HomeMy WebLinkAboutSLEEPY HOLLOW BLK 1 LT 7Sleepy Hollow
Block 1
Lot 7
#051-501-41
NAME
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
PFIONE
~GRADE
LOCAT,LEOA'DESCR'PT'ONoN
Well J Absorption area [DwDwelling
DISTANCE TO:
Manufacturer
Liq. ( IF HOMEMADE: inside length J~th
NO. OFBEDROOMS
PERMIT NO.~,
Liquid depth
Well Dwelling PERMIT NO.
DISTANCE TO:
Manufacture~ Liquid capacity in gallons
Foundation
Nearest lot I/~)
DISTANCE TO: ¢/~)~) !
Total lengt h2~cJ~es
Material beneath tile
PERMIT NO. ~.~¢.~,(~ ,
Distance between li1~.~/¢//~ ~'
Total effective [~o~tion area
PERMIT NO.
Type of crib Crib diameter Crib depth [ Total effective absorption area
Well Building foundation Nearest lot Hne
DISTANCE TO:
Depth Driller Distance to Iot line PERMIT NO.
DISTANCE TO: Building foundation Sewer ~ine Septic ta~ Absorption area(si
OTHER
PIPE MATERIAl/) .~ ~ /~.
SOIL TEST RA~-ING
INSTALLER
REMARKS
APPROVED~~~~ [DATE
72-013 (Rev, 3/78)
LEGAL
F'ERMIT NO. ( 8:t.la40¢:]; >
RPI::'L I CRNT
L. OCRT 101",1
LEGRL
FII.. LRR:::;ON DBR RUSTI
HIL. E t0 E. R. F?.[)
L.7' [3t. SL. EEF"¢ HOLLOH
L.O'f' E;.'[ZE 50:1_:t. 4 SQLIF:IRE F:EIET
"F'¢I::'E OF:' SOIL. I::IBSORPTICiN S'¢S;TI£H I:S: TREI'.~CH
t'"lFI).:;IHt. IM i'.,ILIHE~E:R OF' BEDROCd'tS = 4
SOIl... RIaTING ':iSQ FT/'BR)= 85
THE RE6~t. IIREED SIZE OF THE SOIL. RB'.'5ORPTIOI'4 ':S't'L:;TEEt'I IS:
THE LENGTH DIMEN%ION IS TFIE I.~ENGTH '::IN FEET) OF THE TRENCH OR DRFIINFIELD.
THE DEF'TH OF' FI TREI",IC:H Of:;?. PIT IS "FHE D IE;]'FtNCE E:ETHEEN 'rFIE SI...II~!F'F:ICE i]F.' THE
GROI..IND FIND THE BOTTCIf"I Of:: THE E',:qCFI',/F:ITION ,::IN F:EET).
TI-.IERE Ir'."!', NO :'7.,E"F HIDTH FOR TF:~:ENCHEE;.
-I"HE GRFI'v'EL DEf:'TH IS THE HINZHI...IH DIEF'TI-t OF GRFI'v'EL E~ETHEEi'.,I ]'HE OI..ITFFll. J._ PIPE
FIND THE DCr'rTOl'd OF ]"HE EXCF:I'v'FITZOI'.,! (II'.,I FEET).
F'ERH I T FIPF;'L I CRNT [~FI':':] ]",LIE RESF'CINE; I D I L I 'r'¢ TO I 1'.4FORM 'I'H I S DEPFIR]"MEN'T' [:,LIE: I NG TFIE
I NSTF::ILL. I'::I"f' I ON I hlL:i;F'ECTI ONS OF FIN'¢ HELL.'.E; FI[:,JFtCENT TO TH I S': F'ROF'ERT'T' FIN[:, THE
NUMBER OF REE;I[:,E:NCES -I"HFIT THE HELL HILL SER'v'E.
.................... 'T' ~.,,.~ 0 < ;:2: ::, Z ~',~ SE; F:" EE c:-r z ,::) N rE; ~::~ ~:;~: E
E[F:IC:KF :[I...L I I'.,IG OIc FIN'.¢ S'¥'STEH H I THOUT F ! NRL. ]: NSPECT I ON FIN[:,
[:,EPF'IF~'.TFI[!:i',I]" HILl.. BE SI.JEL~[?CT 'TO PROSECLI]"ION.
F:IF'F'ROVRL B"d -H'IIS
M I N I MUH D I S;TRNC:E BE'I'HEEN F:i HELL.. FIND F:IF,IY ON-'.:.; I -I"E :SEHFIGE D I SPOE;F:IL S"r'STEI'"! Z 5
±00 FEET FOR FI PRI'v'FFT'E HEL.L OR t50 TO 200 FEET FROH FI F'UE~LIC HELL [:'EPENDiNG
I.Jl'::'O[q "FHE "I"'T'F'E CII::' [:'I. JE:I..IC HELL..
MINIMUM D]:STF:INCE F'ROI¥1 Fl F'RI'v'FtTE 1.4ELL. TO FI F',~:~:I'v'FITE LS, EI,]ER LIi',IE IS ;;;:5 FE:ET FIN[::,
'FO FI COHHLItqIT'¥' SE:HER LINE IE; 75 I:::'EET.
OTHEI:;i: RE(;!UIREi'fEI'.,I'FS i"]Fl"r' I:::IPPL~i{ E;F'ECIFICR-f'IONS F:II'.,!D CONS'I"RLICTION DIF'IGRRM:S RRE
F:I~/FI I !_.F:iEIL. E TO I 1'4SUF::E F'ROPER I N'.:STFILL. FIT I ON.
I CERTIF'¥' "FFIFIT
t: I FIM FFIf,IILIFff:~: HITH ]"FIE: REQUIREMENTE; FCIR OI'.,I.-..SITE SEHERL::; FIND HEL..L.L'$ Fl':2i; '_SET
F:oR-rH D'¥' THE MUNICIF'FIL:I:'Tk' OF FINC:HORRGE.
;::2: I HILL INEYf'I:':IL.L THE S'¢STEM IN FIC:CORDFINCE I-4ITFI THE: C:ODES;.
]:: I UNDEF?.E;TFIN[:, THFIT THE ON-SITE SEI.4ER E'7'r'S"f'EM ivil':l"].' REQUIRE Ei",ILF:IRGEMEi",IT i;::: FHE
RE::];I[:,ENCE IS REHO[:,ELEi'}~TC~INCLIJ[:,E HORE THF:IN 4 E:EDROOHS.
F:IFFL. ZCFINT PI~/'~!':3,0N f)DFI RUEFF[ HOi¥1ES
O & E ENG,,qFERING & DEVELtJF MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 686-2280
Russell Oyster Earl EllIs
694-2774 SOIL LOG 688-2280
Mailing Address:
Legal Description:
Depth (feet)
Soil Characteristics
9__
10___
PLOT PLAN
11
13__
14__
15 ___
16__
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit
Comments:
PERC. TEST
No_ !'"' If yes, what depth
Drain Field
Performed by: [)ate: ~.//
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX272, CHUGIAK, ALASKA 99567 ·TEI. EPHONE689-2759
OWNER OF LAND /
ADDRESS /' ~
LEGAL DESCRIPTION
DATE - Started ~
~(, ;='; ! (.~ DEPTH OF WELL /
I0 ~t ! /,:~ ~', STATIC LEVEL OF WATER FT.
~ < / /"/~ ~ ~' ''~ ~' DRAW DOWN FT. ':
Emled ': :~ / GA~.PER HR
KIND OF CASING
PERMIT NUMBER_?C,/ : ~ / ).
KIND OF FORMATION:
Ft. to ~Ft.
From '~/ :[ Ft. to_, ,', ~Ft.
From Ft. to Ft. '// /~:~ ~" Frmn
From ~,:~ Ft. to /;:~'~_Ft. .h ;,': ~ ;z ~.,:~,~:~,~, Frmn
From ~ ~::, Ft. to_dC ~ Ft~
From "i ~ Ft. to /.ali Ft. '~ ' From
From ~ ~ / [ 5
From Ft. to.~Ft.
From z L, Fi. to ,' ~ _Ft, From
From /:~;~/ Ft. to/:, ~,~ Ft. /d~.z:J,~,%'~'-,~; d /4 .... ' -~ From
From/'~:, Ft. to L' ~ Ft.
From~Ft. to Ft From~
Ft. to_ _Ft.
Ft. ta__.Ft. ~
Ft. to Ft.
__FI. 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. to Ft
MISCL. INFORMATION:
DRILLER'S NAME
PERMIT NO.
[:,EF'FIRTMENT ~ ..... HEFILTN FiND EN',,,'IRGNMENTAL '.~'.OTECTION
025" STREET., ANCHORAGE, FIK. S~.
264-47;~0
8q. 0100 )
RPPL. ICRNT F.'.ICHFIRD L. EGG PO BOX 27;;;.' CHUGIIr~K
LOCRTI ON PETERS
LEGRL L7 8:1. SLEEPY HOLLOW S?D LOT SIZE
688-275S-~
~.~0 SQ, IJF~RE FEE'f'
MINIMUM DISTI::INCE BETP.IEEN FI WELL FIND ANY ON-SITE SEWRGE DISPOSRL SYSTEM IS
:i.E'~O FEET FOR R PRI¥1BTE HELl... OR :'L50 TO 2E¢.0 FEE'f' FROM R PUBLIC WELL DEPEN['.,ING
UPON THE TYPE OF PI..IBLIC I,.IEI..L
MINIMUM DISTRNCE FROi',I R PRIVRTE WELL TO FI PRIYRTE !.-.]EWER LII'.,IE IS 25 FEET RND
TO R COMi','iUNITY SEI,.fER LINE IS 75 F'EET.
I-4ELL LOGS FIRE RE[:,~UIRED RND MUST BE RETURNEI} TO ]"NE DEPFIRTi',IENT P~ITHIN ~0 DRYS
OF TNE WELL COMF'LE'f'ION.
OTHER REg&.~IREi','IENTS MRY RPPL..Y. SPECIFICRTIONS FIND CONSTRUCTIGN DIFIGRRMS RRIE
FIVFIIL. RSLE TO ~NSURE PROPER INSTF~L. LFIT ION.
I CERTIFY THRT
d.: I FIM FRMILI. FIR WITFI ]''PIE REQUIREMENTS FOR ON-SITE SEWERS AN[;, klEL. LS RS;
FGRTH BY TI-tE MUNICIF'I~LITY OF RNCNORFI~]E.
2: I 1.4ILL INSTRLL 'THE SYSTEM IN FICCORDRf',ICE WITN THE CODES.
RPI?L I CRN].' R. I ¢k~RE,~D (~..E£!iG ~,'/
I-",.:,UED E 'r ........... " .RTE;
SET
I
® Municipality of Anchorage
On -Site Water & Wastewater Program -_
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
=
Parcel I.D. e D. 051-501-41 Expiration Date: � '�z -- / �-
1. GENERAL INFORMATION
Complete legal description SLEEPY HOLLOW S/D; BLOCK 1, LOT 7 I
Location (site address) 23645 CHARLIE ROAD, CHUGIAK; AK, 99567
Current Property owner(s)
Mailing address
Real Estate Agent
2. TYPE OF DWELLING
TOM & MARIE SULLENTROP Day phone
23645 CHARLIE ROAD, CHUGIAK. AK. 99567
CIO AGENT
BROOKE STILTNER W/ REMAX Day phone 244-6742
® Single Family (w/wo ADU) t` €: r
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4, TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
W aiverNariaoce request fou
Received by i
COSA to ba release to the
N/A
3
unless otherwise requested by the engineer.
COSA Fee $ 5"I
Date of Payment Ib( 211/y
Receipt Number 0d 5-�() G
COSA # od(-1141` 11415141
Date:
Waiver Fee $
Date of Payment
Receipt Number.
Waiver #
distance:
TYPE OF WASTEWATER DISPOSAL:
®
Individual On-site
❑
Individual Holding tank
❑
❑
Community On-site
LJ
❑
Public Sewer
❑
unless otherwise requested by the engineer.
COSA Fee $ 5"I
Date of Payment Ib( 211/y
Receipt Number 0d 5-�() G
COSA # od(-1141` 11415141
Date:
Waiver Fee $
Date of Payment
Receipt Number.
Waiver #
distance:
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, l verify that my
investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. l 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(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 -ANCHORAGE, AK, 99507
Engineer's Printed Name
Engineer's Comments:
JEFFREY A. GARNESS, P.E.
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operationallife of all wells and
septic systems depend on the local soils condition, 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 the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there am no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
otherperson orparty is not authorized, nor will it confer any legal right whatsoever.
6. DSD SIGNATURE
0� System #1 Approved for bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
r
Phone 337-6179
Date
bedrooms, with the following stipulations:
t i="1 Lc i I
C�
.,i..
r°ROFESS
Cy r,
ON-SITE'
WATER AND
VVnu� NATER o=
� PROGRAM
Jsfirpo ��� l
C'
By: (L /-V f. �, 7 + — a=, Original Certificate Date: O
,i
The Mahlc/pallty or Anchorage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civif engineer registered in the State of Alaska.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
i�111aC9:1i41:1111[15
COSA Checklist �� Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
repo inh?mi
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description:
A. WELL DATA
SLEEPY HOLLOW S/D; BLOCK/, LOT
Parcel ID: 051-501-41
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (YIN) YES
Date completed 4/5/1981 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth 160 ft. Cased to 82 ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 4/5/1981 10/6/2014
Static water level 109 ft. 83 ft.
Well production 10 —9 P.M. 3.96+
g.p.m.
WATER SAMPLE RESULTS:
Coliform e0� colonies/100 ml. Nitrate 2s mg./L. Collected by: GEG, Ltd.
Arsenic: Nil ug./L. Date of sample: 10/6/2014
NOTE: 33 YEAR OLD SEPTIC TANK IS LIKELY
B. SEPTIC/HOLDING TANK DATA APPROACHING THE END OF ITS USEFUL LIFE
Tank Type/Material SEPTIC/STEEL Date installed 6/3/1981
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO h High water alarm (Y/N) N/A
Date of pumping is%L 14 Pumper S"'' 10 7 t�v M��"�
C. ABSORPTION FIELD DATA BELOW EXISTING GRADE
Date installed 6/3/1981 Soil rating (g.p.d./ft'or /bdnT 855 System type TRENCH
Length 40 ft. Width 3 ft. Gravel below pipe 5 ft.
Total depth `8.5 ft. Eff. absorption area 400 ft' Monitoring tube YES Depression over field NO
Date of adequacy test 10/6/2014 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 26 in. Water added 840 gal. New depth 32 in.
Elapsed Time: 130 min. Final fluid depth 26 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date
NOTE: NEW MONITORING TUBES WERE INSTALLED AFTER THE TEST WAS PERFORMED. BOTH MTS WERE DRY.
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)—
"Pump on" level at in. "Pump off' level at wa er alarm level at
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
100'+
On adjacent lots 100'+
Absorption field on lot
100'+
On adjacent lots 100'+
Public sewer main
N/A
Public sewer manhole/cleanout NIA
Sewer /septic service line
25'+
Holding tank NIA
Animal containment areas
50'+
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING
TANK ON LOT TO:
Building foundation 51+
Property line
5'+ Absorption field '5'
Water main N/A
Water service line
10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line IOl'I- Building foundation 10'+ Water main N/A
Water service line 10'+
Curtain drain NONE KNOWN
F. COMMENTS
"PER INSPECTION REPORT.
G. ENGINEER'S CERTIFICATION
Surface water 100'+ Driveway, parking/vehicle storage 10'+
Wells on adjacent lots 100'+
certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date 10 /ollg
(Rev. 10112112)
* ?\ A -L,. Nei *
Ire A. Gar ss..,
,E 3
!01 Zo
pRnss\0N�:•••
11114.lk.o•
TTrfy.•{Aman, ,
TTEV. (AmAwa>
_� RSNTET
5 52' We f 10xao'ee. '
255 69 NT o
aux Bxnol s,eaac
T
r
t
m EXISTING - T °a
HOUSE R i
C. s �q 50.0' CO's
I
�
I
ELL
SHOP
m
rt4
Ui $
I
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p,0'
R0
I GNP -�-
co
UNDER NO CIRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRUCTION OR FOR ESTABUSHING BOUNDARY OR FENCE UNES.
THE SURVEYOR TAKES RESPONSIBIUTY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL LIABILITY ONLY FOR THE COST OF THE SURVEY.
LISTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
El OT SURAEY SURVEY TYPE
SYMBOLS
❑ FOUNDATION AS -BUILT
❑ MAL STRUCTURE AS -BUILT
SET RE BAR DRAINAGE I ASPHALT
❑ PLOT PUN .... AS -BUILT ... LOT SUR
SURVEY ... TOINMAPHY
o FOUND REBAR - - -FENCE ..:=� CONCRETE
OO n ASSUMED ELEV. ®
CAMON AS -BOLT... NO coRtim SET
it I( NN METAL FENCE WOOD DECK
PLOT PLANS & LOT SURVEYS
NOTE:
IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO
ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE
CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE
SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS,
TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE
ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW
THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS
MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED.
WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT.
ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED.
SURVEY CERTIFICATION
•�r��
Prepared by
Robert E. Johns, Jr. & Assoc.
PLOT PLAN
MANNerr --w d
.t.CF
0 •,•••
4+.
Arc.)
Professional Land Surveyors
vMMNthekr
AV
1700 Awa.
ANCHORAGE, ALASKA 99504
V•
Scale: 1„ _ 501
Rec. Lot S.F.
Rec. Piot Fla No.
''.'��•.
FOUNDATION AS-BUILTAff
•• 4••' •••••••r
— J
Date Suneye d: 10/14/14
Drown eY REJ
Checked
b MK
L AIME++.,. a. Aa.Ivr ar•wyr Uwe I
..a eW �NM!lXI�
/
. ......
•N5,•JR. ••••
ar,r.. r I,Taa,.11al r awr n..r..
an mw .rraaa.Nanaa .It ,aMr -,�Date
•.....�
.ill• T
-.2-46;;
�•••
Drown:
10/16/14
Grid:
N W 1160
WO
14-482
FINAL STRUCTURE AS -BUILT
yJ a — •: ,e0:
.♦ f°' •'••p..
Legal Description:
4 RM E Mlnl f. I+IY u'Ih Mt 1
T,on awA.IwI r r.-wrT ...r> WI
eA. Na e,n i ew
✓••'O �J<.�
++ ea. .�
Lot 7 Block 1
rnsw .. ar
" "'
P fees, peA
++��a„���:�•'�
SLEEPY HOLLOW
DA~DE RECEIVED .... //
INSPECTION APPOI NTMENTS
~ME' TIME TIME
-~-AT E DATE DATE
MUNICIPALITY OF ANCHORAGE MUNICIPALNY ~F ANCI-IOR~a
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION D~PT.,O~ ~(~T~/ ~' '
~ 825 L Street- Anchorage Alaska 99501
ENVIRONMENTAL SANITATION DIVISION 00T 8 1981
Telephone 264-4720
DIRECTIONS~ Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing,
~ ~RTY O~NER ~ /f PH NE
PROPERT RE NT( d erentCromabove) PHONE
MAILING ADDRESS
~ LENDING INSTITUTION ] PH~B~ .. ~.
I LEG LDESCRIPT N
STREET LOCg, TION /,
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One ~ Four
SINGLE FAMILY [] Two I--] Five
[] MULTIPLE FAMILY ,[~ Three [] Six
~'. WATER SUPPLY
L~ Other
L
"~1 INDIVIDUAL- ' ATTACH WELL LOG. A well og is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled orlor to that date, give we]
[] PUBLIC UTI LITY depth (attacl~ log f availableJ
8. SEWAGE DISPOSAL SYSTEM
[~ NDIVIDUAL/ON-SITE** 4~['/ YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE Mus'r ACCOMPANY EACH REQUEST BEFOBE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTI LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septie~L~r [~Holdin§ Tank
Size: ] If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL~
4. DISTANCESwELL TO: Septic/Holding/, ~-~ /) Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
ROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED ~,~
DATE BY
72-010 (Rev. 6/79)