Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
HomeMy WebLinkAboutNORTH WOODS UNIT 4 BLK 18 LT 3Northwoods
#4
Block 18
Lot 3
#051-064-43
wm.: rr
Grr�
Tw.ny.p;
Well:
To
From
WAN
svrRu w,w.
LaL w
6
Municipality of Anchorage
Development Services Department ;.is
Building Safety Division
Onsite Water and Wastewater Program, 4700 S. Bragaw SL
P.O. BOX 196650 Anchorage, et
AK 995136650
I
ON-SITE WASTEWATER DISPOSAL YSTEMAND R WELL INSPECTION REPORT, I a
ar ��OTD l PID Number. _ 0 -
r
Wastewater System: ❑New
0 Upgrade
,< v� I r %SG7-S6y ABSORPTION FIELD
T1
3 NunDMM8a0par (�
/ XO«p w� OswW.Trnwh I7 BRd 0Mwnd
O Odw. •
LEGAL DESCRIPTION B°rR""a
❑ New ❑ Upgrade
F1.
r,.
SEPARATION DISTANCES
Fppwpyy�
FL
Septic
Tank
Absorption tilt Holding
Field Station Tank
RVPnvWa
Sdrer Lira
f
)a rf
ton I r
�13 C~ om.1, i
n.�w..: � T
bop
.S
Gawl ftm
TANK
181 Septic ❑ Holding ❑ S.T.E.P.
., --D/ r.
HIVE
LIFT STATION
BENCH MARK
Inspections performed by: 17034
y:17034 Bayle River Lap Rem tot
L n
Atat�yss77 "
Developm nt Services Department Approval
Reviewed aria accroved by
•R., .:.h� Date: _(/ 11�
�. owwa.n Rrws:
13 FL
- rj-0q
0 Other.
ZF—
W Ga.
loo F,.
M S ROBERT C COWAN
CE • 8801
N.
PERMIT N0. SW040153
PACE 2 of 3
Municipalit of AnchorQge
DEPARTMENT OF HEATH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O.
hon: 343-4744
ON—SITE WASTEWATER DISPOSAL SYSTEM e, Alaska LAND/OR 9-6650 *e1WELLe INSPECTION REPORT
LEGAL LOT 3 BLOCK 18 NORTH WOODS #4 S/D P.I.D. NO. nrli_nQ.1_I4
PERMIT NO. SW040153
PACE 3 OF 3
DEPARTMENT ANDhHUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
6650 0 hon: 343-4744
ON—SITE WASTEWATER DISPOSAL SYSTEM e, A[Qska LAND/OR 9-6650 0 Tele
1WELLe INSPECTION REPORT
LEGAL LOT 3, BLOCK 18 NORTH WOODS #4 S/D P.I.D. NO. 051-064-43
ST1 ST2 -,-98.0'
FINAL GRADE
NEW
94.9 1300 GALLON
POLYETHYLENE
SEPTIC TANK
FINAL GRADE
MTI =90.0'
' = OFFSET
C01=98.3'
CO2=98.4'
2" INSULATION
COI=94.2'
CO2=94.0'
MT2=90.0'
NO WATER FOUND
84.0' B.O.H.
2" INSULATION
94.6'
CO3=96.1'
C04=96.1'
CO3=94.0'
C04=94.0'
N. T. S.
i ROBERT C. COWAN 1,
,A
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 South Bmgaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Permit Number: SWO40153
Legal Description: KORTH WOODS UNIT 4 BLK-18_LT-73-P
Design Engineer: 0003 S & S Engineering ry
Owner Name: Eric Fisher
Owner Address: 23524 Blue Skies Drive
Chugiak , AK 99567-5640
Date Issued: May 27, 2004
Expiration Date: May 27, 2005
Parcel ID: 051-064-43
Site Address: 023524 BLUE SKIES DR
Lot Size: 27553 SO. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit Is for the construction of:
Q✓ Disposal Field Q✓ Septic Tank Ej Holding Tank E3 Privy Private Well
❑Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specked 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 DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 (24 hours). ( Not required for a Water Supply Permit only).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By. ?W2
2
Date: L/}7 �0
Issued By. I-Vk--
1 tU Date:s� 2i o
l ZNv
Municipality of Anchorage
• -• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program t
4700 South Bragaw St.
P.O. Box 196650 Anchorage. AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
OiG-SITE ScWER/\A'ELL PERivtIT APPLICAT!n-�t
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O S ) — 0 fo K —H3 Permit Number SW
Property owner(s) Erre /7� 5 A er Day phone5S,-? / / — 73
Mailing address (1) D/3/5�T , ghtN /5�k-,Cs D6ye-
Mailing address (2) LG, .1q IA k f k Q Zip Code _ 29547
Legal description (Lot, Block s Sub'd.) L E. R l ocL 19 /llOMxods --*f
Legal description (Section, Township & Range)
Lot Size^ 22 553 Acre /S9 Number of Bedrooms _
THIS APPLICATION IS FOR:
Sewer Only ❑ Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for
Single Family Dwelling and is in accordance with applicable Municipal Codes.
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
/X)... e...t_ of.... et.&a 00;77
(Signature of property owner or authorized agent)
Permit Fees: y 6 O_ a' Waiver Fees:
Date of Payment: f /ay /o y Date of Payment:
Receipt Number: t.7 S- d G Y fj Receipt Number:
(Rev. 12100)
May 21, 2004
ROBERT C. COWAN, P.E.
CML ENG W EERS
(907) 6942979
FAX (907) 6941211
1EAUHAMHORITY
MUNICIPALITY OF ANCHORAGE
ArmwAM
Development Services Department
P.O. Box 196650
Anchorage, AK 99519
SEWERSWATER
AUN E MNSgNS
REFERENCE: Lot 3, Block 18, Northwoods Subdivision #4
nRILWATER
�
It is requested that you issue a permit to install a septic system upgrade to serve the
existing four bedroom dwelling on the referenced property.
A test hole was excavated and a percolation test performed. The approximate location of
STUDIES
ENGINEErONGAAGFXPWS
the test hole is located on the attached site plan. At the time of excavation 4/4/92, no water
was found. After monitoring, ground water was not found.
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
WEU TEST
areas or drainage patterns by the installation of the proposed septic system. The
construction of this system will not prevent any future development on any of the adjacent
properties.
WE PLANS
If you require additional information, please contact us.
Sincerely,
ROAD DESIGN
z
RobertC. Cowan, P.E.
WkTEST
RCC/bjj
Enclosure
PEACOIATIOR
TEST
STKXTLAk&
►ECKANI x
INSPECTIONS
CNSRE
WASTEWATER
DtSPOMSYSTE4
DESIGN
,
17034 NORTH EAGLE RNER LOOP • SURE 204 • EAGLE RNER, ALASKA 99577
15 TELECOM & ELECTRIC EASEMENT
------------ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2
n "
fes, a-
r� `
ON Cr. uu
0
,O„f ?� ^Y z
O
0= �14
NZ fp
vo"m 3Sf1ON
=!O r -O v=8 3e 4
•zm ONI151%3
DOK
r
O
y
la
O Z Z x
007Cy
1.1. sp°
Z
zOzomo °
p
C n
r
�mr
,N•1 Q p Z
a o pp om oO
Df=f1
x=o
O
1 .0& NIP
1 A
31111--5 31VN831ly --'01 min
LL--------------- o
z
0
r
O
y
... O
H
1" = 40'
DESIGN
p O
mo;z
SA
SITE -PLAN
I
rrnr
X'V
=
°
m
� • (1 m
l�.Ai r
D
A
not
cr
I
$
r
y
Di
o c "=
om
K ` N
O
Tl
I
O
�•
>n "
,,o
x=
y
0
N
�y
A
NRD<�N
C'1-1
"i
'�
Co�
,04
l
I
.I�
rl""
j
-1 D
H.1
-J
M
NNO
o c
I
C
O
l
IS
mD
Dr
n m
x I
N
—1 I
ra�.yy
ry
°l VI A
I�
-----------------------'Z--�
\OO
n
2 �
--_D—O
m II
... Z>
11011
O
O O�
v
Gi X
15 TELECOM & ELECTRIC EASEMENT
------------ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2
n "
fes, a-
r� `
ON Cr. uu
0
,O„f ?� ^Y z
O
0= �14
NZ fp
vo"m 3Sf1ON
=!O r -O v=8 3e 4
•zm ONI151%3
DOK
r
O
y
la
O Z Z x
007Cy
1.1. sp°
Z
zOzomo °
p
C n
r
�mr
,N•1 Q p Z
a o pp om oO
Df=f1
x=o
O
1 .0& NIP
1 A
31111--5 31VN831ly --'01 min
LL--------------- o
z
0
r
O
y
... O
H
N�
f
A m
p O
mo;z
SA
I
rrnr
X'V
=
°
m
� • (1 m
D
A
ti
Dip
r
y
2ti
K ` N
O
Tl
Ul
�•
>n "
,,o
>1
N
N�
f
A m
p O
mo;z
SA
X'V
=
D
A
ti
Dip
r
2ti
K ` N
O
Tl
mr
Xom
>n "
,,o
>1
N
O
Z
O
I
PER
LEG
E
10
11
12
13
14
15
16
17
19
19
20
TEST RUN BETWEEN -f— FT AND 4�5 FT
COMMENTS
PERFORMED BY: 17034 Eagle River Loop Road No. 294
ig a Iver, Alaska 99577 CERTIFY THAT THIS TESTWASPERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON T IS DATE. DATE:
72-008 (Rev. 4/85)
S&
FEALTHA.UDRORTy
APPROVALS
SEWERBWATER
IA NDnNSgNg
SEWER&WATER
INSPECTION
RNGINEERINOSTU71ES
ANDREPORTS
WELLINSPECTION
6 FLOW TEST
SITE PWL4
ROAD DESIGN
SMTEST
PERCOLATION
TEST
STINICIU AL&
MECHANICAL
INSPECTIONS
ONSRE
WASTEWATER
DMPOSALSYSTEMT
DESIGN
RO6ERTC. COWAN, P.E.
CML ENGINEERS
(907)694-2979
FAX(907)694.1211
ON-SITE NVASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
REFERENCE: Lot 3, Block 18, Northwoods Subdivision #4
May 21, 2004
GENERAL:
1. The scope of this project includes the replacement of the existing 1000
gallon septic tank with a new 1300 gallon HDPE septic tank, and additional
length added to the existing trenches to serve the existing four bedroom
residence located on the referenced property.
2. Construction shall be in accordance with the approved site plan and design
drawings, Municipal permit with any special provisions or conditions, and
all applicable State and Municipal Wastewater Disposal Regulations.
3. The contractor shall be responsible for obtaining any necessary
underground utility locates.
4. Unless specifically agreed otherwise, the property owner shall be
responsible for final grading areas subsequently depressed from soil
settling.
5. Contractors installing wastewater disposal systems'must be certified by the
Municipal Health Department for system installations. Owners installing
their own systems must also receive prior approval from the Municipal
Health Department.
SEPTIC TANK INSTALLATION:
I. A septic tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two 4" cleanouts for pumping access.
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER ALASKA 99577
Page 2
Lot 3, Block 18, Northwoods Subdivision 04
May 21, 2004
2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank.
3. All standpipes on the septic tank shall extend a minimum of 12 inches above final
grade.
4. Septic tanks installed with less than 4 ft. of cover shall be insulated.
5. A foundation cleanout shall be installed one to four feet from the building foundation.
In the line between the tank and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic tank). These cleanouts
shall be located on undisturbed soil not more than 10 ft. from the tank. The first
cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be
to clean toward the septic tank.
6. Final grading over the septic tank shall be such that a positive slope exists away from
the septic tank.
ABSORPTION TRENCII/DRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The bottom of
the excavation shall be within 2 inches of level. If the sidewalls of the excavation
become smeared, they must be raked or scratched (ruffed -up) before gravel (sewer
rock) placement.
2. Once the gravel is installed, the distribution pipe is to be installed level with the
perforations faced downward. Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier must be installed between the final gravel layer and the native soil
backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill.
4. Monitor tubes shall be of four (4) inch diameter, installed approximately in the
locations shown on the design, and extend a minimum of 12 inches above final grade.
The portion of the monitoring tube extending through the gravel shall be perforated
from the bottom of the trench to the invert of the distribution pipe. This is equivalent
to the effective depth of the gravel as noted on the design.
