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Home My WebLink AboutDELUCIA LT 35Delucia Lot 35 #051-141-13 MUNICIPALITY OF ANCHORAGE DEPARTMENT 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 LOCATION ~ v2 .~ ' DISTAN~O: /~ r )' / I ~ z Manufacturer / ~ __ 1 " o~ Liq capacity n g~ onsl [ nsdelength ' ? ~ ~0 IF HOMEMADE: Well Dwellin9 ~ ~ ~ DISTANCE TO: ~ ~ ~ Manufacturer ~ Well / Foundation - ~ ~ ~ ~ ~o. of lines / I ken,th ~ac~in~ *ot~e~thiof lines ~ ~T~p of tile to finish grade ~ Material beneath tile / ~ I ~ngth Width Depth ~ ~ I Type of crib Crib diameter Crib depth ~m [ Well Building foundation " ] DISTANCE TO: ]Class Depth Driller / ] Building foundation Sewer line DISTANCE TO OTHER PIPE MATERIALS SOIL TEST RATING REMARKS %~~. , DATE Dwelling ~, / Width Material Nearest T re n c h~._~.~ inches ~/'OO"' inches IP/H. ONE EW NO. OF B~_ OOMS P ER M 1~7~.~ ~.~ ? No. of ~.rtments Liquid depth PERMIT NO, Liquid capacity in gallons PERMIT NOr i( /t~ .'~9 Dista. nce Total ef~ctive absorption area PERMIT NO. Total effective absorption ]rea Nearest lot line Distance to lot line PERMIT NO. Septic tank Absorpt on area(s) LEGAL _c T "_::" [::*EL.L!(:;' ]; R SUE; O & E ENG..,IEERING & DEVELOF .,/lENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Performed for: Name: SOIL LOG Tel. No. Mailing Address: Legal Description: Earl Ellis 688-2280 Depth (feet) Soil Characteristics 0 1 2__ 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10__ PLOT PLAN 11__ -12 13__ 14__ 15__ 16__ Ground Water Encountered: Yes Proposed Installation: Seepage Pit Comments: No ~ Drain Field.__ PERC. TEST If yes, what depth Performed by: AS-BUILT I hereby certify fi'~at I have surveyed the folluw.L~g des~'ibed property: ~:=~:._- ~[-- + .... ~=~z _.~::.L-: ...... ~ ~ ~- .,,~. ~ ~,., ~ ml~- ~chorage Rearing Precinct, At~ka, m~d lhat the impr~'e- men~s e;ituated ~ereon are v;Rlfin ~e property ~nes and do not ,~verlap or encroach on the properly lying adjacent there- ~o, that no ~mprovements on p~pe~ lying adjacent thereto encroach on lho premises in ~uestkm and that there are no roadways, transm~sion lines or other visible easemen~ on said property except as indicted he.on. [)~tted at Ea,(la River, Alaska ROBERT C. JOHNSON ~;' ECAL~: Registered Land Surveyor No, 1" r= ~' ~,," Box 456, Eagle River, Al~ka Phone (907) 69~2~3 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 19 2O Township, Range, Section: SLOPE SITE~LAN WAS GROUND WATER /L.~- ENCOUNTERED? /:£/? '2'- S L IF YES, AT WHAT O DEPTH? p E I]eplh to Water Alter ..... Monitoring? Dale: Gross Net Depth to Net Reading Date Time Time Water Drop / PERCOLATION RATE __ (m~nutes/mch) PERC HOLE DIAMETER COMMENTS TEST RUN BETWEEN __ FTAND FT [-:':~ '-~ ~:/'- 'T',~-~K'/-~ ti. -- /'~'.::. L .:. ,7 ;7-/,' /:> PERFORMED ~'~ S ENGINEERING 17034 Eagle Ri~er Loop Rea~i No. 204 ~ : ,/"~'~'~' - .... CERTIFY THAT THIS~EST WAS ACCORDANC~~~~tCIPAL GUIDELINES 1N EFFECT ON THiS DATE. DATE: ~' . 72-008 (Rev. 4/85) PERFORMED IN • GE 8V •, Municipality of Anchorage , " On-Site Water and Wastewater Program . gill I lai (907) 343-7904 SA ETY CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-141-13 Expiration Date: 5: 2 / W 1. GENERAL INFORMATION Complete legal description DELUCIA LOT 35 Location (site address) 22855 NEEDELS LOOP, CHUGIAK,AK 99567 Current Property owner(s) MATTHEW&SARAH NELSON Day phone Mailing address 22855 NEEDELS LOOP, CHUGIAK,AK 99567 Real Estate Agent Day phone _ 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual El Individual Water Storage ❑ Holding Tank ❑ Community Class_Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver/Variance request for: Distance: Received by: kQ air' izia Date: _ �� / COSA to be released to the engineer,unless of i requested by the engineer. COSA Fee $ 52,10 Waiver Fee $ Date of Payment .A/2i /f ' Date of Payment Receipt Number 0967O Receipt Number COSA# am?/061 Waiver* If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system _ Certificate of On-Site Systems Approval Checklist Legal Description: DELUCIA LOT 35 Parcel ID: 051-141-13 A. WELL DATA Well type PRVT If A, B, or C provide PWSID# Well Log (Y/N) Y Date completed 9/14/1981 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth242 ft. Cased to242 ft. Casing height (above ground) 24+ in. FROM WELL LOG AT INSPECTION Date of test 9/14/1981 2/1512018 Static water level 151 ft. 154 ft. Well production 10 _ g.p.m. 4.7+ g.p.m. WATER SAMPLE` RESULTS: Coliform /1/ colonies/100 mL Nitrate S.S7mg/L Arsenic: _ N i ug/L Date of sample: 2/15/18 Collected by: ARCTERRA B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC I STEEL Date installed 6/14/2014 Tank size 1000 - gal. , Number of Compartments 2 Cleanouts (Y/N) Y . Foundation cleanout (Y/N) Y(IN CRAWL SPACE) Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping__�/ G / //I __- - PumperU 0&L- C. ABSORPTION FIELD DATA Date installed 10/9/1981 Soil rating (g.p.d./ft2 or ft2/bdrm) 85 System type TRENCH Length 32 ft. Width 3 ft. Gravel below pipe- ft. Total depth 10.7 ft. (Measured 2/15/18) Eff. absorption area 256 ft2 Monitoring tube Y Depression over field N Date of adequacy test 2/15/18 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 470 gal. New depth 0 in. Elapsed Time: 1 min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N &type) N ______.___ If yes, give date _ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanchorage.ak.us (907) 343-7904 '051-141-13 Parcel I.D. 1. GENERAL INFORMATION CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Expiration Date: '~ Complete legal description DELUCIA SUBDIVISION; LOT 35 Location (site address or directions) 22855 NEEDELS LOOP * CHUGIAK~ AK 99567 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address JANIE DALTON Day phone.274-5166 22855 NEEDELS LOOP * CHUGIAKf AK 99567 Day phone RANNA FEKRAT w/ PRUDENTIAL& W. Day phone 3201 'C' STREET * ANCHORAGE, AK 99503 563-5500 Unless otherwise requested, HAA will bo held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 $. TYPE OFWATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site 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 titIe (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 samples. (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. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1,285.00 at, or pdor I to closing for the engineering services provided. I 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my sea/affixed hereto and as of the validation date shown below, I vedfy 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 vedfy 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 cedes, ordinances, and regulations in effect at the time of installation. NameofFirm ALASKA WATER &: WASTEWATER CONSULTANTS, INC. Phone 337-6179 Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date Engineer's Comments: In conducting this evaluation, AWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results desc#bed the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of att wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions ara outside the control of the eva/uator of the system. Satisfactory test results do not guarantee futura performance of the system, nor do Ihey guarantee that there are no hidden defects or encroachments. AWWC, thc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD, The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any ' · other person or party is not authorized, nor will it confer any legal #ght whatsoever. 5. DSD SIGNATURE ~ Approved for ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the ~owing stipulations: ..... .. %% Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements ~4" ~ '~ Supplemental Engineefs Reo~ Other Original Certificate Date: Municipality of Anchorage Development Services Department Building ~afety Olvisinn On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanc~omge,ak.us (507) 343-79O4 Legal Description: A. WELL OATA Well ~ ~IVAI'~ HEALTH AUTHORITY APPROVAL CHECKLIST DELUCIA S/D; LOT ,t5 Parcel ID: 051-141-1,1 If A. B, or C provide PWSID/t N/A Well Log (Y/N) YES Date completed 9/14/1981 Sanltal7 seal (Y/N) YES Total depth 24.2 ft. 242 ft. Cased to FROM WELL LOG Date of test 9/14/1981 Static water level 151 ft. Well production 10 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi. Amenic: N/A mg./L. O. SEPTIC/HOLDING TANK DATA Tank Type/Material Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 5/15/2oo2 154 ft. 5.5+ g.p.m. YES 12+ in. Nitrate 1.97 rog. IL Other bacteria __ Date of sample: 5/15/2002 Collected by: * IN CRAW{. SPACE STEEL Date installed 0 colonies/100 mi. AKWWCt INC. lO/9/ 9Sl Tanksize 1250 gal. NumbarofComparb-nents 2 Foundation deanout (Y/N) eYES Depression over tank (Y/N) NO Date of pumping 5/15/2002 Pumper C. ABSORPTION FIELD DATA Date Installed to/g/~g81 Length 32 ft. Claanouts (Y/N). YES High water alarm (Y/N) N/A JR*S PUMPING ** SUMP APPEARS TO DtTEND ABOUT 6.5' BELOW INVERT Soil rating (~lor fla/'edrm) 85 System t~3e TRENCH Width 3 .ff. Gravel below pipe **4 Total depth lO.3 ft. Eft. absorption area 256 ft= Monitoring tube YES Date of adequacy test 5/15/2002 Results (Pass/Fall) PASS Fluid depth in absorption field before test O in. Water added 740 gal. Elapsed T'm'te: 5 min. Final fluid depth 0 in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) New depth Absorption rate >= 450+ NONE: KNOWN If yes. give date Depression over field NO For .1 bedrooms 5 in. .g.p.d. D. LIFT STATION Date ;n~talled Size in gallons Man~ "Pump on" I~vel at in. "Pump off' n. High water alarm level at ~ ,in. Da..~J.t.aJ.t.aJ.t~ . Cycles tested. Meets alarm & circuit requirements?. Septic tank/lift station on lot Absorpti~>n field on lot Public sewer main Sewer/septic service line E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: 100'+ 100'+ N/^ 25'+ SEI~ARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line Water main N/A Water service line 10'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Water service line 10'+ Curtain drain NONE KNOWN F. COMMENTS Building foundation. 10'+ Surface water 100'+ Wells on adjacent lots. 100'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/deanout Holding tank N/A Absorption field. 5'+ Surface water. 100'+ Water main N/A Driveway, parking/~mhide storage 10'+ G, ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal reco~s that the above systems am in conformance with MOA HAA guidelines in effect on this date. Engineers Printed Name Date .~..~_~ Z a~P~EY ,,~ 0ARNESS Date of Payment Receipt Number (Rev. 12/0t) Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 35, Delucia S/D 5-12-88 Location (address or directions) Needles Drive (b) (c) Property Owner Mailing Address A. H. F. C Telephone: Home Business Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent Jack White Co.--Cori Crowder Address 1092~ Eagle River Road: Eagle River: Ak. Telephone 6 9 4- 5 5 0 0 (e) Mail the HAA to the followina address: or: Check here [~ if hold for pick up. List contact person and day phone numDer below. S & S Engineering 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 TYPE OF RESIDENCE Single-Family [~ Number of Bedrooms 3 WATER SUPPLY Individual Well I'~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 fRev 8/86~ Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S &S Enqineerinq Telephone 694-2979 Address 17034 Eaqle River Loop Rd. No. 204 Date =,- '1 R - R R ENGINEER'S ORIGINAL STAMP AND SEAL ARE ON FILE WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES Engineer's Seal DHHS APPROVAL Approved formh'r'~=,= (q) bedrooms by / Approved X~ Disapproved Terms of Conditional Approval Conditional Date 6 - 8 - 8 8 CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 IRev 8~86t Back MUNtCIPALtTY OF ANCHORAq~IUNICIPALITY OF ANCHORAGE (MOA) r. NVtP, ONMENTAL SERVICES DIVI~:L~I~LTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 ',' ::.¢ t 8 1986 64-4744 Legal Description: ~ RECEIVED WELL DATA Well Classification ! .It~~ ~/~0/%~- If A, B, C, D.E.C. Approved (Y/N) Well Log Present.N) y Date Completed '¢~" ~'~t'° ~1 Yield Total Depth ~ Cased to Static Water Level ~"~ Casing Height Above Ground Electrical Wiring in Conduit(~N) Separation Distances from Well: To Septic/R~ Tank on Lot Depth of Grouting ~ Pump Set At L-)~(-~ · Sanitary Seal on Casing ~i"/~l) "/ Depression Around Wellhead (Y/I~1'~. ' · On Adjoining Lots To Nearest Edge of Absorption Field on,Lot [<'/'~" ~ · On Adjoining Lots ~,. To Nearest Public Sewer Line ij 1'¢i IJ~ To Nearest Public Sewer Cleanout/Manhole [jk To Nearest Sewer Service Line on Lot Water Sample Collected by ~.,~.,~t. ~...~.~....~1~_~.~.c,~¢~.Z41~.3(,I . Date Water Sample Test Results~'~"~¢~J'~\g.~:"r~E"'('"1'"~'¢- ¢~'~'~g~"~'~'-""~ Comments ~¢-~ ~,.- i¢"t;~cL~ ~<t~¢,~'~' ,'~. ~¢'-¢'¢'4"~'~ B. SEPTIC/144~b[~kNG TANK DATA Date Installed Standpipes ~/Y~N) \/ Air-tight Caps ~N) Depression over Tank (Y~ Pumping/Maintenance Contract on File (Y/N) r.-~ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic~Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course Size ~.'~'O No. of Compartments Foundation Cleanout (Y/I~ Date Last Pumped .~ ~ ~,""'~ 'for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page I of 2 72 026 fRev 8/86t Front C. ABSORPTION FIELD DATA ~ -... ~ Soils Rating in Absorption Strata ~. Type of S~ '"~'~-~~ Date Installed ~, ~ _c~. ~ ~;_>~ Length of Field Width of Field "~ Depth of Field ~__ _.....~-~-~-Cca~J.Bed Thickness Square Feet of Absorption Area ('~"~ '~ '")Standpipes PresenlC~/N) Depression over Field (Y/tL~ ~'"'~-J ~-'"~Date of Last Adequacy Test _~'~.'~_ Resu,ts of Last Adequacy Test`cc '-- Separation Distance from Absorption Field: I I TO Water-Supply Well 1 /2~'/~/'~ To Property Line To Building Foundation ~C'~' ! To Existing or Abandoned System on Lot ¢/~1~ 'On Adjoining Lots ~ To Water Main/Service Line ~ ~.-¢' f~ ~ To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course ~,,.~'L--2 I-t¢- To Driveway, Parking Area, or Vehicle Storage Area \ \ O ! Comments ~ ~"1~ i~.~~L~ '~"¢__~'~;'4-Z~1" -'~"%~¢~".,~ ' D. LIFTSTATION ~/A Dar e I n s~'~:J.....~,,~ Dimensions Size in Gallons ~ Manhole/Access (Y/N) "Pump On" Level at ~ "Pump Off" Level at High Water Alarm Level at ~ Vent (Y/N) Tested for ~A Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines Signe~ & $ ENGINEERING Date 17034 Eagle River Loop Road No. 2D~.., Receipt .o. /[h~ Date of Payment ':~/Y Amount: $ /¢0~ Page 2 of 2 72-026 fRev 8/86} Back in effect on the date of this inspection. DATE R ECEIV~E~' I NSPECTI ON APPOI NTM ENTS ~'I~IME TIME TIME DATE DATE INSPECTOR / MUNICIPALITY OF ANCHORAGE MUNIC~2AUTY ( DEPARTMENT OF HEALTH& ENVIRONMENTALPROTECTIO~,EFT. C:F ~: L .' & 825 L Street - Anchorage, Alaska 99501 ENYJRO;'.:;./,F ~;,~:: .. ::~ ~c'rION ENVIRONMENTAL SANITATION DIVISION u[~' Telephone 264-4720 DI R ECTI ONS: Complete all parts on page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing. MAILING ADDRESS ~ROPERTY RESIDENT (If different from above) ~ PHONE - PHON~ 2. BUYE.~~ ~~ . _ MAILING ADDRESS MAILING A~DRE~S ~ ' PHONE 4. REALTOR/AGENT ~/~ ~// i 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE S INGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY INDIVIDUAL* COMMUNITY [] PUBLIC UTILITY [] One [] Four [] Other~ [] Two [] Five ~i~ Three [] Six * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** /~l~/ 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) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY [] ONE [] TWO NUMBER OFBEDROOMS [] THREE [] FIVE [] FOUR [] SIX [] OTHER 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM []INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified [~]Septic T. ank ~)r [] Holding Tank Size: /'.z~ ~-U If Tank is homemade give dimensions: PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SQILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELL TO: Septic/Holding Tank IAbsorption Area [Sewer Line I Nearest lot Line Absorption Area to nearest Lot Line 5. COMMENTS DATE E~]''' APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED IBY 72-010 (Rev. 6/79)