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HomeMy WebLinkAboutT12N R3W SEC 21 S2N2NE4NW4SE4T12N R3W SEC 21 S2N2NE4NW4SE4 #015-281-54 On -Site Water and/or Wastewater System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP161108 Tax Code Number: 01528154000 Work Type: SepticTank Upgrade Permit Effective Dates: May 23, 2016 to May 23, 2017 Design Engineer: PANNONE ENGINEERING SERVICE Subdivision: T12N R3W SEC 21 Site Legal Address: T1 2N R3W SEC 21 S2N2NE4NW4SE4 G:2735 Owner/Address: HELMS STEPHEN & LINDA PO BOX 190384 ANCHORAGE AK 995190384 Site Mailing Address: 11640 JEROME ST, Anchorage This permit is for the construction of: N Disposal Field Y Septic Tank N Holding Tank Lot Size in Sq Ft: 108900 Total Bedrooms: 3 N Privy N Private Well N 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 Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received Issued By: MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-3 9104 9 70 Development Services Division g Fax: 907- 97 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION ImV MAY 12 N10 It' Parcel J.D. 015-281-54 Property owner(s) Stephani Lacher Mailing address 11640 Jerome St„ Anchorage AK Day phone Site address 11640 Jerome St., Anchorage AK Legal description (Sub'd., Block & Lot) T12N R3W S21 S2N2NE4NW4SE4 Legal description (Township, Range & Section) Lot Size 108,900 Sq. Ft. APPLICATION IS FOR: (® all that apply) Absorption Field ❑ Septic Tank ❑x Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms 1.1 APPLICATION IS AN: TYPE OF DWELLING: Initial ❑ Single Family (SF) ❑x (w/wo ADU) Upgrade 0 Duplex (D) F1Renewal F-1 Multiple Dwellings ❑ (SF and/or D) THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. oT property owner or authorized agent) Permit/Rush Fees: al.5— Waiver Fees: _ Date of Payment: 612-11 Date of Payment: Receipt Number: 0011 Receipt Number: Permit No. 05Q6(o((Of Waiver No. Permit App__ :L.:c. Pannone Engineering Services LLC Steven R. Pannone, Principal Registered Professional Engineer - E-mail: steve@oaneneak.com 19 May 2016 Subject: T12N R3W S21 S2N2NE4NW4SE4 Tank Replacement Permit Request Design Narrative This is a design narrative for a permit to install an upgrade septic tank to be issued for this property. The proposed system will serve an existing three-bedroom (3) house. Currently the lot is developed. This lot and the surrounding lots are served by private wells. The well on this lot and the surrounding wells are over 100' from the septic system. 1. System Design. a. See Sheet 1 of the design package. 2. Surface Water: There is no surface water within 100 feet of the proposed septic tank. The proposed tank upgrade will maintain at least 100 feet from all surface water and drainage ditches. 3. Topography: The existing topography generally slopes from the east to the west in the area surrounding the septic system at approximately 2-5%. There are no steep slopes within 50' of the proposed tank. The proposed tank will maintain 50' separation all steep slopes. 4. Drawing Markings: The Drawings are marked "For MoA Review Only'. When written notification that the review is complete and that there are no further comments is received from MoA On -Site Department, the note will be removed and "Issued for Construction" drawings will be issued. The proposed installation will not affect the future development of this or the surrounding lots. Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 Physical: 332 East Manor, Anchorage, AK 99501 Telephone: (907) 272-8218 FAX: (907) 272-8211 INSTALL 1250g SEPTIC TANK (P) �— _ W/ DCO AFTER TANK z WELL E 'i Qo 0 0 I Q a w U w U l3 / l yam: _ . - . - . - . - -- - A4- W \ � z%-5% 100.8 2%-5% I 103.4 WELL 196.9 REMOVE 1250 SEPTIC TANK E 58,4 2%-5% / INSTALL 1250g SEPTIC TANK (P) �— _ W/ DCO AFTER TANK z 0' Qo 0 0 ow O U Q a w U w U mz �w p Jj NOTES: FOR CONSTRUCTION DRAWN I JRL SITE PLAN 1250 g SEPTIC TANK (P) PROFILE PANNONE ING SVC, LLC P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 T12N R3W S21 S2N2NE4NW4SE4 STEPHENI LACHER 11640 JEROME ST ANCHORAGE, AK 99516 CE 8149 05/18/16 Scale 1" = 50' P.I.D. NO 015-281-54 PERMIT NO. OSP161108 Sh eet 1 OF 2 SPECIAL PROVISIONS TO SPECIFICATIONS 1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON—SITE WASTEWATER DISPOSAL SYSTEMS AND AND IN ACCORDANCE WITH AMC 15.65 AND 15.55. 