Page 9
Lot 3, Block 18, Northwoods Subdivision 84
May 21, 2004
5. Backfill over the final gravel layer must not be less than twenty-four (24) inches.
Insulation must be installed when the backfill depth is less than thirty-six (36) inches.
The finish grade over the trench must be mounded to prevent the formation of a
depression after settling.
MINIMUM MATERIAL SPECIFICATIONS:
1 • Any septic tank proposed for installation must be constructed by a Municipal approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
Tyne of Pice Perforated Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F8 10 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be approved by the inspecting
engineer.
3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco,
or equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
passing the #200 sieve.
7. When sand is being used as a filter material, its gradation specifications must conform
to current M.O.A. or D.E.C. requirements, which ever requirement applies.
• Page 4
Lot 3, Block 18, Northwoods Subdivision N4
May 21, 2004
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the installation of
the wastewater disposal system. These inspections will occur as follows:
1. The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any gravel. A septic tank may be
set in place, but may not be backfilled before this inspection.
2. The second inspection must be conducted after the placement of the silt barrier,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting
engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a
pre -construction meeting will take place on-site. The inspecting engineer will not coordinate,
direct or control in any way the contractors activities.
The owner shall contract with the contractor to perform the work outlined in these
specifications and plans and in accordance with the attached M.O.A. permit. There will be no
contractual arrangement existing between the contractor and S & S Engineering. S & S
Engineering shall be the owner's representative and will inspect the work as stated above to
document the contractors activities. Final acceptance of the contractors work rests with the
owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor
to carry out the work in accordance with these construction documents. S & S Engineering's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incident to this project.
CONTRACTOR / INSTALLER
Municipality of Anchorage Page of
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: `J4��� PID Number: ©4:G i
Name: ,J0+k.tG,�j,�r—��f��' ,._t 5�.
Wastewater System: New ❑ Upgrade
Addr as: Gam' "�
80
ABSORPTION FIELD
Phone:
No. of Bedrooms:
eep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other
LEGAL DESCRIPTION
Soil Rating: /
�'C
Total Depth from original grade:
0 GPD/S .Ft.
Lot: Block:Subdivision:
'
Depth to pipe bottom from original grade:
-'
Gravel depth beneath pipe
4!
Ft.
Ft.
Township:
Range:
Section:
Fill added above original grade:
'Ft.
Gravel length:
lb2
U-
Ft.
WELL: ❑ New ❑ Upgrade
Grave4dep+h: Wt p(} q^ f
Number of lines: Distance between
—.7
✓ Ft.
,�-
Classification (Private, A,B,C):
Total Depth:
Cased To:
Total absorption area:
Pipe matelriiall: i 25I O
_• _340
1
Ft.
Ft.
I/ ( iO SC. Ft.
D'S 1 r T! 15+
Driller:
Date Drilled:
Static Water Level:
Installer: 4--n
^-
Date install
Ft.
i� Vim `�
Yield:Pump
Set at:
Casing Height Above Ground:
TAN
GPM
Ft.
Ft.
SEPARATION DISTANCES"
-Septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
MaigcXpLlyr �1
Capacityin gallons:
From
Tank
Field
Station
Tank
Sewer Lines
`� " —� `
Well
��
Zci7-►'
�--
____
Material:
Number of Compartments:
Surface
Water
I��-!�
I�1-t.
—
—
_--
LIFT STATION
Lot
,t n /
2d /
Size ons: Manufacturer:
Line
Foundation
14f
f
—
____
"Pump on" level at:
'Pump o 1 at: High water alarm at:
Curtain
t
[77'
Pump Make & Model
I Electrical Inspections performed by:
Drain
Remarks:
BENCH MARK
Location and Description:^,.
O�1 LL Lyi
�r--r7,��
1 �*-rG l-I.t✓`J I �!'S �-t l�.ld -� L� .
Assumed Elevation:
I a
ENG�I® 1SSEAL 41.
fw ®
0P O
..$$IIIIM
Ar•
p1�$
Inspections performed by.. 0", 1st'—
2nd
P;JRJ. HAFER��
Department of Health and Human Services approval
`€'; �,� No a .15 ®®•}^ _�
Reviewed and approved b : Oce a Lt
pP Y Date: i� �Pz
�{` •itl T• 6 \ F��
pRo
72-013 (1/91) MOA 25
Perin;t No. Page 2 of �-
Municipality of Anchorage
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
Legal Description: w pa�'S t-�1'i'F` l�iL-i1E� L.&rpSl N0.:
of
' q 1
C85 L__-- exp rip
1�
Co
J
Oat.
11 *i^a
A
0
`r Q py ,,dgryry /J a®®�®
L
U4Zl �I' Cd'�Q:w��.yy a9P4Bm •JSA::I�
�14�'f� 9`
72-013 A (2/91) MOA 25
1
Z
N
72-013 A (2/91) MOA 25
e
���yyy CDU^4 9
sR e ++ fi• ��
C`l,F°nb° pM;� off.^�a:J7
®-
m
®S
e
���yyy CDU^4 9
sR e ++ fi• ��
C`l,F°nb° pM;� off.^�a:J7
PAGE 1 OF
MUNICIPALITY OF ANCHORAGE �� q
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650 S Los
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920057
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:GARBERSON JOHN M &
OWNER ADDRESS:HC 80 BLOCK 5052
CHUGIAK, AK 99567
PARCEL ID:05106443
LEGAL DESCRIPTION: NORTH WOODS UNIT IV BLK 18 LT
3
LOT SIZE: 27553 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
DATE ISSUED: 4/17/92
EXPIRATION DATE: 4/17/93
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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
THE ABSORPTION SYSTEM MUST BE INSTALLED IN ACCORDANCE WITH
THE ENGINEERS DESIGN DATED 4/13/92.
DATE: �Z0�
RECEIVED BY:
ISSUED BY:
DATE: 4A4.1157 _
1
rZ
0
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694.1211
Municipality of Anchorage
HEALTH AUTHORITY DEPARTMENT OF HEALTH AND HUMAN SERVICES
APPROVALS 825 L Street
Anchorage, Alaska 99501
SEWER & WATER
MAIN EXTENSIONS REFERENCE: North Woods Subdivision Phase #4, Block 18, Lot 3
Request you issue a permit to upgrade the septic system
SEWER &WATER serving the referenced property.
INSPECTION
An adequacy test was performed on the existing system and the
absorption capacity of the system was found to be inadequate.
ENGINEERING STUDIES A test hole was excavated and a percolation tests was
AND REPORTS performed in the area of the proposed upgrade. Attached is
the proposed upgrade design.
This property is served by a Community water system. There
WELL INSPECTION are no protective well radii which encroach upon the property.
&FLOW TEST As can be seen from the site plan this lot is large enough for
another future upgrade. We do not anticipate any adverse
effects on neighboring properties by the installation of the
proposed septic upgrade.
SITE PLANS
If you have any questions or require additional information
for your review, please contact us.
ROADDESIGN Sincerely,
SOIL TEST ROGER J. SHA
RJS/lsu
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
�,. 30'
SCALE
UPGRADE
BLUE SKIES DRIVE
�y' a
Z 60 smypr�
{{Y�i']H'h'�R'�$�a?
`tom C IId`
�
p O
�
3 m
01
�Z
yCy
r-
mzm
cb
m
� ?
0
0
UPGRADE
I m
a
m
A
ti
Ob
9 b
O r
O D 0
cn (nNTI
I_
II Zo „
o)A t
o �7 i
S-
43 :U O
b
cl
tb
ti C�
0
m I oj;
ti
N ? n o
rcb
to
� n
3 H
O
Q
(1J
�y' a
Z 60 smypr�
{{Y�i']H'h'�R'�$�a?
`tom C IId`
�
�
r
n
•ta
o
_
cN
b
n
�m
b
y
n
z
o
n
n
47'
o
—h
n
y
47'
o
y
�
O
I m
a
m
A
ti
Ob
9 b
O r
O D 0
cn (nNTI
I_
II Zo „
o)A t
o �7 i
S-
43 :U O
b
cl
tb
ti C�
0
m I oj;
ti
N ? n o
rcb
to
� n
3 H
O
Q
(1J
�y' a
Z 60 smypr�
{{Y�i']H'h'�R'�$�a?
`tom C IId`
I
PERFO
LEGAL
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
TEST RUN BETWEEN 'T FT AND '-Z—FT
COMMENTS
S ENGINEERING
PERFORMED BY:17034 Eagle River Loop Road No. 2Q4 CERTIFY THAT THIS TEST WAS PERFORMED IN
Eagle River, Alaska 9957.7 � \4
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON T IS DATE. DATE:
72-008 (Rev. 4/85)
MUNICIPALITY OF ANCHORAGE
/ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME `7/'v'/ s� ,(
,5te e/ � L , �i IQ
P/H-OCNCE p `
[PIOd '"�0 �/
NEW
❑ UPGRADE
MAILINrq{iESS /, lsYd^^�&
LEGAL D/ WOCC�T///N a2mG/ Cs� l l�l /dAhd.. eGod 3 1 G �
LOCATIO
NO. OF BEDROOMS
V
DISTANCE TO:
II N
�U!/�
Absorption area
Dwelling `
/2
P IT N
y
WQ
Manufacturer / �,n��,
Material ��
No. o ompartments ,7
Liq. capacity, g
lions
IF HOMEMADE:
Inside length
Width
Liquid depth
6
J(DZ
DISTANCETO:
Well
Dwelling
PERMIT NO.
O Z F
Manufacturer
Material
Liquid capacity in gallons
D
w=
DISTANCE TO:
Well
Foundation ^�
Nearest lot line 3S /
PE IT NO
J z w
F_W
No. of lines
Length of eachu
-
G /
Total lengttyo ,line
Trent �id i, 7
�3
Distant etween lines
C�
cc H
In
Top of tile to finish grade`
Material beneath tile {{
& inches
Total effective absor ti n area
-.
W
Length
Width
Depth
PERMIT NO.
C7
Q 1-
M_
LU
Type of crib
Crib diameter
Crib depth
Total effective absorption area
W
y
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
W
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
o
z
b.
r Q�
6
-'
PIPE MATERIALS ^��
SOIL TEST RATING
INSTALLER
A
REMARKS„_,
- AZ
6_1B5' — 4
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
y, MUNICIPALITY OF ANCHORAGE
Departmentr"� Health and Environmental rotection
825 _' Street, Anchorage, AK. 501
264-4720
Permit #-_s # # # HANDWRITTEN PERMIT
*&6 AND/OR ON-SITE SEWER PERMIT
Applicant: G r Mailing Address:
Location: Phone Number:
Legal Description: Ad T' 1 &&,,ft4 r uft dg� -7P—' W lX Lot Size:
Type of Soil Absorption System Is:
Trench: Drainfield: _ Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: Soil Rating(sq.ft/br) 1.30
The Required Size of the Soil Absorption System'Is:
DEPTH LENGTH .�GRAVEL DEPTH 'S WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(W9tfrl"NG) TANK SIZE _ � GALLONS #
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
# # # TWO(Z) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection.and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
I certify that:
(1) I am familiar with the requirements for on-site sewers
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require
the residence is remodeled to include more tha ed
Signed: V , O Issued by:
Applican %
Date: k-15-
t
SWP/024(1/81)
and wells as
i
.� SOILS LOG
MUNICIPALITY OF ANCHORAGE
• .r DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264.4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: S+ -c iC S ka ! S �,'/� DATE PERFORMED:
r�
LEGAL DESCRIPTION: No-w=ds PIrx. K 19 L- ot-3 fn 1-1 K $T63 02�}
SLOPE SITE PLAN
(F EFS
19 1
2 ��M� I'gh� bro v/I Sil Sammy 9ru {I
3-
4-
5-
6-
7-
9-
10
45679
10,
Date
Gross
Net
11
Net
:-,f,!ding
WAS GROUND WATER
Time
Time
Water
ENCOUNTERED? h%o
12
6 -to
2 a8
j49 ►+ .s
17
IF YES, AT WHAT
18ta
to
DEPTH?
13
L+8
• re Raid, Jr.
4• s'o
a
14
Date
Gross
Net
15
Net
:-,f,!ding
i •► OF 4L
Time
Time
Water
i�P�����••��a��ai�
6 -to
2 a8
j49 ►+ .s
17
Via.-a.w...• 6 N..
