft
Water Main > 10'
171
Yes
if No
ft
Community Wells > 200'
n Yes if No ft
Water Service Line > 10'
0
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required
Building Foundation > 10'
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
❑
Yes
if No 8**
ft
Wells on Adjacent Lots:
Water Main > 10'F71
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
0
Yes
if No
ft
Community Wells > 200' ❑✓ Yes if No ft
Surface Water > 100'✓1
Yes
if No
ft
F. ENGINEER'S COMMENTS
* See Advantex Field Maintenance Report
**W R050037
G. ENGINEER'S CERTIFICATION
l certify that / have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date. r
I
COSA Checklist yellow sheet
CO9 1
Steven'R Panncnei
rF•. C� S i 4� ,•iC o
-,'*OFESS' \\ -
Pannone Engineering
-7it ieerf ngr S r;, it e ,9 LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail: steve@panensak.com
14 January 2021
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road
P. 0. Box 196650
Anchorage, Alaska 99519
Subject: Mountain Park Estates t#2 ES L11
13120 Lupine Road
Certificate of On -Site Systems Approval
Ladies and Gentlemen:
Pannone Engineering Services performed an adequacy test on 1/6/2021 for the purposes of obtaining a COSA on
the above referenced property. The well and septic system were tested and evaluated for a 3 -bedroom single
family dwelling (SFD). The Cosa was Approved on 1/14/2021 by the department for a 3 -bedroom SFD, the
homeowner would like to sell the property as a 4 -bedroom SFD. The system was retested and evaluated by
Pannone Engineering Services on 1/13/2021 as a 4 -bedroom system. The system was designed using an
application rate of 1.0 gpd/sf based on the latest edition of AMC 15.65 an application rate of 5.0 gpd/sf should be
used for a percolation rate of 11mpi as shown on the test hole no. 1 soils log.
System Design:
No. Bedrooms: 4 (600gpd)
Test Hole #1 Perc Rate: 11mpi
Application Rate Cat///: 5.0 gpd/sf
Area Required: 120sf
System Components
1500 -gallon Advantex Tank w/ax-20 pod and aux pump vault
Sys Type Bed: 15'wide x 30'Long x 0.5' Effective
Total Area: 450sf
Based on the above and data collected during both adequacy tests changing the classification of this system from
3 -bedroom to 4 -bedroom will not pose a threat to public health on this or surrounding lots. I have attached a new
COSA application and Checklist with this letter requesting a 4 -bedroom approval.
Please contact me if you have any comments or concerns.
Sincerely,
Steven R. Pannone, P.E.
Owner/Civil Engineer
Ar,chorage mailing: P.O. Box 100217, Anchorage, f;I< 995:10-0217
Palmier Mailing: P.O. pox :1807, Palmer, AK 99645
Telephone: (907) 7115-8200 FAX: (907) 745-8201
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC211014
Subdivision: Mountain Park Estates #2, Block: 5, Lot: 11
A water sample revealed a nitrate concentration of 8.42 milligrams per liter (mg/Q.
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. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. 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.
W."NICI-TAI-ITY
ATA,`,--kk,NR','E 1) NVASTMATEU
1NIFE".'NANCT, AIs)R`,J7AIRl ACRIP A-l'i-N-1- N"',
'rms Ni fA D F—f-
AG! E MENT hereon A
NOW herein lb: ARVIVEN, alul the Municipalky Of
in womanve- 'xii-i",
Aim, C 5 of the muma] the,
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Ward a: "Ity WO&JAW)
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y
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V page 3 of 3
.F^� van ® Field MaIntenance Report Anchors eTank
Annual Inspection Qn7_�79..qrA1
ProknyOwnsrAntalns 6
Previous Current
rsRyan
2nd Compartment Current
Mathias
7aarry
Betts
shaAddreaa
Conloct Phora
13120 Lupine Road, Anchorage AK 99516
(907) 240-8430
AX She ID 6
county ID a
Pod 6
RTU GUL 6
Pats of last impoctlon
AX -105755
SWO50165
205171
RTU105610
10128/2019
Retrieve O&M Into
Daily fibw
Recirc ratio_
Timor nottings:
Perform Field Sampling/Observations
NTU (15!t NTUa) pH (6-9) DO (2-6)
Odor of Sample
Typical Musty ❑ Earthy CJ Moldy
Non-typicalilfldo ❑ Cabbago ❑ Decay
Oily flim in PVU ❑ Yes A) No
Foam 1. tank Dyes o
Check Control Panel
Recirc Amps Discharge Amps
Audible and visual alarms Oto
Dial tono (telemetry only) ENS I "(;.
