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Home My WebLink AboutPOGGAS BLK 21 LT 8 S2Poggas Block $2 of Lot 8 #0 ! 8- ! 22-06 AN£HORAG. E AREA BOR '- GH Anchorage, Alaska 90503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION SE~IC TANK~ DISTANCE FROM WELL MAILING ADDRESS .~R/~-- ~X ///.,.~ ~ PHONE. · ECAL D~SCmPT~ON /~', b ~'~,~/ /%~ ~ vk- MANUFACTURER~ MATERIAL HUMBER OF COMPARTMENT~ / INSIDE LENGTH ~ INSIDE WIDTH -- LIQUID DEPTH ~ LIQUID CAPA~ITY/~ GALLONS NUMBER OF LINES DISTANCE BETW TRENCH WIDTH IN, TOTAL EFFECTIVE · ABSORPTION AREA SQ. FT. LENGTH OF EACH LINE ~ · DEPTH OF FILTER ~FINISH GRADE MATERIAL BENEATH TILE IN. ABOVE TILE IN_ WELL: TYPE ~~--- CONSTRUCTION DEPTH "~,~--' DISTANCE FROM: BUILDING FOUNDATION NEAREST ~ NEAREST . ~ SEPTIC SEEPAGE LOTLINE .~3 , SEWER LINE [{~'/t, TANK //7, SYSTEM CES5POOL APPROVED OTHER SOURCES DISTANCES; IHSTALLED BY: ~ SEWER LINt DEPTH: PIPE MATERIAL: LOT SLOPE~ ~/~/E . REMARKS [_~AGRAM OF SYSTEM I I G.A GREATER ANCHORAGE AREA E3OROUGH DEPARTMENT OP' Efl¥IRONMEflTAL, SEWAGE DISPOSAL SYSTEM ~. APPLICATION AND PERMIT INAL INSPECTION; Z4 IIOUR flOTICE REQUIRED. BACKFILLING OF' ANY SYSTEM WITHOUT FINAL INSPECTION DY' THe- TYPE , 41NIMUM DISTANCI~'~, REQUIREMENT~ #OUNDATION TO $[1~['1C TANK . ~,~ NATER MAIN YO EEPTIC TANK PIT ..-...:.es~._.__, DRAIN FIELD Municipality of Anchorage Development Services Department · Building Safety Division/ ~/ ,~ ¢/ On-Site Water & Wastewater Program 4700 B~ag~w. Street · P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS FOR A SINGLE FAMILY DWELLING Parcel I.D. 018-122-06 1. GENERAL INFORMATION COSA# '~)~__~/ Expiration Date: Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address POGGAS S/D; BLOCK 21, LOT 8, S 1/2 1,,5,,502 OLD SEWARD HIGHWAY * ANCHORAGE, AK * 99515 AUGUST &: KRISTINA BERGMAN Day phone `-550-025`-5 13502 OLD SEWARD HIGHWAY * ANCHORAGE, AK * 99515 Day phone TAMMY GILLS W/ DYNAMIC Day phone ,,5111 C STREET * ANCHORAGE, AK * 9950`-5 727-8115 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: ,_5 3. 'TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well · Individual On-site 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 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. 4. STATEMENT OF INSPECTION BY ENGINEER As certi£ied bymy seal affixed h~eLu ~,~d as o, ,~ vo,,u~,tun d~,,~ o,,~,v,,,~o,~,v,,~'~ .... ,~ .... w,,,~;~" ,,,~,*"~* ,,u,~"' 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 GARNESS ENGINEERING GROUP, Ltd. Phone 557-6179 Address 5701 E.. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer, sPrinted. Name JEFPREY A. GARNESS, P.E. Date Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described 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 all 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 are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. 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 right whatsoever. DSD SIGNATURE i/Approved for Disapproved. Conditional approval for bedrooms. · ON-SITE . WATER AND : : WASTEWATER : bedrooms, with the following stipulation~ :. PROGRAM .. .. ,.. -'¥x. ~4EN~' o~_~¥,'-' Attachments: '1~ COSA Checklist Septic System Advisory Well Flow Advisory ( Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other / ?~~- Original Certificate Date: CERTIFICATE Municipality of Anchorage Development Se~ices Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 ~ Anchorage, AK 99519-6650 ~ www.muni.org/onsite (907) 343-7904 OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: A. WELL DATA Well type PRIVATE Date completed '8/1973 Total depth *75 ft. PO(;GAS S/D; BLOCK 21, LOT 8, S 1/2 If A, B, or C provide PWSID# . Sanitary seal (Y/N)YES Cased to *t~. N/A Well Log NO Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. Date of test Static water level Well production FROM WELL LOG AT INSPECTION 9/13/2010 42 4.83 g.p.m. WATER SAMPLE RESULTS: Coliform ~ colonies/100 mi. Arsenic: ~D,~ Ug./L. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size ~ gal. Foundation cleanout~(Y/N)_ Nitrate ND mg./L. Date of sample: 9/8/2010 Other bacteria . Collected by: colonies/100 mi. GE(; Ltd. IPUBLIC SEWERI Number of Compartments Depression over tank (Y/N) Date installed Cleanouts (Y/N) High. wat~ Date of pumping Pumper ABSORPTION FIELD DATA ~ Date installed ~ . Soil rating (g.p.d./ft2or ft~/bdr..,,.n3.)/'~System type Length ~.ft. Width _,,-'"' ft. Gravel below pipe' ft. Total depth ft. Eft. absorptio~tf~ ft2 Monitoring tube Depression over field F~ti~ ~fe~td~iqnU~ before test in'"'"' Results (Pa~vS~tFe~il)added~ gal' ~rw dep____tbhedrooir~ Elapsed T~.Jm~: _ min. Final fluid depth in. Absorption rate >= g.p.d. At,rejuvenation treatment (past' 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed "Pump on" level at ~ Size in gallons~.. ~ .in. "Pump off" level at .in. ~ J Cycles tested E. SEPARATION DISTANCES Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A Absorption field on lot N/A Public sewer main 75'+ Sewer/septic service line 25'+ Animal containment areas. 50'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank N/'A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: . iPUBLiC SEWERi Building foundation Property line Absorption field Water main Water service line Surface water .,-.- Wells on adjacent lots ~~ SEPARATION DISTANCE FROM ABSOR~LOT TO: Property line ~~~_____..~l~qfl~3oundation Water main~ Water~~ SwUe~asCoenWaa~arc~nt i.~1s Driveway, parking/vehicle storage F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through fieldinspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date C~/~L/. ~O COSA Fee ~; Date of Payment Receipt Number (Rev. 11/05) /.-/.¢ o Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Arsenic Advisory Certificate of On-Site Systems Approval # 101224 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 21, Lot 8 S1/2 of Poggas_ Subdivision. This inspection revealed an arsenic concentration of 10.3 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Information on arsenic is available from the On-Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On- Site Systems Approval. Aarow Pump & Well Service LLC (907)346-9355 Inspection Report 13302 Old Seward Hwy Run camera down well to 42'. No perforations found. Brian R. Wille Aarow Pump & Well Service LLC Municipality of Anchorage Development Services Department Building Safely Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.munl.org/onsite (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 018-122-06 1. GENERAL INFORMATION Complete legal description Poggas S/D, BIk 21, Lot 8, South half Location (site address or directions) .13302 Old Seward Hwy. Anchorage ' Current property owner(s),Harlod Green Mailing address PO Box 201142, Anchorage, AK 99520 HAA# Expiration Date:. c~ _,/. O ,.~ Day phone 336o1980 Lending agency Mailing address Day phone Real Estate Agent Mailing Address Day phone Unless oth6rwise requested, HAA wfll be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WAS'~ ~-WATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer The Municipality of Anchorage Development Se~ces 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 lhe 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 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 Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(am) safe, functional and adequate for the number of bedrooms and typo 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 lime of installation. Name of Firm Watkins Engineering, Inc. Phone 349-1851 Address P.O. Box 110443, Anchorage, AK 99511-0443 Engineer's Pdnted. Name Cindy W. Ellis Date -~"~-'"]" 0'~ 5. DSD SIGNATURE [.~ Approved for 3 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other OriginalCertificate Date: ~o' /' Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Westewater Program 4700 South Bragaw St. P.O. Box 196650 Ancflomge, AK 99519-6650 www,muni.org/onslte (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Poggaa S/D~ Block 21, Lo~ 8, South 1/2 A. WEll DATA Well type Date completed mM. Total deplh 75 ft. Date of {eSt Static water level Well production NA WATER SAMPLE RESULTS: Coliform o colonies/100 mi. A~enic: NA mg.A. B. SEPTIC/HOLDING TANK DATA Tank Type/Material NA - publlo leweT Tank size __ gal. Foundation cleanout (Y/N) Date of pumping C. ABSORPllON RELD DATA Date installed NA Length Total depth ft. Date of adequacy test IfA, B, orC provide PWSID # - Sanlta~ seal (Y/N) Y. Casedto 50+ ft. FROM WELL LOG