HomeMy WebLinkAboutT12N R3W SEC 15 LT 120
MAILING ADDRESS
LEGAL DESCRIPTION
I'
MUNICIPALITY OF ANCHOEIAGE
DEPARTMENT OF HEAl_TH & ENVIRONMENTAL PROTECTION
ENVlRONMENI'AL ENGINEERING DIVISION
825 L Street * Anchorage, Alaska 99501 T,;lephone 264-4720
ON-SITE SEWAGE: DISPOSAt. SYSTFM AND/OR WELL INSPECTION REPORT
PHONE NEW
LOCATION
~ ~ Manu facture~
IF HOMEMADE: s de lenqth
Dwelling
NO, OF 8ED~MS
,--~
PERMIT N ':, · ~
No, of c partments
Material
Mat er*a~ b'~eatl~ tile
Topoftiietofinishflrade ~ / ~6 inches
Type of crib
Width Depth
Crib diameter Crib depth
Liquid capacity in gaBons
PERM'IT NO.
Distance betwe~s
PERMIT NO.
Total effective absorption area
Nearest lot line
Well foundation
DISTANCE TO:
Class Deptl~ Driller Distance to lot line IfPERMIT NO,
DISTANCE TO: BuihJing foundation Sewer line Septic tank ~Absorp~(~araroa(s)
OTHER
PIPE MATERIALS
REMARKS
LEGAL
DATE
" E:,EF I::if:~.Ti"lEt',lT F',~=' HEFIL. TH RI'.,IE:, EN',,,' I t;:Clt-,~i,IEN].'RL ~"'¢,.':LIq f:.L: I ]. O1"4
':'" ~ " S].'REET., F:INCHIZIRRISE., Fit,:;. ':~
IF:Ii':',IMLII"i P,!Ut"lfi:EF:4: ElF E:E[:,ROOf'IS =* 3
SOIL. RATING
"HE RE(;!IJ:[tE:ED S:[ZE OF "FHE SOIL FIF.:'_'i;CIRF'-rIE~;'.,I S'~.'STEFI
]'FIE LENGTH [)IFIEI'.,!SIOi'.t :iS THE L.ENI3TH (IN FEET:) OF THE TREi'.,ICi.4 OR [:)RFIINFIEL.[:,.
THE E, EF'TH OF FI ].RENCH Of;:'. PI]'' ;[$ THE DISTFINCE; E!:ETi,~EEP.i ]'PIE SUI-~:FRIE:E OF THE
GF~:OLJI'.,ID Rl'.,l[> THEE E:O].'TOM OF' THE E::-::CR',,,'R'rlC;?.,I ,::IN FEET>.
THEi;'.E T'.E: I",E~ ~;ET I.,Ii[[;:'TH FOR I'REi%!CHEE':.
THE ~3~;?.FIVEL. E:'EPTH ~fS THE i"l):NIi"lUl"l [:,EP'rH OF
Fir.ltl'::, THE [:.H_-ITTOf"I OF THE E',:'.;CF4',,,'FI].'ION ,::IP',! FEET;:'.
F'ERH i 1" FIPPL.]: Ct:IP',I-f' HFIS ].'HE ~;?.ESPOf.,I:5 :[ E: I L i T'~" TO :[ NFORH TH l S I:)EF'FIRTi"IEi"4T DI_Jf;;'. I l'.,IE~ THE
]:NfE;TFILLFI'T']:E~i"4 Ii.4'_:.:F'ECTZONS OF FU",!"r' I,iELL. S FI[::,..TRCEI",IT -FO THIS F'ROF'ER'r'~.' Fii'.,IB, THE:
I'.,ILIt,IBEI~! IZI[:' [:,'.E'.E;,I.C:,ENCEEi; THRT THE I.,.IELL ~.,.I]:LL.
