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HomeMy WebLinkAboutGRANITE VIEW #1 BLK 10 LT 4 & LT 5 N2Gronite View lock lO Lots 4 & ! 4- 302 -39 Nov 07 1805 25p Ari u : a gie VVG 1! & Pu Tp Se! '--�072430742 q! Developm, ent Services Department Buddnq, Scfely bivision On -Site Wcter & Wastewalter Program AM W 4700 Eknxe Mad P.U. Box 196650 6L An,_� or,aqe, A, K 99507 A F 8 Y07) 343SP04 Pump Installation Log Well DrUling Permit Number: S4+ •_..__. Date of bsue:_ Parcel Identificatimi 0 1 Legal WcripMi ovpwrNarme & Addregg- vleoj A.3A 4 L5 N 2 - Pump Installatimi Date: Funip Intake Depth Below Top of"Well Cishig! fetr Parnp Mladeu �kr �3115 Pump sire'%lip Pitless Adapler Burial Depth: feat Pitless Adapter 'Qanufactur-er's Name - e) A- Pifiess; Adapter Inmaller: Aj X AM WhIfe(,'wd upon Compledop KV, No Method of Disinfecdol": Comments: Pump Imtallei N2rne: Attendan: 1he jmmip:nqaj1y shot juaQj: a pump WIWIn Q TO tllne DSD vi_t)�a K) Lays ot-purrip,.riswIlation. Municipality of Anchorage Page ! of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~c~J~z~O~LG~- PID Number: 01~1~0~L Name: :J~D/rH /~. ~ Wastewater System: ~ New ~ Upgrade ~: ~o21 ~/T~ ~c. ~o~-~?~ ABSORPTION FIELD Phone: ~ ~j~ ~ No. of Bedrooms: ~ ~ ~Deep Trench ~ Shallow Trench D Bed ~ Mound ~ Other LEGAL D ESCR I PTI O N so, Rating: Total Depth from original grade: 0.~ GPD/Sq. Ft. Lot:~ ~ ,~ ~ ~ Block: J~ Subdiv~ion:~l~ ~ Depth to pipe bottom~from original grade: Ft. Gravel depth beneath~ pipe Ft. Township: ~ IRange: ~ ISection: Fill added above original grade: Gravel length: ~ ~ ~0 ' · 5~- I.~ Ft. {00 ~ ~A~ Ft. WELL: ~x~T~ ~ New D Upgrade Gravel width: , Number of lines: Oistance between lines: O, S Ft. ~ l/ / Ft. Classification (Private, A,B,C): Total Depth: Cased To: ~ Total absorption area: Pipe material: ~T~ ~ ~T~ Ft. ~ Ft. I00~ SQ. Ft. Driller:~D~eD~ ~c Water Level:Ft. Installer:~e~ ~ Date installed: ~- ~_ Yield:~~pM II~ Ft.I~ Casing Height Above Ground:Ft. TAN K SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding ~ublic/Private Manufacturer: Capacity Jn gallons: From Tank Field Station Tank S .... Lines ~ ~O~A ~ ~ /~O Well- [0~ / ~ O~ ' ~ ~ ~ ~ Material: ~TEE~ Number of Compartments: Sudace Water tOO'+. ~oo'~ ~ ~ ~ LIFT STATI Lot Size in gallons: Manufacturer: Line ~ ~0 ~ ~ ~ Foundation ~ i ~ ~ ~ ~ ~ ~ "Pump on" level at: "~~ High water alarm at: Cu~ainDrain "~0~, ~ ~0 ~ Pu~~trical Inspections pedormed by: Remarks: BENCH MARK Location and Description:  I0~. 0 ~, Assumed Elevation: 17034 Eagle River L~p Roa~, Ne, ~ Inspections perform~:R~v:r,A,=:~=~s~ ' Dates: 1st ~-~-ff~ 72-013 (Rev. 9/91) MOA 25 Permit No. SW940262 Page 2 of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report LOT 4 & 5 N2, BLOCK 10, GRANITE VIEWaS/DiDNo.:_p Legal Description: 01430259 FINAL GRJDE~ 7.5' ~06 MT2 i FINAL 10~00 GAL SI~PTIC T~NK ~--:; N LOT 5 'REN~HES ,L--I 100' WELL RAD o DRIVE N1/2 LOT .5 T~4 8%o' 87.o · 82.5' W~TER FOUND 7-B--94 SCALE 1' = 40' i (ABAi~DONED COMPLETELY' i ' lOGO SERf C TANK EXISTING SiEPTIC TANK ! LO! 64. A! B FCO 10i'' 44' .....sT..t, ,...~..9.~. ST2 45? 50' C01 48!' 52' C02 49i' 5.5' CO3 47i' 43' C04 SSi 60' .._..c....o..~..~.QiT.. C06 92~ 59' MT1 82! 