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Home My WebLink AboutMAJESTIC VALLEY ESTATES BLK 3 LT 11Municipality of Anchorage ® Development Services Department Building Safety Division On -Site Water & Wastewater Program, 4700 Bragaw St. - P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Page 1 of 3 Onsite Wastewater Disposal System and/or Well Inspection Report Permit Number: SW09DO31 PID Number: 050-731-23 Name: NILS HVIID Wastewater System: ❑ New ® Upgrade Address: 26123 IMPERIAL DRIVE * EAGLE RIVER, AK ABSORPTION FIELD Phone: No. of Bedrooms: (907) 694-0363 3 O D eep Trench Q Shallow Trench O Bed O Mound ❑Other LEGAL DESCRIPTION Sea RotHg:Tad 3.0 GPD/SQ. rt. Depth tram atgtr,d wodo: SEE DWG. rt. Block: Lot: Subdivision: Depth to Pipe bottom hem orlq+rwr grade: Grovel depth beneath Pipe: 3 11 MAJESTIC VALLEY ESTATES SEE DWG. FL 0.50 rt. Township: Range: Section: — — — rZ odded above oegrw 9nde: Gro,'eI W+sM: 30 SEE DWG. FL rL Grovel width: number of tlmee: o+eto=o between a,ee: WELL: ❑ New ❑ Upgrade 5 Ft. 1 — FL Cbewf�cot.on PO cite, /vB.0 : low Dev Co—d iw Told oboorptbn dna: 150 Foe motorial: D 3034/ F-810/SCH 40 R Ft. saw R Dw« We DrWod: staUo wale. rte: —olkr. SOUTH FORK Date &wt°*ed: 5/6-18/2009 FL CONSTRUCTION ,Held: Pump Set AL eoetrw Hoot Abo" erotmw: TALK CPN SEPARATION DISTANCES Oseptic OHolding OS.T.E.P. 13 other To Septic Tank Absorption Field Lift Station Holding Tank ubtic/Privote sober Uwe lam` 'r "GREER c'p"� in 9d� 1500 From Well too'+ 100'+ 100'+ — 25'+ ueter{a: STEEL Nvmbor of ee.mport « ta: 2 Surface Water 100'+ 100'+ 100'+ — — LIFT STATION Lot Line 5'+ 10'+ 5'+ — — Sue in gdtorw: 1500 morAdoctura: QUANICS On lore/ at ump oft layel OL High water dem+ OL Foundation 5'+ 10'+ 5'+ — — TIMER TIMER 44" Pump Motu x Model: Clectrled Mwpeotjo. pwformed br: Curtain Drain NONE KNOWN P—TE-30—PLUS RISING SON ELECTRICAL BELCH MARK Remarks: 'QUANICS AEROCELL SYSTEM Loo and Deoulption: OLD SEPTIC TANK WAS ABANDONED PER UPC. TOP OF MAN HOLE LID i010 GAUGE DEEP BURIAL TANK. Aw-wriod Elarcboru 84.38 ENGIN E£as a Inspections performed by:.GEG, Ltd. Dates: 1st 5/6/2009 4pQ�oO Q a 2nd 5/7/20090 ,• ��.°F �oo 3rd 5 $ 2009 ov-f-0 Development Services Department Approval p 4 y 1. * Conditional approval: Date: . ."••...."" J r Corn ss.: D Q • V 9• E-79 ; m® �4�4d'°nofesstol" _ - Reviewed and approved by: r Date oma (Rev. 4/06) 0 (1a.1vCgr 01,11d 0.19 Quanc a Advance Trcatmcnt System 1011* 03 ar�rt GARNESS ENGINEERING GROUP, Ltd -------- ENGINEERING oSALES -CONSULTING L ---- January 25, 2019 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Rd. P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 Ref: Majestic Valley Estates S/D; Block 3, Lot 11 (26123 Imperial Drive, Eagle River, AK) Memo concerning converting CAT III AWWTS to CAT II AWWTS septic system To whom it may concern: The permitted septic system was installed on the referenced property on 5/6-18/2009 and start up shortly after installation. According to ARM Septic Services, LLC, the monitoring tubes in the drainfield has been checked on 12/20/2018. In order to simplify the overall operation and maintenance of the system, we are proposing that this unit be permanently configured as a CAT I I system. Our justifications are as follows: • The receiving soil had percolation rates