2. SCOPE OF WORK: REMOVE 1250g SEPTIC TANK (E) & INSTALL NEW 1250g SEPTIC TANK WITH DCO AFTER TANK. 3. THE CONTRACTOR (BOTH WELL AND SEPTIC SYSTEM CONTRACTORS) SHALL HAVE ANY WELL LOCATION AND SEPTIC LOCATION STAKED AND ANY LOT LINE AND WELL RADIUS SHOWN ON THE PLAN WITHIN 30 FEET OF THE PROPOSED SYSTEM STAKED BY A REGISTERED LAND SURVEYOR BEFORE STARTING THE WORK. 4. THE CONTRACTOR IS RESPONSIBLE FOR ALL R.O.W. AND OTHER REQUIRED PERMITS, OTHER THAN THE ATTACHED. 5.- THE CONTRACTOR SHALL CALL FOR LOCATING OF ALL BURIED UTILITIES 6. THE CONTRACTOR SHALL PROVIDE 24 HOUR NOTICE TO THE ENGINEER PRIOR TO START OF WORK. ALL SURVEYING AND LOCATES SHALL BE IN PLACE PRIOR TO NOTIFYING THE ENGINEER. 7. THE CONTRACTOR SHALL NOTIFY THE ENGINEER OF ANY DISCREPANCY BETWEEN THE APPROVED DRAWINGS AND SITE CONDITIONS/LIMITATIONS POTENTIALLY CAUSING THE NEED TO MODIFY THE DESIGN. 8. AT THE COMPLETION OF THE WORK, THE CONTRACTOR SHALL SUBMIT RED—LINE AS—BUILT DRAWINGS TO THE ENGINEER. THE RED—LINES SHALL INCLUDE PIPE LENGTHS, ORIGINAL GROUND ELEVATIONS, PIPE ELEVATIONS, AND TANK ELEVATIONS. 9. THE CONTRACTOR SHALL PROVIDE PHOTOGRAPHS OF THE SYSTEM INSTALLATION TO INCLUDE BOTTOM OF EXCAVATION, TOP OF PIPE WITH CLEAN—OUTS AND MONITOR TUBES INSTALLED, INSTALLED TANK AND FINAL GRADING. 10. THE CONTRACTOR PROVIDED DATA (UPON WHICH THIS RECORD DRAWING IS BASED) APPEARS TO REPRESENT THE PROJECT AS CONSTRUCTED. THIS DATA IN CONJUNCTION WITH THE PERIODIC FIELD OBSERVATIONS BY THE ENGINEER (OR HIS DESIGNEE) AS REQUIRED BY AMC 15.65 DOES NOT GUARANTEE THAT THERE ARE NO HIDDEN DEFECTS BY THE CONTRACTOR. 11. THE CONTRACTOR SHALL SIGN THE FOLLOWING: 12. 1 CERTIFY THAT ALL WORK WAS PERFORMED IN ACCORDANCE WITH THE APPEND PERMIT, AND ANY AND ALL CHANGE ORDERS, AND THAT THE AS—BUILT REDLINES ARE TRUE AND ACCURATE REPRESENTATION OF THE PROJECT AS CONSTRUCTED. CONTRACTOR: m TITLE: ABBREVIATIONS - - WATERLINE/- TH TEST HOLE - - WELL RADIUS (P) PROPOSED - DESIGN PARAMETERS (E) EXISTING PRIMARY SEPTIC SYSTEM - NEW SEPTIC CO CLEAN-OUT NO. NO. BEDROOM: 3(450 gpd) MT MONITOR TUBE NO. TANK SIZE: 1250g _ - TYP TYPICAL NOTES: PANNOoNE4 ENGRACK AK 99510 PHONE (907) 272-8218. FAX (907) 272-8211 ,SOF ... ... . .. .. ... Dat 05/18/16 FOR CONSTRUCTION Scale NTS P.I.D. NO T12N R3W S21 S2N2NE4NW4SE4 STEPHENI LACHER 11640 JEROME ST ••�}8 •�'•p4���8 CE 8149 —281-54 DRAWN JRL PERMIT NO. 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Box 196650, Anchorage, AK 99518-6650 (907) 343.7904 ONSITE WATER SUPPLY PERMIT Renewal Permit Number: SW700034 Legal Description: Ti 2N R3W SEC 21 S2N2NE4NW4SE4 Design Eng1neer. 0000 ZZ - NONE NEEDED Date Issued: Apr 23, 2010 Expiration Date: Apr 23, 2011 Parcel ID: 015.281.54 Site Address: 011640 JEROME ST Owner Name: MARK AND BARBARA FULLMER Lot Size: 108900 $0. FT. Owner Address: PO BOX 243394 Total Bedrooms: 1 Permit Bedrooms: 1 ANCHORAGE, AK 99524 - This permit is for the construction of: ❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑Privy Private Well ❑ Water Storage All construction must be in accordance with: 1. The allached approved design. 2. Ali requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (1aAAC72 ) and Drinking Water Regulations (18AACSO ). 3, The engineer must notify DSD at least 2 hours prior to each Inspection. Provide nottfication by calling (907) 343.7904 (24 hours). ( Not required for a Water Supply Permit only). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either. A. Open and closed on the same day. B. Covered, seated, and heated to prevent freezing. Received By: Issued By. Date: /"' �v Date: �I Municipality of Anchorage Development Services Department i Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, Alaska 99507 www.muni.orglonske (907) 343-7904 ON-SITE SEWERIWELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I. D. co I g— ? iS 1— t; Property owners} 1 `N 11t. r k•'•er Day phone =A %A %kIOS Mailing address P 0 63>11)* VA 33N Zip Code Site address k< (0Ay j\eyoe`' Sir Zip Code _ RC1 t(crSib Legal description (Sub'd., Block & Lot) 51 N � NE tjVj 5E w_ 52l T17 k3� Legal description (Township, Range & Section) - Lot Size 10 ti\ 0 0 Sq. Ft. THIS APPLICATION IS FOR (S all that apply): Absorption Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ,q Water Storage ❑ Number of Bedrooms I THIS APPLICATION IS AN: Initial O Upgrade ❑ Renewal R I certify that the above Information is correct. I further certify that this application is being made for a Single Family DweAling and is in accordance with applicable Municipal Codes. (Signature of pro(%ny, owner or authorized agent) Permit/Rush Fees: Nr ClAwr P Waiver Fees: 4u�a'41p L �r (4D Date of Payment: Receipt Number. Receipt Number. (Rev. 11105) MUMCIPALITY OFANCHORAGE Development Servkes DeWment Onsite Water d Wastewater Program 4700 South Bragaw Street P.O. Box 186650, Anehorage, AK 99519-66W (907) 343-7904 ON-SITE WATER SUPPLY PERMIT Upgrade Permit Number. SWO90033 Legal Description: T12N R3W SEC 21 S2N2NE4NW4SE4 Design Engineer. 0000 ZZ - NONE NEEDED Date Issued: Apr 15, 2009 Expiration Date: Apr 15, 2010 Parcel ID: 015.281.54 Site Address: 011640 JEROME ST Owner Name: MARK AND BARBARA FULLMER Lot Size: 108900 SO. FT. Owner Address: PO BOX 243394 Total Bedrooms: 1 Permit Bedrooms: 1 ANCHORAGE. AK 99524 - This permit is for the construction of. ❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy Private Well ❑ Water Storage All constriction must be in accordance with: 1. The attached approved design. 2. Ali 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 DSD at least 2 hours prior to each Inspection. Provide notification by caging (907) 343-7004 (24 hours). ( Not required for a Water Supply Permit only). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either. A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By. Issued By. Date. /G �Pr U Date: Municipality of Anchorage Development Services Department Building Safety Division i on -Site water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage. Alaska 99507 www.muni.orglonsite (907) 343.7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 0/5' -Z 81 - S`/ Property owners) Mark ❑ a'yA 64� bc^ F' 11 "'e ✓ Day phone Z Cj7 4305, ❑ Mailing address 'P 0 6 v,% 2-4 33 4 4 Zip Code 99sL y Water Storage Site address /) &q o Je'ome Zip Code 995 6 Legal description (Sub'd., Block & Lot) na►sobat ( Av�e°( Legal description (Township, Range & Section) 'S 1/1. rJ res N Y4 N Yu S 2► iIt ") 23r.� Lot Size 109 900 Sq. FL THIS APPLICATION IS FOR IS all that apply): Absorption Field ❑ Septic Tank ❑ Holding Tank ❑ privy ❑ Private Well Water Storage ❑ Number of Bedrooms THIS APPLICATION IS AN: Initial Upgrade ❑ Renewal ❑ I certify that the above Information is correct I further certify that this application IS being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature grprroperty owner or authorized agent) Permit/Rush Fees: Waiver Fees: Date of Payment: Date of Payment: Receipt Number. �? Receipt Number. (Rev. 1145) ' hj a• iD�'':TS"Lu.; :/�s.a� • .:. ; . o .: '8/86 C i h I yo K. N. o�: r_ tr N y o. j is I '. W Ow 2 ; Q tj w �.. . It tu> 24 .Tom. I' :... �: V I t 382. ..... } ..... �. �. V H.�w 'ice V. .Z I ..-...... IV3..`� .. t. :......... r _ a 4P 41 w 43 t ku t jj .I Vio rR as- UILT r ,':,y,; herebyCeniry I�G'ECF.h'T tFiE^C7 ti'^"�� 1'�t't"Y 'f the allowing chora' e P �'" ��{j,. 7 ` • i pmvementsi j::1.I•r.—�-+. k 1 o not overlap i .:.('}� rr.,+•,v,,:,. j t I f :oa i hei no imprc t>.' 