HomeMy WebLinkAboutKASILOF HILLS BLK 7 LT 6Kasl'*lof Hills
Block 7
Lot 6
#015-132-11
AI 192RAMIrA 1
Municipality of Anchorage
On -Site Waxer and Wastewater Program - (907) 343-7904
1 _JaLU j } o
NOV-
ON-SITE WASTEWATER INSPECTION REPORT L
Permit Number: OSP141456 PID Number: 015-132-11
Dwelling: 0 Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New 0 Upgrade
Name:
KEN ROBERTSON
ABSORPTION FIELD
❑ Deep Trench n Shallow Trench ❑ Bed ❑ Mound
Address
10701 STROGANOF DR ANCHORAGE AK 99507
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
5
5.0 GPD/SF
6.9 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
2.9 Ft.
Gravel depth beneath pipe
4.0 Ft
Subdivision Block Lot
KASILOF HILLS 7 6
Fill added above original grade
0-0.5 Ft.
Gravel length
30 Ft.
Township Range Section
Gravel width
5 Ft.
Beds: Number of Lines
NA
Distance between lines
I NA Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
1
From
Tank
Field
Tank
Line
300 Ftp
1
NA Ft.
Well
>100'
** 90'
NA
NA
>25'
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ■ Other d 0.
Manufacturer
ANCHORAGE_
Capacity
2000 Gal.
Surface water
>1001
>100'
NA
NA
Material
Number of compartments
Lot Line
>5'
>10'
NA
NA
STEEL
2
NA
Foundation
>5'
>10'
NA
NA
LIFT STATION
Manufacturer
Capacity
Curtain Drain
>50'
>50'
NA
NA
Gal.
Remarks EXISTING SEPTIC SYSTEM ABANDONED
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
PER UPC REQUIREMENTS
** PER WAIVER OSP1411457
Pump make and model
Electrical Inspections performed by
PIPE MATERIAL Housetotank 3034 Tankto
drainfield 3034
Installer
A+ HOME SERVICES
Drainfield 3034 COIMT3034
Inspector ANSON MOXNESS & LARS SPURKLAND
BENCH MARK (Assumed elevation)100 ft
Ins daction
1" 1113/14 11/3/114
Location and description
tes: 2m
3011/4114 4'"
BOTTOM STEP DECK STAIRS
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
Conditional Approval: Date
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LAFIS E. SPURKLAfvD; Z /
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Approve Date+40
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Inspection KepoR_y-1-11.doc
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24.5'
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30.5'
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INSTALLED 5 -BEDROOM SEPTIC SYSTEM':w
INSTALLED 2000 GALLON SEPTIC TANK
1 AX -20 ADVANTEX TREATMENT PODS
TRENCH LENGTH 30 FEET
TRENCH WIDTH 5 FEET
MAX EXCAVATION DEPTH 7 FEET
ROCK DEPTH 4.0 F££T
NOTE. THIS IS NOT A SURVEYED PLAT. WELL k SEPTIC
LOCATIONS TAKEN FROM ON -SIT£ WATER AND WASTE WATER
DEPARTMENT DOCUMENTATION. ALL LOCATKINS SHOWN ARE
APPROXAMIF..
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4' CONTOUR LINES
25 D 25 50 SCALE 1' = 50 FT. 700 125 150 - +pr,,:I_ mj ;
SPURKLAND ENGINEERINGKASILOF HILLS BM 7 LT 6 SEPTIC SYSTEM ASBUILT
203 V 15TH AVENUE
ANr.H Arc 49501 11 KEN ROBERTSON BATE HOV 11 2014
IPERMIT B OSP141456 PID It 015-132-11 KASILOFHILLSB7L6.SC50-ASB.DV6
4.0 ft of Septic Rock
Effective
5— BEDROOM SFR.
ANT£X Category -RI AVVTS
2000 GAL B17UBL£ POD
ABVANT£X CATEGORY -111 AVVTS
ELEV.=14' Below E.G.
NO SCALE BENCHMARK BOTTOM SEP OF DECK STAIRS
ASSUMED ELEVATION: 100 FEET
SPURKLAND ENGINEERING KASIL OF HILLS BN 7 L 0 T 6 SEPTIC SYSTEM ASBUILT
203 W15tgh Ave KEN ROBERTSON DATE: NOV 7, 2014
Ancor279-3916 a Ak 9950 11 1 10701 STR96AACF BR, ANCHORAGE; AK 99516 SHEET: 3/4 GRIDS 2541
' PERMIT # 17SPI41456 PARCEL IB # 015-132-11 KASILOFH1LLSB7L6B3-ASB.DV6
On -Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSP141456
Tax Code Number: 01513211000
Work Type: Septic Upgrade
Permit Effective Dates: October 31, 2014 to October 31, 2015
Design Engineer: SPURKLAND E
Subdivision: KASILOF HILLS
Site Legal Address: KASILOF HILLS BILK 7 LT 6 G:2541
/LJ -31- / -f S—.1001
)/ ' � — /Y //' U,l
Owner/Address: ROBERTSON KENNETH G &
FARNSTROM HELEN E 10701 STROGANOF DR ANCHORAGE AK 995076477
Site Mailing Address: 10701 STROGANOF DR, Anchorage Lot Size in Sq Ft: 30949
Total Bedrooms: 5
This permit is for the construction of:
Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater
Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80).
3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received
Issued
Municipality of Anchorage
Development Services Division
On -Site Water and Wastewater Program
meat �,
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Department
**** VARIANCE/WAIVER REVIEW ****
Waiver#: OSP141457 COSA#: Permit#:OSP141456
PID#: 015-132-11
Legal Description: Kasilof Hills, Block 7, Lot 6
Engineer: Spurkland Engineering
Applicant: Ken Robertson
Your request for a waiver of the required 100 feet horizontal separation from the absorption field
to the private wells on Kasilof Hills Block 7 Lots 6 and 7 has been approved. The approved
separation distance is 90 feet.
Your request for a waiver of the required 50 feet horizontal separation from the absorption field
to the 25% or greater slope has been approved. The approved separation distance is 10.0 feet.
This waiver approval applies to the proposed absorption field only. Any future upgrade to the
on-site wastewater disposal system will require all separation distances be met or another
approval from this department.
® The affected adjacent property owner(s) have been given a 7 day notice regarding this
waiver.
® Notarized letter(s) of non -objection have been received from the owner(s) of the affected
adjacent property.
® Adjacent properties are not affected by this slope waiver.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I
Waiver is Granted: X Waiver is not Granted:
Date: 119A, Approved bt�z_ (
Name of Reviewer
................................................•..............................
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPW—DATION
Parcel I. D. 015-132-11
Property owner(s) KEN ROBERTSON
Day phone 727-2180
Mailing address
Site address 10701 STROGANOF DR., ANCHORAGE, AK 99516
Legal description (Sub'd., Block & Lot) KASILOF HILLS BLOCK 7 LOTAO
Legal description (Township, Range & Section)
Lot Size Sq. Ft. Number of Bedrooms 5
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(0 all that apply)
Absorption Field
E]
Initial ❑
Single Family (SF)
El
(w/wo ADU)
Septic Tank
Ej
Upgrade 0
Duplex (D)
F-1Holding
Tank
F-1Renewal
El
Multiple Dwellings
❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
SLOPE & WELL TO SEPTIC Distance: 10,&90,
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
V
property owner or
Permit/Rush Fees: S I
Date of Payment: 10 ( 10tI -A e.�
Receipt Number: 06 15C\
Permit No. 65P1y H6(o
Perm@ App_9-1-12.doc
Waiver Fees: I k u
Date of Payment: 101 I6ftq_
Receipt Number: 0('5966
Waiver No. 051'jL4 MSI'
Spurhland Engineering
Environmental Consulting and Design
SEPTIC SYSTEM DESIGN
KASILOF HILLS BLK 7 LOT 6
Municipality of Anchorage October 27, 2014
Development Services Department
On Site Water and Wastewater Program
4700 Elmore Road
Anchorage, Alaska 99519
Subject: Septic System Installation Permit
10701 Kasilof Dr. Anchorage, AK 99516
Ladies and Gentlemen:
I am writing to request a septic system installation permit for the above referenced property. The
existing septic system is surcharged and occasionally backs up into the house. The proposed
system will serve a 5 -bedroom single-family residence. Soil logs, design calculations, a site
plan, design drawings and construction specifications are enclosed for your review.
Design Cates: No groundwater observed.
(9/18/14).
Soil rating. From test hole (9/11/14).
Use Cat III Advanced Treatement System
11.4 min/in = 5.0 gal per sq.ft./day
No. of Bedrooms 5
Required Area per Bedroom: 15015 =30 sq.ft.
Total area required: 30 x 5 = 150 sq.ft.
Use shallow trench with 4 feet of effective depth
Minimum trench length= 150/5*0.50=15 ft
System: We are proposing a 2000 gallon Advantex wastewater treatment system with 2 AX -20
treatment PODS followed by a wide trench absorption field consisting of 130 foot trench with 4
feet of sewer rock (300 sq.ft.). The trench will be installed in the bench cut for the house in such
a way to minimize impacts to the existing deck and so that ground surface at the ends of the
trench is at approximately the same level.
203 West 15th Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland@gci.net
Spttrktand Engineering
Environmental Consulting and Design
Soils: A test hole was excavated on September 11th, 2014. See the attached soil logs.
Groundwater was not observed on September 18th, 2014. Ground water monitoring will continue
through construction of the septic system.
Surface Water: There are no surface waters within one hundred feet of the proposed septic
system upgrade.
Topography: A level bench was created for the construction of the home. The surrounding
hillside slopes down to the west at 25-35%.
Waivers: Slope- The proposed drain field will be located on the flat bench described above.
The end of the trench will be a minimum of 10 feet away from the grade break to a slope greater
than 25%. The final grade will be vegetated. Daylighting of septic system effluent is not
anticipated. See slope profile (Sheet 4/4).
Septic Absorption Field to Well- Due to the excessive slopes and existing
development patterns with regards to well placement, we are applying for separation distance
waviers to the wells on Lot 5 and 6 Block 7 Kasilof hills subdivision.
According to the well driller's log, the well on the referenced property was drilled on June 12th
1972 and has a total depth of 202 feet, a static water level of 22 feet below the top of the casing,
and a yield of 5 gpm. The well log shows that the well casing is drilled in to bed rock at a depth
of 21 feet. The well logs for both Lot 5 Block 7 and Lot 7 Block 8 are also bedrock wells with
casings extending to a depth of 11 and 12 feet respectively. Static water levels of 50' feet and 12
feet were recorded on the well logs.
The original septic system was installed in June of 1972. It consists of a 1250 gallon septic tank
and a log crib. The system has been operating at a reduced capacity for several years. The septic
tank will be replaced during the proposed septic system upgrade with an Advantex advanced
wastewater treatment system.
Soil logs indicate the following site conditions: a shallow layer of organics; a silty sandy gravel
with some sand to a depth of 14 feet. Bed rock was observed at 14 feet. Ground water was not
observed during the excavation on September 11th, 2014. Ground water was not observed during
test holes excavated in 1972 (June) or 1995 (August).
203 West 15th Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland@gci.net
I ts-�
Spitrkland Engineering
Environmental Consulting and Design
Mitigating Factors:
The well head for Lots 5 & 6 are located up gradient from the septic tank. If the septic system
were to overflow, it would drain away from the well head, making surface flow contamination
from the septic system impossible.
An Advantex advanced wastewater system is proposed for the septic system upgrade. Advanced
wastewater systems have been installed in the MOA for over twenty years and have a good track
operational history, discharging wastewater effluent that meets secondary wastewater treatment
standards. Further protection would be provided by the Advantex Vericom Monitoring system,
which notifies Anchorage Tank & Wielding of any high water condition or operational problems.
Waiver Request: 90 feet from septic system absorption field to the well on Lot 6
90 feet from the septic system absorption field to the well on Lot 5
Included for your review is the proposed septic system design and site plan, the well logs for
Lots 5 & 6 Block 7 Kasilof Hills and Lot 7 Block 8 Kasilof Hills.
We plan on using the existing drain field as the reserve site for this installation. With advanced
wastewater treatment the existing field is oversized for 5 bedrooms.
The installation of this septic system will not prevent wells and septic systems from being
installed on the adjacent lots. The proposed septic system will not change the general slope of
the area. Ponding and/or concentration of surface runoff will not result from this installation.
If you have any questions or concerns, please contact me at 279-3916.
Sincerely,
Lars Spurkland, P.E.
Civil Engineer
203 West 15`h Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland@gci.net
Spur land Engineering
Environmental Consulting and Design
Municipality of Anchorage October 10 , 2014
Development Services Department
On Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, Alaska 99519
Subject: Septic System Installation Permit
Kasilof Hills Block 7 Lot 6
Ladies and Gentlemen:
We are the owners of Kasilof Hills Block 7 Lot 5. On October 10 , 2014 we were notified that a
waiver of the required separation distance between a septic system absorption field my well has
been requested by Ken and Helen Robertson, owners of Kasilof Hills Block 7 Lot 6.
After reviewing the plans, we feel that the impact on our property will be negligible and
therefore agree to the waiver and consent to installation of the Robertson's septic system as
shown on the design plans which have been submitted to MOA.
Sincerely,
C
N
David A. Veryrtigge, Co-owner
Kasilof Hills lock 7 Lot 5
10741 Stroganof Drive
Anchorage, AK 99507
0907) 344-4192
Lori A. Verbiugge, Co-ovh
Kasilof Hills Block 7 Lot 5
10741 Stroganof Drive
Anchorage, AK 99507
(907) 344-4192
203 West 150i Avenue Suite 202, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland@gci.net
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NOTE. THIS IS NOT A SURVEYED PLAT. WELL k SEPTIC
LOCATIONS TAKEN FROM ON -Sq£ WATER AND WASTE WATER
DEPARTMENT DOCUMENTATION. ALL LOCATIONS SHOWN ARE
APPROXIMATE.
50 0 50 100 150 200 250 300
SCALE: I' = 100 FT.
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SPURKLAND ENGINEERING
KASILOF HILLS BLK 7 LT 6SEPTIC
SYSTEM DESIGN
203 V 15TH. AVENUE
ANCH, AK. 99501
KEN ROBERTSON
DATE SEPT 10 2014
(907) 279-3916
10701 STROGANUF DR ANCHORAGE AK 99507
SHEET, 1/5 GRID: EV2541
PERMIT # OSP141XXX PID # 015-132-11 KASILOFHILLSB7L6.SCIO0,DVG
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INSTALL 5 -BEDROOM SEPTIC SYSTEM
INSTALL 2000 GALLON SEPTIC TANK
2 AX -20 ADVANTEX TREATMENT PODS
TRENCH LENGTH 30 FEET
TRENCH WIDTH 5 FEET
MAX EXCAVATION DEPTH 7 FEET
ROCK DEPTH 4.0 FEET
COVER 3 FEET (MIN.)
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INSTALL 5 -BEDROOM SEPTIC SYSTEM
INSTALL 2000 GALLON SEPTIC TANK
2 AX -20 ADVANTEX TREATMENT PODS
TRENCH LENGTH 30 FEET
TRENCH WIDTH 5 FEET
MAX EXCAVATION DEPTH 7 FEET
ROCK DEPTH 4.0 FEET
COVER 3 FEET (MIN.)
NOTE: THIS IS NOT A SURVEYED PUT. WELL d SEPTIC th •
LOCATIONS TAKEN FROM ON -SNE WATER AND WASTE WATER ��
0£PARTMENT DOCUMENTATION. ALL LOCA7IONS SHOWN ARE /,,, .................. 0
APPROXIMATE. RS SPURKLAND ij
f't
♦ s No. CE -11500 AV
S 59 75 CALE, 1' = 50 FT. 125 150 ••• �j 1; SS�i�••
25 0 25
SPURKLAND ENGINEERING KASILOF BILLS BLK 7 LT 6 SEPTIC SYSTEM DESIGN
203 V 15TH. AVENUE
ANCH. AK. 99501 KEN ROBERTSON DATE: DCT 2 2014
007) 279-3916 11 10701 STROGANOF DR ANCHRDAGE AK 99507 SHEET•• 2/5 GRID, SV2541
PERMIT # DSP141XXX PID # 015-132-11 K4SIL9FHILLSB7L6.SC50.BV6
4'
CONTOUR LINES
NOTE: THIS IS NOT A SURVEYED PUT. WELL d SEPTIC th •
LOCATIONS TAKEN FROM ON -SNE WATER AND WASTE WATER ��
0£PARTMENT DOCUMENTATION. ALL LOCA7IONS SHOWN ARE /,,, .................. 0
APPROXIMATE. RS SPURKLAND ij
f't
♦ s No. CE -11500 AV
S 59 75 CALE, 1' = 50 FT. 125 150 ••• �j 1; SS�i�••
25 0 25
SPURKLAND ENGINEERING KASILOF BILLS BLK 7 LT 6 SEPTIC SYSTEM DESIGN
203 V 15TH. AVENUE
ANCH. AK. 99501 KEN ROBERTSON DATE: DCT 2 2014
007) 279-3916 11 10701 STROGANOF DR ANCHRDAGE AK 99507 SHEET•• 2/5 GRID, SV2541
PERMIT # DSP141XXX PID # 015-132-11 K4SIL9FHILLSB7L6.SC50.BV6
5— BEDROOM SFR.
9NT£X Catego Y -X AVVTS
40 ft of Septic Rock
Effective
NO SCALE
2000 6AL DWDLE POD
ADVANT£X CAT£60RY-111 AWWTS
ISPURKEAND €NGIN€€RINGI I KASILOF HILLS BLK 7 LOT 6 I I SEPTIC SYSTEM SCHEAMT1C I
203 Anchorage age Ak 99501 Ave
AnchoKEN ROBERTSON DATE: SEPT. 20, 2014
279-3916 10701 STRMANOF DR., ANCHORAGE, AK 99516 SHEET1 3/4 GRIDS 2.541
I PERMIT # OSP141XX PARCEL ID # 015-132-I1 KASILOFHILLSB7L6D3.DV6 I
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203 W. 15th A ve. Ste. 202A
Anchorage, AK 99501
TEST HOLE I --L—
DEPTH
—L
DEPTH
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
SOIL LOG AND PERCOLATION TEST
cnu OESCRIPTION DATE._-�ZlIZZ4
s
WAS GROUNDWATER OBSERVED. __ No —
IF YES, AT WHAT DEPTH. • —
AFTER MONITORING PERIOD: — -Arx___
DATE OBSERVED: _= /1B/14
PERCOLATION TEST.•
dy Gravel
red Bedrock 0 14'
VOTES. PRE-SOAKED
FILL DATE I
GROSS TIME
NET TIME
DISTANCE
I DROP
14.500' 911 14
10:25 AM
0 m1n.
14.313
10:55 AM
30 min.
11.500
3.000
13.500
11:25 AM
30 min.
11.625
2.688
11:55 AM
30 min.
10.750
2625
PERCOLATION RATE. 11.4 minutes/ inch
PERC HOLE DIAMETER. 6 inches
TEST RUN BETWEEN __4 FT AND FT
SITE PLAN.•
N
SEE ATTACHED SITE PLAN
MEASUREMENTS ARE FLOAT READINGS
PERFORMED BY.- Anson Moxness. 1, Lars Spurkland P.E. CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
SPURKLAND ENGINEERING KASILOF HILLS BLK 7 LT 6 SOIL LOG PERCOLATION TEST
203 V 15TH AVENUE
ANCH, AK. 99501 KEN ROBERTSON DATE, SEPT 12, 2014
(907) 279-3916 10701 STRDGONUF DR ANCHORAGE AK 99507 GRID #1 EVE541
PERMIT # PID # 015-132-11
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
BETWEEN MUNICIPALITY OF ANCHORAGE
AND Kenneth G. Robertson
THIS MAINTENANCE AND REPAIR AGREEMENT made and entered into as of this
29th Day of October
of 2014, by and between Kenneth G. Robertson
herein the "OWNER," and the Municipality of Anchorage, herein the
"MUNICIPALITY." In consideration of the mutual covenants contained herein, the
parties to this Maintenance and Repair Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. Municipality grants permission to
Owner to utilize and operate an Advanced Wastewater Treatment System
(AWWTS), described as
Kasilof Hills Subdivision, Lot 6, Block Seven, Anchorage, Alaska
located at (legal description).
10701 Stroganof Drive, Anchorage, AK 99507
2. Definitions.
Alteration. Any change to the design or function of an AW WTS that
includes the installation or removal of any parts, components or pieces not
included in the original construction permit and design.
Certificate of On -Site Systems Approval (COSA). An approval by the
Municipality of existing water and wastewater disposal systems given at
the time of property sale and title transfer in accordance with Anchorage
0 Municipal Code (hereinafter, "AMC") 15.65. These approvals certify that
the systems are adequate for the homes that they support and meet the
codes that were in place at the time of system construction.
Damage. Any man-made or natural change in a system that would inhibit
the system from performing as designed.
Maintenance and Repair. The scheduled and as needed replacement of
existing parts, components and pieces of an AW WTS that were included
in the original design which would allow the AW WTS to continue to
perform as designed.
Permit. Ah On -Site Wastewater Disposal Permit as required by AMC
15.65 to construct and operate an AW WTS.
3. Term. The tern of this Maintenance and Repair Agreement shall begin on the
date of approval by the Municipality to operate the installed system or issuance of a
COSA, and shall continue while the AW WTS is in use or is operational or until the
property is sold or title is transferred by the owner and a new COSA is issued to the
new owner or transferee of the property.
4. Alterations, Installation and Removal of Additional Eouimnent. Prior to
performing any alterations to an AW WTS, the owner agrees to obtain an On-site
Wastewater Disposal Permit from the Municipality in accordance with AMC 15.65.
5. Maintenance and Repairs.
A. Throughout the term of this Maintenance and Repair Agreement, the Owner shall
maintain their AWWTS in a satisfactory condition capable of producing treated
septic effluent in accordance with the equipment's approval for operation in the
Municipality. The owner shall enter into a service agreement with an AW WTS
9
0 service and maintenance provider approved by the municipality and the
manufacturer of the AWWTS for the entire term of the AWWTS. In addition, it
shall be the responsibility of the Owner during the term of this Maintenance and
Repair Agreement, and any renewals thereof, at the owner's sole expense, to pay
for any and all: (1) repair(s), (2) maintenance, (3) adjustment(s), (4) replacement
costs, and (5) inspection costs.
B. Owner agrees to comply with all applicable ordinance, laws, regulations, rules
and orders for the AWWTS.
C. Upon request by the Municipality, the owner agrees to provide the Municipality a
written schedule of routine maintenance and repairs which have been performed
on the system. When a record of maintenance is documented and maintained by
the system vendor, the owner agrees to allow the Municipality access to this
information.
D. Owner acknowledges that the fine for failing to maintain and repair an AWWTS
may be assessed in accordance with AMC 14.60 for improper discharge.
E. Owner agrees that only maintenance and repair personnel approved by the
Municipality will inspect and make any necessary maintenance, repairs or
permitted alterations to the system.
F. Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS upon 24 hours written notice.
G. Owner agrees that any sale or transfer of title of the property will not occur
without a new Certificate of On -Site Systems Approval.
0
• H. Owner agrees that the AW WTS installation and maintenance requirements as
provided by the AW WTS vendor/installer and approved by the Municipality are
the governing guidelines for the construction, maintenance and repair of the
Owner's AW WTS.
I. Owner agrees to provide and maintain a telephone connection to the AW WTS as
required by the AW WTS approval.
6. Nonwaiver. The failure of either party at any time to enforce a provision of this
Maintenance and Repair Agreement shall in no way constitute a waiver of the
provisions, nor in any way affect the validity of the Maintenance and Repair
Agreement or any part hereof, or the right of such party thereafter to enforce each and
every provision hereof.
7. Amendment.
A. This Maintenance and Repair Agreement shall only be amended, modified or
changed by a writing, executed by authorized representatives of the parties, with
the same formality that this Maintenance and Repair Agreement was executed
with, and such writing shall be attached to this Maintenance and Repair
Agreement as an amendment.
B. For the purposes of any amendment modification or change to the terms and
conditions of this agreement, the only authorized representatives of the parties
are:
0
a. Owner: Kenneth G. and Helen E. Robertson
b. Municipality: Director Community Development or designated authority
0
0
C. Any attempt to amend, modify, or change this contract by either an unauthorized
representative or unauthorized means shall be void.
8. Jurisdiction: Choice of Law. Any civil action arising from this Maintenance
and Repair Agreement shall be brought in the Superior Court for the Third Judicial
District of the State of Alaska at Anchorage. The laws of the State of Alaska shall
govern the rights and obligations of the parties under this Maintenance and Repair
Agreement.
9. Severability. Any provisions of this Maintenance and Repair Agreement decreed
invalidby a court of c peten
provisions of the intenance
OWNER:
By:
Kenneth obertson
STATE OF ALASKA
THIRD JUDICIAL DISTRICT
jurisdiction shall not invalidate the remaining_
and Repair Agreement.
) ss.
name)
Date: 10/28/2014
The foregoing instrument was acknowledged before me this 28t&y of October
2014,by Kenneth G. Robertson
NOTARY PUBVC FOR ALASKA_
My Commission expires: � " l'% /
MUNICIPALITY:
PUBLIC
iBy: (signature) Date:
name) Title:
L
`inAS HD I GP EER ANCHORAGE AREA ROROI' 1
DL.ARTMENT OF ENVIRONMENTAL QUALI
3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279.8686
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
/MAILING
NAMELIL/—(( /� t��_<=1 5 -- --- — ADORE=SS /f', /_i�1T�1�C_!; JI _k ---PHONE {6L—
LOCATION k (11= . � 2"/ C /%1/ /= "-� . LEGAL DESCRIPTION �_ (/-/_.%_�Wial 1. [; /
SEPTIC TANK:
DISTANCE FROM WELL_ —MATERIALS <-121A ' NUMBER OF
__(�''�'- ��__•�Z _COMPARTMENTS_
LIQUID CAPACITY ��-�� ____GALLONS. INSIDE LENG
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PITS
OUTSIDE DIAMETER
LIQUID
_INSIDE WIDTH __DEPTH_=
OR WIDTH LENGTFI ,j DE=PTH.
LINING MATERIAL�'� <)��� — .. DISTANCE FROM WELLBUILDING FOUNDATION -t
NEAREST LOT LINE -;?_7 TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
TILE DRAIN FIELD:
SQ. FT.
TOTAL LENGTH
DISTANCE FROM WELL--_--__— FOUNDATION NEAREST LOT
NUMBER OF LINES___ DISTANCE BETWEEN_bINES` TRENCH WIDTH_ _. ___IN. TOTAL EFFECTIVE
ABSORPTION AREA - -SQ FT. LENGTH OF EACH LINE--.----
DEPTH.
INE—.___.DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE__ IN. ABOVE TILE--
WELL:DISTANCE FROM o WATER
TYPE l'l IT'd IM)i DEPTH 26 ' , BUILDING FOUNDATION. ___.SAMPLE._--- , NEAREST
NEAREST SEPTIC SEEPAGE OTHER N,"
LOT LINE SEWER LINE , TANK C�Cf SYSTEM___ /('u / ., CESSPOOL_/ `'A ` SOURCES
DIAGRAM OF SYSTEM
DISTANCES:
/)/-/ L'/)sr lf'on
ky ialp'il0
DATE i/�.;(t'_. %'J ��% I APPROVED
- -- n A AA n
GREA "ER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO.
3500 TUDOR ROAD POUCH 6-650
ANCHORAGE. ALASKA 99502
TELEPHONE 2798686
SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT
NAME_ OF APPLICANT-L:E-lii(\'�T l` I I F-
INSTALLATION LOCATION
) MAILING ADDRESS -LI•�1 (�'`�- PHONC "�,
LEGAL DESCRIPTION - I -/r
INSTALLATION OF: SEPTIC TANK
TYPE ANO S17F nF FACT] ITY Tn BP cPavPn
SEEPAGE
/":I/`'
PIT—
-�/ /"1 '4.
DRAIN FIELD —�—OTHER
FINANCED THROUGH TO BE INSTALLED BY
SOIL TEST RESULTsi-` 'w\�)1YY`r NOTE: THIS PERMIT 15 NOT VALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED _
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK SIZE SEEPAGE AREA SIZE TYPE
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK
J
FOUNDATION TO SEEPAGE PIT--� DRAIN FIELD
SEPTIC TANK TO SEEPAGE PIT WALL / S
SEPTIC TANK !� SEEPAGE PIT �`� DRAIN FIELD
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK
DRAIN FIELD
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
i
. SEEPAGE PIT /`p ly
ALSO CONSIDER AREA WELLS.
SEEPAGE PIT
SEPTIC TANK, SEEPAGE PIT DRAIN FIELD
TO RIVER, LAKE, STREAM.
CAST _IRON INTO AND OUT OF SEPTIC TANK AND INTO _CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL ,
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
DIAGRAM OF SYSTEM
HEALTH AUTHz
Y
OR
LICENS€D DESER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORD
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. r j/
DATE ��• �- APPLICANT'S SIGNATURE
INANCE NO. 28.68 AND THAT THE ABOVE
_ATER ANCHORAGE AREA BOROL
DEPARTMENT OF ENVIRONMENTAL QUALITY CASE #
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99502
Performed For •T• e I CL_— Date Performed .i_,,,„ ,�, 70'1;2
Legal Descrir.tion: Lot Block _Subdivision ja,;jI , Hil>t—
This Form Renorts Soils Log x Percolation Test
Denth
Feet Soil Characteristics
i.oA SU 1 l
2
3 —
A _
5 Ji'J el]- :-rade(i 52--'Yj L
(1-25)
Was Ground Water Encountered? no
If Yes, At what Denth?
Reading
Date
Grass Time
Net Time Death to H2O I Net Uronl'
Date:
viat, uii FcaL'e jinuLe
Proposed Installation: Seeoaae PitDrain Fie1d _
Death of InletDeath To Bottom Of Pit Or Trench
COMMENTS
— [� � 4=Lutlxla a nztid.1 11�u Clv�hnla rixln ota r�nc),amunria
Test Performed By2t
S'�o�
Data Certified By: —
Date:
M -W DRILLING, Inc.
11. O. Boy: 4-1728 A 2811 Dawson
A C 907-27ti-17.1:
ANCHORAGE, ALASPA 99509
DRILLING LOG
Well Owner � _ Use of Zi7
Location (address of: Township, Range, Section, if known; or distance main road—
�
Size of casin____---_Depth of Hole—__ _._ _._feet Cased to.__ —feet.
Static water ievel ft. (above) (below) land surface. Finish of well (check one) open end
Screen ( ); Perforated ( ).
Describe screen or perforation----
Well
erforation Well pumping test at —gallons per (hour) (minute) for--__ hours with_
of drawdown from static level.
Date of completion --
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
_TO_
--TO----
--TO-----
-TO
TO-__ _TO __—TO
--TO-
----TO--
--TO---
-TO
O__TOTO --
-TO_ - -
Z, -
- — ——
.9 — Contract -or
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I. D. #
1. GENERAL INFORMATION
Complete legal description
HAA #
Lot 6; Bloch. 7; Ka6ito6 H.iM Subdivision
Location (site address or directions) 10701 StAogano6 V&i.ve
Property owner
Lana Shea
Mailing address Juneau, Atazka
Lending agency
Mailing addre
Day phone
Day phone
Agent Baitbana Ercni4,se VISTA REAL ESTATE Day phone 562-6464
3000 C StAeet #101
Address Anchanage.. A.Pa,,.ka 99503
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS' 4
3. TYPE OF WATER SUPPLY:
Individual well XX
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 XX
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 021
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation dates h own 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 furtherverify 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.
i
Name of Firm —E> � S �6I� Z�^�C Phone �9 '2�%9
Address
Engineer's signature
6. DHHS SIGNATURE
XApproved for te bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Date /c>- /Z-92
OF 44
i9 a/ aaW Aa4e4P
b aas a mR:
>�+�T�,..�:aauasuannaasaaae�ne, a
bedrooms, with the following stipulations:
By: Date _/0 - 1.3 - 7,;,-
—
111TIr
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_ 1/91) Back MOA 021
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:LOT 6, �1 i �r KAd(LOP µtc.rc�ID Parcel I.D.
A. WELL DA
Well type
r ��_
Sewer service line a� Petroleum tank I v0rJF_- Kn,pU,
14�45. c -7-IM6-
WATER SAMPLE RESULTS:
rnYj
Coliform — 0 Nitrate Other bacteria O
Date of sample: -2 ZCollected by: S ENG (NE6f211V(
S. SEPTIC/HOLDING TANK DATA _-12,
Date installed ` Tank size12� Cs(-+�_ Compartments
Cleanouts Y fV) ON Foundation cleanout OI) VQ . Depression (Y/J�p C)
High water alarm (Y/% o Alarm tested (Y/6q ri/
Date of pumping Pumper Mf SF/Zwc p&
SEPARATION DISTANCES FROM SEPTIC/ TANK TO:
Well(s) on lot —On adjacent lots_ (0O Foundation r
To property line
'A0 1 -f -
Absorption field
I
Surface water/drainage /Dd �-
Water main/serviceline__oZS
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
IUA�E
If A, B, or C, attach ADEC letter. ADEC water system number _Aja
Log present &N)
Date completed
— �^ ���� 2 _ Driller
Total depth Lo? / Cased to
oZ ( } 3 L�-k Casing height
Sanitary seal (61N)
JAS
Wires properly protected (t /N) �4_�S _
m
FROM WELL LOG
AT INSPECTION c
Date of test
6' 12- -1-2—
'n O Z
`�2 ;70
Static water level
n rn D
L
Well flow
g.p.m. g1P. ��,� m o
ua
Pump level
u
d- r" 0
SEPARATION DISTANCES FROM WELL TO:
rrnn
0
Septic/hefr g tank on lot
_ `(pl
; On adjacent lots 100 _
Absorption field on lot
COQ
—; On adjacent lots /on
Public sewer main
N/A Public
sewer manhole/cleanout &)/A
r ��_
Sewer service line a� Petroleum tank I v0rJF_- Kn,pU,
14�45. c -7-IM6-
WATER SAMPLE RESULTS:
rnYj
Coliform — 0 Nitrate Other bacteria O
Date of sample: -2 ZCollected by: S ENG (NE6f211V(
S. SEPTIC/HOLDING TANK DATA _-12,
Date installed ` Tank size12� Cs(-+�_ Compartments
Cleanouts Y fV) ON Foundation cleanout OI) VQ . Depression (Y/J�p C)
High water alarm (Y/% o Alarm tested (Y/6q ri/
Date of pumping Pumper Mf SF/Zwc p&
SEPARATION DISTANCES FROM SEPTIC/ TANK TO:
Well(s) on lot —On adjacent lots_ (0O Foundation r
To property line
'A0 1 -f -
Absorption field
I
Surface water/drainage /Dd �-
Water main/serviceline__oZS
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATIION J nn
Date installed YManufacturer
Size in gallons
Vent(Y/N)
High water alarm level
"Pump on" I
Manhole/A cess (Y/N)
Meets MOA electrical codes ff/N)
SEPARATION ID STANCE FROM LIFT STATION TO:
on lot
D. ABSORPTION FIELD DATA
On adjacent lots
"Pump off" level at
Cycles tested
Surface water
Date installed 6^��- 72 Soil rating L2-5-Sc�/32 System type JF_EPA& . Pt
Length iv, `A' (61 Width O / Gravel thickness 6 r Total depth /r'
Total absorption area Cleanouts present MN) ONE L " C-.7
.
Depression over field (Y/6 Date of adequacy test 6 (�1_
Results (&s/fail) PftsS for -4-t, _ bedrooms
Peroxide treatment (Past 12 months) (Y/(g (vy� W N If yes, give date -/'t
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ion � � On adjacent lots Property line o2 o
r
To building foundation 3a To existing or abandoned system on lot Ni4
r`
On adjacent lots ' _ Cutbank I✓ Water main/service line y�
/Ov
Surface water Driveway, parking/vehicle storage area /y
Curtain drain NONE- k0U in)
E. ENGINEER'S CERTIFICATION
1 certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this insp?' tion.
5 8, Sc ENGINFERING
Signature 17034 Eagle River LOOT) RAad No. 204
Eagle River, tliaska 99577
Engineer's Name 7
Date�—
HAA Fee $ (70 ' w
Date of Payment 1Z) ` —/�/�
Receipt Number ,24-1116 `- 'VW3)
Waiver Fee: $
Date of Payment
Receipt Number
s, ;At
140. R'15
Jp �e9 P�
OOo V000�00 ���a •?
• � 0e0 ^..'-'3n 1r, 4 -SIO ��i "8
a � e0 6
pp
Cn E�` I)i,
f. ag .N
s, ;At
140. R'15
Jp �e9 P�
OOo V000�00 ���a •?
MUNICIPALITY OF ANCE[ORAGE
Dl�;JSION OF ENVIRONMENTAL, HEALTH
DEPAR7:MEW OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH A=IORITY APPROVAL CF,IMFICATE
1. General Information
Application Date �1/4zii—_—
(a) Legal Description (include lot, block, subdivision, section, towiship, range)
(b)
Location (address or direct
Applicants Address
(c) Applicant is (check one) Lending Institution
Buyer ; Other (explain) ; }
�-c�/bu i lde r.
(d) Landing Institution A _ Tblephone �
Address
(e) Real Estate Co. & Agent
Address
Telephone
2. Tye of Rasidenc
Single -Family I
Number of Bedrooms
3. Water Sp�
Mull.--i-Family r�jj Other -(describe)
X
Individual Well/ Community Pub].ic
Note: If ccAimarity well system, must have written confirmation from the State
Department of Enviroramintal Conservation attesting to tlxn legality and status.
Is the well adequate for the number of bedrooms specified in this H_AA (] 'N) ---
4. Sewa e Disposal
Onsite Public �p Community r_—_j Holding Tank
Is the wastewater disposal system adequate for the number of. bedroomsYY N)
(Page 1 of 2)
2-15-94
5. F.n i.neerirq Firm P.rovidinq Inspections, '!Lsts, Data and Information
I certify that I have checked, verified, or conformed t -o all MOA HAA Guidelirfes in
effect on the date of this inspection.
Signed
Name of Vkrm
Address/)f���
Signed by
Date / f
(ENGINEER SEAL)
6. DHEP Approval
Approved for l IadroaTis
Approved E::j Disapproved F—_�
of Conditional Approval
Da tea
Te le
" 0, v h
a dt � r�
. Ei��°� ®p oaoCooyap �b��
tr
�0'i oe aic�.ga� a� isaooee yn •e
e.
Je l6roy C. Raid, Jr. <vA
No. 2251-C
Y
By Date
Conditional U C-)
-��--��� a cam- .�n�-- __��` ' � ►� �.? `��� �J ��., Lamm_
The Municipality of Anchorage Departrpnt of Health and Environmental Protection does
not guarantee the continued satisfactory }performance of the water supply and/or the
wastewater disposal. :system. This approval indioate.sl that., as of the validation date
shavn above, }cased on the data and information furnished by an ergireer registe�-�d in
the: State of Alaska, the water supply and wastewater disposal system is safe and f unc-
tional for the number of bedrooms and type of structure indicated.
(DHEP SEAT )
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
A. FALL DATA
Well Classification fi��Gll VK/GcCi-�� If A, B, or C, D.E.C. Approved(Y/N)
Well Log Present X ) Date Completed 6117--2-- Yield7647,0m
Total Depth ' ? `! Cased to?L1 ` Depth of Grouting
Static Water Level Pump Set At �vnti�»ret
Casing Height Above Ground _ ;, p� Sanitary Seal on Casing
Electrical Wiring in Condui' Depression Around Wellhead (Ye.
Separation Distances frau 1
To Septic/Holding Tank on Lot 1�2 6 On Adjoining Lots _ �
To Nearest Edge of Absarption Field on Lot ; On Adjoining Lots Z00 �/-
To Nearest Public Sewer Line _ NI;� To Nearest Public Sewer
Cleancut/Manhole N bi To Nearest Sewer Service Line on Lot !U /a=
Water Sample Collected By nPi/ Date
Water Sample Test Results 22 1la 6V 20 7
Cawents W
fir r
B. SEPTIC/HOLDING TANK DATA
Date Installed e a Size /. Z.ti L> No. of Carpartments %
Standpipes 61N) Air -tight Caps N) Foundation Cleanout
Depression over Tank () -Date Last Pumped _1-e14' a
Pumping/Maintenance Contract on File ixT) N for
Holding Tank- High -Water Alarm (YM) ,4- Temporary Holding Tank Permit (Y/1q) N
Separation Distances frau Septic/Holding Tank:
To Water -Supply %11 �� To Building Foundation /y "
To Property Line _ °�K' To Disposal Field? `7.:e
To Water Main/Service Lire _ f. ¢l To Stream, Pond, Lake, cr Major Drainage
Course
Comment
(Page 1 of 21
2-15-84
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IUNICIPALITY Of ANCHORAGE
DEPARTMEN OF HEALTH AND ENVIRONMEN PROTECTION
<� 825 L Street, AnchoracrP, Al ka 9950].
264-4720
Date Re eived: October 28, 1977
#l: Time 10:00 am � #2: Time 10.00 m #3: Time
Date 11-1-77 Tuesday Date 11-477 Wed. Date
Insp Buchholz Insp Allers Insp
REQUEST.' FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request:
Mailing Address: Phone: _
2. Property Owner: Joseph P. Stanton Phone: 344-5275
Mailing Address: Star Route A Box 94-M 99507 _
3. Legal Description: Lot 6 block 7 Kasiloff Hills Subdivisij _
4: Single Family Residence: (x) Number of Bedrooms: Four
Multiple Family Residence: ( ) Number of Bedrooms:
5. Well System: Individual Well (x) Community/Public System ( )
Permit # Depth of Well 200' Well Log on File ( )
Construction Bacterial Analysis
6. Sewage Disposal System: On-site System (x) Public Utility ( )
PermiL # /Y /r, Installed 1872 Installer
Septic Tank Size 1,250 gallons Manufacturer _ pr_aron cancrat
�,
Absorption Area 522 sq.' Soils Rate �� _ Material
7, Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest Lot line — Absorption Area
to Nearest Lot Line
Page Two
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 6 Block 7 Kasiloff Subdivision
Comments:
Affadavit Attached: ( ) Letter Attached: ( )
Approved: ' �cDate: (_12__ i
Disapproved: Date:
Department Worksheet:
Y ,
G`
