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Home My WebLink AboutNORTH WOODS BLK 3 LT 34Northwoods Lot 34 Block 3 #051-731-48 ,eMUNICIPALITY OF ANCHORAGE »c I �VAI�Ty 0". `�. /- On-Site Water&Wastewater Program :\o . `% 4700 Elmore Road • �,�. PO Box 196650 �, .,fir Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax (907)343-7997 http:l/www.muni.org/onsite V 7. 'F4 I)c Irirtmcnt 44,CM00.FG6 On-Site Wastewater Disposal System Permit W;z0AS Permit Number: OSP181098 Effective Date: 5/22/2018 Expiration Date: 5/22/2019 Work Type: SepticTank Upgrade Tax Code Number: 05173148000 Site Legal Address: NORTH WOODS BLK 3 LT 34 G:1459 Site Mailing Address: 22645 NORTHWOODS DR, Chugiak Owner: DAVIS BENJAMIN A& RACHEL M Lot Size in Sq Ft: 22219 Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 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 c------X.... s..5/2-7/Date: 4 Received By: Issued By: AC /`�G"'0Y4 Date: —5--/Z /0 MUNICIPALITY OF ANCHORAGE •..._. Community Development Department • �. J Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On-Site Water&Wastewater Program • ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 0 51- 73( - yC 8 Property owner(s) .b,4'uIS Day phone ?-s'- 751 ? Mailing address 2 2.‘4e 5 /I c.c.-NI w o od s D r Site address Sr-+¢- ,, // '/ Legal description (Sub'd., Block& Lot) Nor' U) oci r e3 L3"4 Legal description (Township, Range & Section) Lot Size 2 2, a/4 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field ❑ Initial ❑ Single Family(SF) p (w/wo ADU) Septic Tank Upgrade 8 9 10 ,I plex(D) ❑ Holding Tank ❑ Renewal ti u ��i I •�. .ple Dwellings ❑ Privy ❑ `F and/or D) Private Well ❑ a MAY 18 2018 Water Storage ❑ z. h� THIS APPLICATION INCLUDES A VARIANCE I WAIV - i ST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. E (Signature of property owner or a orized agent) Permit/Rush Fees: 215 Waiver Fees: Date of Payment: .Jr' 12018 Date of Payment: Receipt Number: OB021 I) Receipt Number: Permit No. OSPl'itdtS Waiver No. Permit App_9-1-12.doc I\ERTERIM ENGINEERING SteveEng.com Steve Eng, PE, PH 907-694-7028 SteveEngPE@gmail.com Date: 5/14/18 Number of Pages: To: MOA On-Site Services Subject: North Woods Block 3 Lot 34 Septic Tank Failure The subject septic tank has failed- a new tank will replace the old one. The existing trench/bed appears to be working OK w/diverter valve. Please issue a permit so the tank can be replaced. The existing trench/bed will remain. Please review as soon as possible. If there is need for additional information or clarification please give me a call. Thanks-Steve \CTHRIM ENGINEERING SteveEng.com North Woods Block 3 Lot 34 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing:This is an existing 3-bedroom home.Most of the neighboring lots are developed. The current eaprtic a half acrehas failed-the trench&and are served by the public d still function (diverter valve).These lots are adverse impacts are expected from tank replacement. The easements are depicted on the lot. The slope is indicated in the area of the septic system. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications(AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. • New 2-compartment, 1000 gallon septic tank. Watertight couplings on inlet&outlet. • 5' minimum between the tank and bed. 10' to property lines. • 4' of cover or insulation is required for tank; an equivalent of 1" insulation for 1' foot soil cover. Minimum of 2' soil with insulation. Tank& solid pipe must be set on well compacted,stable soil. • 4" diameter cleanouts with airtight caps are required 1' to 4' from foundation wall, prior to any 90 degree bend in 4 inch line,in each tank compartment,and two adjacent opposing cleanouts between the tank anda the ss towards to eltank and towards not more the from the tank positioned to provide cleanout absorption field. • All cleanouts must extend to at least ground level. • In solid pipe runs,ASTM D-3034 may be used in lieu of cast iron. • Insulation must be placed over any pipe installed under driveways or parking areas. • Approved pipe materials include cast iron,PVC ASTM D3034,PVC ASTM F789, ABS ASTM D2661, • Sewer Service Line is minimum 2%slope. • Septic Tank to be pumped every two years or when required. • Insulation board to be extruded direct burial polystyrene(Dow Styrofoam HI/equal) 0.1:e./14,491114 a 4, e.1" t* 9 1 • 1,-T:\ Steven W. ng 4 4i0 :I'? PR°FESs,+�'�a• DESIGN NOTES: 1 . Existing Bed Remains In Place. 