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Home My WebLink AboutEKLUND #1 BLK 5 LT 2Eklund Block Lot 2 #050- 541 - 10 Municipality of Anchorage ...:;.~ Development Services Department .~. gu~mg Safety Division On-Site Water and Wastewater Program, 4700 S. gragaw SL P.O. Box lg6650 Anchorage, N< g9619-~.."0 Page www. ci. anchorage, akus (907) 343-7S04 O,-SrrE WAs'rmATE, DtS~'OSA[ S~STm ^,D/OR WE[t mS~'EC*~O. REPO.T Permit Number:...~.)t~Oo.~E.~' PID Numbe~ (~-,~"~- 5"t-i// -/~ "": t{;rk L.dv;9~en W~stew~erS~s~em: D.ew ~mr*de ~ P..*fhrr br; w E. tol..l~;~.'.//K qq 57 7-q731 ABSORPTION FIELD LEGAL DESCRIPTION '~,0o.o~ *~'~"*~'~-'~': ~ ~,. "~5 ~'~""~k~J~l-'~""~w''. ~.?~,~z_ ,, Well: O New O Upg~de ~ J SEPARATION DISTANCES ~septz O Ho~ing ~ S.T.E.P. O Othec ': I0~' I0~' 105' 5 I'~' ~/ ~.- ~~, ,/X '-'- -'- ,~.,~ 71' 73' ~0' ~,, ~ J ~ ' BENCH MARK Inspections performed by:£egle River, Ale~k,, 9957'/ Dates: Developmem Se~ices Depa~ont Approval Re',iewed ,nd approved by: ~ Date: PERMIT NO. $W020285 PACE 2 OF 3 D .......... ~u~_~ip..~_u~. y_o..~ ff. FAI~IMi:N1 UI- HI=AL1H AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION · P.D. Box 196650 e._Ancho~oge, Al~sk(l 99519-6650 · Telephone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 2, BLOCK 5, EKLUND #1 P.LD. NO. 050--541--10 LOT 4 / J I I I I I i I i / / / / / / / / / / / / / / I / I ,~ ii 'Oo./ ! \ ,, \ / / \ \ \ ,/ ./ / ,/ / · / / / PARK PER~{IT NO. SW020285 PACE 5 OF -~ D ........ M u n_i_c ip. g_.t i ~. y_o. ¢ .A.n_c h.o, .r' g g.e. bI~AN/MbN/ Oh HbAL/H ANL) HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION p.n. Box 196650 .Ancho."'c~ge, A_,.tc~skn 99519-6650® Tetephone: 343-4744 ON-SITE WASTEWATER DISPOSAL :SYSTEM AND/OR WELL INSPECTION REPORT LEOAL LOT 2, BLOCK 5, EKLUND #1 P.I.D. NO. 050--541--10 FINAL GRADE _ / _ :97.2' INSULATIO~,.,/ CONDUIT 1~' DISCHARGE PIPE 550 GALLON FAT ALBERT WITH PUMP ASSEMBLY f- MTI =101.1' yFINAL UTI GRADE w / FVI =101.8 I~rv?=~ot-9' J ....................... *"~ ;~'~' ~ORIGINAL GRADE UTI =97~~ % DIST. MNE-98.1 ~ , ~ ' N.T.S. A B FCO 21.0' 55.0' ST1 74.5' 108.5' ST2 78.0' 112.0' TMT 80.5' 114.5' MH 75.0' 111.5' FV1 86.5' 105.0' FV7 98.0' 117.5' MT1 79.0' 101.0' · NO GROUNDWATER 90.3' B.O.H. ~ 694 1211 P.02 0CT-16-~2 14:~ ~S ENGII',~r.J~IFIG ...- ,, *,, ,., , ~, ,~t,a-,au.~* p. ! October 14, 2002 Fax~ 907-6P4-1211 Electr~_' ~! work performed TWEED Excaw*i~.~ & Construction 17034 Eagle River Loop Rd, Suite 202 F. aglc l~v~*, ,~ 99577 On behalf'or: S & $ E~lneeting To whom it may concern: The r. lectr~ imtallagon of the litt slation at: lot 2, block $ - Eldund #1 4546 ?amh~ Drive, Chugiak, Alaska was I~:fotmed by a ~ ckcr~ian, in accord~c¢ with the current _~t~onal elcctric codc. Under pe'na]~, ofpojury, [ certify the above inforrnagon to be true and c0rrecL $inc,~ly, ALI,lED ALASKA F.J.,ECTRIC~ LLC Tweed £xcavat~ & Con.~ruct~on P.O. P,e~ 876310, FFasilla, Alaska g9687 0~ce (907) 373-$895 / Cel1232-lt687 / Fax $73~3894 MUNICIPALITY OF ANCHORAGE Development Services Department On. Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Aug 12, 2002 Expiration Date: Aug 12, 2003 Permit Number: SW020285 Legal Description: EKLUND #1 BLK 5 LT 2 Design Engineer: 0003 S & S Engineering Owner Name: Kirk Ludvigsen Owner Address: 4546 PANTHER DRIVE EAGLE RIVER, AK 99577-9731 Parcel ID: 050-541-10 Site Address: 004546 PANTHER DR Lot Size: 61177 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of,Naska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Parcel I.D. DeVeJop~erit Sei-VJces ~epartme~t Building SafelY blvlslon On-Site Water and WasJeWaler Program 4700 Soulh Bragaw SI. P.O. Box ~g6650 ~orage, AK 995t9.6650 ~.cl.anchotage.ak.us (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FA, MILY DWELLING O ~O - ~'z.//.- / ~) Permit Number SWOZ Properly owner(s) Mailing address (1) Mailing address (2) Legal description (Lot, Block & Sub'&) Legal descdplion (Section, Townshlp & Range) Lot Size ..t.,~ ~, I 3, .~ ) THIS APPLICATION Is FOR: Sewer Only Sewer and Well Sewer Upgrade THIS PROPERTY Not Tub Swlmmtng Pool Therapy Pool [] Number of Bedrooms Well Only Water Storage Jacuzzl Water Softening Unlt ["'1 I cedify thai Ihe above InJ'ormalion Is correcL I fudher cedify that Ihls application Is being made for a Single Fatally Dwellln[j and Is In accordance wilh applicable Municipal Codes. ~/~2 ~ $ & $ ENGINEERING (Slgnalure of properly owner or aulhorlzed agent) Permll Fees: I~ ~ ~ O. e~ Waiver Fees: Date oi~ Payment: ~/)..//O "z.