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Home My WebLink AboutEAGLE PARK BLK 3 LT 8 • Municipality of Anchorage On-Site Water and Wastewater Program •(907) 343-7904 Page / of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP/ 7/ /3Z PID Number: 050 782 Z3 Dwelling?/Single/Single Family(SF) ElDuplex(0) El /Multiple (SF and/or D) Project: ❑ New Upgrade Name: ABSORPTION FIELD t`K•sf.#• f/`�C'C,J.cf F ,� Address ❑ Deep Trench El Shallow Trench ❑ Bed ❑ Mound 2 C 7f' RAN/ Q give ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade ?C3-Q !p O 7 17e GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision /1 Q �i p Block Lot Ft. Ft. �,L7 Z J /T,�- 3 R 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 Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist.between trenches From Tank Field Tank Line Ft2 Ft. Well /��J / �7 -- ( TANK Septic ❑S.T.E.P. 0 Holding 0 Other 1 ✓� toem- �Mann�uf`actturer p ��- . I Capacity Surface Water / f /� A/V e_t/aky �e I A � /ZSC Gal. ! �� /�l/ Material Number of compartments Lot Line ie) (4- / f."-- — -- Z NA c5 TEE-C-- � LIFT STATION � /Foundation /Q f /G - r Manufacturer Capacity Curtain Drain vNft .1AJC., — I- Gal. Remarks ��A/g e L�G6- �� r 7--//‘/GA / Pump on level at Pump off level at High water alarm at R C4 S ,4/ 0 ! (--/A/E in. in. in. d JV6----f?— Pump make and model Electrical Inspections performed by Installer PIPE MATERIAL House to tank Tank to � 1 � // .3 dreinfield d Sas y N 4-f V (7Q A S , Drainfield ]°" CO/MT D3014 Inspector � I p /Y d r 'AZ G N , BENCH MARK (Assumed elevation) /6j O ft Inspection 1° b r3 T 2^° }�3�r 7 Location and description dates: r/ /� f _ 3'd 6p / (7 4'h f/ Q P .lJ.� c_ COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stargp; - . CIF Ar 4t!.. Conditional Approval: Date �'•••� ` Approved ,�' Date_6 '2-3-17 LSS•`'4� , �,,.--a s Inspection Report_9-1-12.doc AS—BUILT MEASUREMENTS A B ST1 41 17 ST2 48 24 DCO 52 27 P 4'`71- / h7V/ Pw DCO . —2 t31 Existing Trench 43 _CO ' Location Existing MT/CD • (Surip) 100 ° 20� utility Easement — ��+°F '� EAGLE PARK 1' = 50' NORTHRIIV! #'�49 RECORD ENGINEERING BLOCK 3 LOT 8 PO Bax 770724 -: ,rte LAYOUT Eagle River. Alaska 99577 �`- • J WASTEWATER UPGRADE i 907.694. 7028 �` ��,�� REPLACE SEPTIC TANK 6/17/17 12 of 3 Foundation Cleanout Elevation @ 91' 7 Tank Cleanouts Elevation @ 87' Fin ^amide Opposing Cleanouts Between Septic Tank & Trench _.71 4 Foot Cover or Equal ,—Elevation @ 86.5' "" ---� i To Trench 1250 Gallon Steel levation @ 88' 'Anchorage Tank' Ele ion @ 86.3' lid Pipe Matched Elevations To Existing FCEI & Line NORTHRIM4sm* SEPTIC TANK RECORD EAGLE PARK ENGINEERING , Po Box „0,24 - , : t BLOCK 3 LOT 8 Eo9le River, Alaska 99577 907.694.7028 ‘1191/7 TANK REPLACEMENT 1)ate6/17/17 rwn BY: SE $Cole: 1• = 5 :3 of 3 I SE MUNICIPALITY OF ANCHORAGEt'n fit / On-Site Water&Wastewater Program \O St, �1 PO Box 196650 4700 Elmore Road 1- Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 1 http:/lwww.muni.org/onsite __� Department FNcN ORAGF' On-Site Wastewater Disposal System Permit Permit Number: OSP171132 Effective Date: 6/13/2017 Work Type: SepticTank Upgrade Expiration Date: 6/13/2018 Tax Code Number: 05078223000 I c v\k IO/ 13 Site Legal Address: EAGLE PARK BLK 3 LT 8 G:0056 Site Mailing Address: 20719 RAVEN DR, Eagle River Owner: BROWNE SUSAN G & STEFF W Lot Size in Sq Ft: 46042 Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 4 This permit is for the construction of: ❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy ❑ 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 Special Provisions: Prior to construction, the wells to the south are to be located and confirmed to be over 100' from the tank and field. Note on the Inspection Report. Received By: / Date: ‘4?-// Issued By: Lk,%' Lf / / Date: 6/13///7 MUNICIPALITY OF ANCHORAGE -AT .T----)Community Development Department , _e.-'2-1Phone: 907-343-7904 Development Services Division � Fax: 907-343-7997 On-Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 050 - 782— Z3 Property owner(s) /?0 tA4(6 Day phone t g-l-?" 