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T12N R3W SEC 27 LT 56A REM
al.JG-17-2i 15 08:06f: FROM: TO:3437997 P. 1 -i Development Services Department i t. ,mei Building Safety Division �, o I On-Site Water & Wastewater Program 4700 Elmore goad 2 P 0.Box 196630 Anchorage, AK 99507 �s, 1.,S Mask Begich areiv way / to Mayor 0907)343-7904 Well Log Permit Number:OSP15 i 243 Date of Issue:July31,201*arcl Identification Number: Date Started:OAS Date Completed:8/11/f5-- is well located a:approved permit location?11(j Yes Lii No Legal Description: TI2N R3`VV 5E0271at56A REM(3:2936 Property Owner Name&.Address: David Rathke 4351 DeArmeun Rd. Anchorage,AK 95516 Borehole Data: Depth(ft) Method of Drilling':J air rotary U cable=-oel Soil Type,Thickness& !b'atet Strata Fiona To --- __..___ _ Casing type:steel it Stickup __.___ ..__. 0 r 2 ' 1 Wall Thickness: .25D_ inches overburden �--~ •2 ,��~ � I Diameter:. 6 _inches Depth: 143 feet 1R Liner Type; slit&gravel ; 4_ 20 { Diameter: inches Depth: feet ! moist silt&grave: 20 _ 24 J Casing stickup above ground: 2 feet silty clay&gravel 4 42 Static water level(from ground level): 66 feet drysilt&gravel .; 42 I 60 i Pumping level: feat after hours pumping ___gprn dry silty clay 60 100 -- i Recovery Rate: 13 _gpm gravel w/little 1420100 105 Method of Testing: airlift gravel w clay wet { _-' ._._.�--� ' _ 105 110 f Well Intake Opening Type: _ dry silt&gravel 110 132 (5n Open End 7 Open Hole i moist sand&gravel 132 140 0 Screened Start feet Stopped--feet —--r---- {-i Perforations Stan feet Stopped.__ feet gravel w/ H2O ___ -� 140X 143 I -- --•r•— Grout Type: Bentantte V'olusnegranules _ __1— Depth. 20' Start O feet Stopped 20' feet � Pump:Intake Depth 110 feet + Grundfos SQE 1 Pump size 1/2 hp Brand Name • —� Well Disinfected Upon Completion?n Yes 0 No Method of Disinfection: chlorine , Comments: ' Wel!Driller: Hefty Drilling,Inc. 1 --— L .. 3540 Akula Dr. Water Sample Results: Arsenic: N P vyL Anchorage,AK 99516 — Nitrares: 3102,,mgiL Total Coliform Bacteria: ��:oE<�niti.s!i OOmi, ^�—__ ._.. Other.Buten,' N c)11100i AL Attention: The well driller shall provide a welt log to DSD within 30 days of completion. 1 I I HLJa-7-2015 0. 15F FROM: TO:3:13_._,9' P,i; Development Services Deportment • Building Safety bivision • f S ` On-Site Water d: Wastewater Program 04. 0 ".. �" 4700 Elmore Road v n P.O. Box 196650 ` ,,i I C. Mark 8eglch Anchorage, AK 99507 SAF `'Y Mayor www.rpuni,org/cnsiig (907)343-7944 Pump Installation Log Well Drilling Permit Number:-5tr e5IaHS Date of Issue:X417 3!, Ci!5 Parcel identification Number: Legal Description • Property Owner Nsme&Address: �.�1 _.. . _11.1.1 ..._.__.. _ _ ��_ �- s _ ... Pump installation Date: g_ rte,'"_ j5 Pump Intake Depth Below Top of Well Casing: /10 feet Pump Manufacturer's Name: Cliohe(,�o) Pump Model: /0 50f a 9- ? 00 Pump Size IA hp Pitless Adapter Burial Depth: JV feet Pitless Adapter Manufacturer's Name: i./-ra Pitless Adapter installer: Hd47 }70(1 ?5 , Well Disinfected Upon Completion? Yes fi No Method of Disinfection' Comments: Pump Installer Name: 3:4 Al 7 )/4 Z Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. R.1:3-7-2015 03:1 EF F P0r: TO:.313799; P.2 Municipality of Anchorage Community Development Department On-Site Water and Wastewater Program 4700 Elmore St.