HomeMy WebLinkAboutHIDEAWAY LAKE BLK 2 LT 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROYECTION
ENVIRONMENTAL ENGINEERING DIVISION
82§ L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
L
[] UPGRADE
Manufacturer
IF HOMEMADE: I Inside length
Well I Dwelling
Width
Orib diameter
Foundation~
T o t al~/.~ ~.~t ~,.o f lines
Material beneath tile
Depth
LOT 1 Block 2 Hideaway Lake Subdivision
NO, OF BEDROOMS
~),T.~NO_.. ~..
No. of ~tments
Liquid deptb
Crib depth Total effective absorption alea
Well Building foundation Nearest lot line
Depth Driller Distance to lot line PERMIT NO.
Building foundation Sewer line Septic tank Absorption area(s)
PERMIT NO.
IMaterial Liquid capacity in gallons
Trencb;.~.~b~ I 'ta cy/~een ,ine,~
OTHER
DATE LEGAL
[:,EF'FII;::TMIEIqT , ..... Hb.':FILTH FIND E]'.,IV I I:RCff',IMEN]"FII ...... '.~:OTEC'I" I 01",1
8;25 '"L'" STREET., Fff.~CHORFIGIE:., IqK. :~S'~SCtJ~
PE F::i"I 1' T NO.
F:IPPL Z CFINT I:~:,!i::H COf',IST. I hlC.
L.OCF:ITI 07.,I "['J..2N lq'.::.]-":.[,.! S24
LEC'iFIL. I...OTJ. E',L. OCK;2 H I [:'EFII.,.IFFr' LFIKE
'T'~'IZ'E OF SO I I.... FIE:SOI'~:IZ'T I 0[",] 'Z;'T"STEM I S: 'T'RENC:H
LO'T SI;Z'E 45S~59 SQI...IFtRE I::'E':ET
MFIXIMLIM I'.,tlJMB,ER OF BE]}RC'u]i"IS ..... ¢
'i"HE REQUIRED S!,:'ZE OF 1"HE SI]II.... F'-IBSORF'TION S'T'STEH IS:
THE LENGTFi I:::,IMEI'.,ISiCP.,I IS THE L..ENGTH ( It",1 FEET::, OF 'THE: TREt'..tCH OR [:,RFItNFiELD.
T'HE [:,[!i:F']"FI OF FI TREI'.,ICH OR P]:T tS THE I} ]: STlaNCE.: BE:TI.,.IIF2EI'-,I THE SURF'FICE OF' THE
(:?iROI...tlq[) FIND ]"FIE E',0TTCff't OF THE E::.:',CFtVFIT I ON ,:: :[ N FEE]' ).
THERE IS I",10 rE;ET' 14tD'I'H FOR TF.':EI'.,!CHE::E;.
THE GI:;i:Ft',,,'EI_..C:,EF"T'H ]:'.ii; THE MINIMI...IM [:,EPTH OF' GRI::IVEI_ BE:TI.,.IEEI'-,I THE] OI...ITFFII_L PIF'E
F:INI]:, THE BCrT'TOM OF THE E::.::CFI'v'FI'['ION ,:: I1'.,I F'EET.':,.
F'ERM I T FIPF:'L,. I C:FII'.,IT I.-IFI:iT, THE k- E- '-'z, F" -. 1,1' 'z, ] [:, .[ l. I I ~ T(] I I'.,IFORM T'H I S DEPFIRTMEN]' [:,I JR I NG TFIE
i 1'.,I!!'5, TI::IL. LF:IT I ON I N::'5, PECT' i C)l'-,i:~; OF Fti",!"r' I,.IEL..i_S F:IDJF:ICEI",IT TO TH I S PROPEI:¥T"T' f:ll",ll]:, THE
?',IUME:ER OF RESIDENCES THFFF THE I.,.IELL. I.'.IIL..L SERVE.
..................... -F 1!.4] C" "::1 ;:TJi': ]:" ]J] I1'"'~!1 ]i!iii;; IF:z" E~:E EZ: "]- ~] lC, !P",~. FIE;; IF:Il ft::i;:
['],'FICI<F:'.T. I_L 1' I",IG OF FII",I'T' S'T'S'TEM I.,.! I THOUT F I NFIL. I NSF'ECT ]: 01",1 FII",ID F:IF'PRCffv'FIt_
DEF'FIRTME]",IT I.,.IIL. L E',E '.:i;LIE:.jrEc"I" TO I:::'ROSECI.j]"ICiN.
