HomeMy WebLinkAboutSKY RANCH ESTATES #2 BLK 2 LT 22
Municipality of Anchorage page _J__ o~
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 345-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: .__5.W c~ 30 I'/L~ ........ PID Number: Ol,53°2L/~
Name: Wastewater System: [] New 1~ Upgrade
JEFF + KRIS'FIN ~o6N£5
Address:
11"711 Sh~ET£ANb HT$ CI~,, ~c~ 9~-,6 ABSORPTION FIELD
I No ol .~drooms ~f Deep Trench I~ Shallow Trench [3 Bed E] Mound O Other
0,~O GPD/Sq Ft 10,~' !
"°' 22. 2
Township:l: N I rian[,e%i s.o,io,,I Fill addnd above original grade: Grave, length:
~ 2~ 0.~ ~, ~' ~1~' '- ~ Ft.
Number o~ lines: ~ Oisiance between lines:
SEPARATION DISTANCES ~Seplic O Holding 0 S.T.E.P.
From Tank Fmeld Slalmor, Tank Sewer Lmnes
We, ~ - - ~ -- Co~cRg'r~
Water ~/~' >~oo ~ - '>~o~' LIFT STATION ~,A,
L
Remarks: ~¢ph~ t~n~ ~z ~,~ ~'~ BENCH MARK
I~0~+ ~llon, ~ con,~a~t~tn~ m~cre~ ~nl¢ LccationandDescription:
Inspections performed by: ~LA~oP }gE'l¢ 5F6g Dates' 1st
Department of He nd Hum endces appro~al/
Reviewed and app
72-013 {Rev. 9'91} MOA 25
PermitNo._ .~I,v c~'801'7fit Page 2. of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVlRONMEN'DAL 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: .LOT 2'2, I~LK .2. , ¢&-¥/~/]NCff EST, t~2. PID No.:
TRENCN
3 BDRM
HOUSE
C.O, "b
'T' I E_~
:~oM A I5
~L' go'
72-013 A {Rev 9/91) MOA 25
Flattop Technical
14530 Echo Street
/t.nchorage, Alaska 99511
Permit No. ~ ~j~.~_O~!__-7 ~ __ Page
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: ~,¢T 2~,~tl< '2, SKY~,~NC// EST,'~t'2 PIDNo.: Ol
SEPrrc_____'[ANIC J)
VERTICAL SCALE: / =S
l~o doRIzo,',{T4c SCALE
FoR L/IY OU'F
Flattop Technical Services
14530 Echo Sh'eet
Anchorage, 2-[laslcc~ 99516
CONC. SLAB
ELEV ; I00,o t ..~
r
~o~%O~ oF TRENC~
T. 14. Cz
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:SW930174
DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES
OWNER NAME:ROGNES JEFF R & KRISTIN A
OWNER ADDRESS:il711 SHETLAND HTS CIR
ANCHORAGE, ALASKA 99516
PARCEL ID:01530246
DATE ISSUED: 6/22/93
EXPIRATION DATE: 6/22/94
LEGAL DESCRIPTION: SKY RANCH ESTATES #2 BLK 2 L
T 22
LOT SIZE: 15801 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE: ATTACHED APPROVED DESIGN.
2. ALI, 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 (18AACS0).
3. THE: ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CAI, LING 343-4329 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY: C 0~/.
DATE:
CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS
TIfEODORE F. MOORE, P.E. June ~.~A, 1993 14530 ECHO ST.
PH: (90?) 345-1355 ANCHORAGE, ALASKA 99516
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sh's:
The purpose of this letter is to provide the requh'ed design nan'ative ill support of our application for a
permit to upgrade the wastewater disposal facilities on Lot 22, Block 2, Sky Ranch Estates #2, located at
11721 Shetland Heights Cimle. While it is not backing up, the existing soil absorption system was found
to be operating in a surchm'ged condition, and thus cannot qualify for a HAA certificate until it is
upgraded. Soils logs, perc test results, a site plan, design drawings and specifications m'e enclosed for
your review.
The proposed system will be constructed between test holes #1 and #2. As can be seen from the soil
logs, the native material between between 3.5 and 16.5 feet below ground level is a gray sandy silt with a
measured perc rate of 10 minutes per inch. Using a slightly conservative soil application rate of 0.6 gpd/
square foot, specified in the wastewater ordinance for soils with perc rates between 15 and 30 minutes per
inch, this 3 bedroom residence requh'es a total absorption m'ea of (3 x 150)/0.6 = 750 squm'e feet. Tile
proposed 73 foot long trench with 6 feet of sewer gravel beneath the horizontal distribution pipe has a total
effective absorption area of 756 square feet. Ten feet of trench length, where it passes through the
vicinity of the old septic tank, have not been counted in the calculation of effective absorption area.
The topography of the lot in tile vicinity of the proposed construction is generally level, with a slight
slope down towards the west.
The proposed project will have no known impact on present or future water supply and wastewater
disposal systems serving adjacent properties, nor will it have any impact on reserved space/surface and
subsurface, or on di'ainage.
Please give me a call at 345-1355 if you have any questions on this submittal.
Sincerely,
Ted Moore, P.E.
