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THUNDERBIRD HEIGHTS BLK 2 LT 3
Onsite File r Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP 191123 PID Number: 051-721-07 Dwelling: 0 Single Family(SF) ❑with ADU ❑ Duplex (D) ❑ TWA Single Family, Project.❑New . © Upgrade Name ABSORPTION FIELD Michelle L. & John C. Eicher Site Address ❑ Deep Trench ❑Wide Trench ❑ Bed ❑ Mound 25016 Thunderbird Dr., Chugiak, AK ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot Ft, Ft. Thunderbird Heights 2 3 Fill added above original grade Gravel length Township Range Section Ft. Ft. Gravel width Beds:Number of Lines Distance between lines SEPARATION DISTANCES Ft. Ft. To' Total absorption area Number of trenches Dist.between trenches Septic Absorption Lift Station Holding i Sewer From Tank Field Tank Line Ft2 Ft. Well 1 00+ TANK t l Septic 0 S.T.E.P. 0 Holding ❑ Other Manufacturer Capacity Surface Water i 100+ Anchorage Tank 1250 Gal. Material Number of compartments Lot Line ; 5+ ' NA Steel 2 iLIFT STATION Foundation 10+ i Manufacturer Capacity Remarks Sump at end of drainfield replaced Gal. with cleanout and monitor tube. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034Tank to 3034 Installer _ drainfield __ . ARM Services Drainfield CO/MT3034 Inspector Crewdson Engineering LLC BENCH MARK (Assumed elevation) 100 ft Inspection 1r4/30/2019 "°4/30/2019 Location and description dates: 4 - .- 3 Bottom of siding at "A" on record drawing ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engine tamp 'c� OF A..q X11 Conditional Approval: Date �,tp../ I� 00 o, �'v '' i / `//' ---- - --_---- _—. -- /A ,Jam-s A. Crewdson• % Septic System — ) `� C11527 APPro I— Date l7� ,i,.p : �.'1-NP��'.." Note: this approval does not include well permit requirements. AL LC.\\AN1�-' (Rev 05/02/18) — S89°51'11"WS02738 — — _ __ / / / WK /s ti /w / /Q / LOT3 / .`' / SEPTIC TANK /j v ANCHORAGE TANK AT-1250 \ FCA /� I� • M1 • SS11-/—* / io O ti / Z> S SWING TIES(feet) 4 BR SFH I i zA B I 1 FC 5.79 52.31 I/ / Si 19.61 50.27 • /. 52 26.56 53.32 DC 29.35 54.82 ,� ', DRIVEWAY / . . Cl • • 83.12 93.80 B • • . . / . • / I PLAN M1 80.08 91.13 / / SCALE: 1"=30' — — — — — / / _ _ S 89°51'11_W 173.45 _ _ _ / NOTES LEGEND 1. (E)SEPTIC TANKS ABANDONED IN PLACE IAW THE BENCH MARK CODE. (E)-existing (N)-proposed BOTTOM OF SIDING AT"A" AMC-Anch.Muni.Code ASSUMED ELEV 100' BR-bedroom c#-cleanout 2"INSULATION ELEV DC-double cleanout EG 98.6' EG-existing ground ELEV-elevation FG 98.9' FC-foundation cleanout Si S2 DC FG-finish grade I _I IN - eccordance with INVV-invert M#-monitor tube MIN-minimum IIII S#-septic tank cleanout SFH-single family home TOT-top of tank SEPTIC TANK - WK-water key box ELEV: TOT 95.18' INLET INV 94.60' OUTLET INV 90.43' PROFILE NOT TO SCALE Crewdson Engineering, LLC Thunderbird Heights, Block 2, Lot 3 ������k\, ,��.F A�gsl�I Septic Tank Upgrade Record Drawing9so 4.6 ,,,. '.:v Plan and Profile Views *� TM " *�� JaA.Crewdson • j moo. Prepared for: Pmes. C11527 .A/ Civil&Environmental Engineering Michael Eicher Date: 5-29-19 1t`�lFgFS:••A-fi��� PO Box 871389 Chugiak AK 99567 • cellc.1@oullook.com Permit: OSP191123 Page: 1 of 1 �\��N"`���� Cal/Text:907-280-9493 • Fax:907.888-2295 ALL NFORMATION SHOWN ON TES DOCUMENT IS THE PROPERTY OF CREWDSON ENGINEERING.LLC AND SHAU.NOT SE USED FOR ALLC#112279 ENGINEERING OR CONSTRUCTION PURPOSES WITHOUT WRITTEN PERMISSION FROM CRENOSON ENGIIEERING.LLC MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP191123 Work Type: SepticTank Upgrade Tax Code Number: 05172107000 Site Legal Address: THUNDERBIRD HEIGHTS BLK 2 LT 3 G:1865 Site Mailing Address: 25016 THUNDERBIRD DR, Chugiak Owner: EICHER MICHELLE L & JOHN C Design Engineer: CREWDSON ENGINEERING, LLC This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date Expiration Date Lot Size in Sq Ft: Total Bedrooms: f DeIM1,tInC nt 4/23/2019 4/22/2020 21090 ❑ Private Well ❑ 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: r Issued By:Date: Z 3 N MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-721-07 Property owner(s) Michelle & John Eicher Day phone Mailing address 25016 Thunderbird Drive, Chugiak, AK 99567 Site address Same Legal description (Sub'd., Block & Lot) Thunderbird Heights, Block 2, Lot 3 Legal description (Township, Range & Section) Lot Size 21,090 Sq. Ft. . Number of Bedrooms' 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) Q (w/wo ADU) Septic Tank Q Upgrade El Duplex Duplex (D) ❑ Holding Tank El Renewal El Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that t/above information is correct. I further certify that this is in accordance with applicable al Codes. >- IR of property owner or authorized agent) Permit/Rush Fees: Date of Payment: q/23 1 i q 4 Receipt Number: (y L13OYL Permit No. 6SPIq // 23 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safetyl0n site Water and WastewatefformslClient FormsTermit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191123, Rebecca Carroll, 04/23/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191123, Rebecca Carroll, 04/23/19 714P4 (Rev. 3/78) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME P t[�y�� / _ NEW Q .5_1 LIVZUPGRADE MAILING AdDRESS :001P LEGAL DESCRIPTION 1-3 r3 Z 111:r. -r//-7 LOCATIONa ///1 NO.OF BEDROOMS e-/ /d ✓4r DISTANCE TO: Ornu�/�� Absorption area Dwelling PERf��o0/ OO Ole 0 EQ Manufactur e I , Mat � a,_No. 11sn of compartments Liq. capacity in goon G(� MEMADE: Inside length Width Liquid depth 13 Y DISTANCE TO: Well Dwelling PERMIT NO. J t�2 0 F Manufacturer Material Liquid capacity in gallons D w= DISTANCE TO: /Y .U/ Q 'u Foundation Nearest lot Ime f PEH T pl / J LL Z No. of linesth�of each I Total I.,e91h of lines Tren idth Distance lines (r etween f.?"t ( S(J �/ '-50 a Inches fp inish µ bene tile Total 2 of tile grade ! ryl u effective absorption area o � inches Length Width epth PERMIT NO. W Q F Type of crib Crib diameter Crib depth Total effective absorption area W 1 DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. J WT+ DISTANCE T0: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS C S01 L T EST RATI N INSTALLER i L�17C C . REMARKS 6r1 f M >~ 3X �.�• .• ••.. a P XLXC7 / c va ................. , Robert A. She4 W 1157-E S�.•e, ••No. t r; \a •jrOFF.S4l3o APP ED DATE LEGAL S & S Enginwzing 714P4 (Rev. 3/78) tl U N I C I F '"L_ I T V O F Ff"C:"Qf G E DEPARTMENT (""\HEALTH AND ENVIRONMENTAL( /� R FOTECTION 625 'L STREET, ANCHORAGE, AK. 99:,d1 264-4720 Otyl—� I TE SEWER UF='GRnE>a F'•ERM I T PERMIT NO. ( 610616 ) APPLICANT MR.R: MRS. GEORGE FINNELL1 204 THUNDERBIRD DR., EKLUTNA 666-3365 LOCATION 204 THUNDERBIRD DR., EfCLUTNA LEGAL L3 62 THUNDERBIRD HEIGHTS S/D LOT SIZE 21090 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING CSO FT/BR)= 65 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: F>EF='TH= 71 LENGTH= 221D GRFIk'EL LAEF}TH= 4 THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN 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 CIN FEET). REG!U I RELY •SEF=T I G -rnNK S I =E= S1010 GRLL-(DNS PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DUPING THE INSTALLATION INSPECTIONS OF ANY !JELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. --- TL44 C r ] FARE REG!U I REO --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT I4ILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 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=•ERM I T E}{F=� I RE'S F?ECEME*ER T1s 1L 1 CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. �s1.3�?