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DELUCIA LT 6
#051-141-21 / MUNICIPALITY OF ANCHORAGE / DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I� ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME ' PHONE EW _212 F_ UPGRADE MAI L[LAG ADDRESS� C LEGAL DESCRIPTION r LOCATION /w,/ NO. OF BEDROOMS v y DISTANCE O: Well r�l/ Absorp arpra�_ / Dwelling �— �, PE IT''� O. -, 'G �� HManufactu J No, of compartments y Liq. ty-jrj_gqllons IF HOMEMADE: Inside length Width Liquid depth Z DISTANCE TO: Well I Dwelling PERMIT NO. Sz F Manufacturer Material Liquid capacity in galloris w_ DISTANCE TO: Well ( 4 — Fo dation f — Neares+-�x line L PERfV�F�.NOy. G Ci J LL No. of lines Length o ach lingo Total le th of I e Trench idth Distance t li s '— c3 ---I Inches ����� p� Top of rile to nis ra eri I be e ti e Y rl Its (7 S'/gy Total effect' e absorption area Z inches W Length Width Depth PERMIT NO. C7 Q I— as W Type of crib Ci d m er Crib depth Total effective absorption area LU DISTANCE TO: Well Building foundation Nearest lot line J Class C/7 Dh Driller Distance to lot line PERMIT NO. W 3: DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIAL 41 SOIL TEST R ING INSTALLER J REMARKS k r , (' t py A1 ° 5e i riU Cf No. 1457-E ca` D DATE LEGAL .+�.yy4i a t.;iAdC; 1 K!!7 E �y r [A:PPROV z m , a. PH. 6C0q_12'D1iU /L-ur'S mvv. s//b) M -W DRILLING, Inc. P. O. Box 4-1224 • 1310C International Airport Road (907) 274-4611 ANCHORAGE, ALASKA 99509 DRILLING LOG Well Owner Richard Sassara / Sassara Construction Location (address of: Township, Range, Section, if known; or distance main roa Lot 6 Dalucia Subdivision Size of casing__6°Depth of Hole-293—feet._Cased to -161—_ feet se of WellDomestic Static water level_ft. O (below) land surface. Finish of well (check one) open end Screen ( ); Perforated ( X ). Describe screen or perforation Perforated from 158 to 163 Well pumping test at 1/3 gallons per (1) (minute) for 1 hours with 10 of drawdown from static level. fJUNICIPALIiy 1 Date of completion- August 10, 1982 LNV!: WELL LOG Depth in feet from RJCE\/ round surface Give details of formations penetrated, size of material, col d 0 TO-- 2 Casing stickup -- ----- ----- 2 TO _ Organic material _ ---�- -�'O-- ---- Silty gravel---. —___7__TO—__3_5__ Sandy loose gravel - 3 5- - To— 3) ravel_35--_TO--3) Silty hard pan wit1i ravel—____—__ 3 9_TO—_40 Sandy gravel amn_L _-4Q_ —TO— i 3 Y-- Silty g:r'ay_ l l y hard- pan -- 130----TO--142-- Sand------- _.11�2_TO—__L60 _ Si I ty =aye1 —_ .-- Sandy urave" ).-. "ti ---___---- —16� —TO Bedrock Berl rnrl__ _ _ r -- ---TO----I'M-- �xYific'ti G'c;ilir.l;.tr3 ��3tific<tte \4,'• ,ala t;;"� ---TO— TO O TO 7000 q= nr y -OSTE� �; a X nil &I L 0 0WTW4YQ MYTER OF ?E%95�Q27�90- 7 44 1% �Eo(jm j>IKE45190 TV T&F nEW074 , I,! ME" ON T"E rojyQK Qw Dv"j"o tj�n ?�E UEPTH OF R TRENC4 04 41v jS -% OlSOPPEE IETW"E" TYE ZoFPW� 04 SOTTON &P THE WIPY"TION F" OERY. THERE TS No TET W1QTW POP TRENCHER. YKE QRRVEL DEPTH TO �"E: 011MMUN M401 GO GP%kin FE7-144n 7M %7""LL 005 THE F07TON OF TPE E�G 9 -0 T ; 04 " 7 0 WE 10; EYE fIV 115 EEZ Foo , 1 - H "1 "PP�ICQNT ASS 741 FQ �N"O"4 7WIS E&F"'nvoy cosmq OF O9PEPTY RNP MUMSEP QP RESI&ENCET TWT OR A 1 0 A 05 YOKE " 17 7 1 11v 0 1 1� OR Fw sh 54 K Gv 1-4 1: f? Q 1-1 gF py" sugTEM PITyanq F hvs� !NspEnl Law pno PFQQQa?L E 0 1 4 CEIRF"ENT HILL 6H SUBYECT 70 PROMOT10". SOILS LOG MUNICIPALITY OF ANCHORAGE �i DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ❑ PERCOLATION 825 L. Street, Anchorage, Alaska 99501 264-4720 TEST SOILS LOG - PERCOLATION TEST PERFORMED FOR: E1C'-1� (�% 1' K , S As./} DATE PERFORMED: Jid��-f I3.%ZS LEGAL DESCRIPTION: GSL4 U gEPO H SLOPE SIT PLAN PK'E:E�' +� c N 3 J 5 -- 6 7 iY A RA s `— – 9 10. WAS GROUND WATER 11 S ENCOUNTERED? L AY • 12 l) P IF YES, AT WHAT _ E 0 tDEPTH? ' 13 14 15 16 17 18 19 20 fu r; �t-••Roiert A• •�' Ko. 1437 ' Reading Date Grass Time Net Time Depth to Water Net Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN AND FT 72-008 (6/79) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. l -.l. lswal HAA # W �� ���, Expiration Date: 1. GE�t L IMH�I?MATION% pi S -� C�h. 407-6' Corete legaC'i�e„scY�ptipn _ U 1i9 Location (life, addrdtt or'direptions) _/27/3 1C. -Ne -W ehLD Curr ht Ptoperty owpe(f 5 , 6vCIY / ,%A"of #2 Day phone Mailing ddcPss;: *' / 9 7/3 /?I&S /tCL¢Q Lending agency Mailing address Real Estate Agent Mailing Address Day phone g.4i28. A L'_f7%,-. 