Loading...
HomeMy WebLinkAboutOUR MOUNTAIN BLK 1 LT 3MUNICIPALITY OF ANCHORAGE Development Services Department Phone: (907)343-7904 On -Site Water & Wastewater Section Fax: (907)343-7997 Parcel ID 051 -111-42 Certificate of On -Site Systems Approval OSC261051 Expiration Date: 6/15/2026 Legal description OUR MOUNTAIN BLK 1 LT 3 Site address 20527 MARK CIR Current property owner(s) CHAMPINE THEODORE RJR & The On-site system(s) is/are approved for bedrooms X Conditional approval for 3 bedrooms, with the following stipulations: By: Comments or conditions: This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Service Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's submittal. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other MUNICIPALITY OF Development Services Department On -Site Water & Wastewater Section Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 05111142000 Complete legal description Our Mountain Block 1 Lot 3 Location (site address) 20527 MARK CIR Current property owner(s) CHAM PINE 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: � Private Well serving # 1 dwelling units F-1 Other Non-public well as regulated by MOA F-1 Water Storage F-1 Community Well or Public 4. TYPE OF WASTEWATER DISPOSAL: � Private Septic E] Private Septic serving 2 dwelling units ❑ Holding Tank R Community Septic or Public Sewer 5. SEPTIC TANK: DO Steel F-1 Plastic F-1 Concrete r_1 Fiberglass Age 45 - See advisory if steel or fiberglass older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed � Deep Trench ❑ Wide Trench El Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ Waiver Fee $ Date of Payment Date of Payment COSA # C9 � c -L 110 ( 0 S ) Waiver # COSA Application_Apr2025.doc COSA Checklist_May2025.docx COSA Checklist Legal Description: Parcel ID: If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ 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. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D.DISPOSAL FIELD DATA Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: Veterans United Home Loans www.veteransunited.com 573-876-2600 x1430 Please note, we are a VA approved lender, but not a government agency Date: 3/17/2026 Loan Coordinator Cert RE: 400226110494979 The escrow holdback agreement has been approved by Veterans United Home Loans for the decommission and installation of a new septic tank including all fees and permits. This delay in completion is due to weather conditions in the State of Alaska prohibiting the completion of repairs prior to closing. The Final CD will collect $34,101.15 from the seller to fund the holdback account. The completed work should be completed within 120 days of closing. The money shall be held in escrow until such time as a final unconditional Certificate of On-Site Systems Approval is issued by the On-Site Water & Wastewater Section. Please let me know if you have any questions. Sincerely, Emily Cassidy Loan Coordinator Team Lead Ph: 573-876-2600 x1430 E: emily.cassidy@vu.com MUNICIPALITY OF ANCHORAGE Development Services Department COSA NO- OSC261051 Aw On -Site Water and Wastewater Section CONDITIONAL COSA AGREEMENT SUBDIVISION: OUR MOUNTAIN BLOCK: 1 —_ _LOT 3 Thebuyerof the above referenced property agreestocom plete all the conditions required on the Conditional Certificate of On -Site Systems Approval (CCOSA) issued by the Municipality of Anchorage (MOA) by the above referenced date. Failure to do so will result in a daily fine of up to $300 every day after the expiration of the Conditional COSA (see AMC 14.60.030). Additional fees will be assessed for inspector's time associate with violations at $145 per hour (minimum one hour) i he buyer, once owner, shall be responsible for all violations on the property. Dvj contents, and acknowledge I am r Signature: Buyer Name (Printed): STATE OF ALASKA THIRD JUDICIAL DISTRICT 5 (BUYER) have carefully read this agreement, understand its esponsible for compliance with Municipal Law /0 2wow 4e�7 The foregoing instrument was acknowledged before me this ID day of r� ,2 0 alp by 1 1 ••. r VI NOTARY PUBLIC FOR ALASKA My Commission expires: Pace 1 of 1 COSA Checklist_May2025.docx E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Disposal Field on Lot > 100’ Yes if No ft Neighboring Disposal Fields > 100’ Yes if No ft Sewer Line/Main > 100’ Yes if No ft Sewer Manhole/Cleanout > 100’ Yes if No ft Sewer Service/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required) Tank to Foundation > 10’ Yes if No ft Field to Foundation > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main/Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F.ENGINEER’S COMMENTS G.CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Phone Engineer’s Printed Name Date C&M Engineering Services Ph: 907-854-5558 Email: cgbalzarini@gmail.com ESTIMATE For Engineering Services Ordered By Champine DATE:3/9/2026 Legal Our Mtn B1 L3 COST BREAK DOWN CHARGE RATE QTY TOTAL as-built survey $900.00 1 $900.00 permit closeout and unconditional cosa $500.00 1 $500.00 Total:$1,400.00 Remarks: Thanks! Please contact us if you'd like to pay by credit card. PLEASE MAKE CHECKS PAYABLE TO:C&M Engineering 30840 PRUDHOE BAY AVE EAGLE RIVER AK, 99577 THANK YOU! ON-SITE WATER AND WASTEWATER COSA FEES * USE ONE FORM PER APPLICATION * LEGAL ADDRESS: _________________________________________________ ENGINEERING COMPANY: __________________________________________ COSA # (ON-SITE TO ENTER): ______________________________ ITEM Qty PRICE TOTAL COSA Existing On-site Systems $550 Existing On-site Systems with Active Drainfield Upgrade Permit $280 Well-Only (on public/community sewer) $280 New (Initial) On-site Systems $75 Conditional Approval (in addition to other COSA fee) $290 Misc. COSA Renewal $145 COSA Change Order (1/2 hr. min. review) $145/hr Expedited Review (add 60% to applicable fees) 60% Waiver (if multiple, only charge for most expensive) Tank or Field to Lot Line $225 Well to Tank or Field $1180 Other Waiver to AMC Chapter 15.55 and/or 15.65 not listed above $145/hr GRAND TOTAL Key #50 Cash/CK/CHG _______ (Updated 12/18/24) C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: CONDITIONAL COSA REQUEST FOR OUR MOUNTAIN BLOCK 1 LOT 3 Dear Reviewer, The above referenced property is currently served by a septic system with an older septic tank that requires replacement. We are requesting a Conditional COSA for the replacement of this tank. The conditional COSA is justified for the following reasons:  The property is covered in snow, the ground is frozen, and weather conditions remain cold. The installation of a septic tank in these conditions is higher risk due to steep access to the yard. Aside from dangerous access conditions, frozen soils can cause issues with fill placement and compaction resulting in settlement of the new tank, pipes, and backfill material.  The existing septic tank appears to be functional. The levels in the tank do indicate some leakage, however wastewater is able to flow from the tank to leachfield without interruption. Allowing the tank to remain in service for 2 to 3 additional months is not likely to result in a significant risk to health or life safety.  In the unlikely event that the tank becomes compromised prior to its replacement, lines may be snaked and the tank may be pumped intermittently for a limited time.  The nitrate test results from the well indicate a nitrate concentration 0.5 mg/L. This is an indicator that effluent potentially leaking from the tank is not adversely impacting the water quality of the aquifer. Funds will be escrowed to ensure completion of the septic tank replacement work can be completed. At least two bids for the work have been solicited by the owner for this work. A letter describing the escrow funds and conditions for disbursement is attached. The requested date for completion of the work, and request for a full unconditional COSA is 6/15/2026 Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 3/4/26 CHARLES G BALZARINI CE-13854R E GI S TEREDPROFE S S I O N A L E N GINEER 3/4/26 Our IVlountain Lot 3 Block 1 #051-111-42 Permit Number:OSP261025 Tax Code Number:05111142000 Work Type:SepticTank Upgrade Effective Date: Design Engineer: Site Legal Address:OUR MOUNTAIN BLK 1 LT 3 G:1361 Owner:CHAMPINE THEODORE R JR & Site Mailing Address:20527 MARK CIR, Chugiak Lot Size in Sq Ft:45195 Total Bedrooms:3 This permit is for the construction of: Disposal Field Septic Tank Holding Tank Privy Non-Public Water Well Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Coodinate with On-Site staff regarding preferred method. 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing 3/6/2026 3/6/2027 C&M ENGINEERING SERVICES Expiration Date: ¨þ ¨¨¨¨ Issued To: Issued By: Date: Date: 3/6/2026 3/6/2026 C&M ENGINEERING SERVICES Isatou B Njie MUNICIPALITY OF ANCHORAGE On-Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On-Site Wastewater Disposal System Permit C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: PROPOSED SEPTIC TANK REPLACEMENT FOR OUR MOUNTAIN BLOCK 1 LOT 3 Dear Reviewer, The above referenced property is currently served by a septic system with an older septic tank that requires replacement. We are requesting a permit to install a new septic tank as shown on the design drawings. Our review of available documentation and field investigation show that this project will not adversely impact any nearby Wells, Wastewater disposal systems, replacement disposal sites, or drainage flowing onto and off of the subject property. As shown on the plans, the tank will be greater than 10’ from the house foundation and 5’ from the field. The fit between the tank and field may be tight. The contractor must notify the engineer and MOA if the tank location needs to be adjusted in order to maintain the required separation distance. The tank will be of MOA approved construction. The tank must be covered with a minimum of 2” moa approved insulation and 3’ of cover or a minimum of 4’ of cover without insulation. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 3/4/26 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP261025, Isatou Njie, 03/06/26 CHARLES G BALZARINI CE-13854R E GISTEREDPROFE S S I O N A L E N GINEER 3/4/26 1 /--... LOT 7 BLOCK 2 TRACT 2 Noo·o9•02f'r-~~~-{Noo·os·12 .. E 200.45' R) N0?"24'24"£ ~r-----__;----------=-------~~(N~o.,_,7·0 8 •44 ,,£ 't- ~ur iwC:S ~ hpPD FeNetf> tli,As LOT 3 " SEPTIC ~~ C:1 {, )~ LOT 4 BLOCK 1 ~ = FND 2" BC MONUMENT @ = FND S/8" REBAR / ~ \~· ANCHORAGE RECORDJNGl>ISTRICT. ALASKA f LOT"ft:MH)~---- 0 UR MOUNT A1N S ___ UB_D_I_Vl-SION • \1.5' EXISTING i-l HOUSE ~ ( A NOTE: 1) It is the contractor's responsibility to check tor of foundation gr.id• nnd buildins sctbnclu in relation to the lot line and casements. 2) Elevations are-assumed.fo~l datum. LOT 2 BLOCK 1 LOT 3 BLOCK 1 PLAT 76-311 SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a --~'~~'-~'\\\\ v~~U S tJ}?p r .... ; ~<t> .... •······•~l ... 1' ,, ~ LAND .. :et.. physical wrvey o u,tS property 11S shown on this drawing and that die -• '\. ~l, C\ ~ ~ 0 <J(/j; ,r: improvements siruated hereon arc within the property lines and no ,( S..., ~ • ._,~ • ·~+ •• ~~~ ~ ~ L-enc_hroac __ run_cn_ts_c_XJSt_· _otbcr_than __ no_tcd. _______ --1 / *~_.· 49TH ···:ti It ~ ~ J, EXCLUSION NOTES: It is the owners responsibility 10 detcnninc l • • • ·~· • • • • • • • • • • • • • • • • • • • • • • ·~ ~ tl. ' O the cxJstcnce of any CtiCfflCll1S.. coveoanl$. or rcslriaions which I l... { f U • ..-.-=-. ~ do not ~r on uu·. rccor~ liiubdi~ision plaL Unda no circumswice I ·;0· • ~ • • • • • • • • • • • • • • • • • ·: • -~ ·l . dl .. . (") should any 1nform~11on on llu.s draw mg be used for construction of 'fi ~ . OHN L. SC~· ~ll • . 1 • fen~. muemres, unprovemenli. or for establishing boundary lines. ,.~~ ••. 1S-1.Q408 .•• c...l.fJ/1! "\· -~-.~~ • iuaJt w.-i ~ -w,.; ,•,..., ·-•. c-<l~( J .. •• c,->S 1831 Talkeetna Street WAY 8. 2014 1•.40• \\~,. ~--.P.J-4j•· o<'~~ An(cho)raee. iluJca 99508 1 4-017 .,, ,, ... ~'•ulon6 '\.--907 22?-1'-~ office 14-012g .,,,,,,~-(907) 274-4992 tu - IVIUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH& ENVIRONMEN'iALPROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 2_64-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MAILING A D./I~ R ESS LEGAL DESCRIPTION LOCATION r~ t~ IAbsorption area __¢ ¢ Dwelling ,~/w'//~-~ /~ ~/( [ Material ~ Liq. cyaSy~n ~llons IF HOMEMADE: Inside length 'Width DISTANCE TO: Iwell Dwefiin9 Ne. OF BEDROOMS PERMIT NO. No, of compartm~.~ Liquid depth PERMIT NO. Manufacture~ Material Liquid capacity in gallons DISTANCE TO: Foundation~:.~ g/, I Nearest lot lil~.~ ! PERMIT NO, Total len~no~ We, // ? / No. of lines // Length of~ne ~ Top of tile to finish grade ~__ ~ Material beneath tile Length Width Depth PERMIT NO, Type of crib Crib diameter Crib depth Well Building foundation Driller Depth DISTANCE TO: DISTANCE TO: Building foundation Sewer line Distance between lines Total effective absorption area tTotal effective absorption area Nearest lot line Distance to lot line PERMIT NO. OTHER PIPE MATERIALS ///~ ..,,~ _~ ,~.. REMARKS DATE LEGAL 0 0 0 0 0 0 0 0 0 0 0 0 ~_ ~ ~ E~. ,~ ~_ ~ ~ ~. ~) ~ 0 0 0 0 0 0 0 0 0 0 FI F' F' L I C: F:Ii"4 T LC)I:::FIT ]: ON I... E G I::'1L. L"E:F'FIFCTME:NT ~: HEFI!...TH FIND EI",I',,,' I F'.ONHENTFII 3TECT I O1'.,I S;2.~5 '" [.. '" S'I"[~:EET., FINC:HOI:;.'.FICi[E., FtI-:::. 'S, 9)!SEI'LI. ;2 6,4.-- d. 7'2,'...3 .%::;; E~.: I~?.1~ EE: If:~: If::" Eiii:: IF;Z: If'.'if % '-~ .... "1" E: E:, H ! S;:5 1 G I'"tFI[~:I.::: E:,I:;i: Z ',,,'E L.EIT :~: BL.K Z OUR MT. L. OT SIZE ,::il:!.SE;C:~ SL';]I.JFtI:~tE: FEE~r' 'r'T'PE OF SO I L. FIE:SEIF'.F'T :1:O1'.,1 S.';'T'S;TE:H I :E;: TF.:ENCH HI::I',:'=:IMI...I;r'I NLIME~E.:.Fi: OF E:E[:'ROOH~; = SOIL. RFFrlNG ,:: ,'S, i:;! F'T,.."DR:: THE F;:EC!I...I ]~ F:ED S; J Z.F.'. OF 'T'I--IE L:.;O I L. FIEL'.5Of~:F'T ~ Eilq S'T"Z';TEH ]: :S: THE: LENGTH E:, I I'"IEI'.,IS; I Oi'.,l I S; THE [...E:I'.,IGTH ,:; 11'4 F:'EET ::, OF' THE "I"f~:ENCH OR [:,RFI I I'.,IF' I El_.[;,. THE DEF'TN OF R TF4:EI'.,IE:H OF: F'IT I~; THE E:,ISTFINCE BETI,.tEEI'-,I THE SLIRFFtC:E OF' THE: GF'.OLINE:, FIND THE: BE)TTOH OF THE EMCFI',,,'FIT]:Cd'.,I ,:: IN FEET::,. TPIEF:E: I:5 NO SET HiDTH FOR 'TREI'.,ICFIES. THE GRFI',,,'EL E:,EF'TH IS; THE: I"IINIHIJH B, EF'TFI OF GRFI',,,'EL BETHEEN THE OLITFFIL. L. F'IF'E FIND THE BOTTE)H ElF THE E'XCFIVFIT I O1'.,I ,:: :[ N FEET .'.',. F:'[!~:[;i:I',t I 'T FIF'PL :1: C:I::INT HI::IS; THE I:;~'.E:SI::'OI'.,IrB I D I L Z T'¢ 'rE, I I'.,tFOF4:H ']"FI I 'Z-'; DEF'FI~'.'I"HEi'.,tT I)UF-.". I NL:i THE I N:STFIL. L. FIT I 01",1 I t'.,I:SF'EE:T Z ONg-; OF' Rl'.,l'.r' I.,.IEL. L'.S F]C,..TF1CENT "FO TH Z :S F'F.:OF'E'F.:T'T' Rt",ID THE I'.,IUi"IE~Ef4'. OF F.'.E."SIDENCE:S THFIT "I"FtE: I.,.IELL. I.,.IILL ............... -!r- ~...~ n:z~l ,::: 2 :::, :]_* ~-...~ s; E:-:" EFZ C: T' ~_" ,Z'Z~ ~'.-.I1 S; E:::l[ ~1: IE E~i: EE uL:.:.~ ILJ % If:s: E'2: IIZ:: E~FICKF I L.L. t NG OF FIN'T' S'T':STEH P.I Z THOUT F t NFIL I N::6F'EE:T ]; ON FINE:, F:IF"'PFi:O',,,'FiL B"r' TH 1:5 DEF:'RFi:'f'MEI'.,I'I" !-,.I I L.L E',E Z,L.IE',.~TECT TO PROSECUT I CIN. M l I",11 h'll..If,1 [::, I L:.:'TFIF,ICE E~E:TI.,I[.!:EN F:I [,.!EI._L. FIND Ftl",l'.r' Ol",l"-S i TE $EI.,.!RGE E:' I :SF:'O:SFIt... :F.;'Y:E;"I'EH :[ :5 :I..E~C'~ F'IEIET I::'OF:: FI PF.:i',,,'FITE HELL O1:~'. '1_5C:~ TO 2E,~l FE;ET F'ROH R PUBL. IC: 14EL. L. E:,IEF'EN[>ING UI::'ON THE T'T'F'E Cfi:' F'I..IE:LIE: HELL HIt",IIMLfH E:, ]i :i!;I"FINCE F'Fi:OM FI F'RI',,,'FITE P.IEL.L TO FI F'IE:I',,,'FITE E;EP.I[.T.R LINE I'S; 2!5 F'EE'f' Fli'.,ll.":, TO Fi COMHUNIT'T' :SEI.,.!ER LINE ]::E; 7!5 FEET. CFt"HE..'R I~'E'..:~ IF.':EHENTS; I"1F1'¢ FIF'F'L.'T'. S;F'EC]:F]:CFIUFIOI'.4'..:.:. F:Ii'.4E:, COi'.,I'~STF~'.I..ICTICd'-,! E:, ]i FIGf4:F:II','I:S I:I[;i:E:: FI',,,'FI ]: L. FI[.:~LE TO f I'.,ISI_I[;:E F'F4:OF'ER I NtSTFtLLFt'F T FII'.,I. I E:EF:T I F'"r' THFIT ::L: I Rf,1 FFIM :[ L I FIR I.,.1:[ TH THE REQIJ I F:E:I"'IEI'.,IT:E; F'OF..: OIq-S I TE SEI.,.IEF:S F:INE:, I,.IEI....I...S FE5 SET F'CII:;i:TH E','T' THE HUI'.,IIC:IF'FILIT'¢ OF FINCHORFIGE. ;.:.i'.: I I.,.IIL. L IN:'STFILL THE S"r'S'FEH IN FICCCff~:E:,FINCE H:[TH THE CODE::L:;. :7;: I UI'.,IE:,EF.'.':STFII'.~D THFFI" THE CR.,I-5IT[.:: 'r-.,EI,.IER S"r'STEM HWT' t:i:EL::.'UI[;;'.E EN[..FIF.:GE:ME:NT :IF THE r~:E'.S l DEIqC:E I ~ RE:I',IO[::,ELEI:::, TO ]: t'.,ICLUE~ HOF.:E "EHFd'.,I ~: ..................... ....................... :: .... ,,,, O&E ENG,NEERING & DEVELOr ,,4EN'F CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 hu~aell Oyster 694-2774 F'erformed for: Name:_ f/~ f Mailing Address: '~-"~'¢~' Legal Description: ~'-¢;,r- '~-; ~_~,~./c-_ // SOIL LOG Earl Ellis 688-2280 Depth (feet) 0 Soil Characteristics 5__ 6__ 7__ 9__ 14__ 16 Ground Water Encountered: Yes Proposed Installation: Seepage Pit__ No ~/'~' If yes, what depth. Drain Field PLOT PLAN PERC. TEST Comments: Performed b:~'~ Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL,~¢,, FOR A SINGLE FAMILY DWELLING Parcel liD: '~2~'/'-////-,¢¢~- ,. GE.E. :L . ORMAT,O. Complete legal description Lot 3, ' Location (site address or directions) Current Property owner(s) Mailin~ ~dress HAA# ~::~(~1("~-~ Expiration Date: Block 1, Our Mountain S/D 20527 Mark Circle Nieves Miljure Day phone Lending agency Day phone Mailing address Real Estate AgentBAcky Powell/Remax Day phone 276-2761 MailingAddress2600 Cordova, Ste 100, Anchorage, Ak 99503 Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] [] Individual Holding Tank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal~and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. Certificates are ~alid 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. 72-025 (Rev. 01/00)* Name of Firm Address STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation based on procedures outlined in the Health Authority Approval Guidelines for the Health Authority Approval application show that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on- site water supply and/or wastewater disposal system is in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Phone Engineer's Printed Name DHHS SIGNATURE ~ Approved for ~ bedrooms. Disapproved. Conditional approval for __ ~"~.0 L'J/~/'J Date '3 / ~ Q_.~. o ¢ ~ ........ ~,.~,.,,~.,,,:,..,,~, "O"ERT C. COWAN . bedrooms, with the following sti~ulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: ~ - ~/_../z. ¢ 0 Original Certificate Date: Reissue Date: 75-025 (Rev. 01/00)' A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal 0/N) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVIC~[ (.. L I V [~ [J Environmental Services Division 825 L Street, Room 502° Anchorage, Alaska 99501° (90~/~3~z07~00 Health Authority Approval Checklistr,~ur~c,~^u~ or IfA, B, or C, attach ADEC letter. ADEC water system number Cased to Casirig height (above ground) Wires properly proteetec~) FROM WELL LOG Date of test ~/~-~'/,/~'~ Static water level ~,~' Well production ~ g.p.m. AT INSPECTION g.p.m. WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: B. SEPTIC/HOLDING TANK DATA (¢]¢ ~ ~)~;;:~ Other bacteria Collected by: ! Date installed ~/~/ Tank size Number of Compartments ~ Cleanouts ,~N) Foundationcleanout ~,J).?;f~--'~/ , Depression(Y/d ~(/'(') High water alarm (Y/N) ,,/~//,/~ ,W , .- i Date of Pumping ~/J~'/¢/'~ Pumper ..J?~ 5' / C. ABSORPTION FIELD DATA Date installed ~'/,,~/ Soil rating (g.p.d./ft2 o~ ~b~ ~ System t y p e '"~- ~'~-/~ Length ~ / Width ///~/~- Gravelthickness below pipe /('~ /Total depth // / Effective absorption area z~ /~ Monitoring Tube presen~/N)~'~ Depression over field (Y~/(/'O Date of adequacy test ,'~//~/~,~rT.j Results~Fail)/,,/~,5' For '~"'/2/~--'~'~ bedrooms Fluid depth in absorption field before test (in,); .~- Immediately afte'~¢'//7) gal, water added (in.): ? // Fluiddepth '~ (ins) Minutes later: /~ Absorption rate = 4,~/0 "'~g,p.d. Peroxide treatment (past 12 months)(Y/N)/(~('-'/~/~'~(//"~/ If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed ,// Manhole/Access (Y/N) ~,~ High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot On adjacent lots On adjacent lots Public sewer main /'~,//.,/~ Sewer/septic service line ~-/''/~ Lift station A,,/ //¢J' / SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation //(-,~ ~ Property line ;~/'~ Absorption field Water main/service line .~ '¢~ Surface water/drainage /~,~/ ~ Wails on adjacent lots Public sewer manhole/cleaeout ,/~//~r SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /~.) ~'¢'- Building foundation /~) /'¢- Water main/service line Surface water / ~'7) / '¢- Driveway, parking/vehicle storage area Curtain drain /N/ O/~/~- /~-"~/~/"~/~/,/1,/ Wells on adjacent lots /) ~ 0 F. ENGINEER'S CERTIFICATION I certify that l have determined thru field inspections and review of Municipal record.~.~¢~t~Jl~'~b~¢,tems are in conformance with.MO~ H4A..~ideline, c,in effect on this date, Signature ~ Engineer's Name ~,3~;- ~. ~o~ Date ~/~o/¢o . __,?...:, .~,,,.,,-¢- Receipt Number ~/'~ ~) ~,) .,L Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* ~2-23'00 16:05 FROM'CTE ENVIRONM~NTAL zt~.~ CT&E Environmental Servicee Inc. T-??B P.02/0~ CT&£ Ref.# Client Name Project Name/~ Client Scruple Matrix Ordered By PWSID Sample Remarks: 1001131001 S & S E~gineerhag L3; B1; O~ Mm L3; BI; Our Mm S/D Dnnking Wa~er 0 Client PO~ Printed Date/Time 03/23/2000 13:54 Collected Date/Time 03/19/2000 11:15 Received Date/Time 03/20/2000 10:30 Technical Director Stephen C. Ede Release~ ~~// ~ATERe DEPT PQL units Heth~ Atto.aWe Prep AnaLy$i~ LimiTS On:e Dn:e Init 0.608 O.SO0 mO/L EPA 300.0 (~10) 0~/20/00 S% HICRO LAB Tota~ CoLiform 0 cot/lOOmL SH18 9222B KaP MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D.# ~....~ \ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner Mailing Address '7~; (' ('~ (c) Lending Institution AL/~- Mailing Address _/t,./ /,~9 (d) Real Estate Company and Agent Address Telephone: (home) Telephone_ Business ~-----7/-~: .-d- <~ -- (e) Telephone~._~ ~. '~ '- /('.?~ ~- Mail the HAA to the following address: (or check here I~, :'if hold for pick up.) List contact person and day phone number below: TYPE OF RESIDENCE Single-Family~ Number of bedrooms --% WATER SUPPLY Individual Wel~"-- Community [] Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. SEWAGE DISPOSAL On-sit Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health AUthority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional.and adequate for the number of bedrooms and type of structure indicated herein, I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection, Name of Firm Address Date Engineer's Seal 6. DHHS APPROVAL ~ .'* ~" Approved for o2 bedrooms by,~,~-,'?,__//~ ~///~/~-;?, -,.¢~<~-- Date Approved ~/~ Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 DHHSdo not conduct inspections or analyze data before a certificate is issued. The MunicipalityofAnchorage is not responsibleforerrorsoromissions in the professional engineer's work. 72-025 (Rev 7/88)Back Page 2 of 2 A. WELL DATA Well Classification MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: Well Log Present (Y/N) , Date Completed Total Depth ~.~' Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Y SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot / (~_%.) ~ ..fo. To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line /~/,//ti. To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results If A, B, C, D.E.C. Approved (Y/N) __ Yield ~-'~) ,.. Pump Set At ;%'~/~ ' Sanitary Seal on Casing (Y/N) ~ Depression Around Wellhead (Y/N) ; On Adjoining Lots ~i~o ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole .~/~/_E_~' ,' ; Date ~/d;/~' Comments SEPTIC/HOLDING TANK D~¢~A ate ,nsta,,ed ¢ / /~0C-2(2~-',[ No, of Compartments Standpipes (Y/N) Y Air-tight Caps (Y/N) __~' Foundation Cleanout (Y/N) .~/ Depression over Tank (Y/N) /~J Date Last Pumped. ~// Pumping/Maintenance Contact on File (Y/N) /~//~ ;for /~// Holding Tank High-Water Alarm (Y/N) k(//~ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Building Foundation 'Fo Disposal Field -7 · -/ To Water-Supply Well To Property Line '~© To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA .,.-- 7 /i~,~i/r~.' Soils Bating Jn Absorption Strata ~.g 5'f '/~f- Type of System Design ~ .c / Date Installed ~"/~-- ~-,~'~/)/ ~,~) Length of Field Width of Field ~-~ ~ ~ Depth of Field Gravel Bed Thickness /© ~ .... Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well :~ / To Building Foundation Lot h,,/ To Water Main/Service Line ~) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line ~¢C) ' To Existing or Abandoned System on ; On Adjoining Lots -~ ':¢-© ~ To Cutback (if present) Comments Date Installed N Size in Gallons "Pump On" Level at Alarm Level at High Water Tested for Meets MOA Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) Comments "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitt'e,.~'~ Bedroom~ating Against HAA Request** I certify that I h,~ye checke¢~_vedCied, or conformed to all MOA and inspection. /// ~. /' ~ ~ Signed ~/~'~// ~ - Receipt No. ~/4~/,,~ Date of Payment Amount: $ 72-026 IRev 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 ~in effect on the date of this Engineer's Seal CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE(907) 562-2343 FEDERAL TAX ID # 92-0040440 !,r, boratory Supel;'~lsm :,S?};?lfflI C. ?',DE MUNICIPALITY OF ANCHOFIAGE t' .,-_!'AP, ~IWEN'I OF HEALTH AND ENVIRONMENTAL PROTEC'I'~ON DIVISION OF FNVIRONMENTAL HEALTH (~,:~ ! IF!CA rE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 4/9/86 :,-~-. A- INFOFIMATION I_egal Description (include lot, block, subdivision, section, township, range) ,;'7 ,,;:', ()Z~,z _~/~) LoZ 7A~z~ (3) Ou~ Rou~Z~.Ln Locahon (address or directions) (b) ikppl~cantNall~e~z:~zb~. .?r~m./r'/v~Telephone:Home Applicant Address P, ~oz ~71~22 (c) Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~ · Other ~ (exp[ n~; _. ;10 (d) Lending Institution Address _L(ZD~__ ¢~ r/. ZL.L_/2~.~/, o ~. (e) Real Estate Company'and Agent ~o~_ Address ~l r, ~ Telephone ~1o ~ (f) Telephone 272- 1 99508 Mail the HAA to the following address: ~.Z,~ 6xS-_~Y~Z~ (,,_~_,) 522-1212 TYPE OF RESIDENCE Single-Family[] Multi-Family [] Other Number of Bedrooms 7/z/t~z¢. ( J ) WATER SUPPLY Individual Well E~¥ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4, SEWAGE DISPOSAL Onsite ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 72-025(ll/84) ~ -~,~V~i)li"~O NSPECI OhS, ~'ES'IS, FILE SEARCH, DA'IAANL~INFOttMAIION h :~'}d helelo al~d as of the validation date shown below, I verify that my investigation of this I-lealH1 that the on-site water supply and/or wastewater disposal syslem is sale, functional and adequate ~s and type of structure indicated herein. I further verity that based on the information Anchorage files and lrom my investigation and inspection, the on-site water supply and/or system is m compliance with all Municipal and State codes, ordinances, and regulations in effect on I.~AGLBgI~LBB,-A~ 99577 _. P, 0. BOX 773294 694-5195 " Approved for ~.~/',L,~?~_ bedrooms by ..... -~x~ te Approved ','~k~''~ Disapproved Conditional lerms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 MUNICIPALITY OF ANCHORAGE HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 MUNICIPALITY OF ANCHORAG2 DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION Legal Description: WELL DATA Well Classification ,/Cg~,~ / /./'~// ,~-/./~.~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) /v' Date Completed_~-~/~--';-/°¢~q-- . Yield '-~ Total Depth '~'~'//%'~ z~¢ Cased to/'z/~' / D~pth of Grouting Casing Height Above Ground Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot /¢)¢' / To Nearest Edge of Absorption Field on Lot //,F' / To Nearest Public Sewer Line Cleanout/Manhole /¢/~J To Nearest Sewer Service Line on Lot ¢'~ ~- / Water Sample Collected by ~)' 4 ~ ~-,,~.:~/,~,~'¢ r,~.1 ; Date Water Sample Test Results ....~, ¢,..~r ~ Depression Around Wellhead (Y/N) ~/// ; On Adjoining Lots ¢'/¢)¢* ~ ; On Adjoining Lots ~'/'¢¢ / To Nearest Public Sewer B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) _/F Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) //'b// Separation Distances from Septic/Holding Tank: To Water-Supply Well /~¢2" To Property Line Z/..~- / To Water Main/Service Line ¢/,,~ '" Course ~' ~" ¢) / Size /~¢'¢ ~.4~,/ No. of Compartments ~ Air-tight Caps (Y/N) ~/t,' Foundation Cleanout (Y/N) /V Date Last Pumped '~/,~.//¢?'~'~ ii' I ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test ,fi'* ¢'j ~ ,~ Separation Distance from Absorption Field: To Water-Supply Well //P ' To Building Foundation /¢¢' / Lot /¢,/~,,-2 ~_ To Water Main/Service Line ~'¢ / To Stream/Pond/Lake/or Major Drainage Course To Driveway. Parking Area. or Vehicle Storage Area Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line ',~-2.~ / To Existing or Abandoned System on ; On Adjoining Lots '/-'2.~ / To Cutbank (if present) Comments LIFT STATIO N,,¢/,~ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroon~ Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~-'~2"~~ Date Company .~/'~'~',~-,¢¢-,$, MOA No. .... Receipt No. Date of Payment : ~ .~ ~ ~, .: , . . :~; .~'/'e?~;,'~:'?,~ /:}:: '~"' ~ 'Engineer's Seal Amount: $. Page 2 of 2 DA'I' ~'"~"'~ C E I V E D INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE ~,,, DATE MUNICIPALI'[Y OF ANCHORAG~ MUNICIPALITY OF ANCHORAGE DEPT. OF I!FAL]'II &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~viRONMENTAL i'hO~ECTION 825 L Street - Anchorage, Alaska 99501 ,z 1981 ENVIRONMENTAL SANITATION DIVISION -)b'~" Telephone 264-4720 ..o .ST .o.A...OVA. o. DIRECTIONS'. Complete all parts oe page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing, 1, PROPERTY OWN~ /' ~ .~' ' I PROPERTY RESIDENT (If different trom auo~ . ' ' ~ ' ~ PHONE 2, BUYE~ ~ PHONE MAILING ADDRESS -- / ~/ / / 3. LENDING I~ST)TUTIO~- ~ ~ ,~ ~ ', ' / , MAILINGADDRE~) .~ ~ _ ~ / / 4.MAiREALTOR/AGENTLi NG ADDR E~ ~/'~ ~~ I PHONE' 5. LEGAL DESCRIPTION STREET L C TION . 6. TYPE OF RESIDENCE  S INGLE FAMILY [] MULTIPLE FAMILY i~U M'~B E R/R"~ F ~B E D R O O MS [] One I--~ Four [] Other [] Two [] Five .~,, Three E] Six 7. WATE~ BUPPLY ~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTILITY depth (attach log if available,) 8. SEWAGE DISPOSAL SYSTEM [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS  SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY [] INDIVI DUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified. INSTALLER []Septic Tank or [] Holding Tank Size: /(~)C) If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER~~ TOTAL ABSORPTION AREA MATERIAL Septic/Holding Tank [Absorption Area ISewer Line I Nearest Lot Line 4, DISTANCES / I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS / / _. BEDROOMS )e~ [~] CONDITIONAL APPROVAL (letter must ac~/~mp.n¥