HomeMy WebLinkAboutRABBIT CREEK VIEW & HEIGHTS BLK 11H LT 15ARabbit ere k Vi w&H ights Block 1 IH Lot 1SA #020-581-69 Municipality of Anchorage Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 545-4744 On-Sits Wastewater Disposal System and/or Well Inspection Report Permit Number: SW990264 PID Number:, 020--111--61 Nome: CLARK OLSEN WastewaterSystem: [] New · Upgrade Address; 17031 NICKLEEN ST. ANCH. AK, 99510 [u",ER/LOWER]ABSORPTION FIELD [UPPER/LOWER] Ph°ne:(907) 545--7492/235--9344 No. of Bedrooms: 2 [] Deep Trench · Shallow Trench [] Bed [] Mound [] Other LEGAL DESCRIPTION .0,. Ra~ng: Total Depth fTom o.ginal grade: 0.8 oPg/S~. ~. **4.0 MAX/1.5 MAX 15 11 RABBIT CREEK HTS 3.5 MAX/I' MAX F~ 0.54/0.50 Ft. -- -- -- SEE AS-BUILT DRAWING n. 33'/42' (75'TOTAL) WELL: [] New [] Up.~.- 5 ~t 2 N/A F~ Ft. 575 S~. F~ ASTM D-3054/F-810 ~ A+ HOME SERVICES 9 27799 - 11/10/99 SEPARATION DISTANCES [] Septrc [] No,d~.g · S.T.E... From Tank Reid StoUon Tank s~w~r U,, ANCHORAGE TANK 1250 Well 100'+ 100'+ 100'+ - 25'+ Mof,~o~= STEEL ,,mm of comparbnent,: 2 Sur~aCewater 100'+ 100'+ 100'+ - LIFT STATION Une 5'+ 10'+ 5'+ - - 1250I ANCHORAGE TANK/ORENCO SYSTEMS Foundation 5'+ '5'+ 5'+ - - ~-2" 42" 44" Curtoln Pump Maim & HHF Drain *** NONE KNOWN 20 OSI 05 M.O.A. I I Remarks: * 5' WAIVER GRANTED WITH ISSUANCE OF PERMIT. BENCH MARK · , TO TOP OF SAND. TOP OF MANHOLE. · **UPPER TRENCH IS 5' FROM FOUNDATION DRAIN (DRAIN IS BELOW FOOTER AND ABOVE THE SEPTIC SYSTEM). NO WATER 98.66 ,, DRA,N D UR,NC PER,ODS OF RA,,PA". Inspections performed by: AWWC, INC. Dates: 1st ~/~z/g,-./~s/,, . ..:... Department of Health, d_ H. ~n/a)n S, e,~ic.e~s approval ~i'~".~ ...v. ~ :-7B53.......',.~ Reviewed and approved by:/~_~. 7~a:~l~_ Date: ~ ,~ ~..~o~O~.~=' '¢~%~' AS-BUILT DRAWING .~CEL .o .U..E.:o=o_ 1 ' ,--61 / LOT 16, BLOCK 11 /% ~ ~ % I co4 A~SKA WATER AND WASTEWATER CONSULTANTS, INC. PHONE: (907) 337-6179/F~: (907) 338-324B ~ " ' RABBIT CREEK HEIGHTS, LOT 15, BLOCK 11 ...... ]'~' ~; ......... ~PE OF WORK: AS-BUILT OF SEPTIC SYSTEM UPGRADE ,....~ ~ .K.:~ ...... : PREPPED FOR: PHONE NUMBER: ~0~¢¢~ fi,, A. Gorness..¢¢ 545-7492/255-9544 ~E~953 . '"' PERMIT NUMBER; sw,,o26, AS-BUILT DRAWING *oB,,o NUMB*020_,,,_6, TANK SET LEVEL WTHN 0.01 FEET /~1i',P~¢/¢~-'¢8,4. ~ N~W 12~0 ~LON LOWER TRENCH UPPER TRENCH ALASKA WATER AND WASTEWATER CONSULTANTS, INC. 6901 DE~R R~, SU~ 2B. ~OHO~GE, ~. 99504 PROFILE AS-BUILT OF SEPTIC SYSTEM UPGRADE ~~.....f PEEPARED FO~: PHONE NUMBER: 545-7492/255-9544 m~: DroWN m:K.D.W. 1 40' 11/24/99 = 5 OF 5 P~ E~S. ELECTRIC 2?2 4590 ED'S ELECTRIC INC. 3138 COMMERCIAL DRIVE ANCHORAGE, ALASKA 99501 ANCHORAGE (907) 272-4591 Fax: (907) 272-4590 ' ADDRE..~S: PHONE # MUNICIPALITY OF ANCHORAGE Department of Heaith and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 Upgrade Date Issued: Aug 0~999 Site Address: 017031 NICKLEEN ST Total Bedrooms: 2 Permit Number: SW990264 Legal Description: RABBIT CREEK HEIGHTS BLK 11 LT 15 Design Engineer: 0041 AK Water & Wastewater Consulta Owner Name: Clark Olsen OwnerAddmss: 17031 NICKLEEN ST ANCHORAGE , AK 99510-1020 Expiration Date: Aug 08, 2000 Pamel ID: 020-111-61 Lot Size: 42103 SQ. FT. 1~) ~ ~_~-:-~.~c~ Permit Bedrooms: 2 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 Drinking 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 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: ~_c~ ~~ Date: Alaska Water & Wastewater Consultants, Inc. October 6, 1999 Murficipality of Anchorage Department of Health & Human Services Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 6901 DeBarr Road, Suite 2B ~ Anchorage, AK ~ 99504 (907) 337-6179 ~ Fax (907) 338-3246 Consulting Engineers EC£1V£D OCT 6 199 ua/th .,. ~, ~ ~ ~tt~roat~ ~rOge ere/Ce~ Ref: Revised Septic Design for Rabbit Creek Heights, Lot 15, Block 11 To whom it may concern: A permit was issued by yom' department on 8/9/99 for the septic system upgrade on the reference property. The original design called for one 5 foot wide drainfield that was 75 feet long. After the first 33 feet of the drainfield were excavated, a large buried brash pile was discovered that prohibited the rest of the trench to be installed in that area. The 33 foot length of the trench was installed completely and a new test hole was dug to the north of the proposed second half of the drainfield. Comments regarding the proposed upgrade are as follows: 1. SOILS: Test hole #3 was excavated to a depth of 7 feet and groundwater was encountered at the bottom of the excavation. Eight days later, groundwater was found to be at 5.5 feet below grade. There were approximately 2 feet of organics and loam at the surface of the test hole followed by a GM material to a depth of 5 feet. From 5 feet to the bottom of the test hole was a SW/GW material. Two perks test were performed in this test hole on two different dates. The first perk test was performed at a depth of 3.5 to 4.0 feet and the soils perked at a rate of 21.8 min./inch. Due to the fact that the perk test was performed during a heavy rainfall, it is our opinion that this perk test is not truly representative of the overall soil absorption. Consequently, another perk test was performed 7 days later at a depth of 2.0 to 2.5 feet and the soil perked at a rate of 6.8 min./inch. 2. TRENCH DESIGN: a. Percolation Rate: 21.8 min./inch, 6.8 min./inch ~14.3 min./inch average) b. Allowable Application Rate: 0.8 gallons/day/ft~ c. Number of Bedrooms: 2 d. Design Flow: 300 gallons per day e. Minimum Absorption Area: 375 ft2 f. Square feet already installed: 165 ft2 g. Max/mum total depth: 2 feet ~/x h. Effective Depth: 1 .