that ranged from 10 minutes per inch. Given this percolation rate, a 3.0 gpd/sq.ft. application rate is required for a Cat II system. The residences on this property have a total of 3 bedrooms, so 150 sq./ft. of absorption area is required for a CAT II system (450 gpd / 3.0). The new 2009 drainfield has 150 sq./ft. of absorption area. In short, the drainfield meets the Cat II absorption area requirements. At this time. we request that your department approve a CAT II configuration be used at the referenced property, Upon your concurrence, we will have ARM Septic Service, LLC, either leave the Jandy valve actuator in the discharge position; or have them completely remove the actuator and leave the valve in the open position. We will also have them place a CAT II sticker on the control panel. , M.S. 3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259 Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com i N ORIGINAL GRADE AT HIGHEST POINT = 98.5 MOUND IS TOPSOILED AND SEEDED r�pp FINAL GRADE = 98.60-99.78 QUANICS AEROCELL 650 TREATMENT UNIT DANDY VALVE CO MT4" INSULATION MT CO CO TH#1 > LA 6" BY 4' WIDE RIDGE INSULATION CENTERED ' OVER PIPES 4 Y OF SAND T0 P- 95.00 r5 a � r� INVERT OF PIPE = 95.50 m o r- Z BOTTOM OF SYSTEM = 92.50 O W z C) a W mcg i✓ RELETIVE ELEVATION OF BOTTOM OF TEST HOLE = 86.50 z`—' (WATER AT 89.00 ON 5/4/09) o m w z < W C) r W J a �I Li < O O 00LJ . •'a � tr � � _� o v) i m O —j0 4 v) W — M Jm )< ¢z 6i < d a w o Lj a 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 NAME [~NEW /~ ~.,~ ~ [] UPGRADE MAILING ADDRESS LEGAL DESCRIPTION F/~~'- ~ ~ ~ ~/~5 LOCATION NO. OF BEDROOMS We] Manufacturer ~. ~.~[. Liq. capacity in oallon, DISTANCE TO: [Well PERMIT NO. No. of compartments Inside length Liquid depth ~ PERMIT NO, Manufacturer Liquid capacity in gallons DISTANCE TO: Well NO. of lines / ~ength //~ I of each line Foundation ¢~ , Total length of lines ~-0 ~ Material beneath tile Material Neares~lot lin)~ Trench width .~C) inches -rop of tile to finish grade Length Width Depth PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. Building foundation Sewer line Septic tank ! Absorpt on area{s) DISTANCE TO: l PERMIT NO. Distance betweeD lines Total effective absorption area OTHER MATERIALS SOIL TEST RATING INSTALLER REMA~S APPROVED ~ ~ DATE 72-0~ 3 (Rev. 3~78) LEGAL /~o.r //. I:::l [::' I:::'l., ]i '": f:::l I. Ii )C: FIT ]; i'l..llii: I.[ii:ir'41?i'l'H I'::':i:f"l!:!:i'"l:::i;:!;Cd'"l :(:!i; 'TILE: i..l!i:[",ll:;!i"['l'l ':::l:f',I I::li!:l!i:'l:) O1':' THE TF?.I:?"I(:::H O?';: -I"1"I1!!: [:."[::.F'TH (.~1i:::' i::'1 TI:;~:E!:I"'IC:H O1:"i: I:::';1:'1' ];:'i!; TI'II:!:: I:::' :[ :::i;'FI::!I'"!CI!:: E:E:'f'I.'.IF:[:::Iq 'fI!F.:: :ii;I.II:;'::F:'l:::l(:::[i:: O1:::' Till:: (!i[;i:l::il..If',l[:) F:II'"I[:) TI'If:i: [!!:CI'I"TOH O1:::' TI"II-~: F-::XC:I:::I",'ff::I'[' :!: I:)[",l ':: :1: I'"! I::'[i::[:::T I'l'll!i:F;:l!:i: :1::::" I",ff:l ';ii;l~:T 1-'-I:!:[::'Tll !::'OFf: 'll~'llii: GF?.[::]","liil.. [:)I?~1::''1~1'1 :l:'ii; TI"i[:!: I"i:!:H):HI...II"I I::'[ii:[::'Ttl Cfi::' I;:~it;?.l::l","!::i:!. !!!!"[::'i'I.'.I[!!E?"! IH[i: I:::llq!::) TI'lEi: I:!?'()'["I"OH OF 'I'HE [!i:XC:F:I","I:::IT ]: O["'1 ':: :!: I"'l l:::'[ii:!E"[' ::'. I::'l:ii:f:;i:l'"l ]: 'T' I:':ll:::'[::'!. :1: CI:::IF,I"I" Hl:::l:iii; 'l'l"lli!: I:;~:l~::!i!;l::'Ol'"l:ii; :J: I::i: ]' [... :Il Tl'i'1 'l"(:J :Ii I'"l[::'l:)l:;;:J'l 'l"l '! :1: ?i; [::,I:!::[::'I::IF¥1'I"I!!