HomeMy WebLinkAboutROLLING HILLS VIEW ESTATES BLK 5 LT 3AOnsite File
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Jul -1.) 1:S I V.,+U�i
446-k Pagf,h
Mayor
Deveiopment Services OePcWtMent
Ruilding Sa-Fety Division
OM -,Site Water & Wastewater Program
4700 Elmore Road
P-0, Box 196550
,4X-1-horope, AK 99507
(91M 343-7904
Pump Installation Lo
Wvll
P11rcel Identificatiori -Sumber:_ O5D -32Z- 31
Legal Description
I P6 I 1 11 /� N J / S ES
CO 85
Pumpnp
r
PlInip Intake Dep-th Below- Top of We'U, catiinb:'
feet
Pump l►-Iod ei:
PURIP Size $ d,p
Pitless Adapter Burial Depth; feet
Pitiess Adapter A-lauutact-urer's, Nalne.:
Pidess Adzpter Installer:
Well Disinfected Up(jU Completion? No
Metkod of Disinfettion. /--I\- esE,
comments.
PUMP Installer None:
A(A(
Date of issue:
Property--
Owner Name &Add
P. I
Utention: The puajD 44(allt.- shal'
t0 the SD vik'nin 30 days Of PUMP instfllat.'on.
(~ MUNICIPALITY OF ANCHORAGE
. DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage. Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS ~
Well Absorption area D~eliing ~ PERMIT
~ ~ DISTANCE TO; /OO ~ ~1 /O g~O
~<~z Manufacturer ~ R~ Material ~ N°'°fc°mpartments
~ N Liq. capacit~s IF HOMEMADE: Inside length Width Liquid depth
~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
~=Q DISTANCE TO: Well / ~0 ~' Foundation ~ , Nearest,otlin. 3/
m ~~ No. of lines Length of each line~ Total length of lines / Trench width[~ Distance between lines
~Q~ Top of tile ,o finish grade ~ ~' * Material beneath tile, ~ inches Total effective gs~¢ion area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOl L TEST RATING
INSTALLER ~"~
R EMAR KS ~ '
APPROVED DATE LEGAL
by
DOC Co. dba
SULLIVAN WATER WELLS
P. O. BOX 272 CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS / ~ /?
LEGAL DESCRIPTION
DATE - Started r
PERMIT NUMBER
? f:~::' ~ , ~t-*~ DEPTH OF WELL
~.~ ~. /~,:~.~2~,~:~ c~ ~;'~7 ~ STATIC LEVEL OF WATER FT.
/~;' /" ~,: ..... '~ ~: '< ~'~ .... .... ~RAW DOWN FT.
Ended GALS. PER HR -
KIND OF CASING
KIND OF FORMATION:
From - Ft. to · Ft.
From Ft. to '/ Ft.
From Ft. to Ft.
From ~? Ft. to , ~ " Ft.
From: ~ '" Ft. to ~ -" Ft.
From Ft. to ,Ft.r-~
From, ;' Ft. to / ~, Ft.
From , Ft. to /- Ft.
From___Ft. to Ft.
From ~ 7"Ft. to :/,, Ft.
From'-'~ Ft. to '7 ~ ~ Ft
From Ft. to Ft
From__Ft. to Ft.
Fromm7 ~ , Ft. to / ,? Ft.
From__Ft. to Ft.
From Ft. to___Ft
From Ft. to Ft.
From
From
From
From __
From
From
From
From
From
From
From __
From
From
From
From__
From
From
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. te Ft.
_Ft. to Ft.
Ft. to Fl
Ft. to Ft,
MISCL. INFORMATION:
, ; ~ /
PERMIT NO.