I!]:PIL':I<iFILL. ING OF FIl"4'~r' S'.r'S-rEI"I I.qlTHOUT F;[NIqL IN'_=;PECTION R~'~E:, FIPPRO',,,'PIL E:'~" THIS
E:,EPFIRTI'IE[',IT I,.I ILI_ Ei:E ~SL.I~2:.~'ECT TO PROSECUT I ON.
i','IIN:[i','IUH D:[S'T'RNCE BE'T'I,IEEN R I,IELL RN[) laP.,l'.r' OI'.,I--SITE :E;E;I,.!FIGE [)ISF'OSR[. ::];'-r'STEM IS
::L00 [:[:ZEE].' FOR la PF~I',,,'I::ITE I.,.IEI..L OR'. J.!~.;tE~ "FEi 2C~C~ FEET FI:~'.CII"I 1=I PUE:L. IC ].,.IEL. I_.
IJF'~OI',I '['H[:~ T%"PE OF PUE:LII2: I,.IELL.
P'III'4IPiLJI"I E)ZSTF:II",ICE FF~:C~i"i [:t F'Fi:I',,,'FI'rE I,.!EL.L TO I=1 F'RI',?FITE SElqEF~ LINE ]:S 2~:.:[ FEET
TO la C:iEIl',ll',ltJt4IT'~.' SEI.,.IER LINE ZS i75 FEET.
I.,~ELL LOGS FIRE [;:'.Et;!UIREE:, FIN[;, i',iUST E[E RETLI[;:NED 1"El THE [;,EF'F:IF,~'.TI'IENT I,.IZTH];I'4 ]]:0
OF ].'HE !~4EL..L COI',IPLET:[E~i'4.
OTt..IEF4: REi:;!LIIB'.EI*'IEI'.,IT';~; i"ll::l"r' FII::'F'L'~". SPECZFICFITIONS F:lf4[) COi'qs'r'Ruc].':[ON E:, ]; RGf;~'.Fli',I:E; RF.:E
R',,,'I::I ]: L.F:IBLE TO ]'i'.,ISURE Pf('.OPER [ NS].'FILLFIT ];
I C:EF~'.'FIF',' ].'HRT
:1.: I RI'"I FF~i'"I I L I FiR [,~ I TH "['PIE: F;4E~U I REP'IEI'.,IT:E; FOR Ol~--'S I TE :5Et,.IERS RFI[::, 14ELL.'-:.; F~:E; SET
FOF?.I'H [D'~" "I"I-IE MLli'.,! IiE: ! F'F:IL I "F'T' OF
2: I I-,I:[LL IP.,!STFILL ]'FIE': S'~-'STEI"I ]:1",1 I~ICC:ORE:'ir~Ii",IC:E !.,.IITH THE CO[:)ES.
:-J:: I Uf,I[:)ER'-:~T'FIf'~D THFI].' THE (:)N--E;I-I"E: SE[,.IER S,'T'STD"I MI:I'~" F['.EI~:!I..I :[ RE ENLFIRI]EMENT :IF THE
~','ES I [:,Ef',ICE I ~; REP'IOE)ELEC' TO I NCLU[:'E f"IORE THFIf',t ~: E',E[:,ROOM'-'];.
S I I]~h,lE[): .........................................................................
F-IF'PI.. :[ CRI'qT ',,,'f~LI_E%' L-:.ON'_.'~:TRUCT I ON
'~' -' si r~r'. E:%"- .... . ....... [:'FITE--
'*?4. I?_'[
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Ancl~orage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
[] PERCOLATION
TEST
1
2
3
4
5-
6-
7
8
9
10
11
12
13
14
15-
16-
17-
18-
19-
20
COMMENTS_
PERFORMED BY:
SLOPE SITE PLAN
WAS GROUND WATER
L
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water ~'.~z_ Drop ~.
