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STOCKHAUSEN LT 22
~GREA,,'R ANCHORAGE AREA BOR~..,GH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH MANUFACTURER '~ .~-- INSIDE WIDTH__ MATERIAl LIQUID DEPTH NUMBER OF COMPARTMENTS LIQUID CAPACITY GALLONS, TILE DRAIN FIELD: I'~/~v~, D,STANCE EROM WE,, - FOUNDAT,ON NUMBER OF LINES *~-~ ABSORPTION AREA ~'fq2) 0 NEAREST LOT LINE TOTAL LENGTH OF LINES DISTANCE BETWEEN LINES TRENCH WIDTH SQ. FT. LENGTH OF EACH LINE DEPTH OF FILTER IN. TOTAL EFFECTIVE DEPTH: TOP OF TILE TO FINISH GRADE MATERIAL BENEATH TILE ~_ f IN. ABOVE TILE IN. WELL: TYPE BUILDING FOUNDATION CESSPOOL APPROVED CONSTRUCTION NEAREST NEAREST LOT LINE __ SEWER LINE__ OTHER SOURCES. DISAPPROVED REMARKS DEPTH SEPTIC SEEPAGE TANK SYSTEM DISTANCE FROM: DISTANCES: INSTALLED BY: '%~-~-(? - SEWER LINE DEPTH: PIPE MATERIAL: LOT SLOPE: REMARKS: DIAGRAM OF SYSTEM DATE ~ APPROYED 'i i.lli: I..ii::N .:i i I't D :[ PIEhi:E; :t: l:)t",i ): S THE LENGTH ,:: 'tj i'.! FEE't ) OF;' THE: "i'I:RtEJ",!(Z::H I:::ll::i: !:::,J:;~:t:;:l :[ i",IF' :!: !EI..D. il-Iii: DEEt'::'TH "F FI TI:REt",ICH ":F' i:::';l:T .t_, F![: DL[:ii;TFiI',!(:::Ei E:I;::'ThlIEE;N THE: ~ii;Ul:;~:l=;'l:::l(:li:_' (;IF' 'IHE I]iI;;:(:ZiJ..tt'..tJ) !:;lJ".![) fHiE B(;i"J"'TEit"J F'F:' THE: E':;:.:;Cf::['v'F:i"l';[(]li'.] ,:::(t",! F:'EE'T). I, . .! ....... NJ" ;{:;~i['l" t.t:[[:,-i"H F:(3F: ....... r"' ~' '~ :[ :E; ' -' ' ' : :: .......... _. _ ! r!l:: a ,:.. v c.L. DEI::' i'1~ TI~E !',i ;f: !'..I ~ i'qLlt',i [:,Ei:t':"TH F F:' .:d.,:.. v t:::.t... E..&.. i I tL=.E .I d 't"l.lli;i: f'll .!TI:;:I=It...L. I=' :i: ...... T'HE fJ:(3TTO?,I Ed=' FHE EiZ;:.::E:F:IVF! F :[ Ot'4 F ~ i'-] F:'iiii:!_::'t ::,. lq C:OI',I'i"]:Ir',II. JOI..I::J; FtF:i:£i'.4T'EF,If:IhIE:E :...!ll.t,ll ;[:E; RE(;iL.H!:!~:Ii!(IZ). :iZr:' i:::1 i',IF:IZl;hFFIii:NF:ff.,IE:I[ I=~E;l:;i:!i;E?liEi'.,l*t ]Z:E; i'.~,O"f' k;IEl="f' E:UF;;:I::~:ENT '¢q t"IF:I'T' E~[ii; I:;;:E)'_:.!IJ:[I;~:IED "i'O ~::.~',lt. F ~ 'lilE ·' ;::-, _. t ." I .'. u'q S"¢:E;TE?q F!ND..."OI:,;: '-,.'c ! i"tF:!? I?dE ';= ! IF',.fF:'f': f 'i'(Z] P!:;i:[;:r_:J;[iiZCI..l't' ]; ON. :[ i;::t;iiZi:;~:'l':[l:::'"l" 'I't'IFI"I' :i.; f::'i3i;?.iJ-I I:i;'T' i'I'IE I'll..iN;!X$);PF:Ii,.,]/f'"/ Eft= F!N(;]:I'I(Z)F;?.FIGE. ?.: ;[ !4]iI..L ];tq::~;TFtLI,. THE!; ::?'/!ii;'TEH ;[.t',l I=IE;E:Ot:;~;DFIi",!(];:Ii; i,,~;[I'I-'I THE:; E;ODE:i!;. ]ii;; I:;~: l'i?::; ]]Ii) E;i",f E: E~; i:::lt",l[:, !,.IE!.,I..S FIS SE'I E; N l...t:::ti;i: G E; H!E N F ;t; 1::' 2204 For Performed Leeal qescriotion: Lot 22 Block ?his ~orm Reeorts Soils Lee Cleveland Anchorage, Alaska 99503 Clement 0ate perf0rmed__~_31_/76_~ Subdivision Stockb/)iqle~_S32JadJaLiSd~nn-- Percolation Test___yes Oeoth Feet Soil Characteristics 2-- Silt (ML) ..................................... Perc 6 -- test Sandy Silty Gravel (GM) ii-- 18-- 20-- Was Ground Water Encountered? No I~ Yes, At what Depth? I iReadinq F No bedrock encountered Date 8/30/76 Grnss Time Net Time . 4 0_h.r_~ Denth to H20 inches 2 saturat( 2 3 Net Dron inches ~eriod 0 4.5 1 3/4 Percolation Rate 1"~40 Minute Prnnosed Installation: Seeoa~e Pit Drain Field De~th of Inlet Depth To Bottom Of Pit Or Trench ~nUHENTS: 285 s~'~A--~-~--a~5~e area r~q~ired per bedroom. Test Performed a Certified B)' CONSTRUCTION TEST · . ................... LAB Date: .... ' ' O Et E GED', .-CHNICAL Et DEVEL_?MENT CO. Russell Oyster 694-2774 Soils Et Foundations Perfomed for: Legal Description: Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or688-2280 SOIL LOG Ear/Ellis 688-2280 Land Development Depth (feet) 0 1 So~l Charactertstic~ 2 3 6 ? 8 9 10 . 11 12 ~.., 14 15 16 · Ground Water Encountered: Yes__ Proposed Installation: Seepage Pit No /~ If yes, epth Drain Field Performed by: Date: ALASKA ENVIROI~'~.NTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue Suite B ANCHORAGE, ALASKA 99503 Phone 276-1361 SHEET NO. '~ OF c^~cuL^~EOSY _ ,~g~ ~P-~ DATE CHECKED BY DATE SCALE ALASKA UIgO[lmahTAL COIhTI OL ~nqincerinq 13 ~nuiPonm~nlol $~udi~s Mr. Robert Robinson Department of Health and Environmental Protection 825 L Street Anchorage, Alaska 99501 Mr. Robinson: I am writing you on behalf of Mr. Finis Sheldon, of ERA Finis Realty and Development Company, concerning Lot 22, Stockhausen Subdivision ($W 1/4 Sectio~ 3 T15N R1W SM). The original home upon this property was lost to fire, and Mr. Sheldon would like to build a duplex, containing two 2-bedroom units, while utilizing the existing well and septic system. As shown in the enclosed drawing, the existing well is 100 feet from the clean-out of the Jet Aeration unit. The standpipes for the drainfield could not be located due to snow cover. However, based upon Municipality of Anchorage records, the nearest edge of the drainfield lies within approximately 110 feet of the well. I am aware that construction of a duplex upon this property would normally require reclassification of the well as a Class C system, requiring 150 feet of separation between the well and any portion of the septic system. The lot is not large enough to allow placement of a septic system at such a distance, as shown on the enclosed as-built. A well log was not available to verify the depth of water production or the type of strata encountered during drilling of the well. I have obtained MOA records for the surrounding lots concerning the location of septic systems and wells, but I am unable to verify the separation distances of surrounding sewer systems from the well for lot 22. Due to the amount of snowcover in this area, it was not possible tove~ify that the required 150 feet separation can be met. It is necessary to obtain verification of these separation distances following breakup to ensure compliance with the requirements of a Class C system. At present, I can not verify these distances from the available information. On behalf of Mr. Sheldon, I would like to request a waiver of the required 150 feet of separation between his well and septic system, and permission to operate the existing systems in conjunction with the proposed duplex. I would greatly appreciate your assistance in reviewing this information. Should you have any additional questions, please feel free to contact me at 561-5040. Sincerely, ~ Harald R. Ehlers Environmental Engineer HRE/caj 1200 LUcsl 33r(I/~uenut. ~uite [3, Anchoru§e, filosko 99503.[907) 561-5040 Everett ~{onegger % Golden Alaska Realty 1~42 East 6th Avenue ~chorage, Alask 99501 Subjeet~ I~t ~2 Stookhousen Subdivision Approval for your ~]dividual newer and ~{ater faoilitien will not be granted until th~ followiag items have been comp! eted: ( ) A w~ll log i~ su3~m~tted to thin ~epartment. The top of the well oa~ng is sealed ~ith a sanitary seal ~o that it is wa%er tight. ( ) The depression or pit around th~. well easing should b~ filled with in~p~rvtou~ ty?~ soil ~o that it slopes away from the ~ell Whe .well ~asing is extended twelve(l~) in~h~s above ground level. oonstruction, also, ~o ins%%re th~ minim%m~ distance 'The s~ptic tank this office. () () A four(4) ~%ch ~amt iron cleanout be in,tailed to th~ n~ptic tank or leaching area. A r~rcolation ~est be .performed on th~ ~xlsting leaohing area. Thin will determin~ if the system is ad~q~at~ according to ~ational Standard~. A list of private firms January 31, !979 Page Two ~he number ~he ~ew~r ~y~tem was o~iqinally app~0ved for, ( ) co~nect to the publi~ sevter which 1~ availabl~ to t~ave ~n ~rrect~. If there are any f~h~r ~stions, Sincerely, Robert C. Pratt~ R.S. Assooiate Sp~eialist Alaska U.S.A. Federal Credit Union 777 Jun~a~ Street 99501 UMMLI'"1 U7Y F Development Services Department On-Site Water & Wastewater Section Parcel I. D. 051-062-28 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Complete legal description STOCKHAUSEN LOT 22 Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: I— I " Z©ZZ Location (site address) 21241 GINGER LEE DRIVE, CHUGIAK, AK 99567 Current property owner(s) CHERIE LINDEKUGEL DECLARATION TRUST Day phone Mailing address Real estate agent PO BOX 671896. CHUGIAK. AK 99567 2. TYPE OF DWELLING: Z Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 2 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® 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 $ 55 Waiver Fee $ Date of Payment 20 A02 j Date of Payment Receipt Number 70 6 26 2 Receipt Number COSA # OS C-2 11 5 5 (o 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 FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 9117/2021 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to r �,q/ these various and dynamic characteristics and are outside the control of the evaluator of the �y well and septic system. Therefore, any estimate of how long a system will function satisfactory g�Q: • .. �,9 ��� for current or future occupants or guarantee that no unseen encroachments, deficiencies or J discrepancies exist can be given by First Water Consulting& FWCS ' / * • TH .......* r r .�� ...� i 6. DSD SIGNATURE Curtis Huffman / System #1 Approved for 2 bedrooms ����`��s••. CE 128991 . 0 !iTF�F9���� System #2 Approved for bedrooms �\ PROESSOFESS1�Nt'� Disapproved Conditional approval for bedrooms, with the following stipulations: G Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other Legal Description: STOCKHAUSEN LOT 22 Parcel ID: 051-062-28 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) Water storage tank volume NA gallons Date drilled CIRCA 1976 Well disinfected for coliform test? ❑ Yes ® Nc Total depth 95+ ft PER ACOUSTIC TEST READINGS ® Coliform bacteria is Negative Cased to UNKNOWN ft Nitrate 6.97 mg/L ElNitrate less than MRL (ND) ® Sanitary seal is functioning correctly Arsenic ug/L ® Arsenic less than MRL (ND) ® Wires are properly protected FW`'r5 Casing height (above ground) 18+ in. Collected by Date of flow test for COSA 9/9/2021 Static water level at beginning of test 80 ft. Date of Sample 9/9/2021 Well production at time of test 4+ gpm Comments COLE SULLIVAN SCOPED WELL & NEW PITLESS INSTALLED. B. TANK DATA C. LIFT STATION Age of tank(s) 45 years ❑ Required maintenance completed Tank type/material SEPTIC / CONCRETE Age of lift station _ years Measured operating fluid level in septic tank 50" Lift station material ® Standpipes/foundation cleanout per record drawing Comments: Date of pumping 9/9/2021 D. ABSORPTION FIELD DATA Which system tested (date installed) 10/14/1976 ® ALL standpipes present per record drawing Total measured depth from grade 8.7 ft (max) Adequacy test date 9/10/21 Results 2 Pass For 2 bedrooms Fluid depth prior to test 26 in Measured depth to pipe invert from grade *2.6 ft (min) Water added 500 gal ❑ N/A – pressurized field New depth 73 in F-1 Monitor tubes _go to bottom of effective. Jf not, state depth into effective 6.1' INTO THE 8' ED Elapsed time 30 min — ®Code -required soil cover over field ** Final fluid depth 26 in ® System presoaked Absorption rate 300+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) Gallons introduced 2000 gallons If yes, enter date Comments/Deficiencies: *INVERT AT SUMP. **LOWEST ELEVATION OF FIELD / LEAST COVER --NO KNOWN FREEZING ISSUES 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 Wells on Adjacent Lots: Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' Surface Water > 100' ® Yes Animal Containment > 50' ® Yes if No ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ®Yes if No ft ® Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ft ft ft ft ft ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ® Yes if No ft Private Wells >' 100 _ ®Yes if No Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No _ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION - 1 certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Aw Aw •.c� ��� '.... ....�. • Curtis Huffman ��� ��Gj•.. CE 128991 ..•�w��/� ROFESS� NV`�,s-�,d ft ft Nitrate Advisory Certificate of On -Site Systems Approval # OSC 211556 Subdivision: Stockhausen lot 22 A water sample revealed a nitrate concentration of 6.97 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. rj1 3EE NOTE_ - 'GRAVEL :DRIVEWAY. I I I I Lot 22 0.71 Acres I Lot 23 10' M.E.A. EASEMENTS (BK. 84, PG. 245) EAST 178.19' I WOODEN FENCE SHED I� f SEPTIC PI -9.8'x14.2' DECK Lot 13 10' UTILITY EASEMENT / / 2.0' CANT \ WOODEN FENCE-///- WEST ENCE WEST 178.56' Lot 21 / / / / NOTE: THE GRAVEL DRIVEWAY ENCROACHES ONTO LOT 23. MORTGAGE SURVEY _x_ SCALE _ 1__= 40__ GRID NW 1460 Project No 21-625LA1 __ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, (n C. (907) 522-6476 Phone (907) 522-4625 Fax Professional Land Surveyors ken®longsurvey.com o OF 4 �Op jonathan®langsurvey.com I hereby certify that I have surveyed the following described property: LOT 22, STOCKHAUSEN SUBDIVISION (RLAT No. P-450) Anchorage Recording District, Alaska, and that this Mortgage Location Survey is a representation of the conditions that were found on the date the survey was performed. This survey does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained hereon shall not be used to establish any fence, structure, or other improvements. Dated this the _ � _ Day of __� �i s-� �___, L- c:L l _, at Anchorage, Alaska It Is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plot. r Q) 49TH y .. V�44'lFo '' ..LS -5202. ''. gJpG p�R��FeS510NAL AECC963 PORCH 35.6 M - N 2.0' ( n M WELL C) Z 2.0'x16.2' a rn CANT S p 26.2' Z 1.5' CANT I I I I Lot 22 0.71 Acres I Lot 23 10' M.E.A. EASEMENTS (BK. 84, PG. 245) EAST 178.19' I WOODEN FENCE SHED I� f SEPTIC PI -9.8'x14.2' DECK Lot 13 10' UTILITY EASEMENT / / 2.0' CANT \ WOODEN FENCE-///- WEST ENCE WEST 178.56' Lot 21 / / / / NOTE: THE GRAVEL DRIVEWAY ENCROACHES ONTO LOT 23. MORTGAGE SURVEY _x_ SCALE _ 1__= 40__ GRID NW 1460 Project No 21-625LA1 __ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, (n C. (907) 522-6476 Phone (907) 522-4625 Fax Professional Land Surveyors ken®longsurvey.com o OF 4 �Op jonathan®langsurvey.com I hereby certify that I have surveyed the following described property: LOT 22, STOCKHAUSEN SUBDIVISION (RLAT No. P-450) Anchorage Recording District, Alaska, and that this Mortgage Location Survey is a representation of the conditions that were found on the date the survey was performed. This survey does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained hereon shall not be used to establish any fence, structure, or other improvements. Dated this the _ � _ Day of __� �i s-� �___, L- c:L l _, at Anchorage, Alaska It Is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plot. r Q) 49TH y .. V�44'lFo '' ..LS -5202. ''. gJpG p�R��FeS510NAL AECC963 - / MUNICIPALITY OF ANCHORAGE ~ ~M~' *;~,[~lON I'" .......... ~// ENVIRONMENTAL ENGINEERING DIVISION ~ Telephone 264-4720 RECEIVED RE~UEgT FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FA~ILITIE~ ;)1 RECT!ONS: Complete all parts on page 1, Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER MAILING ADDRESS PROPERTY RESIDENT {If different from above) 2. BUYER MAILING ADDRESS ~ ~' ~. REALTOR/AGENT PHONE IPHONE 5. LEGAl. DESCRIPTION STREET LOCATION NUMBER OF ~ BEDROOM [] One [~ ~vCd" [] Five , ' Three [] Six [] Other * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975, For wells drilled prior to that date, give well depth (attach log if a~/ailable.) * I f individual/on-site, give installation dat~. ~ ~ ~ -~ ~' ~.~ If system is over two (2) years old an adeciuacy'~f [~-~equired TYPE E~SING LE FAMILY [] M U L~-PL~E FAMILY WATER S Y 7. ~DIVIDUAL* [] COMMUNITY [] P U ~ D.k.k.k.k.k.k.k.k~J T I L I T Y 8. s E WA¢~iA~ it¥1~,t/MO N .S i T E., [] PUBLIC UTILITY 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 I NSPECTO R INSPECTOR I NSP ECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FiVE [] OTHER [] MULTIPI'E FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVI DUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [~INDIVIDUAL/ON -~'E DATE INSTALLED E3PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or E~Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER~.__. TOTAL ABSORPTION AREA MATERIAL 4, DISTANCESwELL TO: Septic/HoldingTank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line ~OVED FOR '~ ~ ~~ ~ON DITIONA L A~L (lette~t accomp/~fifi~ DATE -~ ~*' ~/~ i~Y(ti~) /~ 72-010 (Rev, 3/78)