SoT 2 ~
15"
,,~ / ~I HoLE LoT 22
Flatto~ Technical Semites
14530 Echo Street
Anchorage, Alaska 995]
LOT 22., BLK 2, SKYRANCH
.~ITE PLAN
SCALE'. 1"=3o'
DATE:
D~,~ BY.'
NOT~.. TH~s 15 NOT
~LL LocAT{o~I ~
,~1~.~ AP?Rox Ir'lATE ,
NEw IooO 6AL
PLAN VIEW
1'= 10t
S[CT ~oN "A -A"
1"= 5~
/ Hoi41TOf- TuBE
' 2~
10.5t EXCAVATION
~]at[0'~ Te'ch~ica] Se~ices
14530 Echo Street
Anchoraqe, Alaska 99516
LOT 9.2, BLk 2, 5KYRAt~C~t ~2
50IL ABSORPTION-FRENCH
PLAN, 4- CROSS SEC_'FIoN
SCALE
Flattop Technical Services
14530 Echo Street, Anchorage, AK99516
Phone (907) 345-1355
Lot 22, Block 2, Sky Ranch Estates #2
11721 Shetland Heights Circle
Wastewater disposal system installation
Specifications
1.0 General:
1.1 The scope of the project consists of abandonment of an existing 1250 gallon septic tank and
installing a new 1000 gallon septic tank followed by 73 lineal feet of soil absorption trench containing a
toted of 6.5 feet of sewer gravel.
1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor
deviations from these drawings may be allowed or required by the engineer condacting the inspections.
All construction procedm'es and material specifications shall conform with Municipal and State
requh'ernents. All separation distances shall be in conformance with Municipal requirements, unless
specifically waived.
1.3 The conU'actor shall be responsible to obtain any necessary utility locates, and to work around any
bm'led utilities.
1.4 The contractor shall provide adequate cover material and rough grading over all system
components to ensm'e that proper drainage is achieved after settlement and that there are no residual
depressions. Insofm' as possible the contractor shall minimize damage to trees and existing lawn areas.
1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after
the soil is compacted, as well as placement of topsoil and reseeding all areas disturbed by the construction.
2.0 Septic Tank:
2.1 The existing septic tank is to be properly abandoned by thoroughly pumping, removing, crushing
and bm3'ing on site, or by another approved method.
2.2 The new 1000 gallon septic tank shall be Municipally approved, and shall be set level on
undisturbed soil.. Each compartment shall be equipped with a watelXight manhole cover and a 4" cleanout.
If the tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial type, rigid
insulation.
2.3 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The
waste line from the residence to the septic tank shall have a minimum slope of 1/4"' per foot, and the waste
line between the tat~k and the soil absorption system shall have a minimum slope of 1/8" per foot. A
double cleanout shall be installed within 5 feet downstream of the septic tank.
3.0 Soil absorption system:
3.1 The soil absorption system shall be constructed by excavating a 73 foot long U'ench to a total depth
of 10.5 feet below the present ground elevation in the vicinity of test hole #2.
3.2 The bottom of the wench excavation shall be level. Any compacted or smeared sidewall surfaces
shall be raked to allow proper infilu'ation.
3.3 A total of 6.5 feet of approved sewer gravel shall be placed in the bottom of the excavation with
the perforated distribution pipes laid level such that the pipe inverts we no less than 6 feet above the bottom
of the sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing the
g200 sieve.
3.4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on
the design drawings. The portion of the monitor tube extending through the sewer gravel shall be
perforated.
3.5 Approved filter fabric shall be placed over the entire top surface of the sewer gl'avel before backfill
with clean soil.
3.6 The top surface of the cover material shall be raised a minimum of 6 inches higher than the
surrounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill
slopes shall be no steeper than 3:1.
3.7 After the baclffill material has stabilized, all m'eas distm'bed by the construction shall be covered
with 4 inches of topsoil and seeded with grass to promote rapid revegetation. This work shall be the
responsibility of the property owner, unless specific m'rangements m'e made with the septic system
installer.
4.0 Inspections:
4.1 A total of 4 engineering inspections will be required during the course of the project: (1) initial
stakeout with the contractor to establish the location of the system mid to discuss the plans, specifications
and construction procedures, (2) after the native material has been excavated to expose the infila'ative
surface to ensure that it is level and at the right elevation, and conforms with the soil test information, (3)
after the sewer gravel is in place and the disu~ibution pipes have been laid and connected up to the septic
tank, but prior to placement of filter fabric, and (4) after final backfill and grading is complete. The septic
tank requh'es one inspection after it is set level and the piping connected, but prior to backfill. This
inspection may be incorporated with any of the above inspections.
4.2 The inst~ller shall coordinate the timing of the inspections with the engineer sufficiently far in
advance to ensm'e the availability of the engineer.
.ERFORMeD F F
~'l~tfS]~ T~'~fi~! Services
~ - 14530 Echo Street
Anchoraqe tUc:~!,'a 995!$
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
ROGNES
LEGAL DESCR PT ON LoT 2'~. ~LK 2
~L FILL
2 PT
3 ,~h~ REbblS~/
7-
8-
9-
10-
11
12
13
14
15
16
18
19
20
COMMENTS
t4'2'T°wnship'sLopERange' Section: SAC. S~i2Tt~ PLAN
SANDY Lo~M
SoM~ COBBLES 4 GRAVEL
~fo "7
~OCKE TS OF F~NE ,~ND
WAS GROUND WATER
ENCOUNTER ED?
