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HomeMy WebLinkAboutLAKE RIDGE TERRACE BLK 11 LT 5MUNICIPALITY OF ANCHORAGE z` 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. 051-323-32 1. GENERAL INFORMATION Expiration Date 6,-23 - ZZ Complete legal description Lake Ridge Terrace, Block 11 Lot 5 Location (site address) 14423 Don Circle, Eagle River, AK 99577 Current property owner(s) Frank & Sharon Calazza Day phone 360-0168 Mailing address Real estate agent PO Box 771601, Eagle River, AK 99577 2. TYPE OF DWELLING: ❑� Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic Q 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 $ 02 Waiver Fee $ Date of Payment .5 f 6 ao,-u Date of Payment Receipt Number OSq `1 `{D Receipt Number COSA # O S C E 10 SSS 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 Forge Engineering Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller, P.E. Date 3/15/22 6. DSD SIGNATURE System #1 Approved for _1L bedrooms System -#2 Approved for bedrooms Disapproved �'�•�F ACq�l�1 BenjarroSchiller t✓� �Fc •. CE 12592 • ���� .�'fl�c • . 3/15/22 , •'* AW' dw <<l�\ROFESSOW Conditional approval for bedrooms, with the following stipulations: O,c-14�i��� `oV V1qT WA FR AI GGA 9)J��1111VICF,,`.. ,. . . Original Certificate Date: 3 2 - Z Z The Municipality of Anchorage Development 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 Checklist blue sheet Legal Description: Lake Ridge Terrace, Block 11 Lot 5 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA Parcel ID: 051-323-32 Structure served by this system 0 Well log is filed with Onsite (or attached) Well production at time of test 2.1 gpm Date drilled 1978 Water storage tank volume N/A gallons Total depth 175 ft Well disinfected for coliform test? ❑ Yes ❑ No Cased to +40*ft 9 Coliform bacteria is Negative 9 Sanitary seal is functioning correctly Nitrate 6.36 mg/L ❑ Nitrate less than MRL (ND) R Wires are properly protected Arsenic ug/L 0 Arsenic less than MRL (ND) Casing height (above ground) 36 in. Collected by Forge Engineering Date of flow test for COSA 10/4/21 Date of Sample 3/15/22 Static water level at beginning of test 14.8 ft. Comments *Well log records gravel, sand, and clay strata befrore reaching bedrock @ 112', indicating that casing must extend further than 40'. B. TANK DATA Age of tank(s) <1 years Tank type/material Septic/Plastic Measured operating fluid level in septic tank N/A 0 Standpipes/foundation cleanout per record drawing Date of pumping Tank installed on 1/10/22 D. ABSORPTION FIELD DATA 5' Wide Trench Which system tested (date installed) 1/12/22 Al ALL standpipes present per record drawing Total measured depth from grade 10.1 ft (max) Measured depth to pipe invert from grade 6.1 ft (min) ❑ N/A — pressurized field Fi-I Monitor tubes go to bottom of effective. If not, state depth into effective STATION ❑ Require int, Age of lift station Lift station material Comments: completed ActeZquacy test date Resu EJ Pass For bedrooms Fluid dept rior to test in Water added gal New depth Elapsed time mi ❑® Code -required soil cover over field Final fluid depth in ❑ System presoaked Absorption rate gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 m ths) _ date of test) Gallons introduced N/A gallons If yes, enter date Comments/Deficiencies: New septic system COSA Checklist yellow sheet 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' F Yes Community Sewer Manhole/Cleanout > 100' ✓� Yes if No ft Q Yes if No ft Neighboring Tank > 100' Fl� Yes if No ft Private Sewer/Septic Line > 25' 0 Yes if No ft Absorption Field on Lot > 100' [D Yes if No ft Holding Tank > 100' R Yes if No ft Neighboring Absorption Fields > 100' ✓Q Yes if No ft Water Main > 10' Animal Containment > 50' ❑✓ Yes if No ft F,71 Yes if No ft Yes if No ft Water Service Line > 10' 0 Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway Community Sewer Main > 75' 0Yes if No ft r,/1 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' F Yes if No ft Surface Water > 100' U Yes if No ft Property Line > 5'✓0 Yes Yes if No ft Wells on Adjacent Lots: 0 Absorption Field > 5' El Yes if No ft Private Wells > 100' ✓Q Yes if No ft Water Main > 10' ✓0 Yes if No ft Community Wells > 200'✓0 Yes if No ft Water Service Line > 10' 0 Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0✓ Yes if No' ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' 0✓ Yes if No ft Water Service Line > 10' F/ Yes if No ft Community Wells > 200' 0✓ Yes if No ft Surface Water > 100'✓0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that l 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. COSA Checklist yellow sheet OF • !�Cq�,���} ' 49 TM • Benjarr( 'Schiller i FFG' •. CE 12592 • cv`4� i��� • • 3/15/22 • • •�U Air, Nitrate Advisory Certificate of On -Site Systems Approval # OSC221088 Subdivision: Lake Ridge Terrace Block 11 Lot S -A water sample revealed -a nitrate concentration of 6.36 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 muni org Nitrate Fact Sheet 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 watertreatment 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. v Ma�hng Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org Onsite File Lake Ridge Terrace Block 11 Lot 5 #051-323-32 kI \.V VJ - I U1 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211471 PID Number: 051-323-32 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name Frank & Sharon Caiazza ABSORPTION FIELD ElDeep Trench AWide Trench ElBed ❑ Mound Site Address 14423 Don Circle ❑Other Phone (907) 360-0168 �Numberof Bedrooms Soil Rating Total depth from original grade 0.8 GPD/SF 8.5 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 4.5 Ft. Gravel depth beneath pipe 4.0 Ft. Subdivision Lake Ridge Terrace Block Lot 11 5 Fill added above original grade 1.6 Gravel length 78 Township Range Section Ft. Ft. Gravel width 5.0 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 780 Ft2 1 Ft. Well >100' >100' N/A N/A' >25 TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1250 Gal. Surface Water >1 00' >1 00' N/A N/A Material Plastic Number of compartments 2 Lot Line >5' >10' N/A N/A NA Foundation >1 0' >1 0'' N/A N/A LIFT STATION urer Capacity Gal. Remarks Alarm location installed by Installer PIPE MATERIAL House to tank D3034 Tank to D3034 drainfield Northern Excavation Drainfield D3034 CO/MTD3034 Inspector J. Millette BENCH MARK (Assumed elevation) 100 ft Inspe 151 1�9�22 1/10/22 Location and description tion 31" 1/12/22 2 a 4m Bottom of siding @ point A ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp ,q4q��,�r Conditional Approval: Date s.F ®*: 49TH •*� F,% ...-� Septic System "' Benja%' iSchiller ���F�'`�rF C3/115/222 Approve Date —� `� 2• . . • •�������� l,lI0NP4a F�PROFE0 Note: this approval does not include well permit requirements. `�.�. kI \.V VJ - I U1 LAKE RIDGE TERRACE, BLOCK 11 LOT 5 PERMIT # OSP211471 / \ LOT 2 \ EXISTING FIEL'TO REMAIN IN \\ PLACE FOR}�UTUREUSE. 8' \ MINIMUM SEPARATION FROM NEW FIELD CONFIRMED AT CONSTRUCTION ' WELLS)EXISTING w/ 100' RADII \ LOT 4 I \ / ® \ / MT2 \ 75' LONG x 5' WIDE,4' EFFECTIVE\ DEPTH ABSORP ION TRE 01 MT1 NEW 1250 -GAL SEPTIC FD / /0 TANK w/ 20" MANWAY —� A 4-1 LOT 5 ENGINEERING �,Nn OF At \,1 49 TH ..� • % Bea i Schiller 2592 t �l►�� PROFESSIONP�'.�r PLAN AS -BUILT 0 50 100 FEET 111=50' PID # 051-323-32 \ I /Z, a 10' UTILITY EASEMENTS 0 PT2 20' UTILITY EASEMENT EXISTING TANK DECOMMISSIONED IN PLACE EXISTING WELLS W/ 100; F�4DI1 LOT I A B FCO 33.1 7.3 MH 31.0 18.4 SV 32.2 22.0 2CO 33.8 25.3 C01 45.7 47.5 FD 37.5 45.0 CO2 41.6 57.4 MT1 --VT--2 41.5 56.0 107.3 101.5 CO3 114.4 105.5 TRACT H TRACT K LEGEND CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FD - FLOW DIVERTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LAKE RIDGE TERRACE, BLOCK 11 LOT 5 PERMIT # OSP211471 m PID # 051-323-32 0� �- 0 97.0 FINISH GRADE 95.4 ORIGINAL GRADE DRAINFIELD ROCK 86.9 86.9 78' GROUNDWATER @ 82.9 ON 10/29/21 rm PROFILE AS -BUILT (NO SCALE) SOILS LOG AND PERCOLATION TEST E N G I N E E R I N G LEGAL DESCRIPTION: LAKE RIDGE TERRACE, BLOCK 11 LOT 5 PERFORMED FOR: FRANK CAIAZZA DATE: 111112022 PARCEL ID#: 051-323-32 DEPTH PERK TEST 2 (feet) 1' OB 1 2 SILTY SANDY GRAVEL 3 .ta 4 PERC TEST LOCATION 5 6 7 8 9 10 11 12 13 14 15 16 17 18 1 COMMENTS: DATE READING START TIME NET TIME (MINUTES) DEPTH To WATER NET DROP (INCHES) INCHES) 1/11/22 1 4:30 30 416 $ is 4 is 2 5:01 30 416 8 16 4 1Ll 6 3 5:32 30 4 6 8 �0 4116 6" DIAMETER TEST HOLE PRESOAKED PRIOR TO TESTING PERCOLATION RATE: 6.5 (MIN/INCH) SITE PLAN TECHNICIAN: J. MILLETTE STATE OF ALASKA 13925 DEPARTMENT OF NATURAL RESOURCES DIVISION OF MINING, LAND & WATER Alaska Hydrologic Survey WATER WELL LOG Revised 08/18/2016 urilling started: / / Completed:_ 8 / 6 / 1978 —Pump Install: rough Subdivision Block Lot7 Property Owner Name & Address Eklutna LAKE RIDGE TERRACE JB11�05 ARTHUR R CUMMINGS , Well location: Latitude Longitude Meridian S Township 015N Range 002W Section 36 SE 1/4 of SE 1/4 of NE 1/4 of NE 1/4 BOREHOLE DATA: (from ground surface) Drillinmethod: it rotary, . able tool,E]Other Suggest T.M. Hanna's hydrogeologic classification system* httos://my.ngwa.org/NC Product?id=a 185000000BYub3AAD Well use:OPublic supply, QDomestic, EIReinjection,[:]Hydrofracking Depth © commercial, DObservation/Monitoring,[]Test/Exploratory,OCooling, From To Irrigation/Agriculture,OGrounding,ORecharge/Aquifer Storage, [IHeating,[]Geothermal Exploration,QOther Fluids used: Depth of hole: 175 ft Casing stickup: ft Casing type: Casing thickness: inches Casing diameter: inches Casing depth: ft Liner. type: Depth: ft Diameter: inches Note: Well intake opening type: 0 Open end,' pen hole,E]Other Screen type: , Screen mesh size: Screen start: ft, Screen stop: ft, PerforatedElYes I� No Perforation description: Perf from: ft, Perf to: ft, Perf from: ft, Perf to: ft Gravel packedQYes [I No Gravel start: ft , Gravel stop: ft Note: Static water (from top of casing): ft on / / Artesian well Pumping level & yield: feet after hours at gpm Method of testing: Development method: Duration: Recovery rate: onm Grout type: Depth: From Include description or sketch of well location (include road names, buildings, etc.): Final pump intake depth: Pump size: AS 41.08.020(b)(4) and AAC 11 AAC 93.140(a) require that a copy of the well log be submitted to the Department of Natural Resources within 45 days of well completion. Well logs may be submitted using the online well log reporting system available at: https:Hdnr.alaska.gov/welts/ OR email electronic well logs to dnr.water.reports(a-)alaskagov *Guide for Using the Hydrogeologic Classification System f Water Well Boreholes by Thomas M_ Hanna NrwA P, ­ Volume ft. To ft Model: hp Brand name: Was well disinfected upon completion? Yes No Method of disinfection: Was water quality tested?LjYes nNo Water quality parameters tested: Well driller name: Company name: 4AY WILLIAMS DRILLN . I....G ............................................. Mailingaddress: .................................................................................... City: State: AK Zip: Phone number: ( _ Driller's signature: Date: Anchorage Municipal Code 15.55.060(1) and North Pole Ordinance 13.32.030(D) require that a copy of this well log be submitted to the Development Services Department/City within 30 days of well completion. City Permit Number: Date of Issue: Parcel Identification Number: - 1* d r rA z h • C i3�as- LAS c a -t 3 > >> rn O e 'D r' 'rf "rf E` i�"t • 'rl ':f. is, if 'rf "s7 'zy "=S > C7 `� tG .t D D RA ON rl e 'D r' 'rf "rf `sf ^rf ':f 'rl ':f. "sf 'rf "s7 'zy "=S > C7 `� tG .t D D D Alb D p O y-03 OH H y ILIN 00 > i MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program Pd Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone. (907) 343-7904 Fax: (907) 343-7997 http:/ANww.muni.org/onsite On -Site Wastewater Disposal System Permit ca�1n`nj, v n r. Deportment Permit Number: OSP211471 Effective Date: Work Type: Septic Upgrade Expiration Date: Tax Code Number: 05132332000 Site Legal Address: LAKE RIDGE TERRACE BLK 11 LT 5 G:0553 Site Mailing Address: 14423 DON CIR, Eagle River Owner: CAIAZZA FRANK M & SHARON Lot Size in Sq Ft: Design Engineer: FORGE ENGINEERING Total Bedrooms: This permit is for the construction of: 11/15/2021 11/15/2022 60662 C Disposal Field R1 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 15.55 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 (2417). 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 r al Provisions: A portion of the proposed absorption field is outside the 30 ft radius of a percolation test 15.65.210C.4). An additional percolation test shall be conducted at time of construction for the portion of ld outside the 30 ft radius. If results require a design change, construction shall stop pending review and val of a change order. Please submit results with inspection report (or change order, if required). Veronica Pope GE 2021.11.15 Received By: 17:38:26 -09'00' Issued By: Date: i Date: !�� 4 ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-323-32 Property owner(s) Frank & Sharon Caiazza Day phone 360-0168 Mailing address PO BOX 771601, Eagle River, AK 99577 Site address 14423 Don Circle Legal description (Sub'd., Block & Lot) Lake Ridge Terrace, Block 11 Lot 5 Legal description (Township, Range & Section) Lot Size 60,662 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑X Initial ❑ Single Family (SF) ❑X Septic Tank ❑X Upgrade IN (w/wo ADU) Holding Tank ❑ Renewal ❑ Duplex (D) ❑ Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / 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 owner or authorized agent) Permit/Rush Fees: 5 � 5 _ Waiver Fees: Date of Payment: 12 Q b a i Date of Payment: Receipt Number: —OLI 355-b Receipt Number: Permit No. OSP 211 y 1 Waiver No. Permit App_'- : :-..:c November 5, 2021 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 11/5/21 Subject: Lake Ridge Terrace, B11 L5 – 14423 Don Circle Septic system design Dear On-Site Services Engineer: The owner of the above lot intends to sell their 4-bedroom home on the property and the septic has reached the end of its life, so we are submitting this permit application for the construction of a new septic system. The attached site plan identifies the location of the home as well as the proposed septic location and well. No conflicts exist between this proposed system and any other well or septic system, whether on this lot or adjacent lots. The ground surface on the lot slopes toward the west between 20-40%. There are no slopes greater than 46% within 100 feet downslope of either the primary or alternate site. The current design meets all MOA provisions for slopes between 25-46% (MOA Wastewater Code 15.65.210.B.4.a). Contours are shown on the site plan showing the grade and direction of flow. Stormwater drainage will not impact this septic system. The new trench will be constructed parallel to the slope as much as possible. Wells on this and adjacent lots are shown. The new system will be a minimum of 100’ from all wells and surface water, and more than 5’ away from the septic tank. The existing septic trench will be greater than 8’ from the new trench. Please refer to the attached test hole log, plan and profile pages for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211471, Rebecca Carroll, 11/15/21 Benjamin Schiller CE 12592R EGISTEREDPROFES S I O N ALENGINEER 1"=50' CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FD - FLOW DIVERTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND CO LAKE RIDGE TERRACE, BLOCK 11 LOT 5 FEET 0 50 100 NOTE: NO SLOPES >46% OR SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM. THIS DESIGN MEETS ALL MOA STEEP SLOPE PROVISIONS. ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS. 4-BDRM HOME November 8, 2021 SHED TH#1 20' UTILITY EASEMENT 10' UTILITY EASEMENTS400410420 430CO MT MT FDNEW 1250-GAL SEPTIC TANK w/ 20" MANWAY & DOUBLE CLEANOUTS ON BOTH SIDES DECOMMISSION EXISTING TANK PER UPC 75' LONG x 5' WIDE, 4' EFFECTIVE DEPTH ABSORPTION TRENCH EXISTING FIELD TO REMAIN IN PLACE FOR FUTURE USE. EXPOSE TO CONFIRM 8' MINIMUM SEPARATION FROM NEW FIELD EXISTING WELLS w/ 100' RADII EXISTING WELLS w/ 100' RADII Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211471, Rebecca Carroll, 11/15/21 LAKE RIDGE TERRACE, BLOCK 11 LOT 5 TYPICAL TRENCH SECTION (NO SCALE) NOTES: 1. GRADE AREA OVER TRENCH TO DRAIN AWAY 2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2' WITH 2" OF INSULATION 3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY Benjamin Schiller CE 12592R EGISTEREDPROFE S S I O N ALENGINEER4" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK 5' 6" 6" 3' - 6" 4' DESIGN FACTORS:SYSTEM REQUIREMENTS: 600 GPD PEAK FLOW PERK RATE: 3.3 MIN/IN APPLICATION RATE: 0.8 GPD/SF (CONSERVATIVE RATE USED) SHALLOW TRENCH SYSTEM 1250-GAL SEPTIC TANK BOTTOM OF TRENCH: 8' BELOW GRADE FLOW LINE ELEVATION: 4' BELOW GRADE TOP OF TRENCH: 6" ABOVE GRADE 600 GPD / 0.8 GPD/SF /5' WIDE * 0.50 REDUCTION RATE (4' EFF DEPTH) = 75 LF TRENCH REQUIRED (75 LF SPECIFIED) November 8, 2021 GEOTEXTILE FABRIC Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211471, Rebecca Carroll, 11/15/21 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST TECHNICIAN: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 DEPTH (feet) PROJECT No.: TEST HOLE 1 SLOPE SLOPE SITE PLAN DATE READING GROSS TIME (minutes) NET TIME (minutes) DEPTH to WATER NET DROP PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH) TEST RUN BETWEEN: FT. and FT. COMMENTS: (inches)(inches) J. Millette DATE OF MONITORING: WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING: IF YES @ WHAT DEPTH?15' 3.3 6 3 4 10/28 1 2 3 4 5 6 GM (SILTY SANDY GRAVEL) Professional Engineers Stamp: Yes 12.5' 10/29 Lake Ridge Terrace, Block 11 Lot 5 10/22/21 051-323-32 Frank Caiazza 2:481 2 3 4 5 6 3 12 16 / 7 4 16 1' OB 10 Benjamin Schiller CE 12592R EGISTEREDPROFE S S I O N ALENGINEERNovember 5, 2021 3 8 16 2:59 3 12 16 / 7 4 1610 3 8 16 3:21 3 12 16 / 7 3 1610 3 7 16 3:32 3 12 16 / 7 0 1610 3 4 16 3:44 3 12 16 / 6 14 1610 3 2 16 3:56 3 12 16 / 6 13 1610 3 1 16 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211471, Rebecca Carroll, 11/15/21 Tract H Tract K PLOT PLAN ___ AS BUILT _X_ SCALE _1= __ 60__ GRID __NW 0553-- Project No. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone (907) 522-4625 Fax 000000pp oo ()F q�pp� Professional Land Surveyors kenOlangsurvey.com yjonothanOlangsurvey.com c OOD I hereby certify that I have surveyed the following described property: TERRACE SUBDIVISION No. P-549) o 49TH "' ��� LOT 5, BLOCK 11, LAKE RIDGE (PLAT Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed (7o'p•' KENN ' G. NG z premises and that there are no roadways, transmission lines or other visible o G oOfn�'•.t(���21 easements on said property except as indicated hereon. ,•'�� 1p' - Dated this the ___3�___ Day of _________—,—____—, at Anchorage, Alaska LS -5202 .•' y�o� a "•"" dOo 4ppRaFfSSIONA� �o It is the responsibility of the owner to determine the existence of any easements, OOpppoo� covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 ,~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT [] UPGRADE MAILING ADDR~S~ LEGAL DESCRIPTION LOCATION NO, OF BEDROOMS We]Il ~ ¢ / Absorptio~area Dwelling PER M IT ~ . - ~ Manufacturer ~ Mater~ No. ofcompartmen~ ~ N Liq, ca Ions' Inside length Width Liquid depth ?~ IF HOME.DE: 0 ~ ~ Manufacturer Material kiquid capaciW in ~allons ~ Foundati* ~O¢ Nearestlotli~ ¢ ~ DISTANCETO:~ Well /~/ ~ Total lengt~s~ Trench width Distancebet~e~lines No. oflines ~ Length ofeachline ~ ~ Zop of tile to finish 7 inches Tota]effective~s~tionareapERMiT NO, Length Width Depth ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ 'Well Building foundation Nearest lot line ~ DISTANCE TO: ~ DISTANCE TO: Building~tion Sewer line/~ Septic tank/~ / Absorption area(s} / OTHER PIPE MATER~L~ ~ ~ SOIL TEST RATING~ q 5 W .~ INSTALLER O ~ i ~ ,.,. !::!R'T'H .,. R C:t..IhlM .1: NGS:; L5 B:t.:JH LK 1'7.':I[:'L3E 'i"ERRFfCE I::1F' P L I C 1:::1 t",! ~!" I,.. 0 C F! T ]: 0 N L ~z aHL -t ii. OF q']Tt RE'ZZRETIOtq SYSTEM I"IF:!::.:; ]: MUM F,IIjMBEF.: OF E:EE:,ROOMS = 4 SIZE OF THE SOIL FIE:SOF.:F'T!ON SYS.7['EM IF.";: ~:-]~i~~ If""" '" --" " :]~4~J-. ~--. ~'~; ~"".~111'~i~ '"~' ['"'"~ ..' "['HE LEt'.tG"rH DIMEt'-,1SIOIq IS THE LEIqGT,H' (IN FEET) OF ]"FIE; TRENCH [:iR DRFIINF'!EL.D. 'T'HE DEPTH OF FI TF.':ENCH O1:;,' PIT IS; THE D]:STRt'.,tE:E BETHEEI'.,I THE SURF'I::tCE O1::' THE (]il:;;:CllJi'.,!E:, Ft!",tD "t"HE BOT'T'OM O1::' THE E',:,','CRVF:IT.'I:ON (It",l FEET). THERE IS'; NO '."~;ET H]:[:,TFI F'OR TRENCHES. THF£ GRI:::I',,,'EI... DEI:::'TH IS THE MINIMUM E:,EF'TH OF GRI::I"/EL. BETHEEN THE OIJTFFILI... PIF'E I::IND ]"HE BOTTOM OF THE EXCF!',,,'FITZOI'.,I (I!",l I::'EET). PEI:;;:M I '!" F"it:::'F'L: I CFINT HFtS:; ]"HE RESt::'ONS I B I L I TY TO I NFORi'"i TH I S [:,EI::'F!RTMENT DUI:;.". t I'.,IG TFtE ]:t",t:E;TF:ILLFITION Z!q"2;F'EC]"IONS OF FIt'-,!Y ,WEL. LL:: F:I[:,JF1CENT 'T'O TH ZS PROPERTY FIF,ID THE I'qUMBER Ci[:' RESIDEI'-,!CES 'FHF:iT 'I"HE HEI...L 14ILL SER',/E. ....................... ""F I!..,,-ti (D ,,:: ;'2~:: ]:,, ..'711;: l~..a SE;; jr.:::- EE: C::: ""IF" .]E C~ tP..,,!I :~; Flt 11~: EFZ IF;E E% C;:.~ IL.~ % fF;?.' EC E;: E',RE:I<F ! LL_ X NG OF' FINY SYSTEM I.,.I Z THOLIT F! NF:IL.. t' N:.::';PEE:T I ON FIt',II) FtI:::'PF,;:CPY'FIL E:"r' TH I S DEF'!:::IRTMENT HIL. L. E',E S~;IJF',JECT "FO F'ROSECUT:[ON. I"! I i~',l ]: I'"ILIPi [:, i :5]"F':II'qCE BETHEEt'.,! FI HELL F:llq[:, t::I!",!Y ON'.-.S :[ TE SEHFtC:iE I:::, :[ SF'OSRL SYSTEM ]: ~; ::L!-/.IO I::'IEET F:OR R I::'RI',/FITIE !,.!EL.L.~ OR 15,9 TO ;2:Eu;i) FEE]" FROM R F'LIBL]:C I-..!['ZLI... DEPENI}'.t;I'.,IG IJ[:'EIN THE TYF'E (:iF: PUE:,'LIC HIEL..L.. HEL.I.. L. OGS F:!RE F.:EC!UIRED F:ffqP MUST E~E RETUI:;d'.,IE[:, TO TIqE DEF:'RRTMEI'.,IT Hi'TH]:i'.4 .~:(:_"~ [:,FtY:!i; OF'- THE HELL. C:C)Mt:Z'LE]"I Oi",i. OTF!ER REC!IJ I R!EMENTS MFtY I::iF'F'LY. SPEC :[ F' 1' E:FfT ]: O!",1':}; FII'-4[) COt",IS'~;TRUCTZ Ot'4 [:, Z t:':IGRt::IMS !aRE I:::I',/'Fi I L..!::if':",L.E!: "I"L] I N'/'jLII:,i:E I:::'RC.'IF'EI:;: ); F,I'.'STRLLI::IT ): ON. :[ CERTIF:'Y THFIT :L: ! FIFt I::'F:IMiLt'FIR .[,I:I:TH THE REQLI'I:F.:Eh!EI',I'T".:.i; F:OR ON..<ii~;I]"tE S;EHERS FiI'.41} HIEL. LS F:!'}.:; ':'ii;ET FOF.'.TH .BY THE I',!IJN .T. E: Z F'I:::IL 1' TY OI::' Ft?.,!CHOF'.I::!GE. 2: I H]:LL !I'.,I:.::;]"F:ILL ]"HE SY:E;'FEM II'.,I F!E:CORDFtNCE H:[TH THE CODES. ]:: ): LIN[:,EI:~:STF!N[)]"HI::IT THE ON-S:;ZTE S!!ENER SYSTEM MFIY I:~:EC!U ]: RE li'2]'.&.F:IF~:(:!iEP'IEi'4T Z F THE F':E2~ZD!EI',!CE tS REMIEI[)ELE[:, 'T'O ]:I'.,ICLIjDE MORE( 'T'HFIt'.,! 4 E:EDI:;.':OOP'!S. FIF'PL I CFiNT RRTHUR CLIMM I NC!iS ]: E',Y. O ~ E GEC' ECHNICAL ~ DEVELjPMENT CO. Box 90, Davis St,, Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 S0]L LOG Soils ~ Foundations Performed for: Name: ~-~ ~'~r ~-_~,v,~,%~,~t,S Lega~ Description: ~-~' ~ ~'~ ~ ~ ~ ~_~.~~ _ Depth (feet) Soll Charactertstic~ Ear/Ellis 6~8-2280 Land Development Tel. ,o. A" 5 6 7 8 9 10 1] 12 ~5 ~6 Ground Water Encountered: Yes~ Proposed Installation: Seepage Pit Comments: .~7~ ~ ~,j~ ~©~ ' No ? If yes, whet depth Drain Field ,/ Performed by: ~I~.~5 /__~H~,i~e~ Date: i::1P F:' L. I C R N T i. '] T F:i'T' '[ L E G l::l L I::IRTHUR R. CI. JMiqlNG:5 GEN I}EL [)I3N IS: I RE:I_E L5 B:t:l. LFIKERI[:,GE TEF.:RFIC[:/. :5,-.-'[:, L.(]'T' '.:-- '[ Z E f'l I N I MUM [)I S'T'RNCE E:ETNEEN FI WELL RNB FINY ON-':'7, I 'T'E SE[,.IRGE [.', I S:,F'OL:.;FIL. SYSTEM I :E; :]j;!:IE-I F'EET FOR R F'RIVFITE 1.4EL. L..~ EIR [LSE~ TO 2(i)E! FEET FROM FI PUBLIC WELL. [)EPEN[:,INEi LIF'ON THE TYPE OF' PUBL. t C NEL. L.. I.,.IEL. L LOGS FIRE REQUIRED FIND MUS:;T BE RETURNED TO THE [:,E:F'RRTMENT' N ITHIN S0 [:,FIYS OF THE NELL C:OMPL.ETION. O't"H[ER B'.E[.:gJ ]: REMENT:E; MRY FIPF'I-Y. SPEC l F I I]:Fl"i' l ONS FIN[:, FI',/FI I L.F'IE:I_E TO Z NSURE F'I;.'.OPER ! NS'TF~LI_I'aT Z ON. ! CERT i F:'"r' '1"hilt:IT :1.: I f:ff"t Ff:tMII_iFIR t.,.I!]"H THE REQUIREMENTS.'; FOR ON-SITE: ZE:t.,.IE]:;-:S FIN[:, 14ELLS F:IS SET FOR'TH 8Y THE MUNICIF'FILITY OF' FINC:HORI:':IGE. :E:: I I,.IIL.L II'.4S"FFILL THE SYSTEM IN FICCORC, FINC:E !-,.IITH THE COl}ES. 'Z; t GNEB,: RF'PL. I CFIN]" I::IRTHUR I:;.':. CUMi"I I IS'SUE[:, BY. ..................................... ...... [ RTE. 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 1.. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA # ~,~O,y,~ 5ob 5; Block il; Lake Ridge Terrace Location (site address or directions) 14423 Don Circle Eagle River, AK ...." - / ~Arthur Cummings ~,Property owner ~,/~ ~': i' ' ~ S' ".' '.~4423 Don Circle ~ .Mmhng addre s '.. ' .Lending agency ........... '~Mailing address ,/' Eagle River, Day phone AK 99577 Day phone 271-5829 Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUM, BER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well xy_x NOTE: :,., ~. -. 'lng to the legality and status of system. Public water If community well system, provide written confirma, tion from State ADEC attest- '~YPE OF WASTEWATER DISPOSAL: Individual on-site NOTE: Holding tank Community on-site PubLic sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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 all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S & S ENGINEERING 17034 Eagle 14iver Loop Road NO, 204. Phone ~ ¢/~ - ~_c/, '7 ~ Address Eagle River, Alaska 99577 EngineeCs signature ..... Date '7/-~'~/¢/7 DHHS SIGNATURE 'WApproved for 4 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments "1 , - v Date 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. 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. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · ENVIRONMENTAL SERVICES DIVISION Legal Description: A. WELL DATA Well type ¢/~/\//~ Log present CN) Total depth Sanitary seal ~N) Health Authority Approval Checklist /~4./~ // '~,4-/~',~ ~tO.~'~_~ Parcel I.D.: JUL 2 2 1997 RECEIVED If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to FROM WELL LOG Casing height (above ground) Date of test Static water level Well production Wires properly protected~/N) y AT INSPECTION 7 · ?'7 g.p.m. ~ ~ g.p.m. WATER SAMPLE RESULTS: Coliform ~ Date of sample: Nitrate 0,/° Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ,/O - '~ ~ Tank size Foundation. cleanout (~/N) Date of'Pumping C. ABSORPTION FIELD DATA Data,installed / Length, ' ~/ 3'~ ' Width.' Effective ~bso~'ption arena Date of adequacy test /4~c-0 Number of Compartments '~ i CleanoutsCN),_~. Depression (/~ /-) High water alarm (Y(~) Pumper Soil rating (g.p.d./ft2 or f¢/bdrm) ~¢'//~'-///~'~System type ~ I Gravel thickness below pipe ,2 / Total depth Fluid depth in absorption field before test (in.); 1 ¢2 ¢ Immediately after~/~o gal. water added (in.): Fluid depth /¢" (ins) Minutes later: ~'~ Absorption rate = .g.p.d. / Peroxide treatment (past 12 months) (Y~) A~,V~-.- (4,~ ~'~/J If yes, give date Monitoring Tube present ~N)__/~/___ Depression over field (Y~ Results~-_ Fail)~P¢~'~ For / bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION F. Date installed Manhole/Access (Y/N) "Pum~ High water alarm leve.~ a.~t* ~ *Datum SEPARATION DISTANCES Size in gallons "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /O0 \~ On adjacent lots Absorption field on lot '\ c~C~ On adjacent lots Public sewer main ~ l,/x Public sewer manhole/cleanout Sewer/septic service line ¢-ff~' \ ~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ¢-- lA-- Property line vo \ ~' Absorption field Water main/service line lo \'~ Surface water/drainage '~::2o \ ~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water Curtain drain Building foundation (,o ~ ~ Water main/service line I ~' Driveway, parking/vehicle storage area 5"-~ I~,,,',.)OL/D/~ Wells on adjacent lots /~o I ¢- ENGINEER'S CERTIFICATION ~,~ ~ ' I certi~ that I have determined thru field inspections and rewew of Municipal reco~e ab( ~s are in conformance with MOA HAA guidelines in effect on this date. Signature ~)/~r ~ .~-' ' ~:~~ ~: ::~ Engineer's Name Date ' ~-"~-: ~ . HAA Fee $. ~ ' ~ Date of Payment Receipt Number ~-'~/~ O¢~F/¢:~.7~~ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number JUL-08-199? 14:21 CT&E ESI ANCHORAGE 907561530~ P.02/07 CT&E Ref.# 973590001 Client Name S & S Engineering Project Name/# N/A Client Sample ID L5 BiI Lk~dg¢ Tcrr. O.$. Tap Matrix Drinking Water Ordered By PWSID 0 $'-mple Remarkl; Client PO# Printed Date/Time 07/08/97 12:58 Collected Date/Time 07/02/97 09:30 Received Date/Time 07103/97 10:00 Technical Director: Stephen C. Ede Totat coliform Resqtts O,lOO u o ALLowabLe Prep AnaLysis Units Method Limits bate Oate ln~[ 0.100 mg/L $M18 6500-NO3F 10 max 07/03/97 JBL cot/3OOmt SM18 92226 07/0~/97 TMW '' MUNICIPALITY OF ANCHORAGE DEPT. 07 '.';i DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~":I'~/~~ON;Z'ENTAL F';;C: ;;!CTION  825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND 8EWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPE[ITY O~/NER /,-) / P~ONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) ~ / PHONE MAILING ADDRESS 3. LENDI.NG INSTITUTION 4, REALTOR/AGENT ~ ' / E MAILING ADDRESS 5. LEGAL J~ESCRfPT, ION ~ STR EE~ LOCATI O~ ~ ~ ~ One ~ Four ~SING LE FAMILY ~ Two ~ Five ~ MULTIPLE FAMILY ~ Three ~ Six [] Other 7. WATER SUPPLY [~F~N DIVI DUAL* [] COMMUNITY [] PUBLIC UTILITY *ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available.) 8. SEWAGE DISPOSAL SYSTEM [~INDIVI DUAL/ON-SITE~ [] PUBLIC UTILITY **If individual/on-site, give installation date //Y_),//'Z/:7 If system is over two (2) years old an adequacy test [~ required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE I NSP ECTOR INSPECTOR INSPECTOR DIRECTIONS: 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 E~PUBLIC UTILITY ?(_~ ~-~ Connection__ ---.Verified INSTALLER .~ /~ / []Septic Tank or []Holding Tank Size: /~J__.~.3 If Tank is homemade $OILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area ISawer Line Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS ~- APPROVED FOR 5~'~' BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) []DISAPPROVED DATE BY (Title)~ [ // LEGAL DESCRIPTION 72-010 (Rev. 3/78)