~;NT !;::,l.ll:;i: :!: :1: I",!:!:!;"I'I::II..I...I:::IT :!: I:)1'.,! :1: I'.,I'_:51'::'I:!!:I::::T :!: CIJ'.,I?::; CJI:::' I:::ff',!"r' J,.!l!!i:L.L.::i!; i::il;::,..:ll::l(;:Ei:i",J'j' 1'(3 "J'l I ): ::!; I:::'t;' :': .::' Cl:;:-I'"r' ?::Ih,l[::' Fill!: PIUI"IF!!',[:'I';? Cfi::' I;i:l:ii::iii;]:l:::'!ii:h!('.:[i?:!; 'I'HI:::IT I'l"l[ii' !.,.!Fi:LI.. I.,.J:[!..I.. '_: i; l: !: l:;?. ',,,' l: !: . DEPRRTMEN~ OF HERLTH AND ENVIRONMENTRL F'ROTECTION , ' 825~"L~ STREET., RHC:HOR~GE., RK. 9L~501 l*liL_b 'R~-4B, C~q--S Z TE 25EL,~E~: F'E~Pl Z T PERMZT NO. "' ( LOC:RT I ON ~ T~F'E OF SOZL RBSORBTZON -,'~STEH ZS: ~~ t'IR::<IHUt'I NUHBER OF BEDROOM'S = ~ SOIL RRTING ('~0 FT/E',R::,= THE REQUIRED SIZE OF THE BOIL RBSORPTION SYSTEM IS: THE LENGTH DZMEN~ZON ~% THE LENGTH (~t'~ FEET) OF THE TRENCH OR DRR~NFZEED. TH~ DEPTH OF R T~ENCH, OR F'ZT ZS THE DZSTRNCE 8ETHEEN THE SURFRCE OF GROUND RND THE BOTTOM, DF THE EXCR'¢RT~ON ,::ZN FEET). THERE ZS NO SET W~DTH FOR TRENCHES. THE GRRVEL [EFTH THE hl~NZhlUH DEF'TH OF GRR~/EL BET[4EEr.4 THE OIITFRLL P~F'E ) ' IS BND THE BOTTOM OF THE E,'~CMkRTIUN (IN FEET). E:E~LI I F~E[:, bqEF"T I i] Tt~f-4~::: S I ZE= /~ F'ERtIIT RF'PLICRNT HBS THE RESF'ONSIDILIT'¢ TO INFORH THIS [:'EF'RRTMENT DIIRING THE INSTRLLRTION INSPECTIONS OF R[.t~' HELLS TO THIS PROPERT'¢ RND THE R D J R C E N -r ' NUMBER OF RESZDENCES THRT' THE WELL WZLL SERVE. . E,H_.KFILLING OF Rt'JY' S'¢STEM~[4ITHOUT FINBL ZNc, FE_.TIOH RNE) RPPE']VRI E:'¢ THI~ DEPBRTMENT HILE-BE SLIBJECT TO PRI3SECUTION. - - MINIMLIM DISTRNCE BETHEEN R WELL RND RNa' ON-SITE SEWRGE DI_,FE:,HL S~',STEM 1OO FEET FOR 8 F'RIVRTE WELL: i~L4 TO 200 FEET FROM R PUBLIR !.4ELL DEF'EN[)ING I_IF'I]I[,] THE Tb'F'E OF FLE, L, II': HELL WELL LOGS RRE REQUIRED BND HUST E:E RE'TLRNED TO THE DEPRRTMENT WITHIN OF THE HELL COrtF'LETION. 13THER REQLIIREMENTS [,1BY RF'F'Lb'. SF'ECIFICRTIONS RND CONSTRUE:TION DIRGRFiMS RRE R'di~ILRE:LE TO INSLIRE PROF'ER INSTRLLRTION. I CERTIF'¢ THRT 1: ~ Rr,1 FRI'IILIRR NITH THE'REQLIIREMENTS FOR ON-SITE c - _EHER:, RND WELLS RS SET FORTH B~' THE MLINICIF, RLiT,Y ~OF RNCHORRGE. 2: I HILL INSTRLL THE S'¢STEH IN RCCORDRNCE HITH THE CODES. Z<: ~ UNDERSTi~ND THRT THE :ON-SITE SEb. IER SYSTEM HR'¢ REQUIRE ENLRRGEMENT IF THE RES;IDENCE IS REMODELED TO'INCLUDE MORE THRN 8 DEDROOHS. LF~T S!ZE ~~ '5.;,URRE FEET O~E Russe# Oyster 694-2774 Soils ~ Foundations Performed for: Name: GEOT_CHNICAL El- DEVELC MENT Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Mail lng Address: SOIL LOG Legal Description: Depth (feet). o 'rel. No. S, oll Charactertstic~ CO. Earl Ellis 688-2280 Land Development 2 3~ 4, 6~ 7~ Ground Water Encountered: Proposed Installation: Comments'. Yes No Seepage Ptt____.~ Drain Field~ Performed by: Date: 0 0 0 0 0 0 0 0 0 0 0 0 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CER'rlFtCATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date May 5, 1988 GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 1 I... Block 3..' Majestic Valley EstateS Location (address or directions) (b) Property Owner Ra6er~t Bou~tang Telephone: Home 694-9~4 _ Mailing Address- .~R 17.~7; Eagle River: Alaska 99577 Lending Institution .,N" B,A, ":.Mailing A~Jdress '' Ay/.o. ho,tag¢0 Ald,4,~z¢. R'eal Estate Company' and'Agent Address Telephone Mail the HAA to the followina address: or: Check here,~, if hold for pick up. List contact person and day phone number below. S ~ S ENGINEERING/694-2979 17034 Eagle River Loop Road, Suite 204 Eagl~ River, Alaska 99577 (c) (d) Telephone Business (e) TYPE OF RESIDENCE Single-Family [] Number of Bedrooms WATER SUPPLY Individual Well~ Community [] Public [] Note: If comm unity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status, SEWAGE DISPOSAL Onsite,~ 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. Page 1 of 2 72-025 fRev 8/861 Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 aJJ Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Date Telephone Approved for.7~J"~, ~/~_ bedrooms by Approved ~../"~ Disapproved Terms of Conditional Approval Conditional Date CAUTION The Municipality of Anchorage Depadment of Health and Human Services (DHHS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 fRev 8/86) Back WELL DATA Well Classification _{ 1'3~%~Jl ~0/5~- If A, B, C, D.E.C. Approved (Y/N) Well Log Present~/N) y Date Completed .~'-i?..4¢ '¢ ~'¢i Yield Total Depth ~__ Cased to _ ~'\~ / Static Water Level .-~,27~. Casing Height Above Ground Electrical Wiring in Conduit ~..~N) Separation Distances from Well: Depth of Grouting Pump Set At Sanitary Seal on Casing~'~/N) Depression Around Wellhead (Y/~;~ To Septic/H'01'd~g Tank on Lot I ~..2~ ; On Adjoining Lots To Nearest Edge of Absorption Fiel ot _.'~ \""~- I ~Z~//; ;On Adjoining Lots \ To Nearest Public Sewer Line ~Jt~/~' To Nearest Public Sewer Cleanout/Manhole t To Nearest Sewer Service Line on Lot "~C) /rog'- Water Sample Collected by ~'~¢""~¢'? ~t II-.J~;"~_;~/--t i'-~(~ ; Date Water Sample ~est Results ~"~ ~%q'-'~ :-~¢~,~-'"~"¢~/ '-- ~2:~,/"'¢:'-¢1~, B. SEPTIC/HOLDING TANK DATA Date Installed ~¢¢ J"~-~ Size I ¢4~..~(¢' No. of Compartments Standpipes<(.~'/N) '¢ Air-tight Caps ¢'~/N) '7 Foundation Depression over Tank (Y~)) ~ Date Last Pumped Pumping/Maintenance Contract op File (Y/N) .,,/ ; for Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/l'f~Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72 026 fRev 8/86/ Front ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field '"~ Square Feet of Absorption Area Depression over Field Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot I"~/~'~' To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~ ~ ¢.~-~O~2.Ji~¢~ I Type of System Design "T.'~ Length of Field Depth of Field Gravel Bed Thickness Standpipes Present ¢-~N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots "~'¢)"'~ To C~L~tbank (if present) Size in Gallons~"~-'---~ ~ "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) ~~"Pump~ Off" Level at Vent (Y/N) Pum~p~ es during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA apd HAA..g uidelines in effect on the date ~..¢,& S ENGINEERING .,~'~//~-~ ~grrea- .... , --- ~,..~ ..... Date 17034 Eagle ~ei ~ff ..... ,~0. ~u4 Co--River, Alaska 99~77 MOA No. ate of .a ent Amount: $ 2~ Page 2 of 2 72-026 fRev 8/86) Back of this inspection. CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. FEDERAL TAX iD # 92-0040440 ANALYSIS REPORT BY SABLE fox Work Order B 6545 Date Report Printed: D~Y 12 88 8 09:46 Client Sample ID:Lll, B3 ~JESTIC EST. P~SID :UA Collected [lhY 9 88 8 10:30 Es. Received MAY 9 88 8 14:00 h~s. Preserved with :4 DEG. C Client Name : S & S ENGINEERING Client Acer : SNSENGP P.O.