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Home My WebLink AboutPROSPECT HEIGHTS #1 TR A1PPo p¢ct Heights TPoct ! 5- 09 ! -49 ~ 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 NA~I 1PHONE I ~r"N EW ~ ~Z Manufacturer~ ,~_~ Materi~.-~ ~ ~ No. of com~ments Liq. Bapacitv in gallons Inside length Width Liquid depth ~ ~ ~F HOmE.gE: ~ ~ DISTANCE TO: Well h~ ~ Dwelling PERMIT NO. O Z ~ ~anufacturer~/~ Material Liquid capacitv in gallons ~ Well 'Foundation Nearest lot line Length of each lin~ Total lengt~ o~ I~s~ Trench~ Distance between Pines - Top of tile to finish grade No. of ]~nes / ~S~ ~S ~,~ ~nches Total effete a~;ption area ~__ ~/ Material beneath ti,~ inches ,S Length ~idth Depth PERMIT ~ ~ TVpe of crib Crib diameter Orib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: a Class Depth ~riller Distance to lot line PERMIT ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATJN~ /~ INSTALLER ~ REMARKS STAR ROUTE A AI~/CltORAOE~ ALASKA 99502 SlX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF 375 ~£. DRILLED AT THE RATE OF PER FOOT. WELL LOG: 33 .... 74' /~.oos~d¥ cj~.~e.,L ~.Ot.k 25oo/ c.2~..0~ .f. Ae. ~o.'u~_~..iort. ~)2~.. /lo-oioo. n-~ o./'. ose..?. COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF THANK YOU VERY MUCH. DATE BERNIE CLAUS OF RAMPART DRILLING WORKS '['-r'F:'IE OF' '."~:0 ]_' L. RE~S;Eff?.E:T :!: O1'.,! S;'.¢'.'ST[EI'I :l::S: "I'REiqCH I'"IFIX]iI'"IUFi I",!UHE:[~'IR OF BE':DRCIOHSB .... ~. '['HIE RE:(;IU l RIEl::, :S :[ Z:E OF: THE SO Z t... F:IBS;O!:;;iF'T :[ I~IN S;'¢:5TE1"t l ~.-;: THE: I..EhiGTH D I I"tEN~; ]: Olq .'[ :~; Tl...![!i: LE:.'i'-,IGTI~I ,:: I N F'[~ET :.', OI.:: TH!E TFi:E!'.,ICId (iFf: DRI:::I ).' IqF' t EL.I::,. THE I:)Et::'TH OF' F:i TF;:EN, OH OIR F'.'[T :IS; "['HE D:[!.5"I'IaI'.4C:E-: E~ETk!EF:::N THE $i;LIF:~F:'I::IC:E: Cfi: THE GRCd. JND FIIqD THE: Eu.3TTOi"I OF:' THE E?,:'::CF:t',,,'R'f' :[ CIN ,:: ]: I'-,I F'E:.E'I' ). THERE: THE GRFt'v'EL. DEPTH :[~i; THE H ZN].'P'IUI'"t [::,E:F'Tt-.I OF L~iRI::I',/EI_ E',E:THEFZN THE: OUTFVFII_L. F:'ZF:'E F:IND 'T,L~t::~ E~O'i'TCH"I OF TH[Z E;;';:C:R',,,'I"::IT Z ON ,:.' Z N F'EET ::,. i:::'E:I:RH ]: T F~F'PL.. ]: CF:II'-,iT PIRS THE RESF'ON~; ]: D :( L :[ T'?' TO ]: NF'Cff;-:.'H TH :[ 15 [:)EF:'R[;;:"I"I"I[.::I"4'[' l::,l. Jl:~: :[ I'.iIG THE :[I"'~!~;TFtLLR'I"].'Oi:',I ]:I'4?,[::'[:ECT:[C~N'Ji~; Of:' RN"r' HELL. E; I:::ID.JRC:[::-.NT TO TI"IZ:5 F::'RCIPEFi:T'¢ Ri",IE:' THE; .NUHEi=E:F~: OF' Fi:ES; .T. [)D:NC:E':~', THF:IT THE I.,.!E:I....L.. !-,.I B[::II.'i:~::~I::: .]: I...L. :[ iqG CIF: RI",I'¢ ':'.';¥?I"EH H ): THC)U'I" F:' _T. NRL. ].' !"]f.:;F:'EC"I" :[ Oiq Rt",ID F:IF:'F'Fi:O'v'F:!I... E:"r' TH:i: I:."Ii:i:I:::'F:IRTHtZNT [4 Z LL [i:EC '.:..:,LIEL:[[£C:'T 'T'O F'IRO:~!;[~C:I. JT ]: CII",t. i-'i:[I",I:[HU!"'I I_::':I~S;"f'Fti"4CE E:ETHEEt",I R HE[..L. FtI"4D F:!I",I"? OhI'"-:E;:["FE [SEI.,.IRGE: :].J2)E~ P:'E:E["[' F:'OI:;~ FI F'F~::['v'RTE: !.'~E[..L..; ::l. r5C1 TO ;[?.E~EI F'f:EET F;'ROH F:! PLIEH... :[ C: HELL. [)E[P[END]:NEJ LIF'ON THE 'F"r'F:'E OF:' PI..I[3L. ZC HE:LL.. HE[LL. [..OG~5 !:I[4:E RE:QUZF?.[CD FIND I'i1..1:5T' E',E RETI"LIRN[ED TC) THE: DE:PFff?.'['HEI"4T' I.,.II'T'HZN OF TI.-IE~ 14EL..L CCIHF'L.ETZON. O'['HE::R REQLI~F;:[ZHENT:i~; fqFl"r' RPF'L'¢. F~F'E:C::[F:]:CFrTZoN:~; l::!hl[) C:O!'.,t~;TF;'.LtCTZON [) ]: FIGF?.FIH~; F:IRE i::i¥1::IZ L.F:iE~L..E: TO ]:N~;L.IRE: PROPER Z N~5'f'FiLL. RT ZON. ]: C:[ii:IRTZ F:'tr' :L: ]: ¢:1l"1 FF!t?tZL.]:F:IFi: f4:[TH THE: F..'EQLI.T.F;:I:![HE:iqT~5 FOR CIlq--':'¢z'rE t~:~;E!.,.li!::R:~i; 1::~i'.4[::, I.,.IE'L.L:~!; FI:~!; FORTH B'¢ THE: i'"IUN :[ C: :[ F'FIL ]: T'.r' O1::' F!I'.4C:HC~F4'.FIC:iEL 2: ]; 14 .T.L.L ]: N~i~;'I"FiLI.... THE: ?