HomeMy WebLinkAboutKNIK HEIGHTS BLK A LT 7Name
Secnon
~ SEPTIC
~} HOLDING
~n gallons
TYPF F~_~TEM
[] TRENCH ~ BED~ --
~ [] W. DRAIN [~ OTHER
orlgJdaJ grade depth from origina~ grade
g
depth beneath P~pe
absorphon area ~ /
Jines
WELLS
MUNICIPALITY OF ANCHORAGE
DE~ ~.RTMENT OF HEALTH AND HUMAN SER~.~ES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, TelephOne 264-4720 ~) / '7 ~) ~ ~' O 7
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
DISTANCES
~,~,~,~ ¢ SEPTIC ABSOI]P'
FIELD WELL
LOT LINE
~ FOUNOATION ~
TANKS . e~c) location ol wen. septic system, proper~y hnes, tounda~
[] OTHER (Identify)
nspectJons Performed by:
Date:
certify thai Ibis inspection was Peflormed according lo afl
Date: ~~ /
Hearth Department Approv~
72-013 (3/85)
ENGINEER'S SEAL
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
~ Township, Range, Section: '7~'~./J ,~_~J
1 OL-
2
4
5
6
7
8
9
10-
11
12
13
14-
15-
16-
17-
18-
19-
20-
SLOPE SITE PLAN .
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH;' p
E
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATJ ON RATE
TEST RUN BETWEEN
COMMENTS ,~e/4. ~?~;r~'~ ~,~.~" ~"O~'/.i~.~.~,~ Fff-4'~
¢~'~ [minutes/inch) PERC HOLE DIAMETER __
~' ~" FT AND ~ FT
PERFORMED BY: ~"~"'~'~ ~'" d/'~'/*J I ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE: OP'~- ~{r ~
, 5 .. 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
:, P H O'~ I ,~NEW
LEGAL DESCRIPTION
LOCATION - '~ -~ NO. OF BEDROOMS
J Well Absorption area Dwelling PERMIT NO,
DISTANCE TO: ~ '~
~ ~ ~ ~ Manufacturer ~ ~ Material ~ ~ ~ N°' of compartments
~ Liq. capacityingallons, .~.~,. ,- ', IF HOME,DE:. Insidelength '~ I~ Width ~ i i-~ Liquiddepth J~
~_~0 Z ~ Manufacturer~ ~ /~ Material Liquid capacity in gallons
a Well Foundation Nearest lot line PERMIT NO
~ DISTANCE TO: ~ ~ ~ ~ ~._~ ~j~,~.) ~
~ ~ ~ No. of lines Length of each line~ Total length of lines Trench width Distance between lines
~ ~ Top of tile to finish grade L'[~ I (.}. il Material beneath tile ~D(~ inches Total effective absorptions{area
~ Length ~'~ ~rb~a~idth Depth PERMIT NO.
~ ~ Type of crib i meter Crib depth Total effective absorption area
~ Well ' Building foundation Nearest lot line
~ DISTANCE TO:
~ DISTANOE TO: BuildM~ foundation ~ewer line 8eptio tank Absorption area(s)
OTHER ~0~ T~ ~
PIPE
MATERIALS
SOl L TEST RATING (:, z'~~ ~ % r
INSTALLER ~,
REMARKS
AP~bVE~ /~ DATE LEGAL
72-013 (Rev. 3/781
L E! C R 'T' ! 0 H
H ]: N ~: HUH D i ::5-FRNC*!;~: ..t.::~=!!~::THk~:}!:ZN F:¢ HEL. L
:i..';='-IO FEET F'OI:;?. Fi F:'!;;:tVFFrE NELL..;
:!_~5E~ TO 2:g?;~i FEET FFi:OH !':I F'I. iE::L.t:E: HELL DEF:'iTiqI.>ZNEi LiF'O'N THE 'T'q'LF'"'F: OF .F'L!IT. iL. ZE: i.,.iEi.!
NELL LOGS ?:!F'.E ~:.;:~)]:!Ll]]~ikiJ.'> .F:!?4.(> ?~U'-:.?'}'
[)F' THE NELL
OTi"~EF: RE)5:!Li Z ,%~--':HENT'.'5 I"Ii:::i".," R?F't..q'L 5;F'k'C Z I:::'X CF!T Z[ ONS!; FIN[:' C:O,5~STRUCT :t .Oh! g' :JZ FiGRRi'"15 iqF::E
R',,,'R ! [._i::!DLE TO :i:i"~5UR:E F'Fi:OF*ER )1NSTFiLL.,.':::~T:(
j. T ,"~1' '"' !:::'f:iH :i: [.. ! FIR: h .................... T '1" - 'j"fqF · ......... '" "~ ............. i ~' ' ' ......'" .............
FOF:TH..=t",'" THE HUN:Ii
;~. T i,.~:[LI_ Z~'45;'TI::ILL '!"I.E 55'¢:STEhi 'r~.~ ,'",'"-.--,",-"~ ,' ....
- ..~,, fi,,. L .- ~.t. -~, .--t=. ['.~'-'f'J". . -r'~qi=.'- ?f"d'"H::"::......,,.........
..-: ......... · .... ~,,-
................... ~'-. ....... q'~ ~' ~ FH'qF~ ~'~; ..... ,-,?-, ~ ~, ..... ~ ..-'a"'-
CONSULTING GEOLOGIST
EIOX 476-N'1, STAR ROUTE A . ANCHORAGe., ALASKA 99507 ~, PHONf{ 344-707!
SOILS LOG
Location ~1 ~ ~ [00 t a ~ E ~ ~~ j
Soil Type Water Level
Remarks
0
2
4
6
8
~o
12
18
20
Coo
Total Depth of Excavation
Groundwater
~Not Reached
.Depth, if Reached
Classification Method
·/Visual
( ) Sieve Analysis
()
14
Material at Total Depth
Bedrock
~Not Reached
Depth, if Reached
Gary F. Player, Consul[ing Geologist
Well Owner ~J.m Yd. ller
Loc, it, ion (address o1: 'l'ow~hl~, l~.nge, S~"llon, if km~vnj or dtlt. l~ J ~ ' ~ .
S~tlc water lever t't. (~t~;,b) (below) la~t~l surface, Finish of well (check one) ope
S~r~n ( ); Perforated ( ).
D~crib~ s~l~n or perforetlon NIA
Well pumping t~st at ,~ gallo~ ~r '~'r) (minute) for 1 ~o~ of ~awdo~ from s~tfc le~l.
Date o¢ ~mpletlon ~/~ $
Depth la fcet from
ground surface
Giw details of formetlon~ penetrated, size of materl~l, color and JumineJ~
0 TO 2.
leo TO ZOO
2oo~.i,o 2o~3
Casini: s Cfck:,p
Si]tv gravel: cobbl~
.NWWA Ce~tlfl~l ~
M-W DRILLING,
Well Owner
Location
DRILLING LOG
(address of: Township, Range, Section, if known; or distance me
*.. )/ feet Cased to_ '
(below) land surface. Finish of well (c
).
Size of casing .Depth of Hole
Static water level ' "'~.~ fi Ob~-~)
Screen ( ); Perforated (
Describe screen or perforation
Well pumping test at * gallons per.~14'Sfl~) (minute) for
of drawdown from static level.
Date of completion
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of materia
___TO
: TO
~' r ~ TO.
: ~ TO. 2 i),
'(,:~ TC ~'~-.
TC
T£
Tfi
T£
T£
__T£
TO
TO
Use of Well "'~ ~ :r ~ ~
.n road
~et
eckone) open end ( ' );
th ~,~ ! 0';,, ,ft.
color and hardness
WA Crucified Contractor
~ie~c ho's, ~ & 973
2 -- STATE
~_._/ MUNICIPALITY OF ANCHORAGE ,, /
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
43/?~;3 ~_o~
Application Date
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, townshi
Location (address Oi' directions)
3, range)
(b)' ~,pplicant' Name', ~Y/ P'~/~f Telephone: Home ~,~¢5"- (,,6~ Bus.ness
' ' - ~' Ider~ r ~; Othe
, ,:: (c) A~ s he kPn E g:n fi wnedbu
plicanti (c c e): endin I s tution~; O i ; Buye rD (explain);
' ~"'"" '~ ".' ~ ~ ....-~ ~e,~o.e
~'. ( -~e.~i.~ ~ns~u~io. ~~ '
"'-.:: :::::,Address - ·" ~ ................ ., . .......
Mail the HAA to th
Note: if Community Well system must have Written C0nfirmation from the State Department of Envir°nmental c°nservati°n
.... attesting tothe legality and status. , ..... :*", ':i'7'7*''~'' : ...........
72-025 (11/84)
Page I of 2
ENGINEERING FIRM PROVIDING~ ~PECTIONS, TESTS, FILE SEARCH, DAT -../ND 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 inv'estigation 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
Address
Date
Telephone
6. DHEP APPROVAL . . .
The Mu~cipaiity of Anchorage Depa~ment of Health and Environmental Protection (DHEP) issues Health Authority /
Approval certificates based solely upon the re presentations given ~n paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a counesy to purchasers of homes and their lending
institutions in order to satisfy ce~ain federal and state requirements. Employees of DHEP do not conduct ins pections or
analyze da{a before a ce~ificate is issued. The Municipality of Anchorage is not responsible for errors or ommsions in the
professional engineer's work. -
Page 2 of 2
72-o25 111/84)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
Legal Description: ~.~7'"'~
Well Classification
Well Log Present
Total Depth ,;~..O~' Cased to
Static Water Level ~ /~.~,,~.
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
/'~///'~3''~' If A, B, C, D.E.C. Approved (Y/N)
Date Completed -'~": 5"~?,~' Yield
Depth of Grouting ,'~/~'
Pump Set At ~/~
Sanitary Seal on casing ~)N)
Depression Around Wellhead
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Line A//,,~ To Nearest Public Sewer
Cleanout/Manhole ~//,~ To Nearest Sewer Service Line on Lot
Water Sample Collected by ,~¢~' /~, /,~/Z~",,~' ; Date
Water Sample Test Results .,~..,~.~,.~r_~,~/
Comments (~ f/-/~/-&' /~J '77'"'~J'7'~ ?-570"~7
B. SEPTIC/HOLDING TANK DATA
Date Installed ~"~"'~"'?~" Size /~.-:~5'~ No. of Compartments
Standpipes~l) Air-tight Caps~N) Foundation Cleanout~)
Depression over Tank (Y~) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ~/~F ; for
Holding Tank High-Water Alarm (Y/N) ,4,)/~-- Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
!
To Water-Supply Well
To Prope~ty'L~ne~:~ -"
T.O ~water. Mai n/Ser~i~ine
..i'C0urse '
Comments.., '
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page:l 6f2.. i ,.;-'~ :~'"
72-026 (Rev 81861 Front
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
/
Width of Field
Square Feet of Absorption Area
Depression over Field (Y~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well //-~" /
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes PresentON)
Date of Last Adequacy Test
!
To Property Line
T~r Abandoned System on
; On Adjoining Lots
To Cutbank (if present) ,'~//~
/0
D. LIFT STATION
,ze,n
"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)
ring Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that l h,~/h~e~ v~fied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ ~' ~,~'z-~ Date ~" / ~ ~' ~'
Company ,/~5 MOA No.
Receipt No.
Date of Payment ¢~/-- ~ ~---,
Amount: $
Page 2 of 2
72-026 fRev 8/86~ Back
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~ --~
FEDERAL TAX ID # 92-0040440 ~
CHEMICAL & GEOLOGICAL LABORA~TORIES 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
PRIVATE WATER SYSTEM
Name ¢) Phone No.
Mailing Address
City State Zip Code
Mo. Day Year
SAMPLE TYPE:
~ Routine
[] Check Sample (for routine sample
with lab ref. no,
[] Special Purpose
.) [] Treated Water
~] Untreated Water
SAMPLE Time Collected
NO. LOCATION Collected By
~ I z-7 ~,~ '"'~;"¢ /¢¢¢' I /x~-. ~,~J
31
4 I I
S I
TO BE COMPLETED BY LABORATORY
Date Received
Time Received
Analytical Method:
Analysis shows this Water SAMPLE to be:
/~ Satisfactory
[] Unsatisfactory
[] Sample too long in transit; 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*
'2/=c-~1 i-71
I
I I-iq
I F~
Analyst
ox.G-
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE '
BACTERIOLOGICAL WATER ANALYSIS RECORD
Membrane Filter:. Direct Count
Verification: LTB
Final Membrane~_~sult~
Reported ~/~_~ ~
TNTC = Too Numberous To CoUnt
BOB
~aate
Time:
Coilformll00ml
Coilformll00ml
a.m.
OB -- Other Bacteria
APPLIC ' NT FILLS OUT UPPER HAl - ONLY
Property Owner ]:~
Mailing Address /,~/'/,/~.
Zip
Code
Lending Institution / ~ Phone
Address ~ Zip Code
Type of Resi~nce
Single Family
Multiple Family No. of Bedroo~ ~
~ Other
Water Supply
~lndividual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach log if available).
~ Public Utility
Sewer Disposal 7g
~ Individual Year Individual Installed:
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED,
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspsstor
Field Notes: ,~-- / ~-~_~ MUNICIPALITY OF ANCHORAQI::
/~ L..~ r'~f:~ I[NVIRONMENTAL PROTECTION
RECEIVED
( ) APPROVED BEDROOM8 *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL"
DATE
BY:
8oils Rating Date ~wer Inslalled Well To Absorption Area Well Log Received
Well to T~nk Septic T~k Size
72-023 (3182)
~. DA¥~2-/R ECEiV ED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR _
MUNICIPALITY OF ANCHONA~'
MUNICIPALITY OF ANCHORAGE DEPT. OF I!EALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROT~NMENTAL P:OTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION j 1981
Telephone 264-4720 R E C [ I V [ D
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND 8EWER FACILITIES
DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing.
1. PR ER Y qWN R
PROP~RT~ R~SlDENT (If different [rqm a~e) PHONE
" PHONE
MAILING ADDRESS I
MAILING ADDRESS ,__ ~ ~ /
., ,, /
' MAILI~ADDRESS .~ .~/ ~ ~ /
5. LE(~AL D~SCRIPTION
STR".Er ~o¢~,o~ · , /. ,~ O~
NUMBER OF~BED~MS
~ SINGLE FAMILY ~ OneTwo ~ Four ~ ' Five
~ MULTIPLE FAMILY ~ Three ~ Six
E~ Other
7. WATE~ ,SUPPLY
~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
*ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8' SEWA~E/'DISPOSA L SYSTEM INDIVIDUAL/ON-SITE**
.,~x. 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) r
/. / : ,' .~ ~ ~ -' ~ ~ - ,~ ~-':"~
THIS SIDE FOR OFFICIAL USE ONLY
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 REOEIVED
PERMIT NUMBER
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY (~-'~
Connection Verified INSTALLER
E~]Septic Ta_j:~ 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 I Nearest Lot Line
WELL TO:
I
I
Absorption Area to nearest Lot Line
5, COMMENT8
[]!;~/~PPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accoflpany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)
ANCHORAGE, ALA,~K~\ .~,:M0,
, 2t',,.4-.4111
(}E(}f/GE M. SUi LIV/k,~
July i0, 1981
Bob/Laura Smith
Star Route A Box 1691L
Anchorage, Alaska 99507
subject: Lot 7 Block A Knik Heights Subdivision
Approval for Lhe individual sewer' add water faci].ities
cannot be granted, until the following items have been
completed:
(1 The water analysis report needs to be submitted to
this office from the Chem Lab, 5633 B Street,
for our review.
The septic tank pumped wLth a receipt submitted to
_~ this offJ. ce,
If tner-~ are any further questions please call this office
at 264 --4"/20.
Sincerely,
Robert C. Pratt, R.S.
Associate Specialist
RCP/ljW
cc: Tansamer ica Tit ].e
· t
207 East Northern L~gn s Boulevard
99503
Potti/Betty
% Century 21 - Heritage Homes
207 East Northern Lights Boulevard
99503
,: MON]CIPALITY OF ANCHORAG[:
, MUNICIPALITY OF ANCHORAGE DEPT. OF ','
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC'r~,(~RONi;',ENT,~J_
~ 825 L Street - Anchorage, Alaska 99501
~ ENVIRONMENTAL ENGINEERING DIVISION ~ iX'~'
Telephone 264-4720 ......
)IRECTIO~S: Complete ~1 par:s on page ~. Incomplete requests will not be processed. Please allow ten (10) ~avs for processing.
~. PROPERTY OWNER PHONE
MAILIN~ ADDR~SS~ '
PROPERTY RESID~NT-(]f different from above) ' - PHONE
2. BUYER ~ PHONE
MAILING ADDRESS
3. LENDING INSTITUTION ~ PHONE
MAI LI NG~ADDR ESS
MAI LING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6, TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One [~ Four
[] Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available.) ~_~ ~ { ~
8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
**If individual/on-site, give installation date /9
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)
t._.-
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
I NSP ECTOR i NSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
: P 'R'G T 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 "Z).~
Connection Verified ., INSTALLER
[]Septic Tank or [] Holding Tank
Size:_/_~..~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSQRPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
WELL TO: /~,3
Absorption Area to nearest Lot Line
5, COMMENTS
~ ~iOsN~IpT;~EA~APPI~DVAL (letter must aEc°mpady certificate' ~' --~'//~
DATE BY (Title) / /
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
