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Home My WebLink AboutFREEMAN LT 12Freeman Lot 12 #016�112�09 Permit Number:. SW020233 Max Conn 11430 Hawkins Lane · - 522-5424 Municipality of Anchorage Development Services Department Building Safety Division On-~te Water and Wastewater program, 4700 S. Bragaw St. P.O. Box 196650 Anchorage, AK 99519-66~0 www.d.anchomge.ak.us (907) 3437904 Page of ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PID Number:. 016-112-09 WastewaterSystem: []New [] Upgrade LEGAL DESCRIPTION 12 Freeman [] New [] Upgrade SEPARATION DISTANCES ABSORPTION FIELD 1.2 ~ 16.5 ~. 12.5 - 13.0 ~, 3.5 1.0 ~, ~ ;~. 5.0 ~. 463 ~ D2751 1D30~ Naska Divem 7~7~2 TANK ~ptic ~H~i~ ~S.T.E.P. Septic Abso~lJon ~ Holding Tank Field Stat~ Tank w,~ 60 108 NA NA ~-~w,~ None None NA NA ~u~ 70 35 NA NA ~,~=,, 25 75 NA NA c.~,,~ o,~ None No~e NA NA ~""': Existing (1960) concrete septic tank was partially exposed and found to be in good condition. Trench was moved toward the south and extend. ed due to soil conditions. Se~rUne Unknow~ I 1000 cd. NA Concrete 1 BENCH MARK Northwest comer of concrete step at back door to garage. 1 00.0~ Engineer's Stamp Inspecfions performed by: CindyW. Ellis, P.E. Dates: 1' Development Services Department~ ~Y Reviewed and approved by; ~:~~/[Z ~"ate: ' -- ..... Permit No. SW020233 Poge 2 of 2 Municipolity of Anchoroge DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchoroge, Alosko 99519-6650 Telephone: 343-4744 On-Site Wostewoter Disposol System ond/or Well Inspection Report Legol Description: LOT 12, FREEMAN SUBDIVISION F PID No.: 016-112-09 LOT 13 /.,/~/~ TIC TANK COl~--- ~-, ~2 BDR~ MOUSE '~ ___ / ~/ A~ I ~ C02~ y I ~ LOT 12 / 30' TEST MOLE/ 'X LOT 11 / ~IUS - ~ ~ / / 100' W~ ~IUS x / SCALE: 1":50' MARK A B OCOI 58.0 28.3 ST 66.5 29.0 DC02 72.8 33.3 BV 73.7 33,8 D¢03 101.0 55,0 CR~B 105.7 75,3 C01 95.9 92.2 MT1 95,9 94.4 C02 83,4 108.1 faT2 83.7 106.6 MUNICIPALITY OF ANCHORAGE Development Sen/ices Depa~nent On-Site Water & Waslewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Jul 18, 2002 Expiration Date: Jul 18, 2003 Permit Number: SW020233 Legal Description: FREEMAN LT 12 Design Engineer. 0844 Watkins Engineering, Inc Owner Name: max corm Owner Address: 8034 queen victoria dr anchorage, AK 99501- Parcel ID: 016-112-09 Site Address: 011430 HAWKINS LN Lot Size: 48167 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage Ail construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either. A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 ON-SITE SEWER/VVELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING O Parcel I.D. 016-112-09 Permit Number SW Property owner(s) Max Conn, Attorney in Fact for J.V. & Ruby Conn Mailing address (1) 8o34 Queen Victoria Drive Mailing address (2) Anchorage. AK Legal description (Lot, Block & Sub'd.) Freeman S/D Lot 12 Legal description (Section, Township & Range) Lot Size 1.10 acres Day phone 522-5424 Zip Code 99518 Acres/Sq.Ft. Number of Bedrooms 3 THIS APPLICATION IS FOR: Sewer Only [] Well Only [] Sewer and Well [] Water Storage [] Sewer Upgrade [] THIS PROPERTY CONTAINS: Hot Tub [] Jacuzzi [] Swimming Pool [] Water Softening Unit [] Therapy Pool [] I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and Is in accordance with applicable Municipal Codes. (Sig,,o,,~,= ~,f property owner or au odze Permit Fees: Date of Payment: Receipt Number. (p z.z_cf 3~O (~1~, (Rev. 12~00) Waiver Fees: Date of Payment: Receipt Number:. Watkins Engineering, Inc. P.O Box 110443, Anchorage, AK 99511 (907)349-1851 cwellis@gcLnet July 18, 2002 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 RE: Freeman S/D Lot 12 Subsurface Disposal Field Upgrade To Whom It May Concern: Attached please find the application and supporting documentation for upgrading the subsurface disposal field for the referenced 3 bedroom house. This house was built in 1959 and the initial septic system installed in 1960 with a 1000 gallon concrete septic tank and a cesspool. The cesspool was abandoned in 1968 and a log crib installed. The cdb was recently tested in conjunction with the sale of the property, and it accepted only 80 gallons of water per day. Thus, it is proposed to install a new absorption field. The existing septic tank is proposed to be used, since it is concrete and believed to be in good condition. The tank is 58 ft from the well, which was acceptable when it was installed in 1960. It is also proposed to keep the crib as a reserve system. It was originally approved for a 3 bedroom house. Two test holes were dug to a total depth of 20.5 ft, the limit of the excavator. There was 11.5 ft of unclean fill dirt in Test Hole (TH) #1 and 11.0 ft in TH#2. A one-foot layer of organics was below the fill, with one foot of light brown silty sand (SM) below it. From there to the bottom of the hole was clean black sand (SP). No water was encountered when the THs were dug or 7 days later. We request that the proposed drainfield have a maximum depth of 16.5 ft, or 4 ft above the bottom of the TH, which will ensure a 4 ft separation to groundwater. We believe that this would not violate the requirement of 6 ft from impermeable soils, since there is no shallow bedrock in the area. This can be confirmed by an adjacent well log which shows gravel and silt to a depth of 121 ft. Soil logs from adjacent lots also penetrated 13.5 ft and 14.5 ft below the organics. A percolation test was run on TH#2 from the surface through a 4 inch perforated pipe, with the bottom at 13.3 ft. This spanned the SM and SP matedaL The pipe was filled with 6 inches of water, which was vedfied by a color-changing paste. After 10 minutes, the water level was measured. After 1 hour of monitoring, the sustained percolation rate was determined to be 3.1 minutes per inch. The proposed design is based upon this rate. Sewer Upgrade Permit Application for Freeman $/D Lot 12 Watkins Engr, /nc.; July 18, 2002; page 2 Proposed Design: 3 Bedrooms x 150 GPD/BR = 450 GPD 450 GPD / 1.2 GPD/square ft = 375 sq. ft required System Type: Shallow trench (5-wide) Maximum Depth: 16.5 ft Effective Depth: 3.5 ft Length Required: 375 sq. ft / 5 ft x 0.54 (Reduction Factor) = 40.5 ft Proposed Length: 42 ft. Separation to well: 100 ft + I am not aware of any adverse effect that this upgrade would have on any adjacent properties' water and wastewater treatment needs. Thank you for consideration of this permit application. If you have any questions or need further information, please call me at 349-1851 or 360-3389 (cell). Yours truly, Cc: Max Conn Attachments: Permit Application & Fee Site Plan, 100 scale Proposed Upgrade Plan, 30-scale Soils Log and Perc Test (2 THs) Well log from Lot 7 Soils Logs from Lots 8 & 13 DESIGN CRITERIA: 3 BDRM X 150 -- 450 GPD SOILS = 450/1.2 = 375 SO FI' REQ'D 375/5 x (0.54) = 40.5' TRENCH: 16.5' DEEP 3.5' EFFECTIVE 5.0' WIDE 42' LONG (TNl2) FILL - 1 1.0 -12.0 OR -13.0 SM SP -20.5 __ /-EXISTING WELL 100' RADIUS , t> -MONA AVENUE- EXISTING HOUSE~-- [XI~ING SEPTIC T~K~ ~ EXISTING WELL · ~MOUND OVER 'o. ~ /f-GRADE ,,~...--- FILTER FABRIC -MONA AVENUE- -KLATT ROAD- I I [ SepticDesignPreporedFOrMAX CONN . ~....~.F_..~ FREEMAN SUBDIVISION Prepored By:. · · . Watk,ns En ,neer, Inc.DATE. 7/18/02 . SCALE' 1 "= 100' Ci Cindy W. Ellis, P.E., M.S. ' ~... cE.~os~ ...~ P.O. BOX 11044~ D~WN: DdR ANCHO~GE, A~S~ 9951t-044~ CHECKED: CWE PHONE: (907) 349-1851; FAX: (907) 349-1934 EXISTING WELL '-~._ 100' RADIUS~ ............ UTILITY DLSEMEN! LOT 15 EXISTING LOG CRIB TO RE~N~ ~ '~ ./, -'" ~-EXISTING TEST HOLE IdT ~"~' PROPOSEO SE{'nC ~4, S~TEU~ ; DOUBLE C.O. """" .... TH~ 1 ~',, JJ ~ t~'"'--30' TEST HOLE ~ ~ P-,~iuS - TYP EXISTI,NC WELL/Xx 100 RADIUS~ x -- EXISTING 2 BDRU HOUSE..~ LOT 12 LOT I1 % % % Prepared By: Septic Design Prepared For MAX CONN LOT 1 2 FREEMAN SUBDIVISION Watkins Engineering, Inc. DATE: SCALE: Cindy W. Ellis, P.E., M.S. P.O. BOX 110443 DRAWN: ANCHORAGE, ALASKA 99511-0443 CHECKED: PHONE: (907) 349-1851; FAX: (907) .349-1934 Per,on'ned For:, Legal Descflption: Dep~ (Feet) 1- 2- 10- Municipality Of Anchorage Development Services Department Suilding ,Safety DMslon On-~ite Water and Wastewater Program 4700 South Bregaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.rnunLorg/onstte (907) 343-7904 Soils Log - Percolation Test $lape Date Per~ommd: Tovmship, Range, Section: Site Plan F':I. LL F b A--r 12- Or~ or~ O.e. iC-s J2,5 ~- 5~ biflhr brough ~8- eo- ~ ,5 COMMENTS WAS GROUND WATER ENCOUNTERED? NO IF YES. AT W~AT DEPTH? L ..,.: Reading Date Gross 13me Net Time Depth to Water Net Drop PERCOI.ATION RATE (.Inut.e'n*) PERC HOlE DIAMETER TEST RUN B E'I%'VEEN FT AND FT PERFORMED BY: ~/~'~[ ~'). ~/~i ~b ' ~/~/"~'/~.'.~ERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WI~H ALL STATE AND MUNICIPAL GUIDELINE~N EFFECT ON THIS DATE. DATE: Perforated Fo~:. LegM ~scdption: Depth (Feet) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Sou~h Bragaw St. P.O. Box 196650 Anchorage. AK 99519-6650 vAvw.muN.org/onslte (907) 343-7904 Soils Log Fr~ar~ L~~r - Percolation Test Date perforated: Township. Range, Section: S~pe Site Plan ~N 3- ¢7~LL ?. 8- 17- 18- 19- 2e ~ ,G F L~ WA~ GROUND WATF. R E.COU.~.EO? N0 IF YES, AT WHAT DEPTH? L 0 Del~h to Water After FLAT Reading Date Gross Time Net Time Depth to Water Net Drop I '7- Ii- O2- 2.: I"g O ~o" ~ · , TESTRUNBEl16~EN 12,~ FT /~O 13,'~ FT PE.FO.MED..: i F---IhS, P.E., D/l,s ~ECERTIFYTHATTHISTESTWAS PERFORMED IN ACCORDANCE ~NITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Well · ~.- ..._ ,/_ *,~,,~"' Size of ca~mg....~...~.~.~_.n~...