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Home My WebLink AboutTALUS WEST #1 BLK 3 LT 29 ~./ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION · 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE [] UPGRADE MAIL~ADDRESS~- .~ .~ . [ ~ · Well . ~ Absorptio Dwelling PERMIT NO. ~ Manufacturer ~~ M a~ No. of~artments' Li,. c~a~tbi~,~s I, "OMEMAO.: Inside length Width~ Liq~th ~ ~ DISTANCE TO~ ~ Dwelling PERMIT NO. · --~O ~ ~ Ma~ ~ ~" Materi~~ ~ capacity in gallo~ Q Well - ~~ Nearest lot line PERMIT NO. -- No. of ~lines Length of .ach~:~ Total length of ,,.~ Trench width.~;jnche,/0 ,istanc%~., ~ ~ ~ Top of tile to finish grade Material beneath tile ~ Length Width Depth PERMIT NO. '~ ~STANcEType~TO: ~rib dian~ Crib depth~ / ~'~;b~ a~a ~ ~~ Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO; Building foundation ' Sewer line Septic tank Absorption area(si OTHER PIPE MATERIALS REMARKS ~ f Z ~ ~ ~ ~ JRMES DELRN¥ SRR 1585-D RNCH 89 WILDERNESS DR. LT.. 29 BLK g TRLUS WEST S?D LOT SIZE HF F_ I -.HNT LiT CRT I C N L. EGRL TVPE OF qF~IL HE,--,uRF rIuN -'"-- , ,-'. · -. .... b~_,TEH I_-,. TREN..M 19000 SQLIRRE FEEl' MR;:.::IMUM NIIMEER OF E:EDROOHg = THE REQUIRED :,I~.E OF THE :,UIL HB-~DRPTION [:, E F' T H .... :.1_ ::L L E !'-,~ ~3. T ~-4 ~= ~:-"; ._':'~ L3 F: R ",,-" E [_ [:, E F' T l..-~ == 7 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETf4EEN THE SURFFICE OF THE GROUND RN[:, THE BOTTOM OF THE EXCRVRTION (IN FEET)· THERE IS NO SET WI[.',TH FOR TRENCHES· THE GRR',,,'EL DEPTH IS THE MINIMUM DEPTH OF GRR'¢EL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE E::'.':CRVRTION (IN FEET). F'ERMIT RPFLI...MNT HRS THE RE-PuN_,IE, ILIT~ TO INFORM 'THIS DEF'RRTMENT DLIRING THE INSTRLLRTION IN_FEL. TIuN_-, OF RN'¢ WELLS RDJRL]ENT TO THI'5 FR_FERT~ RND THE NUME:ER OF RESIDENCES THRT THE NELL HILL _,EF..,~E. 8RC:KFILLING GF RNV '='"-- , ':' -' - -'' -,~_,TEH HITHOUT FINRL IN_,FEL. TIuN RND HFFR_,RI._ BV THIS DEF'RRTMENT HILL BE SUB.fEF.'T TO FRO_,ECUTIuN. MINIMUM DISTRNCE BETWEEN R WELL RND RNV ON-SITE SEWRGE DISPOSRL S~'LC, TEM IS ±00 FEET FOR R PRIVRTE WELL OR ±50 TO ::-"OE~ FEET FROM R PUBLIC WEL. L DEPENDING UPON THE T'¢PE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRI',,,'RTE HELL TO R PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNITV SEWER LINE IS 75 FEET. HELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~E~ DR"r'S OF THE WELL COMPLETION. OTHER REQUIREMENTS MR"? RPPL. V. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRtLRBLE TO INSURE PROPER INSTRLLRTION. I CERTIFV THRT i: I RM FRMILIRR klITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH 8V THE MUNICIPRLITV OF RNCHORRGE. ~: I WILL INSTRLL ]'HE SVSTEM IN RCCORDRNCE WITH THE COB'ES. ]:: I UNDERSTRND THRT THE ON-SITE SEWER SVSTEM MRV REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN ~ BEDROOMS. "'RF'F'L I CFiNT~ ~ ~ ..IRMES~E~V 0:, DEPARTMENT ~,~HEALT;-; AND EN\RRONMENTAL PROT~J'ION Pouch ~-SS0, Anchorc?, Al~ka ~SO2 276-2221 SOILS LOG - PERCOLATION TEST PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3- 4 5 6 7 8 9 10 11 13- SLOPE · SITE PLAN I 14 15 16 20- WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? ' ' I ~ I G ~ O:S Net Depth to INet : Reading Date , Time Time Water Drop I ; z-/-7-~/[ 3om;,, hS,,~. ~ I "5 ::q4'-~/ ] '~o,,.Z... I z- , [ PERCOLA--iO N RATE ~ ~;~ (minutes/inch) TEST RDN £STWEEN /~- ~:T AND /'~ FT ~ERFORMED BY: DATE: 'ti! M-~/ DRILLING, Inc. P. O. Box 4-1224 · 1310C International Airport Road (907) 274-4611 ANCHORAGE, ALASKA 99509 DRILLING LOG Well Owner Location (address of: Township, Range, Section, if known; or distance main road Size of casing_ 'r Static water level '~ ' Screen ( ); )' Describe screen or perforatiorL