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Home My WebLink AboutMCCABE LT 5Onsite File #018cm231 =m23 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program, 4700 South Bragaw St. A F T V P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Page 1 of 3 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: SWO30270 PID Number: 018-231-23 Name: KAREN FOGARTY Wastewater System: ❑ New ■ Upgrade Address: 13341 McCabe CIRCLE ABSORPTION FIELD Phone: No. of Bedrooms: (907) 345-7803 3 ❑Deep Trench []Shallow Trench ❑Bed ❑Mound ■ 5—WIDE LEGAL DESCRIPTION Soil Rating: 0.8 Total Depth from original grade: 10 MAX GPD/Sq. Ft. Ft. Block: Lot: Subdivision: Depth to pipe bottom from original grade: Grovel depth beneath pipe: — 5 McCabe 6 MAX Ft. 4 FI. Township: Range: Section: Fill added above original grade: Grovel length: - - - SEE DWG Ft. 60 Ft. WELL: Gravel width: 5 Number of lines: Distance between lines: — ElNew E]Upgrade Ft. 1 Ft. Classification (Private, A.B.C): Total De Cased To: Total absorption area: Pipe material: D 3034/ F-810 Fl. Fl. 600 SO. Ft. Driller: Date Drilled: Static Water Level: Installer: AKWWC INC. Dale installed: 8/1/03 Fl. Yield:Pump Set At: 7Cosingight Above Ground: TANK CPM Ft. Ft. SEPARATION DISTANCES ■ Septic ❑ Holding ❑ S.T.E.P. ❑ Other To Septic Absorption Lift Holding Public/Privote Manufacturer: ANCHORAGE TANK Capacity in gallons: 1000 From Tank Field Station Tank Sewer Lines Well 100'+ 100'+ - - 25'+ Material: STEEL Number of compartments: 2 Surface Water 100'+ 100'+ — — — LIFT STATION Size in gallons: Lot Line 5'+ 10'+ — — — :;�2� "Pump on" level at: "Pump off" at: High water alarm at: Foundation 5'+ 10'+ — — — Pump Make ode/; Electrical Inspections performed by: Curtain Drain NONE KNOWN BENCH MARK Remarks: Location and Description: OLD SEPTIC TANK WAS FILLED WITH DRAINROCK SILL OF GLASS SLIDING DOOR ON DECK Assumed Elevation: 100.00 Fl ENGINEER'S SEAL) 6QpQ00�� v�0 AKWWC, INC. 8/1/03 p 4 * Q Inspections performed by: Dates: 1st �•••••••••• ••••• •••••.•••••� 2nd 8/2/03 Q 3rd 8/2/03 QQO '• of y A. Garn ss..' Development Services Department Approval —795 �p9 e' 0��P i(� Date: ' �v Reviewed and approved by: a� o, t10` o '=7 OfeS510 p (Rev. 12/01) �40000�� PERMIT NUMBER: swO30270 AS—BUILT DRAWING EXISTING b • ..b •� �'� : t00' WEII RADIUS 1 y PARCEL ID NUMBER: 018-231-23 7- -1 FCO ---T-5547 1.5 ST1 63.9 12.1 ST2 69.4 17.8 DBLI 71.3 20.8 DBL2 72.7 22 FD 75.4 25 C01 92.5 43 MT1 86.3 37.2 CO2 62.7 53,8 MT2 66.1 55.7 CO3 97.6 44.8 MT3 97.2 44 C04 73.7 20.1 ADDITION NEW DRAINFIELD h / r C - ,CO2 C04 12 SM72 NEW 1000 GALLON Dgv Bt2 i i' SEPTIC TANK MTSi i T3 Coli. � THEA AI.ASFA WATER & WASTE'4�ATER CONSULTANTS, ENC, 3701 E. TUDOR ROAD. SUITE 101 . ANCHORAGE, AK 99507 - FHONE (907)337.6179 '. FAX (907)338-324 PREPARED FOR: PHONE NUMBER: KAREN FOGARTY (907) 345-7803 LEGAL DESCRIPTION: McCabe SUBDIVISION; LOT 5; TYPE OF WORK: L AS—BUILT DRAWING OF SEPTIC SYSTEM UPGRADE 10' UTILITY EASEMENT OLD DRAINFIELD s I 8/4/03 �`""(�F �4I IN NWN BY: B.S.G. O 1LE: 1 " = 40' ........ .. ..........:... ;E NUMBER: u 2 OF 3 fr A. G rness:' Q�s E-7953 mm`i DVQd rofessi000\ 40pOC�<Spcc� PERMIT NUMBER:/� AS _BUILT DRAWING R /� WIPARCEL ID NUMBER: SW030270 n n r�1VNG 018-231-23 ST1 TOP OF TANK AT INLET — 93.55 INVERT OF BUNG AT INLET — 92.9E ORIGINAL GRADE = 98.27 — 98.41 ZELATIVE ELEVATION AT BOTTOM OF TH 82.41 FINAL GRADE — 97.87 ST2 NEW 1000 GALLON SEPTIC TANK —TOP OF TANK AT OUTLET — 93.55 4" INSULATION INVERT OF BUNG AT OUTLET — 92.72 NAL GRADE = 99.16 — 99.22 TER FABRIC OF PIPE = 92.41 AVERAGE BOTTOM OF TRENCH = 88.41 AVERAGE j 8/4/03 .�!.A�*' f.•+ti. .d:�, ._:1. .. .