HomeMy WebLinkAboutPREUSS #4 BLK 9 LT 6Preuss
Block 9
Lot 6
#050-572-60
From
Well
SuHace
Water
Municipality of Anchorage Page I 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; ....c,~. 0000q'O ! PID Number: 0 $'0- $'72- ~0
Wastewater System: [] New 'l~Upgrade
LEGAL DESCRIPTION
,,~er [] Upgrade
Ft Ft
ABSORPTION FIELD
~( Deep Trench
Soil Rating:
SEPARATION DISTANCE~3
Shallow Trench I-1 Bed ~ Mound ~ Other
Total Depth from original grade:
11.5"
5'.S' Ft
Gravel length: ..~..~ I Ft
Lot
L~ne ~ ~- ~
$
Inslatler: ) --
T~,NK
~Septic i~ Holding D S.T.E.P,
Manufacturer; Capacdy in gallons'
LIFT STATION
Curtain
Drain
>edormed by:
marks: BENCH MARK
ENGINEER'S SEAL
~."
Department of Health and Human Seduces approval ~_' c~ .~
Permit No.
SW0000401 Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 543-4744
On-Site Wostewoter Disposal System and/or Well Inspection Report
Legal Description: Pruess #4, Lot 6, Block 9
PID No.: 050-572-60
60' ST. (LUCAS AVE;)
Scale 1'-40' ~
-I
ELI~VATIDNS
(NOT TO SCALE)
163.34'
163.54'
~ 27.1' 45.8'
O ~ 38.8 to3.0'
00.0'
TEST HOLE
MONITOR TUBE
SEWER CLEAN OUT
EA~EMr.NT
EXISTING LEACH LOC CRIB
Dr,vewoy
Deck
5/3'~/m
ENGINEER'S SEAL
~.~....-x.. ...............
~;~.lOUtS A. BUERA::~ ~
~oo~5.' ~-~,,} ...~
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street. Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Sep 27, 2000
Expiration Date: Sep 27, 2001
Permit Number: SW000401
Legal Description: PREUSS #-4 BLK 9 LT 6
Design Engineer: 0024 Eagle River Engineering Services
Owner Name: RICHARD & NANCY BARNHART
Owner Address: 20714 LUCAS AVENUE
EAGLE RIVER, AK 99577-8781
Parcel ID: 050-572-60
Site Address: 020714 LUCAS AVE
Lot Size: 19600 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit Is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
Ail construction must 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 engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either. A. Open and closed on Ihe same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
Date:
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
October 20, 2000
Jim Cross, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re:
Lot 6, Block 9, Pmess Addn #4
Narrative & Permit Continuance
Dear Mr. Cross:
We received a septic tank upgrade permit last month as an emergency effort and this is the
continuation of that permit SW 401 for the septic leachfield upgrade portion. This upgrade will
have very limited impact on adjacent properties for the following reasons:
The surrounding lots have public water connections, allowing sufficient room for
septic sites.
2. Immediate neighboring septic systems are all +30' distance.
3. Reserve space is adequate, due to absorption capacity of the soil in this area (GP).
4. Drainage will not be affected and is not a major consideration in our design.
There is a new septic tank installed and this leachfield will be installed in summer of 2001.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\1997~00-062~^g2
60' ST. (LUCAS AVE)
NO WELL
165.,34'
· .?..~., .. o ;!. '~
~ ~' ~'.'~-,-...: ;- z
- ~0 ~ I ':"' q" ~
~ ~ roge House o
~ I ~ -New tonk m some
~m ~ .... ~;v~rPmace os old one.
~ s;on volve.
, I
I
163.34'
WELL +100'
~ - TEST HOLE
· - MONITOR TUBE
o - S~ER CL~ O~
~ ~ - ~EUENT
m- EXISTING L~H LOG CRIB
NO WELL ON LOT ~- Drivewoy
NO KNOWN CURTNN D~INS ~- Deck
SEPTIC UPGRADE SITE PLAN
LEGAL: LOT 6, BLOCK 9, Pruess ~4
OWNER: Richord ond Noncy Bornhort ~r.,' _ I ".~/~
- ~ ........................
JO~OO-OS2wS[ ~1[:10-24-00~ Seiki 1 = 40'!~.~ ......
EAGL~ RIVER ~NGIN~RING ~RVICE~ ~ ... ~-~ ...~
P.O. Bo~ 778~4
EAGLE RIVER, AK. 99577"~,:'o
(907) 694-5195 FAX: (907) 694-3297
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box 773294
Eagle River, Alaska 99577
(907) 694-5195
ERES Project No.: 00-062
Calculated By: LB
Date: 10/24/00
Legal: Pruess ~ Lot 6 BIk 9
Single Family 3 Bedroom Dwelling
TEST HOLE
Deep Trench Subsurface Wastewater Disposal Field
Water use at 150 gallons per bedroom = 450 gallons
Percolation rate = 7 minutes per inch
Wastewaterapplication rate = 0.8 gallons perday persquare foot
Required absorption area = 563 square feet
Trench width (W) = 3 feet
Graveldepth (D) = 5.5 feet
Required length = Required absorption area 12 / D
Required length = 563 / 2
Required length = 51 feet
Total Excavation Depth = 11.5 feet
5.5
00.062cal 5:03 PM10/24/00
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage. Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
I0
11
12
13
14
15
16
17
18
19
20-
COMMENTS
Township. Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
IF YES. AT WHAT ~
DEPTH? /g' · p
E
SITE PLAN
ale
I
Gross Net DePth to Net
Reading Date Time Time Water Drop
:~ / ~'!,-,~ .,,.~ /., .' ~,~',,J' ~.~ ~a°
PERCOLATION RATE ~ (mmuteshnch) PERC HOLE DIAMETER
TEST RUN BETWEEN b/' FT AND w/' ''%'- FT
PERFORMED BY: ~1~....~. I ~-'"'~-~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE~ DATE; ~,'/~-- ''~ ~*/'~ ~ ~'~
12-0~ (Rev. 4/85)
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: Lot 6, BIk 9, Pruess
October 24, 2000
A. GENERAL
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of llealth and State
Department of Environmental Conservation requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet
Municipality of Anchorage, Department of Environmental Conservation requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any
adjacent multi-family wells.
7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer
approval.
8. It is always recommended that a surveyor locate the nearest lot line position and the location of any
easements.
9. Any remaining open test hole excavations shall be filled.
B. SEPTIC TANK
I. Septic tank is installed new 10-00.
C. TRENCH
I. The trench is to be located as shown on the plan.
2. The bottom of the trench shall be level, plus or minus 1.5".
3. The total depth of tbe trench excavation is not to exceed I 1.5' in relation to the ground surface at test
hole.
4. The effluent line is to be connected into the existing leachpit line with the option of using a diver~er
valve to keep the leach pit online. The effluent line within the new trench shall be laid level within
0.03'.
5. The trench gravel is to be covered with typar fabric material.
6. Soll or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed
over the leachfield.
7. The area over the trench is to be finish graded to prevent ponding of surface water runoff.
8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any
Class 'C" well, or 200 feet to any community well.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH = I 1.5' GRAVEL DEPTtl = 5.5' under pipe, 2" over pipe
TRENCH LENGTtl = 51' TRENCH WIDTtl = 3'
SOIL RATING = 0.8 GPD/ft2 BEDROOM CAPACITY = 3
SEPTIC TANK = existing
Twenty-four (24) hours notice required for all inspections.
\1997~0o-062spcc2
Municipality of Anchorage Page /
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: ~' Z,~-',d~/_/~ / PID Number: g:)~-o - ,5-.~ _ 40
LEGAL DESCRIPTION
WELL: N,~ O New
(Private. A.B.C):
~:~
of
Wastewater System: [] New [] Upgrade
ABSORPTION FIELD
ri Deep Trench C] Shallow Trench
Sod Rating:
[] Upgrade
Total DePtll;
Ft. FI.
Ft.
SO FI
TANK
Well
Surface
Water
Lot
Line
Foundation
Curtain
Drain
GPM
SEPARATION DISTANCES
ri Bed I'1 Mound ri Other
fade:
Remarks: ..~'/v.-~//,~r,~., ..F ,,, ~,,~ BENCHMARK
I
ENGINEER'S SEAL
2nd~i~ i ~~.~.'
Depa.ment of Health and Human Se~lces approval I ~ c~ .~-~
I '
~l~Septic ri Holding ri S.T.E.P.
Manufacturer: Capacity in gallons:
Permit No.
SW000401 Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O, Box 196650 Anchorage, Alaska 99519-6650 Telephone: 543-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Le al Description: Lot 6, Block 9, Pruess
PID No.: 050-572-60
60' ST. (LUCAS AVE)
;cole 1'=40'
I
I
I
163.34'
'-; ';.
;'." ~,;:~r";" ~
Shed C,~'~New tank in same
/ place os old one.
163.34'
Swing T;es
· - MONITOR TUBE
o - SEWER CLEAN OUT
EASEMENT
=.~-=- EXIS~NC LEACH LOC CRIE
~,,. -~- Drivewoy
~.-~.-7-~-~_ Deck
9-29-00
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Sen/ices
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Sep 27. 2000
Expiration Date: Sep 27. 2001
Permit Number: SW000401
Legal Description: PREUSS #4 BLK 9 LT 6
Design Engineer: 0024 Eagle River Engineering Services
Owner Name: RICHARD & NANCY BARNHART
Owner Address: 20714 LUCAS AVENUE
EAGLE RIVER. AK 99577-8781
Pamel ID: 050-572-80
Site Address: 020714 LUCAS AVE
Lot Size: 19600 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well
[] Water Storage
All construction must 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 engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered. sealed, and heated to prevent freezing.
Received By:
Issued By:
Date:
Date: ?'27-00
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
September 26, 2000
Jim Cross, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re.'
Lot 6, Block 9, Pruess Addn//4
Narrative & Permit Application
Dear Mr. Cross:
The proposed septic tank upgrade will have very limited impact on adjacent properties for the
following reasons:
The surrounding lots have public water connections, allowing sufficient room for
septic sites.
Immediate neighboring septic systems are all +30' distance.
Reserve space is adequate, due to absorption capacity of the soil in this area (GP).
Drainage will not be affected and is not a major consideration in our design.
This is a septic tank replacement in the same area as the old tank, which has structurally failed.
There is one cleanout after the tank and we will install another cleanout after the tank. There is
no foundation cleanout. We do not plan on installing a foundation cleanout and have confirmed
that there is a means of snaking the line from inside the building. The tank collapse is an
emergency situation and we will be applying for an upgrade of the leachfield after a test hole is
completed under the same permit fee and application.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\I99~00-062NAR
I
· .: . lines and do not ~'etlap ~ enc~
~ / ' ~t¥ lying idjo~ent thoro ~ch
~ ~ ' '~r.--.. ~uesttcn :nd that the~ ire no ~wi?s. ~.mission
.~..t C~ ' ~ indi~t~ he~
· ~.. ~at~ at ~gle Ely.. Alaska . '
~ox 4~':. ~a~le Ri~r, Alaska
1' 3 0 1 Phone
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
LEGAL:
SPECIFICATIONS FOR SEPTIC TANK REPLACEMENT
Lot 6, Block 9, Pruess Addn #4
9/27/00
A. GENERAL
I. The site plan drawing shall be a part of this specification.
2. All materials and workmanship shall meet the requirements of Anchorage Department of
Health and Environmental Protection Permit.
B. TIlE SEPTIC TANK
1. Septic tank construction shall be a 1000 gallon steel txvo compartment tank approved by the
Municipality of Anchorage.
2. Septic tank is to be installed level on original base material.
3. Ali connections are to be made with caulder couplings.
4. The existing tank is to be pumped ifpossible, and buried onsite.
5. New tank to be provided with 2 cleanouts after tank (one is existing).
6. No foundation cleanout is required.
\1997~00-062spec
~GRE~.~,,ER ANCHORAGE AREA BO[~JGH
~_~/~ Department of Environmental Quality
~ 3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
MAILING ADDRESS. PHONE.
LEGAL DESCRIPTION 1o¢ ~ ~.~,¢ ¢ /~¢~$
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH
~/t~ /70/0?
MANUFACTURER ~'/7~/-~ ,.~,f._ MATERIAL ~'7-g~.f_. NUMBER OF
COMPARTMENTS
INSIDE WIDTH LIQUID DEPTH __.LIQUID CAPACITY /OOZ) GALLONS.
SEEPAGE PIT:
NUMBER OF PITS
BUILDING FOUNDATION
ADDITIONAL ABSORPTION / ~--'~'~ 7~'~r~1
6'
CRIB SIZE: DIAMETER ?/DEPTH ~/ DISTANCE FROM: WELL
TOTAL EFFECTIVE /7/~-6
NEAREST LOT LINE /~1. ABSORPTION AREA (WALL AREA)
/
SQ. FT.
TYPE CONSTRUCTION
BUILDING NEAREST NEAREST
FOUNDATION_ LOT LINE SEWER LINE
CESSPOOL OTHER SOURCES
APPROVED DISAPPROVED REMARKS
DISTANCES:
INSTALLED BY:
PIPE MATERIAL:
DEPTH
LOTSLOPE: )~/~ /~ .
REMARKS:
Form No, EQ-031
DISTANCE FROM:
SEPTIC SEEPAGE
TANK ~, SYSTEM
DIAGRAM O F~ff~.~.
GreATEr ANCHORAGE Area BorOUGh
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-4~61
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
PERMIT NO.
NAME OF AFPL,CANT F,m H
INSTALLATION LOCATION -~ s ~
INSTALLATION OF: SEPTIC TANK ~ SEEPAge PiT
· DRAIN FIELD J OTHER
FINANCED THROUGH ~ TO BE ] STALLED ~
SOIL TEST RESULTS ~ ~/I?H~UT SOIL TES
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK~-~/
DIAGRAM OF SYSTEM
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
FOUNDATION TO SEEPAGE PIT C~/L/ DRAIN FIELD
SEPTIC TANK TO SEEPAGE Pit WALL
SEPTIC TANK ~ ., SEEPAGE PIT .DRAIN FIELD
TO NEAREST LOT LINE.
tO0 '
WELL TO SEPTIC TANK . SEEPAGE PIT
DRAIN FIELD ~ALSO CONSIDER AREA WELLS.
WATER MAIN TO SEPTIC TANK . SEEPAGE PIT
DRAIN FIELD
!
SEPTIC TANK,iA,,//~U ., SEEPAGE PIT /~)6 , DRAIN FIELD
TO RIVER, LAKE· STREAM.
· CAST IRON INTO AND OUT OF SEPTIC TANK AND
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
OR
LICENSED DESIGNER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS Of GREATER ANCHORAGE AREA BORO~)ORDINANCE NO. 28-68 AND THAT THE ABOVE
//
DESCRIBED SYSTEM S IN ACCORDANCE WITH SAIO CODE
Legal Description._/~-[~ ~_-~ E~t~ u $ .~
This form reports.' Soils log F
~ GREATER ANOIORAGE AREA BOROI~'~
Department of Environmental QuaHty
3330 "C" Street
(T'!/-~~/ ,,~,.~. ~.~.~ Anchorage, Alaska 99503
SOILS LOG - PEROLATION TEST
Date Performed
Percolation test
Depth
Feet
1-
2-
3-
4-
5-
6-
7-
8-
lO -
11 -'
,12 -
13 -
14 - ~
Was ground water encountered?
If yes, at what depth?
Reading Date
Percolation rate
Gross Time
minute.
· Proposed installat-lC'n? Seepage Pit
Depth of Inlet ......... ·
COIl~ IEIITS:
Net Time
Drain Field
Oept~-~--tob-ottomo-f--pit or trench
Depth to Water
Net Drop
E¢~-040 (6/74)
Certified Dy:
Dd te:
· 'DEPARTMENI~F HEALTH AND ENVIRONMEN,. ~-PROTECTION
.' 825 L Street, Anchorao~. Alaska 99501
~/'.' %j~. 264-4720
Time
Date
Insp
%2: Time I ', ~/~ ~9/y% #3:
Date . a -~~_~ S
Insp ~n~
Time
Date
Insp~
UEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request: National Bank of Alaska % Ruth La Bar
Mailing Address: Pouch 7-025 99510 Phone: 265-2883
2. Property Owner: Lionel E. Hamel
Mailing Address: Star Route Box 5718 99577
Phone: 694-9016
3. Legal Description: Lot 6 Block 9 Preuss Subdivision #4
4: Single Family Residence: (x) Number of Bedrooms: ???
Multiple Family Residence: ( ) Number of Bedrooms:
Well System:
Permit #
Construction
Individual well (x) Community/Public System ( )
Depth of Well Well Log on File (
Bacterial Analysis
m
Sewage Disposal System:
Permit #
Septic Tank Size
Absorption Area
On-site System ~ Public Utility ( )
Installed~ ~/ Installer
Manufacturer ~%%f ~
Soils Rate ;~15-- Material
7. Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest Lot line Absorption Area
to Nearest Lot Line
, Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 6 Block 9 Preuss Subdivision ~4
Comments:
Aff~a- t' Att~~
Letter Attached: ( )
Date: .
Date:
Department Worksheet:
L-~MUNICIPALITY OF ANCHORAGEkj
' ~ Department of Health and Environmental Protection
~.___~"--'~]1~ ~ 825 L Street, Anchorage, Alaska 99501
LL%~/~ 264-4720 /'~ or:~
quest for Approval of Individual Sewer and Water Facilities
1. .
' 2.
e
Property Owner:
Mailing Address:
Name of Buyer:
Mailing Address:
Phone:
Lending Institution: /J ~ ~
Mailing Address: ~~ /~- ~ 2~-
Metaling Address: ~ ,/ ~ ~~ ~ '
Legal Description: ~ ~ ~~ /~
street Location: ~ c~ ~~
Single Family Residence: (~ Number of Bedrooms:
Phone:
Phone:
Multiple Family Residence: ( ) Number of Bedrooms:
Water Supply: *Individual Well (~ Public/Community System (
If Individual Well, well depth
If Community System, name of system
Sewage Disposal System: *~n-site System
If On-site System, date of installation:
(/ Public System
*NOTE:
A well log is required on ALL wells drilled since 6/75.
** If on-site sewer system is over two(2) years old, an adequacy
.test is required by this department. MUNiC~^[~¥~QF~CH~essin~
A fee of $25.00 must accompany each reque~T.~o~LT~~ ~
can be initiated. ENVIRONMENTAL PROTF. CTION
3/77
APR 5 I978
RECEIVED