6,4j Day phone Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 Health Authority 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. Name of Firm r�%2?ffiP/iyl /=n1G' phzw- z�; Address / 7°737 f.3'FArc f94 -A) C- f'Qe Engineer's Printed Name STEu'E CE&C S. DSD SIGNATURE ✓/ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: Original Certificate Date: 11_10_047 (Rw.01102) Municipality of Anchorage • Development Services Department,'°^° Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: 49L tJG_LC>% Parcel ID: A. WELL DATA Well type -2— If A, B, or C provide PWSID # Well Log (Y/N) Date completedottz Sanitary seal (Y!N) Wires properly protected (Y/N) Total depth j 3 ft. Cased to AS ft. Casing height (above ground) zy in. FROM WELL LOG AT INSPECTION Date of test Static water level ft. ft. Well production 0.33 g.p.m. ©. 5 ' g.p.m. WATER SAMPLE RESULTS: Coliform Q colonies/100 mi. Nitrate Zmg./1. Other bacteria d colonies/100 mi. Arsenic: .002- mg./I. V Date of sample: /0 26'19e Collected by: B. SEPTICIHOLDING TANK DATA Tank Type/Material CRC -6f .STEL Date installed J'//61aQ2 Tank size Z00a gal. Number of Compartments Z Cleanouts (Y/N) \l Foundation cleanout (Y/N) V Depression over tank (Y/N) _� High water alarm (Y/N)_ Date of pumping % d Pumper TRrs P(Jpk4J'1n(C C. ABSORPTION FIELD DATA Date installed 8/0 2 Soil rating or ftz/bdrm) 00 System type 7-R�5k1 C f Length _4,0 ft. Width 5- ft. Gravel below pipe Z ft. Total depth 7 ft. Eff, absorption are QO fe Monitoring tube _,Y_ Depression over field V Date of adequacy test /S U Results (Pass/Fail) bOXP For 3 bedrooms Fluid depth in absorption field before test _ in. Water addedy�al. r New depthLj__ in. Elapsed Timer min. Final fluid depth --7- in. Absorption rate >= 4s-0 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) 00164 If yes, give date Date installed Size in gallons Manhole/Access (Y/N) 'Pump on" level at in. "Pump off' levelat in. High water alarm�ftvr t in. Datum Cycles tested Meets alarm & cirequirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: r Septic tank/lift station on lot /AQ Absorption field on lot /00 �T Public sewer main 0, Sewer /septic service line 2.$ t On adjacent lots On adjacent lots JOL1 rr Public sewer manhole/cleanout Holding tank A0`14 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation J� Property line /Q rr Absorption field S Water main X14 Water service line d �� Surface water Wells on adjacent lots 6'12'0' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /O 'r Building foundation (Q f Water main Water Service line W �f Surface water G Driveway, parking/vehicle storage Curtain drain VA(tC Wells on adjacent lots /6a �r F. COMMENTS G. ENGINEER'S CERTIFICATION rx I certify that I have determined through field inspections and 0 00G,, review of Municipal records that the above systems are in e conformance with MOA HAA guidelines in effect on this date. �� R„" Engineer's Printed Name 5 T7 60f 45;VX Ott - Date / fi�lfdy HAA Fee $ y—:36 'T Date of Payment I I JOE;10� Receipt Number (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number ..s.�A•r6i �.... • g4evFFl W � 4 (i1�pROFE5St�Na„w Municipality of Anchorage Development Services Department °« ' Building Safety Division SA 6SA a On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Health Authority Approval # 040593 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block , Lot 6 of Delucia subdivision, the well's productivity was determined to be 0.5 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3 -bedroom residence is 0.31 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. 11 4 C4; 8!44�M; ICS ReEil 1047146001 I"t New NonhRim Engineering Project Namel# Delucia sm 46'rW :llent Sample TD Delucia SID Lo r6 datrix Drinking Water 'WS1D 0 :9C,7 SS,5SOi • 2 J All Dstesaluies are Alaska Standard Time Printed Date(Pimc 11/022004 13'47 Collected Date/Time 10/262004 10:40 Received DatelThne 10262004 10:44 Technical Director _ Stembeh. Ede Total NO2 &. NO3 analyzed by Mat -Su Test I ab of Aalaska in Palmer, Alaska era er Results PQL Units Method Container ID Allowable Prep Nidvsis Limi[s Dale Date rr it katals Department Arsenic , 0.00200 U 0.00200 m&'L EP200.9 C(<-0.01) I0i31/114 11,r01/04 JdP . , 4 f.4: 0: 44A!d: 1001 ESIS301 M p. 3 0 Kiat=su Test Lab of Alaska Water Quality Testing Mile 82 Palmer-Wasilla Hwy. Midtown Ccmmunn7 Business Park Phone: (907) 746-0005 Email: mafauteseabOronershee em.. Client: SGS Envromental 200 W. Potter Anchorage. Ak. 99518 Attn.: Forest Taylor Client ID: Drinking Mater Delude -1047148001 PWSID 0: Source: 07—AC 6,CLrCf,+ M.S.T.L.