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HomeMy WebLinkAboutHIGHLAND TERRACE #5 LT 4Highland Terrace #5 Lot 4 #050-312-28 Municipality of Anchorage Development Services Department :jr.l 'ry' \ Building Safety Division' •' ' 3/ w On -Site Water and Wastewater Program, 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 Page 1 of www.d.anchorage.sk.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: 5 N1*O G• o %1 S l PID Number: oSo - 3 /,? - R 9'• Brian Mitchell Wastewater System: ❑ New m Upgrade " 19611 Cicutta Way, Eagle River, Alaska ABSORPTION FIELD Pn 317.3608 r aMbM.• 3 P D••P T M O Sw Tran O e•a O Mowll O aaw Sol It" TOW DWMe OnWiW Wee• LEGAL DESCRIPTION 0.6 Gpost' Varies from 7.56 to 6.8 Fr. ena. La fs r D•pe n PP•eoeaee M1WIwl ane• Gr WtfieMw•mpp 4 Highland Terrace #5 Varies from 3.7 to 2 Fr. 4 Fr Towrwhv {iMq• smart Fe MUU,e • OnWnr pear 0 Grn L,npm. 47+47=94 Fr. Fr. Well: .ar.UQ New ❑ Upgrade G".M rneN: M w0 Mw, . 2 QM. Dslw•n Mw, 10 &5* 3 F,. Ft G••" W (Pnna, A. S. CI: TOM DWM C•.•a n TOM •DnreaOr M,• 752 Fp• M,Mn•1 ASTM 3034, F-810 FI. R Fe P1M DM•DNnO. stox WN,r L•rM MWW Dean Cons D•w MOM" 8/28106 Ft Yna PvewanM a"'`HMO`i emnGr°"'e TANK GPM FL Ft SEPARATION DISTANCES ❑ Septic ❑ Holding ❑ S.T.E.P. ❑ Other. To Septic Absorption LM Holding Wodpnvale •"""` From Tank Field Station Tank Sewer Dne " F1_0 MMMMI aaDMO,Mt•. WA 110+ft 130+ ft WA WA 25* ft sw!&x,W~ 100+11 1100+ it NIA WA LIFT STATION ua Maws. Lor L+w 60+ It 30+ R WA WA GM � , 'PwnP on• rrei n 'P�•P orr n..r M. Hqn w•W rMm M. FM t,Oi 20+ ft 56+ It ` .WA WA Pr•rw M,t• 4 MaeM EwaatM ln"•Oam• pMbmMl ey COnMn Dnn ---- WA WA WA BENCH MARK Loudon Ma M•mpaan Bottom of siding on the prow of the house. wr•uan. ��`�� 1ri1• 100.00 FL F. Kenley Dates: 1M 8/28106, 11 a.m.P tal \t ••••.��t Inspections performed by: . ' 2ne 8/28/06, 3 p.m. Development Services Department Approval Conditional Approval Date: II�19,EY. *00 Date: Reviewed and approved by: • ' �\�� law Ounl i I I \ 1 i 1 / I 'oo• I I key/ 1 RSO' l / VJ I / I I / I / \ I / \ ZEPTIC AREA/ / r / I °o t 3 /$.PER CODEY W . 9' E.D.. S0' E /'30. g), \ 0 1 I I / / / Tract 18 �-�'--- Lot 5 780.9 /-\-\__-- ------ T.\ 70. / — - E6.4' I ------ M I es � I 101.4 1 101s I 1 I ' ' ZEPTIC I AREA —7 \� ABSOR4TION SYSTEM PLAN (ASBULT) 0.... %I1 Aw ' 1 -------------------------AWy. 7 1/ ----*: 49TH 000. .v DOUGLAS T. KENLEY, P.E. Cirri En9m<e AS -BUILT .. ...... j ..Lm MTM. r.DRAWINGS / Douglas T. Kenley HIGHLAND TERRACE 05. LOT 4 S/D /11 �slFaFp ?'76 EAGLE RIVER, ALASKA ' " 050-312-28 '""`"'•• SW060281 1�\\ROFE "` 11 -07 -OA—"" DTK — FK I — 1" = 60' " * 06112 1 SHEET 2 OF 4 / ZEPTIC / AREA��\\I 6\ y \ ETHREE _ \ BEDRI �,T.H• \ \\ \ RESID `'J3 0 EXISTING © 2 1000 GALLON / SUNSET TANK (2) 3'Wx4'E. 47"1� �/ cJ ( ABANDONED A3 PER CODE 3'Wx9' ' M 0' l'/0 \ FAT p Lot 5 DOUGLAS T. KENLEY, P.E. CiO Enq:n.a Mwt w��.u. rr.u...ww • Mn.wwn BRAIN MITCHELL HIGHLAND TERRACE N5. LOT 4 S/D EAGLE RIVER. ALASKA FD.. 050-312-28 " 11-07-0 °'-" OTK ° FK "' 1• v 40' DRAWINGS SW060281 06112 SHEET 3 OF 4 CAR PORT 0 / / _ OF Aqs� -%% III i * 49 THS? �/..i D0gilla s . Kenley C -8176 III;; \p� E �7o�_ 4' PVC FROM TANK :R 89.3' NCHES PROFILE OF TEST HOLE & FLO SPLITTER U FLOW PROFILE OF NEW LEACH FIELD DOUGLAS T. KENLEY, P.E. Ci i En9n.v rwe �mrtu� • r.r-.ur.ww . INrlirxn "'BRIAN MITCHELL "HIGHLAND TERRACE 15. LOT 4 SID EAGLE RIVER, ALASKA ".. 