HomeMy WebLinkAboutDORA #2 LT 12Dora
Lot 12
#014-251-29
PERMII" NO.
[:,EPFIR'T]'"IENT OF:' HE:R!_'TH 8h,lD EIq'v' I ROI',IMENTFII... ":'ROTECT I ON
825 ...... STREET., FINCHORF~GE., FIK. 9 ..... 0:]..
264-47;:20
b.,llE L, b. F'E F.:: I'-1 Z -lr"
,:: 8i:t_05]i: ::,
RPF'I.. I CFIt'.,tT T. STEt.,.tFIR CONST.
LOCRT I ("~r.,I
LEGFIL. L:1.2 [:,ORR 2
8.$20 NILLII.4F~ CIRCLE
L. OT SIZE
]:]:7::-8684
;20000 SQUF:IRE' FEE]"
MINIMUM DISTRNC:E 8ETI.,.IEEN R I.,.IEI...L RN[:, I::~N'.¢ ON-SITE SEb. IlaGE DISPOSRL S"r'STEM IS
:L00 FEE]" FOR R PR IVRTE NELL OR :1.50 TO ::"00 FEET FROM R PUBLIC NEL. L DEPEN[:'ING
UF'ON THE T'¢PE OF PUBLIC 1.4ELL
MINIMUM DISTRNCE FROM R PRIVRTE I.,.tELL TO R PRIVRTE SEWER LINE IS 25 FEE]" FIN[:,
TO R COMMUNIT'¢ SEI.4EF:'. LINE Il'-:; 75 FEE]".
WELL. LOGS RRE RE6!UIRED RN[.'-" MUST BE RETURNED TO THE [."EF'F~RTMENT FIITHIN
OF' THE 1.4ELL COMPLETION.
OTHER RE~2UIREMENTS MR'¢ RPPL'¢. SPECIFICRTIONS RND CONSTRUC:TIOI"4 DIFIGRRMS RRE
R'v'RILRBLE TO INSURE PROF'ER. INSTRLL. RTION.
I CERTIF'¢ 'THRT
:t.: I 8M FRMIL. IRR I.,.IITH THE REQUIREMENTS FOR ON-SITE SEI.,.IERS RND NELL. S RE; SET
FORTH B"r' THE MUNICIPRLIT'¢ OF' P~NCHORRGE.
2 ' I N ILL it N:STR[...L THE .E,'¢'.=;TEM .[ N J~:OF.:[:,RNCE 1.41 TH THE CO[:'E'::;.
:.:.:; I G N E [:' ' IR P F' [ 4 T T ~. ~.' ..~, (] N S T.
\,'4. 0
ERANS
C�t ` Municipality of Anchorage 5
On-Site Water and Wastewater Program
(907)343-7904
5 e r F. r f
Certificate of On-Site Systems Approval
Parcel I.D. 014-251-29
Expiration Date: / ` -
2' f
1. GENERAL INFORMATION
Complete legal description Dora #2 L12
Location (site address) 8510 Rosalind St. Anchorage, AK 99507
Current Property owner(s) Mike Watson
Day phone
Mailing address 8510 Rosalind St. Anchorage, AK 99507
Real Estate Agent Day phone
2. TYPE OF DWELLING:
O Single Family(w/wo ADU)
❑ Duplex
E Multiple Dwellings(Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well [] Individual ❑
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer 0
WaiverNariance request for:
Distance:
Received by: yt"-o
Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 5 2l Waiver Fee $
Date of Payment io`iq he Date of Payment
Receipt Number 6Q(e5q-6 Receipt Number
COSA# 2)5C igiGtaZ Waiver#
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,based on procedures outlined
in the Certificate of On-Site Systems 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.
In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system.These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system.The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907)745-8200
Address P.O. Box 1807 Palmer, AK 99645
Engineers Printed Name Steven R Pannone Date 10/18/18
6. DSD SIGNATURE \
System#1 Approved for if bedrooms .:Steven X2. :•rinone. Are
�� I.% CE-8149
System#2 Approved for bedrooms Otty' ' •��,,r'
Disapproved 1\\.\`�*
Conditional approval for bedrooms,with the following stipulations:
J�\Gi�N�l i 1 Uti'VI, .
�� 1/1447-Eli,
�-
o wAS ER AN p �
PROGwgTER c
o-0, RqM .�°
• TSFRvICf n
p\ S-., \���k(/ Original Certificate Date: t 0 —,2 5-- I.
