HomeMy WebLinkAboutSEQUOIA ESTATES BLK 1 LT 7·
equo a
St.
lock I
Lot 7
017-152
-'07
Municipality of Anchorage 'Page t of ~ _
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Ilnspection Report
Permit Number: ~,~V,J o..~ O ~_2~Z~ PID Number: ..~\'-"~ - ~ ~-
Name: ~O ~m~~)~, Wastewater System: 'D New U grade
~ddress: ~1 ~--~UO~ ~'P--~ ABSORPTION FIELD
Phone: ~_~ No. of B~rooms: ~ Deep Trench ~ Shallow Trench ~Bed ~Mound ~'Other
LEGAL DESCRIPTION ~o~ R;ting: ~otal D~pth from~rlglnal grade:/'
I-~ GPD/Sq. Ft. ~ 5 ~ ~ / ,,
Lot: ~ BIock:~ ~-~Subdiv~i°n:~{ ~ [ ~ ~, Depth to~,pipe bottom~ / ~fr°m~°rtglnal~ '~g~de:-- Ft. Gravel depth~beneath~ pipe Ft.
Township: ,~ lRange:~{~ Section:~/~ Filladdedabove~lnalgrade: Ft. Gravellength~ ~ Ft.
~'~~ ~ Ft. Number{ of lines: Ol~lan~een~ lines'.
I U New ~ Upgrade / i Gravelwidth:~/~
Ft.
Classification (Priva~~ Total/Depth;/Ft. ~To: Ft. Total absorptlon~ ~'~area:~ SQ. Ft. Pipe~o~materish
Driller: Installer: Date Inst~lled;
Yield: ~- Pump 8et al: O~sing ~und:
/ GPM FL ~,. TANK
SEPARATION DISTANCES ~ s~ptio ~ Ho~ai~g ~S.T.E.P.
TO Septic Absorption Lift Holding =ublic/Private Manufacturer: CapsCity in gallons:
From T~nk Field Station Tank 8ewerLines ~)~,~- IS~o,
/ Material: Number of~padments:
Su~ace f I
Water ~JOo >,oo >~ >t~/ ~~ON
Lot
Line IO/~ ~OI lO/~ ~ + ~ Manufacturer:~ , ,~
Foundation ~ I+ ~G I~ t ~ I~ ~ "Pump on" level at: "Pump off" level at: I High Water alarm at:
- ~z" ~ ' l ~.
Cudain NO~
Drain ~ ,~ ~ ~ Pump Make & Model Electrical Inspections pe~ormed by:
Remarks: ~~ (~ OU~-~ i~ ~ENCH
Location and Description;
. J Assumed Elevation:
Inspections pedormed by: ~ ~SS Dates: 1st to ~ ,~,.-,,,
2na .......
Department of Healtkand Human Se~ices approval ~-'~.
Reviewed and approved by: · ate: /2 -2 g-~
/
[3
72-013 (Rev. 9/91) MOA 25
NEY/ TRENCH, 61' LBNG,
TRENCH IS BVERSIZE]]
BY APPROX, 5OX,
TEST HOLE M,T
LOCATION, PERK
TESTS V/ERE 3-5
FEET NORTH BF
1,/_~5 INCH PVC PRESgLJRE%x~"
LINES (2) TO OLD BED AND NEY/
TRENCH, LINE TB OLD BED
~/AS NOT INSPECTED BY
ENGINEER, --
iI
M,T, 'F' ° EXISTING BED
INCH DIA, PVC ~
FBUNDA]'IBN C/O,
NE~/ t850 GALL. BN
STEP TANK, THE
ls't C/I] BN THE
TANK IS PT,
THE CENTER OF THE
MH IS PE]INT
C/D
AC = 51,1
BC = 26,6
AD = 5%6
BI) = 24,0
BF = 50,7
EF = 77,2
AS-DUILT DRAWING
V/ELL
SEPTIC UPGRADE AS-BUILT'
PREPARED FORI
PREPARE]] BY'
DATE~
LOT 7, BK 1, SEQUI]IA EST,
GENO KASTIGNETTI
ALASKA V/ATER & ~/A§TE~/ATER SERVICES
10/26/96 I)RAV/N' GARNE~S SCALE' 1' = 30'
A. GarneS~ ."
CE-7953
AS-IUILT DRAWING
[iROUND COVER OVER THE TANK IS
IS APPROX, 90,5 FEET, COVER = 4 FT,
NEW 1250 GALLON STEP TANK.
1,25 INCH PRESSURE ANCHORAGE TANK, INLET INV, -- 4 INCH ~]A. PVC LINE FROM
NE~ TRENCH, & BL~ . = 8~,94 HOUSE, INVERT AT FDNDATION C/O
TANK SET LEVEL, ~ITHIN .D~ FT, = B8,~, D~OP FROM C/D TO TANK
= ~,66 FT, OVER APPROX. 75 FEET,
~LBFE I~ GREATER THAN ~%.
