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HomeMy WebLinkAboutBRISTOW LT 3  MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I ENVIRONMENTAL ENGINEERING DIVISION  825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE [~'~W MAILING ADDRESS F / LEGAL DESCRIPTION LOCAT'ON IWell.. _ Absorption area Dwelling PERMIT NO, ~, I-Z ~ Manufacturer ~____~~-'~.. C~""- ~'~'~ ~ Mate ria,~ p,~ . No. of compartments, ~ I- Liq. capacity in gallons Inside length Width Liquid depth /~i~1~;) IF HOMEMADE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O Z <~ Manufacturer Material Liquid capacity in gallons E~ Well Foundation Nearest lot line IL PERMIT NO. D,STANCE TO: /0 ~m ~. ~ No. of lines Length of each line Total length of lines Trench width Distance between lines . inches I.- ~ Top of tile to finish grade Material beneath tile Total effective rea ~ inches Length Width Depth PERMIT NO. ,~ I- Type of crib Crib diameter Crib depth Total effective absorption area '" Well Building foundation Nearest lot line u~ DISTANCE TO: .j Class Depth Driller Distance to lot line PERMIT NO, ,,,J '" Building foundation ' Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE MATERIALS SOl L TEST RATING / 7~-~ INSTALLER REMARKS APPROVED / DATE LEGAL 72-013 (Rev. 3/78) DEF'RRTMENT ,.,F HERLTH RND EN'v'IRONMENTRL F'ROTECTION ..... ~:,.~,~ ..' ." ,~ , ' · -' ~ -" , ~}- ~' '~t' ,.,~.., L _,TF. EET., HNI.,HCRRUE. .......... .'.~~t;:" ['-IEEE ~'~B' ':'~'~---S ~ TE SEI-~EF: F'ER~~/ HFFL]L. HNT :,TEFHEN L. ~,~ ~ EE:,U[~ ~.R BO,., ~,,~,~ E, '- '' _.E. RD. LOCRTION OFF RHE, BIT :-' ' _ _. :,QUREE FEET. LEGRL ~D ~0 8RZ$~OW ~U8 LOT ._ ..,_,_,.. _ TYF'E OF =,O~L ~E,=,_RFT~UN =~'_TEfl I,~ ~[:' ~ fl~,.',, Z MUM NUHBER OF BE[.,RDUM_, = < SO ~ L RRT ~ N6 /.. -~E' .... ~ ~ ' '- '-"q IS' TFIE REQU IF. Er.' :,I~E OF THE =,0 IL RBSORF'TION ~,- TEM E?EF"]'H= ~ bi[-~lSTH= ~ ~3~:R',¢'EL D, EPTFI= ' I~ ,- THE LENaTH [:,ZtIEN:,Z~N Z~ THE LENGTH ,::ZN FEET) OF THE TRENCH [~""DRRZNF~ELD. THE DEPTH OF ~ TRENCH OR P~T ~S THE D ISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTON OF THE EXCRVRTZON (~N FEET). Tl~g T~:EF~2H l-I ~ DT'H I S ~]~. -_,BIZ~ FEET THE GRR',,,'EL DEPTFI ~S THE M~NZ~UM DEPTH OF URH,/EL BETWEEN THE OUTFRLL F'~PE RND THE BOTTOM OF THE ENE:R',/RT~ON (~N FEET). # # SEPT I F'EF?.M I T RPPL I CRNT HRS THE F.'.E_,POfL.:, I B I L I TY TO INFORM TH I $ [:,EF'RRTMENT DUR I NG THE INSTRLLRTION IN=,FE_.TIEN=, OF RNY WELLS RDJRCENT TO THIS PROPERTY RND THE N_IflE, ER OF RESIDENCES THRT THE HELL WILL :,EE,E. T [..I m:: ,:: '; ::, ............. ~ 'ir I'-,ISF'EI-:T T CmI'-.~S RI:~.'E REf;_--!LI ]: RED :"'" '" I"1" '-"! BHL. KFI LL IN.~ nF RNY _,r =,TEM WI THOUT FI NRL INSPECTI ON RND RPPRO',/RL BY THIS =,UE,..TEt;.T TO F R D.=,EE. UTI ON. DEF'RF.:TMENT WILL BE '-- ' " ' '~" ~ MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWAGE DISPOSRL SYSTEM IS 100 FEET FOR R PRIVRTE WELL OR ~50 TO 208 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTRNCE FROM R PRIVRTE WELL TO ~ PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE [)EPRRTMENT WITHIN ~0 DR9S OF THE WELL COMPLETION. OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. I CERTIFY THRT 1: I RM FRMILIRR I.,.IITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE. 2: I WILL INSTFILL THE S'¢STEM IN RCCOR[:,RNCE WITH THE CODES. --<: I UN[:,ERSTF~ND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN ~: BEDROOM_,. / // .:-... d, ,/ --- Pe rfo rmed Legal This S{)II,S l,O(; I'EI{{)I,ATION TEST For. ..... /_~_ e/~..._/3 ........ ~_~. t. _~_F.i~ZLv] ....................................... L)a te Pc form reports' Soils log ........ ~ Percolation [est Del) th Feet 10- ll - 12- 13- 14- Was ground water encountered? If yes, at wi~at depth? Readi ng [)ate Gross Time Net Time Depth to Water Net Urop ......................................... ~'.Li~P__6.~ .............................. /]~ -Proposed installat]~? oeepage Pit .......................... Drain Field Del)th of Inlet . Depth to bo[tom oF pit or [re~ci, Box 1369, STAR I~OL'TE A ANCHORAGE, ALASKA 99602 344-7714 SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF DRILLED AT THE RATE OF PROPERTY OWNER /7~o LOCATION OF WELL SITE DRILLER B~ ~ WELL LOG: 0 ..... 10' 10 .... 15' '180 Jlq,,o0 PER FOOT. Bob Su~o 344~549 41---.44' ,o~ ~ eh.o~,r~ eom,~. ~ho,,t ,rede ,tltzm. 1/2 ~P~ V,i~.ZcL. 166--16.9' /~ po,'~ou~ ~ ~ or~ ,~ 174--177' ~ ~oc~ eha~u~ on~ ~ ~. 7o,t~. ~,~'~ p~d.u.c,t~a ~ 150 ~ !~. I~ou~L. 3600 ~ p.~. 24 I~u~ 3/4 Ho,~e e~4.,~ pu.~p el~u,,t.~ .be. ,4n~~ ~ ~ o~C~. 2..au~ ua.,Le,t p,~.,eeu,te cu~ a~. ,etmu,Ld..be ,b'mo,tpo,ta, Ae. cL ~ ev~,t:.ea aJ~a. 180 7~..: ;3420.00 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. S3420.00 WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF THANK YOU VERY MUCH. DATE BERNIE ~'~LAUS OF RAMPAR,T DRILLING WORKS l O, th.~ 1950 6ERVICE CHARGEOF 1~% PER MO~ W BE ABS~SED ON PAST DUEACCOU~. 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING '70 Naa # GENERAL INFORMATION Complete legal description Location (site address or directions) m Property owner ~:>1) J3 ~W'+ Mailing address Le n d, n g ag e n cy ~¢~"/~/~ Mailing address Day phone Day phone / /1 ,,, Agent /, 61/) IA ©~H~ f) Day phone J Address 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 C,o-,,,5'~~ ~, '~'~e,~,~ Phone ~z~-~oco/~;~,~-.9o~8 Address ~"ck~'"a~'~"~l ~ 9~lg~~ ~le ~lO~ Engineers signature ~ ~ ~~ ~ Date SIGNATURE Approved 'for ~'~---~--~ ~:-~) bedrooms. / Disapproved. Conditional approval for Se DHHS bedrooms, with the following stipulations: Additional Comments By: ~ ¢'~ Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based omy 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 ;a the professional engineer's work. 72-025(Rev. 1/91) Back MOAii21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal .Description: Parcel I.D. O I"+ ~,~ t-3co o ~)¢¢:t) A. WELL DATA Well type ~'~ljf/~'p'''~ Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level If A, B, or C, attach ADEC letter. ADEC water system number ~¢J ~,L.L-" Date completed ~'~r Io~ ~)~O Driller '~'~,p,~f-¢r I'-~-~ ' Cased to ¥ FROM WELL LOG Casing height Wires properly protected (Y/N) AT INSPECTION g.p.m. SEPARATION DISTANCES FROM WELL TO: I00' ~" ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~.~o} ~ ~O Tank size Ioo0 Oleanouts (Y/N) ¥ High water alarm (Y/N) Date of pumping Compartments Foundation cleanout (Y/N) ')/ Depression (Y/N) Alarm tested (Y/N) Z SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot -t- too' To property line Surface water/drainage On adjacent tots Absorption field __ --i-toO' Foundation ~*' Water main/service line 72-026 (Rev, 7/91)Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access Vent (Y/N) "Pump on" level~,,Ist [, I''~ .--~"Pump off" level at High water alarm level I ~ ~...~~cles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE~ LIFT STATION TO: Well on lot~ On adjacent lots D. AB~IELD DATA Surface water Date installed ,~ ~ [ 3~x:;) Soil rating t ~ 5-~//b~¥~ System type ~-~ Length ~ ~' Width Gravel thickness ~ Total depth Total absorption area ~) G ~ Cleanouts present (Y/N) ~ ,~ Depression Over field (Y/N) ~ Date of adequacy test ~~ Results (pass/fail) pM ¢ for Peroxide treatment (past 12 months) (Y/N) ~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ t oo' On adjacent lots If yes, give date t~o Property line To building foundation + ~o' To existing or abandoned system on lot On adjacent lots .¥-~oO' Cutbank 4"t °O~ Water main/service line Surface water -'¢~oO' Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Bac~< MOA 21 Waiver Fee: $ Date of Payment Receipt Number · ~! 3330 INDUSTRIAL AVENUE 2505 FAIRBANKS ST. Constructi Engineers NORTHERN TESTING LABORATORIES, INC. FAIRBANKS, ALASKA 99701 907-456-3116 ANCHORAGE, ALASKA 99503 907-277-8378 9601 Buddy Werner Drive Anchorage AK 99516 Attn: C. Landers Report Date: 06/24/93 Date Arrived: 06/21/93 Date Sampled: 06/19/93 Time Sampled: 1700 Collected By: CAL Our Lab #: Location/Project: Your Sample ID: Sample Matrix: Comments: Lab Number Method A124228 risto-- L3 Water Parameter Units * Definitions * B = Below Regulatory Min. H = Above Regulatory Max. E = Estimated Value M = Matrix Interference D = Lost to Dilution MDL = Method Detection Limit Date Date Result * MDL Prepared Analyzed A124228 EPA 353.3 Nitrate-N mg/L 1.8 0.5 06/22/93 Reported By: Susan C. Tifental Microbiology Supervi~sor NORTHERN TESTING LABORATORIES, INC. 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 · FAX 456-3125 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 · FAX 274-9645 DRINKING WATER ANALYSIS REPORT FOR TOTAL COLIFORM BACTERIA Constructing Engineers 9601 Buddy Werner Drive Anchorage AK 99516 Collected by: CL Sample Type: Routine Untreated Method of Analysis: Membrane Filtration Comments: Sample Sample Location Date Time Public Water System I.D.# Date Received: Date Analyzed: Date Reported: Next Sample Due: 06/21/93 Time Received: 11:15 06/21/93 Time Analyzed: 16:00 06/24/93 Time Reported: 10:07 Comments: S = Satisfactory U = Unsatisfactory POS = Positive Test Result ND = None Detected TNTC = Too Numerous To Count (>200 Colonies) CG = Confluent Growth HSM = Heavy Sediment Masking, Results May Not Be Reliable SA = Sample Age >30 Hours But <48 Hours, Results May Not Be Reliable Old = Sample Age >48 Hours, Too Old For Analysis R = Resample ReqUired NT = No Test * # Colonies/100 ml ** # Colonies/mi Lab# Total* Fecal* Other* HPC** Coliform Coliform Bacteria Result Comments 1 L3 Britow Sub 06/19/93 17:00 AA2103A 0 NT 0 NT S _Susan C. Tifental Microbiology Supervisor MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL )~J ~_ ~~.~ 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) Location (address or directions) (b) Prope~y Owner ~0b6F+ ~ dl,t~t~ OeH~i-, Telephone: Home ~qS- 11~5'~ Business ~4 '~-¢:~' X~,4'3' ~ . .'. ~ 7 '. (c) Lending Institution ,~rz:~'~ /~Ct'/~'~ Telephone ~,¢- .5-[¢~ (d) Real Estate Company and Agent ~/~ ¢~4[~ ~C~¢,~ Telephone ~/~ (e) Mail the HAA to the followinq address: or: Check here~ if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family,l~ 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 J~ 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/Rev 8/861 Front 5. 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 inspecti?n. Name of Firm ~.~/~7~?J~¢/,~ O~'i~//tl~-./"~,,! ~- Telephone ~"/-~- Address z~2~O/ ~//¢'~ ~/~'// .~Q~/~' ~,ff~df'~.J¢, /~/~, Date /- ~ ¢ - ~ ~ DHHS APPROVAL Approved for '~ bedroom~ by Approved / /~ Disapproved Terms of Conditional Approval Conditional Date 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 $ 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 (Rev 8/861 Back ,~c.,~ ~, ,~MUNICIPALITY OF ANCHORAGE (MOA) , O~ ._F~.~.~'ct\O ~4~= H AUTHORITY APPROVAL HAA ~.~ ~ ~'~0' .... ALT ( ) ,~C~. ~%~ ~, CHECKLIST- FEBRUARY 1984 64.4;20 ~ <~'~ ~ ,~ Legal Description: L ~ WELL DATA Well Classification Well Log Present (Y/N) f If A, B, C, D.E.C. Approved (Y/N) Date Completed ~ - ~O Yield Total Depth /~ {3 ' Cased to ! Static Water Level ~ C) ' Casing Height Above Ground I, ~'- ' Electrical Wiring in Conduit (Y/N) Y Separation Distances from Well: To Septic/Holding Tank on Lot ~ I C)O To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line "iL'/ Cleanout/Manhole ~ I OO ' Water Sample Collected by d,~,~' Water Sample Test Results Depth of Grouting - Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots .-P t O O +/~O' ; On Adjoining Lots -(' IOO ' To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~{- ~-O ; Date } - 7__ ~ -- ~' "~ Comments B. SEPTIC/HOLDING TANK DATA Date Installed Size Standpipes (Y/N) Y {~ ~.~ Air-tight Caps (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 -I'- / O o ' To Property Line -.i- /~ l To Water Main/Service Line "f- / 0 0 ' Course .f- ( o O No. of Compartments . Y Foundation Cleanout (Y/N) Date Last Pumped J -Z-'I - 3 7 ; for Temporary Holding Tank Permit (Y/N) +-Go To Building Foundation To Disposal Field ) ~ ~ 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 Width of Field ~'/-"- ~ Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test ,~. Separation Distance from Absorption Field: To Water-Supply Well + t OO ' To Building Foundation ~' ~-~ O / Lot ~O,~J ~ I~,~J To Water Main/Service Line .+- I OO To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design ~ Length of Field ~ ~ t Depth of Field :~ ,,/~t~/~.), S" Gravel Bed Thickness i ~ Standpipes Present (Y/N) '~J Date of Last Adequacy Test J .,~ To Property Line To Existing or Abandoned System on ; On Adjoining Lots '+ ! O O To Cutbank (if present) "~' /00 ' '4'100 Oo tP>,' LIFT STATION "Pump On" Level at ~ High Water Alarm Level at Tested for Electrical Codes (Y/N~...~, Comments t--'-' Dimensions Manhole/Access (Y/N) "Pump Off" Level at -~"- ~'Pum~Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I _h. ave. ch.e.cked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~[,~///~r~ ,~,--. Date '/- '-~ ~' --'z~2 C o m p a n y ~'4-5~/"~-~/~/5i Receipt No. Date of Payment Amount: Page 2 of 2 72-026 (11/84) DATE RECEIVED : , NSPECTiON APPO, NTMENTS ~TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR ' NS P E CTO R pl..y.,, ~.~' MUNICIPALITY OF ANCHORAGE ~UNIC:IPALITY OF ANCHOI~AGF  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECI[~. OF 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ;;, Y[ECTION ENVI RONMENTAL SANITATION DIVISION ~ ~" ~' Telephone 264-4720 DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. MAILING ADDRESS -- 2',44 PROPERTY R ESI DENT (If different,from ~bove) ~ PHONE 2. BUYER PHONE MAi LING ADDRESS 3, LENDING INSTITUTION I PHONE I MAILING ADDRESS I PHONE 4. REALTOR/AGENT/~' MAI LING ADDR ESS 5. LEGAL DESCRIPTION STREET LOCATION TYPE OF RESIDENCE NUMBER OF~BEDROOMS [] One [] Four SINGLE FAMILY ~-~ [] Two [] Five [] MULTIPLE FAMILY ~ Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM [~J INDIVIDUAL/ON-SITE** [] PUBLIC UTI LITY * ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give wel depth (attach Icg if available.) //~ ~0 YEAR ON-SrTE 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 [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVI DUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or []Holding Tank Size: )~- 0 If Tank is homemade give dimensions: [] ONE [] TWO PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER NUMBER OF BEDROOMS DATE INSTALLED INSTALLER SOILS RATING [] THREE [] FIVE [] FOUR [] SiX TYPE OFTANK MANUFACTURER TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line MATERIAL Septic/Holding Tank IAbsorption Area Sewer Line [] OTHER iNearest Lot Line 5. COMMENTS DATE ~VED FOR __~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev. 6/79)