HomeMy WebLinkAboutSLEEPY HOLLOW #2 BLK 2 LT 12Sleepy Hollow
#2
Block 2
Lot 12
#051-501-25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 204-4720
- ON-SITE SEWAGE DISPOSAL. SYSTEM AND/OR WELL INSPECTION REPORT
NAME__—.��__�_..__�.—�_.._.__-_,__.. PHH`O/NSE/ 7l KNEW
❑UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
NO. OF BEDROOMS
Well Absorption area / Dwelling ^ /
DISTANCE /V/� —� 't �� ¢
u Y re —/ 111 _
PERMIT NO.
_ G✓ w w
F- z
w�
Manufacturer
6- ssf�
Material
srsf�
No. of compartments
z
w
Lic. capacity in gallons
IF HOMEMADE:
Inside length
Width
_
Liquid depth
z
DISTANCE TO: Well Dwelling v
yr
PERMIT NO.
Liquid capacity in gallons
TZ H
Manufacturer / Material
OJ
Law
a
Well
DISTANCE TO:
_ N /� -
No.
No. of Tines Length of each line /
Foundation / Nearest lot line �md'
/'
fie_- fj 1
Total length li / Trench
PERMIT NO'92/0/5-
92 / 015"
H Q
/
of eas mid�t�)
��14 inches
Distance between II as
�
.-___ -'---_
Top of rile to finish grade /
±
__
- - - -__ L`�_
Material beneath ti .�..
�ainches
—J'
Total effective ab or do rea
ul
Length
Width
Depth -'
PERMI"f"f NO,
(7-.-
<J
Type of crib
_._
Crib diameter
-_ _
Crib depth
Total effective absorption area
w
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Calm0Lf_�
Depth
Driller
Distanc'et o lot line
_
DISTANCE TO:
_Building foundation
Sewer line
Septic tank
IPRMITNO.
sorption area(s)
OTHER
--
®—
—
PIPE
MATERIALS
Clu r .£/2o/v Ft/L,
SOIL TEST RATING /'
-__/�J
/=
INSTALLER
//'��I '�/e /� �^/� /
Ll W /Y C /� _r>(/ / / LL $-A)
FiEMAR KS
I
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as
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"Ir IN
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0
No. 1457.E
T'
APPROVED Zr�1-¢}•[q r,I p'WW—q � DAT.
�8 Yf•32 � tl�'ty1eF�11'IV\x
LE
(� Vii.(
�� /
/moi
�-
i11Vr R (II.A„4C!1 t'SBil
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/y
v�
2-U73 (Mev. 3/78) .� / Q
,
U-11_ I r -d I: A I F-- P=1 N_. I 'I'' -p ° 111 F- 9q r -d K_-: F-1 F-_ F-9 CA E--- � 3( & �
DEPARTMENT L HEALTH AND ENVIRONMENTAL , ?TECT•ION
825 'LSTREET, ANCHORAGE: AK. 99501 �ca�
264-4720 _
L=• IF. E 1."-11= F.:� 1=' E F = Pi I _r 01 'X)L
PERMIT NO. f: 821015 -
APPLICANT HAROLD D GROSS 3443 BOBBIE CIR 344-536 r
LOCATION \J
LEGAL L12 B2 SLEEPY HOLLOW LOT SIZE 999999 S QUARE-rEE`1
TYPE OF SOIL ABSORPTION SYSTEM IS: DRAINFIELD
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SC? FT/BR)= 125
THE REQUIRED SIZE: OF THE SOIL ABSORPTION SYSTEM IS:
c. E F " -r 1-9 = :ILO L ! r'd Ci T F II -- -d- II F^ F1'1•' L C -m IE F=" -1' F-1= 2=_-_ 'To
THE LENGTH DIMENSION I5 THE LENGTH (IN FEETI OF THE TRENCH OR DRAINVIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE: BOTTOM OF THE EXCAVATION (IN FEET).
1- F-1 E T F E r d IC.: I-1 14 I [Da -r F-1 I : �p . 0C-012_1 F -1 - E= -r _
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE: OUTFALL F'IF'E
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
F? � � 1_ � I ��� � Cti 11 F"' -[' I A� IT1- H r -d F-=_ ._'�. I � 1:� -_� �_ K� Awy 491 A:,�a 1='! L _ 1 _ A_:A r•� "='
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS, DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
_r 1.11e_g< C14403 FAFR1s FTFEGaA_M T F- EC.:. _..._
BACKFILLING OF ANY '=SYSTEM WITHOUT FINAL INSPEC::TION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON -•SITE SEWAGE DISPOSAL SYSTEM Is
1010 FEET FOR A PRIVATE WELL. OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC:: WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE 'SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION,
F'EFes`M I _r E'XF-" I: F -CE'c C?Er'_'IEr"11�-�:EFP -MlL= :1 -*i.=+_^
I CERTIFY THAT
1: I HM FAMILIAR WITH THE REQUIREMENTS FOR Ora -SITE `;EWERS AND WELLS AS `-:ET
FORTH BY THE MUNICIPALITY OF ANCHORAGE. -
: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODE..