The Municipality of Anchorage Development Services Division (DSD)issues Certificates of On-Site Systems Approval(COSA)based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sneet_r '• c
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: Dora #2 L12 014-251-29
Parcel I D:
A. WELL DATA
Well type Private If A, B, or C provide PWSID# _ Y
Well Log(Y/N)
Date completed 4/27/81 Sanita seal Y/N Y Y
rY ( ) Wires properly protected(Y/N)
Total depth 98 ft. Cased to 98 ft. Casing height(above ground) 29 in.
FROM WELL LOG AT INSPECTION
Date of test 4/27/81 10/16/18
Static water level 45 ft. 41.7 ft
Well production 10 g.p.m 4.1
9.10.m•
WATER SAMPLE RESULTS:
Coliform t'16(9 colonies/100 mL Nitrate 1\1-7 mg/L
Arsenic D•1 ug/L Date of sample: 10/16/18 Collected by: PES
d(
B. SEPTIC/HOLDING TANK DATA ?LA \,L Se.We,-
Tank Type/Material -D t installed
Tank size gal. Number of Compartments Cleanouts(Y/N)
Foundation cleanout(Y/N) Depression ov a�t'nk(Y/N) High water alarm (Y/N)
Date of pumping m per
C. ABSORPTION FIELD DATA ?ub`\L Sz L,Je r
Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) r / System type
Length ft. Width Gravel below pipe ft.
Total depth ft. Eff. absorption area ft2 Monitoring tube Y Depression over field
Date of adequacy test Results' Pass/Fail) For bedrooms
Fluid depth in absorption field before test�i in. Water added gal. New depth in.
Elapsed Time: min. Final ierd depth in. Absorption rate >_
/ g.p.d.
Any rejuvenation treatment(pa,1- mo.)(Y/N&type) If yes, give date
•
D. LIFT STATION
Date installed Size in gallons Manhole/Access(YIN)
"Pump on"level at in. "Pump off'level at in. High water alarm level at in.
Datum Cycles testefl/ Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
1Septic tank/lift station on lot N/A On adjacent lots 100 +
On ad'acent lots 1001+
Absorption field on lot N/A 1
Public sewer main
78'+ Public sewer manholelcleanout 1001+
Sewer/septic service line 25'+ Holding tank N/A
Animal containment areas N/A Manure/animal excrete storage areas N/A
SEPTIC/HOLDING TANK ON LOT TO: •?vvC So Je c
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO:
Property line Building o ndation Water main
Water Service line �S ace water Driveway, parking/vehicle storage
Curtain drain / Wells on adjacent lots
F. COMMENTS
Survey on file.
G. ENGINEER'S CERTIFICATION OF:ALAI kl
1 certify that I have determined through field inspections and o, ��Q ,jam -77 tr
review of Municipal records that the above systems are in Al*: •!! /\\ •*'
conformance with MOA COSA guidelines in effect on this date. 0•• •-- 'Zt�' � P•-
Engineer's Printed Name Steven Pannone r••:Skeveri .'f�onriorie:..�
CE-8149
Date 10/18/18 k, � •
��
� �sii�'�.�
COSA canary sheel_2-6-15.doc
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT • �'i2 907-343-7904
On-Site Water and Wastewater Section Fax: 343-7997
www.muni.org/onsite �I
Arsenic Advisory
Certificate of On-Site Systems Approval # OSC181562
Subdivision: DORA #2 lot 2
A water sample revealed an arsenic concentration of 26.7 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Information on arsenic is available from the On-Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-Site
Systems Approval.
Mailing Address: P.O. Box 196650 *Anchorage,Alaska 99519-6650 *www.muni.org
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
01~-251~29 HAA#
1. GENERAL INFORMATION
Complete legal description
Lot 12, Dora II Subdivision
Location (site address or directions) 8510 Rosalind Street
Property owner
Mailing address
Lending agency
Mailin. g address
Agent
Address
Glenda Radvansky
Day phone
8510 Rosalind Street
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
Two (2)
NOTE:
Individual well XXX
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer x××
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
o
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 Anderson Engineering Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Enginee~ssignature ~'~~ ~'~ ~ Date 4/3/00
o
DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
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 DH HS 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 engineeds work.
Municipality of Anchorage APR
DEPARTMENT OF HEALTH & HUMAN SERVICES~uN~c~P^uT
Environmental Services Division ......
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description: Lot
A. WELL DATA
Well type Private
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Health Authority Approval Checklist
12, Dora II Subdivision PamelI.D.: 014-251-29
Y
98'
IfA, B, or C, attach ADEC letter. ADEC water system number
4/27/81
Date completed
98'
Cased to Casing height (above ground)
Y
FROM WELL LOG
4/27/81
Wires properly protected (Y/N)
Date of test
45'
Static water level
10
Well production
WATER SAMPLE RESULTS:.
