HomeMy WebLinkAboutMUIRWOOD PARK BLK 4 LT 7'0
Muirwood Park
Block 4
Lot 7
#011-422-84
Municipality of Anchorage Page 1 of 3
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage. AK 99519-6650
www.cl.anchorage.ak.us (907) 343.7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW030068
PID Number: 011-422.84
Crown Pointe Inc.
Cro
Wastewater System: New
Address
P.O. Box 112313 Anch. AK 99511
ABSORPTION FIELD
Phone
N,~ of Bedrooms
5' W ide Trench
345.6277
Five 5
Sou Raung
Toni Depth from w9ml Wade
LEGAL DESCRIPTION
1.2 GPD/Ft'
9 Ft.
B.mk La subd.wvon
Depth to ppe boltptn troth W.WnM Wade
Gave depth beneath p.pe.
4 7
Muirwood Park
5 Ft.
4 Ft.
Tbwnsh.p Range
section
Ful adoed above ongrwl Wade
Dra+e Length
0.1 Ft.
65.5 Fl.
QIM,e w.dth.
Nuhro d lines
Pstanoe between Imes
Well: Municipal Water System
5 Ft.
1
FI.
Claevl.Uaon 1pnuale. A. S. CI:
Total Depth,
eawto
ptalabwpbW aN
F.Pe 1BNl.
Ft.
Ft.
655 Ftp
ASTM 3034 PVC
Q.Iler
Date Dulled'
Stat; W ata Leel
inW.W.
M—.atabed.
Sanders and Sanders
61212003
Ft.
yield
Puns Set al
Cavng Heghl Above OoteW
TANK
rpm
FI.
Ft
SEPARATION DISTANCES
0 septic ❑ Holding ❑ S.T.E.P. ❑ Other:
To
Septic
Absorption
Lift
Holding
ubhUPnvale
hanuvacture,Y'
Anchorage Tank
1,500
From
Tank
Field
Station
Tank
Sewer Line
Wel
>200'
>200'
NIA
NIA
>25'
t
Stee el
uh r d.va,tmenp
Two (2)
>100'
>100'
NIA
NIA
LIFT STATION — NONE ON LOT
surllade Wel&
Lot Um
>5'
>10'
NIA
NIA
Da,
LMhuT3cmrer
>5'
>10'
N/A
NIA
Fourbalgn
in
In
m.
None
Noted
Purnp Maks Mode
Eleck.ul Inapecbons wimmed or
cwl3n Man
Re11k'kk
BENCH MARK
ora w end U,iWIP110"
Back Deck Northeast Corner.
100.0 Ft.
Engineers Stamp
Odk1
V 444
ma"
�p ,........ q �i
C7
#0
Inspections performed by: A Harala
sl
Dates: 1 6/2103
49th , t �0
- .`....
2n 612/03
Department of Health and Human Services approval
:..y..)..._ ..... ...............
rA 1, UTHAEL E. ANDERSONc,r
0, %
No. cE-.set
Reviewed and approved by:
Date:•��4I��oPESSIaP�•�
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number: SW030068
N 89'50112"E 52.82'
Page 2 of 3
PID No. 011-422-84
�
� MUIRWOOD PARK SUBDIVISION
:tso \ LOT 7, BLOCK 4
41,507 S.F
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A.C. DRIVE o
Five Bedroom o
I House
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64.4'o
N 90'00'00"E 167.19' z
PLAN AS -BUILT
SCALE 1• = 40'
Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number: SW030068
x-97.5
/ N ycum
C6 UU UU
1,500 Gatton
kptic Tank
PID No. 011-422-84
v S Ln
U 1- S U
PROFILE AS -BUILT -
Scale: 1" - 10'
• ' MUNICIPALITY OF ANCHORAGE Z
Development Services Department
On -Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Permit Number: SW030068
t,,Legal Description: Muirwood Park Block 4 Lot 7 '
Design Engineer: 0014 Anderson Engineering
Owner Name: Crown Pointe, Inc.
Owner Address: PO Box 112313
Anchorage , AK 99511 -
Date Issued: Apr 08, 2003
Expiration Date: Apr 07, 2004
Parcel ID: 011-422-84
Site Address: PO Box 112313
Lot Size: 41507 SQ. FT.
Total Bedrooms: 5 Permit Bedrooms: 5
This permit is for the construction of:
❑✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy
All construction must be in accordance with:
1. The attached approved design.
❑ Private Well ❑ Water Storage
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 1BAAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
r✓�.,-lam ��
Date:
4 -IO -03
6 �1� Date: /,q
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
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. C) 1 ( -qA0_—g `I Permit Number SW 030068
Property owner(s) Crown Pointe Inc. Day phone 345.6277
Mailing address (1) P.O. Box 112313 Anchorage AK 99511
Mailing address (2) Zip Code
Legal description (Lot, Block & Sub'd.) Lot 7 Block 4 Muirwood Park Subdivision
Legal description (Section, Township & Range)
Lot Size 41.507 SF Acres/Sq.Ft. Number of Bedrooms Five (5)
THIS APPLICATION IS FOR:
Sewer Only ® Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade ❑
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
OL
(Signature of property owner or authorized agent)
ee'
Permit Fees: 400 aiver Fees:
Date of Payment: tl- s - 0.3 Date of Payment:
Receipt Number: SS' Z $� Receipt Number:
(Rev. 12/00)
ANDERSON ENGINEERING
P.O. BOX 240773;
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
March 28, 2003
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 7, Block 4, Muirwood Park Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 7, Block 4, Muirwood Park Subdivision intends to construct a five -
bedroom home on the lot. We are therefore requesting a permit be issued for the
construction of a new septic system to serve the home. The attached Site Plan and
backup documentation identify the location and configuration of the new septic system
and alternate site and the parameters used in the design. Also identified on the plans
are the proposed water service line location, test hole locations and well and septic
systems on the surrounding lots. The subdivision is currently served by the Municipal
water system. Drainage arrows are also shown and current drainage patterns will be
maintained after construction.
The test hole placed near the location of the proposed absorption trench indicated
clean gravel with varying amounts of silt and a percolation rate of 2.7 minutes per inch.
No ground water was found during placement of the test hole and none was noted
during the monitoring period. We are therefore proposing to place a new 1,500 -gallon
septic tank and a new 63' long by 5' wide by 4' effective depth absorption trench. The
total depth of the trench will be 7' below the surface with the distribution pipe at 3' below
the surface. Sufficient fill will be placed to prevent freezing of either the septic tank or
the absorption trench.
The ground surface on the lot slopes as shown on the site plan from south to north at
flat to 5% slopes. The absorption trench will be constructed parallel with the slope as
much as possible in conformance with Municipal requirements. All components of the
new septic system will be constructed a minimum of 100' from any surface water and
wells in the area and 10' from the water service line on the lot.
If the system is constructed in accordance with our design the following statements
apply:
The system, if constructed as designed, will have no adverse impact on the wells
Lot 7, Block 4, Muirwood Park
March 28, 2003
Page Two
in the area or those to be constructed in the future.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely, e
Michael E. Anderson, P.E.
Attachments
49th
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No. EE -4381
105' 100'
N 89'50'12"E 52.82' 5/8" REBAR
(TYP PER PLAT)
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Alternate Site
63' Lon x 5' Vi e O TH 4 -a
K 4' Ef Depth
Absorpti n Trenc q
1,50 Gallon 110•tj
26 Septic nk V.
N 2d 1
110' x rn 7 A C�
FIN. FLR. • • ? ` .' . •. .. vp i
EL. - 112• A.C.. DRIVE ' , b rT
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N 90'00'00"E 167.19'
15 SITE PLAN
SCALE 1" = 40'
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Kiltir"AiPI `on An
LOT 7,- BLOCK 4, MUIRWOOD PARK
DESIGN FACTORS:
5 Bedroom House
Perc. Rate: 2 - 5 Min./Inch
Application Rate: 1.2 GPD/SF
SYSTEM REQUIREMENTS:
5' Wide Trench System
1,500 Gallon STEP Tank
4' Drain Field Rock
5 Bedrooms X 150 GPD/1.2 GPD/SF (Application Rate) = 625 SF of Absorption Area
625 SF/5 LF (Width)" .5 (Red. Factor) = 62.5 LF Trench Length
Therefore: Construct a 63' Long X 5' Wide Absorption Trench With a 4' Effective Depth.
Flow Line Elevation in Trench to be 3' Below Original Ground Surface. Total Depth to be 7'
Below Existing Ground. Maintain 10' Separation From Water Service Line on the Lot.
Place 2" of Direct Bury Insulation and 2' of Fill Over Absorption Trench or Provide
Minimum 3' of Cover to Prevent Freezing. Provide 4' of Cover Over Septic Tank.
2'6"
6"
4'0"
Natural
Backfill
.51011
Geotextile
Fabric
4" Perforated
PVC (ASTM 3034)
Drainfield
Rock
TYPICAL WIDE TRENCH SECTION
(NO SCALE)
NOTE: Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 4' Separation From Groundwater.
Minimum 100' From Wells in the Area.
Minimum 100' Separation From Surface Water or Streams.
�>}
, 49th ee //r ___1
"M rn
F, i. MICH. ANDERSON : •�
�C,/ff�.• NO. CE -4381 ••. jr�4,-7ff
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Municipality of Anchorage
Development Services Department/On-Site Water and Wastewater Program
4700 South Bragaw Street, Anchorage, AK 99516-6650
SOILS LOG - PERCOLATION TEST
Performed For: White Raven Development
Legal Description: Lot 7.Kincaid Park Subdivision
SLOPE
1® OG/PT North
2
3
4
+ 5
10
11
12
13
14
15
16
17
18
1
GSM
Was Groundwater
Encountered?
If Yes, What Depth?
Depth to Water
After Monitoring
Date:
SP
South
Date Performed: 1/21102
CITE PI AN
No S
L
O
None P
2/28102 E
Reading Date Gross
Time
Net
Time
Depth To
Water
Net
Drop
22 -Jan 2:06
5.25"
2:21
15
9.13"
3.88"
2:22
5.25"
Performed By: Alan Harala_ I; Michael E Anderson Certify That This Test
2:37
15
8.75"
3.5"
2:38
- ::Y !'�.•
5.38'
2:53
15
8.82"
3.44"
2:54
5.25"
3:14
15
8.69"
3.44"
M/
9
Bottom of
Hole �` "` Perc. Rate: 6 MinJlnch Perc. Hole Diameter:'8"
;.` Test Run Between 5 Ft. and 6 Ft.
1:;:
Comments: Test Cavity was Presoaked Prior to Test.
Performed By: Alan Harala_ I; Michael E Anderson Certify That This Test
Was Performed
In Accordance With All State and Miiri'icipal Guidelines In Effect On This Date:
312102' '
- ::Y !'�.•
.. 4� icy '.
ht ..' (
to r♦ J�'
Municipality of Anchorage
Development Services Department/On-Site Water and Wastewater Program
4700 South Bragaw Street, Anchorage, AK 99516-6650
SOILS LOG - PERCOLATION TEST
Performed For: White Raven Development Date Performed:
Legal Description: Int 7_ Kincaid Park Subdivision
SLOPE SITE PLAN
OG
1
GP/GM
TESTHOLE NO.4
4
Some
5 Cobbles
61 Clean
10
11
12
13
14
15
South
Was Groundwater
Encountered? No S
If Yes, What Depth? L
SPIGP Depth to Water O
After Monitoring None P
Date: 2128102 E
314" - 2"
Cobbles
Perc. Rate
< 5 Min./Inch
>51% Sand
18
Bottom of
19 Hole Perc. Rate: 2.7 Min./lnch Perc. Hole Diameter: 10"
Test Run Between 5 Ft. and 6 Ft.
Comments: Test Cavity was Presoaked Prior to Test.
Performed By: Alan Harala. I, Michael E_ Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 312102
ff J
. 49th
G:
j Wr� •. VC ALL E. ANDERS-ON W i
4o. CE -4381
• r ,
1/21/02
X52.82'
L= 9.33'
R=10.00
Z =32.18'..:
=50.00....
`Y 0, 1. .
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w TH
^? n-4
^ :
i 41s407 s.tt.: ' t3
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• O A G
O N
4.. -3
i N I
u,
t N90'00'00"E v
Reading Date Gross
Time
Net
Time
Depth To
Water
Net
Drop
22 -Jan 2:48
6"
3:03
15
.12"
6"
3:04
6"
3:14
10
10"
4"
3:15
6"
3:25
10
9.88"
3.88"
3:27
6"
3:37
10
9.81"
3.81"
If
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 7, BLOCK 4, MUIRWOOD PARK SUBDIVISION
GENERAL:
1. The scope of this project includes the procurement and placement of a
new 1,500 -gallon tank at the location shown on the site plan. Work
also includes the construction of a new absorption trench 63' long by
5' wide by 4' effective depth also at the location shown on the Site
Plan. The total depth of the trench will be 7' below existing ground and
the distribution pipe will be placed at 3' below the surface. All
components of the new absorption trench and septic tank must be
constructed a minimum of 100' from any surface water in the area and
10' from the water service line on the lot. A minimum of 4' of cover is
required over the septic tank and 3' over the absorption trench. In lieu
of cover 2" of direct bury insulation and 2' of cover may be placed.
2. Construction shall be in accordance with the approved site plan,
design drawings, Municipal Permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater
Disposal Regulations.
3. The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the
location of all lot lines.
4. Unless specifically agreed otherwise, the contractor shall be
responsible for final grading areas subsequently depressed from soil
settling. Property owner shall be responsible for revegetation of
affected areas unless specifically agreed otherwise.
5. Contractors installing wastewater disposal systems must be certified
by the Municipal Department of Health and Human Services for
system installations. Owners installing their own systems must receive
prior approval from D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
1. A new 1,500 -gallon septic tank must be procured from a certified
septic tank manufacturer if the existing tank is found to be defective.
2. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts for pumping
access.
3. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
4. All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct
burial insulation.
' Lot 7, Block 4, Muirwood Park
March 29, 2003
Page 2 of 3
6. A foundation cleanout shall be installed one to four feet from the
building foundation. Two cleanouts are required between the tank and
the drainfield.
7. Final grading over the tank shall be such that a positive slope exists
away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown on the
design. The bottom of the trench shall be within 2" of level.
2. Distribution piping must be placed level with perforations down atop a
level bed of drainfield rock. Rock should then be placed over the pipe
to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between the drainfield
rock and the natural soil backfill. •
4. Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated.
5. Contractor shall verify the septic tank and drainfield are a minimum
100' away from any private water wells in the area, 150' from a Class
"C" Well or 200' from any community well.
6. Direct bury insulation must be placed over the distribution system if
less than 3' of backfill depth is available. Finish grade over the trench
must be mounded to prevent settlement or depressions.
7. Grade area surrounding the absorption trench to drain away.
8. A minimum 2' of accepting soil is required below the drainfield rock for
a 5' wide trench. Contractor shall verify this condition prior to
placement of the rock. All pockets of unacceptable materials must be
removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a municipally approved septic
tank manufacturer.
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated
and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and
ASTM D2662 or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Fernco, or equal).
Lot 7, Block 4, Muirwood Park
March 29, 2003
Page 3 of 3
/
5. A p ermeable 9 eotextile fabric (Typar, Mirafi or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing
the #200 sieve.
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These
inspections must be conducted under the supervision of a professional
engineer registered in the State of Alaska. The first inspection must be
conducted after the excavation of trenches, beds or pits and before the
installation of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement of the
geotextile fabric, gravel, distribution piping, standpipes, cleanouts and
insulation. No backfill should be in place at the time of inspection.
Contractor and
notes for use nllprepaaing the rovide a certifieall
d asI buil of thle comple ed system.construction
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
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. 11.422.84 HAA# //ff D3o&oq
Expiration Date:
1. GENERAL INFORMATION
Complete legal descriptiori Lot 7, Block 4, Muirwood Park Subdivision
Location (site address or directions) Park West Circle
Current Property owner(s) Crown Pointe, Inc. Day phone 345.6277
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing.Address .
2-
P.O. Box 112313P.O. Box 112313 Anchora�e,AK 99511AK 99511
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
Five 5
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
❑
Individual On-site
❑
Individual Holding tank
❑
❑
Community On-site
❑
®
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (NAA) based only upon the representations given in paragraph 5 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 less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year foi 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 State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm Anderson Engineering Phone 522.7773
Address P 0 Box 240773 Anchorage AK 99524
Engineer's Printed Name Michael E. Anderson, P.E. Date 12/212003
4 .., W /i*
NICNA0. E. ANDERSON •;i r
5. DSD SIGNATURE
,��' NO. CE -381
Approved for _� bedrooms. ��,;5;.••
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments f ON-SITE
cc: • • "rr li�_1rf1:
WASTEWATER
S. o••
/1111)1111
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date:
(Rev. 12/00)
............ . . T .................... . _ - ., _� , .�_� ._........
it
Municipality of Anchorage .•.
• '"' Development Services Department ;{' } °;
O
Building Safety Division
On -Site Water & Wastewater Program
j 4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
j
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 7. Block 4, Muirwood Park Subdivision Parcel ID: 011.422.84
A. WELL DATA
Well type If A, B, or C provide PWSID # Well Log (Y/N)
Date completed _ Sanitary seal (Y/N) _ Wires properly protected (Y/N)
I„ 'I
Total idepth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. I ft
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Ii
Coliform colonies/100 ml. Nitrate mg./I.
Other bacteria colonies/100 ml.
Date of sample: " Collected by
B. SEPTIC/HOLDING TANK DATA
i
Tank Type/Material SepticlSteel
Date installed 61212003
Tank'size 1 1.500 gal. Number of Compartments 2
Cleanouts (YIN) Y
I.
Foundation cleanout (Y/N) Y r'', Depression over tank (Y/N) N
High water alarm (YIN) N
Date of pumping Pumper New Construction
I
C. ABSORPTION FIELD DATA
I
Date installed 6/212003 Soil rating (g.p.d./ft2 or ft2/bdrm)1.2 GPDISF System type 5' Wide Trench
Length 65.5 ft. ; Width 5 ft.
Gravel below pipe 4 ft.
Total depth 9 ft. Eff. absorption area 655 ft2 Monitoring
i
tube Y Depression over field N
Date of adequacy test Results (Pass/Fail)
For _ bedrooms
j Fluid'depth In absorption field before test _ in. Water added_ gal. j New depth_ in.
Elapsed Time: _ min. j ',Final fluid depth _ in.
Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) N
i
If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at _ in.
Datum
E. SEPARATION DISTANCES
Size in gallons
"Pump off" level at _ in
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
Septic tank/lift station on lot N/A On adjacent lots NIA
Absorption field on lot NIA On adjacent lots NIA
Public sewer main NIA Public sewer manhole/cleanout NIA
Sewer /septic service line NIA Holding tank NIA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5' Property line >5' Absorption field >5'
Water main >10' Water service line >10' Surface water >100'
Wells on adjacent lots >200'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
i
Property line >10' Building foundation >10' Water main >10'
Water Service line >10' Surface water >100' Driveway, parking/vehicle storage >5'
Curtain drain None Noted Wells on adjacent lots >200'
F. COMMENTS i
G. ENGINEERS CERTIFICATION ++`Q ,..• ♦ ♦♦
review of at I have determined through field inspections and :♦♦♦
certify ■ 49th
Municipal records that the above systems are in ■•••• �'
conformance with MOA HAA guidelines in effect on this date. i�..............
MICHAEL E.• ANDERSON,
Engineer's Printed Name Michael E. Anderson, P.E.♦� s'•., No. CE -4381
.•
Date 121212003 ♦♦♦♦���� •++
HAA Fee $ ''c3'I 5 Waiver Fee $
Date of Payment 17- 0�3 Date of Payment
Receipt Number Receipt Number
(Rev. 12100)
i
in.