%or G ~.~ i. Reduction Factor: N/A j. Width: 5 feet k. Length: 43 feet 1. Sand filter: 1 ft. (minimum) k. Effective absorption area = 215 ft2 (215ft2 + 165ft2= 380ft2) 3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed upgrade. 4. TOPOGRAPHY: A topography drawing was attached with the original design package. There are no slope concerns. I am unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact me at 337-6179. Thank you for your assistance. Sincerely, President HARWOOD L LOT 3, BLOCK 11 RABBIT CREEK HTS. S/D LOT 17 BL~CK 11 RABBIT ~EK HTS. S/D LOT 16, BLOCK 11 I\ CREEK HTS. S/D \ / LOT 4, BLOCK 11 RABBff CREEK HTS. S/D LOT 14, BLOCK 11 RABBff CREEK HTS. S/D .. LOT 5, BLOCK 11 RABBIT CREEK HTS, S/D TH~2+ 2 BEDROOM HOUSE ! SEP~C // SYSTEM (SEE DESIGN, PAGE 2 OF 2) L£ ALASKA WATER AND WASTEWATER CONSULTANTS, INC. 6901 DEBARR ROAD, SUITE 28. ANCHORAGE, AK. 99504 PHONE~ (907) 337-6179/FAX: (907) 338-3246 LEGAL DESCRIPTION: RABBIT CREEK HEIGHTS; LOT 15, BLOCK 11 ~PE OF WORK: SITE PLAN PREPARED FOR: PHONE NUMBER: CLARK OLSEN (907) 545-7492 LOT 6, BLOCK 11 RABBIT CREEK HTS. S/D LOT 7, BLOCK 11 RABBIT CREEK HTS. S/D SEPTIC s¥~eM q~ DAT~:7/27/99 IDRAWN BY: IsGALE IPA°E: A.C.G. 1 = 100' 1 OF 2 I h ~EXI~ING 1000 *ALLON SEmlC P~OPE~ UNE ~D ~E ~00 ~ELL ~IUS ~ ~D BY A ~E~I~ED ~ND SU~O~ PRIOR TO CON~RU~ON. ~ ~ ~E ~ENCH SH~ BE ~D P~L ~ TO ~E SLOPE CONTOURS, J L_ J LEGAL DESCRIPTION: RABBIT CREEK HEIGHTS, LOT 15, BLOCK 11 REVISED DESIGN OF SEPTIC SYSTEM UPGRADE (PERMIT ~ SW990264) ..,; ~REPARED FOR, PHONE NUM.ER: OLS N A.C.G. 1 : 40' 1 OF 2 M'r V ~ 0 co lo 2' P~) ~P ~' DON~, ~P I' (MINIMUM) M,OA, ~0~, ~P I' ~ CDEV, W~P, IN~A~ON i~ ~S~ WAlK A~ WAS~WA~R CONS~TA~S, INC. 6901 DE~RR RO~, SUI~ 2B. ANCHO~GE, AK. 99.504 · DETAIL OF REVISED SEPTIC SYSTEM UPORADE (PERMIT ~ SW990264) ~ ~..~....~ C~RK OLSEN ~TE:10/6/99 JD~WN BY: lsd: J PAOB ALASKA WATER & WASTEWA~R CONSULTANTS, INC. ,=, OF' LEGAL DESCRIPTION: RABBIT CREEK HTS. SUBDIVISION; LOT 15, BLOCK 11 PERFORMED FOR: O,,RK OLSEN ...L=/..A :~ ~.-'~..: , '.,~f r~ ~' ~. garness; I I ...... ' TEST HOLE #1 -'~t~;.",, ,.' ...... ,.~-~ ~EPTH ~ feet) i ORGANIC AND FILL SOIL CLASSIFICATIONS / \ / _~  GH CL LIGHT SAND AND SW SC ~ DEPTH TO DATE 5 '~ +TH~2 GROUNDWATER SMALL ROCKS DRY 6/30/99 (HARDPAN) ~ DRY 7/7/99 11 DATE READING CLOCK NET TIHE WATER LEVEL NET DROP TINE (NINUTES) READING (INCHES) 12 7/1/99 PERC, HOLE WAS PRESO~ED 4+ HOURS PRIOR TO TEEING 13 1 3:12 ~ 6" 2 3:42 30 3 9/16" 2 7/16'; 14 3 ~ 3:43 ~ 6" 4 4:13 30 3 11/16" 2 5/16" 15 ~ 5 4:14 6" ~s ~ s ~:~ 3o _ ~ ~/~" 2 1/4" 17 18 19 PERCOLATION RATE 13.3 (HIN,/INCH) PERC. HOLE DIA, 6 (INCHES) 20 TEST RUN BETWEEN 6.0 FT. AND 6.5 FT. COHHENTS: PERFORMED BY A~SKA WATER ~ WASTEWATER. I, JEFFR~ A, GARNESS, CERTI~ THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEUNES IN EFFECT ON ~ATE: DEPTH TO DATE GROUNDWATER DRY 6/~0/99 DRY 7/7/99 ALASKA WATER & WASTEWATER CONSULTANTS, INC. ISOlLLOG - PERCOLATION TEST I , PERFORMED FOR: CLARK OLSEN ~...~-~. ~. .1.......~. ". ~ ~ '...d/~fj rE ~/A. Garness..,' "'[ I TEST HOLE #2J ;; ORGANIC ~: AND FILL 2 SM SOIL CLASSIFICATIONS PLA,N'p-'~ .,-,¢~' ,, \ \ \ GC OL BONDED blL ~ SW HH ] j: DEPTH TO DATE 3ROUNDWATEI; ML WITH SOME SEEPING @ 7,0 6/30/99 LIGHT SAND AND 9 GRAVEL STANDING WATER X HOUSE Itl ON BOTTOM 6/30/99 ......... ~ L 7/1/99 PERC. HOLE WAS PRESOAKED 4+ HOURS PRIOR TO TESTING 1 3:14 6" _ 2___ 3:24 10 1 7/8" 4 1/8" 3 3:25 6" 4 3:35 10 2 1/16" 3 15/~6" 5 3:36 6" -- __ _____ 6 3:46 10 2 1/4" 3 3/4' 7 3:47 -- 6" __ __ __ 8 3:57 10 2.0" 4.0" 9 3:57 -- 6" __ -'-- 10_ 4:07 10 2 1/4" 3 3/4'7~ -- 11 4:08 -- 6" __ 12 4:18 10 2 3/16" 3 3/16' PERCOLATION RATE 2.6 (HIN./INCH) PERC. HOLE DIA. 6 (INCHES) 20 ~ TEST RUN BETWEEN 3.5 FT. AND 4.0 FT. COHHENTS: PERFORMED BY.ALASKA WATER & WASTEWATER. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WAS PERFC/RME/~) IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON DATE: 'Ti 2-~,J ~ DEPTH TO DATE 3ROUNDWATEI; SEEPING @ 7,0 6/30/99 ~TANDING WATER ON Bo'FrOM 6/30/99 8.3' 7/6/99 ALASKA WATER & WASTEWATER CONSULTANTS, INC. PHONE (907) 337-6179 * FAX (907) 338-3246 LEGAL DESCRIPTION: RABBIT CREEK HTS. SUBDIVISION; LOT 15, BLOCK 11 PERFORMED FOR: CLARK OLSEN ¢~; .................. DATE PERFORMED: 0/27/99 ~fi~ '4. II %_~ ' · I TEST HOLE #,3] "1~,.,',,,. '. ............ DEPTH ~ 1 ..... ORGANICS/LOAM PAGE 1 OF 2 ~'~'c "~ GW ,~ ORG 4 ~M GC OL ~%~ SW NH 5 ~ sP CH / 3ROUNDWATER DATE 5.5' 10/5/99 '~ ~ BEDROOM t % HOUSE ] 11 DATE READING CLOCK NET TIME WATER LEVEL NET DROP TIME (MINUTES) READING (INCHES) 12 9/28/99 PERC. HOLE WAS PRESOAKED 4+ HOURS PRIOR TO TEEING 15 1 ~7 6" 2 ~:27 30 4 7/8' 1 1/8" 14 ~ 3:28 6" 4 4:OB 30~ 4 11/16" 1 5/16" 15 5 4:09 -- 6" -- -- 16 6 4:39 30 4 5/8" 1 3/8" 17 18 19 PERCOLATION PATE 21,8 (HIN./INCH) PERC. HOLE DIA. 6 (INCHES) 20 TEST RUN BETWEEN 3.5 FT, AND 4,0 FT. COHHENTS: PEECO~TION DATA ON THIS PAGE FOR LOWER BENCH PEEK TE~ ONLY. PERFORMED BY A~SKA WATER ~ WASTEWATER. I, JEFFR~ A, GARNESS, CERTI~ THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON DATE: DEPTH TO 2ROUNDWATER DATE 7' 9/27/99 5.5' 10/5/99 ALASKA WATER & WASTEWATER CONSULTANTS, INC. 