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HomeMy WebLinkAboutDELUCIA LT 48DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGENVESTERN PUBLIC SERVICE AREA OFFICE
555 CORDOVA STREET
ANCHORAGE, ALASKA 99501
TONY KNOWLE$, GOVERNOR
(907) 269-7505
August 4, 1995
RECEIVED
Mrs. Dorothy M. Roberts
22774 Needels Drive
Chugiak, Alaska 99567
Subject:
AUG 1 4 1995
IViu,,,(;,~ahty ol Ancl3orage
Dept. Health & Hum_an 8eryices
Lot 48, Delucia Subdivision, Chugiak, Alaska, Class C Public Water System and
Wastewater Disposal System, ADEC Project Numbers 9621-DW-212-015 and
9621-WW-212-049, Review
Dear Mrs. Roberts:
I have reviewed your July 31, 1995 submittal regarding the upgrade of your three bedroom
single family home into a two bedroom Bed and Breakfast. Based on this review, I have
the following comments.
From the submitted information, it appears that the existing water system met all
regulations and guidelines when it was installed. Based on this information and the fact
that the demand on the existing water system will not be increased, it appears that the
water system will be able to meet the demand without modifications. Therefore, the
existing Class C Public Water System serving the two bedroom Bed and Breakfast located
on the above-referenced property is approved for the concerns of this Department. A final
Operation Certificate, constituting this approval, is enclosed.
The existing three and eighty-five hundredths (3.85) milligrams per liter (mg/I) of nitrate (as
nitrogen) is above ambient levels for nitrate (.4 to .9 rog/I) normally found in groundwater
in the State of Alaska. Although the nitrate level is above ambient conditions, it is below
the maximum concentration level for nitrate (10 mg/I) set in the State Drinking Water
Regulations, but the existing level does show degradation of the water quality of the
aquifer that you are withdrawing water from for drinking. Due to the possibility of continued
degradation of the aquifer's water quality and to ensure the public health will be protected,'
semi-annual analytical results for nitrate (as nitrogen) and total coliform bacteria will need
to be submitted to this Department. I recommend that the water samples be collected.
during February - March and August - September of each year. If nitrate levels remain
over eight (8) mg/I for more than two consecutive samples, either engineering plans for the
Mrs. Dorothy M. Roberts 2 August 4, 1995
-installation of a nitrate removal system or notification of some other solution will need to
be' submitted to this office.
Due to the monitoring requirements of the operation approval, please ensure that the
Public Water System Identification (PWSlD) Number 218465 is placed on all analytical
results submitted to this Department.
The existing wastewater disposal system was not tested to determine if it will accept the
waste flow from the one bedroom single family home and two bedroom Bed & Breakfast
on the given day that it was tested. However, based on the information that you did
supply, the existing soil absorption system has been resting for the last four years. As a
result of the Soil abSOrption system resting, the system should be able to accept the
Wastewater flows from the proposed two bedroom Bed and Breakfast and one bedroom
single family home. Thus, in accordance with the provisions of 18 AAC 72, Wastewater
Disposal Regulations and the Department's guidelines, the wastewater disposal system
serving the facility on Lot 48, Delucia Subdivision is approved for operation. This letter
constitutes final operation approval for the existing wastewater disposal system.
These approvals do not imply the granting of additional authorizations, nor obligate any
state, federal, or local regulatory body to grant required authorizations.
Thank you for your coordination with this Department. If you have any questions, please
do not hesitate to contact me.
KKK/cf
Enclosure: As Stated
CC:
Sincerely,
Keven K Kieweno, ~.F.
District fingin~r
Lynn Johnston, ADECISCROIEH/DW, wlo Enc.
Jim Cross, P.E., MOA/DHHS, wlo Enc.
MUNICIPALITY OF ANCHORAGE
, DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
(l ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME IPHONE I []NEW
LEGAL DESCRIPTION
NO, OF BEDROOMS
Well Absorb' Dwelling PERMIT NO.
~ ~ Material No, of compartments
~Z Manufacturer ¢~~
Liq. capacity in gallons Inside length Width Liquid depth
/~O IF HOME--DE:
Well Dwelling PERMIT NO.
~g~ DISTANCE TO:
~ -- ~ Manufacturer Material Liquid capacity in gallons
O Well Foundation Nearest lot line PERMIT NO.
~ DISTANCE TO:
~ ~ Z No. of lines Length of each line Total length of lines Trench width Distance between lines
~ Z ~ inches
~ Top of tile to finish grade Material beneath tile Total effective absorption area
~ inches
~ Length~ .~ ~l~<~Width Depth PERMITNO.
~ ~ Type of crib / Crib diameter Crib depth Total effective absorption area
~ -- Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
m Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOIL TEST RATING ~
INSTALLER
-/
/
, , -
/
72-013 (Rev. 3/78)
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Gr--'ER ANCHORAGE AREA BOROL !
DEI'ARTMENT OF ENVIRONMENTAL 0. UALIT'r
3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION ~_1 uC-, a :'~ L,,a/,',~,:~,,~-,
MAILING
ADDRESS qt~'~" r~/_4 Jt~Jc,~_,~. ""~, A'~,2PHONE~I
LEGAL DESCRIPTION /..-0'~ Z.~
SEPTIC TANK:
DISTANCE FROM WELL
LIQUID CAPACITY t3 L~)~ C~
GALLONS.
MATERIAL
iNSIDE LENGTH
NUMBER OF
COMPARTMENTS
INSIDE WIDTH
!
LIQUID
DEPTH
SEEPAGE SYSTEM:
NUMBER OF PITS
LINING MATERIAL
NEAREST LOT LINE
SEEPAGE PIT:
OUTSIDE DIAMETER
OR WIDTH
DISTANCE FROM WELL ! l~'
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
LENGTH j~--I , DEPTH
, BUILDING FOUNDATION
,~'~ SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL~/ C I:C~HNIpA-TIOE~
NUMBER OF LINES ,~ DISTAN E BETWE ~
ABSORPTI~EA SQ. FT. LENGTH
OF
EACH
LINE
DEPTH: TOP OF TILE TO FINISH GRADE
NEAREST LOT LINE
TRENCH WIDTH
DEPTH OF FILTER MATERIAL BENEATH TILE
TOTAL LENGTH
OF LINES ,
~~M. IOIAL EFFECTIVE
IN. ABOVE TILE ,
WELL:
TYPE DEPTH
NEAREST SEPTIC
LOT LINE SEWER LINE . TANK
DISTANCE FROM
, BUILDING FOUNDATION.
~-/~.~ t SEEPAGE
SYSTEM_
WATER
SAMPLE
CESSPOOL
, NEAREST
OTHER
, SOURCES ~
DISTANCES:
DATE
DIAGRAM OF SYSTEM
APPROVED
G.A.A.B.
-- ,' Grr--,_, ER ANCHORAGE AREA BOI-~OUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. -
3500 TUDOR ROAD POUCH 6-650
· ANCHORAGE. ALASKA 99502
TELEPHONE 279-8686
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
INSTALLATION OF: SEPTIC TANK
SEEPAGE PiT DRAIN FIELD
OTHER
SOIL TEST RESULTS
COMPLETION DATE ANTICIPATED
NOTE: THIS PERMIT IS NOT VALID WITHOUT ~OIL TEST
FINAL INBPECTIONz 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL IN~ECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SE.,CTANKS,ZE SEEPAGEA.EAS,ZE,t x :
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT
SEPTIC TANK TO SEEPAGE PIT WALL /'
, DRAIN FIELD
/
· DRAIN FIELD
SEPTIC TANK , SEEPAGE PIT
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK
DRAIN FIELD
WATER MAIN TO SEPTIC TANK , ~/~/
DRAIN FIELD i
TO RIVER, LAKE, STREAM.
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL,
SEEPAGEP,T /~ ~,
ALSO CONS,DER AREA WELLS.
