HomeMy WebLinkAboutSKY RANCH ESTATES #2 BLK 1 LT 1
Municipality of Anchorage Page 1 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISIO'N
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: SW980459 PIDNumber: 015-302-24
Name; Sandy Potter Wastewater System: [] New ~ Upgrade
Address:
P. O. BOX 111313, Anch., AK 99511 ABSORPTION FIELD
Phone:
No. of~edrooms:- [] DeepTrench ;z~:ShallowTrench [] Bed Fl Mound [] Other
346-2004
LEGAL DESCRIPTION soil Rating: Total Depfh from original grade:
· 4 5 GPO/Sq. Pt. 7
Lot: 8lock: Subdivision: Depth to pipe ~ogom Irorn original grade: Gravel depth beneath pipe
1 1 Sky Ranch Ests #2 3 Ft. 4' Ft.
Township: Range: Section: Fill added above originlal grade: ; Gravel ~ength:
~. 100 ~.
WELL: 3Publ~c Water Sys[em Gmvelwidth: Numberoflines:
Classification (Private, A,B,C): Total Depth: C~ed To: Total absorption area: Pipe material:
Ft, FL 1,111 SO. Pt ASTM D3034 PVC
Drgle~ Dale Drilled: Static Wafer Level:Installe~ Nor ths tar Date installed:
Ft. Earthmov~ r~ 12 / 19.20 / 9
Yield: GPM PumpSetat: Fi, C~ingHeightAboveGtound:
Ft TANK Existing
SEPARATION DISTANCES ~ptic s Holding S S.T.E.P.
TO ~Septic AbsorptionLift HoldingPubli~PH~ate Manufacture~ Capaci~ in gallons:
WelY > 200 ' > 200 ' N/A N/A >200 I Material: NumberofCompa~ments:
SudaCewater>100' >100' N/A N/A N/A LIFT STATION - N/A
Lot > 5 ' > 1 0 ' N/A ~/A N/A Size in gallons: Manufacturer:
Line
Foundation ,> 5 ' > 1 0 ' N / A N / A N/A "Pump on" level at: "Pump orr' level at: High water slarm at:
Cu~ainDrain None on Lo~ PumpMake&Model Electricallnspectionspedormedby:
Remarks: Existing Septic Tank was BENCH MARK
uncovered, inspected and verified Loca(ionandDescripUon: Front Deck
for continued use.
100.0
ENGINEER'S SEAL
Inspections peflormed by: A. Ha~ala Dates:lst 12/19/98
Reviewed
and
approved
72-O13 (Rev. 9/91) MOA 25
Permit No.
2 3
SW980459 Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LegalDescription: LT 1, BLK 1, Sky Ranch Estates, #2 PIDNo.:_015-302-24.
,.I
· , ,_~" ~ .~' i'r,- - -'~- , r_ -._- ?~-~
'- . -- bend '~, . .
low. .~ ~ ..~ :. : [' ' ~ ' -
sPl~t~,er { ~ / clean outs
~' ~ Cl~ d~verter valve
TEE ; I
~, ~ ...... ~,'000 gallon
'~ ~ "deck ~
-': s~ept ic tank
C3
3 BR house
drivewayt
I PLAN
I
~_l~/. ; ....... ! .....
~ ,"~--~-~~ .......
aCproX. ~
location
of water
service
- llne
AS-BLT
20'
3 3
Permit No. SW980459 Page of
"' Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P,O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LegalDescription: _LT 1, BLK 1, Sky Ranch Estates, #2 PiD No.: 015-302-24
diverter
valve
flow ;
splitter C2
100 LF x 5' W, 4' E. D.
absorption trench
C
.$
88,
BOH= 8 of~
LEGEND:
C clean out
MT monitor tube
ELEVATION AS -BLT
1" = 10"
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4-
5
6
7
8
9-
10
11
12
13-
14
15
16
17
18
19-
20
SP
Municipality of Anchorage
DF_PARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alasl~a 99502-0650
SOILS LOG -- PERCOLATION TEST
Sandy.Potter
DATE PERFOF
Lot 1 , Block I r Sky Township, Range, Se~ion:
SLOPE
Ranch Estates No. 1
TESTHOLE NO. 1
COMM~_NTS Perc.
WAS GROUND WATER NO
ENCOUNTERED?
L
IF YES, AT WHAT O
DEPTH? p
E
~2/19/9e
SITE PLAN
mm~mg? L~one
Ill
pERCOLATION RATE ''~ ~' irm~utes/mch) PERC HOLE DIAMETER
TEST RUN BETWEEN '~"'" .FT AND ~' Fi'
Cavity presoaked prior to testing.
-- Michael E. Anderson ~/ ,/--.~
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATF- DATE: /~/ '
72-008 (Rev. 4/85}
Municipality o! Anchora9e
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 #L" Street, Anchorage. Alaska 995020650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DE$CRIFTION:
3
5
6
7-
8
9
10
11
13
14
15
16
17-
18-
19
20
Sandy.Potter
SP
DATE
Lot 1, Block l, Sky
Ranch Estates No.
TESTHOLE NO. 2
Township, Range. Section:
I SLOPE
I
I
WA~q GROUND WATER
ENCOUNTERED? NO
IF YF.~, AT WHAT
DEPTH?
