HomeMy WebLinkAboutTIMBER RIDGE BLK 4 LT 1BTimber Ridge
Block 4
Lot 1 B
#050-321-62
TANKS
MUNICIPALITY OF ANCHORAGE ^,
n
DE iTMENT OF HEALTH AND HUMAN SER, ES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
f
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
No of Companmenu
DISTANCES
TYPE OF SYSTEM
� r } .T c k4
FROM TO
SEPTIC
TANK
ABSORPTION
FIELD
WELL
Tal a11ed aWre 11-9inal grade
WELLVerm41
FT
Orerr44,119:11
1,N2 /�wc�.Yy A_45S J'
No No 01 bedroomsye40
Total absorption area
IDistance blween lines
S-0"/SOFT
LOT LINE
EOLf
$al rating
Vipe me ,nal
41157-el
386
Geocs
s/�n 3•+ J•/ y7a
Inslaaer
Sobel, islon// %�Qe& ec!
FOUNDATION
S
/7
ection�"/(•6
AS -BUILT DIAGRAM
1Snow location of wen.
sepoc systom. Dropeny
ones. toundabon.
�' yv J C C
driveway wale, bodies
etc)
TANKS
SEPTIC ❑ HOLDING
Manulactwer
Gapecnv m gallons
Awc.c ?c-.ik
/�So
Mnlene4
No of Companmenu
TYPE OF SYSTEM
,K TRENCH ❑ BED ❑ W. DRAIN ❑ OTHER
Depin Io p, Wltom 110.
Total depth Ilona original grade
onq,nal grade FT
Tal a11ed aWre 11-9inal grade
Glevel depth beneath pipe
FT
Orerr44,119:11
Gravel width ,
3
346 FT
Total absorption area
IDistance blween lines
S-0"/SOFT
Number lit Imes
$al rating
Vipe me ,nal
/
1A S SOFT
s/�n 3•+ J•/ y7a
Inslaaer
Date Installed
• WELLS
PRIVATE e f ❑ OTHER Iidentifvl
REMARKS:
dea . .<</ G.fket v+ T�-K
Scale: s ENGINEER S SEAL
In rlm0 bJ'agfa ncr nomeenng yServICe3 ;���• '� ;'�
w �y!' ^ , •''.�
---P,0.-BoX473294v `ti�: ••,.4•e.. �v �R L`�
Dd1B Eagle River, AK 99577 - sL•G �j' YYe �j �A
694.5195
f
fill
H1. -^.a..
•,• . sae Lee•e«i.e
certify that this inspection was performed according a all V n�ti ••�•••••-••••••••••�• a'
lccis A. Bafcrd Jpf
Municipal and State guidelines in died on this dale. �w�2' �'! s••, CE -5713
Health Department Approval:
1 LVt-� E Date. OfE 51 , oe
72-013 (3re5)
' DRILLERS NAME ,
Wrrt:,&f ir, P.
t :.
.'DOC Co •w •.
..
SULLIVAN'NATER 'WELLS
•
;.
_ ►,O.ltO%772, CHUGIAK,ALASKA99567 • TELEPHOHE68&2769
r� a t3Dd n1 eIG(YDEPTH OF WELL
G+
OWNER OF LAND Sz .+«�
I ,
S'� I �°�' ^� �I-A STATIC LEVEL OF WATER FT.
Za .
ADDRESS
JZ)DRAWDOWNFT.
LEGAL DESCRIPTION M-0Qs A/Qs -
i
DATE • Surted `/ Ended ¢ GALS. PER HR '
KIND OF CASING ��
PERMIT NUMBER
KIND OF FORMATION:
From e—Ft. to.—FL o up C AA U 41E From Ft. to
Ft.
From _3_Ft. to1$_Ft. rdnlj7 <C 7*. From Ft. to
Ft.
From FL to Ft. fill/ }C Fiom Ft. to
Ft.
1
from I Ft. to .j Ft. yl -4.04� ra 4407je From Ft. to__,Ft
Ft. to FL Ct.A Y i C e,4 AF4 From Ft. to—F'
From
From77 Xt. to /�rFL 0,:From Ft. to
Ft.
_�g.°,W'J
l. dq�' o G � *44Frum Ft. to
From.�FL to / 7� F�
�
FL
�,Ccc� From Ft. to
From FL to Ft. - .
FL
f
From / 7 Y FL to_��Ft rl c O rCUC- le--' y/ From FL to
Ft.
�
From Etta FL !7-��� fe'f"� Fromr_Ft. to
Ft.
From FL to Ft. �s �'� From Ft. to
Fl.
Fromlq-2—Ft.t Ft. [�r�d oL.C_ l2r'_�..�From Ft.lo
Ft.
From FL to EL From FL to
Ft.
From Ft. to Ft. From Ft, to
Ft.
from Ft. to Ft. From Ft. to
Ft.
r From FL to Ft. From Ft. to
Ft.•
From FL to—Ft.-From Ft. to
Ft
MISC6. INFORMATION: :
�o 4 C -; ,
' DRILLERS NAME ,
DEPARTMENT n HEALTH AND ENVIRONMENTAL OTECTION
825 STREET, ANCHORAGE, AK 99bOI
264-4720
gyp
SEW[=1R Z< WELL f='1 M I T
PERMIT NO: 86086
DATE ISSUED: 10/14/06
APPLICANT: ROBERT J. MCKAY
ADDRESS: BOX 103443
ANCHORAGE,
AK 99510
CONTACT PHONE: 265-3406
LEGAL DESCRIP: SUBDIVISION: TIMBER RIDGE
LOT: 1D
BLOCK: 4
SECTION: 6
TOWNSHIP:
14N RANGE: 1W
LOT SIZE: 77000 (SQ.FT.
OR ACRES)
MAX BEDROOMS: 4
Listed below are the options
available to
you in designing
your septic
system. Choose the option
best fits
your site. - -
- - -
- - - - - - - - - - -
- - - - - - - - -
-that
Tf3ENC1-1
I--iED
W 7Jr1cFa T N
DEPTH 'TO PIPE BOTTOM (FT.)
4.0
5.0
4.0
GRAVEL DEPTH (FT.)
0.0
0.5
3.5
TOTAL DEPTH (FT.)
12.0
5.5
7.5
GRAVEL WIDTH (FT.)
2.5
20.0
5.0
GRAVEL LENGTH (FT.)
32.0
38.0
54.0
GRAVEL VOLUME (CU.YDS.)
25.2
28.2
40.0
TAN:' SIZE (GALS)
1,250.0 **
1,250.0*
1,250.0 **
SOIL RATING (SQ.FT./8R)
125
125
125
**-TANIMUST -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.
�. I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
1. 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 ma::imam of 4 bedrooms and
any enlargement will require an additional permit.
IF A LIFT STATION IS
THEN (1) AN ELECTRIC
WILL NO'T BE APPROVED
ELECTRICAL WORK MUST
SIGNED
APPLICANT: ROBERT J.
ISSUED BY
INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,.
IL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
BE DONE BY A LICENSED ELECTRICIAN.
DATE:
2- L9_=_-- -----------
MCKAY
---------- DATE:
I
x SOILS LOG
MUNICIPALITY OF ANCHORAGE ❑ PERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST .
825 L Street. Anchorage, Alaska 09501 . 264-4720
SOILS LOG — PERCOLATION TEST
T.. o&c
PERFORMED FOR: �4 �"+ •��t�"r•. of `�` DATE PERFORMED: 9� f /
' t T /vlv f/ w SG L,. 6
LEGAL DESCRIPTION: �OT �O�K �''•G aE SITE PLAN
17
16
19. -
20
/to
parr] H+d G/
WAS GROUND WATER IVO
ENCOUNTERE /�
IF YES, A
DEPTH?
Groes Net
Reading Date Time Time S� 1�•�'k �
Gl+i
do 6r N�4 llrlwt/ 4�iN Y
19TH ,d w
• Louie A. Bulera
CE -6736 �or -
vgo
e•e�••o •, •••••• �.—� PERCOLATION RATE
7ESSOL
TEST RUN BE AND
s 7
1'A%
Lf Be.(r&&1.
Eagle River Engineering Services CERTIFIED BY: �DATE: �� �elee
PERFORMED BY: ox 773194
Eagle River, AK 99577
OU -519S
naoe te/79> '
Z
ASO Rfa ��•.••. •:'•
\ Ret eRrE �
itrrn'Aft CA
pROFESSI�
ft.aT: �s��i3O.,a•
"G�lo: }.tvt 255
i
100
4v .
,
NOa• .
/N
!� Pro�ote.Q •
wall ,�• c, . 'I• 6 t
• , '• -torr-.
*septic plan*only CEt,�No
well to be locator DszAiNe80..9114cGT1Gy)___.' :'
by surveyor.
PLOT .PLAN AS BUILT SCALE (°=$p�.
KENNETH G. LANG, L.S. 1731 GEORGE BELL CIRCLE, ANCHORAGEr ALASKA 99515 (907) 345-6476
I HEREBY CERTIFY THAT I HAVE'SURVEYED..THE FOLLOWING DESCRIBED : .rrCB• 1
PROPERTY,. LOT Ipj BLOCK' 4 ; ' Tl NMFiI C_ r1OCG0¢ gd O
AWCA40MAX-;G RECORDING DISTRICT, ALASKA, AND THAT THE IMPROVE- ��:�4'',.•""'•�.','`�t '"` ' _
MENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND
DO NOT ag���' .__„ •��q:
ENCROACH ONTO THE PROPERTY AQJACENT THERETO, THAT NO IMPROVEMENTS
ON THE PROPERTY. LYINGADJACENT THERETO ENCROACH ON THE SURVEYED
PREMISES AND THAT _THERE ARE NO ROADWAYS, TRANSMISSION LINES OR_'-r2bc
OTHER "VISIBLE EASEMENTS ON SAID PROPERTY EXCEPT AS INDICATED yaw �, LIX,C- S� u¢8 f
HEREON. 4s •`^ l"" 4b
DDAATTED-THIS THE -j DAY OF QTpf5&2 ; 196(0, AT ANCHORAGE,
t.
MunicipalityPOUL;H 6-650
ANCHORAGE, ALASKA 99502-Ofi50
of (907) 264-4111
A/per
nchorage _ TONY RNO VYI(S
MAYOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Permit #: 840141
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot 1B Block 4 Timberidge 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, Supe visor
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SWP/057
n
w
- - r--= I P's1L I T'T IDF= HFaCH►DRRt3-E
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, Af( 99501
264-4720
Co r -i — =. I T E :ETC-: L4 E Ft �':. L.J E L L- I -r
PERMIT NO: £40141
DATE ISSUED: 04/05/84
APPLICANT: HAMMAN CONST.
ADDRESS: P. 0. BOX 617
EAGLE RIVER, AK, 99577
COFJTACT PHONE: 273-3916
LEGAL DESCRIP: SUBDIVISION: TIMBER. RIDGE LOT: 16 BLOCK: 4
SECTION: C. TOWNSHIP: 12N RANGE: 11.1
LOT SIZE: 43000 <so. ft OR ACRES)
MAX BEDROOMS: 3
LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR. SEPTIC
SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR. SITE.
I CERTIFY THAT:
1. 1 AM FAMILIAR WITH THE REQUIREMENTS FOR OPJ-SITE SEWERS AND WELLS AS SET
FORTH B4' THE MUNICIPALITY OF ANCHORAGE (MOA) AND THE STATE OF ALASKA.
2. I WILL INSTALL THE SYSTEM IFJ ACCORDANCE WITH ALL 1-10A CODES AND REGULATIONS;
AND IFJ COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
s I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREFIENTS FOP, THE SET BACK
DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR PUBLIC
SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR 14EAP.BY LOT.
4. 1 UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 2 BEDROOMS AND
ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT.
IF A LIFT STATION IS INSTALLED IFJ AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) All ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT All ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK. MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED
APPLICANT:
ISSUED BY
DATE:
--- DATE: /jv-;E� -
TF?Er-JCH
F3EC�
L4_ E>FRF1 I r -J
DEPTH TO PIPE BOTTOM (FT.)
4.0
4.0
4.0
3.5
GRAVEL DEPTH (FT.)
8.0
0.5
7.5
TOTAL DEPTH (FT.)
12.0
4.5
5. 0
GRAVEL WIDTH (FT.)
2. 5
17.0
34.0
41. 0
GRAVEL LENGTH (FT.)
24.0
30.3
GRAVEL VOLUME CCU. YDS. )
18. 2.
21.4
TANK: SIZE (GALS)
1, 000. 0 :+:k
1, 000. 0 *:»
:1,1000. 0 *»
SOIL RATING (SQ. FT. /BR)
125
125
125
- »»-TANK MUST HAVE AT LEA_�T- TWO -COMPARTMENT- -
- - - - -
- - - - - - - - - - -
I CERTIFY THAT:
1. 1 AM FAMILIAR WITH THE REQUIREMENTS FOR OPJ-SITE SEWERS AND WELLS AS SET
FORTH B4' THE MUNICIPALITY OF ANCHORAGE (MOA) AND THE STATE OF ALASKA.
2. I WILL INSTALL THE SYSTEM IFJ ACCORDANCE WITH ALL 1-10A CODES AND REGULATIONS;
AND IFJ COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
s I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREFIENTS FOP, THE SET BACK
DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR PUBLIC
SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR 14EAP.BY LOT.
4. 1 UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 2 BEDROOMS AND
ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT.
IF A LIFT STATION IS INSTALLED IFJ AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) All ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT All ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK. MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED
APPLICANT:
ISSUED BY
DATE:
--- DATE: /jv-;E� -
SOILS LOG
\ t MUNICIPALITY OF ANCHORAGE
❑ PERCOLATION
- DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST
11 W _ 825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
A.7 e�,t 6/7
fle,, slk,ur. vsr�7
PERFORMED FOR: DATE PERFORMED' ,
T
LEGAL DESCRIPTION: //h's,!>P nril�'P `r�'6�✓ Ldt /� ���
SLOPE 7, SITE PLAN
(FEETIY/OR GiJN/C�
1
2
3
4 1
5 St. c(� E►a
6 -
7
8
9
10
11
.42
13
14 %S/.ne -0/;CJ
15 l('w-FrP)
16 Q6vi . of Hsk
17
*• T
..C.-.-.Vir" I
1 2225-E:
P A . 1 NE 25, 1971
WASGROUNDWATER ^,O
ENCOUNTERED? 'V
IF YES, AT WHAT
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
20 j10, . ��„
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS
EX 3 - C76 O
PERFORMED BY: 1-• jg 'ff'{ry CERTIFIED
72-009 (6/79)
Municipality of Anchorage v
• -tel Development Services Department t. Te.
j' Building Safety Division z
On -Site Water and Wastewater Program
4700 Bragaw Street
R A S N!
Anchorage, AK o g/on
www.muni.org/onsite
`7 �l
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING �{S�
Parcell.D. M-321.62 COSA #_ C1
1. GENERAL INFORMATION Expiration Date: 0
Complete legal description Timber Ridge, Block 4, Lot iB
Location (site address) 19;27 Canyon View Drive Eagle River. AK 99;77
Current Property owner(s) Prudential Relocation Inc. Day phone
Mailing address 1626o N. 71n St.. 2nd Fir Scottsdale AZ 85254
Lending agency Day phone
Mailing address
Real Estate Agent Jodie Moses/Prudential lack White Day phone -277-7292
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
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 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
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 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 imn Pannone Engineering Services LLC Phone 272.8218
��
P.O. BOX102QSG Anchorage AK oaS10
1� gineer s Printed Name Steven R. Pannone P.E. Date (1) _
Engineers Comments: In conducting an adequacy lest, I attempt to provide a thorough, conscientious engineering analysis of the system to
accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions
encountered at the time of the lest, and separation distances measured to readily identifiable features.
The operational life of all wells and septic systems depend on the local soil condition, ground water •• „ to
levels that may fluctuate during the year, and the water usage of the family being served by the system. �! F f..• `„•.,•, ���
These conditions are outside the control of the evaluator of this system. All systems eventually fail andr r #
satisfactory test results do not guarantee future performance of the system, nor do they guarantee that cz 43 r_,.X'% 00
there are no hidden defects or encroachments. PES can therefore not provide any waranty for future �• •--•-•-*••„�
performance nor give any estimate of how long the system will continue to meet the operational -
requirements of the NIDA DSD. The content of this report is for the sole benefit of the owner listed 0.
above. Any reliance upon or use of this report by any other person or party is not authorized nor will it #, Ko CE
confer any legal right whatsoever. �� �' "'•»...„,„...••"• "'�
5. DSD SIGNATURE ��aa�F{sE �:�•�
aa...•.•
Approved for bedrooms.
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: Original Certificate Date:
(Rev 11M
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: _Timber Ridge. Block c. Lot iB Parcel ID:_0r0--A21.62
A. WELL DATA
Well type !'_ If A, B, or C provide PWSID # _ Well Log (Y/N) Y
Date completed 1 a 8 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth _zoo ft. Cased to gift. Casing height (above ground) 36_in.
FROM WELL LOG AT INSPECTION
Date of test 5/1/1984 o/19/2007
Static water level 70 ft. 77 ft,
Well production .75 9 P -m• o.7(recovery test) g.p.m.
WATER SAMPLE RESULTS: �-.��
Coliform colonies/100 mL Nitrate t��mg/L Otfler bacteria—olonies/100 mL
Arsenic: mgll Date of sample: go �rG Collected by: Laura Pannone
B. SEPTIC/HOLDING TANK DATA (�oLT �'lu slog 5
Tank Type/Material _ Anch. Tank Steel Date installed 2012-4/so86
Tank size 12So gal. Number of Compartments a Cteanouts (Y/N)
Foundation cleanout (YIN) Y Depression over tank (Y/N) N High water alarm (Y/N) N/A
Date of pumping 9/2012007 Pumper JR's Pumoina
C. ABSORPTION FIELD DATA 1075
Date installed 10125/1986 Soil rating W+441F-or fe/bdrm)
125 System type Deep Trench
Length 36 ft. Width -4.5 ft. Gravel below pipe 7 ft.
Total depth ;<s fL Eff. absorption area Soy fe Monitoring tube Y Depression over field N
Date of adequacy test gL9/2oo7 Results (Pass/Fail) pass For y bedrooms
Fluid depth in absorption field before test 4 in. Water added600 gal. New depthg in.
Elapsed Time: I_S min. Final fluid depth 2 in. Absorption rate >= 60o+d.
9.P•
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date
D. LIFT STATION
Date installed Size i allons Ma�
'Pump on' level at in. 'Pump o vel at High
Datum Cycl 'testedet
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
; .,s (Y/N)
alarm level at in.
�& circuit requirements?
Septic tank/lift station on lot ioo+ On adjacent lots ioo+
Absorption field on lot ioo+ On adjacent lots ioo+
Public sewer main ioo+ Public sewer manhole/cleanout too+
Sewer /septic service line So+ Holding tank too+
Animal containment areas ioo+* Manure/animal excrete storage areas ioo+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation s' Property line io+ Absorption field q+
Water main ioo+ Water service line ts+ Surface water too+
Wells on adjacent lots ioo+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line to+ Building foundation to+ Water main ioo+
Water Service line tt+ Surface water ioo+ Driveway, parking/vehicle storage t'**
Curtain drain None Observed Wells on adjacent lots too+ _
F. 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 guidelines in effect on this date. •.."""""" ".. •""""""""
0.
Engineer's Printed Name Steven R. Pannone. P.E. �j� ''•.,,
eke', r.�•,•�.`......., . ''�
Date 13070 eye..:••••'
Date of Payment - r i o l u a
Receipt Number
(Rev. 11/05)
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LOT .1-B, BLOCK 4, TIMBER RIDGE SUBD
z
Municipality of Anchorage .,
•�/ �
Development Services Department
P
/ Building Safety Division
On -Site water and wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Nater Well Advisory
Health Authority Approval # 080232
During a recent Health Authority Approval on-site inspection and test of the
potable water supply well on Block 4, Lot 1 B of Timber Ridge subdivision,
the well's productivity was determined to be 0.7 gallons per minute. The
minimum well productivity required by this Department (AMC 15.55) for a
4 -bedroom residence is 0.41 gallons per minute. Although the subject well
currently exceeds this minimum requirement, all parties concerned are
advised that the production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering lawns and
gardens may be required.
