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HomeMy WebLinkAboutTIMBERLUX #3 BLK F LT 14 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: OSP221341 Work Type: Septic Upgrade Tax Code Number: 01827180000 Site Legal Address: TIMBERLUX #3 BLK F LT 14 G:3136 Site Mailing Address: 4540 TIMBERLUX CIR, Anchorage Owner: CLARK -BERRY CHLOE K & Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date Expiration Date Lot Size in Sq Ft Total Bedrooms: �1»cnt 1 llepartmetut 10/10/2022 10/10/2023 35719 0 Disposal Field 0 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 Veronica Pope 2022.10.10 Received By:*kl�11:43:05 -08'00' Date: I Issued By: Alfil Date: 3 Community Development Department- r- Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 018-271-80 Property owner(s) Chloe Clark -Berry & James Berry Day phone Mailing address 4540 Timberlux Circle, Anchorage, AK 99516 Site address 4540 Timberlux Circle Legal description (Sub'd., Block & Lot) Timberlux #3, Block F Lot 14 Legal description (Township, Range & Section) Lot Size 35,719 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial ❑ Single Family (SF) ❑X (w/wo AD U) Septic Tank ❑X Upgrade ❑X Duplex (D) EJ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: S�I �� Waiver Fees: Date of Payment: 2- Date of Payment: Receipt Number: 75P Receipt Number: Permit No. 05/222 13`-1 ) Waiver No. Permit App_::- : ._..:c August 25, 2022 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Timberlux Subdivision, Block F Lot 14 Septic system design Dear On-Site Services Engineer: The owner of the above lot would like to replace his older septic system, so we are submitting this permit application for the construction of a new one. The attached site plan identifies the location of the home as well as the proposed septic location. No conflicts exist between this proposed system and any other well or septic system, whether on this lot or adjacent lots. The ground surface on the lot is relatively mild with no major slopes. (There are no slopes greater than 25% within 50 feet downslope of either the primary or alternate site.) Contours are shown on the site plan showing the grade and direction of flow. Stormwater drainage will not impact this septic system. The new trench will be constructed parallel to the slope as much as possible. Wells on this and adjacent lots are shown. The new advanced-treatment system will be a minimum of 50’ from all wells and surface water, and the trench will be more than 5’ away from the septic tank. Please refer to the attached test hole logs, plan and profile pages for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221341, Deb Wockenfuss, 10/10/22 x x x x x x x Benjamin Schiller CE 12592R EGISTEREDPROFES S I O N ALENGINEER 1"=50' 40' LONG x 5' WIDE, 1' EFFECTIVE DEPTH ABSORPTION TRENCH 1500-GAL ADVANTEX TANK w/ AX20 POD CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND TH#1 TIMBERLUX #3, BLOCK F LOT 14 FEET 0 50 100 ≥10' NOTE: NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS. TIM B E R L U X C I RCL E 3-BDRM HOME 9/9/22 10' U T I L I T Y E A SE M E N T 380 385 390 385 390 395 DECOMMISSION EXISTING TANK PER UPC ABANDON EXISTING TRENCH 50' WELL RADIUS ≥5' SEPTIC BED LOCATION ON NEIGHBORING LOT LOCATION SEPTIC SYSTEM ON ADJACENT PROPERTY IS TO THE SOUTH Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221341, Deb Wockenfuss, 10/10/22 TYPICAL TRENCH SECTION (NO SCALE) NOTES: 1. GRADE AREA OVER TRENCH TO DRAIN AWAY 2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2' WITH 2" OF INSULATION 3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY Benjamin Schiller CE 12592R EGISTEREDPROFES S I O N ALENGINEER4" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK5' 6" 2'-6" 1' DESIGN FACTORS:SYSTEM REQUIREMENTS: 450 GPD PEAK FLOW PERK RATE: 32 MIN/IN APPLICATION RATE: 2 GPD/SF 5.0' WIDE TRENCH SYSTEM 1500-GAL ADVANTEX AWWTS BOTTOM OF TRENCH: 3.5' BELOW GRADE FLOW LINE ELEVATION: 2.5' BELOW GRADE TOP OF TRENCH: 0.5' ABOVE GRADE 450 GPD / 2 GPD/SF /5' WIDE * 0.88 RED. FACTOR = 39.4 LF TRENCH REQUIRED (40 LF SPECIFIED) GEOTEXTILE FABRIC TIMBERLUX #3, BLOCK F LOT 14 9/9/22 2" INSULATION Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221341, Deb Wockenfuss, 10/10/22 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 DEPTH (feet) TEST HOLE 1 DATE READING START TIME NET TIME (minutes) DEPTH to WATER NET DROP PERCOLATION RATE: (MIN/INCH) (inches)(inches) DATE OF MONITORING WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING IF YES @ WHAT DEPTH? 7/1/22 1 2 3 GM (SILTY GRAVEL) Professional Engineers Stamp: NO TIMBERLUX #3 BLOCK F LOT 14 7/14/22 019-271-80 JIM BERRY 11:311 2 3 0 12:02 12:32 2.5' OB 30 Benjamin Schiller CE 12592R EGISTEREDPROFES S I O N ALENGINEER7/14/22 PERC TEST LOCATION TECHNICIAN: L.TIDWELL 1 116 N/A 9.0' 7/13/22 COMMENTS: 6" DIAMETER TEST HOLE PRESOAKED PRIOR TO TESTING SITE PLAN 1116 USCS SOIL CLASSIFICATION WAS VISUALLY DETERMINED 0 30 15 16 15 16 0 30 15 16 15 16 32 5.5' 10/4/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221341, Deb Wockenfuss, 10/10/22 NILNICIPALI:TY OF, ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM VIAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE ANP REPAIR . R�EtEMENT, herein the. iAGREE viENT" made and entered. .,into ""as of this L// A DayT of L J,4&4k of'07�! by and between y herein the "OWNER," and the Municipality of Anchorage, herein the ` ML`NICIPALITY", in accordance with Anchorage Municipal Code (AMQ 15.6-5.365. In consideration of the mutual covenants contained herein, the parties to this A,�,recmcnt ac-,rce as follows: 1. Advanced Wastewater Treatment Systems. The. Ylunicipality grants permission to the 0wzzer to utilize and operate an Advanced Wastewater Treatment System (AZA WTS), described as Advantex System located at (legal description) Timberlux #3, Block F Lot 14 2. Maintenance. Repairs and Alterations. (0,vner is required to read, understand and initial each section) Througllort the terns of this Agreement. the Owner shall enter into a service agreement with. an. A'W'\ TS service and maintenance provider approved by the .Municipality or the manufacturer's representative. The AW%7TS shall, be maintained in. a satisfactory condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's appro.-,, al for operation in the Municipality. It shalt be the responsibility of the Ov per during the terns of this flgreement to pay for all repair(s), maintenance; adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (ty*cally $400 to $600). Owner agrees that only maintenance and. repair personnel approved by the Municipality, or the manufacturer's representative i�dll inspect and make any necessary maintenance, repairs or permitted alterations to the system. 0,N,.zer acknowledges that regular maintenance of an AW,)VTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. OSJ1 8/2018) Page] of 3 Owner acknowledges that the Municipality may request records of maintenance and repairs from the;manufacturer`s representative or maintenance provider. Owner acknowledges that the fine for failing to maintain and repair an ARTWTS may be assessed in accordance w-ith AMC 14.60.0' 0. } Owner agrees to grant the N- 4unicipality reasonable access to test and inspect the (� ANN W S. The .Municipality will ,give at least 24-hour notice. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On-Site Systems Approval. - Owner agrees that the AWWTS installation and maintenance requirements as provided TL_jby the AW-WTS vendor/installer and approved by the MunicipalRy are the governing1 szuidelines for the construction, maintenance and repair- of the Owner's AWNYTS. Owner agrees to maintain remote monitoring of the AW'W TS as required by the AW WTS approval. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and shall continue while the AWW TS is operational or until title is transferred. 4. Nonwaiver•. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the. provisions, nor in any way affect the validity of the A;__ Irene or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and. Municipality. Any attempt to amend. this agreement by either an unauthorized representative or unauthorized means shall be void. G. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the patties under this Agreement. 7. Severability. Anyprovisions of this Agr cement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. ( ev. 05 l8.1)018) Page 2 of 3 OWNER- By: �S (signature) (print name) STATE OF ALASKA } ').ss. THIRD1I.MICI.AL DISTRICT } Date: The foregoing instrument was acknowledged before me this (e day.of OCA. 20 Ly . �'AW►E SRRy NOTARY PUBLIC FOR ALASKA 1iIy Commission expires: .51-312-1 NIUNICIP ALITY: By: lit/ ib azure) (print name) NOT,��•:�,,� 9� IC �FALAS'�p�,,� Date: Title: (rei-. 0.5118120I8) Page 3 of 3 O V 00y S 00,00". ,9' 03' R SO WELL �6, .00. '0;X . • o o) -� S0.00 , o 9S Loft 13 , ,cu m o , • 1). Ul -c 2.0'x9.0' CHIMNEY Lot 15 \ 4) x N SEPTIC O z .0. PIPES i 1 ca \N 02 Lot 12 \ s 10UTILITY EASEMENTS Lot 11 PLOT PLAN ___ AS BUILT X SCALE _ 1"__ 50' _ GRID _SW 3136Project No. __22=241A1_ _ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Long Assoc*lates, o n c. (907) 522-6476 Phone (907) 522-4625 Fax o.0 00 Professional Land Surveyors ken®longsurvey.com jonathanOfangsurve .com do �. ..••"'••.. .�. oD S I hereby certify that f have surveyed rveyed the following described property. ��,• 104 •49TH LOT 14 BLOCK F. TIMBERLUX SUBDIVISION — ADDITION No. 3 (PLAT No. 71-240) Anchorage Recording District, Alaska, and that the improvements situated thereon are POAwithin the property lines and do not encroach onto the property adjacent thereto, that 0 no Improvements on the property lying adjacent thereto encroach on the surveyed ' 'rn- KENNETH G. �LA . . ...... premises and that there are no roadways, transmission lines or other visible J 0 easements on said property except as indicated hereon. �'�► • . 'a-� �L7.D p �� ' • • . S-5202. C3 %off' of'`"�-'�_------ —= = at Anchorage, Alaska �o A • • ..... • • foo Dated this the NN___ Day ___ , __ ROFESSIONP- a Opoo ooao It is the responsibility of the owner to determine the existence of any easements, O covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 MUNICIPALITY OF ANCHOtUXGE Ht~/~th and Environmental Prot, tion · Fourth Floor West ky'2 825 L Street Anchorage, Alaska 99501 264-4720 SEPTIC-lANK: i:R('rd W: LL _~ :.W',f,LJi /,CiLJREi4 ~ --- L,!& F(::RhiL _~ ...... COMPARTfAENTS ~ , =¢o , LIQUID CAPACITY/~ GALLONS. 'IILE DR/~,IN FILL[): FOTAL LENGTH ~;E E P,"\G E PIT: Log Crib __Rings__ Crib Size: Dh'\M[] IR _ _DEPTIt ____DISTANCE FROM: WELL 'IOTAL EFFECTIVE if CARt:S7 tOT LINE ..... Ai~SORPIION AREA (WALL AREA) _SQ. FT. ;'Tell C ].a s s :_~_~_ Depth: _ {e]]. Distance To: Lot Line Bldg: Sewer Line: Pipe Naterials: {} ef nedreoms: &¢ Installer: ~gL~¢~_ Roma~:]:s: F EF.,il I [ FEET Th'F'E OF E;OIL REr.:5OI';?.E~TION 2;'.r'STE:I"I :[~:;: 'rF:ENCH .. _ '::..7,q! I- I ,.. E,F ..... ~....,U ,~,11:~:;-:', ]:1"1 M NUhlDEF'. 13f:' ,,_ ,.. ,::,.. ri "'"' ''= . .. ~,~ TH[-Z F'.Er2L.III:::E[:, ~;IZE OF TIIF_.' ;:, .IL ~B::,F_[;.I II_N :~_]EII I ES:* E F::' "ll-' ~ ..~ :;=: THE L. ENGTIt D][HEN~SiOIq I£; THE L. ENGTH (:IN FEE:T) OF THE TRENCH OF?. D[;?.FIINF]:EI....D. ]"tie DEPTH OF FI TRENC'II OF.' PIT :IS -rilE DI:51"FINCE DE"I'[,.IEE[',I THE %IJF::FRCE OF THE GF.'.EIUND ANI]:, ]'FIE: [::OTTOI'4 OFt THE tEXCFI'v'RTION (;IN FEET). TI. IEF,:E _TS NO L=;ET I.,.Ii'DTH TIlE GI';;'.FI',/EL DEPTH ]:S THE I'iZNZHUP1 DEPTH CIl:': GI:~'.R',/EL BETHEEN THE OUTFFILL F'IF'E FIND ']"tilE DOTTOH OF TIIE E',:4CI::I',,,'RTZON (:]:i'-,I FEET). F?.EE ,l~::-~t~--~ % lt--:fEE E:, l-Ill_, THE f,.E::, UN=,IE,!I-1 F TO INF'ORH TI. lIE; DE:F:'FiRTHENT E.I..IF.I[' .. TIlE ,.-E.flI FIPF'LIIS:FiI'.4T · :':'- "' ~' .... .,- ., .... I.k..I._L_ H[...J-.u. EII1 'T'I3 TIII- If _FEF. I F:IND THE '~I'~STF:ILLF]TION II",I~;F'EECTIIDNE~ ISII:::' I:::lN"i" ~' ,::~ -. -,-. :, ... . .,: ......... '~l..ll'lE,~..p.. (cfi:. I-:.I:._,IDENL. E.-, TFff:FT THE HELL HILL H!NII'ILIM DISTFfl',ICE E':ETHEEN FI HELL FIND RN"? Oi",I-C;ITE ff;EHRGE E:'I'.SF:'OSFtL S¥'.~VFEH ±00 FEIET FOR R PI;:I'v'RTE: HELL..~ :!1_58 TO 21Z:iE~ FrEET FF:Or'I 19 F'LII3LIC HELL DE:F:'EN[:']:NG UPON THE: T'.,-'PE OF: PUBLIC HELL.. NELL LOGS FIRE REC!I_IIF~:ED Fii'.,~[:, HU'.¥T DEE F?.ETURNED 'T'O THE DEF'IgI:¥1"HENT I.,.ItTHIN Fi',/FiIL. FIL:~LE: TO IN:E;.,LI[':?.E F'F:tEff:'EF:: ZNL:TT'FILLFIT]:ON. I C[;RT]:[':",' l'tla'l'' 1: I RM FFIHIL. IFIF?. I,.IITI'I THE t~:EQUtl;;'.EHENTL:'; FOR ON-E;I-FE SEI.qERS FIND WEL[_.~2; RS SET FORTH [?.d TIdE HUN I C ~ F'F:IL ]: T'T' OF F]NE:HOF'.IaGE. 2: I NILL. lhlSTRLL THE ?gS'TEH tN fgCCOF~DFINC:E HITH THE CODES;. 2:: I LINE:,EF:STFIND 'f'HFIT THE ON--2 HER SW~5"I"EH HR"r' REC!UIF'.E ENL_FIRGEP1EEINT IF TIlE R:ESIE:,ENC:E :~DEI._ED TEl 'THRN 4 E:EDF'.OOHS. I_., I El.. De,~ ?ment of Health and Environment{ 7rotection 2516 E. Tudor Road Anchorage, Alaska 99507 276-2221 ~-? ~>-~'/( SOtI,S 1,0(1 I'I';IIOI,ATION TEST .................... ", Legal Description: This form reports: Soils log. Percolation Lest De p t h Feet 11 - 12- 13 - ~-- 14 -~ ~: Was ground watar encountered? Reading Date Gross Ti me If yes, at wi~at depth? Net Time Depth to Water Net Urop -Proposed instal,la-E~[Jh¥ '-~¥e~¥.qe Pit ___. Orain Field Depth to'~b¥O:O¥--o¥-'pi~ or trenci, ~ Depth of Inlet ................ - .............................. . ~_~APPLii' ~NT FILLS OUT UPPER "A~~ ~ONLY Buyer Address Zip Code Lending Institution ~ J~ ~ ~ ~ ~ )~-~ ~p~.& t~ Phone Address ~ ~ ~,/ [~ /~ ~ ~ ~ ~,~ ~,~ /~,':/ ~ r2 ~ ZipCode Legal Description ~ ~ ~ / ~ ~ ~ C /{ /;' ~m~ L~ Type of Residence ' Single Family ~ Multiple Family No. of Bedrooms ~ Other Water Supply ~ Individual A~ACH WELL LOG. A well log is required for all wells drilled since June 1975. ~ Community For wells drilled prior to that date, give well depth (attach log if available). ~ PubPc Utility Sewe~ msposal / ~ Individual Year Individual Installed: ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Dale Date Date Date Inspector Inspector Inspector Inspector Field Notes: MUNICIPALITY OF ANCHORAGE ~.~ ~ DEPT. OF H~.i',LTII & ;._2 /~/~ ENVIRONMENTAL PROTECTION OCT 7 ~'~" RECEIVED D ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) CONDITIONAL APPROVAL* DATE ~ [ ~ [ ~ -- ~ ~ Soils ~ng~ 0 Date ~wer Installed Well To Absorption Area WeB Log Received /~ ~ ~ ~ ~ ~ WelltoTa~k Septic T~k Size ~ ~ 72023 {3182) ALASKA eI/ufRoiqm rlTAL COF1TROL SeRb' ES, IJqC. ~.qifl~rin§ $ ~t~uironmcnl~l Studies DECEMBER 1 1983 STEPHEN & KAREN CHRONISTER 2031 BELAIR DRIVE ANCHORAGE AK 995803 SELLER - STEPHEN & KAREN CHRONISTER BUYER - C. BERRY SUBDIVISION - TIMBERLUX BLOCK - F LOT - 14 ADEQUACY TEST FOR SEWER SYSTEM THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN UNKNOWN AREA. THE SYSTEM IS CAPABLE OF ACCEPTING 675 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 675 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 3 BEDROOM HOME. SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR THIS 3 BEDROOM HOUSE. 1200 ~Jesl 33rd Auenue, Suile J~ · AncJ~orage,/~loska 99503 · (907] 276-i361 October 19~ 1983 So A. Chronister Star Route A Box 4'77-Y Anchorage, AK 99502 Subject: Lot 14~ Block F, 'i'imberlux Subdivision Approval for the individual sewer and %.;ater facilities cannot be granted until the follo~ing items have been completed: ~ The septic tank pumped with a receipt submitted to this department. o An adequacy test needs to be performed ou the existing te,~ %;ill determine if the system is J eaching area. 'i'h is ~ adequate according to ~ational Standards. A listing of private firms performing the test is enclosed. '.~his report needs to be sub]nitted to this office for our review. Please ~lotify this Department tot' a reinspection ~;hen the co~cted. If there are any noted discrepancies have been .... ''' ~"~ ~ -' . 264.-4720. [urther questions, please call t~is o_fzce at S inmerel~ Jim ~oberts Associate E~%vironmcntai Specialist jR54/ej/E2 Lee Chronister 'i'o t e~ i~ealty 724 E. iSth Anchorage~ AK 99501 ~U~!CIFA~ i~:/ O' : ,-.'~'r'..~,or.. ,AGL': ~UNICIPALI~ OF ANCHORA~ DE~, OF HEALTH & ENV~ROf4MEt4'F~,~ ENG ~EER g~ D V S ON OCT 6 1978 Telephone 264-4720 FOR APPROVAL OF INDIVIDUAL ~h ~,' ':: ~ 'f, Fl . .............................................................. ~'~?~ JS-f'f~:E E'F ~OCATIOH ~ J' ~] One L~ Four E~I Ortner I ~ SING~,EFAMII-Y ~] Two ~ Five '-' J ~ MULT, PI_E EAMILY [~J Three L~J Six I ~ INDIVIDUAL* '~'ATTACH WELL LOG, A well Icg Cs required for ail wdb dril[ed '[~3 COMM UI',IiTY since June 1975. Fo we s c r ed pr or to that date, give ~ PUBLIC I.J'l ! L ITY depth (attach log if available.) ~-// ~ ............. ~ ...... ** **if individua',/on-site, awe ;nstal!ation dace . If system is cve~ two (2) y~ar~ oki ar, adequacy test is required ~] PtJ¢l_lO UTILITY by this Department. THE INSPECTION FEE MUST AOCOMPANV EACH h[:,~ JEST ~EFOR- * ~O~.~..~.~. ~= ..AN ~.. JT TIIISSIDE FOR OF£1CIAt. USEONLY INSPECTION APPOINTMENt, S '1'1M L: ~iM [: ............................... DIRECTIONS: UAYE ........................ nA K[; ............................. 1. I'YPE OF RESIDENCE f,~tl[,¢~[][ ti OF 8~I}ROf.hViS [%] SINGLE FAMILY O ONE F~.] THREE [~ FIVE [Z/ OTIIER [Z] MUI.T!PI_E FAMILY F~3 TWO E~ FOUR [-~] SIX , 2. ¢:AT,~:,., 3lJ, , LY - ~-) INDIMID/JAL DEPTII OF WEt. L [2] COMMUNITY [7~ PURl. lC UTILITY Cormcclion Vr~,'ified ~d6'-~ED ............... % L-EiINDIVI DUAL~()N -SITE [_~ P(I[~ [.IC UTILITY C_]Septic Tank or [~] Holdin(i Tank Size.:. ~ _~_..~"'~___ If Tank is hon-[en~ade 5. COM[\~ENTS ................ ........ I;~/API~I~()VED [:OR .__.4,_ .... 13EDROOMS [~.] CONDITIONAl_ APPROV/',.17JIettFr must accompany cm tific3te) ~DISAI'PROVED