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HomeMy WebLinkAboutSIEFKER #2 BLK B4 LT 1 Municipality of Anchorage Page 1 of 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: SW940341 PID Number: f(~-,') I~Z--) '- ~'~b~--'l c':':':':':':':':':~;~~z) Ed & Sherry De St. Remey Address: 1150 1 J~rome St-.. Phone: IN° of Bedrooms: 3 LEGAL DESCRIPTION Lot: Block: Subdivision: 1 4 Siefker Township: Range: Section: T 12N R3W 21 WELL: [] New [] Upgrade :lassification (Private. A,B.C): Total Depth: Cased TO: Ft. Ft. Date Drilled: Static Water Level: Ft. Driller: Yield: Pump Set at: Casing Height Above Ground: GPM Ft Ft. SEPARATION DISTANCES TO From Well Surface Water Lot Line Foundation Curtain Drain Wastewater System: [] New ~ Upgrade ABSORPTION FIELD Remarks: Deep Trench [] Shallow Trench [] Bed 0 Mound []Other Soil Rating: 125sq. ft/bedro~b/sq. Ft. Depth [o pipe bottom from original grads: 6 FL Fill added above original grade: 0.5 FI Gravel width: 3 Ft. Total absorption area: 376 se. Ft. Installer: Nielson Brothers Total Depth from original grade: 10 Gravel depth benealh pipe 4 Ft. Gravel length: Number of lines: Distance between lines: 1 N/A a. Pipe material: ASTM D3034~ FStO Date installed: 9-2R & 29-94 TANK [] Septic [] Holding [] S.T.E.P. Manufacturer: Capacity in gallons: Material: LIFT STATION Size in gallons: Manufacturer: on" level at: "Pump off" level at: High water alarm at: Pump Make & Model Electrical Inspections performed by: BENCH MARK Location and Description: Garage Finished Floor Elevation Inspections performed by: Stan Dolloff Dates: 1st. 9/28/94 2nd 9/29/94 Department of Health and, Human. Services approval R eviewedandapprovedby: ~/.~ '~~ Date: /¢-.2'4% Assumed Elevation; 101.87 FI, ENGINEER'S SEAL /~Cy~ ?, Jo n Earl Simpso~' ~'~ 4 ',~ 02%% CE- 8061 .~-. u % ~}../,'A',~ ? %0~"'...;;¢' 72*0Ia(Rev 9t91) 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 IXVJMBER:SW940341 DESIGN ENGINEER:ENVIRONMENTAL MANAGEMENT, INC. OWNER NAME:WALKER E F & HARTMAN J T & OWNER ADDRESS:il501 JEROME ST ANCHORAGE, ALASKA 99516 DATE ISSUED: 9/12/94 EXPIRATION DATE: 9/12/95 PARCEL ID:01527253 LEGAL DESCRIPTION: SIEFKER #2 BLK B4 LT 1 LOT SIZE: 49061 (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. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE C~PTERS 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 343-4744 (24 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. 09-01-1984 i0~08 807~724158 ENVIROMENTAL MANAGEMENT INC. P.02/05 SPECIFICATIONS FOR UPGRADE OF EXISTING ON-SITE SEPTIC SYSTEM Legal Description: Lot 1, Block B4, Slefker sub,//2 Owner: Ed and Sherri de St. Remey 1, The septic upgrade is for a single family residence only. 2. The attached drawing anti/or site plan shall be part of this specification. 3. All materials and workmanship shall meet the Anchorage Department of Health and Human Services requirements. 4, All soils teats are advisory to the design and are to be verified or mo0ified in the field by the engineer. Upon completion of the excavation, soir conditions present in the walls anti floor of the deep trench Should be logged. 5. All excavations and depths are advisory and are to be verified or modified in the field by the contractor to meet Municipality of Anchorage requirements. 6. It is the responsibility of the engineer to obtain all necessary permits or easements and to locate any adjacent multFfamily wells, 7. The ex=avation is to be exactly In the area shown on the site plan, any deviations requires engineer approval. 8. It is prudent that a surveyor lobate the nearest lot line position and the '. ~t0Catlon of any easements. 9. Inspection of on-site wastewater disposal system Installations are required, and shall be in accordanae with the Municipality of Anchorage Wastewater Disposal Regulations Section 15.65.150. B. Existing Septic Tank The existing septic tank Is a 1,000 gallon, two compartment, steel tank installed June of 1983. The integrity of septic tank will be verified by the engineer during the dralnfleld installation. The existing on-site septic system is a trench system. This system has failed and can no longer properly absorb the effluent coming from the septic tank, EllensHD'~EMI Jobs\6285 de St, Remey A ball valve will be placed in the existing system after the septic tank and the proposed drainf[eld ~nnection as shown in the attached drawing, eD~jottouV ~to d i/AI!] 3 ill il 09-0i-1904 10:10 90787~4i59 ENVIROMENTAL MANAGEMENT INC. P,05/05 13. Pr0~3osed Dralnfield I~Dsa~3 T~ngh) The bottom of the trench shall be level, plus or minus 1,5 inohee, Two cleanouts and one monitoring pipe are to be Installed in the bed. The drainlield pipe In the trench will be connected to the line going into the septio tank es shown In attached drawing, The dralnfleld pipe will be laid over a minimum of 4 feet of gravel bed with an additional 6 inch layer of gravel Installed to provide a minimum of 2 inches of gravel over the drainfield pipe. A nontoxlo silt barrier will be placed between the final gravel layer and Ihs native soil The fill over the trenoh should be graded to prevent ponding of surface water, Piping materials use for dralnfleld Installation shall be 4" ASTM P3034 or ASTM F789 (PVC) pipe or approved MOA pipe, All pipe must be labeled with the ASTM designation on the side or show proof of ASTM equivalency, E. [~ec0mmended Dralnfleld Dlman$ign~ Proposed Trench: 47' long X 4' depth X 2 walls = 376 ~;I, fi, Total width = 3' Percolation Rate = 1.0 rain,linch (see Municipality of Anchorage 8oil Log - Peroolation Test for Lot 1, Block B4, $iefker Sub. #2) (3 bedroom)(150 gallon .aer..,gay Der bedroar~ = 375 sq. fi, 1,2 gpd/sq, f~, EllansHD~MI Jobs~;~BS de St, Remey w J_N31,~P, SVP, XIITI.~n iBBHI 9 ~I, VOt:t::?£ w 825 "L" Street, Anchorage, Alaska g9502-0650 / / LEGAL DESCRIPTION: ~ 1, ~OCX B4,S~e~e% Township, Range, Section: ~,~ /, ~/~ Subd~v~sZon ~2 SLOPE SIT~ PLAN / 1 S~Zt ~/ some sand (~) Orangish-grey., moist, , soft 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O Poorly graded sand w/silt and some gravel (SP) Grey, moist, medium to dense WAS GROUND WATER NO ENCOUNTERED? S L IF YES, AT WHAT 0 DEPTH? P E COMMENTS Deplh m Waler Alte~ Monitoring? ~ Gross Net Depth to Net Reading Date Time Time Water Drop 8-1fi-94 2r1~f15 6" I 2~1~:%J l~Jq min " 2:19:D1 fi" 2 2:21:02 2~fll mln 4" 2" " 2:23:45 6" 3 2:25:45 2:00 4" 2" " 2:28:15 4 2:30:15 2:00 4" 2" " ]2:31:12 6" 5 12:33:13 2:01 4" 2" @ 13 ft. encountere approx, 6 inch diam rocks Limit of Excavation PERCOLATION RATE 1 (m,nules/,nch) PERC HOLE DIAMETER TEST RUN BETWEEN 6.5 FT AND 7 FT 125 square ft./Bedroom PERFORMED BY: qee._n_ no!!off I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE: 72-008 (Rev, 4/85) Date Drilledl Static Water Level lo3 Draw Down fee t Gallons Per Minute Total. Feet of C~sin~ 117 ~y~ ~terial Drilled~ 0 feet ~? £ee~- to ~102 feet Si]tv to 104 to Hefty Drilling S.R.A. Box 1553 H Anchor~.ge,Alaska 99507 (~ MUNICIPALITY OF ANCHORAGE ,DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION/~,~Z~_~-~-(~:,~,~.~<~- 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~FIGN E~' ~ NEW ~AILING ADDRESS ~EGAL DESCRIPTION ~OGATIO~ NO. OF BEDEOOMS ]ero,.e off Abs°rpti°narea3"' Dwelling. Z PERMITNO ' .~ ~'~"~ Z Manufacturer~fi ~'~¢F Material~.~ ~/_~._ No. of compartments Liq. capacit~ ~n~lons IF HOMEMADE: Inside length Width Liquid depth ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. .J~Z O z ~ Manufacturer Material Liquid capacity in gallons 9 Well Foundation . f Nearest lot line , :,:~ No. oflines / Lengthofoachline~, Total length of linesg8' Trenchwidth.~Oinchos Distance betweon lines .~ ~ ~ Top of tile to finish grade j/ Material beneath tile ~*~ inches Tolaleffectiveabsorption~area m Length Width Depth PERMIT NO. ~ w Type of crib Crib diameter Crib depth Total effective absorption area m Well Building foundation Nearest lot line ~ OISTANCE TO: ~ Class Depth Driller Distande t~lot I)n~ ' ~ERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER SOIL TEST RATING '1 g ~NSTALLER i)-0 Fi~ ~ " APPROVED DATE LEGAL 72-013 (Rev. 3/78) PERM t T I'.,10. DEPFIF.:]"HENT HEFII_TPI Ftl'..l[:, EI'.,IV iRONHENTRL ':OTECTI OIq 82'5 "' I... "' ~:64-4720 [..,..~ I[iiF- L. Il. .... "::at ~'".,.il IlZP, C3~ th.,.il ..... :t~!;; ]:: qf'" E¥£ :t2E; EYe' Ih. il E: IF:~'.' .il:::" E:~ IF-:: IPll ][ "T' ,:: 8 ].": 05 i:~:6 FtPF'L. i C:FINT L OCI'-'I T :1: ON L.E.'GFIL. [)l::liq i'iFIR CONS"[];.:IJCTION L I BI<4 '5' I EF"KE!:R S [.-] E:, ',,,' 8607 COF.'.B I N [:,R I ',,,'E LOT SIZE '..5~99:/.'~S~S.~ !i:'..;I.T~LIFIRE FEE:I" "["¢F:'E OF" SOI I... FIE:SORf:'T I Ol",I S"/STEH 1,5,: TRENCH i"IFIXII"'IUM i'.,IUME',E:R OF BE[:,F.:OOMS = ]: SI"'I:[L RFITII',IG ,::S6! FT,-.'BF..:)= ;iL~;O TFIIE REL::!LIIRE[:, SIZE OF ]'HE SClIL. F:tE:SEIF..'F'TIOI'-,I S'¢STEH IS: THE L. ENG]"H [:, I I"iEN:T.', I ON ]: S THE L. IEI",ICJl"H ,:: 11.4 t::'EET) O1::' THE TRENC:H OR [:,RFt I tqF' I ELD. TFIE DEF'TI-I OF R TRENC:H OF.'.' F'I]" I:S THE E:,Z'_"~;TFINE:E E~ETNEE:t'.,I 'T'HE :!:]UI:~,:FF:tCE OF' THE GROLIND FIND THE E~CITTEd-"I OF THE EXCf:I',/RTION (II",t FEET). THEF..'E IS NO SET 1.4 I E:, ]].4 I:::'OR 'T'REI'.,IC:HES. TFtE (:~ii:~:FI',,,'EL. I}IEF'TH IS "I'HE I'"II.I',IIMLIM [:,EF'TH OF GF..'R',,,'IEL. BET!.4EEN THE OUTFFIL. L PIPE FIN[:, THE BCITTOH OF'" THE EXC:R',,,'FtT I Cit",t ':: I N FEET ). F'ERH I T FIF'F'L I C:FII',IT HFIS THE: RE:SPONS I B I I_.. I T¥ TO I I'-,tF'ORI"I TH :1:,5, B, EF'FIR]"t','IEN]' [:,UF.: I i'.,IG THE i NSTFILL. FITI O1'.,I INSPECT 1 O1",1'..'~; OF FIN"r' 1.4ELI...'S, FII:::'JI::ICEIqT "['O TH I :E; PF.':OPEF.':T'¢ FIl'.4B, TFIE i",IUI"IE:EI::,'. OF F.:ES I [:'E:I",ICES THFFF THE I.'.IELL. 1.41 LI_ 'F;ER",,'E. .................. "~- If.,.if ('} ~::.': ;.Lz-.:: ::,, .-il: il"-,[ :::-E'; P' IE:: C]: T' :E. C" l"-,tt :t~:'::; F:~ If:;;:'.' E E~: tE ,~..:~ il_il :[ It~: ~.] [::,, ........................ BFIC:KFI LI... I I",tG OF FIN? ::S'¢STEM i.41 TI-4Oi...I]" F I i",IR[... I 1"4SPEC]" 1 ON FINE:, Fff::'F'F:iO',,,'FIl._ B"r' TH I '5, i}EPFIF.'.THEI'4T 14ILL BE SUBJECT TO PROSECUTIOI',I. M II'.,IIr,iLIH F.:,ISTF:INCE BETI.,.IE:EN F:l I.,IEL.L FIND i::ll",l"r' OI",I'"'S.T. TE SE:I.4FIGE [:'ISF'OSFtL.. S"r'STEH IS :1..OO FEET FOR Fl F:'F.'.'I',,,'FtTE I.'.IELL OR :L50 TO 200 FEET FROM FI F:'I...tE~LIE: t.,.IELL [.':'EPEi"4DZNG UF'OI",t THE TYPE OF PUBLIC 1.4ELL. i'"I.T.i",IIHUH DIS'TFINC:E FROM R PR I ',,,'RTE 1.4EL. L TO R PF'.I',/~3TE SEI.,.IER L. INE IS 25 FEET RI",I[:' TO FI COHt'"IUtqIT"r' SEI.,.tER LINE: ];:.5 75 F:EET. t.'.IEL..L. LOG:E; FIRE RE(.:.!UIF.:EE:' RI",I[:' i"iUST BI:' RE]'LIRNE[:' TO THE DEF'F:IRTHEIqT I.,.IITHIN ~:O DF~"r':S O1::' THE NELL COMPLETZON. OTHER REQUIF.'.'EHENTS I'"lFl"r' lal::'PL'.r'. SPECIFICI::ITIOI',IS FIl'.,IE:, CON'.F.;TRUCTIOt'.,I DIFIGRFtMS F:tRE I:::IVI::I I Lf::IE~L.E TO I NSLIF..'E: I::'ROF'E:R I NSTFILLFI'[' I ()1',1. IP E: If;E: E.tl % T' liD: :::-:: F:" X il:a: E¥£ "_':E; tE::, E: C: E: If'""] ..FZ: E=-.. tF~:: Z~i:: ::IL .... Z CEF.:T I F"¢ 'THFtT :L: I FIH F'F~I'IZLIF~F.'i I,.IITH THE RE6!UIREHENT:.::; FOR Ot'.,I-SITE SEI.4ERS RNE:, !.,.IEL. LS FIS SET FOF. YI"I4 B"¢ THE MlJi'.,I I C IF'RL ]: T¥ OF' FIt'.,tC,~-IOF.'.RGE. ~;.::: I I.,.tILL INSTFIL..L.. THE S'¢STEM IN FICE:OI::~:[:,FIi'qCE !.,~!ITH THE CODES. Z'-:: I LINI}EF..:STFINE.', THFIT THE ON-SI]"E SEI.,.IER S'¢::'STEH MFt'.r' R[D:'4LIIRE ENLI::If;-':GEHEN]" IF THE f;:EStDEi",ICE tS F'.EHODEL.ED TO INCLLIF:,E h'IORE THFII',I 2: BE[-',F.':OOMS. '5' I GNED: FIF'PLICFINT [:,FIN MI"aR CONSTRI...ICTION OflN i~'IFIR COJ",P.~ FRUO ¥ ION SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 0L 2 3 4 7 SLOPE 10 11 12 13- 14 15- 16 17 18 19 2O COMMENTS 72-008 (6/79) WAS GROUND WATER ENCOUNTERED? IF YES, ATWHAT DEPTH? Gross Readin9 Date Time Net Time Depth to Water Net Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN CERTIFIED BY: FT ANE / ! MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot. 1 Block 4, S±efker Sub. Location (site address or directions) orE O'Halley 11501 Jerome Sto, Anchorage, AK Property owner Mailing address Lending agency Mailing address Agent Address Ed & Sherry de St. Remey 11501 Jerome St. Anchorage, AK Day phone_344-2292 99516 Day phone .. Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well × NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank ' Community on-site · Public sewer NOTE: Community well Public water .::_'~ ,.. If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. ,' ',,, If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. ' 72-025 (Rev, 1/91} Fronl 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, a,nd,re~gulations in effect on the date of this inspection. ...... · ~..~.~;. '~ :.~ , . .:~.-...~,'.~*.'? .:*:. . .... , ~:._ E~vi~or~ental~anagement, Inc~/ " ~_~*~' 272-9336 N~,,,~ v, r,,,,, ~ ,, r,,u.~ _...~ ee/~/~ ~cnorage,AK ' 99503 Address 206 E. Firew , St~ 201, Engineer's signature ~ Date ,- ~ -~( ~ 6." DHHS SIGNATURE ' ~ Approved for ~ Disapproved. Conditional approval for bedrooms. /~%;% CE ..... /,,,4' bedrooms, with the following stipulations: Additional Comments 'The MU~lCl[~lty of Anchorage Department of Health and Human Services (DHHS) i~ues Health Authority -Abprgval Ce~,f[cat~ased only upon the representat ons g yen n paragraph 5 above by an ndenendent profe~io~aleng~er mgmtered in the State of Alaska. The DHHS does this as a county to purchasem of homes and theic lending ~nshtut~ons ~n order to ~t~s~ ce~mn f~eral and state requlrements,.Employ~s of DHHS do not conduct inspections or anal~e-data before a ce~ificate is issued. The Municipali~ of Anchorage is not r~ponsible for errom or omi~ions in the prof~ional engin~fs work ~.1~1) ~ck MOA~I Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Lot 1 Block 4 Siefker Sub. t~o. 2 Well type Private Log present (Y/N) yes Total depth 117 ft. Parcel I.D. If A, B. or C, attach ADEC letter. ADEC water system number Date completed June 25, 1983 Driller hefty Drillinq Cased to 117 ft. Casing height 21" Sanitary seal (Y/N) Yes FROM WELL LOG Dateoftest June 25, 1983 Static water level 103 ft. 5 Well flow Pump level1 Bottom SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot 113 ft. Public sewer main N./A Sewer service line N/A 116 ft. Wires properly protected (Y/N) Yes rn AT INSPECTION ~~ August 25, 1994 ~2~ ~ 96 ft. ~ no ~ ~ mO g.p.m. 6 .g.p.m. ~ ~ ~ ~ Bottom ~ ~ ~: ; On adjacent lots 100 ft. + ; On adjacent lots 100 ft. + Public sewer manhole/cleanout N/A Petroleum tank N/A WATER SAMPLE RESULTS: Coliform 0 c~./¢'~, ~¢,%/?P¢?r,;/ Date of sample: Aug,/st 25, 1994 Nitrate ~o(¢?, ,¥/Z- Other bacteria Collected by: Simon Schroeder B, SEPTIC/HOLDING TANK DATA Date installed June 1983 Cleanouts (Y/N) yes (one) High water alarm (Y/N) N/A Date of pumping ?-2,7 -' ¢/Y' Tank size 1000 gal. Compartments 2 Foundation cleanout (Y/N) Yes Depression (Y/N) No Alarm tested (Y/N) N/A Pumper 0/~ /~c. Z)~,~/~' ~,~,,',~, ~c¢'r,/,~¢,, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: 116 Well(s) on lot On adjacent lots To property line 79 ft. Absorption field Surface wateddrainage None Obse=ved 100 ft. + Foundation 20 ft. 5 ft. Water main/service line N,/A 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Not applicable Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed O~ - 2.~, Length /~/_? ~/ Width Total absorption area Date of adequacy test .M/A ' Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/Ft2) Gravel thickness Cleanout present (Y/N) Results (pass/fail) System type Total depth Depression over field (Y/N) for After test If yes, give date ~/~ /d Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot IO ~ ~'/. On adjacent lots /Dc> + ¢'/-', Property line To building foundation ~0 ~. To existing or abandoned system on lot On adjacent lots Surface water Curtain drain j}¢ r,~. Cutbank ,,~)/A Water main/service line Driveway, parking/vehicle storage area /~ ¢~ /'z e E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conf~rmed S,,n.,ure Engi~e John S71mpson~ -- D~etet~,-' August 29, 1994 Date of Payment Receipt Number 72-026 (3/93)* Back to all MOA and HAA guidelines in eff_e~ .q~. ~ ~ this inspection. ! :2% /./ ~ ~., CE-80~ ,...~:,/} Waiver Fee $ Date of Payment Receipt Number iT1;::. '7"q. 'q4 .....12: 51 ,:i;T:~,E El-It ~ l E!L~II'II'IEI ITRL LA[-: ~_--;EN~ ~ 1CES; ~ 9El?2T24159 I IFL ~-'-'~, DA2'__ L"F~E Rel Il Matrix Commercial Testing & Engineering Co. Environmental Laboratory Services ~,~',~',~r-a~-ar~'',~'-ar,~'',~',~r-ar,a~'~r-'~''~'''~'f''~'~ I~BORATORY ANALYSIS REPORT 04.4367 OUTSIDE [:AUCET Df"; ST. ILEMJ~Y/I.TI ULK4 * \VATER Clicnl Nali~e If NW1RONMENTAL M(iMT INC (uM]) WORK Order 8 ] (,0% (hdcrcd By ~IMON PrhdedDatc 08/29/94 t~z~ !l:4g h~. l'rojct:~ Name Collected ~ic 08/2g/94 Projeot/ 6285 Received J.~tc 08/26/94 PWS~ Tcchai cai Dirccl~*r S]~}'HEN C, ED I: QC Allowable Ext. Anal Parameter [>,csulls Qual {hills Mdhod I..imits Date Dale lllJl ............................................................................ ' ............ ~,~F-CM1t. NilrMe-N 0.68 mgfl, EPA 353.2/300.() l o Dept, Health & Human Services * Sec Speci~ hlslmctimiu ,4boy c UA = Ihmvailuhle * * See Satnplc II.c~Harks Ab,)ve NA = Not Analyzed I1 = Undetected. Rel)Orted vaJm is iht: practit:al q~mntiIication limiL LT= [.,ess Than D = SecomNry di ltdiuil. G['= ('h'eaicr 'lltan 5633 B Stre0t, Anchorage, AK 99618-1000 --. Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMEN'FALFACILITI[$1NALASKA, COLORADO FLORIOA, ILLINOIS, MARYLAND. N~WJERSEY. OHIO' UTAH' WEST VIRGINIA Drinking Water Analysis Report for Total Coliform Bacteria FUZAD INSTRUCTIONS ON R,5'I."JKR.5'E 5'I])E BEFORJZ CO£LECTJNG SAMPLE 12:51 CT:~E EI'I"IF!IZIIIHEIITAL LFIE: 'E;ERL~I,E:ES. - qa?7'?P41%'q IIFI.-'-'= DA~ Commercial Testing & Engineering Co. Environmental l. aborato~ So.ices [IIll~llIilillttttlllli~ 5633 B Street Aechorago, AK 99518-1600 Teh (907) 562-2343 Fax: (90~) 561~5301 MUST BE CONIPLETED BY WATER SUPPl.[ER O PUBLIC WATER SYSTE1YI LD. # [~~"~' .~l ~ATE WATER sYSTEM S,,'kMPLE DATE: Month SAMPLE TYPE: ~i,,/Routine u Repeat Sample (for rou'tine sample with lab ref, no. ') [] Special Purpose Da)' Year [] Treated Water D// Untreated Water Tim e Collected Collected . By TO BP; COMPLETED BY LA._BOP, ATOR Y Analysis shows flus Water SAN~LE Io be: · m" Satisfactory O Unsatiafacto~ gq Smnp[c over 30 hours old. ~esul/s may be tu~eliable :%mple Ic~o Ion~; m transit; sfunple should O [;ot bt: .vet 48 hot,ws old at cxmnination to indicate reliable results Please scad new sample via spec~ delivery mail. Date Received ( '~ ~ !~S>/~5/~-- Time Received 03 ~i) 0 C¢--> Analysi~ Bega~ Analytical IMetlmd: ~ Membnme Filter o MMO.MUG Number of colonies/! 00 mi. Lab Ref. No. Result* Analyst Fa~ed Client notified of unsatisfactory results: [] Phoned Spoke Dale; ['ime: Vaxcd MMO-MUG Itesult: TotM Coliforn~ Membrau¢ Filler: DiredComd ' Verification: LTD Fecu I Colifotm~ Con£wrnn lion BACTEPdOLOGICAL WATER ANALYSIS RECOKI) ]X Coil. ~ Colonies/1 O0 ml BGB COLIFmM Cull f._ol~pJ100 mi c T,,,,e r m~'t6 GOnOrola do Survedlanue) Member al ,he SGS G oup(So .... ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA. ILLINOIS, MARYLAND, NEW JERSEY, OH O, UTAH WEST VIRGINIA CUSTOMER'S OR{DER NO. DEPT. AOORE$S Steam Thawing · Line Cleanin Jeffing Service ~gt~ ~oniface. Par~wa¥ P,O, Box 466 ~Ince 1972) . 338.-'~h~t76 * 244-7948 0 14 REC'O 8Y 5L320/01320 ~.F.E? THIS SLIP FOR REFERENCE MUNICIPALITY OF ANCFIORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~ I ~ - ¢'-'-O,."'~ 1. GENERAL INFORMATION (Musl be completed prior to submittal) (a) Legal Description (include lot,' block, subdivision, section, township, range) LOT I; BLOCK ~ SEIFKER Location (address or directions) 11501 Jerom~ Street, Anchorage, (b) Property owner __ Mailing Address (c) Lending I'nstitution Mcnic.