HomeMy WebLinkAboutCONIFER HEIGHTS BLK 2 LT 13 MUNICIPALITY OF ANCHORAGE
He~ =h and Environmental Prote, ion
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
264-4720
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE
FROM WELL MANUFACTURER ~__MATERIAL
INSIDE WIDTH LIQUID DEPTH
INSIDE LENGTH.
NUMBER OF
COMPARTMENTS. ''~
LIQUID CAPACITY~O GALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WEL~,"~,~a~' __
~ of Lines ~
ABSORPT,ON AREA
DEPTI t:
FOUNDATION NEAREST LOT LINE
DISTANCE BETWEEN LINES CJ~ .TRENCHWIDTH"~. IN.
ti DEPTH OF FILTER
TOP OF TILE 'I'O FINISH GRADE ~(~
TOTAL LENGTH
OF LINE
TOTAL EFFECTIVE
MATERIAL BENEATH TILE ~:~1.~. i IN. ABOVE TILE ~', IN.
SEEPAGE PIT:
Log Crib Rings
BUILDING FOUNDATION
DIAMETER ~ OR WIDTH , LENGTH , DEPTH
Crib .Si~.e: DIAMETER~DEPTH DISTANCE FROM: WELL
TOTAL EFFECTIVE
, NEAREST LOT LINE ~ ABSORPTION AREA (WALL AREA)
SQ. FT.
Well
Class: ~9 Depth:
Well Distance To: Lot Line
Bldg: Sewer Line:0.%%~
Pipe Materials:
# of Bedrooms:
Installer:
Remarks:
APPROVED .~ ~ _'~~~
F'ERr"I I ].' NO.
FFFLI_.~I'-,Ir FILFt'_."-';I<'F~ RIIILE:,ING ,~ DESIG .-'rb:'L F..UE, T DR
i'"1 'I-IRD
L. OCF~TION J::"EIRT ~ J~ ~ . · DR
LEGFIL L.::LZ'-': E;2 I_.~INIFE~.. HTS --,,'[.'
TYF'E ElF SOIL I=IBSORBTI fin SYSTEM IS ' TF.:ENCH
DEPRRTMEN].' fi" HERL. TH RNE:, EN, IF.._NrlEN].ML F "TEE:"r'IF, N
:5:25 '"L C;TF.'.EET.. RNC:HORRGE, RI.:::.
· ' 264-4720
,:: 780152 )
'~ 'B. 5 0 2
LOT SIZE
40000 '= L-]LtI::IF.'E FEET
MFI,':.::IMUM I.,I_ME, I::.t:.. OF BEE.,F..UOI'I:, =
SO I L RRT I NG ,:: Si::! FT,- BR .., -,.-.,'-'=._,
THE REQLJIRED SIZE OF THE SOIL RBSORPTION S9STEM IS:
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF 'THE TRENCH OR DRRINFIELD.
'THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUND RND TFIE BOTTOM OF THE EXCRVRTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN ~HE OUTFRLL PIPE
RND THE BOTTOM OF' THE EXCRVRTION (IN FEET).
t.-EF..MIT I-~F'PL_ICRNT HRS THE RESF'ONS IB IL ITY TO INFORM THIb DEF'RRTMENT R, URI NG THE
· ' ....... "'' ......Ul",lz, OF
II'.,Iz, THLLHFIOr. J II'4-.,FEL. 1 I- '= F-IN'¢ 14ELLS FIDJFICENT "Dq THIS PROPER'I'¥ IZlND THE
NUMBER r]F F.'.EST_DENCES THFIT THE W£LL WILL SERVE.
T' l...i C, ,:: 2: :.) I i'-,I =, F. E C: T I 0 ~'-,I $ ~-] F-: E Fi: E rJ II , Z F~: [E [)
BF:ICKFILLING OF= RN"r' SYSTEM WITHOUT FINFIL INSPEC:TION RND HFFF.._ ,RL E,m THIb,
DEPFIF.:TMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DIS].'RNCE BETWEEN R WELL. RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS
t00 FEET FOR R PR IVf:ITE WELL.~ OR
150 TO 200 FEET FROM FI PUBLIC: WELL DEPEN[:,ING UPON ]"HE T'¢PE OF PUBI..IC WELL
WEL. L LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 3:0 DR'T'S
OF THE WELL COMPLETION.
o'r'HER REL.]LIIREMENTS f',1R¥ RPPL'¢. SPECIFICRTIONS FIND CONSTRUCTION DIRGRRMS RRE
R',,,'RI LRBL. E 'TO INSURE PROPER INSTI=ILLFITION.