THE LINE FROM THE FOUNDATION C/O
TO THE S,T,E,P 'rANK ~AS NOT INSPECT-
ED ~Y ~HE
~ -FOR LOCATION OF M,T SEE PLaN DRA~ING
GRBUN~TRENCH ELEVIs 9~,~BVERDE ~
NIGHER, MINIMUM COVER ~ ~FILTEE FABRIC OVER ~RAINEOCK
= 3,1 FEET, ~ ~ / ENTIRE LENGTH DF TRENCH
.~ f'~- ~1,~5 INCH ~IA,~ SCHEDULE 40 PVG,
~1~ ~' ~ 3/16 INCH HOLES AT 4 FT
I;11;~:,/: C, NB GROUNDWATER OR IMPERMEABLE ~OtL TD ~EPTt. I OF tG FEET,
F~ I¢~ ; ~. TRENCH LENGTH : Gl+ FEET
E, TOTAL ABSORI TIBN
~ENCHMARK IS TOP DF fi~S LINE
~HERE IT ENTERS THE HOUSE,
PREPARE]] BY~ ALASKA WATER ~ WASTEWATER '~.,.
DATE, 10/26/96 ])WN~ 6ARNESS SCALE, NTS
FROM USPS ANCH PROC/DIST 9~7 288 3'161
!NGPECTION: Voice 563.3464 tNSPtECT1ON.' FAX (B07) 34~2~ , INFO:
.... ??~' ...... ~ '~ ......... dj
DO NOT R, FMOV5 THIS NO~CE ~
To',rP~ P, ~1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE)
PERMIT
PAGE 1 OF 1
PERMIT NUMBER:SW960334
DESIGN ENGINEER:ALASKA WATER & WASTEWATER SERVICES
OWNER NAME:CASTIGNETTI GENO J JR &
OWNER ADDRESS:6841 SEQUOIA CIR
ANCHORAGE, AK 99516
DATE ISSUED:10/03/96
EXPIRATION DATE:10/03/97
PARCEL ID:01715207
LEGAL DESCRIPTION:
SEQUOIA ESTATES BLK
1 LT 7
LOT SIZE: 48472 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAAC80) .
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE 8OIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND N~ATED TO PREVENT FREEZING
THE FOLLOWING SPECIAL Pi 0VISIONS.
RECEIVED BY: ~/~/q ~
DATE
8471 Brookridge Drive N Anchorage ~ Alaska 99504
(907) 337-6179 ~ Fax (90'7) 338-3246
Consulting Engiueers
September 16, 1996
Municipality of Anchorage
Department of Health & Human Se~wices
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Sewer Permit for Lot 7, Bk 1, Sequoia Estates.
To whom it may concern:
The subject 3 bedroom house is served by a private well and septic system. The septic system is
currently surcharged, and periodically backs up into the residence; therefore, it needs to be
upgraded. Comments regarding the proposed upg[ade are summarized as follows:
1. Soils: Attached is a copy of the soils log. The soils from a depth of 2 feet to 7 feet perked in
the range of 3-5 minutes/inch. To account for possible changes in the soil profile, and the fact
that the home has a hot tub and a water softener, I am proposing to use an application rate of .8
gpd/ft2.
2. Trench Design:
g.
h.
i Width: 2 feet nfinimum
j. Reduction Factor = N/A
k. Length: 60 feet.
1. Effective absorption area = 570 ft2
Percolation Rate: 3-5minutes/inch
Application Rate: 1.2 gallons/day/fi2, but will use. 8 gallons/day/ft2
Number of Bedrooms: 3
Design Flow: 450 gallons per day
Minimum Absorption Area: 562.5 fi2
System Type: trench
Effective Depth: 4.75 feet
Total Depth: 6.75 feet
MUNICIPALITY OF ANCHOP. AG~
ENVIRONMENTAL SERVICES DIVISION
SEP 5 1996
RECEIVED
3. Surface Waters: There are no surface waters within 100 feet of the proposed septic system.
4. Slopes: In the vicinity of the new trench, the lot slopes downhill (10-20%) from east to west,
and is generally flat in the north/south direction. There are no slopes in excess of 25% within 50
feet of the proposed trench.
I am unaware of an;g adverse impacts this installation would have on adj.acent wells or septic
systems. If you have any questions, please contact me at 337-6179, or on my digital pager at
1-800-481-1162. Thank you for your assistance.
Sincerely,
,P.E.,
Principal
m.s.
Geno Kastig. nettil.wps
AREA
LDT 6, ~K 1
SE~UBIA E~T.
PVT. ~ELL ~
SEPTIC,
SEPTIC
LOT 5, ]~K 1~ SEQLIBIA EST,
PRIVATE WELL & SEPTIC
PER ~HHS RE£DR~):~,
TRENCH
/
~ELL
LBT 8o ~;EQUDIA EST.
