HomeMy WebLinkAboutDORA #2 LT 7Dora #2
Lot 7
#014-251-24
F'E:RMIT' NO.
DEF'F:IF.':T!"IE:N-f' ~ ....... HEFtL"f'H FIND EN',,,' t ROfqI'"IE:NTRI_ - '-::O'T'ECT 101"4
825 '"~ STF.:EET., £:INCI'-IOF~FIGE., RI',.'.'. .91:.. J::L
264-47';70
,:; 8±1. Ct48 ::,
RPPL I C:RNT
L. OC:faT I ON
i....EGRL
T. STEklRRT CONSTRUCTION
L7 [)ORR 2
842~:') [,.I ILL l .[,.IR C I F.:C:LE
LOT SIZE
::.Z0000 SQUFII:~:E FEET
MINIMUM [:,ISTRNC:E: BETklEEN ft 14ELL. RND F4P,I'¢ ON-SITE SE[,.IRGE [:,I:~=;F'OS¢~L S?STEM IS
:.t00 FEET FOR R F'RIVRTE 14ELL. OF..' d..50 TO 200 FEET FROM R PUBLTC 14ELL. DEPENDING
UPON THE TYPE OF F'UBI..ZC klEL. L.
MINIMUM DZSTRNC:E FROM R PR Z ',,,'RTE I4ELL TO R F'RZ',,,'RTE SEMER LINE I$ 25 FEET
TO R COMMUNITY SE~qER LINE IS 75 FEET.
I.,.IELL LOGS RF,:E RE6!UIRED BND MUST BE RETURNED TO THE DEPRRTMENT MITHtN "-::':0
OF TFIE .[4ELL COMPL. ET ION.
OTHER REQUIF.'.EMENT$ MR'¢ RPPL..'¢. SPECIF'ICRTIONS aND CONSTRLICTION DIRGRR.hlS aRE
R',,,'FIi'L.F~BL.E TO INSUF.'.E PROPER INSTRL. LRTION
I CERTIF'? THRT
±: I R.M FRMIL. IRR MITH THE: REQUIREMENTS FOR ON-SITE SEklEF.':S laND !.,.IELLS RS SET
,= UR'f H B'¢ THE MUNIC:ZF'RL.[Tt? OF RNC:HORRGE.
2. I ~,.IIL. L .ZN_SI'FILL THE L~'¢STEM IN ~RC~RNC:E l.,.lI'f'H THE; C:ODE2,.
.~:i; I 3NE[:': _F4pF' .... -r'- STEklRRT CC, NS'I'RLiC~I-:i~';5~.5 ...........
ISSUED B'¢ .........~ .~~,FITE ........ ~/~._~/
Municipality of AnChorage
Development Services Department
Building Safe~ Division
On-Site Water & Wastewater Program
4700 E!more Road
P.O, Box 196650
Anchorage, AK 99519-6650
vcw-w.munioorg/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS
FOR
APPROVAL
A SINGLE FAMILY DWELLINg
O
Parcel I.D. 014-251-24
1. GENERAL INFORMATION
Expiration Date: '7"' / ~-//
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
DORA #2 LOT 7
8410 ROSALIND DRIVE *ANCHORAGE, AK
PREFERRED PROPERTIES Day phone
8410 ROSALIND DRIVE *ANCHORAGE, AK
748-4597
Day phone
STEVE SHELL W/ PRUDENTIAL Day phone 551-96.35
,3801 CENTERPOINT DRIVE #200 *ANCHORAGE~ AK 99505
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well ·' Individual On-site []
Individual Water Storage [] Individual Holding tank []
Community Class Well [] Community On-site []
Public Water System [] Public Sewer ·
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems
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.
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
invest~ation, based on procedures outlined in the Certificate of Qn-Site Systems Approval Guidelines for this application,
shows that theo,,-s.~ ;'~ ,,a,e, sup~l:, and/or ..... .,~...,~,,~..=,¢ ..... ¢~; ~,.,.~.~;o,.~.~l. ~sys*,~m.~,, ,~ie t-,w[~'~ safe, ..,,~¢.n~-finn~! ...... and adequate
for the number of bedrooms and type of structure indicated herein. I furt,her verify t,~at based on the
..orm~,on obtained.~,,, ,,,~ M.n,c, po,,,~ u~ ,-,n~.ho, °ge files and from my investigation and i,*sp¢''~i,~'~,,, ~.,~,, 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.
Phone 337-6179
Address ,5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. 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. 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 DSDo 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.
DSD SIGNATURE
[~'"" Approved f-or ~'
Disapproved.
Conditional approval for
bedrooms.
~"~. WATER AND
,...
bedrooms, with the following sbpulabort~
~,¢,~ '. .-'Z'-'S'
Attachments:
~..,.a o,~', Ch~.ur~us~
Septic System Advisory
Well Flow Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
By:~
(Rev.
Original Certificate Date: /-'-/
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
CHECKLIST
~'.=i=::=:;m:
Legal Description: DORA #2 LOT 7
Parcel ID: 014-251-24
A. WELL DATA
Well type PRIVATE
Date completed 4/21/81
Total depth 109 ft.
If A, B, or C provide PWSID# N/A
Sanitary seal (Y/N) YES
Cased to 109 .ft.
Well Log (Y/N) YES
Wires properly protected (Y/N) YES
Casing height (above ground) 12+
in.
Date of test
FROM WELL LOG
4/21/81
AT INSPECTION
Static water level 43 ,ft.
36 ff.
Well production 9.00 g.p.m.
3.00 g.p.m.
Nitrate ~mg./L
Date of sample: /'7///£/////
WATER SAMPLE RESULTS:
Coliform :O colonies/100 mi.
Arsenic: ~:~ug.lL.
SEPTIC/HOLDING TANK DATA
Collected b~
B. PUBLIC SEWER
Tank Type/Material Date installed
Tank size gal. Number of Compartments ~~
Foundation cleanout (Y/N) Depre~ High water alarm (Y/N)
Date of ~~~~~-)umper.
........_..-----'-'
C. ABSORPTION FIELD DATA
Date installed
Length
Soil rating (g.p.d./ft2or ft2/bdrm)__
ft. Width ,ft.
.ft. Eft. absorption area ft~ Monitoring tube _
Total depth
Date of adequacy test Resul~ (P~ss~l~-~
Fluid depth in absorption fiel~ in. Water added ~ gal.
Elapsed Time: ~.~dr~~ Final fluid depth~ in. Absorption rate >=
An ' enation treatment (past 12 mo.) (Y/N & type) If yes, give date
System type
Gravel below ~.
,/~Depression over field
For,~bedrooms
New depth in.
g.p.d.
LIFT STATION
Date installed
"Pump on" level at
in.
Size in gallons Manhole/Access ~ ~
"Pump off" leve~ater alarm level at
,in,
Da._~9._mtum ~ Cycles tested
E. SEPARATION DISTANCES
Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A
Absorption field on lot N/A
Public sewer main '50'+
Sewer/septic service line 25'+
Animal containment areas 50'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Manure/animal excrete storage areas
PUBLIC SEWER
'50'+
100'+
Building foundation Property line Absorption field
Water main Water service line Surface water ~
Wells on adjacent lots ~
S EPARATI ON D I ST ANCE FR OM ABSORP T,~ TO:
Property line .... ~ndation Water main.
Water service line / Surface water Driveway, parking/vehicle storage
Wells on adjacent lots,
F. COMMENTS
*MEETS SEPARATION DISTANCE REQUIREMENTS FOR 1981 CODE REGULATIONS.
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.
Engineer's Printed Na~ne JEFFREY A. GARNESS
Date C~/l~"/l'l
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
SGS Ref.# 1 ] 11234001
Client Name Garness Engineering Group, Ltd Printed Date/Time 04/15/2011 9:26
Project Name/# Dora #2 L7 Collected Date/Time 04/04/2011 3:00
Client Sample ID Dora #2 L7 Received Date/Time 04/04/201 I 16:45
Matrix Water (Surface, Eff., Ground) Technical Director Stephen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date [)ate Init
Metals by ICP/MS
Arsenic ND 5.00 ug/L EP200.8 C 04/12/11 04/14/11 SCL
Waters Department
Total Nitrme/Nitrite-N ND 0.100 mg/L SM20 4500NO3-F B 04/12/11 AYC
Microbiology Laboratory
Colony Count 0 col/100mL SM20 9222B A (<200) 04/04/11 DLC
Fecal Coliform 0 col/100mL SM20 9222B A (<1) 04/04/11 DLC
Total Colitbrm 0 col/100mL SM20 9222B A (<1) 04/04/11 DLC
Lot 4
Lot 3EAST 60.00 ,Lot 5
.. ' ,,,, ] // // .." ~ '~:
o~c~"'~ I ~-IL 10' Utility Easement ..... --/--/
'--LL!~ I Wood fenc%
~:) ~~ld shed
Well°
~- LOT 7
Z !~ J/--Wood fence
Lot 8 ~ .~'~"l~,astic f snce ] '-' Lot 6
jj ok,
I~~' ~ ' :'--~17.9 '-j '
iL 36 , 0
chO'7,~,, :' ~.~Split Leve :n .~' Z
m ,,,, : ,' ;:) HOl ,e
.-( , /'2.0 C t-
36' -- "--,
i .
[[[[~ deck
36.0
Split Level Frame .~
House b
2.0 OH -~
36.0 '~ ---6;,6
~deckt- -:-_:'..~
Encroachment
SCALE: 1"= 20'
L=36.14 NB'i°00'00"E o~
8358B
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT ARE NOT SHOWN HEREON.
Holt
AS-BUILT NO CORNERS SET THIS DATE
BE
I hereby certify that I have performed a Mortgagee's inspection
of the following described property: LOT 7,
DORA SUBDIVISION No. 2
Anchorage Recording Precinct, Alaska, and that the
improvements situated thereon are within the property lines
and do not ovedap or encroach on the property lying
adjacent thereto, that no improvements on the property lying
adjacent thereto encroach on the premises in question and
that there are no roadways, transmission lines or other
visible easements on said property except as indicated
hereon.
Dated at Anchorage, Alaska
this 24th day of March .,2011
FRED WALATKA & ASSOCIATES
Engineers and Surveyors
(907-248-1666)
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
RECEIVED
9 000
dAN
Mt)NICIPALi FY OF A,NCHOP~E
)NMENTAL SERVICES DIVI'
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
01 4-251-24 HAA#
1. GENERAL INFORMATION
Complete'legal description
Lot 7; Dora Subdivision #2
Location (site address or directions)
Property owner
Mailing address
8410 Rosalind Street
Anchorage, AK
330-6136
Jacki williams Dayphone
8410 Rosaland St. Anchorage, AK 99516
Lending agency
Mailing address
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well xx
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.
72q)25 (Rev. 1,'91) Front MOA#21
5. 'STATEMENT OF INSPECTION BY ENGINEER
Wastewater Consultants_, II1c. ?
Shall be PAID $ ~ at,
-or prior to, closing for the
Engineering S~rvices Provided,
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 investigation and inspection, the on-site water
supply and/or wastewater disposal.~¥~ ~tc~o~P/l/Yance with all Municipal and State codes,
ordinances, and regulations in effect ( ~ Ge date.of.~f'X'~s,in_spection. Was)~vat~ ~u/onsult~n{s, mc.
Engineer's signature (~ ~//~, ~-/~L~ Date
DHHS SIGNATURE
/~ Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with thee following stipulations:
Additional Comments
The Municipality of Anchorage 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 DHHS 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.
