HomeMy WebLinkAboutSUNNY VALLEY LT 11 REM ~') 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
LiqlISTANCE TO:
LEGAL DESCRIPTION
Iwe,,
Inside length
IF HOMEMADE:
Dwelling
Well
DISTAN C E~,TO:
Lengt of each line
No. of lines ~
Top of tile to finish grade
Fou ndationz~) ¢
Depth
Crib depth
Building foundation
W dth
PHONE
'¢
Material
Nearesf lot line~ ~*
Trench width
inches
~(~ ~ inches
NO. OF BED.~OMS
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMIT NO.
Distance between~y~j~ f
PERMIT NO,
Total effective absorption area
Nearest lot line
Driller Distance to lot line PERMIT NO,
DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
~ /// /.,v~z~.~ 7-~'~
PPROVED
(Rev. 3/78)
by
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX972, CHUGIAK, ALASKA99E67 · TELEPHONE 688-2759
OWNER OF LAND /~//~ a.O ~qg ~C'~_? ~.
ADDRESS tod) ;o~/O ~ ' ~c~ ~3 ~ ~
LEGALD~CRI~ION ~ 7/ ,~e~O~ O~/~
DATE- Sta~ed .~//-~7/ Ended <~ ~/~ /
PE~ITNUMBER ~:/ O /~/~
DEPTH OF WELL
STATIC LEVEL OF WATER FT.
es<bRAw DOWN FT.
GALS. PER HR ~O
KIND OF CASING ~ ~ ~ <9
KIND OF FORMATION:
From /'? Ft. to
From Ft. to
From '7-"{:' Ft. to
From / ') 5'"FL ~o
From Ft. to--
From //7 Ft. to
From / {'~ ~d Ft. to / 6,
From __Ft. to
Ft. d) L/~ ~ ~ ,~ ~" [fid' '~'"/ From.-
. Ft. /~//d; ¢'(~? ~ From__
. Ft. ~,/,_7,,~'5~f~' A d~,a~.~. From
Ft ~ 6' 7'"
Ft.
Ft.
Ft. ~Z~.~ ~' t ~kt~at, e~ From__
From
From
From
From
From J (,, I Ft. to ] ~6 Ft, ~ ~o < /<' From
From /~*~r Ft. to
From Ft. to Ft.
From t '~;~: Ft. to ~cYt.d?,';,e'~< "~:~, : From
From c)5OFt. to~-q''t~ Ft. fif&%~9..~ ~.~c./~<~ /3~9oz'-''-t~:~''' From__
Fromm2 ~'(~L Ft. to ~0 Ft. ,,,'~/Z'~dC~O~./< Zi--~.Ce'~ From
From Ft. to Ft._ From
From__Ft. to Ft. From__
From Ft. to Ft. From
Ft. to--
Ft. to
Ft. to
Ft. to
Ft. to
Ft. to
Ft. to___
FL to
Ft. to
Ft. to___
__Ft. to--
Ft. to
Ft. to_
Ft. to_-
Ft. to
FL to___
Ft. to_--
.Ft.
Ft
Ft.
Ft
Ft.
Ft
Ft.
Ft.
Ft.
Ft
Ft.
Ft
Ft.
Ft.
Ft.
_Ft.
Ft
MISCL. INFORMATION:
DRILLER'S NAME
PERHIT NO.
k'~ .... , L-'¢._.,=, ER
F'F'LICRNT N..~. HAL&ER F'O E'2: "'q'-' .... ~"~/
LOCATION HILE <. ~,..~ ER
LEGAl LT 1t ;UNN'¢ VRII EN' ~,."D LCT SIZE :tCIC~E~RRE .F~T
T'¢F'E OF SC, IL RBSORF'TION S'¢STEt'I IS: TRENCH
P!RXIP1UP1 NI..If~IE~ER OF BEE:,ROIJHS = ~ SOIL RRTIN~=
THE REEUIRE[ SIZE ZF THE SOIL RBSOFF'TION S'¢STEH IS: ~"~
[ EF q H--- 7' liEf-~G'TH= (;e; G~!R%.'EL E~ER:FH= 5
- ,' ..~:1'.
THE _ENGTH D If,IENSICIN IS THE LENGTH (IN FEET? _.I~F THE .TRENCH OR DRR INFIELD.
THE B, EF'TH OF' R TF. EN-.FI F~R F'IT IS THE ~[:,ISTRNCE BETNEEN THE SLIRFRCE OF THE
3ROUND AND THE E, uTTON OF THE E::4C:RVRTION (:IN FEET::,.
~" FOR TRENCHE_,.
THERE IS NO ..CF 14IDTH ' ' ' "~
THE GRR',/EL [:,CF'TH IS THE ',IINIHUP1 [:,EP'FH OF mRHFEL BETNEEN THE OUTFRLL PIPE
RN[:, THE E, OTTOfl OF THE EXC:R',,,'RTICIN (IN FEET>N
~'Ei]:~L~ ! REg. SEPT I ~2 T(4~-.~ .... '~ I
PERHZT RPPLIE:RNT HAS THE ..~=,._,.,=,_~z%-~-~ ~ .~ ZNFORbl %H.IS DEPRRTHEHT [,IIA'ING THE
!NSTRt_LRTION INSPECTIONS-OF RN'¢ NELLS RD, JRC~T_. TO THIS PRLPE~l T AND THE
NUNBER. OF RESIDENCES THAT-THE NELL NILL FER,E.
, - II' FHI--'
RRRKFILLI'[;~G I:~F RNY SN'ST~M:'NITHEILIT 5~;NRL IF~¢F~CTION RN[:' RF'PRO","RL E'~
E:,EPART NENT 'N [ L~',..'BE '~OE:JE~:~, ~0 PROSECUTION.
P1ZNZPtL~ ~,[S~4L:E ~BETNEEN H NELL HND PI['~' ON b, ZTE _,,E[4H~E ~Z=,FO=,HL
~8¢'~¢EE'~ FOR R F'RZVRTE NELL OR ~58 TQ. 2¢8 FEET FROP! N F'LIBU[C [,.1~1_ DEF'ENDZNG
.IPON THE T'¢F'E OF F'UBLZC: NELL. '~' -
HZN[NUM DZSTRNE:E EROH R PRIVATE NELL ~'0 A PRIVATE SENER I_ZNE ~S 25 FEET' AND
TO R COHHIzfNZ'T~'~':%EI.'.IER LZNE ZS 75 FEET. '
NELL LL"=_, ARE RE6IUZREE:'.,RNB MUST E,E RETIIRNED TO THE'DEF'RRT~ENT 1.4ZTH[N ='a
OF THE NEBL E. Lf4FLETZON.
CTHER RE6!UZREHENTS NR'¢ APPLY. SF'EC:ZFZCRT[ONS AND CONSTRUCTZON E)ZRURHPI_. FIRE
R'¢Al LADLE TO I~;C~IRE ;F'ROPER INSTALLATION
Z _.ERTZF~ THAT ''
&. Z Rf'l FRHZLZRR NZTH.~THE RE6iUZREHENTS FOR ON-SZTE =,EthER_,. RNE:' LIELL_ H=, SET;
..... T ' '- " -I N* FI~HME
Fn~TH. BN--.1HE'H-H--.IFHLIFN LF R'-.H- - ·
2'. f' NILL INSTRLL THB SN'S~Ef4"IN 'RCt;uRDRNL:E NITH THE CODES.
~: I UNDER~q'RND'THFiT THE ON--SI.TE =,ENER SN'STEN NRY RE~LIIRE ENL. HR~=EHEN~ IE THE.
RESI[~E~'~CE I5 REP1ODE~ED TO ,INCLIj[:,E ~iORE THRN'2:.~:EDROOf'15. ..
"' . .:',' "'' ,,: :', /
I SSI.lED, B'~' ~_~_~__XN.,:..:~DR'T'E~_~-- V4.
O & E EN(~TNEERING & DEVELOF~qlENT CO.
Box 90, Davis St,, Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster
694-2774
Performed for:
SOIL LOG
Name: ./')/~:
Mailing Address' (~).
Legal Description:
Earl Ellis
688-2280
Tel. No. ~"'?q :' '"'~t/~
Depth (feet)
Soil Characteristics
PLOT PLAN
PERC.