PVT. WELL
/
SEPTIC
AREA
NBTEI THIS IS NOT A SURVEY, THE LBCATIDN DF STRUCTURE~, WELLS, AN]0 SEPTIC SYSTEMS ARE GENERAL,
SEPTIC UPGRADEI
PREPARED FBRt
PREPARED BY'
DATE'
L. rlT 7, ]~K 1, SEQLJDIA EST,
GENB KASTIGNETTI
ALASKA WATER & WASTEWATER SERVICES
9/1G/gG i DRAWNI GARNESS ISCALE, 1' = 100'
NOTE, TO THE WEST OF
NEW TRENCH THE LO]'
DOWNHILL_ (EAST TH WE:
10% TO 80×, THERE ARE
SLOPES GREATER THAN
WITHIN 50 FEET OF TH[
TRENCH,
NEW 60 FD[]T
TRENCH,
[HE '~~..~_._ /---- EXISTING gED
.OPES
M,T,
1,85 INCH PVC PRESSURE
LINE, TIE INTO BED
TH, GROUND
ELEV, = 9R,O--
BOTTOM DF TH
= 76,3,
86,6
NEW 1850 GALLON
STEP TANK,--
CID
0,5
CIO
HOUSE
--~5,4
KISTING FBUNDATIBN C/B,
INVERT = 88,6 (APPROX,)
4 INCH DIA, PVC (I)3034)
SLOPED AT 1/4 INCH PER
FOOT,
THE NEW STEP TANK SHALL BE EQUIPPED WITH
DUAL OUTLETS, AN]] PLUM:BED SO THAT FLOW CAN
BE ALTERNATED DETWEEN THE NEW TRENCH AND
THE OLD DRAINFIELD, 'rilE CONTRACTOR SHALL
PROVIDE A 1,R5 INCH, SCH 40 PVC, PRESSURE
LINE TO THE TRENCH AND THE BED,
WELt_
APPROXIMATE
LOCATION DF
DRIVEWAY
SEPTIC UPGRADE,
PREPARED FBRi
PREPARED
DATE, 9/16/96
LOT 7, BK 1, SEQU[]IA EST,
GENB KASTIGNETTI
ALASKA WATER & WASTEWATER SERVICES
DRAWN, GARNESS SCALE, 1~ = 30'
[frey A. GarneSs
CE-7953
TOTAL ,TRENOH LENGTI~
~ 60 PEE~.
TOTAL ABSORPTION AREA
= 570 SQUARE FF~T.
WITH NATIVE S'OiL AND MOUND.
TOPSOIL ~ RESEEDING- $1~ALL SE' TPIE
REPSPON~IBILtTY OF THE PI~OPEt~T~ OWHEF~.
FABRIC SILT BARRIER.
2 IN~ OF J3OAI:~Q INSULATION IF SOIL
COVER IS LESEi THAN 3 FEET, INSULATION E~HALL
COVER THE ENTIRE WITH OP THE TRENOR.
!~, 2 FEET MIN.
BENCHMARK I$ TOP OF GAS LINE WHERE IT
-- 1,2~ INOH SOH 40 PVO. 3/16 INCH HOLES AT.
4'0.0, (16 HOLES TOTAL). ALL HOLES FACE
DOWN. 2" OF DRAINROCK OVER PIPE. DO
NOT PYRAMID DRAINROOK OVER THE PIPE.
DR/~INROCtC DEPTH SHOULD BE- TI:tE SAlr/IE
A~S THE ENTI~ WITH OF THE TRENO~
TUBE ~TYP).
PERFORATED IN DRAINROCK.
NO TE:
1; TRE~HE~ ~ALL RUN PAR~LLE~ ~0 THE
2. F~. [O~TI~ ~ OLE~OUTS AND
3, CON~TRUOTION PRAOTIOES, AND MATERIAL
SPFCIFICATION~ SHALL OOMPLL Y WITH
ANCHORAGE MUNICIPAL CODE I~.6~, "WASTE-
WATER DISPOSAL ~EGULA TIONS".
INSTALLATION SHALL COMPLY WITH SPECIAL
~0~0~ A~' ~' OE THE ~' P~
~A~ BO~T~ A~' ~WA'LL~ SHA~L
DRAI~K- ~L ~ ~OREENED PE~
REJEC TED.
ENTEF~S- TT'IE HOUse-, A SSUMEi~ ET. EVA TICII~t = IO'O. O0-
TRENCH.,DETAIL: LOT 7, BK. 1, SEQUOIA ESTATES
PREPARED FOR: GENO" KA'STIGNETTt
ALASKA. WATER & WASTEWATER SERVICES
· t
DATE: 9/-16/96. Dt4/N: GARNESS. SOALE: N~TS
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "t.' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR= ~----~1~
LEGAL DESCRIPTION:, _
2 ..--
5
6
10
11
12
13
14
15
16
17
18
19
20-
'~OMMENTS _
~S...'-CTownsh~p, Range, Section: /,J
SLOPE
, '
..'SITE
WAS GROUND WATER
ENCOUNTERED?
IF YES, ATWHAT
DEPTH?
L
Gross Net Depth to Net
Reading Date Time .Time Water Drop
,4,-
ID ~ 3/~~ ' ~ I~
3, ID
,"'"" (minutes/inch) PERC HOLE DIAMETER
~' FT AND ~ ...... FT
~ ~ .~ c_~,~'/~-'z
PERCOLATION RATE
TEST RUN BETWEEN
72-008 (Rev, 4/85) .
NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHON~ [~-N EW
,~ ~ ~'~ S'~' E~] UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
DISTANCE TO:
Manufacturer
Well Absorption area
i~JoT ~J (I,Z.~
NO, OF BEDROOMS
P E R ~T~Nt~'~.~
No. of co~)artments
Liq. capacity in gallons IF HOMEMADE: Inside length Liquid de~.th
DISTANCE TO: Well --~ Dwelllng..~ PERMIT~ NO,
Foundation
Total length of lines
Material beneath tile
Manufacturer
Dwelling1'3,
Material
Depth
Materi~al
Nearestlot~.z~~ ~1--'~-!line
Trench width
WO )~ I ~
inches
Well
DISTANCE TO: ~/O"¢ ~ I~
No, of lineLi .LengtJ~ of eacl).line~/ ,,
Top of tile to finish grade
Length Width ~
Liquid,~capacity in gallons
PERMIT NO.
Distance~ bet~een~r n~s.
;~ ,cf,~' , ~.& '"5, Z, $'-
Total effective absorption ar~a
PERMIT NO.
Type of crib ~ Crib diameter ~ Crib depth ~ Total effective absorption area
Well Nearest lot line
DISTANCE TO: ~
Building foundation
Driller
Depth
Distance to lot line PERMIT NO.
DISTANCE TO: Building foundation ~ Sewer line ~ Septic tank Absorption area(s)
Class
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
DATE
72-013 (Rev. 3/78)
Date Drilled ~
Static Water Level ~.Q feet
Draw Down ,',I \ feet
WELL LOG
qeou~oa Subr!.
Gallons Per Minute
Total Feet of Casing
~. 7-4-
.Type Material Drilled~
~2D f~
73~ f~et
llefty Drilling
S.R.A. Box 1553 H
Anchorage ,Alask~
99507
MUNICIPALITY OF ANCHORAGB
OEP'F, OF HEALTH &
ENVIRONMENTAL PROTECTION
SEP 5 1984
RECEIVED
l'lLlf-4 I E: I ElL I
DEPARTMENT Oh HERLTH RND ENVIRONMENTRL h'ROTECTION
825 L STREET, RNCHORRGE,. RK 99581
264-472~
g--it4---S I TE SEI~4EF: .~,;'; 1,4Et_L F*EF:t'I I -F
pERMIT NO:
DRTE ,I::',I.IE[:
:=:4E'1291 HAND 1.4R I TTEH
05,."'04/84
RPPLICANT:
ADDRE= ....
C:ONTH~.T PHONE:
CHBRLES HRDDY NEW WORLD INC
P 0 80~
ANCHORAGE, Bt{ 995ti
345-3854
LE =AL DP~..F.. I P:
LOT :S I ZE:
LOT LOCRTION:
SUBDIVISION: SEQUOIR ESTATES
SECTION: 26 TOHNSHIP:
48472 (SQ. FT. OR RCRES)
SEQUOIA CIRCLE
LOT:
RANGE
BLOC. K: '1
CERTIFY THRT:
1.' I BM FFIHILIRR WITH THE REQUIREMENTS FOR ON-SITE SEI.4ERS AND WELLS RS 'SET
FORTH BY THE MtJNICIPFtLITY OF ANCHORAGE (MOB) FIND THE STRTE OF RLASKR.
2..I WILL INSTRLL THE SYSTEM IN ACE:OR[:,RNCE WITH FILL MOA (.*.ODES AND REGULRTIONS.,
: AND IN COMPLIANCE 14ITH THE DESIGN CRITERIA OF THIS PERMIT.
~ I WILL: ADHERE TO ALL MOA AND STRTE OF ALASI<R REC,!UIREMENTS FOR THE SET BRCK
,DISTRNCES FROM ANY EXISTING WELL., WASTEWATER DI'SPO'SRL SYSTEM OR PUBLIC
, SEI4ERRGE SYSTEM ON THIS OR ANY RDJRCENT OR NERRBY LOT.
IF.A LIFT STATION IS IN_,TRLLE~ IN AN AREA CO',/EF.:ED BY MOI~ BUILDINg3 CODE'-].,
THEN ,;:.~) RN ELECTRICAL I""ERMIT AND INSPEC:TION MLIST BE OBTAINED.~q"°'~.¢ AS-BUlL.TS
WILL'NOT BE APPRO',,,'E[:, WITHOUT RN ELEL:TF,.IE. AL INSF'ECTION RI_FORT., AND ,:'~) THE
ELEC:TF.:ICAL: WORK MUST BE DONE BY A LIC:ENSED ELEE:TRICIRN,
BF'PLIC~NT' CHBRL~ HBDD~ NEW WORLD INC
ISSUED 'BY ~~ ~~ DATE:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
DATE PERFORMED: Iq
!
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
WAS GROUND WATE~
ENCOUNTERED?
SLOPE
L
O
P
E
IF YES, AT WHAT
DEPTH?
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
J , TEST RUN BETWEEN ~- FT AND FT
72-008
DATE: d/~-~2/r~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street ~,,-~
P.O. Box 196650 [ i ~ /
www. muni.org/onsite
(907) 343-7904 .~
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. o17-z52-o7
1. GENERAL INFORMATION
Expiration Date: g/~)l/
Complete legal description Sequoia Estates, BIk z, Lot 7
Location (site address) 684zSequoia Circle
Current Property owner(s) Geno & Debra Castignetti
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
Day phone
Day phone
Christine Dooley / Dynamic Properties Day phone 2z+6-7653
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site
Public Sewer
TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class ~ Well []
Public Water System []
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based °hthe information
obtained from the Municipality of Anchorage files and from my investigation and inspection, 11~e,:,on~site water
suplppwly, andk~r, wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
.., ~di~a~'lees "and regulabons in effect at the time of insta at on
Name of Firm Pannone Engineering Services, LLC Phone 272-8218
Address P.O. Box zoo2z7, Anchorage, AK q95zo
Engineer's Printed Name Steven R. Pannone, P.E. Date :~z/3o/2ozo
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions
encountered at the time of the test, and separation distances measured to readily identifiable features.
The operational life of all wells and septic systems depend on the local soil condition, ground water
levels that may fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of this system. All systems eventually fail and
satisfactory test results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. PES can therefore not provide any warranty for future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed
above. Any reliance upon or use of this report by any other person or party is not authorized nor will it
confer any legal right whatsoever.
5. DSD SIGNATURE
'/'/ Approved for ~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
A=
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: ..Sequoia Estates, BIk % Lot 7
WELL DATA
Well type Private
Date completed ?hh. q8,.
Total depth 32_~ ft.
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
parcel ID: o~7-~2-o7
IfA, B, or C provide PWSID # ~
Sanitary seal (Y/N) Y
Cased to 260 ft.
FROM WELL LOG
7h1~98~
~98
7+
Coliform ......Ne§ colonies/100 mL
Arsenic: ...ND ug/I
B, SEPTIC/HOLDING TANK DATA
Tank Type/Material Steel / S.T.E,P.
Tank size =.2~;o gal.
Foundation cleanout (Y/N) Y
Date of pumping ~12_~12o~o
C, ABSORPTION FIELD DATA
Well Log (Y/N) Y
Wires properly, protected (Y/N)
Casingheight (above ground)
AT INSPECTION
ft. 209 ft.
g.p.m. . ~.5+ g.p.m.
Nitrate o.xx~ mg/L
Date of sample: ~x/~912o~o
in.
Other bacteria Neg colonies/100 mL
Collected by: Pannone Engineerin_~
Date installed
Number of Compartments _~ Cleanouts (Y/N) Y
Depression over tank (Y/N) N High water alarm (Y/N) Y
Pumper A+ Home Services
Date installed 3.ol2/.h.~6 Soil rating
Length 6~+ ft. Width 2+
Total depth _8 ft. Eft. absorption area 572+ ~
Date of adequacy test ~.~.f,,.12oxo Results (Pass/Fail)
Fluid depth in absorption field before test _o in.
Elapsed Time: =.2o min. Final fluid depth _o in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
(g.p.d./~ or ft2/bdrm) =.2 GPDISF
ft.
Monitoring tube Y
Pass
System type Deep Trench
Gravel below pipe ~.7
Depression over field N
For 3 bedrooms
Water added~52 gal.
Absorption rate >=~';
N
New depth_o in.
~jO+ g.p.d.
If yes, give date
D=
LIFT STATION
Date installed ~ol2,.Iz996
"Pump on" level at AA in.
DatUm BOT
E. SEPARATION DISTANCES
Size in gallons
"Pump off" level at AA in.
Cycles tested 3
Manhole/Access (Y/N) Y
High water alarm level at ~
Meets alarm & circuit requirements? Y
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot zoo+
Absorption field on lot zoo+
Public sewer main 75+
Sewer/septic service line 25+
Animal containment areas
On adjacent lots zoo+
On adjacent lots zoo+
Public sewer manhole/cleanout zoo+
Holding tank zoo+
Manure/animal excrete storage areas zoo+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation zo+ Property line zo+
Water main ~o+ Water service line 25+
Wells on adjacent lots zoo+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line zo+ Building foundation
Water Service line =~+ . Surface water zo6+
Curtain drain 5o+ Wells on adjacent lots zoo+
COMMENTS
Absorption field ~+
Surface water zoo+
Water main 75+
Driveway, parking/vehicle storage
lO+
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 Steven R. Pannone~ P.E.
Date
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
zzl~olAozo
~~,,,,,~,,.~ .......... ~,~
Waiver Fee $
Date of Payment
Receipt Number
S,GS
SGS Ref.# 1106272001
Client Name Pannone Eng. Sty. Printed Date/Time 11/24/2010 16:53
Project Name/# 6841 Sequoia Circle Collected Date/Time 11/19/2010 16:45
Client Sample ID 6841 Sequoia Circle Received Date/Time 11/19/2010 t7:17
Matrix Drinking Water Technical Director Stephen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic
ND 5.00 ug/L EP200.8 B (<10) 11/23/10 11/24/10 NRB
Waters Department
Total Nitrate/Nitrite-N 0.113 0.100
mg/L SM20 4500NO3-F C (<10) 11/23/10 AYC
Microbiology Laboratory
E. Coli
Total Coliform
Negative I 100mL SM20 9223B A 11/19/t0 DLC
Negative 1 100mL SM20 9223B A 11/19/10 DLC
~/30~0~0 10:17 ~68~770 ~P~US PA~E 01
CUSTOMER
7501 E. 140th Avenue
Anchorage, Alaska 99516
345-1890
P~-o~e N. ngh~e~i~g
INVOICE #
39330
Block Lot
DATE DESCRIPTION AMOUNT
n-~.~-~o ~.~ sq,~i= &/.~ r~ ~q.~y. t~ ~"~~~~.-, s~6~.c,o
; '. ,: . '~'~ '~'~ .' i ';'"'""1
..... .'~.r~.: .,,.' ....
,,,,,
,, R RKS ".:c: :,'
.,=. ...
....
.. · ..,. .: .. ..... ~. ' ~,,,.~.~,,
:', ,, ' ?" 'i , ~ ', ....
~ N[E~$ TO ~ DONE A~IN IN 8 MONTH8
' Good 8haps
Jim sap missino or ~ Cut s~ndpipe ~o~' abov~ flmund ~ Needs 8eptictrin,
needs ~plaoin~
o~ELL
LiFT STATION
ASPHALT
S 86°~'0~, 'E
2~8.30'
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN
EXISTING STRUCTURES AND PLATTED LOT LINES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL
STRUCTURES OR FENCELINES.
EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT, ARE NOT SHOWN HEREON.
NOTE: ANY FENCELINES SHOWN ARE LOCATED APPROXIMATELY AND ARE NOT TO BE USED TO DETERMINE PROPERTY LINE.~
OR LOCATE STRUCTURES.
AS-BUILT SURVEY
NO CORNERS SET THIS DATE SCALE:I" = 30'
I HEREBY CERTIFY THAT I HAVE PERFORMED A
MORTGAGEE'S INSPECTION OF THE FOLLOWING
DESCRIBED PROPERTY.
LOT 7, BLOCK 1, SEQUOIA ESTATES
ANCHORAGE RECORDING DISTRICT, ALASKA AND THAT
THE IMPROVEMENTS SITUATED THEREON ARE WITHIN THI~
PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXl,
OTHER THAN NOTED.
DATED AT ANCHORAGE, ALASKA THIS 1ST
DAY OF DECEMBER 2010_,
HOLT LA-ND SURVEYING
TEL. 345-5513 11450, FB 143-58
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
~.¢o - ~,o - o~'- OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, townshi,.~, range)
Location (address or directions)
Property Owner [.4dgLE-Y~ V....Jmt~. Telephone:Home ~l~-l&,ol Business
1
Mailing Address fo~ I $.~eu~,~'%
'
Lending Institution ~¢~ E~ ~;~ Telephone
Mailing Address
(d)
Real Estate Company and Agent
Address
Telephone
(e)
Mail the HAA to the followina address: or; Check here"J~ if hold for pick up.
List contact person and day phone number below. "' /"~
TYPE OF RESIDENCE
Single-Family ~
Number of Bedrooms
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 well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 trey 8/86~ Front
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.g
~ ~ ~ ANCHORAGE, ALASKA 99501
CONSULTING ENGINEER TELEPHONE: (907) 279-3916
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O.BOX 6-6650
ANCHORAGE, ALASKA 99502-0650
JUNE 2, 1987
Subject: Ground Water Monitoring
Lot 7, Block 1, Sequoia Estate
Gentlemen;
Per your request a test hole was drilled and a monitoring tube
installed on subject lot on May 26, 1987. Total depth of testhole
was 19 feet. Ground water was not encountered during drilling,
nor was any water observed on June 1, 1987, seven days after
installation.
Tobb~n Spurkla~d.P.E.
MUNl¢lPALl'fy Oi: ANeNt_ .i~f~I~Pf~LITY OF ANCHORAGE (MOA)
RV lC
ENVtgONMENTAL S~ ~[~A~'~UTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
MAY :1. 3 i9B7 264-4720
RECEIVED Legal Description:
WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth ~ ¢~, ,¢' ~,1~
Static Water Level
Casing Height Above Ground Jt'~ ~l
Electrical Wiring in Conduit (Y/N) ~
Separation Distances from Well:
To Septic/Holding Tank on Lot /~'¢' ¢'
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
'~'~- ~ If A, B, C, D.E.C. Approved (Y/N)
/ Date Completed _~7, 7' /'~¢ Yield
Cased to
/ 77
No/vd
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
/ ¢,~ ¢' On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on
Date "~-/~'~ z'~ ~'
B. SEPTIC/HOLDING TANK DATA
Date Installed /~/,'~'~"/o~ t// Size t ~ NO. of Compartments
Standpipes (Y/N) _'"~u¢'¢ Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~x,/ Date Last Pumped ~/~/
Pumping/Maintenance Contract on File (Y/N) ~//~. ; for
Holding Tank High-Water Alarm (Y/N) ~4'/,,~ Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
To Building FOundation J---~
To Disposal Field Iff
To Stream, Pond, Lake, or Major Drainage
Comments
Page I o~ 2
72-026(11/84)
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 Field:
To Water-Supply Well
To Building Foundation ~:~
Lot
TO Water Main/Service Line .~ ! o
To Stream/Pond/Lake/or Major Drainage Course
To Driveway,. Parking Area, or Vehicle Storage Area
Comments
Type of System Design ~ ~.,,D
Length of Field ~ /-) ~-~'*
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line .~
To Existing or Abandoned System on
; On Adjoining Lots ~ /
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
~ certify t hat I .~ve~h.ecked.~,. v~rifitd.~r conformed to all M~)A a~nd HAA guidelines in effect on the date of this inspection.
