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) NOSdWIS qq~ON~ :lN~3Iqdd~ 'N~I3I~IDBq3 G3SN33Iq ~ i8 3NDO 38 IS~W ~OM 9~3I~£3393 3Hi (£) ON~ ~i~O~3B NOI±33.~SNI ']~3I~13B]B N~ i~OHtlM 03AOB~ 38 iON ]]IM SI]I~8--S~ (~) ~03NI~180 38 ISAW NOII33~SNI ON~ IIWB3~ ~3IB133~3 N~ (S) N3HI ~S3003 8NIO]IA8 ~OW 18 OB~BA03 ~3~ N~ NI 03]]~ISNI SI NOIi~iS .LdI] ~ ~I '~oI ~q~emu '~;~md sIq~ ~o w~m~o uOIsmp mq~ q~!~ m~ueIId~o~ u~ puc ~suo~elnOea puc smpoo ~DW lie 'eHseI~ ~o ~e%S mq~ puc (~OW> :lc41 ~jT1Ja~ I ~N :)~3098 8~ 0~0~ S3qQ3BN (S383~ ~0 'l~'OS> OG~S' NSI :8IHSNMOI 6 :NOI±33S ~I3~qBO :NOISIAIO8AS :NOI.L~DOq iOq :3ZIS 10'9 :~IW3SBO 9~939 ~£~9-9£~ £0~66 )~ ~BS~BOHDN~ I0~ BIIOS OB3MB~I~ M I08 O/3 NOS,dWIS ~8/0~1Z0 :3NOHd 13~±N03 :SSB~OO~ :lN~3I~d8~ :O3~SSI 3i~O :ON ilNW3d i I WW3.-~ )J3N3S 3.1 I S--NO 0~l~.-~9~ NOI±33108~ ]~±N3WNO~IAN3 ON~ Hiq~3H BO iN3WiB~dBO 3~z~-~O~-~3N~ ~0 ~iI--l~.~ I OINf-~bW gpO. I~" Co± 4~, / [~)~-_~L.L,~{~ ~1o~',/, PROJ. NO.L=k:Ied~~ DWG. NO: ,, , GAAB-HD-~ 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,