RECEIVED
Municipality of Anchorage JAN 19 200~
DEPARTMENT OF HEALTH & HUMAN SERVICE,~UN~aP^Uf
Environmental Services Division q,'3NM£NTALSERVICE~(~'~F'~)
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description:
~RA c;IIRr~IVIRIQN #'~.' I C)T 7 Parcel I.D.:
014--751--~4
A. WELL DATA
Well type pRWA.TE If A, B, or C, attach ADEC letter. ADEC water system number
N/A
Log present (Y/N) YES Date completed
· Total depth 109' Cased to I c)¢1'
~/~t/~
Casing height (above ground)
Sanitary seal (Y/N) YES
Wires properly protected (Y/N)
YES
FROM WELL LOG
AT INSPECTION
Date of test 4/21/81
Static water level 4,3'
4R'
Well production 9.0 g.p.m.
7_g
g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 Nitrate
Date of sample:
B. SEPTIC/HOLDING TANK DATA
0.5_~ mg,/L Other bacteria 0
Collected by: A.W.W.C., INC.
Date installed Tank size _ Number of Compartments ~__
Foundation ~leanout., (y/~larm (Y/N)
Dateof Pu ' Pumper
C, ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./fF or ft2/bdrm) System type
Length ' Width ' Gravel thickness below pipe ~__
Effective absorption area Monitoring Tube present (Y/N) .~epression over field (Y/N)
Date of adequacy"test __ Result~ For__
. .
Fluid depth in absorpt~~;~_ Immediately.__ after gal. water added (in.):
~(past 12 months)(Y/N)If yes,'~''''''''(~tes later: Abs°rpti°ng;vleda~e g.p.d.
bedrooms
72-026 (Rev. 3/96)*
LIFT STATION
Date installed Size in gallo
Manhole/Access (Y/N) _ ~ "Pump off" level at*
High water alarm level at* *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELLON LOT TO:
Septic/holding tank on lot N/A
On adjacent lots
100'+
Absorption field on lot N/A
Public sewer main "~ 50'+
On adjacent lots 100'+
Public sewer manhole/cleanout ¢ 50'+
Sewer/septic service line
25'+ Lift station N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation Property line Absorption field
W~/serwce ii e water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water
Curtain drain
Wells on adjacent lots
Building foundation
HAAFee $. ,....-~'~) . c~
Date of Payment ~///' ~/~,-~
Receipt Number
Waiver Fee $
Date of Payment
.) Receipt Number
72-026 (Rev. 3/96)*
~1-18-00 09:14 FROU'CTE ENVIRON~NTAL 5515301 T-Z45 P.01/0Z F-570
CT&E Environmental Services Inc.
Laboratory Division
200 W. PoEer Ddve
Anchorage, AK 99518
Tel. (907) 562-2343
Fax.(907) 5§1-5301
RECEIVED
dAN 19 ~000
MUNICIPALI1'¥ OF ANCHORAG[:
~NMENTAL ,,SERVICES DWI
CT&I~ Ref #:
Client Name:
Project Name.
CJ~ent Sample ID.
Matr,x
PWSID
'Sample Remarks-
1000188001
AK Water & Wastewater Cons.
n/a
Dora ~2 Lot 7
n/a
Client PO#. nla
Pdnted Da[e/Time: 01118100 09 15
Collected Date/T~me; 01/13/00 13:25
Received DatefT~me 01/~3J00 14 00
Technical Director' Stephen1 E~ie
Released Ry: ,~,/~ · / ,~
Results PQL Units
AllowaDle Prep Anaryais
Methaa Limrts Date Date
Total Coliform (MF)
N~trate
0 col/100 mi SM9222R 01/13/00 KAP
0.53 0 5 mg/L EPA300 10.0 01/13/00 GCP
o00
· 0'1/14/00 09:50:13 AM
01/14/00 10:31 FAX ~001
N 90°00'00"W 60.00'
--
~--~-- ~'~ -1 -
-" ..........
oWEL~
N
,14
R o s_A ¢._.Np__S T g¢ ~'L - -~
DAY OF JAr~UAFIY 2000
APPLIC NT FILLS OUT UPPER HA[ ONLY
Property Owner \~"~'~.~"--~?'~'>% ~,~. "~--(,.~ C-~'~' Pho~ne
Mailing A,d~';Iress 7%~"~"~-~{ ~'?~-.~'-~'~.- ~.'"'~'~-"c~"'~'~ "X."",~,-, C_.~'x.L.~?~.~C~. ~ , ~-,~'~--... Zip Code ~',A'J~.:~O ~!,,
Address Zip Code
Lending Institution ~~ ,~1~ ~,.,[~,?~,,~7/._~-~"~,... ~-~"~'~-~3~,~'~. Phone
Address ',~.X~,'~C~'-~ ~:~,~.~\<~'.,ST,..~, ~\~--~. '~'~'\~'~,~'5 Zip Code
Realty Co. & Agent ('_o~,~,~'~c~,,~.~ ,,_..~..~,-,,,,~, X~..~.-~,,',~',;~b~k Phone
Address ~.~X,.~.',,,~,,.~,-.~...~,,~ ~,.~,',~,',.;..,~..,j~.,~ Zip Code
Street Location ~",,"~L.~ ~'~3~'~."~-,'~,~,~b,
Type of Residence
~ Single Family
[] Multiple Family No. of Bedrooms ~,
[] Other
Water Supply
'~lndividual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
[] Community For wells drilled prior to that date, give well depth (attach log if available).
[] Public Utility
Sewer Disposal ~.~.~
[] Individual Year Individual Installed:
~ Public Utility
[] Holding Tank l -"d~O'~"/~ When Connected to Pub c Ut~.~.ity; .... ~..;
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector InsPrl~r
Field Notes:
~UNICIPALITY OF ANCHORAGE
DEPT. OF H~AL'[tt
~.NVIRONM,": NI'AL
~'~ APPROVED BEDROOMS *CONDITIONS OF APPROV,~~' ~=~ ~ I,,
( ) DISAPPROVED
(DATE) CONDITIONAL/5 _~'~3{~APP'~OVA~
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
72,023 (3182)
- ~ DATE RECEIVED '
INSPECTION APPOINTMENTS
TIME ' TIME' ~__/ TIME '
NSPE ' .
. MUN ' ·
MUNICIPALITY OF ANCHORAGE DEPT. OF H~AL'ri4
~~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT~IRONM[NDkL FkOTECTION
E ~' ~ 1981
~~ NVI RONMENTAL SANITATION DIVISION '
~ Telephone 264-4720
- EE(EIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete request.will not be proceed. Please allow ten (10) days for processing.
1. PROPERTY OWNER r ~ ' j PHONE
MAILING ADDRESS ' - ~ '
PROPERTY RESIDENT (If different from above) ' ' PHONE
2. BUYER ' ' ' ' ' PHONE
G A DRES'S _ ' ~ '
~ ,
3. LENDING INSTITUTION
.
. , ~1 ""°~' '
Is. LEGAL DE$C~_.~'I(:JN:p 7
I ~TREET LOCATION
I . ' ENCE-
I~ SINGLE FAMILY
[] MULTIPLE FAMILY
7. WATER,~j?UPPLY
'~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
~. SEWAGE DISPOSA~L SYSTEM
INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
r
- ' U 0MB~=R OF,BEDRbOMS r, r
[] One [] Four [] Other__
~ Two [] Five
[] Three [] Six
*ATTACH WELL LOG. A well log is required for all wel s drilled
since June t975. For wells drilled prior to tint,ate, g ve well
depth (attach log if available.) ~ .~/~
YEAR ON-SITE SYSTEM V~AS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79) /
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Hold ng Tank
Size: If Tank is homemade
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION AREA
4, DISTANCES "
WELL TO:
Absorption Area to nearest Lot Line
NUMBER OF BEDROOMS
[] ONE [] THREE
[] TWO [] FOUR
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
[] FIVE
[] SlX
LOG RECEIVED
PERMIT NUMBER
DATE I NSTA LLED
INSTALLER
SOILS RATING
MANUFACTURER
MATERIAL
[] OTHER
Septic/Holding Tank IAbsorption Area
ISewer Line
INearest Lot Line
5. COMMENTS
DATE
[]~-"~APP ROV ED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)