The URL can be used to link to this page

Home My WebLink AboutVALLEY VIEW TERRACE BLK 1 LT 11 ~,~ 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 I~1EW MAILING ADDRESS LEGAL DESCRIPTION LOCATION ~ ~ ~A~ ~ ~ D'STANCETO: Jw~"~ +700 IAb'°rpti°'"r~" D~,,i,g PERM'TNO.~O¢~ Liq. capacity in gallons Inside length Width Liquid depth ~ ~ IF HOME.DE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O ~ ~ Manufacturer Material Liquid capacity in gallons Q Well Foundation Nearest ]ct line PERMIT NO. ~ ~ DISTANCE TO: ~ ~ No. of lines Length of each line Total length of lines Trench width Distance between lines ~ Top of tile to finish grade Material beneath tile Total effecti area Q inches Length Width i Depth PERMIT ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: CJass~ Depth Driller Distance to lot llne PERMIT NO, O/~L/[~( ~ ~ DISTANCE TO: Building foundation Sewer line Septic tan~O O Absorption area(s) OTHER SOIL TEST RATING/ ~ ~ ~1~- INSTALLER ~> t ~ 0 REMARKS ~~ / APPROVED / /I DATE LEGAL 72-013 (Rev. 3/78) by DOC Co. dba \jIWATEL WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2759 OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE - Started Ended PERMIT NUMBER KIND OF FORMATION: From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft, From Ft. to Ft. From From Ft. to Ft. Ft. to From Ft. to Ft. Ft. From Ft. to Ft. From From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: DEPTH OF WELL STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR KIND OF CASING From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft 1�7I ILA�Ii7Ly`►[JuU PERMIT NO. RF'PL ! CRNT L. OCRT I ON LEGRL 'DEFRRTMENT O~UERLTH RND ENMIRONMENTRL ~tTE,::TION/,~___-' 825 ~;TREET, 264-4729 ~ z/ I.SELL R~-SL~ 0~4--S Z TE SEi.,IEF: F'EF:f-1% T ,' ,_,ue46~ ) ~(~. /O-Id _%0 - " ' * ~, ~, BILL WHU..ER P. 0. BO,.', 2~L~<,"'-'" E.R. '"~'--~ '='~' , LO~IEF TRRRRCE LOT ~l BLL ~ VRLLEY MiEN TERR. LOT =,I~E _.~8=~_'~O~_IRR~ FEET - ,,-']~, , - c,,,- DRRINFIELD TYF'E OF SBIL ME.'=,cF. FTIuN _,',=.TEM IS: MRXIMUM NUMBER OF. T .'"B '~- SOIL RFITINQ (SQ F , R..- ~2~8 THE REQUIRED SIZE OF THE SOIL RE,._,ORFTION _,T_,TEM I=,. C'-'EP1-H--- (~;. 5 LE[-~,-3TH= ±~. ~: GRR%."EL C, EPTH= ';. -_ THE LENGTH [IMEr,I_IuN IS THE LENGTH (IN FEET..', OF THE TRENCH OR DRRIhlFIEL[:,. THE DEPTH OF R TRENCH FIR PIT IS THE [:,ISTFINCE BETWEEN THE SLRFRCE OF THE GRFIIND RND TFIE BOTTOM OF THE EXCFIVRTION (I[4 FEET~ ~ THE GRFWEL DEPTH I'-~ THE MINIMUM DEPTH OF GRRME~~B:~-'E~L PIPE RND THE BnTTOM OF THE EXCR'v'RTI8N <IN FEET.'.,. I{-.._E C::!.L{ I: RED _.EFT F'ERMIT RPPLICRNT HH_ THE RE_,FON_IBILITY TO INFOF.:M THIS CEFRETNENT DLIRIN~ THE IN=THLLHTIuN IN-~PEE. TI8N_ OF FINY ~ELL_, RDJRCENT TO THIS F'ROPERTY RND THE NUMBER OF RE_,IBENL. E=, THRT THE NELL NILL =EF..~¢E. ........ T ~-.-1 ,_3 .'.. ,=_';" ..," ]: l'-.[ =. P E k. T'-- --' ! 0 [-.~ S RRE F-~ E ,_.~ LI ]: EHL. LFILLING OF RNY -~:,TEM NITHOUT FINRL INSF'ECTION RND RPPROMRL BY THIS [.~FISF;.TMENT NILL BE =,UE, JEL. T TCI PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SENRGE DISPOSRL S~STEM IS ~88 FEET FOR R PRIMRTE WELL OR ~58 TO 208 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC NELL MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIMRTE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. NELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~8 DRYS OF THE NELL COMPLETION. OTHER REQUIREMENTS MRY RPPLM. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. F'ERf-1 I T E)~:P I RES [)E£:EtdBEF-: I CERTIFY THRT 2.: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND NELLS RS SET FORTH BY 'THE MUNICIPRLIT'¢ OF RNCHORRGE. ;2: I WILL INSTRLL THE S'¢STEM IN RCCORDRNCE WITH THE CODES. Z.:: I UNDERSTRND THRT THE ON-SITE SEWER S'¢STEM MRY REQUIRE ENLRRGEMENT IF-THE RESIDENCE IS REMODELED TI_', INmZ:U_IDE MORE THRN ~ E:EE:'E~ si GNEr,: ..............= - O & E EN~.~,qEERING & DEVELOi' ,~/1ENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Performed for: Name: ~/~- L Legal Description: SOIL LOG Mailing Address: ~z ~,:.~ // Earl Ellis 688-2280 (feet) Soil Characteristics 8__ 9__ 10__ 11__ 12__ 13__ 14__ 15__ 16__ Ground Water Encountered: Proposed Installation: Seepage Pit.__ Comments: Performed by: Yes ~-~"'No___ If yes, what depth Drain Field___ PLOT PLAN PERC. TEST GE BL Municipality of Anchorage On -Site Water and Wastewater Program < (907) 343-7904 SAF E T Y CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 050-352-34 1. GENERAL INFORMATION Expiration Date: _A � �doc Complete legal description Valley View Terrace Block 1 Lot 11 Location (site address) 23452 Lower Terrace St. Eagle River, AK Current Property owner(s) Daniel Smith Day phone Mailing address 23452 Lower Terrace -St. Eagle River, AK Real Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class _ Well ❑ Public Water System ❑ Waiver/Variance request for: 3 TYPE OF WASTEWATER DISPOSAL: Individual ❑ Holding Tank Community ❑ Public Sewer ❑ Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ _625-0 Date of Payment 5/1 'RU a 2 Receipt Number 09 R 09 G COSA# _�SG22122Z Waiver Fee $ Date of Payment Receipt Number Waiver # Distan 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. Name of Firm ARCTERRA CONSULTING, INC. , , _ Phone 696-6111___ Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS - _ _ Date l_"��.- Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. �� ,1.,<f >� 6. DSD SIGNATURE System #1 Approved for 3 System #2 Approved for bedrooms. r KENNETH ' `' ' ``us j ~ bedrooms. '�ti AIV � j; frVrt Disapproved. Conditional approval for — bedrooms, with the following stipulations: YC0F (r(((, eG � iC 1P ��_ ZER AN_D.----- - - .. , _ WAST_•v'!ATER o -- -- -- PRO-GKAV— co 0 J,pe -. ALJ �\Gai�,,\` SER— By: �1j - Original Certificate Date: _ g _ 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 COSA blue sheet 10-10-12-doc COSA Checklist Legal Description: Vallev View Terrace Block 1 Lot 11 Parcel ID: 050-352-34 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) Date drilled 7/19/1987 Total depth 405 ft Cased to 57 ft Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 25 in. Date of flow test for COSA 5/3/22 Static water level at beginning of test 102 Comments in B. TANK DATA Age of tank(s) 9 years Tank type/material Holding/Steel Measured operating fluid level in septic tank 57" K Standpipes/foundation cleanout per record drawing Date of pumping 3/21/22 D. ABSORPTION FIELD DATA system tested (date installed) ❑ ALL Stan es present per record drawing Total measured depth grade ft (max) Measured depth to pipe invert fro ade ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, s �' depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Well production at time of test 0.17 gpm Water storage tank volume 500 gallons Well disinfected for coliform test? ❑ Yes E No [l Coliform bacteria is Negative Nitrate mg/L ® Nitrate less than MRL (ND) Arsenic ug/L [■1 Arsenic less than MRL (ND) Collected by Arcterra Consulting Date of Sample 5/3/22 C. LIFT STATION 11 uired maintenance completed Age of lifts years Lift station material Comments: Adequacy test date Results ❑Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Fi uid depth in Absorption r gpd Any rejuvenation treatm ast 12 months) If yes, enter. date 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 Community Sewer Manhole/Cleanout > 100' ® Yes if No ft [0 Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' Yes if No ft Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ® Yes if No ft ® Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No 5+* ft Surface Water > 100' ❑ Yes if No 40+** ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: ❑ Yes Absorption Field > 5' ® Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' ® Yes if No ft Community Wells > 200' Yes if No ft 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) Buil in ation > 10' ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' 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 We _ ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS *Meet code at time of installation. **Waiver# OSP131011 Granted 2/12/13 G. ENGINEER'S CERTIFICATION 1 certify that I 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. COSA Checklist yellow sheet MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904 On‐Site Water and Wastewater Section Fax: 343‐7997 www.muni.org/onsite Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org Well Water Advisory Certificate of On‐Site Systems Approval # OSC221222 Subdivision: Valley View Terrace, Block: 1, Lot: 11 This well’s productivity was determined to be 0.17 gallons per minute. The minimum well productivity required under (AMC 15.55) for a 3‐bedroom residence is 0.31 gallons per minute or 150 gallons per day per bedroom. Although the well production does not meet this requirement, water storage has been provided to meet minimum code requirements. This advisory must be attached to all copies of the subject Certificate of On‐Site Systems Approval. ZVOOmO0= a ,< �Mmm�-Znrmi O�-A, ate" ,_,Z m0 ;5:�mzZ.go In H n Z 0 G W i �mLnH("0mz Z, ZO?DZM m (A j F o O X p 0 M H .� a N H rn �'-�cn0 zOao=��H �>> zzQ,� W o m a m p z a SHC 1 v00 apG�-IMG n pZZ c Oxy= momm H O L, p m r- o aO m a z-, m UMZE Z G 9 HZ Zcin r G 1 z mrn O m a z M- z mem im�c^ Z M (A O m�HG Z mO OOcL,O cn m -main Z C oZcn m a Z m m Oa mpmy p m z0 -M Z Fn Z= r- � p H 1. m mZ �S Z�^a� N Z y O -n co W WaP= Ln=go �OH> w a = Z m 'S- m >;E C: a � m m Ln < H m Z Gl �m—I<> D X S H z T —{ H m Vl n m m Vl H = C D O O m D D —I —i 'D G) ;o S m H m < D m ;a 3 z ;)a—I-ow n -< ;u m _ -i O n O S r < O Z7 D H m ;a > z Z:9 0 Gl mmH mzv)Zz D � y L r m Z 0 ND0O VtH ® Vt H 0 F-� 7C Z —I —1 wD Oce -+ <Dn = H m -I H V1 0- > vD N m m D V w LA —I m m T z zOzv nm0 0 Z —I D '< (%1 H O z S m m r O H O m —i m Fs m m w w o r r n O0� H H N z -n > m D m 70 < H H w m < -v m —1 0-0 m -V m e® m w D —I O n -< w m 3 m Ln v 00 D V) c < m I MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL iL/2"-)~)/'~ OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date _~ ~ // -~-~ ~ GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property Owner Mailing Address (c) Lending Institution Mailing Address (d) (e) Telephone: Home . Business Real Estate Company and Agent [~ ~ ~ ~ ~ ~ ~ ~ ~O ~ ~ ~1 Telephone ~ ~ ~{-- ~ ~( Mail the HAA to the followin~ address: or: Check here ~old for pick up. List contact person and day phone number below. S & S ENGINEERING 17~ Eagle Riv~ ~p R~d No. 2~ TYPE OF RESIDENCE Single-Family ~ Number of Bedrooms WATER SUPPLY Individual Well ~ommunity [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite Eib/Public [] Community [] Holding Tank [] Note: If commur~ity 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 fRev 8/86~ Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval 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 $ & $ ENGINEERING 17034 Eagle Rives' Loop Road No. 204 Address Date Telephone DHHS APPROVAL Approved for '~/'~/'¢--~-- C~)bedrooms by ,~-' Approved Disapproved Conditional Terms of Conditional Approval CAUTION 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. ']'he DHHS 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. Page 2 of 2 72-025 trey 8/86) Sack HEALTH AUTHORITY APPROVAL (HAA) 264-4744 NOIglAlO ~]DIA~]~ IVIN]WNO~IAN] ]gV~OHDNV JO ~$IWdIDIN~ Legal Description: ~ ~.~/ WELL DATA Well Classification Well Log Present~) Total Depth (7/L~ ~ Static Water Level ~7~ ~' ~ Casing Height Above Ground /~_¢~ t, Electrical Wiring in ConduitS) Separation Distances from Well: To Septic/Holding Tank on Lot /c~c:, ~ To Nearest Edge of Absorption Field on Lot (o ~ ¢ .CD - ~ If A, B, C, D.E.C. Ap/proved (Y/N) Date Completed C) -~_,~ :'_~.~D /%1/-/$ ~,O'?Yield Cased to ,~'~ ~'~Depth of Grouting Pump Set At L~. Sanitary Seal on Casing~'N) Depression Around Wellhead (Y~ ; On Adjoining Lots ; On Adjoining Lots /,:::~¢~/'¢- To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments ' /~//,4 To Nearest Public Sewer "J/,,q To Nearest Sewer Service Line on Lot 2~--~ ~' / B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes(~N) Air-tight Capsl~/N) Depression over Tank Pumping/Maintenance Contract on File (Y/N) .. Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: / ~-/W' -/-,3o Size /&-5't~ No. of Compartments ~ Foundation Cleanout (Y~j~ Date Last Pumped -)~ ~, ~ '¢~¢:~' /'-~/,z~. ; for Temporary Holding Tank Permit (Y/N) ~//Oi To Water-Supply Well To Property Line To Water Main/Service Line (O Course To Building Foundation To Disposal Field /Z ¢ ' To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026 IRev 8/86~ Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /(~ - fL/- Width of Field Square Feet of Absorption Area Depression over Field (Y,~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design ~/~ Length of Field r~ / Depth of Field /~',~' / - -5~' S'' Gravel Bed Thickness o. g' ~ Standpipes Present (~N) Date of Last Adequacy Test "~ ' / ~ -r_~ '~ To Properly Line To Existing or Abandoned System on ; On Adjoining Lots ,.~/-/- To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to alI,M2A and HAA guidelines in effect on the date of this inspection. ;'~;da ~7~:~la~lleNER~vRe. l~Ngt%%~.R°ad N°'M2Do~eNo ('¢~/~-~//~9 ..~ ~ '" "'"" .... Receipt No. ~O~ - Date of Payment ~ - ~ D-~ Amount: $ ~ ~, O~ Page 2 of 2 ~ DATE RECEIVED '~ INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE DEPT. ~c.,_, 1 5 gS0 ENVIRONMENTAL SANITATION DIVISION T.,e.,o.e =6,-47,0 RECEI ED REgUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FAOILITIE8 m0~~ b~o~, [x~ 5. LEGAL DESCRIPTION Lo/*-' i/ /~/W STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS [] One [] Four ~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [~ Three [] Six [] Other 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.) 8. SEWAGE DISPOSAL SYSTEM [~I INDIVIDUAL/ON-SITE** /~' ~;='0 YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE ~UST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-o~o (Rev. ~/~o) 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 UTi LITY Connection Verified__ LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEIVl PERMIT NUMBER [~31NDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or []Holding Tank Size: I ~--S~O If Tank is homemade SOILS RATING give dimensions: ~OTAL ABSORPTION AREA MATERIAL ~_~.C.(~ 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Li~le 5. COMMENTS ~ APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY ~ .. / // 72-010 (Rev. 6/79)