_._�v'uU���- ISSUED PPLICANT MP,. t, MR . GEORGE FINNELL V4. 0 MUNICIPALITY OF ANCIIOR �Jlth and Environmental Pr fiction ' Fourth Floor West - 825 L Street Anchorage, Alaska 99501 264-4720 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING ABORU-S Sao 1._C = � — nllo::Ea76 -5551 T; C'_71 4V e__ LEGAL 1.•E. SC R )FIT I ON NUMBER OF -2 —COMPARTMENTS r POLI `:,_LLl1"�'??�.___-- !� %✓•'-%i'i•C_l UfiER _ ___— �� — L!•1'(� i31AL ___.--.--COr•1,1R PTf.7EflTS LIQ:Jiq DEPTH -- LIQUID CAPACITY 000 GALLONS. TILL Diu%m F ILLI): TOTAL LENGTH LOT LINE.__ OF LINE 7 ssoZV'r NU Of Line:; _ _-_-- .— ultir:,ticE BET'.•dECN Lli lL-5 _---.----TRENCII YlIDTIWJ.._ IN. -TOTAL EFFECTIVE SQ. IT. LENGTII OF EACII LINE ( OEFTH OF IILTER I p 1 UJ u+ 1IL!_ 70 I I':I',I, G AI;C 3..--_ MA11 RIAL BCNF_ATII TILL —4/—W AGOVE TILE IN. UI E7 CR _OI3 YIIDTII —• LING TH—• DCPT1I Log Crib _Rings_ Crib Size: DIX,10c.R... UEI'TII_ DISTANCE FROM: WELL IOTPL EFFECTIVE !.,i R'!r.t:•: F^'J: J; U.'! 10.1_ f3CARLST LOT LIVE_—. APIlURPTION AREA(WALL AREA) SQ. FT icllk\� Class: ^ Depth: ;ell Distance TO: Lot Line — i3ldg: So% oorr Line: Pipe materials: ayj� i of E3cdroo:n.s - I Enstallor: �. Rema UAIl:a 3 �— APPROVED r UAIl:a 3 �— APPROVED TYPE OF SOIL ABSORSTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING CSO FT/BR)= 85 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: OF=PTH= 7 LEt4wrv4= 32 C3RFr%?EL E>EF}TF-F= 4 THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN 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 CIN FEET). REOLJ I REO SEPTIC TFrt4 C S I 2"Ew= 1.OF+0 C3FiFLLOt4S PF CTFCFIGE PFLF rJlr OPTION A PACKAGE PLANT MAY BE INSTALLED AT THE PERMITTEE'S OPTION SUBJECT TO THE FOLLOWING CONDITIONS: 1. EITHER A CLASS I OR II NSF APPROVED PLANT MAY BE INSTALLED. 2. A CONTINUOUS MAINTENANCE AGREEMENT IS REQUIRED. IF A MAINTENANCE AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED TO ENLARGE THE SOIL ABSORPTION SYSTEM AND/OR YOU MAY BE SUBJECT TO PROSECUTION. ---------------------------------------- --- --------------------------------------- --- TWO C 2 7 I NSPECT I Ot+15 nF eE RE:(; U I FZEF7 --- 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 IS 100 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL. 'OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. PERFYI I T EXP I RES [7ECEt1EsER 31r 15 7 7 I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEW FIR SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE E THAN 3 BEDROOMS. _'--y( /1 '_ - APPLICANT ISSUE�D/ B-IY_��/ HARRISON DEV V3. O OF FitACIV4^"2 FA C3 ., DEPARTMENT 0. HEALTH AND ENVIRONMENTAL FmJTECTION 1 �� 825 'L' STREET, ANCHORAGE, AK. 99501 1� 264-4720 _ OtJ — S I T E S E W E R F=)'[-= R M I T PERMIT NO. C 771028 ) 'APPLICANT HRRVELLE HARRISON DEV, 3201 C ST (CALAIS OFFICE CENTE 276 5551 LOCATION THUNDERBIRD DR LEGAL L3 82 THUNDERBIRD HTS SUB LOT SIZE 21090 SQUARE FEET TYPE OF SOIL ABSORSTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING CSO FT/BR)= 85 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: OF=PTH= 7 LEt4wrv4= 32 C3RFr%?EL E>EF}TF-F= 4 THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN 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 CIN FEET). REOLJ I REO SEPTIC TFrt4 C S I 2"Ew= 1.OF+0 C3FiFLLOt4S PF CTFCFIGE PFLF rJlr OPTION A PACKAGE PLANT MAY BE INSTALLED AT THE PERMITTEE'S OPTION SUBJECT TO THE FOLLOWING CONDITIONS: 1. EITHER A CLASS I OR II NSF APPROVED PLANT MAY BE INSTALLED. 2. A CONTINUOUS MAINTENANCE AGREEMENT IS REQUIRED. IF A MAINTENANCE AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED TO ENLARGE THE SOIL ABSORPTION SYSTEM AND/OR YOU MAY BE SUBJECT TO PROSECUTION. ---------------------------------------- --- --------------------------------------- --- TWO C 2 7 I NSPECT I Ot+15 nF eE RE:(; U I FZEF7 --- 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 IS 100 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL. 'OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. PERFYI I T EXP I RES [7ECEt1EsER 31r 15 7 7 I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEW FIR SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE E THAN 3 BEDROOMS. _'--y( /1 '_ - APPLICANT ISSUE�D/ B-IY_��/ HARRISON DEV V3. O 0 & E GEC"ECHNI CAL & DEVEhPMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 6942774 or 666-2260 Russel Oyster fad Ellis 694.2774 SOIL LOG 6ee-2290 Soils & Foundations ` ` \ Land Development N O.V f1LL — �A'4Y'���Sc1J Performed for: Name: '&\'x. C`��_e � r= n.sf�et g Tel. No. 2"7 1, 1 Mailing Address:�t>.�.�, n X44_ C� +� 320\ caasB Legal Description:_ ��� Z lT.�...uo�c�cs.Rn �4_>c�>cs .�Sv.P-,r> Depth (feet) Soil Characteristics 0 1 W%�0VCGNaks. 2 3 4 5 GW — :So.%'>DY G�A�fts_. W.�v� CcA4iv�cs %c-, 6 \� 11. \j 7 8 9 10 11- 12- 13 213 �etca T. 14 Z7 -S Ground Water Encountered:, Yes No If yes what depth �\ Proposed Installation: Seepage Pit Drain Field Comments: 7 t4ts iA 4-VV,4-n 3r+ IS' .J r�\"%-y- `J' ♦n'£S T4 GG 4f> Performed by: —L�)) 14 Date: N*�,t \q J, \c177 January 4, 1978 Harvelle Harrison Dev. 3201 C Street Calais Office Center Anchorage, Alaska 99503 Subject: Lot 1 Block 1 Thunderbird Heights Subdivision Permit 1771024 Lot 8 Block 3 Thunderbird Heights Subdivision Permit 1771025 • Lot 3 Block 2 Thunderbird Heights Subdivision Permit 1771028 A permit issued by this department for well and/or sewer system has expired. Permits are issued on a calendar year basis, as stated on the pernit, by authority of Municipal ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date. If there are any further questions, please contact this office at 264-4720. Sincerely, Health and Environmental Protection Sewer and Water Section T� � o yGti�E �D I D'4z" s TOP OF FOUNDATION WALL ELEVATION • IT SHALL BE THE RESPONSIBILITY OF THE BUILDER ELEVATIONS BASED ON DATUM OR OWNER TO VERIFY THAT BUILDING LOCATION SHOWN MEETS ALL SUBDIVISION COVENANTS AND PREPARED FOR. LOCAL ZONING CODES AND ORDINANCES. f/q/VG/% • /�p�riJOn PLOT PLAN TRycI<LOT 3 BLOCK Z uts. L2 rnrE NYMAN THUfVOERB/RO HE/GHTS u«.✓ye ,Rlo r I FAN fe-r N YALE "- 3d OF ql XI LI ,..... 9�.1 h:••• ,t ttl 1':49 T //�� 7 •.. •Q.s .....� JACK W. GARRISOi N F• NO. 949•S .; *I'i CS7 ll� I 6 r E Pt4N5 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On-Site Systems Approval Parcel I.D. 051-721-07 / (Z - _02U Expiration Date: 1,` 1. GENERAL INFORMATION Complete legal description Thunderbird Heights, Block 2, Lot 3 Location (site address) 25016 Thunderbird Dr., Chugiak, AK 99567 Current property owner(s) Michelle L. & John C. Eicher Day phone Mailing address same Real estate agent Day phone 2. TYPE OF DWELLING: E Single Family (w/wo ADU) n Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic Water Storage ❑ Holding Tank ❑ Community Well 0 Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ 63-0 Waiver Fee $ Date of Payment 5-12Q!(9 Date of Payment Receipt Number 400-73W-4 Receipt Number COSA# Q sefgi/g3 Waiver# 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. I acknowledge that On-Site staff may visit the site to verify the information submitted. Name of Firm Crewdson Engineering LLC Phone 907-280-9493 Address PO Box 671389, Chugiak, AK 99567 Engineer's Printed Name James Crewdson Date 5/29/2019 A c`o��a\}cl \ �q 1 i Q�' X9' 11 6. DSD SIGNATURE /' •: t i" / N. System #1 Approved for bedrooms / •A .James k*Crewdson; ge System #2 Approved for bedrooms 1 011527 GI .• % Disapproved t>>CV oiffsm Py r Conditional approval for bedrooms, with the following stipulatios: \00(((((rfrt, ,.k. o OFq/lve(/r�i �� Py - - ON-SITE m WATER AND 0 WP,STEWATER O PROGRAM 6, iii By: 1/k----\__ V7 Original Certificate Date: CO—1 7-1? 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 COSA Checklist blue sheet COSA Checklist Legal Description: Thunderbird Heights, Block 2, Lot 3 Parcel ID: 051-721-07 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) Well production at time of test =• r Date drilled Water storage tank vo - - gallons Total depth ft Well disi. - -d for coliform test? ❑ Yes ❑ No Cased to ft • Coliform bacteria is Negative ❑ Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND) El Wires are properly protect-• Arsenic ug/L ❑ Arsenic less than MRL (ND) Casing height -•- • - ground) in. Collected by D. - • ow : • • Date of Sample Static wat r level at beginnin• of test ft. Comments Community water B. TANK DATA C. LIFT STATION Age of tank(s) New year.s ❑ Required maintenance completed Tank type/material ST/steel Age of lift station years Measured operating fluid level in septic tank 49" Lift station material El Standpipes/foundation cleanout per record drawing Comments: Date of pumping new tank, not required D. ABSORPTION FIELD DATA upgraded to 4br in 1981 Which system tested (date installed) 8/6/81 Adequacy test date mens ❑ ALL standpipes present per record drawing Results ❑✓ Pass For 4 bedrooms Total measured depth from grade ft(max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade 3 ft(min) Water added 600 gal ❑ N/A—pressurized field New depth 0 in ■❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 120 min depth into effective 0Code-required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 600+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet • 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' Community Sewer Manhole/Cleanou _ :. ❑Yes if No ft ill Yes if No ft Neighboring Tank > 100' ❑Yes if No ft Priv. - - -' er/Septic Line > 25' ❑Yes if No ft Absorption Field on Lot> 100' ❑Yes if No Holding Tank > 100' 0 Yes if No ft Neighboring Absorption F'- _ S0' Animal Containment> 50' 0 Yes if No ft ❑Yes if No ft Manure/Animal Excreta Storage > 100' ommunity Sewer Main> 75' 0 Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water> 100' 0 Yes if No ft Property Line > 5' El Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' CI Yes if No ft Private Wells > 100' 0 Yes if No ft Water Main > 10' El Yes if No ft Community Wells >200' ✓❑ Yes if No ft Water Service Line > 10' El Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Q Yes if No • ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' Q Yes if No ft Water Service Line > 10' El Yes if No ft Community Wells > 200' 0 Yes if No ft Surface Water> 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION �Q� 9.F. A�4S1I, i �1 •� ll I certify that I have determined through field inspections and review %i..' , TH f:\ %•'9* of Municipal records that the above systems are in conformance with /..:fir 0 MOA COSA guidelines in effect on this date. , a EER�S 1� �.Jar rewdson-�+v,+, • 011527 /Aft! >> PkiiSS10t '— COSA Checklist yellow sheet VTC L I\Mb 9c1 I `,..• V� i 1 0 % . NO.( �• o I , 1b lei \ o N9cl.- „ ..A ) ' \ 4\ 'e • �\ V q I +( , Q ' , I y ' 7 ~r Q r , , ,; : • .. •. , — co ./ u• .•..• n,. �• /S ,v •i V1 d ..�—63 --_---r.- • • A ' •.. H• �` • x.,34 GTS ••••.,....,_ „,j,,9”--� cam: i �'�%-A-'=i.� ��,-i4// 5'46 .....,,i,9 ASBUILT-NO CORNERS SET THIS DATE. SEWARD & ASSOCIATES LAND SURVEYING 688-4566 I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE] Aiiiiilk—lFOLLOWING DESCRIBED PROPERTY: 1 =20' s• OF A��** Thunderbird Heights Subd. ,Lot 3,B1k. 2 DATE �II �� ,.