#: 20041055 Sample Matrix: Comments: 0 P.O. Box 2749 Palmer, Ak. 89945 Fax: (907) 7454018 Data Arrived: 10/28/04 Report Date: 10/28!04 Sample Date: 10128!04 Sample Time: 1040 Collected By: B Method Parameter Units Results MDL Date Preoered nate wnMviM un SM 4500-NO3-E Total NO3/NO2 mg/L Legend: MRL • Method Report Level MCL - Max. Contaminate Level 8 - Present M Method Blank E • Estimated Value H • Above MCL D - Lost to Dilution Reported By Jon Paul Campbell Lab Supervisor 1.19 0.50 10129(04 10/29/04 10.0 10-18-04 01:10PM FRCP -CUE ESI. $,,S ENV SERVICES 907505301 SGs=&E ENVIRONMENTAL SERVICES Drinking Water Analysis Report for Total Coliform Bacteria MUST BE COMPLETED BY WATER SUPPLIER Pum WAl" Sutra oa 016M E WAM MOM U _ P food 1Cu.ea two awes T-594 P.01/01 F-496 200 W. POTTER DRIIA ANCHORAGE, ALASICA 99516 Tal: ti0749SZ-2343 Fmc 907 -661 -MI .046715 0 aedns.aa ps.mmooee SAMPLE COLLECTION: SAMPLE TYPE: Iota: t� O Roagee 13 Treated Water C% I s � IFINIVI d OC AM PMere. at C3 Repeat sample ntrented Water towns �c yy2 p Lr/�^ (mlwtcte0ho. V ❑ Special Purpow . Tnropaud to tae er:Same ea collector Other. .a.. Be cOMPLETEO BY LABORATORY Romple Receiving:- Date: /C> []o.mgrw.rada.s.aN ❑ RUSHBAMPLE tpy`/ Time: / x.60 harm am be axaxaaN 1 Oelfvery Method: C- Recelved By! _5 Phow It 10wwo Fox is ,n .................................... ........................................ ................................................/............... Sant w' teriologlcal Water AnaNaie Record• . NIANNUa NAI muLTS: ANC FSK AM Trow Cauan: DI"110 r AnaNeir a n: Mahan f' aaato Carat Mt.fAeRANE FIL1SR t�c&M1TR Ptldned ❑ FaxedC AwYytlerl Metlwrh ppaC Coart CgadWtaamL towTirm. —� Illemtimne Filar vonA T MMO MUG (PIA) Satisfactory SR ❑ Un3atl8faCtOry oree.n. ( rerc •r..n.......ac.w ..---.._..... . (...iw __ OateRlme• IO �t�f'bt% 1190 w •aerY.wh ,n Jli3 Pumpin PO Box 773415 Eagle River, AK 99577 (907) 694-64541 jf110np gi@;i itlon Jennller SW196ew ._ Po Bae 671416 Chuglak. AK 69567• (907) 688.5887 I��,�,,,,-r,, !tits kTortnatlon Jamyar 10713 Ranch Road ChuOlak. AK 89567 (ems) 0884M 360.7137 Bsrvita Typo aepeC Bervks Under ak Additional Location Commarnts: Green ranch. 6'a an house. Chain Ink toning, One-Kelohe-pcoaoJmtQ may W M fance. worn bottagwerly hiendly). Amps a lot but WWI bite 4tdrm septic b the right able and visible - ground level - Urder RUOam plants Dwaram; Goone Planned: 1000 Gallons Actual: Hose Length: 4 Double Tank; 10 Pump System: �( Tsai BafflesOuNec � I eantesDucat: IJ NonTexable Total Taxable Total Tax Total Brand Total Estimated Charges. $120.00 $0.00 $0.00 $120.00 Askin Charges: Cusbmsr agrees 10 the terms and c ndillona printed On the bock. THIS IS A BINDING AGREEMENT. Brgwturs nd Ties of Customer Represenatow pea Acceptad by JRs Pumping Date Accepted For your added convenience the socept American Express/ DlCovsrolsa and Mostar Card payments over the phorw Oar 30 aye 1.6% WIN be 01MVed or THERE WILL BE A DELIVERY $46.00 For NBF CMake Relumed Received Nov -04-2004 12:04 From- To -Prudential Vista R.E Page 002 Service Agreement Number. 014400 Order Oats: 02 -Up -MU SaMw Oats: 074ep-1004 12:00 am Taehniclam Butch Job peempeam 15000 P.O. Number. Tom; Not 30 Salesrop: Mkols Job Type Repeat yap Book: Map Grid: 36 - - --' - Croas Sfrsets: Naedtee Looe_ -- - —Job t.arrxrrenle: ILut BaN Og/0Wi 16005 I -Go Over Isnw 1v/ how - pocked and pumped lank - lavals normal Tau Percent: 0 Ory F"or lath a a Men Tax Extension Actual 1 $120.00 No NO 3120.00 Green ranch. 