Loading...
HomeMy WebLinkAboutSKYWAY PARK ESTATES BLK 4 LT 6AOnsite File Skyway Park PID 019�141�26 Prior to any COSA the field to property line separation needs to be addressed. MUNICIPALITY 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.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP251240 Work Type: SepticTank Upgrade Tax Code Number: 01914126000 Site Legal Address: SKYWAY PARK ESTATES BLK 4 LT 6A G:2729 Site Mailing Address: 11901 TOY DR, Anchorage Owner: WASCHKE TERRY & MARTHA JOINT Design Engineer: FIRST WATER CONSULTING This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: 2,0 r s;. 10 f t?eparet��ent 7/23/2025 7/23/2026 46257 ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued to FWCS Date: 7/23/2025 Issued By: _ &!;e' [ Date: 4 MUNICIPALITY OF ANCHORAGE At Development Services Department -343-7904 Phone: 907-343-7904 On -Site Water & Wastewater Section ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 019-141-26 Property owner(s) TERRY & MARTHA WASCHKE Mailing address 11901 TOY DRIVE, ANCHORAGE, AK 99515 Site address 11901 TOY DRIVE, ANCHORAGE, AK 99515 Day phone Legal description SKYWAY PARK ESTATES BLOCK 4, LOT 6A Number of Bedrooms 4 Engineering Firm FIRST WATER CONSULTING Building Permit Number APPLICATION IS FOR: (Z all that apply) Disposal Field ❑ 91 El D R 1-1 Septic Tank Holding Tank Privy Well Water Storage Not Applicable X APPLICATION IS AN: Initial D Upgrade nx Renewal 1-1 THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Permit/Rush Fees: 01?� Date of Payment: 711(01'2- Permit No. 05P2512't6; May 2025 Waiver Fees: Date of Payment: Waiver No. Distance: 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / FirstWaterAK@gmail.com ! !! July 16, 2025 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: SKYWAY PARK ESTATES BLOCK 4, LOT 6A The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic tank on the above referenced lot. We propose to install a 1500-gallon epoxy steel STEP septic tank per the attached design to serve the existing 4-bedroom residence. An existing waiver of 84’ to the current tank exists and due to the field area, etc…this separation is to maintained. The 84’ well radius is to be staked prior to installation. Groundwater was noted in the MOA on-site file, but if shallow groundwater is encountered during installation the tank may need to be anchored or other action may be required. The lot and area are served by private water and any encroaching wells, easements, … must be staked prior to construction. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251240, Ben Cogger, 07/23/25 24.1 7.0 8. 0 30.2 47 .8 8.1 26. 2 35.5 14 . 2 1.9 11 . 9 2.0 7. 7 6.7 15 . 5 8.0 12 . 1 7.9 12. 6 9.5 11.3 FIRST WATER CONSULTING SKYWAY PARK ESTATES BLOCK 4 LOT 6A DESIGN DETAILS: Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251240, Ben Cogger, 07/23/25 ,~ ~ MUNICIPALITY OF ANCHORAGE /~/ · DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION '-~-/- ~ L~ 825 L street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MAILING ADDRESS EGAL DESCRIPTION LOCATION PHONE [~N EW ,~/~ - C~;~'~' [] UPGRADE NO, OF BEDROOMS Well z Absorption area ]Liq capac ty n ga ons ] _ ] Inside length /~ ~0 IF HOMEMADu: DISTANCE TO:~ell /Dw "ir'g ] DISTAN Well Foundation/ Length Width Depth DISTANCE TO: g DISTANCE TO Building foundation Sewer Fine IDwelllng ~c~ / Materia]~/O z Nearest lot line Trench widt~c9 inches inches ¥ No. of compartments Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. Distance between lines Total effective absorption area PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line J PERMITPERMIT NO, Septic tank ~o~ ~rea(s) I OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS APPROVED DATE LEGAL 72-013 (Rev, 3/78) PERM]:T' NO. FIF'F'I... ): _'" FIHT E:ETT'.r' J CHFINB, LER F'O E, .. =. 4:J.~.... FINCI'"IORFIGE 5~:95'E::1. _'..44-.~,...,~:,..., L. 0 C FI T I 0 I",1 LEGFtL L..E;FI E4 '..:.,K"r'i..IFl"r' F'K E::,] "II'E:.', L. OT :,Ia.l: '/~ ::;k:~ '3 'S ::.: $6!IJFIRE E'EET '1 rFE OF' :,uIL RE_uFJ lION _.,~_lEli .