HomeMy WebLinkAboutSAND LAKE #2 BLK 6 LT 6Sandlake #2
Lot 6
Block 6
#011-133-31
MUNICIPALITY OF ANCHORAGE
4;
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
PHONE
EF6 EW
❑UPGRADE
Kf114�d'k IY. UJI-)PSI)
MAI LING ADDRESS _
LEGAL DESCRIPTION
LOCATION
NO. OF BEDROOMS
/
Well
Absorption area
Dwelling i
PERMIT NO.
Uy
DISTANCE TO:
dotnrvwi_r>�0��
H z
w F
Manufacturer//''/�t
9_) gni. �' i�
Material _
J
No. of compartments
y
y
Li capacity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
4 z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
= Z FManufacturer
-
Material
Liquid capacity in gallons
Well
Foundation
Nearest lot line l
PERMIT NO. ®
3 %
w =
DISTANCE TO:
/y} �3
CJ Y
J LL z
No. of lines
Length of each line
Total length of Ines
�
Trench wid� ,
Distance between lines
2 w
F —
P_ /
&
inches
oc
cc F-
Top of the to finish grade I
Material beneath the
Total effective absorption area
i
U
T< ,.�
� �
� inches
Length
Width
Depth
PERMIT NO.
w
a
Q F
Type of crib
Crib diameter
Crib depth
Total effective absorption area
as
W
w
rn
Well
Building foundation
Nearest lot line
DISTANCE TO:
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
Building foundation
Sewer line
Septic tank
Absorption area(s)
DI STANCE TO:
OTHER
W
PIPE MATERIALS
�
�
fit.%3�ilzy
SOI L TEST RATING
p
i
-
INSTALLER } 1 L7/3 a' t "J 6
Cl
EHN
U'; I J7
��
REMARKS
Ccs
_41
tu
0
7 93
14
APPROVED DATE LEGAL
/�6. lYC} i 3 Lt `.i � f'L�rl� . ��.s l� v Pf
72-013 (Rev. 3178)
x^x�����r- r -H " _Lnir ir- �o,m�_,"'"»^»"�.
/ }w
DEPARTMENT HEALTH AND ENYIR0NMENTHL,.OTECTION
825 'L�'STREET,
ANCHORAGE99501
' ^ 264-4720 U
�
PERMIT NO ( 8]0124 )
/
�
APPLICANT MARK TOUSEN SRH BOX 4035 8 99502
LOCATION
i
LEGAL L6B6 SAND LAKE #2 LOT SIZE 999999 SQUARE FEET
| TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
�
'
MAXIMUM NUMBER OF BEDROOMS SOIL RATING (SQ FT/BR)= 100
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
��� 0 ::LuD �F.!,C-lVF_::"9 �P"F:�'-IF " �-- '-'
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH OF H 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). `
P. -'F-- C -A I_J TL C -A �r-- F=� -Ir T C_ -IF ��� _�-. 1 7"' E=� �0 C-71 10 0 Fl I I C# P-J'—c=
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.
-IF 1-4 CH
< ;2' "!F. F='F: 17-- _F 10 FA P-! FE
P -c 0= C-! U
I I R-- F= C'
BACKFILLING OF
ANY
SYSTEM WITHOUT FINAL INSPECTION AND
APPROVAL
BY THIS
DEPARTMENT WILL
BE
SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.,
I -IF �041F:�, I , ����: 7- -
I CERTIFY THAT
«� 7 �m FAMILIAR UTT�� TA�� REQUIREMENTS FORON-SITE SEWERS AND WELLS AS SET
�� ^ ... ..^�����.` .~��� ���� ���������� �
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS.
SIGNED-eZf� ----- IC
APPLICANT 11A TOUSEN
ISSUED BYQ__-_71�&___i_ ---------- ------ - D A T E
IF THE
V4i 0
X SOILS LOG
u
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION O PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 _ 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: - Z7 yt f —{ DATE PERFORMED: 7
LEGAL DESCRIPTION: /1 ^—'��-CL 2 ze Y� Z
r—_ 1 SLOPE SITE PLAN
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
60
fE S,
'-f /cc, 47 iv'p '
Cs n)
COMMENTS
PERFORMED BY: 1 1 a
72-008 (6/79)
WAS GROUND WATER L
ENCOUNTERED?
O
P'
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
TEST RUN BETWEEN
CERTIFIED BY:
FT AND
(minutes/inch)
FT
DATE: —? /y i-1
e
CONSTRUCTION AN® OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
PUBLIC WATER SYSTEM
APPROVAL TO CONSTR
Plans for the construction of i3 LID L IC (r LOX 9 — 12, Jcl -Ls* 5 tVX4
J jLI b r A[C C— 4 ( 3� I — C- A —f b Cc n / ��<c A r public water system located
in 19 -he Vtdt"aC Alaska, submitted in accordance with 18 AAC 80.100
by 14 L ce c kc, {amu ly`Uy.ywetn}a t✓o A fvv JS have been reviewed.and are
�( approved.
❑ conditionally approved ee attached conditions).
E - �UrYY
bY TITLE DATE
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Change (contract order no.. Approved by. Date '
or descriptive reference) :
$g yam{ ¢p� y p Rry � T? i� S � r_ ;5 € 3eby
�f a V rue;
A'�Wts #\FTe}�rXF atLi 3 '§ SE r LY 3 ,X•'4^L' R
6 . rue; -!fit k
u
VQ
sggel• a z - z, ��„ z e`� �rt� r. � � f� fs�. z'�y F q�®
F'tfic"iFi$ ::Onr'
+-
C r r BY - TITLE DATE f
J
C-
Municipality of Anchorage
• Department of Health and HumanServices
Division of Environmental Services _
On -Site Services Section -825 "L" Street Room 502
: P.O. Box 196650 -Anchorage, AK :99519-6650 "
.: www:ci:ahchofage.ak.us ;..i , ,
;(907)343 -4744 r1 1.` f
CERTIFICATE OF HEALTH AUTHORPTY /APPROVAL
�.
FOR A SINGLE FAMILY: DWELLING'
Parcel' I.D ,9 11 AI 3 3-3 rt HAA# fhb
4f '` `� Expiration Date:
;�'1 +GENERAL INFORMATION
Complete legal description
liot 6, Block 6,` Sandlake Subdivision //2
Locatyon(slteaddressordirections) 8253 Seaview Street
' Dale Girvan 229=1103'
Current Property pwner(S) -Day phone
.:Mailing address
Lending agency Day phone
Mailing address
Real Estate Agent Prudential Jack White/Elaine Girvd)ayphone 229-1103
Mailing Address 4241 B Street Anchorage AK 99503'
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:
2." NUMBER OF BEDROOMS: 3 _
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: _
Individual Well `❑ Individual On-site Q -
Individual Water Storage - ❑ Individual Holding Tank ❑
Community Class - Well ®- Community On-site ❑
Public Water System ❑_ .
Public Sewer ❑
The Municipality of Anchorage Department of Health and Human Services (DHHS) 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) on properties served by a single family on-site
wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners.
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
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.
72-025 (Rev. 01/00)'
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 Health Authority Approval Guidelines for the Health Authority Approval
application show that the on-site water supply and/or wastewater disposal system is safe, functional and .
adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-
site water supply and/or wastewater disposal system is in compliance with all applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
S & S ENGINEERING
Name of Firm_ 7034-Eagl �y—Phone' G 71 y — D-9 -7 %
Address Eagle River, Alaska 99577,
Engineer's Printed Name n R rF ✓LTC C a w fiN Date 3 a 1 a
/ I
of A[gSf�fa
'NEER's
• .1 N.. h
6. DHHS SIGNATURE y
ROBERT C COWAN •',I�@
Approved for. 3 bedrooms. p�a�sr, Ce 8801
Disapproved. I n,"
Conditional approval for bedrooms, with the following stipulations.
Additional Comments
Attachments:
HAA Checklist Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: Q���� _ / G(i. Original Certificate Date:
Expiration Date: 6 " 3 0 -0 p Reissue Date:
75-025 (Rev. 01/00)'
-3/-00
Municipality of Anchorage
< C VEE
DEPARTMENT OF HEALTH & HUMAN SERVI&W 2 7 2000
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501,N1'34'�SYgrzgce
AL SERVICES DIVI,, -
Health Authority Approval Checklist
Legal Description:L�a��FQ�jt(p(�j% Parcel I.D.:
A. WELL DATA
Well type /lt/ll /% t I AWB�
, or C, attach ADEC letter. ADEC water system number /� 9
Log present (Y/N) /sed
completed
Total depth
Sanitary seal (Y/N)
FROM WELL LOG
Date of test
Static water level
Well productiong,p,m.
WATER SAMPLE RESULTS: ZI
Coliform / Nitrate
Casing height (above ground)
Wires properly protected (Y/N)
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
AT INSPECTION
Date installed Tank size l(df/ Number of `C,,o��mp
Foundation cleanout�Y N) ( Depression (Yo --A&9
Date of Pumping / Pumper X1bIZ'rH&AA1-0
C. ABSORPTION FIELD DATA
g.p.m.
Other bacteria
artments Z Cleanout6N)-5L
High water alarm (Y/N)
Date installed Soil rating (g.p.d./ft2 or 2/bdrm /QD System type T&AICH
Length Width 3 Gravel thickness below pipe Total depth %
Effective absorption area 0 Monitoring Tube presen Y ) Depression over field (Y/6 O,60
Date of adequacy test Results Pass Fail) For /) (VZ bedrooms
Fluid depth in absorption field before test (in.); _�_ Immediately after✓Yl gal. water added (in.): (o
Fluid depth (ins) Minutes later:_ Absorption rate = T 45 t> g,p,d.
Peroxide treatment (past 12 months) (Yo /VOA16-I�NgWll If yes, give date
72-026 (Rev. 3/96)'
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
ii
"Pump off" level at*
On adjacent lots
On a jaoent lots
_ Pu c sewer manhole/cleanout /V
Lift station _� /f
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
FoundationJ. `/D Property line 1j 5 rr0 G/0 Absorption field S rt
Water main/service line 1(9,1 Surface water/drainage Cl f Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line 1p <2� Building foundation %� / Water main/service line A?
I�JQr ins ori /eparL�
Surface water /O� r� Driveway, parking/vehicle storage area "+�— �NSl6��/GQ
/
Curtain drain /MONC— e-^//rwfi/ Wells on adjacent lots I -/I-
F. ENGINEER'S CERTIFICATION
1 certify that 1 have determined thru field inspections and review of Municipal
in conformance with MO HAA guideel`iPes in effect on this date.
Signature ��Z Ld2✓�-- /
Engineer's Name (L D g 4z -A- T Ca.4a
Date
�3 / a I / 0)
HAA Fee $ �_il J(� `Co
Date of Payment v5 e
Receipt Number `/ ) ?6W
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
'L ROURT C. COWAN f C-
�'�; CE -8801
are
MUNICIPALITY OF ANCHORAGE��
• DEPARTMENT OF HEALTH & HUMAN SERVICES M}i
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
Parcel l.D.# 0\\ - ISS -21\ HAA# IAROL2C)IsI
1. GENERAL INFORMATION
Complete legal description iz, &
Location (site address or directions) �� ✓ i
Property owner A E+ rC— Day phone
Mailing address
Lending agency
Day phone
Mailing address ^�
Agent N a -o � D^ kiH { i" Day phone q q 7&c% I
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well )_
Public water
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
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 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 further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm - l a hh r rr et u a� T Phone
Address
Engineer's signature
6. DHHS SIGNATURE
Approved for bedrooms.
VA
Disapproved.
Conditional approval for
Additional Comments
Date '? `% L
bedrooms, with the following stipulations:
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.
72-025 (Rev. 1/91) Back MOA N21
Municipality of Anchorage
Department of Health & Human Services M
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: 1,/b g , 0/Z"Z l-4 � Parcel I.D.
A. WELL DATA
Well type Al If A, B, or C, attach ADEC letter. ADEC water system number 2 1,6'1 b
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
Date completed
Driller
Cased to Casing height
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
Wires properly protected (Y/N)
AT INSPECTION
r/ 1,41CIPALITY OF VIVAWNmEN A $FpVIICES DSIV S ON
1992
g.p.m. R E f {rt ' E D
Septic/holding tank on lot ' "'' ; On adjacent lots `
Absorption field on lot
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed�ZIS 1a Tank size '� Compartments
Cleanouts (Y/N) oQ— Foundation cleanout (Y/N) x Depression (Y/N) N
High water alarm (Y/N) Alarm tested (Y/N) p �//A
�"ice /
Date of pumping G Pumper - (''S S /az
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot N��— On adjacent lots 7 Foundation
To property line Absorption field - Water main/service line
"q/,a.
Surface water/drainage
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION p�5r
Date installed
Size in gallons
Vent(Y/N)
High water alarm level _
"Pump on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
"Pump off" level at
Cycles tested
Surface water _
D. ABSORPTION FIELD DATA
Date installed / �;-3 Soil rating /0-0
Length t) & Width `12 /4 Gravel thickness _
61
System type
Total depth
Total absorption area 3 i �L Cleanouts present (Y/N)
Depression over field (Y/N) t-71 Date of adequacy test
Results (pass/fail) a jS for .3 bedrooms
Peroxide treatment (past 12 months) (Y/N) If yes, give date
SEPARATION DIS,f-ANCE FROM ABSORPTION FIELD TO:
Well on lot On adjacent lots J U (' _ Property line i i b
To building foundation j To existing or abandoned system on lot
On adjacent lots-> CutbankWater main/service line > �2,!�:
Surface water NA Driveway, parking/vehicle storage area � %jJ✓1i�c J_
Curtain drain ��%1i(-z�2 r.��y 4'/�Cp
E. ENGINEER'S CERTIFICATION /
1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
l
Signature
Engineer's Name V. oL��
Date
HAA Fee $ Z 20 Waiver Fee: $
Date of Payment 3— L" J Date of Payment
Receipt Number. L Receipt Number
l
72-026 (Rev. 3/91) Back MOA 21
ANCHORAOF DIS I'RICT OFFICE
60() I_=, 1, I-UIOND BLVD, S41 E '470
ANC,,L- (-)k.AGr, ALASKA 995+
March 2, 1992
a
(907) 349-7755
My rev,p- , r�T $tI r�. CJrt�u C�( Mic ii 1 #SIS ��f l� PSV=talSa' $�1a $�i6 Lot 6, Block 6, ,Bared Lake
#2 §� Umivi .ion, Glass A' Public `'Water � ySlem, is in col-ni aliance with the routine e;0lifotrri
bye { r y ilf r (,0 c listed ;n 18 AAG 80,200; Table Cj.
3".i14frofjrTl�"smm n 11 rltt Ass's ,-Tent
�.f
o
20PEST 15YH.AVENUE SUITE 206
ANCHORAGE, ALASKA Y9502^3Y04
(90) 279-3916
SEPTIC. SYSTEM ADEQUACY TEST
LEGAL: Lot 6, Block 6, Sand Lake 412
LOCATION: 8253 Seaview
OWNER: AHFC # 45651
RESIDENCE: Single Family, 3 Bedrooms
14ELl.: Co'munity Water System PWSID 215469
SEPTIC SYSTEM: FROM MUNICIPAL RECORDS: 3 Bedroom System
TANK: Greer Steel 1000 Gal" Two Comparts.
ABSORPTION SYSTEM: Trench
ABSORPTION AREA: 312 Sq. Ft.
SOIL RATING: 100
INSTALLATION DATE: 3/15/83
LA
DATE OF LAST PUMPING: Anchorage 1992
DATE OF TEST: February 1, 1992
TEST: System was inspected and measured. Tank
rnm^^���w^�~
was
found with 5.5 feet of cover an d with a liquid level of 48 inch
-
es. Trench monitor tube was 10 deep and dry"
of clean water was added to the trench while
the
930 gallons
t levels in the tank and the monitor tube were monitored"
|he
water level in the tank did not change, while the level in
the
wa �' 6 �nches Within 1O minutes the monitor was dr-y.
monitor rose .
t th e code requirements
TEST RESULT:: This system inee �
of
the Health and Social Services
Department of the Municipality of Anchorage.
NOTE The operational life of all septic systems dependslon
4- t
the
uare
local soil conditions, groundwater levels that may uc
being serve�
during the year, and the water usage of the family
the o+
zne
b the system These conditions are outside control
y ^ W Lherefore not give
~ -��
any
ti stem e can ~
l tor of this sep c sy . n `,,.^�_
e«a ua ^^ ~-t ill function sat�sfactory
this sysrem w
for
estimate of how long
current or future occupants. / ~`.
c `' ` APPLIC VT FILLS OUT UPPER -HA[, ONLY
Time
-- / ,- ,�
PrG;pa•r'q Owner 0%
r� //
Phone
��/
Mailing Address Zi
/.�_ -7 p Code
Date
Buyer
Date
Address Cj Zip Code .9(—:"-6 2—
-Da&e 5 ?
S'
Lending Institution/% (� //
Phone
Address ��i -� _. c-�. Zip Code
Realty Co. & Agent
Phone
Address/ Zip Code
-
Legal Description G
Street Location
(�) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL
Type of Residence
T-ySmgIe Family 1
( ) DISAPPROVED
❑ Multiple Family No. of Bedrooms
( ) CONDITIONAL APPROVAL'
❑ Other
DATE '7 —
Water Supply
❑ Individual
ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975.
'Community
For wells drilled prior to that date, give well depth (attach log
if available).
❑ Public Utility
Septic Tank Size
Sewer Disposal
Individual Year Individual Installed:
Well to Tank
❑ Public Utility When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
-Da&e 5 ?
S'
Inspector
Inspector
Inspector
Inspector
Field Notes:
(�) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL
( ) DISAPPROVED
_
( ) CONDITIONAL APPROVAL'
DATE '7 —
BY:C
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
Septic Tank Size
Well to Tank
72023 (31821