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Home My WebLink AboutSAMPSON ESTATES BLK 1 LT 14mpson Block 1 Lo1' /.4 #051-053-62 MUNICIPALITY OF ANCHORAGE 0O~ i- 8 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ~ ENVIRONMENTAL ENGINEERING DIVISION ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME P~ONE ~ MAI LING ADDRESS LEGAL DESCRIPTION LOCATION NO, OF BEDROOMS Well Absorption area Dwelling PERMIT NO. ~ ~ O~ DISTANCE TO: /o ~ ~ ~ Manufacturer No. of compartments ~ ~, c~ o~0 ~ Material Liq. capacity in gallons Inside length Width Liquid depth i~s~ IF HOME.DE: ~ v Well Dwelling PERMIT ~ ~ ~ DISTANCE TO: O ~ ~ Manufacturer Material Liquid capacity in gallons ~=~ DISTANCE TO: Well / ~ ~ Foundation ~ Nearestlotline ~3 PERMITNO. ~O3 ~ ~ g No. of lines Leith of each )ine Total length of lines Trench width Distance between lines ~ ~ ~ Top of tile to finish grade Material beneath tile ' Total effective absorption are~ Length Width Depth PERMIT NO. ~ D Type of crib Crib diameter Crib depth Total effective absorption area m Well Building foundation Nearest lot line ¢ DISTANCE TO: [Class~ . [ Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line -~ ~/ Septic tank/o~/ Absorption area(s) OTHER PIPE MATERIALS SOl L TEST RATING INSTALLER REMARKS ,;~ ...... - , - l sr__ _ APPROVED 72-013 (Rev. 3/78) ;'~UNZ C i~ AL fT¥ ON-SITE PER~.IT PATE ZSSv~O: S~.~ 1727-~A ~Su~AGE, gK 99516 CONTACT P~ O~',E: 546-2671 SUeDIVISiON: LOT HEALTH ANO £~ViRCN~£NTAL PROTEcTIoN ~25 L STREET, ~NCHCRAG£, AK 99~01 ~4-4720 SE,,ER ~ ~JELL PER/',I~ LOT: 14 8LOCK: ~ ...... ~ .... : ~, ~U~ THAT 5EST =-x,- DES~6N~NG YOUR SEO. T~C ....... ' ~,a YOUR SITE. ',. CH dE~ ~RAVEL DEPTH (FT.) 4.0 4.0 4 O TOTAL DEPTH (FT.) 5.S n GRAVEL hZDTH (~T.) 9.5 -' ~.5 G~AVEL LE~;GT~ (Fr.) 2.5 22,9--- SS.g GRAVEL VOLU~:E (CU. YDS.) .~ 41.0~ ~5.9 -'-,. 5 33.4 48,1 TA~K SIZE (GALS) t-350.0 S0!L RATinG (S~,FT,/a~) 150 t50 - - *_* TANK ""USI ~AVE ~? -.~ 150 ........ , LE~] TNO CONP.aRTAI£NTS ~ CErTIFy TN.At: ................... ~__ "'~AR WITH TNt o~ ..... ~RTH EY TN; F;~,,-~,2-'~' ~uU!~EF~NTS fO~ 0~-~- 2. I -azLL Z~ST~LL TNt· o~TY OF ANCHORAGE (t¢O~) DISTANC;:~ F~ ,~,~,.~u~ AND STAT~ OF A~ov,, , ~-.-~,,~uc ~f~TEP ON T~tc ~,, -:'-~' ~a~W~TER Dl~pne,,, ~LZ '~ m~c SET ~( ...... ~r~ ADDITIONAL if A LiFT SI'ATZON ~e eLecTRICAL W~) ,,~ e~ .~--,uu~ ~N ~LECTRIr~ ~,,v~*~-"' ~.~NED; (2) AS-n~t MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -F PERCOLATION TEST PERPORMED EO"': L.~-,"-r~ N LEGAL DESCRIPTION: L!~ ~ ! 'ff ~ Io~1~ I IFE FITI~I 2 3 ~ 5 6 7 8 9 10 11 12 13 14- 15- 16- 17 18 19- 20- COMMENTS ~...~'0/[ ,'_c (/.~$ w~"'7~ g/~ PERFORMED BY: V~72-008 (6/79) ~' SOILS LOG, PERCOLATION TEST SITE PLAN WAS GROUND WATER S ENCOUNTERED? ///O L 0 P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE d2" (minutes/inch) TEST RUN BETWEEN ~ FT AND -E~- ~ s','H-.e~?~'~ sTsC',-V -~,',', CERTIFIED BY: /~ -[-'~ 0 0 0 0 0 0 0 0 0 0 0 0 o 1:::: CERTIFICATE OF ON-SITE SYSTEMS APPROVAL 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 FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-053-62 COSA# O~ Expiration Date: 1. GENERAL INFORMATION Completelegaldescription Lot 14, Block I, Sampson Estates Location (site address) 22150 Sampson ])rive Chugiak, Alaska 99567 Current Property owner(s) Michael & Laura 0iyienk Day phone Mailing address 22150 Sampson Drive Chugiak~ Alaska 99567 Lending agency Day phone Mailing address Real Esta.~e ' ' ~ ~Agent Carey Mailing Address , 1 0421 Unless otherwise requeste~f, COSA will be held by DSD for pickup. Parker/Exit Realty Day phone VFW Road, Suite 205A Eagle (907)775-5913 River, AK 995.77 2. NUMBER.OFrBEDROOMS: 4 TYPE OF WATER .SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding Tank Community On-site Public Sewer [] [] The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent p~ofessional 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 ~nd State codes, ordinances, and regulations in effect at the time of installation. , Name of Firm Pinard Engineering Phone(907) Address PO Box 871347 Wasiiia, Alaska 99687 Engineer's Printed Name Paul E. Pinard~ P.E. Date 232-1347 DSD sIGNATURE ~"'"' Approved for Disapproved: bedrooms. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well .Flow Advisory Nitrate Advisory (Rev. 11/05) X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: ~- ,~ q -/// Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: A. WELL DATA Well type Date completed 8/6/84 Total depth 1 30 ff. Lot 14, Block 1, Sampson Estates Parcel ID: 051-053-62 If A, B, or C provide PWSID # NA Well Log (Y/N) Yes Sanitary seal (Y/N) Yes Wires properly protected (Y/N) Yes Cased to 1~1 ft. Casing height (above ground) 1 8+ FROM WELL LOG AT INSPECTION 8/6/8/, 8/2o/11 115 ft. 125.9 ft. 10 g.p.m. 5.3, g.p.m. Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate I. 67 mg/L Arsenic: ND ug/L date of sample: 8/15/11 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tanksize 1250 gal. Number of Compartments 2 Foundation cleanout (Y/N) Yes Depression over tank (Y/N) Date of pumping 8/24/11 Pumper C. ABSORPTION FIELD DATA Date installed 9/11/R2., Soil rating (~.~q~ ft2/bdrm) 1 50 Length 45 ft- Width 24 ft. Total depth --4-- ft. Eft. absorption area 10~gt2 Monitoring tube Date of adequacy test ~ Results (Pass/Fail) ~ Fluid depth in absorption field before test 0 in. Water added~O0 gal. Elapsed Time: 150 min. Final fluid depth 0 in. Any rejuvenation treatment (past 12 mo.) (YIN & type) in. Collected by: Pinard Engineering Date installed 1984 Cleanouts (Y/N) Yes No High water alarm (Y/N) S~n~tary Pumpers NA System type Seepage Bed Gravel below pipe 0.5 ft. Depression over field ~ For ~ bedrooms New depth 0 in. Absorption rate >= 600+ g.p.d. Kn nwn If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at __ in. "Pump off" level at __ in. High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main 100~+ 100~+· NA On adjacent lots 1 O0 ' + On adjacent lots 1 O0 ' + Public sewer manhole/cleanout NA Sewer/septic service line 2~ ' -I- Animal containment areas 50 ' + Holding tank ~[A Manure/animal excrete storage areas 1 00 ' + SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~ ~ + Property line ~ ~ + Water main ~A Water service line 10 ~ + Wells on adjacent lots 1 O0 ~ + Absorption field :5 ~ + Surface water 100 ' + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 1 0 ' + Water Service line 1 0 ' + Curtain drain~one Known Building foundation 10 ~ + Surface water 1 O0 ~ + Wells on adjacent lots 1 O0 ~ + Water main Driveway, parking/vehicle storage 1 0 ' + F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Paul E. Pinard, P.E. Date 8/26/11 COSA Fee $ &¢' q 0 ~ ,~- g~,' Waiver Fee $ Date of Payment ~'~o~1tl C,_.~C:~ i,~"-:~'~/i,~?)~ ~ Date of Payment Receipt Number I ~ ~-~ I~'' Receipt Number (Rev. 4/10) PINARD ENGINEERING P.O. Box 871347 Wasilla, AK 99687 (907) 357-ENGR (3647) WELL FLOW TEST LOCATION: Lot 14, Block 1, Sampson Estates JOB NUMBER: 11-261 DRILLER: Syren Brothers Drilling Inc. DATE OF TEST: 8120/11 DATE WELL COMPLETED: 8/6/84 FIELD STAFF: PJ Pinard WELL DEPTH: 130' STATIC WATER LEVEL (top of casing): 125.9' Elapsed Static Flow Cumulative Time Time Water Ra~ Gallons Rema~s (Minu~s) Level (gpm) Pumped 9:30 AM .... 125.9' 5.3 --- Sta~ Test - Meter 171000 9:45 15 125.9' 5.3 80 171080 10:00 30 126.0' 5.3 160 171160 10:15 45 125.9' 5.3 240 171240 10:30 60 125.9' 5.3 320 171320 10:45 75 125.9' 5.3 400 171400 11:00 90 126.0' 5.3 480 171480 11:15 105 125.9' 5.3 560 171560 11:30 120 125.9' 5.3 640 171640 11:45 135 125.9' 5.3 720 171720 12:00 PM 150 125.9' 5.3 800 171800 12:15 165 125.9' 5.3 880 171880 12:30 180 126.0' 5.3 960 171960 12:45 195 125.9' 5.3 1040 172040 1:00 210 125.9' 5.3 1120 172120 1:15 225 125.9' 5.3 1200 172200 1:30 240 125.9' - 1280 Stop Test 172280 RECOVERY All well protection features are adequate. Average Flow Rate: 5.3 gpm Comments: DURING THIS TEST, THIS WATER SUPPLY WELL WAS CAPABLE OF PRODUCING 5.3 GPM. THIS TEST DOES NOT CONSTITUTE A WARRANTY OR GUARANTEE THAT THE WATER SUPPLY SYSTEM WILL CONTINUE TO FUNCTION AND PRODUCE AT THIS RATE. Reviewed by: Date: Paul Pinard 8/22/11 PINARD ENGINEERING P.O. Box 871347 Wasilla, AK 99687 (907) 357-ENGR (3647) ADEQUACY TEST LOCATION: Lot 14, Block 1, Sampson Estates. APPLICANT: Michael & Laura Olyienk 22150 Sampson Drive Chugiak, Alaska 99567 SEPTIC TANK TYPE/SIZE: Steel11250 Gallons, per MOA Records ABSORPTION SYSTEM: Seepage Bed, per MOA Records DAILY FLOW: 4 BEDROOMS x 150 GAL/BR = 600 Gallons JOB NUMBER: 11-261 DATE OF TEST: 8/20/11 FIELD STAFF: PJ Pinard NUMBER OF BEDROOMS: 4 SCUM: 0.1' SLUDGE: Minimal NEEDS TO BE PUMPED: Yes No CURRENTLY IN USE: Yes No XX TEST DATA Time Flow Volume Cumulative Septic Tank Septic Soil Absorption System Comments Rate Volume Tank AM (GPM) (GALs) (GALs) Liquid Level A Level Monitor A SAS Monitor z~ SAS * Tube 1' Level Tube 2* Level 9:35 5.3 - 4.0' 0.0' 0.0' Start Flow- Meter 171030 9:50 5.3 80 80 4.1' 0.1' 0.0' 0.0' 0.0' 0.0' 171110 10:05 5.3 80 160 4.1' 0.0' 0.0' 0.0' 0.0' 0.0' 171190 10:20 5.3 80 240 4.1' 0.0' 0.0' 0.0' 0.0' 0.0' 171270 10:35 5.3 80 320 4.1' 0.0' 0.0' 0.0' 0.0' 0.0' 171350 10:50 5.3 80 400 4.1' 0.0' 0.0' 0.0' 0.0' 0.0' 171430 11:05 5.3 80 480 4.1' 0.0' 0.0' 0.0' 0.0' 0.0' 171510 11:35 5.3 160 640 4.1' 0.0' 0.0' 0.0' 0.0' 0.0' 171670 12:05 - 160 800 4.1' 0.0' 0.0' 0.0' 0.0' 0.0' Stop Test - 171830 RECOVERY Date Time SAS MT1 SAS MT2 *ALL MEASUREMENTS IN FT. TEST: PASSED XXX FAILED COMMENTS: System appears to be operating satisfactorily. There was no measurable liquid in the SAS MTs prior to or at any time during the test. Reviewed by: Paul Pinard Date: 812211 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.orglonsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING cos^# b 0, ¢b Parcel I.D. O~l'~)-~?')"~n-":~' ' 'II Expiration Date:_ / 1, GENE~L INFORMATION Complete legal description Location (site address} Current Property. owner(s) Mailing address Lending agency SAMPSON ESTATES; BLOCK 1, LOT 14 22150 SAMPSON DRIVE *EAGLE RIVER, AK RU$~FI L & ROMAINE HEAP - Day phone 22150 SAMPSON DRIVE *EAGLE RIVER~ AK Day phone 688-6490 Mailing address Real Estate Agent Mailing address KAY HANKS W/ PRUDENTIAL E.R. Day phone 688-3248 16635 CENTERFIELD DRIVE *EAGLE RIVER, AK 99577 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class .Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer regis[~Ed in th~-St~te~f-A[a.~k'a.--C~ttificates 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 samples. (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. Engineers Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, DSD Guidelines & Regulab~ns. The reported results described the pe/fon'nance of the sepb~ systems depend ~n the Iocal soils condition, groundwater levels that may fluctuate dudng the year, and the water usage of the family being served b the s ........ ...~ ..~ ,~ u~ u~ ~ne eva/uator of the system. Satisfacfo~y test v~-u/ts cio no[ guarantee future performanco of the system, nor do they guarantee that any wamanty or futura estimate of how long th; system wi~ conti%Ue~Utol°r~eneC/ ~vide operational requirements of the ADEC or MOA DSD. The content of this report is for thes°lebenefitoftheownertistedabove. Anyretianceupcoort~seofthisreportbyeny other person or pady is not authorized, nor will it confer any legal Ifght whatsoever. Approved for _ L,/. t edrooms Disapproved. Conditional approval for . bedrooms, with the fllowing stipulations: 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I vefffy 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 bedroom$ and type of structure indicated herein. I further veri[y 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. NameofFirm _GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address _,3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK Engineer's Printed Name _ JEFFEEY A. GARNESS, P.E. Date Attachments: CaSA Checklist _ ~ Arsenic Advisory Septic System Advisory _ Well Flow Advisory Maintenance Agreements Supplemental Engineer's Reort Nitrate Advisory _ Other _ O. ,na, Ce.,.=te Date: .q-- / n g 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 0N-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SAMPSON ESTATES; BLOCK 1~ LOT 14 Parcel ID: 0 *1 A. WELL DATA Well type pR~VAT£ If A, B. or C provide PWSID# N/A Date completed 8/6/1984. Sanitary seal (Y/N)YES. Totaldepth 130 ft. Casedto 131 .ff. Date of test Static waterlevel FROM WELL LOG 8/6/t984 115 ft. Well production 10 WATER SAMPLE RESULTS: Coliform ~ 0 . coloniesll00 mi. Arsenic: ~ ug./L. Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 6/26/0'/ 122 ft. YES YES 12+ in. g.p.m. *7+ .g.p.m. *PER CHRIS WOOD P.E. EAGLE RIVER ENGINEERING SERVICES Nitrate ~ mg.lL. Other bacteria 0 colonies/100 mi. Date of sample: 0/11/'~J Collected by: GEG Ltd. B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1250 _gal. Number of Compartments 2. Foundation cleanout (Y/N) 'YES. Depression over tank (Y/N) NO. Date installed 1984 Cleanouts (Y/N) ' YES High water alarm (Y/N) N/A MCDONALDS PUMPING New depth Date of pumping 9/1/08 Pumper ' A C. ABSORPTION FIELD DAT ~,l~[LOW eXISTING CRAOL] Date installed 9/t ~/~s84 So rating (g.p.d.lft~oQ 150 System type BED 0.5 ft. Length 45 ft. Width 24 ft. Gravel 'below pipe Total depth 4 ft. Eft. absorption area 1080 ft~ Monitoring tube YES. Depression over field NO Date of adequacy test 6/26/07 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 2 in. Water added 600 gal. 4 in. Elapsed'Time: 1440 min. Final fluid depth 0 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date BED WAS CHECKED AND FOUND DRY ON 9/11/08 D. LIFT STATION Eo Date installed Size in gallons. Manhole/Access (Y/N) ~ Pump on" level at in. "Pump o~ level '. High water alarm level at .in. Datu._.____m ~ Cycles lested. Meets alarm & circuit requirements? SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot Public sewer main Sewer/septic service line , 100'+ N/A Holding tank N/A Animal containment areas. 50'+ Manure/animal excrete storege ereas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ,5'+ Property line ,5'+ Waler main N/A Water service line 10'+ 100'+ On adjacent lots. 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Absorption field. 5'+ Surface water 100'+ Property line 10'+ Building foundation 10'+ Water service line 10'+ Surface water 100'+ Curtain drain NONE KNOWN Wellson adjacentlots 100'+ COMMENTS Water main N/A Driveway, parking/vehicle storage 10'+ G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Pdnted Name JEFFREY A. GARNESS Date COSA Fee $ Date of Payment Receipt Number "~"~ (Rev. ~ Waiver Fee $ Date of Payment Receipt Number ..... · Iu-.t ...... / ....... ASBUILT NO CORNERS SET THIS DATE. S['~ARD & ASSOCIATES [AND SURV%-~ING 688-4566 I HEREBY CERTIFY .THAT I HAVE SURVEYED THE SCALE, FOLLOWING DESCRIBED PROPERTY.' 1"=40' Sampson Estates,Lot 14,Blk. 1 DATE, ~A.~.." AND ~T NO ENm~HMENTS EXIST ~CE~ AS 6-24-91 INDICA~. IT IS THE RES~SIBILI~ OF THE ~EMENTS~ ~VENANTS~ OR RESTRICTIONS ~ ~56t , WHI~ ~ NOT ~EAR ~ THE RE~ ~BDI- VISI~ P~T. UND~NO CIRCUMSTANCES S~, FB: e ~ .'..~ · ~ DATA H~ K US~ F~ OONS~U~ION 21-57 t. %".. ...... · '~ ~ FENCE LIN~ OR ~R E~LISHING ~ND' DRAWN' A~ LINES. D}~ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage. AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 1. GENERAL INFORMATION Complete legal description Location (site address) COSA# Expiration Date: Current Property owner(s) Day phone ,~-,~, g - 6, I ~, ~ Mailing address Lending agency Day phone Mailing address Real Estate Agent Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: ~ 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site [~ Individual Holding Tank [] Community On-site [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) issues Certificates of 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 omission,s tn-the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validafion 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 lype 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. Name of Firm EagIe River Engineering Services ic.;2i VFW Rd., $,,i[~ 2bi Phone Address F.~gle River. AK §9577 Engineer's Printed Name ~,,t-1~lS"l'OPll12t,~ ~. _~,L')oo'rb Date "7/~"/ 5. DSD SIGNATURE ~ Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: '~-- (~ ~ ~) .'~ 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: ,~/~ ~:~D,,~ F. <~--r-/~ T~5- / ~ I ~ I'~ ! A. WELL DATA We, ty pe'"~?~ I VA 'TF__- Date completed ~/~! Totaldepth ~"~0 ff. Date of test Static water level Well production Foundation cteanout ~/N) Date of pumping (~ / I~/~r' C. ABSORPTION FIELD DATA IfA, B, or C provide PWSID # __ Sanitary seal {~/N) ~E.~; Cased to _L?L]_ft. FROM WELL LOG ~1 5 ft. I ~ g.p.m. Parcel ID: 0,,~'-/- O.~.~-G ~ Well Log (~/N) Wires properly protected (~IN) Casing height (above ground) AT INSPECTION I P.'7-. ft. 77 g.p.m. Other bacteria Collected by: ~' coloniesll00 mL Absorption rate >= For ~ bedrooms New depth 0~- in. g.p.d. Y-~.tO~L.~'~ If yes, give date ~ I ~ in. Date installed Length Total depth ~¢' fl. Date of adequacy test Fluid depth in absorption field before test ~ in. Elapsed Time: I,,.~{~in. Final fluid depth Any rejuvenation treatment (past 12 mo.) (Y/~ type) Results'~Fail) ~ Water added (,~,3~el. b Soil rating (g.p.d./ft~ Or~-'~ I ~'O System type ft. Width ~'Jr-' fl. Gravel below pipe O,~ ft. Eft. absorption area I.O~0fft Monitoring tube ~ Depression over field WATER SAMPLE RESULTS: Coliform.,v..._~L.colonies/l~,. 00 mL Nitrate ~ mg/L Arsenic: ,bT- ug/L date of sample: ..~)/0 ~' B. SEPTIC/HOLDING TANK DATA Tank Type/Material ~ C--7c'7'1 C.. [ [~ Tank size ]~0 gal. Numar of Com~ments ~ Depression over tank (Y~ ~0 Pum~r ,~ ~ ~ V 30 in. ' Date installed Cleanouts I~N) High water alarm D. LIFT STATION Date installed Size in gallons · Pump on' level at__eve, at ~ in.~\~"~'Hi~alarm level at in. ~ Cycles tested Meets ala~Tn & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot ! O.