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HomeMy WebLinkAboutT15N R1W SEC 8 LT 26 N2TISN RIW
8
Lot 26 N2
#051-092
!,
-20
N1/2 of LOT 26, SECTION 8, T15N9 R1W
wuw a,: CKLD W: D+TL: 9-19-05 s..ccu
B.J.J. JHM r R.C.C. "�" 1 OF 1
q DESIGN CRITERIA' CONTRACTOR IS REOUIRED TO
OBTAIN UTILITY LOCATES
3 BDRM = 450 GPD PRIOR TO ANY EXCAVATION
SOILS = 1.0 GPD/SO.FT. WORK. /
450/1.0 = 450 SOFT. REO'D.
1"34 EAGLE RIVER LOOP ROAD
EAGLE RIVER. ALASKA 91777
PWNEJI (907)694-2979
FAXf (907)994-1211 APPROX. WELL RADIUS
DRAINFIELD CRITERIA:
3.0' DEEP (ADD 2' MOA APPROVED SAND)
D.5' EFFECTIVE (COVER FIELD WITH 2- INSULATION)
Z 5' WIDE
g 90' LONG (20 45' LONG EA.)
CL REDUCT. FACTOR=0.7
PRO
ALL PORTDNS OF
WITH LEM THAN
COVER REQUIRE I
1
LOT 23
FLAT*
FLAT*
2-3%
SHOP
GALLON
BALLAST
4
O�VI
0
LA
o0
I
OF
01 C. COWAN
CE -5801
�� •'i SSt+•"�
LG
y
(fid
L J
n
y
APPROX. WELL RADIUS CONTRACTOR MAY VARY THE
EXACT DIMENSIONS AND DESIGN
PARAMETERS IN THE FIELD
NECESSARY TO MEET SITE CON01T1
I
L
0
by
SULLIVAN
P.O. BOX 670272, CHUGIAV~ ALASIC~, 99567 · TELEPHONE 686-2759 d UL 0 5 2001
HOLE nATA
DEPTH
ADDRESS PO ,~3 ~ ~ ~,'~ 0,~ (~. C/~'..! ~
LEGAL DESCRIPTION T /~ ~ ~1~ ~ ~
PERMIT NUMBER OOOIg& Date of lssue ~ -~-.~;
T~'INDENTIFICATION NUMBER~- O~ - ~
Is well Io~ted at approved pe~it Io~tion? ~ No
Method of Drilling: ~o~ ~ ~ble tool
Depth of well: ~O~
Casing Type ~ ~L Wall Thickness ~ ~ inches
Diameter ~ inches, depth /~ feet '
Casing Stickup Above Ground: ~ feet
S~tic Water Level (from ground level): ~ feet
Pumping level: feet affer~ bm. pumping qpm
Re~ver Rate: ~ qpm
U thod o T ti.g:
Well Intake Opening Type: ~n End ~ Open Hole
oened: Sra. ~t ~ped feet
GmutType: ~, rg V~ume /~a
Depth: from ~ feet, to ~ feet
Pump Intake Depth: feet
Pump Size .bp Brand Name
Well Disinfected Upon Completion? ~s ~ No
Method of Disinfe~ion: ~l~4~ ~0 ~'
Comments:
Drillers Name
Municipality.o.f Anchora{]e
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality
of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. MatSu Borough:
Department of Environmental Conservation.
MUNICIPALITY OF ANCHORA GE
Department of Health and Human Servfces
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650. Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WATER SUPPLY PERMIT
Initial
Date Issued: Jun 27, 2000
Expiration Date: Jun 27, 2001
Permit Number: SW000196
Legal Description: T15N R1W SEC 8 LT 26 N2
Design Engineer:. 0000 None Required
Owner Name: Raymond & Polly Neketemff
Owner Address: PO Box 672036
Chuglak, AK 99567-2036
Parcel ID: 051-092-20
Site Address: 020840 CRABTREE ST
Lot Size: 54450 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 2
This permit is for the construction of;
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
Ail construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either:. A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Date:.
NAME
_.',. : 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
DISTANCE TO:
we"~O0 / -/-,-
Length of ach line/~Z..
Crib diameter
NO. OF BEDROOMS~
NO. of com/partments ~..
Inside length Width .iquid depth
Dwelling PERMIT NO.
.iquid capacity in gallons
· Material
Total lang.. 9 f li~es~ I Trer~/wi~lth
PERMIT NO. ,
depth
Well Building foundation Nearest lot line
Sewer line . Septic tank
Building foundation
OTHER
LEGA.
PIPE MATERIALS
REMARKS
PERMIT NO.
Absorpt on area(si
.~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION [3 PERCOLATION
TEST
Pouch 6.~50. A~m'age. Al~kl 99602 276-2221
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: ~~'~ ~ 40 i~'~' O'-/~ DATE PERFORMED: / ? 0~T 7~
SLOPE SITE
2
3-
4-
5-
6
7-
8
9
10
11
12
13
14.
16-
17-
18-
19-
20-
DEPTH?
COMMENTS
72.008 (7/76)
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN FT AND FT
CERTIFIED BY/~~ ,,
(minutes/inch)
DATEJZW r?/
MUNIUPAUTY OF ANCHORAGE
a
Development Services Department
`� p
p p Phone: 907-343-7904
On -Site Water & Wastewater Section - Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051-092-20
1. GENERAL INFORMATION
Expiration Date: 1 — q 2 © Zo
Complete legal description T1 5N R1 W S8 L26 N2
Location (site address) 20840 Crabtree St.
Current property owner(s) John Spring Day phone
Mailing address
Real estate agent Day phone
2. TYPE OF DWELLING:
Fx_1 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
FX_1
Private Septic
Fx_1
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee S 412.50 CO UI 0_
Date of Payment 31/2 r7,1 02 D9 O
Receipt Number ( -I 9 9 �16'i
COSA # DSC 20) 966
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
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.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA
COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time
of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on
the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not
guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot
provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole
benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly
recommends buyers hire their own engineer to evaluate this report.
Name of Firm Pannone Engineering Services
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R. Pannone P.E.
Phone (907) 745-8200
OF ALgs�
,`P• A
49 THi
6. DSD SIGNATURE lop, • .. ... . • • • • • . • •
System #1 Approved for bedrooms Steven f2. 'Pann*o' ie ,
CE 8149
System #2 Approved for bedrooms ��s'•
Disapproved�t
Conditional approval for bedrooms, with the following stipulations:
llllll((^(({{{{4
ON-SITE
WAgT[•'•iril4T�R z
PROGRAM o
`- G fr' Original Certificate Date:
.9bV(j
The Municipality of Anchorage Development 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 Checklist blue sheet
Legal Description: T15N R1 W S8 L26 N2
If more than 1 septic system on lot: COSA Checklist # 1 of 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 8118/2000
Total depth 200 ft
Cased to 173 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 31 in.
Date of flow test for COSA 8/6/2020
Static water level at beginning of test 64.1 ft.
Comments
B. TANK DATA
Age of tank(s) 15 years
Tank type/material STEP/St-1
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 8/20/20
D. ABSORPTION FIELD DATA Shallow Trench
Which system tested (date installed) 9/28/2005
❑ ALL standpipes present per record drawing
Total measured depth from grade 3.25 ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A -pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
Parcel ID:
Structure served by this system 1
0.51-092-20
Well production at time of test 0.43 gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes ❑✓ No
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic 14.149 ug/L ❑ Arsenic less than MRL (ND)
Collected by Pannone Engineering
Date of Sample 08121/20
C. LIFT STATION
❑ Required maintenance completed
Age of lift station 15 years
Lift station material Steel
Comments:
Adequacy test date 81112020
Results ®✓ Pass For 3 bedrooms
Fluid depth prior to test 0 in
Water added 500 gal
New depth 0 in
Elapsed time 0 min
Final fluid depth 0 in
Absorption rate >450 gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
IN
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
F,71
Yes
Community Sewer Manhole/Cleanout > 100'
E] Yes
if No
ft
M Yes
if No
Neighboring Tank > 100' r-71 Yes
if No
ft
Private Sewer/Septic Line > 25'F71 Yes
if No
Absorption Field on Lot > 100' Fv� Yes
if No
ft
Holding Tank > 100' 0 Yes
if No
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' [✓ Yes
if No
�✓ Yes
if No
ft
if No
ft
F. ENGINEER'S COMMENTS
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' M Yes
if No
ft
0 Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' 0 Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
Q Yes if No ft
Property Line > 5'
F,71
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
0
Yes
if No
ft
Private Wells > 100'✓l Yes if No.
Water Main > 10'
✓�
Yes
if No
ft
Community Wells > 200' Q Yes if No.
Water Service Line > 10'
P/1
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
U✓
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
❑✓
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
0
Yes
if No
ft
Private Wells > 100' Yes if No
Water Service Line > 10'
Q
Yes
if No
ft
Community Wells > 200' 0✓ Yes if No
Surface Water > 100'
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l certify that / have determined through field inspections and review �� Y
of Municipal records that the above systems are in conformance with 4
MOA COSA guidelines in effect on this date. p
te-ven R-
an one
CE 8149 `i
COSA Checklist yellow sheet
ft
ft
ft
ft
OSA Checklist 41�J,
Legal Description: T15N R1W S8 L26 N2 Parcel ID: 051-092-20
If more than 1 septic system on lot: COSA Checklist of Structure served by this system 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 9/20/05
Total depth 73.9 ft
Cased to unknown ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA "U!'e°"" .d
Well production at time of test 0.43 gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes E] No
❑ Coliform bacteria is Negative
Nitrate 3.54 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Sullivan's
Date of Sample 9/25/20
Static water level at beginning of test not required ft.
Comments This data for well #2- per DW no well flow was required on this well. Cap welded on by Sullivan's water wells 10/8/20 see receipt
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed)
❑ ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 81112020
Results ❑Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
❑ Code -required soil cover over field Final fluid depth in
❑ System presoaked Absorption rate gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months)
date of test) If yes, enter date
Gallons introduced gallons
Comments/Deficiencies: data for tank, lift, field and distances for septic system on checklist for well #1- This checklist is for well #2
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
❑ Yes if No ft
Wells on Adjacent Lots:
Community Sewer Manhole/Cleanout > 100'
❑✓ Yes
if No
ft
✓❑ Yes
if No
Neighboring Tank > 100' El Yes
if No
ft
Private Sewer/Septic Line > 25' 0✓ Yes
if No
Absorption Field on Lot > 100' 0 Yes
if No
ft
Holding Tank > 100' ❑✓ Yes
if No
Neighboring Absorption Fields > 100'
Animal Containment > 50' ❑✓ Yes
if No
❑✓ Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' Yes
if No
ft
❑✓ Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑ Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
❑ Yes if No ft
Property Line > 5'
❑ Yes if No ft
Wells on Adjacent Lots:
Absorption Field > 5'
❑ Yes if No ft
Private Wells > 100' ❑ Yes if No.
Water Main > 10'
❑ Yes if No ft
Community Wells > 200' ❑ Yes if No.
Water Service Line > 10'
❑ Yes if No ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below
Property Line > 10'
❑ Yes
if No
ft Wells on Adjacent Lots:
Water Main > 10'
❑ Yes
if No
ft Private Wells > 100' ❑ Yes if No
Water Service Line > 10'
❑ Yes
if No
ft Community Wells > 200' ❑ Yes if No
Surface Water > 100'
❑ Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l certify that l have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.loon
ee
COSA Checklist yellow sheet
t en F'. Pcaniorie
CE 8i4,; -
ESS!?vial..-
ft
ft
ft
ft
DEVELOPMENT SERVICES DEPARTMENT 8Ai
On -Site water and Wastewater Section
www.muni.org/onsite
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC201466
Subdivision: T15N R1W Sec 8, Block: , Lot: 26 N2
907-343-7904
Fax: 343-7997
A water sample revealed an arsenic concentration of 14 micrograms per liter (ug/L).
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Mailing Address P. O Box 195650.. *Anchorage, Alaska 99519 6650 *www mum org � ,
P.O. Box 670269 Chugiak, AK 99567
P: (907) 688-2759 F: (907) 688-2259
TO: Billy Hughes — Precision Home Group
20840 Crabtree
Chugiak, AK 99567
Water Samples & Abandonment
Run Well.
Pull water samples, run to lab, remove system.
Approved well abandonment with MOA.
Weld on cap so well can be used in the future.
Date: 10-8-20
MUNICIPALITY OF ANCHORAGE
X
Development Services Depailment
On , -Site Water & Wastewater Section Phone: 90"1-343-7904
Fax: 907-343-7997
Lift Station/Pump Vault
Maintenance Log
Owner
ptic Tank: -
SeStreet Address 20 C
-Sludge level . __inches -Pumping: required yes
,f o *Pumping completed e no
L�ft statiow.
.Pump basket cleaned (Le -c/ no -Effluent filter cleaned es no
-Control floats cleaned no -Proper float settings confirmed 0 no
-Operation satisfactoryQp
�n o
-Dedicated electrical alarm circuit
@s
.tnr
no ®Audible inside dwellin es
0
-Alarm system operate satisfactor of satlggLtou
il&anhole Riser
-Ground water intrusion at riser to tank connection yes n
v�r
-Ground water intrusion around pipe penetrations e no -Weep hole functionac es io
-Manhole lid: Functions �s no Insulate es o Properly SecuredCy
Other _;es no
-All manufacturer required inspections and maintenance completes es no
Comments:
Noriff-mmiTj
Technician
Date of maintenance
Company
dL-,41
Signature Date
I' APPLIC'"'IT FILLS OUT UPPER HA['~"ONLY
Buyer
Address Zip ~e
Phone
Address Zip
Type ot Resl~nce
~ Other
~ Comm~lty .D / For wells ~111~ prior to th~ date, give well depth (attach I~ If available).
Sewer Disposal ..
Indlvid~l ' Year Indlv~ual Instatled:
~ Holding Tank
NOTE: THE INSPECTION ~E MUST AC~O~A~EK~ RE~EST BEFORE ~OCESSING CAN BE N T ATED
Time Time Time Time ~.~/
Inspector Inspector Inspector Inspector
-o.e,. ' RECEIVED
( ~APPROVED BEDROOMS~ 'CONDITIONS OF APPROVAL
( ' ) DtSAP~OVED
DEPABTMEMUNICIPALITYNTOI: OF ANCHORAGE DEPT C, l- ~.~LT, r! & / I
T F HEALTH & ENVIRONMENTAL PROTECI~iI~;~)NM[NT~ p,,OTECTION ~ 11~ I .. )
- JUL 6 '.
ENVIRONMENTAL ENGINEERING DIVISIONT. e~.e ~ ~7~ ..RE~EI~~.
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
PHONE
PHONE
2. BUYER
MAILING ADDRESS
3. LENDING INSTITUTION
JPHONE
MAILING ADDRESS
4. REALTOR/AGENT
JPHONE
MAILING ADDRESS
SINGLE FAMILY
MULTIPLE FAMILY
NUMEER OF BEOROOMS
C-t One [] Four
[] Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
8. SEWAGE DISIN~SAL sY~rEM
~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
· ATFACH WELL LOG. A well log is requiresl for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
If system is over two {2) years old an adequacy test is required
by th[s Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72~0t013/78)
THIS SIDE FOR OFFICIAL USE ONLY
TIME
DATE
INSPECTOR
DIRECTIONS:
INSPECTION APPOINTMENTS
IME
DATE
INSPECTOR
DATE RECEIVED
TIME
DATE
INSPECTOR
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
f--IINDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
i-'lSeptic Tank or I-'lHolding Tank
Size: If Tank is homemade
give dimensions:
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE [] OTHER
[] TWO [] FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATEINSTALLED
INSTALLER
SOILS RATING
TYPE OF TANK MANUFACTURER
TOTAL A~SORPTION AREA MATERIAL
Septic/Holding Tank
4. DISTANCES
WELL TO:
Absorption Area to nea~elt Lot Line
COMMENTS
DATE
LEGAL DESCRIPTION
[] APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate}
[~DISAPPflOVED
72-010 (Rev. 3/78)