The URL can be used to link to this page

Home My WebLink AboutTIMBERLANE PARK #1 BLK 1 LT 16Timberlane Park Block 1 Lot 16 019-142-09 Municipality of Anchorage Page J 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: ~J' ~(~O,~-,~)~ PID Number: O,/~-/z/,~. Name: ~ ~t ~~ Wastewater System: DNew ~ Upgrade *'"~"J l a¢O ~b~G~ ~ 0~ ABSORPTION FIELD Phon~ ~ ~ ~No.o~edrooms: ~ Deep Trench ~ Shallow Trench ~ Bed ~Mound BOther e Total Depth from original grade: LEGAL DESCRIPTION So,,a,.,: ~5 e,./S,.~t. I1' Lot:/ ~ Block:/ ~ ~r/~' Subdiv~ion: ~ Depth to pipe bo~om/~/ ~ ~% ~fr°m original grade: Ft. Gravel~.~depth beneath pipe Ft. ~¢ Gravel length: / ¢~. /OO 8~ ~t. WELL: Cp,~ ~ New ~ Upgrade G~a~e, wldt,:~ ~ Nu~¢,i,es: Cla~ificatio~P~v~te, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Drilled: StaticWaterLevel:I taller: Date installed: ~ ~. ~. TANK SEPARATION DISTANCES u s~,tic u ,o~in~ ~S.T.~.,. To Septic Abso~tion Lift Holding ~ublic/Private Manufacturer: Capacity in gallons: From Ta.k Field Station Tank Sewer L,nes ~r~ ~ ~ ~ ~ I Materlak M Number of Com~ments: Su~ace / Water /¢~+ /O~W /0¢% ./~ ~/~ LIFT STATION Lot / i ~ ~/~ Sizein gallons: Manufacturer' "Pump on" level at; "Pump off" level at: High water alarm Cu~ain Drain _ Pump Make & Model -- I Electrical ,n~edormed by: Remarks: BENCH MARK J Assumed Elevation) P~ Alae~ Wate~ ~ Waete~a~ 2~4~~/~'" ,nspections pedorme~ East Ch,,e, ~,~]e ~ ~ ;~ ~ ,~:~:~ A~eh~r~e~ ~.~ ~'~ Dates: 1st 71 ~/~ ~l. 1 ~u;~ ..... ,.... Depadment of Health and Human ~e~ces appr~a~ %~;z.. C.E. Reviewed and approved by: , Date: [ -~ 72-013 (Rev. 9/91) MOA 25 ~r'RMIT NUMBER s~Bo~o~ AS-BUILT DRAWING PARCEL 019-142-06 ~OU'rd ~ENCH NO~ TRENCH 1,~ ~~ ~ a~.g S.T.E.P. TANK ~ = 90,75 ~ = 90.75 ~C T~K W~ ~USH~ ~ / ~D~L! , 7~.1 aS.0 ~ =: ~ ~1 104.5 11~.0 ~ ~. . ~2 111.5 120.2 t ~ _~/ ~ PREPPED ~: ALASKA WATER & WASTEWATE~ ~'~'~ '"'-' ~:: TIMBER'NE PARK SUBDIVISION ~1, LOT 16, BLOCK 1 ~ ~?.~...~/~.. ~ ~..:.:...:~ ~E OF WORK: _ ~AMES .P. WiLLIAM~; PR~ ~R: PHO~ NUMa~: ~ '. NO. 9608 .' ROBERT SEXTON 567-4544 OR PAGER; (saB)4B9-4013 ~?~ '-... c.E. ..' DA~:7/15/9a/' ~ A.C.G.: I = 50' 1 OF 3 : ~rofeselo.~e~ ~ _ Alaska Water & Wastewater Consultants, Inc. 7320 East Chester Heights Circle ~ Anchorage ,~ Alaska 99504 : Phone (907) 337-6179 - Fax (907) 338-3246 August i8, 1998 Municipality of Anchorage Department of Health & Human Services P.O. Box 196650 Anchorage, AK 99519-6650 Attn: Laura Montgomery REFERENCE: Lot 16; Block 1; Timberlane Park #1 Status of septic system documentation ldunici aliW ct hnchora~.e Dept. Heaplth 8, ~4uman SorwceS A permit (#SW980206) was issued to upgrade the referenced septic system 6/25/98. The septic system has been installed and electrical inspection has been done. We are waiting for an alarm to be installed inside the residence prior to submitting the documentation and as-built of the septic system to your department (DHHS) for review and approval. If you have any questions, please contact me at 337-6179 or 244-9612. Thank you for your assista~e. JAO/gk RECEIVED MAR ~ 2 1999 Municipality of Anchorage Oept. Health & Human Services Alaska Water & Wastewater Consultants, Inc. 7320 East Chester Heights Circle ~ Anchorage ~ Alaska 99504 : Phone (907) 33%6179 ~ Fax (907) 338-3246 August 18, 1998 Municipality of Anchorage Department of Health & Human Services P.O. Box 196650 Anchorage, AK 99519-6650 Attn: Laura Montgomery REFERENCE: Lot 16; Block I; Timberlane Park #1 Status of septic system documentation RECEIVED AU(; 18 1998 Municipality of Anchorage Dept. Health & Human Servicea A permit (#SW980206) was issued to upgrade the referenced septic system 6/25/98. The septic system has been installed and electrical inspection has been done. We are waiting for an alarm to be installed inside the residence prior to submitting the documentation and as-built of the septic system to your department (DHHS) for review and approval. If you have any questions, please contact me at 337-6179 or 244-9612. Thank you for your assista~l~e. JAG/gk MUNICIPALITY OF ANCHORAGE DEPART~/ENT OF HED. LTHIUND ~ SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WAETEWATER DISPOSAL SYSTEM (UPGRADE) PERi~IT PERi~IT NUIV/BER:SW980206 DESIGN ENGINEER:ALASKA WATER & WASTEWATER SERVICES OWNER NAME:SEXTON ROBERT L & SUZY K OWNER ADDRESS:il740 TIMBERLANE DR ANCHORAGE, ALASKA 99516 DATE ISSUED: 6/25/98 EXPIRATION DATE: 6/25/99 PARCEL ID:01914209 LEGAL DESCRIPTION: TIMBERLANE PARK ~1 BLK 1 LT 16 LOT SIZE: 52708 (SQ. FT.) NL%V/BER OF BEDROOMS: 4 THIS PERi~IT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 /%ND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SD/4E DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED By: DATE: DATE: Alaska Water & Wastewater 7320 East Chester Heights Circle N Anchorage ~ Alaska 99504 (907) 337-6179 - Fax (907) 338-3246 Consulting Engineers June 22,1998 Municipality of Anchorage Department of Health & Human Services Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Septic Upgrade Design for Lot 16, Block 1, Timberlane Park Subdivision #1 To whom it may concern: The existing 4 bedroom house is served by a private septic system and well. The existing trench is surcharged and must be upgraded prior to the sale of the house. Four test holes were excavated to the north and south of the existing septic system. The test holes that are to the south of the existing septic system (lableled TH#3 and TH#4) will be used for the proposed upgrade. Comments regarding the proposed upgrade design are summarized as follows: 1. SOILS: Attached are the logs for TH#3 and TH#4 which shows the soil profile, and the percolation test results. Below the organics, the soil is a dense/dry silty, sandy gravel (GM) to a depth of 17 feet (bottom of both test holes). No groundwater was encountered during the excavation of the test hole. One soil percolation test was performed on test h01e #3 at :5)5 to '6.0 feet which perked out at a rate of 30 minute/inch. Test hole #4 was unable to have a percolation test performed on it due to recent rain and sloughing onto bench. It was visually rated as the same soil type as in test hole #3. 2. TRENCH DESIGN: a. Percolation Rate: 30 minutes/inch b. Allowable Application Rate: 0.45 gallons/day/ft2 c. Number of Bedrooms: 4 d. Design Flow: 600 gallons per day e. Minimum Absorption Area: 1333 ft2 f. Effective Depth: 8.5 feet g Width: 2 feet h. M~mmum Length: 100 feet total length (2 ~ 50 long eac ) i. Effective absorption area = 1700 R2 (>1333 ft2 OK) j. Maximum depth = 11 feet · 3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed upgrade. 4. TOPOGRAPHY: The average slope on this property is a <10% running from south to north. In short, there are no slope concerns. I am unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact me at 337-6179, or 244-9612. Thank you for your assistance. SJ les P. Williams, P.E. vii Engineer LOT 16, BLOCK 1 CD ...... WEST K~TT ROAD ,~~ PREPPED ~: A~S~ WATER ~ WASTEWA~R TIMBER'NE PARK SUDIVISION ~1, LOT 16, BLOCK 1, ~/' SITE P~N ROBERT SEXTON (888)489-4013 ~AT~6/22/98 jD~wa ~: js~e NOTE: THE CONTRACTOR IS RESPONSIBLE FOR HAVING SOUTH AND EAST PROPERLY LINE; AND THE 100' WELL RADIUS FLAOGEO BY A REGISTERED LAND SURVEYOR PRIOR TO CONSTRUCTOR. ~H~2 EXISIING WEST TRENCH TO BE USED AS A 1500 GALLON S.T.E.P. SYSTEM WITH DUAL OUTLETS 1.25' HDPE PIPE SLOPED ~ACK TO UFT STAllON FO)) DRAINAGE OF UNE, PROPOSED TRENCHi 11' DEEP BY 2' WIDE BY 50' LONG WITH 8.5' OF SEWER DRAINROCK. MAINTAIN 20' SEPARATION BETWEEN TRENCHES. THESE ARE PRESSURIZED TRENCHES SEE ATTACHED DETAIL, PAGE 5 OF 3) \ \ SEPllC TANK AND E~ST TRENCH TO BE ASAHDONEO IN PLACE. WEL WEST KLATT ROAD PREPARED BY: ALASKA WATER & WASTEWATER LEGAL DESCRtPllON: TIMBERLANE PARK SUBDIVISION #1, LOT 16, BLOCK 1 TYPE OF WORK: DESIGN OF SEPTIC SYSTEM UPGRADE PRE~°ARED FOR: PHONE NUMBER: ROBERT SEXTON 567-45~4 OR PAGER; (888)489-4015 ID~WR BY= ,S~= I PAGE: 6/2~/.8 I J.L.M. I ' = 50' I 2 or3 ~0' -,.-L--~ I/B" PlA, HOi.t~5, F/~I~ ~OWNW,~ (24" 0,6,) 1,2.~' I~IA, LA11~~1' ( 2.e HOb~5 I~t~ I..A11~F-.~ ) ~t/8" ~A, ~1~5, ~K~P I~DVvNW/~ (24" 0,6) PREPARED BY: AI SI{A WATER & WASTEWATER .EGAL DESCRIPTION: -I}-[ TIMBERLANE PARK SUBDIVISION; LOT 16, BLOCK 1. PfPE OF WORK: DETAIL OF PRESUURIZED TRENCHES =RE-PARED FOR: PHONE NUMBER: · ROBERT SEXTON 567-4544 OR PAGER, (888)489-4015 3ATE' IDRAWN BY SCALE: ! PAGE: '6/22/,B I ~'~'~' N.T.S. I ~ oF ~ · , ALASKA WATER & WASTEWATER _~,,~ J SOIL LOG - PERCOLATION TEST] LEGAL DffSO~I~TION; TIMBER~N~ PA~K SUBOIVISION ~1. LOT 16. DATE PERFORMED: 6/8/98 /~fl~ ". C.E ." t race '..... '..,.. ~,~ fe~t) I//?{ TEST HOLE 2~?'.,,¢ /I SOIL C~SSIFICATIONS ~.,~ ..... ORGANICS ~ GM CL GC OL ~ SW MH 7 DEPTH TO ~~.o.,. ~ ~/~/~ 1~ DATE REABIN6 CLOCK NET TI~E I WATER LEVEL NET BROP TI~E (~INUTES) READIN6 (INCHES) 17 18 lg PERCO~TION ~TE - (~IN./INCH) PERC. HO~ DIA. - (INCHES) 20 TEST RUN BETWEEN - ~. AND - FT. COHNENTS: SOl~ UNSUITABLE. NO MONITORING TUBE INSTALLED. PERFOMED BY A~SKA WATER & WAST~ATER ~A / ~ ~ , CERTI~ THAT THIS WAS PERFORMED I~ ACCORDANCE WITH ALL S ~E'AND MUNIOIP~: GUIDELINES IN EFFECT ON THIS D,T~. D*T~: DEPTH TO GROUNDWATER DATE DRY 6/8/98 [SOIL LOG - PERCOLATION TESTI LEGAL DESCRiPTiON: TIMBER--NE PARK SUBDIVISION ~1, LOT 16, BLOCK 1 PERFORMED FOR: RICHARD dORD~ IV~J' %dAMES (feet) ORGANICS 4-- SILTY SAND TO GC ~ ~ OL ; DENSITY SM OH 6 -- INCREASES SC 7-- DEPTH TO DATE I lo~ VISUALLY 11 -- DATE READING CLOCK NET TIHE WATER LEVEL NET DROP TIHE (HINUTES) READING (INCHES) 12-- 6/8/9~_ 4:30 PM BEGIN 4-HOUR PRE~ 13~ 6/9/98 1 5:25 PM ~ 2 3:55 PM 30 MIN 5 1~/4" _._ 3/4" 15~ ~ 19-- PERCO~TION ~TE 40 (NIN,/INCH) PERC. HOLE DIA. 6 (INCHES) 20~ TEST RUN BETWEEN 4.5 FT. ~D 5.0 FT. COHHENTS: PERFOMED BY A~SKA WATER ~ WASTEWATER I, , CERTI~ THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE· DATE: DEPTH TO DATE 3ROUNDWATER DRY 6/8~9B DRY 6/19/98 ALASKA WATER & WASTEWATER ISOIL LOG - PERCOLATION TESTI ~)' 4~ DATE PERFORMffD: 6/11/98 ~ ". NO. ~608 2-- SOIL C~SSIFICATIONS ~ '~ ~ 7-- DEPTH TO DATE ,' '"- GM GROUNDWATE~ SILTY, SANDY GRAVEL ~ DRY 6/19/98~~ ' 9-- (GRAY IN COLOR) - DATE READING CLOC~ NET TIME WATER LEVEL NET DROP TIME (MINUTES) READING (INCHES) ~ 6~/9~ PRESOAMED P~? ~ TESTING ~ .~ 2 6:45 PM 6" _ ~ 3 7:00 PM 5 1/2" .... S 7:15 PM _.~F __ 6 7:45 PM 30 MIN 5" _1" PERCO~TION ~TE 30 (~IN./INCH) PERC. HOLE DIA. 6 (INCHES) TEST RUN BETWEEN 5.5 FT. AND 6.0 FT. PERFOMED BY A~SKA WATER A WASTEWATER ', ~j¢(~ JL ¢ d ~ CERTI~ THAT THIS WAS PERFOEME~ IN ACCORDANCE WITH ALL S AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: DEPTH TO DATE GROUNDWATER DRY 6111198 DRY 6/19~98 !.'AL..ASKA WATER & WASTEWATER__ ~t,~,. PHONE (gO7) 337-fltTfl * F~ (gOT) 33B-3~'~ ~SOIL LOG - PERCOLATION TESTJ ~." ~ "~ ~ o~sc~,~,o~: ~,~,~ ~ ~o,~,~,o~ ~. ~o~ ,~. ~o~ ~ ~, ....... ~t~t:~ ....... ~ [ .JAMES P. WILLIAMSt DATE PERFORMED: 6/11/98 ~ ". NO. 9608 ..' ~tt,:-..... ~.~.....%~ DEPTH (f ~ ORGANICS SOIL C~SSIFICATIONS ~ ,~ ~ ',%:.:~:' GW ~: ORG ~,, ~/o~ ~ I ~//~ ~c . ~ OL ~ ~, _~ /~ ,,, Ii M JI~J il DENSE/DRY . . , "~[~JllUll SILTY, SANDY _ DRY. 6/11/98 ~ ..... /-/ j II LJ[I Iq II GRAVEL 9[j~jjj~ Jl GRAY IN COLOR) ..... ~ , 1o ~ ~ 11 DATE READ NG ~ CLOCK NET TINE WATER LEVEL NET DROP TIHE (HINUTES) READING (INCHES) 12 6/12/98 PRESOAFED PRIOR T TESTING 13 --- ~LE T ) PERFORM PE~CO~TION TI ST O~6 19~ PERCO~TION ~TE N/A (NIN./INCH) P~RC. HOLE DIA, 6 (INCHES) 20 TEST RUN BETWEEN 5.5 FT, AND 6.0 COHHENTS: VlSU~LY ~D SOIL AS ~E SAME 80IL ~PE ~ DENSI~ AS ENCOUNTERED IN TEST HOLE THIS WAS PERFO~ED~ IN ACCORDANCE WITH ALL ~f~'AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DEPTH TO ~ROUNDWATER DATE DRY 6/11/96 DRY 6/1g/gB MAILING ADDRESS LEGAL DESCRIPTION / ~ ~"O IF HOMEMADE: ~,~ DISTANCE TO: JWell ~O _~ ~ Manufacturer -I ~ No. of lines ~ Length ~f each I~e ~ ~Op of tile to finish ~rade / ~ ~ Type of crib ~ Crib diameter ~ DISTANCE TO: Well ~ Class Depth ~ DISTANCE TO: Building foundation ' ~J MUNICIPALITY OF ANCHORAGE ,, /j DEPARTMENT OF HEALTH 8( ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 SITE SEWAGE DISPOSAL SYSTEM AN ' , D/OR WELL INSPECTION REPORT Mside length Width Dwelling Material /~ / I Foundatlo~.~/ Nearest lot line Total length of li~es I Trench ~th //~ ' inches Material beneath tile Depth Crib depth Building foundation Total effective absorption area No. of compa?~ents Liquid depth PERMIT NO. Liquid capacity in gallons Distance between lines Total effective )n area SOl L TEST RATING REMARKS Driller Distance to lot line PERMIT NO. Sewer line Septic tank Absorption area(s) OTHER DEF'RRTMENT OF'~Ef:ILTN RND ENVIF.:ONMENTRL F'R~. ?ECTION 825 '"L'" STREET., RNE:HORRGE, RK. E¢9501 264-4720 ~:~0420 ) PERMIT NO. RPPLICRNT LOCRTION LEGRL CHRRLES WIKHEIM TI MBERLRNE RD L±6 B:1. 'FIMBERLRNE PK SRR BOX i?OB DD502 LOT SIZE 'TYPE OF SOIL RBSORBTION S'YSTEM IS: TRENCH MRNtMUM NUMBER OF BEDROOMS = 4 SOIL RR'FING (SQ FT/BR)= ~XO TNE REQUIRED SIZE OF THE SOIL RBSORPTION S'¢STEM IS: E:"EF'-FH= :.IL. :1_ L EI"-,U "3 T I-i = :.t_ :_t_ ~1- L3 F-: F¢,,-" E L_ E:.E F" T ~== THE LENGTH DIMENSION tS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF ~ TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF 'f'F1E GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. ]'FIE GRRVEL DEPTH IS THE MINIMLIM DEPTN OF GRRVEL BETNEEN THE OUTFFILt_ PIPE RND ]'HE BOTTOM OF' THE EXCRVFITION (IN FEET). PERMIT RPPLICRNT HAS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTRLLFITION INSPECTIONS OF RNY WELLS RDJFICENT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THFIT THE WELL WILL, SERYE. BRCKFILLING OF RNY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS DEPRRTMENT NILL BE SUBJECT TO PROSECUTION. MINIMUM DISTFINCE BETWEEN B NELL fiN[) RNY ON-SITE SENRGE DISPOSRL. SYSTE:t,'I IS ±00 FEET FOR ~ PRIVRTE NEt. L; OR ~50 TO 200 FEET FROM R PUBLIC NELL DEPENDING LIPON THE T~PE OF' PUBLIC WELL. OTHER REQUIREMENTS MRY RPPLY. SPECIFICBTIONS fiND CONSTRUCTION DIRGRRMS RRE flVflILRBLE TO INSURE PROPER INSTflL. LRTION. F"EF.-:/-1 ~ 'T E:,.::F" Z RES I CERTIFY THRT ±: I BM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SENERS RND WELL.S RS SET FORTH BY THE MUNICIF'RLITY OF RNCHORRGE. 2: I WILL INSTRLL THE S¥S'¥EM IN 8CCORDRNCE WITH THE CODES. ]:: I UNDERSTRND THBT THE ON-SITE SEWER S"r'STEM MRY REL.?~LIIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN 4 BEDROOMS. S I GNED: .................................................. RPPL ICflNT CMRRLES WIKHEIM ISSUED BY ...................................... [)RTE .................... ',/]:. 2 LEGAL ~1~ ~ I ~l'ml~'r~ P~ LOT ~.IZE ~0~fi SQLIARE FEET ClI'-.t-':-S X TE '---;EI-.]EI~.: ,I F'EF~'I-'I I [" PERHIT NO. ( I ' ' ! I~ , , 7~O Sk THE REQUIRED SIZE OF T,~E, SOIL ABSORPTION*-,'_-T_';TEI1 "- ' IS: ' [:'EF'TH= ~ t 'LE[411]TH= ,[ I'-t ' - ,, , , ]3E.H'...'EL. ,i E:,EF THE LENGTH DI£,lEl,-,LS, Ir~t,,,I IS THE LENGTH (II,-,~ ,FEET) OF .THE TRENJH OR [:'RRINFIEEP. THE DEPTH OF A TREN(:H, OR PIT I'_-'i THE [:'ISTRNCE E, ETt,IEEi,! THE 'qlIRFRF:E OF THE GROUND AND THE BOTT0r,1~ OF' THE EXCA',,,'RTIOI,.{ <IN FEET). THERE IS !,-JO SET !,,IIDTH,FOR TRENCHES. ~ ',' " THE QRR'¢EL DEF'TH I~, THE I,IlNIP1UH DEPTH OF GR:R',,,'EL E:ET¢,~EEI,,.! THE C,~UTFFILL PIF'E AND THE BOTTOH OF 'r~E,EXCRVRTI,ON~<,IN FEET). , F-."EL%!LI I AEC, SEF'-IF. I U--: , TRf-.iI<: ".~_-~ I ZE= FERhllT FtPPLICRNT HAS T~E RESPOI"4SIBILITY TO INFORhl THIS DEF'ARTP1ENT Z)LIE:ING THE ~ ' INSTRLLATIOH IN_PEC:TICll,.IS, OF AN~r' HELLS RD..TRE:ENT TO THIS PROF'ERTY 'AND THE NUHBER OF RESIDENCES THATITHE NELL, HILL qERVE TI*.I~Z:~ ( 2 ;' I i"-.ISPECT I :~l"'4S AF:E F4EL-.!Li E, AL.k. FILLING OF ANY L'*,r'STEI~1~NITHOUT ,FINAL INSPECTION AND RF'RRO',/IRL 'E:Y, THIS DEPFtRTHENT 14ILI''BE SUB.fEC:T TO PROSECUTION.' , ' ,' ±0OHI N I P1UI,'IFEET DI STRNC:EFoR A PR.I VRTE BETNEEN ' 8, NELL;NELLF, AND ANY ONL-SI TE SENAGE ', [. I_,F O.~L JR '150 TO 208 FEET FROP1 A P.IE, LIL;, NELL BEF'EI,4[)II,,~O UF'OI,'I THE TYPE OF FUE, LIL.' ' * NELL HELL LOGS ARE REQUIRED 'AND, I'II_IST BE RETLIRNED TF~ THE [:'EF'ARTHENT HIiTH',IN ~0 DRYS OF THE NELL COI"~PLETION,' ~ . , OTHER REQUIREPIENTS £'1¢¢r' 'RPFt'Ly. SF'ECIFICRTIFq.4'-~ AND C:OI,,iSTRI~CTIoi,.~ " , , - - DIFII-~RHi"I~. At~:E R'¢RILRE:LE TO INSURE F'RCiF'EI~: [i",ISTRLLRTION. ., , F'ER]"I I T EXF' T F.~E5 E:tECEr'IE:EF.: I CERT'fF~r' THAT '1 , ~ ±: I AP1 FRi"IILIRR NITH THE ~REQLI]rREI'"'IENTS FL-IR ON-SITE sENER-':; 'AND I,I~LL~ RS SET q ' BY FLF.'TH THE HLll,4ICIF'RLI'T'¢ ,OF ANCHORAGE. 