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HomeMy WebLinkAboutLOYE BLK 3B LT 2AAper, - 5�:\- l0`1 Municipality of Anchorage V.. Development Services Department Btulding Safety Division ...... On -Site Water and Wastewater Program, 4700 S. Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 Page / of 3 www.ci.anchorage.ak.us (907) 343-7904 ON-S(rE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: SW d 30 t/ / 6 PID Number, Name: /16"f4 w Gtt_�(ge Wastewater System: ®New []Upgrade Addreae,: 2 S,5 OS ,EoteF2NF oQD ABSORPTION FIELD Phoria: N Def or Bedroom 0 DM TMKh o srw.. TMKh o Bed Cl ►a.w 5j.J n0 E Vote.: LEGAL DESCRIPTION WRamp: O Tod Depthkom on9nal grade: GPaF� Ft Stock: _ Lot: Subolwstan: ♦ Q y� 3 L Deport to me twmnn tan dnpW prase: Gravel depth Oatntl, p W. Z Ft. .Z FL Township: Ranpe: Section: Fl added above, avid vadc /. S Grab Lergec SS Fl. Ft. Well: ❑ New ❑ pgrade G"as"wdI` S taariberabull: asancebetween anos: Ft. Z 16 FL Classification (Private. A �_ Taal Depth:Gsed b: Fl. R Tod atnapean are: (± 71" F1' PC* mateny: PVC 303 Dnr. Dat kd: Sla ata Leri: Installer. vE4nl Date kuta6e¢ /O/Z3 R 03 Yield:Puny c crept Above Gran¢ TANK cPM Ft. FL SEPARATION DISTANCES fl Septic (3Hokftng ❑ S.T.E.P. ❑ other. To Septic Absorption Lift Holding ubfldPtivale From Tank Field Station Tank Sewer Line Gat. Well r _106f / 2 d rt --� —' 6t7 f f Material: % esa,eer a earwnnena: Z Surface Water /06'-f. /d D rT„ _ �. LIFT STAT)ON Lot Une SQ rt ,Z O rt •, �- Gal. acaaer. mwuf'PYrtp Found bon /a f{, So rr W. level Vurtp till' Itvel water alarm at: n. h �. Curran Dram .•.. PonO Moak Model Ekdntal an Performed bY: Remarks: BENCH MARK Location and De=pom msurteo e"am. Q FL Engine mp F At1 11 041, Inspections performed by: AIdrd / Dates: 1" 3 17.3 Ts 149H rid 3 N Development Services Department Approval �j Steven W, En; ;' 1.4 ' Revieowed and approved by: l� Date: Z'/.S- O s� •� PE 6256 1� 9F0p ..,,•.,,. 0 1 ,967TWCU 1 \ It -WALL f( = EXMTM 19 / 197 WELL LL A \ � •.. • • a •��':�" \ 1 TreAS-BL�T r / \ PROPCSED DRANRELDS. VZFVAT THAT ARE 4 FEET DEEP MAXWM BY SS FEET LOrav EACH (1 t0 FF 2 FEET a CLERK ASHCD �09 M I i I � CDD)JIIIIm x TO MMPLMY B Septic Tank C.O. 1 27.6' 44.2' Septic Tank C.O.2 29' 50' Trench C.0.1 68' 91' Trench C.0.2 117' 133' ' 116' Trench C.O.3 84C.0 125' 144.6' nch.4 i c&D F � n°,i. tDpCK. TCP.,X $LAPt I II I I DIMENSIONS A TreAS-BL�T 3 4.3 O r V A z ��l O to e+ --1 O O 3 � � v2 N C� v• D o Z + A c r� o O O NCD P r O O 3 m --i N M r M 3 X� D n m QI z H 1 Z D = a D 7C Z 0 -u ti O 70 < C O H -9 H m < h m td r II a 1 ro N 0 -< m n o 1 W t7 T 1 V(+ 3" o —i ni N u N 1 v - D W N U, N Ln f^l m O e+ --1 O O 3 � II II (n D o Z + A c r� o O O NCD P r O O 3 m --i N 3 X� • rs rri 7 0 O Q ii m Q h O 3 11 N Q� -11 O c 3 \ p C+ O 3 (7 m P 3 O D 3 C) m O 3 O tA 0 C+ 0 3 ID II o is In cn 3 + co n Q 3 O c C+ Ln w m h m m 3 W m C+ n P 3 R° UCl m Q MUNICIPALITY OF ANCHORAGE 111 Development Services Department C) On -Site Water & Wastewater Program r 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Permit Number: SW030416 Legal Description""LOYE"BLk ..3B LT -�'i.I Design Engineer: 0041 AK Water & Wastewater Consultant Owner Name: Jan Lemeries Owner Address: 25505 EAGLE RIVER ROAD EAGLE RIVER. AK 99577-9691 to /0: oz. / () Date Issued: Oct 06, 2003 Expiration Date: Oct 05, 2004 Parcel ID: 050-521-69 Site Address: 025505 EAGLE RIVER RD Lot Size: 84071 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: ❑✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy All construction must be in accordance with: 1. The attached approved design. ❑ Private Well ❑ Water Storage 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 engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Date: fQ • 1603 Issued By: A k Date: Mr -4o Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-521-69 Permit Number Property owner(s) LEMERIES Day phone 694-4066 Mailing address (1) 25505 EAGLE RIVER ROAD • EAGLE RIVER AK Mailing address (2) Zip Code 99577 Legal description (Lot, Block & Sub'd.) LOT 2. BLOCK 38: LOYE SUBDIVISION Legal description (Section, Township & Range) N/A Lot Size 1LI 103 1 Acres q.Ft Number of Bedrooms 3 THIS APPLICATION IS FOR: Sewer Only ❑ Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade N THIS PROPERTY CONTAINS: Hot Tub ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal codes. ALASKA WATER & WASTEWATER CONSULTANTS INC. Permit Fees: 400 Date of Payment: 10-';-0S Receipt Number. Waiver Fees - Date of Payment: Receipt Number. ALASKA WATER & WASTEWATER CONSULTANTS, INC. October 2, 2003 Municipality of Anchorage Development Service Department Building Safety Division On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Proposed Septic Upgrade for Lot 2, Block 313; Loye Subdivision To whom it may concern: The existing 3 bedroom house is served by a private well and a private septic system. The existing septic system consists of a 1000 gallon steel septic tank and a deep trench type drainfield. The drainfield is in a state of failure and must be upgraded prior to the sale of the house. A test hole was excavated south of the existing drainfield. We are proposing that a new 1000 gallon septic tank and dual 5 -wide trench type drainfields be installed. The drainfields will be designed around the 30 foot radius of this test hole. Comments regarding the design are summarized as follows: 1. SOILS: See the attached logs which shows the soil classifications, groundwater monitoring, and the percolation test results. It is our opinion that an application rate of 0.6 gallons/day/ft2 should be used. 2. TRENCH DESIGN: a. Percolation Rate: 15 minutes/inch b. Proposed Application Rate: 0.6 gallons/day/A2 c. Number of Bedrooms: 3 d. Design Flow: 450 gallons per day e. Minimum Absorption Area: 750 fie f. Total Depth: 4.0 feet (max.) g. Effective Depth: 2.0 It. Width: 5 feet i. Reduction Factor: 0.70 j. Minimum Length: 2 @ 55 feet loy each (I 10 feet total length) k Effective absorption area = 786 ft 3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed septic system. 3701 E. Tudor Road, Suite 101 • Anchorage, AK 99507 Ph: (907) 337-6179 * Fax: (907) 338-3246' Website: akwwe.com 4. TOPOGRAPHY: The area around the proposed drainfields is a 15 to 20 percent slope running from approximately north/northeast to south/southwest. There is a slope greater than 25 percent approximately 65 feet downhill from the test hole. We do not anticipate any slope concerns with this slope. 'Ale are unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assistance. / A P.E., M.S. NOTE: A site plan drmt,ing, a design drawing, a soils logs, and a 7 page construction specification letter which are all part of the design package for this septic system. 3701 E. Tudor Road, Suite 101 ' Anchorage, AK 99507 Ph: (907) 337-6179 " Fax: (907) 338-3246' Website: akwwc.com 110. ti \ S sc LOT L�LOCKK 3B; y19I 1 NO ENCROACHMENT CONCERNS 10 EXISTING I � � ♦ 3 BEDROOM I If I 1 HOUSE I I r EXISTING IV, f SEPTIC SYSTEMLC 1 : •,,y;,; y I LOT t, BLOCK 3; , \ \ K.-,.a'i:%1•.: I VALLEY VIEW ESTATES— C;EPTIC ARS \ �\ PROPOSED SEPTIC U GRADE (SEE DESICN,PACE 2 OF 2) I LOT 6; CROLL S/D \ i (� LOT 2, BLOCK 3; �\ I VALLEY VIEW ESTATES NO ENCROACHMENT CONCERNS I I I ALASKA NVATKR & WASTE AVATKR CONSULTANT3.INC. 10/2/2003 J.L.M. LE: yr 1" = 100. ....:... PREPARED FOR PHONE NUMBER: PAGE NUMBER: LEMERIES 694-40( 1 1 OF 2 LEGAL DESCRIPTION: LOT 2, BLOCK 38; LOYE SUBDIVISION TYPE OF WORK: SITE PLAN FOR PROPOSED SEPTIC UPGRADE ...... A. or ess,: �'rofesslo��. � --N-EXISTINC 1987 WELL - INSTALL FI Alu PROPOSED 1000 SEPTIC TAP PROPOSED DRAINFIELDS. EXCAVATE TW THAT ARE 4 FEET DEEP MAXIMUM By BY 55 FEET LONG EACH (I 10 FEET TC ADD 2 FEET OF CLEAN, WASHED SEWE \09O 4 CLEANOUT I A C TANK TO COMPLETELY f , INOTE: THE CONTRACTOR SHALL HAVE THE EAST PROPERTY LINE FLAGGED BY A REGISTERED LAND SURVEYOR PRIOR TO CONSTRUCTION. TOP OF ALASKA WATER & WASTE NVATE R CONSULTANTS, INC. - 3701 E. TUDOR ROAD. SUITE 101 - ANCHORAGE. AK 99507 - PHONE (907)337-6179 - FAX (907)538-3206 PREPARED FOR: PHONE NUMBER: LEMERIES 694-4066 LEGAL DESCRIPTION: LOT 2, BLOCK 3B; LOYE SUBDIVISION TYPE OF WORK: DESIGN OF PROPOSED SEPTIC UPGRADE I INSTALL DOUBLE CLEANOUTS 10/2/2003 DRAWN BY: J.L.M. SCALE: 1" = 40t . .. .. . . . .... .......... ...... ... ...... PAGE NUMBER: 2 OF 2 ffr y E A. Go S.: 7953 rof esslolid�'�;� �..... _.................. _....__.....__._. _... ._ .. .............._...... ... ..__..._........._....... ALASKA WATER & N VASTEWATER CONSULTANTS. INC. SOIL LOG - PERCOLATION TEST LEGAL DESCRIPTION: LOYE SUBDMSION; LOT 2, BLOCK 3B PERFORMED FOR: LEMERIES DATE: 9/25/2003 DEPTH -r (1eetM ORGANICS TEST HOLE 1 _ 1 r t) Tili . 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 SM TO GM/SM (DENSER W/ DEPTH) OIL CLASSIFICATIONS DEPTH TO GROUNDWATER m�IIL'll �/VZZ..Q Nam�I111Z JM" sm 10' 9/29/2003 9.5' 10/2/2003 2 1440 30 I37al 3 1440 DEPTH TO GROUNDWATER DATE SEEPS ® 8@&12' 9/25/2003 10' 9/29/2003 9.5' 10/2/2003 2 1440 � I I EXISTING i / 1 \ 3 BEDROOM i / \ HOUSE I \\ EXISTING i SEPTIC \ SYSTEM 'Po SITE P N 9Q 1=10 DATE READING CLOCK TIME NET TIME (MINUTES) WATER LEVEL NET DROP READING (INCHES) 9/29/2003 1 1410 — 6' — 2 1440 30 3-1/2" 1-1/2* 3 1440 — 6' — 4 1510 1 30 4" 2" 5 1510 — 6" — 6 1540 30 4` 2" 19 PERCOLATION RATE 15 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES) TEST RUN BETWEEN 4.0 FT. AND 4.5 FT. 20 A FOUR HOUR PRESOAK WAS PERFORMED: N YES ❑ NO SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORMED BY: JODY MAUS COMMENTS: PERFORMED BY AKWWC, INC. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WA P FORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: 10.4 L '6 Trruftr drilling +rug b) DOC Co. dba SULLMN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 9 TELEPHONE 688-2759 OWNER OF LAND Al U I i DEPTH OF WELL 'j - STATIC LEVEL OF WATER Fr. ADDRESS LEGAL DESCRIPTION 4' 11 DATE - Started � / Ended PERMIT NUMBER KIND OF FORMATION: DRAW DOWN FT. GALS. PER FIR KIND OF CASING From Ft. to Ft. to__�_�',Ft_ Ft. Ko: orn—Ft. From �J From Ft. to Ft From Ft. t O� From Ft. 40 Ft. From Ft. to Ft From —Ft. to Ft. -J From From —Ft. to Ft Ft. to-/ FromFt. e. to _Ft. to Ft. From From Ft.to _Ft z_ From F t. to Ft to From Ft. Ft. From, Ft. to Ft From Ft. to Ft. Ko: orn—Ft. From to Ft. From Ft. tot) 40 Ft. From Ft. to Ft. �44A. e�,!a �4 From Ft. to Ft. From J c! Ft. to-/ Ft. e. From _Ft. to Ft. From Ft. to : ?ll Ft. z_ From—i F t. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. ;Y4 From Ft. to Ft. From Ft. to_ Ft. .//i�'&,j V'v From Ft. to Ft. From - Ft. to Ft. N t - ,From Ft. to—Ft. From Ft. to Ft. From Ft. to Ft. — From- Ft. to.,�,Y,,) Ft. f From—Ft. to—Ft. From Ft. to Ft -L From —Ft. to__MLINICR� DEF MISCL. INFORMATION: DRILLER'S NAME — OF ANCHORAGE I&= 2 81987 RECEIVED Cp 1=7 121 ONT CT 1-1121 IR not us? EH: K DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 122 1^1 W A.- g ._ PERMIT NO: 870058 UPGRADE DATE ISSUED: 04/22/87 APPL[CANT: HENK & GLENNE LEMEREIS ADDRESS: SR 1B BOX 1752 EAGLE RIVER, AK 99577 CONTACT PHONE: 694-4077 LEGAL DESCRIP; SUBDIVISION: LOYE LOT: 2 BLOCK: 3 SECTION: 23 TOWNSHIP: 1511 RANGE: 1W LOT SIZE: 1.93A (SQ,FT. OR ACRES) I certify that: 1. I am familiar, with the requirements Wr on~site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State o� Alaska` 2. I will install the system in accordance with all MOA codes and regulations; and in compliance with the design criteria of this permit. 3, I will adhere to all MQA and State of Alaska requirements fbr the set back distan JAR A i ti ll t e., w at ter disposal system or public sewera ent or nearby lot, SIGNEDDATE: _ APPLICANT: H / ISSUED BY DATE: "0mv��-���____-__'___--- --��-~~�-r-~~---- 00 / -720 - Z. Sr.^��° � ' ^ 0 N 1 2 y3 .r\ yU ,Loy is T c4!0!4,- L07w 3Loc-K3)?,/ 6 = 71 2 9,2,87 1-6 �/,VOWLEDC`EM�1,'Vr Q, /975• VI)JISSION EXPIRES ,/.S-........•1..,... I gj6d 59 Ma I gj6d 59 (�rrtt�ie� �xil�tng ��p� by A & L DRILLING COMPANY BOX 97, EAGLE RIVER, ALASKA 99577 • TELEPHONE 694.2588 OWNER OF LAND 9&-1 /-u %l != /, f DEPTH OF WELL Cca 0Q ADDRESS ,LEGAL DESCRIPTION l/AK' U4<c/= f' DATE - Started f 7 Ended (� I Ab � PERMIT NUMBER / k O KIND OF FORMATION: STATIC LEVEL OF WATER FT of �j f= S^ i DRAW DOWN FT. GALS. PER HR c U KIND OF CASING From ``J Ft. to Ft. () �'=/�u%t9._s{i From 0 Ft. to 5 F:? Ft. From :>� - `• Ft. to Ft. to 6a Ft. Z1- 1)A'4M2,` U Y' Y0 ,/�rJ �'b?� From ,3 57 7 ") Ft. to .) _� �a Ft. From Ft. to Ft. From d Ft. to f) Ft. /��� �" do d/. ✓!r_=j- From From Ft. to Ft. From e) 3 Ft. to J /0 From L' Ft. to i� b� Ft.�� v i�lo- J ' < <'r 1 �! j is From Ft. to f--. <:> a Ft !� C rl;= ) , /-" ; , J if -.7' From z Ft. to �`� Ft. Cr °` S <'fa/ / From Ft. to Ft Ft. From :>� - `• Ft. to / Ft. ✓ "��� �s7�[=- From Ft. to Ft. From �� _S' % Ft. to-,) 3 -1 Ft. /��� �" do d/. ✓!r_=j- From Ft. to Ft. From e) 3 Ft. to J /0 Ft. c Frpm Ft. to Ft. Ft. Frnm /J Ft to 1 ±_Ft. if -.7' n � / 4 0 4 'v 2. 5 -6, -Vis Ft. From (iJ Ft. to 3 / �� Ft. �Jcud < K F9 U✓l / /From Ft. to Ft. From ._M/ Ft. to A�Ft. '6/SGJ 04— /-' From Ft. to Ft. From -] `iEFt. to ,) t •2F't. 1= GZxf<r"USF om Ft. to Ft. From f l. -.i Ft. to '4 "' Ft. pl= 'V /,'0 r--'< ,ra / From Ft. to Ft. From f� ' c) Ft. to `l �r d Ft, 16 /--4 � � �. i4 r IAW62 62 From Ft. to Ft. From `/ () Ft. to 3-0 > Ft. A ` y ? ° c /G � � 1:7- From Ft. to Ft. Frnm /J Ft to 1 ±_Ft. if -.7' L'�f ��``" Fom _Ft.t0 Ft. From a.. r -f Ft. to 0 Ft. From Ft. to Ft. From / " Ft. to `, Ft. / - '%' rm`',%'% i'' ' /J From Ft. to—Ft. MISCL. INFORMATION: i nVil r FA'Q NAMF i' 6 k -P 11 4 A Vs 3. S'-' r - I I-- .i s -ri. e_r a`-- a-- a n � _-- n a •__ = x-:.- 9 _ n +__.a %-- DEPARTMENT CSF HEALTH AND EtJVIRC INMEN T AL PROTECTICIN M' . r B 5 !i- STREET. ANCHI-JR.AGE: AK. 9'— i ':_Fit'iIT NC.I. f. 8051.4 S1EFEI 5�EAGLE RIVER aICANTHENDI CHLEhEG.1. it -ION LOWE rrD VALLEY V E.W EST, il.. .'_L2' LOWE S/D VALLEY VIEW EST LOT SIZE O S=!iJARE FC:ET MIUM DISTANCE BETt=TEEN A WELL. AND ANY FIN—'SITE SEWAGE D I SF'CISAL ''S'r STEP1 i s i FEET FOR A PRIVATE WELL: FIR i TO yCCl FEEL' FRCrt9 A PUBLIC WELL DEFENDING UPUN THE TYPE OF F'UPL.II= LIEL.!_. _ Li tI�S' ARE REQUIRED �I F:F_C? AND MUS BE RETURNEC> TO THE DEPARTMENT WITHIN 3F? Dt �'r'_ THE WELL COMPLETION. i! -F? REQUIREMENTS MAY APPLY. S•PEI= I F I I_:AT I ON_ AND CCIN'=TRUCT I CiN DIAGRAM_= ARE :i I LABLE TO INSURE PROPER I tJ'=:TALLAT I ON. ERT I FY THAT I AM FAMILIAR WITH THE REQUIREMENTS FCtR ON—SITE SENERS AND WELLS AS SET 'TH BY THE MUNICIPALITY CIF ANCHORAGE. I WILL INSTALL THE SYSTEM IN ACC:ORDANC:E (WITH THE LODES. aNED:--------.—______._.----.-----__.___----------.____--- APPLkC:ANT HENDRICH LEMEREIS L I _ \\��: — L 2 \\\ _ _ 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 NAME PHON NEWp ❑ ' c'/c % ��� J '—��� UPGRADE MAILINGA�% 1 SC) d LEGAL C�iRI TIOQL ..� • C� LOCATION �y/� n NO. OF BED' OMS ell i Absorption area Dwelling PERMI U DISTANCE O:11V ' 0 I 0 0 -t- _ y 1,_ z Manufacturer Material - No, of compart ents wr -K-¢f N Liq. capacit in gallons ingallons HOMEMADE: Inside length Width Liquid depth -TO: Wel Dwelling MIT NO. �UZ DIS - Liquid caps 'rt. in gallons O? anufacturer aterial _-- ` O Well `i- Foundation f Nearest lot liner l� 7' PER J = Lu DISTANCE TO: Q 0 / LL z No. of lines Length of each line r Total length of lines t// Trench widt Distance b tween lines .wa z w g Q inches 4 H Top of the to finish grade Material beneath tile Total effective abs pion a 0 inches Length -Width Depth -'-es PERMIT NO. w C7 41- Type,o#- ib Crib diameter Crib depth otal effective absorptio a, re�a o.uj ✓ w Well uilding foundatio Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. J W ✓ DISTANCE TO: Building fon ation Sewer line Septic tank Absorption area(s) OTHER '/ _+ PIPE MATERIALS SOIL TEST RATING ,I INSTALLER a r REMARKS p 0 i,1 ti o45 re / O / .s M APJ/PJRO `DATE �] LEGAL ~ PERMIT NO HPPLICHNT LOCHT1ON �������� L_ J.': _ �F_ C"'m 0=1 P-4 r�P.- 1� DEPHRTME: NT Of. HEHLTH HND ENVIRONMENTH[ TECTIOld T�ENCH OR DRHINFIELD L. TREET, HNCHORHGE/ HK. 99501 OR PIT IS THE DISTHNCE BETNEEN THE SURFHCE OF THE GROUND 264~4720 THE BOTTUM OF THE EXCHVHTION (IN FEET) THERE IS NO HENK LEMEREIS LEGHL L2 B]B LOYE S/D PO BOX 8882 C/O T.LORD ' LOT SIZE 84070 SQUHRE FEET TYPE OF SOIL HBSORBTION I:E: : TP:ENCH MAXIMUM NUMBER OF BF: DRO4 SOIL RHTING THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS: �W V 'T, F -A :1. oil �FEE �cls �F. = --7-.����� ` ������ AS \� ` THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE T�ENCH OR DRHINFIELD THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE BETNEEN THE SURFHCE OF THE GROUND HND THE BOTTUM OF THE EXCHVHTION (IN FEET) THERE IS NO SET WIDTH FOR TRENCHES. THE G1GVEL DEPTH IS THE MINIMUM DEPTH OF GRHVEL BETWEEN THE OUTFHLL PIPE HND THE BOTTOM OF THE EXCHVHTION (IN FEET) ������������ ������� ������� ������ ������ PERMIT RPPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE INSTHLLHTIQN INSPECTIONS OF HNY WELLS HDJHCENT TO THIS PROPERTY HHD THE NUMBER OF RESIDENCES THHT THE WELL WILL SERVE. �������������� ����� ���������- ~�� BACKFILLING OF HNY SYSTEM WITHOUT FINHL INSPECTION RND HPPROVHL BY THIS DEPHRTMENT WILL BE SUBJECT TO PROSECUTION MINIMUM Eli ISTHNCE BETWEEN H WELL HND HNY ON—SITE SEE WHGE DISPOSHL SYSTEM IS 100 FEET FOR H Pf-,!IVHTE WELL/ OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL OTHER REQUIREMENTS WAY HPPIM SPECIFICHTIONS HND CONSTRUCTION DIHGRHMS FIRE: RVHlLHBLE TO INSURE PROPER INST�LL8TION �KEUTWO 1 0- FSE 1-0 F=p I ITZ EFE AS K;u EE: EE RW,g E--.�,��� I CERTIFY THHT 1� I HM FHMILIHR WITH THE REQUIREMENTS FOR ON—SITE SEWERS HND WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE 2: I WILL INSTHLL THE SYSTEM IN HCCORDHNCE WITH THE CODES ]� I UNDERSTHN ON-SITE SEWER SYSTEM MHIt' REQUIRE ENLHRGEMENT IF THE SI*CIA ED���~—~~ ' j HPPLl LEMEREIS ^ ��SSUED BY ~~__DHTE_ " L� M - R&M CONSULTANTS, INC. 5024 CORDOVA ■ SOX 6087 • ANCHORAGE, ALASKA 99502 ■ PH. 907-279-0483 • TLX. 090-25360 ENGINEERS GEOLOGISTS - PLANNERS SURVEYORS June 7, 1979 R&M No. 951180 c Hank Lemeris c/o Tom Lord P.O. Box 8882 Anchorage, Alaska 99508 Subject: Soil Investigation for Sanitary Sewer System, Lot 2, Block 3-B, Loye Subdivision Eagle River, Alaska Dear Mr. Lemeris: At your request of May 23, 1979, we conducted a subsurface soils investi- gation at the proposed location of the sanitary sewer system on the subject lot. The investigation complied with those procedures required by the Municipality of Anchorage Department of Health and Environmental Protec- tion. This investigation, which was accomplished on June 5, 1979, consisted of a test hole excavated to a depth of 19 feet below the existing ground surface. The test hole was sited according to your instructions and its location is shown in attached Drawing A-01. Drilling was accomplished with a rotary drill rig using continuous flight solid -stem auger with an outside diameter of 6 inches. In addition, all material brought to the surface by the augers was continuously monitored by an experienced engineering geologist. The topography at the drilling site is generally gently -sloping to the south. At the time of the investigation the site had been stripped of original vegetation. The top of the test hole was located at original ground surface. ANCHORAGE FAIRBANKS JUNEAU VALDEZ WASILLA r�� June 7, 1979 Hank Lemeris Page -Z- The soils encountered in the bore hole are shown in the test hole log in Drawing A-01. This log displays specific conditions encountered at the test location. However, subsurface conditions may vary in other parts of the lot without any apparent surficial evidence of the change. Groundwater was not encountered and bedrock was not encountered. At the time the hole was drilled seasonal frost was not present and permafrost was not encountered. A percolation test was performed within the bore hole at the depth shown in the attached Table 1. All depths were measured from the top of the hole. The data in Table 1 show average infiltration from the depths indicated to the bottom of the hole. The measured percolation rate was 5.7 minutes per inch. We appreciated this opportunity to be of service to you. Please contact us if you have any questions concerning this letter or if we can be of additional service. Very truly yours, R&M CONSULTANTS, INC. Ernest R. Rahaim Staff Geologist GS:ERR/dj/ATSI-I Gary ith Proie Manager PERCOLATION TEST TABLE 1 R&M No. 951180 ELAPSED WATER TIME LEVEL INCREMENTAL DROP TIME (MINUTES) (INCHES) (INCHES) 3:00 0 24 0 3:01 1 25.5 1.5 3:03 3 28 2.5 3:05 5 29.75 1.75 3:10 10 32.25 3.5 3:20 20 35.5 3.25 3:30 30 37.75 2.25 3:40 40 39.75 2.0 3:50 50 41.25 2.5 4:00 60 43.-0 1.75 5.25 Inches 5.7 Minutes Per Inch BORING NUMBER 1 Date Completed: 6,7-79 rL x x o W 0 SOIL DESCRIPTION N Jd QE w ox ON �O oaQ. WATER TABLE Boulders at Surface —LAPPROX STRATA CHANGE a SANDY GRAVEL w/ SOME SILT, GM o .a QQ.o lJ" o .a a '-.Q'. 0'- 19' Numerous Cobbles 0 e otr-o o -o :o o. c A' a' o o: 0 O 10 a 0 °o. — — — — — 12' oe SILTY GRAVEL w/ SOME SAND TRACE CLAY, GM IS a Ao0 00 r .a 6p0^ o�0 �oO 9 a° 19" 'T.D 20 130 LOCATION SKETCH No Scale 0 401Z 1 O0 NOTE: DISTANCES SHOWN ARE APPROXIMATE AND HAVE NOT BEEN MEASURED BY SURVEYING METHODS. EXPLANATION r UN ROZEN GROUND `FROZEN GROUND WD-WHILEDR/LL/NG TYPICAL SOILS LOG A.B-AFTER BORING Ss L4 "SPLIT SPOON WITH /40 LB HAMMER Sz L4"SPLIT SPOON WITH 340 LB. HAMMER Sh 25" SPLIT SPOON WITH 340 LB. HAMMER Sp 2.5" SPLIT SPOON, PUSHED A AUGER SAMPLE Ts SHELBY T03E Tm MODIFIED SHFLBY TUBE Bs BULK SAMPLE SAMPLER TYPE SYMBOLS ,ca,0 ORGANIC o 0o GRA VFL ,u..� MATERIAL 000 COBBLES B ® CLAY BOULDERS ® SILT ® BEDROCK SAND ICE, MASSIVE SOIL SYMBOLS ORGANIC MATERIAL ''o Little Visible Ice 0-10 Vz b� 'aro A B L_/CE DESCRIPTION �'� SAMPLE NUMBER I Ss,72,57.1%,85.9pcf � � L- DRY DENS/TY b•.o S "4'•� WATER CONTENT ppb" BLOWS/FOOT CSAMPLER TYPE � .�a D. DW N. F e. 17-1ERR D Lot 2, Block 3-B GRIo. SW 263 CKD. R&M CONSULTANTS, INC. V.� lEw-'ll-s'ta'tes-/-aYL S �t GEOLGG16T5 PLANNERS SURVEYORS GATE. 6-7-79 WATER TABLE —LAPPROX STRATA CHANGE BEDROCK �"'�• / Eagle River PROJ.No.951180 f.; • '� Municipality of Anchorage On -Site Water and Wastewater Program J-4 (907)343-7904 Certificate of On -Site Systems Approval d A G Parcel I.D. 050-521-69 Expiration Date: 1. GENERAL INFORMATION Complete legal description LOPE BLOCK 3B LOT 2 Location (site address) 25505 EAGLE RIVER RD, EAGLE RIVER, AK 99577 Current Property owner(s) WILLIAM HOLLAND Day phone 227-1480 Mailing address Real Estate Agent BLAKE JORGENSON Day phone 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) JUL 2 5 2014 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ WaiverNariance request for: NONE TYPE OF WASTEWATER DISPOSAL Individual Holding Tank ❑ Community ❑ Public Sewer ❑ Received by: °i//� l�ra awt 3� Date: 5 `� COSA to be relea to a engineer, unless otherwise requested by the engineer. vT COSA Fee $ !2.4* — Waiver Fee $ Date of Payment ( 3L51 i ( Date of Payment Receipt Number Receipt Number COSA # c5c't' 19>5 Waiver # S. 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, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm SPURKLAND ENGINEERING Address 203 W. 15TH AVE.,STE.202A, ANCHORAGE, AK 99501 Engineer's Printed Name LARS SPURKLAND 6. DSD SIGNATURE -- � System #1 Approved for 3 bedrooms System #2 Approved for _ bedrooms Disapproved Conditional approval for bedrooms, Phone 279-3916 Date 4/21/2014 f `rtti.OF At5���t 11 with the following Stl timet �� i BY Original Certificate Date: s Th uni " of rage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the re esenta ions given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Nue sheet S ., If more than 1 septic system is on the lot: COSA Checklist # 1 of 1 Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: LOYE BLOCK 313 LOT 2 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID # Date completed 4/28/87 Sanitary seal (Y/N) Y Total depth 380 ft. Cased to 200'5 ft. FROM WELL LOG Date of test 4/28/87 Static water level 225 Well production 1_5 WATER SAMPLE RESULTS Parcel ID: 050-521-69 Well Log (Y/N) Y Wires properly protected (YIN) Y Casing height (above ground) 12+ in. AT INSPECTION 4/21/14 ft. 232 ft. 3.0 g.p.m. 9 - p.m - Coliform NEG colonies/100 mL Nitrate ND mg/L Arsenic ND ug/L Date of sample: 4/17/14 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1000 gal. Number of Compartments Foundation cleanout (Y/N) Y Date of pumping 3-3-14 C. ABSORPTION FIELD DATA Collected by: ANSON MOXNESS Depression over tank (Y/N) N Pumper JRs Pumping Service Date installed 10/23/03 Cleanouts (Y/N) Y High water alarm (YIN) N Date installed 10-23-03 Soil rating (g.p.d./f:2 orfe/bdrm) 0.6 System type 5-vvIUL Length 2 X 55 ft. Width 5 ft. Gravel below pipe 2'2 ft. Total depth 4'5 ft. Eff. absorption area 766 ftp Monitoring tube Y Depression over field N Date of adequacy test 4/21/14 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0,20 in. Water added 460 gal. New depth 4.5,24 in. Elapsed Time: 40 min. Final fluid depth 2'22 in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date _ D. LIFT STATION Date installed W "Pump on" level at _ Datum Size in gallons _ in. "Pump off' level at E. SEPARATION DISTANCES WELL ON LOT TO: Cycles tested Septic tank/lift station on lot 100 + Absorption field on lot 100+ Public sewer main NA Sewer /septic service line 251+ Animal containment areas 50+ Manhole/Access (Y/N) _ in. High water alarm level at Meets alarm & circuit requirements? On adjacent lots100 + On adjacent lots 1001+ Public sewer manhole/cleanout NA Holding tank NA Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5'+ Water main NA Water service line 101+ Wells on adjacent lots 109+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water Service line 10'+ Curtain drain 501+ (N.O.) F. COMMENTS G. ENGINEER'S CERTIFICATION Surface water 100'+(N.O.) Wells on adjacent lots100 + I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSH guidelines in effect on this date. Engineer's Printed Name LARS SPURKLAND Date /24/14 COSA brown sheet 10-10-12.dm Absorption field 5 + Surface water 1001+ Water main NA Driveway, parking/vehicle storage10 in. 49 S .SPURKLAND: r '. 15 PRO ES -v` Municipality of Anchorage • Development Services Department *A9 Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 6 5(3- Sa/- 69 HAA #�`�C) �.� 1. GENERAL INFORMATION Expiration Date: Complete legal description Lo1/E QLOGk ,3Ci �,prZ Location (site address or directions) 2S ;os, F�CLE R�✓f 2 2Q�A Current Property owner(s) Af__n/K * ('L AfC &- fj52&bay phone Mailing address_ 255QS r.g 17,..c�n A- A Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF.WATER SUPPLY: - Individual Well Individual Water Storage Community Class Well Public Water System 3 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given In paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C.well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. TYPE OF WASTEWATER DISPOSAL: Individual On-site ta ❑ Individual Holding tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given In paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C.well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION 8Y ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm _/1IO27_/-f4rh ENC(Af6&e1A(C Phone 144-7024' Address / 7,?37 nra, a P4,c%j rjfzux, Engineer's Printed Name 5M6y(E 461 C 5. DSD SIGNATURE _ Approved for 3 bedrooms. Disapproved. Date RIJ-103 OF A1.4%11 io c: Steven W. Eng: ••. PE 6756 •' • �`� 11@ �F9 •�. w• G�� v Conditional approval for bedrooms, with the following stipulations: Additional Comments � S : ON-SITE0. Attachments: HAA Checklist . X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: A/• Original Certificate Date: (11". oto) Ir ,..�......�.�,. n.r �... •.. •........•r r. ... ... i�. •. .,�.�,.. , �1-.•w+•••-Yr•=w-+. y.. ..-..... A..... �... ._. .. ....... ....... ......... Municipality of Anchorage • Development Services Department % Building Safety Division' On -Site Water & Wastewater Program ' • ` T 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /,o Y4 : IeG'(t Gk .3a L 07- Z Parcel ID: O SO 521 A WELL DATA Well type P If A' B, or C provide PWSID ft Well Log (Y1 N) Date completed c. 7 , Sanitary seal (Y/N)� ' Wires properly protected (YIN) Total depth 3 tO ft. Cased to 2Zd ft Casing height (above ground)' / 6 In. FROM WELL LOG AT INSPECTION Date of test '�f/p7 71i�/Q3 Static water level 2 Z3 ft 2 2 Z ft Well production �. wS g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform O colonies/100 ml. Nitrate Gwt mg.11. Other bacteria O colonies/100 mi. Arsenic: mg./l. Date of sample: �°? Collected by: orf� C/o', B. SEPTIC/HOLDING TANK DATA Tank Type/Material AAICt o'2.4615 % f{P(���STr%EL Date installed /CMZ �63 Tank sizeGoo gal.Number of Compartments Z Cleanouts (YIN) y Foundation cleanout (YIN')Depression over tank (Y/N) /J High water alarm (Y/N)' _ Date of pumping A-1 �umper ws / STEL C. ABSORPTION FIELD DATA Date Installed /0/0 j/0-7 ! Soil rating (g.p.d./ft2 or4r ) 6_6 Length 5S ft. Width ft• Total depth _LL ft. Eft: absorption area Y ft2 System type Gravel below pipe 2 ft. Monitoring tube Depression over field AC For bedrooms Date of adequacy testlEl� T Xr;5 ^ Results (Pass/Fail) Fluid depth in absorption field before test = in. Elapsed Time: = min. Final fluid depth = in Any rejuvenation treatment (past 12 mo.) (YIN & type) _ I! Water added= gal. New depth= in. Absorption rate >= - g.p.d. If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) 11-1 "Pump on" level at in. "Pump of rt level a _ in. High water alar eve/ at in. Datum Cycles test Meets al t;< circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAift station on lot /4001'0- Absorption field on lot 1201.0. Public sewer main A(//I- Sewer /septic service line 650 1 -/— On adjacent lots /OQ 110 On adjacent lots Public sewer manhole/cleanout ^`'1'f Holding tank &Xf SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation O �'0- Property line SG `T'* Absorption field o70 Water main 9114 Water service line yd f Surface water 1,06.1- Wells aG.* Wells on adjacent lots //)G It SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 20'� Water Service line SG �t Building foundation 50 �'` Water main A(/ --t Surface water /0C) Curtain drain J'(/4 Wells on adjacent lots /G G t F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Date 12-1,f/o.3 HAA Fee Date of Payment � Receipt Number f `4 (Rev. 12101) Driveway, parking/vehicle storage 2G I* dw of •A Stever. J+l •. W. En ;• ; , PE 6256 Waiver Fee S Date of Payment Receipt Number, ASSUILT SWARD 6 I HEREBY CERTIFY THAT I HAVE SURVEYED THE sCAL/'SSG FOLLOWING DESCRIBED 'PROPERTY, AND THAT NO E�ICROACHA(E S, EXIST LXCEPT AS T'4lZ6�7 INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY GRID.- EASEMENTS, RID=EASEMENTS, COVENANTS, OR RESTRICTIONS So✓Z6z WHICH DO NOT APPEAR ON THE RECIMED SUM- -- V a Ie 0 ATES LAND SURVEYING 694-0820 ` P�� OF.A��s�` August 311, 1977 To. Building Department Subject- T,Ot 2 Iaye Subdivision This department has no objection to a workahop being construction on the subject property. e7c3 sewer and -rrator facilities. if there are any Burt -tar gaestions> please contact this office at 264--472.0 Sincerely, Los. N.BUCI-11101Z, R.S. sanitarian I;NB/ljh r- �V D / MUNICIPALITY OF ANCHORAGE MUN CIPALITY OF ANCHORAGE DEPARTI4?ENT' OF HEALTH & ENVIRONMENTAL PRO'rECWCW DEPT. or- i'.- `�!"-_ & ^ � II7.5LStreet - Anchorage, Alaska99501 ENVIRON WE—N, A -. �f CfION ENVIRONMENTAL ENGINEERING DIVISION .t °" ' .4 Telephone 264.4720 REQUEST T FOR APPROVAL OF INDIVIDUAL WATER AND SE*F(AEl[VIED DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten ('10) days for processing. " 1. PROPERTY OWNER s�_—._—-----�----------��_'.—_-_-��--- PHONE_ MAILING ADUfiC55 /1 �_'��_I>QLi</�✓ (...._t-� X�'%v�,—__�—/%fyG/_- / il_��<_{�.Lice...=f-(ir-�' z_--�--�T Pf1 PROPERTY RFSIDENl- (If rdifferent from above) �U SG1 j��i U/$i viv f�GGG�<,3' L oT 2, 0Nt: fiTL _ 7-66—Y PHONE MAILING ADD?(=SS PHONE MAILING ADDRFSS 4. REALTOR/AGENT PHONL- MAI LING ADDRFSS �--- 5. LEGAL DESCRIPTION STREET LOCA-noN/ n 6, l"YPE O^F-/RESIUENCC- NUMBER OF BEDROOMS SINGLE FAMILY 0 One ❑ Four El Other -.v!_._ E-1 Two ❑ Five MULTIPLE FAMILY CQ"' Three 0 Six - ---- - ----• 7. WATER SUPPLY .—. e._.d__.______--_....,. .s.,�.a... _..__...__. ( INDIVIDUAL' "ATTACH WELL LOG. A well log is required for all wells drilled J COMMUNITY since June 1975. For wells drilled prior to that date, give well CJ PUBLIC UTILITY depth (attach log if available.) 8.SEWAGE/DISPOSAL SYSTEM , `*If individual/on-site, give installation date S vx 7�! LJ INDIVIDUAL/ON-SITE** If systern is over two (2) years old an adequacy test is required 0 PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUS`r ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 77.-010(3/78) Af I (3LIC 7,01H) Of0-ZL -------------------------------------...--- _ _ NOIJ.dIHJSJO-IVDd-I -------------------------------------- ----(� 1)!1) AB1... ---- -- --- --- ---- - AJ.V0 c-IaAOHddvsln L (clivai lido Aurdw000e 1611W aalJal)-1VAOLlddV `JVNOI.LIQNOD CJ HO:J GIAOl &d j )111'1 ;o -I j' :1�I-ILO C7 S1NAIAMOO 'S � --_- l� --- - -------------T'----- O�1nIa�3H X0-1 II o.J_ 1 i ;1,4% lul'l10M0$ ROIf/(lol;dloS(I�j'l >IIIL16UIf)iOHw)11 (10$1 _-_. ______-_-- "1V IU JIV','; VAIV NULLM10SHV -]V.1.01_ _ �- H:IHfu,,)v.If1NVW >INVl JO:AdA.l. - UNI.1,VU $'1105 opeulauloy SI >luel . jI1Y >IuNJ 6ulPlollf Ito;pll i :111d9(3I. 1 - , -------_-- ----------U13TIVJ.SN1. 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