· SEEPAGE PIT
DIAGRAM OF SYSTEM
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FIT'rED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
// .,
- ///" HEALTH AUTHORITY
OR
LICENSED DESIGNER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 2S-S8 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. / ,~ ~
DATE APPLICANT'S SIGNATURE r _:/ '
Performed For
Leoal qescription'
This Form Reports Soils
"One test is x,,~,rth a thousand opinions"
~2~ TUDOR ROAD. ANCHORAGE:, ALASKA 99507 · T[LEPHON~ 333-8472
Kenneth P. Johnson Oate Performed
Lot 4~ Block Subdivision~
ye~
8-1-72
De luc ia Chu~iak
Percolation Test
q
1N
nenth
feet
Soil Characteristics
%ilt Overburden ( ML )
Silty Sandy Grave] ( GM )
Sand & Gravel ( SW )
Was Croun,i Water
· c Ve~ ~t what
Percolation Rate
R,. ~(~ir~ !~ate q'n~s Time Net Time
i
Hi nute
Proposed Installation' Seepage Pit yes Drain Field
Den. th of Inlet 2~' Depth To Bottom Of Pit Or Trench
cn,MENTS- Seepage pit dimensions 18ft x 13 ft. x 8 ft. Test pit dug h ft. below seep~e
pit, nc bedrock or water table found. 13,~ aq. ft.. ~bsnrptinn ~l"ea required per bedroom
Test Performed By /.,~ ~~ Data Certified By:~-~-,~,~
/~.~ ~ ~l~~.~e'~' Date :___~f /,'_7
Well Owner
M-W DRILLING, INC.
DRILLING LOG
.Use of V~eI1
Location (address of: Township, Range, Section, if known; or distance main road
Size of casing. :''' Depth of Hole ~ © y feet Cased to ? 0 ~:, feet
Static water level ~ $ ft. (~ (below) land surface. Finish of well (check one)
Screen ( ); Perforated ( ).
Describe screen or perforation
Well pumping test at 7 .~ gallons per
of drawdown from static level.
..... :/L/' 7 ~'
Date of completion
open end (
(minute) for i hours with
W[[£ £OG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
);
ft.
TO.
TO.
TO.
TO.
.TO.
TO.
.TO.
TO.
TO.
TQ
.TO
.TO.
__.TO
.TO
.TO.
,>~et ~ravel
Boulder
Silty sand & grave]:
3oulder
2 -- STATE
MUNICIPALITY OF ANCHORAGE
· DIVISION OF ENVIRDNMENTAL HEALTH
DEPARTMENT OF HEALTH AND ~~ PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date June 6, 1984
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (add,ess or directions)
~¢edles Road
(b) Applicants Name Randall Simpson
Applicants Address c/© 801 W. Fireweed, Suite 201, Anchorage, AK
(c) Applicant is (check one) Lendir~g Institution I i; Owner~ilder ~ ;
Buyer ~ ; Other ~ (explain);
(d) Lending Institution Telephone
Telephone 688-~07Q
99503
Address
(e) Real Estate Co. & Agent Bob Martin, Commonwealth Area Realtors
Address 1o.O. Box 770-249, Eagle River, AK 99577
Te le phone
2. _Type of Residence
Single-Family ~
Numbe~ of Bedrooms
3. Water Supply
Individual W~.ll ['~
694-9555
Multi-Family
Other (describe)
Conlm~$ity~
Note: If cu~,,~nity ~11 system, must hav~ written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Is the well adequate for the number of bedrooms specified in this HAA (Y/N) ¥~
4. Sewage Disposal
Onsite ~ Public ~ Co~,,%~anity .~--] Holding Tark
Is the wastewater disposal system adequate for the r~ of bedrooms (Y/N) Yes .
[Page 1 of 2]
2-15-B4
5. Ehgineerinq Firm Providing Inspections, Tests, Data and Infcrmation
I certify that I have checked, ~rified, c~ confczuv~d to all MDA HAA Guidelines in
effect o~l~the date of
signed ~_~z-~v~/- - Date June 6, 1984
Name of Firm Entech Engine6~rs, Inc. Telephone 694-3574
Address 13 LeDoux, Eagle River, AK
SiGned by Vernon L. Roelfs, PE
Date June 6, 1984
( ENGINEER SEAL)
6. DHEP Approval
Appro~d for_~__ kedrocms
App~o~d/~ Disapp~o~d .~--~
Terms of Conditional Approval
99577
Conditional ~-~
Date
ae
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
NOI1O]lO~d Tv'IN~",;';N O~J I ANzi
Lot 48, Delucia Subdivision
Well Classification Private
Well Log P~esent (Y/N) Yes
Total Depth 207 ' Cased to
Static Water Level 100'
Casing Height Above Ground 12" +
Electrical Wiring in Conduit (Y/N) Yes
Separation Distances f~cm Well:~ ,~ ~ ~
TO Septic/Holdir~ Tank on Lot" 69',~.
If A, B, c~ C, D.E.C. Approved(Y/N) N/A
Date Cc~leted 10-5-77 ~ Yield 10 gpm
205' ?-,.i Depth of G~outing Unknown
Pump Set At Unknown
Sanitary Seal on Casing (Y/N)Yes
Depression Around Wellhead (Y/N) No
; On Adjoining Lots 100' +
To Nearest Edge of Absoz~ption Field on Lot 105' ; On Adjoining Lots 100' +
To Nearest Public Sewer Line N/A To Nearest Public Sewer
Cleanout/Manhole N/A To Nearest Se~er Service Line on Lot 65'
Water Sample Collected By Mik~ M~an ; Date ~-17-8~
Water Sample Test Results Q colonies/lO0 ml (Negative)
Cc~ents
B. SEPTIC/HOLDING TANK ~ATA
Date Installed 8-7-72 Size 1000 gal NO. of Ccmpa~tments 1
Standpipes (Y/N) Yes Air-tight Caps (Y/N)Yes Foundation Cleanout (Y/N) No
Depression over Tank (Y/N) No Date Last Pumped 5-18-84
Pumping~Maintenance Contract on File (Y/N)N/A ; for N/A
Holding Tank High-Water Alarm (Y/N) N/A Temporary Holding Tank Permit (Y/N) N/A
Separation Distances f~om Septic/Holding Tank:
To Water-Supply Well 69' To Building Foundation 11''
To Property Line 50' + To Disposal Field 36'
To Water Main/Service Line 15' + To Stream, Pond, Lake, cr Major Drainage
Course N/A
Comments
[Page 1 of 2]
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 8-7-72
Width of Field 15'6"
Gravel Bed Thickness
Square Feet of Absc~ption Area 342 sq ft Standpipes Present (Y/N)
Depression over Field (Y/N) No Date of Last Adequacy Test
Results of Last Adequacy Test ~dCquate
separation Distance frc~ Absorption Field:
To Water-Supply Well 105' To Property Line 50' +
To Building Foundation 20' To Existing or Abandoned System c~
LotNone located ; On ~joining Lots 50' +
To Water Main/Service Line 50' + To Cutback(if present) N/A
TO Stream/Pond/Lake/or Major Drainage Course J O0 ' +
To D~iveway, Parking Area, c~ Vehicle Storage A~ea JO'
Conm~nts
138 gpd/bdrm TS~pe of System Design Seepage pit
Length of Field 15 '
Depth of Field 6'
?-82
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
Conl~ents
** Check Permitted Bedrocm Rating A~ainst HAA R~quest **
I certify that I have checked, verified, or confo~ff~d to all MOA HkA Guidelines in effect
on the date o~ this ir~pectic~.
Company-Entech Engineer~,,/Inc,
KB1/d5/s
Date Juu~ 6; 1984
MOA No. ST84-018
[Page 2 of 2]
2-15-84
E TECH ENGINEERS, /NC.
CIVIl · SANITARY
June 20, 1984
Mr. Jim Hayden
Alaska Department of Environmental
Conservation
437 "E" Street
Anchorage, AK 99501
Re .-
Separation Distance Waiver; Well to Septic,
Single Family Dwelling; Lot 48, Delucia Subdivision
Dear Sir,
On June 5, 1984 we prepared a Health Authority Approval
Application for the above referenced property and submitted
it to the Muncipality of Anchorage Department of
Environmental Health (DEH). Subsequent to submittal of the
application, we were advised by the DEH that since the
septic tank was 69' from the well, an ADEC waiver would be
required.
In August 1972 when the septic system was installed,
only a 50' separation was required between the well and the
septic tank. However, the well was not drilled until 1977.
By that time, the regulations had changed and, thus, a
waiver is required.
We have reviewed the well log (see attached copy) and
it appears that the aquifer is suitably isolated from the
shallow soil strata. There is a 14' thick layer of hardpan
between 42' and 56' depths, and there is essentially hardpan
with some boulders and cobbles from 66' depth all the way
down to 170' depth. The aquifer begins at 1' depth.
The tank was pumped as part of the adequacy test and we
then observed it. The tank is fitted with an airtight cap
and, structurally, the tank appears sound, although we did
not dig it up. All things considered, we believe that it
would be highly unlikely that the septic tank could be a
-source of contami~%~R&%, for the well in the
future.
If you ny__ .Ti.. ~; please do not
cc
~ac~en~
foreseeable
hesitate to
/_cere.ly, /7 _ /
Vernon L. Roe/~s, PE
HAAApplication
13 LE DOUX LANE · EAGLE RIVER, ALASKA 99577 · TELEPHONE (907)694-3574
437 "E" STREET, SUITE 200
ANCHORAGE, ALASKA 99501
BILL SHEFFIELD,
Telephone: (907)
Address:
274-2533
July 18, 1984
Mr. Vernon L. Roelfs, P.E.
EnTech Engineers Inc.
13 LeDoux Lane
Eagle River, AK 99577
Dear Mr. Roel fs:
Subject:
Waiver Request to Waive the Horizontal Separation between the
Well and the Septic Tank to 69 ft on Lot 48, Delucia Subdivision,
( 8521 -WA-O11 )
The Department has reviewed the subject waiver request and cannot grant the
waiver because it was not demonstrated that the separation distances required
at the time the well was drilled were clearly not necessary to prevent con-
tamination of the well.
Si nc~grely,
q)l~Cde~ E. Erickson
Environmental Engineer
BEE/rosin
TECH ENGINEERS, INC.
CIVIL · SANITARY
June 5, 1984
Municipality of Anchorage
Department of Health & Environmental
Protection
825 "L" Street
Anchorage, AK 99501
Re:
Randall Simpson Health Authority Approval (HAA)
Application; Lot 48, Delucia Subdivision
Dear Sir,
During the period from May 16 to May 18, 1984, we
performed research, investigations and testing persuant to
Health Authority Approval on the above referenced lot.
We performed a flow test on the well and found the
output to be adequate for a 3 bedroom house. (Refer to
Water Yield Test, attached). We also took a water sample
for bacteriological analysis and results were negative
(Refer to Chemical & Geological Laboratory Analytical
Report, attached).
We also performed an adequacy test on the septic system
and found that it absorbed at a rate of 10,000 gallons per
day (gpd). This is more than the 450 gpd required for a 3
bedroom house and the system is therefore adequate. The
septic tank was pumped as part of the test and the volume
was verified to be 1000 gallons.
To our knowledge, we have assembled all available
information on the HAA Checklist and Application Form.
1
13LEDOUXLANE · EAGLE RIVER, ALASKA 99577 · TELEPHONE (907) 694-3574
We offer this information for your review.
call if you have any questions.
Please
CC
Bob Martin, Commonwealth
Area Realtors
Attachments
HAA Application
HAA Checklist
Water Yield Test
Sewer As-Built
Well Log
Chemical & Geological Testing Lab,
Total Coliform Analysis
Vernon L. Roel~'s, PE
2
MUNICIPALITY OF ANCHORAGE
:- ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO~ALITY OF ^NCHORAGE
825 L Street - Anchorage, Alaska 99501 DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720 SEP 2 8 1978
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND ~r~ EI~I'~TffS
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER i PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHON, E
2. BUYER ' PHONE
MAI LING ADDRESS
3. LENDING INSTITUTION I PHONE
I
MAILING ADDRESS
4. REALTOR/AGENT I PHONE'
I
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
/~Z *--~ /~:~¢~A2~ ~Y~:: 0 ~: //~{/'~ ~: NUMBEI~ OF BEDROOMS
6, TYPE OF RESIDENCE
[] One [] Four [] Other
~~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
**If individual/on-site, give installation date
If system is over two (2) years old an adequ;cy test is required
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
I NSPECTI ON APPOI NTM ENTS
TIME TIME TIME
DATE DATE DATE
I NSP ECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
E~ PUBLIC UTILITY
Connection Verified
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SlX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions: ! '~
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
DATE INSTALLED
i NSTA L LER
SOILS RATING
Septic/Holding Tank IAbsorption Area ISewer Line
[] OTHER
Nearest Lot Line
5. COMMENTS
[~]"~PROVED FOR ..~ BEDROOMS
CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
4.1
2"/6-2221,