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HomeMy WebLinkAboutSCIMITAR #2 BLK 2 LT 23Scimitar #2 Block 2 Lot 23 #051-132-41 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 S'�p Page ON-SITE WASTEWATER INSPECTION REPORT 2 Permit Number: OSP211265 PID Number: 051-132-41 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New FE -1 Upgrade Name CHRISTOPHER & KIMBERLY WILKINS A ORPTION FIELD ❑ De Trench El Wide Trench El Bed ound Site Address 19636 TULWAR CIRCLE, CHUGIAK, AK 99567 Other Phone Number of Bedrooms Soil Rating Total depth f original grade 688-9433 (C/O ARM SEPTIC SERVICES) 4 /SF Ft. LEGAL DESCRIPTION Depth to pipe invert from orig EXISTING el depth beneath pipe Ft. Subdivision Block Lot SCIMITAR #2 2 23 Fill added above original g JG!!length Ft. Ft. Township Range Section - - Gravel width Ft. Beds: Number of Lines Dist a between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total orption area Number of trenches Dist. between t ches From Tank Field Tank Line Ft2 Well I 100+ I EXISITNG _ _ 125'+ TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER TANK Capacity 1250 Gal. Surface Water 100+ EXISTING _ - Material Number of compartments Lot Line 5+ EXISTING - - NA PLASTIC/HDPE 2 Foundation Q+ I EXISTING _ _ LIFT STATION rer Alarm location Capacity Gal. Remarks installed by Installer PIPE MATERIAL House to tank D3034Tankto D3034 drainfield ARM SEPTIC SERVICES, LLC Drainfield EXISTING CO/MTD3034 Inspector GEG CONSULTANT, JODY MAUS BENCHMARK (Assumed elevation) 100.00 ft Inspection 1� 7/22/2021 Location and description es: Zd 31d 41h THRESHOLD OF BACK DOOR FOR GARAGE A ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's tamp Conditional Approval: Dateo �� 'q PN o* H O ffre A. G ness••' Q �p • � ��' • • Septic System Approved Date I f 1 D ,2021 �^ ,.. -�• � coo %G\ Note: this approval does not -include well permit requirements.O'p rofesslo #AECC884 trcev varua io/ PERMIT OSP2 NUMBER: RECORD DRAWING Y Y I N G PARCEL ID NUMBER: OSP211265 051-132-41 / A B / DBLZ 30.7 1 19.5 / 1 DBLZ 30.7 20.0 MH 30.8 20.9 7� ST1 31.4 23.9 DBLZ 31.7 24.8 I DBL3 32.0 25.6 1 C01 41.0 31.7 INOTE: PIPE LOCATIONS ARE SHOWN PER GEG SHOTS TAKEN 1 1 WITH LEICA DISTO S910 LASER i 7� 1 DISTANCE METER. SWING-TIES rFFT I TO HOUSE CORNERS WERE ALF 1 I 1 GENERATED IN AUTOCAD. / <� Rq0/LS EXISTING WELL I I I ( I 1 1 PAVED DRIVEWAY I I 1 I e�fs 1 F � � F � ASF t 1 1 � I i NOTE: OLD SEPTIC TANK DECOMMISSIONED PER UPC B PER THE CONTRACTOR I 1 1 1 INSTALLED DOUBLE \` CLEANOUTS (DBLZ & DBL2)� NEW 1250-GALLON GREER I 1qN PLASTIC SEPTIC TANK 1 SSS sots INSTALLED DOUBLE CLEANOUTS (DBL1 & DBL2) 1 I IEXISTING DRAINFIELDF� ` SHED I 1 \ 1 i SHED i 1 1 10 INSTALLED CLEANOUT (C01) 1 1 AT BEGINNING OF DRAINFIELD. I I NEW TANK IS 5+ FEET FROM EDGE OF DRAINFIELD. i I � I I � I/ 1 I I 1 1 NOTE: THE NEW TANK WAS INSTALLED NEW A LOW LYING (<30" SCALE: TALL) DECK. NO DECK SUPPORTS ARE WITHIN 5' OF NEW TANK. 1"= 30' 77"77 77,77,77"77�: ' • }} Ar ;• 9 ti21_"'_"_`111_11115 ENGINEERING, SALES, CONSULTING 3701E TUDOR ROAD, SUITE 101' ANCHORAGE, ALASKA `PHONE (907)337-bt79'WEBSITE ww.v.garnessengineenng wm+'•;•0••-•"•"• • • • •• ••• •••• ••••.•••!�•y!!•' PREPARED FOR: CIO ARM SEPTIC SERVICES PHONE NUMBER: PAGE NUMBER: ♦ t-_ ; J y A. SS CHRISTOPHER & KIMBERLY WILKINS 688-9433 2 OF 3 }}�'r ''• C 7953 ;'•SAV PROJECTILEGAL DESCRIPTION: DRAWN BY: }�♦���fi0A''• 16 2.1 ''•���IV SCIMITAR #2; BLOCK 2, LOT 23 J.L.M. i}!•'/•(•�•� '(•p\, �" TYPE OF WORK: DATE: ���S-i�l►�'� RECORD DRAWING OF SEPTIC TANK UPGRADE 8/6/2021 #AEccsaE4 %" " OERM IT NUMBER: I OSP211265 RECORD D RAW I N G PARCEL ID NUMBER: 051-132-41 051-132-41 FINAL GRADE ION TOR 3@ 9 ®®'�®ILI {4wr®f ,r GARNESS ENGINEERING GROUP, Ltd ®.....::.... .......... ............. ::..... r ENGINEERING SALES CONSULTING 3701E. TUDOR ROAD, SUITE 101 'ANCHORAGE, ALASKA -PHONE (907)337-6179'WEBSITE:-game ngmeedng.cam ••• • ••••••••••••• ..........