HomeMy WebLinkAboutSPANISH HILLS LT 3Spani
h Hill
Lot 3
#017-151-03
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Water System Permit
Permit Number: OSP231197
Work Type: Well Upgrade
Tax Code Number: 01715103000
Site Legal Address: SPANISH HILLS LT 3 G:2939
Site Mailing Address: 13301 CARITA LN, Anchorage
Owner: BUNKER MATTHEW K & JULI S
Design Engineer:
This permit is for the construction of:
Effective Date:
Expiration Date
Lot Size in Sq Ft:
Total Bedrooms:
V„cnc S
A0
N
Department
7/10/2023
7/9/2024
47425
❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy Z 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:
To close this permit please submit:
1. Well Log
2. Pump Install Log
3. Water sample results
4. Well Decommissioning Log
Rsceived=By: -Fo Ocy/1 e r Date:
Issued By: Date: %����
101
1
Development Services Department i;" j% Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel 1. D. 017-151-03
Property owner(s) Matthew & .hili Bunker Day phone 907-240-3938
Mailing address 13301 Carita Lane, Anchorage AK 99516
Site address 13301 Carita Lane, Anchorage AK 99516
Legal description (Sub'd., Block & Lot) Spanish Hills Lot 3
Legal description (Township, Range & Section)
Lot Size 47,425 Sq. Ft. Number of Bedrooms 6
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑ Initial ❑ Single Family (SF) 0
Septic Tank ❑ Upgrade Fx� (w/wo ADU)
Holding Tank ❑ Renewal ❑ Duplex (D) ❑
Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well Fx�
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Cod S.
(Signature of property owner or authorized agent)
Permit/Rush Fees: Z. S_ Waiver Fees:
Date of Payment: Z zo Z 3 Date of Payment:
Receipt Number: D I C-) `0 Receipt Number:
Permit No. OS P F_ 311 cl7 Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
June 21, 2023
Municipality of Anchorage
Development Services Department
4700 Elmore St.
Anchorage, Alaska 99519
RE: Application for a replacement well
Spanish Hill Subdivision, Lot 3
Please see the attached as -built for the proposed new well placement. It will be placed near the existing
well. The purpose for the new well is to drill a deeper well for better flow rate, at the depth of
approximately 350 feet.
I submit this attestation with my permit application, that I have confirmed the necessary minimum
separation requirements for those items listed in permit requirements for a private water well. These
include:
Curtain Drain
Hydrocarbon storage tanks
Sewer, Septic, water wells, as per current MOA COSA data
Animal containment areas
Manure storage areas
Public sewer manhole or cleanout
Other sources of potential contamination
Aw"
Matthew K. Bunker
Homeowner 13301 Carita Lane
Anchorage, Alaska 99516
907-240-3938
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Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211295
PID Number: 017-151-03
Dwelling: K Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New Q Upgrade
Name
Michael Stewart Harding & Glenna
ABSORPTION FIELD
Deep Trench ❑Wide Trench
El Deep Bed El Mound
Site Address
13301 Carita Lane
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
6
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Gravel depth beneath pipe
Subdivision
Block Lot
Spanish Hills
3
Ft.
Ft.
Fill added above original grade
Gravel length
Township Range Section
Ft.
Ft.
Gravel width
Beds: Number of Lines
Distance between lines
SEPARATION DISTANCES
Ft.
Ft.
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft2
Ft.
Well
TANK ❑® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Greer
Capacity
1500/1000 Gal.
Surface Water
1W 7-
-
Material
Number of compartments
Lot Line
5'+
NA
HDPE
1/1
Foundation
1p'+
FT STATION
anufacturer
[Alarm
Capacity
Remarks
renco
1000 Gal.
location
Garage
Electrical installed by
Installer
PIPE MATERIAL House to tank 3034 Tank to3034
drainfield
Dean Construction
Drainfield CO/MT3034
Inspector Pannone Engineering
BENCH MARK (Assumed elevation) 100 ft
InspectionX51 9/16/21
Location and description
es: 2 nd
3r
41h
Garage FF
ON-SITE WATER AND
WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
Date
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Steven 'r<. Pannone Fe
�d �� . CE 1t�
Septic System
Approved
_ Date
Note: this approval does not include well permit requirements.
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NOTES:
RECORD DRAWING
SEPTIC TANK
DRAWN I LJC/DRM
SITE PLAN
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RISER
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CLEAN OUT
i CLEAN OUT
LIFT STATION
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' 'BUENA� s
PANNONE ENG SVC LLC (C t. 1088)
P.O. BOX 1807 PALMER. AK 99645_.
PHONE (907) 745-8200 FAX (907) 745-8201
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REVISIONS
DATE
70/7/2021
SCALE
1" = so'
SPANISH HILLS LOT 3
MICHAEL STEWART HARDING & GLENNA_-
RAE EMERICK
SITE: 13301 CARITA LANE
ANCHORAGE, AK 99516
017-151-03
PERMIT N0.
OSP211295
SHEET
2 OF 2
MUNICIPALITY OF ANCHORAGE
On -Site Water& Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP211295
Work Type: SepticTank Upgrade
Tax Code Number: 01715103000
Site Legal Address: SPANISH HILLS LT 3 G:2939
Site Mailing Address: 13301 CARITA LN, Anchorage
Owner: GM HARDING TRUST
Design Engineer: PANNONE ENGINEERING SERVICES
This permit is for the construction of:
Effective Date
Expiration Date
�t-Hent ,
�°
EG �
v
Department
Lot Size in Sq Ft:
Total Bedrooms:
7/29/2021
7/29/2022
47425
❑ 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
i
Special Provisions: A minimum 20 -inch manway riser shall be provided to the first compartment of the septic
f I tank, in accordance with AMC 15.65.205F.1.
r1
Received By: Date:
Issued By: Date: 7 2 9 zoz T
L
MUNICIPAUTY
Y
Community Development Department
Development Services Division
On -Site Water & Wastewater Program
ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 017-151-03
Property owner(s) Michael Stewart Harding & Glenna Rae Emerick
Mailing address
Site address 13301 Carita Lane
Day phone
Legal description (Sub'd., Block & Lot) Spanish Hills Lot 3
Legal description (Township, Range & Section)
Lot Size 47,425 Sq. Ft. Number of Bedrooms 6
APPLICATION 1S FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(Z all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF)
X❑
(w/wo ADU)
Septic Tank
X❑
Upgrade X❑
E71
(D)
Holding Tank
❑
Renewal 1-1Duplex
Multiple Dwellings
❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION
INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I 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: 9 ;2'� 5 Waiver Fees:
Date of Payment: 71Aol2 o t % _ Date of Payment:
Receipt Number: ® `1 1(0.36 Receipt Number:
Permit No. Oslo of 11-q .s Waiver No.
