HomeMy WebLinkAboutRABBIT CREEK VIEW & HEIGHTS BLK 2H LT 11ARabbit
k
View & H
ight
Block 2H
Lot
#020- 551 - 10
MUNICIPALITY OF ANCHORAGE
Community Development Department
Development Services Division
On-Site Water & Wastewater Program
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 020-551-10
Property owner(s) Mark & Ramona Schimscheimer
Mailing address 3161 Austria Drive, Anchorage, AK 99516
Day phone
Site address Marino Drive
Legal description (Sub'd., Block & Lot) Rabbit Creek View ~rl~ Heights, Block 2H, Lot 1 lA
Legal description (Township, Range & Section)
Lot Size 20,972 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
([~ all that apply}
Absorption Field []
Septic Tank []
Holding Tank []
Privy []
Private Well []
Water Storage []
APPLICATION IS AN:
Initial []
Upgrade []
Renewal []
TYPE OF DWELLING:
Single Family (SF) []
(w/wo ADU)
Duplex (D) []
Multiple Dwellings []
(SF and/or D)
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
('Si'gnature of property owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number:
Permit No.
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
Permit App__- .- ,_.~.c.
Pannone Engineering Services LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E-maih steve(~panenRak.com
March 6, 20:13
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
4700 S. Bra§aw Street
P. O. Box :196650
Anchorage, Alaska 995:19
Subject:
Rabbit Creek View and Heights, Block 2H, Lot 11A
Septic System Permit Upgrade Request
Ladies and Gentlemen:
I am writing to request a permit to install a well and septic system be issued for this property. The
proposed systems will serve a proposed three (3) bedroom house. Currently the lot is undeveloped. A new
1500g S.T,E.P. tank with AX20 Pod and Auxiliary pump vault will be installed. A new well will be installed.
The surrounding developed lots are also served by private wells. There are no wells within :100 feet of this
system.
Soils. A single test hole was excavated by Pannone Engineering Services in October of 20:12, and
the ground water monitored for seven days. Water was monitored to a depth of 7.0 feet in the test hole
after the seven day monitoring period. Bedrock was not encountered in the test hole. It is my opinion,
based on the results of the percolation tests and overall soils appearance; an application rate of 2
gallons/day/square feet should be used for a CAT III wastewater system.
Soil Absorption System Design.
a. See Sheet 2 of the design package.
3. Surface Water: There is no surface water within :100 feet of the proposed septic tank and drain
field. The proposed drain field upgrade will maintain at least 100 feet from all surface water and drainage
ditches.
4. Topography: The existing topography slopes from south to north at approximately 5%-7% in the
area of the proposed drain field.
5. Drawing Markings: The Drawings are marked "For MoA Review Only". When written notification
that the review is complete and that there are no further comments is received from MoA On-Site
Department, the note will be removed and "Issued for Construction" drawings will be issued.
Mailing: PO. Box 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor, Anchorage, AK 9950Z
Telephone: (907) 272-8218 FAX: (907) 272-82:[1
Page 2 of 2
The proposed installation will not affect the future development of the surrounding or existing lots. There
are no wells or septic systems within 100 feet of the proposed septic location.
If you have any questions or concerns, please contact me at 272-8218.
Sincerely,
Steven R. Pannone, P.E.
Owner/Civil Engineer
Attachments
-Soils Log
-Septic System Design
N~ailing: P,O, Box 100217, Anchorage, AK 995i0-0217
Physical: 332 East Nlanor Ave, Anchorage, AK 99501
Telephone: (907) 272-821g FAX: (907) 272-8211
ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND
REPAIR AGREEMENT
MEMORANDUM OF UNDERSTANDING
BETWEEN MUNICIPALITY OF ANCHORAGE
THIS MEMORANDUM OF UNDERSTANDING made and entered into as of this
,.]o/ Dayof /~t~'~ ~ of 20 / ~, by and between ,
herein the "OWNER," and the Municipality of Anchorage, herein the
"MUNICIPALITY." In consideration 0fthe mutual covenants contained herein, the
parties to this Memorandum of Understanding agree as follows:
1. ADVANCED WASTEWATER TREATMENT SYSTEMS. Municipality
grants permission to Osvner to utilize and operate an Advanced Wastewater
Treatment System (AWWTS), deseribed as /Z} ~5> ~/~-[/Q 7-'E3Z located
2. Definitions. f'~ - 2/~ ]- - / I ./4
A. Alteration. Any change to the design or function of an AWWTS that
Includes the installation or removal of any parts, components or pieces not
included in the original construction permit and design. Prior to
performing any alterations to an AWWTS the owner must obtain a
Wastewater Disposal System Construction Permit from the Municipality
pursuant to Anchorage Municipal Code (hereinafter, "AMC") 15.65.