[ .... :'HE LENGTH [:,IMENSION IE; THE LENGTH '.':IN FEET) OF THE TRENC:H OR [:,RRINFIEL.[:,. THE [:,EPTFI OF R TRENCH OR PIT I:5 THE DiSTI:~NCE BE:TWEE:N "tHE ~;(iI~F'RC:E OF :'FIE GROUND RND TI-IE BOTTOH OF THE EXCR',,,'RTZON ,:;ZN FEIET). THERE Z5 NO E;ET P.IIDTN FOR TRENCNES. THE GFrRVEL DEP'FH I~5 THE MINIMUM DEPTN OF GRFIVEL BETWEEN 'THE OUTI::'RL.I_ PIPE RND THE BOTTOH OF' THE EXCRVFITZON/(ZN' FEET). F'ERMIT I:tPF'LZE:F:II"~T HFI~S "FHE ;'""¢ '- ': ........... . ","r F.. E ~ F - ~ ~.:", 11 .~ ]. L i F 'r '[' 0 I N F 0 R 1'"1 ] ~ ] .[ .:, [:, E F' FI R TM E N T E:' I..I R Z N G T H E ......... '=' '" -' " " '-' rFIZ_, F RUFERT~ Rf.,IE:, THE Z P~: T LLr. PI I Z. N Z [ L ~ EL.: Z JN., ElF Fllq'¢ I JELL:, RD.J'I:II:}EI",KF TCl '' '= :' ' - ' - '" ' .' NUHE:ER OF I..E...,ZEENLE.. THFIT THE WELL. P.IZLL SERVE. ............... -~' ~r'"'~ ~=~ ":" ,=:: H'" :E I; .L._.II:-. E.L- If % r",t'-P'::; ti-liE:J:: F."l.:-?.E;';!lt..lt ][ II~'.'EEIIZ:: E, PI L.I-...I- I L L I i 4 b 0 F Fl[',,l'.r' .., ~ _, T [: i' I 141 T H 0 IJ 1" F ~ I II- L I I' I... F E .. ]' 1 _ i ,t FIN E:, P F F t~. _, M L E:'.r' 1 I I I ... [:,EPRRTHENT P.IIL. I.. EE ::,UE,..'IE...."I TO FF.L.:,EL.I...IFIuI,I. HINIPIUH [)]:2;TRNCE'.' E:ETI,.IEEN FI I.,IE:L.L (:IN[:, I=ll'.,l'-r' ON-SiTE :F.';EI.,IRC~E [:,ISPOSRL S.';"r'STEH IE; ::L00 FEET' FOR FI PRI',,,'FITE I-,~EL.I_ OR :1.50 TO ;?.00 FEET FROM FI PUE,'LIC WELL [:'EF:'EI",IDINL"{ LIPCd",I THE T"r'F'E OF F'UE~L. IC NELl.... HINIMLIM [:'ISTFINCIE I::'F.:OH FI PRI',,,'RTE I.,-!ELL 'FO R PRI',,,'R~rE ':SEI,.IEF;.: LINE: IS 25 FLEET FIND TO FI COI','IHIJNIT'.r' SEI,.IER LINE IS 75 FEET. OTHER REE~UIIrf:EMEI'.,I]"S HFI"r' FIPF'L'¥'. SPE;CIFICI:IT]:OI",IS FIND CONSTF;:UC]'ION [:,IFIGRI::IM'.'7, FII'~'.E FIVRILFIli~LE "FO INSIJRE F'F. zOPEF.: II",ISTFILLR'FION. i CERTIP"'T' TI'"IFIT :L: I RH F'I::IHILIFiR I.,.IITI-I THE REQI. r. IIREHENTL:; I::'OR ON-SITIE SEWERS RF,IE) WELLS IRS SE'T FORTH B'¥' THE MLINZCZF'RLIT'¢ OF' RNCHORRGE. 2: I WII_L. INtS'T'RI.L THIE S'¢STEM IN RCCORDRf',ICE FILTH :"HE CODES. ]:: I LII'.,I[:,ERSTRND THRT THE ON-SITE SEWER S"r'STEM MFI"r' RE:QUIRE ENLRRGEIdE;I",IT IF TFIE REBII}ENCE IS REMOC'E[.ED 'TO IIqCLU[:,E MORE THEIN 4 BEDROEd'"tS. : F: F L I I]:F NT/ BIETT'¢ .T_- FIRHE,I_ER... '7 ' : . : .. '/F'~/ .... ' ¢).' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMEN'FAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION ]'EST SOILS LOG PERCOLATION TEST LEGAL DESCRIPTION: )PE SITE PLAN WAS GROUND WATER ENCOUNTERED? DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop ~/~:~ o -~TT, 5~/- ~). L. cf ~ ~ I~,'1~ ~,L~q (minutes/inch) ~ FT AND PERFORMED BY: 72-008 (6/79) 20 PERCOLATION RATE TESTRUN BETWEEN MEMORANDUM State of Alaska To: Alaska Environmentla Control Service, Inc. 1200 West 33rd Avenue Suite B Anchorage, Alaska 99503 EROM: Bruce E. E'irckson/.~¢~ District Engineer~OW,~. DATE:August 1, 1984 FILE NO: TELEPHONE NO: SUBJECT: Waive Horrizontal Separation Between a Private Well and Septic Tank on Lot 6 A, Block 4, Skyway Park Estates 8521-WA-016 The Department has reviewed the subject waiver request and hereby waives the horrizontal separation on tile subject property to 84 feet between the well and septic tank. 02.00IA(Rev. 10179) 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 ~,L:~,\ - ,C~[z3 HAA # GENERAL INFORMATION Complete legal description Location (site address or directions) I I BO i ~ ¢_~ Property owner Mailing address t. ending agency Mailing address Day phone ,-~i) a y phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: c// TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from Stale 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: 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, and regulations in effect on the date of this inspection. Name of Firm ~::~ ~' ~,' ~'~'-- ~ v'-'¢/ I~'~-' Phone Address ~% ~ 1~ Engineer's signature ~~~~ Date ~' ~' ~ ~ f DHHS SIGNATURE /~' Approved for / - Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: 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 engineeCs work. 72~25(Rev, 1/91) Bsck MOA#21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. WE L DATA Lo Well type_ ~ Log present (Y/N) Total depth Sanitary seal (Y/N) Parcel I.D. If A, B, or C, attach ADEC letter. / ADEC water system number Date completed J%.