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Home My WebLink AboutKASILOF HILLS BLK 6 LT 1KasI*Iof H1*11s Block 6 Lot 1 #015-132-36 M&A-" 5/-T//y Development Servi-ces Deportment �-� 3uildirc, Safety Division On-5Ite wcter WcSi'e-water proor GTri 4100 Bragcw Street F.O. Box 195650 Mark Begich Anchorage, .A 99519-5650 Mayor nnv!•r.inuninr�; onsite (907; 343 ?404 Pump Installation Log Well Drilling Permit Number: SW Date of Issue: Parcel Identification Number: Legal Description Prope Owner Name &Address: \Jason wooq ., /0(000 Siclora)p La4q tZ.. Pump Installation Date: !f ^ I Pump Intake Depth Below Top of Well Casing: 560 feet Pump Manufacturer's Name: Pump Model: �''tjfQfi�SaJ Pump Size hp Pitless Adapter Burial Depth: 10 feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Completion.^ Yes ❑ No Method of Disinfection: r/� Comments: Sats 0jq' wo o4er Anchorage Pump & Well Service Pump Installer Name: 330 East 76th Avenue Anchorage, Alaska 99516 Phone: 907-243-0740 Fax: 907-243-0742 Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. �— 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 VVNLL INSPECTION REPORT NAME IC I NEW ❑UPGRADE MAI LING ADDR ESS LEGAL DESCRIPTION Lo i _RLam"X l2 V, -A 11-0 F 1411,0z LOCATIONNO. 1 144.,zL , Sra/0V-® OF BED OOMS e y DISTANCE TO: Well Absorption area Dwelling P—o PERMIT NO. a 1 O 6 S9U a Z w I—a Manufacturer A C a (' E YA NA Material Yt� ld i,_ No_ of compartments VJ Lin. rapacity in gallons F HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. = Z Manufacturer Material Liquid capacity in gallons O w 2 DISTANCE TO: Well Foundation Nearest lot,1ine p PERMI N e J LL z No. of lines Length of each jne Total length Os Trench width Distance between lines F z W 1 (��L, � ,fZ inches ¢ Fes- Top of tile to finish grade �, Material beneath tile Total effective absorption area 4IR6) cc inches Length Width Depth e PERMIT NO. Lu Q F w� Type of crib Crib diameter Crib depth Total effective absorption area LU DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot Ij;1c PERMIT NO. w-- DISTANCE TO: Building foundation Sewer line — - Septic tank — — Absorption area(s) OTHER PIPE MATERIALS — — CAST WWN I, PVA SOIL TEST RATING i INSTALLER REMARKS IN I /Lem C, /;v r � WE'LL, 6 o o aura — — C )�*:.49T_q LEGAL I {;. •oo••s•oso•o••�.o•ooi•� • o. 2225_E 1`1UNES ; APPROVED DATE ee •J3871 `q , �,y o ' •FSG ��/% � �- �-� l , �3 t� � ,� I�� t l�; !ls THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS: KA BE: 40`1- 1-1 n a 1-4 ci _T_ H_ sm Q ��M MU, u___ A_ THE LENGTH DIMENSION IS THE LENGTH (IN FEE OR DRHINFIELD THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE GROUND AND THE BOTTOM OF 1-1-111-- 1" 9 A HE��A po.":.. -B " IFT: 1117 N Q H_.B BL'.'N 92.�H F" E".��-U THE GRAVEL. DEPTH IS THE MINIMUM DEPTH OF GR TF .IE UU[�HLL -`E HND THE 8OTT0M OF THE T! ON (IN FEET) -~`--- �EGAU I F'.i"E-_'M�,��'�C 7. -y"101 N P, 1 A too M 120 RA rot A_U W P4� PERMIT 8PPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE INSTAL. LHTION OF HNY WELLS HDJHCENT TO THIS PROPERTY HND THE NUMBER OF FRESIDENCE5 THAT THE WELL WILL SERVE. �� ~�_ BHCKFILLING OF HNY SYSTEM WITHOUT FINAL. INSPECTIONION HND HPPROVHL BY THIS DEPHRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTHNCE BETWEEN H WELL HND HNY ON-SITE SEWHGE DISPOSHL ';'T'!-- IS 100 FEET FOR H PRIYHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTHNCE FROM H PRIVHTE WELL TO H PRIVHTE SEWER LINE IS 25 FEET HND TO H CCAMMUNITY LINE IS 75 FEET. OTHER R�QUI�EMENTS MHY CCNSTRUCTION DIHGRHMS HRE HVHILHBLE TO INSURE PROPER INSTHLLHTION Flo i:=": F; v in i v x ��Q Q M 0 EE.: F.��"_" _1_., Q A. I CERTIFY THHT 1: I HM FHMILIHR WITH THE REQUIIREMENTS FOR ON�SITE SE�ERS HND WELLS RS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE 2� I WILL INSTHLL THE '_::;YSTEM IN HCCORDHNC� WITH THE CODES. ]� I UNDERST�N � I E S�WER SYSTEM MHY REQUIRE ENLRRGEMENT IF THE �]\ L^ y4ljHy/uVx o/�o4 �m .v`�............ �., 0 `' ��-�u `�� ' o//l.ty»L' ~ ~ ^' ] �� 4' '� - ' - '� K_p41�� F� � ��^�� »��~ ~ u��. �^ ��^��w��F� ,�� ucf�� _�� 7-��" � «~ DEPHRTMENT OFHEHLTH HND PROTEC 825 'L' STREET, HNCIC, Fe. HGE, HK. 264-4720^� �^��wu�»��v6 o��oU....�U_.-��Ex��-T�� U��:D,�U��Fi�� 8�n�.��i��:yv�V'�-�z' HPPLICHNT G. CHRLSON 82] WEST5] HVENUE 278'.�] UNFIT IOh! / LEGHL L 1 B 6 KHSILOF HILLS S/D LOT SIZE ]8000 SQUHRE FEET TYPE OF SOIL HBSORPTION SYSTEM IS: DRHINFIELD y ` MAXIMUM SOTL RATING (SQ 1:5/1130— 125 \v THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS: KA BE: 40`1- 1-1 n a 1-4 ci _T_ H_ sm Q ��M MU, u___ A_ THE LENGTH DIMENSION IS THE LENGTH (IN FEE OR DRHINFIELD THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE GROUND AND THE BOTTOM OF 1-1-111-- 1" 9 A HE��A po.":.. -B " IFT: 1117 N Q H_.B BL'.'N 92.�H F" E".��-U THE GRAVEL. DEPTH IS THE MINIMUM DEPTH OF GR TF .IE UU[�HLL -`E HND THE 8OTT0M OF THE T! ON (IN FEET) -~`--- �EGAU I F'.i"E-_'M�,��'�C 7. -y"101 N P, 1 A too M 120 RA rot A_U W P4� PERMIT 8PPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE INSTAL. LHTION OF HNY WELLS HDJHCENT TO THIS PROPERTY HND THE NUMBER OF FRESIDENCE5 THAT THE WELL WILL SERVE. �� ~�_ BHCKFILLING OF HNY SYSTEM WITHOUT FINAL. INSPECTIONION HND HPPROVHL BY THIS DEPHRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTHNCE BETWEEN H WELL HND HNY ON-SITE SEWHGE DISPOSHL ';'T'!-- IS 100 FEET FOR H PRIYHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTHNCE FROM H PRIVHTE WELL TO H PRIVHTE SEWER LINE IS 25 FEET HND TO H CCAMMUNITY LINE IS 75 FEET. OTHER R�QUI�EMENTS MHY CCNSTRUCTION DIHGRHMS HRE HVHILHBLE TO INSURE PROPER INSTHLLHTION Flo i:=": F; v in i v x ��Q Q M 0 EE.: F.��"_" _1_., Q A. I CERTIFY THHT 1: I HM FHMILIHR WITH THE REQUIIREMENTS FOR ON�SITE SE�ERS HND WELLS RS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE 2� I WILL INSTHLL THE '_::;YSTEM IN HCCORDHNC� WITH THE CODES. ]� I UNDERST�N � I E S�WER SYSTEM MHY REQUIRE ENLRRGEMENT IF THE �]\ L^ y4ljHy/uVx o/�o4 �m .v`�............ �., 0 `' ��-�u `�� ' o//l.ty»L' ~ ~ ^' iICIPALITY OF ANCHORAGE Department of Health and Environmental r_otection 825 L Street, Anchorage, AN. 99501 264-4720 # HANDWRITTEN PERMIT aE -Ret/OR ON-SITE SEWER PERMIT Applicant: co✓>_-C-Mailing Address: Location: Phone Number: %Y Y3 O 2 LegalDescription: �/ �:7�© /�!� 5�L r�_iLot Size: J 00 U Type of Soil Absorption System Is: Trench: Drainfield: _r- _ Seepage Bed: Holding Tank: _ Maximum Number of Bedrooms: Soil Rating(sq.ft/br) Z S The Required Size of the Soil Absorption System Is: DEPTH LENGTH GRAVEL DEPTH / WIDTH _ The length dimension is 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). 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). * * REQUIRED SEPTIC(HOLDING) TANK SIZE _ �6 U GALLONS # 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. # # TWO(2) INSPECTIONS ARE REQUIRED # # # 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 is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 u 1 I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will inst 11 t system in accordance with codes. (3) I u e a the on-site sewer system may require enlargement if the r ence i remodeled to include more that Y-bedrooms. Signed: Issued by: Ap lic fit Date: SWP/024 (1/81) 6k- � �®/ (ice XSOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264.4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: 9 A aril so V) _ DATE PERFORMED: LEGAL DESCRIPTION: L0 -L I I-- S LdJir (o. 14 *Ls ( "p A 1 its SLOPE SITE PLAN -F/ ' ORGAEN� C 0 VAR BUatIMN 2 —=-3 • J • O 6 ''oto 4 - 1 5- 6 6 - rct GRti� f�1 t�1n 7 r 9 r v P to 10 - 1 P a—� 12 a 13- 14 Date � i qlxis li. Net Time Depth to Water Net Drop �) TH 49 16 17 :, o. 2225-E:.9 JUNE 25, 1971 19- PTO] r COMMENTS PERFORMED BY: 72-008 (6/79) WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? �GS L O P E Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION / ^ RATE (f��Q � (minutes/inch) tETrLl RUN BETWEEN .z"ClQ•0 AT F.Q.q. cd %e CERTIFIED BY: II DATE: -7411 _ y -g 7- pe -1 e -s 0 11C %o�Cr . � %� C� iiYj c: r' �a /,�✓ !