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HomeMy WebLinkAboutROCKHILL BLK 4 LT 3  " MUNICIPALITY OF ANCHORAGE rDEPARTMENT 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 ]PH~_ON E W LOCATION NO, OF BED~OO~S I Well Absorpti Dwelling ~I PERMIT NO. DISTANCE TO:  kiq. capaciw in flallons Insido Ion~th ~idth liquid dopth IF HOMEMADE: ~ ~ ~ DISTANCE TO~ ~ - Dwelling PERMIT NO. ~ Manufacturer/~/~· Material Liquid capacity in gallons ~m ~ ~o. oflinos ~ ~on~th of oa~ I~ ~ lotal Trench midth Bistance botwoon linos ~ T°P °' tile to finish grade ~ ~' ¢ ' Material beneath the7~______ " inches T°ta' effec~ ~zti~ a~ea Length ,Width Depth PERMIT NO. ~ ~ Type of crib meter Crib depth Total effective absorption area ~ ~ ~ ~e~ Building foundation Nearest lot line ¢ DISTA E Class ~ --' Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS ~~/ C SOl L TEST RATt N6 INSTAELER DATE LEGAL APPLICANT LOCATION LEGAL DEF'RRTMENT O~F HEALTH AND ENVIRONMENTAL PR":TECTION /'4,,~ fl .ha /A " ., ,:,,-..-._, ' L : TEEET, HI',I_.HURAbiE., AK. 9q. 5Ri JAK C,]NSTR 25:1.:1. CHILKATT C:]~'~ .L~.,'<~'e/, e'lg'"'t-}l-8%~'4~'°g~ ~'L'U~" ROCKHILL S/D ~ ~J]~/ r__v/ LOT SI-'E 411~I0~SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: 'TRENCH MRXIMLIM NUMBER OF BEDROOMS SOIL RATING (SQ FT?BR)= t58 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: C. EPTH== :.t. ~Z" LE[4GTH=: __~c8 ,SRR%"EL DEF'-IFH= ~ THE LEN=TH DIMENSION IS THE LEN=TH (IN FEET:) OF THE TRENCH :R DRRINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL. DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). F~." E,;.,LI Z REP..., SEF'T I C TR[4PC S I ZE= :t ~=---'~ 0¢i", ,3RL_L,D[-4S PERMIT RPPLICRNT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE iNSTALLATION INSPECTIONS OF Ably WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. TI--~CI < 2 ::, I ~'-.~'_~PEC:..T I CIf-.~--~ RRE REI~!L...~ I BRCKFIL. LING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUT.ION. MINIMUM DISTRNCE BETNEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR R PRIVATE WELL OR i50 TO 208 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.. MINIMUM DISTANCE FROM R PRIVATE NELL TO 8 PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. NELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTRLLRTION. F"ERP1 I T E~<P I F.:ES [)EC:EPIBER _~::l., I CERTIFY THAT t: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. "~: I UN[.EEz. THN[. THAT THE ON-z. ITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS. V4, 0 t"'~[~.lH ~ ~.~ ~..7~.~S~ = ~ ~L!~L f~IT[I~G (~'~} ~t-~l~::~= DEP T)-(~ ~.~-~ L EF~OTH-- 38 ,~.,"'). VEL DEPTH~- B · RED SEPT I ~ T~NK S 1 2E~ tp]~B O~LLON~ LEGAL DESCRIPTI ON: ~ ~ [] SOILS LOG: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST 825 L. Street, Anchorage, Alaska 99501 264~4720 SOILS LOG - PERCOLATION TEST ~"~'/"~ ~"/~ U~-''~ ~"'"/'~) ~-'/! DATE PERFORMED: SLOPE 5( uT 10 11 12 13- 14- 15- 16 17 19 20 COMMENTS ENCOUNTERED? P E IF YES. AT WHAT DEPTH? Gross Net Depth to Net ": Reading Date Time Time Water , Drop PERCOLATION RATE S (minutes/inch) TEST RUN BETWEEN ~ r ~.~ . FT AND , FT -,- x'~ ~,f,'/ ~/~ .~. BOx 13(19, 8?AR I~0~?~ A A~c~o~, A~.~s~ 9950~ SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF ~21o00 PER FOOT. ~oh.n. %..Lr~ed.~ 694-2275 DRILLED AT THE RATE OF ProPErTY OWNER LOCATION OF WELL SITE DRILLER WELL LOG: Co4~ of ~,vi22.2n.~: ~21.00 X 60 f~e2.: ~1260.00 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PaYabLE TO RAMPART DRILLING WOrkS for THE SUM OF ~1260o00 THANK YOU VERY MUCH. DATE ~ 154h, 1981 BERNie CLAUS OF RAMPART DRILLING WORKS .............. 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 1. GENERAL INFORMATION complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Day phone Day phone-- Agent Ao[K~,~ ~P~/~ /~/~.