2: I HILL INSTALL THE SYSTEH IN ROZ:ORPAI,.~¢:E NITH THE I]:O[:,Eq ' 'i' , ~: I UNDERSTAND THAT THE 'ON-SITE SEHER SYSTEH HAY REOUIR~' ENLRRGEh~E,~¢ IF THE ,-,:ESIDEI,-IL.E IS RE[1CIDELED,TO, INCLUDE, i',IORE: THRN :::_ BEDROCPlS. /~ r ' 'Applicant : - :' : - - ' FT/BR) = 330 TYPE OF SOIL RBSORBTION SN~TEH IS ,'~..~4~ c ~ '~, ," HRXIf'ILIH NUHBER OF BEDROOHS' =,Z.j~ ', r SUIL RATING <,Z~~ ~,~ONSTRUCTION TEST L~B ~j' "One Test is worth a Thousand Opinion~" 2204 Cleveland Anchorage, Alaska 99503 277-0231 Performed for Mr. Legal Description: This Form reports: C. Wikheim Lot 16 -Block 1 SOILS TEST yes Date Performed 7/17/79 SubdivisionTimber Lane Park Sub. PERCOLATION TEST yes Depth Feet Soil Characteristics Peat Brown Silt 3.0' Brown Sand -SP- 15' Brown Silty Sandy Gravel Bottom of Test Hole -GM- Was Ground Water Encountered If YES, What depth? No Reading t Date Gross Time i Net TLme Depth to H20 Net Drainage I 7/17/79 ! 16" Saturation) Period No Water Percolation Rate 1"/60 3.0 Hours 3,5 Hours 4.0 Hours Minute 14" 16.5" 17.0" Proposed Installation: SEEPAGE PIT DRAIN FIELD Depth of Inlet Depth to Bottom of Pit or Trench CO~C4ENTS: 320 Square Feet drainaqe area required per bedroom. Test Performed 2 ] ./2" 1/2" by D. Paul {~.~4 ~,~ Data Certified By: Construction Test Lab Date :_ 7,/] 9,/79 KL~TT_ ~O.4D D~UILT" ..j ~o, 0 I hereby certify that I have surveyed the following described property, Lot /6 /~bock Addition T/,.,~E-~/_/f/,/E /~4/~,~/~,~Z~,. 7¢/Jc#/ recording Precinct, AJaska, and that the ~mprovements situated thereon are within the property lines and do no! overlap at encroach on the property lying adjacent thereto~ that no improvements on property lying ~djacent thereto encroach on the premhe~ in question and that there are no roodway~, transmission lines or giber vi*ible easements on ~aid property except as indicated hereon. Anchorage, Alaska _ _~,,~ '~ APPLI(', ,NT FILLSOUT UPPER HAI~. ,. ONLY P,oper,y Ow.e~. Address Lending Institution ~5~ ~ ~}~ ~ ' ' Phone Address .~ Realty Co. & A~nt M ~ L(~ ~{~V~ ~O~ ~ Phone ~Single Family ~ndividual A~AOH WELL LOG. A w~l Icg Is required for all wells drilled since June 197~. ~ Co~munity For wells drilled prior to that date, give well deplh (attach Icg if available). Sewer Disposal ~,ndividual Year ,ndividual ,nstaged: ~ Public Utility ~ Holding Tank When Connecled to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date inspector Inspector Inspector Inspector Field Notes: ~1 ~. ~ ,~ ~(~C[ ~ MuNICIpALi~ OF ANCHORAGE ~ O ~ : o .CT:ON RECEIVED ~ APPROVED BEDROOM8 *OONDITION8 OF APPROVAL ( ) CONDITIONAL APPROVAL' Soils Rating Date ~wer ~nstaged ~ WeN TO Absorption Area We~l Log Received Well to Tank Septic T~k Size 72-023 CHEMICAL & Gi~,~ OGICAL LABORATORIES ~' ALASKA, INC.~ TELEPHONE (907)-279-4014 ANCHORAGE INDUSTRIAL CENTER ~ 274-3364 5633 B Street ~ Drinking Water Analysis Report for Total Coliform Bacteria TO SE COMPLETED BY WATER SUPPLIER I.D. NO. Water SYstem Name .. Phone No. Mailing Address Citv State MO. Day Year Zip Code SAMPLE TYPE: 'q Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water D Untreated Water SAMPLE NO. 1 2 LOCATION · ,~-~-,_ .~'~ ~, _~L,: ,. Time Collected Collected By TO BE COMPLETED BY LABORATORY Aha vsis shows this Water SAMPLE to ee: [] Satisfactory [] Unsatisfactory [] Samole too long ntranslt; sameleshould not De over 48 hours old at examination to indicate reliable results Please sene new sample. Date ecelved 7/. ./ ' ' Time Received ' ' ' Analytical Method: [] Fermentation Tube ~/Membrane Filter Lab Ref. No. Result* Analyst ,-.. I [--F-I I F-[-I I I-[-I READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Presumptive :t0ml 10mi /0mi 10mi 10mi lo0rni O./ml . 24 Hours 48 Hours Conflrmstow 24 Hours , [1UIROIlm [1TAL CO[1TROL $8RUIC $, ~nqineerin~j $ ~nuironmental Inc. 6/26/81 ROBERT SEXTON KLATT ROAD ANCHORAGE AK 99502 SELLER - ROBERT SEXTON SUBDIVISION-TIMBER LANE BLOCK-1 LOT-16 THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 1666 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 3 BEDROOM HOME. THE SEPTIC TANK WAS PUMPED ON 6/25/81 N%UNICIpALITY OF ANCHORAG5 DSPT. OF 14,~ALT ~ & i~NViRONME. NT,~L F Zo?