� :F y:�resm v/ia rRoc'Af c) w rgr'e(�t 7"pr►�.. Rr iso f�1 t'A7 t _'Y, 1p ONO r 'r 0 SOILS LOG �- MUNICIPALITY OF ANCHORAGE % DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION Pouch 6860, Anchorage, Alaska 99602 276.2221 TEST SOILS LOG — PERCOLATION TEST PERFORMED FOR: DATE PERFORMED: //-8 -79 LEGAL DESCRIPTION: L.b'- -/ -'.moo DEPTH I pr�;pn1ca 6tnd Ur�nil ip 3i/fes SLOPE SITE PLAN �FE(7� 60,, 1 IT I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ��✓, ��,i*y fan:>y yrnvP/ �M) o ° ° o o �P-1-tirocun o ' ' Lain �r;s�5frire Ira ✓e/ % �6W - .SK/) Grar' �oi�ta r l >'raee 7t' /),', /ar �/Ci tri �/S _SGiir„ U` 5 O �JU ve SGT' Or7 Oi cxlfl!! 16- A 6 '�-��laR1l� OF A 4. %% Jul .QI. +�.+•+N•a•o••+• U1 AS 17 �. r ; ,, -7'/ •. �. e4 r: i . .. ' 18 e i /(,0°�° as ati°aa°a�•••••••aHYs• A �•-3,74490, a.a .•... •+.<. 19 . •�•� = Richard A. Lowman � WAS GROUND WATER S —� _ _•__ _ __ ENCOUNTERED? 1�n_ LO, P--j------I-.- __�—i_. ..._.._� _.-------- ---- --40 Ei IF YES, AT WHAT (a0 DEPTH? 1 t Reading Date Gross Time Net Time Depth to Water Not Drop I i - p --G T i i 1 i I i --�! - - A WAS GROUND WATER S —� _ _•__ _ __ ENCOUNTERED? 1�n_ LO, P--j------I-.- __�—i_. ..._.._� _.-------- ---- --40 Ei IF YES, AT WHAT (a0 DEPTH? 1 t Reading Date Gross Time Net Time Depth to Water Not Drop ••°••.<ac=+'+•Q�.�.e► PERCOLATION RATE -(minutes/inch) Aw Q'?s�4 TEST RUN BETWEEN FT AND FT COMMENTS /�f'/ar>;i.,- /�Y/ �G /2/CLQ :2Z/2 ?„/YY.', ..<jT - PERFORMED BY: CERTIFIED BY: /t//1r,v/NG - Zry AFic�R.c, DATE: //-/O - 'NICIPALITY OF ANCHORAGE Department c_ Health and Environmental _:otection 825 I, Street, Anchorage, AK. 99501 264-4720 r S # # HANDWRITTEN PERMIT # # 9 t r�(-o WELL PERMIT Applicant: % LMailing Address: Location: - _ Phone Number: J-7 o y v Legal Description: Lot Size: Type of Soil Absorption System Is: Trench: Drainfield: _ Seepage Bed: Holding Tank: Maximum Number of Bedrooms: Soil Rating(sq.ft/br) DEPTH The length dimension is 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). 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). # REQUIRED SEPTIC(HOLDING) TANK SIZE = GALLONS # # Permit applicant has the responsibility to inform this department during the in.stallation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED 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-•s.ite,.sewage disposal system is 100 feet for a private well or 150 to 200 feet f,iOm a public well depending upon the type of public well. Minimum distance f-rom:.A private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 3 1 The Required Size.offthe (,Soil Absorption System Is: J, LENGTH GRAVEL DEPTH _ WIDTH I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will in 11 the system in accordance with codes. (3) I un a t t the on-site sewer system may require enlargement if the yid e .,'/'remodeled to include more t --bedrooms. Signed: Issued by: � i --�- p , Date: SWP/024(1/81) January 4, 1982 G. Carlson 823 W. 53rd Anchorage, AK 99502 Permit ` 810605 Subject: Ll B6 Kasil.of Hill A permit issued by this department for a well and/or sewer system has expired as of December 31, 1981. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal Ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date. If an engineer inspected the installation of the on-site sewer system, please have them send us the as-bui.lts for our files. If there are any further questions, please call this office at 264-4720. Sincerely, //�� r4 6S �- -C Les N. Buchholz. Program Manager�- Sewer and Water Program Enclosure: Copy of Permit <af� 1 .bei Ks r2 c9 to a 4�y U: :L Irl r>;) ;^'•t® � rll u: � bi CU 11; c i 2 tL O ) fD fti , L va Ea LU <af� 1 .bei Ks r2 c9 to a A U: � rll u: � bi 11; c i r.: fD fti , va Ea r 4y tt); -i i•Z �-A €'-. "�+ pal ' 1-4 �Ui o: 2i Gi N d ri rA! Oi 0 : •.-1: a:! 01 co co cd: O: •I -Ai ,-1: of Od c:;: o 01 JJ F1 F� r 4A HV, (:, L4 I -i Ga A tt); 1-4 �Ui Q7 ? Q)i [� C.:� N+ E-4 Ew Ei Ew [a Ea F� E� Ei fw kl Fw Ste; Si; bre F>n Fie G�i 6:v G -a w r/ t to! 1 Q o 0 9 G1 Pi p Ci I [1 H EA C•+ E4 t< [-4 [_+ it E'+ :+ n Ed C r) i E i E^ F4 E E+ E•i Ey C h. (✓ : lam; l'+ a; �� -1 k•I N [�i ! 