^e r Z DRAWN BY: ALASKA WATER & WASTEWATER B.S.G. CONSULTANTS, INC. SCALE: 3701 E. TUDOR ROAD, SUITE 101 - ANCHORAGE, AK 99507 - PHONE (907)337.6179 - FAX (907)338-3246 N.T.S. PREPARED FOR: PHONE NUMBER: PAGE NUMBER: KAREN FOGARTY (907) 345-7803 3 OF 3 LEGAL DESCRIPTION: McCabe SUBDIVISION; LOT 5; TYPE OF WORK: PROFILE AS -BUILT DRAWING OF SEPTIC SYSTEM UPGRADE All; 1 'Filill IVA a(3,11d, = 7953 f'� a44Voo�c° 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: SW030270 Legal Description.:MCCABE LT 5' Design Engineer: 0041 AK Water & Wastewater Consultani Owner Name: Karen Fogarty Owner Address: 13341 McCabe East Circle Anchorage , AK 99516 - Date Issued: Jul 24, 2003 Expiration Date: Jul 23, 2004 Parcel ID: 018-231-23 Site Address: 013341 MC CABE CIR Lot Size: 51963 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: ❑✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy All construction must be in accordance with: 1. The attached approved design. ❑ Private Well ❑ Water Storage 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. Received By: Issued By: Date: ! 1 V� Date: 24 03 Municipality of Anchorage � s sail i'". y�e tel' Development Services Department Building Safety Division I' On -Site Water & Wastewater Program s A Y 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. 018-231-23 Permit Number 5'1,1030270 Property owner(s) KAREN FOGARTY Day phone 345-7803 Mailing address (1) 13341 McCABE EAST CIRCLE * ANCHORAGE. AK Mailing address (2) Zip Code 99516 Legal description (Lot, Block & Sub'd.) LOT 5. McCABE SUBDIVISION Legal description (Section, Township & Range) N/A Lot Size _5\ Acre /Sq.Ft. Number of Bedrooms 3 THIS APPLICATION IS FOR: Sewer Only ❑ Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade THIS PROPERTY CONTAINS: Hot Tub ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ I 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. ALASKA WATER & WASTEWATER CONSULTANTS INC. Permit Fees: Waiver Fees: Date of Payment: (�� Date of Payment: Receipt Number: �� 4 Receipt Number: ALASKA WATER & WASTEWATER CONSULTANTS, INC., r July 17, 2003 Municipality of Anchorage Development Service Department Building Safety Division On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Proposed Septic Upgrade for Lot 5; Mcabe Subdivision To whom it may concern: The existing 3 bedroom house is served by a private well and septic system. The existing septic system consists of a 1000 gallon septic tank and a deep trench type drainfield that is surcharged and must be upgraded prior to selling the house. A test hole was excavated east of the existing drainfield. The drainfield will be designed around the 30 foot radius of this test hole. We are proposing that a new 1000 gallon septic tank and a 5 -wide type drainfield be installed. Comments regarding the design are summarized as follows: 1. SOILS: See the attached logs which shows the soil classifications, groundwater monitoring, and the percolation test results. It is our opinion that an application rate of 0.8 gallons/day/ft2 should be used. 2. TRENCH DESIGN: a. Percolation Rate: <1 & 10 minutes/inch b. Proposed Application Rate: 0.8 gallons/day/ft2 c. Number of Bedrooms: 3 d. Design Flow: 450 gallons per day e. Minimum Absorption Area: 562.5 ft2 f. Total Depth: 10 feet (max.) g. Effective Depth: 4 h. Width: 5 feet i. Reduction Factor: 0.5 j. Minimum Length: 60 feet long k Effective absorption area = 600 ft2 3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed septic system. 4. TOPOGRAPHY: The area for the proposed drainfields is relatively flat; in short, there are no slope concerns. 3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507 Ph: (907) 337-6179* Fax: (907) 338-3246 * Website: akwwc.com We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you hav any questions, please contact us at 337-6179. Thank you for your assistance. , Sincerely, PIE.. M.S. NOTE: A site plan drawing, a design drawing, a soils logs, and a 7 page construction specification letter which are all part of the design package for this septic system. 