HomeMy WebLinkAboutKASILOF HILLS BLK 3 LT 3AOnsite File
Kasilof Hills
Block 3
Lot 3A
#015-161-94
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP221171 PID Number: 015-161-94
Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade
Name
HELENE &BARNA MIKES
ABSORPTION FIELD - EXISTING
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
10021 COBRA ST, ANCHORAGE, AK
El Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
4
GPD/SFJ
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Fill added above original grade
Ft.
Gravel length
Ft.
KASILOF HILLS 3 3A
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Fe
Ft.
Well
100'+
--
25'+
TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER
Capacity
1250 Gal.
Surface Water
100'+
--
Material
HDPE
Number of compartments
2
Lot Line
51+
--
NA
Foundation
rl'+
__
LIFT STATION
Manufacturer
Capacity
Gal.
Remarks VERIFIED 5'+ TO FIELD & 100' TO TANK.
Alarm location
Electrical installed by
PIPE MATERIAL House to tank 3034 Tank to 3034
Installer DENALI EX
drainfield
- -- — - _ -
- - Drainfield _ - CO/MT 3034
Inspector FWCS
BENCH MARK (Assumed elevation) inn ft
Inspection1516/28/22 „d 6/30/22
dates:2
Location and description
3b 4t'
BOTTOM OF SIDING
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Conditional Approval: Date
Q'�`.'• '
*: 49 7H ....�:*
' . "" """'; "
• Curtis Huffman
/
Septic System
Approved -
+� Date ^ z� ,2CE
�'•,
��c�X AMW
l
. 7/8/228991• ���
l�iFDpROFESSIONP�.r
Note: v
e approval does not Include well permit requirements.
(Rev Ub/U2/18)
PID: 015-161-94
PERMIT: OSP221171
a
d-
CO0
MT
4%
z
°4
M
FCO
A
EXISTING FIELD
C
F DCO
DCO CO MH
STAKED 100'
WELL RADIUS
DECOMMISSIONED
PRIOR TO CONST.
STAKED 100'
EXISTING S.T. &
WELL RADII /
INSTALLED NEW
1250 -GAL
VERIFIED
HDPE TANK
PRIOR TO CONST.
WITH DCO.
APPROX.
FCO DCO H
00
DCO
A—C=33,4'
B—C=37,8'
9&95
�FINAL GRADE
A—D=37,3'
92.95
B—D=40,5'
A—E=41.2
92.37 1,250 -GALLON
HDPE TANK
2.20
EXISTING REM
B—E=44,2'
A—F=41.9'
B—F=42.8'
SEPTIC SECTION
KASILOF HILLS 133, DA
PREPARED FOR:
HELENE AND BARNA MIKES
10021 COBRA STREET
ANCHORAGE, AK 99507
FIRST WATER CONSULTING
13030 SUES WAY
ANCHORAGE, AK 99516
907-350-9566 firstwaterAK@gmoil.com
JurrUK IsJtKVIGtJ:
�.�'• OF..AL4.
�C AlnH
VA
DATE: 7/8/22 s Huffman.• �SURVEY: KGLCE 128991.
DRAWN: FWCS Ns 7/8/22 . •'�v
SCALE: 1" = 20' %MSS104�
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MUNICI PAUTY OF AN C H ORAG E
4n -Sita Ylfater & Wasfawater Progrm
PO Bux 19665a 4700 Elmore Rmd
Andharage, A asks 990164655 Phan% (50T) 343-7904 Fax! (9W) 343.7 97
ratp. hwLm.rnuai.nrglom!Aa
On- I-te Wastewater Disposal System Permit
Fermlt Number. O P221171 Ef olive Date:
Work Type; SepftTank Upgrade ExpiratJon bale:
Tax l±odo Number; 61516194040
Site Leel Address: ICASILOF H I LLS $LIC 3 LT 3A G_2641
Site Mailing Address: 10021 00VFA ST, Andhoraga
Owner: MIKES BARNA E $ HELE NE J Lot Size in S q Ft:
Des iga Englnner` F I RST VVATER 0ONSULTING Total Dedroorrl5;
Th I& parmit is for the conalruciion of:
618f2029
6812023
49066
❑ DisposaJ Fldd 0 Septic Tank D HaldIng Tank ❑ Privy ❑ Pnivato well U Water Storage
All construcGon shaII be in accordance with:
1_ The attadhod approved design.