~- Absorption field on lot -t- Public sewer main Sewer/septic service line Animal containment areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 4- Water main '~10 I Water service line -~ ~ (~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 4 L(~~ Building foundation Water Service line -~ Curtain drain -~ ~'O On adjacent lots On adjacent lots Pubtic sewer manholelcteanout Holding tank Manure/animal excrete storage areas Absorption field Surface water Water main Driveway, parkingNehicle 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. Engineer's Printed Name C~ t I,~. ~'T'Ot~t I ~.~ ~_.~.'~c.c'~'~ Date of Payment "~-- ~ - ~ Date of Payment R~eipt Numar ~ ~ ~ ~ ~ ~ R~ipt Numar (Rev. 11/05) ~ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program ',~'?,~ 4700 SOuth Brag~W St '~:~.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. ~1~'1 - 05 5'-'~ ~- 1. GENERAL INFORMATION HAA# Oqoo'b5 Expiration Date: .~~,~ Complete legaldescription SAMPSON ESTATES; LOT 14~ BLOCK 1, Location (site address or directions) 22150 SAMPSON DRIVE * CHUGIAK, AK. 99567 Current Property owner(s) HAROLD AND GAlL WEST Day phone 688-9378 Mailing address 22150 SAMPSON DRIVE * CHUG~K, AK. 99567 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: I'SEPTIC SYSTEM SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well [] Individual On-site [] Individual Water Storage [] Individual Holding tank [] Community Class Well [] Community On-site [] Public Water System [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given ~n 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 samples. (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. 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 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 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 0ARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Phone Date 357-6179 Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured ~o readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being sewed by the system, These conditions are outside the control of the eva/uator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can therefore not-prove- any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The ~oqte~ ~f this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by anY other person or party is not authorized, nor wi//it confer any legal right whatsoever. DSD SIGNATURE ~ Approved for Z-'l Disapproved. Conditional approval for __ bedrooms. bedrooms, with the fllowing stipulations: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance ^greement Supplemental Engineer's Reed Other Original Certificate Date: (Rev. 12~)1) CYcles tested High Water alarm level at in. Meets alarm & circuit requirements?. ~ in 100'+ ~ sewe r main Water service Surface water. water main abov~e systems are in MOA HAA guidelines in effect on this date. Waiver Fee $ Date of Payment Receipt Number FILE No.584 10×21 '04 1B:16 A$~UILT-NO CORNERS SET THIS DATE. I HEREBY CERTIFY ,THAT ! HAVE SURVEYED THE FOLLOWING D/SCRIBED PROPERTY= Sampson Estates,LOt 14,Blk', 1 r AND THAT NO ENCR~HMI~NTS' EXIST EXCEFT AS INDICATE. D, IT IS THE 'RESPONSIBILITY OF THE .OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT N=~EAR ON THE RECORDED SUBDI' VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HERE;ON B~ USED FOR CONSTRUCTION OF FENCE LINES.~ OR FOR ESTA~LISHIN6 BOUND- ARY LINES. 