HomeMy WebLinkAboutSHANGRI-LA ESTATES EAST BLK 4 LT 8Block 4
Lot 8
#020-043-78
Permit Number:
Tax Code Number:
Work Type:
On-Site Water & Wastewater System Permit
OSP151056
02004378000
WellSeptic
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Initial
Permit Effective Dates: April 28, 2015 to April 27, 2016
Design Engineer: ANDERSON ENGINEERING
Subdivision: SHANGRI-LA ESTATES EAST
Site LegalAddress: SHANGRI-LA ESTATES EAST BLK 4 LT 8 G:3239
Owner/Address: ANCHORAGE DEVELOPMENT &
CONSTRUCTION LLC 9441 ABBOTT LOOP ROAD ANCHORAGE AK 995074221
Site Mailing Address: 16357 MOUNTAIN BREEZE DR, Anchorage
Lot Size in Sq Ft: 40000
Total Bedrooms: 4
This permit is for the construction of:
Y Disposal Field Y SepticTank N Holding Tank N Privy Y Private Well N Water Storage
All construction must be in accordance with: 1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater
Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80).
3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing
MUNICIPALITY OF ANCHORAGE
Community Development Department
Development Services Division
On-Site Water & Wastewater Program
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWERNVELL PERMIT APPLICATION
Parcel I.D. 020-043-78
Property owner(s) Anchorage Development & Construction LLC Day phone
Mailing address 9441 Abbot Loop Road Anchorage, AK 99507
Site address Mountain Breeze Drive Anchorage, AK 99516
Legal description (Sub'd., Block & Lot) Shangri-La East, Block 4, Lot 8
Legal description (Township, Range & Section) '~¢N'4'"'*
Lot Size 40,000 Sq. Ft. Number of Bedrooms Four (4)
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
([] all that apply)
Absorption Field [] Initial [] Single Family (SF) []
(w/wo ADU)
Septic Tank [] Upgrade []
Duplex (D) []
Holding Tank [] Renewal []
Multiple Dwellings []
Privy [] (SF and/or D)
Pdvate Well []
Water Storage []
THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I fudher certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: ~c~ )¢ ~'~'- ~'~g~//-- Waiver Fees:
Date of Payment: -~/,;~///~"' C~ Date of Payment:
Receipt Number: (~Q'~-'~ Receipt Number:
Permit No. CY-D~/~"',/O~--~ Waiver No.
ANDERSON ENGINEERING
P,O: BOX 240773
522'77731 677-7766 (FAX)
March 23, 2015
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Su~ect:
Lot 8, Block 4, Shangri La Estates East Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 8, Block 4, Shangri La Estates East Subdivision intends to construct a
new four-bedroom home on the lot. We are therefore requesting a permit be issued for
the construction of a new well and septic system to accommodate the home. The
attached Site Plan and backup documentation identify the location and configuration of
the proposed well and septic system along with the alternate site. No conflicts exist
between the proposed septic system and well or septic systems on adjacent lots.
Drainage arrows are shown on the site plan showing the grade and direction of flow on
the lot. The drainage pattern will not be changed as a result of this project.
The test holes placed on the lot in the area of the absorption trench and alternate site
indicate silty gravel with sand (GM) in the zone specified for the absorption trench. The
pemolation rate of the soil was determined to be less than 1minute per inch. No
groundwater was found during the placement of the test hole and none was noted
during the monitoring period. Plat notes require the use of nitrate reducing septic
systems on the lot. We have therefore specified an Advantex Treatment System to
accommodate four bedrooms. An application rate of 5.0 gallons per day per square
foot was used in the design of the absorption system. We are proposing to place a new
1,500 gallon Advantex Tank and AX-20 Pod and a 25' long by 5' wide by .5' effective
depth absorption trench to treat and dispose of the effluent generated in the house. A
minimum of 2' of filter sand will be placed beneath the drainfield rock to slow the
percolation of the septic effluent. The elevation of the distribution line in the absorption
trench will be 3.5' below the surface and the total depth will be 4' plus 2' for the filter
sand. A minimum of 3' of fill or 2" of insulation and 2' of fill will be placed over the
absorption trench and 4' over the septic tank. The surface of the lot will allow gravity
flow from the pod to the absorption trench so an add on lift station is not required.
Lot 8, Block 4, Shangri La East Subdivision
March 23, 2015
Page Two
The ground surface on the lot in the area of the septic system slopes to the northwest.