6'a an house. Chain Ink toning, One-Kelohe-pcoaoJmtQ may W M fance. worn bottagwerly hiendly). Amps a lot but WWI bite 4tdrm septic b the right able and visible - ground level - Urder RUOam plants Dwaram; Goone Planned: 1000 Gallons Actual: Hose Length: 4 Double Tank; 10 Pump System: �( Tsai BafflesOuNec � I eantesDucat: IJ NonTexable Total Taxable Total Tax Total Brand Total Estimated Charges. $120.00 $0.00 $0.00 $120.00 Askin Charges: Cusbmsr agrees 10 the terms and c ndillona printed On the bock. THIS IS A BINDING AGREEMENT. Brgwturs nd Ties of Customer Represenatow pea Acceptad by JRs Pumping Date Accepted For your added convenience the socept American Express/ DlCovsrolsa and Mostar Card payments over the phorw Oar 30 aye 1.6% WIN be 01MVed or THERE WILL BE A DELIVERY $46.00 For NBF CMake Relumed Received Nov -04-2004 12:04 From- To -Prudential Vista R.E Page 002 -I N99 O's 9'w it7v•O' -- ,00wfv..a�.c r i • y.Y 2� i ..a 0 � Iw q • Q D� 0 - �r�N K "'VlNf .oiif"t f 0 i �I m o s-9 �1r✓ /00.0 max, §-- F� A 10 s r .'A . iYE. EDL ES _.. la?11/E ' EASEMENTS OF -RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT ARE NOT SHOWN. The information hereon is for the use of lending institutions shoving the relationship of existing structures and platted easements and lot•.1ines.. It isnot to be used for positioning additional structures or fe6celines. p/ys RECERT: 7-21-89 4/ ,S•-09 ••.� Dasm M&Fk Av s LS • 691 e RECERTIFIED 7-21-89 AB•BU•ILT'No oorriei'd e.bt •this, ate I hereby certify that 1 have performed a Morlasee's speetion of the follbwln` described property: Delucia Subd., Lot 6 Anchorite Racordins ProclnoL Alaska, and that the Imprt ments situated thereon are within the proppearty lines and not overlap or encroach on the property lyin` adjacent Ur to, tfiat no im rovementa on propeM lying adjacent the] encroach on the prein sex in question and that them are roadways, transmission lines or other visible easements paidproperty except a Indicated hereon. Detod at Aneborega, Alaska this ' 5 'd...? April 1089 688-4566 - NUNICIPALITY OF ANCHORAGE Ail • DFPARTMENT OF HEALTH & HUMAN SERVICES Diviaion of Environmental Servicesffil On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERT' APPR:.' Parcel I.D. # 1. GENERAL INFORMATION Complete legal description TE OF Hr-."d,Tl' AUTHC'RITY ''L`i I EILINC HAA#Ihd �2_0Z�� Location (site address or directions) Property owner-Qi6Y.4.✓v i�cio/ '`"�'�.v Day phone Mailing address ?0• 'do'r y Lending agency Day phone Mailing address Agent Day phone A rlri race Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: `� L/ 3. Tf 4 347, °r . . Individual well ✓ MAY 12 1997 Community well Municipality of Anchorage Dept. Health & Human Services Public water NOTE: If community well system, provide written confirmation from Stale ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-M(Rev.1/91) Front MOAM21 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 T 1t��,cJe.j5'y Address Engineer's signature 6. DHHS SIGNATURE __X_ Approved for !F(7)bedrooms. By: Disapproved. Phone (Q07, 7ya -/07,� Date —S -7-i Conditional approval for bedrooms, with the following stipulations: This certificate of Health Authority Approval is based on water storage capacity only. The well serving this property does not meet the minimum required well production. Additional Comments 7717 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 ANCI FICRAGE Municipality of Anchorage EWIRONMENTALSERVICES D DEPARTMENT OF HEALTH & HUMAN SERVICES MAY 12 199 Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 34RE.M o Y 1_ / C D Health Authority Approval Checklist Legal Description: < r F Parcel 1. D.: A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed '' Vh- Total depth '2e 3":�� Cased to /6 5 / i Casing height (above ground) Sanitary seal (Y/N) Date of test Static water level FROM WELL LOG zLe Well production WATER SAMPLE RESULTS: Coliform e7_ Nitrate g.p.m Wires properly protected (Y/N) _ AT INSPECTION ,Zc,U - , I- �/. L' �/"'o . Other bacteria '24" Date of sample: .,',"� 'Z� /V�/- 7 Collected by: 'r �' `'1 9, B. SEPTIC/HOLDING TANK DATA Date installed -47//V6' `' Tank size Number of Compartments Cleanouts (Y/N)Y Foundation cleanout (Y/N) A' Depression (Y/N) A-" High water alarm (Y/N) Date of Pumping `'1?7 Pumper C. ABSORPTION FIELD DATA Date installed � � Soil rating (g.p.d./ft2 or W/bdrm) �� a �" System type Length —Width f i Gravel thickness below pipe / 5 Total depth �{ Effective absorption area =f -L Monitoring Tube present (Y/N) Y Depression over field (Y/N) . Date of adequacy test 'A7 7 Results (Pass/Fail) , ": _" -,'ss For bedrooms Fluid depth in absorption field before test (in.); Immediately aftery��gal. water added (in.): 