DEPRRTMENT 0 HEALTH RND ENVIRONMENTAL t )TECTION
825 ~L' STREET, BNCHORAGE, BK. 995~t
264-4728
l--tELL R[4E:. C,[-4--SI-rE SEL4ER PEF:ld IT
( 8~0090 )
APPLICRNT
LOCATION
LEGAL
JAMES; R GRIFFITH PO BOX "101i07 995~0
L]:B5 ROLLING HILL=. ESTRTES LOT SIZE
~?-648~
999999 SQUBRE FEET
TYPE OF SOIL BBSORPTION SYSTEM IS: TRENCH
MBXlMUM NUMBER OF BEDROOMS
SOIL RATING (SQ FT?BR)= ±99
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
[:~EF'TH= 2[~L LE~-41]TH= 2;:-=: l~] F-: R %-' E L [:~EPTH= .~2----:
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINF'IELD.
THE DEPTH OF B TRENCH OR PIT IS THE DISTBNCE BETWEEN THE SURFRCE OF THE
GROUND BND THE BOTTOM OF THE EXCAVBTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRBVEL BETWEEN THE OUTFBLL PIPE
AND THE BOTTOM OF THE EXCAVBTION (IN FEET).
PERMIT BPPLICANT HBS THE RESPONSIBILITY TO INFORM THIS DEPBRTMENT DURING THE
INSTRLLBTION INSPECTIONS OF ANY WELLS ADJBCENT TO THIS PROPERT9 BND THE
NUMBER OF RESIDENCES THBT THE WELL WILL SERVE.
T~4,2, ( 2 ::. l" ~'4'_-]F'E,Z:T I L--,~"--I'__--] RF-:E RE,i]!Li I RE[:-.
BRCKFILLING OF RNV SYSTEM WITHOUT FINRL INSPECTION RND RPPR. OVRL BY THIS
DEPRRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTBNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSBL SYSTEM IS
100 FEET FOR R PRIVRTE WELL OR t50 TO 200 FEET FROM B PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTBNCE FROM R PRIVRTE WELL TO A PRIVBTE SEWER LINE IS 25 FEET RND
TO R COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MA9 BPPLg. SPECIFICBTIONS AND CONSTRUCTION DIBGRRMS BRE
RVBILABLE TO INSURE PROPER INSTBLLBTION
F'ER~fl I T E::-=:.F' I F~ES [:-,EE:E~"flE:FR _~=:- ;1... 'IL'~ 8__~-:
I CERTIFY THBT
i: I BM FAMILIBR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF BNCHORBGE.
2: I WILL INSTBLL THE SYSTEM IN 8CCORDBNCE WITH THE CODES.
3: I UNDERSTBND THBT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
~F'_F'LICANT .~ES R GRIFFITH
V4. 0
PO 0 u ~-'i 6-6,50
ANCHORAGI, i,I i',. !t, ?(i{';:-; 0650
(907) 2.64-411 i
DEPARTibl[: N [ OF I IEAI.."I'I-I AND [ N\/I~I()R, iV]I P~ 1 Al. PROq [{CI ](,)1~
~Permit %: 820045
~January 31, 1983
TO: Permit Applicant
Subject: Lot 3 Block 5 Rolling Hills View Estates Subdivision
A permit issued by this department for an individual well
and/or on-site sewer system has expired as of December 31,
1982.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log needs to be sent
to this department for documentation of the installation
date and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files and documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerel~
Robert C. Pratt, R.S.
Acting program Manager
Sewer and Water Program
RCP/ljw
enc: Copy of Permit
SWP/057
DE:F'F~F.:'THEi',!'T OF' HEFILTH FINE:, ENViF:EJN.r"iEi',!'TFIL F'~:~%iTECTION
825 "L." STREET, RNCHORFIGE., RK. 99501
264-4720
F:IF'F'L. I E:F:hN T
!... OCF!T 3: ON
"-","- - "' I ti: :' ""F.'~:' -'
T'¢F'E qF SO.f.L REL::F-.'F'TI'/N ::,.::,TEll t ....... FL, P,
THE R'FZ;: .I[~'E'I::, ':-:;I2:E OF' THF. :.:-:;O];L RE:E;ORF'TION ~;"r'~.;TEI'"I IS:
"FHE LEh,t(:iTFt [:,IHENS]ZON :[~:; THE LENGTH (:If~ FEET) OF THE TREHEH OR
THE OEF'TH OF F! TF:ENCH OF: PIT :[:5 THE C,Z:D'TFtNCE DETHEEN THE ~L,iRFi:::ICE OF THE
GROUND FIND THE BOTT'OH OF 'THE EXCFi'¢Rff'ION~(~N FEET).
