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Home My WebLink AboutCAMPBELL HEIGHTS BLK 4 LT 11B 8144R Lot 11A Chain link fence 30 Wood fence (typ) N89059'11"E 126.06 V W a, " Lot 11B Shed � o O Well LO deck o 28. W I 0 70.0 o Lot 12A do- N 1 Story Frame House Mo LO cv 0 27.8 70.0 0 Z deck o r I ; Asphalt ` _- - - Z V J cli 30— N89°58'03"E 126.14 LO N LIDN E. 67th Avenue RECERTIFIED 12-23-19� V AS-BUILT NO CORNERS SET THIS DATE 1 hereby certify that 1 have performed a Mortgagee's inspection AW P,S� in accordance with ASPLS Standards of the following r • • described property: LOT 11B, BLOCK 4. o •• 49th 4 CAMPBELL HEIGHTS SUBDIVISION ^ • Anchorage Recording Precinct, Alaska, and that the •�� -GJ�� improvements situated thereon are within the property lines and do not overlap or encroach on the property lying 00 #4 A . Elizabeth L. Walatka , P adjacent thereto, that no improvements on the property lying �s�� • • 8036 — LS • • �Ckls adjacent thereto encroach on the premises in question and �� 9Fo • • • • a o that there are no roadways, transmission lines or other SCALE: V= 30'0SSIONA�•�`� hereon. visible easements on said property except as indicated %% �%I Dated at Anchorage, Alaska this 24th day of APRIL 1994. THOSE SHOWNN ON THE RECORDED EASEMENTS RECORD, OTHER THAN FRED WALATKA & ASSOCIATES, L.L.C. PLAT ARE NOT SHOWN HEREON FB 19-8, p9 58 BE 907-248-1666 Engineers and Surveyors UNLESS OTHERWISE NOTED. BEP This drawing is a representation of conditions found at the time the mortgage location survey eras performed. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained on this drawing shall not be used to establish any fence. structure or other improvements. This drawing shall only be used for a single property transaction. Use of this drawing by the original client or by others at a later date without the consent of Elizabeth L. Walatka is a violation of Federal Copyright law. Unless gross negligence is discovered, the liability extent of the preparer is limited to the amount of fees collected for services in preparation of this product. c=�mR Z r m •Z��Gc-IN,ZI vNNOzo �0<mr0-0-czm6-oow a• Y:�. 7-il d., I :._. li :• _: .. 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CD ��omL 8 s O CD 0 19 Lt LV L `fl. l Y s o EF ,r PW c I � • r GARNESS ENGINEERING GROUP, Ltd - - - ENGINEERING -SALES -CONSULTING _ January 20th, 2020 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Ref: Water Sample Results for Campbell Heights; Block 4, Lot 11 B To whom it may concern: Per conversations with the buyer (owners daughter), the subject lot has an arsenic removal system. However, it is unknown if the raw water has arsenic. Records research was conducted on the "nearby" lots (attached), and the wells did not appear to have arsenic. GEG field technician (Erik Widger) believes that his sample point (outside hose bib) was raw (untreated) water. The subject lot water samples came back as non-detectable for Arsenic, which is unusual given that there is (reportedly) an Arsenic removal system. If you have agy�questions, please contact us at 337-6179. Thank you for your assistance. rely, q. Gar eds, P.E., M.S. nt 3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259 Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com 56'18910 7 'A Municipality ®f Anchora On -Site Water and Wastewater Program a- JAN 2 2020¢ (907)343-7904 4 A E T Certificate of On -Site Systems Approv\a0,1 6-8 c. C" Parcel I.D.014-072-70 Expiration Date: 4-, 1. GENERAL INFORMATION: Complete legal description Campbell Heights*, Block 4, Lot 1113 Location (site address) 3401 East 67th Avenue *Anchorage, AK Current Property owner(s) Kacy Williams (Daughter) Day phone 907-242-0741 Mailing address Real Estate Agent Day phone 2. TYPE OF DWELLING: SUBMI TTAJ Z Single Family (w/wo ADU) F� Duplex JAN 2 3 2020 ❑ Multiple Dwellings (Single Family and/or Duplex) AMNEWEARP 3. NUMBER OF BEDROOMS: .3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 19 Individual ❑ Individual Water Storage El Holding Tank 0 Community Class Well El Community El Public Water System 0 Public Sewer 19 WaiverNariance request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ z Waiver Fee $ Date of Payment I 26 2 0 Date of Payment Receipt Number 0 U Z-7 G Receipt Number COSA # OS (-, 1010 Lb Waiver # I 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507 l Engineer's Printed Name: Jeffrey A. Garness Date: In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. .The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. 6.. )SD, SIGNATURE System #1 Approved for 3— bedrooms System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms, with the 0 F� I 5 . T M.4 .ate. ;V CE -7953 LC •6 z��1F°o �\. _rofessio' o #AECC884 M Ff'�n/ingm�fq�l�ti°pts B ��- "' i Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other •I' 1 Legal Description: CAMPBELL HEIGHTS; BLOCK 4, LOT 11 B Parcel ID: 014-072-70 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 19f) Total depth *32+ ft Cased to UNKNOWN ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 'woi19 Static water level at beginning Of test 14.3 ft Comments *PER GEG WELL FLOW TEST B. TANK DATA Age of tank(s) Tank type/materia Measured operati ❑ Standpi ou Dat pumping — Well production at time of test 5.8+ gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes ❑ No j Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by GEG, LTD. Date of Sample 12/30/19 & 1/13/20 Sf=T,— A-r- r✓t- SO 6, -f7_Gk AWWU SEWER I C. LIFT STATION years ❑ Required maintenance comp) Age of lift station rs n level in septic tank Lift station materi ndation cleanout per record drawing Comment D. ABSORPTION FIELD DATA Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A — pressurized field El Monitor tubes go to bottom of effective. If not, st depth into effective ❑ Code -required soil cover over fiel ❑ System presoaked (Required if vacant f eater than 30 days prior to date of test) t itroduced gallons ents/Deficiencies: COSA Checklist yellow sheet AWWU SEWER Adequacy test date Results ❑ Pass F bedrooms Fluid depth pr' test in Wat ded gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' NSA Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft 2 Yes if No ft Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No NSA ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ❑✓ Yes if No ft ❑✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑✓ Yes if No ft ❑✓ Yes if No ft From Septic/Holding Tank Lot to: AWWU SEWER on (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' If No ft Property Line > 5' ❑ Yes if No ft Wells on Ad' ots: Absorption Field > 5' ❑ Yes if No Private Wells > 100' E] Yes if No ft Water Main> 10' I No ft Community Wells > 200' E] Yes if No ft Water Servic _ 10' ❑ Yes if No ft If septic tank is under driveway comment below AWWU SEWER From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑ Yes if No ft If absorption field is under drive ment below Property Line > 10' ❑ Yes if No ft Wells on ots: Water Main > 10' ❑ Yes if No Private Wells > 100' ❑ Yes if No ft Water Service Line > 10' s if No ft Community Wells > 200' ❑ Yes if No ft Surface _ 00' ❑ Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet #AECC884 ~!..~ ~; ~ .".' · ,;,, ,:.'.'. [~. ~: DEPARTMENT. OF HEALTH & HUMA~N SER, yICES .,~. ~ / ~,., ,,..: .... ~.~ ...? ~. ~, ~,~_...~,,,,: -,.,,-.. ; ,..,., ~.~Jl[;~/J',,'D v s on of Environmental Services ,,- ,. ,., ~ ....... ..... ........ , .... P.O Box19~0, Anchorage Alaska ~51~0 ..... -. ..... , , , ' GERTFGATEOFH~LTHAUTHO~I~ . .,. · . :, .... ,..~ , ..~:,: ~ ~., .~ .... , APPROVA~ FOR A SINGEE FAMILY.DWELLING ................. ~:: ~- 71:,~ .GENE~E INFORMATION '.', ':. ,' '~:.. '.g'..: '_ .-,.~ ~- .~4 ,.,.~ .;- ~:,A ~.-'-..~: ...... ',,' ~' '~' "~ "-:" ~ '~ : '. .... ' -:-"' "~ . r~*'~; "~ 4. C~-b~H~'~b~ ~' ~~ ' ~ *r 'Comp ete e~al descr pt on .. . ,,:....'.~....,: ,~.., ,~... .:, ~,~. .~ ~..,~ .~;.. f. ',, .... ~,.,'~'~.',.V ,~._..~',~..; ,*.~ ........ , ,., *.'., ,,~,; ''.~' , ,: ,. ,' .. '. e aaares= ~.uuu~? , ~ . . .. ....... ' 'owner,-' .0~ O~u~ :Da~ phone. '..: :. ~:. *.~gA~' gg"aA.~V,:. '.-..::, :: ',.'" ,.'-: ..... ~' '. ..... " "* ';Day phone ~ ........... ,Dav._. ..... '~ ...'~. :'. ~'~:':~ ~'.,. '",~.T..~. ',.: *"' :/.' '~,'~' ~ othe~l~ r~uested,'H~ will beheld forplckup.. :,...~ ~' m:..~.,~,'., '.: '* ,: ..:~ .... ' :~NUMBER.OF BEDROOMS ....... 3 .......... .. ~ , , Commuq~.we! ..... ,. . .......... .,., ~' .... ., ,. . ,...,*...~ ,. ~. .,, ..:,~ ~, -~,.. ~ ,,;, .. ~..~ .... . ,. ~- .. .... ~,~T;. ;~ ~mmuni~ well svstem/~Drovlde wrt~en conf~rmation from State ADEC a~es~ ~-:/:-'. ,,: ' ina to the legah~ and status or sy~mm..:: ?.,~ .: · ,,. ~ :,,. ~,'~.:..,-..~ --..~ ,.-~".F~'.-., ~ '~"~". ~ ' ", ~ ,~ . .-~-, ,, ~ .... . '~ -', ~-~- ,* ; ~.'~.~ : *,~ ,' .~_, ':*,~.::,,.,:Hodn~tank ,.-~ ..... :.~,.: - . , .:~,,..,: ~. ..~ ,:.,; -:'~ -, .; CommpQI~Y~,S!te -.,=,. . ......:, ~,',-:v ..... ,t, ,~,,~', ~-C~ ~ .,=.,? . , ,. :.~ ~ ,., ,. . ,, ~ ~.,..=, . ',,~ . . . ,:;~,/, . ,- ,,,,.~ ;:? .~ . · .~':~, ~.~:~a~esting to the~egali~ and s~at~s ofsyste~. ~-. ,,~, ~., ,.:= ...:....... ~ ::, ,.,.~:;~,.' :~:~:,, ,~.~. '," ,' ,:'5. .rSTATEMENT OF,INSPECTION BY,ENGINEER . ,"~ .:,, ,:' , , ..., ::-, ,'~ ~,*, ' ,~..AS Ce~t f ed by my sea afl xed hereto and as of th~ vahdatmn date shown be ~)W I ~,er fY that my ,~! :~.., .,, *. ,~,investlgation of this Health Authority Approval application shows that the on-site ,w. ate[supply ,-" *.', ' ;". and/or wastewater d sposa System s safe ,fu.,n. ci~onal and adequate for the number of ~rooi~s '.' '., :',!-,: ... % ,, .',',' 7. and type of structure Ind mated herein. I further.verifY that based on the Information obtained from, ,:~, ~;',~,,'., T the Mumcipallty of Anchorage files and from my investigation and Inspection, the on-site water ;.; .:.', 'i.' "- ~., 'supply and/or wastewater'disposa system s n'c~'~p anco w th all Municipal and state c~:~es,':: ;;. ·, , .: .... ordinances ~and regulations in effect on the date of this Inspection. ~., .:.-,,. ...... :. ',' ~ :~,..~:. :r'. · , Encllneer's s onature ~/~~ :: ' - . ~ .... ,, ,.. ,. ..... ,... ,: ,... , .. ........ ~,, ~ .:..,.., ., ...... ,.....:,, ,,.,... '~*,, '.'. .- ':'' '. ' ": ' .'" ....... - .L .......... .'" . .... . -!.... "~' . Al~l~roved lot, ..... ..,bedrooms.--.,--,. ,: .:- .- .-,,.. :.,. ...... :.:-~.-~. ......... :_. ~ .- .,-,-;'.,...~. -,: . , Cond~tmnal approvaltfor . ,.,:..bedrooms, .w~th the ,following,stipulations. · :.,~ ~. , · Add~tlonalComments · ' · ............. ' . .............. , --, ': ~:.~:'!:~' .,. ..... , .. . .. . . ....... ,..., ,; ...., ..... .... . ..... ; ,. ":"i;" ";. ;'~h~,Uuniclpa~li~/of Anchorage Department of Healtl~'ar~d Human Serv.c~ (Sili-Is) I~'sues Health A~th;3rlty '.' ,, ..Approva, l~Cert f cates,based only upon the representations given In paragraph 5 above by an independent ',,;:"' ~ · ¢)rofessional iin~ineer registered in the State of Alaska.~l'he DHHS does this as a courtesy to purchasers of homes - ,,~ !, and the~ r lending Institutions In order to set~sfy certaln federal and state requirements. Employees of DHHS do not ,., '.':',t~'.;conduct inspections or analyze data!before a certificate Is lesued.',.The~Munlclpallty,of'Anchorage:ls~n0t,, ~ .,;' · .:-~:,: r~Sl~6hsible fc~r errors or 0mi~si0n~ tn the professional ~nglneer's work.. Municipality of Anchorage Department of Health and Human Services HEALTH AHTHORI'D' APPROVAL CHECKLIST ' Legal Description: LoTIII~ /I~;4 C../'~'d~u_ Parcel I.D. A. Well Data Log present (~ Total depth Sanitary seal If A, B, or C, attach ADEC letter. ADEC water system number ~./ Date completed '~- /~ ~! Driller _ (..,)~'~ Cased Io ~ ~'~ Casing height //"r'-~ Wires properly protectec~) ~".~ "'~ O~ /~'-~_.c.~%ROM WELL LOG Date of test Static water level Well flow Pump level1 AT INSPECTION SEPARATION DISTANCES FROM WELL TO: SepUc/holding lank on lot ~O~' p~'ET, JT~ ; on adjacent lots Absorption field on lot ~J'O/~J(_~ /~:~/~-xO?'- ; On adjacent lots Public' sewer main ?-5~''' ~"~' Public sewer manholelcleanout Sewer service line Z ~'/--,~- ,Petroleum tank WATER SAMPLE RESULTS: Coliform 6~)//'490"'v~ Nitrate Date of sample: 4/4 / · B. SEPTIC/HOLDING TANK DATA i~1 O. IO ~/~ Otherbacterla 0/~00~'~ Date installed ,Tank size CompaAments Cleanouts (Y/N) Foundation cleanout (Y/N) High water.alarm (Y/N) ~ Date of pumping -- ~; '7~ - SwEe~s~o~II~; DISTANC ES FROM S~G TANK TO: ' -i~:' ' ~.O~ a 'djacent lots Foundation To property line J Absorption field Water main/service line CONTINUED ON BACK PAGE Date Installed ' ~ze ~ gallons Vent (Y/N) 'Pump on' level at Hig~ water alarm level Meets MOA elect~cal codes (Y/N) SEPARATION D~ION TO: On adjacent lots D. ABSORPTION FIELD DATA Manufacturer ' Manhole/Access (Y/N) · ~at Surface water System lype ' J - To~ Depr..e.~n over field (Y/N). if or Bedrooms Well on lot To building foundation On adjacent lots Sudace w/atef,.'/''''' n drain E. ENGINEER'S CERTIFICATION jAfter lest If yes, give date Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area Dare'installed Soil rating (GPD/FF) L~ngth W'dh .Gravel thickness T~)tal absorptior{'ama - .Cleanout present (Y/N) Date of adequacy.test Results (pass/fa~) Water level in abs°q~lion field before test peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABS : ./On adjacent lots H~F~$ ~g ,~ . Wa~erF~$ Date of Pay~ ~ - / ~ --?~ Date of Pay~. R~Nu~r ~,~ ~ ) Re~i~Nu~r CT&E Ref.# Client Sample ID Ma~x Commercial Testing & Engineering Co. Environmental Laboratory Sen~ices ~-.~e-~'~,~:a,:~.~:~'~'~'~-~'.~.~.~-~-~-fffJJffffffljjs~ LABORATORY ANALYSIS REPORT 94.1466-3 L1 lB,B4 CAMI'BELL llEIGI ITS SA) WATER Client Name S & S ENGII~EERING WORK Order 77198 Ordet~l By PJS Printed Date 04/08/94 ~ 10:35 hts. Project Name Collected Date 04/04/94 ~15:55 hrs. Projecb/ Received Dar e 04105194 ~09:30 hrs. PWSID UA Technical Director STEPI IEN C. EDE Sample Remarks: ROUTINE SAMPLE COLLECTED BY: SS QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 0.10 U mg/L EPA 353.2/300.0 10 04106/94 LLII * See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported vulue is lhepractical quantification limit. LT= Less'lhan ~ D = Seconchry ~lulion. GT= Grcat er 'l~an 5633 B Street, Anchorage. AK 99518-1600 --Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ~LASKA. COLORADO, FLORIDA. ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA IV, UNIC1PALITY OF ANCHOP, AGE MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ~'-~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMFNTAL PROTECTION · ~ 825 L Street - Anchorage, Alaska 99501 t ENVIRONMENTAL SAN:TATION DIVISION JUl 2 0 1981 Telephone 2644720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER F - DIRECTIONS: Complete all parts oat page I. Incomplete ~e~luests will not be processed. Please allow ten (tO) days for processing. t. PROPERTYOWNER, /~ ~ ~ . (,~_.~P~..~'~t.. J PHONE MAILING AODR'ES$ ~ ~'/ PROPERTYRIE$1DENT (H dj flare t~from ,bo.) PRONE- 2. BUYER PRONE MAILING ADDRESS 3. LENDING INSTI,~UTION PRONE MAILING ADDRESS -' / ~' ~ ~ ,~. REALTOR~A~ENT - '~ ?~'*~0~ J PHONE TREET LOCATION ~ 6. TYPE OF RESIDENCE NUMBER DE,BEDROOMS ~ SIN'GLE FAMILY [] One [] Four [] Two [] Five [] MULTIPLE FAMILY ~ Three [] Six 7. WATER SUPPLY ~ INDIVIDUAL· [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DtSIK)SAL SYSTEM [] INDIVIDUAL/ON-SITE*· ~ PUBLIC UTILITY [] Other · ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) ~ ~ ' ~// YEAR ON-sITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. ~., THIS SIDE FOR OFFICIAL USE ONLY ~ 1. TYPE OF RESIDENCE ' ' ' NUMBER OF BEDROOMS ~' r-I SINGLE FAMILY [] ONE [] THREE [] FIVE I-'1 OTHER [] MULTIPLE FAMILY [] TWO [--I FOUR [] SIX 2. WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL · . 4. DISTANCESwELL TO: Septic/Holding Tank IAb$ocption Area JSewer Line J Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS []:~P~PPROV ED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY ~.~ 72-010 (Rev, 6/79)