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HomeMy WebLinkAboutGOLDEN VIEW HEIGHTS LT 4C2 (Rev 05/02/16) Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSPn1250j PID Number: U20-042-56 Dwelling: A Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name LACY ABSORPTION FIELD ❑■ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 157QQ WIND SONG DR El Other Phone Number of Bedrooms. il.Rating Total. depth. fro original grade 4 1.2 GPD/SFJ 10 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 3 Ft. Gravel depth beneath pipe 7 Ft. Subdivision Block Lot GOLDEN VIEW HEIGHTS LOT 4C2 Fill added above original grade .5 Ft. Gravel length 36 Ft. Township Range Section Gravel width 2 Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Lift Station Tank Line 504. Ft' 1 Ft. Well 100,+1 00+ I �0+ TANK © Septic ElS.T.E.P. ❑ Holding El Other Manufacturer Capacity GREER/ANCH TANK 1250 Gal. Surface water 100'+1 100,+ Material PLASTIC Number of compartments 2 Lot Line 110,+1 1o,+ ' NA Foundation10'+ l 1 0'+ l LIFT STATION Manufacturer Capacity Gal. Remarks TANK DEMO PER UPC, Alarm location Electrical installed by to PIPE MATERIAL House to tank 3034 dTank rainfie ld 3034 Installer MIKE N ANDERSON, P.E. Drainrield 3034 CO/MT3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 101 ft Inspection 8-31-23 `d 9-1-23 Location and description V dates: 2 — TOP OF MANHOLE Td 4,h ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date CE- �4^6 Septic System" Approved Date_;=�: 1 Note: this approval does t include well permit requirements. (Rev 05/02/16) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSC231339, Deb Wockenfuss, 09/15/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSC231339, Deb Wockenfuss, 09/15/23 / �nrene Municipality of Anchorage _ Urpartmenr P.O. Box 196650 ® 4700 Elmore Road Anchorage. Alaska 99519-6650 ® (907) 343-7904 ® Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Division On -Site Water and Wastewater Program * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV231048 COSA#: Permit#:OSP231259 PID#: 020-042-56 Legal Description: GOLDEN VIEW HEIGHTS LT 4C2 Engineer: Mike N. Anderson Your request for a waiver of the required 5 feet horizontal separation from the tank to the absorption field has been approved. The approved separation distance is 2 feet. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. ............................................... ■ ............................. ■ 1 Waiver is Granted: X Waiver is not Granted: Date: q / — Z Approved by: G� Name of Review6V **** VARIAN C E/WAIVER REVIEW **** SEPT. 15, 2023 Municipality of Anchorage Development Services Dept. On-Site Water & Wastewater Section Anchorage, Alaska 99519 Phone 343-7904 Re: 2’ SEPTIC TANK TO FIELD WAIVER Legal: GOLDEN VIEW HEIGHTS LT 4C2 To Whom it may concern: This is a request for a 2-foot waiver between the tank and field. My justification is the bottom of the tank is about 1.5 feet above the bottom of the leach field. The field was installed less than the required 5 feet because of the property line off-set of 10 feet on the south end of the field and the shed, see the site plan. The granting of this waiver will not impact any of the neighbors or affect the system. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSC231339, Deb Wockenfuss, 09/15/23 Lot 4C1 Lot 3A2 O O co UJ M O c0 O O 0 ►i Lot 3A1 N89059'05"E 190.00 M Wen o I Shed N 00 12.3 N Window well .I 49.3 30. 0 1 Story Frame © . ' OF A ' c; House with 4 ' 2.0 `n Basement N r. 18.3O o Ent 32. 0 5.Q deck I L6 '.: I LOT 4C2 C0 N- I 28.0 �- I deck Conc. block I E W C ret. wall I cin O Iw a �r) I o Manhole _�" o I � O a I Septic t -� Wood ret. wall vent p i yp) 0 Z I I 00 00 and do not overlap or encroach on the property lying improvements I 8 / .• izabeth L. Walatko•, ,a / 10' Utility Easement N N89059105"E 190.00 f Shed encroaches 2.3'+ Lot 4C3 :1. 1 RECERTIFIED 9-05-23 �(/U AS -BUILT NO CORNERS SET THIS DATE This drawing is a representation of conditions found at the time the mortgage location survey was performed. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained on this drawing shall not be used to establish any fence. structure or other improvements. This drawing shall only be used for a single property transaction. Use of this drawing by the original client or by others at a later date without the consent of Elizabeth L. Walatka is a violation of Federal Copyright law. Unless gross negligence is discovered, the liability extent of the preparer is limited to the amount of fees collected for services in preparation of this product. OF A ' I hereby certify that I have performed a Mortgagees inspection Aft► .`�,• , • . , • in accordance with ASPLS Standards of the following described property: LOT 4C2, WQ-� 49 th • y , GOLDEN VIEW HEIGHTS SUBDIVISION 00 * 00 Anchorage Recording Precinct, Alaska, and that the • • • • • • •00 improvements situated thereon are within the property lines 00 00 and do not overlap or encroach on the property lying improvements / .• izabeth L. Walatko•, ,a / adjacent thereto, that no on the property lying adjacent thereto encroach on the premises in question and 8036 — LS A. that there are no roadways, transmission lines or other 1— 40' , �Fo • • . •�o .W .SCALE. 1 '°RaF • ' � \.P visible easements on said property except as indicated hereon. Ess�oNA � t Dated at Anchorage, Alaska - this 23rd day of JULY , 1987. EASEMENTS OF RECORD, OTHER THAN / -7" 20-3 THOSE SHOWN ON THE RECORDED FB 22-4, pg 27-28 FRED WALATKA & ASSOCIATES, L.L.C. PLAT ARE NOT SHOWN HEREON Recert 10-06-10, 11-22-22 BEEngineers and Surveyors 907-248-1666 UNLESS OTHERWISE NOTED. LT This drawing is a representation of conditions found at the time the mortgage location survey was performed. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained on this drawing shall not be used to establish any fence. structure or other improvements. This drawing shall only be used for a single property transaction. Use of this drawing by the original client or by others at a later date without the consent of Elizabeth L. Walatka is a violation of Federal Copyright law. Unless gross negligence is discovered, the liability extent of the preparer is limited to the amount of fees collected for services in preparation of this product. MUNICIPALITY OF ANCHORAGE ,V0 nt. On -Site Water & Wastewater Program �o ., _ s�, PO Box 196650 4700 Elmore Road - ' `tj Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 htip://www.muni.org/onsite L)epartment On -Site Wastewater Disposal System Permit Permit Number: OSP231259 Effective Date: 9/1/2023 Work Type: Septic Upgrade Expiration Date: 8/31/2024 Tax Code Number: 02004256000 Site Legal Address: GOLDEN VIEW HEIGHTS LT 4C2 G:3238 Site Mailing Address: 15700 WIND SONG DR, Anchorage Owner: LACY MARK A & LAURIE A Lot Size in Sq Ft: 31350 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 4 This permit is for the construction of: Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall 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 shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: • 7 day groundwater monitoring is required. 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. Date: Issued By: L_ Date: MUMUPAUTiY@FAHCHORAGE z Iz Development Services Department �` Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 020-042-56 Property owner(s) LACY Mailing address 15700 WIND SONG DR Site address SAME Day phone Legal description (Sub'd., Block & Lot) GOLDEN VIEW HEIGHTS LT 4C2 Legal description (Township, Range & Section) Lot Size 31.350 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field 0 Initial ❑ Single Family (SF) El (w/wo ADU) Septic Tank X ❑ Upgrade ❑ (D) ElRenewal Holding Tank E] Renewal❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Z Waiver Fees: Date of Payment:��lSZZ3 Date of Payment: Receipt Number: 0/5110/ Receipt Number: Permit No. DSpz 3I2. ,59 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc August 23, 2023 Municipality of Anchorage Development Services Dept. On-Site Water & Wastewater Section Anchorage, Alaska 99519 Phone 343-7904 Re: Septic permit Legal: GOLDEN VIEW HEIGHTS LT 4C2 To Whom it may concern: This is a request for a septic permit on the above referenced lot. A single test hole was completed which showed SP/GP soils for the entire 19-foot depth, with no water during the excavation. All of the surrounding systems show excellent soils plus this system lasted for over 40 years. A simple gravity flow deep trench system has been designed, see the site plan in the same place as the old trench. The slope at the leach field area is between 15 and 20 percent with no cut banks or open water within 100 feet of the site. This new septic design will not impact any of the surrounding properties. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231259, Deb Wockenfuss, 09/01/23 SEPTIC FIELD SECTION DESIGN CRITERIA: 7' EFFECTIVE 4 BDRM X 150 = 600 GPD SOILS = 600/1.2 = 500 GPD 500 GA/14 = 36 2.0' WIDE 36' LONG (1) TRENCH 11' DEEP 1. 0 ' 2.0' -11 -4.0 MOUND OVER FILTER FABRIC SEWER ROCK ‘3,3( GRADE 1"=200' PROPERTY LINEPROPOSED DRAINAGE FIELD EXISTING HOUSE -W I N D S O N G D R I V E - EXISTING WELL 100' RADIUS SCALE: DJRDRAWN: DATE: GOLDEN VIEW HEIGHTS LOT 4C2 Anchorage, Alaska MARK & LAURIE LACY 8/9/2023 -F E J E S R O A D - -A M B E R W O O D C I R - -E 156TH AVE -WEST CIR- -GOLDEN WOOD LN- SEPTIC SEPTIC 19 (TH#1) 1.0 SP/GP ORG Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231259, Deb Wockenfuss, 09/01/23 1"=50' EXISTING DRAIN FIELD TO BE REPLACE, EXISTING HOUSE EXISTING WELL 100' RADIUS GOLDENVIEW HEIGHTS LOT 4C2 DR I V E W A Y PROPOSED RESERVE FIELD WELL GOLDENVIEW HEIGHTS LOT 4C3 -W I N D S O N G D R I V E - MT SCALE: DJRDRAWN: DATE: GOLDEN VIEW HEIGHTS LOT 4C2 Anchorage, Alaska MARK & LAURIE LACY 8/9/2023 PROPOSED NEW 1,250 GALLON PLASTIC SEPTIC TANK EXISTING RETAINING WALL GOLDENVIEW HEIGHTS LOT 4C2 GOLDENVIEW HEIGHTS LOT 3A2 GOLDENVIEW HEIGHTS LOT L-2 GO L D E N V I E W H E I G H T S LO T 4 C 1 SHED 20% CO CO CO SEPTIC AREA WELL WELL WELL 10' UTILITY EASEMENT SM/GP SOILS W/ NO WATER -16' GM/GP SOILS W/ NO WATER -16' GW SOILS W/ WATER -9' SP SOILS W/ NO WATER -16' MAINTAIN 10' TO DECK SUPPORT, 5' TANK TO FIELD, 10' FIELD TO FIELD 20% 20% vacant lot TH#1 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231259, Deb Wockenfuss, 09/01/23 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Section �r 4700 Elmore St. P.O. Box 196650 Anchorage, AK 99519-6650 (907) 343-7904 Soils Log - Percolation Test Performed For: Laaa. a/ MA""w,�e - f.n Date Perk Legal Description: ro IAN n.n /-A z teJ d-t4tS Township, Range, Section: Slope T �- f.� c Z I -TFT] III MMEN611 6i ISP/ C-� 7- s Lay ,ems 9_ G Lt 11 13- 16- 17- WAS GROUND WATER /O ENCOUNTERED? IF YES- AT WHAT DEPTH4 ` 0 Depth to Water After p Monitaringt F °@ *:*49TH .......... ..... •. ... 1 ! . V • MICHAEL N. ANDERSCN ff,• CEJ9469 PERCOLATION RATE Z. (ndnuteslinc) PERC HOLE DIAMETER r: TEST RUN BETWEEN FT AND 9:7-- FT PERFORMED BY: n-1 NLA, I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:2 8065D Lot 3A2 I Lot 3A1 , Lot 4C1 i N89°59'05"E 190.00 I 1shed¥ we„o i,N. T r w.indeIN wdi I..I.:.`` .-.I I. : ` 2o ; `BEato:u::£e*:lt{Te £.¢'.,.:.Oi ::.h`5.±Ent'8[:ck.32., hLOT4C2r. = i=28.0-.deck;.` Cone. block II!EE ret. wall I % 01 ldi ol Septicvent(typ)/ woodret.Wan I I Ila,- 1=----TbTbtfrit7-E=s;in-e=t---------Err-----J-; N89o59'05:'hEeden:r:aoc.h::23'±r i Lot 4C3 RECERTIFIED 11-22-2 AS-BUILT . Elizabeth L Walatka SCALE: 1"= 40' EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT ARE NOT SHOWN HEREON UNLESS OTHEFtwISE NOTED. iffi;\H.E{.Stol"±€[+:~~~ 8036 - LS F822i4',.pgr7:2gctiz_ Recert 10-06-10 LT 2NfflN)ERssETTHlsDATE I hereby certify that I have performed a Mortgagee's inspection in accordance with ASPLS Standards of the following described property:_ _________LOT 4C2, ___._ _ __ _ _ __ GOLDEN VIEW HEIGHTS SUBDIVISION Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within the property lines ahd do not overlap or encroach on the property lying adjacent thereto, that no improvements on the property lying adjacent thereto enoroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alaska this 23rd dayof JULY ,1987. 907-248-1666 FRED WALATRA & ASSOCIATES, Engineers and Surveyors This drawing is a representation Of conditions found at the time the mortgage location survey was performed, This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose, The information contained on this drawing shall not be used to establish any fence. structure or other improvements. This drawing shall only be used for a single property transaction. Use of this drawing by the original client or by others at a later date without the consent of Elizabeth L. Walatka is a violation of Federal Copyright law. Unless gross negligence is discovered, the liability extent of the preparer is limited to the amount of fees collected for services in preparation of this product, ' NAME MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERINGI}IVISION 825 I.. Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELl_ INSPECTION REPORT DESCRIPTION =~-- ~ ~1 Well ~ [AbsorPtio,~ a[e~ DISTANCE TO' ~ ' ' ( I~,q. capac[Ry~in gallon~ ~ ............ ns de lengtl /~'~ wd~ ~ ~, ~ Foundation J DISTANCE TO: J ~ ~ I No, o,lines J [ Le,lgtll~ ~hl~mn' _ e Tota~l~l~ Ii'les I Top of t la to finish g~ade ~ M~e~al )~$~t le [ Type of crib Crib diameter Crib~ ~ ~ Well Buildingfoundation ~ DISTANCE TO: Dwelling Width Materia~ inches PERMIT NO. Liquid capacity ill gallons PER: , To~e.c~i~ze a~s~rptio~-~ area Total effective absorption area Nearest lot [Pile Distance to lot line PERMIT NO. Soptic tank Absorption area(s) OTHER PiPE MATERIALS _ SO,LT S,'.A ,.O REMARKS DATE LEGAL fizz< ' ~y c').,V MUNICtP>,LITY OF ANCHORAGE I)EP[. OF HE/',LTH & ENVIRQNMEN [AL PROTECTION J~O',J 2 'fj84 F'ERHIT NO, D E:¥:'la R T I'fl [:.:i I",t '1" HEFtL. TH AND ',F.",25 '" L '" E;'I'F~'.EE'f'., lat'.,lCHCIF~'.laGE., I::IK. ~.-fr t[~-: L.L... E:-:~ l"..,,~ !E:, Cn ~'-,a ...... E[~; 3t: "-i- E!E ?EF..'; E: P,i EE: Il:Z: ,:: 8:1. L:.32 d.).~: .':, t::ll::' F' L. I C: la N 1' L 0 C FI T I 0 N [.., E L-:i FIL. L. OT E;IZE FEET 'I"'T'F'E OF L:';OIL~ RE:SEIF4:F:'TIEIN S"r'?,TEH IS: TRENCH r,lR::.::Zr,lUr,1 I'.,II..IP1E:EFi: OF EE[',[~'EI'.)I"'IL=; .... :.: :.~;OIL F:'.la'T'II"~G ('?'.:.! F.]",.'"E:R)= THE: F.':EL.-.!I..IIF::FZr.':, :,].,~E. C~F' ' ,-ri' ~ ,,~'q", ' F~ ""'"-'~ ...... FI-'tE ::,_.fL. PIE, E;E~kFTI_N :, t :,'] [:.PI "'. I~ ..........-~ L_ E: lb,il ~ -t"" F-~l === ~, ~:~~~ ~." !~ ",,,." IE k.. [Z::, E~.'. fr':::' ~- ~'-'1! THE L. ENGTH DIt"'tENSIOI",! IE; THE LENG'i"FI ,::II",! FEET:." OF TFIE 'f'r4!Ef",IC:H OR E:,[qrF:IINFIEL. r?,. THE I)EF"f'H OF FI TRENCH OR F'];q" :[:.5 ]",LIE: DI:-3TFINE:E BETI.,JEEN THE ::SUF.:FlaCE OF .]"FIE GREIUI'4[:, FIN::, THE E',OT'TOf'I OF" THE: E::.::CFI',,,'FtTION ,:: IN FEET). THEF.:E Z':!; IqO SET I.,.I_f[::,'TI--I F'Of-:': TF.:EIqC:HES. THE GF. rFI',,,'EL [)EF'TH I5 THE I"IINIHL.IH DEF'TH OF GRFI',,,'EL BETI.,.tEEN THE OUTFFILL F'IF'E Rt.,tD TFIE BOTTOI"I OF THE E',:.,:Cla',,,'FITION ,::IN F'EET.':,. F'ERr,t]: T RF."F'L I Clal'.(f' FiRS TFIE RE%PONS ].' B I L. Z T'¢ TO ];. NF:Ol~ff'l TH Z S DEF'FI[~'.THENT DUF..' Z b,lG THE .'[.i'.,l%TF1L. I._laTICIl'-~ ZNtSF'ECTIONS OF RN'.r' HELL:E; R£:,.YRCENT TO THIS F'ROPERT"r' FIND 'rPIE t'.,II..Ir,'IBE[~: OF RE% .~ [:,ENC:EE; THFIT 'rile HELL. I.,I 1' L.L E;EF,",,,'E. E:FIE:KF I L.L I IqG OF RN"r' S"r'STEf'I N I THOUT F' I NlaL I N'.E;F'EE:]"I ON Rl',lr.:, FIPPROVlaL E?¢ TH:: S [:,EF'FIRTHENT 1.4IL. L BE E;IJB..!EC:T TO F'F:.:C)SEE:I..rTION. MIN:[I',IUFI DISTFINCE BE'r!-,.IEEi'.,! F:l t.,.IEL. L. RI'K:, FIF,l"r' OI",I'"'L:,,ITE SEI.,JlaGE [:,I2;POL:;lal_. S¥S'FEH ::LEICI FEET FOR la F'F.:I',,,'FITE: NEL. L. OR '.l.5CI l"O 2EIEI FEE:']" FF;'.Ol'"l Ft F'UE:L..IC klEI...L. L':'EF'ENDING UPON THE T'¢F'E OF F'UBLIC FIINIPIUP1 [:'ISTlaI",ICE FF..'OH R F'RIVFITE NEL. L. "f'O la PRI',,,'r-:ITE :5E:t.,.fER L.]:NE I:E;, 25 FE:ET FINC, TO ]':1 COHP1LfN:[T"r' !5EI.4ER LINE ]:L:'; 75 FEET. t.,.IEI_L LE,3$ Flfq:IE REL.-.!UIF?.ED I::II",ID klUS"I" BE F?.ETIJ[;'.NIED TO TH[E 13, EF'RRTr,IENT I.,.IITHIN Cfi:' .]'HE NELL. COHP[..ETZON. 0'1"HEr4: F::E6'!U I f~:EI','IE:'.NT:.:.'; HR'~.' FIF'F'LY. E;F-"EC: I F I CRT' ]: R'v'FtILFIBL. E 'T'O INSURE PROPER IIqS;I"RL.I_RTII31'4. :[ E:EF::TIF'.r' THFIT ::L: I Ri"1 FFIHILIRR NI'f'H THE: RE:6!LIIREf,IEH'r'z"-; FOF.: ON-~.'3ITE SEI,.tEF.:S FIN:) N[:.:.L..LS FI:E;, E;ET FOF..'TH B'./ 'THE HUNICIF'laLIT'¢ OF RNCHEtRlaGE. 2: I I.,.IILL INE;TFILL THE S"r'STEP1 IN F:ICCO[,:".DFINCE klITH THE E:O.F;,ES. :~:: I IJNDE[~::E;TFIN[':, THFtT THE Of',I-'S]:TE SEI-,~EF.". ~;'¢E;TEf'I r"tla'¢ F.:EQLtIF:':E ENLlaf;::GE[P1EN'T' IF THE REE; I DENCE I E; REt"IO[:,ELE[:, 'r'Q I NE:I...LIDE I',IOE'.E -f'l*.llaN 4 E~E;[:,ROOhlS. S I GNE[';,: iIF'P[.. I CFINT ,.)' l P1 !? ~9 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 020-042-56 Legal description GOLDEN VIEW HEIGHTS LT 4C2 Site address 15700 WIND SONG DR Expiration Date: Current property owner(s) HILL TRAVIS EVIN & JOY LYNN X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for Comments or advisories: By: _ 4LA ",y 12/15/2023 bedrooms, with the following stipulations: Original Certificate Date: 9/15/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist Absorption Field Advisory Tank Age Advisory Other X Well Flow Advisory Nitrate Advisory Arsenic Advisory COSA Approval_June 2022 MUNICIPALITY I� Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1N 1. GENERAL INFORMATION Parcel I.D. 020-042-56 Complete legal description GOLDEN VIEW HEIGHTS LT 4C2 Location (site address) 15700 WIND SONG DR ANCH AK Current property owner(s) LACY 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑■ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel X Plastic ❑ Concrete ❑ Fiberglass Age NEW - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed 0 Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑■ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ s o Waiver Fee $ G� Date of Payment Date of Payment COSA # CSS 2- 3 / 3 3 Waiver # COSA Application_June 2022 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSC231339, Deb Wockenfuss, 09/15/23 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & FIUMAN SERVICFS Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 1. GENERAL INFORMATION Complete legal description Lot 4-C2; Golden View Heights Subdivision Location (site address or directions) ] 5Z.QO N'ind Song D~"i.ve, Ancho~'agez Alaska Property owner Joe Roseman Day phone 345-4593 Mailing address P.O. Box 111320, Anchorage, Alaska 99511 Lending agency Mailing address Day phone Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WA'I'ER SUPPLY: individual well ~ Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOAII21 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/orwastewaterdisposalsystem is safe, functional and adequate for the number of bedrooms and type ofstructureindicated herein, lfurtherverifythat 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. 5 & 5 ~NGiNEEEING Name of Firm w~tt,4 Eagie ~,iYei* Loop Road NO, 204 Phone Address Eagle River, Alaska 99-~77 Engineer's signature Date DHHS SIGNATURE /~'- Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Ld)'~, ¢ -C2._ ,C"¢2:~,~)~J~.) Ut~JcJParce, I.D. ADEC water system number %C..,Lp,.)~ J?~l Driller Cased to ~;~ ~/' Casing height Wires properly protected (Y/N) A, WELL DATA Well type ~l~-I6)f°PTf~- If A, B, or C, attach ADEC letter. Log present (~N) V~-----------------~SDate completed Total depth ~ ~_ r Sanitary seal (Y~) ~'/~ Date of test Static water level Welt flow Pump level FROM WELL LOG g.p.m. AT INSF'ECTION ¢_¢ ~ MUNICIPALITY OF ANCHORAGE J (_~_ c:~ _ -- i:lq~IRONMENTAL SERVICES DIVISION OCT ~" ~:> g.p.m. RECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot IO~ Absorption field on lot Public sewer main _)'2J//4 Sewer service line /~-J/~' ; On adjacent lots ; On adjacent lots [00 Public sewer manhole/cleanout J'"J//~ Petroleum tank __ ,~CAJ .F_ WATER SAMPLE RESULTS: Coliform ~ Date of sample: JC) J~/c~ 2 Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed -'~-2-~X'~ ~ Cleanouts (Y/N) water alarm (Y~.~ High Date of pumping Tank size /000 ~'-~(--- Compartments Foundation cleanout Y~N) ~/~ _ Depression (Y/~ ,/~J/P~ _Alarm tested (Y/~_.)~_ Pumper_ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot [ (")~ On adjacent lots To property line c~L~ ~4- Absorption field Surface water/drainage [(-~ ~- Foundation Water main/service line 72 026 (Rev. 7/91) Front CONTINUED ON BACK PAGE Vent(Y/N) -~ ~~P~-~ve, at High water alarm level ~ Cycles tested ___ Meets MOA electr~__ ~ ~?~--GfSTANCE FROM LiFT STATION TO: ~¢-on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA '~-'~--(~ [ Soil rating Date installed Length o~-c~ Width Total absorption area Depression over field (Y/~) Results (pass/fail) Peroxide treatment (past 12 months) (Y/(~ Gravel thickness ~ / Total depth Cleanouts present (~N) Y~-~ Date of adequacy test //O/~//~'~ for ,~'~ /~O'~ ~tk~O¢cr~ If yes, give date /'J/,/) bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot To building foundation On adjacent lots '~ Surface water Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection, Signature Engineer's Name Date ;; ,. $ ENGINEERING ] ?',)34 ;~agle River Loop ROaC] '- ............ , ......... 9577 HAA Fee $:~, ! '7 _~t~), Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES OF ON-SiTE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) L. oT ¢ /; Location (address or directions} . · (b) Property Owner/Sf~ 5.7; NCOU,¢.,/ ~ Telephone: Home Mailing Address " '~"" Business (c) Lending iqstitution " Telephone Mailing Address ..... - · ", (d) Real Estate Company'and'Agent, Address ~'/~/'~-/~z- E~) Telephone __ ,_~ V¢'-¢G (e) Mail the HAA to the followina address: or; Check here old for pick up. List contact perso..n &nd. day p.hone number below, TYPE OF RESIDENCE Single-Family'~ Number of Bedrooms .¢ WATER SUPPLY Individual Well~' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attestin9 to the legality and status. SEWAGE DISPOSAL Onsite~/ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 fRev 8/861 Front 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 waetewater 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 /~-~L" ~' (/'V'~" . Telephone ~---~"//'-- ~O FO Address t ;~,-(:::E~ IA/ .~/"~-f~ (~'-LZ,'f'~' ('? Date ~//~/~ 7 DHHS APPROVAL Approved Disapproved ConOitional Terms of Conditional Approval 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 fRev 8/861 Back 1¥ OF ANCHOTAGE MuN~ct?ALI ~,-~.',/tcEs otVIsI~NICIPALITY OF ANCHORAGE (MOA) ~NV ~ON~N HEALTH AUTHORITY APPROVAL (HAA) C~ ECKL ST- FEBRUARY 1984 ~U~ ~ 0 ~9~? 264-4744 WELL DATA Well Classification Well Log Present(~N) Total Depth ~¢- ~zl Cased to Static Water Level ;~-~ / Casing Height Above Ground Electrical Wiring in Conduit (~N) Separation Distances from Well: To Septic/Holding Tank on Lot [ (~.~' / To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results (./~T -~- If A, B, C, D.E.C. Approved (Y/N) Date Completed ~.'[--~LA/~/~' 17¢/ . Yield ~f ) ~' Depth of Grouting Pump Set At Sanitary Seal on Casing ~)/N) Depression Around Wellhead (Y/~) ; On Adjoining Lots {~0 I On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot __./'V'//~ ; Date '~'/~' Y Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes(~N) Depression over 'rank (Y/~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarmriy/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well / (~ ~' i Size Air-tight CapsO/N) No. of Compartments Foundation Cleanout/~?N) Date Last Pumped _ 6"'~' ;for Temporary Holding Tank Permit (Y/N) To ProPerty Line To Water Main/Service Lfne ~'~- ~' / -/- Comments To Building Foundation bb-¢ / To Disposal Field __~'~ / f ~'''~ To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72 026 IRev 8/861 Fronl C. ABSORPTION FIELD DATA Square Feet of Absorption Area Depression over Field (Y/¢ Results of Last Adequacy Test Soils Rating in Absorption Strata Date Installed ~/t/ ¢'/~"'/ Length of Field '~ Width of Field '~'/ F/~,~? /q..S'~2, Depth of Field [/ Gravel Bed Thickness '~Z ~ ~ ~' F./:~,~.¢ ,.t¢¢ Standpipes PresentON Date of Last Adequacy Test ~A\TI 5 F~c Separation Distance from Absorption Field: 12. o ' Type of System Design To Water-Supply Well To Building Foundation Lot ,/~J///Jr To Water Main/Service Line /~//~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Corn merits To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) /t//~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Man. ess {Y/N) ~...-¢'~Pump Off" Level at ~r~ua~'- Vent (Y/N) / Pumping Cycles cy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Date Company MOA NO1 Date of Payment ~/~ ~ MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF KE~TH AND ENVIRONMENTAL PROTECTION APPLICATION FOR ~ALTH AUTHORITY AJPPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block~ subdivision, section, township, range) ' directions) ~ Location (address or ~~ (b) Applicants Name ~--~---'1 V~ ~,Te].e~hone - Home Business Applicants Address (c)Applicant is (check one)Lending Institution ~---[ ; Owner/builder Buyer ~ ; Other ~ (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address (f) Telephone Mail the HAA to the fo].lowing address: 2. T~e of Residence Single-Family ~p Multi-Family ~--~ Other (describe) Number of Bedrooms ___~_ 3. Water Supp]zX Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Di_jj_posal Onsite~ Public ~ Community F--~ 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] 5. Engineerin$ Firm Providin~ Inspections, Tests~ File Searc_h~, 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 M~nicipality of Anchorage files and from my investigation and inspection, the on-site ~.rater supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firmt ~'.~3~ ~ (~5 Telephone ~-~,~p -- DHEP A roval ,,'/ z~,., ,~.~,~ o , , Approved ~ Disappro _d ,,~;,~ ,,,:,.~.~, '~'Condition 1 Terms of Conditional Approval CAUT I 0 N THE MUNICIPALITY OF ANCHORAGE DEPARTbIENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY JOPPROVAL CERTIFICATES BASED SOLELY UPON TIlE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. T~iE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. TIlE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19--84 A® Well Classification Well Log P~esent (_Y/N) Total Depth ~7 ' Card to Static Water ~1 Casing ~ight ~ Gr~nd ~" ML~qICIPALITY OF ANCHORAGE (MOA) HEALTH AU~ORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 LegaI Description: Electrical Wiring in Conduit (Y/N) h~ . Separation Distances from Well: To Septic/Holding Tank on Lot I O4~ / To Nearest Edge, of Absorption Field on Lot To Nearest Public Se~w~,.r Line %d/~ I,iL!NICIP/fi,i'i'Y O? Df!Pl', OF l'tOV 2 !984 If A, B, o~ C, D.E.C. Approved(Y/N) Date Co~%31eted '_~r~ IT ~ I. Yield ~ Depth of G~outing Pump Set At Sanitary Seal on Casing (Y/N) Depression A~ound Wellhead (Y/N) [orb · ; (hi Adjoining Lots ~)O.'-~7% I~0~'' ; On Adjoining Lots. To Nearest Public Sewer Cleancut/Manhole. D/(% To Nearest Sewe~ Service Line on Lot Water Sample Collected By -~ ¢'.q(.~.-. Date {rD ~.~,~ Water Sample Test. ,, .Results .__~$~6cTo¢ C~ments ': S IC/HOLDIm raTA Date Installed ¢~ ./t e/~ ! Size ~ em%- Standpipes (Y/bi) g~-__~ Air-tight Caps (Y/N)~--~ Depression ove~. Tank (Y/N) %_30 Date Last Pumped . Pumping/Maintenanoe Contract cfi File (Y/N)M/~- ; fo~ Holding Tank High-Water Alarml (Y/N.)~4/F~ .Temporary Holding Tank Permit (Y/N)B_/~___ Separation Distances f~om Septie/llolding Tank: To Water-Supply We 11 ~ (~ ~/ To P~operty nir~ _ ,~' ~ ~. To Water Main/Service Line ~,.~ -t'-- No. of C(~a~tn~nts ~ Foundation Cleanout (Y/N)y~-~.~ To Building Foundation '2~--¢) / To Disposal Field ~ To Stream, Pond, Lake, c~ Major Dr, ainage Conmsnts [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 6~.~3 ~ Type of System Design Date Installed ?/' ~ /~l (~"~ ' Length of Field ~ ! Grail ~d Thick.ss ~ ~ S~e Feet of ~so~ption ~ea '~ %~Stan~i~s ~esent (Y~) Results of ~st A~qua~ ~st Separation Distan~ f~ ~so~ption Field: To ~te~-Supply ~11 ~ ~'~-~ / To Building Foundation , 7~.~ To Existing or ~ndo~d System To Wate~ Main/~vi~ Line ~i /~ T© ~t~(if pre~nt) TO Stre~ond~ke/~ Majo= ~aina~ C~se To ~iveway, Parki~ ~ea, ~ Vehicle Sto~a~ ~ea ~ ~' Con~nts D. LIFT STATION Date Installed ~,Di~nsions /' Size in Gallons ............ Manhole/Access (Y/N) ~ "tka,~ On" Level at ~,.- ....... "~ ~f" ~vel at / High Water ~ ~1 at ....... / Vent (Y~) / Tested fo~ ...,/ ~ing s ~i ~st. ~ets ~A Electrical Co~s (,Y~) Co~i~'~nts / ** Check Pe=mitted Becl~oom Rating Against HAA Request I certify that I have checked, verified, o~ conformed. . to all MOA HAA~,~i'i?,%; f~' ~S~ in effect on the date of this~.i~spec~ion. /-'i "j~;,. , Slued -~ g~ Date /b ~- ~9. "f%Ift~ / %"~ ~'. KB1/d5/s ~%o C~- $g16 2-15-84 ~" 5, ,;' RECEIVED INSPFCTION APPOINTMENTS ~NSPECTOR INSPECTOR, ~ ~ -~ '~ ' INSF ECTOR MUNICIPALITY OF ANCHORAGE ~UNICIPALITY OF ANCHORAGE DEPT. OF ~:RLNI &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~vIRONMENT,~,L ~ ;.~.'~ECTION 825 L Street - Anchorege, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION ~'~P ~ ~ ~]~'~ Telephone 264-4720 N VIDUALWATER AN REQUEST FOR APPROVAL OF I DI DS DIRECTIONS; Complete all parts on page 1, Incomplete requests will not be processed. Please allow ten (10) days for processing. 1, PROPERTY OWNER ~' ~ ~ ~ ' I~HONE PROPERTY RESIDZ~If different fr~n above)' 2, BUYBR --' PHONE 1NSTI TUTION , PHONE MAILING ADDRESS 4, REALTOR/AGENT ] PHONE STREET LOCATION B, TYPE OF RESIDENCE [~],"~SING LE F:AMI I_Y [] MULTIPLE FAMILY NUMBER OF BEDROOMS E] One [] Four [~ Other E] T~v~o El F:ive I~]/~h ree El Six 7, WATER SUP~LY ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM I~1N DI VI DUAL/ON-SIT E** [] PUBLIC UTI LI'TY ATTACH WELL LOG. Awell log is required for all wells drilled since June 1975. For wells drilled prior to ~hat date, 9iv~e well /] depth (attach log if available,) O.,,~C///~gj. ~ ~ NOTE: THE NSPECTION FEE I~1UST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [~] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVI DUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line I~ APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (Better must accompany certificate) [] DISAPPROVED DATE BY