PERCOLATION RATE /~?, ~' (minutes/inch)
TEST RUN BETWEEN ~ ~ . FT AND ~ . FT
72-008 (8/79)
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. Ct. (-~/*-~"*~ Cf'~. - C¢-~L¢:~
1. GENERAL INFORMATION .
Complete legal description /~T
Location (site address or directions)
Property owner ~--~'-B~'z"r- L, f'/L~-c~.L,/:/A.,d~--T'
Mailing address ~/¢ ~--A~-~- ~',~,/~-'~'
Lending agency
Mailin. g address
Day phone _ ~ q'/~- ~'
Day phone
Agent -'T--o ~1
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
individual well ~ _
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
lng 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. ~/9~) 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 structu?e 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~:PA ~_~c~ ~_.~ ~'./c._ Phone
Address '~. o ,~,o~<~ /c:~_.~-~ ,4~,~,~ /~[~ c2~-/
EngineeYs signature
DHHS SIGNATURE
Approved for z¢f
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 ragistered in the State of Alaska. The DH HS does this as a courtesy to purchasem 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
Environmental Services Division [:EB ] 8 1999
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
.~,, ~) pdl:~ u'l Anchorage
rJlJ~ I~h & Human Semite8
~ealth Authority Approval Oheoklist
Legel Description: _Z./Z¢! T~7_,~ ?P_.&L.o, ,~LK'-
A. WFLL DATA
Well type ~T'~F2 '-'J AT ~';
Log present (Y/N) \
Total depth '-~--¢:~-
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ..~--//¢ /~ I'
Cased to ~O ''¢ C;tsing height (above ground)
Wires properly protected (Y/N)
Date of test
Static water level
Well production
FROM WELL LOG AT INSPECTION
g.p.m.
WATER SAMPLE RESULTS:
Coliform ........ ¢.~ "~ Nitrate O,/Of) L) : Other bacteria
Date of sample: "~//q/~t '? Collected by: ~'~/~ '~"
B, SEPTIC/HOLDING TANK DATA
Date inStalled ~-/~"~/~( __ Tank size
/~.,~"'~
Foundation cleanout (Y/N) ,'LJ
Date of Pumping' ~//~'/¢¢
C. AIEISORPTION FIELD DATA
Date installed ,~/~-*i~L Soilrafing (g.p.d,/ft~o fl~dr~ /~0 _Syetemtype
Length ¢,'~ Width __ ~ t Gravel thickness below pipe ~ Total depth
Number of Compartments ~._- Cleanouts (Y/N) 'T~
Depression (Y/N) *'L/' High water alarm (Y/N)
Pumper J/-J -C-~~.4'f~
Effective absorption area ,..~'qO Monitoring Tube present (Y/N) "¢~ffDepression ever field (Y/N) ~
Date of adequacy test. '~//lq/?' ? Results (Pass/Fail)~DA,~; For_ '~/
Fluid depth in absorption field before test (in,);~Ll ~"~' Immediately after ~¢D gal, water added (in,):
Fluid depth"~"r (ins) Minutes later: /~'~4./ Absorption rote = bop g.p.d,
Peroxide treatment (past 12 months) (Y/N) /['/ If yes, give date
bedrooms
72-026 (Rev. 3/96)*
LIFT STATION
Date installed /1//// ~_
Manhole/Access (Y/N) .~---~P~p on" level at* "Pump off" level at*
High w~ t ff~h ' *Datum
C.~Leie~t ested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Lur~o~t--1~-e~uP~'r'On adjacent lots
Absorption field on lot /O,~ On adjacent lots
Public sewer main
Public sewer manhole/cleanout
Sewer/septic service line
--~ ~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~Y'O~' Property line ~-.S-I Absorption field
Water main/service line ~o{ Surface weteddrainage /c:'o-r Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Surface water
Curtain drain
Building foundation /::~,.~- i Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots
ENGINEER'S CERTIFICATION
I certify that I have determined
in conformance with MOA HAA guidelines in effect on this date.
Signatur~ ~
En.~ineer's Name ._.~-r~ ~.---~"~"~"~"~'~h ~J/,) ~ ,,~'~. ~'~. ~ .
Date
HAA Fee $
Date of Payment
72-026 (Rev, 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
Steven R. Pannone, P.E.
Consulting Eagineer
PD Box 102954
Anchorage, Alaska 995 J 0
(907) 272-8218
Legal:
Owner:
Residence:
SEPTIC SYSTEM ADEQUACY TEST
Lot 120 T12N,R3W, S15
Mr. Robert McElhaney
4510 East 10lst Ave, Anchorage, AK 99516
Septic System:
(from MOA records)
Date of Pumping:
Date of Test:
Tank Size: 1250 gallons. Absorption System Type: trench
Absorption System Size: 90x3x3 Absorption Area: 540 s.l~
Installation Date: 5/81 Soil Rating: 180 sffbr
2/16/99 By: A+ Home Service
2/14/99
Test Procedure: The System was inspected and measured. Tank was found with 4 feet of cover.
Liquid depth ~vas measured to be 50 Inches. The drain field was found to have 36 inches of cover and a
total depth ot'6 feet. There was no liquid measured in the field's monitor tubes. Water was added from the
well at a constant rate of 6 gallons per minute (GPM). The water levels in the tank and dram-field monitor
tubes were monitored. A total of 600 gallons of water was added. No rise was noted in the field or the
tank. The infiltration rate was monitored for 15 Minutes. At the end of this period the water level in the
field returned to the original leveI. During this period, a total of 600 gallons were absorbed. By extending
the observed infiltration rate, a total absorption rate of 600+ gallons per day xvas amved at.
An adequacy test to determine the wells production was conducted at the same time as the septic system
adequacy test. The initial static level of the water was found to be I77 feet below the top of the casing, with
a total depth reported to be 272 from MOA records. Water was pumped from the well at a constant rate of
6 gallons per minute (GPM) for 2 hours. A total o1'600 gallons were pumped from lhe well with the static
water level drawing down to 2 feet below the top of the well casing. The water quality was tested as part of
this test. Results are pending from the laboratory.
TESTS RESUUFS: This system meets the code and operational requirements of the Municipality of
Anchorage.
In conducting an adeqnacy test, I attmnpt to provide a thorongh, conscientious eogineering analysis of the syste~n. The
reported resnlts describe the perfommnce of the system nnder 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, gn'ound water levels that nmy fluctuate during the year, and the water usage of the
family being served by the system. These conditions am outside the control of the evalnator of this system. All
systems eventually fail and satisfactory test results do not guarantee furore performance of the system, nor do they
guarantee that there are no hidden defects or encroachments. We can therefore not give any estinmte of how long lhe
system will continue lo meet the operational require~nents of the Munic!palily and Stale.
CT&E Ref.~
Client Name
PrOject Name/g
Cliom Sample
Matrix
Ordered By
PWS~
990562001
Pam~one Eng. Sly.
L 120 T12N R~,W $15
From Ho~ Bib
D:fl~:~Lng Wa[er
Prinlefl Dada/Time 02/22/99
Coll~Date/~me 02/14/99 16:00
02/:t8/~9 ~o vari~ file nitraze va~e.
Hitrate'~ 0,100 u O.1G{~ t~/c EP,*, 300,0 10 ~lax OZJlS/<J9 (}211BJ~ SCI.
Rick Mystrom,
Mayor
Mmdcip i ,ty of Anchorite
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
March 3, 1999
:Steven R Pannone, PE
PO Box 102954
Anchorage, Alaska 99510
Subjcct:
Waiver Request for TI2N R3W Section 15 Lot 120
Waiver Request #WR990014
Parcel ID #015-.482-08
HA990066
Dear Mr. Pannone:
Your request for a waiver of the required 100 feet horizontal separation from the
septic tank to private well has been approved. The approved separation distance is 90.0
feet.
