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Home My WebLink AboutSUE TAWN ESTATE #2 BLK 4 LT 1 MUN ICIPALITY OF ANCHORAGE On-Site Water & Wastewater program' PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax (907) 343-7997 http ://www.mu ni. org/onsite Effective Date: Expiration Date: Lot Size in Sq Ft: TotalBedrooms: 61212022 61212023 54800 4 I I :'q: Special Provisions: 1 A C-OS-A is- rgguifed W_hen closing this per:mit. Received By: On-Site Wastewater Disposal System permit Permit Number: O5P221147 Work Type: SepticTank Upgrade Tax Code Number: 05151140000 Site Legal Address: SUE TAWN ESTATE #2BLK 4 LT 1 G:.1060 Site Mailing Address: 23612 CHARLIE RD, Chugiak Owner: HUSEBY BRADY D 50% Design Engineer: EKLUTNA ENGtNEER|NG, LLC* This permit is for the construction of: E Disposat Field ,EI Septic Tank E Hotding Tank E privy EI Private Wetl E Water Storage AII construction shall be in accordance with: 1. The attached approved design. 2. All requirem te of AlaskaWastewater 3. The wastew services De Development 4. From October '15 to April 15, a subsurface soil absor shall bg gither: v ^|-,,,r I v, q Duvrur r6uE luil dusut ezing weather a. Opened and Closed on the same day, or b.".Covered, sealed, and heated to-prevenffreezing---- * lssued By: MUHMPAU !I Y OF AHCH(0R,,,, GE ',. _4 Development Services Department $:_ Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 05151140000 Property owner(s) HUSEBY BRADY and HUSEBY RUSS Day phone Mailinq address 16542 MERCY DR EAGLE RIVER, AK 99577 Site address 23612 CHARLIE RD Chugiak Legal description (Sub'd., Block & Lot) SUE TAWN ESTATE #2 BLK 4 LT 1 Legal description (Township, Range & Section) Lot Size 54,800 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank 0 Upgrade Q Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ -- - THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: �2Z2_9 Date of Payment: / 0 Receipt Number: cog ( I� Permit No. O.SPZ?- I I `-I% -5- / I S/ Zo 2iz Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewatefforms\Client FormsTermit Application.doc Eklutna Engineering, LLC curtistownse nd @gma i Lcom May 27,2022 Subject: Sue Tawn Estate #2 Block 4 Lot 1 Upgrade Septic Tank Permit Request Narrative osP22tt47 This is a design narrative for a permit to install a new septic tank on this property. The existing tank is 43 years old. The homeowner is desiring to replace the tank. The proposed system will serve an existing four (4) bedroom house. The existing septic tank will be removed and disposed of and a new L,25O gal septic tank will be installed. Double cleanouts will be provided downstream of the tank. Soils. The soil in this area is composed of sandy gravel. A test hole had previously been dug during the month of July to a depth of L4' . No groundwater was encountered' Soil Absorption System. The existing soil absorption system is a 44' long x 3' wide x 72" effective depth trench system. The field was tested May 2022 for adequacy and passed. lt is holding 37" of water. lt will not be upgraded at this time. Wells. This lot and the surrounding lots are served by private water wells. MOA has documentation for these wells. There are no wells within 100' of the proposed septic