18ta
to
•.
L+8
• re Raid, Jr.
4• s'o
a
22-8zi
.-20
3O
'6 e& Cr 110 C
ea
Date
Gross
Net
Depth to
Net
:-,f,!ding
Time
Time
Water
Drop
6 -to
2 a8
2 +$
to
L+8
4• s'o
22-8zi
.-20
3O
zZ8
q- 54
2_
10
2
3a
—
z ty Aro
2L
ZT
2 'T 8
to
• 2'/
.2-4 '.
I
PERCOLATION RATE +S (minutes/inch)
TEST RUN BETWEEN FT AND 12 FT
COMMENTS _Soz to4ea l� 13ofl �%� 1�na. 1 •2 }v it)
PERFORMEDBY: T>arc!j CERTIFIED BY: DATE: 3.
72-008 (6,179) -
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section _ Fax: 907-343-7997
Parcel I.D. 051-064-43
Certificate of On -Site Systems Approval
Expiration Date: _ 3 2 `t — z S
1. GENERAL INFORMATION
Complete legal description NORTH WOODS #4 BLK 18 LT 3
Location (site address) 23524 Blue Skies Dr
Current property owner(s) WILLIAMS
Mailing address
Real estate agent
Amanda
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
Day phone 982-0545
Day phone 982-0545
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
$550
COSA Fee $ i f
Date of Payment
Receipt Number 031 79 D
OSC211148
COSA#
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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm NorthRim Eng. Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date 3/4/20
OF
*
6. DSD SIGNATURE
s10
System tl Approved for bedrooms f` stere E^9 Q::
System #2 Approved for bedrooms
3/4/21 'or
Disapproved
Conditional approval for bedrooms, with the following stipulations:
Original Certificate Date: 7
The Municipality of Anchorage Development Services Division (DSD) issues Cenificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional ci:.,il engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist
Legal Description: NORTH WOODS #4 BLK 18 LT 3
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Comments
B. TANK DATA
Age of tank(s) 17 years
Tank type/material seP1CPL=
Measured operating fluid level in septic tank 50
❑Q Standpipes/foundation cleanout /per record drawing
Date of pumping 3-30 -Z
D. ABSORPTION FIELD DATA 6/9/04
Which system tested (date installed) same
❑■ ALL standpipes present per record drawing
Total measured depth from grade 7.5 ft (max)
Measured depth to pipe invert from grade 3 ft (min)
❑ N/A — pressurized field
Al Monitor tubes go to bottom of effective. If not, state
depth into effective
Parcel ID: 051-064-43
Structure served by this system
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes Q No
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by
Date of Sample
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 3129121
Results S Pass For 4 bedrooms
Fluid depth prior to test 23&5 in
Water added 600 gal
New depth 291,10 in
Elapsed time 30 min
V Code -required soil cover over field
Final fluid depth 2611,8 in
❑ System presoaked Absorption rate 600 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) no
date of test) If yes, enter date
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
1411111101MM, 0011KC-61011
From Private Well on Lot to: (Please enter distances if less than required or if cornrnunity weil)
Septic Tank/Lift Station on Lot > 100'
Yes
Neighboring Tank > 100' ❑ Yes
Absorption Field on Lot > 100' F-1 Yes
Neighboring Absorption Fields > 100'
El Yes
Community Sewer Main > 75' E] Yes
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
Community Sewer Manhole/Cleanout > 100'
Yes
if No ft
rl Yes
if No
It
if No ft
Private Sewer/Septic Line > 26 M Yes
if No
ft
if No it
Holding Tank > 100' El Yes
if No
It
F/1
Animal Containment > 50' Yes
if No
ft
if No ft
Yes if No ft
Water Main > 10'
M-,
Yes
Manure/Animal Excreta Storage > 100'
ft
Community Wells > 200'
if No ft
C] Yes
if No
ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
Yes
if No
ft
Surface Water > 100'
Yes if No ft
Property Line > 5'
Yes
Yes
if No
ft
Wells on Adjacent Lots:
Q
Absorption Field > 5'
F/1
Yes
if No
ft
Private Wells > 100'
Yes if No ft
Water Main > 10'
M-,
Yes
if No
ft
Community Wells > 200'
nv Yes if No ft
Water Service Line > 10'
El
Yes
if No
I'Adi
If septic tank is under driveway
comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Q
Yes
it No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
0
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100'
El
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that / have determined through field inspections and review
of AXOnicipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
49 TH
Steve Eng
CE -6,256
I Nt4i, I-A-lpi
OD'DE'/ M ,E$,.60 QO N
Q�1j
spo
O
<
3HIR
N
p 1
Fy�L
u.
W o
_
�1
tlo F 3
M6
-
n
M
s K y
PU
14
Wr
W4
�•
m�V—m
5 a
"'z
9•at
t] N M"
[qi �.{ ����N�
s/>
m
o F• � 2 � �i
H
iiz iZL�Kp>�a2
OtU6
AH
yp
YQW
�2Ns
•
U,
N
u'i�.
4u�Hp
.................. ................... ._..
�LuW
>m�
m~W
5°
tatW.iP
W
,�.Fl-
W
�
WN
mo2at;oQn
m
Q�1j
spo
N
p 1
Fy�L
_
�1
tlo F 3
-
n
M
s K y
14
Wr
5 a
"'z
9•at
[qi �.{ ����N�
to
iiz iZL�Kp>�a2
OtU6
%
�2Ns
•
p y
iil
� ag
Mag
d''{h. QOQ��ppQ�.
------------------------------ ...... .........
'J.JYS3 X313 9 373t .91
.................. ................... ._..
O
0o EI trio m
• � •II �
Qpv � �'•�c
3/779
CL
to
OQ
vi
zm
s J
Municipality of Anchorage
Development Services Department =`
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99519-6650 �..Ax
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-064-43 COSA#
1. GENERAL INFORMATION Expiration Date: ? ` � LA
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
23524 BLUE SKIES DRIVE, EAGLE RIVER, AK, 99567
ERIC FISHER Day phone
23524 BLUE SKIES DRIVE, EAGLE RIVER, AK, 99567
Day phone
688-4662
Real Estate Agent DAR WALDEN W/ KELLER WILLIAMS Day phone 865-6500
Mailing address 101 W. BENSON BLVD, #503, 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
❑
Individual Water Storage
❑
Community Class Well
❑
Public Water System
E
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
0
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 seat 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, LfD. 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 life 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.
