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HomeMy WebLinkAboutHIGHLAND TERRACE #5 LT 5 "'~A M E MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAl_ PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Ancl~orage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECI'ION REPORT --'-- -[P~ONE t ~J~NEW MAILING ADDRESS LEGAL DESCRIPTION LOCATION DISTANCE TO: Manufacturer Well Liq. DISTANCE TO: Absorption area Inside length Dwelling Mat_~rial Width NO, OF BEDROOMS PERMIT NO. No, of compartments Liquid del)th IF ROME[vlA D E: Well Dwelling PERMIT NO. Manufacturer Liquid capacity in gallons Well DISTANCE TO: Length of each line NO, of lines / Top of tile to finish grade Length Material Foundation I Nearest"lot line Total length of lines I l'rench width Material beneath tile W-L. Depth Width PERMIT Total effective absorption area PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE 'rD: Class Depth Driller Distance to lot linc -rPERMIT NO. / Building foundation Sewer line Septic tank / A~-~'o~pti~aarea(s) DISTANCE TO: / OTHER PIPE MATERIALS ~,, 11 l~j~/5),'~"/-I~ _~,~,~'r~-~, PV'C ,r--2~:,-~ z~-~,o3z~ SOIL TEST RATING INSTALLER REMARKS LEGAL PERMIT NO, DEPAF',TMENT nF HEAL. TH AND ENVIRONMENTAL r P'~TE(..fIU[~ B,: .... TREET, FiNCHORFIGE.. Fir<. ~ RPPL I CANT LOCAT I ON LEGFIL CALKINS ENTERPRISES BOX 6E:"--': ER 995?'7 C I CUTTA L5 HII3HLRND TERRACE FIDI)N ~5 LOT SIZE 6~,4.-2555 246000 SQLIRRE FEET 'T'YPE OF SOIL RBSORBTION SYSTEM IS: TRENCH MRXIMUM NUMBER OF BEDROOMS = 4 SOIl,. RATING <SQ F'TZBR>= :t. 00 THE REI~LIIRED SIZE OF: THE SOIL ABSORPTION S'¢STEM IS: THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF TtJE TRENCFI OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE E:ETHEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVRTION <IN FEET). THERE IS NO SET HIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE f'IINIHUt'I DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE FIND THE BOTTOM OF THE EXCRVRTION (IN FEET). PERMIT RPPL. ICRNT HAS TFIE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY I.,IELLS FIDJFK]ENT l'O THIS PROPERT'f 13NJ:, THE NUMBER OF RESIDENCES THRT THE NELL 14ILL SERVE. BRCKF~L. LING OF RN'¢ S'¢STEM NITHOUT FINAL. INSPECTION RND RPPRO',/RL B'¢ THIS DEPARTMENT N~LL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETNEEN I-3 HELL FIND AN~¢ ON-SITE SENAGE DISPOSAL. SYSTEM :LOA FEET FOR R PRIVATE WELL.~ OR 1L50 TO 200 FEET FROM fl PUBL. IC NELL DEPENDING UF'ON THE T'¢PE OF' PLIBLIC NELL. OTHER REQUIREMENTS I'IRY 8PPL'¢. SPECIFICATIONS RNC, CONSTRUCTION [:,IRGRRM5 ARE AVAILABLE TO INSURE PROPER INSI'ALLRTION. F' E 1:;,%' M I T E ~.-I P I R E E; E-", E: C: E !-¢i .F,,3 EE R Zg: :J_ .,, dL .?m ;.':' I CERTIFY THAT l: I RM FAMILIAR HITH THE REQUIREMENTS FOR ON-SITE SENERS fiND WELLS F:IS SET FORTH BY THE HUNICIPRLITY OF ANCHORAGE. ~: I WILL INSTALL THE S'¢STEH IN FICCORDRNCE NITH THE CODES, ]~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAN" RE, QI,JIRE ENLRRGEMFZNT IF THE RESIDENCE IS REMODEL. ED TO INCLUDE MORE THAN 4 BEDROOMS. RPPL ~CRNT CRLKZNS ENTERPRISES Soil Log~; for: !,'.:~silof Ilills S;bd'lvision }ilock 2 I:)t 5 ri'lock 2 Lot 4 [a~!'te R!w:r Ad,'ln ~ Ln: ~; Bi,Jck F Lot 18 .>uuJ~vls(on, Lot 1J; ..... ~ ~ ~' '~ (')~ )ir C)l~? ~"~' .... . ' [] SOILS LOG PERFORMED FOR: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99502 776-222t SOILS LOG- PERCOLATION TEST ? " . PERCOLATION 'TEST DATE PERFORMED: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 9 SLOPE SITE PLAN 10 11 WAS GROUND WATER ENCOUNTERED7 /~/('~ 12 13 IF YES, AT WHAT DEPTH? 14 15 16 17 18 19 2O Gross Net Depth to Net Reading Date Time Time Water Drop (minutes/inch) PERCOLATION RATE TEST RUN BETWEEN FT AND FT PERFORMED BY: ~/,)~ ~ ~y CERTIFIED BY: ~i~Nl~f. --~Y ~ DATE: ~--/7 '- ~ 72-008 (7/76) ACCIDENT: SLOPE TEST d£g OFF ACCIDENT PRINTED IN U.£ A. APPROVED TOO[. PUSHER F::'IEI:~;b'I ]; T NO. I:::1F:'I:::' L. '; .': I:::IN T L C C:I::I"I" :1:01",1 L.E;Gi:::IL. L-.:I:::ILI< .'[ U':-:; Ei",l"f'. L. OT !5 I...ItEiHL.FII',II?, TEilCd~:FIC:E I_OT :~:i; ;[ ZE I','l):l',l]:r,lUl',l I)t'.:~;'T'I::II.,IE:E E:E:"f'I,,.IE:EN I::1 !.,.IEL. L FII'.,IE:, F:ll',l"r' Eff',I"-!~:';I'T'E '/.'i;E:I.,IFIGE E:,I!!;F:'O':*:!;I:::IL. 2!;"r':::;TEI"'I :l..Elel I:'EET F'QI::~: I::1 PF.'.).",,,'I::ITE I.,.IEL.L CIF:'.' 2E'~EI FEET F:CIF.". FI [::'I...IE~L. '[ C: I.'4ELJ ..... P.IEI....L.I..CIG'.:¢ F:tF.':E F~::EL.-.!LI]:F.'.E:D FIN[::' i'"tl...l~..;'f' BE: F;:..E'I'LIF.".NIED TO THE E:,EI::'I:::tl;~'.TI"IE:NT I.,.I:[TH]:i",I 2i:EI OF 'THI.::}.': i.'.IEL.L. C:EII"'IF'L.E;T ]: Oi",1. OTHE:I:;:: RE!L.-.!U ]: F.'.[.:;I"I[F:i'.,FI"!::; i"lFl"r' IRF'F'L"r'. ::'~;F'EC ~. F ]: E:la'l"~. Oi",l'/.i; FII",IE:, CCfi",I'.E;'I"I:;.:UC'[' Fl',,"f::l ]: LFIE~LE TO ]: I".t'}.U.Ji~'.E I::'E'.OF:'Ei:~: ]: I",I:ETI"FIL. t...RT ~. QN. ]:. C:EI:;~:"I" :[ F:'"r' "I'HF'IT ::L: :1: F:Ii'"I l:::l:::li"l:[L:[l:::t[<': 1.'.1:['['I"t THE RIE6!U]:REI'"IENT':-:; FOR E$,I"'"S]:I"E 'SEI.,.IEI:;?.::T.'; F;II",I[::' !.,.IE:L.I...:~:i; I::'ORTH [3"¢ "i"HE I"IUI",t Z C ]: F:'I":IL. ]: T"r' O1::' FII",IC:HO[;.'.I=IGF/.. 2: ]: l.'.l];I..J.... ]:t",I::':';TF:ILL THE: S"r'L~;TEI"I Zf',I I:IE:C:OI'~'.E:'FII",IC:E!: I.,.I]:TFI '['HIE C:QE:'E:E;. MUNICIPALITY OF ANCFtORAGE DEPARTMENT OF HEALTFt & 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. ]UNICIPALITY OF ANCHORAGE RONMENTAL SERVICES DIVISION AUG 0 6 1997 RECEIVED GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Ad dress Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ¢ % 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. 72-025 (Rev. 1/91) Front MOA #21 5. 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 of this inspection. - Name of Firm Address Engineer's signature H,H~.GNATURE ~ Approved for - '¢~ KND Engineering 'Phone 20441 Pt~migan E~vd. Eagle Riv~j', AK bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 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. 72-025 (Rev. 1/91) Back MOA ~21 MUNICIPALITY OF ANCHORAGE Municipality of Anchorage ENVIRONMENTAL SERVICES D~ DEPARTMENT OF HEALTH & HUMAN SERVICES AUG 0 6 1997 Environmental Services Division 825 L Street, Room 502. Anchorage, Alaska 99501. (907) 3{¢¢/'41~ I ~,/f¢ ~ Health AuthoritY Approval Checklist Legal Description: //~///~n_f//~+'f~f~ ~ ~-m~/~'' Parcel I.D.:.~¢~ - ~3/~. A. WELL DATA Well type //'/,¢/'/ If A, B, or C, attach ADEC letter. ADEC water system number Casing height (abeve ground) Wires properly protected (Y/N) Log present (Y/N) I Date completed Total depth Sanitary seal (Y/N) AT INSPECTION 7-17,77 g.p.m. /~'7 g.p.m. FROM WELL LOG Date of test Static water level /VA Well production WATER SAMPLE RESULTS: Coliform ~ Date of sample: 7' ~ Z/- ~' ? B, SBPTIC/HOLDING TANK DATA Date installed & - ?,~ . Tank size Foundation cleanout (Y/N) ,/¢ Date of Pumping -~-,~-¢'/~ C, ABSORPTION FIELD DATA Date installed ~-' ~'~ _ Length. ;.'.'3 ~7 / Width Effective absorption area /-/z//~// Date of adequacy test. ~-,//¢- ¢' ~' Fluid depth in absorption field before test (in.); Fluid depth ¢¢ (ins) Minutes later: / Peroxide treatment (past 12 months) (Y/N) Nitrate ,~, 3 ~-¢ Other bacteria C ella ct e d by: /1¢//,/,//'~/~'7~//¢~ ~f-'~,¢ ,~%')/J~"[,~'~l~umber of Compadments ~. Cleanouts (Y/N) Depression (Y/N) ,A// High water alarm (Y/N) Pumper Soil rating (gc.d./.'-t2 or fF/bdrm) Gravel thickness below pipe Monitoring Tube present (Y/N) A/' Results (Pass/Fail) lq¥O _ SyStem type ~ / Total depth /,~-' __ Depression over field (Y/N) . For Immediately after~,?/ gal. water added (in.): Absorption rate = /-¢~OO ¢- g.p.d. If yes. give date bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) /- /~ump on" High water alarm level at* *Datum Cycles tested J E. SEPARATION DISTANCES Size in gallons J /' level at* ~"Pump off" lev X SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /¢~ Absorption field on lot Public sewer main Sewer/septic service line ! On adjacent lots /¢(.~ -h On adjacent lots / C~¢ ~. -F Public sewer manhole/cleanout /~O ¢~ Lift station ~/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~/~ Properly line /~ 4- Absorption field ~' Water main/service line ~'d) -(' Surface water/drainage //--~ ¢' Wells on adjacent lots ! /DO + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /D ' '~ Surface water /~O "P Curtain drain //)~ ~ -h Building foundation /C~ f-fi Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots /~ F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review in conformance with MOA HAA guidelines in effect on this date. Date ~~ 7 HAA Fee $ ~'~' ~ Date of Payment (~/~/~-~ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number NOBTBEBN TESTJN61 LAB©[1ATO 3330 INDUSTRIAL AVENUE 8005 SCHOQN STREE F FAIRBANKS, ALASKA 99701 ANCHORAGE, ALASKA 99518 1907) 456 3116 * FAX 456 3125 /907)349 1000 , FAX 3t~9 1016 KND Engineering 20441 Ptarmigan Blvd. Eagle River, AK 99577 Report Date: Date Arrived: Date Sampled: TAme Sampled: Collected By: 07/25/97 07/24/97 07/23/97 1454 S. O. · Attn: Ken or Dee Our Lab #: Location/Project: Your Sample ID: Sample Matrix: Comments: Lab Number Method A150720 19620 Cicutta Lt 5 Highland Terr. #5 Water Parameter Units ** Definitions ** B = Present in Blank H = Above Regulatory Max E = Estimated Value M = Matrix Interference D = Lost to Dilution MDL = Method Detection Limit Date Date Result * MDL Prepared Analyzed A150720 SM 4500E Nitrate-N mg/L 3.36 1.00 07/24/97 R~~.'-~Dani~l J. Bacon Operations Manager NORTHERN TESTING LABORATORIES 3330 INDUSTRIAL AVENUE FAIRBAIXlKS. ALASKA 99701 (907) 456..3116 o FAX 456 3175 8005 SCI lOON STREE'I ANCHORAGE ALASKA 99518 (907) 349. 1000 o FAX 349 101G DRINKING WATER ANALYSIS REPORT FOR TOTAL COLIFORM BACTERIA KND Engineering 20441 Ptarmigan Blvd. Eagle River AK 99577-3736 Phone Number: Fax Number: Collected by: SO Sample Type Untreated Routine Method of Analysis: Membrane Filtration (SM 9222 B) Date Received: Date Analyzed: Date Reported: Next Sample Due: Comments S = U = POS = ND = TNTC = CG = HSM = SA = 7/24/97 Time Received: 08:55 7/24/97 Time Analyzed: 16:30 7/25/97 Time Reported: 18:35 Satisfactory Unsatisfacto1¥ Positive Test Result None Detected Too Numerous To Count (>200 Colonies) Confluent Growth Heavy Sediment Masking, Results May Not Be Reliable Sample Age >30 Hours But <48 Hours, Results May Not Be Reliable Old = Sample Age >48 Hours, Too Old For Analysis Comments: R = Resample Required NT = No Test * # Colonies/100 mi ** # Colonies/mi Sample Sample Total* Fecal Other* HPC** Date Time Coliform Coliform Bacteria Result Lab~ Location Comments 7/23/97 14:54 0 ND 0 NT AC5888 Lt5 Highland Terrace, Satisfactory 19620 Cicutta 7/23/97 16:46 0 ND 0 NT AC5890 L1 B4, Mountain Manor Satisfactory Sherri L. Trask Environmental Analyst Northern Testing Laboratories, Inc Anchorage, AK 7/25/97 APPLI¢ NT FILLS OUT UPPER HAl "ONLY Prpeer(V 0.vner i'_.i-..~.,' .! ~. -k~,~ ~: .:~. ~' ~ ,. i~, .,~_ . ,, t '.- - -;. '. ';, '"C~ Zip ()ode' ¥')' "''" Mailing Address . (, :,~., i :: : '~..~: ~ ... , , Address , ,, ( (' ( i ', 'k'% :' '/, . , ,,.. Lending Institution ~ ("~ 'I t.. '.,...( , .,.,',~.. ~ ,;,-'(: ,/ ~-- ,,; :/ Phone Realty Co, & Agent .~.. .. ~ :. Address ~;:- :: :,. ~7~ ~- ~' ..... :~' ' . . ,':> .-,; .... . I '~ / ¢-%,,% '-.' Legal Description /'. ( '~ :~ ~:~ ~ .... . . Type of Residence ' '  ¢ingle Family ~Multiple Family No. of Bedrooms O Other Water Sup~p)y ~J,~Cl'~idual ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. [] Community For wells drilled prior to that date, give well depth (attach Icg if available). [] Public Ulility Sewer Disppsal !c:~-? ?. [].Irfd~idual Year Individual Installed: [] Public Utility When Connected to Public Utility: [~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Date Date Date Inspector Inspector Inspector Inspector Pield Notes: ~-~ APPROVED BEDROOMS ) DISAPPROVED ) CONDITIONAL APPROVAL DATE _~-- -- ~ ~ AUG 2 9 ]983 "[Vlunicipality of Anchorage" 'CONDITIONS OF APPRC~Ji'0/-/iTiOR.j81 Pr0tec~f0n,' Soils Rating Date Sewer Installed Well To Absorption Area Well to Tank Well Log Received Septic Tank Size 72-023 Flodin Enterprises S.R. 1 Box 2570 Chugiak, ~< 99567 Jim Dittlinger c/o Real Estate Store 823 W. 53rd Anchorage, AK 99504 SEWER ADEQUACY TEST Legal: Location: Owner: Residence: Water: Sewer: Lot 5, Addition 5, Highland Terrace Subdivision Cicutta Way, Eagle River Jim Dittlinger Four Bedroom, Two Stories On Site Well From Municipal Records Tank: Fiberglass, 2 Compartment, 1250 gallons Absorption System: 37' Drain Trench Soil Rating: 100 Installation Date: June 1978 Date of Test: September 16-21, 1983 Test Procedure: The system was inspected on September 10, 1983. The septic tank was nearly full and the drain trench was dry. The residence had been vacant for approximately two months. Prior to conducting the test the tank was pumped. The tank was then filled with clear water on September 16, 1983. To saturate the absorbtion area and establish a static water level, 700 gallons of water was added to the drain trench on September 17, An additional 660 gallons was added to the trench on September 18. The test commenced on September 20, with the introduc- tion of an additional 660 gallons. The rate of appli- cation was 5~ G.P.M. Test Results: The system accepted the 660 gallons with no signs of stress (backing up into tank) and recovered to the static level after a 24 hour period. The system should be approved as meeting the Municipal Requirements. September 9, 19[!3. c/o 82~.~ W. 53rd LOt S Add ;J~'. Highland ,'~oj.~:tacc, Eaqle _River. Ai)bu?oval for the individual sewor arid wal;or faci].itio~:~ canriot (?anted until tho fo.l.J_owing J. to~-~s have })ecn completed; existin, g leacl~illg a~ea. '.['hi[~ Lost wilJ. determJ, ne if t;h(~ system is ~)~-.2,Je({uat~ according i:o ~.lational Starldar(Is, A 1'~'~ . private firms performing the test it; enclor;ed, '~h:i.s (ghe to~> of the well ca:~ing should be sealed so that :[t iS uatOl: tight, Exposed electrical wi*'~,,- to the well head are in ' '" ¢~of the ;qunicipality ol:. Anchorage codo~; an(] mu~t })e onca~:ied in conduit. ih= depwes;3J, on over 'th(. Please notify this ~)epartment for a ~:einspection v/hen tim noted ~]J. scrol)arlcJ.~f~ have been corrected. If tllo~:e are any further quofi'tJ, onr3, [)lease (:all this office at 264-4720. ',-1 J nc'c~re 1~ J ICl '//;9/ J iu't ,%,~,oc~. ~t(. IJnv:irol~aenl:~l Specia i,qt MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 82S L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SFWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. PHONE M~LING ADDI~ESS -~ .,..-~- ' ~ PROPERTY RES DENT (If di[ferent from above~ 2, BUYER PHONE PHONE MAILING ADDRESS 3. LENDING INSTITUTION PHONE ,.) ? 4, FIEALTOR/AGENT MAILING ADDRESS PHONE 5. LEGAL DESCRIPTION Lq- '-.7-P-.. STREET LOCATION CI £JJ s. TYPB O "ES'OENCE ~ SINGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY NUMBER OF BEDROOMS [] One ,J~ Four [] Two [] Five [] Three [] Six [] Other INDIVIDUAL' [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM .~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY NOTE:THE *ATTACH WELL LOG. A well Icg ~s required for all wells drille(] since June 1975. For wells drilled ~ior to that date, give well (attach Icg if available.) :~77~] deoth ** f individual/on~site, give installation date ~,--- ~', -- ? ~. f system is over two (2) years old an adequacy test is reouired by this Department. INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-01 O(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS , TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIR EC'FIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] IN DIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area S[Sewer Line I Nearest Lot Line 1 WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS [~/"APPROV ED FOR 4~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev, 3/78)