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HomeMy WebLinkAboutLAZY ACRES LT 15' ;Ib %~.~ 01 21  MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAl.. PROTECTION ENVIRONMENI'AL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME ~P0H O N E I ~ NBW 7-3444292 [] UPGRADF MAILING ADDRESS LEGAL DESCRIPTION LOCATION Richard Hope 2315 E. 72nd, Anchorage, Ak. 99507 Lot 15, Lazy Acres Subdv. 8321 Pokey Circle Well Absorption area DISTANCE TO: I ~/~ fit~mm W~+~r 7! Manufacturer ................ L,q. capac,ty ,n I OOO L IF H?MEMADE:Inside length IWe~ Dwelling / I Well Foundation /DISTANCE TO: I n/a I /No. of ~i.~, I Length o¢ each line Total length of lines / I ~ 24 24~ /Top of tile to finish grade Material beneath tile ~ 24" Width /Type of crib Crib diameter Orb depth ~ Building foundation DISTANCE TO: Well ICl~s Depth Driller Building foundation Sewer line DISTANCE TO: QTHER PIPE MATERIALS Cast Iron & P.V.C. Green SOIL TEST RATING 90 sq. ft. per bedroom INSTALLER Schachle Excavating REMARKS Dwelling __ 8f Material WidthStee-I Material Nearest lot line 10~ Trench width 36" inches NO, OF BEDROOMS 3 PERMIT NO. 800088 No. of compartments 2 com~. Liquid deptli PERMIT NO. Liquid capacity in gallons PERMIT NO. 8000~8 Distance betweee lines Total effective absorl)tion area 288 ~n. P ER M [,T NO.' n/a Total effective absorption area Distance to lot lin~ P~RMIT NO. | n/a~- Septic tank I Absor~)tion area(s) APPROVED DATE LEGAL ?¢/~~~;:~,¢~/~ '~ f " //¢/~'/¢~ Lot 15, Lazy Acres Subd. ~013 (R~(3/78) / PERMIT NO. I--'ILIII%II I ,]: I I--'FtL ][ TSr' CIF- DEPARTMENT OF HEALTH BN[:, EN',,,'IRONMENTFIL. F'ROTECTION 82.5 "L" STREET, BNCHORFIGE, BK. 9950:1. 264-4?20 800088 ) FIPPLICRNT LOCBTION LEGRL RICHRRD HOPE LINK 2~±5 E. 72ND LOT SIZE T'¢PE OF SOIL RBSORPTION S'¢STEM IS: TRENCH blFIXIMUM NUMBER OF BEDROOMS 244-4292 24000 SQURRE FEET SOIL RRTING (SQ FT,."BR)= 90 7'HE REQUIRED SIZE OF THE SOIL RBSORPTION ~,'¢STEM IS: [) E F' T I-~ =: :-~: L E I'...! u]~ T H = ;~: 5: 6 R R %-" E L_ [> r-z] F' ]~ H := ~ THE LENGTFI DIMENSION IS; THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS TIlE DISTRNCE BETWEEN THE SURFRCE OF TFIE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET 14IDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GF.'.8',,,'EL BETWEEN THE OtJTFRLL PIPE RND THE BOTTOM OF THE E',:'~CFIVBTION (IN FEET). PERMIT RPPLICRNT HRS THE RESPONSIBII..IT~¢ TO INFORM THIS DEPFIRTMENT DURING TI4E INSTRLLBTION INSPECTIONS 01-- FIN¥ WELLS A[:'.TACENT TO THIS PROPERT'¢ RN[:' THE NUMBER OF RESIDENCES THRT THE NELL WILL SERVE. .......... TII.40 ( ;----" ) I I'4SPE'i. CT I C" ~"",~'----., RRE RE L--..".L.I I RE~[:" ............. BRCKFILLING OF' RN'Y $'¢STEM 1,4ITHOUT FINRL INSPECTION RND FtPPROVFIL B'Y THIE; DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTRNC:E BETWEEN R NELL FIND RNY ON-SITE SENRGE DISPOSFIL SYSTEM i00 FEET FOR R PRIVRTE WELL OR '15¢'..] TO 200 FEET FROM FI PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTFINCE FROM R PRIVRTE WELL TO t-] PRIVRTE SEWER LINE IS 25 FEE7' RND TO R COMMUNIT~r' SEWER LINE IS '?5 FEET. OTFIER REQUIREMENTS MR9 RPPL"r'. SPECIFICFITIONS RND CONSTRUCTION DIRGRRMS RRE FI',,,'FIILRBI_E TO INSURE PROPER INS"rRL.LFITION. F'EF~:i'.I I T E~-::F' ][ [;~ E r~; ~.,E,]:EI'.IE:ER 3::[.,, I CERTIF'¢ THRT :l.: I FIM FFIflILIBF../UITH THE F.'E.~;.IIREMENTS FOR. ON-SITE SEWERS RN[:, WELLS RS SET FORTH B'¢ THE MLIN~CIPFILIT'¢ OF FINCHORFIGE. 2: I MILL INS.,TFILL TFI_E SYSTEM IN RCCORDFINCE WITH THE CODES. _.-.: I t.INDERST/~ND T~RC¢ THE uN-.=,ITE z,E~4EF.. .:, .r e, rEM MM'r RE~...t.IIKE ENLFIRGEMENT IF THE RESIDENCE ~D~j~. REM/~.DELE[:' TO INCLU[:,E~MORE THRN ]: BEDRr]OMS. ~/.IF3F'PL I CMNT R I JHHF..[: H ...~PE LOT SIZE ~z-t,-(~O© SQUARE FEET TYPE OF SCIL RBSORBTION SYSTEM IS; MAXIMUM NUMBER OF BEDROOMS = ~ SOIL RRTIr. IG (SQ FT/BR)= ~ 0 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: C.E 'TH '," bE OTH ...... l; THE LENGTH DIMENSION IS THE LENGTH (iN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE E×CRYGTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). REC-,1U I RED SEPT I O Ti:iNK S I ZE= I00 © C~F~L. LONS PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF 8NY WELLS ADJACENT TO THIS PROPERTY AND THE NLIMBER Of RESIDENCES THGT THE WELL WILL SERVE. TPIO ( 2 ) I N~PF, CT I Of, IS ~'~RE REQL~ I RED BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND 8PPROVRL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSGL SYSTEM IS 200 FEET FOR R PRIVGTE WELb OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPGRTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY 8PPL~. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS 8RE AVAILABLE TO INSURE PROPER INSTALLATION. PERM ! T EXP I RES DECEMBER ~'1., i~79 I CERTIFY THAT :k: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH BY THE MtJNICIPRLIT¥ OF ANCHORAGE. 2: I WILL INS~-L THE S~STEM IN RCCORBRNCE WITH THE CODES. ~: I IJNBERSTRN~ THaT THE ON-SITE SE~ SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE ,I~"RE ~OPELED TO INCLUDE~ORE THAN ~ BEDROOMS. ,, ..... : .... SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST Pouch 6.650, Anchorage, Alaska 99502 276-222~ SOILS LOG - PERCOLATION TEST PERFORMED FOR: N/~/-w~'~ LEGAL DESCRIPTION: ~--~/ 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O DATE PERFORMED: -- r.o~/olog (sob,~,,3,~/or) t~ SLOPE 14, I~Bo SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop (minutes/inch) PERCOLATION RATE TEST RUN BETWEEN FT AND ---- FT ~ l/owe d, DATE: COMMENTS ~ ~0~"' WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: Well Classification Well Log Present (Y/N) Total Depth Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments If A, B, C, D.E.C, Approved (Y/N) Date Completed Yield Cased to Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date SEPTIC/HOLDING TANK DATA Size Air-tight Caps (Y/N) Date Installed Standpipes (Y/N) _ )/ Depression over Tank (Y/N) /%/ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: TO Water-Supply Well Ac) ~ To Property Line '~- ¢'~ / To Water Main/Service Line '+ Course "/'/~) ~ / No. of Compartments 7 Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation ~'~ To Disposal Field / O ~ To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed / O//~/o¢O Width of Field 3 ~ ....-¢'1:ype of System Design -' "J~ength of Field ~-~ ct/ ' Depth of Field ~ t Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well A~/Ct ~-/- To Building Foundation / Lot ~/ OA~' To Water Main/Service Line J'- ~--O/ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test Y To Property Line To Existing or Abandoned System on ; On Adjoining Lots ,~:~ To Cutbank (if present) · ¢-/00 / + ¢_,5-" 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 ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have. check.ecl, ,verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~ ~'~/'~'¢¢'"'- Date /~J 0 l-'~, '~)! / '~ ~r¢-~ Company(:~''4.~''/T' ~dZ~' ~OA No. ~T ~ ~ 0~ ReceiptNo. / 00 / CO // Date of Payment ///~/~ ~ Amount: $ ¢¢ ~ Page 2 of 2 72-026 (~ 1/84) 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 /~ Ok,))'7.) / c~ ~'~ GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) q, (b) Property OwnerIru°'~'ll~ Telephone: Home Mailing Address. (C) Lendinglnstitution ~j,lL%~c~-cr~'''-%'''j "~¢-w~,R.,v-~ e,,, ,~.~" ~o~ Telephone Mailing Address ~ ~0 b L ~ '~ 0 ~ ~ (d) Real Estate Company and Agent Business Address Telephone (e) Mail the HAA to the foltowina address: or; Check here ~ if hold for pick up. List contact person and day phone number below. 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 IRev 8/861 Fronl ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~/~(.2,&~'7". /_~.--/~(-~/~,..~- "~.Z~,A,.2 C Telephone Address r~¢' O/ ~ ~//.,~ ~'.) ,~/ ~"~ '~'"_/~/L~'~",,'~ ,,~,/~. Date DHHS APPROVAL Approved for ' Approve? Terms of Conditional Approval i Disapproved Conditional. CAUTION 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. Page 2 of 2 72-025 IRev 8/86) Back 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 15 Lazy Acres Subdivision Location (address or directions) 8321 Pokey Circle, Anchorage Property Owner Diane E, Rumey Telephone: Home Business Mailing Address 5200 West 82_Avenue Lending Institution National Bank of Alaska Mailing Address C Street/Northern Lights Blvd, Real Estate Company and Agent Address (b) (c) Tetephone Telephone (e) Mail the HAA to the followina address: or: Check here E~, if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family Et~ Number of Bedrooms three(3) WATER SUPPLY Individual Well [] Community [] Public [~x Note: tf community well system, must have written confirmation from the State Department of Enviromnental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite ~xx Public FI Community [] Holding Tank Note: tf 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-o25 (R~v 8/86i Fronl ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal end State codes, ordinances, and regulations in effect on the date of this inspection, Name of Firm Flattop Technical Servicee Telephone Address Date Engineer's Seal This is a re-type of the original copy the applicant delivered to this department on November 3, 1986. The lending agency provided this department with a copy since this department's copy was not available. DHHS APPROVAL ~ ~_.~..~ Approved for three (3) bedrooms by fLt~ .--/,,L..-t...t £ ( Approved xxxxx Disappr Conditional Terms of Conditional Approval Date April 4, 1985 CAUTION 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. Page 2 of 2 72-o25 fRev 8/86) Back ~qELL DATA Well Classification Well Log P~esent (Y/N) Total Depth Static Water Level Casing Height Above Ground Electrical Wit ir. Separation Dista To Septic/Holdin To Nearest Edge ~ TO Nearest Publi~ Cleancut/Manho] ~1:>¢~_0 Wate~ Sample Col] Water Sample Tesf Cc~r~nts MUNICIPALITY OF ANCHORAGE (MO~; HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Cased to Legal Description: · ! MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & I~NVIRONMENTAL PROIECTION RECEIVED If A, B, c~ C,' D.E.C. Approved(Y/N) Date Co,~pleted Yield Depth of Grouting. Pump Set At trig (Y/N) ,ad (Y/N) B. SEPTIC/HOLDING Date Installed IO/~/(~O Size I0o0 (~{ No. of Cu,pa~tments Standpipes (Y/N) 7' Air-tight Caps (Y/N) W Foundation Cleanout (Y/N) Depression over Tank (Y/N) ~ Date Last Pumped -~/~/~%f'~ ' Pumping/Maintenanc~ Contract on File (Y/N)N.~. ; for Holding Tank High-Water Alarm (Y/N) ~q}. .Temporary Holding Tank Permit (Y/N) Separation Distances f~c~ Septic/Holding Tank: To Water-Supply Well ~./~. To Property Line ~d' To Water Main/Service Line Course O¥c~, ~r ~A~ ~oo' To Building Foundation ~' To Disposal Field { ~2 ' To Stream, Pond, Lake, c~ Major D~ainage Conm~nts ReCeipt ~ Date Paid: Arno un t: [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed (o/g/go Width of Field ~ ' Square Feet of Absorption A~ea Depression over Field (Y/N) Results of Last Adequacy Test ~'/~e~/~ Type of System D~sign Length of Field E y ' Depth of Field ~ r Gravel Bed Thickness 0~ Standpipes P~esent (Y/N) fqoa e Date of Last Adequacy Test Separation Distanc~ f~cm A~sorption Field: To Water-Supply Well N.A. To ~o~rty Li~ Ed' To Building Foun~tion ~6" To Existing or ~ndo~d System Lot No~F ; ~ ~joining ~ts ~ 3o ' To Water Main/~=vi~ Line ~ ~ To ~t~(if pre~nt) N~e To St=e~ond~ke/~ ~jo= ~aina~ C~se ~r~ec ~ {oo' To ~i~way, Parki~ ~ea, ~ Vehicle St~a~ ~ea ~ $~' D. LI~ STATION Date Installed Size in Gallons "P~%u On" Level at High Water Alarm Level at Tested for Elect~ical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Co~%~nts Company KB1/d5/s Check Permitted Bedroom Rating A~ainst HAA Request I certify that I have checked, verified, ~ conformsd to all MOA HAA Guidelines in effect on the date of this inspection. MOA No. [Page 2 of 2] C) tta. t/oj/t~.o [tUNIC I PAL ITl OF 1. ~noral l~fo~atioa Appllc~tioa D~[~ Location (~dr~os or dlr~c[lo~) (b) Applicant~ N~n~ ~l).'~t L. ~.~ Telop~no - Ho~a Applicants ~dre~n~~. ~ ~-~,,~ ~ ~. (c) lppliean~ i~ (check one) Le~i~ Ine[icuCton ~ ; ~er/~lder ~1; Bu~ ~ ; O~h~r ~ (~platn)l (n) a~a! 8m~atm Co. & Addraoo "~x Tolaphono \ [~0o I o~ 2] DA't~E RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE I NSP ECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE ~'~i~l- ~)h iJEALliJ ~k MUNICIPALITY OF ANCHORAGE I--'NVIRONMENI'AL PROTECTION  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION  825 LStreet-Anchorage, Alaskag9501 OCT 1~ ~ 1980 I ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please ellow ten (10) days for processing. 1. PRO P Ej~ T,Y OTN E R ./ PHONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2, ~UYER ~ ~ PHONE MAILING ADDRESS 3:' LENDINCy~NSTITUT, ION . ~'~) PHONE MAILING ADDRESS 4. REALTQR/,AGENT PHONE MAILING ADDRESS 5. LEGAb DESCRIPTION , o6 / s STREET L~CATION 6. TYPE OF RESIDENCE ,~ SINGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY [] INDIVIDUAL* ~ COMMUNITY PUBLIC UTILITY NUMBER OF~BEDROOMS [~ One [] Four [] Two [] Five ,,~ Three [] Six [] Other * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM yiN DIVI DUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAs 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 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 []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified iNSTALLER [~SepticTank 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 IAbsorption Area Sewer Line Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS ~-~' APPROVED FOR '~'~'~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY 72-010 (Rev. 6/79)