- Date o~ Payment: ~ecelpl Humber: .o ~ 3 ~ ~ '-/ Recelpl ~umber: (Rev, 17034 Eagle River Loop Road, No. 204 Eagle River, Alaska 99577 September 17, 2002 ROBERT C. COWAN, P.E. CML ENGINEEP~S; (9O7) 694-2979 FAX (907) 694-'121 so~. TEST MUNICIPALITY OF ANCHORAGE Development Services Department P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 2, Block 5, Eklund S/D it is requested that you frY,SC permit~to install a septic system to serve the existing four bedroom dwelling on the referenced property. A lot line waiver is also requested for zero feet. A test hole was excavated and a percolation test was performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation on 9/I 6/02 the test hole was found to be dry. We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent properties. If you require additional information, please contact us. Sincerely, RCC/j}un Enclosure 17034 NORTH EAGLE RIVER LOOP * SUITE 204 · EAGLE F~IVER. ALASKA 99577 LOT 2, BLOCK 5, EKLUND S/D J.II.M R.CC. g-19-02 DESIGN CRITERIA: 4 BDRM = 600 GPO 360 SQ.FE. REQ'D. BED CRITERIA: 2.5' DEEP 0.5' EFFE~IVE 18' 20' LONC Z STRUCTURES, EASEMENTS, OR ENCROACHNEN~ SHOWN ON THIS SITE PLAN ARE AS SHOWN ON AN AS-QUILT SURVEY DRAWN BY: I~'[LLIAM D. FLEMING / LOT 4 / 10' Ufil Esmt ~ ' / ALL PORIIONS OF SY.STEM WITH LESS THAN 5.5 &OT[~J ~'~ COVER REOUmE inSULaTiOn. 58' LOT I CONTRACTOR IS REQUIRED TO OBTAIN UTILITY LOCATES PRIOR TO ANY EXCAVATION WORK. EXISTING SEPTIC TANK \ (TO SE PU~PE0 ~ PARK CRUSHED & SYSIEU TO BE ~BANDONED~ -REQUESTED LOT LINE TO ZERO FEET ,ED 550 GALLON FAT ALE~ERT TANK ) 1300 GALLON HDPE SEPTIC TANK AREA TO BE FILLED TO LESS THAN 25% Munlcipallty ~f Anchorage Developmen! Servia:es Department Building Sa[ely Divlsloll On-Site Water and Wastewater Program 4700 S~th Bragaw SL P.O. Box 196650 A~chorageo AK 99519-6650 www.cl,ancho~a~e.ok.u$ (907] 343-7904 Soils Log - Percolation Test Depth (Feet) I- .'"' O 3- °~'~. ,: ./ 8- .'"" 13. 14- ' 15- 16- 17- 18- 19- 20- ENCOUNTERED? IF YES. AT WHAT DEPTH? Dale: Dale Gross Time Nel Time Depth Io Water Net Drop o ~) 1074" ~o '~o I b '/Z~ ~,'/4-' o o I0~ ~o '30 I~?~." PERCO~,_ATIOH F~TE ~__~ (~rmute~,x:h) PERC HOLE DIAMETER TEST R~ BE~EEN ~ ~ ~/O_. ~ COMMENTS~ ' ' ~ -- PERFORMED IN ACCORDANCE WITH AIr STATE ~D MUNICIPAL ~UI~[INES IN EFFECT ON Municipality of Anchorage Development Services Depaifment BuUding Safely Dlvlslo~ On-SIle Water and Wastewater Program 4700 Soulh Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www,d.encho~aqe aku$ (907) 343*7904 Soils Log - Percolation Test Performed Fro*: /-.--L,/~) V ~ ~'5 ~'--~ Sk~e Site Plan Depth (Feet) 1- 4-/. 6- O ':-' 10- ' ' / 13- t" 15- 16- 17- 18- 1g- 20- Reading Dale Gross Time Net Time Depth lo Water I Net Drop PE RCOU~TION RATE TEST RUN BETWEEN COMMENTS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Building Sa[ely P.O. Box 19~ ~age, AK gg519-6650 Soils Log Percolation Test Depth (Feet) §. 7°0 .' 0- 10- 12- 13- 14- '15- '17- 18- 20- WASO.OUNOW^TE. __, O ENCOUNTERED? ,. IF YES, AT VVTIAT DEPTH? . O Deplh lo Waler After p Monitoring? E Dale: Reading Dale Gross Time Net Time Depth to Water Nel Drop 0 0 8" -- o o g~" -- 3 o ?o i i" ~" o o - 7,0 ~o I l Y4" :~" PERCOLATIO~I RATE TEST RUN BETWEEN jt O Im'r~l PERC HOLE DIAMETER ~ FT AND ~ FT COMMENTS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON Ti-IlS DATE. DATE: RO6ERT C. COWAN, P.E. CML ENGINEERS (907) 694-2979 FAX (907) 694-1211 INTERMITTANT DOSING SAND FILTER SPECIFICATIONS Lot 2, Block 5, Eklund Subdivision September 17, 2002 GENERAL STATEMENT OF WORK The work and plans covered by these specifications consist of fumishing all labor, materials, tools, transportation, and equipment necessary to complete an Intermittent Dosing Sand Filter system as described herein and on the attached drawings. All work under this project shall comply with current Municipality of Anchorage (MOA) Regulations. 4 Bedroom House 600 GPD Use 18' x 20' Bottomless Sand Filter and absorption area (360 S.F. required) Sand filter to be constructed on accepting soil with all organics removed. (bottomless · only.) SITE INVESTIGATION The Contractor must carefully examine the project documents, have full knowledge thereof, have investigated the site, and be satisfied with the conditions affecting the work. Conditions include, but are not limited to those bearing upon transportation, disposal, handling and storage of materials, availability of labor, water, electric power, roads, and uncertainties of weather, physical conditions at the site including all underground utilities, the conformation and condition of the ground, the character of equipment and facilities needed preliminary to and during prosecution ofthe work. The Contractor must be satisfied with the character, quality and quantity of surface and subsurface materials or obstacles to be encountered. Any failure by the Contractor to become acquainted with the available information will not relieve him/her from responsibility of performing the work as stated in these specifications and drawings. Location of utilities will be the contractor's responsibility. 