4 t :. � . dcroaClti On, tl edways, tram roe exce ated at Aneh EASEMENTS OF SEC RD, OTHER THAN his THOSE SHOWN ON,•f E RECORDED j, l ' " ' PLAT+ARE NOT SHO HEREON. Sro I i gl7n 248.1666 ORNERS SET THIS DATE I have pertormoa a Mortgagee's InBpection I .T)2.A1f :R3W 5,lq, AV - ding Preoinct, Alaska, end -that the ed thereon are tnln the property Imes and ,roach on the pro�eny lying edjacen{ thereto, ents on Property -lying adjacent: thereto emisda In quest)oh:and that therd are no ,Ion lines or othed visible easements on said Indicated hereon.: s, Alaska day bf4"C-14 t9 FRED AL:ATKA A ASSOCIATES Englneers and Surveyors \\ • ^ MUNICIPALITY OF ANCHORAGE n DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 26411720 ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAM PHONE jaNEW ccnaijA ❑ UPGRADE MAILING ADDRESS I_ 1` LEGr DESCRIPTIONYiS�Z' r t1� 41ty y, -0)-d u �0 52 i Sic z 1 P-3 W LOCATION NO.OF BEDROOMS L�q - Ck4il OF' � i DISTANCE TO: Well1 O / Absorption e� / Dwelling , PERMIT NO. acC)417 Uy _ �Q Manufacturer Material No. of compartments Wl a Liq, capacity in gallons IF HOMEMADE: Inside length Width _ Liquid depth DISTANCE TO: Wall Dwelling PERMIT NO. i —i02 CIE f cturer Manufa erf5 Li pacity in gallons O DISTANCETO: Well / Founda n / 14ne PER O. Nearest T w= .-�- Q 1-7 w ZNo. of lines�7 Len th of each line Total len nes o lines r Tren h width Distancye between lines 1- 2 W `., • inches (,.0 <tt Top the fin Material beneath Total H of to a lite "--ep effective absorptio area p /VAIN p`I— inches i Length Wi Depth PER W c7 j F Type of cri Crib tlia ter depth Total effective ab prion area i W G W Well Building foundation Neares Zine (STANCE TO: J Class Depth Driller Distance to lot linePERMIT NO. J W DISTANCE TO: Building foundation Sewer line Septic tank Absorption areas) OTHER i PIPE MATERIALS N SOIL TEST RATING 293 INSTALLER W �Tt `1L �vwN i REMARKS - C Sci 'L 0 AL � � �' t t s C' 9 •lP02-� • P TH - � i ... i•+M um`-'�e't' �I }0 TftD1A •A. FISCHER �•• 01 AF APPROV t r 4 LEGAL NE%q.,Nw%,SC�4.St�21i iI ZR";sYL,NrZ, � Z w vs1 , 72-013 (Rev. 3178) 1, PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT PHONE: LEGAL DESCRIP: LOT SIZE: MIJN I C IAL I TY UF= ANCI-%-QRAGE DEPARTMENT HEALTH AND ENVIRONMENTAL ROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 UN— ; I TE 060417 UPGRADE 11/07/136 BOB MC GAHA 11640 JEROME ROAD ANCHORAGE, AK 99516 345-0070 SEWER F�EFzM I T SUBDIVISION: SUBDIVISION: TIA_LULAH(PROPOSED) LOT: 2 SECTION: 21 TOWNSHIP: 12N RANGE: -'W 1.25A (SQ.FT. OR ACRES) Nc se` 2/ i BLOCK: NA i i I certify that: a 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. 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 an this or any adjacent or nearby lot. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITH„ ECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK' /MUST BE ONE BY A LICENSED ELECTRICIAN. SIGNED ' DATE: APPLICANT: BOB MC GAHA ISSUED BY , �• DATE: ,,'�"� i - ern ��- ... -- --- -�^v-J _ _ , ``.. �` -- -- - '- —'�_• .-_ �"'JJ9 �- - W © � / LLF m I S2� CIO Z ✓�� DRAIN A4E eaC Ji44: 1 •ter IC` Z isz i !z I W C 130 3d i PRoPosED SE�nc. SYS COT Z dF F'RoPoSa=D LoT I Z LUALA'&ABZ •I OF A�4 v�ic l= I oo f\XSi E ; NBA r'.lDlz)N OLD Ar p ��: .A•••'.V �l CG �I�d� I� ��,.... p... `a- . .�SEpTIC THOM0.f.: Al T►iN� ;ti.nuao N PERFORMED I Ti;W ESR GI)NE�EiRI(NG EON! TR C OR 11600 CANGS RD. ANCHORAGE, AK. 99516 (907; 345-7WO LEGAL DESCRIPTION: V l (. '•t rt���r^ DEPTFESH • /1•L CT 2. TIT C'A'P z) - .SLOPE IF�'��'"`�� 3- �4 Is - 6. 7- 10 11 12 13 14 1s 16 17 18 19 20 IsAv4 •t CmmxU S��Tw1iY CEJ o' ( jORG/�N�4S PERFORMED r S%% -T/ ejvr%t`f 5,%\.T •....... . * 9TH 17 amp-MLT'gow Reading SOILS LOG Gross Time PERCOLATION Depth to Water I TEST 17 amp-MLT'gow Reading Dote Gross Time Net - Time Depth to Water I _ Net Drop 1 ,o 1.910 i4 47 — Z 66 11 s 4p � w11 Z� .1 / / T 3 to z; va 3o M;N 4.Y4 1 h 4t ; t z� w- I s 11 Co 13cl tm: ea 5'% 1 YL 1, PERC(._..TION RATE (minutes/inch) TEST RUN BETWEEN --2L FT AND 4 FT THOM A. FISCM - %.•.. CE - 6793 `a} t`*;2•�� WAS GROUND WATER t JO S ENCOUNTE'AED' c P E IF YES, AT WHAT DEPTH) Reading Date Gross Time Net Time Depth to Water Net Drop lou I L 3S ori SYS • / t r t Y -z .