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HomeMy WebLinkAboutBRION LT 172ABrion Lot 172A #051-231-82 ��� 1 i_ Municipality of Anchorage Development Services Department pP . �_} Building Safety Division ',icy On -Site Water and Wastewater Program, 4700 Elmore St. P.O. Box 196650 Anchorage, AK 99519-6650 Page www.ci.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: S W 0/0 124 PID Number: 051- 231 - 18 of Name: 3 i Br io r, Wastewater System: gNew ❑ Upgrade Address: Po Box 527 5Kw6NTNR,AK 9560 ABSORPTION FIELD Phone: Number of Bedrooms: it 0 Deep Trench 0 Shallow Trench %Bed 0 Mound 0 Other. LEGAL DESCRIPTION Soil Rating: 1.0 CPC/in' Total Depth from original grade: 1.9 Ft. Block: Lot: Subdivision: [IL Depth to pipe bottom from original grade: 1.3 FL Gravel depth beneath pipe: 0.5 Ft. Township: Range: Section: ISN Rt'k/J I2, Fill added above original grade: 1-2. FL Gravel Length: LIZ Ft. Well: Z New ❑ Upgrade Gravel width: 15.5 Ft. Number of lines: Distance between lines: Ft. Classification (Private, A, B. C): ?gm.)A.ib Total Depth. -14v Ft. Cased to. 94 Ft. Total absorption area: 6SI Ftp Pipe Material: FBI° S 3o3y Driller:Date 55411it t \ W1.115 Dolled: 10 26O'i• StaticWater Level: 32 FL Installer: OWN6lZ Date Installed: (01/9/0? Yield: 8* '/T` GPM mpS at: e* 7� Casing Height Above Ground: +1. J Ft. TANK - s R' • 1 1 STANCES teSeptic • Holding • S.T.E.P. • Other: To From Septic Tank Absorption Field Lift Station Holding Tank 'ublic/Private Sewer Line Manufacturer i A nci1or4ya /,4n k Capacity: Gal. KC0 Well I 100o + (0o } — .— 25 `$ Material: / / S1/4rsL Number of Compartments: Z Surface Water ALD. ,vo — LIFT STATION Lot Linet rj 'l' r IO } — -' -Size:; Gal. Manufacturer. Foundation 5j t} 10 + _.- - "Pump on° level at: in. "Pump off' level at: in. High water alarm at: C ,n N,o° N.0. — —, Pump Make & Mad Electrical Inspections performed by: Rema BENCH MARK PerOl�q�n t•• L • 1 C . • AA I /, 4. . .• ..• Location and Description: r '. L.r - en S. NE o nrc2 &ALA(re Assumed Elevation: 100 Ft. Inspections performed by: LARS S v2kic,� r) Dates: tat 446 '' - ,' grA s�11 co. 4 1 4t,, i% • 49TH // 2"d 1012z10-4_ Development Services Department Approval Conditional Approval Date: JLP id ,(,, �/ •' LA. 'E. SPU-% •. /70•Cii ��'RS10 1*-_ \,,,����� . Reviewed and approved by: OVVVIQ�) /! Date: la%i13 (Rev. 04/06) ((( 1 1 1 1 1 1 SWING TIES 1 A 8 C 11.5 47 D 39 69 E 49 77 F 52.5 79.5 G 54 81 H 54 70 I 61 77 J 71 53 K 74.5 58 L 78 63 M 81 65.5 RERLACEMEI T SLOPE (5X 1 8 W LEVEL '-BENCH MARK tie 5 Mir 1 1 1 1 1 1 1 INSTALLED 4 -BEDROOM SEPTIC SYSTEM 1500 GAL. SEPTIC TANK LENGTH 42 FEET WIDTH 15.5 FEET DEPTH 1.8 FOOT ROCK 0.5 FEET INSULATION 2 IM COVER 2 FEET Septic Area lSPLALEIOPT IREACR RES CALLS .XYhW APPLICATI I RATE 6 SAL PEI? SO FT/MY APSCRPTION AREA=15064V6=100 SR FEET 5-1/IM Rail 05 TT RIEJ: LEMNT = a FT LOT 175 (VACENT) 25 0 25 50 75 100 125 150 SCALE 1' = 50 FT. SPURKLAND ENGINEER/NG 203 W 15TH. AVENUE ANCH. AK. 99501 (907) 279-3916 T15N RI W SEC 18 LOT 172 BILL BRION 19341 RICHNER ROAD SEPTIC SYSTEM DESIGN DATE: SEPT. 16, 2008 SHEET: 2/3 GRID: 2630 PERMIT # SW070124 PLD # 051-231-18 TI5NRI WS18L 172112, D WG 15.5' x 42' BED NTS 0 • DOUBLE CLEANOUTS 15.5' Wide +. 42' Long 1.8' Deep N. T S 0.5' Rock 2' Insulation 2-3' Cover lydn) Qo o a tlon Clean ou 1- a NO SCALE L. W `" Monitor o Cleanouts 0 TH 1 2-3' Cover 2 -Inch Insulation lev.= + 1 Elev.=+ 100.4' II as 10-3-08 .2' t 1 - 41=11 11 II II II 11 II II II II II II II II 11 II II II 11 II 11- I -]II II II n — D.G. E/ev.=98.7' 111 I �I �LIIII111=11=11111111111111=11=.11=11=11=111111=111111111111111=11=11=1'--ii=i-11.1 IIIIII r • 1. 1 11,-11=1=11=11-11-11-11-11-11-1-11-11-11-I1-1- 11 -II-I-II- •.2 • `- Elev. =98.2 1 . 1 -11-11 11 _ 11. 1171-11 11 11..11.. =-11 11 .11.11-11-1 _ II 11 n-' Top Pipe EIev =977' Bottom Exc. E/ev - 969''.C!:••••••••••••••••••,:r:,..:!.•:•:•:•:•:•.• Silt Barrier •E OF . QS ft Septic Rock '\ —*at• of •.• Effective i 49th 'I \' �`*% B.O.N. Elev.=88.7' * NO SCALE * RELATIVE TO DRAIN FIELD A5 RS PURKLAND j L�• 1�1),�, ; No. C -11500 i�s, 44, BENCH MARK BOTTOM SIDING NE CORNER GARAGE '1,�1 ";�� �0. ASSUMED ELEVATION 100' SPURKLAND ENGINEERING 203 W15th Ave Anchorage Ak 99501 279-9916 T15N RIF SEC 18 LOT 172 BILL BRION 20875 B/RCHWOOD LOOP SEPTIC SYSTEM AS -BUILT DATE] SEPT. 16, 2008 SHEET] 3/3 GRIDS 2630 PERMIT / SW0700124 PARCEL ID / 051-231-18 T15NR1 WS18L 172D3.DWG May 24 13 08:54a Sulliven Water Wells 907 688 2759 QCcrttfteb Drilling log by DOC CO. tlba SULLIVAN WATER WELLS P.O. BOX 670272, CHLIGVAK, ALASKA 99567 •TELEPHONE 668-2759 ^11(in OWNER OF LAND: ADDRESS: LEGAL DESCRIPTION: -r,64i Q� t 4J€ L61 DATE /6 —? ✓ ~ � ` PERM'TNUMBER: 0'10139 late of Issue)t^'k -s"7 -01 1. TAX IDENTIFICATION NUMBER: 1 - �y�2-1- is well located at approved perm.: location? liSiYes 0 No Method of Drilling: irrotary J cable tool Depth of well. Casing Type `7 'Ct Wall Thickness ___4,2712,71_11 inches Diameter tL' incnes,deutn.