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Home My WebLink AboutKENO HILLS #1 BLK 4 LT 3 e ~ MUNICIPALITY OF ANCHORAGE ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION EN~/IRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE ~' NEW MAILING ADDRESS NO. OF BEDROOMS J~ell I Absorption area Dwelling PERMIT NO. ~ ~ DISTANCE TO: ~ Z Manufacturer ~ ~ Material~ No. of compartments~ ~ ~O IF HOME,DE: ~ ~ Width Liquid depth ~ ~ DISTANCE TO:' Well Dwelling PERMIT NO. ~_~O ~ ~ Manufacturer ~ ~ ~ Material Liquid capacity in gallons ~ ~eH Foundation Nearest lot line PERMIT NO. DISTANCE TO: Distance between lines Length of each~ Total length of I~s~ Trenc~wi~t h inches No. of lines ~ ~ Total effective absorption area ~ Top of dle to finish grade ~ O ,, Material beneath tile 5I O inches ~O Length Width Depth PERMIT NO. ~ ~ Type of crib Crib Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ass Depth Driller Distance to lot line PERMIT NO. m Absorption area{s) ~ DISTANCE TO: Building foundation Sewer line Sept$c tank OTHER SOIL TEST RATING INS~LLER ~ DATE LEGAL 72-013 [Rev. 3/78) ~ ,' 205 SIX!INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF DRILLED AT THE RATE OF ProPertY OWNE ~. Per FOOT. ;74943 L~cu~c~ ~. 99504 LO~ATION Of WELL SITE ~L. B~. Smb. wELL lOg: 26,',..--55' S2J.,~ q.,tazre. J.. od.Ch. 2~/~ c2zn]. &,Lr~Le.¢. Sor~e~__~_~:r,~ o~ ~a,Le.~;:a,L 26 S~ c,kW. w. Ubh. 15~ qyuzt~e.L, ,~q.L~o ~z ~ t~a,Le,t &ea/tJ~q..~and at. 55 55~--99' t4a. cdpa~.Some 99'-205 B~ocA. R ~~ ~788 Zo 194 ~. ~ '~Yed.,L C~p: ~/70.00 CO~T INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. write CHECK PaYAble TO rampart DRILLINg WORKS For THE SUM Of I THANK YOU VERY MUCH. DATE ~U~¢ 73~ , 78 BE~ CLAUS~OF RAMPAR~ DRILLING~~WORKS SERVICE CHANGEOF I~% PEr MONTh WILL be ASSESSED ON PAST DUE~~ PERMIT NO. APPLICANT LOCATION LEGAL DEPARTMENT r--HEALTH "ND ENVIRONI~ENTI~L..-'-'OTECTION ~(.., ~ELI .... ND ON--5 I TE SE~ER PERM I ~ ~PRIN DRIVE L~ B4 KENO HILLS ADDITION ~l LOT SIZE 114273 ~QURRE TYPE OF SOIL RBSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RRTING THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS: DEPTH= 8 LENGTH= 76 13R.~, VEI DEPTI |= 4 THE LENGTH DIMENSION IS THE LENGTH (IN FEET> Of THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVATION (IN FEET). RE(~U I RFD --c:EPT I C TANK S I ZE= 12:50 t31=ILL O1'-.i$ PERMIT RPPLICRNT HAS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS RDJRCENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. TWO (2) INSPECT I OIN$ ARE REt-'~U I RED BACKFILLING OF ANY SYSTEM WITHOUT FINRL INSPECTION AND RPPROVRL BY THIS DEPRRTP1ENT WILL BE SUBJECT TO PROSECUTION. MININUM DISTRNCE BETWEEN R WELL AND RNY ON-SITE SEWAGE DISPOSRL SYSTEM IS i00 FEET FOR A PRIVRTE WELb OR i50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 20 DAYS OF THE WELL COMPLETION, OTHER REQUIREMENTS MRV' RPPLY, SPECIFICRTIONS AND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLATION, PER'FI! T EXP I RF_~ DFCFI'IBER _~:1_~ i975 I CERTIFY THRT l: I AM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS AS SET FORTH BY THE MUNICIPRLITY OF ANCHORRGE. 2: I WILL INSTALL THE SYSTEM IN RCCORDRNCE WITH THE CODES. 3: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS R~MODELED TO INCLUDE MORE THRN 4 BEDROOMS. ................. Performed For ~enal ~e$crt~tton: Lot ~ ~1oc~ 4 Thts ~orm Renorts Sotls Lon 2204 Cleveland Anchorage, Alaska 99503 FUsaro Construction Date Performed 5-30-78 Subdivision Keno Hills Addition #1 PercolattonTest_ .neDth ~eet 2-- 10-- 14-- 16-- 18-- 20-- Sotl Characteristics Slightly silty sandy gravel with occasional cobbles Bottom of test hole Was Oround Water Encountered? Yes, At what Depth? Readtnq Date Grnss Time Net Ttme Depth to H20 Net Drop J J * · i · t Percolation Rate fltnute Prnnosed InStallatloh': 'Seepaae Ptt Dratn Fteld Depth, °f~5~nlet~u ' .Depth_ To Bottom Of PJt Or Trench CA~.PENTS. · 'sq. ft. drainage ar, ea V~ou~rmd. n~r h~a .... Bye_ Data Certified B~. Test Performed CTL Date: 5 - 3 o - 7 David Paul ~UNICIPALITY 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 GENERAL INFORMATION Complete legal description Location (site address or directions) Property 'owner Mailing address Lending agency Mailing address Agent /N. A. Address j--~ck ~ Prxm 7-~xor~i Dayphone Fir~ Na¢'l ~an~ of ~eg Day phone ( ~3a ~inanc%) Day phone 2. NUMBER OF BEDROOMS: 3, TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NQTE: Individual well ~ Community well Public water 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 NOTE: Holding tank CommUnity on-site PUblic sewer If community wastewater system, PrOvide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA#21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Fl,~ b/'~fp 7-~,c/~);~f _{'er~'~(~, Phone ~q3"- Address Iq~30 ~c~a ~/'2 ~rA~r~/ ~ Engineer's signature ~~ ~ ~ Date ~r~ · THEODOJ~E F. MOORE .* . ~ ~;~ · C,- beOrooms. DHHS SIGNATURE ~ Approved for Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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 #21 Municipality of Anchorage ,~ De partment of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LOT ~ ~Lk: u~. E~0 HI L~.-~ ~1 Parcel I.D. A. Well Data Well type ~>RtV/~TE Log present (Y/N) Total depth 2. o5 Sanitary seal (Y/N) If A, B, or C. attach ADEC letter, ADEC water system number N.~t. Date corn pleted /o 113/'/8 Driller Cased to c/~l ' Casing height I '~" Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG AT ,.SPECT, O" /'. .30 33 ~,. z./. g.p.m. ~ 7.~ g.p.m. , Y SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~'5~ To C.O. Absorption field on lot Public sewer main ~. Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: 7--/~-z Nitrate yd' ~,/-E Other bacteria Collected by: ~"/~/~ TTo? T~Cl-I B. SEPTIC/HOLDING TANK DATA Date installed ~.?./7~ Cleanouts (Y/N) ~/ High water alarm (Y/N) N ,/~ Dateofpumping ~"1' /'~ / ~ ~ · Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Alarm tested (Y/N) Tank size Foundation cleanout (Y/N) (~A / Compartments :7_ "/ Depression (Y/N) Well(s) on lot ~$' ~',ee~ To property line .~ ~'o Surface water/drainage Foundation !o' Water main/service line CONTINUED ON BACK PAGE 72-026 [3/93)* Front C. LIFT STATION 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 On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~-/73 Soil rating (GPD/Ft2) I c;?p/F{,~- System type Length 7~ ' Width 3 ~ ~ Gravel thickness ~' Total depth ! O Total absorption area '780 Cleanout present (Y/N) ~/ Depression over field (Y/N) Date of adequacy test ~' / 17 / ~ 3 Results (pass/fail) ¢'~.r for ¥ Bedrooms 'kWater level in absorption field before test ~'" After test (9" Peroxide treatment (past 12 months) (Y/N) lq o N ~- k'~/o ~/N' If yes, give date I,~, ~ , SEPARATION DISTANCE FROM ABSORPTION FIELDTO: ~¢~-ty ~ ~mn,~r ~ Wellonlot ]lO' FRo~ C.D. Onadjacentlots ~/oo ' Prope~line To building foundation 2~ ' F~o~ C,o, To existing or abandoned system on lot On adjacent lots ~ 5b ~ Cutbank N,~, Water main/sewice line Sudace water ~/oo Driveway, parking~ehicle storage area Curtain drain Iqot.1g oE,$~ R VE ~> E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in e~_ ~e date of this inspection. Signature ~~ Engineers-' Name · ....... H~ Fee $ ~ Date of Payment ~ ~7~' ~ ~ Date of Payment Receipt Number ~ ~ ~/ ~7~ ~ Receipt Number 72-026 (3~3)* Back COMMERCIAL TESTING & ENGINEERING CO, ......... REPORT of ANALYSIS Chemlab Ref.# :93.3570-1 Client Sample ID :L3. B4 KENO HILLS ~1 Matrix :WATER :TED MOORE ctName : Project# : PWSID :UA :68620 :07/27/93 5633 B STREET ANCHORAGE. AK 99518 TEL: (907) 562-2343 FAX: (907) 561-5301 WORK0rder RePort Com~leted Collected :07/22/93 Received :07/22/93 Technical Director:STEPHEN Released By : @ 11~45 hrs. @ 13.i5 hrs. Sample Remarks: ROUTINE SAMPLE COLLECTED BY: CHRIS. Parameter Results Nitrate-N 0.46 Qc Method mg/L EPA 353..2/300.0 Allowable Ext. Anal Limits Date Date Init i0 07/26 LLH · * Above ' · * ~ J~ve U = , RePorted value is the practical quantification limit. D = Secondary dilution. UA = Unavailable NA = Not Analyzed LT = Less Than GT = Greater Than ENVIRONMENTAL SERVICES IN ALASKA COLORADO, UTAH. ILLINOIS, OHIO, MARYLAND. WEST VIRGINIA, NEW JERSEY. SOUTH CAROLINA Muni pality of Anc rage Department of Health and Human Services Torn Fink, 825 "L" Street Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 October 5, 1993 Ted Moore, P.E. Flattop Technical Services 14530 Echo Street Anchorage, Alaska 99516 Subject: Waiver Request for Lot 3 Block 4 Keno Hills Subdivision #1 Waiver Request %WR930055, PID %020-171-17, HA930523 Dear Mr. Moore: Your request for waiver(s) of the required 100 foot horizontal separation of a septic system to a private well has been approved. The approved separation distance(s) are a private Well to the septic tank of 93 feet. This waiver approval applies to the existing septic system to well separation only. Any future upgrade to either will require all separation distances be met or another approval from this department. Sincerely, Daniel J. Roth Civil Engineer On-site Services ~_rog .r .am ~ana .ger On-site Services ljm:%6 ~MUNICIPALITY OF ANCHORAGA~,z Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR~LL~_~_ PID~ ~)Q~-\~\-~ HA# ~~.~Permit Date Received: August 27, 1993 Legal Description: Lot 3 Block 4 Keno Hills Subdivision Engineer: Applicant: Ted Moore, P.E., Flattop Technical Services 14530 Echo Street, Anchorage, Alaska 99516 Jack & Pam Tuomi Waiver Requested: Private well to septic tank - 93 feet Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: ~ Waiver is NOT Granted: List Conditions or Reasons for above: Date, Rec 9: 25081/9773 Reviewer Amount: $ 625.00 Date Paid: Au~ 27, 1993 I I ~E R~£,~u I T F 2. -I- X=, 72--*' ,Z 2.7 17.3 / P 'TECHNICA t 1¥[[, 8t ENVIRONMENTAl, EN(;INEERIN¢: · ENERGY CONSERVAT[ON& ANALYSIS TIIEODORE F. MOORE. I'.E. 14530 ECHO ST. PH: (907) 345-1355 ANCHORAGE, ALASKA 99516 August 27, 1993 M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: By means of this letter we are requesting issuance of a separation distance waiver allowing the existing septic tank on Lot 3, Block 4, Keno Hills S/D to remain 93 feet from the private well on the same lot, instead of the normally required 100 foot separation. A site plan and copies of relevant backup documents from DHHS files are enclosed, as well as an application for a HAA certificate. According to the driller's log, the well was completed on June 13, 1978 and has a total depth of 194 feet and a yield of 4 gpm. The log indicates that the subsurface soils are predominantly sandy clay and hardpan, with bedrock being encountered at 99 feet. A small aquifer was encountered at 125 feet, and a more productive one between 188 and 194 feet. On July 22, 1993 we conducted a yield test of the well. The initial static water level stood at 33 feet below the top of the casing. Steady pumping of 756 gallons of water from the well at the maximum pump output to 7.7 gpm caused the water level inside the casing to be drawn down to 108 feet, but no further. Based on these test results we concluded that the total yield of the well is in excess of 7.7 gpm, which is more than adequate for any single family residence, and also exceeds the FHA lending criteria that a well be able to supply 720 gallons of water within a 4 hour period. Water samples collected on July 22 were satisfactory, showing 0 coliform or other bacteria per 100 ml., and 0.46 mg/l of nitrate-N. According to the as-built inspection report on file at DHHS, the wastewater disposal system was installed in December of 1978 and consists of a 1250 gallon septic tank followed by 78 lineal feet of soil absorption trench containing 5 feet of sewer gravel. The Municipal inspection report dated 12/11/78 indicates that the well was still proposed at that time, however the inspector's earlier undated field notes clearly show that the well was already drilled at the time the soil absorption system was being installed. Apparently the inspector did not verify that the required 100 foot separation distance was maintained between the well and the septic tank, nor did the person who signed the HAA certificate in February of 1979. Measurements made by our fu'm on July 22 of this year indicate that the well casing is located 95 feet from the septic tank cleanout - otu' waiver request of 93 feet is to allow for probable underground projection of the tank slightly closer to the well. On August 17, 1993 we conducted an adequacy test of the wastewater disposal system, after the horizontal distribution pipe had been jetted out by Roto Rooter. The bottom of the monitor tube in the trench is approximately 78 inches below the outlet of the septic tank, and based on capacity measurements of the trench we concluded that the trench is filled with sewer gravel up to the level of the outlet of the septic tank. Thus, even though the maximum fluid depth of 69" measured in the monitor tu~ d~ng ~s test is greater than the reported gravel depth of 5 feet, we do not believe the system was operating in a surcharged condition. On August 17 the initial fluid depth in the trench was 46 inches, and the addition of 852 gallons of water caused this fluid level to rise to 69 inches. After the system had had an opportunity to absorb for 200 minutes it required 100 gallons of water to bring it back up to the same level. Based on our test data we concluded that the system is able to accept water at a rate of slightly over 700 gallons per day, which exceeds the Municipal requirements of 600 gallons per day for approval of a 4 bedroom residence. The topography of the lot slopes generally down from east to west, however the well is located atop a low ridge which slopes towards the northwest. The grade over the trench slopes gently towards the west, however starting approximately 15 feet west of the trench the land drops off at approximately 45% down towards Spain Drive. The trench is deep, and no effluent was daylighting from it during our test. The topography is such that effluent from the septic tank, were it to fail, would flow almost directly away from the well. The shallow soils log prepared in May of 1978 in conjunction with the installation of the septic system indicates the shallow soils to be a slightly silty sandy gravel with a visual soil rating of 150 square feet per bedroom. This material should be able to provide good ~tration of septic tank effluent. The relatively slow absorption rate measured in our adequacy test also indicates that the soil is not overly permeable. As mentioned above, the well log shows relatively impermeable silty gravel, sandy clay and hardpan all the way down to bedrock at99 feet, with the first aquifer being tapped at 125 feet. The fact that the static water level was at 33 feet indicates that the aquifer is confined and artesian. As such, it would be almost impossible for contaminants originating on this lot to make their way into the aquifer and be drawn into this well. The following is a breakdown of how waiver analysis points could be assigned using the DEC's 1985 "Separation Distance Waiver Guidelines for SCRO". Category Vertical distance to water table (125' aquifer - 10' tank = 115') Soil sorption ((89' x 4.5) + (26' x 6)/115) = Permeability (perc rate > 50 min./inch) Water table gradient (assume +5% parallel to topography) Horizontal separation (93') Total Points 7.08 4.84 3 4.5 2.72 22.14 Based on this point assignment it appears that the requested waiver can be safely granted without undue concern as to the potential for contamination of the well on this lot from the septic tank on this lot. The fact that the recent water samples were satisfactory further supports this conclusion. Please feel free to give me a call if you have any questions on this analysis. Sincerely, Ted Moore, P.E. cc: Jack andPamTuomi LOT 4 LOT 6 LOT 4 BLOCK 2 LOT 5 NOTE: NO OTHER WELLS OR SEPTIC SYSTEMS WITHIN 100 FEET OF L3,B4 WELL AND SEPTIC SYSTEM 45% 2% 2% EXISTING WELL ¢~ 2-10%~ R 100' :PTIC TANK LOT 3 BLOCK 4 4SDR~ HOUSE SOIL ABSORPTION LOT 2 \ \ \ 20 0 20 40 60 80 100 FEET LOT 3, BLOCK 4, KENO HILLS S/D WELL AND SEPTIC SYSTEM SITE PLAN FLATTOP TECHNICAL SERVICES 1 INCH = 60 FEET 14530 ECHO STRF~T DRAWN BY TFM ANCHORAGE, ALASKA 99516 AUGUST, 1993 NOTE: THIS IS NOT A SURVEYED PLAT. ALL LOCATIONS SHOWN ARE APPROXIMATE. , ': -~*¢~2~ - (¢/ :L MUNICIPALITY OF ANCHORAGE ~ ENV RONMENT,,',; ,:: CT ON ~ L~~ 825 L Street- Anchorage, Alaska 99501 u,,u [~VllO~[l?A[ [~81~[f~116 ~lVlllOI Telephone 264-4720 RE C E i V[ D REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page' 1. Incomplete reques~ will not be processed. Please allow'ten (1~) days for processing,~',, 1. PROPERTY OWNER I PHONE MAILING PROPERTY R ESI DENT Jif different from above) ~ ¢ PHONE 2, BUYEa / ~ PRONE MAILING ADDRESS 3, LENDING INSTITUTION I PHONE MAILING ADDRESS ' 4. REALTOR/AGENT ~ PHONE I MAILING AD~ ESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE [~ SINGLE FAMILY [] MULTIPLE FAM LY NUMBER OF BEDROOMS [] One ~ Four [] Two [] Five [] Three [] Six [] Other WATER SUPPLY [] ND VIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled s~nce June 1975, For wells drilled prior to that date, give well depth (attach log if available,) 8. SEWAGE DISPOSAL SYSTEM ~ NDIVIDUAL/C N-SITE** [] PUBLIC UTILITY **If individual/on-site, give installation date If system is over two (2) years old an adequacy test is required by this Department, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECE VED ~ INSPECTION APPOINTMENTS ' . ' · TIME TIME ' TIME DATE DATE - DATE INSPECTOR ' INSPECTOR INSPECTOR DIRECTIONS:r 1. TYPE OF RESIDENCE NUMBER OF:BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FiVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2. WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ~ PERM T~NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank , Size: . If Tank is homemade SOILS RATING give dimensions: TYPE O F TAN K MAN U FACTU R ER TOTAL ABSORPTION AREA MATERIAL 4; DISTANCES wer Line Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS · IZ~PPROVED FOR ~" '~ BEDROOMS [] CONDITIONAL APPROVAL (letter mustaocompany certificate) [] DISAPPROVED DATE BY/~T~e) LEGAL DESCRIPTION 72-010 (Rev, 3/78)