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HomeMy WebLinkAboutPTARMIGAN ROOST BLK 3 LT 5Ptarmigan Roost Lot 5 Block 3 #020-042-90 ---� - --MUNICIPALI MUNICIPALITY OF ANCHORAGE DET�MENT OF HEALTH AND HUMAN DEPT, OF HEALTH 6 - ENV, Df PROTECTION SERVES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ;r,r vk 2 2 ENV ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTIO Name Gene P. 5ry01e- DISTANCES;" Admess r FflOM TO SEPTIC ABSORPTION Aktt� TANK FIELD WELL `5 pnwon—I"`5.%�—'57^+' Permit No ND°er WL p /03 / Q �Tr'.tt/ 8 do 36-3 LEGAL OESCRianOM LOT LINE tiOIL f s -p —20 Lot Blocs SUINJ,Vt$iD0 ' �"' ��°Jt Townnbh,p. Range. Section FOUNDATION Sr Z O Gf T///V R3 ce- AS -BUILT DIAGRAM (Show IWabon of wen. sept¢ system, progeny lines. louncation TANKS driveway. water Oodles. etc) , IP SEPTIC ❑ HOLDING r, tib we I Manufacturer Capacity m gallons An<401- C /2Y0 Material S tee 1 No. of COmpanmenla TYPE OF SYSTEM - [X TRENCH ❑ BED ❑ W. DRAIN ❑ OTHER ^7 [hpth 10 pl�Whom Irom wq.nat graadede Total depth nom ony,nal gyne 00 FT Et'•D,, F,a auded aWve Ongmayladu FT Gravel depth bene"I PipeFT rd r' FT w Graver mny:n Gravel width 5-D FT 3 - 5- FT 101-1 absorption area I Distance bsiwem bites b�O SOFT FT co r Numtxr tit -nes Sud raring Pipe material SOFT c/ 303y FS/0 Insla,ler 4'>".9 (a Date mstalied _ A -y 26, 27 /y86 p WELLS des ❑PRIVATE ❑ OTHER (Identify) de»Lcalun 1A.a.L1 total Depth Cawd l0 J2 FT FT REMARKS: / 10 WPA' Inspections Performed by. ENGINEERS SEAL _A 1' t Cei�`��"— •�'Yl�� CMify Ilial Nis inspection was performed according To ell Municipal end Slal guidelines In fled on Nis date: Z7 4" kJ 70l i�ti•Y )� i �` '� fT /' Health Department Approval: Dale 72-019 (9,85) Sent By: ; 9073467767; May -26.00 15:04; �j Rj G C. i 7 Ail ! ai i K . � O ... i d ! d G C. i �. P..,•� i s 1 s •jI yy117 1�•' •tr. .L. W.' ..Y..; , k. � W.: W w l+.' 4. Page 212 F: i 7 i• 0: ! ai i 1 i ! i i ! ••! ... v -I ?i i �i.41 ►� 1. ! ji i i Hi tD1 . •� .1 1 i •r.i � ,;W. e.l=..e� Vii. •i, •! 1 i -' 1 = ! i �. P..,•� i s 1 s •jI yy117 1�•' •tr. .L. W.' ..Y..; , k. � W.: W w l+.' 4. Page 212 F: MU" I C I Too_ I TY 0f= ANCI-1J 1= -AGE •.� DEPARTMENT C HEALTH AND ENVIRONMENTAL . .OTECTION .�• 825 L STREET, ANCHORAGE, AY 99501 264-4720 ON—S I TE SEWE=F=; F 'I=QO0M PERMIT NO: 088030%86 Z%L /En9i.at�r dirrPeaTbn DATE ISSUED: ^^ 1 / APPLICANT: GENE P. HRYNER /����� of o.�, q,•.�0.� ADDRESS: 8200 KID RD. ANCHORAGE, AK 99507 CONTACT PHONE: 344-5807 LEGAL DESCRIP: SUBDIVISION: PTARMIGAN ROOST LOT: 5 BLOCK: 3 SECTION: 2 TOWNSHIP: 11N RANGE: 3W LOT SIZE: ,E!Q.6 (SQ.FT. OR ACRES) MAX BEDROOMS: 4 3 Listed below are the options available to you in designing your septic system_ - --- Choose the option that best fits Your site. - - - ' H'tEhlC1 1 -� laEDW _ DFZA I h1- - - DEPTH TO PIPE BOTTOM (FT.) 14:0' 4.0 4.0 GRAVEL DEPTH (FT.) tv.O: •' 0.5 TOTAL DEPTH (FT.) 3.5 GRAVEL WIDTH (FT.) X2."5 4.5 7,5 � 5.0 ,�.2 ' GRAVEL LENGTH (FT.) 22.0 .0:"O"1 41.o 65. 0 GRAVEL VOLUME (CU.YDS.) 30.1 33.5 48.22 TANK; SIZE (GALS) 1,250.0 1,250.0 ** 1,250.0 ** SOIL RATING (SQ.FT./BR) 150 150 150 a* TANK: MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - I certify that: 1. I am familiar with the requirements for on-site sewers 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 regulations, and in compliance with the design criteria of this permit. 3. I will adhere to all MDA 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. 4. I understand that this permit is valid for a maximum of 4 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST HE OBTAINED; (2) WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND ELECTRICAL WORE; MUST HE DONE BY A LICENSED ELECTRICIAN. SIGNED APPLICANT: ISSUED BY CODES, AS-BUILTS (3) THE DATE: 2� DATE:-8���-- hIuIV I C 7"•AIL I TY OF= AN CI 7FiAtsE DEPARTMENT uF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 ON—SITE BEWEFi a WELL- 'PEF--�M1_r �2 PERMIT N0: 860189 0 DATE ISSUEll: 06/23/86 Q o� APPLICANT: GENE P. BRYNER ADDRESS: 8200 KIP ANCHORAGE, A: 99507 COP41ACT PHONE: 344-5804 LEGAL DESCRIP: SUBDIVISION: PTARMIGAN ROOST LOT: 5 BLOCK: 2 SECTION: 2 TOWNSHIP: 11N RANGE: 3W LOT SIZE: 36978 (SQ.FT. OR ACRES) MAX BEDROOMS: 4 Listed below are the options available to you in designing your septic System. Choose the option that best fits your site. +� GRAVEL LENGTH ? 