Well pumping test at '~ ~'" gallons of drawdown from static level. Depth of Hole lt. Perforated ( feet Cased to - / feet (below) land surface. Finish of well (check one) open end ( ~: ); (minute) for i hours with Date of completion- b/'i ~r / ~]' WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness :'! _TO~ - - _TO TO ft. ~ ~ _TO r/ TO /: TO TO ___TO_ -- TO_ TO_ TO_ _TO_ TO_ __.TO_ NWWA Ce~ti[ied Contractor {Jertilicate No's. 814 & 973 3--CONTRACTOR 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) Property owner Mailing address Lending agency Mailing address JJ Agent Address /¢4~'~//z~,7'i /'~///1:2~ /"~.~/~;'¢~ Day phone / 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. 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. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer 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 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 westewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verifythat 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 Address Engineer's signature KND Engineering 2~¢~41 Plural§an Blvd. Eagle River, AK 99577-8736 Phone ~:¢ .~;'4-~ - 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 ~ c,ess~onai engineer reg stered in the State of Alaska. The DHHS does this as a courtesy to purchasers of hemes g sbtut~ons m order to sat sfy certain federa and state reqmrements. Emp oyees of DHHS do not :cr'zuct r~Soections or analyze data before a certificate is issued. The Municipality of Anchorage is not '.-'~ccns =.e 'or errors or omissions in the professional engineer's work. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVlC~E C E IV [ D Environmental Services Division 825'%" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 JUN 25 1996 HeaLth Authority Approval CheckList Mumc,pality of Anchorage Oept. Health & Human Se~Jce$ A. ?/ELL DATA Well type_ Log present (Y/N) Total depth Sanitaw seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~¢¢/~ [ / Cased to ~' '7 ~ Casing height (above ground) Date of test Static water level Well production Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION /() / g.p.m. ,f, Bo Co WATER SAIvlPLE RESULTS: Coliform_ .x//_) (oJ //Nitrate_ Date of sample: ~,/Q~/~v SEPTIC/HOLDING TANK DATA Foundation cleanout (Y/N) /. <~ y / Other bacteria Collected by: _ t~M/) ~q(~ [//] ~'/7 Number of Compartments r~ Cleanouts (Y/N) High water alarm (Y/N) ABSORPTION FIELD DATA ~ Date installed g///~/~/ Soil rating (gpd/fl2orfl2/bdrm) ~'~) ¢ ~ .... System type ~)~ Length ~-/ ' Width -'~ / Totaldepth /'~¢ ~L (/l'l?/~ Gravel thickness below pipe ~ / ~ " Effective abso~tion area ¢/~ ¢ Mmfitoring Tube present(Y~). ~ Depression over field (Y~_ x Date of adequa~ test ~ ~ Results Cass~ail) For ~ ~ bedrooms Ftuid depth in absorption fidd before test (in.); ~//¢[mmediately ~er¢~gal. water added (ia.): Flniddepth ~ ~(%ins.)Minutes later: /~ /' g.p.d. Abso~tion rate = ~ 4'/ Peroxide treatment (past 12 months) (Y~) ~ If yes, give date Lllrl' STATION Date installed Mauholc/Acccss (Y/N) High water alarm level at* Cycles tested Size in gallons / / ~ "Pump on level at*. /'Pump ofF' level at* _ // ' SEPARATION DISTANCES Septic/fielding tauk on lot Absorptioo field oo lot Pablic sewer main Scxver/septic service line SEPARATION DISTANCES FROM WELL ON L/.O? TO: //9o., /Be/' ; On adjacent lots ; On adjacent lots Public sewer ~nanhole/cleauout Lie statiou SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: / Building foundatioo /d..) Propmly liue /69 ~ 4- Absorption field_ Water main/service Iioe ~.'~' / 4- Surface water/drainage //d2d~ t./. Wells on adjacent lots SEPARATION DISTANCE FROM A SORP nON FIELD ON LOT TO: Building foundation /~0~ 4 Water mai~ffservice line Surface water /~ ~ 4- Curtain draiu .