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HomeMy WebLinkAboutVALLI VUE ESTATES #1 BLK 1 LT 29 ~ ] 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 [~NEW /~1 /~-¢~/7'~. ~'V~ ~'l ~ 0 [~UPGRADE MAILING ADDRESS loz; / S- ,~,'., Tree ".~;,~.~ ~.,~4o~..~.._ /ll,~,rl<,,. ?~ s'-/~ LEGAL DESCRIPTION LOCATION NO, OF BEDROOMS --~ Liq. capacity in gallons DiSTANCE TO: I Well I Absorption area WidthDWelling PERMIT NO. ~ ~ Manufacturer Material No. of compartments Liquid depth DISTANCE TO: PERMIT NO. Manufacturer WellF HOMEMADE: DwellinglnSide length Well ) of tile to finish grade Width Crib diameter Well DISTANCE TO: OTHER PIPE MATERIALS foundation Material Liquid capacity in gallons Foundation . Nearest lot line - , PI~)~I. IT NO. Total length of lines Trench width ~, ~O5 '1 Distance between lines l~/ J ~0~ ~O~nch~s J Depth / PERMIT NO. / Crib depth Total effective absorption area Nearest lot line Distance to lot llne Sewer llne Septic tank Absorption area(s) SOIL TEST RATING INSTAI~LER Building foundation Driller 72-013 (Rev. 3/78) PERMIT NO. DATE LEGAL : : :: MUNCIPALITYOFANCHORAG :"::~::::~: ~' :~: =, ::?:: :: : .::: -.~,DEpARTMENT bF HEALTH AND ENVIRONMENTAL PR0~EcTION · ~' ~,oN ::: : : ::= 825 L; sift; A~che~ge,.Alaska 99501: 264~20: .: :. :: Date: Tid~e : Time . : water':' Drop : :~'~ :' :: :z '02 , : ALASKA ellUIROIqllleF/TAL COF/TROL B RuIC S, ~nm]ineem'inq $ ~nuironmcnl,~l Studies Department of Health and Human Services 825 L. Street Anchorage, Alaska 99501 Attn: Susan Oswalt May 31, 1985 Dear Susan: This is in regards to Valli Vue Estates Lot 19, Block 1. A permit was issued to build a septic system for this lot based on a soils test done in 1974 in which SP sand rated at 150 sq.ft./bd, was recorded from 4 to 8 feet in a 14-foot deep dry test hole. The excavated trench was not in clean SP sand. Although there were pockets of sand, they made up less than 10 percent of the side wall area. I believe the trench was dug right through the original 1974 test hole, because it was done with a backhoe, and a fill area was encountered within the upgrade trench which was exactly the size of a backhoe test hole. I performed a test within the trench and the percolation rate i~ 42 J minutes per inch. The system has been enlarged accordingly. If you have any questions please feel free to contact me at 561-5650. Sincerely, Approved by: Darcy~vens Engineering Geologist 1200 L~¢sl 33rd Augnug. Suite [~, Anchoroqe, /~laska 99503 ~,(907) 561-50z!0 '' GRE; ER ANCHORAGE AREA BOI UGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME O~J~. ~--~/¢2/~F~' MAILING ADDRESS ,/~.¢/&a? LOCATION ,~-/A/ ~'~4%~ ~,,'e'. LEGAL DESCRIPTION SEPTIC TANK: DISTANCE FROM WELl MANUFACTURER NUMBER OF ~7~-/~ '~/~-MATERIAL /-~/L/"~/~¢¢~¢ COMPARTMENTS INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY /~'~ GALLONS. SEEPAGE PIT: NUMBER OF PITS / DIAMETER OR WIDTH ¢'~'~/ LENGTH ;2, f~-,*' DEPTH / ~ ! LINING MATERIAL CRIB SIZE: DIAMETER__DEPTH ~'/ DISTANCE FROM: WELL TOTAL EFFECTIVE BUILDING FOUNDATION '~O!"f NEAREST LOT LINE ~-~/¥- ABSORPTION AREA WALL AREA) ~--g .SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE ~ g:' ,')q/n CONSTRUCTION BUILDING NEAREST FOUNDATION LOT LINE CESSPOOL OTHER SOURCES APPROVED DISAPPROVED NEAREST SEWER LINE REMARKS DEPTH DISTANCE FROM: SEPTIC SEEPAGE TANK SYSTEM DISTANCES: INSTALLED BY: PIPE MATERIAL: ~'~-,5~-'- I~OA/ LOT SLOPE: REMARKS: Form NO. EQ-033 DIAGRAM OF SYSTEM DATE G.A.A,B. GREATER ANChOrAgE AReA BorOugh DEPARTMENT OF ENVIRONMENTAL QUALITY SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT PERMIT NO. INSTALLATION OF: SEPTIC TANK / SEEPAGE PIT /, DRAIN FIELD FINANCED THROUGH TO BE iNSTALLED BY PHONE , OTHER, NOTE: THIS PERMIT 15 NOT VALID WITHOUT BOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION, MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT ~ O~ ., DRAIN FIELD SEPTIC TANK TO SEEPAGE PiT WALL / SEPTIC TANK -, SEEPAGE PIT DRAIN FIELD TO NE.A~EST LOTJ.~E. DRAIN FIELD ALSO CONSIDER AREA WELLS. ,,7 /o DIAGRAM OF SYSTEM WATER MAIN TO SEPTIC TANK -, SEEPAGE PIT DRAIN FIELD , SEPTIC TANK, .//~ SEEPAGE PIT ~<~) , DRAIN FlEl~~ TO RIVER, LAKE, STREAM. CAST l~ON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PET FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL I~IAGKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION, I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREAT ANCHORAGE AREA BOROUGH ORDIN CE NO. 28-68 AND THAT THE ABOVE DATE APPLICANT'S SIGNATURE ~.~ R&M Civil En#ineer$ ENGINEERING & GEOLOGICAL CONSULTANTS 229 EAST 51st. AVE. - P.O. BOX 6087 -- ANCHORAGE, ALASKA 99503 TELEPHONE 907--279-0483 TELEX 090--35419 Geologist~ Land Surveyors JAMES W. ROONEY. P, E. MALCOLM A. MENZIES, P,E,, L,S. JAMES H, WELLMAN, P.E, June 17, 1974 No. 462041 RALPH R, MIGLIACCIO £nglneerlng Geologist Rappe Excavating 8001 Arctic Blvd. Anchorage, Alaska Re: Test Hole and Soil Log Report for Sanitary System Lot 29 Block 1 Valli-Vue Estates Dear Mr. Rappe: We are submitting herewith the test boring results and our comments regarding soil conditions encountered at the subject site. This investigation was performed in accordance with your request of June 15, 1974 and those procedures outlined in a letter dated September 13, 1971 by Mr. Rolf Strickland of the Greater Anchorage Area Borough Department of Environmental Quality. A single test hole was put down withim the Lot 29 area for the purpose of defining general subsurface soil conditions for the proposed sani- tary sysytem. Excavation was accomplished with a tractor-mounted backhoe and the test hole was extended to a total depth of 14.0 feet below ground surface. The final log prepared for the test hole has been included in Drawing A-01. Ground water was not encountered in the test hole. ~ We appreciate being given this opportunity to be of service to you. Should you have any questions with regard to the above, please do not heisitate to contact us. Very truly yours, R & M ENGINEERING & GEOLOGICAL CONSULTANTS, INC. JWR:kd xc: GAAB FAIRRANKS JUNEAU THai SILT, TRACE SAND (FILL) ORGANICS SILT, TRACE SAND (ML) SAND, TRACE GRAVEL (SP) ,?.0~ 2.5' 8.0I SILTY SANDY GRAVEL W/COBBLES (GM) NO WATER TABLE 14.0' T.D, NOTE: Test hole excavated with tractor mounted backhoe. Engineering ~ Geological Consultants Inc. ANCHORAGE FAIRBANKS ALASKA JUNEnU RAPPE EXCAVATING LOG OF TEST HOLE ANCHORAGE, ALASKA 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 AU'FHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description ~,~- ~'~r Location (site address or directions) / o~, / ~- ~t ~-/,~ Property owner Mailing address ~"~ Lending agency Mailing address Day phone Day phone &~-5'7- 3 q/~ Agent ,"~'~F,',~'~'- '- ~.,,'b~-. 0~ Address -- Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ ~ TYPE OF WATER SUPPLY: individual well Community well ~ Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: individual on-site Holding tank Community on-site Public sewer NOTE: 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 = 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 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 inves_ti_gation 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 Phone Address ~'co d- Engineer's signature ,~- E~_~ Date DHHS SIGNATURE ~' Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 4-22 -?? 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 p rofessional engineer registered in the State of Alaska. The D H 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. RECEiVE APR 1 5 1999 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVI~,:4~glPALITY OF ANCHORA(~w ~, Environmental Services Division ~NVIRONMENTALSERVIC[$ DIVI~--~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval CheckliSt Legal Description: /~ ~-~, ~ .,¢-/ V,~.~i I/c,¢ ~-<~. ¢~/ Parcel I.D.: o,'z - ,3¢~--,o/ A. WELL DATA Well type '/~ ' If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed Total depth -- Cased to ~ Sanitary seal (Y/N) -- Casing height (above ground) -- Wires properly protected (Y/N) -- FROM WELL LOG AT INSPECTION Date of test f Static water level Well production '~ g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform '~' Nitrate Other bacteria Date of sample: / Collected by: B. SEPTIC/HOLDING TANK DATA Date installed (,,//¢/'7~/ Tank size Number of Compartments ~ Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y' Depression (Y/N) ~ Date of Pumping ,¢ -/O -~'¢ Pumper -~.~',/'//¢~ ')" High water alarm (Y/N) C. ABSORPTION FIELD DATA Date installed .~'/~ ' ~ Gravel thickness below pipe .~,/2-/ Length /,5'/ Width .~or'/Go * © Total depth Effective absorption area Monitoring Tube present (Y/N) ~v(~ Depression over field (Y/N) Date of adequacy test ¢'/- &,~ ~' ~ Results (Pass/Fail) /24 s,~ For ~ Fluid depth in absorption field before test (in.); ¢ ¢, Immediately after/y'SE)gal, water added (in.): Fluid depth ,,'/-~ ~ (ins) Minutes later: /.~,¢;d¢¢-~ Absorption rate = ~¢70~'~ g.p.d. Soil rating (g.p.d./fF or ft~/bdrm) $~,Z System type bedrooms /7 Peroxide treatment (past 12 months) (Y/N) tv' If yes, give date 72-026(Rev. 3/96)* i~)~e-/z ~z~,,/ ~c~,0~ (~ ~'~ 5~ Co~v~ ~i~D. D. LIFT STATION Date installed Manhole/Access (Y/N) ~ High water alarm level at* ~ Cycles tested ~/ E. SEPARATION DISTANCES Size in gallons "Pump on" level at* "Pump off",level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation /~/ Property line ~ 3~)c'/'~/- Absorption field /~' Water main/serviCe line ?/o Surface water/drainage ~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: ~(~ Property line ! ~' ~) Building foundation x'vo~ '~'(~ Water main/service line ~/o Surface water ~ 4~' Driveway. parking/vehicle storage area Y-/,~,~,~,~ ~,¢E,~-~ ~ Curtain drain ,v/A- F. ENGINEER'S CERTIFICATION Wells on adjacent lots I certify th~-L~ve determined thru field inspections and review of Municipal in conforr~ance ~vith MOA HAA oJ~idelines in effect on this date. Engineer s Name- ~ ~ " are HAAFee $ ~-~:) Date of Payment ~-'~,'/~'~/~ Receipt Number /---~'~7 ~'' 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ("~\ ~ - '~-~ - q~\ HAA# ~-~ ~ .~t~ ~,t~ \ 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner /~ ay ~eMj'~,.., Day phone Mailing address IO~l~ ~aln ~ee DC;~c/ ~A~c~ Lendingagency C,~/ ~o'~ (~1 ~) Dayphone Mailingaddress qO~ ~. ~ev ~'o~V~. ~ Agent ~on¢ Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site ~ Holding tank Community on-site Public sewer NOTE: 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 by 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 'F*fczH'¢f T~cA~;~af .~¢rv'~¢,~/ Address /.~l..,g--~ ~ Engineer's signature Phone Date ~'~ DHHS SIGNATURE ~-- Approved for 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 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. 72~}25 {Rev. 1/91) Back MOA ~1 .~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LOT 25' SL/~ 1 t,'ALLI Vu'~' -¢¢ ! Parcel I.D, A. WELL DATA · Well type ~A ~ If A, B, or C, attach ADEC letter: ADEC water system number Log present (Y/N) Date completed Driller Total depth Cased to Casing height Sanitary seal (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG Wfres properly protected (Y/N) AT INSPECTION g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ; On adjacent lots Absorption field on lot Public sewer main ; On adjacent lots Public seWer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed (°/l°i I '/~ Tank size Cleanouts (Y/N) Y : .... Foundation cieanout (Y/N) Y High water alarm (Y/N) t~,A: ,~ ~ ' - ', Alarm tested (Y/N) Date of pumping ~'/¥/~) ~ " _~. , Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot iq.~;; Compartments '~ Depression (Y/N) To propertyline Surface water/drainage N 72-026 (Rev. 7/91) Front ' CONTINUED ON BACK PAGE C. LIFT STATION N, A-. Date installed ~ Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed Length ]~,1 Width Soil rating 342 d/~D,~M System type ' Gravelthickness 2.' ~ 5' Total depth Total absorption area Il Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Cleanouts present (Y/N) Date of adequacy test for If yes, give date N ,4, SEPARATION DISTANCE FROM ABSORPTION FIELD TO: To building foundation On adjacent lots z'/5 ' Cutbank ~{,/I. Surface water >- /oo Onadjacentlots N./), Propertyline I~ ?¢,~ ~4z' F~o~, ¢.o. To existing or abandoned system on lot -¢ ' Curtain drain bedrooms I~$p. ~'£P, Water main/service line Driveway, parking/vehicle storage area f'brw~46 ove.~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Engineer's Name HAA Fees //70 Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev. 3/91 ) Back MOA 21 DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE DISTRICT OFFICE 800 E. DIMOND BLVD., SUITE 3-470 ANCHORAGE, ALASKA 99503 WALTER J. HICKEL, GOVERNOR (907) 349-7755 April 22, 1992 FOR: S & S Engineering PWSID # 210605 My review of the records on file in this office reveals that the Valli Vue Subdivision Class "A" Public Water System, is in compliance with the routine coliform bacteria sampling requirements listed in Table C, and with the inorganic sampling requirements listed in Table B of 18 AAC 80.200. Sincerely, Bgron Roys Project Engineer BR/cf · ., ~ ~MUNIC~IPALITY OF ANCHORAG~ DEPARTME~ 'OF HEALTH AND ENVIRONMEN~~. PROTECTION 825 L Street, Anchoraa~. Alaska 99501 264-4720 #1: Time c~J~Ht #2: Time Date _ -. ~ Date Insp ~ - ~~q~ Insp Date Received: February 27, 1978 ~3: Time ~i~ Date Insp ~A5 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WAT .R A3CILITIES 1. Lending Institution Request: Alaska Pacific Bank Mailing Address: Post Office Box 420 99510 Phone: 276-3110 2. Property Owner: Paul Eggert Mailing Address: 10615 Main Tree Drive 99502 Phone: 3. Legal Description: Lot 29 Block 1 Valli Vue Estates Subdivision 4: Single Family Residence: (x) Multiple Family Residence: ( ) Number of Bedrooms: Three Number of Bedrooms: o Well System: Permit # Construction Individual well ( ) Community/Public System (x) Depth of Well Well Log on File Bacterial Analysis ( ) 6. Sewage Disposal System: Permit # Septic Tank Size Absorption Area On-site System (x) Public Utility ( ) Installed 1974 Installer I~ /~) Manufacturer ~?. ~7~F~L Soils Rate ! 7~' Material Distances: Well to Septic Tank Sewer Line Nearest Lot line to Absorption Area Absorption Area to Nearest Lot Line Pag~'Two Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 29 Block 1Valli Vue Estates Subdivision Comments: Affadavit Attached:~. ). Approved: (~'~ C)~ q~,~-' Disapproved: Letter Attached: ( ) Date: 3J lo ~3~ Date: Department Worksheet !~UNICIPALITY OF ANCHORAGE:~'~ Department of Health and Environmental Protection 825 L Street, Anchorage, Alaska 99501 264-4720 ~equest for Approval of Individual Sewer and Water Facilities 1. Property Owner: Paul Egbert Mailing Address: 10615 Main Tree Drive Phone: o Name of Mailing Address: Lending Institution: Mailing Address: Buyer: Dr. Raymond Fed3~- c/o AMU, Anchorage Alaska Pacific Bank P.O. Box 420, Anchorage, 99510 Phone: 277-7140 Phone: 23~-3110_ o Realtor/Agent: Denali Realty/Grayce 0akley Mailing Address: Phone: ~m7556 __ Legal Description: Street Location: Lot 29, Block 1 Valli Vue Estate_s 10615 Main Tree Drive Single Family Residence: (X) Number of Bedrooms: Multiple Family Residence: ( ) Number of Bedrooms: 3 Water Supply: *Individual Well ( ) If Individual Well, well depth If Community System, name of system Public/Co~unity System (x) unknown Sewage Disposal System: *~n-site System (x) Public System ( ) If On-site System, date of installation: 1974 *NOTE: A well log is required on ALL wells drilled since 6/75~ ** If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fee of $25.00 must accompany each request before proc~ssinq can be initia~ed. 3/77