None
12/19/5
~ITE PLAN
tl
[I
Same
PERCOLATION RATE
{~OMME~CTS
were ±den[ical [o Testhole No. 1.
TFs'r RUN aETWEEN ~. ~T AND m
Perc. Cavity presoaked prior to testing. Materials encountered
Michael E. Anderson ~/,~/~
ACCORDANCE W~TH ALL ~TA3'E AND MUNICIPAL GUIDELINES IN EFFEC~ ON THiS DAT~ DAT~ ~ 7 ¢ ~
72~ (R~. 4~}
IN
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 995~9-6650
(9O7) 343-4744
ON-SiTE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Dec 08, 1998
Expiration Date: Dec 08, 1999
Permit Number: SW980459
Legal Description: SKY RANCH ESTATES #2 BLK 1 LT 1
Design Engineer: 0014 Anderson Engineering
Owner Name: SANDY POTTER
Owner Address: PO BOX 111313
ANCHORAGE , AK 99511-1313
Parcel ID: 015-302-24
Site Address: 005001 WHISPERING SPRUCE DR
Lot Size: 16875 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
[] Disposal Field [__~ Septic Tank [] Holding Tank [] Privy
[] Private Well I~ Water Storage
All construction must be in accordance with:
1. The attached approved design.
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 DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 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.
Date:
ANDERSON/BOUTET 9075226779 12/09 '98 17:31 N0.855 03/03
FAX MEMO
To: Dan Roth
With: MoA/DHHS
From: Mike Anderson
Date: December 9, 1998
Subject: Lot 1, Block 1, Sky Ranch Estates No. I
Message;
We dug two testholes along the west side of the property and
found very fine silty sand which percolated just over 30 minutes
per inch. We are therefore redesigning the trench for the west
side of the property as shown on the attached Site Plan. These
soils are better than the ML found in the testhole on the east
s~de.
We will still place the diverter valve and the splitter valve to
enter the new trench in at least two places, We will try to
maintain 10' from the old trench, Our testhole uncovered a
portion of the old trench and found it to be in excellent
condition with all of the biomat gone. We are also trying to
maintain 4' above the water level achieved by Mark Pearson in
his testhole, The water level In the testhole on the east side is
still over 14', We did not encounter any water on the east side,
We hope to complete construction in the next two days, Please
call me it you have any questions,
3__Pages Being Transmitted
ANDERSON/BOUTET
9075~6779
ANDERSON ENGINEERING
P.O, B~x 240773
ANCHORAGE, AK 99524,
(907) 565-7:155
(907) 337.8855
12/09 '98 17:31 N0.855 02/03
ANDERSON/BOUTET 9075226779 12/09 '98 17:31 N0.855 01/03
East Klatt Road
~ater Sez ~ice
Whispering Spruce Drive
SCOPE OF WORK:
Verify Integrity of Existing Septic Tank.
2. Place Diversion Valve in Existing Service Line.
3. Pl~,ce Flow Splitter Valve at Location Shown.
4. Construct 140' Long x 5' Wide x 2' ~ffective' Depth
Absorption Trench at Location Shown.
5. Total Depth of Trench to be 6.5' From Original Ground.
SITE PLAN
SCALE 1" = 40'
December 8, 1998
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Attention: Dan Roth
Subject:
Lot 1, Block 1, Sky Ranch Estates Subdivision No. 1
Septic System Design
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
We have revised the design for the septic system upgrade for Lot 1, Block
1, Sky Ranch Estates No. 1 to take advantage of surface area on the
property which has not been previously used for the absorption of septic
effluent. We have also incorporated the existing absorption bed into the
system for use at a later date if necessary. It is hoped the absorption bed
will regenerate itself over time and provide absorption capacity in the
future.
The new design includes the placement of a diversion valve in the existing
transport line. It also includes placement of a flow splitter valve and the
construction of a total of 140' of 4' wide absorption trench with an
effective depth of 2'. The total depth of the trench has been limited to
6.5' even though the testhole recently completed by Alaska Water and
Wastewater Consultants indicated groundwater at a depth of 14.5'.
The new trenches will be constructed a minimum of 10' from the existing
bed and 10' from the eastern property line. We are also limited by the
requirement of the 10' separation from the house foundation. Although
space is limited, it appears the trench can be successfully placed in this
location.
Lot 1, Block 1, Sky Ranch Estates No. 1
December 8, 1998
Page Two
If the system is constructed as designed the following statements apply:
The system, if constructed as designed, will have no adverse impact
on the wells in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact
on existing septic systems in the area or those to be constructed in
the future.
3. The system, if constructed as designed, will have no adverse
impact on reserved space, either surface or subsurface, on any lots
located in the area.
The system, if constructed as designed, will have no adverse impact
on drainage patterns in the area. The current drainage pattern wi
be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
East Klatt Road
2
Whispering Spruce Drive
SCOPE OF WORK:
1. Verify Integrity of Existing Septic Tank.
2. Place Diversion Valve in Existing Service Line.
3. Place Flow Splitter Valve at Location Shown.
4. Construct 140' Long x 5' Wide x 2' Effective Depth
Absorption Trench at Location Shown.