~,Y~ ~f~/~ Dayphone ~--~/q/~ Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: -~ ~ TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: If community well system, provide written confirmation from State ADEC,'attest- ing to the legality and status of system. ' ''~ 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 STATEMENT OF INSPECTION BY ENGINEER. As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~(~1') Fnnln~,~n~, Phone /~ ~/~ - 6/// 20441 Ptam~a. avd. Address =o,~ ~ .... A~. ......... Engineer's signature ~.~. Date 6. DHHS SIGNATURE Approved for ~[.~,~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments --/ Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval: Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH H$ 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. 1/91) ~ac~ MOA ~ Municipality of Anchorage {)CT 1 'l '1°J96 DEPARTMENT OF HEALTH & HUMAN SERVICES EiVE Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 ® (907) 343-4~ 6 . Health Authority Approval Checklist LegalDesc,ptm: B/e'"/ PareelI.D.: A. WELL DATA Well type ///~67/ Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well production If A, B, or C, attach ADEC lecer. ADEC water system number y Date completed q///~/~/ Cased to /~t:9 ' Casing height (above ground) y Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION ,g,O g.p.m. ~, Ge g.p.m. WATER SAMPLE RESULTS: Coliform / Nitrate Date of sample: /D/'5 /Gdo B. SEPTIC/HOLDING TANK DATA Date installed ifa/5/~/ Tank size Foundation cleanout (Y/N) tl/ Date of Pumping /~// 30 6v 2. Other bacteria Collected by: ,4",4,//,,,D Number of Compartments ~ Cleanouts (Y/N) . Depression (Y/N) Att High water alarm (Y/N) Pumper ~ 4' Y C. ABSORPTION FIELD DATA Date installed ~////d~/' Length 2~G ~ Width Effective absorption area Date of adequacy test /O/! / Soil rating (~2 ~~./~-t:9 Gravel thickness below pipe System type / Total depth Monitoring Tube present(Y/N) }/~ Depression over field (Y/N/ A/ ~, Results (Pass,ail) ~55 For ~ ~edrooms Fluid depth in absorption field before test (in.); d~fZ" immediately after/ag:rd)gal, water added (in.): /..~/2," Fh, id depth (~f/~ tt (ins.) Minutes later: ~, O Absorption rate = 5/ff-~5) ~ .g.p.d. Peroxide treatment (past 12 months) (Y/N) /V/ If yes, give date ~ D. LIFT STATION Date installed Manhole/Access (Y/N) Sizein gallons / / / '~Pump on" level at* / "Pump off' level at* ./ *Datum / / High water alarm level at* / / Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Lift station /1/fi` Fo Surface water /D D t 4- Curtain drain /b O / 4~ ENGINEER'S CERTIFICATION SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~ / Property line /D ~ 4' Absorption field Water main/service line ~.~ '* Surface water/drainage //9?9 -~ Wells on adjacent lots ~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ~O t ~ Water main/service line ~.~.~. Driveway, parking/vehicle storage area ~t9 "~ Wells on adjacent lots ~' ~ 9q/al t/~' Property line 1 certify that I have determined thrufield inspections and revtew ofMumctpal recorth~'~l~a~e 0~14 ?e~,rns are m conJbrmance wtth MOA tt~ gutdelines m effect on thts date. Signature Engineer's Name ........................................................................................................... ............ Waiver Fee $ Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.doc 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 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Na~ "- - ...... -. - Telephone: Home ~'~ ' '~1~{~ Business ApphcantAddress ~-~ ..z .... , ..... O' ~ ~.t, ~ V./,t~ ~ .. (c) Applicant is (check one): Lending Institution ~; Owner/bui der ~; Buyer ~; Other ~(explam); (d) Lending Institution (e) (f) Telephone Real Estate Company and Agent Address 3'D-<? / C~ ~-~/' Telephon~ Mail the HAA to the following ~ddress: TYPE OF RESIDENCE Single-Family [~Multi-Family Number of Bedrooms Other WATER SUPPLY Individual Well [~rCommunity [] Public [] Note: If comm unity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite IZ~ 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. 