HomeMy WebLinkAboutMCMAHON #1 BLK 3 LT 26McMahon
lock
Lot 2:6
017-361
-06
.I
ENVIRONMENTAL ENGINEERING DIVISION
/ ~' 825 L Street L :Anchorage, Alaska
ON-SITE SEWAGE DISPOSAL SYSTEM A[~Dv(~I~~~~ION REPORT
NAME
IPHONE II--]NEW
KEA/NET'H KETZ MAY ~ 'i 19~4
MAILING ADDRESS ........
LEGAL DESCRIPTION ~~1 V. ID
LOT Ze ~ .~ ~N~
LOCATION
~D~ 5H/A~ .o. OF aEDROOUS
DISTANCE TO: IWell I Abs°rpti°n area ~ i Dwelling
O~ ~.~ I PERMIT NO.
~ Z Manufacturer 3~ I ~0~
~ ~ c~y ~ ~ E~ Materia~ No. of compartments
.Liq. inside length Width
, in gallons IF HOME,DE: Liquid depth
~ ~ DISTANCE TO: Well Dwelling t PERMIT NO.
O Z ~ Manufacturer
~ -- ~ Material Liquid capacity in gallons
O Well ~ Foundation PERMIT NO.
m ~ ~ DISTANCE TO: /~ ~ ~/ ,/'[ Nearest lot line ~ t
_~ ~ mZ No. of lines / Length of each libel Total length of I~s J' Trench width Distance'~ 'obetween~'~ lines
~ ~ ~ Top of tile to finish grade ~ I ' Material beneath tile ~ inches
Total effective absorption area
Length Width Depth
m -, PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ DISTANCE T~; I Well Building foundation Nearest lot line
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer'line, Septic tank Absorption area(s)
OTHER
PIPE MATERIALS '" ~/'b~r~
PV.C, ~ ~.~, .t '~ .......
SOIL TEST RATING ~ ..,
NSTALLER ; ~J ~At '-OJlT__,~l
R EMAR KS ~' C,~ .
I ,
-~.~, ~4 ~'2 / ~ .. ~"~'"'~'~"~ ~,,.~_l~ ~' ~ k.~,
~..- ~ ...~,~,
j~..~~~......,=.,~ ,
¢~ ~ NO. 986-E c-~
,Ea'rthwork,
Excavation & Paving Co.
Phone563-3379 · P.O. Box 102281 · Anchorage, Alaska99510
May 25, 1984
Municipality of Anchorage
Dept. of Health & Environ-
mental protection
825 L Street
Anchorage, Alaska 99501
Gentlemen:
MUNICIPALITY OF ANC~'IORAGE
DEPT. OF HEALTH
ENVIRONMENTAl. PRO.~AiON
MAY 3 ~ ~84
RECEIVED'
Enclosed, septic inspection report for permit #84-0329
showing all work completed.
Sincerely,
E~EXCAVATION
Owner
& PAVING CO.
CT:bms
Encl.
c.c. Mrs. P~t Ketz
MUN 'r C T Pi:IL T T'~ ,~1:~ Rr-.ICHF_,RRGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL pROTECTION
'825 L STREET, ANCHORAGE, AK 99501
264-4720 i
PERMIT NO:
DATE ISSUED:
APPI' ICANT
ADDRESS:
CONTACT PHONE:
O1'-.I--5 T TE
05?ll~
KENNETH KETZ
~-~0 C ST
ANCHORAGE, BK. '.~50~
~45-.~168 :
PEAr'1 I T
LEGAL DESCRIP:
LOT Si~E:
LOT LOCATION:
.SUBDIVISION'ii MCMAHON . ~:
SECTION: 28: TOWNSHIP: i2N
22050 (SQ. FT. OR ACRES>
DOROSHIN
,LOT: 25 : BLOCK:
· . RANGE~' ~W
I CERTIFY THAT:
i. I AM FAMILIAR WITH THE REQUIREMENTS FOR ON'SITE SEHERS AND WELLS'AS SET
FORTH BY TH~MUNICIPALITY OF-ANCHORAGE <MOA> AND THE STATE OF ALASKA.
2. I WILL INSTALL THE SYSTEM IN ACCORDANCE MITH ALL MOA CODES 8ND REGULATIONS~
AND IN COMPLIANCE ~ITH THE DESIGN CRITERIA OF THIS PERMIT.
~.. I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS'FOR THE SET BACK
DISTANCES FROM ANY EXISTING WELL,-WASTEWATER DISPOSAL SYSTEM OR PUBLIC
'SEWERAGE SYSTEM ON THIS OR 8NY ADJACENT OR NEARBY LOT.
IF ~ LIFT STAT~ON IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN'(i> AN ELECTRICAL PERMIT AND'INSPECTION MUST BE OBTAINED~ (2) AS-BUILTS
INSPECTION REPORT~ AND (~) THE
ELECTRICIF~N.
Permit %
WELL AND/OR ON-SITE SEWER PERMIT
Applicant: K~/~.,~ ~-~ Mailing Address:
Location: 7~_o~/~.O Phone Number:
Legal Description: ~7- Z~ ~ ~ /~ ~/~/f~/v~O~/
Type of Soil Absorption System Is:
MUNICIPALITY~OF ANCHORAGE
Department ~ Health and Environmental,~rotection .
.. 825 '= Street, Anchorage, AK. '>J~501
264-4720
~C/ 03 >g * * * HANDWRITTEN PERMIT * * * ~//Z3 ~,'/~.~r"~Cf
Lot Size:
Trench: ~ Drainfield: _ _.~eepage Bed: Holding Tank:
Maximum Number of Bedroom~__/~z~/~ Soil 'Rating(sq%ft/br) '/~"-g~ ~ /~-~'
The Required Size of the Soil. Absorption System Is:'
DEPTH '~.'~-~'LENGTH /~. O / GRAVEL DEPTH ~ ''~''' WIDTH' ~-~"" /
The length dimension is the length(in fee~) of the trench or drainfield. Th~
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 = 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. '
* * * TW0(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection .and approval by this departmen
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 fee
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 ~ine
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, i 9 * *
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 in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 bedrooms.
S igne'd:
Applicant
Issued by:
Date:
SWP/024 (1/81)
, , . .: ~E.P~gT~ENT 0F HEflLTH. eN~ ENVIRONHENTflL PROTECTION":' ~ ,.,
.. , .. . .
THE LENGTH DZI'IENSZON ~S THE LENGTH (ZN FEET~ OF THE TRENCH OR DR~ZNF[ELD,'.'..''
THE DEPTH OF fl TRENCH OR PZT'[5 THE DI~TflNCE BETWEEN THE SURFflCE OF THE
"6ROUND fiND THE BOTTOH-OF THE EXC~VflT~ON (IN FEET). ... .
.. THE 6RflVEL DEE'TH 15 THE HZN[I,1UH DEPTH OF 6RflvEL BETWEEN :T'HE."OUTFflLL PZPE
fiND THE BOTTOH'OF THE EXC~',/~TZON .(IN FEET)'. "
REQUZRED'.- SEPTZo., T~t~K ~ -~ZZE= --,88 6~ELC~NS'
~: ,: .......... ... . . :..... . ..
PERi,lIT flPPL~flNT'Hfls THE"REsPoNSiBIE[Ty. TO ]NFORH THZS DEP~RTHEN~' DU~ZN6 THE
ZNST~LL~T]ON ZNSPEOT~Ot.lS OF tiNY IdELLS ~D~flOENT TO THZS PROF'ERTV ~ND THE"' ":
NUHBER OF RES1PENC:ES TH~T THE WELL IDYLL SERVE.'·
BfiCKF[LLZNG' OR fl~Y.S~STEH ~[THOUT'FZN~L ZNSPECT~ON fiND flPF'ROVflL BY THiS ......
DEP~RTHENT'ld~EE BE'SUBCECT TO PflOSECUT]ON. "" .... : ~', · ":,-
. .' ~.~. ,~ ,:, .,,.',;. .. ,.~ . ,:...'~ .2~ ~',. , · .. .' ".' · ... . , ; ....
~[ N[ f lUH !.. D[ STflNOE BETWEEN ' ~' NELE" fiND fit'iV ON-S Z TE SEI,IRGE D z SPO$flE ' Sy~T~'M' '~ ~' .' '~'-,. '
&Oe~FEET.'.FOR' fl'PRZV~TE NELL OR ise. To 28e, FEET FROH fl F'UBLZO WELL DEPEND[NG'~..:
I'iZNZHUH D'ZST~NOE"FROH fl PR[V~TE' ldE L' "" ....
· . PRIV~TE sEwE~: L~NE [ FEET fiND '"'
OTHER REQUZREHENTS/'I,I~V' ~ppLM." . SpECzFz~T~ONS''fiND CONSTRucT~f4' 'DZ~G'~fl¢,lS RRB '
flV~L~BLE TO" ZNSURE PROPER ZNSTfiLL~TZON." ':
...."/ .; '- .,.. ,. ., 4 ; · . , , .. . ,'~, '.' ~ -. ..
RESIDENCE IS:RE~O~E~ED TO INCLUDE, HORE. THAN'4' BEDROOMS.' ...... "' "' '"" ·
PERMIT NO.
BPPLICFIt`IT
LOCRTiON
LEGAL
DEP~RTMENT L,r-' HEALTH AND ~NvIRONM~NT~L--'~P~oT~TION
825
~L ~ STREET.. BNCHORBGE..
; .~ 264-472(~
I TE ~SELqER~. LIP~]RRE, E F'ERr-1 I T
I<EI"g`IETH KETZ
..~L2G B3 HCMRHON '
i.
33]:0 C ST FIt`ICHORRGE, FIK 99503 345-3±68
LOT SIZE
TYPE OF SOIL FIBSORPTION SYSTEM IS: TRENCH
MAXIMUM I,`IUMBER OF BEDROOMS = 4 SOIL RATII,`IG (SQ. FT?BR)=
THE REQUIRED SIZE OF THE SOIL FIBSORPTION SYSTEM IS' /.47 '
E:'EPTH= 10 LENGTH= 10 G F-:' A"..-' E L DEPTH=
THE LEI'`IGTH DIHEI'`ISIOI,`I IS THE LENGTH (IN FEET) OF THE TRENCH OR DRFIINFI'ELD.
THE DEPTH OF F! TREI'`ICH OR PIT IS THE DISTAI~`ICE BETWEEN THE SURFRCE OF THE
GROUI,`ID FII,`ID THE BOTTOM 0F THE E>::CAVATI01,`I (IN FEET).
THERE iS l,`i0 SET WIDTH EOR TRENCHES.
THE GRAVEL DEPTH IS THE MII,`IIMUM DEPTH OF GRFIVEL BETWEEN THE OUTFALL PIPE
AI,`ID THE BOTTOM OF THE EXCFIVATION (IN FEET),
REm;.,I_i i F-:E~-., '--~EF'T i mS: TR I-~ '--~ I ZE= 500 L~RLLOI--~_'~;
999999 SQUFIRE FEET
0~-~ )o -//-~_.~
PERMIT RPF'LICFII'`IT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURII'`IG THE
II'`ISTRLLATIOI'`I II'`ISPECTIOI'`IS OF RI'`IY WELLS RD,TACEI,`IT TO.THIS F'ROPERT%' AND THE
I'`IUHBER OF RESIDENCES THAT ,THE WELL WILL SERVE.
TI-4~] ( 2 ) I I'-.I:~;F'E~]T I Or-.IS RF-:E REQI_I I RED
BFICF':FILLII,`IG OF ANY SYSTEM WITHOLIT FINAL II'`ISPECTIOI'`I BI,,ID RPPF.'OVRL BY THIS
D'EPARTf'IEI',IT WILL BE SUBJECTi TO PROSECUTIOI'`I.
"MINIMUM DI~TFII'`ICE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
'±00 FEET FOR FI PRIVFITE WELL OR i50 TO 20C'~ FEET FROM FI PUBLIC WELL DEPEI,`IDII,`IG
UPON THE TgPE OF PUBLIC WELL.
HINIMUM DISTFINCE FROM R PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUI,`IITY SEWER LII,`IE IS 75 FEET.
,~OTHER REQUIREMEHTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILFIBLE, TO INSURE PROPER INSTFILLRTIOI,`I.
F'ERI'-I I T E::-::P I RES DECEI'-IE:ER _~.-:.-1 .. 19::-' ~
I CERTIFY THAT
· .1.: i RI"1 FFII"IILIFIR WITH THE REQUIREMENTS FOR ON-SITE SEWERS lIND WELLS RS SET
FORTH BY THE MUI'`IICIPALITY OF: ANCHORAGE.
2:: I 1.4ILL IHSTRLL THE SYSTEM!IN 'ACCORDANCE WITH THE CODES.
3.: I UNDERSTFIND THAT THE oN-SITE SEWER SYSTEM MAY REQUIRE ENLF:IRGEMENT IF THE
F-:ESIDENCE IS REMODELED TO INCLUDE 190RE THAN 4 BEDROOMS.
- LICANT/ I<Ei'`II'`IETH i KET~
\
POOCid 6-650
ANCHORAGE, ALASKA 99502-0650
,,~C.r, 2d4-~ : ' :
r~ h%"~' K,";()WL [;
fl PARTMENT O!' liT. AL. It, ,'~;~l; [iNVIRONMENTAL PtiOI'ECTION
~Permit #: 821080
· January 31, 1983
TO: Permit Applicant
Subject: Lot 26 Block 3 Mc Mahon Subdivision
A permit issued by this department for an individual well
and/or on-site sewer system has expired as of December 31,
1982.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
if you have drilled the well, a well log needs to be sent
to this department for documentation of ~e. installation
date'and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our fiies and documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerel~
Robert C. Pratt, R.S.
Acting Program Manager
Sewer and Water Program
RCP/ljw
enc: Copy of Permit
SWP/057
PERMIT [40.
MIJN I' C I ?.RL I TY OF R~O~-~.~RRGE
DEPARTMENT r)HERLTH AND ENVIRONMENTRL' .OTECTION
825 'L' STREET, ANCHORRGE, AK. 99501
264 -4720
ON--5 I TE 5EI4ER IJPGRRDE PEAr-11 T
821080 )
APPLICANT KENNETH KETZ ~0 C STREET ANCHORRGE 99503 274-7621
LOCATION ·
LEGAL 'B~ L26 MCMRHON LOT SIZE 999999 SQUARE FEET
-
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH lC ¢1
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING <SQ FT?BR>= i25
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DEPTH= -11:3 LENGTH= -1([i GRR'-~'EL DEPTH=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET> OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTRNCE BETNEEN THE SURFRCE OF THE
GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET>.
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE
ANB THE BOTTOM OF THE EXCAVATION <IN FE~T>. .
?0 o ?"c4 c q c, .K
RE~IJIRED SEPTIC TRt~K SI----E= 500 GRLLi3;4/¢~/'__~
PERMIT RPPLICANt HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENt'DUR~NG THE
INSTALLATION INSPECTIONS Of ANY WELLS ADJACENT TO THIS PROPERTY RND THe
NUMBER OF RESIDENCES THAT the Well WILL SERVE.
TI40 ( 2 ) I t4SPECT I Of 4S ARE RESU I RED
BACKFILLING OF ANY SYSTEM WITHOUT FINAL ,INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SENRGE DISPOSAL SYSTEM IS
100 FEET FOR R PRIVATE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM R PRIVATE WELL TO R PRIVATE SEWER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MRY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERM I T E.'~P I RES DECEblBER ~-1.. -198:::>
I CERTIFY THAT
l: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SENERS AND WELLS RS SET
FORTH BY THE MUNICIPRLITYiOF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY,REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
V4. 0
ANCHORAGE AREA BOR>"$H
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION~ REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE ~
FROM WE/~TURER(.~/~'/r/ g7 ~;;~. MATERIAl.
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH
NUM.ER OF
COMPARTMENTS /
CAPAC ITY,/~ ~:~) ~~) GALLONS.
SEEPAGE PIT:
NUMBER OF PITS / DIAMETER .
LINING MATERIAL~-~'~C ~/i~_~CRiB SIZE: "DIAMETER
BUILDING FOUNDATION , NEAREST LOT LINE
OR WIDTHZ t~),!
TYPE hi V~ CONSTRUCTION
BUILDING NEAREST NEAREST
FOUNDATION , LOT LINE , SEWER LINE
LENGTH?~.~ !
DEPTH
DEPTH ~ DISTANCE FROM, W
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA)
DEPTH
SEPTIC
TANK
DISTANCE FROM:
SEEPAGE
SYSTEM '
· CESSPOOL .i ' OTHER SOURCES
APPROVED
DISAPPROVED
REMARKS
DISTANCES:
INSTALLED BY: .5~ ;~ ~"]C'C~/~. ~
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form No. EQ-031
DIAGRAM OF SYSTEM
q,
'
DATE?
GrEATEr ANCHOrAgE ArEA BorOUGh
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-456 !
PERMIT NO.
SEWAGE DISPOSAL SYSTEM M APPLICATION AND PERMIT
TO BE INSTALLED BY
OTHER
NOTEz THIS PERMIT IS NOT VALID WITHOUT SOIL ~ES~
INSTALLATION LOCATION
· INSTALLATION OF: SEPTIC TANK
TYPE AND ~IZE OF FACILITY TO BE SERVED
FINANCED THROUGH
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: Z4 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL SE SUBJECT TO PROSECUTION.
MINIMUM DISTANCES, REQUIREMENTS DIAGRAM OF SYSTEM
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT DRAIN FIELD .
SEPTIC TANK TO SEEPAGE PIT WALL
SEPTIC TANK . SEEPAGE PIT , DRAIN FIELD
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK I SEEPAGE PiT
DRAIN FIELD ALSO CONSIDER AREA WELLS.
WATER MAIN TO SEPTIC TANK SEEPAGE PIT
DRAIN FIELD
SEPTIC TANK, , SEEPAGE PIT DRAIN FIELD
TO RIVER, LAKE, STREAM.
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
LICENSED DESIGNER
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DATE APPLICANT'S SIGNATURE
FORM NO. LQ-016
· ' G,"'"'XTE GU
.. R ANCHORAGE AREA BOROU
·
' ~ · , 2330."C". Street
, .? ' Anchorage~,.Ataska 99503
Performe'd for
Legal ~Description: /~-~-
lhis form reports: Soils log'~ '
.. Percolation test
Depth
Feet
2-
2-
4-
5-
6-
7-
8-
· 10 -
11 -
12 ....
13-
14-
Was ground waterencountered? IqLs'" If yes, at what depth? .........
Reading Date m ' '.Gross 'Time Net Time Depth to H20 · Net DrOp
· Percolation r,~te minute.
' ...... m:
PropoSed installation: .Seepage Pit: ......... Drain Field
..... ' ....
Depth of Inlet ' . De~th to bottom of pit or trench ....... .
COMMENTS: ..............
Performed By:!
iCertified By: Date:
Municipality of Anchorage .
Development Services DePartment
Building Safety Division
On-Site Water and VVastewater ~Program
4700 Bragaw Street
P,O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite ~
(907) 343-7904
CERTIFICATE OF ON-SITE SYST!EMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 017-361-06
GENERAL INFORMATION
Complete legal description
Location (site address)
C'OSA #.
Expiration Date:
McMAHON #1 BLOCK 3, LOT 26
3861· DOROSHIN AVENUE, ANCHORAGE, AK 99516
Current Property owner(s) BRADY STRADLEY
Mailing address
Lending agency
Mailing address
Day phone
POBOX 110817, ANCHORAGE, AK99511
Day phone
Real Estate Agent
Mailing Address
BARB HUNTLEY & ASSOC.
Day phone 227-5228
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPEOF~TER SUPPLY:
~. individU'al 'V'~,'i!:?~;,'
....:':'i~'. Individual water~!orage
COrrlmunity Class i::: Well
15'ubiic V~,~iei-'System
TYPE ~OF WASTEWATER DISPOSAL:
~;~ lndMduaI On-site [~
r"] tndMdual Holding Tank ['--]
[] Community On-site r'-]
[-i Pu b'lic Sewer E~]
The Municipality.of Anchorage Development Services Department (~D) issues Certificates of On-Site Systems
Approval (COSA)based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-~ite wastewater 'disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by :Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Sm
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS' Date 12/20/2011
Engineer's Comtnents: This investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to(he conditions as of the day tested. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate dudng the year and the
water usage of the family being served by the system. The operational 'life of all well and septic systems are
subject to these vadous and dynamic characteristics and are outside the control of the
evaluator of the well and septic, system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
bedrooms.
DSD SIGNATURE
'L'""'"' Ap proved for ~
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
Arsenic Advisory
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Maintenance Agreements
Supplemental: Engineer's Report
Other
Original Certificate Date:. / c~-- 3 (~- il
Municipality of Anchor. age
Development Services. Department
Building Safety Division
On-Site Water,& Wastewater Pro, mm
4700 Bragaw street~
P~O, Box 196650
Anchorage, AK 99519-665{)
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS ~PROVAL CHECKLIST
Legal Description: MeMnON #1 BLO(3( 3, LOT 26 Parcel ID: 017-3~61-06
A. WELL DATA
Well type PRIVATE IfA, B, or C provide PWSID #
Date completed 197S+/- Sanitary seal (Y/N) ~_
Total depth * 184' ft. Cased to * 40'+ ft.
FROM WELL LOG
Date of'test
Static water level
Well production
WATER SAMPLE RESULTS:
- g.p.m
Well Log (Y/N) N
~;'Wires properly protected (Y/N) Y__
Casing height (above ground). 20 in.
:AT iNSPECTION
12/2/2011
'147 ff.
4.5 g.p.m.
Coliform o .colonies/100mL Nitrate 4.34 *mg/L
Arsenic: ND rng/I Date ofsample: 12/3./13. & 12/19/13.,~ ~ .. Collected by:.,A~cTe~a
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Concrete & Steel Date installed ~ Tank size 1000 & 500 gal.
Number of Compartments I & 1 Cleanouts (Y/N) _Y_ Foundalioncl~rmut (Y/N) Y__ Depression over tank (Y/N)
High water alarm (Y/N) N Date of pumping ,12/1/2011 Pump~;~, McDonald~
C. ABSORPTION FIELD DATA
Date installed ~ Soil rating (g.p.d./ft2 or ft~/bdrm)i.~,~, System type ~
Length 20/18 ff. Width 24/3 ff. Gravel below pipe 6/3~5·,:~:,~ Total depth ~0/10ff.
Eft. absorption area 528 / 126 ft2 Monitoring tube Y Depre~n over field N
Date of adequacy test 12/2/201_3. Results (PasstFai~,.~ass For..~ bedrooms
Fluid depth in absorption field before test 0 ! 0 in. Water adde~ 6~8 gal, .New depth 3.0 in.
Elapsed Time: 1200 min. Final fluid depth 0/0 in. Absorption r~. >=600. +_ g.p.d.
Any rejuvenation treatment (pa~t 12' mo,) {YIN &type) Nil ya~, give'date ....:.
· D. LIFT STATIOlir
Date installed
"Pump on· level at in.
Datum.
SEPARATION DISTANCES
Size in gallons
"Pump off' level at in.
Cycles tested
Manhole/Access (Y/N).
H~ water alarm level at in,
Meets alarm. & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption field on lot .100'+
Public sewer main
Sewer/septic service line
Animal containment areas 50'+
On adjacent lots lOO'+
On adjacent lots loo'+
Publtc'sew~er manhole/cleanout 100'+
Holding.:tank
Manurefei~imal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON~OT TO:
Building foundation 5'+ Property line $'+ Absorptionfield 5'+
Water main 10'+ Water service line ~0'+ Surface water 10o'+
Wells on adjacent lots 100,+
lo0'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT.TO:
Property line lo'+ Building foundatisn 10'+
Water Service line .. lo'+ Surface water lOO'+
Curtain drain Sly+ (No~te K~towa)
COMMENTS.
Water main 10'+
./Driveway, parking/vehicle storage
:"Wells on. adjacent lots 100'+
10'+
.*Per MOA records and· the attached AAROW ce_~in§ veri[-~k)n ie~,ter.. Vacant system surcharg_~.
with 2000 9allons prior to testing.
G. ENGINEER's CERTIFICATION
I certify that I have. determined through field inspections and
review of Municipal records that the above systems are in,
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name KI~NNtlTHM. ]~OFFOS
COSA Fee $490.00
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver' F~ $
ID-ate ofi.~ment
Receipt. NUmber
Dec 23 11 08:23a Dad 3388078 p.1
Aarow Pump & Well Service, LLC
P.O. Box 110496
Anchorage, AK 99511
Office: (907) 346-9355 · Fax (907) 333-8976
Eagle River: (907) 622-9335
CUSTOMER
._~u,_~. .~_c_c_.c:
JOB SITE
/ /
II'VOICE DATE WELL ~IBPTH I SWL ~" CHLORINATED I PU~IP DE
' L
.................. ~~o ~~~~~_~_~
~BOR HOURS RATE AMOUNT TOTAL MATERIAL
L
/
W~RK ORDERED BY~ DATE comP. TOTALLABOR l,
PAY THIS AMOUNT
Than k You
SIGNATURE.
(I Hereby Acknowledge the Satisfactory Completion of the Above Described Work and agree that if above work is not paid for in 90 days I agree to allow Aarow
,~ Pump & Well Service, L.L.C. the right to remove unpaid for equipment and charge for labor already performed & labor to remove unpaid for equipmen[)
TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE.
SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS.
147.00'__ S88° 05' 00"E
27
IJ.I
10' UTIL ESMT
62.0'
1~. EXISTING ~=.
~ 1~ HOUSE ~
J '"""' Il ,' III 62.0'
N88° 05' 00"W 147.00'
35.5'
o
WELL
DOROSHIN AVENUE
"'r'] LOT SURLY
UNDER NO CIRCUMSTANCES SHOULD AN AS-BUILT BE USED FOR CONSTRUCTION OR FOR ESTABUSHING BOUNDARY OR FENCE UNES.
THE SURVEYOR TAKES RESPONSIBlE"PI' FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL UABIUTY ONLY FOR THE COST OF THE SURVEY.
PLOT PLAN
I h~"~y ~r'Ufy UIOt I ~M p~)~:dly
FOUNDA~ON AS-BUILT
~NAL S~U~R~ AS-~ILT
[] rou.oA~o. AS-BUILT
[] FINAL SIRUCTURE AS-BUILT
[] PLOT PLAN . .. AS-BUILT... LOT SURVEY . .. TOPOGRAPffy
~ AS-BUILT... NO CORNE~S ~-T [] RECERllFICA'EON AS-BUILT... NO CORNI~ ~
PLOT PLANS &: LOT SURVEYS
IT IS THE RESPONSIBIUTY OF THE BUILDER OR OWNER, PRIOR TO
CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE
TO FINISHED GRADE AND UTIMTY CONNECTIONS AND TO DETERMINE
THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT.
SURVEY CER~FICA~ON
SURVEY TYPE
SYMBOLS
SET REBAR ~ ~ DRAINAGE ~ ASPHALT
FOUND RE:BAR c c c Woo0 FENCE ~ CONCRETE
ASSUMED E3-EV. X X X METAL FENCE ~ WOOD DECK
NOTE:
ONLY THOSE IMPROVE:MEN'rS ABOVE: GROUND AND ~$1BLE WILL BE
SHOWN. FENCES, WE:U_S, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS,
ETC., ARE SHOWN tN THEIR APPROXIMA'IrE LOCATION, ONLY. SNOW
MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED.
ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED.
Robert
Scole:
Dote Surveye~
Prepared by
E. Johns, Jr. & Assoc.
Professional Land Surveyors
1700 Brink Drive.
ANCHORAGE, ALASK.A 99504-
jRec. Lot S.F. IRED. Plot File No.
1":11/30/130' 1 [pow. ,:,. REJ Jc~"''ed b~MK
12/01/11 I~''' 2835 Iw'°' 11-414
Dote Drown:
Legal Description:
LOT 26 BLOCK 3
MCMAHO.N #1
USTED DISTANCES PREVAIL OVER SCAUNO. REPROOUCTION MAY CAUSE ERRORS IN SCALE.
SGS ReL# 1116006001
Clie.nt"Name ArcTcrra Engineering and Surveying Printed Date/Time 12/22/2011 10:53
Project Name/# 3861 Dorosiny McMahon B3 L26 Collected Date/Time 12/19/2011 15:45
Client Sample ID 3861 Doroshin McMahon B3 L26 Received Date/Time 12/19/2011 16:08
Matrix Drinking Water Technical Director Stephen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Microbiology Laboratory
E. Coli Negative 1 100mL SM20 9223B A 12/19/11 MEM
Total Coliform Negative 1 100mL SM20 9223B A 12/19/11 MEM
2 of 3
SGS Ref.#
)'Client Name
Project Name/#
Client Sample ID
Matrix '
1115793001
ArcTerra Engineering and Surveying
McMahon 1 B3, L26
McMahon I B3, L26
Drinking Water
Printed Date/Time
Collected Date/Time
Received Date/Time
Technical Director
12/27/2011 13:52
12/01/2011 16:00
12/01/2011 16:30
Stei~hen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Hardness as CaCO3 179 5.00 mg/L SM20 2340B C 12/02/11 12/05/II SCL
Waters Department
Total Nitrate/Nitrite-N
4.34 0.100 mg/L SM20 4500NO3-F B 12/07/11 AYC
Microbiology Laboratory
E. Coli
Total Coliform
Negative I 100mL SM20 9223B A 12/01/11 DLC
Positive 1 100mL SM209223B A 12/01/11 DLC
Private Individual Analysis
Alkalinity 136 10.0 mg/L SM20 2320B D 12/05/I1 CDE
Aluminum ND 20.0 ug/L EP200.8 C 12/02/11 12/05/11 SCL
Antimony ND 1.00 ug/L EP200.8 C (<6) 12/02/11 12/05/11 SCL
Barium 9.48 3.00 ug/L EP200.8 C (<2000) 12/02/11 12/05/11 SCL
Cadmium ND 0.500 ug/L EP200.8 C (<5) 12/02/11 12/05/11 SCL
Calcium 54600 500 ug/L EP200.8 C 12/02/11 12/05/11 SCL
Chloride 18.4 0.100 mg/L EPA 300.0 D (<250) 12/12/11 12/12/11 SDP
Chromium ND 2.00 ug/L EP200.8 C (<100) 12/02/11 12/05/II SCL
CO3 Alkalinity ND 10.0 mg/L SM20 2320B D 12/05/11 CDE
Conductivity 388 1.00 umhos/cm SM20 2510B D 12/05/11 CDE
Copper 18.6 1.00 ug/L EP200.8 C (<1300) 12/02/11 12/05/I1 SCL
Fluoride ND 0.100 mg/L EPA 300.0 D (<2) 12/12/11 12/12/11 SDP
HCO3 Alkalinity 136 10.0 mg/L SM20 2320B D 12/05/11 CDE
Iron' ND 250 ug/L EP200.8 C (<300) 12/02/I1 12/05/11 SCL
Lead 2.96 0.200 ug/L EP200.8 C (<15) 12/02/11 12/05/11 SCL
2 of 5
SGS Reft# 1115793001
Client Name ArcTerra Engineering and Surveying Printed Date/Time ,- 12/27/2011 13:52
' Project Name/# McMahon 1 B3, L26 Collected Date/Time 12/01/2011 16:00
Client Sample ID McMahon 1 B3, L26 Received Date/Time 12/01/2011 16:30
Matrix Drinking Water Technical Director Stel)hen C. Ede
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Private Individual Analysis
Magnesium 10500 50.0 ug/L EP200.8 C 12/02/11 12/05/11 SCL
Manganese 43.1 1.00 ug/L EP200.8 C (<50) 12/02/11 12/05/11 SCL
Nickel ND 2.00 ug/L EP200.8 C (<100) 12/02/I1 12/05/11 SCL
OH Alkalinity ND I0.0 mg/L SM20 2320B D 12/05/11 CDE
pH 7.80 0.100 pHunits SM20 4500-H B D (6.5-8.5) 12/05/11 CDE
Selenium ND 5.00 ug/L EP200.8 C (<50) 12/02/11 12/05/11 SCL
Silver ND 1.00 ug/L EP200.8 C (<100) 12/02/I1 12/05/11 SCL
Sodium 5250 500 ug/L EP200.8 C (<250000) 12/02/11 12/05/11 SCL
Sulfate 14.9 0.100 mg/L EPA 300.0 D (<250) 12/12/11 12/12/11 SDP
Total Dissolved Solids 214 10.0 mg/L SM20 2540C D (<500) 12/05/11 KAN
Zinc 291 5.00 ug/L EP200,8 C (<5000) 12/02/11 12/05/11 SCL
Arsenic ND 5.00 ug/L EP200.8 C (<10) 12/02/11 12/05/11 SCL
Thallium ND 1.00 ug/L EP200.8 C (<2) 12/02/11 12/05/11 SCL
3 of 5
... APPLIC'~'iT FILLS OUT' UPPER~HALr'"ONLY
Fro~perty Owns: /~'/~o J 1 ~' "J-~Z- " Phone
Buy'er ..~:t-,~ d l. V 8r~ de V ~ ~' .... '
Realty Co. & A~}ent ~'~'~-.-// ~'0~--~ ~ Phone
Address ~
Type of Residence
'-~Slngle Family
*l-] Multiple Family No. of Bedrooms
D Other
Water Supply
J[;~lndividual . ATTACH WELL LOG. A well Icg Is required for all wells drilled since June 1975.
I-I Community . . For wells drilled prior to that date, give well depth (attach Icg If available).
i-I Public Utility
Sewer Disposal /
.l~lndivldual 'Year Indlvldual Installed:
F1 Public Utility When Connected to Public UtlHty:
FI Holding Tank ·
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. ..
Time Time Time Time "
Date Date Date Date
Inspector Inspector Inspector Inspector :
Field Notes: .MUNICIPALITY OF ANCHOP. AGE
DFPT. Or V~LTII ~'.
~ ~ t ENVII~NMEI' 4TAL F gO ,'F.~fION
OCT '71982
RECEIVED
( ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL '
DISAPPROVED ~
·
11 .
Soils Rating Date Sewer Installed Well To Well Log Received
Well to Tank Septic Tank Size
72-023 (3/82)
ALASKA ellUlROlllllellTAL COI1TROL $1 RUICeS, IllC.
I~nqinecrinq ~ (~nuironmental Studies
October
MUNICIPALITY OF ANCHORAGE
ENVI~:ui ¢;,;f-, ;AL f'.,O'. £CTION
OCT ? 1982.
Department of Health and Environmental Protection
825 L Street
Anchorage, Alaska 99501
On October 1, 1982, we performed a health authority at the
property located at McMahanSubdivision, Block 3, Lot 26. The
well is located over 100 feet from the on-site sewer system.
All standpipes are properly capped and the well has a sanitary
well seal. The top of the well extends approximately one foot
above the ground level. On this date a water sample was
collected for bacteriological analysis. The results were
negative, a copy of the analysis is attached.
Sincere ly,
~//d" im Green Engineer
Enclosure
~.~ 'Or
1220 U.Jest 25th Auenue · Anchoraqe, Alaska 99503 · (907) 276-1361
AL'ASKA' I I1UIROIlmI IITAL COFITROL $1 RUlgeS, IFIC,
J~nqin((rin9 ~- ~nuironm(nlal Stu(Jies
lO/1/82
A/IUNJCIPALITY OF ANCHORAGE
DFPT, O. )'~t, LT~'i ,t
ENVI,ROI,It,'~6t, FAL
OCT ? 1932
RECEIVED
FIRST NATIONAL BANK/JULIE
1821 S. GAMBELL
ANCHORAGE AK 99502
SELLER - KEN KETZ
SUBDIVISION-MCMAHAN
BUYER-STRADLY BRADEY
BLOCK-3 LOT-26
ADEQUACY TEST FOR SEWER SYSTEM
THE TYPE OF ABSORPTION SYSTEM IS A PIT WITH AN AREA OF 528 SQFT.
THE SYSTEM IS CAPABLE OF ACCEPTING 600 GALLONS OFiWATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 900 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A
4 BEDROOM HOME.
THE SEPTIC TANK WAS PUMPED ON 10/1/82 .
SEPTIC TANK ADEQUACY
THE EXISTING SEPTIC TANK VOLUME OF 1000~ GALLONS IS INADEQUATE BY
250 GALLONS FOR THIS HOUSE OF 4 BEDROOMS.
1220 lUcs! 25th Aucnu¢ · Anchoraq¢, Alaska 99503 · (907) 276-136l
October 12, 1982
Ken Ketz
330 C Street
AnChorage, AK
99503
Subject: Lot 26 Bl~ock 3 McMahon SD
Approval for the individual sewer and water facilities cannot
be granted until th~ following items have been completed:
The application shows the number of bedrooms exceeds the
number the on-si~e sewer system was originallY designed
for. An !upgrade.!will be required. Prior to any upgrade, a
permit needs to be issued from this department.
Please notify this Department for a reinspection when the
noted' discrepancies ihave been corrected. If there are any
further'questions, please call this office at 264-4720.
Sincerely,
Robert C. Pratt
Associate Environmental Specialist
t~ GREATER ANC"ORAGE AREA BOROUGHI ~
DePartment of Environmental Qualiltyi :
IStreet, Anchorage, Alaska 99503 ', ~274-4561
!Mailing Address:
?. Property Owner:
Time of iinSpection
Date of IinSPection
l:i: REQUEST FOR APPROVAL OF ' ;
INDIVIDUAL SEWER & WATER FACILITIES :
I :~ ! FOR '~ '
qPJ~ /i Phone:
Phone:
iMailing Address: 'i:: ; ~
3. Legal Description: ~ .~ ~ /~ ~ ~ c~ '~'~h --~.,,,~'.m"'
4. ~Location: ~ ' ~V~ '
5. Type of facility to be:i~nspected ~ ~o. of bedrooms ~
;A. lype ~ ~; ~ B. ~epth
~C.., Construction ,,: n. Bacterial ~nalys~s
7 .Sewage Disposal System: ~ ' '
g. Installed /~ 7q',~?;~ B. Installer ~~Y ~x~
:C. Septic Tank: I. ~Size 2. Manufacturbr[ .
D. Seepage Pit: 1. '.A]b~orption Area~~,~ 2. Material
]E. Disposal Field: TOtal length of lines ~~ ~ ; '~
8. ~Distances: ':~ ' : ,.:
;A. Well to: Septic tan~k~/~o/~ ,, Absorption area ~/, Sewer Lines/~
~earest lot line ~',~ Other contamination
~B. Foundation to septic"~:tank ~ , Absorption area ; ¢
~6. Absorption area to 6arest lot line
EQ-034 (1/74) ': ;:': ; Page. 1 of two, page, s:[
'1 ~' ~ [ ~ :I
:"'..,Pag~ '2 of two pages - R6''"~t for Approval oi~ Individual "-~.~r & Water Facilities
Comments
ApProve~~. _~'~ _~~ Disapproved . Date ~..~___~=L'~'
Y ~pp~oval ,Valid for One year from date. signed
Greater Anchorage Ar~a Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
Certify that the infomiiation contained in this request for approval to be a true and
accurate representation ~f the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED ' Ii
EQ-034 (1/74)
Date
GREATER ANCHORAGE AREA BOROUGH_..
Department of Environmental Quality
3330 "C" St., AnChorage, Alaska 99503 - 274-4561
1. Type of Inspection:
2. Property Owner:
Mai-1 i n.g Address:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
CMRO VA .
FHA CONV
Day Phone.
3. Name. of Buyer:
Mailing Address:
4. Name of Lending Institution:
Ma'iling Address: ~_~ ~.
Name of Realtor or.Agent:
Day Phone
Phone
Phone
Mailinlg Address:
Legal Description:
Location:
Type of Facility to be inspected:
Water Supply
Type of Supply: Public Utility Individual
If Individual, number of. dwellings presently served
If Individual, depth of well
Sewage DispoSal System
· Type of System: iPublic Utility
If Individual, date of installation
No.~ Bdrms. ~
Individual (on-site)
E0-037 ()/74)