TEST
~,'., ' .~'~
,~. ",.'-~ ~'Z--~ -~..~-~- ~ 2 2,'~,'-'/,
Oround Water Encountered: Yes No ~ . I ;~,~what de~th
proposed Installation: Seepage Pit Drain Field. ~"'
Comments: ~ ~'~m~ ~- ~'~ ~ ~
Pedormed by: / / L ~t ~ ~' ( ~ /~{ %'~*~
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 DWELL!h~G
050-354-20-000 HAA #
GENERAL INFORMATION
Complete legal description
LOt 11, Sunny Valley
Location (site address or directions) 22335 Eagle River Road, Eaale River, AK 99577
/P~'oj~eCty owner Janet Stiles
;.. Mailing address
..... Lend!rig agency
Mailing address '
AJgent Virginia Kohfield
Address
Day pnone 694-6256
??qq5 ~gl~ P{ver Road, Eagle River, AK 99577
Day phone
Day phone
16600 Centerfield Drive, Eagle River, AK 99577
694-4200
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
3
NOTE:
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.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
CommunitY On-site
Public sewer
xx~
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 Dy 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
Address
Engineer's signature
17034 Eagle River Loop Road Np. 204
Phone
Date -7/,3- 7 /O 2/
DHHS SIGNATURE
' l/ Approved for
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional .engineer's work.
Municipality of Anchorage ,ill] 27 1998
DEPARTMENT OF HEALTH & HUMAN SERVICES'
Environmental Services Division MUN~OP^U'~Y OF ANCHORAGE
825 L Street, Room 502 · Anchorage, Alaska 9950'~/1{~/~-~
Health Authority Approval Checklist
LegalDescription: Le'F I/ S,~y v4uc~.y ParcelI.D.: 05-0 --5¢ ¥ - '~-O
A, WELL DATA
Well type
Log present (Y/N)
Total depth ~ L/0
Sanitary seal ~/N) 'Y '~ J'
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed z.//~.~ //~' f
Cased to ) ) -/ Casing height (above ground) ~ "/-
Wires properly protected (~/N)
Date of test
Static water level t 3 /
Well production
WATER SAMPLE RESULTS:
Coliform O
Date of sample: ''/I I ~ / fl (~
B. SEPTIC/HOLDING TANK DATA
Date installed 0' / $- / ~' ! Tank size
FROM WELL LOG
O. G ? g.p.m.
AT INSPECTION
(2.3.
g.p.m.
Nitrate 0, / Other bacteria O
Collected by: S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
I o ~ 0 Number of Comparlments ;;L Cleanouts~/N) t/~ ~
Foundation cle~nout'(Y~l).,., ''~ 0 Depression (Y/~ /~ 0 High water alarm (Y/~ /v 0
"" '1 .... -
DateofPu i~g"'~J ~3 1~/~" '~.:Pumper
C. ABSORPTi'ON. FIELD DATA' : .:
gatein~.alle ~ /,.c-'[~ ! . Soilrating (g.p.d./ft~ '3 3-0 SYstemtype T.~.~.c~./
Length '~ ~ ~-. Width . ~ Gravel thickness below pipe G o Total depth
Effective absorption area (~ ~ ~ /~r ~'-Uon toring Tube present ~/N)~/EJ' Depression over field (Y/~
Date of adequacy test ~/'~}fl~ Results ~Fail) ~J~/~Sf For '-~
Fluid depth in absorption field before test (in.); 0 A~ Immediatdy after~/¥ ~ gal. water added (in.):
Fluid depth (ins) Minutes later: ! ~ I Absorption rate = z./~d + .g.p.d.
bedrooms
Peroxide treatment (past 12 months) (Y/N) ~v ,~,,x~ ~,-~0 ~,,~ If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
F.
Date installed Size in gallons
Manhole/Access (Y/N) "Pump on" level at*~.~ .~---~ "Pump off" level at*.
High water alarm level at* ~atum
Cycles tested
SEPARATION DISTANCES
Absorption field on lot
Public sewer main fa /4-
Sewer/septic service line 9.-,~ .z
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot /O O ~ ~
I00 r.p
On adjacent lots ) OO
On adjacent lots 1 o 0
Public sewer manhole/cleanout
Lift station fa/,~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation g--O Property line ~ '-H Absorption field
Water main/service line /o + Surface water/drainage Jo o Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line '~' ( ~' 4, ,¢ ~,~) Building foundation 2 ~- Water main/service line
Surface water / 0 o 4- Driveway, parking/vehicle storage area ~
Curtain drain No,.,& ~o~ Wells on adjacent lots /~o i¢
ENGINEER'S CERTIFICATION' ~ .
~ certify that ~ haVe determined thru fie~d inspecti~ns and review ~f Municipa~ re~t~`~?~4 I~tems are
in conformance with MO~ ~A guidelines in effect on this date.
Signature
HAA Fee $.
Date of Payment '7/~7/c~
Receipt Number 057~.~-
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
MUNICIPALITY OF ANCHORAGE
M E M 0 R A N D U M
WATER WELL ADVISORY
HEALTH AUTHORITY APPROVAL NO. HR ~O / ~
During a recent Health Authority Approval on-site inspection
and test of the potable water supply well. on Lot ~[
Block -- of Ju/~//Vx// F~L~y Subdivision, the well's
productivity was determined to be ~. ~ gallons per minute.
The minimum well productivity required by this Department
(AMC i5~55) for a ~ bedroom residence is O, ~ gallons
per minute. Although the subject well currently exceeds this
minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies of the subject
Health Authority Approval.
~R~nq
ROBERTC. COWAN, RE.
ROBERTA. SHAFER, EE.
ROAD DESIGN
WELL RECOVERY TEST DATA
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
CLIENT: ...,~F~ t~ I~'1'
WELL LOCATION (legal):, ~'
WELL DEPTH:
CASING DEPTH: [1~
TEST PROCEDURE: MISC DATA:
1) Draw water down to pump. Casing Height:
2) Shut pump off"15-60 min. Sanitary Seal?
-record time Wires In Conduit?
-record meter reading Grading O,K.?
3) Turn pumpon. Drawdown, Pump Depth:
4) Shut pump off. Samples Taken?
-record time Date:
-record meter reading
5) Calculate gal./min, recovery.
TEST DATA:, START TIME: ~. :Oq STATIC WATER LEVE. L: I '~' /
TRIAL I PUMP m T,ME I .ETER m GAL. IN.
OFF 4',~0 ~ ~ ~
OFF % /~
OFF
3 ON
OFF
OFF
4 ON
OFF
OFF
5 ON
OFF
RESULTS: WELL CURRENTLY PRODUCES:
FLOW RATE NOT GUARANTEED--SUBSEQUENT VARIATIONS CAN OCCUR.
17034 NORTH EAGLE RIVER LOOP. SUITE 204 · EAGLE RIVER, ALASKA 99577
RickMystrom,
Mayor
Department of Nealth and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
http:ffwww.ci.anchorage.ak.us
April 29, 1998
Robert C. Cowan, P.E.
S & S Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Subject: Waiver Request for Lot 11 Sunny Valley Subdivision
Waiver Request #WR980013, PID #050-354-20
Dear Mr. Cowan:
Your request for a waiver of the required 10 foot separation
between an on-site wastewater disposal system and a lot line has
been approved. The waived distance is 2 feet from the leachfisld to the
south property line.
This approval applies to the existing on-site wastewater disposal
system lot line separation only. Any future upgrade to the on-site
wastewater disposal system will require all separations be met or
another approval from this department.
If there any further questions or concerns regarding this waiver,
please call our office at 343-4744.
Daniel J. Roth
On-site Services
ljw #7
~MUNICIPALITY OF ANCHORAGE~'/
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR9 WR980013 PID9 050-354-20 HA~ Permit
Date Received: April 20, 1998
Legal Description: Lot 11 Sunny ,Valley Subdivision
Engineer: Robert C. Cowan, P.E., S & S Engineering
17034 Eagle River Loop Road, Suite 204, Eagle River, Alaska 999577
Applicant: Sarl B & Janet M Stiles
Waiver Requested:
of 2 feet/
Lot line waiver of the leachfield~and the south property line
Criteria: 1. Geology:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
Points:
3. Other:
Waiver is Granted: Y Waiver is NOT Granted:
List Conditions or Reasons for above:
Name of Reviewer
Rec #: #03574/9114 glllount: $ 115.00 Date Paid: April 20, 1998
APPROVALS
SEWER&WATER
INSPECTION
WELLINSPECTION
& FLOWTEST
SiTE PLANS
ROADDESIGN
SOILTEST
STRUCTURAL&
MECHANICAL
INSPECTJONS
ROBERT C. COWAN, P.E.
April 17, 1998
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot 1 l; Sunny Valley Subdivision
CIVIL ENGINEEP~
(907) 694-2979
FAX (907) 694-1211
RECEIVED
APR 20 1998
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
Request you grant a waiver for the horizontal separation distance between the
leachfield and the south property line at two (2) feet.
We do not anticipate any adverse effect on the adjacent properties. The property
line is adjacent to a road right of way, see attached asbuilt survey.
If you require additional information, please contact us.
Sincerely,
RCC/gk
attachment
17034 NORTH EAGLE RIVER LOOP· SUITE 204 · EAGLE RIVER, ALASKA 99577
~P1~-07-98 TUE 16:55
RE/~iR× OF E~GLE RIVER F,qX NO, 9076960214 P. 02/02
.... ~ :.;..:.:. ,~...~.:...~.,.~.:.,i..::'...:..~' :~."~,?.~:..':? ~:i~?:~ :.?~:-~:.:?~i~!~..'~:..i~.~i~,i
; APPLI{.~,NT FILLS OUT UPPER HA~. ONLY
~, . -:. , , / . Phone
PropertyOw~ner F'- ' ' ' ~ ' -' .... ~ '; ~" ' / '-
~. . ~ ~ Zip Code '' : ~ ,.~ / .-~ ~ ..
~ : . _. .. .~( Zip Code '-'
/.;./~./.. ;/ -. , / ,.~' .' . : .). :' /' Phone
Time Time Time
Date Date Date
Inspector
Field Notes:
l.j,o .o
Inspector
Inspector
Inspector
J U L 0 1 1983
"Municipality of At~,hor~
"Dept. of ~teaJ~h &
E~vJrorm~P~ ~'o~tJum"
('~)) APPROVED BEDROOMS ) DISAPPROVED
) CONO T[ON APPROVAL'
By:DATE '~2~:~A~. .
*CONDITIONS OF APPROVAL
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well to Tank
Well Log Received
Septic Tank Size
INSPECTION APPOI NTM ENTS ~-~
~UN]CIPALI~ OF ANCHOEAG~
MUNICIPALITY OF ANCHORAGE D~PT. OF H~AL7H &
825 L Street - Anchorage,
Alaska
SE P /981
~ Telephone 264-4720 RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACI~TI~
DIRECTIONS: Complete all parts on page 1, Incomplete reques~ will not be processed, Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
MAILING ADDRESS
PROPERTY RESIDENT (H different from above) PHONE
MAI LING ADDR ESS
I
MAI LING ADDR ~SS
MAILING ADDRESS
5. LEGAL DESCRIPTION
;TREET LOCATION
6, TYPE OF RESIDENCE ~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OFxBEDROOMS
[] One [] Four [] Other
[] Two [] Five
E~~ ':~rhree [] Six
7. WATER SUPPLY
~ INDIVIDUAL* * ATTACH WELL LOG. A well Icg is required for all wells drilled '
[] COMMUNITY since June 1975. For wells drilled ~3rior to that date, give well
[] PUBLIC UTI LITY depth (attach icg if available.)
8, SEWAGE DISPOSAL SYSTEM
I~1 INDIVIDUAL/ON-SITE** /~1 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 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
E31NDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBL,C UT,L,TY
Connection Verified
INSTALLER
[]Septic Tank or [~] Holding Tank
Size: /~-(~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
I[~'"A~P ROV E D FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
DATE [] DISAPPROVED B Y~"~~''' ,~ /'"'"
72-010 (Rev, 6/79)