4"51 c -vs Fluid depth (ins) Minutes later: Absorption rate = _/ & g.p.d. Peroxide treatment (past 12 months) (Y/N) 't'! If yes, give date — 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) Size in gallons "Pump on" leve] at* High water alarm level at*Datum Cy ested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: * sG Septic/holding tank on lot Absorption field on lot Public sewer main Sewer /septic service line _°'P-um}��off" level at* RECEIVED MAY 12 1997 MUnicipality of Anchorage Dept. Health & Human Services On adjacent lots On adjacent lots i c�7 111�/- i Public sewer manhole/cleanout Lift station '`J1111 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation IV F/- Property line 71,- Absorption field Water main/service line Z� f'�7/-Surface water/drainage " Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water /t/o .cJ,,� Building foundation Curtain drain nJc' moi= �"�� �''�� ��' `--X `-5 r-- F. = F. ENGINEER'S CERTIFICATION Ff- /Z.114 - Water main/service line Z.2- Driveway, Z.2- Driveway, parking/vehicle storage area Y Wells on adjacent lots I certify that I have determined thru field inspections and review of Municipal reciti&WabbW systems are in conformance with MOA HAA guidelines in effect on this date. v , r Signature l -�.� L C %c �. ( r Engineer's Name �l_JC G- F> ��z 44..� Date HAA Fee $ 7� 60 CjU Date of Payment Z-/ 7 ,/ Receipt Number z1 4 . T ) / 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number Douglas T. Kenley, PE 9960 E. Puffin Drive, Palmer, Alaska 99645 (907) 746-1073 May 7, 1997 Mr. James Cross Municipality of Anchorage Health & Human Services On-site Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Re: Well and septic adequacy test on Lot 6, Delucia Subdivision. 19713 Ranch Road, Chugiak, Alaska 99567 Owner: Mr. Harvey Finch Dear Mr. Cross: RECEIVED MAY 12 1997 Municipality of Anchorage DePt. Health & Human Services An adequacy test was performed on the well and septic system on the above-described property by Fred Kenley on April 26, 1997. The absorption system performed adequately for a three-bedroom home; however, the well had a static water level of 202.6 feet. The total depth of the well from the well log is 203 feet. During the test, water was pumped from the 1500 gallon water storage tank that had been installed in 1989 at approximately 3 gallons per minute. After pumping 602 gallons, the water stopped flowing. The water level in the water storage tank was measured at 3-1\2 inches. The timer turned the system back on, at which time the well was able to pump water into the tank. The test was then discontinued as no water could be drawn from the system while the well was pumping water into the water storage tank. The water level in the water storage tank was measured at 6 inches on the 28th of April. The owner said that they had been using water sparingly. The well is evidently not producing even at the one-third gallon per minute rate. The owner said that they have had water hauled in twice in the eight years that they have owned the house. When the well and septic system were installed in 1982, the static water level of the well was 148 feet. The well flow was recorded at one-third of a gallon. S&S Engineering performed an adequacy test on the well in 1989, at which time the static water level was recorded at 168 feet. The well flow was then recorded as one-third of a gallon also. Your office had only one reference to the water storage tank, with no reference to permits or as- builts available. Since April 26, Fred Kenley has checked with your office again to make sure that there were no files missing from your hard copies. To date, research indicates that it was a HUD home and HUD requested that the 1500 gallon water storage tank be installed in 1989 by Tweed Excavation. S&S Engineering has advised that they did not do any engineering work on the tank installation and further that engineering was not required at that time by the municipality. RECEIVED MAY 12 1997 Municipality of Anchor ge The water storage tank is located directly behind the dwelling at a disa ���i iutal}6¢�,ices feet from the septic tank and 50 feet from the absorption field. Your office was notified of a letter written to the Federal Housing Authority, submitted by S&S Engineering, requesting a waiver