[o~- !~c~V~ Driller Cased to l'~,~ Casing height Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow g.p.m. Pump level SEPARATION DISTANCES FROM WELL TO: ( , Septic/holding tank on lot ~' ~ ~'¢,~ t.,~¢4.~) Absorption field on lot [ O ~ Public sewer main ['~,,~ Sewer service line ~"¢;¢._5 AT INSPECTION I//'?//~J ~' t,~NtClPAu'rY OF ANCHORA(~E ?~ ~, ,~NVIP, oNMENTAL SERVICES DIVISION RECEIVED ; On adjacent lots ; On adjacent lots I 6o Public sewer' manhole/cleanout Petroleum tank I~///_~, WATER SAMPLE RESULTS: Coliform (~ Nitrate _ t Date of sample: ~/1'7 l~ ¢- Other bacteria · Collected by: B. SEPTIC/HOLDING ~TfNK DATA Date installed ~/~//~ '5 Tank size J~?'- ,~O Compartments Cleanouts (Y/N) ~_ _ Foundation cleanout (Y/N) ~.. Depression (Y/N) High water alarm (Y/N) fh//~k- Alarm tested (Y/N) t¥'/'A Date of pumping '/'5'"/~ ~ Pumper /Jr ~d E4 C-¢..~ ~ / SEPARATION DISTANCES FROM SF_PTIC/HOLDING TANK TO: Well(s) on lot f~¢ On adjacent lots To property line ¢:¢--~ 'j- Absorption field '/~) Surface water/drainage Foundation_ Water main/service line 72-026 {Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Dateinsta,ed Size in gallons ~ ~ Vent (Y/N) '~' "Pump on" level at High water alarm level ~ O Meets MOA electrical codes (Y/N) y Manufacturer 'k Manhole/Access (Y/N) "7/ "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 (P/¢" J/~ Length c~ t~ Width ~ Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating I ~ Gravel thickness Cleanouts present (Y/N) System type ~"/~/'~' Total depth Date of adequacy test for ¢ If yes, give date '/,71q bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /0 ~ TO building foundation On adjacent lots ,'~ ~) Surface water Curtain drain On adjacent lots /~t2 Property line ,/~) ~' - To existing or abandoned system on lot Cutbank b4,/~.~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on thedate of this inspection. Signature '~,,~ ,~ EngJneer'sNam ~,~-'~ Date I l,;z_O [ q Z- ' HAA Fees / j~ _o~ Date of Payment /-,~/- ~ '-~--' ,~ Receipt Number o?.~.'~ ~;/-- ~"-? 72-028 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number 205 NEST ~5¥H, AVENUE SUITE 206 ANCUOAABE, ALASKA 99502-3904 SEPTIC SYSTEM ADEQUACY TEST LEGAL: I_OCATION: J. ]. 9(]) J. Toy B1 vc:l ,, QWNER: RES I DENCE: S:L ngle Fami I y ~ 4 Bedr'c)c.n?, WELL: F'r'iva{'.e~ On Site SEPTIC SYSTEM: FROM MLJNII]IPAL RE(3[)RDS: 4 Bedroom .c/iystem TANK: Anc:hc~rage ]"ank 1250 Gal. Two Compacts,, ABSEIRF:'T I ON SYSTEM~ Wide SOIL. RAJ' ]] J~JG ~ I NSTAi..L. AT I ON DA'I' E :: 6-21-83 DATE OF LAST PUMF~IN6: Anch,, Cess Foc,.I. Jan :1.5 :l. 99'2 [)ATE OF TEST: January :1.7~ 1992 ]'ESi' PROCEDURE: System was :i. ni~pec'i".ed and measured. Tank was · l:ound with :];.5 Tee'ti of c::c)ver and wi tll a liquid level (:)~: 37 :i. nch water' levels :in the tank and 'Lhe monitor tubK~ LqE:')K'~;:~ IllOFliJ,'[=C)rc~d. TI]cc) water ].(:~ve]. in the tank cl~d not change~ wl"l i ]. (-:, 2,5 ~nc:hes o.J: water TE~T ~I_T: This ~ys'[:g~ tl~e~t~; thee L:od~ r'(;~CJL.til-'~tT~eFIt~?, 0'~ the Health and Soc:i. al Services NOTE The oi:)el"ational l:i.~Fe c)~: a].l septic systems dependr~ on the lc)ca], so:i. 1 c:om"~ditiom'ls~ groundwatel'" levels that may f].Ll(Zl:Llat:~e c:h.u":[ rig 't.'.l'~a yc:~ar' ,~ and 'l".he t,~a~'l:~r' t..t~:~][a by thce system. ']'l'lese conditions are c:Jutside the con'J:rol o'F the evalua'l:or' c:)~ '[:his s(6:~p'[::i.c: system, J-ge can tl'~ere'Fol'e riot give any (,:z,~:~t:~mat(~ of ho~ lorlg tl~is system will c::urr'er'r~: o~' '~Cutur'c:, 203 WEST 151H, AYENUE SUITE 206 ANBIOAAGE~ ALASKA 99502-5904 (907) 27%5916 RESIDENTIAL ~JELI_ INSPECTION LEGAl_: LOCATION: OWNER: TYPE] OF WELL: WELL. LOG AVAILABLE: I',lc~ INSTALLATION REQUIREMENTS MET:~Yes WELL YIELD FRSM WELL LOG: PUMP YIELD FROM TEST': 6 Gallons per" Minute DATE OF INSPECTION: January :[7~ 1992 TEST PROCEDURE: We].l was p~ul~pecl at a constant r'ate while the pr'c)be. At t. he I]eg:i.r~r~J. ng o.