3: I UNDERSTAND THAT THE ON-SITE SEWER .SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED f - INCLUDE MORE THAN 3 BEDROOMS.
SIGNED:_`
�iF' LIC:A►•a'C H 'OI.•D D GRCIE,S
0
ISSUED BY ry- --�___ _lvl_Z't-_t (DATE_.___<p c'__ V4.0
CONSTI.UCTION
r- TEST- LAB
aERFORMED FOR:
:EGAL DESCRIPTION:
THIS FORM REPORTS
Harold Groes
Lot 12 Block -
W Visual Soils Examination
DEPTH SOIL
=EET DESCRIPTION
NOTES
BOTTOM OF HOLE
rYAS GROUND WATER ENCOUNTERED
YES, WHAT DEPTH_
_EGEND
- Perc zone
b S - Sample token
-- Frozen zone
-- Water table
No
18� W. 48TH AVE STE 'C'
ANCHORAGE, ALASKA 99503
248-1333
DATE PERFORMED_1OL 0/81
Subdivision, S1eeD} Hollow
O Percolation Test
w
a
0
J
V)
W
U)
Z
LU
cD
GENERAL SITE SLOPE
=.FADING DATE
Silty Sand - SM
NET TIME""'y"`-` `'"` DEPTH TO H2O
31
—
Sandy Gravel - GP
6
14'
BOTTOM OF HOLE
rYAS GROUND WATER ENCOUNTERED
YES, WHAT DEPTH_
_EGEND
- Perc zone
b S - Sample token
-- Frozen zone
-- Water table
No
18� W. 48TH AVE STE 'C'
ANCHORAGE, ALASKA 99503
248-1333
DATE PERFORMED_1OL 0/81
Subdivision, S1eeD} Hollow
O Percolation Test
w
a
0
J
V)
W
U)
Z
LU
cD
GENERAL SITE SLOPE
=.FADING DATE
GROSS TIME
NET TIME""'y"`-` `'"` DEPTH TO H2O
NET DRAINAGE
1
_
dft
' RCOLATION RATE: _
ROPOSED INSTALLATION
�,Ole,IAENTS :
DRAINAGE REQUIREMENTS 125
O SEEPAGE PIT O DRAIN FIELD O OTHER
-EST PERFORMED BY: Kevin Braun_ DATA CERTIFIED BY: v�
—�
DATE: ----
Id -S-4
,3B
P
r�. t ®,JA-�r
eLAvc �a
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4.q at
2 r
Y.P53(k?i?^�w*5�'I rt�flHlFRitYFhwNs'_�'?�u� rsanY��6L.919M�1rtw;x .JP+a�" rlwrityi.Ak'z` -�ntrt-Rewe st.e e48iAaax rms�rw`w,PS'.r .evl�i�+•.Fm.?�el� T4i' xiiYhw:.� .. �. b.,+_»r.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite (907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-501-25 COSA # Q SC IQ i tgp5
Expiration Date: !�--,Z
1. GENERAL INFORMATION
Complete legal description SLEEPY HOLLOW #2 BLOCK 2, LOT 12
Location (site address) 18861 MOUNTAIN ROAD, CHUGIAK, AK 99567
Current Property owner(s) WILLIAM D. GEIGER Day
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
PO BOX 672001, ANCHORAGE, AK 99567
Unless otherwise requested, COSA will behold by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
❑
Individual Water Storage
❑
Community Class A Well
Public Water System
❑
Day phone
Day
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 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 ARCTERRA CONSULTING. INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 05/14/2012
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future`#L
occupants or can ArcTerra guarantee that no unseen + t,,,
encroachments, deficiencies or discrepancies exist.* ,t
5. DSD /SIGNATURE
V Approved for _ �_ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
GUSA Gheckfist X Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other
By: ' Original Certificate Date: K j
(Rev. 11/05Y
Municipality of Anchorage
• '� Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite (907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: SLEEPY HOLLOW #2 BLOCK 2, LOT 12 Parcel ID: 051-501-25
A. WELL DATA
Well type PUBLIC If A, B, or C provide PWSID # 213522 Well Log (Y/N)
Date completed Sanitary seal (YIN) Wires properly protected (Y/N)
Total depth ft.
