HomeMy WebLinkAboutDONALD C SCHROEDER #2 LT 7A Municipality of Anchorage Page
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
Name~.....~___.~ ~~ ¢~~ Wastewater System: ~ New ,~grade
A~e~. ¢¢ ~ ~/¢ ~//.¢.¢~ ~+ ABSORPTION FIELD
Phono: ~o. o~ ores: ~ Doep Trench ~ Shallow Trench D BoO ~ Mound ~ Other
LEGAL DESCRIPTION SoilRating: ~.~ GPD/Sq. Ft. Total Depth from original g~e:/
Lot:.. ~ -.Block~o~~Subdivisi~~~ ~Depth to pipe bottom from original~rade:¢ / Ft. Gravel depth beneath pipe ~ /Ft.
Township: I Range: [Section: Fill added above original gr,de: ¢ Gravel length:
Number of lines: ~ Distance between lines:
WELL: ~ New ~ Upgrade Gravel width: ~ /
Cia~fication (Private. A,B,~): ~ Total Depth: Cased To: Total absorption area: Pipe m~erial: ~/~
Driller: ' Date Drilled: Static Water Level:Ft. ,~:r~,~~ ~y~. Date nsta ed ~/O
"~ield: I Pump Set at: I Casing Height Above Ground:
SEPARATION DISTANCES Ceptic ~~ Holding ~ S.T.E.P.
To Septic Absorption Lift Holding ~ublic/Priva~ Manufacturer: ~ Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~ ~
~ Material: Number of Compartments:
Surface /~ /~ ~ ~ LIFT STATION
Water ~
Lot ~ Size in gallons: ~ Manufacturer:
Line ~ ~J
CurtainDrain ~ ~ ~ ~~, / ~ Pump~ode, I Inspections performed by:
Remarks: BENCH MARK
~~~ ( ~~~, J Assumed Elevation:¢~
S & S EHGINEERING ~ '/~;J
Inspections performed by: __-- ~,u~: 1st~//=~ /~~
Eagle River, Alaska ~9~11
2nd
Department of Heal~and ~uman Services approval
Reviewed and approved by: Date: _--
72-013 (Rev. 9/91) MOA 25
Permit No.
SW920367 Page 2 of 2
Municipality of Anchorage
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
DONALD C $CHROEDER #2, LOT 7A 05052185
Legal Description: PID No.:
CO 1 C02
/84'5'4 ///FINAL GRADE MT1 C04
i co~5~?~
/-- 88.9' i 84 9'
lOOO GA,, ~ ~__~=.!=~
· SEPTIC 91.4'
~[~ -'- / ~R :~8~,5'
83.
7g.5' NO WATER FOUND A 78.5'
N.T,S.
WEL~ t~' WELL~DIUS
~XIST. 10
A B
C01 17.0
C02 28.0 57.0 I ~ ~ co5 ..
C03 42.0 69.0/ .~'~.
33.0
NEW TRENCHE~
004 50.0
C05 56.5 47.0
MTi 37.5 36.0
M T~ 48.5 48.0
72-013 A (Rev. 9/91) MOA 25
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:SW920367
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:FEDERAL NATIONAL
OWNER ADDRESS:P.O. BOX 2614
PASADENA, CAL,91102-2614
DATE ISSUED:10/26/92
EXPIRATION DATE:10/26/93
PARCEL ID:05052185
LEGAL DESCRIPTION: DONALD C $CHROEDER #2 LT 7A
LOT SIZE: 80250 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT:
3
THIS PERMIT IS FOR THE CONTRUCTION 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
October 20, 1992
ROBERTSHAFER, PE
ROGERSHAFER, PE
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Lot 7A; Donald C. Schroeder Subdivision
Request you issue a permit to upgrade the septic system serving the
referenced property.
The existing system failed a recent adequacy test. A soils test was
performed and an upgrade design completed. (Attached)
The proposed upgrade is to be installed on a slope greater than 25%.
However, due to the density of the soils; heavy organic and vegetation
cover; and failure of the existing system without effluent daylighting,
there should be little fear of effluent daylighting through the steep
slope.
We do not anticipate any adverse effects on neighboring properties by
the installation of the proposed upgrade.
If you have any questions or require additional information for you
review, please contact us.
Sincerely,
RJS/tv
Attachment
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
SCALE
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRiPTiON: "/A'
1
2
4
5
6
7
8
9
10
Township, Range, Section:
~,~ SLOPE
11
12
WASGROUNDWATER ,j~
ENCOUNTERED? · ~
13
S
L
IF YES, AT WHAT O
DEPTH? p
E
14
15
16
17
18
19
20
Depth to Water Alter _
Monitoring? \c~-~-'~?., Date:
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN '~ FT AND ~" FT
COMMENTS
PERFORMED BY: S & S ENGINEERING ~ ~
17034 Eagle River Loop Road No. 204
ACCORDANCE WlTIE~Ie ~I~j~'K/AIk~k',~I~iFFL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE:
O 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
IPHONE 25-:Z EZ EW
~MAILING ADDRESS
LEGAL DESCRIPTION '
LOCATION NO. OF BEDROOMS
PERMIT NO,
Well Absorption~rfia Dwelling /
DISTANCE TO:
~ ~ Material No. of compartments
[ ~ Manufacturer
~ h Liq. capacity in gallons IF HOMEMADE: Inside lengt~ Width Liquid depth
Well Dwelling PERMIT NO.
~ ~ DISTANCE TO:
O ~ ~ Manufacturer Material Liquid capacity in gallons
Q Well Foundation Nearest lot line PERMIT NO~
~ ~ Z No, of lines Length of each line Total length of lines Trench width Distance between lines
~Q ~ ~ Top of tile to ~.r~, beneath tile ~ ' inches Total effect~¢~n area
Length Width Depth PERMIT NO.
< ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Welt Building foundation Nearest lot line
~ DISTANCE TO:
Building foundation Sewer tine Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING .
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
P E F:I"t ]: T N O.
FiF'F'L. I CFtNT
LOCI:~T ! UI ~
L.E: 3RL.
E:,EF'F!F.:Tr,tEI'.,tT r-,,::' HEFIL. TH FIN[:, E:N'v'iF:CIN. HENTRL. "?-.'?D'TECT]:3N :~.~. ~_~/~ .~
O;1:5 '" :~;TF4:EE't"., RN(':HCtF.:FtCiE., P.K. :~':..Y'L
254-47;:.:.]0 T ''] J
i~..:~ E~ * .. L. IF~ Ih,,,lf EZ::. ,:::l, t"-~ .... :2+2; ][ 'TiE .::,.::; El th,q1EZ If~: if'-:":" E:Z IFE". F.lj %
F'FiTF: Z C:K 5L..FiTEF.: 4907 F..L' ' LL 'Z' h..:,l' ..... DF.'¢ S~9504. .:. 4 4 ,.:: .% x. ,::," ' ' '" "-'"" ~¢: ,, ,?
:SCF.IF.:OE:E:,EF: tBE:,
'~ '- -' '¢ ' ', '" . '" LOT :5 ]: ZE!: : F~;::'R¢' :5[.1LtFff4::E r:E:ET
L ," .:,L. HF...JEE. EF.. TF.':RC ,-'
'T'¢F'E OF S;O]:I~ REE3PPT]:Of.! :5'?"STF..:rt !:5. "FF.:ENCH
!',tRXIHUH NUHBER OF BEDROOH:5
THE REC~UZF:ED SIZE OF' THE
'THE LENGTH DIt"IEN[SION IS THE I._E'NGTH <IN FEET> OF THE TRENCH OR DRR]:NF]:EL.D.
'THE DEPTH OF' FI TF..'ENCFI OF..' PTT :[E; THE [':,ZL=;TI.':INCE BETHEEN THE SLIRFRCE OF':' THE
GROUND FIND THE E~OTTOr"t OF THE EXCR',,,'F".IT ]: ON ,:.' IN FEE'F.':,.
THERE t'5 f'.,tF~ SET I,.i]:[:,TH FOF,.': 'IF. EI',I..HE=,
THE GRFIVEL DEPTH ]:'.:-5 THE t"'I ]: N ]: HUH DEPTH OF G~tFIk,'EL. BETHEEI'.,I THE: OUTFFILL F"rF'E
FIN[:, THE BOTTOH OF THE E';.-','CR',/RT ]: ON <]:N FEET).
F [::.F.I t.[ 1 RF'F'L I CRh,IT HR.E; THE ~:E2;F'Of.,I."51 B I L. ]: T'¢ TO I NFORFI "FH I S DEF'RRTP1E:NT [:,UR ]: NG ]"HE
IN'~Ft"RLLRTICN [I4.=.[-E._.iILf,I=, OF flN'¢ F.IELLfE; FiE:,J'RCEN'r' TO THItB
r' ~ _ r' r: r~. ~' RN[:, THEE
N I IE, E.F OF RE:St[:,ENCESq THRT TF!E HELL HILL. CF~",,'
HiNIMUH DIS'TRNCE BETHEEN R HELL RND RI",!'T' ON-SITE SEWRGE DIS;F'OSRL S"r'L::;TEM IS
±00 FEET FOR R PF.:t'v'FFFE HELL OF..' ±..'50 TO 200 FEET F'F,'OH FI PUBL]:C 1.4EL. L.
UF:'ON ']"HE 'I"'¢PE OF I::'LIE=L]:C F.IEL. L.
r'I]:N]:r"!UH D]:9;;TRNC:E FF.:OH R PR]:VRTE t.4ELL TO R F'F.:]:'v'RTE S;EHEF..: LINE ]:2; ;2:!5 FEEl" FIND
TO R COHP1UN]:T"r' :SEI.4EF: L]:NE ]:~; 7'~; FEET.
HELL LOGS; RF,'E. RE6!U]:F.:E:D Rt'.,ID HUtST BE: F.:ETURI",IE[:, TO '['HE DEPFIF::T'HENT t,.t]:THIt",I :2!:O B',R"r'~;
OF THE t4ELL COI'"IPLET]:ON.
OTHER F.'.E6!U]:F'.'.Er'1ENT25 I'dR"r' FIF'PL'T'. 2;F'EC]:F]:CFIT]:ON2:; RND CONS'TF:UCT]:OI",I D]:F!GF..'FIH'.'ii;
RVR]:LRBLE TO ]:.NS;URE F'F.'.'OF'ER INSTF'ILLFIT]:ON.
....... E 193; [:, Z5:: ::11 ....
if::' E IF;..': Ih'l :t T' LT.: ..-.-. F ]I: ir4: E ,Z: E I'.1 E:: E IF;: ::IL.
I CERTIFY TPIRT
±: I RH FRH]:i._IRR HI'TH TPIE REQUIREr'IEI".,ITS; FOR ON-SITE 5EHER$ RND 1.4E:LL:5 RS !'.;ET
FORTH B"r' THE r,ILtI'qICIF'F~L]:Th.' OF F/i'.,!CHORFIGE.
2: I f,.t ILL I NS:;TFtLi.. THE S'-?$TE!'"I ! N RCCORDFINCE H I TI.-I THE
Z: I I. JNE:,EF.:STFt~[:, 'T'HRT THE ON-SITE FEI-4EI~: ~:'¢5'rEr'! r,lR'?' RE6!UIRE ENI._FIt:R(3EHE!'.~.T
RE.S; ]: [:,ENC:~Z/F~Er'Ic~[:,ELE[:,': '' TO INCLUDE r,'IOF::E THFIN 2!: BE[.:,F,.:oor,t:5.
RF'F'L I C:F-INT F'FITF.: ICI'( FSL. F:tTEF..~
ir. f.' '~: JE[, Bh". ................... DRTE ..... _-: ........
I F' T FtE
,~:'~a! .Oescr:c,L ion:
*his' Fern re-z,s': s:
2204
CO:;Si'R'SC'/iON T}:]S,? i'.'-.B MUNICIPALITY OF ANCHORAGE
· DEPT. OF I i!ALTH &
"One q'es~ i s ~,'g;~t h a Th~'lsand O:-J. :'i iE-~tF~I~D'I~IMENIAL F;:,pTECTION
C!eve]ani Anchora}e, Alaska 99503 277-0231
JAN 2 ~ 1980
' - Subdivision=scnreeoter buod. ~,22racZ
Feet
12" Peat
Character i st ic S
Brown Sandy Gravel
Cobbles
Trace of Silt
(GP)
15'
Bottom of Test Hole
's.s '=round~ "-,,a=er = Encountered
f YES, ;';hat depth?
NO
o
hi. _-i--[-Il-r-7 '-r-Ti-'] iL L_J_J_L-ri
--' /I. i I[-
I
eai! ::g ~ Date
I.
Gross T]sne
Net
ercolat ion Rate Minute
..~os=d Installation: SEEPAGE
1
Ti_me Depth to H20 / Net Draina!e
t.
PIT DR\IN WIELD
Box 10-378 · 10300 Old Seward Highway
(907) 349-8535
ANCHORAGE, ALASKA 99511'
Well Owner
Location
Lot
DRILLING LOG
Pat Slater f Use of Well Domestic
(address of: Township, 1Rangel Section, if known; or distance main road
7 Schroeder tract
Size of casing 6" _Depth of Hole 400' feet Cased to 22,95 ' feet
Static water level 63 ft.
Screen ( ); Perforated (
Describe screen or perforation
Well pumping test at ~ .ga'lions per
of drawdown from static level.
Date of completion ._Tune
(below) land surface. Finish of well (check one) open end ( X~//k/);
(Rn:tm~) (minute) for
!6, :1 98?
hours
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
0 .TO 2 Stick up
2 .TO 4
4 .TO 21
21 TO__200
200 _TO 400
TO
TO
TO
.TO.
TO____
.TO.
TO
.TO
TO
Fill - gravelly
Damp silty gravel
.Gray bedrock
Bedrock - Small Water seaps in Sporadic Fractures
Througho~f
NIVW A Ct;rtlh,~i
\ k~F,l.'L2~ ~
1--CUSTOMER
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date ~...~/,.,4' / ~'~'
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
(b)
Location (address or directions)
Applicant Name P~'~ 5M~e~ Telephone: Home
ApplicantAddress 5 ~ t~'2 ~ ~,t~ B ;~e~ ~!~
Business
(c) Applicant is (check one): Lending Institution [] ' Owner/builder ~; Buyer []; Other [] (explain);
(d) Lending Institution (:', ('~'
Address 207 ~'.
(e) Real Estate Company and Agent
Address
Telephone ~6'$ ~ ?.~' 7'2
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [] Multi-Family []
Number of Bedrooms 3
Other
WATER SUPPLY
Individual Well [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the. legality and status.
Page 1 of 2 72-025 (11/84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
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 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 investigation 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.
_mL'
~ T
· HEODORE F. MOORE ·
~ ~ ". CE- 3589 ..'.~- ~ Engineer's
Seal
Approved for '-~--~J bedrooms b
Approved
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
Page 2 of 2
72-025 (11/84)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description:
MUNICIPAUTY OF ANCHORAOE
DEPT. OF HEALTH &
ENVI/~NMENTAL PROTECTION
MAY 0 5 ~
RECEIVED
Well Classification .,Pr;v~'g If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) ~' D.~owleted ~' / lO"/~. Yield
Total Depth ~/00' Cased to/' ~ ~_~ Depth of Grouting
Static Water Level . ~ .~ oO'~.,/ "f-- ~,,/e k-
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
Y
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole ,1~.
water Sample Collected by "rF
Water Sample Test Results
Comments ~Zn ~b(e ~
~tto~.c~c e.a~(I ~ro~ or
BI, A.
Pump Set At
Sanitary Seal on Casing (Y/N) Y'
Depression Around Wellhead (Y/N)
N
; On Adjoining Lots '~ IOO'
I ?-,¢' ; On Adjoining Lots · too'
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date. ,b"/~
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) ~ Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~11 '
To Property Line ~' lO'
To Water Main/Service Line Course ~ too '
No. of Compartments ~-
Foundation Cleanout (Y/N) ~'
Date Last Pu m ped ,5"/,¢'/~'O~
;for N,/).
Temporary Holding Tank Permit (Y/N) N, ~,
To Building Foundation
To Disposal Field
Il'
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2.~ ~~ ~-
72-026(11/84)
C, ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 6'(' E.~ / ~9
Width of Field 36'"
IFc,
Square Feet of Absorption Area
Depression over Field (Y/N) N
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
8¢~r,~ Type of System Design
Length of Field .-~'
Depth of Field ,f, i
Gravel Bed Thickness 6' ~
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line ~ 40 '
To Existing or Abandoned System on
; On Adjoining Lots '~' 3'~ '
To Cutbank (if present)
~>
Comments
D. LIFT STATION N,,4.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed -~'-~ -~' ~ Date '~'/~'/~'
Company J~(~/-~,/~--'' /'~'c~n;¢~ _,CuC.¢ MOA NO.
Receipt No. '~ ~' '~- ~ c~ .~, _4,~,~c' ~","on~.--~'~,
Date of Payment ~- ~ ~ ~ r.. ..... .~.n~
~ _% THEODORE F. MOORE
Page 2 of ~ '~.~-. CE- aSe9 -~.~
72-026 (11/84) ~ mr~t0~
Engineer's Seal
APPLI 'NT FILLS OUT UPPER HAl. ONLY
OWner"'~ ' ~''u~) ~A ~ L.. ,'~T~___~,. ' ,
Property ,:/ ~At 2tC~' ~ Phone
Address Zip Code
Realty Co. & A.nt ~d~ Phone
Address Zip Code
Street Locatlm
Type of Resl~nce
~81ngl° Family
~ Othor ,
Water Supply
lndlvidual A~ACH WELL LOG. A wal is for all wells drilled since June 1975.
Icg
required
Community For wells drilled prior to that date, give well depth. (attach Icg if available).
~ Public Utitlty
Se~er Disposal
lndlvidual Year Individual Installed:
~Publtc Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CANBE INITIATED,
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Noles:
( ,~).,.,'A'PPROVED BEDROOMS ~ *CONDITIONS OF APPROVAL
( ) DISAP~OVED
Soils Rating Date ~wer Installed Well To ~sorption Area Well Log Received
~~ Well to Tank Septic T~k Size
72.023 (3182)