¢:~:;TIEI',I :[ N FIC:C:OI~:t::,i:::iNE:E !.,.I :[ TH THE /ii:: Z I.JI"~IDE:F?.'.'?.;Ti:::iI'.,I[) "['HFIT 'f'HF~: Ol"4-'.:]!;]:'f'E; :E;EHE.:I:R ?'r'2;-f'EFI P1F:I"? [;.':[!!:(;!UZRI~E EI'.4L.F:ilRE~iEJ"IE:iqT I::::E::"~; :i;[::,Et",ICE Z :5 R;Ri"tODEL. EZ:, TCI ~ NCLIjDE i'"lOFd:i( 'I"FIF:IN 4 BEt')REuZIH% RF'F'I...:[ CFthlT I::lEilf;[:f:'!P'l ki. LO","E 1'2 ................................................................ FoP /0 ~' Was Ground Water Encountered? If Yes,' At What Depth LocaTion Sketch Resting I DaTe t ~ ac, re Gross Time Net Time Installation:' Seepage Pit z/ o Depth To H?O Drain Field Deonh Of Inlet Depth To Bottom Of Pit Or Trench Test Parfor~ B~:.~~ ' · Da~e: x WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological ~ GeophysicolSurveys Drilling Permit No, LOCATION OF WELL (Please complete either la, II) or lc.} A.D.L. No. la.llBorough Subdivision Lot Block I'~.J '/4qtrs. Secfion ,o. TownshiPN[~ Re,ge EF'~ Meridian ~OISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL: ~ · Address: Street Address and Area of Well Location ;:,]).C.~F)i';[o;:: WELL LOG Feet Below ~. WELL DEPTH: (final) 5. DATE OF COMPLETION Material Type Top Bottom ' ~ Above or ~ Below land surface Date ~ ~ ~ ~>~ II.PUMPING LEVEE below Iond surface ond YIE,D V ~llo]lO~d ~'VI~/'~o~IAH: Material: ~ Neat Cement ~ Other: ..... xtw 4~ ~[~Vd~[~[ ~ IS, PUMP: (if available) HP 15. Water Temperature ~.o ~ F ~ C ~ '~ 'Authorized Representative ~EPRRTMENT OF HERLTH RND ENVIRONMENTRL PROTECTION 825 L STREET¢ RNCHORRGE, RK 9950~ 264-4?20 t]-,[4--$ ~ T'E ~-4E;..L F"ER~"I :[ T F'ERMI T NO: [)RTE ISSUE[..,: FPLI R [."[:,RE SS: C:ONTRC. T F'HONE: LEGRL DE=,UF..I F. LOT SIZE: LO]' LOCRT I ON: ,=,404-. 4 06,..' 'I --':,." 84 BRRBRRR RINGGOL[) ~'_-000 SLRLOM RN ~:HC~RRGE., RK L~52L6 SUBDIVISION: PROSPECT HTB SECTION: · .25R (SQ. FT. OR RCRES) SLRLOM RND SCHUSS LOT: TR R-± E:LOCK: NR RRNGE: 2:H I CERTIF'¢ THRT: .1. I RM FRMILIRR WITH THE RE6,~UIREMENTS FOR ON-SITE SEWERS RND HELLS RS '_-]ET FORTH B'¢ THE MUNICIPRLIT'¢ OF RNCHORRGE (MOR) RND THE STRTE OF RLRSKR. 2. I HILL INSTRLL THE S'¢STEM IN RCCORDRNCE WITH RLL MOR CODES RND REGLILRTIONS., RND IN COMPLIRNCE WITH THE DESIGN CRITERIR OF THIS PERMIT. ~:. I HILL R[)HERE TO FILL MOR RND STRTE OF RLRSKR REQ~IREMENTS FOR THE SET BRCK DISTRNCES FROM RN'¢ ENISTING 1.4ELL., NRSTENRTER DISPOSRL SYSTEM OR PUBLIC SEWERRGE S'¢STEM ON THIS OR RN¥ RDJRCENT OR NERRB'¢ LOT. S I GNE[:, · [:,RTE: RPPLICRNT: BRRBRRR RINGGOL[¢'J Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: PROSPECT HEIGHTS #1 TRACT A1 Parcel ID: 015-091-49 A. WELL DATA Well type PRIVATF. IfA, B, or C provide PWSID # __ Date completed 5/1979 IN) & 8/1984 ($) Sanitary seal Total depth 485 IN) / 200 (S) ff. Cased to 74 / 69 FROM WELL LOG Well Log (Y/N) _Y (Y/N) Y Wires properly protected (Y/N) Y ft. Casing height (above ground) 12 & 24 in, AT INSPECTION Date of test 1979 ! 1984 Static water level 72 / 78 ft. 67N/71 S ff. Well production 1.03 Total g.p.m. 2.72 N / 0.44 S g.p.m. WATER SAMPLE RESULTS: B= Coliform NEG colonies/100mL Nitrate 6.74 N / 6.02 S Arsenic: ND .rng/I Date of sample: 10/15/2011 SEPTIC/HOLDING TANK DATA mg/L Collected by:_ ArcTerra Tank Type/Material Septic/Steel Date installed 5/24/1979 Tank size 1250 gal. Number of Compartments _2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) X Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 10/17/11 Pumper A+ C. ABSORPTION FIELD DATA Date installed 5/2~/1979 Soil rating (g.p.d./ft2 or ft2/bdrm) 85 System type TRENCH Length 45 ff. Width --3 ff. Eft. absorption area 340 ft2 Monitoring tube Y Date of adequacy test 10/18/2011 Fluid depth in absorption field before test 0 Elapsed Time: 1__ min. Final fluid depth 0 Gravel below pipe 4_~ff. Total depth 9.~7 ff. (Measured 10/18/11) Depression over field N Results (Pass/Fail) Pass For 4 bedrooms __ in. Water added 600 gal. New d. epth- ~1.. in. __ in. Absorption rate >= 600+ g.p'. :,: ,~ ' ;'" Any rejuvenation treatment (past 12 mo.) (Y/N & type) NIf yes, give date--_=- LIFT STATION Date installed "Pump on' level at Datum in. E. SEPARATION DISTANCES Size in gallons "Pump off' level at __ Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main ~5'+ Sewer/septic service line 25'+ Animal containment areas 50'+ in. Water main 10'+ Wells on adjacent lots loo'+ Manhole/Access (Y/N). High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots 3,00'+ On adjacent lots :tOO'+ Public sewer manhole/cleanout :tOO'+ Holding tank :too'+ Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water service line ~O'+ Surface water :too'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: 10(Y+ Property line :to'+ Building foundation 3,O'+ Water Service line 10'+ Surface water :tO0'+ Curtain drain 5O'+ (None Known) F. COMMENTS North well deepened to 485' in 1985 & fracted in 2005 Water main :to'+ Driveway, parking/vehicle storage. 5'+ Wells on adjacent lots :tOO'+ E.S,.EE.'S CE. F, CAT, O. I certify that I have determined through field inspections and :~~ review of Mun'.~..ip~..I records ~at the a~ve systems are confo~an~ w~ MOA COSA gui~li~s in effe~ on ~is ~te. Engineers Print~ Name KE~E~ ~. D~S ~.~~~ Date 10/31/11 COSA Fee $490.00 Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Community Development Department Development Services Division On-Site Water and Wastewatcr Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On-Site Systems Approval # 111429 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block , Lot of Prospect Heights # 1 Tract A1 subdivision. This inspection revealed a nitrate concentration of 6.74 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On- Site Systems Approval. .............. S G,S ........... SGS Ref.# 111512200 l Client Name ArcTerra Engineering and Surveying Printed Date/Time 10/26/2011 8:25 Project Name/# Prospect Hts. 1 LotA-1 Collected Date/Time 10/18/2011 12:00 Client Sample ID North Well Received Date/Time 10/18/2011 13:00 Matrix Drinking Water Technical Director Stel~hen C. Ede Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 10/18/11 10/19/11 NRB Waters De, ar tment Total Nitrate/Nitrite-N 6.74 0.100 mg/L SM204500NO3-F B (<10) 10/20/11 AYC Microbiolo~/ Laborator~ E. Coli Total Coliform Negative 1 100mL SM20 9223B A 10/18/I1 DLC Negative 1 100mL SM20 9223B A 10/18/11 DLC $ GS ............ SGS Ref.# 1115122002 Client Name ArcTerra Engineering and Surveying Printed Date/Time 10/26/2011 8:25 Pro. jectName/# Prospect Hts. 1 LotA-1 CollectedDate/Time 10/18/2011 12:30 Client Sample ID South Well Received Date/Time 10/18/2011 13:00 Matrix Drinking Water Technical Director Steohen C. Ede Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init bletals b~r ICP/blS Arsenic ND 5.00 ug/L EP200.8 C (<10) 10/18/11 10/19/11 NRB Waters Department Total Nitmte/Nitrite-N 6.02 0.100 mg/L SM204500NO3-F B (<10) 10/20/11 AYC 14icrobiolo~r Laborator~ E. Coli Total Coliform Negative 1 100mL SM20 9223B A 10/18/11 DLC Negative 1 100mL SM20 9223B A 10/18/11 DLC LOT 15 '0. TRACT TRACT A-2 >' WELL A-1 / ANCHORAGE RECORDING DISTRICT, ALASKA AS-BUILT OF: PROSPECT HEIGHTS ADDITION NO 1 TRACTA-1 PLAT 73-160 SURVEY CERTIFICATION: I, John L. Schuller, have conducted a physical survey of this property as shown on this drawing and that the improvements situated thereon are within the property lines and no enchroachments exist other that noted. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. Under no circumstance should any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. WORK ORDER NUMBER: DATE: l SCALE: IE--M^IL: iOCT 22, 2011 /1"=3o' 1 I -- 0 4.1 I°~^~ '": I°"[°~[° ~"t ~"'° "'~"~': 23. SEPTIC · VENT (typ) / WELL / / / / / / / / JO. O' / / GRAV, I~L D/W / / / JO. O' / / / / LOT / 28 FND 5/8" REBAR NOTHING FND NOTE: Basis of Bearing for this survey 'was chord bearing at ROW Slalom Drive. 1831 Talkeetna Street Anchorage, Alaska 99508 (907) 227-1455 office (907) 274-4992 fax I MUNICIPALITY oF ANCHORAGE ~ Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D.# (-%;\ ~ _(~o\\ _ t._~, o~ HAA# ~\~ ~ ~'~/-'~'~----------------~1~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Tract A-I; Prospect Heights Subdivision #I Location (address or directions) 9900 Slalom, Anchorage: Alaska (b) Property owner HcJw~.~.¢ amd S~,~a~ S;f~a~/ma~ Telephone: (home)(603} 32.9-41~uSs0iness Mailing Address (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent Address ?;¢D1 Cf .<~t~_¢¢t, q(:~(e ~00. ~n~_b_o~_age. z(a_xka 99503 Telephone 56~-5500 (e) Mail the HAA to the following address: (or check here Gl, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING/694-2979 17034 Eagle River Loop Road, Suite 204 "- Eagle River, A~aska 99577 TYPE OF RESIDENCE Single-Family [] Number of bedrooms ordered by Barbara Parker WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. SEWAGE DISPOSAL On-site I~ 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 Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functiona 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 in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address 17054 Eagle.Ritver, _.t..L°°P'qe~77Rea~t No. 204 Eagle Rtver~/'~'"'~'- - Date Telephone 6. DHHS APPROVAL Approved for ~/ bedrooms by Approved ~" Disapproved Terms Of ConditionaJ Approval Conditional 'f;1,qlt'iR The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 72-025 (Rev. 7/88)Back Page 2 of 2 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) UNiCiPALiT'~'~, EC.;KLI,$~_~ FEBRUARY 1984 ENVIRONMENTAL SERV~,..~ t);¢,~TM APR 1 2 1990 Well Classification Well Log Present~:C'~N) "-/ ?ate C~omPleted Totalue~l¢~'~ ' ' · . pth uased to~ ~Depth of Grouting Static Water Level ~ I ~ ~ ~, Casing Height Above Ground. ~ Electrical Wiring in Conduit ~N) SEPARATION DISTANCES FRoM WELL: To Septic/Holding Tank on Lot" ~.~ To Nearest Edge of Absorption Field op Lot / To Nearest Public Sewer Line /~ To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Legal Description: '"T-~ ~ ~ / If A, B, C, D.E.C. Approved (Y/N) __ 4 ¢/¢~ Yield Pump Set At 0~&~ Sanitary Seal on CasingCC~N) Comments Depression Around Wellhead (Y~ r~X To Nearest Public Sewer Cleanout/Manhole ~ '¢~ ~ ~ I~'~~ ; Date ¢3¢_~- ~ o ; On Adjoining Lots \ ~ I._,L ; On Adjoining Lots ~. ~ I'Jr- B. SEPTIC/HOLDING TANK DATA Date Installed ~-'~-~ Size \~-~'~ No. of Compartments Standpipesd~/N) '~ Air-tight Caps 4::P/N) Depression over Tank (Y/.¢~ ,, Pumping/Maintenance Contact on File (Y/Ni~//~ Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well [.~--~ To Building Foundation To Property Line "~c;> To Disposal Field To water Main/Service Line ~. ~t .~_ To Stream, Pond, Lake °r Major Drainage Course \ o,::::~I ~ Comments~' ~)'~'['" S .