2_ All requirements speclWd In Anichprsge Municipal code Chapters 1:5,$6 jand 16,65 and the State of Alaska
Wastewater Disposal RegMations (18AAC72) and Drlrikirrg VY;6ter Regulations (1BAAC80)
3. Thn wa�#+awa1*-r oMe requires inspections durlrrg tftiiii mstalration The angfneer oholt rrtrtlty the Dcw1opmani
Servloe5 Cepartment per PINK 15,65_ PrOvIde Yrelification by calling X7) 3-7904 (2417),
4, Farr October 15 to April 15, iR &vbsurface soil absorption syslern Under ooristruction during freezing weather
shalt tte either,.
a. Openod and Closed on the sarne day, or
b. Covered, sealed, and heated to proverrt fang
Recaivii!d y,
1$sued By.Ptt*Z'0i'
6/8122
calf.:
oiate:
4
MUNICIPALITY OF
rl`t'
Development Services Department
On -Site Water & Wastewater Section
Parcel I.D. 015-161-94
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Property owner(s) HELENE & BARNA MIKES Day phone
Mailing address 10021 COBRA STREET, ANCHORAGE, AK 99507
Site address 10021 COBRA STREET, ANCHORAGE, AK 99507
Legal description (Sub'd., Block & Lot) KASILOF HILLS B3, DA
Legal description (Township, Range & Section)
Lot Size 49,066 Sq. Ft. Number of Bedrooms 4
Phone: 907-343-7904
Fax: 907-343-7997
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF)
0
(w/wo AD U)
Septic Tank
El
Upgrade Q
Duplex (D)
El
Holding Tank
ElRenewal
❑
Multiple Dwellings
❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
Ignature of property owner or autnorizea agent)
Permit/Rush Fees:.2 2.5 Waiver Fees:
Date of Payment: %/ 1 / '� Date of Payment:
Receipt Number: q D 10- , Receipt Number:
Permit No. 0 S r 2.2- I I-7 I Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / firstwaterAK@gmail.com
June 1, 2022
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: KASILOF HILLS B3, L3A
The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic
tank on the above referenced lot. We propose to install a 1250-gallon HDPE tank per the
attached design to serve the existing 4-bedroom residence. The lot and area are served by private
wells. The design will not impact any of the neighboring properties. Please contact us if you
have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221171, Rebecca Carroll, 06/08/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221171, Rebecca Carroll, 06/08/22
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
MAILING ADDRESS
LEGAL DESCRIPTION
-~ L~ DISTANCE TO.. J I~-~ t pJo ] area~_ I Dwelling
~1- I,- . ~ w~anufacturer v "1~¢~-- ~- -"¢' (,.~'~ /~ I ~%~ Mated
~ I LIq' C' IF HOMEMADE: Inside lengt~h _~idth- --
DISTANCE TO: Well Dwelling
Manufacturer
DISTANCE TO: Well ~'~) ~ , Foundation "~',.~O Nearest lot lin~
Length of eac ~ ~ lU~e~-.~ Trench
~.~ ~ Total length of ~ --
inches
Material beneath tile
finish
Length Width
Type of crib 'Crib diameter
Well
DISTANCE TO:
DISTANCE TO:
Depth
Building foundation
Depth
Crib depth
Sewer Pine
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
72-01'3 [IR nv":R/~/R)
iNC. OF BEDROOMS.~
] RM'TN05
Liquid depth
PERMIT NO,
capacit-~~-y~Ons ? ;
Liquid
PE.M,T NO¥
Distance
~ef fective a~rea
PERMIT NO.
Nearest lot line ~~ ' ---
Distancetololl~nb_t PERMIT~_ ~ ~ __
Septic tank~,~ t Absorption area(s.) O ~ ,
DATE LEGAL
t=t[:'I:::'L I CI::INT PFd..IL. LOOM I S 1.2~:,4.~!~ NORENE
'l"[.-II'i!: L. [EI'm,tG'I:'H 1)I I'"IEN'.i~; ! ON I ::5 THE: LE:N(3TH ,:: I I'.,1 FE:ET ::, OF: 'l'I..llE 'F!:~:I:ZNCH O[R [)i:;i:i::111.,~1:1:' ]: fEI.C,.