Permit App_-'- :- :-..:c:
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211295, Rebecca Carroll, 07/29/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211295, Rebecca Carroll, 07/29/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211295, Rebecca Carroll, 07/29/21
Municipality of Anchorage Page .
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: S~,/~,"~ ~.~ PIDNumber:
N~: ~~ ~ ~. ~ O ~ ~ Wastewater System: D New ~Upgrade
Address: ' ~
L3~ I ~.~ ABSORPTION FIELD
Phone: Nc. of B~rooms: ~ Deep Trench D Shallow Trench ~ Bed ~ Mound D Other
LEGAL DESCRIPTION so, Rating: Total Depth from original grade:
~,~ ~sq.~t. ~ - I
Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township:~ Range~ .ti Section: ~ Fill added aboveooriginal~ ~grade: FI. Gravel length: ~ Ft.
Number of lines: Distance between rises:
WELL: O New D Upgrade Gravel~e?~ ~ Ft. ~ ~q I~ Ft.
Classification (Private, A,B,C): T~tal Depth[ ' Cased To: Total absorption ares: Pipe material:
Ft. FL ~O SO. Ft.
Driller: Date Drilled: SlalicWaterLevel: installer:
Date ins~lled:
-' Casing Height Above Ground:
Yield: Pump Set at: TAN K
GPM . Ft. Ft.
SEPARATION DISTANCES ~Septic ~ Holding D S.T.E.P,
To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallon~:
From Tank Field Station Tank Sewer Lines ~--~ --.
Material: Number of Compartments:
Surface
Water ~/~ N/~ ~/~ LIFT STATION
Lot Size in gallons: Manufacturer:
Foundation
Curtain Drain ~- ~ ~ ~ i Pump ~ Ma~e ~ ~ & Model ~ ~ Electrical inspections ~ ~ performed ~ ~ by:
Remarks: BENCH MARK
~ ~ J Assumed Elevation:
Inspections performed by: Dates: 1st 7
Department of H ma es appro
Reviewed and aoprovod~~~~e:
72-013 (1/91) MOA25
4PPRDK. L~lCA~DN
AL(GNMENT [~F EKISTING
TREN£H UNKNDWN ·
87
67
$CALE~
i' = 50 FT,
1~$ 15'8
TDBBEN ~URKLAND P,E,
203 ~ 15TH, AVENUE
ANCH, AK, 9950!
LDT 3 SPANISH HILLS SAD
SHELBY STASTNY
13301 CARITA ££IVE
SHEET, 2/3 GR~D,2939 I
Tube ~ (~-1/4 PV£ $/l&' No/es ~ 6'
No,Ilar Tube ~ 0 ~ 500 ~AL
ACR£AGE t IFT
STAT]DN
I 0 ooo
GREER TANK
~. 3 rt o~ Cover
6'
500 GAL LIFT 2TATIflN --
~ Gal 2TEP Tank
l' = 15 FL
TUB~EN ~PURKLAND P,E, LOT 3 2PANI~ HILLS SEPTIC SYSTEM AS ~UILT
6751 W, ~IMDN~ BLV~,
ANCH, AK, 99502-3904
Honlfor Tuloe ~-~ 0
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
(ENGINEER'S SEAL)
SLOPE SITE PLAN
10
11
12
13
14
15
16
17
18
19
20
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Beplh to Waler Aller
I~lonilerin[~? Bale:.
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE __
(minutes/inch) PERC HOLE DIAMETER
~ ~ .. TEST RUN BETWEEN FT AND __ FT
PERFORMED BY: ~ CERTIFY TMAT THIS~ST WAS ~ERFORME~
72-00~ (Bev.
3500
LOT: 3 ~LOC~ ~UBD~ 9PhNISH NII.LS Dfl~; 12/191199l
0 0
NO NONCOFt?L}EANC~ OBSERVED ~. ] CORRP. C~ION,~ ESSENTIAL
WILl, ~gXA~N~: AY NEXT iNSPECTION [ ] DO NO~ CONCEAL UN'~L
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW910373
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:STASTNY JOHN S &
OWNER ADDRESS:13301 CARITA LANE DR
ANCHORAGE, ALASKA 99516-3713
DATE ISSUED: 12/11/91
EXPIRATION DATE:12/11/92
PARCEL ID:01715103
LEGAL DESCRIPTION: SPANISH HILLS LT 3
LOT SIZE: 47425 (SQ. FT.)
NUMBER OF BEDROOMS: 6 THIS PERMIT: 6
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AACS0).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
DATE:
It-
DATE:
(907)
SEPTIC SYSTEM DESIGN
LOT ~ SP6NISH HILLS
SHELBY STASTNY
I",1o Gr'~]und Natel'" Ol'" Impel'"vic]u~ L.,::'~yel~ to ;[6 ~:t,,
l.h~ c.~ F'r'e~3 ~,Ltr' i Z ed
Sc:ill. 1 I:::a'kiF,¢ ~) .".!!; 'f't: F'rc:~m '!'.e~.~.d: Oct'..
4~31~d. ri / i r'l = ,, ;i!!; gal/mi
BED
TOTAL LENGTH
TOTAL NIDTH
AREA 72 X 42 =
TOTAL DEPTH
ROCK DEPTH
COVER
SEPTIC TANK
72 FT.
42 FT.
5024 SQ.FT.
4 FT.
.5 FT.
