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HomeMy WebLinkAboutHIDEAWAY LAKE BLK 1 LT 2Hideaway Lake Block 1 Lot 02 #015-471-06 0 3 D,5: 2101'9 2 21: 3', 9 0 7 -'3-'5-X3202" ALPINE DRILLiNGi PAGE 01/0i Permit NizaiNr; 9SW— Date of Issue; Parcel Identification Nun-iber: Date Started. 6-20-'1f3 Date Completed, 6-21-19 Is well located at app,-oved permit. location? N Yv% N -T 4) Legal Description; Hideaway Lako Block I Lott Property Owner Nam & Address: Richard Henningsen 10860 Hideaway Laky Drive Anchorage, Alaska 99507 Borebole Data, Soil Type, Tliickness & Water Strata existing well san4y grmelly dir slipy watepsand & ,Tavel Depth (ft) T Frc)III To Method of Dxiltfing x air rotary 0 cable too] — —,*---- Casing type: steel I 0 95 inches 95 116 Diainater: 6 hw.1 hes Depth: 18 -,feet I Liner Type. _ 116 H8 Diameter: inches Depth: feet Caskig sticleuip above ground: 2 feet stutie water level (ftom guoulvl 91 fee't Pumping level: -90 feet after 2 hours puinping 12 gpnn Recovery Rate- .12 gpir Method of Testiug:!qjr IjEr Well Intake Open.hig Type: x Open End Ej Open Hole Screened Start' feet StoplleA Perforations Start feet Slopped Leet Grout Ty pe. —bent—ani_se Volume: Lb? Start 0 %t Stopl2ed feot Puixp: Intake Depth feet Pwiip size lip Brand Narns Well Disinfected U(IOU Completion? 0 Yes 0 No Method of Disinfection. Comments: Pb Box 110496 Anchorage AK 99511 72-013 (Flee. 9/91) MOA 2S Municipality of Anchorage Page / of _sem DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 0 Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: S �✓ �iBOC7 �/ PID Number: 0/5 - Y,? / - 06� Name: AA iCl-EL T. 01 Nlei/ El System: New C3 Upgrade Addreaa:"q /C$CoO E !� Y L41—IC �R i(� ABSORPTION FIELD Phone: 7 yS—,SiB No. of Bedro ms: 25 Dee Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other P LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: ' /• d GPD/Sq. Ft. Lot: Block: / ubdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe 1_14C4JA y L 3' Ft. 5 Ft. Township: Range: Section: Fill added above original grade: Gravel length: r _ ^— Ft.LMb /G ..,.._ .�r ro-41 Ft. lines: Distance bet een lines: WE ❑ ew ❑ Upgrade Gravel width: 51 Ft. CO Ft. Classification (Private, A,B,C. Total Depth: Cased To: Total absorption area: Pipe material: Ft. Ft. SS"O SO. Ft. I 7h �&3a 3 `/ F8/© Driller: Date tl: Static Water Level: Installer:}� d2 S Date installed: y Ft. Cl\U '✓Rc/e//(7C Yield:Pump Set at: Casing Heigh ve Ground: TANK GPM Ft. SEPARATION DISTANCES X'Septic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lin Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines CX -fjjQ Well- rMaterial: /li0 f- /00, S- K la A / o 4 S'iL L Number of Compartments: o2 Watere /00 /,)0,1L N /00 LIFT STATION Lot Size in gallons: cturer: Line /0 FoundationS r r r{ 'Pump on" level at: "Pump off' at: High water alarm at: / 0 f / 0 CurtainPump A A Make &Model Electrical Inspections performedby: Drain N N Y Remarks: S77,c C /N7c i. — cep BENCH MARK tY !JE TE L -. Location and Description: _ M - S(j C111e,41 ex AT -T4 6#4) r5 fd,L3�vCr -a.2 raw z cn� v SE T o 0 -FL LrQR G AV e,(. No 6144o CK Pit aAt'� O 4Ti Assumed Elevation: .. w1 - s. IMPR� fL.v LdQ4 v1L(; lh 4 -.✓r C'h. VLO )4,1,Ch�, %i/3O.Tljn4L /0 °Ip A'4 i76d [-r A T %sNG-(d Fat CoNA, C0.14-,jp Inspections performed bye & `ENGINEERING callic teS: 1St S-/91- 9,5' .. 20WAN A`\ ­ROS Eagle River, Alaska 99577 2nd `5 -do - F E - 8sol -s �cE 3,ad�s Department of Health and Human Services approval tt'e`\c,.Ls" n_s Reviewed and approved by: w • ��"� Date: 6. 