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) * TANS: MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I certify that: I. I am familiar with the requirements for on-site sewers 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 regulations, 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. 4. I understand that this permit is valid for a maximum of 4 bedrooms and any enlargement will require an additional permit. 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 WORT: MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED AF'F'L I CAt DATE: (0- f ISSUED BY A• -F/ DATE: TF2ENC1-1 33EIE) W _ 13FRA I N DEPTH TO PIPE BOTTOM (FT.) 4.5 5.0 4.5 GRAVEL DEPTH (FT.) 7.5 0.5 3,5 TOTAL DEPTH (FT.) 12.0 5.5 8,0 GRAVEL WIDTH (FT.) 2.5 24.0 5.0 GRAVEL LENGTH (FT.) 51.0 47.0 81.0 +ter GRAVEL VOLUME (CU.YDS.) 37.8 41.8 60.0 TANK SIZE (GALS) 1,250.0 *+r 1,250.0 1,250.0 +t SOIL RATING (SQ.FT./BR) 188 188 188 +� GRAVEL LENGTH ? 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) * TANS: MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I certify that: I. I am familiar with the requirements for on-site sewers 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 regulations, 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. 4. I understand that this permit is valid for a maximum of 4 bedrooms and any enlargement will require an additional permit. 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 WORT: MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED AF'F'L I CAt DATE: (0- f ISSUED BY A• -F/ DATE: ALASKA ENVIRONMENTAL CONTROL SERVIC INC. 12d0 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561.5040 JOB- T �•r/.R�ar( %'T C.S BHEET NO. r 1 OF CALCULATED BY DATE ..f --'y CHECKED BY ..... c am, JR -2251 .._-----'.D.a..l.'R:iTWI<[Bi� 1986 1`FF Tut i b<�..s J•:Ord . ._..__._. � _.—_.___.__.. i.__.:.___ Al/K• _. � k •oo 36J V76 .37 rF if Gu. /„ 66: wa-k ALASKA ENVIRONI)4ENTAL CONTROL SERVIC � INC. .1200 West 33rd Avenue Suite B ANCHORAGE, ALASKA 99503 Phone 561.5040 .IDB f�r<t.m .'�Yf1.—Loo,{f Gt S 8/or t BHEET NO. OF CALCULATED BY_p� DATE.A.A /3 /4e6 CHECKED BY / DATE SCALE •'+ YOYO i A Septa E. t3; i I , ry 1 I _ Cabs I i -T- I ' ! � i iE!C ef� " ,; , t - 1--- — —- - ; —--�--;_ rD Ufa _ n _io�rD•, t ;LI _. -_�.- __ _-' FIo•ASC I _._ . %jGP�ldplf?t__.3( ��f �fnef . -F moo• %�.S„' t M� I I i /p/r.Sl fe fD,t�.m __ i�Y ... ..��A _.�7ifryt� !•n !Vy �OJ_ ..__'i�fJ'�1'.�%fF /y %J �I�� OL.. /00•..7T•'M hF ._ _-_ ' __ .41•!•'l Y(—S7V,G� I 1 w s /oP /c? 3 - Y P/o i pp i° S, Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG - PERCOLATION TEST r PERFORMED FOR:__. 6"C Bryne— DATE LEGAL DESCRIPTION:. tvA. m' 3 Ls Township, Range, Section: 14 ML f, 14- is- 16- 17- 18- 19. 4 - 1516171819 20 z 7// SITE P'. w■■■■■■■mamummummm �■. ■am.■■.I■■m 10 WASGROUND WATER AO ■0\10m0.1 In- F. !, 1f• ENCOUNTERED? ■ommmmmimm■ 11 mo_■•-■m■om■ S ■■■.■.■■■■ IF YES, AT WHAT L 0 12 ■■m■■■..■■ DEPTH? P So I•^� and ll� E 13 .! rry kt Depth to Water Atter • 1 ! • ' y A -I F6 Monitoring? batt 14 ML f, 14- is- 16- 17- 18- 19. 4 - 1516171819 20 z 7// SITE P'. w■■■■■■■mamummummm �■. ■am.■■.I■■m ■0\10m0.1 In- F. !, mommmmommm ■ommmmmimm■ mo_■•-■m■om■ ■■■.■.■■■■ ■■m■■■..■■ PERCOLATION RATE (mmute5nnch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT COMMENTS -$'o� / 4-" .2 '/o /O t7 V%!Vo /fv f, -d ,�- /}'-p n PERFORMED BY: A -C- CC �6 02� I t� f�yC �L'E1ifIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT O THIS DATE. DATE: -/ Z �" 72-M (Rev. 4,115) J r . ��•�,UNICIPALITY OF ANCHORAGE n DEPARTMEN. OF HEALTH AND ENVIRONMENTAL PRO. _.;TION !e\ PERCOLATION • • TEST 4 625 L. 61,w* An home.. Alaska 99501 2644720 SOILS LOG - PERCOLATION TEST PERFORMED FOR1r/j\I yPy�I C�1W�/I� /�/�•�•� c' `I'yvC_' DATE PERFORMED: •+ LEGAL DESCRIPTION: 1 1 •. Ys11 Ir,(% 1 Rryy- 1 �`-'�-lI�I V10h /1Ci ---Is Lo 1 2 37 4, 5- 6- 7 6-7 e• • s: 10- 11 12 . 13 14 15 16 17 16 19 20 COMM OL V aM &,M brown10tal SraVel ! gravel n , dry es So ncLLk %�}y gavel • ew e5 cbrk,grey dry Cobbles Common WAS GROUNDWATER A ( ENCOUNTERED? IF YES. AT WHAT DEPTH??/ Reading DateGross Time Net Time Depth to Water Net Drop 630 43 9 3YN /o min 1.72 e21 fNz V'�I Bj VY7 m/ 2: VIP2(0 a /3D 3 /0:07 iu: oY 1.(.(. .20 /0:/y Om t/ I: QQ .12 _0 /40 lvo 1.71 .Ili PERCOLATION RATE G *VOW ••� .... . ........... M��� PERFORMED BY: TIF? -••w �I!Rr. .DATE:5411 _ • C. REID, [n/afei• .n o.•-. sfoK+� •• CE • 225) : Ar G�6�Sb lw l� t+' l ( a• jr r i '• .....••' 4 aQr fFs .�• D• [iwewS /t1 pIDIEiSICI� �,�•� Municipaidyg of Anchorage POU -_4 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNO WLES. MAYOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit #: 840357 January 31, 1985 TO: Permit Applicant SUBJECT: Lot 5 Block 3 Ptarmigan Roost Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as -built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Keith E. Bandt, SuP a visor Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 O" --'c I TE 1EWEFR *, LJEL-L F}EFZt-1 I -r- PERMIT PERMIT NO: 840357 DATE ISSUED: 05!18/84 APPLICANT: DONALD G. WOODRUFF ADDRESS: P 0 11-1665 ANCHORAGE, AK 99511 CONTACT PHONE: 345-6076 LEGAL DESCRIP: SUBDIVISION: PTARMIGAN ROOST LOT: 5 SECTION: 2 TOWNSHIP: 11N RANGE: 3W LOT SIZE: 36978 (SQ.FT. OR ACRES) LOT LOCATION: WINDSONG DR MAX BEDROOMS: 3 LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING SYSTEM. CHOOSE THE OPTION - - - - - - - - - - - - - THAT BEST FITS - - - - - - - - YOUR SITE. TFSEhFCH - - - - - - - - F3E0 ;DEPTH TO PIPE BOTTOM (FT.) 4.0 . 4.5 GRAVEL DEPTH (FT.) 9.5 0.5 TOTAL DEPTH (FT.) 13.5 5.0 r GRAVEL WIDTH (FT.) 2.5 21.0 GRAVEL LENGTH (FT.) 30.0 41.0 GRAVEL VOLUME (CU. YDS. ) 27.7 31.8 TANK SIZE (GALS) 10000.0 ** 1,000.0 SOIL RATING (SO. FT. /BR) 188 188 BLOCK: 3 YOUR SEPTIC - - W. E>FZR I IV 4.0 3.5 7.5 5.0 61.0 45.1 1, 000. 0 ** 188 *W TANK MUST HAVE AT LEAST TWO COMPARTMENTS - - - - - - - - - - - - --- - - - - - - - - - - - - - - - - - - - - - - - - - I CERTIFY THAT: I. I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS 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 MOR CODES AND REGULATIONS, 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. 4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 BEDROOMS AND .ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. 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 5 � �8 • � fL --�^ DATE: ------------------------------- APPLICANT: DONALD G.�WOODRUFF ISSUED BY ---- DATE: �� g ---- C�-� ------------ --'- --------- MUNICIPALITY OF ANCHORAGE �f \I DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED LEGAL DESC LI OL. v GM dArk Sra el GM Sa to s41h j gravel brmn dr Cobbles y GM Sand1 C ->M1 yaVe1 -dew co b\ es dork,grey dry So WAS GROUND WATER /` /^ L ENCOUNTERED? O Cobbles P comm,r��y� IF YES, AT WHAT E y) 1 DEPTH? Xv SOILS LOG 0 t),3 -r7 PERCOLATION TEST DATE PERFORMED: n1 V SITE Reading Date Gross Time Net Time Depth to Water Net Drop, t14,0 613093 9 3 1-9 3 9•y'l /o inin 1.'72 .2-1 yz0 �'3of�3 g: y7 2.Ou q: 67 / iwIn I.8m 2l0 /U m Lmb 20 N a 61(30�s3. /0:6v 2. 0!7 I.I li2 29 %Orrin "PZ0 /0.'30 Z. S & iolX193 7O :'70 /D i 1.91 . I y PERCOLATION RATE TEST RUN BETWEEN ❑' bcyl►-r�nm 1nP�„\APS, PERFORMED BY:. COI OW I &ate—s CERTIFIED 72-008 (6/79) FT FT DA 1045 MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH t£ HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 (907) 3434744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING Parcel l.D.