S
IF YES, AT WHA'r
DEPTH?
I}
Oeplh [o Waler Alle~
Reading Date Gross Net Oopth to Net
Time Time Water Drop
i~-~PRESo/~, s~/~o[~- Io:~o~.oc~ :2'/
10WB',°°
.... [Ko3:oo 15 2t Y~ ) Y~
*H~O H:o3: 3o 23
~.H20 Il:lq:°° ~S ~
ft~;o 11,3~,~' ' o 23 ~,
PERCOLATIONRAIE _/O (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ FY AND ~,-.~ FT
CERIlFY THAT THIS TeST WAS PERFORMED iN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev 4/85)
FERPORMED POR:__2E FF
~.d'tt6~5 T685~E~I Services
,~. .... 14530 Echo Street
.Anchoraffe, Alc::',l,'.q 995!8
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
RoGN~,
LEGAL DESCRIPTION: LoT 2'~, ~LK 2
pT
~L FILL
~f~ R£DDIS~
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
5k~l~/l~Cl'l ¢2T°wnship, Range, Section: $E¢ ~'2,,
5jNb¥ ADA,'4
ff.,Il, ~l BUT L£~¢
ANb ~ORE 5/}Nb
COMMENTS
CoME CoBBLE~
ANb
'FO ~ '
SLORE
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, A'F WHA F
DEPTH? ~,/~ O
E
Deplh Io Water Aller I(~, ~.G,L,
SITE PLAN
Gross Net Depth to Net
F~eading Dale
Time Time Water Drop
PERCOLATION RATE
}EST RUN BETWEEN
(minutes/inch) PERC HOLE DIAMETER
. F'[ AND FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFEC] ON ]'HIS DATE·
72-008 (Rev. 4/85)
CER]IFY THAT THIS TEST WAS PERFORMED IN
DATE:
GREA1ER ANCHORAGE AREA BORg GH
Department of Environmeni~al Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
MAlt. lNG ADDRESS .%i~,/~ t~'~,"~-~" I'~ PHONE
LEGAl_ DESCRIPTION ~'~
SFPTIC TANK:
DISTANCE (~l
FROM WELL"~¢) }
INSIDE LENGTH
MANUFACTURER
NUMBER OF
COMPARTMENTS
INSIDE WIDTH
LIQUID DEPTFI__ __LIQUID CAPACITY_® GALLONS.
NUMBER OF PITS ---
LINING MATERIAL
BUILDING FOUNDATION__
ADDITIONAL ABSORPTION
DIAMETER OR WIDTH
CRIB SIZE: DIAMETER
NEAREST LOT LINE ,
LENGTH____, DEPTH
DEPTH .... DISTANCE FROM: WELL
TOTAL EFFECTIVE ;
ABSORPTION AREA (WALL AREA) ~1'$~ ~"
SQ. FT.
WELL:
TYPE ~'~-F~ff~ tl~..
BUILDING
FOUNDATION
CESSPOOL _
APPROVED __ DISAPPROVED _
CONSTRUCTION
NEAREST
LOT LINE
OTHER SOURCES
..... DEPTH
NEAREST SEPTIC
SEWER LINE TANK
REMARKS .....
DISTANCE FROM:
SEEPAGE
SYSTEM
DISTANCES:
INSTALLED BY: LO(.~'(~- _~_~/~ (_.
LOT SLOPF
REMARKS: --
Form No, EQ-031
DIAGRAM OF SYSTEM
APPROVED
G.A.A.B.
25J~0 E.
DE:F'Fh~:Tf,IEN'I" : HERL.'I"N RN[:, Ef.,l',,: I RONHENTf:IL ,' -'l"[:J- T"~ N
, UDOR RE:,. · FINC:NOF,'.f:I[~iE.,
PERMIT NO. ( 7~;;T'.~,¢, )
SRR :t.6 :'.'::5 [:,
E, LI',. 2 =,K-r RRNr_':N ES'f'RTES
FIF'F:'L I CRNT NEI. [:,RE'¢HRi"I~
LOCFITION =,HEY~LCff., HEIGHT.:. CIR...LE
L.E(IFIL
LOT .., I ~E
T'T'F'E OF SOIL F:IBSORBTION SYSTEM I.=,. TRENCN
' ,' I 4
HR,,,Ii'ILM F,IIJHBE'R OF E:EDROOHS =
(=:,U FT,"BR ) =' :1 ....
SOIL RAI'INI3 ,-"l · o=
THE REQLIIRED SIZE OF THE .~IJIL I--IB~ORFIlOrl .=,T~TE.M
THE LENGTH DIMENSION IS THE LENOTFI (:IN FEET) OF THE TRENCH OR I)t;.:RINF'IISI._D.
THE DEPTH OF R TRENCH OR PIT IS THE DI~;"FFINCE BET;,.IEEN THE SURFRCE OF THE
GROUND FIND THE BOTTOM OF THE EXCRVRTION',:.'IN FEET>.
'THERE IS NO SET WIDTH FOR 'FRENCHES.
TNE GRRVEL DEPTH IS THE MINIMUM DEPTH 01:' EiRRVEL BETNEEN THE o(.rTFRLI.. P;rF'E:
AND THE E:OTTOH OF THE EXC:RVRTION (IN FEIET).
EITHER FI C.[_Rz~_ I OR II NSP ,~PF'ROVED PLF1NT I"IFPr' E:E IN.::,IPLLE.L..
R C:ONTINUOUS MRINTENRNCE RGREEMENT IS F.:EQtJIF,:ED. IF' R MRIhI'FENRNCE
- ~.. ~ .,. ;,., - ::,. I L.
t.~REEMEf',IT I:, NOT KEPT :':LRRENT YOU MR'¢ BE F,'EQLIIF,'ED TO ENL. FtF.L~E. TFIE ' '
'"' .":' ' , , "r'OU .'5,1JELTEIZ T T(:I PR.: 5ECI.JT 1 ON.
FIE:SORPTION mN_,3'EM FIND/OR r,lR'.¢ BE
IF' FI CLRSS'; I S'YSTEM IS LSED THE LENGTH IS 4.,':i-. 0 FEET.
_.LA__ II SN.'STEM IS U_.ED THE LENGTH IS ...6. O FEET,
q ,,~ , '- ' ' rlI.L
EIRC:I<FILLING OF RNY _'T~TEi'I ;,JlTHOtJT FINRL II'.,I.=,PE...I'ION AND FIPPI;.:OVFII_ E:"r' "" '::'
[:,EF'RWFMENT !.,.IILL BE _,UE, JEL. T TO PROSE::LFrION.
HINIIqLIr,'I DISTRNC:E EETNE. EN R WELL Rf'4[.~ RN'T' ON-SITE =,EIIR.*E. !:':,IqF'F':;Pll : 'r_TEll )
:1. OO FEET Fr:IR Fl PRIVRTb: WELl- OP, ;'~OO FEET FOF-: FI F'UBI_IC WELl..,
...., ........ f-, ~
>f-EL. IF I-.RTIONz RND CONSTRUCTION [:,IRGRRr,'IS FIRE FIVRILFIBLE TO INSUF,'E PR. 3PER
]: I'4.S T'Rt_LRT Z ON.
]: CERTIF"r' THRT
d.: I RM FRMILIRR Hl'r'H THE REO. UIREEMENTS FOR ON-SITE SEWERS RND 14ELLS RS SET
F;'ORTI-; B'T' THE i"IUNICIPRLIT'T~ OF FINCHORRGE.
2:': I WILL INS'FRLL.. THE SYSTEM IN F:ICCORDRNCE 14ITH TFIE CODES.
2~:: I tJNDERSTRND THRT THE ON-SITE SEWER SN"S'TEM I'"IRY F.:E:C,!tJIRE E:NLRROE.r. MENT IF' TF'IE
RESIDENCE IS REMODELED TO INCL. UDE MORE THFIN 4 BEDROOI"IS.
RPPLI CRNT NEIL DRIE'¢HFIH
MUNICIPALITY OF ANCHORAGE
Department of Health and Environmental Protection
SOILS LOG
PERCOLATION TEST
Performed for Neil Dreyham Date Performed 5/18-19/76
Legal Description Lot 22, Block 2, Skyranch Estates Subdivision
(See back for hole location)
l0
Dark, red-brown, silty, sandy gravel (GM)
Perc rate = 225 ft.2/bdrm.
Gray-brown, silty, gravelly sand (SP)
Perc rate = 150 ft.2/bdrm.
Gray~ silty, sandy gravel (GM)
Perc rate = 225 ft.2/bdrm.
No water table encountered.
AVERAGE PERC RATE FROM SOILS LOG = 210 ft.2/bdrm.
Date Net Time Depth Net Drop
5/18/76 7 min. 17.5 in. 10.5 in.
12 min. 27.0 in. 20.0 in.
5/18/76
5/29/76
24 min.
35.0 in.
28.0 in.
1229 min. 95.0 in. 83.0 in.
· ~/19/76 1331 min. 102.0 in. 95.0 in.
Percolation Rate 14 minutes/inch = 185 ft.'~/bdrm.
INC.
July 22, 1975
R & M NO. 562068
J~c~ Nam~el
5706 East Northern Lights Blvd.
Anchorage, Alaska 99501
RE: Test Hole and Soil Log Report for Sanitary System
Lot 22, Block 2, Sky Ranch Estates
Dear Mr. H~pel:
We are submitting herewith the test boring results and our comments regarding
soil conditions encountered at the subject site. This investiga%$on was per-
formed in accordance with your request of 7-18-75, and those pro6~dures out-
lined in a letter dated December 19, 1974 by Mr. Rolf Strickland of the Greater
Anchorage Area Borough Department of Environmental Quality.
A single test hole was put down within the Lot 22 area for the purpose of defin-
ing general subsurface soil conditions for the proposed sanitary system. Ex-
cavation was accomplished with a tractor-mounted backhoe and the test hole was
extended to a total depth of 14.5 feet below ground surface. The final log prepared
for the test hole has been included in Drawing A-01.
Ground water was not encountered in the test hole.
We appreciate being given this opportunity to be of service to you. Should you
have any questions with regard to the above, please do not hesitate to contact us.
