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Home My WebLink AboutWORLD TOP ACRES LT 4World Top Acres Lot 4 #015-163-53 Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP1 91143 PID Number: 015-163-53 Dwelling: Z Single Family (SF) El with ADU F-1 Duplex (D) El Two Single Family Project: El New Z Upgrade Name AVA ANDERSON ABSORPTION FIELD - EXISTING El Deep Trench El Wide Trench 1771 Bed F-1 Mound Site Address 11260 HIDEAWAY TRAIL, ANCHORAGE El Other Phone Number of Bedrooms Soil Rating depth from original grade 4 GPD/SF �Total Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Fill added above original grade Ft. Gravel length Ft. WORLD TOP ACRES 4 Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well 100'+! 25 TANK Z Septic [__1 S.T.E.P. ❑R Holding El Other Manufacturer ANCHORAGE TANK _F4aterial Capacity 1250 Gal. Surface Water 100'+ i __ STEEL Number of compartments 2 Lot Line 10'+ NA Foundation 10'+ LIFT STATION Manufacturer Capacity Gal. Remarks Tank insulated & 5'+ from deck supports. Alarm location Electrical installed by Tank to 3034 PIPE MATERIAL House to tank 3034 Installer PCN drainfield Drainfield CO/MT 3034 Inspector FWCS BENCH MARK (Assumed elevation) 100 ft Inspdatesn ectio15110/18/2019 Zed 10/19/2019 : Location and description 3`d4th POOR SILL ON-SITE WATER AND WASTEWATER SECTION APPROVAL or- AQ Conditional Approval: Date all TH f . ......... ....... Curtis Huffman Septic System Approved - CE 128991 Date Lt112/11/2QQ-AW 4P F'o PROFESSOW Note: this approval does not include well permit requirements. NN, s (Rev Ub/U2/18) 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.orglonsite On -Site Wastewater Disposal System Permit Permit Number: OSP191143 Work Type: SepticTank Upgrade Tax Code Number: 01516353000 Site Legal Address: WORLD TOP ACRES LT 4 G:2640 Site Mailing Address: 11260 HIDEAWAY TRL, Anchorage Owner: ANDERSON AVA L Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 5/7/2019 5/6/2020 51412 ❑ 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 Received By: Issued By: Date: K� / Date: J 4 M MNMPAUTY OF ANCHORAGE Development Services Department \�f. Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 015-163-53 Property owner(s) AVA L. ANDERSON Day phone 9073609890 Mailing address 11260 HIDEAWAY TRAIL, ANCHORAGE, AK 99507 Site address 11260 HIDEAWAY TRAIL, ANCHORAGE, AK 99507 Legal description (Sub'd., Block & Lot) WORLD TOP ACRES LOT 4 Legal description (Township, Range & Section) Lot Size 51412 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) Septic Tank ® Upgrade (w/wo ADU) Holding Tank ElRenewal ❑ Duplex (D) El Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. FWCS m Brent Western (Signature of property owner or authorized agent) Permit/Rush Fees: 92 Waiver Fees: Date of Payment: C1/ 2A I Date of Payment: Receipt Number: Permit No. 03,01911g3 Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc Michael N. Anderson, P.E. Civil/Structural Engineering and Construction 4661 Natrona Ave. Anchorage, Alaska 99516 Phone 345 -3377 / Fax 345 -1391 Support Services Brent M. Western 907-440-4601 April 27, 2019 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: WORLD TOP ACRES LOT 4 To whom it may concern: The owner has requested we proceed forward to obtain a septic permit to upgrade the aged septic tank on the subject lot. The proposed upgrade will serve the existing 4- bedroom house. The lot and area is served by a private water and will not impact any of the neighboring properties due to the lot layout. Please contact Brent M. Western or me if you have any questions. Sincerely, Michael N. Anderson, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191143, Rebecca Carroll, 05/07/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191143, Rebecca Carroll, 05/07/19 Municipality of Anchorage Page / of _.