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Home My WebLink AboutEAGLE CREST #1 TR A LT 79Onsite File Eagle Crest #1 Tract A Lot 79 #050-304-32 MUNICIPALITY OF ANCHORAGE SEWER 82 2283 ro wATF , CONNECT PERMIT �� wF� P �G w ti i `l V a v, 1 � y'O�Qq<1ry OF AG�O�T DATE OF APPLICATION WATER a SEWER UTILITIES SCHEDULED COMPLETION DATE 6-29-82 3000 ARCTIC BOULEVARD J9SINGLE FAMILY PHONE -277-7622 ❑ MULTI -DWELLING No. APTS ❑ COMMERCIAL LOT/TRACT l BLOCK — ❑ INDUSTRIAL SUBDIVISION TAX CODE s:-5 C- 3941 �`GR ID_1iL,6J� -S-DRAWING No. New BUILDING ADDRESS_Fagle River Rnad OWNER MAIL ADDRESS PHONE CONTRACTOR= AWWU ASSESSMENTS (License abond required ❑ Paid previously ❑ON PROPERTY ONLY ❑ Main extension agreement SvAIN TAP -TO PROPERTY LINE ONLY ❑ Subdivision agreement ❑ MAIN TAP aON PROPERTY CONNECT El Extended connect agreement ❑ Pending -AMOUNTS PTE CONNECTION SIZE 4" CHARGE INSPECTION FEE PERMIT FEE REIMBURSIBLE NUMBER DEPOSIT TOTAL PERMIU IrunED BY: ❑ PAID ❑ CASH ❑ CK#. INSPECTED BY. �E-n�l« t.✓✓ �trt� DATE. PERMITTEE MAI L (PLEASE PRINT) AWWU ADDR. 3000 Arctic PHONE= I HAVE READ THE CONDITIONS AND REGULTIONS ON THE REVERSE SIDE OF THIS PERMITAND AGREE TO COMPLY WITH THEM PERMITTEE SIGNATURE POST INA CONSPICUOUS PLACE ATTHE JOBSITE 80-021 ( 4/80) INSPECTORS COPY Z y a m my m o m y cl) cn 0 Z m z cmi D_ r Z w O I� z SEWER INSPECTION REPORT Z z O � -I D m cn x O r O D y CD M Z r2 O m T � n y CD m Z x -I M x O M r r � Z D m Z to x 7C O m r --I m c) w— x cl r m D Z O C -i cn CA m -I D r r m MUNICIPALITY OF ANCHORAGE WATER & WASTEWATER UTILITY 3000 ARCTIC BLVD. PHONE:(907)564-2762 BLOCK/LOT/TRACT: LT 79/ SUBDV: EAGLE CREST #1 TAX CODE: 05030432000 GRID: NW0055 WASTEWATER 5201447 CONNECT PERMIT DATE OF APPLICATION: 10/13/2020 SCHEDULED COMPLETION DATE: 12/31/2020 STREET ADDRESS: 19533 EAGLE RIVER RD Eagle River, AK 99577 OWNER: HAUGSTAD HOWARD 0 & CAROL A REVOCABLE LIVING TRUST MAIL ADDRESS: 19533 EAGLE RIVER ROAD EAGLE RIVER, AK 995778455 PHONE: CONTRACTOR: JR's Septic Pumping LLC SINGLE FAMILY DUPLEX ❑ Repair Existing Service COMMERCIAL ❑ MULTI -DWELLING No. APTS 0 PHONE: CONTRACTOR: JR's Septic Pumping LLC ASSESSMENTS ❑ Repair Existing Service Main Line Extension Q On Property Only ❑ City Tap Have Been Levied Hydrant Only YTo Be Levied ❑ Main Tap - To Property Line Only Comments: - -#kso • o S 6nJA ov ❑ Main Tap & On Property Conned Disconnect Row No. R & R - Main Tap Only Owner Staff c M, CONNECT SIZE 4 in ISSUED WWGEH INSPECTION FEE $112.00 Ef PAID F� CASH PERMIT FEE $77.00 F-] CHECK RCC $1.69 OTHER uI Z C REIMBURSABLE DEPOSIT $0.00 INSPECTED BY C i,. \ V,L_C- NUMBER TOTAL $190.69 DATE `�. - ��\- Z`• REMARKS INSPECT SEWER SERVICE LINE PERMITTEE (Please Print) JR's Septic Pumping LLC MAIL ADDRESS 16718 Mercy Dr Eagle River, AK 99577 SIGNATURE EMAIL PHONE (907)694-6454 POST IN A CONSPICUOUS PLACE AT THE JOB SITE •.�, INSPECTOR COPY ''�� DATE 12/31/2020 TIME 12:00 AM INSPECTOR SCHEDULED SUBDIVISION EAGLE CREST #1 BLOCK/LOT/TRACT LT 79/ INDICATE NORTH �' �`� �` t 'ho 1533 gq L; u-c1(� (atvir �2.un.c SIZE MAIN: TYPE MAIN: DEPTH AT MAIN: AT PROP. LINE: , CONNECT LOCATION: COMMENTS: INSPECTED BY: DATE: �k-� k GREA,,.R ANCHORAGE. AREA BORL_GH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE ~_,~..~/ . NUMBER OF FROM WELL.~-' MANUFACTURER C~__~-~_MATERIAL ~ ~/ COMPARTMeNTS.~' INSIDE LENGTH ' INSIDE WIDTH ~ LIQUID DEPTH LIQUID CAPACITYZ~0GALLONS. DISTANCE FROM WELL ~>~ / FOUNDATION ~ ~' NUMBER OF LINES / DISTANCE BETWEEN LINES ABSORPTION DEPTH: TOP OF TILE TO FINISH GRADE NEAREST LOT LINE /~'~ /oFTOTALLINEsLENGT~:>~3 ~' TRENCH WIDTH~'~ IN. TOTAL EFFECTIVE SQ. FT. LENGTH OF EACH LINE (:~4~' / ~ nEPTH OF FILTER ~ ~ATE"IAL BENEATH TIL[~( IN. ABOVE TILE ~ IN. WELL: BUILDING NEAREST FOUNDATION LOT LINE CESSPOOL OTHER SOURCES APPROVED DISAPPROVED NEAREST SEWER LINE SEPTIC TANK REMARKS DEPTH SEEPAGE · SYSTEM DISTANCE FROM: INSTALLED BY: SEWER LINE DEPTH: PIPE MATERIAL' LOT 5LOPE:~I"_~f ~'IoF4- T'13 . REMARKS: /2~¢ Form EQ-032 ~/.~ ~:~. DIAGRAM OF SYSTEM G.A.A.B. *' J*" "' '"' "':* :" ENV~I~ENT,U, '- ,-, -,* ~v~-W DRILLING, Inc. * - '!'. .' P.O. BO~ 4-1224 · 1310C International Airport Road , ,~- ~ (907) 274-46].1 MAY 2 0 ' ' : - , ~ i ' ANCHORAGE, ALASKA 99509 WeU Owner DRILLING LOG LocaUon (address of: ~o~hip, Range, Section, ff know~; or d~tance mainroad T.TO. 1~ Add E. ~ro~t ~ubd. RECEIVED Use of Well Dom Size of casing A"' Depth of Hole ?R.t. 6 feet Cased to '~9,1.6 feet 'Static water level ,'q,~,q ft. (abo~) ~ ,(,.b'elo~v) land surface. Finish of~.well (check one) .Screen ( ); Perforated ( ; ..,~). , '; , .J · . · , - r Describe' screen or perforation \ ' ~ ' Well pumping test at' .~'~" ~gafiok~s ,per.~(h0U~:)c (minute) for of drawdown from static level. :' :' . Date of completion ' ' open end( × ); 'ho~rs with' , 1,0~c~ca . ft. Depth in feet from ground surface ~ ~0 ~ "~ TO ~ '~ '150 ~0 175 !75 T0,205 ~05. TO ~O0 ?CO TO ?~ ~ TO ~ ~75 TO ~8 F>ilty' ~rmvel & bould -.* Giv~ details of formations.penetrate~i,-~tze of ~naterml; col6r and hardness · / .... '"----' ' ' ~ : -'~'~' T' - O~?~n{~.e- .- ~.. f ,% . ,c&vin~ GraveI'& Send 'Cav:.nq qravel-~ome xwte.~ ' '' TO TO' .TO TO. 2--STATE PERI'II T N0. ~APPLICANT LOCATION LEGAL S~J Et~TERPRISES, BOX 8-9785 ANCHORAGE 99508 6~4-9958 EAGLE RIVER ROAD L79 ERGLE CREST SUBD ADD I LOT SIZE 151BO SQUARE FEET TYPE OF SOIL RBSORBTIOt'~ SYSTEIi IS: TREt'~CH MRXII'IUIi t'IUr'IBER OF BEDROOI4S = 3 SOIL RRTI~JG THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: DEPTH= -1._.?. LEI'46TH= 27 GRR'v'EL DEPTH= 7 THE LE/'~GTH DIMENSIOt~ IS THE LEHGTH (IH FEET) OF THE TRBICH OR DRAINFIELD, THE DEPTH OF R TREHCH OR PIT IS THE DISTANCE BETWEBI THE SURFACE OF THE GROUteD At'iD THE BOTTOri OF THE E×CRVRTION (IN FEET). THERE IS t~O SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUIt DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE Rt.,ID THE BOTTOM OF THE EXCRVATIOI.~ (IN FEET). REnU I RED SEPT I ¢ TRNa.-. S I ZE= -1080 6iRLLOI'-,IS ' E:RC[(FILLIHG OF Rt. IY SYSTEM ~IITHOUT FIHRL IHSPECTION At.iD APPROVAL BY THIS i DEPRRTMEtlT WILL BE SUBJECT TO PROSECUTION. MItlII,1Uri DISTRt-~CE BET~EEH R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTBi FEET FOR A PRIVATE ~ELL OR 2~ FEET FOR R PUBLIC ~IELL, SPECIFICATIONS AHD COt~STRUCTION DIRgRRriS ARE AVAILABLE TO ItlSURE PROPER NSTALLRT I ON. ' PERI1 z t %-'RL ! D fOR: Ot4E ~'ERR FROfl ISSUE I CERTIFY THAT i: I Afl FRriILIRR WITH THE REQUIREfIENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH BY THE MUt,IICIPALITY OF Bt.~CHORRGE, . 2: I WiLL INSTBLL THE SYSTEM It~ ACCORDANCE WITH THE CODES. · 3: I Ut.~DERSTAt~D THAT THE Of FSITE SEWER SYSTEM MAY REQUIRE EHLRRGEMEHT IF THE , RESIDE~ I~CLUDE MORE THAN ~ BEDROOtiS, Russell Oyster 694.2774 Soils ~t Foundations 0 8. E GEO.'~_.CHNICAL 8- DEVEL./"~?MENT CO. Box 90, Davis St., Eagle River, Alaska 99677 694-2774 or 688-2280 Ea# Ellis Land Development ~tltng Address: ~. Perfome~ for: Legal Description:, Depth (feet) Sotl Characteristics 0 1 2 3 5 6 10 11 12 Ground Water Encountered: Yes No If yes, what depth Proposed Installation: Seepage Pit Drain Field / Con~nents: ~'"~-'-< ,~-,.~.-,-'¥,~ %~.~.c~.-f~ Performed by: Date: MUMCPAUTY O %HCHORAGE Ro Development Services Department j Phone: 907-343-7904 On -Site Water & Wastewater Section Fax.- 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-304-32 Expiration Date: 2 & I o 0Q 1a 1. GENERAL INFORMATION Complete legal description Eagle Crest #1 Tract A Lot 79 Location (site address) 19533 Eagle River Rd, Eagle River, AK 99577 Current property owner(s) Howard & Carol HaugStad Day phone Mailing address Real estate agent 13535 Hwy 101 South, Tillamook, OR 97141 -Joe-- Bell (Firebird Realty) Day phone (907)350=4047 2. TYPE OF DWELLING: 0 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 Q Private Septic ❑ 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 $ 2-,W r -ff- / 6,5 j Date of Payment 1 I a (P I �0 Receipt Number d 0 D COSA #Q5 PZZ102 1 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller, P.E. (M.J.) Date 1/19/2022 .low 0 *� STH 6. DSD SIGNATURE 0 '• • • r'' IL System #1 Approved for 3 bedrooms Benjan-vrr Schiller / �� F'• CE 12592 .•�`�.®r System #2 Approved_for bedrooms �s�•. 1119/22 �,�w _.. F�F�pROfESS10Nt`�'.,o� Disapproved Conditional approval for bedrooms, with the following stipulations: ,c J� `g �o Jm JJ . `;1;1( t t (torl 4r/(/ Q0', ON-SITE m WASTr u'h'ATER o PROGRAM �F�r s" 0)))))))111 1 By: j?��Q,ms Original Certificate Date: 1 1/2 (1014- 0 122 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 COSA Checklist yellow sheet COSA Checklist Legal Description: Parcel ID: If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test?Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample Comments __________________________________________________________________________________ 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 C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: 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 Code-required soil cover over field System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Adequacy test date Results Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: Eagle Crest #1 Tract A Lot 79 050-304-32 ■6.6+ 5/10/1976 334 ■ 334 ■ ■ 19 Forge Engineering (Pending) 1/18/22 281 1/18/22 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 Neighboring Tank > 100’Yes if No ft Absorption Field on Lot > 100’Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’Yes if No ft Holding Tank > 100’Yes if No ft Animal Containment > 50’Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft From Septic/Holding Tank on Lot to:(Please enter distances if less than required) Building Foundations > 10’Yes if No ft Property Line > 5’Yes if No ft Absorption Field > 5’Yes if No ft Water Main > 10’Yes if No ft Water Service Line > 10’Yes if No ft Surface Water > 100’Yes if No ft Wells on Adjacent Lots: Private Wells > 100’Yes if No ft Community Wells > 200’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 Property Line > 10’Yes if No ft Water Main > 10’Yes if No ft Water Service Line > 10’Yes if No ft Surface Water > 100’Yes if No ft If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’Yes if No ft Community Wells > 200’Yes if No ft F. ENGINEER’S COMMENTS G. ENGINEER’S CERTIFICATION I certify that I 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. 1/19/22 n/a ✔ ✔ ✔ n/a ✔ ✔ ✔✔ ✔ (1) H E__ - ----------- Lot 78 T 4'9t1h'N_ /Maur Surveying — I 0 is 30 US SURVEY FEET _Shed Lot 62 S 89*45'21" W 131.01' X_ X 10' utility Ease._ Shed 1;�_) -- — — — — — — — — 91 O 43.4' O O M Lot 71 80 ]Lot 7(()' N 89'45'21'"E 131.83' .:''�OFAq�ll �. 419 .... .. .. .. ere urs L 79 > E5 -1 EAGLE RIVER ROAD ?2 M Cf) A1W AW OF NOTES -All dimensions shown are grid bearings and ground distances, record boundaries are per Plat No. 63-70 -49th Star has conducted a physical survey of the property and all details shown on this Asbuilt Survey are correct. Under no circumstances should any data hereon be used for establishment of property lines. -It is the owners responsibility to determine the existence of any easements, covenants, or restrictions; no title research performed. AS BUILT SURVEY LEGEND 49th Star Surveying Lot 79, r(D_) Power Pole PO Box 738 Girdwood, AK 99587-0738 Eagle Crest, Addition 1, OW Well (907)891-6111 Eagle River, AK X X Jeremy@49thStarSurveying.com Fence W.O. 2143 11/6/21 SCALE: 1"=30' #1: Time Date Insp · ' ~MUNICIPALITY OF ANCHORAGE... EAGLE RIVER AREA DEPARTME;- 'OF HEALTH AND ENVIRONMENT} PROTECTION 825~'L Street, Anchorage. Alaska 99501 264-4720 Date Received: March 14, 1978 #2: Time #3: Time Date Date Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: Mailing Address: Phone: 2. Property Owner: Mailing Address: Donald/Gail Mac Kenzie Star Route Box 1380 99577 Phone: 694-3221 3. Legal Description: Lot 79 Tract A Eagle Crest Subdivision 4: Single Family Residence: (~ Multiple Family Residence: ( ) Number of Bedrooms: Three Number of Bedrooms: 5. Well System: Individual well (~ Community/Public System Permit # Depth of Well _~%~ ~ Well Log on File Construction Bacterial Analysis 6. Sewage Disposal System: On-site System (x) Public Utility ( Permit # ~&~%.%/~ Installed %q~ Installer Septic Tank Size ~(~-~.% ~% Manufacturer C~,~¢- Absorption Area ~ Soils Rate ~ Material ~Q~,.~. e Distances: Well to Septic Tank ~' to Sewer Line Nearest Lot line to Nearest Lot Line to Absorption Area ~' Absorption Area ~'~LINICIPALITY OF ANCHORAGE Department of Health and Environmental Protection 825 L Street, Anchorage, Alaska 99501 ~'--~quest for Approval of Individual Sewer and Water Facilities Property· Owner: Mailing Address: Name of Buyer: Mailing Address: Donald and Gall ~acWenzim ~R BOw l"~{'J ~a~]~ R]ve~ q9~77 Phone: 694-3221 '" ~ Phone: 3. Lending Institution: ~//> _~.~ Mailing Address: Phone: ..-~., Realtor/Agent: Paramount Pmope~t]e~ Mailing Address: 220 E, Int'l Ai~oo~t Rd. 99~n> · Phone:~-. Legal Description: Eagle Crest Sub. T~act ~ Lot 79 Street 'Locationi ~.4 Eagle Rive~ Rd. Single Family Residence: Multiple Family Residence: Number of Bedrooms: ~ Number of Bedrooms: Water Supply: * Individual Well If Individual Well, well depth (X) Public/Community System ( ) If Community System, name of system Sewage Disposal System: *~n-site System k ) Public System ( ) If On-site System, date of ~nstallation: 1977 *NOTE: A well log is required o~ ALL wells drilled since 6/75. ** If on-site sewer system ~s over two(2) years .test is required by this department. ~NVIRONMENT~ A fee of $25.00 must accompany each request before processing can be initiated. ~AR ~ 4 1978 3/77 RECEIVED ?age Two Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 79 Block A Eagle Crest Sudivision Comments: Affadavit ~~ Attached: Approved: Disapproved: Letter Attached: ( ) Date: Date: Department Worksheet: /,-.,MUNICIPALITY OF ANCHORAGE.~ DEPARTMEN' JF HEALTH AND ENVIRONMENT;~PROTECTION 825 L Street, Anchorage, Alaska' -99501 279-2511, ext. 224 or 225 Date Received: April 20, 1977 #1: Time 10:00 a.m. #2: Time #3: Time Date 4-21-77 Thurs Date Date Insp Dixson Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: First National BAnk of Anchorage,.. Mailing Address: Post Office Box 720 99510 Phone: 276-6300 2. Property Owner: S & J Enterprises Mailing Address: Box 89075 99508 Phone: 694-9958 3. Legal Description: Lot 79 4: Single Family Residence: ( ~ Number of Bedrooms: Multiple Family Residence: ( ) Number of Bedrooms: 3 e ® Well System: Public/Community System: ( ) Individual Well: ( Permit# Well __ Well Log on File Construction Bacterial Analysis Sewage Disposal System: On-site System ~ Public Utility ( ) Permit # ~ ~ 0 Installed ~/~ Installer Septic Tank Size f~O~ Manufacturer Absorption Area ~ Soils Rate /~ ~ ~ Material Distances: Well to Septic Tank to Sewer Line ~ /~ ' Nearest Lot line to Nearest Lot Line /~ ; to Absorption Area ~' / Absorption Area ,/ ..... ,,O~UT~ oI:,i,~',4~JN1:CIPALITY OF ANCHORA ! ..~,~ ~, Depa=~eAt:..~f~lth and Environmenta..'Protection { ~~'~ ~['~.O~AL~'~'"~-~e~, anchorage, Alaska 99501 "' ~;~e~ ~o::~o~o~,o" ~.~*w~ S~e= ~n~ ~r. ~c~.~:t~.. 1. Property Name of Buyer~ Address Phone: Mailing : Institution: Lending Mailing Address: Phone: Se Realtor/Agent: Mailing Address: Phone: Street Location Single Family Residence: Multiple Family Residence: (~N~mber of Bedrooms: ( ) Water Supply: *Individual ~';ell If Individual ~qell, well depth Number of Bedrooms: ( ~Public/Co~munity System If Community System, name of system ( ) 8. Sewage Disposal System: On-site System (~Public System ( ) If On'site System, date of installation: *t~OTE: A well log is required on ALL wells drilled since 6/75. 3/77 . ,age .Two ~ · ~ '- ' Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 79 Tract A Eagle Crest Subdivision Comments: Affadavit Attached: ~(i) · Letter Attached: .( ) · . ~ Approved: ~ Date: Disapproved: Date: Department Worksheet: