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HomeMy WebLinkAboutKNIK HEIGHTS BLK C LT 5Knik Heights
Block C
Lot 5
#017-034-05
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Mark Begich Anchorage, AK 99507
Mayor www.muni.orttlonsite
(907) 343-7904
Pump Installation Log
Well Drilling Permit Number: SW_ Date of Issue:
Parcel Identification Number:
Legal DescriptionPrope Owner Name & Address:
r�LAn-V a-0 w ifR
Pump Installation Date: Lf - a8 -
Pump Intake Depth Below Top of Well Casing: 8 7 feet
Pump Manufacturer's Name: 4%1 .MC QoMA t -
Pump Model: a.'3 Q 3 L 3
Pump Size I/' -.hp
Pitless Adapter Burial Depth: 19 feet
Pitless Adapter Manufacturer's Name: /
Pitless Adapter Installer:
Well Disinfected Upon Completion' IZ Y es ;J No
Method of Disinfection: C a f9 LLIE—TS
I Comments:
11AriChoeA4%- j. P�+►�►� SFav,c� 11
Pump Installer Name:
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650 Page of
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: Gvv 03 0 d I O PID Number: n 17 — 0 3q— 0 5
Name i I C7 VA 1rtTl,C-L /
Wastewater System: C3New Upgrade
Address
R—ng
ABSORPTION FIELD
Phone Number of Bedrpoms
A_
eep Trench ❑ Shallow Trench O Bed i] Mound ❑ other
LEGAL DESCRIPTION
$oil Rating :
/,
Total Depth from original grace
p M11/0
Fl,
Block: Lot. Subdivision:
`-
Depth to Pipe bottom ham original grade-
Gravel depth beneath pipe
o.
) ,
C 5 N 4- � R"T
! Ft.
6 FI
Township Range: Section:
Fill added above original grade:
Gravel Length:
—0 — FL
0 Ft.
Well: ❑ New ❑ Upgrade
Gravel wdtr[
Number of Imes:
1
Distance between liner
I
FI
Ft
Ctass.6cat,on (Pnvate, A. B, C): bI
Total Depth:
Cased to
Total absorption area:
Pipe Maleenal
y
Ft.
Ft.
Fe
ja L) I b L 3O L.
Driller \CJ
Date Drilled:
static Water Level,
hstanar/ J� /
Date Installed: 3
Yield V \ i
Pump Set at:
Casing Height Above Ground:
TANK
GPM
Ft.
FL
SEPARATION DISTANCES
�� ���
S//
eptic ❑ Holding ❑ S.T.E.P. ❑ Other:
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer
Capacity
From
Tank
Field
Station
Tank
Sewer Line
A N (_ 1+ Q�} L N V—
Gal
Wei
101
11 O
C1 o
Material: _
S T,� L
Number of Compartments
VL-
Surface Wa'er
N Q
NI
0
LIFT STATI N
Size:
Manufacturer.
Lot Line
�
1 f
• i
Gal.
'Pump on- level at.
'Pump otr ievel
High water aia" at
Foundation
in
in
in
Cura,n Oran
NIU
`
tV'
t4Ii
I
Pump Make d Model
Electrical In pections performed by:
(�
Remarks
BENCH MARK
X15 71 tj6 '— NIL C ►2v 14 —L
Location and De cation:
PJo Sie�i K
l-N- N R,fL 1 =
Assomea E-"Stcn
N / E' UVK -it
=0i�«�S _ta p
\i
Ami'%
0G«e0944040t D
i h 11.
so.
aa 'r��l
%
/C
Inspections performed by: Dates: 1a' `Ii4, 3
N:'�9
2nd 1 L ID
a"
OrDevelopment
Services Department Approval
Tn�
Reviewed and approved by: Date:
tie cams mai
10.e• 1_'MII
�, P
FESS����
0
- — — — — — — — — — — — — — i \
I r - - - - - - - - - - - -- --^=-T
I I I
I I .©
I I
I I
I I
I I
I L ---------- —�
-�- Lyell
gym. = m e m ... J—M — —
t,.
E 1
I AVSTALLED �-aFOrPobU — — — — �— J •; � � ;.,
I 11250 CA TANK W/DtYERTERVALYE � �'J o :.� •::
50 FT LONG 11 NCH
I I MAL aEPW It TT _C7iVE
1 1 17 ED AV EXl8W IWNCH I 1
.;
I I CRUSR O ANO XWO ExL W TANK I a
I 1 I AcCt7 !T
I 1 I ac 39.
I I RD u
I AE 78 �� •.��i��,'
aE 99 O �E
1 L — — — — — —— — — — —— •���p:••. •.......
r — — — — — —— — —— — �.....4..th
J !.......................
....... i
1 TO N AND
1 1 6 •i♦� NO. CE -2225 •�L•
.••''•
F-1 411
I O 25 50 75 too 125 150 Well F4a"�••��
I SCALE! 1' = 50 Y
I I I I
I I I
I I I &710V MAN:
eormm mm w�V c"" HOUSE
MUM ELEV. t00.00 FT
TOBBEN SPURKLAND P.£.
203 W 15TH. AVENUE LOT 5, BLOCK C KNIK HEIGHTS SEPTIC SYSTEM AS BUILT
ANCH. AK. 99501 1'1600 SHELBURNE DATE. APRIL 21, 2003
907 279-3916 PHIL GRA WUNDER SHEET- 2/3 GRID. 2836
PERMIT # SVO30010 PID # 017-034-05 KNH00052.DVG
Standard Trench:
2' Wlde
50' Long
10' Beep
6.0' Sewer rock
3' Cover
Sl( t Ba
6.0 ft of Septic Rock
Effective
O Foundatlon Clean out
Monitor
NO SCALE
dO4b/P C'
Poll
1250 go, Sept1c tank
1250 GAL SEPTIC TANK
WWH MAN' eatnw MW
ASSUkW EUX 100.00
TOBBEN SPURKLAND P.E. LOT 5 BLOCK C AMY HEIGHTS SEPTIC SYSTEM SCHEMATIC
203 W15th Ave PHIL GR4WUNDER DATE, JAN. 170 2003
Anchorage Ak 99501:)7q-qqlrl 11 f26W SHELBUW Rm SHEETt 3 3 GRIDi 2836
PERMIT SW030XXX PARCEL ID 1 170-034-05 KNH00053.DWG
*- 15-- D 3 e C7' o aq'
MUNICIPALITY OF ANCHORAGE
Development Services Department 3,
On -Site Water& Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Permit Number: SW030010
�Legat Description: KNIK HEIGHTS BLK ".0 LT.:::5
Design Engineer: 0007 Tobben Spurkland, PE
Owner Name: Phil Grawunder
Owner Address: 12600 SHELBURNE ROAD
ANCHORAGE, AK 99516-2921
Date Issued: Jan 23, 2003
Expiration Date: Jan 23, 2004
Parcel ID: 017-034-05
Site Address: 012600 SHELBURNE RD
Lot Size: 43500 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit Is for the construction of.
❑✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
t/ Date: 7.0 -5_
Date: ZZ23103
y
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.enchorage.ak.us
(907) 343-7904
ON-SITE SEWERMELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 01-7 --0 -S 4 — Permit Number SW 0300/0
Property owner(s) �1.� ( I em uJ'u yr Day phone
Mailing address (1) Ia[D b S j,_j_ e&4 e ;i? c
Mailing address (2) Zip Code
Legal description (Lot, Block & Sub'd.) 1-e -t S 131/- (2 i.Zlam) i kL H t^ 1 Cr H i
Legal description (Section, Township & Range)
Lot Size I—Y751 Acre Sq.Ft.
THIS APPLICATION IS FOR:
Number of Bedrooms �(
Sewer Only ❑ Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicableMunicipal Codes.
�___-- ,
(Signature of property owner or authorizefi'agent)
c
Permit Fees: �� Waiver Fees:
Date of Payment: t (l �0 3 Date of Payment:
Receipt Number: Receipt Number:
(Rev. 12/00)
T.S PU PaLAM P.E.
203 W 15th. Avenue, Suite 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
SEPTIC SYSTEM DESIGN
LOT 5 BLOCK C KNIK HEIGHTS S/D
PHIL GRAWUNDER
12600 SHELBURNE ROAD
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
Anchorage, Alaska 99519-6650
January 9, 2003
We are submitting an application for the upgrade of the septic system for this lot. The submittal
consists of three (3) drawings showing the present improvements on the lot and the adjoining
properties, (sheet 1/3), the proposed improvements of the lot, of which only the septic system is
subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil
logs and percolation tests of applicable testholes are also enclosed. The septic system design is
based on the following:
No Ground Water or Impervious Layer to 17 ft.
Use Standard Trench
Soil Rating. From Testhole 12/19/02
3 min/in = 12 gal per sq.ft/day
No. of Bedrooms 4
Required Area per Bedroom: 15011.2 = 125 sq.ft.
Total area required: 125 x 4 = 500 sgft
Testhole depth 17 feet
Bottom Rock At 11 feet
Top Rock At 4 feet
Rock Depth 7 feet
Minimum Trench Length 500 / 14 = 36 ft.
Use 50 ft
SYSTEM CONFIGURATION
STANDARD TRENCH
TOTAL LENGTH
50 FT
TOTAL WIDTH
2 FT
TOTAL DEPTH
11 FT
ROCK DEPTH
7 FT
COVER
4 FT
SEPTIC TANK
1250 GAL
The installation of this septic system will not prevent wells and septic systems from being installed on the adjacent
lots.
There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots.
The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface
runoff will not result from this installation.
' � ♦����(� x''1,1111
♦♦ `p, .,,. ...........11
... 11
fir
:. 49th•.0•' IS
....'r .............................. . .
.i
Ick•.
TO EN SPURKLAND
11c °• No. CE -2225 ' Ar
111 R •. •.•••�+�1
its
50 0 50 100 150 200 250 300
SCALD 1' = 100 FT.
L — -i r-
- 13 I 4 44
I 1 1 �1;••� r
® I
Bell I
I I I
I
12 1 5 1
A 11 5��� i -•� Q
I ,,v
�I I III L�
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1 11 111 6
III - fell
I I I
------J L — — — — —— I
S —
TOBBEN SPURKLAND P.E. LOT 5, BLOCK C KNIK HEIGHTS SEPTIC SYSTfAI DES/GN
203 W 157H. AVENUE 12600 SHfLBURNf DA TE.- JAN. 9, 2003
ANCH. AK. 99501 SHUT. 1 3 GRID: 2836
907 279-3916 PHIL GRAWUNDER
PERMIT # SV030XXX PID # YY KNH0C05LDWG
-———————— — — — — —,
Ir - - - - - - - - - - - --
•'• tea.- : ° }:. ►1
I I I
I I ,©
I I I
I I
I I
I I
IL ---------- —,
..� m
------- -- — J
ACTALL I -BEDROOM SY57EY TH
1 11250 CAL W VE b
50 TT Loxc neL�cH
I (TOTAL DEPTH 11 TT
7 TT Or SEWR ROCA; L"WMT
1 I TAE By USW TREWH
I 1 I
I I E+WW AND XW 1Z5TW TANK I
I .�• 11
111 N
I 1 I l�
LLI------- -----
r — — — — — — —
---r------- — ——
—�
I I I
I I 1 6
I I
I
Iq5 1 0 R5 50 75 Lav 125 150
1 . 1 SCALE+ 1'= 50
.�- Well
1
1
I
a
4
108NN 5PURKLAND P.E. LOT 5, BLOCK C INK HEIGHTS SEPTIC SYSTEM DESIGN
W 15TH. AVENUE
ANCH. AK.
99501 12600 SHELBURNE DATE. JAN. 9, 2003
ANC :
907 SHEET.• 23 GRID2836
� 279-3916 PHIL GRA
PERMIT # SV030XXX PID # YY KNH00052.DWG
Standard Trench.,
2' Wlde
50' Long
11' Beep
7.0' Sewer rock
3' Cover
SIl t
7.0 ft of Septic Rock
Effective
O Foundation Clean out
Monitor
r1.0.1m ,,,+c
NO SCALE
1
do4b�P 4� O 1250 ga! Septic tank
Pqh
O4eS.
1250 GAL SEPTIC TANK
T❑BBEN SPURKLAND P.E.203 LOT 5 BLOCK C ANIK HEIGHTS SEPTIC SYSTEM SCHEMATIC
Anchorage Ak 99Ave PHIL GRA WUNDER DATE, JAN. 17, 2003
An501 12600 SAUBVRW Ra(D SHEETS 313 GRID, 2836
PERMIT SW030XXX PARCEL ID f 170-034-05 KNH00053 DWG
•.
Municipality of Anchorage / ®h� er1GWIEER"E f ••••«•••••• ��h
Development Services Department Q .• 'a•
Building Safety Division :9 els
y On -Site Water and Wastewater Program * �491H %s
47CO South Bragaw SL ��•••••«•••••••••••"•••
P.O. Box 19605 9-6
0 Anchorage, AK 9951"050
www6anchoraee.ak.us • •• •«.•••••
(907):53 7-004 ": T SPUMA : A
-132.Soils Log - Percolation rest ��F•'"••••''����'�
Performed For:11t.-Z &L foa L-+ 01 "GSI"' Date Performed:
Legal Description: Lo T tj BK e tit t`1 11C .Township, Range, Section:
I �,__ sa• or,
Depth
0
1_ // bRGA�1lcS
2 — n
4- Loc,C
5
Jr
7-
10-
11-
-10-11 S�IML
12-
13-
14-
15-
16-
17
2-13-
14-
15-16-
17 D Orr o IL4
WAS GROUND WATER
t
ES CC U:ITERc.7
1�� O
S
IF YES. AT WHAT DEPTH?
LD
Depth to Water Aher
p
klonitor)ng.
E
Daze:
1 C o
ading Dave Gross TimeI Net Time Depth to Water Net DrcP
r�
b10 I S3`i1 3/G L o
.o I q1 I 10 I 029 I 4�
OF NOLO tc I I 51 I to I '17. til
1 J-
1c- ° 1; 01 1 t� ( i/ 3/
20- 5'/ I t 1 L o 'J 3 '3
FERCCLATION RATE ,h4�Gesirct) FERC HCL E DIA),IET-eR W l
TEST RUNSET`NEEN_FT AND -_FT
C0..I,aZ_,ITS 1 e lce_ VA c l� ut-cr� 'i�.L c S ra ttic�Q
—L
PERFOR%IED BY: I ,� t S CERTIFY THAT THIS TESTWAS
PERFOR.%IED IN ACCORDANCE VAT HALL STATE AND MUNICIPAL iICIPAL GUIDELINES IN EF261i.3FECT ON THS DATE. DATE:
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC`rION
I ENVIRONMENTAL ENGINEERING DIVISION
\ 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME//�� t,�� v
F,c 1y //�-. &c IIT I��D - -- —---------- ..�
PH�O/NF
/ %" tYlX1i4
NEW
❑UPGRADE:
MAILING ADDRESS /1
.-5 09 '8o/L� J' _%Z l7 Nc /fo QIiG�� %��iYS�7 9 9.5-0 7 --
LEGAL DESCRIPTION
LOCATION
Well Absorption area Dwelling
v DISTANCE TO: � ryF (�p� IvZ,N __.
NO. OF BEDROOMS
PERMIT NO.
�7106'11'
Z
a
LU FQ-
Manufacturer
Mate' /
No. of compartments
to
city in gallons Inside length
ILiq. rapa%-�IF HOMEMADE:
S �
Width
Liquid depth
x
DISTANCE TO ------_®_ Dwelling
Material -"�
PERMIT N ���`Manufacturer
r"ry 'n a� al Ion, sem_`_
w z
DISTANCE TO:
r
- -
Fo ndation
G)_`_'_
Nearest lot line �-
PERMIT NO. y�
`wz
H,z�
No. of lines
Length of eacfh line
W/
Total length of lines
�/r
Trench width
inches
Distance bet�yejn es
ab
oA
Top of tile to finish grade f
Material beneath tile 7
9 eralaea
Total effective absorption area
6 s
�
Lu
e Width
Depth
PERMIT r
_
Type of crib Crib diameter
Cri a sorption area
��-
y
o�
n 1.
Building foundation Nearest lot line
uJ
Class.p- Depth
!L
Driller Distance to lot line
PERMIT NO.
w
�
DISTANCE TO: Building foundation
Sewer line Septic tank
Absorption areas)
OTHER
LEGAL
PIPE MATERIALS
SOIL TEST RATING
/y S's/ vim
-
IN TALLER
-r7ZE PP EZ ' Xry.
—
—
-
Q
-
0
i
i
REMARKS
J
APPROVED �� DATE
SXR.
72-013 (Rev. 3/78) F J,
WAIL ?R WELL LOG
MUNICIPALITY C. N( r ^ L
FOSS DRILLING ASSOCIATED DEPT. c
909 CHUGACH DR. #37 I :VIRON.. -ur:•_ oN
ANCHORAGE ALASKA 99503
' I AY l 1:
WELL OWNER Frank Bethard USE OF WELL Domesticl�/
WELL LOCATION Lot 5 Blk, C Knik Hts. Subdivision R E C E" "f r D
SIZE OF CASING 6" DEPTH OF HOLE 89 FT, CASED TO 89 FT.
STATIC WATER LEVEL 67 FT. G. P. M. 20 WITH 22 FT. OF DRAWDOWN.
REMARKS
DATE COMPLETED 3-25-79 PUMP TO BE SET AT 88
0 to25
25to65
__L,5to88
88 _to_
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
Alluvium; light brown color of medium hardness
Till; grey color and hard
Alluvium; grey color of medium hardness
Sand and gravel with water
.-H
DEPHRTMENT OF HERLTH HND ENVIRONMENTHL �pOTECTION //�
264~4720
PERMIT NJ. )
HPPLICANT �R� 1698K 995�7 I44
� *u
LOC8TION \
LEGAL L5 Bi]< C KNlK HTS S/D LOT SIZE 4]560 SQUHRE FEET
TYPE OF SOIL RBSORBTION SYSTEM IS: TRENCH
�
MAXIMUM NUMBER OF 4 SOIL
THE REQUlRED SIZE OF THE SOIL RBSORPTIUN SYSTEM IS�
�ENE �-, 0~I -, I :j_.. L_ F.'K III GO -1-F-I Q (SMIROJUK_
THE LENGTM IS, THE LENGTH (IN FEET) OF THE OR DRHINFIELD
THE DEPTH OF H TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFHCE OF THE
GROUND
AND THE BOTTOM OF THE EXCHVIll, 1ON (IN 17F.:ET).
THERE IS NU SET WIDTH FOR TRENCHES
THE 13R8VEL DEPTH IS THE MINIMUM DEPTH OF, GRHVEL BETWEEN THE OUTFHLL PIPE
RND THE BOTTOM OF THE EXCHVHTION (IN FEET)
�L-2 T.: 171 ENE Kow �BEE �-1 - 11 1:3 W 1"T III l< SO 21 FR_ ::::�; �������I'l��
PERMIT ITY TO INFORM THIS DEPHRTMENT DURlNG THE
INSTRLLAT�ON INSP�CTIONS OF ANY WELLS HDJRCENT TO THIS PROPERTY AND THE
NUMBER OF RESIDEN�ES THHT THE WELL WILL SERVE
I. Ic-.11 ���F7,: "IT- 1'. Il -,A �PEN.'. �0, J Y tPi"i"���
BHCKFILLING OF ANY SYSTEM WITHOUT FINHL INSPECTION AND RPPROVHL BY THIS
DEPHRTMENT WILL BE SUBJECT TO PROS�C�T�O�
MINI�UM DISTHNCE BETWEEN H WELL HND HNY ON-SITE SEWHGE DISPOSHL SYSTEM lS
100 FEET FOR H PRIVHTE WELL/ OR
150 TO 20@ FoET FOROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL
WELL LOGS RRE REQUIRED AND MUST BE THE DEPHRTMENT WITH1N ]0 DHYS
OF THE WELL COMPLETIO�.
OTHER RECUI FEMENTS MHIFICHTIO@S HND CONSTRUCTION DIHGRHMS HRE
HVHILHBLE TO INSURE PROPER INSTHLLHTTON.
Foo FS! to! 1-1 1: -V ENE �00, 1 lot H Y& ED- to: C; K 10 13 WIFE W!
I THAI-
.1
HHT1I HM FHMILIHR WITH THE REQUIREMENTS FOR ON .... SITE SEWERS
FORTH BY THE MUNIClPALITY OF ANCHORHGE
2� I WILL lNSTHLL THE WITld THE CODE�
]� I UNDERSTHND THHT THE ON~SIT� SEWE� SYSTEM MRY REQUlRE
MINISOM
HND WELLS HS SET
ENLHRG�MENT IF THE
PERFORMED
❑ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
Pouch 6.650, Anchorage, Alaska 99502 276.2224
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION:
COMMENTS
Date
DEPTH
Net
Time
Depth to
Water
(FEET)
1
2
3
q
l
d�
5
x1
6
I
X
7
8
Com,` ys
9
�v
10-
11
-----12
13
c,�;-14
is-
16
,7
18-
8'19.20
'19.-
20-
COMMENTS
PERFORMED BY:
72-008 (7/76)
WAS GROUND WATER S
ENCOUNTERED? J, C> L
O
P
E
IF YES, AT WHAT
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
l
d�
x1
I
X
Com,` ys
�v
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND �`l FT
CERTIFIED BY:
DATE:
Lo io
�a� Municipality of Anchorage ,f0
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program 5 ♦ , t T
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ek.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. D/%— 03LOD
HAA #�/S 7S
Expiration Date: V-_75. irk_
1. GENERAL INFORMATION
Complete legal description L07 5 th VLC K N 1 K �4 F T S
Location (site address or directions) I c2 /a &0 S H a L D 0 0— tJ I=
Current Property owner(s) PIX,- 1 67rA u-uuc( er Day phone
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
l ib oy S Lt -�_ f to u- r ►n e
Day phone
�a Llea r.y 61!OI;U4411Day phone 96 5 -4 7
Unless otherwise requested, NAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
12/
Individual On-site
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm _ I n tih-t an �a r 1'� L iL"J t- Phone Al 9 - 39 � 4�
Address ao 3 14 91) 3
Enaineer's Printed Name
r trin k� Date
...i
t� T
7 00�%y
'V �c o Tobiy.n °Fart:?cad
5. DSD SIGNATURE OOu�%a CM :=
0
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
OF At
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X Maintenance Agreements
Supplemental Engineer's Report
Other
By: A Original Certificate Date:
(Rev. 0f
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water & Wastewater Program .
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650
www.cl.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lo 4 6 5 )Ce ,V tA \ Y— 1-1 tF- t41+ T s Parcel ID: © / 7 — d 3' i - -
A. WELL DATA
Well type
Date completed 5 bq
If A, B, or C provide PWSID # t -4/A. Well Log (YM)
Sanitary seal (Y/N) 4—
Total—
Total depth�ft. Cased to ft.
FROM WELL LOG
Date of test tv 1-7/7
Static water level fio 7 ft.
Well production RAZ ' g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mi. Nitrate 0.6 "mg./I.
Arsenic: f// mg.11. Date of sample: yko 3
B. SEPTIC/HOLDING TANK DATA
Tank Type/Mateftl Aolttt„ 1 g k 54d
Tank size 19,60- 6f? gat. Number of Compartments
Wires properly protected (YM)
Casing height (above ground) lain.
AT INSPECTION
7I ft.
% 1�z. g.p.m.
Other bacteria colonies/100 mi.
Collected by: Lc la ri cy(
Date installed a/���b 3
Cleanouts (Y/N)
Foundation cleanout (Y/N) 4 Depression over tank (Y/N) 4 High water alarm (YM) j1L.1
Date of pumping_ Pumper N�A
C. ABSORPTION FIELD DATA
Date installed LI/b Soil rating (g.p.d./ftp orft2/bdrm) System type %2kNGf�
Length 00 ft. Width g.1 ft. Gravel below pipe a ft.
Total depth I I ft. Eff. absorption area j2gQft2 Monitoring tube Depression over field tl
Date of adequacy test WA Results (Pass/Fail) t• Forq_bedrooms
Fluid depth in absorption field before test ✓n. Water added ✓al. New depth ✓ in.
Elapsed Time: zmin. Final fluid depth"/in. Absorption rate >= (J0•0 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) V"" If yes, give date t/
D. UFT STATION
Date installed
'Pump on" level a7in.
Datum
E. SEPARATION DISTANCES
Size in gallons ManhAccess (Y/N)
"Pump off" level at _ in. gh water alarm level at
Cycles tested Meets alarm 8 circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 1 O I On adjacent lots 100+
Absorption field on lot 1 1 D On adjacent lots 1909 *
Public sewer main r(/rte Public sewer manhole/cleanout /NIA
Sewer /septic service line u Holding tank NIA -
SEPARATION
%
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation j' Property line 3 0 Absorption field
Water main N�!> Water service line !� 0 * Surface water
Wells on adjacent lots i /
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line �g Building foundation 113 D Water main N/A
Water Service line p h Surface water N (l? Driveway, parking/vehicle storage 50
Curtain drain N U Wells on adjacent lots > //9th
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I cerW that I have determined through field inspections and
review of Municipal records that the above systems are in
.,
conformance with MOA HAA guidelines in effect on this date. /� �; , �,^..; . F
:�_�,
Engineer's Printed Name I O%J e y SiD u r Y,� oc H Al
Date A SAA. f al, e2D b�
uv
HAA Fee $ �J 75 —
Date of Payment `i/ydo3
Receipt Number 3 y 1yQ
(Rev. 12/01)
Waiver Fee $ La t< 1 I kq`_7 ! , 0
/ //
Date of Payment 11//03
Receipt Number 3 V j y
in.
9- .51744mene
N04 Oz I145. oo
W'
104
t
Y.
Hse.
I PCC
P.01
'OOF
SC -4 Le,-
4
8
I
h�@WN—Cerw*y ftt I haw Prior a
�"" =�"md 4
of ft lo". P(
or A* ON
l*ft/aQAW *Tw*�V*% Anchor&" A*cod#V pr9drct At&"&, aF4 that V"
hw w0waft I &;s
No. p
jrrproaments "tod thereon are within Vw PoWtY W" vd
do Mt OVOW Of sw0sch On Ow PMWV " "MCW
fW4406 Cwt no kw*mrrwon prop" " 048mg Oweto
wtc� w r4 prern"s on questim Ow "I #we an no
roadways, transmission In" of OUW vwbm "Wwts on "ki
Drowtv Orewl 0% Imeliew", h—
0
40
Vfflis
!Q
,kQ
Ci
10, wit
,
NOaOzw 14 1:00
QUILT NO CORNERS SET THIS WE
I
h�@WN—Cerw*y ftt I haw Prior a
�"" =�"md 4
of ft lo". P(
or A* ON
l*ft/aQAW *Tw*�V*% Anchor&" A*cod#V pr9drct At&"&, aF4 that V"
hw w0waft I &;s
No. p
jrrproaments "tod thereon are within Vw PoWtY W" vd
do Mt OVOW Of sw0sch On Ow PMWV " "MCW
fW4406 Cwt no kw*mrrwon prop" " 048mg Oweto
wtc� w r4 prern"s on questim Ow "I #we an no
roadways, transmission In" of OUW vwbm "Wwts on "ki
Drowtv Orewl 0% Imeliew", h—
SG$
SCS Ref.# 1031810001
Client Name Tobben Spurkland P.E.
Project NamcI# Lot 5 Bk C Knik
Client Sample ID Lot 5 Bk C Knik
Matrix Drinking Nater
Sample KemarKS:
Parameter
Waters Department
Nitrate -N
Microbiology Laboratory
Total Coliform
Results
0.658
0
All Dates/Times are Alaska Standard Time
Printed Date/Time 04/09/2003 17:04
Collected Date/Time 04/04/2003 13:40
Received Date/Time 04/04/2003 15:00
Technical Directorephen CEd
Released By ,/
Allowable Prep Analysis
PQL Units Method Limits Date Date Init
0.200 mg/L EPA 300.0 (<=10) 04/05/03 1S
col/100mL SM18 9222B (<=j) 04/03/03 KAP
do
Te
jF
Or
..... ........
"a' 14%
t --S C; ... ..... ...
....
fL
do
ir
K*
LL
t1�
pit r. OL 9- . I
F'
JI6 w
F
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. # —0 3H —d 5 HAA # _Hh `9 05 75
1. GENERAL INFORMATION
Complete legal description IL 4 E i G. !4 T E
L 5 -
Location (site address or directions) (a 0 00 r V, P
Property owner -a 1A Day phone 34 S -
Mailing address
Lending agency 3 °'` Day phone
Mailing address -
Agent P , �r� �� Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: `/ _
3. TYPE OF WATER SUPPLY: /
Individual well l/
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system. J: ,
4. 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 MOAM21 -
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.
Name of Firm ° 61 -5 Ll 9„� \/1,c-Li,-�4 ?-t= -Phone
Address 0 3 l � '2_0
�7_n n. /% Iol_ 1.,,
Engineer's signature
6. DHHS
SIGNATURE
Approved for. bedrooms.
Disapproved.
Conditional approval for
Additional Comments
By:
Date
AA*ra
06.
Ao s 'a cEsn;
bedrooms, with the following stipulations:
UJITIC
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 orderto satisfy certain federal and state requirements. Employees of DH HS 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-M (Rev.1/91) back MOA e21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Parcel I.D. U l 7 E) J) CD=s
A. Well Data
Well type If A, B, or C, attach ADEC letter. ADEC water system number N/A
Log present (Y/N) Date completed Driller r—b
Total depth 63
Sanitary seal (Y/N)
Cased to g q
� tt
Casing height-��
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
Date of test 3 ' 9-6` N
Static water level _ 12 j
Well flow C9-0 g.p.m.
Pump levell 8 !' i (�
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot i 0 On adjacent lots
Absorption field on lot j ,i 1, ; On adjacent lots 7 1 L> --C)
Public sewer main N/ Public sewer manhole/cleanout_
Sewer service line % y Petroleum tank N CJ
WATER SAMPLE RESULTS:
Coliform v Nitrate Other bacteria
Date of sample: j L7 �% 9 L 9 �I _Collected by: = q
B. SEPTIC/HOLDING TANK DATA
Date installed Tank size Compartments
Cleanouts (Y/N) � Foundation cleanout (Y/N) Depression (Y/N)
High water alarm (Y/N) N�`- Alar tested (Y/N) I
Date of pumping NO t/ � � (�I � � Pumper CO
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 0 Y On adjacent lots i ((51-0 Foundation
To property line > / t-7)Af5 C7
bbsorption field Water main/service line .
N `
�
Surface water/drainage ) o
72-026 (3/93)' Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent(Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Date installed -3 ' / 7 -
Length
Width
On adjacent lots
7
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Surface water
Soil rating (GPD/Ft2) / t;1 () System type 2 fE N
l
Gravel thickness 81 Total depth b )
Total absorption area l25� Cleanout present (Y/N) _Depression over field (Y/N)
Date of adequacy test Results (pass/fail) r for Bedrooms
Water level in absorption field before test After test
Peroxide treatment (past 12 months) (Y/N) If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on I
On adjacent lots > / Property line
To building foundation 3 9r 1 To existing or abandoned system on lot N //!-
On adjacent lots C) Cutbank Nzj� Water main/service line > Is- v
Surface water j�. l t� _Driveway, parking/vehicle storage area > 5
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that / have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
HAA Fee $ >> bo� • 00 Waiver Fee $ _
Date of Payment o \ Date of Payment
Receipt Number ��� ��� ID `(� 1 _ Receipt Number.
72-026 (3/93)' Back
Commercial Testing & Engineering Co.
Environmental Laboratory Services :.��✓� 'r���f� e���v�c���
CT&E Ref.# 94.5372-1 LABORATORY ANALYSIS REPORT
Client Sample ID LS/BC KNIK HGH
Matrix WATER
Client Name
TOBBEN SPURKLAND, P.E.
WORK Order
10245
Allowable
Ext.
Ordered By
T. S. SPURKLAND
Printed Date
10/25/94
r 07:53
Units
hrs.
Project Name
Date
Collected Date
10/19/94
Q 17:00
0.46
hrs.
Project#
EPA 353.2/300.0
Received Date
10/20/94
Q 17:00
MCE
hrs.
PWSID
UA
Technical Director
STEPHEN C.
EDE
Released By
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: T.S.
* See Special Instructions Above UA = Unavailable
** See Sample Remarks Above NA = Not Analyzed
U = Undetected, Reported value is the practical quantification limit. LT = Less Than
D = Secondary dilution. GT = Greater Than
5633B Street, Anchorage, AK 99518-1600 — Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, 01110, UTAH, WEST VIRGINIA
QC
Allowable
Ext.
Anal
Parameter
Results
Qual
Units
Method
Limits
Date
Date
Init
--------------------------------------------------------------------------------------------------------------------
Nitrate-N
0.46
utg/L
EPA 353.2/300.0
10
10/20/94
MCE
* See Special Instructions Above UA = Unavailable
** See Sample Remarks Above NA = Not Analyzed
U = Undetected, Reported value is the practical quantification limit. LT = Less Than
D = Secondary dilution. GT = Greater Than
5633B Street, Anchorage, AK 99518-1600 — Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, 01110, UTAH, WEST VIRGINIA
Time
APPLII
NT FILLS
OUT UPPER HA! ONLY
4roperty Owner •-
, .. -
..
-- Phone
Mailing Address -"' -
- /y' -' ���•%
- Zip Code
Buyer
Date
Date
Address '; j_ :
• ' ,.