Very truly yours,
R & M CONSULTANTS, INC.
JWR/ja
xc: GAAB
T.H.-1
7-18--75
ORGANICS
ORGANIC SILT
0.0I
3.0I
SILT, SOME SAND TI~ACE GRAVEL
NO WATER TABLE
14.5' T.D.
Log Represents
Lot 22 Block 2
Sky Ranch Estates
Engineering ~ Geologic(Il Consultants Inc,
ANCHORAGE FAIRBANKS ALASKA JU.EAU
Jack Hampel Property
Log of Test Hole
Anchorage, Alaska
DATE 7--22--75 ]SCALE 'L"-3' IDWN 8Y WE,D JCHKDOY WED Ip~O4. NO. 562068 IDWG NO. A-01
ANCHORAGE, ALASKA 99501
of (907) 264-4111
l ChOr ¢ EORO. M. EU.L,VAN
MAYOR
ENV R 0~ ~ ~'~k~ ~ ~,,~
DEPARTMENT OF HEALTH AND DEPT. OF
ENV[RONMEN1 AL
May 19, 1980 I~/~AY 2 8 1980
RECEIVED
Sue Remlee
Star Route A Box 1621
Anchorage, Alaska 99507
Subject: Lot 22 Block 2 Sky Ranch Estates Subdivision
Approval for your individual sewer and water facilities
can not be granted until the following items have been
completed:
(1) The septic tank pumped with a receipt submitted
to this department.
If there are any further questions,
office at 264-4720.
Sincerely ,~
Fo~b~r t~C.
Associate Specialist
please contact this
RCP/ljw
CC:
Ronald D. Miller
% Bowden Co. Realtors
8403 Little Dipper 99504
PENINSULA
ENG]INEERING
2820 "C" Street, Suite #3
Anchorage, Alaska 99503
276-4855
!.i: 2
November 15, 1980
Susan Renele
Shetland Circle
SRA #1621
Anchorage, Alaska
Re:
Lot 22 Block 2 Skyranch Estates #2 (file #80-E-23)
Sewer System Adequacy Test
Dear Ms. Renele:
As per your request, I have performed an
above listed property in accordance with
Anchorage guidelines.
adequacy test on the
the Municipality of
The system consists of a septic tank in con~ination with a
drainfield and was tested as follows:
1. Water was fed into the absorption system at approximately
10 g.p.m, for a total time of 65 minutes on two consecutive
days and the depths in the drainfield and septic tank were
monitored at regular intervals. The total volume added to
the system was 650 gallons each day. The depths recorded
are listed on the attached data sheet.
The test results indicate that the system is functioning nor-
mally and would, in my opinion, be considered adequate for
the existing four bedroom home.
Sincerely,
Wayne Henderson, P.E.
TEST DATA LEGAL DESCRIPTION: Lot 22, B±k 2 Skyranch Est ~2
DATE
WATER LEVEL
SEPTIC TANK
WATER LEVEL
DRAINFIELD
TIME
(MINUTES)
il/il/80
11/12/80
52" 0
53" 0
53" 0
53" 0
53" 0
54" 0
54" 0
54" 0
54" 0
54" 0
54" 0
54" 0
54" 0
54" 0
54" 0
54" 0
54" 0
54" 0
0 (9:00
5
10
15
20
25
35
45
55
65
0 (9:00
10
20
30
4O
5O
60
65
am)
am)
MUNICIPALITY OF ANCHORAGE
Development Services Department
OnSite-Water-& Was e��Section - -- - -
Parcel I.D. 015-302-46
Certificate of On -Site Systems Approval
Expiration Date:
Legal description SKY RANCH ESTATES #2 BLK 2 LT 22
Site address 11721 SHETLAND HEIGHTS
Current property owner(s) Jeff and Kris Rognes
Phone: 907-343-7904
X The On-site system(s) is/are approved for Y bedrooms
Conditional approval for bedrooms, with the following stipulations:
rax: UU1- 1-343 --
Comments or advisories: Buyer is to be aware that there is a belly in the sewer
line upstream of the septic tank. Periodically this line clogs and is required
�0z
to be jetted/snaked every few years. This is not a code violation so is not required
to be repaired in order to obtain a COSA.
