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HomeMy WebLinkAboutSNOWLINE TERRACE LT 2Snowline Terrace Lot 2 #015-163-63 Development 5ervices Department \ BuRdin4 Safety Division 1 On -Sitz Water & Wastewater program 4700 Brogaw Street P.C. Box 196650 Mark Begich Anchorage, AK 99519-6650 - Mayor sVWW.MUni nm/onsite (907) 343-7904 - Pump Installation Log Well Drilling Permit Number: SW_ Date of Issue: Parcel Identification Number: Legal Description 5'1\1 © VV z. l / % -TER l'1 Property Qwnelr Name & Address: rD&2vkAi /� I K SN Au -IRS Pump Installation Date: /Well Pump Intake Depth Below Top of Casing: 1 %Q feet Pump Manufacturer's Name: 'RaP _75_a -e— -A- Pump Model: '�g rj 7 Pump Size !� hp Pitless Adapter Burial Depth: 1' Z feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Completion'? Yes ❑ No Method of Disinfection:��i��� Comments: A Anchorage Pump & *Neil Service Pump Installer Name: 330 East 76th Avenue Anchorage, Alaska 99516 Phone: 907-243-0740 Fax: 907-243-0742 Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. Municipality of Anchorage Community Development Department Page 1 of 3 On -Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP131267 PID Number: 015-163-63 ❑ New 0 Upgrade Name: Warren Penny ABSORPTION FIELD E] Deep Trench 2Shallow Trench ❑ Bed ❑Mound Address 11361 Snowline Drive Anchorage, AK 99516 ❑ Other Phone Number of Bedrooms Soil RatingTotal depth from original grade 3 1.2 GPD/SF 5.7-5.9 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 1.8 Ft Gravel depth beneath pipe 4.OFt, Subdivision Block Lot Snowline Terrace 2 Fill added above original grade 3-4 Ft Gravel length 43 Ft. Township Range Section Gravel width 5Ft. Beds: Number of Lines I Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 430 Ftp Ft. Well >100' >100' N/A N/A >25' TANK ZSeptic ❑ S.T.E.P. El Holding E] Other Manufacturer Anchorage Tank Capacity 1,000GaI. Surface water >100' >100' N/A N/A Material Number of compartments Lot Line >5' S'** N/A N/A Steel Two NA Foundation >5' >10' N/A N/A LIFT STATION Manufacturer Capacity Curtain Drain None Noted Gal. Remarks **See Lot Line Waiver. Pump on level at Pump off level at High water alarm at Existing Septic Tank Decommissioned in Accordance in. in. in. with Municipal Code. Existing Absorption Trench Pump make and model Electrical Inspections performed by Connected with Flow Diverter Valve. Installer PIPE MATERIAL House to tank D3034 Tank to drainfieltl D3034 G & R Excavating Drainfield HDPE CO/MT D3034 Inspector MEA BENCH MARK (Assumed elevation) 100.Oft Inspection dates: 8/12/13 2�d 8/13/13 Location and description 3" 8/14/13 4'" Front Door Stoop. COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL EW F ®®® Conditional Approval: Date ° 4918� '# MICHAEL E. P,�q�5?^,iV �0 f�. Cf - 4381 Approved Date /3-1)� ° pRorfss�oNa a" — Inspection Report _t-1-1 .d M ((0 I N c I mtoS �� tr�yl•� 4W ••'• N 00.08 45 165.12 v o LIF UNS s'D OEC WOV15'E 154.79' �o u,S%3S'D OEO CP CL z ���• � @� z"^ SNOWUNE DRIVE ��... o = z ® "e0 m O = p M � s £ v r a i y I m Ln / �) 10 I v) , aW m H oto Cd V m v` __� h -q Q a Q II v0 �Wyy ®W CJ p W° o W W I N 3 1 N O . 7 0_' p t m m 3 a W V LLJ V Q C Z �cti 7 �LLJ d \ q OI M N Ml Q J CL0 L W y U f fIIl Of tp ccs f in aiU s�o LL r� W 3 mac G m m o' ET! o o 0 aUU9 0 W O Q U O N o Ne r � of 9 J� n 04 N CL N �� tr�yl•� 4W ••'• N 00.08 45 165.12 v o LIF AV i •A M 1 �o £ W U oO:; s: z ���• � @� z"^ SNOWUNE DRIVE ��... Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904 Permit Number: OSP131267 On -Site Wastewater Disposal System or Well Inspection Report 88.5 U 90.2 �99.3 UU 1,000 Gallon Septic Tank 16.1 Page 3 of 3 PID No. 015-163-63 93.6 = v f II n 90.4 2'. Insulation and Ga.o4de Fabric Drainfield Rock 84.5 43' (Total Effective Trench Length) 73.4 No Groundwater 8l12Y20'13 PROFILE AS -BUILT No Scale 94.7 88.5 ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 FAX MEMORANDUM DATE: September 16, 2013 TO: Jeff Poet FROM: Mike Anderson. P. E. SUBJECT: Snowline Terrace, Lot 2 Certificate of On Site System Approval (COSA) The test hole placed during the subdivision phase of Snowline Terrace was still in place when work started on the construction of the new septic system. This test hole was 17' deep with water at 16'. A copy of the test hole is attached. The location of the hole is also shown on the plan and profile as built drawings. ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 FAX September 8, 2013 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: Lot 2, Snowline Terrace Subdivision Separation Distance Waiver Absorption Trench to Lot Line Dear On Site Services Engineer: The topography of Lot 2 and the location of the well on the lot required placement of the north end of the absorption trench to be .5' from the north lot line. Placement of the absorption trench at this location does not impact the property to the north or the septic system on that lot which is nearly 100' to the west. We recommend a waiver be issued allowing the trench to be .5' from the north property line. Sincerely, Michael E. Anderson, P.E. Municipality of Anchorage P.O. Box 196650 • 4700 Elmore Road Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997 http://www.muni.orgiOnsite Development Services Division On -Site Water and Wastewater Program e't ell �° a � �. ry Department **** VARIANCE/WAIVER REVIEW **** Waiver#: osp131323 PID#: 015-163-63 COSA#: osc131469 Permit#: osp131267 Legal Description: Snowline Terrace L-2 Engineer: Anderson Engineering Applicant: Warren Pennv Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 0.5 feet. This waiver approval applies to the existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. ® The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected adjacent property. ❑ Adjacent properties are not affected by this waiver. ............................................................................... Waiver is Granted: X Waiver is not Granted: Date: 3 Approved by: ` eviewe�L—�--� ................................................ ......................... Rec#: 06142G Amount: $200.00 Date Paid: 9110/13 **** VARIANCEIWAIVER REVIEW **** On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP131267 Tax Code Number: 01516363000 Work Type: Septic Permit Effective Dates: August 19, 2013 to August 19, 2014 Design Engineer: ANDERSON ENGINEERING Subdivision: SNOWLINE TERRACE Site Legal Address: SNOWLINE TERRACE LT 2 G:2640 Owner/Address: PENNY WARREN D 11361 SNOWLINE DRIVE ANCHORAGE AK 995161155 Site Mailing Address: 11361 SNOWLINE DR, Anchorage This permit is for the construction of: Lot Size in Sq Ft: 49390 Total Bedrooms: 3 Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Special Provisions: Proposed system too deep for soils information submitted. The Engineer needs to do an additional test hole prior to the construction of the septic field. Construction may proceed at your own risk before the 7 day water monitoring is complete. Please submit stamped and signed results with the As -built Inspection Report. If the results require a design change, construction of the system will stop pending On -Site review and approval. Received Issued By MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 015-163-63 Property owner(s) Warren D. Penny Mailing address 11361 Snowline Drive Anchorage, AK 99516 Day phone 748-3233 Site address Same Legal description (Sub'd., Block & Lot) Snowline Terrace, Lot 2 Legal description (Township, Range & Section) Lot Size 49,390 Sq. Ft. Number of Bedrooms Three (3) APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (M all that apply) Absorption Field 0 Initial Q Single Family (SF) El (w/wo ADU) Septic Tank Q Upgrade F-1 Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Dis tance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. owner or authorized agent) Permit/Rush Fees: ✓ 3 Waiver Fees: Date of Payment: Date of Payment: Receipt Number: Receipt Number: Permit No. 05Pl31 a6 3 Waiver No. Permit App_9-1-12.doc ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 FAX August 12, 2013 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 Elmore Road Anchorage, AK 99519-6650 Subject: Lot 2, Snowline Terrace Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The existing absorption trench on the subject lot has failed and must be replaced prior to the issuance of a Certificate of On Site System Approval (COSA). We are therefore requesting a permit be issued for the upgrade of the septic system to accommodate the three-bedroom home on the lot. The attached Site Plan and backup documentation identify the location and configuration of the existing and proposed septic system. The existing Septic Tank will be uncovered, inspected and verified suitable for continued use. The existing absorption trench will be left intact and tied to the new system with a flow diverter valve. Also identified on the plans are the locations of the existing well on this and adjacent lots and adjacent septic systems. No conflicts exist between the proposed septic system and the wells on this or adjacent lots. Protective radii are shown to the adjacent wells. Drainage arrows ground surface contours are shown indicating the current drainage patterns. The drainage patterns will be maintained after construction. The test hole placed on the lot indicated Silty Gravel with Sand (GM/SM) to a depth of 11'. No groundwater was encountered and none has developed during the monitoring period. The percolation rate in the GM soil tense was determined to be 2.5 minutes per inch. We have designed the new trench with an application rate of 1.2 gallons per day per square foot. We are proposing to place a 38' long by 5' wide absorption trench with a 4' effective depth. The total depth of the system will be 6' with the distribution line at 2' below the existing surface. A flow diverter valve will be placed to connect the existing trench to the system for future use. The ground surface on the lot slopes to the west in the area of the absorption trench. Lot 2, Snowline Terrace August 12, 2013 Page Two The trench will be placed parallel to the contours of the ground as much as possible and in conformance with design criteria. A minimum of 100' will be maintained between all components of the septic system and the proposed well and from any surface water in the area. If the system is constructed in accordance with our design the following statements apply: 1. The system, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. 2. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. 3. The system, if constructed as designed, will have no adverse impact on reserve space, either surface or subsurface, on any lots located in the area. 4. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, WjE a'L,, Michael E. Anderson, P.E. Attachments e 44:4 1 MICHAEL E. ANDERSON No. CE -4381 PAYNE LOT 2 Y��STONERIDGE LO i i i i i i SNOWLINE TERRACE i LOT 1 i i i i i PARCEL 58 i i i i i i (n i � i z i oY' 0O . - --J et` c m OMMON DRIVEWAY � --------- ------ Wit----------------- -- --------i 'Z1 UARCEL ------------------ i STONEVEW LOT 2 Gt�i®p STONEMEW �`-- ------_____ _ LOT 1 i i i i i i i i i i i _J i .�OF,gG���4 .. � ? AREA MAP 49th I 00 ` ANS .....(JN SCALE 1" = 100' ' No. CE 4381 ��rl'•.•, a �_ 1 1� 1, S; .d P� ���� � W� a St { \ • w m =o 1 �...�' mo• r>,I ` 3,3y 111 y J 1♦. cw Y e aso�3 lHin ,0l 0O: rE • �•�•• --- �: :Q Z ' 30 I 11, n� �... RE��i�•� W � �= W > � OD VF I Ink I 'E I r W ° D N°L z Wi �0 3zc 0 N U �NJ � c o O O U ry z a O r cn w Q J Lv Ni W w OI N WNT O O 'x Tp J v O OM w = I O w¢ W 0 QUEl- 0 LLI LLJ > 5~Z L/ wL 0o Z z° `N0 3: a` / /l O V / W I � z i O J I O °s O I ooa x c I V! a 00' c N c y 0 N C-6 X _° U O J c mo I O y3 -ZOL Z (9 y c oa°o~ o u O f='� ° F ° >° `oa ,96'96Z M.£l,Z£.00 N NU N N O WU 0¢ tivMv� SNOWLINE DRIVE ti oa��� D 0-60 p W tlE�u=>.'. W O E�0' U O (n o3a`w J "o LOT 2, SNOWLINE TERRACE SUBDIVISION DESIGN FACTORS: SYSTEM REQUIREMENTS: Three Bedroom House 5' Wide Trench System Pere. Rate: 2.5 MindInch 1,000 Gallon Septic Tank Application Rate: 1.2 GPD/SF 4' Drainfield Rock 3 Bedrooms X 150 GPD/1.2 GPD/SF (Application Rate) = 375 SF Absorption Area 375 SF/5 SF/LF*.5 (Red. Factor) = 37.5 LF Trench Length THEREFORE: Construct an Abosrption Trench 38' Long x 5 Wide x 4' Effective Depth. Flow Line Elevation in Trench to be 2' Below Original Ground Surface. Total Depth to be 6' Below Existing Ground. Provide 4' Cover Over Septic Tank and 3' Cover Over Absorption Trench. 1'6" Natural Backfill Geotextile Fabric C:1 E 5' Perforated 'C (Holes Down) Drainfield Rock TYPICAL 5' WIDE TRENCH SECTION •..�� oF•�a� (NO SCALE) .• p .................... �1 NOTE: Grade Area Over Trench to Drain Away. : � :' u Minimum 6' Separation From Bedrock.....;:. 49th :.. Minimum 4' Separation From Groundwater. Minimum 100' Separation From Wells in the Area 1� MICHAEL E. ANDERSON •, •.''t Minimum 100' Separation From Surface Water �i" No. CE -4381 P �.J1'.. . s, MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 4700 BRAGAW STREET ANCHORAGE, AK 99519-6650 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: Lot 2, Snowline Terrace PERFORMED FOR: Warren Penny DATE: 7/19/13 PROJECT No.: PARCEL ID#: TECHNICIAN: JB DEPTH TEST HOLE 1 (feet) 1 OB/OG 2 3 4 --1 1 GM/SM 5 6 8 9 10 WAS GROUND WATER ENCOUNTERED? NO IF YES @ WHAT DEPTH? 0 I 1 B.O.H. DEPTH OF WATER AFTER MONITORING: None DATE OF MONITORING: 8/15/12 in 15 16 17 18 19 DATE READING GROSS TIME (MINUTES) NET TIME (MINUTES) DEPTH TO WATER (INCHES) NET DROP (INCHES) 7/19/1 TEST HOLE PRESOAKED PRIOR TO TESTING: 1 3:48 10 2.50'/6.50" 4.00" 2 3:59 10 2.75"/6.75" 4.00" 3 4:10 10 2.50°/6.50" 4.00" 4 4:21 10 2.50^/6.50° 4.00" 5 4:32 10 2.25'16.25^ 4.00" 6 4:43 1 10 2.75^/6.75° 1 4.00" PERCOLATION RATE:25 (MIN/INCH) PERC. HOLE DIA. 6 (INCHES) TESTRUNBETWEEN: S FT. arid--6—FT. COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST. TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS DATE: 7/19/13 �ms MUNICIPALITY OF ANCHORAGE DEPARTMENI OF HEALTH & ENVIRONMENTAL. PROTECTION ` ENVIRONMENTAL ENGINEERING DIVISION \ 825 [-Street- Anchorage, Alaska 99501 Telephone 264-4720 \\ ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT � X"`W NAMEMv � J ❑UPGRADE —l MAI LINGy ji /0-- ,,, T / 9 "7 iia �. i_zJ LEGAL DE''S�CRRIPTION//'1 c LoT c>2 StJ{Z1� LOC%\ION V ,�ee++, �/� ll � 1 C� �1�1J r Well Absorption a) ea 1PERMI � NO. OF BEDt`(30MS tA) PE% Uy DISTANCE TO: /06 Q r __ j �7L f 17 Ma[eriad!'C�V, No, of compartmentsMf Wp //�DS Inside length Width Liq. c�parriy 0 IF HOMEMADE: Li CJ : Liquid depth ❑J OZ Well Dwelling DISTANCE TO: PERMIT NO. 2 Z H Manufacturer Materizl Liquid capacity in gallons ❑ w y u. Z W 1 t DISTANCE TO: No. of lines Len th of i h f�/te g FoundatioQ_ Nearest lot lirr e7 -�A-, J — Total 1."rtl IJJl Trench Fh PERMIT N {� Distance he�'y a jiAs Zw r—a `. ! jes (� (�� inches /V 47" F ❑ — Top of rile to finish grade t Material beneat rile ( inches Y� Total ef(ay:tjyg absorption area Length Width Depth PERMIT NO. w C7 a H _ Type of crib Crib diameter Crib depth _ total effective absorption area M w Us TO: WeII Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. to to � DISTANCE TO: _ Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATEFXLS/ kYUV SOILTESTRATING I NSTAI7�ERR, - - REMARKS z Cr APPROVE � DATE(/ jS� LEGAL/ �v__1 / 72-013 (Rev, 3/78) ctaq-."scvvtat 4maU 80, .1 Imtol'u) Jo/'.t .lied tock.. Iu. 'Zo -100' Ccd.tock.. "it sullmen'taty. tacj_ 765 to 775 fe.et. 19� to 200 Pcat 4h.ow4 2 rjptl -in.vica.6c, ct -.1t at teaYIvc ;�Trii lytjUi, 710 jhotUd. be tn,6.taLL(ud .20 a21. 00 X 20 0 f-p-ct 14200. 00 p�, -=A w t'j" .M _U Seczt. Mill ,� L.P;, wt t.i COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING: 'WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF x4700.0' THANK YOU VERY MUCH. BERNIE CLAUS OF RAMPART DRILLING 'WORKS ` t 9-.1 9_9 11 -di TE: C':: 7l F ! A I__ y. f "v ° CA q:::: If -'11 q" -A Y t --q C) Fe.IP-10 EE �C� ^ DEPARTMENT Or HEALTH AND ENVIRONMENTAL ' "'OTEC:TIOi.j �1 264-4720 / 825 'I. STREET, ANCHORAGE, HK. 95 _1 II Lo_(' L�O7(/��1�/,�1,/16/"��1 L4 E= L. L. K FJ E'> CA PA T: --E- E -m : „ F.L t,] EE K q-- IE K i...q :..._q_. PERMIT NO. ! 810317 APPLICANT BOYD L. WALKER P.O. BOX 10-197c; LOCATION SNOWLINE DRK15TH AVE. LEGAL LOT 2 SP+pab1LINE TERRACE SUB LOT SIZE TYPE: OF SOIL ABSORPTION SYSTEM TIS: TRENCH 'e UT i MAXIMUM NUMBER OF BEDROOMS :-: _ SOIL. RATING (SO FTrB14.:: - 85 Ire toc!Ell ; It REQUIRED SIZE OF TT -IE ::OIL ABSORPTION SYSTEM IS: -q"E-q= lLw q �'1`4 (u V...q q _7�..e�=• `:�qn°fi=b°.•"E tl._. E:'eYciq.-I-q._q THE LENGTH DIMENSION 15 THE LENGTH <IN FEET) OF THE TRENCH OR DRAINFIE'LD. THE DEPTH OF R TRENCH OR PIT IS TETE: DISTANCE BETWEEN TETE SURFACE OF THE GROUND AND TETE BOTTOM OF THE. EXCAVATION ':IN FEET). THERE 15 NO SET WIDTH FOR TRENCHES. TETE GRAVEL DEPTH IS THE MINIMUM DEPTE OF GRAVEL BETWEEN THE OUTFALL. PIPE: AND THE BOTTOM OF THE E ;CA'•;'ATIOM`' IN FEET). q -t_ 10, oil !__! X F tl . E: • a-. F= -Y- I YC:= E_ q.:4 P4 PC _:'C A.>= K _ A . CER E -a u_ -- i 1:3 Fit— PERMIT 1t_ PERMIT h"PPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING TF-Iti INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THF NUMBER OF RESIDENCES THAT THE WELL WELL. SERVE, -q_ 14f-4 ,c: a, :.a 1< q° B'_=: E E_= am " q ' T: ® o N' 9' !=-Y E�•::t Ev o ! q.._! :IC q4' E t_s __ _...- BACKFILLING OF ANY SYSTEM WITHOUT" FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WIL-L.. BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL. AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM Is :I.00 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC: WELL. DEPENDING UPON THE: TYPE: OF PUBLIC: WELL. MINIMUM DISTANCE FROM A PRIVATE: WELL TO A PRIVATE _EWER EINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE: RETURNED TO THE: DEPARTMENT WITHIN 30 DAYS OF TETE WELL COMPLETION. OTHER REQUIREMENT'S MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO I INSURE. PROPER INSTALLATION. E a F-_ v E_ = Vq IL_p E : FT _011., ::d.. _-e 1=9 q - I CERTIFY THAT 1: I AN FAMILIAR WITH THE REQUIREMENTS FOR ON --SITE SEWERS AND WELLS AS STET" FORTH BY 'TETE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. _.: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE: ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDF•:Cn��LT_. Af-'A :E=I9A#op ISSUED BY -DATE._. S 5 ...._.A V4. 0 I ES� a5 43560 _QUARE FEET 01 An SOIL. RATING (SO FTrB14.:: - 85 Ire toc!Ell ; It REQUIRED SIZE OF TT -IE ::OIL ABSORPTION SYSTEM IS: -q"E-q= lLw q �'1`4 (u V...q q _7�..e�=• `:�qn°fi=b°.•"E tl._. E:'eYciq.-I-q._q THE LENGTH DIMENSION 15 THE LENGTH <IN FEET) OF THE TRENCH OR DRAINFIE'LD. THE DEPTH OF R TRENCH OR PIT IS TETE: DISTANCE BETWEEN TETE SURFACE OF THE GROUND AND TETE BOTTOM OF THE. EXCAVATION ':IN FEET). THERE 15 NO SET WIDTH FOR TRENCHES. TETE GRAVEL DEPTH IS THE MINIMUM DEPTE OF GRAVEL BETWEEN THE OUTFALL. PIPE: AND THE BOTTOM OF THE E ;CA'•;'ATIOM`' IN FEET). q -t_ 10, oil !__! X F tl . E: • a-. F= -Y- I YC:= E_ q.:4 P4 PC _:'C A.>= K _ A . CER E -a u_ -- i 1:3 Fit— PERMIT 1t_ PERMIT h"PPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING TF-Iti INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THF NUMBER OF RESIDENCES THAT THE WELL WELL. SERVE, -q_ 14f-4 ,c: a, :.a 1< q° B'_=: E E_= am " q ' T: ® o N' 9' !=-Y E�•::t Ev o ! q.._! :IC q4' E t_s __ _...- BACKFILLING OF ANY SYSTEM WITHOUT" FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WIL-L.. BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL. AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM Is :I.00 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC: WELL. DEPENDING UPON THE: TYPE: OF PUBLIC: WELL. MINIMUM DISTANCE FROM A PRIVATE: WELL TO A PRIVATE _EWER EINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE: RETURNED TO THE: DEPARTMENT WITHIN 30 DAYS OF TETE WELL COMPLETION. OTHER REQUIREMENT'S MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO I INSURE. PROPER INSTALLATION. E a F-_ v E_ = Vq IL_p E : FT _011., ::d.. _-e 1=9 q - I CERTIFY THAT 1: I AN FAMILIAR WITH THE REQUIREMENTS FOR ON --SITE SEWERS AND WELLS AS STET" FORTH BY 'TETE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. _.: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE: ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDF•:Cn��LT_. Af-'A :E=I9A#op ISSUED BY -DATE._. S 5 ...._.A V4. 0 6��j evev 410 / f G� 01V 9,ys M/t \1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION CONTINUATION SHEET NAME OF ESTABLISH ENT DATE OF INSPECTION TYPE OF FACILITY PAGE OF J _ ,__ --. \f e3 R ECEIV�/`E�'D BY — — � TITLE INSPI/EfsT2� BV C—l`\-1J—� DATE 72-018 16/78) .Ilv , S7Of1i;�}\A5�<:1,.,I1 (y J>✓ 1..1 Xrl� ��i �\ .t1 Al ) 4 f ) pt 1. %�F��JF:.e;3 �, }]\,iAt} C-€.'���@ /1��1�?�.Reb�' �-f':�z%�-5 �. Jl �l„ y�`��-,% �°`\�-"• <i ' 4 l'. �% j t Ct c -1, i .J 1. qe-v� �� DOUGLAS A. STARK and ASSOCIATES, CONSULTANTS 957 Westbury Drive • Anchorage, Alaska 99503 a Phone: 777-4300 March 22, 1981 moil Tests Date of tests: March 17, 1981. Parcels-- Snowline Terrace (Sk'11$ NE1,4 SZ% NIPA S24, T12N, RM -19 SAI) Lot 1 — 10' west of middle of back line Lot 2 — 10°' west of middle of back line Test method:- A nodwell--mounted 6" drill bored to 17° at both sites. Samgles-were taker-- at 10r. A second hole was drilled to 8' and wetted. A percolation test was made the next day. Attachments: lot map, soil gradations. • ` z 5t � l�•tITN� ;�' ••o u.••u•aae e• `•�••. •• uua..a.as. '-J; No, 1814-E 7' MARCH fl, 1969 �' �Y AO�,F, •• `�,,; .l13vr •ue•siuf �v�;y loT 3`k 3 > ^ v ` \ h r 1 1 � tA u 7 y s J Q J a, NL GIAAIv Q wh?tI. 4 1.uT 2 v 1 1 � 7 y J Q J s� 117,1:16, G wo'• ".� lw /i t M 0111 Organization e Management • Engineering • Surveying • Planning • Human Resource Development 0 Gia C,,-) `--L�> M �k L CX _ ` G �� kv S -1I Parcel I.D. 015-163-63 Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Expiration Date: .11 J 15 - 1,3,3 Complete legal description Snowline Terrace, Lot 2 Location (site address) 11361 Snowline Drive Anchorage, AK 99516 Current Property owner(s) Warren Penny Day phone 748-3233 Mailing address Real Estate Agent 11361 Snowline Drive Anchorage, AK 99516 2. TYPE OF DWELLING: (] Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: Three Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request Received by: Dater COSA to be released to thcs'engineer, unless otherwise requested by the engineer. COSA Fee $ ' ,Gb Waiver Fee $ a0lo, W Date of Payment '?10 5 Date of Payment q 110113 Receipt Number onff14 & I og'6 Receipt Number / �(o2�(r2a . COSA # V� l��`��) Waiver # 0J�� J 1✓ 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, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) In compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. Phone 522-7773 Date 6er' e v 0.7 6. DSD SIGNATURE p(rG System #1 Approved for bedrooms°M10AVL woeasoN J o U- 4381 g a System #2 Approved for bedrooms A Disapproved iIt orris sm�Q�® Conditional approval for bedrooms, with the following stipulations: By: Original Certificate Date:_1 - 1 The MY ip ity��f nchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet(l.i c If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Snowline Terrace, Lot 2 A. WELL DATA Well type Private If A, B, or C provide PWSID #_ Date completed 6/1181 Sanitary seal (Y/N) Y Total depth 200 ft. Cased to 200 ft. FROM WELL LOG Date of test 6/81 Static water level 90 ft. Well production 5 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 3.67 mg/L Arsenic N/D ug/L Date of sample: 8/16/13 B. SEPTIC/HOLDING TANK DATA Parcel ID: 015-163-63 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) >12 in. AT INSPECTION 8/28/13 85 ft. 3.66 g p m Collected by: Anderson Engrg. Tank Type/Material Septic/Steel Date installed 8/12/13 Tank size 1,000 gal. Number of Compartments 2 Cleanouts (YIN) Y Foundation cleanout (YIN) Y Depression over tank (Y/N) N High water alarm (Y/N) _ Date of pumping New Const. Pumper C. ABSORPTION FIELD DATA N Date installed 8/13/13 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 GPD/SF System type 5' Wide Length 43 ft. Width 5 ft. Gravel below pipe 4 ft. Total depth 9-10 ft. Eff. absorption area 430 ft2 Monitoring tube Y Depression over field N Date of adequacy test New Const. Results (Pass/Fail) For _ bedrooms Fluid depth. in absorption field before test in. Water added gal. New depth in. Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed "Pump on" level at in. Datum E. SEPARATION DISTANCES WELL ON LOTTO: Size in gallons 'Pump off' level at in. Cycles tested Manhole/Access (Y/N) _ High water alarm level at Meets alarm & circuit requirements? in. Septic tank/lift station on lot >100 On adjacent lots >100' Absorption Feld on lot >1 00' On adjacent lots >100, Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line '25 Holding tank N/A Animal containment areas Manure/animal excrete storage areas >100' SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5 Property line >5 Water main >10 Water service line >10' Wells on adjacent lots > 100' ABSORPTION FIELD ON LOT TO: Property line 5'** Building foundation > 10, Water Service line >10, Surfacewater >100' Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS **See Lot Line Waiver. G. ENGINEER'S CERTIFICATION I certify that f have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Michael E. Anderson, P.E. Date 9/8/2013 COSA brown sheet -1 0-1 0-12.doc Absorption field >5 Surface water >100' Water main N/A Driveway, parking/vehicle storage > 10' J MICHAEL E. ANDERSON CE - 4381 O $ O Ov.7 E a - <-• a °NOO—= S 'Oa ° 3a3=ooa z «° 7 070 ' a a * a -coo. O Oa 7 a O23a Hyla 2 n a a a Z O a� �. Zva 0 P _=ire n 3 0 =Z O am - 0O ma'sau�o a w 00 'C so 140-00=D< aaas�a. n O •• 0700me O °`t °Oa, n7 O$ °3_,*kao.c Ci Oco OOo a°O., ^n 2320 a3 G a ,Ogg n° i «as,so?o 2 nu wO �mE 3 i m, O u 7g a aa, 0 a s a.. AN 3 7 3 0 0'0 v °e m 0 —av � Q 2230 so 0 102 C6 O 0,4 ° p I. O v O "o on o. .eSs3° 3m o 77 v_3 3 aZaa s 40 goy Y« ° °� a _O 03 ° o dg3a:✓ :mac r Z: ; CO IQ 17: >fd M 0 3A18a 3NIIMONS x ppp o3o`n�oe�SN� i � ;� ./IfI (n� PA 11�.iA..- 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 furtheruerifythat 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 F (c�Fp % ecG'r„ ca / Svc c Phone 3 HS- i33 s - Address 15S U S /3 -V, A;;0 ere Engineer's signature Y�i c Date'-f�l z2/ 99 u OF At all 4. /� 3 TH 1� Veee..00N.uu...ur.aru$ THEODORE F. MOORE AV" t I L7, 41. 6. D`H/HS-SIGNATURE 2 L Approved 'for / bedrooms. Disapproved. Conditional approval for bedrooms '.with. the following stipulations: Additional Comments By 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 5 above by an independent Professional engineer registered in the State of Alaska. The DHHS does this as acourtesy to purchasers of homes and their lending institutions in orderto 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-M(Rev.1/91) Back-MOAe21 r�kC17'1VL 0 Municipality of Anchorage DEPARTMENT OF HEALTH& HUMAN SERVI i�CNNui+ 'r+vvt.nu Environmental Services Division eNvie ENIALSEkVICIiS 41V 825 L Street, Room 502 o Anchorage, Alaska 99501 • (907) 343•-4744 Health Authority Approval Checklist Legal Description: 4,q f2, Sn c,c-u ljn e 7�! r- -e r a Parcel I.D.: 0=/ci-3 -- 6 —_ A. WELL DATA Well type If A, E3, or C, attach ADEC letter. ADEC water system number _ N. A. _ Log present (Y/N) Y __ Date completed 6,11181 _—_ Total depth _ 200' Cased to _ e0 ' _ Casing height (above ground) i z Sanitary seal (Y/N) Y' Wires properly protected (Y/N) _�' _ FROM WELL LOG AT INSPECTION Date of test �I / B/ _— 9 / L3 9 2 Static water level _ 90, --_ _ 6 8 Well production ��g.p.m. _--7.3 g. p.m. WATER SAMPLE RESULTS: Coliform --Q cal / l u0m-� -Nitrate _3_2- `/ m /.,L Other bacteria _ lvn zre a r /eof --- Date of sample: 199 __ Collected by: B. SEPTIC/HOLDING TANK DATA Date installed size L'UU_ Number of Compartments 2 Cleanouts (Y/N)_Y _ Foundation cleanout (Y/N) _ Y __ Depression (Y/N) N High water alarm (YIN) _ k/ • /J. _- Date of Pumping_ 9/2Y/99 _Pumper_ ryoceecerr "(, ;„� D b 1, C.G. /nJfu ePl a( hcfw•ren /u� H f el�C C. ABSORPTION FIELD DATA Date installed 7 / /3 / 8/ __ Soil rating (g.p.d./ft2 or ft2/bdrm) RS" ! 1' _ System type f3cQ�m Length 3 W ' —Width -7 —_ Gravel thickness below pipe _ h'' �Total depth 7S__ �4 Effective absorption area --Z7 2 h� Monitoring Tube present (Y/N)--L- Depression over field (Y/N) Date of adequacy test _ 161 / S / 99 _ Results (Pass/Fail) _PGS/—_ For —_bedrooms Fluid depth in absorption field before test (in,); —0 Immediately after o / gal. water added (in.): _/:2 _ Fluid depth _ O (ins) Minutes later: Absorption rate = _> yS0—g.p.d. Peroxide treatment (past 12 months) (YIN) -None t-:noc If yes, give date N. A. —_— S'n r/�/ren Clan/ /-r.T. inl/i;�//ior '�n fr'lnch �' fivm ,env! /v /Y/9'J 72-026(Rev.3/g6)" Y. Pe,_ 11/6/90 H'419 o/afu stiPef D. LIFT STATION N.A. Date installed Manhole/Access (Y/N) _ High water alarm level at* _ Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot lob' On adjacent lots /00+ Absorption field on lot 100 * On adjacent lots 160 -r Public sewer main Al. A. Public sewer manhole/cleanout N • A Sewer /septic service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 13 Property line %a' Absorption field x I'T Water main/service line 7 to ' Surface water/drainage t Is" Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ?01 Building foundation /0,+ Water main/service line > to Surface water > r oo' Driveway, parking/vehicle storage area > 3o Curtain drain None seep Wells on adjacent lots > t0c) ' F. ENGINEER'S CERTIFICATION �E ar, I certify that I have determined thru field inspections and review of Municipal records thgf the Aditetsystems are in conformance with MOA HAA guidelines in effect on this date. Signature Engineer's Name Y � CSvo P V A 71 �l)n;�r_r ,�dc70itCp Date D ere- ber 22, 1999 C • 3 3; e° R HAA Fee $ Waiver Fee $ Date of Payment 2'/ ,/ . Date of Payment Receipt Number C Receipt Number 72-026 (Rev. 3/96)* 12-22-00 08;10 FROM -CTE ENVIRONMENTAL 5615301 �1�► CUE Environmental Services Inc. Cf&E Reim 996707001 Client Name Flattop Technical Srv. Project Name/0 Lot 2, Snowllnc Terrace CRea Sample 10 Lot 2, Snowlme Tcrrace Matrix Prinking Water Ordered By PWSID 0 Sample Remarks T -TIT P 02/03 F-010 Client Pon Printed Date/Time Collected Dare/Time Received DmvlTime Technical Director Released Rv/f, 9, Pre -Pard Colis/NO3 12/2 1/1999 19:22 12/15/1999 14'00 12/15/1999 15.05 Stephen Ede At lowaM a Prep Mat ys is Parameter Resat rs PQL units Method Limi rs Dare Dace Init WATERS DEPT Nitrate -N 3.24 0.500 mg/t EPA 300.0 (00) 12/15/199912/15/1999 SCL MICRO GAB Total Cotttorm 0 cot/100mr. SM18 92220 12/15/1999 jol ITY • Department of Health th & Hum ORALE Department of Health &Human Services �r DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel l.D.# Vn )-laHAA #, 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) t47—.z �A 3I✓ SEG yy Location (address or directions) / l3 G l J.Jo�u�lE (b) Property owner 4044^1 �'f}['/fEL� Telephone: (home) ,50-3333 Business Mailing Address 1101 3c%N�A�E 1�jrll AK (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address Telephone Telephone (e) Mail the HAA to the following address: (or check here, if hold for pick up.) List contact person and day phone number below: / 2. TYPE OF RESIDENCE Single -Family? Number of bedrooms 3 3. WATER SUPPLY Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On -sited 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. 72-025 (Rev. 7/88) Page 1 of 2 Sm.--i.i•rai. ).J ./:a.. .... n.If. 1,11.'...:..rt W.s.IIII—.a r:..,-, 11':-.,,..uI1t.. x- Te-. v.. .f .-1..r q.'7—aa 11-111 ;1" ....4 .. I X..l.\.-.:."'1r' ..._.. Z 1 Z abed MO.B WO/Z �.e) sao-zL -NioM s,jaaulbua leuo!ssajoid ay; ul suolsslwo io sioaaa ao; olq!suodsai jou sl a6eaogouy jo Ailledio!unw agl •ponss! sl aleo!;ljaao a aaolaq elep az/leuu jo suo!loodsui jonpuoo jou op SHHa;o saa (oldw3 •sjuawajlnbaa ajels pup leaapa; ulpliao (;sljes olaapio ul suoilnjllsul 6ulpual alagj pup sawog ;o saasegoind of (sajanoo p Sp s!gl S00P SHHa agl •e�lsply to GMS agj ul paaajsl6aa aaeu!6ue leuo!ssa;oad luepuadepu! up /.q anogs g gdea6ejed u! uanl6 suol;ejuasaadaa agj uodn Rluo paseq pajeoilpeo lenojddvAjlaogjny glleaH sanss! (SHHO) Sao!AaaS uewnH pue gl!paH;o luawliedaa abpaogouy;o /jlledlolunw age, NOIlnyo leuo!j!puop oO — 0ll_ aleG r N lenoaddy leuo!llpua-,);o sWial panoaddpslp,'y;, panoaddy !q swooapaq Jo; penoiddy 1VAOUddtl SHHa '9 ,4t"J6,d a f,✓ zf a t �$ 9 9 O.f XP9 Oelssaappy .(SSS -6L2 auogdelal 5�� Wald;o eweN •uo!joadsui slgj jo a;ep agj uo joa;;a ul suo!jeln6aa pue 'seoueulpio 'sapoo alplS pup led!o!unW Ile 4l!M aoup!ldwoo ul sl wajs (s lasods!p aajeMalssm ao/pue Alddns aejum aj!s-uo agl'uopoedsul Pus uo!je6!;Sanu! Aw wojl pue sell} a6eaogouy ;o /jlledlolunw agj woa; pau!e;qo uo!jpwao;ul agj uo paseq legj AjuaA aagjan; I •ulaaag pejeo!put aanjonajs;o ad (l pue swowpeq;o aagwnu agj aol ejenbape pue leuo!joun; 'e;es sl wels(s lesodslp aaleMalseM jo/pup Alddns jajeM 0;19-uo egj )egj SMogs leAoaddy Al!joglny gjleaH s!g; jo uo!jp61,jsanul Aw legl jlaaA l'Molaq uMogS a;pp uoljeplleA ag;;o se pup olaaag pax!j;p leas Aw Aq pa!;!laao sy NOIIVWMOdNI aN'd VIVO 'HOEMS 3'lld'S1S31'SN01103dSNI ONIOIAOMd WHId UNIM33NION3 '9 ___....- _..._....T__—"`__...... .. _•.-.__,.-. .. ..�.. .:.:_ ..., �.�-... .•, a..�...a.... .-».•.+.a.+v-n n.r^;..•ro»acm.xcwr«ire-r:.. .—.�r� _ MUNICIPALITY OF ANCHORAGE (MOA) • 1PAUTY cHoRlIhdkatlmrity Approval (HAA) { MENTAL SLQFItEE' K14jQ(TM FEBRUARY 1984 343.4744 A1:1 Q 9 1900 Legal Description: `-O7r Z 5r1o�1u✓� ii�RP/jtd Tim 24 A. WELL DATA Well ClassificationR/✓/`?`7�� _ If A, B, C. D.E.C. Approved (Y/N) Well Log Present((Y N)D--//a__te Completed 6-1-5'1 Yield Total Depth � Cased to _'4 —'Depth of Grouting Ai %1 _ I Static Water Level 7C Casing Height Above Ground _— Electrical Wiring in ConduitO)N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot — To Nearest Public Sewer Line tJ1A To Nearest Sewer Service Line on Lot Water Sample Collected by Pump Set At Sanitary Seal on CasingON) Depression Around Wellhead (Y�% On Adjoining Lots zoo '4 /O° 7` ; On Adjoining Lots 10'e -,t To Nearest Public Sewer Cleanout/Manhole � A zs'r [-, RFiD ; Date -5-7-6-9n Water Sample Test Results %SACT -6- A1/7/1i}71F_5 ;-'- 6 Comments 64Ew z� -T�5/ 3-30-90• B. SEPTIC/HOLDING TANK DATA Date Installed 7-yj-KI Size 150V No. of Compartments Standpipes (Y N) Depression over Tank (Y/N) Air -tight Caps(Y N) Z Foundation Cleanout(OYN) Date Last Pumped 15 I CG.7 Pumping/Maintenance Contact on File (Y/N) kA Holding.Tank High -Water Alarm (Y/N) _ ✓� Temporary Holding Tank Permit (Y/N) ��tJL4 SEPARATION DISTANCES;FROM SEPTIC/HOLDING TANK: To Water -Supply 'Weil /U To Building Foundation /G To Property Line To Water Maip/Servlce Line To Stream;,Pond; Lake ofW _Plor Drainage Course Comments' To Disposal Field 72-026 (Rev. 718B) From Page 1 of 2 yo r Ly S5AJmVJu.✓�V_ T�rvnrE C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 7-13 Width of Field 3 Square Feet of Absortion Area Depression over Field (Y No _ Results of Last Adequacy Test M Type of System Design T&Ak-11 Length of Field 3`f � Depth of Field 7 15r Gravel Bed Thickness Statndpipes Present N) Date of Last Adequacy Test 3 - 36 -%° TE x SEPARATION DISTANCE FROM ABSORPTION FIELD To Water -Supply Well /" J-,�' To Property Line 16 -/- To To Building Foundation To Existing or Abandoned System on Lot Al/A ; On Adjoining Lots Za i To Water Main/Service Line /o % To Cutback (if present) 414 To Stream, Pond, Lake, or Major Drainage Course /°a f To Driveway, Parking Area, or Vehicle Storage Area Zo JT Comments Sy n+ V�a.4o aews1-r D. LIFT STATION '-Bate.Installed Dimensions Size in Ga io Manhole/Access (Y/N) "Pump On" Level at "Pump Off' Level atvel High Water Alarm Leat Vent (Y/N) Tested for o� Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments "Check Permitted Bedroom Rating Against HAA Request" I certify that I have checked, verified, or conformed to all MOA and HAA guidelines1paq#4ftoq Jhe date of this inspection. OF A B4 6 /�J�— Signed 4 �®{,, �e••e•uose• •s��0 /9'�i� 16 •% CompanyTK Date �-� -- 7p i �eee.:..e. 600.0 n eelCs Seal d MOA No. /O'Gi�IZ `e •ee• •••n•e••e• �.• e C. R0EID� JR. • �1� S CE -2251 'AV %�/ /� %d/ / e• •• �lOp/Oj�10t1a®am Receipt No. ,2,1-) p � Receipt No. � y � � � �� Date of Payment 1 Waiver Fee: $ Amount: $ ��� �� Date of Payment 72-026 (Rev. ]/88) Beck Page 2 of 2 A 'C5 ALASKA RUIROIlO1(nTAL COnTROL SCRUICCS, InC. a Enqineerinq & Enuironmental Studies P. 0. Dox 240808 Anchorage, AK 99524--0888 (907) 279-5553 *':* FAX (907) 278-8708 April G, 1990 Department of Health & Human Services Municipality of Anchorage 825 L Street, Fifth Floor Anchorage, AIC 99501 ATTN: Dan Roth RE: Lot 2, Snowline Terrace Subdivision Dear Dan: On March 28, 1990, I used Carl's Excavating to dig a test hole 10 feet north northeast of the end standpipe in the field. The hole was 12 feet deep. A monitor tube was installed. The system bottom .is at 7.5 feet below the ground. The distribution pipe is at 3.5 feet below the ground. There was about a half inch of water in the standpipe. The test hole was dry to 12 feet. The top 3.5 feet was a sandy loam. From 3.5 feet- to 12 feet the soils were a very clean, loose, dry, gravelly, coarse sand. Carl's helper had helped install the system. The water problem referred to in the MOA notes was in the flat part of rnrs�b'esr.-ssnb2raer�c+e-�-�+�ka-9�nes-�-tsaat�ss the lot and not in the area where the system was installed. I hope this clears up the questions about the original inspection. I.�1 N o..o 'V •• �ff �t •BI•,1 H.OH �. o.o...o.. .......... e ll:R , REID, J2 F .2251 ` r . kyr r LCR/sr Sincerely yours, Lera C. Reid, .I Ph PC, DRli P sidant °a CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. �i 5633 8 STREET ANCHORAGE, ALASKA 99516 TELEPHONE (907) 5622343 FEDERAL TAX ID N 920040440 IA,BORATORIES ANA6Y87S REI`UR1HY tiA11PL8 fur: Work Oadnr d 20611 Uatc. Roport :limed: IfAR 22 90 t 17:19 C1.ront Sample O:LOT 2 SLOP AL % TERRACB - OUTSUA VAP KNIO :UA Coll octad ?dA{ 26 `JU � itilDf, hie. ;r; c.ei YsFi IdAh 27 90 i? 09:00 hex. Ilei�Oi'vo l with :AS tt84UIREP Ann1.yl:lo Coclpiot¢d :NU 28 90 _nboiatoxy SupnrNi/%9oc :SY8PN81I C. li0t'. „o l.eae cd liy �;peclal Y1iet[uct: fhcntl.o)) Ref a: 9005]? Lab 3rapl ID: t I`atriY WATER Cl rent Nar:o : 7, G C S Mali, Aout : iM8 Sro 1'.0,3 110118 V'Y'a f) RIJfl 8 Oxdorcrl ily : S'AHA Rr'lp Send Report". to. L)AEi:S 'ler:.'unator Tostetl Rend t Unitc fethod LI:II,ttc 60"1 F, 353.2 LO &wllplo NOIMI8 SIWW @ floiatks: zikl[P B CHLA,TU 6Y L, MID). i Test.v C:+ifan�Iad Sue f;pac iia. Ln;tin�alons Abode liA=Um:.'tatlt:bie 1;1;= None Uatectoci "Soo Ssmpl.o Rorlsarks Abo�n IV, Hnt A;:a]prcdLool; Tla&' O:i-.l-toat cr S'hse, MUNICIPALITY OF ANCHORAGE C ENVIRONM�S%TA V DIVISION MUNICIPALITY OF ANCHORAGE 0 / S / DEPARTMENT OF HEALTH & HUMAN SERVICESI' r g 1 g 1988 DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE F ON -SITES EWER AND WATER FACIOF INSPECTION FOR HEALTH OLRrYY APPRC C E V E D 264-4744 Application Date ,/� GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) 0 g r oo~!V, (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) /) V, / 5a vuti,/ �14 Lrl� �/� -1 (b) Property Owner Telephone: Home Business 1 Mailing Address (c) Lending Institution Mailing Address _ (d) Real Estate Company and Agent Address _ Telephone (e) Mail the HAA to the followino address: or: Check here 0, if hold for pick up. List contact person and day phone number below. / 2. TYPE OF RESIDENCE Single -Family, Number of Bedrooms 3 3. 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. 4. SEWAGE DISPOSAL Onsite'p l 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 (Rl� 8186, From 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 inspection. Name of Firm rid 5 Telephone Address �7� J 1-✓ ��° 141,2' 5tf/7r Date '---/i-6 r 34.{- O 3 � ." Vn co �v�: f .�••. �•• . •�efl'eCf.8E8t3a4s•: v f 4 '% CE -251 6. DHHS APPROVAL Approved forfi,' ,4 ( bedrooms by Date Approved a Disapproved Terms of Conditional Approval 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 (Rc� 81861 Back d!5 16 6 3 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL- (HAA) MUNICIPALITY OF ANCHORAG@IECKLIST - FEBRUARY 1984 DEPT. OF HEALTH & 284-4744 ENVIRONMENTAL PROTECTION /-t'% Legal Description: _ FEB 18 iw -7 v3 5�� Z A. WELL DATA R Ef. E l,,J/4� Well Classification �A7lv'7�f If A, B, C, D.E.C. Approved (Y/N) /T Well Lo Present Y/ "�`�' 5iiptLl Log � �1) Date Completed Yield r Total Deptha7L7e1y Cased to—' Depth of Grouting Static Water Level 7n•� ' Pump Set At r Casing Height Above Ground — Electrical Wiring in Condui (YeN) Separation Distances from Well: To Septic/Holding Tank on Lot Sanitary Seal on Casing (Y/ ) Depression Around Wellhead (/N) r On Adjoining Lots /®Tr To Nearest Edge of Absorption Field on Lot �6ry -t' ; On Adjoining Lots /©V _ To Nearest Public Sewer Line — 14 4 To Nearest Public Sewer / Cleanout/Manhole ^Aj���11 To Nearest Sewer Service Line on Loth-�' Water Sample Collected by -j tT tJ/y�d / _ ; Date Water Sample Test Results _1 07—Z61— Comments )GJ&L- !'zv�J %L --r B. SEPTIC/HOLDING TANK DATA Date Installed —7- � Size � Sz�o No. of Compartments 1 _ Standpipes (01 ,I) Air -tight Caps qjN) Foundation Cleanout(NN) Depression over Tank (YO Date Last Pumped 7 `y6- r° 15, /!25 Pumping/Maintenance Contract on File (Y/N) /A for IJA" Holding Tank High -Water Alarm (Y/N)— Temporary Holding Tank Permit (Y/N) 41 Separation Distances from Septic/Holding Tank: r To Water -Supply Well Z — To Building Foundation r To Property Line IV To Disposal Field To Water Main/Service Line _ Course Comments Page 1 of 2 12026 IRov 61861 Front To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata's Type of System Design Date Installed � .- Length of Field 34/ Width of Field .3 Depth of Field /l. Gravel Bed Thickness i Square Feet of Absorption Area `J 7 Standpipes Present Y/ ) pp� Depression over Field (Y/Iv)) Date of Last Adequacy Test Results of Last Adequacy Test /("t1s'47t Separation Distance from Absorption Field: i � To Water -Supply Well 1610'% To Property Line AG %° i To Building Foundation 16To Existing or Abandoned System on Lot % On Adjoining Lots 7-e To Water Main/Service Line /6 ' f_ To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course & To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date d Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access(Y/N) "Pump Off" Level at " Check Permitted Bedroom Rating Against HAA Request'" Vent(Y/N) during Adequacy Test. Meets MOA certify that I hav he /ked, v rified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed l /r Date 7 �� �� as`a�OF A44 Company MOA No. •••ee .ecce -n m ( a, A� Receipt No. Date of Payment 0 8�101y11�•• e i•••�• * ®® Amount: $ / 7 C R�19'e•.� Y •Be ee Page 2 of 2 72-026 (Rev 8/86) Back LEV •� �`AY CE -2251 ��(! •••e,e.ae••° 4� ®®�4tt®mm�"`rQ°ea SEAL) �� epe0000°ee O1 °Okp 4 U s Y u Municipality of Anchorage v Vie° Y i is DEPARTMENT OF HEALTH &HUMAN SERVICES 60000° ' ` o•, o�E'ooeo 825 "L" Street, Anchorage, Alaska 99502-0650 0' °eoeo eyy?d SOILS LOG — PERCOLATION TEST g�o lx0' C REID, JR. -60 a a 2251 0F+� 060 PERFORMED FOR: LP)l 49— re� RP _ DATE PE�Frif�iL+10i ryry G7,~Y' LEGAL DESCRIPTION: �cC �h®w(/ge, l.rr �, Township, Range, Section: 11alu SLOPE SITE PLAN 1 2 13 14- 15 16- 17- 18- 19- 20 COMMENTS ad�d6/ �O D•�H1 CIA 4^ 100re dry? Coarse rive/(7 WAS GROUND WATER ENCOUNTERED? s IF YES, AT WHAT ,__e, 0 DEPTH? O P E Depth to Water Aller Monitoring? Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE _ (minutesiinch) PERC HOLE DIAMETER TEST RUN BETWEEN _ FT AND __ FT PERFORMED BY: _'Z-� /LF' CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) ALASKA ENVIROit,AENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561.5040 JOB 44T S,AJ/ ),19' :ZE-,2RACEf _ SHEET NO. OF g CALCULATED By A DATE CHECKED BY �3 JE�� CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. -- x5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 5622343 .......,oa,ez FEDERAL TAX W # 92.0040440 ANALYSIS REPORT BY SAMPLE for Work Order # 5169 Date Report Printed: FEB 15 88 9 12:52 Cl lent Sample ID:LT 2 SNOWLINE TERRACE PWSID :UA Collected FEB 11 88 9 16:45 hrs. Received FEB 12 88 9 08:00 hes. Preserved with :REFRIG Analysis Completed :FEB 12 88 Laboratory Supervisor :STEPHEN C. EDE Released By : 3�%e—�. L� Client Name : AECS Client Acct : ABECSRP P.O.# NONE REC'D Reg # Ordered By : A. WIEN Send Reports to: I)AECS 2) =C=�=CC-L-OC:� Cr ..tl:: _•w�-.._-Y.�C� OGLCCE6� -L�._ •• _�.!'� .. .. L�S� - .. .. ..._ .. .. Special w Instruct: Chemlab Ref #: 9089 Lab Smpl ID: 1 Parameter Tested NITRATE -N Sample ROUTINE SAMPLE Remarks: COLLECTED BY A. WIEN Hatrix: Water Result/Units Method 2.4 mg/1 EPA 353.2 I Tests Performed x See Special Instructions Above UA=Unavailable ND= None Detected v See Sample Remarks Alcove NA= Not Analyzed LT=Less Than, GT=Greater Than Allowable Limits 10 Time APPLIC NT FILLS OUT UPPER HAI ONLY Property Owner .Boyd Phone and Donna Walker (Former owner;) Mailing Address r n,�^1 Zip Code q� T.�T1G�iQi'1'.��rt.���344-404t- VY1 Buyer Buyer Craig Jones (nawwowner) Address naae1AA- 62 Tx oimexiEl�lziIi€sa-1-s_ Zip Code ar. 4603 Lending Institution Phone Lomas & neddl ton Iff e This transaction closed April 27, 1!183 through Transamerica Ti Address Zip Code Realty Co. & Agent `- Coldwell Banker/Jack White Co. Whitney Ellison Phone 277-1 Address3201 "C" Street, Sit i to 1 00 Zip Code Legal Description Lot ?. Snowline Terrace Street Location Snowline Drive & 115th Ave. Type of Residence Single Single Family Inspector Multiple Family No. of Bedrooms___ ❑ Other Inspector Water Supply / / 40, hR Individual [ax,a /[-X/ ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975. ❑ Community ENVIRONMENTAL PROTECTION For wells drllled prior to that dale, give well depth (attach log if available). ❑ Public Utility b^� Se r Disposal Individual Year Individual Installed:_ I_q.0_l_ [[[]]] Public Ulility When Connected to Public_Utill y: ❑ Holding 'rank RECEIVED (_ ) APPROVED BEDROOMS NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time — TimeI ( ,.I\ni LA"1.7=x u vLo LA °a� . Date Date Date Date — � ) rnoy\ Inspector Inspector Inspector Inspector Field Notes: c a✓'` CEPT. OF HEA LTI I A ENVIRONMENTAL PROTECTION MAY RECEIVED (_ ) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED (` ) CONDITIONAL APPROVAL' DATE BY: Soils Rating Date Sewer Installed Well To Absorption/Area y /Pa Well Log Received / Well to Tank Septic Tank Size ]202](]182) Co. 53 way lo, lqw3 Bc'yd ;111(1 Donna Ualkel.' P. 0. Kox io-243 anchorage, "K 9951.1 Subjects Lot 2, Knowline Wuracc� A,Qroval for the individual sewer and water Cacilitics cannot to granted until the following items have boon completed. A four (d) inch clonnouL needs to he installed to the SOP - 0 ic tank. A four (4) inch cleanout needs to he installed to the Joaching area. please notify this nepartunBL for a roinspocLion Wen t&t noted Oincrepanciels have hoe" corrected. Xf there are any i"rther queuLionB, pleaou cool thio office at 25e-4720. Hincuruly, Roburt C. Pratt AssuciatQ Environmental Specialist RP40/uj/El gf ;rr s1 4tr I SNOW LIN[ r(2rzgr(- `Af- COMMO,J DRWEW ONC LN<nD POWs}stUNF A, P.l, t_. Ne`/y. - Sr Yµ uW f - - NWY14 SPYlF Se YqN wly- 5'2¢ T1LN R3W &M $Z11 Ttln. z,I hereby certify that I have surveyed Lot 21 Snowline f�.Terrace Subdivision, Anchorage, and that the improve— Men ts situated thereon, are within the property lines except as -shown nnddocot overlap oencroach on sp.......9..r.., .4�°.........:�.� .b0the roert1lg aaenitheretoexceptas shown,. that no improvements on property adjacent thereto encroach on the premises in question, p•••••.•....°....•...... r except as shown•, and that there are no roadways, I� •••DOUGLAS A STARK• �, p J,,,transmissionl lines, or other visible easements � '•• 00, N. s�4o. `°•a a'': except as indicated hereon September 24, 1981 /� tonao to tti-� i ii f f>t1 �• r. <- '/ ; r tr3� N 89 °43' 3o'•E L 99. S6 — "i' J•. V, Ler 2 SivowLINC t6/rRAct • - - I o y, 2�•� So w r `Gr S/v l / e� Fll 5�0 R( -A —xJ 89°59 45"F 249.30• �10'0r,Ti r.. <:C ---1 / COMMO,J DRWEW ONC LN<nD POWs}stUNF A, P.l, t_. Ne`/y. - Sr Yµ uW f - - NWY14 SPYlF Se YqN wly- 5'2¢ T1LN R3W &M $Z11 Ttln. z,I hereby certify that I have surveyed Lot 21 Snowline f�.Terrace Subdivision, Anchorage, and that the improve— Men ts situated thereon, are within the property lines except as -shown nnddocot overlap oencroach on sp.......9..r.., .4�°.........:�.� .b0the roert1lg aaenitheretoexceptas shown,. that no improvements on property adjacent thereto encroach on the premises in question, p•••••.•....°....•...... r except as shown•, and that there are no roadways, I� •••DOUGLAS A STARK• �, p J,,,transmissionl lines, or other visible easements � '•• 00, N. s�4o. `°•a a'': except as indicated hereon September 24, 1981 /� tonao to tti-� i ii f f>t1 �• r. <- '/ ; r tr3� I� Time �. Time -- ae — Date - Date Date Inspector — — Inspector Inspector ----- -- Comments -- ------- Conditional Approval Date Sewer Installed `�' Permit No. — Septic Tank Slze-- '-7,_ r Holding Tank Size Solis Rating -- Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property Owner p.,,n �ij /¢- �¢ /I ' Phone r'q Melling Address �. 0, Buyer — ,V7 Address / Lending InstitutionFo U$ --' Phone / Address 7-'GC�z(1�� —011) Realty Co. & Agent T ,a p Phone .�:---- Address Legal Descrlptlon —%yU� ,. .- /1�Oa� /A) E, ,0,ve4af r— v -- fi Street Location Typgyf Residence — Ingle Family ❑ Multiple Family No. of Bedrooms. ❑ Other - - Wateri—Supply ------u— Individual ATTACH WELL LOG, A well log is required for all wells drilled since June ❑ Community 1975. For wells drilled prior to that date, give well depth (attach log if ❑ Public Utill� available.) Sew'aae Disposal ndivldual Year Individual Installed: _ ❑ Public Utility - When Connected to Public Utlllty: ❑ Holding Tank -----`— NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.