•P.O. Box 196650 Anchorage,AK 99519-6650•h!tp:lfwww.muni.orgtonsite•(907)343-7904 Weil Decommissioning Log Legal Address: Subdivision_._ Block Lot S(0A T IA IV R 3 W Section 2 2_.tot 5(A — On-site Water&Wastewater Program certified contracts•performing the wed dreammissloning: tiaSnrl: II, '` V ,/� S(Qnrfurw. Company: 1 I p 1 eiy., --- -�- —- - -I - — -- Wett decommissioning date 8-(/" 15. Method of decommissioning:AMC 15.55.0601.1 a. 0 b. El c. t Location:Use the space betow to provide a draw)ng of the property showing the following items; . • Nonh arrow • Decurn'nissioned wet, • Other water wets on the property. • Two seperots swing-So dtolonoes for each wall drown on the draeing, Nate:The swing-tie distances shalt be measured tram either permanent Overage or the property corners. N . ,._„_ ► Zi.I.,. 3) El.EVATlONSOnS> `”I _ _ S DATA. R Z RORY CJ01/1x`r CHASE' 70' 1...,2 -•. �t '- 1Y0010441E "moi; ? N �. S.7'X 1,f'' . .4) HPUSE 'Y E �W °' .., tet• CXit!��ct CHASE ti rir: Jr J76' r ��t Car -�1'. ,FJ.f'_•fit $-y, *1:3' i r - 4YJ li art' ' �t- S re4Cc 1E,w-re, " r L. SEf OEM 1 ri— ?¢s' I [ �� r ° {"-", t Jyrhi.r e C ?0' /. .y ,: 400 S`0_._._ •t \ ; r)e...t( p-ivhr i • J orf h. _-_."'�.. :' = 37J' ' l!' 7 4411 .. • I `. 4::. t.flsa,1C I/). \ ia?LYc;i•4Y•.1 i ?...).. -. \ ,,,� J i t _ -.�86 . w r .. 11) y�Sled II 1°.\:/7:.::, • .':I i :. \ \ I L _ Irl • i F Y - Y . j i E J7d' Lace' S 89649'00° 'Ifir' 185.13' (P. : • 1 -- i drr i. 5 PNS77C arra *\ uac) S 89'118'19° W 'I 64.50' (M) . _''� a �+ 2,tn+c d tcsnr' Carp �.-. F 1 Zf3I 1--75F. - i IK " •.. 2Qa F -- ---. LV -•?7r---- ,,, _____ -7;r----________. __�,,..-_ c'6(fE'631/X:. WELL.1-. ' ..� irr—-• -- --- .... DEARMOUN ROAD l - `° Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ;~u)~lf~ e~'° $ PID Number:_ (2~8 - Oq - Name: _ ~ ¢0~~ ~ ~o~ Wastewater System: D New ~ Upgrade Pkonm ~ ~ No, of ~room~: ~ ~aap Trench ~ Shallow Trench ~ Bed ~ ~ound ~ Oth~, - Range: J Fill added above original gra e~ ~ Ft, - Gravel width: Number of lines: Distance between lines: WELL: B New ~ Upgrade J~ Ft. ~ ~,~ Ft. ~Classification (Private, A,B,C): ~ Total Depth: Cased To: Total absorption area: Pipe materiah ~JO OdlJer: Date Drilled: SJaficWater Level: nstaller: Date installed: Casing Height Above G~ound: Yield: ~ GPM Pump S~t: Ft. ~-- Ft. 'rANK Q S.T.E.P. To Septic Absorption Lift Holding ~ublic/Privat( Manufacturer: Capacity in gallons: From Tank Field Ststion Tank Sewer Lines ~¢~ Number of Compa~ments: Material: Su~ac~ LIFT STATION Water /o~1~ I~O I~ .... snufacturer: Pump Ma 0del Electrical I,,¢pections performed by: ~ BENCH MARK Remarks: ~' ~A¢~ U¢~a~ Assumed Elevation: e artment of Health_and Human Serwces approval Reviewed and approve y: :_d - .¢~ ~ *'"' ParmitNo. SW960005 2 2 Page of Municipality of Anchorage DEPARTMENT OF HEAl. TH AN[) HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telepl~one: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report LOT 56, SECTION 27, T12N, R3W S.M. AK. 01809246 Legal Description: PID No ' STS 98,0' EXISTING 93.?'~~ tO00 GAL SEPTIC TANK NE\ RADIUS FINAL GR -93.5' TH MT1 LOT 56 98.5'~,. C03 MT2 GRADE iNSULATION ~._ 93,2 g BDRM lOUSE 87.6' FOUND -t5=-95 ~TING BED SUCH AS 5TING 1000 ;EPTIC TANK ST1 C01 FD CO3 C04 MT1 ;AL, ENG NEER'~ SEAL AND IqA I NTENANC~ Lc§of-. D~scAiption: ,Lot 56~ ~ec'27; TI~Ni ~5~I S,M. DATE A~d~ Tweed Ex~v~ng & ~ons~on 11034 ~a~l~ RZv~ Loop Road S~t¢ 202 Eag~.~v~, AK 99577 694-~7~ fax ~694-IB5~ WAR~Y~ Th~ ~ompa~ (Tweed Ex~v~ng ~ Q~ Sand ~ 6rav~} a~r¢~ to p~ of ~h~ absoap~on b~d w~ f~ and r~q~r~a rep~c~¢~ ~ to d~f~v~ mat~ w~n (~} y~ra of ~ Th~ piping from ~h¢ 6¢ptie t~nh ~o th~ hous~ and g~ clean Th~ septic tank and ~ The ~in¢ from Zh~ septic ~.~n~ to th~ absorption 6~d. On a a~i-an~ basiS du~n9 th~ p~riod of th~a agr~,~m~n~, Tweed Ex~v~n~ ~n<~ p~wpoa~, The homeowner a~r~ ~o provide access comp~an~ to t~s a~r~z~ and progrm~ for ~ length of th~ In the ev~ thc Homeowner r~qu~S~a Tweed Ex~ava~in9 and Com4~ru~ to p~fo~ m~an~ to th~ sys~ oth~ than ~ ~p~fi~ in th~ at~ch~ propos~ or cov~ed by ~ra~y, ~ Hom~own~ sh~ pa~ Tweed Ex.yoUng ~nd Co~¢u~on a ~t~somable ad~o~ ~ha~ for ~h~ wo~ aaaomp~shcd ~ w~ ~ for any r~p~ porto, ~q~pm¢~ uS~ o~ ln~d~ supp~. Additionally, r~aonabl~ ~arg~ wh~ th~ need for wor~ ~ a r~ of Zh~ Hom~own~r'a f~ure to ~nsua~ ~omp~an~ w~ o~n~ i~u~ons, from execs of ~ke a~on {he resull of force maj~ [i.~. ~{hquak~, f~ood, ~d s~p} or ~rom per~ons no~ a~ho~zed b~ Tw~ Ex.yoUng and CO~U~On i~ng wi~ the Sy~ 2n any waq, or r. 3 Clair & Barbara Bamsey FA× NO. ~U'/ '/hZ 1~'/3 OPERATION ~ ~INTE~A~(3~ PROPOSA£ P~op~ opcJcation and mai~nane¢ 24 impor~nl to ~ long t~ p~tfo~an~ of an on-S~ ~6~ ~6p06~ S~6Z~, ~h~ op~o~ ~ of ~ on-6~ ~ust¢~ ~Spo~ 6~6~6 depends on ~o~ 6o~ con~o~, ~oun~ l~ve~ reeog~z~d p~of~sio~ f~t ~h ~ ~s~on and op~o~ ~ste~l~ ~spos~ sy~6. St~ Fl'lC TANK* Thc 6'~udg¢ ~nd sm ~cewm~atio~ in lh~ s&p~'~tnk ~ho~d b~ m~6~cd ~n~. Yhe sep~c ~ sho~d bc p~P~ wh~ lh~ 6~dg~ ~on r~ch~ ~5~ of tank eapa~. An ~t~alc w~ ~ ~mpos~d ~n ~c Mu~p~ of Ancho~¢ b~ ordl~n¢~ 4~ ~ ~ acP~e ~nE be p~p~d on a ~o f~tequency. DRM ~F I E LD / A~OR~ ION BEDS /TRENCH~ /~OU~S , ~h~ ~fe of the sysl~ o~ d~ine if ~e s~t~n, ~ b~ng ab~ed ~rougk ov~r-satu~j~on i.c. ZO~ ~te ~Ow~ tO run ~rng th~ ~6ton * Sep~c ~nk p~ping ~ b~ by a c~i~d s~p~ p~P~. p(~p~ coSZ w~l b~ p~d fait by ~t~ HomeoWn~ ~r~e~ ¢o ~ 6¢p~c ~nk collator. w~ ~un~on Sa~6fa~o~Y for ~ ~t~: or f~ occu~, A~ syphons ~at~q f~. Som~, 6y6t~6 ~v6 been known to last 15 - ~0 to/~ o~c 6y6t~S ~v~ f~ in 5 ~ 5 y~rS, floWeV~, t~t prop~ op~a~o~ and m~e~neC, ~ toag~v~Y o~ a 6yat~ ~n b~ e~tcnd~d. 0 0 d 0 0 0 0 0 0 0 0 0 0 l~l~!OAk ,(q ~u.i~d ~uoo.1Od 0 0 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AMD HUMAN SERVICES P.O. BOX 196650, 825 "L" Sg?REET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT NUMBER:SW960005 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:POLZIN ANTHONY J & ROBERTA OWNER ADDRESS:4351 DEARMOUN RD ANCHORAGE, ALASKA 99516 PARCEL ID:01809246 LEGAL DESCRIPTION: T12N R3W SEC 27 LT 56 (UPGRADE) PERMIT DATE ISSUED: EXPIRATION DATE: 1/10/96 1/10/97 LOT SIZE: 54450 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD SYSTEM ALL 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 ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLZNG 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAD PROVISIONS. SPECIAL PROVISIONS RECEIVED BY: ~//~/~// ISSUED BY: DATE: / -/¢ - ROBERT C. COWAN, RE. ROBERTA. SHAFER, RE. CIVIL ENGINEERS December 18, 1995 (907)694-2979 FAX (907) 694-1211 HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN ID(TENSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOWTEST ROAD OESIGN SOJLTEST STRUC~'URAI & MECHANICAL INSPEC¥1ONS MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 56, Section 27, T12N, R3W, SM, Ak. Request you issue a permit to upgrade the septic system serving the three bedroom house on the referenced property. A test hole was excavated and a percolation test performed in the area of the proposed upgrade. The approximate location of the test hole is located on the attached site plan. At the time of excavation no water was encountered ill the test hole and after seven day ground water monitoring, water was found at ten feet. Attached is the proposed upgrade design. We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. If you require additional information, please contact us. Sincerely, Robert C. Cowan, RCC/gk P.E. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 o EAGLE RIVER, ALASKA 99577 DESIGN UPGRADE U PROFILE BED DESIGN DEEP ';::O 0 © U Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: /~ i',J ')- /-/ O /q ~' LEGAL DESCRIPTION: .LO ')~ '~'' ~ DATE PERFORMED: Township, Range, Section: '7'/~ ,~/ / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 J ,)- ) 'F/') ~'- WAS GROUND WATER ~ ENCOUNTERED? IF YES, AT WHAT DEPTH? Oa, g. COMMENTS. I]eplh to Water Aller /0 Monitering? SLOPE SITE PLAN Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (' I (minutes/tach) PERC HOLE DIAMETER TEST RUN BETWEEN ~ _ FT AND _ 72-008 (Rev. 4~85) HEALTH AUTHORITY APPROVALS SEWER&WATER INSPECTION WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAl & MECHANICA~ INSPECTIONS ON SiTE W,~STEWATER 0~SPOSAISYSTEM DESIGN tcnee ,m ROBERT C. COWAN, RE. ROBERTA. SHAFER, RE. ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERI~L SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 REFERENCE: Lot 56, Section 27, T12N, R3W, SM, Ak. GENERAL: 1. The scope of this project includes the installation of an absorption bed to serve the 'three bedroom residence located on the referenced property. The existing septic tank is to be excavated to verify its integrity. If of poor integrity, the tank is to be abandoned and a new 1000 gallon septic tank installed. The existing leachfield is to be abandoned such that it may be used in the future. Construction shall be in accordance with the approved site plan and design drawings; Municipal permit with any special provisions or conditions; and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling° On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 17034 NORTR EAGLE RIVER LOOP · SUITE 204. EAGLE RIVER, ALASKA99577 Page Two Lot 56, Section 27, T12N, R3W, SM, Ak. Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. LEACHFIELD BED INSTB_LLATION: Excavate the proposed Bed Area to the depth shown on the design. The bottom of the excavation shall be within 2 inches of level. If the bottom of the excavation becomes smeared, J_t must be raked or scratched (ruffed-up) before gravel or sand placement. If a sand layer is required, place sand over entire excavation to the required depth shown on the design. The top of the sand layer must be within 2 inches of level. Sewer rock shall be placed uniformly throughout the entire bed. Perforated distribution pipe must be installed level with perforations down. Gravel depth below the perforated pipe shall be a minimum of six (6) inches. Gravel depth above the perforated pipe shall be a minimum of two (2) inches. The total gravel depth throughout the entire bed shall be a minimum of twelve (12) inches. The perforated distribution pipes must be as shown on the design but, no more than six feet apart. The distance between the outermost perforated distribution pipes and the sidewa].l of the absorption bed must be no more than three feet. Page Three Lot 56, Section 27, T12N, R3W, SM, Ak. De Silt barrier material must be installed between the final gravel layer and the native soil backfill, unless insulation is used, then the silt barrier should be installed over the insulation. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed at the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel depth shall be perforated six (6) inches below the bottom of the horizontal distribution lines. The monitoring tube should not extend below the bottom of the gravel surface. Backfill over the final gravel layer must not be less than twenty--four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finished grade over the bed must be mounded to prevent the formation of a depression after settling. MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: T__y_pe of Pipe Perforate~ Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick burial polystyrene (Dow Chemical Company equal). extruded direct Styrofoam HI or Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). Page Four Lot 56, Section 27, T12N, R3W, SM, Ak. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill· 6. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. 7. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements. INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before · this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way 'the contractors activities. Page Five Lot 56, Section 27, T12N, R3W, SM, Ak. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering° S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER ALASKA eDUIRODmeFITAL COFITROL $eRUICES, IDC. ~nqineerin~I $ ~n~ironmental Slit(lies TO RECEIVED DATE AUG 8 1991 SUBJECT Municipality of Anchorage ~-/~ Dept. Health & Human Se~viee8 ,' ~J~.i~'~,~"), DEEPARTMEk T OF HEAl TI- & ENV RO \IMENTAI PRO1 FCTION ~// ..... I ;~ 825 t. SI'rent - Anchoraqe, Alas <a 99501 T¢ epl nn~ 264-4720 ..... ~._~ ON-,,I rE SEWAGE DISPOSAl. SYSTEM AND/OR WEI_I_ INSPECTION REPORT PERMIT NO. .~. t_ength %c,a~_h~ line Total length of lines Nearest lot line PERMIT NO. DISTANCE TO: Building fo ndation Sewerlhle OTHER PiPE MATERIALS SOIL. TEST RATING iNSTALLER REMARKS APPROVED DATE! LEGAL 72-013 (Rev, 3/78) FIT Z ON DEFIRMOUN[) fl~ ~ TYF'E ElF REN_.H I"HE RE~S!LIiRE[:, SIZE OF THE SOIL FISSORPTION SYSTEM IS: / ."S ~:-S ~) THE LENGTH [:' Z MEENG ]: ON ZS THE LENG-rH (IN FEET) OF THE TRENCH OR E:,RIgZNFZEL. E:,. THE E:,EPTFt OF FI TRENCH OR PIT IS THE C,~STRNCE BETWEEN T'HE %URFFICE OF T'HE GROUND RN[:, THE E~O-rTOM OF -rile EXCIq',/FITZON (IN FEET). THERE ZS NO SE"r I.,JZE:,TH FOR TF~ENCHES. THE GRF]YEL DEPTH ZS THE MINIHUH E:,EP'rH OF' GRFI'v'EL BE'I"I,~EEF,I T'HE OLITFFIL. L F:'~PE FffND 1-HE BOT"rOH OF THE EXC~RVI~'rZON <ZN FEET). F E:F.H I T ...... :,: ;, :c; :, - ,: , ' ' ' f Fl I :, E:,EF'FIR1T,1ENT [)I_IE'. I ?QI3 THE bFFLI~.HNT I]1t_ I'HE F.E_f ..hl_.,IE, ILI]~r TO INFORM "' I.l'J... I - LLh 1 _ N :[ N_,F E_.T ]... N.:, OF I~NY [4ELLS Ft[:,JFICENT TO "['H I S F'r~toPERI'Y FIND THE NI...IHBER OF RE:,IL.E~',ILE:, THFFI' THE P~ELL_ I,.tI[.L _,ER,E. F=H_.KFILLIN..~ OF FINY :,~:,TEi'I k!I'FFIOUT' FINFIL INSPEO-f'ION FIN[:, ~IFFF_ FIL E,~ FHI=, £.L~ HI~.] i'l[:l'.,ll HILL E,E '~' :,I_IE, J EL. l F R _ :,EL. UT I _ N. h'IINIh'IUH DISTFINCE E',ET[4EEN I:t P.IELL FINE:' FINY ON-SITE LSEklRGE [:'ISPOSRL SYST'EM IS l~lE1 FEET F'OR FI PRIVFYf'E I,.IELL OR :LSE1 T'O 2E1E~ FEEl' FROi'q Fl F'UE,'LIC WELL E)EPENE:,ING UPON THE TYPE OF F'UE:LIC HELL. 1[I",IZi"IUH E)!SI'FI!!CE Ff;~'OH FI F'RI',,,'FITE I.,.IELL TO I::1 FI~.I"' "-HIE"- SEWER LINE TS ;::'~ FEET' FINE:, ~i FI COMi"IUNIT~. SEPJER LINE IS 7'5 F'EEET'. I,.IELL L(']S H~..~: RE~;]LIIREE:, FINE:, f"IUST E:E RET'URI',IEE, TO THE ",-" "',- · · [..~:F RI. 1HENT N I-tH I N ]:~l L"' H~'~.'""'=, OF \l-FIE F]E':LL COHPLETI:i'.I. OTFIER F::~EQLIIF:<EHEI'~TS MFIY FIF'PLY. SPECIFICFFTIONS FIND CONSTF~LICTION E:'IF~GRFth'IS FIRE FI',,,'F~ILFIE,'LE TO ~NSLIRE F'ROF'I~R INSTF:ILLFITION. I CERTIFY THFIT i: I FIM FFtMILIFIR WITH THE RE6]UiREMENTS FOR ON-SITE SEWERS FIND WELLS BS SET FOR-IH 8Y THE MI_INICIPRLITY OF FINCHORFtGE. 2: I I,JIL. L. INS'rFILL THE SYSTEM IN BCE:ORDFtNCE klITH THE COl)ES. ]~: I UNDERSTFiND 'THFFI THE ON-SITE SEI.4ER SYSTEM MFIY REQUIRE ENLRRGEI'qENT IF THE RESI[:,ENCE IS REMODELED TO INCLUDE MORE THFIN ]: BEDROOMS. FIF'F'LIOANI' E[ [:'ORFID, O NORTH , SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -- PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: DATE PERFORMED: SLOPE 1 2 3 4 8 §- 10- 11 14 17 20- SITE PLAN ENCOUNTERED? O IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop DATE: PERCQI..ATIQN RATE (minutes/inch) TEST RUN BETWEEN FT AND FT COMMENTS '~-~J~ ~_~ .