Original Certificate Date: 4/3/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA ApprovMjune 2022
t
MNPA1" OF ANCHORAGE
Development Ser --ices Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
.Ge rtificate-of O-n=Sjte-Systems Approval Application -
1. GENERAL INFORMATION
Parcel I.D. 015-302-46
Complete legal description SKY RANCH ESTATES 42; BLOCK 2, LOT 22
Location (site address) 11721 Shetland Heights Circle *Anchorage
Current property owner(s) Jeff & Kris Rog nes Day phone 441-8043
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑■ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: FN� Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic [N—J Concrete ❑ Fiberglass
Age 50 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed 0 Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee Waiver Fee $
Date of Payment 3 ,/Z 7/3013 Date of Payment
COSA # 05C 2 2 1 or,_63- Waiver #
COSA Applicabon June 2022
rin%
COSA Checklist
Legal Description: SKY RANCH ESTATES #2; BLOCK 2, LOT 22
Parcel ID: 015-302-46
30g4
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA COMMUNITY WATER SYSTEM
❑ Well log is filed with Onsite (or attached) Well production at time of test
Date drilled Total depth ft Water storage tank vol u gallons
Cased to ft Well disinfec or coliform test? ❑ Yes ❑ No
❑ Sanitary seal is functioning correctlyE:I- Ariform bacteria is Negative
❑ Wires are properly protected Nitrate mg/L ❑ Nitrate less than MRL (ND)
Casing height (above ground) Arsenic u /L
g ❑ Arsenic less than MRL (ND)
Date of flow test for COSA Collected by
Static water lev eginning of test ft. Date
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping 3/17/2023
❑ Required maintenance completed, if AWWTS
Comments: SEE ATTACHED EMAIL FROM ARM REGARDING TANK BAFFLE
C. LIFT STATION
❑ Required maintenance com
Age of lift station years
Lift statin erial
DATA IS FOR 1976 TRENCH
D. ABSORPTION FIELD DATA
Which system tested (date installed) 1976
Adequacy test date 3/13/23
❑ ALL standpipes present per record drawing
Results 0 Pass
9.66
Total measured depth from grade (max)
ft
Fluid depth prior to test 15
Measured depth to pipe invert from grade 5.0 ft (min)
Water added 683 gal
❑ N/A — pressurized field.
New fluid depth 32 in
❑ Per record drawings, field is insulated.
Elapsed time 130 min
❑ Monitor tubes go to bottom of effective.
Final fluid depth 26 i,n
If not, state depth into effective EAST: 4.5'-4.7' WEST: 4.08' 4.25'
Absorption rate 600 9pd
in
� 323
�l
t 2
❑ Presoaked required If FIELD STATUS�'c
OST RE OVERY
(Required if house vacant or field not us r more Effective depthr re, drawings) 72 in
than 30 days prior to date of test
Gallons introduced gallons date Effective depth used it
Effective depth emainin
a '
Any rejuvenrment (
eatpast 12 months)
enter date D
In
Comments/Deficiencies: TESTED 1976 TRENCH ONLY - EAST TRENCH IN 1993 SYSTEM WAS DRY DURING GEG INSPECTION
SEE ATTACHED EMAIL FROM ARM SEPTIC SERVICES AND OWNER REGARDING THE OUTLET BUNG AND SEWER LINE
PRIOR TO TANK. ADDITIONALLY, SEE ATTACHED LETTER FROM GEG REGARDING BUNG AND SEWER LINE
COSA Checklist—June 2022
9%V1
if
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100'
Community Sewer Manhole/Cleanou _
❑Yes
if No
ft
Yes
if No
Neighboring Tank > 100' ❑ Yes
if No
ft
Private Sewe is Line > 25' [:]Yes
if No
Absorption Field on Lot > 100' ❑ Yes
if No
ft
ding Tank > 100' ❑ Yes
if No
Neighboring Absorption Fields > 100'
Animal Containment > 50' E] Yes
if No
❑ Y
I No
ft
Manure/Animal Excreta Storage > 100'
CommunitySewer M _ 5' ❑ Yes
if No
ft
❑ Yes
if No
❑ N/A — Served by Community
Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s)
on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑ Yes
if No *5+
ft
Surface Water > 100' ❑ Yes
if No
Tank to Property Line > 5' ❑■ Yes
Field to Property Line > 10' ❑■ Yes
Water Main > 10' ❑■ Yes
Water Service Line > 10' Z Yes
if No ft Wells on Adjacent Lots:
if No ft Private Wells > 100'
if No ft
**
if No ft
Community Wells > 200'
❑ Yes if No
[—]Yes if No
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
*MET CODE AT TIME OF INSTALL **ASSUMED BASED ON WATER KEY LOCATION
ST1 IS APPROXIMATLEY 2' FROM DRIVEWAY
ft
ft
ft
ft
ft
ft
ft
ft
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Garness Engineering Group, LTD. (GEG) Phone 907-337J-6179
Engineer's Printed Name Jeffrey A. Garness Date 31 7.3
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in i
accordance with the guidelines and regulations established by the Municipality of Anchorage and industry
practices. The reported results describe the condition of the systems on the date/s of the evaluation. O OF q / 0444
Separation distances were measured to readily identifiable features. Hidden defects or encroachments may o C�
exist that were not identified during the evaluation. The operational life of all wells and septic systems depend O�P� . (/ . • S �0
upon a variety of variables, including (but not limited to) soil conditions, groundwater levels (that may fluctuate p�-' •.'� Q
during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing i0 c L� 9iTH
the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not �• • • • • • • • 1.. • •
....
guarantee future performance of the systems; therefore, GEG makes no warranty (express or Implied) regarding P / l
the future performance of the well or septic system. GEG makes no representation whether an altemative well V .......... • ......�
or septic system can be installed on the property in the event either of the current systems fail to perform Q' Jf A. Garness_)- G
adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG 01 B
CE—7953 p�
to perform the evaluation. Reliance upon the information provided in this report by any other person or party Q s ,c�O
(including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. 04FP e Foo
LICENSE 440aProf essio� o�
COSA Checklist June 2022 #AECC884 04000 00
Od
GARNESS ENGINEERING GROUP, Ltd AeroCell
• ENGINEERING SALES > CONSULTING Aresrr.2 Awhar+zed Denlor
March 30th, 2023
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Tank Baffle at Sky Ranch Estates #2; Block 2, Lot 22
To whom it may concern:
Per ARM Septic services camera inspection, the outlet bung on the septic tank is horizontal (not
vertical). Additionally, per ARM camera inspection, there is a belly in the sewer line prior to the
tank. We request that your department allow for the sewer line and bung to remain as is.
Justifications for allowing this is as follows:
• Per the owner (email attached), clogging is a rare occurrence of the septic system (once
every two to three years).
• The belly has likely existed for the life of the system.
• We request that the department issue an advisory notice regarding the belly prior to the
septic tank. If the buyer is uncomfortable with the deficiency, they may resolve it at a
later date.
• Per Ted Moore, PE inspection report, the concrete septic tank is 3 compartments.
• It is plausible that an additional compartment could increase the amount of grease
and/or sludge removal. A baffle opening is typically in the midline of tank, which is
intended to limit sludge and or grease/scum from entering the other side of the baffle (by
drawing from mid -depth).
• Per ARM Septic services camera inspection, the baffles appear to be in "good condition"
• The drainfields have existed for a significant period of time (1993 and 1976). Given the
age of the drainfields, the bung configuration does not appear to have negatively impact
the longevity of the drainfield.
We feel there is minimal risk in allowing the system to remain as is. If you have any questions,
please contact us at 337-6179. Thank you for your assistance.
Sincerely, / A
JeffreX' Qarndst P.E., M.S.
Presi ent
3701 East Tudor Road, Suite 101 *Anchorage, Alaska 99507-1259
Phone: (907) 337-6179 * Website: www.garnessengineering.com
David Garness
From: Jeff Rognes <jeffrognes@aol.com>
Sent: Tuesday, March 21, 2023 8:45 PM
To: David Garness
Subject: Re: Sky Ranch Estates #2; Block 2, Lot 22
David,
We have had the occasional blocked line when someone(usually a guest) has used too much toilet paper. It has
happened maybe once every two or three years.
Jeff
Sent from my iPhone
On Mar 21, 2023, at 4:42 PM, David Garness <David@garnessengineering.com> wrote:
Jeff,
Per the inspection report by ARM services, there is a belly in the line before the concrete tank. I was
wondering if you have had any issues with clogging of the sewer line prior to the tank.
Sincerely,
David Garness, P.E., M.S.
Civil Engineer
Garness Engineering Group, Ltd.
3701 E. Tudor Road, Suite 101
Anchorage, Alaska 99507
Phone: (907) 337-6179
Mobile: (907) 632-4528
Website: www.garnessengineering.com
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David Garness
From: ARM Septic Services, LLC <armservicesak@outlook.com>"
Sent: Friday, March 17, 2023 1:16 PM
To: David Garness
Subject: Re: 11721 'Shetland Heights Circle Tank inspection "
Helo,
It should also be noted that an approximately 8' long belly exists right before the tank. Not sure if you need that info for
the COSA or not.
Let me know if you have any questions.
Thanks!
Nathaniel Swanberg
Septic Technician
ARM Septic Services, LLC
Ph: (907) 688-9433
Cell: (907) 854-1684
Email: ARMServicesAK@outlook.com
Pers: swanberg.n_armservices@outlook.com
Website: www.ARMServicesAK.com
Facebook: www.facebook.com/ARMServicesAK/
On Mar 17, 2023, at 1:09 PM, ARM Septic Services LLC <armservicesak@outlook.com> wrote:
Hello David,
Please see the attached files regarding our recent inspection at the subject property. The video is from
the inlet side of the tank, and the photo is from the outlet side. Baffles appeared to be in god condition
and not damaged, but I'm not sure what to make of the outlet baffle T being horizontal. I'll have to defer
to you on the legality of that. Center baffle of the tank appeared to be made of concrete and in good
condition. The cleanout just upstream of the tank that was broken at/below grade was repaired and
extended above grade.
Let me know if you have any questions.
Thanks!
Nathaniel Swanberg
Septic Technician
ARM Septic Services, LLC
Ph: (907) 688-9433
Cell: (907) 854-1684
Email: ARMServicesAK@outlook.com
David Garness
From: David Garness
Sent: Friday, March 17, 2023 4:00 PM
To: 'Wockenfuss, Deborah M.'
Cc: Jeff Garness
Subject: FW: 11721 Shetland Heights Circle Tank inspection
Attachments: 11721 Shetland Heights Tank inspection 5.mov
Deb,
Below is an email from ARM Septic Servcies. As can be seen below, the baffle is "good condition", however, the outlet
bung is horizontal (not vertical), In theory, this would allow grease and/or solids to enter the drainfield. However, the
drainfield has been in use for a significant period of time and is still functioning. In short, although the outlet baffle
positioning is not ideal, it does not appear to have significantly reducing the life of the drainfield/s. In short, we are
requesting that your department allow the outlet bung to remain "as is". Please let me know if you have any questions.
Thank you
Sincerely,
David Garness, P.E., M.S.
Civil Engineer
Garness Engineering Group, Ltd.