system. Neighboring Wastewater systems. lmmediate neighboring septic systems are all +10' distant from property lines. Surface Water: There is no surface water within 100' of the tank. The proposed tank upgrade will maintain at least LOO' from all surface water and drainage ditches. Topography: The existing topography in the area of the tank is flat with slopes less than 1% in any direction within 25' of the tank. The proposed installation will not affect the future development of this or the surrounding lots. Sincerely, Curtis L. Townsend, P.E. Attachments t. 2. 3. 4. 5. 5. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221147, Deb Wockenfuss, 06/02/22 I /* IY \l SCOPE OF WORK1. RTMOVE EXISTING SEPTIC TANK.2, PLACT NEW 1,250 GALLON SEPTIC TANK AND TIE INTO TXISTING ABSORPTION SYSTEM. THI TANK IS TO BE PROVIDED WITH MINIMUIV 2O,, A MANWAY RISER SERVING THE FIRST COMPARTMENT. PROVIDE DOUBLE CLEANOUTS.3, LOCATE BTGINNING OF FIELD AND EXTEND MISSING CLEANOUT.+. ALL CONSTRUCTION TO BE IN ACCORDANCE WITH ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTTRS 15.55 AND 15.65. \ ) ( I I I IL_-- SLOPE \ tz NEIGHBORING WELL IS lOO'FROM PROPERTY LINE ^'</ci 2 .V NEIGHBORING WELL IS TOO,FROM PROPERTY LINE \ \ \- \ \ \s \^_- \\ \\ \\l\l\t// /.s > LINE Permit Drowings Prepored for BRADY HUSEBY 23612 Charlie Rd Chugiak, Alaska 99567 SUE TAWN ESTATE #2 BLOCK4 LOT 1 osP221147 EKLUTNA tNG/NIf R/NG, LLC 19162 IVOUNTAIN ROAD CHUGIAK, ALASKA 99567 (e07) 406- 1 058 DATE:61112022 DRAWN:CLT SCALE:1" = 30' PID: 051-511-40 SHEET 1 OF 2 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221147, Deb Wockenfuss, 06/02/22 AN ADDITION IS TO BE CONSTRUCTED ONTO THIS HOUSE. THE FOUNDATION WALLS OF THE ADDITION WILL MATCH THE WALLS OF THE EXISTING HOUSE. THIS VIEW SHOWS THAT THE TANK CAN BE WITHIN 6, OF THE FOUNDATION WALL AND NOT PENETRATE THE SOIL BEARING PRISM. Ffo a Ltlt_ =<-)l-r-)O ---l OO 1 250 GAL Permit Drowings Prepored for BRADY HUSEBY 23612 Charlie Rd Chugiak, Alaska 99567 SUE TAWN ESTATE #2 BLOCK4 LOT 1 osP221147 EKLUTNA ING/NIIR/NG, LLC 19162 MOUNTAIN ROAD CHUGIAK, ALASKA 99567 (e07) 406- 1 os8 DATE:512712022 DRAWN:CLT SCALE:1" = 5' PID: 051-511-40 SHEET 2OF 2 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221147, Deb Wockenfuss, 06/02/22 h--~' MUNICIPALITY OF ANCHORAGE~,..~,~j,~//q,~/~ (~--~/¢~Z./ /~- / ' DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ~-* ~---~/'~%~¢'v~ ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ~-~./r~4._ ON-SITE SEWAGE DISPOSAL SYSTI~M AND/OR WELL INSPECTION REPORT PHONE [] UPGRADE NAME LEGAL DESCRIPTION LOCATION ~ / DISTANCE TO: ---- ~ Manufacturer ILiq. capacity in ga ons DISTANCE TO: We I Absorpti~?~ea inside length Dwelling J Dwel~ NO, OF BEDROOMS No, of co~tments Liquid depth PERMIT NO. Manufacturer Liquid capacity in gallons Total I~f~ines Material bedeath tile Well / DISTANCE TO: No, of lines ~ I Length~l~of ac li/~e Top of tile to finish grade Material Nearest I~i~, Trench width inches inches Width Length Depth Distance between lines Total effective absorption area PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot llne DISTANCE TO: Septic tank Class Depth Driller Distance to lot line PERMIT NO, DISTANCE TO: Building foundation Sewer line Absorption area(s) OTHER SOl L TEST RATING INSTALLER APPROVED ' DATE LEGAL h4Lti'IE',ER OF RL.].