This advisory must be attached to all copies of the subject Health Authority
Approval.
M6
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES MV
Division or 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 I.D. #. 050-321-62 HAA # . (. iG C(G622 -
1. GENERAL INFORMATION
Complete legal description TIMRFRIDGF S ten MSIO i. t OT 1 E PLOCK 4
Location (site address or directions) 1f592 CANYON `IE
Property owner DAVE s. Anent JENNY - Day phone 761-7645
Mailing address 12523 CANYON VIEW
Lending agency
Mailing address
Day phone
Agent CAPOLF PFNNE7r - Day phone 751-7648
Address DYNAMIC PROPERTIES 3111 "C" STREFT ANCHORAGE AK 90503
unless otherwise requested, NAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual well xxx
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 xxx
Holding Tank
Community cn-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 MCA 921 Computer version
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1,110.00 at,
or prior to, closing for the engineering services provided.
S. 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. r �,
Name of Firm
Address
Phone (907)337-6179
Engineer's Signature t - ' 'I Date 1//% /6)
In conducting this evaluation, AWWC, ln�!ttetmpted to provide a thorough, conscientious engineering ana
system In accordance with ADEC and Mb D14hS Guidelines & Regulations. The reported results described the
performance of the system under the conditions encountered at the time of the test and separation distances
measured to readily Identifiable features. The operational life of all wells and septic systems depend
on the local soils condition, ground waterlevels that may fluctuate during the year, and the --
usage of the family being served by the system. These conditions are outside the control
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 any warranty for future estimate of how long the
system will continue to meet the operational requirements of the ADEC or MCA 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.
6. DHHS SIGNATURE
_Je:�f Approved for_4 bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
By:
Date ZZ - 2 7-0
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 net responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) 6acx MCA 921 Computer Version
RECEIVED
Munldpallty of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVIC%V 0 9 2000
Environmental Services Division
825 "L" Street. Rm 502 Anchorage, Alaska 89501 (907) 343.4744
MUNIGPALITY OF ANCHORAGE
Heafth Authority Approval ChecklistT� tON
Legal Description: TIMBERIDGE SUBDMSION: LOT 1 B BLOCK 4 Parcel I.D.: 050-321-62
A. WELL DATA
Wen Type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number N/A
Log present (Y/N) YES Date completed 5/84
Total depth 200' Cased to 81'-6" Casing height (above ground) 18"+
Sanitary seal (YM) YES Wires property protected (YM) YES
FROM WELL LOG
Date of teat 5/84
Static water level 70'
Well production 0.75 g.p m.
WATER SAMPLE RESULTS:
AT INSPECTION
10/31/00
2.9 g.p.m.
Collfonn
0 Nitrate 3.91 mg/L Other bacterla 0
Date of sample: 10/31/2000 Collected by: A.W.W.C.. INC.
e. SEPTICIHOLDING TANK DATA
Data instated 11 /20/86 Tank size
1250 Number of CompaMMtS 2 aganouts (Y/N) YES
Foundation deanout (Y/N) Y Depression (Y/N) NO Ngh water alarm (Y/N) N/A
Date of Pumping 10/31 /00 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA [SUMP/MT]
Data installed 11/20/86 Son rating (g.p.dJft2 or ft21bd®) 125 System type TRENCH
Length 36' Width ___I&—Gravel Gravel thickness below pipe 7' Total depth 11.3'
Effective absorption area 504 SO Fr Monitoring Tube present (Y/N) YES Depression over field (YM) NO
Date of adequacy test 10131/00 Results (PasslFan) PASS For 4 Bedrooms
Fluid depth in absorption field before teat (in.); 0" Immediately afters—tot. water added (in.r11-5/1 -0
Fluid depth 0. (Ina) Minutes later. 14 Absorption rate = 1 600+
Permdde treatment (past 12 Months) (Y/N) NONE KNOWN If yes, give date
rocas twv. 3INer ooeow.r ft"
0. LIFT STATION
Date installed Size In
Menhole/Acoess (YIN) "Pump on' levet at'
High water alar level at'
Cycles
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
level ar
Septidholdig tank on lot 100'+ On adjacent kfts 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main N/A Public sewer manhole/deanout N/A
Sewer/septic service line 25'+ LIR mon 100'+
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Foundation 5'+
Property line
5'+
Absorption field
5'+
Water maiNservice One 10'+
Surface waterldrainage
100'+
Wells on adjacent lots
100'+
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Property One 10'+ Building foundation 10'+ Water maln/servlce One 10'+
Surface water 100'+ OdvMy, parking/vehide storage area 10'+
Curtain drain NONE KNOWN Wells On adjacent I ts4 100'+
F. ENGINEER'S
I cot* Drat I i
ofMrm/dpslq
whir MOA HA
Engineer's
HAA Fee
Date of Payment L
Receipt Number (4e'Y'Y7
Held kMeWons and revlew
systems are In conformance
;n this date.
Waiver Fee $
Date of Payment
�� Receipt Number
-07-00 16:45 FR011-CTE ENVIROMENTAL
CE Environmental Services Inc.
LTA..
CUE ReLN
1006923001
Client Name
AK Water & Wastewater Consultants Inc.
Project Name/N
TWZer Ridge SID
Client Sample ID
Lot 1B Dlk 4
Matrix
Drinking Water
Ordered By
PWSID
0
Sample Remarks:
5615301 T-383 P.02/03 F-683
Client PON
Printed Date/f imc
Collected Date fime
Received Date/Time
Technical Director
J��
Released B:/a
11107/2000 13:51
10/31/2000 16:10
11/01/2000 10:45
�S.teephhen C. Ede
W/ -J�
Allowable Prep Analysis Init
Parameter Resale PQL Units Mahal Limits Date Date
Waters Department
Nitiatc-N
Microbiology Laboratory
Total Coliform
r-
3.91
0
0.500 m8/L EPA 300.0
coV100mL SM199222B
10 max l 1101/00 SCL
11/01100 KAP
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES M1
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
Parcel I.D. # f1=f ' ' �Ia N — I ,") HAA # 0 1ci Q C"S)-1
1. GENERAL INFORMATION
Complete legal description
Lot 18; B£ock 4; Tamben Ridge Subd�vi6ion;
Location (site address or directions) 19523 Canyon View Da.ive
Property owner Robert 9 Donna Mc Kay Day phone
Mailing address Faafe R.iveA APaska 99577
Lending agency
Day phone
Mailing address
Agent Logi. C710wde2 RE/MAX OF EAGLE RIVER Day phone 694-4200
16600 CentenbiDncve
Address Suite 201
Eagte Riven, Ataska 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual well XX
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 XX
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.
72-025(Ro.V91) From MOA,21
1c. row %� 11611,"" smu
•NJom sdaau!6ua leuoissolad atll u! suo!ss!wo Jo siona Jol alq!suodsaJ
IOU s! e6eJoyouV ;o AI!led!oiunyl ay1 •ponssi si aleo!l poo a eJolaq elep azAleue Jo suo!loadsui lonpuoo
IOU OP SHHO to s9aAoldw3 •sluawaJnnboi alels pus leJapa; u!elJao A;s!les of JapJo u! suo!lnl!lsu! 6u!pual J!aq) pue
sawotl to sJasegoJnd of Asalinoo a se siyl saop SHHO ay1 •e�sely to 91LIS ayl u! poials!69J Jaau!6ua leuo!ssalad
3uapuadapu! up Aq anoge S t4deJ6eJed ui u9A16 suoileluasaJdaJ ayl uodn Aluo paseq s0le3!l!u80 IenaddV
AIuo4lnV tilleaH sanss! (SHHO) sao!AJaS uewnH pue ylleaH to Iuawliedaa a6eJogouV;o Apled!o!unw a41
•� o •
muo!lelnd!ls 6u!mo!lo; ayl yl!m 'swoaJpaq
Z6 -b1-8 also
NUUIIVJ
sluawwo0 leuo!i!ppV
Jo; IEAoldde !euoq!puoC)
•p9naddes!0
In
•swooJpaq Jo; panaddV
3un1VNJIS SHHO '9
wnleu6!s sdaaw6u3
LLS66 t1se1V'JaAla 816c3 ssalppv
auNd tar *ON oeoy dooz jamy w6ra V=Z wJ!d;o awsN
ONI1133NION3 S'8 S
•uolloadsut s!yl;o alep ayl uo loa;;a ui suo!leln5cu pup 'saoueulpJo
'sapoo a;elS pup ledlolunVy Ile yl!m eouelldwoo ul s! walsAs lesodslp Jalemalsem Jo/pue Alddns
Jolem el!s-uo atll'uo!loadsut pus uo!le61;sanu! AW woJ; pue Sal!) a6eJot4ouV10 Al!led!o!unyq ayl
woJ; pau!elgo uo!lewJo;ui ayl uo paseq leyl A;uaAJaUIJn; I'u!aJaq paleo!pui aJnlonJls;o adAl pup
swooJpaq;o Jagwnu ayl Jo; elenbape pup leuo!loun; 'ales si walsAs lesods!p Jalemalsem Jo/pue --
Alddns Jalem el!s-uo ayl leyl smogs uo!leo!Idde IenoJddV A;uoglnV WleaH s!yl;o uo1le61lsanu1
Aw leyl ApJaA I 'molaq umogs alep uollep!IeA ayl;o se pue olaJay pax!;;e leas Aw Aq pa!;!lJao sV
H33NION3 AS N01103dSNl d0 1N3W31V1S 'S
Municipality of Anchorage
Department of Health & Human Services IN
HEALTH AUTHORITY APPROVAL CHECKLIST EXTW
Legal Description: Lar 14' eL--V-4 T r1EG-y moa l I.D.
A. WELL DATA
Well type O" L t>etliv If A, B, or C, attach ADEC letter
ADEC water system number 4A p
Log present Date completed S- el Driller SJLL r JA -kJ
� N ) `�
Total depth ZO 0' Cased to $1 Casing height
Sanitary seal (�/N) J Wires properly protected&N)
Flo tro t� oN F) c.E,
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
1171
�5 kPA.
g�
SEPARATION DISTANCES FROM WELL TO:
a
AT INSPECTION o
Q
Do
U-1
V
m
>
o
W
L.0
z
�
`
r r�
a b l
<65T S{
AL
Pgcfr
Septic/holding tank on lot to o t ; On adjacent lots toot}
Absorption field on lot koe �L ; On adjacent lots
Public sewer main d Public sewer manhole/cleanout
Sewer service line '2-5� 1+ Petroleum tank
WATER SAMPLE RESULTS:
Coliform O 401.Ltco. ,, Nitrate Other bacteria 'Joar-
Date of sample: r3 -15,9q, Collected by: Z� S
B. SEPTIC/HOLDING TANK DATA
Date installed 1v . Z' '$ b Tank size 11,Sy Compartments 2-
Cleanouts(YYN) � j Foundation cleanout WN) — Depression (Y&
High water alarm (Ya Alarm tested (Y/N) �lA
Date of pumping Pumper L
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
sr -P
Well(s)onlot 1 oO�k Onadjacentlots loOtk Foundation
I ) + ' " 11
Topropertyline Lo Absorptionfietd 10 Water main/service line to•
Surface water/drainage
72.026 (Rev. 751) From CONTINUED ON BACK PAGE
C. LIFT STATION
Date Installed
Size In gallons
Vent(Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes
Well on lot
Manufacturer_
Manhole/Access(Y/N)
FROM LIFT STATION TO:
D. ABSORPTION FIELD DATA
On adjacent lots
off" level at
— Cycles tested
Surface water
Date Installed 2S,6L Soil rating VZ15-b/6¢_ System type
Length 3(o` Width3.51 Gravel thickness— L!f )
... Totat depth
Total absorption area 5-n4 Cieanouts present O/N)
Depression over field (Y& IJ Date of adequacy test L
Resultsbedrooms
a s ail) for_ 9a0C (=j�
Peroxide treatment (past I2 months) (Y151) �� ILA 6%, NN If yes, give date 0-14
SEPARATION DISTANCE FROM ABSORPTION FIELD TO: ,
Well on lot- LDot .1, On adjacent lots Property line --LV
To building foundation _- I o Ik To existing or abandoned system on lot - flj
On adjacent lots 3oI� Cutbank '5_6t Water main/service line_ 1DI'f
Surface water I otk Driveway, parking/vehicle storage area S 14 -
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
S & S ENGINEERING
Signature 17C24 Eagle River Loop Road No. 204
ag a River, Alaska
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number 3 S
72-026 (A" 3/91) Bxh MOA 21 0.5 -a 3
Waiver Fee: $ _
Date of Payment
Receipt Number
.. 'S.:4M '••w
CIIEAIICAI, & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
-033 H ETFEEI ANCHORAOF. ALASKA 09510 TELEPHONE (907)6622m rAk (907) 661-6301
Client saaple IC : Ilk 14 t11Q11 IIDCI
MID : 01
Collected ►DC 19 92 t 15:50 bro.
Received AUG 14 92 l W00 hrs.
Ptttstved with AS RtQnIRID
Analysis Completed r AUG 17 92
Laboratory supet.tsot TIPIIty C. IDI
10106141 IT t 6o4:4�
��
1111,1313 ACSOLT9 for isytICI 1 57045
Cbeelab Sat .1 92.4196 saaple 1 1 Rett':a RATIl
Client Rene IS & S IkCIR1119
Client lest 119619CP
SP01 :
Rept :
World By tR. 9RAfsk
Recd Reports to:
1)3 & s 190181E m
2)
POt t909t tIC1I11D
...........................................................................................
hterout Reealte Erato method Alleveble Moats
--- ----- -------�-- ------------------------- -----
5.0
RITAATI R /1IPA 753.2 30
Semple RM-Ist ums CCLSECTCD III I.J.1.
lourke :
................................
.....................................................................................................
1 tuts PI[formed . $ee special Insttuettom Above C1-11navailable
ID• Rom Ditaetod .. Sw saspis Rmatks Above
RI- Rot Analyred LT-.ut T ar., C2-CteRtez than
Momtur a1 Ana SOS Group (Soe dt6 Odndreis de Survsllanes)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION CWENWROIkiMENTAL HEALTH
,'CERTIFIC
'ATE OF IZfHORIiYAPPROVAL '
OF ON-SITE SEWER AND.WATER FACILITY
-4720
264
J.
t•Apphtication Date
17
6-1
r`.:' (a) �' Legal Description (include lot, block subdrvtsion section township; rangej�, r< , '•{ .) .,� * r ,`�'
t, smeqs 4 ;4 8
(b).- Applic nt Name
V, "A
13 ju,- raimeE
"
Applicant Is (check brie) Lending Institution [3 Owner/bbilder M Buyer Other 13.(explain);
Ti r
(dff Lending Institution C �t--.;National ".Bank'llf-'L—`Telephone
1z �, I -; �V. -, !�, , �.. r
Address . dr a BrgrjChLk-,AnChf)ra9e
. ffi�
e (ate Company Ad Agenty
W
TeePhone
NAt 6 J
I - ft*AWft*j ,
WATER SU' P
d'Iel mmurnty O Public 11
V"
-�fir State Dep I Gon servaio
te I m y well jyj sthavewritle aji6hfrdmthi
attestin a aIlty and status.
f
DISPUbAlr,
SEWAGE
01
Iding T
w,:
i n
,Onsite _Public Comi-ir"Zi'ity
%%�P*Uyeol
'NAAM46". a Conservation
*onfii I
V
Note: if comrTiu6ity well system,'must have written c i nfi& , j
to the legality and status-:� T,
attesting
0, - ^ t, 1, - , r -4 j %- 1,;1,
72-025 (1144) . .....
,4
,.4
-.Pagel
, .
5. ENGINEERING FIRM PROVIDII, INSPECTIONS, TESTS, FILE SEARCH D�A AND INFORMATION
.r. As certified by my s;ji affixed hereto and as of the validation date shown below, I verity that my l6vastigation oft is Health,.
�ind/or jWj�iiiwafWdii06sat system is safe, lunctional an a equate Authority Approval shows that the orkite water supp
-"for the number
b�a .0,--
be
dx
9,i
S. -a .
..
p . -e
.Of
r' u".c
!.ur..e'
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?
i
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er
e
'
I
I" hcr�ve"rfy. that --ase on
rm
from the uni ipa ityAnchoTgelesnd Ir.m;�nve t t spction heon-site wate
u I n
;wastewateri;posal systemi5In all
and ej1orcFantes and regulations In effectI on 4
1 e date
0fthis inse!on . .e (y
!NamA rn 'EAGLE RIVER RN SERVICES'` ee
. I ..
AK 99577
All
rofessional enginee s work.
1-4 Z -
!-M uveal .7 rGt
4?
MUNICIPALITY OF ANCHORAGE (MOA)
11CKAUIY opWWTHORITY APPROVAL (HAA)
Dm. OF HEALMOIECKLIST - FEBRUARY 1994
"lRpNMEMAL MTECnON 2644720
/ G S�6fc6i-+F
51987 Legal Description: Z07- r
_ -rly- R Iw Sr G
A. WELL DATA RECEIVED
Well Classification !(l tTt If A. B. C, D.E.C. Approved (YIN) 7"Filpo 12-1i-e)l
Well Log Present (YIN) y
Date Completed r��`/ Yield 6P11
2 oo ' Cased to 7A Depth of Grouting Nij
Total Depth 9 la__
Static Water Level Pump Set At _
C in (YIN' Y
Casing Height Above Ground
SanitarySeal on as
Electrical Wiring in Conduit (YIN) % Depression Around Wellhead (YIN)
Separation Distances from Well:
/H Idin Tank on Lot
/Say
On Adjoining Lots /CO
To Septic o g -
To Nearest Edge of Absorption Field on Lot /ES ; On Adjoining Lots �0 y
To Nearest Public Sewer Line 2 S T To Nearest Public Sewer
Cleanout/Manhole
NA To Nearest Sewer Service Line on Lot NA
Water Sample Collected by
E,,.:"< . ;Date !z-zs-Et
Water Sample Test Results 4�- {
mq
Comments
S. SEPTIC/HOLDING TANK DATA
S-86
/O-2?J o No. of Compartments `-
Date Installed Size f
Standpipes (YIN) Y Air -tight Caps (YIN) i Foundation Cleanout (YIN)
Depression over Tank (YIN)
A.! Date Last Pumped Ne.
Pumping/Maintenance Contract on Fite (Y/N)
N R ;for NR
Holding Tank High -Water Alarm (Y/N) V4 Temporary Holding Tank Permit (YIN) AJT
Separation Distances from Septic/Holding Tank: S
To Water -Supply Well /SU To Building Foundation
To Property Line
To Disposal Field / /
To Water Main/Service Line
Tfa To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-0260 ti64)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata -JLS gG.D.-
Type of System Design TXE-"c ro
Date Installed /0-2,r - e6 Length of Field 3L
Width of Field 3 : 't Depth of Field —1
Gravel Bed Thickness 7
Square Feet of Absorption Area rid b Standpipes Present(Y/N)
Depression over Field (Y/N) AJ
Results of Last Adequacy Test NA
Separation Distance from Absorption Field:
To Water -Supply Well /S -r
To Building Foundation /71
Lot — "A
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course _
To Driveway. Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION d/
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at _
Tested for
Electrical Codes (Y/N)
Comments
Date of Last Adequacy Test N<
To Property Line ST
To Existing or Abandoned System on
; On Adjoining Lots
— To Cutbank (if present) SrU
00 -0
Dimensions
Manhole/Access (Y/N)
- "Pump Off' Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
" Check Permitted Bedroom Rating Against HAA --
Request
I certify that I have cke lie
ormed to all MOA and HAA guidelines in
effect on the date of this inspection.
Signed
_ /1-29-86'
Company rN- Ff
MOA No. ST Zsi
Receipt No. on
f
Date of Payment
C•° .?,
Amount: $Jq
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�,,, •' <. . �1 Engineer's Seal
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CD W ! �C4Y- �
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Page 2 of 2
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