Date of test
Static water level
Well production
Cased to ft.
FROM WELL LOG
ft.
Casing height (above ground) in.
AT INSPECTION
WATER SAMPLE RESULTS:
Coliform NEG colonies/100mL Nitrate 2.90 mg/L
Arsenic: ND mg/I Date of sample:5/4/2012 Collected by: ArcTerra
B. SEPTICIHOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 10/2/19 Tank size 1000 gal.
ft.
9 -
p.m -
Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (YM) Y Depression over tank (YM) N
High water alarm (YM) N Date of pumping 5L4112 Pumper JRs
C. ABSORPTION FIELD DATA
Date installed 10 2 982 Soil rating (g.p.d.W or ft /bdrm)125 System type Trench
702' mevsu,e�f'5�/;29/L2 Atm/✓lY.
Length 52 ft. Width 5 ft. Gravel below pipe 3.5 ft. Total depth_ .
Eff. absorption area 481 ft Monitoring tube Y
Date of adequacy test 5/4/12
Depression over field N
Results (Pass/Fall) Pass For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 470 gal. New depth 0 in.
Elapsed Time: 0 min. Final fluid depth o in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) Nit yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at _in. Pump off' level at _in. High water alarm level at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
Animal containment areas
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 51+ Property line 51+ Absorption field 51+
Water main 101+ Water service line 10'+ Surface water 1001+
Wells on adjacent lots 2001+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 101+ Surface water 1001+ Driveway, parking/vehicle storage 101+
Curtain drain 50+ (None Known) Wells on adjacent lots 200'+
F. COMMENTS nn
q- 1.2 Neu: tfl-r insWItdjo 219's wt
% 2 o�a.J 13 'l2
'Per previous COSA/HAA annotation—the monitoring tube does not extend to the total depth as indicated on
field readily took the water injected with no observations of water remaining in the monitoring tube
a
G. ENGINEER'S CERTIFICATION
1 certify that I have determined through field inspections and
review of Municipal records that the above systems are inIw g'
conformance with MOA COSA guidelines in effect on this date.
Engineers Printed Name KENNETH M. DUFFUS
Date 05/14/2012
COSA Fee $490.00
Date of Payment 51�s1(a
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
JOS
NOTE:
NO WELL WAS LOCATED AT
THE TIME OF THIS SVRVEY,
AMEN ■smssssissssss■MEN mmHg YC1,1190N NOT% It q N w�' r aDIRy to d.tw l,. LEGEND: SET F1Y0 ,
wwc °n ll ... .L...!+.• rr _., . :+no 1. w rnak V"# fp"N v,.C�, It r " 0
RANDY HAF�DMAN ' I"khja°otppWaWn #.dwedl"myahNOTU AyrkrKAy�yv
with REL AX OF EAGLE RIVER I Vndw " adu wf we &n " an° dam e°rdan M fl
a
U"d tx " • T
7ww..ww.,a.— �•w:awcwsiwal.aww.ww�anaw iw°trvotlon or M Mfaptiq papart) iMa. ap%C-%— %
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, :AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FORA SINGLE FAMILY DWELLING
Parcel I.D. 051-501-25
1.. GENERAL INFORMATION
HAA�—
Expiration Date: Z /
�y3r6�
Complete legal description Lot 12, Block 29 Sleepy Hollow Subd. , #2
Location. (site address or directions) 18861' Mountain Road Chugiak, Alaska 99567
Current'Property owner(s) Steve Haas Day phone (907) 441-6347
Mailing address PO Box 671051 Chugiak, Alaska 99567
Lending agency Day phone
Mailing address
Real Estate Agent None Day phone
Mailing Address...,
Unless otherwise+requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:.'-',
3
3. TYPE OF WATER -SUPPLY: ' .
TYPE OF WASTEWATER DISPOSAL:
Individual Well -" \
❑
Individual On-site
FXI
Individual Water Storage
❑
-Individual Holding tank
❑
Community'Class ; - ;.. - Well
❑
Community On-site
❑
Public Water System
®
Public Sewer
[]
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
Municipality of Anchorage
i Development Services ,Department *A11
Building Safety'Division
On-Site Water & Wastewater Program - I
+ 4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
I ,I www,ci.anchorage.ak.us
(907) 343-7904
f ! HEALTH AUTHORITY. APPROVAL CHECKLIST
Legal Description: Lot '12, Bk '2,iSlee y Hollow Subd. , #2 ;Parcel ID' 051-501-25
A. WELL DATA'} NA — Public ,WS i
"If
Well type _ ��` If A, B,� or C provide PWSID # r' Well Log (YIN)
M ; Date completed Sanitary seal (Y/N) Wires properly protected (Y/N)
Total depth Cased to' ' ," ft. Casing height (above ground) in.
FROM WELL LOG'i AT INSPECTION,
Date of test
i l I, I;
Static water level
ft.
ft.
Well production �: E�g.p�m m.
l g.p.
! WATER SAMPLE RESULTS:
€ I
Coliform colonies/100 ml. Ni rate mg./l. .Other bacteria :� colonies/100 ml.
Dat6e'of sample: Collected 6' ', i I
I B. SEPTIC/HOLDING TANK DATA I, t
TakType%Material 'Septic/Steel' I{ Date n t ( 10/2/82
t . s i s galled
Tank'size l 000 gala ' Number of: Compartments 2 ' � Cleanouts (Y/N) y
is � �
Foundation cleanout (Y/N) Y Depression over tank (Y/N) ' N High water alarm (YIN) NA
I
Date!of pumping 1 /20%04 Pumper
'JR Pum ing
I I 5
,. .
I'
C. ABSORPTION FIELD DATA •• ; �I` „
f
i Date installed :10 2 82 : Soil rating (g.p.d./ft2 or, ft2/bdrmj125 k;sf/bdsystem'type Mod. 5W Drainfield
Length 52 ? ft ,Width : 5 ' �ft Gravel below pi 3.5 e , , t pe ft.
Total 2
a depth
7. ft. Eff. abso tion are 81
l ` , , P rp a li 4 ft ; Monitonng tube , Y Depression over field N
G
I' Date ;of adequacy test 1 /1 3%04' " Results (Pass/Fail) Pas s For _3 bedrooms
Fluid depth in absorption field befo�e;test i 0 'I in Water added 480 al.
9 New depth 0 in.
Elapsed Time::90 min.;Final fluiddepth' 0 in. F Absorption rate ,>= 450 d.
jg.p.
Any r�ejuvenation treatment (Past 12 mo.) (Y;y/N & type) None "Known If e'
s, give date
i w i r
PINARD ENGINEERING
P.O. Box 871347
Wasilia, AK 99687
(907) 357-ENGR (3647)
ADEQUACY TEST
LOCATION: Lot 12, Block 2, Sleepy Hollow Subdivision, Unit #2
APPLICANT: Steve Haas
PO Box 671051
Chuglak, Alaska 99667
SEPTIC TANK TYPESIZE: Steel/1000 gallons, per MOA Records
ABSORPTION SYSTEM: Modified "5" Wide, per MOA Records
DAILY FLOW:
3 BEDROOMS x 150 GAL/BR = 450 gallons
TEST DATA
JOB NUMBER: 04-003
DATE OF TEST. 1/13104
FIELD STAFF: PJ Pinard
NUMBER OF BEDROOMS: 3
SCUM: 0.0' SLUDGE: Minimal
NEEDS TO BE PUMPED: Yes XX No
CURRENTLY IN USE: Yes XX No
Time
Flow
Rate
Volume
Cumulative
Volume
Septic Tank
Septic
Tank
Soil Absorption System
Comments
pM
(GPM)
(GALs)
(GALS)
Liquid Level
A Level
Monitor
Tube 1'
A SAS
Level
Monitor
Tube 2•
A SAS
Level
1:00
5.3
-
-
4.0'
-
0.0'
-
Start Test- Meter 123760
1:15
5.3
80
80
4.0'
0.0'
0.0'
0.0'
123840
1:30
5.3
80
160
4.0'
0.0'
0.0'
0.0'
123920
1:45
5.3
80
240
4.0'
0.0'
0.0'
0.0'
124000
2:00
5.3
80
320
4.0'
0.0'
0.0'
0.0'
124080
2:15
5.3
80
400
4.0'
0.0'
0.0'
0.0'
124160
2:30
80
480
4.0'
0.0'
0.0'
0.0'
Stop Test 124240
RECOVERY
Date Time ST MT1 SAS MT1
'ALL MEASUREMENTS IN FT.
TEST: PASSED XXX FAILED
COMMENTS: There was no measurable liquid in the SAS MT prior to or at any time during the test.
However, based on Record Information on the system and our field measurements, it does
Not appear that the MT extends fully to the bottom of the drainfield.
Reviewed by: Paul Pinard�f
Date: 1/14/04
FROM : PINARD ENGINEERING FAX NO. : 907-357-3647 Jan. 22 2004 12:39PM P1
M(> A
PINARD ENGINEERING
Paul F- Pined
AegWored Eegine6 /AK & ID
P.O. Box 871547, W"PA, AK 99887
(907) 357•ENGR (3847)
llzz fol-
tk-t-5 en
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•
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I��YOD D�O• h
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• •o goo*0000
t
s
O 000ao0
jOro00r oOD00�`-F-+'�
, 9 -Lw*
...............................
NOTE: MARK E. DAVI$ • = •�
NO WELL WAS LOCATED AT % LS -7]]9 ta•�
THE TIME OF THIS SURVEY. .,, '••,,, •,
SOA •••: •••. '���
�roO�•�iondti�•0
■aaaaaaaaaa�aala�a��aa�a■ zau3fOH WO fi It i, b+s.+w•.'r w�;trto d.lan+4r LEG17* SET FIND .
RAN EY M•AROMAN s r.�•..... ; ts-srr�l. s:rKw+ i. •r ratrkt«r t,fr" v,Mwr ��r @. p
�rl�bl� ,, AN �PIw N W ••whd w+bdM.t�w PtaL MOTs x�y kytpµ ypWyprt
wlth RE[uAX OF EAGLE RIVER usw ne sru+•vune.. andar .,y roto wdan N taul tai wa a TOZK g
'��-setae- eDaaQerme3neaaae Q ttsn•wetlon a M »lvbtt�r•q Mrvwty Ih.a Eva- r-- x --
••,:..� I "u EY COtYrr.0ft tM1im tsar Ov+ovciw o QVI'"O" �
Municipality of Anchorage
�• , -� Development Services Department
Building Safety Division
\ Onsite Water and Wastewater Program
4700 South Bragaw St
P.O. Box 196650 Anchorage, AK 9951M650
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-501-25
1. GENERAL INFORMATION
HAA # #Ir' CoV? y
Expiration Date: I1/2 1/02.
Complete legal description
Lot 12, Block
2, Sleepy Hollow
Subd. ,
No.2
Location (site address or directions)
18861 Mountain
Road Chugiak,
Alaska
99567
Current Property owner(s) Leslie Brundige
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
c/o Raney Hardman M RE/MAX 16600 Centerfield Dr.#201
Eagle River, Ak 99577
Day phone
Raney Hardman — RE/MAX
16600 Centerfield Dr."#201
Unless otherwise requested, HAA will be held by DSD for pickup.
Day phone (907) 694-4200
Eagle River, Ak 99577
2. NUMBER OF BEDROOMS:
3
3. TYPE OF WATER SUPPLY:'
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
IE
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
L]
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 d by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approve; are required for the transfer of
title (except between spouses) for properties served by a single-family or, -s 'e wastevat?r 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 vatic water samples.)
Certificates are valid for one year for properties served by Class A or B we!ls or a pubiic water system. The
Municipality of Anchorage is net responsible fer errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm Pinard Engineering
Address PO Box 871347 Wasilla, Alaska
Engineer's Primed Name Paul E. Pinard
Phone (907) 357-3647
99687
Date
eod >0000 0
/
goo „
G"o o00oaao .0006460.0 1"
0. Paul E. PMafd : - "r
5. DSD SIGNATURE ��� °ee• CE -4793 0.6,7,
e _
Approved for bedrooms.
°•°►tie
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
\'kkkk PL17Y Or
q��'/
Additional Comments �J;' • �n • �y0
A
• �4V' AND `=
am PROG
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: �tc • Original Certificate Date: s/21/U2-
(R., Ov02(
i
Municipality of Anchorage A06
sole
• Development Services Department
Building Safety Division `
On -Site Water & Wastewater Program •' • "•
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519.6650
www.ci.anchorage.ak.us
(907) 943-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 12, Block 2, Sleepy Hollow Subd f2parcel ID: 051-501-25
A. WELL DATA 8/A — Public WS
Well type _ If A, B, or C provide PWSID # _ Well Log (Y/N)
Date completed _ Sanitary seal (YIN)_ Wres pmpefly protected (Y/N)
Total depth ft Cased to ft Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level R ft
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate mg./I. Other bacteria oolonies/100 mi.
Arsenic: _ mg.A. Date of sample: _ Collected by:
B. SEPTICIHOLDING TANK DATA
TankType/Material Septic/Steel Date installed 10/2/82
Tank site 1000 gal. �/ umber of Compartments 2 Cleanouts (Y/N) Y
Foundation deanout (YIN) L-- Depression over tank (YIN) N High water alarm (Y/N) N/A
Date of pumping 8/7/02 Pumper JR' s Pumping
C. ABSORPTION FIELD DATA
Date installed 10/2/8 Soil rating (g.p.dAe ortt21bdrm)125 of/bdSyswm type Drainfield (Mod. 5W)
Length 52 It Wdth 5 it Gravel below pipe 3.5 ft
Total depth 7 ft Eft. absorption area 481 ft Monitoring tube Y Depression over field a
Date of adequacy test 7/24/02 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test U in. Water added 500gal. New depth 0 in.
Elapsed Time: 75 min. Final fluid depth 0 in. Absorption rate >= 450 g-p.d,
Any rejuvenation treatment (past 12 mo.) (YIN & type) Hone Known If yes, give date
D. uFTSTATION N/A
Date'Installed Size in gallons ManholefAccess (YIN)
'Pump on" level at _ in. 'Pump ofr level at _ in. High water alarm level at in.
Datum Cycles tested Meets alarm b circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: NIA
Septic tankllift station on lot On adjacent lots
Absorption field on'lot On adjacent lots
Public sewer main Public sewer manholetcleanout
Sewer /septic service line Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5' Property line 651* Absorption field 5'
Water main 101+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots IR/A
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 101+ Water main 101+
Water Service One 101+ Surface water 1001+ Driveway, parkingNehide storage 101+
Curtain drain NIA Wells on adjacent ktis H A
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Paul E. Pinard
Date 8/14/02
HAA Fee $
Date of Payment
Receipt Number
(Rev. ??(0t)
Waiver Fee $
Date of Payment
Receipt Number
�y~�'•• ••s*
'9J�a
fee so
/..� .•....•..�.
t£. Pinard
• d CE -4793 ' f
•. .r
PINARD ENGINEERING
P.O. Box 871347
Wasilta, AK 99687
(907) 357-ENGR (3647)
ADEQUACY TEST
LOCATION: Lot 12, Block 2, Sleepy Hollow Subdivision, Unit 92
APPLICANT: Leslie Brundige
16861 Mountain Road
Chugiak, Alaska 99567
SEPTIC TANK TYPESIZE: Stee111000 gallons, per MOA Records
ABSORPTION SYSTEM: Modred "5" Wide, per MOA Records
DAILY FLOW:
3 BEDROOMS x 150 GAI BR - 450 gallons
TEST DATA
Time
Flow
Volume
Cumulative
Septic Tank
Septic
0.0'
Rate
0.0'
Volume
0.0'
Tank
pAl
(GPM)
(GALs)
(GALs)
Liquid Level'
ALevel
3:40
6.7
-
-
4.0'
-
3:55
6.7
100
100
4.0'
0.0'
4:10
6.7
100
200
4.0'
0.0'
4:25
6.7
100
300
4.0'
0.0'
4:40
6.7
100
400
4.0'
0.0'
4:55
100
500
4.0'
0.0'
RECOVERY
Date Time ST MT SAS MT
1�1
JOB NUMBER: 02463
DATE OF TEST: 7/24/02
FIELD STAFF: PJ. Pinard
NUMBER OF BEDROOMS: 3
SCUM: 0.0' SLUDGE: Minimal
NEEDS TO BE PUMPED: Yes No XX
CURRENTLY IN USE: Yes XX No
Soil Absorption System
Monitor ASAS Monitor ASAS
Tube 1'
Level Tube 2' Level
0.0'
-
0.0'
0.0'
0.0'
0.0'
0.0'
0.0'
0.0'
0.0'
0.0'
0.0'
*ALL MEASUREMENTS IN FT.
TEST: PASSED XXX FAILED
Comments
Start Test -Meter 120360
120460
120560
120660
120760
Stop Test- 120860
CONINIENfS: There was no measurable liquid in the SAS NIT prior to or at any time during the test.
However, based on Record Information on the system and our field measurements, It does not
appear that the MT extents fully to the bottom of the drainfield.
Reviewed by: Paul Pinard
Date: 7/28/02
Bent By: RE/MAX OF EAGLE RIVER, INC.; 9078980214;
Rug 09 02 11140a Rent A Can Tellot Co Inc
MU Pemplai
PO Box 773511
Eagle Rivet. AK 99577
(907) 694-6454, —
Rswai
2W.CoMon ata.100
Aft Cdbn Rew
Abetape. AK WW
Oct) a"mi
arddr
JaeWA bfb f rami - . .
Rarw
I/l$i LlouWh Rd
too AMr, AK WT7
MM A944 OD
ample 8aniot Lh w 71K 1
AOAWW Leoalon Canmwda:
Hmm is vwrK h On wKM. NO f aq.
Pt" b w Ne We **A:1 be NmEM
Aug•12.02 1:41PM; Page 2/3
907-684-6432 P.1
Job D"Wom: 10000
P.O. Number.
Toms: NK So
$ensR mwmift
wo Bode
CIM aseen.
Job Cesanwb: hm off 10 64 of ba*o
►corp W* erw Of 4
1
7aa ►wow t
D _
Aiw tech A 2 atm Tm
W= No No
Dltowrc
Service Agroement
ow DWK 05-iwp zoos
$Orvko Data: OYAJW.= +toD.m
Twtww: Don aorutz
Jab roe: Aapst:
Na0 Odd 46 • .
*-7
a:ttmwmisn AcaW
$14.00
Cailonm Named: 0
— GaWls Achar
Mose LKVM;
DDA4 Tonk: D
Amp &Ai m: ❑
$shoe WDL ❑ s
Bann Oww [3
L_. _
MonTaetdo TOW TetabY TOW
telmtemd GttorOem: Swoo $0.00
Adaar Chrpr:
Cu.mm« ovsa a w hrm. r.d eonalKr pksK m w btot. Tna u A etNoiNa AORIaMWT.
ebntede woTwo or GLMorwr R.mwwftwo Dow
AooytlM 7At ti+P`W Dam AdampYd
Pow yav tided cwftw ww.. romm am Wn *soli ewd pgmwsm oar r.. pbww. .
Tw ToW brand Tsai
30.00 $M•00
i
NOTE:
NO WELL WAS LOCATED AT
THE TIME of THIS SURVEY.
A0 v+
.r1. i!.
:.......................
O MARK E. DANS
+� LS -7376 t�
.. ....I _."6
■ ONE eeaaMMEEMM REMmemeu• xn.usow WO]p u r Use ow*,' r .arty to o6tamirm LEGEND: SET FND
=...e.--_ �y ._....�..., ..:r. en i, a ratnensnr l" r,M"Wp .n• NO 0
R AN EY H A R D M AN I Which 1e het .Cour iw the . i" wddhiefon sJoL NOTL• y,m• k cKQ yp,yygT
with RE[MAX OF EAGLE RIVER 1 undr " ereuTetaner Wn m any data Wean M used tar „A w TA= d
-me,aee-Mepeae
Naeesease
ee seeetrvetlon or W °etarNor9 WWaty thew rpa- —■-- x -
.., I wmtY aamurna; LutTM4 1191 4WQW jW 0 otwu"o- 0
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 —_ZZZI =_S
1. GENERAL INFORMATION
(a) Legal De cription (include lot, block, subdivision, section, township, range) _
Location (address or directions)
(b) Applicant Name�,�_
Applicant Address U?
(c) Applicant is (check one):
e_nz`—Q11y_ Telephone: Home 6/ �a Business
ing Institution ❑ ; Owner/builder 11; Buyer ❑ ; Olhorfvl (explain);
(d) Lending Institution �['r �Wc�— °'r`-s—e Telephone
Address
(e) Real Estat
Address
Telephonf
(f) Mail the HAA to the following address:
2. TYPE OF RESIDENCE
Single -Family X Multi -Family ❑ Other
Number of Bedrooms—_ -
3. WATER SUPPLY
Individual Well ❑ CommunityA Public[:]
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
C 4. SEWAGE DISPOSAL
d
cOnsite [ Public ❑ Community ❑ Holding Tank ❑
t
Note: If community well system, must have written confirmation from the Stale Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2
72-025 (11,04)
Mi
5. 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 any 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.
e` -
ki %t
Name of Firm _
Address
Date
6. DHEP APPROVAL
Telephone
Approved for l! — bedrooms by 61T 7�AA�4
Approved— Disapproved —__ Conditional —
Terms of Conditional Approval
CAUTION
o� °nTS..o •. � e. o. o re =•
r,
IC�*crt A. .PihaSof
l'do, l4i/•C
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.
Page 2 of 2
72-025 (111II4)
1 1 1
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264.4720
MUNICIPALITY Or ANCHORAGE
DEPT. OF HEALTH .&
ENVIRONMENTAL PROTECTION
API', 26 1985
Legal Description: L�z_�rX � "� ���
A. WELL DATA
Well Classification A ---If A, E3, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Date Completed
Total Depth — Cased to — Depth of Grouting —
Static Water Level — Pump Set At
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N) _ Depression Around Wellhead (Y/N) _
Separation Distances from Well:
To Septic/Holding Tank on Lot Gia AOn Adjoining Lots ZOO 0`
To Nearest Edge of Absorption Field on Lot l —; On Adjoining Lots —ail �.
Yield
Sanitary Seal on Casing (Y/N)
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HQWD+" TANK DATA
— To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Date
Date Installed /nZ- - 82-- Size 00 : No. of Compartments
StandpipesCY)N) _ — Air -tight Caps ON) Foundation Cleanout (YQ_
Depression over Tank (Y/_v _-- Date Last Pumped �L - 2,2, -9r
Pumping/Maintenance Contract on File (Y/N) —_ ; for fVZ^_
Holding Tank High -Water Alarm (Y/N)_ Temporary Holding Tank Permit (Y/N) _ a
Separation Distances from Septic/HefdimzyTank:
To Water -Supply Well _ 2�� t+ To Building Foundation
To Property Line _ iDS To Disposal Field
To Water Main/Service Line — 695- L
Course _1
Comments
Page 1 of 2
72-026(11/84)
To Stream, Pond, Lake, or Major Drainage
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 0//w—, Type of System Design pk^(Q ru6xx)
Date Installed -1 " e,7— Length of Field SZ /
Width of Field &D(r Depth of Field 7 .Vz. /
Gravel Bed Thickness ¢z q
Square Feet of Absorption Area 4310 Standpipes PresentP;1)
Depression over Field (Ye Date of Last Adequacy Test Z3 - 86-
Results
SResults of Last Adequacy Test 57_15/=11. c /y2V
Separation Distance from Absorption Field: /
To Water -Supply Well 2�u �% To Property Line S
To Building Foundation
Lot N
/
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
•i�7r1107ii-
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
To Existing or Abandoned System on
On Adjoining Lots .3V / F
�
To Cutbank (if present) 4
J
s-3 , �-
Dimensions
Manhole/Access(Y/N)
"Pump Off" Level at
** Check Permitted Bedroom Rating Against HAA Request **
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I have checked, verified, or conformed to all MO land H A guidelines in effect on the date of this inspection.
Signed ti ENG11CU11M GRB '196) Date 2 S
r:f, SaIUEF?, ALASK4 �9S7T
Company MOA No.
1% 604 2 79
If
Receipt No. 2:)
4 e°°•• °°•°�S�
Date of Payment `� ��` i ] °� r� •~e�z'$bs1
Amount: $
Kober) A. Shofar
A°ee No. 1457.E
T� e
Page 2 of 2
72-026 (11/84)
S�SSC�
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
DATE: -,/-
PWS
PWS I .0 .#-2 13 sz —.?-
To
To Whom it May Concern:
DILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address -
274 -2533
According to records on file in this office the _ Sly c_
r/0Water System is in compliance with the State Drinking
Water Regulations
v
Sincerely,
F -
APPLI( 'IVT FILLS
OUT UPPER HAI ONLY
Time
Properly Owner
/yi I le L'.1_ /._) G." A, Q
Time
Phone
Mailing Address
„y Lf �� �� x��J���' ( //�'
Zip Code
Buyer
n
q - CA, 9�
Date
Date
Address
Date
Zip Code
Lending Institution
/� / /I La / f Jr`) ^✓ f� �? !`
i- C.+ �'? /9 ,�: /•' C -z-
Address
(�� '�%
Zip Code
)Phone
yl?(,-I)-2C>c.J
Realty Co. & Agent
---
7 _- i / '
---/-----
O / /� 7:' U -;
Phone
Address
1 / f4—_ZipCode
Inspector
Field Notes:
Legal Descriptlon
,� J Y j L 7( 2 /
C' / 3' It/ e)
Street Location
Al Q (/ !Ll TA //L/ _ %11 C�/l
DEPT. OF FIFALTf l ..
Type of Residence
ENVIRONMENTAL PROTECTION
Single Family
AUG g i 19£;3
❑ Multiple Family
No. of Bedrooms__-?
RECEIVED
(�) APPROVED BEDROOMS
❑ Other
OF APPROVAL
( ) DISAPPROVED
Water Supply
-!
( ) CONDITION APP
❑ Individual
'!
ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975.
,[y7 Community
rn -���
For wells drilled prior to that dale, give well depth (attach log
If available(.
❑ Public Utility
BY:
Sewer Disposal
,2 Individual
-
_—-----�—_ —- t- !
Year Individual Installed:
—
El Public Utility
Well To Absorption Area
When Connected to Public Utility:.____
Well Log Received
❑ Holding Tank
Well to Tank
Septic Tank Size
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
-v fid) c\ .. ? P u
Time
Tinnie
Time
Time
n
q - CA, 9�
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
MUNICIPALITY OF ANCHORAGE
DEPT. OF FIFALTf l ..
ENVIRONMENTAL PROTECTION
AUG g i 19£;3
RECEIVED
(�) APPROVED BEDROOMS
'CONDITIONS
OF APPROVAL
( ) DISAPPROVED
( ) CONDITION APP
pV-AL'
DATE 0
BY:
Solis Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
Well to Tank
Septic Tank Size
72 023(31a2)