~CTION !98! 1220 LUest 251h Auenu¢ · Anchora§e, J~JosJ(~ 99503 ·/907) 276-136f CHEMICAL & GlO. LOGICAL LABORATORIES L.~.~" ALASKA, INC. , 274-3364 5633 B Street Drinkin vvater nalysis Report for Total Colif rm Bacteria TO BE COMPLETED BY WATER SUPPLIER I.D. NO. Water System Name Phone No. Mailing Address MO. Day Year Zip Code SAMPLE TYPE: [] Routine [] Check Sample (for routine sam ~31e with lab ref. no. ) [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. r I I LOCATION Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~1~] Satisfactory [] Unsatisfactory [],Sample too long in transit; sample should noz be over 48 hours old at examination 'to ndicate reliable results. Please send new samr~le. Date Received 4, /~/ '', > / r '' Time Received / " / ~'~'~ '' ''f Analytical Method: [] Fermentation Tube ~1 Membrane Filter Lab Ref. No. Result* Analyst '"'' '-~' '1 ~ ~'"'~ i I--T-1 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 (b) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Presumptive 10mi 10mi 3.0mi 10mi 10mi 1.0mi 0.lml EMB Broth 24 hours~ MultiPle Tube Report: Membrane Filter: Direct Count Verification: LTB ' 10mi Tubes Positive/Total 10mi Portions 825 "I/' STREET ANCHORAGE, ALASKA 99501 (907) 264 4! 1t June 17, 1981 Robert L. Sexton % Bob Quist Northland Realty 2832 C Street Anchorage, Alaska 99503 Subject: Lot 16 Block I Ti~mberlane Park Subdivision Approval for the individual sewer and water facilities cannot be granted until the following items have been completed: t ) (2) The water analysis report needs to be submitted to this office from the Chem Lab~ 5633 B Street, for our review. Effective June 1, 1981, the lab fee is $20.00. The areas around the standpipes need to be fllled in with impervious type soil. Thls will need to be, rein-spected by this office. (3) The septic tank pumped with a receipt submitted to this office. (4) An adequacy test needs to be performed on the existing leaching area. This test will determine if the system is adequate according to National Standards. A listing of private firms performing the test is enclosed. This report needs to be submitted to this %ffice for our review. If there are any further questions, please call this office at 264-4720. Sincerely, James S. Roberts Environmental Specialist JSR/ljw ~ C ~MUNICtPALITY OF ANCHORA~~ , Departme~/of Health and Environmen~x~z~Protection 825 L Street, Anchorage, Alaska 99501 264-4720 uest for Approval of Individual Sewer and Water ,F~a~cilities Property Owner: Mailing Address: Phone: Name of Buyer: Mailing Address: Phone: Institution Lending Mailing Address: ~-z~ Phone: 4. Realtor/Agent: Mailing Address: Legal Description. Street Location: Phone: 6. Single Family Residence: (/) Number of Bedrooms: Multiple Family Residence: ( ) Number of Bedrooms: 7. Water Supply: * Individual Well (~ Public/Community System ( ) If Individual Well, well depth If Community System, name of system o Sewage Disposal System: *~n-site System (~ Public System ( ) If On-site System, date of installation: *NOTE: A well log is required on ALL wells drilled since 6/75. ** If on-site sewer system is over two(2) years old, an adequacy .test is required by this department. A fee of $25.00 must accompany each request before processing can be initiated. 3/77 J~ly 17~ 1978 Charles Wikheim % National Bank Of Alaska Pouch 7-025 Funchorage, Alaska 99510 Attention: Ruth Subject: Lot 16 Block 1 Timberlane ,. ubch.vmsmon This department can not approve the request for the sewer and water facilities for the following reasons: (i) The well is buried. The well must be exposed for our inspection. We will inspect for construction of the well and also to see if it meets the miniuium distance requirements from any sewer system. The tank must be uncovered to verify its size and pumped to detei~!ine it~ size. (3) ~%en the sewer system is located and it it is the proper distance away from the well, a percolation