Coliform 0
Date of sample: 3 / 27 / 00
B. SEPTIC/HOLDING TANK DATA -
Date installed
Foundation cleanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Length Width
Effective absorption area
Date of adequacy test
Fluid depth in absorption field before test (in.);
Fluid depth (ins) Minutes later.'.
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
AT INSPECTION
4/2/00
47'
g.p.m.
6.8
g.p.m.
Nitrate .531 mg/L
Collected by:
Municipal Sewer System
Tank size Number of Compartments __
Depression (Y/N)
Other bacteria 0
MEA
Pumper
Municipal Sewer System
Soil rating (g.p.d./fF or fF/bdrm)
Gravel thickness below pipe
Monitoring Tube present (Y/N)
Results (Pass/Fail)
Immediately after
Absorption rate =
System type
Total depth
Depression over field (Y/N) __
For
gal. water added (in.):
g.p.d.
If yes, give date
bedrooms
Cleanouts (Y/N).__
High water alarm (Y/N).
D. LIFT STATION -
Date installed
Manhole/Access O'/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Municipal Sewer System
Size in gallons.
"Pump on" level at*
*Datum
"Pump off" level at*
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: None on Lot
Foundation Property line Absorption field.
Water main/service line Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line Building foundation
Surface water
Curtain drain
F. ENGINEER'S CERTIFICATION
I certify that I have determined tJ
· in conformance with MOA HAA guidelines in effect on this date.
Signature ~ ~ ~
Engineer's Name Michael E. Anderson, P.E.
Date 4/3/00
Septic/holding tank on lot N/A
N/A
Absorption field on lot
>75'
Public sewer main
>25'
Sewer/septic service line
Wells on adjacent lots
None on Lot
Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots
HAA Fee $
Date of Payment Z~/~-'/~"~
Receipt Number ~-'-~
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
On adjacent lots > 1 00 '
On adjacent lots > 1 0 0 '
Public sewer manhole/cleanout > 1 0 0 '
Lift station N/A
· -: On-Site Services Section .:,- ..
· - · _ ..... CERTIFICATE OF HEALTH AUTHORITY "~- :v .' ..... ::,,'
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ~ / ~ "%~"'/ ~'¢¢
1. ~ENERAL INFORMATION
_Complete legal description
Location (site adi:lress or directions)
8510 Rosalind Stre~.t
Anchorage, AK
C/~/¢e~ L~
Day phone
Anchorage, AK 99507
Day phone ' ..
..;,: , Unless otherwise requested, HAA ~,ill be held for pickup.
2. NUMBER OF BEDROOMS: : ~
-3. ,.,,,.TYPE OF WATER SUPPLY ........ -,,~ ........... . .... ..,:-
~ommunl Well ...... ;~ '~;
...'. Public water . .;~ ,..
NOTE: .. If communi~ well system, provide wri~en confi~ation from ~ng to the legah~ and status of system.
549-584'0 .'
4. TYPE OF WASTEWATER DISPOSAL:
Holding.,. ... tank. ,..,:. .... ::
COmmunl~ on site
NOTE: If co;';u"P'' ~::' '..,.,, . ., wastewater' "' ........ system,: ...... 'provide .... ' "" ~" -"wr,.e. .... confirmationfrom'; .... "'< :':'~ " ~ ""~"' FState ADEC
.aResCng to the legali~ and status of system, .-, ' '~'.'
(R~, 1~) F~ MOA ~1
Property owner
MaiJJng address 8510 Rosalind Street
Lending agency
Mailing address
Agent'
Address '~ 5400 Des~cP.Z S,t.~: Anchorczq~,
AK
· Day phone
STATEME~.'.0F INSPECTION. BY, ENGINEER
"A~ ce~ifi~Y"Se~l' ~ffi~ hemt~'-ahd'a'~f;the validation'date eh I I ved~ th
investig=ion of.this Health:A~th~ri~'APpr°~a~ appli~ti°n'sh°ws
and/or w~tewater dispo~l'system is ~fe, fun~ional and ad~uate for the numar of b~rooms
and ~pe of structure indi~t~ heroin. I fu~her veri~ that bas~ on the information ob~in~ from
the Municipali~ of Anchorage fil~ and fmm my inves~ation and ins~ion, the on-site ware
supply an~or w~tewate~: diSp°~l'system is in compliance with all Municipal and S~te codes,
-~.:... -
o~inances, and r~ulatiOns in eff~t'on the date of this ins~ion.