~,,~f.. ....................... ..,...: ..... ~.~ .............. . - . ~ .... ~ .... :~-WECEWE ........... D~t~ce to water w~le p~p~~~.~.~..at rate .,V '~ 7 - ~1° 7 °"~ ' 9 DriUer ~, :17- I~49 ~O~.q. $ DELTA DRILLING COMPANY SRA BOXY394 B MUNICIPALITY OF ANCHORAGE · .DEPARTMENT OF HEALTH AND ENVIRONMENTAl- i)ROTECTION %~ ~2S L. St~Nt. AJ~.h~og*, Alamo ~$01 264-4?20 SOILS LOG -- PERCOLATION TEST PERCOLATION 12- 13- 15 16- 19- WAS GROUND WATER e L 0 · £RCOLATiON RATE TEST RUN .£TWEEN COMM£NTS r~- ~1~ ~. / 8 I1- "l o ENCOUNTERED7 IF ¥£$. AT DATE PERFORMED: /~/ E 0 TE~ RUN BE~EEN ~ FT AND ~ . unicipality of Anchorage Deveiopn~ent Services Department Building Safety Divi,=ion On-Site Water and Wastewater Program 4700 South .~ragaw SL P.O. Box 196650 Anchorage, AK 99519-6050 wvw.d, ancnora9e.ak.us (907) 343-7904 CERTIFICATE OF H= ,LTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ParcelI.D. O/b- //Z-Oq Expiration Date: 1. GENERAL INFORMATION Complete legal description ~'F ~_E 1,14 ~ rt ~.Location (site address or directions) Current Property owner(s) ~ ~.~, Mailing address L~nding agency Mailing address . Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: -~ 3. TYPE OF WATER SUPPLY: ' Individual Well J~] Individual Water Storage r-J Community Class ~ Well [] Public Water System [] TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding tank [] Community On-site [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representsficns given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. CertJflc.~tes of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates ma,,/be reissued for a pedod of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public w3ter system. The Municipality of Anchorage is not responsible fcr errors cr omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified b~ye,m.y seal affixed hereto and as of the validation date shown below, I verify that my investigaticn, based on pr.~:~ures outlined in the Health Authority Approval Guidelines for this application, shows that the site wate~st~'lSly'and/or wastewater disposal system is(are) safe, functional and adequate for the number cf bedrooms and type of structure indicated herein. I further vedfy that based on the information obtained from the Municipalit7 cf Anchorage flies 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, ~ar~d regulations in effect at the time of installation. Phone ~;~q- 1~51 N~me of Firm [/k)gT'/¥~JY/~' ~]/,j~gF'j/'~') ~YlC, Address ?O ~ I10~ '1~'~.~', t~J~ ~j~j~ll Engineefs Pdnted Name ~j/4.~ /A J, E/lib DSD SIGNATURE ~ Approved for ,-~ Disapproved. Conditional approval for Date bedrooms. bedrcoms, with the following stipulations: Additional Comments .' ..... .. ~':' ON-SITE : . WASTEWATER . - ~ .. FROC~M · '~2<o~ ...... ~5~& Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Odginal Certificate Date: Munic~PMitY of Anchorage DevelOpmenton~eeu,d~O wa=Services & safety Wastewater Division Department' Program 4700 South Bmgaw St. P.O. Sox 196650 Anchorage, AK 99519-6650 www.d.anchomge.ak, us (0o7) 343-70o4 Legal Descd~on: HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Date completed lqt~O Toteldep~ 24~2.