17034 NORTH EAGLE RIVER L.CX~P · SUITE 204 · EAGLE RIVER, ALASKA 99577 Page 2 Lot 2, Block S, Eklund S/D September t7, 2002 SEPTIC TANK / Lll:'r STATION / AIR COMPRESSOR General The work under this section consists of the performance of all operations pertaining to furnishing and installing the septic tank/lift station, air compressor and piping to the sand filter. B. Materials 1. Tank a. Septic tank shall be a two compartment tank of at least the minimum size indicated on the drawings and MOA approved. b. First compartment shall have a separate 4" pump-out riser. The second compartment shall have a separate 4" pump-out riser. 2. Manhole Riser or Lift Station Tank a. An additional second compartment manhole riser shall be capable of being equipped with the following: 1. A junction (Nema 4x) box or equal, bonded or attached to the pump basin. 2. LtL listed electrical cord grips, installed in the J-box. -OR- b. An additional tank (M.O.A. approved) may be provided for the effluent pumping assembly and the items in (a.) above. Effluent Pumping Assembly, Controls, Alarm & Piping a. Effluent pumping assembly shall be of approved materials, including the following: 1. A 110 volt or equal LI.L. Listed effluent pump. Page 3 Lot 2, Block 5, Ek]und S~D September 17, 2002 2. High-density PVC cylinder housing the pump, with level controls and screen, serving as a baffle to prevent the screen from clogging. 3. All piping shall be PVC or other non-corroding material. b. Pump controls and alarm system shall be an approved system with the following options consisting of: 1. Event counter 2. Elapsed time meter 3. Program timer 4. 10 watt heater 5. Remote alarm panel option with a minimum of 80 DB sound pressure at 24", operating temperature 30AC to 65AC, continuous sound to be located in the home. 6. Oil-tight visual alarm with push-to-silence feature. Automatic audio-alarm reset. 7. 15 amp motor rated toggle switch, double pole, double throw with three positions; manual (man), automatic (auto) and center (off) (H.O.A.). 8. Nema 4x-rated, fiberglass, or equal, enclosure with hinged Cover. 9. All controls to be installed as per manufacturer's recommendations. 10. Control panel to be installed on outside wall of home within sight of septic tank/lit~ station. c. Piping from the septic tank to the sand filter is to be 1 1/4" PVC schedule 40 solvent weld piping properly bedded as described in Materials Specifications and sloped to drain back to the lift station. Insulation board 2" thick and 2' wide centered over pipe is to be placed where soil cover is less than 4' depth over pipe. Page4 Lot 2, Block 5, Eklund S/D September t7, 2002 d. The air line fi.om thc house to thc filter is to be HDPE arctic insulated pipe 3/4"-2" SDR- I 1. The compressor will have a gauge (0-10 psi) and he installed in a heated area, crawl space, or garage. 4. Air Compressor a. Air compressor shall be a THOMAS LINEAR SERIES model number 5060-A or 5070V-A or M.O.A. approved equal. CONSTRUCTION SEQUENCE In order to insure proper installation, the system is recommended to be installed in the following order: I. Sewer line fi.om house to tank II. Septic tank/lift station III. Sand filter IV. Leachfield bed (if required) V. Final grading CONSTRUCTION 1. Construction Instruments Contractor shall provide instruments such as transits, or levels, for establishing proper elevations and levelness of pipe or materials. 2. Pipe Laying All pipe shall be laid with material free of large or sharp rocks and organic matter. Each section of pipe shall be handled carefully and placed accurately. The spigot end shall be fully inserted pointing in the direction of flow and glued in place to make a water tight seal. Page 5 Lot 2, Block 5, Ek;und S/D September 17, 2002 Each section of pipe shall be properly supported to insure true alignment and an invert which is smooth and free from roughness or irregularity. At all times, when work is not in progress, open ends ofpipe and fittings shall be closed so that no undesirable substance will enter the end of the pipe or fittings. 3. Bedding of Pipe for Sewer Lines The pipe should be bedded with materials free of large or shaxp rocks and organic matter, compacted. Native materials may be used as back fill material above the pipe, provided it is free of large rocks and organic matter. All lift stations shall be installed in accordance with the manufacturer's recommendations and standards. Electrical installation is to be in accordance with the National Electric Code (latest adopted edition) by a licensed electrical contractor, with M.O.A. inspection where required. If MOA inspection is not required, a licensed electrician is to provide a letter to the Engineer stating that the system meets or exceeds all applicable codes. 4. Excavation Excavate to proper depth to allow gravity flow, install tank level, tolerance 0.05 foot, on undisturbed or compacted classified sand fill material. Create a level sand surface over the tank and add 2" burial foam +35 PSI directly over tank. Mound unclassified soil over tank with a minimum of 2 feet ofcover and anti-flotation weights that may be required in areas of shallow ground water. 5. Connections All connections to be as per MOA requirements, PVC 3034 piping with Caulder or equivalent couplings for inlet riser pipes. All tank connections are to be completely water tight. SAND FILTER The work under this section consists of the performance of all operations pertaining to furnishing and installing the sand filter. Page 6 Lot 2, Block 5, Eklund S/D September 17, 2002 A. Materials 1. Sand Filter a. Liner (if required - not required for bottomless sand filter) - OSI Model LI or equivalent. 30 mil PVC cut and fabricated to provide water tight enclosure of filter sand volume. Seams to be permanent as per Manufacturer's recommendations. All connections, such as boot flanges, through sand filter to be permanently bonded to the liner. b. The Contractor shall provide a washed sand to meet ASTM C-33 Concrete Sand Specifications with the additional requirement that all but 1% of the materials passing the #100 sieve be removed. All aand shall be approved for use by the Municipality o f Anchorage (M.O.A.). If the sample does not meet specifications, all sand will be removed and replaced. c. The Contractor shall be responsible for providing pea gravel that shall be a washed material containing no fines (0% passing the #100 sieve) and a maximum size of I/4" diameter. d. The Contractor shall provide the manifold assembly. The manifold assembly shall be of approved materials with orifice shields and flushing assembly. All drilled holes to be cleaned of burrs and pipes flushed, prior to assembly. Flushing valve to include riser to finish grade. Lateral distribution piping is to be laid level (@ + 0.05'). e. Side walls and top ofthe filter box to be insulated with 2" direct burial polystyrene insulation. f. The Contractor shall be responsible for providing filter fabric. g. Air coil in sand filter to be geoflow WF16-4-24 150 LF placed 6" above bottom of sand. Construction of Sand Filter The sand filter construction is to follow procedures as outlined below, as applicable to this design. Page ? Lot 2, Block S, Eklund S/D September 17, 2002 Pea gravel and filter sand arc to be hand leveled to proper depth (tolerance within 0.05 feet) in filter, taking care not to allow mud or fine soil material into the filter or gravel layer. This would include any soil material picked up by excavation machinery buckets while loading specified material. The Contractor should estimate filter material volumes such that allowance is made fo,r wastage of material in contact with the ground at site. The area over the sand filter to be finish graded with a minimum of 2 feet of cover and to prevent ponding of surface water run off. Side slopes shall not exceed 3:1. Thc Engineer will reject any sand or pea gravel that does not meet specifications or is contaminated in transit or while handling. If such material is placed in the filter, all soil material may be required to be removed and replaced with new material. CONTRACTOR / INSTALLER M-nicipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewmcr Pmgram 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519~o~-~1 www.ci.anchorage.ak.us (907) 343-7904 Waiver Review Worksheet WI~: WR020071 PIl~: ~1}0-541-10 I"IA~: Permit~: Date Received: 9120/02 Legal Description: Eklund #1 Block 6 Lot 2 Engineer:. Bob ¢owan PE $&$ Enalneaflna. In¢, Applicant: Kirk Ludvlaean ,O Waiver Requested: 0 feet from eb~omtlon field to lot line Criteria: Geology A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: Points: Waiver Is Granted: ~ Waiver Is not Granted: Ll~t Conditions oe Reasons for above: ~ .~ E /~)'/7'/;/ ('/cf ~ Name of Reviewer Rec~: 25901 Amount: $150.00 Date Paid: 912312002 Geor§e 1: tVuerch. Mayor Municipality of Anchorage Building Safety Di%4sion Anchorage l.a.l Ali. America City 2OO2 9/23/2002 Robert Cowan, PE S & S Engineering 17034 Eagle River Loop Rd. Suite 204 Eagle River, AK 99577 Subject: Waiver Request for Eklund Block 5 Lot 2 Waiver Request #WR020071 Parcel ID #050-541-10 Dear Mr. Cowan: Your request for a waiver of the required 10 feet horizontal separation from the absorption field to property line has been approved. The approved separation distance is 0.0 feet. This waiver approval applies to the existing absorption field to property line separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this deparanent. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, Civil Engineer On-Site Water & Wastewater Program P.O. I~)x 19(W~50 · Anchorage, Alaska 00519-6(550 · Tclcphonc: (907) 843-8301 · Fa.x: (907) 8~t3-8200 4700 South Bragaw Street * Anchorage, Alaska 9D507 h t tl~://www.cl.nnchoragc.ak.us oGREA ER ANCHORAGE AREA B0k ,dGH Department3330°f EnvironmentaIc Street Quality Anchorage, Alaska 99503 INSPECTION REPOf(T ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE ? ,~.' / ' .... _~ :/-( /' NUMBER OF ¢.p~ FROM WELL " MANUFACTURER ~' K( ( /~ MATERIAL (- COMPARTMENTS , INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH .... LIQUID CAPACITY_ ¥~ ¢' ¢'; GALLONS. SEEPAGE PiT: NUMBER OF PITS f DIAMETER__ LINING MATERIAL~:/~// ~ ~¢ CRIB SIZE: OR WIDTH DIAMETER___ BUILDING FOUNDATION____, NEAREST LOT LINE__ ADDITIONAL ABSORPTION LENGTH,;) '~ DEPTH / DEPTH _ - DISTANCE FROM: WELL //C? ./ TOTAL_ EFFECTIVE ABSORPTION AREA (WALL AREA) SQ. FT. WELL: TYPE CONSTRUCTION BUILDING NEAREST FOUNDATION LOT LINE CESSPOOL OTHER SOU RCES APPROVED _ DISAPPROVED _ __ NEAREST SEWER LINE REMARKS DEPTH DISTANCE FROM: SEPTIC SEEPAGE TANK SYSTEM DISTANCES: INSTALLED BY: LOT SLOPE: ~ r REMARKS; DIAGRAM OF SYSTEM APPROVED 4 6 10 12 14 16 18,, 20 "One test is worth a thousand op'.io.s ' ~ 2204 Clevela~nd Anchorage, Alaska 99503 Legal ~escri~tion: Lot,,,,~_ Block ~'Subdivision This ~orm Renorts Soils Lo~ ~,~ Percolation Test ~e~th Feet Soil Characteristics Was Ground Water Encountered? /~//0 J/oDe I~ Yes, At what De~th? t Readinq Date Gross Time Net Time Depth to H20 Net Dron Percolation Rate Hinute Proposed Installation: Seeoaqe Pit Drain Field Depth of I~Let '7 Denth~To Bottom Of,_FDPit_O~ Trench_._____~_ Test Performed By ~v~ ~9-CL(~ Data Certified BY: ~7-7---, Da te: ~////Z/,. ,-- _ I..OT '- ......... . PI'JiNIP'iiJFi E;,ISTFiNC:E Bt;:,;'i"t.~IEEi',I Ft HEL.L FtN[) :i,OP.i FE;E;T FOI';-": FI PF;:Z'v'FITE HELL. (;ii;:' TILE' 14Et,~.l. C;0t'~IPLEY;(ON. 5F'EC: ); !':' !' C:F:iTi C6,k~i; FINE:' COt',ISTI;iiLIC:T :E N~!;:;'I' i :IL..t...F:I"i' ;( OF,I. ::L: :l: i::ii"t F:'i:::li"t}: L.. :(l::t[.~: [',l:!: 'i"H THE: [;:E);~Lt:!;i;;:t~'~l'"il~i(i",t'i' E; t;':(:)t:;~ ON,--?J ): 'i"[~ ... ~:,.[.IE.[ ........ FtI",!I:) f4t~'::L..I,.,E; FIE; OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE - Started PERMIT NUMBER by A & L DRILLING COMPANY BOX 97, EAGLE RIVER, ALASKA 99577 · TELEiaH0iME 694-2588 Ended DEPTH OF WELL STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR KIND OF CASING KIND OF FORMATION: From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft From Ft. to Ft From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft From Ft. to Ft. From__Ft. to Ft.. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft From FT. to .Ft From Ft. to_ Ft From__ Ft. to Ft. From Ft. to Ft~ From __ . Ft.r~ FL From Ft. to Ft From Ft. to Ft. From Ft. to Ft. From Ft. to Ft._ From Ft. to Ft. From .Ft. to___Ft. From__.Ft. to___Ft. From__Ft. to__Ft. From__.Ft. to Ft. From Ft. to___Ft. From Ft. to Ft. From Ft. to__Ft MISCL. INFORMATION: DRILLER'S NAME Muuicipaliiy of Anchorage Development Services DelJartmen{: Building Safety Division On-Site Water and Wastewater Program 4700 Soulh Bragaw St. P.O. Box '196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak. Us (907) 3,t3-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-5/~1-10 1. G E N E R_ ,,,~.~I~].F-O R MATIO N .~'~ ~ ~":. Comp[~'l~al'description Lot 2: Location (sRe"aiJdress or directions) 4546 Expiration Date: ///(,/~,7 Block 5: E~l~nd ,q.hd~v~sqnm -~1 Current Property owner(s).,Kir k LudviRsen Mailing address -" s'ame Lending a~n~y Day phone 349-6550 Day phone Mailing address Real Estate Agent Mailing Address · Unlessoff~erwiserequested. HAAw#lbeheldbyDSDforpickup. 2. NUMBER OF BEDROOMS: 4 Day phone 3. TYPE OF WATER SUPPLY: Individual Well Individual Waler Storage Community Class ~ Public Water System Well TYPE OF WASTEWATER DISPOSAL: Individual On-site [~( Individual. Holding tank Commumty On-site [] Public Sewer The Municipality of Anchorage Developmen! Services Department (DSD) Issues Certiflcates of Health Authority Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional civil engineer registered In the Stale of Alaska. Cedificales 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 waler supply system. DSD also Issues HAAs upon request to homeowners. Certificales of Health Authority Approval are valid for 90 days [rom the date of issue for properties served by a private or Class C well and may be reissued wllh new water sample results less than 30 days old. (Cedilicates may be reissued for a period o~' up to one year with valid water samples.) Certilic'~tes are valid t'or one year for properties served by Class A or B wells or a public waler system. The Municipalily of Anchorage Is no{ 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 da(e shown bel(~'~, I verify thai my Inves{tgalion, . based on procedures outlined In the Health Aulhorily Approval Guidelines for this application, shows that Ihe on-silo water supply and/or wastewater disposal sysle~ la(are) safe, functional and adequate for the number of bedrooms and type of struclure Indicated herein. I [udher Verify Ihat based on Ihe Information obtained from the Municipalily of Anchorage files and from my Investigation and Inspection, the on-site waler supply and/or waslewater disposal system Is(ara) In compliance wilh all applicable Municipal and State codes, ordinances, and regulations In effect at the time of installalion. NameofFirm S & S En~,ineerin¢. Address 17034 N. EaF, le River Looo Ste. Engineer's Printed Name Robert C. Cowan 5. DSD SIGNATURE /'/' Approved for ~t' Disapproved. Conditional approval for Phone 694-2979 204 Ea~,le River, A~ 99577 Date ').//0/~ 'Z. bedrooms. bedrooms, with the following stipulations: Additional Comments By: Attachments: HAA Checklist Septic Syst. em Advisory Well Flow Advisory X Maintenance Agreements SUpplemental Engineer's Report Other Odgin~l Cedifica[e Date: M.nicipality of Anchorage Development Services Department Building Safely Division On-Site Water & Wastawater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanctmmge.ak, us (907) ~,3-7g04 HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA · ,. ' Well type ~. Date completed ~_~G Total dep~ ~,~) ft. IfA, B, otC provide PWSlD # .~ Sanity =esJ (Y/N) Y, FROM WELL LOG we.u ~og (Yin) Wires properly protected (y/N) Casing height (above ground) "~,~' in. AT INSPECTION Static water ~vel ' ~'g~' ff. ~ ff. Well production ,,~1. O g.p.m. 4' O g.p.m. WATER SAMPLE RESULTS: Coliform O coloniesJl00 mi. ~_~eni. c: ,,~. Nitrate O. 3o'7 mg./I. Other bacteria 0 colonies/100 mi. B. SEPTIC/H,,OL-~G TANK DATA - Claanoute (Y/N) '7' Tank: __ gal. ",.~ ~'NumberofCompartmenla Fou~da;;ncfeal!p~(y/N) L/ · Depmssionoverlank(y/N) Data. of pumping /~J~.,,-'~. Pumper C. ABSORPTION FIELD. D.A.T~,A'~,,,) Data installed il rating (g.p.d./ff~ or ~rodrm) Data of adequacy test /'~ ~--'"~ Results (Pass/Fell) Fluid depth in absorption field befora//M~'/' in. Elapsed Time: min. /;~nal fluid depth Any rejuvenation treatment (~a'st 12 rno,) (Y/N & type) High water alarm (Y/N) ""/ Systam type Gravel below pipe ~eZ~"' ff. y Depression over field ~,J For ~ bedrooms Water added gal.-- N~p~epth in. in. Absorption rate>=/ g.p.d. If y~ give date D. UFT ~TATION 'Pump on' level at ~¥ in. Datum T/~,,K ~ro~ S ze in gaaor= 'Pump off' level at.~ in. cycles tested aanhote/Access (Y/N) "-/ High water alarm level at ~ g in. Mee~ earm & dn:u~t req~mm~nts? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: tank/lilt station on lot /~,O ~ ~f/0~ ~' ' Septic Absorption field on lot / On adjacent lots /00 ' On adjacent lots / Public sewer main ////q' ~ Public sewer manhole/deanout S~v~?/septic sewtce line '~ ~ ,'~' Holding tank ~/,~' SEPARATION DISTANCES FROM SEPTIC/HDL'E'fl~G TANK ON L°T TO: Building foundation .~' /v'.- Pmbe~y line '~'/~- Absorption field Water main ~,J/A ' Water sendce line /O "/' Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Pmpertyline (:::~)/R~ Building foundation .'//'~-' Watermain Water 8ewice line /(~7 Cu=in d ain D~veway, pa~ng/vehide storage O / HAA Fee $ Date of Payment Receipt Number (l~v. 12~ol) F. COMMENTS O. ENGINEER'S CERTIFICATION I cer~/fy that I have determined through field i~spect~ons and review of Municipal recess that the above systems ere in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name ~a~,,~.r- C". /<) //·/0 ~.. Waiver Fee $ Date of Payment Receipt Number T~ A IJ'~ A PANTHER DRIVE (POSTED) - 6x25xOZ AS t DATE NOTES: Easements plat are nat provided by ciient. or builder, prior c~nneclions, ~1 to appel' on the recor EleVOliOns based on indicoledo and beor~ LOT Z, BLOCK EKLUND SUi~D I VI ADDITION NO. PLAT NO. 71-115 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 l\(9 Application Date _August 5, 1986 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 2; Block 5; Eklund Subdivision Addition #1 Location (address or directions) (b) Applicant Name Pat Hauard __ Telephone: Home 694-9257 Business Applicant Address SR 2313 Eagle River Road, Eagle River, Alaska 99577 (c) Applicant is (check one): Lending Institution []; Owner/builder [~; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Heritage Homes/Suzanne Cool Address BOX 126 Eagle River Roads Eagle River, Alas]ca Telephone 99577 (f) ~]~e HAAtothefoltowingaddress: S & S Engineering SRB 196X Eagle River Road Eagle River, AlaSka 99577 TYPE OF RESIDENCE Single-Family ~] Multi-Family Number of Bedrooms 3 Other WATER SUPPLY Individual Well ~] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite~[]f, 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. 72-025 (11/84) Page 1 of 2 ENGINEERING FIRf~I PROVID,...G INSPECTIONS, TESTS, FILE SEARCH, L... f'A 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 trom 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 Name of Firm Address Date DHEP APPROVAL Approved for '/¢~-"~'~ bedrooms by ~ ~" /4~'' '~17~'¢,~.~,~.~,.~-, Date Approved ' z'~'~ . Disapproved Conditional. Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) A~C~ ~ of '~ o ~'0~ ~.?~. ~.~. ?~ HEALTH AUTHORITY APPROVAL (HAA) ~ ~ C ~ ~9 ~ 264-4720 ~gg~ g~ Legal Description: WELL DATA Well Classification,~/M'¢¢/¢- If A, B, C, D.E.C. Approved (Y/N) Well Log Present' '((.~N) Date Completed ~-'/? ~ Yield ~'A/E~'c'~c',//~J // Total Depth ~ ~.O ¢ Cased to ~/O_~ ,~'~Z~ Depth of Grouting /'~ ~ Static Water Level ~ ~" Casing Height Above Ground Electrical Wiring in Conduitl~N) Separation Distances from Well: To Septic/Holdifr~Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleano0t/Manhole Water Sample Collected by : J: ~/"¢¢'¢--/?/~/ ;Date Water Sample Test Results ~-~ ~ ~/~ ~ ~ Comments ~ ~/~ ~¢~~ Pump Set At L,, / Sanitary Seal on Casing~N) Depression Around Wellhead (Yin) ; On Adjoining Lots //OD. t'~ ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~--~ / B, SEPTIC/~TANK DATA 0/:// /,~ CDate Size Installed No. of Compartments Standpipes Air-tight Caps Y~) Foundation Cleanout (YO Depression over Tank (y0 Date Last Pumped Holding Tank High-Water Alarm (Y/N) ~ Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/H~Tank: To Water-Supply Well ,,~ ~7~ ! ¢ To Property Line //(~ To Water ~/Service Line Course ! To Building Foundation ~ · 17/ To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 7/?,~_4 ! Width of Field Square Feet of Absorption Area Depression over Field (Y N~). Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Type of System Design ~/")¢ '~ / Length of Field ~ Depth of Field //O · Gravel Bed Thickness ~ ~ Standpipes Present~/N) Date of Last Adequacy Test ,~,,/~ ~ ~ To Property Line ; On Adjoining Lots To Existing or Abandoned System on To Water Main/Service Line ~¢q3 ¢.¢ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments /00 ~_r/~_ To Cutbank (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions ~/~Vlan hole/Access (Y/N) / ~.~p Off" Level at ¢ ' Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certif~ ~ I~~j~lfied, or conformed to aliSA ~ HAA guidelines in effect on the date of this inspection. Signe~R ~ ~X Date ~~ '~ Com~~~ MOA No. ~ ~00 ~ ReceiptNo. ~00 I O0 / ¢ Date of Payment Amount: $ __ Page 2 of 2 72-026 (11/84) SCALE ROBERTA. SHAFER HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN CIVIL ENGINEER 694-2979 September 28, 1986 MUNICIPAUTY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION Municipality of Anchorage Department of Health and Human Services 825 L Street Anchorage, Alaska 99501 RECEIVED ATTENTION: Steve Morris REFERENCE: Lot 2; Block 5; Eklund Subdivision Addition Dear Steve, Request you approve the attached Health Authority Approval application and grant a waiver to the horizontal separation distance between the private well and the septic tank. The well and septic system was installed in September, 1976 and at that time the Greater Anchorage Area Borough allowed the septic tank to be installed 76 feet from the well. Attached for your review is a site plan and waiver review work sheet along with other documents required for a Health Authority Approval. Based upon the risk analysis shown on the waiver review work sheet it is our opinion that the horizontal separation distances prescribed by 18AAC72.021 are not required in this case. If you r/equate additional information, please contact us. ~O~RT A. SHAFER, P. E. k~S/ss SRB 196X EAGLE RIVER, ALASKA 99577 P.O. BOX 66,'50 ANCHORAGE, ALASKA 99502-0650 (907) 264-4'111 I-ONY KNOWLES, MA YOR DEPAFIT~'~ENT OF HEAl. TH & HUMAN SERVICES October 6, 1986 Robert A. Shafer, P.E. S & S Engineering SRB 196X Eagle River, Alaska 99577 Subject: Lot 2 BLock 5 Eklund Subdivision #1 Waiver Request~ WR86-145 Dear Mr. Shafer: Your request for a waiver of the 100 foot separation required between the septic tank and well on the subject property has been granted. The required distance has been waived to 76 feet in this case° This waiver is valid for the existing three bedroom single family dwelling only. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/ljw APPLIC F,!LLS OUT UPPER HAL ONLY ' i~ ; t / Phone Property Owner ~' .~ -i~ ' ~ ;' ' /'b,'' /'' / Mailing Address,~.( .., ~' :'/ ,,:< ( "' ';~ ~ ,~ ':i,' ..! ,,/( /:,.~ ~,~, .+.. , ,,,~.;; Zip Code / ~ Buyer Address Zip Code Phone Lending Institution (. ' i ¢ Address .: /;.:' "'~ ~ " Zip Code ;".. f .j' ~ ; /'~ / ~' ~' , . 1' ~ ~ [ ' :' Phone RealtyCo. & Agent ~ '~ k. ) ( / ~'~L ¢ )L , ,~ : , )q ,:~ /' ~; ' i -: Zip Code , Legal Description ,:. ~:' , . Type of.,Besidence '" :~r / ~'~ngle Family ~ Multiple Family No. of Bedrooms_ ~ Other Water SBpply ~¢,F~ividual A~AOH WELL LOG. A well Icg is required for all wells drilled since June 1975. E] Community For wells drilled pdor to that date. give well depth (attach Icg 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 RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector ( ) APPROVED BEDROOMS ~ *CONDITIONS OF APPROVAL ( ~,DISAPPROVED · Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size 72-023 (3182) We certify there have been no c~'~anges to this As-Built Date Date Da~e Inspoctor Inspoctor In~poctor Gommonts /~, ~ ~ ~' Gonditional A~proval Well to Tank / , , APPLICANT FILLS OUT LOWER HALF ONLY Property Owner /~:~h¢ ~/z/CL / ; ~/~ '~ Phone¢ Address Type,of Residenc~ ~ Multiple Family No. of B~dvooms ~ Other Watff~ Supply ~ Individual ATTACH WELL LOG. A well log is required for a~l wells drilled since June ~ Community 1975. For w~ls drilled prior to that date, give well depth (attach log if ~ Public Utility. available.~ Sewage Disposa~ ~ IndMdual Y~ar IndivMual ~nstall~d: ~ Public Utility When Connected [o Public Utility: ~ Holding Tank AS.BUILT SURVE'r %%1;' -':"./ '-. I hereby certify that I have surveyed the following described property. LOT 2, BLOCK 5, EKLUND SUBDIVISION,ADDITION NO.I Anchorage Recording Precincts Alaska and thai the improvements situated thereon are within the property lines and do not eve. r-lap or encroach on the property lying adjacent there- lo, that no improvements on property lying .adjacent thereto encroach on the premises in question and that there are no roadways~ transmission lines or other visible easements on said property except as indi-" cared hereon. Dated at Eagle River~ Alaska~ this 5Ih day of March, 1980. Richard P. Hankins Registered Land Surveyor il / 5'/ ~ ~, ¢~o6'o5 F- t~4.So ~o EXCAVATION ROBERT A. SHAFER WORK CIVILENGINEER 694-2979 Re/Max Realty ATTENTION: Virginia Kohfield P.O. Box 848';. Eagle River, Alaska 99577 Dear Ms. Kohfield, April 26, 1982 MUNICI?ALITy OF ANCHORAGE ENVh ~ !: ", ,~ ~ , I Reference: Lot 2: Block 5: Eklund Subdivision A sewer system adequacy test was performed on the system located on the referenced property as you requested. The septic tank was pumped and verified to have a capacity of 1000 gallons. The absorption trench was tested for percolation over a period of 48 hours. During the last 24 hours of the test 486 gallons was placed into the absorption trench by continuous flow ~ithout any adverse effect on the system. It can be concluded from this test that the waste water disposal system serving the three bedroom residence located on this property is currently functioning adequately. However, the system cannot be guaranteed against subsequent failures. The cleanout pipe, as referenced by the Municipality, on the sum~ at the end of the trench has been extended as required. If we may be of further assistance, please do not hesitate to call. , /. ?' ~OBERT A. SH~ER, P.E. /~s/ss cc: Municipality of Anchorage Department of Health and Environmental Protection SRB 196X EAGLE RIVER, ALASKA S~C' t DATE RECEIVED I-' IN TION APPOINTMENTS TIME / TIME TIME / '3:, INSPECTOR INSPECTOR I NSPECTO R MLIN c p/t tTY OF ANCHORAGE DEPI-, MUNICIPALITY OF ANCHORAGE ENVIROi ,~; ,, DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVI fiONME~TAL SANITATIO~ DIVISIO~ REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES 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 PROPERTY RESIDENT (If different from above) / PHONE 2, BUYER PHONb 3, LENDINGINSTIT~TION , ~ PHONE I MAILING ADDRESS 4. REALTOR/AGENT I PHONE I MAI LING ADD~ESS 5. LEGAL, DESCRIPTION TR/E~T LOCATION 6. TYPE OF RESIDENCE , SINGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTI LI':TY NUMBER OF~BEDROOMS [] One [] Four [] Two [] Five F~ Three [] Six [] Other ATTACH WELL [(~G. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available.) 8. SEWAGE DISPOSAL SYSTEM ~. INDIVIDUAL/ON-SITE** [] PUBLIC UTI LIT, Y YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72 010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE ~J OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX ~ERMITNUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL I~] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER [~Septic Tank or ~]Holding Tank Size: / (~(:/0 If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER /(~ . ~ ~ ~ TOTAL ABSORPTION AREA MATERIAL 4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line WELL TO: _ _ Absorption Area to nearest Lot Line 5, COMMENTS [~-~-APP R OV E D FOR - BEDROOMS [~ CONDITIONAL APPROVAL (letter must accompany certificate) l/J ~). ~'/~[] DISAPPROVED _ DATE BY ~ 72-010 (Rev. 6/79)