2. Sewer Service Line minimum 2% slope. 3. Replace Septic Tank/Decommission Old Tank Per UPC. Connect New Tank To Existing Bed. 4. Lots Served by Public Water. 5. No Conflicts Within 200'. 6. Check Condition Of Sewer Sr Line— f No Replace ECOIf Necessary. 7. Add Double Cleanouts 1000 Gallon Sep-tic Tank w/DCD's Decommission Old eptic Tank P. ' UPC Septic Area Flat Slope Trench Location L33 ilverter Valve Flat Slope DCO it fco ,e)/-, (o O-o /`�O ti <°°4 3 Bdr rm 9s1Septic Area c�°oonA waCt ter Lihe 0 L35 tat Slope Flat Slope cte ye ..° Flat Slope \C`i d`' ,koo aor �r Y = 40' NORTHRIM _. - °F.k ``� NORTH WOODS ENGINEERING - ' K 3 LOT 34 DESIGN * .49m � *.1 BLOC SteveEng.com -:-• ••••• _ Po Box 770724 LAYOUT Eagle River, Alaska 99577 %A, ..-A, WASTEWATER UPGRADE gp769470Z8 a F /� REPLACE SEPTIC TANK °°t5/14/18 of 3 Foundation Cleanout Tank Cleanouts Fin ade Dpposing Cleanouts Between Septic Tank & Trench 4 Foot Cover or Equal 1000 Gallon Steel To Bed/Trench 'Anchorage Tank' Or Equal lid Pipe Match Elevations To DESIGN NOTES: Existing FCD & Line 1. Use Existing Trench/Bed w/Diverter Valve. 2. Septic Tank & Solid Pipe to be Placed on Compacted, Stable Soil, Free from Boulders. 3. Sewer Service Line is Minimum 2% Slope & 3' Cover. 4. Water-Tight Couplings. 5. See Specification Sheet. 6. All Work To Conform to Municipality of Anchorage (AMC) Requirements & Specifications. 7. Decommission Old Septic Tank Per UPC. 8. If No FCO, Install DC❑'s. NOR THRI M �•�% ' 001 ENGINEERING :��" SEPTIC TANK PROFILE NORTH WOODS SteveEng. com * PO Box 7707241 tSt.»Cr, • 4 BLOCK 3 LOT 34 Eagle River, Alaska 99577 7 907.694.7028 ' �� = TANK REPLACEMENT Dotc5/14/18 IDrawn BY: SE re.: 1• = 53 of 3 I SE DE 1TMENT OF HEALTH AND HUMAN SER' ES ·, ' ' "J" Environmenlal Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPGSAL SYSTEM AND/OR WELL INSPECTION REPORT Name D~/~/~' ~', ~ ~ ~ DISTANCES SEPTIC ABSORPTION Address ~)~ / TANK FIELD WELL Phone(s) / Permi[ NO. No/of ~roSms WELL Z~-~[ ~/~ -- ~ LOT LiNE Lot ~ Bl°ck ~ Subdivms'°~ ~J FOUNDATION /~' Townsh,p. Range. Section TANK~ N Material No. of Compadments Depth to p*pe bottom from Total depth from obgmal grade Fml~ added above original grade Gravel depth beneath pipe ~ FT ~ FT ~] ~' X ~ z~v~' Totalabsorplmonar:a / ~ ~O SO FT Distancebe[weenlines ~ FT Number ol hnes Z~ ~ PRIVATE , ~OTHER (Identify) REMARKS: ~¢ ~ /O /~g ~ ~ /~ / Scale: /"= ~' ENGINEER'S SEAL I 72-013 (3185) DtL::PARTHEI".tT JIF I'"I!iSAL TH AND iENV ! RONM[<iqT'AI... F'I:~:OTEC T :[ ON (325 I... S'f'!::iEET, ANCH[]I::i'.AGE:, Al< 995C)! 264.'""4720 f='IE F!M ! "f DATE AP PI... I [:;ANT :~ A D D R E S S ~ CONf'AC::T PHONE: )::)Al...[:: C. FOSS :i. 336 INGRA Atq[]HOF?.AGE, AK ;:2.48-342 :t. 9950 . =o~ DIESCRIF:': LOT S I ZE: SLJBD I V I S I []N,~ I\I[:IRTHWC)CIDS SECTION: 34 TOWNSHIP 22()0() (SQ. FT. OR ACRES) LOT: 34 EL. dCI...: 3 :[5N RANGE: 1W ]: cer'L:i.f'y that.: :[,, I am familiar' with the requirements f'or on-site sewers and wells as se'L forth by the Hunicipality of Anchor'age (MOA) a~i']d the State c,f Alaska. 2, I w:i. 11 :i. ns'Lal ]. the sys'!:.em in' acc:ordarice wi'l.h al 1 MOA codes arid pe~]iLt].at and in compliar'ic8 with the de~igt'l criter:i.a of this 3,, I v,~:i.l:!, adhere to all MOA and State of Alaska pequir, emerrLs f'or' the set bac:t.:: distances from any exist:Lng well,, wasLewater disposal, system c)r s~..~¢.~(.:.