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Home My WebLink AboutTUXEDNI PARK BLK 1 LT 1Tu dni Park Block 1 Lot 1 #041-022-01 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: .~ ~4/0~00 ~_~ PID Number: ~*(/ Name: ~'.~/2 ~x./ ~¢ ~ ~. ~ Wastewater System: D New. ~ Upgrade e~/ c~e~ ~., ~ A~, ..99~o~ ABSORPTION FIELD P~one ~Y7 ' 9~ ' IN°'°'~d'~m,: ~OeepTrench =ShatlowTrench DBed mMound =Other LEGAL DESCRIPTION so,,.,.~: TownsAip: J Range: J Secbon: Fill added ~bove original grlde: Gravel length: I I WELL: EX~Z~ D New ~ Upgrade Gravel w,dlh: ~ F, Numberolllines:ljDista~e"t~n~" Y,cie: GPM,I Pump Set .,: FI I C.s,ng He,g.I A~. Gt0un~:Fi. TANK SEPARATION DISTANCES ~ Se~,~ a ,o~in, ~ S.~.~.P. Well I~ ~ I1~--' ' -- ~ ~* ~ttl Surface w,~ ~o' to~, - - - LIFT STATION p. Line I~ ' I ' -- -- - Foundation ~, ~, _ -- . "Pum~ °""'eve' a': I"Pump ofr"eve',': I H,g~ water"a~m ,~ Curtain pum~ Make & U~el I Electrical Inspections pe~fo~me~ Remarks: N~: ~~,~ ~/=/~ BENCH MARK ENGINEER'S SEAL Inspections performed by:. ~(~/~ ~<cA ~uc Dates: 1st ~1/~ -', ~.~,,; · ~",~, ..... Department of Health and Human Services approval ~..,~,,~o,m~ ,. ~oo~ Reviewed and approved by: ~, re' ~ ,['.~;7- '*, , / PERMIT NO: SWOOOO93 PID NO: 041-022-01 / / / / / / / LOT 1 BLOCK 1 PAVED DRIVE SWING TIES: FROM: COR. "A" COR. "B" TO: S.T.C.O. "C" $9' 30' S.T.C.O. "D" 65' 37' DBL C.O. "E" 67' 40' VALVE "F" 68' 41' TR. C.O. "G" 46' 39' TR. M.T. "H" $1' 41' TR. C.O. 'T' 84' 63' PIT C.O. "J" 56' 31' PAGE 2 OF 3 LOT 2 VACANT 'NEVV 44' LONG SOIL ABS. TRENCH ~W. 6.0' SERVER GVL. EXISTING SEEPAGE PIT BULL RUN DIV. VALVE DOUBLE CLEANOUT NEW 1250 GAL. SEPTIC TANK 100' LOT l, BLOCK 1, TUXEDNI PARK SEPTIC SYSTEM UPGRADE AS-BUILT INSPECTION - PLAN VIEW FLA'rroP TECIrNICAL SERVICES 14530 ECIIO STREET ANCI IORAGE, ALASKA 99516 SCALE: 1" = 30' DRAWN BY TFM OCTOBER, 2000 PERMIT NO: SWOOOO93 PAGE 3 OF 3 PID NO: 041-022-01 INV. 89.5' 4'+ SOIL COVER 1250 GALLON~ SEPTIC TANK '~E~SOIL COVER-- ~__INV. INV. m/j BOTTOM / TRENCH ELEV. 82.7' MAX. WATER ~: IN T.H. #1 M.T.~ ',: ELEV. 78.4' ' ' 5111/00 ' ' LOT 1, BLOCK t, TUXEDNI PARK SEPTIC SYSTEM UPGRADE AS-BUILT INSPECTION - CROSSSECTION FLAI'FOP TECII'NICAL SERVICES NOT TO SCALE 14~30 ECIIO STREET DRAWN BY TFM ANCl IOP, AGE. ALASKA. 99~ 16 OCTOBER, 2000 MUNICIPALITY OF ANCHORAGE Department of Health and Human Sen/ices On-Site Sen/ices P[ogram 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Jun 06, 2000 Expiration Date: Jun 06, 2001 Permit Number: SW000093 Legal Description: TUXEDNI PARK BLK I LT 1 Design Engineer: 0019 Flattop Technical Services Owner Name: Janis Burton Owner Address: 9501 Chenega Dr. Anchorage, AK 99507-1204 Parcel ID: 041-022-O1 Site Address: Lot Size: 53660 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 the same day. B. Covered, sealed, and heated to prevent freezing. Received By: '~.-.~ Issued By: ~ Date: O'"'/IZ./c:z~ Date: ~'-- 7--~ Fhck I!,fystrorn. Mayor Mmficipali ' of And oragc Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage. Alaska 99519-6650 hit p://www CL ancl~or age.ak.us June 7, 2000 Ted Moore Flattop Teelmical Services 14530 Echo St. Anchorage, AK 99516 Subject: Waiver Request for Tuxedni Park, Lot 1, Block 1 Waiver Request #WR000034 Parcel ID #041-022-01 SW000093 Dear Mr. Moore: Your request for a waiver of the required 10 feet horizontal separation from the on-site wastewater disposal system to property line has been approved. The approved separation distance is 1.0 foot. This waiver approval applies to the existing on-sitewastewaterdisposal system to property line separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely, Daniel J. Roth Civil Engineer On-Site Water Quality Program WRY: WR0000~4 PID~: 041-022-01 Date Received: June 27 2000 Legal Description: Tuxednl Park~ Lot It Block I MUNICIPALITY OF ANCHORAGE Department of Health & Human Sewlces On-Site Sewlces Waiver Review Worksheet HA~: Engineer:. Flattop Technical Services 14530 Echo St.~ Anchorage~ AK 99510 Applicant: Janle Burton Waiver Requested: Lot-line waiver Permit~: SW000093 Criteria: 1. Geology Points: A. Watar Table B. Soil Soq)tJon C. Permeability D. Water Table Gradient E. Horizontal Separation 2. Special Conditions: 3. Other. Total: Waiver Is Granted: '~ Waiver is not Granted: ListConditionsorReasonsforabove: ~'EE~ EA,, [.,. I iu .~$Ip I$ o~ Date: Rec~: 06700 Amount: $115.00 By: .]