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Home My WebLink AboutT12N R3W SEC 15 LT 130TI R3W · 15 Lot 130 #015-482-14 Municipality of Anchorage Page I o! '~' 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 F~ ~, ~ Wastewater System: D New. D Upgrade . ~o. ol8~rooms ~DeepTfench D Shallow Trench DBed DMound DOther WELL: E~T D New a Upgrade Gravelwidlh: SEPARATION DISTANCES ~sep~ic a Holding 0 S.T.E.P. Sudace I Remarks: ~I~ ,~/~/g~ ~,~ BENCH MARK v ENGINEER'S SEAL Inspections performed by:. FI~F~.Tec4 Department o[ Health and Human Services approval ': ~' ' -- I PERMIT NO: SWOOOO88 I PID NO: 015-482-14 SVV~NG TIES: FROM: COR."A" COR."B" TO: S,T. C.O. "C" 25.5' 36.5' S.T.C.O. "D" 24' 41.5' DBL C.O. "E" 19.5' 43' VALVE "F" 24' 42' DBL C.O. "G" 28' 46' TR. C.O. "H" 53' 67' TI~ M.T. 'T' 56.5' 50' TI~ C.O. "J" 7t.5' 49' R 100' WELL NEW 1000 GALLON SEPTIC TANK.....' PAGE 2 OF 2 ORIGINAL W. 6.1' SEWER GVL. BELOW PIPE , T.H. T.H. ', #2 #1 PLAN VIEW SCALE: 1" = 30' ~ INS. 2' SOIL COVER ~ 96.2 'SEPTIC TANK,, \INV ELEV. 78.5' (DRY) 2.0' SOIL COVER 94.1' ,, , , 94.1' 60' LoNG SOlLABs. TRENCH W. 6.1' GVL. BELOW PIPE ' ' ~'~- BOIl'OM EXCAVATION ELEV. 88.0'--~ PROFILE VIEW NOT TO SCALE LOT 130, SEC. 15, TI2N, R3W, S.M. SEPTIC SYSTEM UPGRADE AS-BUILT INSPECTION REPORT FLATrOP TECHNICAL SERVICES 14~30 ECIIO STREET Al,ICl lOP, AGE, ALASKA 99516 SCALE: AS NOTED DRAWN BY TFM OCTOBER, 2000 MUNICIPALITY OF ANCHORAGE Department of Health end Human Services On-Site Services Program 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: May 04, 2000 Expiration Date: May 04, 2001 Permit Number: SW000088 Legal Description: T12N R3W SEC 15 LT 130 Design Engineer: 0019 Flattop Technical Services Owner Name: Pamela A. Barbeau Owner Address: 4311 E. 104th Ave. Anchorage, AK 99516-6310 Parcel ID: 015-482-14 Site Address: 004311 104TH AVE E Lot Size: 46200 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 ( 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: ~Se'-/ ~{0~ Oate:y-¢ -00 CIVIL & ENVIRONMENTAL ENGE'dEERLNG · ENERGY CONSERVATION & ANALYS~ THEODORE F. MOORE, P.E. .14530 ECHO ST. PH: (90?) 345.1355 ANCHORAGE, ALASKA 995t6 September 27, 1999 M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: The purpose of this letter is to provide the required design narrative in support of our application for a permit to upgrade the wastewater disposal facilities on BLM Lot 130, Section 15, TI2N, R3W, S.M., located at 4311 East 104th Avenue. The original soil absorption system is no longer able to accept the wastewater load generated in the residence. Soils logs, perc test results, a site plan, design drawings and specifications are enclosed for your review. The proposed system will be constructed in the vicinity oftest hole 2. As can be seen fi.om the soil log, the native material between 1.5 and 4.5 feet below ground level is a gravelly silty sand with a measured percolation rate of 12 minutes per inch. The native material below that depth is a sandy silt with a measured percolation rate of 44 minutes per inch. The design loading rate from a three-bedroom residence is 450 gallons per day. Using the soil application rates specified in the wastewater ordinance the upper stratum can accept 0.8 gpd/sq, ft. and the lower stratum can accept 0.45-gpd/sq. ft. For the proposed trench with effective 6-foot sidewalls extending from 1.5 to 7.5 feet below ground level the combined wastewater acceptance rate per foot of trench is (3 x 0.8 x 2) + (3 x 0.45 x 2) = 7.5 gpdA.f. The proposed 60-foot long trench has a total acceptance rate of(60 x 7.5) = 450 gallons per day. The topography of'the lot in the area ofthe proposed trench construction slopes downward towards the south at approximately 8%. 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 ifyou have any questions on this submittal. Sincerely, Ted Moore, P.E. · LOT 125 ,' , , , ";,,~, WELL · ,' ~o~=s ' "LOT 130 .......... R ~00' ', ' ' ~EPTIC ' ~WELL ', [ SYSTEM ". ' ~,' ~TRENCH LOT 131 THIS END OF LOT ', / CONSTRUCT ~ LONG ', ~ SOIL ABSORPTION TRENCH .. , WITH 6' G~. BE~EEN . ' 1.5' & 7.5' ~ELOW GND. L~L '....'; ', ROADWAY & PUBLIC UTILI~ ~SEMENT ~ST 104~ A~NUE LOT 1, FINLEY S~ LOT 130, SEC. 15, TI2N, R3W, S.M. o WELL AND SEPTIC SYSTEM SEPTIC SITE P~N SYSTEM ~OP ~C~C~ SEDUCES 1 INCH = 50 FEET 14:530 ECHO S~ET DRAWN BY TFM ~CHO~G[.~S~ ~]6 SEPTEMBER, 1999 NOTE: THIS IS NOT A SURVEYED P~T. ALL LOCATIONS SHOWN ARE APPROXIMATE. ~ DOUBLE C.O.-~ //~ ~.~ TO ORIGINAL TRENCH WASTE LINE ~ . . M HOUSE ~X~ ~ / ~ BULL RUN FRO ~,~) (~=~ DIVERS,ON VALVE NE~V 1000 GAL ,, ~ ~ ~ ~ ~ 4 DI~ ASTM D-3034 SEPTIC TANK ~'~ NON-PERF. PIPE NEW 60-FOOT LONG SOIL ABS. TRENCH 'A ' r~ j .4- DI~ ASTM F-810 W. 6.0 FEET GRAVEL BELOW DIST. p-~_-: .-~.? ! .i//'..[~':: .~;~ PERF. PIPE ~ .......................... :=::oI, PLAN VIEW SCALE: t" = 10' CLEANOUT MONITOR TUBE MOUND BACKFILL 1.25 FEET ORIGINAL GROUND BOSOM OF ~CAVATION X-SECTION "A - A" SCALE: 1" = 5' LOT 130, SECTION 15, TI2N, R3W, S.M. SEPTIC SYSTEM UPGRADE PLAN AND CROSS-SECTION FLATTOP TECH]~qCAL SERVICES 14530 ECltO STREET ANC!IORAGE, AK, 99516 SCALE: AS S11OWN DR~WN' BY: TFM SEPTEM]BER, 1999 TEST HOLE FLATTOP TECHNICAL SERVICES 14530 ECHO ST. ANCHORAGE, ALASKA 99516 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: BLM Lot 130 Sec~on 16. T12N. R3W S M DATE PERFORMED: Juh/15. 1999 PERFORMED FOR:.~p_azg_~arb~u DEPTH~ (feet) P[ andloam SM Sandy, gravelly loam ML Sandy silt Damp, dense MI/GM Sandy silt Dry, softer lflan overtying ML Pockets or rocks end gravel 6' - 8' SLOPE 8% ML Sandy silt Dry, dense Harder digging 17 BH. 18- 19- 20- Depth to Groundwater Date ..Nq groundwa[~r 7/15/gg Momtor tube dry 7~2/99 O% Clock Net Time Percometer Net Drop Date Reading Time (minutes) Reading (inches) 7115 12" Presoak O 7/22 1Z' Resoak Start 3:06 25 11116 #1 3:36 30 25 11116 #2 4:06 30 24 3/16 13116 #3 4:36 ~g 23--~/~6 j 718 PERCOLATION RATE 44 (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN 8.5 FT AND 90 FT COMMENTS: PERFORMED BY FLATTOP TECHNICAL SERVICES. I ~.~/~.~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~ / 3. Z./,~,9 TEST HOLE LEGAL DESCRIPTION: DATE PERFORMED: PERFORMED FOR: FLATTOP TECHNICAL SERVICES 14530 ECHO ST. ANCHORAGE, ALASKA 99516 SOILS LOG - PERCOLATION TEST BLM Lot 130 Se~en 15 TI2N R3W. S.M July 15. 1999 Para Barbeau DEPTH (feet) 13- '14- 15- 16- 17 18- 19- 20- COMMENTS: Pt SM Reddish silty loam SM Gravelly, siltysand Loose. dry ML Dry sandy silt Similar to stratum perc'ed in TH #1 SLOPE J8% SITE PLAN \ RENC H 111 I ....... ....... Depth to Groundwater Date _bl.0_groundwat er 7115LgL Monrtor tube dry 7/22/99 0% Date Reading Clock Net Time Percometer Net Drop Time (minutes) Reading (inches) 7115 12" Presoak I 7/2~ , 12" Resoi).k 5 ~ Add water & start :~L03 10 1/4 #1 3L33 30 12 314 2 1/2 Add water 3:34 10 114 #2 4:04 30 13 2 3/4 Add water 4:04:45 10 118 #3 4:~:-~5 30 1:~ 2 718 I PERCOLATION RATE 12 (rninutes.qnch) PERC HOLE DIAMETER TEST RUN BETWEEN 2.5 FTAND 3.0 FT Monitor tube remained dry despite heavy rain durinq past week with test hole only partial/~/y backfilled. aII PERFORMED BY FLATi'OP TECHNICAL SERVICES. I ,~/'...g.~"~ '/] ~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: September 22, 1999 3.0 Soil absorption system: 3.1 The soil absorption system shall be constructed by excavating a 60-foot long trench to a depth of 7.5 feet below original ground level in the location shown on the site plan. The long axis ofthe trench shall parallel an existing contour of the land. 3.2 The bottom ofthe excavation shall be level. Any compacted or smeared surfaces shall be raked to allow proper infiltration. Sand for leveling or serving as filter material shall comply with Municipal specifications. 3.3 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 of the sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing the #200 sieve. 3.4 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. 3.5 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. Ifthe 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. 3.6 The top surface ofthe cover material shall be raised a minimum of 15 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. The area around the trench shall be graded to direct runoff away from the trench. 3.7 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. 4.0 Inspections: 4.1 Aminimum of 4 engineering inspections will be required during the course ofthe project: (1) initial stakeout with the contractor to establish the location of the system and to discuss the plans, specifications and construction procedures, (2) at, er 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. The septic tank requires one inspection after it is set level and the piping connected, but prior to backfill. This inspection may be incorporated with any ofthe above inspections. 4.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in advance to ensure the availability of the engineer. Flattop Technical Services 14530 Echo Street, Anchorage, AK 99516 Phone (907) 345-1355 BLM Lot 130, Section 15, TI2N, R3W, S.M. 4311 East 104th Avenue Wastewater disposal system installation Specifications 1.0 General: 1.1 The scope ofthe project consistsofreplacement oran existing 1000-gallon septic tank with a new one and construction ora new 60-foot long soil absorption trench with 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. i.4 The contractor shall provide adequate cover material and rough grading over all system components to ensure that proper drainage is achieved a~er 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 of topsoil and reseeding all areas disturbed by the construction. 2.0 Septic Tank: 2.1 The existing septic tank may be retained in service, only if it's structural integrity has been verified by the inspecting engineer, and if it has functional cleanout pipes with airtight caps, allowing pumping access to each compartment. Any existing septic tank or seepage pit which is not retained in service must be properly abandoned by thoroughly pumping, removing the top and backfilling with soil. 2.2 The new 1000 gallon, 2 compartment septic tank shall be Municipally approved and shall be set level on undisturbed soil. Each compartment shall be equipped with a watertight manhole cover and a 4" cleanout. Ifthe tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial type, rigid insulation. 2.3 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The waste line from the residence to the septic tank shall have a minimum slope of 1/4"' per foot, and the waste line between the tank and the soil absorption system shall have a minimum slope of !/8" per foot, A cleanout shall be installed within 5 feet of the building foundation, and a double cleanout shall be installed within 5 feet downstream of the septic tank. A "Bull Run" diverter valve shall be installed downstream of the double cleanout allowing future reconnection to the original trench, if desired. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEAl. TH 8z ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 'Felephorm 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT MAILING ADDRESS f) ~ f .)~ ~ell J IF HOMEMADE: Inside length Well DISTANCE TO: Dwelling Width DISTANCE TO: No. of Ib~ Top of tile to finish grade Type of crib Width Crib diameter Crib depth Well Building foundation DISTANCE TO: Class Depth Drillel NO. OF BEDROOMS No, of e~ mpartment~ Liquid dopth ITotal effective absorption Nearest lot Distance to Jot line Septic tan PERMIT NO. Liquid capacity in gallons PERM,T els [a nc~w/~ ?es -- ,ot~T~e~sorl)tion area PERMIT NO. PERMIT NO. DISTANCE TO: 13uilding foundation Sewer line Absorption area(s) OTFIER PIPE MATERIALS SOIL TEST R ATIND INSTALLER REMARKS APPROVED ~ /~ /" //.- DATE ?~013 (Rev. 3118~ -- LEG L PEF?.MIT NO. FIF'PL I CFINf LOCFFr' I Obi LEGFIL bL I ................. STE'v'E RMS"I"RLIp -I. 4 _ -IE, U:, 1 hiE:,::, F:'K.__ U., fl · LL.E r [:'EI4¢~RT LOTt]:O ~5±ST:L2NR31.q LO-I' SIZE 40000 S6!LII::IRE[ FEET 'I"¥PE[ OF' SCIII_ FflE~SCII:[:F:'q"ION SYSTEM IS: YRENCH HR>::II"IUM NUMBER OF BE[:,ROEIMS .--= ;3: SOIL RR'f'ING ,::S.6-.! F]",-"E:R)= ±50 THE t,?EQU:[F?.E[:, SIZE OF THE :E;OIL RBSORPTION S"r'STEM I!5: THE LENGTH [;,Ih'IENSION I:.~; THE: LIZNG'FH (IN FEET;' OF THE TI;'.ENE:H OR [:,RF~INF;'IEL[:,. THE DEPTH OF FI TF:E'.'hlCH 0[4: F'IT IS THE [:,ISTRNC[:.' BE-f'HEEN TFIE SIJRFFICE Eft: 'rile GROI_IND FIND THE BOTTOM OF' ]"HE EXCFIVRTION ,::IN FEET). TlflERE IS NO SET 1.4IDTH FOR TRENCHES. THE GRIq'v'EI._. DEPTH IS THE HINIt,'IUM [':,EF'TH OF GRFtVEL BETklEEN THE OLITI='I::t[J... PIPE FIt.,ID THE BOTTOH OF THE EXC:FI'v'RTION ,:; IN FEET;,. F'I.ZRHI T FiF.~F'LICFINT HFIS THE REL:;F'ONS I[3 IL I"F'¢ -FO INFEIRt,'I THIS [:~EF'FIRTMENT I>I_IRING THE I NSTRLLFI]"ION J:t-,ISSF'E):]:]-IEtN'.:~; ElF RN'¢ I.,IELLS R[.',JlaCENT TO THI!.:'; PROF'ER]"¢ FIN[':, THE NLIHBEF: OF RESIDENE:ES ]'HFIT THE 1.4ELL. klILL SER',,,'E. E:FIE:KF;[L.L. ING OF' FIN"r' L:;'¢STEM NI-f'HOUT FI NFIt_ INSPECTI ON RN[:' FIPPF?.OVf:IL. E:',r' 'THIS DEF'Fff~'.THENT HILL BE SUB.]'ECT TO PROSEL~:U]"ION. I"IlIqIMUH D I~'3'f'FINCE BETI.,IEEN R NELL. Fii',lD FIN"r' ON'-''''''''ITE [SEI.,IFIGE D ISF'OSIqL '3'¢STEM IS ±OO FEET FOR FI PF:i',,"RTE HELL OR ±50 TO 200 FEET FROM R F'UE~LIL: 1.4EL.L DEPEN[.:,:[NG UPON THE "rYF'E OF I::'UE',LZC HELL. HINIMIJh'I DISTFINCE IrzROH FI F'RI'v'FCFE NELL ]"O R PRI'v'FITE SEFIER LINE IS 25 FEET RND TO FI E:OHHIJNIT"t SEI.4ER LINE 1;'.:5, 75 FEET. I,.IELL LOGS RRE REC..!UIF'::E[:' RND MUST BE RETLIRNEC, TO THE B, EF'FIRTMENT 1.4I-Ft~IIN 30 DFIh"S OF: -I'HE 14ELL COMF'LIETION. O'FHER REg!UIREMENTS t'IFI'¢ RPF'L."r'. SF'ECIFIC:RTIONS RN[:' CONSTt',:'.'LIC-I"ION DIFtGRI::tHE; RF'.E I::t',,,'R I L.I::IE~LE -ro INSURE F'ROF'EF'. I NSTFIL.I_RT I ON. I F:ORTH [-'?¢ THE HUN ICIF:'FILIT"r' OF F]NCHORFI(.~E. 2: I NILL II",ISTFILL THE S'¢F';TEH IN FdCCOR[:,FINCE HITH THE CEd)ES. _"i~: I IJN[)ERSTFIN[:, TI-IFFF THE ON'"'S'ITE SEHEF'. Sh"STEH HFI"? F'.E6:!UIF4'.E RES, I[>ENCE IS RE:MOI:>ELED-FO It,ICLU[:'E i',lOr~'.E TFIiqt.4 2: E:E[:,I4:OOMS. --:-C?/ .~"' FIPI::'L:~ CFINT STE'v.~' FII"E:iTRUP ISSUE[:, '::'~,~. ~-.~,~:: CEF:TIF¥ THFI-I~ I FIH F'FII"II[._IF~R HITH THE REL.qUIREHENTS FOR ON-SITIE SEI*I[i~I~:.'.:.'; RI'.,ID [,.IELJ_.S FISS SET EhlLFIRGEh'IEt,IT IF THE [~$OI LS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMEN'FAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERCOLATION TEST PEREORMED ED.: ~LL ltd L t~o~-~ ~EOA'DESCR,PT,ON: Log-/Jo 2 4 5 6 7 9 10 11 12 13 14 15 16 17 18 19 20 SLOPE COMMENTS__ WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? S P E G*oss Net Depth to Net Reading Date Time Time Water Drop 'ERCOLATION RATE /1 (minutes/inch) TEST RUN BETWEEN CERTIFIED BY: 72-008 (6/79) 6 DATE RECEIVED INSPECTION APPOINTMENTS TIME TIM~ TIME INSPECTOR INSPECTOR INSPECTO~ MUNICIPALITY OF ANCHORAGE . DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~ICIPALI 'Y OF ANCHORAGE ENVIrONmENTAL SANITATION DlVlSIO~ Telephone 264.4720 DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10} days for processing. 1, PROPERTY O~NER '~b PHONE -- PROPER-FY RESIDENT (If different from above) ' PHONE MAILING ADDRESS ~ LE~DING INSTITUTION PHONE -- 4. REAL~OR/AGEN'r [ PHONE MAILIND ADDRESS E, LEGAL DESCRIP'I'ION STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF~I3EDROOMS ,~ -Z_ One [] Four SINGLE FAMILY ~ Two I-] Fiva [] MULTIPLE FAMILY [~ Three I-~ Six [] Other WATE.:R UPPLY INDIVI DUAL* ' ATTACH WE LL LOG. A well log Is required for al walls drilled 'l~J COMMUNITY since ,June 1975. For wells drilled prior to that date, give we [] PUBLIC UTI LITY de,th (attach log if available,) S, SEWAGE DISPOSAL SYSTEM ~ NDIVIDUAL/ON-SITE*' ~ C~ I YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THr[ INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, THIS SIDE FOR OFFICIAL USE ONLY I. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FiVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DR I LLE D [] PUBLIC UTi LITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBUC UT UTY Connection Verified INSTALLER []Septic Tank or []Holding Tank Size; ?(::i'~'~,')t-'~ If Tank is Ilomemade SOILS RATING i§ive dimensions: TYPE OF TANK MANUFACTURER . /~{J.~0~-- TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS [~"~APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY 72-010 (Rev. 6/79)