HomeMy WebLinkAboutTURNAGAIN BLK 4 LT 5La 'r [-...~ MUNICIPALITY OF ANCHORAGE ) DEPARTMENT OF HEALTH & ENVIRONMENTAl.. PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 [. Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAl_ SYSTEM AND/OR WELl_ INSPECTION REPORT ' Weld , Dwelling PERMIT NO.~ DISTANCE TO: ' No. of lines Len;th of each line Total length of I~nes Trench width Distance between line~ OTHER SOIL TEST RATING l A~ DATE LEGAL 72-013 PERMIT NO. C, EpARTMENT L~..,/HEFILTH AND ENVIRONMENTRL X.~...'3TECTION LL~z~ I/~:~TL~ ,_,~ ..... TREET., HNL, HOF.'HbE.. RK. c'.':'-~F~l ,-,-~ - :R . · F' FIFPLI _.RNT LOC:AT I ON LEGAL AMFAC MORTGAGE _.JFF KL, BTT ROAD LOT 5 BLK 4 TLIRNAGF~IN :LIB 40t E. N.L. E:. LOT _~I~E 2-~:000 _,[..(]ARE FEET TYF'E OF =,UIL HE,_~ORFTI_N =,~=,TEM IS: TEENCH MAXIMUM NUMEER OF BE[:,ROOMS = 4 '-~OIL RATING ,:'~,,~.3 FT?BR)= t00 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: C, EPTFt= ~1~ LEf~GTH= lei GRR%,"EL [)EF'TH= ~ THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF B TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE ENCAVBTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). F~.EL-=IJ I E~."E [:. SEF"]- I C: T~::~--~l-( "--; ~ ZE= 5E~0 GFIL [_ C~I'-.~'?].. RE=PON:-IBILIT~ TO INFORM THIS DEF'BRTMENT DURING THE F'ERMIT APPLICANT HAS THE ' '- '-': · " · INz, TMLLHTIUN IN--,FEL. TICH- OF ANY WELL:, ADJACENT TO THIS FRLIPERT~ AND THE NUMEER OF REzIDENuE_ THaT THE WELL WILL _,ER E. TI...IL-:~ (: 2 ) I ~.~SF'ECT I g~'-.~:-. RRE REL-~.LI ! RE[-" E, HE. KFILLINB OF ANY qYSTEM WITHOUT FINAL INSPECTION AND RPPROVAL BY THIS DEPARTMENT WILL BE _,LIE, JEbT TO PROSECUTION. MINIMUM DISTBNCE BETWEEN A WELL ~ND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVBTE WELL OR t50 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC NELL MINIMUM DISTBNCE FROM A PRIVATE WELL TO B PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVRILABLE TO INSURE PROPER INSTALLATION, F'EF.'~"~ ][ -I" E,- .F I F:~.' E_ L-)EL-Et"IE:ER _:.:L.. I CERTIFY THAT t: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET' FORTH BY THE MUNICIPALITY OF ~NCHORAGE. 2: I WILL INST~LL THE SYSTEM IN ACCORDANCE WITH THE CODES. g: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCB I~ ~]~ODE ED TO INCLUDE MORE THBN 4 BEDROOMS. ',/4. 0 October 10~ 1980 R&M No. 051001-81 Ms. Colleen McGrath AMFAC Mortgage Corporation 401 E. Northern Lights Blvd. Suite 210 Anchorage, Alaska 99501 Re: Adequacy Test on Existing Sanitary Sewer System; Consisting of a Septic Tank With a Leach Field; Lot 5, Block 4, Turnagain Subdivision, Anchorage, Alaska Dear Ms. McGra~h: Per your request of October 2, 1980 Dan Cooper of R&M Consultants conducted a test of the sanitary sewer system on the above described property. The test indicates acceptance rates determined under conditions at the time tested. Actual system performance over long periods of time depend on factors which cannot be evaluated by this test thus our office cannot warrant the suitability or fitness of the system for either an extended period of time or for user demand in excess of the expected flow noted herein. Factors affecting system performance include: 0 0 0 Actual use demand on the system; Fluctuations in groundwater levels; Physical conditions of the septic system, leach field, trench or seepage pit and soil. It should be noted that while a septic tank and leach field disposal system is one of the most reliable methods of sewage treatment and disposal it is nearly certain that the leach field or seepage pit will fail sometime during the useful life of the structure. Studies indicate leach fields, trenches and pits have a life expectancy of ten to twelve years under optimum conditions. All septic systems have a finite hydraulic loading capacity which can be expected to decrease with time. Because the house on the lot is occupied, we assume that the leach field was at its normal degree of saturation. During this test the liquid level in the septic tank was monitored as water was added to the system. The measure- ments and calculations are summarized on the following table: ANCHORAGE FAIRBANKS JUNEAU Ms. Colleen McGrath October 10, 1980 Page 2 FIRST DAY Date: October 6, 1980 Water Added To Septic Tank Liquid Level Measurements Taken From Top Of Standpipe TIME GALLONS TOTAL LIQUID ADDED GALLONS LEVEL 10:39 0 0 5.5' 10:51 50 50 5.4' 11:02 50 100 5.4' 11:13 50 150 5.4' 11:24 50 200 5.4' 1t:35 50 250 5.4' 11:47 50 300 5.4' ]1:59 50 350 5.4' 12:12 50 400 5.4' 12:28 50 450 5.4' 12:35 50 500 5.4' 12:46 50 550 5.4' ]2:59 50 600 5.4' 1:12 50 650 5.4' Date: October 7, 1980 TIME SECOND DAY GALLONS TOTAL LIQUID ADDED GALLONS LEVEL 10:11 0 0 5.4' 10:26 50 50 5.4' 10:37 50 100 5.35' 10:48 50 150 5.35' Ms. Colleen McGrath October 10, 1980 Page 3 TIME GALLONS TOTAL LIQUID ADDED GALLONS LEVEL 10:59 50 200 5.35' 11:10 50 250 5.35' 11:22 50 300 5.35' 11:33 50 350 5.35' 11:44 50 400 5.35' 11:55 50 450 5.35' 12:07 50 500 5.35' 12:18 50 550 5.35' 12:29 50 600 5.35' 12:40 50 650 5.35' Remarks: Rained all day and the previous night. Date: October 8, 1980 THIRD DAY - Septic Tank Level 5.45'. The meter used during the test was a Rockwell 5/8" standard water meter which had previously been calibrated by R&M Consultants, Inc. The total daily load for the four bedroom residence is six-hundred (600) gallons; surge capacity is four-hundred eighty (480) gallons. The Municipality requires the system to accept a surge capacity of 80% of the total daily load at a rate of ten (10) gallons per minute, tested for a two day period and to accept the total daily load in twenty-four (24) hours. Failure Criteria is as follows: o Water rises excessively in septic tank at or before 80% of total load is added. o Effluent overflows the system. o Water level does not return to wwthin one-inch of static level. The first day of testing, the system accepted six-hundred fifty (650) gallons in one-hundred fifty-three (153) minutes which is more than the total daily load. Ms. Colleen McGrath October 10, 1980 Page 4 The second day of testing, the system accepted six-hundred fifty (650) gallons in one-hundred thirty-nine (139) minutes which is more than the total daily load. The static water level on the third day had returned to within one-inch of the initial static level. We can therefore conclude that the system is disposing of effluent at an adequate rate for a typical four bedroom residence. We have appreciated this opportunity to be of service to you. us if you have any questions concerning this test or if additional service. Please contact we can be of Very truly yours, R&M CONSULTANTSf INC. Richard S. Giessel Senior Engineer DC: RSG/jz 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 TPHONE NAME LEGAL DESCRIPTION LOCATION DISTANCE TO: F- ;~ Manufacturer Lie)' c(~a~Y ~aIIOns DISTANCE TO: Well ] Absorption area IF HOMEMADE: Dwelling Width NO. OF 8~E~ROOMS No, of comp~ments Liquid depth Well PERMIT NO, Manufacturer Material Liquid capacity in gallons Well Foundation Nearest lot line PERMIT NO, DISTANCE TO: Length of each line Trench width No, of lines Total length of lines Distance between lines inches Top of tile to finish grade Material beneath tile Total effective absorption area inches Length Width Depth PERMIT NO, Type of crib Crib diameter Crib depth Well Building foundation DISTANCE TO: Class Depth Driller DISTANCE TO: Building foundation Sewer line OTHER PIPE MATERIALS Total effective absorption area Nearest lot Iine Distance to lot line Septic tank SOl L TEST RATING iNSTALLER'~ [ ~ REMARKS 72-013 (Rev. 3/78) DATE LEGAL PERMIT N0. RPPLICRNT CHERt' RNN JONES L.OCRTION KLRTT RD LEGRL L 5 B 4 TURNRGRIN DEPFIRTMENT ;' ' HEALTH RND ENVIRONMENTAL , ;OTECTION ~'l~ ~ 825 "E~ STREET, RNCHORRGE, RK. ~L~5~41 264-4728 2:4E4 N. FLOWER 3:g723:22 LOT SIZE '14E~014 _,wLRRE FEET ,-"t ' ¢' ' - '-'"- I~. [)RRINFIELD T'¢PE OF --.LIL F'IB-~OFFTI-N =,'r:TEM "=' MRXIblUM NUMBER OF E:E[~ROOMS = ~ =,CIL RRTING (~0 FT/BR)= THE REQIJIRED =,I~E OF THE SOIL RBSBRPTION S'YSTEM I_,. C. EPT~,-~= i ~-.7.-~ LE[-~,] I-H= O ~] R F-~ ".?E L L].EPTH= ~:'i THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). 'THE ]-RE~4C:H I,-~I [)TH IS ~]d. OIEl~Zl FEET. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE 0UTFRLL PIPE RND THE BOTTOM OF THE E~CRVRTION (IN FEET). F'ERMIT RPPLICRNT HR-~ THE REz, PON=,IBILIT'P TO INFORM THIS DEPRRTMENT DURING THE IhL-,IRLLH]ILN INSPECTIONS OF RNa-' WELLS RDJRCENT TO THIS FF_PERT~ RND THE NLIMBER OF RESIDENCES THRT THE WELL WILL SERVE. ~, ,- '-' ] ....... A ..... B'¢ THIS ERF:KFTLLING BF RNY ~=,TEM WITHOLIT FINRL IN=,FECTI~N RND DEPRRTMENT WILL BE =,UBJEL. T TO PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RN9 ON-SITE SEWRGE DISPOSRL S~r~STEM IS ±E1E1 FEET FOR R PRIVRTE WELL OR 25~} TO 2~}El FEET FROM R PUBLIC WELL DEPENDING UPON THE T'¢PE OF PUBLIC WELL MINIMUM DISTRNCE FROM R PRIVBTE WELL TO 8 PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNIT'¢ SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MR'¢ RPPL9. SPECIFICRTIONS 8ND CONSTRUCTION DIRGRRMS RRE AVFIILRBLE TC IN'~ IRE PRrIPER IN'~TFLLRTION. ~ .A ~ ~ .... ;. .- .:, PEF~M I 'f E,,-~.F I F:ES [)EC:E][1BEF~ 2:1.. IL~ ~.8 I CERTIF'¢ THRT t: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH B'¢ THE MUNICIPRLIT'¢ OF RNCHORRGE. 2: I WILL INSTRLL THE S'¢STEM IN RCCORDFINCE WITH THE CODES. ]:: I UNDERSTRND THRT THE ON-SITE SEWER S'¢STEM MR'¢ REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN 3; BEDROOMS. APPLICRNT 6~R'¢ RN~JONE:, / f INSPECTION APPOINTMENTS ,ME DATE INSPECTOR TTME ! DATE MUNICIPALITY OF ANCHORAGE -: DEPARTMENT OP HEALTH & ENVIRONMENTAL PRO~JcK~LF[~Lll'Y ©F AN~HoORA~I: DEPT. OF ', ~.,t. Ti~ ~ B25 L Street - Anchorage, Alaska 99501 ENVIRONMEi ,q >.L i:; )~£CT]©N ENVIRONMENTAL SANITATION DIVISION 9 980 Telephone 264-4720 DIRECTIONS: Complete all parts oil page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. P,HONE -1. PROPERTY OWNER pR~P~ER ~' RE~SIbENT (if differen~ fro hove) PHONE PHONE PHONE 4. REALTOR/AGENT 5, LEGAL.DESCRIPTION /STREET LOCATe'ON NUMBER OE~BEDROOMS ~ [] One [] Four [] Other '~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [~ Three [] Six 7. WATER SUPPLY ~ 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 UTI LITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM [~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED· NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH ~EQUEST_REFORE PROCESSING CAN BE INITIATED. /vF D - THIS SIDE FOR OFFICIAL USE ONL~ , ~l / 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2, WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTi LITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM []INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: If Tank is homemade give dimensions; NUMBEROFREDROOMS [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATEINSTALLED INSTALLER SOILS RATING TYPE OF TANK MANUFACTURER 'OTAL ABSORPTION AREA MATERIAL Septic/Holding Tank 4. DISTANCES WELL TO: Absorption Area to nearost Lot Line [] OTHER Absorption Area Sewer Line Nearest Lot Line 5. COMMENTS DATE FOR BEDROOMS I~CONDITIONAL APPROVAL (letter must a~any certificate) ,//'~ 72-010 (Rev, 6/79) ~u~,~¥on~. ~ MU~IRA~JTY OF ANCHORAGE Hay 14, 1980 R~ ~O. OS~.Io~¢'.EALTH & ENV[RONMENIAL ~OTECTJON 1980 Ron J. Blue 1398 Klatt Road RECE! ED Anchorage, Alaska Re: Adequacy Test on Existing Sanitary Sewer System; Lot 5, Block Turnagain Subdivision, Anchorage, Alaska Dear Mr. Blue: Per your request of May 9, 1980, we conducted a test of the sanitary sewer system on the above described property. During this test the liquid level in the septic tank was monitored as water was added to the system. The measurements are summarized in the following table: Time Liquid Level Below Top of Standpipe Total Gallons Added 12:40 8.08' 0 12:47 7.98' 25 12:56 7.89' 50 2:12 7.82' 75 2:22 7.84' 85 2:33 7.89' 90 2:40 7.86' 105 3:47 7.74' 150 3:55 7.60' 175 4:25 7.72' 175 The meter used during the test was a Rockwell 5/8" standard water meter which had previously been calibrated by R&MConsultants, Inc. May 14, 1980 ~r, ~lue ' "Page -2~ If the 3 bedroom residence on the property is to house 6 people, the average load on the system can be expected to be 450 gallons per day or .31 gallons per minute. During the test, the system accepted 40 gallons in 97 minutes. This indicates an average effluent acceptance rate of approximately 0.41 gallons per minute at the time of the test. We can therefore conclude that the system is disposing of effluent at an adequate rate for a 3 bedroom residence. We appreciate this opportunity to be of service to you. Please contact ns if you have any questions concerning this test or if we can be of additional service. Very truly yours, R&M CONSULTANTS, INC. Jan '~c~ Cecere ProjeCt Manager JC/dj/AT&SI-H FHA Porm 2573 ~ \%,~ Form Approved Rev. July 19.? · '~ FBDEgAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296.8 "" HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--TO BE COMPLETED BY FHA INSURING OFFICE MORTGAGEE First National Ba~k of Anchorage. PROPERTYPADDRESS Anchorage MORTGAGOR OR SPONSOR Ntelssn Real Estate SUBDIVISION NAME J Turn-q-.~n S/D TiTAL NUMBER, j_~3~BASEMENT s [] No WA SUPP Y B : [~ Public system [~ Community system SEWAGE DISPOSAL BY: --]Public system ] Community system [] New installation SERIAL NO. BLOCK NO. LOT(O. Can attic or other area be made Into additional bedrooms? (If Yes, how mony~) F~]Individual [] Individual SYSTEM DESIGNED FOR [~ Yes ]'--]No PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH It is the opinion of the [] State [] County [] Local Department of Health that this individual water-supply system [] is [] is not satisfactory as a domestic water supply for the subject property. It is the opinion of the [] State [] County [] Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: [~Can be expected to function satisfactorily, and [] Cannot be expected to function satisfactorily is not likely to create~_an insa, gitary cond~non// ' ,GNWRE ' '. :. T,TLE Feb, :S~ lgT0 .... NOTEJ the,'healtl}/authority should complete the appropriate opinion statement above and afflx date, signature title the spaces provlded~¥}F.F~ Use of tile ab e grid for Health Department Inspector's sketch as well as use of the bock of this Form is at the option of the health autho{it PART Ill.--FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that'the Individual water-supply system be considered [] Acceptable [] Not Acceptable Sewage disposal be considered [] Acceptable [] Not Acceptable. DATE SIGNATURE HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM REPORT OF INSPECTION~INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [] Septic tank. [] Cesspool. Septic Tank~ Distance from well,__ __feet. Material, Total liquid capacity, Inside length, feet. Inside width, Distance from: X,Vell, feet; foundation, Inside diameter,. .feet. Depth,_ gallons. Capacity inlet compartment, feet. Liquid depth, feet. SECONDARY TREATMENT consists of [] Tile disposal field. Tile Disposal Field: Distance from: Well, Total length of tile lines, Trench width,_ Length of each line, Number of compartments. .gallons. feet; nearest lot line at [] front, [] side, [] rear, feet. Liquid capacity, .gallons. Lining material [] Seepage pits. Other feet. feet. feet, square feet. inches. feet; foundation, feet; nearest lot line at [] front, [] side, [] rear,. feet. Number of lines, Distance between lines, inches. Total effective absorption area in bottom of trenches, feet. Depth, top of tile to finish grade Type of filter material: [] Gravel. [] Broken stone. Other Depth of filter material beneath til% inches. Depth of filter material over tile, Seepage Pits: Number of pits____. Outside diameter, feet. Depth,- -feet. Lining material Distance from: Well,. feet; building foundation, feet; nearest lot line at [] front, [] side, [] rear, Inspection made by= [] State. [] County. [] Local Health Authority. Inspected by. Date of inspection , 19 feet, REPORT OF INSPECTION~INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main,__, feet. Size of main, inches. Individual wells [] are [] are not customary in neighborhood. Give most recent record of failure of wells in immediate vicinity to furnish adequate supply of water Properties in neighborhood E] are [] are not being developed with both individual water-supply and sewage-disposal systems. Lot size:~ .feet wide feet deep. Dwelling set back from front property line, feet. Individual water supply from: [] Drilled well. [] Driven well. [] Dug well. [] Bored well. Distance of well from~ Building foundation, seepage pit, Well constructlom feet; tile sewer, -feet; cesspool, feet; nearest lot line at [] front, [] side, [] rear, feet; septic tank, feet; disposal field. feet; other sources of possible pollution,, feet. Dia~neter .... inches. Total depth, feet. Type of casing, Approximate depth to pumping level of water in well. feet. Approximate yield,. Sealed watertight to depth of_ feet, Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill. Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Yes. [] No. Pump~ [] Shallow well. [] Deep well, Length of drop pipe,_ feet, Pump capacity,. Located in: [] Basement. [] Pumproom off basement. [] Pumphouse above ground. [] Pump pit. Pumproom properly drained: [] Yes. [] No. Pump ~nounting watertight: [] Yes. [] No. Type of storage: [] Pressure. [] Gravity. Capacity, gallons, Has bacteriological examination of water been made? [] Yes. [] No. If answer is "yes," give date Quality of water [] is [] is not satisfactory for human consumption. Installation [] does [] does not comply with approved exhibits, if any. Inspection made by: [] State. [] County. [] Local Heahh Authority. Inspected by Date of inspection __ , 19 Depth of casing, gallons per minute. gallons per minute, (TITLB) feet~ feet; feet. IN~qIDUAL SE;.;AC~E AND WATER FACILI~S//~LL-gz~'~' . (Yi.tl out in Triplicate) /'' ~.~... -~~~' /{~~~. ~1~0' ' "/ ~ , "'/ ~" -~~ ~ ~~ - ':" . .. , 6, Well data: 2. Septic tank, ~ _ ',. 3, Seepage Area..... /~ ~ , 8, Cesspool'__ , 5. Property Line, ~/ , 6. Other sources of poss~l~ contamination~ i.e,~ creeks~ lakes~ houses~ ba~n~ drainage ditch, et~. 7, Sewage disposal system. a, Age Of sysie~ b. _Septic ta~k capacity ir, gallon.. c. Name of septic tank manufactu.~e~ , . 1, If "home made" show diagram on reverse side of this form, d.' Disposal field 1, Distance ~o p~ope~ tln~_/~/ to house fotmdat3 on e. Percolatio~ Te~t '~-esults f. Percolation Test performed by .......... · Use the reverse .side of this form to show diagram. Diagram should include ~x%he foilowing ~nformation: p~operty tinas~.well location, house location, m~ptio tank location, disposal area location, location of percolation test~ an~ direction of ground slope. The ~r~ox~tion On this form is true and correct to the best of ~y knowledge. Signature of Applicant Date Signed _TO BE FILLED OUT BY HEALTH, DEPART~,~ENT PERSONNEL he above described sanitary facilities are hereby approved ~ubject to the Conditions: The above described sanitary facilities are disapproved for the following / v the date of ''-/ Aptera% is valid for one year following approval.