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Home My WebLink AboutPTARMIGAN ROOST BLK 3 LT 6Pta .migan Roost Block 3 Lot 6 #020-042-8§ Municipality of Anchorage Department of Health and Human Services Division of Environmental Se~ices On-Site Services Section 825'L' $~eet Room 502 P.O. Box $96650 Anchorage. AK 995t9-6650 Page www.cl, anchorage.ak.us (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL iNSPECTION REPORT Permit Number:. _'E-.-.-.-.-.-.-.-.=~_~ ~ p_"SU et~ PID Number:. 0~-~ - C~H~ - ~' ~'-- Name Wastewate, Syste. ; .ew ~. ABSORPTION FIELD LEGAL DESCRIPTION s~..~. /' 9-- c~,' Well: ~[~.New [] Upgrade c..,~,.~.~: ~..O ~,. ~ ~.'t~.o.,~ ~, 'p_,~ ~, TANK SEPARATION DISTANCES ~,sept~ I-I Holding I-I S.T.E.P. I"1 Other:. Septic Absorption Lift H~ding %l~ic/P~i~ale Tank Field Station Tank Sewer Line ,~ ~ e' ~ '1~ ~'t~ ~ :,i' Engine_e/,'~..SJamp ,.--~.~,-..' . · .~ ,.cZ h . Department of Health and Human Servmes approval Reviewedandappr°vedby:~/~/~ ~" ~ Date: Z// .2~,.~ (... ,.,.) _ , Permit No. SW990368 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage. Alaska 99519-6650 Telephone: ,343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: LOT 6, BLOCK 3, PTARMIGAN ROOST SUB. PID No.: 020-042-85 GRND. PiPE MARK IA B [LEV J ELEV, co, ,8.,. 19., 19,.8d9 C02 31.5' 19.8'196.65191.65' TCm 33.2' b2.' J 96.75~ TC02 270' 1177, 196851 C03 26.1; /19;8' J96;65~90.85~ C04 47.0. 131.5' 194.35190.6'/ MT1 39.7. 137.0' [94.75~ co5 4zo 1s9.4· /~/~co~ /I .' ~ '. ~ ASBUILT , SC,L~ ~=~o '. Municipality of Anchor. age Department of Health and Human Services 825 'L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 t~'ck Mystrora htr p:l/www,ci.a nchorage.ak, us Mayor Permit Number: #SW 990368 Date oflssue: 9-30-99 Date Started: 10-8-99 Date Completed: I0-8-99 Legal Description: Property Owner Name & Address: Boreholc Data: Soil Type, Thickness & Water Strata Ptarmiqan Roost BIk 3 It 8 Gary Drew c/o Mike Anderson 14250 Goldenview Dr Depth (ft) From To Stick-up 0 2 gravelly silt 2 22 bedrock 22 277 RECEIVED APR 17 000 D Mun.~Clpatity Ot Anchor ept. Health ~ w ..... age -, mm~n ~orVIcO$ Parcel Identification Number: 020-042.85 Is well located at approved permit location? [] Yes [] No Anchorage, Ak gg516 Method of Drilling [] air rotary [] cable tool Casing type: steel' Wall Thickness: .250 inches Diameter: _~ inches Depth: 28 feet Liner Type: Diameter: inches Depth: ~ Casing stiekup above ground: _~ feet feet Static water level (from ground level): 18 feet Pumping level: 277 feet after ~ hours pumping _~ gpm Recovery Rate: _~ gpm Method of Testing: Airlift Well Intake Opening Type: [] Open End [] Open Hole [] Screened Start ~ feet Stopped [] Perforations Start feet Stopped feet feet Grout Type: bentonite # 8 Volume: ! bg Depth: Start feet Stopped feet Pump: Intake Depth feet Pump size ~ hp Brand Name Well Disinfected Upon Completion? [] Yes [] No Method of Disinfection: Clorine Tablets Comments: Well Driller: Alpine Ddlling & Enteqodses P.O. Box 110496 Anchorage AK gg51. 1 Attention: The well driller shall provide a well log to the property owner within 30 days of completion and thc property MUNICIPALITY OF ANCHORAGE Department of Health and Human Sen/ices On-Site Services Program 825 L Street. Room 502 P.O. Box 196650, Anchorage. AK 99519-6650 (907) 343-4744 to, ,qc) ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Date Issued: Sep 30, 1999 Expiration Date: Sep 29, 2000 Permit Number: SW990368 Legal Description: PTARMIGAN ROOST BLK 3 LT 6 Design Engineer:. 0088 Anderson Construction & Eng'g Owner Name: Gary Drew Owner Address: c/o Mike N. Anderson Anchorage, AK 99516- Pamel ID: 020-042-85 Site Address: 016321 SANDPIPER DR Lot Size: 36419 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: [] Disposal Field [] SepticTank [] Holding Tank [] Privy [] Private Well [] Water Storage 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 Ddnking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to Apd115, 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: Michael N. Anderson, P.E. 14250 Goldenview Dr. Anchorage, Alaska 99516 Ph 345-3377 Fax 345-1391 Date September 17, 1999 Municipality of Anchorage Department of Health and Human Services On-site Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Subject: Ptarmigan Roost Subd. Lot 6 B 3 To Whom it may concern: This a request for a new four bedroom septic system and well permit on the above lot. One test hole was excavated on the southwest property line, another test hole was excavated by someone else on the north side but this was in a shallow hole therefore it was not considered. The soils were gray sandy gravel with no water observed during excavation but this changed at~er the 7 day monitoring period with water at 12 feet. The perc rate was 1.5 minute per inch which translates into a trench length of 50 feet with 4 feet affective depth using a 5 wide trench. No surface water was found and the lot slopes away to the south west. This new system will not prevent future wastewater and well development on the adjoining lots. The lot directly to the west is being cleared for a possible home site but no pert hole yet. The existing systems on the surrounding lots appear to be performing adequately. Please feel free to call with any questions concerning this system at 345-3377. Michael N. Anderson, P.E. VACANT / / / / .' / / / / '-. / / / VACANT // ../ ~__ / / / / / / / / / / .f250 /GALLONG ii ..1~ //DOUBLE ii .1'~11 / / / / / / / / / / / / /' / / / / \ \ / I11 ' ~ , / / '-, -'C.O. ,,.,- , SYSTEM SEPT~ DESIGN PREPARED FOR GARY DREW LOT 6, BLOCK 3 PTARMIGAN ROOST SUBDIVISION PREPARED BY MICHAEL N. ANDERSON, P.E. 14250 N. GOLDENVIEW DRIVE (907) 545-3377 / FAX (907) .345-1391 SCALE: 1"=30' SEPTEMBER 17. 1999 'DESIGN CRITERIN // / ADJAC~NT 100' / \ 4 BDRM - 600 GPD / ./~-./ WELL~[~ADIUS SOILS = 1.2 GPD/SQ. FT. )~.""/ ,/\ ~oo/~.2 = ~oo s~. ~..~Q'~ ~..'/ 'X / // .. ,/ ~ENCH: ~" - X ,- ~.0'_ DEEP ~ ./ ,/ ". ,' 4' E~q~ VACANT ~." / x ,, ~ ~ m~ ~.o. ~,o~ - ~..',, "~ ,,' /~ /~TEST HOLE (TH) '.(0~ , / // /~0' ~US I'..¢' ~,.:~ / . ~ x.% w~,mT / .'~ / ~ TEST ....... ~.~/ / ~ X~%~y~ ~Y ~,ERS "x ' ~,'~' / ~'~ 7 ~..~Z. / ~ L..---~c ...... .. '. ~L- / ,/,' -~ ~ A' , '-:X / . ~ ...... · ' -" ',/¢' /Z~' / ~ ~ % ".-%%' -~/', / /' ,' ./ /'-, ¢' /" / % ~ % .-t~,t ~,' ', . ..-' - - -,'x ~-" -" / ~ ~ ~ -.'<';" ~ WELL RADIUS~ ~, ~ '~ ~ ~ / ,, ~. ,, -./ / , / / ' ~-~ GARY DREW LOT 6, BLOCK 3 ~. PTARMIGAN ROOST SUBDIVISION PREPARED BY ......... ~'~ ~:~~'.. MICHAEL N. ANDERSON. P.E. ~ . ' 14250 N. GOLDENVIEW DRIVE (g07) 345-3377 / FAX (907) 345-1391 ~-~'' ~/~ .'~'~ SCALE: 1"=50' SEPTEMBER 17. 1999 PERFORMED FOR: LEGAL DESCRIPTION: 2 3 4, 5- 6- 7- 8- 9- 10- 11- 12- 14- 15-. 16- 17- 18- 19- 20- Municipality el Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 'L' Street, Anchorage, Alaska 99502.0650 SOILS LOG --- PERCOLATION TEST WAS GROUND WATER ENCOUNTERED? I'~( (~) SLOPE SITE PLAN IF YES. AT WHAT DEPTH? E OeKa t~ ww~ Nter ~ ! PERCOLATION RATE /J~' Immutes.',.'~,c.i PERC HOLE DIAMETER TEST RUN BETWEEN ET ANO. Fl' :OMMENTS PERFORMED oY; hi,· k. ,' ( ,~ .~ ..,-,,~ , CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DAT~ ~/~ 4 ~ ~ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 i~ 5~t Anchorage, AK 99519-6650 , www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. GENERAL INFORMATION Complete legal description Location (site address) Current Properly owner(s) f~ COSA# C Expiration Date:_ Day phone /O Mailing address Lending agency Day phone Mailing address Real Estate Agent · Mailing .Address UnleS~ Otherwise requested, ~:'' ~OSA will be held by DSD f:o/~pickup. 2. NUMBEROF BEDROOM, S: Day phone 3.. TYPE OF WATER suPPLY: Individual Water Storage [] Community Class __ Well [] Public Water System [] TYPE OF WASTEWATER DISPOSAL: Individual On-site [~ Individual Holding Tank [] Community On-site [] Public SeWer 1'-] l I II The Municipality of Anchorage Development Services Depadment (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 System's Approval are required for the transfer of title (except' between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site SYstems Approval are valid for 90 days from the date of issue for properties served by a private or class c well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER Engineer's Printed Name I'"'[; jo~ ~~~l P.. ~'-; As certified by my seal affixed hereto and as of the validation date shown beloW, I verify that my. investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the~nfo/m~ation obt~ine~.from the Municipality of Anchorage files and from my investigation and inspection the sup~¥and/or wastewater disposal system is(are) in compliance with all applicable Municipal and Stat~ ~?o~d~ances, and regulations in effect at the time of installation. . · ' Phone ~ ? $ -- .5. DSD SIGNATURE {/~ Approved for Disapproved.. bedrooms. Conditional approval for bedrooms, with the following stipulations: Attachments:. COSA Checklist Septic System Advisory Well .Flow Advisory Nitrate Advisory (Rev. 11105) X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: ~ - '~ 0 ~' / F.~ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: A. WELL DATA Well type ~r; Date completed CO[~ Total depth, ~77 ft. Parcel ID: O ~ ~'~ - ~ IfA, B, or C provide PWSID #~ Sanitary seal (Y/N) _Y_ Cased to ~'~ ft. Well Log (Y/N). {~"~ Wires properly protected (Y/N) casing height (above ground) in. Date of test Static water level [ ~C Well production ~ WATER SAMPLE RESULTS: Coliform ~ colonies/100 mL 'Arsenic: ~) ugi~) FROM WELL LOG AT INSPECTION g.p.m. /-/~ g.p.m. Nitrate 40~. I mglL · date of sample: °d///~/~/0 Other bacteria O 'colonies/100 mL B, SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size /.1..~ 0 gal. Number of Compartments ~ ' Foundation cleanout (WN) 'Date of pumping. ,~/ Date installed Cleanouts (Y/N) 1~t High water alarm (Y/N) Pumper .~0~ ~c~ ~e~ · C. ABSORPTION FIELD DATA Date installed ./0/! 5/~-~' Soil rating (g.p.d./ft2 or ft2/bdrm) /, · Length <~ 0 ft. Width ~ ft. System type 5 Gravel below pipe Total depth ?,H ft. Eft. absorption area ~(~)~ft2 Monitoring tube Date of adequacy test ~/!'~//O Results(Pass/Fail) Fluid depth in absorption field before test ~<~ in. Water added Elapsed Time:~L~0min. Final fluid depth ~ (" in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) Depression over field For t..// bedrooms New depth ~ ! in. b O0 '/ g.p.d. If yes, give date D. LIFT STATION Date in~ze in gallons ~ Manhole/Access (Y/N) . "Pump on level at . in. ir~----~.~ter alarm level at Datum J Cycles tested ' Meets alarm & circuit requirements? E, SEPARATION DISTANCES in, Absorption field on lot · Public sewer main Sewer/septic service line · SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot / DO / ..p- t oo~ -F. IC)O/ 4- JO0"+' Animal containment areas ! ~0 / -4- On adjacent lots On adjacent lots ! Public sewer manhole/cleanout Holding tank Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation '7 / ~ '~ / · Property line '~ ~' ~ Absorption field Water main / OO/---/- Water service line ~Or J''- Surface water ~/O &)~-~ · Wells on adjacent lots / O O "/- SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ! 5' ~ Building foundation '=~ ~' ~ Water main · Water Service line (~50~ Surface water / O 0 f Driveway, parkingNehicle storage Curtain drain ~ ' Wells on adjacent lots ~O COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidel~e~ s. i2n ~ffe_~ct °_.n this da---te'~4~ ~ _ Engineer's Printed Name I- t/' P~ Date ?I'~C) I/O COSA Fee $ '~';'~ Date of Payment Receipt Number. (Rev. 11/05) ,~lJ~LWaiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 wv4v.munl.orglonsite (9O7) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 020-042-65 t. GENERAL INFORMATION Complete legal description . Ptarmigan Roost Block 3 Lot 6 Location (site address) . 16321 Sandpiper Drive COSA# Expiration Date: Current Property owner(s) Cheryl & Jori Penn Day phone Mailing address 16321 Sandpiper Dr. Anchorage, Alaska 99516 Lending agency Mailing address Re~l Estate Agent Mailing Address. Day phone Barbara & Clair Ramsey Day phone 261-7552 3111 c Street, Suite 100, Anchorage, Alaska-9'9503 Unless otherwise requested, COSA will be held by DSD for plckup. 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 [] Indivlduai-H~lding Tank '1'-I Community On-site []. Public Sewer [] The Municipality of Anchorage Development Services Depadment (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-fatally on-site wastewater disposal and/or water supply system. DSD also.issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a pedod of up to one year with vaIid water samples.) CedJficates 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. STATEMENT OF INSPECTION BY ENGINEER As ceffified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewatar disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure Indicatad herein. I further verify that based on the information obtained from the Municipality of Anchorage flies and from my Investigation and Inspection. the on-slte water supply and/or wastewater disposal system Is(am) in compliance with all applicable Municipal and State codes, ordinances, and regulations In effect at the time of Installation. Name of Firm Wafldns Engineering, Inc Address p.o. Box 110443 Anchorage. AK. 99511-0443 Engineer's Printed Name Cindy W. Ellis 5. DSD SIGNATURE Approved for ~ Disapproved. Conditional approval for bedrooms. Phone (9o7) 349-1851 Date May 2, 2006 bedrooms, with the following stipulations: Attachments: COSA Checklist. Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other //z::~~Orig[nal Certificate Date: .-~- 8" ~) ~ Municipality of Anchorage Development Services Department Bulldlno safaty Division On-Site Water & Wastewater Program 4700 Bragaw Slmet P.O. Box 196650 Anchorage, AK 99519.6650 www.muni.org/onslte (~z) CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Oesctlpfion: .Ptemllgan Roost Block 3 Lot 6 A. WELL DATA Parcel ID. 020-042-85 Well type Date~ I0/8/g9 Total deplh .277 fL ' Date of test Stelic water level Well I~xlucl]on If A, B, or C provide PWSID # Sanitary ~eat (Y/N) Yes Cased to 28 ft. FROM W;:[I LOG .October 8, lgg9 !8 ft. WATER SAMPLE RESULTS: Collfom~ 0 colonies/100 mL Arsenic: <0.005 rog/! 8EPTIC/NOLDING TANK DATA Well Log (Y/N) Yes Wl~e$ pmpe~ protected (Y/N) Yes Ceslng height (atx~ve ground) ,24 AT INSPECTION 4.~2 ft. 4,~' ~' g.p.m. Nitrate .,~..100 mg/L Ol~er bacteria 0 Date of ~ample: 4~1~e~u12~oe Collected by: .Cindy Ellis/Rocky Tralnor oola~ie~100mL Tan}( 'l'~/pe/Materlal Steel ~epl~ Tank Tank Nz.e 1250 gaL. Number Of Camparlmente 2 Foundafion cteanout (Y/N) Y~ Depression over tank (Y/N) No Date Of pumping ~...~ 1/2oo6 Pumper Issacs Pumping ABSORPTION FIELD DATA Date installed ,Oc~31:mr 15, 1999 aear.x (Y/N) High water alaml (Y/N) N/A Date ~;telled 10/15/1~g9 ~ ruling (g.p.d~ft~ m ~) !,2 . __~ ~ ~fl~ Tm~ ~ ~ · · ~ 5 fL G~I ~ pl~ 4 fL T~ de~ ~ EfL a~ ~ ~ ~ M~ ~ Y~s ~pm~ ~r field No D~ ~ ed~ ~t ~11A~ ~ (Pa~all) Pa~ Fm 4 ~ R~d ~ ~ a~ field ~m ~t 31 in. Water add~7 gal N~ de~ 37.75 In. ~ ~: 1~ ~n. ~ fl~ d~ 32.75 In. ~Uon r~ >= ~ g.p.d. ~ ~n ~t ~t 12 ~.~ ~ & ~)No .' ....... ff~, g~ UFT STATION Date installed N/A *Pump on' level at * in. Datum SEPARATION DISTANCES SEPARATION DISTA&ICES FROM WELL ON LOT TO: Septic lankfliff atat]on on lot 112' At--on field on lot 121' Public sewer main 100'+' Sewer/septic sewloe line 1t4' Animdi conlainmant areas 100'+ Size in gallons 'Pump off' level at in. Cydes taated On adjacent lots 100'+ · Onadjacantlnts 100'+ Publlo sewer manhdie/Cleanout 100+ Holding tank N/A Manure/animal ex=eta storage areas .100`+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 7' Property line 35' Absorption field 15' Water main 100'+ Water sewice line 40`+ Suffaon water 100'+ Wells on adjacent lots .100`+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 15' Building foondatlon 25' Water main 100+ Water Sewlce line 60`+ Surface water 100'+ Drtveway, parcJng/~hi~e storage.35' CuOaln drain N/A Wells on adjacent lots 100'+ F. COMMENTS: Well rate resalcted to avoid ,,iff Intrusion. Wala~ level et 14~. from top of ~aelng. In. ENGINEER'S CERTIFICATION I certify that I have determthed through field thspec~na and retSew of Mun/~pa/ n~da that the above systems are In conformal~e with MOA COSA guide#nee In effect on ff#s date. Engineer's Printed Na~le Clnd~ W. Data MW 2. 2006 COSA Fee $~ Date of Payment Receipt Number (R~. Waiver Fee $ Date of Payment. Receipt Number CE - fO~/7 SGS Ref.