NA lt. g.p.m. Pamel ID: 018-122-06 Well Log (Y/N) .N Wires prope~ protected (Y/N)Y Casing height (above ground) 13 AT INSPECTION 5-16-05 39 6.3 g.p.m. Nitrate <0.1 mg.A. Date of sample: Other bacteria 1 colonies/100 mi. Collected by: Watkin8 EnRineerinfl Date instuUed Cteanouts (Y/N) High water alarm (Y/N) Number of Compartments Depression over tank (Y/N) Pumper Soil radng (g.p.d./ft2 or ft2/Ixlrm) ft. Width ff. Eft. absorption ama ft2 Monlterlng tube Results (Pass/Fail) Fluid depth in abeorpben iteid before teSt in. Elapsed Time: min. Flual fluid depth Any rejuvenation treatment (past 12 mo.) (Y/N & type) Water added gal. New depth in. Absorption rate >= If yes, give date System type Grovel below pipe Depression over field . For bedroonl~ g.p.d. LIFT STATION Date installed NA Size in gallons 'Pump on' level at in. 'Pump off' level at in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM W~LL ON LOT TO: Septic tenk/llfl station on lot NA AbsolT~Jon field on lot NA Public sewer main 7~- Sewer/septic service line 25* Manhole/Aocess (Y/N) High water alam~ level at Meets alarm & circuit requiremen'm? On adjacent lots NA On adjacent lots N~ Public sewer manhold/cleanout 100+ Holding tank NA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Al~sorption field Surface water Property line NA Water Service line Curtain drain F. COMMENTS Water main Driveway, pmtdng/vahic~e storage Building foundation .NA Property line Water main Water sen~tce line Walls on adjacent lots, SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Surface water Walls on adjacent lots *H_~_,~ but n 1964; well approved 1973. Deepest water depth in casing at 50' dudng test. G. ENGINEER'S CERTIFICATION I certify eat I have determined through lleld inspec~on.s a. nd mvfew of Municipal records that the above syatems are ~n E.ginee s mioted Nam Cindy W. Ellis $, Date of Payment ;"""""""""~-/,,~ ~/a ;,',',',',',',',','~ Date of Payment Receipt Number ,~'~'~:)~)~',~.-; Receipt Number (Rev. -*7- D £A,~MI~Nll; OF lI~¢0~. OTIIER THAN PI.~T Aft£ NOT SHOWN HEREON. ~A&I:~AG~y NO CO~N£R~ SET THIS DArK hereby cerU~, t~tt ! ~lvc ~rrorm~ ~ Mort~cc'~ ~. 8prd,on or U:c ~oHow~ de~rlbc~ ~per~; - ~ ~* mlnb IltuoLe~ thereon tre*~lthin ~e p~pe~ ~nel lad ~o not ~erlip or encroach o~ ~ ~Pert7 I~ng u~Jlcent there. ~dwlyl, ~lflfmJ~on lines or ot~lr visible ~uementl on hid ~ropert~ except os Indie.~ hereon. )lt~D W~T~A ~ A~SOCI~TEG · ~glnterl Ind ~u~ey~s 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.cl.anc~3mge.ak.us CERTIFICATE OF HEALTH ,UTHORITY .&,PPROVAL FOR .6, SINGLE FAHILY DWELLING Pat:el I.D. 018-122-06 ¶. GENERAL INFORMATION HAA~ HA000592 Expiration Date: I ~-. ".>'"o ¢:3 I iCompletelegaldescrlption POCGAS S/D; S 1//2 OF LOT 8, BLOCK 21 Location (site address or direction.s) 13302 OLD SIc'WARD HIGHWAY ANCHORAGE, AK 99515 Current Property owner(s) Mailing address 'Lending agency Mailing address Real Estate Agent Mailing address MIKHAIL VORONIN Day phone .227-7675 13302 OLD SEWARD HIGHWAY ANCHORAGE, AK 99515 Day phone PRUDENTIAL V1STA/ DAVID RODRIGUE'Z Day phone 727-7227 Unless otherwise requesled, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: ;3 TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Publlc Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Publlc 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 AJaska. Ceffificates 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. Ce~ficates of Health Authority Approval ara 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 less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties sen/ed 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 $=~0e:t90 a}, or pdor to closing for the engineedng services provided. · 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 Authod~ Approval Guidelines for this applica#on, 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 infonwation obtained from the Munidpali~y of A~chorage files and from my inves~gation and inspection, the on-site water supply and/or wastewator disposal system is(are) in compliance with all applicable Munldpal and State codes, ordinances, and regulaUons In effect at the time of Installation. Name of Fin'n ALASKA WATER & WASTEWATER CONSULTANTS. INC. Phone Address 