This xvaiver approval applies to the existing septic tank to private well separation only.
Any future upgrade to the on-site wastewater disposal system will require all separation
distances be met or another approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-4744.
Sincerely,
Daniel J. Roth
Civil Engineer
On-Site Water Quality Program
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR~ ~j0 q~fh~h %~[ PID~ 015-482-08
Date Received: Feb 18, 1999
HA~ ~q~(~ Permit
Legal Descrlption: _T12N R3W.Section 15 Lot 120
Engzneer: Stew~n R Pannone, PE
PO Box 102954, Anchorage, Alaska 99510
Applicant: Robert L McElhaney
Waiver Requested: Waiver from the private well to septic tank of 90'
Criterza: 1. Geology: Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
3. Other:
Waiver is Granted: _ ~ Waiver is NOT Granted:
List Conditions or Reasons for above: ~'ff ~7%D~A~
Rec #: #04497/0964
By:
Amount: S 625.00
Name of Re. viewer
Date Paid: Feb 18~ 1999
4.2
2.:2.
2. q
I
Steven R. Pannone, P.E.
Consulting Engineer
P. O. Box 142025
Anchorage, Alaska, 99514
(907) 272-8218
February 16, 1999
RECEIVED
Municipality of Anchorage
Dept. of ltealth & Human Services
On-Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519
FEB 18 1999
Mut~loip~lity o~ AnchO~'age
Oept, Health & I-tum~m Services
Attn.: Mr. J/m Cross, P.E.
Subject:
Lot 120, T12N, R3W, SI5
Septic tank to well waiver
Dear Mr. Cross;
I am writing to request a separation distance waiver between the well and the existing septic tank and drain
field on the above referenced lot. i conducted a Health Authority Investigation on this lot on February 14,
1999. The adequacy investigation report has been submitted to your office for review. I)uring this HAA
investigation, I discovered the well and septic tank are closer than the required 100 feet. The distance
measures out to 90 feet to the 1,250 gallon septic tank. The drain field is located over 100 feet from the well
serving this property. Attached is a site plan showing the adjacent properties, general site topography and
approximate location of wells on each lot.
Lot 120 is approximately 1 acre in size. The lot slopes from the southwest, with the southern end dropping
offsteeply to an undeveloped forest. The well is situated approximately 20 feet northeast of the three
bedroom home. The tank and drain field are located west of the house along the top of the steep h/Il and
approximately 130 feet fi'om the neighboring well to the southwest. The soil absorption system was
installed in May of 1981.
The well on lot 120 was drilled May 18, 1981. There is a well log available for the well on this lot. I found
that it is cased to over 40 feet, the static water level was 176 feet below ground level, and the total depth is
reported to be 272 feet deep from MOA records. The ground water in this area typically flows from the
south to the north. A well flow test showed the static water lowered one foot while flowing at
approximately 6 G.P.M Water samples were taken during the IfAA investigation. I am awaiting results ot'
the analysis of the water, and will pass them on to you as soon as I receive them
Mr. Jim Cross, P.E.
Februa~ 16,1999
Page 2
Tbe soils on l,ot 120 were logged to be clay with layers of sand and gravel intermixed to a depth of 272 feet
below ground. No water was encountered above the clay layer.
As outlined under I 8 AAC 80.020 and 18 AAC 72.02I(a), 1 have calculated the following points:
Distance from sewer system bottom to groundwater 7.0
Soil sorption below sewage system 3.5
Soil permeability below the system 2.0
Water table gradient 6.0
Horizontal separation _2.~9
Total Points 21.4
16-25 Ahnost sure to be free from any form of contamination t'rom household sewage.
In my opinion, this waiver request meets the above criteria for approval and does not constitute risk to
health. I hope the above information will assist you in determining that the waiver should be granted. If
you have any questions or concerns, please contact me at 227-3522 or 272-8218.
Sincerely,
ne, P.E.
Civil Engineer
Attachments
C:\WORK\1201'12NR3WS 15 WVR xxq~d
WAIVER REQUEST
WASTEWATER ABSE1RPTION SYSTEM
LOT 180 T12N, R3~, §15
PERMIT ND, SW
lO,nd
EXIST'E]
' ])R..IN r
,.~Xt.8 ~ .G
SEPTIC
TANK
· . :, EXIS}
104 h AVE
P.I.ll. NB~ 015-488-08
PREPARE]] FBR~
Robert NcELhaney
4510 East lOlst Ave
Anchorage, AK 99516
(907) 346-2075
PANNHNE END, gVC
P, B, BOX 102954
ANCHORAGE, ALASKA 99510
272-8218 Phone & Fo, x
DATE, a-I~99 I DESIGN
gCALE'
Z ~
Well Owner
WILSON WELL DRILLING
1:305 W. 45TH STREET'
ANCHORAGE. ALASKA 9950:3
PHONE 272-934:3
,~ DRILLING LOG
Use of WeD
Location (address of: Township Range, Section, if known; or distance main road
~t i/ I' I i~
Size of casing ~e __Depth of Hole~~ ,.,Q feet Cased toe~'Ol J/ feet
Static water level 1~(~ ft. (above) (~ land surface. Finish of well (check one) open end ( ,~
Screen ( ); Perforated ( ).
);
Describe screen or perforation
Well pumping test at ~ gallons per (hour)
of drawdown from static level.
Date of completion ~. k~. C~-,.'.. l~"] 9
(
(~ for ~ hours with ~ ~t.
WELl. LOG
Depth in feet from
ground surface
_TO¸
.TO
Give details of formations penetrated, size of material, color and hardness
¸Il
~ INSPECTION APPQINTMENTS I -~ z RECEIVED
-~ATE ff f~'~' DATE----- DATE
I NSPEC~OR NSPECTOR I NSP ECTOR ~
MUNICIPALITY OF ANCHORAGE MUNICIPAt. ITY O~ ANCHORAG~
DEPT OP AL[H &
~- DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION · (j ECT[ON
/ ~ 825 L Street - Anchorage, Alaska ~9501 ~NVIRONMFN I~,L
ENVIRDNMENTAL SANITATION DIVISION /.N0{~ '[ '[ 'ia~i~
Telephone 264-4~20
31RECTIONS: Complete all harts oil page I, Incommode requests will not be processed, Please aH~w ten (10) davs for processing,
PHONE
PHONE
PHONE
MAILING ADORESS
3. LENDING INSTITUTION
MAILING ADDRESS
PHONE
4, REALTOR/AGENT
PHONE
MAILING ADI)RES~
LEGAL DESCRIPTION
~E ET LOCATION
TYPE OF RESIDENCE NUMBER OF BEDROOMS
E~ One [~ ~our
~ SINGLE FAMILY [] Two [] Five
~ MULTIPLE FAMILY ~ Three [~ Six
~WATER SUPPLY
~ INDIVIDUAL" ' ATTACH WELL LOG. AweHIogisrec~iredforal wellsdrHled
~ COMMUNITY since June 1975 For wells drilled prior to tibet date. give well
~ PUBLIC UTI LI TY depth (attach Io~ if available.)
[] Other
'~,~ SEWAGE DISPO,~AL SYSTEM ~//
J~ 'NDIVIDUAL/ON-SITE'" ~EAF ON-SITE SYSTEM WAS iNSTALLED,
F~ PUBLIC UTILITY ~-~- I-~ ~J
NOTE; THE INSPEOTION FEE MUST ACCOMPANY ~ACH REQU ~ST BEFORE PROCE~SI~ CAN BE INITIATED,
72-o10 (Rev. 6179)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTI LITY
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:_ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATER~AL
4, DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE ~.~ . '