- ~. If A, B, or C provide PWSID # ~nltaryseal (Y/N~ Y Cased to ~'~O It. FROM WELL LOG Static water level ~ Wall production WATER SAMPLE RESULTS: Wa, Log (Y/N) ~ W~res pmpedy protected ~) ~/ : AT INSPECTION Casing height (above gm~.~ O ~ in. g.p.m. ~'' ~ , g.p.m. Arsenic: coidnles/lOOmL Nitrate O,~mg~l. Ot~erbacterle O colonies/lOOml. mgJ1. OateofsamPie: b . Z.// -0 2. Collected by : ~/ ~ ~ ~ B. SEPTIC/HOLDING TANK DATA Tank Type/Material Date Date instelled /qb ~) Cleanoum(Y/N) Y High water alarm (Y/N) ~ C. ABsoRPTIoN mELD DATA Oateinstailed 7° ~.''7,0Z- S~llratino (g.p.d./f~or~!bem~) I,~- Systemtype.~/d//~)~ Length ~ 0 :V~qdth 5,0 fL Gravel below pipe :~ ' ~ fL Toteid~l~thlb'~ff. ft'Eff, absosoq~u,',t[onema'~'~ ' Monitoring tube ~ Depression over field /~/ Date of adequacy test ~1~If'~'~ ResultsCPess/Fetl) '"- 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 mjuvenaflol~'lteatment (past 12 mo.) (Y/N & type) F If yes, give date ~ 'Pump on' level at Datum Size in gallons E. SEPARATION DISTANCES Manhole/,~ _ _~'~_ss (Y/N) High water alan~ level at Meets alarm & drcuit requirements? in. SEPARATION DISTANCES FROM WELL ON LOT TO: ,Septic lankaiff station on lot Absorption field on lot Public sewer main /~ 100 on adjacent lots ,~ IZO On adjacent lots Public sewer manhole/cleanest Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation · ~'/~ properly line ''/~= Absorption field Water main ~/A Water sendce line ), ~'O Surface water Wells on adjacent lots )t~) SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:.. P. roper ,ne Wster Se~ce line. )'B0 Bulid!ng foundation ~75 Water main '. ~)'"/K/'/~' Curtain drain Su ce ter Wells on adjacent lots F. COMMENTS (3. ENGINEER'S CERTIFICATION I cerSfy ~hat I have detenwlned ff~mugh field Jnspec~ons and m~w of Mun~l ~s ~at ~e a~m ~ am in ~a~ ~ M~ ~ ~ellnes ~ eff~ on ~ls da~. g/lis Engin,~s P,n~ Name ~'~y O= ofP ent Receipt Number ~:~ '=~'//~ '~ (Rev. Waiver Fee $ Date of Payment Receipt Number ,~t~__ CT&E Environmental Services Inc. CT&E Ref.# 1023744001 Client Name Wa~ilm Engineering Project Name/# Freeman S/D, L 12 Client Sample ID Freemans/Plot 12 Matrix Drinking Water Ordered By PWSID 0 Sample Remarks: All Dates/'flmes are Alaska Standard Time Pflnted Date/Time 06/26/2002 10:41 Collected DatetTime 06/24/2002 15:45 Received DatedTlme 06/24/2002 16:25 Technical Director · Released By (~~ Parameler Results PQL Units Method Allowable P~p Analysis Liraita Date Date Init Wa=ers Department N~te-N 0.200 U 0.200 mg/L EPA 300.0 (<10) 06/24/02 JDT Microbiolog~ Laboratory Total Coliform col/100mL SMI8 9222B (<I) 06/24/02 KAP INSPECTION ~:PORT~ ON-SITE S£WAC~ DISPOSAL S¥STEH capacity 1~ ga~ons. Inside len~h Inside width.,, Liquid depth SEEPAGE SYSTEM: Seepa[e Pit: Nu~e~ of pl~s / Outsld~ dla~e~ ~ om width // ~ len~h ~ ~ / ~ ~ g (wall fo~da~ton ~ ~ nea~s~ lot line Total effective ~so~ion a~a ~a) sq. ~ !ILS D~IN FIELD: Dtst~ce f~om well ~ fo~dati~ , hearst lo~ line Total len~h of lines_ Nu~e~ of lines Dist~ce between lines T~ench width in. Total effective absorption are& Depth= Top of tile to finish ~ade tile., inches, Above tile .~LL: ~'- sq. f~. Length of each line Depth of fllteP material beneath Type~)~,7~Distance from building foundation I~1 , hearst lot line,~'~' _ ~ nearest SO~S, Health Authority ~IAG~ OF SYST~ Application to Install: Septic t~__, Seepage pit , DraJm field, , Other To Serve the Following FaCility //~JT~ -- Fin~ced ~u~h To be Installed by ~:~ ~ Percolation Test Results Anticipated Date of Cospletton BELO~ TO BE FILLED OUT BY HEALTH DEPA~TEENT This Is to serve an~/~ / DISTANCES: He~th Authority as described below. Septic t~k size[~, · pe~tt to install a Size of unit to be served__..,~. DIAGRAM OF SYSTEM I certify that I am famtllar~ith the requirements of Creater Anchorage Area Borough Ordinance No, 28-68 and that the above described system is la accordance with said code. APPLIC~?,JT FILLS OUT UPPER HAI.~ONLY - Address Zip Address Zip Address Zip ~ Other ~ Indlvld~/ A~ACH ~LL LOG. k w~l log Is requlr~ for all weTIs drilled since June 1975. ~ ~mm~ity For welts ~llled prior to that date, give well depth (attach I~ If available). ~ Public Utility Sewer Disposal ~ Holding Tank NOTE: THE INSPECTION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Date Time Time Inspector Inspector Soils Rating I /c°Y~°Fl°",s 9F APFROVAC Well Log Received Septic T~k Size " HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART L--TO BE COMPLETED BY FHA SEmAL NO. TOTAL N~MIIR: J · f DY- []No [] Public system [] New installation [] Community system S~WAG! D~SPOSAL [] Public system --'1 Community system PART IL--TO BE COMPLETED BY HEALTH DEPARTMENT REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM I~IIMAIIy 111EATNiINT consists of [] Septic tank. O Cess~x~ul. Sepek t~t Distance from weJJ.__f~t. Material.. Inside length,, ftc. Inside width f~t. ~uid &~h, Number of compartments feet. gallo~s. 61' · amu!m ~lsuol[eg · ~aj.. "uopnllOd alq!ssod ? ~a>jnos ~aq~ :~a) 'pla9 lesods!p :~aj '~lu~l )?das :~aaj '3eaJ I-I 'ap!s I-I 'luoJj I-I ]~ au!l ~oI ]saJeaU *.laa)' · ainu!us Jad suol[~S 'uopepum)) ~U!pl!nt] Ja]e,a JO Xlddns a]enbape qs!uJn) ol .(]~u!~A ai~!patum! u! $ll.),~ JO ami?J 1o pJ()~"),l lua)~J i5ouJ a^!L) Tooq~oqq~!au u! Azeu~nn~ xm aJe [] a~e [] $[la~* lenl~.^!pul W]ASAS A'kldflS-tl~tVN~ l¥I101AIONI--NOIA3]dSNI dO A~fOd]H b. Detergem~ . well d. Distance from well to closest existing or proposed: ' 1. 6ewer line 2. Septic tank 3. Seepage Area u,. CeeepoolZ S. Proper~y LAne O~her sources of possible contamlneticm, i.e., creeks, lakes, houses, bat-a, drainage ditch, etc. 7. ~ d.'Lapos,~l system. b. Septic Tank capacity in gall~ c. Na~ of septic t~ m~ufactu~ 1. If "h~ mede" ah~ diagram ~ ~varae s~de o~ ~bAs ~o~. d.' Disposal field or seep~e pA~ size ~d t~e ~~/~/~/~ .. / e. Percc~fL't£~ ?e's~ se the rev~rae .side of ~hze fo~ ~o sho~ ~. D~a~ should ~nc~ude he f~in~ inflation: p~pe~ l~ss,vell location, house l~atl~, ~c tank l~atl~, dis~sal a~a loca~i~, ~oca~i~ o~ pe~olati~ tes~, ~ di~c~L~ of ~und slope. 9. The ~m~m~u~Cion on ~hAs ~orm is true and correc~ ~:o the best o~ m~ Mnowledge. $:~Fnatur~ of Applicant Da~e Sl~ned TO BE FILLEO OUT BY HEALTH D£PART~IENT PEB$ONNEL ~e ~o~ descried s~i~a~ facilities a~ he.by ~pproved, s~ec~ ,to, ~he Coudit iouo:, [] The above described sanitary facilities ar~ disappr~ved for ~:he follo~ir~ "' --~"oval la valid for on,,, yoa~ follo~ini the data of approval, ..- CPJ: aw