~ /// BY: CERTIFIED BY: 72-008 (6/79) 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 1, GENERAL INFORMATION Complete legal description Lot 56; Se, c 27; T12N; R3C'); S.M. Location (site address or directions) 4351 DeA~,oun Anchorage, AK Property owner Mailing address Lending agency Mailing address Agent Address A~t~,ony Polzin C/0 PHH Homeq~ty Day phone 563-5500 C/O Jack White. Re~ Est~ 320i "C" Street Su~t6 200 Anchorage,, AK Day phone 99503 Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 ~ TYPE OF WATER SUPPLY: Individual well XXX Community well Public water NOTE: DIVISION 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: XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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 Add ress 17034 Eaglei~ ~ Engineer's signature Phone Date DHHS SIGNATURE __ Approved for --~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 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. 724)25 {Rev. 1/91) Back MOA #21 btUNICIPAtii ¥, ~1. A ~unicipalJty of Anohorafle '~'~t~v~c~ ~. DEPARTMENT OF HEALTH & HUMAN SERVICES ~/~,. Enviror, menta, Settees Division 825%" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4'~ Health Authority Approval Checklist Legal Description: ?o-r 56 ~ .4ae-..r~o,,4 7~7t q'iz¢l tP, SoJi ~.~.Parcel I.D.: A. WELL DATA Well type {9¢4,3&q¢. __ If A, B. or C, attach ADEC letter. ADEC water systenl number Log present (Y/N) ¢,1 Date completed "7/"7/(~t Total depth _ }~16/q/q,) Cased to ,Z.,' ~ (I/q/qt. Casing height (above grouod) Sanitary seal (Y/N) ~ Date of test Static water level Well production FROM WELL LOG Wires properly protected (Y/N) ,¢ AT INSPECTION '~. '2, g.p.m. WATER SAMPLE RESULTS: Coliform Date of sample: 2./Iq /qt,, Nitrate /o/~/ /~;~//~. -- Other bacteria B. SEPTIC/HOLDING TANK DATA Date iastalled ~./~.e. / ~, Tank size I ooo Number of Compartments ~ _ Cleanouts (Y/N)~ Foundation cleanout (Y/N) x/ Depression (Y/N) _ t4 High water alarm (Y/N) p,l /.fi, Date of Pumping ~'/~6/q~_ ~l Pmnper A't' C. ABSORPTION FIELD DATA Date iastalled q-._/Z~/q 6. Length t~ ~ Widll'. Effective absorption area O.~ Soil rating (g.p.d./ft or fr-/bdm9 _ O. 'l System type. {g IGravel thickness below pipe O. ~ t Totaldepth M0oitoring Tube present(Y/N)~ Depression over field Date of adequacy test Iq/,*, - Fluid depth in absorption field before test (in.) Fluid depth . "~ .(ins.) Minutes later: Peroxide treatment (past 12 months) (Y/N) Results (Pass/Fail) '--' For ~ bedromns Immediately after~~_ gal. water added (in.): ~- Absorption rate = ~ _g.p.d. If yes, give date ~ D. Lilt STATION D~ , Size in gallons High ;vater alarnHcvel a_~l*~ *Datam ~ SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field oo lot Public sewer maio Sewer/septic sel~ice line ; On adjacent lots ; On adjacent lots Pnblic sewer maoholc/clcanout. Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Building foundation ,.~ I 'e Property line ~ I '~ Absorption field Water main/service line I O 4- Surface water/drainage I Oo ~ ~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Surface water Curtain drain i'~ ]~- ENGINEER'S CERTIFICATION Water main/service line Driveway, parking/vehicle storage area __ 5'0 Wells on adjaccot lots F. ye I certify that 1 have t&tel'lllined thrufield in,~ in confi~rmance with MOA [I~ guidel~ w of Municipal records tt*at:th~'-3,pstems a 'e Signature 5 & S , 17034 ~t~le Riv~pj NO. Engineer s Name ~gle l~iver, .......................................................................................................... ....... 7 ;z ..... HAA Feo ~ ' ~ ' Waiwr Feo Date ofPayllmnt ~/~Z Date of Payment Receipt Number /~ ~0/~1 Receipt Numb,r Rev. 8/95 eSS: haa.wk.doc 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 1. GENERAL INFORMATION Complete legal description _ ~,~. ~ ,~-~ Location (site address or directions) /-/,~ ~] ~ /'-~-¢-p44 c) ~ ~'/ Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3, TYPE OF WATER SUPPLY: e NOTE: Individual well ~' Community well Public water 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) Fronl MOA #21 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 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 / '~"/'2/~"~ ~(/~¢~''~'~l~-k~¢ ~- Phone_ ¢~-"~5]-z~ /'~:;~ Address ~ '~ ~ / ~'" ~¢/ Engineer's signature '~-~-~~'---- Date /2.