"FHEJ [:,[EI:::'TH CIF FI 'T[~!ENCH OF:: F']:l" ]::~i; THE I:) I '=]; T FI [.,I C: [ii: E',ETH[:Z[i]'.4 T'HE ':51. Jl;i:F'FICE: OF: -f'l. ql~:
G[~'. O L.I[.,IE:, FIN[)
'['IqEI:~:E:.' ]:~i; NO !i;ET
THE Gl:~:l::l',,,'[ii:L. I:,['Z[::'TH I S THE M I I'.,I I I¥1LtM I:)EI:::'TH O1= C~I~i:I:::I',,,'[!~L.. E',ETklEE:N THE OUTI:::FIL.I... I::' ]: F:'E
FIN[::, THE P, OT'i"OM OF THE [i]:.::CFIVFFf't
[::'E!I;[:MIT F:FF:'F'L. ICI::FI'.,IT I"lFl!; THE F?E':;F'r'i'.,I'.~:JiEIL. IT'T'
I I'.,I~;'T'I:;:IL.[~.I:::rT I O[.,1 I N~i;F:'ECT I [)N'.E;
NI..IME:IEF?. C F' I:,?.E:5 1 C,E[.,!C:ES TI..IFIT TH[i: I.,.IEL. L. I.,.I I L.L !~;EF,~'.',,,'E.
I','11 I'.,I t MUM [:, I :STI:;'INC:E E:ETt.dt:ii:EN Fl klEl_l.. I::IN[:, FIN'.? O1'.,1-.'.!~ I TE S[EI.,.II::I(3[i: 13 1 ::SF:'O:E;I:;:II_ '.!:~;"r':i!;"l"[!!:l'"l I S
l.(!!lO I:::I:E['ZT r::'oP. F:l F:'F.:I',,,'F:iTE[ t.,.Ili::LL.~
::L'.50 'I'Ci 2El[i) F'EEFF FR:OM i::1 [:'I.J[]:I~. ]: E: I.,.tEL. L C, EF'EI",I[::,ING UI:::'OF,I THE: T"r'[::'E O1:::' I:::'UI:!i',L. IC: !.,.1[!!:!..I ....
I.,.IEI_L LO(3:!5 FII~tE [?.['~]~:!I..IZ[;i:[~]]) laN[) ML.I~;T E:E: t:'~ETIjI:~:NEI)TO ]'HE: [:,EPI::IIq:THENT HI'I:'HIN :ii:E!]
O1:':' THE I,.I[:::L.L. E:OMF'L. IETION.
O]'k'lli[F: I:;i:EC.:!U :[ IE:EM[i]",Ff'~'~; ['IFI'T' F:ll::'l:"'L'r'. :151:::'[:.:(::: I f:' I C:I::IT I t]11'.,1:!): F:ll",l[) I]:OI",I~.~;TI:~:I.Jl]:T ICI[',! [):[ I::IC:iI:;N:::IM:i5
I:::t",,'F:IIL. I::t[i:LE: "['O ]:[',I:!';I.JF,~:E [:'F;?.OF'EF~:
I CEI:~'.T I F:"T'
:1.: I I:::1["1 [:'f:lMIl..IFff~: I.,!I-I"lq THE
I:::'OI;..'TH E:"r' THE MUNIC:IPI::il...!T'T' OF'
2: ~ I.,.t ILL I NSTFII..I_ ~1"1"11~: iiS'T'!~;TE:M
:~:: I LIN[:'E:[~:STF:IN[) TH[aT THE ON-'::5]:TE
I:;~:ES l I:::,[EI'.,ICE I :~; [;~[~IO[::,EI...IEI:) ~1'O
,,;/'/I//
........... z~'l,~~ '
. . c,
(90Z) 278 1551
March 15, 1979
W.O.# A18796
GridS: 2641
Mr. Paul Loomis
1340 Norene Street
Anchorage, AK 99504
Subject:
Subsurface Investigation for Suitability of
On-Site Sewer, Lot 3A, Block 3, Kasilof Hills
Subdivision
Dear Mr. Loomis:
Transmitted herein in accordance with our agreement are the
results of the above referenced investigation as performed
by us on March 13, 1979. The scope of this project is the
investigation for suitability of an on-site sewerage system.
Included in this transmittal are:
Test Hole Location Sketch
Test Hole Log
Explanatory Information
Figure 1
Table A
Sheets 1-3
The exploration was conducted using a continuous flight
solid stem aguer. The rig is owned and operated by Denali
Drilling, Inc. Drilling was supervised, the test hole
logged and percolation test performed by ~r. Larry Scbmidt,
technician for Alaska Testlab.
The log of the test hole is included as Table A of this
report. In interpreting the log, it would be helpful to
utilize the explanatory information contained Jn Sheets 1-3
of the report.
When drilling was completed a 3/4" slotted PVC pipe was
inserted in the hole to aid in determining the free water
level. For the percolation test, -the test hole was filled
with water and left overnight to saturate. On returning the
next day, the hole was refilled with water and the drop in the
water level carefully monitored over the next 60 minutes.
Mr. Paul Loomis
March 15, 19'79
Page 2
This procedure is not a standardized percolation test,
however, we understand that the Municipality of Anchorage,
Department of Public Health and Environmental Protection
prefers tests performed in this manner to evaluate a site
for a proposed on-site sewerage system.
Using the above test, the observed minimum percolation rate
was 20.0 minutes/inch.
No water table was observed during drilling. It should be
noted though, that the free water level normally fluctuates
seasonally and with precipitation.
We hope this report meets your present needs. If we can be of
further service, p].ease feel free 'to contact us.
Very sincerely,
A LA S KA T E S T LAB
Melvin R. Nichols, PE
Laboratory Manager
Enclosures
Test Hole #1
TABLE A
WO IIA18796
Date: 3/13/79
Logged by: LJSchmidt
Depth in Feet
From To
0.0 2.5
2.5 9.0
9.0 17.0
Soil Description
Organic overburden.
F-3, brown Sandy Gravelly Silt, ML, dry to
damp, particles to 1", estimated silt content
30% to 40%.
F-2/F-3, brown Silty Gravelly Sand, SM, dry
to damp, particles to 1-1/2", estimated sand
content 40%, Silt content 25% to 35%.
Bottom of Test Hole:
Frost Line:
Free Water Level:
17.0 ft.
1.0 ft.
None observed
Sample Depth
NO SAMPLES TAKEN.
Type of Dry
Sample Strength Group Unified
PERCOLATION RATE was 20.0 minutes/inch
Remarks: 1.
3.
5.
6.
Type of Sample, G=Grab, SP = Standard Penetration,
U = Undisturbed.
Dry Strength, N=None, L=Low, M=Medium, H=High.
Group refers to similar material, this study only.
General Information, see Sheet 1.
Frost and Textural Classification, see Sheet 2.
Unified Classification, see Sheet 3.
WATE~ WELL LOC-
FOSS DRILLING ASSOCIATED
909 CHUGACH DR. #37
ANCHORAGE, ALASKA 99503
WELL OWNER Paul H, Loomi5
WELL LOCATION Lot 5A Block 5 Kasilof }{ills
MUNICIPALITY O,':- ANCHORAGE
DEPT. C, 8:
i iVI,RON ;Nl/:t. CTION
USE OF WE.L.L._Domestie
SIZE OF CASING 61'
STATIC WATER LEVEL
REMARKS
DEPTH OF HOLE 6.__~FT. CASED TO
27 FT. G. P.M. 8 WITH__~
.. ~ ~ FT.
FTo OF DRAWDOWNo
DATE COMPLETED 5/4/79
PUMP TO BE SET AT__ 75'
0 to 10 Alluvium; brown color of medium hardness
10 to 30 Alluvium; grey color of medium hardness
30 to 35
3_~__to 45
45 to 55
5~ to 6..9
~_to ?o
'Lo to 7!
71 to 75
75___to 76
to
to
to
to
to
Alluvium; light brown color of medium hardness
Till~ ~rey color and hard
Bedrock~ blue-~rey color and soft
Bedrock~ ~rey color and medium hero. ess
Bedrock~ brown color and hard
Bedrock~ g~ey color~ hard~ with water~ 2 G.P.M.
Bedrock~ light ~reen color and very hard
Bedrock; light green color~ hard~ with water~ 6 G.P.M.
