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LAKE RIDGE TERRACE BLK 3 LT 5A
Municipality of Anchorage ' On-Site Water and Wastewater Program • (907) 343-7904 Page / of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: Q SP i 7/e 1 ( PID Number:O 51313 O ti Dwelling:. Single Family(SF) ❑ Duplex(D) ❑ Multiple (SF and/or D) Project: ❑ New N.Jpgrade Name: C.S / / FPABSORPTION FIELD Address L�. f� A,� [peep Trench ❑ Shallow Trench ❑ Bed ❑ Mound 7 da 3 rf41Zs ❑ Other Phone Number of Bedro s Soil Rating Total depth from original rade 2 z 9 —0(S 3 ' GPD/SF Ft. LEGAL DESCRIPTIO Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision / fi � Block Lot 3. ..5 Ft. S .J Ft. !�11_ �--� (2/Li CIF �Cf 4 3 SA Fill added above original grade Gravel length Township Range Section ---%.•-- Ft. -3S Ft. Gravel width Beds:Number of Lines Distance between lines SEPARATION DISTANCES 3 Ft. — — Ft. To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist.between trenches From Tank Field Tank Line 3 8 S FF / Ft. Well �0°,f-�o°;g10044 /004 _ ZS r4- TANK 13Septic ffiS.T.E.P. (7 Holding 0 Other Manufacturer fff Capacity Surface Water /06'9-/1O f /QGf AA JC_ >4c) /c— y?bh t /a so Gal. Material Number of compartments Lot Line /Q' t (0;` /G' — S7 e'/ Foundation .6 (Q (1-- .. /Q � - NA LIFT STATION ( Manufacturer Capacity Curtain Drain 5'6-4- so!t S-"a it — 4,�/� 1002ACL T_ J t_ 5 Q Gal. Remarks Pumpp on level at Pump off leevvlel`Jat High water alarm at `"7' C in. r 4{ in. s�' in. Pump make and model Electrical Inspections performed by /3.Sei 051 6 57-/fff` 2,\Eft.,1 Jd-. PIPE MATERIAL House to tank f� �,,y Tank to A��,ds Installer ^\ r �+�7c drainfield L 6---.01-r V Drainfield AIT&S CO/MT Q,302/ '1 Inspector /'/ �l 6444 BENCH MARK (Assumed elevation) Q Oft 7 Inspection dates: 1 o 9 /7 2� a" l oi! 7 Location and description �,r�S SLG b 3111f/6 /7 4th / COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp Conditional Approval: Date E 1 • Approved i ,oq 1rQO 722.0. ': Date al 17 t., Inspection Report_9-1-12.doc AS - BUILT MEASUREMENTS • A B ST1 48.5 74 ST2 52,5 77.5 Riser 54 79 MT 76 97 New Leachfield w/ 1.25' Schedule 40 PVC Pressure Distribution James Way -".-----,JNo Neighbor Conflicts � , o Existing Trench d _Q._ --7 Lot 6 m M Lot 4A TH0 5% Slope Septic Riser 0 / SST T '` 5% Slope Pressure Line To * Decommission: Old Trench Line d Old New 1250 Gallon0 Septic Tank Per UPC STEP Tank fco 5% Slope 3 Bcirrn 5/ Slope Weol 8100.0 Well Well Well Lot 12A Well Lot 11 ) t IVORTHRIM ��P�����Z�� LAKE RIDGE TERRACE ENGINEERING * :49m -^ ' BLOCK 3 LOT 5A ;RECORD Po Box 770724 A:10' : i LAYOUT Eagle Rives. Alaska 99377 WASTEWATER UPGRADE 907. 694. 7028STEP TANK/TRENCH 8/21/17 192411E1C)f 3 Foundation Cleanout Tank Cleanouts Final Grademu, iee /Elevation @95' 1 G a o n i 141 TPank Ilevation @ 91' Elevation@ 91' j__ �'I�,!'^ --�To Absorption Trench �s sit I% Elevation @ 90. I 1 Diverter Valve To Old Trench levation @ 96' I III 1.25' Schedule 40 PVC Force Main ii 5 1 57. Slope me1 Elevation @ 96' I Original Ground/Final Ground 30 Elevation @ 92.5' '-''''�"' tea....., • . 9,0 -•a•,....._, -tea...%., . Elevations Both Ends ::s:.•-:,:., Effective Depth--.- Elevation epth--=Elevation @ 87' -..-3.0-,..- T 3.0� TH Elevation @ 81' (Dry) =��,� o� �r ' TRENCH END VIEW LAKE RIDGE TERRACE NOR THRIM i. ENGINEERING i.*. •49m*,�-�. �`' - STEP TANK/TRENCH BLOCK 3 LOT 5A PO BOX 770724 I sir.. t Eagle River.694 7028S774.6‘"74221///Jr 907RECORD—UPGRADE Date: BY: role: • 8/22/17rawn SE i• = s I94(ET 3 of 3 SE Rising Son Electric Services LLC. 4 36784 Eklutna Lake Rd. Chugiak, AK 99567 (907) 622-6777 t. f--11rt,` _' t`' /' August 21, 2017 Re: 17800 James Way Dear Bobby Dean: The lift station at the above referenced address has been wired in accordance with NEC and State/Local codes. Thank you for your business. Sincerely, i Lk. a Keller, Owner Administrator License Number 2065 Specialty Contractor license Number 38497 JN` PALITr aF MUNICIPALITY OF ANCHORAGE \, On-Site Water&Wastewater Program 5�; 7 `, PO Box 196650 4700 Elmore Road Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 r, http://www.muni_org/onsite 1116_01 JAI Dt2partntcnt 'N CH ORRG� On-Site Wastewater Disposal System Permit Permit Number: OSP171211 Effective Date: 8/8/2017 Work Type: Septic Upgrade Expiration Date: 8/8/2018 Tax Code Number: 05131304000 Site Legal Address: LAKE RIDGE TERRACE BLK 3 LT 5A G:0653 Site Mailing Address: 17806 James WAY, Eagle River Owner: SLIFER DONALD T & ROSWITHA Lot Size in Sq Ft: 26500 Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 3 This permit is for the construction of: 0 Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 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 Received By: Date: App /1 �/7 �0 7 Issued By: "s I .261,e8 Date: CSS Y'/ UNI CDPALETY OF la NCHO ' PAGE Community Development Department _ P.• -. + - • !04 Development Services Divisiona . • On-Site Water & Wastewater Program AUG 0 7 2017 ON-SITE SEWER/WELL PERMIT APPLICATI• "s. ti "cv Parcel I.D.Q5/ "33/3- 3L/' `` 01 6 9 Lc) Property owner(s) SLffp L Day phone Z2?--5700 Mailing address / 7(roc g-s 1.--(J* 70 address -S-4-'41 / Legal description (Sub'd., Block & Lot) ,e/i3C 4OZI C-,E 13 3 L 1 4 Legal description (Township, Range & Section) Lot Size Z 6;500 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field , Initial ❑ Single Family (SF) ;8:0 (w/wo ADU) Septic Tank r. Upgrade MFkDuplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ rY Water Storage ❑ • / • A THIS APPLICATION INCLUDES A VARIANCE 1 WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property ow or authorized agent) Permit/Rush Fees: 50 -- 3'00=9104D 4a Waiver Fees: Date of Payment: g j 7 lit Date of Payment: Receipt Number: °Mc.b Receipt Number: Permit No. 121I Waiver No. Permit App_9-1-12.doc NICRTI-- 1 ENGINEERING SteveEng.com Steve Eng,PE, PH PO Box 770724, Eagle River AK 99577 (907) 694-7028 SteveEngPE@gmail.com Date: 8/8/17 Number of Pages: To: MOA On-Site Services Subject: Lake Ridge Terrace Block 3 Lot SA Septic System Upgrade The subject property has been served by a septic system for a number of years.The septic tank is to be decommissioned and a new STEP Tank/trench system installed. The design calls for a new 35' long trench with new STEP tank: the old trench to be connected via diverter valve. The entire subdivision is on private wells and septic systems. The terrain slopes east to west. The slightly higher ground required a STEP Tank to access. Please review the wastewater system design for the existing 3-bedroom, single family home. I have included design plans& specs, design guidelines, & soil tests. If there is need for additional information or clarification please give me a call. Thanks-Steve fl- M ENGINEERING SteveEng.com Lake Ridge Terrace, Block 3 Lot 5A SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: This is an existing 3-bedroom, single family home. A septic tank is currently in use- this will be decommissioned per UPC and new STEP tank w/ trench installed. The existing trench will be connected via diverter valve. Neighbor lots are served by septic systems and private wells; there are no conflicts. The topography slopes from east to west as depicted in drawing. Recent soil test reveals silty fine sand w/gravel, no groundwater. An application rate of 1.2 GPD/FT2 will be used for the trench. Length= 375 FT2/5.5' x 2 = 34.1' trench, Say 35', 5.5' effective depth. 9' total depth. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications(AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. • New 1250 Gallon STEP tank. Anchorage Tank or Equal. • 5' minimum between the tank and trench. 10' minimum to property line from trench. • 3' of cover and insulation is required for force main; 2" Minimum thickness for insulation. • Tank& solid pipe must be set on well compacted, stable soil. • 4 inch diameter cleanouts with airtight caps are required 1' to 4' from foundation wall, prior to any 90 degree bend in 4 inch line. • All cleanouts must extend to at least ground level. • In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron. • Trench to be placed level, minimum of 4' to groundwater, 6' to bedrock. • Drain rock to be '/2" to 2 '/2" screened. Drain rock to be distributed uniformly. • Force main to be 1.25" Schedule 40 PVC or equal. • Distribution pipe to be 1.25" Schedule 40 PVC w/ 1/8" orifice @ 18" on-center. • Silt barrier(filter fabric) to be installed above the drain rock. • Smeared bed must be raked or scarified before drain rock placement. • The finish grade must be mounded to promote drainage away from trench. • Insulation must be placed over any pipe installed under driveways or parking areas. • Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, • Sewer Service Line is minimum 2% slope. • Septic Tank to be pumped every two years or when required. • Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal) OF �p.�E..•,,.•••••• �I� .• rfoi : 1. •••4 ia 0it4r M III .:• j999 9 Steven W. rtq 4; . •• 646 •: Jr- DESIGN NOTES: 1 . New Trench Depth At 9'. 2. 1 .25" Schedule 40 PVC Force Main. 3. 3' Cover Or Insulate Force Main. 4. Lots Served by Private Water Wells. 5. No Conflicts Within 200'. 6. Connect Existing Trench To STEP Tank Via Diverter Valve. 7. Check Well Separation Prior To Construction. 8. STEP Tank NOT Under Driveway. James Way �No Neighbor Conflicts 1.25" Sch 40 PVC Line Existing Trench To Old Trench Via Diverter Valve MT 5/ Slope Lot 4A 5/ Slope Septic t / 0TH / 5/. Slope New Leachfield w/ 146100 . 1.25" Schedule 40 PVC Pressure Distribution lecommission Old Septic Tank Per UPC Install Diverter Valve ,d 5% Slope Inside 2nd Riser - New 1250 Gallon Q STEP Tank 5% Slope 3 Bdrrn 57. Slope Weol ci 100.0 Lot 6 - � I Well Well. 0' Utility Esmnt - Well Lot 12A Well Lot 11 I NOR THRIM =''F- `'I' 4� LAKE RIDGE TERRACE 1 40 ENGINEERING I* 49m * BLOCK 3 LOT 5A PLAN PO Box 770724 �+a, ;�.���� LAYOUT Eagle River, Alaska 99577 +,, .,60 �. : WASTEWATER UPGRADE Date: EET: 907. 694. 7028 STEP TANK /TRENCH 8/8/17 12 of 3 Foundation Cleanout Tank Cleanouts Final Grade MR - - 1250 Gallon �, STEP Tank 4ovI• orIFiit ' : ----.To Absorption Trench u■ ■i■1 i � Diverter Valve To Old Trench 1 N5 1,25' Schedule 40 PVC Force Main li II5% Slope _11 I Original Ground/Final Ground • DESIGN NOTES: 3 0 1. Depth of' Trench is 9'. 1.25' Schedule 40 =.::.::!:: 2. STEP Tank & Solid Pipe to be Placed on Compacted, PVC W1 Orifice 9 0 Stable Soil, Free from Boulders. 3. Sewer Service Line is Minimum 2% Slope & 3' Cover. 4. Water-Tight Couplings, Effective Depths =;.:;:: 5 5 5. See Specification Sheet, 6. All Work To Conform to Municipality of Anchorage (AMC) Requirements & Specifications. 7. Force Main 4' Cover Or Insulate, 3.0-..-- 8. ,0-►8. Distribution Pipe To Be 1.25' Schedule 40 PVC w/ 1/8' Orifice @ 18' On-Center. 9. Decommission Old Septic Tank Per UPC. 10. Connect Old Trench Via Diverter Valve. _.e.c._ . . '! LAKE RIDGE TERRACE NORTHRIM y�\'' '' TRENCH END VIEW ENGINEERING * :49Di STEP TANK/TRENCH BLOCK 3 LOT 5A PO Box 770724 sem.w • t Eagle River, Alaska 99577a /7 citf 907-694-7028 x'44 C ) I = UPGRADE Dote: wn By: SE 1 ' = 5 1 s"EET3 of 3 8/7/17 I IScole: SE S❑ILS LOG - PERC❑LATI❑N TEST 2T1- IM ENGINEERING Date Performed: 8/1/17 Performed For: Rowi Legal Description: Lake Ridge Terrace B3 L5A DEPTH (FEET) Organic T,H, Location: See Attached Design MP.2 .. 3 _ 4 - . • SM Silty Sand 5 - 0. w/ Gravel 6 _ • Fine Sand -0.•••• :.•' Groundwater? No 7 - Depth -- 8 - . a Water Depth 9 - After Monitoring.None Date: 8/7/17 10 - # Date Gross Time Net Time Depth Net Drop 11 - n` •:... 1 8/4 0 -- 7' -- 12 - ::-',�•.' 2 8/4 10 10 min. 10.5' 3.5' • '` 13 - • 3 8/4 12 -- 7' -- 14 - :. .:.::- 4 8/4 22 10 min. 10.5' 3.5' 15 - 5 8/4 25 -- 7' -- 16 - 6 8/4 35 10 min. 10.5' 3.5' 17 - 7 8/4 37 -- 7' -- 18 - 8 8/4 47 10 min. 10.5' 3.5' 19 - 9 8/4 50 -- 7' -- 20 - 10 8/4 60 10 min. 10.5' 3.5' 21 - Percolation Rate 3 min./inch Perc Hole Diameter 6' Test Run Between 2' and 3' Comments: Presnakpd. MeacurPd to nenre t 1/16th inch. Performed By NorthRim Eng, I CERTIFY THAT THIS TEST WAS Performed in Accordance with All State/Municipal Guidelines in Effect ON THIS DATE. DATE: 8/7/17 -• it NORTHRIM ‘i:i � TESTHOLE LOG TH ENGINEERING ` 49 PD Box 770724 ' 111 t Logi* River. A/osko 99577 �a-,nw 907.694.7028 17T/ s GEOTECHNICAL Dot.: IsTEET: 8/7/17 ~ £/~\\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECI'ION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE MAILING ADDRESS LEGAL DESCRIPTI~ON ~ell / Absorptipn a~ea__ ! DwelHng PERMIT NO. ~ Manufacturer ~ ~ ~z Material No, o, compartments Liq. capaciw in g~oj~s H--MEMADE Inside length Width Liquid depth /oo0 6 ~ D~ TO: Well ~elHng~ PE~IT NO. O z ~ ~ufacturer ~erial gallons ~ DISTANCE TO: W~ /~ ~ ~ Foundation Nearest lot linex ~ PERMIT NO.~ ~ ~ No. oflines , Length of each~ne. ~ Total length of ~nes. , Trenchwid,h~ ~ Distance betwee~ lines Material b~neath ~le ~ , ~- Top of tile to finish grade /~ Total effective abs~ption area Length Width ~ ' .~-~ Depth~ PERMIT NO. ~ ~ ' ~ ~ ~ / ~ / Total effective absorpt~ Type~f crib Crib d Crib depth ~ DISTANCE TO: ~ %%~ / Building f~ation Nearest lot line ~ ClassltCb~V¢~¢~ Depth Driller Distance to lot line PERMITNO. ~/~O/~/~) ~ ' OTHER PIPE MATERIALS SOILTESTRATING ~ [ ~ ~ .~ APPROVED¢ / DATE LEGAL :,DEFHRTMENT L,¢ HERLTH RND ENVZRONMENTRL r'ROTECT~ON , ,-,.~,~ ....... '" 9950i ~ ~ ~ ,:,~_~ L.'" STREET., MNUHORHbE., AK. 264.-4~20 MR'?,~MttM NUMBER OF BEDROOMS : :: :,3~L R. RT~NG (':E~ FT~E,~ ..... Z~.. ..-~,_.-:,~, ./ THE LENGTH D~MENS~ON ~5 THE LENGTH (~N FEET.'.', OF THE TRENCH THE DEPTH OF A TRENCH OR F'~T ~S THE E:,~ST~NCE BETWEEN THE _,URFMuE OF THE GROLIND aND THE BOTTOM OF THE EXC:~V~T~ON (~N FE~ ~~HE: TF:E~-~C:H t..~ Z D, TH ~ ~; ~5. ,~ZaE~' FEET'. TH~ GRRVEL DEPTH ~S THE M~N~MUM DEF'TH OF GRR',,,'EL E:ETWEEN THE OLITFRLL F'~F'E AND THE BOTTOM OF THE E,~:,L.R,~T~ON ,'~N FEET). F _ Rl'd I l N 0. ,- .':'"F ' t?¢~2R BLUE SPRUC:E LANE RPPLiCRNT RICHARD F UT~.b_F.. - LOCATION JAMES WR"r' L. EGRL LOT 5R BLK 2: LAKE RIDGE TERR. LOT 'L:;IZE T'¢PE OF SOIL RBSORPTION _-,~=TEil IS: DRRINFIELD RED,. SEF'T I C: -, ,-- , ~, , 'v TO INFORM TPIIS r:,EF'RRTMENT DURING THE F'ERMIT APPLICANT HAS THE F..E_,FON_IE, ILI-f. - - I.NSTALLRTION INSPECTIONS 0F ANY WELLS ADJRC:ENT TEl THIS PF._FEF.] ~ FIND THE N~MBER OF RESIDENCES THAT THE WELL WILL SERVE. T ~.--~ C, .:'. ,=_'-:" .':, .... :-- WITHE_IT FINRL. IN=,FEL. TIUN FIND MFFE_,HL THIS BACKFILLING OF ANY =~_TEfl ,- ..... ,' DEPRF.:TMENT WILL BE SUBJECT TO PRZSECUTION. MINIMUM DISTANCE BETWEEN R WELL RND ANY ON-SITE SEWRGE DISPOSRL SS'STEM 100 FEET FOR R PRIVATE WELL OR t50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM R PRIVATE WELL TO R PRIVATE SEWER LINE IS 25 FEET AND TO R COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS RRE REQUIRED AND MUST BE RETURNED TO THE DEP8RTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICRTIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F'EF-:I'-I ][ T E:=-=:F' :I. F::E$ [:,FC:E f-IE:EF-: 2::1.. 1 .... I CERTIFY THAT f: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AN[:, WELLS RS SET FORTH E:Y THE MUNICIPALITY OF RNCHDRRGE. 2: I WILL INSTALL THE SYSTEM IN RCCOR[:,ANCE WITH THE ]ODES. , T~ ' ' 41 RF-'3EMENT IF THE 3: I LtNDEF.:STRND THRT THE ON-SITE SEWER. SYSTEM MAY F..E:.LIIF..E E~'- -. " · RESIDENCE IS REMO[:'ELED TO INCLUDE M]RE THAN PERFORMED FOR: [] SOILS LOG MUNICIPALITY OF ANCHORAGE . DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST 1 2 3' 5 7 8 9- 10- 11 12 13- 15- 16- 17 18 19- 20- COMMENTS PERFORMED BY: SLOPE SITE PLAN WAS GROUND WATER Vf~ [ ENCOUNTERED? ~ o IFYES, AT WHAT /0 DEPTH? Gross N et~/j~ Depth to Net Reading Date Time Tim Water Drop ' P~RCO LATION RATE 30 (minutes/inch) f ~m; FTAND ~ ' TEST RUN BETWEEN FT CERTIFIED DATE~ TY OF ANCHORAGE T OF HEALTH & ,, TrrAffirb Or it u 4gEpA,,ENTAL PROTECTION by DOC Co. dba SULLIVAN WATER WELLS RECEIVED P.O. BOX 272, CHUGIAK, ALASKA 99567 9 TELEPHONE 688-2759 OWNER OF LAND ec) rz DEPTH OF WELL C., 4 ADDRESS Ai -1) STATIC LEVEL OF WATER FT. LEGAL DESCRIPTION !T -oZA z DRAW DOWN FT. DATE - Started Ended GALS. PER HR 0 PERMIT NUMBER KIND OF CASING KIND OF FORMATION: From -.Ft. to -,,Ft. From Ft. to Ft. From Ft. to Ft From Ft.- to Ft. From Ft. to 'T." Ft. From Ft.', to Ft. From Ft. to Ft. c, 'l d From Ft. to Ft From Ft. to Ft. IYA`-4! From Ft. to Ft From Ft. to. 0 Ft. C_��f i�.,a:/ tFI-1 From Ft. to Ft. From_ Ft. to Ft. 4-<_p 7— From Ft. to Ft. From Ft. to _2" _�Ft. From Ft. to Ft. From Ftto i Ft. S74 From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From 4 Ft. to Ff. A q�z From Ft. to Ft. From Ft. to Ft. '12 From Ft. to Ft. From Ft. to Z '2Z Ft. From Ft. to Ft. From Ft. to Ft. c"JI14 r4T 42f From Ft. to Ft. From Ft. to 1 1 Ft. 4r—" 4 From Ft. to Ft. From Ft. to Ft. h x From Ft. to—Ft. From Ft. to Ft. From Ft. to Ft MISCL. INFORMATION: 6 -s+°o DRILLER'S NAME 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 Parcel I.D. 051-313-04 1. GENERAL INFORMATION Expiration Date ��lCs2� Complete legal description LAKE RIDGE TERRACE BLK 3 LT 5A Location (site address) 17800 James Way Current property owner(s) Goulet Mailing address Real estate agent Laura 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 632-1243 Day phone 632-1243 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Waiver Fee $ Date of Payment Date of Payment Receipt Number Q ZC�% Receipt Number COSA# 05C,2_1110 -L Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm NorthRim Eng. Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng 6. DSD SIGNATURE System #1 Approved for 3 bedrooms System 42 Approved for bedrooms Disapproved Date 3/4/20 +�E OF :'CSP jk S'f�*f f�f a* :49TM ffA stege -Eng, ; i : �Qr_ 4%21'+ Conditional approval for bedrooms, with the following stipulations: By: t,vt 1 Original Certificate Date: The Municipality of Anchorage Development Services DMsion (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsiblo for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other Al ��PI-SITE G? g WATER AND z -- o WAS oRnGb AM 0 o4� 5 /V )SER..:1 By: t,vt 1 Original Certificate Date: The Municipality of Anchorage Development Services DMsion (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsiblo for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other Legal: Description: LAKE RIDGE TERRACE BLK 3 LT 5A If more than 1 septic system on lot: COSA Checklist # _—of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 2/96 Total depth 223 ft Cased to 100+ ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 2/17121 Parcel ID: 051-313-04 Structure served by this system Well production at time of test 2 gpm Water storage tank volume 500 gallons Well disinfected for coliform test? ❑ Yes NO No ❑ Coliform bacteria is Negative Nitrate 1.52 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by NRimEng Date of Sample 2/26'2' Static water level at beginning of test 104 ft. Comments Well deepened 2/96. Flow Improved. Jim Sullivan reports pump set at 201' B. TANK DATA Age of tank(s) 3.5 years Tank type/material septicStl Measured operating fluid level in septic tank 50 ❑ Standpipes/foundation cleanout per record drawing Date of pumping 9125/20 D. ABSORPTION FIELD DATA 8/10/17 C. LIFT STATION ❑ Required maintenance completed Age of lift station 3.5 years Lift station material Stl Comments: Which system tested (date installed) same--- Adequacy test date 2J7/21 1101 ALL standpipes. present_ per record drawing _ Results ..✓ Pass ----For 3-- bedro Total measured depth from grade 9 ft (max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade ft (min) Water added 450 gal ❑ N/A – pressurized field New depth 1 in ❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 30 min depth into effective _ ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Final fluid depth 0 in Absorption rate 450 gpd Any rejuvenation treatment (past 12 months) no If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Building Foundation > 101 Yes Community Sewer Manhole/Cleanout > 1001 Yes if No ft M Yes if No ft Neighboring Tank > 100' Yes if No ft Private Sewer/Septic Line > 251 r* -,l Yes if No ft Absorption Field on Lot> 100' R Yes if No ft Holding Tank > 100' Q Yes if No ft Neighboring Absorption Fields> 100' Yes if No Animal Containment > 50' Q Yes if No ft [E] Yes if No ft Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' El Yes if No It 2] Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q Yes if No ft Surface Water > 100' Yes if No ft Property Line > 5' Building Foundation > 101 Yes if No It Wells on Adjacent Lots: Absorption Field > 5' Q Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' Water Main > 10' Yes if No ft Community Wells > 200' Yes if No ft Water Service Line > 10' Water Service Line > 10' Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances it less than required) Building Foundation > 101 Yes if No ft If absorption field is under driveway comment below Property Line > 10' Q Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' 0 Yes if No ft Community Wells > 200' S Yes if No ft Surface Water > 100' Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION / certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. 'R Ar V r 490 stew Eng CE -6256 RAJ 21" *" o z' /, CHAIN-LINK I"ENCE-VI --7 Lot 11 � � � JAMES WAY Lot 5—A SEPTIC PIPES 1O�2'x12'2' SHED ` / . RAMP + Lot 4-A WOODEN — 10.3'x20.2' SHED FENCE __ | � 10' UTILITY EASEWENTS-' | | `` Lot 12-A . . . PLOT PLAN AS BUILT SCALE 1, 40' GRID NW 0653 _ Project No. 17-277ZLL__ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, in C (907) 522-6476 Phone (907) 522-4625 Fox Professional Land Surveyors kan*langsurvey.com OF A I hereby certify that I have surveyed the following described property: LOT 5-A, BLOCK 3, LAKE RIDGE TERRACE SUBDIVISION (PLAT 71-293) Anchorage Recording District, Alaska, and that the Improvements situated thereon are within the property Unam and du not encroach mnfw the property adjacent thereto, that no Improvements on the property hying adjacent thereto encroach on the surveyed prum|nou and that there are no roadways, transmission lines or other visible eoo*rnontm on said property except as Indicated hereon. Dated this the 1|`"__ Doy of , -�c-i_iof Anchorage, /Womko It Is the responsibility of the owner to determine the existence of any mommrnento, -`4%11�1xss§� \ \ \ ` | | / / / / / / ' / / / / / PLOT PLAN AS BUILT SCALE 1, 40' GRID NW 0653 _ Project No. 17-277ZLL__ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, in C (907) 522-6476 Phone (907) 522-4625 Fox Professional Land Surveyors kan*langsurvey.com OF A I hereby certify that I have surveyed the following described property: LOT 5-A, BLOCK 3, LAKE RIDGE TERRACE SUBDIVISION (PLAT 71-293) Anchorage Recording District, Alaska, and that the Improvements situated thereon are within the property Unam and du not encroach mnfw the property adjacent thereto, that no Improvements on the property hying adjacent thereto encroach on the surveyed prum|nou and that there are no roadways, transmission lines or other visible eoo*rnontm on said property except as Indicated hereon. Dated this the 1|`"__ Doy of , -�c-i_iof Anchorage, /Womko It Is the responsibility of the owner to determine the existence of any mommrnento, -`4%11�1xss§� Lift Station/Pump Vault P .. , - * �J Owner3-)(4.fr & 4- -sravi Septic Tank: 6-"' V1 Z,+ -Sludge level ches -Pumping Lift station: Phone: 907-343-7904 Fax: 907-343-7997 Street Address MOO 0, S required ves o -Pumping completed (YeA no -Pump basket cleaned Qe no -Effluent filter cleaned no -Control floats cleaned es no -Proper float settings confirmed (6 no -Operation satisfactory QYb no Alarm System: -Dedicated electrical alarm circuitk423_no -Audible and visual alarm inside dwelling es no -Alarm system operatii�n sat Wtor of satisfactory Manhole Riser -Ground water intrusion at riser to tank connection e n -Ground water intrusion around pipe penetrations yes -Weep hole functional no -Manhole lid: Functional e no Insulated dRb no Properly Secured -ey-e� no Other -All manufacturer required inspections and maintenance completed e no Qualified Maintenance Provider: Technician5`J3 Date of maintenance" CompanyA010\.11 , Signature Date Municipality of Anchorage • II ,,,� On-Site Water and Wastewater Program c'- (907) 343-7904 - A4- r 4aa a CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-313-04 Expiration Date: N aV o y/ 20 17 1. GENERAL INFORMATION Complete legal description Lake Ridge Terrace Block 3 Lot 5A Location (site address) 17800James Way Current Property owner(s) Slifer Day phone 229-0154 Mailing address Same Real Estate Agent Prudential Day phone 2. TYPE OF DWELLING: • :a6 8 g 70 77 ® Single Family.(w/wo ADU) , L �� W ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) E AUG 2 2 2017 ,i- 1K 16 ti c 3. NUMBER OF BEDROOMS: 3 << o� s 9 c;\ 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class C Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Received by: 4 Date: d72 'E//7 COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 03°--r`"I l 111 • Date: Date of Payment g I a 3/11 Date of Payment Receipt Number b��� Receipt Number COSA # cY-f \318' Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, 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 NorthRim Engineering Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 8/22/2017 • • 6. DSD SIGNATURE ' V =4'? ♦; r System #1 Approved for y pp � bedrooms. System #2 Approved for bedrooms. • Stele , W. Etc Disapproved. , c�P tlI. •� pL�'�: 't OFE`.Y Conditional approval for bedrooms, with the following stipul s4"� VJ 1-CR ANO WAS�°�RAM ,c 'RR() By: 01COriginal Certificate Date: ,?d I 7 The Municipality of Anchorage Devlopment Services Division(DSD)Issues Certificates of On-Site Systems Approval(COSA)based only upon the representations 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 engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheep 9-1-12 doc If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On Site Systems "A\ pproval Checklist Legal Description: 4/4-14:---- /...6CE eE(2/Z-/I('�� 6? L 5.4 Parcel I D0S f,7l.?Gt( A. WELL DATA P Well type If A, B, or C provide PWSID# Well Log (Y/N) y Date completed 27f e Sanitary seal (YIN)__ Wires properly protected (Y/N) r l Total depth ZZ3 ft. Cased to /Dai� / -ft. Casing height (above ground) /2 in. ¢- FROM WELL LOG AT INSPECTION Date of test. z/ft; D. LIFT STATION / Date installed p �/ Size in gallons C Manhole/Access {YIN) 14� y "Pump on level at in. "Pump off level at � in. High water alarm level at .� in. Datum 9 a t4rw Cycles tested 3 Meets alarm& circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot /(:)() '" On adjacent lots /a d Absorption field on lot /o6 ":"- On adjacent lots /60 1 _ r Public sewer main /es6 "T" Public sewer manhole/cleanout . /OO '7`" Sewer/septic service line 2 E. r"fr Holding tank 400 (f f Animal containment areas 5.0 f Manure/animal excrete storage areas /a0 ;;- SEPTIC/HOLDING TANK ON LOT TO: Building foundation l Q ,' Property line /( t Absorption field 't' r Water main /a '1" Water service line /0 f* Surface water 7116 f_ Wells on adjacent lots /4a f ABSORPTION FIELD ON LOT TO: ( Property line /0 ' Building foundation /el "r- Water main /as l4 r f Water Service line /a '' Surface water /DO 'f' Driveway, parking/vehicle storage /d�-r`' Curtain drain 5'G fl" Wells on adjacent lots /OG (ie.— F. COMMENTS G. ENGINEER'S CERTIFICATION �OEqLo I certify that I have determined through field inspections and '•. review of Municipal records that the above systems are in17 1 conformance with MOA COSA guidelines in effect on this date. . -':-, ...c ,....-- k f Engineer's Printed Name 7:61/' /54) C .:',2 . Date (1 pZZ 1'T pi2Z/1, * ., • , a w0* .... .0s�.."5• COSA yellow sheet_2-6-15.doc • >— I— Y w V) (10 ce k D = 1 N N \ 7 JAMES WAY o S 89'53'00"E 125.00' Lot 5—A 21,177 s.f. SEPTIC PIPES 4- — - 0 w �� 0 10.2'x 12.2' SHED b --J '' w/ 4.0' RAMP Zv o w. co \ g o cox 0 CV / \ .. . Lot 6 0 / .. o 0 2� Lot 4—A Lc,C Z x • �,Ico �i\-- 0 �c-C1 \ � 25 7' `ti° (L��O ��`3 O QUO )if' Q- �0 � � R/ I CHAIN-LINK FENCE x JA ,s O(€., ,i ° WELL x l J WOODEN _ 10.3'x20.2' SHED I \x FENCE —47-4N 89'53'00"W 86.77' 7 1 \ 10' UTILITY EASEMENTS / Lot 11 1 I 1 \ Lot 12—A / PLOT PLAN AS BUILT _x_ SCALE 1" = 40' GRID NW 0653 Project No. 17-277/A1 _ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates , inc . (907) 522-6476 Phone Q�oQo0p04 (907) 522-4625 Fax o O F A QQ4 Professional Land Surveyors kenOlangsurvey.com o .......4.1.6\11 jonathanOlangsurvey.com G I hereby certify that I have surveyed the following described property: Q • ���P ,A'' ��V LOT 5—A, BLOCK 3, LAKE RIDGE TERRACE SUBDIVISION (PLAT 71-293) 0 * 49TH . *�D Anchorage Recording District, Alaska, and that the Improvements situated thereon are Q i D within the property lines and do not encroach onto the property adjacent thereto, that Q r s '1 4' • no improvements on the property lying adjacent thereto encroach on the surveyed 'KENNETH G. LANG o K) premises and that there ore no roadways, transmission lines or other visible �, easements on said property except as indicated hereon. a.`ki ` ',. F. J � 0 P�. .LS-520 . Dated this the _ Day of , , at Anchorage, Alaska Q p NOS �O4R() SsioNA� it Is the responsibility of the owner to determine the existence of any eosements, �o00ooa" covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.Q. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # d~l-;J/)-o~/~, 1. GENERAL INFORMATION Complete legal description Lot 5A; Block 3; Lakeridge Terrace Location,,(site,address or directions) 17800 James Way Eagle River, AK ,~ R.ro'pe rty-:'ewner. ',.. Mailing ....... address ....... ~Lend~ng agency l~lailir~g address ' Agen{ & Joan Moody 17800 James Way Eaqle Day phone River, AK Day phone 694-6406 99577 Day phone Address 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. 3N NOTE: ndividual well Community well Public water 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. 1/91) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S & $ ENGINEERING 17034 Eagle Eiver Loop Road No, -2~, Address Eacjle River, A, laska 99577/ Engineer's signature , " Phone (2 C~ cf' - 3- c/ 7 ¢/ Date DHHS SIGNATURE "/ Approved for ,3 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 'The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOAIf21 Legal Description: Ld'I' ~i~t MUNIcIPALITy Municipality of Anchorage ~/VV/~o~E~"rAL' ~s~ ~^/c''~ ''~'~c~ DEPARTMENT OF HEALTH & HUMAN SERVICES , , '- '~ Environmental Services Division 5EP OR 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) ~3-4744~ Health Authority Approval Checklist A. WELL DATA Well type Log present ~/N) Total depth ~.Z- 5 / Sanitary seal CN) Date of test Static water level FROM WELL LOG If A, B, or C, attach ADEC letter. ADEC water system number Date completed Z/~ (- P ~ ~/"~"' ~"") l'Or~- p~t-~ OK / '' Cased to ~ Casing height (above ground) Wires properly protected ~N) AT INSPECTION Well production WATER SAMPLE RESULTS: Coliform O /, 5' g.p:m. , g~) Nitrate ';'~- ¢ I Collected by: g.p.m. Date of sample: ,, +.. - B. SEPTIC/HOLDING TANi~ DATA Date installed ~/~/~'./ Tank size / / Foundation, ole~'fibbt" ~) Date of:pump';~:i C. ABSORPTION FIELD DATA. ' Other bacteria C2 S & $ ENGINEERING ,'-T"~P. gm ~'/~',,~',,, =-;,- -: .... L==F R=-'. ~c,, 204 Eagle RNer, Alaska 99577 .//.~) Number of Compartments' ~-- Cleanouts~N) ¢~¢ Depression (Y~) J~0 High water alarm (Y/N) 19)¢ Pumper .~. Date'installed 1~/¢//~t/.,' Soil rating (g.p.d./fF or fF/bdrm) ,~g'~ ,,~_~ System type bf~q~¢~:lDJ') Length ' ~(~ Width '-~/ ~/ ~1 ,, Gravel thickness below pipe Total depth Effective absorption area i0[ .or- 3¢-'J'-z' Monitoring Tube present (~) q.~% Depression over field (YIl~ ~')~) Date of adequacy test ~{'? 2.~?. ? Results(~Fail) .?~ ~'~ For ~'~.1~:~ bedrooms Fluid depth in absorption field before test (in.); I~l/'z.~ Immediately after ,'~J0gal. water added (in.): 15I/¢~ Fluid depth \5~'1¢ (ins) Minutes later:~ Absorption rate = ~:¢)0-¥' g.p.d. Peroxide treatment (past 12 months) (Y/N) CD.l,~'~ .~..k!~ If yes, give date' " 72-026 (Rev. 3/96)* D. LIFT STATION~~ · Date installed ~ Size in gallons Manhole/Access (Y/N) ~level at* High water alarm level at* *Datum ~ Cycles tested E. SEPARATION DISTANCES "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 100j ~' Absorption field on lot I O0 ¢ ~ "On'adjacent lots On adjacent lots Public sewer main '~-~' ~ )' Public sewer manhole/cleanout Sewer/septic service line '7..¢'~r Lift station I (~0/-.~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation I0~4' Water main/service line Property line lo! ¥ Absorption field ~ ~r Surface water/drainage !r)n~ -j' Wells on adjacent lots /¢)o' '/" SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property lin~ . ~'(',~ ~'~'~uilding foundation t0'~ Water main/service line Surface water [ibC) t-~p Driveway, parking/vehicle storage area Curtain drain Wells on adjacent lots (00 ~ ')- F, I certify that I have determined thru field inspections and review of Municipal racer are in conformance wi. th,MOA HAA guidelines in effect on this date. Eng neer's'Name ~ ~d ~.~ '~- ~ ~ ~-o~,'~ ' ;: /¢7 Date ] ( ? ( ~ 7 HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHORAGE MEMORANDUM WATER WELL ADVISORY HEALTH AUTHORITY APPROVAL NO. ~~l~ During a recent Health Authority Approval on-site inspection ~-~ potable water su~pl~ well on Lot ~M% and te-~ of tt~e , gm~k ~l ~ Block ~ of ~%~,D6~ 1L~£~¢~ Subdivision, the well's productivity was determined to be ..~ gallons per minute. The minimum well productivity required by this Department (AMC 15o55) for a ~ ~ bedroom residence is , ~J gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies ~f the subject Health Authority Approval. 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. # 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING LocatiOn: (site address or directions) '- Property owner Mailing add ress Lending agency M~iling address Age"i :'~-L~_~ ~ Address Day phone Day phone Unless otherwise requested, HAA will be held for pickup. '... ~ . Ind~wdual well . "< · · · .? ,~.,~:,,, :: . Communi~ well ~" ........ ~ ~ '~" D .......... '~" '~ I-~' ~ ~: · Public water NOTE: If community Well system, provide written confirmation from Stat~,DEC' atte~ ing to the legality and status of system. ;,,,,,(,/,/,., (";I'. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-~25 (Rev. 1/91) Front MOA~Zl Engineer's signature STATEMENT OF INSPECTION· BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verifythat 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 ali Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm /K'~D ~-,u~'~-~,J4, Phone /~¢~/' ~/// ,~K q~77 6. DHHS SIGNATURE bedrooms. Date ~ Approved for ~"z "'"'COnditional apProval'f0r bedrooms, with the following stipulations: 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 DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Em ployees of DHHS do not conduct inspections or analyze data before a certificate is' issued, The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025(Rev. 1/91) Back MOAtY21 ,~, Municipality of Anchorage Department cf Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ,,,(:2r,~., ,~'/?c~,, ,~,~_.~,.,,'~ Z-~_,-,--- Pamel I.D. A. Well Data Well type Log present (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed -~/////~'.~ Drill.er ~/~,/~,~ /o~ ~ /~ Casing height .2~ '/ Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 Cased to FR/~ M W/E,~/TL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot /~t~ ' '~ Public sewer main ~/,,~ / Sewer service line ,,7~ ' Y- Wires properly protected (Y/N) AT INSPECTION g.p.m. ~.~/ ' MUNICIPALI'I-Y OF ANCHO~,~~- ENVIRONMENTAL SERVICES DIVISION g.p.m.,.-'~,~'t~ 2 r~ 1995 RECEIVED ; On adjacent lots ; On adjacent lots ./<; ~ c./ Public sewer manhole/cleanout Petroleum tank ~.~ WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate ,/7~ '~/~// Other bacteria ~,/~ ~o/.~,-,.~ Collected by: ,~'/,4,('~/) ~ B. SEPTIC/HOLDING TANK DATA Date installed ~/'~ / CleanoUts (Y/N) y Tank size /,~c) Compartments ,7-. High water alarm (Y/N) Date of pumping Foundation cleanout (Y/N) k/ Depression (Y/N) Alarm tested (Y/N) ~' Pumper ,~/~ ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /~-'~/-W On adjacent lots To property line )~ ~ -~ Absorption field Surface water/drainage 72-026 (3/93)* Front /,,~o/-/- Foundation /,~ "'/- 5-/~ Water main/service line CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARA~ATION TO: ...W. elt-onqot On adjacent lots Manufacturer Manhole/Access (Y/N) Sudace water D. ABSORPTION FIELD DATA Date installed ~,//~'/ Length //Z~ ' '~ Total absorption area Date of adequacy test Width Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/FF) ' ~ Gravel thickness Cleanout present (Y/N) Results (pass/fail) /~ ~" for After test If yes, give date System type '77~-~.~ e, 4¢ Total depth Depression over field (Y/N) ~,~ Bedrooms '~'",~ i~t~T~.~.t_~-b, mT' L~ E',,:~ ,¢¢-'~r..~ ¢r d.O ~ ?o° "~..~b . SEPARATIC)N DISTANCE FROM ABSORPTION FIELD TO: Well on lot_ '1"o building foundation p / -~- On adjacent lots Sudace water Curtain drain E, ENGINEER'S CERTIFICATION On adjacent lots /,~ ' -/- Properly line ~c,' ~K To existing or abandoned system on lot ,~.,/',~- Cutbank ~//'~ Water main/service line ~ %' Driveway. parking/vehicle storage area I certify that I have checked, verified, or conformed to afl MOA and HAA guidelines in effect ~~is inspection. Signature_ ~. -~~ ~?::;~ '~¢~q~.*,~,~:~ ' .~ ::.?~:? ~¢~ Fngineees Name ~ d CA "~. ~ ~.S ~' ,. CE 7116 I~TM ''~¢ HAA Fee $ _ ~C)o, c:%.) Date of Payment ~(~- ~ ~1 ~- Receipt Number , / OP/ Waiver Fee $ Date of Payment Receipt Number To: Robby Robinson Municipality of Anchorage From: Walter and Joan Moody P.O. Box 672396 Chugiak, AK. 99567 Oct. 17, 1995 Dear Mr. Robinson, This letter is in regard to our conversation about our well problems. To refresh your memory I'll again explain our situation. In July of this year we bought our home which is located at 17800 James Way in Eagle River. On September 27, one of our commodes hung up and at 3:00 a.m. awoke to the sound of air gurgling through the pipes. We investigated and found that our 500 gallon holding tank was empty. We turned the system off'til morning and then back on to see if we had any water. In approximately 5 minutes, the well quit pumping. We were shocked to say the least. No water!! Since then we have been pumping it every two hours during the day to refill our tank and to keep our pump from burning up. The problem seems to be that our well is not producing 2.8 gallons a minute as the well test showed at the time of closing. We have talked to our realtor, the mortgage company, and Kenneth Duffus, the engineer who did the test, with no satisfaction or answer to our dilemma. At this time we are asking you to help us find out if the well test was done correctly as our system has two pumps and a holding tank. In my opinion, our well couldn't have gone from a 2.8 gpm to approximately .25 gpm in less than 4 months. Any assistance you can offer us at this time is much needed and greatly appreciated. //]Sincerely, _ ~ Walter and Joan Moody Legal description of property at 17800 James Way: Lot SA; Block 3; Lakeridge Terrace Subdivision 4,,-.,, / : ,,.- :.,_,.,.,:/,,/: :.?.,::'" /:,,.'1':.:.?-'? :"'" ?A ,.-,->,:/./--> ::;,,-../,.: g' / CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS THEODORE F. MOORE, P.E. 14530 ECHO ST. PH: (907) 345-1355 OCtober o^~v, 1995 ANCHORAGE, ALASKA 99516 RECEIVED Joan Moody P.O. Box 672396 Chugiak, AK 99567 Dear Mrs. Moody: NOV ;~ 1995 Municipality of Anchorage Dept. Health & Human Services Per your request on October 30, 1995 1 conducted a yield test of the well serving your residence on Lot 5A, block 3, Lakeridge Terrace S/D, located at 17800 James Way in Chugiak. The test results show the well yield to be 0.44 gpm. The following is a report of our test procedure and findings. A copy of the well test data is also enclosed. According to the driller's log, the well was completed in March of 1981 and has a total depth of 121 feet and a yield of 2 gpm. The log reports that the well casing is perforated between the 100 and 103 foot levels. On the date of our test the static water level stood at 101 feet below the top of the casing. I understand that the well pump had been turned off for over three hours prior to the start of the test, so this should represent a stabilized static water level. The water system includes a 500 gallon non-pressurized storage.tank located in the crawl space which is supplied with water by means of a submersible pump located at the bottom of the well. A booster pump then pumps water from the 500 gallon storage tank, as needed, to pressurize a small "Extrol" pressure tank. Because the storage tank contained an unknown quantity of water at the start of our test, we were not able to isolate and directly measure the amount of water being produced by the well. Instead, our detemfination of the well yield is based on the rate of recovery of the water level inside the well casing. When the well pump was turned on at the start of the test, the pump ran for 7 minutes before the water level was drawn down to the pump intake at 124' below the top of the casing. We then shut the pump off and monitored the rate of water level recovery 1.25 hours as the well gradually refilled back up to 103 feet. We then ran the pump for another 6 minutes to draw the water level back down to the pump intake, and once again measured the rate of recovery of the water level for another 1.25 hours. Based on our test data we determined that the total yield of the well is 0.44 gpm. This measured yield is slightly in excess of the minimum Municipal criteria for approval of a 3 bedroom single family residence. However, this well yield does not meet the FHA lending criteria that a well be able to supply 720 gallons of water within a 4 hour period, with a minimum of 1.0 gpm being actual production. Inexplicably, the well has no automatic pump protection shut-off device, which is very important for a low production well such as this one with minimal water storage inside the well casing. I strongly recommend that you look into installing a "Coyote" or similar conu'oI device which will automatically shut off the pump when the water level is &'awn down to it, and then restart the pump after a pre-set time period such as 30 minutes or an hour. Installation of such a device will make your life much simpler as well as prolonging the life of the pump. Two good installers that I could recommend are Dave Hm~per at Alpine Drilling and Cml Hefty at Hefty Drilling. Alternatively, or in addition, you might consider making additional perforations of the well casing in the zone of the aquifer in the hopes that this might increase the yield to closer to the 2 gpm reported on the driller's log. Finally, you could have the well deepened, which would at least increase the storage and might encounter a more productive aquifer. If a better aquifer were not encountered, the casing would have to be re-perforated at the 100 - 103 foot level. In conducting a yield test we attempt to provide a thorough, conscientious engineering analysis of the system. The reported results describe the performance of the system under the conditions encountered at the time of the test. Well yields may vary significantly on a seasonal basis based on the recharge characteristics of the aquifer being drawn upon by the well. Please feel free to give me a call if you have any questions on this report. Sincerely, Ted Moore, P.E. FLATTOP TECHNICAL SERVICES .14530 Echo St., Anchorage, AK 99516 Ph. (907) 345-1355 ADEQUACY TEST DATA SHEET Legal Description:, Street Address: Client Name: Test Date: Initial Conditions: Float #1 in set Float #2 in set Float #3 in set Float #4 in set '. Wate~ added through: Tested By: 7~ ~oo~ " b,t.o. " b.t.o.-- " b.t.o.-- ~" b.t.o. ACTION TIME H20 METE} NET. GAL WELL TA'KEN LEVEL IO:~ to%' o~ IO; qq; ~o l'a~ I~ : ~ I 11,'~: ~o I~ Io.'fW ~o7 IZ .'Of lip J' ,. , IZ.'Z~ ,, M~co~e~ ~n~ )~ Ip I ' ~ Measured Well Yield --Io'6/,va~/~p=~,v ,~Adequate for 3 Bdrms Unit Abso. rption Capacity = Sorge Capacity = Average Absorption Rate = Adequate for ~ Bdrms MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~:;f/ 3/.~ 04 HAA# .~-- 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Lot SA, Block 3, Lake Ridge Terrace Location (address or directions) (b) Property owner Mailing Address (c) Lending Institution Mailing Address A.H.P-R- ~26103 Telephone:(home) 520 R_ 3~h Anchorage, Alaska Telephone Business (d) Real Estate Company and Agent Re/Mm~ Address · 16600 Centerfie!d nr · 694:4200 Telephone Mail the' HAA~to the following address: (or check here,,[~-if hold for pick up.) List contact.person and day phone number below: S & S ENGINEERING 17034 Eagle R~ver Loop R~d No. 204 Eagle River, Alaska ~9577 '" (e) 2. TYPE OF RESIDENCE Single-Family ~3 Number of bedrooms 3 3. WATER SUPPLY Individual Well r~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page I of 2 ')JJOM s,Jaau!J~ua IBUO!SSajoJd aqi u! suo!$s!uJo Jo sJOJJa JO~. alq!suodsaJ ),ou s! abeJoqouv jo Xl!led!o!un~ aq/'panss! s! eleo!i!lJao e eJo,Jaq elep aZ,~lBUe Jo suoRoadsu! ~onpuoo ~,ou op SHHQ ~o sea~oldLU3 'sluawaJ!nbaJ ajgls pub iI.~Japaj u!e)`Jao/~Js!lBs o), Jap JO u! suop, nl!lsu! I~u!pual J!aqi pub SaLuoq ~0 sJaSeqoJnd o), Xse~Jnoo e se s!q~ seop SHHQ aq/ 'B~tSelV Jo ale)`8 aql u! paJa~s!l~aJ JaaU!bua leUO!SSa~oJd ~,uapuadapu! ue Xq aAoqe ~ qd~i~eied u! ua^!§ suo!im, uasaJdaJ aql uodn ,~lUO paseq peieoWJao ieAoJddV ~l!Joqln¥ qlleaH senss! (8HHCl) sao!^JeS uewnH pue qll~aH ~o lueLUlJ~decl al~eJOqOU¥' ~o Xl!led!o!unlAI eqL leAoJddv leUOR!puoo ~o SLU~e/ euoqdele2 sseJppv w~!::l Jo eUJeN · uoRoadsu! s!4)` jo e)`ep eH), uo )`oejje u! suo!)`elnbeJ pue 'seoueu!pJo 'sepoo e)`e)`S pUB led!a!unl/N lib 4)`!M eoue!ldwOO u! s! wm, sXs leSOds!p Je~e~e~se~ Jo/pue Xlddns Je~e~ e~s-uo eql 'uo!~oedsu! pue uo!~eS!~seAu~ ~ woJ~ pue selY eSeJoqouv jo ~!ledla~unR eq~ woJ¢ peu!e~qo uoRew~oju~ e4~ uo peseq ~eq~ ~peA JeqHnj I 'u!eJaq pe~ea!pu! eJn~on~s jo ed~ pue swooJpeq jo ~eq~nu eq~o~ e~enbepe pueleUOROunj 'ej~s s! we~sXs lesOdsip Je~eMelS~M Jo/pu~ Xlddns JeleM eHs-uo e4~ ~ql SMOHS leAo~ddv 4~poqlnv qlleeH s!ql ~o uo!~e6!~SeAU! ~w ~q~ XJpeA I 'MOleq UMOqS elep UoR~P!IeA eql Jo se pue o~eJeq pexy~e leas Xw Xq pe!~!lJeo sV ' NOI~V~NOJNI aNY v~va 'HO~S ~qlJ 'S~SB~ 'SNOI~O~dSNI 9NlalAO~d ~1~ 9NI~NIgN3 'g " /~ _~,~O*-~.~'~:~NICIPALITY OF ANCHORAGE (MOA) ~ ['--~ ~"~.~_<::)'" Health Authority Approval (HAA) ~ ~ ~ ~ 343-4744 ~ ~ .~ ' (.~ Legal Description: ~ ¢~ ~ A. WELL DATA ~ Well classification "'~~ If A, B, C, D.E.C, Approved (Y/N) ~ Well Log Present ~)~ Date Completed ~ ~ ~ ~ ~ Yield ~, ~ ~ Total Depth ~ Cased to '~ Depth of Grouting ' - ~ Static Water Level ~ ~ Pump Set At ~ [ ~ Casing Height Above Ground [ ~ ~ ~ Sanitary Seal on Casing~N) ~ Electrical Wiring in Conduit~N) ~ Depression Around Wellhead (Y~ ~ SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ~ ~ ~ ; On Adjoining LOts ~ ~ To Nearest Edge of Absorption Field~n~ Lot ~ ~ I~ ; On Adjoining Lots ~, ~ To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole ~ To Nearest Sewer service Line on Lot ~ ~ Water Sample Collected by ~ ~ I~~ ; Date '~ ~ ~ Comments ~ ~ ~~ ~ ~ ~ B. SEPTIC/HOLDING TANK DATA Date Installed "~--~--I~1 Size Standpipes~/N) "/' Air-tight Caps ~N) Depression over Tank (Y/~[:~ P~Jmping/Maintenance Contact on File (¥/N~ Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Li'ne To Water Main/Service Line No. of Compartments ~ Foundation Cleanout~N) /~/~ Last Pumped ,~ .~._ ~ ; for ' Temporary Holding Tank Permit (Y/N) To Building Foundation ...~.~::~ l.j~ To Disposal Field ~ , ~-'/ To Stream, Pond, Lake or Major Drainage Course Comments "~-.~ ~_~.?~ ~_~ 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed "~ ~ ~ Width of Field /'~ Square Feet of Absortion Area ~ ,~/fz.~ Type of System Design / Length of Field Depth of Field Gravel Bed Thickness ~" Statndpipes PresentdC~TN) '~/ / Depression over Field (Y/~ r---% Date of Last Adequacy Test Results of Last Adequacy Test ~-?/~-~5'~\~¢~-~~ ~-~ ~ ~ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well TOLotBUilding Fou nd a~.~ ~//~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Exist ng or Abandoned System on Adjoining Lots To Cutback (if.present) Comments D. LIFT STATION ~/~ Date Installed "Pump On" Level at~~ High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at ~-"-"~rLt~"~ NP~ es-duper i n~g.~A d~e q u a c y Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Company Eagle MOA No. Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ANALYSIS REPORT BY SAMPLE £o~ ¥1o~k Ozde~ ~ 9822 Date Report Pzinted: OCT 17 88 @ 15:45 Client Sample ID:LSA, B3 LAKERIDGE TER. ?WSID :UA Collected OCT 12 88 @ 15:30 hrs. Received OCT 13 88 @ 15:00 hrs. Presezved with :4 DEG, C Client Name : S & S ENGINEERING Client Acer : SNSENGP P.O.~ NONE REC'D Req ~ Ordered By : RJS Analysis Completed :OCT 14 88 Send Repozts to: Labo~atozy Supezv~so~ :STEPHEN ~. EDE 1)S & S ENGINEERING Special Instruct: Chemlab Re£ ~: 3012 Lab Smpl ID: 1 Matrix: WATER Allowable Paramete~ Tested Result/Units Method Limits NITRATE-N 0.40 mg/1 EPA 353.2 lO Sample ROUTINE SA~PLE Remarks: SAMPLE COLLECTED BY RJS. 1 Tests Performed ' See Special Instructions Above UA=Unavailable ND= None Detected "See Sample Remarks Above NA= Not Analyzed nT=Less Than, GT=Gzeatez Than F .RECEIVED ; INSPECTION APPOINTMENTS . TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECT©h MUNICIPALITY OF MUNICIPALITY OF ANCHORAGE DEPT. OF H~AL~4 & DEPARTMENT OF HEALTH & ENVl RONMENTAL PROTEC;~'tI~I~,©NMENTAL 825 L Street - Anchorage, Alaska 99501 ENVI RONMENTA L SANITATION DIVISION Telephone 264-4720 R E C E ~ V E D REQUEST FOR APPROVAL OF INDIVIDUAL ~ATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page ~, Incomplete requests will not be processed. Please allow ten (~0) days for processing, 3. PROPERTY OWNER PHONE MAI LING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2, BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION PHONE MAILING ADDRESS 4. REALTOR/AGENT I PHONE MAI LING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE /~ SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four [] Two [] Five ~ Three [] Six [] Other 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 depth (attach log if available,) 8. SEWAGE DISPOSAL SYSTEM ~ 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 01,0 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL. [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAl_ SYSTEM []INDIViDUAL/ON -SITE []PUBLIC UTILITY Connection Verified E~Septic Tank or []Holding Tank Size: tf Tank is homemade give dimensions: [] ONE [] TWO PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING NUMBER OF BEDROOMS '~THREE [] FIVE [] FOUR [] SIX OTHER TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) I~}~'"DISAPP R OV E D DATE