3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com cs'EPTIC ARS I McCABE S/D LOT 7 McCABE S/D \� y\ ��✓' �� LOT 2 \ r � r \ MCCABE S/D y LOT 6 I i 100' WELL R421LI� MCCABE S/D /LOT 3 i f yR(ha 100' WELL { 1 I 00'W 1 , \ McCABE S/D \ LOT 4 r C EXISTING SEPTIC EP ICCM CSEPTIC ARD- EXISTING RDEXISTING BEDROOM HOUSE ___---___-_-_.---------------..-_-------.-__-_-_ iI OLSON HEIGHTS I I �C LOT 6, BLOCK 1 I I 1 3 OLSON HEIGHTS 1 +rr' LOT 7, BLOCK i I � ! i III y li 1 y y. \ LOT 18, BLOCK I KNIK HEIGHTS S/D r "I iI i IIu LOT 16, BLOCK I KNIK HEIGHTS S/D PROPOSED SEPTIC UPGRP f (SEE DESIGN PAGE 2 OF I I I I E I i I I i I I AR _.------_---1 T._._.__...-.__--_... -- 1 I! OLSON HEIGHTS LOT B, BLOCK 1 J� \ I MULBERRY S/D 1 \ ! TRACT A-1 ( WELL & SEPTIC l I 11 AREA 100'+ 1 1 I! I I it i 1 I r I I i IIIA 1 ! i - '. VAI C: 7/17/2003 < y ` r, z\z\h c ''• n. (1�a� �>' �! •'' '7V 1 `'M1A DRAWN BY: ALASKA WATER & WASTEWATKR C.J.G. :�•` 'T �- Y' IFI SCALE - ' INC. CONSULTANTS,✓ * ...I 4. 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 ' FHONE 907)337-6179 ' FAX (907)338-3246 1 — loo, . ....... PREPARED FOR PHONE NUMBER: PAGE NUMBER: KAREN FOGARTY 345-7803 1 OF 2 f y A. Gar' . s.. �tF, @ 95 1 o`%J LEGAL DESCRIPTION: McCABE SUBDIVISION; LOT 5TYPE t+vl ^e OF OF WORK: SITE PLAN FOR PROPOSED SEPTIC UPGRADE fessio�o��'�'r' PROPOSED 1000 GALL01 SEPTIC TANK MAY REQUIRE THE USE OF A LIFT STATION. INSTALL DOUBLE CLEANOUTS INSTALL FLOW DIVERTER AI A►SKA WATER & WASTEWATER CONSULTANTS, INC. 01 E. TUDOR ROAD, SUITE 101 - ANCHORAGE, AK 99507 " PHONE (907)337-6179 - FAX (907)1 8-32Z EPARED FOR: PHONE NUMBER: KAREN FOGARTY 345-7803 AL DESCRIPTION: McCABE SUBDIVISION; LOT 5, �E OF WORK: DESIGN DRAWING OF PROPOSED SEPTIC UPGRADE z 10' UTILITY EASEMENT EXISTING DRAINFlELD TO BE USED AS A RESERVE SITE. I f� DATE: 7/17/2003 IN, DRAWN BY: C.J.G.d P' 'r2�O SCALE: = 40' ..�. . 4... .... ... ........ of 2OF2 4 f"S i \' b EXISTING ' * WELL PROPOSED ADDITION too, WELL RADIUS x PROPOSED DRAINFlELD. EXCAVATE A THAT IS 10 FEET MAXIMUM BY 5C FEET WIDE BY 600 FEETELONG. \ 4 FEET OF CLEAN, WASHED DRAINROCK. / \ e 13' N EXISTING SEPTIC TANK TO BE O — ---— a NED 3..�A—.�----- PROPOSED 1000 GALL01 SEPTIC TANK MAY REQUIRE THE USE OF A LIFT STATION. INSTALL DOUBLE CLEANOUTS INSTALL FLOW DIVERTER AI A►SKA WATER & WASTEWATER CONSULTANTS, INC. 01 E. TUDOR ROAD, SUITE 101 - ANCHORAGE, AK 99507 " PHONE (907)337-6179 - FAX (907)1 8-32Z EPARED FOR: PHONE NUMBER: KAREN FOGARTY 345-7803 AL DESCRIPTION: McCABE SUBDIVISION; LOT 5, �E OF WORK: DESIGN DRAWING OF PROPOSED SEPTIC UPGRADE z 10' UTILITY EASEMENT EXISTING DRAINFlELD TO BE USED AS A RESERVE SITE. I f� DATE: 7/17/2003 IN, DRAWN BY: C.J.G.d P' 'r2�O SCALE: = 40' ..�. . 4... .... ... ........ of 2OF2 8 9 10 SM 11 TIME (MINUTES) READING (INCHES) 12 13 14 15 16 B.O.H. 17 1s 19 PERCOLATION RATE <1 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES) TEST RUN BETWEEN 4.0 FT. AND 4.5 FT. 20 A FOUR HOUR PRESOAK WAS PERFORMED: [-IYES ENO SOILS LOGGED BY: SUSAN OSWALT PERCOLATION TEST PERFORMED BY: JOSEPH MARCHE171 COMMENTS: PERFORMED BY AKWWC, INC. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: DEPTH TO DATE GROUNDWATER DRY 7/14/2003 DRY 7/16/2003 ootSop �0 d ALASKA LSKA NCA.•TER & WASTEWATER O •' �7 m. U~18C. CONSULTANTS, 101 • ANCHORAGE, AK. 507PHONE. 7337-19 FAX: (907)33a-3246 W RE a 3701 E DO ROAD, SUTE SOIL LOG — PERCOLATION TEST 0 OO Ga LEGAL DESCRIPTION: McCABE SUBDIVISION; LOT 5 . e . ess. DO PERFORMED FOR: KAREN FOGARTY DATE: 7/14/2003 (J�� d'�4� DEPTH (feet) OQ'adp fess�On0& TEST HOLE 1 �0000000�' 1 ORGANICS (PAGE 1 OF 2) 2 SOIL CLASSIFICATIONS �?; ,•a' GW �� ORG aTH#1 GP MIL GM CL 700' WELL RADIUS _y GM/GP 4 z. GC OL ° SW MH 5 e • o e SP CH SM ' ,' OH 6 SC 7 DEPTH TO DATE GROUNDWATER DRY 7/14/2003 DRY 7/16/2003 � o �< �Pnc ARS i •'1''�+yd•'5��'y � i .