HomeMy WebLinkAboutTHUNDERBIRD HEIGHTS #3 BLK 6 LT 13Onsite File
Thunderbird
Heights #3
Block 6
Lot 13
#051-582-29
Permit OSP221250 is to upgrade to a 5-
bedroom tank, but the field is sized for 3-
bedroom. Only a 3-bedroom COSA approval
can be granted until the field is upgraded.
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP221250
Work Type: SepticTank Upgrade
Tax Code Number: 05158229000
Site Legal Address: THUNDERBIRD HEIGHTS #3 BLK 6 LT 13 G:1865
Site Mailing Address: 24506 TEAL LOOP, Chugiak
Owner: CURTNER F RICHARD
Design Engineer: EKLUTNA ENGINEERING, LLC*
This permit is for the construction of:
Effective Date:
Expiration Date:
Lot Size in Sq Ft
Total Bedrooms:
mcnt
o Sn
c
n
N
Department
7/15/2022
7/15/2023
20000
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received B)
Issued By:
I
Date: / r
Date:
5
0- 0-9 2
MV UHMPAUTY OF AHCHORAGE
<<}
Development Services Departments f Phone: 907-343-7904
On -Site Water & Wastewater Section = Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051-582-29
Property owner(s) CURTNER F RICHARD
Mailing address 1381 Hillcrest Dr #102 Anchorage
Site address 24506 Teal Loop Chugiak
Day phone
AK 99503
Legal description (Sub'd., Block & Lot) THUNDERBIRD HEIGHTS #3 BLK 6 LT 13
Legal description (Township, Range & Section)
Lot Size 20,000 Sq. Ft. Number of Bedrooms J
APPLICATION IS FOR:
APPLICATION 1S AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑
Initial ❑
Single Family (SF) []
Septic Tank 0
Upgrade F
(w/wo ADU)
Holding Tank 1:1Renewal
ElDuplex
(D) ❑
Privy ❑
Multiple Dwellings ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
-THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above infoation
is correct. I further certify that
this is in accordance with
applicable Municipal Cods
(Signature of property o e
or authorized agen) /
Permit/Rush Fees: ) '� 5 Waiver Fees:
Date of Payment: 7 1UDate of Payment:
Receipt Number: 02 f a IJ Receipt Number:
Permit No. D SP �-) 1 JOU Waiver No.
G1Development ServicesMuilding Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221250, Rebecca Carroll, 07/15/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221250, Rebecca Carroll, 07/15/22
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1,500 G
PLASTIC TANK
MtN 7.75
Septic Tcnk Permit Drcwing Prepored for
RICHARD CURTNER
24506 Teal Loop Chugiak, Alaska 99567
THUNDERBIRD HEIGHTS #3A BLOCK 6 LOT 13
osP221250
IKLUTNA ING/N[[R/NG, LLC
19162 MOUNTAIN ROAD
CHUGIAK, ALASKA 99567
(e07) 406- 1 058
DATE:71612022
DRAWN:CLT
SCALE:1"= 5'
PID: 051-582-29 SHEET 2OF 2
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221250, Rebecca Carroll, 07/15/22
~'~ ~) 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 E~NEW
MAILING ADDRESS ~ ~/~ ~
LOCATION / NO. OF BEDROOMS
~ DISTANCE TO: I Wel~ I Absorptionaroa~, Dwellings/ PERMITNO.
~=~< Manufacturer ~ ~6~_ ~, Material>¢~ "~/ No. of compartments
Liq, capacity in gallons Inside length ' Width Liquid depth
/APO IF HOMEMADE:
~ ~ DISTANCE TO: Well DwelJlng P~RMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
O Well ~ Foundation Nearest lot line / PERMIT NO
Trench width . Distance between
--~ No. oflinest Length ofeachlinj~ i ~ inches
Top of tile to finish grade Material beneath tile ~ Total effective absor tion area
Length Width Oepth PERMIT
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIAL>/~ ~ ~
SOIL TEST RATING 'PSw
REMARKS
7-/Y-
72-013 (Rev. 3/78)
PERMIT NO,
MUNIClPF~LITY OF
DEPARTi"IENT ~ HEALTH AND EN.~IRONMENTAL'' ~0TECTION
825 'L' STREET, ANCHORAGE, Al<.
264-4720
L--IN--S T TE SE&,JER F'ERI~.I T T
( 800~_~4 )
APPLICANT JAK CONST
LOCATION RAVEN
LEGAL LT lS BLK6 THUNDERBIRD
TYPE OF SOIL ABSORPTION SYSTEM IS:
CHILKAT CT BOX 25ii
LOT SIZE
TRENCH
21000 SQUARE FEET
MR;~IMUM NUMBER OF BEDROOMS
SOIL RATING (SQ FT/BR)= 95
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
IDEPTH: 8 L E~-~,]TH: --~6 GF~RVEL [:,EPTH: 4
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE ENCRVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE E~CAVATION (IN FEET).
i~:EC-~LI I RED SEPT I C: TRr~--. S I ZE= i000 GHLLOr-~S
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
TWO ( 2 ) I ~sPECT I O~S ARE REQL! I REC-
BRCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS ~5 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PER~ T T EXP I RES DECEP18ER -~i.. i-q-88
I CERTIFY THAT
i: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2~ I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES,
2: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
V4. 0
PERMIT NO.
[:,EF'FIRTMF_'NT I_')F HEF:IL]'H FIND ENVIRONMENTFIL PROTEC.:TION
825 "'1...-' STREET., RNCHORFIGE., HI-:::. 9950i
( 7:~0522 )
FIF'F'L I CFINT
LOCR'I" I ON
LEGRL
JFIK CONST.
RFIVEN
L.:[.3 BE; -FHUN[)[_:.'R8t Ri]:, HTS
CHILKWF CT BOX
LOT SI 2:[:
694 StSi
21000 SQURRE FEET
TVF'E OF SOIL I:IE,'SORDTION SVSTEM IS;: TRENCH
MFl',,.():ldt.lld NUMBER OF DEDROOHS = 2-.'
SOIL RRTII",IG <SQ FT/BR)= 5'5
I-HE REQLIIRE[:, SIZE OF THE SOIl_ FIE:SORPTION S'¢ST'EM t.S:
THE LENGTH [>IMI:TNSION IS THE LENGTH (IN FEET) OF' TIlE TRE]',ICH OR DRF:IINFtE1..D.
THE DEPTFI OF' R 'FRENCH OR PIT IS THE [:,!STFINE:E BETHEEN THE SURFRCE OF THE
GRCIU~",tD RN[) THE: K:,'OTTOM OF ]"HE E',:",'CAVATION '.'.'IN FEET).
THERE IS NO SET NIDTH FOR TF'.ENCHES,
TF!E GRF¢,/EL DEPTH I:-T, THE MINIMUM DEPTH OF GRRVEL E,'ETHE"EN THE OUTF'FILL F:'IPE
FIND THE BOTTOM OF- THE EHCFI',,,'RTION (IN FEET).
PERMIT FIPPLIC:RNT FIRS THE RESPONSIBILIT'.? TO INFORM THIS DEPFIRTMENT DURIi'.4G
INS"t"RLLFITION INS;PECTIONS OF RN"r' I,.!ELL. S RDJRCEi',I-f' TO THIS PROPERT'.? FIN[.', TFIE
NUMBER OF RESI[:,ENCE:S THFFI" ]'FIE WELL 1.4ILL SERVE.
THE
8RCI<FILI_ING OF RN"r' S"r'STEH HITHOLIT F'INFIL INSPECTION FINC, FIPPRCF,/FIL. E:'T' THiS
DEPRF..:THENT I-,.IILL BE SUBJECT ]"O PROSECUTION.
MINIMUM D!S'TF:ff4CE BETHEEN FI P.IELL RND RIq'T' ON-.SITE SEHFIGE I}ISF'OSRL SYSTEM IS
iO0 FEET FOR R PRI',,,'RTE I.,.IEL. L.~ OR
::i..Se~ TO 2:00 FEF_'N" FROi"I F! PtJBLtC 1.4ELL DEPENDING LIPON TIlE T'-r'F'E OF PLIBL. IC .I-,.1[]]_[
OTHER REQUIREMENTS i'dR"r' RF'PLY. SPECIFICRTIOi",IS FIND COI",IST'F".UCTION DIRGRRMS FIRE
FI',,,'RIL. REd. i-FO INSURE PROPER INSTIaLL. RTIOIq.
I CER]'iFV THI::IT
±: I RM F'RMIL. IRR HITH THE REQLIIREMENTS FOR ON-SITE SEHERS I::IND I.,.IELL.S RS SET'
FORTH Bh" ]"FIE MUNICIPFILIT'-r' OF' FINCHORRGE.
2: I HILL ]:I',I'.STRLL -f'HE S"r'STEPI IN RCCORDF:INC:E HITH THE CODE-S.
]:: I UNDERSTRND TFIFIT ]"FIE ON-'SITE SEI-qER SYSTEM i'"IR'T' REQUIF'.':E ENL.FIRGEMENT IF TPIE
RESIDENCE I~; REMODELE[) TO INCL. LI[)E MORE I"HFIN 3 ErE[:,ROOHS.
_, ! bi ,lEI..,: .............................
Ft~F .J'FIK CONST.
.[ :,::,UE[. [],~ '[
O & E ENG,NEERING & DEVELO, ,vlENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster
694-2774
Performed for:
Legal Description:
Earl Ellis
SOIL LOG 688-2280
Depth (feet)
Soil Characteristics
8__
9__
10__
PLOT PLAN
11__
13__
PERC. TEST
14__
15p
16__
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit
Comments:
No /~ If yes, what depth
Drain Field
Performed by:
Date~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL 0-7_ joLjc '
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date( "� jyq 87
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
LOT 14 BLOCK 6, THUNDERBIRD HEIGHTS.j3 T16N, R1W, Section 25
Location (address or directions)
144 TEAL LOOP ROAD
(b) Applicant Name AUDREY MASON Telephone: Home NA Business 694-4200
Applicant Address P.O. BOX 772849, EAGLE RIVER, AK 99577
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer ❑ ; Other Q9X (explain); REALTOR
(d) Lending Institution Telephone NA
Address ron
(e) Real Estate Company and Agent Rfi7AX OP EAGLE RIVER. ATFN: AUDREY MASON
Address P -O. BOX 772849, 1=.A .1RR�TVFR AK 99577
Telephone 694-4200
following(f) Mail the HAAto the
. • FOR PTCIalP BY U:I: ENGTN=ING S=CES
2. TYPE OF RESIDENCE
Single -Family UC Multi -Family ❑ Other
Number of Bedrooms
3. WATER SUPPLY
Individual Well ❑ Communityll 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 KX 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)
(r9n 0 SW -LL
.. /".
Z to Z abed'
->ILom s,Laaw6ua leuolssajoid
ayl u! suo!ssiwo Lo sLoLLa Lol alq!suodsal lou si a6eLoyouy to Apedioiunyy a(11,panssi si aleoll!lLao a aLolaq elep azAleue
Lo suoiloadsui lonpuoo lou op d3H0 to saaRoldw3 sluawannboi alels pue IeLapal uleuao Als!les of iapio u! suo!lnl!lsu!
6u!pual ilayl pue sawoy to sLaseyoLnd of (salLnoo a se s!ttl saop d3H0 ay1 'eNsely 10 MIS ayl u! paLa3516a1 Laau!6u8
leuo!ssalad luapuadapul ue tg anoge g ydeAcied ul uaA16 suopeivasaLdal ayl uodn Ltlolos paseq saleopiliao lenaddy
A1!Lo14iny ylleaH sanss! (d3H0) uo!)oaIOJd Ieivawuol1Au3 pue 411eaH to luawlleda0 96eLoyouy to Al!led!ounyy ay1
9CL9.33 'a
cLatn3 ^r 91-101
..........o.....
NOI1nV0
FPO
lenaddy leuo!1!puo0 to swLal
leuoll!puo0 panoLddesl0— panaddy
ale0� ��� L(q swoapaq 7� Lo1 panaddy
( 1VAOHddV d3H0
Y
a1e0
ssaLppy
•uolloadsui s!yl to olep eql
uo toolla ul suolleln6ei pue 'saoueu!pLo'sapoo ale1S pue led!o!unVy Ile yl!m aoue!idwoo ul si walsAs lesods!p Lalemalsem
Lo/pue Alddns Lalem al!s-uo ayl 'uo!loodsui pue uo!le6llsanw Aw wo11 pue sal!1 a6eLoyouy 10 Apledlalunpy eql wo11
pau!eigo uo!lewLolui ayl uo paseq leyl A1!Lan LaylLnl I •u!aLay paleolpu! aLnloruls 10 adAl pue swoapaq to Lagwnu 0(11 Lot
alenbape pue leuo!lounl'ales st walsAs lesodslp Lalemalsem Lo/pue dlddns Laiem al!s-uo ayi leyl smogs lenaddy Aj!Loylny
ylleaH s!yl to uo!le61lsanul,tw le(11 Al!LaA I'molaq umoys alep uollep!len ay110 se pue olaLay pax!{le leas Aw Aq pa!1!lLao sy
r.
NOIIVWHO.4NI ONV VIVO'H0HV3S 311-4'S1S31'SNO1103dSNl `JNIOIAOUd WH13 `JNIH33NION3 *9
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^
MUNICIPALITY OF ANCHORAGE (Ii
MUNICIPALITY OF ANCHORAGE
HEALTH AUTHORITY APPROVAL (HAA)
ENVIRONWNTAL SERVICES DIVISION
CHECKLIST - FEBRUARY 1984
SEP 31987
4720
Legal Description: f /3 6�/is ! T +• 6..
RECEIVED
Z21eje,r Jf'3 7-/1"'V,o? s"dr
A. WELL DATA
Well Classification
If A, B, C. D.E.C. Approved (Y/N)
Well Log Present (Y/N)
Date Completed Yield
Total Depth Cased to Depth of Grouting
Static Water Level
Pump Set At
Casing Height Above Ground
Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots
To Nearest Public Sewer Line
To Nearest Public Sewer
Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by
; Date
Water Sample Test Results
Comments ,Z%'1ASli
B. SEPTIC/HOLDING TANK DATA
Date Installed % Size 4250 541r No. of Compartments 59 -
Standpipes;
Standpipes (Y/N) y Air -tight Caps (YIN) y — Foundation Cleanout (Y/N)
Depression over Tank (Y/N) /✓ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ; for
Holding Tank High -Water Alarm (Y/N) �� Id' T k P Y/N
Separation Distances from Septic/Holding Tank
Temporary Ho Ing an ermU ( )
To Water -Supply Well To Building Foundation X
To Property Line 4/.2 / To Disposal Field --I-
To Water Main/Service Line �/� To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-026(11184)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata Type of System Design
Date Installed 1980 Length of Field 39
Width of Field 3,e Depth of Field rT`
Gravel Bed Thickness
Square Feet of Absorption Area 3 Standpipes Present (Y/N) ~�
Depression over Field (Y/N) Date of Last Adequacy Test 7
Results of Last Adequacy Test Sa7`'r `t`"y /' JS,, 6 rim,. 2ti fu 3 (;? P w< ae
Separation Distance from Absorption Field:
To Water -Supply Well %160 To Property Line S
/
To Building Foundation a To Existing or Abandoned System on
Lot 4 ; On Adjoining Lots t 30 '
To Water Main/Service Line 410 To Cutbank (if present) N/
To Stream/Pond/Lake/or Major Drainage Course '��
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
�t
Date Installed
Size in Gallons
"Pump On" Levet at _
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
— 'Pump Off' Level at
•' Check Permitted Bedroom Rating Against HAA Request ••
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date 9Z3lff 7
Company �✓P F,f• MOA No. .ST —�7_ ` s
Receipt No. /O D / OO a J
Date of Payment 3
Amount: $ lDU
U
Page 2 of 2
72-026 (11,84)
OF, At
�r�T-1 ��.�-•
Louis A. Butora
CE -6736
Seal
APPLIC~_AT FILLS OUT UPPER HAL, .,ONLY
Property Owner ,/~ ~ !~/~.~ ~ ~ ~.~, Phone
· /~/ ~,'/"v'~ i? ' /,'/ ~?i:,'C/~%~
Buyer /
Address Zip Code
Lending Institution Phone
Address Zip Oode
Realty 0o. & Agent ~ .~/~. :~ < ~,;~ ~ ~:~/.~ ~- ~ ~ ~, .~ Phone
Legal Oescription
S~r..t ~.~S~ ,,-,:~,
~ Multiple
8ewer ~isposal
Time Time Time Time/ I
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
(.~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
DATE J~ ~,~ (.E~ ~
Soils Rating Date Sewer Installed Well TO Absorption Area Well Log Received
Well to Tank Septic Tank Size
72.023(3182)
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
I NSP ECTO R INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~CiPALJTY OF ANCHORAGE
~ 825 L Street - Anchorage, Alaska 99501 DEPT. OF HEALTH &
( ENVIRONMENTALSANITATION DIVISION ENVIRONMENTAL P~iOT£CTION
Telephone 264-4720 00T ~ ~_ 1980
DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing·
MAILING AD D~{ ESS
PRO~SERTY RESIDENT (If'different from a~ove) PHONE
2. BUYER ~ PHONE
MAI LI N~ AE~DR~SS
3. LENDING INSTITUTION ' ~ ' PHONE-'
MAI'I~I N~G ADleR E~S
·
4. REAI~TOR/AGENT~ ~ / ', J PHONE
MAiLiNGADDRESS r~'~'~d
I
[] One [] Four
[~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY J~ Three [] Six
[] Other
7. WATER SUPPLY
[] INDIVIDUAL* * ATTACH WELL LOG. A well Icg is required for all wells drilled
~ COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTILITY depth (attach Icg if available.)
8. SEWAGE DISPOSAL SYSTEM
,~ INDIVIDUAL/ON-SITE** .,,/~'~ 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
[] iNDIVIDUAL/ON -SITE ~ DATE INSTALLED
[]PUBLIC UTILITY -~ .~ (~(~
Connection Verified INSTALLER
[]Septic Tank or E~]Holding Tank
Size: [~'~ ~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL AESORPTION AREA MATERIAL
4, DISTANCESwELLT0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
[~"~ APPROV ED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY ~
72-010 (Rev. 6/79)