72 025 (11/84) Pan~ I of P 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 ApprovaJ 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 flies and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. ~'~ ~¢ ,,~'~,~ ~ ~-~-/' Name of Firm ,~,~'~' ~ ~',~z~/~ Telephone Engineer's Seal DHEP APPROVAL Terms of Conditional Approval Date CAUTION The Muncip'~llity of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval ceriificates 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. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: /,¢,, /I MUNIClPAUTY OF ANCHORA(3~, DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION NOV ][ 8 Jgj ' WELL DATA Well Classification /./¢,~'¢z~:,/'~,-~-/ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) //~i.~ Date Completed ,5;///~/~/ "~ Yield Total Depth ¢ 0 / ~ Cased Static Water Level .-~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Welt: To Septic/Holding Tank on, Lot Depth of Grouting /~///' Pump Set At ':":'~',/:-'~ ~-~">~ Sanitary Seat on Casing (Y/N) /'~ -~' Depression Around Wellhead (Y/N) /~¢' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments ./,~ /.~, ~.¢-~z**.~.'.,;...~ ; On Adjoining Lots --5' / ~ o / ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on B. SEPTIC/HOLDING TANK DATA Date Installed ~'/'~ Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well -~ /'~ To Property Line ~ To Water Main/Service Line ~--' Course Size / ~:~ O o ~ No. of Compartments Air-tight Caps (Y/N) ,,/¢~¢~; Foundation Cteanout (Y/N) /¢/~: Date Last Pumped ~-"/'/~/~'~-~"~ /u~,~' ;for Temporary Holding Tank Permit (Y/N) To Building Foundation ~ / ~ To Disposal Field ~' / ~ To Stream, Pond, Lake, or Major Drainage Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installe. d Width of Field ~,'~/~'~ ~-'--~ Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test ~'~---.:~-~ Separation Distance from Absorption Field: To Water-Supply Well ~ To Building Foundation ~ Lot TO Water Main/Service Line .~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments .~' ~ ~ Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line ? To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) </ , LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** .~ ~'~2',.~ I certify that I hav~ checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Company ~'/'~ ~' ~ MOA No. ~-' o~ ~.~-c.~. J ~ Receipt No. ~ ~ ~ ~ ~ ~ Date of Payment i ~ ' I~-~ b~ Amount: $ ~O~ Seal Page 2 of 2 72-o26 (11/84) PAY TO THE ORDER OF FOR SHIP FROM SPECIAL INSTRUCTIONS S T--"~ ~TOR " I DSTOCK r"]WNS[~ ' EIcM~: r-l~-/ MONTH DAY CODE[ IMONTH 11 ,, I, 121, APPROVAL TYPE HANDLING DEL. CODE QUAN.i STOCK NO. l THIS IS PART CASH OF A PART ORDER, PRICE SERVICE DEPARTMENT SALES PROMOTION COPY CASH PRICE Anchorage Recording Precinct, Alaska" LOT 9URVEY CERTIFICATION LEGEND hereofi, and ~3f the improveme~s sifuo~ed thereon ore wlfhln the prop- o = Iron pipe and/or rebor recovered erfy lines and do not overk3p ~'encro<x~ on edjecenf property and tlx31' f~o o : 2 x ~ hub a t(~-.k recovered in crdestlon and that fnere are no roodwoys, utilily Iine~ er ofher visible eaSemems on s<3id properly excepf os indicated hereon. Date 03 I~. /. BUTTON Registered £and Sut~,eyor 519 W. £ighth Ave. Anchoraget Alos~a 99501 Prepared by: (9o7) ~9-ezoo DATE: 5-15-02 TO: FILE FROM: Jeff Poet MUNICIPALITY OF ANCHORAGE Building Safety Division MEMORANDUM