# 020-042-90 1. GENERAL INFORMATION Complete legal description PTARMIGAN ROOST SA), LOT 5. BLOCK 3 Location (site address or•directions) 16001 WINDSONG DRIVE, ANCHORAGE AK. 99516 Property owner IFN AND ROSE MARIE HALE Day phone -345-6820 Mailing address 16001 WINDSONG DRIVE. ANCHORAGE AK. 99516 Lending agency Day phone Mailing address Agent DONNA ORR w/ PRUDENTIAL JACK WHITE Day phone (907) 240-7493 Address 4241 B STREET. ANCHORAGE AK. 99503 Unless otherwise requested, NAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well xxx Community well - Public water NOTE: IIf 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 xxx - Holding Tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC Ing to the legality and status of system. 72-025 (Rev.1191) Front MOA a21 Computer Vemlon Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $2090.00 at, or prior to, closing for the engineering services provided. 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, l 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 ori -site water supply and/or wastewater disposal system is in compliance with all Municipal d State codes, ordinances, and regulations in effect on the date of this Inspection. Name of Finn Engineer's Phone (907) 337-6179 In conducting this evaluation, AWWC, Inc. tt rode a thorough, conscientious engineering a6ysls of the system In accordance w8h ADE C and M A H 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 lite of all wells and septic systems depend on the local soils condition, ground water levels that may fluctuate during the year, and the usage of the famly being served by the system. These conditions are outside the control c the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nordo theyguarantee that there are no hidden defects or encroachments. AWWC, Inc. can therefore not provide any warranty for future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DHHS. 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. a 6. DHHS SIGNATURE Approved forbedrooms Disapproved Conditional approval for Additional Comments By:, bedrooms, with the following stipulations: Date ti-- 1'00 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 order to 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. 72-025 (Rev.1191) Back MOA R21 Computer Version Municipality of Anchorage DEPARTMENT OF HEALTH S HUMAN SERVICES Environmental Services Division 80 V Street, Rm 602 Anchorage, Alaska 99501 (907) 34311744 Health Authority Approval Checklist Legal Descrlptlon: PTARMIGAN ROOST S/D: LOT 5. BLOCK 3 Parcel I.D.: 020-042-90 A. WELL DATA • PER DHHS RECORDS REVIEW ON 5/3/00 •• PER 1993 FAA M Well Type PRIVATE B A. S. or C. attach ADEC letter. ADEC water system number N/A Log present (YQ4) YES Date completad 7/31/86 Total depth 60' Cased to 45' Casing height (above ground) 16' Sanitary seal (YIN) YES Wires properly protected (Y/N) YES FROM WELL LOG Date of test 7/31/86 Static water level 32' Weti production 3 a.p.m. WATER SAMPLE RESULTS: AT INSPECTION 4/14/2000 Courorm 0•0 Nitrate 04.07ma/L Other bacteria '•0 Date of sample: 4/18/00 k 4/25/00 Collected by: A.W.W.C., INC. S. SEPTiCIHOLDINO TANK DATA Date installed 8/26/86 Tank size 1250 Number of Compartments 2 Cleanouts (YIN) YES Foundation cleanout (YIN) YES Depression (YIN) NO High water alar (YIN) N/A Data of Pumping 4/14/2000 Pumper A+ HOME SERVICES C. ABSORPTION FIELD DATA 10 MT DOES NOT EXTEND TO BOTTOM OF TRENCH Date installed - • 27/86 Soil rating (g.p.dJR2 or »ffn 150 System type TRENCH Length 52' Width 3' Caravel thldmess below pipe 6' Total depth 12'+/- AT WT Effective absorption area, 600 $O FT Monitoring Tube present (Y/N)-UL Depresslon over field (YIN) NO Date of adequacy test 4/14/2000 Results (Pass/Fag) PASS For 3 Bedrooms Fluid depth in absorption field before test Ona; 07 Immediately atter 626 gal. water added (In.$ 10 Fluid depth 6.5 (aro) Minutes later. 250 Absorption rete . 450+ Perodde treatment (past 12 months) (Y/N) NONE KNOWN B yes, give date ----- 72.ONSm. 3WCwp rVerdan 0. LIFT STATION Date installed Stze Manhole/Access High water alarm E. SEPARATION DISTANCES level aC "Pump or level at' *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: SEE WAIVERREQUEST Septicfiotding tank on lot '98' On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent kits 100'+ Public sewer main NSA Public sewer manhole/deanout N/A Sewer/septic service One 25'+ Lift station N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5'+ Property line 5'+ Absorption field 5'+ Water maln/servlce line 100+ Surface water/drainage 100'+ Web on adjacent lots 100'+ SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: Property One 10'+ Building foundation 10'+ Water maiNservice line 10'+ Surface water 100'+ Driveway, parldngNehide storage area 10'+ Curtain drain NONE KNOWN Welts on s F. ENGINEER'S I Coro that / i Engineer's HAA Fee S Date of Payment Receipt Number r2 -M Pw• 7WeT CWwmr VGnbn lnspecM= and review ems are In Contbrmance Welver Fee Date of Payment Receipt Number LTA CT&E Environmental Services Inc. Laboratory Division 59 200 W. Potter Drive Drinking Nater Analysis Report for Total Colifonn Bacteria Anchorage. AK 99518-1605 Tel: (907) 562.2343 READ INSTRL'CTIO.VSONREVERSESIDEBEFORE COLLECTI.YGSAMPLE Fax- (907)561.5301 MUST BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY 13 PUBLIC WATER SYSTEM I.D. N LTJ DO PRIVATE WATER SYSTEM Send Results X/ Send Invoice .�., rYm .�., ..m•�r ..+ _01"ISUN1111ft MIR- \{. Y Ya. Ym r goal r1aparr Road 54 Anchorage. AK 99604 YY. w Yr a Send Results o Send Invoke oa.. m. Y,Wn, u A Yr SAMPLE DOTE: off] FEF5 Month Day Year SAMPLE TYPE: Analysis shows this Water SAMPLE to be: `i Sactory D Unsatisfactory D Sample over 30 hours old, results may be unreliable D Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received Analysis Began 151A5 Analytical Method: '-Membrane Filter o MMO-MUG Result* Analyst 1001?50 VRoutine D Treated Water o Repeat Sample (for routine sampleUntreated Water with lab ref. no. D Specha Purpose Time Collected SAMPLE LOCATION Collected By 2&�Mt �Lot & &&02_aw G�fs Comments: benllo A.U.&C. ® S1 L-- Anch Fbks Jun ❑ Faxed Date: Time: Client notified of unsatisfactory results: Phoned Date: BACTERIOLOGICAL WATER ANALYSIS RECORD N1M0-MUG Resah Total Coliform E. Coll Spoke with Time: Membrane Filter. Direct Count 0 Colonies/100 ml Verification: LTB BGB COLIFIRM Fecal Collform Confirmation Final Membrane Fllte esults _ Col/lfo�rfml/100 ml Reported By ate Time v v hrs r�M_a Member of the SGS Group (Sr ENVIRONMENTAL FACILITIES IN ALASKA. CALIFORNIA, FLORICA. ILLINOI12 ...' '-4 r6ndrals de Surveillance) Faxed TVTC-TM Neme 'To C"M oa -othv seeene "gOURI. NEW JERSEY. OHIO. WEST VIRGIUV 04-24-00 11:41 FROWaE ENVIRONIENTAL aG- CTLE Environmental Services Inc. CT&ERctw 1001646001 Clent Name AK Wats & Wastewater Consultants Inc Project Name/# ptarmigan Roost Lot 5 Bk 3 Client Sample ID Ptarmigan Roost Lot 5 Bk 3 Matrix Drmking Water Ordered By PWSiD 0 5615301 T-480 P.02/03 F -T65 Client POn Printed Date/time Collected Date/time Received Date/time Technical DirteWr 0424/2000 15:35 04/192000 16:00 04/192000 11:40 Stephen C. Ede ie� .4-� Alloratae Prop Analysis Parameter Results PDL Units Metnou Limits Dau Date Init UATERS DEPT mitrate•N MICRO LAB Total Coliform 4.07 0.500 ro/L EPA 300.0 30 OB. No Colt % cal/1001AL SM18 92228 .A�, `D w / - 1.4,E CD iry (410) 04/19/00 SCL 04/19/00 KAP Municipality ofAnehorage Department of Health and Human Services di -1h5 - 825 "L" Street Rick M1tystrom. P.O. Box 196650 Anchorage. Alaska 99519.6650 h avor hltp:'www a anchorage ak us June 2, 2000 Jeffrey Gayness Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, Suite 2-13 Anchorage, AK 99504 Subject: Waiver Request for Ptarmigan Roost, Lot 5, Block 3 Waiver Request #WR000023 Parcel ID #020-042-90 HA000176 Dear Mr. Gamess: Your request for a waiver of the required 100 feet horizontal separation from the septic tank to private well has been approved. The approved separation distance is 98.6 feet. This waiver approval applies to the existing septic tank to private well separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely, Ate-4uV Daniel J. Roth Civil Engineer On -Site Water Quality Program MUNICIPALITY OF ANCHORAGE Department of Health & Human Services On.Slte Services Waiver Review Worksheet WR#: WR000023 PID#: 020-042-90 HAM HA000176 Permit#: Date Received: May 4, 2000 Legal Description: Ptarmigan Roost, Lot 5, Block 3 Engineer. Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, Suite 2-B, Anchorage, AK 99504 Applicant: Steven & Rose Marie Hale .......... Waiver Requested: 98.65 foot waiver from the well to the septic tank Criteria: 1. Geology Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: 2. Special Conditions: 3. Other. Waiver is Granted: X •••••••••• Waiver is not Granted: List Conditions or Reasons for above: �s E F_ R 27-A r UbV Date: 5--2¢ -00 By: jAAZ .......... Name of Reviewer Rec#: 06711 Amount: $625.00 Date Paid: May 4, 2000 4 , t I WAIVER RV4MXSr FOR Lor r Bloc, IIwAIVER REQu,ESr VUMVEIP WR000023 k WAIVER 1QE4 57 FOR ON -LST WELL rO 7'pAW OE' 90. 6S' EEEr 5 F- P7/ L r.#VAe - TWE st Pr/c TAmk wA t Covfrmftemp /w ALI /hmir DP / 9L9C. TNIf $for WWW rA/vkC is COw17RwLTED L trH /wvs/tr1 NtLOSP ry 7IIE rnwk Rr r/IE /Aoic; xxx ncoOLarLtr- pjf"0/u71Ow MAwMk£ Co✓zI r % (cst m v6Arf LII-IL1290 („Ars -ry R _rvd T/bNr fowpL►wbS TD C*Aooecr 41" Pvc P/Psro TKE rm...Ir. oea rvnry rvrvry (W W q TER V ELL - rm.c IvmrER &,SLL /.v iv.IEi71o.v Dots NOr Nwr A IvELL , &. 77IE,PE ARE /VLIM6R6u.1 WELL Lo6S OM Lort, THESE &.ELL Lobs /wPICArZ T144T BEORatk 1$ PRF✓A/16A4. /,v rme AREA APPpox/H.lrstr AT '-30 f6ET yDEP. w4rEl¢ SAmPLEf F)PuM THE WELL /.v QuilripAv lweilOrf r/IA+r NO /Aerie ARE Pn ESFwr Aro NITK/►7Ef 4,er 4.07^.*A, rHE A.Iraprs lfviL IAO rMf Iworc.►r6S rAe*r TjI/tNIrO..rE IN 7vi1 ..LOLL 11 P/►CK6KsK�>' A//r/R/y7r AMG /1 40t7 LA'rl-r AYor BE/E+L. Ccv7R/B4 r0 OY rHE SfAric TMrK /w. Q u A: rrf 0A,,, I W.9 TER TROLE TpwK 8'asri — 3o sr r. 04..'. 2Z' 7 = r x=.7i*2 2.7 W W W SC,L SORDT/o�" NNN ry SANoY &movrL to aae �iQatlANt? SNKF.4CE 7 C B or. are. aaa �� P�nxFae��,ry w p TER THOLE &R -4016v7' —S % P. 2.o �oR�zowr�� senaRg.r,a,v 98. s' _ •. 3 6aaNp rorpt /2.4F CoutLus,ov As &AY .4 ml##NgL w otu oca •r. /. r '�o of rye of Equ #Aro too -tier sr^4m*; 1f 80 -WO /90Ua k'4r#A %*AJ*lES 444 Aelf4rA049 AS.O 'r 14C, 9wCRVACK•4Gv7 Has fx,Sr•o Polo/S'YEAQl... 6tRgN7, &-.glwrR. ALASKA WATER E7, WAST'EWA rJt:�ii CONSULTANTS, INC. May 3, 2000 Municipality of Anchorage Department of Health & Human Services Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 Attention: Mr. Dan Roth Ref: Waiver Request for Well Separation to Septic Tank for HAA Ptarmigan Roost SID, Lot 5, Block 3 WELL AND SEPTIC TESTING: The existing referenced 3 bedroom house is served by a private well and septic system. On April 14, 2000, we performed a well flow test and a septic adequacy test at the subject property. As per MOA records, the septic system consists of a 1250 gal tank and a 50 ft long deep trench -type drainfield, both installed in August 1986. A total of 626 gallons of water were introduced into the cleanout in the drainfield, which was completely absorbed within 250 minutes. During the well flow test, the well produced an average of 5.4 gallons over 115 minutes. These results are sufficient for a 3 bedroom house. WAIVER REQUEST: The well on the subject property is located 98.65 ft from the septic tank on the property, when measured edge to edge. This distance was measured with a Topcon GPT -1003 surveying instrument. Measurements on previous HAAs indicated a distance of 101 ft and 103 ft, but were probably in error due to the fact that there are several trees between the septic tank and the well and the terrain is not flat, making it difficult to measure with a tape. Measurements could also have been made from center to center, rather than edge to edge. Attached are a site plan, a detail drawing, and a topography site plan showing the encroachment. As can be seen on the detail drawing, the septic tank encroaches upon the well's 100 ft protective radius. We request that your department issue a 96 foot separation distance waiver from the well to the septic tank. Justification for the waiver is as follows: The location of the septic system is in a very visible area (uphill from the driveway) so that if any effluent were to surface, it would be noticed and the problem corrected. Recent well water samples indicated that no bacteria was found, and the nitrate levels were 4.0 mgA, which is less than the maximum allowable of 10 mgA (see attached results). The well on the subject property is 60 feet deep. There was no well log in the MOA hard files. Therefore, we are proposing to base our evaluation on surrounding well logs. 6901 Debarr Road, Suite 213— Anchorage, AK 99504 — Ph: (907)337-6179 — Fax: (907)338-3246 Attached are the well logs for the following lots in Ptarmigan Roost S/D: Lot 7, Bk 3; Lot 2, Bk 1; Lot 11, Bk 2; Lot 10, Bk 2: Bedrock was encountered in these wells between 9 feet and 33 feet. Silty gravel appeared to be the predominant soil over the bedrock. Based upon the recent water sample results, it appears that the aquifer has been moderately impacted by nitrates; however, it is reasonable to assume that there is minimal additional risk to the aquifer associated with granting the subject waiver (2% reduction in separation distance). With the granting of this waiver, we also request that you issue a Health Authority Approval. If you have any questions, please contact meat 337-6179. Thank you for your assistance. M.S. 6901 Debarr Road, Suite 213 — Anchorage, AK 99504 — Ph: (907)337-6179 — Fax: (907)338-3246 i I LOT 8A. I GOLDENVIEW HEIGHTS S/D I VOA IW > I 1 I I� O— — — — -------------- MID S2. S 1/2, S 1/2. N 1/2. ICD --------------- NW I 4, SECTION 2, T11N, R3W ZO --------------------- r N I 1 LOT ec. ° j GOLDENVIEW HEIGHTS S/D I3 � I 1 i / -------- I — ------------------- LOT 1, BLOCK 1; PTARMIGAN ROOST S/DLOT EXISTING j PTARMIGANBBLOCK ROOST 5/D SEPTIC EXISTING 3 BEDROOM '!1 / / HOUSELOT 4. BLOCK 3; / / I Qom• PTARMIGAN ROOST S/D �G /• ���•/• I / 3: �• LOT 6, BLOCK 1 / PTARMIGAN ROOST S/D OfLLI Qe� LOT 4, BLOCK 2: �� EL Q LOT 4, BLOCK 3: PTARMIGAN ROOST S/D PTARMIGAN ROOST S, LOT 3. BLOCK 3: NI PTARMIGAN ROOST S/D DATE.4/21/2000 DRAWN BY: M. ALASKA «TATER & WASTEWATER CONSULTANTS. INC. SCALE:J•L — 100 """'• • /. .•... 6901 DEBARK ROAD, ELITE Ire • ANCHORAGE. AK 9950. • "M9071337-0179' FAX (9072338-]266 PAGE NUMBER: PREPARED FOR PHONE NUMBER: MARIE HALE 345-6820 1 OF 2 „„ .. „.,,, �, f re Gamess; STEVEN & ROSE yl�, ai •, C 7953 LEGAL DESCRIPTION: PTARMIGAN ROOST S/D; LOT 5, BLOCK 3, F, ��� o e' ••.,,,...• ' �o��> v'y7y�v TYPE OF WORK: SITE PLAN FOR WAIVER REQUEST hfossxo(, i W � z 100' WELL RA IUS _Z CALAS KA RATER & WASTEWATER CONSULTANTS. INC. 5901 OFSARR RDAD SUTF 29 • ANCHORAGe AK 9950. • FHONe (901)331-0119' F" (901)535-526 REPARED FOR: PHONE NUMBER. STEVEN & ROSE MARIE HALE 345-6820 EGAL DESCRIPTION: PTARMIGAN ROOST S/D; LOT 5. BLOCK 3. YPE OF WORK: WAIVER REQUEST DRAWING -\\L__-__ II SEPTIC TANK TRENCH TYPI PASSED ADE ON APRIL 4/21/200 AWN BY: J.L.M. ALE: 1"=30' GE NUMBER: 2 OF 2 EM. / ALLON EEP / ELD. ST / �r...: A.� Gamess; 7953 F ..... ' •co4o e W � z 100' WELL RA IUS _Z CALAS KA RATER & WASTEWATER CONSULTANTS. INC. 5901 OFSARR RDAD SUTF 29 • ANCHORAGe AK 9950. • FHONe (901)331-0119' F" (901)535-526 REPARED FOR: PHONE NUMBER. STEVEN & ROSE MARIE HALE 345-6820 EGAL DESCRIPTION: PTARMIGAN ROOST S/D; LOT 5. BLOCK 3. YPE OF WORK: WAIVER REQUEST DRAWING -\\L__-__ II SEPTIC TANK TRENCH TYPI PASSED ADE ON APRIL 4/21/200 AWN BY: J.L.M. ALE: 1"=30' GE NUMBER: 2 OF 2 EM. / ALLON EEP / ELD. ST / �r...: A.� Gamess; 7953 F ..... ' •co4o e �IIVD"�1,4G DRIVE R,?g327' o o. urnr Y � LASCIIEN( (ae' ' I p fp �O.p 4 iN. '' •' 4 Q O zo w lao r mLA 0 ID co to o C) *� tio: o Q z g ISI. c I=1 \r Iml \ mI J � z No S?9beGT2i \ N .)p, f;q rn \\ I I o 04 •�^�p��4��t r0 Ari Nhl %A;3 . :_.Ar MUNICIPALITY OF ANCHORAGE !T/ DEPARTMENT OF HEALTH & HUMAN SERVICES O Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION �� t g Complete legal description HAA # VAQC 3 Location (site address or directions) 16001 WindfQr,q T%r. Property owner Di17r]� Day phone 3 41s_1116 8 Mailing address {�• 0. f3o)c 113023 , &AC rayt- 9R5/l Lending agency' Day phone Mailing Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well —�- Community well 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 x Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-02S (A.. 1191) Pont MOA 021 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. Name of Firm/ PoArcdnSu0T Phone Z5$- Z'/ZO Address 1503 'W, 33,' ,e - Engineers signature ��t "y1. Date 815, r �: p9Ttj r A NI.•°•�)�00000000 /J .fn A // J iN.i.1YN....N..• Wilt V. ALWAM CE -13N _, 6. DHHS SIGNATURE _)C_ Approved for �_ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: J04$4 L IT=i- Date L9A7/Tj 111TIC 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 order to 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. 72M(RW7/91) B.k MOAN21 Municipality of Anchorage a ARL Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lf 5, Blk. 3, P�Armhla4, )ZwdParcelI.D. D'Z'O �DVy-90 A. WELL DATA Well type 1 V4+V' If A. B, or C, attach ADEC letter. ADEC water system number N Date completed 9113119 ✓�% W/�/QmS Log present (Y/N) � Driller Q u O Total depth 61D Cased to 60 Casing height / Sanitary seat (Y/N) N Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION MUNICIPALITY OF ANCHORAGE /,j /9 3 ENVIRONMENTAL SERVICES DIVISION Date of test /O v 1993 ... 32' Zo. Y`' AUG '1%1 Static water level 3 �� F Well flow 3 g.p.m. RK E I V`I E D Pump level Unkncwa (/nkn.wn 1-7 SEPARATION DISTANCES FROM WELL TO: /00r i Septic/holding tank on lot /01 ; On adjacent lots Absorption field on lot l03 ; On adjacent lots / 00 Public sewer main NZA ^ ' btic sewer manhole/cleanout Public sewer service line /1��/ t Petroleum tank Al WATER SAMPLE RESULTS: Coliform )JAYIP Nitrate 3.8 Other bacteria Date of sample: 6X3 4 3 Collected by: /gA&V ) B. SEPTIC/HOLDING pTANK DATA Z Date installed oZ2 A.1 Tank size 1250 9u�� Compartments Cleanouts (Y/N) �- Foundation cleanout (Y/N) Y Depression (Y/N) N High water alarm (Y/N) / N/%} Alarm tested (Y/N) N/� Date of pumping , _ 92 �� SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: s Well on lot /0% ' On adjacent lots /00 Foundation To property line t Absorption I ield 5 Water main/service line 41 �v�A Surface water/drainage NIA CONTINUED ON BACK PAGE 72-M IRW. 2191) Front MOA 21 I- C. LIFT STATION ,t' /� Date Installed IV1 Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off' level at = High water alarm level Cycles tested _ Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots — Surface water _ D. ABSORPTION FIELD DATA 8/z/8G z Date installed Soil rating 150 System ren r t Y type Length 52 Width • 3' ` Gravel thicknessy ' Total depth /0 r Total absorption area 0 ,5t. t r Cleanouts present (Y/N) Y Depression over field (Y/N) _N Date of adequacy test 813113 Results (pass/fail) 0-5S �/ mC for bedrooms Nv w�fd+ t� a{{er (tS . Peroxide treatment T (past 12 months) (Y/N) N If yes, give date _ SEPARATION DISTANCE.FROM ABSORPTION FIELD TO: 1 r ' Well on lot 10 3 n —On adjacent lots Propertyline Sof To building foundation / To existing or abandoned system on lot iV�v4 Onadjacentlots—��� Cutbank N/`Watermain/service line—/VIA Surface waterDr Curtain drain / � `NSA iveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION /certify that/ have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. SignatureC�. • J/�t2tn� j�Q,� • ;stt' Engineer's Name EaK% TTi1rrnetvt «:...:99AUSMAN Date4AVeCE 13 HAA Fee $ —11 O , 00 Waiver Fee: $ Date of Payment B-11-96 Date of Payment Receipt Number 02. 6 Receipt Number 72-M (ROY. 3/91) Seek MOA 21