HomeMy WebLinkAboutHIGHLAND TERRACE LT 2Onsite File
Highland
Terrace
Lot 2
#050-312-06
Municipality of Anchorage
On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201049 PID Number: 050-312-06
Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ D Duplex p (D) ❑Two Single Family Project: ❑New RE Upgrade
Name
CLARISSA VOTH
ABSORPTION FIELD
RE Deep Trench ❑Wide Trench ❑ Bed ❑Mound
El Other
Soil Rating Total depth from original grade
1.2 GPD/SF 12 - MAX. Ft.
Depth to pipe invert from original grade Gravel depth beneath pipe
SEE DWG. Ft, 6 Ft.
Site Address
10921 HIGH BLUFF DRIVE, EAGLE RIVER, AK 99577
Phone Number of Bedrooms
240-0355 4
LEGAL DESCRIPTION
Subdivision Block Lot
HIGHLAND TERRACE - 2
Fill added above original grade
SEE DWG. FL
Gravel length
45 Ft.
Township Range Section
-
Gravel width
2 Ft.
Beds: Number of Lines
-
Distance between lines
-
SEPARATION DISTANCES
70
From
Septic
Tank
Absorption
Field
Lift Station
__[
Holding
Tank
Sewer
Line _
Ft.
Total absorption area Number of trenches Dist. between trenches
540 FC _ Ft.
TANK ®Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Well
PUBLIC
PUBLIC
PUBLIC
Manufacturer
GREER TANK
Capacity
1250 Gal.
Surface Water
100+
100+
_
_
Material
HDPE PLASTIC
Number of compartments
2
Lot Line
10+
10+
_
_
NA
Foundation
10+
10+
_
_
LIFT STATION
a er
Capacity
Remarks REQUESTING 5 LOT LINE WAIVER TO RESERVE SITE
Gal.
BE AMENDED TO ALLOW 2 FEET SEPARATION TO LOT LINE.
Alarm locationinstalled
by
PIPE MATERIAL House to tank Tank to
Installer D3034 drainfield D3034
NORTHERN EXCAVATION Drainfleld D3034 CO/MTD3034
Inspector JODY MAUS, GARNESS ENGINEERING GROUP, LTD BENCHMARK (Assumed elevation) 100.00 ft
Inspection v 8/5/202�c 8/6/20 Location and description
dates:
Std 8/6/20 4t^ - BOTTOM OF SIDING ON CARPORT NEAR POINT "B"
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp
conditional Approval:1 , OF 4/
Date 4 ..
0o
. *....... ...... �..... .��.
ll ;.�1; .f,..
Septic System �� i/frey A. r � ss.•'
Approved Date 1 1y 20.21 Qp9 :• C —7}Q53 .c
Note: this approval does not include well permit requirements. 4�p�p�ofess o�°oma
#AECC884
(Rev 05/02/18)
PERMIT NUMBER:RECORD DRAWING 1 A� pJI-,1(V/tV( I N G PARCEL ID NUMBER:
OSP201049 050-312-06
I
I
I
(
I I
I
I
5' LOT LINE WAIVER
(GRANTED FOR RESERVE SITE
REQUESTING WAIVER
BE AMENDED TO 2 FEET -
RESERVE SITE
NEW DRAINFIELD
I
I I
INSTALLED DOUBL
CLEANOUTS
(DBL5 & DBL6)
i
I
( I
I
4
1250 GREER PLASTIC
SEPTIC TANK
x
9
�5 8
3 w EXISTING 0
o0 GARAGE U o
Qz
UO
U
DBL1
57.0
92-4
PAGE NUMBER:
DBL2
56.6
91.9
NEW SEPTIC TANK WAS INSULATED WITH 4" OF RIGID
DBL3
52.8
27.5
61.6
DBL4
54.0
27.3
61.3
FC01
15.3
27.8
-
FCO2
49.8
26.3
60.5
MH1
55.5
27.7
ST1
59.5
28.5
DBL5
60.8
26.6
58.4
DBL6
60.3
25.6
57.5
C01
56.0
16.2
45.7
MT1
55.5
15.9
45.7
CO2
36.2
11.0
MT2
35.5
10.3
EXISTING FOUNDATION CLEANOUT (FC01) WITH
DRIVEWAY PAVER COVERS, NEW SEWER LINE
FROM FC01 TO NEW SEPTIC TANK
APPROXIMATE WATER SERVICE LINE LOCATION PER
CONTRACTOR. LOCATED BY ONE STOP SERVICES
(CONTRACTED BY OWNER). PER CONTRACTOR, WATER
SERVICE LINE IS 10+ FEET FROM NEW SEWER LINES, GEG
WAS NOT NOTIFIED OF LOCATE AND WAS NOT ABLE TO
VERIFY SEPARATION DISTANCE WAS MET
INSTALLED DOUBLE CLEANOUTS
(TH DRIVEWAY
PAVER COVERS. NEW SEWER
LINE INSTALLED FROM DBL CO'S
_ r TO NEW SEPTIC TANK
R��M
4" "OUSE
WATER MAIN LOCATION PER
AWWU RECORD DRAWINGS
NOTE: THE OLD SEPTIC TANK FOR THE HOUSE AND
THE OLD SEPTIC TANK FOR THE GARAGE WERE
DECOMMISSIONED PER UPC PER THE CONTRACTOR.
GEG, LTD, WAS NOT AWARE OF THE SEPTIC TANK
THAT SERVED THE GARAGE AT THE TIME OF
INSTALLATION. DISCUSSED WITH TIM EKLUND WITH
MOA ONSITE DEPARTMENT WHILE ONSITE AND HE
STATED TO DECOMMISSION THIS TANK THE SAME AS
SEPTIC TANK FOR HOUSE, PER THE OWNER, ONLY A
SINGLE TOILET AND SINK EXISTS IN THE GARAGE.
"ARNESS EN"INEERIN" "ROUP_w td
ENGINEERING SALES= CONSULTING ..... 9,
3701 E. TUDOR ROAD, SUITE 101 `ANCHORAGE, AK 99507' PHONE (907)337-45179' FAX (907) 33&3246 " WEBSITE: www.gamessengineenng.com
PREPARED FOR:
PHONE NUMBER:
INSTALLED DOUBLE
PAGE NUMBER:
CLEANOUTS
NEW SEWER LINE FROM CONNECTION POINT TO
(DBL3 & DBL4)
NEW SEPTIC TANK WAS INSULATED WITH 4" OF RIGID
PROJECT/LEGAL DESCRIPTION:
INSULATION BY 4 FEET WIDE CENTERED OVER PIPE
OLD LOG CRIB WAS
PER THE CONTRACTOR, EXISTING SEWER LINE HAD
DECOMMISSIONED PER UPC
4+ OF INSULATION OVER THE SEWER LINES.
PER THE CONTRACTOR
DATE:
WATER SERVICE LINE LOCATION PER
AWWU WATER CONNECT CARD. WATER
LINE LOCATED BY ONE STOP SERVICES
-WATER KEY BOX LOCATION PER
(CONTRACTED BY OWNER)
AWWU RECORD DRAWINGS
WATER MAIN LOCATION PER
AWWU RECORD DRAWINGS
NOTE: THE OLD SEPTIC TANK FOR THE HOUSE AND
THE OLD SEPTIC TANK FOR THE GARAGE WERE
DECOMMISSIONED PER UPC PER THE CONTRACTOR.
GEG, LTD, WAS NOT AWARE OF THE SEPTIC TANK
THAT SERVED THE GARAGE AT THE TIME OF
INSTALLATION. DISCUSSED WITH TIM EKLUND WITH
MOA ONSITE DEPARTMENT WHILE ONSITE AND HE
STATED TO DECOMMISSION THIS TANK THE SAME AS
SEPTIC TANK FOR HOUSE, PER THE OWNER, ONLY A
SINGLE TOILET AND SINK EXISTS IN THE GARAGE.
"ARNESS EN"INEERIN" "ROUP_w td
ENGINEERING SALES= CONSULTING ..... 9,
3701 E. TUDOR ROAD, SUITE 101 `ANCHORAGE, AK 99507' PHONE (907)337-45179' FAX (907) 33&3246 " WEBSITE: www.gamessengineenng.com
PREPARED FOR:
PHONE NUMBER:
PAGE NUMBER:
CLARISSA VOTH
240-0355
2 OF 3
PROJECT/LEGAL DESCRIPTION:
DRAWN BY:
HIGHLAND TERRACE; LOT 2
J.L.M.
TYPE OF WORK:
DATE:
RECORD DRAWING OF NEW SEPTIC SYSTEM
1/7/2021
Q
SCALE:
1"=40'
*_*ws aILwit•11
4........ ....................
♦ J• e amess .: cu r
♦+�� �, Cj 7 53 .A
+1*: r•• ; P `zi..�<<40
LICENSE �ESS� #
#AECC684 11 �il�M J
PERMIT NUMBER: PARCEL ID NUMBER:
OSP201049 RECORD D RAW I N G 050-312-06
FINAL GRADE STI
TOP OF MH LID = 98.73 = 98.57-98.58
MH
TOP OF TANK @ TOP OF TANK @
INLET = 94.63 OUTLET = 94.63
2" OF INSULATION
INVERT OF BUNG
@ INLET = 94.04 NEW 1250 GALLON INVERT OF BUNG
GREER HDPE @ OUTLET = 93.79
SEPTIC TANK
FINAL GRADE 1 N1T1 ORIGINAL GRADE @
C0
= 99.27-99.97 CO2 MT2 HIGHEST POINT = 99.21
TH#1
/f
FILTER FABRIC
10
INVERT OF DIST.
LINE = 93.21
BOTTOM OF
TRENCH = 87.21
RELATIVE ELEVATION OF BOTTOM OF TEST HOLE = 80.71 (TH DRY ON 3119/2020 8 8/5/2020)
lw**,t1\1 lk M
OF
OlrTp
kG
' ..... '.... 4 .........................
-- ENGINEERING,=SALES -CONSULTING
3701E TUDOR ROAD, SUITE 101•ANCHORAGE,AK99507-PHONE (907)337-6179' FAX (907)338.3246'WEBSITE.www.gamessenglneenngcomi TMz .... • • •.•..••...•.•..• ••.•...tj�0
PREPARED FOR: Pff
HONE NUMBER: PAGE NUMBER: ♦ � A. Game s LZ rr
CLARISSA VOTH 240-0355 3 OF 3 ♦,►♦ �,'�
PROJECT/LEGAL DESCRIPTION: DRAWN BY: ♦ !l •
HIGHLAND TERRACE; LOT 2 J.L.M. ♦1c�Q��`'`p��••.• ;....�(��''A�, ���`
TYPE OF WORK: DATE: LICENSE +i1M\rt���►"'~•
RECORD DRAWING OF NEW SEPTIC SYSTEM 1/7/2021 #AECC884
5KWARD & A.66UUlKfB6 WIND 5ME11ING 694,-UbZL4
I HEREBY CERTIFY -THAT I HAVE SURVEYED THE I SCALE. Z
FOLLOWING DESCRIBED PROPERTY:
'01
DATE-
PDAT
AND THAT NO ENCROACHMENT6 EX'IST EXCEPT AS
INDICATED. 17 IS THE RESPONSIBILITY OF THE
OWNER -10 DETERMINE THE EXISTENCE OF ANY GRID:
EASEfWENTS, COVENANTS., OR RESTRICTIONS
Duan. Me:rr
WHICH DO NOT APPEAR ON THE RECORDED SUSDI- SQward
VISION PLAT- UNDER NO CIRCUMSTANCES SFOLU F8 --
MY DATA HEREON BE USED FOR CONS'TRUCTION
OF FEMCE LIMES, OR FOR ESTABLISHING BOUND-
ARY LINES. DRAWN:
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box ? 96650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
httpj/www.mwni.orgionsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP201049
Work Type: Septic Upgrade
Tax Code Number: 05031206000
Site Legal Address: HIGHLAND TERRACE LT 2 G:0155
Site Mailing Address: 10921 HIGH BLUFF OR, Eagle River
Owner: VOTH CLARISSA
Design Engineer: GARNESS ENGINEERING GROUP LTD
This permit is for the construction of:
❑ Disposal Field Z Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date
t„cnr
�J
Ik•parnncnt
Lot Size in Sq Ft:
Total Bedrooms:
4/1/2020
4/1/2021
P1+P r o
❑ 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
/t
Date:
Date:
Municipality of Anchorage
P.O. Box 196650 ® 4700 Elmore Road
Anchorage, Alaska 99519-6650 ® (907) 343-7904 a Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Department
On -Site Water and Wastewater Section
y t��l.C�it t
llcp:u•tntcltt
x* x x VALIANCE/WAIVED REVVIEW x x x x
Waiver#: OSV201013 COSA#: Permit#:OSP201049
PID#: 050-312-06
Legal Description: Highland Terrace Lot 2
Engineer: Garness Engineering Group
Applicant: Clarissa Voth
Your request for a waiver of the required 10 feet horizontal separation from the reserve
absorption field to the property line has been approved. The approved separation distance is'�,,b
feet. See engineer's waiver request for justifications.'
This waiver approval applies to the proposed reserve absorption field only.
............................................... ■ ............ \ . ax n .......... t . ■ t
Waiver is Granted: X Waiver is not Granted:
,0
Date: 3 31/,� ()�DA roved b :pp Y -
Name of Reviewer
**** VARIAN C EMAIVE R REVIEW ****
EPS
MUNICIPALITY OF /INCH i A
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. 050-312-06
Property owner(s) CLARISSA VOTH Day phone .G40-0355
Mailing address 10921 HIGH BLUFF DRIVE, EAGLE RIVER, AK
Site address 10921 HIGH BLUFF DRIVE, EAGLE RIVER, AK
Legal description (Sub'd., Block & Lot) HIGHLAND TERRACE S/D; LOT 2
Legal description (Township, Range& Section)
Lot Size Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
{® all that apply}
Upgrade
Absorption Field
Q
Septic Tank
I -Xi
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
APPLICATION IS AN:
Initial
❑
Upgrade
Q
Renewal
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
LOT LINE WAIVER TO RESERVE SITE
TYPE OF DWELLING:
Single Family (SF) ID
(w/wo ADU)
Duplex (D) ❑
Multiple Dwellings ❑
(SF and/or D)
Distance: 5'
I certify that the above information is correct. l further certify that this is inaccordance with
applicable Municipal Codes.
i
f'
(Signature of property owner or authorized agent)
Permit/Rush Fees:. Sqs, Waiver Fees:
t /r
Date of Payment: c3��11 oC1Date of Payment:
Receipt Number: Receipt Number:
Permit No. COP 9 6 l dLi 1 Waiver No. V 2C I !3
GADevelopment ServiceslBuilding SafetyMn Site Water and WastewateffomtslClient FormsTemtit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201049, Rebecca Carroll, 04/01/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201049, Rebecca Carroll, 04/01/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201049, Rebecca Carroll, 04/01/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201049, Rebecca Carroll, 04/01/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201049, Rebecca Carroll, 04/01/20
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DATE SCHEDULED 10171f TIME 10!o6 INSPECTOR 1
SUBDIVISION HIGHLAND TERRACE BLOCK/LOT/TRACTLT 2
INDICATE NORTH
hoose
SIZE CONN 1"
CORP. STOP
CURB STOP C TO C
FT. COPPER PIPE
1 1/4" OR 2" KEY BOX
FT. THAW -WIRE
THAW-PLATE/NUT
KEARNY CONNECTOR
OTHER
C a /i 4 e a xe0 7/o �.I i s • "S
31+e -cl/ e, J, /d �i'7 5 r'Ole /loose
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I-I�DOMESTIC ONLY
I J FIRE LINE ONLY
0
Fl�_
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BOTH FIRE & DOMESTIC
FIRE HYDRANT ONLY
m
0
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b�3
SJn
DATE OF TAPE / / BY
SIZE MAIN I I ALLEY STREET ; EASEMENT
TYPE MAIN EXCAVATOR
DISCONNECTS j YES f NO SIZE OF DISCONNECT
COMMENTS
KEY BOX LOCATION '?S- /� D S �_
s 4_/Gok cr ljous, =�
INSPECTION REPORT
-±'LINE BLOWN OUT 14 / 7 INSULATED
�T- .B. & T.W. - OK AFTER BACK -FILL
I OPEN BORE FLUSH
1 200 LB. TEST
MAIN CHLORINATED
CHLORINE FLUSHED ! /
-105K TO TURN -ON DO NOT TURN -ON
INSPECTORGrJ
DATE (o / 7 / y'
COMMENTS
Go�1�7leGIC' V -F 17 0/ .OhsSiLhC IC-
CS.'S Cahhpc7�e.of
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not overlap ae et:<ta:eh aQ thef pr iYnlwineent l
tare that as lmpttrY meat{t on Pr•opettj ltfrLi Adjacent til
'� -• �-'. „ W� •.,.� e"Craactt at 'tie Premises in Question amd that there al
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1
Carroll, Rebecca M.
From:Jody Maus <Jody@garnessengineering.com>
Sent:Wednesday, April 1, 2020 11:04 AM
To:Carroll, Rebecca M.
Cc:Jeff Garness; Sonja Blewett
Subject:FW: Comments from MOA for Highland Terrace L2
Attachments:Comments on Highland Terrace.PNG
Follow Up Flag:Flag for follow up
Flag Status:Flagged
Becca,
Per my conversation with the owner’s son on 3/12/2020 while I was on property and logging the test hole, he stated to me
that the well that is shown on the as‐built survey was decommissioned when they connected to AWWU water service.
Please place this email in the file as documentation of my conversation with the owner. I can reconfirm that the well does
not exist during construction if you require. Please place this as a special provision if you feel it is necessary to have
confirmation that the well has been decommissioned.
Sincerely,
Jody Maus
Consultant
Garness Engineering Group, Ltd.
3701 E. Tudor Road, Suite 101
Anchorage, Alaska 99507
Phone: (907) 337-6179
Fax: (907) 338-3246
Mobile: (907) 223-0555
Website: www.garnessengineering.com
oGRE/'
ER ANCHORAGE AREA B0F
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
UGH
NAME
INSPECTION
REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
MAILING ADDRESS ~i/~, J~_, /eX/ /.~¢ /~/,,~.1~/(~/¢/~// RHONE LEGAL DESCRIPTION Z~/t /~" //~¢/f- :~'~/~
SEPTIC TANK: UL;c-
FROM WELL ~-g~'
MANUFACTURER CK ¢~ MATERIAL COMPARTMENTS
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH _LIQUID CAPACITY /~ .GALLONS.
SEEPAGE Pit:
NUMBER OF PITS / DIAMETERS~) ,OR WIDTH /*q . LENGT./~,__ DEPTH
3' /07'
/--O~-¢ ' ~'~' DISTANCE FROM: WELL
LINING MATERIAL CRIB SIZE: DIAMETER_ DEPTH -.
~U,L~,~ ~OUNO~T,O~_(~~ ~, TO~L :~C~,W
, NEAREST LOT LINE . ABSORPTION AREA (WALL AREA) ~ _SQ. FT.
ADDITIONAL ABSORPTION
WELL:
TYPE :~/)~'~// CONSTRUCTION ~)'~/~Ji.~/~J'~j~/ DEPTH DISTANCE FROM:
BUILDING NEAREST NEAREST SEPTIC £.-,/ SEEPAGE I~ I
FOUNDATION __ LOT LINE SEWER LINE TANK ~/ SYSTEM
/~/
OTHER SOURCES
CESSPOOL
APPROVED
DISAPPROVED REMARKS
DISTANCES:
INSTALLED BY:
PIPE MATERIAL:
LOT SLOPE:
Form No, EQ.031
DIAGRAM OF SYSTEM
INSTALLATION LOCATION
GREATER ANCHORAGE AREA ~3OROUGH
DEPARTMENT O1" ENVIRONMENTAl. QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 2:74-4561
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
PERMIT NO. _
SEEPAGE PIT ('""/ DRAIN FIELD . OTHER
COMPLETION DATE ANTICIPATED
TYPE
~41NIMUffi DISTANt. ES, RBQUIRIi:MF-NT$
..... DRAIN FIELD -
, DRAIN FIELD
/ /o0 /
· SEEPAGE PIT
ALSO CONSIDER AREA WELLS.
\~/ATER MAIN TO SEPTIC TANK SEEPAGE PIT
DRAIN FIELD_
Fca'
SEPTIC TANK, SEEPAGE PIT __ DRAIN FIELD
TD RIVER, LAKE. STREAM.
CAS] IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP Of
EXCAVATION 5 FEE]' INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
ID IA(~R~ M OF
G[~AVEL BAI01~FILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
I CERTIFIP/Y~/]HAT I AM PAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO, 28-68 AND 'rHAT THE ABOVE
DESCRI(E/~ SYSteM IS IN ACCORDANCE WITH SAID CODE. ~
DAT APPLICANT'S SIGNA
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAl_ OUALITY Case #
3330 "C" Street
NCHORAGE ALASKA 99503
Legal Description: Lot ~ B~o~k S u b d i v i s 'i o n__Z~2 ~'~ ZSiZ~___
This Form Reports Soils Log__~ Percolation Tesl:
Soil Test Must Be Logged To 4' Below Proposed Seepage System
Depth
Feet Soil Characteristics
Was Ground Water Encountered?
It: Yes, At What Depth?
._J__L_ I
Reading
Date
Gross Time
N e t T i in e
Percolation Rate Minute
Proposed Installation: Seepage Pit
Depth of Inlet
COMMENTS: ___/~_~)
Depth to H20
Net Drop
Drain Fie'Id
Depth to Bottom of Pit Or Trenc~ .......
Test Performed BY_~_= ~]' ~ Date Certified
Date:
Time Time
Date Date
Inspector Inspector
Comments
Date
Inspector
Date Sewer Installed
Permit No.
Septic Tank Size
Holding Tank Size
Soils Rating Well To Absorption Area Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner
Mailing Address
Phone
Buyer
Address
Lending Institution
Address
~o. & Agent
Phone
Phone
Type ,cf Residence %3 Single Family
[3 Multiple Family
[] Other
No. of Bedrooms
Wate, r,,Supply 4'~ Individual
[] Community
[] Public Utility
ATTACH WELL LOG. A well log is required for all wells drilled since June
1975. For wells drilled prior to thai date. gwe well death (attach Icg if
available.)
SewAge Disposal
ff~ Individual
[] Public Utility
EJ Holding Tank
Year Individual Installed:
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.