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HomeMy WebLinkAboutLAKEWOOD HILLS LT 11B Municipality of Anchorage Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: SW980444 PID Number: 01 5-~1~-n~ Name: Riz and Donna Bigelow Wastewater System: D New ~Upgrade Addre~s:10600 Hillside Dr. Anch., AK ABSORPTION FIELD NO. of ~rooms: Phone: 2 7 6--5 0 0 4 Three Q Deep Trenc~ ~Shallow Trench ~ Bed O Mound ~ Other Total ~ept~ from original gra~e: LEGAL DESCRIPTION so~, .aung: .6 G~O/~m Lot; 11 B slock: _ _ Sub~ivisioo:. = De~{n {o pipe boltom/rom ongrnalgrace: Gravel dept~ ~eneath pipe ~aKewoo~ H~s 2.5 Township; I Range: S~don: Fill addea aDove original grade: Gravel length: 2' - 3' NumDer of lin~: 0~ be~ I~n~ WELL: ~xls~i~9 : . G~vel ~ium: 5 Cl~ili~lmn (Private. A,B,C): Total Oe~m: C~ To: Total a~sor~tion area: Pl~e mate~al: Private ~t. R. 750 s~t. ASTM D3:0'34 PVC m. Northstar Rar~hmnv 11 /25-28/98 Yield: GPM Pure, Se[at: :- ~,.~"g~[i¢'*~o'"Gr°""~:' ~,. er~ANK.Existing:._ SEPARATION DISTANCES $ s,p.~ a Holding S S.T.E.P. , To Seplic Ab~tion Li~ Helding Publi~Pnvate Manufacturec Ca~aci~ in gallone: It Mamrial: Num0er of ~mpa~ments: wel~ >100 >100' ~/A ~/A ~/A Conc~e[e One s.,~. J>~oo'>~oo' ~/A ~/A I~/A LIFT STATION WaterI ~ Lot >5' >10' N/A IN/A ~N/A Size in ga,Ions: Manufacturer: Line ! I Foundation > 5 ~ > 1 0 ~ N/A N/A N/A "Pump on" level ¢[: "Pump off" level at: Hig~ wamr alarm a~: Cu~ain None Dn Lot ~um~Make &Modal ~ El~ncal Insertions ¢edo~ ~y: Orain BENCH MARK Remarks: Diverter Valve and n~w ~rench LOc~li~n an~ Oescriplion: CoQcrete Porch Stoop placed under this permit. Existin) tank inspected and found suitable  A~um~ ~ation: ~o= co~[~ued use. 100.0 Inspections peflormed by: Anderson Eng. Dates: 1st 11/25/98 Department of Health and Human Se~ices approval Review and app ov.d /Z' J Municipality of Anchorage Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, AK 99519-6650 343-4744 On-Site Wastewater Disposal System or Well Inspection Report Permit Number SW980444 PID No. 015-312-03 . A B DV 25.5 71.3 C1 30.3 73.2 M1 37.6 75.9 C2 102.8 124.5 M2104 0 125.3 1,000 gal. M2' C2 . septic tank · TH C1 . . ""' ....... , ~.,,' ~^ · ' I Diverter 75' non~ X 5' Wide., ' M~. Ig~J,X- k-4'-~f~ ce tiye Depth "' I v~v~ kbsorption Trench ~ 25~ X 35' I Ab$. Be~t I 3 BR house· Parking Area/ Driw~way ! scale: l" = 30' Municipality 'of Anchorage Page 3 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, AK 99519-6650 343-4744 On-Site Wastewater Disposal System or Well Inspection Report Permit Number SW980444 PID No. 015-312-03 94.9 To Septic Tank 9' Geotextile Fabr Rock 89 86 75' NOTE: Existing Line Intercepted After Double Post Tank Cleanouts. New Diversion Valve and New Absorption Trench Constructed Under This Permit. PROFILE AS B ILT HORIZONTAL SCALE 1' = ~A~ ~ ~ NO VERTICAL SCALE ~~~ 688-3199 C ~, "' ' .... '"' ~'-"~ ADDR ......................................................................... ;;~,-~ ~ ~' ~ ~ i~ :GA~. PER HR, ; . ~. . ~ ~.~ DATE-~ARnD,...-.~;3~.~. ............................................................. ;~IC~~'';' : "~;,',~. 0g'6'~i~ ~ 53 2~ ~'a~ DA~ - ENDED ..... ~.~}- ...... ' .......................................... -.'~i;'; KIND OF CAS~G .~.~ ................. ~ 3 ~oln S~ b Uil " FROM ............... .. 7 ~erburde~ ' ' ".'~ :" FROM ~.~.TO~ I .rs .......... " ...... _~..~ ' 7 '~ ~' ,~ llS~r sand & Gravel ;:'-'~ ;' 'FROM ~.~0 115 ~ ,n 117~ ~oulder /i~;;; ' FRo~..:. ~;;;~J.:..~.~;;~L~"~'~' ~ ...................... ~.'~-. ' 237-- Sand t Gravel ~ F~n~ 230 ~ l · ' ..................... FROM ....... ~.}.~...... ~. TO 2~0~ Rock ~ FROM --~ ..... ~. TO ~', ---~. -- '-' ~ " ~ROM .... ~. TO .,.~,~ ~ .... FROM ...... _:~ ~.TO ..... ~ ..... · ...... ~ MI~INFO~A~ION: No wurrnn~y or no varrantie~ ~plicd. 9e~ puap a~ 230 iC, ~ ~'...~ MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Nov 16, 1998 Expiration Date: Nov 16, 1999 Permit Number: SW980444 Legal Description: LAKEWOOD HILLS LT 11B Design Engineer: 0014 Anderson Engineering Owner Name: C. G. & DONNA~d~F~t;;;~ (~.L~\ ~,~,--~ Owner Address: 11562 DISCOVERY HEIGHTS CIRCLE ANCHORAGE , AK 99515-2719 Parcel ID: 015-312-03 Site Address: 010600 HILLSIDE DR Lot Size: 46200 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must 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 engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Date: Date://--/~ -- ~'~/ MEMORANDUM DATE: November 16, 1998 TO: Dan Roth FROM: Mike Anderson, P.E. ?ltl ~M~ RECEIVED t OV I co 1998 Municipali , O°lot' Health ~Yb~,f,~'~enoraao ,uman ServiCes SUBJECT: Lot 1 lB, Lakewood Hills Subdivision Septic System Upgrade Permit We have revised the permit application and design of the absorption trench for Lot 1 lB, Lakewood Hills to a 5' wide shallow trench with 4' effective depth. This will provide a safety factor in the event groundwater appears in future years. At the time of our test no groundwater was found nor has any been noted in the monitor tube since then. We do acknowledge, however, that LeRoy Reid performed a test on the property several years ago that did show the presence of groundwater at 8' below the surface. Please review the revised application and, if possible, issue the permit as soon as possible. Thank you. November 16, 1998 Municipality of Anchorage Department of Heath & Human Services 825 "L" Street Anchorage, AK 99502-0650 Subject: Lot 11B, Lakewood Hills Subdivision Septic System Design Impacts to Adjacent Properties Dear Onsite Services Engineer: The existing absorption bed on Lot 11B, Lakewood Hills Subdivision is currently in a state of failure and must be replaced. We are therefore requesting a permit to construct a new absorption trench on the lot to serve the house. The existing 1,000 gallon concrete septic tank has been uncovered and inspected and is suitable for continued use. The attached site plan and backup documentation describe the proposed system and show the location of the new trench. The testhole placed on the property revealed silty sands and gravels which percolated at a rate between 18 and 25 minutes per inch. Groundwater was not encountered during the excavation nor was any noted during the monitoring period. A testhole on the property completed at least 12 years ago by LeRoy Reid revealed water at 8'. We have therefore designed a 5' wide absorption trench with 4' of gravel beneath the distribution line. The trench will be 75' long with a total depth from original grade of 6.5'. The ground surface of the lot slopes gradually from east to west at grades between 0% and 5%. The absorption trench will be placed across the slope near the west property line. A flow diverter valve will be installed and the existing absorption bed plumbed into the line for use at a future date if necessary. Lot 11B, Hillside Park November 16, 1998 Page Two If the system is constructed as designed the following statements apply: The system, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on reserved space, either surface or subsurface, on any lots located in the area. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, Michael E. Anderson, P.E. Attachments se-pC:Lc Lc 20 AREA MAP SCALE 1" = 100' 'Road B 1,000 gal. . . , - . . T D~vert( r W~de X 4 Effective - ~i. Existing 25' X 35' Absorption Bea >(To Remain)' Park. ing.. Area/ . Driw .~way scale: 1" = 30' LOT 11B, LAKEWOOD HILLS DESIGN FACTORS: SYSTEM REQUIREMENTS: Three Bedroom Home Perc. Rate: 20 - 30 Min./Inch Application Rate: .6 GPD/SF 5' Wide Trench System 1,000 Gal. Sep. Tank (Exist.) 4' Drainfield Rock 3 Bedrooms X 150 GPD / .6 GPD/SF = 750 SF of Absorption Area 750 SF/5 LF Wide X .5 Red. Factor = 75 LF Trench Length Therefore: Construct a .5' Wide Absorption Lateral 75' in Length with 4' of Drainfield Distribution Pipe in Trench Placed. at 2.5' Surface. Trench System With One Rock Beneath the Lateral. Below the Original Ground Natural Backfill Geotextile Fabric 4" Perforated PVC (Slots Down Drainfield Rock NOTE: TYPICAL 5' WIDE TRENCH SECTION Grade Area Over Trench to Drain Away. Minimum 3' of Cover over Septic System. Maintain 10' Separation From Lot Line. PERFORMED FOR: LEGAL DESCRIPTION: LT liB, Lakewood ~,1 ls S/DTownship, Range; Section: 3 6 11 I2 13 14 15 16 17 18 19 SLOPE SITE PLAN WAS GROUND WATER ti ENCOUNTERED? S L IF YES. AT WHAT 0 DEPTH? P E Gro~ Ne~ D~[h .to Net Reading D~e Time 'l'ime W~ PERCOLATION RATE '~ Immute~mc~) PERC HOLE DIAMETER __ PT^ND ~,.~' rr PERFORMED B¥;~ ! ~ ~TIFY T .H~,T~T,H~ IS/~TE.~ T WA~ PERFORMF-D IN PERFORMED FOR:. Municipality of Anchorage DEPA.RZ.MENT OF HEALTH & HUMAN SERVICES 825 L Street, Anchorage, Alasl~a 99502-0650 sOILS LOG -- P£RCOLATION TEST DATE PERFORMED: LEGAL DESCRIPTION: LT llB, Lake~ood E~.11s S/I)Townst~ip, Range; Section: 1 2 3 .~4 8 9 10 11 12 13 14 15 16 17 18. COMMENTS WAS GROUND WATER ENCOUNTERED? SLOPE SITE PLAN IF YES, AT WHAT DEPTH? Gro~ N~t Depth .to Net Re~dlng Da~e Time Time Water Dro0 I~;11 ' " '/.. "~ I~:~ "' ~',~ PERCOLATION RATE {m]nute~mcl~) PERC HOLE DIAMETER FTAND F / / PERFORMED BY:,~~--' ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: LOT 11B, LAKEWOOD HILLS SUBDIVISION GENERAL: 1. The scope of this project includes the construction of a new 75' long X 5' wide X4' effective depth absorption trench at the location shown on the site plan. A new diverter valve must also be placed to tie in the existing absorption bed for possible future use. The existing 1,000 gallon concrete septic tank is suitable for continued use. 2. Construction shall be in accordance with the approved site plan, design drawings, Municipal Permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The Contractor shall be responsible for obtaining all underground utility locates and for the layout of the septic system and verification of the location of all lot lines. 4. Unless specifically agreed otherwise, the contractor shall be responsible for final grading areas subsequently depressed from soil settling. Property owner shall be responsible 'for revegetation of affected areas unless specifically agreed otherwise. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Department of Health and Human Services for system installations. Owners installing their own systems must receive prior approval from D.H.H.S. before beginning system installation. SEPTIC TANK INSTALLATION The existing septic tank has been uncovered and inspected and found to be suitable for continued use. No work is anticipated on the septic tank at this time. Lot 11B, Lakewood Hills November 10, 1998 Page Two 2. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 3. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 4. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial insulation. 6. A foundation cleanout shall be installed one to four feet from the building foundation. Two cleanouts are required between the tank and the drainfield. 7. Final grading over the tank shall be such that a positive slope exists away from the septic tank. DRAINFIELD CONSTRUCTION: 1. The drainfield shall be constructed to the dimensions shown on the design. The bottom of the trench shall be within 2" of level. 2. Distribution piping must be placed level with perforations down atop a level bed of drainfield rock. Rock should then be placed over the pipe to provide a minimum of 2" of cover. 3. A silt barrier or geotextile fabric must be placed between the drainfield rock and the natural soil backfill. 4. Monitor tubes must be 4" in diameter and installed at the locations shown on the design. The portion below ground must be perforated. Lot 11B, Lakewood Hills November 10, 1998 Page Three 5. Contractor shall verify the septic tank and drainfield are a minimum 100' away from any private water wells in the area, 150' from a Class "C" Well or 200' from any community well. 6. Direct bury insulation must be placed over the distribution system if less than 3' of backfill depth is available. Finish grade over the trench must be mounded to prevent settlement or depressions. 7. Grade area surrounding the absorption trenches to drain away. 8. A minimum 2' of accepting soil is required below the drainfield rock for a 5' wide trench. Contractor shall verify this condition prior to placement of the rock. All pockets of unacceptable materials must be removed and replaced. MATERIAL SPECIFICATIONS: 1. Septic tanks must be constructed by a Municipally approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662 or A.B.S. (perforated and solid). 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Co. Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted watertight couplings (Caulder, Fernco, or equal). with Lot 11B, Lakewood Hills November 10, 1998 Page Four 5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed between the final drain rock layer and the native soil layer. 6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing the #200 sieve. INSPECTIONS: A minimum of two inspections are required by Municipal Ordinance. These inspections must be conducted under the supervision of aprofessional engineer registered in the State of Alaska. The first inspection must be conducted after the excavation of trenches, beds or pits and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled. The second inspection must be conducted after the placement of the geotextile fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No backfill should be in place at the time of inspection. Contractor shall provide a copy of all field survey layout and construction notes for use in preparing the certified as-built of the completed system. 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 NAME PHONE ~' Jl~:~ E~NEW ~q~ ~ J~UPGRADE MAILING ADDRESS LEGAL DESCRIPTION /- II ~6 LOCATION I w~.H _Or DISTANCE TO: ~ ~.~ !- :~ Manufacturer  Liq. capacity in gallons ~ DISTANCE TO: IWellIF HOMEMADE: ~O Z ~ Manufacturer ~ I ]Well mu-I= I DISTANCE TO: _~u-Z INo. oflines /~ ILength of.~ac~hline I'-~ Top of tile tZnish grande . "~ ,~ I- I Type of crib Crib diameter ~' DISTANCE TO: Well ~ I¢lass Depth ~ DISTANCE TO: Building foundation Inside length Dwelling Foundation Total length of I~'nes //~ ~ Mat eri'al'be n ea~fl tile Depth Crib depth Building foundation Driller Sewer line OTHER PiPE MATERIALS TEST~ SO,L INSTALLER REMARKS Dwelling Material W dth NO. OF BEDROOMS PERMIT NO. No. of compartments Liquid depth PERMIT NO. JMaterial Liquid capacity in gallons P~-RMIT NO. Trench width ~, ~ /~t inches g inches Distance between lines To ta I¢c~e~.,~o r p t i o n area PERMIT NO, Total effective absorption area Nearest lot line Distance to lot line PERMIT NO. Sept c tank Absorption area(s) APPROVED DATE LEGAL F'ERMI'!" NO. '~ DEF'RRTMENT OF' HERLTH Fff.,![:, EN'v'IF'.ONMEN't'F~,L F'ROTECT!OI',I 825 '"L'" STF::EET., RNCHOF.:FIGE., Fi}:::. 9950:t 26'4.--4728 < 8i061-':L=: ) FIF:'PL~ZCF~NT I_OCFtTION ~ EGFIL GENE F'OLLET H ]' L._'.:. I [:,E [:,R I VE L ±-I_B LFtKEHO0[:, HILL"_'-.'; '=;LIE: E:O;:-:; iO 046 LOT SIZE T'¢PE OF SOIL HE,=,_RFIIr-IN '=;'.r'STEM IS: DF.:RINFIEL[:, 3:44-6±0G 4C~C~00 '~LT!IJRF.'.E' FEET '_=,OIL RATING ,::S..i~ FT,.-"E:F.:)= f83 THE RE~;fl. JIRED SIZE UF THE bUiL. ME,_,-_IF..[ TIUN z,'~_,TE.I! I_,. TFIE LENGTH DIMENSION IS THE LENGTH (IN FEET.'., OF THE TRENCH OR DRRINFIEL_D. THE [:,EF'TH OF FI TRENCFI OR PIT IS THE DISTRNCE BETI,.!EEN THE SURFRC:E OF THE GROLIND RN[:, THE BOTTOM OF THE ENCRVR"rION (IN FEET::,. TNE QRRVEL. DEPTN ZS THE MINIMUM DEPTH OF GRRVEL BETklEEN THE OUTFRLL PIPE RND TNE BOTTOM OF THE EXCRVRTZON (IN FEET). F'ERMIT RF'F'LICRNT HH::, TFIE F,E=,FLNz, IE, t_I~ .r TO INFORM THIS DEF'FIR]"MENT [:,URING THE INSTRLLRTI iN !NSPECTIANS OF RN~r' WELLS FI[:,.TRF:ENT 'TO THIS PROPEF.:T'T' RND THE _ NUMBER 1iF RESIDENCES TFIRT 'FFIE I...IELL W. ILL .=,Efi BRCKF'ILLING r]F RNa" .=T=-TEI1 ITHAU'f' FINRL TN':-:F'Fr':TION RND FiPPRO',,,'RL B'¢ THIS [:,EPRRTMENT HILL BE :5_E ]'EC T TO PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RN"r' ON-SITE SEWRGE DISF'OSFIL SYSTEM IS leo FEET FOR R PR!VRTE WELL OR :1.50 TO 200 FEET FROM R PUBLIC 1.4ELL DEPEN[:'ING UPON ]'HE TYPE OF PUBLIC WELL. MINIML!M DISTRNCE FROM R PRI'¢RTE HELL ]"0 R PRIVRTE SEWER LINE IS: 25 FEET RND TO R COMMUNIT'T' SEI.,.IER LINE IS 75 FEET. OTHER REQUIREMENTS Mf~'¢ RF'PLY. SF'ECIFICFqTIONS .FIND, CONSTRUCTION DIRGRRMS 8F.':E R',,,'RILRBLE TO INSURE: PROPER INSTRLLRTION. i C:ERTIFY ]"HR'r ..'1_: I RM FRMILIBR WITH THE REQUIREMENTS FOR ON-SITE SEHERS FIND WELLS RS SET FORTFI B'¢ THE MLINICIPFtLIT¥ OF 8NCHOR~GE. 2: I WILL INSTFILL THE SYSTEM IN FqCC:ORDRNCE HITH THE CODES. 3: I UNDERSTRN[:, THRT THE ON-SITE SEHER B'¢S]'EM MR'r' REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLU[:,E MORE THflN 3 BEDROOMS. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG-- PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: ~ ~:~/~' LEGAL DESCR, T,ON: /- o DATE PERFORMED: SLOPE SITE PLAN 10 11 12 13- 14- 15- 16- 17 18 19 2O PERFORMED BY: ]'- }/o~'J WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop ,f /y~ /? Io '-/. b ~- 0,o~. ? /p ?: 1o ~, 3~ v, 12. ~ /,~: y3-- Io q, PERCOLATION RATE / ¢ (minutes/inch) TEST RUN BETWEEN ~- FT AND ~,~ FT OAAB HD I ~ GREATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-251 ! INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME LOCATION SEPTIC TANK: DISTANCE FROM WELL LIQUID CAPACITY SOd GALLONS. MAILING '"" ~ ADDRESS '~"/' y ~ /~, rg~e.~..,~ PHONE MATERIAL ~'~r/~ NUMBER OF ~ COMPARTMENTS / ~/~$~ /~ UQUJD ~NS~gE LE~OT~ ~NS~E W~D~H D~P~ SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS LINING MATERIAL NEAREST LOT LINE OUTSIDE DIAMETER ~ OR WIDTH J"/'//~ DISTANCE FROM WELL / TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) LENGTH / , , DEPTH BUILDING FOUNDATION .z ~ F SQ. E~. TILE DRAIN FIELD: WELL: tYPE J~k/o t /,~' ~'~-~'-') DEPTH FOUNDATION ~~ DISTANCE BETW~ TRENCH WIDTH ENGTH OF EACH LINE ~: DEPTH OF FILTER MATERIAL BENEATH TILE. TOTAL LENGTH OF LINES IN. TOTAL EFFECTIVE IN. ABOVE TILE t WATER SAMPLE ~'%" O , NEAREST OTHER · CESSPOOL ~ , SOURCES__ NEAREST LOT LINE , SEWER LINE DISTANCE FROM ., BUILDING FOUNDATION SEPTIC .~,"~ / SEEPAGE , TANK , SYSTEM DISTANCES: DIAGRAM OF SYSTEM DATE GAAB-HD-2 GREATEI~ ANCHORAGE AREA HEALTH DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 5'.00 ~OROUGH Ca,eNo. 279-2511 SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT NAME OF APPLICANT ~,,~f.;/a'~,&"/V~",/'~. RESIDENCE ADDRESS '~.// ,,,~ ,..~,,)z,,,¢ ,Z~/F. LEGAL DESCRIPTION APPLICATION TO INSTALL: SEPTIC TANK ~ , SEEPAGE PiT. ~ ,DRAIN FIELD TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH ~TEST RESULTS MAILING ADDRESS ---~-/~'/'¢7' LOCATION OF INSTALLATION ,~..~,'-~- ~/~' ,OTHER TO BE INSTALLED BY ~Z~,////I] ANTICIPATED DATE OF COMPLETION BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT THIS IS TO SERVE AS ,~' /~_.~Z~-'~'- , PERMIT TO INSTALL A '=~'~¢~'~--~'~=" ~~ AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED -- ~ /~'~-ZT/2,~, /'¢0'~?- · SEPTIC TANK SIZE //~/~ TYPF ~¢~/O/e'~-'&-/'~'"SEEPAGE AREA TYPE DIAGRAM OF SYSTEM DISTANCES: Health mriW I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No, 28-68 and that the above described system is in accordance with said code. ]REATER ANCHORAGE AREA BOROUC'H HEALTH DEPA~:T:'~ENT 327 EAGLE STREET ANCHORAGE, ALASKA 99501 p~r~oPmed For Eugene M. Pollet Date Performed 10-17-69 Legal Desc~,iptzon: Lot~z~-i~, ~ubd~vzsmon Lakewood Subdivisio, This ~' ~ Repomts a: S~Log ~--YP~c'~'~ Te$1 De?th F .-- Soil Charae'teris~ics ! ~T~'~so,pr- · Location Sketch Depth To H20 Net Drop Drain Field ALASKA GEOLOGICAL CONSULTANTS October 27, i969 Mr. Eugene M. Poller 514 West Fireweed Lane Anchorage, Alaska 99503 Re: Soil percolation characteristics for property located in N-~- of Lot 11, Lakewood Subdivision Dear Mr o Poller: This letter is to certify that an investigation of the soil percolation characteristics has been conducted on the above-mentioned property. It was determined at the time of the investigation that a percolation test was not necessary and the information enclosed herein reports the soil characteristics for the proposed sewer system. The location of the septic tank and cesspool excavation are shown on %he attached Greater Anchorage Area Borough Health Depa?tment form. This investigation was made in accordance with the Greater Anchorage Area, Borough Health Department specifications. Respcc[fully subnfitted, .ALASKA GEOLOGICAL C.ONSULTANTS "James .A. Hmnilton ~AH:js E llc o cc: Greater Anchorage Area Borottgh Health Department 825 L. S'T'REIET~, At'.ICHORAGE, Al';:: 995C):1 2.64'""4720 t.")":.~ /t',?S~ lC) ~ CONTACT' F:'HL' NE: L.EGAL. DESCF;'.:[ F",' SUBD I V I S :I:ON: LAKEWOOD H I L.LS L.O]': :[ :lB BLOCI<: N/A SEC]' ]: ON: J. 4 TOWNSH ]: F': 12N RANG!E: c, ~- .~ .,, :I.. ,..* ...... I .... 2.5A (SQ~ F:'T,, OR ACRES) cer't i f'y ]: ~:tiil {'¢~d~iJ.].J.;~tl- t*¢:i.'Lh the rec:iuir(~)merrL~4~: {or on-site s{c~ers and wells as set ~'c, rth by the Nun:i. cipal:i, ty o{' Ar'ichor-age (MO~) and the S'Late c)¢ Alaska, ]: w:i. ll ins'Lai], the system in accopdanc::e w~'t:.h all MOA codes and reguIat:i.~n~ and in cc~ml:~liance wi'lib 'Lhe desj. Dn triter, ia o{' this ....... [ t...¢ ....... [ ~=~dk,~,:r~= ~..~.~ ~].]. ,lt..¢,.-~ ~nc.~ ~:~L,~ o.[ A.!.aska r'equ].pement:.s {or the set back d is'Lances {' r'om any ex :i.s{ ing ~.~/~ was'Lewat~:~.r (::lisl:]osa:l. system or' pub ]. ic se,,,er age sy~~~ c:,,~¢~, a,:::ent. ,:,r near by :l. c:,',:... ....... ) ~ .................. D A F E:. ~', MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 01 5-31 2-03 HAA # ~.~ ~ %,'(':..i_\ '-~ '~ 1. GENERAL INFORMATION Complete legal description Lot 11B, Lakewood [{ills Subdivision Location (site address or directions) 10600 Hillside Drive Property owner Mailing address Lending agency Mailin_g address Agent Address C. G. Bigelow Day phone 276-5004 10600 Hillside Drive Anchorage, AK 99516 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Three XXX Individual well Community well Public water 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. 11911 Front MOA~21 STATEMENT OF INSPECTION BY ENGINEER As certified by myseal 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, lfurtherverifythatbased 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 alt Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Anderson Enqineerinq Address P.O. Box 240773 Anchorage, AK Engineer's signature Phone 99524 522-7773 Date 1 2/1 /98 DHHS SIGNATURE / Approved for ~r~(:~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: 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. 72-3'25 (Rev. 1/91) Back MOA ~21 Municipality of Anchorage J~ E C E I V ~~ DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division D£C 1 ]99 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907~z~-i~7,.4.4 ~, . . p?,lity of Anchorage uept. Health & Human Services Health Authority Approval Checklist Legal Description: Lot I 1 B: f,akc_w~n¢, f4-i 11 ~ Parcel I.D.: 01 5-31 2-03 A. WELL DATA Well type Pr±vate Log present (Y/N) Total depth 2 4 0 ' Sanitary seal (Y/N) Date of test Static water level Y IfA, B, or C, attach ADEC letter. ADEC water system number 7/30/86 Casing height (above ground) Wires properly protected (Y/N) Date completed Cased to 237 ' FROM WELL LOG 7/30/86 200' 10 Well production WATER SAMPLE RESULTS: Coliform 0 Date of sample: 10/12/98 B. SEPTIC/HOLDING TANK DATA >2' Y AT INSPECTION 10/.12/98 176' g.p.m. 3,9 g.p.m. Nitrate 5.7 mg/L Other bacteria Collected by: T. Kimbrouqh Date installed 1 0 / 30 / 69 Tank size 1: o 0 o Foundation cleanout (Y/N) N Depression (Y/N) Date of Pumping .. k :. :;'-'~2;¢,, Pumper C. ABSORPTION FIELD DATA Date installed 11/2~:/~8-''~' ., "¢~oil rating (g.p.d./ff~ or ff~d~) ,6 Length 75' Effective absorpbon area 75~0 Date of adeqUacytestE~'~Vdb Fluid depth in abso~tion field before test (inS; Fluid depth (ins) Minutes later:. Peroxide treatment (past 12 months) ~) Numberof Compartments 1 Cleanouts (Y/N) ¥ Gravel thickness below pipe High water alarm (Y/N) N System type ~nch 4 ' Total depth 6.5 ' Monitoring Tube present (Y/N). Y Depression over field (Y/N) N Results (Pass/Fail) pR .~.~ For 3 bedrooms Immediately after gal. water added (in.): Absorption rate = g.p.d. N If yes, give date 72-026 (Rev. 3/96)* LIFT STATION - None Date installed Manhole/Access (Y/N) High water alarm level at* on Lot Cycles tested SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot > 100 ' >100' Absorption field on lot Public sewer main N/A Sewer/septic service line > 100 ' On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station N / A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation > 5 ' Property line > 5 ' Water main/service line > 25 ' Surface water/drainage > 1 0 0 ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water Curtain drain >100' >100' Absorption field > 5 ' Wells on adjacent lots > 1 0 0 ' 0 ' Building foundation > 10 ' Water main/service line > 25 ' 100 ' Driveway, parking/vehicle storage area > 50 ~ None on Lot Wells on adjacent lots >100' F. EN(~INEER'S CERTIFICATION I certify that I have determined thru field inspections and re in conformance with MOA HAA guidelines in effect on this date. Engineer's Name Date Michael. R- And~r~on: 11/29/98 HAA Fee $ ~,C') C~. Date of Payment Receipt Number (© 72-026 (Rev, 3/96)* are Waiver Fee $ Date of Payment Receipt Number 0CT-15-{}8 20:4{} FRObt-CTE ENVIEONMENT^L ~tK C T&E E nvimnmen~lS err lees Inc. CT&I~ Ref,# 985948007 Client Name Proj ec~ Name/s CHeat Sample Mat~ D~in$ Wa~er Ord~ By PW$~ 0 $~pleRemark~: Ni~rage-N 5,70 un~ ts O.IOO ril~/L Client Printed Date/Time 10t15/98 1;5:15 Collected Date/Time 10/12198 15:30 Received Date/Time 10/12/98 16:45 Teelmic$1 Director: Stephen C. Ede Releazed B~ Peep AnaLysis EPA 3OO.O 10 r~laX 10/1)19S lO/lSygS ~CP RECF_.IYED DEC 199 ) iVJumC~pal~t¥ ul ~oc)~orag. e Dept. Health a Human gerv~ces OOT?l?g8 20:50 FROM-CTE ENVIRONMENTAL 5815301 T-039 P.12/12 F-125 CT&E Environmental Services Inc. Laboratory Division ~~,~~'arl~'~ar~,am,amra,'fa~e,arara,~ar~a,a-ar~,,e'-, 200 W. Pmmr Drinking Water Analysis Report for Total Coliform BacteriaT,,,:^"*"*'a"°' t~D INSTRUCTIONS ON REYERS£ SIDE B£ffOt~ COI~.LECTING ~AMP~E F~x: (~7) 561-~30Y_ MUST BE COMP/ETE-D'BY WnT~R SUPPLIER T~ BE COMPLETED BY L~BO~ORY El PUBLIC WATER SYSTEM LID. ~. PRIVATE WATER SYSTEM ~- Send Resutto m Seod Invoice Analysis shows zh~s Water SAMPLE w be' Satisfactory Unsatisfactory Cl Sample over 30 hoars old, resuks may be unre}iable Sample too tong in ~ranslt; sample should not be ov~ 48 hours old at exummation new staple vm spemal ~liveG marl. AnalyllCal Method: ~g'..Mcmbrane Filter [3 HMO-MUG · Number of colomea(lO0 mi- SAMPLE DATE: ~ontl/ SAMPLE TYPE' ~ Routine [] Repeat Sample (for routine sample with Jab re[ no. ) Cl Special Purpose SAMPLE LOCATXON Day Year O Treat:d Water [] Uuweated Water Comments. Time Collected Collected By S85848 Client notified of unsatisfactory results: Phoned ~pu~e wltl~ Da~: T, me BACTERIOLOGICAL WATER ANALYSIS RECORD BCB £. Coil ?il MMO~MUG liquid: T~al Coliform Membrane Filmr: Direct Count V~rifieafion: LTB Fecal Coliform Confirmation Repo~d By COLIFIRM C°i°nle~/lO0 mI R~E~.rE/[~.F¢~.., Coliform/lO0 mi Muuic;pah~y ~i A,~cnorage Time ...../~ h~ept. Health & Human Semices ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA. ILLINOIS. MARYLAND, MICHIGAN, MISSOURI. NEW JERSEY, OHIO. wEST VIRGINIA .~ NORTHLAND PUMPING SERVICE '11301 WILLENE DR. · ANCHORAGE. AK 99516-1362 (907) 3~4-7146 Invoice N~ 30 TOTAL ~.oo MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-BITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, townshi Location (address or directions) (b) Applicant Name Applicant Address (c) range) Telephone: Home"-::'~'~ -- ~'~ I ~' Business Applicant is (check one): Lending Institution [3; Owner/builder¢; Buyer []; Other [] (explain); (d) Lending ,nstitution/C~,'"~J'/~- (e) Real Estate Company and Agent Address Telephone Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family/~ Multi-Family Number of Bedrooms Other WATER SUPPLY Individual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite [] 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. Page 1 of 2 72-025 (11/84) ENGINEERING FIRM PROVIDINg, ~SPECTIONS, TESTS, FILE SEARCH, DA'~ .AND INFORMATION AS certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this'Heatth Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Date DHEP APPROVAL Approved for ,¢¢ Approved ~/¢g'_. Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 fl 1/841 NOR'I'HERN TESTING LABURATORIES, INC. 600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99701 907-479-3115 6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99518 907-349-8623 nking Water Analysis Report for Total Coliform Bacteria [] PUBLIC WATER SYSTEM I.D. # [] PRIVATE WATER SYSTEM NAME Mailing A,c~s ;~2 Ci~ State SAMPLE DATE: C.) .~ MO. SAMPLE TYPE: /[~ Routine [] Special Purpose 'LETED BY CLIENT /~ ~;>~'~ Phone ~' {~'ZT~O~-l Day ~¥ear "" Purchase Order No. ,~o~// Zip Code [] Treated Water [] Check Sample (for original contaminated sample with lab reference no. [] Untreated Water Sample Time No. Location Coll~'t~l I L~-z- II r5 Collected by Laboratory Ref. No. ~.~ ~c~-- ,4-4 o?os ~ hUG 1. '{; ~"~ 9 10 ,f , R~R L~BOR~TOR¥ USE ONI~¥ CASH CHARGE PREPAID TRANSMITIAL SPECIAL INSTRUCTIONS MAIL HOLD FDS PICKUP TO BE COMPLETED BY LABORATORY Received at: ~ Anch. [] Fbks. Date Received Time Received Urb Next Sample Due COMMENTS: SATISFACTORY ~'~ UNSATISFACTORY U RESAMPLE R OTHER BACTERIA OB TOO NUMEROUS TNTC TO COUNT Dire~t Verification Final Count LSB BGB Result* *N(e'~6~oliform Colonies per 100 mis. Date / ISAACS PUMPING SERVICE (Norm Tibbetts Owner) 62~.8 (~uinhagak Street ANCHORAGE, ALASKA 99507 Phone 563-3300 CUSTOMER'S ORDER NO. A~I claims and returned goods MUST be , MUNiCIPAU~/' OF ANCflORAO~ DE?T. OF HEALTH & · E~VIRONMENTAL pROTECTION t986' RECEIVED MUNICIPALITY OF ANCHORAGE (MOA, HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: WELL DATA .. N~o \ Well Classification .~..3.~ ~,./~q-'6 (. c,,dcc~ .] If A, B, C, D,E.C, Approved (Y/N) Well Log Present (Y/N) .~tI Date Completed Total Depth ~-/"(-~ Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot '7/-:~/o0 (-0 Depth of Grouting ¢.~//Ct Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) /o°'~-/:z~ ¢"~' ; On Adjoining Lots ~.~ To Nearest Edge of Absorption Field on Lot t'70¢'/'~''/; On Adjoining Lots To Nearest Public Sewer Line ,,.-,//4 To Nearest Public Sewer Cleanout/Manhole ,~-~/',4, To Nearest Sewer Service Line on Lot Water Sample Collected by ,,,Z.//~- K,~i~-'~,~/ -, ~'~ ;Date Water Sample Test Results ~m~ ~-~ Comments ~ ~A~ t~ ~m~ ~'~ * ~)~P--L- ....... B. SEPTIC/HOLDING TANK DATA Air-tight Caps (Y/N) / Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /,///4 Separation Distances from Septic/Holding Tank: No. of Compartments ck._? Foundation Cleanout (Y/N) Date Last Pumped ('~/,'¢/ ! / - ; for A',//~ Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line To Water Main/Service Line Course ~J/~ Comments To Building Foundation To Disposal Field /0 To Stream, Pond, Lake, or Major Drainage Page 1 of 2 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/B t/~l Width of Field ~-"~¢-%~ Square Feet of Absorption Area Depression over Field (Y/N) /V/ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well / To Building Foundation Lot ~.-%'7~ ~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design~ -.-'-.-'-.-'-.-'-.- Length of Field ,.~'~'~ Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) ~t'~/ / Date of Last Adequacy Test 17 To Property Line 2;o~- To Existing or Abandoned System on ; On Adjoining Lots ~'~'~C,P To Cutbank (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments ~ Dimensions Manhole/Access (Y/N) "Pump Off" Level at ~ing Cycles during Adequacy Test. Meets MOA *'~eck Permitted Bedroom Rating Against HAA Request ** Z certify that I hay.,9 che,.c~e,d.c~,e¢,f, ied,/~r conformed to all MOA and Sign ed ~.~'~ ¢;~*' ,~"~/' Receipt No. ate of Amount: $ HAA guidelines in effect on the date of this inspection. Page 2 of 2 72-026 (11/84) DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME / DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~viRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION JUN I98i Telephone 264-4720 DErEI~/E~ DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. PROP~ RESIDENT (If cliff,eh, f~ ~b~e)'x ' ' 2. BUYER k PHONE MAI LING ADDRESS 4. ~A~U~ / , PHO~ 5. LEGAL DESCRIPTION . STREET. LOCATION ' B. TYPE OF'RESIDENCE NUMBER' OF~BEDROOMS [] Other 8. SEWAGE DISPOSAL SYSTEM /~. INDIVIDUAL/ON-SITE~ [] PUBLIC UTILITY [] One [] Four "~J2-~ SI NG LE FAMILY [] Two [] Five [] MULTIPLE FAMILY ~ Three [] Six 7. WATER SUPPLY ~.~ '~.. INDIVIDUAL* ~- - "~ *ATTACH WELL LOG. A well Icg is required for all wells drilled COMMUNITY cA-. -~ ~0.q9 since June 1975. For wells drilled prior to that date. give well [] PUBLIC UTI LITY depth (attach)OD if a~ailable.) c~ jl/"c~ /Z-;~- r NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY / Connection Verified iNSTALLER []Septic Ta~nk or [] Holding Tank Size: ) ~(~) O If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS IJ~APPROVED FOR .-~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE