HomeMy WebLinkAboutGALLAGHER LT 3Gallagher
Lot
020-161
-12
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program, 4700 Elrnore Road
P.O. Box 196650 Anchorage, AK 99507 Page of
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: sw~'090196 PID Number:
020-161-12
Name:
William I. Ennis Wastewater System: [] New [] Upgrade
Address:
8690 Paine Road Anchorage, AK 99516 ABSORPTION FIELD
Phone: Number of Bedrooms:
3 [] DeepTrench [] Shallow Trench [] Bed [] Mound [] Other:
Soil Rating: Total Depth from odginal grade:
LEGAL DESCRIPTION GPD~F~ Ft.
Block: Lot: Subdivision: Depth to pipe bottom from odginal grade: Gravel depth beneath pipe:
3
Gallagher Ft. Ft.
Township: Range: Section: Fill added above original grade: Gravel Length:
Ft
Well: [] New [] Upgrade G~ve~ width: Ft. Numberof lines: I Distance between lines:Ft.
Classification (Private, A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material:
Existing Ft. Ft. Ft2
Ddllen Date Ddlled: Static Water Level: installer: Date Installed:
Ft. Phillips Construction North 10/01/09
Yield: GPM Pump Set at: Ft. Casing Height Above Ground:Ft. TANK
SEPARATION DISTANCES [] Septic [] Holding [] S.T.E.P. [] Other:
T~ To Septic Absorption Lift Holding )ublic/Pdvate Manufacturer: Capacity:
From~
Tank Field Station Tank Sewer Line Anchorage Tank 1000 Gal.
Material: Number of Compartments:
wel~ >100' >100' N/A N/A >25' Steel Two (2)
Surface WaterLot Line>5'>100' >100'> 10' N/AN/A N/AN/A ~ Size: Gal. IManufacture~LIFT STATION
"Pump on" level at; "Pump off" level at: in, High water alarm at:
Foundation >5' >10' N/A N/A in, in.
Pump Make & Model Electrical Inspections performed by:
Curtain Drain None Noted
Remarks:
Existing Septic Tank Pumped, Crushed and Backfilled. BENCH MARK
Location and Description:
Septic Tank Only and Two Post Tank Cleanouts Placed Garage Slab,
Assumed Elevation:
Under this Permit. Et.
Inspections performed by: M. Anderson Dates: Ist 10-1-09
,,-.
2nd 10-1-09 ~ ~ , .,
Development Services Department Approval
Conditional Approval Date:
Reviewed and approve Date: /
Permit Number: SW090196
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904
PAINE
Page 2 of 3
PID No.: 020-161-12
LEGEND
Sl - Septic Vent
C1 Cleon Out
M1 - Monitor Tube
TH - Test Hole
20' Utility Easement
Exleting 66' Long x 5' Wide x 1'
Effecflw ~ N~ort~on Trench to
Remain in Service.
Three
Bedroom ~=Ung ~ Tank
Home and Backfllled,
Floor
PLAN
AS-BUILT
S2 10.1 38.4
SCALE 1" = .50'
Permit Number: SW090196
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Page 3 of 3
PID No. 020-161-12
R .,-: ,- /r~1~01.9
I I I //Existing I ~' Finished
111,000 Gallon
//97.45J Septic Tank I ~97.3
Tank Only Replaced Under This Permit. ExiSting Tank Pumped, Crushed
and Backfilled on Site.
PROFILE AS-BUILT
No Scale
MICHAEL ~ AND~SON
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Sep 30, 2009
Expiration Date: Sep 30, 2010
Permit Number: SW090196
Legal Description: GALLAGHER LT 3
Design Engineer: 0014 ANDERSON ENGINEERING
Owner Name: WILLIAM I. ENNIS
Owner Address: 8690 PAINE ROAD
ANCHORAGE , AK 99516-5558
Parcel ID: 020-161~12
Site Address: 008690 PAINE RD
Lot Size: 53351 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
['--] Disposal Field [~] Septic Tank
Holding Tank r~ Privy [~ Private Well
[] Water Storage
All construction must 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 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.
Date:
Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
www.muni.org/onsite
(907) 343-7904
ON-SITE SEWER/VVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 020-161-12
Property owner(s) William L. Ennis
Mailing address 8690 Paine Road Anchorage, AK
Site address 8690 Paine Road Anchorage, AK
Day phone
.Zip Code 99516
.Zip Code 99516
Legal description (Sub'd., Block & Lot) Lot 3, Gallagher Subdivision
Legal description (Township, Range & Section)
Lot Size 53,351 Sq. Ft. Number of Bedrooms
Three (3)
THIS APPLICATION IS FOR ([~ all that apply):
Absorption Field []
Septic Tank []
Holding Tank []
Privy []
Private Well []
Water Storage []
THIS APPLICATION IS AN:
Initial []
Upgrade []
Renewal []
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number:
(Rev. 11/05)
Waiver Fees:
Date of Payment:
Receipt Number:
September 27, 2009
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject:
Lot 3, Gallagher Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The septic tank on Lot 3, Gallagher Subdivision is failing and must be replaced. We
are proposing to replace the tank with a new 1,000-gallon steel septic tank to serve the
three-bedroom home on the lot. We are therefore requesting a permit be issued for
the construction of a new septic tank to serve the home. The attached Site Plan and
backup documentation identify the location and configuration of the existing septic
system and the location of the new tank. Also identified on the plans is the existing well
on the lot. The new tank will be placed more than 100' from the well on this lot and
those in the area. The existing tank on the lot will be properly disposed on the property.
The drainage patterns will be maintained after construction.
The ground surface on the lot is basically flat in the area of the new tank, but falls
toward the north property line. The new septic tank will be constructed near the
location of the existing tank and as parallel with the slope of the land as possible in
conformance with Municipal requirements.
If the tank is constructed in accordance with our design the following statements apply:
The tank, if constructed as designed, will have no adverse impact on the wells in
the area or those to be constructed in the future.
The tank, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The tank, if constructed as designed, will have no adverse impact on reserve
Lot 3, Gallagher
September 27, 2009
Page 2 of 2
space, either surface or subsurface, on any lots located in the area.
The tank, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
YS. '~ TM ~'~ b-LHil2, H
XVM $,9NI)'t
3AIWa .LW380W
I
III
PAINE ROAD
20' Utility Easement
Ex|.'~ting 66' Long x 5' Wide x 1'
Effective Depth A~sorpflon Trench to
Remain in Service.
Three Pump, Crush and Abandon
Existing Tank in Place.
Bedroom Place New 1,000 Gallon
Home Septic Tank and 2 Po~
Tank Cleanouts. Verify
Foundation Cleanout and
Inetall If Necessary.
II hSubdivision /Ca ag er- ~
10' Utility Easement F
Existing
Well
S 89'43'52" W 138.83'
LEGEND
SV - Flow Sp_litter Valve
CO Clean Out
MT - Monitor Tube
TH - Test Hole
SITE PLAN
SCALE 1" = 50'
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 3, GALLAGHER SUBDIVISION
GENERAL:
The scope of this project includes the pumping, crushing and backfilling of
the existing septic tank on the property and the procurement and placement
of a new 1,000-gallon septic tank at the location shown on the Site Plan.
Work also includes the verification of the integrity of the foundation cleanout
and placement of two new post tank cleanouts. The new delivery line must
then be tied into the existing absorption trench line. The new septic tank
must be placed 100' from all private wells and any surface water in the area
and 10' from the water service line from the well. A minimum of 4' of cover is
required over the septic tank.
Construction shall be in accordance with the approved site plan, design
drawings, Municipal Permit with any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal Regulations.
The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the location
of all lot lines. The Contractor must also verify the location of wells in the
area and assure that the separation distances are met.
Unless specifically agreed otherwise, the contractor shall be responsible for
final grading areas subsequently depressed from soil settling. Property
owner shall be responsible for revegetation of affected areas unless
specifically agreed otherwise.
Contractors installing wastewater disposal systems must be certified by the
Municipal Development Services Department Building Safety Division On-Site
Water and Wastewater Program for system installations. Owners installing
their own systems must receive prior approval from the On-Site Water and
Wastewater Program before beginning system installation.
SEPTIC TANK INSTALLATION
1. A new 1,000-gallon septic tank must be procured from an approved source
and installed at the location shown.
2. A septic tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two 4" cleanouts for pumping access.
Lot 3, Gallagher
September 27, 2009
Page 2 of 3
3. The septic tank shall be sufficiently bedded to prevent settling or shifting of
the tank.
4. All standpipes on the septic tank shall extend a minimum of 12 inches above
final grade.
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial
insulation.
6. A foundation cleanout shall be installed one to four feet from the building
foundation. Two cleanouts are required between the tank and the drainfield.
7. Final grading over the tank shall be such that a positive slope exists away
from the septic tank.
DRAINFIELD CONSTRUCTION: - EXISTING ABSORPTION TRENCH TO REMAIN IN
SERVICE
1. The drainfield shall be constructed to the dimensions shown on the design.
The bottom of the trench shall be within 2" of level.
Distribution piping must be placed level with perforations down atop a level
bed of drainfield rock. Rock should then be placed over the pipe to provide a
minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between the drainfield rock
and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the locations shown on
the design. The portion below ground must be perforated.
Contractor shall verify the septic tank and drainfield are a minimum 100' away
from any private water wells in the area, 150' from a Class "C" Well or 200'
from any community well.
Direct bury insulation must be placed over the distribution system if less than
3' of backfill depth is available. Finish grade over the trench must be
mounded to prevent settlement or depressions.
7. Grade area surrounding the absorption trench to drain away.
A minimum 2' of accepting soil is required below the drainfield rock for a 5'
wide trench. All pockets of unacceptable materials must be removed and
replaced.
Lot 3, Gallagher
September 27, 2009
Page 3 of 3
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a municipally approved septic tank
manufacturer.
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and
solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662
or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow
Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Fernco, or equal).
5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing the
#200 sieve.
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These inspections
must be conducted under the supervision of a professional engineer registered
in the State of Alaska. The first inspection must be conducted after the
excavation of trenches, beds or pits and before the installation of any gravel. A
septic tank may be set in place, but may not be backfilled.
The second inspection must be conducted after the placement of the geotextile
fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No
backfill should be in place at the time of inspection.
Contractor or owner shall provide a copy of all field survey layout and
construction notes for use in preparing the certified as-built of the completed
system.
~. MUNICIPALITY OF ANCHORAGE
I · DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone ~ ~720
ON~ITE SEWAGE DISPOSAL SYSTEM AND/OR WELL IN~ECTION REPORT
NAME
IPHONE J J~i~ NEW
MAILING ADDRESS
LEGAL DESCRIPTION
__. v DISTANCE TO: I Well i(~O -I-
I- Z Manufacturer
~ ~.~r~ ~v' Material
Liq. capacity in gallons Inside length Width
!O~X~ IF HOMEMADE: Liquid depth
I~ v DISTANCE TO: Well Dwelling PERMIT NO.
O Z ~ Manufacturer
-r -- I- Material Liquid capacity in gallons
~o I Well Foundation ~-----~l Nearest lot line/z//
~-r DISTANCE TO: [00 "~ PERMIT NO.
I
Total
length of lin, es; Trench width Distance between lines
.J Z No. of lines Length of each line
I-~. Top of tile to finish grade
C] Length /~'~ ~" iWidth~-'~ J, t z~ * DepthMaterial beneath tile /~. inches Total effective..~.~[~absorption~[.. J~' 'aree~
m PERMIT NO.
m~-'~ I- Type of crib Crib diameter Crib depth Total effective absorption area
~ Well
DISTANCE TO: Building foundation Nearest lot line
.d Class D~-p[;, Driller Distance to lot line PERMIT NO.
UJ
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
APPROVED DATE LEGAL
MUNICIPALITY OF ANCHORAGE
, Department~f Health and Environmenta~-%~rotection
~ 825 o Street, Anchorage, AK. _9501
264-4720
* * * HANDWRITTEN PERMIT * * *
Permit ~2~2~ WELL AND/OR ON-SITE SEWER PERMIT
Applicant: LF~/;q ~p ~A~;¢L
Location: ~[l~ ~
Legal Description: ~ 5 ~=ll~q~-
Type of Soil Absorption System
Mailing Address:~5~
Phone Number:
Lot Size:
Trench: Drainfield: Seepage Bed.. / Holding Tank:
Maximum Number of Bedrooms: . 3 Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is: '
DEPTH ~- / LENGTH 3 <¢4 GRAVEL DEPTH
WIDTH 17
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(HOLDING) TANK SIZE = /OOo 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(2) 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.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system/3~
(3) I understand that the or~sit~
the e ' ence is emode
pplicant
accordance with codes.
sewer system may require enlargement if
include more that 3 bedrooms.
Issued by:
Date:
PERMIT NO.
MUNICI~LITY_ OF- ANC~RAGF
DEPARTMENT L HE
825 'L~' STREET, ANCHORAGE, AK. 99501
264-4?20
L~ELI Al%ID ON S I TE SEWER PERM I T
( 830159 )
APPLICANT
LOCATION
LEGAL
LESLIE MCDFINIEL W.
GFLL~R
ENNI
NORTHERN LIGHTS
LOT SIZE
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS
274-5623
SQUARE FEET
SOIL RATING (SQ FT/BR)= 258
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DFPTH-- 7 LFNGTH= 1'1 _~ GR.~].~'EI DEPTH-- -'1.
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 OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
REQU I RED SEPT I C TANK S I ZE= i000 GALLONS
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURI~ THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
TWO (2) INSPECT I O~S ARE REQU I RED
BACKFILLING ~ ANY SYSTEM WITHOUT FINAL INSPECTION FIND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
~INIMUM DISTANCE BETWEEN fl WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
[00 FEET FOR fl PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
JPON THE TYPE OF PUBLIC WELL.
~INIMUM DISTANCE FROM R PRIVATE WELL TO R PRIVATE SEWER LINE IS 25 FEET AND
FO fi COMMUNITY SEWER LINE IS ?5 FEET.
~ELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DAYS
]F THE WELL COMPLETION.
]THER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
~VFLlLRBLE TO INSURE PROPER INSTALLATION.
PERM I T E×P I RES DECEMBER
[ CERTIFY THAT
L: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
:ORTH BY THE MUNICIPALITY OF ANCHORAGE.
B: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
~SSUED
V4. 0
SOILS LOG
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
?
10
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 2C~. ~.720
SOILS LOG - PERCOLATION TEST
,J
SLOPE
[] PERCOLATION
TEST
11
12
13
14,
15-
16
17
18
19
20-
COMMENTS
PE.FORMEDBY: P e.
/ 3T S-OZq
72-008 (6/79)
WAS GROUND WATER S
ENCOUNTERED? Y~'~
P
IF YES, AT WHAT E
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
CERTIFIED BY:
(minutes/inch)
FT AND -- FT
~TE:
PERFORMED FOR:
LEGAL DESCRIPTION:
1
.2
3
4
5
6
7
9
10.
11
12
13
14
15
16-
18-
19-
20-
COMMENTS ,~ ri; t
SOILS
LOG
· MUNICIPALITY OF ANCHORAGE
/
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION *: '~
825 ~ Sweet, An~horage,.Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST '
SLOPE SITE PLAN
tq'~'te o~ ,'to ~,,~.&
PERCOLATION
TEST
WAS GROUND WATER
ENCOUNTERED? [%JO I~
0
P
IF YES, AT WHAT E
DEPTH?
Reading Date Gross Net Depth to Net
' Time Time . Water Drop
Z .. I, Ot ~'O .oo ..o~
a~o i~ o6 ' SO - . ~ ~ -.
~ ,. 4s"~b' ~O tO , ~* . O'F
PERCOLATION RATE ~ ~ .(minuteslinch)
" TEST RUN BETWEEN ~ FT AND '~ tlZ FT
PERFORMED BY: C~..~,r~c~' } U%,~,~-
Box ~:~69,
344-77~4
SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF
DRILLED AT THE RATE OF .i724,00 PER FOOT.
PROPERTY OWNER ~. ,.o ,~. B.C/~_ ,~.~ .'~.~-.~'~37
LOCATION OF WELL SIT~'
DRILLER
WELL LOG:
0 .... ?o~
-' 3
44--735'
To~ ~o~o~
~eeZ o~,'
Co~ o~ 3.~/1~.i~¢: J24.00 pe.~ ,Lt X 135 ~e~;t: ~324o. 0o
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF 5324 0.00
THANK YOU VERY MUCH.
DAT~
7983 BERNIE C~I~ OF RAMPART (~L~ING WORKS
SERVICE CHARGEOF 11~% PER MONTH WILL BE A~SE:~SED ON PAST DUEAC~uM-r~
· APPLICANT FILLS OUT UPPER HAI - *ONLY
PropeMy Owner
Mai~ing Address
Buyer
Address
Zip Code
Phone
Lending Institution
Address
Realty Co. & Agent
Address
Zip Code
Zip Code
Legal Description
Street Location
Phone
Phone
Type of Residence
'~ Single Family
Multiple Family NO. of Bedrooms_
[] Other
Water Supply 'J~ Individual
[] Community
[] Public Utility
Sewer Disposal
'~ Individual
[] Public Ulility
D Holding Tank
ATTACH WELL LOG. A well log is required for all wells driled since June 1975.
For wells drilled prior to that date, give well depth (attach log if available).
Year Individual Installed:
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REi~UEST BEFORE PROCESSING CAN BE INITIATED.
Time Time
Date
Inspector
Field Notes:
Date
Inspector
Time
Inspect/~
("~ APPROVED BEDROOMS ) DISAPPROVED
) CONDITIONAL APPROVAL*
*CONDITIONS OF APPROVAL
Soils Rating
Well To Absorption Area [ C~ O '-~
Well to Tank / C~ 0 f;~-
Well Log Received
Septic Ta~k Size
06~000110
I