test will be required. The two(2) firms that the percolation test ar~ R & M Engineering, 279-0483z or J.MoL. Engineering, 276-4113. If the percolation test fails an u~rade will be necessary. Prior to the upgrade a soils test must be obtained and a permit must be issued by this department. If there are ~uy questions, please contact this office at 264-4720. Sincerely, Robert C. Pratt, Sanitarian RCP/19h Datq. ALASK ' qPARTMENT OF HEALTH AND SOCIAL S'~ ~CES -~- ~ DIVISION OF PUBLIC HEALTH ~ J Lab. No. BACTERIOLOGICAL WATER ANALYSIS Office PLEASE MAIL RESULTS TO: NAME ADDRESS :ITY ZIP CODE Sample collected by Phone No. Date Collected Sampling Address Time Specific place of collection . ' - REASON FOR SAMPLE SUBMISSION: [] Illness suspected [] Health Regulated Establishment r~l'Other _ ,i~.-, . I WATER SAMPLE SOURCE [] Well Type of casing ·" [] Improved (Enclosed, Covered) Spring [] Surface (Reservoir, stream, lake) [] Holding Tank [] Other Analysis shows this WATER SAMPLE to be: [7~-satisfaetory [] Unsatisfactory [] Questionable --] submit other sample [] Sample mo long in transit To h~dicate reliable results. Sample should not be over 48 hours old at time of examination. [] Bottle broken or leaked in transit. [] Other SANITARIAN'S REMARKS Sanitarian's Signature: [READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev 1978 "\ -? .... ?.., -._ . ?/ /, / ~.! /~ , 24 Hours Confirmatory 24 Hours 48 Hours TO F * Florence ~' o La~j ~- · Fifth Floor Fourth Floor SUBJECT Lot 16 Block 1 Timberlane Subdivision Refund Please MESSAGE DATE July 27~ 19' This gentleman cam in on July 26, 1978 and filled another one and paid the fee again. We are already working his paperwork and would like for you to make the necessary arrangements for a refund to him° Thank you. REPLY Redlf, prm® 4S 471 SIGNED SEND PARTS 1 AND 3 WITH CARBON INTACT - PART 3 WILL BE RETURNED WITH REPLY.~ DETACH AND FILE FOR FOLLOW-UP REQUEST FOR ^PPROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Triplicate)' um~ of person requesting approval v Nu~er o~ ~drooms in house 5. Water. Analysis: a. b. Detergent__ Well data: b. Depth 1, Sewer line 2. Septic tank 3, Seepage Area Cesspool~_ 5. Property Line 6. Casing Size Distance from well to closest existing or proposed: Other sources of possible contamination, i.e., creeks, lakes, houses, barn~ drainage ditch, etc. Sewage disposal system. a. Age of system b. Septic tank capacity in gallons c. Name of septic tank manufactu~,r 1. If "home made" show diagram on reverse side of this form. d.' Disposal field or seepage pit size and type ~ ~¢~r 1. Distance to property llne_ , to house fouBdation .e, Percolation. T~st'~esults f. Percolation Test performed by Use the reverse .side of this form to show diagram. Diagram should include ~['~-~he fo~_lowlng info~matlon: ~Foperty lines~.well location, house location, W~l~-£c tank location, disposal area location~ location of percolation test, an~ direction of ground slope. 9. The lnfo~,~.tlon on this form is true and correct to the best of my knowledge. \ 'S~gnature ~f Applicant Date Signed' T~O BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL [~he above described sanitary facilities are hereby approved, subject to the .~ Conditions. ~ ~ ~ ~ ~ ~ / ~ .~ '~ .~ The above described sanitary aczlztles are dlsepproved for the following following the date of CPJ:'dW t } MUNICIPALITY OF ANCHORAGE ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION S2B L Street - Anchorage, A{aska 99501 ENVIRONMENTAL ENGINEERING DIVISION ~ ~ ;': Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL ~ AND SEWER FACILITIES ~)IRECTIONS: Complete all parts on page 1. Incomplete requests will not be ADDRESS PROPERTY RESIDENT (~f different from above) BUYER Pleaseallowten(10) daysforprocessing. PHONE PHONE 3, LENDli~ ~'UTION PHONE 4. I PHONE MAILING ADDRESS STREET LOCATION ~ ' I · \ , One " Four [] Other I~' SI~GLEFAMt~ ~ ~ / / ~ Tw~ ~ Five ' ~ MULTIPLEFAM~ ~ / ~ T~ ~ ~ix U COMMUNITY ~ ~nce June 1~. For wells drilled prior to that date, give well ~ PUBLIC UTI LITY ~ ~depth (att~ log if available.) 