HomeMy WebLinkAboutROCKHILL BLK 3 LT 10Rockhil Block 3 Lot 10 #015-063-08 '^ MUNICIPALITY OF ANCHORAGE ^� DEt _.RTMENT OF HEALTH AND HUMAN SER. ,ES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name _ DISTANCES TO SEPTIC ABSORPTION WELL Address FROM TANK FIELD Jtwj.,1Uode Tree :.moi -td 1 g 3-7 H Permit No. No of Bedrooms 5&2- /62x30 to R6&I-76 1 .3 /0 Township, Range, Section 5'14- r12,V A031,LJ TANKS WELL LOT LINE FOUNDATION >. 20/ AS -BUILT DIAGRAM (Show location of well, septic system, property lines WELLS �] PRIVATE ❑ OTHER fldentifv) Classification (A,B,e) Total Depth cased to FT FT Installer Date Installed: REMARKS: r NeLu �,ej ex caveCfed Lfn S_iF� /0" I'mrorteyAA ,S`v ce A I t H ce i Municipal and State guidelines in effect on this date: Health Department Approval: 0 Scale: ,r� Inspecions Performed by: Date: / 1 _ 17 1A, inspection was performed according to all _L- Date: Eil r ❑ SEPTIC ❑ HOLDING Manufacturer Vz /I Capacity in gallons Material M.of Compartments TYPE OF SYSTEM ❑ TRENCH BED ❑ W. DRAIN ❑ OTHER Depth to pipe bottom from Total depth from original grade original grade t FT A7 Fill added above original grade Gravel depth beneath pipe FT( - Gravel length t Gravel width / FT Total absorption area y Distance between lines %Z Z SQ FT' Number of Imes Soil rating Pipe material �0 SQ FT //�� r lif �� YV E 8� Installer C t Dt )✓11 I WN t Date Installed / /12 , WELL LOT LINE FOUNDATION >. 20/ AS -BUILT DIAGRAM (Show location of well, septic system, property lines WELLS �] PRIVATE ❑ OTHER fldentifv) Classification (A,B,e) Total Depth cased to FT FT Installer Date Installed: REMARKS: r NeLu �,ej ex caveCfed Lfn S_iF� /0" I'mrorteyAA ,S`v ce A I t H ce i Municipal and State guidelines in effect on this date: Health Department Approval: 0 Scale: ,r� Inspecions Performed by: Date: / 1 _ 17 1A, inspection was performed according to all _L- Date: Eil r Date completed ............ f.../..~{.....¢.! ...................................................................... Depth of well ........... ..~..~.~ ................................................. i .................................... Size of casing ............ ..~a..f[.~ .............................................................................. Distance to water ........................ ..~....~ .................................................................. Distance to water while pumping ........... '~..~.([ ............................... at rate of ................................................ gallons per hour. Formation Driller DELTA DRiLLiNG COMPANY SRA. BOX 394 B ANCHORAGE, ALASKA 99507 �����������������~�x� ���A�C��� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STv ANCHORAGE, AK 99501 264-4720 PERMI[ NO: 860176 UPGRADE DA[E ISSUEU: 06/16/86 APPLICANT: TOM KAUPP C/8 NHAWTHORNE ADDRESS: 7127 OLD SEWARD HIGHWAY ANCHORAGE, AK 99518 CONTACT PHONE: 344~4711 ��/�'��~�� M/ LEGAL DESCRIP: SUBDIVISION: ROCKHILL LOT: 10 BLOCK" 13 SECTION: 14 TOWNSHIP: 12N RANGE: 3W ��� LOT SIZE: 43591 (SQ,FT" OR ACREG> LOT LOCATION LONE TREE CIRCLE ��C-7� ^��»��^ : �� ���/ x��'- ��y� /���a�� I certify that: ~ ' � �� 1.. I am familiar, with 'Lhe requirements for sewers and wells as set forth by the of Anchorage (M(DA) and the State of Alaska. 2" I will insta]l the system in accordance with all MOA codes and regulat.ions, and in compliance with the design criteria of, this permit" 3. I will adhere t.o all MOA and State (::)fAl�ska requirements for t�he set back distances from any existing well,, wastewater, disposal system or public sewerage system on this or any adjacent or nearby lot. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (�) All ANINSPECTION AN ELECTRICL PD BE MUST OBTA INED; (2) ASBUILA" S WILL NOT BE APPROVE IT T AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICALO MUS ICENSED ELECTRICIAN. /^-��DATE APPLICANT: TOM KA0PP C/O NHAWTHORNE ' ISSUED BYDAT-� _ ..~�-__.�~~___�~ ~�����__��~~��~~ 7/1vc? 7--"Z ���;v«�v�� 12 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264.4720 SOILS LOG — PERCOLATION TEST � SOILS LOG - ❑ PERCOLATION. TEST PERFORMED FOR: L9 m i2 P _ DATE PERFORMED: LEGAL DESCRIPTION: L I 3 `"' ec c K 1 1 4- I X I �3 W 1 2- 3 4 6 F4 Orgc.»iC5 QecQarvi. S., �a Cr h�oi5� �r n S I' 150-0 In d Sa rY,a" ;"I 3"Layers Molst io Wet Depth to Water SLOPE •.e.••oo x: p • ••nt 17 gv, �.a a� .xa ITE PLAN iEi 4 g DEPTH (FEET) Cis Awrri)t i i H11] CiM S 17 r I c MI Sa S• //�, (���»f 8- 101 101 5,P I ( r Sa -- C ) e ca. ,M014- wee WAS GROUND WATER 11 12 H13 SM S; 5 a 14 15 16 Date F4 Net Time Depth to Water Net Drop •.e.••oo x: p • ••nt 17 gv, �.a a� .xa e, ee p •Om �N a®+ iEi 4 g 19 Cis Awrri)t i ENCOUNTERED? /PS 512219y, IF YES, AT WHAT 13S' DEPTH? 51301g6 Reading Date Gross Time Net Time Depth to Water Net Drop Y i ,/ (9ga '3 Reasc 4 PERCOLATION RATE (/S e I ILa bkm ( - TEST RUN BETWEEN FT AND FT COMMENTS S��rse5t 6ed. 1X5-1Pvn d' PERFORMED BY: A.AlowJ l e ✓VI e CERTIFIED BY: DATE: �� v 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 C T PHONE p NEW ❑UPGRADE MAILING ADDRESS / l G-% LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS VY DISTANCE TO: Well �T� N, Absorption area ^1 Dwelling , r/� f— PERMIT NO. 036 F_ z LU Manufacturer Materia No, of compartmen( (n Liq. capacity in gallons I F HOMEMADE: Inside length Width Liquid depth O Y J�2 DISTANCE T0: Well Dwelling PERMIT NO. O < Manufacturer Material Liquid capacity in gallons O w= DISTANCE TO: Wel W o� Foundation !� ly Nearest lot line V PERMIT NO. CJ W LL Z No. of lines Length of each e Total length of li es Trench width inches Distance between lines at P: 0 Top of file to finish grade , 3 Material beneath tile �, / , S i„elies21 Total effective bsorption area W Length Width Depth PERMIT NO. QF wa Type of crib Crib diameter Crib depth Total effective absorption area y DISTANCE TO: Well Building foundation Nearest lot line Class 0 i Al,W Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS %j9-5 e P SOIL TEST RATING t INSTALLER REMARKS vo° r APPROVED DATE ry— I'�/LEGAL n� Pi U r4 10 n I I -F '-0 #::1 F= n N §:= V�: R! n 0 DEPARTMENT' HEALTH AND ENVIRONMENTAL C-ITECTION 01 LAS. AL -V_ 825 `L' STREET., ANCHORAGE, AK 99501 264-4720 �§ L.j F= L_ I F=l " r.a 0 " - E_Rr I -r FE '-17, E: t -J U_ FR F* E: -r FR rl 1 _r PERMIT NO. < 8107367 ) b " f,� L S APPLICANT JAK CONST 2511 CHILKAT CT 694-3`1.81 LOCATION LONE TREE LEGAL LIO B2 ROCKHILL LOT SIZE 42000 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: DRAINFIELD MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SO FT/BR)= 150 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: 1L. c. F= I=Dl _r _r '52- ENE-EF:10 -A== THE LENGTH DIMENSION 15 THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). E r"=- L411C.5ri-: E I - -=:; -5. I210CE-1 F:- EFF:.-F_ THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). 2 L_ -F -FnNK -S-1 Z!F= INDCIC-1 C3" PERMIT' APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL. WILL SERVE. -r 1 0 rA:E5 n= - E_ FR - U C-1- U I F-" C -a FE BACKFILLING OF ANY SYSTEM WITHOUT FINAL, INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL. BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL. SYSTEM IS 100 FEET FOR A PRIVATE WELL OR .150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL 'TO A PRIVATE SEWER LINE 15 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. r -" U- F --"M I -r F= X F:=,, I F;;."F: ES 0 U 1:FE r-1 F -=."U FR :3 J- , __JL sl A I CERTIFY THAT 1: 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND HELLS AS 'SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: 1 UNDERSTAND THAT THE ON --SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE 15 REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. S I GNED: �7 APPLICANT JAK CONST I SSUED 4,1'4 0 ro C.c�y.� T: Sy + g�y�rAL " irscrt i c3. T f 'vE-TfSLG S) 1 H cw a pr, spml #-:lP-4#> CDI?4 S TS E " tmi C • A i r trT[3. C Sig -367 > PAQPLICANT J8K t MT - 2-15I<i CHIL AT CT 634-3i.8L L OCAT I ON LIME TREE LE{.TSL ` Lts 83 RLIGM€LL CLOT SIzE 42ottv sawpe FsEr I TVP9 OF SOIL RBSEMPTIGN 49?STEN IS: MMENFEELD ;' M-0 M OF gemm= I SOIL RATING <SO FT/W>-" 059 a ' TI -E RA -M ME6 I e-'rF THE 'SOIL ABSORPTION ISTEM I S ! T LEF#3Ti# i}ii" dISION La ME LS TH Cid MET) MMMOR 0mtWfcL0- T W DEPTH OF A TRENCH 13R PIT IS THE DISTRNUE BETWEEN THE Sl-W80E OF THE rAokm nm T}TE aorrm op Tom"4 x riam -c IN FeEn. TSE DEPTH IS MINIM" Tit OF i�L T�II THE Loi -L PIPE em rw ooTrai c�p Tw oo>mritm <EN r). #ZE=t:aLT I #DT=I PEMIT 8PPLICPINT HAS THE RESP 18 fL I TY TO twopm rm t oa:�iw wcw cdjR t no 't'w tl',taTHLl-ffT fLll EW-EPECTIONS 13F AW 14ELLS RDJACENr TO T14IS PRUIPERTV AM THE A# t OF RESI HAT ME moi. ML SERYfL I :� i i7its� " i ?�I TtT ffl T iT� 680 LLL E 17JF` '" S'�TEM WITMMT FIMIL IW�TI� € T r�L ," THLS NtMLPPJM 0L'5TfVM BETWEEN N WELL HNO PW ON-SITE _ DISPOSAL Santm I'5 - { 1 PELT FOR A PRIVATE tai_ �.3R i TO21V,t T F�# A .iC k�.i.. t ' ?Iii �. TTS T"r"y OF PUBLIC WELJL mrNf"A oT:jrtVjoX P a PRI rE I-V" To H PREYRTE SMER LINO tS 2S MT,nm 'TO €1 c-XV#M f rV ER LINE IS 75 PTS T' t LrjasARE tMEO A�* "JST BE RETURNED TO THE 1DE. T t+iT WITHIN 39 t OF THE WELL COMPLETIOK ARE [LAUD TO IRRM PROFFER €NISTR_LRTT f-PFa T 7 I=XP I Rem l t CST LFY T RT .: I AM FAMILIAR WITH TWE WI TS FOR ON-SLTE SO4ERS AM WELLS tis SET FORTH GV 17 -le NJ"ICIFILITV OF I MILL INSTALL THE STEM IN ale'_ WITH Cs i. 3e 1 IJMCRSTFM TMAr THE ON-SITE '-M" SVSTEN MAY #2&JUE �301ENT IF THE Re-sicENCE is tlxo-EO To IMLOC E' Timet 3 aEEORC-+tea_ i ------------------- #x�iT JAK M16T V4- If--- 72.008 16/791 MUNICIPALITY OF ANCHORAGE r r • . DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TCl EST TEST i \ 825 L. Street, Anchorage, Alaska 99501 284.4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: J IG C_C\/JS DATE PERFORMED: LEGAL DESCRIPTION: U /Z o G t r/ L DEPTH SLOPE SITE PLAN (FEET) ii t, 3 o 6- /4 /✓� \ Perms Re'IA 6 9 10 } i T 11 WAS GROUND WATER �� lj S f L d ENCOUNTERED? / L v o 12 P C y-6 V 2 / IF YES, AT WHAT '� E a. 13 DEPTH? 1 Z 5^ 14 - Reading Date Time. Not Time -Gross hWatorto Not 15 = 1 16 ®�►1�, ® A L 1 18 `eb �n °°° seeeee e.. e...eo°®Spee °e 19 NO. 1732-E 20 4'.; �� June 22,1968 �A �s p �� `.e PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT COMMENTS PERFORMED BY: ' ( �w'C-i �CERTIf1E08Y: ` DATE: IE) —�?'l 72.008 16/791 l D; ar �a' V(a r(t Municipality of Anchorage Development Services Department Building Safety Division ` i On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 995195650 www.muni.org/onsite (907) 343-7904 Parcel I.D. CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING ,lip-wir-16111.1 1. GENERAL INFORMATION Complete legal description Rockhill Block 3 Lot 10 COSA # MIN Expiration Date: 9 —/8— 0 Location (site address) 9820 Lone Tree Drive, Anchorage, AK 99516 Current Property owner(s) Robert Rembish Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 9820 Lone Tree Drive, Anchorage, AK 99516 Unless otherwise requested, COSA will be held by DSD for pickup. Day phone Day phone Day phone 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well✓❑ Individual On-site ❑✓ Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Onsite Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of Onsite Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seat affixed hereto and as of the validation date shown below, 1 verify that my investigation, based on procedures outlined in the Certificate of Onsite Systems Approval Guidelines for this application, shows that the on -she water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Watkins Engineering, Inc. Phone 349-1851 Address P.O. Box 110443, Anchorage, AK 99511.0443 Engineer's Printed Name Cindy W. Ellis Date 49h 6. DSD SIGNATURE CKdy W Ellis Approved for 3 bedrooms.CE.1ow ' •...... Disapproved. OAOFrH c Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory _lam Other By: O`� / Gam. Original Certificate Date: (R" 11A5) Municipality of Anchorage • Development Services Department Building Safety Division ` OnSfte Water tL Wastewater Program 4700 SragaW Street P.O. Box 198850 Anchorage, AK 99519-6850 www.munLarglonsto (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Rockhltl Bloc* 3 Lot 10 Parcel ID: 016.063-08 A. WELL DATA Wetl type Pri If A, S. or C provide PWSID # _ Date completed 8113181 Sanitary seal (YM) Yes Total depth 49 ft. Cased to >40 ft. FROM WELL LOO Data of test June 13, 1981 Static water level 27 ft. Well production 40 9 -p.m - WATER SAMPLE RESULTS: Coliform 0 coloniesn00 ml Nitrate 9.04' m91L Arsenic: �.� mgn Date of sample: 41=r B. SEPTIC/HOLDING TANK DATA Tank TypelMaterlal Steel Septic Tank Wetl Log (YM) Yes Wires property protected (YIN) Yes Casing height (above ground) 24 tn. AT INSPECTION Mandl 21, 2007 31 ft. 5.1 9.p.m. Other bacteria 0 colonie31100 mL Collected by: Rocky Trainor/Brian Wille Date Installed May 28, 1981 Tank we 1000 get. Number of Compartments 3 Cleanout (YM) Yes Foundation cleanout (Y/N) Yes Depression over tank (YM) No High water alarm (YM) WA Date of pumping March 21, 2007 Pumper Isaac's Pumping Service C. AB LD DATA bed: 6/17/B8 Date 981 Soil rating (g.p.dJW or fe/bdrm)150 System type Trench / Bed Length 68; 3809 bed ft. Width 3 ft. Gravel below pipe 3.6; 0.5 ft. Total depth 8.6 :10.4 R Elfa tact ga 482 ft= Monitoring tube Ye Depression over field NO Dat of adequacy test 3121=7 Results (Pass/Fai Pass For 3 bedrooms bed 360 Oal 725 7 37.6 ; 0 in. Fluid depth in absorption field before test 24-5 ; 0 in. gal. New depth Elapsed Time: W min. Final fluid depth 29 ; 0 In. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) No If yes, give date D. LIFT STATION Date installed WA 'Pump on' level at _ in. Size in gallons Manhole/Access (YIN) 'Pump ofr level at _ in. High water alarm level at in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lUt station on lot 134' Absorption field on lot 1417+ Public sewer main 100'+ Sewer /septic service one 804 Meets alarm 6 circuit nspuirerrrents9 On adjacent kits 100'+ On adjacent lots 100'+ Public sewer manholeldeanout 100'+ Holding tank WA Animal containment areas 100'+ Manureianimal excrete storage are 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 27' Property line59_ Absorption flew 10' Water main 100'+ Water service line I W+ Surface water 100'+ Wens on adjacent kits 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line IV Building foundation 43' Water main 10(Y+ Water Service Una 100'+ Surface water 100'+ a^waY, Peddrq/vehicle storage 7' Curtain drain WA Wells on adjacent k1b 100'+ F. COMMENTS: ry 725 7 90" Warr kilo MnrL era 350 Wrs pro W. Bae isms "&y %T?M WM $woo" vneea sraysae'speln 10 6 ppm (Masts + NMO!) an 4u2r07, 10.a ppm On dale? (Meats + n&M) 610.2 ppm #Mnft anWm and07. Vats was kwpamep by Avow Pump d Wes Services (sea a(tlid ad loner). and found mechanically sound Final nilrats test 0.04 ppm (none + nitres) an 6"7. G. ENGINEER'S CERTIFICATION I cerWy chat I have determined through field krspec dorrs and review of MuniclPal records that the above systema are in confm0noe with MOA COS4 guidelines m effect on this date. Engineer's Printed Name Cindy W. Ellis Date10 % COSA Fee S Waiver Fee S _ Date of Payment//'j%D Date of Payment Receipt Number _ 9599 Receipt Number, (Rev. 1IMS) WY W. MIS CE • low j. Municipality of Anchorage l •�' `: Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsitc (907) 343-7904 Nitrate Advisor Certificate of On -Site Systems Approval # 070189 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 3, Lot 10 of Rockhill subdivision. This inspection revealed a nitrate concentration of 9.04 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. June 12, 2007 Regarding Rockhill, Block 3, Lot 10. After running the well for four plus hours I pulled a sample which showed a nitrate level of 9.04. Watkins Engineering pulled three previous samples in May and April all above 10. Past samples from this well and others in the surrounding lots were all high dating back Into the 90's. This lot's well log shows a cay(silt) layer from 8'-26'. With a layer like this no surface water should be able to penetrate through to the 45' aquifer. A camera was sent down hole after running the water on the casing for four hour's and no entry was observed. It is our belief that nitrates in the 45' zone are coming from elsewhere in the area and further work on this well would not lower the nitrate levels in this area. Thank you, Brian R. Wille Aarow Pump & Well Service LLC. SGS ReLM 1072507001 Client Name Aarow Pump & Well Service Project Name/# 9820 Lone Tree Client Sample ID 9820 Lone Tree Matrix Drinking Water PWSID 0 All DatesITImes an Alaska Standard Time Printed Daterrime 06/072007 16:19 Collected Date ime 06/042007 14:10 Received Date/time 06/042007 14:40 Technical Director Stepbes C. Ede Samplc Remarks: 4500-NO3 -Total Nitratc/Nitritc -The matrix spike recovered below the QC criteria. The batch LCS is within QC limits. Allowable Prep Analysis Parameter Results PQL Units ktedw Container ID Limits Date Date Init Waters Department Total Nitntc/Nitrite-N 9.04 0.100 mg/L SN120 4500NO3-F A 00) 06/06/07 JDS SGS ReLB 1072148001 Client Name Watkins Engineering Project Namely Rockhill Blk 3 Lot 10 Client Sample ID Rockhill Blk 3 Lot 10 Matrix Drinking Water PWSID Sample Remarks: All DalesITImes are Alaska Standard Time PrintedDate/Pime 05/30/2007 13:50 Collected Datd(lme 05/152007 14:40 Received Date/Ilme 05/152007 15:00 Technical Director Stephen C. Ede AIIeWaDle Prep Me�ysu Parameter Results PQL Units Method Container ID Limits Date Dere Init Haters Department Nitrate -N 10.2 • 0.100 mg/l, SM204500NO3-F A (<10) 05/16/07 IDS SCS RetN 1072053001 Client Name Watkins Enginecring Project Name/N Rockhill DIk3 Lot 10 Client Sample ID Rockhill Blk3 Lotl0 Matrix Drinking Water PIVSID 0 Samplc Remarks: All DateMmes are Alaska Standard Time Printed DateMme 05/142007 8:04 Collected Datdl7me 05/092007 16:00 Received Datt/fimt 05/092007 16:30 Technical Director Sttphto C-Ede Allowable Prep Analysis Parameter Remtts PQL Units Method Container ID Limits Date Date bit Waters Department Total Nitrate/NitriwN 10.8 • 0.100 mg/L SM20 4500NO3-F A (<10) 05/10/07 1DS III W4161 SCS RM 1071344001 Client Name Watkins Engineering Project Name/# Rock hill Block 3 Lot 10 Client Sample (D Rock hill Block 3 Lot 10 1llatrix Drinking Water PWSTD 0 All Dates/T7mn are Alaska Standard Time Printed Date/fime 04/132007 8:09 Collected Date/Time 04/02/2007 13:00 ReceivedDate/Time 04/02200714:20 Technical Director Stephen C. Ede Sample Remarks: 353.2 • The MS for Total Nitrate/Nitrite recovered below the QC criteria. The batch LCS is within QC limits. Allowable Prep Analysis Parameter Results PQL Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic Waters Department Total Nitratc/Nitrite-N Microbioloav, Laboratory Total Coliform ND 5.00 10.5 • 0.100 0 ug/L EP200.8 mg/L EPA 3532 C (<10) 04/06/07 04/12/07 TK B (<10) coV100mL SM209222B A (<1) 04/03/07 IDS 04/02/07 DPT 4IIU,NICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date f'/?G! ,g6- 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Z'10 13 3 �dcKl),// Si 4 7n -z 3 1 Location (address or directions) -5)S,2n Lohv (b) Applicant Name O «A Telephone: Home 3 467 123 7 Business 36 L ZOO Applicant Address z? hye- (c) Applicant is (check one): Lending Institution El; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution --nTelephone Address - (e) Real Estate Company and Agent __AI' 5, Address Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other 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 the legality and status. 4. SEWAGE DISPOSAL Onsite Of Put .:ic ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION r 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 watersupply 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 .&AJ Telephone -3 * + 4-711 Address -? 1 27 D S i i� ✓ �/ �} r.. r � 9 `)' D Date 0 / O '9-6 to WATER WELL NOTE: This Health Authority Approval inspection merely certifies that the subject water well produced 150 gallons per bedroom per day and that certified laboratory tests showed no presence of coliform bacteria in a sample of that water. No warantee or certification is expressed or implied concerning the long term adequacy or safety of the water supply. ON-SITE SEWAGE DISPOSAL SYSTEM NOTE: This Health Authority Approval'•°e ta° 9•s:9 inspection merely certifies that the subject on-site sewage disposal 0 0• ° :00 system accepted at least 150 gallons of water per bedroom per day ° ° •o 0° ' as determined by methods approved by the Municipality of Anchorage •NEIL. Department of Health and Human Services. No warantee or d• °. THORNE ; d t CE certification is expressed or implied concerning .the long term 2•?�,"°, �• ,.yy adequacy of the on-site sewage disposal system. Construction data reported on buried system components is from MOA files and was .c not verified during this inspection. �av�Z°s' 6. DHEP APPROVAL 7/ % L7� Approved for % Lim bedrooms by L,CJ-'�. Date—.�/iyL� Approved /V Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of 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 the professional engineer's work. Pane 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: /C7 73 3 A. WELL DATA Well Classification pr I (/PCt e If A, B, C, D.E.C. Approved (Y/N) N 1A Well Log Present (Y/N) X Date Completed 6 -1 3 '6'1 Yield � � �'� 04 Total Depth 49r Cased to y4-0� Depth of GroutingA/ 64 Static Water Level 2 R ' Pump Set At V'I v w H Casing Height Above Ground Q Sanitary Seal on Casing (Y/N) L Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot / 2 S�v On Adjoining Lots 42d � To Nearest Edge of Absorption Field on Lot 166 r.4- ; On Adjoining Lots o o a To Nearest Public Sewer Line /UZ4 To Nearest Public Sewer f Cleanout/Manhole A)1A To Nearest Sewer Service Line on Lot 30 Water Sample Collected by /l Date Sl/ Ig Water Sample Test Results 5 Comments B. SEPTIC/HOLDING TANK DATA Date Installed r -31 Size _1640 No. of Compartments Z Standpipes (Y/N) y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped 6*- 1 2 -A Cc Pumping/Maintenance Contract on File (Y/N) !J %A ; for Holding Tank High -Water Alarm (Y/N) 101A Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well 1 a S r To Building Foundation - v To Property Line I 0'4- To Disposal Field /a To Water Main/Service Line 30 To Stream, Pond, Lake, or Major Drainage Course MUNICIPALITY OF ANCHORAC3E Comments ENVIRONM NTAL_PROTECTION JUN 2 01oo Pagel of RECEIVED C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /5-0 Type of System Design Date Installed Jun e Rin Length of Field 3A Width of Field 19 Depth of Field P„ 2 �o �� ✓J� Gravel Bed Thickness Square Feet of Absorption Area Depression over Field (Y/N) — Results of Last Adequacy Test Separation Distance from Absorption Field Standpipes Present (Y/N) Date of Last Adequacy Test New To Water -Supply Well To Property Line �D To Building Foundation 301-r- To Existing or Abandoned System on Lot aD ZE ; On Adjoining Lots AIM To Water Main/Service Line V30F 30 -I- To Cutbank (if present) A)/A To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION � J� Date Installed / Size in Gallons "Pump On" Level at High Water Alarm Level at — Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that ch c <e ,/ve , or conformed to all MOA and HAA guideli nes in effect on the date of this inspection. Signed ate G 42 D AB 6 Company /li�a�✓��toyne-E�.,brOANo. Receipt No. Date of Payment o �✓ �e�• °•tJrdV 7"r Amount: $ � .� •••° Page 2 of 2 72-026 (11/84 ,•• •.i a N�Z °`!{F p¢o•0 of • .,EI H WTfiORN= L CE - 4369b tJ °e 4 ° „tiJ fj JML LABORATOnIES, INC. 7127 .OLD SEWARD HIGHWAY LABORATORY Y'.D. # /w ANCHORAGE, ALASKA 99518 (907)344-8551 BACTERIOLOGICAL WATER ANALYSIS TO BE COMPLETED BY WATER SUPPLIER FOR LAB USE ONLY DATE COLLECTED TIME COLLECTED TYPE OF SYSTEM MONT DAYS YEAR ❑ PUBLIC ❑ INDIVIDUAL ❑ RESUBMIT SAMPLE P Sample rejected because: I.D. NO. (PUBLIC'SYSTEMS) . RCLE CLASS CHECK ONE OR MORE A 8 C esntial ❑ Sample too tong in transit. Sample should not be over 30 hours. NAME OF S STEM TELEPHONE NUMBER ❑ Sample received too late in week U Not in proper container SYSTEr, ADvnESS ° i g ❑ Leaked out ❑ Insufficient information provided. CITY ST ZIP CODE �� Please read instructions on form. ❑ Other (Specify) LOCATION WHERE SAMPLE WAS COLLECTED } 'COLLECTED BY:(SIGNATURE) RECEIVED FROM/ TYPE OF SAMPLE RECEIVED BY Q 1&el_ (CHECK ONLY ONE THIS COLUMN) DATE i /� a' TIME 3 '7-13 X04 ❑ DRINKING WATER ❑ CHLORINATED ANALYTICAL METHOD: ✓CHECK TREATMENT ❑ FILTERED ' / IEMBRANE FILTER ,EVNTREATED OR OTHER A3 RAW SOURCE WATER ❑ FERMENTATION TUBE ❑ NEW CONSTRUCTION OR REPAIRS Date & Time Started ❑ OTHER(Specify) Date & Time Completed 44/,6 � 'Pooh .5x6 IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NON -CONFORMING SAMPLE? ❑ YES 01NO PREVIOUS COLLECTION DATE LABORATORY RESULTS' ❑ RESUBMIT SAMPLE ANALYSIS REQUESTED (IF OTHER THAN TOTAL COLIFORM) SEND REPORT TO:(PRINT FULL NAME,ADDRESS AND ZIP CODE NAME Hok-!d2 IN©Y �1-le_ Test unsuitable because: y _ _ - ___, ___ _ - - -���nj _. C onflueiit Growth ADDRESS 7 /, 2 i NTTC CITY _x4ti e L STATE (L ZIP 9 ,j S/�} 1V,I�YST SATISFACTORY UNSATISFACTORY ❑ BACTERIOLOGICAL WATER ANALYSIS RECORD FOR LAB USE ONLY TOTAL COLIFORMS Membrane Filter: Direct Count Coliform/100ml aVerification: LTB FECAL COLIFORMS BGB Final Membrane Filter Results Coliform/100ml OTHER Reported By Date Time A.M. P.M. READ SAMPLE COLLECTION INSTRUCTIONS ON BACK OF FORM MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 6 / / Z. /86 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) L lo 13 3 Pock A; 11 5 )4 T�z v �'��✓ Location (address or directions) 9r��� Lone �ree. (b) Applicant Name ecA ✓ i2 'R T Applicant Address Li (c) Applicant is (check one): Lending Institutio ❑ ; EE (e) Home 34-6 I "37 Business 1-& 2 62-oc ilder 4 ; Buyer ❑ ; Other ❑ (explain); -ending Institution t address c Telephone Seal Estate Company and Agent address Telephone i t ✓lail the HAA to the fo ow g a ress l 6100 2. TYPE OF RESIDEN Single -Family Multi ily ❑ Number of Bedrooms 3. WATER SUPPLY z Individual Well W Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsitelg Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) 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 this Health Authority Approval shows that the on-site watersupply 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 ,Una -w i La r h e � h a� r- Telephone 3 4 4- 4-7 /1 Address `7 /2-7 D_ 5 N w y Rbe-4�, A k - 9 SI 0 Date 61 Z / 2, / S �i WATER WELL NOTE: This Health Authority Approval inspection merely certifies that the subject water well produced 150 gallons per bedroom per day and that certified laboratory tests showed no presence of coliform bacteria in a sample of that water. No warantee or certification is expressed or impliedconcerning the long term adequacy or safety of the water supply. - 0r:::t - ON-SITE SEWAGE DISPOSAL SYSTEM NOTE: rid. � �t Uspa ao °e as de. r7 k{ e Do}w,n+_._+ No warantee or certification is expressed or implied concerning the long term pct adequacy of the on-site sewage disposal systema Construction data _d� reported on buried system components is from MOA files and was not verified during this inspection. New d,-alvi'Fie.101 LeikD 6. DHEP APPROVAL Approved for bedrooms by Date Approved Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not colduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in professional engineer's work. PanEi 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA, HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 9861 T M1 n 264-4720 NOIIJ3102d 1V1N3WNOMAN3 Legal Description: 70/7 /,54&e H11V3H do -1dao SSDVdO Y,1l1Vd0INqW A. WELL DATA —/1 Z A) 3 L'L) Well Classification ___ A T//A7L' If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) _YC_ Date Completed Yield > /a 9ogn Total Depth Cased to > 410 Depth of Grouting A Static Water Level ZS 1 Pump Set At e Casing Height Above Ground Z Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Yes Depression Around Wellhead (Y/ Separation Distances from Well To Septic/Holding Tank on Lot/ci?T On djoim g Lits To Nearest Edge of Absorption Field on Lot /60 r ; On Adj fining L is To Nearest Public Sewer Line �� To N�arest P lic Sew r Cleanout/Manhole /�'�� To Nearest Sew Service in on Water Sample Collected by lle'4 Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed f Si eA0010ca,4 No. of Compartments �- e)pcz e — �Qeioored Standpipes (Y/N) Air -tight Caps (Y/N)� Foundation Cleanout (Y/N) W SPD Depression over Tank (Y/N) lvn Date Last Pumped 8( Pumping/Maintenance Contract on File (Y/N) &/� for AW Holding Tank High -Water Alarm (Y/N) NA Temporary Holding Tank Permit (Y/N)_ Separation Distances from Septic/Holding Tank: r To Water -Supply Well /o?S To Building Foundation To Property Line /�'� To Disposal Field To Water Main/Service Line Course Comments Page 1 of 2 72-026(11/84) To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /Sd F- M Type of System /Design Date Installed �'/�� f981 Length of Field 0 Width of Field 3 Depth of Field C •5 Gravel Bed Thickness Square Feet of Absorption Area y1oZ Standpipes Present (Y/N) &.5 Depression over Field (Y/N) ,�es Date of Last Adequacy Test S =/ 9 -,V6 Results of Last Adequacy Test .Al,o&4r/Ile— T FA/ZEn r°a )00 'AL Separation Distance from Absorption Field To Water -Supply Well lIfso To Property Line /0/" - To Building Foundation .S1 To Existing or Abandoned System on Lot A/d e cAg- ; On Adjoining Lots AM "y To Water Main/Service Line �� ! To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway. Parkins Area. or Vehicle Storage Area �' D. LIFT STATION �2e Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments U 5Y"0.J2 Dimensions Manhole/Access (Y/N) "Pump Off" Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I e heF <e , verifi,e or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ` ate �,� 294 Company r - n ®®rC [p MOA No. / r- ® Receipt No. 8g0g 1/ Date of Payment �, ` 1�-%�( Amount: $ 5 qd Page 2 of 2 72-026 (11/84) � NEIL HAwTFiORN= CE - A3G9 ` R, �. f? .� vl�R ••eoaeevmr •, ,.f 5. LEGAL DESCRIPTION A— Df,.� ECEIVED INSPECTION APPOINTMENTS TIME TIME TIME _ _ ` _ � 0 j r�I-_91 A qn - DATE DATE W DATE Io a M y, -_t- 9 INSPECTOR INSPECT R INSPECTO , since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTI LITY depth (attach log if available.) �, MUNICIPALITY OF ANCHORAGE DEPr. OF I:'r-.LI. i & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTII§NVIRONMENTAI. ko- i_CfION 825 L Street - Anchorage, Alaska 99501 JUL 3 ENVIRONMENTAL SANITATION DIVISION Telephone 264.4720 RECEIVED ECI"ED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE „Z MAILING ADDRESS r d P ` PROPERTY RESIDENT (If different from above) ONE 2. BUYER PHONE g ®� MAILING ADDRESS / 7 3. LENDINGINSTITUTION a PHONE MAILING ADDRESS ,� 7_ r 4. REALTOR/AGEaNT ..��PHONE MAILING ^ADDRESS 5. LEGAL DESCRIPTION A— c / k STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS ❑ One ❑ Four ❑ Other i� SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY kyThree ❑ Six 7. WATER SUPPLY INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTI LITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM J6 INDIVIDUAL/ON-SITE** ! YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) 44 a-Itz, I A 1 6 00 �C."" N THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE. ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: 1 L✓ j 6 "If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL It 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS [APPROVED FOR _� BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY