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HomeMy WebLinkAboutPETERSON LT 64B 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: Y,,~/~-r 'T'~o~=,J Wastewater System: [] New )~ Upgrade Address: C a'~S~,'~ ABSORPTION FIELD No. of Bedrooms: Phone: ~. ~ ~ D Deep Trench ~Shallow Trench D Bed D Mound D Other Total Depth from original grade: LEGAL DESCRIPTION SoilRating: O.~ GPD/Sq. Ft. ~'~ Lot: ~H ~ Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth bene~h pipe Township: Range: Section: Fill added above original grade: Gravel length: g~ Gravel width: Number of lines: Distance between lines: Driller: ~ Date Drilled: Static Water Level: ~nstaller: ~ GPM PumpSeta,: Ft. CasingHeightAboveGrou;:: TANK SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. To Septic Absorption Lilt Holding Public/Private Manufacturer: Cap~cityin gallons: Prom Tank Field Station Tank Sewer Lines ~O~ ~ ~ J O O Material: Number of Compa~ments: Su,ac~ ~ LIFT STATION Water [ OOt~ 100~ ~ ~ ~ Foundation ~1~ ~ ~1~ ~ ~ ~ "Pump on" level ~High alarm at: Cu~ain Drain Remarks: BENCH MARK Location and Description: Assumed Elevation: Inspections performed bv' Ala,ka Ware, & Wastewat~ates. 1st 7-z2-,8 ~ ~:'~';"~ "7320 East Chester Hts. CI~Fe ' ~ .... ~. ~ J Department of Health and Human Services approval ~,~%,%, I~ ...'~ Reviewed and approved by: ~/~, ~Date: 7-50"?¢ 72-013 (Rev. 9/91) MOA 25 PERM[r SW980242 NUMBER: AS ~ BUILT DRAWING PARCEL 051 - ID17 NUMBER:i \I -F=c-5---'C=/ ' - WELL 'D-~'~ ' ~ ~ ~ ,-~ ~CH~S 0~' J ~FINAL ~) / ~ ~60 - ~ ~ ' / /= gg.O0 / ~ JJ Il /INSU~TION /l~r:J.~ ~ '/ , Jill j_// /J.~_~ __. / ~E~ISTING TRENCH ~~S~ / TE~fiSRARILY ABANDONED · j: ~'-~:~ /(R~SE~W SITE) ~ ~1/ ~ ~ /~. .... ~ ~,,,~,,,, 10' UTILI~ EASEMENT BIRCHWOOD LOOP ROAD '"~'~""~ '~: WASTEWA~R ~ ~ o~ - ~ ~,-~ ALAS~ WATER & ~.. · .... :~,~ PETERSON SUBDIVISION, LOT 64B ~ ......... ~ .... KURT THORSON 688-9026 v0 ~,'"~ J.L.M. 1 = 40' 2 0F 2 '~~ 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: Jul 16, 1998 Expiration Date: Jul 16, 1999 Permit Number: SW980242 Legal Description: PETERSON LT 64B Design Engineer: Alaska Water & Wastewater Services Owner Name: KURT THORSON Owner Address: 19182 BIRCHWOOD LOOP ROAD CHUGIAK , AK 99567-6610 Parcel ID: 051-171-38 Site Address: 019182 BIRCHWOOD LOOP RD Lot Size: 46250 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [~ SepticTank ~ 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 ( 18AACS0 ). 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. Alaska Water & Wastewater 7320 East Chester Heights Circle ~ Anchorage - Alaska 99504 (907) 337-6179 ~ Fax (907) 338-3246 Consulting Engineers July 9, 1998 Municipality of Anchorage Department of Health & Human Services Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Septic Upgrade Design for Lot 64B, Peterson Subdivision. To whom it may concern: The existing 3 bedroom house is served by a private septic system and well. The existing drainfield is surcharged and must be upgraded. Two test holes were excavated to the west of the existing septic system. Comments regarding the proposed upgrade design are summarized as follows: 1. SOILS: Attached is the soil logs which shows the soil profile, and the percolation tests results. The soil below the organics is a SM/SP material with some gravel to a depth of 13 feet in both test holes (bottom of test holes). No groundwater was encountered during the excavation in the test holes. Two percolation test were performed~at 6.5 feet to 7.0 feet in test hole #1 and at 6.0 feet to 6.5 feet in test hole #2. The soils perked out at a rate of 17 minutes/inch in test hole #1 and at 30 minutes/inch in test hole #2.. 2. TRENCH DESIGN: a. Percolation Rate: 17.1 and 30 minutes/inch b. Allowable Application Rate: 0.6 gallons/day/Ct2 c. Number of Bedrooms: 3 d. Design Flow: 450 gallons per day e. Minimum Absorption Area: 750 ft2 f. Effective Depth: 4 feet g. Reduction Factor = 0.5 h. Width: 5 feet i. Minimum Length: 75 feet long j. Effective absorption area = 750 ft2 k. Maximum depth = 7 feet 3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed upgrade. 4. TOPOGRAPHY: The topography of the southern portion of this property is generally flat; in short, there are no slope concerns. I am unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact me at 337-6179. Thank you for your assistance. ~ Uri~ ,. ~ame .... LOT 35 LOT 34 LOT 56 ~ ~ ,~ LOT 65 ~ N SERVES BY A PRIVATE SE~'IC ~, LOT 64A '~ A~ /////~ AND A CLASSFRoM"C" WELL.PROPOSEDWELL LOT 65 [31RCFIWOOD LOOP ROAD LOT 68 LOT 67 ~ LOT 66 I WASI~WA~R ~ "~ ALAS~ WATER & PETERSON SUBDIVISION; LOT 64B, SITE P~N ~REPARED FOR: PHONE NUMBER: ~. '~. /CE-~ 7953 KURT THORSON 688-9026 J.L.M. 1 = 100' 1 OF 2 '~%%~ / \ / 10' UTII..I'Pf EASEMENT \ ! / I i 100' WELL F~ADIUS , I WELL E) \ \ I! \ / \/"X \ ('" \ / I \ / ". / ,c. ,/'\ / LOT 64A ".. // ~'~,gF~..,/' \ ~ ~ ~, ~ LO I- 65 0 ED TRENCH----- "" -'~ ~,.~--.--~ .... ~[q PROP S' \/ \ \ ._ -X,5~ 7,': Lo~ ~Y 5' w~o~ \ /.-,,0 ¢.~¢ ~ %, >~ SEPTIC TANK ;~.J %. / OR CONCR~'E AND BE I1~ ~ ~' ~INSTAt_L / 'r CO ~' L-INSTALL BULL RUN / / ]0 UYI[.I~ ~SEMEN / BIRGHWOOD ~OOP ROAD ..EPETE"SONoF WO.,(: SUBDIVISION, LOT 64B DESIGN OF SEPTIC SYSTEM UPGRADE ~U.T T.O.SO. 6~-.0~6 A.C.G. 1 = 40' 2 OF 2 ALASKA WATER & WASTEWATER ,. ~ 7320 E. CHEER Hm. CIRCLE ' ~CHO~GE, AK. 99504 PHONE (907) ~7-6179 * FAX [907) ~38-5246 [SOIL LOG - PERCO~TION TESTl ." ~ERFOR~ED FOR: ~UR~ THORSON DATE PERFORMED: 6/26/98 .... ...' ('..0 7=7: [TEST HOLE ~1 1 2~T~.~ i SOIL C~SSIFI~ATIONS -'TCZ,¢~7 il ..... ~ t ~: ~ GW ....... ORG I · LOT ~ 6~A ' .......~ ..... ~ W/ SOME GRAVEL ~4~ GN ~."7,'>v','] CL ,~ ~--s;~:[i ?,"",' Ge --x;' r OL ,, sw ',, LOT 65 ~:~t, [ GROUNDWATER~ ~',~? ~ TH~I~ ~+~1 8Ih.~:; ~ DRY 6/26/98 .... ~! ~i _?RY_ _ 7/7/98 i g--: h~ ~ ~: ~ S;ITE PLAN' ~ 'J, =100.. ;~?~ DATE READING CLOCK NET TIME WATER LEVEL NET DROP 11 --~}~,~ ~ ~ TIHE (HINUTES) READING (INCHES) 6/26/9E BEGAN PR[SOAK PERI(~D ~ 8:30 AM 13-- 1 2:34 2 3:04 30 1" 5 1 4 --. 3 3:04 6" -~ ~:~ ~o ~ ~/4~; ~/~" 15-- 5 3:34 6" ' 6 ~:0~ ~0 16~ 7 ~:07 6" 1B~ 19-- PERCO~TION ~TE 17.1 (NIN.tlNCH) PERC. HOLE DIA. 6 (INCHES) 20 TEST RUN BETWEEN 6.5 FT. AND 7.0 FT. COHHENTS: PERFOMED BY A~SKA WATER A WASTEWATER I, , CERTI~ THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: DEPTH TO DATE GROUNDWATER DRY 6/26/98 DRY 7/7/98 ALASKA WATER & WAS FEWATER,_ ~--' 7320 E. C'HESTER HTS. CIRCLE: * ANCHORAGE, AK. 911504 LEGAL DESCRIPTION: P~ERSON SUBDIVISION, LOT 64B PERFORMED FOR: KURT THORSON DATE PERFORMED: 6/26/98 ~~7 ~- ~ DEPTH ~ .~ (r..~) .... TEST HOLE ~2 2_~t~.~ ~ SOIL C~SSIFICATIONS ../' ~'": ~ GP ; : HL w~uj~O' WELL ~lU~ ~ / ~ L'OTt 64A 4~i:: W/ SOME GRAVEL ~i6~ CE ~; ~ SW ; : ?,%%~ SP ;" ~"? '-' CH ! ~'~ ~ LOT 7-- ~i ~ DEPTH TO DATE ~:~ GROUNDWATER 8-- ~*:' i ~ DRY 6/26/98 ~J'~ :~ DRY 7/~/98 ~ ~ SITE PLAN L = GO ~;~.~ :: CLOCK NET TIHE WATER LEVEL NET DROP 11 -- :,,, ~ i DATE READING TIHE (HINUTES) READING (.INCHES) ~; 6/26/98 BEGAN PFESOAK PERIIID ~ 8:30 AM 13~ B.O.H, 1 3:07 7 1/2" ~ 2 3:37 30 6" 1 1/2 1~ 3 3:37 4 4:07 30 5" 1 15~ - 6" 5 4:07 16-- ~ 6 5:07 60 4" 2" 17~ 18~ 19-- PERCO~TION ~TE 30 (NIN./INCH) PERC. HOLE MIA. 6 (INCHES) 20 TEST RUN BETWEEN 6.0 FT. AND 6.5 FT. CONHENTS: PERFOMED BY A~SKA WATER · WASTEWATER I. , CERTI~ THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: DEPTH TO DATE GROUNDWATER DRY 6/26/9B DRY 7/~/98 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 ~EW~___~ I~ 7 ¥- % [] UPGRADE NAME MAILING ADDRESS LOCATION ~.