B. Certificate of On-Site Systems Approval. An approval by the
Municipality of existing water and wastewater disposal systems given at
. the time of property sale and title transfer in accordance with AMC 15.65.
These approvals certify that the systems are adequate for the homes that
they support and meet the codes that were in place at the time of system
construction.
C. Damage. Any man-made or natural change in a system that would inhibit
the system from performing as designed.
D. Maintenance ~md Repair. The scheduled and as needed replacement of
existing parts, components and pieces of an AWWTS that were included in
the original design which would allow the AWWTS to continue to
perform as designed.
E. Permit (Construction) An On-Site Wastewater Disposal System
Construction Permit as defined by AMC 15.65.
F. Permit (Operating) An Advanced Wastewater Treatment System
Operating Permit. An annual permit, issued by the Municipality, that
allows the Owner to operate an AWWTS, upon meeting all the
requirements of this agreement, the conditions of Operating Permit, the
requirements of the On-Site Wastewater System Construction Permit and
all relevant provisions of AMC 15.65
3. Fee. Owner shall pay to Mtmicipality an annual fee of ~ E ~ O
($ C) .00), payable on or before the issuance of the operating permit and annually
thereafter. The annual fee is due on or before the anniversary date of the approval by the
Municipality of installed system.
4. Term. The term of this Memorandum of Understanding shall be for the life of the
AWWTS.
The term begins on the date of approval by the Municipality of the installed system and
shall continue while the AWWTS system is in use or operational or until the property is
sold or title is transferred by owner and a new certificate of On-Site approval is issued to
the new owner or transferee of the property.
5. Alterations~ Iustallation and Removal of Additional Equipment. Owner agrees
not to make any alterations, removal of parts or additions to the AWWTS without a
Construction Permit from the Municipality.
6. Maintenance and Repairs.
A. Throughout the term ofthis Memorandum of Understanding, the Owner shall
maintain AWWTS in good repair. In addition, it shall be the responsibility of the
Owner during the term of this Memorandum of Understanding, and any extensions or
renewals thereof, at the owner's sole expense, to pay for any and all: (1) repair(s), (2)
maintenance, (3) adjustment(s), (4) replacement costs, and (5) inspection costs.
Further, Owner agrees to comply will all applicable ordinance, laws, regulations,
roles and orders for the AWWTS.
B. Owner agrees to provide the Municipality a written schedule of routine
maintenance and repairs which have been performed on the system pursuant to the
terms and conditions contained in the Owner's AWWTS Operating Permit. This
schedule shall be submitted to the Municipality annually upon the renewal of the
permit. The schedule of maintenance and repair contained in the Owner's AWWTS
Operating Permit is: ~ //t Ft t2~ f
C. Owner acknowledges that the fine schedule for failing to maintain and repair an
AWWTS are codified in AMC 14.60.
D. Owner agrees that only maintenance, repair personnel certified by the
Municipality will inspect and make any necessary maintenance, repairs or permitted
alterations to the system.
E. Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS upon 24 hours written notice.
F. Owner agrees that any sale or transfer of title oftbe property will not occur
without a new Certificate of On-Site Systems Approval.
G. Owner agrees that the relevant provisions of the standard specification guidebook
for AWWTS is the governing professional guidelines for the construction,
maintenance and repair of the Owner's AWWTS,
7. Nonwaiver. The failure of either party at any time to enforce a provision of this
Memorandum of Understanding shall in no way constitute a waiver of the provisions,
nor in any way effect the validity of the Memorandum of Understanding or any part
hereof, or the right of such party thereaRer to enforce each and every provision
hereof.
8. Amendment.
A. This Memorandum of Understanding shall only be amended, modified or changed
by a writing, executed by authorized representatives of the patties, with the same
formality of this Memorandum of Understanding was executed and such writing shall
be attached to this Memorandum of Understanding as an amendment.
B. For the purposes of any amendment modification or change to the terms and
conditions of this contract, the only authorized representatives of the parties are:
Owner:
Anchorage: Purchasing Officer
C. Any attempt to amend, modify, or change this COntract by either an
unauthorized representative or unauthorized means shall be void.
9. Jurisdiction: Choice of Law. Any civil action arising from this M~morandum of
Understanding shall be brought in the Superior Coua for the Third Judicial District of the
State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and
obligations of the parties under this Memorandum of Understanding.
10. SeverabilRy. Any provisions ofthis Memorandum of Understanding decreed
invalid by a court of competent jurisdiction shall not invalidate the remaining provisions
of the Memom.~..~ Understanding.
By~/~.~.~ -- By:
~sTATE OF ALASKA )
THIRD JUDICIAL DISTRICT )
MIINICIPALITY:
Iq&day
The foregoing ipstrument was acknowledged before me this
of
OT XCI [ ¢ FOr.
My Commission expire'g~l~j~
MUNICRAUT OF ANCHO, RAGE
C3
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 02055110
9. GENERAL INFORMATION
Expiration Date: �
Q
Complete legal description Rabbit Creek View and Heights 132H L11A
Location (site address) 8121 Marino Dr.
Current property owner(s)
Mailing address
Day phone
Real estate agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
El
Private Septic
F1
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $
Date of Payment 1112-31121
Receipt Number c2m, 7 _3
COSA # D.�GZI 1 t 9 5
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
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, 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.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA
COSA guidelines and regulations. The reported results describe 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 soil condition, ground water 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 this system. All systems eventually fail and satisfactory test results do not
guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot
provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole
benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly
recommends buyers hire their own engineer to evaluate this report.
Name of Firm Pannone Engineering Services Phone (907) 745-8200
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name
6. DSD SIGNATURE
Steven R. Pannone P.E.
Date -2fO4F0-1
System #1 Approved for 3 bedrooms ��;5 annon9. e
o14g ..cQ�
System #2 Approved for bedrooms s
Disapproved
Conditional approval for bedrooms, with the following stipulations:
WAST" VATER
l PROGKAM
JJJ�
J�
By: ��� i1%fi 9. uUvX Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Checklist
ascription: Rabbit Creek View and Heights 132H L11A
than 1 septic system on lot: COSA Checklist # 1 of 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 6/3/13
Total depth 72 ft
Cased to 72 ft
WE Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 24+ in.
Date of flow test for COSA 4/20/21
Static water level at beginning of test 33 ft.
Comments
B. TANK DATA
Age of tank(s) 20131$ years
Tank type/material `se Gjs�-j
Measured operating fluid level in septic tank
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 7/20/20
D. ABSORPTION FIELD DATA shallow trench
Which system tested (date installed) 4/17/13
❑ ALL standpipes present per record drawing
Total measured depth from grade 3 ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies: +/-2" rigid insulation over field
COSA Checklist yellow sheet
Parcel ID: 02055110
Structure served by this system 1
Well production at time of test 4...._ gp
Water storage tank volume na gallons
Well disinfected for coliform test? ❑ Yes No
(Coliform bacteria is Negative
Nitrate mg/L [�J Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by PES
Date of Sample 4/20/21
C. LIFT STATION
❑ Required maintenance completed
Age of lift station 8 years
Lift station material Poly
Comments:
Adequacy test date 4/20/21
Results ❑✓ Pass For 3 bedrooms
Fluid depth prior to test 0 in
Water added 477 gal
New depth 0 in
Elapsed time 120 min
Final fluid depth 0 in
Absorption rate 450 gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
DISTANCES
ivate well on Lot to: (Please enter distances if less than required or if community we
From Absorption Field on Lot to: (Please enter distances if less than required)
Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
Q✓ Yes if No ft M Yes if No ft
Neighboring Tank > 100' MV Yes if No ft Private Sewer/Septic Line > 25' ED Yes if No ft
Absorption Field on Lot > 100' MV Yes if Na ft Holding Tank > 100' �✓ Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' El Yes if No ft
[✓� Yes if No ft
Community Sewer Main > 75' M,/Yes if No ft Manure/Animal Excreta Storage > 100'
[]✓ Yes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' 171 Yes if No 5' ft Surface Water > 100' �✓ Yes if No ft
Propert
Building Foundation > 10'
E✓
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
[]✓
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
[✓I
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
❑✓
Yes
if No
ft
Community Wells > 200' [✓ Yes if No ft
Surface Water > 100'
0
Yes
if No
ft
y Line > 5'
[✓ Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
[✓ Yes
if No
ft
Private Wells > 100' 0✓ Yes
if No
ft
Water Main > 10'
❑✓ Yes
if No
ft
Community Wells > 200' F-1 Yes
if No
ft
Water Service Line ? 10'
[]✓ Yes
if No
ft
If septic tank is under driveway comment below
Building Foundation > 10'
E✓
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
[]✓
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
[✓I
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
❑✓
Yes
if No
ft
Community Wells > 200' [✓ Yes if No ft
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
Tank to building of 5' was allowed at time of construction.
G. ENGINEER'S CERTIFICATION
I certify that t 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.
,:?10 4 Zz-
COSA Checklist yellow sheet
9F -1k
co' 49 TH 9
even RPannone
CE 8149
\�_�'OFESSiOyF .�
MUNICIPALITY OF ANCHORAGE
; 'i
gaiw. 16
11,64 l i t N 51kyl I RZY
THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and
entered into as of this 36-V- Day of _ �,r � of 20")-� , by and between
Ja�fc�H k-43AA- C" S , herein the "OWNER," and the Municipality of
Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code
(AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this
Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the
Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS),
described as AU ate, Q.x
located at (legal description)
2. Maintenance, Repairs and Alterations.
(Owner is required to read, understand and initial each section)
Throughout the term of this Agreement, the Owner shall enter into a service agreement
with an AWWTS service and maintenance provider approved by the Municipality or the
manufacturer's representative. The AWWTS shall be maintained in a satisfactory
condition capable of performing as designed and producing treated septic effluent in
_ accordance with the equipment's approval for operation in the Municipality.
�S It shall be the responsibility of the Owner during the term of this Agreement to pay for all
repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This
includes an annual maintenance fee (typically $400 to $600).
7 Owner agrees that only maintenance and repair personnel approved by the Municipality
or the manufacturer's representative will inspect and make any necessary maintenance,
repairs or permitted alterations to the system.
Owner acknowledges that regular maintenance of an AWWTS reduces the potential
failure of the system, which could include sewage backup and costly repairs or drainfield
replacement.
(rev. 05/18/2018) Page 1 of 3
c^
Owner acknowledges that the Municipality may request records of maintenance and
repairs from the manufacturer's representative or maintenance provider.
J Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be
assessed in accordance with AMC 14.60.030.
c� Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS. The Municipality will give at least 24-hour notice.
c^'
t� Owner agrees that any sale or transfer of title of the property will not occur without a new
_ Certificate of On -Site Systems Approval.
Owner agrees that the AWWTS installation and maintenance requirements as provided
by the AWWTS vendor/installer and approved by the Municipality are the governing
guidelines for the construction, maintenance and repair of the Owner's AWWTS.
3SOwner agrees to maintain remote monitoring of the AWWTS as required by the
AWWTS approval.
3. Term. The term of this Agreement shall begin on the date of approval by the
Municipality to operate the installed system, or upon transfer of title, and shall continue
while the AWWTS is operational or until title is transferred.
4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this
Agreement shall in no way constitute a waiver of the provisions, nor in any way affect
the validity of the Agreement or any part hereof, or the right of the Municipality
thereafter to enforce every provision hereof.
5. Amendment. This Agreement shall only be amended by authorized representatives of
the Owner and Municipality. Any attempt to amend this agreement by either an
unauthorized representative or unauthorized means shall be void.
6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be
brought in the Superior Court for the Third Judicial District of the State of Alaska at
Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the
parties under this Agreement.
7. Severability. Any provisions of this Agreement decreed invalid by a court of competent
jurisdiction shall not invalidate the remaining provisions of the Agreement.
(rev. 05/18/2018) Page 2 of 3
OWNER:
By:--�� (signature) Date: 2 i
�w�% Swe_n•,s S (print name)
STATE OF ALASKA )
THIRD JUDICIAL DISTRICT ss.
)
The foregoing instrument was ackno ledged before me this L day of b 1
2W , by_. I Q�4 yy�h Swam► �_
NOTARY PLIC FOR ALASKA STATE OF ALASKA
My Commission expires: _ — ZOZ SJ NOTARY PUBLIC �.
Liz Kowat
My Commission Expires January 6, 2025
MUNICIPALITY:
By: Q�,fi (signature)
/fe 6e rca &t -r -a / (print name)
(rev. 05/18/2018)
Date: 5Z 0 1 31
Title:
Page 3 of 3
07/06/2020 15:04 8686770 APLUS
366 447
m Nil■ n NN R slump R NNN■N■EN on
� MORE R WE RRR R R R RR I N l
SWIM MEN sin RI IRR on a NINE
d�rar�T � r Field Maintenance Report
Annual lnspE Iction
Pmperry Gwr�rlrncuir>g ■
Mark Schimschelm ,r
Site Add rem
8121 Marino Drive, Anchorage AK 99516
Ax $ile Ip A cauft Y m rt
AX -131383 OSP131031
Retrieve O&M Into
Daily flow
Recirc ratio
Time—,ernng;:
Perform Field Samp. ng/Observations
NTU (15 T NTUS) �pr 1 (B•9) DO (2-6)
Odor of 3amplc
Typical Mutat ❑ E&dhy 7_ Moldy
Nan-typlaai Sulfa g ❑ Cabbage ❑ Deeay
Oily film to PVU Yes �c
Foam In tank Yes o
Check Control Pane
Recirc Amps Discharge Amps
AudNo and visual ala ns RTOK
Dial tone (tslometry crr y)as No
Insp-11Clfaan Pump System
Inspect Clean
Rlsor/Lld .......... .........
Splice Box ......... .........
LM
Float Conic . . . . . . .. ......... .
Floats ............. ......... .
Pump.. ........... .........
Biotube!" Flitar . . . ... .... . ... .
Biotube Pump Vault . ..........
ReelrCUlating SpI tterl 1lve.......
_
comments
Signature_
E n N N rrm
R R R R R >trin
operator
Larry Betts
P'4"
WU NAR. N
415780 RTU128421
Measure Sludge/Scum
Sludge
PAGE 17
AnchorageTank
907-272-3543
Co Ua Phnnn
(947)555-5555
Rota of La t Impm-bn
05/4512019
Scum
1 St Compartment
Curre�ta
Pmvlaue
Current
Previous
2nd Commmmnt
Current
Previous
Current
prevroua
Inspect/Clean AdvanTex Fllter
Odor, AYNormaf ❑ Pungent
Biamat. Normal ❑ Excessive
Bridging/Ponding: _ None/Minor [ Exaes%Ivo
inspeattCiean discharge Pump System
Inspect
Rissr/Lid
Splice Box
Float cords
InspectlservtCe Other Systema Components
inspect Clean
Disinfection ]Equipment � . , &. ala
Observations
Inspect Clean
Literals/orirrcas
Pod Bartram
Intake vent _ r
Inspect Clean
Floats � +�
Pump
Inspect Clean
Diapers Laterawordllcos .R Apir
Additional SOrvioes Rendered
❑ Cleaned textile sheets? ❑ Replaced UV items?
❑ ReDlaced/Used other items?
Parts Used: W . Warranty, 6 e Billable (t% appropriate soloed on)
w H seem Number Descrlptwn
Final/Safety Inspection
q RSV reinstalled e�Lkls bolted on
RManlfcld roconnected: flush valvas closed J' Cantrol pane! reactivated
Summary/Recommendations
ystem performing, no further action needed
❑ r-111 for Service
Date
Fax completed form to 1,866-384-7404
❑Tank noods pumping
❑ Ot1,ee?