Signed ~ ~' Date ~"/~'"-/~' '~
Company MOA No.
Receipt No.
Date of Payment
Amount: $ ~/'d~----~
Page 2 of 2
72-026 (11/84)
Engineer's Seal
,~ ~ ~ ANCHORAGE, ALASKA 99501
CONSULTING ENGINEER TELEPHONE: (907) 279-3916
RESIDENTIAL WELL INSPECTION
LEGAL:
LOCATION:
LOT 7, BLOCK 1, SEQUOIA ESTATE
6841 SEQUOIA CIRCLE
OWNER: HUXLEY
TYPE O~ WELL:
SINGLE FAMILY
WELL LOG AVAILABLE:
YES
INSTALLATION REQUIREMENTS MET: YES
WELL YIELD FROM WELL LOG:
7+GALLONS PER MINUTE
PUMP YIELD:
6.5 GALLONS PER MINUTE
DATE OF INSPECTION:
MAY 5, 1987
TEST PROCEDURE: WELL WAS PUMPED AT A CONSTANT RATE OF 6.5
GALLONS PER MINUTE FOR 90 MINUTES. A TOTAL OF 550 GALLONS WERE
DELIVERED. DRAWDOWN AND RECOVERY MEASUREMENTS WERE UNSUCCESSFUL
DUE TO O~B~R?C~ONS IN,THE ~ELL CASING AT .2~0 ~E~. TOTAL WELL
DEPTH 325 FEET.
TEST FOR COLIFORMS:
NEGATIVE.
WATER WAS TESTED FOR COLIFORM BACTERIA AND
NITRATES oN MAY 5, 1987. BOTH TESTS WERE
TEST RESULT:
THIS WELL MEETS THE REQUIREMENTS OF THE
MUNICIPALITY OF ANCHORAGE.
The Municipal requirement for well flow is 150 gallons of water
per bedroom per 24 hours.This well surpasses this requirement.
The assessment of the condition of this well applies only to the
conditions as of this date. The flow rate of the well may change
due to subsurface conditions that may not be observed from 'the
surface, and changes in land use and other factors that may
impact the conditions of the aquifer feeding the well.
CONSULTING ENGINEER ~ u, ,~ ANCHORAGE, ALASKA 99501
TELEPHONE: (907) 279-3916
SEPTIC
SYSTEM
ADEQUACY
TEST
LEGAL:
LOCATION:
LOT 7, BLOCK 1, SEQUOIA ESTATE
6841 SEQUOIA CIRCLE
OWNER:
HUXLEY
RESIDENCE:
WELL:
SEPTIC SYSTEM:
SINGLE FAMILY, THREE BEDROOMS
PRIVATE, ON SITE
FROM MUNICIPAL RECORDS:
TANK: GREER STEEL, TWO COMP. 1000 GAL.
ABSORPTION SYSTEM: BED
ABSORPTION AREA: 720 SQ. FT.
SOIL RATING: 150
INSTALLATION DATE: JUNE 1984
DATE OF PUMPING:
DATE OF TEST:
MAY 6, 1987. ANCHORAGE CESSPOOL PUMPING
MAY 5, 1987
TEST PROCEDURE: SYSTEM WAS INSPECTED AND MEASURED. TANK WAS FOUND
WITH 15.5 FEET DEEP, WITH 10 FEET OF COVER AND 48
INCHES OF LIQUID. CLEANOUTS TO BED WERE 10 FEET DEEP AND DRY.
MONITORING TUBE-WAS &0~5-EEET DEEP AND HAD 5 INCHES OF LIQUID.
550 GALLONS OF CLEAN WATER WERE ADDED TO THE SYSTEM
WHILE THE WATER LEVELS WERE MONITORED. NO CHANGE IN THE TANK,
ROSE 2 INCHES. SIX HOURS LATER THE LEVEL IN THE BED WAS 5.25
INCHES. - ....... -
TEST RESULT: THIS SYSTEM MEETS THE CODE REQUIREMENTS OF
THE MUNICIPALITY OF ANCHORAGE.
The operational life of all septic systems depends on the local
soil conditions, groundwater levels that may fluctuate during the
year, and the water usage of the family being served by the
system. These conditions are outside the control of the evaluator
of this septic system. We can therefore not give any estimate of
how long the system will continue to meet the operational requi-
rements of the MuniciPality and State.
,~3- ;-,,. .
bfUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR ~ALTH AUTHORITY APPROV~ CERTIFICATE
1. General Info~ation Applic~tion Date ~7
(a) Legal Description (include lot, block, subdivision, section, to~mship~ range)
Location (address or direqtions)
3~s~-
(b) Applicants Name ~'~ I~AD~tL Telephone- Itome Buslness~
(c) Applicant is (check one) Lending Institution
Buyer ~_~ ; Other L~.-~ (explain);
(d) Lending Institution
~_ ; Owner/builder
Telephone
Address
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the ILgA to the following address:
2. Tyj?e of Residence
Single-Family I~
Number of Bedrooms
3. Water Supply_
Individual Well ~
Multi-Family
Other (describe)
Note: if community well system, must have written confirmstion from the State
Department of Environmental Conservation attesting to the legality a~zd status,
4. Sewage Dis_~osal
On,lite ~[ Public ~--.~ Community L----~ Holding Tank ~]
Note: If community well ~ystem, must haw: written confirmation from the State
Department of Envirot~mental Conservation attesting to the legality and status.
[Page 1 of 2]
5. J~n__g. ineering Firm Providiq~ Inspections, Testsz. 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.
e
Name of Firm_~_ ~C~__
Address
__J3oO co
DHE P.. A__p.~pr o v a 1
Approved for ,~ bedrooms
Approved .:.~. ~./ Disapproved
(ENGINELR SEAL)
Cond i t ional
Terms of Conditional Approval
CAUTION
TIlE HUNICIPALI'I;Y OF ANCHORAGE DEPAR~XqENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DIIEP) ISSUES IIEALTH AUTHORITY APPROVAL CF, RTIFICATES BASED S_0~[_~'[LY_.' UPON TIIE REPRESENT--
ATIONS (lIVEN IN PARAGRAPtl 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTiSRED
IN THE STATE OF ALASKA. THE DHEP DOES Tills AS A COURTESY TO PURCIIASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE=
MENTS. FJ,1PLOYEES OF DHEP DO NOT CONDUCT iNSPECTIONS OR ~UNALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OHISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DItEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-34
ae
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
- Legal Description: Lo~ 7
Well Classification ~ 4_~, If A, B,
Well Log P~esent ~N) Date ~le~d
Static Wate~-~1 ~ ~q~
Casing ~ight ~ G~nd ~ ,'~ '
Elec~icaI Wiring in ~nduit ~)
~p~ation Dictates ~ ~11:
To ~ptic~olding Ta~ ~ ~t'~ ~5
To ~a~st ~ of ~so~tion Field on
To Newest ~blic ~= Line
Cl~an~t~a~ole ~'~ ~ ~est ~ ~Vi~ Li~ on ~t
Watt= S~le Colle~ed By ' ~, ~~ ; ~te
Watt= S~le Test ~sults ~
Sanitary Seal on Casing Y~N)
Depression Around Wellhead _(Y~
; On Adjoining Lot's~ 1('30f
; On Adjoining Lots ~_~' !~)~ #
To Nearest Public Sewer
B. SEPTIC/HOLDING TANK DATA
Date Installed A/~ $ / 8 q Size l OOf9 No. of C~,%~amtn~nts ~
Stan~i~s ~) Air-tight Caps (Y~' Foun~tion Cleanout ~)
~p~ession o~r Ta~ (Y~) ~te ~st P~d ~.~ ,%Xl S ~'
P~ing~intenan~ ~n~a~ ~ File (Y/N) ; f~ ~ '
Holding Ta~ High-Wate~ Ala~ (Y~) ~ ~a~y Hold{~. Tank ~r~t (Y~) ~
~p~ation Dictates ~ ~ptic~old~g Tank: /
To Wate=-Supply ~11~ L.~~
To Building Foundation"''l~, ~
To Disposal Field ~4[' Il,~
To Stream, Pond, Lake, c~ Majo= D~ainage
!
[Page 1 of 2]
C. ABSORPTION FIELD DATA
Soils Rating in Absorption St~ata~.~O
Date Installed ~ ~ &/A~ ;~ LI
Width of Field ~ I~
Square Feet of Absorption A~ea~'~O
Depression over Field (Y~
Results of Last Adequacy Test
I
Separation Distano~ from Absorption Field:
To Water-SUpply Well~ ~OI~ To P~o~erty?Line
To Building Foundation '~-~{ ! To Existing or Abandoned System on
Lot ~ · ; On Adjoining Lots
To Wate~ Mafn/Se~vice Line ~ To Cutbank(if presen~)~I
To St~eam/Pond/Lake/o~ Major D~i'nage Cou~s~..~
To D~iv~ay, Parking A~ea, o~ Vehicle Storage A~ea
~%/~ Type of System Design
of Field
Depth of Field ~ q.,.~
Gravel Bed Thickness ~
Standpipes P~esent Y~N)
Date of Last Adequacy Test
/
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water AlarmLevel at
Tested for
Electrical Codes(Y/N)
Co~nts
Dim~ ns ions./~'
Manhole/Ac~/.(Y/N )
"Pump Of~FLevel at .
/ Vent (Y/N)
Pumping Cy/~es du~ing Adequacy Test.
/
/
Meets FDA
Check Permitted Bed~ocm Rating Against HAA Pequest
I certify that I have checked, verified, o~ confo~Ted to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed.~,~__;~__ Date
KB1/d5/s
',t, ~_ %/ \. 1
[Page 2 of 2]