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HomeMy WebLinkAboutZANTHA VISTA #1 BLK B LT 6antha Vista #1 Block B Lot 6 #015-472-16 10/07/13 11: 58AM ANCHORAGE WELL s PUMP 19072430'742 W.01 C)n.v�l,r,^scn# 52rviL'LS pv.par•t•rnenr .suowaawrm r ��l Cin-�.rT='- '�b`r_.t;;r• ?+ 1'•!a�#�wa#�r Prcgrcm Pump Installation Lag Well Drillinri Permit Durnben SW_.. _ Date Of Issue:....._._.. Parcel Identl6eatiOa— Legal Descriptiuu Property Owt3Si Nam & A Tf} # Pump lnstailation Date: t pump Intake Depth Below Top ni•1Ycll Casing: feet Pump Mauufacturer's dame: Pump Model:— Pump size lip . Pitless Adapter BUriai Death.: ILO feet Pitless Adapter Manufacturer's dame: [ Pitless Adapter lu.`atklier: P()4` Well Disinfected Upon t_ ,mploioa?" iQ- 0 � 1) ,Method Of Dl$int'NCtiOW C:ommenls: i '—.--_'ARhora9a Pump & Well Sen Pump Installer Name: 330 Fast 76th Avenue Anchorage, Alaska 99518 Phone, 007-243-0740 Fax: 907-243-0742 Attentiva: 'Che rump itL5Caltc; shall provide e p+nvp instaliation 10& t(� the [-)ST) within 30 nays of p,tmp in'Mallatton. 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 —v — ONE � NAMEPH NEW \ SSA \.,,L1 C W IS V_ 44--I ❑ UPGRADE MAILING ADDRESS p LEGAL DESCRIPTION �1 \--�b -1)D YF A \5t4 LOCATION NO. OF BEDROOMS -- II Absorption area Dwelling DISTANCE TO: tOQ \� So U"— PERMIT NO. Cc�� P 2 Manufacturer Material No. of compartments — N Liq. capacity in gallons IF HOMEMADE: Inside length 1 Width � Liquid depth `\ �— `�7 r�r-�(� A ���iii��� Z DISTANCE TO: Dwelling PERMIT NO. 2 z h Manufacturer `—k-- --_ Material Liquid capacity m gallons w = DISTANCE TO: ell , — Foundation 0.11 'T Nearest lot line PERMIT NO. �O Lie u O ue ~—a No, of lines Length of each li 1. Total length of lines 14 Trench width � Inches Distance between lines „ T-1 Q t_ _ Top of rile to finish grade 1 \4 Material beneath rile Total effective absorptiony area (O inches 5 Length — Width — h Dept - PERMIT NO. w aF Type of crib C ib ameter Crib depth Total effective absorption area wa w rn I Building foundation Nearest lot line DISTANCE TO: Depth Driller Distance to lot line PERMIT NO. Jgjass J m �+ Building foundation Sewer line Septic tank Absorption area(s) DISTANCE TO: Y_ ----- OTHER u PIPE MATERIALS tayrn SOIL TEST. RATING p_ CJ ' INSTALLER REMARKS J. 0� J a ICV tai •A f --- OVED — DATE LEGAL -�Q 72-01TIRev. 3/78) WELL LOCAT WATER WELL LOG MUNICIPALITY OF ANCHORAGE FOSS DRILLING DEPT. OF HEALTH & 1336 Ingra Street ENVIRONMENTAL PROTECTION Anchoraire. Alaska 99501 SIZE OF CASING DEPTH OF ROLE9FT. CASED TO. Z-16 FT. STATIC WATER LEVEL �,_,FT. YIELDe__GAL.PER.MIN. WITH�q�—, FEET OF DRAWDOWN. REMARKS_ -- �.— --- —. DATE COMPLETED -/ b.=_�—PUMP TO BE SET AT����J Lt ALL `' o- �t0 �t0- mx �t �t 0— �t o - t0 _—t 0— _®t 0- —_0-00- 0—. —. o 0- ---wt 0- 0- 0— MUNICIPALITY _m,.0_v.0— pl 13���� DEPARTMENT HEALTH AND ENVIR0NMENT8L ._JTECTlONtjz� I 825 /L/ STREET/ RNCHORRGE, HK 99501 264~4720 -�y/� ���� ��� ��-05��� ��FU�� �0��1� /U,0U PERMIT NO. ( 780687 ) APPLICANT CARL E LUCHSINGER BOX 94 SRR 99507 � LOCATION SNDWLlNE DR LEGRL L6 BB ZHNTHH VISTA S/D LOT SIZE 54000 SFEET�� LL}�J/��'//`/^ 8Q� TYPE OF SOIL RBS[)RBTIDN SYSTEM I�� ,: TRENCH ^�vu,/� MRXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT/BR)- v*= �,5 ` THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: x~ - � �� �P�8� |t� /� ~1n FTEE01-A :c FlEEC> If 1 ���ll-�f. 1: 00— fl, At T1 CR ���L. C3 KA TH: FERMIT HPPLICHNT HHS THE RESPONSIBILITY TO lNFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY' WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. / 'r ~-- K Il! :,.-. ��! �- F" FE ED -F X C�:o 5%u �g-,:-!: F_.%* C." 1 FREEK> �~~ RHCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. . MINIMUM DISTANCE BETWEEN 8 WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR O PRIVATE WELL/ OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL WELL LOGl'..; ARE REQUIRED AND MUST BE RETURNE[xT0 THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION, OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARI-''.: AVAILABLE TO INSURE PROPER INSTALLATION. If I K IFT PrIl �11. ef­14 F" 1 It EE 10 E> EE ED K H ­q IET EE FQ Oil-, CIL ED 71 E -Di I CERTIFY THAI ATHHM F THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH 8Y LITY OF ANCHORAGE. 