~'-C") t 4- ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area .'".,(~) Wells oo adjacent lots /OZ') 1 4 Property line S~gnature ~ ........................................................... ~h~_ .,o.. .,k~ ....................................... r[~S~ .......... Apee ~ ~ u~' Waiver Fees Date of Payment ~ /~-,~ Date of Payment Receipt Number _/9 ~,r: C~) Receipt Number Rev. 8/95 OSS: haa.wk.doc CT&E Environmental Services Inc. Laboraton/Division ~ Laboratory Analysis Report CT&~ Ret',# 9&2411.96241 lO01 Client Sample 1D L29 tl3 Talus West #1 Matrix Drinking Water I'WSID 0 $~upk Rom~ka: Collected Date 06118/96 Te~lmical Director: ~ephea C. Nethod 0.200 n'~/L EPA $53,~ 0 ~ot/lOOmL ~18 92226 200 W, Potter Drive, Anoherage, AK 99618-1605 -- Tel: (907) 562-2343 Fax: {907) 561-5301 3180 Psger Reed, Fairbanks, AK 99709-5471 -- Teh (907) 474-8656 Fax: (907) 474-9685 ENVIRONMENTAL FAClLIIIES IN ALASKA, CALIFORNIA, FLORrDA, ILUNOIS, MARYLAND. MICHIGAN, MISSOURI, NEW JERSEY, OH[O, WEST MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING O / ~ ~, ¢ ~ o jo--- NAA# ~_\~-~%L[ ~), 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Locatioo,(&Sdres~ or:direStions) (b) Property owner ~' Mailing Address ' '-"- ~ Telephone: (home) Business (c) Lending Institution" ' · "' .;' Mailing Address Telephone (d) Real Estate Company and Agent Address ~"~' ¢ Telephone (e) Mail the HAA to the following address: (or check here"~ if hold for pick up.) List contact person and day phone number below: TYPE OF RESIDENCE Single-Family~ Number of bedrooms 3. WATER SUPPLY Individual Well'S2. Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site!DL 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 (Rev. 7/88) Page I of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FiLE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto end 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 informetion obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or westewater 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 /'¢,E'~-,5 Telephone 2 ? ~ ~ _~--~ > ) 6. DHHS APPROVAL Approved for Approved ,~ bedrooms by r . . Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 7/88) Back Page 2 of 2 ~ MUNICIPALITY OF ANCHORAGE (MOA) (, ~,~[~z'~,~, , . Health Authority Approval (HAA) 't 'i: ~ 1 '.~,:_ ..~>oola°° Legal Description: /_o~ Well Classification Ll~;p~:(~t ~ a sei~d t ~ Date Completed(~J~,J Static Water Level (~ '~'5~ / Casing Height Above Groun'd Electrical Wiring in Conduit6/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ~//~ To Nearest Sewer Service Line on Lot If A, B, C, D.E,C, Approved (Y/N) C-/F-W/ Yield ~; Pump Set At Sanitary Seal on CasingON) Depression Around Wellhead ; On Adjoining Lots /~ /4~a '~' ; On Adjoining Lots /~ To Nearest Public Sewer Cleanout/Manhole ,~./~4' Water Sample Collected by Water Sample Test Results Comments ~ ~'.J~.7_.c /'~.,,,.J B. SEPTIC/HOLDING TANK DATA Date Installed "/'-/~/ Size /oz~O No. of Compartments StandpipesON) Air-tight Caps L(~N) Depression over Tank (Y/~ Pump!rig(Maintenance Contact on Fi~e (Y/N) Holding Tank H gh~V~ater A arm (Y/N) SEPARATION DISYAN~CE,S~ FROM S~PTIC/HOLDING TANK: To Wafer-Suppl~Well ', · ' /~3 To Property.L~ne . ~' To Water Main/Service Line ,," To Stream, Pond, Lake or Major Drainage Course Comments , Foundation Cleanou~. '_N) __ Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field 72-028 (Rev. 7/88) Front Page 1 of 2 C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed '~r/r' /~'[¢ '~'~/ · Width of Field Square Feet of Absortion Area ¢/r~ Depression over Field (Y~'~.~ Results of Last Adequacy Test '~t~/~¢' SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line Type of System Design Length of Field ~/ ' Depth of Field / Gravel Bed Thickness Statndpipes Present~N) Date of Last Adequacy Test /t-o '/ To Property Line /~' -4- To Existing or Abandoned System on ; On Adjoining Lots /,~ /~ /'¢ To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION , D~te-tnstalled Size in Gallor~- "Pump On" Level at "'-' Dimensions Manhole/Access (Y/N) "Pump Off" Level at High Water Alarm Level at ~"~.-- Vent (Y/N) Tested for "--.-- Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) ............ Comments .... **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection, Signed Company Date /'~' -/~' ~ MOA No. ~?'¢ Receipt No. Date of Payment Amount: $ ~ Receipt No. Waiver Fee: $ Date of Payment. 72 026 (Rev 7/88)Back Page 2 of 2 ' ~ CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. /~'~-' 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAi~PLE for Work Order ~ 10509 Date Report Printed: NOV 21 88 @ 23:19 Client Sample ID:L29, B3, TALUS W, PWSID :UA Collected NOV 16 88 6 19:45 hrs. Received NOV 17 66 6 11:30 hrs. Preserved with :4 DEG. C Client Name : AECS Client Acct: AKECSRP P.O.$ NONE REC'D Req # Ordered By : Analysis Completed :NOV 18 86 Send Reports to: Laboratory Supez~i3pz ~STEPHEN C. EDE 1)ARCS Released By : ~ ~". ~ 2) Special Instruct: Chemlab RoE #: 3470 Lab Smpl ID: 2 Matrix: WATER Allowable Parameter Tested Result/Units ~ethod Limits NITRATE-N 1.2 mg/1 EPA 353.2 10 Sample ROUTINE SAI~PLE Remarks: SAt~LE COLLECTED BT A, WIEN. i Tests Performed See Special Instructions Above UA~Unavailable ND~ None Detected "See Sample Remarks Above NA= Not Analyzed LT=Less Than, GT=Greater Than ~..., APPLI~.NT FILLS OUT UPPER HA Property Owne'~ ~'~',~- //~?[' ~Lo/~e IJ ...... Phone Address Zip code Lending InstItution ~1~.~ S~,~, //l~/_w*/v~w ~,, / Phone Realty Co. & Agent ~~-~-~z/ ~]~L~G : -/-~,~/~...~ ~ ~'~~"~ ~ Phone Address Street Locatic~ Type of esidence ~D Other U] Community For wells drilled prior to that date, give well depth (attach log U available). Sew Disposal {D Noldin~ laak NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Inspector Insp~tor Insp~tor Insp~tor Field Notes: ( ~ APPROVED BEDROOMS ~ *CONDITIONSOF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* 72.023 ~ ~NSPECTION APPOINTMENTS (P~C(~_' '~-t~p DATE DATE DATE INSPECTOR INSPECTOR NSP ECTOR MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECTION DEPT. OF HEALTH & 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL [~OTECTION E~VIRO~E~TAL SA~ITATIO~ DIVISlO~ Telephone 264-4720JUL 2 9 1.981 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER~I~I~~ D DIRECTIONS: Complete all parts o~ page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing, 1. p~ERTY OWNER ' PHONE PROPERTY RESIDENT (If different from above) PHONE BUYER O}~ PHONE MAILING ADDRESS 3. LENDING INSTITUTION PHONE MAILING ADDRESS 5, LEGAL DESCRIPTION I STREEI' LOCATIC~ 6. TYPE OF RESIDENCE I~'~SING LE FAMILY MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four [] Two [] Five ~ Three [] Six [] Other 7. WATER SUPPLY [~;k/"l NDIVI DUAL* [] COMMUNITY [] PUBLIC UTI LITY ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM Ng I~--~'iNDiV[DUAL/ON-SITE** J YEAR ON-SITE SYSTEM WAS INSTALLED. EZ] PUBLIC UTI LITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 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 UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER l~Septic Tank or []Holding Tank Size: . If Tank is homemade SOILS RATING give dimensions; TYPE OF TANK -- MANUFACTUR~-R TOTAL ABSORPTION AREA i --' --f~TERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS ~'E~'~-APPROVED FOR "~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED