HomeMy WebLinkAboutKNIK HEIGHTS BLK I LT 4KnI*k Heights
Block I
Lot 4
#017-372-30
10/03/2012 04:39 9@72430742 AWPS, DIC. PAGE 01/01
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Tell DriIIiso 'ermhN tuber 3W�_ rate of issue:
arcel ,aQnilficaticn Number;,,,,,_,_
Prop erey Owter Name & Address:
wnp Iakake Depth &Iow'lop of Wal; Casing: f rk
nmp M;,uuf.%aurar'e Kama:
amp model: W-5 la,
umv Size 1 hp
iiiess �3apCaz 8,trLd Dept, IV feat
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ArtanAo¢: The pump �u= shall provide a pump +-hien log is true &�- watt n 30 da/s of ptm y vLstallatcra_
Development Services Department
Building Safety Division O
On -Site Wcter & Westewater program
4700 B Street
P.O.tSay
ax 1 196650 _
Anchora.�
Mark Bench 3-, Ar 99519-6650
Mayor www -or. o,o/nnar._
(9C71343.7904
Pump Installation Log
Well Drilling Permit Number: SSV_ Date of Issue: _
Parcel Identification Number: GI - 37 iL 30
Leval Description
m, oT5
�L Ly
Property Owner Name & Address:
L a w c 1 1 8a wv,+avV
�(,3(� St7cl BprnG Q
hV)Ji 4,rexci r, iq etc7qC/ 56
Pump Installation Date; /O 2 OFA
Pump Intake Depth Below Top of Well Casing: f((o feet
Pump Manufacturer's Name: ReC-ITp, j(e-• b
Pump Model: /D O C.3 I/ C -M5 Z V b i
Pump Size hp
Pitless Adapter Burial Depth: 1 Z feet
Pitless Adapter Manufacturer's Name: /Vlft
Pitless Adapter Installer:
Well Disinfected Upon Completion^.M Yes C No
Method of Disinfection:
ccvfcc6�wY t"tYpac�ort 1C.
Comments:
Pump Installer Name: S�GVG J P�%SO
Attention: The pump ir=lle shall provide a pump installation log to the DSD within 30 days of pump installation.
-
Municipality of Anchorage Page 1 of 3
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.sk.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: _EW020259
PID Number: _C?1Z-A312_30
Nam
Wastewater System: Upgrade
Lowell Bauman
Address:
4630 Shelburne Place Anchora a AK 99516
ABSORPTION FIELD
Phone:
Number of Bedrooms:
5' Wide Trench
345-0713
Four 4
Soil Rahng
Total Depth ham onginel grade
LEGAL DESCRIPTION
1.2 GPD/Ft?
12 Ft.
Block Lot. Subdivision:
Depth to pipe bottom from onginal grade:
Gravel depth beneath pipe:
1 4
Knik Hci&lhte
8 Fl.
4 FL
Toenship: Range:
Section
Fig added above original grade:
Gravel Length:
- Ft.
50 FI.
Gravel width.
Number of lines:
Distance between lines:
Well: Existing
5 Ft.
1
- Ft.
Classification (Private, A, B. C):
Total Depth:
Cased to:
Total absorption area,
Pips Material.
Fl.
Ft
500 Fe
A5TM 03034 PVC
Driller.
Date Drilled
Static Water Level:
Installer.
Date Installed
Ft.
Acrexle S 5tem5
8/21/2002
Yield:
Pump Set at.
Casing Height Above Ground
TANK
GPM
Ft.
Ff
SEPARATION DISTANCES
® Septic ❑ Holding ❑ s.T.E.P. ❑ Other.
To
Septic
Absorption
Lift
Holding
ublic/Private
Manufacturer.
apaatym aeons
From
Tank
Field
Station
Tank
SewerLlne
Anchorage Tank
1,250
Well
>100'
>100'
N/A
N/A
>25'
Material.
5teel
Number of Companments,
Two 2
Surface Water
>100'
>100'
N/A
N/A
LIFT STATION — NONE ON LOT
Size
Manufacturer.
Lot Line
>5'
>10'
N/A
N/A
cal
>5'
>10'
N/A
N/A
'Pump on' level at.
'Pump off" level at:
High water alarm at:
Foundation
In
In
in.
None
Noted
Pump Make d Model
Electrical Inspections performed by
curtain Drain
Remarks
BENCH MARK
Viverter Valve Placed and Exietinel Absorption Trench Tied in
Location and Description:
for Possible Service in the Future.
Back Deck Southeast Corner.
Assumed Elevation:
100.0 FL
Engineer's Stamp
a.....�.�
....... „ q�♦♦
+ 49th ♦�
Inspections performed by: MFA
Dates: tat _812112002
.....t. ..... .. .. ....••{{.� .A....�... 00�
10
•`9L!"�
!`.:'
-•%MICHAEL E. ANDERSONtv
2nd _8121/2002
♦1�-5,% No. CE -4381 / 4�� ar,
Department of Hevilth and Human Services approval
♦pfF� •.�'.'
Reviewed and approved by:
Date: VLO/? 10M)444%%%E
.................
: `'�
_ _
(Rev
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
Permit Number: SW020259 On -Site Wastewater Disposal System or Well Inspection Report
SHE�BURPIE EAST 193.03
Pl-ACE
sLPO
ooh
A
S1 19.1 32.6 VON
S2 16.6 40.1
M 1 32.6 35.8
C4 35.3 33.6
C5 50.5 81.2
Diverter
Valve
PLAN AS -BUILT
SCALE 1 " = 40'
Home
S1
C4
a5e�
49th
Page 2 of 3
PID No. 017-372-30 1
MICHAEL E. ANDERSON
6. NO. CE43e1
Existing
-p'
Well
sLPO
ooh
A
S1 19.1 32.6 VON
S2 16.6 40.1
M 1 32.6 35.8
C4 35.3 33.6
C5 50.5 81.2
Diverter
Valve
PLAN AS -BUILT
SCALE 1 " = 40'
Home
S1
C4
a5e�
49th
Page 2 of 3
PID No. 017-372-30 1
MICHAEL E. ANDERSON
6. NO. CE43e1
Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number: SW020259
PID No. 017-372-30
PROFILE AS -BUILT
Scale: 1' - 10'
t
MUNICIPALITY OF ANCHORAGE
Development Services Department
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: SW020259
Legal Description: KNIK HEIGHTS BLK I LT 4
(911a I 5 ' 30Trwr
Date Issued: Jul 31, 2002
Expiration Date: Jul 31, 2003
Parcel ID: 017-372-30
Design Engineer: 0014 Anderson Engineering Site Address: 004630 SHELBURNE PL
Owner Name: Lowell Bauman Lot Size: 41600 SO. FT.
Owner Address: 4630 SHELBURNE PLACE Total Bedrooms: 4 Permit Bedrooms: 4
ANCHORAGE , AK 99516-2930
This permit is for the construction of:
❑✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
Ali 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.
5. The following special provisions.
Received By:
Issued By:
Date:
Date: J'1 02
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.anchorage.ak.us
(907)343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 017.372.30 Permit Number SWO20259'
Property owner(s) Lowell Bauman Day phone 345-0713
Mailing address (1) 4630 Shelburn Place Anchorage, AK 99516
Mailing address (2) Zip Code
Legal description (Lot, Block & Sub'd.) Lot 4, Block I, Knik Heights Subdivision
Legal description (Section, Township & Range)
Lot Size q1600 Acres/ q.Ft.
THIS APPLICATION IS FOR:
Number of Bedrooms Four (4)
Sewer Only ❑ Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
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 applicable Municipal Codes.
r;j,, �
(Signature of property owner or authorized agent)
Permit Fees:
Date of Payment: -t- na 0.0�[0
Receipt Number:
(Rev. 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
July 25, 2002
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 4, Block I, Knik Heights Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The existing absorption trench on the subject lot has failed and must be replaced to
prevent property damage and a possible health problem. We are therefore requesting
a permit be issued for the construction of a new septic system to serve the four-
bedroom home. The attached Site Plan and backup documentation identify the
location and configuration of the new septic system and the parameters used in the
design. Also identified on the plans are the test hole locations and the locations of the
existing system and wells on the adjacent lots. Drainage arrows are also shown and
current drainage patterns will be maintained after construction. A Bull Run Flow
Diverter Valve will be placed to tie in the existing absorption trench for future use.
The test holes placed near the location of the proposed absorption trench indicated silty
sand with some gravel and a percolation rate of less than 1 minute per inch. We are
using an average application rate of 1.2 gallons per minute per square foot to design
the new absorption trench. No groundwater was found during the placement of the test
holes and none has been noted since. We are therefore proposing to construct a 5'
wide shallow absorption trench with 4' of drain field rock beneath the distribution pipe.
The total depth of the trench will be 8' with the distribution line at 4' below the surface.
The total length of the trench will be 50'.
The ground surface on the lot slopes as shown on the attached Site Plan with fairly
steep slopes in the front of the lot just off Shelburne Place. The new absorption trench
will be constructed in a fairly shallow area in the back of the lot in conformance with
Municipal requirements and parallel to ground contours where possible. All components
of the new trench will be constructed a minimum of 100' from the well on this and
adjacent lots. The system will also be constructed a minimum of 100' from any surface
water in the area.
If the system is constructed in accordance with our design the following statements
apply:
Lot 4, Block I, Knik Heights
July 25, 2002
Page Two
1. The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
y iin". ,.J, T, 0'-�
Michael E. Anderson, P.E.
Attachments
: 49th h
1 �� �•V:OHAEL E••AN" ERSON
No. OE -4331 i
9
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No. CE -4381
.....
AREA SYSTEM PLAN •�F�"
'��' .... �.
SCALE 1" = 100'
SCOrt ut- YWUKtc:
1. Pump and Remove Existing Septic Tank.
2. Intercept Existing Sewer Service Line Near Foundation..��.�� OF 1 • �h♦♦♦
3. Place New 1,250 Gallon Septic Tank. `."
..•••••" ♦♦
4. Place 2 Post Tank Cleanouts and Flow Diverter Valve.
5. Tie in Existing Absorption Trench.
49th '
6. Construct New 50' Long X 5' Wide X 4' Effective —: . ......• ......••• .....
Depth Absorption Trench. i ............... .... .....
7. Regrade All Disturbed Areas. ♦ III ♦ c=:NiCHAEi E. ANDERSON •:
♦ if •., ho. P�
B. Revegetate Area As Required. ♦ r CE -438'
SITE PLAN ♦''��° ��
SCALE 1" = 40'
LOT 4, BLOCK I, KNIK HEIGHTS SUBDIVISION
DESIGN FACTORS:
4 Bedroom House
Perc. Rate: <I MinAnch
Application Rate: 1.2 GPDISF
SYSTEM REQUIREMENTS:
5' Wide Trench System
1,250 Gallon Septic Tank
4' Drainfield Rock
4 Bedrooms X 150 GPD/1.2 GPDISF (Application Rate) = 500 SF of Absorption Area
500 SF/5 LF (Width)'.5 (Red. Factor) = 50 LF Trench Length
Therefore: Construct an Absorption Trench 50' Long X 5' Wide X 4' Effective Depth.
Flowline Elevation in Trench to be 4' Below Original Ground Surface. Total Depth to be 8'
Below Existing Ground. Maintain 10' Separation From Existing Trench. Place Bull Run
Diverter Valve and Tie In Existing Trench for Future Use.
i D3034
Rock
TYPICAL WIDE TRENCH SECTION
(NO SCALE)
d 49th h�
NOTE: Grade Area Over Trench to Drain Away. ; --
Minimum 6' Separation From Bedrock. ..; ....
••• ■
Minimum 4' Separation From Groundwater.�0 c: MICHAEL.E. ANDERSON
Minimum 100' From Wells in the Area. ##-s,%y No. U-4361 f' :
Minimum 10' Separation From Water Service Line. # #���FO .............. pL�.�
Municipality of Anchorage
Development Services Department/On-Site Water and Wastewater Program
4700 South Bragaw Street, Anchorage, AK 99502-0650
SOILS LOG - PERCOLATION TEST
Performed For. Lowell Bauman Date Performed: 7/19/02
Legal Description: Lot 4. Block I. Knik Heights Subdivision
3
4
5
6
7
13
14
15
16
17
18
OG/OL
TESTHOLE N0, 1
SW/SP
avert
North
C
0
South
Some Silt
Was Groundwater
Encountered? No
If Yes, What Depth?
Depth to Water
After Monitoring None
Date: 7/25/02
Bottom of
Hole
S
L
0
P
See Site Plan
2%
Reading Date Gross
Time
Net
Time
Depth To
Water
Net
Drop
21 -Jul 12:41
0.875
12:51
10
Dry
11.125"
12:52
0.75
1:02
10
Dry
11.25"
1:03
0.75
1:13
10
Dry
11.25"
Perc. Rate: < 1 Min./Inch Perc. Hole Diameter. 6"
21H Test Run Between 4 Ft. and 5 Ft.
Comments: Test Cavity was Presoaked Prior to Test.
Performed By: Mike Anderson, I, Michael E. Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 7/26/02
Municipality of Anchorage
Development Services Department/On-Site Water and Wastewater Program
4700 South Bragaw Street, Anchorage, AK 99502-0650
SOILS LOG - PERCOLATION TEST
Performed For. Lowell Bauman Date Performed:
Legal Description: Lot 4. Block I. Knik Heights Subdivision
SLOPE SITE PLAN
OG/OL
TESTHOLE NO, 2
SW/SP
Some Silt
Bottom of
Hole
South
Was Groundwater
Encountered? No
If Yes, What Depth?
Depth to Water
After Monitoring None
Date: 7/25/02
7/19/02
See Site Plan
2%
Reading Date Gross
Time
Net
Time
Depth To
Water
Net
Drop
21 -Jul 1:15
0.5
1:25
10
Dry
11.5"
1:26
0.75
1:36
10
Dry
11.25"
1:37
0.75
1:47
10
Dry
11.25"
Perc. Rate: < 1 Min./Inch Perc. Hole Diameter. 6"
Test Run Between 4.5 Ft. and 5.5 Ft.
Comments: Test Cavity was Presoaked Prior to Test. Same Material as Test Hole No.1
Performed By: Mike Anderson, I, Michael E. Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 7/26/02
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 4, BLOCK 1, KNIK HEIGHTS SUBDIVISION
GENERAL:
1. The scope of this project includes the pumping and removal of the
existing septic tank on the lot and the procurement and placement of a
new 1,250 gallon septic tank at the location shown on the site plan and
the construction of a 50' long by 5' wide by 4' effective depth
absorption trench also shown on the Site Plan. The work also includes
the placement of a Bull Run Flow Diversion Valve to tie in the existing
absorption trench for future use. The total depth of the trench will be 8'
below existing ground and the distribution pipe will be placed at 4'
below the surface. All components of the absorption trench must be
constructed a minimum of 100' from the well on this and all adjacent
lots. A minimum of 4' of fill must be placed atop the septic tank and 3'
of fill atop the absorption trench. In lieu of fill 2" of direct bury
insulation may be placed with 2' of fill atop the insulation.
2. Construction shall be in accordance with the approved site plan,
design drawings, Municipal Permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater
Disposal Regulations.
3. The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the
location of all lot lines.
4. Unless specifically agreed otherwise, the contractor shall be
responsible for final grading areas subsequently depressed from soil
settling. Property owner shall be responsible for revegetation of
affected areas unless specifically agreed otherwise.
5. Contractors installing wastewater disposal systems must be certified
by the Municipal Department of Health and Human Services for
system installations. Owners installing their own systems must receive
prior approval from D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
1. The 1,250 gallon septic tank must be procured from an approved
septic tank manufacturer and installed at the location shown.
2. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts for pumping
access.
3. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
4. All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
Lot 4, Block I, Knik Heights
July 25, 2002
Page 2 of 2
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct
burial insulation.
