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Home My WebLink AboutMCMAHON #2 BLK 10 LT 7 - 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 MAILING ~DDR~/' -- ~/-- NO. OF BEDROOMS / Well Absorption crea DISTANCE TO: ~.:/~ Manufacturer ~ Materi~L ~ No, of compartments Liq. capacity in gallons DISTANCE TO: I Well ~STANCE TO: I ~ No of hnes ~ Length of each hpe / ' Top of tile to finish grade ~ ~ Width Type of crib ~ area DISTANCE TO: ~Cl~s Depth Building foundation DISTANCE TO: Inside length Width Liquid depth Dwelling PERMIT NO. Material Liquid capacity in gallons Foundatio~) i .~ Nearestlotline,~)I PERMITNO. ~_ Total length of lin~7/~,I Tren° hinches Distance between lines Material beneath tile~.~v~'/¢') inches Total effective absorption area Depth PERMIT NO, Crib depth Total effective absorption Building foundation Nearest lot line Driller Distance to lot line PERMIT NO. Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOl L TEST REMARKS APPROVED ~'2~-013 (Rev. 3/7-~ v .~ DATE LEGAL PERFORMED FOR: LEGAL DESCRIPTION: MUNICIPALITY OF ANCHORAGE ~ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99602 276-222'[ SOILS LOG - PERCOLATION TEST LOG [] PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19- 20- SLOPE SITE PLAN ~ ~ ~-' - ! ~ i I : ~ : - ' r , , i------~ i i .; .. WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST ~_~UN BE'I~NEEN (minutes/inch) FT AND, '7- FT CERT, ,ED" : il ?' TE: d'.- / z_ .- 72-O08 (7/76) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description r.ot 7; Block 10; McMahon Subdivision Location (site address or directions) 13101Killey Property owner Maiiing address Julia Bevins Day phone Lending agency Mailing address ' Agent DeAnn Gleason/CRAWFORD REAL ESTATE Address 3380 c Street, Suite 110, Anchorage, Alaska Un/ess otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 ~ TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: Day phone Day phone 99503 562L5592 If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and 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 Address Engineer's signature DHHS SIGNATURE Approved for Disapproved. Conditional approval for ............. RING 17034 Eagle River Loop Road No. 204 E~gle River, AiasJ(a ~5~! Phone Date bedrooms. 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 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 MOAiff21 '* ~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAl. CHECKLIST Legal Description: /-.Oq- '-TT-! I~L~ lO! /~¢,/~N "~D Parcel I.D. A. WELL DATA Well type Log present ~_.~N) Total depth Sanitary seal ~/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed 6- ~%-~ Driller --~Y~E~ Cased to (~(~' Casing height Wires properly protected (~/N) ~/~--~ Date of test Static water level Well flow Pump level FROM WELL LOG g.p.m. AT INSPECTION MUNICIPN, ITY I~NVIRONMI~Nf^L SEI~VI¢I"$ DIVISION EIVED SEPARATION DISTANCES FROM WELL TO: Septic/h~tank on lot Absorption field on lot Public sewer main ~')//~ Sewer service line '~t~t4~ /00 ~ lO0 + ; On adjacent lots /00 '~' ; On adjacent lots /00' '.~- PUblic sewer manhole/cleanout ~J/~- Petroleum tank WATER SAMPLE RESULTS: Coliform (~ Nitrate Date of sample: ~--~-~H _c~ ~ Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts ~N) High water alarm (Y/[~) Date of pumping Tank size Io~.~.;>O ~'Pr~- Compartments Foundation cleanout ((~.N) ~/ti~__~, DePression (y/~_.~ Alarm tested (Y/~__)~ /%)/$ o%'-"~ -~ ~ Pumper /~r' 4- Well(s) on lot 100' To property line lO Surface water/drainage SEPARATION DISTANCES FROM SEPTIC/I IOLD;NG TANK TO: f On adjacent lots (0 0 ~- ¢ Absorption field ~ [OO' F Foundation .~,(~ 4- Water main/service line ~ 4- 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIF'r STATION ! Date installers. ~ Size in gallons ~ Vent (Y/N) "Pu~ High water alarm level ~"~'-C*y~es tested Meets MOA electrical codes (Y/N) ~ SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water Man u faotu rer Manhole/Access (Y/N) "Pump off" level at D. ABSORPTION FIELD DATA Date installed :.