of the three gallon per minute requirement. Your office supposedly received a report of the adequacy test performed by S&S Engineering for the Health Authority's approval in 1989, with the comment that a 1500 gallon water storage tank had been installed underground at the back of the house. Sincerely, Douglas T. Kenley, PE CE #8176 - ......._. - . — . k—li. i-+-ovoo rax; (,9U/) 474-9685 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN. MISS011RI Now icocev nut^ ,. ------------------------------------------------------------------------------------------------------ MAY-02-1997 13:22 CT&E ESI ANCHORAGE 907 561 5301 P.02/03 ,,�1 IL CT&E Environmental Services Inc. C'1&E Ref.# Client Name Project Name/# Client Sample TD Matrix Ordered By PWSYD 9721.30001 Douglas Keriley P.E. Lot 6 Delucia Water Drinking Water Client PO# Printed Date/Time 05/02/97 09:44 Collected Date/'T'ime 04/28/97 14:1.5 Received Date/Thine 04/29/97 15:50 Technical Direetor: Stephen C. Ede Released By - 0.wxxp1C ICCIIIdrK$; Sample collocted by: i~rcd Kenley CT&E Microbiology Drinking Water Progfarn certification status is provisional as of 4/3/97. Parameter Nitrate•N Total Coliform Cf Allowable Prep Anatysis Results PQL Units Method Limits Date Date Init 0.100 U 0.100 mg/L SM18 4500•NO3F 10 max 04/10/97 JBL 0 Col/100mL SM18 92228 04/30/97 RAM r x`99 y� �Ur nm 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 SINGLEFAMILYDWELLING Parcel I.D. # n�` - 1 LI 1-"a 1 HAA # k1 QS�� C-) c Rd 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner f'I�il'� .to Telephone: (home) Mailing Address (c) Lending Institution Mailing Address A R 1 E t t Com an and A ent Telephone I Business ( ) ea sae p y g Address Telephone (e) Mail the HAA to the following address: (or check here:*6if hold for pick up.) List contact person and day phone number below: 17034 Eagle River Loop Road No. 204 age River, Alaska 9957 2. TYPE OF RESIDENCE Single -Family Number of bedrooms 3. 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 th legality and status. 4. SEWAGE DISPOSAL On-site` Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7;88) Page 1 of 2 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 S & 5 ENGINEERING Telephone9 17034 Eagle River Loop Road No. 204 Address r Alaskz 99577 Date 6. DHHS APPROVAL Approved for �3 bedrooms by _-�— rLZ"L�'� Date Approved _Z Disapproved Conditional Terms of Conditional Approval CAUTION 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) 6aCk Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) *ALI, y OF IOW#Mhority Approval (HAA) �i,lLvtkM�ibyl3 - FEBRUARY 1984 343-4744 2 s; 1989 Legal Description: A. WELL DATA RECEIVrr"' Well Classification If A, B, C, D.E.C. Approved (Y/N) Well Log Present (VN) _ Date Completed �2 Yield �Q Total Depth2-C'_2;' Cased to k12Depth of Grouting Static Water Level xt � Pump Set At " ti Casing Height Above Ground \-Z-a" Sanitary Seal on Casing4DN) Electrical Wiring in Conduit&/N) Depression Around Wellhead (YOP r-1 SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot � ��l ; On Adjoining Lots l A - To Nearest Edge of Absorption Field o Lot 1. )A- ; On Adjoining Lots To Nearest Public Sewer Line r-% � To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by Date 7— 25 Water Sample Test Results�����-`-rtes Comments B. SEPTIC/HOLDING TANK DATA Datp Installed �b-tc -ize X G�L-� No. of Compartments Standpipes(LDN) Air -tight Caps(�PN) y Foundatif%Z. leanout(�jNY Depression over Tank (Y/6 D to Last Pumped' ' Pumping/Maintenance Contact on File (Y/N) ; for AL f4 c . Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) = `� k SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: 1 To Water -Supply Well COI fir- To Building Foundation To Property Line ►�. To Disposal Field \'Z �-1 /;l�( To Water Main/Service Line I + 1 To Stream, Pond, Lake or Major Drainage Course 1. ` Comments S� r5 � �� Mei a � �� Via✓ 72-026 (Rev. (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 1 c��;-��- Type of System Design `���nex� Date Installed 0 — Length of Field moi �► Width of Field ��' Depth of Field ravel Bed Thickness Square Feet of Absortion Area �Je;q� `` '� Statndpipes Present (VN) Depression over Field (Y/� r:- Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: 1 To Water -Supply Well `�-�,�" To Property Line 2-n To Building Foundation To Existing or Abandoned System on Lot `� ; On Adjoining Lots a" To Water Main/Service Line �� t'� To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course t 1� To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Dat Installed Size inGa "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent(Y/N) I certify that I have checked, verified, or conformed to all MOA and inspection. S & S ENGINEERING Signed 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99377 Company Date MOA No. Receipt No. Date of Payment Amount: $ Receipt No. Pumping Cycles during Adequacy Test. HAA guidelines in effect onAtt&of, this 'n KW84al Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 wnwbac J "ss Ti00. 41i7 ��: CHEMICAL & GEOLOGICAL LABORATORIES A ANCHORS OF ALASKA, INC. 4WN\ 5633 STREET AGE, LASKA 99518 TELEPHONE (907) 562-2343 A�7� FEDERAL TAX ID # 92-0040440 LABORATQRIES 'MkLY313 RFPORT J JR2 fr,-L Wofk G&:#[—.JE 2te Rwxrr 5 eG» JUL 27 G@ S g0 rk?-e--ved 'With :AS REQUI.RED a » -- a sli p a-, v! s 0 . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ri—ruc "herrilab Yef ': 6"« " a n ". Tp r) 1 7 D' � L i , x Met 2«e s lil 'RATE - N 3et p; 2 1 Tpx- T) 3pe Roma:c A&,"ve U-1 92224 Pra es.aewz qcwH JUL 2s 69 , ws oc liz s ? C,. # N"" ii, RE 7) ;;uer;ed 3!J a@336 S» Rj 0 rk?-e--ved 'With :AS REQUI.RED a » -- a sli p a-, v! s 0 . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ri—ruc "herrilab Yef ': 6"« " a n ". Tp r) 1 7 D' � L i , x Met 2«e s lil 'RATE - N 3et p; 2 1 Tpx- T) 3pe Roma:c A&,"ve 1� r MUNICIPALITY OF ANCHORAGE �J 14 J ' 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 August 4, 1988 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 6; Delucia Subdivision Location (address or directions) (b) Property Owner 041 41A N,, ,F• Telephone: Home Business Mailing Address 99 F $-V A V �' (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent RE/MAX OF EAGLE RIVER — Pat Angevine Address._ 16600 Centerfield Drive, Suite 201, Eagle River, Alaska 99577 Telephone 694-4200 (e) Mail the HAA to the following address: or; Check here ®, 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, Alaska 99577 ordered by Pat Angevine 2. TYPE OF RESIDENCE Single -Family 9 Number of Bedrooms 3 3. WATER SUPPLY Individual Well 121 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 Q 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 72-025 (Rev 8/86) Front 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 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 S & S ENGINEERING Telephone 17034 Eagle Ri.yer Loop Road No. 204- 7 Address Eagle River, Alaska 99577 Date 6. DHHS APPROVAL Approved for 3 bedrooms by Approved - Disapproved Terms of Conditional Approval Conditional CAUTION Date 9-/g-,eP 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 1 72-025 (Rev 8186) Back A. WELL DATA `YNIICIPALITY OF ANCHORAGE (MOA) (F EALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 AQA 264-4744 5 �1)C� a CE�v �D Legal Description: Z &' ��/�Gl 45�-, Well Classification �/ If A, B, C, E.C.Jkpproved (.Y/N) / Well Log Present C(Y/N) Date Completed Z Yield Total Depth Z d 3 Cased to Depth of Grouting LA_ Static Water Level 1/ 5 Pump Set At L(, Lt— Casing Height Above Ground ✓� Sanitary Seal on Casing Y/ ) Electrical Wiring in Conduit (Y N) Depression Around Wellhead (Ye Separation Distances from Well: To Septic/He.Tank on Lot �� n f ; On Adjoining Lots /UD r To Nearest Edge of Absorption Field on Lot n �_ ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole p To Ne rest Sewer Service Line on Water Sample Collected by SJR ���/e�y ; Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed o �v Z Size �y 7- 7 f /U l 729 7 �or�U No. of Compartments Standpipe (Y/ ) Air -tight Caps (Y/ ) Foundation Cleaou Y/ ) Depression over Tank ( N) Date Last Pumped 1 v Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) /L Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Heldia Tank: r To Water -Supply Well �U � � To Building Foundation / J To Property Line �` To Disposal Field / 2 i To Water Main/Service Line Zd 7L_ To Stream, Pond, Lake, or Major Drainage Course %/u D Comments Page 1 of 2 72-026 �RPv 8.861 Front 7/� C. ABSORPTION FIELD DATA 41 Soils Rating in Absorption Strata AL20, Type of System Design Date Installed s oA 2 Length of Field 4;�2� Width of Field "5-- Depth of Field ¢ Zi Gravel Bed Thickness Z Square Feet of Absorption Area 3d Standpipes Presen (Y ) Depression over Field (/N Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well zay To Building Foundation Z 5 - Lot W To Water Main/Service Line ! � To Stream/Pond/Lake/or Major Drainage Course To Property Line ; On Adjoining Lots To Existing or Abandoned System on �o r 4— ..4 --1 — �/v �✓ gr- To Cutbank (if present) /cscg n.r To Driveway, Parking Area, or Vehicle Storage Area J� ( 14, Comments D. LIFT STATION Date Installed Dimensions Size in Gallons Man ole/Access (Y/N) "Pump On" Level at P p Off' Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all Aa d HAA guidelines in effect on the date of this inspection. Signed S S ENGINEERING ate 17034 Eagle rarer • 704 Compa &-Wyer, Al -aka 99577 MOA No. fir 1 Receipt No. Date of Payment �^ ^� AV °'•�*;�•r•g. Do A °� Amount: $ 1 D -- - o. „•, Seal os'$of-6a Page 2 of 2 72-026 (Rev 8!861 Back -....,.. • • •e V3 � + 4 + Q Nix 1{67y f g HEALTH AUTHORITY APPRO': ALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUCIES AND REPORTS WELL INSPECTION & FLOW TEST SI'-_ PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Mr. Eldon Young FEDERAL HOUSING AUTHORITY Department of H.U.D. 701 C Street Box 64 Anchorage, Alaska 99513 ROBERT A. SHAFER MUNICIPALITYOFA CIV►L ENGINEER Au �tSt 18, 1988 DEPT NCHORAGE 694-2979 g OF HEALTH & ENVIRONMENTAL PROTECTION REFERENCE: Lot 6 and Lot 2.2; DeLucia Subdivision Dear Mr. Young, AUG 19 1988 RECEIVED The private wells on each of the referenced properties have been tested to determine their flow. Each of these tests were performed over a four hour period with the results showing that the well on Lot 22 will produce 26 gph while the well on Lot 5 proluces 20 (ph. The t,wner of these two properties is prepared to instar. an approximate 1.500 gallons of water storage on each property. This will provide twice the quantity of water that would normally be required to produce 3 gpm over a four hour period. Water storage tanks will consist of 1500 gallon steel tanks, buried next to the foundation of each hoi.7se with a heated manhole over each tank. The manhole will house a jet pump and provide access tc the float switch and timer which will be necessary to control pumping cycles of the submersible pump within the well casing. `.t'he jet pump will. draw from the storage and pressurize the distribution system upon demand. These wells currently produce an adequate amount of water to satisfy Municipal Ordinance requirements. The Municipality of Anchorage has issued health Authority Approvals on each of these properties and has no objections to providing additional storage even though it is not necessary to satisfy Municip�::l requirements. Request you evaluate this proposal and, upon completion of work, waive the requnt for each well to produce 3 gpm. S Water supply for the above properties is adeoluate to meet requirements established T A. SHAFER, P.E. by Municipal Ordinance and the additional ss storage proposed will aid in meeting instantaneous demands. Mun cipality of Anchorage Department of Health and Human Services 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 Time APPLIC "` NT FILLS OUT UPPER HAf 'ONLY Property Owner i Phone MaiL.',g Address Zip Code Buyer Date Date Address Date Zip Code Lending Institution Phone Address A. '. .," � cf t!'i �"r�� i �, f -r �; ;, s is �;_.+ r �r Zip Code Inspector Realty Co. & Agent Inspector Inspector Phone Pb `4 Address' ; Zip Code Legal Description r Field Notes: Street Location ti 'CONDITIONS OF APPROVAL ( ) DISAPPROVED Type of Residence ( ) CONDITIONAL APPROVAL' Single Family V DATE ❑ Multiple Family No. of Bedrooms'- ❑ Other Soils Rating Water Supply �!� JL Well Log Received?,L, Individual �'-Q� ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. Community For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility Sewer Disposal Individual Year Individual Installed: ❑ Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date / Z Inspector Inspector Inspector Inspector Pb `4 G Field Notes: ( ) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' 4—Ir 2- o �Y DATE B t Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received?,L, 'f — `8 Z__Well to Tank Septic Tank Size ; 72023 (3182)