{ NONE REC'D Roq { Ordered By : R. SMAFER Analysis Completed :MAY 11 88 Send Reports to: Laboratory Supervisor :DANIEL J. BACON 1)8 ~ S ENGINEERING Released By : ~,~,~ 2) Special Instxuct: Chemlab Rof {: 9969 Lab Smpl ID: I Matrix: Water Allowable Parameter Tooted Result/Units Method Limits NI~RATE-N 0.83 rag/1 EPA 353.2 10 Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECIED BY RJS Testa Performed ' Soo Special Instructions Above UA=Unavailable None Detected "See Sample Remarks Above Not Analyzed LT-Los8 Than, GT-Greater Than CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER ~ATE WATER SYSTEM Name Phone No. S & $ ENGINEERING 17034'Eagle River Loop Road Mailing Ad~/e,RJYert Alaska 99577. Zip Code City State Mo. Day Year .) [] Treated Water [] Untreated Water SAMPLE TYPE: ~&/'. Routine [] Check Sample (for routine sample with lab ref, no. [] Special Purpose SAMPLE NO. LOCATION / Time Collected Collected _~___._ TO BE COMPLETED BY LABORATORY Date Received Time Received Analytical Method: s shows this Water SAMPLE to be: isfactory [] Unsatisfactory [] S~imple too long in tCansit; sample should not be over 30 hours old at examination to Indicate reliable results. Please send new sample via special delivery mail. Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* I I FTq I Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Couot Verification: LTB Final Membrane F~,~t~.. Repoded By 'rNTC = Too Numberous To Count I OB = Other Bacteria ~ Coilform/100ml BGB Coilformll00ml PART ! OF 2 REIVI~IrqDER TO FOLLOW MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT, OF H[2ALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~I~ONMEN'I'AL P[~OTECTION ~ ~ 825 L Street - Anchorage, Alaska 99501 / ENVIRONMENTAL ENGINEERING DIVISION JUL 1 6 1979 Telephone 264-4720 _ . . ~EQUEST FOR ~PP~OV~L OF INDIVIDUAL ~TE~ ~ND SE~n F DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE MAI~G ADDRES~ ~ P~OPERTY RESIDENT (If different~om above) PHONE 2, BUYER 'PHONE MAILING ADDRESS 3, "LENDING INSTITUTION PHONE MAIL~NGADDRESS~ ' ~' ' 4,.FIEALTOR~GENT ~ PHONE I MAILING ADDRESS - 5, LEGAL DESCRIPTION STREET LOCATION 6. I'YPE O~fRESIDEN(~E' .~ SINGLE FAMILY [] MULTIPLE FAMILY [] Other NUMBER OF BEDROOMS [] One [] Four [] Two [] Five [~ Three [] Six . 7, WATER SUPPLY ~ INDIVIDUAL* * ATTACH WELL LOG A well log ~s required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give wel [] PUBLIC UTI LITY depth (attach Icg if available.) 8. SEWAGE DISPOSAL SYSTEM '*If individual/on-site, give installation date INDIVIDUAL/ON-SITE** If system is over two (2) years old an adeqb/acy/test ii required [] PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-01013/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TiME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 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 [] I NDIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER F-ISeptic Tank or []Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS ~ APPROVED FOR ~.~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany/.~ertificate) [] DISAPPROVED DATE BY ~Q,~ .~~ ITitle LEGAL DESCRIPTION ~ ' 72-010 (Rev. 3/78)