�="3'�•6T' I C , o i I ; SITE PLAN 1"-100 , DATE READING CLOCK NET TIME WATER LEVEL NET DROP 7/16/2003 ppEO P`' P �P�ER S aTH#1 DATE READING CLOCK NET TIME WATER LEVEL NET DROP 7/16/2003 ppEO P`' P �P�ER S A LA.SKA WATER & WASTEWATER p�� ". CONSULTANTS, INC.O - ..... .. .. . . .... ..... ... 7 R 9 — (907)338-3245 c c.com O' SOIL LOG — PERCOLATION TEST r0. ,,. LEGAL DESCRIPTION: MCCASE SUBDIVISION; LOT 5 QO .J tf e A. ar ess:' PERFORMED FOR: KAREN FOGARTY DATE: 7/14/2003 C —7953 O��,ost '•. . •' `�o 4p 4a �oAo (feet] TEST HOLE #1dp�OfessiQO\co 40000 1 (PAGE 2 OF 2) SOIL CLASSIFICATIONS GW ORG GP ML GM CL 3 4 GC OL 5 6 7 9 10 11 12 13 14 15 16 17 18 w a o_ z 0 J O E- Fw- o: 0 z 0 a U u- 0 - ti 0 U J 0 w w V) &MA DEPTH TO GROUNDWATER PATE WATER LEVEL READING OF � E P PGE 1 12:23 - 6' - SEE PAGE 1 OF 2 FOR SITE PLAN DATE READING CLOCK NET TIME TIME (MINUTES) WATER LEVEL READING NET DROP (INCHES) 7/16/2003 1 12:23 - 6' - 2 12:53 30 2 1/2- 3 1/2- 3 12:53 - 6" - 4 1:23 30 3" 3- 5 1:23 - 6" - 6 1:53 30 3„ 3„ PERCOLATION RATE 10 (MIN./INCH) 19 20 Ij1 JIB TEST RUN BETWEEN 7.0 FT. AND COMMENTS: PERC-HOLE WAS PRE-SOAKED FOR 4+ HOURS PERC. HOLE DIA. 6" (INCHES) 7.5 FT. PERFORMED BY ALASKA WATER & WASTEWATER I, JEFFREY A. GARNESS, CERTIFY THAT THIS IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: McCABE LOT 2 McCABE S/D LOT 3 / LOT 18, BLOCK I KNIK HEIGHTS S/D 'IC ARS McCABE S/D LOT 7 McCABE S/D LOT 6 McCABE S/D LOT 4 )N HEIGHTS OLS( HEIGHTS MULBERRY 6, BLOCK 1 LOT 7, LOCK 1 TRACT P 0 ON HEIGHTS FIELD VERI LOT , BLOCK 1 FIELD \ 3,00' 1 1 IDOR RO E I( • AGE A 50 "PHONE (907)3 179 `FAX (907)358- �R PHONE NUMBER r"IPAGE NUMet'K. v 1 3d5-7808 11 1 Vh I I LOT 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 NAME ._ PHONE 6 ._3/ .SINEW ❑ UPGRADE MAI LING ADDRESS asci Chi LEGAL DESCRIPTION LS M&C04e SL LOCATION NO. OF BEDROOMS U DISTANCE TO: Well _ �yw_'�' Absorption area Dwelling PERMIT NO. G .Y a Q wF Manufacturer � � � Material � � No, of compartments Liq. capacity in gallons Q IF HOMEMADE: Inside length .�- Width ,,,� Liquid depth �• J t7Z DISTANCE TO� Well Dwelling PERMIT NO. d z Q 2 F Manu rer Material Liquid capacity i w= DISTANCE TO: Well `��- Foundation T �� Nearest lot line , PERMIT NO. �� y O LL z H Z w No. of Ines Length of each Is'pe/� O� `7 Total length of lid§ oZ % Trench width �; inches Distance between lines �J ¢ F a Top of tile to finish grade ¢-' Material beneath tile it hes Total effective absor io are Length Width Depth PERMIT NO. Q F• as w Type of cribdiameter Crib Total effective abs r.pttfF area LU W ANCE TO: Well Building foundation Neat lot line" ' Depth Driller Distance to lot line PERMIT NO. LU DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS 3)3b3 v SOIL TEST RATING 1S" p INSTALLER REMARKS �o N r � ( b _ c F o APPROVED DATE LEGAL �i -711&1,C1 t-5 72-013 (Rev.'3`/78) /� _ r~^ �U r-4 I C I -Ir V ��-::- n r-.1 V-1 F=1 C3 E---' ~ ,D2PARTMENT C HEALTH AND ENVIRONMENTAL | JTECTION ( |� 825 /L/ STREET/ ANCHORAGE., HK. 99501 ^\ ` 264-4720 �� _�� PERMIT NO. ( 810440 APPLICANT JHK CONST. 2511 CHIAKHT CT. 694~I19JR, �� LOCATION MG CHBE CIRCLE / LEGAL LOT 5 MCCHBE SUB LOT SIZE 53000 SQUARE FEET . TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = ] SOIL RATING (SQ FT/BR)= &50 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: ["--a r=- f-' _r t-l� "1 :2 :2-e=o ��rt-l��w "�:D THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. ' THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE 15 NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). ��1 F:;;? E- C_- ��I I:Z- �� IF. 1 2' EE = J 124 "_ #---# �" I A - 1=1�� PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. _r L�� Z�C BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ON --SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS QF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLYSPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F=*F=F:;?M I -IF FEXF-� I ENUE ��EFME�l=FR :E:-1 � .1�� I CERTIFY THAT' 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR QNSITE SEWERS AND WELLS MS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS. APPLICANT JHK CONST. '34I T t`t!