I CERT I F""r' THRT
:1.: I BM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RN[." WELLS RS SET
FORTH 8"r' THE MUNICIPFILIT"r' OF FINCHORRGE.
· -';'.: I WILL INSTRLL THE S'¢STEM IN RCCOR[:,RNCE WITH THE CODES.
3:: I _II'.4E:EF.:%TRN[: THRT THE ON-SITE SEWER S'¢STEM I'"JFI'T' REQLIIRE ENL. RF.:GEMEI'.4T IF TFIE
RESI[:,ENCE /~ REMO[:,ELEC, TO INIZ:LI.I[.'.,F.,,'"FTET~E THRN 3: BEDF.:OOMS. //
ISSUED
GARY PLAYER VENTURES
CONSULTING GEOLOGIST
BOX 476-lvl, STAR ROUTE A · ANCHORAGE. ALASKA 99507 · PHONE 344-7075
SOILS LOG
16
18
2O
Soil Type Water Level Remarks
Total Depth of Excavation
Groundwater
~/Not Reached
Depth, if Reached
Classification Method
~/Visual
( ) Sieve Analysis
()
Material at Total Depth ~-~
Bedrock
f,~)%ot Reached
Depth, if Reached
Gary F. Player,
Consulting Geologist
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
Qn-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWI:LLING
Parcel I.D. # ?~.\~ _(~.o\ 0~ ._ ..-~.L/
1, GENERAL INFORMATION
Complete legal description
HAA #
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent ./~/, ~,-,
Address
(:{ ~.-/~ e~ '/'~,~j~, Day phone ff Y~- t 7/~
~e~ ~o~+~¢ Day phone 5~'~-~ ~
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 '.~
TYPE OF WATER SUPPLY:
Individual well ""'
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
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.
NameofFirm I~ (~ J'~-~/ 7-ec /~ ~ ~ c~ ( _~ r v~ ¢ ~/
Address
Engineer's signature
DHHS SIGNATURE
/~' Approved for -~
Disapproved.
Conditional approval for
Phone
Date
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
Date//- ~7-¢2
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /- 1~; ~ :2, Co,ti F.~ R1-5 Parcel I.D.
A. WELL DATA
Well type ~RtVATe
Log present (Y/N) Y
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
Date completed
Cased to
ADEC water system number
~ / ~ 5 / 7 8 Driller
~ ~/o Casing height
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
AT INSPECTION
JO J ~ J MUNICIPALITY OF ANCHORAGE
~;~%';~ONMENTAL SERVICES DIVISION
OCT 1 5 1992
I, ~ ~'/'~"~ g.p.m.
RECEIVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot~ ,qS" ~
Absorption field on lot ~ f 15°'
Public sewer main ,>/oo'
Public sewer service line ~,/oo '
WATER SAMPLE RESULTS:
Coliform <:~ c~/ //~:c,O ,-~./._ Nitrate
Date of sample:
; On adjacent lots '~ loc)
I
; On adjacent lots
Public sewer manhole/cleanout ;>/Do
Petroleum tank
,z. O. I/'~'/.~ Other bacteria
Collected by: ~LATT OP 'T£ cO
B. SEPTIC/HOLDING TANK DATA
Date installed ~1 J z
Cleanouts (Y/N) ~
Tank size j o00 ~'A/.. Compartments
Foundation cleanout (Y/N).. ~ Depression (Y/N)
High water alarm (Y/N)
Date of pumping Io/13J'~Z
Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lOt ?~-'
To property line ~' _~o '
Surface water/drainage
On adjacentlots '~'/°°
Absorption field [q'~
Foundation
Water main/service line
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
Date installed ~
/
Length 2 ~' Width ::3
Total absorPtion area 230 m~ ?ER INSP. t~EP,
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot ~
To building foundation
On adjacent lots
Surface water ~
Curtain drain
Surface water
Soil rating 85' '"'//t~pi~ System type Tr~EN¢~
Gravel thickness '7 Total depth
Cleanouts present (Y/N) '7'
Date of adequacy test
for
If yes, give date /~./1..