8 72-013 (Flee. 9/91) MOA 2S PERMIT No. SW980081 PAGE 2 OF 2 DEPARTMENT Anchorage SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 •Anchorage, Alaska 99519-6650 • Te'l'eahone 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL Lot 2, Block 1, Hideaway Lake OLD DRAINFIELD-\ 110 SErBACK w NEW DRAINFIELD�� Y TH Q J RENS i ,p0 HELL W_.W—W W_W LSI EXISTING WATER LINE P.I.D. NO. 015-471-06 FINAL GRADE MT COI = 88.75' CO2 = 88.7' -7G�GRQUND WATER r,4.3 B.O.H. LO"VALVE ATH ►2 DN M\ \ LO /EXISTING 1250 GAL. TANK r Sn N STz ri �J CO2 O O MT1 B SZ; O� I-10, ASPHALT LOT 2 MTI = CO2 = = 83.8' SQa� P SCALE 1 40, R6bERT C. COWAN 1 CE -8801 r PERFORMED FOR: LEGAL DESCRIPTIO (FEET) 2 3 4- 5- 6- 7 567 8 9 V i 10- 12 0 12 m.`. 13` 14- 15 16- 17- 18 61718 /. 0A6.09,19 cS Emmummm■■■'. ■■■ummm■m.I p O-A,444f— 4.94,4 y,� 6cc4SOa —qt LAv4.25 0 i -- S'0' =. '0' of WAS GROUND WATER 0 ENCOUNTERED? 19 20 COMMENTS s IF YES, AT WHAT L DEPTH? O P E Depth to Water Aller �I Monitoring? P.. y 6 Date: PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT S & S ENGINEERING PERFORMED BY1 p oa o. I CERTIFY THAT THIS TEST WAS PERFORMED IN pp �� ACCORDANCE , � #dt*lf@ AR=IPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: / 2y 72-008 (Rev. 4/85) PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE' DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW980081 DATE ISSUED: 4/28/98 DESIGN ENGINEERS & S ENGINEERING EXPIRATION DATE: 4/28/99 OWNER NAME:O'HARA MICHAEL J & PATRICIA A OWNER ADDRESS:10860 HIDEAWAY LAKE DR ANCHORAGE, ALASKA 99516 PARCEL ID:01547106 LEGAL DESCRIPTION: HIDEAWAY LAKE BLK 1 LT 2 LOT SIZE: 51649 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD SYSTEM 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 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PR04T'S'I'0NS:' EXISTIN u�FTION FIEID` nn,. V` ISSIONED A G 0 D mi" ABS1"0Ata $TISFS `bpi OF b.. s».k.9.. J5.. .e v tip.... .. ..m._ ... • �, RECEIVED BY. ,��� DATE: S& April 8, 1998 ROBERT C. CIVIL ENGINEERS (907)694-2979 FAX(907)694-1211 HEALTHAUTHORITV APPROVALS MIJNICIPALITY OF ANCHORAGE Department of Health and Human Services SEWER&WATER P.O. Box 196650 MAIN EXTENSIONS Anchorage, AK. 99519 REFERENCE: Lot 2, Block 1, Hideaway Lake S/D SEWER & WATER INSPECTION Request you issue a permit to install a septic system to serve the existing four bedroom house on the referenced property. ENGINEERINGSTUDIES ANDREPORTS The existing system does not meet Municipality requirements and needs replacing. One test hole was excavated and percolation tests were performed. The approximate WELL INSPECTION location of the test hole is located on the attached site plan. & FLOW TEST At the time of excavation, groundwater was encountered in the test hole at 15 ft. After seven day groundwater monitoring, the monitoring tube was checked and groundwater SITE PLANS was found a 14.5 ft. We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. ROAD DESIGN If yourequireadditional information, please contact us. SOILTEST� LL Sincerely, PERCOLATION TEST Robert C. Cowan, P.E. STRUCTURAL& RCC/jlm MECHANICAL INSPECTIONS Enclosure ONSITE WASTEWATER DISPOSALSYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 P.E. i." = 60'I SITE PLAN I DESIGN SCAL 0> NNU700 �—] vNmvoOv O�NA d C mxr o x C�7 �cnv C z z r mm Z C\J y K JDc Zovim°m Oma C7 i� II q�y qy� aHz sm Z I II zo m � � C. w I H.. 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Z ✓Ci+. �6 b� DESIGN DETAIL qy< X r ' x J p o Z Gi £ N 0 O O t.-4 0 O N D I m 2 m m 0 p � m OAD0 n D m I p D a E � Z � � I � r E -iZm�� Oz �O p 10' MIN. 0 1 re- ° EXISTING 4 z L< o BDRA,I, HOUSE Z W D Ll Gw rn-nA C O r x J O N O t.-4 0 O m A NCA ; � 0CA 0 m m OAD0 n D N m r � fn AO9mz y;~p n O02-xm Ln SCZ7 S>X0 Z rr) E -iZm�� Oz xi?c�om_omym N Z�-NImK fOO. 2p. wo>zom� m mmx g-1zZz.0 n±t0 Z OO 9AA c� orz x yM o v m m0 v 0 =n y ° / I rn-nA C O r x J t.-4 t7 NCA ; N 0CA m OAD0 n N m � 0 Ln m IIO� �►� 0) m a OD m ro p O x J t7 g m ON to 00 y Ln a 0) m m C) rn OD mmx x o O C� v 0 =n y O O '.>. j N .0 00 Ao�z o Vl z OCy <yC �y!• z �� �.d� a Municipality of Anchorage hP DEPARTMENT OF HEALTH R HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST r ROBERTC. COWAN r e L�n4•. CE -8801 .�.' PERFORMED FOR: F-VON7✓ i,. 17- Ttf-i On/ ry+� DATE PERFORM ED:'':; -'-.;i'g LEGAL DESCRIPTION: J,47_ iiz. K ( a) 06,4Wky 1hi jownship, Range, Section: DEPTH SLOPE SITE PLAN 18- 19- 20- COMMENTS (FEET) j 8 ;< 2 3 < Poc,2L'� G-2gAED 4 � . SP 5 SoHrc GP.AVsi L 12- 6 SAl S)t ry SifNO 7 18- 19- 20- COMMENTS 8 ;< 9 10- 012,3 12- 13- 14- 1415 15- 16 16 S f, 17 . p, 0- 181920COMMENTS WAS GROUND WATER ENCOUNTERED7 y�5 S IF YES, AT WHAT LO DEPTH? P E Depth to Water Ager ' Monitoring? / 4 Date: PERCOLATION RATE a (minutes/inch) PERC HOLE DIAMETER 6" TEST RUN BETWEEN G FT AND —7 FT PERFORMED BY: 17034 Eagle Rivet' Loop Road No. 204 CERTIFY THAT THIS TEST WAS PERFORMED IN Eagle River, Alaska / // v ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ` 70/ d 72-008 (Rev. 4/85) ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Lot 2, Block 1, Hideaway Lake Subdivision April 8, 1998 GENERAL: 1. The scope of this project includes verification of the integrity of the existing 1250 gallon septic tank, and replacing the tank with a new tank of the same capacity, if the integrity is unacceptable. Additionally, the project includes the installation of a leachfield trench to serve the existing four bedroom residence located on the referenced property. 2. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater. Disposal Regulations. 3. The contractor shall be responsible for obtaining any necessary underground utility locates. 4. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: 1. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 3. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. Page Two Lot 2, Block 1, Hideaway Lake Subdivision April 8, 1998 5. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. 6. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: 1. Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed -up) before gravel (sewer rock) placement. 2. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. 3. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. 4. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. 5. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIMUM MATERIAL SPECIFICATIONS: 1. Any septic tank proposed for installation must be constructed by a Municipal approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Page Three Lot 2, Block 1, Hideaway Lake Subdivision April 8, 1998 Type of Pine Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). 5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. 6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. 7. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements, which ever requirement applies. INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: 1. The fust inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. 2. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property. Page Four Lot 2, Block 1, Hideaway Lake Subdivision April 8, 1998 Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre -construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER 72-OWRev. 3/78) a -_IVIUNICIPALITYOFANCHORAGE DEPARTMENT OF HEALTH 81 ENVIRONMENTAL PRO"V`ECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 -SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT 6Ea���- v PHONE l"''o� ❑UPGRADE r LEG DESCRIPTION i �-a g LOCATION NO, OF BEDROOMS F Absorption area Uy DISTANCE TO: Absor l P �( Dyyel�pg �� PER l Manufacturer ��/" I�-'' Qz r� � w �R�Q�/� Mat No. of coroQartments n F J Lig. c p city iagallons a�IF HOMEMADE: Inside length Width Liquid depth Dz DISTANCE TO: Wel Dwelling M Oz FQ- Manufa r aterial Liquid capacity in g ns m= DISTANCE TSi Well D® Foundatiob Neare r�oYlige No. of lines PERMIT ZW 1= Q x Lengt Or ea in line Total I n of lines Trench wi C � Distance between lines F Top of tile to finish rade C3 orches g Material beneath rile � Totalctiv sorption xF.�/./ Length Wi th th U 1ailn.s area w PERMIT NU. Qd F- w a Type of crib diameter Crib dept P Total effective absorption area w y DISTA TO: Well Building founda " n Nearest lot line J Class Depth Driller Distance to lot line PERMITNO. W DISTANCE TO: Building foundation Sewer line nk Absorption area(sl OTHER PIPE MATERI Sen 3 E SOIL TEST RATING INSTALLER �c7 /�-- REMARKS !-3 / D r 24 APP O D DATE LEGAL 72-OWRev. 3/78) a OWN M -W DRILLING, Inc. .'0. Box 4`1224 • 1310C International Airport Road (907)274-4611 ANCHORAGE, ALASKA 99509 " nRII I INC. l AR Well Owner l a)L n i Litt b kit) �__ 1 Use of Well Dorn. Location (address of: Township, Range, Section, if known; or distance main road Lot 2 Block 1 Hideaway Lake SubdihiaiQn Size of casing 5'"- Depth of Hole 94 feet ` Cased to 23 -feet Static water levet 55 ft. (abovii)` (below) land surface. Finish of well (check one) open end Screen ( ); Perforated Describe screen or perforation Well pumping test atmgallonsper (ho` Y) (minute) for hours with ft. of drawdown from static level. Date of completion September- Y`„f9_n1 WELL LOG r Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness 0 TO 2 Casixl Z TO 3 MUMCIP i3Tc7.Y'i.l.` ALITy OF ANr y�%tG'F 3 TO .41 _ VIR'JNM HfALT,•i Saodv Gr�v'b1 �NTa. aroTE&rl 41 TO 63 Sand', t -3 G L%2 63 TO 33 /Cn s -TO- -TO- air .d; -TO- .' vcft TO Ceetif cit eNo 82rtifled 4 & TO b F= DEPARTMENT ` �• r��'. EALTH AND ENVIRONMENTAL <0TECTION 1 a L' S'TREE'ANCHORAGE, Ah _5f -3T; AN 5 � i �a.aE=rr��-�r a PERMIT NO. ( 810201 ) APPLICANT WAYNE LITTLETON 4.945 WESLEYAN LOCATION HIDEAWAY LAKE ESC LEGAL L2BI HIDEAWR4 LA}::ES TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH c ash-l�-Sf! r� LOT SIZE 45555 SQUARE FEET MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SO FT'BR)= :=5 THE REQUIRED SIZE OF THE SOIL ABSORPTIU_iN SYSTEM IS: Cp E-'='' � �{ = :� . �.-. � r'*' H, j "�' � = ... In IQ! F=t °.° mo i_._ THE LENGTH DIMENSION IS THE LENGTH (IN FEET OF THE TRENCH OR URAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTAMar_.E BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE iXCAVATIbN '(IN FEET THERE IS NO SET WIDTH FOP TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCA`,MTION' � IN FEET`'. s" nr_a_r_ar'.:F PERMIT APPLICANT HAS THE RESPOK'�'IBILITY TO INFORM THIS DEPARTMENT DiSIRING THE INS=TALLATION INSPECTIONS OF ANY'WELL•S ADJRCENT'Thi THIS 'PROPERTY ANDTHE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. — _ — T W r3 < = "_ F ' E—=+A` _r i C-1 r E Eti F=l F� 1~ F';-> iE t -e BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON—SITE SEWAGE DISPOSAL SYSTEM IS 100 `FEET FOR A PPI +'RTE '[BELL OR 150 TO 2C1O FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LIME IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN `0 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPEC:IFIC:ATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTRLLATIOP"a. I CERTIFY THAT 1: S AM FAMILIAR WITH THE REQUIREMENTS, FOR ON—SITE SEWERS FIND WELLS AS FORTH BY THE MUNICIPALITY OF ANCHORAGE; 2: I WILL INSTALL THE SYS SYSTEM Ota ACCORDANCE b.!STH THE CODES. : I UNDERSTAND THAT THE Ota—SITE SEWERr �Y_TEP1 t9Ar PEC21_tSRE ENLARGEMENT IF THE RESIDENCE IS REMODELED'TO`INCLitGE MORE THAN 4 BEDROOMS. SIGNED:____-- APPLICANT . 'NE LITTLETOta IS_,1_IEC; B4 — ---SSSS------—,t--__GATE--- '--��� b'4. 0L 4946a.; T.� '' i 231" FiLf f 3t 'r LAWS LOT SIZE OF N t? [L 1 2 3 5 6 8 I Peat, PT Dame, brown0 sandy 9rave7, GW—"—`__�•__.,, 2 3 4 �y� 5 t Grab sample ? --- �s,lty 1Q Damp, brown, sand 17 Bottom ot Y gravel, GM 13 tom of Hole` - 14 r5 16 NorE. 17� " N, 1• No groundwater 18 2• Estimated P +t�ula able at time 19 F ,a, do 2 f 'iq. n rate of dril7ink Min/inch. g 20 21 I Al 22 i { 24 �� ��b niGb ,/ ..r,�� �, _J DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE DISTRICT OFFICE 800 E. DIMOND BLVD., SUITE 3-470 ANCHORAGE, ALASKA 99515 I .. 349-7755 ez G!a August 4, 1992 RECEIVED AUG 101992 Municipality of Anchorage Mr. Wayne Littleton Dept. Health &Human Services 10860 Hideaway Lake Anchorage, Alaska 99516 RE: Lot 2, Block 1, HideawaVubdivision Anchorage, Alaska, ADEC Project Numbers 9221-DWW-035 and 9221 -DW -082; Review Dear Mr. Littleton: This is in response to a submittal, received in this office on June 1, 1992, in which Mr. Theodore F. Moore, on your behalfrequested approval for the on-site water and wastewater disposal systems located on the above -referenced lot due to the proposed change from a single family residence to a Bed and Breakfast. 1 have completed my review of the submitted information and have the following' comments. WASTEWATER DISPOSAL SYSTEM Based on the submitted information it appears that the wastewater disposal system was installed substantially in accordance with State regulations and guidelines at the time. The results of the adequacy test also verify that on the day the adequacy test was performed the wastewater disposal system was accepting the necessary flows. In addition, there will not be an increase in the volume of wastewater being treated and disposal by the existing -- wastewater disposal system due to the change from a single family residence to a bed and breakfast. Therefore, the wastewater disposal system is approved for the concerns of this Department. The enclosed signed Approval of On -Site Residential Water and Sewer Systems, constituting this approval, is enclosed for the existing wastewater disposal system. WALTER J. NICKEL, GOVERNOR DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE DISTRICT OFFICE 800 E. DIMOND BLVD., SUITE 3-470 ANCHORAGE, ALASKA 99515 I .. 349-7755 ez G!a August 4, 1992 RECEIVED AUG 101992 Municipality of Anchorage Mr. Wayne Littleton Dept. Health &Human Services 10860 Hideaway Lake Anchorage, Alaska 99516 RE: Lot 2, Block 1, HideawaVubdivision Anchorage, Alaska, ADEC Project Numbers 9221-DWW-035 and 9221 -DW -082; Review Dear Mr. Littleton: This is in response to a submittal, received in this office on June 1, 1992, in which Mr. Theodore F. Moore, on your behalfrequested approval for the on-site water and wastewater disposal systems located on the above -referenced lot due to the proposed change from a single family residence to a Bed and Breakfast. 1 have completed my review of the submitted information and have the following' comments. WASTEWATER DISPOSAL SYSTEM Based on the submitted information it appears that the wastewater disposal system was installed substantially in accordance with State regulations and guidelines at the time. The results of the adequacy test also verify that on the day the adequacy test was performed the wastewater disposal system was accepting the necessary flows. In addition, there will not be an increase in the volume of wastewater being treated and disposal by the existing -- wastewater disposal system due to the change from a single family residence to a bed and breakfast. Therefore, the wastewater disposal system is approved for the concerns of this Department. The enclosed signed Approval of On -Site Residential Water and Sewer Systems, constituting this approval, is enclosed for the existing wastewater disposal system. Mr. Wayne Utteton August 3, 1992 Page 2 DRINKING WATER SUPPLY SYSTEM From the information that has been submitted, it appears that the water system was installed substantially in accordance with State regulations and guidelines for public water systems at the time. Including the fact that there will not be an increased in the peak demand placed on the existing water system resulting from the change (going from serving a single family residence to a three bedroom bed and breakfast) and the analytical results for Total Coliform Bacteria and Nitrate (as nitrogen) returned satisfactory, the water system is approved for the concerns of this Department. The Final Operation Certificate, constituting this approval, is enclosed for the existing Class C Public Water System. At this time, the Department is assigning Public Water System Identification (PWSID) Numbers to all Public Water Systems in the State. As a result, the PWSID Number assigned to this system is 21779. The present State Drinking Water Regulations do not require any routine water sampling for Class C Public Water Systems; however, I recommend that you have water samples analyzed for Total Coliform Bacteria and Nitrate (as nitrogen) twice a year during the months of March and September. If you do sample, please place the assigned PWSID Number on the lad request form so the results will be credited to proper file. Thank you for your cooperation with this Department. If you have any questions, please do not hesitate to call. Sincerely, 4ev-, /Z _Keven K. Kleweno_ District Engineer Enclosure: As Stated cc:Joh Smith; DHHS,�/o DTq Ted"Nfoore,' :Flattop Technical Services KKK/pf Municipality of Anchorage On -Site Water & Wastewater Program (907)343-7904 � c CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 015-471-06 Expiration Date: z MAR 2 ? 2014 1. GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address Real Estate Agent HIDEAWAY LAKE S/D; BLOCK 1 LOT 2 10860 HIDEAWAY LAKE DRIVE ANCHORAGE, AK, 99516 STEVEN DUNN & LAURA MCARDLE Day phone C/O AGENT 10860 HIDEAWAY LAKE DRIVE, ANCHORAGE, AK, 99516 JULIE ERICKSON W/ REMAX/DYNAMIC Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: 242-9282 TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual On-site 0 Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ W aiverNanance request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ ��! (WI I Waiver Fee $ tl Date of Payment ��J`� i jlDate of Payment Receipt Number/b n'c� Q �yy�{� Receipt Number COSA # tolyl yl`i a Waiver# Distance: — 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, l 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. f 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. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK, 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Lto attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described 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 aft wells and septic systems depend on the local soils condition, groundwater 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 the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit ofthe owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal fight whatsoever. 6. DSD SIGNATURE System #1 Approved for bedrooms. f System #2 Approved for Disapproved. Conditional approval for bedrooms. NIT.7T 337-6179 Date 3h CiLIP bedrooms, with the following stipulations: OF A, ness,- —79P3 OF A*, r(t J2 16, ON-SITE =� WATER AND �0 WASTEWATER � w� PROGRAM By:/%"�G �'"y f ( �f Original Certificate Date: — The Municipality 96Anchorage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatations 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 engineers work. 7. ATTCHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory fe- 111(151 ` Nitrate Advisory Arsenic Advisory Other If more than 1 septic system is on the lot: COSA Checklist # _of_ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: HIDEAWAY LAKE S/D; BLOCK 1, LOT 2 ParcellD: 015-471-06 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 9/15/1981 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 94 ft. Cased to 93 ft. Casing height (above ground) 72+ in. FROM WELL LOG AT INSPECTION Date of test 9/15/1981 3/13/2014 Static water level 55 ft, 50 ft. Well production 10 g.p.m. 3.34+ g,p,m, WATER SAMPLE RESULTS: Coliform Or, colonies/100 ml. Nitrate �'�9 mg./L. Collected by: GEG,. Ltd. Arsenic: G Ja ug./L. Date of sample: 3/13/2014 B. SEPTIC/HOLDING TANK DATA *DOUBLE CLEANOUTS INSTALLED PRIOR TO TANK. Tank Type/Material SEPTIC/STEEL Date installed 5/20/1981 Tank size 1250 gal. Number of Compartments E Cleanouts (Y/N) YES Foundation cleanout (Y/N) *YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 3 e Pumper A-+ Py,4,Fs S&-z.Vw�S C. ABSORPTION FIELD DATA Date installed *5/19-24/98 Soil rating .p.d./ rft2/bdrm) 1_2 System type TRENCH Length 55 ft. Width 2.5 ft. Gravel below pipe 5 ft. Total depth **10.8 ft. Eff. absorption area 550 ft' Monitoring tube YES Depression over field NO Date of adequacy test ***3/13/2014 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test DRY in. Water added 720 gal. New depth 7 in. Elapsed Time: 125 min. Final fluid depth 3 in. Absorption rate >= 600+ g.p.d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date *NOTE: 1981 TRENCH IS CONNECTED VIA DIVERTER VALVE AS RESERVE SITE. SUMP FOR 1981 TRENCH ONLY EXTENDS 56" BELOW INVERT OF DRAINPIPE AND WAS DRY UPON INSPECTION. ***HOUSE WAS VACANT AT TIME OF TEST. 2000+ GALLON PRE—SOAK (3/12/13) AND ADEQUACY TEST PERFORMED ON 1998 TRENCH. D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N)— "Pump on" level at in. "Pump off' level atwa er alarmlevel at Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+/100'+ On adjacent lots 100' Public sewer main Public sewer manhole/cleanout Sewer /septic service line 25'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line *10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *PER 1998 INSPECTION REPORT. NOTE: PRIMARY AND RESERVE DRAINFIELD MEET ALL SEPARATION DISTANCE REQUIREMENTS. ALL DECK PILINGS ARE 6'+ FROM SEPTIC TANK STANDPIPES. G. ENGINEER'S CERTIFICATION OF 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. Da J ..A:.......ess; ... Engineer's Printe Na a JEFFREY A. GARNESS QQ s CE 795 Date (Rev. 11/05) wim 0 d xs 9 Municipality of Anchorage Development Services Department Building Safety Division ,. On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING (�j Parcel l.D. 015-471-06 HAA# C) —I 1. GENERAL INFORMATION Expiration Date: I — g —03 Complete legal description HIDEAWAY LAKE SUBDIVISION: LOT 2. BLOCK 1. Location (site address or directions) 10860 HIDEAWAY LAKE DRIVE * ANCHORAGE, AK 99516 Current Property owner(s) Mailing address Lending agency 'Mailing address Real Estate Agent Mailing address MICHAEL do PATRICIA O'HARA Day phone 10860 HIDEAWAY LAKE DRIVE * ANCHORAGE, AK 99516 Day phone DAVE WINDSOR w/ REMAX PROPERTIES Day phone 727-3300 2600 CORDOVA STREET * ANCHORAGE, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well 0 Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site 0 Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given In paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions In the professional engineer's work. Note: Alaska Water and Wastewater Consultants, inc. shall be paid $ at, orprior to closing for the engineering services provided. 4. 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 Health Authority 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 riles 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. Name of Firm AKA WATER & WASTEWATER CONSULTANTS, INC. Phone Address 3701 E. TUDOR ROAD, SURE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: in conducting this evaluation, AKWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described 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 soils condition, groundwater 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 the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AKW WC, Inc. can therefore not provide any warranty or future estimate ofhow long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE V Approved for _! bedrooms. Disapproved. 337-6179 Date A7 & Conditional approval for bedrooms, with the fllowing stipulations: Attachments: L� HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other WATER AND R PROGRAM •' i ANT SEN 1� Jyyllrl,u J! 1111111 By: Original Certificate Date:O 3 (Rev.12101) Municipality of Anchorage Development Services Department Building Safety Division On Site water & Wastewater Program 4700 South Bragaw St P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ek.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: HIDEAWAY LAKE SUBDIVISION, LOT 2. BLOCK 1 Parcel ID: 015-471-06 A. WELL DATA Well type PMVAtE if A. B, or C provide PWSID# N/A Date completed 9/15/1981 Sanitary seal (YIN) YES Total depth. g4 ft Cased to 93 ft. FROM WELL LOG Date of test 9/15/1981 Static water level 55 ft. Well production 10 g.p.m. WATER SAMPLE RESULTS: Well Log (YM) YES Wires property protected (YIN) YES Casing height (above ground) 12+ in. AT INSPECTION 63/2003 67 ft. 6.8 g.p.m. Coliform 0 colonies/100 ml. Nitrate 3.12 mgJL. Other bacteria 2 colonies/100 ml. Arsenic: N/A mgJL. Date of sample: 6/3/2003 Collected by: AKWWC, INC. B. SEPTICIHOLDING TANK DATA *DOUBLE CLEANOUTS INSTALLED PRIOR TO TANK Tank Type/Material STEEL Date Installed 5/2011981 Tank slze 1250 gat. Number of Compartments 2 Cleanouts (Y/N) YES Foundation deanout (YIN) .*YM Depression over tank (YIN)) NO High water alarm (YIN) N/A Date of pumping ,� � Pumper A+ Onme- SeSttice-s C. ABSORPTION FIELD DATA Date installed 5/192411998 Son ratingp.d r ftlbdrm) 1.2 System type TRENCH Length 5 ft. Width 2.5 ft. Gravel below pipe 5 ft. Total depth •10.54 ft. Elf. absorption area 550 fe Monitoring tube YES Depression over field NO Date of adequacy test 613/2003 Results (Pass/Fall) PASS For 4 bedrooms Fluid depth in absorption field before test DRY in. Water addedMvgal. New depth 11.5 in. Elapsed Time: 1140 min. Final fluid depth DRY in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed "Pump on" level at in. Datum E. SEPARATION DISTANCES Size in gallons High water alarm level at Cycles tested Meets alarm & circuit requirements?. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 1000+ Public sewer main N/A On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/deanout N/A Sewer /septic service line 25'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line •10'+ Surface water 1000+ Driveway, parking/vehide storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that / have determined through field inspections and e 4�tr review of Municipal records that the above systems are in """ "' '""" conformance with MOA HAA guidelines in effect on this date. Je Ga ..ss� •• Engineer's Printed Name JEFFREY A. GARNESS40 E— 53 Date "'� 'e'�►l� Ie#006100� �C HAA Fee $ 37S• — Date of Payment $ - 4 Receipt Number (Rev. 17101) Waiver Fee $ Date of Payment Receipt Number Jun 12 03 01:47p David Windsor (907) 2767414 p.2 $_R a S1�38.08� W > r lQoo qh 76.70 0 i Ti _ APPLOeA,�NT FILLS OUT UPPER H; ONLY Time - 'Property Owner ILI I C LCJ /1/ Phone Mailing Address 2 Zip Code Cr? . Buyer Address` � nP Inspector Inspector --..--.- Zip Code Inspector ion k y `� �I �.: Phone ( ) DISAPPROVED - '—' Zip Code � j 07 /ri-�` (js ent 5Address BY: Phone Soils Rating Date Sewer Installed Zi Code Well Log Received NQ n i "T if4atAlC� Septic Tank Size $� 7202313821 c LC Gf r Street Location TYpeof Residence _.. Single Family - ❑ Multiple Family No. of Bedrooms ❑ Other Water Supply `\ ..... . �l Individual �7 Community - ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. ❑ Public Utility For wells drilled prior to that date, give well depth (attach log if available). Sewer Disposal f Individual n p - Year Individual Installed: �j Public. Utility ❑ Holding Tank When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Ti _ Time Time - Time to - Date Date Date Inspector Inspector Inspector Inspector Field Notes: ( ) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED - ( ) CODIITIQ�((lAAL APPpOrl-' DATE� BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received NQ -6-- S 1 Well to Tank Septic Tank Size $� 7202313821