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Home My WebLink AboutSCHROEDER LT 88A�jch�oec�er SIO Q sm0 — OS2-47—Ooo 6►cxK IV III =50 Pip &PT 1. 1 WATER WELL RECORD STATE OF ALASKA MUNICIPALITY OF ANCHCOIS41WRTMENT OF NATURAL RESOURES DEPT. OF HEALTH &.I SS1� ENVIRONMENTAL PROTECTI8ryon of Geological &Geophysical Surveys LOCATION OF WELL (Please complete either to, Ib or IC.) I7 Borough CC>>Subdivision Lot Block Ib. 1/4 q rs. �—of—of—of -- Ic.11 DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS MAR 9 Iona. Drilling Permit No. A.D.L. No, Section No. Township N ❑ Rang E E]Meridian S� WE] 3. OWNER OF WELL: j, - Address: Street Address and Area of Well Location 2. WELL LOG Feel Below 4, WELL DEPTHL (final) 5. DATE OF COMPLETION Surface -I, — Materiol Type Top Bottom 6, ❑ Cable tool 1❑ Rotary ❑ Driven Dug Auger ❑ Jetted ❑ Bored ❑ Other 7. USE:' -Q Domestic ❑ Public Supply ❑ Industry ') ❑ Irrigation ❑ Recharge ❑ Commerical _::,�'. l; j , ❑ Test Well Other: — S. CASING Threaded - Q Welded diam. in. tom_ It. Depth Weight lbs./ft. diom. in. to ft- Depth Stickup ft. 9. FINISH OF WELL: Type: _ Diameter:- Slot/Mash Size: Length: _ Set between ft. and ft. Backfilling _ Gravel pock _ — 10. STATIC WATER LEVEL: _ft. — Above or Below land surface Date Equipment used: _ I I . PUMPING LEVEL below land surface and YIELD ft. after hrs. pumping :i, g.p.m. ft. after firs, pumping g. p.m. 12. GROUTING Well Grouted: ❑ Yes O No Material: ❑ Neat Cement ❑ Other: 13. PUMP: (if available) HP Length of Drop Pipe ft. capacity g. p. m. ❑ Subm. ❑ Jet ❑ Centrificol Other 14.REMARKS 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Water Temperature --o This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Registered Business NameContract License Number a', Address: Signed :r/i ✓�/,� 7��.� - ��iiJ"._(:C- Date: — Authorized Representative Form 02-WWR (11/61) Copy Distribution: WHITE-Slote DGGS, PINK -Driller, CANARY- customer CjF 0 SI1.TL IDF A(_p,`;KA 4 i ME NT 01- hJGTUPAI (, n'=S.on Of IS, Ccloq,CC) GeDFhySica S:r,eys Drlllinq Pbrrnll No. 1('17 OF %YELL, (Pleore complete eltF.or to, lb or Ie.) A.U.L. No. nigh ScbC vial on Lot Olc(k� b_J I/. QI r1 Seclion No Tc 11 a hip 9 R Nr� cngo Fr sndion r _ l of II S IC. F. AND DIRECTION FFCId RCAD !',l E h SECT!OIIS 3. OWNER OF WFLI S!rrcI 'Sr(. r.s cnd Area of Cr 11 Lor a lion II G Fr of Br Iow Surfoco Na e i a 7) FA - -Top ---�Bottom Adduce: r. t ELL [ EV H (hrol) r. DATE OF CDIAPLETION fl {s e Icol lcry Drivon fluq T❑ie ..el s drilled cer L=;er I e! :ed U Berod L] DIFeI: 't[-c•I It true Ie'LF be s' %.USE:rf.c-� P.,: Ic SuDPIY Indu slry 8,. e1 Q' go c n. r -e Ical �J Tee' 1YolI �] s r:--- i CASING: -� r!•rr Cdedi -� Ve ldod d:cn, Adduce: r. t ELL [ EV H (hrol) r. DATE OF CDIAPLETION fl {s e Icol lcry Drivon fluq T❑ie ..el s drilled cer L=;er I e! :ed U Berod L] DIFeI: 't[-c•I It true Ie'LF be s' %.USE:rf.c-� P.,: Ic SuDPIY Indu slry 8,. e1 Q' go c n. r -e Ical �J Tee' 1YolI �] s r:--- 0. CASING: -� r!•rr Cdedi -� Ve ldod d:cn, -' in. to 11. Depth %,night is %ff ('-c m, in. to fi. D';.Ih S!icvup f 1. 9. FINISH OF WELL: Typo_ ,cme-or'-. Sloljll0{h cli0: i_cnglh So! 1W ten rI c'.d ft_ Dcckfill:-g 10. STATIC N'AT ER IFVFL_fl. 'cte 6[CCo Of L Pei(r' '.-'e Id'ra'.0 ECciI rr ent .sed II r_.,, 1 ;. E': FL t, e'ce IcnC surface cd 1'E LD II cf!or _ _hrs. Pun_Pinq It ofler nr e. pump nq g p ?. 12 6 ROUTING Aell Grccfod: yes No IJ c'brial: l� 3. PL IL P: (If c.c 'oh!e) HP N Length of D'ap PrPO 1t. (opo0ily g G_m u' � Ur, �'`J LSubm. Jet U Cunlrifical U O1 hor r o 0 u 19. REMARKS: 4I ER nFLL CCR TR ACI CR S CE HT I'=IC AT IO N: l5. Vlcler Te •n pe rot ure — T❑ie ..el s drilled cer ry d c'icr :^e II,; 't[-c•I It true Ie'LF be s' cl ny 1.-cr le'.ge c^e Lelie f; ' 'ter e (\\\ AAfAl L RILL SHEFFIEI D, GOWRNOR, C\J I�l �1dt j� DEPT. Off, ENV ORION MENIFA1L �flE�f��:E�®'7�Y1'��[� 7b/eP"m 000 274-2533 address: FACILITIES CONSTRUCTION &OPERATION 437 E Street Suite 200 Anchorage, AK 99501 May 18, 1984 Mr. Robert A. Shafer, P.E. SRB 196X Eagle River, Alaska 99577 RE: Separation Waivers Lots 88A, 88R and 88C, Schroeder Subdivision Firelake Interceptor, Phase I11, 581-1, Project No. 12718 Dear Mr. Shafer: Thank you for your leiter of May 18, 1984 in response to my letter to you on April 16, 1984 concerning the referenced request. The letter supplements the data which you provided -in your original request of April 8, 1984 and answered our concerns raised during the review. Those concerns have been adequately addressed and/or corrected (specifically waterproofing manholes FL -15 and FL -16) and the waivers are hereby granted. This letter amends my letter of October 4, 1982 to (now) include the existing wells located on Lots 88A, 888, 88C, Schroeder Subdivision. Sinvely, GregU"'� 9✓ a e . Construction Grants Engineer 9E1PT. OF ENVIRONMENTAL. CONSERVATION FACILITIES 8 CONSTRUCTION OPERATION April 16, 1984 Mr. Robert A. Shafer, P.E. SRB 196X Eagle River, Alaska 99577 BILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 437 E Street Suite 200 Anchorage, AK 99501 RE: Separation Waiver Lots 88A, 88B and 88C, Schroeder Subdivision Firelake Interceptor, Phase ll, S81-1, Project No. 12718 Dear PAr. Shafer: Your April 8, 1984, referenced waiver request has been reviewed in accordance with the 'viastewater Regulations (18 AAC, Chapter 72). The request must be denied. The engineering report did not clearly demonstrate that less than the standard clearances between water sources and sewerage are justified. Specifically, the following ccmments are provided: 1. The request did not provide adequate on-site information concerning andn other groundwater conditions, surface topography, geology, Y environmental conditions which are important in setting the separa- tion distances. 2. The request did not report the fact that Manholes FL -15 and FL -16 (within 100 feet of private well on Lot 88C) were not specifically constructed to watertight standards using a water containment membrane. During construction of the Firelake Interceptor, all pipe penetrations in and out of those affected manholes constructed within 100 feet of a private well were sealed with reinforced flashing to prevent damage. Manhole FL -14 is one of those specifi- cally constructed manholes. 3. The request failed to explain why the recent wells on Lots 88A and 88B were dug in their present location after the sewer interceptor was constructed on Iris Way. Why not near the back area of lot? Mr. Robert Shafer -2- April 16, 1984 4. The request did not clearly state, in your professional engineering judgement, you conclude the lesser separation distances are justified. erproof no sect 1 on the 1 on contract documennts. aterplf ruct Waterproof g of ManhoIesFL-15pandeFL� o 161stneeded. Should you require further information, please don't hesitate to contact this office. Sincerely, I /L ,y)v,/Greg M�ae r/ Construction Grants Engineer GM/ jfr Attachment ngt1r\ po� A April 8, 1984 ADEQUACY TEST WATER AND SEWER INSPECTION WELL INSPECTIONS AND FLOW TEST SITE PLANS ROAD DESIGN SOILTEST ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN EXCAVATION WORK Department of Environmental Conservation "TTENTION: Greg Magee Construction Grants Engineer 417 E Street Anchorage, Alaska 99501 Dear Mr. Magee, REFERENCE: Firelake interceptor; Phase 11 HOBERT A. SHAFER CIVIL ENGINEER 694-2979 Tn June 1982 the Anchorage Water and Sewer Utilities requested approval from the ADEC to construct, maintain and operate the