!
Ioo
On adjacent lots Property line
!
To existing or abandoned system on lot ~,~.
Cutbank 3' T° {~,w/~,~/~r~ ~,4U. Water main/service line
Driveway, parking/vehicle storage area
bedrooms
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature ~--'~,~v-~_.~_
Engineer's Name
Date (~ /'
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA
Waiver Fee: $
Date of Payment
Receipt Number
y' Municipality of Anchorage,
Department of Health and Human Services
Tom Fink, 825 "L" Street
Mayor P.O. BOX 196650 Anchorage, Alaska 99519-6650
343-4744
November 10, 1992
Ted Moore, P. E.
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
Subject:
Waiver Request for Lot 13 Block 2 Conifer Heights S/D
Waiver Request 9WR920066, PID 9015-093-25, HA920692
Dear Mr. Moore:
Your request for waiver(s) of the required 100 foot horizontal
separation of a septic system to a private well has been approved.
The approved separation distance(s) are 95 feet from a private
well to the septic tank.
This waiver approval applies to the existing septic system to
well separation only. Any future upgrade to either will
require all separation distances be met or another approval
from this department.
Sincerely,
Daniel J. Roth
Civil Engineer
On-site Services
/'~c'~/~C°ncur:
/~ohn Smlth, P.E.
/Program Manager
On-site Services
ljm:~6
Ti'~.IVIq ~t~$ Ft ITE~ b.,t TIq XL~~ F-oR
0 ~ r ff ~ I, u L. ~ lP" - o ~ r z g T- - C L £,,~-,,v ~ ~ T'..<.
Co~.~ T~ t T~9
OF 7-H,E
-~ ~LL PAT~-
D~t~ TH o ~
//T' T/F,['
2.?
/7.2
I
~ Pb~,r ¢,~/~,f. re.
THEODORE F. MOORE, P.E. Octo~r .~, 1992 14530 ECHO ST.
PH: (907) 345-1355 ~CHO~GE, ~KA 99~16
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sirs:
By means of this letter we are requesting issuance of a waiver down to 95.feet of the normally required
100 foot separation distance between the private well and the septic tank on~ ~0[!:!3~:BlOck 2, Conifer
Heights S/D, located at 7915 Port Orford Drive. A site plan and copies of releg~t :baCkup documents are
enclosed to assist you in your review. Since the deficient separation distance was officially noted and
approved by the Municipal inspector at the time the system was installed in 1978, I understand that DHHS
policy is to not require payment of the normal $410 waiver fee in this situation.
According to the driller's log, the well was completed in April of 1978 and has a total depth of 330 feet
and a yield of 2.5 gpm. The log indicates the subsurface soil type to be predominantly silty sand down to
bedrock which was encountered at a depth of 190 feet. At the start of our well yield test on October 8 the
static water level stood at 239 feet below the top of the casing. Steady pumping of 152 gallons of water
from the well at the maximum pump output of 5.6 gpm caused the water level to be drawn down to the
level of the pump intake at the bottom of the well. We then turned the water off and measured the rate of
recovery and number of gallons that could subsequently be pumped over two recovery and drawdown
cycles. Based on our test data we determined that the total yield of the well is 1.2 gpm, which exceeds the
Municipal criteria for approval of a single family residence. Water samples collected on October 5 were
satisfactory, showing 0 coliform or other bacteria per 100 ml., and less than 0.1 mg/l of nitrate-N.
