Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
SAMPSON ESTATES BLK 4 LT 5
Onsite File #051-811-10 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201043 PID Number: 051-811-10 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑■ Upgrade Name DANALYN KUMMERT ABSORPTION FIELD 0 Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 22611 GABRIEL CIR., CHUGIAK, AK 99567 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 854-0744 1 3 0.8 GPD/SF 11.8 (MAX.) Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade SEE DRAWING Ft. Gravel depth beneath pipe 6 Ft. Subdivision Block Lot SAMPSON ESTATES 4 5 Fill added above original grade SEE DRAWING Ft. Gravel length 50 Ft. Township Range Section - - Gravel width 2.5 Ft. Beds: Number of Lines N/A Distance between lines N/A Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 600 Ft2 1 N/A Ft. Well 1001-+- 1001+ — — 254 TANK X Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity GREER TANK 1000 Gal. Surface Water 1001+ 1001+ _ _ Material Number of compartments Lot Line 51+ 10,+ - - NA PLASTIC/HDPE 2 Foundation 10'+ 1 10,+ _ _ LIFT STATION Manufacturer Capacity Remarks *TIM EKLUND WITH MOA ONSITE DEPTARTMENT Gal. PRESENT (ONSITE) FOR BOTTOM OF TRENCH INSPECTION. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank D-2661 Tank to D-3034 drai NORTHERN EXCAVATION Drainfield D-3034 coIMTMr D-303 Inspector GEG CONSULTANT, JODY MAUS BENCH MARK (Assumed elevation) 100.00 ft Inspectio i51 4/3/2020 2nd *4/4/2020 Location and description 3b 4/4/2020 411 _ BOTTOM OF SIDING NEAR FOUNDATION CLEANOUT ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp _oo6QQQ Conditional Approval: Date ••. S, � o � •..-"' o�.. 4 ........................... .... Septic System Approved \P� Date y A`�c�rr, ss: p CE— 95 _r("ACj22VLX :ZU ,coo Note: this approval does not include well permit requirements. ro tesslo C" o #A��QQpOo� ECC884 tO." nrnvvl ON PERMIT NUMBER: PARCEL ID NUMBER: OSP201043 RECORD DRAWING 051-811-10 NOTE: THE CONTRACTOR INSTALLED (DROVE) 2• (I.D.) STEEL PERFORATED MONITORING TUBES (MTS) NEAR THE CENTER AND AT THE SW END OF THE OLD DRAINFIELD. MT3 WAS DRIVEN TO 4 FEET BELOW INVERT OF DIST. LINE (UNTIL REFUSAL) AND MT4 WAS DRIVEN TO 3.5 FEET BELOW INVERT OF DIST. LINE (UNTIL REFUSAL) PER THE CONTRACTOR. DRAINROCK PRESENT BUT APPEARED TO HAVE PIT RUN TYPE MATERIAL MIXED IN WITH SEWER DRAINROCK PER THE CONTRACTOR. NEW INSTALLED DOUBLE CLEANOUTS (DBL1 & DBL2) NEW 1000 GALLON GREER PLASTIC SEPTIC TANK INSTALLED NEW FOUNDATION CLEANOUT (FCO). PLUMBING IN CRAWLSPACE WAS RAISED IN ORDER TO ACHIEVE GRAVITY / FLOW TO NEW SEPTIC TANK/DRAINFIELD > a OLD DRAINFIELD TO BE / USED AS A RESERVE SITE /CONTRACTOR INSTALLED / NEW MONITORING TUBE (MT4) IN EXISTING DRAINFIELD (SEE NOTE) INSTALLED FLOW DIRECTOR (FD) / :d CONTRACTOR INSTALLED / .< 40� NEW MONITORING TUBE d " - (MT3) IN EXISTING /11 DRAINFIELD (SEE NOTE) /11 V d a. jj ° ° e .d WELL dA . -e - a- e e d d °d e \ Ia•. v a / vO.WF44 ,gojL a. I I I I N NOTE: OLD SEPTIC TANK II WAS DECOMMISSIONED PER 1 SCALE: UPC PER THE CONTRACTOR. \ 1-30 . OF 1�1 lAwF 44 GARNESS ENGINEERING GROUP, Ltd ;....::...:..:......................::....., CIVIL & ENVIRONMENTAL ENGINEERS • •• , 3701E. TUDOR ROAD, SUITE 101ANCHORAGE, AK 99507' PHONE (907)337-6179•FAX (907)33&3246' WEBSITE: www.game engineering.com %• ••••• ••••••••• •••••••••�;!•� PREPARED FOR: PHONE NUMBER: PAGE NUMBER: (n e y A._Garn, ss B Lv i DANALYN KUMMERT 854-0744 2 OF 3 �j J, z CE -79 3 ��AV PROJECT/LEGAL DESCRIPTION: DRAWN BY: •� ' o \� SAMPSON ESTATES; BLOCK 4, LOT 5 J.L.M. ��j♦FO �ppp�'���.....?" P�� TYPE OF WORK: DATE: LICENSE,rj%FES"���• RECORD DRAWING OF SEPTIC SYSTEM UPGRADE 4/7/2020 #AECC88a i PERMIT NUMBER: PARCEL ID NUMBER: OSP201043 RECORD DRAWING 051-811-11 FINAL GRADE = STl TOP OF MANHOLE LID = 99.91 99,87-99.88 MH1 TOP OF TANK ON TOP OF TANK ON INLET = 95.81 OUTLET = 95.81 INVERT OF BUNG @ OUTLET = 95.20 INVERT OF BUNG @ OUTLET = 95.01 1000 GALLON GREER PLASTIC SEPTIC TANK MT1 C01 ORIGINAL GRADE MT2 CO2 FINAL GRADE = TH41 = 97.95- 99.00 (@ 99.42-100.24 HIGHEST POINT) FILTER FABRIC 0 0 0 0 0 INVERT OF DIST. 0 LINE = 93.20 0o AT EACH END 0 0 0 6' OF EFFECTIVE 0 0 0 0 a 0 0 0 a a 0 BOTTOM OF —f2.5' WIDE TRENCH = 87.20 RELATIVE ELEVATION OF TEST HOLE #1 = 80.50 (TEST HOLE DRY ON 4/3/2020) J\ ••. 1. V. t • `9#L IA.....:.�♦ �'0GARNESS ENGINEERING GROUP, Ltd .. CIVIL & ENVIRONMENTAL ENGINEERS r 10 3701 E. TUDOR ROAD. SUITE 101 'ANCHORAGE, AK 99507 'PHONE (907) 337-6179' FAX (907)338-3246'WEBSITE:a gamessengineering.— •••••• •• • •• •••••••• •••••••••••�; PREPARED FOR:ONE NUMBER: PAGE NUMBER: ♦ � A. Gar e1ss :° Lu T H■ DANALYN KUMMERT 854-0744 3 OF 3 ��� CE- 53 1 ,' PROJECT/LEGAL DESCRIPTION: DRAWN BY: ♦� i �• - SAMPSON ESTATES; BLOCK 4, LOT 5 J.L.M. 10 TYPE OF WORK: DATE: LICENS 441ROFES\ w� RECORD DRAWING OF SEPTIC SYSTEM UPGRADE 4/7/2020 #AECC8e4 �����\ OF.A2`` oO CD 49 rH `Y S '4" fig SHANE A. HOLT LS -5914 4 c l fessiona� �o NOTE A T/TLE REPORT WAS NOT PROVIDED FOR THIS SUP VEK.. THEREFORE, THERE MAYREEASEMENTSAFFECTINGTHS PROPERTY NOT SHOWN HEREON GRID NW1560 PLAT 84-10 T HEINFORMATION HEREONISFOR THEUSEOFLENDING 1N57/TU77ONSSPECIF/CALCYTO SHOWANY CONFLIC755ETWEEN EXIST/NG STRUCTURESANO PLATTED LOTLINESAND/OR FA5EMENTS-AN5175 NOTTO HE USED FORPOSIDONINGA00I77ONAL STRUCTURES, IMPROVEMENTS OR FENCELINES. EASEMENTSOFRECORD, OTHER THAN T HOSEAPPE9RING ON THE RECORD PLAT, ARENOTSHOWN HEREON (UNLESS INDICATEO) NOTE; FENCELINES 77-1ATMA YAPPEAR ON THISDR4 WINGARENOT TO 6EUSED TODETERMNE PROPER7YLINESORPOSMONADDT77ONAL IMPROVEMENTS. ANYPA VING SHOWN HEREON MA YBEAPPROXIMATEDUE TO FYCESSIVESNOWAND/OR ICE. AS -BUIL T SURVEY 1 " = 40' +IaaasErrFnsonse - —.— I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY LOT5, 8LOCK4 SAUPSONESTATES ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE, ALASKA THIS 7TH DAY OF APRIL , 2020 F8 202-45 203-5S HOLT LAND SURVEYING 9309 GROVER DRIVE ANCHORAGE,AK 99507 345-5513 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201043, Rebecca Carroll, 03/23/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201043, Rebecca Carroll, 03/23/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201043, Rebecca Carroll, 03/23/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201043, Rebecca Carroll, 03/23/20 72-013 (Rev. 3/78) MUNICIPALITY OF ANCHORAGE �� •-` a°°°°° DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION £ ENVIRONMENTAL ENGINEERING DIVISION_ 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 40�000000v ON OY •° SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION R ;;;nnev ,ORT°°° res R NAME ���� Sly ,(1'tCC i.� t PHOr�N t/�6q%� C -- ff MAILING ADD�RESS - , r / , fv LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS U Y DISTANCE TO: Well z5 r Absorption ara� til Dwelling, r PERMIT fjAlO. n� I__ N F Manufacturer /P�j n1�, 02�tT Material � S 2T, G No. of compartments G Liq. capacity in gallons Inside le g h IF HOMEMADE: A �. Width NZ/11- Liquid depth q P _ ' v O --'---�----WzLI-_s DISTANCE TO: �----- Dwellin Dwelling �-' ---PERMIT-F70. z ,^ O Q Manufacturer -`� _------'--� "`'-' �� teciaL Li uid capacity qin gallons O 12y w Well / r DISTANCE TO: i3, Foundation Nearest lot line/ / G PERMIT Af OL �j Lu LL z No. of liges Length of each line ,� � / Total length of lines Trench width / Distance bet we n lines Q aw b 4 Twat the to finish grad ` / % inches Material beneath tile Lf, 7W Total effective absor tion area Length W� �(� inches Depth 6 g �, f; Lu PERMIT NO. C7 Q F- Lu a Type of crib Crib diameter jl n epth ,_-_�, - Total effective absorption area ti DISTANCE TO: Well Building founds ion Nearest I�?re-_�__ -u w Clas�. //�� A v/4q�L �F,_c��i:��J Depth , / / L Driller -/`C / /rroa . , Distance lot line 9 Z PER NTIM 0. DISTANCE TO: Building fo90//tion Sewer 1'n / Septic�nk / Absorption��eals)� OTHER I 1 oG ,,v � Z:' PIPE MATERIALS I 1 _17 I . WREMARKS i 2r Z ^'K !/vST.1? Lam/ 111w, ZG— z; /T;:y rf1,,zl/� ✓' �s7 /�,iJ L-r� .noz/' f 1 _ - _. �7niliil'i �•- O n imp �! "'- Gc'7 / � r n s 76 A/7- - /I/o ma- ,D e — APPROVED DATE LEGAL 72-013 (Rev. 3/78) .x rn 0 Q: rl : c7 ; N: o: w i a z d a H A .wd a rj o H A Ea 0 0 ro° 0 Cd 4-1 H P 0 4N H Cd0 �° � o V) r -N H P, 0) Cd W �3: x z° z z 0 Q O w z U Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] -Q : � -3 . F• rs rs cFc. w ri w cFi, w [� F, u 01. • • • : T-1: 04 OW w: CO C): u T. F-: cry 0: O O ©'i CIJJO O O O O 0 o 0 O o g F al: P�: b3r= .: w - w . . �t-L w w w w . + ; w _ 3 O\• O: H;�Q , O z i 3 > z = a 3 Y • Q � m w O x w V q a O O O O O O O O O O O O G' O a -. Q d ¢ a q z x w x w x m w w x a x w w w x w a w x w x w x w z Q VV w >_ w U)Z a a w Id W Q m d M a n i y; <d : y: cd c U i. rl i ~ W LL a H: cd: d: bo Cd : o; 02 co u`�i bjO; m o: -f': o y� \O: Oc O E O: H t N i �' i N� C'7 H: (`'7 0: 0 0 0 0 0 0 0 0 0 0 0 0 U: rn x: co off; F F F F F F F F F F F F Y p w W w W ; ° kF. kF, fi ri cF:. fi QPCI; I: I: If ce)q W Z o: q E F" i \C): C:): O O i O ; N > OW i CO -1 U. ? q O J 0 O v� ti v� vFi w w O O O O O O O O O O O O cd w I I 1 O Cd a W Cd W x a W W Od w w .� w w p w w w w w w w w w w w w p -, F F Z Onsite Community Molding Tank -- Public .x rn 0 Q: rl : c7 ; N: o: w i a z d a H A .wd a rj o H A Ea 0 0 ro° 0 Cd 4-1 H P 0 4N H Cd0 �° � o V) r -N H P, 0) Cd W �3: x z° z z 0 Q O w z U Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] .. aCHv+2Aou _ - C ifi Tr PT JF N AL :-{ -6ND ;,it1IRG'd ENTAL PRCT CTI^P n ?- jTw fT A'iC f� i .� ="iK ?9:r:7 ' 264-47110 _ - i L'_ _ - _ e -rte✓_/ Ii irW,t{ � j:_� v ti:'41T .i DATA' .TSSUCD; j APPLICANT: T' JM^ R`j't - ,ii V �ITUt 5 f 'vTC^ CONS! s'JCTI0,P AGcS ?C- C rr�;;_LL PLA.Ca_ _ ' ANCHCJRASvr AK Y9 J7 - 00A41TACT PHDNF: 5)6e LL GAL vt3CRIP: SUz�_DIVISIC°!: SAMPSON ESTATES SE1&IC 1. 3 r TOWIr NSHIP: IANGE: 1`N ��()CK: 4 LOT I� CS .f7. LCT LCCF TtCN: i2IAi. CIRCLa - �iAX EaF0f 0A 3 .SYiTEM;. C�C�SrLl Z:I:Y C?TT.},�4 AVaIL� Le r:C YOU 1N DE T ti?M1'u YC�? aE�TIC - - - - - - - - _ - -:i - f - - ..E,T fITZ YCuR SIT -7. r-fb?.CH _ –.� – – – _ �oc—b – - – – –– – DEPTH TO ?IFTT) r, tsT.) J v. :, 4. RAVEL DcEPT { '.) TOTAL ur ? 5 T� {FT.� .) � . GkAV - L N'IDTis (FT.) •' G.5 ,. s G13A4�LL Z3. j � s ,AV"L VJLU, c (CU.YDS,) 7 ,J- 44.J r� SUIL RAII^{sV(�.'v.FT,/"��) ice`" �: �t irC)0 x TANK ,"'rLST aAV� E 4.T LEAST T. Cv - - - - - 'MPA RT `*4NT I - - - - - - - - - - - - - - - - - - - - - - - CLT_FY Tf;,tq A ' FA ijt iAR WITJH TF n'i zL NENTS FUit SITF S';wYKS AND W LS AS .SET FrUR78.' `Y THE '"UNICIPA.LITY OF AN CH, 0pA4DA.) A> IH STA?' ')t ALASKA. Z. I LL IN SF -IL_ THE JtN ='ACCC?DAN +.7TH ALL ICA Cr DES AND ANJ r .KFste'LATIJPii IJrF'L A",C HI'ts Ti~ JFSI 'ti C?I? YI Jr 7HIS r.Ri r IT .ILL ADHL+?c4TO ALL ',�iA AND 3T.A.TL Cr :ALASKA ,')E^tJ"'�tt: 1TS FOP T?E a=T AC{ D., i yiJC FriC nNY 'XISTiNIG" WELL wASTEWAT R I°P S;:L SYSrcil n? ?UE':LIC k C n n. is .i_Y3 T ";�/ t H L e � ! d yy ( r, ���yy fi A'Y .D-{J����L T`T^iT Cay Nr_�Fy_Y LOT. ((`� (';1 [[��{� :a _ °I �i = �f J T AND T {.j AT '1 i }J -"T 1✓ V A 1 (- t .i F V �'l .l r •� J A ti D 6;'.Y = LhRav`l NT tti I LL r,='C'LADD1TIC A.L P tIT. If A LIF TTAT10, Y v TALL E C 1 AN A E. CC'dED Y + G c a 1Er THEN (i) AN L^CTR!CAL . : J:LDTAa:� r0DFS., ILL ACCT E a I� JV,n WITHOUT FAN L?CTtICAjJ'fVj?