� 2,81571 30mla 5'% 1 YL 1, PERCOLATION RATC 8O Iminutst/inch! TEST RUN BETWEEN - FT AND 8 FT DATE: 3L�ffi PERFORMED LEGAL eo, F `, T -5T yPiT EW 'TES E+ G1DN1E� IING E©N•STRNCTOR 2 �l� i i �zxtvtt 3- 4- 7 4 7 8 97'// 10 11 S�IrT' SP1�loD`{ S��T CMS) 40W11w► INUi 12 INA/r/am 15 is r ,�� 17 *��'n�TH�• 18 No' 11600 CANC£ RD. ANCH(''"G£, AK. 99516 .9071 345-700a i SO LS OG PERCOLATION TEST DATE PERFORMED:}_ Reading Date Gross Time Net Time Depth to! Water Net . . Drop I a ZEr I z: z5 l -0 "( Z Y4— ¢ 4 11 v%;4 YM► - 3'%4- 4% 3 I VA 43 8/3 Z 1/z 5 � ` Z : 2$ 3o vvl�►� 00 �4 PERCOLATION RATE 131.3 (minuteslineh) 2 a TEST RUN BETWEEN Z FT AND i FT ENCOVN EREII ER ENCOUNTERE7' Min IF YES. AT WHAT ... DEPTH? Reading Dant Gess Time Net Time Depth to Water Net Drop I a ZEr I z: z5 l -0 "( Z Y4— ¢ `- 2 v%;4 YM► - 3'%4- 5 � ` Z : 2$ 3o vvl�►� ��a �4 19 - THOM A. RSCHEir ' ! CE - 6793 • �pd4Ar 20 Mtn •......• Q, . 34Y �b.¢i... f' p� +�P PERCOLATION RATE 4 O ,minutes/inchl TEST RUN BETWEEN FT AND �_ FT COMMENTS �aj?.M 7 7�1= 1\A 1 A ,I/ ..Il fi%� 1/_ a %. . V. GJ= l/. �� 7 1 T1 7 L% 0 Z coi � M •- • ..+•.a a ..� •a1 r DATE: O/ n 11/6/1986 Steve Morris Dept, of Health 5 Human Svcs. Municipality of Anchorage Ireq 4.a7B Anchorage, AK. z C Dear Mr. Morris: The following is our proposed septic design for Lot 2 Tallulah Subdivision (PROPOSED). T:;>Z- 4 S.eAm Should LT Z tZSo 37 4 Bea.. y. 2913;Z/ee. = 1172 Win! z 4.7' 7r w there be any questions please contact me at n45-7008 Sincerely, Thom A. Fischer P.E �R,-1 to M 1 R OF A;qo 9t14 a� "�%�8p CE•4:73 ��Ar t yam••'•., ••;<:'.r J i WHITEWATER ENGINEERING CONSTRUCTOR 11600 CANGE ROAD • ANCHORAGE, ALASKA • 99516 9 PH. 345-7008 T: P 2. Z;o (M = z.o x sell U 98 `wL� 7— 5' 5 � Z251 St s Vie' 0 T:;>Z- 4 S.eAm Should LT Z tZSo 37 4 Bea.. y. 2913;Z/ee. = 1172 Win! z 4.7' 7r w there be any questions please contact me at n45-7008 Sincerely, Thom A. Fischer P.E �R,-1 to M 1 R OF A;qo 9t14 a� "�%�8p CE•4:73 ��Ar t yam••'•., ••;<:'.r J i WHITEWATER ENGINEERING CONSTRUCTOR 11600 CANGE ROAD • ANCHORAGE, ALASKA • 99516 9 PH. 345-7008 T: P 2. N,T D•nE '1� SWC: `wL� 7— 5' 5 � Z251 St s Vie' 0 Qa z. ( 55 7 r1vE - 5(,S 1 7 = 353 T:;>Z- 4 S.eAm Should LT Z tZSo 37 4 Bea.. y. 2913;Z/ee. = 1172 Win! z 4.7' 7r w there be any questions please contact me at n45-7008 Sincerely, Thom A. Fischer P.E �R,-1 to M 1 R OF A;qo 9t14 a� "�%�8p CE•4:73 ��Ar t yam••'•., ••;<:'.r J i WHITEWATER ENGINEERING CONSTRUCTOR 11600 CANGE ROAD • ANCHORAGE, ALASKA • 99516 9 PH. 345-7008 P • Municipality of Anchorage, On -Site Water and Wastewater Program (907)343-7904 PTGE +}<i S r s r 11 err CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 015-281-54 1. GENERAL INFORMATION Expiration Date:1 g [.e Complete legal description T12N, R3W, SEC 21, S2N2NE4NW4SE4 Location (site address) 11640 JEROME ST ANCHORAGE AK Current Property owner(s) STEPHANI LACHER Day phone Mailing address Real Estate Agent 11640 JEROME ST, ANCHORAGE, AK 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System Waiver/Variance request for:_ Received by: o®/V t 1, 3 Day phone OCT 6 n 20i5 TYPE OF WASTEWATER DISPOSAL: ® Individual ❑ Holding Tank ❑ ❑ Community ❑7 ^ ❑ Public Sewer ❑ COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ !PLCO Waiver Fee $ Date of Payment fi 21/ r rL 52 Date of Payment Receipt Number Receipt Number COSA # ac i cJ i J01 Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 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 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 MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE. Engineer's Printed Name MIKE N ANDERSON, PE Date 10/20/15 6. DSD SIGNATURE id System #1 Approved for _ bedrooms. System #2 Approved for Disapproved. Conditional approval for bedrooms. � n � Yes e ° ............. t° e MICHNCL ixl' ANDERSON bedrooms, with the following stipulations: Original Certificate T"uriicipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approvall, (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet 10-10-12.dos If more than 1 septic system is on the lot: COSA Checklist # _of Structure served by