5. Total Depth of Trench to be 6.5' From Original Ground.
SITE PLAN
SCALE 1" = 40'
LOT 1, BLOCK 1, SKY RANCH EST. NO.
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Three Bedroom Home 5' Wide Trench System
Perc. Rate: 31 - 60 Min./Inch Verify Existing Septic Tank
Application Rate: ,45 GPD/SF 2' Drainfield Rock
3 Bedrooms X 150 GPD / .45 GPD/SF = 1,000 SF of Absorption Area
1,000 SF/5 LF (Width) X ,7 (Red, Factor) = 140 LF Trench Length
Therefore: Construct a 5' Wide Absorption Trench System With Two
Laterals As Shown on tt~e Site Plan with 2' of Drainfield Rock Beneath the
Lateral. Distribution Pipe in Trench Placed at 4,5' Below Original Ground
Surface, Flow Splitter Valve and Flow Diverter Valve Required at
Location Shown, Mound Over Trenches to Provide Positive Drainage Away
From Area.
Natural
Backfill
Geotextile
Drainfield Rock
NOTE:
TYPICAL WIDE TRENCH SECTION
(NO SCALE)
Grade Area Over Trench to Drain Away,
Minimum 3' of Cover over Septic System.
Minimum 10' Separation From Lot Line,
Minimum 4' Separation From Groundwater.
Alaska Water & Wastewater Consultants, Inc.
6901 Debarr Road State 2B - Anchm age ~ Alaska 99504
(907) 337-6179 ~ Fax (907) 338-3246
Cousulting Engiueers
November 18, 1998
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Sewer Upgrade for Lot 1, Block 1, Sky Ranch Estates Subdivision #2
To whom it may concern:
The existing 3 bedroom house is served by an onsite septic system, and a private well. The
existing bed is will not pass an adequacy test and must be upgraded. Commems regarding the
proposed upgrade are summarized as follows:
1. GENERAL: As can be seen on the site plan and design, there is limited area to install a new
septic system. The site limitations are as follows:
· The location of the house
· The location of the existing septic systems
The location of the water line
Given these site restrictions, we propose to install a Innovative Bottomless Intermittent Sand
Filter.
2. SOILS: On November 9, 1998, a test hole was excavated and a percolation test was
performed in the area of the proposed septic upgrade. As can be seen from the attached log, the
soil below the organic layer is a 6 inch GP lense to a depth of 2 feet. At 2 feet, the soil transitions
to a SM/SW material to a depth of 3.5 feet and th~'n transition~to a ML material to a depth of 17
feet (bottom of test hole). Ground water was encountered at the time of excavation at 14.5 feet.
Two percolation tests were performed between 1.5 to 2.0 feet and 5.0 to 5.5 feet. and determined
the rates to be at <1 minute/inch in the upper bench md 60 minutes/inch in the lower bench.
3. TRENCH DESIGN: Bottomless Inte~xnittent Sand Filter (ISF)
a. Percolation Rate: <1 and 60 minutes/inch
b. Allowable Application Rate for ISF: 2 gallons/day/fi2
c. Number of Bedrooms: 3
d. Design Flow: 450 gallons per day
e. Minimum Absorption Area: 225 fl2
f. Effective Depth below pressure pipes: 3 inches
g. Width: 10 feet
h. Length: 36 feet.
i. Effective absorption area -- 360 ft2 (>225 fi2 OK)
j. Air Supply: Thomas Industries, Model 5070, "Anchorage Tank".
k. Air Supply Line: "Wasteflow" emitterline, 1/2 inch I.D, "Anchorage Tank".
1. Sand Material: G~2ra! PavLng Przduzts "W[-lee-tkottd-Sav~' ~'F~O_ ~w
m. Pea Gravel: 100% passing 3/8" sieve, less than 20% passing the 1/4" sieve, and
less than 1% passing the #8 sieve.
We are proposing to excavate down to a depth of 3 feet (remove all organics), place a m'mimum
of 6 inches of sand, install the air supply line, and cover it with 1.5 feet of sand. On top of the
sand, we will place 6 inches of 3/8 inch pea gravel, with the pressure laterals midway in the layer.
We will use a conventional lift station (Anchorage Tank), equipped with a programmable timer so
that flow can be intermittently dosed to the ISF.
4. SURFACE WATERS: There are no surface waters within 100 feet of the proposed septic
system.
5. TOPOGRAPHY: As cau be seen on the topography site plan, the slope of the lot is at a
grade of approximately 5% to 7% running fi'om southeast to northwest. In shorts, there are no
slope concerns.
6. MATERIALS AND CONSTRUCTION PRACTICES: The materials used, and the
construction practices will comply with DHHS' "Intermittent Sand Filter Design, Installation &
Maintenance Manual". The contractor should read this document prior to construction. Copies
are available at the Municipal Onsite Services office (5th floor, 9th & L St.).
7. CLOSING: I am open to any suggestions fi'om your department, which would be an
improvement to the proposed design. I am unaware of any adverse impacts this installation would
have on adjacent wells pr septic systems. If you have any questions, please contact me at
337-6179. Thank you ~ffr your assistance.
