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MADDUX PARK LT 3
Maddux Park Lot 018-251 -03 MUNICIPALITY OF ANCI',ORAG;:_ DEPT. OF HEALTi ENVIR©~MF. NTAL PRGT£CTIoN ~U~I01PALITY OF DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION NAME PHONE [] NEW MAILING ADDRESS LEGAL DESCRIPTION LoT ~_~ LOCATION / I DISTANCE TO: Well I'Z~ ! ~ IManufacturer ~ ~ ~ ~ ~ Manufacturer ~Z J DISTANCE TO: J I I~ ~ ~ g No of lines. Length of eac~line h Top of tile to finish grade ~ I ~ J ~gth Width ~ ~ ~ Crib diamete~ ~ IC,~ r~ Depth ~ J ~ Budd,ng foundat,o~ JAbsorption a~a I Dwelling Mater~.~._ ~ Inside length I Width Dwelling Foundation iD otal ,e.it. Material beneath tile~:~ I Depth Sewer line ll..X¢/ OTHER PIPE MATERIALS SOIL TEST RATING,~/~,~ ~ ~ INSTALLER REMARKS DATE Material ......... Nearest I~ Trenc ~ ~.~t~ APPROVED )/ SEc-, 3~ NO. OF BE~_7~OOMS No, of coJ~)artments Liquid depth PERMIT NO. Li~-8id~apacity in gallons Distance between lines Total effect~vi~e al~g~ptio~/area I.¢o ~' / PERMIT NO. Crib depth Total effective absorption area Building foundation Nearest lot line Driller Distance to lot line PERMIT NO, Absorption area(s) Septic tan,k , 72-013 (Rev, 3/78) FII:::'F'L.. Z Cl::]l",ff: [:::OP',tT FIC T F'HOI",IE: I...EiGI:::IL E:'ES[:[~.: Z F': I....Of F; ir. 2:[!:: [!i:l_O[:l<: I:.,I1:::1 .1: IS:Ei:F: T ]: FY'ri "i"HF:IT: ii... .1: Fll"I F::I::Ii"IZI....~.I-';II:;i: I.,.t.'l:'T'l-.] THE I:;i:[~:[i:!i...t]:[ii:EI,i[!:l'.~T::!; F'OF;i: Ot'.,].-..S:['T'lii!: S[~:I.,.I[!!:[~::~:; FII",ll)I.,.II!E..L'.F-:, t:"IS SE'T' F'l::iFi:ff'l...I li~','.r' 'l"l'-'l[~: Ht. JI",I :!: [:: ]: I:::'I::I!... ]: T"r' Ii.IF: I::II",t[:HI:::L[;i:F:II::~iE <:1'"1[)1::1) I::1[',1[:' TI'E: STI::ITE 01::: I::II....FISI<:[::I. 2. I 1.,.1:1:1.].. :[]",ISTF]I...L.. THE S"J":i!;'I"E['"I :[t",! ::::::::::::::::::::::::::::::::::::::::: [,.I:[TH Ii:iLL. 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F:'EI;i:H :!: T F~lq[::, :1: I'.,ISF'E[:T ]: Ol",l I"II.J'.TI' 13E [E:'T'F1:1: NE[::,.; ,:: 2 ::, FIS..,..[~:',LI:[ LTS !.,.I ]: LL NO"I" I:::',E F:IF'I:::'I:;i:[I',,,'[EI:::, I.,.I :1: I"H[~IJT FIN ELECI"F:: I [:1::tl.. :[ N:ii;F'Ii!~:[:T .1: Ol'.,l [',i:Ei:P[::I[~:T.: FINI:, ,:: ]: ::, THE EL.E[::Tfi~'.I{:::I:::iI... H[.1F~:I< t"tUST E',E t::,Oi",IE [ii:'~.' Ii:il L..:[[:E['4SE[::, EI....[i:[::"I'I:;i: ]: [: I FIN. FII:::'F:'L ]: [:: FI l'.,l l" ~-'t"E~ S[::HI:~::E[:[::: MUNICIPALITY OF ANCHORAGE Department ~f Health and Environmenta3 ~rotection 825 Street, Anchorage, AK. ~501 264-4720 * * * HANDWRITTEN PERMIT * * * Permit ,~lEEct WELL AND/OR 0N-SITE SEWER PERMIT Applicant: ,~¢~3~, ~L~ Mailing Address: Location: 5 ~ ~ ._.~ ~©~ ~ C~ Phone Number: ~ .~_ Legal Description: ~c~ -~ ~Y~d~ ~b Lot Size: l]~(Z>~] Type-of Soil Absorption System Is: Trench: Drainfield: Seepage Bed: Holding Tank: MaxJ~nuz~, Number of Bedrooms: ,~ Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is: DEPTH /~ LENGTH ~..~F GRAVEL DEPTH ~ WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is n~ set width for trenCh¢~. The gravel depth is the minimum deptbF~of^g~avel betF .~. ~g~t~p~nd the bottom of the excavation(in feet .~-~~~-~ L'~v * * - S-d * ° REQUIRED SEPTIC(HS&~i"~6) TANK SIZE- GALLONS Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. ~inimum distance between a well and any on-site sewage disposal system is 100 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 sewer line is 25 feet and to a conununity sewer line is 75 feet° Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 * * I certify that: (1) I am farailiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may~quire enlargement if the res~denc~ is remo~el~ to include more tha~ ~ ~edrooms. Signed: ~p~l ~nt ~ ~ Issued Date: SW~/024 (1/81) r MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telepho~te 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PT~,~ ,~'N EW ,AME " 'Jr<t°h e .E c h re ek m,s¢lj 7 UUPG.ADE LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS DISTANCE TO: ' ~ Materi~ No. of ~ompartments ~ b Liq. ~ataacity.~ g~llons Inside length ~ Wiflth Liqu'~' flepth -- ~0 ~ U IF HOMEMADE: - ~ ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO~ O ~ ~ Manufacturer Material Liqu~capacity in gallons ~ DISTANCE TO: Well Foundation~ ,,~ Nearest lot line [ ~ , PERMITNO.~O~+~ J~a mg No. ol I~ s~ e Length of eac ~n~ Total len9 h ~Ali'es Trench width, g0 *~inches Distance betw~g~ines N ~ ~ Top of tile to finish grade Material beneath tile Total effectiv~gbsorp~ion area ~ ~ inches Length Width Depth P~RMIT NO. ~ ~ .... ~e~absorption ar ~ D Type of crib ~diameter Crib depth / u~ ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ ~ Class Depth Driller Distance to lot line P~RMIT NO,~ m Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE MATERIALS ~ ' INSTAELER REMARKS ~)' APPROVED ~ ~ DATE LEGAL 72-013 (Rev. t78) WATER WELL RECORO STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES 0ivlslon of Geologl~o~.~ Geophy~loal.$urvey~ L0~ATION'OF' WELt., (Pleale ~om~.lef$, 01the~' Io~ I1~ or I(~.) A.O,L, No. +;:. ~ ,~;. '.-, , ......................... : · . , : ~:. ~e~e~lo~ ~' ' . aefle~ .................... ;,... :.._= · .; ~ ....... TYPa~ ....... - _ ...... ~": ~. , · - ~. . . . '~ ~ ,.~ . "~" 4~ ........ ' ' " ............. :, II, PUMPING LEVEL below Iond aurfage ofl~ ,YIEbO ~"' ~.:' ~ . 14, REMARgO~ 16, WATER. ~ GONTRACTOR'~ CERT'IFICATION~ lB, ~glet T~nDerqture . , ~ ~ F ~ 0 rh[~ ~1~ wa~ 6filled ~f m~Jur,[sdl~llon end Ibis ee~ort I~ l~ue to fhe~bestpl my knowledge and bellefl Authorized ~VI-W DRILLING, Inc. P.O, Bo×4-1224 · 1310ClnternationalAirport Road (907] 274-461 ] ANCHORAGE, ALASKA 99§09 DRILLING LOG Well Owner , .SJ2P-C~ck, ,.Use of Well dom. Location (address of: Township, Range, Section, if known; or distance main road Lot 3 Maddux Subdivision Size of camng- . Depth of Hole 69 feet Cased to 68.8.., feet Static water level /0 ft, ~ (below) land surface. Finish o£ well (check one) open end .( x-X .); Screen ( ); Perforated ( ) Describe screen or perforation N/A Well pumping test at 6 gall'0ns per (h~r~ of drawdown from static level.: Dat~ofcompletion . ~/26/79 - Depth in feet froTM ground surface (minute) for, l. hours with -,, ].00% . , , ~,x WELL LOG ~ive details of formations penetrated, size of material, color and hardness 0 TO 2 TO ZL ,. 50 50 'PO 65 · 65 _ "0 _69 ~a s ir~g s t ickup Organics Silty g?avel: occ. cobble _ Grave] ly Wa_~_e_T._. 8!-' av~e ,p [0 .TO. December 29, 1978 0780761 Stephen Schreck Star Route A Box 4029-2 Anchorage, Alaska 99502 Subject: Lot 3 Maddox Park Subdivision A permit issued by this department for well and/or sewer system has expired. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date° If there are any further questions, please contact this office at 264-4720. Sincerely, Les N. Buchholz~ R. So senior Environmental Specialist LNB/ljw enc: copy of permit L.. Z Z I:::11"" I.l!i(iiil:::ll.. '1'1'!1!~ I....I!!!LN[~Jq'I'I [:' :1] !'"lli!!]",!:i~; ]] EIN '_1: ::ii; I¥'IE:~ I...J!ii]",l~]i"l'l'l I' .. .1] '.!L~; 'I'I'JE] J'], ]1] '.!~ 'I'F: Nl":l::i' lii?,Fi:'!'H!!{[]",l '1'I II]! ?~;l..lt:?.l:::'!:::t[::t]~] r]li::' 'l"l.)l~:~] [:it;?.Ol..IN[:, 1: :1t'.,1[:, 't"1-!~ I:'~ ":'l"'Fqh'l Ell::" 'FILE E',:.:',E:I:::I',,,'I:::IT:I:I:~II'.,I TI...II~J] ~t.~. ,~ I.. [:,~]::'TH ]]:~; 'I'I'K~] I'"I]:NII'"II...IFI L.'::.F' ~ll I:::!1",1[:~ 'l'!'llJJ~ I~']"l"'Trlh't "11: 'I"HE I:.,.,..I.l,liJl"iN ,:: 'J] t'.,I t:::'I;.}~]T>. 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'.~(;I:::'I:}]E: I I ' I .~ ~ d...~. T "1 '( I'q':i: .. I:~'.~] I:':'F'. ] I:X'l::"l;? :1] I",1:~{;"1'1:::11 ..t.]:::l'l" ][ EII",I. '!'1"1[!: [._l{i~l'.,l(:ii'l'l-[ l::, :!: f"t[~:l'.,l:!ii; :i: OIq :l: :!ii; 'Fklli!: I..[:_::I'.4G'I"H ,:: :!: N I:::l:i:ii:/[' ::, OF' '['I.'It:F: l't:;;:li!i:l'.,!C:l I Cfi;i: I::,1:;i:1:::1 :!: NF:' :I: li!:i .1:':,. TI. II:~: DI!i!:PTH OF:' I:::l Tl:~'.[ii:l'.,l(:::ll O1:;;'. I:::':!:T :i::!i; TI.II:!!: !;::, :I: ::i!;'I"]::'INC:[!:: l!',t!:i:'l't.,.lt!!~l~-:t'.,! I't1[!:: :~i',l...l[;;:l:l:::lC:l:!: ()l'::' "l'['.ll!;i: GIq:OL.II'.,I!:::, I:::11'.,11.::, 'TI'II:E [?,O'TTOFi OF:' "Fl'.l[!: [!i:::.::C:f::I',,,'F:IT J: (:[N (:[1",1 '['l..l[!!:[;i:[!!: ]:'_'-.:.; f',lO :i!;l:!/l" I.,.t:[l')"l'l'l F:'OFi: '['1..!t_:i: I:~il:;i:l:::l*,,,'f.i:l.. t::,[i::l:':'TII ]::!ii; TI'II!: F[ :[ N :( I-"IL.II'"I E:,I:~:I::'TI"} Cfi:::' I::il~:'.l::l'v'l::L. li~;l!i;'l"t,.![i::lii:N 'II. IE!: C[I..ITF;'I:::I1.}.. !:::' :!: }::'f:!: I:::IF,I[::, "1'[,.11:~: F!~O I'TI::)I"I OF:' ["Il[i,: [:!::;':',C:f::I',,,'I:::I"i' :f: O1',,t ,:: :!: 1"4 I::'1~:I:~:'1" ::,. PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6.650, Anchorage, Alaska 99502 276-2221 SOILS LOG - PERCOLATION TEST COMMENTS SOILS LOG E] PERCOLATION TEST SLOPE SITE PLAN r -] - i :" - J..-.~ WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN FT AND (minutes/inch) -- FT CERTIFIED BY:~--------~ ~'~"~ DATE: 72-008 (7/76) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater prOgram 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FORA SINGLE FAMILY DWELLING /~ ~ Parcel I.D. o~8-2~-o3 1. GENERAL INFORMATION COSA# O..~ C EXpiration Date: Complete legal description Maddux Park, Lot 3 Location (site address) 3640 Ivory Drive Current Property owner(s) JamesCammon Mailing address Day phone Lending agency Mailing address Day phone Real Estate Agent Mailing Address Bob Bear ! Dynamic Properties Day phone Unless otherwise requested, COSA will be held by DSD f(~r pickup. 2. ~. NUMBER OF BEDROOMS: 3, TYPEOF.WATER SUPPLY: IndividUa Individual Water Storage Community Class ~ Public Water System .6 Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [~ [] Individual Holding Tank [] [] Community On-site r-~ [] Public Sewer [~ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems 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 may be reissued for a period 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 water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 Pannone Engineering Services, LLC Phone 272-823.8 Address P.O. Box 3.00217, Anchorage, AK 9951o Engineer's Printed Name Steven R. Pannone, P.E. Date 2/21/203.1 Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. PES can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized nor will it confer any legal right whatsoever. 5. DSD SIGNATURE ~ Approved for ¢ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL .CHECKLIST .Legal Description: A. WELL DATA Well type Private Date completed zlzgl~989 Total depth ~95 ft. Maddux Park~ Lot ~ IfA, B, or C provide PWSID # __ Sanitary seal (Y/N) Y Cased to =95 ft. Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform . Ne9 colonies/100 mL Arsenic: ~ ug/I B. SEPTIC/HOLDING TANK DATA Tank Type/Material Career/Steel Tank size ~25e gal. Foundation cleanout (Y/N) _Y_ Date of pumping 6/z,.12e=o C, ABSORPTION FIELD DATA Date installed 818/~98~_ Length Total depth ~..~o ft. FROM WELL LOG alzg/=.Q89 zo=. ff.' zoo g.p.m. Parcel ID: Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) 25 AT INSPECTION ~/al2ozo 95 ff. 7.o+ g.p.m. Nitrate O~(,.,~, mg/L Date of sample: 21=.12o~ in. Other bacteria Ne9 colonies/100mL Collected by: DRM Date installed 8181z98a Number of Compartments _~ Cleanouts (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Pumper Alaska Sewer & Drain Soil rating (g.p.d./~ or ft2/bdrm) 85 SFIBR System type Deep Trench Gravel below pipe 6 Depression over field N For _~ bedrooms Water added622 gal. Absorption rate >= 6oo+ Date of adequacy test a=.18/2o=o Results (Pass/Fail) __ Fluid depth in absorption field before test o_ in. Elapsed Time: zoo min. Final fluid depth _o in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N ft. Width 4 ft. Eft. absorption area 4zt~ ft2 Monitoring tube Y Pass New depth=_3 in. g.p.d. If yes, give date D. LIFT STATION Date installed "Pump on" level at __. in. Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot lOO+ Absorption field on lot lOO+ Public sewer main 75+ Sewer/Septic service line Animal containment areas Building foundation 11 Water main lO+ Wells on adjacent lots in. Size in gallons "Pump off" level at~ Cycles tested Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots lOO+ On adjacent lots lOO, Public sewer manhole/cleanout lOO+ Holding tank . 10o+ Manure/animal excrete storage areas lOO+ Absorption field 6 Surface water loo+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Property line lo, Water service line 25+ lOO+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line lO Water Service line 25+ Curtain drain 50+ COMMENTS Recertification Building foundation lO Surface water lOO+ Wells on adjacent lots lOO+ Water main 75+ Driveway, parking/vehicle storage lo+ in. G. ENGINEER'S CERTIFICATION I certify that I 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 Steven R. Pannone, P.E. Date' COSA Fee $... Date of Payment Receipt Number (Rev. 11/05) .~.~ of- ~.~ t.~. 'L.'~,,,, · ,,..,,,,~..<./ ; -;..- ,.~_~ '..,~ ~ .......... ..... ~_~_~.' Steven' R. '~'~_-'-.. ~,~ ~.~ ~,-~ / ~- ............... Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. O18-25:[-O3 1. GENERAL INFORMATION Complete legal description Maddux Park, Lot 3 COSA# Expiration Date: Location (site address) 264o Ivory Drive Current Property owner(s) James Cammon Mailing address Day phone Lending agency Mailing address Day phone Real Estate Agent Mailing Address Bob Bear / Dynamic Properties Day phone Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4, TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [~ [] Individual Holding Tank E~ [] Community On-site r-I [] Public Sewer J-"] The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems 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 may be reissued for a period 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 water system. The Municipality of Anchorage is not responsible for errors or omissions in the profess~nal ~n~gineer's work. 4. 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 Pannone Engineering Services, LLC Phone 272-8218 Address P.O. Box 100217, Anchorage, AK 995zo Engineer's Printed Name Steven R. Pannone, P.E. Date z~/~7/:zo~o Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. PES can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized nor will it confer any legal right whatsoever. 5. DSD SIGNATURE .~£, 'v'~ Approved for~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory~ X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: ///;~ ~-///6) A= Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. munLorg/onSite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Maddux Park~ Lot'~ WELL DATA Well type Private Date completed ~.1~qh.989 Total depth ~-95 ft. Date of test Static water level If A, B, or C provide PWSID # ~ Sanitary seal (Y/N) Y CaSed to =95 ft. FROM WELL LOG =.1=.~h.989 ~.Ol ff. Well production ~oo WATER SAMPLE RESULTS: Coliform Ne§ colonies/100 mL Arsenic: ND ug/I B. SEPTIC/HOLDING TANK DATA Tank Type/Material Greerlsteel g.p.m. Parcel ID: Tank size ~25o gal. Foundation cleanout (Y/N) Y Date of pumping 61~J2o~.o C. ABSORPTION FIELD DATA Nitrate o.~,68 mg/L Date of sample: =.',/81',o.,o Number of Compartments ~_ Depression over tank (Y/N) N Pumper Alaska Sewer & Drain Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) 25 AT INSPECTION · , =.1812o', o 95 ff. 7.0+ g.p.m. Date installed 8181~c~8,. Length :~'-.F ft. Width ~ Total depth ~o ft. Eft. absorption area ~/+ ft2 Date of adequacy test ~.~.1812o~.o Results (Pass/Fail) __ Fluid depth in absorption field before test O in. Elapsed Time: ~.oo min. Final fluid depth _o in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N in. Other bacteria Necj colonies/100 mL Collected by: Pannone Encjineerin9 Date installed 818h.98,. Cleanouts (Y/N) Y High water alarm (Y/N) N System type Deep Trench Gravel below pipe 6 Depression over field N For & bedrooms Soil rating (g.p.d./~ or ft2/bdrm) 85 SFIBR ft. Monitoring tube Y Pass Water added6~2 gal. New depth~ in. Absorption rate >= 600+ .g.p.d. If yes, give date D. LIFT STATION , Date installed "Pump on" level at~ Datum Size in gallons in. "Pump off" level at ~ in. Cycles tested E. SEPARATION DISTANCES Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot ~.oo+ Absorption field on lot Public sewer main 75+ Sewer/septic service line. 25+ Holding tank ~oo+ Animal containment areas 5o+ Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: On adjacent lots ~.oo+ On adjacent lots ~oo. Public sewer manhole/cleanout Building foundation ~.~. Property line ~o+ Absorption field 6 Water main ~.o+ Water service line 25+ Surface water ~.oo+ Wells on adjacent lots ~.oo+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: loo+ 1oo+ Property line ~o Water Service line 25+ Curtain drain 50+ COMMENTS Building foundation ~.o Surface water ~.oo+ Wells on adjacent lots Water main 75+ Driveway, parking/vehicle storage loo+ 10+ in. G. ENGINEER'S CERTIFICATION I certify that I 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 Steven R. Pannone, P.E. Date COSA Fee $ Date of Payment. Receipt Number (Rev. 11/05) OF 4/ ~ ~ ;." ~ ".;.~ % ~ : 49TH ~ : J.....~,.~ ......... ~ ..... ~.~3,~reven ~. wannone,~ Waiver Fee $ Date of Payment Receipt Number 24 HOUR EMERGENCY SERVICE ~46157 Anchorage Eagle River Mat Su 248-9557 694-9557 376-4600 PO Box 221914 - Anchorage, AK 99522-1914 o Office 248-9551 - Fax 248-9559 YOU-R PROFESSIONAL SEWER & DRAIN CLF~ANING SERVICE LICENSED L,L,C. : INSURED Customer Name Address ,~[0~'~ Phone Power Snake Steam Thawing Hydro.,Jet Cleahing Sewer Line Camera Service Call Vac Truck / ~S-- Septic Pumping Extra Man Parts/Tax TOTAL / ~'-' ~ Camera Inspection !~,lnstall Clean Out ~, Hydro-Jetting [] Vacuum Truck [] Steam Thawing [] Excavation [] Install New Toilet PO# ./ Technician ~ "~0.%~-~ (--~ No Warranty~, Customer S~gnature NOT RESPONSIBLE FOR CRACKED OR BROKEi~ORcE~.AIN FI)~-FU~ES/OR LOST OR BROKEN CABLES IN DRAIN LINES. CUSTOMER AGREES TO PAY FOR DAMAGED OR BROK_~N CABLES, JET HOSES ETC. DUE TO FAULTY PLUMBING, AS WELL AS ANY AND ALL OTHER FEES INCURRED AT THE TIME OF SERVICE. There will be a $30.00 charge on all NSF checks. A collection fee of 40% will be added if sent to collections. PAYMENT DUE ON RECEIPT Finance charge of 0.875% per month, or annual rate of 10.5% is applied to past due balances. LOT 2 6" Spike (Typ) % Found 5/8" Rebar LOT 5 Found I 1/2" Alcop LOT 5 sq.ft.:l: LOT 4 10' UTILITY EASEMENT Set 5/8" Rebor with YPC LS-9020 EAST 156.30' Set 5/8" Reber with YPC LS-9020 LOT 1 LOT 2 Note: Building plans were not provided to Lontech for the development of this Survey. Lontech cannot be responsible for encroachments caused by building dimensional changes. Drainage ~-~ Proposed Finish Grade [PFO 111.75'1 £1ev.(No Datum) ~ Legal Description: AS-BUILT SURVEY Lot .3, Moddux Pork !Ordered By. dames Cammon Legend: Set Fnd Septic Standpipe 5/8"RB W/CA.o (~) 5/8" RB 0 Water Well 3.25" ALMON. -~MONUMENT ~ Fence--X, X-- Light Pole EXCLUSION NOTES:It 'is the owners' respons~dity' to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. NOTE: It is the contractor's respons~ility to check top of foundation grade & building setbacks in relation to Iotlines & esm'ts. ILAND & CONSTRUCTION SURVEYORS--PLANNERS_ENGiNEERSI SURVEY CERTIFICATION: LANTECH has conducted a physical survey of this 440 West Benson Boulevard, shire 200 Phone: 562-52911 property as shown on this drawing and to the best of our knowledge and Anchorage, Alaska 9950.3 Fox: 561_66261 abilities, ell dimensions have been measured true and correct. Plat No: P-554 lC, rid No: SW5054 IDat~. JULY 9, 2007 IDrawn S)~ TM won ~.~,, 2007LH138 IFb/Pg: 66e./54-35,691/62 IScale: 1"=.30' IChecked B~. APH Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 018-251-03 GENERAL INFORMATION Complete legal description Location (site address or directions) Lot 3 Maddux Park Expiration Date: C~_ J~- OJ~ 2640 Ivory Drive, Anchora,qe, AK Current Property owner(s) Joe Caperton 3900 C Street, Anchorage, AK 99503 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Day phone 339-6500 Day phone Day phone · Unless otherwise requested, HAA will be held by DHHS forpickup. HAA picked up by: NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well 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 representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Cedificates of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to home owners, 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 less than 30 days old. Certificates are valid for one year for properties served by Class A or B wells or a public water system, The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. (Rev. 1 IFJg) 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 Health Authority Approval Guidelines for this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on- site water supply and/or wastewater disposal system is in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at lhe time of installation. Name of Firm Pannone Eng..Svc. Phone 272-8218 Address P.O. Box '102954~ Anch, AK 99510 Engineer's Printed Name Steven R. Pannone,..P.E. Date. ~o lq/c_) Engineers Comments: In conducting an adequacy test, ] attempt to provide a thorough, conscientious p ' pe y ditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all ,~ v, ells and septic systems depend on the local sod condmon, ground water levels that may fluctuate ~ during the year, and the water usage of thc family being served by the system. These conditions are ~ outside the control of the cvaluator of th~s system. All systems eventually fail and sabsfactory test results do not guarantee future performance of the system, nor do they guarantee that there arc no hidden or encroachments. PES can therefore not provide any warranty for future performance nor give any est,mate ofhow long the system wdl contmue to meet the operatmnal requ,rements of the ADEC or '~,',".. MOA DSD. The content ofth~s report ~s for the sole benefit of the owner hsted above. Any rehance upon ~; use ~f th~s rep~rt by any ~ther per~n ~r par~y ~s n~t auth~r~zed n~r wdl ~t confer any legal r~ght ~ Approved for LtL bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Well Flow Advisory Expiration Date: (Rev. 11/99) Supplemental Engineer's Report Other Original Certificate Date: ~C~ Reissue Date. Legal Description: A. WELL DATA - Well type P Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Lot 3 Maddux park Date completed 1/191t989 Total depth 195 ff - Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform '"'~ colonies/100 mi Date of sample: 5121/2003 SEPTIC/HOLDING TANK DATA Parcel I.D.: 018-251-03 If A, B, or C provide PWSID # Sanitary seal Y Cased to 195 ft FROM WELL LOG 1/1911989 lOl ft 100 g.p.m Tank Type/Mate. rial Greer Date installed(~/8,~84 U~l~Tank size Cleanouts ~ Foundation ~eanout Well Log Y Wires propedy protected Y Casing height (above ground) 25 AT INSPECTION ~121/2003 96 ft 6.67+ g.p.m Nitrate -'~mg/1 Other bacteria Collected by: ~.aura Pannorle Fluid depth in absorption field before test Dry in. Water added613 gal. Elapsed Time: 50 min Final fluid depth Dry in Any rejuvenation treatment [past 12 mo.) (YiN & type) H (Rev. 11/99) In. coloniesll O0 mi 1250 gal Number of Compaf[ments_2 Depression over tank IN High water alarm NIA Date of pumping 5121(2003 Pumper A+ Home Services ABSORPTION FIELD DATA Date installed {~1811984 Soil rating (g.p.d./ft= or ft=/bdrm) 86 System type Trench Length 34,5 ft T(.)'~'~ Width 4 ff Gravel below pipe 6 ft Total depth li)~' ~ Effective absorption area 41 ~ ft= Monitoring tube Y Depression over field N Date of adequacy test. 5121/2003 Results (Pass/Fail) P For 4 bedrooms New depthZ in. Absorption rate >= 600+ g.p.d. If yes, give date D. LIFT STATION % Date installed ~allons__ Datum ,/_~,~ Cycle~ E. SEPARATION DISTANCES in Manhole/Access High water alarm level at in Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100% On adjacent lots 100+ Absorption field on lot ,~ 1.00+ On adjacent lots ..100+ Public sewer main NIA Public sewer manhole/cleanout 100+ , LPP Sewer/septic service line ~ ~¢~' ¢- olding tank NIA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 11' Property line 20+ Absorption field 6' Water main 10% Water service line 10'+ Surface water None Observed Drainage None Observed * - Wells on adjacent lots 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 25+ Building foundation 10' Water main 25'+ * Water Service line. 25'+ Surface water 100% . Driveway. paddnglvehicle storage .20'+ Curtain drain None Observed Wells on adjacent lots t02' F. COMMENTS G, ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance With MOA HAA guidelines in effect on this date. Engineer's Printed Name . .Steven R. Pannone, P.E. Date Date of Payment -Receipt Number (Rev, 11199) Waiver Fee $ . Date of Payment Receipt Number Robert E. Johns, gr. & Assoc. ' "~ ~ ~ ~ ......... ~~~' _"-r~'"""~v"~ ~"-.~":'"~". ... . Professlonal,~.~ ,Land,,~, Surve~rs,, ~..,..¢~:~;~ I = 3 0 ~ ~ ' ~ ~ ~ REJ MLJ ~....~. ~ MAY ~-2003 >~_ ~ ~1 Z..~A~~~~ ~~/~"fM'.~ ~ ~: MAY 23,2003 m":3034 "'~ 23123 *~j*. .......... %~ ~ ~: ~T PLOT P~S · LOT ~R~ IT I~ ~[ R~BIU~ ~ ~[ ~UI~ ~ O~R, PRi~ TO ~LY ~0~ IMPRO~N~ ABO~ ~OUND ~ ~IS~ ~E E~N~ OF ANY ~ ~ ~ Rffi~lffiffi~ MAY ~T ~ ~PRO~ ~ B~NO ~ AND ~ICH DO NQT_APPCAR ~ ~ R~C~DED ~UB~ P~T, A~ DIgTANCES ARE RECORD UN~ O~R~S~ NORD. U~ HO ~R~T~ ~ ~ ~T ~ U~ F~ ~ ~ ~ ~ ~ND~Y ~ ~ ~E ~R~ T~ES ~ F~ ~E ~ ~ ~Y ~O ~ ~ U~ ~LY F~ ~E ~T ~ ~E ~R~, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH &HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 0~~ ~-"'L~\- C'J.~ NAA# 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Day phone Lending agency Mailing address Agent Address '~.~0 D~y phone Day phone ~"-b~)~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water SUl~)ly 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 Address Engineer's signature '~-'~ ~~ Phone DHHS SIGNATURE ' .~ Approved for ¢ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments BY: Date 72q)25 (Rev. 1/91) Back MOA ~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: J-tv~ ~ ~ o~Y,. '~<2-0¢ff' Parcel I.D. A. Well Data Well type ~ Log present (Y/N) y Total depth ( (o/'?) I ~'~ ..~ Sanitary seal (Y/N) % FROM WELL LOG If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to (~'~. Wires properly protected (Y/N) AT INSPECTION jOr2 g.p.m. -Z ~ Date of test Static water level Well flow Pump level1 MUNiCIPAUTY OF ANCHORAGE ~.j,.~¢j?,ONMENTAL SERVICES DIVISION !:;' 1 q 199~ g.p.m. RECEIV[D SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main f"'"///~ Sewer service line *) / 0 ; On adjacent lots ~ /0,,~ ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ¢/ Date of sample: . ¢';.~ Nitrate ~--')'-~!~ I Other bacteria Collected by: B, SEPTIC/HOLDING TANK DATA Date installed 0¢/r¢ / ~¢r"c/ Tank size /~-~"O Cleanouts (Y/N) ¢~-- Foundation cleanout (Y/N) High water alarm (Y/N),, Date of pumping ~/.~/¢~ Compartments y Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I To property line _'~ ~,~ Surface wateddrainage On adjacent lots Absorption field Foundation J { Water main/service line .'~ ! 0 72-026 (3/93)* Front CONTINUED ON BACK PAGE Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ¢ Length '~ y, ~ Width Total absorption area f-7[/ y Date of adequacy test ~/'7/¢~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/FF) oO'/c~ / Gravel thickness ~:~ Cleanout present (Y/i) yp Results (pass/fail) System type Total depth ! 0 Depression over field (Y/N) for ¢ After test 1~ ~f If yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ l ¢ To building foundation On adjacent lots .~' Surface water Curtain drain On adjacent lots '~ ~) ~:~ Property line '~ ~ To existing or abandoned system on lot ~/A Cutbank Water main/service line ~ ,.¢ 0 Driveway, parking/vehicle storage area ~ ,5'" ID E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effechon the date of this inspection. Date Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number '-- DATI~"R~'CEIV ED INSPECTION APPOINTMENTS TIME TIME TIME INSPg~TOR INSPECTOR INSPEC~[cIPALI~ OF ANCHORAGE ~~ DEPT. OF ,,~ALTH & MUNICIPALITY OF ANCHORAGE 82~ L Street - Anchorage, Alaska 99501 ' ENVI.ON.ENTAL SANITATION DIVISION RECEIVED Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES )IRECTIONB: Complete ail parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days Jor processing. PHONE 1, PROPERTY OWNER c_~ ~ ~z ~ .. MA~EING ADDRESS PROPERTY RESIDENT(If different from above) [ ' ' PHONE MAILING ADDRESS 3, L~NDINglN~TITUTION J P~ONE ~AI LING ADD~ESS 4, B~ALTO~/A~NT ~ ~ J P~ON~ I MAILING ADDRESS 5, LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE ~ SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One [] Four [] Two [] Five ,~- Three [] Six E~ Other 7. WATER SUPPLY ~___ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) s, SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONL, 'lJ. 1. TYPE OF RESIDENCE ¢J~. SINGLE FAMILY [] MULTIPLE FAMILY 2, WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY "Co~nnection Verified 3. SEWAGE DISPOSAL SYSTEM []INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Sept,lc Tank or [~]Holding Tank Size: /C~d~ ~ If Tank is homemade give dimensions: NUMBER OF BEDROOMS [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line Absorption Area Sewer Line [] OTHER Septic/Holding Tank INearest Lot Line 5, COMMENTS DATE [~'~APPROV ED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) /'% [] DISAPPROVED BY'~' L ~~ 72-010 (Rev. 6/79)