-3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ID qtp O 3r1a PID Number: 0 I� — 163 — 3 Name. A 1-i_ e- N 'I /� M I� S Wastewater System: ❑ New Upgrade ��--�— --ABSURPTION Address: 319 -Lo NIDIEA& Y e/kt FIELD — Phone------ No. of Be r oms: vDeep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil eating: Total Depth from original grade5 : Lot: ✓' Block: pp Subdivision : 1N o-e2angt�v ? /T (S Depth to pipe bottom from origgiinal grade: Ft Gravel depth beneath pipe Ft Township: lion'.�a Pill added above original grade: Gravel length: ry5 WELL: E) New Upgrade Gravel width: Numberoflines: Distance belween lines: r.❑ Ft. 1. Ft. Classification (Private, A,Q. C): ^ Total Depth: To: — Total absorption area: Pipe material:,IJFt. LCad FL 7,0 SD. FL Fri /(7 �iUDriller: Date Drilled: Water Level: Ft. Installer: .e— Date installed: IO £ /VA �l Cl Io Yield Pump Set at: Casing Height Above Ground: —GPM Ft. -- FI. — —• TANK — SEPARATION DISTANCES i(Septic ❑Holding ❑S.T.E.P. To From septic Tank Absorption Field Lilt Station Holding Tank Public/Private Sewer Linea Manufacturer:_ Capacity in gallons: AL,Ltf1 g,1, f✓ 4167 Q Well 2 ?)v t rp 1 -'{o f ) /0O Material: Number of Com artments: 3 �-ee� Surface Water v-. `� __ LIFT STATION Lot Line �50 I ' Size in gallons I Manufacturer: Foundation ( � "Pump on" level at:: .'Pump off' level at: High water alarm at: Curtain Pump Make B Model Electrical Inspections performed by: Draina----- Remarks: BENCH MARK I, Ole/ 4t Location and ['lescription' _ / AG c`� O°v✓LOU wn,_D ils S Assumed Elevation (� .A ^Vl t Inspections performed by: Dates: 1st 2nd -i Department of Heal In and In ark S rvices approval Reviewed by: lYu fJ U Date: lu 13r'y6 and approved •kw 72-010 (Rev 9/91) MOA 25 I I I � We71 I I I I I I I I I I I I I I I I I \ STEEP SLOPE CO rF G BD 2r FTT I O QB CE 43 --_ E, BE 74 BF 32 B AT 54 EMT BG 55 AG 52 0 A H T— 14 c CO L4 1 48 FT, DEEP 75 FT. LONG 5 FL SEWERROCK 4444.. Well -4 1 1 4 m 4 4 1 4 4 LE ,SLOPE _ _ _ _ .. .. -... _ ......... 4 4 4 1 .. 11. "Asult Or I : G'•'' � o0o I is 491h... 4444 �......1lR.M�i TO EN SPURKLAND ••' �� ♦1� �T., No. CE-2225Ar ,••�� FESS mom 25 0 25 50 75 loo 125 1s4� jyell SCALE- 1" = 50 FT, OS OO IQBBLN SIJUHKLANU N.L. LOT 4 YYORLD TOP ACRES SEPTIC SYSTEM AS BUILT 203 W 15TH. AVENUE DATE: OCT. 9, 1996 ANCH. AK. 99501 11260 HLDEAWY TRAIL 1-1 — -- JAMES ALLEN SHEET: 2/3 GRID: 2640 Standard trench : 2' Wide 75' L ong 8' Deep 5' Sewer rock 3' Cover MT NV SCALE Cleanouts Monitor CO �— 3' Cover 1[95 0 E950 —� SIL T BAnn, ICS 89.8 5 Ft or Septic Rock NO SCALE 3 49th o 11 �? T BEN SPURKLAND •'� Ijc °•i 2�„ r�, •. No. CE -2225 111 F'�''•............ FESS of k cpJ 96.52 IE 96.79 IE 95.0 89.8 5 10/Iqo 1250 gal. septic tank BENCH MARK. FINISH FLOOR ASSUMED ELEV 100.00 TOBBEN SPURKLAND P.E. I L077 4 TOP WORLD Ai nESI SEPTIC SYSTEM AS BUILT I 203 wroth Ave 11260 HIDAWAY ]'RAIL DATE: OCT, 9, „q_,q,� JAMES ALLEN 1996 Anchorage Ak 99501 : 2640 siiEET 3/3 GRID 3 O ° O c O N O o 1250 gal Septic tank a c o c � v L2 v �u/R�v32J 3 49th o 11 �? T BEN SPURKLAND •'� Ijc °•i 2�„ r�, •. No. CE -2225 111 F'�''•............ FESS of k cpJ 96.52 IE 96.79 IE 95.0 89.8 5 10/Iqo 1250 gal. septic tank BENCH MARK. FINISH FLOOR ASSUMED ELEV 100.00 TOBBEN SPURKLAND P.E. I L077 4 TOP WORLD Ai nESI SEPTIC SYSTEM AS BUILT I 203 wroth Ave 11260 HIDAWAY ]'RAIL DATE: OCT, 9, „q_,q,� JAMES ALLEN 1996 Anchorage Ak 99501 : 2640 siiEET 3/3 GRID PAGE 1 OF 1 PARCEL ID:01516353 LEGAL DESCRIPTION: WORLD TOP ACRES LT 4 LOT SIZE: 51412 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: 1.) REPLACE SEPTIC TANK WITH A TWO COMPARTMENT 1250 GAL. SEPTIC TANK AS SHOWN ON THE DESIGN. 2.) PERFORM ADDITIONAL T.H. NEAR SOUTH END OF TRENCH AND SUBMIT SOILS LOG. 3 . ) ENTER DISTRJ-BI3-T-I-¢�INE AT OR NEAR MIDPOINT OF TRENCH. RECEIVED BY ISSUED BY DATE: C1-.4/6 % 1/ DATE: Q ?190176' MUNICIPALITY OF ANCHORAGE I �M DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 �- p ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW960321 DATE ]ISSUED: 9/30/96 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. EXPIRATION DATE: 9/30/97 OWNER NAME:ALLEN JAMES & VICTORIA OWNER ADDRESS:11260 HIDEAWAY TR ANCH, AK. 99516 PARCEL ID:01516353 LEGAL DESCRIPTION: WORLD TOP ACRES LT 4 LOT SIZE: 51412 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: 1.) REPLACE SEPTIC TANK WITH A TWO COMPARTMENT 1250 GAL. SEPTIC TANK AS SHOWN ON THE DESIGN. 2.) PERFORM ADDITIONAL T.H. NEAR SOUTH END OF TRENCH AND SUBMIT SOILS LOG. 3 . ) ENTER DISTRJ-BI3-T-I-¢�INE AT OR NEAR MIDPOINT OF TRENCH. RECEIVED BY ISSUED BY DATE: C1-.4/6 % 1/ DATE: Q ?190176' T. SIN, P.11 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907)279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 4 WORLD TOP ACRES JIM ALLEN Municipality of Anchorage September 15, 1996 Department of Health and Social Services September 26, 1996 820 I Street Anchorage, Alaska 99501 We are submitting an application for the installation of a septic system for this lot. The present installation, installed in 1979 has failed and must be replaced. This submittal consist of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only septic system are subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following : REVISED September 26, 1996 Ground Water at 13 ft. Assume rise to 12 ft. Use Standard Trench Soil Rating. 7 min/in = .8 gal per sq.fUday No. of Bedrooms 4 Required Area per Bedroom: 1501.8 = 187.5 sq.ft.. Total area required: 187.5 x 4 = 750 sgft. Ground Water at 12 ft. Bottom Rock At 8 feet Top Rock At 3 feet Rock Depth 5 feet Total Trench Length 750/04 = 75 ft. SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 75 FT TOTAL WIDTH 2 FT TOTAL DEPTH 8 FT ROCK DEPTH 5 FT COVER 3FT EXISTING SEPTIC TANK 1250 GAL Check Integrity, Replace if Leaking The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. I I I I I I I I I I I I I I I � STEEP SLOPE I I I I `� I I \ I I — EXIS 1250 GAL TA K 0 D I i NEW DRAINFIELD / S FT. DEEP 75 FL LONG 5 FT. SEWERROCK Well . I. LOPEOF .......... .... ................... '.L'. .��•�n�p� 10 25 0 25 50 75 100 125 150(, Well 1 " SCALE: = 50 FT, Y PROPOSED XPROVEMRNTS 0 0 EOBBEN SPURKLAND P.E. LOT 4 WORLD TOP ACRES SEPTIC SYSTEM DESIGN 203 W 15TH. AVENUE DATE: SEPT 3, 1996 ANCH. AK. 99501 260 AITRAIL — JAMES ALLY LEN SHEET: 2/3 GRID: 2640 Standard Trench ; 2' Wide tank 75' L ong A 1)2.&IY(, 8' Deep p 5' Sewer rock L.- ]3' c 3'Cover J v J � S 1 � NO SCALE SILT RARRI 5 Ft of Septic Rock q Cleanouts Monitor 3' Cover NO SCALE SEPTIC SYSTEM SCHEMATIC WE �7. 6 c std " a a EO 0 1250 gal Septic tank EXISTING CHECK INTEGRITY, REPLACE IF NEEDED i 49th �:�• TO BEN SPURKLAND a, �J No. CC -2225 .' INSTALL DOUBLE C.O. fl A 1250 gal. .septic tank EXISTING 1)2.&IY(, RrV13C17 BENCH MARK. FINISH FLOOR ASSUMED E! EV 100.00 TUBBEN SPURKLANB P.E. LOT 4 TOP WORLD ACRES SEPTIC SYSTEM DFStCN 203 W15th Ave 11260 HIOAWAY TRAIL DATE: SEPT. 3, 1996 Anchorage Ak 99501 JAMES ALLEN 11 SHEET 11— 1-13/3 GRID 2640 'IFS PURRILAz D P. Eo 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907)279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 4 WORLD TOP ACRES JIM ALLEN Municipality of Anchorage Department of Health and Social Services 8201 Street Anchorage, Alaska 99501 sNOVIR NM AuTy0" ENTAI SER Nell ktt©ON SSP 18 1996 Recel Vee September 15, 1996 We are submitting an application for the installation of a septic system for this lot. The present installation, installed in 1979 has failed and must be replaced. This submittal consist of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only septic system are subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following : Ground Water at 14 ft. Use Standard Trench Soil Rating. 7 min/in = .8 gal per sq.ft/day No. of Bedrooms 4 Required Area per Bedroom: 150/.8 = 187.5 sq.ft.. Total area required: 187.5 x 4 = 750 sgft. Ground Water at 14 ft. Bottom Rock At 10 feet Top Rock At 3 feet Rock Depth 7 feet Total Trench Length 750/14 = 53.6 ft. SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 54 FT TOTAL WIDTH 2 FT TOTAL DEPTH 10 FT ROCK DEPTH 7 F COVER 3FT EXISTING SEPTIC TANK 1250 GAL The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Pending and/or concentration of surface runoff will not result from this installation. r, d Municipality of Anchorage ,r DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR:. '',IH ALLEN —_ ---DATE PERFORMED: q15-... L SI Iv LEGAL DESCRIPTION: W( KK 1.,,D T op /�.Lo_aS Township, Range, Section: Erb{ Lo -i- L O1-� SLOPE SITE PLAN jfi I—TT-1 r --7---r T'I--TTT 1 -owl / v / 2 - �7 reLv Gil 1 SI N p1 L"_ YU C.N} 3 - ✓ --- 4 - Pi vie 17 •� T5a¢f a�.vt 4 /1019- 18-_ 1012 18• 19.- 20 - COMMENTS 20COMMENTS WAS GROUND WATER — ENCOUNTERED? S IF YES, AT WHAT L DEPTH? O P E Depth to Water Aller 1 ( C111 -i-46 Monitoring? _ Cale: _ 9eadin 8 Y 11�In ate Gross 9 Time Net Time Depth to Water Net Drop 6- 7 < L- y- —Y- 7_t�_ 8_ 10•_— " -c 11• '- 12.- 13.- 3 14.- b -C -C 16 F 16 • -- 17 •� T5a¢f a�.vt 4 /1019- 18-_ 1012 18• 19.- 20 - COMMENTS 20COMMENTS WAS GROUND WATER — ENCOUNTERED? S IF YES, AT WHAT L DEPTH? O P E Depth to Water Aller 1 ( C111 -i-46 Monitoring? _ Cale: _ 9eadin 8 Y 11�In ate Gross 9 Time Net Time Depth to Water Net Drop y- —Y- 7_t�_ _ 1+30 b PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN �_ FT AND - 61?.- FT PERFORMED 8Y: ar--,;_.._ __ r _ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE: AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DA"L. ATE: _a^� /_ 72.008 (Rev. 4/05) / S GRA P, LOT ,,P •; I � LOT 2 N II II 100 150 ._ -_200 250— 300. -- I'll COLE, 00._—,SCOLE, 1- _ 100 FT. I I I I � VACANT — LOT 1 III STEEP S OPEOO Cel I LOT Wel] 0 nT n LO ............... _. LE .SLOPE ................. 112 rH AVF. LOT I C7� �J LIT 2 , I , Lar 1 \ 0 ( N SO C_ OS G 1 well P KAY tYNG- -le VVL'MLNTS EOBBEN SPURKLAND P.E. LOT 4 WORLD TOP ACT?ES sEPiic sysrEM oEsicN 203 W 15TH. AVENUE P.E. 11260 HID ACE£NAIL )AT E: EP 3 199 GRID: 2640 ANCH. AK. 9901 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION O(ct) 825 LStreet - Anchoraye, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME AA `lrj•-/NiZ PHONE -y �ZG NEW 1:1 UPGRADE MAILING ADDRESS LEGAL DESCRIPTION L_ W D R o LOCATION t NO. OF BEDROOMS - Well `/ DISTANCE TO: Absorption ar a,. � Dwelling > r PERMIT NO. a Q N f Manufacturer /f_J i- V-- Material C� l - No. of compartments ` Lie. capacityin gallons IF HOMEMADE: Inside length Width Liquid depth OJ DISTANCE TO: Well Dwelling PERMIT NO. UZ 02 F Manufacturer Material Liquid capacity in gallons O= DISTANCE TO: Well /�O r Foundation zO r Nearest lot line f PERMIT NO. J w Z Z w No. of lines / Length of eac line Total lengt f lines Trench width inches Distance between lines H _ ___ ____(_J-L)__ F Total effective absoroknp area Top of We to finish grade Material beneath tile inches . 61-- length Width Depth PERMIT NO. w 7 Q k- wn Type of crib Crib diameter _ Crib depth Total effective absorption area N DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. J w DISTANCE TO: Building foundation _ Sewer line Septic ta nk Absorption areas)�+ OTHER PIPE MATERIALS SOIL TEST RATING -- a -- INSTALLER 0le��in7S(. e- - REMARKS c e °°. o. •.. a•• Drav J. • HermonYK rW � Q�9F °0'°•..°09.•.• .•ANN OV A oP S' fe�iQgcr�®.a o APPROVED �, DATE LEGAL F-� I��r /o—Z��° 72-013 (Rev. 3/78) W' "ON WELL DRILLP 1305 W. 45TH STREET ANCHORAGE. ALASKA 99503 PHONE 272-9343 DRILLING LOG Well Owner. �� i(l �S_ L rw Use of WelL'L� Location (address of: Township, Range, Section, if known; or distance main road- -►oo-e3 Size of casing—CL—Depth of Hole I D t feet Cased to v ^ feet Static water level -ft. (above) (below) land surface. Finish of well (check one) open end ( ); Screen ( ); Perforated ( ). j Describe screen or perforation L t^'x=K-S-,,t k-`^ Well pumping test atV 5-3o gallons per (hour) of drawdown from static level. Date of completion—N'-) 1%t''1f` LPA IC -1 0 i (`inut ) for_ hours witft. WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness 0 TO_J 0--c fw C cerci I ct(rC�P �TO S�� F �t�Tp `�`f I _ I✓, c� cC�N .�C`� A o_f'2(n(Q- T9 a--L�2 . `'ATO LL— _ C A 0-t.- 6o TO My Comn,Issicn N*63 G G A9l Nov=L 29, 1901 ,' -hn3 �-11 F " U. ��I :jj i.� L. DEPHRTMENT OF HE8LTH HND ENVIRONMENTHL PR�TE�TI�N 825 'L' STREET, HNCHORRGE, HK99581 264-472(: TYPE �F SDIL HBSORBTIOki SYSTEM IS� ~- -If XIMUM NUMBER OF BEDROOMS = ] SOIL RHTING (SQ FT/BR}= 15o THE REgUIRED SIZE OF THE SOIL HBSOP I�N SYSTEM IS� ,( of C �It�� It:�� THE LENGTH �IMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHlNFIELD THE DEPTH OF H TRENCH OR PIT IS THE DISTONCE BETWEEH TH1 RFHCE OF THE (L.. -ID 1: 11, THE BUTTOM OF THE EXCHVHTlON (IN FEET) THERE IS NO SET WlDTH FOR TRENCHE� THE GRRVEL DEPTH IS THE OINIUUM DEPTH �F GRHYEL BETWEEN THE OYTFHLL PIPE HND THE BOTTOM OF THE EXCRVHTION (1N FEET) ` PERMIT HPPLICHHT HHS TU1 1 m:EFPO1.,ISIBl1 8RTME1' .11 L)URING IL IN�THLLHTIDN lNSPECTIONS OF HNY WELLS HDJHCEHT Tn THIS PROPERTY HND THE NUMBER OF RESIDENCES THHT THE WELL WlLL. SERVE BHCKFILLING OF HNY Sy�TEM WITHOUT FINHL INSPECTION RND HPPkO�HL RY THIS DEP8RTMEHT WILL BE SyBJI TD PROSECUTI0N �j 1 0 �', < '-,� �. �i� :`• r �� < its �j 1 0 -.. __ .__ ._.. _ _ __ __. .._ _ .. .. _. _ _ 1 __. PARTMENT OF ENVIRONMENTAL .1ALITY n I? { PLATTING OR PLANNING & ZONING CASE REVIEW tir. i) CASE NO. 3 8 ( 6 TITLE:�� Date Case Received — By Suspense Date Comments to Planning Department For Planning & Zoning Commission Meeting Date _ ROUTING _-- Environmental Engineering Air Pollution Noise L J Environmental Sanitation COMMENTS:-�-, _% N v 0 a� Z� v 0 `4 C v � N v 0 Municipality of Anchorage On -Site Water & Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 015-163-53 1. GENERAL INFORMATION Complete legal description WORLD TOP ACRES LOT 4 Location (site address) Current Property owner(s) Mailing address Real Estate Agent Expiration Date: 11260 HIDEWAY TRAIL *ANCHORAGE. AK 99507 JEFF & DEANNA BERTRAND Day phone 11260 HIDEWAY TRAIL *ANCHORAGE AK 99507 LINDSAY SIZEMORE W/ KELLER WILLIAMS Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: 346-4117 727-8445 TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ Received by: COSA to be released to the engineer, unless othemise requested by the engineer. COSA Fee $ LA41C) r Date of Paymentl �a-I l�J G (Y� Receipt Number_ 6$1506, COSA # OSC l 3110$ r .. Date: Waiver Fee $ Date of Payment Receipt Number. Waiver # 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational fife of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will. continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 6. DSD SIGNATURE System #1 Approved for bedrooms. System #2 Approved for Disapproved. Conditional approval for Z bedrooms. bedrooms, with the following Phone 337-6179 Date ? & f ` ey arness.� CI -7993 ei ON-SITE WATER AND WASTEWATER Original Certificate Date: —_9l — / 3 The Wicipeo orAncty6rage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (CC SA) based only upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State ofA'rIska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTCHMENTS: / COSA Checklist v Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other (Rev. 11M) If more than I septic system is on the lot: COSA Checklist # _of_ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: WORLD TOP ACRES LOT 4 Parcel ID: 015-163-53 A. WELL DATA *WELL HAS PLUG IN IT, SO IT WAS NOT POSSIBLE TO OBTAIN WATER LEVEL. PUMPED 800 GALLONS IN 139 MINUTES. Well type PRIVATE If A. B, or C provide PWSID# N/A Well Log (YIN) YES Date completed 11 /5/1978 Sanitary seal (Y/N) YES Total depth 120.5 ft. Cased to 120.5 ft. FROM WELL LOG Date of test 11/5/1978 Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION ztnt'-tr 8 348 /13 Static water level ARTESIAN ft. *ARTESIAN ft. Well production 25-30 g.p.m. y ycr 9 p,m. WATER SAMPLE RESULTS: C7 Coliform n0 colonies/100 ml. Nitrateo •� y mg./L. Collected by: GEG. Ltd. v Arsenic: ► (Ckug./L. Date of sample: 3/8/13 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 10/1-2/96 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression overtanktt1ank (Y/N) NO %High water alarm (Y/N) N/A Date of pumping 3 � � Pumpers l C coy—) C..I Cil C. ABSORPTION FIELD DATA *RELow FxisTiNr, rRAnF Date installed 10/1-2/1996 Soil rating (g.p.d./ftor /bdrm 0.8 System type TRENCH Length 75 ft. Width 2 ft. Gravel below pipe 5 ft. Total depth *8.66 ft. Eff. absorption area 750 ft2 Monitoring tube YES Depression over field NO Date of adequacy test 3/8/13 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 0 in. Water added 800 gal. New depth 0 in. Elapsed Time: E min. Final fluid depth E in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give date — D. LIFT STATION Date installed Size in gallons Manhole/Access (YM "Pump on" level at in. "Pump off" level' .High water alarm level at Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot loo ,+ On adjacent lots 100'+ Absorption field on Public sewer main 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Sewer /septic service line 25'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field Wt, 4.83' Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *PER PREVIOUS COSA �� Ac LEu«ld 52.'.00.��i�hl'� Cj-�S,z�NLr 15 9' G. ENGINEER'S CERTIFICATION I cerfify 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. Engines rsPdn d Nat a JEFFREY A. GARNESS Date 37 'n 13 (Rev. 11105) ...... ............ .Je r A. Garness.: 1-7943 ' � G451- 145,00 -3- 5 890 55 4-5/w 299.87 UPPER �Nack AGREE 0 155.07 Recerf 3-1-13 13 -z5 -r3 {i! s '.�Pas��.s.w.+waasrwua..a s �� P B➢ e'il'3' p � h ffi SCALE%ffi JF< a Ra 'c 4 i,QA EASEMENTS OF RECORD; OTHER THAN THOSE SHOWN ON THE RECORDED PLAT ARE NOT SHOWN HEREON. rrnua4LL R 8) 75 D 9 O 0 vl WELL _U -- o AS -BUILT NO CORNERS SET THIS DATE Urs I hereby certify that I have performed a Mortgagee's inspection of the following described property'. LoT 4, WotzLD TOP .44-RE5 5U8b. Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property lying: adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission Anes or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alaska this 2Isf-A day of MARciy 1932 FRED WALATKA & ASSOCIATES (907) 248-1666 Engineers and Surveyors r< j 40= 9 Y. egsr `3, 5 890 55 4-5/w 299.87 UPPER �Nack AGREE 0 155.07 Recerf 3-1-13 13 -z5 -r3 {i! s '.�Pas��.s.w.+waasrwua..a s �� P B➢ e'il'3' p � h ffi SCALE%ffi JF< a Ra 'c 4 i,QA EASEMENTS OF RECORD; OTHER THAN THOSE SHOWN ON THE RECORDED PLAT ARE NOT SHOWN HEREON. rrnua4LL R 8) 75 D 9 O 0 vl WELL _U -- o AS -BUILT NO CORNERS SET THIS DATE Urs I hereby certify that I have performed a Mortgagee's inspection of the following described property'. LoT 4, WotzLD TOP .44-RE5 5U8b. Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property lying: adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission Anes or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alaska this 2Isf-A day of MARciy 1932 FRED WALATKA & ASSOCIATES (907) 248-1666 Engineers and Surveyors h� II MUNICIPALITY OF ANCHORAGE. AN 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 AU' HORITY APPROVAL FOR A SINGLE FAMILY DWELLING � Parcel I.D. # �� 3 _ �3 ✓ HAA # 1. GENERAL INFORMATION Complete legal description __L, i 4//—l' T � P Ac✓�rS Location (site address or directions) Property owner Day phone ? /o/ 75�� Mailing address 26c�_ /t/ ra ✓T ✓ %} �_� 9�`�� Lending agency Y1 `i 1c _a Day phone -1 7 Mailing addresses 1 Agent t ._ :._ �s=�� 11,�aDay phone _�� 9, 4 (> Address 1-2- 4 y'ir Unless otherwise requested, HAA will be heli for pickup. 2. NUMBER OF BEDROOMS: 4- 3. TYPE OF WATER SUPPLY: Individual well Community well Public water — NO'rE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tan:; 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 021 5. STATEMENT OF INSPECTION BY ENGINEER I 1.1 M 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 �/ 'gA.'/ /no>'v! P —/_:!:�,, r . Phone 3`7 9� � 7 Address % /a 7 /e r! - u G r� a I� -9 9 / Engineers signature 2�2Date 7 _ DHHS SIGNATURE �J Approved for — `L— bedrooms. Disapproved. Conditional approval for Additional Comments It1TIC bedrooms, with the following stipulations: Date 4-25-7-7 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 orderto 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(ReAM) BaCk MOA#21 MUNICIPALITY OF ANCHORAOL ENVIRONMENTAL SERVICES DIVISION Municipality of Anchorage APR 10 1997 e*D DEPARTMENT OF HEALTH & HUMAN SER\ fft V Environmental Services Division fft� �� ED 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: _ arcel I.D.: � Jf - 1a3 -5.3 A. WELL DATA Well type f A, B, or C, attach ADEC letter. ADEC water system number Log present(Y/N) Date completed 11 / 7,6 Total depth 12/9. / _ Cased to 2.,2D, Casing height (above ground) 3.5-, Sanitary seal (Y/N) Date of test Static water level Well production Wires properly protected (Y/N) N FROM WELL LOG AT INSPECTION ��TESIAN �F ' /z �£--- --Lou�IIV4 — WATER SAMPLE RESULTS: Coliform 1119-1.9 /-Loi✓INS g.p,rn. 7 Nitrate _ 01 Ste_ Other bacteria _— Date of sample: _ 4 X2 /9 Collected by: __,5_ 5- B. B. SEPTIC/HOLDING TANK DATA g.p.m. Date installed wL� (9 p_ Tank size L2�� Number of Compartments Cleanouts (Y/N)_ Foundation cleanout (Y/N) X__ Depression (Y/N) /l _ High water alarm (Y/N) Date of Pumping Ave=W _ Pumper Date installed 10 2 C� Soil rating (g.p.d./W or ft2/bdrm) _ O, 9 System type D �G 1✓c f{ Length 75-1 Width 2 _ Gravel thickness below pipe A Total depth 4 6FC? Effective absorption area 759Monitoring Tube present (Y/N) l Depression over field (Y/N) _ N_ Date of adequacy test _Z/= W Results (Pass/Fail) '30'7 VOM For 4 bedrooms Fluid depth in absorption field before test (in.); _ Immediately after_ gal. water added (in.); _ Fluid depth ___ (ins) Minutes later:— Absorption rate = _g.p.d. Peroxide treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)* COMMIT/JT, Wel-& 1 S A FI -0 t,-I)IVC WCL t. PF/c/«e 11- VP SEf/L, PR 5S, lo!/MO SND TASK IN 1lovSE -7-0 60osT' /�RESsdi?c=, D. LIFT STATION N//7 Date installed Manhole/Access (Y/N) High water alarm level at* _ Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 200 ! On adjacent lots i Absorption field on lot god + On adjacent lots /DU Public sewer main /1f U Public sewer manhole/cleanout N1� Sewer /septic service line 2 f Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: / 5's: TA.�x co #z To Foundation 7 r Property line 50 Absorption field TR6 vcy TvB� tL / / r / Water main/service line 2, r Surface water/drainage /oo Wells on adjacent lots /o,,) + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /� / Building foundation !o r Water main/service line ;2 S /a r ! Surface water 1c)0 4- Driveway, parking/vehicle storage area r r Curtain drain (dO -1- Wells on adjacent lots 100 '4" F. ENGINEER'S CERTIFICATION I certify that / have determined thru field inspections and review of Municipal records that,therabove,systems are in conformance wi M A HA guidplqlnes effect on this date. Signature Engineer's Name Date �7 /_9 HAA Fee Date of Payment <-/-10- 7/ Receipt Number o�'z� %? 7 5 I / 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number - DAl'E RECEIVED INSPECTION APPOINTM NTS T;ME TIME TIME. DATE I DATE DATE- - ❑ One ❑ Four El Other —\C)" �A—L� INSPECTOR INSPECTOR INSPECTOR ---- ------..174--- I INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled MUNICIPALITY OF ANCHORAGE - MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF HEALTH & 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PF,OTECTION ENVIRONMENTAL SANITATION DIVISION OCT 161�$0 Telephone 264-477_0 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWORPN VED DIRECTIONS: Complete all parts on page 1. Incomplete requests will not he processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER , - PHONE MAILIN ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2. BUYER — PHONE - MAILING ADDRESS 3. LENDIIN INSTITUTION /J — _-F-PHONE / 0 eXD MAILING ADDRESS / _AI 4. REALTOR/AGENT PHONE T - MAILING ADDRESS 5. LEGAL DESCRIPTION � STREET LOCATI N 6. T PE OF RESIDENCE -NUMBER OFrBEDROOMS ®SINGLE FAMILY ❑ One ❑ Four El Other -❑ Two ❑ Five ❑ MULTIPLE FAMILY B1- Three ❑ Six 7. WATER SU PLY I INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled - ❑ COMMUNITY since June 1975. For wells drilled prior to that elate, give well _❑ PUBLIC UTILITY (attach log if available.) B. SEWAGE DISPOSAL SYSTEM _depth GR' 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 ❑ SINGLE FAMILY ❑ MULTIPLEFAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED lo INSTALLER C, nJ— ❑Septic Tank or ❑ Holding Tank Size: -,I- 2� If Tank is homemade give dimensions: SOILS RATING .DC7 TYPE OF TANK MANUFACTURER J TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS 111 --APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE ) BY 72-010 ( Rev. 6/79)