HomeMy WebLinkAboutT12N R3W SEC 22 LT 48 S2T12N, R3W
Section 22
S2, Lot 48
#015-142-31
Municipality of Anch0rage Page I of 3
· 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:. SW990097 PID Number: 015-142-31
Naffle:Sandy K. Potter Wastewater System: ~ New [] Upgrade
^~fe~:P.O. ]]ox 111313 Anch., AK 99511 ABSORPTION FIELD
p~o~e: 346-2004 ' Three I~ Deep Trench r"l Shallow Trench I-IBed r'lMound "1Other
LEGAL DESCRIPTION
WELl' [] New
Existing rL rt. 1,073 so.r, ~STM D30~4 PV~
Ft. Acrea(~e SYstems 5/25,26/99
SEPARATION DISTANCES I~ s~,~¢ [3 Ho,d~.g ~ s.~.£.P.
,mm ~ r~ s,.~o. ~r,.~ s~,~u~ Anchorage Tank I ~ 000
Well- >100' >100' N/A N/A N/A Material: Steel Tw9
sudace >100' >100' N/A N/A N/A LIFT STATION - N/A
Lot
Line
'.
3
Foundation
None qoted On Lot iPumpMa~e&lda3~el IFJ~.=dcaltns~mp~om~U~-
Curtain
Drain
I
BENCH MARK
Remarks: See ~etter Reqard[n~ Distance
From Foundation To Tank. Top o£ ~oundation
Wall at Corner A.
Inspecti0nspedormedby: ~I'A Dates:,,, 5/25/99 ~-~~~_~
Department of Heal!h and t-lumen Services approval 9h'~k....~4~...:,~..~
Reviewed and appr0ved by: ~ Oate:/-/I-~O
Municipality of Anchorage Page 2 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, AK 99519-6650 343-4744
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number SW990097
30' I -
· N 00°01'00"W 165.08'
PID No. 015-142-31
BARONIK. '°-
"· STREET
Site
S1
S2
H1
C4
C5
A
13.5
18.8
28.4
40.3
B C
14.4
14.7
21.9
55.8
38.3 29.9
Existing
Well
AS;BUILT '.,
SCALE 1" = 60'
,!
· N 00002'00"W
165.08'
BIRCH ROAD
'Municipality of Anchorage Page 3 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, AK 99519-6650 343-4744
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number SW990097
PID No. 015-142-31
93.6 /
96.8
Geotextile
~Drainfield
87.2 ' /
89.4'
Fabric
il~ Rock
81.0
I
ANDERSON ENGINEERING
P.O. BOX240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
MEMORANDUM
DATE:
TO:
FROM:
SUBJECT:
December 10, 1999
On Site Services Engineer
Mike Anderson, P.E. 7'~ ~
South ~ Lot 48, Section 22, T12N, R3W
Septic System As-Built
Septic Tank to Foundation Separation Distance
The as-built for the septic system on the subject lot shows the septic tank approximately
3' from the house foundation, The septic system was constructed in the late May of this
year and the foundation placed later in the summer. The primary foundation for the
house is located more than 5' from the tank.. The cantilevered 3' X 11' section of the
house, however is only 3' from the tank. The structural loads to this area were
designed to be carded by the pdmary house foundation, The builder apparently made
a field decision to place a foundation under this cantilevered area to provide additional
support. Loads to the foundation at this location are so slight, however, the footing and
foundation are not justified,
The sept[.c tank is more than 5' from. t.he primary foundation for the house. If the tank
should fad at some time m the future t s unlikely the foundation would settle as a result.
I am confident, based on the design of the house and the structural loading, that
placement of the tank within 3' of the cantilevered section of the house will have no
adverse affect. I therefore recommend the tank placement be allowed within 3' of the
foundation at this cantilevered section. A drawing of th.e house foundation showing its
proximity to the tank is enclosed for your review. Please let me know if you have any
questions.
Primary'House
Footing and Fouhdatic
Wall .~
1,000 Gallon
Septic Tank
:ion
Cleanout
11' X 3' Cantilever
Footing and Foundation
MUNICIPAUTY 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
Initial
Date Issued: May 17, 1999
Expiration Date: May 16, 2000
Permit Number: SW990097
Legal Description: TI2N R3W SEC 22 LT 48 S2
Design Engineer. 0014 Anderson Engineering
Owner Name: Sandy K Potter
OwnerAddross: PO BOX 111313
ANCHORAGE, AK 99511-1313
Parcel ID: 015-142-31
Site Address: 011550 TOTEM RD
Lot Size: 103075 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:
Date:
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
May 6,1999
Municipality of Anchorage
Department of Health and Human Services
825 'L' Street
Anchorage, AK 99502-0650
Subject:
South % of Lot 48, T12N, R3W, Section 22
Septic System Design Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer.
The owner of the South % of Lot 48, T12N, R3W, Section 22 intends to construct a
three bedroom home on the lot. We are therefore requesting a permit to construct a
septic system on the lot to serve the house. A well is currently in existence on the lot
and will be used to provide water to the house. The attached site plan and backup
documentaton describe the proposed system and show the location of the septic
system, alternate site and existing well. A.n old absorption crib and. fiberglass septic
tank will be demolished and abandoned in accordance with Municipal and ADEC
requirements.
The testholes placed on the property revealed poody graded silty gravel which
pemolated at rates between 54 and 57 minutes per inch. Groundwater was not
encountered dudng the excavation nor was any noted dudng the monitoring pedod.
We have therefore designed a deep absorption trench with 6' of gravel beneath the
distribution pipe. The trench will be 85' long with a total depth of 9'. Mounding may be
required to provide minimum coverage over the trench to prevent freezing.
The ground surface on the lot slopes to the west from the proposed house location at a
rate approximating 4%. This is the area of placement for the absorption trench. The
trench will be constructed perpendicular to the slope. No conflicts exist with other lots
in the area where septic systems have been or will be constructed. A park is currently
in place to the south of the lot and no development will take place there. The lot to the
north and east is currently vacant. The lot to the north and west has a well that is more
than 100' from either the new or replacement absorption trench. The lot is 610' long by
165' wide and contains more than enough room for the systems without conflicts with
adjacent properties.
If the system is constructed in accordance with our design the following statements
apply:
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future. The existing well on the lot
will be put back into service.
South % of Lot 48, T12N, R3W, Section 22
May 6, 1999
Page Two
The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on reserved
space, either surface or subsurface, on any lots located in the area.
The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
Park
Area
VACANT
NOTE:
KLATT ROAD RIGHT OF WAY
SITE PLAN
SCALE 1" = ,40'
Existing Septic Tank and
Absorption Pit to be Aba
doned in Accordance with
State and Municipal Requ
ments.
Lre-
S1/2 LOT 48, T12N, R3W,
DESIGN FACTORS:
Three Bedroom Home
Perc. Rate: 54 to 57 MinJInch
Application Rate: .45 GPDISF
SEC. 22
SYSTEM REQUIREMENTS:
Deep Trench System
1,000 Gal. Septic Tank
6' Drainfield Rock
3 Bedrooms X 150 GPD I .45 GPDISF = 1,000 SF of Absorption Area
1,000 SFI12 SFI LF of Trench = 83.3 LF Trench Length
Therefore: Construct a Deep Absorption Trench System With One Lateral
85'. in Length with 6' of Drainfield Rock Beneath the Lateral.
Distribution Pipe In Trench Placed at 3' Below the Original Ground
Surface. Total Depth to be 9' from Original Ground.
6II
NOTE:
Backfill . ./~ Geotextile
;' ~ Fabric
4" Perforated
PVC (slots Down)
Drainfield
3'
TYPICAL DEEP TRENCH SECTION(No SCALE)
Grade Area Over Trench to Drain Away.
Minimum 4' From Groundwater.
Maintain 10' Separation From Lot Line.
p;RFORMED FOR=
LEGAL DESCRIPTt ON:
,H
L
7
8
10-
13-
14-
15
16
17
19-
20
WAS GROUND WATER
ENCOUNTERED?
IF YES. AT WHAT
D£PTH? . pO
E
I' I. I I I~-,tF.i i
illllllll
~.u..~ ~ "~'
'Perc. Cavity presbaked prior to testing.
· Michael E. Anderson Z--///~,~ .
ACCORDANC[ ~qTH ALL ~TAT~ AND MUNI~pAt GUID~.INC$ IN EFF=OT ON TH~ DAI~ 0A~ ~/~ fT 7 '
72~ IR~. ~l
L;GAI. DE~CRIP'rt ON:
IVlunicipafityotAnchorage ~.g~...__..,,.~(r '/ ~'; I
D-"PAF;TM~'NT OF HEALTH & HUMAN SERVIC£$ /~'~'? 49m____...~..,,., :'..$:4 I
SOILS LOG -- PERCOLATION TEST ~k~C~E.'A~DERSOH .:/~ I
1
2
3-
4-
8
'10 -
11
12
13-
14-
15
17.
18-
19-
2O
COMM~_N'~
WAS
GROUND WATER LI
ENCOUNTERED?I~1
IF YE~, AT WHAT /'
DEPTH?
Pert. Cavity pres'oaked prior to testing.
P£~FORMEDBY:.,~ .t 2~J/~"~l~'~(~'~"" ~ERTIFY THAT THtS TEST WAS pERFORMEO IN
Michael E. Anderson
ACCORDANCE WITH ALL ~TATI~ AND MUNICIPAL GUIDE.[.JN=-~; IN EF;-:.CT ON TH]~ DAT~ ~)AT~
72-008 (Rev.
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: Sll2 of LOT 48, T12N, R3W, Section 22
GENERAL:
The scope of this project includes the procurement and placement of a
new 1,000 gallon septic tank. It also includes the construction of a
new 85' long x 3' wide x 6' effective depth absorption trench at the
location shown on the attached Site Plan. The total depth of the
trench will be 9' below existing ground. Mounding over the trench may
be required to provide a minimum of 3' of protective cover.
Construction shall be in accordance with the approved site plan,
design drawings, Municipal Permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater
Disposal Regulations.
The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the
location of all lot lines.
Unless specifically agreed otherwise, the contractor shall be
responsible for final grading areas subsequently depressed from soil
settling. Property owner shall be responsible for revegetation of
affected areas unless specifically agreed otherwise.
Contractors installing wastewater disposal systems must be certified
by the Municipal Department of Health and Human Services for
system installations. Owners installing their own systems must receive
pdor approval from D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
1. The 1,000 gallon septic tank must be procured from an approved
source and installed at the location shown on the plans.
A septic tank is to be constructed by a certified septic tank
· manufacturer. Co~nstruction shall include two 4" cleanouts for pumping
access.
The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
Tanks installed without 4' of cover shall have a minimum of 2" of direct
burial insulation.
A foundation cleanout shall be installed one to four feet from the
building foundation. Two cleanouts are required between the tank and
the drainfield.
South %, Lot 48, TI2N, R3W, Section 22
May 6, 1999
Page 2 of 3
7. Final grading over the tank shall be such that a positive slope exists
away from the septic tank.
DRAINFIELD CONSTRUCTION:
The drainfield shall be constructed to the dimensions shown on the
design. The bottom of the trench shall be within 2" of level.
Distribution piping must be placed level with perforations down atop a
level bed of drainfield rock. Rock should then be placed over the pipe
to provide a minimum of 2" of cover.
A silt barrier or geotextile fabric must be placed between the drainfield
rock and the natural soil backfill.
o
Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated,
Contractor shall vedfy the septic tank and drainfleld are a minimum
100' away from any private water wells in the area, 150' from a Class
"C" Well or 200' from any community well.
Direct bury insulation must be placed over the distribution system if
less than 3' of backfill depth is available. Finish grade over the trench
must be mounded to prevent settlement or depressions.
Grade area surr~)unding the absorption trenches to drain away~
A minimum 2' of accepting soil is required below the drainfield rock for
a 5' wide trench. Contractor shall vedfy this condition prior to
placement of the rock. All pockets of unacceptable materials must be
removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a Municipally approved septic
tank manufacturer.
The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid) ASTM D3034 or P.V.C. (perforated
and solid), ASTM F810 or H.D.P,E. (perforated, but not so id) and
ASTM D2662 or A.B.S. (perforated and solid).
Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Femco, or equal).
.South %, Lot 48, TI2N, R3W, Section 22
May 6, 1999
Page 3 of 3
5. A permeable geotextile fabric (Typar, Mirafl or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing
the #200 sieve.
INSPECTIONS:
A minimum of two inspections are required by Municipal Ordinance.
These inspections must be conducted under the supervision of a
professional engineer registered in the State of Alaska. The first
inspection must be conducted after the excavation of trenches, beds or
pits and before the installation of any gravel. A septic tank may be set in
place, but may not be backfilled.
The second inspection must be conducted after the placement of the
geotextile fabdc, gravel, distribution piping, standpipes, cleanouts and
insulation. No backfill should be in place at the time of inspection.
Contractor shall provide a copy of all field survey layout and construction
notes for use in preparing the certified as-built of the completed system.
GRE/ ANCHORAGE AREA BOr? "iGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
MAILING ADDRESS '.~2Q~ ~//C/'/,~/~O/'Z PHONE
LEGALDESCRmnON 5~/~ Z~-r 4~
SEPTIC TANK:
DISTANCE / NUMBER OF
FROM WELL /'~ MANUFACTURER ~'(~1~)/<23/¢(-'~ MATERIAL TP~'~:~"~O I~L3 COMPARTMENTS (
INSIDE LENGTH '~ INSIDE WIDTH LIQUID DEPTH ~ LIQUID CAPACITY /~OO GALLONS.
SEEPAGE PIT:
NUMBER Of PItS / . DIAMETER / OR WIDTH ~, f LENGTH ~¢),f DEPTH /~ !
LINING MATERIAL//~q (?/~/~O CRIB SIZE: DIAMETER '~ DEPTH "7 DISTANCE FROM: WELL /~/0 /
BUILDING FOUNDATION 'z'//'2 , NEAREST LOT LINE ~'~-~ ! TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA) ~_~O SQ. FT.
ADDITIONAL ABSORPTION
WELL:
TYPE ]~,~r~/V.
BUILDING ~/~ /
FOUNDATION
CESSPOOL ~---
APPROVED
CONSTRUCTION ~ /' 0~-~/ZL]~, 5~Jr~f--~ DEPTH
NEAREST [~z NEAREST SEPTIC
LOT LINE '/~) SEWER LINE /0 ~/- TANK
OTHER SOURCES
DISAPPROVED
REMARKS.
, DISTANCE FROM:
/~ / SEEPAGE
SYSTEM //--/~
DISTANCES:
DIAGRAM Of SYSTEM
INSTALLED BY:-~-~
PIPE MATERIAL:~*~ Q~tgT
LOT SLOPE: fA}¢~ ~/~L~
REMARKS: ('I~/~C~I~ ~ ~ I~
Form No, LO-031
DATE
GREATER ANCHORAGE ArEA BorouGH
PERMIT NO.
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
FINANCED THROUGH
SOIL TEST RESULTS
COMPLETION DATE ANTICIPATED
TO BE INSTALLED BY
, OTHER
THIS PERMIT I$ ~OT VALID WITHOUT SOIL TEST
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.
SEPTIC taNK size i ~ ~) ~ tYPe SEEPAge area SIZE tYPE
WELL TO SEPTIC TANK
DRAIN FIELD
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
MINIMUM DISTANCE~, REQUIREMENTS
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE Pit ~ / , DRAIN FIELD
SEPTIC TANK TO SEEPAGE PIT WALL
SEPTIC TANK , SEEPAGE PIT ., DRAIN FIELD
TO NEAREST LOT LINE.
SEPTIC TANK, , SEEPAGE PiT
TO RIVER, LAKE, STREAM.
DRAIN FIELD
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDJSTURE~ED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INST LATION.
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE ]~O. 28-68 AND THAT THE ABOVE
//~! GREATER ANCHORAGE AREA
Department of Environmental Q .ity
' 3330 "C" Street
,. Anchorage, Alaska 99503
C f~orm SOILS LOG - PEROLATION TEST
Legal Description:~'~--~'-'--~"-':"--~ q8' '~' ~ ~ ~----~,~
This form reports: ~~j .11 Percolation test
Depth
Feet
11 -
12-
13-
14- ~
10 - ,5',7o,00
Was ground water encountered? ~,.)_ .__ If yes, at what depth? ...............
Reading
Date
Gross Time
Net Time
Depth to Water
Net Drop
Percolation rate minute.
-Proposed installation: Seepage Pit Drain Field
',, Depth--~b~-t~n--o~-~)it or trench
._Jepth of Inlet ............. .
COI,1MEIiTS:
EQ 040 (6/74)
CONSTRUCTION
TE:ST L. AB
MATERIALS TESTING * QUALITY CONTROL
SOILS ENGINEERING
2204 Cleveland Ave. / P.O. Box 10-1126 / Anchorage, AK 99510 / 277-0231
710 3rd Ave. / P.O. Box 60547 / Fairbanks, AK 99706 / 452-1267 · 456-5155
July 19, 1979
Ernest Motichka
SRA Box 1636, A
Anchorage, Alaska
Re: Adequacy Test, South 1/2 of Lot 48, Sec. 22
T12N R3W
Dear Motichka:
The septic system located on the above referenced pro-
ject tested as follows:
700 gallons of water in 24 hours.
If you have any questions concerning this test, please
contact our office.
Very truly yours,
CONSTRUCTION~~/j~ LAB
David Paul
Laboratory Manager
DP/gk
"Professionals working to destgn and butld a better Alasl~
MUNICIPALITY OF ANCHORAGE DEPT. OF V, EALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOT~t~VIRONMENTAL pF, OTECTION
825 L Street - Anchorage, Alaska 99501
JUN 2 0 1979
ENVlRONMEN'I:AL ENGINEERING DIVISION
Telephone 264-4720 RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing,
1. PROPERTY OWNER
MAiLING A~D D ~ ESs
PROPERTY RESIDENT {if different from above)
PHONE
PHONE
2. BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION I PHONE
MAI LING A DDR ESS
4. REALTOR/AGENT [ PHONE
MAi LING ADDR ESS
5. LEGAL DESCRIPTION
STREET LOCATI OA1 '
I 6. TYPE OF RESIDENCE -
[~SING LE FAMILY
[] MULTIPLE FAMILY
~O~B~ OF
w ne ~ Four
o ~ Five
Three ~ Six
Other
7. WATER SUPPLY
[~'iNDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8' s EWA~ iA,~iSD~,~_/L N .S i T E., **1 f individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
[] PUBLIC UTILITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TiME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. 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 DRILLSD
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] iNDIVIDUAL/ON-SITE DATE INSTALLED
Connection Verified
INSTALLER
E~]Septic Tank or E]Holding Tank
Size: /(~(:~) If Tank is homemede SOiLS RATING
give dimensions'. ~ ~ .
TYPE OF TANK MANUFACTURER
TOTALABSORPTIONAREA MATERIAL .._~ I ,.~:~ i~1~. ''~' Nearest Lot
4, DISTANCES Septic/Holding Tank Absorption Area I Sewer Line Line
WELL TO: [ ..~ (p
Absorption Area to nearest Lot Line
5. COMMENTS
[~" APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must acco/~,any certificate)
[] DISAPPROVED
DATE BY (Tit~ /
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
g
DTI002352
~LAT OF
B.I_M LOTS
IN SEC. ~, TI~N,
~A REI~cAT OF ~.L.M;
TRYCK, NYklJ~N & flAYE~