8. SEWAGE DISPOSAL SYSTEM . ~ ~ If in'dual/on-site, give installation date ~ ~u~ ~ PUBLIC UTI LITY ~y this Department. NOTE: THE INSPECTION FEE MUST ACCO~NY EACH REQUEST BEFORE pROcEsSING CAN BE INITIATED. 72~10(3/78) THIS SIDE FOR OFFICIAL USE ONL. ' DATE RECEIVE[) INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1, TYPE oF RESIDENCE NUMBER OF BEDROOMS :__ [] sINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SiX I PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connectio~ Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIViDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size; If Tank is homemade SOILS RATING : give dimensions: : TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line §. COMMENTS [] APPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev. 3/78) DEPt. OF HEALTH & MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street- Anchorage, Alaska 99901 J U i'~ i 5 1981 ENVIRONMENTAL SANITATION DIVISION REOUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FA~I LITIES PHONE MAILING ADDRESS PR OPER~Y,R)~D ENT (If d,fferent from above) PH ONE 2. BUYER PHONE MAI LI N~ A~DR ESS 4. REALTOR/AGENT PHONE MAId'S ADDR~S~ - 5. LEGAL DESCRIPTION TREET LOCATIO~ 6. TYPE OF RESIDENOE NUMBER OF~BEDROOMS ~ One '.~ Four ~ SINGLE FAMILY ~ Two' '" ~ Five ~ MULTIPLE FAMILY ~ Three ~ Six [] Other 7. WATER SUPPLY ~, INDIVIDUAL* * ATTACH WELL LOG. A well log is require~ for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTILITY depth (attach log if available.) 9. SEWAGE DISPOSAL SYSTEM ~, INDIVIDUAL/ON-SITE** ./~ 7 ~ YEAR 0N-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. · THIS SIDE FOR OFFICIAL USE ONLY ~ 1, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE E~] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTI LITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] I NDIVI DUAL/ON -SITE E~PUBLIC UTILITY Connection Verified S~ii Septic Tank or [] Holding Tank ze: / "~.~ ~ If Tank is homemade give dimensions: DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED SOl LS RATIr~G TYPE OF TANK MANUFACTURER FOTAL ABSORPTION AREA MATERIAL Line Septic/Holding Tank Absorption Area 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line Nearest Lot 5. COMMENTS [~.~-¢'AP P R O V E D FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72 010 (Rev, 6/79) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVII~UAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE Charles Wikh ~%~ MAI LING ADDRESS PROPERTY RESIDENT (If different from above) 277-0548/35 PHONE PHONE 2. BUYER MAILING ADDRESS 3. LENDING INSTITUTION National Bank of Alaska % Ruth PHONE 726-1132/28 MAILING ADDRESS Pouch 7-025 99510 4. REALTOR/AGENT JPHONE MAILING ADDRESS B. LEGAL DESCRIPTION Lot 16 Block 1 Timberlane Subdivision STREET LOCATION Klatt Road - 1 mile in f~om Old Seward Highway, S. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One [~X Four [] Other [~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six 7. WATER SUPPLY [~ INDIVIDUAL* * ATTACH WELL LOG. A well Icg is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach Icg if available.) ~ INDIVIDUAL/ON-SITE** **1 f individual/on-site, give installation date ,. If system is over two (2) years old an adequacy test is required [] PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE N~UST ACCONIPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY ~ DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE NSPECTOR INSPECTOR INSPECTOR )IRECTIONS: NUMBER OF BEDROOMS 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTI LITY Connection Verified 3, SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified [~]Septic Tank or E~Holding Tank Size: If Tank is homemade give dimensions; [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATEINSTALLED INSTALLER SOILS RATING [] OTHER TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line WELL TO: Absorption Area to nearest Lot Lille ._// _ [~ONDITIONAL APPROVAL (letter n~ acco~ ~icate) DATE ~ ~ ]~ [~ BY(Title) ' I ' L ;..~,,I, ' ......... ' LEGAL DESCRIPTION ~__~ fi 72-010 (Rev. 3/78) - Z !. <> °