[.E. 4 ....... 'THFFf' THF !.,.JELL. ~,!ZLL DEF'R?.T'HEN"f' i.,IZL. L. BE '.SUE.:rECT TO F'?.O:~ECUT:(ON. OF' THE i.4ELL. E:ONF'LET:[E~N. ...... :i*. ~r r THRT DEPFIRTMEi'.iT; ~ HERLTH FIHE) EN',,,'IF:Cq.~f'IEH I'FIL, 'b]TEC:TI/~d,i 825 ~-'~/ STREET, RNC:H()RFIC~E, BI<. '_:.~,..,~1 ~ ~,,.,¢...L. F'ERPIlI NO. < > RXIMUM NUME'.ER OF EED~'ZEMS = ~ SOIL SCaURRE FEET HE REQLII,q:EE SIZE OF THE SOil FIBSORPTION :-.. E F. T H-=: L_ :_ '¥' H := >/ THE LENGTH DIP1ENSIOH IS THE t_EHGT!4 , £t-i FEET) OF 'THE TREHCH OR [F. HI~r lEt_Et. THE DEF?H OF Fi 'FRENCH OR PIT I'% THE C, ISTRNE:E E'.ETHEEH ]'HE SIJRFRCE OF THE GROLIN[> RND THE BOTTOM OF THE E':*'Zi~k.'RT~qH (IH FEET). THERE IS HO SET HIDTH FiR TRENCHES. THE G~,B. EL DEPTH IS THE MINIP1UH ~,EF'TH OF GRB'.,,'EL E:ETHEEN THE CILITF'FILL PIPE BND THE BOTTOM OF THE E..,L. Mv~TI}H <IN FEET). ;:E6:!l_l I E:E[:, :SEF'W' lC C: -FF:IPJt-::: Lmm; I ZE== /~¢'O sS~BL_LIZIPiL5 ERMIT FiPF'LIC:Rt.IT HFIS THE RESF'OfISIE:IL!T'¢ TO It-,!FORM NSTFILL. FITION IfA:]PEC:TIONS OF F~iqS' HELI_S Ft[)JFICEN]' TO 'UMSEF: OF RES, IDENCES THFIT THE WELL 14iLL ~ER%,'E. THIS DEF'FtRTMEHT [)UR:[HG THE TtiIS F'ROPERT'¢ FtH[) 'FIiE T I..~11]~ < '.-'l~ ) I I'-.i tm; F' I:]: 17_: -V I :3 f'-.I 'S Ft F::: E I~: ~:-: 6:! El I I~: E [:, :RCKFILLIHG OF FiN'S SYSTEM HITHOUT FINFiL INSF'ECTION FiND FiF'F'F<OVRL E:"r' THIS ,bPFiR'i"MENT I'IILL BE SUBJEC:T TO PROSECUTION. !IHII'iLIf'l DISTRNC:E E:ETI.]EF_N Fi HELL RH[:, RN'T' ON--SITE SEMFuSE DISPOSFiL S'T'SFEM IS .DE1 FEET FOR Fi P'RIVFiTE 14ELL; OR .5C~ TO 2F_40 FEET FROM Fi PUBLIC: HELL C, EF'ENDIfa] LIF'IZ~F-I THE TYPE OF PUBLIC: '.iELL IEI_L LOGS FIRE REQUIRED FIHD PllJST 8E RE FURNED TO THE DEPRRTMEHT HITHIN 38 DRYS iF THE WELL C:OMPL. ETICIN. ~THER REQUIREMENTS P1RN' RPPLY. SPECIFICFiTIONS RND CONSTRLICTION DIRGRFIHS RRE .!/RILFIBLE TO INSLIRE PROF'ER INSTFILI FIT!EIN. : CERTIF'¢ THRT : I 8M FRMILIRR FilTH TIiE REC.'~JIF:EMEt'IT-q FOR OH-SITE SEHE:RS RND 14ELLS RS ORTH E:Y TFIE MUI-IICIPFIL i-fY OF RNCHORFtGE. · : I NILL INSTFILL ]'HE SYSTEM IH FiC:CORDFiHCE HITH THE CODES. :: I UNDERSTRND THRT ~iE ON-SITE SEHER S'YSTEH MRS' REQUIRE EHLRRGEMEHT :EsIDEHCE IS REMO[:,EL~,,, TO INCLLIDE MORE THRN ~ BEC, ROOM% , * u .....~- .- 2z:,~.p~-~ .......... ~ .............................. SET IF THE V:% '2 I · i I.:as 9rouud water encountered? _]U__Q ....... If )'es, at what 0 0 0 0 0 0 0 0 0 0 0 0 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 HAA # 1, GENERAL INFORMATION Complete legal description LZ/B4 Sue Tawn Estates '~ Location (site address or directions) Corner of Melissa & Charlie Roads Peters Creek P~perty owner /,Z,J//~'.? 'J~ ,"~¢,d¢ OrA/ Day phone Mailing address ~ ('~ ¢~).~/' ~D¢~- Lending agency /¢2/~¢%~;¢¢ ,..~¢?,,¢~ ¢,~ .~....~/.,.,¢~¢¢, Day phone Mailing address -~('~ /:~-~-? /~/~-¢~"~ ./-~//~/~¢'"~? ¢/. Agent Day phone Address 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. four ',j NOTE: Individual well x Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site 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. 1/91) Front MOA#21 s)uewwoo leUO!)[pp¥ :suoBelndBs 8U!MOllO~ eq) q))~ 'sLuooJpeq JoJ leAoJdde leUOB!puoo 'peAoJdd~s!o 6969 ~966 MV 'eIITseM ouoqd 'swooJpeq _~ JoJpeAoJddv ~M~AVNOI$ SHHO ~ ~'/~'~/ eJn)eub!s s,Jeau!6u3 aAV Uu.~u~alt '3 I~I ssoJppv wJH jo OWeN '9 HM=INIONM AM NOIJ..')=IdSNI dO ANM~/V£S !; Legal Description: Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST L1/B4 Sue Tawn Estates ~'~'/ Parcel I.D. A, WELL DATA Well type pr~v~r~ Log present (Y/N). N Total depth approx. 265' Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed 1979 Driller unknown Cased to unknown Casing height ?. 5 ' y ': Wires properly protected (Y/N) y Date of test Static water level Well flow Pump level FROM WELL LOG AT INSPECTION SEPARATION DISTANCES FROM WELL TO: RECEIVED M~JNICIPAUTY O~ ANCHORAGE ENVIRONMENTAL SERVICES DIVISION g.~92 RECEIVED Septic/holding tank on lot approx. 150' ; On adjacent lots 100'+ Absorption field on lot ; On adjacent lots 100' ~ Public sewer main ncnc Public sewer manhole/cleanout acne Sewer service line approx. 150' PetroJeum tank non~ WATER SAMPLE RESULTS: Coliform satisfactory Date of sample: 9/29/92 Nitrate Collected by: Other bacteria A. Giddings-engineer B. SEPTIC/HOLDING TANK DATA Date installed 10/29/77 Tank size .~,.~, .,, ~,""~' Compartments 2 Cleanouts (Y/N) ¥ Foundation cleanout (Y/N) ¥ Depression (Y/N) High water alarm (Y/N) N Date of pumping "/J'Z"/ Alarm tested (Y/N) Pumper N SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot appr,~,,: !50' Onadjacentlots lOO' ~ To property line 10' + Absorption field 7 ' Foundation 7 ' Water main/service line 6f~ ' + Surface water/drainage 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION NONE Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Manufacturer _ Manhole/Access (Y/N) "Pump off" level at Cycles tested Surface water D. ABSORPT'ION FIELD DATA Date installed ___ Length Total absorption area Depression over field (Y/N) Results (pass/fail) PASS Width 528ft N Soil rating ~/hed~:c~omSystem type --Peep 'P4ce_n,'~h __ Gravel thickness 6_L Total depth 13.5j Cleanouts presen[ (Y/N) Y Date of adequacy teat for four b~drooms Peroxide treatment (past 12 months) (Y/N) N If yes, give date SEPARATION DIS'rANCE FROM ABSORPTION FIELD TO: Well on lot appro×, 165' On adjacent lots 100'+ Property line tO'+ To building foundation 30' To existing or abandoned system on lot none On adjacent lots 50'+ Cutbank 100'+ Water main/service line 70'+ Surface water __.].o0 ' + Driveway, parking/vehicle storage area 502_+ 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 insl,eclion. Engineer's Name Date I0/, HAA Fee $ / '~'~) °~¢ Date of Payment / ¢-/ '-9 ,P~ Receipt Number ~:~-'~/~/~ (~ '~/~ 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number -( Municipality of Anchorage ( Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L1/B4 Sue Ta~'n ~.states Parcel i.D. A. WELL DATA Well type p~i~=t~ Log present (Y/N) 1~ Total depth approx. 265' Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed 1979 Driller unkno~m Casedto appears at [east Casingheight ?.5' 4u]:t ¥ '- Wires properly protected (Y/N) y FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line approx. 150' approx. ATINSPECTION [47' g.p.m. 6 g,p.m, 202J-+ ; On adjacent lots 100'+ ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform satisfactory Date of sample: 9/29/92 B, SEPTIC/HOLDING TANK DATA Date installed 10/39!77 Cleanouts (Y/N) ¥ High water alarm (Y/N) Date of pumping Nitrate Collected by: Other bacteria A. Ciddings-engineer Tank size 1250 Compartments 2 _ Foundation cleanout (Y/N) ¥ Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK TO: Well(s) on lot To property line 1o' + Surface water/drainage On adjacent lots !00'; Foundation 7 ~ Absorption field ?' Water main/service line 6n,. CONTINUED ON BACK PAGE DA~-E'~EC FJ;V E D 3:IME ~ TIME TIME DATE ~ ~ DATE DATE INSPEC R INSPECTS1 ~ ' INSPECTOR /~NICIPALITY OF ANCHORAOE DEpT, OF H%ITH ~ ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE DEPARTMENTOFHEALTH&ENViRONMENTALPROTECTiON ~ECEi~j~D 825 L Street- Anchorage, Alaska 99501 JUL ~' ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts o]~ page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing, 1. PROPErTy O~WN~R PHONE 3. LENDINO~I~UTI_ON/ PHONE STREET LOCATION ~ / ~ / ~ - -- ' ~ I ~N~EFAU,LY ~ ~o ~ Five ~ ~ ,Three ~ Six [] MULTIPLE FAMILY 7, WATER SUPP· ~VIDUAL* [] COMMUNITY [] PUBLIC UTI LITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) ~IVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAl. [] COMMUNITY [] PUBLIC UTI LITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] I NDIVI DUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [] Flolding Tank Size: If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA NUMBER OF BEDROOMS E~] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL OATEDRfLLED LOG RECEIVED PERMIT NUMBER DATEINSTALLED SOl LS RATING MANUFACTURER MATERIAL [] OTHEFt 4, DISTANCESwELL TO: Septic/Holding/~"~-- Tank Absorptlon/~ 0 Area Sewer Line Nearest Lot Linu Absorption Area to nearest Lot Line 5. COMMENTS DATE []~APPROVEDFOR ~ '~BEDROOMS [] CONDITIONAL APPROVAL {letter must accompa~v~certificate) [] DISAPPROVED BY 72-010 (Rev. 6/79) DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts orl page 1. Incomplete re,~l~ests will not be processed. Please allow ten {10) days for processing. PROPERTY RESIDEN~ (If differen~ from above) 2. BUYER ~AILING ADDRESS MAILING ADDRESS 5. LEGAL DESCRIPT ' STREET LOCATI : -~ 6. TYPE OF RESIDENCES- - NUMBER OF~BEDR(~OMo~_,_]] I ~ [] One ~ [] Other ~_,~S~NG LE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six WATERR SUPPJ. M-- SUPP ~ NDIvI DUAL* ~ ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTILITY depth (attach log if available.) 8, SEWAGE DISPOSAL SYSTEM [] PUBLIC UTI LITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN RE INITIATED. 72-010 (Rev. $/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] iNDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE [~] PUBLIC UTILITY Connection Verified []Septic Tank or [~] Holding Tank Size: If Tank is homemade give dimensions: TYPE OF TANK NUMBEROFBEDROOMS [] ONE [~] THREE [] FIVE [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATEINSTALLEO INSTALLER SOILS RATING MANUFACTURER OTH E B TOTAL ABSORPTION AREA MATERIAL Septic/Holding Tank Lim~ Absorption Area Sewer Line 4. DISTANCES WELL '1'0: Nearest Lot Absorption Area to nearest Lot Line 5. COMMENTS E] APPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY 72-010 (Rev. 6/79)