�CT:C'� rF�C�T�� .hD)(i)�T�ILTS EL=CTRIC,L w-Ok<, '?UST Y ,,j „ > s 15N �� iL� Ce�� • � <<�pv _- �, _- -- --_A G T . , Ake-`LI£AtiT. `_ -- -- ------ - - - - -- - Tt, N V :r I ,(��, �,q T,� .:.5 rz.'7T)' ,.CP,ST'?Uy':.CV 1 MUNICIPALITY OF A,4CHORAGE DEPARTPENT OF HEALTH AND ENVIRONMENTAL PROTECTION ---_.___.__.----_825__ L S T R El: E T ANCHORAGE. AK ----94-5D1_ :. ------ 264-4720 PERMIT NO: 840402 APPLICANT: TIMMERMAN VENTURES FENTON CONSTRUCTION ANCHORAGE, AK 99507 CONTACT PHONE: 563-8236 LEGAL DESCRIP: SU9DIVISION: SAMPSON ESTATES LOT; (5 13LOCK SECTICN: 3 TOWNSHIP: 15N RANGE; IW _4 0149 - - _( S Q R_ A C R E S LOT LOCATION: GA8RIAL CIRCLE MAX BEDROOMS: 3 LISTED BELOW ARE THE COTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE, - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - DEPTH TO PIPE 30TTOM (FT.) 4.0 4.0 _G R_A_V.Z L--D.EP-TH-- (2F -- ---- - TOTAL DEPTH (FT.) 3. D-4. 5 7.5 GRAVEL WIDTH (FT.) 2.5 22.0 5.0 G RkVE LL.E NG T H -_(FT.)- GRAVEL VOLUME (CU.YDS.) 34.7 35.8 —7-3 54.0 TANK SIZE (GALS) 1t000.0 l'000.o 1i,000.0 SOIL--FA—TING_ 213 TANK MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I CERTIFY THAT:-, WITH TH E ,� V U_mf T FORTH BY THE MUNICIPALITY OF ANCHORAGE (149A) -F _-$-E AND THE STATE _ET ------ OF ALASKA. 2- 1 WILL'INST4LL THE SYSTEM IN ACCCRDANCE WITH ALL MOA CODES AND REGULATIONS., - _MP AAC c_._W - ITH T _---- A N -D -1 N_ C.0 - L�L c . - -, __HE__. D ESUA - C Rt T - F R-1 A__OF. Tj4 3. 1 WILL ADHERE TO ALL MCA AND STATE OF ALASKA _T _ REQUIREMENTS FOR SET BACK DISTANCES FROM ANY EXISTING WELLP WASTEWATER DISPOSAL,§Y'STEM -THE OR PUBLIC _E W.EjtAG_E.__ S 3-15 M. __C N_ _.TH_I_S... C_+_ ANY ---A D_J_A_f 111...03 EA RBY_ __N 4. 1 UNDERSTAND THAT THIS PERMIT IS VAI Tl 9 n P A _MA�tTMIIIJ eYC , I m r ft n n ^ u r A,4 X44 �e ee eea� d MUNICIPALITY OF ANCHORAGE e o ®eooaeaToHoaeoe•Sed DEPT. OF HEALTH & ��. � ENVIRONMENTAL PROTECTION �Ja •eaaaoos :eA eaa ae• aJames R. KneyBE ( �, 198CE - 60 " V RECEIVED �� 4 / `� /(,f�i/�/ Com✓ i 0 ❑ SOILS LOG r ^1 MUNICIPALITY OF ANCHORAGE +.r1 DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 S SOILS LOG - PERCOLATION TEST PERFORMED FOR: GOn CQv2S4'WA0,17 DATE PERFORMED: S— Zo - z/ LEGAL DESCRIPTION: lnf/nG4t Net Drop / d O 7- /v v 779 S 3 S, O SLOPE --------- v /ro r /0-Z SITE PLAN w.ce x i zo DEPTH (FEET) 7 1 2 OvP �- b4�d." 0�<•,� �+��Qm1 OF A �e 3 4040 .-*P00f-49TH� •••s -9*��� 4 .... .k�,./ 0 f 51 es R. Kinney d�'�,'••. CE - 6036 4� i yrs 6+��P2t �'�'• ''�� 4��� .... e 7 S . s 9 1 V a 10- 11 I� I 12 13 14 15 16 17 18 19 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? M) Reading Date Gross Time Net Time Depth to Water Net Drop / d O 7- /v v 779 S 3 S, O -1 --------- v /ro r /0-Z r� /U w.ce x i zo 7 20 I I PERCOLATION RATE 00n"/� // (minutes/inch) L�l / TEST RUN BETWEEN /l FT AND FT ,,OMMENTS ��/Jn �� Gvi // !y f oLzi� rn Lo �oi�of2cl G✓ M >CB�� Sni � /'4 �/ni. - zzJ � �1� r .�� JrO"O✓i1' PERFORMED BY: /.����� CERTIFIED BY: Qk ��� DATE: S-Z/'s'/ »-nnn /f./901 Certificate of On -Site Systems Approval Parcel I. D. 051-811-117 Legal description Sampson Estates Block 4 lot 5 Site address 22611 Gabriel Cir Current property owner(s) Boudinot Expiration Date: 10-24-2023 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date:o This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory X Tank Age Advisory Arsenic Advisory Other COSA Approval—June 2022 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 05181110000 Complete legal description SAMPSON ESTATESBLK 4 LT 5 Location (site address) 22611 GABRIEL CIR Current property owner(s) BOUDINOT JOSHUA Day phone 280-9005 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: ■❑ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ■❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑■ Plastic ❑ Concrete ❑ Fiberglass Age 2 yrs - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed A Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Distance: Expedited review requested: ❑ By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $_6`5_0 Date of Payment COSA# OS Caz���� Waiver Fee $ Date of Payment Waiver # COSA Application June 2022 COSA Checklist Legal Description: SAMPSON ESTATESBLK 4 LT 5 Parcel ID: 05181110000 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _ A. WELL DATA X Well log is filed with Onsite (or attached) Date drilled 5/30/84 Total depth 141 ft Cased to 141 ft A Sanitary seal is functioning correctly ®❑ Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 9/14/22 Static water level at beginning of test 115 ft. Comments B. TANK DATA Measured operating fluid level in septic tank 49" Date of pumping 10/12/22 ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 4/4/20 X ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade 6 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. 00-1 Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comm ents/Deficiencies: COSA Checklist June 2022 Well production at time of test 6+ gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑® Coliform bacteria is Negative Nitrate 9.79 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by NRim Date 9/14/22 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 9/14/22 Results Q Pass Fluid depth prior to test 0 in Water added 450 gal New fluid depth 5 in Elapsed time 30 min Final fluid depth 0 in Absorption rate 450 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 72 in Effective depth used 0 in Effective depth remaining 72 in From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout 2IGO' �] Yes if No ft [0 Yes if No ft Neighboring Tank > 100' Yes if No ft Private Sewer/Septic Line > 25' n Yes if No ft Absorption Field on Lot > 100' Yes if No ft Holding Tank > 100' @]Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' g Yes if No ft [E Yes if No_ ft Manure/Animal Excreta Storage > 100' ft Community Sewer Main?: 75' R]Yes if No_ ft RYes if No D N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' NYes ifNo_ft Surface Water > 100' R1 Yes if No ft Tank to Property Line >5' Field to Property Line > 10' Water Main > 10' Water Service Line > 10' F. ENGINEER'S COMMENTS Yes if No ft Yes if No ft Yes if No ft [0 Yes if No ft Wells on Adjacent Lots: Private Wells ?� 100' Community Wells > 200' a] Yes if No ft g Yes if No ft If tank or field is under driveway comment below G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Finn NorthRim Engineering Phone 694-7028 Engineer's Printed Name Steve Eng Date 9/20122 .......... COSA Checklist June 2022 www.muni.org/onsite Nitrate Advisory Certificate of On -Site Systems Approval # OSC 221475 Subdivision: Sampson Estates Block 4 Lot 5 A water sample revealed a nitrate concentration of 9.79 milligrams per liter (mg/Q. 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. Ma�lmg Address P O Box 196650 *Anchorage, Alaska 99519 6650 * wwuv muni org r From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening, or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Ma�lmg Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org Municipality of Anchorage on -Site Water and Wastewater Program (907) 343-7904 Cr:�ifiCate ofn-33ite SystelTi5 Approval Parcel I.D. 051-811-10 Expiration Date: 1. GENERAL INFORMATION: EP(A / v S Complete legal description SAMPSON ESTATES; BLOCK 4, LOT 5 Location (site address) 22611 GABRIEL CIRCLE CHUGIAK AK 99567 Current Property owner(s) DANALYN KUMIMERT Day phone 854-0744 Mailing address 22611 GABRIEL CIRCLE: CHUGIAK, AK 99567 Real Estate Agent FIEIDI .CLEMENT Day phone 727-0616 2. TYPE OF DWELLING: Eg Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 9 aoJa 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: individual Well 0 Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community Public Water System ❑ Public Sewer ❑ 1 waiver/Variance request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the, engineer. COSA Fee :� $� Date of Payment Receipt Number d �y9 Com_ COSA #__��1 Waiver Fee Date of Payment Receipt Number Waiver # -5. -STATcMcNT-OF-INStPECTION -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: Gayness Engineering Group Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road Suite 101- Anchorage Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: Ld 4o In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system �� Uva in accordance with the guidelines and regulations established by the Municipality of Anchorage and o` industry practices. The reported results describe the condition of the system/s on the date/s of the p O ry4�,L�� evaluation. Separation distances were measured -to readily identifiable features. Hidden defects or �%` •' - encroachments may exist that were not identified during the evaluation. The operational life of all wells �* �: 4 H and septic systems depend upon a variety of variables, including but not limited to, soil conditions, • • • • • • •• • • • • • • • • • • • • • • • groundwater levels (that may fluctuate during the year), quality of construction (materials and 0 / workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the O fey Go ness: system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of Q.r��, the well or septic system. GEG makes no representation whether an alternative well or septic system 0 s CE —7 can be installed on the property in the event either of the current systems fail to perform adequately in 60"fP� •- co G the future. The content of this report is for the sole benefit of the person/party that retained GEG to a �i ,n, '-ofessio� o pa^orm the aL i Reliance upon the information provide it ; s. ,apo^ by. any. other. person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal `��p W((( Wq whatsoever. oF'y'��, #AECC884 6. DSD SIGNATURE `e �TY, / J System #1 Approved for OSI-SITE bedrooms CATER AND System #2 Approved for bedroomsWASTI=v`►ATER o: -LJI &P rvvGd PROGRAM �. Conditional approval for bedrooms, with ts: - ,! o2 Bygb�lAuaa�r_a�s Original Certificate Date: '7 � o 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 X Nitrate Advisory X Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet 10-10-12.doc COSA Checklist Legal Description: SAMPSON ESTATES; BLOCK 4, LOT 5 Parcel ID: 051-811-10 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA ❑■ Well log is filed with Onsite (or attached) Date drilled 5/30/84 Total depth 141 ft Cased to *40 ft ❑■ Sanitary seal is functioning correctly Al Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 2/24/20 Well production at time of test 5+ gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes ❑■ No ❑■ Coliform bacteria is Negative Nitrate 10.6 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑■ Arsenic less than MRL (ND) Collected by GEG,LTD. Date of Sample 2/24/20 Static water level at beginning of test 116.1 ft. Comments "PER ARCTIC PUMP & WELL'S PUMP INSTALLATION LOG DATED 3/6/2020 (SEE ATTACHED) B. TANK DATA Age of tank(s) NEW years Tank type/material PLASTIC Measured operating fluid level in septic tank NEW ❑■ Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA DEEP TRENCH Which system tested (date installed) NEW IN ALL standpipes present per record drawing Total measured depth from grade 13.0 ft (max) Measured depth to pipe invert from grade 6.2 ft (min) ❑ N/A — pressurized field ❑■ Monitor tubes go to bottom of effective. If not, state depth into effective C. LIFT STATION ired maintenance completed Age of lift stayears Lift station material Comments, Adequacy test date NEW Results ❑✓ Pass For 3 bedrooms Fluid depth prior to test NEW in Water added NEW gal New depth NEW in Elapsed time NEW min FNCode-requiredsoil cover over field Final fluid depth NEW in Absorption rate 450+ gpd ❑ System presoaked (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N/A date of test) _ If yes, enter date Gallons introduced N/A gallons Comments/Deficiencies: 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 if No Community Sewer Manhole/Cleanout > 100' 2] Yes if No ft E] Yes if No Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25'2] Yes if No Absorption Field on Lot > 100' 0 Yes if No ft Holding Tank > 100' ❑✓ Yes if No Neighboring Absorption Fields > 100' Animal Containment > 50' Q✓ Yes if No El Yes if No ft Q. 1 .. ............. .......� f r y A Garne Q QO CE— 9 J�'L,IJ 4� reo Profess,o ,Ion°� o0 a ME C884 Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 0 Yes if No ft E] Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' ft ft ft ft ft U Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' S Yes if No ft Private Wells > 100'✓❑ Yes if No. Water Main > 10' Q Yes if No ft Community Wells > 200' ❑✓ Yes if No _ Water Service Line > 10' 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' [D Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' Q Yes if No ft Private Wells > 100' 0 Yes if No Water Service Line > 10' Q Yes if No ft Community Wells > 200' ❑✓ Yes if No Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 000060 ADO _ 0F• A �Op 1 certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with 4 MOA COSA guidelines in effect on this date. ...... ... . . ..... ........... 00 COSA Checklist yellow sheet Q. 1 .. ............. .......� f r y A Garne Q QO CE— 9 J�'L,IJ 4� reo Profess,o ,Ion°� o0 a ME C884 ft ft lit ft MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904 On‐Site Water and Wastewater Section Fax: 343‐7997 www.muni.org/onsite Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org Nitrate Advisory Certificate of On‐Site Systems Approval # OSC201143 Subdivision: Sampson Estates, Block: 4, Lot: 5 A water sample revealed a nitrate concentration of 10.6 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. Since nitrates are known to slowly increase, we recommend you monitor the water quality. 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. Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org Nitrate Fact Sheet From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as “blue baby” disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a medi a with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several “wet chemical” methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive “screening test”, and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. ARCTIC PUMP & WELL INC. Jim Sullivan PO Box 770197 Eagle River, AK 99577 _ (907)688-2510 j� (907)243-2282 jimcr arcticpump.com Pump Installation Log Well Drilling Permit Number: SW Parcel Identification Number: Date of Issue: Arctic Pump & Well, Inc. Page 1 of I Legal Description: Sampson Estates Property Owner Name & Address: Lot: 5 Danalyn Kummert Block: 4 22611 Gabriel cir Chugiak ak Pump Installation Date: 3-6-20 Pump Intake Depth below Top of Well Casing: Pump Manufacturer's Name: Pump Model: Pump Size: Pitless Adapter Burial Depth: Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: U/K Well Disinfected Upon Completion? Yes Method of Disinfection: Chlorine Comments: well casing 40'+ with no perforations verified by camera Casing extended to 18" above ground and MOA well seal and conduit installed Pump Installer Name: Arctic Pump & Well, Inc. Arctic Pump & Well, Inc. Page 1 of 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 investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm-)AN1G',!5 n • •e �s �p Address asjj C�•Y/�iic%(Z, �n lU�zr %C ,�,��.. 11 is Date �� //art off .° 49TH �® (ENGINEER SEAL) d ��^^� JAMES R. KINNE a 10 �.. CE -6036 ®'�'® 6. DHEP Approval , �F®• • • • OH�° ROFESSI��"' Approved for bedrooms B a�FESS; J .. Y �- �I�Da t e Approved Disapproved Conditional Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURC1hkSERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. 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 PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 1 7-19-•84 MUNICIPALITY "OF ANCHORAM4 DEPT. OF HEALTtI UIRONVENTAL PRoiECTION' MUNICIPALITY OF ANCHORAGE (MOA) SEP. 1 3 HEALTH AUTHORITY APPROVAL (HAA) RECEIVED CHECKLIST - FEBRUARY 1984 Legal Description: �O-r A. WELL Az1TA Well Classification nj,dLAJ If A, B, or C. D.E.C. Approved(Y/N) Well Log PresentrbN) Date Completed 6 -0 t/ Yield�,f Total Depth JJ�.Cased to Jq 1 CL Depth of Grouting Able fU%,4 Static Water Level `fp1 Pump Set At 130 P Casing Height Above Ground 14, Sanitary Seal on Casing (�Y/N) Electrical Wiring in Conduit('M/N) Depression Around Wellhead (Y -Separation Distances from till: 1 To Septic/Holding Tank on Lot 13 On Adjoining Lots To Nearest Edge of Absorption Field on Lot f2 i On Adjoining Lots IWo,7e To Nearest Public Sewer Line A114 To Nearest Public Sewer �ft� Cleancut/Manhole NIS To Nearest Sewer Service/ Lime on Lot Water Sample Collected By Ej4M4 Date Water Sample Test Results ComRlents B. SEPTIC/HOLDING TANK IATA Date Installed j "-,?O-fq Size 000�np _ No. of Cc artuents Z Standpipes &A)Air-tight Caps Y ) Foundation Cleanout ( /N) Depression over Tank (Y ) Date Last Pumped 4/eu.) r✓� u� Pumping/Maintenance Contract on File (Y )% for Holding Tank High -Water Alarm (Y Temporary Holding Tank Permit (YX) Separation Distances from Septic/Holding Tank: To Water -Supply TAJell j1 ?•Ff To Building Foundation F To Property Line gnf To Disposal Field elllcJ To Water Main/Service Line IA To Stream, Pond, Lake, cr Major Drainage Course Comments (Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 22-5 Type of System Design Ao 7r&?c,k Date Installed 15-36-- ``q Length of Field Width of Field Depth of Field 5 Gravel Bed Thickness If Square Feet of Absorption Area ! Standpipes Present) Depression over Field (yiN Date of Last Adequacy Test N/A AJeW Results of Last Adequacy 'lest Ailn- Separation Distance from AbsQrption Field: To Water -Supply Wb 11 11S N IGniI To Property Line �F To Building Foundation q 7 To Existing or Abandoned System on Lot 8� ; on Adjoining Lots /)al ,J/2Sn� f To Water Main/Service Line & 9&, aftht To Cutbank(if present) A/04e rQ2Se11 To Stream/Pond/Lake/or Major Drainage Course ALI fees&,, J To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION fq ! -./14 Date Installed Dimensions Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes-(Y/N) Comments J Manhole/Access (YM) "Pump Off" Level at Vent (YIN) Pumping Cycles ging Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all on the date of this inspection. Signed - � � oe + Date Company z din e,,_�'C� MOA No.510-tWV KBl/d5/s effect r 9TH *'/ o. . ../ W JAMES R UEY ✓f � .224 4! [Page 2 of 21 i 84