HomeMy WebLinkAboutDORA #2 LT 14Z
P~RMIT NO.
DEF'FIR]"MENT r"' ..... HEFILTH RND EN'v'IRONNENTFIL '"-"':'O"FEE:~r'ION
825 '"L STREET'., RNC:Fit'3RRGE., RK. 9E:,....,t
264-4720
>
FIPPLICRNT "F. S'T'EWFIR CONS'T.
L. OCRTtON
LEGFlL [_t4 DORFI 2
8428 WILL. IW8 CIRCLE
L(]T SIZE
20000 S(;!I...tFIRE FEET
MINIMUM DISTRNCE BETWEEN Ft WELL 8ND FINY ON-SITE SEWFIGE DISPOSFtL S'-r'STEM
t00 FEET FOR R PRIVRTE WELL OR :L50 TO 200 FEET FF.:OM R PUBLIC 1.4EL. L DEPEN[:,ING
IJPON THE TYPE OF F'UBLIC WEL. L
MINIMUM DISTFINCE FROM R F'RIVRTE WELL TO R PRI',,,'FITE SEWER LINE IN-.', 25 FEE]" RND
TO R COMMLINIT'T' SEHER LINE IS 75 FEET.
WELL LU.~=, FIRE REC.!UIF.:E[:, FINE:, M.Iz, T E,E RETURNE[, TO THE [:,EF'RRTblENT ~,.IITHIN
OF" THE WELL COMPLETION.
OTHER REQUIREMENTS MR¥ FIF'PL'¢. SPECIFICFtTIONS RND CONSTRUCTION DtRGRRMS RRE
R'v'¢~IL. RBLE TO INSURE: PROF'ER INSTFIL..LFITION.
I CERTI F~'
:.1..: I RM FRMILIRR WI'TH THE REQUIREMENTS FOR ON'-SITE SEWERS RND WELLS RS SET
V4, 0
Parcel I.D. #
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA #
j RECEIVED
JUL 08 1998
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SF. RVICF.$ DIVISION
GENERAL INFORMATION
Complete legal description
Lot 14; Dora Subdivision #2
Location (site address or directions)
Property owner
Mailing address
Jane
1 4901 S.
8530 Rosalind Street
Anchorage, AK 99516
Day phone 344-7823
~Tinsor Anchorage, AK 99516
Lending agency
Mailing address_.
Agent Alene
Address
Palmer/
Polar
Day phone
Realty Day phone 275-91 47
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well xxx
Community well
Public water
NOTE:
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
Public sewer
NOTE:
XXX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1191) Front MOA ~21
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 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 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
Engineer's signature ~
DHHS SIGNATURE
V Approved for
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: //1 ~. Date 7- /O - ¢--'/~
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.
72-025(Rev. 1/91) Back MOA~21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
A. WELL DATA
Health Authority Approval Checklist
~j ~-~T' tz::~- Parcel I.D.:
Well type ~V"'~'o If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) ~'~-'~-----~ Date comP eted ~c'/~--~8/~/
Total depth ~ ~" ~ ~ !'4''
Sanitary seal (Y/N)
Cased to
Casing height (above ground)
Wires properly protected (Y/N)
FROM W~ELL LOG
Date of test
Static water level z:3C"~ !
Well production
WATER SAMPLE RES~ILTS:
Coliform(~ Nitrate
AT INSPECTION
,
g.p.m. 4-o ,~r'~ g.p.m.
"'~1~ Other bacteria.
Collected by: ~----4 (,~=~ / LL/'c~----'f,u/~--tF'~'
El. ~K DATA
Date installed ~ Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N) Depression ~/~arm(Y/N)
Date of Pumping Pumper
N FIELD DATA
Date installe'~'--,~
Length
Effective absorption area
Soil rating (g.p.d./fF or fff/bdrm)
System type
Gravel thickness below pipe Total depth
nt (Y/ '
N) Depression over field (WN)
Date of adequacy test Results (Pass/Fail)~'"--~ For bedrooms
Fluid depth in absorption field before test (in.); Immediate~~ded
(in.):
.
Fluid depth. (ins) Minutes later: Absorption rate = -~.~.~.d.
'-,¥-:, - :~' i-- i-..!. ~- . - .-.
Peroxide treatment (past 12 months) (Y/N) If yes, give date
72-026 (Rev. 3/96)*
~anhole/Access (y/N)ate installed ~ ,,Pump off,"Size'lfi gall°ns '-'~"~ level at
High~ *Datum
Cyc~ted ~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
CES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation -~~ Property line Absorption field ...----.-~
Water main/service line ~rainage ~lots
SEPARATION DISTANCE FROM ABSOR~
~r:::c: I~1~~ ~,.~...~i,~1~ foundatio; ._~ _ _~. _W~ne
F. ENGINEER'S CERTIFICATION A ~.-.~'~_~'~'%~z//
Engineer's Name/
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
~1JL-02-1998 18:28 CT&E ESI ANCHORAGE
~ CT&i Environmental ~ervloea Ino.
9075615302 P.02/05
CT&E Ref.# 9852~5001
Client Name AK Water & wa~tewator Services
Prodect Name/# N/A
CNmt. S~ple ~ Lt ]4 D~ta 8/D ~2
Order~ B~
PWS~ 0
Sample Remarks:
Client
Printed Date/Time 07/02/98 16:15
Colletted Date/Time 06/29/98 t7:20
Received Date/Time 06/30/98 i0:45
Technknl Director: Stephen C. Erie
Para.ret ReBut
Units
Atiowabte Prep Anat¥~i~
Limits OaC~ Date Init
Total CoLiform 0
N~rete-N 0.100 U
0.100
cot/iOOmL
iMIB 9ZZZB 06/]0/98 TM~
EPA 300.0 t0 max 06/50/98 06/$0/9~ RMV
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions) '~
Applicant Name ~iK~.
Applicant Address
(b) Telephone: Home .~g5~'-$'0 '7'5Z Business ~
/
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other ~ (explain);
(d) Lending Institution
Address.
(e) Real Estate Company and Agent
Address ' CZ~/ ~. S'~
Telephone ,,.~',.~ - / 7 .~:~
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family,J~ Multi-Family []
Number of Bedrooms '~
Other
WATER SUPPLY
Individual Well~r' Community [] pUblic [] '
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite [] Public~" Community[] Holding
Tank
[]
Note: I! community 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 (11/84)
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 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 regulations in effect on
the date of this inspection.
Name of Firm ,~~'/,~,' ~fJ/'~J'"g?3E,~ ~~T'~ep~oone ~~
Address /~ ~~~ ~~ ~ ~~~ ~~ ~~
'
Date
Engineer's Seal
Approved 'L_'/ bedrooms by Date
'Approved '/ ' Disap~d~ --"~o dr~it;onal
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an 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 requirements. Employees 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.
Page 2 of 2
72-025 (11/84)
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description: 'r'l,,.~/t)
casing Height Above Ground
Electrical Wiring in Conduit ON)
Separation Distances from Well:
To Septic/Holding Tank on Lot
Well Classification ~ 0~'~... ~"~' If A, B, C, D.E.C. Approved (Y/N)
Well Log Present(~N) . Date Com_ pleted ~/'/~2~//~;~! Yield
Total Depth //,4~' ~' Cased to //~_~ ' Depth of Grout ng
Static Water Level ~,~.~,.~.t ~ Pump Set At ,~,~,~
O, ~' '~ Sanitary Seal on Casing ~N)
... Depression Around Wellhead (Y/~
~Y'~" , On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ~J~,4- ; On Adjoining Lots
To Nearest Public Sewer Line ~:;)/'f' f To Nearest Public Sewer
Cleanout/Manhole /~ ~ _~' To Nearest Sewer Service Line on Lot ~'~
Water Sample Collected by _/~/-~ ~ ~ ; Date '~',,~'/~"_
Water Sample Test Results ,.~.~'~'S --~:1~.'~_.,? ,~
B. SEPTIC/HOLDING TANK DATA "- ~>c~Jol~C ~F~,OF.j~
Date Installed Size No. of Compartments
StandPipes (Y/N) ~'~.~.Air-tight Caps (Y/N) 'Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~ Date Last Pumped
Pumping/Maintenance Contract on File (Y)~,,,~_~_~ __; for ____
Ho ding Tank High-Water Alarm (Y/N) . i~l,,,~Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well To Buildii'l~dation _
To Property Line ' To Disposal Fiel'~',,,_ .
To Water Main/Service Line To St~ke, or Major Drainage
Course
Comments )~"-~F_~ .'"*_~_~u,,~ ~
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption
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
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
__ Standpipes Present (Y/N)
Date of Last Adequacy Test
To Pro Line
; On Adjoining Lots
To Cutbank
To Existing or Abandoned System on
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
Pumping ~Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Date ~'/o~/~~'
MOA No.
Company
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 I11/84)
Engineer's Seal
ALASKA { lldIRonm lqTAL COF/TROL $ RuIC $, Irlc.
~nclin¢¢rinq $ ~nuiro~mcntclJ Studies
INDUSTRIAL IND
2121 4TH AVENUE SUITE 1500
SEATTLE WASHINGTON
98121
SELLER-MIKE JOHNSON
JULY 16 1985
INDUSTRIAL IND
2121 4TH AVENUE SUITE 1500
SEATTLE WASHINGTON
98121
50430
LEGAL:DORA #2 BLOCK 0 LOT 14
FLOW TEST ON WELL
WELL FLOW DATE-AUGUST 9 1984
A FLOW TEST WAS PERFORMED ON THE WELL. 628 GALLONS OF WATER WAS
PUMPED AT A RATE OF 5.1 GPM OVER A DURATION OF 3 HOURS.
THE DRAWDOWN WAS 76.5 ! WITH A RECOVERY TIME OF 30 MINUTES
AND THE STATIC WATER LEVEL WAS 60.85 FEET.
THE WELL IS ADEQUATE FOR THIS 4 BEDROOM HOME.
1200 U Jest 33rd Aucnu¢. Suil¢ B * J~nchora§¢. Alaska 99503.{907) ,561-5040
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMEN~ OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
i. General Information Application DateI __: :',Zji,
(a) Leg'~'~pescription ~hclu~de lot,. block, subdivision, section,/townsbip, range)
Lo~kt~p]; LaddCess or dir.ectigns)
(b) Applicants Nam.e~,L.( "~':~'L ':~ -Home
' i~' °: "l~!~ .~lephone Business
(c) Applicant is (check one) Lending Institution ~ ; O~er/builder ~ ;
~ ; Other, ~..( " / '
Buyer
..... explain); ./-i:'~' ?/::' ":'-
w Telephone
(d) Lending Instltuti~n ~ ..
Address ~
(e) Real Estate Co. & Agent ,/'i-~L',' 'i ~,.. It('Q ~
Address /:" j'.> I'":'. ' /.~ ,~.~ z ~:.' .: ~' /
'? ../: - -) ..-./., 1
Telephone /:. ( ,~
(f) Mail the HAA to the following address:
2. ~Tpe of Residence
Single-Family~
Number o~ Bedrooms
Multi,-Family ~--~
Other (describe)
3. Water Supply
Individual Well~
Community ~
Public~-~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. 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.
[Page 1 of 2]
5. .E~ineerin~ Firm Providin~ Inspections~ Testsp File Searchp D~ta 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, ordimances, and regula-
tions in effect on the date of this inspection.
Name of Firm.
Address / > / /'i' Y'°' f ~ ." i_~ _.~ ' /'t"~ />'."//(' /~ _'~ O~ 4~ ~- ~,
(~~ s~ )
DHEP Approval
Approved for
Approved ~
,/. bedrooms
Disapproved
Conditional
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SO'LELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES ~ND
THEIR ~]NDING INSTITUTIONS IN ORDER TO SATISFY C~RTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES 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 SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classification /~/D/U/.~ ~ ~, ~, ~ c, ~.~.:9. ~~~> .~/n
Static Water Leal _~, ~'~),, - ~ Set ~t .~ ~/~. /~
Casing Height Above Ground , ~ 7~, Sanitary ~ on Casing (~1)
Electrical Wiring in Conduit ~N..) Depression A~ound Wellhead _(_Y~
Separation Distances f~cm Well,' ~4///~
To Septic/Holding Tank on Lot ..
To 'Nearest Edge of Absorption Field on Lot
On Adjoining Lots ~//.~..
To Nearest Public Se~r Line ~-~F- ' To Nearest Public Sewer
Cleancut/Manhole. /tO~ '~- To Nearest Se~r ServicejLi~ on LOt ~/O'-'
Water Sample Collectedly /~, /~,~ ;Date ~/F//~F , , '
Water Sample Test Results ! ' '
Cc~ents
~ ~z. ~tl Fl~.
I
SEPTIC/HOLDING TANK DATA '-=-
Date Installed
Standpipes ..(..y ..~N)
Depression over Tank
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances f~cm Septic/Holdin¢
To Water-Supply Well
To P~operty Line
To Water Main/Service Line
Size
... Aid-tight Caps (Y/N)
(Y/~.) Date Last Pumped
, ;
Course
Comments
NO. of
Cleanout (Y/N)
Holding Tank Permit (Y/N)
Foundation
To Disposal Field
To Stream, Pond, Lake, c~ Major D~ainage
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Stzata
Date Installed
Width of Field
Squaze Feet of Absorption A~ea
Depression over Field
Results of Last Adequacy Test
Separation Distanc~ f~cm
To Watez~-Supply Well
To Building Foundation
Lot
To Water Main/Service
To Stream/Pond/Lake/c~
To D~iveway, Pa~king
Ccmmsnts
Type of System Design
of Field
Depth of Field
Gravel Bed Thickness
Standpipes P~esent (Y/N)
Date of Last A~iequacy Test
Field:
To P~operty Line
To Existing or Abandoned System cn
On Adjoining Lots
To Cutbank(if present)
D~ainage Course
Vehicle Storage A~ea
D. LIFT. STATION. ___ N//~
Date Installed D/nsiQnS
Size in Gallons /~nhole/Access (Y/N)
"Pump On" ievel at / "Pump Off" Level at .......
High Water Alarm Level at . /_ Vent (Y/N)
Tested for ~ __~m~ing Cycles du~ing Adequacy Test. M~ets MOA
Electrical Codes(Y/N) ~.~__ ~, ~ ~ , ,
** Check Pem~itted Bedz/ocm Rating Against HAA Request **
I certify that I have checked, verified, or ~onfomred to all MOA HAA Guidelines in effect
on the date of this inspection.
KB1/dS/s
[Page 2 of 2]
~ , DATE RECEIVED
INSPECTION APPOINTMENTS
DAT DATE ' ~ ' DATE ~/'~ /
INSPECTOR I NSPECTO 7 .I NSPECTOR
J ~ ,J MUNtC PAL TY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPt', OF HEA~TH & '
~ DEPARTMENT OF HEALTH &ENVIRONMENTAL PROTEGII:II~NDNM.':NTAL PROTECTION
~ Telephone 264-4720 . .
R.ECEI'VED
:REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS= Complete all parts on page 1. Incomplete requests will not be processed. P easeallow ten (10) days for processing.
1. PROPERTY OWNER _ PHONE
, 77. 57'£~a~AB ~o~u~/'/'vc?ia/0 ~. _Z',,~¢ . ~'7-~2~g ~'
MAi LI N(~ ADDRESS '
'PROPERTY RESIDENT (If different from above) ' PHONE
MAI LING AODR ESS'
3. LENDING:INSTITUTION - ~ . ~ /J ...... I' PHONE '
4. REALTOR/AGENT ... I PHONE
~/2 G~,~-~' '- 1~7~/'-
MAi LING ADDRESS
ISTREET LOCATION
16. TYPE OF RESIDENCE ' - NUMBER OF~BEDROOMS
~ One ~ Four ~ Other
~ SINGLE FAMILY ~ Two -~ Five
~ MULTIPLE FAMILY ~ Three ~ Six
~WATER SUPPLY " '
~'. INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
~ COMMUNITY since June 1975, For wells drilled prior to that date, give well
~ PUBLIC UTI LITY depth (attach log if available.) .....
8. SEWAGE ~IS~SAL SYSTEM ........
~ INDIVIDUAL/ON-SITE~ , YEAR ON-SITE 8YSTEB WAS INSTALLED.
: PUBLIC UTILITY
NOTE: THE I~SPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE I~I~IATED,
1. TYPE OF RESIDENCE
[] SINGLE F;AMI LY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTI LITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] I NDIVI DUAL/ON -SITE
F-IPUBLIC UTILITY
Connection Verified
[--]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
THIS SIDE FOR OFFICIAL USE ONLY
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SIX
[] OTHER
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
MATERIAL
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
Septic/Holding Tank IAbsorption Area [Sewer Line
Nearest Lot Line
5. COMMENTS
DATE
I~'/APPROV ED FOR Z~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
IBY ~ ~~
72-010 (Rev. 6/79)