HomeMy WebLinkAboutLA FORET LT 3
NAME
MUNICIPALITY OF ANCHOHAGL--
DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO'FEC'FION
ENVIRONMEN'I'AL ENGINEERING ,DIVISION
825 [. Street - Anchorage, Alaska 99501 Telephone 2B4-4720
ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WEiI.L INSPECTION REPORT
MAILING ADDRESS
LEGAL DESCRIPTION ,
LOCATION
~--~: IManufacturer--DISTANCE TO:
Uq. ' Inside length
IF HOMEMADE:
Well Dwelling
DISTANCE TO:
PERMIT NO.
uid capacity in
-7
~ .~ . Foundation
DISTANCE TO: ~ (.,~-_A
No, of lines0~'~ ~-~ Lengtil of each ~ ~
Top of tile to finish grade
Length Width
Material beneath tile
Nearest ]et line
Typo of crib Crib depth
Well
DISTANCE TO:
Distance bet~-~een Hnes
T~)-i~al effective absorption area
I effective absorpt]
Depth Driller
Building foundation Sewer line
Septic tank
PERMIT NO.
Absorption area(s)
OTFIER
PIPE MATERIALS
SOIL TEST RATING J'
INSTALLER
REMARKS
DATE LEGAL
WATER WELL LOG
FOSS DRILLING ASSOCIATED
909 CHUGACH DR. #37
ANCHORAGE, ALASKA 99503
WELL OWNER 1Richard W. Lsster
USE OF WELL
WELL LOCATION Lot ~j Block --, LaFaret Subdivision
Domestic
SIZE OF CASING 6"
STATIC WATER LEVEL
REMARKS
DEPTH OF HOLE 269
178 FT. Go Po Mo
FT. CASED TO 269 FT.
t~. WITH 59 FT. OF DRAWDOWNo
DATE COMPLETED ]0/6/80
PUMP TO BE SET AT 268'
~0 to4~ Organic: brown color~ soft
_~to~5 Alluvium: grey color, medium hardness
~_to95 Alluvium: high proportion of silt, grey color, and soft
.~__to 12____0 Till: grey and hard
1.~0 tol_~.7 Alluvium: grey color, medium hardness
1=4L~_to15____5 Alluvium: high proportion of silt, with water(1.5 g.p.m.),
~O
grey color, medium hardness
1~5to170 Alluvium: grey color, medium hardness
1~7~_to180 Alluvium: blue-grey, and hard
180 to252 Till: water saturated, grey color, and hard
252 to255 Silt, Sand and Gravel: grey color, with water
255 to268 Till: water saturated, grey, and hard
26_~8to 26___9
to
Sand and C,r~vel: grey, with water
MUNICIPALITY OF ANCHORAGE
D~PT OF .....
ENVIRONMENTAL ~. 7 iECTION
tO
to
to
to
to
., uv 2 5 980
R.,i C F I\/!:_ 0
RPF'LICRNT
LOCRTI O1'4
LEGRL.
RIE:I...IFIRD IA. LESTER
G I i'.,IF'OL.E CIRCLE
2¢'~55 CL. IF'F'"SI[:,E E:,RIVE
LOT } LB:FORET S/D:
LOT SIZE 42P~Or3 SQURRE FEET
T'¢PE OF SOIL f:IE::SORF:'TICIN S¥STEI'd IS: TRENCH
HR:qII"IUt,'I NUt,IBER OF BEDROOMS
SOIL RFITII',IG '::SQ FT,.'"E,'R::'= 225
THE REQUIR. E[:' SIZE OF THE SOIL FIE:SORF'TION S'¢STEM iS:
THEE LENGTH [:,IHENs;ION IS; ]"HE LENGTH ,::IN FEET.'., OF THE TRENCH OR D.F..:RINFIELD.
THE BEF'TH CIF FI TRENCH OR F'.'IT IS THE DISTRNF:E BETHEEN THE SUF.:F'FICE OF' THE
GF;;:OUND RN[:, THE BOTTOH OF:" THE E,'..::CFIVRTIF~N ,:.'IN FEET).
Tf-.IEF;'.E IS NO SET HI[.',TH FOF.: TRENCHE':;.,.
THE GRI:~',,,'EL. DEPTH IS THE HINIP1UH DEPTH OF GF..'RVEL. BETHEEN THE OUTFI:ILL. PIPE
FIND THE BOTTOP'I OF THE E',:.::E:FI',,,'RTION ,:.'IN FEET).
F'ERHIT F:IPPLICRNT HFIS THE F;.'.ESPOi'.~SIBILIT'¢ TO INFOF..'H ]'HIE; B, EPFIRTMENT [:,UF.:ING THE
I NSTI::ILLFIT I ON I NSF'ECTI ONS OF RN"r' IAELL'.'E; I::ID.J'I-'~E:ENT TO TH I S PF.':OPERT'¢ F'INB, THE
NUHBER OF" RESIDENCES THFIT THE HELL HILL SERVE.
E:IaCKFILI_ING OF RN"r' S"¢STEH HITHOUT F'"ZNI"-tL INSPECTION FINE:, RPPROk"RI~ B'¢ THIS
[:'EF'FflRTHENT HILL BE SUB...TECT TO
HINIP'ILIh'I [:'ISTRNE:E BETI.,.IEEN R HEL. L RND Rh~'t' ON-2;ITE C;EHRGE DISPOSRL S"¢S"I"EH IS
:t00 FEET FOR FI PRIVFITE 1.4ELL. OR :1St.-'l TO 200 FEET FROH R PUBLIC HELL DEPENDING
UF:'ON THE T"r'F'E OF::' PI. JE:LIC HELL..
HINIP1UH £:'ISTRNCE FF..'OH R F'F.'.IVRTE HELL TO F:I PF.'.I'v'RTE SEI.4ER LINE IS 25 FEET RND
'T'O R E:OHHI..INIT'¢ SEHER LINE IS 75 FEET.
NELL LOGS FIF.'.E F.':EL'"~.UZF::ED FINE:' hlUST BE RETUF-.'NED TO THE DEF'RRTP'IENT HITHIN 3:O [."R'¢S
r"~F THE 1.4E'"LL COt'IF'LETION.
ECl"HER REQUIREHENT2; HFI"r' RPF:'L'¢. SPEE:IFICR'r'fONS RN[:, i2:ONSTRLICTION [:,IRGF'.RHS RRE;
FI',,,'RIL. FIBL. E TO INSURE PF:'.OPER INSTRLLFITION.
I C:ERTIF"r' THFIT
t: I RP1 F'FIHILIFIR NITH THE REI..'c.!UIREHENTS FOR ON-SITE SEI4ERS RN[:' HELLS RS SET
F'ORTH B'¢ THE HUNICIF'RL. IT'¢ OF I~NE:HORRGE.
2: ]: HILL INSTRL. L THE 5'Y'STEf'I IN I:~C:C:ORDRNC:E HITH THE CODES.
3:: I UNDE{RSTF:IN[) THRT THE ON-5;ITE 5EI.4ER S"F'STEH MR'¢ REQUIRE ENL¢~RGEP'IENT IF' THE
F;'.ESi; l [:,ENC:E I S REHOB'E:L.E[:' TO I NCLUE:'E HORE THRN g BEE:'E'.OOI'dS.
FIF:'F'LIE:FINT R~E:HFIRE:, 1.4. LESTER ~~
'F'¢F'E OF '?_-~IL FiE'._qO~:F'TICIN '.::;'¢STEM IS~-'--/
MR;.::IMIJM NIJHE:E~'. OF E',EDF:OOHS = ~ SOIL ~:R]"ING ,:5(J FT,?BI;:)=
THE F:EGLIIt;:ED SiZE OF THE SOIL. CE;S0~tF'TION S'¢STEM IS:
E:, tE F" -r t4 ..... L_ E: l'-4 I:i ]- FI ;= O I]i [~: I:'1 ,. E L- [;' E F' T' H
THE I_ENGI'H [:,II'IENSIOIi ZE; THE LENGTH ,(IN FEET..') OF THIr{ Tr~ENCH OR DRfllNFIEI_D.
THE [:,EF'~I4 OF R TRENCH ON: PIT ~:5 THE D}E;TRHC:E E=ETWEEN THE SURFRC:E OF THE
GRC,..IIiD RI.ID THE E=OTTOf'I OF THE E::qE:RVRTION (IN FEET).