//~ /4/ DHHS SIGNATURE Approved for Disapproved. bedrooms. Conditional approval for 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 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 Legal Description: A. WELL DATA Well type 2 Log present (Y/N) Total depth Sanitary seal (Y/N) Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL, CHECKLIST · ~2 Z/~ ~', ~¢- ,,L ~ 7 Parcel I.D. c¢,/~ - -F/C-/,% IfA, B, orC, attach ADEC letter. ADEC water system number / Date completed ~ ?/"-~ / Driller / / ~ Cased to / / ~ Casing height Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow ¢?/ g.p.m. Pump level MUNICIPALI/rY OF ANCHORAGE AT INSPEC"~J~J)J~JONMENTAL SERVICES DIVISION ¢, R-ECEIV[!D g.p.m. Absorption field on lot Public sewer main SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot / /'¥'~//~ Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank h¢'.,,~, WATER SAMPLE RESULTS: Coliform /~ / Nitrate Date of sample: _ / '~,//~l/'//1~ t /, (-,7.~ Other bacteria ~//.~ Collected by: ~"~( ~4~'¢-~(- ~/~ B. SEPTIC/HOLDING TANK DATA Date installed ~'/'~- '~,¢/ Cleanouts (Y/N) _ ~ High water alarm (Y/N) Date of pumping Tack size /¢2 ¢-O Compartments ~// Depression (Y/N) J'"~/ Foundation cleanout (Y/N) t,v'/'/~_ Alarm tested (Y/N) / ";2'/z"-I/d ' Pumper 1.,~ ~ ~_ C. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /r,~D '~ On adjacent lots To property line Surface water/drainage Foundation_ Water main/service line 72 026 (Rev. 7/91) Fronl CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D, ABSORPTION FIELD DATA Date installed Length :~ O Width / Total absorption area .,~'/ Depression over field (Y/N) Results (pass/fail) '~ _,~% Peroxide treatment (past 12 months) (Y/N) Soil rating ~:/'O Gravel thickness Cleanouts present (Y/N) Date of adequacy test for ~ System type. ~ Total depth bedrooms If yes. give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellonlot / 50 ~1~ On adjacent lots ~ /' ¢':~:~ Propertyline '~ O ~'~ To building foundation f//{¢.O ~ To existing or abandoned system on lot On adjacent lots ~ //~-~;' Cutbank /"/'//,~ Water main/service line Surface water h-//~ Driveway, parking/vehicle storage area Curtain drain 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. Engineer's Name "'~¢ ~'~ ~-'( Date 1%'//~ / R( HAA Fee $ / ¢0 ~ Date of Payment o~- //- ¢ ::~J Receipt Number °?'~/-/(¢"~' -~ (~'~'~/ 727026 (Rev 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number ANCHQ~AGE, AkASKA SEPTIC SYSTEM ADEQUACY TEST LESAL: I.ot 56~ Se*c:,, 2'7. T:I2N R3W LOCATION: .435] I}eAr moun OWNER: Don Idouser RESIDENCE: S:i.n~jle Fami]y~ 3 Bedrooms WELL: Pr~vate, On Site SEPTIC SYSTEM: FR[]M MUNICIF:'AL RECORDS: 3 Bedroom System T'ANK: At, chert'age Tank 1250 Gal,, I-wo Compar"t:s. ABS[]RF'T I ON SYS"rEM: Bed ABSORF'TI[]N AREA: 510 Sq. Ft:,, SO]:L RA-[ING: 90 I NS'I AI...L_A'T I ON DATE: 6---28'-'S :L DATE OF LAST PUMPING: Dec. 4 199:i Isaacs DATE OF TEST: Dec:. .4~ 199:[ -rEST PROCEDURE: System was :i. nspected and measured. ]anl.:: was; · Found w:~'l:l'l 3,,5 fee't: o'F cover and w:i'Lh a :Liqttid ].eve:L o'F 48 ir';c::hes,, ]ged moreL'Lot' tt.tl::~c)was 5 deep with EL, 5 J. nches of wa'Ler'. ~a'l.:er ].eve].s J.n the tank and 'l:.hia r[iof]itor tLtl](.;, were moni'bored. wa~f.:q'" :Level in ~he tank did not: c:hange~ wh:i.]e tl~e ].eve1 mon:itor' roSE, 4 J nc:lies. Dur':[ng