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HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES #1 BLK 4 LT 4 (~ 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 MAILING ADDR.~SS LEGAL DESCRIPTION LOCATION ~0. OF DISTANCE TO: ~- Z Manufacturer ~ Materi~ / ~ No. of compartments Liq.~apa~' i__~°ns IFHOMfiMADE: Insidelen~th ~idth ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O Z ~ Manufacturer Material Liquid capacity in gallons ~ Nearest lot li~ Total len. th o/ lines Tre,,ch w~ Distance ,~es ~/~ ~ .o. oflines / Length o~,~,* MateX~oathtile~ inches . ' ;~ Top of tile to finish grade Length Width Depth PERMIT DJ ~ H 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. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS / /] ~ ] DATE , ~EGAL 72-011 ~v, 3/78) DEF'FIRTMENT C. FIEFILTH FIN[:, EN',,,'IRONMENTFIL I 3TECTION \ . · · ,::,~... '"L'" :,TF..EE r., HNI_.HURHGE., ' ;2E; 4- 47';? 0 L.JEL_L_ Fgi"4E:. _ I'-#--__.- I T'L-_ .:,EL.IE:.F~ F '- .... R="~' f~ ' ICo /( ' ':¥~I(~ fl FIPPLICFtNT BILL NEIL PO BOX Z.':26:.t RNCH 9.95:10 277-6469 LOCRT I ON LEGRL L4 B4 MOUNTRIN VFtLLEY EST LOT SIZE S~.'.~9999 SQLIFtRE FEET' TYF'E FIF SOIL FIBSOF.:F'TION =,x=,l Ell IS: IF. EN_.t4 / MH,.,IMt..IM N_ME, EF. GF BEr:,ROGMS = -.,: SOIL RRTING THE F.'.ELX!UIRED SIZE OP' THE SOIL ABSORPTION SYSTEM E) E: F" -Ir' H :== ~L=.];, L. F_- !'-,! 12.~ 1' H = 4 7 ~3 I~.." e ',,-' E IL_ [::, E F' T ~'4 = 4- THE I..ENGTH DIMENSIGN IS THE LENGTH ,:IN FEET) OF THE" ' F' , '/' rF..EN ~.H '"iF., DRR I NFI ELD. THE DEPTH OF F:I TRENCH OR PI]' IS THE [:,I':;]'FINCE BET!.,.IEEN THE SURFFICE OF THE GROUND 1-3ND ]"HE BOTTOM OF." THE EXCFIVFtTION (IN FEET::,. THERE IS NO SET 14IE:,TH FOR TRENCHES. "['HE GRFIVEL DEPTH TS THE MINIMUM DEPTH OF." GRFIVEL BETWEEN 'THE OUTFFILL PIPE FIND TFIE BOTTOM OF THE EXCRVRTION (IN FEE.'T). PERMIT RPPL. ICFINT. HRS THE RESPONSIBILITY TO INFORM THIS DEF'F~RTMENT DURING THE INSTRLLRTION INSPECTIONS OF: FINY HELLS RD.]'RCENT TO TFIIS PROPERTY FIND ]'HE NUMBER OF RESIDENCES THFIT THE HELL HILl_ SERVE. BFIL]KF'ILLING OF FINY SYSTEM H~THOLIT FINRL INSPECTION RND FIPF'F.'.OVRL BY THIS C, EPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTRNCE BETHEEN R WELL FIND ANY ON--SITE SEHRGE [:,ISPOSFIL SYSTEM IS tE~E~ FEET FOR FI PRIVFITE HELL OR ±5E4 TO 2¢.'~0 FEET FROM R F'LISLIC WELL DEPENDING UPON THE TYPE OF' PUBLIC HELL MINIMUM DISTRNCE FROM R PRIVATE WELL TO Ft PRI'v'FITE SEI.4ER LINE IS 25 FEET RND TO A COMMUNITY SEHER LINE IS 75 FEET. HELL LOGS ARE REg!UIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ]:0 DAYS OF THE HELL COMF'LETION. OTHER RE¢;.UIREMENTS MRY FIpp/.y. SPECIFICFITIONS AND CONSTRUCTION DIRGRIqMS IqRE FWRILABLE TO INSURE PROPER INSTALLATION. I CERTIFY ]'HAT 2L: i BM FRMILIRF.: WITH THE REQUIREMENTS FOR ON-SITE SEWERS F.IN[:, HELLS RS SET FORTH 8Y THE MUNICIPALITY OF RNCFIORRGE. 2: I HILL INS'I'FIL. L THE SYSTFM IN RCCOF.'D¢~NCE HITH THE CODES. 3:: I UNDERSTI~F,tD THFIT THE ON-SITE SEI.4ER SYSTEM MFIY REQUIRE ENLARGEMENT IF THE RES I [:,ENCE I S F.:EMGDELE[:, TEl I NCLLIE:,E MGF.:E THRN 2.': BEEs, ROOMS. ' !PIE I.,IENG"t-H I)]t"IENS]O/~ i5 THE L£NGTH (]N FEET) OF THE Ir,~iNr_;H OR: IDRRINFIELD,. jh~ [~EPIH OF R l~..£NC:H OF~ [--'IT ]$ 7H[ J~IE.'TRNC;E ~E'IHIEEN 'THE SLIRFFI[:.'E OF THE )klE~.E. ]g NCJ 5ET H.I:D'[H FO~ :l~ O~:R~EL I)EP'JH )E. IHF; MINIMUM DEPIH OF GRRVEL BE'IHEEN THE rJJJTFRLL PiPE It/I) ~'{%Z E. OTTOM OF '/HE £XCRVRTZON (IN FEET). THE NELL N]LL ~RVE. NELL OChre'LET] ON. RE~LII~NT5 ~' RPPLV. ~EC:IF3C;R~IONE. ~ND CC~-JSIRUOT]ON ~]RGRRM5 RRE :: LRDL[ TO JN~URE PROPER ]NE, TRLLRTZ~. O & E ENC.NEERING & DEVELO, MENT Box 90, Davis St,, Eagle River, Alaska 99577 694-2?74 or 688-2280 CO. Russell Oyster 694-2774 SOIL Performed for: Name:~ ~ ~ t~it- ~: /~/tL~-'~' ~ M ailingAddress: /:- E ,/~ ~., Legal Description: ~,,.~ ~/ ~: ~ 4 X~;'~7 Depth (feel) Earl Elli~ 688-2280 10__ 11 12 13__ 14____ 15__ Soil Characteristics PLOT PLAN PERC. '['EST 16__ Ground Water Encountered: Yes f No Proposed Installation: Seepage Pit Comments: If yes, what depth__ Drain Field Parcel I.D. # 1. 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 GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent L o ~' ~",. Day phone _~-~-~ - ~/'~ O Day phone Address SZ, Sc "c" s,g.-,.,jl Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 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. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA~21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. NameofFirm ~'"-~o~.e.~l ~lmtJ¢~',-Np.~ I~,~.~ Phone ~¢¢--7~'- $c~//¢ Address ~0~ ~ 1~-~ ~ Zo~ Engineer's signature Date DHHS SIGNATURE {,'"" Approved for "~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA ~21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division ,,~,,,..,,~.,~,~,,.r 825 L Street, Room 502 · Anchorage, A aska 99501 · (907}'343-4744 Legal Description: A. WELL DATA Well type. Log present (Y/N) Total depth Sanitary seal (Y/N) Health Authority Approval Checklist L. oT ~, ~)V,,~, ~ ~'~,OOI,~,'f,-P~F4, Parcel I.D.: If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to '7/= ' FROM WELL LOG Date of test IO/2~/~ ~' Static water level u~O ( Well production t~.~'- g.p.m. WATER SAMPLE RESULTS: Coliform ~) Nitrate Date of sample: O ff/,;Lc~/~ ~' B. SEPTIC/HOLDING TANK DATA Date installed ~c~/~ [p~n~ Tanksize Ioc~:~ Foundation cleanout (Y/N) Date of Pumping ~/~ 1~'/~ ?/ C~ ABSORPTION FIELD DATA Date installed ~ ,;2._ Length ~ '7 / Width Effective absorption area Date of adequacy test _O ~/,,t. ~/ Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Collected by: Other bacteria Number of Compartments Depression (Y/N) I~ High water alarm (Y/N). _Pumper C~-o O~ ~v~ Jrt,,,- ~-/ _ Soil rating (g.p.d./fF or fF/bdrm) Gravel thickness below pipe Monitoring Tube present (Y/N) y Results (Pass/Fail) Fluid depth in absorption field before test (in.); Fluid depth ~-~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) ~"~\ g.p.m. __ Cleanouts (Y/N) ? _ iP.