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK. 99504 PHONE (907) 3'47-6179 * FAX (907) 3,38-5246 [SOIL LOG - PERCOLATION TESTI LEGAL DESCRIPTION: PERFORMED FOR: DATE PERFORMED: RABBIT CREEK HTS, SUBDIVISION; LOT 15, BLOCK 11 CLARK OLSEN 9/27/99 I TEST HOLE #.31 PAGE 2 OF 2 SOIL CLASSIFICATIONS ORG ML CL OL NH CH OH SC DEPTH TO ~ROUNDWATEH DATE SEE PAGE 1 OF 2 DATE READING CLOCK NET TINE WATER LEVEL NET DROP TIHE (NINUTES READING (INCHES) 10/5/99 PERC, HOLE WAS PRESOAKED 4+ HOURS PRIOR TO TESTING  1 2:01 6" 2 2:31 30 11/2" 4 1/2" 3 2:32 6" -- 4 3:02 30 11/2" 4 1/2" 5 3:03 -- 6" -- 6 3:33 30 19/16" 4 7/16" PERCOLATION RATE 6.8 (MIN./INCH) PERC. HOLE DIA. TEST RUN BETWEEN 2.0 FT, AND 2.5 FT. CONHENTS: PERCOLATION DATA ON THIS PAGE FOR UPPER BENCH PERK TEST ONLY. PERFORMED BY ALASKA WATER &: WASTE'WATER. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON DATE: 6 (INCHES)  ~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME P ONE MAILING ADDRESS LEGAL DESCRIPTION Manufacturer Material  No. of compartme ts Liq. capaclW in gallons I~side length Width Liquid depth ~,~ IF HOMEMADE: ~ ~ ~ISTANCE TO: Well DwelEng PERMIT NO. O Z ~ Manufacturer Material ~ Liquid capacity in gallons ~ Well . Foundation Nearest lot Erie PERMIT ~ ~-- .~--~ ~ inches OTHER INSTAELER 4,0 - .. 72-013 (Rev, 3/78) MATIMPAILOT MMII 1100 wl� 1201 R olm ST. 99515 A ANCHORAGE9 ALASHA 34lw7714 SIX INCH WATER WELL DRILLED -----------OUT TO THE DEPTH OF 195 3t. DRILLED AT THE RATE OF 822.00 PROPERTY OWNER at. Rtchaa Denn" LOCATION OF WELL SI BeAnU Claire DRILLER WELL LOG: PER FOOT. C42W Pt 185 4 only. 345-7779 u. i S B4.y Sur,. af. 0 16' StLt t Bandy. wet .Gine gnawa wt th 45% cLau bindeA. cel 16---4Q' Tine gtaw" 30% clay.. d weAnt 4m&U bouldt" 49 99' Hardpan R cemented q tav" S.tl tv. dmu4 wate2 mater lot at 63 fit. lJeak v"t4 99--195' BeAtack. Sed&wIAattack ma t"ta t. good wa A bea ting polo" bed sack uy at 193 to 195 A. Tata.t waken yt&.0 vw4tAy {.tan tAJA atea.-dhow a qU Pffl. Il6W good qu_aL/} a,Ua 3/4 Ho24e Su neA4 G.te pump ahoutd be tn4tatttd .ten. to �L(teen {u -t a" bottom. WateA uzouuy back up to 28 A of 4a4�aee. Steal ea4tn,; d2Wen to ".ftt4a t at 99 A. - 070 MUNICIPALITY OF ANCHORAGE ` 31C eA J DEPT. OF HEALTH 6 ToE C-0M4tT Q fRQTFCTI : $22.00 p" �t X 185 4: 84070.0 ta( fAUG211986 RECEIVED e et-, I �P COST INCLUDES ALL LABOR AND MATERIAL=LETION FF�S�A ING. WRITE CHECK PAYABLE TO RAMPART DRIL I S- TfQ HE SUM 70.00 THANK YOU VERY MUCH. BERNIE CLAUS OF RAMPART DRILLING WORKS DATE OoG�t 16th, 1985 Com. SERVICE CHARGEOF IV&% PE/R MONTH WILL �E ASSN C ON PAST DUEACCOUNNTTS. · E}.N--~ 'Ir TEK 850& 17 E~E~I~IER & MICHAEL P'DENNIS -~,5~1 N-SNOWBEAr ANCHORAGE, AK 9951& 2~8'-142& 1 42000 (SQ; FT. 2 TOWNSHIP: liN' RANSEi 5W OR ACRES) are the option~ available to you in de=ig~ing ,youp Choose-the option that best Fits your site. TRENCFt .BED PIPE BOTTOM (ft.) , 5.0 6.0 (FT.') ' 5.0 0.5 (FT.) lO. 0 ~. 5 (ft.) 2.5 20.. 0 - (~.t.) 58.0 58.0 (CU. YDS.) - 29. ~ 28.2 (GALS) 1~000..0 ** 1,000.0 ** ~AT~.NS (SQ. FT./BR) 287 ~50 ML~T HAVE AT LEAST TWO'COMPArTMENTS FAmiliar 'with the pequirements for on-site sewe~s-i M~ni':ipality o~ Anchorage (MOA) and .1 the syjtem in accordan:e with all .MOA lance with the desig~ cpiteria ~{, thi's peP~lt. t~ all MOA a~d State o~ 'Alaska requi~ement~ ~ any eAisting ~!1, waste~atep dtsp~al syst~m~ age ~y~em ~n this or any adjacent o~ nearby'lOt. . . that this pepmit is vali~ For a maximum ~P :~nlar~em~nt ~ill.pequlPe an additional perm~t~, ~'' ~STALLED IN AN AREA,~VERED BY PERMI~ AND INSPECTION A L'ICEN'~EDELE~TRIG{AN, Permit Applic t: i MUNICIPALITY OF ANCHORAGF.,i,_ Departmen' Health and EnvironmentIrotection 825 Street, Anchorage, AK. ~T9501 264-4720 ~ ~ ~ HANDWRITTEN PERMIT ~ ~ ~ WELL AND~ ON-SITE SEWER PERMIT Location: ~ ~rb, Phone Number: Legal Description: Size: Type of Soil Absorption System Is: Trench: ~ Drainfield: Seepage Bed~ __ Holding Tank: Maximum Number of Bedrooms: F Soil Rating(sq.ft/br) DEPTH The Required Size of the Soil Absorption System Is:' /0 LENGTH 7c~/ _ GRAVEL DEPTH ,~'- WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). '< ~ ~ REQUIRED SEPTIC(HOLDING) TANK SIZE = /0~0 GALLONS ~ ~ Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * ~ ~ TWO(2) INSPECTIONS ARE REQUIRED ~ ~ ~ Backfilling of any system without final inspection and approval by this departmen~ will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee~ for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. ~ * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 % ~ ~ I certify that: (!) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that 3 bedrooms. Date: . SWP/024 (1/81) ~ I"II-I~'~DEFRRTMENT'~HERLTH-1' C: ]~qL I T'.r" O,,F. RNC:IRRt3E ~-'~.~" '' RND ENvIRONMENTRL~OTECTION -- 825 '"L" STREET., RNCHORRGE, ~K. L~50! 264-4728 ~!ELL RP-~C, C,~--S Z TE 5EL.~E~: PER~ I T PERMIT NO ( 8284~: .., RPPLICRNT MICHREL DENNIS BO)< J.t2 GIRDWOOD 248-±426 LOT SIZE 42000 SQURRE FEET TYPE OF SOIL RBSORPTION SYSTEM IS: TRENCH MRXIMUN NUMBER OF BEDROOMS SOIL RRTING (SQ FT?BR)= 246 THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS' [:. E F' T H = 1 E-i L E ~'4 !.3 T H = 7 4 ¢3 ~;~: ]-~ %,' E L_ [:" E F' T H = 5 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD THE DEPTH OF R TRENCH OR FIT' I_~ THE [I--/IRNuE) '- ' ~ BET.4EEN' t THE' SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET) THERE IS NO SET WIDTH FOR TRENCHES. THE GR~VEL DEPTH IS THE MINIMUM DEPTH OF P -~RM~EL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). F-~'E~_-~-_~ El I RE[) -- EPT I C TR~'-,~:; S I ZE= 1888 F~FtLLE~NS PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING INSTRLLRTION INSPECTIONS OF RN9 WELLS BDJRCENT TO THIS PROPERTY RND THE NUMBER OF RESIDENOES THRT THE WELL WILL SERVE. THE TI,..IC~ ,:.' 2 ::, I I'-.!.SPEC:T I Ol'4__c,, RRE F..:E C-...~L~ 1' BRCKFILLING OF BN"r' S'"?STEM WITHOUT FINRL INSPECTION RND APPROVRL BY THIS DEPRRTMENT HILL BE SUB.TECT TO PROSECUTION. MINIMUM DISTBNCE BETWEEN R WELL RND RN9 ON-SITE SEHRGE DISPOSRL S?STEM IS ±00 FEET FOR R PRIVRTE WELL OR &50 TO 200 FEET FROM R PUBLIC WELL. DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRIVBTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET BND TO R COMMUNIT9 SEWER LINE IS 75 FEET. WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MR9 RPPLV. SPECIFICRTIONS RND CONSTRUCTION DIBGRRMS BRE RYRILRBLE TO INSURE PROPER INSTRLLRTION F"EF--: hll I T E::-<P I F:ES [:.EC EI'-IE:EE: --'--(-1.. 19:32 I CERTIFY THRT &: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND HELLS RS SET FORTH B9 THE MUNICiPRLIT¥ OF RNCHORRGE 2: I HILL INSTRLL THE SYSTEM IN BCCORDRNCE WITH THE BODES. ~: I UNDERSTRND THRT THE ON-SITE SEWER SVSTE~I MR9 REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE TNRN ~ BEDROOMS. V4. 0 Lu ! MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [~SOrLS LOG ~ ~PERCOLATION TEST L~GAL DESCRIPTION: 10 11 12 13 I 2 3 4 5 15- 16- 17- 18- lg. 20 SITE PLAN WAS G.DU.G WATER PO t ENCOUNTER ED7 P IF YES, AT WHAT E DEPTH? Net Depth {o Net Reading Date GrOSSTime ~ 'r~ ' ~ Time , Water Drop ~ 5~ PERCOLATION RATE · TEST RUN BETWEEN COMMENTS c~/J ~/'~' ~v~l PERFORMED SY:~' ~7' /~ ' ~'~ cE~T 72-008 (6/79) Parcel I.D. 1..GENERAL INFORMATION 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 FOR A SINGLE FAMILY DWELLING o2o_ Complete legal description COSA# Expiration Date: RABBIT CREEK ~ S/D; BLOCK 11~-/-LOT Location (site address) 17031 NICKLEEN STREET * ANCHORAGE, AK * 99516 Current Property owner(s) Mailing address DANA BRUDEN Day phone 345-7808 17051 NICKLEEN STREET * ANCHORAGE, AK * 99516 Lending agency Day phone Mailing address Real Estate Agent RONA FLORIO W/ HOMES UNLIMITED Day phone 748-4500 Mailing address 1545 G STREET~ #104 * ANCHORAGE~ AK * 99501 Unlessotherwise ~queste~ COSA willbeheldbyDSD ~rpick~. 2. NUMBER OF BEDROOMS: 2 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 samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system, The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the 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 Anchorege 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 GARNESS ENGINEERING GROUP, Ltd. Phone 357-6179 Address 5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not author~z_ed, nor will it confer any legal right whatsoever: DSD SIGNATURE ~'"'/Approved for ~ bedrooms. Disapproved. Conditional approval for ~ WATER AND ~ WASTEWATER bedrooms, with the following stipulations: '~;,~O, pRoGRAM Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmom Road P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanchorage.ak.us (907) 343-79O4 A. WELL DATA Well type PRIVATE CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: RABBIT CREEK HEIGHTS S/D; BLOCK 1 I~LOT 15,,~ Pamel ID: 020-%T~..t.--.6~ l'BEDROCK AT 99'I IfA, B, orC provide PWSID# N/A YES Date completed 10/16/1985 Sanitary seal (Y/N) YES YES Total depth 199 ff. Cased to *99 ft. 12+ in. FROM WELL LOG Date of test 10/16/1985 Static water level 28 .ft. Well production 8 g.p.m. WATER SAMPLE RESULTS: Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 5/22/2012 35 .ft. 6.39+ .g.p.m. Arsenic: ND ug./L Coliform 0 colonies/100 mi. Nitrate 0.428 mg./L Collected by: GEG, Ltd. Date of sample: 5/22/2012 B. SEPTIC/HOLDING TANK DATA Tank Type/Material $.T.E.P./STEEL Tanksize 1250 gal. Number of Compartments 2 Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO Data of pumping 5/15/2012 Pumper AROUND THE CLOCK PUMPING Date installed 11/74/1999 Cleanouts (Y/N) YES High water alarm (Y/N) YES C. ABSORPTION FIELD DATA I'BELOW EXISTING GRADEI Date installed 11/,~/1999 Soil rating ~or ft%drm) 0.8 53 & 42 Length 75 TOTAL ft. Width 5/5 ft. ~ ~.'~'Total depth ~1.o * ft. Eft. absorption area 375 ft2 Monitoring tube YES Date of adequacy test *'5/22/2012 Results (Pass/Fail) PASS Fluid depth in absorption field before test 0 in. Elapsed Time: - min. Final fluid depth 0 Any rejuvenation treatment (past 12 mo.) (Y/N & type) Water added 330 gal. New depth in. Absorption rate >= 300+ NONE KNOWN If yes, give date System type SHALLOW DUAL TRENCH Gravel below pipe 0.5/0.5 ft. Depression over field NO For 2 bedrooms 0 in. g.p.d. **TESTED WEST TRENCH ONLY. EAST TRENCH WAS DRY, OLD BED WAS DRY ALSO D. LIFT STATION Date installed --11/2 ¢/1999 "Pump on" level at.~44 in. Datum~OTTOM OF TANK E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100% AbsorplJon field on lot 100% Public sewer main N/A Sewer/septic sewice line . 25'+ Animal containment areas. 50% Size in gallons 1250 "Pump off= level at _42 in. Cycles tested_ 3 Manhole/Access (Y/N)_ YES High water alarm level at. 45 _ Meets alarm & cimuit requ rements'~ YES in. On adjacent lots 100'+ On adjacent lots 100% Public sewer manhole/cleanout __ Holding tank N/A 75' (HOLDING TANK ON LOT 16) Building foundation 5'+ Water main N/A Wells on adjacent lots _ 100% Manure/animal excrete storage areas _ 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Property line 5% Absorption field 5'+ Water service line_ 10'+ _ Surface water-- I00'+ Property line _ 10'+ Water service line 10'+ Curtain drain _ NONE KNOWN F. COMMENTS SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation *5' Water main N/A Surface water _ 100'+ Driveway, parldn~vehicle storage. 10% Wells on adjacent lots_ 100'+ *WAIVER GRANTED AT TIME OF CONSTRUCTION. SEE 11 $0 1999 AKWWC iNC. INSPECTION REP ORT~ ~view of Munid~l ~s ~at ~e above systems are in ...... Engineers Pd~d Name _ JEFFR~ A. GARNESS v~~ ~;;~..:...~ COSA Fee $ Date of Payment_ Receipt Number (Rev. 11/05) qqo Waiver Fee $. Date of Payment Receipt Number. Municipality of Anchorage Development Services Department Building Safe~y 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 Parcel I.D. 1. GENERAL INFORMATION CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING o2o-111-61 HA # ©%Oqcgl Expiration Date: / ~ - ~. L.~ . 0 ,.~ Complete legal description RABBIT CREEK HEIGHTS SUBDISION; BLOCK 11, LOT 15 Location (site address or directions) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address 17031 NICKLEEN STREET * ANCHORAGE, AK CARLA DOROFF Day phone 345-7808 17031 NICKLEEN * ANCHORAGE AK, 99516 Day phone Day phone Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 2 ~3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well PUblic Water System TYPE OF WASTEWATER DISPOSAL: · Individual On-site · [] Individual Holding tank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for propertie¢ served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and es of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 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 alt applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. NameofFirm ALASKA WATER &: WASTEWATER CONSULTANTS, INC. Phone 557-6179 Address 5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date Engineer's Comments: In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AKWWC, Inc. can therefore not previde any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: ON-SITE t WATER AND : = . WASTEWATER . Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reo~ Other (Rev. 12/01) Original Certificate Date: ff --~-~ ~ - ~),-~ 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 Legal Description: A. WELL DATA Well type PRIVATE HEALTH AUTHORITY APPROVAL CHECKLIST RABBIT CREEK HEIGHTS; LOT 15, BLOCK 11, Parcel ID: 020-111-61 IfA, B, orC provide PWSID# N/A Well Log (Y/N) YES Date.completed 10/16/1985 Sanita~ seal (Y/N) YES Total depth 199 ft. Cased to 99 ft. FROM WELL LOG Date of test 10/16/1985 Static water level 28 Well production WATER SAMPLE RESULTS: 8 Coliform ~ colonies/100 mi. Arsenic: N/A mg./L. B. SEPTIC/HOLDING TANK DATA ft. g.p.m. Nitrate 0.559 mg.tL. Date of sample: 6/5/2003 Tank Type/Material Tank size 1250 gal. Foundation cleanout (Y/N) YES Date of pumping 6/9/2003 C. ABSORPTION FIELD DATA Date installed 11/24/1999 (33+42) Length 75 .ft. STEEL/S.T.E.P. Number of Compartments 2 Depression over tank (Y/N) NO Pumper. ~'BELOW EXISTING (;RADE Soil rating ~r ft~/bdrm) 0.8 Width 5 .ft. Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 6/5/2003 36 .ft. 7.68 g.p.m. YES 22 in. Other bacteria ~) colonies/100 mi. Collected by: AKWWC, INC. Date installed 11/24/1999 Cleanouts (Y/N) YES High water alarm (Y/N) Y A+ HOME SERVICES Total depth *2.9-4.7 It. Eft. absorption area 375 ft~ Monitoring tube YES Date of adequacy test 6/5/2003 Results (Pass/Fail) PASS o/ Fluid depth in absorption field before test 0 in. Water added 700 gal. Elapsed Time: 6 min. Final fluid depth"~/ in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN System type TRENCH#I/TRENCH#2 Gravel below pipe 0.5 ft. Depression over field NO For 2 bedrooms New depth 1¥~5 in. 300+ g.p.d. If yes, give date - D. LIFT STATION Date installed 11/24/1999 Size in gallons 1250 "Pump on" level at 44 in. "Pump off" level at 42 in. Datum BO'FI'OM OF TANK Cycles tested 2 E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer/septic service line 25'+ Manhole/Access (Y/N) YES High water alarm level at 45 in. Meets alarm & circuit requirements? YES On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manholetcleanout Holding tank N/A N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property 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'+ Water service line 10'+ Curtain drain NONE KNOWN F. COMMENTS * WAIVER GEANTED Building foundation. *5' Surface water 100'+ Wells on adjacent lots 100'+ Absorption field 5'+ Surface water 100'+ Water main N/A .Driveway, parking/vehicle storage 5'+ G. ENGINEER'S CERTIFICATION / 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 Prin~ed Na,me Date ~/'~. ~-'/~.~ JEFFREY A. GARNESS HAA Fee $ Date of Payment Receipt Number (Rev. 12/01) ~ 0.O~) r~lWaiverFee$ 6/18/2003 Date of Payment 57292 c~,'""~' Receipt Number 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.cilanchorage.ak,us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 020-111-61 1. GENERAL INFORMATION Expiration Date: c:~ , l ~ ' ~ -~ Complete legal description RABBIT CREEK HEIGHTS SUBDISION; BLOCK 11~ LOT 15 Location (site address or directions) 17031 NICKLEEN STREET * ANCHORAGE, AK Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address CARLA DOROFF Day phone 5¢5-7808 17031 NICKLEEN * ANCHORAGE AK~ 99516 Day phone Day phone Unlesso~erwisemqueste~ HAA willbeheldbyDSD ~rpick~. 2. NUMBEROFBEDROOMS: 2 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 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 propedies served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system, The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the n umber 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 afl applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER &: WASTEWATER CONSULTANTS, INC. Phone Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 357-6179 Engineer's Comments: In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being sen/ed by the system. These conditions are outside the control of the evaluator of the system. Satisfactoo/ test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AKWWC, Inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. DSD SIGNATURE ~'/ Approved for ~ bedrooms. Disapproved. Conditional approval for __ bedrooms, with the fllowing stipulations: . ON-SITE Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reed Other (Rev. 12101) Original Certificate Date: Municipality of Anchorage Development Se ices 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 Legal Description: A. WELL DATA Well type PRIVATE IfA, B, or C provide PWSID# N/A Date completed 10/16/1985 Sanitary seal (Y/N) ¥ Total depth 199 ft. Cased to 99 ft. FROM WELL LOG 10/16/1985 28 HEALTH AUTHORITY APPROVAL CHECKLIST RABBIT CREEK HEIGHTS; LOT 15, BLOCK 11, Parcel ID: Date of test Static water level ff. Well production 8 g.p.m. WATER SAMPLE RESULTS: Nitrate 0.559 rog.IL. Date of sample: 6/5/2003 2 Depression ever tank (Y/N) NO Pumper. ~*BELOW EXISTING GRADE I Soil rating ~r ft2tbdrm) 0.8 Coliform 0 colonies/100 mi. Arsenic: N/A mg./L. B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL/S.T.E.P. Tank size 1250 gal. Number of Compartments __ Foundation cleanout (Y/N) YES Date of pumping 6~'9/2003 C, ABSORPTION FIELD DATA Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 6/5/2003 36 .ff. 7.68 g.p.m. 020-111-61 YES YES 22 in. Other bacteria 3 co on es/100 mi. Collected by: AKWWC, INC. Date installed 11/24/1999 Cleanouts (Y/N) YES High water alarm (Y/N) Y A+ HOME SERVICES Date installed 11/24/1999 (33+42) Length 75 ft. Width 5 ft. Total depth *2.9-4.7 ft. Eff. absorption area 375 ft2 Monitoring tube YES Date of adequacy test 6/5/2003 Results (Pass/Fail) PASS o/ Fluid depth in absorption field before test 0 in. Water added 700 gal. Elapsed Time: 6 min. Final fluid depth 00/ in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN System type TRENCH#l/TRENCH#2 Gravel below pipe 0.5 ft. Depression over field NO For 2 bedrooms 0 ¥ New depth 1.25 in. 300+ g.p.d. If yes, give date - D. LIFT STATION Date installed 11/24/1999 "Pump on" level at 44 in. Datum B0'Iq'OM OF TANK E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Size in gallons 1250 "Pump off" level at 4-2 in. Cycles tested. 2 Septic tank/lift station on lot100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer/septic service line 25'4- Manhole/Access (Y/N) YES High water alarm level at 45 in. Meets alarm & circuit requirements? YES On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manholetcleanout Holding tank N/A N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation. 5'+ Property 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'+ Water service line 10'+ Curtain drain NONE KNOWN F, COMMENTS * WAIVER GRANTED Building foundation '5' Surface water 100'+ Wells on adjacent lots 100'+ Absorption field Surface water, 5'4- 100'+ Water main N/A Driveway, parking/vehicle storage 5'+ 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 Na~e Date JEFFREY A. GARNESS HAA Fee $ ~ Date of Payment ~:)' I ~' 0.~ Receipt Number ~J~, ~ (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 020-111-~1 HAA# ~r~:~0%77 Rabbit Creek Heights S/D; Lot 15, Block 11, Location (site address or directions) 17031 Nickleen Street Property owner Mailing address Lending agency Mailin_g address Agent Address Clark Olsen 17031Nickleen Street Dayphone 345-7492/235-9344 Ancgoraqer AK 99510 Day phone Day phone Unless otherw/se requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well sYstem, provide written confirmation from State ADEC attest- lng to the legality and status of system. xx TYPE OF WASTEWATER DISPOSAL: Individual on-site 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 (Rev. 1/91) Fronl MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this/~spection. AJ..A~KAWATE ,&,WASTE'WA; ,Lq Nam. e of Firm ~ D'~ i~~ T- Phone Adaress . -CI'-~O~,R I A ' ' Engineer's signature ~1 /,~, ~~ _ _ Date Alask~ Wg;e'r ~ Wastewater Consultants~lnc. Shall be PAID $ ~-~-O-- a{, or prior to, closing for the En_gineeri ', ~' ~':"'~i"~ Provided. DHHS SIGNATURE × ^ proved for Disapproved. Conditional approval for bedrooms. bedrooms with tile following stipulations: Add t 0nal Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Municipality of Anchorage NOV DEPARTMENT OF HEALTH & HUMAN SERVIC_~,~I~ciP^U¥'~ Environmental Services Division ENVIRONMENTAL SERVICES DIX~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type PRIVATE Log present (Y/N) Total depth Sanitary seal (Y/N) Health Authority Approval Checklist RABBIT CREEK HTS; LOT 15, BLOCK 11 ParcelI.D.: 195' 020-111-61 If A, B, or C, attach ADEC letter. ADEC water system number N/A YES Date completed 10/16/85 Cased to 99' Casing height (above ground) 18"+ YES Wires properly protected (Y/N) YES AT INSPECTION Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform O Date of sample: 11/15/99 B. SEPTIC/HOLDING TANK DATA Date installed 11/9/99 Foundation cleanout (Y/N) Date of Pumping NEW C. ABSORPTION FIELD DATA Date installed 9/27/99-11/10/99 Length 75'+ TOTAL Width (33'+ & 42'+) FROM WELL LOG 10/16/85 28' 8 g.p.m. 11/13/99 29' 6 g.p.m. Nitrate 0.953 mg/L Other bacteria 0 Collected by: A.W.W.C., INC. Tank size 1250 Number of Compartments 2 Cleanouts (Y/N) YES YES Depression (Y/N) NO High water alarm (Y/N) YES Pumper - [UPPER/LOWER] * TO TOP OF SAND BELOW FINAL GRADES Soil rating (g.p.d./ff2 or ft2/bdrm) 0.8 System type TRENCHES 5' Gravel thickness below pipe *0.5' Total depth *4.7/2.9 MAX Effective absorption area 375+ SQ FT Monitoring Tube present {Y/N) YES Depression over field (Y/N) NO Date of adequacy test NEW Results (Pass/Fail) For ~~edrooms depth in absorption field before test (in _.);__ ~. water added (in.): Fluid Flu[~ Absorption rate = g.p.d. P.._~c,.~,v~F~-~atme nt (past 12 months) (Y/N) if yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed 11/9/99 Manhole/Access (Y/N) YES High water alarm level at* 44" Cycles tested NEW E. SEPARATION DISTANCES Size in gallons 1250 "Pump on" level at* 4-2" "Pump off" level at* *Datum BOTTOM OF TANK 4-2" SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line 100'+ 100'+ 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout Lift station 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5'+ Property line 5'+ Absorption field Water main/service line 10'+ Surface water/drainage 100'+ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10' Curtain drain HAA Fee $_ Date of Payment Receipt Number 5'+ Building foundation *5°+ Water main/service line Surface water 1 go'+ Driveway, parking/vehicle storage area 5'+ NONE KNOWN Wells on adjacent lots 100'+ 100'+ 10' *WAIVER GRANTED WITH ISSUANCE OF pERMIT F. CE.T,F,C^T.O. I certify that l h/~e_t~r_¢'n~'~ ~ield inspoctions and review of Municipat ~re inconforman~ewitl~gt felinesineffectonthisdate. Signature Engineer's Name' ' JEFFREY A. G^RNESS Date ~o,_ -. ..... ..'%~.%:~ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 10' UTILITY EASEMENT ~.'~: ~l:~ ~ MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~- / \ \-(.cz- \ HAA# ~,~C~i L[ ~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) lxJ t L.E (b) Property owner A ~ ~"%~__~ Telephone :(home) Mailing Address Business $"~' ! (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here~, if hold for pick up.) List contact person and day phone number below: 2, TYPE OF RESIDENCE Single-Family ~ Number of bedrooms 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th leg'ality and Status. 4. SEWAGE DISPOSAL On-site ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev 7/88) Page 1 of 2 '~JOM s,Jeeu!§ue leUOlSSejoJd eql u! SUO!SS!LUO JO SJOJJe JOJ elq!suodseJ hOU s! abeJoqou¥ jo/9,lled!o!unR eq_L 'penes! s! eheo!Jll, Jeo e eJojeq ehep eZXleUe Jo suo!hoedsu! henpuoo ~ou op SHHQ jo seeXoldUJ3 'm, ueuJeJ!nbeJ ahems pue teJeP@J u!e~Jeo Xjs!~es oh JepJo u! suo!~nh!hsu! §u!puel J!eqh pue SeLUOq JO sJeseqoJnd oh XseHnoo e se s!q~ seop SHHQ eqJ. 'e~SelV jo ehe~,$ eq3 u! peJehs!6eJ Jeeul6ue leUO!SSejoJd huepuedepu! ue Xq a^oqe g qdeJBeJed u! ua^lb suo!lelueseJdeJ eq] uodn/JlUO peseq leAoJddv Xhpoq]nv q~leeH senss! (SHHC]) eeo!^JeS ueuJnH pue HhleeH JO hUeLU~,Jedec] ebeJoqouv jo Xh!led!a!u nI, N eql leUO!~,!puoo le^oJddv leUO!~,!puoo Jo SLUJe/ peAoJddes!(3 ~ peAoJddv Xq SLUOOJpaq 7'.. JOe pe^oJddv 'lVAObldd'~ SHHa '9 lees S,Jeeu!J~U::l A. WELL DATA Well Classification Well Log Present (Y/N)~/~5 Date Completed MUNICIPALITY OF ANCHORAGE (MOA) ~ Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: z/'~ T /,,~¢ /~'c~' // 1'7o '5/ z~'z4~z-~c~%,J IfA, B, C, D.E.C. Approved (Y/N) 10 -/4o- ~- Yield C¢ ot 1~ ~ Total Depth I °).,5-" Cased to Static Water Level Z- ~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Depth of Grouting Pump Set At /t-, Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) /,,J SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ;On Adjoining Lots ~ [ CO I ~-O' ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole .~/.4. To Nearest Sewer Service Line on Lot Water Sample Collected by I( t,J ~ ~¢ ~,L~ Water Sample Test Results ~OL~. tcol'2.,*A, -- (2 ~" Comments h,J ;Date B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) /"u O Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) ,',J/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well t O0o No. of Compartments Air-tight Caps (Y/N) ¥~..S Foundation Cleanout (Y/N) Date Last Pumped ~'-~'1- ~U jTg,,')d3 /k J//k ;for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field '~ t. OO' To Property Line To Water Main/Service Line ~. O To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed l 0 - 7_ - Width of Field /5- 85-- too Square Feet of Absortion Area Depression over Field (Y/N) t'J O Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ~ I To Building Foundation Lot To Water Main/Service Line 4-0 ' To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line '~ To Existing or Abandoned System on ; On Adjoining Lots ~ -5-0 ' To Cutback (if present) > ~oo D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for ~ Meets MOA Electrical Codes (Y/~)----'~''~ Comments Dimensions ~ Manhole/Access (Y/N) ~ "Pump O~ .