~l*.::;~jf;::, ~ys'~..em on 1:.h:i.s of any adjac:ent oP n~arby IF: A LII::'T' ST'AT]:ON IS INS'f'AL..LED IN AN ARE:A COVERED BY M[)A BU]:L. DING CODES, ]'HEN (:I) AN EI...E[]TRICAL. F'ERMIT AND tNSPECT]:ON MUST BE OBTAINED; (2) AS-BU!LTS W];LL. I'qCYt" BE AF::'I:::'ROVIED WI'I'HOUT AN ELECTRICAL INSF:'ECT'ION REPOR]'!I AND (3) THE [ELECTRICAl_. ~"lt..l~."f' BE DONE E~I....ICEIxLSED EI...,tECTF~I~;IAN. AF'F'LICANT': DALE C,, F:OSS :t: SSL!ED BY 5 ..------3 ~-//'""- 6 7 8 9 10- 11 12 13 14- 15 16 17 18 19 20 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ~"~CL\~. ~"~'~,~ (ENGINEER'S SEAL) DATE PERFORMED: ,,_~ 30 '- ~ ~/ Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? ~ 0 S IF YES, AT WHAT OL DEPTH? p Depth to Waler Alter/,.~,..~/ Monitorin,? Dale: ~'- ~ ~8~' SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop 1135~ ~ I.~t II TS' lO /, f.-f~ . PERCOLATION RATE __ TEST RUN BETWEEN __ (minutes/inch) PERC HOLE DIAMETER FT AND '~ FT PERFORMED BY; /~C~.~ tf-/~-- .,~'~-~O ~/ [ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~"--~/--~ ~ 72-008 (Rev. 4/85) .~__~../~/~,,~ ~ ALASKA UIROnmenTAL CONTROL seiqOice$, Inc. ~ncjin~rin~ ~, ~nui~onm~nt~l Stucli~s PERCOLATION TEST DATA SHEET CLIENT ___'~t~' ADDRESS L-~ ZIP CODE LEGAL LOCATION TOTAL DEPTH OF HOLE ZONE TESTED DATE ~-/0~ ~' ft. ft TO ~ ft Test Holes # / Diameter of Hole ~t! READING # CLOCK TIME NET TIME i DEPTH TO NET DROP RATE (min/in) DATUM .A~ ~ ~'/. ~,,~ ~o ~,~/ .~ /'~' -~ ' FINAL PERCOLATION RATE PERFORMED BY "-~-~3,~ .(mi n/i n) Sqqare feet per bedroom. 276-1361 ALASKA g~IROI~mE~FITAL COFITROL SE~F~v, CE$, IF1C. (~ncjineeNn9 [, ~nuironmental Studies PERCOLATION TEST DATA SHEET ZIP CODE ~9~"~ / LEGAL LOCATION DATE TOTAL DEPTH OF HOLE ZONE TESTED ft. f~ TO .~';~' f~ Test Holes # ~- Diameter of Hole ~ READING # CLOCK TIME NET TIME DEPTH TO NET DROP RATE (min/in) DATUM ,,, ~ ~/~/ ~/~ ~o ~,~ . ~ / .~ ~ FINAL PERCOLATION RATE PERFORMED BY ~//~-'/~ Square feet per bedroom. .(min/in) ~:~-"l:~)E' ~-N~i-~,' _, INC. ~ , SHEET NO OF 1200 West 33rd Avenue, Suite B ANCHORAGE,A~SKA 99503 CALCULATED BY ~'''~/~ DATE (907) 56~.5~o CHECKED BY DATE ...... ~. ~ ~ ........ ~ : : .1~,~' : ' ............................... ~ __ ~ .~v~ ..~ ~ ...... ~ :~ ...... .... ~. ~ . ~=.. : ~ ~--.~. ~ ~, ~' [ ~ ......... ~.. ~ ~ ......... ..................... ~ .................. ~2~... ~.~ ~ . ~ )~ .... ..~ ~;.... ..~. .... ~.~., . . ~.... .~ ........ ~ ........... ~ ........ ........ ...... : ....... ALASKA 6¥,,JIROFIITleF1TAL COF1TROL IFIL ~nqineerinq 8 ~nuJronmenlal $1udies Municipality of Anchorage Department of Health & Human Services 825 L. Street Anchorage, Alaska 99§0! Attn: Dan Bolles August 4, 1986 Re: Lot 34, Block 3, Northwoods Subdivision Dear Dan: This letter is a follow up on our telephone conversation of Thursday, July 31, 1986 regarding the as-built for the upgraded on-site sewer system and Health Authority Approval blue sheet for the above subject lot. Your concern mas the absence of a note on the as-built with respect to minimum cover over a shallow portion of the absorption area. While on-site I instructed the contractor to insulate the southern half of the bed with at least 2 inches of MOA approved insulation and then cover the area with at least the minimum backfill required. He informed me that his intentions were to do just that. 0n August 4, 1986 I reinspected the site and found a minimum of 1.8 feet and a maximum 2.5 feet of cover over a small portion of the absorption area. Two inches of insulation plus 1.8 feet of backfill makes the minimum total effective cover over the system, 8.8 feet. It is my opinion that this should be adequate cover in this area. If you have any questions please feel free to call me at 561-5040. Sincerely, Steven F. Cords Civil Engineer 1200 UJcsI 33r',J AUCml¢. Suite B, Anchera§¢. Alaska 99503 .~{907) 561-50/40 "x_/ MUNICIPALI'FY OF ANCHORAGE ~, .. DEPARTMENT OF HEALTH & ENVIRONMENI"AL PROTECTION ' ' ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAl_ SYSTEM AND/OR WELl_ ~NSPECTION REPORT NAME lPRONE LEGAL DESCRIPTION ¢ /' ~O, OF BEDROOMS LOCATION ~ , Well/., .¢,/ Absorptio~ area / Dwelling PERbilT NO. DISTANCE TO:¢~ . ~ ~ Manufacturer ¢ Mate~l/ No. of compartments ~ ~ DI STAN~: Well Dwellin9 PERMIT NO. O z < Ma~turer ~ / "Liquid cap--lions ~ :~ 51~/ Foundation ' ~ ~ DISTANCE TO: /9 2FF ¢ c, ~ ~ ~ No. of lines f e , Total length of lines [ Trench width Distance between J.ines ~ ~ ~ TOp of tile to finish grade Material beneath tile ~ ~ ' ~ ~ J~S Total effective, ~ rptionarea Length ' Width ~ Depth~ PERMIT NO. T~pe of crib }Crib diam~~ ~ ~ ~cr~[TO Cr ~effect ~ : Bui~dadon ~earest lot line~ t~ Depth Driller Distance to I~t line PERMIT NO. ~ .. ~, Building foundation Sewer Hne Septic tank Absorption area(s) ~ DISTANCE TO: QTHER PIPE MATERIALS SO~L TEST RATING INSTAELE~ ~ R EMAR~S , WCD:~:~ DATE LEGAL 72-013 ( ev. 3/78) i ~x F'ERHIT NCL F F _ I F:RN'F LOC:RT ! ON L.EGRL I":,EF'FIRTMENT F~F' HERLTH FINE:, EN',,,'IRONt'IENTFfl- pRCTECTI 3N - - 9'95E i LOT SIZE FRFINK E:ETHRRD PETERS CREEK L."--:4 B3 NORTFIP.IOOD ':':UB ;-~E~2E',.:'I S, QURRE FEET TYPE OF L=;OII- FtE::SORF'TION S':'STEbl IS' TF. ENL. H MFi::.::IML.IM NUME:ER 3F E:E[:,ROOM:5 = 5: 'SOIL RRT!NG ¢.:'5;~ FT,'''E:R)= THE F.:EC.!LITRED =,Z~.E OF THE SOTL REPSF~RF'T .r ON L:;'¢STEM 'rS i;2 L E l'-.l ~Z~ T ["-il == -=,. ,=- _r:. E [:" T ll'J. .... THE LENGTH [:, I HEN'=; I ON IS THE LENGTH ,::IN FEET::' OF THE TREI'.,!CH OR [:,RRINFIELD. THE DEPTH OF FI TRENCH OF.: P'rT 'rS THE E:,'rSTRNCE E,~TI.,.tEr=.I", THE .SJRFRF:E OF THE GROLIN[:' FIND THE E:OTTOM OF THE E"-:CRVR'f"r'N <TN FEET:' _ . TF, ENCHE-,. THERE IS NO '_=,ET ktlE:,TH FnF .... '= THE GRR',,,'EL DEPTH 'rS THE M'rN.rMLIM DEF'TH OF GRR,EL BETNEEN THE OLtTFRLL P.rPE:: c".'r-,:,' ,~T T ON ':' .r N FEET ). FIND THE E,3TTOM OF THE F:E"~"-lJ :E RE[:" .:=.E. EF ] I C: F'ERMIT RF'F'LICRNT HRS THE RESPONSIBILIT'¢ TO INFORM THIS DEPRRTMENT [:,UF.:ING THE INSTFILLRTION INSPECTIONS OF RN'¢ HELLS R[:JRCENT TO THIS PROPEF:T'¢ RN[:, THE NUMBER OF RE'=]I[:,ENCES THRT THE 14ELL NILL .......... TII....~ C, ,:: 2 .?., :[: PqlSF"E C: T I · · ~u OF FIN'T' S'¢STEM H.r"rHOLIT F.rNFIL 'rI'.~qF'ECT.rON FtlqD RF'F'Fi:O',,,'RL B'¢ TH'rS E: FI C K F I L L z t'. -' - DEPRF..'.TMENT W'rLL BE :,..E ., E...T TO PROSECUT:i:ON. M.rlqTHUr,1 E:, 'r STRNCE DETHEEN R NELL FINE:, RI"J.'T' OI'~-S'rTE SENRGE D'r'.SF'OSRI- SYSTEM 'rS NELL DEF'END ]:NG :1.~_'-~ FEET FOF.'. FI FF..I ,kITE NELL OR '15R TO 2~lP_-I FEET FF.:OH .FI PUBL'rC UPON THE TYPE OF F'UE:LD:: I.,.IELL. ,: , ,q, F'R'r',,,'RTE NELL TA FI PRI',,,'FITE ..,EI-IER L.rNE .rS ':,5 FEET FIND M.rN'rML.IM £:,.rL=,TFINCE FRLM F-t - TO R COMHUN.rT'T' '_=,EI.4ER L.rNE .r':; 75 FEET. SF'E _. 'r F _ ~.R - - OTHER F, E7!U'rREMENTS MFI'T' RF'F'L'¢. ' P. 'fp T.rOI",IL-% FIND RFd'4STRUCT.rON E:, .r RGRRMS FIRE FIVFt'r LF-18LE TO ~ 1'.,19URE F'ROF'ER I NL=,TFILLFtT I ON. PEEF..:F-I ]E '~ ~_ ::---:F" :E. F." EE:----; -! C:ERTIF'T' THRT _ , _ .1.: I RM FRMILIRR I.,.IITH THE F.'E,UIF. EMENT"', FOR ON-SITE SENER':; RND HELLS R'E, SET FORTH E,"¢ THE MUN:[CIF'FILIT'T' OF RNCHORFIC~E. - · ~-r~t 'r~J'-TFa. LL THE '='¢'qTEH TI'.4 Ft't. CFIRE:,FtNCE HI'FH THE C:O[:ES. _ ......... '.:;IGNE[[:-.--- : -- -- - -: ..... ./~-,A-/ ............. T'-?--',, ,EE:, B"-~:?,~%~':--- ~,-¢-''~'~:~'::; ................ ?-"~ ,~ / / ./ / F'OUN DATION ONLY' S ENGINEERS (907) 274 -9597 5610 ~ILVERADO WAY, SUITE A-7 ANCHORAGE , ALASKA I hereby certify that Ihove surveyed the following described property,Lot 54' ,BIk. 3 N~RTH * ~iVoGD5 .~U~D. Anchorage Recording Precinct ~Alcsko ,oDd th~ the improvements situated thereon ere within the proper-fy lines and do not overlcp or encroach on lhe property lying adjacent thereto~ that no Improvements on property'lying adjacent theretoencrooch on the premises in question ond that there ore no roadways, transmission lines or other visible easements ansaid property excep! as indicated hereon. Doled this ~t~ doyof JULY w19~l ,'Anchorage t Alaska. It is the responsibility of the owner or builder,prior to construction ~fo verify proposed building grade relative to finished grade end utility connectionsond lo determine the existence of any easements ~covenonts~or restrictions which do not appear on the recorded subdivision plat. 99502 : CHECKED BY: ;~ '%j~ MUNICIPALITY OF ANCHORAGE",~_.. ~.e~--~.'' DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION I-t . PERCOEAT ON . Pouch ~650, An~orage, Alike 9~502 27~2~ TEST SOILS LOG- PERCOLATION TEST PERFORMED FOR: ; ' DATE PERFORMED: '~ ~ ~ ~SLOPE SITE P~N · , :,.,~, i :" ' IF YES, AT WHAT : .. [] 12 .. 13 ' DEPTH? ' " ti.. Reading .Dete Gron . Net Depth to' Net Time Time Wete¢ Drop ~z,'z~ · ,, ~o ~a ~ ~qy~ /,'/~ ,, ¢o ~o i/~4z 14 15, 16- 17- 18- 19 20 /' 7~f~ PER CO LAT'O~" "ATE TEST RUN ~E~'~ · COMMENTS Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 wWW.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051 -731-48 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Expiration Date: Northwoods Sub. blk. 3 Lot 34 2264~ Northwoods Dr chuo_iak: AK 99~67 Current Property owner(s) Echo Echero Day phone Mailing address Lending agency Day phone Mailing address Real Estate Agent Joe Perozzi/ReMax ER Day phone~ Mailing Address Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] [] Individual Holding tank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by ad independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority 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 sample results less than 30 days old. 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. (Rev, 11199) 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 Health Authority Approval Guidelines for 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm. KND En_oineering Phone_(gQZ)_.6A_6,61 1 ! Address 20441 Ptarmigan Blvd Engineer's Printed Name Ken Duffus DHHS SIGNATURE /""" Approved for '~ Disapproved. Conditional approval for Eagle River, AK 99.~i77 Date 6/20/00 bedrooms. bedrooms, with the following stipulations: Additional Comments By: Attachments: HAA Checldist X Septic System Advisory Well Flow Advisory Maintenance A,qreements Supplemental Engineer's Report Other Original Certificate Date: Legal Description: A. WELL DATA Well type Public Date completed __ Total depth. Date of test Static water level Well production Municipality of Anchorage A ~ C E I V Department of Health and Human Services Division of Environmental Services JUN 2.2 On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 ~UNI¢~^U]'¥ O.r-ANCHOJ~,GE www.ci.anchorage.ak.us (907) 343-4744 "mr~k~MENTALSERVICE,~ HEALTH AUTHORITY APPROVAL CHECKLIST Northwoods Sub, BIk. 3 Lot 34 Parcel I D. .:0~~'~ If A, B, or C provide PWSID # __ Well Log __ Sanitary seal __ Wires properly protected__ ft Cased to ft Casing height (above ground) FROM WELL LOG AT INSPECTION WATER SAMPLE RESULTS: Coliform N/A colonies/100 mi Nitrate ft ft g.p.m g.p.m mg/I Other bacteria 1000 gal Number of Compartments2 Depression over tank _N colonies/100 mi System type Bed ft Gravel below pipe .5 ft Monitoring tube Y Depression over field N Pass For 3 bedrooms Water added630 gal. New depth4 in. Absorption rate >= 450+ g.p.d. Y/Terralift If yes, give date ..~'?~/~--~ Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Steel Date installed 7/1/1986 Tanksize Cleanouts Y Foundation cleanout Y Date of pumping 4/412000 Pumper JR's C. ABSORPTION FIELD DATA Date installed '7/~, Soil rating (g.p.d./~ or ~/bdrm) 256 Length 60 ft Width 20 Total depths ft Effective absorption area 1200 ft2 Date of adequacy test ~//~//DO Results (Pass/Fail) Fluid depth in absorption field before testO in Elapsed Time: 180 min Final fluid depth_0 in Any rejuvenation treatment (past 12 mo.) (Y/N & type) (Rev. 11/99) High water a~arm NA D. LIFT STATION Size in gallons .