Name - --
bedrooms, with the following stipulations:
Conditional approval' for'
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 inspectlon, s,or analyze data before a certificate is issued. Th,?Muni~ipality of Anchorage is not
,,:~ ............ -., .,~,.,~, ........... .'~ ............... ~b"'.. ~ ~:'~ ~:~.:~. ~,:~:',- - ' .' .... i-~,:~)i~.'~' ",.
.... ~pOnsible for errors Or Omissions in the professional engineer's work: ~- ,.,
. , 72.g~(Rev, 1/91) ~ MOAi~I
.' .t-- · . ,,-:::. ?.~,'.:,'
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A. Well Data
Well type ~&UPr~F~
Log present(~N)
Total depth
Sanitary seal (~N)
If A, B, or C, attach ADEC letter. ADEC water system number
Y~--~ Date completed ~'/-~-<~ ( Driller ~'~r~r~
c~ ~ Cased to ~ casing height //~ ''~'
I Wires properly protected (~N)
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG . AT INSPECTION
·
10 g.p.m. ~,~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main '~,,~
Sewer service line .
; On adjacent lots
; On adjacent lots
Public sewer manhole/cteanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform /
Date of sample: I/~/~[
Nitrate
I 0 ~.,) L Other bacteria
Collected by: ~ ~ ~----~GI~J~,~/¢
IC/HOLDING T~NK DATA - rt UE/~ '~' ~ ~ ~ ------
/ ~'-~ Tank size __ ~ .Compa~ments ~
Cleanouts (Y/N) ~undation cleanout (Y/N) ~ ~Depress~
High water alarm (WN) ~ ~ Alarm tested (YIN) ~
Date of pumping ~ ~ Pumper ~
SEPARATION DISTANCES FROM SEPTIC/H~
Su,ace water/d~ ~
72-0~ CONTINUED ON BACK PAGE
.IFT STATION
Date
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DI~
lot
D. ABSORPTION FIELD DATA ~//~
Date '
Length Width
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
level at
Manufacturer
Manhole/Access (Y/N)
~p off" Level at
tested
FROM LIFT STATION TO:
On adjacent lots
Surface
Soil rating (GPD/FF)
Gravel thickness
__Cleanout present (Y/N)
Results (pass/fail)
System type
Total depth __
Depression over
for
Bedrooms
yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELr
Well on lot
To building foundation __
On adjacent lots__
Surface
drain
On Pro~'~y~
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in e~,,~.¢'~.~'~f this
inspection.
Signature -
Engineer's Name -,
'
/
Date
H~ Fee $ ~. ~ Waiver Fee $
Dato of ~agmont
Receipt Number ~ ~ ~//9 Receipt Number
72-026(3/93)* Back
" INSPECTION APPOINTMEntS ~ ~~
MUNiCiPA.~_ _ EPT Or HE/,LTH
LITY OF ANCHORAGE ENVIRONME .~,
, . NTAL ~ kC'~ECTION
//~; ~. 825 L Street- Anchora~.Alaska 99501
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1, Incomplete requ~ will not be proc~d. Please a Iow ten (10) days for process ng.
' 1. PROPERTY OWN~ " ~ i PHONE
'MAILING ADDRESS -- ' .
PROPERTY RESIDENT (If different from above) ~ PHONE
MAILING ADDRESS ~ '
3, LENDING IN~IT~TION -- -- ' ~ ~ I PHONE
MAILING ADDRESS ' - r
4. REALTOR/AGENT ~ ' ~ ~ ~ ' ' I PHONE
MA, LING ADDRESS ~~ ~-
5:' LEGAL DESCRII~TION "
$~ HEET LOCATION
6. TYPE OF RESIDENCE ....
1~ SINGLE FAMILY
[] MULTIPLE FAMILY
7. WATER SUPPLY
INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
~. SEWAGE DISPOSAL SYSTEM
[] IN DIVIDUAL/ON-SlTE**
~ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
, UMSE"op.EDRoOM
[] One J~ Four [] Other
[] Two [] Five '"
[] Three [] Six
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 availab e.)
YEAR ON-SITE SYSTEM WAS INSTALLED.
1, TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
THIS SIDE FOR OFFICIAL USE ONLY,
[] ONE
[] TWO
NUMBER OFBEDROOMS
[] THREE [] FIVE
[] FOUR [] SIX
[] GTHER
2. WATER SUPPLY !
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
PERMIT NUMBER
DATE INSTALL ED
INSTALLER
SOILS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
Septic/Holding Tank
IAbsorpti;)n 'Area
Sewer L.i~e
INearest Lot Line
~5. COMMENTS
DATE
? APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
IBy
72-010 (Rev, 6/79)