tl'~c? nex'b 90 minuted the water level in the m(::)l]:itcH" dr'opped 2.5 i l](]hes. I'he r/el, xt day 't:lae ].c:,ve] :in hhe mc)h:itor '[:tJl:~h) was chec:l.::ed,, -fh~a water ]eve]. had dropl:)ed an additional 2.5 ir~(::hes~ to a hot:al depth o~ 7.5 inch .... es,, Ow:~r' the next s6)w;~ra], days th[.,) water level c:c)rYLir~Lu:~d E(3 drop 't:o a 'f:i. nal del}Eh o4: 4.5 il~ches,, At that ti. me the tank was full arid (::orllrllericed to discharge to the bed. Tl'lese readJ, r~(]~ J. rldi(::atE~ ent~>)r :i ng ti'm:, [:)~:,~<::1., TEST RESULT: -I'h:is syst(:)m meets 'blare (::ode reqt.i:i, rements o.~ /:he Heal th al-id [:J(:) 6: J. ,~ :[ Se:r-vic:es NE)TE "['1~(:~, oper-at:i, orlal lJ'f¢ o-F ali sept:i.c systiems depends on t. he ]. cx::al sc:x[ 1 c(:)nd J (: i ()rl{~; v ~-}J'"OLtr]cJu~BI:ECr iL evel s that may f 1 Ll(]tLlat~~ clurirlg 'l:hc.~ y{,~ar ,¢ and t.h(;.) water usago o.f 'l:he f ami ].y be:i.r'u.~ served I:)y 't:he sys(iem. These c:C]llc:l:i, tiol'lf~ 205 WESl 15~U, AVENUE SUITE 206 ANCHORAGE, ALASKA 99502-~904 (907) 279-3916 RESIDENTIAL WFLL INSPECTION LEGAL: LoL 56~ S~(_'i. 27,~ T12N R3W LOCATION: 4.,,,_ 1 DeArmoun OWIqER: Don I"lOLt set TYPE OF WELL: F:'rivat. cg~ S~ nglt:? Fami]y WELt_ LOS AVAILABLE: Yes INSTALLATION REQUIREMENTS MET:Yes WELl_ YIELD FROM WELL LSS: 4. [aallons per- Mir~u'be~ PUMP YIELD FROM TEST: 6.5 Gallons per I*tinute DATE OF INSPECTION: Dec.. 4..~ 1c791 TEST PROCEDURE: We].] was pumped at a constant rate wh:i.].e ~:he pr'obe~ At the l:)er.]i['-,ninl;] o~ the test wa'Eer :level was found at 58 4:eet below roi:) o~ c::asil]g.. At a pumlaim'~g rate (:~ 6.5 gallons p~r' m:i. nLtte the wakem' TI. eve]. dr'opp~d t'.o ]. 19 '[:e(.,?'t: a4 tier 25 a'm:[r~ut:~:'~s of pt.tml:):i I'~g , AL 'Lhat 'k :[ m~.? t:he we] 1 was dry, Wel 1 was al. ]. owecl to ·Feet:. ]'lie ~ell was 'Ebon pumpect at :1..7 gpm ~c]r 25 fl~J.f]utes c:aus:[ng the:, water ]c~vc:,] Lo rise 8 ~(met. The ~l(:)w was; 'Ehe~ increased [:o 4 gpm t,,~:[t(::h cat.uaed 'Lhe yea'kef lev(,gl and 2C) rain, A t.o'La/], c) f 530 water' :1 eve)]. F'l::)?,e to 5f3 -[:(:9t:e'k ~ a I ': 0 % r-e:,covc:,r'y~ TEST FOR E.COLI AND TOTAL.~uNITROSEN: an:: ':~ al. ,",:~t'.rc,,:p~n on E,,[]olJ 0. Tokai Nitrogen Max. allowable t: :i me the TEST RESULTS: 'l'his well rneets the requir'ement, s o'F the Municipali'ky o-f: Ar'lc:horage. THIS WELL .WILL PRODUCE MORE T_HAN ~. GALLONS PER MINUTE FOR MORE THAN FOUR HOIJRS The Municipal requirement ~or mall flow is 150 gallons of water per bedroom per day. This ~.~ell ~xceed this requirement, The assessment o~ the aomdition of the well applies only to the conditions as o~ the day tested. The flow rate may change due to subsurface conditions that may not be observed from the surface, and changes in the land use and otber factors that may impack the aquifer feeding the well. Time Date Inspector Comments Time Date Inspector Date Inspector Conditional Approval Date Sewer Installed Soils Rating Permit No. Well To Absorption Area Well to Tank SePtic Tank Size Holding Tank Size Well Log Received APPLICAN'r FILLS OUT LOWER HALF ONLY Property Owner Mailing Address Buyer Address Lending Instltut Ion.~.~ Phone Address Realty Co, & Agent Address Legal Description Street Location Phone Type gf Residence ~ Single Family ~ Multiple Family ~ Other No, of Bedrooms Water, Supply Iq Individual [, Community L3 Public Utility Sewage Disposal I~t Individual [] Public Utility [~ Holdla~.Tank ATTACH WELt_ LOG. A well Icg Is required for all wells drilled slnse June 1975. For wells drilled prior to that date, give well depth (attach Icg if / / Year Individual InstaDed: '~t When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY IEACH REQUEST BEFORE PROCESSING CAN BE INrflATED.