6. A foundation cleanout shall be installed one to four feet from the
building foundation. Two cleanouts are required between the tank and
the drainfield.
7. Final grading over the tank shall be such that a positive slope exists
away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown on the
design. The bottom of the trench shall be within 2" of level.
2. Distribution piping must be placed level with perforations down atop a
level bed of drainfield rock. Rock should then be placed over the pipe
to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between the drainfield
rock and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated.
5. Contractor shall verify the septic tank and drainfield are a minimum
100' away from any private water wells in the area, 150' from a Class
"C" Well or 200' from any community well.
6. Direct bury insulation must be placed over the distribution system if
less than 3' of backfill depth is available. Finish grade over the trench
must be mounded to prevent settlement or depressions.
7. Grade area surrounding the absorption trench to drain away.
8. A minimum 2' of accepting soil is required below the drainfield rock for
a 5' wide trench. Contractor shall verify this condition prior to
placement of the rock. All pockets of unacceptable materials must be
removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a municipally approved septic
tank manufacturer.
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated
and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and
ASTM D2662 or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
Lot 4, Block 1, Knik Heights
July 25, 2002
Page 3 of 3
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Fernco, or equal).
5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing
the #200 sieve.
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These
inspections must be conducted under the supervision of a professional
engineer registered in the State of Alaska. The first inspection must be
conducted after the excavation of trenches, beds or pits and before the
installation of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement of the
geotextile fabric, gravel, distribution piping, standpipes, cleanouts and
insulation. No backfill should be in place at the time of inspection.
Contractor shall provide a copy of all field survey layout and construction
notes for use in preparing the certified as -built of the completed system.
MUNICIPALITY OF ANCHORAGE
y DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 LStreet - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME b r^ PHONE {
(30 VCA_ lel C — j I�r C UPGRADE
MAILING ADDRESS f ,
LEGAL DESCRIPTION
f 6 I IAV, _ �\
LOCATION
NO. OF BEDROOMS �
DISTANCE TO:
Well
��
Absorption area f
5
Dwelling .
(R
PERMIT NO. .
('U Jb
LJ x
O�C�
w Q
Manufacturer �-
Material_S�PCa /
l
—
No. of co partments
I_
to
Liq. cal) ga ns
_
IF HOMEMADE:
Inside length �s
Width _._._
Liquid depth
-
®
DISTANCE T
Well
Dwell in -
ERMIT NO.
aZ <
Manu fac r �.�
Mate .�
Liyuid capacity in g ons
w T
DISTANCE TO:
Well A,
-� „��,
Foundation
�U
Nearest lot line r
O
PERMIT NO.
('f` Q -3 o
� u z
No. of lines Length of each lire
� Epi-- 4 (
Total length of lines Trench width `h
t'- inches
Distance betwee lines
GL
�
rt
¢ k-
--
Top of file to finish grade
- -- .3cz
Material beneath file I- 7-
—�
Total effect absor"tion area
Length
Width
Depth
PERMIT NO.
w
Q I-
a�
Type of cri,rib
diain
Crib de
T ecti e absorption
N
DISTANCE TO:
Well
wilding found
Nearest lot I
J
I
Depth
Driller ®�
Distance to lot line _
PERN4IT NO. 0 G 1 ()_7
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area (sl
OTHER
PIPE MATERIALS
i U
SOIL T STRATING!-�
INSTALLER
rz+ H
i
REMARKS
1,k(i
LEGAL
•,
l�
I
APPR VED DATE
III
?d
L,l
4�
:T: '_N_• tl.0 cu I=- F=h R"-4 G:I--N A_: A IF", IF"' Y:3 1-- � ✓
DE�:t'f=iC<:]"IlENT HEALTH ANDf.rIVIF,Or-V,IEr•dTh�ll_ �=i"'fE,=:TTiipdj
.
u.' STREET., FiNF HORAGE: Fit:::.
26.;,t--4 i �i C-1 ��
-r -"-a
�(AAA.
11-3 EER,_ R_ 11:111,4 N::,-� Y_.vA R'•,s -•_- mm�.• 1 s—=-"_ : FTS 0--o IE-'.'. Fp.` N'-° a _-" � �° a l..Y.
PEFT'JIT [IL-1.
1=iPPL...E i_.Fii'•d E BOB t;Urdt+.[..l 4 _,:LJ.. BISHOP IJH'r' 7111
LCA( AT J: i-ird _ FlE'L.E C!UEr:rdE P I-FIC:E:
I. E GAL_ L. 4, BK I KNIT . HTE". l_OT" SIZE 4_-Z000 m.(;ILIRF::E P'EET
T'r'P'E 'I I.... ABSORPTION S'•r'_;TEM I S : TRENCH
f1f='I;{TPII_it'I rdl_N'"IC:,FF' OF EEC:F:C1 :7 =: :C Cii:L f'FiT'Ird� (SQ FT,'BR)= :t.5,-,
THE'.* F::Ei!UIRED SIZE OF THE SOIL- ABSORPTION SYSTEM .T.'";:
1r. ` LH': F=., ....N R a : • 11. —1. 11— FE V4123 .,.0, a_.I =_ =-. ED 93 `•4 a PE I_ Ca CC.:`.. I=mo-,, -IF V -N
THE I._L .IG'TH E'l T IlE_I'-dS T ON IC; THE I_Er• NTH 1:: I r•d FEET) OF THE: TRENCH OR DRA I NF I EL.E:I.