~~M e n hol~/Access in High water alarm level at __ Meets alarm & circuit requirements? Date insta ed. "Pump on" level at. ~evel at Datum ~ Cycles tested SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanldlift station on lot NA On adjacent lots NA Absorption field on lot NA On adjacent lots NA Public sewer main NA Public sewer manhole/cleanout NA in Sewer/septic service line NA Holding tank NA SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK ON LOT TO: Building foundation 10+ Property line I 0 + Absorption field Water main 10+ Water service line I 0 + Surface water 10+ 100+ Drainage 100+ Wells on adjacent lots 200 + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 5* Building foundation 1 0 + Water main I 0 + Water Service line 10+ Surface water I 00 + Driveway, parking/vehicle storage I 0 + Curtain drain unknown Wells on adjacent lots 200 + COMMENTS * lot line waiver on file at DHHS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Kenneth M. Duffua Date 6/20/2000 HAA Fee $ Date of Payment Receipt Number. (Rev. 11/99) Waiver Fee $ Date of Payment Receipt Number Parcel I.D. # 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 051-731-48 GENERAL INFORMATION Complete legal description Northwoods Lot 34, Block 3 Location (site address or directions) Property owner Kenneth & Pamela Anderson Mailing address 22645 Northwoods, Chugiak, AK City Nor tgage...'.~. ;', :' Lending agency Mailing address Agent 99567 Day phone 349~1116 696-07.01 Day phone ll4'0t..Old Glenn Hwy~';&$uitA ll0A, Eagle River, AK N/A Day phone 99577 Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water X If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Fronl 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, lfurtherverifythatbasedontheinformationobtainedfrom 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 Eagle River Engineering Services Phone 694-5195 Address P.O. Box 773294, Eagle River, AK 99577 Engineer's signature * '¢' ~--'-' Date DHHS SIGNATURE Approved for Disapproved. Gonditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: 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 engineeCs work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /¢~//~o~p~ £~f .~ ,~/d ~ Parcel I.D. DG/' ?~/- ~ A. Well Data Well type Log present (Y/N) Total depth Sanitary seal (WN) Date of test Static water level If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to FROM WELL LOG Casing height Wires properly protected (Y/N) ~ AT INSPECTIO~ Well flow g.p.m. ~/ g.p.m. Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot //// ; On adjacent lots Absorption field on lot Public sewer main Sewer service line WATER SAM~E RESULTS: ,~e of sample: ; On adjacent lots Public sewer manhole/cleanout PetroleUm tank Z B. SEPTI~I-1~9~BIN~TANK DATA Nitrate Other bacteria Collected by: Date installed D ?/o°/~ Tank size ,/~ 0 D D Compartments Cleanouts (Y/N) ,V/--5 Foundation cleanout (Y/N) ,/~0 Depression (Y/N) High water alarm (Y/N) /,//~ Alarm tested (Y/N) /V//~) Date of pumping 0 ~/~-'~/~-~ Pumper ._~-~_ 5' ,/~/D SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /~//~] On adjacent lots 'f' ~-O/.) ! Foundation To property line ~ 0 Absorption field ,~ ~ / ' Water main/service line Surface water/drainage /'//~ CONTINUED ON BACK PAGE 72-026 (3/93)* Front C. LIFT STATION Date installed Size in gallons /'~/)~ Manufacturer ~ Vent (Y/N) "Pump on" level at ~ "Pump off" Level at High water alarm level ~ Cycles tested Meets MOA electrical codes (Y/N)_~~ SEPARATION DIST.~-~FROM LIFT STATION TO: Well o~oY''''~ On adjacent lots Surface water D, ABSORPTION FIELD DATA Date installed 0 ?/ Length ~ P' Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Width /~L)O ¢ Cleanout present (Y/N) ,¢[.¢///l/¢ ~-/ Results (pass/fail) Soil rating (GPD/Ft2) ~2~, ¢d'/,,~ ~ System type ~ ~.(-.) ¢ Gravel thickness ~-¢ /~ ~~~ ,4,,~Total depth 2,~-- Y~'~ Depression over field (Y/N) P,,/~- ,~ _~ for ~.~ Bedrooms After test ~..2 ~- If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water On adjacent lots ¢' .2~00 ' Property line To existing or abandoned system on Jot /~ Cutbank /"////~ Water main/service line Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in.~ffeetOn thermate of this inspection. Signature ~ ~~--- - Engineer's Name LO ~/q ~.Y~ ~ ~ . HAA Fee $ ~"'~O'q~ ¢,.C~ Date of Payment 7 ~-,24~'. ? Receipt Number ,/ ~' ('¢~2 '~ / Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back ~ MUNICIPALITY OF ANCHORAGE '--=/ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date ~.~--~ 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) (c) Applicant Name P.'¢~-~ ,~-4:~-~' Telephone: Home Z,¢'~-...~,¢'~__/ Business Applicant is check one): Lending Institution []; Owner/builder/~/; Buyer []; Other [] (explain); ~(d) Lendir~g Institution (e) · Real :Estate Company and Agent Address .. TelePhone (f) Mail the HAA to the following address: Telephone ,A//A TYPE OF RESIDENCE Single-Family,~' Multi*Family Number of Bedrooms Other WATER SUPPLY Individual Well [] Community.J~ Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite,~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental ConserVation / attesting to the legality and status, / Page 1 of 2 72-025 (11184) ENGINEERING FIRM PROVIDIN~.~.JSPECTIONS, TESTS, FILE SEARCH, DA~.AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ,,~ ~--~'~ ~ //~/~, Telephone ~ ~ Address /~ ~ ~V~ ~U/~ ~W~d~~ ~ Date ~~ DHEP APPROVAL Approved for (. /%edrooms by Approved ~.//~ Disapproved Terms of Conditional Approval Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) MEMORANDUM DATE: TO: FROM: SUBJECT: July 22, 1986 File: Lot 34 Block 3 North Woods Subdivision Steve Morris, On-site Services Property Line Waiver to Adjacent Lot (Lot 35) A waiver of the 10 foot setback requirement requirement to the adjacent lot was granted for the absorption bed/ This system will not impact the operation of the septic system on the adjacent lot (Lot 35). sS~/ljw CC: Leroy Reid, PhD, P.E. A.E.C.S., Inc. 1200 West 33 Avenue, Suite B 99503 '~' MUNICIPALITY OF ANCHORAGE ~ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FAC ILITY 264-4720 Application Date O%.~/ Legal DescriptLon (include lot, block, subdivision, section, township~ange) Location (address or directions) , GENERAL INFORMATION (a) (c) Applicant is (,check one):.;l'~nding Institution []; Owner/builder'S; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family'~ Multi-Family Number of Bedrooms 3. ~WATER SUPPLY Other Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL ' ' Onsite~, Public [] Community [] Holding Tank [] Note: If corem unity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality ano status. Page I of 2 72-025 {11/84) I'NFORM'ATION 5. ' ENGINEERING FIRM PROV D NG NSPECT ONS'TES,,TS .~ILE SEARCH, DATA AND ' As certified by my seal affixed hereto an0 as of the.validation date shown below I verily that my investigation of this Health Authority Approval shows that the on:site water supp y and/or~astewater disposal syst~.is.saf~ functional and adequate for the number of bedrooms and type of structure indicate8 herein. I fuHher ver fy that based on the information obtair~d 'from the Municipality of Anchorage tiles and [ro~r~y nv~*~,i~ation'and' nspection~, the on-site water supply and/or .,.. ' ' wastewaterds osa system s ncomp ancewtha Municipa).a~dStatecodes ordinances and regulations in effect on ' ' Address ' 6. DHEP/ r,.. v .,, Approved 1or ~/w~ bedrooms by Approved Disapproved ' Conditional ' '" Te;ms o,' Conditional Approval ~ . , . . . -..'.~ .,. .....~.:.~/; : :. ... .,., . ~ -. ' ' '~ ~;~: ' ' ' : ":'~2~""' ~' ~"' '~~ '~' " ' ~'~~~'~'*' *'~2'('"""~' ¢' ' ~ ¢~' ''~: · ' ~ ,L~,' ,~, z ' '. :' ': ,"&~'. ' .r'.?-.: ~:.~, ':' .'. ~ ':';( :';~t'~ '~:¢1,~:~,*¢;~k~1¢%¢.~ ,,~:~;~/'.{~¢:,~, ~t '~ : ;(~(, .:', ~¢,~' - ::¢"~¢F" ::'; '~:-' :':'~-'~;~h~:'~l:,'~"; J]>;'~i:~ ,-.'-"' :: ' :4"~,~ .,. - ..... ,.~ [)...., ,~, ,. ._, . ........... '~'~'¢.~"~/~~'.; '¢ >.,,-;' ..-~.~- ;%-:;. !'~,~.~:~¢.¢ .er .~. %.¢..-,,~*~"'¢;"~" r,,.~ r~t[1 ~[<'~,~, -"~ ,..:.',~ :' ,,-.?_ :, .,. . . ,: ........................ ... ............. ......... ,, ,., .. ....... ....... ,.,...,.. · -'. · · ".'- '; ';'' "': ' " '' '' ?" ..... .~' The Mun~ pality of Anchorage Depadment of Health and Environmental.~rotectioB (DME~) ssues .Health:Authorit' : Approval certificates based solely upon the representations given in paragrap~ 5 above by an independe.nt I '. engineer registered in the State ol Alaska. The DHEP does t~is as a.c~urtesy'to purchaser~ 0f homes a~d. their lending-', , , institutions in order to satisfy certain federal and Stat~ requ rements Employees of DHEP do. not. co ]duct nspections or" analyze data before a ce~ificate is.issued. The Mu~ · professional engineers work...., :,~i ~;":: .";: , 2.' . : Page 2 ct 2 '-: :'", :::i'.: ;-.' ' ."~'":;::'.,::,:~:';.: .... . . ,.. ..... . .. -.(,.'.:,; ~.:.':;~.;:; .- , ' ' . ' ~2-025(11/84['' ,, ' .., MUNICIPALITY OF ANCHORAGE HEALTH AUTHORITY APPROVAL (HAA) MUNICIPALITY OF A~)~A~k4j.~ST DEPT. OF HEAL'I~ ',~' - FEBRUARY 1984 ENviRONMENTAL PROTECTION 264-4720 WELL DATA Well Classification RE6EIV D If A, B, C, D.E.C. Approve N) r ,"¢ To Septic/Holding Tank on Lot oining Lots To Nearest Pu'lC~ewer To Nearest Sewer S?rvibe,,~on Lot ; I~ate ~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~ Standpipesg~N) Air-tight Caps~N) Depression over Tank (Y~t,~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line ~¢ To Water ~ain/Service Line Course ./~ Size /¢¢JD t¢~/¢~ No. of Compartments Foundation Cleanout (Y~ Date Last Pumped W'/,g ;for Temporary Holding Tank Permit (Y/N) To Building Foundation o To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~" Width of Field Square Feet of Absorption Area Depression over Field (Y~)) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well t To Building Foundation Lot To Water Main/Service Line ~'~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments '"'7~-¢'Z~' /¢'"?//;~/¢¢~'/~ Z~/'F/E~ ,/-c¢,~ Type of System Design Length of Field -~-~ / / Depth of Field /429 Gravel Bed Thickness (~' / Standpipes Present'N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots ,~J¢'/ '~' To Cutbank (if present) /o~/.-P LIFT STATION H'gh Water Alarm Level at ~ Vent (Y/N) . odes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have/,,~c/ke~, ver~,!ied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~/--~'~ '/~A'///~'"'"~ Date ~-~ ...... Company /~.a ~' MOA No. Receipt Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 JOB SHEET NO CALCULATED BY CHECKED BY SCALE OF DATE Time~ e Time Date Inspector Date Date Inspeotor Inspeotor Comments Permit No. Well To Absorption Area Well to Tank Conditional Approval Date Sewer Installed...¥~ Soils Rating DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION RECEIVED Septic Tank Size Holding Tank Size Well Log Received APPLICANT FILLS OUT LOWER HALF ONLY Property Owner }3ot]q. ar(:[ (':o~s%rt..c'h~l-!,,' ~ ' ~nc . Phone Mailing Address~ ]?ox 1698~K, >,ncho~cle ~ A~( 99507 ..... .~d~-1615 Buyer i)ale anc~ ~ebra ~.'oss Address 909 Chuoach ?~ay, space 37, Anc]~orage, Ai& 99503 Lending Institution United Bank. of Alaska ~ Attn ~ Ida Phone Address 6)45 G, Street, ~.nchoraqe, Alask8 99501 276-~911 Realty Co. & Agent ~E~I,'~A~ Properties, Iz~c. Attn= Will Easo~ or Bob Address 2702 Gambell St., suite 101, ~chorage, AK 99503 276-2761 Legal Description Lot 34, Block 3, N~rt!~ ?7oo(]s S/D (~eters Creek) Street Location N}IN !9orth~'ooc~s Drive Type 9f Residence ~ Single Family ~ Multiple Family No. of Bedrooms ~ Other Water Supply [] Individual ~ Community [] Public Utility ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) t Sewage Disposal )~ Individual [] Public Utility [] Holding Tank Year Individual Installed: 1981 When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.