~: the test. wa'her :l. evel was -Found ai-. 30,,5 '~eet bel~:)~ t. op of casing. At a pumping ratca o.F 6 gallons per ~li iqute till? J.~a'~]E~l"' ]. eve]. dr"opped 6 ii. i]c:h(~)~kB, a '~:c)t:al (::)~ 900 I.:lal 1 ohs TEST FOR E.COLI AND TOTAL NITROGEN: Water' ~.~as testecl -for E,,Cc~l:[ ar'id reit. al r'li'hrc)ge)n on Januar'y :1.8~ 1992 IE.Col± C). Tot:'.al Nitr'o{4en 2.7 mfj/1. Ma,x. allowab].e 'To'hal Nitl"oger'l ],0 mci/1. TEST RESULTS: -Fl"~i t; wel 1 m(,:,~,.)ts t. he rc.!qui r"emen'Es c)~ Lhf~ Hunil:::J. pal:i, ty o'~ Anchorage. ]'FILS WELL WILl_ PRODUCE MORE .THAN 3 GALLONS PEER MINUTE FOR MORE THAN FOUR HOURS ]"he MunJc:i. pal r'~;;qu:[r'ement ~or" well fZI. ow is 150 ga]lons of wa'her" per" bedroom per" clay. This well exc:e6~d t:his requir"emerrt:., I'he ~:u~isossment o'f the conclit:i, on o4: the wl{;¢l I appl:i.e:,s on].y to the c:ond:[t:i, orls as of the clay tested. The fio~g F-,'.¥be fil~:ty C:]'~4Al]ge (:It.re '['.o and char~ges in aqLLi f (~r CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMEFICIA[. TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562.2343 ANALYSIS RESULTS for INVOICE t 50459 CDemlob ROE.$ 92.0217 Sample ! 3 MAtrix: WATER FAX: (907) 561-5301 Cllsnt Sample ID PWSID Collected Reoetved PreaerYed with 6A/4 SKYWAY PARK ESTATES Client Name :TOBBEN SPURKtAND, P.E. UA Client Aeet :TOEEENS JAN 17 92 6 h~s. BPO! : PO# :NONE RECEIVED JAN 17 92 ~ 16:00 bzs, RoqE : AS REQUIRED Ordered By :TOBBEN EPURNLAND Anelysls Completed : JAY 20 92 Send Eeporte to: Laboratory Supervisor : STEPIIEN C. DOE I)TOBBEN SPORKLA~D, P.E. Released By : 2) Parameter Results ~nlts Method Allowablo Limits I{ITRATE-N 2.7 mE/1 gPA 353.2 10 Sample ROU~IN~ SAMPLE COLLECTED BY: TOBBEN, TAG MARKED SAMPLE COLLECTED AT ger~rks: 1630 ~RS. WE RECEIVED SAMPLE AT 1600 MS. 1 Teste Performed See Special Imtruetions Above UA-Unavailable NO- None Detected "See Sample Remarks Above Nh- Not hnelyzed LT-Lesa Than, OT-Greater Than Member of the SGS Group (Soc,OtO G,~nOrele de Surveillance) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF liEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAl.) (a) Legal DescriJ]t,~)~(inc de|et, block, subdivision, section, township, range) Lecati~n} (address or~ (b) ~Propedy Owner ~ t ~ . cTelephone: Ho~e .. ~ Business (c)--.,~.,--- ~.-.L~t~tiO~.'>~'~'~? . - Telephone _ Mail~/~res~..4 ~t~' ~ ~' (d) Real Estate 8~pany and Agent ~5~ ~K~¢, Address Telephone ~- 1~17 (e) Mail the HAA to the followino address: or: Check here ,[~if hold for pick up. List contact person and dsy phone number below· TYPE OF RESIDENCE Single-Family'~. Number of Bedrooms WATER SUPPLY Individual Well~ Community [] Public [] No(e: If community well system, must have written confirmation from the State Department of Environmental Conservation attestihg 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 Environ mental Conservation aitesting to the legality and status. Page 1 of 2 72-025 fray 8/861 Front leUO!SSejoJd eq~ u! sue!ss!u Jo Jo sJo~Ja Joj elq!Suodse~ ~ou s! e6aJoqouv jo Al!led!o!un~ sql 'penss! s! e~eofj!peo e eJojeq e~sp ezAieus Jo suo!~oedsu! ~onpuoo ~ou op SHHQ jo saaAolduJ3 's~ueLua~[nbeJ e~e)s pus Icj@psi u!epao Ajsi~es o~ Jap Jo u! suo!~m.!~su! 5u!puel J!eql pus sauJoq jo sJeseqaJnd oh AselJno9 a se s!ql seep SHHQ eqJ. 'e~SSlV jo el~S eq~ u! paJais!6eJ Jesu!Sue leUO!SSato~d luapuedapu! us Aq e^oqs S qds~ea~ed u! UaA!8 suo!le~uaseJdeJ aql uodn /~luo peseq se~eafjipeo le^o~ddv ~poqln¥ q~leeH sanss! ($HHQ) seo!^~aS ueuJnH pus q~lSeH Jo ~ueLupedaQ ees~oqou¥ Jo ,g,!led!a!un~ eqJ. NOI,.LnVO le^oJdd¥ leUO!l!puoo Jo SLUJe/ leUO!$!puoo panoJddes!a '~x~ peAoJdd¥ '9 uJJ!:f jo euJeN ~7~ ~.~-~ / ~)~ auoqdele/ ff~('/'uo!loodsu ! uo lOalle u! suo!