~-~o~.- ~ Length L~L~ .Width ~ Total absorption area L'/cqCD .~ ~' DePression over field (Y/~).~ ~',~ Results a~/fail) '~NS.S Peroxide treatment (past 12 months) (Y/~) Soil rating ~Co ~'~//~J~, System type Gravel thickness 5 * Total depth /0 -// Cleanouts present ((~N) Date of adequacy test for ~ bedrooms ~',~c~T ~mow ~ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /OO To building foundation On adjacent lots ~O' Surface water Curtain drain ~k.~tSM~ On adjacent lots IO(~ ~- Property line LeO' ~- To existing or abandoned system on lot ¢ Cutbank /0d ¢- Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect date of this inspection. Signature Engineer's Name Date S & S ENGINEERING 17034 Eagle River Loop Road NO, 20_4 r~agie River Aiauka 9'~577 HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number 72*026 (Rev. 3/91) Back MOA 21 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ANALYSIS RESULTS for INVOICE I 52981 Chemlab Re£.# 92.1614 Sample % 3 Matrix: FAX: (907) 561-5301 Client Sample ID : L7 BiO MC~AHON S/D PWSlD : UA Collected : APR 18 92 @ Received : APR 18 92 @ 13:30 Preserved with : AS REQUIRED Client Name :S & S ENGINEERING Client Acc# :SNSENGP Req# : O~dered By :$IM WILLIAMS PO# :NONE RECEIVED Analysis Completed : APR 21 92 Laboratoxy Supexvisox 2_STEPHEN C. EDE Send Reports to: 1)S & S ENGINEERING Parameter Results Units Method Allowable Limits NITBATE-N 1.4 m~/1 EPA 353,2 10 RECEIVED JUL 2 19 2 D Municipality of Anci;orage ept Health & Hurnar~ Services Sample ROUTINE SAMPLE COLLECTED BY: UA. NO TAG FOR THIS SAMPLE. Remarks: I Tests Performed * See Special Instructions Above UA-Unavailable ND= None Detected "See Sample Remaxks Above NA= Not Analyzed LT=Less Then, GT=GKeater Than ~SGS Member of the SGS Group (Socibt~ Gbn~rale de Surveillance) MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF, -~: ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING: ' ~f~l\']- ,~l~-~- ~)~-~O HAA# ~¢:~°tF¥'"{;b-,~ Parcel I.D. # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t. block, subdivision, section, township, range) Lot 7; Block 10; Mc Mahon S~§divZsion ~ Location (address or directions) I 3101 Killey Str¢6t (b) (c) Property owner Julia Stahman/John B6vin Telephone: (home) Mailing Address 15101 Kil£¢~] St. Anchorage, Ala~kzz 9~$~ Business Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent Address (e) Telephone- Mail the HAA to the following address: (or check hereY~, if hold for pi(~k up.) ' ' ' ' '"" ' List contact person and day phone number below: S & S ENGINEERING 17034 Ea~le Ri~er Loop Road No. 2~4 Eagle River, Alaska ~2577 2. TYPE OF RESIDENCE Single-Family [~x. Number of bedrooms 4 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If co.r0munity,:well-system must have,written-confirmation from the State. Depa[.t, mentof Environmental- - Conservahonattest~ng'to'th legahty and status. ' ......... 4. SEWAGE DISPOSAL - On-site E~(,~,- Public [] Community [] ...... Holding Tank [] - - - : .... ' ', : ~ ,~*;' 1 ...... ' :' Noi~ I{'c~mm'unit~ Well system, must have w~'itten c~nfi~'maiicJ-n'~r0~'{h'~ Stat; aep,~[t'r~er~t.'~f invi-r0nm~al Conservation attesting to the' legailty and status ............ ... _ ........ ¢,., .... : ....... _ ,. ; ,- 72-025 (Rev. 7/88) Page 1 of 2 ' 5. 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.that my investigation of this Health Authority App[o~/al shows that. the on-sire.water supply and/or'wasteWater'disposal system is safe, functional.~nd adequate for the number of bedrooms and type of structure indicated I~e~ein. 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 ineffect on the date Of this inspection.'? '.'~'. ''~- '! Telephone Name of Firm Address 17034 F. agle ~ive, r._L~o~,p.~,Road No, 2~ Date THE CONDITIONS OF THE H.A.A. ISSUED ON JUNE 21, 1990 HAVE BEEN MET. SEE LETTER ATTACHED. Approved for_'~ bedrooms by Approved" ' ./V-x. '/;'~- Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 ~nalyze'da~a before a'certificate is is'sued. The Municipality of Anchorage is not responsible :f°r errors'or, omissions in the professional engineer's work. 72-025 (Rev. 7/88) BP. ck Page 2 of 2 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN ROBERT SHAFER, P.E. ROGER SHAFER September 14, 1990 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION Mr. Kip Clapper 6300 Downey Finch Drive Anchorage, alaska 99516 REFERENCE: Lot 7; Block 10; M~Mahon Subdivision; 13101 Killey Street, Anchorage E, 1 8 1990 RECEIVED Dear Mr. Clapper, At your request we have performed a septic system adequacy test on the referenced property as per a conditional Health Authority Approval dated June 21, 1990. The septic tank was pumped by A+ Home S~rvices just prior to testing. On September 11, 1990 water was added to the septic system while water level measurements were taken from the monitoring tube located at the end of the l~achfield. From this test we have found the system to be functioning adequately for the 4 bedroom residence located on the property. However, the system cannot be guaranteed against subsequent failure. If we may be of further service, please contact us. glunicipality of Anchorage Department of Health & Human Services 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 Parcel I.D. # ~ ' MUNICIPALITY OF ANCHORAGE ~ (~rt,_~'~l , Department of Health & Human Services : . .,~ ~ .DIVISION OF ENVIRONMENTAL SERVICES · CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING ['~'~ - .~lr',;~ - ("~ HAA # GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description Iinclude 10t, block, subdivision, section, township, range) (b) Property owner (c) (d) (e) Location (address or directions) Mailing Address Lending Institution Mailing Address Telephone: (home) '~ ~'5--3'¢¢f' Business Mail the HAA to the following address: (or check here ~, if hold for pick up.) List contact,person and, day phone number below: ,- ', ~ /..:.,. ;. Real Estate Company and Agent Telephone ~ ¥$--~'4¢ ¥¢ 2. TYPE OF RESIDENCE Number of bedrooms Single-Familyl~ 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 I of 2 '~JoM 9.jeeu!bue leUO!SSe,toJd eH), u! suo~ssluaci'~o s~0JJe~°~'elq~su~dse] ~,ou s~ eSeJ°qou¥ jo ~Lledlolunw eqJ. 'penes. s. e~,eo~,t!),Jeo e eJojeq e),ep ez~leue Jo suo.],o~)dsu~),onpuoo),ou op SHHC] ,to see~oldUU3 .s~,ueuaej!nbeJ e~e~s pue le~epe~ ui!e),Jeo,~,tsi~es o~,~epJo u! suo.~m, Bsu! 5u!puel ~!eq), pue eeuJoq ,to sJeseqoJnd o), ,~seunoo e su s!q), eeop SHHQ eq.I. 'e~Sel¥ ,to e~e~,S eq), u! pe~e~s!Se~ ~eeu!Sue leUO!SSe,to~d ],uepuedepu! ue/~q e^oqe ~ qdeJ[JeJed u. ue^.8 suo~ueseJdeJ eq~, uodn ~lUO peseq leAoJdd¥/~],poq~n¥ q~,leeH sense! (SHHC]) seo!MeS ueuJnH pue q~,leeH ,to ~ueuu),JedeQ e§eJoqou¥,to XLled!o!un~ eql leUOB!puoo peAoJddes!O ,~., pe^oJddV k Jo,t pe^o~ddv 'l¥^Oadd¥ SHH(;] '9 lees s. Jeeu!Su=~ MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 ;~;~ C. PALI1Y OF ANCHORAGE Legal Description: ~VlRONMENTAL SERVICES DIVISION A. WELL DATA Well Classification Well Log Present (Y/N) Y' Total Depth BO' Cased to __ Static Water Level q! ~ Casing Height Above Ground 2 0 1990 Date Completed Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot IO7' % To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by ~, -/'.-¢. Depth of Grouting N,~.. Pump Set At %> qV ~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) If A, B, C, D.E.C. Approved (Y/N) Yield .-~ T,,C~/cr,, oo. ; On Adjoining Lots ~ ~ !1o' i On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ; Date 5-/~ r' 2~ I'~,E'C',e'~/ No. of Compartments Air-tight Caps (Y/N) Y Foundation Cleanout (Y/N) Date Last Pumped ,P/~/gd) N,~. ; for /V,/~.. /V,~I. Temporary Holding Tank Permit (Y/N) N,,,q-. B. SEPTIC/HOLDING TANK DATA Date Installed 5-/l'&/7~ Size To Building Foundation To Disposal Field Standpipes (Y/N) Y Ci) Depression over Tank (Y/N) ~ Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well 142 '? ' To Property Line ~ To Water Main/Service Line ~> ~,~- ' To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88} Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Flating in Absorption Strata Date Installed ,6-/I ~ / 7~ Width of Field 3' ' Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field ~/ Depth of Field I! Gravel Bed Thickness 6'~ StCndpipes Present (Y/N) Date of Last Adequacy Test ~'r~ c4 SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot ~ (~0~ To Water Main/Service Line ~ 83'' To Property Line ~o ' To Existing or Abandoned System on ; On Adjoining Lots ~ ~¢' ' To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments 7'h¢ ~1 ~o~-l~/~n /-~¢~c/~ /~'~( D. LIFT STATION N,,4. 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 guidelines in effect on the date of this inspection. Signed Company Date MOA No. / 7¢), oo Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back ~ W Z Z~.~ ~.:~ %~ngineer's Seal Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343 FEDERAL TAX I.D. #92-0040440 ANALYSIS MEPORT BY SA~VPLE ior Work Order ~ 21600 Date Report Printed.: ~,[[Y 10 90 @ 0%34 Client Sample IS:L?. BiO MC}&~HON FROiI~ HOSE BIB PWSID ;UA Collected ~J 8 90 ~ 13:15 hrs. ReceiYed f~AY B 90 ~ !4:30 h~s. Client Name : FLATTOP TECHNICAL SRV Client hcct; FLAYTOT P,O.~ NODE RECEIVED Ordered By : TED ~OOBE Send Report? to: AnMysJs Completed :~Y 9 90 Laboza~ory Supe=viso~,:ST~PHEN C. EDE i?i, ATTO? TECHNICAl, 3RV , ~.~/~ , ~~ ~)~D~C Released ~y : ~.~.; W////-~-~ ./.~~%/~-~--' ~ ' ' Instruct: Chemlab R~i ~: 901265 Lab Smpl ID: 5 }~,at~lx: WATER lllewable Pazamet ez Tested P, esult Units Bletho~ Limits NIT~ATE--N 1.9 rr,~ / 1 EPA 353.2 10 Sample ~OUTINZ S~.MPLE. Remarks: SAI4PLE COLLECTED BY C. ALLARD. [lon~ Detected ~* See Sample R~ma~ks ~,bovo Not Analyzed LT=Les* Than, GT:Great~r Than MUNICIPALITY OF ANCHORAGE DEPT. OF I,'EALTH DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL i~/~OT~CTiON 825 L Street * Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION '[L~ 1 Telephone 264-4720 REQU EST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FRAEcICLI~/E~/ED DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PRO ERTYOWNER PHONE -MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION I PHONE I MAILING ADDRESS 4. REALTOR/AGENT I PHONE MAILING ADDRESS STREET.. L, gC.A.T~ ON 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One ~ Four [] ~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three I--I Six Other 7. WATEI[I/SUPPLY [~E] INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE~* [] PUBLIC UTILITY * ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that d~te, give well depth (attach Icg if available.) ~:~-v~_~ ~ ~t~, 0 _o. ~ **If individual/on-site, give installation date OU~ (~')~ 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 RECEIVED INSPECTION APPOINTMENTS TiME TIME TIME DATE DATE DATE t NSP ECTOR INSPECTOR I NSP ECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS ~ SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY ~ INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER ~ INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY ~_ Connection Verified INSTALLER 'l~3Septic Tank or [] Holding Tank (~ o, ,~c3Y~ Size: ~...~,' If Tank is homemade SOILS RATING give dimensions: ~.~, TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL Septic/Holding Tan k 1Absorption Area [Sewer Line ~(~earest Lot Line 4. DISTANCESwELL TO: (~-~e~:~J - Absorption Area to nearest Lot Line 5. COMMENTS []:~APPROV ED FOR ~r' BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev. 3/78)