: •
j `, Zip Code
Lending Institution
_
��
Phone
Inspector
_ _
_
Inspector
Address
Zip Code
Realty Col. & Agent
f/ , ;_ _ .
.. - ,,,
-. ,.�� , ; !
Phone
MUNICIPALITY OF ANCHORAGE
Address
- %i �;-
..
Zip Code
Legal Description _✓
_, - F`,: _.
�f-T—
j� !
jr,., %j ..;:; ,: .
Street Location � / !
i r
r'
Type of Residence
``O Single Family
RECEIVED
( ) APPROVED BEDROOMS
❑ Multiple Family
No. of Bedrooms
( ) DISAPPROVED
❑ Other
( ) CONDITIONIL APPROVALOf'
Water Supply
_
DATE 2b
Individual
BY:
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
❑ Community
Soils Rating
For wells drilled prior to that dale, give well depth (attach log if available).
❑ Public Utility
Well Log Received
Sewer Disposal
Well to Tank/ Z) K)
Septic Tank Size
" { Individual
Year Individual Installed:
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
.c.j CA i
Dale
Date
Date
Date ,.
Inspector
Inspector
Inspector
Inspector
,,11
lL`1�k
Field Notes:
MUNICIPALITY OF ANCHORAGE
DEPT. OF H J,LTH :.
{TSU
ENV IROPROTECTION
R f)
MAR
RECEIVED
( ) APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONIL APPROVALOf'
DATE 2b
BY:
Soils Rating
Date Sewer Installed
Well To Absorption Area %i)fff)
Well Log Received
Well to Tank/ Z) K)
Septic Tank Size
72023 PIK]
I
April 1, 1983
John & V;A;a chitv"Ood
3300 A-rctic Blvd, 4202
Anchorage, Al, 991A0;
Subject, Int !), l3lock C. Ifnik nett is SuNlivisim
ApprovaJ, f'or the individual smlur and water taoilitteo ("almot
he granted until the J-o-II.-Lowbal items tlave heon covipleted..
'I'lle water arialySivi r(Ij)QYlC, to DC sum fittedto thi-,i
Ottic.'e j.ro'll-I tje Chou Lcib, 5633 to Unout, for OLN 17010aw.
wle uegilc Louilz lumped with a mccAlpt. MAMMA to this
departilmlit .
Ple-au,e, notify thh; DeVal7thit'llt fr)z cl ):oiwipuctiall %)IIen 1.1lu
noted discvepaeeleo have bec'.11 corrected. I1 there are eAlly
I.m.-ther questions, please Cali, tAlis, of--L-I.ce at 204-1720.
S incere I Y,
1"obelt C. Prab:
Spccialif-;i,
_�QUNICIPAiL (l'f ANI&()PAd -
i
MUNICIPALITY OF ANCHORAGE
DE:PT OF I1-,1.1II &
LNVIRONIVdMJ\( PI-1GIIC_TION
- DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
�
AU2 U 19%9 �
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
R E C E - ("j
+✓
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER
FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNER
FRANl'?, t5
MAILING ADDRESS - - - - -
s' A cff,�
PROPERTY RESIDENT (Ifdifferent from above)
PHONE
�
2. BUYEP.m
PHONE
y0 �r
MAILING ADDRESS
3. LENDING INS ]TUTION�m
PHONE
MAILING ADDRESS
4. REALTOR/AGENT ��
NCA - WVE57 lkl_O i
PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION - - -
6. TYPE OF RESIDENCE - - NUMBER OF BEDROOMS
4_1 SINGLE FAMILY ❑ One ❑ Four ❑ Other _
❑ Two ❑ Five
❑ MULTIPLE FAMILY 41l-�Three ❑ Six
7. WATER SUVWY-
P'
INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY depth (attach log if available.)
S. SEWAGE DISPOSAL SYSTEM -��-
Ft�- INDIVIDUAL/ON-SITE** **If individual/on-site, give installation date .
If system is over two (2) years old an adequacy test is required
❑ PUBLIC UTILITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
if I
of J ����, �,�.,
� � I� � 1
1
THIS SIDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLEFAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY �ev
❑ INDIVIDUAL
❑ COMMUNITY
-
❑ PUBLIC UTILITY
Connection Verified___
PERMIT NUMBER
DEPTH OF WELL
---
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified _._
PERMIT NUMBER
DATE INSTALLED
-INSTALLER -
SOILS RATING
❑Septic Tank or ❑Holding Tank
Size: 1 If Tank is homemade
give dimensions:
TYPE OF TANK - -
MANUFACTURER
TOTALABSORPTION AREA -
MATERIAL
4. DISTANCES
WELL T0:
Septic/Holding Tan
(�
--Fk
A bsorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
LST APPROVED FOR _ BEDROOMS
❑ CONDITIONAL APPROVAL (letter milst accompan certificate)
❑ DISAPPROVED
DATE -. - - - BY (Title) -
LEGAL DESCRIPTION
72010 (Rev. 3/76)