5. DSD SIGNATURE
10 Approved for bedrooms.
Disapproved.
337-6179
Date b (,7.
.gs�oo
94�T
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Llaintenance Agreements
Supplemental Engineer's Report
Other
CEj7153
Ec
"rof ess'10— `
OF
ON-SITE
WATER AND
WASTEWATER
PROGRAM
By: LO(1 r Original Certificate Date: (12—
(Rev. IV05)
Municipality of Anchorage
�`11 pL ab<
• Development Services Department
Building Safety Division
On -Site Water & 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
ulvir
Legal Description: NORTHWOODS S/D #4; BLOCK 18, LOT 3 Parcel ID: 051-064-43
A. WELL DATA
PUBLIC WATER
Well type If A. B, or C provide PWSID# _ Well Log (Y/N)
Date completed Sanitary seal (Y/N)_ Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (abo round) in.
FROM WELL LOG AT I CTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RES
Coliform colonies/100 ml. Nitrate mg./L. Collected by:
enic: ug./L. Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/HDPE Date installed 6/9/2004
Tank size 1300 gal. Number of Compartments E Cleanouts (Y/N) YES
Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (Y/N) N/A
Date of pumping 7/11/2012 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA
Date installed **6/9/2004 Soil rating .p.d./ r ft2/bdrm) 0_6 System type DUAL TRENCH
62 & 64
Length 126 TOTAL ft. Width 3 ft. Gravel below pipe 4 ft.
Total depth *7.4-7.5 ft. Eff. absorption area 1008 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 8/3/2012 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test ***21 in. Water added 650 gal. New depth ***48 in.
Elapsed Time: 135 min. Final fluid depth ***41 in. Absorption rate >= 600+ g,p,d,
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date
**DUAL TRENCHES ORIGINALLY INSTALLED 5/6/1992. TRENCHES WERE EXTENDED IN 2004 TO
SERVE 4 BEDROOMS. ***TESTED WEST TRENCH ONLY. FLOW SPLITTER APPEARS TO BE OUT OF
LEVEL. EAST TRENCH WAS 997 FULL UPON INSPECTION AND NOT TESTABLE.
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N
"Pump on" level at in. "Pump off' 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
Absorption field on lot
Public sewer main
Sewer /septic service lines
PUBLIC WATER
On adjacent
On adjacent lots
manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 200+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water service line 1o,+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 200+
F. COMMENTS
F
G. ENGINEER'S CERTIFICATION o 9
p�P .' •.S�oOd
I certify that t 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
date. G.. ess:r p
Engineer's Printed Name JEFFREY A. GARNESS �Qo9 C 5 .•'\�0�
Date % j 6I12_ Ldp Pti $./. b/// Zo\ Erol
_Pr fecsi0� o
COSA Fee S U an -
Date of Payment g /, "
Receipt Number
(Rev. 11/05)
Waiver Fee
Date of Payment
Receipt Number
m
° k /
§)
3 /HG S3 */ 727
§
!
o%
�\
k!!} S\\
/
} t
,
ME
§
!
)
§55
\
Wel
M!
®G®
_
1.0
N]§| |;
,.
,
§;|§!•
§
2\
\§/|
`
§kms
i
2 @~i
!2§
A
�
§
!
o%
�\
k!!} S\\
/
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. # Qc;1 _064-43 HAA #
I„�
1. GENERAL GENERAL INFORMATION
Complete legal description Lot 3; Block 18; North Woods Subdivision #4
Location (site address or directions)
23524 Blue Skies Drive
Chuaiak. AK
Property owner The Associates Relocation Day phone
Mailing address C/0 Prudential Jack White Resl Estate
Lending agency Day phone
Mailing address
Agent Sallie Nickerson/ Prudential Jack Why phone
.}
Address 3901 tto" street- Anrhnraga AN AgSQ
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well XX
Public water
NOTE: 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 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-M (Rev. 1/91) Front MOA #21
5.
6.
By:
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm ALASKA
Address
Engineer's signature
Alaska Water &
WASTEWATER
Wastewater Consultants, t,
Shall be PAID $�L�� +>
or prior to, closing for the
Engineerin r.,. s; Provided:
DHHS SIGNATURE
Approved for THE EE bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Phone
— Date 9 c
... yy UN. M' • M
w
bedrooms, with the following stipulations:
122, Date-
72-025
ate
a
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA a21
provide written confirmation from State ADEC attest-
tus of system.
4L
xxx
�Holding tank,' "M
,,,,.Cornmunity on site
'N
V, i F, Ph A
Public sewer
NOTE: If community wastewater system, provide written confirmation from
attesting to the legality and status of system.
72-025 (Rev. 1/91) From MOA #21
9
19 agency
Day phone
address-'
AIX e,
Kathy GeActclU Gkea.�and Reattll
Day phone
694-9125
1�11 'Ann, .VII U
11411 Oz OennI; Zaglte:!Ri. vek
!",V
wy,.�-�,lr '::99577
provide written confirmation from State ADEC attest-
tus of system.
4L
xxx
�Holding tank,' "M
,,,,.Cornmunity on site
'N
V, i F, Ph A
Public sewer
NOTE: If community wastewater system, provide written confirmation from
attesting to the legality and status of system.
72-025 (Rev. 1/91) From MOA #21
9
v- On
AIX e,
provide written confirmation from State ADEC attest-
tus of system.
4L
xxx
�Holding tank,' "M
,,,,.Cornmunity on site
'N
V, i F, Ph A
Public sewer
NOTE: If community wastewater system, provide written confirmation from
attesting to the legality and status of system.
72-025 (Rev. 1/91) From MOA #21
A. WELL DATA
Well type If A, B, I oi,,'C, dakh AD80 16tter. A
FROM WELL LOG AT INSPECTION -
R
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES M},t
b 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. # ��� l�� ��—HAA #
1. GENERAL INFORMATION
Complete legal description Lot 3; Block. 18; No&th Wood #4
Location (site address or directions) 23524 Blue Siziu Dkive
Eaa2e Riven. AK
Property owner Kay Addn.ibi Day phone (h) 688-6593
C/0 11411 U2d Glenn Hwy. (w)694-9125
Mailing address Eagle Riven, AK 99577
Lending agency
Mailing address
Day phone
Agent Kay Addkisi (owner/agent) GREATLAND REALTY Day phone 694-9125
Address 11411 U2d Glenn Hwy. EAGLE RIVER, ALASKA 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well XXX
Public water
NOTE: 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 XXX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA 1121
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify 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 5 & s ENGINEERING Phone
17034 I_a jle River Loop Koad
Address 3"<,=fie, eZav ce.r, Alaska 99577 /t
Engineer's signature Date "f - 61-
6. DHHS SIGNATURE
_42L Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
Date _
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025(Rev.1/91) Back MOAN21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:i-6'r3 6L� �S �o�r� �s Pakcel I.D. a:g-6144/-
A. WELL DATA
Well type If A, B, or C, attach ADEC letter. ADEC water system number 2► 3 0o I
Log present (Y/N) Date completed Driller
Total depth Cased to Casing height
Sanitary seal (Y/N) Wires properly protecte
FROM WELL LOG AT INSPECTION m
Date of test :
� o
n
Static water level 1'11 D
n D�
Well flow g.p.m. g.p.m. IT7 m •T
A D
mp level C F
rn w N
c7
SEPARATION DISTANCES FROM WELL TO: N m
tk g
Septic/holding tank on lot yoo ; On adjacent lots
�k
Absorption field on lot �'� o ; On adjacent lots
Public sewer main Public sewer manhopout
Sewer service line roleum tank
WATER SAMPLE RESULTS'
Coliform Nitrate Other bacteria
D e of sample: Collected by:
B. SEPTIC/HOLDING TANK DAT
Date installed S 48 3 Tank size 166 6 Compartments 2
CleanoutsOY N)� (,Q '001Foundation cleanout G/N) Depression �
High water alarm (Y/l�l 04 Alarm tested (Y/N) �4
Date of pumping i lr - i 3 Pumper ,T_i�. G -E 55Pa a L
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Wells) on lot o On adjacent lots Lc Foundation
To property line Absorption field 4$ t Water main/service line S
Surface water/drainage %D
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y
Manufacturer
_ Manhole/Access (Y/N)
" p off' level at
Cycles tested
SEPARATIO ANCE FROM LIFT STATION TO:
on lot On adjacent lots
D. ABSORPTION FIELD DATA
Surface water
Date installed S- 7,22— Soil rating 0, t. 67Pa� 2_ System type T/LF Lha
g b Z � Width
Length % 3 Gravel thickness `� Total depth
Total absorption area / Cleanouts present &N)
Depression over field (Ya r Date of adequacy test 'J/.4-
Results (pass/fail) 2-ES5 -1"gd for 3 bedrooms
Peroxide treatment (past 12 months) (Y& Al If yes, give date —..4 A -
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 26 o t �--
To building foundation o
On adjacent lots
Surface water
S.0 I d—
Curtain drain �l
o t OL-
E. ENGINEER'S CERTIFICATION
-On
_On adjacent lots 1_�.4_ Property line 3 a
�
To existing or abandoned system on lot /o /f
ri/Cutbank .A- Water main/service line 2S 14--
Driveway, parking/vehicle storage area So t
l certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Signature Eagle Raver. Alaska 99577
Engineer's Name
Date 4—,(0_q,5
HAA Fee $ L
Date of P&yment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
date of this inspection.
Waiver Fee: $
Date of Payment
Receipt Number
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
April 5, 1993
Mr. Ray Shafer
S & S Engineering
SUBJECT: Northwoods Subdivision
Class "A" Public Water System, PWSID 213001
Dear Mr. Shafer:
WALTER J. HICKEL, GOVERNOR
(907) 349-7755
I have completed a review of this office's files concerning the monitoring status of tha
above -referenced Class "A" Public Water System and found the following:
1. The last satisfactory Total Coliform Bacteria Sample results was submitted
to this Department on March 4, 1993. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
2. The last inorganic Chemical Contaminants Sample results were submitted
to this Department on April 21, 1992. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
3. The last Radioactive Contaminants Sample results were submitted to the
Department on July 1, 1992. This does meet the provisions of 18 AAC
80.200(a), State Drinking Water . eguF ati—T ons.
4. The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC)
were submitted to this Department on June 2, 1992. Based on analysis of
the previous VOC samples results have been satisfactory. This does meet
the provisions of 18 AAC 80.200(a), State Drinking Water Regulations.
Issuance of this letter does not imply that the above -referenced Class "A" Public Water
System is in compliance with other provisions of the State Drinking Regulations.
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. # �'� } (�In L j — L� HAA # )> Qq 2L3t]0
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address.
John Gatbet6on
0946
Lot 3; Block 18; Notth woods Phase IV
23524 Btue Skies Dxive
Day phone
Day phone
Agent Rae Hatt GREATLAND REALTY Day phone 694-9125
11411 02d Glen Highway
Ad d ress
Unless otherwise requested, HAA will be held for pickup.
3
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well XX
Public water
NOTE: 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 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.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Phone
S & S ENGINEERING
Address 17034 Eagle River Loo Rn oad No 204
Eagle River, Alaska 99577 .
Engineer's signature Date
6. DHHS SIGNATURE
X__ Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
wOf At- w
�s
WrNo
r Pij ¢ as+ �q
'ilr aasc��'if�ri x.r^i • 9.
noGEN 3...FIAFER
15 or.