According to the as-built inspection report, the wastewater disposal system was also installed in April
of 1978, and consists of a 1000 gallon steel septic tank followed by 25 lineal feet of soil absorption trench
containing 7 feet of sewer gravel. To assess the adequacy of the system we ran a total of 482 gallons of
water into the system over a two day period, while monitoring the fluid levels in the septic tank and in the
soil absorption system standpipes, before, during and after the flow of water was stopped. The initial
fluid depth in the monitor tube at the end of the trench was 71 inches. With the soil absorption trench
filled to a depth of just less than 7 feet, we measured the absorption rate to be approximately 500 gallons
per day. This rate is slightly over the minimum Municipal requirement of 450 gallons per day for approval
of a 3 bedroom residence.
The residence is situated on the top of a knoll, with the topography sloping steeply down towards the
west from the septic system, and more gently down towards a swale on the east side of the well. The
overall slope of of the hillside in this area is down from east to west, which should also describe the
overall slope of the water table gradient and direction of flow of the aquifer.
The following is a breakdown of how waiver analysis points could be assigned using the guidelines
promulgated by D.E.C's SCRO.
Criteria description
Distance to water table (239 static - 3' casing - 10' septic depth = 226')
Soil sorption ((174' x 2.5) + (3' x 0) + (49' x 6))/226' =
Permeability ((174' x 2) + (3' x 0) + (49' x 3))/226' =
Water table gradient (probably slopes down to west, but assume 0%)
Hg~4~ontal Separation (95'~
Total
Points
7.66
3.22
2.19
2.9
2.8
18.7
Some additional mitigating factors supporting the granting of the requested waiver are as follows:
(1) The house is situated between the well and the septic tank, thereby providing a barrier to surface
flow from a failing septic tank.
(2) The water sample results demonstrate no contamination at the present time.
(3) The separation distance was approved by the Municipal inspector at the time of installation.
It is my opinion that this waiver can be safely granted without concern as to contamination of the well
by the septic tank. Please give me a call if you have any questions on this waiver request.
Sincerely,
Ted Moore, P.E.
cc: Ruben Yang
2. oT 2
EL~ ~
/
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So~L
-~ WEL L
LOT I'Z
?o%~. /
I
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Lot 7
LoT g
_F.1..attoP Technical' Services
r 14530 Echo Street
Anchorage, Alaska 9951 e
LoT 15 BLOCK 2 Co~t
/
WELL ANb SE?TIC_ S"/5TEM
,5iTE PLAN
SCALE; I"=/~0'
I)ATE '.
NOTE: THIS I£ NoT
A ~u~VF_'~Eb ?LAT.
ALL LocATIoN S
ARE APPR~A~E.
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
ANALISIS RESULTS for INVOICE t 59213
Chemlab Ref.t 92.5477 Sample ! 1 Matrix:
WATER
FAX: (907) 561-5301
Client Sample ID : 13/2 CONIFER HTS FRONT HOSE EIB
PNSlD : UA
Collected : OCT 5 92
Received : OCT 5 92 ~ 16:25 h~s.
Pxeserved with : AS REQUIRED
Client Name :[LATTO? TECHNICAL SRV
Client Acct :FLATTOT
BPOI : POt :NONE RECEIVED
~eqt :
Ordered By :TED MOOHE
Analysis Completed : OCT 7 92
Send Reports to:
1)gLATTOP TECHNICAL SRV
2)
?aramete~ ~esults Units Method Allowable Limts
NITRATE-N ~(0.10) ag/1 EPA 3S3.2/300.0 10
Sample ROUTINE SAMPLE COLLECTED BY: CHRIS.
Ramazks:
1 Tests ?e~fozmed ' See Special Inst~uctions Above UA-Unavailable
ND- None Detected *' See Sample Remarks Above
NA- Not Analyzed LT-Less Than, GT-6zeater Than
Member of the SGS Group (SociGtG GGn~rale de Surveillance)
' ~-"' "'" ~' - INSPECTION APPOINTMENTS ' ~
DATE DATE _ ~ ~DATE /
INSPECTOR INSPECTOR ., . ~INSPECTOR f~~'
' , MUNICIPALITY OF ANCHORAGE- -
~ DEPARTMENT OF HEALTH & ENVIRONMENTAL I~ROTECTION .