3701 E. Tudor Road, Suite 101
Anchorage, Alaska 99507
Phone: (907) 337-6179
Mobile: (907) 632-4528
Website: www.aarnesseneineerine.com
From: ARM Septic Services LLC <armservicesak@outlook.com>
Sent: Friday, March 17, 2023 1:09 PM
To: David Garness <David@garnessengineering.com>
Subject: 11721 Shetland Heights Circle Tank inspection
Hello David,
Please see the attached files regarding our recent inspection at the subject property. The video is from the inlet side of
the tank, and the photo is from the outlet side. Baffles appeared to be in god condition and not damaged, but I'm not
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES_
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage,'Aiaska 99519-6650
343-4744
ParCel I.D. #
- CERTIFICATE OF HEALTH AUTHORITY
APPROVAL. FOR A SINGLE FAMILY DWELLING
,"~o~-- L'J/O HAA#_
GENERAL INFORMATION
Complete legal description .
Location (site address or directions)
Property owner ~{;.[-,L,~ ~,~;,,~,- ~-;u,'~) '~"~-~-~,'[' _ Day phone
Mailing address ~, O. ~,~. ;Z $Co'-~ cl o
Lending agency Day phone
Mailing ·address-
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: '~
NOTE:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water .
If community well system, provide written confirmation from State ADEC attebt-
lng to tile legality and status of system. ~: ~ ' ,., ,
TYPE OF WASTEWATER DISPOSAL: '.
Individual
on-site
NOTE:
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system. ~ ~ ..
72-025(Rev, I/91) Front MOA#21
5. STATEMENT OF INSPECTION BY 'ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance .with all Municipal and State codes,
ordinances, and regulations in effectpn the date of this inspection.
Address ~o 5 ~ t~-J--% # ~0._%
Engineer's Sign';ture "~-~'- ~ Date Y~-/¢.~"
/
6. DI~HS SIGNATURE
' ::X Approved for "~ bedrooms.
__ Disapproved.
__ Conditional approval for
.bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the profesaional engineer's work.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type ¢/~_ i~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Cased to Casing height
Wires properly protected (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
g.p,m.
AT INSPECTION
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Sewer service fine
Petroleum tank
WATER SAMPLE RESULTS:
Coliform Nitrate
Other bacteria
Date of sample:
Collected by:
B. Sr-'PTIC/HOLDING TANK DATA
Date installed ~7/0 ~/ /'-Y ~
Tank size /~2~.~,~ Compartments
Cleanouts (Y/N) '-,/ Foundation cleanout (Y/N) ',/ Depression (Y/N)
High water alarm (Y/4 h,¢//,~ Aa~rm tested (Y/N)
Date of pumping ~°~/,5~ / '~ LI Pumper ,/~ ''~-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ?"//~,, On adjacent lots /~'J,,~ Foundation
To properly line ¢~- '~ Absorption field ~ Water main/service line
Surface water/drainage ~/O
72-026 (3/93)* Frol~t CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N)
"Pump on" level at
Manhole/Access (Y/N)
"Pump off" Level at
High water alarm level
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed 7//~/
Length q7¢'/~= ~_5 ~ Width
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/Ft2) ~, /~¢ System type
Gravel thickness ,~ Total depth
Cleanout present (Y/N) "j Depression over field (Y/N)
Results (pass/fail) ~'~ far
If yes, give date
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /'~//,,~-
To building foundation
On adjacent lots ;>
Surface water
Curtain drain
On adjacent lots /"¢/¢A Property line
To existing or abandoned system on lot
Cutbank /'1/~ ~-~ ~ Water main/service line
Driveway, parking/vehicle storage area
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to afl MOA and HAA guidelines
Signature
Engineer's Name
Date
HAA Fee $ ~-~(~ ~ / ~
Date of Payment ¢~ ¢¢~-~, -- ~'15'
Receipt Number ¢~)/~-- f"~ ~'~'-'-~
,/
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
in effect c
this inspection.
.... DA'T E ~-~'C E I V E D
· INSi~ECTION APPOINTMENTS
TIME TIME TIME
SPEOTOR INSPEOTOR INS.EOTO¢
MUNIC PAL TY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO~I'ITY OF ANCHORAGE
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND
DI REGTIONS: Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing.
~ PROPERTY OWNER PHONE
~AI LING ADDRESS
PR OP E~f~EN; ~,~nt fra~ ~;( PHONE
~AI LING ADDRESS
~1 LING ADDRESS
REALTOR/AGENT
~. LEGAL DESCRIPTION
STREET LOCATION
5, TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One [] Four
""~ SINGLE FAMILY [] Two I-] Five
[] MULTIPLE FAMILY ~. Three FI Six
Other
7, WATER SUPPLY
[] INDIVI DUAL* * ATTACH WELL LOG. A well Io§ is required for all wells drilled
,::l~ COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTILITY depth (attach log if. available.)
8. SEWAGE DISPOSAL SYSTEM '~
~, INDIVIDUAL/ON-SITE** "///J~'~- 7~YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTI LITe'
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCE,)$1NG CAN BE INITIATED.
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 RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -8lTL DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified iNSTALLER
[~SepticTank or E~]Holding Tank
Size: /~-..~'~ If Tank is homemade SOILS RATING
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
' 5, COMMENTS
PP.OVEDFO. BED.OOMS
[] CONDITIONAL APPROVAL {letter mu party certificate)
72-010 (Rev, 6/79)