1 :•1 r -i b� 1••: Ci t lei 1-4 a Ii P-14 74 spa N a.: r w Fit {%4 i -t {•< FZ� F�J €'-1 {L1 r", �Z•a i9 €Z4 {'•1 0 C1 1 Ia A NHAWTH'.ORNE-ENGINE]-RING 41.0,i—ARM71C BOULEVARD NhiF,WTHORNE - ENGINEERING S uii-E-eW 5 7 01c] ANGH©RAGE- -ALAS ICA 99503 Anch., AK 99502, 344 4711 90a -77 -l -e09 sf12 7 4?4 r 0- :3 `i o �F �� v ro I C, .Y l u c e + w; v 0- A o t./ - AoV >C, . y1 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program a 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak, us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. 015-132-36 HAA#_ntA C!5a 1. GENERAL INFORMATION Expiration Date: .-2 — /- D -C Complete legal description KASILOF HILLS SUBDMSION• LOT 1 BLOCK 6 Location (site address or directions) 10600 SIDOROF LANE * ANCHORAGE. AK 99507 Current Property owner(s) JIM & ANDREA DRAM Day phone 346-2804 Mailing address P.O. BOX 112828 * ANCHORAGE AK 99511-2828 Lending agency Day phone Mailing address Real Estate Agent BONNIE MEHNER W/ PRUDENTIAL JACK WHITE Day phone 563-5500 Mailing address 3201 C STREET, SUITE 200 * ANCHORAGE, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site 0 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 Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 samples. (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 seal affixed hereto and as of the validation date shown below, 1 verify that my investigation, based on procedures outlined in the Health Authority 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. 1 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 51010 WOOS, o ,110— s, an regu a (ons m e ec a e 1me o installation - and. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name ,JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE _1Z Approved for '7L bedrooms. Disapproved. Phone 337-6179 Date 10 f Z4 o 4 Conditional approval for bedrooms, with the fllowing stipulations: Note: The well for this property meets existing State and Municipal Codes. There are nitrates be performed to insure the wells continued present. It is suggested that periodic Current nitrate concentration is 8.1 mg/L EPA maximum concentration is 10.0 mg/l. More information on nitrates is available from the On -Site Services Program, at 343-7904. Attachments: HAA Checklist Cis Manitenance Agreements Septic System Advisory Supplemental Engineer's Reort Well Flow Advisory Other By: Original Certificate Date: (Rev. 12101) �, �GT'flGl Developm 2. 9 -P.M. zrnes/100 ml. Nitrate mg /L vvai YES i'Wnn VFX"' " TU/14/Z004' 1.96 g.p.m Other bRcterta-C46 colonies/100 ml� Collected by-, GEG Ltd 4.F; Date installed 7/21/1981 MAnnniite IVlAn VFC 600+ 9.d ve date — Surface wati Wells on adj anhole%Pc High water alarm level.. at in. _Meets alarm & circuit requirements? �.'�� On adtacent lots. 8 u� On adjacacent lots ?Fubl`ic manhole/cleanout w N/A ;. sewer Nrf!"¢k.. "YY J,„,,vv�ry�.e�yq.�p$x}rimdznpbnvMm�reu.:bvG Holding dank N/A w... 5`+ Absorption field dine 10'+ Surface water 100'+ e foo nF -"W6 iefermined t rough field iinspections and Q ,t records that the above systems are in IOA HAA guidelines in effect on this date . . , , .......... A ness: Ja JEFFREY A GARNESS QQ �i —7953 ori p ��o ! a/ %lied n. „p\ e Waiver Fee $ f e7 jut 1, 777777777777777 Date of Payment _;'!) /27/42y Receipt Number (G� /• GARNESS ENGINEER! CONSULTANTS & GENERAL October 15, 2004 Municipality of Anchorage Development Service Department Building Safety Division On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Septic System for Kasilof Hills Subdivision; Lot 1, Block 6. To whom it may concern: We request that your department issue a 5 foot lot line waiver from the northeast property line to the existing drainfield. I am unaware of any adverse impacts this waiver would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assistatllce. .E., M.S. 3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: garnessengineering.com E of Anehnrac P.O. Use 196650 • Anchors c. Alaska 99,579-0650 • TEl,tilrone (907) 3$+4-830] • Tlax (967) 343-8200t 4700 Bragaw Street • Anchorage, Alaska 99507 ; r Mayor Mark Begich `AIXIV'rnr'n' °r' Building Safety Division O1 Nov 04 Garness Engineering Group, Ltd 3701 E. Tudor Road Suite 101 Anchorage, AK 99507 Subject: Waiver Request for Kasilof Hills Block 6 Lot I Waiver Request #WR040080 Parcel ID #015-132-36 Dear Mr. Garness Your request for a waiver of the required 10 feet from the Absorption Field to the Property Line is approved. The approved separation distance is 5 feet. This waiver approval applies to the existing Absorption Field to Property Line separations only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, /��tt Jeff oet Engineering Tech On -Site Water & Wastewater Program Community, Security, Prosperity S B1.3� 2B.31 SG S SINGLE FAMILY FRAME HOUSE / 0 Im 9 IF Q2. o, 3Pv �O ro �� WELLG opo Z 1 O opO��i00O� 4 49 TH� . 0000 SHANE LS-6914 HOLT.- ;G pgGRE551ONPI' V�� /5 AS-BUILTSURVEY SCALE: I"= 40' , I HEREBY CERTIFY THAT I HAVE PERFORMED A MORTGAGEE'S INSPECTION OF THE FOLLOWING DESCRIBED PROPERTY. LOT 1, BLOCK $, KASILOF HILLS SUB, THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SNOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LIN ES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL ANCH ORAGE RED ORDING D ISTRI CT, ALASKA AND THAT STRUCTURES OR FENCEIINES. THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT, ARE NOT SHOWN HEREON WITH IN THE PROPERTY LINES AND THAT NO VIS ISLE NOTE: ANY FENCELINES SHOWN ARE LOCATED APPROXIMATELY AND ARE NOT TO HE USED TO DETERMINE PROPERTY LINES ENCROACHMENTS a IST OTHER THAN NOTED. OR LOCATE STRUCTURES DATED AT ANCHORAGE, ALASKA THIS _13TH_ ANY PAVING SHOWN MAY BE APPROXIMATE DUE TO SNOWCONDITIONS. DAY OF OCTOBER 2004 HOLT LAND SURVEYING 9507, FB 11487, GPS -2 TEL. 3455513 UTILITY I ESMT. 1 1 11 I II I 1 I�D u+ r N 10 0 E9 I T •1 W N I W n Ir N W t< o 1� N I 1 I 111 I I I 1 I SG S SINGLE FAMILY FRAME HOUSE / 0 Im 9 IF Q2. o, 3Pv �O ro �� WELLG opo Z 1 O opO��i00O� 4 49 TH� . 0000 SHANE LS-6914 HOLT.- ;G pgGRE551ONPI' V�� /5 AS-BUILTSURVEY SCALE: I"= 40' , I HEREBY CERTIFY THAT I HAVE PERFORMED A MORTGAGEE'S INSPECTION OF THE FOLLOWING DESCRIBED PROPERTY. LOT 1, BLOCK $, KASILOF HILLS SUB, THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SNOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LIN ES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL ANCH ORAGE RED ORDING D ISTRI CT, ALASKA AND THAT STRUCTURES OR FENCEIINES. THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT, ARE NOT SHOWN HEREON WITH IN THE PROPERTY LINES AND THAT NO VIS ISLE NOTE: ANY FENCELINES SHOWN ARE LOCATED APPROXIMATELY AND ARE NOT TO HE USED TO DETERMINE PROPERTY LINES ENCROACHMENTS a IST OTHER THAN NOTED. OR LOCATE STRUCTURES DATED AT ANCHORAGE, ALASKA THIS _13TH_ ANY PAVING SHOWN MAY BE APPROXIMATE DUE TO SNOWCONDITIONS. DAY OF OCTOBER 2004 HOLT LAND SURVEYING 9507, FB 11487, GPS -2 TEL. 3455513 10-26-04 04:23PM FROM-CT&E ESI SGS ENV SERVICES 9075615301 T-744 P.02/04 F-740 SGS Ref.# 1046774001 All Dates/Times are Alaska Standard Time Client Name Gayness Engineering Group, Ltd. Printed Date/Time 10/25/2004 16:02 Project Name/# Lot 1, Block 6, Kasilof Hills Collected Date/Time 10/14/2004 8:48 Client Sample 1D Lot 1, Block 6, Kasilof Hills Received Date/Time 10/1'4/2004 14:04 Matrix Drinking Water Technical Director _ Steph1C. Ede Sample Remarks: Nitrate was analyzed by Mat -Su Test Labs of Alaska. Pammeter Res"ItsAllowable Prep Analysis PQL Units Method Container ID Limits Date Date Init Microbiology Laboratory Total Coliform 0 col/100mL SM20 9222B A (<=1) 10/14/04 DKC 10-26-04 04:23PM FROM -CUE ESI, SGS ENV SERVICES 9075615301 T-744 P.04/04 F-740 MatoSu Test Lab of Alaska Water Quality Testing Mile 3.2 Palmer•Wasllla Hwy. P.O. Box 2749 Midtown Community Business Park Palmer, Ak. 99646 Phone: (907) 746.30115 Email: mat•sutesdati0ronershsa.com Fax: (907) 745.7010 Client SGS Environmental Date Arrived: 10/15/04 Report Date: 10/18/04 Sample Date: 10/14/04 Attn.: Forest Taylor Sample Time: 0848 Client ID: 1048774001 Collected Ely; PVVSID #: Source: M.S.T.L.#: 2004970 Sample Matrix: Comments: Method Parameter Units Results MDL Date Prepared Date Analyzed MCL SM 4500-1403-E NO3 mg/L 8.10 0.50 10/18/04 10/18/04 10.0 Legend: MRL = Method Repon Level MCL - Max. Contaminate Level B = Present In Method Blank R = Estimated Value H = Above MCL D = lost to Dilution r- R� d ByJon Paul Campdell Lab supervisor MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES �} Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 0 /J t 1 - b HAA # 1. GENERAL INFORMATION Complete legal description La -L 1 �4 Location (site address or directions) 106 U e7 S� JA'ra--Q- Property owner 116��S C�g 6c� r Day phone Mailing address 1 0 ('0w Lending agency t`I & Qe_�T_ F_ %e Day phone Mailing address - Agent �aly �1 �aW Day phone -7k-- J77 -L, Address Pje-c iy v� 1 -70r�- (f�awch�� Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: '3 N 3. 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. 4. 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. 1/91) Front MOA 421 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my 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 / 9�'9 tf �o lai4 Phone Address o�� 3 l i�/ l J (4 Q Engineer's signature 6. DHHS SIGNATURE _ Approved for Disapproved. 13 bedrooms. Conditional approval for Additional Comments Date bedrooms, with the following stipulations: By: 4211 t.l ?CIW Date NUTIC 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 orderto 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. 1/91) Back MOA 021 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:''( l 4J Yt `- _ Parcel I.D. �' / `' ' ✓-' A. Well Data Well type If A, B, or C, attach ADEC letter. ADEC water system number _ Log present (Y/N) _ ,a Date completed �7 G''y.` f. ' Driller 3 .o . A? f A Total depth `f Cased to , _Casing height y Sanitary seal (Y/N) " / Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test '��n Li �r�, / 1 3 MUNIODAUTY nF 4W FIORAUE / Static water level ENVIRONMENTAL SER`: K ES U)VISION _ r)�- � �l Well flow v° g,p.m. g.P.m. 1 1993 Pump levell F>,5 ` R E i E I `/ E SEPARATION DISTANCES FROM WELL TO Septic/holding tank on lot _ f ! ; On adjacent lots Absorption field on lot %% ; On adjacent lots % Public sewer main /- Public sewer manhole/cleanout je"fyr•- Sewer service line �! U Petroleum tank i-1 Ca WATER SAMPLE RESULTS: Coliform r> / Nitrate 3, l',�� Otherbacteria(0 Date of sample: yI q/ r),.-3 Collected by: %- J-� <''t• G B. SEPTIC/HOLDING TANK DATA Date installed ��/� Tank size Asa Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Y Depression (Y/N) _ High water alarm (Y/N) 1`// / Alarm tested (Y/N) �/ Date of pumping A7G Q 3 Pumper _ ;)ej4 t -6t' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot //15 On adjacent lots > /,14E) Foundation To property line >/O Absorption field Surface water/drainage i/V Water main/service line > IL) 72-026(3/93)•Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons_ Vent(Y/N) ��N .11 N High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: On adjacent lots Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed �� Soil rating (GPD/Ft2) System type C A944_ Length Width !i Gravel thickness f Total depth t1 Total absorption area ��,�lJ Cleanout present (Y/N) �/ Depression over fiield (Y/N) Date of adequacy test L142 -I Results (pass/fail) for Bedrooms Water level in absorption field before test After test 44-• r Peroxide treatment (past 12 months) (Y/N) If yes, give date {teen As R. '� : !3��wi vv�✓ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: L Well on lot On adjacent lots ? % Property line To building foundation ams To existing or abandoned system on lot On adjacent lots i [sem Cutbank Water main/service line i Surface water 1-4 1 C) Driveway, parking/vehicle storage area i 5 C.) Curtain drain (,j � C,✓ E. ENGINEER'S CERTIFICATION l certify that I have checked, verified, or conformed to all MOA and HAA guidelines in the'd,�te.of this inspection. Signature Engineer's Name VJC.1I'L c, Date a� HAA Fee $ / VAC Waiver Fee $ Date of Payment Date of Payment Receipt Number` =�?_ �� Receipt Number. 72-026 (3/93)` Back CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 13 STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562.2343 FAX: (907) 561-5301 REPORT of ANALYSIS Chemlab Ref.# :93.1676-1 Client Sample ID :1/6 KASILOF HILLS Matrix :WATER Client Name :TOBBEN SPURKLAND, P.E. Ordered By :TOBBEN SPURKLAND Project Name Project# PWSID :UA Sample Remarks: ROUTINE SAMPLE COLLECTED BY: STUART. Collected :04/29/93 Received :04/29/93 WORK Order :65496 Report Completed :05/03/93 Technical Director :S Released By ; APy @ 14:00 hrs. @ 14:30 hrs. EDE 'el QC Allowable Ext. Ana]. Parameter Results Qual. Units Method Limits Date Date Init ----------------------------------------------------------------------------------------------- NITRATE-N 3.62 mg/l EPA 353.2/300.0 10 04/30 LLH * See Special instructions Above UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D = Secondary dilution. GT = Greater Than ��! 3GS Member of the SGS Group (Soci6t6 Gen6rale de Surveillance) 6751N.0MSN0BLVD. AHCHO8A8[/ALASKA 99502-JY04 (9O7>279~3916 Municipality of Anchorage May 25, 1993 Division of Environmental Health Department of Health and Social Services S20 I Street Anchoragc, Alaska 99501 SubjectN HAA for Lot i Block 6 Kasilof Hills Gentlemen; By researching tIe files for this, and the surrounding lots, I found a soil log by Moening Gray, dated 11~10-79` which showed no �ater or bedrock to 15 feet. The location sketch indicated that then testhole was in the general vicinity of the septic system. Other testholes showed no bedrock or water down to 12 feet. One loti, for lot to Block 4 showed bedrock at 4 feet. The permit for this system shows at trench opLion witt a total depth of 8 feet. My inspection report, dated 7/21/81, shows a total depth of 9 feet, with the romment that insulation was placed over the system. trench, and additional fill placed over the My interpretation of the information from Lhe files is that the system was installed accorJing to the permit, and that additiona1 fill was placed over the system to protect it from freezing, Nothing in the files indicates that ground water separation or 6e6rock separation is less than required, .E. MUNICIPALITY OF ANCHORAGE DIVISION OF ENVI:RONMEN`IA , HEM,11.1 DEP RI'MEW OF HF.AL'1' l AND ENVIRONMENTAL PROTFC`.rION APPLICA'T'ION FOR HEALTH A IUORITY APPROVAL-, CERTIFI(ATE 1. (pneral Information Application Date (a) Legal Daf.::ript-ion (i.ncAu(3e l.ot., block, subdivision, section, to,.Rlship, range) Lot 1 BLocic 6 ,Kasi_lof Hills Subdivision Location (address or directions) 10600 Sidoroi Lane (b) Applicants Name G TC, Carlson and Lois S. Chai)sl_or 'mlephOnxa 346 _3477 Applicants Add-ess SR Box 21.44-D, Anchorage 99507 (c) Applicant is (check one) Lending Institution �� % O.vner./build,=r �� p { ,.��._ Buyer 4 Other-� (explai_n); (d) Lending Institution 1,arti <°!' T>�,r Telephone ; _ /7-i_} Adctz-ess ;J 7 ': 7 (e) Peal. Estate Cc< & Agent A) /!1 Address Telephone 2 , 7 of I?r� s idenee Single -Family Family Other (&l,scribc) Ntlli bey, of Dedrocnrs 3. Water Supp .y Individual Nell Ej CcHifnUnity F I I.ublic Note; If ccATnanity well system, must have written confir_-maticn from the State Ibpar_tmant: cf Envi-ronzcx=.ntal Conservation attesting to the legality and status. Is Lhe well adecifate for the number of bedrocafus specified in this HAA (YM) ` 4. Sewaqe Disosal. Ons i-te P-- �I Tkibl is �C Community f—:j Holding Tanlc I.s the wastewater disposal- system adequate for the number of bedrocros (Y/N) [Page 1 of 21 2-1.5-84 5. Pngineerina Firm Providinq InSr)9ctions, 'Jhst.s, Data and Information I certify that E. have checked, verified, or corifornrd to all MOA HAA Guidelines in erect on the d�te, of tliis/ inspr_ct.on. +^ "' Signed �.._ _ l/ _.Date ,..��•�.� �� -3 � � = Name of Fizz "I f I 0 ;; :Telenhor� Address = ' 1 2,_ Signed by Date.—_� (ENGINEER SEAL) 6. DHEP Approval Approved for -- — be drocros BY �6_-�-�- Approved I Disapprow'd. Conditional Terms of Conditional Approval_ Date T The Municipality of Anchorage D.�partm-�nt of [bal.th and Environmental Protection does riot guarantee tha continued satisfactory performance of the water supply and/or the wastewater disposal system. This approval. indicates that, as of the validation date shown above, based on the data and information furnished 1y an engineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func-- tional for the numter of bedrocxs and type of structure i.rdic.atad. (DHEP SEAL) 7. Mail the HAA to the following address, KB2/d5/s (Page 2 of 21 2-15--84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Lot 1, Block 6 Legal Description: Kasilof H611s Subd. A. WELL DATA S r i Z12 N P,:3 VV — Well Classification If A, B. or C. D.E.C. Approved(Y/N) AIM- Well rWell Log Present (Y/N) S Date Completed ' -' �_ Yield Total Depth J9 ° / J� Cased to �,?O Depth of Grouting 11A1KA(61-)1J Static Water Level% Pump Set Casing Height Above Ground '31 Sanitary Seal on Casing (Y/N); Electrical Wiring in Conduit (Y/N) &S Depression Around Nbllhead (Y/N)AIQ Separation Distances from Well: To Septic/Holding Tank on Lot /Cka� ; On Adjoining Lots / � To Nearest Edge of Absorption Field on Lot / ; On Adjoining Lots z6Ln', To Nearest Public Sewer Line _ZML? To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot DO Water Sample Collected By 4LZ'11�11'y Dates? Water Sample Test Results _ Convents B. SEPTIC/HOLDING TANK DATA Date Installed -c2/- FZ Size=, No. of Compartments �. Standpipes (Y/N) ZC; Air -tight Caps(Y ) z Foundation Cleanout (Y/N) K Depression over Tank (Y/N) AIZ) Date Last Pumped -Ie/ ,5 L~mac!©�a� Pumping/Maintenanee Contract on File (Y/N) for _ Alllv- Holding Tank High -Water Alarm (YM) ,� Temporary Hold ng Tank Permit (Y/N) Separation Distances from Septic/iolding Tank: i To Water -Supply Wb11 /�,� ��"- To Building Foundation To Property Line �� " To Disposal Field_ ZCL) _ To Water Main/Service Line /; �'`c To Stream, Pond, Lake, or Major Drainage Course N Comments [Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA e�o,a1V'f�FwFi7 Of ANCtlORA9 DEPT OF HEAUH & � SAtia.''ng Soils Rating in Absorption Strata /Q(>�,(�%J,rfi'/�7Type of "SVs�i �sgno"ECTIo1V Fin/ /- Date Installed Length of Field Width of Field Depth of Field Gravel Bed Thickness® Square Feet of Absorption Area L/ao Standpipes Present (Y/N) )/ Depression over Field (Y/N) NO Date of Last Adequacy Test ��-� �•-�� Results of Last Adequacy Test �,917`er Separation Distance from Absorption Field: To Water -Supply Well /Q0 ' ;0- To Property Line _,:5-' To Building Foundation e;R ' To Existing or Abandoned System on Lot N On Adjoining Lots 3�� To Water Main/Service Line "`jr To Cutbank(if present) ,-;,, To Stream/Pond/Lake/or Major Drainage Course // To Driveway, Parking Area, or Vehicle Storage Area /!Q ' J �• Com4*ent5 '1)7%Z3/A/ f /! r GUi s �VOTGi 42 7 2- / If 6 r ILs57_e124) X CLAD k-'.7: D. LIFT STATION IV/A J Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes(Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA HAAilid�l.,i s in effect on the date of tis pe ion. Signed c a'w� . Date i F 71 �t Company e- MOA No. 5TJ39 -6)29 f-, o rENG_ ERs `1 KBl /d5/s [Page 2 of 21 J NEIL NA":'"! "..:?I'. F::__ 2-n15-84 i ->; r' L APPLI( AT FILLS OUT UPPER HA, ONLY Properly Owner L �, v+, L p (a Time Phone Mailing Address I Zip Code C11(car Date Date -Buyer(_¢�4`F Date Inspector ri C) fP5 ) Address Zip Code Lending Institution-<=c>�>\��s G:>P;.r,.>= <`� �'c,.,, --T Inspector Phone Address+�,a-+� "1i - - �I �� c +.�� ay ..l.�c-1� �t=_. Zip Code Realty Co. & Agent � Phone ( ) DISAPPROVED Address Zip Cade ( ) CONDITIONAL APPROVAL' Legal Description Street Location '-Z A kL, y, Ev - Type of Residence Single Family a ❑ Multiple Family No. of Bedrooms �? ❑ Other Water Supply P Individual ATTACH WELL LOG. A well log is required for all wells drilled since June 1976. ❑ Community For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility Well Log Received Sewer Disposal s6 Individual Year Individual Installed 't L'4- ❑ Public Utility When Connected to Public Utility: _ ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date j Date Date Date Inspector Inspector Inspector Inspector Field Notes: r� APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' - 43 ; -9'- DATE BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received 6 � Well to Tank Septic Tank Size 72023131821