~i~(~ ~,~ Foundation Cleanout ¢~N) ~ Oate Last ~ ~ ~ O ~/~/ Pumped; for ' Temporary Holding Tank Permit (Y/N) /'5//5 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 Design Length of Field Depth of Field Square Feet of Absortion Area Depression over Field (Y~:~) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: Gravel Bed Thickness ~r' ~ Statndpipes Present dpi~/N) Date of Last Adequacy Test To Water-Supply Well To Building Foundation Lot To Water Main/Service Line V 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 ~ To Cutback (if present) / o..,, STA,,O. p 1A- Date I~alled _ __/'' High Water Alarm Level at-'~'"'"~ Dimensions Manhole/AcCess (Y/N) "Pump Off" Level at Vent (Y/N) Tested for ~~....~. Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ., **Check Permitted Bedroom..Ratifl)g Against HAA Reques¢* I certify that I have checked,/ve/r'ifi¢d; or conformed to all MOA and HAA CompanySigned S Date of Payment~ /~ ¢ O Waiver Fee: $ Amount: $ / ~,-~O Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~._.~~ 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order $ 20885 Date Report Printed: APR 9 90 ~ 09:04 Client Sample ID;TRACT A-1 PROSPECT NTS $I NORTH WELL PWSID :UA Collected APR $ 90 @ 12:R5 hrs, Received APR 5 90 ~ 15:30 ks. Preserved with :AS REQUIRED Client Name : S & S ENGR Client Acct: SNSENGP P.O.$ NONE RECEIVED Req $ Ordered By : R. SHAFER Analysis Completed :APR 6 90 Send Reports to: Laboratory Supervisor :STEPHEN C. EDE 1)S & S ENGR Special Instruct: Chemlab gel ~: 900764 Lab Smpl ID: I Matrix: WATER Allowable Parameter Tested Result Units Method Limits NITRATE-N 0.48 mR/1 EPA 353.2 10 Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY RJS. 1 Tests Perfo[med * See Special Instructions Above UA:Unavailable ND= None Detected ** See Sample Romar]cs Above NA= Not Analyzed LT=Less Than, GT=Greater Than CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~,~..~.,~ 5633B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE foz Work Order ~ 20885 Date Report Printed: APR 9 90 @ 09:05 Client Sample ID:TRACT A-1 PROSPECT HTS ~1 SOUTH ~LL PWSID :UA Collected APR 5 90 @ 14:40 ?~e. Receiyed APR 5 90 ~ 15;30 bxs. Preserved with :AS REQUIRED Client Name : $ & S ENGR Client Acct: SNSENGP P.O.~ NONE RECEIVED geq ~ Ordered By : R. SHAFER Analysis Completed :APR 6 90 Send Reports to: Laboratory Supe{¥/~or/:STEPHgN C. EDE 1)S & S ENGR Special Instruct: Chemlab gel ~: 900764 Lab Smpl ID: 3 Matrix: WATER Allowable PaYametsl Tested Result Units Method Limits NITRATE-N 1.9 mu/1 EPA 353.2 10 Sample ROUTINE SA~LE Remarks: SA[,~LE COLLECTED BY RJS. I ~ests Performed * See Special Instructions Above UA=Unavailable ND~ None Detected *' See Sample Remarks Above NA= Not Analyzed LT=Lees Than, GT=Gzeater Than MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) 9°,0o (b) (c) Property Owner ~;~'cL~g~/~),,_ll~i~,,/~ Telephone: Home ,5 t¢'(.o ~ Lending Institution Telephone BusineSs Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the followin~ address: or: Check here ~, if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family~ Number of Bedrooms WATER SUPPLY Individual WoII~Q Communityl-I PublicF'l 4:~~ Note: If community well system, must have written confirmation from the State Department of,Enviro, nmental Conser/vation attesting to the legality and status. SEWAGE DISPOSAL "' ~ ' ' Onsite~ Public [] Community [] Holding Tank [] ~' Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 fRev 8/86~ Front ENGINEERING FIRM PROVIDIN. INSPECTIONS, TESTS, FILE SEARCH, D~-,. A AND INFORMATION 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 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. J 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. Name of Firm ~. ~ Telephone Address / ~0 "~ ~ Approved for /~,,~5'_/,-¢.~ bedrooms by Approved ,/X'~.._ Disapproved Conditional Terms of Conditional Approval CAUTION 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. Page 2 of 2 72-025 fRev 8/86)Back MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: If A, B, C, D. EC. Approved (Y/N) Date Completed ~"~'7~ /0~'~'' ~)t/ Yield / Depth of Grouting ~ ~ ~ ~ Pump Set At ~. Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Well Classification Well Log Present (Y/N) Total Depth,-~TEt,2,OO Cased to Static Water Level /,~ ~ I Casing Height Above Ground I,~ Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/l~l~',~;~g Tank on Lot To Nearest Edge of Absorption Field To Nearest Public Sewer Line NONE Cleanout/Manhole /VO ,A/~ Water Sample Collected by ~" '~ Water Sample Test Results Comments ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on ;Date B. SEPTIC/I=I~t=t~N~ TANK DATA Date Installed ...~,,~ t/, '~ ~ Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well /,,~-~ To Property Line To Water Main/Service Line Co u rse Comments Size /,~, ~O No. of Compartments '7- ~-/~) Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) Date Last Pumped ~/-~/~ "7 /~'/"~ ;for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field "~-~ 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 ~/0 Type of System Design Length of Field Depth of Field Gravel Bed Thickness ¢ Standpipes Present (Y/N) Date of Last Adequacy Test ?'//~"/~'7 To Property Line ,,¢O ~" To Existing or Abandoned System on ; On Adjoining Lots ?/¢-~ To Water Main/Service Line ~/9 To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Cutbank (if present) A/OA/~-- D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or~onformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed /."~---"~ Date ~-¢~,~ ~//~ '~ / Company MOA No. Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) Engineer's Seat ,~-,,,203 W. 15th AVE 'C" SUITE 203 ANCHORAGE, ALASKA 99501 TELEPHONE: (907) 279-3916 SEPTIC ADEQUACY TEST LEGAL: LOCATION: OWNER: RESIDENCE: WELL: SEPTIC SYSTEM: 99 SLALOM RICHARD & BARBRA RINGGOLD SINGLE FAMILY, THREE BEDROOMS PRIVATE, ON SITE FROM MUNICIPAL RECORDS: TANK: GREER STEEL, TWO COMP. 1250 GAL. ABSORPTION SYSTEM: TRENCH ABSORPTION AREA: 360 SQ. FT. SOIL RATING: 85 INSTALLATION DATE: MAY 1979 DATE OF PUMPING: MARCH 24, 1987. ISAACS PUMPING SERVICE DATE OF TEST: MARCH 24, 1987 TEST PROCEDURE: SYSTEM WAS INSPECTED AND MEASURED. TANK WAS FOUND WITH 4.5 FEET OF COVER AND 46 INCHES OF LIQUID. SUMP WAS FOUND 9 FEET DEEP AND WITH 2.5 FEET OF VERY HEAVY SLUDGE..THIS SLUDGEWA~.PU~PED OUT AN~6~0 GALLONS O~ CI.~AN W~ W~AS ADDED TO_Q_THE SUM~CAUSED 6.5 INCHES OF WATER TO _~ MEASURED IN THE SUMP. 2.5 H~URS~ATRR~L S~ TEST RESULT: THIS SYSTEM MEETS THE CODE REQUIREMENTS OF THE MUNICIPALITY OF ANCHORAGE. The operational life of all septic systems depends on the local soil conditions, groundwater 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 septic system. We can therefore not give any estimate of how long the system will continue to meet the operational requi- rements of the Municipality and State. CONSULTING ENGINEER '"'-'"', 203 W. 15th AVE "C" SUITE 203 ANCHORAGE, ALASKA 99501 TELEPHONE: (907) 279-3916 RESIDENTIAL WELL INSPECTION LEGAL: LOCATION: 9900 SLALOM OWNER RICHARD & BARBRA RINGGOLD TYPE OF'WELL: WELL LOG AVAILABLE: INSTALLATION REQUIREMENTS MET: YES PUMP YIELD: 5 GALLONS PER MINUTE DATE OF INSPECTION: MARCH 24, 1987 TWO WELLS IN SERIES SERVING ~Q~. '~'~,'~,'-~CE YES TEST PROCEDURE: THE TWO WELLS ARE CONNECTED A~:~-:CON~ROL'LED BY FLOAT SWITCHES. WELL NO. ONE PUMPS INTO WELL NO. TWO WHICH ACTS AS A STORAGE RESERVOIR. ON/OFF LEVELS FOR WELL NO. ONE WAS FOUND TO BE 145 AND 170 FEET BELOW TOP OF CASING. TOTAL DEPTH OF WELL 200 FEET. PUMP INSTALLED 15 FEET OFF BOTTOM. WELL NO. 2 IS 375 FEET DEEP. WATER LEVEL WAS FOUND AT 138 FEET AT BEGINNING OF TEST. WELLS W~E GALLONS PER MINUTE U~'~ILL THE PUMPS SHUT OFF. 590 GALLONS WERE DRAWN~ IN I TIME PERIOD OF 2 HOURS. WELLS WERE ALLOWE~- R~RGE F 0 R ~-.~~-T.H E N.-RU ~P_E~DR-Y_A GA_I_N . ~.10 GALLONS WERE ........ ~ RECOVERED. THIS~li COMBINED PRODUCTI0~E OF .73 GPM FOR A TOTAL OF 1051.2 GALLONS PER DAY. TEST FOR COLIFORMS: WATER WAS TESTED FOR COLIFORM BACTERIA ON MARCH 21, 1987. TEST WAS NEGATIVE. TEST RESULT: THIS WELL MEETS THE REQUIREMENTS MUNICIPALITY OF ANCHORAGE; OF THE The 'Municipal requirement for well flow is 150 gallons of water per bedroom per 24 hours.This well surpasses this requirement. The assessment of the condition of this well applies only to the conditions as of this date. The flow rate of the well may change due to subsurface conditions that may not be observed from the surface, and changes in land use and other factors that may impact the conditions of the aquifer feeding the well. MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARITMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date 9-5-84 (a) Legal Description (include lot, block, subdivision, section, township, range) Tract A1 Prospect Hts. Sub. (b) Location (address or directions) 9900 Slalom, Anchoraf~q~ Alaska Applicants Name RoMo Rinf~old/Barbara Ring~elephone - Home346-3335Business 346-3335 gold Applicants Address same as above (c) Applicant is (check one) Lending Institution ~ ; Owner/buildec~ ; Buyer ~ ; Other~ (explain); (d) Lending Institution Alaska Pacific Mortgage Telephone 562-6100 (e) Address _P.O. Box 100420, Anchorog.~ka 99210-9986, c/o I,indm ~ Real Estate Co. & Agent Not Applicable Address (f) Telephone bIail the HAA to the following address: 2~ ~ype of Residenc~ Single-Family~ Number of Bedrooms 3. Water Su~! Individual Well~ 0 Multi-Family~-~ 3 Other (describe) Community ~-~ Public ~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Sewage Disposal Onsite ~, 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. [Pa~e 1 of 2] 5. _EDgineering Firm Providing. Insp____~ections, 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 this 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. 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 in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection° Name of Firm Ocean Technology, Ltd. Telephg~n~?~_~.~8~l Address 2502 W. Northern T,~ght,~ ~vd.~ Anchora?e~= Alaska g~ Approved fl( Disapproved Condition~ CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY A~I INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. F~MPLOYEES OF DHEP 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. (DHEP SE~L) RR4/ej/D18 [Page 2 of 2] 7-19-84 ,~'\,~UNIC PALITY OF ANCHORAQE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION! MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) I984 Well Classification /~J/u~ 7~ Well Log P~esent (Y/N) ~ Total Depth ~ 0 ("b Cased to Static Water ~1 ~ ~ ~ Casing ~ight ~ Gr~nd Elec~ical Wiring in ~nduit (Y~) Sep~ation Distan~s ~ ~11: To ~ptic~olding Ta~ ~ ~t If A, B, c~ C, D.E.C. App~oved(.Y/N) Date Completed ... l~dmp Set At .. ! 100 ~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot To Nearest Public Sew~ Line /L)//~ TO Nearest Public Sewer Cleancut/Manhole ~3/,~ To Nearest Sewe~ Service Line on Lot /~'~' Wate~ Sample Collected By Wate~ Sample Test Results C~t~tents B. SEPTIC/HOLDING TANK DATA Date Installed ~ ~ 'q '? ~ Size I ~2~ Z-d} ~..(, No. of Cc~a~tm~nts Standpi~s (Y~).