this system _ Certificate of On -Site Systems Approval Checklist Legal Description: T12N, R3W. SEC 21, S2N2NE4NW4SE4 Parcel ID: 015-281-54 A. WELL DATA Well type Private If A, B, or C provide PWSID # _ Well Log (Y/N) N Date completed 1967 ? Sanitary seal (Y/N) Y Wires properly protected (YIN) Y Total depth 180 ft. Cased to 40+ ft. Casing height (above ground) 12" FROM WELL LOG AT INSPECTION Date of test 812812015 Static water level ft. 121 #t. Well production g.p.m. 5+ g.p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/100 mL Nitrate ND mg/L Arsenic: ND ug/L Date of sample: 812812015 Collected by: 907 Water Well Services B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC I STEEL Date installed 1112511986 Tank size 1250 gal. Number of Compartments 2 Cleanouts (YIN) Y Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (YIN) N Date of pumping Pumper MUM" la z? 15 l t�r„d 2 ovpik, C. ABSORPTION FIELD DATA —1985 SYSTEM TESTED Date installed 11125/1986 Soil rating (g.p.d./ftz or felbdrm) 293 System type BED Length 94 ft. Width 2.5 ft. Gravel below pipe 7.0 ft. Total depth 11,,ft. Eff. absorption area 1316 ft? Monitoring tube Y Depression over.field N Date of adequacy test 812812015 Results (Pass/Fail) PASS For 3 bedrooms"" Fluid depth in absorption field before test 44 in. Water added 450+ gal. New depth 81 in. Elapsed Time: 24 HRS min. Final fluid depth 41 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) UNKNOWN If_yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. . "Pump off' level at in.High water alarm level at _ in. Datum E. SEPARATION DISTANCES Cycles tested Meets alarm & circuit requirements? WELL ON LOT TO: Septic tank/lift station on lot 1001+ Absorption field on lot 100'+ Public sewer main 751+ Sewer/septic service line 50'+ Animal containment areas 1001+ SEPTIC/HOLDING TANK ON -LOT TO: On adjacent lots 1001+ On adjacent lots 1001+ Public sewer manhole/cleanout 1001+ Holding tank NA Manure/animal excrete storage areas 1001+ Building foundation 5'+** Property line 51+ Absorption field 54 Water main 100'+ Water service line 101+ Surface water 100'+ Weiss on adjacent lots 1001+ ABSORPTION FIELD ON LOTTO: Property line 10'+ Building foundation 10'+ ** Water main 104 Water Service line 101+ Surface water 1004 Driveway, parking/vehicle storage 101+ Curtain drain 504(None Known) Wells on adjacent lots 1001+ F. COMMENTS HR 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 guidelines in effect on this date. Engineer's Printed Name MIKE N. ANDERSON, PE Date 1012412015 COSA canary sheet -2-6-1 15.doc h~P��• OF a L'QS �� �+ r� p % MICHAEL N. ANDERSON :0 CE 9 § $k\ —1.3_sea— � _ .M . _ m � — � ■ \ ) $k\ � � ■ \ ) e ¥\ �§7■ | 7 12 ( £ � m ■ — \ . § — — — — . } °\ . \* _gym -ISMJIS_/ /__I� — — — — _ ANS — A'Iunicipality of Anchorage Development Services Department Building Safety Division _i On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.orglonsile (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING . � 0 r/11/0e, Parcell.D. OrS -Z5f -SH COSA# OlPuP0 Expiration Date: //_/0_0& 1. GENERAL INFORMATION Complete legal description Sri;,. N '� N E-* ""of S E r/y Se c Z 7 li-No R 3 W Location (site address) 11 6y0 J;e•-om a SA Current Property owner(s) ._ �.� Er Oe.6 6o e L . /A>fvn Day phone Mailing address 116&10 Terv^,r i SA.y AAcA&o-.?%< A -k 99S/e' Lending agency Day phone Mailing address Real Estate Agent FS 13 0 Day phone Mailing Address i Unless otherwise requested, COSA will be held by DSD for pickup. Pfterle to It J"f o, o^ Oe 6 6se 3HS-8H/s' c..Rin CcvA ^��✓y f^r p•u. 2. NUMBER OF BEDROOMS: i/ 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal andlor 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 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. 