- J/+rte} ■ �y +g 1 �,3d �y �y -ey 41 264--472-26 { 43 3 FPICMT ,JAX i T. gk$it 0411"-r CT. ,vire iF sorL Asswriam sa %iTEI't d s . T# #-tt PMIMM N-Q4W-R L-0; RECD = s sorL SQAr040 <SO Ffo�M)= L-50 TW- RE J IRFD SUE E OF THE OIL. t SSAW- r IM 5� TEM IS! 414 -3t9l. i ME E..MITH IDItW51 I'S TW LVIGTH {Its FEET? CC THE TRa R C#ZftINFIE'LQ- ME DEPTH OF A TREMH OR P1r IS TWE DISTFOCE BETWEEN THE SLW OF TFC 1-33R3LM AND TW- L 0T TOM OF THE CXCA AT f N j [it T). TRO Z--; NO SET 14IDTH FOR TRS tom. THE L DEPTH I's TW MINIPI M CI+TH 13 A3... £ETHE)m THE OJTFRJ- FLM 3W THE 90T Y13M OF THE 00ZRYRT Il3N < IN i-'"EE0. 71=ImK jSr n°j-=:t- A-e%C30 PERa9I r spPL i mor to Tw RespoNs d a LL € ry ro twopm n4 dS cepm rn N r ouR rm T# e tNSTHLLATIOt INS-FE3TiQua LW Ater wi Ls Rojw--ENr To Tmrs pRfwepry AND ME t'-414WR CAIF RESFOC _ 3 THAT THE wCu. WILL. SERM amr,%FrL.LrN,l sirssrem wini3UT PtNoL ;hr�-,rtom Aw ri v'`A!. ov Miti VEPfiRTPWNT 141L.L BE SIJSJ r Tri' PRt +."Y3rtom -MIN EMM DISTAN09 SCMEeN A PWLL AND ANY t?I,} - ITE 3E v1sposm Tios mi I's 100 MSr FOR A PRIVnM PXX.L 13P i59 TO 28A FEET FROM A PUBLIC W&J_ C INn 141NIMM DISTANOE FROM A PRIVATE WELL TO A PRfYATE SEWER LIPS Is 25 Feer Amo TQ .A C13T JNITV SaIER LIts t; in ME 1.19-L Lw—j FIRE REOUIREO A�JD tit ST 8E RE1'URN90 TO 1"M 0e5,FWtMMr WITHIN 30 DAYS 13F Tw t*LL 1_-x-QqpLErt . or RIeQuim%Nis we PPPLY. spEcwtcArms Am CattyrmicTIa" oI f +3ERT iI=Y THST &; I Rt! FRUL IAtt 14 t !* i THE RE4 IREMENTS P13R ON-SITE '00?pib NO W -Ls Aa SeT F13RTH GY T't #.: MN IC IPA L i TY OF MCHORME : I WILL tMTALL THE s'f i r# ref twxrjRf>PmE lam Tse com! 2: i 101DERSTAM& "T N I T£ 5YSTEM MRV € eQU iW. Eta! ARC3EMENT IF THE 'sIC � 0 1NCLI� THAN Sit: __ �. _ --- ----_......�_ LE NT JAK CLINsr- s i i sr ,.. [b 1 �- a3 L,,\ pc,,�) a - G f� �� ai �� tA OL� � C(t--, kA) AC, nuc- �� C�,� C �0�1. - �I -,A, - �a A4 ac, k--�,. �A L--') C_C_d - Dk__Q - '�,rg 6r . Cc ev ,�C,eR, U14 t ............. r I Well Log For......... V Location.. .... :... Date completed........? ! ............ ............................... Depthof well .......:.: ... 1 ................... I ............. I............................................... Size of casing .................................... 77"i e - Distanceto water....::........1.:........................................................................ Distance to water while pumping .......... I ...........................I...............at rate of..... ` - � gallons per hour. Formation from f to I � I I I I I Municipality of Anchorage • Development Services Department Y e .c Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 s CERTIFICATE OF HEALTH AUTHORITY APPROVAL y FOR A SINGLE FAMILY DWELLING Parcel I.D. 018-231-23 HAA# 0�V� 1. GENERAL INFORMATION Expiration Date: 03 Complete legal description McCABE S/D: LOT 5: Location (site address or directions) 13341 McCabe CIRCLE Current Property owner(s) KAREN FOGARTY Day phone (907) 345-7803 Mailing address Lending agency Mailing address Real Estate Agent Mailing address 13341 McCABE EAST CIRCLE ANCHORAGE AK. 99516 PHYLLIS KRUGER w/ PACIFIC RIM PROPERTIES 3000 "C" ST. ANCHORAGE AK, 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System 3 Day phone Day phone 727-8439 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. TYPE OF WASTEWATER DISPOSAL: Individual On-site 0 ❑ Individual Holding tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by, seal