•• PREPARED FOR: C/O ARM SEPTIC SERVICES PHONE NUMBER: PAGE NUMBER: ♦ � ".re . arness Q� CHRISTOPHER & KIMBERLY WILKINS 688-9433 3 OF 3 ®O��J,'••• C 7953 , °moi PROJECTIEGAL DESCRIPTION: DRAWN BY: # o SCIMITAR #2; BLOCK 2, LOT 23 J.L.M. ♦j �„� �.••`'�� ®o TYPE OF WORK: DATE: LICEN4444 OFESS� . RECORD DRAWING OF SEPTIC TANK UPGRADE 8/6/2021 #AECC884 ®ra+® Scale 1" = 50' Frontier Surveys, LLC Project No: 21-386 Ordered By: ARM Septic Services LOT 22 GREEN HOUSE Q r? r 99.& T T LU lb PAVED DRIVEWAY F� uV rya V 5 x SHED f ° z SHED �, �fl LOT 27 11.9 P N SHED 10 — �d sus N 57.8 N S$9° 25 'QQ'E 200.86 Lot 23, Block 2 Scimitar Subdivision Unit Na. 2 \ t° � 48, S22 Sq. Ff. +I- f9636 Tulwar Circle 2 Story Woad Frame House With Attached 2 Car Garage LOT24 NOTE: ADDITIONAL SEPTIC S TA NDPIPES MA Y EXIS T UNDER DECK, FIELD SURVEY UNABLE TO ACCESS, y Electric Meter/Outside Power � Telephone Pole –oma Overhead Utitity Gas Meter ® Deck –x— Fence 0 Concrete 1511 Septic �W; Water Well -L; Mailbox r ' �— 50,0 RAD. LOT 25 LOT 25 General Notes: 0 25 50 100 1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright laws. 2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. Scale f n Feet 3. All measurementsisetbacks are to the visu alla pparent building footprint. 4. All dimensions to property lines are plus/minus p.1ft. PROFESSIONAL SEAL This survey comp{ies with the ASPL5 Mortgage Location Standards. The survey represents visible improvements and conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances should this document be used for construction or for establishing a boundary or fence line. IAS -Built Re -Certification Survey of. Lot 23, Block 2 Scimitar Subdivision Unit No. 2 I, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or under my direct supervision on July 29th, 2021. Frontier Surveys, LLC FRONTIER, 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 Slli'Ve 5•., 907.460.1686 - info@frontiersurveys.com www.f rontiersu rveys.com Date:7/30/2021 Plat: 74-190 Grid: 1261 \-A O EDGE OF PAVEMENT 34 4 1ox20•a ICHO ESUT ESMT. LU lb PAVED DRIVEWAY F� uV rya V 5 x SHED f ° z SHED �, �fl LOT 27 11.9 P N SHED 10 — �d sus N 57.8 N S$9° 25 'QQ'E 200.86 Lot 23, Block 2 Scimitar Subdivision Unit Na. 2 \ t° � 48, S22 Sq. Ff. +I- f9636 Tulwar Circle 2 Story Woad Frame House With Attached 2 Car Garage LOT24 NOTE: ADDITIONAL SEPTIC S TA NDPIPES MA Y EXIS T UNDER DECK, FIELD SURVEY UNABLE TO ACCESS, y Electric Meter/Outside Power � Telephone Pole –oma Overhead Utitity Gas Meter ® Deck –x— Fence 0 Concrete 1511 Septic �W; Water Well -L; Mailbox r ' �— 50,0 RAD. LOT 25 LOT 25 General Notes: 0 25 50 100 1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright laws. 2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. Scale f n Feet 3. All measurementsisetbacks are to the visu alla pparent building footprint. 4. All dimensions to property lines are plus/minus p.1ft. PROFESSIONAL SEAL This survey comp{ies with the ASPL5 Mortgage Location Standards. The survey represents visible improvements and conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances should this document be used for construction or for establishing a boundary or fence line. IAS -Built Re -Certification Survey of. Lot 23, Block 2 Scimitar Subdivision Unit No. 2 I, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or under my direct supervision on July 29th, 2021. Frontier Surveys, LLC FRONTIER, 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 Slli'Ve 5•., 907.460.1686 - info@frontiersurveys.com www.f rontiersu rveys.com MUNICIPALITY OF ANCHORAGE - . On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP211265 Effective Date: 7/12/2021 Work Type: SepticTank Upgrade Expiration Date: 7/12/2022 Tax Code Number: 05113241000 Site Legal Address: SCIMITAR #2 BLK 2 LT 23 G:1261 Site Mailing Address: 19636 TULWAR CIR, Chugiak Owner: WILKINS CHRISTOPHER A & Lot Size in Sq Ft: 48922 Design Engineer: GARNESS ENGINEERING GROUP LTD Total Bedrooms: 4 This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing ---"` Received�- Issued By:��� Date: Date: I �• 0 O, j v bu L F.1 -y� f � w^^ E] Fi ; Lim ANCHORAGE Development Services Department � `= On -Site Water & Wastewater Section ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-132-41 Phone: 907-343-7904 Fax: 907-343-7997 Property owner(s) CHISTOPHER & KIMBERLY WILKINS - C/O ARM SEPTIC SERVICES Day phone 688-9433 Mailing address 19636 TULWAR CIRCLE, CHUGIAK, AK 99567 Site address 19636 TULWAR CIRCLE, CHUGIAK, AK 99567 Legal description (Sub'd., Block & Lot) SCIMITAR #2; BLOCK 2, LOT 23 Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) R (w/wo AD U) Septic Tank Upgrade 0 (D) El Holding Tank ❑ Renewal ElDuplex Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 002 Waiver Fees: Date of Payment: `7 r74 � 1 Date of Payment: Receipt Number: d 2 5 1 G Receipt Number: Permit No.0.SP 2 ( � 2.652 2 6 9 Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211265, Rebecca Carroll, 07/12/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211265, Rebecca Carroll, 07/12/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211265, Rebecca Carroll, 07/12/21 �- MUNICIPALITY OF ANCHORAGE t9 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 NAME PHONE EW ` 0 // � 1 / UPGRADE MAILING AD ESS < U LEGAL DES RIPTION (� LOCATION`. "; i NO. OF BEDROOMS / C, Well Absorption area DISTANCE TO: Dwelling PE ITy - '44W z U Y N• Z °•Q wF Manufacturer , ! Material No, of compartments 05 Liqity-1I� allons Z2�Liquid �( IF HOMEMADE: Inside length Width depth O Y DISTANCE TO: Well Dwelling PERMIT NO. Z Q Manufacturer G Material Liquid capacity in gallons b _0 w y DISTANCE TO: Well ` Foundatio Nearest to line / �"J .a-1 PE A4I,TYNJ/( G-%� L- -1 a 2 No. of lines Length. AeacA line Total le h f Y�nes Trent widtF�� Distance b� e �jif�es Z w I'—OC G" Top of file to finish rade g f � inches Material beneath file > C Total effe/ct�'vp� abs do rr ©~ r inches / C 0 Length Width Depth PERMIT NO. UA Q t- Type of crib Crib diameter Crib depth T tal effective absorption area ' wa Lu Well Building foundation :- Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. J LU Building foundation Sewer line Septic tank Absorption areas) DISTANCE TO: OTHER k jo — — PIPE MATERIALS SOILTESTRATI INSTALLE 0 -7tll _ REMARKS i r \CLC- ti+ Af% �( t3 o! 1�7•- � F o'v.• -, (tvIeco A. Shv,%r ` d '�` 1-4o, 14.57.E ,ao IVP °roct�jC�, -�fP �tJ• AP VE j-^'�+rt,;��/�_n,'-�`� DATE LEGAL 72-0113 (Rev. 3/78 Nt. I 1, .J 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 NAME P/F�.ONE NEW UPGRADE MAILING V P,,/J le /,-Z/ v/ LEGAL DESCRIPTION LOCATION�' `0 Tls-� / NO. OF BEDROOMS L) DISTANCE TO: Well Z- Absorption area Dwelling / PE I� Q 2-3 Y a ZQ w b Manufacturer /'^��� / O'er —6[— Muer'. !yE> No. of comfaeytments rn Liq. g1�p gallons IF HOMEMADE: Inside length Width • Liquid dept /1- O 2 DISTANCE TO: Well r D elling PERMIT NO. ®z Q Manufacturer ��` Material Liquid capacity in gallons O w DISTANCE TO: Well Foundati JJ ( 3 6 � r L' IN Ip P R IJ�Q 5? -z- 3 e6 U w a O J w No. of lines Length of ac17 line Total lot th of lines g / / TrenclLpidth L f v� inches Dista ny�be wey� lines F — CC �cc F_ , Top of tile to finish g e Material beneath tile�� � U Total effective sorption area inches Length � s Width Depth PERMIT NO. w �7 I H CL LU Type of crib Crib diameter Cr epth Total effective absorption area lrl to DISTANCE TO: _ Well Building foundation Nearest lot line J Class L) ,;7 Deppe !-Drillsy Distance to lot line PERMIT NO. J � .l LU DISTANCE TO: Building foundati Sewer line Septic tank Absorption area (s) OTHER tL ' PIPE MATERIALS l SOIL TEST RATING 7 INSTALLER REMARKS ..3 L t • � '- DATE APPROVED '~�i: ZGr/ PERMIT NO: DATE ISSUED: APPLICANT: A1)DQE:SS- CONTACT PHONE: LEGAL DESCRIP: LOT SIZE: �11�P-41 :1r. IE:' ' :11" IF- if -')i IL-. I T .. .... le" if."D, F- 11h,11 )[--:]: 11 - -0 C11 IF�� 1E.'D� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGEj, AK 99501 264-4720 C3 POI C]; 3::~IE.: Ei� IE,-...�: 11,4 IF'.-e� �` IUE': R'-' 11 11� 840691 UPGRADE 08/13/84 � STRATA % S&S ENGINEERIN�� EAGLE RIVER,, AK 99577 694-2979 SUBDIVISION: SCIMITAR LOT: 23 BLOCK: 2 SECTION: 10 TOWNSHIP: 151\1 RANGE: RIM 48922 (SOFT. OR ACRES) I certi�y that: 1" I am familiar with the requirements for on~and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2" I will install the system in accordance with all MOA codes and regulati and in compliance with the design criteria of this permit" 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS~BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN" SIGNED � � �>� &.Coles �� �' ~ .-~ Cx u�*^y �� ���� �_- ~~�~ ^_~ ^~� ,_� leg" ' me -'&d, *�' / �« / / � / ~ PERMIT NO: O402]8 DHTE ISSUED� 04/2�/84 YOUR SEPTIC IF R LIFT STATION IS INSTHLLED IN HN HREH COVERED BY MOH BUILDING CUDES, THEN (1) AN B.ECTRICHL PERMIT AND INSPECTION MUST BE OBTHINED/ (2) RS~BUI�T� WILL NOT BE RPPROVED WITHOUT AN ELECTRICRL INSPECTION REPORT/ HND (]) THE ELECTRICHL WORK MUST BE DONE BY H LICENSED ELECTRICIHN ~ ❑ SOILS LOG MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ❑ PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 'a —`' SOILS LOG — PERCOLATION TEST l 'i PERFORMED FOR:',�1 ` DATE PERFORMED: LEGAL DESCRIPTION: 2-3 /�J Y - - 7 J'� /1 ez- P� SLOPE SITE PLAN ( EET) 2 A,1 mi I d L 3 G G � 4 Qv 5 4 0 7 0 V s G u 9 I 10 Li �J u 11 d C 12 GI G 13 J 14 Date Gross Net Time Time Depth to Water Net Drop . ria � •<w Q. 16 /o J'IF • !: ••9U1 � 17 1 18 o %gbwl A. Shw4f y. 20 COMME WAS GROUND WATER 1'// S ENCOUNTERED? VVV 4 L — O P n IF YES, AT WHAT DEPTH? Reading Date Gross Net Time Time Depth to Water Net Drop i PERCOLATION RATE TEST RUN BETWEEN PERFORMED BY: ��I-,1 la+! °* CERTIFI 72-008 (6/79) FT AND (minutes/inch) FT DATE: wprAfipb Drlllin� jag by DOC Co. Uba SULLMN WATER WELLS P. 0. BOX 272, CHUGIAK, ALASKA 99567 a TELEPHONE 588-2759 OWNER OF LAND ADDRESS i,E(;AL DESCRIPTIONS _,2.3-__ ;• _s <<., r . >; - %-f,'„� DATE • Started _ i” ?_'`_—.- Ended- t'ERMITNUMBER .- 0-_-�------- -.---- ;UND OF FORMATION: DEPTH of WELL I "?7 .')<> STATIC LEVEL OF WATG;R FT. --, x DRAW DOWN FT. GALS. PER Hli 4 KIND OF CASING__—_- rom__s"'� Ft. to_—' -�Pt. 'c:��'y. '=-z`-=----- Front --.Ft. to___._Ft rom-,j Ft. to `' I Ft. _'i' i', !.',_r,.r,vs,:, — -- Front ,-rom_` 'j__Ft. to_ iL __Ft. 3,,, rt''19 From _Ft. to. -------Ft. Fir, Ulrom.�_Ft. to _Ft �i4 t r! •'� %,e —: From _ _Ft. to_ Ft. From m='=' _ Ft. to 1I8 t From -.--Ft. to_ Ft.. From I /r.A Ft. toj='_t; z�Ft.. f_ `�..1=_.,1_: r_..'<: From to Ft. _ From Ft. to ---Pt. From_____Ft. to—. From.. L�LFt. to -l --'.L'- -' _Ft._ t-6'2 From Ft. to- From -L,' y Ft. to t"' Ft. � - o' r J' f, �� ,.; . i_',.', --� _�- _ From Ft. to_____� From:LFt. to_ '. `�eF't, `'' n,'r .LA3AL._1_i�, —, - Froin. -Ft. ta_.-_--P't. From_ -___Ft. to _Ft._-_ ``�_' _-_-- From --_--Ft. to_ -----Ft. I " ' _, Ft. _Ftr From `'to-JUL ffJ _ r , <, r'{__ -' l.: _ - From Ft. to`—Ft. From ---Ft. Frmn._- Ft. to_ _Ft. MISCL. INFORMATION DRILLER'S NAME. 0 Front Ft. to --Ft. From --Ft; to__, Fir, T` _ From_ Ft. to ------Ft. / From t�Ft. - to_ = ks.i Ft ._--�; _�f- , _.. ' ---- Frmn.------Ft. to ---Ft. Frmn_-_^Ft. to_ __Ft- : _ _ From Ft. to Ft. From_____Ft. to—. -".'Ft.,-.- From _.Ft. to -_Ft. MISCL. INFORMATION DRILLER'S NAME. 0 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 4c ' CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING r, 7� Parcel I.D. 051-132-41 COSA# o'7 6_? 1. GENERAL INFORMATION Expiration Date: 1 ' d Complete legal description SCIMITAR #2: BLOCK 2, LOT 23 Community Class Well ❑ Location (site address) 19636 TULWAR CIRCLE * CHUGIAK, AK • 99567 Current Property owner(s) GEORGE & SANDRA BUNTING Day phone Mailing address 19636 TULWAR CIRCLE • CHUGIAK. AK • 99567 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well N Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site N 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 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. 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 water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 1 further verify that based on the information obtained from the Municipality of Anchorage riles 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 Finn GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 ' ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, VD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines 6 Regulations. The reported results described 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 soils condition, 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 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 provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or 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 otherperson or party is not authorized, nor will It confer any legal right whatsoever. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Phone 337-6179 Date go�00 co �....:.... ............ Y// oo15 r A. G rness: .CE .. 95 Conditional approval for bedrooms, with the fllowing stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineers Report Other By: 4AZ /, Original Certificate Date: ) 0 - / 9 - a 1 (Rev 11105) Municipality of Anchorage �• �°1 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 0 Legal Description: SCIMITAR #2; BLOCK 2, LOT 23 Parcel ID: 0S-1- Z32_ l � A. WELL DATA Well type PRNATE If A, B, or C provide PWSID# N/A Date completed 5/1984 Sanitary seal (Y/N) YES Total depth 200 ft. Cased to 164.5 ft. FROM WELL LOG Date of test 5/1984 Static water level 155 ft, Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ In. AT INSPECTION 9/30/2009 150 ft. Well production 5 g.p•m• 7.27 g.p.m. WATER SAMPLE RESULTS: . Coliform 0 colonies/100 ml. Nitrate A) t img./L. Other bacteria colonies/100 ml. Arsenic: N ug./L. Date of sample: 9/29/2009 Collected by: GEG Ltd. B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 4/29/1984 Tank size 1250 gal. Number of Compartments E Cleanouts (YIN) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 10/3/2009 pumper SANITARY PUMPERS C. ABSORPTION FIELD DATA Date installed 8/1984 Soil rating (g.p.d./ft'o /bd 85 System type TRENCH Length 41 ft. Width 2.5 ft. Gravel below pipe 5 ft. Total depth *_ft. Eff. absorption area 410 ft' Monitoring tube YES Depression over field NO Date of adequacy test 9/30/2009 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test DRY in. Water added 630 gal. New depth Sin. Elapsed Time: 120 min. Final fluid depth DRY in. Absorption rate >= 600+ • g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date - D. LIFT STATION Date Installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. "Pump off leve High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ *TO FENCED BACKYARD W/ DOGS. On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line 25'+ Holding tank N/A Animal containment areas '40' Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 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 JEFFREY A. GARNESS Date COSA Fee $ LL -01 Date of Payment Receipt Number 0930;7X (Rev. 11105) I ul Waiver Fee $ oQoo 0 .. 4 . ..... ..... P e f Gar ess.: CE _l ofI.YI Date of Payment i Receipt Number SGS Ref.# 1095377001 Client lame Gamcss Engineering Group, Ltd Project lame/# Scimitar #2 D2,L23 Client Sample ID Scimitar #2 D2,L23 Matrix Drinking Water Printed Date/time Collected Date/rime Received Date/rime Technical Director 10/062009 9:56 10/022009 8:00 10/022009 11:05 Stephen C. Ede Sample Remarks: Allowable Prep Analysis Paramctcr Results PQL Units Mcthod Containcr ID Limits Date Date Init Microbiology Laboratory Colony Count 0 coVIOOmL SM209222B A (Q00) 10/02/09 DLC Total Coliform 0 coV100mL SM209222B A (<I) 10/02/09 DLC Fecal Coliform 0 coVIOOmL SM209222B A (<I) 10/02/09 DLC SCS RCEN 1095278001 Client lame Garness Engineering Group, Ltd Project Name/# Scimatar #2 Lot 23 Blk 2 Client Sample ID Scimatar #2 Lot 23 Blk 2 Statris Drinking Water Sample Remarks: Printed Date rime 10/142009 16:12 Collected Date/time 09292009 8:20 Reetired Date rime 09292009 13:45 Technical Director Stephen C. Ede Allowablc Prep Analysis Paramctcr Results PQL Units Mcthod Comaincr ID Limits Date Date Init Metals by ICP/M9 EP200.8 Arsenic ND 5.00 Waters Department NRB Total Nitrate/Nitrite-N ND 0.100 Microbiology Laboratory (<10) Colony Count 9 Total Coliform Positive Fecal Coliform Necative ug/L EP200.8 C (<10) 10/08/09 10/13/09 NRB mg/L SM20 4500NO3-F B (<10) 10/09/09 LCC coVI00mL SM209222B A (<200) col/IOOmL SM209222B A (<1) cot/lOOmL SM209222B A (<I) 0929/09 DLC 0929/09 DLC 0929/09 DLC Municipality of Anchorage • Development Services Department Building Safety Division / On -Site Water and Wastewater Program 4700 South Bragaw St. "' P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 0 CERTIFICATE OF HEALTH AUTHORITY APPROVAL � FOR A SINGLE FAMILY DWELLING Parcel I.D. HAA# d5CQ_757 Expiration Date: 1. GENERAL INFORMATION Complete legal description L 2,3 13 Z. Location (site address or directions) 19936 T L%j_WA-R. G.TRLLL Current Property owners) DAsj0Y 4 DOROTHY µhGK'E IT- Day phone • 6 �$ - /l tial Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 1 9636 r%4tt.JAt2 cd:t2ccE' cht44r4L 4Ac 915.6 Day phone VT If Y CIM 57-e'4D Day phone egg -5-0570 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well [� Individual On-site 01� 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 in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based 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 Stale codes, ordinances, and regulations in effect at the time of installation. Eagle River Engineering Services Phone 69 y - 5196' - Name of Firm 1 Mel VFW Rd., suite 201 Address Eagle River AK 99577 Engineer's Printed Name C unr<ia H&A R. 0000 Date'01i1,o S Iii 5. DSD SIGNATURE -jt C1 OTOPMFLWOOD CHOW Approved for 1 bedrooms. Disapproved.�'N Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: (Rw OV02) Municipality of Anchorage ` • Development Services Department '= Building Safety Division i On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage. AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 i HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: SGy-rylri4(Z'#Z L Z 3 a 2- Parcel Id: 05.1- 132 -91 A. WELL DATA Well type QLi_ATE If A. B. or C provide PWSID # = Well Log ®/N) 11E 5 I Date completed -&Y Sanitary seal &N) Wires properly protected&y N) 1/ES i Total depth ZoD ft. Cased to l6ytsft. Casing height (above ground) 13 in. FROM WELL LOG AT INSPECTION Date of test /.L�5 Static water level / �� ft. % ft. Well production S g.p.m. S. y g.p.m. WATER SAMPLE RESULTS: i Coliform --Q_colonies/100 ml. Nitrate I. d I mg.A. Other bacteria O colonies/100 ml. i i Arsenic: 04 mg.A. Date of sample: > Collected by: .1'0*J H }Y�B7J B. SEPTIC1t16G TANK DATA r� Tank TypelMalerial • STE'E'L Date installed Tank size fzso gal. Number of Compartments Cleanouts(1) t�ES Foundation cleanout(nY N) � Depression over tank (Y& At& High water alarm (YA 1O "0 Date of pumping lWae la `j Pumper J'2 /S C. ABSORPTION FIELD DATA Date installed rokyzls Soil rating (g1.pd:lftii'or ftZ/bdrm) A6 System type _ T R CMG /f i Length_ ft. Width 2. ft. Gravel below pipe S ft. i Total depth ft. Eff. absorption area 355 ft= Monitoring tube la Depression over field ND Date of adequacy test%vs,j <- Result(Pass ail) PASS For bedrooms Ij Fluid depth in absorption field before test Q in. Water added-65 jal. New depths in. Elapsed Time:,fJZvrnin. Final fluid depth _Q in. Absorption rate >= 60- g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) k-0 If yes, give date 'y 1A D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on' level at _ in. 'Pump oRvek9r),ff in .5 (� 'High water alarm level at in. Dat Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/Wil- alien on lot +/ oy Absorption field on lot t 100 Public sewer main t too r Sewer/septic service line -rt(30 r On adjacent lots On adjacent lots t) / +tov r Public sewer manhole/cleanout t /r9O / Holding tank + 1011) SEPARATION DISTANCES FROM SEPTIC/HeLBIN6 TANK ON LOT TO: Building foundation Z Z / Property line 6_/ Absorption field 5 Water main t ZS / Water service line +25' / Surface water —t-100 Wells on adjacent lots +100f— SEPARATION 100r SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 't'/0 r Building foundation +/0 Water main f JW Water Service line t_ 5 Surface water t /rip a Driveway, parkinglvehicle storage *29 / / r Curtain drain tOT Wells on adjacent lots '1'100 F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and T y review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. LA Engineer's Printed NameLHRis1vPH�lC� Itw000 1 CE 14I Date A> - G HAA Fee $ 4 30 'UD i l 4S- 0 ( kUW Waiver Fee $ Date of Payment �12y�Ds Receipt Number 6-3901w- VM (Rev. 12101) Date of Payment Receipt Number 04-11-05 03:27PM FROM-CUE ESI, SCS ENV SERVICES --sG$- 9075615301 T-414 P.02/04 P-330 SCS ReL# 1051779001 All Dates rimes are Alaska Standard Time Client Name Eagle River Engineering Printed DateMme 04/11/2005 11:52 Project Name/# Scimitar #2 BI #2 Lt 23 Collected Date/time 04/OS/200S 17:30 Client Sample ID Scimitar #2 EI #2 Lt 23 Received DateMme 04/062005 14:15 Matrix Drinking Water Tecbnkal Director Stephen C. Ede Sample Remarks: Allowable Ptep Analysis Parameter Rcrults PQL Units Method Contaiaei ID Umits Date Date Init Waters Department Nitrane-N 1.01 0.100 Microbi.olotry Laboratory Total Coliform 0 mg/L EPA 300.0 D (o-10) 04MMS CAM coVIOOmL SM209222B A (o-1) 04MMS TLF .vossz'�er�.. ASBUILT SEWARD tt ASSOCIATES LAND SURVEYING 694-082 1 HEREBY CERTIFY .THAT 1 HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY=, sU-+Y iP1cS�G.a?�1�/ZloTz3,B,r'Z f tt OF. At AND THAT NO ENCROACHMENTS EXIST EXCEPT AS DATE/ INDICATED. IT IS THE RESPONSIBILITY OF THE ; �,`P . • S �! OWNER TO DETERMINE THE EXISTENCE OF ANY rH"'' �� 4 ARID) r..... EASEMENTS, COVENANTS OR RESTRICTIONS �'k!iz6i WHICH DO NOT APPEAR ON THE RECORDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB: I •_ Cu"* Mark S. -.rd ANY DATA HEREON BE USED FOR CONSTRUCTION LS -6918 OFFENCE LINES, OR FOR ESTARI. IsMimm annum- �� Ay,;'•..... „�S�i V-. Lz3 tole AoV 3. I 6.1 t7'awft Ivy �• MSN H 0/ ��/ J Y s' IV fe �1 QY wI Nd9'!2W Zoo Ia1OY1a M• A UIL 8O� Y� — ALASKA ��/-/ LAND SLRW I MHO. OOIIDI Irt M O ~& MMCI M IOa Ntt ftl MKK0/0 ~td" t.or2s,stX2,sC/M17)F�lS✓Q. uN/i�Z •,/.I, s&Yvr w r.ss 00 y%.o�ty r. Ir/ M r. /0NIN0ta MT"Its IIIIN00 am wfI w M,OMInt a0itl 000 M 001 0100tY M a0tO0iIb1 w IOa 00MInI ars &&A~ ISOr.s. Inn r asss.Irlrry w1 00Y. "" ~ O0Y100t "Oft" 00060 to Iwo 001Ogq M OMMaIO 000 IOM MM 000 M 00000w0. I010Ira. 0" tan M IRMI MIKO aY0000" Or we IaYI.II 9.0" Y "C4,26 04N00. O-tOMN1.KH•..IM,���Mt M/Yf�}iC,�,SiG7 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date /0 "__ -Z,-5--e (a) Legal Description ,(incl.0 lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name,�-7/4 T.ele2hone - Home Business Applicants Address '�b V (c) Applicant- is (check one) Lending Institution Owner/builder ; Buyer E::] ; Other E::l (explain); (d) Lending Institution Address (e) Real Estate Co. S Agent Address Telephone _ 12b L, /j (f) tifi the HAA to the >3 following address: 2. Ipe of Residence Single -Family Multi -Family F-1 Other (describe Number of Bedrooms ti i 3. Water Suuly Individual Well[ �l Community Public Telephone Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite Public Community Holding Tank ='T Note: If community we11 system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. fAa no 1 .,F 91 M S 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. Telephone Name of Firm ���--•-�--•--- � �..�;� f Address Date_ / !_/ i z- `�� _� A �4 v j, i :p t: c5 � �. u.� cy sJ.�d` r+ Q �AF 'R �Aa XY �6v9 aon�r' eoa+M..c p t/ !/ (ENGINEER SEAL) J"A� °�"�>'R,.,...�.�.� 6. DHEP Approval Approved for LL -1 bedrooms Approved /K Disapproved Terms of Conditional Approval 1457-, Oro By .��ti ti,_,� �c (t /'L C G Z�.� ��Date.. CAUTION Conditional �e 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 PURCHASERS 01' HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CURTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR iVNALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS CR OMISSIONS 1:N THE PROFESSIONAI, ENGINEER'S WORK. RR4/ej/D18 [Page 2 of 21 (DHEP SEAL) MUNICIPALITY OF ANCHORAGE (MOA) ! ! 1 ! \ 11 D I i) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 N0113110dd "IVINMMIAN9 A. WELL DATA Legal Description: 1 D '1d3a — C/0,/ / .7-1'e Well Classification ��/UG��(If A. B. cr C, D.E.C. Approved(Y/N)) Well Log Present &061� Date Ccupleted ii%t� _ Yields% Total Depth 2 o / Cased to 2 U? DeptH of Grouting Static Water Level /S�v / Pump Set At UL ('-r _ Casing Height Above Ground 3Q /�� Sanitary Seal on Casing (Y ) Electrical Wiring in Conduit (YDepression Around Wellhead Separation Distances from Well: To Septic/Holding Tank on Lot �� / On Adjoining Lots 1019 X To Nearest Edge of Absorption Field on Lot Z?6 ; On Adjoining Lots lbu To Nearest Public Sewer Line /) 1109- To Nearest Public Sewer // ✓`? Cleanout/Manhole AJ To Nearest Sewer Service Line on Lot �/ Water Sample Collected By ES' els Y'' /dee/ ; Date��/l/����c� !�® Water Sample Test Results ' Comments B. SEPTIC/HOLDING TANK DATA Date InstalledSine 12-3-0 Standpipes (Y ) Air -tight Caps/(Y )) Depression over Tank (X Date Last Pumpe No. of Ccrnpartments 2 Foundation Cleanout ( /N) Pumping/Maintenance Contract on File (Y/N) //U-Jy)for- Holding Tank High -Water Alarm LY/N) Temporary Holding Tank Permit (YIWV,11 Separation Distances from Septic/He-1-ding Tank: To Water -Supply Db11 __/2-, Zr To Building Foundation To Property Line To Disposal Field 'Co Water Main/Service Line C50 � / 7 To Stream, Pond, Lake, cr Major Drainage Course fid 0 r -J /z Comments ti lD r✓F_- Receipt # Date Paid: Amount: (Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA X11. Soils Rating in Absor tion Strata 490_ ype of System Design Date Installed l "� ngth of Field - Width of Field j� (�F Depth of Field _ Gravel Bed Thickness Square Feet of Absorption Area �S Standpipes Present (Y ) Depression over Field (y Date of Last Adequacy Test U Results of Last; Adequacy lbst Separation Distance from Absorption Field: To Water -Supply Well _ 1:36 To Property Line /,f To Building Foundation ;3 �_( _ To Existing or Abandoned System on Lot 01J C ; on Adjoining Lots _ /oo A �m To Water Main/Service Line 6-0-1- _ To Cutbank(ifPrsent) 6 —� To Stream/Pond/Lake/or Major Drainage Course /U c) ^/ C _ To Driveway, Parking Area, or Vehicle Storage Area Convents 2 e) L r D. LIFT STATION Date Installed _ Dimensions Size in Gallons M nho /Access (Y.IN) "Pump On" Level at „-- ' Level at .— - — High Water Alarm Level at - Vent (y/N) Tested for Pumping Cy les during Adequacy Test. Meets MOA Electrical Codes(y/N) — - Comments - --- ** Check Permitted Bedroom Rating Against HAA Request I certify that I have checked, verified, or• conformed to all MOA HAA Guidelines in effect on the date of this inspection. /� Signed te�LJ7FDaf Company. o3P11VIt FTKA va77 MOA No. rr ry �r�sy KBl d5 S n ` &*bort A. Sheffer ; t� i -� -F 4J0. lEt57-E d ��•h !F a,a o ` � a3 tl� na as an•^,al�Y tap [Page 2 of 21 2-15-84