HomeMy WebLinkAboutHILLSIDE HEIGHTS LT 3Onsite File
Hillside
Heights
Lot 3
#015-092-76
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211468 PID Number: 015 092 76
Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑E Upgrade
Name
WILSON
ABSORPTION FIELD
❑t Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
9621 HILLSIDE
Other
Phone
Bedrooms
Soil Rating
depth from original grade
pNu�m�beof
1.2 GPD/SF
JTotal
9/9 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
5/5.4 Ft.4
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
HILLSIDE HEIGHTS LOT 3
Fill added above original grade
0.0.4 Ft.
Gravel length
40/42 Ft.
Township Range Section
Gravel width
2.5 Ft.
Beds: Number of Lines
-
Distance between lines
- Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
656 Ft2
2
8 Ft.
Well
+100
+100
-
-
_
TANK ❑■ Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER
Capacity
1250 Gal.
Surface Water
+ 100
+100
_
_
Material
Number of compartments
Lot Line
4
+10
-
-
NA
POLY
2
Foundation
+10
+.10
-
_
ILIFT STATION
Manufacturer
Capacity
Remarks OLD FIELDS REPLACED ENTIRELY
-
_ Gal.
Alarm location
Electrical installed by
Installer
PIPE MATERIAL House to tank EXIST Tankto
3034
GUARANTEED SVCS
Drainfield 3034 co/MT3034
Inspector CHARLES BALZARINI
BENCH MARK (Assumed elevation) 100 ft
Inspection 15' 6/17/22 6/20/22
Location and description
2�d
3`d 6/21/22 41h
TOP OF TANK MH
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
7/21/22 Engineer's Stamp
OF Akq k_k
Conditional Approval: Date
,r
��Q'� . • • ' ' ' , cS�,� 1
OF O*: 49 TH • * r
.. ....
.. • •%
Septic System -�^ '
Approved
COX /ti
j t.HARLES G BALZARINI
-13854
r���61,
I�IIi��Qji�'y� Date _a
.CE ,AMP,�
Note: this approval does not include well permit requirements.
Aw
ll\ pROFESSIONP�'
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trcev eoivu i a/
Municipality ®f Anchorage
P.O. Box 196650 ® 4700 Elmore Road
Anchorage, Alaska 99519-6650 a (907) 343-7904 a Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Department
On -Site Water and Wastewater Section
Ucp;u tment
* * * * VARIANCE/WAIVER REVIEW * * * *
Waiver#: OSV221039 COSA#: Permit#:OSP211468
PID#: 015-092-76
(? � �� +0 PCO
Legal Description: Hillside Heights Lot 3�
w aC`P roved .
Engineer: C&M Engineering OT P � \J e d Se�cvu__,+�°V-\ v'
04,\. ri OT � GC4 Tu +C v,k L } �t ll ecti
Applicant: Leland Scott Wilson V�:1e�'L bSP 2 A H (0E
-(zm L S/ 3/ Z Z _ 0
Your request for a waiver of the required 50 feet horizontal separation from the absorption field
to the excessive slope has been approved. The approved separation distance is 10.0 feet. See
engineer's waiver request and slope sections for justifications.
This waiver approval applies to the proposed absorption field extension only. Any future
upgrade to the on-site wastewater disposal system will require all separation distances be met or
another approval from this department.
Waiver is Granted: X
Waiver is not Granted:
Date: �0 11b Approved by: Q)��
Name of Reviewer
............................................... ■ ............................. ■ 1
**** VARIAN C E/WAIVER REVIEW ****
C&M ENGINEERING SERVICES
Ph: 907-854-5558
Municipality of Anchorage
Onsite Water & Wastewater Program
4700 Elmore Rd Anchorage, Ak 99507
RE: Septic System Upgrade for Hillside Heights Lot 3
Dear Reviewer,
A new septic system was installed at the above referenced property.
The original design involved extending the existing leachfield. Upon excavation of the existing trenches, it
was found that they did not exist. Any biomatted soil was removed and new trenches were constructed in
the plan location. The trenches were erroneously constructed shorter than plan, however the soils
investigation revealed that the soils were better than anticipated. The total length of new trench was 82-
feet with an absorption area of 656 sqft.
We believe this was a result of the existing system not being constructed as documented and the new
trenches having to be constructed in segments due to the limited space available for excavation and
stockpile of fill.
Reconstruction of the trenches was discussed with the MOA inspector during construction. The intent was
to construct them to match the records and extend them 15-feet each.
The new tank was installed 4-feet from the property line instead of the code required 5-feet. We are
requesting the separation distance be waived to 4-feet. The waiver is justifiable as the tank is easily
accessed, there is a fence between properties, and the plastic tank material reduces the likelihood of any
leakage which may impact the adjacent parcel.
Sincerely,
Charles Balzarini, PE
7/21/22
CHARLES G BALZARINI
CE-13854R
E
G
ISTEREDPROFE S S I O N A LENGINEER7/28/22
CHARLES G BALZARINI
CE-13854R
E
GISTEREDPROFE S S IO N A LENGINEER7/11/22
CHARLES G BALZARINI
CE-13854R
E
GISTEREDPROFE S S IO N A LENGINEER7/11/22
CHARLES G BALZARINI
CE-13854R
E
GISTEREDPROFE S S IO N A LENGINEER7/11/22
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3 degas IR,— ---
N89° 53' 56"E 280.52 REC.N00° 02' 59"W 165.44 REC.N89° 55' 01"E 610.25 REC.N89° 55' 01"E 610.19 MEAS.S00° 20' 57"E 164.81 MEAS.N89° 54' 51"E 281.28 MEAS.S00° 03' 48"W 164.82 CALC.
S00° 05' 12"W 165.53 REC.S89° 55' 01"W 280.09 PROR.LOT 2LOT 6BEACON HILLS ESTATESPLAT #69-64LOT 1LOT 2 & 4BASIS OF BEARINGS;;;;;;;;;;;;;;;;;;;;;;;;;℄ HILLSIDE DRIVETOHUOHUOHUOHUOHUOHUOHUOHUOHUOHUMB MB
WSSSSSSSSSSSSCGRAVEL DRIVEWAYSHEDSHEDSHEDEDGE OF PAVEMENT
S89° 55' 01"W 280.12 REC.ASPHALT10' UTIL. ESMT.50.0R.O.W.32.74
0
.
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23.9 29.912.2
4
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.
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10.47.1
10.210.28.210.2
32.7103.669.350.341.015.586.662.9107.8100' WELL RADIUSLot 3Hillside Heights Subdivision46,389 Sq. Ft. +/-9621 Hillside Drive 2 Story Wood Frame HouseWith Attached 3 Car GarageE
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PREPARED BY:FRONTIER SURVEYS, LLC650 W. 58th AVE. SUITE E, ANCHORAGE, AK 99518907-460-1686DRAWN BY: CHECKED BY: DATE: SCALE:DRAWING ID: SHEET 1 of 11.Excepting for gross negligence, the liability for this survey shall notexceed the cost of preparing this survey. Dimensions to property linesare plus/minus 0.1ft.2.This document is created by Frontier Surveys for the purpose of anas-built survey for Lee Wilson, only.3.This document is based on Plat No. 79-257, Anchorage RecordingDistrict.General Notes DisclaimerLegend1. This survey complies with the ASPLS Mortgage Location Standards. The survey represents visibleimprovements and conditions at the time of the survey. This document does not constitute a boundarysurvey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is theresponsibility of the Owner to determine the existence of any easements, covenants, or restrictionwhich do no appear on the record plat. Under no circumstances should this document be used forconstruction or for establishing a boundary or fence line.PS1" = 25ft07/08/202222-357KCScale 1" = 25'AN AS-BUILT SURVEY OFLOT 3HILLSIDE HEIGHTS SUBDIVISION9621 HILLSIDE DRIVECONTAINING: 46,389 Sq. Ft. +/- (RECORD)RECORD PLAT: 79-257Gas Meter Electric Meter/Outside Power DeckSepticTelephone PoleFenceMailboxOverhead UtilityWater WellTel. PedestalMBSeptic M.H.GES[TWPierre M. StragierNo. L.S. - 981207/08/2022REGISTEREDPROFESSIONALL
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RVEYORSC Found RebarFound B.C. Mon.
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP211468
Work Type: Septic Upgrade
Tax Code Number: 01509276000
Site Legal Address: HILLSIDE HEIGHTS LT 3 G:2440
Site Mailing Address: 9621 HILLSIDE DR, Anchorage
Owner: WILSON LELAND SCOTT
Design Engineer: C&M ENGINEERING SERVICES
This permit is for the construction of:
Effective Date
Expiration Date
nr
O:
Departrnent
Lot Size in Sq Ft:
Total Bedrooms:
6/16/2022
6/16/2023
46389
Q Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions:
For the primary field extensions, a test hole and an additional percolation test shall be completed prior to
construction of the absorption field (in locations shown on site plan). The test hole shall confirm minimum
separation to impermeables and seasonal high groundwater, as well as percolation rate. A 7 -day groundwater
reading is required, but construction may proceed at your own risk prior to the 7 -day monitoring. If results
require a design change, construction shall stop pending approval of a change order. Please submit test hole
results with the inspection report (or change order, if required).
For the 4 -bedroom reserve field, a test hole shall be completed prior to construction of the absorption field (in
location shown on site plan). The test hole shall confirm minimum separation to impermeables and seasonal
high groundwater, including 7 -day groundwater monitoring, as well as percolation rate. Please submit test hole
results and any required reserve field design changes with the inspection report.
Received By: Date:
Issued By: Date: Ca l ( 02®02 ig
4
UHC CC ALf TY OF -` H C'H0FR „ GF
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 015 092 76
Property owner(s) WILSON
Mailing address
Site address 9621 HILLSIDE DRIVE
Day phone
Legal description (Sub'd., Block & Lot) HILLSIDE HEIGHTS LOT 3
Legal description (Township, Range & Section)
Lot Size 46,389 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field 0 Initial ❑
Single Family (SF) 0
(w/wo ADU)
x
Septic Tank❑ Upgrade X
Duplex
ElHolding
(D)
Tank ❑ Renewal El
Multiple Dwellings ❑
Privy ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
���, ib S�eeQ Sae
Distance: �0
I certify that the above information is correct. I further certify that
this is in accordance with
applicable Municipal Codes.
C&M ENGINEERING
(Signature of property owner or authorized agent)
Permit/Rush Fees: -59-5-
Date
5q.SDate of Payment: 0 oZ ,24.2 1
Receipt Number: 0 a 12 -7D
Permit No. C2--%2
Waiver Fees: '�- 108. 7
Date of Payment: /o Z17� 0Q�
Receipt Number: 03gEV)
Waiver No. OSVAO 1 n 3
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
C&M ENGINEERING SERVICES
Ph: 907-854-5558
Municipality of Anchorage
Onsite Water & Wastewater Program
4700 Elmore Rd Anchorage, Ak 99507
RE: Proposed Septic System Upgrade for Hillside Heights Lot 3
Dear Reviewer,
The above referenced property is currently served by an older septic system with a failing tank.
The owner wishes to replace the tank and upgrade to a 4-bedroom septic system. The existing fields are
in good condition and they will be extended to accommodate 4-bedrooms.
The drainfields appear to have been installed too close to each other by code at the time of the
installation. It appears they currently meet the 8’ minimum required separation.
We are using the original testhole as a basis for the drainfield design. The percolation rate is 10 minutes
per inch. The original design indicates 165 sqft/bedroom was used as an application rate. The extension
design is based on an application rate of 0.8 gpd/sqft.
The existing drainfields are located near a steep slope. The drainfield extensions are placed to minimize
their proximity to the steep slope. We are requesting the steep slope requirements be waived based on
the following:
• A theoretical 25% slope line 2.5’ above the trench extension distribution line daylights 30.1’ from
a steep slope in the worst case.
• The slope is heavily vegetated.
• The soils are relatively free draining so effluent will tend to migrate vertically vs horizontally.
• The existing trenches already encroach on the steep slope. The extended trenches provide more
absorption area further away from the steep slope.
• There is no history of effluent daylighting out of the steep slope.
The requested waiver distance is 10-feet from the drainfield extensions to the top of a steep slope.
The 10-foot distance is the minimum based on the upper trench.
A reserve site will be located uphill from the existing septic and will require the use of AWWTS, a lift
station, and additional soils explorations.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211468, Rebecca Carroll, 06/16/22
The proposed leachfield extensions will not adversely impact adjacent properties which are relatively
large and already developed.
Included with this letter is a permit application and design package, including plans and calculations.
Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854-
5558 or by email cgbalzarini@gmail.com with any questions or concerns.
Sincerely,
Charles Balzarini, PE
10/21/21
Residence:
number of bedrooms 4 br
Water usage/bedroom 150 gpd/br
Water Usage 600 gpd
system type: Conventional
type: TRENCH
Application Rate
0.8
gpd/sqft
required absorption area 750 sqft
trench width (W) 3 ft
gravel depth (D) 4 ft below distribution pipe
Min Required Length: 93.75 ft
Total Length: 96 ft
Calc By: CGB Date: 10/19/2021
C&M ENGINEERING SERVICES
907-854-5558
Septic Design Calculations
HILLSIDE HTS LOT 3
RESIDENCE/LOT INFO
DRAINFIELD
Based on historic testhole
**DIMENSIONS FOR REFERENCE ONLY. SEE PLANS FOR DIMENSTIONS TO BE USED IN CONSTRUCTION**
includes 66' exist trench plus 30' total
extension.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211468, Rebecca Carroll, 06/16/22
CHARLES G BALZARINI
CE-13854R
EGISTEREDPROFE S S IO N ALENGINEER8/28/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211468, Rebecca Carroll, 06/16/22
CHARLES G BALZARINI
CE-13854R
EGISTEREDPROFE S S IO N ALENGINEER12/12/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211468, Rebecca Carroll, 06/16/22
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UNW1N*SCHEBEN *K0RYNTA Tiz-N
t=0 CONSULTING ENGINEERS and SURVEYORS 103 E 261h Ave Anchorage, Alaska 99503
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SCALE I DATE W.O. F.B: Z JGRID 2q r
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I HEREBY CERTIFY .THAT I HAVE SURVEYED THE SC's,.,����►*4
FOLLOWING DESCRIBED PROPERTY: - y �:.Z OF ACS A+
/�//L�.r�O�.(/f/`•1�T�' f�JGQ .CQT� DATE,
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS . ' �+
INDICATED. IT IS THE RESPONSIBILITY OF THE * : H !/V
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID, `.. .. """
EASEMENTS, COVENANTS, OR RESTRICTIONS .. • . d
WHICH DO NOT APPEAR ON THE RECORDM SUBDI— + o .�. A&A s.w 'd
VISION PLAT. CINDER NO CIRCUMSTANCES SHOULD FB, t �'• 15-a9�a �• r
FOR
OF FENCE LINESANY DATA HEONOR FORDESTABLISHING CONSTRUCTION
BOUND-
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NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAl_ ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPQSAL SYSTEM AND/OR WELl_ INSPECTION REPORT
LEGAL DESCRIPTION
DISTANCE TO:
C'>'/-IF HOMEMADE: Inside length I Width
Liq. ca[
DISTANCE TO:
Man u factu~rer¢f~
LDCATION
DISTANCE TO:
No. of lines
Top of tile to finisil grade
Well
Length
Width
th of eaci~
Dwelling
(.~.....-~-~' ] Material
Nearest lot linc
Total length ?f I.~,e, / T,onch widtl~ ,
Material beneath tile
~ 4~ehes
IPHONE
NO. O F~_~B E DR OOMS
PERMIT.~D.
No. of compartments
Liqaid d~ep~t h
PERMIT NO.
PERMIT NO. ~/ O~(j-L.~/
Distance between lin~s
Total effective3~x)t~.~ area
PERMIT NO,
[] NEW
~]-UPGRAD E
DISTANCE T
Crib diameter Crib depth
effective absorption area
DIS'rANCE TO:
Depth
Driller Distance to lot line
Building foundation Sewer line
Septic tank
PERMIT NO.
Absorption area(s)
t- / 0%)
OTHER
PIPE MATERIALS
SOIL TEST RATING
A~PRO/~ED ¢ DATE
U //" '- .
LEGAL
DEF'FIRTMENT 01.- HEFILT'H F-IN[:, ENVIROI'.,tMEI'.,FI'FIL. PNOTECTI
',E~25 "L'" STREET, FINCHORFtGE., I=lK.
F'E]q:MIT t'.,IO. ,:1 ',E:::LE~SS~:L
F:IF'F'L t CFINT JF!N FIFIi'.,I:SEI'.,I
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I'"IFI::.:[II"'IUH NI...IHE:ER OF E:F[:,~'I]I"'I~,'I':; ]~: E;I]IIL F:.H] IN:
T H E R E I]:!1..I ]: R E [:, ':~ ]: 2: ECI F T FI E S O I L FI E: E; O R F' 'f I O N E;'~'E; T E M I E;: ~ _~ ~ ' ¥} u
TFIE LENGTH D~MENS~ON ~E~ THE LENGTH (~N FEET) OF THE TRENCH OR [:,RFI~NF!EI...D.
THE DEPTH OF FI TRENCFI OR F:'~'I" IE; THE E:,IE;T~NCE E:ETHEEN THE E~;URF'FIE:E OF THE
GROIJI'.~[:, Bt'.,IE:, THE BOTTOH OF ]'HE E::-:;CFt',,,'FI"t"~ ON ,:: I N FEET
THERE ~S NO SET I,.I~DTH FOR TRENCHE~5.
'T'HE: GRFI',,,'EL DEPTH ~S TFIE I',t~NIMIJM [)EPTFI OF GRF%,'EL. 8ETHEEN THE OLrTFF~LL. F'~F:'E
FIND THE BOTTOH OF THE E',:.::CFI',,,'FtTION ,: IN FEET::,.
PERH I 'T' FIF'F'L I CFff.,f'I" HR'E; THE RESF:'OI'.,I~: I Ei~ I L. I T'T' TO I I'..IFOF,~:hl TH I S DEF:'RRTHENT E:,LIF: I NG THE
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MUNICIPALITY OF ANCHORAGE
DEPARTIVIENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
3
4
8
10
11.
12
13
14
15
16
17
18
19
2O
[] SOILS LOG
COMMENTS
PERCOLATION
TEST
WAS GROUND WATER
ENCOUNTERED?
IF YES, ATWHAT
DEPTH7
Gross Net Depth to Net
Reading Date
Time Time Water Drop
,.: ... // /
PERCOLATION RATE. /0 (minutes/inch)
TEST RUN BETWEEN .~ FT AND ?/ FT
PERFORMED BY:
72-008 (6/79)
MUNICIPALITY OF ANCHORAGE
Development Services Department 4.. Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-092-76
Legal description Hillside Heights Lot 3
Site address 9621 Hillside Drive
Current property owner(s) Wilson
Expiration Date:
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for
Comments or advisories:
11-4-22
bedrooms, with the following stipulations:
Original Certificate Date: K-,- q- z Z
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory_
Tank Age Advisory Arsenic Advisory
Other
COSA Approval_June 2022
k cl(� / '
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 015 092 76
Complete legal description
Location (site address)
HILLSIDE HEIGHTS LOT 3
9621 HILLSIDE DRIVE
Current property owner(s) WILSON
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: X Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: 0 Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel 0 Plastic ❑ Concrete ❑ Fiberglass
Age 0 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench R Wide Trench ❑ Seepage Pit
Waiver request for: NONE
Expedited review requested: 0
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ Waiver Fee $
Date of Payment I a �0Date of Payment
COSA # OS CZ a 13 � � Waiver #
COSA Application—June 2022
r
Legal Description: HILLSIDE HEIGHTS LOT 3
Parcel ID: 015 092 76
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled unk Total depth unk ft
Cased to +40 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) +12 in
Date of flow test for COSA 7/6/22
Static water level at beginning of test 124 ft
Comments
B. TANK DATA
Measured operating fluid level in septic tank na
Date of pumping na - new
❑ Required maintenance completed, if AWWTS
Comments: New Tank
Which system tested (date installed) 2022
❑ ALL standpipes present per record drawing
Total measured depth from grade 9.3 ft (max)
Measured depth to pipe invert from grade 5.1 ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
❑ Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) no
If yes, enter date new
Comments/Deficiencies: new system
COSA Checklist June 2022
Well production at time of test 4.9 gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 5.18 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by C&M Engineering
Date 7/6/22
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 7/6/22
Results n Pass
Fluid depth prior to test 0 in
Water added 600 gal
New fluid depth 0 in
Elapsed time 0 min
Final fluid depth 0 in
Absorption rate 600 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 0 in
Effective depth used 0 in
Effective depth remaining 0 in
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100'
m❑ Yes
if No
Community Sewer Manhole/Cleanout > 100'
Rn Yes
if No
ft
Q Yes
if No ft
Neighboring Tank > 100' Q Yes
if No
ft
Private Sewer/Septic Line > 25' Q Yes
if No ft
Absorption Field on Lot > 100' [E Yes
if No
ft
Holding Tank > 100' [E Yes
if No ft
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' ❑ Yes
if No ft
R] Yes
if No
ft
ft
If tank or field is under driveway comment below
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' Yes
if No
ft
n Yes
if No ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
m❑ Yes
if No
ft
Surface Water > 100'
Q Yes if No ft
Tank to Property Line > 5'
Q Yes
if No
ft
Wells on Adjacent Lots:
Field to Property Line > 10'
0 Yes
if No
ft
Private Wells > 100'
0 Yes if No ft
Water Main > 10'
R] Yes
if No
ft
Community Wells > 200'
M Yes if No ft
Water Service Line > 10'
Q Yes
if No
ft
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm C&M ENGINEERING Phone 907-854-5558
Engineer's Printed Name CHARLES BALZARINI Date 7/20/22
COSA Checklist June 2022
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC 221366
Subdivision: Hillside Heights lot 3
A water sample revealed a nitrate concentration of 5.18 milligrams per liter (mg/Q.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Please see the attached "Nitrate Fact Sheet" for important
information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Mailing Address P O Box 196650 *Anchorage, Alaska 99519 6650 www mum org
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening, or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
:Mailing Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www mum org
Ph: 907-854-5558
Municipality of Anchorage
Onsite Water & Wastewater Program
4700 Elmore Rd Anchorage, Ak 99507
RE: WELL CASING INTEGRITY FOR HILLSIDE HEIGHTS LOT 3
Dear Reviewer,
We inspected the well casing at the above referenced property with a camera.
The casing was verified to extend more than 40 -feet deep and no cracks or perforations were observed in
the casing.
Sincerely,
Charles Balzarini, PE
7/21/22
/11?i ,�f
r I
CHARLES G BALZARINI'
CE13854- `moi
����y�.-PROFESSI4NP�a'°`�
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
Location (site address or directions) 9621 Hillside Drive
Property owner
Mailing address ~"/'¢ o
Lending agency
Mailing address
Jan Hansen
Day phone
Agent Pat Kruse/ERA_Real Estate Center Day phone
Address 3333 Denali , Suite 110, Anchorage, Ak 99503
277-4372
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
Xxx
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
NOTE:
XXX
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system,
72-025 (Rev. 1/gl) Fronl MOA 121
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and Es 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.
S & S ENGINEERING
Name of Firm 17054 Ea9;~ R;ve~ Loop F,o.~; Nu, 204 Phone
Address Eagle River, Alaska 99577
Engineer's signature ./~/~ F~ ~ Date
DHHS SIGNATURE
Approved for '7-t/~/~/~' bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements, Employees of 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~'25 (Rev. 1/91) B~ck MOA ~1
Municipality of Anchorage MAY
DEPARTMENT OF HEALTH & HUMAN SERVICES
Mf.J~IQPALIf¥ O~ ANCHO~G
Enwronmental' Se~ices Division ~NWRO~ENTA/~..vl~[3 ..... DIVJ3Ju~'~
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
LegalDescription: Co'T- 3 Ft,~.~.£/~ H~/C~I;"J ParcelI.D.: OI$~ - 0?2' 7 (o
A, WELL DATA
Well type ?/~ ¢ ~g
Log present
Total depth
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~ / ¢/ ~ /
Cased to ~/O Y- Casing height (above ground)
Sanitary seal ~/N) ¥ ''¢' -'¢
Wires properly protected ((C/N) Y ~- ~'
Date of test
Static water level
FROM WELL LOG
Well production ~
WATER SAMPLE RESULTS:
g.p.m.
AT INSPECTION
g.p.m.
Coliform
Date of sample: .~ /
B. SEPTIC/HOLDING TANK DATA
Date installed II / ~ / ~ I Tank size
Foundation cleanout
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed /I / 5' / ¢ /
Nitrate ~J- ~/q Other bacteria
Collected by:
$ & S ENGINEERING
17034 Eag{~ ~;W.i: Loop Road No. 204
Eagle River, Alaska 99577
) 00 O Number of Compartments ~-:~ Cleanouts ~¢YN)__
Depression (Y/I~ ~' ~ High water alarm (YR~) ,~, O
Pumper
Soil rating (g.p.d./ft2 or~ )6 5" System type T/~z'/,~ ~//~ .~'
Length (~ & ~TOTAL Width3'/~¢ ro q '/>' Gravel thickness below pipe ~ ¢ Total depth W /
~ O~,,~,~ ~/~/~)
Effective absorption area 6~ ~ ~r Monitoring Tube present~/N) Y~ Depression over field (Y~ ~v0
Date of adequacy test ~/~ / q ~1 Results~/Fail) ~ For ~ bedrooms
Fluid depth in absorption field before test (in.); ))~ Immediately afterdd ~gal. water added (in.): ~ ~Y
Fluid depth ~//I (ins) Minutes later: ~/~ Absorption rate = ~O -F g.p.d.
Peroxide treatment (past 12 months) (Y/N) wo,v¢ ~o,~,,~ If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycle~
E. SEPARATION DISTANCES
Size in gallons
"Pump on~ ~evel at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot / 0 d t .¢_ On adjacent lots
Absorption field on tot ! 00 ,~ On adjacent lots
Public sewer main N t/4 Public sewer manhole/cleanout
Sewer/septic service line ~ S- f4 Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation .? (2 -+ Property line 5' -/
Water main/service line /o .--~ Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line [o 4~ Building foundation $'0 +
Sun"ace water / o 0 -+
Curtain drain
Absorption field
Wells on adjacent lots
Water main/service line
Driveway, parking/vehicle storage area /0
Wells on adjacent lots /
ENGINEER'S CERTIFICATION
~'~'-~-~,~ A "~ re
I certify that I have determined thru field inspections and review of Municipal record~J~b'be~.~e~,s a
in conformance with MOA NAA guidelines in effect on this date.
Signature
Date ~ / / 0 / ~
HAA Fee $.
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
1-99 i5:01 FROU-CTE ENVIRONMENTAL
t CT&EEnvironmuntam$ ,vi e '.¢-
5615301
T-BST P.0g/05 F-61~
CT&U Rer,~ 991954001
Client Name S & S liingmeering
Projex~ Name/# N/A
Client Sample ID ~ 3 Hillside
Marr~ DriVing Wa~er
Order~ By
PWS~
Sample Remarks:
Client PO~
Ih'inted Date/Time 05t 11/99 11.09
Collected Date/T/me 05/05199 10:45
Received Date/Time 05/05/99 12:00
Technical Director: Stephen C. Ede
kimit$ Do~e D~te Init
To~a[ Cotitorm 0
ni~ra?e-N
cOt/lOOmL SMIB 9~D
O.500 t0~/L EPA ~OO.O
05/05/99 gAP
lO [l~x 05/05/~9 OS/PS/~g SCk
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF iNSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILFrY
264-4720
Application Date
1. GENERAL INFORMATION
(a) Legal Description (inplude lot, block, subdivision, section, township, range)
Location (address or directions)
(b) ApplicantName~'~ ~¢~'¢ Telephone:Home3~'~O ~¢ Business¢~F~
(c) Applicantis(checkone):Lendinglnstitution~;Owner/builder~;Buyer~;Other~ (explain);
(d) Lending Institution/~'~'~" ~/'" ~'~'C '/~¢ P~"¢.~ Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f)
Mail tire 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.
SEWAGE DISPOSAL
Onsite B2 Public [] Community [] Holding Tank []
Note: I[ 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 PROVIDIN-,INSPECTIONS, TESTS, FILE SEARCH, D, '. AND INFORMATION
AS certified by my seal affixed hereto and as of the validation d~te shown below, I verify 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 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 _T-~7-~S~¢:', ~,/F~' ~ ~d, ,_~ Telephone
Address
DHEP APPROVAL
A p p rove d ,o r ~--,*¢~,4'_.~'-~'~')be d ro o m s by
Approved '~ Disap~ved
/0,d--¢.c,-4..~ ~- Date 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
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 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
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MO/-~/
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FI-'BRUARY 1984
264-4720
Legal Description:
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
~7
RECEIVED
WELL DATA
Well Classification "~.J zk.-~ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) t-J Date Completed cJ~v-.,..x-~,J.~ Yield
Total Depth /z.5'- Cased to q'J~-~T~ Depth of Grouting
Static Water Level ~'"
Casing Height Above Ground . }
Electrical Wiring in Conduit (Y/l'~)~t~ ---~
Separation Distances from Well:
To Septic/Holding Tank on Lot I~¢)''~ ~-
To Nearest Edge of Absorption Field on Lot
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots I oo'"-
; On Adjoining Lots t~2'+¢':~
To Nearest Public Sewer Line _ ~J/A, To Nearest Public Sewer
Cleanout/Manhole _ ~,/,~- To Nearest Sewer Service Line on Lot _
Water Sample Collected by /Y),lc~ ~-.l~,~Sb-r<.; ~ ~~; Date ~ ~5,
Water Sample Test Results
Comments ~-' ~6bl~ ~ ~ ~¢ ~'~'
SEPTIC/HO~ING TANK DATA ~'~-'/ .
Date Installed ~,~ Size ~ ~ No. of Compartments
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 ~oo+
To Property Line lO ~
To Water Main/Service Line ~o'~'~-%
Air-tight Caps (Y/N)
Foundation Cleanout (Y/N) . ~
Date Last Pumped _ ~ Jq/gg ¢//
; for ~-~J ~
Temporary Holding Tank Permit (Y/N) ~ J¢~
To Building Foundation "7~ ~- ~-"r
To Disposal Field J_o ~::-r
To Stream, Pond, Lake, or Major Drainage
Course
Page 1 of 2
72-026{11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
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 I ~C2~- I:::"r-
TO Building Foundation ,:..~.,..~'+
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
J,=0~¢\¢.,.~,.~..~ )(~2~* Type of System Design -
II/~'1 Length of Field ~_~o...~
.~. S-- 'Lt, % ¢n'- Depth of Field ~
Gravel Bed Thickness ~: ),~'l~,~c--~',J '/-'/L,~'r
~Q .~'~, Standpipes Present (Y/N)
t',.,) Date of Last Adequacy Test Co !~5 ! o~.
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots Ioo+i:zT'
To Cutbank (if present) /'J/,,~
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments ~
Dimensions
Manhole/Access (Y/N)
"Pump Off" Le '~eL4~
~~t (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that l hav~chec,k,6~, ~/~¢fi.,e~,/o, rC;onformed to all MOA and HAA guidelines in effect on the date of this inspection,
Receipt
No,
Amount: $ ~ ¢~ ~ .¢. ~(;,;,%~ % ¢~Engineer's Seal
B.Ef~E, EPPS & FOTTS
2220 EAST 88 AVEiNUE
ANCHO(4A~, AK 99507
(907) 349--6451.
W~ ~LT~
Subclivision:
Lot:
Block:
Client's Name_:
Address:
Initial Reading on Meter:
GALLONS GALLONS
TI[,Rg GPM ~ VOLUME TOTAL VOLUME
~. o _
Io:C~
1%: Iq
NOTES:
Prc~duction Rate: Z.(~ GPM 24-Hour Capacity~/o~o Gallons
· ', INSPECTION APPOINTMENTS
TIM~- TIME TIME
DATE DATE DATE
NSPECTOR INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE ~NVI~u,~MENI'AL
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
Teloph~ne 2~4-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests Will not be processed. Please allow ten (10} days for processing.
1, PROPERTY OWNER PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2, BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION ~ PHONE
I
MAILING ADDRESS
4, REALTOR/AGENT ] PHONE
MAI LING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
E~] Other
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One [~] Four
[~ SINGLE FAMILY [] Two ~] Five
[] MULTJPLE FAMILY [~ Three ~ Six
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
8. SEWAGE.~/tgPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON:SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH BEQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(Rev. 6/79) ~ ~.~)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS "·
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2, WATER SUPPLY PERMIT NUMBER
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified
INSTALLER
F~Septic Tank or []HoldingTank
Size: If Tank is homemade soILs RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
PPROVED POR .% BEDBOOMS
[] CONDITIONAL APPROVAL {letter must accompany certificate/
[] DISAPPROVED
· BY
72-010 (Rev. 6/79)