affixed hereto and as of the validation date shown below, I ven*fy that my investigation, ed on procedures outlined in the Health Authority Approval Guidelines fof'TNs application, show tf�at the on-site water supply and/or wastewater disposal system is(are) safe, functional Ind adequate Tog e, umber of bedrooms and type of structure indicated herein. I further verify that based on tlie, rmatfon obtained from the Municipality of Anchorage files and from my investigation and inspection, he a-ssite water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: in conducting this evaluation, AKWWC, inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AKWWC, Inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for -3 bedrooms. Disapproved. Phone 337-6179 Date v S 03 Conditional approval for bedrooms, with the fllowing stipulations: Ar • r- J ' ON-SITE ER tjINE) . on WASTEWATER r-rWUKAMf �. J O •'f ff•V•`',� Attachments: HAA Checklist Manitenance Agreements Septic System Advisory Supplemental Engineer's Reort Well Flow Advisory Other By: o f Original Certificate Date: (Rev. 12101) Municipality ~ W^txm m�� Anchorage m�u��m�� o m~n x��wxoraN0e Development Services Department Building Safety Division On -Site Water & Wastewater Program 47OUSouth BragawSt. -- P.O. Box 196650 Anchorage, AK 99519-6650 wvmw.oianohomge.ak.ua (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal : Parcel |D: 018-231-23 A. WELL DATA Well type _PRIVATE |fA.B.orCprovide PVVS|O# -m//L Well Log (YYN)-____ Date completed --9/2y/t1Sanitary seal (YYN) YES Wires properly protected (YYN) Total depth 89 ft. Cased to 89 ft. Casing height (above ground) FROM WELL LOG AT INSPECTION YES YES 20 in. Date oftest 9/27/81 6/24/03 Static water level l ft. 7 � Well production 4 g.p.rn. 2.61 9 -P.M. WATER SAMPLE RESULTS: Coliform 0oo|onieo/100 m|. Nitrate 4.59 mg./L. Other bacteria 0 co|onien/100 m|. Arsenic: _N/A_mg./L Date ofsample: Collected by: AKWWC, INC. B. SEPTIC/HOLDING TANK DATA TankType/Matehn| Date installed 8/1/03 Tank size _1000}_gal. Number ufCompartments 2 C|eanoute(Y/N) YES Foundation cleanout (Y7N) YES Depression over tank (Y7N) NO High water alarm (YYN) Date ofpumping N Pumper NEW C. ABSORPTION FIELD DATA I*BELOW FINAL GRADE! Date installed Soil rating rft2/bdnn) System type TRENCH / 5 -WIDE Length 29 60 ft. Width 3 5 ft. Gravel below pipe ft. Total depth 12_/_�0.8 . Eff. absorption area 464 600 ftz Monitoring tuba YES Depression over field NO Date ofadequacy test NEW Reau|ta(Paas/Fai|) NEW For 3 bedrooms Fluid depth in absorption field before test — in. VVataradded _��_ga/. New depth — in. Elapsed Time: __�_�no/n. Final fluid depth_— in. Absorption rate >= — g.p.d. Any rejuvenation treatment (past 12nno.)/Y/N&type) !fyes, give date ____—____ Date installed Size ingallons "Pump on" level ut_____in. "Pu Cycles tested I-- :41:r,-,ll-k4livilLoilikiml]611'fillo- SEPARATION DISTANCES FROM WELL 0NLOT TO: Septic tank/lift station onlot ' Absorption field onlot ' Public sewer main High water alarm level at Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout 1UO'+ 1OO'+ Sewer /septic service line ' Holding tank ' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ONLOT TO: Building foundation ` Property line ' Absorption field ' Water main Water service line 10'+ 8urfaoevvater ' Wells onadjacent lots �00L±�-- SEPARAT|[}NDiSTANCEFROMABSORPTIDNF|ELDDNLOTTO: Property line ` Building foundation 1}4- Water main Water service line . Surface water 100'+ Ohvevvay. parking/vehidentonage __1O'+ Curtain drain NONE KNOWN Wells on adjacent lots ' F. COMMENTS G. ENGINEER'S CERTIFICATION certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. . ........ .. Engineer's Printed Name JEFFREY A. GARNESS C -795 HAA Fee $ bu Waiver Fee $ Date of Payment Date of Payment Receipt Number Receipt Number 08/04/2003 22:01 7625495 PACIFIC RIM PROPERTI PAGE 02/02 Aug 04 03 02:24P Frantzkildamen 2749686 P•a R' �i 4CT 4 0 • VVE41 El DATE � . r • ,e ia- anz� 'FsNr r XJ1.8 S89" 56,4607vv Lot , Block Anchorage Recording Prectnci, Alaska 60_T SURVEY CERTIFICATION �E I herebyowify that Ihave survayedfbepropertyshown and described ia: e harem,and that the Improvernetirs situated thereat are within the prop- oz -1 arty Ilnee arld dons ovorlep or erw000h on adjocent propsrty mO thor n o r, ;mprommems on adjacent property overlap or wwoach on the premises • in question and that there ore no roadways, utility limes orothervrslbta �$: easements on said property noept as indlcated hereon. Scale„, Data -23 <51 Ref. F. B No. i pipe and/or rebar recovered 2 rub 6 took recovered I%Vrebar set this survey Prepared by: gegRiW ® g onal SuNveypr l9OT1279-6M 5/9 W.E/gr*Ave. Andioroye,Alaska 99501 Property of: ,�t'�nrrar-i fit,.-�,•�....,�.1 0�8 MUNICIPALITY OF ANCHORAGE 231 23 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 Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, subdivision, section, township, range) 991— e*7s (b) Prople" Own Telephone: Home Business Mailing / ddcess �33Qr amt` �A�� /,QSLF E At�fN. %%S�6 2.0 (c) (c) LendingfrselaioTelephone Mailing Address= (d) Real Estate Co Address Telephone 35F3' Agent (e) Mail the HAA to the followino address: or: Check here Ltd, if hold for pick up. List contact person and day phone number below. 2. TYPE OF RESIDENCE Single -Family( Number of Bedrooms 3 3. WATER SUPPLY Individual Well[ Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. 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 72-026 (Rev 8/861 Front .s ..:ter. .n.Y .. :..s...�[ n.. ...4.v �a r.l. _.� '. n.n ...i...r. ..... .. ... ... r r .......• ..•. ... r.. ...♦ •n•..r .�- r. �... .•a.. .a ...._. a..... JOU9 (99/8 Aad) SLO-LL Z 10 Z 96ed •Naom s,j99u16u9 leuolssajoid aqj ut suo!ss!wo ao sione aoj alglsuodsai jou sl 96eaoyouy jo Al!ledlolunw aUl -panssi sl 91eo11!ueo a aaojaq elep az (leue ao suolloadsul jonpuoo jou op SHHO jo s9a/%oldw3 •sluawaalnbei alels pue papal ulepso Aples of japio ul suollnl!lsul bulpual alayl pue sawoy jo siaseyoand of /selinoo 8 se s!yl saop SHHQ OU *"sely jo 01e1S 9y1 ul p9a9lslb9J aaaul6ua leuo!ssajoad juapuadepu! ue Ag anoge g ydei6e,ied ul u9A!6 suoljejuasaidej ay1 uodn Aluo paseq seleollpiao !enoaddy (juoyjny ylleaH sanss! (SHH(l) sao!AaaS uewnH pue U1189H jo juawpedaa a6eaoyouy jo Al!ledlolunw ayl NOunvo Ienoiddy Ieuop!puoO jo swial leuo!j!puOO p9Aoaddes!Q panoaddy Fry_ _ alesl 0 Aq swooapaq / aoj panoaddy F r Y LIVA011ddV SHHO '9 p~,`tyvi wlVyVy 14 ''�' : ISZL' �'• 1t �;• nar ,r s/- - ale4 f f6/ AV �J �� . M ssaipp`d FSSS -6L� auoydelal Wald 10 aweN uo!loadsul s!14l jo alep aUj uo joege ul suo!jelnBei pue'seoueu!pio'sepoo ajejS pue led!o!unlnl Ile Ul!m eouelidwoo ul sl welsAs lesods!p jejemelsem ao/pue (lddns jejem aps-uo ayl 'uoljoadsui pue uolle6!jsanu! Aw woaj pue se!!j 96eaoyouy jo tl!ledlolunIN a14l wojl paulelgo uoljewiolul api uo paseq jeyj ljuaA jayl.mj 1 •ulaaay paluo!pui einjonils jo ad (l pue swooapaq jo aagwnu 9W Jo; alenbape pue !euoljoun j'ajes s1 wals (s lesodslp jelemalsem ao/pue AIddns jelem eps-uo aUj leUj smogs !enoaddy Aluoylny 411eaH slyj jo uo!1e611sanu! Aw leUl AjuaA I 'molaq umo14s alep u011ep11eA 914110 se pue olaaay paxllle leas (w Aq paippeo sy NOIIVWHOdNI ONV VIVO `HOUV3S 3114 `S1S31 `SN01103dSNl E)NIOIAOHd WUId JNIH33NIJN3 '9 w mr,, ,' I i i'1 MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL SERVICES DIVISIOtAEALTH AUTHORITY RY 8 APPROVAL (HAA) CHECKLIST AUG 16 1988 264-4720 RECEIVED Legal Description: "7737' $Lk ,,//,fE- A. WELL DATA Well Classification P�✓ATS If A, B, C, D. .C. Approved (Y/N) Well Log Present(/ ) Date Completed 8-/ Yield Total Depth o r Cased to , Depth of Grouting 4)IIA Static Water Level 1% 77 Pump Set At 14 r Casing Height Above Ground 70' Sanitary Seal on Casin(Y N) Electrical Wiring in Condui (Y N) Depression Around Wellhead (Y© Separation Distances from Well: r i To Septic/Holding Tank on Lot �� ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot On Adjoining Lots To Nearest Public Sewer Line VA To Nearest Public Sewer r Cleanout/Manhole A%�� ToNearest Sewer Service Line on Lot Water Sample Collected by A�w A W/147 ; Date jr_Z_sv� Water Sample Test Results " T ^ *-- A)17A_ 4-rES t-, y Comments le kje-z- Fze%J Ta3T B. SEPTIC/HOLDING TANK DATA Date Installed Size /0"00 No. of Compartments Z Standpipes(ON) (Y Air -tight Cap N) Foundation Cleanou (Y N) Depression over Tank (Y& Date Last Pumped X15'w As�ggC�7 Pumping/Maintenance Contract on File (Y/N) A ; for A Holding Tank High -Water Alarm (Y/N) A Temporary Holding Tank Permit (Y/N') �! Separation Distances from Septic/Holding Tank: To Water -Supply Well '> /a To Building Foundation r To Property Line /40 To Disposal Field 7 To Water Main/Service Line /G To Stream, Pond, Lake, or Major Drainage r Course fav d' Comments Page 1 of 2 72-026(11/84) A -S >fe-~ Ls - C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata %50 Type of System Design 7Z'E'�/W Date Installed % _01/ Length of Field 4" or Width of Field 3 Depth of Field �a Gravel Bed Thickness g/ Square Feet of Absorption Area Standpipes Present&) Depression over Field (Y©N Date of Last Adequacy Test Results of Last Adequacy TestaAAr0 Separation Distance from Absorption Field: To Water -Supply Well > A70 0 To Building Foundation Lot 0 To Water Main/Service Line /O ^f' To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments To Property Line To Existing or Abandoned System on I� On Adjoining Lots To Cutbank (if present) .4 i 0.0' Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent(Y/N) ng Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I ha hec d, ver' ied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed G�� '�_--.. Date 471-45"-w GG+ Q %®4 Al • Company / MOA No. ,""''� . Receipt No. v ' .,try °°`°°'° ° Date of Payment (� °•••� ° Amount: $ - Q� 04#9** iS.$� °' •� i tgR C. RVD, JR. A" ��'•• 2251•- a Q 5 _�� E - Page 2 of 2 72-026 (11/84) 777' E RECEIVED INSPECTION APPOINTMENT TIME NUMBER OF,BEDROOMS TIME TIME , ❑ Two ❑ Five t C') ATE DATE DATE ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY 1 INSPECTOR INSPECTOR INSPECTOR ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. F C DEPT. OF H' ALTI I & MUNICIPALITY OF ANCHORAGE MVIRONMENIAL P" OTECTION DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI 825 L Street - Anchorage, Alaska 99501 • - - � q i�S71 i3 OCTC 8 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPEFITYOWNER PHONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE n MAILING ADDRESS 3. LENDING INSTITUTION PHONE i ; MAILING ADDRESS r 4. REALTOR/AGENT - - _ PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATIO 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS ❑ One ❑ Four ❑ Other IK SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY Gk Three ❑ Six 7. WATER SUPPLY Z INDIVIDUAL* * 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.) B. SEWAGE DISPOSAL SYSTEM � INDIVIDUAL/ON-SITE** 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) 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 ❑ TWO ❑ FOUR ❑ SIX ❑ OTHER 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 ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED b �$ INSTALLER ❑Septic Tank or ❑ Holding Tank Size:, /000 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 7Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS ER -'APPROVED FOR .3 BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) G' DISAPPROVED DATE y f-'�u4-4 "-.- BY 72-010 (Rev. 6/79)