Inspect/Clean Pump system
Inspect Clean
Riser/Ud ................ ..
Splice Box ...................
Float Cords ................. .
Floats ........................
Pump.......................G"�',
Biotubo° Filter ...............
610tube Pump Vault ............
Recirculating spllHerVaive......
Measure Sludge/Scum
Sludge
Srt,m
1 at Compartment Current,!
Previous Current
Previous
2nd Compartment Current
Previous Current
Previous
Inspect/Clean AdvmnT'ex Filter
Odor Normal ❑ Pungent
Blomat: Neral Q Excessive
Bridging/Ponding: ones/Minor ❑ Excessive
Inspoct/Clean Discharge pump System
Inspect
Rlsar/Ltd
Splice Box Al
Float Cords
Inspect/Service Other System Components
Inspect Clean
Disinfection EquipmentM Mope
Inspect Clean
Laterala/Oriticas
Pod Bottom
Intake Vent
Inspect CI s
Floats
Pump
In poor Qlaan
real LatoraWOriflc
0hnnnre1lnnn
Additional Services Rendered
❑ Cleaned textile sheets? ❑ Replaced UV Homs?
❑ Roplacod/Usad other Items?
Farts Used: W Q Warranty, B = Billable (,% appropriate selection)
W B atom Number Description
Final/SAfety Inspection
RSV reinstalled
Mantfold reconnected; flush valves closed
SUrdntnry/R60cmntendations
❑system performing; no further action needed
Uds bolted on
ontrof pane) reactivated
❑ Think noads pumping
Fax completed form to 1-866.384®7404
GJi L7: LC1LC1 U4. 14 Qr Oni iCJ
Hr-LUJ
319
�l W MORE MINEWN 19 39YNIMEM110 ME
is BE MEMIRI®� [OEM� Nil �0 MR�mmill
n r,° Field Maintenance Repopt
Unschedule(
PloPcrty Ownar/rrArk(np 4
Ryan Mathias
alae rdd,a�,
13120 Lupine Roa , Anchorage AK 99516
AY. Sho 10 fi L`ounty IFA �-
105755 S WQ50165
Dispatcher CommEl is
Date: 07/23/2020 Time,, 12:00 AM
Please work with I ie pump crew to pump
this tank. Pori neer 5 pOWerwashing.
Notification of site t )edition
❑ Made by VoriCorty 1 Monitoring SyStOm
❑ Made by Romeow er
Xjf Other 1�74 V
Site condition at tint . of Cali
Alarm L Tank Overflow
❑ odor [ Srwage Backup
❑ Other
Field SamplingfObst rvations
Necessary E Not necessary
NTU (ts NTU51 H {fi-81
00 (2-6)
Odor of Sample,
Typical L Musty ❑ Earthy [J Moldy
Non-tyployl L sulfide ❑ Cabbago ❑ Decay
Conditions at site
Alarm On L Yo--, No
Of yes, alarm type` )
Tank Liquid Level. Normal ❑ Nigh [, Low
PUMP Operational? YO ❑ No
Ctroult Sreakcrs
Recirc........ [_ Tripped On D Off
Discharge..... tripped On ❑ Off
Controls ...... [_ Tripped VN On ❑ off
VCOMI ATRTU Board: Of I Dpllcabiel
Documont the panel status W shading the appropriate
Inputs and Outputs as Indic Red by tho yellow and red LEDs,
Inputs O 2' 0 0 a
outputs �.1 d am:, _
POtver On (- O i1� Mashing
(Green LED) - �t
9R;
Opemtor
Larry Betts
f HUG C1J
AnchcrageTank
907-272-3543
Cmt:ct Phana
(907) 240-8430
Qaia of t,nt IPFpeCiiOa
RT610 10/28/20(92Y517
Cause of Malfunction: I� McOhanicai ❑ Process-Rslated
Services Rendered:
Parts used: w = warranty, B = Billable (f appropriate selection)
1'40teSIFlnal Recommendations:
❑ System performing; no further action needed 0 Additional sorvice needed
..Final/Safety inspection:
Lids bolted on?Yee ElNo
(if ci:tmaged, comment KI
}
Control Panel reactivated? YOS ❑ No
CirCUit Breakers:
Reclrc: K] On 0 Off Discharge: aon jJ Off Controls: 74On (_f Off
Time at S1to Thavel Time Total Time: rr
05te? j (Jt7�( 1 Time
Pax completed form to 11-8156�3154-7404
_O
n
ij
V Lot 3
O
O
Q)
CD
Lot 2
Shed
Lot 10
S89'56'06"E 183.00'
Existing House
N89'56'06"W 183.00'
Lot 11
20,130 sf
Lot 12
124E 7th Avenue Survey Certification: I hereby certify that a Mortgagee's
Inspection was performed on the described property,
Anchorage, Alaska 99501 Notes: It is the owner's responsibility to determine the
(907) 306-8104 existence of any easements, covenants, or restriction
mail@S4AK.com which are not on the recorded subdivision plat. This
asbuilt shall not be used for construction or for
establishing property lines.