I"tlf: DEPTH OF H "ft:El'd�.hl OR PIT IE; THE C.jT ,TRrdC:F E;F:'fl•dfwEr,I THE m•I_RFAF-E OF THE
(';F::OFJNU, AND THE F:01"I"01''I OF THE EeXC FIVAT I ON : I hI FEET).
THEREIS NO 'SET WIDTH FOR TRENCHES"..
"I"I-II:: GF.FiVEI,_ E)E:P'TH I, THE I•'1Tr•IllylUlel DEPTH OF C;F'R',fEL.. BETWEEN THE:: CiUTFh-1Ll- PIPE"
AND THE BOTTOM OF THE: E e,"C:R'v'RT I ON ' I N FEET).
FR, _ n ;;a 1_11 JL F� : Nom:: F:"� E= R:.," ,.N_ J.' A .= _i". f=9 R"- a V:-."iE"' "C `E E =� _].. a �" `-`�a Y W� A: a F --e U. I_. A� A P-4
�' ;
PERMIT PIPF'L_ T. C:Fir•dT HR ✓ THE F:E::-P'Cir,I , T E. T L. T T'r` TCS INFORM THIS C,?EP'FIRTI`1ENT DUR T rIG THE
7:YdE,T(II,.L,t91 .T.,:;!rd
INSPEll'TIONS OF ANY WEL.Lw; ADJACENT TO THIS F'F:OPERTY AND THE:
r4l.111E:. E'R OF RES I DEP-JCE'w THAT THE WELL. WI L -L 'SER'-r'E.
F"•I F'z" F F_" F_-717! U a- F- ° a m E: -p _ .. _..... __......
E,R( KFILLIr•di; OF" PIIW-r' SY-;T-EVI WITHOUT" FINAL. IFd -P'EC:TICIN AND FiPPRO'v'RL BY THIS
E;E P'F'IE "i"I''IEEr,I C I.I I L..L BE SUBJEill TO P ROSL-:C L.)T I Ord.
rel:lr•-IIHIJI9 DI' TPIFd,:::E E.,E-E'IJEE1-J Pi WELL. FINE..,, ANY Oral ... SITE :•EWA("IE DISP'O''SAL SY:::;TEM I:;
J.oc..) F"E:L."T FOR PI PRIwRTE WELI.- OR J.50 TO 200 P'E:ET FROM A P'I_IBLI:C: WELL. DEP'ENE:U-11:;
UPON THE T',•'PE OF PUBLIC WELL_.
r'1Tr•.ITr-lull DT'"-JANC:E PROM A P'RV,,,'ATE WELL_ TO FI F'F:T'ti'I=ITE. SEWER L,.II'•dE IS 25 FEET ANE)
TO 1-I c Or'1r'ILJN T T"i' . E:4'.IER LINE IS , 75 FEET.
WELI_ I_,:i:a'• ARE REC70IREE:, AND VILIST BE RETURNED TO THE DEPARTMEI' l" WITHIN i, 1`111 T`:':,
OF THE WELL. (::011P L.ETI ON.
OTI'-IEF; REG 11.31REr'1ENTC; MAY APPI...Y. SPECIFICATIONS Fir"dD C:cir-4sTRLJC:TION DIFIGRRl''1::; ARE,
r`VFIIL_A0t..E TO IhISL.IRE,' PROPER INSTAI-.L.RTION.
IE,- R U=° I ° l :R -1C"' F.E:: =e 6 1 F ;;a IF S. ' = F= - U o_W- E I'" -I I� 4 N �: -'- � - �_ : : � °Ea Y Y
I ,q EF:TT. FY THAT
:I.: I AM FAMII_.]:RF:: WITH THE REQUIRE:IIENT'S FOR OI`+ ;ITE SEWEF!_; Rr•ID WELLS AS SET
FOF:TH BY T'HC-_ r'U_Ir• I IPRL.T,I',r' ()F" At IiOf::R�iE.
I I. ILA_ INSTAL-- 1"HE S'' STEirl 114 RC:(::ORDANC:E W I TFI THE CODES.
T I_il'dE:EE:' '1'f9riE: THATTtIE Ord-rT.'iE Et'•IE;F: 'r'' TEr'I MAYf::E(tl_ITC:E' ErdL.F=tF:i3Ei''1E:r•I'T' IF "I'HE'
RE'w;I['lE::r-,ICE TS REl''ICiDEL.EUl TO INC:l_.UDE MORE THAN 4 E,EDR n II .
RPP'L I C APJT Ea' F::i Icrdt;EL
CONSTRUCTION TEST L71B
"One Test is worth a Thousand Opinions"
2204 Cleveland anchorage, Alaska 99503 277-0231
Performed for_ Bob Runkel _ Date Performed 5/15/80
Legal Description: Lot_ 4_—
Block I Subdivision KNIK HEIGHTS —
This For_n reports: SOILS TEST YES PERCOLATION TEST NO
Depth Soil Characteristics
Feet
ORGANI_C MAT - TOP SOIL
2' ORANGE SILT_—�_—
6' TAN SILTY SAND (SP -SM)
:L 8
TAN GRAVELLY SAND
W/ OCCASIONAL SILT
(SP-150SF/Bedroom)
-BOTTOMVOF HOLE
Alas Ground Water Encountered
If YES, What depth?
NO
JOB # ACTL 80-1336
�f
Gross Time Net T� ne Depth to H2O
Net Drainage
I'll
a
Zeading Date
Gross Time Net T� ne Depth to H2O
Net Drainage
I
_1
lU
Zeading Date
Gross Time Net T� ne Depth to H2O
Net Drainage
I
Percolation Rate_ _ Minute
Proposed Installation: SEEPAGE PIT _ DRAIN FIELD _
Depth of Inlet Depth to Bottom of Pit or Trench
CO_AMENTS: Soil classification and ground water as observed 5/15/80 at the test __
-pi—t- noted above only.
Test Performed by Bob Peters Data Certi{fed Bv: _James R. Ringstad ��
Date 5/19/80
LOCATION OF WELL (Please complete either to, Ib. or Ic.)
WATER WELL. RECORD
STATE OF ALASKA
DEPARTMENTOF NATURAL RESOURES
Division of Geological & Geophysical Surveys
Drilling Permit No.
A.D.L. No.
n
To Borough Subdivision Lot Block Ib. 1/4 qt rs.
E E]Meridian
Section No, Township N 13 E]
%�rii I�; ,�,�l7fi(= /� i _of—of—of _
S❑ W❑
- ,i1:i,
Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS
-
5. OWNER OF WELL:
Address:
�� / 'r�•/ ""'I/ -" --
Street Address and Area of Well Location
-
2. WELL LOG Feat Below - - -
4. WELL DEPTH: (}Incl)
5. DATE OF COMPLETION
-- Surface
M aterial Type Top
Bottom-
���.ft.
`i i. ✓ '�, �j
i'f / -
�,
6, E] Cable tool Q Rotary ❑Driven E] Dug
❑ Auger ❑ Jetted ❑ Bored ❑ Other__
_ / •, r rr is i it/r%�j t-r�/f!✓-. `_' ' / -
7. USE: j" Domestic ❑ Public Supply ❑ Industry
❑ Irrigation [j Recharge E] commerical
❑ Test Well ❑Other:
J r
/�; •: /_,i,, j, � ;,'' i, r/
r r%Cfia'ii 1(J !iCJ (J
: O
/6 CI•
i7 X17%
r-7
8. CASING: ❑ Threaded �j--Welded
/ru"
diem. .-} in to_ ft. Depth Weight Ibs./ft.
diem. in. to _ft. Depth Stickup 1t.
�J0o �4/
,r'f) ,i,�(_)
1J
9. FINISH OF WELL:
r
i
Type f?/?f'ii /'j 4.'. Diameter:
r
Slol/Mesh Size: _ Length:
Sot between ft. and ft.
Backfilling Gravel pack
-/{ i' , �, /�J .; ^i`_;!=4-r.��•_.
/
10. STATIC WATER LEVEL: ft.
❑ Above or W Below lend surface Date
Equipment used: _,(Jrt. _(,l
-
II . PUMPING LEVEL. below land surface and YIELD
ft, otter __hrs. pumping g.p.m.
ft. after hrs, pumping g. p. m.
MUNICIPAL ITY OP A
L&—
12. GROUTING Well Grouted: Yoe >_ No
❑
Material: ❑ Neat Cement ❑ Other:
EDP . AL pK TECTION
15, PUMP: (if available) HP 4
lJ
Length of Drop Pipe ,-3 j'/i ft. capacity g.p.m.
D Subm. ❑ Jet ❑ Canlrifical Other
14. REMARKS:
r
V
16. WATER WELL CONTRACTORS CERTIFICATION:
15. Water Temperature _—° ❑ F ❑ C
This well was drilled under my jurisdiction and this report is true
to the best
of my knowledge and belief;
Registered Business Name
Contract
License Number
Address:
-
Signed: , "; L., -_;i -'] -i; i,_! /�`'
Dale:
Authorized R6presentative
Form 02-WWR (11/81) Copy Distribution: WHITE -State
DGGS, PINK -Driller, CANARY -Customer
MUNlCIPALIlY OF ANCHORAGE
Human Services
825 L Street, Anchorage, A1aska 99501 343�472O
�a/mzt Number: 880193 Upqrade
�atp \``ued: 09/19/88
Uwnrr Name: PE[EK & CAROL SORENSON
Uwner Address: 4630 SHEL8\]RNE PL,
ANCHORAGE. AK 995i�
WELL PERMIT
Parce1 Id: 017~J/;�:!-30
Lot Lega1: Subdivision: KNlK FIE 1GH|S Lot: 4 Block: I
Section: Q lownship: 12N Range: 3W
LoL Size 1 A �sq"ft^ or acres}
x Bedroomshis PermiL: 0 | cit. al CapaciLy: 4
Day Phone:
345~5907
Log must be submitted to Municipality o> Anchorage Department (1 .1 Health
r ' an Services within 30 days of well completion"
AELL lS A8ANDONED PLEASE PROVIDE WRITEN CONFERMATION
|n/�
I. ON.
`v1ilia1' with the requirements for on~site sewers and wel1s as set
Lh by the Municipality o( Anchorage (MOA) and the State of Alaska"
sysIr. em in accordanc:e with all MOA codes and regulations,
and in compliance with the design criteria of this permit^
3. | to all MOA and Gtate of A1aska requirements {or the set back
from any existing well, wastewater disposal system or public
ewerage system on this or any adjacenL or nearby lot"
th t 11 J. e 1Ait is valid ffor a maximum o} 0 bedrooms. I
� the total system is 4 bedrooms and
:itional permit.
DA|E:
D-Fb m
zo Z
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v o m
m
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= c 23=
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m n
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m m m n
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m = ^
n
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= m
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= 4
Q
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f1
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m s m
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-
-
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m m Z D
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MUNICIPALITY OF ANCHORAGE
• T
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF: INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # Ln - 171211_2)HAA # _ iA ) 0a
1. GENERAL INFORMATION (Must be comple+:ed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
4/630 /014'r -P
(b) Property owner Pe-'ec-Clr°% SO T
Mailing Address Z16 30 -5-11,J,��"i
phone: (home) 3VJ'9() 7 Business -7f'9'-5(?/
Ceo
(c) Lending Institutionytiktio Telephone
Mailing Address
(d) Real Estate Company and Agent > /- IU NC' & 0 i c' /_/' `-S Jam" P )�IJD'-4A
Address
Telephone
(e) Mail the HAA to the following address: (or check here,K if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single -Family
3. WATER SUPPLY
Number of bedrooms y
Individual Well X 2 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 A Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
In
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 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 eSSe, �1 �� Telephone 3
Address ZZZQ E7,
Date –7—S— 1 y f s
Eniner's Seal -1
�,r c D.'Moore, Jr . Q j
_�7 1027 E �=
ci
DHHS APPROVAL
Approved for Wit.—bedrooms \ Date 7 Z
Approved �1� Disapproved Conditional
Terms of Co ditional Approval es
CAUTIONr
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)
�������=9 • Health Authority Approval (HAA) p} j
4e1 CHECKLIST - FEBRUARY 1984 -�
L\QP\\ C 343-4744'
\
'�r'�\�� Legal Description:
A. WELL DA�
Well Classification 2 //y d/v, plc, r % �✓�//s o v 41 If A, B, C, D.E.C. Approved (Y/N)
k /a i_ A /0 —/9 F10 /? %9/9/"1
Well Log Pr� �SyY/N)LL_ Date Completed It /o -3/ - Yield _ l9ln
Total Depth /3,3/-5 , Cased to6 /yS' Depth of Grouting __6/,9N
Static Water Level Pump Set At A/
Casing Height Above Ground J Sanitary Seal on Casing (Y/N) 9 Y
Electrical Wiring in Conduit (Y/N) A % 6 % Depression Around Wellhead (Y/N) N
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot L) ; On Adjoining Lots l ��
To Nearest Edge of Absorption Field on Lot oo ; On Adjoining Lots
To Nearest Public Sewer Line Y'ZJ To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by 4A(dy Date -30 -8
Water Sample Test Results 5// T
s' AL
Comments
Il P.�OJC Gv / 0 4 54"-) e /G T// 7-G
B. SEPTIC/HOLDING TANK DATA
Date Installed 22 F0 Size 1250 No. of Compartments* 2 -
Standpipes
Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/NJ* UN/t
Depression over Tank (Y/N) /AV/ Date Last Pumped (a'- 2- - F cl
Pumping/Maintenance Contact on File (Y/N) /V ; for
Holding Tank High -Water Alarm (Y/N) __Al Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well /00 / To Building FoundationO
To Property Line
To Water Main/Service Line
To Disposal Field -)�- S
To Stream, Pond, Lake or Major Drainage Course /Y,/1t
Comments okS Lyes ,4- Ic.4 6v /I «i G/F./1N:✓t w0U/
72-02 (Rev. 7/88) Front Pagel of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata !SO� 6�'� Type of System Design'
Date Installed /'d Length of Field
Width of Field Depth of Field
Gravel Bed Thickness
Square Feet of Absortion Area')( (v /S� Statndpipes Present (Y/N) %r
Depression over Field (Y/N) / Y Date of Last Adequacy Test
Results of Last Adequacy Test ZJ
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well ZoO �.t To Property Line
To Building Foundation To Existing or Abandoned System on
Lot NO ^� � ; On Adjoining Lots /yoN''
To Water Main/Service Line /00 / _ To Cutback (if present) _,/f/aW
To Stream, Pond, Lake, or Major Drainage Course /V0 "-
To Driveway, Parking Area, or Vehicle Storage Area
Comments -k -7 191�1�-5 Z' f4
//yl,.�t�l/
ACCe4/'ce t1a 0'9 m iN /
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Check Permitted Bedroom Rating Against HAA Request"
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
Receipt No.4�1 Z42� 6
Date of Payment �7— 7—
Amount: $ 0 ,
Receipt No.
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
I certify that I have chec ed, r'#ied; r conformed to all MOA and HA9uid'fin°m'�f�ect on the date of this
inspection.'
21
> A D
Signed �,
s�
njo�s��/9�®
Company P � ,
Engineer's Seal
Date
MOA No.Xl/GU
,•
(l `_L `7/��� V r,�\ xis
Receipt No.4�1 Z42� 6
Date of Payment �7— 7—
Amount: $ 0 ,
Receipt No.