/I
o S '~, ~'~
[NOTE: ALI_ PROPERTIES SHOWN IN
E. I(J~l' ROAD
.X~,~ ~HI?ERINC SpRU~F
A~S~ WA~R AND WAS~WA~ CONS~TANTS, ~C.
LEGAL OESCRiPqON: ?~?' 4~ TI~J '..~v~
SKY RANOH ESTATES SUBOIVISION ~2, LOT 1, BLOOK 1, ~..: ..... ~Z~.~,~,.,.:...j
SITE PLaN FOR SEPTIO UPGRADE (ISF SYSTEM) ...
PREPARED FOR: PHONE NUMBER:
SANDY POTTER ( "~ '. ...... '~2~
11/18/98 J,L.M. 1 = 100' 1 OF 3
I NOTE: THE INTEGRITY OF THE EXISTING SEPTIC TANK IS TO BE VERIFIED.
IF OF POOR INTEORI~/, IT ID TO BE COMPLETELY ABANDONED AND A NEW
1250 GALLON S.T.E,P, SYSTEM IS TO REPLACE THE EXIS'~NC SEPTIC TANK
--- AND THE PROPOSED 500 GALLON LIFT STATION,
I~ISTING EEO TO BE USE[)
t~ //~ A RESERVE SITE. LOCATION
APPROXIMATE LOCATION OF BED PER SWING-TIES
ON INSPECTION REPORt.
OF ABANDONED TRENC~
..... ~1.25 INCH HDPE UNE SLOPED BACK TO
~ m ~' 3'~6~kTM :~!lJlll/%L CE NOTE)
mk _:5 ~ I HOUSE L MT~'I~ 13 MT /
'"~' ~ /' ~-~_ \ ! INTERMITfENT SAND FILTER OSF)
F= / -~ x, I EXOAVATE O' Y DE BY 36' LOND
J ~ / ~ ~ / AND ~ FE~ DEEP. ADD 2 FE~
WHISPERING SPRUCE DRIVE
PVC JACKET. THE LINE ~HaLL ~E ~U~]E9 TB a HiNiHUH NOTE: THE CONT~CTOR SHALL HAVE THE ~ST PROPERW LINE
]]EPTB I]F a FEET, F~G~ED BY A REGISTEREO I~NO SURV~OR PRIOR TO CONSTRUCTION.
ALSO, THE CONTRACTOR SHALL HAVE THE E~CT LOCATION OF THE
THE C8~T~SL PANEL ~UB THE STEP TaN~ SH&LL 9E WATER LINE PROFESSIONALLY LOCATED PRIOR TO CONSTRUCTION.
PHONE: (907) 337-6179/F~: (BO7) ~38-~246 "'
SKY RANCH ESTATES SUBDIVISION ¢2, LOT 1, BLOCK 1,
DESIGN OF SEPTIC SYSTEM UPGRADE OSF SYSIEM)
PREPARED FOR: PHONE NUMBER:
SANDY POTTER
11/18/98 J.L.M. 1 = 40' 2 OF
i---A~R Hi~
/ AFFI~OK,
(HOH~. 9~l~bP~, ANP PbU~HIkI~
PLAN VIEW
~-2" ~ IN~AflON
~AS~ WATE~ AND WAS~WA~ CONS~TA~S, ~C. ' A
SKY RANCH ESTATES SUBDIVISION ~2; LOT 1, BLOCK 1 ~[~:' 49Z8~ '"~
BOTTOMLESS SAND FILTER (ISF) RETAIL .. ......
%CANES P WL.AMS~
PREPARED FOR: PHONE NUMBER:
SANDY POTTER
BATE: O~WN
7320 E. CHEER H~. CIRCLE * ~CHO~GE, AK. ~0504 ' '~-.~
PHONE (907) 337-6179 * F~ (9D7) 33B-3246 ~ "
J SOIL LOG - PERCOLATION TEST J~ ~g~uf~
~/ ',JAMES P, WlLLIAMSt
DATE PERFORMED: 11/9/98 ~ *,, NO, 9608 ,:
ORGANICS I TEST HOLE ~1I '~(*~A~{t~o,o..,oo?~"<~
DEP~ ~ .....
: ORGANICS/LOAM
2 GP LENSE SOIL C~SSIFICATIONS
I~t~$~ SH/SW '~ ' ;~ GW ~ OR6 ~ING SEPTIC ~TEMS
"~ ~' I' I ~* ' SILTY S~D TO ,~ :)' ~, WE~ G~ED S~D ~ ~', GPGMGc ~'oLCLML ~ E' K~ ROAD-
E
DEPTH TO DATE
ML - DENSE SILT GROUNDWATER
WITH SIDE WALL 14,5' 11/9/98
SMEARING. BECOMES ~3.5; -"i~i~98 WHISPERING SPRUCE DRIVE
DENSER WITH DEPTH _
~3' ~/~7/~B
DATE READING CLOCK NET TIHE WATER LEVEL NET DROP
TIHE (HINUTES) READING (INCHES)
1/9~ ~_~L~D 3~_CA~I~ 3 TIMES~I~IED ~CH TIME IF LESS THAN
UPPER 10 MIN JTES - WATER DROPPED F~TER THAN 1 MIFUTE/INCH.
--B~NCH
] ~ ~.~/9/9E! - PER~._.OLE PRESOI KE~_F~ ?+~ )U.R~RIO~ TO ~
LO~ER 1 fi',05 .........
JIi/
B,O,H, ..._. 5 5:0Z_ .......... 6"
. 6.. 5.,~7 50 MIN. 5 1/2" 1/2" .
PERCO~'FION ~TE <1/60 (NIN,/INCH) PERC, HOLE DIA, 6" (INCHES)
20~ TEST RUN BE~EE~ 1.5-2.0 FT. AND 5,0-5.5 FT,
PERFOMED BY A~SKI WATER · WAST~ATER I,C~,~ X~~' , CERT'~ THAT
THIS WAS PERFOR~EEIN ACCORDANCE WITH ALLI~TE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS
DEPTH TO DATE
GROUNDWATER
~4.5' _ ..~1/9/98
13.5' 11/10/98
13' 11/17/g8
D~C-1~-~998 15~59
MMC CONSTRUCTION INC
522 53?3 P,O1
· I' ·
TOTAL P.01
Municipality of Anchorage Page _
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: $~]q'Z..,o'?~5~ PID Number: ~1~' ~0 2--'Z-L'~-
Name:~p~ ¢O~t ~ Wastewater System: ~ New ~Upgrade
· ~d~s¢.o, ~X ll{~ /~/~, ~q~tl ABSORPTION FIELD
Phone: ~--~O~ [No %edrooms ~ Deep Trench ~Shallow Trench ~Bed ~Mound ~Other
To,al Depth from ori%~de:
LEGAL DESCRIPTION S°ilRating: ,¢ GPD/S, Ft;
Lot: Block Subdivision: )epth to pipe bottom from original grade: Gravel depth beneath pipe
I I ~¢~~ ~,~ F~ '~ Ft
Ft ~ Ft
Number of lines: I Distance between lines:
WELL: E] New Q Upgrade ~ravelwidth: ~OFt ~[ ~ Ft.
Classification (Private. A.B,C); Total Depth: Cased To: Total absorption area: Pipe msterial:
Driller: Date Drilled: Static W~ter bevel: Installer: Dale installeo ~:
SEPARATION DISTANCES ~Septic [1 Holding U S.T E P.
Water ~ .__ . LIFT STATION
LiRoL°t ~ I [~[ ~ Size~in ~allons: [ M~u~act~ror:
kocation and Desedption:
tf * /.' ,':
Inspoctions pefforme0 by: ~~ ~a,~ Dates: ~st t~ ,q ~
Department of Heal and Hu ervices apprgval/ ~..:'-.~.-" ...... .,.....,,.,. .
Reviewed and approved by _ ~ Date: '<~'
72-013 (Flev 9/91)MOA25 /
Permit No. %~'¢
Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: ~J¥-"( ,D. PaqOH- ~¢"U ~'7_[ bo"i- I/fCppg¢-- I
PID No.:
CO'~Z 7--'¢,'~ q,~
CO
CO
72 013A (Rev 9191) MOA 25
PermitNo, ~W'~. O¢_..~z~ Page '~ of '~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description:
PID No.: 01~'
105
~0
05
O0
~5
9O
72-013 A (Rev. 9/91) MOA 25
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920283
DESIGN ENGINEER:MOUNTAIN ENGINEERING
OWNER NAME:POTTER SANDY K
OWNER ADDRESS:3868 SHANNON CIRCLE
ANCHORAGE, ALASKA 99508
PARCEL ID:01530224
DATE ISSUED: 9/14/92
EXPIRATION DATE: 9/14/93
LEGAL DESCRIPTION: SKY RANCH ESTATES #2 BLK 1 L
T 1
LOT SIZE: 16875 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. AL1, 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 (iSAAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY: ~~ DATE:
ISSUED BY: ~_~a-~_~ ~m-~ '-f~4~ ~-- DATE:
MOUNTAIN ENGINEERING
3868 Shannon Circle
Anchorage, Alaska 99508
(907) 562-1500
September 8, 1992
Municipality of Anchorage
On-Site Services
P.O. Box 19-16506
Anchorage, AK 99519
Dear Sirs:
Re: Skyranch Estates #2, Lot 1, Block 1
Owners - Sandy and Brad Potter
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAl. SERVIcEs DIVISION
SEP 0 ,~ 1~92
RE'CEIVED
The purpose of this letter is to provide the required design
narrative in support of our application for a permit to upgrade
the septic system on 'the above referenced lot. Attached for your
reference are the soils log, percolation test results, a land
surveyor's site plan, and design drawings.
The existing drainfield on the lot has failed, and overflows
periodically on the surface. We performed a soils log and
percolation 'test at the location indicated on 'the design drawing.
The resultant percolation rate was 12 mtn/inch. Groundwater rose
to 10.6 FT from the existing grade during the Groundwater
monitoring period. Design was therefore limited to a bed in
order to maintain the Groundwater separation and to provide the
grade necessary for gravity flow. The application rate was .5
GPD/SF. The house has 3 bedrooms, and the required absorption
area is 3 X 150 / .5 = 900 SF.~We have elected to use a bed size
of 23 FT X 40 FT.
The topography of the lot in the vicinity of 'the proposed bed
slopes towards the north at 1% 'to 2%. The house is on a
community water system, and there are no wells within 200 FT of
the proposed system.
Please contact me at 562-1500 if you will need any additional
information.
Sincerely,
MOUNTAIN ENGINEERING
Mark Pearson, P.E.
Z
I'
/3 ~, 04
L
I herlby certify that I have lurvayed the following delcrlb~d property, Lot / Block / i ;
_,~/~ ~..t6~ICFI EU:'F~.'~51UklIT ~ Anchora~ recording Precinct, Alelks, and thst [
the improvem~tl mltuated th~r~n ~re within the property linem and do not overlap or i
' L
Book No, ~ No,
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
6-
7
8
9-
10- WASGROUNDWATER
ENCOUNTERED?
11
Township, Range, Section:
13-
14-
15-
16-
17
18
19
2O
I
SLOPE
IF YES, AT WHAT SL
DEPTH? [[/ pO
E
Deplh Io Water Alter ~:~/~,_~_.,~
Monitoring? JO~! Dale: .
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE [J' ( (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~2~ FTAND "~ FT
COMMENTS
PERFORMED DY: ~ a"~U~/~,~¥, I ~¢*~ CERTIFY THAT THIS TEST WAS PERFORMED IN
0
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~JJ.~CJ ~.
72-008 {Rev. 4/85)
DEPARTMENT OF HEAL'rH & 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 [] NEW
MAILING ADDRESS
Well ~ Absorption area Dwelling PERMIT NO,
Liq, capacity in gallons ' Inside length ' Width Liquid depth
IF HOME.DE:
~Z DISTANCE TO:
~ ~ ~ Manufacturer Material -- LiqUid capacity in gallons
Q Wel~-~ Foundation
~ -- Top of tile to flni~h grade ~ Material beneath tile
~ ~ Type Cdb d ~te]' Drib epth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO;
~ ~l~ss Depth Driller Distance to lot line PERMIT NO,
~ DISTANCE TO'. Building foundatio~ Sewer line Septic tank Absorption area(s)
OTHER
SOIL TEST RATING
RfiMARKS
. ~, ~ '~,.. 'L...
72-013 (Rev. 3/78)
- '
L,F. Zi3 F:II,
II..,I:.~'L.II ]:::IR I::,P.I::I..I I III
Tt.'l[=i t,..Ei'.,II3TH E:,IMEi'.,I'.k.:i!h:)N "c; TFIE L.Ei'.,IGTH ,:lin I'=IEET', 3F 'I'I:IE: '~' -'~ "=' =' F'
'1'1"1[~i E:,EF'TH 'iF:' I:':1 TI;dEN, CH "f::' F:.. I
I:!i[~'.l:)l..li",ll::, I::1'~"1[:' THE [~:l:]T't"l']['i f.]F: THE [!:;:':',I::FI'v'f::FI']:O~',I ,'
':': .... FF,:.Eil`1
'f'I~IE[~:[E :1:'.~: .i",l(:.~.~ .:L.t H'.I:D'f'H F::]P ' :'" '''' ;:'=
THF=' "::' ,' - T~-"--" " "
~f. 1-1, f .I. ii:fiEF'TH .. ::, T H~:;. ~'13:I".11 i'"ll..li'"l E:,[~:E:"I"H OF" ('iiEE'.I::I;,,'~].. [~:1:}_ I'!.,.I~:~Ei:[",I I"HF: OU'I"FI=tl .!. t'. I' I
F::ll",lt) THE l: '; TT "' f"l OF:' TI4E ................... ,::
- - .f,-,.. . c .......... , I1-1:~ :, I::,EPf:II;;'.TI',~EI'.`1T I::,l. ll;;'.:l:l'.,t(!i
F'I~:P.I,i]:'i ~ f I .-I-,11 Ht ... 'l'l. ll:i: h.f..._f _I,!..:I.L.[I,,I I r "1'-i IhlI='(:U;~',F'I .......
1:~ I I [. I I=lhll::, 'FltlE
II'4'.STFILI..f:ITI':ff.I IH::,t E .fi ~.,!::, OF FIN'./ Ilf.LL:, RD.]T~CIENT TO TI.I:['.:)~; "; .....
I'.~I. IHE~EI;?. OF RI:.:,.II [:N .t .... 'FHF:IT THE I,E~I.I.. !.411_1 ..... L.I..,L
i1~ CEI:;;'.'I'I'F'¢ THRT
:1,: I FIM F'FIIVI:II..IFIF:', I.,,IITH Tt,IE [~:E6!U:[REI'IEhFI~; FOI?. ON,,..d~; :I: TI:: ~:;E!,IEI;?.~ AND !,1[~:1.1.~; F:E~;
I::;[)F;I'H D"r' THE F'IL.II'.`1:IC]:I::'FII.ITV JIF; AI.,ICHORA[3E.
2: I I,.IlL. I... ~F`1',E;"I'f:IL.L. THE ',~'¢~TE~3"i :1~1',,I FICCORDF]NCI~ Hi[TH THE
:]~: :1~ I.JF,II::,E-:I;i',~TFINC, THFIT THE ON--'~:~;~'I'E~ ~EI4E:I~: ~;V'.~;TEH HF:I"r' I,~Ep~U:I:I;'.I~: F,:tql,ARdi[~:FIEq",!T ,1:1=' Till:.:
..:, .I. CiNED:
AFF'L ~C~:~N'I" I.m=~F~.~..r %I',IlTH~,.I:I:CK
GREI
ANCHORAGE AREA BOE JGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOCATION ~'f~, "'Ll-'¢ LEGAL DESCRIPTION
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH
M A N U FAC T U R E R-~. ~-/¢~',~ ~---~ 7-~'~.~. MATERIAl
NUMBER OF
COMPARTMENTS
INSIDE WIDTH
LIQUID DEPTH
.LIQUID CAPACITY ,/~'-f)~ GALLONS.
SEEPAGE Pit:
NUMBER OF PITS /, DIAMETER OR WIDTH
LINING MATERIAL~C'~'-¢"/~/'g//4/ CRIB SIZE: DIAMETER
BUILDING FOUNDATION
NEAREST LOT LINE
ADDITIONAL ABSORPTION
LENGTH DEPTH
DEPTH "'] / DISTANCE FROM: WELt
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA)
SO, FT.
WELL:
TYPE ~:~ .4./f'--/. CONSTRUCTION
BUILDING NEAREST
FOUNDATION __ LOT LINE
CESSPOOL OTHER SOURCES
APPROVED DISAPPROVED
NEAREST
SEWER LINE
REMARKS
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE
TANK SYSTEM
DISTANCES:
INSTALLED BY: ~./~¢.16¢-- ~C,
PIPE MATERIAL:
LOT SLOPE:
REMARKS: '~-¢' ~',.~
Form NO, EQ-031
DIAGRAM OF SYSTEM
,~.~.~ / c. .?- / D /`7/
DATE
APPROVED /~'f"¢~¢'~'~
G.A.A,B,
GREATER ANCHORAGE AREA BOROUGH
SEWAGE DISPOSAL SYSTEM -- APPLICA'rlON AND PERMIT
PERMIT NO.
INSTALLATION OF: SEPTIC TANK SEEPAGE PIT ., DRAIN FIELD
P'N^NCEDTH"OU " F"¢C TO"E '"STALLED"" Zf;
OTHER
NOTE~ THI~ PERMIT IS i~OT VALID wI'rHOUT ~OIL, TE~T
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILL. lNG OF ANY SYSTEM WITHOUT FINAL INSPECTION bY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION,
TYPE
SEPTIC TANK --0 SEEPAGE PIT
TO NEAREST LOT LINE,
WELL TO SEPTIC TANK C~OC~ '~--
DRAIN FIELD
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
SEPTIC TANK, /'00 , SEEPAGE Pit
TO RIVER, LAKE, STREAM·
FOUNDATION TO SEEPAGE PIT
, SEEPAGE PIT
DRAIN FIELD
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIO TANK AND SEEPAge PIT
FITTED WITH Al RTIGHT REMOVABLE CAPS.
GRAVEL, BACKFILL
CONFORM TO BOROU~I] REGULATIONS ~EGARDING INSTALLATION,
I'
I CERTIFY THAT [ AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA [~OROUgH ORDINANCE NO. 2B-§8 AND THAT THE ABOV'
DESCRIBED SYSTEM IS IN ACCORDANCE W]TH SAID CODE.
Performed For Glacier Excavating __Date Performed ~-IT-TLF
Legal r)escrintion: Lot I Block. l,~___Subdivision__~k~_~.anch
Percolation Test
This Form Rep,errs Soils Loq yes
Oeoth
Feet Soil Characteristics
Inlet T~ Seepage Pit
Silty Sand with 2 ft. layer of
Gravely Sand
SW & SM 210
7.i~__~Bottom of Seepage Pit
8--
11 ~:----' Bottom of test pit
Was Ground Water Encountered?_N°
I¢ Yes, At what Depth?
[--R e a d5 n-~.
[ T.
Percolation Rate
Proposed
Den, th of
CF~!AENTS:
Date
Gross Time
Net Time
Depth to H20
·
Minute
Inst~OH: SeenaQe Pit yes Drain
Net Dron
Field
Inlet __ Deoth ~ Bot'~om Of Pit Or Trench
drains~e area ~required~j~_er bedroom_
210 ~,.qL._~.ft. ---- ,o ..... ' --- ~
no_bed?OO~ or--Mg~-b-~jO--~e~ ~_fb~_be]:9~ ~eep_~
Data Certified B~:_~s_~_b;cjx~J_o~.-~e~bl
Test Performed By Jim Mack ---- Date' 5-I7-7~- . ......
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
P~rcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
015-302-24 HAA# '~
1. GENERAL INFORMATION
Complete iegal description
Lot 1r Block lr Sky Ranch Estates No.~?~,%
Location (site address or directions) 5001 Whispering Spruce Drive
Property owner
Mailing address
Lending agency
Mailin. g address
Agent
Address
S~ndy Potter.
P.O. Box 111313
Day phone 346-2004
AnchorageCAK 99511-1313
Day phone
Day phone.
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: Three 3 ) ..
TYPE OF WATER SUPPLY:
Individual well
Community well ××x
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:
XXX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(Rev, I/91) Fronl MOA#21 ~
STATEMENT OF INSPECTION BY ENGINEER
AS certified by my seaJ 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 Mun[cipa]ity'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 Anderson Engineering
Phone 522-7773
Address P.O. Box 240773 AnchoraGe, AK 99524
DHH/S SIGNATURE
~/' Approved for '~.~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
AdditioneJ 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.
Legal Description:
A, WELL DATA
Well type PW$
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
of Anchorage R
Municipality
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 3.43-4.7.44.
Health Authority Approval Checklist
Lot 1, Block 1, Sky Ranch ParcellD.: 015-302-24
Estates No. ~k
Public Water System
If A, B, or O, attach ADEC letter. ADEO water system number
Date completed.
Cased to
Casing height (above ground)
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed 1 992
Foundation cleanout (WN)
Date of Pumping 9/98
C. ABSORPTION FIELD DATA
Date installed 1 2 / 98
Wires properly protected (Y/N)
AT INSPECTION
Nitrate
g.p.m, g.p.m.
Collected by:
Tanksize 1 ,000 Number of Oompartments 2
Y Depression (Y/N) N
_Pumper Rotc Rooter
High water alarm (Y/N) N
Other bacteria
Length. 1 00 ' Width 5 '
Effective absorption area 1 , 111
Date of adequacy test Hew Const,
Fluid depth in absorption field before test (in.);
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
__ Cleanouts (Y/N) Y
System type5 ' Wide Trench
4 ' Total depth 0 '
_ Depression over field (Y/N) N
For Three bedrooms
gal. water added (in.): _ __
.g.p.d.
Soil rating (g.p.d./fF or ff~/bdrm) .45
Gravel thickness below pipe.
Monitoring Tube present (Y/N) Y
Results (Pass/Fail) Pass
Immediately after
Absorption rate =
N/A If yes, give date
F.
LIFT STATION
Date installed
- None on Lot
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation > 5 ' Property line > 5 '
Water main/service line > 2 5 ' Surface water/drainage > 1 0 0 '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line > 1 0 ' Building foundation > 1 0 ~
Surface water > 1 0 0 '
Public Water System
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
"Pump off" level at*
Absorption field ;, 5 '
Wells on adjacent lots > 2 0 0 '
Water main/service line
Driveway, parking/vehicle storage area > 1
Curtain drain None on Lot Wells on adjacent lots > 200 '
ENGINEER'S CERTIFICATION
I certify that I have
in conformance with MOA HAA guidelines in effect on this date.
Signature ~ ~',_~,~t,..~--_..,, '~'~
Engineer's Name Michael E. Anderson, P.E.
Date 3/5/99
HAA Fee $ ?-~, ~-~,~
Date of Payment ~ ~%
Receipt Number ~L~--~\-~ ~
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECTIOI~EpT. OF HEAL'rll &
825 L Street- Anchorage, Alaska 99501 ENVJP.!)NMEN, TAL pF, OTEC.~TJON
ENVIRONMENTAL ENGINEERING DIVISlON,~~--1980'-
Telephone 264-4720 \'"~'/~_ _ _
i)IRECTIONS: Complete al parts on page 1, Incomplete requests will not be processed. Please allow ten (I01 days for processing,
1. PROPERTY OWNER PHONE~is
Larry & Sharon Smi~.hwick
WK- 349-3536
V1AI LING ADDRESS
SRA BOx 1622K, Anchoraqe, AK
PROPERTYRES~DENT If different from above)
same
99507
PHONE
PHONEher
WK- 264-6591
2. BUYER
rl~eodore & Sandy Potter
MAILING ADDRESS
6802 E. 12~aAvenue, Anchoraqer AK
3. [.ENDING INSTITUTION
United Bank Alaska
99504
PHONE
276--1911 ×210
MAILING ADDRESS
645 G Street, Anchoraqet Alaska
4, REAL'I'OR/AGENT
~/a
99501
MAILING ADDRESS
PHONE
E. LEGAL DESCRIPTION
Lot 1, Blk 1, Sky Ranch Estates
STREET LOCATION
~\ NHN Whispering Spruce Drive
S. TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One [~ Four
[] Two [] Five
[] Three [] Six
[] Other
7, WATER SUPPLY
[] INDIVIDUAL~ * ATTACH WELL LOG, Awel o§ s required for all wells driHed
[~ COMMUNITY since June 1975. For wells drilled prior to that date, give we
[] PUBLIC UTILITY ~e~th (attach og if available.)
8, SEWAGE DISPOSAl. SYSTEM
[] NDIVIDUAL ~ON-SITE*- ~' f individual/on-site, give installation date -~ - ~[~ '~ ~ q-¥~l
If system is over two (2) years old an aueouacy test is required t.J.
[] ~UBLIC UTILITY
Dy [nls 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
INSPECTOR INSPECTOR I NSP ECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] ONE [~ THREE [] FiVE [] OTHER
SINGLE
FAMILY
[] 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
ii]PUBLIC UTILITY [._~[3~d~]) '~_ ~.o~_ -~o~
Connection Verified INSTALLER
~Septic Tank or [~] Holding Tank
Size:~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANJ~ ~t~ MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
~ APPROVED FOR .3 BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
DATE ~ DISAPPROVED BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)