2� I WILL E SYSTEM IN ACCORDANCE WITH THE CODES. ]� l UNDE THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLHRGEMENT IF THE RESlDENCE REMODEm TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED�_- _______-_ _____�_-^~_____�____ RPSlCRNT CARL E. LUCHSlNGER � u/' Q VI2 `fa i .. TFI-1 'I 10-•2.5-76 mm p—n' ----- -- — 7.5' oCYe 080:. •qq° SANDY GRAVEL (GP) - Many Cobbles 'oeyle Lt. Brown p; o: ti 12.0' a SILT W/SOME SAND (MT.) Lt. Brown SILTY SAND W/SOME GRAVEL (SM) Lt. Brown 19.0' ° Refusal on Boulder. at 24' <"•.o - - - 24' TH-2 10-25-75 q.._ • 0 SAND W/ SO:iE SILT AND SOItE GRAVEL, (Sit) Brown 0.0' SILTY SAND (SM) Pine, Lt. Broom --- --_ 10.0' o�; SAND Sl/SOME SILT 'ob AND SOIIE GRAVEL (SM) Many Cobbles Lt. Brown 17.0' SANDY GRAVEL W,/ / SOME SILT (Gil) / •-� Lt. Brown, Wet C No Water Table \224.5' TD No {later- Table These logs represent subsurface soil conditions within Parcel 41, NWS, Section 24, T12N, R3W, Anchorage, Ak _ ��o• SAT41TARY SEWER TEST BOLES - GRID R&M CONSULTANTS, INC. CARL LUCHSINGER pROJ.NO. 65637.7 •..""•"" "'"•"'••• •••""--- ---- ANCHORAGE. ALASKA _ _ DWG. NO. A-02 :D -o' SAND W/SOME SILT :,.•7. AND SOME GRAVEL o_ Brown 2..5' SAND W/SO[1E SILT AND TRACP•, GRAVEL, Brown 3.5' - s9. GRAVELLY SAND W/ > o'o TRACE SILT (SP) Many cobbles eb Brown p—n' ----- -- — 7.5' oCYe 080:. •qq° SANDY GRAVEL (GP) - Many Cobbles 'oeyle Lt. Brown p; o: ti 12.0' a SILT W/SOME SAND (MT.) Lt. Brown SILTY SAND W/SOME GRAVEL (SM) Lt. Brown 19.0' ° Refusal on Boulder. at 24' <"•.o - - - 24' TH-2 10-25-75 q.._ • 0 SAND W/ SO:iE SILT AND SOItE GRAVEL, (Sit) Brown 0.0' SILTY SAND (SM) Pine, Lt. Broom --- --_ 10.0' o�; SAND Sl/SOME SILT 'ob AND SOIIE GRAVEL (SM) Many Cobbles Lt. Brown 17.0' SANDY GRAVEL W,/ / SOME SILT (Gil) / •-� Lt. Brown, Wet C No Water Table \224.5' TD No {later- Table These logs represent subsurface soil conditions within Parcel 41, NWS, Section 24, T12N, R3W, Anchorage, Ak _ ��o• SAT41TARY SEWER TEST BOLES - GRID R&M CONSULTANTS, INC. CARL LUCHSINGER pROJ.NO. 65637.7 •..""•"" "'"•"'••• •••""--- ---- ANCHORAGE. ALASKA _ _ DWG. NO. A-02 Municipality of Anchorage •• • Development Services Department Building Safety Division 1 , On -Site Water 8 Wastewater Program +}� 4700 Bragaw Street Sr ly1 P.O. Box 196650 v Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 -4S'� CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. OI S—g7Z-i( COSA# 9/70701 7 1. GENERAL INFORMATION Expiration Date: r ?,e o Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address ZANTHA VISTA /It LOT 6 BLOCK B 11000 SNOWLINE DRIVE • ANCHORAGE, AK _99507 BRUCE HILTON Day phone C/0 AGENT 11000 SNOWLINE DRIVE • ANCHORAGE, AK 99507 Day phone MARGARET NELSON w/PRUDENTIAL Day phone 273-7332 3801 CENTERPOINT DR 1200 *ANCHORAGE AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well lit Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site IN Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given In paragraph 4 by an Independent professional civil engineer registered In the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 Cetificate 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. Phone 337-6179 Address 3701 E. TUDOR ROAD, SURE 101 + ANCHORAGE, AK 99507 Engineers Printed Name JEFFREY A. GARNESS, P.E. Date t 2.12 $/07 - Engineers o7 - Engineers Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines B Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of elf wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions ere outside the control of the evaluator of the system. Satisfactory lost results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the solo benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. • fI(Wrrlfj : �,j AN 1% Conditional approval for � bedrooms, with the fllowing stipulations: �e�•� •. • • • • • . /y" Wf1;V LE TE o Ab4f- Ec OAI G Nom\ • fA% jrA,Snv7c4r vEEo 4,r7TPQ J✓$A+iTTEo 70 OW- ITE NTAT.C4 M S : Wp1ER AS f% s3nLr�/ c PyaAn, VyFie 1_5-J.061 xoo c , rorvg m01 OGW Attachments: i COSA Checklist Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineers Reort Nitrate Advisory Other By Original Certificate Date: 7, 1 Z3 07 (R.n. I uos) Municipality of Anchorage (• --� Development Services Department Building Safety Division _ On -Site Water 8 Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage. AK 99519-6650 www.muni.org/onsite (907) 343-7904 ;CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: 2ANTHA VISTA #1, LOT 6, BLOCK B Parcel ID: A. WELL DATA *OLD WELL WAS DECOMMISSIONED BY ARROW PUMP AND WELL SERVICES Well type PRNATE If A, B, or C provide PWSID# N/A Well Log (Y/N) NO Date completed *PER 1991 Sanitary seal (YIN) YES Wires properly protected (YIN) YES Total depth 61'+ ft. Cased to 61'+ ft. Casing height (above ground) 12 in. FROM WELL LOG AT INSPECTION Date of test ��G 12/12/2007 Static water level ��G�'ft. 57 ft• Well production NO g.p.m. 3.70 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 5.58 mg./L. Other bacteria 0_colonies/100 ml. Arsenic: n 79 ug./L. Date of sample: 12/6/2007 Collected by: GEG Ltd. B. SEPTI WHOLDING TANK DATA *ONLY ONE TANK CLEANOUT Tank Type/Material SEPTIC/FIBERGLASS Date installed 10/11/1978 Tank size 1250 gal. Number of compartments *2 Cleanouts (YIN)' YES Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (YIN) N/A Date of pumping 12/10/2007 pumper McDONALDS PUMPING C. ABSORPTION FIELD DATA BELOW EXISTING GRADE Date installed 10/11/1978 Soil rating (g.p.ddft'o t/bd 85 System type TRENCH Length 74 ft. Width 2.5 ft. Gravel below pipe 2.5 ft. Total depth • 11.5 ft. Eff. absorption area 370 ft' Monitoring lube YES Depression over field NO Date of adequacy test ** 12/12/2007 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before testE 1 In. Water added 1650gal. New depth E in. Elapsed Time: 0 min. Final fluid depth E in. Absorption rate >_ 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date — **PRESOAKED WITH 1000 GALLONS ON 12/12/2007. D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N 'Pump on' level at —in. 'Pump oft" level High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A 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 5'+ 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 00' Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage "0' Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTSLr, •WR910014 (4/12/1991) "SOUTH 9' OF TENCH IS UNDER DRIVE WAY G. ENGINEER'S CERTIFICATION o Vr I certify that I have determined through field inspections and review of Municipal records that the above systems are in 0"""" "' ' ' ' ........ conformance with MOA COSA guidelines in effect on this Q date. J f A. .....ess:...O Engineer's Printed Name JEFFREY A. GARNESS QQ E-795 e`p� Date �ZI2$/04' ��4°� P2�z.6• o �qo4 �ey rofesswo - •� ��OODoo� COSA Fee S y,:; O+ 1-7 5 IL S 6 Date of Payment- I a, a 9.1 O 7 t Receipt Number— O of 4 3 h,ai (Rev. 11105) Waiver Fee $ Date of Receipt Number Municipality of Anchorage . • Development Services Department y :; Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.orglonsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval.# HA070477 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block B, Lot 6 of Zantha Vista #1 subdivision. This inspection revealed a nitrate concentration of 5.58 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. Dec•28. 2001 4:48PM Garness Engineering Group, Ltd. Jeff Gamess To: Subject Goodall, Joe P. RE: zantha.doc No•1446 P. 1 Hello Joe. I sent you a receipt from Aarrow Pump and well regarding the well decommissioning. I Just talked to my field tech that did the testing on this system. He said that the tank cleanout is 5-6 feet from the edge of the driveway. He doesn't think it lies under the driveway, but the only way to be sure of that would be to dig It up and physically verify it. This configuration has been in place for a number of years with, to the best of my knowledge, no adverse impact. A portion of the drainfield is under the driveway and this Issue was addressed on the previous HAA. It Is my understanding that you will issue a conditional COSA that will require letters of non -objection be obtained from the utility companies and MOA ROW. Jeffrey A. Garness, P.E., MS. President Garness Engineeering Group, Ltd. 3701 East Tudor Road, Suite 101 Anchorage, Alaska 99507-1259 Ph: 907.337-6179 Fax: 907-338-3246 email: Ieffeizarrnessenel neerine.com website: www.earnesseneineerine.com From: Goodall, Joe P.[mailto:GoodalUP@d.anchorage.ak.us] Sent: Friday, December 28, 2007 3:34 PM To: Jeff Garness Subject: zantha.doc Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage. AK 99519-6650 www ci.anchoraae,ok us (907) 343-7904 , Analytica International, Inc. • 4307 Arctic Blvd. Anchorage, AK 99503 Phone: 907-258-2155 ' Fax: 907-258-6634 ANALYPICA' GROUP Garness Engineering Group, Ltd. Report Date: 12/12/2007 Attn: Jody GEG, Ltd. Receipt Date: 121611-007 3701 E Tudor Road, Suite 101 Sample Date: 12/62007 Anchorage, AK 99507 Sample Time: 11:30:OOAM 907-337-6179 Collected By: Kh1 Fax: 907-338-3246 Client Sample ID: Sampling Location: Snowiine Dr 11000 Client Project: Private Well Testing Sample Matrix: Aqueous COC ": PWS": Residual Chlorine: Comments: Zcti✓titic� Vi S �-� I L Flamm Definitions: bIRL = Method Reporting Limit MCL = Maximum Contaminant Limit B = Present also in Method Blank I I = Exceeds Regulatory Limit M = Matrix Interference 1= Estimated Value D = Lost to Dilution •• = RL higher than hICL; target not detected TNC = Too Numerous to Count - result rejected Cr = Confluent Growth - result rejected TCNG = Turbid Culture No Growth - rejected Lab": A0712052 -01A Analysis Method Prep Prep Analysis Parameter Result Units Flags MRL MCI, Method Date Date Analyst 9222B (Aqueous) - Membrane Filtration MF , Test was conducted by: Analt•-lica -Anchorage Bacteria, Other <MRL CFU/IOOmL 1.0 12/6/2007 12/6/2007 PL Total Coliform <hIRL CFU/IOOmL 1.0 1 12/6/2007 12/6/2007 PL Lab": A0712052-OIB Analysis Method Prep Prep Analysis Parameter Result Units Flags GIRL MCL Method Date Date Analyst 4500-NO3E (Aqueous) - Nitrate - 7est was conducled by: Analytica-Anchorage Nitrate as N 5.58 mg L 2.5 10 12/7/2007 12/72007 AJ Lab": A0712052 -OIC Analysis Method Prep Prep Analysis Parameter Result Units Flags MRL MCL Method Date Date Analyst 200.8/200.8 (Aqueous) - Family Well Nater 1 lest was conducted by: Analytica - Mormon Arsenic 0.295 ug1L 0.15 10 200.8 12/10200712/10200ZY • ' Reported by: Steve Gaither, Laboratory Project Manager r • Page I of 1 06:038 FROM: AAROW PUMP & WEIR SERVICE, LLC P.O. Box 110496 Anchorage, AK 99511 Office: (907) 346.9355 • Fax (907) 333.8976 • Eagle River: (907) 622.9335 70:3383246 P.1/1 GHWOO E N° 07905 CUSTOMER JOB SITE r- �ruc1- �i�o f c�Q Mar�r�f-Gia-yS?q 1 1 000 w Ai e �}a1c�or44 �AV. X9516 t . L—t-44 /ba-' / -6 7-' -> —r L— !/ d� WELL Dt7T1 aWL CMOANATED P{JA/P DEPiN QUANTITY DESCRIPTION PRICE AMOUNT Vi'deo ell w w*s f; Y• Pro 19yo r Ko o q m.tvq ly r i'K i ' wt Cat fi l'-� m r fo ra tits G / DW ♦ G off- door,f o FT ra 'kq d' belo rade LABOR HOURS RATE AMOUNT TOTAL MATERIAL TOTALLABOR WORK ORDERED BY DATE COMP. TOTAL LABOR PAY THIS AMOUNT Thank You SIGNATURE (I Hereby Acknowledge me SatlSfacfory Completion Of the Above Described Work and agree that If above work Is not paid for In 80 Saye 1 agree to Wow Aerew Pump d Well Somloo, LLC. the right to remove unpaid for equipment and charge for labor already performed 6 labor to remove unpaid for equipment.) TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS. CID \|k § E i En 9 � CC) 8 � 2 C3 k � LOT -- - — E mENT 6� 0: # e PA N VA f y! @ & ON 0 ¥ 0 k , / �SNOWO/E ! i -—---�. % E A Ln m Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 ON-SITE SEWER/WELL SUBMITTAL COMMENT SHEET To: GARNESS ENG Legal description: ZANTHA VISTA #1 BL B LOT 6 ❑Permit ®C.O.S.A. ❑Inspection Report The attached paperwork has been reviewed and is being returned for the following reasons: 1. -ABSORPTION FIELD AND SEPTIC TANK UNDER DRIVEWAY? r A • `r, V k r ^ r ! 5 2. -NEED LETTER OF NON -OBJECTION FOR ABSORPTION FIELD IN EASEMENT. let -d, 3. -WAS OLD WELL ABANDONED PER MUNICIPAL CODE? v'' Name of reviewer: JOE Date: December 28, 2007 Please supply the necessary information and re -submit your request. LEAVE THIS FORM ATTACHED TO THE PAPERWORK 'W 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 ���PPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # _01 5,-��1- 6HAA # I. GENERAL INFORMATION LO Complete legal descriptioh LotX_Block Bp Zantha Vista Subdiv si n_#1 Location (site address or directions) r 11000 Snowline Drive ---- Anchorage, AK Property owner _ Nancy Hutcheon —_ Day phone 346-3623, Mailing address -CLQ rami c Protoarl-i as 1111 trn ,q{-..._CrA i nn nnnharage, AK Lending agency Day phone -- Mailing address_ ------ -� -- Agent.+. lar let- RQXderl ux-DQY-aa"ir• rnnari•i.As: Day phone ''dd �_ Address — -- `—� Unless otherwise requested, HAA will be held for pickup. 2. : NUMBER OF BEDROOMS: 3) 3. )3. TYPE OF WATER SUPPLY: Individual well XX_ Communitywell — Public water — NOTE: If community well system, provide written confirmation from State ADEC a`tteat- Ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XX 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 2oy6v.1/91) front MOAn21 I 5, STATEMENT OF INSPECTION BY EhfGINdR 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 � , — —Phone Addressalts ,'�—wi�— E 1 d, — Date — '� Engineer's signature --- Alaska Water 8 19 "tewater Consultants, Mtn Cu SMII be PAID 11B5 .. A or prior to, closing for the Engineering Services Provit" 6. DHHS SIGNATURE Approved for T kl R rR r1Ebedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: 10 ----Date�{--- pvv —- 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 DFIHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage Isnot responsible for errors or omissions in the professional engineer's work. -. /24261nw.1/01) Back MOA021 RECEIVED Municipality of Anchorage MAY 07 cot 199 DEPARTMENT OF HEALTH & HUMAN SERVICES MUNICIPALITY OF AN Environmental Services Division ENVIRONMENTAL SERVIC 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: <- ti�HA t lS (A iL-�4 SLK 13 Parcel LD.:_L2_1� A. WELL DATA Well type I wA--(E If A, B, or C, attach ADEC letter. ADEp water system number R P nor,y .nal w c I I yot ' ati31,0W will 9l/fe/78 Log present&&P. �well- no Date completed _ view l t XZENrJ�f� /- L1411 r4�e2 f4�e�. Total depth it+.q t� (o' Cased to _ �O 4-- - Casing height (above ground) �� w� c Puo p, Sanitary seal N) _ rE-S ____ Wires properly protected a/N) FROM WELL LOG AT INSPECTION %tu.l ure�Q) Date of test _ fit na ua, IQ 6� l_� 7 olc! ups// 5! 5 nein ta1�� Static water level e1cC wt,ll - I gpw� new w-v1LQ� Well production Nu ___L,2 CQvu we l l _- r� ic_ g.p.m. g.p.m. WATER SAMPLE RESULTS: L Coliform Nitrate 1' &5�/—' — ___nOtherbacteria Date of sample: 7- g_Collectedby: �T8Y/ AWW L _ B. SEPTIC/HOLDING TANK DATA Date installed 0 11 �_ Tank size rasa_ Number of Compartments a_ Cleanouts (_YCWI- Foundation cleanout�l)__ Depression (YoHigh water alarm (Y/r� /J//) Date of Pumping E-,30 _T� Pumper /q'f 7 ro^^� S=�rrcr1 C. ABSORPTION FIELD DATA Date installed _lo I I ��$ Soil ratin[l (g.p_d./fl2 o ftz/bdrm System type.Ti �_ Length yWidth a`-� I__ Gravel thickness below pipe. -Total depth IdMk 43- �T 'MZL P✓e NeNr Effective absorption area 13� SC Monitorriing Tube present ( N) I I�SDepression over field (Y6_ Data ofadnauaovtest I -�� Results(Pass/Fail) Ppt%S For &Ak bedrooms ASauntir9 r67 6 a'6w'z PfW` Fluid depth in absorption field before test (in.); _?- Y__ Immediately afters gal. water added (in.): L c Fluid depth _ ag_ (ins) Minutes later:-_ 1 Absorption rate = _ � _g.p.d. Peroxide treatment (past 12 months) (Y(Ci) Pb -f Ltr_i5LJIf yes, give data _Wh 72-026Rev.3/96Mi F_X-rawns 1-C 13F ow ( )' cav 36- N�„ S,�,w PusT 'T"' D. LIFT STATION to installed �/ Size in ons— Manhole/Access (Y/N) on" level at* "Pump off" level at* High water alarm level a * *Datum Cycles d E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot I oO 4- On adjacent lots I k Absorption field on lot I U Public sewer main 0A Sewer /septic service line OLS 4 - On adjacent lots (�° 4 - Public Public sewer manhole/clean//out Lift station DA. SEPARATION DISTANCES FROM SEPTIC/H✓G TANK ON LOT TO: Foundation jd Property line + Absorption field Water main/service line __LQ_J_Surface water/drainage 106 t Wells on adjacent lots !80 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / V �A VWBuilding foundation G8 Water mai service line i JHJ, io llT FF +' OF Toow-M m� C,�, uOaeA Abvdw Surface water �� � Driveway, parking/vehicle storag area y Curtain drain �UoN�z �r N Wells on adjacent lots CX9 J F. ENGINEER'S CERTIFICATION /� 9 j t)o IL{ CY,(A-`L t) © Lipp— cave H"t q OF- F. u,✓p0A pn.iue l certify that 1 h e determine thru field inspections and review of Municipal records that sten in contormanci ith MOA g iidelin s in effect on this date. ®H �. ZA Signature I� I ., Engineer's Name \ AMEIT WK44W Date S" "9 m : JAMESnVILLIAMS a N C9E.08,.• F�a� HAA Fee $ J�d� Waiver Fee $ Date of Payment ) 1 - �r ! \ Date of Payment Receipt Number Sq j 1 23) Receipt Number 72-026 (Rev. 3/96)* are APR -09-99 10:0? FROXTE ENVIRONMENTAL ME Environmental Servicos Inc. ruree.ed CT&E Ret.# 991385001 Client Name AK Water & Waswwaier Consultants lac. Project Name/# 11000 snowline Client Sample ED 11000 Saowliae Matrix Druxing Water Ordered By PWSW 0 5615301 T-917 P.04/04 F -59T Client PO# Printed Date/Time 04/09/99 10:33 Collected Pate/Time 04/05/99 14:10 Received Date/Time 04/05199 15:00 Technical Director: Stephen C, Ede Released By SM9222R • Haetaria sample Invalidated dtw io laboratory error. Resaalple requested. AllouaDle Prep AnaLYSIS Parameter ar MT Resul[s Pe4units Mexnoc( .� 6imia�s Dew Dave [Bir eitrare•e 4.82 0.500 mg/G FPA 300.0 10 MMA 04/06/99 04/06/99 ser 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.It HAA # 1. GENERAL INFORMATION , Complete legal description�4' 6 lac 1-, 0 Za0ff)a 11gl r� 4v(dn # 1 Location (site address or directions) Hi 000 Snow ()ne oris Property owner Ric k duller Day phone 562-6y6h� Mailing address _ 3OoO c" S{, k 99.5-0�— aneharreyP fF3 v Lending agency Day phone S62-2(151 Mailingaddress_ HGU u/• Tudor Rd 4A_cA 22EV3 Agent 1/15 16L ea( ES {a Fe Day phone Addresses vet, S�• An�horr�e. �}k 99SG� Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: I 3. TYPE OF WATER SUPPLY: Individual well 'l� Community well Public water NOTE: If community well system, provide written confirmation from State ADF-C attest- ing to the legality and status of system. 4. 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 MOAM Can Vow M�-U Ilion "Wald) SZO ZC -> jom s,jeau!Buo leuolssayojd agl ul suo!ss!wo jo sjojja joy elq!suodsaj lou si a6ejogouy yo il!ledlolunW aqy 'penssi sl aleolllljeo a ajolaq elep ez/,leue jo suolloodsui lonpuoo lou op SHHO yo saoAoldw3 -sluewaimbei alels pue lejapal u!eljao Alsiles of japjo ul suo!lnl!lsul 6u!pual jiagl pue sawog to siesegojnd of Asaljnoo a se s!gl saop SHHO GUTlsely to alelS eql ul pajols!Baj jeau!Bue Ieuo!sselojd luapuadepu! ue A,q anoge 9 gdeibejed ul uaA!B suolleluoseidej aql uodn /,luo paseq saleoy!lAo lenojddy A,lpoglny glleaH sonss! (SHH(l) sao!AjaS uewnH pue glleaH yo luewljeda0 a6ejogouy to Alped!o!unlN eql NVI1IlVJ � < ': m :suollelnd!ls bu!Mollol aql ql!m 'swoojpaq sluawwoo leuoll!ppy joy lenojdde 113uo!l!puoo 'panojddesl0 swoojpaq --)V— jol panojddy 3linJ.VNJIS SHHO '9 ROM 0"%r .,,Fu - fq �j Uatu� 6IISA 4 01134 eAnleu6!s s,jaaul6u3 y1Sb6 �W u -y 5 ptf3 /> hl ssajppv auogd frnl w"Z°f n MIA to awuN •uolloadsul slgl to apep eql uo loello ui suo!ll2pbei pue 'seoueulpjo 'sapoo alelS pue Isd!ownW 1113 gl!AA aouelldwoo ui sl walsAs pesodslp jolennalsem jo/pue Clddns jalem el!s-uo ogl'uo!loadsu! pue uo!le6!lsanu! Aw wojl pue salll a6ejogouy to Aj!ledlolun" aql wojl pau!elgo uollewjolui eql uo poseq legl I!J@A jagljnl ! -ulajaq paleo!pui ajnlonjls to adll pue swoojpaq to jaqwnu aql jol alenbape pue leuollounl 'ales si wols/s lesodslp jolennalsem jo/pue Alddne joleM el!s-uo aql legl smogs uo!leo!ldde lenojddy /luoglny gl!eaH s!ql to uo!lebllsanul Aw legl /luaA ! 'Anolaq unnogs alep uo!lep!leA aql to se pue olajaq paxllle leas !w !q pa!lpeo sy a33NION3 AS N01103dSNl d0 LN3Wg.LV.LS 'S MUNICIPALITY OF ANCHORAGE (MOA) • u Health Authority Approval (HAA) t CHECKLIST - F4 44UARY 1984 VED APR 5 1991 Legal Description: Irl f 6 V61clr 1 cam r�adli, # 2 A. WELL DATA Mt. He Health & of Anchorage Dept. Health &Human Services Well Classification Pr(vuk _ If A, B, C, D.E.C. Approved (Y/N) Grp In al cuell (I") C3'!9, cue(!: 9/16(76 or,yy well: Unk Well Log Present (Y/N�New ��Date Completed 1 well; Unk Yield e'w well: orl�q tue((: 99' Zt vnear /•//' /9/ Total[ ew 'Cased to � Wo' Depth of Grouting N,A. wul. Static Water Level UN' wer/' lVew well: SS pump Set At New cu el(: 66 q Ory well: (' ,' — Casing Height Above Ground NtK;- well P Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL Depression Around Wellhead (Y/N) A 132' 6m. or. wC(1 C•U, To Septic/Holding Tank on Lot 2�9' �� N{ well #161 C•�. ; On Adjoining Lots too lo7' cr< well /V Go, To Nearest Edge of Absorption Field on Lot c_2rs_'_.£�nc��r ; On Adjoining Lots > l moo' To Nearest Public Sewer Line -Z (CO' To Nearest Public Sewer Cleanout/Manhole > 100' To Nearest Sewer Service Line on Lot _> iG Water Sample Collected by Flaf( �nt? 7_Prh1iiC4i( Servrre ; Date — 3 /e/9/ Water Sample Test ResultsrX 11 � a= wry " U Cc Comments Ort al well i_r no fr 'ln I,.aind knnf 7n rPCPrve .fir ou/'r'eepr e B. SEPTIC/HOLDING TANK DATA Date Installed (0/(1/78 Size12Gl No. of Compartments Standpipes (Y/N) Y Air -tight Caps (Y/N) r Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High -Water Alarm (Y/N) C Foundation Cleanout (Y/N) Y Date Last Pumped - yr -ZlaCecl _ ;for NSA. Temporary Holding Tank Permit (Y/N) Al, A• SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: 132' Jfm, C.o'. 4& ort (cell To Water -Supply Well231 —a /o del well To Building Foundation To Property Line 9 r from C.0, To Disposal Field To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course > rC'G' Comments 72-026 (Rev7/88) From Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 8,6- 0'63a"v) Type of System Design %✓ench Date Installed Width of Field Square Feet of Absortion Area Length of Field Depth of Field Gravel Bed Thickness (2/ Statndpipes Present(Y/N) Depression over Field (Y/N) N Date of Last Adequacy Test W/y/9/ Results of Last Adequacy Test /4a(eq•uccfe ✓ 4� bed✓oo vir SEPARATION DISTANCE FROM ABSORPTION FIELD: 167' fm, f-0. i& orgy well To Water -Supply Well -- '21Y,5" ;Cm 4r,e 6 •k new c.ell.To Property Line To Building Foundation ^ 73' To Existing or Abandoned System on Lot a, A. ; On Adjoining Lots -> 30' To Water Main/Service Line > 1610' To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course - To Driveway, Parking Area, or Vehicle Storage Area Fer, 9' /3_G6 Comments I'/2.1 Peri lo ire m.f dr*, -en 4- ba Pe%Q -�-hru enol. «,. l,vel(r rrl /lfVyh(7or,ny (G {1 R,'e �•(UO �-r^ar� ct�iSG�rfrUn irC(cP. Lrif f/n{ WeAl iG,' se.ea,ahun elu/Cence from Snow/l-e Di -e e /3,0.w. D. LIFTSTATION IVA. Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access(Y/N) "Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed -r+i-e�-t-.t %UCa'`^`- f ' ``� Company FIa &4 Technlca/ Scar vc«i f - J V, �//9 Engineer's Seal Date /S-/ MOA No. 90 -019 �. ,'�%%l�>j ri Receipt No. Date of Payment — 57— Amount: $--N�✓'� I �`�U �I c /-iia '��✓ p ZS I Receipt No. Waiver Fee: $ � c � Date of Payment r 11Q 72-026 (Rev. viaa) Back Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING 5633BSTREET ANCHORAGE, Al-ASKA99518 TELEPHONE (907)562-2343 FAX: (907) 561-5301 I j:) Te, c I c. 1 0 1 !Jw :c 'I r Vcr �. Municipality of Ancn mirage Lom �Department of Health and Human Services l5 Tom Fink, 825 "L" Street Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 April 12, 1991 Ted Moore, P. E. Flattop Technical Services 14530 Echo Street Anchorage, Alaska 99516 Subject: Waiver Request for. Lot 6 Block B Zantha Vista S/D #1 Waiver Request #WF2910014, PID #015-474-16, HA #HA910110 Dear Mr. Moore: Your request for a waiver of the required 10 foot separation between a septic system and a lot line has been approved. The waived distance is 0 feet. This approval applies to the existing septic system lot line separation only. Any future upgrade to the septic system will require all. separations be met or another approval from this department. Sincerely, Daniel J. Roth Civil Engineer On-site Services DJR/ljm:357 Concur: �hn Smit/,P. E. rogram Manager On-site Services LI-) LO ml CIVIL & ENVIRONMENTAL ENGINEERING • ENERGY CONSERVATION & ANALYSIS TIiEODORE F. MOORE, P.E. PH: (907) 345.1355 April 5, 1991 M.O.A. DHHS P.O. Box 196650 Anchorage, AK 99519 Dear Sirs: 14530 ECHO ST. ANCHORAGE, ALASKA 99516 RECEIVED APR 5 1991 Municipality of Anchorage Dept. Health & Hurnan Services By means of this letter we are requesting a waiver of the normally required 10 foot separation distance between a soil absorption system and a property line down to 0 feet for the existing septic system on Lot 6, Block B, Zantha Vista Addition #L A copy of a marked up as -built survey is enclosed for your reference. The monitor tube at the end of the trench is approximately 2 feet inside the property limits. Since the property line abuts a dedicated road Right -Of -Way, issuance of the waiver will not have any impact on the ability of adjoining property owners to develop wastewater disposal systems on their lots. The existing overhead power and telephone lines are constructed in the road Right -Of -Way, and thus do not conflict. The existing soil absorption trench is constricted 9 feet below ground level, so it does not pose any conflict with future facilities which might be buried above it. Both the lender and the title company have been informed of the present status and do not have any objection to it. Thank you for your consideration and issuance of the requested waiver. Sincerely, Ted Moore, P.E. cc: Rick Fuller, Vista Real Estate cpi m m N Dy U N C w b N°37�7G go^v v i m m y d b e»m ac�� � oma F, o Al m _ v8� --I�-'�—� - DAME RECEIVED INSPECTION APPOINTMENTS TIME - \ TIME - TIME DATE } / DATE DATE INSPECTOR���/ INSPECTOR INSPECTOR _iAULLIM'ALLAC-9E.-,ANG lGRA9E MUNICIPALITY OF ANCHORAGE DEPT. O(: REA& NVIRONMENTAL PRROTECTION DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 N OV 13 1979 00*- ENVIRONMENTAL. SANITATION DIVISION [ Telephone 264-4720 R E !,/ C REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1, JOPERT OWN SR - PHONE / MAI DDRESS PR05PERTY RESIDENT different from above) PHONE /(If 2. PHONE MAIL NG ADDRES 3. LENDING INS�T,ITUTITIIIC�N y T)HONE MAILING ADDRESS 4. REALTOR/AGENT PHONE MAILING ADDRESS 6. LEGA DESCRIP'ri( rf STRE 6. TYPE OFF RESIDENCE - NUMBER OF,BEDROOMS ❑ One ❑ Four ❑ Other J SINGLE FAMILY ❑ Two ❑ - Five 0 MULTIPLE FAMILY ❑ Three ❑ Six ------ 7. WATERS PPLV --- 7, 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 UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM------^--- —%/� INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. PUBLICUTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. -- ------I ------ — 72-010 (Rev. 6/79) - - 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ TWO ❑ THREE ❑ FIVE ❑ OTHER ❑ FOUR ❑ six 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED r 1 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON-SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED I o INSTALLER i i,. -,c O ❑Septic Tank or El Holding Tank Size:If Tank is homemade give dimensions: - SOILS RATING - -•,4� TYPE OF TANK MANUFACTURER t . ,,I ^ 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 R2 --APPROVED FOR !L BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE I(-1rl-71 BY ( 72-010 (Rev. 6/79)