HomeMy WebLinkAboutEAGLE PARK BLK 3 LT 7 ~ MUNICIPALITY OF ANCHORAGE f
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
,'¢;
HOMEMADE:
DISTANCE TO:
DISTANCE TO:
No. of liner
Top of tile to finish
Length
Well
Length
Inside length
Dwelling
J F ou~nd/l~,l[~n
Material beneath tile
~dth Depth
Type of crib Crib diameter
Well
DISTANCE TO:
Class Depth
DISTANCE TO: Building foundation
W dth
OTHER
PIPEMATERIAL,~ ~. ~,
SOILTEBT.?? )
Material
NO. OF BEDROOMS
No~.~compartments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
Crib depth Total effective absorption area
Building foundation Nearest lot line
Distance to lot line PERMIT NO.
Septic tank Absorption area{s)
· 7~VED DATE
LEGAL
PERMIT NO.
APPLICANT
LOCATION
LEGAL
MUhl I ¢ I F .-:IL IT¥ OF AI'-.ICH,.. RAGE
~)EPRRTMENT OF HERLTH AMD ENYIROt'JMENTAL PROTECTION
825 'L'" STREET, ANCHORAGE, AK. .~9501
264-4720
01'4--S ITE SEI,IER PERM
SYDNEY R. HUFFNRGLE P.O. BOX 182, E.R.
RAVEN ST. · E. R,
L7 B~ EAGLE PARK S/D
694-9746
66000 SQUARE FEET
LOT SIZE
TYPE OF SOIL ABSORPTION SYSTEM IS: TREMCH
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING <SQ FT?BR)= 270 /J ~
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: ~ ~~1~°~
D~PTH= ~EIqGTH= RRt'EL DEPTH= ~r
THE LENGTH DIMEHSIO~-I IS THE LENGTH (IN FEET> OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TREt'ICH OR PIT I~ THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND At'ID THE BOTTOM OF THE EXCRVRTIOt'I (IN FEET>.
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE
At'ID THE BOTTOM OF THE EXCRVRTIOt'I (IN FEET>.
REQ~m I RED SEPT I C TRI'41< S I ~--"E.= :1250 GRLLOI'-.IS
PERMIT 8PPLICRt'IT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTRLLRTIODI INSPECTIOt'IS OF AMY WELLS ADJACENT TO THIS PROPERTY 8ND THE
NUMBER OF RESIDENCES THAT THE HELL WILL SERVE.
Ti,-IO ( 2 ::, I I'-ILL:;PECT I ON--'L:; lIRE RE~..U I RED
BACKFILLING OF AN'¢ SYSTEM WITHOUT FINAL INSPECTION AND RPPROV8L BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTRt~CE BETHEEN A HELL AND AMY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR 8 PRIVATE WELL OR 150 TO 200 FEET FROM R PUBLIC HELL DEPENDING
UPON THE TYPE OF PUBLIC HELL
MINIMUM DISTANCE FROM R PRIVATE HELL TO R PRIVATE SEWER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREmeNTS MRY APPLY. SPECIFICATIONS 8~D CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERP1 I T EXP I RES DEC:EPIBER .?-1.-
I CERTIFY THRT
1: I RM FAMILIAR WITH THE REOUIREMENTS FOR ON-SITE SB.IERS At-JD HELLS RS SET
FORTH BY THE MUNICIPRLITY OF ANCHORAGE.
2: I HILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
~: I UNDERSTRND THAT THE ON-SITE SEHER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. /0~ /YZ/- ~ ~,~s '~
A~LICR~ SYDMEY~ HOFFNROLE ~B = It.~/~f
O & E ENG,'~NEERING & DEVELO~'r'~MENT CO.
Box 90, Davis St., Eagle River; Alaska 99577
694-2774 or 688-2280
Ru~ell Oyster
694-2774
SOIL LOG
Performedfoc, Name' .~"~'~ ? ~:~A/~'r;~--4/C~'~"l~3/q' Tel. No.
Earl EIIII
688-2280
q?,s-77
Depth (feet)
8oll Characlerllfl¢~
0
lm
m
7~
8~
9~
12
.eTo
PLOT PLAN
PERC. TEST
/ /,~ ~fr/p~.~..
I?.
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit
Comments:
Performed by:
O & E ENG,,,IEERING & DEVELO~.,/1ENTiCO.
Ru.ell Oyster
694-2774
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
SOIL LOG
Performed for: Name: '--~ P~) H ~"P ~'~']u] '~]-L~/-' ~' Tel. NO
Mailing Address'
LegalDescription: /-07- ~7/ /~'/-oc/4 ~, ~'/~-~C.z~'- ,~/~.~--/~,~'~C//Z~Z).
Earl
688-2280
Depth (feet)
0
1
2
3
Soft CherecteHttlcl
10
11__
12__
13
PLOT PLAN
14
15
16__
~ ~-~O?'p'O,,'~ '~' ~/p- PERC. TEST
No "If yes, what depth
Drain Field
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit
Comments:
Performed by: .~
ITII-I~I I C I F~L I TY OF A~ICH~"~;~AGE
. DEPARTMENT C HERLTH AND ENVIRONMENTAL ~ JTECTION
.,~ -" 825 'L~ ~TREET, ANCHORAGE, AK. ~501
264-4720
I~ELL PEEH [ T
PERMIT NO. ( 8~0220 )
APPLICRNT SYDtIEY R HUFFNRGLE
LOCATION RRVEN ST.
LEORL LT.? BLK. 3 EROLE PRRK S?D
PO BX 102 ER
LOT SIZE
694-9746
50000 SQURRE FEET
MINIMUM DISTRNCE BETWEEN R WELL AND ANY ON-SITE SEWROE DISPOSRL SYSTEM IS
100 FEET FOR R PRIVATE WELL OR i50 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTR~tCE FROM R PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE HELL COMPLETION.
OTHER REQUIREMENTS MRY APPLY. SPECIFICATIONS RND CONSTRUCTION DIRORRMS RRE
AVRILRBLE TO INSURE PROPER INSTALLATION.
PERr~ I T EXP I RES DECEMBER
I CERTIFY THRT
· ~: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH BY THE MUNICIPRLIT¥ OF RNCHORROE.
2: I WILL INSTALL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
..........
V4. 0
OF H~AL?H &
ENVIRONMENTAL P~,OTECTION
DOC CO.
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK. ALASKA 99567 · TELEPHONE 688-2759
MAY 1 5 1981
RECEIVED
OWNER OF LAND '~-! ~ ~'-/~ F ;,'~,~ CC ~ DE~H OF WELL ~ ~
ADDR~S ~ c' ~ ~ ~ ~ o ~ ~ ~ STATIC LEVEL OF WATER
LEGAL D~CRI~ION ~ ~ ~'4 ~< ~ ~ ~ ~P~'- DRAW ~WN ~. ~
OA~-s~.~ ~/'~-,/~/ ~.d~ ~-~-/~' ~A~.~.., /~ ~
PE~ITNUMBER ~1 ~ p~ KIND OF CASING ~ ~o
KIND OF FORMATION:
From /) Ft. to ~
From ') Ft. to '~'
From , ~' Ft. to / C' Ft.
From / ~ Ft. to ~ '~ Ft.
From n.!.' Vt. to/.? Ft.
From / - ~ Ft. to/- ~'' Ft.
From Ft. to Fi,
From__Ft. to Ft.
From Ft. to~__.Ft,
From Ft. to Ft.
From Ft. to Ft._
From Ft. to__.Ft
From Ft. to Ft.
From Ft. to Ft
From __ Ft. to__.Ft.
From Ft. to Ft._
From Ft. to Ft.
From--Ft. to--.Ft.
From__Ft. to Ft.
From Ft. to Ft.
From__Fi. to Ft,
From__Ft. to Ft.
From__Ft. to Ft.
From Ft. to__Ft.
From Ft. to Ft.
From Ft. to Ft.
From__Ft. to Ft.
From Ft. to___Ft.
~From Ft. to Ft.
From Ft. to___Ft.
From - Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft..
From__Ft. to Ft__
MISCL. INFORMATION:
DRILLER'S NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
C/O REUAX o~ EAGLE RIVER
20717 Raven Drive
Ea~Le River, AK
Day phone
16600 Ce~,terfle~.d Prlue
Day phone-
Eaqle R/uer~ AK
99571
Day phone
e
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community ~vell
Public water
NOTE:
XY, X
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
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.
Se
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,
regulations in effect ~
ordinances, an 3n the dd_~te-o'r~is inspection.
Name of Firm__ Phone
Address 17034 Eagle Rl,~c-L~Road ~. 233
Eagle R~
Engineer's signature Date
DHHS SIGNATURE
~ Approved for 4 bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certifica.'es based only upon the representations given in paragraph 5 above by an independent
professional engineer registe,ed 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.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~.,.c,~' q I~/--"~ ~-,~.,~.~-¢~-t..,C-~Lrcel I.D.
A. Well Data
Well lype
Log present ~)N)
Total depth
Sanita~ seal ~/N)
If A, B, or C, attach ADEC letter. ADEC water system number ,3"'-~'-- 8 ! Driller
Cased to
?
FROM WELL LOG
Date of test
Static water level ~ e, /
Well flow ,,~o. o
Pump level1 ~-
SEPARATION DISTANCES FROM WELL TO:
Date completed
~, / ~ Casing height
pmpedy protected (~/N)
Wires
AT INSPECTION
g.p.m.
; On adjacent lots I o ~
; On adjacent lots I o o ~ +
Public sewer manhole/cleanout
.Petroleum tank ~' ~'~
Septic/holding tank on lot J bo '
Absorption field on lot ~ DC> ~ ¥
Public sewer main ~ I ~
Sewer service line ~
WATER SAMPLE RESULTS:
Coliform C3 Nitrate
Date of sample: ~,-/'f-~ //,'-' B -5' f
B. SEPTIC/HOLDING TANK DATA
Date installed '7.- ~.5'"-. ~ t
Cleanouts ~N) ~f
High water alan'n (Y~
Date of pumping
.~. ~. Other bacteria 43
Collected by:
.Tank size ~.'3.-~" D Compartments
Foundation cleanout {~VN) ,~ Depression (Y~
/'/ Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /o ~ ~ On adjacent lots
To property line /'~ / '/' Absorption field
Surface water/drainage / ~'~ ~ ~'
Foundation 5'"/
.Water main/service line '
~z.o2e ra~' F,o~ CONTINUED ON BACK PAGE
C. UFT STATION
Date installed
Size in gallons
Vent (Y/N)
'Pump on' level at
High water alarm level
Meets MOA
Well on lot · ' On adjacent 10ts,
Manufacturer
Manhole/Access (Y/N)
.Surface water
Total al:~orption area
Date of ad~:luacy test
D. ABSORPTION FIELD DATA
"Date installed
. :
' . ' Waler level in absorplion lleid before lest
:, Peroxidetr ament (pa, st
Soil rating (GPD/Ft2) '7---"~ T/~'~ Systemlype
.3 ' .Gravel thicimess / D, 5" Total depth /5~. -~'
Cleanout present ~'/N) ~ Depression over field (Y~ ,J
Results (j~ai]) /~'f~:~ for ;~ Bedrooms
'~-~" .Ntertest '~ /"
,,Jo ,,J.~_/zJ,~ J./~ yes, giVe date' ~/~.
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot J~,~ '¥ On adjacent lots t mo ~'' Property line
To building foundation ,~,~,, .b~ .To fxisting or abandoned system on lot
On adjacent lots ~ ~ ~._~_.~cUtbank ~1~. Water main/service line
Surface water ~ Driveway, parking/vehicle storage area ~"o~
Curtain drain
E. ENGINEER'S CERTIFICATION
I cerO'fy that I have checked, vedfied, or conforr~ed~ all MOA and HAA guidelines in e~t~o.n_ ~I~ this I.n.~on.
'..~ OF , ':
· /, /
..
· 17034£ I,R ~ "·
HM Fee $ f~(~ 43 -, c/Z) Waiver Fee $ '
Date of Payment ~'-"/'",~ ~ Date of Payment
Nur r 0¢0¢,5 .umber,
CT&E Ref.#
Client Sample ID
Ma~x
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~~-l.~.a-~e-~:a-.a-~s-.~-.~-f.~.e-.~.~-.a-.~.~.a
LABORATORY ANALYSIS REPORT
94.2832-3
L7 BLIO EAGLE PARK S/D
WATER
Client Name S & S ENGINEERING WORK Order 79243
Ordered By R..LS. Printed Dale 06/14/94 1~07:18 hrs.
Project Name Collected Date 06/08/94 ~ 13:30 h~.
Project# Received Dar e 06/09/94 1~ 12:00 hrs.
PWSID UA
Technical Director
Rele~d By: .=.~-~'-~
STEPI IEN C. EDE
Sample Remarks: ROUTINE SAMPLECOLLECIED BY: RAY.
QC Allowable Ext. Anal
Parameter Results Qual Units Method Limits Dale Date
Init
Nitrate-N 2.6 mg/L EPA 353.2/300.0 10
06/10/94 DJS
* See Special Instructions Above UA = Unavailable
** See Sample Remarks Above NA = Not Anaiyzed
U = Undetected, Reported value is the practical quantification limit. LT = Less 'l~nn
~ D = Secondary diluHon. GT = Greater 'I~an
5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA. COLORADO. FLORIDA. ILLINOIS, MARYLAND, NEW JERSEY, OHIO. UTAH. WEST VIRGINIA
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
Application Date ~
/
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, tinge)
Location (address or directions)
' Telephone: Home ~'~'/--,'z-O ~'~ Business
(b) Applicant Name ~ ~ :~
(c) Applicant is (check one): Lending Institution r-I; Owner/builder I-I; Buyer []; Other (explain);
Lending Institution *'~'~'~.z--;;v-~'z-.-~'-,,'~/ ~ ~".',<'," Telephone
Address /'
(d)
(e) Real Estate Company and Agent
Address
Telephone
(fL_~'~HAA to the following address:
,T ,~..w. ,~:~r.~.. - -
TYPE OF RESIDENCE
Single-Family, S, Multi-Family
Number of Bedrooms
Other
WATER SUPPLY
Individual Well~ Community ri Public1-1
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
Page 1 o! 2
SEWAGE DISPOSAL
Onsite'~ Public [] Community 1-1 Holding
Tank
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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 wast?water 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 '~ ~ ~.E~iI~F.~I~ Telephone
, ,~ · '~ lg.r.~, -
Address
Date ..........
Approved for ]~-~'"~ be '~'~P--"~.-~-'-'~C' g'~Date
Approved ~. Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data bi, fore a certificate is issued. 'The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
.EALT. AUT.OR,TY A.PROVAL .AA, (13^1333 !
CHECKLIST- FEBRUARY 1984 ' *
Legal De.~s~cription: ~ r~
) ~lY)H ~0 *Zd3Q
Well Classification ~'-;>, ~' If A, B, C. D.E.C. Approved (Y/N)
Well Log Present~) Date Completed ~"-'~ ~' ~ ~ . Yield
Total Depth (~ ~ ~-~" Cased to "~C)~J~ Depth of Grouting '"'--
Static Water Level 'z~c::~ ~
Casing Height Above Ground ~t
Electrical Wiring in Conduit (~N)
Separation Distances from Well:
Pump Set At 0 [~/~.
Sanitary Seal on Casing~'N)
Depression Around Wellhead (Y~
To Septic/l~ Tank on Lot t ~::~ ~ ; On Adjoining Lots
To Nearest Edge of Absorption Field o~ Lot lOOt'+' ; On Adjoining Lots *t, [~.~, I.~
' ~/~ To Nearest Public Sewer
TO Nearest Public Sewer Line fo / ~ 0~:)
Cleanout/Manhole To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments ~ ~)K~!-
Bm SEPTI~ANK DATA
Date Installed
Standpipes~N)
Depression over Tank (Y~)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) /,,3//,,
Separation Distances from Septic/~t,,,ld,.~ Tank:
To Water-Supply Well J
To Property Line
To Water ;,~',~;-.,'Service Line ~ [~. ~''~
Course
Size ~ ~-~"~ No. of Compartments ~-
Air-tight Capsl~N) Foundation Cleanout
Date Last Pumped ~"~
~'~/,A* ; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field /~. r
To Stream, Pond, Lake. or Major Drainage
Comments
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed '7 - ~' -
Width of Field ~"
'~-'~"'3 ~' /P~O_~- Typeof System Design
Length of Field
" Depth of Field
Gravel ~ Thick~
St~ndpi~ Pre~nt
· Square Feet of Absorption Area
Depression over Field (Y.~
Results of Last Adequacy Test
· Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation .,~ t .~.~
Lot
To Water Nlmn'/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway. Parking Area, or Vehicle Storage Area
Comments
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
J~,A.Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Acce~ (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request *"
I certify that I have check~.w;Ly.~[[JJed, or conformed to all MOA and HAA guidelines in effect on the date of this inspecti n
Signed ~n 1~ Date ~ ~ ~/~ ~
Company pH. ~8 MOA No.
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
" APPLIC'"NT FILLS OUT UPPER HA"'%ONLY
Realty~.&A~nt ~' ' ~' ' / .... ~e
Address ~~ Zip
Strut L~ati~ ~O. ~/~
~ Other
Water Supply
mm~lty For wefts ~ill~ pilot Io thM date, give well depth (attach I~ If available).
~ Public Utility
lndlvldl ~ Year Indlv~ual Install~:
Public ~lllty When ~t~ to Public ~tll[ty~ '
~ Holding Tank
' NOTE: THE INSPE~ION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~ESSING CAN BE INITIATED.
Time Time Time Time
'._.. Oate Date Date
Inspector Inspector Inspector Inspector
Field Notes:
i'~APPROVED BEDROOMS 'CONDITIONS OF APPROVAL
(
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
BY:
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
"7-~( W.l,,oTank Septic T,.k-~l.