SUBJ: WR85-053 to Rockhill Subdivision Block 4 Lot 4 The existing waiver is amended to the following: 1. The well on Lot 4, Block 4, Rockhill S/D to the septic tank on Lot 3, Block 4, Rockhill S/D: 83 feet 2. The well on Lot 4, Block 4, Rockhill S/D to the drainfield on Lot 3, Block 4, Rockhill S/D: 85 feet 3. The well on Lot 4, Block 4, Rockhill S/D to the septic tank on Lot 4, Block 4, Rockhill S/D : 98 feet 4. Absorption field on Lot 4, Block 4, Rockhill to the lot line on Lot 4, Block 4, Rockhill S/D: 6 feet See Alaska Water & Wastewater Consultants letter of justification of April 18, 2002 Revised 5-14-02 chora ¢ P.O. BOX 6650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES November 27, 1985 Stanley Brust, P.E. Brust and Associates 1610 Dimond Drive Anchorage, Alaska 99507 Subject: Lot 3 Block 4 Rockhill Subdivision, WR85-053 Review of 1983 Waiver for the Separation Distance Between the Well on Lot 4 and the Septic System'on Lot 3 Dear Mr. Brust: This Department has reviewed a waiver issued June 16, 1983 using separation distance waiver guidelines established by Alaska State Department of Environmental Conservation. This evaluation indicated thatthere is little if any potential for contamination of the well on Lot 4. Please consider this letter to be an affirmation of the waiver issued by this Department in 1983. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/ljw BRUST & ASSOCIATES Engineers - Planners - Surveyors 1610 Dimond Drive Anchorage, Alaska 99507 (907) 562-7878 July 26, 1985 Anchorage Division of Environmental Health Pouch 6-650 Anchorage, AK 99502 Re: Lot 3, Block 4 Rockhill Subdivision. MUNICIPALITy OF ANCHoRAGF. DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION NOV .RECEIVED An inspection was made of the well and septic system at the referenced lot on July 24, 1985. These meet all applicable standards of the Municipality and the State within the lot lines of Lot 3. The well and septic system on Lot 3 were installed in 1981. The well on the adjacent Lot 4 was installed in 1983, 86 feet from the cleanouts of the septic tank and trench on Lot 3. A waiver was granted to Lot 4 by the Department of Health & Environmental Protection in 1983. Since the well on Lot 3 is not affected by this situation a waiver for Lot 3 is not requested. Sincerely, ~E D,', .: RECEIVED INspEcTION APPOINTMENTS TIME ~ TIME TIME INSPECTOR I N S P ECT/~,R ~ } I NSPECTOP~, MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE EPT. OF HF:ALI'H &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~vj ONMENTA[ 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION JUL 3 J Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1, PROPERTY OWNER PHONE PHONE 2, BUYER ~AILINO ADDRESS 3. LE~DI~I~STITUTIO~ I PHONE 4. REALTOR/A~ENT ~ PHONE ~AI~I NG ADD~ESS ~ 5 LEGAL~ O_~ESCRIPTION STREET EOCATION 6. TYPE OF RESIDENCE ~ SINGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY NUMBER OF BEDROOMS [] One [] Four [] Other~ [] Two [] Five ,J~ Three [] Six * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled 'prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [~ INDIVIDUAL/0N-SITE** //¢~'~ / YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-01 0"~ev. 6/79) ' THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE". NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAIVII LY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVI DUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic -r_an.k 9~ © Holding Tank Size: /~'~J If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL T,/~.~_~' 4, DISTANCES Septic/Holding Tank Absorption Area ISewer L~neINearest Lot Line I WELL TC': Absorption Area to nearest Lot Line 5, COMMENTS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED