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Home My WebLink AboutBROADWATER HEIGHTS TR D BLK 1 LT 6Broadwater Height Tract Block Lot 6 #050-131 - 28 MUNICIPALITY OF ANCHORAGE (,~,- DEr TMENT OF HEALTH AND HUMAN SERV :S Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT N~ DISTANCES Address // ~ ~2 ~/~O~ 0 ~ ~ ~ ~ % TANK FIELD WELL~ Phone(s)~¢¢ Z¢~ [ Permit No, ~ i ¢ ~ IN°'°f~°°m~ WELLLoT UNE /1~"0 ' Township, Range, Section AS-BUILT DIAGRAM (Show Iocahon oi well, septic system, property Ides, loundabon, TANKS /~ N Mat~;,~/ / . ~o~ o~ c~.a~.t~ . ~ ~'~ / ~ ~, / TYPE OF SYSTEM2/ ,~.,(~ Depth to p,pe bottom from Total depth from origmal grade -' "~ ~ // ~ ~ ~ ' - Fill added above original grade , G~ave~ depth beneath pipe ~ ~ ¢ k ~ ~ ~ ~ Tota n Distance between I,ne, ~ %~ Number °l hnes ~ S;~"~ P'Pe material Installer Installed ~- -- WELLS ~1; T/~ [ ~ /~' ~ PRIVATE ~OTHER (Identifv)[ ~ ~ nI -- FT Installe~ Da~ Installed: ~ j~ / tE~AtKS: -/ ~ ~"~UI~I , ¢~ ~ ~ Scale: /"= ~0 ' ENGINEER'S SEAL ~//~ ._ ~ ~ ~ ~ ~n~p,~,o,~ ~,o~ by: S & 2 ~4GiNiii~G ,; ......... ~ SR R ! ~6X c,~t~im,t t[is ins~8~was pedormed according to all L ) 'J ~ v (3/85) C:ON"f'AC::T F::'i'"IONE: RON HUNTINGTON :1.;1.842 BF:;,'OADWA'TEF:;,' DR, EAGL.E RIVER, AK 995'T7 694-2922 I..,.EGPd .... L)ESCF:;~IF::': SUBD I V I S I ON: BROADWATER HTS.' LOT: 6 BL..[)CK: 1 Sli!!;CTION: 1 TOWNSHIP: 14N RANGE: 2W L...E!"I S i Zliii:: 2i'. '.1. 6 ;:::.':'. (SE. F;:'T ,, OR ACRES) iii ceri::i.~y t, ha!..~ ~or'.tI"~ by the Mun:Lcii:~.a].ity c~' ~.~nchc, r'age (MOA) and the State ~.'.:,~' Alaska. and in compli,ar'~ce with the des:i.r...~n r::r'iter':La o~' this per'mit. i will adhe:,r'~.-:, '~:.,o a11 MEIA and State c:~' Alaska ~equ:Lr. ements ~'oP the set back (::l:i,s't..ances ~ ~"(:::,m any ex :i. st :Lng wel:l., wastewater', disf.)osal sys't:.em c,r' pub:l. :i.c !.~.;E.:,~/,.u..:.:.:.PE.':~;(j.'.!6:-;, Sy'~:~t(.:.~:'f'~] (;;;,f't 't:.J"i;L'~;~ (;:)1" ar-'~¥.' adjacent (::)r' nea]*l:::,¥ ].a't:.. ]:F:: ~:::~ L...iF::'I ~ii~IA'TII3N J:S .l:l',.iS'l"AL..L.Jiii:.t) ;i;l'--.I AN AF:,~IEA COVERED BY MOA BUII....DII',tG C:ODES, I Ht!iii',l (t) AI'.,t I!!i]..,.IEC'TR];CAL.. I::;'E]::~M]; 'f AND INSPECT ];ON MUS"i' BIE OBTAINED~ (2) AS-BUIL...TS W i L.t .... NEI"I L:~E. AFd::'F:~OVE:.O M I 'I'HOUT AI',I EL. ECTF:;..' ]: CAt_ ~ NSI;::'ECTT' 101',1 REF:'ORT; AND (::i..I) ]"HIE ii!i;Li!ii:CT'RIC;Pd .... MCiF:;~K MUS"i BIE: DONE: BY A I....IF;liii]',.ISED EI....EE;I'RICIAN. ........ ......................................... ......... .......................... ~.:.: I"...IE; b APPL I CAi',.! I": RON HUN"f '.I:NGTON C, ~'" /~~a~-~4"~ MUNICIF~,ALITY 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 PH_ONE _ ~Z Manufacturer____4~~ ~ Liq. ~t~lo;s MEMADE: Inside length Width Liquid depth ~v ~O ~ DISTANCE TO: Well Dwelling PERMIT NO. ~ ~ ~ Manufacturer ~/~7 Material Liquid capacity in gallons ~ Well Foundation 40 ,~ Neare~lin~ ~ PER~Z~ ¢ ~. ~ ~ISTA~Cfi TO: ~2~h~ Total lethe, n, ~ Tren~,~ ,~ Distance ~X~ ' ~ No. oflines / Lengtho, L~ inches Totale~?~so~ti~a~e~ ~ ~ Top of ti~e t~finish g[~d~ ~ ~ial~ath tile Length 'Width 'Depth / PERMITNO. ~ Type of crib Crib di Crib depth Total effective absorption area m Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO, ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: PIPE MATERIALS SOILTESTRATING~~¢ / ' ~ AULE~ / /"'-~ // ~ AP~~~~~ DATE LEGAE 72-013 (.R v. 3~78) [:,EF'RRTMENT 3F HEFILTH FIND EN"IF.:ONMENTFIL F'F.:OTECTION/j ../~.~ ',E:'--~:~ '" L. '" STREET., FINCHORFtGE., FIK. '::~'--.~.50i ,/3,¢. ~t',.~,,, 2"_'64-47':','0 ' /,'~t~/,,47N,,. El I'-.t -- D.--.. I -r E ~1; E I--.! i F2 F' E: F~: I'-1 I "T / ,:: 0i0644 ) RPF'L ICFINT CJ NORTH-ER IC:KSON-BRCKH SR2 BO',:':: 4280 CHIJGIRK LOCRTI ON BRORDWRTER DR. t..EGRL LO'r 6 BLK .1 BF.'.OFIDWFtTER SUB LOT SIZE TYF'E OF SOIL FIE:SORF'TION SYSTEH IS' ]F. EN...H MFtF-','IMUM NUMBER OF BEDROOMS 6:::8-9280 2:':0000 SOUBRE FEET SOIL RRTING (SQ FT,-'BR)= t. 25 THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS: [;:, [':.< F" 'T' I--! :=: :E:: L_ E I'-,1 ~3 ]F H == 4. 7 ~.3 F2. Fl '.,,' E L [:, E P T !-4 == 4. THE LENGTH DIMENSION IS THE LENGTH <IN FEE'},) OF THE TRENCH OR [:,RFIINFIELD. THE DEF'TH OF' R TRENCH OR PIT IS THE [:,ISTFINCE BETWEEN 'THE SURFFICE OF THE GROUND RND THE E:OTTOM OF THE EXCFI',,,'FITION (IN FEET;,. THERF IS NO SE'}' W I[.',TH FOR TRENCHE'=;. THE GRR'v'EL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFFtLL PIPE FIND THE E',OTTOr'I OF THE EF::CR',,,'RTION (IN FEET). PERMIT RPPLIC:RNT HFIS THE RESPONSIBILITY TO INFORM TNIS DEPRRTMENT DURING THE IN:F.';TFILLFITION INSPECTIONS OF RNY WELLS RDJRCENT TO THI'=; PROPERTY FIN[:, THE'. NUMBER OF RES I[:,ENCES THFIT THE WELL WILL SERVE. .......... 'T !...-! C:~ ( :2 ::, I I'-.! '_:; F:' E C: -f' I C~ 1'-,I "_=.; R F: E [4: E ~':~ LI I E: E{; [::, BFICKFILLING OF FIN'r' S'¢STEM WITHOLtT FINFtL INSPECTION RND RF'PROVRL B'¢ THIS [:,EPFIRTMENT WILL E:E SUBJ'ECT 'f'O PROSECUTION. MINIMUM DIS'}-FtNCE BETWEEN 8 WELL RN[:' FtNY ON-SITE SENFIGE DISPOSFtL SYSTEM IS t00 FEET FOR R PRI',,,'FITE NELL OR ±50 TO 200 FEET FROM R PUBI_IC HELL DEF'ENDING UPON THE TYPE OF PUBLIC WELL M I N I MUM D I':';TFINCE FROM R PR I",,'RTE WELL TO Ft F'R I',,,'R'rE SEWER L I NE I S 25 FEET FIND TO FI C. OMMUNITY SEHEF.: LINE IS 75 FEET. OTHER REG!UIREMENTS MRY RPPLY. SPECIFICFITIONS RND CONSTRUCTION DIFIGRRMS FIRE FIVFIIL. RBL. E TO INSURE PROPER INSTFtLLFITION. I CERTIFY THRT i: I FIM FFIMILIFIR WITH 'THE REOUIREMENTS FOR ON-SITE SEWERS FIN[:, WELLS FIS SET FORTH BY THE MUNtCIPRLITY OF FtNCHORFIGE. 2: I 1.4ILL INSTRL. L THE S"r°STEM IN FtC:COR[:,RNCE HITH THE CODES. 2: I UNDEF.'.STFIND THRT 'f'HE ON-SITE SEWER SYSTEM MFI¥ REOUIRE ENLFIRGEMENT IF THE RESIDENCE IS REMODELE[:' TO INCLU[:'E MORE THFIN ]: BEDROOMS. FIF¢?~,_ I CI2iN>.! C:J NOF.:TH-EFCIC'KSOI".I-E:FICKHOE ¥4. 0 /'~'~'~ ,VI, UN!CIPALITY OF ANCI-IORAGL DEPARTMENT OF ttEALTltAND ENVItIONMENI'AL PF',OIECTION 825 L. Strut~t, Anchorage, Alask~ 9950i 2G44720 SOILS LOG - PERCOLA'FIONl'EoT'"' I t'! % i' 1 2. 3 ? ,j ,j 1 0 I1 1 2 1 3 14 ENCOLJN FEF4I:D? L[ r ..... ......................... t , t ..... ...... DEPTtI~ .................................. .__ ,_~ ............................................... '"'" '*"~~z ''" " '~ ' ~':'~ '"~':~"' '" "" "' '"z "' ~' ':''" -"_~ ._._. ,' "'"' - - ff~:--:lx ~ .......... ........... -I ~ .................... i ............. . ...... ~5~.. ' 'F,." ~.~ . ~ ~:.... ...~. ~ '~ ~.0~ ~' I ~ '~ J ~'~'?'/' "'.,',, '> PEF~COLAI'ION RATE .................. m nutt~sli~ch ,? ~ 2,0Or', (6/19) 3rfllin[ by OOC Co. dba SULLIVAN WATER WELLS P.O. BOX272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 OWNER OF LAND ADDRESS ~ 7o;)_ t'~__~c r' ~'.m,,.~,,.C LEGAL DESCRIPTION ZL, (~ ./~;',.;/;:; DATE- Sta~ed '7 ~:' t' Ended PERMIT NUMBER DEPTH OF WELL ::~ '_~t 0 STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR / KIND OF CASING KIND OF FORMATION: From d) . .Ft. From ~ Ft. From~Ft. From -),_'% Ft. From/.ff~') Ft. to From Ft. to.~ From:" ....h Ft. to From,.,.)/,? Ft. to . From___Ft. to From .,~ :~ 2: Ft. From._z ..' '~ .Ft. From_ Ft. From.' ;: '""' Ft. From Ft. From Ft. From Ft. From Ft. to Ft. ~'//' ,2 .... '~ ?' From____ to / ~f~'). . .. Ft. ;.-¥/,,c~,~,~ ..>-~ ~ From ....... ___Ft. to ....... Ft ......... Ft. to .... Ft._. Ft. to ___ Ft._ Ft. to _Ft~ Ft.. F;:',~<: r ..... ::,,":" 3 From ............Ft. to .... ~ c,:~-', ~ · Ft.,/ .~o..< c~,~.,,~z~~ ~'o<'~;~ From ........... Ft. to .... -¢O_Ft.~'~d:~"..:~ ,~,' ~ t~-: *,?/ ~F',,4.~,:7":: From ...... Ft. to ..... Ft Z ,, ',-<?,:::',~ From ........ Ft. to .... to_ Ft. to Ft. to.__Ft. to Ft From ..... Ft. to Ft. Ft. Ft. From .......... Fl. to ........ Ft. From ......... Ft. to ........ Ft From .... Ft. to ........... Ft. From _Ft. to .... Ft. From .... Ft. to ...... Ft. From_____Ft. to Ft. From Ft. to Ft. From__Ft. to .... Ft MISCL. INFORMATION: DRILLER'S NAME Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Parcel I.D. CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOP, A SINGLE FAMILY DWELLING COSA# Expiration Date: 1. GENERAL INFORMATION Complete legal description Broadwater Heights Tract D Bk · Lot 6 Location (site address) ~.8z,2 Broadwater Heights, Eagle River, AK 9q577 Current Property owner(s) Linda & Victor Knox Day phone 694-~682 Mailing address ~z842 Broadwater Heights, Eagle River, AK 99577 Lending agency Day phone Mailing address Real Estate Agent Mailing Address Kathi Olmstead/ReMax Day phone 694-5o5o ....................'"este*' '-'"'SA ;'v;~,;' be-held-by-DSD-for~ickup 2~:~-. NUMBER_OF BEDROOMS: 3. TYPE OF WATER SUPPLY: IndividUal Well Individual Water Storage Community Class __.C Well Pubiic Water-System [] Individual Holding Tank [] Community On-site ' [:--I ........... Public Sewer' : TYPE OF WASTEWATER DISPOSAL: Individual On-site [] 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 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. Pannone Engineering Services, LLC Phone 272-8218 Address _P.O. Box :[00217, Anchorage, AK Engineer's Printed Name ..Steven R. Pannone, P.E. Date zo/6/zz Engineers Commerits: In conducting an adequacy test, ! attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. leThv~l~Pt~t~val~iuf;t~aft;l~Vr~lls .and septic systems depend on the local soil condition, ground water ~ . y lng the year, and the water usage of the familv beim, served h,,,h ..... ,~ l nese conoitions are outside th . , o ~; ..... : ....... . . . e control of the evaluator ofth~s svstem All systems ........ ,- ~.:, __~ ~;~ ..." . satlslactorv test ro~,,1.o ~ ~* ...... ~ _ ~ ~ · J ~vvii[uatl~' ldll i:~llU. ., -~ ... ~ ........ ~,,, guman[ee [uture performance of the system, nor do thev mmrnnt~ thai mere are no redden defects or encroachments PEg can th~.ro¢ ..... ~-- :- "°.---~'"5 ...... · . · ............ tu~c nut provlue any warranty Ior Iuture "...,& .... :[,..,.~ _P_e_r!o:__r_m_anc.e no~r,?v.e.~.y e__s~_mate of how long the system will continue to meet the operational ~;qo;t~e~t~e~/;nn;e~t~OonA I.)~SD. Tl2~.e.c. ontent o.f this report is for the sole benefit of the owner listed . ' ~' pon or use oztms report by any other person or natty is not authorized ...... m :, comer any legal ri-ht whatso .... '--"~ ...... "'"" ~ Approved for ~ bedrooms Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date:.,, / 0 - .~ /~ / / Municipality of ,Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 9951~-6650 www.muni.org/onsite (907) 343-7g04 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Broadwater Heights Tract D Bk ~. Lot 6 A. WELL DATA Parcel ID: Well tyl~)e (:: Date completed Total depth ~ fro If A, B, or C provide PWSID # 862aWAao7 Sanitary seal (Y/N) Cased to f. FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~j_mlonies/lO0 mL Arsenic: ~.mz:~. ug/I B, SEPTIC/HOLDING TANK DATA Tank Type/Material Steel Tank size aeee/~oo gal. Foundation cleanout (Y/N) _Y. Oate of pumping c~/~::>/[! C. ABSORPTION FIELD DATA g.p.m. Nitrate ~:)' ['''/''~ mg/L Date of sample: ~.ol612e~. Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION ~.o/61~o~.a 6.7+ in. g.p.m. Collected by: Laura Pannone / Date installed t (::[~=~1 / L(~ ~'*(tc~ Number of Compartments ~ Cleanouts (Y/N) Y/Y Depression over tank (Y/N) N High water alarm (Y/N) N Pumper ,_T~_ g Date installed Length /,7 & ~,. ft. Width.-~o Total depth _8 ft. Eft. absorption area 64.8 ft2 Date of adequacy test aol6/=oa= Results (Pass/Fail) Fluid depth in absorption field before test 4.8/0 in. Elapsed Time: ~_5 min. Final fluid depth 4.8/o in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N Soil rating (g.p.d./ft2 or ft2/bdrm) ~.~5 ft. Monitoring tube Y Pass System type Trench Gravel below pipe 4. ft. Depression over field N For S bedrooms Water added?no gal. New depth/~8h.? in. Absorption rate >= 7no+ g.p.d. . If yes, give date D. LIFT STATION Date installed "Pump on" level at ~ in. Datum E. SEPARATION DISTANCES Size in~ "Pump o~~__in. cyc,e e \ Manhole/Access (Y/N) High Water alarm level at Meets alarm & circuit requirements? SEPARAT,ON D'STANCE$ FROM WELL ON LOT TO: Septic tank/lift station on lot =Loo ~t.~e-~'~{) Absorption field on lot., =Lz~' Waived Public sewer main ~ Sewer/septic service line Animal containment areas =oo+ Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~o+ Property line ~o+ Absorption field Water main 70+ Water service line 2~+ Surface water On adjac.ent lots On adjacent lots Public sewer manhole/cleanout Holding tank ~oo+ Wells on adJacent lots =oo+ in. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 3.o Building foundation 6~+ Water Service line ~;o+ Surface water =Loo+ Curtain drain None KnoWn Wells on adjacent lots =Loo+ F. COMMENTS Water main ~o+ Driveway, parking/vehicle storage =LO+ G. ENGINEER'S CERTIFICATION I certify that I have determined' through field inspections and revie, w of Municipal records that the above systems are. in comorm~nce with MOA COSA guidelines in effect on this date. , Engineers Printed Name, steven R. Pannone, P.E. COSA Fee $. ('-~(5 -- Date of Payment Receipt Number (Rev. 11/05) waiver Fee $ Date of Payment Receipt Number .4- ZIFO~: THIS [[ i~ thc responsibility of thc owner to dctcrnfinc thc cxistcncc or any c~cmcnL% coYcnilrt[5 or rcstricfions whJc~ do not ap~ on U~c rc~rdcd subdivision plal. Undo:no c~rcu~ccs should any da~a hereon be ~dffor.~cfion or ~or ~tabHsh]ng b~und~ or ~cn~ lin~. ~c su~cyor takes responsibility For Um in]llml ~nsacfion only. ' LOT ~ BLOCX / ~~ ~/~ ~"" ~T~ C?LAT NO.: ANCHO~G~ ~CO~ING DIST~CT .q SBUILT IS NOT TO BE USE~ FOI~ ANY SUBMITTAL TO THE MUNICIPALITY OF ANCHOP. AGE. PP~EPA R ED BY: DOWLING & ASSOCIATES I426 Hyder Street Anchorage, Alaska 99501 DATE: SCALE: ,% ASBUILT REVISIONS WORK ORDER: ~LOTES: EASEMENTS OF PJ~CORD. OTHER TJtkN THOSE SHOWN ON THE RECORDED'tYLAT. ARE NOT' SHOW~ HEREON. t~} BRASS CAP MONUMENT O IKON PIPE · REBAK CORNER FO[fND [] HUD AND TACK DATE FIELD BOOK: GKID NOi:' Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 995198650 www.ci.aechorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-131-28 1. GENERAL INFORMATION Complete legal description Expiration Date: / O -- ~- ~-~-- Lot 6 Block 1 Tract D Broadwater Heiqhts S/D Location (site address or directions) 11842 Broadwater Drive, Eaqle River, AK 99577 Current Property owner(s) Steven Cam Day phone 907-229-0712 Mailing address 11842 Broadwater Drive, Eaqle River, AK 99577 Co. ~j a~'ncy U.S. InspectJRichard Sheehan Day phone 703-293-1525 Mailing address 3650 Concorde Pkwy, #100, Chantillv, VA 20151-1129 Real Estate Agent Judy Rosenburel/Prud. Jack White Day phone 762-5800 Mailing Address 3201 C Street, Ste. 200, Anchoraqe, AK 99503 Unless otherwise requested, HAA wfll be held by DHHS for pickup. HAA picked up by:. 2. NUMBEROF BEDROOMS: 5 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class C Well Public Water System TYPE OF WASTE'WATER DISPOSAL: Individual On-site r~ 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 5 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a pdvate or Class C well and may be reissued with new water sample results less than 30 days old. 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. 5. 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 Health Authority Approval Guidelines for this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further 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 in compliance with all applicable Municipal and State codes, o~dinances, and regulations in effect at the time of installation. Name of Firm Pannone Enq. Svc. Phone 272-8218 Address P.O. Box 102954, Anch, AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. Date ~/'Z2//'~0'~ Engineers Comments: ~, ¢onduct~g aa sctcquacv test, ! attompt to provicl~ a thoro u~7~t, cor~cic=tio~s ~'~'~' ~ / Approved for ~" bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Expiration Date: X -- '~'; B/Ali=RAND .- m: ~ : WASTEWATF~ · .: _. .. -. PROGRA . Maintenance Agreements Supplemental Engineer's Report Other Odginal Certificate Date: '7 Reissue Date: Legal Desc~plion: A. WELL DATA Well type C Date completed Total deplh Date of lest Static water level Well production WATER SAMPLE RESULTS: Colifon~ ID colonieS100 mi Date of sample: 711rd2002 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Steel Municipality of Anchorage Development Services Department Building Safety Division 'On-Site Water and Waste~eter Program . 4700 South Bregaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 34~-7904 O HEALTH AUTHORITY APPROVAL CHECKLIST Lot $ Block I Tract D Broadwater Heiahts Parcel I.D.: 050-13t-28 IfA, B, orCprovidePWstO#11621WAt07 WellLeg Y Sanitary seal Wires propedy pmteoted .It Cased to ~ Casing heigM (above ground) ' in. FROM WELL LOG AT INSPECTION - ll lo . ft fl O.p.m (-~, '7 '~' g.p.m Nitrate ,~1 mg/I Other bacteria ID colonies/100ml Collected by: Laura Pannone Dateinslalled IC~gl/,IC~GG tank~z, ~al Num~rofCom~,~s~l Cleano~s~ Fou~ion~ean~ ~ L~n~ertank ~ H~h~terata~ NIA Dae of ~m~ ~t012002 Pum~r JR's Pumoin= C. ~OR~ION FIE~ DATA D~e in~all~ Iq l/l (O.p.d.m~ or fl=~) ~ ~e of ~ t~ 711~2002 R~ ~ai~ . Flu~ de~h in a~ion fie~ ~fom t~ ~ In W~er ~ gal. Ela~ Time: 1~0 min Final flu~ de~h ~ In Any rej~en~ion tm~me~ (~ 12 ~.) ~ & ly~) N System type Tr~lCh Gravel below pipe Z//. It p For_6 bedrooms New deplh4_[ In. Ab~orplion rate >= 7r~o g,p.d. If yes, give date Date installed ~<~ze in gallons . 'Pump on' level at 7~'~n'Pum~ level at in Datum / Cycle~ tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: .~ Septic tank/lift station on lot 100 On adjacent lots 100+ Manhole/Access High water alarm level at in Meets alarm & circuit requirements? Absorption field on lot 115'- · On adjacent lots 100'+ Public sewer main 76+ Public sewer manhole/cleanout 70+ Sewer /sepfic service line 70+ Holding tank NIA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO.~ Building foundation 67' Properly line 35+ Absorption field Water main ?0'+ Water service line 25'+ Surface water t00+ Drainage 100+ Wells on adjacent lots lQ0+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: :~ Property line 10' Building foundation 65'+ Water main 60'+ Water Service line 60'+ Surface water t00+ Driveway, parking/vehicle storage ~0'+ Curtain drain 100'+ Wells on adjacent lots 100'+ :; ch0£c- LUo. c ¥,' m~ of M~I ..... ~ ~ ~ ~ sy~ ~ ~ ~'~d~ ...... ~ ~ ~ c~ ~ MOA H~ ~l~s m e~ ~ ~s ~. ~= ~ ~,.~ -. -. ~ HAA Fee $ Date of Payment Receipt Number (Rev, 11/00) Waiver Fee $ Date of Payment Receipt Number AS-BUILT . . ~ ~, - . I hereby certify that I have surveyed the ,following described ~orage R~n~ Pr~c~ ~k~ and ~t the improve- men~ situa~ ~e~n ~re ~th~ ~e pr~ ~ and do not ov~lzp ~ e~ch on ~e prope~y ]yi~ a~a~nt ~ ~, ~at no ~p~emen~ on ~ I~g a~s~nt.~' ~n~ach ~ t~ pre~ ~ que~ion and that .~e a~ ~ ~d~ys, ~ansmisston ~ ~r ~r ~ible e~n~ on said property except Lq Indicated hereo~ Dated :at. Earle Eiver, .ALaska -. · - , '." ' . ' .~,. I~- ~ ~o~"~. ' ~ </': ,~' ' - .'. - - . ROBERT C. JOHNSON -~,~,, ' ~T.~ ',, ~ndSu~or~o..~' ~ , 1" m ~; ~. ~ 456, ~g~ River, Al~ka A ~ - ..... . ~. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name"[~:~~_ ~-'Ol.5~,l~t-[-~.~ Telephone: Home ~:~ -/'~'"7C~:~ Business '1-¢~1~ '"' '-L- .czrT-3_- Applicant Address t~?~L~.1~' '[;;z~r'~,~i~,~l-'c~ '~' -"'~--~.C....'-~V~4-.-~ ,t~___, ~--~,~ (c) Applicant is (check one): Lending Institution []; Owner/builder J~,; Buyer []; Other [] (explain); (d) Lending Institution ~ ~'/,~-1C~ ~,~z.- Telephone Address \c.~ k(,.~ ~~ ~, .~ ~~~ (e) Real Estate Company and Agent ~/~ ~~t~ Address ~~' ~~ Telephone ~' ~~ (f) Mail the HAA to the following address: S & S ENGINEERING Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single-Family [~- Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well [] Community,l~ Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. 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 (11/84) ~ jo ~ g§ecl ')JJOM %JGgu!J~ug leUO!SSg~OJd OLI:I U! 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'$NOI.LO~ld~NI 9N1(]1^01:1¢11NI:II.-I ~)NIN]iNIgN~! .§ MUNICIPALITY OF AN~J~I~I~'~PALITY OF ANCHORAGE (MOL, ENVIRONMENTAL SERVlCL~-.~t41~I~UTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 JUN 1 987 264-4720 Legal ~scription: ~ RECEIVED WELL DATA Well Classification Well Log Present(~N) Total Depth Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/J=j~l~rrg-Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ~ If A, B, C, D.E.C. Approved (~}N) Date Completed Yield Cased to .~/ Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) · On Adjoining Lots ¥'c:~c;>~ '~- /; On Adjoining Lots /t5 ~"J" To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ~ ~l~r~' ~~" ; Date Water Sample Test Results '~"~';~ ~ "~~ Comments "~1,,,/O ~J'~'LL.$ ~-~/J/~J ,t~_-,~~_ C>/~JE::; ~;~/,t /--~o ~ 4~,~J~: ~ /--7 B. SEPTIC/I:I~I~'N~ TANK DATA Date Installed Standpipes ~:)/N) Depression over Tank (Y/~ Pumping/Maintenance Contract on File (Y/N!,/ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Neldi~ Tank: ('~////~'~'~''' Size //D~o/,.~IC~ No. of Compartments ~../I Air-tight Caps ~)'N) Foundation Cleanout (Y/(~ Date Last Pumped 7--Jz//- ~ /'~/,~t, ; for ~ Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Water-Supply Well To Property Line To Water Main/Service Line Course Comments / To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /'~ ~ ! / / ~ ~ · ,.~ ¢::> I! Width of Field Square Feet of Absorption Area Depression over Field (Y/~J~ Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present(~N) Date of ~,¢st Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation '~o ~''~ Lot z,,/~, ~ -~,,~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~ ~, ~' ~---' To Cutbank (if present) To Property Line ! ~ To Existing or Abandoned System on Z-~-r-'. On Adjoining Lots 15;-~ t_~ D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signe(~ & $ £N61NEERIN6 Date C 17034 Eagle Riv~ L~ R~d No. 2~ .... Amount: $ Z ~ "O Page 2 of 2 72-026 (11/84) DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA 99501 STEVE COWPER, GOVERNOR / Telephone: {907) Addre~'s: 274-~533 DATE: June 12, 1987 PWS I.D.# Class C To Whom it May Concern: According to records on file in this office the Lot 6, Block ] Broadwater Hgts. S/DWater System is in compliance with the State Drinking Water Regulations Sincerely, Ronald S. Klein Environmental Field Officer GENERAL INFORMATION (a) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date ~7 .-¢ Legal Description (include lot, block, subdivision, section, township, range) "--~'l'O._C_~t--~ Location (address or directions) (b) Applicant Name"C---r=~ ~J~'lt..4~-'f'o~l Telephone: Home Applicant Address ~ ~ ~"'Z.-- '~J~.~c~,/"c,.f~'~.//r'c'r'¢=:~-~ 1;;:;[z-, - (c) Applicant is' (check one): Lending Institution []; Owner/builder~.j Buyer [] · Other [] (explain); (d) Lending Institution AZ,; .'~~ 1:2'~/~"-~'~ Telephone Address I c:;' ~ ~,~ ~ (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the followinq address: S &'S ENGINEERING · SRB 196X EAGLE RIVER, AK V957~ TYPE OF RESIDENCE Single-Family,S- Multi-Family [] Number of Bedrooms ~ Other 3.: WATER SUPPLY ~ ' ' 'Individual Well ~ Community~ Public [] :: Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. " 4. 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, ' .... 72-025 (11/8,4) Page 1 of 2 '' 57:ii ENGINEERING FIRM PROVIDING ,,~SPECTIONS, TESTS, FILE SEARCH, DAT~, 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 ~s in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm 5 & $ ENGINF_FR!NG Telephone ~ ~'~- ~' '~ ~ Address SRB 196X Date EAGLE RIVER~ AK 99577 CAUTION Page 2 of 2 ~2-025 (11/84) The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP)issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. - MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-472O Legal Description: ~, ~ MUNICIPALITY OF ANCHORAGe: DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION 1 5 1986: WELL DATA Well Classification Well Log Present (~) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit iY/N) Separation Distances from Well: To Septic/Hotdh't~Tank on Lot /8 ~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments ~"'~,c,C) ~.,/~Z, L If A, B, C, D.E.C. Approved (YI~N) Date Completed Yield Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots //,,3'" t ;On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date B, SEPTIC/HOLDING TANK DATA Date Installed Stun d pi pes ON) Depression over Tank (Y~) Pumping/Maintenance Contract on File (Y/N) ,,/U/~ ; for Holding Tank High-Water Alarm (Y/N) J"/// '~- Temporary Holding Tank Permit (Y/N) Size_~J~ /~"Z~ No. of Compartments I Air-tight Caps{~N) Foundation Cleanou~ ./<jo Date Last Pumped To Building Foundation To Disposal Field ~ ! Separation Distances from Septic/~g Tank: To Water-Supply Well To Property Line ,/~ To Water Main/Service Line Course To Stream Pond, Lake, or Major Drainage Comments ~x,,",~ ~ c/,~.~ ,,~',,~-.~/,~, Page 1 of 2 72-026t11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field [~0 ~ Square Feet of Absorption Area Depression over Field (YN~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ~ /'..~" To Building Foundation Lot Type of System Design Length of Field /'TZ'~' ¢ /~'/ Depth of Field Gravel Bed Thickness Standpipes Present CN) Date of Last Adequacy Test . ~""' / To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area .Comments ~ ~--~/'-f~/,,~,~' To Cutbank (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) /// ~'Pump Off" Level at ,/1 Vent (Y/N) / ~/~pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have chec-ked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Sig~ed S &S CompanySR J~ ]~X EAGLE Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) DEPT. OF ENVIRONMENTAl, CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA 99501 BILL .SHEFFIELD, GOVERNOR 274-2533 July 14, 1986 S & S Engineering SRB 196X -. Si ..~o~\1~~ E a§le River, Alaska 99577 ~_ Subject: Lot 6 & ?, Block 1, Tract D, Broadwater Heig~([s,_IA~lll~'River, Alaska (8621-FA-147) & (8621-WA-107) Dear Sir: The Department has reviewed the Engineer's request for modification of the subject waiver approval. The waiver is hereby amended for lot 6, block i of the subject subdivision from 3 to 5 bedrooms. Any future expansion of the subject project will require additional approval from this office. Sincerely, Environmental Engineer MPL:caa STATE OF ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION CONSTRUCTION AND OPERATION CERTIFICATE for PUBLIC WATER SYSTEMS APPROVAL TO CONSTRUCT Plans for the construction or modification of__ in by_ public water system located , Alaska, submitted in accordance with 18 AAC 80.100 have been reviewed and are [] approved. [] conditionally approved (see attached conditions). BY TITLE DATE If construction has not started within two years of the approval date, this certificate is void and new plans and specifications must be submitted for review and approval before construction. B. APPROVED CHANGE ORDERS Change (contract order no. or descriptive reference) Approved by o o 4- ,/j..r ' Date C. APPROVAL TO OPERATE The "APPROVAL TO OPERATE" section must be completed and signed by the Department before any water is made available to the public. The construction of t ~,' _ __public ¢--..-[,,s water system was completed on (date). The system is hereby granted interim approval to operate for 90 days following the completion date. BY TITLE DATE As-built plans submitted during the interim approval period, or an inspection by the Department, has confirmed the system was constructed according to the approved plans. The system is hereby granted final.approval to operate. t8-0407 (Rev. 11/83) DISTRIBUTION: 1. WHITE - ENGINEER (Complete Section C) 2. YELLOW - WATER SYSTEM FILE (Complete Section C) 3. PINK - ENGINEER/MUNI-BOROUGH (Complete Section C) 4, GOLDENROD - MUNI-BOROUGH (Complete Section A) ANCHORA6E/WESTERN DISTRICT OFFICE 437 'E' STREET, SUITE 303 ANCHORA6E, ALASKA 99501 274-2533 June 9, 1986 Ur. Lou Butera, PE Eagle River Engineering Services, Inc. PO Box 7732"94 Eagle River, Alaska 99577 SUBJECT: Lot 6 & 7, Block 1, Tract D, BROAOWATER HEIGHTS Eagle River, AK 8621-WA-107, 8621-FA-147 Dear Lou~ The Department has revlewed the Engineer As-built plans for. the,..= subject project. Final approval ts hereby given for the water' system and the "Certificate to Operate" is attached. Any future expansion of the subject project will require additional approval from this office. Well separation distances to private sewer line, septic tank and absorption field are hereby waivered to 70 feet, I00 feet, and 115 feet respectively. This approval is gO[~ valid for twa single-family 3-bedroom residences on the subject praperttes, Sincerely, District Engineer SWEtpkk ENCLOSURE SCALE I I I SCALE INSPECTION TMENnXS_ TIME TIM¥~--~ ~..D (-~ TIME I NEP~CTO~ ~ / INSPECTOR ~ I NSPECTO~ ~ MUNICIPALITY OF ANCHORAGE MUNICIPALI~ OF ANCHO~GE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~EPT, OF HEALTH & 825 L Street - Anchora~, Alaska 99501 ENVIRONMENTAL PROTECTION ENVIRONMENTAL SANITATION DIVISION OCT 2 3 1981 Telephone 264~720 DIRECTIONS: Complete all parts o~l page 1. Incomplete reques~ will not be proc~d. Please allow ten (10) days for processing. m PHONE 1..ROPERTYOWNER MAI LING ADDR ESS PROPERTY RESIDENT (If different from above) PHONE 2, ~UYER PHONE 3. LENDING INSTITUTION ~ PHONE I MAI LING ADDRE88 4. HEALTOH/AaENT I PHONE I MAILING ADDRESS m 5. LEGAL DESCRIPTION STREET LOCATION TYPE OF RESIDENCE J~ SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One [] Four [] Two [] Five ~ Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTI LITY * 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** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) ~;~.~ . THIS SIDE FOR oF~'F~I~IAL~US"E O~N'LY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMi! LY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTI LITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic T. an_k or [] Holding Tank Size: /'~ If Tank is homemade give dimensions: NUMBER OF BEDROOMS [] ONE [] THREE [] TWO '~ ~ ~FQUR PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING [] FIVE [] SiX TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line Septic/Holding Tank Absorption Area [Sewer Line [] OTHER INearest Lot Line 5. COMMENTS DATE [~'~PPROVED FOR ~ BEDROOMS [] CONDITION'AL APPROVAL (letter must accompany certificate) [] DISAPPROVED IBY 72-010 (Rev. 6/79)