HomeMy WebLinkAboutFYFE BLK F LT 19r
Municipality of Anchorage Page of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 n Anchorage, Alaska 99519-6650 ® Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: SW ci`6C (0-7 PIDNumber: ooq �73rS�"
Name: -
er
astewatstem: ❑ New ❑ U rade
� rig -
Address: c G
1i 20
_
.l, ABSORPTION FIEF®
Phone:
No. o-Ledrooms:
❑Dee plench ❑Shallow Trench D Bed ❑Mound ther
LEGAL DESCRIPTION
Soil Rating:
Total Depthfromoriginal de:
GPD/S . Ft.
Lot: ' Block: Subdivision:
Depth to pipe botto m original grade:
Gravel depth beneath p
Fes%
Ft
Ft.
Township:
Range: t
fv
Section:,,4
FiII added above origi grade:
Gravel length:
Ft.
Ft.
Number of lines: .'` 'stance between lines:
�,,�
ELL: L'T New _ Upgrade
Gravel width:
Ft.
Ft.
Classification (Private, A,B,C):
Total Depth:
Cased To:
Total absorption area:
Pipe material:
Ft.
Ft.
Ft.
Driller: /�
Dat Drill : //
_77
Static Water Level:
Installer:
Date insta
AUPI�
%b
� r Ft.
Yield:
Pump Set at: D
"T
Casing Height Above Ground:
_Z_
TA
GPM
Ft.
Ft.
SEPARATION DISTANCES
❑ Septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:
Awapa in gallons:
From
Tank
Field
Station
Tan
Sewer Lines
'«
Well
N
A
j IA-
� �
SD fi.,S..
; Material: Number t' ompartments:
�c
L.I STATIO
s�
Surface
Water
>too
Lot
Size in gallons: Manufac r:
Line
"Pump on" level at: "Pump off" level at: High r alarm at:
Foundation
. (
Curtain
N
Pump Make & Model lectrical Inspections performed by:
Drain
Remarks:
BENCH MARK
Location ' Description:
r-
\1 t tom.. 1.
s
XV,
Assumed Elevation:
E _111111
OF A
s ° D OJ
sc° if
o so es es° s acossa gee"na"" s
r -
-���
Inspections performed by: — Dates: 1 st�"
2nd �"l
� �' e fre A. Garn 5
Y o°• 4�
CE-7953 �z p
Department of Heal d lu n ervi1ces approval
ESSk
Reviewed and approved b . Date'
72-013 (Rev. 9/91) MOA 25
LOCATION OF WELL
BOROUGH
LOCATION/SKET
SUBDIVISION
t _
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
DIVISION OF MINING & WATER MGMT
WATER WELL RECORD
LOT BLOCK SECTION OTRS
WELL OWNER:
SECTION TOWNSHIP I RANGE
El N ❑ E MERIDIAN
El ❑W
DEPTHS MEASURED FROM:❑casing top ❑ground surface WELL DEPTH:
DATE OF COMPLETION
BOREHOLE DATA: Depth of hole: ,`, - ft
Material Type and Color
Depth Depth of casing- _ ft
From To
_ DEPTH TO STATIC WATER LEVEL:
'— — it below L\J, top of casing ❑ ground surface
Date: % /, /�
11
111
/ METHOD OF DRILLING: t air rotary ❑ cable tool
C ❑ other
USE OF WELL: t!�' domestic ❑ irrigation ❑ monitor
Ci public supply ❑ r tiler
CASING STICK-UP: y ft. Diam:� in. ft
Casing type:in. ft
WELL WELL INTAKE OPENING TYPE: open end ❑ screened
12— ❑ perforated ❑ open hole
Depths of openings: e to ft
SCREEN TYPE: Diam: in.
Slot/Mesh Size: Length: ft
GRAVEL PACK TYPE: _
Volurne used: Depth to top:
GROUT TYPE: Volume:
Depth: from ft to ft
age DEVELOPMENT METHOD:
rVice Duration: -52
PUMPING LEVEL AND YIELD:
ft after 5 hrs pumping "� gpm
WELL
DEPTH: _ ft Horsepower.
WELL DISINFECTED UPON COMPLETION? YES ❑ NO
CONTRACTOR INFORMATION: REMARKS:
Registe usiness Name���
,`�� ,�� _ PLEASE MAIL WHITE COPY OF LOG TO:
Ignature of Authorized Resprentative Date DNR/DIVISION OF MINING & WATER MGMT
3601 C St, Suite 800
t ANCHORAGE AK 99503-5935
Phone (907)26 i-8639, Fax (907)562-1384
M10911,41407
SEF 23
W'Urlicipa ity of
Dept; Healti & HL
.............................................. ........-_...... ............
SEP-23-96 MON 08:22 AM HULTOUIST CONSTRUCTION 907 345 5118
Aline rIllin � �
Enterprises t
Domestic— 00mmet'eial
t Pump & Water Systems
P. O. Box 110496 ob me Lo on
Anchorage, Alaska 99$11
(907) 345 - 0202
fonn", -
rV8arr
T
��',
PHONE `�cicn
DATE
TION AMOUNTL
QUANTITY DESCRIPTION
r✓y.f�
LABOR HOURS RATI AMOUNT TOTAL MATERIAL
w
TOTAL LABOR
-
WOWt GRDEFEp BY DATE 06Mp. TOTAL
tA80p
PAY THIS AMOUNT
�--°
Thank. You
SIGNATURE(I HBl by Acknpwi9dge that Satisfactory Corrnpletion of the Above Described Work)
TERMS: ACCOUNTS PAYABLE AT 10TH OF k10NTH FOLLOWING PURCHASE.
$01% fCE CHARGE AT RATE OF 1.5% PER MONTH WILL, BE CHARGED ON OVERDUE ACCOUNTS,
F- .
r
PAGE 1 OF 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 WELL SYSTEM PERMIT
PERMIT NUMBER:SW960167 DATE ISSUED: 7/05/96
DESIGN ENGINEER:ALASKA WATER & WASTEWATER SERVICES EXPIRATION DATE: 7/05/97
OWNER NAME:SHELTON EDWARD W & DONNA
OWNER ADDRESS:1720 E. 59TH AVE.
ANCHORAGE, AK 99507
PARCEL ID:00927354
LEGAL DESCRIPTION:
FYFE BLK F LT 19
LOT SIZE: 7500 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
WELL 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 (18AAC80).
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 SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
DATE IeI96"
DATE• 1
A\lla strut Water & Wastewater
8471 Brookridge Drive — Anchorage — Alaska 99504
Phone (907) 337-6179 — Fax (907) 338-3246
Consulting Engineers
June 28, 1996
Municipality of Anchorage
Dept. Health & Human Services
Division of Environmental Services
On -Site Services Section
P.O Box 196650
Anchorage, Alaska 99519-6650
Ref: Well Permit for Lot 19, Bk F, Fyfe S/D.
To whom it may concern:
o d0•e oeeeao e••ee eee .e
I i
Jeffrey A. ness
�• • l CE-7953
e e
e
��
R
The subject lot is currently undeveloped except for an undocumented well. The well was drilled
in 1991 without a permit. Upon doing the research necessary to get the well approved, I
discovered that it was too close to the sewer manhole located near the northeast corner of Lot 20,
Block F, Fyfe S/D. Because of this encroachment, and at the direction of DHHS, we are going to
decommission the old well, and drill a new one. Attached is the site plan for the new well. If you
have any questions, please contact me at 337-6179, or on my pager at 1-800-481-1162. Thank
you for your assistance.
Owner/Consultant
c.c. John Shelton
John Sheltonl.wps
9 i �O M FED 6C-- vF F—Y-1 s-n J Cz-
UJIF- U - —K -0
M a --.I k+- (-S---
.
o
o
E
AS
NEW WELL TO BE
j 65 FEET SOUTH OF
THE NORTH PROP
ERTY LINE, AND
105 FEET FROM THE
CENTER OF THE MH
NEAR THE NE CORNER
' OF LOT 20.
i
i
VACANT LOT o
SERVICE LINE
SHALL BE 25
FEET FROM
.WELL (MIN.) —
EXISTING
MANHOLE
7YSER
JWU
LTS i
o,
19 LOT 20 LOT 21
EXISTING WELL 70 BE
DEC❑MMISI❑NED B WELL
DRILLER, `
i
t
i
PROPOSED o VACANT L❑T CDVACA T LOT
HOUSE o '
i
150 EET ' .� 50.00 50,00 -'` 50.00
CENTER LINE o
WU ER AW
EAST FIFY NINTH AVE,
0
A.S�UILZ_ _
0
o SANITARY SEWER
EXISTING MANHOLE OF
NEW WELL FOR LOT 19, BLOCK F, FYFE S/D,
® OOoOO 0 eOeOOOO OO9°sO°° °
PREPARED FOR: J❑HN SHELT❑N
effrey A. Garness
® • CE-7953
PREPARED BY: ALASKA WATER & WASTEWATER SERVICES°•e°
®%'ORO0
DATE; 6/28/96 DRAWN; GARNESS SCALE: 1" = 30'�
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18 AAC 72.015 ENVIRONMENTAL CONSERVATION 18 AAC 72.015
TABLE A
NUNEAUM SEPARATION DISTANCES
BETWEEN SURFACE OR SUBSURFACE DRINKING WATER SOURCES
AND POTENTIAL SOURCES OF CONTAMINATION
[Measured horizontally in feet]
Potential Sources Type of Drinldng Water System
of Contamination
Class A & Class C Private
Class B Public Water Water
Public Water Systems Systems j
Systems
Wastewater treatment
worksa, wastewater
disposal systema,
s
privy, sewer manhole
and lift station, sewer
200 150 100�
cleanout
Community, sewer line,-
14.
Co/
holding tank a, other .
potential sources
of contamination'
200 (S/1G075
Private sewer line,
petroleum lines and
100 75 ,� 25
S
storage tanks`, and
drinking water treatment
wastesd
a Distance is measured from the nearest edge of the soil absorption system, seepage pit, septic tank,
holding tank, or privy to a drinking water source.
b Other potential sources of contamination include sanitary landfills, domestic animal and agricultural
wastes, and industrial discharge lines.
The minimum separation distances listed for petroleum storage tanks do not apply to propane, nor
to noncommercial puantities (less than 500 gallons) of petroleum products that are stored in above-
ground storage tanks or drums and are necessary for the operation and maintenance of pumps,
power generation systems, or heating systems associated with a potable water well or other potable
water source.. In this case, "petroleum products" refers to fuel and lubricants.
d Drinking water treatment wastes include the backwash water from filters and water softeners, and
reject water from reverse osmosis units.
5
Municipality of Anchorage.., `.
Development Services Department
Building Safety Division
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
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
HAA# QLtc
i/zgfr
Parcel I.D. 009-273-54
1. GENERAL INFORMATION
• Complete legal description
• Expiration Date:
FYFE SUBDIVI§ION; LOT 19, BLOCK F
Location (site address or directions)
Current Property owner(s)
. Mailing address
Lending agency
Mailing address
Real Estate Agent
.Mailing address
1661 E. 59TH AVENUE * ANCHORAGE,
AK * 99507
PATRICK ACOSTA Day phone AGENT
CARE OF AGENT
Day phone
STEVE LAROSA W/ DYNAMIC PRbPERTIESDay phone 261-7600
3111 C STREET * ANCHORAGE, AK * 99503
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
❑
•
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of 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 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 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. 1 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 ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name
Engineer's Comments:
JEFFREY A. GARNESS, P.E.
In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test and separation
distances measured 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. AKWWC, Inc. 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
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
Date i 1J 104,
OF A 00
o A�.........,
1 f A. Gcir�ress:'
7953 mt
• � tic°�G
Clf rofessio�_C11
d
Approved for bedrooms. lltttttY(((((OF
Disapproved. �V�QpO A�C'Sp
Conditional approval for bedrooms, with the fllowin ulat(oM-SITE
WATER AND ; m
VASIEWAIEFZ
PROGRAM
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
:�v�`(�j •. '• ('QI -
�J `
��j,,'YlCNT S
Manitenance Agreements
Supplemental Engineer's Reort
Other
By:/WF-_4\
Original Certificate Date: 1 Lv 0
U\�
(Rev. 12101)
Municipality of Anchorage
• '� Development Services Department
Building Safety Division
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
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: FYFE SUBDIVISION; LOT 19, BLOCK F
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A
Date completed 7/20/1990 Sanitary seal (Y/N) YES
Total depth 52 ft. Cased to 52 ft.
FROM WELL LOG
Date of test 7/20/1996
Static water level 21 ft.
Well production 5.0 a.0.M.
WATER SAMPLE RESULTS:
Coliform colonies/100 ml
Arsenic: N/A mg./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
.-TITBV
1O
r
Parcel ID: 009-273-54
Well Log (Y/N) YES
Wires properly protected (Y/N) YES
Casing height (above ground) 18+ in.
AT INSPECTION
1/13/2004
27 ft.
3.3
Nitrate U` / )mg./L. Other bacteria colonies/100 ml.
Date of sample: 1 /13/2004 Collected by: AKWWC, INC.
PUBLIC SEWER
Tank size gal. Number of Compartments
Foundation cleanout (Y/N) D ver 'tank
mping Pumper
C. ABSORPTION FIELD DATA PUBLIC SEWER
Date installed Soil rating (g.p.d./ftzor ftz/bdrm)_
Length ft. Width
Date installed
High water alarm (Y/N)
Total depth ft. Eff. absorption area ftZ Monitoring tub
Date of adequacy test Results P ail)
System type
Gravel below i ft.
Depression over field
For bedrooms
Fluid depth in absorption field before in. Water added gal. New depth in.
Elapsed Time: .n. Final fluid depth in.
ejuvenation treatment (past 12 mo.) (Y/N & type)
Absorption rate >= g.p.d.
If yes, give date
D. LIFT STATION
Date installed
Manhole/Ac
"Pump on" level at in. "Pump off" in. High water alarm level at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots 100'+
Absorption field on lot N/A On adjacent lots 100'+
Public sewer main 80' Public sewer manhole/cleanout 100'+
Sewer /septic service line 25' Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation Property line Absorption field
Water main Water service lin u ace water
Size in gallons
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: PUBLIC
Property line Building foundation Water main
Water service line Surface water . way, parking/vehicle storage
Wells on adjacent lots
F. COMMENTS
SEWER
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and T*Odp
review of Municipal records that the above systems are in .. ...........
conformance with MOA HAA guidelines in effect on this date. Q
.,.E .� ....... .........�
J ; r G ness. 0
Engineer's Pri ted✓ ame JEFFREY A. GARNESS �� ' E-7953
Date / I �QQedprofessiond���
HAA Fee $ �.� Waiver Fee $
Date of Payment � Date of Payment
Receipt Number Ins-% c ^� Receipt Number
(Rev. 12/01)
r
MUNICIPALITY OF ANCHORAGE NiCIPALITY OF ANCHORAGE
° DEPARTMENT OF HEALTH & HUMAN SERVICES _ ENTAL SERVICES DIVISION
Division of Environmental Services
On -Site Services Section SEP 23 1996
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744 RECEIVED
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 009 — -L-72 —S¢•'
1. GENERAL INFORMATION
HAA # _ )A 021(aLf--k\S
Complete legal description L i / Gi , g4 F) S`P
Location (site address or directions) '7-1-4- AVE
Property owner �pw fl ��'�"�� Sa��� ; Day phone -5-63- 3-445
Mailing address
Lending agency Day phone�-
Mailing address Al),
Agent Day phone 0-) f
Address �A
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:Li
3
3. TYPE OF WATER SUPPLY:
Individual well`s
Community well C `"
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to -the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on -site
Holding tank
Community on -site
Public sewer ic
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. 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 of this Health Authority Approval application 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 regulations in effect on the date of this inspection.
Alaska Water &
Name of Firm ater Servic Phone ! /
'� `�}31 Brool:t 8
Address nch., 99�. 4
Engineer's signature
6. DHHS SIGNATURE
Approved for
Disapproved.
3 bedrooms.
Conditional approval for
Additional Comments
M
a
Date
.® CF 14 �1
R953
>�� pROFESS���•�
bedrooms, with the following stipulations:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
MUNIti.irrAuI s �.er mjN(_rtUpAGE
ENI+IRONMlEN1ALSERVICES DIVISION
• Municipality of Anchorage SEP 23 1996
DEPARTMENT OF HEALTH & HUMAN SERVICES r,
Environmental Services Division CV
�
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: -e i vim F , y=--Y ir— S /D Parcel I.D.: ooc
A. WELL DATA
Well type 'PVT—' If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) `i F-- Date completed ` 1 I)_0 197L
Total depth ) Z Cased to Z Casing height (above ground)
Sanitary seal (Y/N) `i Wires properly protected (Y/N)�
FROM WELL LOG AT INSPECTION
Date of test —7
Static water level
Well production g.p.m. �" g.p.m.
WATER SAMPLE RESULTS:
Coliform J-J,
Nitrate q ki Other bacteria i
Date of sample: �//6 /�� Collected by:
B. SE C/HOLDING TANK DATA
Date installed
Foundation cleanout )
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Length Width
Effective absorption area _
Date of adequacy test
Fluid depth in
Tank size Number of Compartments Cleanouts (Y
Depression (Y/N)
Pumper
High water alarm (Y
Soil rating (g.p. 2 or drm)
Grav hicknes elow pipe
Tube present (Y,
Results (Pass/Fail)
System type
Total depth
Depression over field (Y/N)
eld before test (in.); Immediately after gal
Fluid depth �' (ins) Minutes later: Absorption rate =
Pere treatment (past 12 months) (Y/N)
If yes, give date
(in.):
ms
72-026 (Rev. 3/96)*
D. LIFT
Date installed
Manhole/Access (Y/N)
High water alarm level at*
E. SEPARATION DISTANCES
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot �-j �
Absorption field on lot 1,J lr
Public sewer main
So 1?E-=4crZ-0s-
Sewer /septic service line_
Size in gallons
"Pump off" level at*
On adjacent lots h'
On adjacent lots
Public sewer manhole/cleanout 3�
Lift station I -
SEPARATION
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation Property line Absorption field
Water main/service line �Suaer/drainage Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD �f�ITTO:
Property line
Surface water
Cu
F. ENGINEER'S CERTIFICATION
Building foun
n/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots
- OF Xq� -
I certify that I ha ter, 'ned t Fi field inspections and review of Municipal records, above t i1 5 are
in conforman - e with HA g�deline in effect on this date.�/ °°° e r
p=='
Signature /
i`
Engineer's Name / �J-#=f'=`i '� C45'-�/, e °° °°°°°�
of A. Garness �w
° o� E-7953
Date /20f�>i F� °•�r<Yv
HAA Fee $ L Z` Waiver Fee $
Date of Payment �l�Z� ! l.L Date of Payment
Receipt Number- "L 7�%G/ % o / Receipt Number
72-026 (Rev. 3/96)*
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