({~ ,~~.~~/.,~_ ;"~ 825 L Street- Anchorage. AlaSka 99501 '
~,~,,,~__ y// ' ENVIRONMENTAL SANITATIoNOIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND sEWER FACILITIES
DIRECTIONS: Complete a parts on page 1. Incomplete requests will not be processed. Please altowtan (10) days for processing.
1PROPERT O' ¥ WNER I PHONE
M A ~ L iDNe~a~ D DC Ra EmsPsb e 11 .
· ' PHONE
PROPERTY RESIDENT (I,f different from above)
Z. 15U
Unknown at this time , . - -
MAILING ADDRESS ' '
3. LENDING INSTITUTION _ , r -.
Unknown at this time I
MAILING ADDRESS .....
4. REALTOR/AGENT . ' ' I PHONE
Elliot C. LawSon - Jack White Company ~277-1553
MAILING ADDRESS '
3201 "C" St., Suite 100. Anchora.qe. AK 99503 ,
*NOTE: Send all info and reports to Elliot Lawson at above a
%
[] One [] Four [] Other
'~ FX~ SINGLE FAMILY [~ Two [] Five
~ [~] *MULTIPLE FAMILY -' [~ Three [] Six '-
C{~ L* *'ATTACH WELL LOG A well og s requ red for all wel s dr lied
I IlO INDIVIDUA . ·
I [] COMMUNITY ) ~ since June t975. For wells drilled prior to that date, give well
! [] PUBLIC UTILITY ¢P~L~ depth (attach log if available.)
] 8. SEWAGE DISPOSAL SYSTEM . - -
I ~ INDIV DUAL/ON-SITE 1978 , YEAR ON-SITE SYSTEM WAS INSTALLED.
] [] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev, 6/79)
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTI LITY
Con nection Verified
THIS SIDE FOR OFFICIAL USE ONLY
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[] PUBLIC UTI LITY
Connection Verified
[]Septic Tank~or []Hold ng Tank
Size: / ~ 0 If'~ank is homemade
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION-AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
NUMBER OF BEDROOMS - . -, I 11L ':: "
[] THREE [] FIVE [] OTHER
ONE
TWO
[] FOUR [] SiX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
MANUFACTURER
MATERIAL
ISewer Line
INearest Lot Line
~ APPROVED FOR -~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
~ATE
72-010 (Rev, 6/79)
· ' MUNICIPALITYOF ANCHORAGE MUNICIPALITY OF ANCH&ORAGE
'DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF HEALTH
~ 825 L Street Anchora e, Alaska 99501 ~I;~fIRONMENTAL PROTECTION
- g
~4~ ENVIRONMENTAL ENGINEERING DIVISION 0CT 1978
~ Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWI~/~"~J3VE~D
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proce~ed. Please allow ten (10) days for processing.
1 PROPERTY OWNER ' ~ PHONE
+ Y t,,
MAI LInG ADDR~S~ ................. /
P~OP~Z~ ~E~I DE~T (If ~ffferen~ fram ~bo~e) ~ PHON~
' PHONE
2. BUYER - - -
MAILING ADDRESS '
MA LI~ADDR~S~ ........ ~
4. REALTOR/AGENT ! PHONE'
I
MAI LING ADDRESS
S
INGLE FAMILY
[] MULTIPLE FAMILY
7. WATER SUPPLY
NUMBER OF BEDROOMS
[] One [] Four
[] Two [] Five
,~ Three [] Six
[] Other
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8, SEWAGE DISPOSAL SYST EM
INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
~* ATTACH WELL LOG. A well tog is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.) t~ ~
**If individual/on-site, give installation date ~.~ .Y~ / .~. ~'o~
If system is over two (2) years old an adequacy test is required
bv 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
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF I~ESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTI LITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVI DUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SlX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
[]Septic Tank or [] Holding Tank
Size: 1 C)~) O If Tank is homemade
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
MATERIAL
OTHER
Septic/Holding Tank IAbsorption Area
Sewer Line
Nearest Lot Line
5. COMMENTS
~ APPROVED FOR -~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
LEGAL DESCRIPTION
72-010 (Rev. 3/78)