6901 DEBARR ROAD. SUITE 28 * ANCHORAGE. AK 99504 Engineer's Printed Name JEFFREY A. GARNESS. P.E. Date 337-6179 Engineer's Comments: . InconducfngthlseyaluaRm, AIMWC, Inc. atternpted~provtdeaff~ough, consden~us engineering analysis of the system In accordance wifft ADEC and MOA DSD Guidelines & Regu~aff~ns. The re~ results described the pedon~.ance =f the system unda, the condiff~ns anceuntered at the Ume of the test, and separaffon distances measured ~o reaciTly Identifiable features. The operaffonal life of all v~lls and fluctuate dudng the year, and the water usage of the fan~y being served by the system. msults do not guarantee fufure ~ of the ~Tstem, nor do they guamntee that any warran~y or futum estlmate of how long the system wgl ccn#nue to meet the q~era~ml requlrements o~ ff~ ADEC or MOA DSD. The contant of ffils repo~ ls for the sote baneflt of the o~41er listed above. Any mSance upon or use of this report by any other person or parfy ls not authodzed, nor wiff it confer any legal tfght whatsoever. e DSD SIGNATURE Approved for Disapproved. Conditional approval for __ bedrooms. bedrooms, .' .. ON-S TE : WAS'i'EWATER : ~,, ,,,~,, . .... .~.c~ 'J/J/-/))))} } Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other Original Ce~ficate Date: ~ - ,,,~"'-~3// Municipality of Anchorage Development Services Department On~ Water & Wamwater Program 4700 8oulh Bragsw St. P.O. 13ox t~8S0 A/~, ~JC G95¶~8850 WELL DATA Well type PmvA'm Date completed Total depth "75 lt. HEALTH AUTHORITY APPROVAL CHECKLIST POGGAS S/D; ,,S 1/2 OF LOT 8~ BLOCK 21 I. PE. ,.sPEc o..EPoRTI IfA, 8, or O pfovk~ PW~ID~ N//A Wel~ Log Casedto 4o+ rc Ca~lnghe~ht(abovegmund) FROM Wlmt LOG AT INSPECTION 11//20,/'2000 Stall¢ water level Well produceon WATER &~MPLE RESULTS: Coliform .~ colonies/lO0 mL Dateof~amPle: ~ CoOectedl~. B. 8EPTIC~OLDENG TANK DATA ,018-122-06 NO 13 In. 4.7 g.p.m. AWllVCt INC. Tank ~flal Tank ~ gnl. Numl~r of ~ _F-mJ~. ~~~,~ (Y/N) ~ water alarm (Y/N). C. ABSORPTION RELD DATA Cycles ~ssted Meets ~l~nn & dmult requirements? F. SEPARATION DISTANCES SEPARATION O;STANCES FROM WELt. ON LOT Sept~ tan~R ~aUm on ~ ~/A Absmp'don ~eld en lot Publ~ eewer nmln 75'+ Sewer/sep'd~ ~ewlce I~ 25'+ On adjacent lots 100'+ On ad]scent lois 10o'+ Publlo sewer manhole/deanout HO~ tsr~ N//A 100' + SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO~ Bulkllng foufldaUon ~~...~~ ~ field ~,~.---------'--'~ Water ~ewlce ,ne Surface water Wefts on adjacent lots. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:. . ~ Pmpe~ line Sullo'Ing foundaUo~ .... Water ~mtce fine ~ Odveway, paddngNeNcle ~orage ~4ehy~~ Wefts on adjacent lots F. COMMEHI~ O. ENGINEER'~ CERTIFICATION ~ cmlEy that I have determined through field Inspec#ons .and mvlew of Munlclpal mcords tJ~t lt~e above ~ystems am ;n Engineers ~ Name JEFFREY A. GARNESS I~ HAA Fee $ Oate of Payment Recelpt Number. Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY 0FANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES. Divislon of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage.'Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description '-Y- 3. e Location (site address or directions) , Property owner Q,~ o~.,..., ~ ,~ r.,~ ~ Dayphone 'Mailing address ~ ~'Z~) Lending agency DaP phone Mailing address., Agent Address Unless otherwise requested, HA~ will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY-' Individual well .. Community well Public water NOTE: Day phone If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-slte Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. Se STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my' Investigation of this Health Authority Approval application shows that the on-site water supply and/or wastowater disposal system Is safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. I furtherverlfy that based on the Information obtained from the Municipality of Anchorage files and from my Investigation and Inspection, the on-site wa{~'r supply and/or wastewater disposal system Is In compliance .with all Munlctpal and State codes, ordinances, and regulations In effect on the date of thls Inspection. N~me of Firm ~}-/d~e-/Z~o~ ~7"rJ &/~J E'~"/'&/~J ~, Phone ~'~- 5Z~'5 / Address P.O. '/~. 7--5/0713 /~r.~or~4, c- AIL- Engineer's signature "~J-~,-, <~ ~--4~,-c.,~.~---- / Date .~ Approved for ~--- Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Tho 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 e n glneer registered in the State of Alaska. 3'he D HHS 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 anaIyze data before a certificate Is Issued. The Municipality of Anchorage Is not responsible for errors or omissions in the professional anglneer's work. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Log present (Y/N) .Total depth Sanitary seal (Y/N) Legal Descriptlon: ~'Ou'~ ~//z, /~o~' ~, ~Oc~c. ~ I Parcel I.D. Well Data Well ~ ~tV ~ .If A, B, or C, attach ADEC leffer. ADEC water s~em nu~er Dale mmplaed ~l~ O~ Draler ~ o~ .Cased to FROM WELL LOG ~, ~-D ! Casing height ~' I?_' Wires properly protected (Y/N) Y Date of lest static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL .TO: 8eptlc/hokllng lank on lot /Jp~J~"' Absorption field on lot ~Jo~ ~. Public sewer main ~./OO ~ Sewer service line ), ~ r' g.p.m. g.p.m, '-" o~ : On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform O Nitrate ~p~--r~-c.~,~,4'~ I,C Olherbacteria ~) Date of sample: ~/t"~)l'~ Collected by: /vi ~"~ Tank size Compartments.~ Cleanouts (Y~oundaflon cleanout (Y/N) Dep~~ High water alarm (Y/N) ~"--'.,~"'--..-~ ~,tarm tested (Y Date of pumplng ~~ SEPARATION DISTANCES FRO~ TANK 'TO; ~ z2.oze ('~:~). F~o~ CONTINUED ON BACK PAGE C. LIFT STATION Manufacturer IELD DATA Length Total absorption1 area Date o! adequacy test Water level In absorption field before test Pemxlde treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION Well on lot To bulk:ling Ioundation On ndjacent lots Sud'ace Soll ratlng (GPD/Ft~) System type Gravel Ihtckness present (WN) Depression { ) (pass/fail) Bedrooms yes, give date To exlsling or abandoned Water main/sewlce llne Driveway, parklng,'vehtcle storage area E. ENGtNEER'S CERTIFICATION I certify Ihat I have checked, ven'fiecl, or conformed to all MOA and HAA g~ti~eline~_~.~.?~,d~t.~3.1~-~te of this Inspection. Englneer'sName /l~tC4~/~-l;~L ~ ,,,Z~OC'IZ£O~ ' ~'"'~!' ~:'' Date HM Fee $ ~DO ,,~ Waiver Fee $ Date of Payment ~ --//'E -~.~ ..... Date of Payment TO ; -7- 0c~1~P1,t #;2~o3 P,02/02 D 0 /- EASEMI:NI$ OF RECORD, OTtfl:R THAN TNOSf' EiiO'6~/ ON THE RECORDED PLAT AbE NOT SHOWN HEREON. IA&CI:~ARy NO COfINERS SET THiS DATE I he?eby certLt'y that I hove performed a Moriagee'a in- spection of thc tollowing described p~perty:. LO~ ~: ,, ~nchorage ~cordin~ ~reclnct, Al~nke. and that the Improve- ments altueted thereon are'within the p~operty UneI and do not overlap or encroach on ~e property lyl/~g adjacent there. ~o. that no tmp~vcmen~ ~n property lying ad~a~nt thereto encroach on the premises l~ 9ueltion and that there i~e ~o ~ntcd at ~chorece. }ltgD W~ATKA & MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES ~ of Environmental Senecas P.O. Box 196650 Anchorage, AJaska 99519-6650 (9o7) 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING o / - / - Lo GENERAL INFORMATION Completelegaldescripfion POGGAS S/D: S 1/2 or LOT 8. BLOCK 21 Location (slte address or direcflons) 13302 OLD SEWARD HIGHWAY ANCHORAGE'. AK 9951.5 Property owner MIKHAIL vORONIN Mailing address 13302 OLD SEWRAD HIGHWAY Lending agency Mailing address Agent Address Day phone 227-7675 ANCHORAGE. AK cj9515 Day phone_ '~cz.v 0 ¢.,.m ~,~... WS'T~/ / C~-~P.4~,,.~--~ Dayphone "~3.'~-"~-7.7_~- Unless otherwise requested, I-IAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUppLY: Individual well xxx Community well Public water NOTE: ff community well system, provide written confirmation from State ADEC afrost. lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding Tank Community on-site Public sewer NOTE: XXX If community wastewater system, prot4de wriffen confirmation from State ADEC lng to the legality end status of system. 72-025 (REV. 1/91) Fm~ MOA #21 Comlxlter Ve~oa Note:. Alaska. Water. and. Was .t~va~r Consu. ltants, In.c. shall be paid $800.00 at, or prior to, c~oslng mr me engmeenng set. cas pro~ded. 5. STATEMENT OF INSPECTION BY ENGINEER AS certified by my eaal affixed hereto and as of the velklation date shown below. I verify that my Investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system Is safe, functional and adequate for the number of bedrooms and type of sb'uctum Indicated heroin. I fudher verify that based on the Information obtained from the Municipality of )action, the on-site water supply and/or wastewater Anchorage files and from my Investigation and Ins ~and ~, and regulations In effect disposal system Is Is in compliance wltn 811Munlctl r 8~ ~m~ ~' ~U~ is Inspacl~. . ALASKA WA'T"'~ & )~ [k~/~l/~ ~)'ER CONSULTANTS. INC. DEBARR lOAD.,~ ~l /2B~AJ~ ;HOP, AGE. ALASKA eh ADFC and MOA DH~ ~ Guidelines & Regulations. The repot on the data ¢ Name of Firm A =hone {907) 337.6179 9-_ _~t4 t l Address 0~1 Engineer's Sig In conducting this evaluatlor ~glneering analysis of the on the ~ca~ ~iis c~nd~n~ gr~und water ~eveis that may fluc~ua~e during~ ~ ~ ~ an? ~ ~wa~ AWWC, inc. cen therefore not provlde any warranty for futura esllrnare or now tong ??_ ~ ~,3.: ~.~ ~ ~ I '".'Y* ~_~ system wfll ~ont~nue to meet the operattonal requlrements of the ADEC or MOA DHHS. ~ Approved for 3 bedrooms Disapproved Conditional approval for bedrooms, with the following stipulations: Additional Comments Date II- The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority Approval Certificates based only upon the mprasentet~s given In paragraph 5 above by an Indepandentof pmfeeslonal englnear registered In the State of Ateska. The DHHS does this as a courtesy to purchasers homes and thelr lending Institutions in order to satisfy certeln federal and state requlramante, Employees of DHHS do not conduct Inspections or analyze date before a certificate Is Issued, The Municipality of Anchorage Is not responsible for ermra or omissions In the professional engioea~s work. 72-025 (Rev. 1/91) Back MOA 1~21 CampuS- Vemio~ RECEIVED Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICE~0v ~ Env~enm Ser~ces DMs~on 2 7 2~ 825 'L" Street, Rm 602 Anchemge, Alaska 99501 (907) :~,3-4744 Health Authority Approval Checklist~At~amm:Esmasee Legal Dasatptlon: A. WELL DATA Well Type PRNAT[ Log pr. ent (WN). Total depth Sanltep/seal (Y/N) POGGAS S/D; S 1/2 OF LOT 8, BLOCK 21, PercalI.D.: I'PER INSPECTION REPOR11 ff A, B, or C, attach ADEC letter. ADEC water ~/stem number NO Date completed '7§' Cased lo 40% Ygs 018-122-06 N/* APPROX. 8/197,3 Casing height (above ground) 1 ,~" FROM WELL LOG AT INSPECTION Date of test J 11/20/2000 StaUo water leve, .,../.~.,C.~ '- ~O' Well pteducUon _ g.p.m. 4.7 g.p.m. WATER SAMPLE RESULTS: -- "~ : Date of semple: 11/16/00 Collected by: A.W.W.C., INC. B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Date Installed Tank size NumbeF ~ I ~ FaundatJon clsenout (Y~ High water alarm (Y/N) Date of Pumper C. ABSORPTION FIELD DATA Date instelled PUBLIC SEWER ~ll mUng ~.p.dJfl2 ~ fl2/bdrm) sysmm type Length Wldlh Gravel thicknese below pipe ~ al3aoq)'don erea Monltortng Tube ~Jl~'/~pmsalon over field (Y/N). Date of adequacy test _~/l?~.u. jt s-(Pa'~-ss/Fell) ~ Far Fluid depth in al3sorptlon~in.); Immediately after gal. water added (in.): __ Ruld d~ePth a / One) Minutea later. Absorplion rate -_ ~nt (past 12 months) (y/N) . Byes, give date r~-e~ (R~, ~r Cem~ vemm D. UFT STATION Date Installed Manhole/Access (Y/N) Size in gallons ~ ' level High water atarm level at' / *Datum E. SEPARATION OISTANCES SEPARATION OISTANCE8 FROM WEll ON LOT TO'. Septic/holding tank on lot N/^ Abeoq~on field on lot N//A Publl¢ ~ewer main 75'+ Sewerl~e~c service line 25'+ On ad, cent lots 100'+ On adjacent lots 100'+ Public ~wer manhole/deanout 100'+ Uft ~efion 10o'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: .. ~ Foundafion Property line ~ field ~~ Wells on adjacent Iote SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation ~pueuC s-L-'~ Surface water ~ ~e atorage area .Wells on adjacent I certify that I tlm~ d~d[n2fj~ld ~ru f[etd/nspec~3ns and revfew . w/th MOA H/~A g~n~ on., aare. Slgnatum~ -- -- .......... HN~ Fee S L"~ f~-°° OateofPayment d - :?.- q.--D ~ RecelptNumber o ~q~ l /Sq~ ~) Waiver Fee $ Date of Payment Recelpt Number .... ' MUNICIPALITY OF ANCHORAGE " Department of Heellh & Human Services ' · , DIVISION OF ENVIRONMENTAL SERVICES. · · . * ..... · . .. .. · 343.4744 ...' .. ~ ..... · CERTIFICATE OF I~iSPEC:rlON FoR HEALTH AOTHORI3;Y APPROVAl: OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1, GENERAL INFORMATION {Must be completed prior to submltial) . (a) Legal Description (Include 10t, block, subdlvlalon, section, township, range) Telephone :~(home) Business Telephone (d) Re.al Eats.!9 Company and Agent ' · ¢OLOOJEL/.. AREA · B,K~IKERtREALTOP,~ Address 4105 Tudo,Y. C.e~.~.. A~elto.'t~e~ At~6~.a 99505 Telephone 561-2488 '" (e) Mall the HAA to the following address: (or che~k' here~, If hold for pl~k up.)' List contact person and day phone number below: 17034 Eagle It. Iver Loop Road 2. TYPE OF RESIDENCE ' "' ' Single-Fatally I~x Number of bedrooms 3. WATER SUPPLY Individual Wall I~y- Community I-I Public · ,Note: If~c, ommunlty..~ll system, m~.Ust J~ave-.w~ritten confin'natlon;from..the State Department of Environmental ' 4, SEWAGE DISPOSAL · ' ..... ' "":'" "' ' ' ". ' · On-sitsl~:~.~;~ Public~ .. Communltyr'l .., HoldlngTankD'. ....... ." ' ' ' ' '"' "~ ..... ' .... "" wrltten"~,~l'i!r.',ma'tl6n f;'~m' the State DePartment of Envlronme~lt~l Note:'lf communlt~/well system, must have Conservation attesting to ~he legality' a.n~ status. ' ~2-o2s~,,,.~ Page 1 of 2 ' ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto end 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 atructu re indicated herein. I further verify that based on the Information obtalned from the Munlclpallty of Anchorage flies and from my Investigation and Inspection, the on;slte water supply and/or wastewater disposal system Is In compliance with all Municipal and Stete codes, ordinances, and regulations In effect on the date of this inspection. Name of Firm, Telephone (~'77','c"~?'7 Address , ....=.u:~ ....... ~ =~-~ ~o. ~ Date // 6. DHHS APPROVAL Approved for Approved. Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health AuthorltyApprovsl cerlficated based only upon the representations given In paragraph $ 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 requlrem ents. Employees of DHHS do not conduct Inspections oranalyze data before s c~rtlficate is Issued. The Munlclpality of Anchorage is not responslble for errors Qr in the professional engineer's work. ~2-02s~v.?~) B,ok Page 2 of 2. MUNICIPALITY OF ANCHORAGE (MOA) ~I~""~.OE · * Heelth Authorlly Approval (HAA) fNVIIONMB~AL~I$10N . CH.ECKLIST - FEBRUARY 1984 Ocr 08 i990 A. ,L,.DA [ECEIYE-D Well Classification 343-4744 · Legal Descr pt on ~o~'~/~ ~ o'fA~,~'i~ ~ · ' ~lc, c.k' ~ I.~ ,~.~?a.~ ~ ~. If A, B, C, D.E.C. Approved (Y/N) Well Log Present (WN)' /'3 ' Date Completed Total Depth OK'3~'~ased to./40'+ StBtlc Water Level z{.O ~' Ca. slng Helg~t Above Groun.d . Electrical Wiring In Con'dult (Y/N) 'Yield :~,~ 6,P,,Vl Depth of Gro~tlng -- ' (..-~- '2- ~'/' ¢/~) Pump Set At ~ I~ I ,~. ''f Sanitary Seal on Caslng (Y/N) t~ Depression Around Wellhead (YIN.) · SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ~li~' To Nearest Edge of Absorption Field on Lot TO Nearest Public 'Sewer Line '7~ '~ To·Nearest Sewer Service Line on I'ot Water Sample Collected by ~ ~ -~ ~c".,t)~ ~)~-~r~, ,' Date Comments "; On AdJ0l~lng Lots ~J' JH ; On Adjolnlng Lots To Nearest Public Sewer Cleanout/Manhole B. SEPTIC/HOLDING TANK DATA Date Installed · Size No. of Compartments Standpipes (WN) Air-fight Caps (Y/N) ' ' Foundation CI~ Depression overTank (WN) ' ' . Date Las~ Pumping/Maintenance Contact on File (Y/N) /.-'"'~ ; for Holding Tank'High-Water Alarm(Y/N) ~.~..~^e~,m~.p. oraryHoldlngTankPermlt(Y/N) . SEPAI~ATION DISTANCES FROM S~NG TANK. · To Water-Supply Well ~ To Building Foundation · To Property'Llne ' / To Disposal Field Wate~ Line - To To Stre'tim, Pond, Lake or Major Drainage Course Pagelof2 "' C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design Date Installed Length of Field " ~ Width of Field Depth of Field J f Gravel Bed Thickness..,~.. ' . , , ~ Depression over Field (Y/N) . ~ ,d~'ate of Last Adequacy Test, Results of Last Adequacy Test ~ SEPARATION DISTANCE FROM ABS~RI~N FIELD: TO Water-Supply Well, ~ To Property Line To Budding Foundati~,.~/ TO Exlstlng or Abandoned System on Lot / : On Adjoining Lots To Cutback (if present). To Water M...~ifl/S~ervlce Line TO _/~m, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments '~'~1~... ~. ?-..,~,,.~J ~..~ D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) ~ High WaterAlarm Lev~ ~ Vent (Y/N) ~ Tested for ~ Pumping Cycles during Adequacy Test. Meets MOA Electrical Cod~s-('3'~N) . ~ Comments ~ ~ '*Check Permitted Bedroom Rating Against HAP, Request" I certify that I have checked, verified, or conformed to all MOA and HAA guIdelines In Inspection. Signed _ $ _~: $ ~,ir,~r r. mN.,., Company. 17034 En~l., River Loop ~{ond No. 20~ Eagle Eivur, ~t~;m~ v~/ Date /a /~ Receipt No. __ Date of Payment Amount: $ Receipt No.. Walver Fee: $, Date of Payment Page 2 of 2 ~."~ ":: GR~T~aA"C"O~-.^~-A SO.OUG. ..'': : · '. "".. '. ~'_~' 'L Dep~t~en~ ~f'Envt~onmen~l' Quality · · ,. ~ . · ' ~.. . .. ~'.. . . ,' · ' ,,,. :~.~.,',.~. : .~4,. i, ~ .' ' ' .. '. ,~ .' ".. ' .'...' .. '. T~;, ,~ :~,~,,U,,' . ~..~0 ~: ,'.'~0.~ ... ... . ~, ~0~ g¢P~gK OF . · ' .... - .I~IVID~L S~ER & ~A~R ~ACILITIESm .. .... FOR · . · · ' ' Phone ~ .'~ · . . '~ .* ., ~d,__ · , .. . ~; · .. . . ~ _~ . . . .... .. ~ ~ . g~ ... - Type of. Facllt~y [o be Inspected* ~ · .' ' . · ~ . / . .. . . · . ~u~ber of Bedtooms~ ~ , " .. '.. ..... ~oll ~ ''" ' ' ~ · ' .' .... s~' ot,,o~,~.sT,~ ~'." ,,......... :'. .. .^. -¢. .B. ' Installer "' :- . . E. ~tsposal 'Field:.. Total Length of. LinKs . · Distances=." ' " :' / '., Noacast Lot L~'n~_ ~ , Other Contamination ' "~'.' O.' Founda%lon to Septic.Tank 70/ ' eaZ.A~S~tion A~a. ~; .... ' · Abso~t$on. Area ~o' Nearest Lo,'Line ~0'~· '* .~,EeSnzaS~..~o~-' Appr6~al :of I~, idUal ,Seiver'&:'W~e~ ~clit~i'e ".'~;. ....... ,'.'. "'..'; .... · . ·" .~age Two ' ' ' ' ' '''. ' ' ': ' ' ~ 'g,' Commentss :- A~p~Wal V~ltd for One Year From Da%e $tgn~d · G~ater Anchorage Area Borough;'De'partment of Envlronme~tsl Quality ' · D!AGRAM OF S¥STEV,. ''1 .1 certify t-haL t. he InformatJbn contained in.this requas~ .for approval to'be'a t~e and ~accu~abe-~ep~esen~a~[a~ 'o'f the 'sub.~ec~ sewer a~ water. .' Signed Date ' (I'tll out In Triplicate) b. Dete~£en~__ '"' Co 1.' S~wev lin%, c$~ff. . ' ' d® S. SeepaSe Cesspool'_ 5. Property L~ne_ 5. Othe~ sources of possible contamination, [.e., c~eeks, lakes, houses, barn, drainag] ditch, etc.. ..... SeweEe.disposal system. /{r~Y a. aze of system Distgnce to p~ope~cy.~n._ /~ I % to house' foundation_~ / ' · .e. Perc~] mtion..Te~ 'resuLts ., .. f. Percolation Test performed by, -. 'x..~... Use the reverse .side of this form to show diagram. Dla£~am should include -.~.~he foilo',,lng information: ~.~ope~y lines;.well location, house location, ~p~ic ~ank location, disposal a~ea location, location of percolation test, a~d direction of ground slope. Th~ ~r~o~,m~ion ~>n ~his form 1~ ~rue a ~ the bes~ of my~ow~dge. ' '/ S~na~u~ F A~plic~t ~ t~Si~n T.O BE .FILLED OUT BY HEALTH DEPARTtfENT PERSONNEL ~-~'iuue-i above described sanitary facilities are hereby approved, subject to the ..... ~o-llowtn? cond~f~lons: ' '- The above described sanitary facilities a~e dlsspproved for ~he following '..~pproval da~e of approval. ~--' CPJ:cw INDIVIDUAL S£WAGE AND ~AT£R FACILI~X£S (Fill out ~n Trtpltca~e)~ 5. ~a~e~ Analys~t b, Dete~en~ '"'' , Distance from well to closest existing cr proposed~ 1. Sewer line , Septic tank.~X~4~.. 3, Seepage Area . q. Cesspool' /'.~_~ / . $, Prope~y Line ~ ;. Other sources of possXble contamination, l,e., creeks, lakes, houses, barn, drainage ditch, etc. · Sewage disposal system. a. b. Age of system~~____~ Septic tank capacity tn gallon% Name of septic ~ank manufacturer If "home made" show die,ram on reverse side of th~s form. d: Disposal field or seepage pit size and.type -e. f. Percolation Tes~ performed by Use the rever~e ~tde of this form to show diagram. Dia~rs~ should include the following info~mtion~ ~Fopel~y lines;.well locution, house location, ~p~lc %auk location~ disposaX a~a lo~t~on~ location of percolation tes~, and d[~ctlon o[ ~und slope. The lnfor~ation on this form [st~e and correct t_o the best of my knowledse. $i~na%ur~ of Applicant ' T.O BE FILLED .OUT BY HEALTH DEPART!lENT PERSONNEL ['--~Tha-' above described san[ta~ facilities are hereby approved, subject to ~he The above described sanitary facilities are disapproved for the following At, a following the da~e of approval, .- CPJ;cw