~8lneaJ pus 'saoueu!pJo 's@poo al8~S pus led!o!unv~ lie q JiM eoUs!ldUJOO u! s! LUaIS,~S lesOdsfp JaleM@~SeM Jo/pus Xlddns Ja~BM al!S-uo aql 'uo!loadsu! pus uo!lee!lsa^u! ALU LUOJj pus saul e6eJoqouv jo Aliledio!unR aql uJoJj pauie~qo UO!~eLUJOJU! aqi UO paseq leqj/~J!Je^ JeLllJnj I 'u!eAeq pa~Bo!pu! eJnjonJls Jo adXl pus suJooJp@q jo JaqLunu alii menbepe pus leUOfiOunj 'a~es s! UJalS,~s lesods!p JeleMelSeM Jo/pus ~lddns ~aleM al!s-uo aq~ jeql SMOqS IS^oJddv A~poqlnv q~lsaH s!qJ Jo uo!lee!isa^u!/~uJ l~ql X~pa^ I 'MOlaq UMOqS alBp uoilep!le^ aql lo se pus oJaJeq pex!Jle leaS,~uJ NOIJ.¥INblOSNI aNY ¥/¥a 'FlObl¥3$ ~-IIJ 'S.L$~.L '$NOIJ. O=I~ISNI 9NlalAOI:Id JNbllJ !DNII~:I~NIeN~ .g r~/,,I.~ClCIPALITY OF ANCHORAGE (MOA) *UT.O.,TY APP.OVAL CHECKLIST - FEBRUARY 1984 264-4720 Well Classification Legal Description: Z_~P'f · .r/~./.) ~ ~-.~. If A, B, C, D.E.C. Approved (Y/N) ,'t///,~ Well Log Preseni (YL/N~. Total Depth )~t- ~-/ Static Water Level ¢~ ,~?' ;~ Casing Height Above Ground Electrical Wiring in Conduit (Yc~ Separation Distances from Well: Date Completed ¢/z/'z',,V:¢~ J,¢' Yield ~.¢~ _ Cased to ,~,-.e-~z'r Depth of Grouting ."J//"~ Pump Set At Sanitary Seal on Casing(~N) Depression Around Wellhead (Y~ To Septic/Holding Tank on Lot ('~ ~¢ / ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot~:) /~' ~ / ; On Adjoining Lots To Nearest Public Sewer Line _ ,'t)Z/4 To Nearest Public Sewer Cleanout/Manhole /J,/,d To Nearest Sewer Service Line on LOt Water Sample Collected by /¢/'~'~'¢ /'~' /¢J)~'-~/ Date Water Sample Test Results Z~.'/¢d~ ~ ""'~'-- "~//~'~"'¢¢~'~' /° Comments ~ ¢J~/'-¢' /~/-~J "~7" B. SEPTIC/HOLDING TANK DATA Date Installed ~ ~?~'/~ Standpipes(~N) Depression over Tank (Y~'4~) Pumping/Maintenance Contract on File CY/N) / Holding Tank High-Water Alarm (Y/N) _ /J/ccc Separation Distances from Septic/Holding Tank: To Water-Supply Well 5¢'¢// Size /'~-c~ No. of Compartments Air-tign! Cans~.~N) __ __ Foundation Cleanou (~N) Date Last Pumeed ~27~¢?~'¢'~ Temporary Holding Tank Permit (Y/N) _ To Building Foundation 3'o Propel:ty ~.ine · ,~d Water Ma b]Serv ce Line To Disposal Field '¢" 'Fo Stream. Pond. Lake, or Major Drainage 72-026[11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~' ~/ Width of Field :%' Square Feet of Absorption Area Depression over Field (Y~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present(~N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) .,,J//4 Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for ~/,'~' Electrical CoO~s.~.N) Comments A"/?~--~ Dimensions / Manhole/Access(~)N) "Pump Off" Level at ~'"~ ~ Vent Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Bating Against HAA Request ** I certify that I hav..9.~eC'~d,.vej'ifi.~d, or conformed to all ~OA and HAA guidelines in effec[ on the date of this inspection. Signed ~ ~' ,~'~//""'"'~ Date '~" /'~/ Company /~¢~' MOA No. O~--/ Receipt No, Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) "(]:{E-E-,'CECTRiC DOCTOR, INC. /~)/,)/ JOB INVOICE "We IViake House Calff," ~'~ ANCHORAGE, ALASKA 99503 MECHANICS HELPERS "O8 IH N. 'l'r(. o755 are held and [irmly bound unto the 0 ..... ), lawqJI money of ~he Uni(ed L bind ours(pves, our heirs, executors, ;en ts. ~bove bounden principal has or is about to ontractingin the State olAaska in accor. nd contributio']s due the State and poliUcal ~d is written shall not exceed the sum anti shall be continuous un. 'artment of Commerce and Economic ff cancellation to the Department of J shall apoly to all liens and bond is app:icable under law, even it nd or the liabilities are enforced after ir hands and seals this SURETY _ I~ns~u_r.a~n.c_. ~.__Com~ua_n_y- ~ Car,'ol 1~-"~/~ ,~enter ~09. Anchorage, AK 9951~ ~¥ ~OT~ PR~ROI?AL AND Note: Surety's Power of Attorney must bo attached if not already in vour file with the Division of Occupational i i::ensillfl' Pouch D.LIC, .hJneau, Alaska 99811. 11:111 (REV C. W. Gustafson. ' (Su rety'~eal) r: .-~..FFH!2 ,i" ~LASKA , R.,. I,,,SU~ ANCIi ..., ,,, 1 ,i 1988 Alpine Drilling & Enterprises Domestic -- Commercial  Pump & Water Systems P.O Box 110496 I Job Name~'~.ocatlon chorage, Alaska 99511 INVOICE No_ 2486 DATE QUANTITY DESCRIPTION AMOUNT ..~~-, Thank You SIGNATURE (I Hereby Acknowledge Ihe Satisfactory Completion of the Above Described Work.) TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL DE CHARGED ON OVERDUE ACCOUNTS. CItEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.& FEDERAL TAX ID # 92-0040440 MI~.L¥SIg P, gPI)R~ BY :~M~PLF, Cox Wolff: Oxdor ~ v?5s D:~te P,.,,port ?~:Jnttld: JUL J2 88 :* J5:O0 Collectod Jill 8 O8 ~ [2:05 hrs. l[ec~lved JUL B 08 0 .[5:00 hxo. Presorv~d with ,4 DEGREES C Cla. ont EPA 3532 gel,,ark:: BM.YPI,E COLLECI'}~D BY ~. MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL t~]ALTH DEPARTME..NI' OF I~AI.TH AND ENVIRONMENTAL PROTECTION APPLICATION FOR ImM,TH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date __~-~Z~' (a) Legal Description (include lot, block, subdivision, sectioa, township, range) Location (addr.?.ss or directions) Applicants address.~(~_~.~- ~ / g Buyer [~ ; Other ~2 (explain); (d) Lending Institution ~ Tele~!~ Address (e) Address Telephone (f) Mail the HAA to the following address: 2. T_2~i~e_.of Residence Number of Bedrooms ____~-_~_ 3. Wat~er Su_~.l__~ - Individual Well ~.~ Community [_---__] Public 2~[ Note: If community well system, must have w~itten confirmation from the State Department of Enviro~ental Conservation attesting to the legality and status. 4. Sewage I)is.~osal Ousite [~ Public [~ Community ~[:~ tlolding Tank ~"-X Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legaIity and status. [Page 1 of 2] 5. En~ineerin~ 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 this Health Authority Approval 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 informatien obtained from the M~nicipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or w~stewater disposal system is in compliance %~th all Municipal[ and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm_~_~_~k ~L~k_~ Telephone ~// DHEP Al~r oval , Approved for Approv~d~_~ ~ Disapproved ~__ ConditionaI Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCItORAGE DEPARTMENT OF ~ALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES }~ALTH AUTHORITY A~]?ROVAL CERTIFICATES BASED §O__L.~!?_f UFON THE REPRESENT~ ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INI~PEN~:N~I' PROFESSIORAL ENGINEER REGISTERED IN TIlE STATE OF ALASKA. THE I~EP DOES Tills AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAl, AND STATE REQUIRE~i MENTS. EMPLOYEES 0F'DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN T}~ PROFESSIONAL ENGINEER'S WORK. (DIIEP SEA1,) RR4/ej/D18 [Page 2 of 2] 7'-19-84. WELL DATA Well Classification ~ O~T~' Well Log P~esent (_Y.~ Total D~pth ~2~.~;~ Cased to MUNICIPALI~"f OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL CHECKLIST - FEBRUARY 1984 If A, B, C~ C, D.E.C. ApprOved.(Y/N) ~//~. Date Cc~pleted ~ff~v~/w7 Yield ~//~/~ Depth of Grouting Static Water Level Casing Height Above Ground Electrical wiring in Conduit .(Y~ Separation Distances f~om ~ll: To F~pti~/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public ~wer Line _ ~/~ Sanitary Seal on Casing De[~ession Around Wellhead (Y~ ; On AdjOining Lots ~<)u~, ; On Adjoining Lots~$6 _ To Nearest Public Hew~..r Cleanout/Manhole~ ~.//~ To Nearest Sewer Service Lir~.~ on ~t ~3/D Water S~ple Colleoted By ~)~ ~ ~ ; ~te ~/~ ~ , __ Water S~le Test l~sults ~%-~o~f B. SEI~£IC/HOLDING TANK DATA Date Installed _~_/~,/~ 5 . Siz~ ! %q O No. of Ccr~pa~ta~.nts ~ Standpi~s ~) /__ Ai~'-tight Caps ~) __ Foundaticn Cleanout =~) P~.%ng~alntenan~ Con~a~ c~ File (Y~ ~' for ~~ C~oc F~6 Holding Ta~ High-Wate~ Ala~ (.[~) ~/~ Tem~ra~y Holding Tank ~r~t (Y/N) ~ ~p~ation Dlstan~s ~ ~ptic~olding Tank: To Water-Supply Well_'~-- To Property Line .~ To Water Main/Service Line Cou~ ~/~ . Counts . ~ ~5~. /$q-~-~e'~. To Building Foundation __ To Disposal Field To S~aam, Pond, Lake, c~ Major D~ainage [Page 1 o~= 2] 2-15-84 C. ABSORPTION FIELD ~TA Soils RatinG in Absorption Strata Date Installed Width of Field Square Feet of Absorption A~ea Depression over Field (Y~ Results of Lest Adequacy Test Type of System Design Length of Field Q O ' Depth of Field ~ ~ Gravel Bed Thickness ~ ~ ~; ! Standpipes P~esent ~/N) Date of Lest Adequacy Test /3/~ Separation Distanae from Absorption Field: To Water-Supply Wall J O To Buildin~ Foun~tion Lot ~3ol ~ ; TO Wate~ Main/~vi~ Line ~/~ To ~t~(if ~e~nt) To St~e~ond~ke/~ Majo~ ~ai~ C~se To ~iveway, Pa~ki~ ~ea, ~ Vehicle St~a~ ~ea D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at Dimensions ~9~ ~.~'~'~- High Water ~ ~1 at ~,~' Vent ~) Tested fo~ ~/~ ~ing Cycles ~ing Adequa~ ~st. Electrical Co~) Meets MOA ** Check Permitted Bedroom Rating Against HAA l~quest I oe~tify that. I have checked, verified, o~ confo~msd to ali. MOA on the date of this inspe~ticn. KB1/dL/s [Page 2 of 2] HAA ~G~4~_ ~s in effect Date MOA No. 2-15-84 ALASKA el dlROrlmellTAL COIITROL SeI uICI S, IllC. ~nqin¢¢rinq $ ~nuir0nmenlal Slu~ics August 8, 1984 Department of Health and Environmental Protection 825 L Street Anchorage, Alaska 99501 Attention: Keith Bandt Subject: Skyway park Estates, Block 4, ~ot. 6A ])ear Keith: On June 19, 1984, this officer performed a well flow test on the subject property's well. The well flow rate was 1.0 gpm ~u]d was sustained throughout the 3 hour pumping phases of the test. Static water level was at 29.56 feet, with a maximum drawdown to 29.6]. feet (maximum of 0.05 feet). Total recovery occurred within 10 minutes. Although the flow rate should have been increased, this test is representative of the productivity of the well. The minor amount of drawdown, combined with the quick recovery indicates that the well is adequate for the 4 bedroom residence. If this office can be of further assistance, please do not hesitate to contact us at 561-5040. Sincerely, Larry MontgomCZy. ~'~//~ Envirom~ental Eag~n~-er L~4/caj 1200 LDesl 33r~J Aucnu¢. Suil¢ ~,Anchoro(l¢. Alosk~ 99503,t907) 561-50z10 APPLI( Property Owner --Mailing Address h ~X ~ ~/~' /~/-/, fl/~ Buyer . .. Address NT FILLS OUT UPPEFI HA' "ONLY Zip Code ~'~4'~/ ZIp Code Lending Institulion /, . ~ ~ Phone t?/ i~ > ',~ :~.- /1 ,:~: ~. ('~>. ~:/vh~/ Address Zip Code Realty Co. & Agent Phone Address Zip Code Type of Residence ~ Single Family [] Multiple Family No. of Bedrooms [] Olher Water Supply ~ Individual ATTACH WELL LOG. A well 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). Sewer Disposal ~ Individual Year Individual Installed:_ [~ Public Utility When Connected to Public Utility: [~ Holding 'rank NOTE: THE INSPECTION PEE MUST ACCOMPANY EACH REC~JEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Ti~ k~ Date Date Date Date Insp~lor Insp~tor Insp~tor Insp~h~{ , ~ d ' ~ . ~ ~ dn¢f~l~J¢~. '"'/ '- RECEIVED ( ~( APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVe" ,Soils Rating Date ~wer Installed Well TO Absorption Area Well Log Received Well to Tank Septic T~k Size ApUi' ].2, 1983 Approval loc tha~ individual sower and u~.l..(c,(; 'lluom the 31w,1 Lab, 5633 B Uti:eel;, (ou our review. size of the septic tank. ,~3oi. 1 test ha:: beeu }?~.,rforuaed and sulm~itttM to this office~ '2he ieachin(l area ilas been relocated at; lei~s'i; 1.00' f~om any weJ 1 ~ 'iq~,ts Iii, eld will need to be dJ. sconlleCtecl v/hen Ule upglTo, dc has been colapleted, May 30, 1979 Beryl E. Gilbert % Bowden C. Realtors 301 East Fireweed Lane Anchorage, Alaska 99503 Subject: Lot 6A~l~k~Skyway Park Subdivision Bett~andler~roperty Approval for the individual well and sewer facilities will not be granted until the following items have been completed: (1) Expose the well for our inspection to determine proper construction, also, to insure the minimum distance requirements are met between the well and sewer system. (2) A water sample needs to be taken for bacterial analysJ, s, this office was unable to get the sample on May 25, 1979 due to the dog in the yard. (3) A four(4) inch cast iron cleanout be installed to the septic tank or leaching area. The standpipes to the septic tank and leaching area were not accessible for inspection. Notify this office for a re-inspection when descrepancies have been corrected. If there are any further questions, please contact this office at 264-4720. Sincerely, Robert C. Pratt, R.S. Associate Specialist RCP/ljw cc: Alaska Mutual Savings Bank Mortgage Loan Department Post Office Box 1120 99510 June 12, 1979 Deryl Gilb<.~rt % ~3o'wden Con~pany Realtors 30.3. East Fireweod Lan~ A~lchorage, Alaska 99503 Lot"d~-]'~lock 4 Sk~,ay Park ~ubJe~t: ...... Subdivision ?he on-~slt(~ sewer and w~ll on ~e subJe~t property can ;~ot be approved ~.~'~t~l tho following descr~panGies have bean (1) The well casing is raised twelve(12) inches above level. (2) The well ]lead is sealed with a sanitary seal. (3) The w¢.~].l floor is sealed with four(4) tnch(~s of cement;. Expose th{~ septio tank to verify its e~istence. If there. is a tank, it must b{0 at least fifty(50) feat away from any well. It must b¢~ pumped {~o verify its capa~ity. It must be at least 1,250 gallons. If thc; standpipe in the front yard serves a Gesspool~ it is only sixty.-four(64) feet from th~ w(~lt, It ¥~ill need to be abandoned and caved in. A new' l~aohing araa willnneed, to bo installed ono-hundre(l(100) feet from any (6) If the l~a~hing ar(3a is in another location, it will to be exposed so that we Gan determine if it n{e~.~ts the proper distance requiremsnts. Jun~; 11, 1979 (7) If. it is on~-hundre, d(100) f~et away from any well~ you will need te haw~ an adequacy '~un~. performed. It i'~ ~loes not pa.~]s the adequac~ tent a new loacRing area will be require[l. (8) i~.f an upgrad~ of the synt(~m in nec~ssary, a p~rxait n~ust b~ insued by this department. A soils '~e~st will be required if the leaching area neod. s to be upgraded. If t:her.'e ar~ any further q~stions, pleaso contact this office at 264-~4720 o Since:rely, Robert C. Pre'bt, R.S. Associate Specialist. cc, ~ Alaska ~utual Savings Bank Igort.qa(3e Loan .Do}?artment Post Office ]3ox 1120 99510  ,2 i!i7g ENVIRONMENTAL ENGINEERING DIVISION MAY ~ ~, Telephone 264-4720 DJ~F l~l~ ~ r r~, REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SI:W~I~F~.I¥I~"~') MUNICIPAL ~', Of' /'~NCHORAG~/ MUNICIPALITY OF ANCHORAGE DEPT. c% [.~ ~, / DEPARTMENT aP HEALTH & ENVIRONMENTAL PROTECTIO.N/IR©t N1.,,. h.O~ .CT[ON 825 L Street - Anchorage, Alaska 99501 DIRECTIONS: Complete ali parts on page 1. lecomptete requests will not be processed, Please allow ten (10) days for processing. 1. PROPER OWNER MAILING ADDR ES~' PHONE PROPERTY RESIDENT (if d fferent from above) I1,~ ~ o / ,sw / ~ ..% .,~... ~,..,'o ,.~ ~ ~ ~ , /~ 2. BUYER PHONE PHONE MALLING ADDRESS 3, .ENDING INSTITUTION PHONE MAILING ADDFIESS MAI Lll~ ADDRESS 5. LEGAl. DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One [~ =our ~. SINGLE FAMILY [] Two [] Five [] MULTIPLEFAMtLY [] Three [] Six 7, WATER SUPPLY ~Z~ INDIVI DUAL* ' ATTACH WELL LOG. A well Icg is required for ell wells drilled [] COMMUNITY since June t975, For wells drilled prior to that aate, give wel [] PUBLIC UTI LI TY depth {attach Icg if available.) ,~/~'~ ' Other_ "~'. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE" [] PUBLIC UTILITY ** f individual/on-site, give installation dete / ¢~] b~- . If svstem is over ~wo (2) years old an adequacy test is reouired Dy this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BI=FORE PROCESSING CAN BE INITIATED, THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INsPECTIoN APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR I NSP ECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [~ MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2. WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DR I LLE D [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] I NDIVI DUAL/ON -SITE DATE INSTALLED [Z/PUBLIC UTILITY Connection Verified INSTALLER E~Sep~ or []Holding Tank Size: ~7~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Lb]e [] APPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany.~ertificate) ¢>'-DISAPPROVED DATE ~ BY (Title~.~ LEGAL DESCRIPTION 72-010 (Rev, 3/78)