-. Le~,~nn 30,000 NE 51st Wa~, ,, (206)834-9379 Telephone:[nome) Business ¢~as, Washington 98607 Telephone Mailing Address (d) Real Estate Company and Agent Address ~2350 Industry Way, CENTURY 21-PACIFIC NORTH ATTN: Kevin Hanrahan Suite 208, Anchorage, Ak. 99515 Telephone 34501444 (e) Mail the HAA to the following address: (or check here ~3Xif hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 37034 Eagle RI,vet Loop Road No. 204 Eagle River~ Alaska 99577 2. TYPE OF RESIDENCE Single-Family ~ Number of bedrooms 3 3. WATER SUPPLY Individual Well {~X Community [] Public [] Note: If community well system~ must have written confirmation from the State Department of Environmental C0nserva~ion attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [~K 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. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of thi,~ Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functiona and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm_ Telephone -- L~ ¢¢'~ ~7 ~' S & S ENGINEEKING 17034 Eagle River Loop Road No. 204 Date 6. DHHS APPROVAL Approved for.~--r'~_ - bedrooms b . Approved ~--~"~Di~ roved. Conditional Terms of conditional Approval_ Date The Municipality of Anchorage Department of Health and Human Services(DHHS) issuesHealthAuth°rityAppr°val cerificated 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 BHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 A. WELL DATA';, ~,~ , Well Classification --1 f'--~(~ Well Log Present ~N) __~ Total Depth ~ ['~ ~Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (~;ZN) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: ~---6:>'i~ If A, B, C, D.E.C. Date Completed ~ ' ~-.--~'"~ · '~-.~";~ ,t Yield ~' Depth of Grouting \ \ / ~ Pump Set At Sanitary Seal on Casing Depression Around Wellhead / / L~ ; On Adjoining Lots To Nearest Edge of Absorption Fie(d/eh Lot ~.\ ~-~ I/~¢ ;On Adjoining Lots To Nearest Public Sewer Line ~ To Nearest ~blic Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ~ Water Sample Collected by ~ ~'¢~, ;Date. Water Sample Test Results ~~~ '~ ~~~y Comments B. SEPTIC/HOLDING~TcANK DATA Date Installed L¢~/(~'~-~ Size Standpipes CERN) '~ Depression over Tank (Y/6!~ No. of Compartments Pumping/Maintenance Contact on File (Y/N) ,, / Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Building Foundation To Disposal Field Air-tight Caps./N) "'r Foundation CleanoutCN) ; for Temporary Holding Tank Permit (Y/N) r~/~.,~ To Water-Supply Well To Property Line To Water Main/Service Line To Stream; Pond, Lake, or Major Drainage Course Comments ./~r- .~;:¢-~ 72-026 (Rev. 7/88) Fronl Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Str~ Date Installed~'/~) Width of Field Square Feet of Absortion Area Depression over Field (Y~[.)~ Results of Last Adequacy Test \ '-~ O ,7¢¢--'- Type of System Design 7~'~'-""~~ Length of Field Depth of Field Gravel Bed Thickness ~:~ ,~' ~-'~-~J~> '¢' Statndpipes Presenf~:~N) r~ Date of Last Adequacy Test To Water-Supply Well To Building Foundation ~ Lot r~/ /~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments SEPARATION DISTANCE FROM ABSORPTION/FIELD: ~ ~,~ To Property Line ~. To Existin~ or Abandoned System on ; On Adjoining Lots ! / ~. ~ To Cutback (if present) D. LIFT_STATION ~/._../~ D at ekT'h3e.t~ Size in Gallon"~--~ "Pump On" Level at'"'"'"~ Dimensions Manhole/Access (Y/N) High Water Alarm Level at ~ Tested for Meets MOA Electrical Codes (Y/N) Comments "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or' conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Company Date MOA No. 5 & 5 ENGINEERING 17034 Eagle River L~op I~oad No. 204 Receipt No o~/~. Date of PaYment Amount: 72-028 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~°~ FEDERAL TAX ID # 92-0040440 ~- /~ CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. / Anchorage, Alaska 99518 TO BE COMPLETED BY WATER SUPPLIER © PUBLIC WATER SYSTEM I.D.# I I I I I I I "~-PRIVATE WATER SYSTEM S & S ENGINEERING 17034 r-aCe4~h'e~ool~.-~=d4'!=, 20_4_ Mailing Add.ss . Ir. agle River, Alaska 99577 City State Zip Code Mo. Day Year SAMPLE TYPE: ~4.t~_ o ut ine ~ Check Sample (for routine sample with lab ref. no, [] Special Purpose ) [] Treated Water [] Untreated Water SAMPLE Time NO. LOCATION Collected 2 I '~¢/.~.¢¢. ¢-'¢-¢--- I I I I I Collected By TO BE COMPLETED BY LABORATORY sstJs shows this Water SAMPLE to be: isfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Time Received /& ~0 Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE TNTC OB = BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count ~ Verification: LTD BGB Final Membrane Filter Results -~ Reported By~,~;~L~~ Date Time: = Too Uumberous To Count P~m. ONE or ~wo Other Bacteria ~M~D~ TO FOLLOW Collform/100ml Collform/100ml NT~L MUNICIPALITY OF ANCHORAGE ~S DiViSio~ s .wc s JUL DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVA~c~/VED OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) Location (address or directions) (b) Property Owner ~ H ~ ~ . Telephone: Home Business Mailing Address (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent ~,,~..4.~ ~,~, ~'1-~ %~ '~ ,'_O ~'~f.~¢ (e) Mail the HAA to the followina address: or: Check here~ if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family ~ Number of Bedrooms WATER SUPPLY IndividuaIWell~ Community[] Public[] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status, SEWAGE DISPOSAL Onsite/~ Public[] Community[] Holding Tank[] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 ~' ¢35 ,Fee 81861 Front ENGINEERING FIRM PROvIC)ING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as ol',he validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply ano/or ,~,~tewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further red{7 that baaed on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection= Name of Firm ~ ~ Telephone Address Date IR. Engineer's Seal DHHS APPROVAL Approved for '~ bedrooms by Approved ~ Disapproved Terms of Conditional Approval Conditional CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 fRev 8/861 Back NiUNICIPALITy OJ: ANCHOR,~NICIPALITY OF ANCHORAGE (MOA) DEPT, OF HEALTH & HEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL PROTECTION CHECKLIST- FEBRUARY 1984 264-4744 JUL 2 8 1988 RECEIVED WELL DATA Legal Description: /..O'F Il ~,~' ~/ , · / Well Classification Well Log Present (Y/N) Total Depth I t"'? Cased to I/"2 Static Water Level / / / Casing Height Above Ground Electrical Wiring in Conduit (Y/N) ,.Y' Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line If A, B, C, DEC, Approved (Y/N) Date Completed ~¢ ','~' ~,.~ ____ Yield Depth of Grouting /',,J Pump Set At 'i~ '~'t~ Sanitary Seal on Casing (Y/N) Y' Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots 'To Nearest Public Sewer Cleanout/Man hole Water Sample Collected by Water Sample Test Results __ Comments /x/o r,¢ ~ To Nearest Sewer Service Line on Lot ~- ~ ; Date __Th B. SEPTIC/HOLDING TANK DATA Date Installed ¢'/¢-% Size /o ¢f.p No. of Compartments Standpipes (Y/N) 0/'¢~' Air-tight Caps (Y/N) ~ Foundation Clean,cut (Y/N) Depression over Tank (Y/N) /'"// Date Last Pumped 7~;7--,~//~ Pumping/Maintenance Contract on File (Y/N) bC//A ; for __ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ///~' To Property Line .~ To Water Main/Service Line Course Temporary Holding Tank Permit (Y/N) /'////A To Building Foundation ~,~ O To Disposal Field ~' To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026 IRev ~1B61 Fronl C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata _ Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorptio.n Field: /5o To Water-Supply Well //~' To Building Foundation . ¢~-¢ '/- Lot /",//A To Water Main/Service Line .,~ ~ c~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field /"/~;;.;;.3 Depth of Field __ Gravel Bed Thickness Standpipes Present (Y/N) Date._of Last Adequacy Test To Property Line ,~-~ ¢' To Existing or Abandoned System on ; On Adjoining Lots *~ ~ /~ To Cutbank (if present) l"//'/A- Comments D, LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions ManhoLe/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified,,cr conformed to ail.MOA and HAA guidelines in effect on the date of this inspection, Signed % ~~x..i.4~ Date /~,5/ ,~ Company MOA No. Amount: $ ! · ,..- Page 2 of 2 Engineer's Seal 72-026 fRev 8/861 Back CONSULTING ENGINEER ~ o~ G ANCHORAGE, ALASKA 99501 TELEPHONE: (907} 279-3916 RESIDENTIAL WELL INSPECTION LEGAL: Lot 1, Block 4, Siefker S/D LOCATION: 11501 Jerome OWNER: AHFC TYPE OF WELL: Residential WELL LOG AVAILABLE: Yes INSTALLATION REQUIREMENTS MET:Yes WELL YIELD FROM WELL LOG: 5 Gallons Per Minute PUMP YIELD FROM TEST: 5 Gallons Per Minute DATE OF INSPECTION: July 22, 1988 TEST PROCEDURE: Well was pumped at a constant rate while the drawdown was monitored with an acoustic probe. At the beginning of the test water level was found at 111 feet below top of casing. At a pumping rate of 5 gallons per minute 'the water level dropped to 112 feet immediately and stayed at that level for the remainder of the test, 80 minutes. A total of 450 gallons were pumped. The well recovered immediately after pump shut off. TEST FOR E.COLI AND TOTAL NITROGEN:. Water was tested for E.Coli and total nitrates on July 23, 1988 E.Coli 0. Total Nitrates .5 mg/1. Max. allowable Total Nitrates 10mg/1. TEST RESULTS: This. well meets the requirements of the Municipality of Anchorage. THIS WELL WILL PRODUCE MORE THAN 3 GALLONS PER MINUTE FOR ~HAN FOUR HOURS -- MORE The Municipal requirement for well flow is 150 gallons of water per bedroom per day. This well exceed this requirement. The assessment of the condition.of the well applies only to the conditions as of the day tested. The flow rate may change due to subsurface conditions that may not be observed from the surface, and changes in the land use and other factors that may impact the aquifer feeding the well. ANCHORAGE, ALASKA 99501 CONSULTING ENGINEER TELEPHONE: (907) 279-3916 LEGAL: LOCATION: OWNER: RESIDENCE: WELL: SEPTIC SYSTEM ADEQUACY TEST Lot 1, Block 4, Siefker S/D 11501 Jerome Road AHFC Single Family, Three Bedrooms Residential, On Site SEPTIC SYSTEM: FROM MUNICIPAL RECORDS: TANK: Greer Steel., 1000 gal. Two Comp. ABSORPTION SYSTEM: Trench ABSORPTION AREA: 528 sq.ft. SOIL RATING: 150 INSTALLATION DATE: June 1983 DATE OF LAST PUMPING: July 25, 1988 Marx · DATE OF TEST: July 22, 1988 TEST PROCEDURE: System was inspected and measured. Tank was found with five feet of cover, located in a paved over parking area. The sump to the trench was found 10 feet deep and with 20 inches of water. The residence has been vacant for some time. 450 gallons of clean water was added to the system. The first 100 gallons caused the water to rise 3 inches. The next 350 gallons did not cause an increase in the water level, indicating that the soil absorbed the water as it was added. TEST RESULT: This system meets the code requirements of the Health and Social Services Department of the Municipality of Anchorage. NOTE The operational life of all septic systems depends on the local soil. conditions, 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 this septic system. We can therefore not give any estimate of how long. this system will function satisfactory for current or future occupants. APPLI( NT FILLS OUT UPPER HAl ONLY Mailing Address Zip Code Phone Buyer Address Zip Code Lending Institution Address Realty Co. & Agent Address ~ :~:~'1.! '~,~r. t.~LZip Code Zip Code Phone Phone Legal Description ].~N] ~[ t ('~,1 Street Locaticn . ) I:' i,~.C; i ',~- l- Type of Residence ~'"'Si n g le Family LJ Multiple Family No. of Bedrooms [] Other Water Supply endividual ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975. LI Community . For wells drilled prior to that date, give well depth (attach log if available). [] Public Utility ' Sewer Disposal (~p~dividual ublic Ulility [] Holding Tank Year Individual Installe/~.' ?_ ~/z :5, __ When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Date Date Date Date Inspector Inspector Inspector Field Notes: Inspector MuNiCIPALiTY ENVi RON;,,',Eiql'AL F&o-LCftON (~) APPROVED BEDROOMS ) DISAPPROVED ) CONDITIONAL APPROVAL' 'CONDITIONS OF APPROVAL Soils Rating .. 72,023 (3/82) Well TO Absorption Area /'~1~--"~ .... Date Sewer Installed (O ~- ~ ~ '- '']~ ~ Well to Tank Well Log Received Septic Tank Size loc)