# Client Name Project Name/# Client Sample ID Matrix 1061788001 Waft, ins Engineering Ptarmigan Roost Block 3 Lot 6 Ptarmigan Roost Block 3 Lot 6 Drinking Wa~r All Dates/Times are Alaska Standard Time Printed Date/Time 04/28/'2006 13:07 Collected Date/Time 04/I 1/2006 10:00 Received Date/Time 04/I 1/2006 15:34 Technkal Director Stephen C. Ede Nitfite-N ND 0.100 mg/l.. EPA 353.2 B 04/12/06 ALR ~'~rate-N ~ 0.100 m,~L EPA3,3.2 B 04/12/06 ALR ~4at&ls D~p&~tn~nt I lan:lness as CaCO3 87.5 $.00 mffL SM20 Z340B C 04/18/06 04/27/06 WAW Aluminum 188 20.0 ug/L EP200.8 C ~ ~ L~ ~ E~.S C ~<~ (~.__rsoni¢ 5.00 ugq., EP200.8 C (<-I0) Barium 231 3.00 ugtL. EP200.8 C (<2000) Cadmium ' · ND 0.500 ug/L EP200.8 C Calcium 23100 500 u$~ EP200.8 C Chromium ND 1.00 us/L EP200.8 C (<-I00) Copper ......... 21.ii 1.00 ug/L EP200.8 C (<'1300) Iron 494 · 250 us/L EP200.8 C (o300) Lead 1.25 0.200 ug/L EP200.8 C (<-Iii) Magnesium 7250 ii0.0 us,'L EP200.8 C Manganes~ Iii00 1.00 Phosphorus- '.?. . . ND 200 ugq.. EP200.8 C Fluoride ND 0.100 ms/L EPA 300.0 B (02) Chlerlde 4.ii3 0.100 mg/L EPA 300.0 B (<=250) Potassium ND ii00 ul?~L EP200.8 C Selcnium ND $.00 us/L EP200.8 C Sodium 26000 ii0# uS/L EP200.8 C Silicon 36?0 200 uSq.. EP200.8 C Silver ND 1.00 usq, EP200.8 C Sulfate 31.7 0.100 m$,'L EPA 300.0 B Thallium ND 1.00 ugh. EP200.8 C 04118/06 04/27/06 WAW 04118/06 04/'27/06 WAW 04/18/06 04/27/0(~ WAW 04/18/06 04/27/06 WAW 04118/06 04/27/06 WAW 04/18/06 04/27/06 WAW 04/18706 04/27/06 WAW 04/1~06 04/27~6 WAW 04/1~ 04/27~ WAW 04/1~06 04/27~ WAW 04/1~ 04/27~ WAW 04/1~06 04/27~ WAW 04/11~6 ~4/27~ WAW 04/1~06 04/1~06 DSII 04/1~06 04/l&~ DSH 04/1~06 04/27/06 WAW 04/1~06 04/27/06 WAW (<-250000) 04118/06 04/27/06 WAW 04118/06 04/27/06 WAW (<-I00) 04/18/06 04/27/06 WAW (<=2ii0) 04118/06 04118/06 DSII (.o.2) 04/18/06 04/27106 WAW SGS Ref.# Client Name Project Name~ Oient Sample ID Ma~x 1061788002 Watkias Engineering Ptarmigan Roost Block 3 Lot 6 PUmnigan Roost Block 3 Lot 6 D~nking Water All Dates/I'lmes are Alaska Standard Time Printed Date/rime 04/28/2006 13:07 Collected Date/l'lme 04/12/2006 15:22 Received Date/Time 04/12/2006 15:34 Te~hnlcal Dlreclor Stephen C. Ede PWSID 0 Sample Remarks: Allowable Pr~p Analysis Patamei~ Results I~QL Unit~ Method Coalalncr ID Limits Dale Dato Inil ~.c ~ob:tolo~. L~bor& t:o ~-y To. Coliform 0 col/100mL SM209222B A (<'l) 04/12/06 TLF GRID 3238 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 FAHILY DWELLING Parcel I.D. 020-042-85 HAA~ ~ ,~ 1. GENERAL INFORMATION Expiration Date: Complete legal description ~ PTARMIGAN ROOST SUBDMSION; LOT 6, BLOCK 3, Location (site address or directions) 16321 SANDPIPER DRrVE · ANCHORAGE, AK 99516 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address GARY DREW Day phone 345-9607 16321 SANDPIPER DR~ * ANCHORAGE~ AK 99516 Day phone CAROL BUTLER w/ REMAX PROP~'RTIES Day phone 2600 CORDOVA STREET ',' ANCHORAGE, AK 99503' 257-0409 Unless othen~ise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. T~PE 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 pdvate 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. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $550.00 at, or pdor I to closing for the engineering setvices provided. I 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I vedfy t~at my investigation, based on procedures outiined in the Health Authodty Approval Guidelines forthis 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 ALASKA WATER & WASTE'WATER CONSULTANTS, INC. Phone Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. CARNESS, P.E. Date 337-6179 Engineer's Comments: In conducting this evaluation, AWWC, Inc. atlempted 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 so~Ts 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. AWWC, Inc. can therefore not provide eny wamanty 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 tfght whatsoever. 5. DSD SIGNATURE ~ Approved for ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: ~.G · . ~P_',.- ~.' WATERAND : rn.- ~ t PROGRAM Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other (Rev. 17J01) Original Certificate Date: Municipality of Anchorage Development Services Department Buildln9 Safety Division On-Site Water & Wastewater Program 47OO South 8ragaw St. P.O. Box 196650 Anchorage, AK 995196650 www.~.;~ch~*age.al~us Legal Description: A. WEII DATA Well type plaVA~: Date completed Total depth 277 Date of test SteUc water level HEALTH AUTHORITY APPROVAL CHECKLIST PTARMIGAN ROOST S/Di LOT 6, BLOCK 3~ Parcel ID: If A, B, or C provide PWSID# Sanita~/seal (Y/N) YES Cased to *28 ft. FROM WELL LOG lO/6/1;99 18 It. 2 10/8/99 ft. Well production WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi. Arsenic: .002 mg./L. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL 020-042-85 Well Log (Y/N) Wires propeify protected (Y/N) Casing height (above ground) AT INSPECTION 1/18/o2 35 ft. 3.0+ g.p.m. 12+ in. Nllrate .20 mgJL. Other bacteria 0 colonies/100 mi. Date of sample: 1/18/02 Collected by: AWWC, INC. Date installed 10/15/99 Tanksize 1250 gaL Number of Compartments 2 Cleanouts(Y/N) Foundation deanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Dateofl~umpiog 8/30/2001 Pumper OLD McDONALDS PUMPING ABSORPTION FIELD DATA ~ Date'installed lo/15pg Soil rating ~ fl~Klrm) 1.2 System type TRENCH Length 50 .ft. Width 5 ft. Gravel below pipe 4 ft. Total depth ~.s ft. Eft. absorption area 600+ ft= Monitoring tuba YES Depression over field NO Date of adequacy test 1/18/02 Resufis(PassiFall) PASS For 4 bedrooms Fluid depth in absorption field before test 19 in. Water added 782 gal. New depl~ 25 in. Elapsed Time: 20 min. Final fluid dep~ 23 in. Absorption rate >= 6004- g.p.d. Any rejuvenation treatment (pest 12 mo.) (Y/N & type) NONE KNOWN If yes, give date - D. UFT STATION Date installed .Size in gallons ~ "Pump on" level at in. Pump ~..~. High water alarm level at in. ~ Cycles tested. Meets alarm & circuit requirements?. E. SEPARATION DISTANCES Septic tankJIR station on lot Absorption field on lot Public sewer main Sewer/septic service line SEPARATION DISTANCES FROM WELL ON LOT TO: 100'+ 100'+ N/A 25'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ . Pmper~ line 5'+ Water main N/A Water service line 10°+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water service line 10'+ Surface water 100'+ Curtain drain NONE KNOWN Wells on adjacent lots 100°+ F. COMMENTS On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/deanout N/A Holding tank N/A Absorption field 5'+ Surface water. 100'+ Water main N/A Driveway, partdngNehlcte storage 10'+ G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections end review of Municipal records that the above systems are In conformance wfth MOA HAA guidelines in effect on this date. Engineer's Print7 Nam~ JEFFREY A. GARNESS HAA Fee $ Date of Payment Receipt Number (R~v. 12/00) Waiver Fee $ Date of Payment Receipt Number / Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 wvnv.cLanchomge.ak.us (90~) ~4~7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAHILY DWELLING 020-042-85 HA,6~ ~/::~ Parcel I.D. '1. GENERAL INFORMATION Expiration Date: Complete legal description PTARMIGAN ROOST SUBDMSION; LOT 6, BLOCK 3 , Location (site address or directions) 16321 SANDPIPER DRIVE * ANCHORAGE~ AK Currant Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address GARY DREW Day phone ~/0 CARC~I. BUTLER w/ RI[MAX PROP[RTI[$ Day phone CAROL BUTLER w/ RI[MAX PROPERTIES Day phone 257-0409 2600 CORDOVA STREET * ANCHORAGE. AK 99503 Unless o~herwfse requested, HAA will be held by DSD forpickup. 2. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individua! Holding.. tank Commun,ty On-s,te 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 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 wastowatar 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 prope~es 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 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. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $660.00 at, or pdor to closing for the engineering sa~fces provided. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shovm below, I verify that my Investigation, based on procedures outiined in the Health Authority Approval Guidelines for thls application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and lype of structure indicated herein. I further vedfy that based on the information obtained f~m the Munlcipalfly of Anchorage files and from my investigafl'on and inspection, the on-site water supp~, and/or wastewater disposal system Is(are) In comp/lance with all applicable Munlclpal and State codes, ordinances, and regulations In effect at the time of installation. Name cf Firm ALASKA WATER &: WASTEWATER CONSULTANTS, INC. Addmss 6901 DEBARR ROAD, SUffE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS. P.E. Engineer's Comments: .In co~fuc~g this evalue~, AWWC, Inc. attempted to provue a tho~ugh, consden#ous englneadng analysis of ~e system In accordance ~ ADEC and MOA DSD Guidelines & Regulars. The reported reaul~s described the pen~mance of the system under the condi~on$ encountemd at the time of the te~ and separation d/stances measured to readily lden~able features. The operational ~ of all walls and · septic ~/stems depend ~n the local so85 coedl~on, g~oundwater ~.~s that may ituc~ate during the year, and the water usage of the famliy being sen/ed by the system. These condi~ons are outsk~ the conkol of the evaluator of the system. Sa~sfactoql test msults do not guarantae future pen'om~a~;e of the system, nor do they guerantee that there a~e no IEdden defec~ or encroachments. AWWC, Inc. can thereinm not provide any v, arran~, or future estimate of how long Ihe syslem w~ continue to meet ~e oPe~'aEor~al requlremangs of b~,e ADEC or MOA DSD. The ~ontent of thls mport ls for other person or patly ls not authorized, nor wit it confer any legal rlght whatsoever. DSD SIGNATURE Disapproved. Conditional approval for __ Phone 3.37-6179 Date ~:~/~////~! bed ome. ~.~: WATERAND : TM bedrooms, with the tllowin~ stipulations:~ -. WASTEWATER · Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other Original Certificate Date: Municipafity of Anchorage Development Services Department Or-,-Slte Water & Wa~ewatm' Program 41'00 8aulh Bmgaw ~ HEALTH AUTHORITY APPROVAL CHECKLIST legal Oescdpt~)rc PTARMIGAN ROOST SUBDMSIONi LOT 6~ BLOCK 3 Panel ID: 020-042.85 Be Dateoftest b'~mUo water level Well produclim WAGER 8AMP. LE RESULTS: / [~te of ~m~ole: s/2s/2om c,~ect~ ~. 8EPTICMOLDING TANK DATA Tank 'lyW~datedal S~'EL TankMze 125o gal. Number of Compartments 2 Depm~lon awr tan.~ (Y/I~) No AT INSPEOTION AWWC, INC. Oateofpumplng.~.~~ Puff~oer McDONALDS PUMPING ABSORPTION FIELD DATA I*$~.,,,C S~ ~ THAN 2 YEARS OLd). I Date Installed lO,/ls/lgg9 ~ rating ~or~) 1.2 Sy~am type 'mg~CH length 50 fl. Width 5 It. Grovel below pipe 4.0 Totaldeplh 8.o lt. Eff. absmpUonama 600 It' Monl~tube YES Depresslo~overfleld NO Dateofadequacytest *NEW Results(Pass/Fall) - For 4 bedrooms Elapsed Time: - min. Flnalauld depth - In, Absoq~ rate >- - g.p.d. Any mJuvenaUon treatment (past 12 mo,) (Y/N & IyPe) - If yes. give date - 08t~ Installed 10/15/1999 Ck,anouts (YJN) High water elanlt (Y/N) N/A D. UFT 8'rATION .~Oat~_ Installed Size In gallons ~ Pump on' level at In. 'Punt . High water alarm level at In. ~ Cycles tested Meets almm & circuit requirements? Absorption field on lot. Public: ~ewer main Sewer/sept]o ~ervlce fine F- 8EPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Sep~= lank/lilt ~lon on lot 100'+ 100'4- On adjacent ~. 100'+ On adjacent lots 100'+ Public eewer numhole/cleanout Ho ng tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Absorption field. 5'+ Surface water 100'+ Water main I:)dvmvay, parldng/v~lclemorage !0'+ I:~operl~ Ilrte 10'+ Water sendce Ilne 10'+ Curtallt d~llll NONE KNOWN F. COMMENT8 Building founda~on 5'+ Prope~ line 5'+ Water main N/A Water eendce line. 10'+ Wells oll adjacent Io~ 100'+ SEPARATION DI~FANCE FROM ABSORPTION FIELD ON LOT T~. Building foundal~m 10'+ Surface water 100'+ Wells on adjacent lots 10o'+ O. ENGINEER'8 CERTIFICATION I cettlfy ~hat I have de~er/nined tl~ field in,%oecl~ns end mvlew of Murdcipal mco~ls that the above ~/afems ere In conformence v/Eh MOA I-IAA gufdefnes in effect on this da~e. Englneefsl=~e~lNa~e aE~'PKEY .4. GARNESS HAA Fee $ ~OD-°° Receipt Number /~:~,-~'~" ~ Waiver Fee $ Date of P~ent Receipt Number. Municipality of Anchorage Department o! Health and Human Services Division of Environmental Services On-Site Services Section 825 "L' Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www. ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. OzO -ow. z. - ~'5;'"' 1. GENERAL INFORMATION Complete legal description /.~,~ Location (site address or directions) Current Property owner(s) Mailing address Lending agency e Expiration Date: Day phone Mailing address Day phone Real Estate Agent Mailing Address Day phone Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [~ Individual On-site [~ [] Individual Holding Tank [-I [] Community On-site [] ~ Public Sewer [] The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private cr Class C well and may be reissued with new water sample results less than 30 days old. Certificates are valid for one year for properties served by Class Act B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 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 the Health Authority Approval application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Address ~-.~o ~---~A~.~.~.~0' ~1~.~,c~.1 ~ ~%/~ Engineer's Printed Name ~,c~ ~, ~.~r.~ Date ~o DHHS SIGNATURE ~ -~. - .... · .~ ~.~.. c~-~ ..-~ ~ Approved for~ bedrooms, t.~*. ,// /, .',~ Disapproved. ~t.~R... 0_...,./r~'r,,.'''-_~ Conditional approval for ~ bedrooms, with the following sbpulabons. " Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: '~-' ~ ~J - 0 ~ Original Certificate Date: Reissue Date: 75.02.5 {Rev 01 001' RECEIVED ""Municipality of Anchorage 17', 000 Department of Health and Human Services Division of Environmental Services "~'~,-,'~,ul r ~ OmSite Services Section 825 'L" Street Room .,,,~ "~ S~'vto=< r, .,,. P.O, Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak, us (907) 343-4744 Legal Description: A. HEALTH AUTHORITY APPROVAL CHECKLIST WELL DATA Well type ~ If A, B, or C provide PWSID # __ Date completed /O.,.~-,~q Sanita~ seal ~f~ Total depth 'Z'~ 7- ft Cased to 'Z.~.- ft FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform I~ colonies/100 mi Date of sample:-r---- Parcel I.D.: .. Well Log '~'" Wires properly protected Casing height (above ground) AT INSPECTION g.p.m Z-- g.p.m Nitrate ~-,'rd'~ mg/1 Other bacteria c~lonies/100 mi B. SEPTIC/HOLDING TANK DATA Tank Type/Mater ,, Date installed ~ Tank size Cleanouts ~' Foundation cleanout Date of pumping ~ C. ABSORPTION FIELD DATA in. 2. W'O gal Number of Compartments Depression over tank ,~' High water alarm Pumper Pi, Date installed ~ Soil rating (g.p.d./ft2 or ft2/bdrm) __ Length ~'~ ft Width ~' ft Gravel bolowpipe ,r~,~ ft Total depth ~,,_~ fl Effective absorption area~m ~ Monitoring tube y' Date of adequacy test / Results (Pass/Fall) / System type ~J*/' -f.~ ~ ~---~. _ Depression over field c~ For ~ bedrooms Fluid depth in absorption field before test ~ in Water added / gal, New depth ~ in. Elapsed Time: / min Final fluid depth -~' in Absorption rate >= / g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~-~'"'" If yes, give date __ 72-026 (Rev. Date installed . Size ,n gallons ~ "Pump on" leval at~q---~Pi~ level at in Datu~ Cycles tested E. SEPARATION OISTANCES Manhole/Access High water alarm level at __ in Meets alarm & circuit requirements SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot /~x~ I .~ Absorption field on lot /Ope+ Public sewer main ,'~'/,,~ Sewer/septic service line /PO ~4- On adjacent lots IOot-i· On adjacent lots /~'~ 14- Public sewer manhole/cleanout Holding tank ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main '~J Drainage /'~, o Property line ,~ o Water service line ~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~*e t Water Sewice line Curtain drain F. COMMENTS Absorption field Surface water iffl t. /e,.o f Building foundation '~o cfi. Water main * K/,,~ Surface water tee ! 4- Driveway. i)arking/vehicle storage Wells on adjacent lots tee 14. G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Date ,,~Z_~ o Waiver,, Fee $ Date of Payment Receipt Number 72,026 (Rev. OI-21-O0 Ih;I FPO~-CTE EPVIK~IITjL ,M~,, CT&E Envimnmefltl~ Si f~iml4 ifl~. CT&£ RcC# Clknt' Simpl~ ID OKI.id ~y i00162300l Mike N. Az~-rson. ? G. L 6 G 3 ~-m~a~ R~c~t S/D Client ~ iL~IIRS OPT III?#Te-N