5 FT.
2250 GAL.
ABANDON EXISTING SYSTEM
PUMP AND CRUSH EXISTING TANK
'T'he :[n!!~'ka].].aticln o.1: tl'~i!~ ~eptJ. c '~:¢ys~te~m vd, Il
,ftn3m bc~ ir'l¢:.,~.tl].~.::~cl (::)n 'the ~C;I.j~.%C:¢f¥12 ].Ot~.
CO ~ 0
q~ ~:~ o
~' o
Well
Well
N
q.
50 100 !50 200 250 300
SCALD i' -- 100FT,
TOBBEN SPURKLAN3 P,E, II
203 t,/ 15TH, AVENUE II
ANCH, AN, 99,501 II
LDT 3 SPANISH HILLS S/D
SHELgY S?ASTNY
13301 CARITA DRIVE
SEPTIC SYSTEM DESIGN
BATE, DOT, 30, 199I
SHEET, !/3 GRID, 2939
Well [
T3M ~ARAGE SLAR --
ELEV, 100,00
-~ b/ell
TANK ~ITH 2250 GAL S7EP TANK
,AL. IONMENT, DF, EXISTING
TRENCH UNKND~/tq
98,8
?R~PDSEB
EXISTING
PRESSURIZE9 A3SZ?£P1
TEST ~ It~TAI. LaTII]N
DRAWLING REVISEfl, fiE& .5, 1991
SO 0 .50 i00 150 200 850 SO0
SCAL£: Y' = I00 FT,
]l l~??,s=~,?5, f2~ [[ LDT 3 SPANISH HILLS S/fl ~ sE~T,~ ~T~. ,~s~
:~o w ~o n, ,v:~u: II SHELRY STASTNY II DATE, DeL 30, 1991
ANCH AK 99501 ~~.~ ~
~~ lSSOl C~RIFA DRIVE _~ U SHEET, 1/3 GR[~,2939
4500
6,8.OO
0 ~ [-- I-I/4PV£ I/8'yoloSa't b'
No,trot Tube' -- ~ 0
p' PVC Il) STEP TANK
Nm, 3 Ft oF Cover
0£ 2ed oev. 99~.
£otto~ 0£ £ed Der, 95~-
MPa £1 140
6' o£ Septic rock
Sand Iovelln9 layer
i' = 1~
2,250 6al STEP Tabk
FLOAT SETTINb&
ALARH p 54'
BO£AGD 14p ool
£ESEpVE Cb~ £176AL.
TDBBEN SPURKLAN~] P,E, ~
6751 ~/. DI~DND BLVD,
ANCH, AK, 9950~-3904
(9Q7) E48-5,095 ~
LOT 3 SPANISH HILLS
SHELo~Y STASTNY
13301 CARIfA
SEPTIC SYSTEM DESIGN
DATE, OCT£~EQ 3g 199]
SHEET, 3/3 GRID, £939
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 & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Township, Range, Section: ,--~-~ r~', T/;~/~/
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT Q
DEPTH? p
E
Deplh to Water Alter
Monitoring? Date:
Gross Net Depth to Net
Reading Date
Time Time Water Drop
~ ?'7 ~u ,$~v /'~ t~Z'~
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inch) PERC HOLE DIAMETER
COMMENTS
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFEC~T ON THIS DATE. DATE'
72-008 (Rev. 4/85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: ¢-~('~) ~_~C / ~J
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14-
15-
16-
17
18
19-
20-
WAS GROUND WATER
ENCOUNTERED?
(ENGINEER'S SEAL)
Township, Range, Section:
SLOPE
S
L
IF YES, AT WHAT O
DEPTH? p
E
Deplh t0 Walar After
f~onitoring? Date:
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE Y'~'J (m~nutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~-~ FT AND ~ y~-- FT
COMMENTS
PERFORMED BY: &,L)-Z,.C,f~" ' I ~./~.~. b~'~ CERTIFY THAT ~HIS TEST WAS PERFORMED IN
72-008 (Rev. 4/85)
Municipalil¥ of ~nchor~ge
DEPAffiTMENT OF HEALTH & HUMAN SE~VIGES
8~5 "L' Street, Anchorsge, Al~sk~ gg50~-0~50
SOILS LOG ~ PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION: LO'L
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
,- ~f_.L.L.,t.'~ %4 [~':(~ Township, Range, Section:
SLOPE
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Gross Net Depth to Net
~ '~; ~.ea~,n~ Date Time Time Water Drop
' IOj~3/qt I1"~ ~ II
PERCOLATION RATE ,'~'~/.~0 {minutes/inch) PERC HOLE DIAMETER ~ ti
TEST RUN BETWEEN 7 FT AND '7 7~__ FT
COMMENTS
PERFORMED BY: ~"l~'~:L 'UU ~'~? , ~'- ~-¢-"¢¢'~ CERTIFY THAT T~}S TEST WAS PERFORMED IN
7
AOOORDANOEW,THALLSTATEANDMDN,O,, A,_ U,DE',NES,NE EOTONT.,SDATE. DA E: tq l
72-008 {Roy. 4/85)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-472,0
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE
~rUPGRADE
LEGAL DESCRIPTION
LOCATION / '
NO. OF BEDROOMS
PERMIT NO.
No, of compartments
Inside length Liquid depth
IF HOMEMADE:
DISTANCE TO: DwelUn9 PERMIT NO.
Absorption area I Dwelling
Material
-- /Wid~fi
Well
Len§th
Type of crib
DISTANCE TO:
Width
Crib dia~ele~/~
WeU ~ I ~
Total len. g~h.of.tines
Material beneath tile
Depth
Crib depth
Building foundation
Driller
Sewer line
.~ Material
Nearest ~o, Lline
Trench width
t.~) inches
(-~ inches
DISTANCE TO:
Class
Liquid capacity in gallons
PERMIT NO,, .
~,~.a2~be t we e n I i n es
Total effective a~sor~-ion area
[PE~'IT NO. /'
Total effective absorption area
Nearest lot line
Distance to lot line
ARMIT NO.
~ ~ea(sl
Septic tank
OTHER
SOl L TEST R~-NG
INSTALLF~R
REMARKS
APP/RO)V ED
72-013 (~.~, 3/78)
DATE LEGAL
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Municipality of Anchorage
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION POUCH 6-650
ANCHORAGE, ALASKA 99501
,NS~ECT,Or~ REPORT ON ONS,TE SEWAGE D,SPOSAL
LEGAL DESCRIPTION
~0F BED_ROOMS
SEPTIC TANK
MANUFACTURER
MATERIAL
INSIDE DIMENSIONl
LENGTH [WIDTH
\,'~_SO
JCAPAC TY N GALS.
I#OF CO~ARTMENTS
DEPTH
SEEPAGE SYSTEM
[] TILE DRAINFIELD
NUMBER OF LINES
~q
LEN_~GTH E_ACH. .TOTAL LENGTH
DISTANCE BETWEEN LINES TRENC ~ W DTH
DEPTHS:
TILE TO GRADE FLL BELOW TILE FILL ABOVE TILE
~SEEPAGETRENCH OR [] PIT
FILL MATERIAL DEPTH
E] LOG CRIB
[] RINGS~ DIA.
TOT~.~EFECT VE ABSORPTION AREA;, ~ ~,b~ SQ. FT,
WELL
CLASSIFICATIDN DEPTH PIPE MATERIAL
INSTALLER
REMARKS
DISTANCES
SEPTIC SE"EPAG E SEWER
TANK SYSTEM LiNE CESSPOOL WELL
WELL ~
SYSTEM DIAGRAM
¥ /
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E: :i: 'i'I...I[EI:h I::t C1...t':17.~5 ]: O1:~'. :i:]: I'..I'.~:;F' [:ll::'l::'l:~'.(:)',dl~t) i::'t.I::~F:FI" l'"ll::~'-~" !3[~E
Well Lo~
D~ocation: Lot 3 Spanish Hills
esCription:6'"well cased to II4 ft. approx. 53 ft. east of house
MaSerials: topsoil
-19 gravel
20 4-3 sand
~4. 103 gray clay
IOW II2 silt,sand (water bearin~o)
II2 I20 sand,gravel
Static water level:?6
Yield: 6gpm
Drilled by: Thomas Drillers
P.O. box I0-516
Anchorage,Alaska
995II
License # WD 78020
Completed June 25,I975
bl US H
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. 17-151-03 Expiration Date: 2 (97? -
2
1. GENERAL INFORMATION
Complete legal description Spanish Hills Lot 3
Location (site address) 13301 Carita Lane
Michael Shvearl Harding 3 Glenna Rae Emerich 1 CO-TTEES
Current property owner(s) Day phone
Mailing address
Real estate agent Day phone
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 6
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well 0 Private Septic 0
Water Storage ❑ Holding Tank ❑
Community Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ X50
Date of Payment /0A A
Receipt Number 00'y 2,--2 [T
COSA #
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures
outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or
wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated
herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA
COSA guidelines and 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. Therefore we cannot
provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole
benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly
recommends buyers hire their own engineer to evaluate this report.
Name of Firm Pannone Engineering Services Phone (907) 745-8200
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R. Pannone P.E.
6. DSD SIGNATURE
Date
of q_-qs>,�
x.49 9 I
h; IH
System #1 Approved forbedrooms ' stege,, `P a" in_n •
CE 8149
System #2 Approved for bedrooms
Disapproved ����'OFESS401'
Conditional approval for bedrooms, with the following stipulations:
ttlllttttt(((��,,.
1
Original Certificate Date: 1 C9— t 1 —2/
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
X
Nitrate Advisory
Arsenic Advisory
Other
X
f Y+ �t x '4 €.J�i
Legal Description: Spanish Hills Lot 3
If more than 1 septic system on lot: COSA Checklist # 1 of 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 6/78
Total depth 120 ft
Cased to 114 ft
1111111 Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA
Static water level at beginning of test 84.4 ft.
Comments Well flow information from Sullivan's
B. TANK DATA
Parcel ID:
Structure served by this system 1
17-151-03
Well production at time of test •8 gpm
Water storage tank volume na gallons
Well disinfected for coliform test? ❑ Yes ❑✓ No
Q Coliform bacteria is Negative
Nitrate 15.1 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ND ug/L ❑ Arsenic less than MRL (ND)
Collected by Sullivan's Water Wells
Date of Sample 9/14/21
See letter from Sullivan's regarding high nitrate investigation
Age of tank(s) new years
Tank type/material
Measured operating fluid level in septic tank NA
liffil Standpipes/foundation cleanout per record drawing
Date of pumping NEW -
D. ABSORPTION FIELD DATA Mound
Which system tested (date installed) 1211791
❑ ALL standpipes present per record drawing
Total measured depth from grade 4.0 ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A – pressurized field
0 Monitor tubes go to bottom of effective. If not, state
depth into effective
C. LIFT STATION
NO Required maintenance completed
Age of lift station NEW years
Lift station material HDPE
Comments: 1500/1000 GALLON TANKS
Adequacy test date `0`02'
Results ElPass For 6 bedrooms
Fluid depth prior to test 1.5/0 in
Water added 900+ gal
New depth 2.5/1 in
Elapsed time 137 min
� Code -required soil cover over field
Final fluid depth 1.5/0 in
❑ System presoaked Absorption rate 900 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) —
date of test) If yes, enter date
Gallons introduced gallons
Comments/Deficiencies: SYSTEM GREATER THAN 50% USED.
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
0
Yes
Community Sewer Manhole/Cleanout > 100'
0 Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100' ❑✓ Yes
if No
ft
Private Sewer/Septic Line > 25' M Yes
if No ft
Absorption Field on Lot > 100' 0 Yes
if No
ft
Holding Tank > 100' M Yes
if No ft
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' ❑✓ Yes
if No ft
Q✓ Yes
if No
ft
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' MV Yes
if No
ft
M Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' M Yes if No ft Surface Water > 100' 0 Yes if No ft
Property Line > 5
0
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
ED
Yes
if No
ft
Private Wells > 100' F,71 Yes if No ft
Water Main > 10'
0
Yes
if No
ft
Community Wells > 200' F,71 Yes if No ft
Water Service Line > 10'
0✓
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
�]✓
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
'M
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
/ 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.
COSA Checklist yellow sheet
OF• A��4
kc�
*.-'49 TH.:..
Stevnn..il�Pannone
CE 81.79
�rFSSIMi,
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC 211603
Subdivision: Spanish Hills lot 3
A water sample revealed a nitrate concentration of 15.1 milligrams per liter (mg/L).
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Please see the attached "Nitrate Fact Sheet" for important
information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
lw-
Mailing Address P O Box 196650*Anchorage, Alaska 9957.9 6650 * wuvw muni org
Municipality of Anchorage rGF: A:L
Development Services Department
Building Safety Division .�.p F E 7 Y
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci. anchorage. ak. us
(907) 343-7904
Water Well Advisory
Certificate of On -Site Systems Approval (COSA) # OSC211603
During a recent COSA on-site inspection and test of the potable water
supply well on Lot 3 of Spanish Hills subdivision, the well's productivity
was determined to be .8 gallons per minute. The minimum well productivity
required by this Department (AMC 15.55) for a 6 -bedroom residence is .62
gallons per minute. Although the subject well currently exceeds this
minimum requirement, all parties concerned are advised that the production
capacity of the well may fluctuate. Restriction of non-critical water uses
such as washing cars and watering lawns and gardens may be required.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
�����0N��
LLIVAI, Via
����om.vw �mw.m.o.m�
Drilling ~ PilimQ^ Pumps
P1}.Box 67OZ69[huQiak,AK99567
TO: Mike Harding
13381CaritaLane
Anchorage, AK99Sl6
Camera Inspection Report
Date: 8-13-21
Camera inspection of casing to 50'. Found nickel size hole at 35' and suspect leak from pitless hole
through casing.
Lined well with 30' of 4" PVC environmental pipe. Bottom of liner and shale packer at 50'. Top of liner at
20'. Ran tremie pipe between liner and well casing. Installed Pel Plug bentonite from packer to top of
liner
We also inspected the pitless. it appeared to be sealed, but we installed grout around it for good
LOT 2
N 00012'02" W 65.16'
-- -- -- --- - — CARITA LANE - -
0 20' 40'
00
-P
00
O
02
m
CA)
O
O
O
Ul
EO EO -
LOT 4
REBAR
1
OF gC*lit
s�rr�'�
l!
i
� � • Buicu, S�,ir .� �o
�� s LS -/-1E337 �a`"�
m BUENA-VISTA
P1QFj. ��` , /- �-EOs
E
DRIVE
�1ad'rPS�M�N�_Eo--Eo--
_E0 EO-,
f V
UTILITY
120' X 10' ANCHOR
POLE
F
,EASEMENT
(APPROX.
L LOCATION)
LOT 3
47,425 sq. ft.
wl
tN� WELL
1--;I
w
w
~I
Lo
z
00
(
42.0'
PLASTIC
0
2-STORYcyl w PAVERS
Fl
LOT 2 N
W
FRAME o
HOUSE SHED
m
(
SHED 22.7'
S - 84.2'
4.7� SEPTIC
.N�
I
n'
.NP w :O;•.
CLEANOUT
Q
34.7' ..........................
24.0'
...........
ASPHALT `: SEPTIC
:-::DRIVEWAY:•...
MANHOLES
SEPTIC
STANDPIPES
S 00°11'51" E 165.00'
0
M
-- -- -- --- - — CARITA LANE - -
0 20' 40'
00
-P
00
O
02
m
CA)
O
O
O
Ul
EO EO -
LOT 4
REBAR
1
OF gC*lit
s�rr�'�
l!
i
� � • Buicu, S�,ir .� �o
�� s LS -/-1E337 �a`"�
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines fei 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 272-82t8
Address P,O. Box=oo2t7, Anc;horaqe, AK qq~o
Engineer's Pdnted Name Steven R. Pannone, P,E. Date
Engineers Comments: In conducting an adequacy lest, I attempt to provide a thorough, conscientious engineering a~alysis of the system in
accordance with MOA DSD Ouidclines & Regulations. 'l~e rcpo~cd results describe the performance of thc systcm under thc conditions
encountered at thc time of the test, and separation distances measured to readily identi~ablc fcatures.
Thc operational life of all wells and septic systcms depend on the local soil condition, ground water
levels that may ~uctuate during thc yea', and thc water usage of the family being served by thc system.
These conditions are outsldc the control of thc evaluator of this s~stcra. All systems eventually fail and
satisfactory test results do not guarantee future performance of thc system, nor do they gua.antce that
there arc no bidden dc feets or encroachments. P£S can thcrefore not provide any warranty for future
pert'ormancc nor give any estimate of how long the system will continue to mcct thc operational
r~quirem~ts of thc MOA DSD. Thc content of this r~port is for thc sole benefit of thc owno' listed
above. Any reliance u~on or usc of this report by any other person or party is not authorized nor will it
confer any legal right whatsoever.
I~ Approved for {o 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 Ce.ificate Date: ~ -- J / ~//0
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: SDanlsh Hills Lot ~
A. wELL DATA
Well bjpe P
Date completed 61~1~q78
Total depth ,;~"o .ft
ParcellD: o[7-3~[-o~
IfA, B, or C provide PWSID #
Sanitary seal (Y/N)~
Cased to ~,- ft.
FROM WELL LOG
Well Log (Y/N) y
Wires properly i~rotected (Y/N) Y
Casing height (above ground) ',:~,,
AT IN~PECTION :
JR.
Date of test $1~h.n?8
Static water level 76
86
Well production 6,o
WATER SAMPLE RESULTS:
Coliform ~colonies/100 mL
Arsenic: ~ ug/l
g.p.m.
Nitrate~, {I mg/L
Date of sample: 213,~12oao
g.p.m.
Other bacteria ~ coloniesllO0 mL
Collected by: I, aura Pannone
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material ~
Tanksize ;~ooo gal. Number of Compartments 3
Foundation cleanout (Y/N) Y Depression over tank [Y/N) N
Date of pumping ~,ol:zal:~oo~ Pumper ~,* Home ~;ervlces
Date Installed
Cloanouts (Y/N) Y
High water alarm [Y/N) Y
C. ABSORPTION FIELD DATA
Date installed a:zh.?h, nq', Soil rating (g.p.d./ft~ or ft=/bdrm) e.'{.
Length 68 ft. Width
Total depth 3.n-,..~ ft. Eft. absorption area =1o$o ft=
Date of adequacy test ~ Results (PasslFaill
Fluid depth in absorption field before test o_ In.
Elapsed Time: ~.~o min. Final fluid depth _o. in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No
System type Mound
ft. Gravel below pipe o.~
Monitoring tube Y_. Depression over field N
Pass For _6 bearooms
Water addedo~oo gal.
Absorption rate >= 9oo*
New depths, in.
g.p.d.
If yes, give date
D. LIFT STATION
Date installed =z/z?/zqq=
'Pump on' level at ZZ in.
Datum Bottom of Tank
E. SEPARATION DISTANCES
Size in gallons 5o0
'Pump off' level at ~o in.
Cycles tested =
Manhole/Access (Y/N) y
High water alarm level at ~FI
Meets alarm & circuit requirements? yes
Jrt.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot.
Absorption field on lot
Public sewer main
Sewer/septic service line 5o+
Animal containment areas
On adjacent lots
On adjacent lots ~o0,
Public sewer manhole/cleanout. N/A
Holding tank .,o0+
Manure/animal excrete storage areas .~o0,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~.o+ Property line.
Water main HIA Water service line
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~.o+
Water Service line 5o+
Curtain drain. None Known
F. COMMENTS
Building foundation
Surface water
Wells on adjacent lots
Absorption field ~.o+
Surface water
Water main N/A
Driveway, parking/vehicle storage
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.
Engineers Printed Name ~;teven R. Pannone, P,E,
Date
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Nitrate Advisory.
Certificate of On-Site Systems Approval # 100049
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
3 of Spanish Hills subdivision. This inspection revealed a nitrate
concentration of 9.11 milligrams per liter (mg/L) was reported for the
property's well water sample. The Environmental Protection Agency (EPA)
has established a maximum contaminant level (MCL) of 10.0 mg/L for
public drinking water systems. While private wells are not subject to this
regulation, EPA standards are based on existing health information and can
therefore be used to gauge the relative quality of water from private wells.
Please see the attached "Nitrate Fact Sheet" for important information
regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4p7.0c~roaxg~l;6S6t~et
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. o3.7-:t~3.-o-:{
GENERAL INFORMATION
Complete legal description Spanish Hills Lotg
Location (site address) :~goz Carita Lane, Anchorage, AK
Current Property owner(s) Prudential Relocations, Inc
Mailing address
COSA # ~('C_. ~/¢ //.~ ~
Expiration Date: /0'~- ~-
Day phone
Lending agency
Mailing address
Day phone
Real Estate Agent
Mailing Address
Jodi Moses/Prudential Relocations
Day phone 273-7292
..... Unless otherwise4'equested~COSA-will-be held by-DSD-for pickup:
2. NUMBER OF BEDROOMS: 6
3:-TYPEOFWATER-SOPPEy:- ...................... ;~';15~-bl=' WASTEW/~TER DiSPOsAL: .....................
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
[] Individual On-site
[] Individual Holding Tank
[] Community On-site
[] 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 .,, 272-8218
Address P.O. Box ~.oo23.7, Anchorage, AK qqSlo
Engineer's Printed Name Steven R. Pannone, P.E. Date 7D.6/10
Engineers Comments: in conducting an adequacy test, ! 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 oround water
levels that may fluctuate during the year, and the water usage of the family brine serv'e~ bv the ~wt~m ~?~'~.,'~ ..~.~-.....~-~,
Th..es~e conditions are. outside the control of the evaluator of this system. All systems eventually fail and
s. anslactory te.st results do not guarantee future performance of the system, nor do they guarantee that
. the~ are no h~dden defects or encroachments. PES can therefore not provide any warranty for future ~.....~.~..~.~...'.'~....~
per~o, rmance n? g~ve any estimate of how long the system will continue to meet the operational
reqmrements or'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 nerson or ,,~,~, is not authoriz~a .... :" :~~'4
confer any legal right whatsoever.
i~ Approved for ~ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
~' ~~'~'/~ Original Certificate Date:
Municipality of Anchorage'
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bregaw 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: SpanishHills Lot ]
Parcel ID: o"7-"g=-oat
A. WELL DATA
Well type _P
Date completed 612,;h.n?8
Total depth :t~,o ff.
If A, B, or C provide PWSID #
Sanitary seal (Y/N)_Y_
Cased to. =a4. fi.
FROM WELL LOG
Date of test ' 612nla978
Static water level 76
Well production 6.0
WATER SAMPLE RESULTS:
Coliform /,-~--~ colonies/100 mL
Arsenic: .o ug/I
B. SEPTIC/HOLDING TANK DATA
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground). 3.2+
AT INSPECTION
ft. 86 ft.
g.p.m. =.o~ g.p.m.
Nitrate -t mg/L
Date of sample:
in.
Other bacteria ~ ~,__~ colonies/100
mL
Collected by: Laura Pannone
Tank Type/Material .,,, Greer Steel
Tank size 2000 gal.
Foundation cleanout (Y/N) Y
Date of pumping ..=-ol2812oo9
C. ABSORPTION FIELD DATA
Date inStalled
Number of Compartments _2 Cleanouts (Y/N) Y
Depression over tank (Y/N) N High Water alarm (Y/N) Y
Pumper A+ Home Services
Date installed =21', 71', ~9.,Soil rating
Length 68 ft. Width. zr5
Total depth ~.,;-/,.= ft. Eft. absorption area 3060 ft2
Date of adequacy test ~,1',~1~o.,o Results (Pass/Fail)
Fluid depth in absorption field before test o in.
Elapsed Time: 3./,.4.0 min. Final fluid depth _o in.