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
C6
BE'SSE r EPP.S & Fufm
2220 EAST 88 AVENUE
&4CHORAGE r AK 99507
(907) 349-6451
WATER WELL `.GEST
Date:_
LOCATION:
Subdivision:a�
Lot:
f JJ Block:
Client's Name: r, 7vme �ruQ" 1,,e5 ✓c �Vor4
Address:
OMS
Meter-
NOTES:(DwMO
''tJ.r'✓lo `":J -SII �n
'reduction Rate:
rC�yC:'N q 2
C n Gc/��/ � o.)✓ //-JJii1C/G
— GPM 24 -1 -Hour
Gallons
cZ „
/: -;'L
GALLONS
GALLONS
FIELD
METER
VOLUME
TOTAL
M TOR LEVEL
READING
A r t
�w c`
3
C-
f'0 77Z
c
109(,
6
5
1_5 I c c>
4+.
z us
I
Aq
ILL
CC)
114! 15
6
_GLB_77_ (
r L45
TS
6
L=
16 15
a
--
NOTES:(DwMO
''tJ.r'✓lo `":J -SII �n
'reduction Rate:
rC�yC:'N q 2
C n Gc/��/ � o.)✓ //-JJii1C/G
— GPM 24 -1 -Hour
Gallons
A
W
U ^o
aa)
W c v m
N N Y M
Z +v+ mo < M
[L ait¢Ln
C 'n '0 w Ol
a ¢ a
E-1 0 (L
U z w v
N
.01,
12
L
- --
-
0
Pj
w
S
V
v
Q
C
CE
Q
V!
.
IC
i
O
q
t
!
O
.01,
12
L
NORTHERN
TESTING
LABORATORIES,
INC„
60C UNIVERSITY PLAZA WEST
SUITE
FAIRBANKS. ALASKA 99769
907=179-3115
2505 FAIRBANKS STREET
Time
ANCHORAGE ALASKA 99503
9072778378
Besse, Epps & Potts
2220 E. 88th Avenue
Anchorage, AK. 99507
Attn: Andy Potts
Source: W BI NO Hts.
Sample ID#: A063089-2
Date
Arrived:
06/30/89
Time
Arrived:
1410
Date
Sampled:
06/30/89
Time
Sampled:
1130
Date
Completed:
07/05/89
Parameter Unit Result ADEC MCC*
Nitrate -N mg/ 1
<0.50/<0.50 10
l
Reported By: Date: 07/05/89
Francois Rodigari, Anchorage Operations Manager
-- -----------------------
* MCC = Maximum Contaminant Concentration
NORTHERN
TESTING
LABORATORIES,
INC.
6C9 UNIVERSITY PLAZA VIEST.
SUITE A
FAIRBANKS, ALASKA
907.1793'
2g-05 FAIRBANKS STREET
ANCHCRAGE. ALASKA= 3
907277 b-"
Quality Control Report
Client: BEP
ID#: A063089-2
Listed below are quality control assurance reference samples with a known
concentration prior to analysis. The acceptable limits represent
a 95% confidence interval established by the Environmental Protection
Agency or by our laboratory through repetitive analyses of the
reference sample. The reference samples indicated below were analyzed
at the same time as your sample, ensuring the accuracy of your results.
Sample # Parameter Unit Result Acceptable Limit.
EPA WS378-12 Nitrate -N mg1l 7.70 7.27 8.01
Reported By: Date: 07/05/89
----------------- -----------------------
Francois Rodigari, Anchorage Operation Manager
5. LEGAL DESCRIPTION
DATE RECEIVED
�iJ�fi44r/!'%/7".S
INSPECTION APPOINTMENTS
5 �13tpce2'dL �rf!
6. TYPE OF RESIDENCE
TIME
V,,, --SINGLE FAMILY
TIME
TIME
0 Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER_,SUI�`Y
DATE
LY INDIVIDUAL*
DATE -
DATE -
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
B. SEWAGE DISPOSAL SYSTEM"—
INSPECTOR
❑ INDIVIDUAL/ON-SITE**
INSPECTO
INSPECTO `\ 1
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
•
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF HEALTH &
825 L Street - Anchorage, Alaska 99501- ENVIRONMENTAL PP,OTECTION
ENVIRONMENTAL SANITATION DIVISION OCT 2 0 1980
Telephone 264-4720
pp ((''�I
REQUEST FOR APPROVAL INDIVIDUAL D
OF WATER AND SEVAkUdI I��
DIRECTIONS: Complete all partson page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER
- - - - - -
PHONE -
/
/��W- r__ °�%l�r�X
MAILING ADDRESS
-
r -
Aac 2(/F2 �/
PROPERTY RESIDENT
(If different from above) - - - -
(If
PHONE -
2. BUYER
- "—
PHONE-
1,4-2:g4 2LStSI S IS
MAILING ADDRESS
3. LENDING INSTITUTION -HONE
MAILING ADDRESS
—/--
4. REALTOR/AGENT
- PHONE - -
7]_
MAILING ADDRESS
-
5. LEGAL DESCRIPTION
,�2
- `7' f7. /c71.[�C:K
�iJ�fi44r/!'%/7".S
STREET LOCATION
5 �13tpce2'dL �rf!
6. TYPE OF RESIDENCE
NUMBER OF,BEDROOM'S %-A
V,,, --SINGLE FAMILY
❑ One our ❑ Other _
0 Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER_,SUI�`Y
LY INDIVIDUAL*
*ATTACH WELL LOG. A well lag 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.)
B. SEWAGE DISPOSAL SYSTEM"—
❑ INDIVIDUAL/ON-SITE**
4'2Z�_YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79) - -
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED _
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
EJ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑SepticTankor ❑Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY