HomeMy WebLinkAboutLAKE RIDGE TERRACE BLK 11 LT 11Onsite File
Lake Ridge
Terrace
Block 11
Lot 11
#051-323-26
page ? Of
Report for On -Site Water and Sewer System Certification
Audit Stamp No
I. GENERAL INFOPN.ATION
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O � WALTER J. NICV(EL, COVERNOfl
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFRCE
800 E DIMOND BLVD., SUITE 3470
ANCHORAGE, ALASKA 99515 (907) 349-7755
August 19, 1994
Mr. Robert Shafer; P.E.
S&S Engineering
17034 North Eagle River Loop
Suite 204
Eagle River, AK 99577
RE: Lot n, Block 11, Lakendge Terrace Subdivision; Operation Approval Onsite
Class 'C' Public Water and Wastewater Disposal Systems. ADEC Project Nos.
9421 -DW -243-044, and 9421-W W-24&023.
Dear Mr. Shafer:
This letter Is in response to the materials received in this office August 5, 1994, requesting
operation approval of be above on-site water and wastewater disposal systems. The
Department has completed its review of the submitted materials which Included a cover
letter, completed Class 'C' public water system checklist, completed report for on -we
water and sewer systems, well How results, engineered as-bullts of the water and
wastewater disposal systems and results of raw water sample analysis. Resod upon this
review it appears that the above omske systems Were Installed in accordance with the
guidelines and regulators in effect at the time. This meets the concems of this
Department, therefore, approvaito operate Is granted based upon thefollcwing conditions
and comments:
Ddnkina Water System
This water system was previously assigned the following public water system identification
number(PWSIDno.)218255. Please reference this number when submitting future water
samples so Net this system maybe property credited. Results from the water sample
analyses provided reveal elevated nitrate levels of 9.4 mg/) which approaches the
maximum con aminant level (MCL) of 10 Mg/7 as defined under 18 AAC 90.070 for Nis
contaminant. As a result, operation approval will require the following conditions:
Since We action level for Nis contaminant has been exceeded (5.0 mg//)
quarterly monitoring for total colHarm bacterla and Inorganics for nitrate. If
during sampling the nitrate levels for Nis system exceed the MCL, treatment
will be required to reduce this contaminant or a new drinking water source
may be required.
Mr. Robert Shafer, P.E. 2 August 19, 1994
Attached is the Construction and Operation Certificate for Public Water Systems verifying
MIS Department's approval to operate the above public water system.
Wastewater Disposal System
1. Based upon the layout of this trench design monitoring tubes should be
Installed at each comer of this system In addition to the ends of the trench
as Indicated in Me submitted as�bulit
Attached we Me following forms whch should be completed and returned to this office:
Certificate of Construction, Owner's Slatemerd, and Data Sheat for domestic
wastewater system.
Thank you for your cooperation with MIs Department, if Mere are any questions regarding
the above please do not hesitate to call.
Sincerely
%�4--
Michael W, E.I.T.
Erwironmemal Engineer
ML/cf
attachments
QGREA'i~ER ANCHORAGE AREA BORbJGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
MAILING ADDRESS '~"~/~ /"~O Y' -~ ~ ~'/~ PHONE
LEGAL DESCR,PT,O. LO FI/f~/.~/c I/ Z,x~,-~', ~,~
SEPTIC TANK:
DISTANCE //~/,C( -
FROM WELL MANUFACTURER .~.,~5',, 7' X~/~,f'?~ ,¢~ MATERiAL/,,~,'/~ 7/,'~"~¢' NUMBER OF
COMPARTMENTS ~'
'' O
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH_ .LIQUID CAPACITY /7.~ GALLONS.
SEEPAGE PIT:
NUMBER OF PITS / DIAMETER __ OR WIDTH ~'~,
LINING MATERIALC/~/~lIVe' / CRIB SIZE: DIAMETER
BUILDING FOUNDATION ,/d~F, NEAREST LOT LINE
ADDITIONAL ABSORPTION
DEPTH DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA, SQ. FT.
WELL:
TYPE
BUILDING
FOUNDATION __
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST
LOT LINE
OTHER SOURCES
DISAPPROVED
NEAREST
SEWER LINE
REMARKS
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE
TANK SYSTEM
DISTANCES:
INSTALLED BY: _.)F//"'"
PIPE MATERIAL: /2////~
REMARKS;
DIAGRAM OF SYSTEM
DATE f~ /9_
%., ,~, 4'
39112
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O ~ E GEO't ~CHNICAL ~ DEVEL~?MENT CO.
Russell Oyster
694-2774
Soils E~ Foundations
Performed for:
Legal Description:
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Ear/E//is
SOIL LOG 688-2280
Land Development
Mailing Address: ~x'~~ ~ ~ t~c.~'~~'~
Depth (feet)
Soil Characteristics
10
16
Ground Water Encountered: Yes
No ~J If yes, what depth__~
Proposed Installation: Seepage Pit Dretn Field
Comments: \ -,-~ ~,.~,~-~w ~.~-~_
MUMCIPALITY OF ANCHORAGE
Development Services DepartmentPhone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051-323-26 Expiration Date:
1. GENERAL INFORMATION
Complete legal description Lake Ridge Terrace Sub, Block 11, Lot 11
Location (site address) 14536 & 14538 Don Circle
Current property owner(s)
Mailing address
Real estate agent
Michael Jones & Kristen Smith Day phone (907) 727-3911
14536 Don Circle, Eagle River, AK 99577
Margie Hudok Day phone
2. TYPE OF DWELLING:
❑ Single Family (w/wo ADU)
0 Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 7
(907) 748-3656
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑e
Private Septic
❑■
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 $ 3_5 Waiver Fee $
Date of Payment 02 0 o? D.:? l Date of Payment
Receipt Number 03 5 397r7� Receipt Number
COSA # OSC � l 1 / 0 / 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 Date 4/15/21
AOil
�9���
6. DSD SIGNATURE
o/ System #1 Approved for �i bedrooms BenjarrnfSchiller
System #2 Approved for bedrooms �� �F6,s•, CE 12592
�� lF9 • . <c�.ow,
Disapproved
Conditional approval for bedrooms, with the following stipulations:
l� ► 5 (kA deo V- M06 re-col-j%
�ti W a Si ze�1
7 - be c l) -o m 5, 40ti -Ue-r on -the " d; -i ort
of -H) e field b'o r iv MJ olu r,' *C_
v LATE R o
cede 1i ic> c -S'-� arra rr� �C e i V ; pROGR AM
o, I - CJC ro 0 ry) Val,
By: i z Lf Original Certificate Date: 51
/,2 O, T
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
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
Nitrate Advisory X
Arsenic Advisory
Other—I ixnk 0.QjL Q favi soru) X
COSA Checklist yellow sheet
COSA Checklist
Legal Description: Parcel ID:
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test?Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date of Sample
Comments __________________________________________________________________________________
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA ______________________
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field
Monitor tubes go to bottom of effective. If not, state
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
Adequacy test date
Results Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
Comments/Deficiencies:
Home was occupied and water was running in the house duing septic test. This initial
surge of water resulted in a higher water level at the beginning of the testing.
Lake Ridge Terrace Sub, Block 11 Lot 11 051-323-26
4.75
3/19/76 550
75
39.8
12.0
22 Forge Engineering
5/26/20
29.4
4/13/21
27
SEPTIC/STEEL
50
11/05/20 Alaska Quality Septic
9/7/76 5/26/20
■7
12.75 2.5
8.9 902
1
■
■
175
3.85 1
>1050*
*Based on the absorption of 902 gal in 175 min, the rate is >1050 gal in 24 hrs
✔
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’
Yes if No ft
Neighboring Tank > 100’Yes if No ft
Absorption Field on Lot > 100’Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’Yes if No ft
Holding Tank > 100’Yes if No ft
Animal Containment > 50’Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
From Septic/Holding Tank on Lot to:(Please enter distances if less than required)
Building Foundations > 10’Yes if No ft
Property Line > 5’Yes if No ft
Absorption Field > 5’Yes if No ft
Water Main > 10’Yes if No ft
Water Service Line > 10’Yes if No ft
Surface Water > 100’Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’Yes if No ft
Community Wells > 200’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
Property Line > 10’Yes if No ft
Water Main > 10’Yes if No ft
Water Service Line > 10’Yes if No ft
Surface Water > 100’Yes if No ft
If absorption field is under driveway comment below
Wells on Adjacent Lots:
Private Wells > 100’Yes if No ft
Community Wells > 200’Yes if No ft
F. ENGINEER’S COMMENTS
G. ENGINEER’S CERTIFICATION
I certify that I 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.
4/15/21
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May 10, 2021
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
5/10/21
Subject: Lake Ridge Terrace Sub, Block 11 Lot 11 – Don Circle
Septic system testing
Dear On-Site Services Engineer:
We were called to the subject property in May of 2020 to conduct adequacy testing on the existing
onsite septic system. Records indicate the initial layout of 88’ of absorption trench with 4’ of sewer
rock was installed in 1976 for a 6-bedroom home. In 1994 the septic tank was upgraded to a 2000-
gallon tank and a 15’ extension was added to the trench, and an unknown portion of the trench that
extended into the 150’ well radius was plugged and abandoned. The soil is rated at 100 SF/BDRM.
We initially tested the septic system for 6-bedrooms (900-gallons) since the septic had originally
been permitted for a 6-bedroom home. 902 gallons of water was added to the trench over a period
of 3 hours with no rise in water level in the monitor tube. We determined that the field passed with
no trouble.
Since that time the building has been re-evaluated as 7-bedroom home. A 7-bedroom septic would
require a minimum of 700 square feet of absorption in soils rated at 100 SF/BDRM. We cannot
determine the total absorption area accurately without knowing the amount of trench that was
abandoned. However, since the trench absorbed 900 gallons of water in three hours, by
extrapolation it is clear that the trench will absorb more than 1050 gallons of water within a 24-
hour period.
In summary, our testing and calculations indicate that the existing septic system is adequate for a
7-bedroom home.
Sincerely,
Benjamin Schiller, PE
April 30, 2021
UTE
E E R I N G
PO BOX 240773
ANCHORAGE, AK 99524
522-7773
677-7766 (FAX)
FORGECIVIL.COM
MOA Development Services, On -Site Water & Wastewater Program
4700 Elmore Rd,
Anchorage, AK 99507
Subject: Lake Ridge Terrace Sub, Block 11 Lot 11 — Don Circle
Well cross -contamination
Dear On -Site Services Engineer:
We were called to the subject property in May of 2020 to conduct adequacy testing on the existing
onsite well. Records indicate the installation of a 75' deep well drilled in March of 1976. This
April, the owner let us know that he was moving forward with selling his home and a water sample
was taken in preparation for the COSA. The sample results show that arsenic is not detectable and
E. Coli/total coliform are not present; however, nitrates were found to be at 12.0 mg/L, which
exceeds the maximum allowable limit of 10 mg/L.
The well log for this property notes that there is perforated casing between 30' and 33', which is
where we believe the primary water source is for the well. While that was acceptable practice at
the time, current MOA regulations require a minimum of 40' of solid casing to prevent the
possibility of contaminated groundwater mixing with the water from the aquifer. This well would
be acceptable as -is, if it weren't for the high nitrate levels suggesting possible aquifer
contamination.
This led us to investigate the adjacent and surrounding wells to see if any other well in the area
was experiencing nitrate trends and if they had perforations above 40'. Our investigation showed
that there did appear to be a trend in nitrates in nine of the surrounding wells ranging from 0.1
mg/L to 12.8mg/L, most of which record a casing depth of 40' or greater with total depths varying
between 80' and over 300'. Some of the properties with nitrate advisories had camera inspections
that indicated no water or perforations above 40'. The following table shows what we found on
the properties we investigated.
Legal Address
Nitrate
Level
Casing
Perforations <40'
Sample Date
Lake Ridge Terrace Bl 1 L3
0.38
None recorded
12/14/12
Lake Ridge Terrace B 11 L4
0.41
None recorded
2/27/20
Lake Ridge Terrace B 11 L5
0.10
None recorded
7/2/97
Lake Ridge Terrace B 11 L6
6.42
None recorded
4/9/20
*Lake Ridge Terrace BI 1 L11
12.00
Yes 30'-33'
4/13/21
Lake Ride Terrace B11 L12
11.80
None recorded
11/16/17
Lake Ridge Terrace BI I L
12.80
None recorded
7/30/20
Fire Lake L E-2
5.99
None recorded
3/31/11
Fire Lake L2 Tr -H—
3.50
None recorded
5/27/92
Fire Lake L2 Tr -K
6.48
Yes16'-30')
3/11/13
In particular we noted one property (Lot 2, Tract K, Fire Lake Sub) with a well pump log in the
municipal file that notes possible water infiltration between 16' and 30'. Samples for this lot were
taken in 2013 for the COSA with a recorded nitrate level of 6.48 mg/L, which is below the 10
mg/L limit. Additionally, the two properties directly adjacent to this have nitrates above 11 mg/L,
while there is no evidence of perforations above 40'.
After looking at these additional water samples, we feel the evidence indicates that the nitrates in
this well are not coming from the groundwater, and that the mixing is not as big a concern as the
nitrate test made it seem. We request that you review this with the view to allowing this well to
continue to function as it was drilled.
Sincerely,
Benj amin�S chiller, PE
907 Water Well Services
22570 Needels Loop
Chugiak, AK 99567
(907)230-1868
907waterwells@gmail.com
INVOICE
BILL TO
Mike Jones Kristen Smith
14538 Don Circle
Eagle River, Alaska 99577
INVOICE #2002
DATE 05/14/2021
DUE DATE 05/14/2021
TERMS Due on receipt
DESCRIPTION QTY RATE AMOUNT
ServicesSystem dilution, Water sample via bailer under well camera video 1 550.00 550.00
System came back with high nitrates over 10. System was run for days to ensure
non stagnant setup. during sample the well produced more than the well pump could evacuate so a 2" suction pump was used with a secondary line down hole to reduce water level. a sample was pulled from end of casing under video
monitoring and sent to the lab. results came back with 11.6. after reviewing the drill log from the state and the original from M-W Drilling. It is found that the well was drilled. Beyond where casing ended no more water was found so it was for
the purpose of water storage for pumping stability. We find no risk of cross contamination as there are no other water producing zones beyond this point. Disrupting any of the current sources would ultimately end production causing the
well to be rendered useless.
1.5% interest per month on all unpaid balances.BALANCE DUE $550.00
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904
On‐Site Water and Wastewater Section Fax: 343‐7997
www.muni.org/onsite
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Nitrate Advisory
Certificate of On‐Site Systems Approval # OSC211187
Subdivision: Lake Ridge Terrace, Block: 11, Lot: 11
A water sample revealed a nitrate concentration of 12.0 milligrams per liter (mg/L).
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. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. 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
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a medi a 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.
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904
On‐Site Water and Wastewater Section Fax: 343‐7997
www.muni.org/onsite
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Septic Tank Advisory
Certificate of On‐Site Systems Approval # OSC211187
Subdivision: Lake Ridge Terrace Block:11, Lot: 11
The septic tank for this property is 27 years old. The average life for a steel septic
tank is 20 years. Typical replacement costs range from $7,000 to $11,000.
This advisory must be attached to all copies of the subject Certificate of On‐Site
Systems Approval.
This is an example of what the metal of a 30 year old steel tank MAY look like.
MICHAEL J. HORNE
LS-5318
ASBUILT SURVEY OF:
SCALE:
GRID No:
WORK ORDER No.
DRAWN:CHECKED:
DATE:
FB BOOK/PAGE:
May 5, 2021 30'
MEJLA NW0553 154/40
Lot 11, Block 11, Lake Ridge Terrace
Subdivision, Plat No. P-549
Eagle River, AlaskaSERVINGALASKASI
N
CE1982EXCLUSION NOTES: It is the owners responsibility to determine
the existence of any easements, covenants, or restrictions which
do not appear on the Plat used for this survey. NOTE: Under no
circumstances should any data hereon be used for construction
or for the establishing of property lines.
SURVEY CERTIFICATION: FARPOINT has conducted a physical
survey of the subject property, the improvements situated
thereon are within the property lines as shown.
PREPARED FOR:
RE/MAX
3350 Midtown Plaza
Anchorage, AK 99503
1.Bearings and distances are record per referenced plat unless otherwise noted.
2.Sufficient boundary evidence was recovered to establish the subject parcel on the ground. Not all
controlling evidence is shown hereon.
3.Only those easements shown on the face of Plat No. P-549 are shown hereon.
ZONING:
CE-R-2A-SL
Fnd Monument
Power Pole
Gas Meter
Electric Meter
Water Well
Septic Vent
Storm Drain
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION '
825 L Street - Anchorage, Alaska 99501
i ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
I. PR,OPERTYOWNER I PHONE
MAI LING ADDRESS
PROPERTY RES:DENT'Hf different'from above)
PHONE
2, BUYE~
MAI LI~ADDR ESS
MAI LING ~:~DRESS ' ~) / ~
4. REAL~R/~GENT ~ PHONE
MAI LI NO~DDR ESS
5. LEGAL DESCRIPTION
STREE.~T~OCATION
6. TYPE OF RESIDENCE j NUMBER OF BEDROOMS
[] One [] Four
[] SINGLE FAMILY E~] Two ~ Five
,~ MULTIPLE FAMILY [] Three [] Six
[] Other
7. WATER SUPPLY
~ INDIVIDUAL* *ATTACH WELL LOG. A well [o§ is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
~,~ INDIVIDUAL/ON-SITE** **If individual/on-site, give installation date~
If system is over two (2) years old an adequacy test is required
[] PUBLIC UTI LITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TiME TIME TIME
DATE- DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROO,.~IS
/
[] SINGLE FAMILY [] ONE [] THREE I~ 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
iNEWAG E DISPOSAL SYSTEM PERMIT NUMBER
DIVIDUAL/ON -SITE . DATE INSTALLED
Connection Verified INSTALLER
Size: I?~) IfTanl~i~J~homemade SOIL.SRATING
TOTAL ABSORPTION AR EA MATERIAL ¢"~ ,"~-~ ~t _.¢'~, t~L ~ot
4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Neares Lin
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
APPROVED FOR BE OMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
72-010 (Rev. 3/78)
DEPT. OF ENVIRONMENTAL CONSERVATION
SOUTItCE~/TRAL REOIO/VAL OFFICE