THEF:E t'S NO SET Fi]:c,"r'H FOF: 'T'FRENCHES.
THE GRR~,,'EEL. [:,EPTH IS THE HINIHUH DEPTH OF GR~gVEL.. BETI,.IEEN THE OU"['FRLL F'IF'E
RNE::, TFIE BOTTOH OF THE EXCfl~,,'RTZON (IN FEET>.
F'ERM i T FIPPL I CF!NT HFI'L:, 'THE: F:ESPONS I E,' ]'. L I 'T;T' TO I .t'.,IF(}!:;.:!',I TH I S [:,EPFiI~t'TMENT' DI...IF: I NG THE
:.r. NST£4.LL. FtT!OI'.~ INSPE:CTIOI',I:5 OF RN"? .NELL~:'; FI[::,JFICENT TO 'THIS PROPEF'.T'¢ FIN[:, 'T'HE
NUI"!E,'ER OF RESIDENCE:.:.; THRT THE NELL I.,.fILL SERVE.
t_:~FIC:k':FILL:I:NG ':t:' FIN',? '-' "-' t. ....
.::.,TOTE. 1 t.,.IITHOLrT F'INF!f.... I.N:EF'E']:TICH FIN[::, FIF'F'Ii?'"VFIL E"¢ 'THI:'~;
I:,EF'FIF.'THENT I..~I~_.L BE SUB,!ECT TO F'F.:OSECUT]:ON.
OF THE HELL. COHP[E'TT:.'H ...¢Z5°
F'OF.:TH B'T' THE HUN I E:Z F'FIL I T'T' r:: F RI'-,!CHOF.:FIGE.
:,E.!.IE.R :,r::,.EH i'"fFt%' F:EOUZF4:E ENLFIF:GEHENT IF THE
1~6Ni~ALITY OF ANCHORAG~
~L C¢~'~ ~l~ PLAN
t$
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description Lot 3; Block 5; Rolling Hills
View Estates
Location (site address or directions) 18920 Upper McCrary
Property owner
Mailing address
Lending agency
Grif fith
C/O REMAX EAGLE RIVER
Eagle River, AK 99571
Day phone 694-6345
16600 C~nt~rfi~ld Driv~
Eagle Riv~, AK 99577
Day phone
Mailing address
Agent A1 Roma~z~wski - REMAX EAGLE RIVER Day phone 694-4200
Address 16600 C~nt~rfi~ld Driv~ S~it~ 201
Eagl~ River, AK 99577
Unless otherwise requested, HAA willbe held forpickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
,.2, f
XXX
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. 1/91) Front MOA ~21
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~NIDN~ AG NOI~O3dSNI dO IN3~31VIS
Municipality of Anchorage ,~
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description'~::~' ''~ ~2_~,¢~' ~2-3o~..~.~ Parcel I.D.
·
A, WELL DATA
Well type ~l~-~/'~<'t-~ If A, B, or C, attach ADEC letter· ADEC water system number
Log present~N) ~ Date completed
Total depth ~-~L,~c~ ~ Cased to
Sanitary seal [(~)N) ~-[
FROM WELL LOG
~Date of test ~ ~ ~'~
Static water level
Well flow
Pump level ~'~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~c:>Ot ¥
Absorptio~ field on lot ~ o ~ ~ ~-
Public sewer main t-~ ~J~
Sewer service line
--~., c~.-~ Driller
~..'~ ~ \~ ~::>~..., casi n g h eight
Wires properly protected ~N)
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATERSAMPLE RESULTS:
Date of sample: ~ ~ ~' L~ ~ c~,-z~
B. SEPTIC/HOLDING TANK DATA
Date installed ~'~
Cleanouts~N)
High water alarm (Y~
Date of pumping
Collected by:
Other bacteria t'~
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Tank size ~, O ~ C:> Compartments
Foundation cleanout~N) q Depression (Y~
6 Alarm tested (Y/N) ~
~- ~'"'~ ,~'~ Pumper "',','~-~"-,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~,O1~
To property line \c>~j~'
Surface water/drainage
On adjacentlots
Absorption field
\c~~'J~' Foundation
~-~ Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level ~
Meets MOA e~~.
SEP~,.~ DISTANCE FROM LIFT STATION TO:
Well on lot On 'adjacent lots
Manufacturer
Manhole/Access (Y/N~.~ ~
"Pump on" level at ~ "Pump off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ~ ~
Length ~>~ ' Width .~
Total absorption, area [.~ '7.-- ,~'
Depression over field (Y/¢~
Results {~fail)
Peroxide treatment (past 12 months) (YN~
Soil rating \~,c~
Gravel thickness
Cleanouts present(~)/N)
Date of adequacy test
for
.~A ;~.t,,,~ ~ If yes, give date
System type
Total depth //
bed¢ooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~oo
On adjacent lots ~ C)~ ~ Property line ~ ~::~\ A'-
To building foundation ~. c:, x &'- To existing or abandoned system on lot
On adjacent lots ~-~:~ ~ ~ ~"\ 1
Cutbank ~:~ Water mai n/service line ~ ~ ~ ~'-
Surface water \ ~c:> ~'&'~ Driveway, parking/vehicle storage area "Cc> ! 4-_
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspecti'on.
Signature
Engineer's Name
Date
S & 5 ENGINEERING
17034 Eagle River Loop Road No. 204
~,v,~,,, ...... ??$77
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
ROBERTSHAFER, PE
ROGER SHAFER. P.E
CIVIL ENGINEERS
WELL RECOVERY TEST DATA (907)694-2979
FAX 694.1211
WELL LOCATION (legal). L~=~
HEALTH AUTHORITY
APPROVALS
SEWER &WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOt. ATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
TEST DATE: 7- -~-~-- ~ ~
WELL DEPTH: ~Lo~~
CASING DEPTH: ~.~' %%~ ~.~.
TEST PROCEDURE:
1) Draw water down to pump.
2) Shut pump off 15-60 min.
-record time
-record meter reading
3) Turn pump on. Drawdown.
4) Shut pump off.
-record time
-record meter reading
5) Calculate gal./min, recovery.
TESTED BY:
WELL DRILLER':'~
DATE DRILLED:
MISC. DATA~
Casing Height:
Sanitary Seal?:
Wires in Conduit?:--
Grading O.K.?:
Pump Depth:
Samples Taken? .'
Date: ~.~ ~t~
TEST DATA: START TIME: \~_--:Dc:~/~ STATIC WATER LEVEL: ~\L~
TRIAL PUMP TIME METER GAL./MIN.
OFF
i ON
OFF
2 ON
OFF
OFF
3 ON
OFF
5 ~0~ .
RESULTS: WELL CURRENTLY PRODUCESt
FLOW R~TE NOT GU/~RANTEED--SUBSEQUENT VARIATIONS CAN OCCUR!
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
Chemlab Ref.# :93.0625-1 REPORT of ANALYSIS
Client Sample ID :L3 B5 ROLLING HILLS VIEW EST.
Matrix : WATER
FAX: (907) 561-5301
Client Name :S & S ENGINEERING Collected :02/16/93 @ 10:00 hxs.
Ordered By :R.3.S. Received :02/16/93 @ 14:30 hrs.
?zoject Name ; WORK Order :63231
Project# : Report Completed :02/17/93
PWSID :UA Technical Director
Released By :
Sample
Remarks:
ROUTINE SAMPLE COLLECTED BY: RAY.
QC Allowable Extract Analysis
Parameter Results Qual. Units Method Limits Date Date Init
NITRATE-N 4.72 mg/1 EPA 353.2/300.0 lO 02/17/93 02/17/93 LLH
* See Special Instructions Above UA = Unavailable
** See Sample Remarks Above NA - Not Analyzed
U - Undetected, Reported value is the practical quantification limit. LT - Less Than
D - Secondary dilution. GT - Greater Than
~__13'-~ Member o, the SSS Gro.~
C OM?/ ; CIAL T, S77["TG o
ENGIN_EF, NG CO. AK
CiqE?dICAL & GEOLOGICAL LABORATO Y
TELEPHONE (907) 562-2343
5¢~3 B Street
Anchorage, Alaska 99518.
Drinking Water Analysis Report for Total Coliform Bacteda
TO BE COMPLETED BY WATER SUPPLIER
[] PUOUO WATER S¥STE,~I I.D. # [ I ._L 1--~--['-~
PRIVATE WATER SYSTEM
Mailing Address
C~y State Zip Code
Mo. Day Year
SAMPLE TYPE:
cL;;~ Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
.) [] Treated Water
[] Untreated Water
SAMPLE
No. LOCATION
t
.time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received
Anal~rtical Method: Membrane Filter
· No. of colonies/lO0 mi.
Lab Ref. No. Result*
Analyst
READ INSTRUCTIONS
Membrane Filter: Direct Count
BEFORE
COLLECTING SAIVIPLE
Verification: LSD
Fecal Coliform Confirmation
Final Membrane Filter Results
Reported
TNTC = Too Numerous To Count
OB = Other Bacteria
~'~ ~S Member of the
BACTERIOLOGICAL WATER ANALYSIS RECORD
~,) Coliform/lO0 mi
BGB
Coliform/lO0 mi
Date _
Time: ( .~-O (--J a.m.
PA:~T ONE OF TWO
REHAINDE~ TO FOLLOW
APPLIC ' NT FILLS OUT UPPER HAF-' ONLY
Property Owner ~lmond~ ']~nc= Phone
MailingAddre~ P.O. BOX 11-2247 Zip Code 9 9 511 345-3821
Buyer
Address Zip Code
Lending Institution ae [t/~. B. Phone
Address Zip Code 99 5~1
Realty Co. & Agent Phone
Address Zip Code
Legal Description Lot 3 Block 5 Rolling Hills View Esta~:es
Street Location]
Type of Residence
[~[ Single Family 3
[] Multiple Family No. of Bedrooms
[] Other
Wa_~r Supply
L3flndividual ATTACH WELL LOG. A w(~l Icg is required for all wells drilled since June 1975.
[] Community For wells drilled prior to that date, give well depth (attach Icg if available).
[] Public Utility
Sewer Disposal
E~ Individual Year Individual Installed: _ 19 8 3
[] Public Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
( ~ } APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
APPLIC~,NT FILLS OUT UPPER HAI'-"~ONLY
P~'o,~ertyOwner ,,/~j,~.! ~//¥/:~: // ~:~ '~,://'¢ Phone
Mai,ing Addre~ . 0/.2 .A/ ~~' ~ ~ip °ode
Buyer
Address Zip Code
Lending Institution Phone
Address ~j/~.~ 4/ v/~j~ ZiP Code
Realty Co, & Agent t / ~ ~ ,v ' Phone
Address Zip Code
-, "~/ '/ J ~'~
Typ~e of~3esidence
L~"Single Family
[] Multiple Family No. of Bedrooms
[] Other
Wa~te~upply ~ ' ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
Vlndividual
[] Community ,,~ For wells drilled prior to that date, give well depth (attach log if available)·
[] Public Utility
Sew~er
[C[,--~d ivid ual Year Individual Installed: / ~ _~'..?
[] Public Utility When Connected to PuBlic Utility: ~-~'
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes: ~ '~"~ ~
( ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ~ ) CONDITIONAL APPROVAL*
,~: (~-~t~,~. ~4~'~ c: ~- ~. ~::~,~
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received