050-312-28 11-7-07 uu.° DTK °•'�' FK NTS 89.2' 75.86' OF'A( 9s�1 i *, 49 TH .4 ' AS -BUILT ...I U!`. . c""" U.. j DRAWING / Do s .Kenley E-8 76,��j-cc i SW060281 OFi o`=�.� 12 SHEET 4 OF 4 MUNICIPALITY OF ANCHORAGE kv (IA Development Services Department On -Site Water d Wastewater Program 4000 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Aug 24, 2006 Expiration Date: Aug 24, 2007 Permit Number. SWO60281 Parcel ID: 050-312-28 Legal Description: HIGHLAND TERRACE #5 LT 4 Design Engineer: 0069 DOUGLAS T. KENLEY Site Address: 019611 CICUTTA WAY Owner Name: BRIAN MITCHELL Lot Size: 52059 SQ. FT. Owner Address: 19611 CICUTTA WAY Total Bedrooms: 3 Permit Bedrooms: 3 EAGLE RIVER. AK 99577.8409 This permit is for the construction of: 0 Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling (907) 343-7904 ( 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. Received B Date: ¢ s o Municipality of Anchorage Development Services Department _Building Safety Division Onsite Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 ON-SITE SEPTICIWELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. n SD - 3119- aR Property phone Mailing address Zip Code Site address I qLP 1 Ole Ll EiC1L Zip Code Legal description (Sub'd, Block & Lot) OYI E,,(1( gk3a /L72,-, i466 Legal description (Township, Section & Range) Lot Size 59, n59 Sq. Ft. THIS APPLICATION IS FOR (®all that apply Absorption Field Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms 3 THIS APPLICATION IS AN: Initial Upgrade Renewal 1 certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or a9horized agent) Permit/Rush Fees: q&D �- Waiver Fees: Date of Payment: Date of Payment: Receipt Number: 0 ` 0qQ Receipt Number: (Rev. 11/05) Douglas T. Kenley, P.E. 9806 E. North Star Circle, Palmer, Maska 99645 (907) 746-1073 August 21, 2006 Municipality of Anchorage On -Site Services 4700 South Bragaw Anchorage, Alaska Re: Mr. Brian Mitchell, Proposed Owner Lot 4, Highland Terrace #5 S/D 19611 Cicutta Way Eagle River, Alaska 99577 REQUEST FOR SEPTIC PERMIT TO UP -GRADE FAILED SYSTEM On June 21, 2006, an adequacy test was attempted and the system was found to be in a failed condition with 64-1/4" of water in the monitor tube at the end of the 50' long, 5' E.D. trench. The drain pipe was located and water was confirmed to be above the inverted pipe. On July 17, 2006, confirmed tests were performed. (See attached site plan.) Test Hole #1 was dug to a depth of 15'and had a pert rate of 16 minutes per inch. Test Hole #2 was dug to a depth of 13' and had a pert rate of 9 minutes per inch. Ager a 9 -day monitoring period, ground water in Test hole # 1 was at a depth of 12.7' from ground level. In Test hole #2, the ground water was 111.8' from ground level. There was a difference of 42" in height between the ground levels of the two test holes; however, the ground water levels varied only approximately 24". The above -referenced property is approximately 52,670 square feet, with a three-bedroom residence. It is proposed to use the area of Test hole #1 as the site of the new replacement system. The area selected is essentially level with very few spruce or alder trees. The upgraded septic system will be two 3' wide, 4' E.D., 47' long trenchs for a total of 94'. The tank is a 1,000 -gallon Sunset plastic tank installed in 1975 which, in all likelihood, will riot need to be replaced. The application rate used in the design was 0.6 GPD per square foot. On-site observation and physical survey show that there are no water wells or private wastewater disposal systems within a 100' radius of the proposed system. The proposed system will have no measurable impact on surface or sub -surface drainage, or on drainage from adjacent lots.I It appears that there is no potential for contamination of adjacent water wells or streams from known sources. Also, the proposed development will not prohibit future development of any neighboring lots. Municipality of Anchorage On-site Water and Wastewater Lot 4, Highland Terrace #5 Subdivision page 2 Attached please find proposed design drawings for a trench system. If there should be any questions concerning the percolation rate or characteristics of the site, please call me at (907) 746-1073 or 243-5372. 1 Sincerely, Douglas T. Kenley, P.E. PE#8176 N { N m v r z Z 0 m N z z s7 ©o©®®o®e0000� a y Ig ig a BRIAN MITCHELL DOUGLAS T. KENLEY, P.E. d S a ra E.,m.« ¢ pg LOT 4, HIGHLAND TERRACE p5 S/D C NM ° P~. �* n 11(..n 74-107, :l EAGLE RIVER. ALASKA Z U) m W V m w bl vv11 V OI > l^ J• Y• N r r I` IAA �A !•�A g0 20 IAA qp �X Jc,05� y �O �O y0 CC L 22 n yyCyyy OSO i50T yljm �p xs F2 (n5t F NNfl yl O OO 2O gN Om� �m gn iy4� i t'�y �T OCOCAm K pp� ZIcr Fl i ~O Zr O�Z� SG Ai � r T > h >� �'yyyy� g gi .tn om 6 gi gFn g np m � 4 fn fn pC2� � Ay OCO z t"z In F;IP g T A rl n Ai rA IOA n 7 S 3 $ $ ? BRIAN MITCHELL DOUGLAS T. KENLEY, p.E. ea I Rnq q LOT 4, HIGHLAND TERRACE p5 SUBDIVISION .. �'" �"•�`� V EAGLE RIVER, ALASKA o Rt R y ppp II m gZ�m ZO f II NA a -a C0 In +�^ mfljn Am 68gq Oo Cln F a €�� NgBg TAP m8� i k o��u\7 ids A � V >� f A J = v m— v II g �j In �'l O� A SOO^ Oo2 lli#nn lO Zr oaf n � g sR`tng Qo g I S 3 $ $ ? BRIAN MITCHELL DOUGLAS T. KENLEY, p.E. ea I Rnq q LOT 4, HIGHLAND TERRACE p5 SUBDIVISION .. �'" �"•�`� V EAGLE RIVER, ALASKA OW 10 A ?a e 1 BRIAN MITCHELL DOUGLAS T. KENLEY, P.E Qpg Y LOT 4, HIGHLAND TERRACE #5 SUBDIVISION EAGLE RIVER. ALASKA Municipality of Anchorage Development Services Department Building Safety Division y,t On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www ci.anchorage ok. us (907)343.7904 Soils Log - Percolation Test Performed For. 'X 3P-1Pn /%l:34GkP // Date AOt </ Legal Description. h /,9�� �Gy/'/1rG lc1.� Township, Range, Section: Slooe Depth orcjnnr'Cs 2- 3- 4. -3-4. 5- Y 0 COMMENTS ' GIh 7- ° X3.75 Depth to Water Atter Yl Monitoring? 8- Q 912 F l'o 9 CU 10. ' I �. 11- 1-12-13-14-15-16- 12- 13- 14- 15- 16- 3�= y0 17- 17- I- 16- 18- 31'� 19- 19- COMMENTS 4 WAS GROUND WATER Date ENCOUNTERED7 y f T5 S IF YES, AT WHAT DEPTH? X3.75 Depth to Water Atter 0 P Monitoring? /,9-7 E Date:. 912 F l'o Site Plan Reading Date Gross Time Net Time Depth to Water I Net Drop 165 Pre yo.4 - I 'd I �. s 3�= y0 — I- 31'� PERCOLATION RATE /(0 lmm1rY,n0h1 PERC HOLE DIAMETER H "� TEST RUN BETWEEN FT AND Al Y FT ._ " i .. PERFORMED BY: "Cr . d Cd- Alen keg I _ PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL I I CERTIFY THAT THIS TEST WAS IN EFFECTN THIS DATE. DATE: 8 -z- 1' O iC 08/16/2006 13:55 FAX 907 343 7997 _ ON SITE Municipality of Anchorage Development Services Department Building Safety Division yf On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519 -Mo w+wv.ci anchoraoe sk vs (907) 3417904 Soils Log - Percolation Test I -r` �d Performed For. Oel vA J Ar-;", Y-ew L4.. Date Performed: � 7/ 4wr 4/ Legal Desenption: ,4!,c" A4nJA7 Towrtship, Range, Saalorc !.'P' -o CA-! A.ri/.NscG X4.'J J WAS DROVND WATER ENCOUNTERED? YA!s IF VES, AT WHAT OfpTN?'y j 0 D•pU loWwrAbr� p Monlmdng? ' . e o•re. 2002 Reading Dale Gross Time Net Time Depth to Water I net pop © z 9/OrFx:4 y°' 3oy.IJ y'iL / 3 /° ./ PERCOLAT)ONaATe N.Y tmwA.. ) PERC HOLE 01A1AeTfn TEST RUN BETWEEN —�; 717PT AND j' FT COMMENTS I PERFORMED BY. /4¢-0427 CJJ A' 'A&19y 1 C FY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINUS tN EFFECT ON 7 IS TE. DATE: iF - Z •'D:e MUNICIPALITY OF ANCHORAGE Hea- i and Environmental Protec on Fourth Floor West 825 L Street Anchorage, Alaska 99501 264-4720 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYS'HHA c1 /- .(�W SIk�NE(2e 1 �J 77 c� 3� NAAAE--.___L�L�_CLQ -`M W MAILING ADDRESS-_. ._--1 _ . �Qn PHONE LOCATION_-�._1_L.._u-��.____LE(--,AL L"r.-SC.RIPTION.____1"_ '��` --CAJ1---------- - ----------- E------------------------- — -- SEPTIC TANK: DISTANCEl I I _ NUMBER OF FROIM WLLL-[Od --_ %VNI`:UFF,CTUREi ��•--fAATEi21AL _ �eU l� SS COMPARTPAENTS_ INSIDE LENGTH --------- ___ INSIDE S'JIDTHLIQUID DEPTH__________LIOIJID CAPACITY' 0000ALLONS. TIL -E DRAIN FIELD-.�J�_4cwj�c� ( 1 TOTAL LENGTH DISTANCE FROM VVI-LL(�`.Q(�F_FOUNDAIION ._t � _30 +._NEjjAm-.sT LOT LINE. -INF.—._ -_OF LINE __ S 4 of Lines _----`__- DISfA.NCE BETWEEN LINES �.�l--I ��_-__TRENCH VIIDTH__ _ IN. TOTAL EFFECTIVE UU AGSORf`110;J AR -A -- - J--___.--_--- SO. I T. L_F_NGTH OF EACH LINE _- ---- ---- DEPT!i OF FILTER DFPTI!: TOP OF TILE_ I0 I lM1;ISIi GRADE _-A_�_5_ MAI ERIA.L 13ENEAI1­4 TILE -_1P� .I^J- ABOVE TILE IN. SE[-_PAGF_ PIT: D1; -`,METER OR WIDTH____, LENG1-1f__, DEPTH Log Crib Rings Crib Size: olArvIETLEt___D[_PTH.- DISTANCE FROM: WELL —�--- TO] AL EFFEC-fIVE BUILDING FOUNDATION_--, NEAREST LOT LINEAPSORPTION AREA (WALL AREA) .SQ. FT. Well Class: Depth: _ Well Distance To: Lot Line j' Bldg: d( Sewer Line: j Pipe Materials: uD .,Je r of Bedrooms: Installer:_ Remarks: LA -, _ ,- . DATE. ��p� 77 APPROVED C`I CA�D \ GREATER ANCHORAGE- AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274.4561 SEWAGE /�DISPOSAL � SYSTEM — APPLICATION AND PERMIT OL- /�A, NAME OF APPLICANT r �-- )l1 I c 1 e -`,'J" INSTALLATION LOCATION LEGAL DESCRIPTIO NL— INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FACILITY TO BE SERVED E PIT DRAIN FIELD OTHER C_ rL FINANCED THROUGH � TO BE INSTALLED BY solL resr RESULTS �� Ci ( NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE /�/ `� O TYPE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK J _. FOUNDATION TO SEEPAGE PIT 7 DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL /3 —/ SEPTIC TANK /6 / , SEEPAGE PIT 2�/)/ DRAIN FIELD 1_ TO NEAREST LOT LINE. WELL TO SEPTIC TANK ��!`� r SEEPAGE PIT DRAIN FIELD ��% ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK _�'-` G / SEEPAGE PIT , DRAIN FIELD SEPTI(; TANK, �`� SEEPAGE PIT �, DRAIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. G.A.A.B. OR LICENSED DESIGNER I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE _ /1/l / APPLICANT'S SIGNATURE s SIZE TYPE DIAGRAM OF SYSTEM AREA BOROUGH ORDINANCE NO. 2e-68 AND THAT THE ABOVE 0 Et E GEO" :CHNI CAL Et REVEL ?HENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster Earl Ellis 694-2774 SOIL LOG 6B8-2280 Soils Et Foundations Land Development Performed for: Name: Ck� Tel . No. Mailing Address:_'�� Legal Description:, Depth feet Soil Characteristics 0 _ n bTs�t��--J66��J\c, 3- 47- 5 —45 _ 6 7 9 .� 10�m 11. 12� 14 15 16 G , � 0W\) e'� C.> %, N x" Ground Water Encountered: Yes-,---,,— No—,,.,- If yes, what depth_ It_ Proposed Installation: Seepage Pit Drain Field ✓ Comments; Vic_ m Zit.'�1n�.?i� apt_ t �� � 's' Performed by:U11- Date: I I a �tc5 °az. a vet_ OWNER OF LAND ADDRESS (�rr ti ft r �xilling40Cng by A & 1, DRILLING COMPANY BOX 97, EAGLE RIVER, ALASKA 99577 9 TELEPHONE 694-2588 1 �'l / 1 .1 1 . DEPTH OF WELL LEGAL DESCRIPTION DATE - Started -,v Ended �z PERMIT NUMBER KIND OF FORMATION STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR KIND OF CASIING From Ft. to Ft. /10r JK From Ft. to ---Ft. From Ft. to Ft. Frojii--Ft. +o ----Ft. From Ft. to, Ft. 1,, From Ft. to_ Ft. From r 'Ft. to Ft. From -Ft. to-- Ft From Ft. to Ft f' i:,q j;,/ From Ft. to___Ft From Ft. to_L_Lit_Ft. I)i' From i Ft. to_ Ft. From Ft. to_)Lj_Ft.__LL, , J From —Ft. to--Ft.--- From Ft. to Ft. j 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 —Ft. to_ Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From—Ft. to Ft. From --Ft. to_ Ft MISCL. INFORMATION: DRILLER'S NAME 13 OF ANCHORAGE O u MUNICIPALITYr� EPAR ENT OF HEALTH & ENVIRONMENTAL PROTECTIu�y/`+ �r (L 825 L Street - Anchorage, Alaska 99501 rJJ D _-nom .!�AIE VIRONMIENTAL ENGINEERING DIVISION Telephone 264-4720 a' t REQ PPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts onpage1. Incomplete requests will not be processed. Please allow tan (10) days for processing. - - 1. PROPERTYOWNER PHONE MAILING ADDRESS �.0. A6 4' f�,�/� ,wPr�w PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE IVIA MAILING AD RD ESS 3. LENDING INSTITUTION fL4*0-J� j a 7`v'a6F2/ uh //� o�:¢yG� [/H (t/�y PHONE 5t -.E t` c 1' e to j-A'e4 s �� d�/b� o C'ernr�N ti* MAILING ADDRESS 4. REALTOR/AGENT — PHONE No h o � — MAI LI NG ADDRESS 5. LEGAL DESCRIPTION —� STREET LOCATION M _CLL v�6i W� rr C je 6: TYPE OF RESIDENCE NUMBER OF DROOMS C4 SINGLE FAMILY ❑ One ❑ Four ❑ Other;_ ❑ Two ❑ - Five ❑ MULTIPLE FAMILY Y-- Three ❑ Six 7. WATER SUPPLY -- �1 INDIVIDUAL* *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1575. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGEDISPOSAL SYSTEM s DO INDIVIDUAL/ON-SITC** **If individual/on-site, give installation date, If system is over two (2) years old an adequacy test is required ❑ PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CANBEINITIATED. THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED .2,CJ 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED C� _-7 INSTALLER ❑Septic Tank or ❑ Holding Tank Size: I L90d If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS KI _APPROVED FOR J� BEDROOMS ❑ CONDITIONAL APPROVAL (letter mu t accompany certificate) (� DISAPPROVED DATEi� -7 BY (Title) LEGAL DESCRIPTION 72-010 (Rev. 3/78) Tilly 26, 15170 k t5 Lona "elf) S t tl -j f,T') Pratt, I Zia, Lo"I hir, thol !-Lot 4s E'T'V:_' ar. a - i Ta unt w.% ticlv. I'm bac i ro I aro an -v tJs at Pratt, I Zia, Lo"I