Y`7'G' m�A9i^IMM®0�• ��+6.�ll
bedrooms, with the following stipulations:
By; Date _15116. 9 -)-
111717
13 -
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: 00;2T��0001::'� `T Parcel I.D. oe5I D
18 1 t_oT -;:�
A. WELL DATA
Well typ�ai .t e::, If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Date completed Driller—
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
Cased to Casing height
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
Wires properly protected (Y/N)
AT INSPECTION
Septic/holding tank on lot 2r!D +_ ; On adjacent lots
Absorption field on lot On adjacent lots _
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Nitrate
Public sewer manhole/cleanout
Petroleum tank
Collected by:
Other bacteria
Z
0
"'
"'Ly 0,11
w
>
'3
LL
g.p.m.0 F
—
W
>-
LL!
zo
i�
UJ
Date installed Tank size 1 Compartments Z
Cleanouts (�Y N) Foundation cleanou (Y N) Depression (Y/
High water alarm (Y/N) �'J f -P Alarm tested (Y/N)
Date of pumping �'Pumper FJrlr-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot rl _On adjacent lots ZOO( Foundation
To property line ' ` t Absorption field Water main/service line
Surface water/drainage .)0,0'4—
FROM
)0,0(' —
72-026 (Rev. gist) Front - CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANC
Well on lot
Manufacturer
Manhole/Ac s (Y/N)
"Pump off' level at
LIFT STATION TO:
On adjacent lots
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed �'IZ Soil rating.... �� System type�►�
Length Width t✓t
Gravel thickness 4-- Total depth �o �
Total absorption area /o Cleanouts present6 l)
Depression over field (Y( Date of adequacy test
Results (pass/fail)
Peroxide treatment (past 12 months) ( Z5
SEPARATION DISTANCE FROM ABSOR
Well on lot �,J�-P On a(
for
If yes, give date
ION FIELD TO:
lots Zt4
--Property Property line � U
bedrooms
To building/
foundation �d L.ZTo existing or abandoned system on lot 1& 14-
i
On adjacent lots �� Cutbank IJ61-1,; Water main/service line ,;?
Surface water I /) D ` Driveway, parking/vehicle storage area
Curtain drain I�0t.1.i- V -11-i Q 1_1
E. ENGINEER'S CERTIFICATION
I certify that l have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
trJ�'k rid ��w,. T•��
S & S ENGINEERING • '(
iln C f n��qq
Signature 17034 Eagle River Loop Road No. 204 G
Eagle River, Alaska 995" �: ?I
Engineer's Name
Date
HAA Fee $ / ZD 'C"
Date of Payment 5_'—1 .5 !]:� y
Receipt Number _Z a7zy—�����
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
F
d
1 ,
/t 1
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99503
FOR: Roger Shafer
S & S Engineering
April 6, 1992
PWSID # 213001
WALTER J. H/CKEL, GOVERNOR
(907) 349-7755
My review of the records on file in this office reveals that the Northwood Subdivision Class
"A" Public Water System, is in compliance with the routine coliform bacteria sampling
requirements listed in Table C, and with the inorganic sampling requirements listed in
Table B of 18 AAC 80.200.
BR/cf
Siin,�ceerely, 4n�
,C,a� Byron Roys
Project Engineer
Time
APPLICNT FILLS
OUT UPPER HAL' )ONLY
Time
Time C3
Date
Date
Pilwerty Owner
Date
Phone
Mailing Address
'Al 1•? Zip Code 3 5
Buyer
Inspector
Address
Zip Code —
Lending Institution
Field Notes'.
AOAW#kl
Phone
MUNICIPALITY OF ANCHORAGE
Zip Code
Address
ENVIRONMENTAL PROTECTION
Realty Co. & Agent
Phone
Address
Zip Code
*CONDITIONS OF APPROVAL
Legal Description
I DISAPPROVED
t,4
Street Location
DATE
Type of Residence
BY:
--jD Single Family
El Multiple Family
No. of Bedrooms —�
Date Sewer Installed
D Other
Well Log Received
Septic Tank Size
Water Supply
0 Individual
Well to Tank
ATTACH WELL LOG. A well log is required for all wells drilled
log
since June 1975.
if available).
---Q Community
crr_
For wells drilled prior to that date, give well depth (attach
Ll Public Utility
Sewer Disposal
L1 Individual
Year Individual Installed:
0 Public Utility
When Connected to Public Utility:
0 Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY
EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time C3
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes'.
AOAW#kl
MUNICIPALITY OF ANCHORAGE
DEPT.OF HEALTH &
ENVIRONMENTAL PROTECTION
I APPROVED BEDROOMS
*CONDITIONS OF APPROVAL
PRFCFIVFD
I DISAPPROVED
) CONDITIONAL APPROVAL'
DATE
BY:
Solis Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
Septic Tank Size
Well to Tank
72-023 (3182)
January 27, 1984
Aractic Development
446U business Park
Anchorage, AK 99503
Subject; Lot 3, Block 18y Northwoodsr 4th
Approval for the individual sewer and water facilities cannot
be granted until the following items have been completed:
�Cuv-e LL!��LNI
Submit the original soils_�J�og
and a copy of the permit for
the on -sit ins is department has no record of
the permit being issued, however you may be able to obtain
one from your engineer or excavator.
Please notify this Department for a reinspection when the
noted discrepancies have been corrected. If there are any
further questions, please call this office at 264-4720.
:sincerely,
Cory W1110;
Acting Sewer & water
Program Manager
CW108/ej/El
Time
APPLI(,wNT FILLS
OUT UPPER HAt ONLY
Property Owner
5k,uc�y) 4 k(-- rj"
Date
Phone
Date
Ilk Zip Code
Inspector
Mailing Address
-J �)
inspector
Inspector
Field Notes:
( APPROVED BEDROOMS Z
Buyer
( ) DISAPPROVED !„3
Address
Zip Code
BY:
Phone
Lending Institution
_
Well Log Received
Septic Tank Size00 L�
Address -
Zip Code
Phone
Realty Co. & Agent
Address-.
Zip Code
LegalDescriptionQ�-C
/
j-1.-6�--
Street Location
Type ofLe4
mgle Family
❑ Multiple Family`
No. of Bedrooms
❑ Other
Water Supply..._
El I''dividual '°-,..z,
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
Community
"''ti.,
For wells drilled prior to that date, give well depth (attach log if available).
❑ Public Utility
Sewer D' posal
ndividual
// f
Year Individual Installed:
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
inspector
Inspector
Field Notes:
( APPROVED BEDROOMS Z
'CONDITIONS OF APPROVAL
( ) DISAPPROVED !„3
( ) CONDITIONAL APBROVL'
DATE
BY:
Soils Rating
Date Se er Installed
Well To Absorption Area
Well Log Received
Septic Tank Size00 L�
Well to Tank
72023 (31&)