48' MT2 87~ 58 SYSTEM (ABANDONED COMPLETELY) ROBERT C, COWAN CE - 8801 72-013 A (1/93) * MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW940262 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:RICH JUDITH M OWNER ADDRESS:9021 GRANITE PL ANCHORAGE, AK 99507-3944 DATE ISSUED: 7/27/94 EXPIRATION DATE: 7/27/95 PARCEL ID:01430239 LEGAL DESCRIPTION: GRANITE VIEW BLK 10 LT 5 N2 4 & LOT SIZE: 16050 (SQ. FT.) NL/MBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION 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 AND 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) 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 SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ROBERT SHAFER, P.E. ROGER SHAFER, P.E. July 09, 1994 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAO DESIGN SOILTEST PERCOLATION TEST Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 'L' Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Granite View Subdivision #1; Block 10; Lot 4 & N½ Lot 5 Request you issue a permit to upgrade the septic system serving the three bedroomhouseonthe referenced property. A test hole was excavated and a percolation test performed in the area of the proposed upgrade. The approximate location of the test hole is located on the attached site plan. At the time of excavation water was encountered at 15 feet and after seven day ground water monitoring water was again found at 15 feet. Attached is the proposed upgrade design. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your review,/~ontact us. /LSU/jk STRUCTURAL & )VIECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA99577 o ~o g~> ~BISat ~lI£B_ ,0I ~007~u ZSnOH I ONI£~IX[~ II % 33¥1d 3.1.1NVSO 3(]VSOdO. [' ~SflOH DNI£glXa ON--SITE WASTEW~T~K DISPOSAL SYSTEM (/)NSTRUCTION PRACTICES and MA'£Fm~IAL SPECIFICATIONS f~f~ENCE: Granite View Subdivision Addn. %1; Block 10; Lot 4 & N½ Lot 5 1. The scope of this project includes the installation of a 1000 gallon septic tank and a leachfield trench to serve the three bedroom residence located on the referenced property. The existing 1000 gallon septic tank is to be excavated, pumped, crushed, and abandoned in place. 2. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The contractor shall be responsible for obtaining any necessary underground utility locates. 4. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SF_~TIC ~ ~ON: 1. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 3. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Page Two Granite View Subdivision Addn. #1; Block 10; Lot 4 & N½ Lot 5 July 09, 1994 4o e Septic tanks installed with less than 4' of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10' from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSOflPTION TRENCH/DRAINFi~LD INSTAr.r.~TION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (roughed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter and installed approximately in the locations shown on the design. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINII~OM l%~/'~aIAL SP~CIFICATIONS: 1. Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. Page Three Granite View Subdivision Addn. ~1; Block 10; Lot 4 & N½ Lot 5 July 09, 1994 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: e Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140/N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the %200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements. INSP~f'~IONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. Page Four Granite View Subdivision Addn. #ir Block 10; Lot 4 & N½ Lot 5 July 09, 1994 3. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required, especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractor's activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractor's activities. Final acceptance of the contractor's work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0§50 SOILS LOG -- PERCOLATION TEST SEAL) PERFORMED FOR: ' '~(.~' ~)y I'~ ~_~. I-'J[ LEGAL DESCRIPTION: L/~L~'.~Township, Range, Section: SLOPE 4 5- 10- WAS GROUND WATER ENCOUNTERED7 11 12 S IF YES, AT WHAT I~_.. O DEPTH? ~'J p E 13- Depth to Water After / Monitoring? "7[t ~*'" Oato: ~,~ SITE PLAN 14 15- 16- 17- 18- 19- 20- Gross Net Depth to Net Reading Date Time Time Water Drop I~:OZ '-- / Yq" '-"  AND FT COMMENTS S & S ENGINEERING ~ PERFORMED BY:1 iO,,,,iq i~agle ~,Jver L~F ~.,O&~ .... ~"" ACCORDANCE V~JI&L~J$1t!~T~J~II~J~Itv~I~I~PAL GUJDELIN~/~ ON THIS DATE. DATE: 72-008 (Rev. 4/85) PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN __ ~ CERTIFY THAT THIS TEST WAS PERI~ORMED IN MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENI'AL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT MAILING A~j~RESS ~ Well - Absorotion area DISTANCE TO: ~ PHONE W ~- 7'7¢b [] UPGRADE /d I NO. OF BEDROOMS3 ~_, Dwelling Materia~__~.~ No. o~_,~mpar t me nts I WidthS__ LiquicLCcpth Manufacturer Liq. capacity in gallons IF HOMEMADE: Inside length Well Dwelling DISTANCE PERMIT NO. gallons DISTANCE TO: "~-'//t~'~'~7~/''~Well ,1 · Foundationo~ ~ No. of li~ Len/~ea~.,O.~ Total length~.~ ~.2°f lines Top of tile to finish grade Material beneath tile Length Width Depth DISTANCE TO: Nearest lot line ~,~) PERMITNO.(~) ~ ~7' ~ Trench width ¢ Distance betwe '/-'3~nch es ~ absorption area PERMIT NO, Depth Driller Distance to lot line PERMIT NO. Absorpt on area(s) DISTANCE TO: Building foundation Sewer line Septic tank OTHER PIPE MATERIALS SOIL TEST RATING I NSTA LI~ER.~.~ REMARKS APPROVED DATE LEGAL PERMIT NO. RPPLICRNT ..TLIDITH M. RICH _ =. I-.ii W. LOCRTION "- ~F. H~I TE PLFICE LEGRL LOT 4 BLK .5 GRRNITE VIEW SUB" DEPARTMENT ~ HERLTH RND ENVIRONMENTRL r]OTECTION ~ )~ ~_'~]-~ ~:25 '"'~ STREET., RNCHORRGE, RK. D~.~ Z¢ - - ?~' ~e, 4-4,' ~_~ ~ ~b~ ~4ELL RF~[) C,[4--S I TE ~]EL4ER F'EF:F1 ~ T --~ :~5 N I STER I R ~:44~772~ LOT SIZE ~6050 z,L&IRRE FEET TYF'E OF SOIL REc, JRFTION SYSTEM IS: TRENL. H MFI,..,IMLIM NLMEER OF BEDROOMS SOIL RRTING ,::SO FT/BR)= ]-'.2:0 THE REQUIRED SIZE OF THE SOIL RBSOF.:PTION SYSTEM IS: [:,EF"TF~= -17' 1.. EF-~,STH= 75 GRR'¢EL [)EPTH= THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTBNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET NIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). E."EL-].L~ I F.:E[:, SEF'T I C: TRI'4F; '--; I ZE~ I ,3,3E'~ aSRLL~DF4S PERMIT RPFLI_.B[~T HRS TFIE RE_,FUN-,IE, ILITY T0 INFORM THIS DEPBRTMENT DLIRING THE INSTRLLRTION IN'--,PEF:TIr~Nq .... OF' RNY WELLS RD.JRC:ENT TO THIS rr~_r","~..~'- ........ RND THE NJME:EF.. OF RESIDENCES THRT THE WELL NILL T[..IC, ,:: :---- ) 1' IqSF'ECT 1' ,DF.IS RF.'E F-:Eg!L! 1' I~:E[:, E, FI3-:.FILL!NG OF RN'¢ _,.~_-,TEI1 WITHOUT F!NRL IN_,FEL. TION RND RPPROYI:~L BY THIS [:,EPRRTMENT WILL BE -,J[,JEL. T TO PROSECUTION. MINIMUM DISTBNCE BETNEEN R WELL RND RNY ON-SITE SENRGE DISPOSRL SYSTEM IS 108 FEET FOR R PRIVRTE NELL OR 150 TO 288 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC HELL. MINIMUM DISTRNCE FROM R PRIVRTE NELL TO R PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS BRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 30 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVR!LRBLE TO INSURE PROPER- INSTRLLRTION. ~ F'EF.~'4 1' T E::<P 1. F.E.:, [:,FC:EF"~E:EF-: 2--:1., ::L_- I CERTIFY THRT !: IRM FRMILIBR WITH THE REQUIREMENTS FOR ON-SITE SEWERS BND WELLS RS SET FORTH B'¢ THE MUNICIPRLITY OF RNCHORRGE. 2: I WILL INSTFILL THE SYSTEM IN RCCORDFINCE WITH THE CODES. 2:: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE TWRN 2: BEDROOMS. F~PPL I CRNT JU[:, I TH M. ¢~ I CH ISSUE[:' E"' CONSTF,dCTION TEST LAB Judy Rich PERFORMED FOR: LEGAL DESCRIPTION; Lo~~ Block THIS FORM REPORTS: E]Visuol Soils Examination 180C '~ 46TH AVE. STE. 'C' ANCHORAGE, ALASKA 99503 248-1333 1(] DATE PERFORMED: 7/28/80 'Subdivision GRANITE VIEW SUBDIVISION D Percolation Test ACTL 80-1407 DEPTH SOIL FEET DESCRIPTION NOTES 4" TOPSOIL 1' TAN SILT DRY ~ TAN SILTY SAND DRY 7' 8' -SM- 9' ~ TAN GRAVELLY SILTY SAND DRY 11.5' -SM- TAN SILTY S~DY GRAVEL BOTTOM OF HOLE WAS GROUND WATER ENCOUNTERED NO IF YES, WHAT DEPTH LEGEND limes ® -- Perc zone 1D S - Sample taken B -- Frozen zone V- Water table GENERAL SITE SLOPE READING DATE GROSS TIME NET TIME DEPTH TO H20 N~:T DRAINAGE SATURATION PE] ~IOD 7/28 12:00 0 HRS. 4 1/2" 0" 7/28 3:00 3 HRS. 8 3/8" 3 7/8" 7/28 3:30 3.5 HRS. 8 //S'* 1/2" 7/28 4:00 4 HRS. 9 3/8" 1/2" PERCOLATION RATE: 60 Min/in. DRAINAGE REQUIREMENTS: 330 S.F./B.R. PROPOSED INSTALLATION: D SEEPAGE PIT ~ DRAIN FIELD O OTHER COMMENTS: TEST. PERFORMED BY: Bob Peters DATA CERTIFIED BY: James R. Ringstad, P.E. DATE: 7/29/80 ,-~ GREATER ANCtlORAGE AREA 60RoUGIL, "" ~epartment of Environmental Qua/ "~y 3330 "C" Street Anchorage, Alaska 99503 SOILS LOG - PEROLATION TEST Legal Descripti on :_/~.c~/~-~/_~~ d-g-~_~.~SmL=~ d'~o~ This form reports: Soils tog_/ Percolation test Depth · Feet 5- 6- 7- lO- 'l 1 13 ~ ~ . // ~as 9round water encountered? Da te Pe rfo rmed .~..2_~:2 6.~.. If yes, at what depth? Reading Date Gross Time Net Time Net Drop Depth to Water Percolation rate minute. .Proposed inst~llat-~-O-~--S-~i-p~-fle Pit ............... Drain Field .... .................... Depth of Inlet Depth to bottom of [)it or trench ...................... COI.IHEHTS: ._: EQ'-040 (6/74) WELL LOG Date Drilled: Static Water Level Draw Down /d) , feet feet Gallons Per Minute ' "6 ' Total Feet of Casi.ng:'"~Z~' Type Material Drilled: 0 feet to to tO MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box' 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 0!4-302-39 .AA# ,, ," 1. GENERAL INFORMATION Complete legal description Lots 4 & 5; Block 10; Granite View Subdivision Location (site address or directions) 902! Granite Place Anchorage ~ AK · Property owner Dan Potts Day phone Mailing address 9021 Granite Place Anchoraqe, AK Lending agency Day phone Mailing address 349-3555 99516 Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well ×× Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: XX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewaterdisposal 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 Engineer's signature ALASKA WATER & WASTEWATER INC. IS TO $ ~©o,oo AT CLOSING FOR ENGINEERING SERVICES PERFORMED. DHHS SIGNATURE /' Approved for Disapproved. Conditional approval for BE PAID bedrooms. bedrooms, with the following stipulations: Additional Comments The Munic'- ty of Anchorage Department of Heal- ~nd Human Services t ~HS) issues Health Authority Approval { ~icates based only upon the represe:" ,,tions given in paragraph 5 above by an independent profession& ~ngineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA k21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SER,V, JCES Environmental Services Division .... r~NMENIAL ~VIC~S DIVISIO 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Health Authority Approval Checklist ¢~.~' ~]~'~/~: IO c"~'~'~Parcel I.D.: Well type ~-z~( Log present (Y/N) 'W Total depth '"7 :~ ~ Sanitary seal (Y/N) y If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to ~7 ~" Casing height (above ground) properly protected (Y/N) y Wires Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform FROM WELL LOG AT INSPECTION /'~ g.p.m. '~' q Nitrate /o ~,/ ~r~//. g.p.m. Other bacteria Date of sample: Collected by: ~, ~- //~..¥.2 ¢~]~ B. SEPTIC/HOLDING TANK DATA Date installed /,' ~ ~- ¢ ~'~ Tank size /, ~' g/~ Number of Compartments 'Z~- Cleanouts (YIN) V Foundafioncleanout (Y/N) ~/ Depression (WN) ~ High water alarm (WN) ~4 Date df Pumping ~ ~ X d---R ~ Pumper ~ ~'~/~< 4 C. ABSORPTIONF!ELD DATA Da~e installed ~ ~ g- ¢ - ~ ~ Length ~(~ ~o t Width ' ~- - ~ / Gravel thickness below pipe Effective aS$orption area / ~ ~ ~ Monitoring Tube present (Y/N) 'y Soil rating (g.p.d./fF or ft2/bdrm) D, '-/-~ System type ,Z~¢~/~ 5- Total depth. · Depression over field (Y/N) )~v/ Date of adequacy test ~ ~ ~- ~'- -- '~/8~ Results (Pass/Fail) /~/A 5~ For -~ bedrooms Fluid depth in absorption field before test (in.); ~ ~ Immediately after+~¢gal, water added (in.): ~ ~ '~ Fluid depth B.~" (ins) Minutes later: ~ Absorption rate = ~O ~ g.p.d. Peroxide treatment (past 12 months) ~/N) · ~ If yes, give date ~/~ 72-026 (Rev, 3~96)* ,~c~' ~.z.~s i~-ro~o~ ~,~-o Uo~--S-Y ('7'f~c-+~ LIFT STATION Date installed ~ Manhole/Acc~ Hig~arm level atc_fydles tested * Size in gal~ns''~ *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: - ~..,~ SI~ S / p~ Septic/holding tank on lot ~ ~O -~ ~v~v~. On adjacent lots Absorption field on lot / ~¢/.F On adjacent lots Public sewer main Sewer/septic service line Public sewer manhole/cleanout / O 0/'/~ Lift station /V/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation :5 '5 r .-./-,[ ¢¢ 0 Property line Water main/service line -' Surface wateddrainage / ¢~E /v~ Absorption field '~ / '~ Wells on adjacent lots /~/d SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /O/4- Building foundation ,~o/¢'' Water main/service line Surface water ! ~-~ £ '(~ Driveway, parking/vehicle storage area Curtain drain / ~¢'¢ 1¢- .... /b/¢¢~'- ~"-~'~¢~ ~c-',q Wells on adjacent lots / ¢' ~ f~ F. ENGINEER'S CERTIFICATIOn// ~cer~fy~ha~h~de~b~in~r~/fff~u~e~d~nspec~i~nsandrev~ew~fMun~c~pa~rec~/r~'~"~ ~"~'~~a' inconform~be:It~A¢~:~delinesine.ctonthisdate. Signature ~/( //~ Engineer's Name HAA Fee $ "~'¢-¢ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number Parcel I.D. # MUNICIPALITY OF ANCHORAGE M/~LIW OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES ENV~qTAL SERVICEs DIVISION Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING AUG 2 9 1997 GENERAL INFORMATION :: Complete legal description r.ot & N½ of Lot 5; Block 10; Granite View S/D Location (site address or directions) 9021 Granite Place Anchorage, AK Property owner ,.Vicki Potts Day phone ':Mailing address P~;O. Box 874922 Wasilla, AK 99687 376-0282 Lend ng agency · · .. .Mail ng address --,Agent , Addr~ss- .¢- Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER As certified by,my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/orwastewater disposal system [ssafe, functional and adequate for the number of bedrooms and type of structure indicated herein, lfurtherverifythatbased on the[nformationobta[nedfrom 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 regutations in effect on the date of this inspection. Name of Firm S & S ENGINEI~RINC. Phone ' ~ c/5/_ ~ (7 7 ~ 17034 Eagle River Loop Roa~ No. 2~ Address ~- ~:--- ~:~-~'- ~ .... Eng'neers signature , ' ~ Date ~/~ ~ /e 7 DHHS SIGNATURE v/ Approved for ~' Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comment,'; By: Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchaser~ of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72~25 (Rev. 1/91) Back MOAlY21 Legal Description: A, WELL DATA ~UNIcIPALiTy Municipality of Anchorage ~NVJ~o~/~ DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-~9 1997 Health Authority Approval Checklist '~ Parcel I.D.: O/ q - Well type ~'A.~ Log present {~N) Total depth -/ 3 Sanitary seal ~/N) If A, B, or C, attach ADEC letter. ADEC water system number ~ Date completed ) / 3- '1 // ~ / Cased to ~) ~ ; Casing height (above ground) Wires properly protected ~/N) y4: $ FROM WELL LOG AT INSPECTION g.p.m. Date of test Static water level t.( Well production WATER SAMPLE RESULTS: Coliform ('~ Date of sample: 0_~//_'~ -~/~ ? B. SEPTIC/HOLDING TANK DATA Nitrate Collected by: g.p.m. Other bacteria (~ $ & S ENGINEERING ~¥J~4 Ea~ie ~iver Loop Koad NO. 2u4 Eagle River, Alaska 99577 Date installed (~/a-9/ eL.f- Tank size ) 0 o O Number of Compartments '~ Cleanouts ((~)N))'4.5' Foundation cle~n, ouL(~)N) ¥/~ Depression (Y/.~ ,c. O High water alarm (Y/~ Dateof.p'6rrf~ihg ~/~",~i/:q7 Pumper /¢¢+ ]:/~,w~ C. ABSORPTION FI'ELD DATA "~ ' Date:ins. tailed C/;~¢'Jq 3~' ' !' Soil rating '~g~./ff~_~:)r ff=/bdrm) ~, ~/'(- System type Length ~' ~ $-0 / Widtl~ ~' $~ ~ Gravel thickness below pipe '-~ ~ Total depth Effective absorption area ) ~ 'd ¢~ Monitoring Tube present ,~)N) V,~-J Depression over field (Y/~) Date of adequacy teSt ~/~"7 / ~/'7 Results (Pass/Fail) i° '~ s'J' For ~ bedrooms Fluid depth in absorption field before test (in.); p/t y Immediately after.~%S'0 gal. water added (in.): I Fluid depth I '6 ~/~," (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) ~,0w~. 72-026 (Rev. 3/96)* Absorption rate = If yes, give date g.p.d. LIFT STATION Date installed Size in gallons "Pumpon~ "Pump off" level at* Manhole/Access (Y/N) High water alarm level at* .~_~--~ *Datum Cycles t~st..~~~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation I ~ 4~ Property line 3 3 Absorption field Water rnain/service line ! 0 -t- Surface water/drainage ? o o ¢- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: / / Properly line 30 Building foundation '3 $' Water main/service line Surface water / p ~ '¢' Driveway, parking/vehicle storage area Curtain drain /oo ~/-"~ ~' M Wells on adjacent lots ENGINEER'S CERTIFICATION · I certify that lhave determined thru field inspections and review of Municipal rec°-~~ms are in conformance with, MQA H,a~c'guidelines in effect on this date. Engineer's Name HAA Fee $ Date of Payment 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number '¥:'~.-'~:~'~: ':" ...... - MUNICIPALITY OF ANCHORAGE ;':' ~.:'/': ~'::;' .... DEPARTMENT OF HEALTH &'HUMAN'SERVICES .~:~ :~?'?:,!",":' ;~ '~:!, '~": ;, ..~.;:.?. · .... -~, Division of Environmental Services ~_ .:, ,.-.; ,.~ . .... - '~ On-Site Services Section' :-"'. :',:;i?-';?'~ ~ . ;".:~?'? ,,~.: :;?'~,--,~ti;.. ! :.'.i:.i;~;/ii~,,[,,~,?:; P.Oi Box '196650 '. Anchoragel;"Al~ka · 995~'9'66507, ,.~,~ .... ;-~: ,': :~:?: ..... :"-.."'-.' ' · '343-47~ .',': ' ', : -..'- '.' '. '.' . ,' · ~ ~ · ;.~h . ......:/~-,?.d-:: ,,. . CERTIF CATE OF HEALTH AUTHOR TY ' :::-'~;- ~?:?~' ':'? "~ '' -~' '~ APPROVAL FOR A SINGLE FAMILY eWE[.LiNG' ~i '. :.~ ..~-~; GENERAL INFORMATION :",~ ~*.~ ,.~ ~-~..-~ '~ ,~ '.~-- .... ? ,?.-:'t,?~¢~?,,;:~.Complete legal, description ..,. Lot ~&-,~,'o~E~-!5~ ~cff .1'o; Ora~ V~,S~b~v~on ~.. ..... ~;~{~'~,:~.~.$;~.~7~ ;, ..:_.:~:.-:: · . ... . : ................... , ....... { ~ ,~.~,,..,-...~ .... . - --.~-.,::----:~ :~:~?, ...... · . , '- ~ · .-,,, ~.. .... ~ ...... t '. ,~..~.,, -'--~ ....... ;.,,.-,,. ~,- .... .... : · ., .}:,'~'/~j:~;~:~}LoCation '(siteaddress 0r di~e ns) :' : .... , ;;:,: i::i, !.:.~;~4~.~;~ NO~E:;:i-:~.~:!f, commumty.weli system; provide written Confirmation ~ro? i, :~?~:i:i;,:i:~..~ :; . ~.:'~:.~ lng to the legahty and status of system. ~: ,':' :~ ~?~- · ~:~: T~PE OF WASTEWATER DISPOSAL: ~'~; ................. Indw;dual on-s~te .... ~? · ~:, :~.~:::~.,:~,? ,.~.~.~:.:-. commum~y wastewater system,.prowde written confirmation from State · ?:~,~::~ ': ' ~ ~ :~ : ttesbng to the legah~'an~status o~sys~ ;~: ,::~ ~ '1 : ' : ;, ' ~ STATEMENT OF INSPECTION BY ENGINEER -- , ,->_, , . . As certified'by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the'information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. :..- .-. Name of Firm :~ ~ ~ ~U~Z~NC Phone L { r ' : ' Address" '~.:,.37034 E,,gle R.v~...~,,..,~,,~,,~,~ "*. :'-:~:: Engin~effs signature:_ . -J~-L. F~ Date ~/6 /~ ~ . ..:-'; . :,-:..,.._..:..:::. ':-;:._.': ;: .-__~. ...... ...... '""-.". -~ ~ ". Con~bo~al:'approval'for ' bedrooms, with the following-stipUlations::` . The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations g~ven in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-02~(Rev. 1/91) Back MOAi~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: £o7-/-/¢'5'-/v ~, !i~.N. I0, Grz,~,/~'; ~//~Pamel I.D. O/q - 30 a - 3~/ If A, B, or C, attach ADEC letter. ADEC water system number Date completed I~ ;~-/- ~1 Driller Cased to '7~ Casing height Wires properly Protected ~N) A. Well Data Well type Log present (~/N) ! Total depth Sanitary seal (~IN) YES FROM WELL LOG AT INSPECTION Date of test I - ~-t- ~1 ~_/~q,~ ::;R::7 ~_ Static water level LtO ~ ~ ~1 ' t'--'t r- I-I-I o Well flow /,o. O .g.p.m. '-/. r.2 g.p.m. <:~ .~ Pump level1 L.,) / ~ ~j/y.. r-r'l ~ ~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I o 5 ' Absorption field on lot Public sewer main Sewer service line ; On adjacent lots Ioo %- ; On adjacent lots I o o -+ Public sewer manh01e/cleanout /oo ~-~ Petroleum tank WATER SAMPLE RESULTS: Coliform .~ Date of sample: (~/~t ~'/~' B, SEPTIC/I~I~:g:i:IiI~-TANK DATA Nitrate ~, .-3/''/~'~'//-- Other bacteria Collected by: Compartments ~ Depression (Y/{~) h,/o Foundation ~ ~ Water main/service line Date installed"':: ~ ;~'°o~'~' -~' Tank size I ¢2OO ,~,_o,~s Cleanouis: ~)~ . :.. :~ :~.~ Foundation clean0ut High water ~la~ (Y~' '~o ~ ~ - Alarm tested (Y~ ~ - Date of pumping ~ .... ~ ~/~ Pumper SEPARATION DISTANCESF:R~M SEPTIC~ TANK TO: Well(s) on 10t-~,,., I o 5~ ~,, ~ On adjacent 10ts I oo ~ To properly line ~ ~ Absorption field ~ ~ Sudace water/drainage ~oo ~+ 72-026 (3/93)' Front CONTIN U ED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DI~~: Well ~ On adjacent lots Manufacturer ,~ Manhole/Access (Y/N) ~ "Pump off" Lev~a{~ Cycles t~ Sudace water D. ABSORPTION FIELD DATA Date installed (¢ - ~ 8 - q ¢ Length . IOo To'r^~ Width T0talabsorpti0n area i©oo ¢ Date of adequacy test ~/- Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/Ft2) O. Gravel thickness Cleanout present ~N) Results (pass/fail) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / ©; To building foundation ~' On adjacent lots Surface water for ~ Alter test System type -~e Totaldepth II. Depression over field (Y~ / Bedrooms / If yes, give date // --/ / On adjacent lots Ioo', Property line -30 To existing or abandoned system on lot I(~ ' ~' Cutbank 5-0 '~ Water main/service line /o ~- Driveway. parking/vehicle storage area ,t"o ¥- Curtain drain k~o~ E. ENGINEER'S CERTIFICATION I cerb'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect~fs inspe'ct~bn. _ / . __ ...... Date / l'b / ~' $ ~, ~,,%., ..'~',~ ~ HAA Fee $ ,~2, ~ Waiver Fee $ Date of Payme~ ~/~/~ ~ Date of Payme~ Receipt Numar /~F ~~ Receipt Number TIME DATE R ECEIVE~i~ INSPECTION APPOI NTMEN:S TIME ~ ,~ TIME I NSP ECTOR INSPECTOR INSPECTOR MUNICIP~,~ITY OF ANCHORA¢~' MUNICIPALITY OF ANCHORAGE DEPT. OF H'-ALTi-! & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI[~IRONMENTAL ; 2OTECTION  825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION , 2 I981 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEW I DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. PR(~PERTY OWNER M A i'L'I~XI G ADDRESS ~ PROPERTY RESIDENT (If different from above) PHONE 2. B U~Y E R PHONE MAIL/LNG ADDRESS 3. LENDING INSTITUTION I PHONE 4. REALTOR/AGENT J PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION -.' ST R E.~'r LOCATION 6. TYPE OF RESIDENCE 0~/ SINGLE FAMILY [] MULTIPLE FAMILY 7. WATER~/SUPPLY ~ INDIVIDUAL* v[~ COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM  i NDiVi DUAL/ON.SiTE~ [] PUBLIC UTILITY NUMBER OF~BEDROOMS [] One [] Four [] Other~ [] Two [] Five J~ Three [] Six *ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) / ~'~)~ P YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) 'iL~ 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 [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection 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 BOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line J Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS I~PPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) ~ DISAPPROVED DATE BY ~ ,,~