~, System type /4' r Total depth _ Depression over field (Y/N) ~'~ For _ ~ bedrooms Immediately after ~1~) gal. water added (in.): L/~o _ Absorption rate = '~ ;~-~ g.p.d. If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION //_~ Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: ~ ,,q-5 ~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~ ~ Property line ~") I C) Water main/service line ) ~t~ Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~ / C) Surface water t,.t [ o Curtain drain ~-,.t On adjacent lots On adjacent lots Public sewer manhole/cleanout r//^ Absorption field ~-O Wells on adjacent lots Building foundation ~ O ~r Water main/service line )~..5 Driveway, parking/vehicle storage area ~0 '/' Wells on adjacent lots ~) ~ ~ ENGINEER'S CERTIFICATION --'~ .%%%.~., / c¢Ri~ that/have dete~ined thru field inspec¢ons and reWew of Municipal rec~¢,'i~a~ ~"~'oVe;~¢~s are in confo~ance with MOA H~ guidelines in effect on this date. ¢ ...... ,:. ·. ~ HAA Fee $ ' Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 0CT-02-1998 14: i~ CTg~E E'SI AHCHLqRAGE ~ CT&E Environmental ~ervices Irlcl F', ~?J2.,' L~G CT&E ReL# Client Name Project Name/# Client Sainple ID Matrix 985371003 Tobben Spurldand P,E, 4/4 Mountain Valley Drinking Water Client PO# PHnted Date/Time 10/02/98 09:58 Collected Date/Time 09/2.9/98 13:20 Received Date/Time 09/29/98 16:55 Teehifical Director; Stephen C. Ede Ordered By PW$ID 0 Released Sample P, enlazks: Nitrsre-N 0.553 0.100 mg/L GPA 300.0 10 max ()9/30/~8 09130/98 6CP MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P,O, Box196650 Anchorage, Alaska 99519-6650 343~4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 5'/~"') - (n~z-)/ - ~°1 1. GENERAL. INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA ~21 s~,uecucuoo leUO!i!PPV :suo!~elnd!~s 6u!~OllOJ eq~ HU~ 's~uooJpeq 'swooJpeq Joj leAoJddB leUO{Upuoo 'pe^oJddeslQ .Joj pe^oJddv//~ ;{BnJ. VN!DIS SHHO 'g · uop, oedsu! s!q)` jo e)`ep eq~ ua loajle u! SUOl)`Bln6aJ pue 'seoueulP~O 'sepoo ale{S pue led!OlunR lie qUM eoue!ldUUOa u! s! LUe~S/,S lesodslp Je]et~e~seM Jo/pue Xlddns Je~e~ aUs-uo eql 'uo!),o@dsu! pub UOl)`e~se^u! Xcu uuo~j pue SellJ eDBJoqouv lo XUledlo!UnlAI eq~ uJoJj paule)`qo UOl)`euujoju! eq~, ua peseq ~eq)` XjHe^ JeqM nj I 'uleJeq paleolpu! eJn),onJ~s to edX~, pue su~ooJpaq to jaqcunu aq{ ~oj e)`Bnbepe pue I~UO!)`ounj 'ales s! uJe~,sXs lesods!p Ja)`e~e)`se~ Jo/pue Xlddns ~e{B~ eus-uo au)` )`eq~, sMoqs uo!{ea!ldde leAoJddv X~lJoqlnv q~,le@H slq)` lo UOl),e6p, se^u! ~uu ),eLI), ~JlJeA { '~oleq u~oqs e)`Bp uop, BPIIB^ au)` Jo SB pub ole~eq pexujB IBeS ~cu ~q paIIIMeO sv I:I:i=INIC'JN~ AB NOI.LO=IdSNI .dO .LN=HN=~J.V.L$ Legal Description: A. Well Data Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST J4,f.4x~4.4.'TA-/AJ /,///F~,~-'¢-'¢ ~;~' Parcel I.D. If A, B. or C, attach ADEC letter. ADEC water system number Date completed l o/7~.~/Z~,-z_-. Driller ~,'y~-~.~v/ ~/4¢ Cased to '? ~'* Casing height ~' Wires properly protected (Y/N) /t~ Well type _P~ b'/h'-'~ Log present (Y/N) Total depth Sanitary seal (Y/N) FROM WELL LOG AT INSPECTION 4-c) y ~ / d~//Z,~- g,p.m. ;~, E.r/, Date of test Static water level Well flow Pump level1 g.p.m. ell2- SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot I Public sewer main / Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank /~© 7"- WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed Io/j~. Cleanouts (Y/N) High water alarm (Y/N) Nitrate ~, ~-~ Other bacteria Collected by: ~) D Date of pumping Tank size I ,o¢2¢.~ Foundation cleanout (Y/N) ~' /~',,~/~ Alarm tested (Y/N) ~ ~ Pumper ~7/'7, '~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Compartments Depression (Y/N) Well(s) on lot To property line '~ Surface water/drainage 72-026 (3/93)* Front On adjacent lots Absorption field Foundation Water main/service line 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) Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed 1 o//~// Length .~'~ Width Total absOrption area Date of adequacy test 7/ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/Ft2) / ~- ~ ~/,~/7__ System type -I'-¢---~ ~ Gravel thickness d'~ Total depth Cleanout present (Y/N) ~r Depression over field (Y/N) Results (pass/fail) /¢/~ ~' for -~ Bedrooms After test If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain ./~o On adjacent lots 1 o ¢~ --~- Property line ~ To existing or abandoned system on lot Cutbank ,'~/.,)~'~- Water main/service line Driveway, parking/vehicle storage area ~-~-~"~"'- E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA gu/de.es in effect on the date of this inspection. David R. Dayton P.E. 20210 Donalar St. Chugiak, Alaska 99567 Signature .~ ~ ~ Engineer's Name /~/~'~7 t7 HAA Fee $ Date of Payment 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number D, R. DAYTON, P.E,, R.L.S. ~]~xX~S7~ Chugiak, Alaska 99567 20210 Donalar (907) 696-2417 August 2, 1993 WELL FLOW TEST Legal Description: Lot 4, Block 4, Mountain Valley Estates, Addn Date of Test: July 29, 1993 Well Depth: 76' Static Water Level: 58.7 feet Driller: Syren Bros. Requirements: 3 BR - 450 gallons/day Test: The well was tested with the existing pump through an outside hose bib. The well was pumped at varying rates to determine the rate at which the water level would remain constant. Results: The well produced 474 gallons in 160 minutes at an average rate of 2.96 gallons per minute. The flow rate at which the water level would remain constant was 3.6 gallons per minute. Maximum drawdown during the test was 15.6 ft. The water level recovered 14.3 ft of the drawdown within 40 minutes. The well is currently producing adequately for a 3 bedroom home. D. R. DAYTON, P.E., R.L.S. ~xX~J~x"~7~ Chugiak, Alaska 99567 20210 Donalar 696-2417 August 2, 1993 ADEQUACY TEST Legal Description: Lot 4, Block 4, Mountain Valley Estates , Addn ~1 Date of Test: July 29, 1993 Septic Tank: 1, 000 gallon, 2 compartment, steel tamk Absorption System: 47' x 2.2' x 4' trench Soils