-~"~'~'~ , Ai~-tight Caps (Y~)~ f F~ndation~51eano~) ~ession o~ Ta~ (Y~) ~te ~st P~d ; ~;, '~ p' 7 ~ - P~ing~intenan~ ~n~a~ ~ File (Y~) ~/~ ; fo~ Holding Ta~ High-Wate~ ~a~ (Y~) ~/~ Te~a~ H~ldi~ Tank ~r~t (Y~) ~p~ation Distan~s ~ ~ptic~olding Ta~: To Water-Supply Well To P~operty Line ~?~3 To Water Main/Service Line Course /~ / ~ Coat,tents To Building Foundation To Disposal Field / dj ~ To' Stream, Pond, Lake, c~ Major D~ainage [Page 1 of 2] 2-15-84 C. ABSOBi~TION FIELD DATA Soils Rating in Absorption Strata Date Installed S ~ ~ ~ -Q~ Width of Field /3 / ~ Square Feet of Absorption A~ea Depression over Field (Y/N) Results of Last Adequac!; Test ~//~D~rd~ Type of System Design Length of Field ~ S't Depth of Field ~ ! Gravel Bed Thickness ~ ~ Standpipes Present (Y/N) Date of Last Adequacy Test Separation Distance f~cm Absorption Field: To Water-Supply Well /~ ~ ~ To Property Line To Building Foundation /~3 / To Existing or Abandoned System on Lot ~3/.zl ; On Adjoining Lots To Water Main/Service Line ~ ~/ ~- To Cutbank(if present) To Stream/Pond/Lake/c~ Major D~ainage Course_ To Driveway, Parking Area, or Vehicle~Stc~age~.A~a ~.~/~. .... C°~nts,/~/~ ~-f~/~C~ ('~ ~ ~ fi/~/i~/:~' /?/~;~'~"? .?'?' LIFT S ON.~. ' Distensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Pumping Cycles du~ing Adequacy Test. Meets MOA Electrical Codes(Y/N) Conments Signed Co~/~any ~.KB1/d5/s [Page 2 Of 2] ....... / on the date of this inspection. · ~'~ Check Permitted Bedroom Rating Against HAA ReqUest. I certify that I have checked, verified, or conforrr~d tQ'~ll MOA HAA Guidalines in effect Date MOA No. 2=15-84 ,/M, P?m S & S ENGINEERING (907) 274- 9397 S610 SILVERADO WAY ~ SUITE A-7 ANCHORAGE , ALASKA ~er~by c~r~ify lh~l Ih~v~' ~urveyed th~ followin~ described properly,Lot 'e~Fc-~T HEigHT5 ~D ~[ I Anchorage Recording Precinct,Alaska ,and that dl¢clnl thltllo encroach on the premise= in queslion and thol there onsm,$aion line~ or other viaible eosemenfl on said properly except os indicoled hereon. oted thi~ ~ day of ~ , 19~ Anchorage , Alaska. ilding grade relative ,o finilhed grade and utility connection, end ,o determine ~diviMoni=tanc~ of plol.°nY ~o~.m~ntl,cov~nontl,or r~=triction= which do hal ~pp~er onthe recorded · " '- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEc/¢IL~IPALITY OF ANCHORAGE DEPT. OF H~AL~it & ' ~ 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND DIRECTION~: Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing, PHONE AAILING ADDRESS PROPERTY RESIDENT (If di{ferent from ab0~e) ' PHONE ~HONE 2. BUYER MAILING ADDRESS' J PHONE 3, LENDING INSTITUTION MAILING ADDRESS . J PHONE d_ 5. LEGAL DESCRIPTION STREET LOCATION 6, TYPE OF RESIDENCE [~'~'~ NGLE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four [] Two [] Five J~]/Three [] Six [] Other 7, WATER SUPPLY J~]'"~' i'~N DI V I DUAL* [] COMMUNITY [] PUBLIC UTILITY * 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 DISPOSAL SYSTEM []~/IN DIVI DUAL/ON-SITE** [] PUBLIC UTILITY **if individual/on-site, give installation date ~..)/;/V ~/' .. ~" /~? If system is over two (2) years old an adequacy te/st is requi~ed by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) 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 2. WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM P~M~T NUMBE~ ~ND~V~DUAL/ON-S~T~ ~? a ] ~ / ~ Connection Verified INSTALLE~ ~ ~ ~epticTanAor ~HoldingTan~ ' Size: / '~,~:- -;~ ~ If Tan~ is homemade gOIL~ RATING give dimensions: ~ ~ TYP~ OF TANN MANUFACTU~ TOTAL ABSORPTION A~EA MATERIAL 4. DISTANCES Septic/H°lding Tank IAbs°rpti°n Area ISeWer Line J Nearest Lot Line WELL TO: 5. COMMENTS ~ CONDITIONAL APR~OVAL (letter must accompany certificate) ~D~SAPP~OVED _ ~ ~i/ ~ L~GAL D~SC~IPTION 72-010 (~ev. 3/78)