HomeMy WebLinkAboutBROADWATER HEIGHTS BLK 1 LT 3#050-081-19
Development 5ervices Department
Building Safety Division
On -Site Water & Wastewater Program
4700 5ragaw
19 r
P.C. Sax
ox 19560650
Mark Begich anc'.orage. AK 99519-6650
Mayor
(907)343-7904
Pump Installation Log
Well Drilling Permit Number: SSV_ Date of Issue:
Parcel Identification Number:
Legal Description
Property Owner Name & Address:
TVID bo"'AS HOBS
Pump Installation Date: /7/1 U
Pump Intake Depth Below Tap of Well Casing:38)
feet
Pump Manufacturer's Name: R.Q,d J7"K&
Pump Model: 10V'1�4 (- gsa
Pump Size I hp
Pitless Adapter Burial Depth: feet
Pitless Adapter DIanufacturer's Name:
Pitless Adapter Installer:
Well Disinfected Upon Completion? Yes Q No
Method of Disinfection:
CLQ PQ,(lefiS
Comments:
Pump Installer Name:
Rojdv, F Ntork
VonW\JerdA,
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
/_L_ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
0* ENVIRONMENTAL ENGINEERING DIVISION
0
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
�
T /,tl / �� Sr
PHO�N`E y
��7 '.276
NEW
❑UPGRADE
/,��-�
MAILINGADDRESS
LEGAL DESCRIPTION
.Svc v.
LOCATION
NO. OF BEDROOMS
DISTANCE TO:
Well�g ♦
/�G
Absorption area
/
Dwelling !
PERMIT N 1-1)�! fi
UY
22
V, �'? e
F- Z
IL
Manufacturer `
/�L —/c S
Material
No. of compartments
H
���C✓S� T 7
/. �. fY t S S
2
N
Liq. J�yC� gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
0 Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
.i(DZ
O Z F
Manufacturer
Material
Liquid capacity in gallons
o
w=
DISTANCE TO:
Well r
/LI
Foundation
.2 (c'
Nearest lot line
�� 019
PERMIT N
7�� j 7
u.
w
of lines /
Length of each�ine
Total length of lines
Trench width
Distance between lines
No.
FJ-- Z
3 inches
Top tile to finish
Material beneath tile
Total
of grade/
effecti absorption area
-3
inches
Z/Z/ _30
Length
Width
Depth
PERMIT NO.
LU
C7
IH
w0.
Type of crib
Crib diameter
Crib depth
Total effective absorption area
W
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
LU
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
R
PIPE MATERIALS 0, L. J /I
2>441,v P/Pt
SOIL TEST RATING
2�
INSTALLER
REMARKS
gv
°•°•rarer°rrr°/q�,,
AW.`�O
•v14
-0
/err*3 rwrr • err0 r•ro'r•r
I
i s•r•a . •e••• •••ror••�
t. Earl P. Ellis F
NO. 1745-E �• ��•
stn °•rrr �
,���
PROFESSO
APPROVE DATE LEGAL
J�
/. 1 i1n�►�t�l/�fT 1417-5-.
72-01 Mev. 3/78) D = /0 ' 4 _ 4,S',/D, i 7 01
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
�son ��1-4= 0. 021 R.. son 1410710- hi= at T5 ���Ny EF R.. 12; ITF Fo" 0- 1-1= �
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
QROUND HND THE BOTTOM OF THE EXCAVATION (IN FEET)
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRHYEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
HND THE BOTTOM OF THE EXCAVATION (IN FEET)
RAZE07IR-A T 10001107" 009710"-w- I K0 0- F4 P4 K IT X 2T E:= 0. CA CA CA ���L. CA 64 E�;:
PERMIT HPPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIUNS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
K 14 C) < 12 Q, 1: 100" to, EEC 11; -y- 1: 173 44 13 FA K Ell ITT PEE ITT P-3 I Fy FE Ky
BHCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION HND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON—SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL/ OR
150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC NELL
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS HRE
AVAILABLE TO INSURE PROPER INSTALLATION.
K EEC F0 01 1 "1-- K 1-0 F" 1: ITT FF ni E> EE C3 K PI E3 EE I'T ��, A- Is 17 E;i;
��,) GREA , -R ANCHORAGE AREA BORA ..GH
(6�1,�1Ct Department of Environmental Quality
�w� 3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEMc'L`fJ-f�
NAME �a/����i � � MAILING ADDRESS -& O ISOx r✓Q9� {/�/e lolVea PHONE &IF7 if tt
LOCATION OFF � K'ttl� Q�1 � f LEGAL DESCRIPTION �a �� AlQ L���
SEPTIC TANK:
DISTANCE ..- NUMBER OF
FROM WELL MANUFACTURERcc.�uSr MATERIAL -sT� G COMPARTMENTS
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY /rBOLS GALLONS.
