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HomeMy WebLinkAboutNORTH WOODS BLK 1 LT 7 k~.~, 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 MAI LING ADDRESS LEGAL DESCR,PT,ON/O O ~ ~ Manufacturer ~ ~e~ M~/~/ Nc. of compartments ~ Liq. capacity i~allon~ Inside length ~id~h Liquid depth O~Z~ ~ ~ DISTANCE TO: Well ~.[ ~~ N-Dwelling PERMIT NO. Manufacturer / ~ /~ Material Liquid capacity in gallons ~:~ DIS;~2CE TO' ~ ~'~' *'~ ,e~o~ne* Trench w~v inches --' Nc. of / Length ~¢,li~ I Total Distance be~ ~ ~ Top of t~ to]inish grade ~erial ben~ tile If Total ef~ctive absD~tion area Length Width "Depth ~ PERMIT NO. ~ ~ Type of crib Crib diam~ Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ class Depth ~r ) Driller Distance to lot line PERMIT NO. ~ ~ DISTANCE TO: Buildio~ foubdSti~n Sewer line Septic tank Absorption area(s) OTHER REMARKS . ~ ~ ~,;~ ,.~,. ~ ';~,,:~"" (Rev. 31781 /~ PERMIT NO. DEPRR'f'MEN. T b,,/ HERL"FH FIN[:, ENVIRONMENTRL ]-~¢.'OTECTION 8;;.25 "L.'" STREET., F:!NCHOF.'.RGE., FtK. 995RJ. 264-4720 ( 8:tOSZ-':7 ) RPPL I CRNT LOCRTION LEGFIL GRE!NER CONST NOF.'.THI.,.IOODS DR. L7 B:2 NORTHb. IOODS SUB F'.O. BOX 25±., LOT SIZE 6D4-S485 21000 SQUBRE FEET TYPE OF SOIl. RBSORPTION SYSTEM IS: TF.:ENCH NUMBER OF BEDROOMS SOIL. RFITING ':12;~ FT,-'"BR)= 280 THE REQUIRED SIZE OF THE :_--;OIL RBSORPT!ON SYSTEM IS: THE LENGTH DIMEF,ISION IS THE LENGTH (IN PEET) OF' ]"HE TRENCH OR DRRINFtELD. THE DEPTH OF R TRENCH OR F'IT IS THE [:,ISTRNCE E, ETNE~N' 'F THE ~.'.qURFRCE OFr THE GROUND RN[:, THE BOTTOM OF THE EXCRYRTION ,.'.'IN FEET). THERE IS [40 SET 14IDTH FOR TRENCHES;. THE GRR'v'EL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETNEEN THE OUTF'RLL PIPE RND THE BOTTOM OF' THE EXCR',/RTION ':.'IN FEET). PERMIT RPPLICRNT F'IRS THE RESPONSIBILITY 'TO INFORM THIS DEPRRTMENT DURING 'THE INSTRLLIq. TION INSPECTIONS OF RNY NELLS R[:,JRCENT TO THIS PROPERTY .,tiN[.', THE NUMBER OF RESIDENCES 'THRT THE 1.4ELL .t4ILL SERVE. 8RCKFILLING OF RNY SYC;TEM WITHOUT FINRL INSPECTION RN[:, RF'F'RO',,,'RL B? THIS [:,EPRRTMENT WILL BE SUBJECT TO PF..'OSECUT!ON. MINIMUM [:,I~..';TRNCE BETI4EEN R WELL RND RNY ON-SITE SEP~RGE DISPOSRL SYSTEM IS ±00 FEET FOR FI PR ! ',,,'RTE !4ELL OR ±50 'TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTRNCE FROM F:I PRIVRTE .WELL TO R PRI'¢RTE SENER LINE IS 25 FEET RND TO R COMMUNITY SENER LIN. E I'5 ?5 FEET. OTHER REQUIREMENTS MRY APPLY. SPECIF!CRTIONS RND CONSTRUCTION DIF!GRFIMS RRE RYFtILRBLE TO INSURE PROPER INSTRLLRTION. F'EF..:~"I Z -f- E ;:..=; $' ]: F.: ~Z :5; [:.,EC: EI-'IE: E F-: .~: ±.. I CERTIFY THRT ±: I RM FRMILIRR .WITH THE REQUIREMENTS FOR ON-SITE SEklEF.':S Rh!D P.IELL. S RS SE]" FORTH B"r' THE MUNICIPRLI'f'Y OF RNCHORRGE. -2: I NILL I[',ISTRLL THE SYSTEM IN RCC:OR[:'RN. CE WITH THE CODES. ]:: I UN[:'ERSTRND THRT THE: ON-SITE SENER. SY"-']TEM MRY REE..'UIRE ENLRRGEMENT IF THE RESIE:'ENCE IS REMODELE[:' TO INCLUDE MORE THRN ]: BEDROOMS. '-51 G ['4 E [:' '~-~-~-. '-/~ ................... RPP[_ I CRN'F GRE I NER CONST 0 & E ENG~qEERING & DEVELOF, MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 SOIL LOG Performed for: Name: ~'7-~'~",~/L/ ~--, ,--~/~','~;-J' ~"~,A/J',77' Tel. No. . Mailing Address: Legal Description: Earl Ellis 688-2280 ~;,¢~-- ~ ~/ Depth (feet) 0 1 2__ 3__ 5__ 7__ 8__ 9__ 10__ 12__ 13__ 14__ 15 16__ Soil Characteristics PLOT PLAN PERC. TEST Ground Water Encountered: Yes__ No ~ If yes, what depth Proposed Installation: Seepage Pit__ Drain Field Comments: Performed by: r APPLI( NT FILLS OUT UPPER HAl ONLY Buyer :/.'-: -¥ , <.x: ,./ r 0 Address Zip Code Phone Lending Inslilution Realty Co. ~ A~nt ~hone Address Zip Code Type of Resi~nce ~ Sin~l~ F~iI~ ~' Mulli~l~ ~mil~ No. of Bedrooms ~ Other W~t~r 8uppl~ ~ Individual A~OH WELL LOG. ~ ~J log is required lot ~11 ~lls drilled sin~ dun~ 19T5.  Community ~ ~ 0 ~ For wells drilled prior ,o that date, give well depth (attach log if available). Public Utility  Individual Year Individual Installed: , ' Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED, Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector ' [NVIRONM2NTAL pROTeCTION RECEIVED ( ) DISAPPROVED ~ ~' U ~ ~ ~ Soils Rating Date ~wer Installed Well To Absorption Area~ ~~ Well Log Received ~ ~ 72-023 (3/82) MUNICIPALITY OF ANCHORAGE Development Services Department a Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 051-731-74 Certificate of On -Site Systems Approval Expiration Date: Legal description NORTH WOODS BLK 1 LT 7 Site address 22606 NORTHWOODS DR Chugiak AK Current property owner(s) JESSE & ELIZABETH FISCUS X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for Comments or advisories: M 9/12/2024 bedrooms, with the following stipulations: Original Certificate Date: 9/12/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 MUNICIPALITY OF ANCHORAGE o. Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application to/' 001- I. P, 14, 1. GENERAL INFORMATION Parcel I.D. 051-731-74 Complete legal description NORTH WOODS BLOCK 1, LOT 7 Location (site address) 22606 NORTHWOODS DRIVE, CHUGIAK, AK 99567 Current property owner(s) JESSE & ELIZABETH FISCUS Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ® Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ® Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 9 - See advisory if steel older than 20 years *Per MOA file — 2014 excavation. 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ® *Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ 5zp `t J3 � 0 Date of Payment 20 Z3 COSA# D�C231?�25 Waiver Fee $ Date of Payment Waiver # COSA Application.doc COSA Checklist.docx COSA Checklist Legal Description: NORTH WOODS BLOCK 1, LOT 7 Parcel ID: 051-731-74 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA - PUBLIC &/OR CLASS “A” WATER Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume NA gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank 50” Date of pumping 8/21/23 Required maintenance completed, if AWWTS Comments: FCO INSIDE HOUSE C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 9/4/1981 ALL standpipes present per record drawing Total measured depth from grade 6.7 ft (max) Measured depth to pipe invert from grade 3.4 ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes (MT) go to bottom of effective (ED). If not, state depth into effective 3.2’ / 2.3’ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced 2000 gallons 8/21/23 date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date 8/22/23 Results Pass 2014 Driven MTs – East / West Fluid depth prior to test 0 / 23 in (Missing ED + fluid Water added 1000 gal 4” / 37”) New fluid depth 1 / 28 in (Into West lateral) Elapsed time 1400 min. Final fluid depth 0 / 23 in Absorption rate 450 gpd FIELD STATUS – POST RECOVERY Effective depth (per 2014 excavation) 42 in (3.5’ MOA file) Effective depth used 4” / 37 in (Missing ED w/ final fluid depth) Effective depth remaining 38” / 5 in Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots & appears approximately 0.3’ & 1.2’ ED is missing per MOA file & 2014 excavation with new pipes that only showed 3.5’ ED. Septic field appears to be operating in the top portion of the trench on the west side. There is no deck over the septic tank as shown on the 2014 survey & the 2014 COSA had a MOA septic advisory. Original MTs at end of trench were at approximately 6” below invert sump at start and end of tests. COSA Checklist.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) - NA Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No 5’+ ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS SEPTIC TANK INSTALLED 5’+ FROM FOUNDATION PER CODE AT INSTALL. G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 8/24/23 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 8/24/23 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) h,,i ~ r-H-~ ~oo~,~ ~ cc~ ~J. L o --/- '7' CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING /$ / c',c,,L / Location (address or directions) (b) Property owner -J-Jr () il'') Mailing Address (c) Lending Institution Mailing Address ~ (d) Real Estate Company and Agent Address ~/~ · ~c Kc.,'~ ~ Telephone: (home) Telephone Business ~6~-.~.~'~ k/ Telephone (e) Mail the HAA to the following address: (or check herek¢~ if hold for pick up.) List contact person and day phone number below: . 2. TYPE OF RESIDENCE Single-Family [Z]/ Number of bedrooms 3. WATER SUPPLY Individual Well [] Community I~/ Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site Er" Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th is Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. [ further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. NameofFirm C~F-~c/l'rq ~ 76F~¢---- Telephone ...~'~_~ -- /31/ Address Date Engineer's Seal 6. DHHS APPROVAL Approved for '~ .bedrooms by Approved .x~.~, 'Disapproved Terms of Conditional Approval No. Conditional The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph S 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 DHHSdonotconduct inspections or analyze data before a certificate is issued. The MunicipalityofAnchorageisnot responsibleforerrorsoromissions in the professional engineer's work. 72-025 (Rev. 7/88) 8ack Page 2 of 2 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) OF Ahl~U~uthority Approval (HAA) SERV~q~HEG~E~ST - FEBRUARY 1984 4 1989 RECEIVED Well Clas~ion Well Log Preseht~(Y/N) Total Depth. Static Water Level To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by __ Date Completed 343-4744 Legal Description: /k, JOF"/-/qcoOocJ~s' /-_o ¢- 7 / Depth of Grouting If A, B, C, D.E.C. Approved (Y/N) 7 Yield Pump Set At Casing Height Above Ground '"-, Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (FYR/oN)M W~W~EL L Depression Ar°und Wellhead (TM) SEPARATION DISTANCES To Septic/Holding Tank on Lot - ; On Adjoining Lots ~ ; On Adjoining Lots To Nearest PubliciSt.war cleanout/Manhole Water Sample Test Results Comments'2~ .~ ¢ B. SEPTIC/HOLDING TANK DATA Date Installed ~,/~-/~/ Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) ! L) OC© No. of Compartments Air-tight Caps (Y/N) Y' Foundation Cleanout (Y/N) /~) Date Last Pumped /k..l .1/~ ;for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line .~ *~ ' '~- To Stream, Pond, Lake or Major Drainage Course To Building Foundation To Disposal Field Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Type of System Des gn _'~.~)/j/,C/~ "~ Length of Field -~1 c/, Depth of Field '-~¢¢' ~('¢~' Gravel Bed Thickness '-7,2~" -X--~'/ Statndpipes Present (Y/N) Date of Last Adequacy Test ~/-/ Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test ,.~'~-'T-/ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well --~-~C)O To Building Foundation ~ ~ Lot To Water Main/Service Line ~ To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments '~ To Property Line /() '$ To Existing or Abandoned System on ; On Adjoining Lots >~0 ~ To Cutback (if present) D.,~LIFT STATION Size in Gallons"----. "Pump On" Level at-"~"'"~. High Water Alarm Level at Tested for Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) ~ Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments **Check Perm~e/~ edroom R¢i"ng Against HAA Request** I certify that I/hav~/cqecke~lcCeSi~ie-~ or conformed to all MOA and inspection. Signed / ///~¢ ~/¢// / ~ " MOA NO. Receipt No. ~-~"/ Date of Payment Amount', $ / ~-~:)' ~) 72 026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 ~es ~n effect on the date of this Engineer's Seal ANCHORAGE/WESTERN DISTRICT OFFICE 3601 C STREET, SUITE 316 ANCHORAGE, ALASKA 99503 GOVERNOR 563-6775 DATE: March 6, 1989 PWSID: 21300~ To Whom It May Concern: According to the records on file in this office, the CHUGIAK UTILITIES/NORTHWOODS S/D is in compliance with the State of Alaska Drinking Water Regulations. Sincerely, VERA E. CRAIG Environmental ficer ~_~, D,..._ .~ RECEIVED INSPECTION APPOI NTM ENTS TIME TIME TIME/~-~\~)~' DATE DATE DATE ,NSPECTO, ,NSPEOTOR ,NSPECTOR  DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECTION DEPT. OF HEALTH & 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION ENVIRONMENTAL SANITATION DIVISION /~U0~' ~ ~9~, Telephone 264-4720 - REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~'~ DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PRO~RTY OWNER ~ .~ PHONE PROPERTY ~ESIDENT {If different fro~ abo~e) ~ ' PHONE 2. BUYER' ~ ~ ~ ' PHONE MAILING'A~R ~SS ' ~ 3. LENDING INSTITUTION PHONE 4. REAL~OR/~GENT ' ' M ' / -- ~ ' PHONE 5. LEGAL DESCRIPTION ;TREET LOCATION ~"~SI NG L E FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four Thr © [] Five ee [] Six [] Other 7. WATER SUPPLY [] INDIVIDUAL* ~'~OMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled l~rior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM ~'1~1 ¥ I DUAL/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) THIS SIDE FOR OFFICIAL USE ONLY 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 NUMBE~ E~] INDIVIDUAL/ON-SITE DATE INSTALLEDL~/~'(:~)L~-~ '7 []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 Sewer Line I Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS [~ CONDITIONAL APPROVAL (letter must accom0an¥ certificate) [] DISAPPROVED DATE BY~~