••""'•.;9 AND THAT NO ENCROACHMENTS EXIST EXCEPT AS 1-14-91 • JL mini(`ATVrl iT le Tuc ocomrvite.,n,, ITv ..... ..•...- .. -' - - - •' -+e Municipality of Anchorage . .aha eo. -.� Development Services Department r Building Safety Division On-Site Water and Wastewater Program • SAF9TT a 4700 South Bragaw St 'P.O. Box 196650 Anchoirage,'AK%99519-6650 t_ www . .ci anchorage ak us (907) 343-7904 •- ;.CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING _ ^ :.HAA # 1 W/fin Parcel I.D. bS I-� '� I l -0(o - Expiration Date: 1, GENERAL INFORMATION Complete legal descripGon`L� nCQ�y%I ►'� t-s Elgitf5 La } 3 Location (site address or directions) a.�[ Current Property owner(s) _ ��+yt .i LILY Day phone Mailing address x.133 (�nl c� &A 7 N/.� Day phone Lending agency 1 IW i.�II{ i•:• .. e • (tJ.. .i.•i',i _ .�i.. fid ..v I11 Mailing address _. _.....�... _ _ _._ .......... Real Estate Agent Day phone Mailing Address , Unless otherwise requested, HAA wiz1 be held by DSD for pickup. ,'2. • NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual _Well .. _.._ ❑ Individual On-site _. Individual Water Storage ❑ Individual Holdinglank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ~ ' µ. --•-N - 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 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 properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties 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 Eagle River Engineering Services - - Phone,(oQq- s IRS F.O. Box 713 , Esigle Mver, AK 995773294 . -i Address Engineer's Printed Name » Date q_4_63 OF S. DSD SIGNATURE ,_jG Approved for 3 bedrooms. ---- Disapproved. _ Conditional approval for bedrooms, with the following stipulations: _._ -i0 Additional Comments S IAFA N SITE �i —v�R�Vd6 , m' : WASTEWATER Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: Original Certificate Date: (Rev. 12100) Municipality of Anchorage Development Services Department Y k Building Safety Division " On -Site Water & Wastewater Program 5 C " 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: 4° '/ 4A B/% .7 H �,ylf, Parcel ID: 05WM- D40 A. WELL DATA �Py 6/, w• — A w'*✓*' Well type _ If A, B, or C provide PWSID # _ Date completed ` Sanitary seal (YIN) _ Total depth ft. Date of test Static water level Well production WATER SAMPL Coliform 7 sample: Cased to ft. FROM WELL LOG Well L Wires erly protected (YIN) Casing height (above ground) in. AT INSPECTION ft. ft. g.p.m. 9— p.m- TS: ;1100 ml. Nitrate Collected by: B. SEPTICIHOLDING TANK DATA Tank Type/Material She - / mg.lt. Other bacteria colonies/100 mi. Date installed _/9S -v Tank size Gid gal. Number of Compartments ei Cleanouts�ON) /s t Foundation cleanput.(Y/N) Depression over tank (YIN) N High water alarm (YIN) A114 t.e.rel....A. w.t rr„ . Date of pumping '1— 3 ` as Pumper SR /"ti ."+,o ..✓f C. ABSORPTION FIELD DATA Date installed / g4r° Soil rating (9.pmJ41V or ftz/bdrm) /lr System type jre...�4 Length _,2,1 ft. Width 4/ ft. Gravel below pipe 4F ft. Total depth 1.2 ft. Eff. absorption area y6,v ft' Monitoring tube _Y Depression over field /✓ Date of adequacy test Results (Pass/Fail) I2sr For bedrooms Fluid depth in absorption field before test O in. Water added 41S1 gal. New depth/4 in. Elapsed Time: 10 min. Final fluid depth o in. Absorption rate >= f NSO g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) *Y g If yes, give date — D. LIFT STATION N&r.1 e Date installed "Pump evel at _ in. tum E. SEPARATION DISTANCES Size in gallons "Pump oft' level at _ in Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Manhole/Access (Y/N) High water alar level at in. Meets alarm & circuit requirements? ,.vi G✓C,✓ b.,+ Lst On adjacent lots W/w On adjacent lots "V.14 Public sewer manhole/cleanout '`'1A Sewer /septic service line w�j/ Holding tank ^ �� SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: /I�h m4•N Fy...A(L rirw � Building foundation /' 4 Property line '`�" Absorption field � OIC SNiv�i//6l Fs+,++dc/ii", Water main tiv r Water service line r/o Surface water I Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line f -/o Building foundation // Water main to v Water Service line f to ' Surface water t Dov ' Driveway, parking/vehicle storage /a Curtain drain /'""r- Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION hem '-, ...nt,�� � ° .r� • q %z��t�„ I certify that I have determined through field inspections and ' v' 'i `� review of Municipal records that the above systems are inpfe 00 q, •.:.. • conformance with MOA HAA guidelines in effect on this date. .ir•'�T •iiilii H i •, w c t T� o 1 L° '! Engineer's Printed Name oh �✓ .�h r"� q T, ; : Date y- 3 - 3 :'•� .•' F: .: e�b 7J' HAA Fee $ �5 Waiver Fee $ Date of Payment Y/—/7 Ln Date of Payment Receipt Number Receipt Number (Rev, 12100) MUNICIPALITY OF ANCHORAGE, f0 4 - r • DEPARTMENT OF HEALTH & HUMAN SERVICES" Division of Environmental Services • t On -Site Services Section • P.O. Box 196650 Anchorage, Alaska 99519-6650 , r 343-4744 CERTIFICATE OF HEALTH AUTHORITY t (� APPROVAL FOR A SINGLE FAMILY DWELLING ' Parcel I.D. # OS/- 72 /- 07- ooy HAA # Rik c L 0 5-02' 1. GENERAL INFORMATION Complete legal description Lor 3 PJCL 2 Tik�n�os,e r3,ad J-grh, ,tt.s Location (site address or directions) ZS'ot I Nocxg,� Doz C 1auc. , �,c•� Q Propertyowner► 4113 moss Dayphoney'G3/Z Mailingaddress 2501L l�ik�.�DE^e13i� Int .00std,^n A 99 7 Lending agency Day phone Mailing address nw� .-� " Agent 4ets"l-t"C' *Af-LIE"a Day phone 41V9/2sr Address Unless otherwise requested, HAA will be hsld for pickup. 2. NUMBER OF BEDROOMS: —7 3. TYPE OF WATER SUPPLY: Individual well _ = Community well -'• r, .. G, , Public water —, NOTE: If community well system, provide written confirmation from State ADE& 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. aanmw.lAo rrOM MOAK1 S. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I fu(therverifythat 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. David R. Dayton P.R. Name of Firm 20210 Donalar St. Phone Chugisk,JUssica99367 Address Engineer's signature Date 2 6. DHHS SIGNATURE Approved for / Disapproved. .✓ bedrooms. i'%, =3`1 Conditional approval for bedrooms, with the following stipulations: Additional Comments M 411Th The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an Independent professional engineer registered in the State of Alaska.The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS 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. reoa)rw. "I) e.k Mw M Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST n v rrJ ^' Legal Description: /or 3 6w- 4P Parcel I.D. OS -1 72! - 0 7 - o o u� Y 2 m A. Well Data Well type KaChe- If A, B, or C. attach ADEC letter. ADEC water system number Log present (YM) Date completed Driller Total depth Cased to Casing height Sanitary seal (Y/N) Wires properly protected (YM) FROM WELL LOG Date of test Static water level Well flow Pump levelt SEPARATION DISTANCES FROM WELL TO: AT INSPECTION g.p.m. g.p.m. Septic/holding tank on lot Z-cc;o +-- ; On adjacent lots Absorption field on lot ; On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA gr pe o L Date installed * 42 19?1 Tank size W szrrl Compartments Cleanouts (Y/N) y Foundation cleanout (YM) Depression (Y/N) High water alarm (YM) �_/Z* Alarm tested (YM) Date of pumping Y / 'i Pumper R n5 -A Avoro Foo 4_6e - SEPARATION DISTANCES FROM SEPTICIHOLDING TANK TO: Well(s) on lot e- On adjacent lots "/llA Foundation 8 To property line Z.0*- Absorption field S Water main/service line -7' s r Surface water/drainage /C'"v7-- 72.MrMM•From CONTINUED ON BACK PAGE `r.1 z 0 0 9' m C. LIFT STATION Date Installed � Manufacturer Size In gallons Manhole/Access (Y/N) Vert (YIN) - 'Pump on" level at 'Pump off' Level at High water alarm level Cycles tested Meets MOA electrical codes (YM) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed 4-1 /9y / Soil rating (GPD/Ftz) SS's/� System type T+ Length 2e Width ZYo Gravel thickness Ste' Total depth 9' Total absorption area �o " �3 z Cleanout present (Y/N) Y Depression over field (Y/N) Date of adequacy test z' 5741 Results (pass/fail) /6 t for 4- Bedrooms Water level in absorption field before test O `� After test D" Peroxide treatment (past 12 months) (Y/N) Al If yes, give date 4' A-oaso Po e- olo/2- SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 'y/A- On adjacent lots Property line 2.0 •t - To building foundation 33 To existing or abandoned system on lot .t/o+v'F- On adjacent lots s •f' Culbantk L& Water main/service bine Surface water 1 ova Driveway, parldng/vehide storage area Curtain drain yNnwk) E. ENGINEER'S CERTIFICATION I certiy that I hake checked, verified. or confofined to all MOA and MAA guidelines in effect on Me date o/ this inspection. David R. Dayton P.E. Signature ` 20210 Donalar St. Engineers Name Date HAA Fee $. "✓d0 1, CU-' Date of Payment C� —& —ISL Receipt Number 33/ 72-026 PW)• Bade .�•y G;c. t;�`� w�V y, I•LJL r. - Waiver Fee $i; �- Date of Payment Receipt Number e i� �� • L. :c RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME i iV s DA DATE � �1DATE SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six INSPECTOR INSPECTOR INSPECT R *ATTACH WELL LOG. A well log is required for all wells drilled 1W COMMUNITY n MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH At ENVIRONMENTAL PROTECTION DEPT. OF HEALTH & 825 L Stmt • Anchorage, Atpea 59501 ENVIRONMENTAL K CTECTION • ENVIRONMENTAL SANITATION DIVISION JUL 31 1981 Telephone 2844720 C f r u REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWBFi fi91{i tk l�r� DIRECTIONS: Complete all parts on page 1. IrronrOlass requests will rat M procaosad. Reese allow ten (10) days for processing. 1. PROPERTY OWNER 1 h 06 PHONE pp PO MAI LING ADDRE $o X1RIP-5-77 PROPERTY RESIDENT (if diflerent from above) PHONE 04 �euaF 2. BUYER PHONE MAILING ADDRESS �joX 10 � Qw NDINOI TITUTION PHONE F1cz-Or 0.\eLs MAILING ADDRESS .9001 A -h 4. REALTOR/AGENT PHONE MAILING A REBS P �- 5. LEGAL DESCF}IPTIQN (n L„ 3 STREET LOCATION a 0,4 \\ 8. TYPE OF RESIDENCE NUMBER OF BEDROOMS ❑ One 2' Four ❑ Other SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY ❑ INDIVIDUAL' *ATTACH WELL LOG. A well log is required for all wells drilled 1W COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM .tW INDIVIDUAL/ON-SITE" FE3 YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72010 (Mev. 6/79) rhIl�- Pah ;�� �(F� I o�>?�o l �� a ,� AC)C,)l I THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE -MJ THREE ❑ FIVE D OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL `0 COMMUNITY D PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM [MINDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER n (. n _1 Septic Tank or ❑ Holding Tank Size: 1 (_Y-T_�L If Tank is homemade give dimensions: SOILS RATING R_6 TYP OFTANK�� t MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES - WELL T0: Septic/Holding Tank Absorption Area Sewer Line rat Lot im AMorption Area to merest Lot Line 5. COMMENTS 42 V We a APPROVED FOR _ BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY 72010 (Rev. 6/79)