referenced sewer system closer to drinking water sources than established by horizontal separation distances specified from the State drinking water regulations. Attached to this letter was a listing of private wells and the proposed exposure to special man holes within a 100 foot distance. ;Iso enclosed was a listing of private wells and the proposed mainline sewer within 75 foot distance. Tn 1981 a well was drilled on Lot 88 of the Schroeder Subdivision adjacent to Tris Way. The Municipality's request for waiver apparently overlooked the existance of this well, therefore your letter dated October 4, 1981 granting the Municipality's requested waivers of 29 wells did not include the well located on Lot 88; Schroeder Subdivision. Recently Lot 88 was subdivided into three lots. The old well. on Lot 88 is not) on Lot 88C. As a result of the subdivision the Municipality granted well permits on Lot 881. and Lot 88B. These wells have been established and also violate horizontal. distance required by state regulations. Based upon information submitted by the Municipality in its original request- for waiver and with the additional information furnished at this time, request that you amend your letter of October 4, 1982 and further grant a waiver for the existing three wells located on Lot 88A, B, and C.' If we may rovide additional information, please do not hesitate to contact us. i/ S incere R ER( SH:'.FER, VrE. S /s s SRB 196X EAGLE RIVER, ALASKA 99577 owl U, Pdj IL 3: F` fP� IL~I T.- "V ��it" ��0i IF -31 E" DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STR�ET� GE, AK 99501 264-4720 IF3 P4~~�..... �~IF�� F"IE-E. VR, 0`0 1-� PERMIT NO: 840529 DATE ISSUED: 06/29/84 APPLICANT: DENNIS SIGLE� ADDRESSI 13040 RACK ROAD ANCHORMGE, AK 99515 LEGAi �ESCRIP: SUBDIVISION: SCHROEDER (ORI8) LOT: 013()BLQ�K: Nh ~ SECTIUN: 2 TOWNSHIP: 141\1 RANGE: 2W LOT SUZE1, 20000 (SQ^FT^ OR ACRES) I certify that:i �miliar with the 'equ 'e ments �or �n~site sew�rs and we11e at; se� Alaska" I a 1 am " fprth by the MunicipalitY o� Ancho'a�e (MOA) and the St�te O� MOA cod�s an� regulatioDsr 2 I will inst�ll the syGtem in " ith all accordancg w it this permt °�or a nd in compliance �ith the design criteria of the set back Alaska requiremen ste0 3 ~ / will a�here to all MOA and �Stat� o� wastewater d�sposa� �ys or public cjistances from any 8: i�ting well , t nearby lot adjaCen or " tew n this or any ",r DATE: GIGNED - APPLICANT: DENm5Lr�n DATE: ISSUED f)Y �� JOE GIELAROWSKI :AGLE RIVER, ALASKA DRILLING CO. 338-5312 LIFETIME ALASKAN SERVING ALASKA P.O. BOX 772847. EAGLE RIVER. ALASKA 99577 [ER OF LAND ...... ...... ........................................................ DEPTH OF WELL ....................................... I ..................................... ........ STATIC LEVEL OF WATER FT . .............. ; ....................................... IRESS... ... ........ �: ..... ............ 11 �; ........... ........................... L -SITE .............. ...... ...... .................................................... DRAW DOWN FT . .... ......... .... ...... 'E - STARTED .... I ........................ ...... .................................................. GALS. PER HR..... . ....... ................ ................................ 'E - ENDED ................... ...... ............................................. KIND OF CASING ... ................................... ........................ ... D OF FORMATION: FROM...................... FT. TO ....... ............................ FROM....................... FT. TO ....................... FT . ....................... FROM...................... FT. TO ......... ........... ....... FROM ....................... FT. TO ........................ FT . ...................... FROM......... 1� ............ FT. TO ........... �7 ........... FT. .......... FROM....................... FT. TO ........................ FT . ...................... FROM........f FT. TO -.:,t............. FT. ....... ;.I.; .............. FROM....................... FT. TO ....................... I FT . ...................... ............ .....I FROM......... i............ FT. TO .......::i;........... FT . ..... ..................... FROM ....................... FT. TO ........................ FT . ...................... FROM ............ .......... '�f FT. TO ........ ; . .......... :1 1 FT...:::.'.....`........'.....':':....... FROM ....................... FT. TO ........................ FT . ...................... FROM ...... --i ........... FT. TO ....... : !J ........... FT, ........ FROM ....................... FT. TO ........................ FT . ........ .. ..... FROM...................... FT. TO ...................... FT . ................................... FROM ....................... FT. TO ........................ FT . ............. FROM...................... FT. TO ...................... FT . ................................... FROM ....................... FT. TO ........................ FT . ..................... FROM...................... FT. TO ...................... FT . ................................... FROM ....................... FT. TO ........................ FT . ..................... FROM...................... FT. TO ...................... FT . ................................... FROM ....................... FT. TO ....................... FT . ...................... FROM...................... FT. TO ...................... FT . ................................... FROM ....................... FT. TO ........................ FT . ..................... 3CL. INFORMATION: DF" I u -P'(; NAME ............................. ; .......................................................................... Q, :j: -!- I U::[] �4 lc:,-.:: 11 it .�� DEPORTMENT OF ��HLTH 8ND ENYIRONME�TOL PR�T��T�ON STRE:ET/ HNC'R1.::: 99501 264_472§ � 8NCHORRGE 694^21]1 � EHGLE RIVE� A- _. ..... P��l"l TT NO. ;.'D]1079 HPPLICHNT: CINDY SIGLER 6 RDDRESS� SRH BOX 1414N RNCHORHGE/ 8K 995Q7 LEGHL DESCRIPTION ~SU8DIYISIONSCHRO[DER BLONR LOT88Q LOT SIZE 0 SQ. TDWRRNGECTION� ~ ...... ... I C: THFiT� J... I Rll FHMILIHR WITH THIT REQUIREMENTS FOR ON-SITE SENERS HND WELLS HS SET FORT|| EY THE ITY OF HORRGE OJ�� I) THE 2 I WILL INSTRLL THE SYSTEM IN RCCORDHNCE WITH THE HHVE �ECEIVED Cl COPY OF THE CODZ SUMMHRY AN[:' WHICH IS PHRT OF T1111-:'. PERMIT ]I UNDERSTRND THRT THE ONITE SEWER SYSTEM MHY REQUIRE ENLHRGEMENT IF THE RESID2NCE IS REMODELED TO INCLUDE MORE THRN 4 BEDROOMS, PERMIT HPPLICHNT HRS THE RESPONSIBILITY TO INFORM PERSONNEL DURING THE INSTHLLHTION INSPECTIONS OF ANY WELLS HDJHCENT TO THIS PROPERTY HND THE N�MBER OF RESIDENCES THRT THE WELL WILL SERVE I� R LIFT STHTION PERMIT AND INSPECTION MUST BE OBTHINEDHS`BUILTS CRNNOT DE RPPROVED WITHOUT RN ELECTRICHL REPORTTHE ELECTRIC8L WORK MUST 8E DONE BY R LICENSED ELECTRICIRN �� ..... HPPLIC8NT� CINDY SIGLER / ~... .... ... ~--^..........-~~^^^~-~~�--~ \�/ Permit # Depar. tmen 825 L MUNICIPALITY OF ANCHORAG' f Health and Environmentz Protection Street, Anchorage, AK. 99501 264-472.0 io;I�' # HANDWRITTEN PERMIT # # W ELL Ak�7��lY�'�AI -�:�IrI� P E RM I T Applicant: �1/�� / . �/ �� ' �' Mailing Address: Location: Phone Number � z�� Legal Description: -� Jc h}-��%.P_�� Lot Size: Type of Soil Absorption System Is: Trench: Drainfield: _ Seepage Bed: Holding 'Dank: Maximum Number of Bedrooms: Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is: DEPTH LENGTH -GRAVEL DEPTH_ WIDTH C� 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 