HomeMy WebLinkAboutGLEN EAGLE BLK 4 LT 3, 4Glen Eagle Block 4 Lot 3 & 4 #050-601-30 Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: .()S P 191009 PID Number- 050-601-30 Dwelling: Fffil Single Family (SF) R with ADU [:! Duplex (D) Ell Two Single Family Project. R New N Upgrade Name SMITH ERIC ABSORPTION FIELD E] Deep Trench [:] Wide Trench ,:] Bed Ej Mound Site Address 23746 The Clearing Dr ❑ Other Phone Number of Bedroorns, Solt Rating Total depth from original grade 244-3616 GPDYSFJ F LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. lGravel depth beneath pipe I F Subdivision Block Lot GLEN EAGLE BLK 4 LT 3, 4 Filf added above original grade Ft. lGravet length I F Township Range Section Gravel width Ft Beds, Number of Lines Distance between lines F SEPARATION DISTANCES TO Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenclics, From Tank Field Tank Line Ft- I F Well 100'+ na na na TANK 99 Septic 0 S.T.P.P. C].Holding �D Other Manufacturer Icapacity, Freer 1250 Ga Surface Water i0o'+ alana tvlateriat Steel Number of mrnpartments 2 Lot Line 51+ na ria NA Foundation =10,+ na na LIFT STATION Manufacturer Capacity Remarks SepticTank Reptacement Ga Alarm location I Electrical inslatled by Tankto D3034 PIPE MATERIAL Flousetotank !D3034 Installer Dan Green d . rainfield Drainfield coiuTD3034 inspector- NorthRinri Eng. BENCH MARK (Assumed elevation) 100 ft inspection1,c 411 t4/1 9 4/19!1•9 Location and descriotion cintes, Z� Deck V 4t, Conditional Approval - Septic System Approved pattw (%'ax Date 111310?0"qo Note- this approval does not include well permit requirements_ Stamp '�Iq :49TH Steve Eng cro 4 .44 CE -6256 ;F Air f 0 / P5 '(?�u AS -BUILT MEASUREMENTS A B T1 30 41 T2 32 48 DCO 33 51 L2 New Well NOR THRI ENGINEER/ PO Box 77072 Eagle River. Alaska 99577 907.694. 7028 Y Utility Easement M The Charing Drive 4 Bdrm tc T1 T2 DC I Well 0 Well a•. ER100 ep is I ank w/ CO's Decommissioned ❑ld Septic Tank PER UPC 50' BLM ROW Wetlan Mappin9— — 20' Utility Easement -4t,` GLEN EAGLE 1' = so' ism•. BLOCK 4 LOT 3, 4 RECORD Ste" WASTEWATER UPGRADE LAY❑UT io/12 ' REPLACE SEPTIC TANK Date:0/26/20 2 of 3 u C1 a, Lo J O O � --I V) �^ D F9 O z fl 0 � Z ti sx e N o my 14 00:70 l J O <p r0 Q ro T� V N4 _ Q 00 O O � --I V) D F9 f'lp O z fl 0 � c C+ Q < `+ cis --J-0Q n Q 7u l J O <p r0 Q ro T� V Q _ Q 00 F— D D Z � (� T F9 F9 70 z o c-� H F - tDd F9 S A O Fri 3 N ro X Q <+ F— F- F9 F9 F O O a z �a7,� F- rrI b 70 : r� < F9 m d� Q � Q � d F— F- u 7U 0 F9 D u iH W z� O N Fql 4�1 m v) :KC < O � N Q r0-0 Do _t r0 `F 1 O f'lp O �Q fl 0 � c C+ Q < `+ cis --J-0Q n Q Qo ID :5 O ° co O <p r0 Q ro �0 Q _ Q 00 0 C+ LA F-1 < h Q < `+ o- Qo ID :5 o o ro c u f7 CD O _ Q 00 � (D c � n � Q O c-� tDd Fri 3 N ro X Q <+ `_+ n (� ro (D Q O ro F- rrI b n : r� < M 9- Q Q � o 90 O N n s m ,i t M �b W �U rql tJ ® •-1 Z —+ -a 0C7 :0M n, (D rta -� !� rn -1 a -v rr, (D tic mrn2: a� rq m r, IN z 9 r- O n a Ila �� 0 -� ,r U) rg r" J a aD fro N PI .� yc 'p or t� ,n,.W � B Q �o 0 MUNICIPALITY OF ANCHORAGE On-Site Water&Wastewater Program ••`:' `S 1 ��. ' 3 PO Box 196650 4700 Elmore Road Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 t 43 httpa/www.muni.org/onsite IZa_l ea N, j 1)cpartmcnt 4'YCMORPGE On-Site Wastewater Disposal System Permit Permit Number: OSP191009 Effective Date: 1/31/2019 Work Type: SepticTank Upgrade Expiration Date: 1/31/2020 Tax Code Number: 05060130000 Site Legal Address: GLEN EAGLE BLK 4 LT 3, 4 G:0160 Site Mailing Address: 23746 THE CLEARING DR, Eagle River Owner: SMITH ERIC & MARY KANCEWICK Lot Size in Sq Ft: 102000 Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 4 This permit is for the construction of: ❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72)and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing • Received By: Date: 2'/i Issued By: fiCu (oute) ___/// • Date: ��9 MUNICIPALITY OF ANCHORAGE 4r,l. Community Development Department Phone: 907-343-7904 Development Services Division -- Fax: 907-343-7997 On-Site Water&Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. (250 - ‘Cj/- 3o Property owner(s) tM / Ti-it (C., Day phone 4148—/26-7 Mailing address 2,3 7'/ TA. C_Ie zr-tig O it 5 ,,.e Site address -. , �J Legal description (Sub'd., Block & Lot) GL etvf-4 C,L- 8 i L 3, ,C/ Legal description (Township, Range & Section) Lot Size ./ 2/DCV Sq. Ft. Number of Bedrooms 1-7 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (E)all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) p' (w/wo ADU) Septic Tank 7 ' Upgrade Duplex (D) 0 Holding Tank ❑ Renewal ❑ Multiple Dwellin R p , Privy ❑ (SF and/or • 77 Private Well ❑ ,N IL Water Storage ❑ a jr ';, L. d _.,.'D > THIS APPLICATION INCLUDES A VARIANCE/WAIVER REQUEST FOR: ,- w Distance: 6 8 L 9 c.;\ I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. Pr_-_ (Signature of property r er or authorized agent) Permit/Rush Fees: 41 225.00 Waiver Fees: Date of Payment: °I1)0 ICI Date of Payment: Receipt Number: 031 I Co Receipt Number: Permit No. OS'Ptq l a Oq Waiver No. Permit App_9-1-12.doc hTF- I M ENGINEERING MEMO Steve Eng, PE, PH (907) 694-7028 SteveEngPE@gmail.com Date: 1/8/19 Number of Pages: To: MOA On-Site Services Subject: Glen Eagle Block 4 Lot 3,4 Septic Tank Failure The subject property requires a new septic tank. The tank is broken, but the bed appears to be working OK. Please expedite a permit so the tank can be replaced. The existing bed will remain. Please review as soon as possible. If there is need for additional information or clarification please give me a call. Thanks-Steve [\bTFIM ENGINEERING Glen Eagle, Block 4 Lot 3,4 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: This is an existing 4-bedroom home. Most of the neighboring lots are developed. The current septic tank has failed-the bed still functions. These lots are near an acre and are served by a private water wells.No adverse impacts are expected from tank replacement. The easements are depicted on the lot. The slope is indicated in the area of the septic system. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. • New 2- compartment, 1250 gallon septic tank. Watertight couplings on inlet& outlet. • 5' minimum between the tank and bed. 10' to property lines & house. • 4' of cover or insulation is required for tank; an equivalent of 1" insulation for l' foot soil cover. Tank & solid pipe must be set on well compacted, stable soil. • 4" diameter cleanouts with airtight caps are required 1' to 4' from foundation wall, prior to any 90 degree bend in 4 inch line, in each tank compartment, and two adjacent opposing cleanouts between the tank and the absorption field, not more than 10' from the tank positioned to provide cleanout access towards the tank and towards the absorption field. • All cleanouts must extend to at least ground level. • In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron. • Insulation must be placed over any pipe installed under driveways or parking areas. • Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, • Sewer Service Line is minimum 2% slope. • Septic Tank to be pumped every two years or when required. • Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal) r- OF 44.• ifte it, • 5,l. • ted CO, DESIGN NOTES: 1. Existing Bed/Trench Remains In Place. 2. Sewer Service Line minimum 2% slope. 3. Replace Septic Tank/Decommission Old Tank Per UPC. Connect New Tank To Existing Bed. 4. Lots Served by Private Water Wells. 5. No Conflicts Within 200'. 6. Check Condition Of Sewer Service Line— Replace If Necess• y. Well 7. Minimum Separation Of Lot Line To Septic Tank Of 5'. The Cle•ring Drive 0' Utility Easement _ _ _ _ _ L2 New Well Well s. / •s / °AP 100 4 Bdrm / sio / A6' �/0 / / AP f Bed ep is an w /CD's a Decommission Old v, Septic Tank PER UPC —' / •'. / AP Wet(a 50' BLM ROW — na MapPln9— — 20' Utility Easement ,'rrr`_MMy_` ` 1' = i NOR THRI __ GLEN EAGLE 150 ENGINEER/ • . 9m '* BLOCK 4 LOT 3, 4 DESIGN Po Box 77072- LAYOUT Eagle River, Alaska 99577 at-us Oir WASTEWATER UPGRADE 1%29%19 Date/29/19 907.694. 7028 REPLACE SEPTIC TANK 1/29/19 12of 3 Foundation Cleanout Tank Cleanouts Fin a� ❑pposing Cleanouts Between Septic Tank & Trench .Lo 4 Foot Cover or Equal 1250 Gallon To Existing Bed MOA-Approved Septic Tank e lid Pipe Match Elevations To DESIGN NOTES Existing FCD & Line 1. Use Existing Bed. 2. Septic Tank & Solid Pipe to be Placed on Compacted, Stable Soil, Free from Boulders. 3. Sewer Service Line is Minimum 2% Slope & 3' Cover. 4. Water-Tight Couplings. 5. See Specification Sheet. 6. All Work To Conform to Municipality of Anchorage (AMC) Requirements & Specifications. 7. Decommission Old Septic Tank Per UPC. 8. Check Condition Of Sewer Service Line. Replace And/Or Insulate If Necessary. -•'�� °FGLEN EAGLE NORTHRIM * SEPTIC TANK PROFILE ENGINEERING • BLOCK 4 LOT 3 , 4 PO Box 770724scarsDis Eagle River, Alaska 99577 �\ a �f ' 907.694.7028 TANK REPLACEMENT pc"' /8/19 rrawnBY: SE rale: 1• = 5 T3 of 3 I SE Municipality of Anchorage Page of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: PID Number: dso6o I Z o Name: Q-?-nloLp Lug Wastewater System: ❑ New J<Upgrade Datil Address: i+C 4� .a�kl(dc�1 La,P��e,,l��. C� ABSORPTION FIELD Phone: (� R 4 _ CI 311 No. of Bedrooms: �,�, - �a"s""L°"� O Deep Trench ❑Shallow Trench Bed Mound ❑ Other LEGAL DESCRIPTION Soil Rating: O• I Total Depth from original grade: 8 GPD/S .Ft. ILA Lot: Block: 41 Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe ° -S 6t_clj C/!t,L'ff to B Ft. © Ft. Township 14 Range: "L.1rtI Section: Fill added aboveonginal grade: Gravel length: I S � S Ft. Sz::� Ft. WELL: C1 New ❑Upgrade Gravel width: i 8 Number of lines: 3 Distance between lines: CO _ Ft. Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: 3034 PVG PR -1 VA -r -C- PO Ft 80 Ft. 9 OO SQ. Ft. Driller: Date Drilled: Static Water Level: Installer: V•/hlGBL GmNaT, Dale installe M -1U 02 ,waj 5� zb v B, .L Ft. Yield: I Pump Set at: Casing Height Above Ground: TANK -1•7 GPM 7 Ft. 1 24•// Ft. SEPARATION DISTANCES IXSeptic 0 Holding ❑ S.T.E.P. To Septic Absorption Lift Homing P /Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines (� SvU%C� f Lh;a' -t I Z_ S, Well 1`75 IBI A_�A N/A IS Material: 1-%Fs.a9;LksS Number of Compartments: Z Surface Water I octet loo+ 't///f N/it I oo r LIFT STATION Lot= lqe> 83 N/ N�q Size in gallons: Manufacturer: r7 4 Line Foundation"Pump z� 37 ,�jr "�/a on" level at: "Pump off' level at: High water alarm at: Curtain 1.(c,u0- J:'—ro wjAj Pump Make B Model Electrical Inspections performed by: Drain Remarks: BENCH MARK Location and Description: .5=Q -.A 6AeA aP t—�✓c+a.— S �4B Assumed Elevation: 100 Et/£EFVffiSPgAL Inspections performed by: Dates: is 2nd J 3 t:aviti ;L L�:ay 4 % S/9/f"y3 Department of Healt appro al �r:� K0. 7`c83�i- p'`;•�. '�'��'•�...,,,,,.• "'w�''A daF3fess�c� �Hujervices Reviewed and approved b —� Date: - w. 72-013 (Rev. 9/91) MOA 25 Permit No. S W 9 3 00$/ Page Z of Z Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report NOS 0 PID No.: 1 v tMT, a 1'3sS Lw-�O oJLl2 co mr C_'t z '[s�N ca 960 Yh �L ,NV a . fTILTEIL FM19QJL �ST?i.. fJ2.iCn GRn_ gg? P�.�TTcw� 72-013 A (2/91) MOA 25 CKJO PER'S SEAL 1 1 B I 44� , 54:9 34�= 4 393 529 s 57,11 Go? 1 v tMT, a 1'3sS Lw-�O oJLl2 co mr C_'t z '[s�N ca 960 Yh �L ,NV a . fTILTEIL FM19QJL �ST?i.. fJ2.iCn GRn_ gg? P�.�TTcw� 72-013 A (2/91) MOA 25 CKJO PER'S SEAL MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825_"L" STREET, ROOM 502 ANCHORAGE ALASKA 99519-6650 PAGE 1 OF 1 t-1 pm �L_)d 6 -)Lr -93 l coL 6-).SA3 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW930081 DESIGN ENGINEER:DAVID R. DAYTON, P.E. OWNER NAME:LUGDON ARNOLD M & JUDY OWNER ADDRESS:HC 83 BOX 1601 EAGLE RIVER, AK 99577 PARCEL ID:05060120 LEGAL DESCRIPTION: R LOT SIZE: 72000 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 5/03/93 EXPIRATION DATE: 5/03/94 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PR RECEIVED B ISSUED BY: DATE: DATE: /"O, z EA'S T i5,0 IRP (Jett. \ o r 1 0 Cavid R. Dayton INI 22-OSt l � _�gQ�rfRGrfSs9'��w` y. , Esxtsr ttSo amt. j' iu+2.,aa'^t*'cosa 1 - la ae co gxl TK?'IV c.o. CN j Mr ` Tk1-B/90 -r4 2. �E;P� 2�Jr6 0.7rrr�nx It 657% QC*a'fl �_-�— IAStF 18 xS0' 3tsd — r ._...._. _... �vmavt'F Soo Gtswc.. C SC?' rl.^�.Jf7 f=C?W /ZEa�iL V.4Tio•v Gi..rc� 3� Mw CoJ�R- F�trc2 R Ste. A c' 3• 0 M r,e, l o owl C"r 6 fQoemw 77- E`. -1ST gL-'PTt t. 'T'h1L iNSUU4TW� (3u WAS., tS (_�45 TAa.0 4` c I sEvr,c o. zzrt *3a•aos -71/E-K6 A/Lav A/U Wer—e.s 4,ol77'1N, /oo/T oA 77,e 5Y57cww, 'T w••.i fab �s'o arGnaFi�r.+r /,.e/.Acr o.J w�s7�-wMe2 5Y57C"S o" +o7',4c-,&,,7- P20P6,�Y' .eCS$2✓6n 51�•5t<3� 54¢P+>�� o't- 'S.�BSuKA4c.S, o.G on1 �.BW*�+4Gc'f. S0,0774 c.cS 11f77 4JPW David R. Dayton P.4F. 20410 Donalar St. _ Ghoglak, Alaska 9DM e Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG - PERCOLATION TEST PERFORMED FOR://O DATE LEGAL DESCRIPTION: 6f ��+<JL/G CL.pi1/pp3 Township, Range, Section: < DEPTHC..�mr� Yt �K,G,MJ«-i 5�es. SLOPE ISS -y (PE �1 I- 7-7 F E 7 8 8.� 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS )'N S GROUND WATER COUNTERED? YES, AT WHAT PTH? 5.U' to Water After oring7 z-,'7 Date: 42-7112-3 PLAN Reading Date Gross Time Net Time Depth to Water Net Drop i� =SJa.I 4 zI Cj3 �0)ot to If 3`r 'z- 01/3 o' 2 '%c f or Z�v O ) b'yI/4 's/(. /0"36 1 10 1 i o'�/r iu: tib I D iC) ICOLATION RATE 3--4 (mmutes/mCh) PERC HOLE DIAMETER & TEST RUN BETWEEN 5 FT AND 4 FT PERFORMED BY: ' 12±EX�� V :lr I (61--V CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 4/7,7/13 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST 1-kzs Ae- 2 I PERFORMED FOR: /t%O L'o GSL,"l/� C) A) DATE PERFi LEGAL DESCRIPTION: (OW ;0- G N j5VCiL4= Township, Range, Section: fir, I51 1 14A)ie) ld ,t DEPTH Sc n SLOPE SITE PLAN /.S 2 3 X05 4- 1011 10- 11 12- 13- 14- 15- 16- 17 21314151617 18 19 20 COMMENTS �pY'irlM o ¢ 1�0 WAS GROUND WATER ENCOUNTERED? 7 IF YES, AT WHAT o� t DEPTH?-- % "— Depth to Water Atter I Monitoring? 1114 Date: 4. L7 3 Reading Date Gross Time Net Time Depth to Water Net Drop 25 to �/ co i 3 3 PERCOLATION RATE 0.1I (minutes/inch) PERC HOLE DIAMETER G TEST RUN BETWEEN —:� FTAND 4— FT PERFORMED BY: 7D ✓A-4� �) Pi I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: /n%3 72-008 (Rev. 4185) MUNICIPALITY OF ANCHORAGE - - DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME C PHONE NEW ad -,20N -.109S/ ❑ UPGRADE MAILI GA2RE,$/D 4S ®� '4S,0EN DESCRIPTION DESCRIPlTIION Z 0 r 3 '91-0ce LOCATION - L EN .E,}l�-L E SUN, &U. NO. OF BE OMS ; DISTANCE TO: .t Absorption a Dwelling , 9 PERMLT ILO. O Y �+ Fa 2 y Manufacturer Sr's / Lr GL SS Material �/ .4 S S No. of compy5tments- ,� Li Zapaci�y in gallons IF HOMEMADE: Inside length Width Liquid depth m DISTANCE TO: Well Dwelling PERMIT NO. - SJ3Z F Manufacturer Material Liquid capacity in gallons DISTANCE TO: Well /D® Foundation �� Nearest lot linelAry PERMIT NO. TU // _ LU LL Z 2 No. of linea/ - Length of eagJyli a Total len h of lines Tre h width Distance between lines w F �+ (rf inches - QF C Top of tileto finish grade z // Material beneath the 4/ H Total effect absorption area T .2 f� inches W Length Width Depth - -PERMIT NO. t7 a F w ° Type of crib "Crib diameter Crib depth Total effective absorption area w DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller- Distance to lot l ine PERMIT NO. J 3 DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING owl Q INSTALLER p� REMARKS (�.OF• 4-4 • ...... &obert A. Sh AS /C s •• No. 7457 , E �19F�•••••.�••®P��� .•• a PRO -F 10N � 6 sc APPROV DATE ^/LEGAL t�J 140 JaN -uts thlev. s/ fb) µ ter: �Jlreaoid v I.ugdOn Use of well_ . Loeatioa (address of:' Tow=hip, lunge. Sec&N4 if kaown; at dbtancs naia road Lest 4 R'k [len Ess le Subd 1* < L4 / i3`f bt l3n/ E-9SM of 'Gc �ry*+th of Hole t30 feet Cased to W.1 feet Stack water levet ) `2_ft. tlbsne) (below) land surface. Finish of well (check one) open end &teen ( ); Perforated ( 1• Describe screen or perfo»t stest .t t:. 1ReU pumptng � � p� pas �settrl (minute) tor�,__.houn with of drawdown from static IML - We of comptetls„ - uJ 78 VML Loo s ; pepth In feet from Ofvg details of formatWu penetrsted, size of material. color and hardness surface Gasinj; atiek•.tp Orzanica ` Silty Rravo! Brody grave l • damp--- t. T0. —7% Slue clay and ravel w _.. — - jilts gravel: vet 61•PO�i % �A� a wl _ surfer asa�ra l "`° ro t,9.. u.. 1nN.y ,�.•..T r 02tificale No*1:11 rs-; V—STATE ' t ,. CjEPARTME:NT CRWEALTH AND ENVIRC NMENTRL 1ECTION ! r 825 ''L' STREET, ANCHORAGE, AK. 9 501 264-4720 UAE_L._L_ FAtAEti PERMIT Pd0 is 780194 APPLICANT A. M. LUGDON 2410+ ASPEN 279 1094 LOCATION CLEARING DR LEGAL L3:'4 B4 GLEN EAGLE S/D LOT SIZE 1024 -OO SQUARE FEET TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT/BR)= 85 THE REQUIRED SIDE OF THE SOIL ABSORPTION SYSTEM IS: to L-E=7r,l fii--6--f— E30o C3F'FA EL- -" THE LENGTH DIMENSION IS THE LENGTH YIN FEET) OF THE TRENCH OR DR:AINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION IN FEET). F` E= C A LJ 1[ F E= E> = E F' -F" I C -f- fol 0st "on lw27E = fly`_• s_n 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. TL -19D < > I 1 S F'Er o I Clr4_= FAF'E F`EOCAL3 I F'E=E> — _— BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM I= 100 FEET FOR A PRIVATE WELL a OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC: WELL.. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CON=STRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER: INSTALLATION. Fp E t 1 T -F E=>4 F` I F' E= °=* CN E CT E UI E> E F' = nL !LOA w -3 I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE. RESIDENCE I501MOPELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED Ad! LICANT A.1 ALUGDON ISSUED 0YY------------!c of --l ----------- PATE___ -q - _LL zy i V_„ a • • SOILS LOG • MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION Pouch 6660, Anchorage, Alaaka 99502 276-2221 TEST SOILS LOG — PERCOLATION TEST PERFORMED FOR:/ / L f" vG '!�— L D Iv DATE PERFORMED:�� 2U LEGAL DESCRIPTION: Zo F( DEPTH FEET) TO�i S' O r L 1 U 2 - 3 gelb 5 D / s 7 9 - 12- -1.8/1 _ 10 11 12 13 14 15 16 17 18 19 r v WA>IIIIIIIIIIIIIIIIIIIIIIIIWATER ENCOUNTERED? t IF YES, AT WHAT DEPTH? SLOPE SITE PLAN t -J I IAB 7 � 7 I I i I I ' I Reading Date Gross Time Net Time Depth to Water Net Drop d r. �,o0 20 PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN �`� Z FT AND 2 FT COMMENTS 67��%T�fC D,L"%•f'C-�'�/1 /7�.T C�7-c?�E�/---S'i1i7/ f ie6ST PERFORMED BY:.> 'S �NG/iUF /.S'rai�/ItIG C E R T I FI EDB C 72-008 (7/76) 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 FOR A SINGLE FAMILY DWELLING Parcell.D. 050-601-21 Lot 4 Vacant - - Lot 3, House 1. GENERAL INFORMATION Complete legal description Lots 3 & 4, Block 4 Location (site address or directions) 23746 Clearin Current Property owner(s) Bob Wick Mailing address Lending agency Mailing address Real Estate Agent Mailing Address HAA #_ C f 6 O 2% Expiration Date: Glen Eagle S/D Street Day phone 696-8831 23746 Clearing Street, Eagle River AK99577 Day phone Remax/Kathi Olm.ctpaA Day phone tig[,_42OC) 16601 Centerfield Dr. Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 Ste 201, Ea Z le River, AK 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual WellX❑ Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ 9577 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) 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 properlties 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 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(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,4Gi 6/GrNG-/--ZNG Phone Address i�34 N E�t��i���L�r,/ lG Engineer's Printed Name Robert C. Cnwan P E Date 4y� .- 0�J ` OSS .... ; y + NGR S,, 4 a ROBERT C. COWAN ,r E 5. DSD SIGNATURE CE Approved for bedrooms. �tlI q)r was. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By. ��.' Original Certificate Date: 1-30-01 (R=_v. 12/0Q) Municipality of Anchorage 2 *GE BVi • ''� Development Services Department e Building Safety Division - On -Site Water & Wastewater Program 4700 South Bragaw St, P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /�%��rl�/ % Parcel ID: 1!20-601 A. WELL DATA Well type /�fvIf A, B, or C provide PWSIvD # = Date completed _` / Sanitary se - Total depth �ft. Cased to !ft. FROM WELL LOG Date of test "T Static water level / lo/ ft. Well production iS 9— p.m-WATER SAMPLE RESULTS: Coliform colonies/100 ml. Date of sample: 0 / B. SEPTIC/HOLDING TANK DATA Tank Type/Material 7-7L, Nitrate 0.!5'-mg./I. Collected by: Well Log (YIN) G -S Wires properly protected49N) Casing height (above ground) Z!in . AT INSPECTION r 44 /o/ 22 ft. 9— p.m- Other bacteria colonies/100 ml. 5 & S ENGINEERING ,17034 Eagle River Loop Road No. 204 Eagle River,Ulat�e Rin??Z7d 61101-116 Tank size I251 gal. Number of Compartments _Z- Cleanout/N) (!:5 Foundation cleanou�N) _Y& Depression over tank (Yo &0 High water alarm (Y/N) / Date of pumping t 14e 19 / Pumper. J� S C. ABSORPTION FIE risnm� a►Dateinstalled S f¢ 93 Soil rating (g.p.d./ft2 or ftzlbdrm)Q_ Spe /J� Length ft. Width �U ft. Gravel below pipe tto =47— Total depth48 ft. Eff. absorption area QM ft2 Monitoring tube 7 va Depression over field Al Date of adequacy test / Results Pas ail) /1For bedrooms Fluid depth in absorption field before test Z�in. Water added gal. New depth 3 in. Elapsed Time: N min. Final fluid depth - in. Absorption rate >= &D g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) /Uay&OW—M If yes, give date D. LIFT STATION Date installed "Pump on" level at In. Datum E. SEPARATION DISTANCES gallons Manhole/Access (Y/N) "Pump off" level at — in. High water alarm level at Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank]9 stahM on lot Absorption Feld on lot Public sewer main N A- 6a+xer /septic service line ZS r+- on adjacent lots �B"O On adjacent lots t"00 r 7— Public Public sewer manholelcleanout_ A/ A Holding tank "fI i9 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation �_ Property line 5' Absorption field S Water main /V 1A Water service line 1r'0 �i- Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Water main N A - Water Service line D 14- Surface water 160 / t Driveway, parking/vehicle storage /Orf Curtain drain B F -f' PDX/Wells on adjacent lots �r Property line /0,- Building foundation %Q d' 0 F. COMMENTS G. ENGINEER'S CERTIFICATION l certify that 1 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 /� � cq¢2t C' COWAr Date // 30/01 HAA Fee Date of Payment Receipt Number 00100£$ (kl?�1?7F o)o!ides/Tion i£0 WV£91:TT TO/0£/ £911000 TO TO NV Waiver Fee $ Date of Payment Receipt Number COWAN 8801 -'Y............. PROFISSol MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division 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 C loci \- a 1 L �A LA i.2�C.1_.C_� n I Parcel I.D. # LXr-'A­ HAA # _ QUI 'A Lo 1. GENERAL INFORMATION Complete legal description Location (site address or directions) 6,«^��� �r- Property owner Mailing address Lending agency Mailing address. Agent Address d`©,c L /�_ r;, o� Day pr &SL /(`ted / r�L' e'4�z' Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 'Y 3. TYPE OF WATER SUPPLY: Individual well Community well Public water Day phone Day phone 99 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front MOA#21 ,U VOW %0-9 M/l'-6) 5ZO-ZL > jom s, aauibua leuolssa;oad a41 ui suoissiwo jo saaja aol alglsuodsa; IOU si abeJogouy ;o Al!ledlolunW ay1 °panssi si aleolllijeo a aaolaq elep azA eue ao suoi;oadsui lonpuoo IOU oP SHHQ to seaAoldw3 •sluawaiinba; alsls pus leaapa; umpao A;sues olaapio uj suognl!lsui bulpual na41 pue Sawo4;o s)asepind of Asalinoo e se SN4 saop SHHQ O41 °e�sely jo ale1S ayl ui paaalsi baa aaaul6ue leuolsseloid luapuedepui ue Aq ano0e g 4dei6emd ul u9Al6 suoilsluesaidej a41 uodn Aluo paseq saleoilpeo lenaddy Alljo4lnd 41leaH sonss! (SHHG; aolAaaS uswnH PUB 411EGH;o luawl.ieda(] abeaogouy;o Al!ledlolunV� a41 :suollelndi;s 6uimollol all yuan `swooapaq r-ry / uee,4ery;,cfil 'Li Fn.<.oq , .3 v IT v i ' aleQ sluawwoo leuolllppy fol lenoidde Ieuoll!puoo •swooapaq 7 •panoaddesla ao; panoaddy 3Hf111/N°JIS SHHa ainleu6ls s, aaul6u3 iifi-6 851201V *1Cn4iJ ssaippv 'is-Llpv^8 W907 auoyd .3.d uoiAM'a Puea walk to aweN •uolloodsui slgl;o alep ay1 uo loalle ui suolleln6ai pue `saoueulpao `sapoo a;elS pus ledrolunW Ile yuan aouelldwoo ui sl walsAs lesodslp aalemalsenn jo/pue Alddns ja;ean al!s-uo a41 °uolloodsu! pue uolle611saAul Aw woal pue sal!; a6wogouy;o Al!ledlolunW ay; woal pauielgo uollm iolu! agl uo paseq 1e41A;!a9na94iJn; i •ulaaay paleolpui ainlonils;o adAl pue swooapaq {o aagwnu ay1 ao; alenbapepue leuolloun;'ales si walsAs lesodslp aaleanalsum ao/pue Alddns ialem el!s-uo ayl ley; sMoys uopuolldde lenojddy Aluoylny ylleaH S1141 Id u01;e61169nu! Aw legl AI!JaA I `anolaq unaoys alep uol;ep!len ayl }o se pue olaaay pax!};e leas Aw Aq paiplaao sy OM E H33NION3 AS N01103dSNl d0 LN3W31VIS 'S Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: WT--_> 3 � � K � Parcel I.D. A. Well Data Well type +>L,0If A, B, or C, attach ADEC letter. ADEC water system number Log present(Y/N) y 0471 completed `'f/U178 Driller YO-IAJ �� U-)Jti Total depth P 0 Cased to Sanitary seal(Y/N) Date of test Static water level Well flow Pump levell Y FROM WELL LOG 7 i6/7e, f 00,1 Casing height Wires properly protected (Y/N) ) > g.p.m. SEPARATION DISTANCES FROM WELL TO: a AT INSPECTION o 3 2-Y/9 � c 2- -z7 Septic/holding tank on lot I l s ; On adjacent lots Absorption field on lot On adjacent lots f00 t' Public sewer main A/o a Public sewer manhole/cleanout Sewer service line 1 57 Petroleum tank /(`on 3 F70 t_ -p WATER SAMPLE RESULTS: Coliform 0 0, +(5 Other bacteria Date of sample: 31 z3 ( 9 3 Collected by: �P_DA, B. SEPTIC/HOLDING TANK DATA Date installed /c, -7,-VTank size I z Compartments Z Cleanouts (Y/N) y Foundation cleanout (Y/N) y Depression (Y/N) High water alarm (Y/N)�ZJtj Alarm tested (Y/N) Date of pumping ;�%93 Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 1-75- On adjacent lots i oo ". Foundation To property line 148± Absorption field � � Water main/service line 5Z� Surface water/drainage /po 4— 72-026 (3/93)' Front CONTINUED ON BACK PAGE 7 gip1. �° U)� w <@ On adjacent lots f00 t' Public sewer main A/o a Public sewer manhole/cleanout Sewer service line 1 57 Petroleum tank /(`on 3 F70 t_ -p WATER SAMPLE RESULTS: Coliform 0 0, +(5 Other bacteria Date of sample: 31 z3 ( 9 3 Collected by: �P_DA, B. SEPTIC/HOLDING TANK DATA Date installed /c, -7,-VTank size I z Compartments Z Cleanouts (Y/N) y Foundation cleanout (Y/N) y Depression (Y/N) High water alarm (Y/N)�ZJtj Alarm tested (Y/N) Date of pumping ;�%93 Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 1-75- On adjacent lots i oo ". Foundation To property line 148± Absorption field � � Water main/service line 5Z� Surface water/drainage /po 4— 72-026 (3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed N� Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" Level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Soil Soil rating (GPD/Ftp) 01 System type 'p Length / Width �� i Gravel thickness C), S, Total depth 3,S Total absorption area G/ v OG Cleanout present (Y/N) I Depression over field (Y/N) N Date of adequacy test AXxJ Results (pass/fail) for Bedrooms Water level in absorption field before test A.//;I-After test Peroxide treatment (past 12 months) (Y/N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot l W I On adjacent lots I oo t Property line To building foundation -e5 / To existing or abandoned system on lot h On adjacent lots j o U + Cutbank N o A' a Water main/service line I -SZ -D t Surface water f O U -1 Driveway, parking/vehicle storage area Curtain drain /l10,u6 LJuC.10A3 E. ENGINEER'S CERTIFICATION I certify that l have checked, verified, or conformed to all MOA and HAA guidelines in David R. Dayton P.E 20210 DonalarSt. Signature 4huglak, Alaska 9451 Engineer's Name-� Date HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)" Back Waiver Fee $ Date of Payment Receipt Number moo' of this inspection. 1-3 Ab 5. L GAL DESCRIPTION DATE RECEIVED INSPECTION APPOINTMENTS TIME LOCATION TIME TIME a:zo 6. TYPE OF RESIDENCE/(+ NUMBER OFsBEDROOMS SINGLE FAMILY ❑ One Four ❑ Other DATE �, DATE DATE C ❑ Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled INSPECTJ(t1 J `(Ilk . ` ❑ COMMUNITY INSPECTOR INSPECTOR ❑ PUBLIC UTILITY depth (attach log if available.) 8. MUNICIPALITY OF ANCHORAGE Z DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION, .- CiiON • 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION t Telephone 264-4720 ki E C ML �) REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DI RECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE _ MAILING ADDRESS :n tee) PROPERTY R ESI DE NT I If different from ab PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION PHONE r 1 /G9 i z B u, @Y)/ ('ca E� MAILING ADDRESS 4. REALTOR/AGENT PHONE MAILING ADDRESS 5. L GAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE/(+ NUMBER OFsBEDROOMS SINGLE FAMILY ❑ One Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ` ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM Z INDIVIDUAL/ON-SITE'*�> , YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) _"a 72-010 1Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY _ .. 1. TYPE OF RESIDENCE ❑ SINGLEFAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ TWO ❑ FOUR ❑ FIVE ❑ OTHER ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER (-� . DEPTH OF WELL DATE DRILLED LOG RECEIVED n, 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITEDATEINSTALLED ❑PUBLIC UTILITY -` Connection Verified PERMIT NUMBER —k4 kLQ INSTALLER ❑Septic Tank or ❑Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption. Area to nearest Lot Line 5. COMMENTS LAY APPROVED FOR _ BEDROOMS ED CONDITIONAL APPROVAL (letter must accompany certificate) %. DISAPPROVED DATE. 7� — BY 72-010 1Rev. 6/79)