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HomeMy WebLinkAboutAUDUBON HILLS TR A1 Municipality of Anchorage Page ~of 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: ~ ~ ~/'1r''5 ~ PID Number: ~)t %' - 2..~! ~- Name: ~ ~ ~ ['~"~ ~ ~ ~ 5 Wastewater System: U New ~Upgrade Address: L~ O~ t ~, ~ ~O n ABSORPTION FIELD Phone: No. of Bedrooms: ~ ~ Deep Trench ~hallowTrench ~ Bed ~ Mound ~ Other L E G A L D E S C R I PTI O N Sol, Rating:/ Total Depth from original grade: Lot: ~__[ Block:~ ~_~ubdiv~ion: ~/ ' Depth to pipe bosom from originalgrade:~ Ft. Gravel depth bench pipe¢ Ft. Township: Range: ~ Section: Fill added above original grade: Gravel length: I Numar of lines: Distance be~een lin~: WELL: ~,e~ D Upgrade Gravel width: ~ Ft. / I ff/~ Ft. Classification (Private, A,B,C): Total Depth: Card To: Total absorption area: Pipe material: Driller: Da~e DriJled: S~ticWater Level: Installer: Date instated: r"um"Se I Casing Heigh, Ab°ye Gr°und: SEPARATION DISTANCES ~eptic ~ Holding D S.T.E.P. To Septic Ab~rption Lift Holding 3ublic/Private Manufacture~ Capacity in gallons: From Tank Field Station Tank Sewer Lines Surface Line Remarks: BENCH MARK , Location and Description: I Assum~ Elevation: / 0 o F~, ENG~~ Inspections pedormed by: Dates: 1st 72-013 (Rev. 9/91) MOA 25 2 2 Permit No. 980458 Page of Municipolity of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchoroge, Alasko 99519-6650 Telephone: 343-47¢4 On-Site Wostewater Disposal System and/or Well Inspection Report Legal Description: LOT A-1 AUDUBON HILLS PID No.: 015-251-64 f ~" ~ S 89'5~7"59~ 150.00' -~ . ~ ..~ / ~" FRONT DOOR ~A XISTINO WELL . ~-¢' EL. 100' ~XX ~ ~EXI%TINO WELL / ' ¢-~. ~'%~ ~ ~3 156.7' I , _ ¢a~k ~11~ [bk/ FRAME HOUSE / g ' ' ' 4 ' ~ ~GREENHOUSE / ~ . z ~ 85' 80'~..~ MT1 90' 79' *C02 ~2' 47' ' C03 72.S' 5U C04 72.75' 59'~'°d' ' - ,- C06 97' 84.4' ASBUILT SCALE: 1"=50' C 01 1.C.0.2n ~C~C.04 NEW S ~DE ]RENCH J ,,.,,' -%.~,' ,,, ,,.,,'- c.0., ~ ~E [X,S~,N~ moo 9~.~ .02'~ f~ %.,'2'. CE ~9469 ... ~ALE: NTS MUNICIPALITY OF ANCHORAGE Department of Health and 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: Nov 12, 1998 Expiration Date: Nov 12, 1999 Permit Number: SW980438 Legal Description: AUDUBON HILLS TR A1 Design Engineer: 0088 Anderson Construction & Eng'g Owner Name: U. L. & CLIENA GROSS Owner Address: 12001 AUDUBON DRIVE ANCHORAGE , AK 99516-2421 Parcel ID: 015-231-64 Site Address: 012001 AUDUBON DR Lot Size: 64600 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. / Date: //-12.-?8 October 31, 1998 MICHAEL N. ANDERSON, P.E. 14250 N. Goldenview Drive Anchorage, Alaska 99516 (907) 345-3377/FAX 345-1391 t ov 03 Municipality of Anchorage Dept. of Health & Human Services On-Site Services Section 825 L Street Anchorage, Alaska 99501 Subject: Lot A-l, Audubon Hills S/D Sewer Upgrade Gentlemen: The sewer system for the three bedroom dwelling on the referenced lot has failed and must be replaced. A single testhole was dug on October 24, 1998 and percolation testing performed. The results are attached for your review. The new system will be a total depth of 5.5 feet and will consist of a single shallow trench 38 feet long with 4 feet of gravel below the pipe. During the excavation for the trench we plan to expose the existing septic tank and verify its integrity. A new 1,000 gallon tank will be installed if necessary in the same place. There is sufficient grade from the tank location to the proposed trench to have gravity entry into the trench. Final grading will ensure sufficient cover over the trench. The new system will be more than 150 feet from the adjacent well which serves a bed and breakfast (duplex) and a second separate dwelling. There is no surface water within 100 feet of the installation site, and there appears to be no adverse impact posed to other lots by this installation. If there are any questions regarding this application, please contact me at 345-3377 or FAX at 345-1391. Michael N. Anderson, P.E. Attach. LDT 4 VACANT WASTEWATER DISPOSAL SYSTEM LOT A-I, AUDUBON HILLS LOT 3 / / AREA SEWER AREA VACANT LOT 1 0 WELL VACAN] DESIGN DETAILS: 1. 3 BEDROOMS X 150 GPO = 450 GPO FLOW. 2, 450 GPO/t2 GPD PER SQ, FT, = 375 SO, FT, ABSORPTION, 3, TOTAL DEPTH F1F SYSTEM 5.5 FTi GRAVEL DEPTH 4,0 FT, 4, 375 SO, FT./5' WIDE TRENCH X R,F. 50% (4' DEPTH) = 37.5 FT. LENGTH, 5. INTEGRITY OF EXISTING 1,O00 GALLON SEPTIC TANK WILL BE VERIFIED DURING INSPECTION. NEW 1,000 GALLON ANCHORAGE TANK WILL BE INSTALLED IF NEEDED. 6, NEW TRENCH WILL BE INSULATED WITH 2' HDPS SHEETS IF <~ FT, FINAL COVER, FABRIC WILL BE USED, 7, OLD TRENCH WILL BE ABANDONED IN PLACE, PREPARED FBR: UWE L. S, CLIONA GROSS 20001 AUDUBON DRIVE ANCHORAGE, ALASKA 995i6 MICHAEL N, ANDERSON, P,E, 14250 GOLDENVIEW DRIVE ANCHORAGE, ALASKA 995~6 DATE: ]0/26/98 SCALE: l'= lO0' DRAWING S-1 PERFORMED FOR: LEGAL DESCRIPTION: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST · ...... ~' NhCH,A~L N AND~PSCN *~' .~ Township, Range, Section: 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18- 19- 20- COMMENTS SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT /.~ ~ / ~) DEPTH? /-J' p E Depth lo Water Alter~,~, ////¢.~ Monitoring? Dale: / ~ Reading Date Gross Net Depth-t~ c~-~ Net Time Time Water Drop ~ /loL~ ~..¥~ ~?~-- ~ ' ~ /lo7 - M~r ~ PERCOLATION RATE ~-' (m~nuteslinch} PERC HOLE DIAMETER __ TEST RUN BETWEEN ~' ~FT AND ~' C3 FT . I CERTIFY THAT THIS.TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) ~~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO1 ECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME ~ PHONE I [~NEW MAILING ADDRESS LEGAL DESCRIPTION ~ DISTANCE TO: jw""/OO/ + IAb~o~rea~/ Dwo,,?~ , PERM,TNO. ~ Z Manufacturer~~ ~ Ma~~~ ~o. of~comoartments ~ Liq~T~ in gallons IF HOME.DE: Inside length W~h r Liquid depth ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. ~ -- ~ Manufacturer Material Liquid capacity in gallons ~Z DISTANCE TO: /OO + ~ / Length of each line ~t ~--~ ~ No. of li~ grade / ~ Total le~h~nes Trench~i~h// inches Distance between lines ~ ~ Top of tile to finish / Material beneath tile / Total effective absorption area ~ ~ inches Length Width Depth PERMIT NO. ~ P Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: . . Cla~~ Depth Driller Distance to lot line P~T ~O~ ~ m Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE MATERIALS SOIL TEST RATING REMARKS [G/ I APPROVED DATE LEGAL '2-013 (Rev. 3/78) PERMIT NO. ~PPLICRNT LUDWIG ZERBE LOCATION AUDUBON DR LEGAL LA-± B2 AUDUBON HILLS S/D ,~L. TH RND EN'v'IRONMENTRL P .,Z:TION [:,EF'RRTMENT 0t 825 '"L'" STREET.. RNCHORRGE, RK. 99501 264-4720 180& E. 68TH ~44 2~6t LOT SIZE 20000 SQUARE FEET T"r'PE OF SOIL ABSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS SOIL RATING ,.':SO FT,.."BR)= 85 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: [:, E F"T'H = 7 LEI'-IGTH= _--~:-- 2 I3 F-: R',,..' E L [:,EF'TH= 4 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIEL. D. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AN[) THE BOTTOM OF THE EXCAVATION (IN FEET). F]:E~;!IJ I ~:E[:, SEF'TIC: TBP4~: L~ I ZE= ~ ISFtLL~]~S PERMIT ~PPLICRNT HAS THE RESPONSIBILIT~ TO INFORM THIS DEPRRTMENT DURING THE INSTRLL8TION INSPECTIONS OF ANY WELLS RDJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. T~-ICI ( 2 :) I I'-,ISF'E~-:T I r~-4_c- FIF-:E F-:EI_---.!LI I F-:E[:, BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AN[:, APPROVAL BY THIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR R PRIVATE WELL; OR ±50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRLICTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F'Ei-~:r-11 T E:=-=:F' I E:E-]S."; [:,ECEf-IE:EF-' 2::1... 197:_=: I CERTIFY THAT t: I AM FRIdlLIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ~CCORDANCE WITH THE CODES. 3; I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENL8RGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3: BEDROOMS. SIGNE[:'' ~~_ '~4IG~ ~ Z~,~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99502 276-222~ SOILS LOG - PERCOLATION TEST ~ SOl LS LOG [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O SLOPE WAS GROUND WATER ENCOUNTERED? SITE PLAN L O IF YES, AT WHAT E DEPTH? : i : Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch} DATE: 72-008 (7~76) 2833 East 7Znd Avenue DALLY DRILLING LOG PENN JERSEY DRILLING CO. Anchorage, Alaska 99502 344-2612 DEPTH OF WELL ................. .~..~.:. ........................................................................... STATIC LEVEL OF WATER FT ......... ..~.~..*. ...................................................... DRAW DOWN FT ................................................................................................... (~ALS. PER HR ......................... ~.~-~.....~--; ................................................................. KIND OF CASING....,~/.~...~]_~ ...... ~..../.L...~...~.....'....~.:~....,'. ......................................... KIND OF FORMATION: FROM ........... ii ............. FT. FROM ........... ~ ............. FT. FROM .......................... FT. FROM .......................... FT. FROM ........... ~..~ .......... FT. FROM .......................... FT. FROM .......................... FT. FROM .......................... FT. FROM ........... i..~. ........... FT. FROM .......................... FT. FROM .......................... FT. FROM ......... ~.ii' ............. FT. TO ..........~ ............. FT.....~./ ......... FROM ......... .-.~ ............. FT. TO .......... i.~ ............. 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 ......................................... MISCL. INFORMATION: DRILLER'S NAME....= ............... ~...,i....~. ...... ~ ...... ~ .......................................................... MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AU'FHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner · Mailing address Lending agency Mailing address Agent Address Day phone "~ Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: '-~ TYPE OF WATER SUPPLY: Individual well ~' 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. 72-025 {Rev. 1/91) Front MOA #21 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 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_tigation 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. Engineer's signature /'~ / /'/~1~.,-~_. Phone "5,,w 5-- %~ '~ ';z- Date ...s / Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Arichorage 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 DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees 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. 72-~25 (Rev. 1/91) Back MOA #21 RECEIVED Municipality of Anchorage DE'C 2 DEPARTMENT OF HEALTH & HUMAN SERVICESMuNi¢iPALrr¥ Environmental Services Division ENVIRONMENTAL SERV/C 825 L Street, Room 502 * Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: Health Authority Approval Checklist ~c~ff. ~G~q ,~'//-5 Parcel I.D.: A. WELL DATA Well type .-~--~ 4~ Log present (Y/N) 7 Total depth ~ ~ ' Sanitary seal (Y/N) y If A, B, or C, attach ADEC letter. ADEC water system number Date completed '7',~ IS ~'~¢¢ Cased to ~"'¢- / Casing height (above ground) Wires properly protected (Y/N) Date of test Static water level Well production FROM WELL LOG · ~.~ ~ ¢_ AT INSPECTION /g2 g.p.m. /'7/- g~' 7' WATER SAMPLE RESULTS: Coliform r.~ Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed '7~ / 2. - '7 ~ Tank size Foundation cleanout (Y/N) y Date of Pumping Nitrate ~z~. C~ "'-p Other bacteria Collected by: /, ~--~-g Number of Compartments D~- Cleanouts (Y/N) . Depression (Y/N) A) High water alarm (Y/N) Pumper /Jr -/~ C. ABSORPTION FIELD DATA Date installed I1t//~/'~¢~ Length ~ ~ / Width Effective absorption area '~ ~ 0 Soil rating (g.p.d./ft2 or f¢/bdrm) ,~ r Gravel thickness below pipe Monitoring Tube present (Y/N) Date of adequacy test Fluid depth in absorption field before test (in.); Fluid depth / (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) Results (Pass/Fail) System type ~- w~.& Total depth __ Depression over field (Y/N) t'f/,~- For f~ bedrooms Immediately after gal. water added (in.): Absorption rate = ~ .g.p.d. If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) ~ Size in gallons ~ "Pump on" level at* ~mp off" level at* *Datu~ E. SEPARATION DISTANCES Septic/holding tank on lot Absorption field on lot Public sewer main SEPARATION DISTANCES FROM WELL ON LOT TO: f ~c:~/+ /~ ~ Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ,~/.~'t Property line ~ ~ t-t~ Absorption field Water main/service line ~-~ / '~ Surface water/drainage ? ~ /~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Surface water Curtain drain Building foundation ~' ~ ~ Water main/service line 2-~ /~ Driveway, parking/vehicle storage area /c~ o -/- Wells on adjacent lots ! ~-~/+ F. ENGINEER'S CERTIFICATION HAA Fee $ Date of Payment Receipt N umber (~" vT/~' ,~z'//6" I certify that I have determined thru field inspections and review of Municipal records tl~f'~'~.a~~stems are in conformance with MOA HA~ guidelines in effect on this date. Engineer's Name ~,r ~,* ( r~ ,fid J W +o~ O~ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* ~ MUNICIPALITY OF ANCHORAGE DEPT, ©: :::".L'F ~ & DEPARTMENT OF HEALTH & ENVl RONMENTAL PROTECTIONE~';VIR©Ni'''':NT'~L ;' :'J' ZCTtON  825 L Street-Anchorage, Alaska 99501 APR 1 9 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 RFCEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DI R ECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY~NER ~ PHONE MAILING ADDRESS -[: PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION,/, ' ' I PHONE MAILING ADDRESS 4. REALTOR/AGENT ~ U" 0f - ~ (.,/ [ PHONE I MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE [~/' SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four [] Two [] Five ~ Three [] Six [] Other 7. WATER SUPPLY ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTI LITY * ATTACH WELL LOG. A well Iog~s required 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 [~'"~1 N D I V I DUA L/ON-SI TE** [] PUBLIC UTILITY **lfindividual/on-s,te, g,ve,nstallat,ondate ~.~'~. ?~ · If system is over two (2) years old an adequacy t~st is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: NUMBER OF BEDROOMS 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX [] OTHER 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM []INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: i~--~ If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING MANUFACTURER MATERIAL Septic/Holding Tank IAbsorptio 1 / Sewer Line ] Nearest Lot Line 5. COMMENTS --APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED LEGAL DESCRIPTION 72-010 (Rev. 3/78)