Any rejuvenation treatment (past 12 mo.) (Y/N. & type)
(g.p.d./ft2 or fta/bdrm) ,o.] System type Mound
ft. Gravel below pipe ,.o.~
Monitoring tube _.Y, Depression over field N
Pass For _6 bedrooms
Water addedgoo gal.
Absorption rate >= 9oo+
No
New depth/, in.
g.p.d.
If yes, give date
D. LIFT STATION
Date installed ~
"Pump on" level at ~ in.
Datum ,. Bottom of Tank
SEPARATION DISTANCES
Size in gallons ;oo
"Pump off' level at ~...~o in.
Cycles tested 2
Manhole/Access (Y/N) Y
High water alarm level at 3~
Meets alarm & circuit requirements? Yes
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot ~.oo+
Absorption f'~ld on lot ~.oo+
Public sewer main N/A
Sewer/septic service line
Animal containment areas ~.oo+
On adjacent lots .,oo+
On adjacent lots ~.oo+
Public sewer manhole/cleanout ,, N/A
Holding tank ~.oe+
Manure/animal excrete storage areas
1OO4-
SEPARATION DISTANCES FROM, SEPTIC/HOLDING TANK ON LOT TO:
Building foundation, ~ Property line. ~.o+ Absorption field ~.o+
Water main NJA Water service line ;o+ Surface water ~.oo+
Wells on adjacent lots ',oo+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~.o+
Water Service line
C~rtain drain, None, Known
F. COMMENTS
Building foundation ~.o+
Surface water ~.oo+
Wells on adjacent lots ~.oo+
Water main N/A
Driveway, parking/vehicle storage ~o+
. r~ ~ . . . ~ ~ed ~mugh field inspe~ons and
I ce~ ~at i have ~
rev~w of ~n~al m~ that ~e above systems am in
constance, w~ MOA CO~ ~i~lines in effe~ on this date.'
COSA Fee $ ~ ~
Receipt Number , ~ ~// ~, ~ ~
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Nitrate Advisory
Certificate of On-Site Systems Approval # 101132
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
3 of Spanish Hills subdivision. This inspection revealed a nitrate
concentration of 8.74 milligrams per liter (mg/L) was reported for the
property's well water sample. The Environmental Protection Agency (EPA)
has established a maximum contaminant level (MCL) of 10.0 mg/L for
public drinking water systems. While private wells are not subject to this
regulation, EPA standards are based on existing health information and can
therefore be used to gauge the relative quality of water from private wells.
Please see the attached "Nitrate Fact Sheet" for important information
regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Prograr~
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cLanchorage.ak, us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O [ ?,- i ~'1 - 0'-~
1. ~GENERAL INFORMATION
complete legal description
Location (site address or directions)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent .
'.Mailing Address
e
Expiration Date: .3 .- I ~ - 0 !/
L ~,¢,r~/ C', ~/ Day phone
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: ~
Day phone
Day phone
e
TYPE OF WATER SUPPLY: '
Individual Well
Individual Water Storage
Community Class -- Well
Public Water System
TYPE OF WASTEVVATER 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 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates 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 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 en procedures outlined in the Health Authority 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 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,
and regulations in effect at the time of installation.
NameofFirm tV~l~-~,~-/ ~( J~l~[
EngineeCs PHnted Name ~,~*~f ~( }~
DSD SIGNATURE
~ Approved for ~
Disapproved.
Conditional approval for
Phone "~ ~'-"5'~ ~ .7--
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date:.
(Rev. 01;0'2)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage,ak.us
(907) 343-7904
'HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Well type
Date completed
Total depth ~
Date of test
Static water level
Well production
If A, B, or C provide PWSID # /
Sanitary seal (Y/N) y
Cased to _~ff. Pdt'lilt"
FROM WELL LOG
L,/2. ,~-'/7~
/-
7a, ft.
g.p,m.
Parcel ID:
in.
WATER SAMPLE RESULTS:
Coliform (~: ' coloniesll00 mi.
Arsenic: f mg./L
SEPTIC/HOLDING TANK DATA
Tank Type/Material ~, {-- · e (
Nitrate C~, q 'mg./L
-Date of sample: ~ ~/'~'
Well Log (Y/N) y
Wires properly protected (Y/N)
Casing height (above ground)
AT. INSPECTION
~-/r..( ft.
c~ ~ ~5'" g.p.m.
Other bacteria 4 colonies/100 ml.
Collected by: /'4/t/-~;f,
Tank size '7..00o gal. Number of Compartments 7__
Foundation cleanout (Y/N)' y Depression over tank (Y/N)
Date of pumping 'iO/~'"~/'u~ Pumper .,~-,u~,~L
C. ABSORPTION FIELD DATA
Date installed {"~/{~/[q( · Soil rating (g.p.dJft2 or fl=/bdrm)
Date installed
Cleanouts (Y/N) '"/
High water alarm (Y/N) .'T~
System type
Length ~ ~ ft. Width /.N'~ '" ft. Gravel below pipe r.,q, ~" ft.
Total depth ~,7'L. ft. Eft, absorption area ~O~o ft= Monitoring tube
Date of adequa'cy test b'/'7--~/~o '~ Results(Pass/Fail)
Fluid depth in absorption field before test ,-41~.-.~.on Water added 'ZO~ogal.
Elapsed Time: ;~[~ min. Final fluid depth ,,,/t? ~-n.,-,~ ,, Absorption rate >=
Any rejuvenation treatm ant (past 12 mo.) (Y/N & type)
Depression over field /~'
For ~ (~ bedrooms
New depth
qoo4'' g.p.d,
/'J · If yes, give date
D. LIFT STATION
Date installed I ~/( ~//'q ~
"Pump on"level at '3) in.
Datum ¢o {'/ot,~ ~/~1. [-~r[~_
E. SEPARATION DISTANCES
Size in gallons 5'vo Manhole/Access (Y/N) 'Y
"Pump off" level at Z.? in. High water alarm level at ~ ~'
Cycles tested /v(({ [~'p {'.~ Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /oo
Absorption field on lot /
Public sewer main ~/~,~
Sewer/septic service line
On adjacent lots ~ I00r'~-
On adjacent lots i O~ ~'~
Public sewer manholelcleanout ~ /,~f.
Holding tank
SEPARATION DISTANCES FROM SEPTIC/I--~EE~I~ TANK ON LOT TO:
Building foundation ~'-/~'
Water main "Z
Wells on adjacent lots I d 0 I-~'-
Property line 5'0
Water service line
Absorption field ~"/'~'
Surface water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Propertyline lo I .i/-
Water Service line ~ ~' ~'
Curtain drain b .~-~ ~, Wells on adjacent lots
COMMENTS
Building foundation
Surface water
Water main 'Z ~ /'~-
G. ENGINEER'S CERTIFICATION
I cerfify 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 /'~l ~'~,'¢ [~'(dd L¢,*,~4
Driveway, parking/vehicle storage.
HAAFee $ "7-'~'7~"-.-P' ,/~'0
Date of Pa ent / :2.- / ['- 0
(Rev. 12/01)
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. ci.anchorage.ak.us
(907) 343-7904
Water Well Advisor~.
Health Authority Approval # 030628
During a recent Health Authority Approval on-site inspection and test of the
potable water supply well on Block , Lot 3 o£ Spanish Hills
subdivision, the well's productivity was determined to be 0.655 gallons per
minute. The minimum well productivity required by this Department (AMC
15.55) for a 0.625-bedroom residence is gallons per minute.
Although the subject well currently exceeds this minimum requirement, all
parties concerned are advised that the production capacity of the well may
fluctuate. Restriction of non-critical water uses such as washing cars and
watering lawns and gardens may be required.
This advisory must be attached to all copies of the subject Health Authority
Approval.
12/11/03 TItU 18:11 FAX 2735~45 PRUdeNTIAL VISTA R.E. ~001
EASEMENTS OF RECORD, CTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT, ARE NOT SHOWN HEREON.
"ASBUILT" No corners set
~ here~y cert~/Ina~, I have su~eyed the fol!:wl'19 Ceec~ibed Fro~erly, Lot "~ · ~,~
the prope~y I~ng ad,aesir ~ereto. t~t no Imprcv~e~ ~ pro~ Iy;ng acjacent t~e~eto
encroa~ on ~e p~emises in q~e~icn end t~at t~ere ~re no foeOwa~, tre~Smisslqn Tines or
~s,~le easements oq saTd psope~t except as Ind ~te~
Anchorage, AJaake.
~ /,./o'~'..2OOB
THE INFORMATION HEREON IS FOR TH~[ USE OF
LENDING INSTtTUTIONS SPECIFICALLY TO SHOW
ANY CONFLICT~ BETW~-EN EXISTING STRUC~RE5
AND ~ ~OT LINE~ OR ~SEME~S AND tS
NO~ TO BE U~ED FOR P~iTIONING ADDITiO~
8TRUC~RES OR FENCELINES.
pg ~c ~
. ~,,~'",,.,~ tI.
~e e~eleee~eeeeeeeee~eeeeee~e~ e ~
t,*~:'.,.. .,.[*~ ·
~ ~0~ eeeeeeeee ~ ~
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
Ol'~/~l~'J- ~D'~ HAA# ///~/7/~.~"~,~'.~'"
GENERAL INFORMATION
Complete legal description L e-i-
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
bore_
Day phone
Day phone
I~. ~,~ Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4, TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
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
o
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 verifythat 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.
NameofFirm -I ,~'~'~'~-~.4 ~')r),~¥"'~lc~.~~''2~-~-- Phone
Address
Engineer's signature
Date
Disapproved.
Conditional approval for
bedrooms.
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.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~-~ T 'z~ ¢'PAI, I~[N MIL¢,..~, Parcel I.D. ~1~ - /4-/- ~
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed P~-~ 1~,7~ Driller
A, WELL DATA
Well type
Log present (Y/N)
~ z¢'O Casing height
Wires properly protected (Y/N)
AT INSPECTION
~.p.m.
Cased to
Total depth
Sanitary seal (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
, 'z./, /. ,~
Date of sample: "~ I
~' ,,¢-- Other bacteria
Collected by: ~ ~
B, SEPTIC/HOLDING TANK DATA
Date installed /
Cleanouts (Y/N) ~
High water alarm (Y/N)
Date of pumping
Tank size 2. ~¢.c¢..~ Compartments
Foundation cleanout (Y/N) : ' Depression (Y/N)
Alarm tested (Y/N) l~/'~'~'
¢¢~',~N- Pumper r~,,~,,~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line ~-'
Surface water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manhole/Access (Y/N) ~"
"Pump off" level at l ~
Cycles tested r,¢//~
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot I ~ O On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed -
Length ~' ~
c~ Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail) '
Peroxide treatment (past 12 months)
Soil rating
Gravel thickness ¢ *~
Cleanouts present (Y/N)
Date of adequacy test
for _
System type
Total depth
bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ) ¢¢'- ~'
To building foundation
On adjacent lots .'~ / ~-~ Property line
To existing or abandoned system on lot
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 d~te of this inspection.
Engineer's Name
Date
HAA Fee $ /7~) ,~
Date of Payment /.~ ~:~ -- ~-~
Receipt Number ,~ ,~D/ ~'-~'~'~ ,)
72-026 (Rev. 3/~1) Baok MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE ..
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) davs for processing.
1. PRGPERTYOWNER [ ~ PHONE
MAI L~NG ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. B~Y~R 0 ~ PHONE
MAILING ADDRESS
4, REALTOR/AGENT
5. LEGAL DESCRIPTION /~
6, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [~ Four []
/~ SINGLE FAMILY [] Two
[] MULTIPLE FAMILY [] Three~'~ J~ Six~.-"
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.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/oN-SITE** **If individual/on-site, give installation date (~J
If system is over two (2) years old an adequacy t'~st is required
[] PUBLIC UTILITY by this Department.
~IOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
._ THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
3ATE DATE DATE
I NSPECTO R INSPECTOR I NSPECTO R
DIRECTIONS:
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [~ OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL 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
I
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
{~APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title) ~
LEGAL DESCRIPTION
72-010 (Rev, 3/78)