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Home My WebLink AboutHUNDRED HILLS BLK 2 LT 1 oGRE?- .R ANCHORAGE AREA Bor qGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATIONX. ~-~ ~AC, L* r~,;~ LEGAL DESCRIPTION SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH LIL MANUFACTURER INSIDE WIDTH NUMBER OF MATERIAL CT'~L. COMPARTMENTS ~- LIQUID DEPTH __ ,LIQUID CAPACITY 1000 GALLONS, SEEPAGE PIT: NUMBER OF PITS I . LINING MATERIAL L BUILDING FOUNDATION DIAMETER ~"-~1 OR WIDTH ~', LENGTH ~, DEPTH ~! CRIB SIZE: DIAMETER DEPTH ~ DISTANCE FROM: WELL NEAREST LOT LINE ~--~-- ~ TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ~('/J~ SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE BUILDING FOUNDATION __ CESSPOOL APPROVED CONSTRUCTION NEAREST LOT LINE OTHER 5OU RCE5 DISAPPROVED DISTANCES: DEPTH DISTANCE FROM: NEAREST SEPTIC SEEPAGE SEWER LINE TANK SYSTEM REMARKS DIAGRAM Of SYSTEM INSTALLED BY: PiPe MATERIAl · ~<~c- I~Ord LOT SLOPE: REMARKS: DATE // G.A.A.B. GREATer ANChOraGE ArEa Borough DEPARTMENT OP ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-456! SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT PERMit NO. INSTALLATION LOCATION 'EGAL DESCRIPT,ON /r /j INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH SOIL TEST RESULTS ~(4~'~ COMPLETION DATE ANTICIPATED MAILING ADDRESS . p/ SEEPAGE PIT ~ , DRAIN FIELD . , OTHER TO BE INSTALLED BY NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE /00-O ~ TYPE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE Pit SEPTIC TANK TO SEEPAGE PIt WALL- / SEPTIC TANK TO NEAREST LOT LINE. , SEEPAGE PIT ., DRAIN FIELD DRAIN FIELD WELL TO SEPTIC TANK / 0 0 r DRAIN FIELD WATER MAIN TO SEPTIC TANK DRAIN FIELD SEPTIC TANK, /DOS SEEPAGE PIT TO RIVER~ LAKE, STREAM. I SEEPAGE PIT //~ ALSO CONSIDER AREA WELLS. , SEEPAGE P~T /00' ., DRAIN FIELD C~AST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP Of EXCAVATION 5 FEET INTO UNDISTURBED SOIIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. DIAGRAM OF SYSTEM GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. I CERTIFY THAT I AM FAMILIAR VVITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. GRINDER AND SON DRILLING 6931Eo lOth. Ave Anch. Ak. 99504 Ph. 333-7701 For W. & M. Johnston Date started April 25 1975 Ftc Well log Depth and Information ?.EcEIVI D' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES. Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot Ii B~ock 2i HundrcdlHills Location (site address or directions) Property owner Mailing address Lending agency Mi~ c~p~a~ly Day phone C/0 R~max Eag'l¢ River Attn: Eva Loken 16600 Cent~rfield Drive Eagle River, AK Day phone Mailing address Agent Eva Loken/ REMAX EAGLE RIVER Day phone 694-4200 Address 16600 Ccnterfi~ld Drive Eaqle River, AK 99577 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well xxx 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 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~ion. Phone ~' ~" Name of Firm ~ ~ $Ne~.2 ENGINEERING Address 17034 Ea~le River Loop Road J ~ EngineeYs signature Date / ~ . //~/~ ~ ~-~ ..~' DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: By: 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 DH HS 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, I/91) Back MOA~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~--~ -c ~ ~"~.Y-- 'Z.- ~,3~--~ F~,~,5 Parcel I.D. A. Well Data Well type Log present ~1) ,-~ Total depth Sanitary seal(~N) If A, B, or C, attach ADEC letter. ADEC water system number ~'~l~. Date completed z'¥~-'~"'-"'75" Driller ~--~f~,.~c,~.~ ~ 5-~ Cased to ~/~ ~ ~' Casing height l~*~ Wires properly protected {~q) '~/ FROM WELL LOG AT INSPECTION Date of test ~.~,,3.5"-- 75'- ~ ~) ~ ~ ~ z/L Static water level ~--{ ~ ~ ~2, / Well flow ~--. C) ~/~.g.p.m. ~L~, Pump level1 ~ ( ~ SEPARATION DISTANCES FROM WELL TO: ~ Septic/holding tank on lot \ ~ ~ ; On adjacent lots Absorption field on lot Public sewer main Sewer service line ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: (/~.~ Coliform ~:) Nitrate Date of sample: ~ ~. ~ Other bacteria Collected by: ~ '~ '~ ~-~,~G/,,(E.~._?--/~ B. SEPTIC/HOLDING TANK DATA Date installed ~'~ -- 7 '~ Cleanouts~l) ~ High water alarm (Y~ Date of pumping size /~)o ~ "" .... Compartments Foundation cleanout (Y~j) /J ~-Depressio. n ~. Alarm tested (Y/N) ~5 ~ ~ Pumper ~. Well(s) on lot To property line /o Surface water/drainage SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: /o~ ! ~' On adjacent lots Absorption field Foundation Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at ~t High water alarm level .C~ted Meets MOA electrical codes (Y/N) SEPARATION DISTA~,E-FR~M LIFT STATION TO: WelT~on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed 5"--- ~ - 7~/ .-,' Soil rating (GPD/Ft2) Length / ~, r ~Width /3 t Gravel thickness TOtal absorption area ~ ~ Cleanout present ~N) Date of adequacy test ~) _ ~ ~ x.// Results ~fail) Water level in absorption field before test ~-'//'" Peroxide treatment (past 12 months) (Y~) //7~' '~/Z~',z- . System type ~, ' ~ Total depth Depression over field (Y~) for After test If yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots ~ ~ 4-- Surface water Curtain drain On adjacent lots /¢O ~ ,u Property line To exi.sting or abandoned system on lot Cutbank/~//,4.~ Water main/service line Driveway, parking/vehicle storage area 5"~<3 E. ENGINEER'S CERTIFICATION Signature ~ o ........... .~../_ / /,v,~ " HAA Fee $ ~-~. Date of Payment Receipt Number 72-026(3/93)* Back Waiver Fee $ Date of Payment Receipt Number Commercial Testing & Engineering Co. Environmental Laboratory Services ~,a~,a~T. er~-j~'J~'~eaJrJJ~'~'~ LABORATORY ANALYSIS REPORT CT&E Rel:# 94,3954-1 Client Sample ID LOT 1 DLK 2 HUNDRED I.'III,L$ Matrix WA TEll, CticntName S & 8 ENGINEEPd.I, IO WORK Order gl 032 Prkntcd Date 05/08/94 r~ 13:41 In's, Ordered By RJS Collected l~ate 08/04/94 ;,~! 10:00 hfs, ProjectNam~ ReccivcdD~¢e 08/04/94 Q~ 14 00 hrs. Project# PWSID JlA 'lbc.~ ~ cai Directcr STEFI'I~N Cl. EDE l~.eleased By:_..~~ ~~ Nitrate-N Qc Ailv~able Ext, Anal Mcthc, d Limits Date Date l.tdt }L¢$lllt,q Q~ UnRs ......... o,2o ¢2¢' ......... 7~/f: ...... ~XS~3Z~7¢7 ........ i6 .............. ~7o~/,74- ms ..... JlA =Unavailable * S~ Special Iltstmctions Above NA =Not A¢.alyzed ** S¢¢ Sample R~rk s Ahoy ~ U = Un&t~t~4 R~o aed wh~ is thc practical qmntification limit, l/I'~ L~s~ ]baa D = 8~on ary c~l~ion, o~= Oearer'~ 5633 B Street, Anchorage, AK 9951 8-16~ -- Tel: {907) 662-2343 ~ax. (907) 561-5301 ...... Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Location (address or directions) (b) Property Owner - '~,;,~v,',J L,/~.~/..~¥ Telephone: Home ~_~t/. ry'~.r.,-~ Business Mailing Address (c) Lending Institution [,-,o~r,.~, 5~,.t -. )~-4/,~7-7'4.~7~'~-'' Telephone Mailing Address (d) (e) Real Estate Company. and Agent Telephone Mail the HAA to the followina address: or: Cheek here ~hold for pick up. List con~a~,t~[~r~NaEq~iYGPhone number below. 17034 Eagle River Loop Road Na. 204 Eagle River, Alaska 99577 TYPE OF RESIDENCE Single-Family ~ Number of Bedrooms WATER SUPPLY Individual Well [~'"Community [] Public [] Note: If community well system, must have written confirmation from the State Departmeni 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 I of 2 72-025 ~Rev 8/86~ 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 flies 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 S & $ ENGINEERING Address 17C=4 ~.---;!--. R!~-~'- L-~'~-~ Date Eagle River~ Alaska ~)9577 Telephone DHHS APPROVAL Approved for ~bedrooms by Approved ('~ Disapproved Terms of Conditional Approval Conditional CAUTION 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. Page 2 of 2 72-025 fRev 8/861 Back MUNJCJPALJ'[¥ OF EN¥~RON~EJ~'T^L SE~VtCF. S D~ItI~I~IPALITY OF ANCHOEAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) APR 2 CHECKLIST- FEBRUARY 1984 264-4720 RECEIVED Leg~, Description: WELL DATA Well Classification Well Log Present(~) Total Depth ~,.~ Static Water Level Cased to Casing Height Above Ground Electrical Wiring in Conduit~(~'N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot If A, B, C, D.E.C. Approved (Y/N) .A~'/,~ Date Completed ~/1~/ ?.~ Yield f_..P. 5' ~P/',// '-~ Depth of Grouting Pump Set At (--~' ~, Sanitary Seal on Casing ~/N) Depression Around Wellhead (Y~) ; On Adjoining Lots /ot~/+ ; On Adjoining Lots To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments To Nearest Public Sewer ~j3, ,-- To Nearest Sewer Service Line on Lot -~-~/¥- B. SEPTIC/HOLDING TANK DATA Date Installed <~/~/ ?C,/ Standpipes ~N) Air-tight Caps~N) Depression over Tank (Yt~ Pumping/Maintenance Contract on File (Y/,~/,,~ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: Size /~ No. of Compartments Foundation Cleanout (Y.~ Date Last Pumped z/// '~'[A ;for Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line To Water Main/Service Line Course To Building Foundation To Disposal Field /~r" To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~"/~'/ Width of Field /~ Square Feet of Absorption Area Depression over Field (Y/~I~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation -~' Lot- ' ] r~ ~/ 4/~//~.. TYpe of System Design -~''~-~)~t'~'~ Length of Field /~' "'--- Depth of Field /'t'>/ Gravel Bed Thickness L~/ ./L .~ ~t~ ~ Standpipes Present ~/N) Date of Last Adequacy Test To Water Main/Service Line t'O 1.4 To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line ~---~- To Existing or Abandoned System on ;On Adjoining Lots ~'ol '~ To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test, Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all M~)A and I~AA guidelines in effect on the date of this inspection. ! Signed . . c c.NG!H"~_R!ta~. Date t'//"Z ~/~ ~ ~~__~_ Company 27~agle Ri~ L~ R~d ~O~o./~ ~J~ ~ ; ~ ~"~'**',, ~*¢ ~,~ Receipt No. ~ ~ 0 / -- 0 0 ~ 3 ~, ,;¢ .~., , ,- Date of Payment ~ --~7-- ~ ~ ~ ~~'~ Page 2 of 2 ~~ 72-026 (11/84) CHEMICAL & GEOLOGICAL LABORATORIES OF AlASKA, INC. Client PO# : VERBAL Req #: Client Smpl ID: LIB2 ~NDREB HILLS S/D 4-16-87/0450 Lab Smpl I0 : 59801 Matrix:Water Sample Rec'd : APR 17 87 REPORTS ADDRESS #1 S & S ENGINEERING 17034 EAGLE RIVER LOOP RD., #204 EAGLE RIVER, AK. 9957? . Date Report Printed: APR 22 87 @ 13:40 Client Account : SNSENGP Invoice No. : 41 Released By REPORTS ADDRESS #2 S & S ENGINEERING 17034 EAGLE RIVER LOOP RD., #204 EAGLE RIVER, AK. 99577 Special SAMPLED BY JDM Instruct: Detection Allowable Parameter Tested Result Units Method Limits Limits TOTAL COLIFORM 0 col/lOOml ~-~ Sample Remarks: 1 Tests Performed * See Special Instructions Above N/D= None Detected ** See Sample Remarks Above Date Date Date Inspector Inspector Inspector Comments Conditional Approval MUNICIDALIT¥ OF ANCHORAGE DF~T C':,. R.ECEI ! B Date Sewer Installed Permit No. Septic Tank Si~e ,..~-_ .~ ¢ Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property Owner iirv:Ln F. M~{rt:Ln Phone SR#2, Box 9373, Eagle River, AK 99577 ,94-9208 Mailing Address Buyer JO_lln F. Lasley PSC2, General Delivery, Elmen~or~ AFB, AK 99506 Address Lending Institution Ke, ln3. er Mortgage (Jo. (.{-;ilrtdy) Phone P. O. Box 1200, Anchorage, AK 99510 .~79-0665 Address Realty Co. & Agent Commonwealth ARHA, Inc., Myrna Johnston , Phone P. O. :Box 249, :Eagle River, AM 99577 594-9555 Address tegalDescription Hundred Hills Subd, Blk 2, Lot 1 NHN Hiland Rd (Mile 7.5) Street Location Type. pf Residence .~ Single Family 2 [] Multiple Family No. of Bedrooms [] Other Wat%r Supply ~ Individual A'II'ACH WELL LOG. A well Icg is required for all wells drilled since June [] Community 1975. For wells drilled prior to that date, give well depth (attach icg if [] Public Utility available.l Sewa~le Disposal T3 Individual Year Individual Installed: 1974..,, >. [] Publio Utility When Conneoted to Public Utility: ~'~1 [] Holding Tank NOTE: THE INSPEOTION FEE MUST AOOOMPAN¥ EACH REQUEST BEFORE PROOESSING CAN BE INITIATED. EXCAVATION ROBERT A. SHAFER WORK CIVIL ENGINEER 694-2979 September 27, 1982 ~MUNICIPALITY OF ANCHORAGE DFPL 0~ !!p',l.T'~ ~, ENVI~ .,'J~~!j:'/',. ! :0 [: : ~ Area Commonwealth Realty ATTENTION: Myrna Johnston P.O. Box 249 Eagle River, Alaska 99577 Dear Myrna, Reference: Lot 1; Block 2; Hundred Hill Subdivision A sewer system adequacy test was performed on the system located on the referenced property as you requested. The septic tank was pumped and verified to have a capacity of 1000 gallons. The seepage pit was charged with 500 gallons of water and after a period of 24 hours all the water which had been added to the crib had percolated out. It can be concluded from this test that the waste water disposal system serving the two bedroom home located on this property is currently functioning~dequately. However, the system cannot be guaranteed against subsequent failures, If we may be of further service, to call. //~O/B ERT A. SHA~/TR, P.E. ~s/ss please do not hesitate cc: Municipality of Anchorage Department of Health and Environmental Protection SRB 19i~X EAGLE RIVER, ALASKA MUNICIPALITY OF ANCHORAGE NtUNICIPAUTY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF I i~!ALTit & 825 L Street - Anchorage, Alaska 995~I' ENVIRONMENI'/~L P,' ) £ZCTIOf'4 ENVIRONMENTAL ENGINEERING DIVlSI--%O~I FEB 1.. 1979 Telephone 264-4720 ,,.,..OVA. A.,. B6 D DIRECTIONS: CompLete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE William E. Johnston 694-9766 MAILING ADDRESS P. O. Box 334, Eagle River, AK 99577 PROPERTY RESIDENT (If different from above) PHONE Vacant -0- 2. BUYER PHONE Richard R. Johnson 862-7111 MAI LING ADDRESS P. O. Box B5-493, Ft. Richardson, Alaska 99505 3. LENDING INSTITUTION I PHONE Spokane MortqaqeI 27~-0543 MAILING ADDRESS 3201 "C" Street, Suite 250', Anchoraqe, AK 99503 4. REALTOR/AGENT I PHONE Myrna Johnston, AREA, Inc. RealtorsI 694-9555 MAILING ADDRESS P. O. Box 249,. E~q~e R~ve~, AK 99577 B. LEGAL DESCR,PTION Hundred Hills Subdivision Lot 1, Block 2 /~/~ ~ STR E ET LOCATI ON Hiland Road Mile 8.5, Eagle River 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One [] Four ~ SINGLE FAMILY ~ Two [] Five [] MULTIPLE FAMILY --] Three [] Six [] Other 7. WATER SUPPLY Drilled April 1975 ~ INDIVIDUAL* 5 3 feet * 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.) 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY **If individual/on-site, give installation date 1974 If system is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE I NSP ECTOR 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 [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY ~-~_ ") ~ Connection Verified INSTALLER [~Septic Tank or [] Holding Tank '~ , ~:~.~/0 o Size: /~ ~ O If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER Absorption Area to nearest Lot Line 5. COMMENTS [~-iAPPROV ED FOR ~._ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY ~ LEGAL DESCRIPTION 72-010 (Rev. 3/78)