Rating: 125 sq. ft./BR Requirements: 3 BR - 450 gallons/day (DHHS Records) (DHHS Records) (DHHS Records) Test: Water was pumped into the trench while measuring volume, time and liquid level in the trench. After pumping was stopped, the liquid level drop was measured at timed intervals. The results were plotted on a graph of time and volume absorbed and extrapolated to 24 hrs. Results: The absorption system is currently functioning adequately for a 3 bedroom home. ENVIRONMENTAL LABORATORY SERVICES 5033 B STREET ANCHORAGE, AK 99518 TEL: (907) 562-2343 FAX: (907) 561-5301 N:ii::r.'&"C¢, -lq 0.9:] il!~/l'~ [':PA ?,5!} o 2/:!i00,0 :].0 0'I/?,') !' Member of the SGS Group (Soci6t6 G6nCrale de Surveillance) ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA APPLIC NT FILLS OUT UPPER HAl - ONLY Buyer Address Lending Institution Address Realty Co. & Agent Address Phone Zip Code ~hone Legal Description .a/ ~I "~/'- ~/ ~Street Location ,/~/'7¢ Type of Residence E~f~S[i~le Family E] Multiple Family No. of Bedrooms. '~"; [] Other Water Supply t:::- -/A · ra E3.~lCc~ivldual ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. E] Community For wells drilled prior to that date, give well depth (attach Icg if available). [] Public Utility Sewer Disposal [] Public Utility [] 14olding Tank Year Individual Installed: __ When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PBOCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: MUNIciPALiTy OF ANCHORAGE /-%Pf, OF H~/\LfH 8, ~NVIRc,)NMRN'£AL PROTECTION RECEIVED ( ,.'),..}.APPROVED BEDROOMS 'CONDITIONS OF A?PROV/AL // ( ) CONDITIONAL APPROVAL* ~ing _/ I o.,e ~wor Installed APPLI( NT FILLS OUT UPPER HA' 'ONLY P'opetty Owner t,'~/il~/?4 lml (2 ~ 6) ~ IJL] I ~ t: I '~ t~,~ ~ , /~ I~. Phone Mailing Addre~ /~Pi'~ ~:?,/~ / ~/(/~ ~'t - ,~ Z:" Zip Code Buyer ~ .4 ~. / Address Zip Code Lending Institution / i o -ti [' /: ~.'/:) (::'.?~/L ':,,~}~.U(: ~ '~ ~ ( /) Z/ Phone ? )Z "/~/2[ Address ~'~ ~" ~2- :~7'~ Zip Code Realty Co. & A~nt Phone Address ~/ ~:~ A~ F: " Zip Code Type of Resi~nce  $1n91o Family / ' Multiple Family No. of Bedroo~ ~ Other Water Supply  Individual ~ ~')~ ATTACH WELL LOG. A w~l log is required for all wells drilled since June 1975, Community /~t:. ~ ,~.~ F . For wells drilled prior to that date, give well depth (attach log if available), Public Utility Sewer Disposal ~. Individual ~ ~ 'l ~ ~ Year Individual Installed: .~'~ ~ ~ Public Utility ~ L~-~ ) ~)- ) ~ '~ ~ When Connected Io Public Utilily: ~ Holding Tank NOTE: THE INSPECT~FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Ti~e~:"~; -~:~-' Time , /' Time / Date Date Date \ / ,-'-% Date \/ Inspector Inspector ~r-~ Inspecto~ Insp~to~ Field Notes: [~' z') ~ICI~A~I~ ~ ~ CNVlR()i4f~,;:h, A.; ,,0, ECTION - i.: 0V 1 6 1982 ~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) CONDITIONAL APPROVAL" - Soils Rating Date ~wer Inslalled Well To Absorption Area Well Log Received /P -- :~ '~_ . Well to Tank Septic T~k Size /OO (~ 72.023 (3182)