M I t'.,I i MI...tM [::, I STI:::II'.,ICE BE"I".~,.IEEI'.,! FI I.,4ELI._ FIN[:, F:If.,I'T' ON-.:.5 1 'I'E :~.']Eb!I::II]E [::, I :-.E;POSIRL S'T'STEM I
::1..122K[~ [:'E:E:']" FOR F:I PR Z',,,'FI"FE I.,.it~EL..I... OR :t. 5C~ 'TO ;;?J;']lEI I:::EI]T[' FROM 1::1 PUE~I....];C 14ELL. DEF'EF, I[:,IN(2:i
UF'OI'.,I 'T'HE T'T'F'E OF PI...IE~LIC 14ELL..
H ): N J.' MUM I} I STFINC:E FROM I::I PR I ',,,'FITE: i.,.IEI_I_ TO F:I PR t ',,,'FITE: SEI.,.IEt~: L I I'.,IE I rE; ;25 FEET F:tI'.,II:)
TO FI COMMLINIT'T' SE].,.IER LII",IE Z:~; '?5 FEET.
t.,.IEL..I_ LOGS laRE REC!U].'RE[)FII'.,II} MUST E',E F.'.ETI..IRI'.,IEI} T'O THE [:,EF'FIRTMI~i:I'.,IT
OF TFIE 1.4EI...I_ I]:OprlPI._ET]:OI'.,I.
OTHER REC!U I REI"'IEN'TS MFI'T' F:tF'F'I_'T'. .L:i;F'IE:C ! F I CFIT I Ot'.,tS FIND CONSTI:;.:LICT' I ON I::.', I FIC. iI:;:r::IMS I::IRE
Fi',,,'F:i:!: L.F:I[3L.E TO INSURE F'ROF'ER .[ I'.,tSTFIL..LFiT I 01'.,I.
I CERTIF'T' THFiT
i: I F:ff,1 FFiM ]: L.. :[ FiR I.,.II'TH THE REQI...IIF~'.EMEN'['S FOR ON-SITE:: SEI.,.IE-:F,~:S Ri'.,ID I.,.tELI_S FIS SE]"
FORTH B'~' THE MI...II'.,I t C I PFiL :[ T¥ OF F:Ii'.,ICHORFiC~iE':.
;:..!i: I I,.I t L.I_ I I'.,ISTFIL. L "i]..IE:: :iS'T'STEM I i'.,I FtCCORDFii'.,tCE 141 ]'H ]'HE C:OI}E'.:ii;.
]:: I t. jI'.,![:,EF.:STFiN[:, THFiT "I"HE ON-.SITE '}:]EI.,.tER :E;'T'STEM I'"lF:l"r' RE(;:!UII;i:E EI",IL.I::tI~'.GEMENT Il:' THE
RE:~!;i[)ENCE IS RE]'"IODE:L.E[:, TO INCLU[:,E MORE 'T'Ht::II",I 4. BEDROOMS.
I:::IF'PL I CFINT R&H COI",!ST. ! NC.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
/,~'" SOILS LOG
~E~i// PERCOLATION
TEST
LEGAL DESCRIPTION: .
1
2
3
4
6
7
8
9
10
12
13
14
15--
16-
17
18
19
20
PERFORMED BY:
72-008 (6/79)
SLOPE SITE PLAN
S
WAS GROUND WATER
E
IF YES, AT WHAT
DEPTH?
PERCOLATION RATE /5' (minutes/inch)
TEST RUN .ETW EN ETAND
Reading Date Gross Net Depth to Net
Time Time Water Drop
-I ~l zO 12; ?~ ,7o
t/ i z t 55' IOh~.4~ ,5~' ,/2
WATER WELL RECORD
STATE_- OF ALASKA
DEPARTMENT OF NATURAE. RESOURES
Division of GeologicBI & Geophysical Surveys
Drilling Per'mil No.
LOCATION OF WELL (Please complete either la~ lb or lc.) A.D.L. No.
B .... .h Suhdi.i.io. Lo, B,oo, '/4g,r.. Section No. TownshiPNE~l
' S[~
--.of--of of --
,qJ DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF %
Street Address and Area of Wall Location
2. WELL LOG Feet Below
4. WELL DEPTH
Material Type Top Bottom
Auger
__ [] Test
9. FINISH OF WE
Slot/Mesh SI
Set between
I0. STATIC WATE¢
Equipme
II . PUMPING LEV
ff.
ff.
12.GROUTING
Material: []
~3, PUMP: (if a
Length of Oral
~ Subm.
14. REMARKS:
16, WATER WELL CONTRACTOR'S CERTIFICATION:
15. Wafer Temper~
This well was drilled under my urisdiclion and this report is Irue to the best of my knowledge an.
Registered Business Name Contracl License Numb
Address; '
Form O~-WWR (11/81) Copy Oistribuhon; WHITE-Stale DGGS, PINK-OriHer~ CANARy
Meridian
Range w~.
WELL:
(final) 5. DATE OF COMPLETION
[]Rolary [~ Driven [] Du~
[]Jetted [] Bored [] Other:
[] Public Supply [] Industry
[] Recharge [] Commetical
Well [] Other;
Thregded ~ Welded
: '~. ¥i.' Deplh Weighl ____lbs./fl.
Diameter:
Grovel pack
LEVEL: - fi, __ / /
or [] Below land surface Dale
used;
below land surface end YIELD
offer ____hrs. pumping g.p.m.
after hrs. pumping g.p m.
Grouted: ~-~ Yes [] NO
Neat Cement [] Other:
available)
Pipe
E) Jo,
belief;
er
Customer
!
ff. capacity
] Cenlrificol
] Other
.... , ........ o El ~ [] c
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL· . ~..,,~4-~('~'/'¢"-. - -/~.~
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a)
(b)
(c)
Application Date
Legal Description (include lot, block, subdivision, section, township, range)
[..oh Z~
Location (address or directions)
Applicant Name ~(~_ ~~ Telephone: Home ~[~L(~ t ~ Business
Applicant Address (0~01
Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain); .
(d) Lending Institution /~. (o.~1'~¢¢ tCc~_t:~¢ ,.~'r,. t;~¢¢R ~ Telephone
Address I¢ { ~e~ ~ ~¢~.¢0~ ~l~¢~ /~ C/~O
(e) Real Estate Company and Agent ~¢~/,¢ ¢r~/~¢~ .~.
Address .~OOO _r~" %,~. / ~ ~ o~/¢ /+~
Telephone_ ~d'~ ~ 7¢~'-~
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [] Multi-Family
Number of Bedrooms
Other
3. WA'rER 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.
SEWAGE DISPOSAL
Onsite [~ Public I-] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11,84)
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 verity that my 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 verity that based on the information obtained
from the Municipality of Anchorage flies 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 . F~'(~/-./'~/~ '~;c~ ;c~/ ~c~ Telephone . ':~ ~-~ t~
Address t~0 ~¢~0 ~ / ~c/to,~ ~ ~1~
Date DEC~i.~ ~¢~ /~.. ?¢~ ~
Engineer's Seal
DHEP APPROVAL , ~
Approved for ~_~'_~""/z~:/) bedrooms by Date--.~-.~4Z-, ._~_¢" ~'~_~
Approved /¢~../~ Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection ([)HEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer 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 requirernents. 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
,~?j,,(M:UNICIPALITY OF ANCHORAGE (MOA)
o, ,.¢ALT. AUT.O,.TY APPROVAL
~'¢\C\9,~ O~ ? ?V,O¢'C1 CHECKLIST- FEBRUARY 1984
"' ~9~3r~'~.~1P'v . ,,,,m 264~4720
~.~ ~ ~i]! L a
~-,~,C,~ '~. ' eg I Description'
WEL DATA
Well Classification ~' f'~''''~c'l~'E If A. B. C, D,E.C. Approved (Y/N)
Well Log Present (Y/N) ~' ___ Date Completed __ ~ / &'.-'-~ Yield
Total Depth '~ q 8 Cased to ! O ~' """~ Depth of Grouting N,,4,
Static Water Level I c,? ~ Pump Set At ~,~ A;
Casing Height Above Ground ! ~" ~ Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot _
Depression Around Wellhead (Y/N)
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line _
Cleanout/Manhole N,/~,
Water Sample Collected by 'T F
Water Sample Test Results
Comments
; On Adjoining Lots ',-
lO d' ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING 'rANK DATA
Air-tight Caps (Y/N)
Date Installed Size
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 fq~/?,
Course
~ [61~ ~[ ( '~"~No. of Compartments ~
¥' Foundation Cleanout (Y/N) N
Date Last Pumped i~/hg/~' ~ ....
/x/, A. ; for iv, ,4.
N,/.1. Temporary Holding Tank Permit (Y/N) 6,~, .4,
To Building Foundation t'3 ¢
To Disposal Field b
To Stream. Pond, Lake, or Major Drainage
Comments
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design
Length of Field "2'~2 '
Depth of Field ! ~
Gravel Bed Thickness Cd;"
~,z.-b~(.. Standpipes Present (Y/N)
Square Feet of Absorption Area
Depression over Field (Y/N) N
Results of Last Adequacy Test ~.'~¢
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot N, D-
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Date of Last Adequacy Test
To Property Line IO ~ '+ ~e. c~.~' .~. ~z
To Existing or Abandoned System on
; On Adjoining Lots ~ -.~¢' ~
To Cutbank (if present) iN,/~.
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** 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 ¢~~ ¢~, ¢"/-¢.¢..~4~ Date i'&/I,~ / ~' ~r'
Company r~/~ ~fl
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Engineer's Seal
.':JML LABoRATC :]lIES, INC,
71.27 OLD{ SEWARD HIGHWAY
ANCHORAG£~ ALASKA 99518
(907)344.8551
~CTERIOLOGICA/ ~TER ANALYSIS
TO BE COMPLETED BY WATER SUPPLIER
DATE COLLECTED 1 TIME COLLECTED I TYPE OF SYSTEM
MONTH DAY YEAR AM [] PUBLIC,INDIVIDUAL
h~ ' ~'¢' I: 'f~'"
I.D. HO. (PUBLIC SYSTEMS)
L-_
NAHE OF SYSTEM
SYSTEM ADDRESS
LO~&T~ON ~H[R[ $~MPL[ ~A~ COLLE~TE~
CIRCLE CLASS
A B C
TELEPHONE NUMBER
ZIP CODE
FOR LAB USE ONLY
[] RESUBMIT SAMPLE
Sample rejected because:
CHECK ONE OR MORE
[] Sample too long in transit.
Sample should not be over 30 hours.
[] Sample received too late in week
[] Not in proper container
[] Leaked out
O~t~'Yt'~E~ .~t¢.~r [] Other (Specify)
COL L. ECTE D BY: ~IGN~~._
F-ICHLORINATED
[]]FILTERED
[]UNTREATED OR OI'HER
TYPE OF SAMPLE
CHECK ONLY ONE THIS COLUMN)
[] DRINKING WATER
~CHECK TREATMENT
[] RAW SOURCE WATER
F'l NEW CONSTRUCTION OR REPAIRS
[] OTHER(Specify)
Insufficient information provided.
Please read instructions on form.
1S THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NON-CONFORMING SAMPLE?
[]~ YES ~NO PREVIOUS COLLECTION DATE
ANALYSIS REQUESTED (IF OTHER THAN TOTAL COLIFORM)
RECEIVED BY ~/~ .:' ,/~.~y,..~
ANALY~OAL HETHOD:
~M~HBRANE FILTER
~ FERME~;TATION TUBE
-Date & Time Started _ 1~-I¢-~ ~'~-O-
Date & Time Completed .~2~--~ ~i~CZ
LABORATORY RESULTS
Analyst ~ ..
[] Other Bacteria
[] Test unsuitable because:
E] Confluent
F1 l n'C
SATISFACTORY ~UMSATISFACTORY []
SEND REPORT TO:(PRINT FUL'L NAHE,ADDRESS AND ZIP CODE
NAME F (cz/'~ 7'~ cl~ ~,,,I ..~r2,.'~,~ '~
ADDRESS /~[.,4"~' ~cA, ~7.
CITY ~ ~ STATE?~zID ~}.~--/6~
BACTERIOLOGICAL WATER ANALYSIS RECORD
FOR LAB USE ONLY
TOTAL COLIFORMS
FECAL COLIFORMS
OTHER
Membrane Filter: Direct Count _
Verification: LTB
Final Membrane Filter Results
Reported By
READ SAMPLE COLLECTION INSTRUCTIONS ON BACK OF FORM
BGB
Date
Cc. liform/lOOml
Celiform/IOOml
Time A.M.
P.M.
DATE:
TO:
FROM:
SUBJECT:
ic p&l ty Aach¢
MEMORANDUM
January 12, 1984
Laura Crow
Environmental Health Division
Request for Refund - Account #2460
Please make arrangements for the following refunds. The
permit arid inspections were completely canceled and permit
voided. -
L & S Construction
8341 Sandy Place
Anchorage, Alaska
99057
Receipt It 2'74896
Amount: $150.00
Account # 2460
Lot 17A Block 4 Colonial Park Subdivision
On-site Sewer Permit with Inspections
Coldwell Banker Jack White Company Receipt tt 274893
3201 C Street, Suite 100 Amount $20.00
Anchorage, Alaska 99503 Account #2460
They decided to go through a private engineering firm for
the water s~nple and inspections. However, $45.00 fee is
retained for certification only as per the new fee schedule.
Thank you.
Laura J. Ward
Office Associate
attachements
91-010 (4/76)
ALASKA enuIRonmenTaL COFITROL SERLJIC $, IRC.
~n§ineerin§ 6 ~r, uironmenlal $Iuclies
January 13, 1984
Department of Health & Environmental Protection
825 L. Street
Anchorage, Alaska 99501
Attn: Robbie Robinson
Dear Robbie:
On January 12, 1984 our company inspected the sewer system and well
located on Lot 1, Block 2, Hideaway Lakes Subdivision and collected a
water sample. The water sample was satisifactory and a copy is
attached.
All the standpipes were capped.
The well is located over 100' from the system and has a sanitary seal,
The wires are encased in conduit. Attached is the well log.
Approved by:
Sincerely,
Gwe~t i Turner
En~/~onment al, Scientist
1200 LLIcsl S3rcJ Au~nue, $ui1¢ B · AncNo~aq¢, Alaska 99503 ,, (907) 276-136I
H. EMIC,4L & GEOLOGIC,4L L.,tBORATORIE$ OF ¢tLA$K/I, INC.
TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER ~ ~
5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM: [ 1 I I 1 1 q (*) See h on back
Water System Name Phone No.
Ciw ~ State Zip C~
Mo. Day Year
SAMPLE TYPE:
Routlno
Check Sample (for routine sample
wtth lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPI. E
NO. LOCATION
Time Collocled
Collected ,~y~._.
12: ~ .
TO BE COMPLETED BY LABORATORY
· Analysis shows this Water SAMPLE to be:
,~ Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 48 hours old at examination to
indicate reliable results. Please send new
sample via special delivery mail.
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
~ Membrane Filter
Lab Ref. No. Result' Analyst
ET]
J Eq-I
READ INSTRUCTIONS
BEFORE
COI_LECTING SAMPLE
06-1.220 (b)
Roy, 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
APPLICi 1T T U HALi-' ' "'~ ~ '"':""
Property Owner ~ t ~,-I ,...v,%'~ ~ r.;c .~i ,~.h,~ Phone
~_/ '~ ~'... ~ ~ '~ ~
_Mailing,Addre~ /~';~1 ~- ,~ ~'"; ~ " /
Address Zip Code
~'" Phone
Legal Description -
Street Locati~
--Type of Residence~ (.~;S{:, ~ ~t,~ ) ~ ..... ¢"--'~ t(". ~C (' ~'"~,.' , __
~hgle Family
~' Multiple Family No. of Bedrooms_ %~
~ Other ~
Water Supply
Cndividual ATTACH WELL LOG. A well log is required for all wells drifted since June 1975.
ommunity For wells drilled prior to that date, give well depth (attach log if available).
~ Public Utility
Sewer Disposal --
, Individual ~4 ,;.~
Year
Individual
Installed:
Public Utility When Connected Io Public Utility:' '
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Dat
Insp~tor Insp~tor Insp~lor Insp~tor
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
Soils Rating Date ~wer Installed Well To Absorption Area ~ Well Log Received
72.023