HomeMy WebLinkAboutMEADOW RIDGE ESTATES BLK 3 LT 7
e MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
.... PHONE- ~ J~NEW
LEGAL DESCRIPTION
Well Absorption area i' Dwelling ~t
DISTANCE TO: ~ ~'~O ~' O~ ~
~ Manufact~ror ~~_ ~aterial ~M N°'°f comoartm.nts
Ikiq. ca~acitg in flallons Inside length ~idth
,~O IF HOMEMADE: ~ In m }n... LiquidOepth ~ I~
~ ~ DISTANCE TO: Well ~ Dwelling PERMIT NO.
~ -- ~ Manufacturer Material kiquid capacitg in ~allons
~ Well I Foundation ~ ~' Neares~l~tline~[~ PERMITNO.
~ DISTANCE TO: ~
~ ~ h.~ Total length o~ lines Trench width Distance between lines
~ Nc. of lines Lengthofeac~ ,~'~'~
~ ~ inches
~ ~ ~ Top of tile to finish grade [ ~ Material beneath tile ~ ~ Total effective absorption area
Length Width Dopth PERMIT NO.
~ ~ Type of crib Crib t Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ ~s,~ ~ Depth Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOl L TEST RATING
INSTALLER ,
REMARKS
DATE LEGAL
77-Q13 (Rev. 3/78)
Steven A. Johnson ,
~ox 76 ·
chugiak, Alaska 99567' .[~
phone: 688-30S5 ,.~-
performed for Linde Hoffman c
Estates__
Legal Descriptio~ Lot ? Bi~ock__~?~eadow Rid~,e ....
percolation Test
Test Pit-nocation-~ ~ E: and 2I S of-NVl corner
0'- 12'
gray brown silty sandy gravel with
angular boulders to two feet
perc tested from 3' to 5'
225 ft2/bdu~
lO
12
no water table encountered
~drock at ~2 feet-
14
16
AVERAGE
Total depth this test
ABSORPTION AREA REQUIRED FROM sOILS LOG = 225
.... .oo
2.40
30 __~ -----------
----------- 2.25
2.00
~ .875 _
~ .75o
3o
16.0
ft. 2/bdrm-
pE~RC RA?.E_(Min / in-)--
10.0
12.5
16.o
l?.o
>?
L
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
~\_ L/Lo \ - .0,?~ HAA# ~-~ ¢?~ °\~' (--'3 1 ~'~-'-~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 7, Block 3, Meadow Ridge Estates, T15N, R1W, Sec. 11
Location (address or directions)
CountL'~z View Drive
(b) Property owner H.U.D.
Mailing Address 222 W. 8th. Ave.
(c) Lending Institution. N/A
Telephone:(home) Business 271-2792
(Box N-64), Anchoraqe, AK. 99513
TelePhone
Mailing Address
(d) Real Estate Company and Agent Associated Brokers / Sandy H-~elmsted
Address 640 W. 35th. Ave, Suite ~1, Anchorage, Ak. 99503-5807
Telephone (907} 563-3333
(e) Mail the HAA to the following address: (or check hereZ3, if hold for pick up.)
List contact person and day phone number below:
Pick-up By Engineer
2. TYPE OF RESIDENCE
Single-Family [] Number of bedrooms 3
3. WATER SUPPLY
Individual Well [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [] Public [] Community [] HoLding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
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MUNICIPALITY OF ANCHORAGE (MOA)
Health Aulhority Approval (HAA)
Cl?A~l¥ oCHEIDI~L/teJ¥' FEBRUARY 1984
~N,,/t~ON~NTA~. SEXY CES P~V[S§;!i'~-4744
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments
Date Completed
Legal Description: /.,o¢ '7 ~
Depth of Grouting
If(~} B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed J~/"/ ~ Size
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
lCO~ ~-: No. of Compartments ~,
Air-tight Caps (Y/N) Y~ Foundation Cleanout (Y/N)
N ~ Date Last Pumped /-/,/',¢~ ~7'~ ~r
N/,~ ;for N/~
Temporary Holding Tank Permit (Y/N) N/A
)/6,5
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well 4- ,~OO'
To Property Line
To Water Main/Service Line + I
To Stream, Pond, Lake or Major Drainage Course
To Building Foundation
To Disposal Field
N,/A
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed I ~"~
Width of Field ~) '
Type of System Design "~r"~.~
Length of Field
Depth of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation ~z '
Lot N//A
To Water Main/Service Line + I O
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
,./.
Comments ~).5
Gravel Bed Thickness ~ '
Statndpipes Present (Y/N) /v
Date of Last Adequacy Test '/J.a ~7,,",:F,?
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ,'~O '
To Cutback (if present)
N/A
D. LIFT STATION N,/¢~
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request** '~
Icertifythatl have checked, verified, or conformed to aiI MOA and HAAguidelines n effect on the date of this
inspection.
J,~¢/~ Eagle River Engineering Services
Signed . ,,
.... 3ox 7732~4
Company £agle River, Al( 99577'
6~'~-5195
Date ¢~
MOA No. ~/-- ~¢~
Receipt No.
Date of Payment
Amount: $
Receipt No.
Waiver Fee: $
72-026 (Rev. 7/88) Back
,-- Engineei"s Seal
Date of Payment
Page 2 of 2
DEPT. OF ENVIRONMENTAL CONSERVATION
/
ANCHORAGE WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
~!arch 20, 1990
STEVE COWPER, GOVERNOR
563-6775
FOR: EAGLE RIVER ENGINEERING
PWSID: ~211431
According to the records On file in this office, the Dawn Water
Co., Meadow Ridq.e Subdivision Water System is in compliance with
the State of Alaska Drinking Water Regulations.
Sincerely,
Richard Sundet
Environmental Fiel[] officer
RS:bas
,~ ~ MUNICIPALITY OF ANCHORAGE ~
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # ~"-?/ /-/~o/ 2,? HAA#
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Meadow Ridge Estates Lot 7 Block 3 T15N, R1W, Sec.ll
Location (address or directions)
Country View
(b) Property owner H.U.D.
Mailing Address 605 W.
(c) Lending Institution ,A//'~
(d)
,4 ,'g-TP-¢/?~-¢' ,/~ .Tg~phone: (home) Business 271-2792
4th Ave. Suite 081 Anchora9e, AK 99501
Telephone
Mailing Address
Real Estate Company and~Agent _The Realty Store
Address 04 '
Telephone ~L4_3~
(e) Mail the HAA to the following address: (or check here [], if hold for pick up.)
List contact person and day phone number below:
Pick-up by Engineer
2. TYPE OF RESIDENCE
Single-Family E~ Number of bedrooms
3. WATER SUPPLY
Individual Well [] Community ~ Public []
Note: If community well system, must have written confirmation from the State Department of Env ronmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site 6~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confir'~atiot~ from the State Department of Environmen.ta!
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
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MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST- FEBRUARY 1984
343-4744
Legal Description: ~¢~f'
~,~t~ ~,~ ~
WELL DATA
Wel~Classification ,,~ ~'
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Date Completed
Depth of Grouting
~, C, Approved
D.E.C.
(Y/N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
,y
Comments
SEPTIC/HOLDING TANK DATA
Date Installed /~?~ Size
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Air-tight Caps (Y/N) _
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped z¢//~ ~'
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: ................
To Water-Supply Well '~ ~¢¢ ~'.~___o. Building Foundation
To Property Line ,-¢'~ /
To Water Main/Service Line /~
To Stream, Pond, Lake or Major Drainage Course
To Disposal Field
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /¢' ~ cc,
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
~" ,_..~ ~' ~,-~, ~. ,,v~ ,~, ,,~¢,¢ ~,- ~- g -/-i,-$ ~¢~
Results of Last Adequacy Test _
SEPARATION DISTANCE FROM ABSORPTION FIELD: .
To Water-Supply Well ~ ~ / ~¢
/To Property Line .... :.
To Existing 0'r AbahS0ned System on
Lo~ .... ~ ............ ; On Adjoini~g..Lots 3¢ /
To Water Main/Service Line ~I¢' / (~o Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area /¢ /
Comments ~%~¢ ~
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA
inspection.
Signed ~~
Company .dgie h,v0r ~ngine~rino Services
Date ¢'"/'~/~/'¢'~ P, 0. Box 7?3294
Ea,]lo River, AK 9~577
MOA No. ,=,2~j--- 694,-5195
Receipt No. ~-'~'-~'~-/////
Date of Payment ~/' ~ ~- ~
Amount: $ / ~. ~
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 322 /
ANCHORAGE, AK 99503
STEVE COWPER, GOVERNOR
563-6775
FOR: Sandy/Eagle River Engineering
DATE: April 27, 1989
PWSID: 211431
To Whom It May Concern:
According to the records on file in this office, the Dawn Water
Compan~/Wynter Park Meadowridge Estates water system is in
~o~pli~nc~-wlth the State o~ Alas]~ d~inking water regulations.
Sincerely,
Environmental Engineer
VEC: kk
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF 14EALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
254-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name¢~/~ /~¢&S Telephone: Home A¢~¢ ~?(/ Business
(c) Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain);
(d) Lending Institution
Address
Telephone
(e) Real Estate Company and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family ~/~ Multi-Family
Number of Bedrooms --~/~/~//¢
Other
WATER SUPPLY
Individual Well [] Community Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ~ Public [] Community [] Holding Tank []
Note: if/'community well system, must have written confirmation from tlqe State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify tl~at rny investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastowater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Address _ /(~'~-.,-,/--/'r~'¥~l/3'7lt~f]
Date ~ ) / ~/~- - ~¢AJ~
Engineer's Seal
DHEP APPROVA.__~L.
Approved for /' z'.(,~/' . bedrooms by _.~/~
Approved ~.. ~.-~ ~ Disapproved
Terms of Conditional Approval
Conditional
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
eagineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
Legel Description'
WELL DATA
Well Classifioation
Well Log Present (Y/N) --
Total Depth - Cased to '
Static Water Level
Casing Height Above Ground -
Electrical Wiring in Conduit (Y/N) -- "
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
NOV ].
CEIVED
tf A, B, C, D.E.C. Approved (Y/N)
Date Completed · ' Yield
Depth of Grouting '
Pump Set At "
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Size .,/15'"'~ No. of Compartments
Air-tight Caps (Y/N) y Foundation Cleanout (Y/N) '~/
Date Last Pumped
A,/ ;for
Temporary HoLding Tank Permit (Y/N)
To Building Foundation ~
To Disposal Field '~
To Stream, Pond, Lake, or Major Drainage
Course ~-- -"
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed //- I(~- ~
Width of Field ~
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
Type of System Design
Length of Field '~..
Depth of Field ~
Gravel Bed Thickness ~
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Water Main/Service Line /~-4'-
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ~
To Cutbank (if present)
LIFT STATION
Date Installed ~ Dimensions
Size in Gallons '~..~._Manhole/Access (Y/N) /
"Pump On" Level at '"'-,,,~ p Off" L ev~~__
THie:thedWfa~r Alarm Level at .~_..j.j~u~s d~Gnt ,Y/N)'~ring Adequacy Test, Meets MOA
%1~: ~Cea~t~od es ( y/N ~......,..,........~ ..j.j~_.~-
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I h~ve c.hecked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed~*.~ Date
Company ~.,."~'~, ~ ~o~¢~-.~4 MOA No.
Page 2 of 2
72-026 (11184)
Receipt No.
Date of Payment
Engineer's Seal
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
To Whom it May Concern:
~co~o ~o ~e~o~s o~
Water Regular'ions
Water System is in compliance with the State Drinking
Sincerely,
. . u~E RECEIVED
INSPECTION APPOINTMENTS
TIME TiME TIME
DATE DATE DATE ~-~-~ [
I INSPECTOR ~ ~-[ \
I NSP ECTOR INSPECTOR
DEPT, OF HEALTH &
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL P~OTECTION
DBPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
OCT O 1980
ENVIRONMENTAL SANITATION DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FAGILITIE~
DiREoTION~: Gomp~ete ~11 p~rts on page 1. Incomplete requests will not be pro~essed. P~e~se ~How ten (10) days for processing.
PHONE
MAILING ADDRESS
~RO~RTY R~DENT (If different f~m ahoy )
PHONE
2. BUYER
MAILING ADDRESS
~ PHONE
LENDING INSTITUTION
~AILING ADDRES~
'~G A~?ESS
LEGAL DESCRIPTION
;TREET LOCATION ·
6. TYPE OF RESIDEN¢
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [] Four
~ Two [] Five
[] Three [] Six
[] Other
7, WATER SUPPLY
[] INDIVIDUAL*
~ COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
/~YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE; THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
12-010 (Rev. 6/79)
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
MULTIPLE FAMILY
THIS SIDE FOR OFFICIAL USE ONLY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3, SEWAGE DISPOSAL SYSTEM
[] INDIVI DUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE [] OTHER
[] TWO [] FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
E~Septic Tank or []Holding Tank
Size: \~3;;~ If Tank is homemad[
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION AREA
4, DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
INSTALLER
SOILS RATING
MANUFACTURER . ~.~,./
MATERIAL
Septic/Holding Tank IAbsorption Area
Line
5. COMMENTS
DATE
E]~J~PROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate}
[] DISAPPROVED
72-010 {Rev. 6/79)