----~"l~e n t (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. . Signed ~~ Company Date ~[~ -- 9~ Engineer's Seal MOA No. ~:~ ~.~ Receipt No. 02/~'"/0 F //L~,, > Date of Payment 0 Amount: $ / ? O~ O0 72-026 (Rev 7/68) Back Receipt Waiver Fee: $ Date of Payment Page 2 of 2 8441 MILES COURT ANCHORAGE, ALASKA 99504 (907)557-6560 Date o~ Testing: Marsh 29, 1990 Legal Description: Lot- ]5, Block- 11 Subd. Rabbit Creek Heights Street Address: 1'7031 Nickleen Number o~: Bedrooms: Rseu]ts o¥ Well Flow ]'est: Average Flow Rate -- }6 gpm The well has a sanitary seal cap and conduit ~or the electrical wiring. No depression was noted around the well. Resu]ts o~ Laboratory Water Analysis: Coliform Nitrate-N -- Laboratory ~or testing: Northern Testing Laboratory Results o~ Septic System Adequacy Testing: Passed House was vacant and therefore pre-soaked with 1630 gallons o~ waLer on March 27~ ~990. On M~rch 29, ~990 a total o~ 450 gallons o~ water was entered into the system. There was no water ~ound in ths ~ield cleanouts or monitoring tubes directly a~ter the water was run into the ~ield. The system passes. Approvals: The well and septic system are approved and certified ~or a 2 bedroom home. These test results are based upon conditions present at the time o.F the testing. The tests ~ollowed standard Municipality o¥ Anchorage testing procedures. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE (DF iNSPECTiON FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 5'z '-- GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Locaiion (address or directions) (c) A~plicant is (check on~): pending Institution ~wner/bdlder ~; Buyer ~; Other ~ (explain); (d) Lendinglnstitution'~r~C~'~T& ~,4~ e~fi~v~C~ Telephone ~,D -JO~'~ (e) (f) TYPE OF RESIDEN~CE Single-Family ~ Mdti-Family Number of Bedrooms Real Estate Company and Agent Address Telephone - MaiI~HAA to the foll~in¢ address: Other 3. WATER SUPPE/ Individual Well ~ Community [] Public [] Note: if corn munity welt system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE~J~POSAL Onsite~' Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) 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 aad type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage flies and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm /j-e-cS' Telephone %--~' ,~ J'-~ ~'o Address / $-~'o c.,3 ~ ~ ~.~ ~ ~/~ ~ 2 ~ ~ / Date ¢'"~ '- ~(~ Approved for ~"g:~ __ bedrooms b/y/¢~"~, 'v-~-~''/-d*'~--~ ~"-Date .~/// ~-~./ Approved__ ~/ Disappro~ Conditional__ Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) 7, CHECKLIST - FEBRUARY 1984 ~ 264-4720 Legal Description: /.~&.~,'f (_.~e.~k' /y,e~/~v:~ Z~7'/5' ~ioc~ ~ ,5~r. /'~ 7// N ~-$~, WELL DATA Well Classification /~¢-,-v,z~% Well Log Present ~N) Total Depth ! ~-' Cased to Static Water Level ~ ~ Casing Height Above Ground Electrical Wiring in Conduit ~)N) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E,C. Approved (Y/N) Date Completed Oct' /6! /~E;3- Yield ~ ~ Depth of Grouting Pump Set At 2. Sanitary Seal on Casing Depression Around Wellhead (Y/~ ; On Adjoining Lots G ~ /O0 To Nearest Edge of Absorption Field on Lot /.Z ~ ¢.o ; On Adjoining Lots To Nearest Public Sewer Line /V/t. To Nearest Public Sewer Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments /c. ,4 To Nearest Sewer Service Line on Lot ~'/- ~.- ~), ,4 E'C ~, ;Date / "z/- ~/~*'-r' f B SEPTIC/HOLDING TANK DATA Datelnstalled /O/Z/~)--' / Size /¢~o ND. of Compartments Standpipes ~¢lq) /q Air-tight Caps Depression over Tank (Y/r'~ Pumping/Maintenance Contract on File (Y/N) .~-/~ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well / ¢l ~.. To Property Line To Water Main/Service Line Course (.T Foundation Cleanout ~) Date Last Pumped A/~ ; for /vA Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /o/2./ Width of Field Square Feet of Absorption Area j Depression over Field (Y/C/ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well / 2_ TO Building Foundation .3 ~- Lot To Water Main/Service Line z/O ~'~' ¢'~ - TO Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field Depth of Field '~¢ - Gravel Bed Thickness Standpipes Pr,esen~} Date of Last Adequacy Test "~' ~' To Property Line '~ (2 To Existing or Abandoned System on ; On Adjoining Lots G U ~ O To Cutbank (if present) A/~ Comments LIFT STATION Date I Dimensions ~ Size in Gallons ~. ~ "Pump On" Level at _ ~'~:r[3mtaJO~f" Level at High Water Alarm Level at ~.~.~ .~'~- ' ~ Tested for Pumping Cycles during Ad~ Check Permitted Bedroom Rating Against HAA Request ** I certi~cked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Sign de~.~¢~---~.~ ~Date cZ/ -'¢~/5 ~'5 ~ ,. ¢,0c~ Company /f'~-'/~ ~ MOA No. ~ ~ o 2~ Receipt Date of Payment Page 2 of 2 72 026 (11/841