°_ feet Liner Type: Casing Stickup Above Ground: feet Static Water Level: �_._.. Recover Hate: _LL_____ gp Method of Testing• Weli Intake Opening Type: J open end open hole J Screened; Start __feet Steppe : _ feet C] Perforation�s_` Start feet SInppe 1 feet Grout Type: ew tri ��rf lune Depth: from t f feet, to___' 7� _�_ feet Well Disinfected Upon Compl4jti ? Wes J No Method al Disinfection: }` .e) Iit4 '%E' gm ---feet Comments: autve Z0ttitf7 0,E of 4t) >die, mat. '4 BORE -CLE DMA p2 DEPTI-I From To C ( 1i -Jt G J WO tf_hui ti fiats `i2-63 156tafdoode i7 704 40,vatke ' 11 Driller's Name rt. fiver ATTENTION: It is the responsibility of :he. property owner to submit a copy of the well log to the proper authority. Municipality of Anchorage: Department of Health & Hume 1 Services and/or Department of Environmental Conservation. MatSu Borough: Department o' Environmental Conservation. MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water 6 Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT Initial Permit Number: SW070124 Legal Description: T15N R1W SEC 18 LT 172 Design Engineer: 0007 SPURKLAND ENGINEERING Owner Name: BILL BRION Owner Address: PO BOX 52 SKWENTNA , AK 99667 - Date Issued: Jun 25, 2007 Expiration Date: Jun 24, 2008 Parcel ID: 051-231-18 Site Address. 019341 RICHNER RD Lot Size: 108900 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: ❑.r 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. L,Sritt .ij Received By: Date � 1' Issued By. Date: 0 /Zs 47 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, Alaska 99519-6650 www.muni.org/onsite (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcell.D. (VSI IR Property owner(s) g i t\ gr inn Day phone Mailing address P.O. I ox 5 2, S kwcn k AK 9q 6(01 Zip Code Site address 19341 RicLnt. Ro2.N Zip Code Legal description (Sub'd., Block & Lot) TIS h/ RPry' 5E G IP) Loi 112 Legal description (Township, Range & Section) Lot Size IN eibD Sq. Ft. Number of Bedrooms `} THIS APPLICATION IS FOR (® all that apply): THIS APPLICATION IS AN: Absorption Field VI, Initial egl Septic Tank 0 Upgrade 0 Holding Tank 0 Renewal 0 Privy 0 Private Well Water Storage 0 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. Lars S pt.(r\ .ZY1 (Signature of property owner or authorized agent) Permit/Rush Fees: 41C[l Do + NV — Waiver Fees: Date of Payment: 5/9•14'01" Date of Payment: Receipt Number. 496-6-C6 Receipt Number. (Rev. 11/05) = Swidand EfginemiBg Environmental Consulting and Design SEPTIC SYSTEM DESIGN TISN RIW SEC 18 LOT 172 Municipality of Anchorage Development Services Department On Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, Alaska 99519 Subject: Well & Septic Permit TISNRIWSEC 18LT172 Ladies and Gentlemen: 1 May 24, 2007 1 am writing to request a permit for the construction of a new well and septic system for this property. The proposed system will serve a shop with a living space above it. It is my understanding that a 3 -bed room single family residence will be constructed at some time in the future. These plans specify a 4 bedroom septic system. A new well will be installed in the north west corner of the property. There are no septic systems within 100 feet of the proposed well locations. Soils: A test hole was excavated on May 1, 2007 under the supervision of Lars Spurkland. See the attached soil logs. Ground water was monitored from May 111 through May 16'", 2007. Ground water was measured at a depth of 6 feet below ground surface on May 16'", 2007. Surface Water: There are no surface waters within 100 feet of the proposed septic system. Topography: The general topography in the area of the septic system is level. The ground surface to the north of the proposed septic system rises at a slope of approximately 20%. There are no man made or natural cut slopes within 50 feet of the proposed septic system. The installation of this septic system will not prevent wells and septic systems from being installed on the adjacent Tots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. If you have any questions or concerns, please contact me at 279=3916. Sincerely, Lat2 Lars Spurkland P.E. Civil Engineer 203 West 15t" Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916 Fax: (866) 354-1597, Lspurkland@gci.net Tx-c);\ yar I&Th, Sp ubl aid Enakfic©roiu Environmental Consulting and Design 1 —t SEPTIC SYSTEM DESIGN T15N R1W SEC 18 LOT 172 Municipality of Anchorage Development Services Department On Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, Alaska 99519 May 15, 2007 We are submitting an application for the installation of a well and septic system for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the well and septic system is subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable test hole are also enclosed. The septic system design is based on the following: Groundwater at 7 Ft. Soil Rating. From Test hole 05/1/07. <I min/in = Install 2' Filter Sand Design Rate 1.0 gal/day/sq.ft. No. of Bedrooms 4 Required Area per Bedroom: 150/ 1 =150 sq.ft. Total area required: 150 x 4 = 600 sqft Bottom Rock At 1 foot below Ground Surface (bgs) Top Rock At 0.5 feet bgs Rock Depth 0.5 feet Total Bed Length 600 /20 = 30 feet USE 20 x 30 FEET SYSTEM CONFIGURATION 1500 GALLON STEP TANK TOTAL LENGTH 30 FT TOTAL WIDTH 20 FT TOTAL DEPTH -3.0 FT FILTER SAND 2.0 FT ROCK DEPTII 0.5 FT INSULATION 2 IN. COVER 2 FT(MIN) 203 Wcst 15th Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916 Fax: (907) 276-6013, SpurklandEng@gci.net 1 1 1 I 1 1 I _N1 F- , PROPOSED WE INSTALL 4-0EDROOM SEPTIC SYSTEM 1500 CAL S.LLP. SEPTIC TANK LENGTH 30 FTE7 WIDTH 20 ,TE7 DEPTH 3 17E1 TITER SAND 2 ITU ROCK 0.5 FTE7 LNSULATION 2 IN. COVTR 2 FEET SLOPE (5% 1 LEVEL N ur Septic Area wrI1. wnr Mad LSP CCM M SA r r n r rd M it t Ca Pr S /7#M I .w>r+ra A A•r 4fl RI rtn o-vrarear S.5 (71102 WOO.sn LOT 175 (VACENT) 25 10 25 50 75 100 125 150 SCALE! 1' = 50 FT. ▪ 4 sin th • ' L4RRS SPURKLAND • T � •• " No. CE -11500 �= bbataaaa ; SPURKLAND ENGINEER/NG 203 W 15TH. AVENUE ANCH. AK. 99501 (907) 279-3916 T15N RI W SEC 18 LOT 172 BILL BRION 19341 RICHN£R ROAD SEPTIC SYSTEM DESIGN DATE: MAY 17, 2007 SHEET: 2/3 GRID: 2630 PERMIT # RID # T15NR1 VS18L 172D2.DVG 20' X 30' BED N. T.S Sit Barrie 20' Vide 30' Long 3' Deep 2' MOA Approved Filter Sand 0.5' Rock 2' Insulation 2' Cover lnin) NG SCALE 1 Monitor 2' Cover (1NSUzAT[) 1500 GAL STEP TANK 1=11-.11=11=11=11=11=11=11=11=1I=11=11=11::11=11=11=11=11=1W1=11=11111111=1=II: n11- •. I=1I=A=11=11=11=11=11=11=11=11=11=11=11=-11=11=11=11=11=r11=11=11=11=11=11::I, LI -11-11=11=11=11=11=11=11=11=11=11=11=11.11—a-11 _ 11-0-11..11-11-11-11-11= ° :II=11=11=11=11=11=11=11=11=11=11=11=11= =11=11=11=11=11=1=11=11=11— :1=11=11=11=11=11=11=11=11=11=11=11 -11-11=11 II-11-11-11-11*11-11. MIME 05 ft of Septic Rock Effective NG SCALE' Foundation Clean out 1500 GAL STEP TANK ••�P( .,---"."••,.. • ///49tfejt h } t2- ,f..i.lJ•.S•.•..1....,....: Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www. d. anchorage a k. us (907) 343-7904 Solis Log - Percolation Test PertomredFor. F:II Bryan Legal Description: 1 15 A1 R I W 5€c 18 LT 17 2 Township, Range, Section: .r Rye utliti 49TH W' `t• i ND : % i - '�'-i — l1' �YFricFcc;f� -- Date Performed 1- 2- 3- 4- 5- 6- 7 8- 9- 10- 11- 12- 13- 14- 15- 16- 17- 18- 19- 20 - Depth (Feet) * ;Q•• 0 • O. 9�. 4 D. •• .o•;o COMMENTS travAVI OH, &m . 6.aH Slope WAS GROUND WATER ENCOUNTERED? e5 IF YES. AT WHAT DEPTH? Depth to Water After Monllo$ng? l (p1 �a me: 511 ‘1011 S L O P Site Plan 10 Reading Date Gross Time Net Time Depth to Water Net Drop Perc bpi_ rill eti 3 4lin en +0 a (\eel' of (a iAtt142?, Drxinec\ Dry ;n Ie45 )1)M% 3 n1lnuk-..r)j?jict, Bete 4, PERCOLATION RATE .0 ( (ntM. rh) PERC HOLE DIAMETER TEST RUN BETWEEN Z FT AND 3 FT (D PERFORMED BY: Lars Spar R`ar1X 1 72 J! CERTIFY THAT THIS TEST AS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELI S IN EFFECT ON THIS DATE. DATE: Sit �0 4 Iitt SpfrrieSSd Engllneertog Environmental Consulting and Design Single Family On-site Wastewater Disposal System Construction and Material Specifications Subject Property: T15N R1W SEC 18 LOT 172 Date: May 24, 2007 General: 1. The owner shall contract with a contractor to perform the work outlined in these specifications and plans In accordance with the attached MOA permit. There is not contractual arrangement between the contractor and the Engineer. The Engineer shall be the owner's representative and will inspect the work to document the contractors activities. Final acceptance of the contractors work rests with the owner and the MOA. 2. The scope of the project Includes the procurement and Installation of a 4 -bedroom on- site wastewater disposal system at the location depicted on the attached site plan drawings. The scope of the work also Incudes the installation of a new 1500 gallon STEP tank, a drainfield comprised of 1 bed, 20 -feet wide x 37.5 -feet long, 1 foot deep, with 0.5 feet of septic rock below the distribution piping. The location of the drainfield Is shown on the attached site plan drawings. The total depth of the field will be 1 feet below the existing ground surface. All components of the proposed septic system must be constructed a minimum of 100 feet from any surface water or water wells in the area. A minimum of 2 feet of earthen cover is required over the septic tank and a minimum of two feet of cover Is required over the drainfield. In addition to the required earthen cover, 2 -inch thick, 40 psi, direct bury board foam shall be Installed directly over all installed piping. 3. Construction shall be in accordance with the approved site plan and design drawings and any special provisions noted on the Municipal well and/or septic permit. All materials, components, workmanship and construction practices shall comply with the Municipality of Anchorage's latest ordinances regarding wells and septic systems, as well as MOA, Development Services Department, On-site Water and Wastewater Program (DSD) polides. 4. The contractor is responsible for obtaining all underground utility locates, layout of the proposed system, and verifying and maintaining all required separation distances to lot lines, surface water, wells, steep slopes, etc. 5. The property owner shall be responsible for final grading any depressions formed from settlement of backfill material. The property owner Is also responsible for vegetation of all areas disturbed by septic system installation activities. 6. Contractors Installing wastewater disposal systems must be certified to do so by the MOA DSD, On-site Water Wastewater Program. Property owners installing their own systems must receive advanced approval from MOA DSD prior to system installation activities. 7. The contractor shall ensure that ALL materials being used are in compliance with the most current guidelines established by the Municipality of Anchorage. Refer to "Standards and Specifications for Component Parts and Materials Used in the 203 West 15th Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916 Fax: (866) 354-1597, Lspurkland gci.net Spay 0atd Enatineeffiiing Environmental Consulting and Design Construction of On-site Wastewater Disposal Systems", Dated December 2000, as provided by MOA DSD, On-site Water and Wastewater Program. Septic Tank Installation: 1. A new septic tank, of the size specified in the design drawings, shall be procured from a qualified manufacture/supplier if the existing septic tank is found to be defective. Construction shall indude two 4" diameter deanouts for pumping access. 2. The burial rating of the tank shall be adequate for the actual burial depth encountered. 3. The tank shall be level and sufficiently bedded to prevent settling of shifting of the tank. 4. All standpipes on the tank shall extend a minimum of 12inches above the final grade. 5. Tanks installed with less than 4 feet of cover shall be insulated. 6. The sewer service line from the house to the tank shall have a minimum slope of 2% unless prior approval Is obtained from the engineer. 7. The inlet and outlet lines from the tank shall be bedded in drainrock or the soil shall be suffidently compacted to prevent future settlement of the soil. 8. Septic tank Inlets, outlets and deanouts shall be fitted with water tight couplings. 9. A cleanout shall be installed 1 to 4 feet from the foundation. 10. Post tank deanouts shall be installed per MOA requirements. Does not apply to pressurized lines. 11. In areas with high ground water, the septic tank shall be sufficiently anchored to resist buoyancy forces when there is not adequate soil cover to resist uplift force. The contractor shall refer to the engineer for direction regarding this matter. 12. The tank backfill shall be graded suffidently to ensure positive drainage away from the tank. 13. All holding tank and lift stations shall have an audible and visible alarm inside the residence being served. 14. All lift stations shall be wired in compliance with all MOA guidelines and the Uniform Electrical Code. A munidpal electrical permit and Inspections must be obtained where required by the MOA. 15. The contractor shall verify that the septic tank/lift station is a minimum of 100 feet from any residential water well, 150' from any class 'C well and 200 feet from any community water wells. Additional separation distances must also be maintained. 16. The contractor shall remove or abandon the existing tank In compliance with the Unform Plumbing Code. Dralnfield Construction: 1. The drainfield shall be excavated to the dimensions outlined in the design drawings. If any discrepandes are noted, contact the engineer immediately for clarification. 2. The drainfield shall be installed parallel to slope contours. 3. The bottom of the drainfield shall be within 2" of level. If the sidewalls or bottom of the excavation become smeared, they must be raked or scarified prior to the placement of filter sand or drainrock. 203 Wcst 1516 Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916 Fax: (866) 354-1597, Lspurkland@gci.net Environmental Consulting and Design I 1 4. The drainfield must be a minimum of 5 feet from the test hole excavation. 5. Distribution pipe Is to be installed level with perforations fadng downward, atop a level bed of drainfield rock. Septic rock shall then be placed atop the distribution piping to provide a minimum of 2" of cover, level across the entire width and length of the trench, above the piping. 6. A silt barrier must be installed at between the final drainrock and the native soil backfill. The silt barrier shall cover the entire drainrock surface. 7. Monitor tubes must be 4" In diameter, installed in the locations depicted on the design drawings, and extend a minimum of 12" above final grade. The portion of the monitoring tube below the septic rock must be perforated and the portion above the drainrock shall be solid. 8. Backfill over the final gravel layer must not be less than 2 feet. Insulation must be installed when the backfill depth Is less that 3 feet. 9. Drainfield back fill shall be mounded to prevent depressions from forming due to subsequent settlement of backfill material. 10. The contractor shall verify that the drainfield is a minimum of 100 feet from any residential water well, 150' from any class 'C' well and 200 feet from any community water wells. Additional separation distances must also be maintained. Inspections: 1. A minimum of two inspedaons are required by the Municipality of Anchorage. These inspections must be conducted under the supervision of a Professional Engineer licensed to practice in the State of Alaska. 2. The first inspection must be conducted after the excavation of the drainfield and before the placement of any gravel. The septic tank may be set in place, but may not be backfilled. 3. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, stand pipes, deanouts, and Insulation, but before the placement of any baddill. 4. The contractor shall provide a legible copy of all field notes relating to system layout and construction to the engineer for the use in preparing the record drawings. 5. The contractor shall coordinate all inspections with the Engineer. A minimum of 24 hours notice is required prior to the start of construction. If necessary, a preconstruction meeting will be held on-site. 203 West 15'" Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916 Fax: (866) 354-1597, Lspurkland@gci.net MUNICIPALITY OF ANCHORAGE DE 1TMENT OF HEALTH AND HUMAN SER' ES Environmental Health Division 825"L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name �pM 2'..0,-1 Address DISTANCES 1? o. gaX (Moo 52 - GIS f ime--crISIert Phone(s) Permit No, No. of Bedrooms Loge -/-4041) 8'l o 2ioo LEGAL DESCRIPTION Lot 111-- Block 12 Block Subdivision FROM TO WELL LOT LINE SEPTIC TANK / 100 ^ ABSORPTION FIELD \3S WELL Township. Range, Section 'Neste1 -I1� is Manufacturer atonal SEPTIC TANKS FOUNDATION 13 ❑ HOLDING Capacity in gallons 0E70 500 L7 TRENCH Depth to pipe bottom from original grade No. of Compartmer$s TYPE OF SYSTE BED D W. DRAIN ❑ OTHER O,6-- FT Fill added la'bove original grade ZN L1'7�. 'F %.�7 FT Gravel length Total absorption area Number of lines ,/ Installer -2j2 FT I(420SQFT Soil rating t7.- SQFT 6 -cc- Gv,,4 i PRIVATE Total depth from original grade 07I -1' �f - eters 17. FT Gravel depth beneath pipe p,S FT Gravel w,dtb °2O FT Distance between line (p FT material ate Installed / Pipe �1-'I-moi WELLS ❑ OTHER (Identify) AS -BUILT DIAGRAM (Show location of well. septic system, property linos, foundation, driveway, water bodie etc.) A Classification (A,B.G) X 1‘,11[4__ Total Depth Cased to FT FT Date Installed', 0 REMARKS: 1 -VC. 5h,d2 � I. __ # kg ----4t-0177., PS S & S ENGINEERING I 17034 Eagle Rho, Loop Ruad N. 204 MunicipaE laaAiM01011Inl iTdate. Health Department Approval: L Scale: f-kj15, Inspections Performed by. Date. 01- t - el Beni thanhi inspection was performed according to all ryy�` � Date ENGINEER'S SEAL F 72-013 (3/85) MUNI C 1PAL_TY OF ANCHORAGE Department of Health v, Human Services 825 L Street, Anchorage, Alaska 99501 343-4720 lE SEWER 4 SEPTIC TANK FERMI1 Permit Number: 370200 Upgrade Date Issued: 08/05/07 Engineer Designed OHner Name: TUM E. BRION / S&S ENG. Owner Address: PO 801 670052 CHUGIAK:, AK 99567 Parcel Id: 051-231-13 Lot Legal: Subdivision: N/A Lot: N/A Block: N/A Section: 18 Township: 15N Range: IW BLM LOT 172 Lot Size 2.5 A fsq,ft, or acres) 6/) , Max Bedrooms: This Permit: 5 Total Ca.pacity:/ / Day Phone: 688-2643 INSTALL PER DESIGN SUBMITTED BY S&S ENGINEERS DEO - 32' 1 30' S 0.5' 2' CF SAND; RATED AT 125 30, FT./ BEDROOM, AS FILTER MATERIAL. I CERTIFY THAI: I. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage :MOAT and the State of Alaska. 2. 1 will install the system in accordance with all MOA codes and regulations, and in eomipliance with the design criteria of this permit. 3. I will adhere to all MOB and State of Alaska requirements For the set back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot, c, 1 understand that this permit is valid for a maximum of 5 bedrooms. I also understand that the capacity of the total system is 5 bedrooms and any enlargement will require an additional permit. Signed, SeAtte44 s<j DATE: (Owner; TOM 8, BAN / 818 PIG. issued By: %a "e DATE: N• S & 3 ENGINEERING 1/034 E. R^ LOOP *204 EAGLE RIVER, AK 99577 PHONE #694 2979 ******************ON—SlTE SEWER PERMIT APPLICATION***************** APPLICANT: TOM B. BRION ADDRESS: BOX 670052 CMUGIAK ALASKA 99567 CONTACl PHONE: 688-2613 LEGAL DESCRlP|ION:L 172 SEC 18 ,[15N,R1W LOT SIZE : 2.5 (rt OR ACRES) MAX. NUMBER OF BEDROOMS : 5 • SOIL RATING125 SQ FT/BR \.'~ . / SOIL TEST DEPTH: 8 FT HIGHEST WATER TABLE DEPTH 5 FT THIS IS AN UPGRADE OF 5 BEDROOM TO THE EXISTING SEPTIC SYSTE.M MIM. REQUIRED RESERVE AREA: 5000SQ.FT CAL. RESERVE AREA AVAIL.: 13000 SQ.FT TRECU EFFECTIVE DEPTH � COVER DEPTH \0 TO|AL DEPTH 0 LENG|H WIDTH �.� ,",�, ��. -- BED [A, IRAINRIH_D 1 0 (� 3O" SPECIAL CONDITIONS OR INSTRUCTIONS: SAND PILTER IS REQUIRED. TOTAi EXCAVATION IS 3 RJ. TWO FEET OF SAND IS [HEN INSTALLED TO MAKE THE BOTTOM OF THE BED AT 1 FT. BELOW ORIGINAL GRADE, 2 INCHES OF INSULATION IS REQUIRED NHERE DEPTH OF SYSTEM IS LESS THAN 3.5' NV" , 1 °a No. .,574 ele ~��-�/�� 141, SCALE Ori z 0 A 9 33o sit, 1, 4 ,) ,, 4fr w� c i z. IAA ttz a r rnD z r 0) H t Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: C -c -c— LEGAL DESCRIPTION: 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Rank( (Farr) V✓,A1tt_ S-5-87 W6"f 11:x'Trv1- A t'F Nt'-t., Township, Range, Section: ri 1 11th 1 1 g SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water Al er Monitoring? 1ic lot Dat 8'3-0-7 S L 0 P E k N -r d c t'�Sr�IT 1 Reading Date Gross Time Ne Time Depth to Water PERCOLATION RATE �! TEST RUN BETWEEN COMMENTS 1704736 1''ill'- �'�'(Jl.) jj PERFORMED BY. 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELIN 72-008 (Rev. 4/95) (minutes/inch) PERC HOLE DIAMETER FT AND L FT Net Drop CERTIFY THAT TIS T ST WAS PERFORMED IN Gr/ 3/O / CT ON THIS DATE. DATE. GAAB"IID"I GR'"TER ANCHORAGE AREA BOROU'H HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM /�,g 9 MAILING j� /) NAME -1 r/�I/%� C///'%!�/%�Tf ADDRESS/�O•� 5'25 (�%�titrir - PHONE__ LOCATION :/,ed/1/40/tip 1-49611 LEGAL DESCRIPTION leer/ 72- ,%�� . /L(/) �• 0�� SEPTIC TANK: DISTANCE FROM WELL 7_S MATERIAL /1 -OCA: LIQUID CAPACITY I Cie! GALLONS. INSIDE LENGTH A<GL.N_leak6/ INSIDE WIDTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF COMPARTMENTS NUMBER OF PITS OUTSIDE DIAMETER OR WIDTH LINING MATERIAL DISTANCE FROM WELL NEAREST LOT LINE TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) LIQUIDA4�-tel <"- DEPTH LENGTH DEPTH BUILDING FOUNDATION SQ FT TILE DRAIN FIELD: / / s / •� TOTAL LENGTH o i+ % DISTANCE FROM WELL ` ?_Q , FOUNDATION NEAREST LOT LINE OF LINES D G / / NUMBER OF LINES 2'/DISTANCE BETWEEN LINES o TRENCHH WIDTH 3/,. IN TOTAL EFFECTIVE ABSORPTION AREA ell/ SQ FT LENGTH OF EACH LINE / & 6/ XI 7• r'� 7 2-.5-- DEPTH: 5/DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE. ell IN ABOVE TILE WELL:�i c c3 / DISTANCE FROM SOF WATER /�L TYPE !- , DEPTH I ,BUILDING FOUNDATION SAMPLE , NEAREST OTHER LOT LINE 7 NEARESECWERST LINE / TANKC / /SEESYSTEMS T_C t CESSPOOL '" SOURCES DISTANCES: DIAGRAM OF SYSTEM DATE /o/CA:7 APPROVED HEALTH AUTHORITY GAAB-HD GREATER 4NCHORAGE AREA 1 )ROUGH HEALTH DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 279.2511 Case No SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT NAME OF APPLICANT/AAfily /!N SG//A/IIATMAILING ADDRh E$5 g`o7I- (# "f l:PHOQNE NO ag..01CA RESIDENCE ADDRESS .di/pw,n P LOCATION OF INSTALLATIONAG+.e.A�.o_O0C / Ler in Sec, ,g TISKR/Gi/S,M. LEGAL DESCRIPTION APPLICATION TO INSTALL: SEPTIC TANK TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH , SEEP GE PIT , DRAINFIELD, OTHER ,e5101 3 � • p,sgze�/Lo-orta TO BE INSTALLED BY PERCOLATION TEST RESULTS ANTICIPATED DATE OF COMPLETIO BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT Tic; ct-el THIS IS TO SERVE AS Mk, ,Coen,, r S , PERMIT TO INSTALL A it", STY on AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVER� �\ 4' /c S PTIC TANK SIZE /en, TYPE ret0Ce- DIST`tiCES: i'Yj i ti al' jvL wefl,C fi473t(, &2 SbP�P/T /f! SEEPAGE ARE __TYPE Sr at 3 70 x 3 3O' DIAGRAM OF S MSN 5See��cAd6{r /Or He r71::7;,4r Health Authority icy Iri,la o 5 n �N c, 2 ai Iwo tst 4011, Nle 5 I certify that I am familiar with the requirements of Greater Anchor. :e Area Borough Ordinance No. 28-68 and that the above described system is in accordance with said code. /n DATE 7/3767 APPLICANTS SIGNATURE / 6— ditA4-0- GREATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT 327 EAGLE STREET ANCHORAGE, ALASKA 99501 Performed For h(1aru„n Sckw 1 J± Date Performed Legal Description: Lotfl Q B1ockc44i Subdivision CASE 11 SP i / f This Form Reports a: Solis rcolation es Depth Feet Soil Characteristics a.7 i igeq /1'. Location Sketch Was Ground Water Encountered? \r/e4 If Yes, At What Depth5 Va tt. Reading Date Gross Time A N ...,-..,--0•....m.. Net Time Depth To H2O Net Drop e7176at7.on ae Proposed installa Depth Of Inlet COMMENTS: nu e on: Seepage Pit 4.�.,.. / Depth To .w IIMI Drain Field L� Bottom Of Pit Or Trench / .. ..6” Test Performed By: 1V ee1 GC n Data Certified By: Date :, MUNI I c:::q r. -.r M..._ I —Iry n_nF:" F1r44M..._M ..-,.M LLU AR1"P'IIa:I'd"F I HEFILTH HNI' ENV1F'ONMEW l=tl..- :ri"F_CTION ' "2"" 'L.' STREET: A HORAoE:, NF:. 99501. a:4-4720 PERMIT NO. 9:1.01733 APPLICANT TOM E. BRION LOCATION LOT :172 E:iRCHWOOD LOOP LEGAL LAT 172 SEC 18 T15N R±N BOX a. CHLIOIF1F::, LOT _;17E 1989Y;;;I0 SQUARE FEET MINIMUM DISTANCE BETWEEN A WELL. AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 1010 FEET FOR FI PRIVATE WE'L.L... OR 150 TO 2061 FEET FROM FI PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM H PRIVATE: FWELL. TO H PRIVATE `NEWER LINE IS 25 FEET AND TO FI COMMUNITY 'SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL.. COMPLETION. OTHER REQUIREMENTS PIR',• FIF'PL'•r'. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS FIRE: AVAILABLE TO IN'.ILLIRE PROPER INSTALLATION. M" EE: IR MI :M: -M- E M-" a RAE en M_. P1 E: r FR :: >: M J. _T.. S •E..:I-. [ CERTIFY THAT :1.: :E FIM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLE FCOR:FFI BY THE. MUNICIPALITY OF ANCHORAGE. 2:T. WILL. INS 14ZLL THE SYSTEM IN ACCORDFANCE. WITH THE CODES. SIGNED APPLICANT TOM B. BRION ISSUED _DATE._...✓.I J a 00 Y to a a 0 O V V Z 3 r iso F WE SERVE ALL ALASKA POST OFFICE BOX 42 - CHUGIAK, ALASKA 99567 w w w w w w w w w w w w 0 0 STATIC LEVEL OF WATER FT 0 0 0 0 0 0 0 0 0 0 0 0 EF F 3 M cG 0 ow. g .a 0 c.., KIND OF CASING 0 0 0 0 0 0 0 O 0 O O 0 x x a x x a x 4 x x x w w w w w w w w w w w w I w EEEEEEE W W 0 0 0 0 0 0 0 0 0 0 0 0 F F F F F F H F F F F F w w w w w w w IL z w 0 0 0 pD WELL - SITE DATE - STARTED DATE - ENDED 044 2 0 0 0 0 0 0 0 0 0 0 0 0 w w w w w w w w w w w MISCL. INFORMATIO w z 0 A ARCTIC PUMP & WELL INC. Jim Sullivan, CPI PO Box 770197 Eagle River, AK 99577 (907) 688-2510 (907) 258-2510 (907) 745-2510 amv n gci ne; Pump Installation Log Well Drilling Permit Number: SW070124 Date of Issue:6-25-07 Parcel Identification Number: 051-231-18 Legal Description:T15NR1 WS18L172 Lot: Property Owner Name & Address: Bill Brion PO BX 52 clrwnntno AIC 00447 Pump Installation Date: Pump Intake Depth Below Top of Well Casing: Feet Pump Manufacturer's Name: Dempster Pump Model: Pump Size: hp Pitless Adapter Burial Depth:10 feet Pitless Adapter Manufacturer's Name: Martinson Pitless Adapter Installer: Arctic Pump & Well, Inc. Well Disinfected Upon Completion? Yes Method of Disinfection: Chlorine Comments:Installed 6-08 Pump Installer Name: Arctic Pump & Well, Inc. Arctic Pump & We!!, Inc. Page I of 1 7 REQUEST FOR APPROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES (rill out in Triplicate) b.. Name of person requesting approval 2. Name of property- owner /. (i7,. 3. :.opal description 4. Number -of hedrooms in house 5. Water, Analysis: a. Bacterial b. Detergent to cF - z 1 /S41/ , /! ,S• Yr7 W 6. Well data: �I� a. lype�.GCPA b. Depth c. Casing Size d. Distance from well to closest 1. Sewer line .36 2. Septic tank rL� 3. Seepage Area / 5 / y 4. Cesspool' 5. Property Line .20<*---. existing or proposed: 6. Other sources of possible contamination, i.e., creeks, houses, barn, drainage ditch, etc. 7. Sewage disposal system. a. Age of system b. Septic tank capacity in gallons c. Name of septic tank menufactuver /DCC lakes, 1. If "home made" show diagram on d: Disposal field or seepape pit size 1, Distance to property linea reverse side of this form. and 1:ypeSG, to house foundation e. Percolation, Test'result.s f. Percolation Test performed by Use the reverse .side of this form to show diagram. Diagram should include -the following information: property lines;•well location, house location, iptic tank location, disposal area location, location of percolation test, and direction of ground slope. 9. The int nation on this form is true and correct to the best of my knowledge. n Sirnature of Applicant Date Signed 70 BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL The above described sanitary facilities are hereby approved, subject to the following conditions: Conditions: 1 OfM� The above reasons: described sanitary facilities are disapproved for the following Date 1.1., rc Approval is valid for one year following the date of approval. CPJ:cw ? GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3500 Tudor Road, Anchorage, Alaska 99507 279.8686 Date Received November 28, 1973 Time of Inspection Date of Inspection Dec 4, 1973 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR F V4 1. Anproval Requested By: Address: Smiley's Realty Eagle River Phone: 2. Property Owner: Marvin Schmidt Phone: 3. Legal Description: T15N, R1W, Sect 18, Lot 172 4. Location: Birchwood Loop 5. Type of Facility to be Inspected: Single Family Dwelling Number of Bedrooms: two (2) 6. Well Data: A. Tyne Drilled B. Depth C. Construction Standard D. Bacterial Analysis Satisfactory 7. Sewage Disposal System: A. Installed 1969 B. Installer C. Septic Tank: 1. Size 1000 Gals2. Manufacturer Stack Steel D. Seepage Pit: 1. Size 2. Material Steel E. Disposal Field: Total Length of Lines 8. Distances: A. Well To: Septic Tank , Nearest Lot Line , Absorption Area , Sewer Lines , Other Contamination B. Foundation to Septic Tank Absorption Area C. Absorption Area to Nearest Lot Line Req.,eet for Approval of Individual Sewer & Water Facilities Page Two 9, Comments: I Aoorove. Sq w Disapproved Date /Z/y/7 3 Approval Valid for One Year From Date Signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities located at: Signed Date GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received OCt 29, 1973 Time of Inspection 10:00 Date of Inspection Oct 30, 1973. REQUEST FOR APPROVAL. OF INDIVIDUAL SEWER & WATER FACILITIES FOR VA 1. Approval Requested By: Smiley's Address; Box 1086 Eagle River AK 99577 , Phone: 2. Pronerty Owner: Marvin Schmidt 3. Legal Description: Lot 172. Sec 18. T15N. R1W Phone: 694-21.15 688-2596 4. Location: S Birthwood Loop. 1 mile on loop, log home. 5. Type of Facility to be Inspected: Single Fawtly Dwelling Number of Bedrooms: Two 12) 6. Well Data: A. Type Hand Duo B. Depth 19' C. Construction D. Bacterial Analysis 7. Sewage Disposal System: A. Installed 1869 B. Installer C. Septic Tank: 1. Size 1000 Gals 2. Manufacturer Stack Steel D. Seepage Pit: 1. Size 2. Material Steel E. Disposal Field: Total Length of Lines B. Distances: A. Well To: Septic Tank 105' , Absorption Area 35' , Nearest Lot Line 20'. 157' , Other Contamination B, Foundation to Septic Tank 'r Absorption. Area C. Absorption Area to Nearest Lot Line Sewer Lines Requast for Approval of individual Sewer & water Facilities Page Two 9. Comments: Hand dug well not of proper construction. Approved Disapproved Joh Date 10-31-713 Approval Valid for One Year From Date Signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be e true and accurate representation of the subject sewer and water facilities located at: Signed Date ve Mr. Dick $ornewan Veterans Administration P.O. box 1399 Anchorage, Ak. 99601 Oat. 29. 1969 SUBJECT, Sewer and Water on Lot �` 1f?; Sea. S. TUN. R1W. S.M., Birchwood Loop Area Dear Mr. Bornemans The Greeter Anchorage Area Borough Health Department inspected the subject property and found the followings 1, Thr well was hand dug and not approved. 2. The sewer eyetee..wf a nesapool and not approved. The owner wishes to upgrade both water and sewer systems. This will include a septic tank inetslletioo ($680.00 Bid) and a new well (ainimua 6760,00 Bid). We suggest 62,000.00 be hold in escrow for the work. The septic tank will be installed within one week and the well will be com- plete within one month. These tarea are agreeable to this De- partment end we approve the sewer end water contingent upon com- pletion. Binoersly. DAVID R. L. DUNCAN, M. D. Medical Director sin RRSIrn 00* Max W. Devine Rolf R. Strickland, k. S. tnvironm.ntal Nnith Supervisor Mr. Marvin Sohmidt Box 825 Chugiak, Alaska 99567 Dear Mr. Schmidt: Oct. 24, 1969 SUBJECT: Sewer and Water Systems In order to receive approval of your sewer and water systema, the following conditions must be met: 1. A septic tank must be installed. The present cesspool can be used as the seepage pit, if desired, and if there is enough gradient for it to be used. 2. A new well must be drilled, making sure to keep it at least 50' from the septic tank and 100' from the seepage pit. These distances change it the well is intended for semiepublic use. Before installing a sewer system, the Borough Health Department must bs contacted and a permit to install obtained. At this time the details concerning the installation of tis sewer system can bs discussed. Thank you for your cooperation. Sincerely, DAVID R. L. DUNCAN, M. D. Medical Director BY: JRLsrn Jon R. Lee, R. S. Sanitarian 1.... Name 2, REQUESR'APPROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Triplicate) of person requesting approval Name of property: owner 3. .egal description `PDT Sgs- Siaer 4. Number of bedrooms in house . 5. Water Analysis: a. Bacterial b. Detergent 6, We11data: a. 1Y1,e 0/,!6' b. Depth 7' c. Casing Size 3° d. Distance from well to closest existing or proposed: 1. Sewer ling 2. Septic tank 3, Seepage Area 4. Cesspool' z17/ 5. Property Line 6. Other sources of possible contamination, i.e., creeks, lakes, houses, barn, drainage ditch, etc. 7. Sewage disposal system. a. Age of system b. Septic tank capacity in gallons c. Natne of septic tank manufacturer 1. If "home rnade" show diagram on reverse side of this form. d: Disposal field or seepage pit size and type 1. Distance to property line to house fsi,pdatton 7.5 e. Percolation Test results f. Percolation Test performed by Use the reverse.side of this form to show diagram. Diagram should include the following information: property lines;•well location, house location, '71-ptiic tank location, disposal area location, location of percolation test, arld direction of ground slope. 9. The retrfl.ation on this forgo is true and correct to the best of my knowledge. The above oll.owing Conditions Signature of Applicant Date Signed 70 BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL described sanitary facilities are hereby approved, subject to the conditions: The above described sanitary facilities are disapproved for the following reasons: lgnature o Offie Date A)roval is valid for one year following the date of approval. CPJ:cw