~.~,.~ . Well Absorpt on are~ ~ DISTANCE TO: ~ ~ Manufacturer [Liq'cap2c~°ns IF HOMEMADE: Inside length Well '/~ / (30, ' No. o[ lines Length o[ each line NO. OF B/?~DROOMS %) Dwelling Mater a L PER M I?,~NO. ,6-' /o/o (% No, ,o~compar tments -'----- Material Nea,'est ~? ,i~ec) / / Trench width J '/- ~ G inches Liquid depth_. PERMIT NO. bi~uid capacity in gailSn§ '-- - Foundatio~ , I PERMIT NO~/O //0 ~ DISTANCE TO: , ~{'p Total length of lines Material beneath tile Depth Top of tile to finish grade Length Width Distance betwem¥1JDes /~ /cL~ Total effective ~bsorptign area PERMIT NO. Type of crib ..- / / --~-I-- ( _ - .... - - - '' .---" -- I Builc~g fo.~.~'~Ol~- Nearest lOt lin~ ...... Depth /iDriller .... Dstanc~t01otline PERMIT~O: c~.._ , /. I u/O/'O ~ Bu Id ng fOUlldatio~.-~ ISawerline _, .~ Septic tank z-~. Absorption area(s} ~C -C ,f ~ DISTANCE TO: OTHER PIPE MATERIA,~ ~C)~ (~ SOIL TEST RATI?/./ 7 I NST A LLE R~ ~ ~ '~'?~(~"'-~--~0 L'~ R EMAR KS DATE LEGAL ~/¢//,¢/ /-~ [;,EF'RF.:THENT ,... HEFILTH RN[:, EN',,,' :i: F.:OI'.4HEI",ITFIL ..... ;.' - TE Z '[' I ON E ;.:'.'5 '" L. :,TF..E[: F., I-t1',1...F1.. F..h 264 '- d. 7' 20 IL..,q EEL. 9_._ F~ ~'-.fl I::]F'F'L~[L-:FINI:, KUF..T C. ~ L.OCFH" 1 O1'~/~/~ E, I RCHHOOD F.:D. 'kOO:t I.,.IEST ;~::L':i:F.'.[;, FI',,,'E. L. EGFIL ¢1.3r~:. 6 ;:~ SQI..IFIF.:E: F:EEET !..OT E;,4-E: E;E:C :t.:E: T::LDN F.':ZI.,.I LOT SIZE T"¢F:'E OF ::i E I L. HE,=,UF...F f T. 1",1 :E;"r'STEH 1:5: TRENE:H THE RE~;!U :[ F'.ED :~.'; I ZE OF 'T'HE: 'L.;O :[ L RBSORPT' 1 ON S'.r'STEH 3('-: THE: LENGTH [)II'"IENSIOI"4 IS THE LENGTH ,::IN FEET') OF "rile TRENCH OF.: [:,F.:RINFIEL..E:,. 1'HE DEPTFI OF FI TF..'ENCH OF.': F'IT I~; THE E:,]:STRNCE: BETFIEEN THE :SLIRFRCE OF' THE E~F.'.OUND Ri'.,IE:, THE BOTTOH OF THE EXCRVRT]:ON ,::IN FEET.':,. THERE :I:S I'.,IO SET [,.t :l: B,"l'l...I FOF.: TRENCHE:'_=,. T'FIE: (3F.'.R',,,'EL E:,EF'TFt ]:.'.E; THE i'¢IIN:[i'"IUH DEPTH OF GRFI',,,'EL. BETI.,.IEE:N TFIE OU"FFFtLL FIND TFIE BOTTC)H OF THE E',,-,:CR',/R'rION ,.'.'IN FEET;,. ? F'EF~:P'I :[ 'T FIF:'F'L :[ E:FII'-,IT FIRE!; THE F:E:E;F'OI'-,IS :[ B I L.. I T"r' TO I NFORH TH t :5 E:,EF'FIF-t"I"t'IENT t:::,LIF.'. :t: NE'i 'f'HE I N:E;,TFIL_I..FIT I ON 11",ISF'ECT 1 O1",fE; OF FI1",1'¢ I.,.IE:LL.S FIE:'J'F~CEN'F TO TH I S r'~'., r ~:.m, ~' FINf':, THE: i',fI. JI1E, ER OF F..Ez, IL.,EN...E .... THWr THE HELL HILL S;EF.:',,,'E. I:::,EF'FIF.:THEi'.4T I.,.I ILL BE 'E UB.]EE:T TO PF:O:E;EE:UT :[ ON. I',I:I:N]:HIJH B, :[ STI=Ir.,ICE E:ETklEEN R HELL RND IIN'¢ :.t. OO F'EET FOR R PRI',,,'FITE NELL OR J.50 'FO ;F.'OE~ FEET FROH R F.'UE,'LIC NELL DEF'END.I:NG UPON ]"HE 'r'¢F:'E OF PUE:LIC klELL. I',I]:N.T. HUH B,I'E;TFINCE FF.:OH R F'F.:I',,,'FITE klELL 1"O R PF:I',,¢RTE: SEI.,.IER L]:NE .f.S 25 F'iZET ~1'.4[::, '1"O I:::1 COf,II',IUI'4IT'¢ SEHEF'. LINE IS 75 FEET. HELL. LOGS RF:E RE~"4UIF..'ED RN[:, HUST BE F.'.E:TURNED TO 'T'HE DEPRF'.THENT klITFIIN :~:O OF THL:: I.,.IE:LL. E:OHPLETICq'.L OTHEF.: F.'.EQU:[F.:EHENTS HR'¢ RPPL.'¢. SPEC:I:FICFITIOI'.,I5 Rt'.4D CONSTF.'.UCTIOi'.,I D;[RGRF. IHS FIF:'.E R',,,'F.I].'I..~RE!:LE TO INSURE F'ROPER II'.,ISTFtLLRTION. I C:ERT):F"r' THRT ::L: I FI1"1 F"FIH]:LIFIR kI:L'TH THE REg!LIIREME:I"4TL"7, FOR CIN-~S):'FE E;EFIE:RS FIN[:, I.,.IEL. I...S RS SET F'ORTH B'¢ TFIE 1','IIJ1'.,I:I:CIF'FIL. I'¥'¢ OF' FINCHORRGE. 2: I I,.I:[LL INSTRLL THE L:;'¢STEH IN RCCOR[:,RNCE P~I'r'H ]'HE CODE%. :.7: I UNE:,ERSTRI'.4D TFIRT THE OI'.4-SITE S;EklER S'¢STEf'I I',1R'¢ F..'EQLI :E RE ENI....F~RGEHEI'.4T :IF' THE F.',ES :f. f.':,ENCE I E; REfflODEI_.ED TO INCLUDE i'dORE TFIR1'.,I Z. BEE:,F.:00HS. FqF"F'Ir~.IZCFtf.21~ KUF.:'I" C. ~;O1'.,11 I 0 by DOC Co, dba SULLIVAN WATER WELLS P,O, BOX272, CHUGIAK, ALASKA 99567 · TELEPHONE688-2759 OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE - Started PERMIT NUMBER r .' , .- -" '"~ bRAW DOWN FT. ;' Ended " GALS. PER HR · ·, KIND OF CASING DEPTH OF WELL , ~ STATIC LEVEL OF WATER FF. KIND OF FORMATION: From Ft. to Ft, From Ft. to : From i Ft. to ' / From__Ft. to From : Ft. to 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. From __ Ft. to Ft. From Ft. to Ft. From From__ From From From From From __ From From-- From From From From Ft. to__Ft. Ft. to Ft. Ft. to Ft. .Ft. to__Ft. Ft. to__Ft __ Ft. to Ft. __ Ft. to Ft. Ft. to Ft. _Ft. to Ft. Ft. to Ft._ Ft. to Ft. Ft. t o.__Ft. Ft. to__Ft. Ft. to Ft Ft. to Ft. Ft. to__ Ft. Ft, to Ft. MISCL. INFORMATION: DRILLER'S NAME WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geologicol & Geophysicol Surveys LOCATION OF WELL Borough (Ple(~se complete either la~ lb or lc.) DISTANCE AND DIRECTION P'ROM ROAO INTERSECTIONS ! SireD! Address end Arco of Well Locofloll WELL LOG Materiel Type MgNIC~&I.ITY O--~ DEPT. OF H ENVIR-Oqq~bT~ Surf(ice Top BOttom © ANCNORA( 16, WATER WELL. CONTRACTOR'S CERTIFICATION: Orllling Permit No, A.D.L, No. Section No. Township N~ Range E~ Merldton sE] wE3 3. OWNER OF WELL: ___ ,=L~_~%L :.:-,.!, 4. WELL OEPTI4: (fln~) ~ ~. BATE OF 6OMPLETIO~ ./':¢(~.. _J : :~_. - I0 - 6. ~ CoLic 'ool ~ Rotary g Driven :Dug E] Irrigation ] Test Well E] Public Supply [] Industry [] Recharge [] Commerical ] Ofhor: CASING: ~] Threaded ~ Welded dtom. - _in. to¢~' ~ ff. Depth Weight 9. FINISH OF WELL'. i¢2' ~' Slol/~o~h Size: Length?. ft. I0, STATIC WATER LEVEL: ~ .., II. PUMPING LEVEL below lend surface and YIELD fl. atler hre. pumping g.p.m. 12.GROUTING Well Grouted: [] YeB .~ NO : M.t.rial: ~] Neat Cement [] Ofhl~r: 13, PUMP: (if avollablo) HP Length of Drop Pipe ft. caprJcity g,p,m. [] Subm. [] Jcl [] C~ntrificol [] OIher This well wes drilled'~nder my/ijurisdlclion or~d this report is lrue Io th~ be.si of my knowledge end belief; ~,,.~ , I / '~, ,.'/ ' t r- ~;]- ."/9 ",'J-, ,";' J] R~gistered businrJss Na~b - Co~lroct License Number ,~,,,,:fL'O, -t~:~,~./ /'~ qct~ tg~l,'~;~,:," .7~' 1¢~,'/ A U~ized Representative Form 02-WWR (11/'81) Copy Dislribulion; WHITE-Stele D665~ PINK-Driller, CANARY-Customer 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# 051 171 38 1. GENERAL INFORMATION Complete legal description Lot 64B; Peterson Subdivision Location (site address or directions) Property owner Mailing address Lending agency Mailing address ' Agent Dick Brown/ Address Kurt Thorson 19182 Birchwood Loop Tarqet Realty 19182 .Birchwood LOOP Chngi~; Ak Day phone Chuqiak, AK Day phone 688-9026 99567 Day phone 6942388 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOi~S: 3 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. XX 72-025 (Rev. 1/91) Fronl MOAIt21 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 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 Name of Firm Address Engineer's signature Alaska Water 7320 East--Coho, ALASKA WATER & WASEWATER SERVICES SHALL BE PAID $1225.00 AT CLOSING FOR SERVICES PERFORMED. DHHS SIGNATURE Approved for -f~/~//~ ~bedrooms. Disapproved. GonditJonal approval for ,.f this inspection. [e Phone Date bedrooms, with the following stipulations: Additional Comments By: 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 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~I ,< C'EIVED Municipality of Anchorage JUL 2 9 1998 DEPARTMENT OF HEALTH & HUMAN SERVICES ~) Environme L I ...... ~ur~ur^Lu~ OF ANCHQP, AGE~-~-'"'"~L--~ nm ~ervlces IJiVlSlOn E '[At, ERVICESDI 825 L Street, Room 502. Anchorage, Alaska 99501 '~v~)~M~3-;~'~44 V,S,O~-..~.' Legal Description: A. WELL DATA Health Authority Approval Checklist L-o-r (,,~'&t ¢~T~-~5o~ -~//o Parcel I.D.: Well type Log present (~YN) Total depth ~ ~o~ ' If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~ -- ~ o - ~, ¢ Cased to cl ff '~' Casing height (above ground) Sanitary seal (~N) Wires properly protected (~) h/~,~ Date of test FROM WELL LOG AT INSPECTION Static water level '~.© g.p.m. ~', 2 Well production g.p.m. WATER SAMPLE RESULTS: Coliform 0 Nitrate Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed Foundation cleanout (~) Date of Pumping ~J ~ ~,,~ Pumper - Ch I reel/L-. Other bacteria 0 Collected by: A~[I~I 'Wat~l' ~ 7320 East Chester tits. Anchorage, Alaska 99504 Tank size J Co o Number of Compartments ~ Cleanouts (~1). ¥'~.~ ~r~ Depression 06~) ~Jo High water alarm (Y/~) ~o C. ABSORPTION FIELD DATA Date installed "7/~- ~/¢1~ Length -75 t Width Effective absorption area "'/~;o Date of adequacy test ~ Soil rating (~r ft~m) O, Gravel thickneSs below pipe _ System type 'T*R,~Jc ~, /-~ ~ Total depth ~. '7 - ~. t Monitoring Tube present (~)N) h/E~ Depression over field (Y~) ~ Results (Pass/Fail) ~ For ~ .bedrooms Fluid depth in absorption field before test (in.); Fluid depth (ins) Minutes later:. Immediately after gal, water added (in.): Absorption rate = g.p,d, Peroxide treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION ~//% Size in gallons. Date ~d Manhole/A~~~''Pump off" level at*_ E, SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: I ~o I +__ On adjacent lots __ ) °°~ + Septic/holding tank on lot Absorption field on lot Public sewer main _ On adjacent lots Public sewer manhole/cleanout ./^ Sewer/septic service line ~ ¢; ~ ~' Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: · Foundation ur.~ t~ Property line %.¢1~ Absorption field Water main/service line I ul-t' Surface water/drainage Ioof+' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Wells on adjacent lots Property line I E, Building foundation Surface water I oo~ ~' Driveway, parking/vehicle storage area I coI Curtain drain Wells on adjacent lots Water main/service line F. ENGINEER'S CERTIFICATION ~ I certify that l have...d~ter¢i¢ed t~m'tCi/bld ~nspections antdhirsevidaet~' · Date ~/~/~ HAA Fee $ ~O-'~ Date of Payment 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 64B; P~terson Subdivision May 14, 1987 Location (address or directions) Property Owner K~.,'l.t & Linda Thorson Telephone: Home 688-9026 Business SR I, Box 2424A, Chugiak, Alaska 99567 Mailing Address (b) (c) Lending Institution Mailing Address. Commonwealth Mortgage Telephone (d) Real Estate Company and Agent Address none/refinancing Telephone (e) MailtheHAAiothefoliowinoaddress:or:Checkhere~,ifholdforpickup. List contact person and day phone number below. S & S ENGINEERING 694-2979 17034 Eagle River Loop Road~ Suite 204 Eagle River, Alaska 99577 TYPE OF RESIDENCE Single-Family [~ Number of Bedrooms 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. 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 fRev 8/861 Fronl 'HJON~ s,Jaeuleua leUO!SSajo~d @ql u! suo!ss!Luo JO sJoJJa Joj elqisuodse~ lou s! eSe]oqouv jo/~!led!o!unlAI eql 'penss! s! e~eo!,qpao e e~oJeq eiep ez/qeue do suo!]oadsu! ¥)rlpuoo lou op SHHQ jo seaAoldLu=l 'slua~ueJinbe~ a]a]s put leJepej u!e~ao/ysRes o~ Jep~o u! suo!]nl!lsu! 6uipual ~ieq~ put seLuoq jo s]aseqo~nd ol,~sapno3 a se s!qi saop SHHQ eql 'eHSelV jo a~,e]S' aql u! paJe~sfee~ JeawSue leUO!SSa~oJd ~uepuadapu! ue ,~q a^oqe ~; qde~13e~ed u! ua^!6 suo!~e]uese~deJ eq~ uodn glue peseq se~eowpeo le^oJddv /~]Moq]nv qlleaH senss! (SHHQ} seo!^]aS UeLUnH put qlleaH jo ~uatuMedaQ a6~oqouv jo /~]!led!o!unR NOIJ. rl'¢O leAOJdd¥' leUO!l!puoO Jo sLuJe/ leUO!1!puoo peAoJddesfQ x/ peAoJddv __..¢' a le~ /~x~7, A q sLuooJpeq ~'1¥AOl=ldcl~'J°J p a^oJddVsHHO ,/ / auoqdala& 'uo!~oedsu! s!q1 jo e]ep u. loel;e u! suo!leln6eJ put 'seoueu!pJo 'sepoo eleiS pu~ ledfo!unlAI lie q)!~ eoUe!ldLUOO uf Jo/put Alddns Jaie/~ a~!s-uo eqi 'uo!ioedsu! put uo!leO!~se^u! XLu LUOJJ put Sely e6e¢oqouv peu!e~qo uo!~eLu]o~uf aqi u. paseq ~eq~ Xjpe^ ]eqpnj I 'u!eJeq paleo!pu! eJn~on~ls jo ad/~ put SLUOOJpaq JO JaquJnu eq~ ~oj elenbape put leUO!l, ounj 'ajes s! Luals,~s lesods!p Je~e~alse/~ Jo/put Alddns q~leeH s!ql jo uo!lee!lse^u! ALU leq~ ~J!JaA I '~oleq u~oqs e~ep uo!~ep!le^ eq~ jo se put oleJaq pexwe leas ,~LU ,~q pewMao sV NOli¥~UO~NI QN¥ ~iYa 'HO~¥~S ~ll~ 'SiSal 'gNOllO::tdSNI 9NlalAO~d ~lJ 9NIM~NIgN3 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPALI'IEA)J:T'Hq~t[CI~K~E:IITY APPROVAL (HAA) ENvi~EPT. OF F'~i~i..iST . FEBRUARY 1984 ONMENTAL P~OTECTIIDI~64.4744 MAY 2 '] 987 Legal Description: J--',, oT RECEIVED Well Classification Log Present (~) Well Total Depth / ~r~~ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (~N) Separation Distances from Well: To Septic/Holding Tank on Lot S- ~ If A, B, C, D.E,CF Approved (Y/N) Date Completed ~//~b¢ Yield Cased to /~,,--~" Depth of Grouting L¢9' ' Pump Set At (2/-~ Sanitary Seal on Casing ~/N) Depression Around Wellhead (Y/~) ; On Adjoining Lots 'To Nearest Edge of Absorption Field on Lot ,'~2~/~/ On Adjoining Lots To Nearest Public Sewer Line "'///A To Nearest Public Sewer Cleanout/Manhole t.//..q To Nearest Sewer Service Line on Lot _ ?.s-?-/ Water Sample Collected by -~-~ ~./(~//'..~,.u'.~.-P-.ll,./~. ; Date Water Sample Test Results ,~'-~ ~¢'z'..C~F/¢2 ~"O,¢y /~'-O/'~ ,~A~"/7-~,,~ ~- Comments I,./~_ .~'~._¢~,,~ /~'~-~r~-~.~,-~4~_---O ~[/~/¢~ ~ B, SEPTIC/HOLDING TANK DATA Date Installed Standpipes ~/N) Depression over Tank (YN~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ,/©o To Property Line /0 /7' To Water Main/Service Line Course , /'/f/~¥/' Comments Size ¢'0 ~<:~ No. of Compartments ~-~ Air-tight Caps Foundation Clean?ut (Y~ Date Last Pumped ~-~/¢'~/~ t..///::~ ; for /"'///~ Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72 026 fRPv 8,'861 Fron~ C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ?/~// ~ ~ Width of Field ,~ t Square Feet of Absorption Area Depression over Field (Y,~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well "'~/-/ To Building Foundation '-/u / ~/,~ Lot To Water Main/Service Line /~ t.f To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field ,,5~ f Depth of Field ~' ~'' Gravel Bed Thickness 5"...¢ Standpipes Present d~/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~¢/¥ To Cutbank (if present) Comments D. LIFT STATION 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 17034;Eagle River I,wp Road No. 204 ~,_~--~,/~,.,~/~::¢ ~ Sig~ ,- -,~- ~--~- -~ Date Company MOA No. ~O ~ ReceiptNo. ~ ~ - ~ Date of Payment '~ - ~ ~- S~ Amount: $ I~, O0 ** Check Permitted Bedroom Rating Against HAA Request ** I cer~if~ t,~ri~i~,~l~l~/~d, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Page 2 of 2 72 026 fRev 8/861 Back LA8 INSTRUCTJ ONS Report Printed: RAY 16 87 ~ 08:0i (.,~ORKOR~ER ~ 5?0 CHEHLA8 REF [,~TE EEGEi~.)ED: !~¥ i5 87 CLIENT: S & S ENGINEER;NG 8~ LL U,iG ADbRESS: IZ034 EAGLE RIVER LOOF' RD,~ ~204 EAGLE ~iVER. AK CONTACT PERSC¢~: PURCHASE OR[ER ~ VERBAL PR~SHISED:?~y 17 87 SHPLS RECEiVED:P~Y i5 87 ~PECi~L ~NSTRUCTi ONS: ~OP[ES HEL[~ FOR PiCK ORDER [~-ITE: ~"!A[ i_~ :.;-7 ViA: P~ANF] DEL .~ EF:Eb ACCT NO: S,NSENS~ (?07) 6'?4-2?7',;' ~ '¢'~17) ..... '~- ... ..b':?I~-£¥,, ;, ORDERED 8¥: Ci lent F'arameter Sample Description H..~.tr ix To Test !'-ie r.h :,0 ~.~r,~ ~.s 5:e.--,~ ~ t L,54B PETERS~ i850 HRS i 20005-TOTALCOLIFORH .-,~i,'iAom: 0 ' ~ $ & $ ENGINEERING 17034 Eagle River Loop Eagle River~ Alaska 9957~: AS-BUILY "2 .... 7:---.'--:" .... '--:'_(!£.L'~ -).;i~_.LL'_~sZ. _ ..:, ,q._ ./ ,..~ . /(z, '/' / t;-. %i ,:? ~ ..... - ~ , ' Anchor;uIe ~lccol~Jng Precinct, AL2ska, and that lbo imprnve- r.c.t ~;vef!ap m' cm:ronch on the pcol;e' y ]yhllJ ;~djacent there- co, tm~t n,~ iml-,rovtm~enls oil proper(y lyil q adjacent thereto 5uid pt'opc:'ty t..,:ct, pt ~is ia(be:dod h?roon. Da:rd ;,I 1' ,::, 1Grot, Alaska MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAl, tiEALTtt DEPARTMENT OF REALTH AND ENVIRONb~NTAI, PROTECTION APPLICATION FOR ~ALTH AUTHORITY APPROVAL CERTIFICATE I. General Information (a) Application Date Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name~ .ne - Home Busines~ (c) ~ppl~cMt~>s (check one) ~endtng Institu~i~n, ~; ~mer/builder~[~ (e) Real Estate Co, & Agent Telephone (_('2 ~/ .... (f) Mail the IAkA to the following address: 2, T~e of Residence Sin le- amily Number of Bedrooms 3o Water e Other (describe) Individual Well'~ Community :7[ Public ~ Note: If community well system~ must have ~,~itten confirmation from the State Department of Environmental Conservation attesting to the legality and status. Sewage Dis op~ 0nsite~ Public ~ Community ~-~ ttolding Tank~ Note: If community well system, must have vgitten confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] E~ng__ineerin?~Firm Providing~ Insj~3ctions, Test_!~a File Sear~l~ Data and Information As certified by my seal affixed hereto and as of the validation date sho~m beIow, 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 ~micipality of ~h~chorage 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 regula- tions in effect on the date of this inspection. Name of ~_~~~_~_ . Date ])HEP A~3roval Approved for ~ bedrooms Approved ~ Disapproved Terms of Conditional Approval (ENGINEER SEAL) Conditional Telephone CAUTION TIlE MUNICIPALITY OF ANCHORAGE DEPARTME~C OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES NEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON T}~ REPRESE~%rI'~ ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGiSTEF~D IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES ~{D THEIR I~NDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND S%%TE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANAI, YZE DATA BEFORE A CERTIFICATE I$ ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK° (DHEP SEAL) RR4/eJ/D18 [Page 2 of 2] 7~19~-84 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH ALri~ORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 IdUHICIPAI.I¥1' r <: ........ Well Classification /9}_ t~ ]nfl Well Log P~esent (Y/N) ~_~ Total Depth 6~/ ? Cased to Static Water Level z/o ~ Casing Height Above Ground ,~ Electzical Wiring in Conduit (Y/N) Separation Distances feom Well: To Septic/Holding Tank on Lot ~ /oo '~- To Nearest Edge of Absorption Field on Lot . To Nearest Public Se~r Line Legal Description: If A, B, ~ C, D.E.C. Sp~o~d(Y~) Date ~leted 7/~/ Yield ~/ ~pth of G~outin9 ~ ~t At Sanit~y ~al on Casing (Y~) ~ession ~ound ~l~ead (Y~) ; On Adjoining Lots /~a ; On Adjoining Lots ?d~ To Nearest Public Sewer Cleanout/Manhole X.~4- To Nearest Sewer Service Line on Lot Wate~ Sample Collected By /~.~ ; Date Water Sample Test Results .~,, '½, ~ ,~-,- f~.7 ~/~/~ ~ fi--' ' ~ .i__z ~ ~ .J B. SEPTIC/HOLDING TANK DATA Date Installed .~,/oc/ Size /~3~ <f'~/ No. of Cca,~a~tm~nts Standpipes (Y/N) ~V Air-tight Caps (Y/N) ./M Foundation Cleanout .(.Y/N) Depression over Tank (Y/N) /t/ Date Last Pumped ~ iz~ & ~-: Pumping/Maintenance Contract on File (Y/N)/Z/~ ; for Holding Tank High-Wate~ Alarq~ (Y/N) /~ Temporary Holding Tank Permit (Y/N) Separation Distances feom Septic/Holding Tank: To Water-Supply Well /wm To P~operty Line /m '~ To Water Main/Se=vice Line COLU~Se To Building Foundation ~o~ / To Disposal Field z/:i- / TO Stream, Pond, Lake, c~ Major D~ainage ComTents [Page 1 of 2] 2-15-84 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /~$' 1 Width of Field 3 / Square Feet of Absorption A~ea Depression over Field (Y/N) Results of Last Adequacy Test S~ ~,.~ Separation Distanc~ from Absorption Field: To Water-Supply Well '*/~ / To P~operty Line /~ / To Building Foundation ~/o ~ To Existing or Abandoned System cn Lot.. /g~_ ; On Adjoining Lots ~'~ To Water Main/Service Line ?O + To Cutbank{if present) To Stream/Pond/Lake/or Majo~ D~ainage Course To Driveway, Parking Area, or Vehicle Storage Area /~ ~ Type of System Design Length of Field ~-~ / Depth of Field ~. m- / Gravel Bed Thickness ~, 3- Standpipes Present .(Y/N) Date of Last Adequacy Test ~ LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested fo~ Electrical Codes (Y/N) Dimensions M3anhole/Access (Y/N) "Pump Off" Level at Vent (__Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Pe~.mitted BedrocTm Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. Signed ~-~A~~/ Date ~~'- Company ~-~dae~ ~./o~/4~/ /q/£.MOA No. ~ZF.-Z'I-~)/ KBlld5/s [Page 2 of 2] ,.,., ~o.. .or, O-. A ~q~'. JUNE ...... 25, 1971 .'i~,~,'~,'~ :_:- 2-15-84 ~'d RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE ,NSPEOTO. 'NS.EOTOR 'NSPEOTO%c L ^ ~,~-~4nRAGE MUNIL. IFP, L, ~ ~ ~ ...... MUNICIPALITY OF ANCHORAGE DEP1. OF HEAU[H  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~VIRONMENTAL PROI'ECTION 825 L Street - Anchorage, Alaska 99501 NOV 1 2 1§81 ENVl RONMENTAL SANITATION DIVISION Telephone 264-4720 R E C E I V E REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PR.{~PERTY OWNER./ MAILINGADDRES8 PROPERTY RESIDENT {If different fram above) ; ~ ; PHONE 2, BUYER /FAJ/ P,O.E LENDING INSTITUTION ~' i!~)'~' .~l~j ~ ~: IPHONE 4, REALTOR/AGENT ~J I PHONE MAI LING ADDRESS 6. TYPE OF RESIDENCE ~ ~'~SING LE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY NUMBER OF~BEDROOMS [] One [] Four  /' Two [] Five Three I-'1 Six [] Other INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY "8, SEWAGE DISPOSAL SYSTEM ATTACH WELL LOG. A well log is required for all wells drilled sinc~June 1975. For wells drilled prior to that date, give well depth (attach log if available.) E~~'' INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OFBEDROOMS [] 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: /O~t~.~lfTank[shomemade give dimensions; PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOl LS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA 4, DISTANCES WELL TO: Absorption Area to nearest Lot Line MATERIAL Septic/Holding Tank Absorption Area ISewer Line I INearest Lot Line 5. COMMENTS [~'"-~PPROVED FOR . .~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY //~~ 72-010 (Rev. 6/79)