21-~ DRAWN' 688-4~66 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING· 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 ~ ' " ' GENERAL INFORMATION Complete legal description Lot 14; Block I; Sampson Esta~tes Location (site address or directions) Sampson D~iv~ Property owner JUry Za§odyn Day phone 522-2275 Mailing address Lending agency NATIONAL BANK OF ALASKA Day phone At, tn: Shi~6ne W~ Mailing address P.O. Box 107025 Anck~.~.~.ge, A~a_~ka q95!0 257-3418 Agent none Day 2hone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: _4- 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. TYPE OF WASTEWATER DISPOSAL: nd v dua on-site . XX ': :. ,: -: . Holding tank ' Community on-site P'ublic sewer ' NOTE: 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 · ::,poM s,Jeeu!6ue leuo!ssejoJd eq~. u! suo!ss!cuo Jo 9JoJJ6) JoJ. elq!suodseJ :~ou s! eBeJoqou¥ jo ./q.!led!o!unlAI eq.L 'p@nss! s! e:~e::)!i!]u@o e eJojeq p].ep eZ,~leu'e Jo suo!~.oedsu! ~.onpuoo ].ou op SHHQ jo see,~old LU':q 's~.ueLueJ!nbeJ e]e~.s pue leJepeJ u!e:peo ~s!].es o3. JepJo u! suo!].n:l.!:~su! 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I 'u!eJeq pe~eo!pu! eJ n~on.qs J.o ed~), pue SLUOOJpeq J.O Jeq~nu eq~ ~oJ. e),enbepe pue leUOi].ounj. 'e,,.es s! uue~s,~s lesods!p Je:l.e,'~e].se~ ~o/pue · ~lddns Je:l.e,'v,. e:~ls-uo eq~ :!.eq).. s~oqs uoi~eo!ldde le^oJddV ~Hoq3n¥ q31eeH s!q:l, j.o uo!~e6!:i, se^u! ~t,.u 3e.q]. AJ!Je^ I ','~oleq u~oqs e~,ep uoi~epile^ eq]. jo se pue o~eJeq pexljJ, e lees A~ ,4q peij!:peo sv I:t:~NIgN~I AB NOIJ.O~tdSNI JO J.N=IIN:I.LVJ-S "9 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lc>-r ~ z~ ~ \ ~--~zx, f-A?~t>~ ¢-_~'r'. Parcel I.D. iNMENTAL SERVICES DIVISION A. WELL DATA jUN 4 1~ Well type Log present (~N) Total depth Sanitary seal ~)N) Date completed ~ ~ b,- ~,~ Driller~,l Cased to ~ O Casing height Wires properly protected I~N) '~ Date of test Static water'level Well flow Pump level ' ' FROM WELL LOG AT INSPECTION g.p.m. '~ ~ ~ g.p.m. Absorption field on lot Public sewer main' Public sewer service line SEPARATION DISTANCES FROM wELL TO: Septic/holding tank on lot 10'7-) ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Date of sample: ~'-'Z. cl -~ I B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (~/N) High water alarm (Y~ Date of pumping Nitrate Collected by: Other bacteria /,~ O/-,J F_.. $ & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Tan k size I '7.-c~ O Compartments ~-- Foundation cleanout (~)/N) '~ Depression (Y/~ . Alarm tested (Y/N) SEPARATION DISTANCES FROM .SEPT C/HOLD NG TANK TO: Well(s) on lot ~o?.-,~ To property line ~,~ f' Surface water/d rainage On adjacent lots AbsorPtion field Foundation Water main/service line 72-0~6 (Rev. 3/91)Front MOA21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) Manufacturer "Pump on" level at High water alarm level Meets MOA electrical ~__ W~I on lot On adjacent lots Manhole/Access (Y/N) Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed o~ _~,¢~( J Length ~1'~' Width 2-4 ' Total absorption area lo.c> ~¢ Depression over field (Y~) r~ Results ~E~/fail) PA-'5~ Peroxide treatment (past 12 months) (Y~J~ Soil rating Gravel thickness O,.S" ' Cleanouts present ~N) Date of adequacy test If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot ~6:x~ To building foundation On adjacent lots System type ~,~ Total depth. Surface water Curtain drain On adjacent lots ~ o ~:~ t'"- Property line To existing or abandoned system on lot Cutbank ~ J~- Water main/service line bedrooms Driveway, perking/vehicle storage area E. ENGINEER'S'CERTIFICATION . I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name 'J y'034 ii~, e P, iv.-:r Loop Road ~o, 204 .~a¢ Ia J~ivm', ¢)laSkp 995Y/ HAA Fee $ ["'7'~1~ ~ Date of Payment (.O' ""t' q J Receipt Number 0'~"~"~ ;::~,~."(_ ~¢),~/~L~' ) 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEAL?H CERTIFICATE OF INSPECTION FOR HEA, LTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~,, fl.)[~'..,4--::~ Telephone: Home ~'/'~- :;Z.q.~--] Business Applicant Address .~5 ~ .,¢c- / ~-'~ -/~/~ ~'~-~'~¢--- -"¢-/~" (c) Applicant is (check one): Lending Institution [-I; Ownef/builder/~ Buye. r F'I; Other [] (explain); (d) Lending InstitUtion.,,~- Address ///~/~////~c~' (-S (e) Real Estate Company and Agent ""~L~ ~ I¢e Address (f) Telephone ~ q~' ,~ 0 0 Mail the HAA to the following address: 1 TYPE OF RESIDENCE Single-Family ~ Mu[ti-Family Number of Bedrooms Other WATER SUPPLY Individual Well~ Community [] Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite ~ Public [] Community [] Holding Tank [] Note: If community weld system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 72-025 01¢84) Address I 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigati(~n 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. ~¢/_ ~ ¢,,¢/.~ Name of Firm- ,~--~ ~"'~-~"~ Telephone Date DHEP APPROVAL Approved for 4 Approved bed r o__o ms by_~ Dis~ ~"-~lCOnditiOnal Terms of Conditional Approval Date ¢~/ -- CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. Tl~e DHEP does this as a courtesy to purchasers of homes and their tending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 MUNICIPALITY OF ANCHOP. AG~ "') DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) "APR g CHECKLIST- FEBRUARY 1984 264-4720 .._,.RECEIVED Legal Desc. ription: ~/.~'/~/,Z. oT' /~/ /L/ Rim WELL DATA Well Classification Well Log Present~:~N) ~ . ~ / Total Depth I'~1 Cased to ~ Static Water Level I~I~ / If A, B, C, D.E.C; Approved (Y/N) Date Completed ~/~/'~ ~ Yield Depth of Grouting A,) ~- Pump Set At ~ Sanitary Seal on Casing ~N) ., Depression Around Wellhead (Y/~. Casing Height Above Ground Electrical Wiring in Conduif~N) Separation Distances from Well: To Septic/Holding Tank on Lot 10~L/ ~; On Adjoining Lots To Nearest Edge Of Absorption Field on Lot / ~i~) I ~--; On Adjoining Lots To Nearest Public Sewer Line .~. ~ To Nearest Public 8ewer Comments ~'~~ ~ ~:~ ~ ~ ~ ~ B. SEPTIC/HOLDING TA'NK DATA Standpipea~N) Depression over Tank (Y/'~) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding TCnk: To Water-Supply Well' To Property Line -')' To Water Main/Service Line Course Comments ~r- ~~-~ Size IZ-~"O No. of Compartments ~'- Air-tight Caps.) Foundation Cleanout~N) Date Last Pumped /0~'¢ ;for 2~)l¢:)¢ Temporary Holding Tank Permit (Y/N) To Building Foundation ~ ~"~ / To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~////'~'y Width of Field Square Feet of Absorption Area Depression over Field (Y/~) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well /~/ 'X- · ¢¢¢' Type of System Design Length of Field Depth of Field Gravel Bed Thickness g:~/~'- · Standpipes Present~N) Date of Last Adequacy Test To Building Foundation Lot /12'/'4"- To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~"/'1~/~.~ To Property Line ¢/.~ To Existing or Abandoned System on ; On Adjoining Lots '~ To Cutbank (if present) ¢~/~-~ / D. LIFT STATION Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical C o d es~.~.N.).~- oo Date Installed Dimensions~~--~ ' Manho~/N) mp Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that l t~ve checked,..v/Crified, or conformed to all ~M~ an/HAA guidelines in effect on the date of this inspection, Signed ~ ~"-~' Date Receipt No.~ Date of Payment L~ Amount: $ &~ Page 2 of 2 72-026 (11/84}