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 TecAn i ea/ S vcz Phone 3 vs - ► 3 s'S' Address l•l 30 @cAo &AXon Rif .finch._ .4 k 99616 Engineer's Printed Name '7htoe(c,-e P": P-ryaee Date yAvwt, 2006 5. DSD SIGNATURE •••••u•••••ssooa F. 4Y,)-� Approved for CE-3U9bedrooms. `����,:.., �•�oF Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By:oe �' Original Certificate Date: (Rev. 11)05) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: S r�; N 1�y N 6 y' Nw 'y, S E "*' Sic L/ Parcel ID: d r S -2B 1 -Sy 7 -AN, A3L✓ A. WELL DATA Well type Pd If A. B, or C provide PWSID # Date completed - 1967 Sanitary seal (YIN) Total depth f d.? ft. Date of test Static water level Well production Cased to _ Yv ft. FROM WELL LOG WATER SAMPLE RESULTS ft. Well Log (Y/N) N Wires properly protected (Y/N) Y Casing height (above ground) /2 in. AT INSPECTION 7/2..0 /a6 17-9" ft. g.p.m. 7.0 g.p.m. Coliform U colonies/100 mL Nitrate 00 s vV mg/L Arsenic: Sr ppb date of sample: _7 2.r B. SEPTICIHOLDING TANK DATA Tank Type/Material sitJ• he / Sf+• I Tank size 124V_ gal. Number of Compartments Foundation cleanout (YIN) Y Depression over tank (Y/N) Date of pumping 7/ lu /O 6 Pumper A - -s- Other bacteria _Q_ colonies/100 mL Collected by: Pr/n/_ d 7-�cti S''c Date installed Cteanouts (Y/N) Y High water alarm (Y/N) W. A i C. ABSORPTION FIELD DATA Date installed ollXfl 6 Soil rating (g.p.d./ft2 or ft2/bdrm)292 „System type 77men cA I Length 941 ft. Width 2•S ft. Gravel below pipe 7.6 ft. 1 Total depth 11.0 ft. Elf. absorption area 1171' fe Monitoring tube Y Depression over field M Date of adequacy test 7/29'/406' Results (Pass/Fail) fdagi For JY (bedrooms I Fluid depth in absorption field before test,'(_ in. Water added VU gal. New depth_42_ in. Elapsed Time: to• min. Final fluid depth V -d In. Absorption rate >= 600! g.p.d. N & �/ Len w If as 9 ive date I-^ Any rejuvenation treatment (past 12 mo.) (YItype) as , a y . D. LIFT STATION N• h. Date installed 'Pump on" level at _ in. Datum Size in gallons "Pump off" level at _in. Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot IDS" Absorption field on lot Public sewer main Y. A% Sewer /septic service line �> 2C Animal containment areas NoAc Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots > too On adjacent lots > too Public sewer manhole/cleanout N• d. Holding tank t✓• A. Manure/animal excrete storage areas I004Pn 0. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 2 U' Property line HiQ ' Absorption field -7!s- Water S' Water main t4.,4- Water service line to' Surface water > tllo Wells on adjacent lots > too' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 44" Building foundation > FuoWater main N• A, Water Service line '> to' Surface water > e G12' Driveway, parking/vehicle storage > 14#0 Curtain drain M.ne t sn Wells on adjacent lots > 44Ro' F. COMMENTS F�aa^slar%on C.o, lr /14C�! I^t•�t •1•R /i•O DltcAatr-.Pi trot J�ia-v, seoXc iknk' ritor VD" VC fDn to f+ be G. ENGINEER'S CERTIFICATION o 6Cee f Hciles'^'c^cP. 1 certify that 1 have determined through field inspections and review o/ Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name 7 -Aeon, .,e t< t'+a•o�e Date 'fA..rorw%: 200 Z COSA Fee $ Yr 0 -% Waiver Fee $ _ Date of Payment 817106 Date of Payment Receipt Number �3Z rA� Receipt Number (Rev. 11/05) C[t-It%l-llwa tw/ri) •+ti^r Ictu.or ea'AA . gne-ie� % OF A aoti `t' j'v�'_ fid �•*", ............... • S THEODopt F. L60CRE • •._ CE.35F,4 _ in. A ho 7 .„ 0 r.•. ;•/ M, V r.t• 0 N L c d h Z * Z o 'f 14 .. v, m h t � ` a 2 0 3 i�Uy7 t p ((v K 7 ho 7 .„ 0 r.•. ;•/ M, V r.t• 0 N L MUNICIPALITY OF ANCHORAGE I DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL I OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION"µ S /L J V �''a �E V j, NW %f SI E (a) Legal Descriptio (inclu`de lot, block, subdivision, section, township, range) 1 5« z4) lzsw 3 nZA1. � nr` Location (address or directions) 11640 =jagami:=- (b) Applicant Name n� yoa-�'j� MC _Telephone: Home ,�7 z ��±� Business n Applicant Address 11640 640 �'CyAE (c) App" -.antis (check one): Lending Institution ❑ ; Owner/builderfEJO Buyer ❑ ;Other ❑ C.n¢rr•ks- Lxr, . ElS'/z_ _ N t/z . MC --y4_. t'm 4 . S(3 -\-A=0 v" 29 D,f;e (W—. (d) Lending Institution Vie/ Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: - _ I i 2. TYPE OF RESIDENCE i tingle -Family Multi -Family❑ Other Number of Bedrooms 1 �C��tt�cct�tr �{cuSC N({j jwo Qcy1zOGMJ ^ SEYP� IS �t5` ' \ FIMHC_ SCy2ovW1S, \ 3. WATER SUPPLY,\ Individual WelIP Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. I 4. SEWAGE DISPOSAL Onsite' Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. i 72-025(11,84) Page 1 of 2 n 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION , As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verily 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. t NameofFirm WHI1U-Q'A1UV_ 0-141V- 9tt4!M Telephone I_TlR7 Date P.O.L.10 of .... ....I .. N$4v THO!A A. hSCHU CE -67;3 Engineer's Seal 6. DHEP APPROVAL Appproved for _rv""C¢ bedrooms by �"-' A' ^^''� Date �2-2,-$/i 1 cc.lD trroNA Approved •J' Disapproved ^ Conditional Terms of Conditional Approval4" cov.r �c+ef �• o� ' Pi ov:oQ+'-�q� o� ..�.2•t.b.,.,/ -x:11 ....ter- �� p,�,,;ao� co,,..ykr- . �::o! K GOW��/.�Tl�OnKS CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending Institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 engineers work. Page 2 of 2 72-02501,84) A. MUNICIPAUTY OF ANCHORAGE DEPT. OF HEALTH d MUNICIPALITY OF ANCHORAGE (MOA) INVIRONWNTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) n� CHECKLIST - FEBRUARY 1984 " 1 284-4720 Le��22I Oescriptio�` s�s/� air \ i�lzo f�cii►. � WELL DATA Well Classification If A, B, D.E.C. Approved (Y/N) N �� Well Log Present (Y/N) O %Date Completed AF'46 <'119 /11°� Yield 4 •Z CC; MtN Total Depth Cased/to Depth of Grouting Nt'A Static Water Level -139 Pump Set At Casing Height Above Ground 1 Z Sanitary Seal on Casing (Y/N) Y� Electrical Wiring in Conduit (Y/N) yes Depression Around Wellhead (Y/N) Separation Distances from Well: t To Septic/Holding Tank on Lot / ; On Adjoining Lots (� / To Nearest Edge of Absorption Field on Lot 175 't- ; On'Adjoining Lots To Nearest Public Sewer Line /A To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot r� Water Sample Collected by c �`" A• r' ;Date Water Sample Test Results F=A Comment* 4o' -r ASS�vNc GASB B. SEPTIC/HOLDING TANK DATA Date Installed J1/S,Size 1 Z_.5D No. of Compartments Z Standpipes (Y/N) Y4is Air -tight Caps (Y/N) YQ Foundation Cleanout (Y/N) Y6 Depression over Tank (Y/N) No Date Last Pumped^' Pumping/Maintenance Contract on File (Y/N) N� A ; for R I Holding Tank High -Water Alarm (Y/N) N R Temporary Holding Tank Permit (Y/N) K I Separation Distances from Septic/Holding Tank: To Water -Supply Well � � To Building Foundation 40' To Property Line �`� r^F To Disposal Field 70 I To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course NI k Comments I Page 1 of 2 72-026111,841 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /6;,>L.`14 ASICA1 Type of System Design Length of Field `14 Width of Field Q r! not ienl...es.Qt a.+ Depth of Field / � / /�_•(( Gravel Bed Thickness l Square Feet of Absorption Area _Jt:J<, 0 Standpipes Present (Y/N) `1�Z5 Depression over Field (Y/N) NQ Date of Last Adequacy Test NEta N/A Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well 1 -7'S ! ^I.- To Property Line 5 To Building Foundation IZO To Existing or Abandoned System on Lot _ CoI-I-- ^Ib i.h CW R ; On Adjoining Lots _ ?A'-4— To Water Main/Service Line To Cutbank (if present) _ N To Stream/Pond/Lake/or Major Drainage Course to /Q C I%.C.I - ) To Driveway, Parking Area, or Vehicle Storage Area 9 O I -i— Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/ 1 _ Dimensions •• Check Permitted Bedroom Rating Against HAA Request •• ,ccess (Y/N) Off' Level at _ Vent(Y/N) _ Pumping Cycles Test. Meets MOA Icertify thatlh checked,veor nformedtoallM07andF{AAguidelinesineffectonthedateofthisinspection. Signed Date 1 4 ew, Company L+Ffnn3 yam. 12"n:.LOtNo. Receipt No. 00 / QO Z/'f Date of Paymeent l Zr_lz6/,6 Amount: $ 6 5--. a Page 2 of 2 72-026 (11,84) +�` OF A4 �'�P• •• „ I` �sf-+0 Engineer's Seal .7 * •'g0Tll •� + ....,{.{...... .:...A •� Ewa► ti ►s- t 0 t ce•srsa ,: •� o ` Jr u f4 �F.•lzsskfa� mac•`