• Checked by: AR Scale 1" = 25' Drawn by. BH Grid SW2839
Job: 2020-97 Plat P-561 Field Book: 150 Date: 1-12-2021
121
0
0
CO
Li
in
--i-
t`0
0
O
U)
30'
30'
Ordered by.
Mathias Construction Inc.
Legal Description:
Asbuilt
y enjamin H mstrom :
O f L 708
4�� @v �i �,—11 ��s�%� ago
4011 ° essiono� \'o`er
Lot 11, Block 5
Mountain Park Estates Subdivision
No. 2
Legend:
Set Rebar with Cap U
•
Found Rebar
O
Monument
Well
Septic
Qs
Gravel
0
Wood Deck
j
.•r.
AO
0,01
°
•
i
i
Septic system Islocated 1
underS
removable deck.
Lot 10
S89'56'06"E 183.00'
Existing House
N89'56'06"W 183.00'
Lot 11
20,130 sf
Lot 12
124E 7th Avenue Survey Certification: I hereby certify that a Mortgagee's
Inspection was performed on the described property,
Anchorage, Alaska 99501 Notes: It is the owner's responsibility to determine the
(907) 306-8104 existence of any easements, covenants, or restriction
mail@S4AK.com which are not on the recorded subdivision plat. This
asbuilt shall not be used for construction or for
establishing property lines.
• Checked by: AR Scale 1" = 25' Drawn by. BH Grid SW2839
Job: 2020-97 Plat P-561 Field Book: 150 Date: 1-12-2021
121
0
0
CO
Li
in
--i-
t`0
0
O
U)
30'
30'
Ordered by.
Mathias Construction Inc.
Legal Description:
Asbuilt
y enjamin H mstrom :
O f L 708
4�� @v �i �,—11 ��s�%� ago
4011 ° essiono� \'o`er
Lot 11, Block 5
Mountain Park Estates Subdivision
No. 2
Legend:
Set Rebar with Cap U
AL. Monument
Found Rebar
O
Monument
Well
Septic
Qs
Gravel
Overhang
Wood Deck
Concrete
Fence
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Lot I I;
Block 5; Mountain Park Est~es ¢~,-
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
13120 Lupine
Real Estate Support Services Day phone
8200 Humboldt Ave. S. Suit6 204 Minneapolis~ MN
Day phone
561-2488
55431
Agent Elaine Girvan/ COLDWELL BANKER
Address 4105 Tudor Center Drive Anchoraqe, AK
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 ',,
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
Day phone 561-2488
99508
Public water
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
NOTE:
'XXX
Public sewer
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
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 further verifythat based on the information obtained from
the Municipality of Anchorage files and from my inves_ti_gation 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.
Address ................
Engineer's sl~vet' Alaska~~ Date /
6. DHHS SIGNATURE
~- Approved for ~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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.
72~25 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /-07' 1/
A. Well Data
Well type
Log present ~N) ~_.%
Total depth ~_. ~'Z__ r
Sanitary seal ~.J~)
/~/,j~ ~ /~Oc/~7'~//,J Parcel I.D.
FROM WELL LOG
Date of test
Static water level
If A, B, or C, attach ADEC letter. ADEC water system number /J//'~
Date completed r~/! 3/~/' Driller K'~'AJ~
Cased to ~'~ Casing height
Wires properly protecte~N)
AT INSPECTION
Well flow
Pump level1
/,JOT- /Avi41U~L&.r- g.p.m. ~, ~
SEPARATION DISTANCES FROM WELL TO:
-~,~c/holding tank on lot JO0 LC- -~
Absorption field on lot FJO/J~- /~/2_~-.c~/.~ ~
Public sewer main
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout ,~'O'-~
Sewer service line ~'/4--
WATER SAMPLE RESULTS:
Coliform ~//~ Nitrate
Date of sample: /(/~ ~ / ~ ~
B~HOLDING TANK DATA
Date installed ~//~/ /~
Cleanout~) yC ~
Petroleum tank
Collected by:
Tank size ~
Foundation c eanou N)
Other bacteria
Compartments
Depression (Y~)
High water alarm(~)'N)
Date of pumping
Alarm tested ~)N) y~-/C
Pumper /L)/,~
SEPARATION DISTANCES FROM 9C-I~r'~HOLDING TANK TO:
Well(s) on lot /C~ ~ ~ On adjacent lots _r~
To property line 3~ + A~sorption field
Surface water/drainage ~-C) h{-~'~ ·
)oLT'L /PSP cT/o/, L-g%,'L7
72-026 (3/93)* Front
Foundation I~~F'
Water main/service line /tO ~-
CONTINUED ON BACK PAGE
C .~-tF-.T~STATI O N
Date
Manufacturer
Size in gallons -'~ Manhole/Access (Y/N) _- -- - -
Vent (Y/N) "Pump on" I ~ '~mp~ Level at
SEPA~TMeets MOA electrical codes (Y/N) -'~'~ ~'~'-STATION TO:
Surface water
.~n lot On adjacent lots
System type
Bedrooms
D~PTION FIELD DATA JVO/.--~'~ ,/~,'L.~:"'J-E'~L.J~ --
Date inst'atie~__ __ _ Soil rating (GPD/Ft2)
~ W~dth
Length Gravel thickness ~_
Total absorption area ~ Cleanout present (Y/N) . De.~:~e'ssion over field (Y/N)
Date of adequacy test ~ Results (pass/fail) ~ for
Water level in absorption field before test ~ J After test
Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date
SEPARATION DISTANCE FROM ABSO~O: ~
TWoeiu~lndi~; foundation ~ To existi'''O'n adjacent lots ~~s tPe~
On adjacent lots ~ Cutbank Water main/service line ~
Surf~ Driveway, parking/vehicle storage area
.....Cuffain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's
Date --*-~,,~ ,,;wr, AiasJ(a ~577
HAA Fee $ ~,
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
~: ' ~ DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR I NSPECTO~ ,NSPECTOR~
DEPT.
~UNIOIPALITY OF ANCHORAGE ENVIRONMENTAL ?;;CTECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street- A,chorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION
' Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIB[6TIONS: Complete all parts on page 1.1~6omplete requests will not be ~reoessed. Please allow ten (~0) days for processing.
~. PROPEBTY OWNER PHONE
~AILIN~ ADDRESS
PROPERTY RESIDENT {If different from above) PHONE
2. BU~ PHONE
~AILING
3. LENDING INSTITUTION I PHONE
MAILING ADDRESS ~
4. REALTOR/AGENT I PHONE
MAILING ADDRESS 7 '
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE [~ SINGLE FAMILY
[] MULTIPLE FAMILY
7. WATER SU~LY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
NUMBER OF~BEDROOMS
[] One [] Four [] Other
[] Two [] Five
Three [] Six
* ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available.)
8. SEWAGE~{~SAL SYSTEM
[]~] INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(Rev. 6/79) ~j~ Cj~C~
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE E~ 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
[] INDIVIDUAL/ON -SITE DATE INSTALLED
EZ] PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line I Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
APPROVED FOR BEDROOMS
CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
72-010 (Rev. 6/79)