TILE DRAIN FIELD:
i r TOTAL LENGTH
DISTANCE FROM WELL OGS FOUNDATION _NEAREST LOT LINE OF LINES
NUMBER OF LINES 7a DISTANCE BETWEEN LINES / TRENCH WIDTH—'
IDTH IN. TOTAL. -EFFECTIVE
ABSORPTION AREA SQ. FT. LENGTH OF EACH LINE J7 / 3c
DEPTH OF FILTER
DEPTH: TOP OF TILE TO FINISH GRADE !� MATERIAL BENEATH TILE_ IN. ABOVE TILE IN.
WELL: +
TYPE_ 74K 12440 CONSTRUCTION `/L 1750 DEPTH ' DISTANCE FROM:
BUILDING / NEAREST NEAREST
FOUNDATION LOT LINE 50 _, SEWER LINE
CESSPOOL
APPROVED
DISTANCES:
OTHER SOURCES
DISAPPROVED
INSTALLED BY: Ae��`J�����
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form EQ -032
REMARKS
SEPTIC / SEEPAGE
TANK �Q , SYSTEM_
G.A.A.B.
GREA R ANCHORAGE AREA BOR IGH
b� 'gyp
dv/I 1; DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO.
"u 33 0 "C" STRE ANCHORAGE, ALASKA 99503
EPHONE 274-4561
N AND PERMIT
SEWAGE DISPOSAL SYSTEM - APPLICATIO ea,,,y v
NAME OF APPLICANT
�-� C'lMAILING ADDRESS! �� '''`HONE f�
INSTALLATION LOCAT
LEGAL DESCRIPTION
INSTALLATION OF: SEPTIC TANK 1.bhhl AL r_ I'll
TYPE AND SIZE OF FACILITY TO BE SERVED
FINANCED THROUGH TO BE INfTALLkD BY
SOIL TEST RESULTS
�L 7r�J NO E: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
�
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK SIZE[—
TYPE
SEEPAGE AREA S/E 0 � �e/�/� ,� -/--
V R/AMr F YYST J a
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK
r
FOUNDATION TO SEEPAGE PIT DRAIN FIELD
SEPTIC TANK TO SEEPAGE PIT WALL / /
SEPTIC TANK SEEPAGE PIT �"" DRAIN FIELD
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK SEEPAGE PIT /" P
DRAIN FIELD /�4 ALSO CONSIDER AREA WELLS.
WATER MAIN TO SEPTIC TANK
SEEPAGE PIT
DRAIN FIELD
!!``'J ///,
SEPTIC TANK/�, SEEPAGE PIT DRAIN FIELD /
TO RIVER, LAKE, STREAM.
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION S FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REM gVABLE CAPS.
GRAVEL BACKFIL
CONFORM TO BOROUGH RE ATIONS REGARDING INSTALLATION.
G.A.A.B.
OR
ICEN �E�IGNE� S71
j ( g
I i
E ,
i
i
f t t [
! I
i f i
g
t--
- _J__1�l_I—- -
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH 6RDINANCE NO. 28.68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
DA�� C APPLICANT'S SIGNATURE
FORM NO. EQ -016
Steven A. Johnson
Box 76
Chugiak, Alaska 99567
Phone: 688-3085
Soils Log
Percolation Test
Performed for _ Tom Allen Date 8/24/78
Legal Description Lot 3, Block 1 Broadwater Heights Subdivision
Test Pit Location 25' E and 59' S of NW corner
0
ML 0'- 1.5' red brown sandy silt with 'some gravel
and organics (ML) 275 ft2/bdrm
2 GW_ 1.51- 10' gray brown sandy gravel w/some silt
GM (GW -GM)
200 ft2/bdrm
4
6
perc tested from 6' to 8'
8
4-3
W
1D
[v
1� 10
4-)
ill
4a
12
14 no water table encountered
16 Total depth this test 14 feet
AVERAGE ABSORPTION AREA REQUIRED FROM SOILS LOG = 208 ft.2/bdrm.
DATF
NET TIME(Min.)
NET DRP In.
PER RAT M'n 'n
8/24/78
30
4.75
6.3
8.o
70
8.75
8.0
9.2
30
2.75
10.0
Percolation rate
10.0
s/inch
Conitzuetion gait -fab
"One test is worth a thousand opinions"
8828 TUDOR ROAD. ANCHORAGE. ALASKA 80807 S TIL[►HOHN 333-8472
Performed For , (/ 1 Date Performed 30 75
Legal Descri nti on : Lot_]SBl ockSubdivision 17 2RO -DW/9-TF&
This Form Renorts Soils Loo Percolation Testi
Denth
Feet Soil Characteristics
1 —
4 —
/d d
5 —
6 —
7 —
B —
10 -
Was Ground Water Encountered?lUo
If Yes, At what Denth?
/U o 6 e cleo c K ��fivt(?c'Ar�&I/- oz (
Percolation Rate P1inute
Proposed Installation: Seenaae Pit Drain Field
Denth of Inlet Depth To Bottom Of Pit Or Trench
CnMr1ENTS : AD& S4 . F7- 1)k A- j/+.6 APEE& �? kF/14PD2Ddrivt
Test Performed By r_v� l�1 L _ Data Certified By: C0/V,5 T�S�LJ�, '
Date `zaO 7,E
A -W DRILLING, INC.
DRILLING LOG
Well Owner _Use of Well`"t�
Location (address of: Township, Range, Section, if known; or distance main road
Size of casing_____, '
Depth of Hole
feet Cased to feet
Static water level
ft. (above'):-
(below) land surface. Finish of well (check one) open end
Screen (
) ; Perforated
Describe screen or perforation
Well pumping test
at - gallons per
(hour) (minute) for hours with
of drawdown
from static level.
Date of completion
WELL LOG
Depth in feet from
ground surface
Give details of formations penetrated, size of material, color and hardness
a. TO ..
C ,A.,..
TO
?00
TO
br�;'S„�t. �J .. Pr.b '.Z y i. ✓-{.: i/ e 0 '��t ..7y .. .i. '. f'�11 � ri+ '�" � � �/'T
s ,.._ ...�...,„
�:
TO
TO
TO
TO
V1,2
TO
TO
:►
s;.
TO-
T
TO
TO
TO
GK $
• '� Municipality of Anchorage_"�
On -Site Water and Wastewater Program
(907)343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 050-081-19 Expiration Date:
1. GENERAL INFORMATION
Complete legal description Broadwater Heights, Block 1, Lot 3
Location (site address) 12124 Rainwater Circle
Current Property owner(s) Alfred Land I I I
Mailing address
Real Estate Agent
12124 rainwater Circle
2. TYPE OF DWELLING:
(] Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Il
Individual
0
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
WaiverNariance request for:
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ `t"Z o. W Waiver Fee $
Date of Payment _912:iB`/ 3 Date of Payment
Receipt Number //O U Qty Receipt Number
COSA# U Se �3/06-j Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Engineering Services LLC
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
6. DSD SIGNATURE
\� System #1 Approved for 3 bedrooms
System #2 Approved for _ bedrooms
Disapproved
Phone (907)272-8218
Date Vu k3
Conditional approval for bedrooms, with the following stipulations:
Original Certificate Date: 3
blb_�
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 blue sheet r c
If more than I septic system is on the lot:
COSAChecklist# + of 1
Structure served by this system 1
Certificate of On -Site Systems Approval Checklist
Legal Description: Broadwater Heights, Block 1, Lot 3
A. WELL DATA
Well type Private If A, B, or C provide PWSID #
Date completed 8/16/76 Sanitary seal (Y/N) Y
Total depth 280 ft. Cased to 31.3 ft
FROM WELL LOG
Date of test 8/16/76
Static water level 38
Well production
3+
ft.
9.p -m.
Parcel ID: 050-081-19
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 12 in.
AT INSPECTION
2/7/13
81
5.5+
ft.
9—
p.m-
WATER SAMPLE RESULTS:
Coliform4VQcolonies/100 mL Nitrate �J P mg/L y(��/// (>
Arsenic tic)ug/L Date of sample: 2/'71/ 3 Collected by r i/
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Fiberglass
Tank size 1000 gal. Numberof Compartments 2
Date installed 10/4/78
Cleanouts(Y/N)
Y
Foundation cleanout (Y/N) Y Depression over tank, (7Y/N) N High water alarm (Y/N) N
Date of pumping �V/? Z i 3 Pumper r ` s P1-' —+
C. ABSORPTION FIELD DATA
Date installed 10/4/78 Soil rating (g.p.d./f:2 or ftz/bdrm) 208Sf/br System type Deep Trench
Length 46 ft. Width 3 ft. Gravel below pipe 7 ft.
Total depth 10 ft. Eff. absorption area 644 112 Monitoring tube Y Depression over field N
Date of adequacy test 2/7/13 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 60 in.
Elapsed Time: 120 min. Final fluid depth 60
Water added 504 gal. New depth 76 in.
_ in. Absorption rate , 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at
Datum
0
Size in gallons _
`Pump off' level at
Cycles tested _
Manhole/Access (Y/N)
in. High water alarm level at in.
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100+ On adjacent lots 100+
Absorption field on lot 100+ On adjacent lots 100+
Public sewer main 75+ Public sewer manhole/cleanout 100+
Sewer /septic service line 25+ Holding tank 100+
Animal containment areas 100+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 5+
Water main 10+ Water service line 10+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+
Water Service line 10+ Surface water 100+
Curtain drain 50+ Wells on adjacent lots 100+
F. 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.
Engineer's Printed Name Steven R. Pannone
Date /-302ZA
COSA brown sheet -1 0-10-1 2.doc
Absorption field 5+
Surface water 100+
Water main 10+
Driveway, parking/vehicle storage 10+
Municipality of Anchorage
..9�) Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519.6650
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. G S'O — 0 81 ^ 19 HAA # ny DLO
Expiration Date: _"5 a' f I
1. GENERAL INFORMATION
Complete legal description rot 3 u ocK 1 $YpArf4A1 PT xPi ohr A a„hdi vt ei nn
Location (site address or directions)
12124 Rainwater Cir.
Current Property owners)
Bob Chivvis Day phone 753-5782
Mailing address 4600 Mara Dr. Anchors a Ak 99507
Day phone
Lending agency
Mailing address
Day phone
Real Estate Agent
Mailing Address .
HAA will be held by DSD for pickup.
Unless otherwise requested,
2. NUMBER 11 OF BEDROOMS
TYPE OF WASTEWATER DISPOSAL:
3. TYPE OF WATER SUPPLY
'
Individual On-site
Individual Well
❑
Individual Holding tank
E3Individual
Water Storage �
11
Community On-site ,
ElCommunity
Class Well
❑
Public Sewer
❑
Public Water System
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by
al an Indareependentfpr rofessthe tional civil
engineer registered in the State of Alaska. Certificates of Health Authority App
title (except system.. DSD also issues HAAs for uponsrequest oyhomeowners.1Certifiion-site
cates ofwastewater
Health Authority Approval erre
supply Y
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and.State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm S & S Engineering Phone 694-2979
Address 17034 N. Ealge River Loop Ste. 204 Eagle River, AK 99577
Engineer's Printed Name Robert C. Cowan Date —id -1 6_60-y-
6.
JOy
5. DSD .._SL00'.SIGNATURE
Approved for 25 bedrooms
;ERT C COWAN
C: - Sao I
Tit F •..
Disapproved. tii',n co
Conditional approval for bedrooms, with the following stipulations:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By. A 2a. --Original Certificate Date: 11
(Rev. 01/02)
Municipality of Anchorage
Development Services Department _ {;
Building Safety Division <
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LoTcJi Goch .�1 1 j3¢�y;pu � 11hrcel ID: 0S —Dg/ — /9
I
A. WELL DATA
Well type rie V)"L' If A, B, or C provide PWSID #= Well Log(MN)
Date completed; 1�{(0 Sanitary seal &N) `ES Wires Well
protected (S%) ES
Total depth IW�ft. Cased to i�_ft.(MeAt fc-) Casing height (above ground) 2in.
FROM WELL LOG AT INSPECTION
Date of test y Io
Static water level ft,
Well production g,p,m, 3,
g.p.m:
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrat�0.S0 mg:/I. Other bacteria colonies/100 ml.
? Arsenic: mg./I. Date of sample: I l 3/ZoUq Collected by: s q{I evulp ,
B. SEPTICIHOLDING TANK DATA rf
E Tank Type/Material 'S64MC- F'Ii3Lr"tfts Date installed l0 5zi3
Tank size loon gal. Number of Compartments Cleanouts &N) `iFrg
Foundation cleanout &)_53 Depression over tank (Y& IU� High water alarm 1�Ut°►
Date of pumping _44— 465 Pumper _ me 3 FL)M1,inod,
C. ABSORPTION FIELD DATA
? Date installed Soil rating (g.p.d./ft2
046i;) Z S stem e . L
i
Y CYp �+�
CArt
Length tib ft. Width - 3� ft. Gravel below pipe ft.
f
Total depth ro ft. Eff. absorption area2qqftz Monitoring tube 165 Depression over field NO
Date of adequacy test bI bResult as Faiq �RSS For bedrooms
a n
Fluid depth in absorption field before test � in. Water addedA�Sal. New depth in.
Elapsed Time: IDmin. Final fluid depth in. Absorption rate >_ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) me If yes, give date
Y
Date installed
"Pump on" level at = in.
Datum _
E. SEPARATION DISTANCES
Size in gallons
"Pump off' level at=in.
Cycles tested —
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 107-
Absorption field on lot los,
Public sewer main NtIV
r
Sewer /septic service line e2rJ
Manhole/Access (Y/N)
High water alarm level at
Meets alarm 6 circuit requirements?
On adjacent lots
On adjacent lots
160 !.{-
Public
001.{ -
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation e 7 Property line S 4- Absorption fie]
Water main NR Water service line 10 f4, Surface water
Wells on adjacent lots t60 t'('
in.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line tD t+ Building foundation 10 1'Z'- Water main
Water Service line 04 Surface water 100 l% Driveway, parking/vehicle storage
Curtain drain PXO& rctuor 00 Wells on adjacent lots M r4 -
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date. +ry'� R09ERT c. tob
14.•8801
Engineer's Printed Name
Date /r b Jo tt`iiF%rE<s�'
HAA Fee $ z1 30 • 04
Date of Payment /1 /7 �o i
Receipt Number
(Rev. 12101)
Waiver Fee $
Date of Payment
Receipt Number
I
11.15-04; 5:26pM;
SGS ReGM
1047321001
Client Name
S & S Engineering
Project Name/N
Lot 3. Blk 1. Broadwater His
Client Sample ID
Lot 3, Blk 1, Broadwater His
Matrix
Drinking water
Sample Remarks:
Nitrate was analyzed by Mat -Su Test Lab of Alaska.
Revised report. Client updated sample ID.
;9D7 5615301 0 2/ 4
All Datuffimes are Alaska Standard Time
PrintedDate/Time 11/152004 15:45
Collected Date/Pime 11/032004 13:00
Received Dsteffime I1/03R904 16:04
Technical Director Steph C. Ede
Parrneon Results PQL Units Method Container U) I.hnir Irsp p to Int
Microbiology Laboratory
Total Coliform 0 ool/100mL SM20 MM A (cel) I IN3/04 DKC
;907 6016301
11-16-04; ^6:26PM; �.rrwanao a4r aorr++ I IWMMFI r. Il1104
rr.w Ips• mow+
Matsu Test Lob of Alaska
Water Quality Testing
Mile i2 Palmer-wastna Hwy.
Midtown Community Business Park
Phone. (80717453005
Client am EroAromental
Emen: a tet.earaseaWroeershse eam
Attn.:
Forest Taylor
Client Q
Lot 3 Block 1 Broadwater Hts. 1047321001
PWSID t7:
Nitrate -N
Source:
cMDL
M.S.T.L*
20041098
Sample MatcAc
Comments:
Method
Parameter
Units
Results
SM 4500-NO3.E
Nitrate -N
mO1L
cMDL
LeOend: MRL a Method Report Lavel
MCL • Max. Contaminate Level
0 ■ Present M Method Blank
E a Eanmated Value
H-AbvnMCL
D - Last to DIMan
e
ReLorfed By Jon Paul Campbell
Lab Supervisor
0.50 111SM4
PA. Box 1749
Palmer. All.88e46
Fax. (807) 1454019
Date Arrived: 1116414
Report Date: 1119104
Sample Date:1 '3/04
Sample Tine: 1300
Cotieew By:
1119/04 10.0
M 4/ 4
OCT So 191 14 12 RE/MAX 4F EAGLE RIVR
• .
ASSUILT-NO CORNERS SET
1p`o,
0
��
0
C,
�
'I
HEREBY CERTIFY THAT 1 HAVE SURVEYED THE SCALE'
'OLLOWING DESCRIBED PROPERTY+ OF A2�4
roadwatez Heigghts 8ubd. Lot 3 Blk. 1 DATE r Qff?,•''"'"'•S'��
►ND THAT NQ ENCROACHMENtfS EXISRT'EXCEPT A9 10=Y2-91 y� H •;�q��
NDICATED. IT IS THE RESPONSIBILITY. OF -THE ':or'* J% 4 jL�
WNER TO DETERMINE THE EXISTENCE OR .ANY GRID+ I •• ••••••••
.ASLMENTB, COVENANTS OR RESTRICTIONS NW 253 ;. • •0 ••�•
MiCH DO NOT APPEAR Ot� THE RECORDED SUBDI•• . ewn. Aur1c a..fe ; 1
131ON PLAT UNDER NO CIRCUMSTANCES SHOULD FB* • 'r.
NY DATA HEREQN BE USEDCOIR CONSTRUCTION 24-74 ` ;f'►�'•.........• ' rt
IF FENCE LINES, OR FOR ESTABLISHING BOUND-.
• 4
RY LINES. i�aww+•
DMS '
T00t xv ImNIoma AM GLI 8L9Z 99L L09 yyg 9090 to/90/TT
Municipality of Anchorage
Development Services Department
,f Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.orglonsite
(907)343-7904
ON-SITE SEWER/WELL SUBMITTAL COMMENT SHEET
To: g! i Engineering
Legal description: Broadwater Heiohts Subdivision. Block 1. Lot 3
The attached paperwork has been reviewed and is being returned for the following reasons:
❑ Original signature or stamp missing on
❑ calculation error in design. _
❑ Additional soils information needed.
❑ Water monitoring results inadequate. _
❑ Discrepancy in information submitted. —
❑ Topographic information missing or inadequate.
❑ Incomplete; missing
❑ Incomplete; missing
❑ Additional adequacy test information needed.
❑ Water sample unacceptable. —
F1 Measured/proposed distancestdimensions missing.—
❑ Locations of all soils, percolation and water monitoring tests not shown.
❑ Proposed system too deep for soils information submitted. —
❑ Well log required.
❑ Omission In narrative. _
❑ insufficient fill over tank or field.—
® Other. Well located in utility easement.
Name of reviewer: julie Makela. P. E. Date: 11/22/04
Please supply the necessary information and re -submit your request.
LEAVE THIS FORM ATTACHED TO THE PAPERWORK
NOV-24-2004 09:33
Mov=ber 1, 1991
S&S ENGINEERING
v,. Ray Reberer
Re/Max of Eagle River
extield
16600 cant Eagle Ri eAlaskariVer 99577Suite 201
907 694 1211 P.03/07
ENSTAR Natural Gas ComPany
A MOON OF SEPGUU.[NW GY COMPOMI*N
3ow Spanard Road
P.O. am 190288
AnW%X&9 . Alaska l9sts 8G i
t60712774561
Dear 14r. Seberert
ENSTAR Natural Gas Company has no objwetion to the vacation
of the utility easement on Lot 9 Block 1 Broadwater Heights
subdivision.
If yhave any questiom please gall me at 2643743.
ou
very truly Yours o
ENSTAR Natural Gas Company
Igao "&&44,1 -
Dan Westervelt i
Right -Of -WP -y Agent
DW/Yh
goo on
Post -It- brand tax transmittal memo 7671
From n r 1
xv
Gat CSG too xv3 9Cr90 WWII
NOV-24-2004 09:33
r E
Cmotor=
November 131 1991
585 ENGINEERING
907 694 1211 P.04/07
..w..r•�M19(RZMX Pr'�bC'f. G.� �� �_ .ate. ��w• .��� �.�. �..���:.-�t.�� w w.���
116800 centerfield Drive, suit@ 201
Eagle River,*klaska 99577 `
SUBJ=: partial vacation of Easement
Dear Mr. Heberer: Iion of
prime Cable of )Llaska has no objection to vacating that Pow
utility easement of Lot 3, Block 1, Broadwater Rei,�ht
the eastern s
Subdivision where the Well encroaches. �
If you have any questions, I can be reached at 786`9305.
sincerely,
e�v
Clint Bousley
System Designer
i
400
yz51 BAtRBAPIISS S1REG1 • pNCiipKAGE. ALASKA "W3' (907)562-1
t_
S00@J IVZI88NiJ�NS-�RII% Sn 6189 CSL 106 XVd BC180 40/"/t1
NW -24-2004 0933 S&S ENGINEERING
4
Mataumnska Electric
Association, Inc.
P.0. Bay 2929
Palmer. Alaska 99645
' S-9328 31
fix M
November S. ]991
To Whom it May Concern:
967 694 1211 P.05/07
A
Matanuska Electric Association, Inc., has no objection to the vacatwn of 15
foot pocket around the well located in the 10 foot platted utility easement
located along the easterly lot line of Lot 3. Stock 1 of Broadwater heights
Subdivision. according to.Plat No. 73-22. Anchorage Recording District. The
utility easement in questlon is along Rainwater Circle.
This requested vacation is to accommodate the encroachment of a water well
in the easement in question.
David E. Ingalls
Real Estate and Properties Officer
9aoM SIY EMIMM MW sn
6L8r CSL 406 OC: so o/Tznf
NOV-24-2094 9933 S&S ENGIhMING 907 694 1211 P.eG/07
Matanuska Telephone ASSOCiation,
PInc-64.
P.O. BOX 9550 ALMF_R.ALASKA 898455%50
PHONE (W7) 7450.510
Thomas K. Minnich
PresidenViC•E.O.
NON-OwEcTION TO EASM= ENCROA T DOCUMENT
PhO116 Assoc
that.ithas no object on to theeplacement att$ henfoll,owing elates
encraaebment within the platted utility
easement located on property
described a+ Lat T�=°e 3 •Block One 1 Broil to Beira S
Township 41�•�, Range..W'�. '. Section�c�r
Third Judicial Distrxet, A4G ound Water
iStrMeridian. .�.Ska. M. g Well and undergs
RecordinglIIeor I�bove Ground Septic system, c.
SYS tem, b. ��. rivewa
d. �� Structure, f• wol Other
Please be advised that should ?fatanuslca Telephone
ebuurried or aerial ion, Inc-
Please
to upgrade, maintain, and or replaceplatted utility easement,
telecommunications facilities within ihee-splatt that may be required to
it will be allowed to do so. Any repaas
the encroachment described above, as a result ofirecord.
construction will be borne by the property to vacate
BLEASE �E; This document is, in no way, an agreement
any portion of the platted utility easement, and should not be
interpreted as such by buyers, governmental agencies, lenders,
owners, Realtors, title companies, and or ixnderwriters-
I
srEcxa%. coxms�zcnls:
This document must be recorded. Matanuska Telepha return the
Inc., will record the original document. Upon
the ret).
recorded document Copies will be sent to the bran at Matanuska
As --Built is retained with the original all docs Building, Palmer.
Telephone Association, Ino.
Alaska.
page one of Two
.r
loo® av Ua3N10N3-='1;[1 GZ93 C2L toee TU 9C190 ♦om/11
S&S ENGINEERING 907 694 1211 P.07/07
Easement Encroachment Doc=ent/MTA
Paae 2
geal^Estate and Properties 6uperv3-s0r
Date: November 14,1941
h b day' of inember -,
THIS I6 TO CERTIFY, that on this tic in and' for the
19sj�, before IIIe the undersigned, a No ary2"PE ZEN, to me
state of Alaska. personally appeared SERNADE
personally known and to me known to be the, individual described in
at she
and who executed the foregai.luf and o l garily for the uses and
signed and sealed the same freely
and unt
purposes therein mentioned.
T.X W2TNESS WHEREOF, I have hereunto set Z'N:;L
hand and affixed my
official seal the day and Year in this ove
Ltv
written.
Y a
GSlUMR(S) ADDRESS
Hy Commission
I
rgg (g) ADDRESS
Please Return To:
Bernadette Zimaermanerties Supervisor
Real Estate. and prop
Matanuska Telephone Association, lac•
Post office Box 3550
Parser. Alaska 99645-3550
BZ/EEDNOFOR.902
i-/,4 �.._-�.��
TOTAL P-07
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
`CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel 1. D. # l� — (S\ ` \ CA
1. GENERAL INFORMATION
HAA# 0QAC 1 L 91-I
Complete legal description Lot 3; Block 1; Bnoadwaten. Heightz Subdiv.(�tion
Location (site address or directions) 12124 Rainwater Ci,%ce.e
Property owner G. t Sennano Day phone 376-2252
Mailing address 12124 Rainwater Cinci'_e Eagte Riven, Ak. 99577
Lending agency Day phone
Mailing address
Agent Ray Hebexen RE/MAX OF EAGLE RIVER Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well XX
Community well
Public water
694-4200
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
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 of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
5 & 5 ENGINEERING
Address 17034 Eagle Rinner Loon Road No. 204
Eagle River, Alaska 99577
Engineer's signature
6. DHHS SIGNATURE
Approved for �� bedrooms.
Disapproved.
Conditional approval for
Additional Comments
M
WTIC
Phone
Date lki—� I L--'f�J,
bedrooms, with the following stipulations:
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 DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: �.!� 1 - �-^ Parcel I.D.
A. WELL DATA
Well type If A, B, or C, attach ADEC letter. ADEC water system number
Log present&N) y Date completed g" �'� 4 Driller
l (11
Total depth 2 Cased to �� I� Casing height
Sanitary seal I) Wires properly protected/N)
Date of test
Static water level
FROM WELL
L /OCG,
Well flow �} � g.p.m. f
Pump level i l�
SEPARATION DISTANCES FROM WELL TO:
1
-O
AT INSPECTION
a
LLJ
o�
L..
o vWi •-- •...p
�: LJ -1
g•p*, c >
z'
w
I
Septic/holding tank on lot `C --,2 ; On adjacent lots o�
Absorption field on lot 1 ; On adjacent lots
Public sewer main D Public sewer manhole/cleanout
1 r //
Sewer service line �� -fit- Petroleum tank 6 �`_� .
WATER SAMPLE RESULTS:
,yl
Coliform �26 Nitrate 491 / % '� Other bacteria
Date of sample: �� _ — l Collected by: S :�J
B. SEPTIC/HOLDING TANK DATA
Date installed dor" 4 7 5 Tank size � cck�> Compartments
Z
Cleanouts( N) Foundation cieanout(fi7N) _ Depression (Yagp
4
High water alarm (Y/N) Alarm tested (Y/N) `--
Date of pumping �2 �2—� 1 Pumper J�1�7 �i�1��1��1
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
r
Wells on lot l (21�i 1
() On adjacent lots � ��� Foundation ?i7i
r
To property line T Absorption field "22 Water main/service line
Surface water/drainage (� L-_1--_:> f r _
72.026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
I
Septic/holding tank on lot `C --,2 ; On adjacent lots o�
Absorption field on lot 1 ; On adjacent lots
Public sewer main D Public sewer manhole/cleanout
1 r //
Sewer service line �� -fit- Petroleum tank 6 �`_� .
WATER SAMPLE RESULTS:
,yl
Coliform �26 Nitrate 491 / % '� Other bacteria
Date of sample: �� _ — l Collected by: S :�J
B. SEPTIC/HOLDING TANK DATA
Date installed dor" 4 7 5 Tank size � cck�> Compartments
Z
Cleanouts( N) Foundation cieanout(fi7N) _ Depression (Yagp
4
High water alarm (Y/N) Alarm tested (Y/N) `--
Date of pumping �2 �2—� 1 Pumper J�1�7 �i�1��1��1
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
r
Wells on lot l (21�i 1
() On adjacent lots � ��� Foundation ?i7i
r
To property line T Absorption field "22 Water main/service line
Surface water/drainage (� L-_1--_:> f r _
72.026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Dat' stalled
Size in gallo
Vent(Y/N)
High water alarm level
,Pump on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots
"Pump off" level at
Cycles tested
Surface water _
Date installed ��� 4–�!rU' Soil rating System type
Length 4(0, Width Gravel thickness :7 Total depth [4�
Total absorption area (�Oq'y" Cleanouts presentd/N)
Depression over field (Y6 Date of adequacy test
Results (pass/fail) for , 3 bedrooms
Peroxide treatment (past 12 months) ( V i`� p '�G?,) � If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots < "a"
a -I- Property line
Well on lot I q 42)
ICaI"�_
To building foundation D� To existing or abandoned system on lot D r_1S
t
On adjacent lots I-,' Cutbank `D ` Water main/service line b 14
Surface water l'�� �' Driveway, parking/vehicle storage area
+> '�_
Curtain drain l` NG YA iae� �—
E. ENGINEER'S CERTIFICATION
1 certify that have checked, verified, or conformed to all MOA and HAA guidelines in effect ol e��ttee�of this inspection.
"
S & 5 ENGINEERING ��;.• °•; �t
Si nature 17034 Eagle River Loop Road No. 20400
g Eagle River, Alaska 7�� ° 4. 9 ITU -16i a
Engineer's Name ® ♦ • • s. ♦ + ♦ �. ♦ ♦�
/ 0
Date �'�•-1 — `� ( �,: F-U:�GE11j.5 FER,PE
s
sAW
ss�oNP..�
HAA Fee $ /
Date of Payment t'
Receipt Number'��?`%�
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS RESULTS for INVOICE # 40870
Chemlab Ref.# 91.6492 Sample # 1 Matrix: WATER
Client Sample ID L3 B1 BROADWATER HEIGHTS Client Name :S & S ENGINEERING
PWSID UA Client Acct :SNSENGP
Collected DEC 6 91 B 07:15 hrs. BPO# PO# :NONE RECEIVED
Received DEC 6 91 @ 15:00 hrs. Req#
Preserved with AS REQUIRED Ordered By :R.J.S.
Analysis Completed DEC 9 91 Send Reports to:
Laboratory Supervisor STEPHEN C. EDE 1)S & S ENGINEERING
Released By 2)
......................�...---...----------....-..------------.-..........-..-.....-----------..---------------
Parameter Results Units Method Allowable Limits
--------------------------------------------------------------------------------------------------
NITRATE-N 0.17 mg/l EPA 353.2
Sample ROUTINE SAMPLE COLLECTED BY: R.J.S.
Remarks:
-------------------------------
10
....................................................................................................................................
1
Tests Performed
' See
Special Instructions Above UA -Unavailable
ND-
None Detected
See
Sample Remarks Above
NA-
Not Analyzed
LT -Less
Than, GT -Greater Than
%i SGS Member of the SGS Group (Socidtd Gdndrale de Surveillance)
5. LEGAL DESCRIPTION
DATE RECEIVED
`
INSPECTION APPOINTMENTS
1
TIME
Ni61BER OF,BEDROOMS
TIME
TIME
DATE
❑ Two ❑ Five
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
❑ COMMUNITY
MUNICIPALITY OF ANCHORAGENN��// RRDEPT. OF HEALTH &
PROTECTION
❑ PUBLIC UTILITY
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEITtIONONMENTAL
8. SEWAGE DISPOSAL SYSTEM
825 L Street - Anchorage, Alaska 99501
•
DEC 10 1979
❑ PUBLIC UTILITY
ENVIRONMENTAL SANITATION DIVISION
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Telephone 264-4720 RECEIVED ECEIVE
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.
1. PROPERTY OWNER
PH NE
/
!/Ila
MAILING ADDRESS'
n
PROPERTY RESIDENT
f different from above)
F
PHONE
2. BUYER
P O E
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS
4. REALTOR/AGENT
A
PHONE
MAI LINO ADD ESS
/l
✓([�
e n
5. LEGAL DESCRIPTION
"+
`
STREET LOCATI N
1
6. TYPE O E IDENCE
Ni61BER OF,BEDROOMS
SINGLE FAMILY
❑ One ❑ Four ❑ Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
Three ❑ Six
7. WATER §UPPLY
FU F\ INDIVIDUAL*
' ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
Ok__ INDIVIDUAL/ON-SITE*
7 YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
G _
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: )000 If Tank is homemade
give dimensions:
SOILS RATING
Z, C)
TYPE OF TANK
MANUFACTURER
_,",
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
W E L L TO :
Septic/Holding Tank Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
[;3- APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE 1 1
BY
M
72-010 (Rev. 6/79)