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Home My WebLink AboutALLEN LT 3Allen Lot 3 #015-271-56 Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP 201157 PID Number: 015 271 56 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑t Upgrade Name YANG ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 11100 CAN G E ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 5 - GPD/SF - Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade - Ft. Gravel depth beneath pipe - Ft. Subdivision Block Lot ALLEN LOT 3 Fill added above original grade _ Ft. Gravel length - Ft. Township Range Section Gravel width - Ft. Beds: Number of Lines - Distance between lines - Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line - Ft2 1 - Ft. Well +100 - _ - +25 TANK X Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1500 Gal. Surface Water +100 - - - Material POLYETHYLENE Number of compartments 2 Lot Line +10 - - - NA Foundation +10 - _ _ LIFT STATION Manufacturer Capacity Gal. Remarks old tank demolished per code TANK REPLACEMENT ONLY Alarm location Electrical installed by PIPE MATERIAL House to tank existin Tank tg drainfielo 3034 d Installer ISABELLE CONSTRUCTION Drainfield existing Co/MT3034 Inspector CHARLES BALZARINI BENCH MARK (Assumed elevation) 100 ft Inspection��t 6/26/20 Location and description nd dates:2 FOUNDATION NEAR FCO 3rd 4"' ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp \ of A�g Conditional Approval: Date AWstll r,`Q., • ,� orC s*: 49TM CHARLES �¢ Septic System G BALZARINI Approved Date 2� �F%, CE 13854 TF Note: this approvales not include well permit requirements.PROFESSkQO (Kev Ub/U2/16) 6/30/20 CHARLES G BALZARINI CE-13854 R E G ISTEREDPROFE S S I O N A LENGINEER06/29/20 Lot 3 Allen Subdivision 49,539 Sq. Ft. +/- 11100 Cange Street 3 Story Wood Frame House w/Attached 2 Car Garage ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;E E E T S SS SS SG W E N89° 56' 40"W 300.07 S89° 56' 40"E 300.04S00° 08' 45"E 165.10N00° 08' 00"W 165.1070.636.3 70.636.3 10.4 14.37.88. 0 8.3 16.2 48.751.3 11.930.1 177.916.3118.0 43.6 0.645.5LOT 2 LOT 4 10 0 ' W E L L R A D I U S P A V E D D R I V E W A Y STONE RETAINING WALL 4x4 SMOKER GRAVEL (TYP.) FIREPIT WOOD SHED SHED ℄ CANGE STREET30.0 R.O.W. PROFESSIONAL SEAL Date:Frontier Surveys, LLC Project No: 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 As-Built Survey of: www.frontiersurveys.com Frontier Surveys, LLC I, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or under my direct supervision on Plat:Grid:Ordered By: 907.460.1686 - info@frontiersurveys.com This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances should this document be used for construction or for establishing a boundary or fence line. June 29th, 2020. Legend: Scale 1" = 50' Lot 3, Allen Subdivision Charles Balzarini 20-252 6/29/2020 77-250 2634 Gas Meter Electric Meter Deck Septic Fence S G E E T Elec. Pedestal/ Outlet Tel. Pedestal ; Water Well General Notes: 1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws. 2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. 3. All measurements/setbacks are to the visual/apparent building footprint. 4. All dimensions to property lines are plus/minus 0.1ft.STA T E O F ALA S K A49 TH ROYEVRUSDNALLANOISSEFORP DERE T S IGER Pierre M. Stragier NO. LS-9812 06/30/2020 W MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite `On -Site Wastewater Disposal System Permit Permit Number: OSP201157 Work Type: SepticTank Upgrade Tax Code Number: 01527156000 Site Legal Address: ALLEN LT 3 G:2634 Site Mailing Address: 11100 CANGE ST, Anchorage Owner: YOUNG STEVEN K & YIAN S Design Engineer: C & M Engineering This permit is for the construction of: Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: i��cnt lleI)artrnent 6/10/2020 6/10/2021 49538 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Date: _ Issued B / y. � �C ( Date: �G �a.-20 5 MUNICIPALITY OF ANCHORAGE Development Services Department AW Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTICM/ELL PERMIT APPLICATION Parcel I.D. 015 271 56 Property owner(s) Young Mailing address Site address 11100 Cange Legal description (Sub'd., Block & Lot) Allen Lot 3 Legal description (Township, Range & Section) _ Lot Size 49,538 Sq. Ft. Number of Bedrooms 5 Day phone APPLICATION IS FOR: (® all that apply) Absorption Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ APPLICATION IS AN: TYPE OF DWELLING: Initial ❑ Single Family (SF) ❑ (w/wo ADU) Upgrade ❑ Duplex (D) FJ ❑ Multiple Dwellings ❑ (SF and/or D) THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: none Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. C&M ENGINEERING (Signature of property owner or authorized agent) Permit/Rush Fees: 0202 `J /& ?> -�'C Date of Payment: Receipt Number: Permit No. Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc COVID-19 257o' DISCOUNT APPLIED C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 6/5/2020 RE: Proposed Septic System Modification for Allen Lot 3 Dear Reviewer, The above referenced property is currently served by a 5 bedroom septic system installed in 1980s. The 1500 gallon tank has failed and is in need of immediate replacement. We are proposing that the existing tank be replaced with a new 1500 gallon HDPE tank constructed and installed in accordance with MOA requirements. A polyethylene tank is recommended. As shown on the plan, the tank will be greater than 10’ from the house foundation. The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover. The repair shall be performed by a moa certified installer in accordance with MOA requirements. Repair of the proposed system will not negatively impact adjacent lots. Upon completion of the installation, a record drawing will be submitted showing the location of the new tank, leach field, well, and other applicable features. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 6/5/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201157, Rebecca Carroll, 06/10/20 LF* CLEANOUT \ \ • MONITOR TUBE Z TEST HOLE 0.5%\ SLOPE INDICATOR \ APPROX. 100' WELL RADIUS \ ALLEN LOT 2 z w m w a w u 0 DRIVEWAY ��SP201157, Re • �r�dll�9 * ; 49 TH •• >k CHARLES G BALZARINI +�'c��,•. CE -13854 .•��`�� >>�_ pROFESSI�NP -� \ 100' WELL RADIUS NEW DOUBLE CONNECT TO EXIST. CLEANOUTS TRENCH. CHECK LINE FOR BLOCKAGES / DEMOLISH EXIST, TANK PER MOA REQUIREMENTS / NEW 1500 GAL HDPE SEPTIC TANK W/INSULATED RISER AT FIRST COMPARTMENT INSTALL PER MANUFACTURER'S \ AND MOA REQUIREMENTS ALLEN LOT 3 - � APPROX. 100' WELL RADIUS / \ALLEN LOT 4 1 I 0 20 40 " = LEGAL DESCRIPTION: ALLEN LOT 3 C&M ENGINEERING SERVICES OWNER: YOUNG DATE:6 907-854-5558 w w U) w z a U SEPARATION DISTANCE NOTES: THE PROPOSED SEPTIC IS GREATER THAN: 100' FROM ANY PRIVATE WELLS 200' FROM ANY PUBLIC WELLS 100' FROM ANY SURFACE WATER 10' TO ANY PROPERTY LINE OR FOUNDATION SITE PLAN MUNICIPALITY OF ANCHORAGE 0TDEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE �] NEW or L L ..L. VAA1 1/� c.1 c .(Al J y 1 AAi K Tf1 n t ❑ UPGRADE MAILING ADDRESS z LEGAL DESCRIPTION 3 t civ .s v S [ r ,2. /` ? h� -A .3 VV LOCATION NO. OF BEDROOMS Well Absorption area Dwelling PERMITNQ..NQ VY DISTANCE TO: j (�L�' �� % jf o 4- S� QQ % H ZManufacturer W / �= 7,4111 - Materi I 7 C E No. of compartments � ,4//(- ,d 4t Liq.capacity in gallons /s ,r IF HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. J Z _ F Manufacturer Material Liquid capacity in gallons O w = DISTANCE TO:Z Well Foundation �, '_ Nearest lot line Q PERMIT NO. �!� J LL Z No. of lines Length of each line Total len th of lines Trench width Distance between lines H Z w / J, Z_ inches Top of tile to finish grade Material beneath tile Total effective absorption area _ p j/ �- �t`�' /G R, X inches Length Width Depth PERMIT NO. w t7 4 H Type of crib Crib diameter Crib depth Total effective absorption area wa y DISTANCE TO: Well Building foundation Nearest lot line Class Depth Driller Distance to lot line PERMIT NO. J LU DISTANCE TO: Building foundation Sewer line Septic tankAbsorption area(s) OTHER t 6 PIPE MATERIALS SOI L TEST RATING 4 6-A., f -M . S INSTALLER ftiAA/,/< YN OS �� C REMARKS SLFG- A�"T/!ri/ /j .fry/L TL" % .45-T/tCA<if p A x _ _.. r R •. •NNN•N•••N NNN1•••.•• HO GE ... • .«.+..•a+esM.• ai/ DEPT. OF HEAT N+ 6bJ & ENVIRONMENTAL O-ECTI �1 ''•••......•see . MAY 121 APPROVED 72-013 (Rev. 3/78) yZ Y Date Static 'Water Level 161 feet Oallora Per Minute ter. Draw Doha feet Total Feet of Casi g u¢ �- �.Fial D:-111edi p (rr• to Deenend well i(7 to 174 pvsvel .066 174 to IR7 el e 182 to F 246 to perforated caging at 167 slid 181 water�o-jrky while test puroyint Hefty Drilling S.°.A. Box 155'3 H A :ohorsgc,nlaakS 99501 Re; Andy Zywot WELL CERTIFICATION Location of well: Lot 3 Allen Subdivision Well Size: 6 inch Well Depth: 168 feet Static Water Level From Surface: 1:48 feet Iroduction of Well on 5-16-82: 4gpm 4 feet off bottom,1 hr This Well should be of sufficient quanity for single family usage as production is at a rate far above minimum Municipal requirements. Well will have to be tested by Municipal or a recognized firm for impurities before. -:using. Alpine Drilling & Ent. 1;.0. Box 4-895 Anchorage, AK. 99509 AA91 08 MUNICIPALITY OF�AN CHORAGE DEPT. OF N" EN�IROtiM`NTAL PROTECTION RECEIVED �U 1-4 1 e::: I F --*=i L_ I -T *-e Ce F=- F=l ��H __�' F --"F--1 f___l FE DEPARTMENT [ HEALTH AND ENVIRONMENTAL JTECTION ' 825 'L' STREET, ANCHORAGE, HK. 99501 264-4720 PERMIT NO. ( 830127 ) APPLICANT -T�^l 144 W 15TH 99501 277-9115 CA - LOCATION LEGAL L] ALLEN LOT SIZE 999999 SQUARE FEET, TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT/BR)= 165 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: E> E: 1� -7- "= ::L --=" L_ E: N Cl -T- "= -* --- C -i Fc" V F= L_ �E: F::"-T��= � THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD. THE DEPTH OF H 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). F;; -'E—= CA U I FZ E= Cx ��I V__; �" U=Z ; I =- 1—== ��&Z-1 1:3 n L_ L_ Cl ":E3 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. ___ -rL4Cs < �2 ----a l r -J—'=; F:" F= I=- -r 11 13 fl-J!S7. F=l F;?- F= �FEE �U I F:;?- F= U_- _ BHCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND TO H COMMUNITY SEWER LINE IS '75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F='E—= F;;.M I -r �X F=' I F;;.E—=:E; C -m E—= r-- E= M E: F="F;;?- 2z:JL^ ��4 —Z.l ___ I CERTIFY THAT 1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS HND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE I REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED ------------------ _ APPLICANT -L�(�r\ ��t�/�/��~ _.-_ - �..-� / ISSUED BY DHTE �Y/� /� ~� Y4 0 ___^^__��______=_==_ _ ____�___� � // 1.1 U" I ®-: I �=1 t- I IF '-e CA F- n t- CI t-• - ' F' F=1,:3 E DEPARTMENT Or HEALTH AND ENVIRONMENTAL r VOTE= T I r std 825 `'L" STREET. ANCHORAGE, AK. 99501 264-4720 CAr-.1 -_'=• I IF FE "-TEL-3EF-' lam'F=F-'r•i I IF PERMIT NO. 830127 DATE OF ISSUE x:15 C7 CA F• N WARNING - DUE TO CHANGING REQUIREMENTS THIS PRINTOUT MAY NOT BE AN EXACT COPY OF THE Off° I G I OVAL PERMIT +' APPLICANT GAIL I Z WOT 144 W 15TH 99501 277-9115 LOCATION N LEGAL L_ ALLEN LOT SIZE 999999 SQUARE FEET TYPE OF SOIL ABSORBT I C N SYSTEM I _ : TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING Q FT/BR) = 165 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM I _ : E>EF•TVi= AL21L..-.EEt4i3IFVA== ot'20 C3F'1=141EL_ E>EF•IFV4_ THE LENGTH DIMENSION I THE LENGTH (IN FEET OF THE TRENCH OR DRA I NF I ELD. THE DEPTH OF A TRENCH Cid' PIT IS THE DISTANCE BETWEEN THE SURFAC=E OF THE C;F'OCIND AND THE BOTTOM OF THE EXCAVATION I N 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 N IN FEET:. F;:?- FE w-! 1_1 I F' E-=: CA =• != F=' -r I ;-: IF""k-_ = I -2"!5 a=1 1a n L.._ L_ CA=- - — - F L.4 CA :a I r-4F'F= 1: T I w-1 r-4 ' 1-1 F' F= F' E 1-! 1_1 I F-' E C■ — — BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION HC' D APPROVAL BY THIS DEPARTMENT WILL BE 'f IB.TEC T TO PROSECUTION. MINIMUM DI+TAN E BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL; OR 150 TO i 200 FEET FOR A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC: WELL. MINIMUM DI_TAN E FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND Ti 1 A COMMUNITY _,EWER LINE IS 75 FEET. OTHER REQUIREMENT` MA`•r' APPLY - SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO i IN=URE PROPER INSTALLATION F• E F: t•1 I T F=' F• I F' E •-• C -a E o-: F= Irl F= E= F' =: AL - AL _2 = _- I CERTIFY THAT 1: I AN FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE _EWERS AND WELLS AS -ET FORTH BY THE MUNICIPALITY C rF ANCHORAGE. RAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. : I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THS RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED: ----•------------------------------------ APPL1CANT GAIL I ZYWC iT ISSUED B4'------------------------------ DATE_= I NSPE+_ T I ON HISTORY -_ EWER 1 0 SEWER 2 0 WELL I NSP 0 WELL LOG GATE 0 DRILLER C)ob"j ovvyU4 SOILS LOG ' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 1:1PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: V' Al r3 4� 4- f /1! j Ir % DATE PERFORMED: T 'Z 6 9-34 LEGAL DESCRIPTION: z L -..v S U►3 iG 71 _8 V� DEPTH SLOPE SITE PLAN (F EET) III n �� 1( S 1 , 2 3 •� v 4 5 6 a �� 7 .y 8 �`•� 9- 10 11 12 13- 14- S,/ h 15 ` / S'/9 6e% Deo) WAS GROUND WATER CvAAre 5.4 (� ENCOUNTERED? 0 P IF YES, AT WHAT E DEPTH? m Y." , 18 O R • • i0i!.s.•1#��. •#1.1#••••••••• • " M •r •�...•.i•.H : 4'C'� 19 1�� c ~ �r Gory J. Mellott ••• CE 5444 •; V Reading Date Gross Time Net Time Depth to Water Net Drop 20 OFESS�aa�� PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT COMMENTS C k -C,4 V 1 Te 0 %3' `% QI C C t_- /1 6AXI PERFORMED BY: 6A1%,>„ 7- 1 � �'``/ CERTIFIED BY: � � �� DATE: 72-008 (6/79) .i i ";i. ^! I ` All ii0NIMIFN I k1, i" X07 _i'1 iON :Permit #: 821116 January 31, 1983 TO: Permit Applicant Subject: Lot 3 Allen 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 the 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 files and documentation. If there are any further questions, please call this office at 264-4720. Sincerely �P' /j' Robert C. Pratt, R.S. Acting Program Manager Sewer and Water Program RCP/ljw enc: Copy of Permit SWP/057 PC)UCI i 6-650 AN!' 0 R A G EL,A. r� .i i ";i. ^! I ` All ii0NIMIFN I k1, i" X07 _i'1 iON :Permit #: 821116 January 31, 1983 TO: Permit Applicant Subject: Lot 3 Allen 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 the 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 files and documentation. If there are any further questions, please call this office at 264-4720. Sincerely �P' /j' Robert C. Pratt, R.S. Acting Program Manager Sewer and Water Program RCP/ljw enc: Copy of Permit SWP/057 _ M U N I f_-_ I F�c n L_ I "lF V IZI F= n " I::-- U4`14:Rn 0 E: DEPARTMENT , HEALTH AND ENVIRONMENTAL OTECTION 825 'L' STREET, ANCHORAGE, HK. 99501 264-4720 L4 1-= I L_ r-4 C)- ID r-J_SE-- 11 -r I-= L4 r=- F;R_' ��FR_ r-1 3:'T, PERMIT NO. ( 821116 ) APPLICANT GAIL I ZYWOT PO BOX 264 CHUGIHK 99567 688-2914 LOCATION LEGAL L3 ALLEN LOT SIZE 999999 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT/BR)= 165 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: ��-F "= �f:'* ��"13-r"= -* 2! C-3 F;;?- F:4 V 1-=: L_ E> 1-= F:" -r "= :-='. THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD THE DEPTH OF H 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). ��U I F;;?-, a L-'-* :F. F= F=* -r I r-- -r " " K �I = F="= �L 22!5 10 �n L_ I C, "� 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. ___ -rWL-3 <;2 > I " S>- F=> E: Z� -r I ID "!R; F4 FR E-= IR FE 0! U I I:R FEE L-,-. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. �FEE �M I -T- E: X F=" I FZ E:!S ��FEE M E� E: FR_ 3:::L _. :lL�� I CERTIFY THAT 1: I HM 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 THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCEIS D TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED�_ ° ---------------- APPLICANT GH��ZYWOT Mike Doyle SRA Box 1751A Anchorage, AK 99507 Permit # 810730 Subject: L3 Allen S/D A permit issued by this department for a well and/or sewer system has expired as of December 31, 1981. 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 should be sent to this department to document the installation date. If an engineer inspected the installation of the on-site sewer system, please have them send us the as-builts for our files. If. there are any further questions, please call this office at 264-4720. Sincerely, 4�;4 Les N. Buchholz R. . Program Manager Sewer and Water Program Enclosure: Copy of Permit ~ ��I C- I P --Fl L_ I _T_ 'w" (�) F07 foi r4 C2 f4M FQ FA C3 E=' DEPARTMENT L HEALTH AND ENVIRONMENTAL OTECTION ~ 825 'L' STREET, ANCHORAGE, HK. 99501 ' 264-4720 U4 E= L_ L_ ��4 r-. T E_- 1.4 E_= PERMIT NO. ( 810730 ) APPLICANT MIKE DOvhw SRH BOX 1751H 149-7207 LOCATION CHHNG RD. LEGAL L3 ALLEN 5/D LOT SIZE 61050 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT/BR)= 165 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: �FE rA 13 -IF "= THE LENGTH DIMENSION IS THE LE E�TH�*Im FkET--OF THE TRENCH OR DRHINFIELD. THE DEPTH OF H 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). Fe- ��I F�_* E= Us �I-= F`F I i::- �" N 1-:c- �I = E== :JL;R!ff, C-21 �" L_ L_ Cl " —'-. 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. -F 1.4 Cl < :2 > I I C__lr4!E- nf;;?F= �� ___ BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ONrSITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 150, T 0 �rEE7!-PROM H PUBLIC WELL DEPENDING ` UPON THE TYPE OF PUBLIC WELL. 1 _ `~^� MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. ��F;'."N I _1F I F -.*F=-*=-- �� IH: A I CERTIFY THAT 1: I HM 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 THE CODES. ]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. ��rv��; �/� �'~. /SOO��' SIGNED:__-��L��___��= _��------------- APPLICANT MIKE DO�� /�7�� S�!�� ~ ��e-71t = SAIr � _____DHTE�Y� tISSUED BY_ =~ Ju"VL°~ t/N4--'_3_S /i4 0+AL/»� /. 40,10 "E3" STFZF=ET tr ANCHORAGE, ALASKA 99Fi03 (ALAWk (907) 278.1551 August 8, 1978 W.O. #A18551 Grid #2634 Mr. George Allen 6209 Chevigney Drive Anchorage, Ak 99502 Subject: Subsurface Investigation for Lots 1, 2, 3 & 4 Allen Subdivision Dear Mr. Allen: Our previous report, dated October 12, 1977 only ran percola- tion tests on Lots 1 and 4, it therefore being necessary to do additional work on Lots 2 and 3. we performed the addi- tional subsurface investigation work on July 19, 1978 per the request of Mr. Archer. Based on the exploration done in October 1977, a11d this more recent exploration of July 19, 1978, we make, the following summary for the design percolation rates on the four lots: Lot. 1, 5.0 minutes/inch Lot 2, 8.0 minutes/inch -•- Lot 3, 10.0 minutes/inch / Lot 4, 5.0 minutes/inch In this second }phase exploration, t=hrpe test voles were ulaced one cacti on lots 1 , 2, and 3. pliougiI Lot 1 hlid bt�cn done previously, the percolation rate shown was- unrcalist.iclly 11i_gh for the type of soil:; encountercd, ,"Id we felt that Justified a retest. Sixteen to 18.0' deep test holes werE:> placed on each lot using a drill rig owned and operated by Denali Drilling, Inc. The drilling was supervised and the test holes logged by Mr. Terry L. Barber, staff geologist with Alaska Testlab. The enclosed 'fable A is the log of those three test holes. After each test hole was drilled it was cased with a slotted, 3/4" PVC pipe, filled with water and allowed to stand over night. On returning the next day, the hole was again filled and the rate at which the water percolated out of the hole measured at 10 minute intervals for at least 60 minutes. The location of the test holes are shown on the attached Figure 1. SOIL CLASSIFICATION CHART �2 \ON CLAY 3U 0 GRAVEL \(,7 \ �' i A 0 IX 2 'T -vim O \61 CLAYEY CLAYEY CLAYEY \� Of?�OR CLAYEY /SiL I Y -/ SILiY i OR r SILTY \ 'A SILTY SAND \ GRAVELLY SAND SANDY GI A V E L GRAVEL o o SAND GRAVk-1_.LY SAND \ SANDY GRAVEL GRAVEL 0 10 20 30 40 50 60 70 80 90 1000 GRAVEL (+- 4 SCRI-EN) EY WEIGHT NOW-- - - - Gko( ltO:,1 SUS( fJ'TIt3! f. ,OIL S F1111 INU'rtC�Af�Jit: UII `, l`ON I 11 IAN ,i'Yo f INCR T1iAN 0.02 mrn, Gf2UUi'� 01 1 ko"I 511501 I'IItit t SOILS: 1 iAININC B! I V`it- 1 1,1 i ANl) I INI. f{ TI LAID r) I l ? �ANU`i' SUII C:UfVIiAIPJIIV(� ii( 74Jf I (J 3 iAiJl> 1`--, I II -!f I? II IAN 0.0? rirti)- f _f C,ItiAVI_L-I-Y ,UILS (UNIAlNIN(;"'Uio I INE -It I IIAN 0.0? ruin. ANC) SANDY SOILS f;iOfZ, f I Infv ([ XCE 1'T I INf SII_l `,ANU�r) CUJ I i�l{JIPJ(; F.�Uf(I I I liUl 1'.'%, 1 IN[ ft 1 I IAN 0.02 rrun. Ci AYS WI I I I I'LAS I k-1 I Y IfJC)f Xf `, 01 r (MO I I fl\N 1 ' I XCf PL VAIZVr-O 7 •1 /\I I_ ',II I" IfV( I '„ANt)Y 1,11 I `, i INf ,It _-1Y `,AfJUS CON IAININ(i PAl){(I II/\fV I'.":, I INI It l I V\N I)_0;' film. l I iAN (.I_iAY WI I i i 1'f iA I ICI I l' INiJI ;�I UI I ! 111/\N il. vAI?vI 1) (:1 /\Y`, �+K r Test Hole Log_ Doscription Guide oil descriptions shown on the lugs are the best estimate of the toil's :rcrisncs at the Lillie of field examination and as such do not achieve the .ran u( a laboratory testing procedure. If the log includes snits samples, samples recrive an independent textural classification in the laboratory .fy the field examination. gs often include the following items: DeTth Interval - usually shrrwn to f1A foot, within that zone no sign, slant ,}range to surf type was observed through drill action, clutter ubwrvation „r sampling. Frust Classificatmo - NFS, F1, F2, F7, F4, scc "Soil Cla-(natio}} ch a r i' ` -------- Texture ++f Soil An. engineering, clauification of the soils by particle 1 err and --pr o p -n Ilo11, see ••StirI (: lassifiucion Chat t'•, nottt the prop,+horns .ere approxlm.,I, and nv,difications to the soil group due to stratiltuunn, inclusluns and cilai+gcs Sir properties are included. Muisturc t -w' -fit this u a qualltat)vr ntr-asure: d_!y, o., it Retic Jpparrnt ulrtace mowwr, dau11s, rnnl,lu" loons p,>ruun sat color, Icss ;halt plascic limit, wet. mI (lee K,,Irr, ,Ilton sott, 11 , Ile sIvC Snil, Tsa-turated, free --ter nr.,y be squcczrd out, if a free draining soil; o:ii r, n[ Jt Irafulal ro,11liure c0occilt, 11 a non tilastic silt or title sand. (The moisture .ontcnt is further defined by reference to PI, LW, NP, W:, or dII,turcy.i Density - refers t„ more-oIJcss nun-n,hesI-- soils, such as sand gravrI mixtures with or with"sat a lure fraction, derived front drilling acts„n andJrr sample daia. usu.illy dcserihe:l .r, very louse, muse, rnedluni dens,, vet}' drnsc. General trurrlt is to portray earthwork characteristic s. $tiffn77r-ss -- refers to n„lett-or Ie Ss cuhrsrve .nils and line grained silts of ilio CIty-Slit grouts, l)-[lvcd Its, Ill dell! action �. nd"or Sample data. Very soft, sv(t, stiff, very ttitl and hard are cornrrlorlly used toms. Patticle $ire - The largest particir -coveted by the split spoun is 1 3ig•' Shelby tube 3", auger [lights 1mUiiate-man) 2", Auger flights (&SO hollow stem} 0'• g". Largrr particles arc described indirectly by action of the drilling and arc referred to as cobbles, 3" to 8 lir boulders 8",. Theirlorc when reviewing the gradation sheets, if any, the descriptwn on the hole fag mux be considered for an indication of }aria Particles. Unlf1ed Sud Classsfnatiun - 'rhis is a two letter code. See Unified ""'`"-a•r',n sheet Inn ±tinier dofmitiun. In carne gases AASHO a,Id;(,r r.. r:.:;:ticauuns may be shown as well as the unified. f.::rr'-arrif Lirn itt -- usrful for Fina grainrd and other plastic soils. P!; natural moisture ,untent bclirve,l to be less than plastic limit P-lr', natural moisture content believed to be between plastic and liquid r timltf L-; natural moisture content believed to be greater than liquid limit Np; nun - pIAIIIc, useul as a modifying description of some silty nlatcrials. Dilatencv - Is Ibe ability of water to migrate to the surface Of a saturated or nearly satu:atcd soil sample when vibrated Sir jolted - usrd as an aid to dcternllnc It a fine grsincd soil it a Shlihtly or non plaitic silt or a volcanic ash. frock flour - finely ground soil that it not plastic but otherwi-e apprars ion r to a clayey silt. organic Conteh,- usually drscribed as Peat• PT, sometimes includes oltetetr panicles such at w„ot{, ural, etc. as a meld It ire Iv .,n u,tv qa nil. soil. Quantrry drscnbr•d n; trace, or an rstirilate of volume. or, rel talc of all organit, -- as Peat. 'This lines enclose utndra, muskrg and bolt material. Muck - a ms,ditier used ter describe very soft, semi -organic deposits sae uA ily occ,ll rig below a peat dcp,,i/t. Amor bus tat - lir, odic Parti:les nrary or ii:lly drvnre.gritrd. Fibrous Peat - organic particles enure Sir Icss intact. fluttorn of Tcstooir - mclu,ics last sau+plc uilrrval. Frost Line - seas,�oal frust depth as dcsenbr,i by drilling aCtnnr anti; err samples at thr tune of drilling_ 1-1 ,:Cn Ground - ,uhrr Ih.ul Irnar Irnc, dcscnhr,l bs' •.,n !,Ics, u.ualiv Includes of Ire content, od tten wlli Inc!ur rn,xi:Ii,ri l.'nitl<r! Classtlitat:o., Inn t frit .u+IS - this I. a spcclal ,as rtiited h+ permafrost studirs. Free 'Xi cer I.rvrl Thr (rel u ,Irl Irvrl nr,tcd dunr+i; drIlhnp,. Ill!, r. n,.rt neceaar:ly the sulk sorer III,!, It the Boll of ,Irlllnlg „r at')Hwr SrapCn%. Stacie water tal,ir ,let er mnla!ton lir other th.,n "", penrahv' sails requucs oh%crvatn,rt wells err P,Ctooleter insi.sllanorls, tr.rd oil! 1' ;n Special .ries, liiuw!6" - The n.unlbrr of blows of a 1 J(I -eight free fallrllg 301 ru advance a 2" spirt spoors 6 the number of blows for a 12" a,ivance is. by dr (intron, the standard penetration. .A -v - natural moisture content of the still sample, .i,uilk n.,t performed on clean sands or gravels below the wails table. TZf - +c of Si-Ir.ple -----._.._ r reign to _ split :,prion driven tn(n the s.>II by 1 aU 1+.lunu weight, a disturbrd Simple, $, thin will tube-St,M)'y • used to obtain undtsturhrd samples u( fine grained soil, -grab" disturl,rd sarnpic from augrr ilights or will lit ttench, cut sample, undisturbr.l Samtlr from -All tit trench. lhv Strcr•�rh - a u,clul In,li.at„r of a soI!'s clayey (cocoon, fJ'Nmr, L °Law, M1I Mcdnnn, H=1#Igh _Grou��t - T 1 1 r vinples arc plated min a11pArrntly s11711 Ar grouP bated uT c, 1l. sr an,I Ic>tnr rand air nbttt.,f i"1,;nrd a i;toup�c .Iti I :,th"T disturbed costs intlwling Attc:brrg l.In r. s, grain syr, lir lir drasrry rclatlnn,hip, etc. n:.+y he perlorn+n{ .,n 011' g+„tip .n+,i air as. i ..:-,i to reflcet thr gene: al dutruIII, I ehara ierlst:ca of thr t.+:” as ;;lied 1 i the grout. fhls a .n import,oi 1, 1, „t the snll analyst and i, it,,d ;u standardirr the vuI nu quahutivr dC(Crl%MIAtl,Jrla and to rcdl c the number sal ytu ntru Uve tcln necr>... Y to dcs.uhe the tut} matt. Depth in Feet From To 0.0' - 0.5' 0.5' - 2.5' y2.5' - 5.0' 5.0' - 16.0' `L Bottom of Test Hole Frost Line: Free Water Level: Table A WO #A18551 Logged By: T.L. Barber Date: July 19, 1978 Soil Description Brown Peat, wet. NFS/F-2, brown slightly Silty Sand, SM, damp, medium density. NFS, brown Sandy Gravel, GP, dry, medium density, particles to 1". F-1, brown Silty Sandy Gravel, GM, highs density. 16.0' None Observed None Observed Lot $2 De th in Feet From To 0.0' - 5.0' 5.0' - 16.0' Bottom of Test Hole: Frost Line: Free Water Level: Table A WO IA18551 Logged By: T.L. Barber Date: July 19, 1978 Soil Description F-2, brown Silty Sand, SM, damp, medium density. F-2, brown Silty C;r_avel� Sand, SM, damp, medium density. 16.0' None Observed None Observed De�r�th in Feet From To 0.0' 0.5' 0.5' - 6.0' 6.0' - 7.0' 7.0' - 18.0' Bottom of Test Hole: Frost Line: Free Water Level: Table A WO #A18551 Logged By: T.L. Barber Date: July 19, 1978 Soil Description Brown Peat, Pt, wet, soft. F-1, brawn Si.1_ty Sandv Gravel, GM, damp, medium density. __ F-2, brown Si_It.Y Send, SM, damp, medium density. F-2/NFS, brown slightly Silty Sand, SM, damp, medium density. - 18.0' None Observed None Observed E a+ 5 ngo50'SO*E 329 95 0 N n ;o 299 87 329.07 �Y•W 1319.49 E �o r►�r�9 4'i 0 aD tD N 89 5950 W \ N 49 493 s.f..' D k 99 Q /%299.91 p I � d W 49,499sf. Tyr 4' 1 299.89 p 4 0 40,50- f- �^ TH 1 19�I . 0 N n ;o 299 87 329.07 �Y•W 1319.49 E �o r►�r�9 4'i 0 aD tD Development Services Department ,, Phone: 907-343-7904 On -Site Water & Wastewater Section - Fax: 907-343-7997 Certificate of On -Site Systems Approval O15 - 271-5or Parcel I.D. Expiration Date: L012 -17 -OZ -0 1. GENERAL INFORMATION Complete legal description ALLEN LOT 3 Location (site address) 11100 CAN GE Current property owner(s) Mailing address Real estate agent YOUNG 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Date of Payment dZ0 1 Receipt Number o 7 a a N_." COSA#0�S(',201293 Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines 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. Name of Firm C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 6/30/2020 of 1 *: 49 TH .* I 6. DSD SIGNATURE ...... System #1 Approved for _-b bedrooms �� gRLES G BALZARKf� System #2 Approved for bedrooms ��Fl��. CE -13854 Disapproved Conditional approval for bedrooms, with the following stipulations: ON-SITE �'� -� WAi�;�ATER o' pROG�\ A� Op'�/�A 11JVl o,r_x\\_tel By: !tet/ Original Certificate Date: Z The Municipality of Anchor, Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist yellow sheet COSA Checklist Legal Description: Parcel ID: If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample Comments __________________________________________________________________________________ B. TANK DATA Age of tank(s) years Tank type/material Measured operating fluid level in septic tank Standpipes/foundation cleanout per record drawing Date of pumping C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA ______________________ Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Code-required soil cover over field System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Adequacy test date Results Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Property Line > 5’ Yes if No ft Absorption Field > 5’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10’ Yes if No ft Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft F. ENGINEER’S COMMENTS 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. V ,5 . - Municipality of Anchorage /. -- Development Services Department Building Safety Division a On -Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage. AK 99507 www.muni.org/onslte (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel l.D.LlJ6o2qI—Sio COSA# 6)80111 Expiration Date: 7' 3 O — O 1. GENERAL INFORMATION 1 Complete legal description Litn 5�0 X07 3 Location (site address) 11,100 l an5t )Pte c /111 T1 't Current Property owners) Wi ili2rn R;00r) Day phone Mailing address Lending agency Mailing address Day phone Real Estate Agent peie Tornnsor% Day phone S3D -1'976 Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: S 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 01 Individual On-site 9: Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) 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-site 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 seat affixed hereto and as of the validation date shown below, I verity 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 ineffectat the time of installation. Name of Firm SP4r klanJ �nyi n eery ny Phone Address 203 W. I511` Ale. s%e.1o3_,ARcAgC51e, AK 9950! Engineer's Printed Name 5. DSD SIGNATURE _/ Approved for bedrooms. Disapproved. Date _ OF A.f ll •tg�lj%� r 1l/ /11,�1�F�FR 1E30 0a�;�� i Conditional approval for bedrooms, with the following stipulations: ►tKM- rT5'.7i0 COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory (Rw r1As) Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: 4 —3 0 D� Municipality of Anchorage •. • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.orglonsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: AIlen 5'D W3 Parcel ID: 015-211-5(o A. WELL DATA Well type Prwt�L t' If A. B, or C provide PWSID # = Well Log (YIN) y Date completed _� _SS (Jeqe'�) Sanitary seal (YIN) Wires properly protected (YIN) Y Total depth Z3ro ft. Cased to Z3(o fl. Casing height (above ground) I Z in. FROM WELL LOG AT INSPECTION Date of test JISS A I pr',l25 ZU08 Static water level 161 ft. 155 ft. Well production 5 t 9-p m. G. c/ g p.m. WATER SAMPLE RESULTS: Coliform --p--colonies/1 00 mL Nitrate mg/L Other bacteria _6 colonies/100 mL Arsenic: -,6— ugA Date of sample: q it Collected by: S uA B. SEPTICIHOLDING TANK DATA Tank Type/Matedal Anc 6rar,T Ak 1500 3i e� Date installed Alaj 12 1 1783 Tank size 1500 gal. Number of Compartments Z Cleanouts (YIN) v Foundation cleanout (YIN) Depression over tank (YIN) High water alarm (YIN) IV Date of pumping 29 2000 Pumper T it4e3 PeM ink �rwi C. ABSORPTION FIELD DATA Date installed AW), 83 5 12 HB Soil rating (g p.d.e o ft=A�drm 1w, System type kep MenC� Length 5Z ft. Width 1.5 ft. Gravel below pipe Total depth ft. Eft. absorption area 837 ft" Monitoring tube y Depression over field N Date of adequacy test 2 0 Results (PasslFail) _S±JL For 5 bedrooms Fluid depth in absorption field before test b in. Water added I1 S00 gal. New depth _15 in. Elapsed Time: W min. Final fluid depth lb in. Absorption rate >= 750 g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) /VD If yes, give date - D. LIFT STATION Date Installed Size in gallons Manhole/Access (Y/N) 'Pump on' I at _ in. 'Pump off" lev t _ In. High water alarm I at in. Dat Cyd sled Meets al circuit require E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankllift station on lot I00r+ Absorption field on tot 10o'4- Public 0or+Public sewer main 77 foo' Sewer/septic service line 25'+ Animal containment areas 50 + On adjacent lots 100+ On adjacent lots 1 DD' t Public sewer manhole/cleanout -77 /oo r Holding tank _ 6y/ Manure/animal excrete storage areas loot SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation lot+ Property line J2 Lt Absorption field 5'1 Water main tort Water service line 10 r Surface water —Al 0. Wells on adjacent lots Itb�+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line to +- Building foundation 10 �+ Water main 101+ Water Service line 10't Surface water N0• Driveway, parking/vehicle storage 10'+ Curtain drain N 0, Wells on adjacent lots 100'+ F. COMMENTS: G. ENGINEER'S CERTIFICATION t 1 gyp. s'r I certify that I have determined through field inspections and 9TH review of Municipal records that the above systems are in i ' ' • l ` / conformance with MOA COSA guidelines in effect on this date. • • ✓ •• r!� j I 11 f • LAP9 E. SP Engineer's Printed Name Lars ..Merit ana �/ �i'. 115C 4§,: Date 4IZd00 /IIt`p'F7�0FSG�`k�'�% / ' � n S%es�� COSA Fee S `["/U 4a Waiver Fee $ Date of Payment t/ •� sly Date of Payment Receipt Number_ IIL q#/ Receipt Number (Rev. 11105) SCS ReLM 1081471001 Client Name Tobben Spurkland P.E. Project Name/M Allen Lot 3 Client Sample ID Allen Lot 3 Matrix Drinking Water PN SID 0 All Dates/rimes are Alaska Standard Time Printed Date/time 04/18/2008 12:19 Collected Datefime 04/112008 16:30 Received Date/time 04/112008 16:50 Technical Director Stephen C. Ede Sample Remarks: Alloxablc Prep Analysis Parameter Results PQL Units Method Container ID Limits Date Date Init Metals by ICP/mg Arsenic ND 5.00 ug/L EP200.8 C (<10) 04/15/08 04/17/08 NRB Waters Department Total NitratcMitritc-N ND 0.100 mg/L SM204500NO3-F B (<10) 04/16/08 LCP Microbiology Laboratory Colony Count 0 cot/IOOmL SM209222B A (<200) 04/11/08 DLC Total Coliform 0 col/100ml- SM209222B A (<1) 04/11/08 DLC Fecal Coliform 0 col/IOOml. Sh1209222B A (<I) 04/11/08 DLC VLu w 40 FA t %J -- --- `r �wK .`.}d' a{ :: =. is TS. �• - -'-..•-• - �'� . f':"; �^�-1�',. � ria. rsi=3Tr�,� ("'..� C - •-- --__ _ . _ ....._ ' W 3 lot - 4 M � z e •: '•��l�oi7 1 1 O N _ o 1 FA t %J -- --- `r �wK .`.}d' a{ :: =. is TS. �• - -'-..•-• - �'� . f':"; �^�-1�',. � ria. rsi=3Tr�,� ("'..� C - •-- --__ _ . _ ....._ ' W 3 lot - 4 M � z e •: '•��l�oi7 1 Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. HAA# 4L, " QZo 004/ Expiration Date: S/,?0/o3 1. GENERAL INFORMATION Complete legal description Lo -i - ArLl L nl Location (site address or directions) 11100 cPTNG Lr— Current Propertyowner(s) I,VArm Dayphone 3(00-5-o7.,j Mailing address 11too LRLNraL- Lending agency Day phone Mailing address Real Estate Agent Chis % Day phone723�— Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: l5 3. TYPE OF WATER SUPPLY:, TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site E� Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (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 we!ls 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 verify that my investigation, based on procedures outlined in the Health Authority 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. Name of Firm 0 L. W" Sv O r V_l w0 7. Address 20 3 w t !7 LA ► zo Engineer's Printed Namer1cLti.4_d S. DSD SIGNATURE Approved for Disapproved. bedrooms. Phone A79-$5110 Date Conditional approval for bedrooms, with the following stipulations: Additional Comments st 2i31VMKSdM Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory By v' J� (R.v. 0110.) Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date:' �� Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorege.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LO T 3 A 1..1.1: til S)D Parcel ID: 015 - 27 I - 5 b A. WELL DATA Well type R If A, B, or C provide PWSID # -!�A Well Log (Y/N) `/ Date completed, 1486 Sanitary seal (Y/N)--f- Wires property protected (Y/N)_!V- Total depth A3_d* _R Cased to 9 R Casing height (above ground) _2� n. FROM WELL LOG AT INSPECTION / Date of test l A tt` 6.1,P, r+.l�i� /7f u Z Static water level 1 b ? ft u jewt.. ft. Well production 5 t g.p.m. b g.p.m. WATER SAMPLE RESULTS: Coliform 4--colonies/100 mi. Nitrate 42tWmg.A. Other bacteria colonies/100 ml. Arsenic: _ mg.A. Date of sample: 57 L Collected by: ! . Sou rlc B. SEPTIC/HOLDING TANK DATA Tank Type/Material S-Cp Lit . S4e4( Date installed l q 8 3 Tank size 1Sro gal. Number of Compartments -2. Cleanoouutss (Y/N) y Foundation cleanout (Y/N) T Depression over tank (YIN) High r alarm (Y/N) r� Date of pumping S1111at Pumper C. ABSORPTION FIELD DATA Date installed I R &S Soil rating (g.p.d.W or ft2/bdrm) JgJ - System type 44m t �+ Length ft. Width ft. Gravel below pipe is ft F Total depth I 1 ft� Efl/. absorption area B Z- R' Monitoring tube Depression over field Date of adequacy test ✓`/7%i Results (Pass/Feil) F For _'5o bedrooms Fluid depth in absorption field before test in. Elapsed Time: hr "t " Final fluid depth 2.7 in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Water addedJL0 gal. New depths in. Absorption rate >= 7S O g.p.d. If yes, give date D. UFT STATION Date installed 'Pump on" level at _ in. Datum E. SEPARATION DISTANCES Ztested2 anhole/Access (Y/N) at _ in. High water alarm level at in. Meets larm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot lo -7 Absorption field on lot 1 3 t) t Public sewer main Sewer /septic service line > ;•5 On adjacent lots Y / tro On adjacent lots 'Y 1 n-0 Public sewer manhole/cleanout 1'4/A Holding tank r4 A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation $0 Property line 3 o Absorption field 1 O Water main AI j,sa Water service line 50 Surface water 1-410 Wells on adjacent lots �t 16-0 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 30 Building foundation 10? Water main tyIA. Water Service line L 1 ota Surface water r4 10 Driveway, parking/vehicle, stoYage 0 Curtain drain t�4 1v Wells on adjacent lots > Iuo F. COMMENTS G. ENGINEER'S CERTIFICATION ' '' -� • ' 1 car* that I have determined through field inspections and , • •' '•"' review of Municipal records that the above systems are in . .......... conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name i o lobe,, SC Ur%LV. Dater 2r+yZ u HAA Fee 8 3�,5 d� Waiver Fee $ Date of Payment 51? �n '1- Date of Payment Receipt Number j' Q 9 �LD Receipt Number (Rev. 12101) (q4�� CUE Environmental Services Inc. CT&E Ref.# 1022418001 Client Name Tobben Spurkland P.E. Project Name/# Lot 3 Allen Client Sample ID Lot 3 Allen Matrix Drinking Water Ordered By PWSID 0 All Dates/Times are Alaska Standard Time Printed Daterrime 05/09/2002 10:05 Collected D2te/17me 05/07/2002 13:00 Received Date/rime 05/07/2002 14:30 Technical Director Stephen C. Ede Released By (,.(_ Sample Remarks: Allowable Prep Analysis Panmctcr Results PQL Units Method Limits Date Date Init Waters Department Nitrate -N 0.253 0.200 mg/L EPA 300.0 (<10) 05/07/02 JDT Microbiology Laboratory Total Coliform 0 coV100mL SM189222B (<1) 05/07/02 KAP 0 LL LL " Cc' -1-N," 017. Time APPLIC- NT FILLS OUT UPPER HAI - ONLY Phone Pre Owner owner �1f� %�(% ; (i Y Mair;ng Address �� rz`� 7� 'f ''�kf, Zip Code Buyer Date Address Zip Code Lending Institution f/ Fc _ /`l /%v v � /jam% ,(//c; — 11'4 -f -'r;-21 Phone Inspector Inspector Address l // N�/(% �v Zip Code l Realty Co. 8 Agent ANCHORAGE Phone Address ' Zip Code ENVIRONMENTAL Legal Description RT -3 o059` Street Location �/ ' /r/ ✓�% Type of Residence Single Family 'CONDITIONS OF APPROVAL Multiple Family No. of Bedrooms T ❑ Other Water Supply Individualir ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For drilled to that date, well depth (attach log if available). 1:1 Community he p(a'8 wells prior give ❑ Public Utility Well Log Received Septic Tank Size Sewer Disposal c: b 5- Individual Year Individual Installed: ❑ Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. " Cc' -1-N," 017. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector ANCHORAGE Field Notes: DEPT. OF HEALTH << PROTECTION 142,0 ENVIRONMENTAL AUG 23,983 RECEW<� ( ,) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL` DATE BY: Soils Rating Date Sewer Installed Well To Absorption Area / Well Log Received Septic Tank Size Well to Tank eq 72023 (3182) 5. LEGAL DESCRI TION 'Za % /��L DATE RECEIVED ' INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL Pf:vTECTION DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 • JUL 15 1981 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNAR NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. PHONE zv�d17Y2-12-arl M ILJ/NS5G��ADD�RESS %?s l� {el7��J�e „ l �� PROPERTY RESIDENT different from above) PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION > PHONE MAILING ADDRESS 4. REALTO /AGENT PHONE r�r a, 17(� ✓i 0 Q J z �'fr �i7�.i MAILING ADDRESS 5. LEGAL DESCRI TION 'Za % /��L s' C', STREET LOCATION 6. TYPE OF RESIDENCE MBER OF,BEDROOMS SING LE FAMILY One _,21" Four ❑ Other _;2r ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled .1000' ❑ COMMUNITY since June 1975. For wells drilled prior to that ate, give well ❑ PUBLIC UTILITY depth (attach log if vailable.) 8. SEWAGE DISPOSAL SYSTEM� —'rra-. �' INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 ( Rev. 6/79) 5�7 S THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS ❑ APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY 72-010 ( Rev. 6/79)