HomeMy WebLinkAboutROCKHILL BLK 2 LT 22
.. ' MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
WELL
Address ~' ~c'~ ~'FROM ~""'~ TANK FIELD
Phone(s) , Permit No. No. of Bedrooms__/ WELL
Township, Range, Section AS-BUILT DIAGRAM (Show location oT well, septic system, properly lines, foundation,
~/~ ~ ,~Z~ .~/~ driveway, water bodies, etc.)
TANKS U
Material No. of Compa~ments
TYPE OF SYSTEM
~ TRENCH ~ BED ~ W. DRAIN ~ OTHER
Depth to pipe bottom from Total depth from original grade
Fill added above original grade Gravel depth beneath pipe
Distance between lines
Total absorption area ~' /~--/
~00 SOFT FT ~ ."L.
Number of lines Pipe material
l Soil rating
~ PRIVATE ~ OTHER (Identify)
Classification (A.B.C) T~ ~o
,~~ FTI FT
I ~ t ~C I~ cedily that this inspmion was pedormed acoorfling to all
Municipal and Stats guidelinu in effect on this date: ~
Health Depa~ment Approval: . - .... ~Date:
LIp g r' ad e
Engineer' Des:i. cned
Name: L, ILL:[AN M. BAGWIELL,
r, ~:.:.>s~: 4045 L. AKE C)T I S I:::'KW'~.
ANCHt:JRAC;JE ~ AK 99508
Day I:::'hone ."
3 4 4- 2. () 2 9
I....o'L I,.. ega 1: Sub cli v i s .i. c}n ,~ ROCKI-{ I L.L,. L..o'L: 22 B I c~c: k:
Section: 14 "fownship~ ],2N Range:
L, ot Size 53800 (sq. ft,, of acres)
Idax Eh,.,:,dr'ooms: This I:~'er'mi'L: 1 To'Lal Capac:i'Ly: 5
...... ~ ..... ' . ,~:: O0
Si!i!]::'ltC TANK= MJ.r'~imum tectal septic tank uap :m.~,t.y. 1, gallons. Each septic
tank mus'L have a'L least 2 compar"Lmer'rLs. Dep'Lh 'Lo top o~' ~ept. ic 'Lank(s) < 4,,0
fee~:, r'eqLl~.r, es ir'isulatic~r'i ovel-
INSTALL. F.ii?.R IENGIIqEE;RS DESIGN: ].5' 'I'RENCH; 5~ OF GF~AVEL... BIEI....OW I:::'IP~/'
I'EItRL. DEF>'I"I...t~ :/2' ADD 5C() GAl ..... T'ANK :1'0 AL.t.,.,OW F:C]F:~ 5 BE:DROEJMS.
I... iSSUED FOR A SINGLE F:AMIL,.Y RES IDtENC}E OIqL. Y AND
i:: XP .[ t.:i!:> ::i,.,=.. / ,..) '''`~ 1/88. NOI' ]: F:'Y DHHS I:::'R ]; OR TO E]ACH -,[ l.'c',.~l' ....... I:L,' ...... I I t,,lfxl.
!::ERTIFY THAI':
I am fam:i, l iar' with 'Lhe f'equ:i, vemer"dLs {or' (:~r"r.'-site sewer's and wells as se'L
~ar"Lh by 'Lhe Munic:~paJ.~ty i::~ Anchor'age (IdOA) and the S'Ls'Le of Alaska.
;i; wil ] :i. nstall the sy~vt,.em :i,r'l a(::ci]r'dallc;e w:i.'Lh ali, M[](;~ cx::~de~ and
ar'id irt c:cimp].iance with the design c:r':i.'[er~:i.a of this per'm:i,t,,
I wi],], adhe~-e 'Lo all ldOA arid State ol Alaslka r, equ:i, rem~.~nt:.s ~(:)r' the se'L back
~[ Ltr'~clc.:¢r'!~'t'.ar'H;J 'tLhat 'Lhis pE.H"fnJ, t J.~i~ valid for' a maximum of 1 bedr'c, cmls. I.
also under'es{ar'id 'Lhat the capacity o.I 'Ll~e total. ~;i~ys'Lem ~ 5 bedr'oc~ms and
.[Jt,,~r~e.i., LIL.LIAN M,, BAI~
T!: :.u6:d By: ..............
~:li,,t :l i' e an add :i. t & ona i per' m i t'..
DAT'E~:
ALASKA eFIUIROnmI nTAL CONTROL SE!RUICeS,
InC.
SPECIFICATIONS FOR A TRENCH-TYPE WASTEWATER DISPOSAl, SYSTEM -
ROCK HILLS SUBDT\;TSiOY, BLOCK ~ ~,O,. 22
The drawings, sheets ~ through 5, shalJ, he a part of this
specificatJ on.
].2
All materials and workmansh]p shall meet the requirements of
the Municipality of Anchorage, Department of Health & Human
Services (DHHS), the condit:lons of the permit, and ail applicable
rules and regulations currently in effect,
i.3 All elewxklons and depths are advisory, and are to be vel:tried
or modified in the fie] 5 by the engineer or inspecting agency.
It is the responsibility of the owner or installer to adhere to
approved designs for installation, maintain the specifiedsepa~
a~s~.ances, and have ~he appropriate inspections
1,5
If the installation is not inspected by an AECS engineer, AECS will
not be responsible for the installed system. An engineer at AECS
should be consulted prior to construction to determine the number of
inspections that will be required and to explain what these
inspections will involve.
2.0 SEPTIC TANK
2.5 If ~here is an existing septic tank, it may be used if it meets the
capacity requirement for the residence and tile approval of the MOA.
2.2
The septic tank shall be a UPC-Approved two-compartment 'tank,
constructed of i2-gauge steel with bitumastic coating and set
]evet on undisturbed so~l. If the tank is buried at a depth of 4
feet or less, it must be insulated with an overlying layer of 2 inch
burial type polystrene rigid board insulation.
2.3
The septic tank and trench shall be a minimum of 100 feet front any
private welt or body of water, 150 feet from Class C wells, and 200
feet from Class A or B wells, unless otherwise specified. Less than
the required separation distance must have prior approval or waiver
by ADEC or MOA.
2.4 The septic tank shall be a minimum of 5 fee'[ from dm house
foundation, and a minimum of 5 feet from the absorption area.
2.5
Piping shall be fitted with a mechanical watertight calder coupling
on the outlet and inlet of the septic tank, Piping shall be 4 inch
solid PVC ASTM D8084 or cast iron, sJoped a minimum of 1/4 inch per
lineal foot. If the piping is buried at a depth of 4 feet or Jess,
must he insulated with an overlying layer of 2 inch burial type
polys'trene rigid board insulation.
C!eanouts shall be instal]ed as designated and capped with air--tlght
rain caps (Jim caps or equivalent), and extended a minimum, of 1 foot
above ground !eve~.
3.0 Absorption Area
The gravel for the trench shall be 0.5 to 2.5 inch, screened rock
with less thano°°~,o passing #200 sieve residual. Al! substitutes must
have prior DHHS approval.
3.2
The bottom and sides of the excavation shall be raked with the
backhoe blade to insure that it has not been compacted during
excavation. The bottom elevation shall be level.
Monitor standpipe(s) shall be placed as shown in the drawings, and
shall be 4 inch rigid PVC ASTM D3034, or cast iron. The section
shown with holes may be 0.5 inch holes drilled on 6-~inch centers on
opposing sides of the pipe, or a regular section of perforated sewer
pipe clamped to a solid section with either a no hub coupling or
a solvent joint. A rubber rain cap (Jim cap or equivalent) shall be
installed over the top of the pipe.
3.4
The distribution pipe shall be perforated 4 inch rigid PVC with a
minimum crush strength of 1500 lbs and shall meet the approval of
DHHS for use as drainfield pipe. All distribution pipes shall be
]aid level.
3.5
Trenches may be paralleled, but must have a minimum separation
distance between the trenches of 10 feet or 2 times the gravel depth
(whichever is greater). 75 feet is the maximum allowed linear length
of any trench.
6
If the final grade over the trench is less than 4 feet above gravel,
insulation is required, usiug burial type polystyrene rigid board
insulation. There shall be 1 inch of insulation for every foot of
soil less than the required 4 feet of cover, but there must be at
least 24 inches of soil cover even though insulation is used. The
solid pipe extending from the septic tank to the drainfield shall
also have 4 feet of cover or an equivalent layer of iusulation to
prevent freezing of the line.
3.7
If insulation is no'[ necessary, -the gravel shall be covered with a
layer of nonwoven Geotextile fabric (such as Mirafai, Fibretex 200
grade, Poly Filter X or equiva!en[).
4.0 INSPECTIONS
4.2
A minimum of two inspections are required for the installation of the
trench, The first inspection will be of the open excavation to
assure that the system is installed in the proper soil strata,
correct depth and meet minimum specified design parameters.
The second inspection will be after placement of the ~ravet, monitor
standpipe and distribution pipe to verify proper installation and
po~ition prior to backfill.
The inspection of the septic tank installation can be incorporated
~ith ally one of the above listed inspections.
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: /"~ E''~ ~-'°4L~"///-~ 5"~-'4
· ..?~EER'S SEAl.}
Township, Range, Section: ?/2,,u /'~ 2z~ ,~/'-/ .
SLOPE SITE PLAN
10
11
12
13---
14-
15-
16
17
18
19
20
WAS GROUND WATER
ENCOUNTERED;)
S
L
IF YES, AT WHAT '" O
DEPTH? P
E
Depth Io Water After ~.,~ _ ~ J '
Monitoring? . Date: ~'~
Gross Net Depth to Net
Reading Date Time Time Water Drop
----..._
PERCOLATION RATE __
(minutes/inch) PERC HOLE DIAMETER __
TEST RUN BETWEEN FT AND FT !
COMMENTS ~L t//~/~'ZL/ ~'7~) /z~ /~C) z~,/,,~.,~f ,F=,~.~,~?.~ ~' '7~ /(~
PERFORMED BY: /~'~' ~ Z-, ,~. E',/~ I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~ ~'°~
72-008 (Rev. 4/85)
ALASKA ENVIRUI~IM~'~ ~/~L
CONTROL SERVICES, INC.
1200 west 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO OF
CHECKED BY DATE
SCALE
!
/
/
/
Anchorage Recoedlng
LOT SURVEY CERTIFICATION
I her~ ce~if~ thal I ~ sur~yed the ~ ~n ~ ~i~
~,~ ~ t~ ~ove~ ~ t~ ore w~hin
~l~s~er~p~h~pro~dy~t~ O :2x2~b
~ ~ ~ th~ ~e ore ~ ~o~, ~ili~ I~s ~ ~er ~si~e
LEGEND
O = )ro~ pipe ond,/o~ rebor recovered
Date ~- ..-..4 ~ Prepared
F.B, No. _ _ . I Property of,:
'' I ,
C. ~ID,- JR.
~ L. BUTTON
Reg/sfered Lgn# Survayor
/&LP,31~,~ UI'~VII'(UIX Mr'l~l I/~L
CONTROL SERVICES, INC.
1200 West 33rd Avenue. Suite B
ANCHORAGE. ALASKA 99503
(907) 561-5040
SHEET NO.
C^LCUL^TE~' ~" /4,
CHECKED BY
OF
DATE
September 16¥ 1988
City of Anchorage
DEQ
Anchorage/ AK 99501
Dear Sir~
This letter authorizes Mr Knud Nielsen to do all
necessary work and obtain all permits necessa~F to
upgrade my existing septic system located on lot 22
Block 2 Rockhill Subdivision.
Sincerely,
Lillian M} Bagwell b~
George E, Bagwell
cc~ Lee Reid
K'nud Nielsen
$~'P ~. 9 1988
,-RECEIVED
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
NAME PHONE I E~NEW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
~~ Absorption area ' Dwelling~ ~ / PERMIT ~O,
~ DISTANCE TO: ~E~ ~/
~ Z Manufacturer Material¢ No. of compartments
~ ~ Liq. capacity in gallons Inside length Width Liquid depth
/~ ~() IF HOMEMADE: .....
~ Well Dwelling PERMIT NO.
DISTANCE
TO:
~ ~ ~ Manufacturer Material Liquid capacity in gallons
Total effective absorption area
Q Top of tile to finish~grade7 ( Material beneath tile ~ ¢
Length Width ~ Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ C~o~ O~ _ ,~ Depth Driller Distance to lot line PERMITNO.
~ ~ DISTANCEI TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS ~
SOIL TEST RATING
INSTALLER ~¢tI~ '
REMARKS
APPROVED -- DATE LEGAL
F'EF:H ;[ T N
!:~F'F'.,. IC:F!NT
LOCRTI
L..E :3F!L.
E:,EF:'FIRTHEN'[' ~ HE:RL. TF. FIND EE1'.,!'v' I F-':Oi",!t'!Ei",FFF'IL..~'~:O't'ECT :[ ON
,. ,2;'T' ~, "' :"
':.";;'.'E .... RE.~.. F., I:~1':4C:HOR-F~GE., Fff:::. ~)::.
,:: E~20E;! 7'
.... B._F.~ F ...... .,.H:[L.L,:5- E.
T'T'F'E OF 2;OZL FIF:E;OI';:F'T:[01"4 E;'T't.E;TEhI~ TRE1',!CH ~
/]
1"!FI::.:;t1"tUH 1'.,!t. JHE:ER OF' E:EE:,F4:OOH'.:~;-~?~ /Z:~// £5OZL Ft':F~TING (:.'.:;L.q FT,.."E:F.:)= :35
EE il::" "'il'"' IH == d.. ;;2 L_ E"£ ~"dl E:.i~ T' F~! ==::_~- ~ E:~ IF:E IF41~ F' T' If'il ....
THE L. E1",iGTH D.'[!'dE1'q::ZZO1"4 ;['~; THE LENGTH ,:.';[1'.4 FEET::' OF' THE TRENCH OR E:,F:FIINFIE:LD.
THE DEF'TFI OF FI TF:ENCH OR PIT IS THE DZSTR1',ICE BE'TI.4EE1",I THE S..iURFFtCE OF THE
C:iROU1'4D t::IND THE E:OTTOH OF THE EXCFIVRTION ,:.'IN FEET::'.
THERE IS NO 2;ET HIDTH FOR TRE1",!CFIEE;.
THE GRR¥'EL DEF:'TH :[."2; THE H;[NIP'ILt1'4 E:,EF'TH OF GRFtVEL. BE'I"F!EEN THE OLrTFFILL F'IF'E
F!I'.4E:, THE BOTTO1',1 OF THE E';-,:CFI',,,'RTIO1'.4 (IN F'EET':). ,-
F'ERhl :[ T RF'F'_ t ::F NT HFI~; THE RE:SF'O!qS :[ E: :[ L. Z T'¢ TO I NFC F:H 'T'H ;[ E, t)EF~FIRTI',IE1'.,tT [:,UR :[ 1'..!t3 "FHE
;[ N:L.:TFE.J_FIT ;[ ON :[ NSF'ECT Z ONE; ': F' F!N'¢ 14EL.LE; .::I£:,.FFff::ENT T) TH:,r. 2:"; F'F.:OF'ERT'¢ RIqB' THE
NL,1HE:E:R OF RE~; t E:,E1'.,tE:E:.:; THFtT THE HEL. L i.,.! ;[ LL. '£;E:R' 'E.
BRCI..'.':FILLING OF RN"r' S¥.'E;TEM 1.4I]'HOUT F'II'-,IRL. INSPECTION RNE:' .RPPRO'v'RL. E:"r' THIS
DEF'FIRTI'"tENT 1.4ILL BE E;UD..TEC:T 'T'O PROSECUTION.
!',I!N!HLIr,! [:,tSTF!1'.,!C:E BE"FHEEN R NELL. R1'.,tD RN'T' ON-.E;ITE SE.U.IFtGE D,1::SF'O::SRL. S'.?~STEH ;[:5
::LOO F'EET FOR R PRI'v'RTE HELL OR t. 50 TO 200 FEET FROhl R PUBLZC HELL DEPENDING
UPON THE T'¥PE OF: PUBL..;[C HELL.
H;[1'.,tZP1LIH D:[E;TFtNCE FF.:OH R PF.:IVRTE HELL TO FI. PRZVR'T'E E;EHER LINE I5 25 FEET
TO F:I C':Or, ff,!U1'4:[T'.r' SEHE!;;~: L.:[NE I'E; 75 FEET.
1.4EL. L. LOGS FIRE REQU;[RED R1'.,ID 1',IU!:ST BE RETURNED TO THE DEPRR. THENT HZTH].'N gO
(:iF TF!E 14EL. L COi',IPLETION
OTHEF..' REC~UI.~'.Ei',!ENT~5 HF:t'T' Fff:'F'L'¢. E;F'ECIF'ICFITIO1',I:5 FINE:, CONEiTRUCTI'ON [:,tRGRF.:IHE; RRE
Fi',,,"RtLFtBLE TO !1'.,ISURE PROPER iN~;TFiLL. FITION.
::L: ;[ FIt','I FFiHI!_;[FIR I:,.I;[TH 'T'HE F.:Er;tU;[RE1','tEIqT:E F'"'~F' ON-:!.~;:["f'E ~;Et.,.!ERS FINE:, HE.'L. LE; RE; E;ET
FOF:TH_,~ '.,'. THE H.11'.4 ;[ F_ Z :'RL '[ T'¢ OF' R1',,IC:FIORFtGE.
, ,..,t:: .:,; .: FE, f ]: 1'q FtC:CCIF~:DFtt"4C:E: H I TH "" -I[: L .JE E..:,.
2: Z H:[LL. I1",!S'I"FIL..L ~"~'"" '-'"0 ....... ---. " .... '-
Z.':: Z U1"4E:,EF-'.S'T'FI1"4E:' THFFT' THE ON-2;I'T'E :~.':E.[,4ER E,'¢E;TEP! HF:I'T' F:E';!_;[F."E E:!'.4._FIF::'3EM. E1",Ff' IF' THE
~:~:EE; Z DE1"4CE 1:5 R. EHODELE[:' TO ,1.' NCL. L!E:,E H :IRE' "FHFf1",! 3: BEE:,ROI:)HS.
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONNIENTAL PROTECTION
825 L, Street, Anchorage, Alaska 09501 264-4720
SOILS LOG- PERCOLATION TEST
PEREORMED EOR:
LEGAL DEscRIPTION:
7
8
9-
10
11
12
13
14
15
16
17
18
19
20
[] PERCOLATION
TEST
DATE PERFORMED:)
SLOPE
. 1
WAS GROUND WATER ~! 0 ~
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND ~ FT
COMMENTS
PERFORMED B.Y.:
~00 r
Date D~illed~
WELL LOG
Static Water Level 40 feet
Draw Down N/A feet
Gallons Per Minute
Total Feet of Uasing 73
Type Material Drilledl
0 feet . to
40 Feet to
50 to
to
to
to
40 Gravel
50 Grmve! w/rimF
73 Sand w/fine Kravel w/ water
Hefty Drilling
S.R.A. Box 1553 H
Anchorage,Alaska
99507
uate
and ,type of structure indicated herein.' I fUrtherverify tha~ based on the nformat on obtain~'fro~:-
~the Mun cipality of Anchorage !lies and from' my invest~ation and insl:~tion, the on-site water'
,supply and/or wastewater.(~[,s. Posa[ ~system is in, comPliance.with all Municipal and State codes,???:~
Ordinances, and '~):n'::{h'~d~.i~:~fihi~:i:~'~lc~n. ' "' · :::"::.' ~':-';;-' ?':!!!i!i'i
."-~..-:':,¢~,FN~r~ofFimia-¢gagle,R~Ver':~n~ineer3_n~ Se~cices ....... :,.,....-. phone .694-5&95;-,~,,.'¢~:?;.,:?.;;,;,¢.?~¢:
72.02~(Rev. 1/91) BaCk MOA~21
Municipality of Anchorage /~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: i~a~-/~///''~ ~,~' ~Z-- ~L~-2---Parce I.D.
A. Well Data
Well type /~/¢A~7~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) )/~'~_.S Date completed ~(~/2~/~'~ Driller
Total depth '~ :~ / Cased to ~ 3 / Casing height
Sanitary seal (Y/N)
Wires properly protected (Y/N) /'~/~
FROM WELL LOG
Date of test
static Water level
Well flow ,
Pump level1 /~//~ ~
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/l',e~g tank on lot /"~ ~/
Absorption field on lot / ~'7 /
Public sewer main ~/~
Sewer service line ..y -~c~,
AT INSPECTION ~-
~ g.p.m, r~ ~ ~
; On adjacent lots ~/DD /
/
; On adjacent lots ~/~
Public sewer manhole/cleanout /('//~
Petroleum tank /,/D/V~ /'~?/~/V?'~
WATER SAMPLE RESULTS:
Coliform --~ Nitrate
Date of sample: 07/~/?~
[~,q~ //H~,/I.- Other bacteria
Collected by:
B. SEPTIC/~G TANK DATA
Date installed O~/~ ~ Tank size
/
Cleanouts (Y/N) t~'~
High water alarm (Y/N)
Date of pumping
Foundation cleanout (Y/N)
Compartments /
)/~ Depression (Y/N)
Alarm tested (Y/N) /'-/'//J~
Pumper /~1
SEPARATION DISTANCES FROM SEPTIC/~ TANK TO:
Well(s) on lot / ~,7., ~ On adjacent lots J'~/O0 1
To property line .~ I ~_~ I
Surface water/drainage
Foundation
Water mainfservice line
Absorption field
· CONTINUED ON BACK PAGE
72-026 (3/93)* Front ~. : , : :- ,, '
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANC~ATION TO:
On adjacent lots
D. ABSORPTION FIELD DATA
Date installed ~/~ ~ /
j /
Length J~ / / ?..~ Width
!
Total absorption area ~ ~
Date of adequacy test ~ ¢/~
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Manufacturer
Manhole/Access I¥% ~
..---"P~mp off" Level at
~ested
Cleanout present (Y/N)
Results (pass/fail)
Surface water
Gravel thickness ~''/5 / Total depth ? ~'///~_~' r~-.~X
/~% Depression over field (Y/N) ~
~ for ~ Bedr~ms
A~er test ~
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /'~ ? / On adjacent lots
To building foundation
On adjacent lots
Sudace water
Curtain drain
¢~/DO / Property line /_/.~ 1
To existing or abandoned system on lot /,~ '
/
Cutbank /,.//n Water main/service line ',~ J o
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I cer~fy that I have checked, verified, or conformed to all MOA and HAA guidelines in
Signature
Engineer's Name
Date
HAA Fee $ ~'
Date of Payment
Receipt Number
]te of this inspection.
Waiver Fee $
Date of Payment
Receipt Number
CE 6736
05/01/95 15:22 COMMERCIAL TESTING -* 98? 694 ~2g? N0,546 [~OE
CT&E Environmental Services inc.
Lubormta,y Division ~ ...... ~ ....
~.~o.,-~ [=~oratory Analysis Repo~
L22 B~ ROC~ILL
~olleo~d Dat~ 0~/~7/95 ~ 15=00 hr~_
~ample R~marks~ 8~PL~ COlLECTeD BY:
~C Allowabl~ E~. Anal
E~IRON~NTAL FAOLITIES IN A~KA, CALIFORNfA, FLORIDA, ILLINOIS. MARY~ND. MICHIGAN, MiMDOUfll. NEW J~SE~ OHIO. WEST VIRGiNiA
Louis Butera, P.E.
Registered Civil Engineer
May 8, 1995
Dan Roth
Municipality of Anchorage
DHHS, Division of On-Site Services
P.O. Box 196650
Anchorage, AK 99519
RECEIVED
MAY 9 1995
Municipality ol Anchorage
Dept, Health & Human Services
Re: Rockhill Lot 22, Block 2
9651 Main Tree Drive
Dear Mr. Roth:
We are requesting a conditional Health Authority Approval on the above referenced lot pending
burial and placement in proper conduit, of the well to house electrical supply wire. Snow cover
and frozen soils make the work unfeasible at this time. Currently, the wire runs across the ground
surface, entering the casing through the opening in the well seal usually occupied by the well wire
conduit; we consider this to be acceptable and sanitary as a temporary arrangement.
If you have any questions, please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\C:\WPWlN60\WPDOCS\1995\95-022A.LTR 1
Parcel I.D. #
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
015-063-19
GENERAL INFORMATION
Complete legal description
Rockhill
Lot 22, Blk 2
Location (site address ordirections)
9651 Main Tree Drive, Anchorage
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
David & Darla Haas
Day phone
600 S McKinley #400. Little Rock. AR 72205
Alaska Pacific Mortgage/Wendy Goldb~ay phone
2600 Dena11 Street, Suite 702, Anchorage, AK
Jack Whit~ Co../Cla~r Rarnsey
3201 C St£eet,
694-5195 msg
258-7534
99503
Day phone 563-5500
Suite !00, ~mchorage, ~ 99503
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
5
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 #91
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 inves_ti_gation 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 Eagle River Engineering Services
Phone 694-5195
Address P.O. Box 773294, Eagle River, Ak 99577
Engineer'ssignature ~,¢:::~-'~-~-"~> Date 07/'L~/95
DHHS SIGNATURE
_'~. Approved for
Disapproved.
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date _
The Municipality of Anchorage Depal~ment of Health and Human Services (DHHS) issues Health Authority
Approval Cer'dficates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHH$ does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
12-825 (Rev. 1/91) 8acx MOA ~21
Louis Butera, PiE.
Registered Civil Engineer
July ~ 1995
Laura Montgomery
Municipality of Anchorage
DHHS, Division of On-Site Services
P.O. Box 196650
Anchorage, AK 99519
RECEIVED
JUL 2 8 1995
MUnicipaji.ty of Anchora
Dept. Health & Huron, ,', g.e
...... oel'vico8
Re: Rockhill Lot 22, Block 2
9651 Main Tree Drive
Dear Ms. Montgomery:
We are requesting full Health Authority Approval on the above referenced property at this time.
The work required to satisfy the conditional approval issued by Mr. Dan Roth on May 5, 1995
has been satisfactorily completed. We inspected the site, and found the house to well wire buried
and properly entering the well seal in conduit.
If you have any questions, please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\G.\WPDOCS\1995\95-022B.LTR 1
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
GENERAL INFORMATION
Complete legal description
Rockb i 1 1
Lot 22, Block 2
Location (site address ordirections)
9651 Main Tree Drive, Anchorage
3.
Property owner
Mailing address
Lending agency
Mailing address
Agent
David & Darla Haas
Day phone
600 S. McKinley fi400. I,i.t~le Rock. AR 72205
Alaska Pacific Mortgage/Wndy GoldbarDay phone
694-5195 msq
258-7534
2600 Dena]i Street Suite 702, Anchoraqe, ~/< 99503
Jack~nite RR/C]aire PRm~ey Day phone 563-550~
Address 3201 c Str~_et c~,,.~+~, ~nn ~,~,-.~ .....
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 5 ~,
TYPE OF WATER SUPPLY:
Individual well x '
Community well
Public water
NOTE: 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: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
5. STATEMENT OF INS, .CTION 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 inves.ti_,qation 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 Finn Eagle River Engineering Services Phone 694-5195
Address P.O. Box 773294. Eagle River. AK 99577
Engineer's signature
Date F-///~8/~-
DHHS SIGNATURE
Approved for
bedrooms.
Disapproved.
Conditional approval for
E.s'(r~k., /'fo,,~ £ Y To ,q,~u~
bedrooms, with the following stipulations:
W£LL I,'v/,'f~' ~, ,¢/~#/T,~/'.I~'' ~E/~£ ?/qop6,~z~"
IVOT BE [~£LbbfbO o/~Tl£ T1¥/$ PEJ~bRTyEA/T'
Additional Comments
Date ~--.f--
The Mur~icipality of An6horage 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 en~igeer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and {heir fending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
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
Parcel I.D. #
1. GENERAL INFORMATION
Complete legal description
Lot 22;
HAA#
Block 2;' Rockhill Subdivision~
Location (site address or directions)
9651 Main Tree Drive
Property owner
Mailing address
Lending agency
Mailing address
Dan Hughes
9651 Main Tree Drive
Day phone .$46-$360
Anchorage, Alaska 99516
Day phone
Agent Mike
PHH/HOMEQUITY
400 East Las Co~i~s Boulevard
Address Sn~',¢~. #.~00
Irving, Texas 75039
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
5 %
Day phone.(214)506-8808
NOTE:
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
o
=
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date
investigation of this Health Authority Approval application shows
and/or wastewater disposal system is safe, functional and adequate
and type of structure indicated herein. I further verify that based on
the Municipality of Anchorage files and from my investigation an(
supply and/or wastewater disposal system is in compliance with al
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
17034 Eagle River Loop Road No. 204
~a~gie ~i~er, Alack, 77~t,
Engineer's signature
DHHS SIGNATURE
. _ ApprOved for
.... Disal~roved.
bedrooms.
conditional approval for
bedrooms, with
Additional Comments
By:
The Municipality of Anchorage Department of Health and Human Services
Approval Certificates based only upon the representations given n paragra!
professional engineer registered in the State of Alaska. The DHHS does this as a
and their lending institutions in order to satisfy certain federal and state requirem,
conduct inspections or analyze data before a certificate is issued. The ML
responsible for errors or omissions in the professional engineer's work.
72425 (Rev. 1/91) Back MOA ~21
hown below, I verify that my
hat the on-site water supply
for the number of bedrooms
le information obtained from
inspection, the on-site water
Municipal and State codes,
Ihe following stipulations:
Date
:)HHS) issues Health Authority
)h 5 above by an independent
,'ou rtesy to purchasers of homes
;htS. Employees of DHHS do not
nicipality of Anchorage is not
(~ Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~'3T' c~o'~; ~-~.4r.-~,~.~CxTJ:,.iI'~ '~/~ Parcel I.D. //~/~---~/,27-/~/~'
A. WELL DA~
Well type "f~&~,LJPcT"~
Log present {~N)
Total depth
Sanitary seal ~N)
Date of test
Static,water level
Well flow
Pump level
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed 0-c~-8*~ D ri I le r J-~'~-F:"I' ,V
Cased to ~r'3' Casing height J'~3..~*t -'~
Wires properly protected ON)
FROM WELL LOG AT INSPECTION
4-0'
MUNtCIPALIT¥ L)r ^i,,iCHOF, AGE
ENViP, ONMENTAL SERVICES DIVISION
JU~ ~0 1992
RECEIVFD
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
:sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank ~0~
WATER SAMPLE RESULTS:
Coliform ~
Date of sample:
ioo'+
Nitrate ~J._,d/_ m~-/R,_ ~ Other bacteria
[-~-- ~ ColleCted by: ~ % ~-I~GugE'F-ILI/~'
/
.. SEPT.C..OLO,.O / /
Date installed ~Jj~l[~ / cJ-.~-~ ~._Tank size ~/~0 G~/;Z~r.m~-Compartments
Cleanouts (j~),N) ~ Foundation cleanout (~N) ~.~ : Depression (Y/i~ Jk-~O
High water alarm (Y/~) ~J//3r :"~ ' '
Alarm tested (Y/N)
Date of pumping '(~) --"~--~ ~,-,~"~ Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /0~ ~+ On adjacent lots
To property line ~--"~' '/' Absorption field
Surface water/drainage J ~ 0' t~
100 "N Foundation__ ~
~, ' water main/service line /0
72-026 Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
D~~")/A Manufacturer
Size in gallons "'~""~. Manhole/Access (Y/N)
(Y/N) "Pum~ "PUmp off" level at
Vent
High water alarm level ~ Cycles tested ___
Meets MOA electrical codes (Y/N) ____
SEPARATION DISTANCE FROM LIFT STATION TO: ~...~...~
Well on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed '~/~/~2../
Length ~'~' / ~0' Width
Soil rating g~'~/~z / System type
Gravel thickness $ ,~ Total depth
Total absorption area ~0 +' ~0o =
Depression over field (Y/~D J/~o
Results (~__~/fsil) ~:/:~.~ ~'~
PeroxMe treatment (past 12 months) (Y,~ ST
Cleanouts present (~N)
Date of adequacy test
for 5
~k30~/~ If yes, give date .
--- bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /~0 "/-
To building foundation
On adjacent lots ~d "J'
Surface water ~ 00 ~+
Curtain drain ~,~bl~.. ~-~
On adjacent lots /¢0 "/" Property line
To existing or abandoned system on lot
Cutbank /~J/~ 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
the date of this inSPection.
S & S ENGINEERING
17034 Eagle River Loop Road NO. 2{]~
Signature =..;., ;,;~,,r, A;..~,. ;;57?
Engineer's Name
Date ~ [ ~ ~
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET
ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
ANALYSIS RESULTS fox I~VOICE { 54349
Chemlab Ref.{ 92.2490 Sample { 5 Matrix: WATER
FAX: (907) 561-5301
Client Sample ID : L22 B2 ROCKHILL S/D
PWSID UA
Collected JUN 1 92 ~ 18:15 hrs.
Received JUN 2 92 ~ 13:20 h~s.
P~ese~ved with AS REQUIRED
Client Name :S & S ENGI~ERING
Client Acct :SNSENGP
BPO{ :
Roq{ :
PO{ :NONE RECEIVED
Analysis Completed : JUN 3 92
Laboratory Supe~_v. ispr :, STEP~N C. EDE
Released By :~~~
Sand Reports to:
lis & S ENGINEERING
Pa~eaetez Results Units Method Allowable Limits
NITRATE-N 4.4 ~/l EPA 353.2 10
Sample ROUTINE SAMPLE COLLECTED BY:
Re~zks:
I Tests Performed ' See Special Instructions Above UA-Unavailable
ND- None Detected *' See Sample Remarks Above
NA- Not Analyzed LT-Les8 Than, CT-Gzeatar Than
~r~_~ Member of the SOS Group (SocibtO G~ndrale de Surveillance)
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Location (ad Cr, es{-~ r.!;d,1~rectio n s)
(b) Proper-ty.~wner'/~/~-'~/~z'~
Mailing Addres~ ~ ~
(c) Lending Institution . . . .. Telephone
Mailin~ ~ddress
Telephone: (home)~¢¢-Z~Z-? Business
(d)
Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here Fi, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family'l~i( Number of bedrooms
3. WATER SUPPLY
Individual Well'~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site'l~i~, Public [] Community [] Holding Tank []
Note: If community weft system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev, 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th is
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 information obtained from the Municipalit'/ 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 ,/~'~"L~"% Telephone
Address /J/~ ~ ~/~ ~.
6. DHHS APPROVAL ~g~///~4~
Approved for ,_'¢" bedrooms by
~ Disapproved Conditional
Approved
Terms of Conditional Approval
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) 8ack Page 2 of 2
A. WELL DATA
M U N I C I PA.~,~,'~?~,~N C H O R A G E (MOA)
HeCtiC. ,~¢~rity Approval (HAA)
~ ~ ~3-4744
Well Classification :~;''E/v//4'¢~'~'' If A, B, C, D.E.C. Approved (Y/N)
Well Log Present OU) Date Completed ~-Z-~'-,~'J~ Yield '~' ,e/~,~
Total Depth 7.,~ / " /j'/,~l
Cased to 7~ Depth of Grouting
Static Water Level '~ ,,~,.:~' / Pump Set At ~/~
Casing Height Above Ground //~ Sanitary Seal on Casing (~N)
Electrical Wiring in Conduit~)'N)
SEPARATION DISTANCES FROM WELL:
/
To Septic/Holding Tank on Lot ,//,~--
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ,~/,~
To Nearest Sewer Service Line on Lot
Water Sample Collected by ,/f'~' /el_, ~J/~--/J
Water Sample Test Results
Comments -)6
Depression Around Wellhead (Y~
/z?' /
TO Nearest Public Sewer Cleanout/Manhole
;Date ~'-,~-~ 'o'~' ~
!
; On Adjoining Lots //~)
; On Adjoining Lots
B. SEPTIC/HOLDING TANK DATA
Date Installed ?-~,x/._~_~' Size
Standpipes~N)
Depression over Tank (Y~
Pumping/Maintenance Contact on File (Y/N)
H old ~ n g ~.p k..~g ~Wat~r~-gla r m (Y/N)
SEPARATION ~ISTANGES,~OM SEPTIC/HOLDING TANK:
P r~rope:ty L.ine ........
To
To ~a~e'r ~ai~S~qi~b L[~e~ ~' /
To Stre~; .. Pond, ka.ke'~r.. ~or.. Drainage Course /~ ~
Comments ~
5'~'o No. of Compartments /
Air-tight Caps~N) Foundation CleanoutON)
Date Last Pumped ~-Z.7-~'~' /~,,'~-~$ '""
;for '/'J//~
/-)/~ Temporary Holding Tank Permit (Y/N)~/~
To Building Foundation
To Disposal Field
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /~o Type of System Design
Date Installed ~,~I~/,4t¢¢. ~/~-~'~///~,P~,~,~Z' ~-~/-~ Length of Field
Width of Field ~ · ~'t~/ Depth of Field ~'~I~
Square Feet of Absortion Area
Depression over Field (Y(~)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
!
Lot ,/0
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Gravel Bed Thickness
Statndpipes Present (~N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present)
Comments
D. LIFT STATION !
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
~-~ _ Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines ir
inspection,
Signed
Company
Date
MOA No.
Receipt NO.
Date of Payment
Amount: $
Receipt No.
~e, ~l~A~ ~l~,,J. he date of this
$
~, .,;.,~, .,,/,,,~ee~ s Seal
Waiver Fee: $
Date of Payment
72-026 (Rev, 7/88) Back Page 2 of 2
- ~ APPLIC-"HT FILLS OUT UPPER HAt;~'ONLY
Property Ov~ner -? /~/ ~- Phone
· '.LT'.-? · , q >?,:/... ~,.'~ 6x' 77~ ~>
Buyer
Address Zip Code
Lending Institution Phone
Address Zip Code
Realty Co. & A~nt Phone
Address Z~p Code
Type of Resi~nce
Single Family
~ Multiple Family No. of Bedrooms
~ Other
Water Supply
Individual A~ACH WELL LOG, A well log is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach log
if
available).
~ Public Utility ~
Sewer Disposal
~ Individual Year Individual Installed: ~ ~ ~ ~
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED·
Time Time
Date
Inspector
Date
Inspector
APPROVED BEDROOMS
DISAPPROVED
CONDITIONAL APPROVAL*
*CONDITIONS OF APPROVAL
Soils Rating Date Sewer Installed
Well To Absorption Area
Well to Tank
Well Log Received
Septic Tank Size