THEF:E IS HO SET I,IIETH FOR T~:ENCt4ES
THE GRB',,,'EL. [:,EF'TH IE] THE MINIHUH [:,EPTH OF 6R~VEL BETI,IEEH THE OUTFRLI_ PIPE
F~HD Tt4E BOTTC$1 OF THE EX(:ff,/RTION (IN FEET),
PE¢:I'IlT RPF'LIC:RNI' HRS t'HE RESPONSIBIL !T'¢ TCI INFORH THIS DEF'fl~:TI'IEHT DUPIfIG THE
INSTRLt_RTICIN INSF'ECTIEIf'~S OF RN'¢ FIELLS R[:,JRCEHT TO THIS F'f;:EIF'ERI"¢ RN[:, THE
NIJME',E~r OF FTE$IDENCES THRT THE HELL HILL SERVE.
BR,Z:KF ILL I NG OF ANY S'¢STEPI I,II'THOUT F l NAL [NSPEC:T ~ON RN[> RPP~:OVRL E?¢ THIS
[:,EF'RF:TMENT HILL BE SUE',3EC:T TO F'EtOSECUTION.
HINIMUM DISTflNC:E BETI,IEEN B NELL RI'iD RNY ON-SITE SEI,IRISE DISPOSRI. S'~'STEM
iGg FEET FOR R F'RIVRTE HELL Ofit &58 'FO 2¢0 FEET FROM fl F'UE:LIC MELt. DEF'EHC, ING
UPCI[I Tile I"f'F'E OF F'UBLIC HEI_L.
HINIMI_IM DIS'FF~NCE FROM R F'RIVRTE HELL 'TO fl Pfi:IVRTE SEI,tEP. LINE I% 2% FEET
TO R COMMLIH~T'¢ SENE~;: LINE IS 75 FEET
HELL LOGS F~:E REI;~I..,IRED RI.lC, Idl..IST E=E FTETI_I~:NED TO THE [:,EPFIRTMENT HITHIH ?E~ [',raYS
OF THE I.IEI_L COMF'LETICIfl.
OTHEFi F:EGI.II~:EMENTS MFtY RF'F'L.N'. SF'EC:IFICRTIOHS RN[:, i::E~NS'FI;:LIC:TION DIRGRRM% RF:E
FI',,,'R I LF~BLE 1'0 I ~.ISI_IRE F'~:OF'ER ] HSTRLL. BT I
! C:EF:TIF"r' TtlFIT
1: I Rt.1 FR/,IIL_IF:tF;: bJITH THE RE~qI_IIR:Ef,1EN-rs FOF.: OH-SITE SEHERS t3NE:, HELLS
FOF'.TH B'¢ THE 1,11.1N I C I F'l'rfl_ I T'r' OF flHCHCIF:RGE,
2: I HILL INSTfll_L I'HE S'¢STEH IN RC:COfiiDRHCE filTH THE- CODES.
2 I IJtlC',Ei;,Sl'Rri[', l'HflT THE ON--:5ITE SEI4~T~: S'¢STEbl MR'¢ F;TE(~IJII;:E EHLRRGEHEHT IF THE
F:ESIDEI-JCE I'E, f~'[:I'IOE:,ELED TO INCI_UE:,E I'IO~:E TH~q/q ~ E~EDROOIflS.
% I GHE[:,:
F~F'F'L I CRt. IT
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
PouCh ~.!!150, Anchorage, Alaska 99602 276-2224
SOILS LOG- PERCOLATION TEST
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRiPTiON:
DEPTH
(EE E'I )
4
10
/~--*~ ~ ,~ IF YES, AT WHAT
DEPTH?
SLOPE SITE PLAN
13
14-
15-
17
18
19
2O
WASGROUND WATER
ENCOUNTERED?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE R% (minutes/inch)
TEST RUN BETWEEN FT AND (,~ r -'~'"~'/, FT
/ ~. /- ~ / ~
72-008 (7/76)
MUNICIPALITY OF ANCIK)PJiGE
DIVISIC%I OF ENVIRONMENTAL HEALT'H
DF~A[tTMENT OF HEAl,Tit AND ENVIRONMENTAL PRfYI'ECTION
APPLICATION FOR HEAL%H ;.IYtHORIi~f APPROVAL CERTIFICATE
Iv G~ne~,a]. Information ~pplieation Date
a) Legal £l~scripticn (include lot, block~ su[x~ivision, section, t~nship, range)
Location (add~ess o~~ d:U.~ec, tions)
Applicants Add~.ess
C ) ' C'
d) Lending institution /~£~//~-/zzg ~/~/~- ~/' .~?~_.~_<ak~= Telephone
(e)
Real Estate CO. & Agent /~Y~/~/ ,~,~-T~f_~a,k/,f~ ,
Acid. ~, ~, ~;~'/
Telephone =~ P~ ~z~
Other (¢k~scribe)
c~,nf~matlc.,n ~n the State
Note: If cv,?~w~p, ity w~ll ~stem, roust na~ ~,mitten ' ' ~'' -''
Dopavt a.~nt: cf [~:virc~%[[~w~tial Ccnseuv~tion attest:lng Lo t~ legality a~d status.
IS the veil ade~la~ fo~ the uum~]~ of bsdr~ s~cified in this Hk~ (Y~)
Onsite [~ ~lblJ. c [~ ~rf~mlnity ~ Holding Ta,~ CE]]
IS the wastewater dis~>sal sys~m adequate fo~t the p~3~r of L~dr~ .JT.Z~2. z
[pa.~ 1 of 2I
2-15~84
5, ~p_q.i.}[~:_e~r_i./?.~_~._~_~_o_v~i..d_%.~2q_-'~n_s~cti°ns, Tests, Data and Inforn~ntion
I certify that I h~ue' ('J~e,~cked~ verifie~, o: confor~w3d to all ~YOA [[AA Guidelines
effect.~n- t-t%e dat~o~ l/Jiis
Add~ess
Signed by
Dat~. ............................................ 2 ......
( ENGINEER S}}iAL)
Approved
Temns of Conditional ApD~oval
1he Municipality of Ancho~¢age l~parinnent of i~alth and Environmental Pr. otection doe~s
not Guarantee t~ continued satisfactory ~rfor~n~ of 't~ watek, supply and/~ the
wastewate~ disposal system, This approval indicates that, as ~ the validation ~te
shoan ~o~, [~d on tff~ data and info~tion f~'~lished ~ ~ e~i~er reqis~red in
the State of Alaska, the rater supply and wastewatel' disposal system is safe and func~
tional for the ~,ln~ cf ~dr~ ~nd t~ of s~uctu~e indicated,
( DHEP SEAL)
7 Mail the HAA to t~ foll¢3ai, ng "dd~'"'~°
[Pa{~ 2 of 2]
2-!5-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
WELL DATA
Well Classification ~Le
Well Log P~esent (Y/N) Y
Total Depth ~... Cased to
MUNICIPALITY OF ANCHORAG~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
JUN 9 1984
If A, B, c~ C, D.E.C. App=oved(Y/N)
Date Completed /~/~/~ Yield
~pth of G~outing ~?
Static Wate~ Level /~ Pump S~t At
Casing Height Above G~ound %~9~' Sanitary Seal on Casing (Y/N)~
Elect3ical Wi~ing in Conduit (Y/N) ~( Depression A~ound Wellhead (Y/N)
Sepa/ration Distanoes f~om Wel~:-~ ~-:~'~"N './,'~it~.(~''~ ;~c~?
TO Septic/Holding Tank on ~c-~i?~_~ ? ':~.-~('"-] ~GC'a Adjoining Lots~_~-~
To Nearest Edge of Abso~ption~Fi%-ld on Lot ~oq ; On Adjoining Lots(_C~l ~rlor
TO Nearest Public Sewe~ Line ~'~ /~ To Nearest Public Sewe~
Cleancut/Manhole ~-\( ~ To Nearest Sew~ Service Line on Lot
Wate~ Sample Collected By ~,'~;~:~..'.z~Q~-c.D ~e ~U~ \~.,
Wate~ Sample Test Results
B. SEPTIC/HOLDING TANK DATA
Date Installed ~-~--80 Size /~,~'~ No. of CQ,~a~tments
Standpipes ,(Y/N) ~ Ai~-tight Caps (Y~) ~ Foundation Cleanout (Y~) Y
~p~ession o~ Ta~ (Y~) ~ ~te ~st P~d '~%~
Pt~ing~.~intenan~ ~n~a~ ~ File .(.Y~) ~ ; for q/,6
Holding Tap~ High-Wate~ Ala~ (Y~) ~ ~a~y Holdi~ Tank ~rmit
To Building Foundation /% !
To Disposal Field ~ ~
To Stream, Pond, Lake, c~ Majo~ D~ainage
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ~ S~/~_~. Type of System E~, sign ~.~
Date Installed ~ -- ~--~) Length of Field ~
Width of Field ~; ~p~ of Field ~ ~ /
Grail ~d Thick,ss ~;
S~e Feet of ~sorption ~ea ~ ~. ~ Stan~i~s ~esent (Y~) ~
~p~ession ove~ Field (Y~) ~ ~ of ~st A~a~ Test ~ -- ~
Results of ~st ~qua~ ~st ~~ /
~paration Distan~ f~ ~s~ption Field:
To ~te~-Supply ~11 ~ ~ / To ~o~ty Li~ ~ '
To Building Foundation ~ ~ To Existin9 or ~ndo~d System
Lot ~ ~ ; ~ ~joining ~ts ~ '
To Wate~ Main/~vi~ Line ~A To ~t~(if p~e~nt) ~
To Stre~ond~ke/~ Majo~ ~aina~ C~ ~ ~ , ~%~ ~ ~
To ~iveway, Pa~ki~ ~ea, ~ Vehicle St~a~ ~ea ~ % ~'
D. LIFT STATION
Date Installed
Size in Gallons
"Pump 0~" 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 du~ing Adequacy Test.
Meets MOA
Co.~a~nts
** Cheek Permitted Be.d~oc~ Rating Against HAA Request
I ce~ifT-~at I/h~a~ehecked, verified, o~ conformed to all MOA HAA C~."..l~-~r~.. in effect
[Pa~ 2 of 2]
2-15=84
MUNICIPALITY OF ANCHORAQ~
D[PT, OF HEALTH &
i~NVIRONMENIAL pROTECTiO~
RECEIVED
July 26, 1984
Department of Health and Environmental Protection
Environmental Engineering DJvlsion
825 L Street
Anchorage, Alaska 99501
Reference: Lot ~, LaForet Subdivision, Anchorage, Ak.
Attn: Susan Oswalt
Susan:
Please find enclosed a copy of the State Department of Environmental
Conservation approval to walve the horizontal separation between the
private well and the septic tank.
As I understand~ this should allow you to continue processing the
municipality permit.
Please contact me iff I can be of any further assistance,
Regards,
Boyd J. Browl
Z~37 "E" STREET, SUITE 200
ANCHORAGE, ALASKA 99501
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
July 25, 1984
MUNICIPALITY OF ANCHORAGE
DEPT, OF HEALTH &
ENVIRONMENTAL PROTECTION
Mr. Boyd J. Brownfield, P.E.
SRA 1563C
Anchorage, Alaska 99516
Dear Mr. Brownfield:
RECEIVED
Subject:
Waive horizontal separation between a private well and the
septic tank on Lot 3, LaForet Subdivision, Anchorage, Alaska
(8521-WA-018)
The Department has reviewed the subject waiver request and hereby waives
the horizontal separation between the private well and the septic tank
for the three bedroom single family house on the subject Lot to 95 ft.
Sincerely,
Environmental Engineer
B E E/rosin
reference: Lot 3, Laforet Subdivision
13300 Ginpole Circle
ADDITIONAL COMMENTS
During the tests there were several discrepancies noted which deserve
further discussion.
1. The Soils Log - Percolation Test conducted on the 22nd and 23rd of
August, 1980 was not stamped or approved by an Alaska Professional
Engineer.
2. The OnaSite Sewage Disposal System and/or Well Inspection Report
dated August 5, 1980 was not stamped or approved by an Alaskan
Professional Engineer.
Comment: While these documents did not bear the PE Seal, they appear
to be complete and representative of the area. In any event, the
Municipality issued a permit on August 27, 1980, presumably using
these documents as guides for the design. There is some question as
to whether a PE Seal was actually required at that time.
3. The Request for approval of Individual Water and Sewer Facilities
dated December 22, 1980 was disapproved by the Municipality on January
12, 1981.
Comment: It appears that the only reason given for disapproval was
"no water". The water Well Log dated Oct 6, 1980 discloses a depth of
hole to be 269 feet with a 178 feet static water level. According to
the report, drawdown test results conducted at that time demonstrated
a continuous flow of four gallons per minute with an eighty nine feet
drawdown. A similar test was conducted by the undersigned on Ju~e 13,
1984 and disclosea'~n-~n~-~-6-~f fou~ galions per minute flow
for a period of four hours with no apparent ill affects, thus
substantiating the previous testing. Drawdown was not measured. This
flow exceeds the minimum continous flow requirement for a three
bedroom home.
4. The physical distance of the water well from the septic tank is
ninety five feet which does not meet minimum distance requirements for
separat~'6~ ....
Comment: While this does not meet todays criteria several
observations are in order.
l'he septic system does not begin free flow of effluent through the
soil until it reaches the absorption field. The physical horizontal
distance of the water well from the field is about one hundred and
nine feet. Further, proof positive of lack of any ill affects by a
five feet descrepancy between actual location and municipal code is
the quality of the water. Results of a membrane filter analysis
performed on June 14, 1985 disclosed no coilform count, thus an
acceptable water quality of the well.
page 2 (Additional Comments)
General Comments: While there may have been several deficiencies
occuring during the construction of the septic and water well systems
in latter 1980, those deficiencies appear to have no detrimental
impact on the successful operation of the entire system over a four
year period.
The present and only owner of the property verifies that all systems
have continuously functioned properly since installation. These
assurances coupled with adequate test results from: a) Septic System
Adequacy Test, b) water well capacity (drawdown) test, and, c) the
Drinking Water Analysis Report tend to eliminate any fears which the
above cited deficiencies may suggest.
CONCLUSIONS:
Based upon the successful operation of the septic and water well
systems for a continuous period of four years and the acceptable
results of all pertinent tests it is my considered opinion that the
system meets the intent of Municipal standards and code. Further,
that if an exception to code is necessary because of earlier
deficiencies during construction, this property meets the tests by
which an acception should be granted by the Municipality.
Lot :.'~-:, Block :-::: Ama -~FOTC.¥¥Z- Sq. Fi'.
Plat File No. %='
otrlc,, Alas,~a " ........ ~ ..... ' ...........~= ...... "
Anchorage Recordinq Di~ ' ,, ,, .ZZ__~.L .......... :' ' . '
~ ~ .'~. ','~ i,~:;:~ ~ ~ ,','.. ~ . ,
~. .'.. /./
I~ '- DATE RECEIVED
INSPECTION APPOINTMENTS ( %..~ '"t
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE MUNICIPALIIY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIONDEPT, OF ',' ,'.1.~ ! J,
825 L Street- Anchorage, Alaska 99501 ENVIRONMI N l,hi · :~ ':CTION
i~) ENVIRONMENTALTelephoneSANITATION264.4720 DIVISION 'i~{"~- ~-~ '7 ~i~t~
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND
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
. PHONE
MAILING ADDRESS
3, LENDING INSTII'UTIO~
MAILING ADDRESS
4, RBAL~OR/AGENT ~ PHONE
I
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION)
6. TYPE OF RESIDENCE
[~//SING LE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [] Four
[] Two [] Five
[~'"-Three [] Six
[] Other
WATER SUPPLY
~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Io§ if available.)
8. SEWAGE DISPOSAL SYSTEM
IZ~" INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED,
NOTE: THE INSPECTION FEE Must ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-0i 0 (Rev. 6/79)~'~1~{'~)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [~ ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIViDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Sepljic, Tank or [] Holding Tank
Size: [,~,~,~-"1~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
[] APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[~I~'T)ISAPPROV ED
DATE BY
72-010 (Rev. 6/79)