~/~L/ Name of Reviewer Date Paid: 6-2-00 Cp,'rl & ENVIRONMENTAL ENGI2qEERLNG * ENERGY CONSERVATION & ANALYS~ TllEODORE F. MOORE, P.E. 14530 ECHO ST. Pti: (907) 345-1355 ANCllORAGE, ALASKA 99516 June I, 2000 M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: The purpose ofthis letter is to provide the required design narrative in support of our application to amend the existing septic tank replacement permit # SW000093 for Lot 1, Block 1, Tuxedni Park S/D to include a new soil absorption trench. This amendment will increase the capacity ofthe wastewater disposal system to 4-bedrooms. A soils log, pete test results, revised site plan, design drawings and. specifications are enclosed for your review. The proposed system will be constructed in the vicinity of test hole # 1. As can be seen from the soil log, the native material below 2.25 feet is a clean gravelly sand with a measured pete rate of I minute per inch. A water table was encountered at 11.5', corresponding to the approximate water elevation in the "duck pond" north ofthe test hole. Because the ground elevation at the location of the proposed trench is higher than at the test hole it will be possible to use an effective gravel depth of 6 feet without encroaching on the required 4-foot vertical separation from groundwater. Using the soil application rate of 1.2-gpd/sq. ft. specified in the wastewater ordinance, this 4 bedroom residence requires a total~ absorption area of(4 x 150)/I.2 = 500 square feet. The proposed 42-foot long trench design with 6 feet of sewer gravel has a total absorption area of 504 square feet. In order to configure the proposed trench within the given topographical constraints, a lot line waiver is requested allowing the east end &the trench to be constructed within I foot of the lot line common with Lot 2. That lot is vacant, and granting the waiver will have a negligible effect on the ability to construct soil absorption systems on Lot 2. In order to maintain the required 100-foot horizontal separation from the existing duck pond the trench will be approximately 10 feet from the assumed edge &the existing seepage pit. Although this is less than the normally required distance &twice the effective gravel depth, we do not anticipate~his creating any problem because the consistently sandy nature ofthe soil allows vertical migration down through the receiving soil. We will verify the absence ofcontaminated soil during construction. The topography of the lot in the area of the proposed construction slopes downward towards the north at approximately 1 Except as noted above, the proposed project will have no significant impact on present or future water supply and wastewater disposal systems serving adjacent properties, nor will it have any significant impact on reserved space-surface and subsurface, or on drainage. Please give me a call at 345-1355 if you have any questions on this submittal. Sincerely, Ted Moore, P.E. LOT 1 BLOCK WELL. LOT 2 VACANT CONSTRUCT NEW 42' LONG SOIL ABS. BELOW DIST. PIPE EXISTING PIT DIV. VALVE NEW 1250 GAL. SEPTIC TANK LOT 1, BLK. 1, TUXEDNI PARK S/D WELL AND SEPTIC SYSTEM SITE PLAN FLATTOP TECIINICAL $1ZP, VlC '-----------------E~ 1 INCH = 50 FEET 14530 ECIIO STREET DRAWN BY TFM ANCIIOP. AGE, ALASIOk 99516 MAY, 2000 NOTE: THIS IS NOT A SURVEYED PLAT. ALL LOCATIONS SHOWN ARE APPROXIMATE. 4" DIA. ASTM F-810 PERF. PIPE \ 42 '~] "A" c.o? ........ CONSTRUCT N~ 42' LONG / SOIL ~BSORPTION TRENCH W. 6.0 GVL. BELOW DIST. PIPE TO II ~ST~N~ ~1 II SEEPAGE PIT P~N VIEW FROM SEPTIC T~K SCALE: 1" = 10' HOUSE MONITOR TUBE CLEANOUT FINAL GRADE fINAL GROUND SECTION "A - A" SCALE: 1" = 5' FABRIC ~IGID INSULATION DIA. F-810 PERF. PIPE ! 1/2" SEWER GRAVEL BOTTOM OF EXCAVATION LOT I, BLOCK 1, TUXEDNI PARK SEPTIC SYSTEM UPGRADE PLAN AND CROSS-SECTION FLATTOP TECIINICAL SERVIC 'F_.S 14530 ECIIO STREET ANCI IORAGE, AK, 99516 SCALE: AS SIIOWN DRAWN BY: TE'Ivl JUNE, 2000 ITEST HOLE LEGAL DESCRIPTION: DATE PERFORMED: PERFORMED FOR: DEPTH~ (f~*t) 1- 2--__ 3- 4- 5- 6- 7- 8- 9- 10- 11- 12- 13- 14 15- 16- 17- 18- COMMENTS: I Lot 1, Block 1, Tuxedni Park May 11, 2000 Burton FLATTOP TECHNICAL SERVICES 14530 ECHO ST. ANCHORAGE, ALASKA 99516 SOILS LOG -- PERCOLATION TEST SM Reddish sandyloam SLOPE SITE PLAN SP/GP Clean gravelly sand Sand content varies from pure sand to sandy gravel Depth to Groundwater Date Water at 13' - 0" 5/11/00 Water at 11' - ~" 5/22/00 Water flowing into hoTe Date Reading Clock Net Time Percometer Net Drop Time (minutes) Reading (inches) 5/11 12" Presoak 27 1/2 Re_soak 27-'~-/2 Start 4;30~25 237Ji8 #1 4;.35L25 ~; 17~7/8 5 1/2 Add water 4:35:47 ~3 3/8 #2 4:40.Z_~7 5 17~_.~/8 5 1/2 Add water 4:41:15 23_3/8 #3 4:46;15 5 17 718 5 1/2 PERCOLATION RATE 1 (minutes~inch) PERC HOLE DIAMETER 8" TESTRUN BETWEEN. 4.5 FTAND 5.0 FT Ground level at test hole is 0.5' lower than invert of new septic tank outlet. 10% PERFORMED BY FLATTOPTECHNICALSERV~CES. I '~,-~f ~ CERTIFYTHATTHISTESTWASPERFORMEDIN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES I" EFFECT ON THIS DATE* DATE: q:fattop rfecfinicaf Services 14530 ~.cfio Street, ~nefiorage, /q1(.99516 ~fione (907) 345-1355 Lot 1, Block 1, Tuxedni Park 9501 Chenega Drive Wastewater disposal system installation Specifications 1.0 General: 1.1 The scope of the project consists ofconstmction ora 42 foot long soil absorption trench containing a total of 6.5 feet of sewer gravel. 1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor deviations from these drawings may be allowed or required by the engineer conducting the inspections. All construction procedures and material specifications shall conform to Municipal and State requirements. All separation distances shall be in conformance with Municipal requirements, unless specifically waived. 1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work around any buried utilities. 1.4 The contractor shall provide adequate cover material and rough grading over all system components to ensure that proper drainage is achieved after settlement and that there are no residual depressions. Insofar as possible the contractor shall minimize damage to trees and existing lawn areas. 1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after the soil is compacted, as well as placement oftopsoil and reseeding all areas disturbed by the construction. 1.6 Prior to start of construction the homeowner shall arrange to have a land surveyor mark the location of tile east properO~ boundary itl the viciniO~ of the proposed constntction. This shall be accomplished by driving 3 laths hlto the grottlld Oil the lille at approximate 50' #ltervals. 2.0 Soil absorption system: 2. I The soil absorption system shall be constructed by excavating a 42-foot long trench to a depth of 8 feet below ground level at the location shown on the site plan. Care shall be taken to ensure that the bottom of the trench is no deeper than 8.5' below the top of the monitor tube for test hole #1. 2.2 The bottom of the excavation shall be level. Any compacted or smeared surfaces shall be raked to allow proper infiltration. 2.3 A total of 6.5 feet of approved sewer gravel shall be placed in the bottom of the excavation with the perforated distribution pipes laid level such that the pipe inverts are no less than 6.0 feet above the bottom ofthe sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing the #200 sieve. 2.4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on the design drawings. The portion of the monitor tube extending through the sewer gravel shall be perforated. 2.5 Approved filter fabric shall be placed over the entire top surface of the sewer gravel. A minimum of 2 feet of soil cover is to be placed over the filter fabric. If the soil cover thickness is less than 3 feet, two inches of rigid, burial type insulation is to be placed over the entire top surface of the gravel, in addition to the filter fabric. 2.6 The top surface of the cover material shall be raised a minimum of 6 inches higher than the surrounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill slopes shall be no steeper than 3:1. 2.7 Unless specifically agreed otherwise the homeowner shall be responsible for arranging to have the site finish graded after the backfill material has stabilized, and for placement of adequate topsoil and seed to promote rapid revegetation of all areas disturbed by the construction. 3.0 Inspections: 3.1 A total of 4 engineering inspections will be required during the course of the project: (1) initial stakeout with the contractor to establish the location ofthe system and to discuss the plans, specifications and construction procedures, (2) after the native material has been excavated to expose the infiltrative surface to ensure that it is level and at the right elevation, and conforms with the soil test information, (3) after the sewer gravel is in place and the distribution pipes have been laid and connected up to the septic tank, but prior to placement of insulation or filter fabric, and (4) after rough backfill and grading is complete. 3.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in advance to ensure the availability ofthe engineer. MUNICIPALITY OF ANCHORA GE Department of Health and Human Services On-Site Servfces Program 825 L Street. Room 502 P.O. Box 195650° Anchorage. AK 995f9-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAl.. SYSTEM PERMIT Upgrade Date Issued: May 09, 2000 Expiration Date: May 09, 2001 Permit Number.' SW000093 Legal Description: TUXEDNI PARK BLK 1 LT 1 Design Engineer:. 0019 Flattop Technical Services Owner Name: Janis Burton OwnerAddress: 9501 Chenega Dr. Anchorage, AK 99507-1204 Parcel ID: 041-022-01 Site Address: Lot Size: 53660 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 ( 18AACS0 ). 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 absoq~tion 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. Date: vlJ h, o Date: ..4"- ~/- 0 0 UPGRADE ~ AREA / / 'AVED DRIVE WELL SEEPAG INSTALL DBL. C.O. INSTALL NEVV -- 1250 GALLON SEPTIC TANK (OUTSIDE 100' RADIUS OF WELL) ~ ABANDON ~ EXISTING INSTALL SEPTIC TANK FDN, C.O. LOT 2 VACANT -- ~,~ GRAVEL DRIVE ) EASEMENT L ,, o ! ............................. ;r ..... LOT 1, BLK. 1. TUXEDNI PARK SID WELL AND SEPTIC SYSTEM SITE PLAN I~LATTOP TECI~IICAL SERVlC .ES 1 INCH = 50 FEET 14530 ECtlO STREET DRAWN BY TFM AI~CIIOP. AGE, ALASKA 99516 MAY, 2000 NOTE: THIS IS NOT A SURVEYED PLAT. ALL LOCATIONS SHOWN ARE APPROXIMATE. Department of Environmental Quality ' 3330 C Street · Anchorage; Alaska 99503 INSPECTION REPORT ON~.SITE SEWAGE DISPOSAL SYSTEM Z~O~' MAILING ADDRESS 0~/~ ~/..)~,t0/~3~/~7Z'~/3 PHONE SEPTIC TANK.. DISTAI~CE fROM WELL g INSIDE LENGTH NUMBER Of MANUFACTU.E.-% ' InS ' ATE.,AL F), COMPA.TMENtS INSIDE WIDTH LIQUID DEPTH I,IQUID CAPACITY /~'O GALLONS. SEEPAGE PIT: NUMBER OF PITS. I · DIAMETER BUILDING FOUNDATION~.~O ADDITIONAL ABSORPTION OR WIDTH .~o~ (, LENGTH. t ~ DEPTH ~.~ ¢ DIAMETER 4 DEPTH G DISTANCE FROM: WELL IOO ! TOTAL EFFECTIVE , NEAREST LOT LINE ~ ~ ABSORPTION AREA (WALL AREA) ~(:~ SQ. FT. WELL.. TYPE .~ BUILDING FOUNDATION '/ CESSPOOL APPROVED CONSTRUCTION ~ ¢~ NEAR~ST ' ~"/~kEST LOT LINE_~O~,? ,/~ SEWER LINE OTHER SOURCES. DEPTH ~'~ DISTANCE FROM: SEPTIC TANK ~' SEEPAGE /~)O · , SYSTEM DISAPPROVED REMARKS DISTANCES: INSTALLED BY: PIPE MATERIAL:'C~E'F Z~)~0 Form No. EQ-031 DIAGRAM OF SYSTEM DATE G.A.A.B. / GREaTEr ANChOrAGE ArEA BOROUGh. ,. 3330 "C'* STREET ANCHORAGE, ALASKA 99503 .... , TELEPHONE 274-456 ! SEWAGE DISPOSAL SYSTEM --.APPLICATION AND pERMIT' iNSTALLATIO. LOCATION 42/~ ~'~'~_~ J~-~. LEGAL DESCRIPTION ~-Z~,~--- ~ ~~ ~~~/ INSTALLATION OF= SEPTIC TANK / SEEPAGE PIT. DRAIN FIELD OTHER FINANCED THROUGH ' TO BE INSTALLED BY SOIL TEST RESULTS // ~P. Hm ~---- -~NOTE~ THIS PERul~ - --- - /////~ _[~-~ ..... COMPLETION DATE ANTICIPATED /~ PHDN~'~~ 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 FOUNDATION TO SEEPAGE PIT r~'~ . DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK .I ~ / , SEEPAGE PIT TO NEAREST LOT LINE. DRAIN FIELD WATER MAIN TO SEPTIC TANK f~:;t DRAIN FIELD SEPTIC TANK, ///~/~ / . . SEEPAGE PIT/~'~ TO RIVER, LAKE, STREAM. DRAIN FIELD SEEPAGE PIT ALSO CONSIDER AREA WELLS. SEEPAGE PIT . DRAIN FIELD CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOlL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM ~O BOROUGH REGULATIONS REGARDING INSTALLATION. O.A.A.B. OR LICENSED DESIGNER SEEPAGE AREA SIZE DIAGRAM OF SYSTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH-SAID CODE. DATE ~/~ . APPLICANT'S SIGNATURE FORM NO, HQ'O! 6 TUDOR ROAD. ANCHORAO£. ALASKA $050? ~ TIILIPHONI' 333*B4"J'2 Performed For' Buck Smit'h :Date Performe~'~'~'~3 Leoal BescriCtion: Lot :q Bloc[: ~ SubdivisiOn ~ Tuxedn5 This ~orm Re~orts Soils 'Lo~ 7es Percolation Test Feet Soil C~ihr~cteristics Was Ground Water Encofintered? I~ Yes, At what Dentt:,?i ;i Readi'nq'-' Dat~ ..... ,j "N-e t "T i m e "nenth to H,~O Net Dron ,! Percolation Rate Minute , Proposed Inst'allation: Seenaae Pit yes __D~ain Field :~' ;. Deoth of Inlet ~ De~th: ~o Bot.tO~ Of Pit Or Trench :rcnMPENTS: 85 sq. f6; drainage area 'r.equired '}~ezj bedroom , ~':. no bedrock or water table ~ift': belo~i seepage pit. .- ,,. , ~., :,[.,?d;,: J~ M~ak er ' ''~ ~:~L' a Cert, fied By: Oonst. ".' ,~t ,Date: Stree! Addfor, s and A~eu of Well Locofion WELL tOG ~ Material Type i t..lo t t om 4 V, ELL P, EP?H: (fin-I) '/ ...... ~.,,-; ' J 5 DATE OF COMPLETION --_Z_L. ~ ¢ ) ~ ~ i .... ~-- .......... J L- - .cnd su,f~ce Dc~e 6. WATER WELL CO~JT~ACTO~'~ ~ERTIFICATIO~: ~ ~ ~-tc~ ~'~r~l 02-WW~ ~H/81) ................ ep~h O~ Ive]] - 7.7.' . ' .................................... '.., .... Size ~ · ' ' ..... ' ........................................ ''. : . oz easLr~g ......,:...~.,j.. · ................................ : ....... '.IDJsia~ce to Water... 22, ................ :. ............ : .......... .i ........ D%~ance" .... . ............ ' .................................. i.'~ ....... i. '.'' '~''' ' .~u water while PUmp~g ~, . Of. . . 300 . . .................. "'" .......... ' .......... ................... ' ' .......................... : .... ' ...... a'k,-rate · : · ' ............ ' ............. gallons per hoar. ~ ~ra ye Sand ------___.,~. _ ~__..~ ye 1 Clay, gravel MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH E. £NVI.~ONMENTAL PROTECTION JUL 8 197b RE.CEIVED / Driller ........ tz ............ 5~2! GOLDEN ANCHORAGE, ALASKA 9950;/ PHONE 344-0551 MUNICIPALITY OF ANCHORAGE ~ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 GENERAL INFORMATION (a) (b) (c) Application Date Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name ~ oo ~ ~ ~ ~/5 Telephone: Home ~- ~7 / Applicant is (check one): Lending Institution ~ ;-bWner/builder ~. Buyer D · Other (e) Real Estate Companyand Agent Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-FamilyJ~ Multi-Family [] Other .umber of B drooms ' (' WATER SUPPLY - ..~ Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Enwronmental Conservation ~ attesting to the legality and status. ' ' SEWAGE DISPOSAL ~i Onsite ~ Public [] Community [] Holding Tank [] . . ~, - Note: If community well system, must have writteh confirmation from the State Department of Environmental Conservat,on ~ attesting to the legality and status. Page I of 2 · ENGINEERING FIRM PROVIDII~G INSPECTIONS, TES'I~S, FILE SEARCH, D~ I'A AND INFORMATION " ,' 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 shows that the on-site water supply and/or wastewate'r 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, t'he on-site water supply and/or wastewater disposal system is in compliance wit.h all Municipal and )State cod.es, ordinances, and re.clul~tions irveffect on ' the date of this insEection...%X NameofFirm ~0~ ~5~~ Telephone ~ 3~--~~ '' :: ' : J~m: 2~, I~ tS! .'. . DHEP APPROVAL ' '""' ". '. Approved for' Ch~ drooms b ~' Date · ADDroved '~ ' '¢" ' .. _' ~ ~ D~sa~ved , Co hal lerms of Conditional Approval: '' N'"' '" ' ' · .. ....... , . . . , . . . . CAUTION ..... :'.-: The Muncipality of Anchorage Depa~ment of Health and Environmental Protection (DHEP) issues Health Approval ce~ificates based solely upon the representations given in paragraph 5 above by an independent · engineer registered in the State of Alaska. The DHEP does this as a cou~esy to purchasers of homes and thei[ .institutions in order to satisfy ce~ain federal and state requirements. Employees of DHEP do not conduct analyze data before a ce~ificate is issued. The Municipality of Anchorage is not res po risible for errors or. omissions in th~ .. . , ................. professional engineers work. .. ~' , ~:. Pa~e 2 o~ 2 72~25 (11/84) .j. ,:. , .,~ ~' ~ MUNICIPALITY OF ANCHoRAGE (MOA) : h~PT ~ ~EALT~t~'i~J'~O&~ APPROVAL (Haa) · £~4Vl RONMENTAL ;PROTECT~CT_TCq, -- mm~=ort~3v 1~o,~ '- ' :i.' . :r: ' ' ti: .... ~ -gE0 2 '~ lg85 ;~1 . Legal Description: ~1 ClassifJice - ~ ,~ ff A, B, ~ C, ~ d(Y~) J~il ~ ~eSent,~<Y~) ~ ~.: ~ : ~te ~lemd :~ ~[: ~':~-- Total mp~' ~: i 7r' ~' ~'~d~ ~ ~o ~p~ Of:~outlng Static J~ter~.~l · ..~ ~.J , ', ~ ~ ~ ~t At Casing ~ght ~'..Gr~nd J~ ~ '~/'[ ' ' Sani~ ~ai on ~Sing (Y~) -- ~essfCn~nd ~l~ead (Y~) : . . "~. ~' ~. 'j,' ,~ . ~p~atlon D[s~n~s ~.~1-1:. ~ :~'o :~est ~blzc ~r Line ?. ~ ~ 'C ';: To ~est ~blic ~r ' Clean~t~ole .:'"~ ~'~ ~ : ~ ~est ~r ~rvi~.Li~ on Wate~ S~le :Colle~ed.By ~1 ~; ~ ~ "~te nts ~ ~: ~ ~ ~ ~B. 'SEPTIC/HOLDING TANK DATA 'i i Date Installed iI No. of i C~ )~t~ents [Page 1 of 2] Receipt ~i Date Paid: . :2-15-84 Ce ABSORPTION FIELD DATA 6- Soils Rating in Absorption Strata Width of Field / L Square Feet of Abscrgtion A=ea Type of System Design /~ Length of Field /~- Depth of Field /o ' Gravel Bed Thickness Standpipes Present (Y/N) Depression over Field (Y/N) /%3 Date of Last Adg_quacy Test sults of Lest Test H Separation Distance frcm A~s-CrPticn Field: To Wate=-Supply W~ll -A /De) ' To Property Line To Building' Foundation + Lot /J d To Water Main/Service Line To Stream/Pond/Lake/c= Majo= Drainage Course To Driveway, Parking Area, c= Vehicle Storage Area ~ ~9 ~ To Existing cr Abandoned System cn ; On Adjoining Lots + /O~) ' + ~9 ! To Cutbank ( if present) /J ~ LIFT STATION Date Installed Size in Gallons "Pump On" ievel at High Water Alarm Level at Tested fo~ Electrical Codes(Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. M~ets MOA ~., ccnm~nts ,** Check permitted Bedroom Ratir~ Against BAA ~equest I certify that I' have checked, verified, ct. confcrm~d to al~ MOA.HAA~Gui...~de~l.-ines in.~fect iSigned i Company ~'~/q~/, [Page 2 of 21 2-15-84 /Vlunicipality Anchorage P.O. BOX 6650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWLES. MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES January 9, 1986 Henry H. Wilson, P.E. Construction Engineers, Inc. 9601 Buddy Werner Drive Anchorage, Alaska 99516 'Subject: Lot 1 Block 1Tuxedni Park Subdivision Waiver Request WR85-065 Dear Mr. Wilson: This department has reviewed your request for a waiver to 82 feet for the separation distance required between the septic tank and the well on the subject property. The required horizontal separation is 100 feet. Based on the information provided about the subject lot, this waiver has been granted. This waiver is valid for a three bedroom dwelling only. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/ljw ANCHOR, GE M'ARKET DAT/ SYSTEIVi IMPORTANT ' 0E,. o,,m,, THIS INFORMATION SHEET MUST GO TO ,T. EI.E .... LENDER WITH THE APPRAISAL REPORJ~.N 9 1986 (APPRAISERS -- PLEASE' FILL OUT COMPLETELY AND USE FORMAT IF AT ALL pOSSIBLE!!) .ESS qEOl Chcn . pr'iV APPRAISAL COMPANY ~o D~e t y~ .~,t ~e z~ ooo OF A~SKA t~ Arctic Blvd.,- Suite 3~ ~no ~n~clng ~V on M~ __ Anchorage, Alike 99~3 ~t~ to ~n,~ 562-2424 ~ [1 T~ ~ 95~! ('~henega ' Add,ess 1/~ Tuxedni Park P~oximity to Subi. ~ FORM Sale-. P.ce $ 213500 1025 PricefLivim:j area $ [~2. Data Souse [~%pec~ Date of Sale a~ DESCRIPTION T,me Adjustment [ [ -8~ L~allon good S,telV,ew good Dmlgn and Appeal [Og R~/aVg+ Oualitv of Const. A~ 197~ Cond,li~ avg.+ Liv,ngAreaRo~ Total:, B'~ms : Baths ' Count a~ Total ~ ; 2 Gr~I L*vin9 Area Batement & Bsmt. 5 1 1 F,n,shed Romi 15~/1~% f in Fu~ttonal Utili~ A,, Co~dizio.i.g none Garotte, P~t G2A(lg) AppraJser ~ Zoning ~Y~ * Lot ~ W1rfrt 0 EUuff' ' si= ~5 0 "0" t~ n C~uster rl ['1 TNHSE eof Units __ ? E~C[ERIOR KITCHEN ID BaJco~y 0 ~u. ~ 0 ~lf Oe~lng 0 ~to~ ~ ~ R~ ~ ~v~l~ ~ ~ ~nd~ ] Stye ~R~ 0 ~ Chut~ 0 St~ ~V~t Fm 0 0 Prow Front ~Ol~w~ 0 J~ 0 Ig 0 u 0 ~ ~ ~ Tub 0 MIc~ ~ Ste~ 0 Jenn~m Gdll O Multiple ~ ~ Raf~g~t~ ~ V~i~ ~lnte~ 0 ~slom ~th O Intem~ AMI~ ~ ~e~ ~Closum n Average Po~:h I'1Wa~k4n Bedro~' 0 E~closed 0 A~lc bt~ 0 ~1 KII~ ~ 0 Mi~ ~set ~m ~ ~1 ~ ~Ave~ ~ ~ ~L~II-I ~Oe 0 Dinette N~ ~ ~ 0 ~enat~ ~P~t~ ~ ~ ~t~ ~ ~tch~ Isl~ ~ ~mg ~nt~ INTERIOR 0 A~ ~O M~ 0 ~BO H~I ~ H~lfl~ O A~e O ~ 0 ~ Ught~ 0 ~al~ 0 ~n ~GI~s Fu~ ? ~ ·. s~ e~ 0 He~ RESlDE~i/~.L /~,[~PRAISAL REPOH ~ Census Trot ~ er ¥~ldl chenega "'i)P 1 ve ty Add,ess, rtCtlor age CountY )e~r~pt~On ice $ ~te ol ~le Loan Term Real Esla~e Ta~ $ IV~l Loan cha~O be ~a~d by ~lle~ ~s a ~ona an: r/Client ~~ A~ra~ser State A1 aslca-- Z,p Code Property R,ghts Appraised ~Mm~m~s PUD Other sales concessions Address ~ Instructions to Appraiser an · lggln 0 am on [] Urban O Suburban ~ [] Over 75% [] :25% to 75% h Rate [--1 Fully Dev. [] Ra~id [] Steady rty Values [] Increasing [] Stable nd/Supply [] Shortage [] In Balance · ting Time [] Under 3 Mos. [] 4--6 Mos. ~t Land Us~5 % 1 Family % 2-4 Family._.__% Apts. _ __% indust rial--~-'5'--% Vacant ~e in Present Land Use [] Not Likely ' OLikely I*l [~Taking Place (*) (') From vacant To ' ~ingl~- familg ,mlnant Occupancy [X-~ Owner % Vacant r'~Tenant ,.- Family Price Range S '~(~)~ to $'~5l~[~ Predominant Value4~_~A~3 · ne~ 10 Predominant Age [] Rural [] Under 25% [] Slow [] Dechning [] Over Supply [] Over 6 Mos. Condo % Commercia Good Avg. Employment Stability [] [] Convenience to Employment [] [] Convenience tO Shopping [] [] Convenience to Schools [] [] Adequacy al Public Transportation [] [] Recreational Fecilities O [] Adequacy of Utihbes [] Property Compatibility [] Protection trom Detrimental Conditions[] Police and Fire Protection [] Oeneral Appearances of Properties 0 Appeal to Mzrket Family Age _ yrs to - Y~ FHLMCIFNMA do not consider race or Ihe racial composition of the neighborhood to be reliable appraisal factors. Res i dent iai ors favorable or unfavorable, alleclmg marketabd~tY {e.g. pubhc parks, schools, v~ neats includmgth, ose.lact L,__ ~..: '~ ~;,4~ =hnv~ aSS Anchorage. Acce55 p~OV~ ~hood loca:eo on :ne -~-=-~ ..... E ~ag an e:<ce~ P~ o~P- amp e A~s rip Oa main enance provl nicipalit~ but ~inte~ ~ferred to as :asians irregular Fair Poor ng classmhcation est and bet use: ~"~ Present use Public Other {Describe] [] :, [] indiv, moll Sewe, [] ind. septic neigh- OFF SITE IMPROVEMEf,ITS Street Access: [] Public [] Private Surface unpaved Maintenance: []Public []P, ivate []Storm Sewer FICurb/outter Present~mprovements []do [] do not conform to zonlng regulati°ns Tope slope to the e~st Size t~pical of area Shape irregular View average Drainage appears adequate [] Underground Elect. & Tel, F-'~Sidewalk I""~Street Lights isthepo~rt~lc~,.~ledinaHUOldo~lifiedSpoda~Fl~odHzzardAr~a? IR-INa OYes ~ments (lavorable or unfavorable including any apparent adverse easements, encroachments or other advi~se condil,ons) Si te has a gent le ~ope upward from road. Site provides a view of the surrounding mountains but tree coverage = area does not allo~ a vie~ of the bo~l area. Natural gas is available to site. :ransportation is available on Tudor Road. .... ~ UnderConst, INo Units ! Tv['~'~pe(det. duplex, semi/det, etc.) jOesignl'ambmer, spI!!level'etc'l_jE".~e"°rWalls Ex~stmgl Irr.°O.ose°l I /, ~ 'l. '- · 1 Ides s~ngle f~mtI~ Ilog r~nch u/b~sementm z~_- Age: Actual lZEfl~t~ve_ w lo_O ~o.~tor,~ ........ ~~~ ~~ ~ Unrestricted [] Other |;pecifyl access occasionailu requires four ~ area ~ys a rep~ pres tge, u lc* = Z),.~ oO~ Sq. Ft. or Acres OCornel Lot Floor Plan ~[pprais.~l ~inp-~n,p of ~laska 3900 ~lr~lit ~oulrbarb ~in~bor~IIt. HENRY WILSON 9601 BUDDY WERNER DR. ANCHORAGE/AK 99516 (go7] ] 46-2000 Construct n .~UN!Cm^L,TY OF ^~~er :23, 1985 ~r. OF HE^CT, & ~=~'~O~E~'^L ~.~OT~Cr~ON ' CHARLES A. LANDERS ': SR BOX I g2-A. MYRTLE DR. EAGLE RIVER. AK 99577 (907) 694-gOg$ :OEC 2 3 1985 P, ECEIVED Re Lot 1 Block 1 Tuxedni Park 'Waiver of Septic Tank ]{ori~ontal Separation Dist- ance~~ Construction for Municipality of Anchorage Div. of Environmental Health 825 L 'Street Anchorage, AK Gentlemen: In checking the subject property for a ~5%A, we .i~ave d~..termined :that the SeparatiOn :distance' between the well' and septic t~nk ~'tandpipe is 85 ft. +_...The -~nspectlon.report for the installation (dated 5-15-: 74) shows a s~ngle-compartment l~250-gallon septic tank.with!a 'sepa- ration from the well~ of 82 f~. - ' · The separation from '.the, Well to the seepage pi~.il standpipe~ is 1'20 f~ _+. An adequacy test per'formed DeCember 9, 1985 proves the seepage, pit to~ be adequate ifor a fo'ur-bedroom home. ~omparison'of the as-built' sur' vey (copy attached) with the test log in the file, reveals that the seepage pit was not .~nstalled near the test pit~ The application for the disposal~ system. Permit i(dated 5-17-73) indi- Cates a 85' deep well iexisted at 'that .time. No well log is available. A flow test performed December 9, 1985 proved the well to be adequate for a four-bedroom home~ The i well was pumped at'7 gpm with virtually'- . no drawdown. A few available well. 10gs from nearby wells are attached. Depths (87', 77') an~ flows (30 gpm, 5 gpm) appear similar to subject. well. Inasmuch'as it is'possible for a septic tank toileak, which would then be a i·ContinuousI sburce of·~ontamination, we attach a worksheet Per Mr. Erickson's lr3-85 Waiver guideline memo. For soil'properties we have used.a composite of the soils per the ~ttached logs of nearby. wells. Our interpretation of the;data availabl~ yields a condition of "almost sure to be free from ahy form of contamination from hOuse- hold sewage" in the Unlikely worst case of :a leaking septic tank. HENRY ~/ILSON 96OI BUDDY WERNER DR. ANCHORAGE. AK ggS 16 (907) ; i'~ Constructihg';Engineers, !nCI' ' ~? Engi~n~'rS;~SurveYors'' ~ CHARLES A. LANDERS SR BOX 192.A, MYRTLE DR. EAGLE RIVER. AK 99577 ~ (907) 694.g09t~ .1/1 Tuxedni Park ~ Waiver i Page 2 In'view of the above, we request that a health .authority approval be ,granted for subject~ProPerty. Please call if any 'other clarification is necessary. Very truly yours, CONSTRUCTING ENGINEERSt INC. Henry:H.. Wilson HENRY WILSON 96OI BUDDY WERNER DR.: ANCHORAGE. AK 99516 (907) 345-:~000 Construcl~~ineers, Eng~rs Inc. CHARLES A. LANDERS SR BOX Ig:~-A. MYRTLE DR. EAGLE RIVER, AK 99577 (907) 694-90~ -78 !1 Z, o Il/ IATE:$ .-,-,-' ...... ~ - ,.:. -, 15th:~AVe'::Suite...2 ;, :.'-..Residence ORAGEi-I :t. ASKA .99501 .... -. ,. st. au.E: 1" = 50 ' r ' : 812099 ,. f"'l ::[8 URVE:Y HUB '.~ :~',"i ~)&T £ ALASKA [IUIRO[Im I1TAL COFITROL $ RUIC $, IF1C. I~ncjincerJn(j ~- I~nuironmentaJ Studies MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL I'2OTECTION MAY '7 I981 RECEIVFD MAY 5 1981 BANK OF THE NORTH 3301 C STREET ANCHORAGE AK 99510 SELLER - BUCK SMITH SUBDIVISION-TUXEDNI BLOCK-1 LOT-1 THE TYPE OF ABSORPTION SYSTEM IS A PIT WITH AN AREA OF 288 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 600 GALLONS OF WATER PER DAY. THE SOILS RATING OF THE SYSTEM AT CONSTRUCTION WAS 85 AND NOW IS 72 SQFT/ BEDROOM. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 4 BEDROOM HOME. THE SEPTIC TANK WAS PUMPED ON 5-5-81 . 1220 LUesI 25th Aucnue · Anchoraqe, Alaska 99503 · (907) 276-1361 825 "L" STREET ANCHORAGE, ALASKA 99501 (907) 264-4111 GEORGE M. SULLIVAN, MAYOR D£PARTMENr OF HEALTH AND ENVIRONMENTAL PROTr-CTION April 24, 1981 Buck Smith 9501 Chenega Drive Anchorage, Alaska 99507 Subject: Lot 1 Block 1 Tuxedni Park Subdivision Approval for the individual sewer and water facilities cannot be granted until the following items have been completed: (1) The water analysis report needs to be delivered to this office from the Chem Lab, 5633 B Street, for our review. (2) The septic tank pumped with a receipt submitted to this office. (3) An adequacy test needs to be performed on the existing leaching area. This test will determine if the system is adequate according to National Standards. A listing of private firms performing the test is enclosed. This report needs to be submitted to this office for our review. If there are any further questions, please call this office at 264-4720. Sincerely, Robert C. Pratt, R.S. Associate Specialist RCP/ljw cc: Alaska National Bank of the North 3301 C Street - Calais II 99503 Howard Swerland 605 West Benson Boulevard 99503 ' ' INSPECTION_ _ APPOINTMENTS TIME ~ TIME TI DATE L, DATE · DATE INSPECTOR !i ' INSPECTOR . INSPECTORi. ~ MUNICIPALITY OF ANCHORAGE.~ MUNICIPALI~ OF ANCHO~GE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIONDEPT' OF HEALTH & ~ ~ 825 L Street - Anchora~, Alaska 99501 ~' ENVIRONMENTAL SANITATION DIVISION Telephone 264~720 REQUEST'" ~FOR AP~ROvAL OF INDIVIDUAL WATER AND DIRECTIONS: Complete all parts on page 1. Incomplete requ~ will not be proceed. Please allow ten {10) days for processing. MAILING'ADDRES~ PROPERTY RESIDENT (If different from Cbov~)~ ' - , PHONE MAILING ADDRESS ~' ~ [ ' ' · I PHONE 3. LENDING INSTITUTION ~ ~~ MAILING ADDRESS ~ ~~ 4. REALTORIA~ENT ' I PHONE. MAILING ADDRESS ~. 5. LEGAL DESCRIPTION Io 7- I STREET LOCATION 6. TYPE OF RESIDENCE SINGLE FAMILY [] MULTIPLE FAMI LY:~ NUMBER OF~BEDROOMS .r-I One ii--] Four [] Two ',i ~1~ Five I--I Three ~I~ Six . [] Other 7. WATE ,R.,~UPP LY INDIVIDUAL' COMMUNITY [] PUBLIC UTILITY ATTACH WELL LOG. A well Io4 is required for all wells drilled since June 1975, For wells drilled prior to that date, give well depth (attach log if available,) ~ 8. SEWAGE DISPOSAL SYSTEM i ' ! INDIVIDUAL/ON-SITE*' YEAR ON-SITE ~YSTEM WAS INSTALLED. I [] PUBLIC UTILITY '- NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE r 72-010 (Rev. 6/79) ROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY TYPE OF RESIDENCE [] .SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] 'INDIVIDUAL, ' [] .COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVI DUAL/ON -sITE '[]PUBLIC UTILITY Connection Verified []Septic Tank or []Holding Tank Size: ~o~-~'r'3 If Tank is homemade give dimensions: TYPE OF TANK - TOTAL ABSORPTION AREA . 4, DISTANCES WELL TO: Absorption Area to nearest Lot Line NUMBER OF BEDROOMS ' [] ONE [] THREE I--I FIVE [] OTHER [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED· LOG RECEIVED · PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING MANUFACTURER MATERIAL I Septic/Holding Tank IAbsorption Area ISewer, . Line INearest Lot Line 5, COMMENTS [] CONDITIONAL A'PPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev. 6/79)