~to~
~to
to
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I. D. 015-161-94
1. GENERAL INFORMATION
Complete legal description KASILOF HILLS BLK 3 LT 3A
ExpirationDate:
Location (site address) 10021 COBRA ST, ANCHORAGE, AK, 99507
Current property owner(s) BARNA & HELENE MIKES Day phone
Mailing address 10021 COBRA ST, ANCHORAGE, AK, 99507
Real estate agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Private Well - - - --
- Z
Water Storage
❑
Community Well
❑
Public Water System
❑
Waiver request for:
Received by:
4
TYPE OF WASTEWATER DISPOSAL:
—Private Septic-
Z
Holding Tank
❑
Community
❑
Public Sewer
❑
Distance:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date:
COSA Fee $ 5,50 Waiver Fee $
Date of Payment 3(,WDate of Payment
Receipt Number 0) 6 3 3' 1 Receipt Number
COSA # 0 5 C-2 2 13 a2 Waiver #
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, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 6/28/22
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the i
system and maintenance. The operational life of all well and septic systems are subject to �/ �
-�1�
these various and dynamic characteristics and are outside the control of the evaluator of the ��•�ii . k
well and septic system. Therefore, any estimate of how long a system will function satisfactory ��Q: • • • • :1
for current or future occupants or guarantee that no unseen encroachments, deficiencies or g•• '.9 �r
discrepancies exist can be given by First Water Consulting & FWCS9 ' 1 *• iii ••*
.. .......
6. DSD SIGNATURE Ir •' • •' •' • •''- /
• • Curtis Huffman
�J
�
System #1 Approved for bedrooms �+��F��s•, CE 128991 .,��.�
eF * - .@/28/2.1 R
System #2 Approved for bedrooms t1,F�PROFESSffi"
Disapproved
Conditional approval for bedrooms, with the following stipulations:
-PGSWei ^� �� c -
^i° ► S (i V v vev
VY OFr(���i�
�J O,
WATER A ND
ST_- WATER
2.;
J`O AM
J .O X95
B kA Original)b��i�
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory Y,
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
Legal Description: KASILOF HILLS BLOCK 3, LOT 3A Parcel ID: 015-161-94
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled 5/4/1979
Total depth 76 ft
Cased to 45 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 5/26/2022
Static water level at beginning of test 25 ft.
Comments
B. TANK DATA
Age of tank(s) NA — NEW TANK years
Tank type/material SEPTIC / HDPE
Measured operating fluid level in septic tank NA
® Standpipes/foundation cleanout per record drawing
Date of pumping NA
D.- ABSORPTION FIELD DATA
Which system tested (date installed) 7/2/1979
® ALL standpipes present per record drawing
Total measured depth from grade 7_5 ft (max)
Structure served by this system
Well production at time of test 4+ gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® No
® Coliform bacteria is Negative
Nitrate 6.61 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
FW�S
Collected by .
Date of Sample 6/8/2022
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _ years
Lift station material
Comments:
Adequacy test date 5/26/2022
Results JK Pass For 4 bedrooms
Fluid depth prior to test 4 in
Measured depth to pipe invert from grade 3 ft (min)
Water added 600 gal
❑ NIA — pressurized field
New depth 16 in
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective 4.5'ED MISSING 4.5'ED
Elapsed time 1440 min
® Code -required soil cover over field
Final fluid depth 1. in
❑ System presoaked
Absorption rate 600 gpd
(Required if vacant for greater than 30 days prior to
Any rejuvenation treatment (past 12 months) N
date of test)
Gallons introduced gallons
If yes, enter date
Comments/Deficiencies: MT/CO AT GRADE — APPORX 4.5'ED OF THE MOA IR 91ED MEASURED NO KNOWN
FROST ISSUES PER OWNER — FIELD MAINLY UNDER DRIVE.
NES
ter.
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
® Yes if No ft
Wells on Adjacent Lots:
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No ft
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No ft
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No ft
Neighboring Absorption Fields > 100'
Animal Containment > 50' ® Yes
if No ft
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No
ft
® Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No ft
Property Line > 5'
® Yes if No ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes if No ft
Private Wells > 100' ® Yes if No.
Water Main > 10'
® Yes if No ft
Community Wells > 200' ® Yes if No.
Water Service Line > 10'
® Yes if No ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below
Property Line > 10' ® Yes if No _ ft Wells on Adjacent Lots:
Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No —ft
Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No
Surface Water > 100' ® Yes if No ft
F. ENGINEER'S COMMENTS
NO KNOWN FROST ISSUES PER OWNER WITH FIELD MAINLY UNDER DRIVE
G. ENGINEER'S CERTIFICATION
�
.. •••• 41�t
I certify that l have determined through field inspections and review ,ANW,�Q�. •' • •!3ii�-- ��
of Municipal records that the above systems are in conformance �°'Qj •;�'
with MOA COSA guidelines in effect on this date. : • . • • ••:�k�
..• .............:.
�.• Curtis Huffman : 4
FO CE 128991
7/8/22..�pA w
OFESStO�A
ft
ft
DEVELOPMENT SERVICES DEPARTMENT
On -Site Water and Wastewater Section
www.muni.org/onsite
V 907-343-7904
Fax: 343-7997
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC 221322
Subdivision: Kasilof Hills Block 3 Lot 3A
A water sample revealed a nitrate concentration of 6.61 milligrams per liter (mg/Q.
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.
Mailing Address P°O 136x'196650*Anchorage, Alaska 99519 6650 *www mum org <;
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening, or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation' distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical' methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
Mailing Address P:O Box 196650* Anchorage, Alaska 99519 6650 *www muni.org
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) IOG~.r
Property owner
Mailing address
Lending agency
Mailing address
Agent ~J'-~ e
Day phone c~ ,~5'?-o/o ~
p ,,,~ ?
Day phone
Day phone
Address '8~OO E~r~,,/~ £¢;~ ~,~c/~0~'~,.~ /}~: 905'o3
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
'~ .C "7
TYPE OF WATER SUPPLY:
Individual well
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.
72-025 (Rev. 1/9t) Front MOA~21
5, STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and typeofstructureindicated herein, lfurtherverifythatbasedontheinformationobtainedfrom
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 ~ J~t~r.,? 7-ecl'~io'~¢~f
Address 1"15 ,.~ 0
Engineer's signature
6. DHHS SIGNATURE
×x
Phone
A-I,~
Date H~.~ 19,. iq,oX
Approved for _Pour (_4_) bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Corrl, n::~b~ _The well ~=n'¢ this prnporty maet~ ow4 ~tJng
State and Municipal Codes. There are nitrates present. It is
suggested ~- ~ '
..... a p~-i~ testing ~ perf~ to ~nsuro t-he ~l-ls
continued suitability. Nitrate concentration is 5.93 mg/1. EPA
By: ~~~~% ~~- Dato 2/22/93
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/gl) 8ack MOA ff21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LO k ~/¢/ ~ I I~'~/ ('(¢4',/¢'~' (~,t(./ Parcel I.D.
A. WELL DATA
Well type /~
IfA, B, orC, attach ADEC letter. ADEC water system number
Log present (Y/N) ~' Date completed_5/ ¥/ 7 ¢ Driller
Total depth `7¢' ' Cased to ~Yb-' Casing height
Sanitary seal (Y/N)
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
Date of test b--I 't / 77 '8. / ¢ I ¢/ -~
Static water level '8 7 ' ~ '
Well flow ~ g.p.m. 7. ~
Pump level ~ -76-' ~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~ ¢ ~'' ; On adjacent lots
Absorption field on lot lob-' ; On adjacent lots -~
Public sewer main iq, AL·
Public sewer manhole/cleanout /~ ' '¢.
Sewer service line "~
WATER SAMPLE RESULTS:
Petroleum tank /\l o,~ ~_
Coliform 0 cc,( I/¢o0~ I-
Date of sample: '~/~) /2 7
Nitrate ~.9~ ~'~.j¢'/"~ Other bacteria O ¢o(/toc*~.E
Collected by: I~I-1~/¢ ~'~c4 ~
B. SFPTIC/HOLDING TANK DATA
Date installed '7 / ?-/??
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size I ~-0 ~/9,¢4/ Compartments
Foundation cleanout (Y/N) T' Depression (Y/N)
N. ,4-. _ Alarm tested (Y/N) hr, //-.
~. / ¢?/~'_~ Pumper ,4 '~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot %
To property line ~ lo ' Absorption field ~ '
Surface water/drainage _
Foundation
Water main/service line
72-026 (Rev. 7/91) Front
CONTINUED ON BACK PAGE
C. LIFT STATION N, ~,
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Date installed '7 / ~- / 77
Length 5-I~ Width
On adjacent lots
Total absorption area ,2/
Depression over field (Y/N) N
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot I O¢'~
To building foundation
On adjacent lots
Surface water _ -~ f
Curtain drain No,~ ~_
E. ENGINEER'S CERTIFICATION
Surface water
Soil rating -2_.z.¢ ~'/~'~-,~ System type
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
for
I~noc¢,,,~ ¢,f If yes, give date
On adjacent lots >, to, o' Property line
To existing or abandoned system on lot
Cutbank '2. / ' Water main/service line
Driveway, parking/vehicle storage area
'7-r
Total depth
Z(9 - 'L//¢/2 3'
bedrooms
72-026 fRev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
Date of Payment
Receipt Number
HAAFee$ /70 ' ~
Engineer's Name 7"}'1~:oc~or'~ F:. Moore__
Date r~c_b 19., /9 ~
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
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
GENERAl. INFORMATION
(a)
(b)
(c)
Application Dare--dc Ic~/ IIYGd
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name ¢~( ~oo~4' Telephone: Home ~ ~/~ .-8Y2 ~ Business
Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other [~ (explain);
(d) Lending Institution
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [] Multi-Family []
Number of Bedrooms /¢
Other
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,
SEWAGE DISPOSAL
Onsite J~ 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)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the vaJidation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the 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. ~(
Address / ~.¢~ /~c~¢ ~'~
Engineer's Seal
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 o1 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 ANCltORAGE (MOA)
HEALTH AUTHORrrY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Descri~ption: h¢2 (:'
Well Classification
Well Log Present (Y/N)
Total Depth '?d
Static Water Level
If A, EL C, D.E.C. Approved (Y/N) I~t,¢i.
Date Completed ~-/e{ ( 79 Yield ~ ~f~n fee
Cased to __-_.;: q_6' '
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Welt:
Depth of Grouting
Pump Set At .r~.~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N) _
To Septic/Holding Tank on Lot '~';!/ ; On Adjoining Lots ~
To Nearest Edge of Absorption Field on Lot lo',~' ' ; On Adjoining Lots 7~ too '
To Nearest Public Sewer Line ~6 D. To Nearest Public Sewer
Cleanout/Manhole N,/~. To Nearest Sewer Service Line on Lot
Water Sample Collected by '3-¢¢.t- ; Date I '~- / t ? ¢'
I
B. SEPTIC/HOLDING TANK DATA
Date Installed '7 / '8,/ 7g
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/NJ
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line ~'
To Water Main/Service Line
Course _~' J~O'
Size iP~O'~/~/ No, of Compartments ;~.
Air-tight Caps (Y/N) '¢' Foundation Cleanout (Y/N)
Date Last Pumped
N,/,~. ; for
N,/~. Temporary Holding Tank Permit (Y/N) tL 4,
To Building Foundation ~ 7 i
To Disposal Field _'--'~' .&""~
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed "7 f g / 77
Width of Field ~,~,. ~t
Square Feet of Absorption Area ,9 ! c~
Depression over Field (Y/N) N
Results of Last Adequacy Test /~¢..-¢¢r~c(x (-e
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot H¢/~ ·
To Water Main/Service Line
¢ ~ //~ ~/"~ Type of System Design
Length of Field .,~t ~
Depth of Field t ~ ~
Gravel Bed Thickness ( 0'~¢3
Standpipes Present (Y/N)
Date of Last Adequacy Test
N,/~, To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course '~. ~o /
To Driveway, Parking Area, or Vehicle Storage Area
Comments .~.~o.~ ~'~ ~, i~ ~'~¢~'~ .~. ~"'
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots '~
D. LIFT STATION N,/4,
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 **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ¢~.~/¢,,,c ~"'~. ~ Date I~/i~ /~¢~'
Company rl~tL/'~ '~f-4 .~'vc( MOA NO. 4~ '¢"' ~'~ ~
Receipt No. /~_~/
Date of Payment
Amount: $ ..... ---/ Engineer's Seal
Page 2 of 2
72-026 (11/84)
P.O. BOX 196650
ANCFIORAGE, ALASKA 99519-6650
(907) 264-4111
TONY KNOWLES.
MAYOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
December 23, 1986
Ted Moore, P.E.
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
Subject: Lot 3A Block 3 Kasilof Hills Subdivision
Waiver Request WR86-172
Dear Mr. Moore:
Your request for a waiver of the 100 foot separation required
between the well and septic tank on the subject lot has been
granted. This distance has been waived to 92 feet. This
waiver is based on your assessment that sJ. te conditions are
such that a public health concern does not exist on the subject
lot.
This waiver is valid for the existing lout bedroom single
family dwelling only.
Sincerely,
Stephen S. Morr:is
Civil Engineer
On-site Services
FLA=TTOP TECHNICAL SERV]
=
CIVIL & ENVIRONMENTAL ENGINEERING * ENERGY CONSERVATION & ANAI,YSIS
TItEODORE F. MOORE, P.E. 14530 ECHO ST.
PH:(907) 345-1355 December 19, 1986 ANCHORAGE, ALASKA 99516
M.O.A. Dept. of Health and Human Services
P.O. Box 6-650
Anchorage, AK 99502
Attn: Steve Morris
RE: Separation Distance Waiver - L3A, B3, Kasilof Hills S/D
Dear Mr. Morris:
By means of this letter I am requesting a waiver of the
required 100 foot separation distance between the well and septic
tank down, to 92 feet on the subject lot. A site plan, adequacy
test data, and other relevant backup material are enclosed for
your review.
The well was drilled on 5/4/79, and has a total depth of 76
feet and a reported yield of 8 gpm. According to the driller's
log, there exists a stratum of hard (glacial) till between 35 and
45 feet which is underlain by bedrock. The aquifer tapped by the
well is in the bedrock between 70 and 76 feet below ground
surface. Thus it appears that the aquifer is well protected from
surface contamination.
At the start of the well yield test the static water level
was at 27 feet below the top of the casing. Steady pumping at
the maximum pump output of 6.1 gpm caused this water level to be
drawn down to 50 feet, but no further. Thus, the well yield is
more than adequate for this 4 bedroom residence. A water sample
taken on 12/17/86 showed no evidence of contamination by coliform
or other bacteria.
The wastewater disposal system was installed in July of
1979, and consists of a 1250 gallon septic tank followed by 51
feet of absorption trench extending from 3 to 12 feet below the
surface of the ground. Although the trench passes under the
p]owed driveway, it has had no problems with freezing during 7
years of operation, and I do not forsee such problems in the
future. To test the system, I introduced over 600 gallons of
water into the absorption field. This caused the fluid level in
the cleanout in the end of the trench to rise from 8.0 to 7.3
feet be]ow ground ]eve], but the fluid leve] returned to it's
original position within 10 minutes of cessation of flow. Thus,
I concluded that the system is performing adequately for 4
bedrooms.
The topography on the ]otslopes downwards at 5 - 10% from
the well towards the septic tank, meaning that in the event of
septic tank failure, effluent would flow away from the well. The
soils were rated at 225 sq. ft. per bdrm. and no water table was
encountered to 17 feet. The Municipally approved as-built
drawing gives no information on the type of couplings on the
septic tank, but the construction appears to have been good, and
the soils are not condusive to rapid percolation, particularly
towards the well. There are no other wastewater disposal system
components within 100 feet of the well.
Based on the foregoing information, it is my opinion that a
public health concern does not exist on this lot, and I recommend
that you grant the requested waiver and Health Authority
Approval. Please give me a call if you have any questions.
cc. Paul Loomis
Sincerely
Ted Moore, P.E.
F/~tt6~ Tecl~n~cal Services
145S0 Echo Street
DA'f"E R E-~CEIV ED
INSPECTI ON APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
I NSPECT~ INSPECTOR INSPECTOR
[~ ,/
b~i:/, c :
RUNIClPALITY OF ANCHORAGE
DEPARTMENT OF H~ALTH & ENVIRONMENTAL PROTECTION
82~ L [tr~t. Anchorage, Alaska 99501 I
ENVIRONMENTAL SANITATION DIVISION
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,
PHONE
~AILING
PROPERTY RESIDENT (If different from abov~ / PHONE
2, BUYER PHONE
MAILING ADDRESS
3, LENDING INSTITUTION J PHONE
MAILING ADD~ESS
4, ~EALTO~/A~ENT J PHONE
I
~AILING ADD~ES~
LEGAL DESCRIPTION
STREET LOCATION
6, TYPE OF RESIDENCE NUMBER OF,,BEDROOMS
[] One I~]' Four
[~ SINGLE FAMILY [] Two F-] Five
[] MULTIPLE FAMILY [] Three I-] Six
E~ Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
ATTACH WELL LOG. A well )DC is required for all wells drilled
since June 1975, For wells drilled prior to that aate, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
I]~ INDIVIDUAL/ON-SITE** Iq~Cl YEAR ON-SITE SYSTEM WAS INSTALLED.
~ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6179)
THIS SIDE FOR OFFICIAL USE ONLY ' '
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY --~C~
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
' 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[] PUBLIC UTI LITY '~ c~ (_~L~
Connection Verified. INSTALLER
[]Septic Tank or []Holding Tank
Size: I,~.~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF 'YANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line
I
I
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL {letter must accompany certificate)
[] DISAPPROVED
DATE BY