707 Mailing address 2O 70 q gave r` ,d r Site address .s�,+-) R.-- Legal description (Sub'd., Block & Lot) OA--?'L./ p,47ek__ €? L cP Legal description (Township, Range & Section) Lot Size I/C#/ Q42Sq. Ft. Number of Bedrooms APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (EI all that apply) Absorption Field ❑ InitialSingle Family (SF) ;,W1 Septic Tank Upgrad \.,,, �6 ..,- �? �1> (W/wo ADU) A I k % Duplex (0) El Tank ❑ Rene a`t ri C Privy ❑ a JUN 1 2 2017 Multiple Dwellings ❑ D 3 (SF and/or D) Private Well t_ ti Water Storage 111 0168L °' THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. i -- ee- (Signature of property owner authorized agent) Permit/Rush Fees: f2lS — Waiver Fees: Date of Payment: (,—/2--41 Date of Payment: Receipt Number: 053111 D Receipt Number: Permit No. Opti 1132 Waiver No. Permit App 9-1-12.doc \RTHI M ENGINEERING SteveEng.com Eagle Park, Block 3 Lot 8 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: This is an existing 4-bedroom home. Most of the neighboring lots are developed. The current septic tank has failed- the trench still functions. These lots are near an acre and are served by the private water wells .No adverse impacts are expected from tank replacement. The easements are depicted on the lot. The slope is indicated in the area of the septic system. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. • New 2- compartment, 1250 gallon septic tank. Watertight couplings on inlet& outlet. • 5' minimum between the tank and bed. 10' to property lines. • 4' of cover or insulation is required for tank; an equivalent of 1" insulation for 1' foot soil cover. Minimum of 2' soil with insulation. Tank & solid pipe must be set on well compacted, stable soil. • 4" diameter cleanouts with airtight caps are required l' to 4' from foundation wall, prior to any 90 degree bend in 4 inch line, in each tank compartment,and two adjacent opposing cleanouts between the tank and the absorption field, not more than 10' from the tank positioned to provide cleanout access towards the tank and towards the absorption field. • All cleanouts must extend to at least ground level. • In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron. • Insulation must be placed over any pipe installed under driveways or parking areas. • Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, • Sewer Service Line is minimum 2% slope. • Septic Tank to be pumped every two years or when required. • Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal) _� OF 44. ig 1.1 Stever. W # "CP P 6245_ '`•.:'fir t .qe • • v �o ° aFP ,.�.. DESIGN NOTES: 1. Existing Trench Remains In Place. 2. Sewer Service Line minimum 2% slope. 3. Replace Septic Tank/Decommission Old Tank Per UPC. Connect New Tank To Existing Trench. 4. Lots Served by Private Water Wells. 5. No Conflicts Within 200'. Mark 100' Well Radius. Flat Slop 2 0 qt Well (- rt, R101 Flat Slope 49' 3 Bdrin E d In `' w New 1250 Gallon Septic Tank w/DCO's 4o- Decommission Old o �e eptic Tank cu ,c❑ PER UPC i \ not Slope 5.'pi-la/,V C W o.f v CIA G ✓E12 /oa ssuried Drainfield Location / —.E__ Ptarmigan Blvd -•'`t °F1 EAGLE PARK 1 = 50' NORTHRIM #�P, _,.. ' , ENGINEERING * :---- BLOCK 3 LOT 8 DESIGN Po Box 770724 • ;, t LAYOUT Eagle River, Alaska 99577 \• # WASTEWATER UPGRADE 907. 694. 7028 06REPLACE SEPTIC TANK 6/12/17 rrOf 3 Foundation Cleanout Tank Cleanouts Fin ade Opposing Cleanouts Between Septic Tank & Trench 4 Foot Cover or Equal 1250 Gallon Steel To Trench 'Anchorage Tank' Dr Equal lid Pipe Match Elevations To DESIGN NOTESExisting FCD & Line 1. Use Existing Trench, 2. Septic Tank & Solid Pipe to be Placed on Compacted, Stable Soil, Free from Boulders. 3, Sewer Service Line is Minimum 2% Slope & 3' Cover. 4. Water-Tight Couplings. 5. See Specification Sheet, 6. All Work To Conform to Municipality of Anchorage (AMC) Requirements & Specifications. 7. Decommission Old Septic Tank Per UPC. Alt • NOR THRIM �l* 49m SEPTIC TANK PR❑FILE EAGLE PARK ENGINEERING - PO Box 770724 Eogb River, Alaska 99577 BLOCK 3 L❑T 8 907.694.'028 7 TANK REPLACEMENT °ata'6/12/17rra" BY: SEI ° ' 1• = 5 I SE , \ . V 4: 0 ----------- -'-''''''''''---,.....-7,-- , 1-> ... -"- A 14 ' `te !>�/y o :' .y Gam' �• . Q w /�. ......-- ::•--Y . o 4, - /', 4 .'-- .�6 a r%Q.�'✓. may/ /P . . . .. _ PPS , fp;a,,, , aNs;- fiG� • ' . .E�% O ' * r1 •- -• • . ii.se4 1-7 . • • a — � . j !r • .. i. . • . .r\ • ;� • o M y•r e•e•••r::�T I7 9,4;?:::'!/.;:gri.„,..... ..ti:1 -4!( v-, Duane Mark Seward : t•10 37 Ii. � 4e.;r••• LS-¢91 QRJ'l� 'pO • f'rj er f /- • 4I _\�¢r 'Ta +NOje '� ��V1%.'' . . -A-7-0O- ah' Yo"Gam/ � /SO. 0D . -" 1 �iofi .zj AS+BUILT "No corners set this date SEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON TIE I hereby certify that I have performed a Mortagee's In- CORDED PLAT ARE NOT SHOWN HEREON. spection of the following described property: ate; Septic System Not Visible) Eagle Park Subd. , Lot 8, B1k. 3 e information hereon. is for the use of lending Anchorage Recording Precinct,Alaska,and that the improve- d menta situated thereon are within the property lines and do stittitioils'. showing the 'relationship of existing not overlap or•encroach on the property lying adjacent there, rutures andlatted easements 'and lot lines. to, that no improvements on property lying adjacent thereto P encroach on the premises in question and that there are no is not to be used for -positioning additional • roadways, transmission lines or other visible easements on ructures or fence lines. said property except as indicated hereon. Dated at Anchorage,Alaska29 89 , �✓r/,.6;47_5-, iP�-�T.` 7 '77 A.s. ; ./2?- this 88 nr 14 �' 688-466 ".,,,/_=-..Zo' _____ _ *%_".' 6:-.7,,:e: .st1✓, -6 SEWARD & ASSOCIATES LAND SURVEYING ~ MUNICIPALITY OF ANCHORAGE 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 D UPGRADE LEGAL DESCRIPTION LOCATION DISTANCE TO: DISTANC~ IF HOMEMADE' Inside length D,STA.CETO: w"'L~ //~ Top of tile to finish grade Length Width Type of crib Material Trench width NO. OF BEDROOMS PERMIT NO. No. of compartments Liquid depth PERMIT NO. ~/in gallons Distance between lines Depth tile PERMIT NO. Well Buitding foundation ,~lass Depth DISTANCE TO: Building foundation OTHER Driller Sewer line PIPE MATERIALS SOIL TEST RATING [ INSTALLER ' ~J / - Total ef fecti~e absor Septic tank PERM,T No.~.l~ Absorption area(sD APPROVED 724313 (Rev. 3/78) DATE LEGAL ! . ,~ r~IUhlICTpRLITY OF ANCHORAGE ~;~0 ~ ~ /DEPART~IENT ~ HEALTH AN~ ENVIRONMENTAL ~OTECTION ~ ~ 825 '~ ~TREET~ ANCHORAGE, A~. ~LJl ~ * '~ ' 264-472~ PERMIT HO. ( 81e184 ) *APPLICANT SYD~EY A. HUFF~RGLE POST OFFICE BOX 182 LOCATION RAVEN STREET LEGAL L 8 B ~ EAGLE PARK ~UBDIVISION LOT SIZE 435C~ SQUARE ~ET T~PE OF ~OIL 8BSORPTION ~TEM I~: TRENCH THE RE~UIRE~ ~I~E OF THE SOIL ABSORPTION SYSTEM I~: THE DEPTH OF R 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 I5 THE MINIMUM DEPTH OF GRAVEL BETWEEM THE OUTFRLL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). RE~U I RED ~EPT I C TA~( 5 I ZE= 125~ GALLo~s PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIOMS OF ANY i. IELLS ADJACENT TO THIS PROPERTY AND THE .. NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. TtWO (2) I r~PECT I 0~5 ARE REQU I RED BACKFILLING OF R~Y 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 .~ 100 FEET FOR R PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC ~ELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM R PRIVATE WELL TO R PRIVRTE SEWER LINE IS 25 FEET AND TO R COMMUNITY SEHER LINE I5 75 FEET. ', WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT ~ITHIH ~0 DAY~ OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICRTION~ AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTRLLRTIOM. PERrl~T E×P~RE$ DECEMBER I CERTIFY THAT l: I R~I FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I ~IILL IHSTRLL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEt4ER SYSTEM MAY REQUIRE EMLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED:_. ,~ APPLICANT SYDNEY A. HUFFNRGLE ISSUED BY ........ V4. 0 AMUNI~IPALITY OF ANCHORAGE~ · , Department( i Health and Environmenta2 ,rotection .. 825 ~ Street, Anchorage, AK. ~9501 264-4720 · * * HANDWRITTEN PERMIT * # · ~/~L~;ND_/OR ON-SIT~ !EWER PERMIT Locatzon, ~,/~.~ ~. Phone Number, T~e of Soil ~sorption System Is: Trench: ~rainfield: Seepage Bed~ __ Holding Tank: The Re~i~ed Size of the Soil ~sorption System Is: · DEPTH /~ LENGTH ~ . GRAVEL DEPTH ~ WIDTH The length d~ension is the length(in feet) of the trench or drainfield. The deDth of a 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 m~ depth of gravel between the outfall pipe and the bottom of the excavation(in feet). · * REQUIRED SEPTIC(HO~ING) TANK SIZE = ~ GALLONS Pe~it applicant has the responsibility to info~ this department during the installation inspections of any wells adjacent to this property and the n~er of residences that the well will serve. ·" ~ TWO(2) INSPECTIONS ARE REQUIRED Backfilling of any system without final inspection.and approval by this depar~ent will be subject to prosecution. Min~ distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from ~ public well depending upon the t~e of public well. Min~ dist~ce from a private well to a private sewer line is 25 feet and to a co~uni~y sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagr~s are available to insure proper.installation. · * * PERMIT EXPIRES DECE~ER 31, 1 9 I certify that: (1) I ~ f~iliar with the requirements for on-site sewers and wells as set forth by the M~icipality of ~chorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled t0 include more~bedrooms. ~pplic~t ~ 'Date: ~ SWP/024(1/81) · O & E ENG.'~.,IEERING & DEVELO[-~/vlENT OO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Ru#all Oyster 694-2774 Performed for:. · Legal Description: 'Depth (feet) Earl EllIs SOIL LOG 688-2280 MalllngAddress:"-/---¥~- /0~-~ /-'-,4//_.,,~- /~,~--~,. /~,~:. Soil Charecterlfllct 1__ 2 3 4 5__ 6~ 8__ 9~ 10 11__ 12__ 13 14__ 15__ 16.__ " I Ground Water Encountered: Yes__No ~ If yes, what depth Proposed Installation: Seepage Pit Drain Field ~ Comments: PLOT PLAN PERC. TEST .~.~-. ,.~ /~ ~. . '/~.' ~'~/ Performed by~ "~'7"~'~-- SULLIVAN WATER WELLS ~.o.~ox~0~.c,~^~.^,^s~^~. ~,~,o,~,~.~,~ zt"~--~ ' # OWNER OF LAND ADDRESS ~ 0 LEGAL DESCRI~ION PERMIT NUMBER S1 XTIC LLVEL 01' WATER [.'[. I)RAT~ I)OV, N FI. c~ts rer Hr o,S KIND OF FORMATION: From O Fi. lo ''~ Fi.~~~J .... From .T Fi. lo g Ft. ,,~IZ;'? 4&~.~' __- From g Fi. to I~ Ft. ;~O / ~do.~ From _L,.~.~:~ F t. lo_/_~ Ft. Froml~';S" Ft. lo/~b Fi- From I~ FI. lo ~aS Fl. ~t6 HT ~t:~ From From~Ft. lo~3~ FL ~t~ ~J~: ~From ' F ~o~ ~ ~ From F~Ft. to~ Ft ~/~ From F~om~Ft. to~ Ft. ~u~'~ .~0 ~rom F~om~Ft. to ~_Ft.~Lo~ ~ From~ e,o~FL~o~et.~t~-ec ~ ¢~ ~ ~ro~ MI~L INFO~MATION: Fr,,m F! Io__,Ft. Front__Ft. lo Frmn Ft. lo__ FI. I o ~PALITY OF ANCHOllAO~ Frmn .... ~D'S. Or hr.m.t~ & From Fl. l- ENVIRONMENTAL PROI~CTION Frmq FI. to F FI. to___ Fl.. Ft. to FI. Ft. to Ft. Ft. to Ft.- Ft. tl~ Ft.. Ft. to Ft FI. to___Ft. Ft. to Ft. .FI. to Ft i '' DRILLER'S NAME /~"~'( ~"°"~ OWNER OF LAND ADDRESS ,c' ~, LEGAL DESCRIPTION ./ DATE - Started .~'/,-,/.c ! PERMIT NUMBER ~'.~ ~7=" SULLIVAN WATER WELL DEPTH OF WELL STATIC LEVEL OF WATER FT. DRAW DOWN FT. c~:~ GALS. PER HR ~ O0 KIND OF CASING (, ~ KIND OF FORMATION: From ~ ) Ft. to ,'~ From 2 Ft. to ~- From " Ft. to From ' ~ Ft. to From ) '~ Ft. to From/- ~ Ft. to From Ft. to Fr~ Ft. to_~.Ft. Fromm. Ft. to Ft. Fromm. Ft. to Ft. From Ft. to Ft. Fr~ Ft. From Ft. ion. Ft. From Ft. to_~.Ft. From Ft. to Ft.~ From Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: From -- Fl. 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. From Ft. to Ft. Fromm. Ft. to Ft. From __Ft. to Fl DRILLER'S NAME Municipality of Anchorage • On-Site Water and Wastewater Program o=.' EItIl) (907) 343-7904 S :. CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I,D.r05-1-4M T2 65-0-1V 2'5 Expiration Date: et La3 'i 7 1. GENERAL INFORMATION Complete legal description Eagle Park Block 3 Lot 8 Location (site address) 20719 Raven Dr Current Property owner(s) Browne Day phone 696-0357 Mailing address Same Real Estate Agent Laura Hamilton Day phone 696-0357 2. TYPE OF DWELLING: +: 8 0/7 ® Single Family (w/wo ADU) ti ❑ Duplex z 4 JUN1 A n.. ❑ Multiple Dwellings (Single Family and/or Duplex) e i A: 3. NUMBER OF BEDROOMS: 4 '\\,,,,,,,:z...„ lc, 68LSc' 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class C Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Received by: dalDate: I6��7 COSA to be released to the engineer, unless otherwise r uested by the engineer. COSA Fee $ 12(o Date: 215 1/- 7 Date of Payment LPf E 1 ` lI Date of Payment (o! 1 / Receipt Number O1'l 1 . Receipt Number ail l c b COSA# 05C-4112-111 Waiver# O 'V 1 [05-Li 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. Name of Firm NorthRim Engineering Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date _6/19401 4'� q f . 6. DSD SIGNATUREA. + 2C System #1 Approved for l,( bedrooms. r ...,-,...v SystemSystem #2 Approved for bedrooms. /4?7/.7-''<> Disapproved. t•,•c'�Sly •� Conditional approval for bedrooms, with the following stipulations: \fi \, ' UI-Aly. sON-SITE .UP WAr BRAND rn. ` WASTEWATER z: RROGRAm L9 s Bye----� • tin,,. .- .4 Original Certificate Date: C —2 3` 17 The Municipality of Anchorage Devlopment 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 blue sheet 9.1-12.doc AT If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Cerrtfficate of On S tc Systems A pprovaD CheckH si: Legal Description: �/�('Lrr /i41 I'C 53 L- ? Parcel I D:d 5f / //2 A. WELL DATA Well type P If A, B, or C provide PWSID# Well Log (YIN) Y Date completed ///f Sanitary seal (Y/N) Wires properly protected (Y/N) yTotal depth 33L[ ft. Cased to 33 y ft. y Casing height (above ground) in, FROM WELL LOG AT INSPECTION Date of test ///OP ( 5/2.5// 7 Static water level Zi.{3 ft. 2 .( ft. Well production g.p.m. / f g.p.m. WATER SAMPLE RESULTS: �/ Coliform colonies/100 mL Nitrate /Cc 8 mg/L Arsenic 51 53 ug/L Date of sample: £7'zS// 7 Collected by: NZ B. SEPTIC/HOLDING TANK DATA Tank Type/Material SZ-44:77C- / ST�fL. Date installed c-/13//7 Tank size/2 56 gal. Number of Compartments 2- Cleanouts (Y/N) Foundation cleanout (Y/N) y Depression over tank (Y/N) Al High water alarm (YIN) /v Date of pumping /ti—Gt.) Pumper C. ABSORPTION FIELD DATA Deep Date installed 7/4/1/ Soil rating (g.p.d./ft2 or ft2`rm) /2-C System type Tr c_4. Length / 7 ft. Width 2• 5 ft. Gravel below pipe IC ft. Total depth 1.cft. Eff. absorption area 5-01 ft2 Monitoring tube y Depression over field// Date of adequacy test s/Zs1( 7 Results (Pass/Fail) P For L/ bedrooms Fluid depth in absorption field before test D in. Water added CG C gal. New depth 6' in. Elapsed Time: 3 G min. Final fluid depth O in., / Absorption rate >= 660 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N &type) UN If yes, give date 'A D. LIFT STATION A/4 Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at _ in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm &circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot /iQ On adjacent lots /do- 4- Absorption 4-Absorption field on lot /foe) T _ On adjacent lots /Q& '7� Public sewer main /76 /f Public sewer manhole/cleanout 7/ 6- f Sewer/septic service line Z 5 / Holding tank /40 '174- Animal Animal containment areas 50 Manure/animal excrete storage areas MDQ SEPTIC/HOLDING TANK ON LOT TO: Building foundation /Q Property line /2:5 7f Absorption field 5 4 Water main 76 /1— Water service line /6 "� Surface water /00 i— Wells on adjacent lots /G ABSORPTION FIELD ON LOT TO: / Property line / Building foundation /d Water main `25r Water Service line .G Surface water 0 Driveway, parkin /vehicle storage 11— Curtain drain 11,4//e- Wells on adjacent lots /t d 174- F. ; -F. COMMENTS ?I' !2 t)6---cc !Arc tor 4-7/Ye l ori/V 7 G. ENGINEER'S CERTIFICATION '71. � OF At `r 1 certify that 1 have determined through field inspections and i'�p•:• ;'. 4 ) review of Municipal records that the above systems are in orgie •. * 1, J� conformance with MOA COSA guidelines in effect on this date. E 4 { Engineer's Printed Name S ( ce: (, ;';.• e; Date ,c//?/// i<` ' Steven ` . E 9 • ' I �IF$�J,•• P 625/6 . r`a� 'Qic �1itor COSA yellow sheet_2-6-15.doc /r'' Municipality of Anchorage pacnt nA^ i i Ila•partmcnl P.O. Box 196650 • 4700 Elmore Road Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997 http:/lwww.muni.org/Onsite Development Services Division On-Site Water and Wastewater Program **** VARIANCE/WAIVER REVIEW **** Waiver#: OSV171054 COSA# OSC171247 Permit#: PID#: 050-782-23 Legal Description: Eagle Park Block 3 Lot 8 Engineer: North Rim Engineering Applicant: Susan & Steff Browne Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 1.0 feet. See engineer's letter for waiver requests. This waiver approval applies to the existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. ❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected adjacent property. ® Adjacent properties are not affected by this waiver. ' Waiver is Granted: X Waiver is not Granted: Date: 6/.2 3/2a i 7 Approved by: 01107-.<7-",_ (2. x l Name of Reviewer **** VARIANCEIWAIVER REVIEW **** • • I .-6 V • • e =60 /$— / T' • C. rE/aT/C' l/QxNT ,'/.7�S Itq/ K°/ 41141/4,>6,,.....y°,-.4,4,7,- -- • ,, tl , • • 4;01 N, . 1 t• • } • rip • • i� • `ro‘„,,t ic`: • `▪ S', ` d k):•' `:)T / •;fir 11 aL.. ......7.../r . . 0., z., . . ,- 4 4., VI III 1,4:• Duane Mark Seward 4 ; LS-6918 . $ M • 20'C/T/L/7-1--- .Z'.9.SE/Y7'.z:-.4/T ,' -,`�/ryTio f/�,a//7 i . AS..BUILT No corners set this date EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE I hereby certify that I have performed a Mortagee'a lo• RECORDED PLAT ARE NOT SHOWN HEREON. spection of the following described property: (Note; Septic System Not Visible) Eagle Park Subd. , Lot 8, Elk. 3 The information hereon is for the use of lendingAnchorage Recording Precinct,Alaska,and that the Improve• menta situated thereon are within the property lines and do institutions shoving the 'relationship of existing -not overlap or encroach on the property lying adjacent there• strutures andplatted easements and lot lines. to. that no improvements on property lying adjacent thereto encroach on the premises in question and that there are nc It is not to be used for positioning additional roadways, transmission lines or other visible easements on structures or fencelines. said property except as indicated hereon. Datedt Anchorage,Alaska a29 Jan. 1989 '''''''''-'77-/ -. this day of �';�"� ��e..Pr 7,-/-'6'773. .-'--2:-)- s7' 688-4566 ",-.743 SEWARD & ASSOCIATES LAND SURVEYING , I\ICRTI- 1 [V. ENGINEERING SteveEng.com Steve Eng, PE, PH (907) 694-7028 SteveEngPE@gmail.com Date: 6/17/17 Number of Pages: To: MOA On-Site Services Subject: Eagle Park Block 3 Lot 8 Lot Line Waiver Request & COSA During a COSA inspection it was discovered that the septic tank required replacement. A question arose as to the location of the deep trench. We investigated the trench location: • During septic tank construction,the end of the trench perforated pipe was exposed. The direction of the perforated pipe was directly to the existing MT/CO Sump. This direction coincided exactly with the reported distance of 25' in the 7/10/81 inspection report. The trench location was spray-painted on the ground surface. • The MT/CO Sump was also inspected. A direction for the perforated pipe from this Sump could be determined from the Cleanout. This perforated pipe direction was laid out & marked on the ground surface with spray paint.The trench end lies within 3'of the property line. • The trench could not extend east of the Sump, due to a cut-bank in that direction. There is no indication from the Sump that the Trench extends to the east. We request a lot line waiver to 1', for the existing deep trench that has been in use since 7/10/81. The location is noted on the attached Record Drawing. If there is need for additional information or clarification please give me a call. Thanks-Ste �..oe11l min1 ti 4rkrow CO err; . 74,17eip t4 c,Jo .• Steve • 4 .,AV 7 Lof • zi .,• � P� 6256 .�V • 4 • kik OFESS�a��..4" MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Divlslon of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 8: Block 3; Eagle Park Subdivision Location (site address or directions) 20719 Raven Drive Eagle River, AK 99577 Property owner Mailing address Patricia and Linwood Wentworth Day phone .20719 Raven Drive Eagle River, AK 99577 696-1219 Lending agency Mailing address Day phone Agent Barbara Crittenden/JACK WHITE CO. E.R. Day phone 11823 Old Glenn Hwy. Eagle River, AK 99577 Address 694-55O0 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 '~ TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: 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 inves.ti.,qation 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. Phone .~'Z/.-~'.~.~ ~' DHHS SIGNATURE .~ Approved for /'~-"- Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date 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. E. mployees 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 A. Well Data Log present(~N) ~ Total depth "5"5 ~ ~ Sanitary seal ~N) Date completed ~\ ~-~ Driller ~,O~..,,~,,1 .~ Cased to ~"~ ~- ' Casing height \ ?--~\ ~'-' Wires properly protected (~N) ~ Date of test Static water level well flow Pump level1 FROM WELL LOG AT INSPECTION "'G [D. CS) g.p.m. L~,. o4''' .g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot toc:, Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manholelcleanout .Petroleum tank WATER SAM PLE RESULTS: Date of sample: ~ -' ~ -'°t'~ Nitrate O. t ~3 Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed "J -~,o .- ~ \ .Tank size Foundation cleanout(~N) Cleanouts ~N) High water alan'n Date of pumping V2..'5-~ Compartments · '7__ ~/ Depression (~ Alarm tested (Y/N) Pumper ~-~. ~-,-~, ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: .... , .~ . . ~ Well(s) on lot ~ (Dq~ ~ To property line \ o t -t--- Sur/ace water/drainage On adjacent lots Absorption field ~" Foundation Water main/service line CONTINUED ON BACK PAGE C. UFT STATION Dale Installed Size in gallons Vent (Y/N) - 'Pump on" level at High water aJarm level ~ed Meets MOA ek~ctrical codes (Y/N) ~ SEP~LIFT sTATION TO: We'ffon lot ' ' '- On adj~ent lots D. ABSORPTION FIELD DATA Datelnstalled ~1 ~\o - Total 'at~sorption area ~" ~ clean°ut present (~N) Date of adequacy test ~ ~i~ ~ct'z> Results (pass/faa) 'Water level In absorplion field before test (~ Per(~xEle treatment (past 12 months) ('~ .Manufacturer Manhole/Access (Y/N) .Surface water. Soil rating (GPD/Ft~) t ~- System type 'T-~._~.~,.~ ~od~ Gravel thicl~ess (~,~ ' Total depth ~.~ Depression over field (Y~) ~..~ for ~1- Bedrooms Nler test ~ c, ,~._ V---~ = ~ If yes, give dale ~(~. SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot . To building foundation On adjacent lots Surface water Curtain drain On adjacent lots ~ [:::)~;~ ~ ~' Property line ~"b. ~ ~ .To existing or abandoned system on lot Cutbank ~\ p, Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I cerff[y that I have checked, ved~jeOTior conformed to all MOA and HAA guidelines in effecton"~,~d~e~! th~S~ ~nspec~on. HAA Fee $ / 70. r/Z) Waiver Fee $ Date of Payment 7 ~ ~'~ ~ Dale of Payment ReceiplNumber ~-~3 (/~,,~/' ) . Receipt Number 72-e2s (3~31. Back 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 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, se.,~Jp, range) ., -- · Location (address or direc~ons) (c) Applicant is (check one): Lending Institution D; Owner/builder r~; Buyer r'l; Other~(explain); ~ (d) (e) Real Estate Company and Agent Telephone (~-~the HAA~'o the following address: TYPE OF RESIDENCE Singlo-Familyy Multi-Family,![] Number of Bedrooms Other WATER SUPPLY Individual Well ~ Community I-I Public l-I Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite~ Publicr'l CommunityD Holding TankD ,- Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed heret(~'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 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 Address Date Telephone 6. DHEP APPROVAL · Approved for ~ bedrooms by Approved ~' Disapproved Terms of Conditional Approval ~z~..~_~_Dat e Conditional 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 before 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 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST o FEBRUARY 1984 264-4720 DEPT. OF HEAt.TH ENVIRONMENTAL PROT~ r, lllI 5 WELL DATA Well Classification ~=' 'lC:' If A, B, C, D.E.C. Approved (Y/N) Well Log Present~)~N) Date Completed ~:~ ~;' '~ ~' ~ Total Depth (z~ ~ ~ Cased to ,~t,<:>¢ -t- Depth of Grouting Static Water Level Z~.l ' Casing Height Above Ground Electrical Wiring in Conduit ~N) Separation Distances from Well: Yield Pump Set At Sanitary Seal on Casing ~'~1) Depression Around Wellhead (Y~) To Septic/f.l~Tank on Lot ~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line t-3//~' CleanouVManhole ~.o f/~. ; On Adjoining Lots t ~ E~)~ ~ ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results ~'~ Comments ~ ~,,.,.~ ..~.~.,-.~ F'"~ ~.-c,~,,,,~ --[-~:;:~"3- ,-~,~ B. SEPTIC/~.te~z~ff~G TANK DATA Datelnstalled q"t(-.'~-~l Size Standpipes~N) Air-tight Caps(~N) FOU t~,~.~ion~ To Water-Supply Well To Property Line To Water Ma~'w~Service Line Course Depression over Tank (Y~ Pumping/Maintenance Contract on File (Y/N)~3 Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/,I,4e~ Tank: Date Last Pumped ' '~' ~ , for Temporary Holding Tank Permit (Y/N) To Building Foundation ~' To Disposal Field '~ 1'4' To Stream. Pond, Lake, or Major Drainage Comments Page I of 2 ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~, '~-.-.~' "=~ I~,,'~- Type of System Design Date Installed .... ~ - J ~ ~ ~ ~ Length of Field Z~.'"~ Width of Field -~;:) qw--_ Square Feet of Absorption Area Depression over Field (Yin) Date of Last Adequacy Test Results of Last Adequacy Test ~ ~:-~ ~,~ ~ Separation Dislance from Abso~'ption Field: Depth of Field Gravel Bed Thickness Standpipes Present.N) To Property Line ~ C::?'~'' To Existing or Abandoned System on ; On Adjoining Lots ~ I To Ct~tbank (if present) To Water-Supply Well ' ~ ~ ~ ~ To Building Foundation ' ~:~ ~ ~ Lot - ~/~ To Water Ma~/Service Line ~ ~::>~ ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Instalred .... Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical C(~d~s (Y/N) Dimensions Manhole/Access (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 certi[y that I have checked, verified, or conformed to all I~A~d HAA guidelines in effect on the date of this inspection. Signed a .~ ? I~,~EEe~,.,~ Date Receipt No. : ...... · ,~{t ~1~ -. Date of Payment Amount: $ Page 2 of 2 i DATE RECEIVED ~MUNIClPALITY OF AIqCHORAG~ MUNICIPALITY OF ANCHORAGE DEPT. OF H'2ALIH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PflOTEC~JlRONMENTAL p~OT~Ci'ION 825 L Street * Anchorage, Alaska 99503 ENV,RONME.TALSA.,TAT,O"D'V'S'O" ^Ut28'/ Telephone 264-4720 DECEI~IEFI REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~l~,ll:'~ DIRECTIONS: Complete all parts o~t page 1. Incomplete ;aqua,ts will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE MAI!~I~G'~DDRfESS ...... PROPERT~ RESIDENT Jif different J~ol~above) · PHONE 2. BUYER PHONE T;~. F~l-vc MAILII~G At')DRESS ' 3, LENDING INSTITUTION I/NONE P.o. J~,~.. Io~., 4. REALTOR/AGENT -~ ' I , -~ PHONE MAILING ADDRESS E. LEGAL DESCRIPTION I L,.,~ ~o )?/K J STR[-ET LOCATION tYPE oF RES,DE.CE '~ SINGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY "{~.~ IN DIVI DUAL' COMMUNITY [] PUBLIC UTILITY NUMBER OF~BEDROOMS [] One ~ Four [] Other [] Two I--I Five ./ [] Three D ~ix ATTACH WELL LOG. A well log is req'dired 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 ~ INDIVIDUAL/ON-SITE" / ~'J YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) o : THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE - ~ NUMBER OF BEDROOMS [:~SINGLE FAMILY I-'1 ONE [] THREE r-I FIVE r-I OTHER [] MULTIPLE FAMILY ,- i--I T~/O {:[~""FOUR [] SIX PERMIT NUMBER 2. W2ER SUPPLY {::::] INDIVIDUAL DEPTH OF WELL ~_~ .,~ · [] COMMUNITY DATE DRILLED [] PUBLIC UTI LITY Connection V~rified LOG RECEtVED NWAGE DISPOSAL SYSTEM PERMIT NUMBER DIVIDUAL/ON -sITE DATE INSTALLED I-'IPUBLIC UTILITY Connection Verified INSTALLER [~"~ptic Tank or I-'lHolding Tank Size: /3'~,-~¢2 *if Tank is homemade SOILS RATING . . / glve dimen$;on$: TYPE OF TANK ' MANUFACTURER ~ . - TOTAL ABSORPTION AREA 4. DISTANCESwELL TO: Septic/Holding Tank IA~sorption Area Sewer Line I Nearest Lot Line I I Absorption Area to nearest Lot Line 5. COMMENTS BEDROOMS [] CONDITIONAL APPROVAL {letter must accompany certificate} [] DISAPPROVED, , ' , 72-010 (Rev. 6/79)