no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). �E REQUIRED SEPTIC(HOLDING) TANK SIZE >�I 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. Minimum distance between a well and any on-site sewage disposal system is 100 feel 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 community 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 3 3 I certify that: (1) I am familiar 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 and rstand that the on-site sewer system may require enlargement if the e idence is remodeled to include more that edr_ooms. Issued b Signed. V Y � � �.1�--T-------��-- plicant Date: SWP/024(1/81) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEAL TH DEPPAR7'MEN'C OF, HEALTH AND ENVIRONMENTAL PR0I.'ECTION FOR HF_AI.7" AUTHORITY APPROVAL CERTIFICATE APPL,ICA'I.ION - Application Date ..?' 1, General Information � vi f (a) Legal DaScription ( include jot, blrk, subdivision, section, township, range) Location (address or directions) (b) Applicants Nair; / Applicants Address? %. r�% !>/ _.! { _ �.'_,._.� (c) Applicant is (check ore) Lending In3ti.tutionrCmi-Kr./bui.lder T-- �. Buyer r Other (explain); (d) Lending InstitutionTe1ephorr. Address (e) Veal. Estate Co. & Agent Address Telephone 2. TX e ofpiderc- Single-Family Number of Dedroonr� 3. water SuPpY Multi -Family Other (<krscriabe) Individual. AbIl CjQ Comumunity Public (A Note: If community wall system, must have written confirmation from the State Cepartment of Environmental Conservation attesting to the legality and satus. Is the well. adequate for the number of bedrooms specified in this HAA ( /HNI) 4, Sewaae Disposal Onsite �. Publi. Community �-1 Holding Tank C Is the wastewaters disposal system adequate for the number of [Pages l of 21 2-15-84 5. 11� Enoinneeri� Fir ovidinc zn�sp�ctions, it's s, Data and -Information I certify tyat I h ve checked, verified, or conformed to all MOA HAA Guidelines in effect on/ he dr inspection. Sig :d -� r Na Firm ' �'Fi Telehoro _ rc (;'' 1� f 7 Signed �. / o 5t.: Date (ENGINEER SEAT) i{h i•il. . . 9 ' E . DHEP Approval Approved for bedrooms By Approved G Disapproved Terms of Conditional Approval Conditional Date (/ The Municipality of Anchorage Department of Health and Environmental protection does not guarantee thecontinued satisfactory performance of the water supply and/or the wastewater disposal system. This approval indicates that, as of the validation date shown above, based on the data and information furnished by an engineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func- tional undt.i.onal for the number of bedrooms and typa of structure indicated. (DHEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Nage 2 of 21 2-15-84 �F I��IC6` ,1.1 Or f10? r U. rr. ;c(I�II MUNICIPALITY OF ANCHORAGE (MOA) EPdVIROid`+;`cfaAL f'.?C)T HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 j r A,.�- We11 Classificatio ., /` If A, B, or Cr D.E.C. Api�oved(Y¢PH-) at Well Log Presen (YDate C mpleted 44 � Yield Total Depth Cased to Depth of Grouting Static Water LevelCr? Pump Set .At Ci Casing Height Above Ground R0 `` Sanitary Seal on Casin (Y l� WN),/ Electrical Wiring in Conduit (Y ) Depression Around Wellhea Separation Distances from Well: To Septic/Holding Tank on Lot v_;1 On Adjoining Lots /� To Nearest Edge of Absorption Field on Lot. j ^; On Adjoining I..ots /V / J _ _ f 7.'o Nearest Public Sewer Line To Nearest Public Sewer f Cleanout/Manhole�la To Nearest Sewer Service Line on Lot Date Water Sample Collected ByLEt -- Water Water Sample Test Results / e r%) 6 - Comments ��'� C' v�1 Me. 13. SEPTIC/HOLDING TANK DATA Date Installed Size No. of Compartments Standpipes (YM) Air -tight Caps (Y/N) Foundation Cleanout (Y/N)_-- Depression over Tank(Y/N) Date Last Pumped Pumping/Maintenance Contract on File ( /N) for Holding Tank High -Water Alarm (Y r _Holding Tank Permit (YM)Separation Distances from Septi /Holding ' nk To Water -Supply 4Ab 11 To Property Line To Water Main/Service Line Course Comments Foundation. To Disposal Field To Stream, Pond, Lake, or Major Drainage (Page 1 of 21 2-1584 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed . Width of Field Type of System Design Length of Field Depth of Field Gravel Bed Thickness `— Square Feet of Absorption Area Standpipes Present (Y/N) Depression over Field (Y/N) i to of Last Adequacy Test —_ Results of Last Adequacy Test Separation Distance from Absor Field To Water -Supply Well _ - To Property Line To Building Foundation _ To Existing or Abandoned System on Lot —; On Adjoining LotsTo Water Main/Service Line _ To Cutbank(if present) To Stream/Pond/Lake/or Major Drainage Course, To Driveway, Parking Area, or Vehicle Storage Area —� Comments -- - — D. LIFT STATION Date Installed _ Dimensions Size in Gallons anhole/Access (Y/N) -- — "Pump On" Level at A Level at — -- High Water Alarm Level at I V N —Vent (Y ) -- _ Tested for �— Pumping Iles during Adequacy Test. Meets MOA Electrical Codes(YM- --- -- Con ments --- - — Check Permi ed Bedroom Rating Against HAA Request I certify t �t I ave checked, verified, or conformed to all MOA HAA Guidelines in effect on the da of �s ction. � C Signe Date MOA No. a �`4�IP1�L'i�iNt6 KB1/d5/s SBD 99G)I ya1 r PHI. ;ar 7 Ycj [Page 2 of 21 2-15-84 C/0 F P MUNICIPALITY OF .ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) K ]'ST - FEBRUARY 1984 CHEC L . - pp22 / ff Legal Description: C� C'�✓YG'c✓-✓ A. WELL DATA Well Classificat:io_ _ If A, B, or C, D.E.C. Approved(Y/N) _JQ� Date Completed G Yield`/'� Well Log Present (Y/iri �P L -- --- %�J Total Depth s. Cased to Z) Depth of Grouting Y, — �itatic Water Level Pump Set At LG °e Sanitary Seal on Casinq(r Casing Height Above Ground � 0 Y Electrical Wiring in Conduit (Y �) __—_ Depression Around Wellhea Separation Distances from Wbll: To septic/Holding Tank on Lot `V On Adjoining Lots To Nearest Edge of Absorption Field on Lot; On Adjoining To Nearest Public Sewer Line 2_7 To Nearest Public Sewer L f To Nearest Sever Service Line on Lot A T Cleancut/Manhole J—�, - Water Sample Collected By Date — Water Sample Test Results Comments le, --- B. SEPTIC/HOLDING TANK_ DATA Date Installed Size _ No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N)—, Depression over Tank (Y/N) Date Last P Pumping/Maintenance Contract on File (Y/N) for -- Holding Tank High -Water Alarm (Y ) `I JJJH:o ding Tank Permit (Y/N)—_ Separation Distances from To Water -Supply Well To Property Line To Water Main/Service Line Course To [uilding Foundation _ To 0�sposal Field To Stream, Pond, Lake, or Major Drainage. Comments — --- [Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption r—, Type of System Design Length of Field Depth of Field o Gravel Bed Thickness Standpipes Present (YAO _ .e of Last Adequacy Test — To Water -Supply Wall Tj Property Line To Building Foundation To Existing or Abandoned System on Lot s; On Adjoining Lots - To Water Main/Service Line- To Cut if resent.) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Stor ge a Conarents D. LIFT STATION Date Installed ®� Size in Gallons "Pump On" Level at High Water Alarm Level Tested for Electrical Codes(YN) Comments ** Check Permit I certify that I on the date of t KB1/d5/s (Page 2 of 21 J le/Access (YIN) _ —o f" Level at Vent (YM) ^ ®. s during Adequacy Test. Meets MOA Broom Rating Against HAA Request checked, verified, or conformed to all MOA HAA Guidelines in effect 77 Date � � 7Z4 MOA No. ENGINEERS SEAL 2-15®84