The new trench will be constructed parallel with the contours of the sloPe as mUCh as
possible in conformance with Municipal requirements. The new septic system will be
constructed a minimum of 100' from all wells and any surface water and 10' the
proposed and existing water services in the area.
If the system is constructed in accordance with our design the following statements
apply:
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
7
LOT 8, BLOCK 4, SHANGRI-LA EST. EAST SUBDIVISION
DESIGN FACTORS:
Four Bedroom Home
Perc. Rate: <1 Min./Inch
Application Rate: 5 GPD/SF
SYSTEM REQUIREMENTS:
5' Wide Trench System
Four Bedroom Advantex Treatment System
with AX-20 Pod - Gravity Flow
.5' Dreinfield Rocld2' Filter Sand
4 Bedrooms * 150 GPD/Bedroom = 600 SF Absorption Area
600 SF/5 GPD/SF/5 SF (Width) = 24 LF Trench Length
THEREFORE: Construct a 25' Long x 5' Wide x .5' Effective Depth Absorption Trench,
Flow Line Elevation in Trench to be 4' Below Odginal Ground Surface. Total Depth to be
6' Below Existing Ground. Provide 3' Cover Over Absorption Trench and 4' Cover Over
Septic Tank. Gravity Flow From Pod to Absorption Field.
2~
.........~eotextile Fabric
% 4" Perforated
PVC (Holes Down)
Drainfield Rock
rFilter Sand
TYPICAL 5' WIDE TRENCH__ ..,--_,,, ,,-...SECTION
NUH-: uraae ~rea uver/rencn [o uraln Away. . ~ /
· · , · ~ F 49~
Minimum 6 Separabon From Bedrock. ..~ .......... . .......... ~.....~
Minimum 4' Separation From Groundwater. ~ ~
Minimum 100' Separation From Private Wells in the Area. ~ .,c~.~.~.;~"?~
Minimum 100 Separation From Su~ce Water or Streams: ~..b%~ N~. c~-~
· ~ ~...~ -'~
~ESS~~
W.O,# 05716
DHI CONSULTING ENGINEERS
800 E. D~MOND BLVD. SUI3E 3-545
ANCHORAGE, ALASKA g9515
SOILS LOG-PERCOLATION TEST
{ ) TEST OLE LOG LGB,
P~FORMEO FOR-ANCHORAGE DEVELOP. &: CONST. DAT~ PERFORaEO: 4-/14/11 '-,-9:'. ,~-
LEGAL DESCRIP130N: LOT 8, BLOCK 4 SHANGRA-LA ESTATES EAST SUBD.
.,'v, ~ 1' SLOPE SITE PLAN
..A,', ORGANrC MA'fL·
I .
5 '~.": .- GREY-BROWN SLIGHILY SILT¢
"., SANDY GRAVEL.,~.
ROCK TO 12".
· ,' ~ NON-CLUMPING.
7 4-.
8 "' :'
":." .: ENCOUNTERED ? NO L
9 !, ,~ .' ~r YES, AT ~14AT
10 ~ B.O.H,, DEPTH ? E
FRACTURED BEDROCK DEP"I3-I OF WATER
11 AFTER MONITORING ? NONE DATE: MAY 13, 2011
14
15
16
17 PEROOLA'nON RATE: 0,,¢ (blINU'TES/INCH.) PERCHOLE DIAMETER:_
TEST RUN BETWEEN: 5.0 FT. AND 5,5 FT,
COMMENTS: THIS TEST HOLE INFORMATION IS PROVIDED TO COMPLY WITH THE SUBDIVISION APPROVAL PROCESS AS
OUTLINED IN AMC 15,6.180.B.1, ANY USE OF THIS DATA FOR ANY OTHER PURPOSE, INCLUDING THE
DESIGN OF AN INDIVIDUAL SEPTIC SYSTEM IS STRICTLY PROHIBrrED, WITHOUT THE WRITTEN CONSENT OF
THE ENGINEER OF RECORD.
l PRIOR TO STARTING THE PERCOLATION TEST.
ALL
SOILS
WERE
PRE-SOAKED
PERFORMED BY: DHI CONSULTING ENGINEERS. I DEE HSGH CF-I~IIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES rN EFFECT ON THIS DATE. DATE: ,.2/07/06 7160SSCBD
345 6 789
'l, 70
�
if:_ �,-.wz. >
' c� Municipality of Anchorage ' ' ,
On-Site Water and Wastewater Program a ���'
(907) 343-7904 �' f e i k
! S A F E T Y
l N
0! ',
Certificate of On-Site Systems Approval 6 a g 5 n E
3
VM
Parcel I.D. 020-043 Expiration Date: D I S-
1. GENERAL INFORMATION
Complete legal description Shangri-La Estates East Block 4 Lot 8
Location (site address) 16357 Mountain Breeze
Current Property owner(s) Richard S Harvey Day phone
Mailing address P.O. Box 111816, Anchorage AK, 99511
Real Estate Agent Day phone
2. TYPE OF DWELLING:
O Single Family (w/wo ADU)
n Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well x Individual E
Individual Water Storage n Holding Tank ❑
Community Class Well n Community
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by. 44=7 Date: S�ZS/jF
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 52L Waiver Fee $
Date of Payment 51 2J) Date of Payment
Receipt Number ()0006 D Receipt Number
COSA# d J6-i� 1 !?' 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.
Name of Firm Forge Engineering Phone (907) 522-7773
Address PO Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, PE Date 5/21/18
6. DSD SIGNATURE ;,,*• 49 TH • �
.� System#1 Approved for 14 bedrooms /�' •'
Michael E.Anderson
nderson :
System#2 Approved for bedrooms l�Oh,
Disapproved
Conditional approval for bedrooms, with the following stipulations:
OF ANC/7•
•� ON_SC�E D
.
\NPRNP EK 0o
o W pR°`-'
r`
By: .P t• En jv. oc� 11' (cle I u:'c Original Certificate Date: My 23 PO&
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 blue sheet f '• c
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: Shangri-La Estates East B4 L8 Parcel ID: 020-043-78
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 6/13/15 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 207 ft. Cased to 13* ft. Casing height(above ground) 24 in.
FROM WELL LOG AT INSPECTION
Date of test 6/13/15 5/18/18
Static water level 34 ft. 33 ft.
Well production 6 g.p.m. 4 0 g.p.m.
WATER SAMPLE RESULTS:(
Coliform !�/e colonies/100 mL Nitrate MO O mg/L
Arsenic !V D ug/L Date of sample: 5/7/18 Collected by: Forge Engineering
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Advantex FAP/Fiberglass Date installed 5/12/15
Tank size 1500 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) Y
Date of pumping Pumper Maintenance services provided by Anchorage Tank
C. ABSORPTION FIELD DATA
Date installed
5/11/15 Soil rating (g.p.d./ft2 or ft2/bdrm) 5 System type 5-Wide
Length 25 ft. Width 5.0 ft. Gravel below pipe 0.5 ft.
Total depth 3.8 ft. Eff. absorption area 125 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 5/18/18 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 0 in. Water added 612 gal. New depth 0 in.
Elapsed Time: 1440 min. Final fluid depth 0 in. Absorption rate >= 600 g p d
None
Any rejuvenation treatment (past 12 mo.) (Y/N &type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot >100' On adjacent lots >100'
Absorption field on lot >100' On adjacent lots >100'
Public sewer main >75' Public sewer manhole/cleanout >100'
Sewer/septic service line >25' Holding tank >75'
Animal containment areas >50' Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
>5' >5'
Building foundation Property line >5' Absorption field
Water main >10' Water service line >10' Surface water >100'
Wells on adjacent lots >100'
ABSORPTION FIELD ON LOT TO:
>10'
>10' >10'
Property line Building foundation Water main
Water Service line >10' Surface water >100' Driveway, parking/vehicle storage >10'
Curtain drain None Noted Wells on adjacent lots >100'
F. COMMENTS
*4.5" PVC Liner from 12' to 52' Below the surface.
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and ,���OF*k\
review of Municipal records that the above systems are in . , A�.gSiil
conformance with MOA COSA guidelines in effect on this date. 40.4:...-.� `I,•.'f��#
Engineer's Printed Name Michael E. Anderson, PE 0*:
*:'49 TH /\ %.*00
Date 5/21/18
I % Michael E.Anderson e
�ri V- 4381-E .**4-k40
COSA brown sheet 10-10-12.doc
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
BETWEEN MUNICIPALITY OF ANCHORAGE
AND STERLING RIPLEY Y.
THIS MAINTENANCE AND REPAIR AGREEMENT made and entered into as of this
21ST Day of MAY of 20 18,by and between STERLING RIPLEY J12.,
herein the"OWNER,"and the Municipality of Anchorage,herein the
"MUNICIPALITY." In consideration of the mutual covenants contained herein,the
parties to this Maintenance and Repair Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. Municipality grants permission to
Owner to utilize and operate an Advanced Wastewater Treatment System
(AWWTS),described as
ADVANTEX WASTE WATER TREATMENT SYSTEM
located at(legal description).
SHANGRI-LA ESTATES EAST L8 B4
2. Definitions.
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.
Certificate of On-Site Systems Approval (COSA). 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 Anchorage
Municipal Code (hereinafter, "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.
Damage. Any man-made or natural change in a system that would inhibit
the system from performing as designed.
Maintenance and 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.
Permit.An On-Site Wastewater Disposal Permit as required by AMC
15.65 to construct and operate an AWWTS.
3. Term. The term of this Maintenance and Repair Agreement shall begin on the
date of approval by the Municipality to operate the installed system or issuance of a
COSA, and shall continue while the AWWTS is in use or is operational or until the
property is sold or title is transferred by the owner and a new COSA is issued to the
new owner or transferee of the property.
4. Alterations,Installation and Removal of Additional Equipment. Prior to
performing any alterations to an AWWTS,the owner agrees to obtain an On-site
Wastewater Disposal Permit from the Municipality in accordance with AMC 15.65.
5. Maintenance and Repairs.
A. Throughout the term of this Maintenance and Repair Agreement,the Owner shall
maintain their AWWTS in a satisfactory condition capable of producing treated
septic effluent in accordance with the equipment's approval for operation in the
Municipality. The owner shall enter into a service agreement with an AWWTS
service and maintenance provider approved by the municipality and the
manufacturer of the AWWTS for the entire term of the AWWTS. In addition,it
shall be the responsibility of the Owner during the term of this Maintenance and
Repair Agreement, and any 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.
B. Owner agrees to comply with all applicable ordinance, laws,regulations,rules
and orders for the AWWTS.
C. Upon request by the Municipality,the owner agrees to provide the Municipality a
written schedule of routine maintenance and repairs which have been performed
on the system. When a record of maintenance is documented and maintained by
the system vendor,the owner agrees to allow the Municipality access to this
information.
D. Owner acknowledges that the fine for failing to maintain and repair an AWWTS
may be assessed in accordance with AMC 14.60 for improper discharge.
E. Owner agrees that only maintenance and repair personnel approved by the
Municipality will inspect and make any necessary maintenance,repairs or
permitted alterations to the system.
F. Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS upon 24 hours written notice.
G. Owner agrees that any sale or transfer of title of the property will not occur
without a new Certificate of On-Site Systems Approval.
H. 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.
6. Nonwaiver. The failure of either party at any time to enforce a provision of this
Maintenance and Repair Agreement shall in no way constitute a waiver of the
provisions,nor in any way affect the validity of the Maintenance and Repair
Agreement or any part hereof, or the right of such party thereafter to enforce each and
every provision hereof.
7. Amendment.
A. This Maintenance and Repair Agreement shall only be amended,modified or
changed by a writing,executed by authorized representatives of the parties, with
the same formality that this Maintenance and Repair Agreement was executed
with, and such writing shall be attached to this Maintenance and Repair
Agreement as an amendment.
B. For the purposes of any amendment modification or change to the terms and
conditions of this agreement,the only authorized representatives of the parties
are:
a. Owner: STERLING RIPLEY Jj2.
b. Municipality: Director,Community Development or designated authority
C. Any attempt to amend,modify, or change this contract by either an unauthorized
representative or unauthorized means shall be void.
8. Jurisdiction: Choice of Law. Any civil action arising from this Maintenance
and Repair 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 Maintenance and Repair
Agreement.
9. Severability. Any provisions of this Maintenance and Repair Agreement decreed
invalid by a court of competent jurisdiction shall not invalidate the remaining
provisions of the Maintenance and Repair Agreement.
OWNER:
(signature) Date: 51/4/ i 8
l S 'l C . int name)
STATE OF ALASKA )
) ss.
THIRD JUDICIAL DISTRICT )
The foregoing instrument was acknowledged before me thisZL day ofkCe -
20 ,by :>k-Y kk�n j
State ofAlaska
NOTARY PUBLIC
NOTARY PUBIC•'OR ALASKA j Kara'lirviford
My Commission expires: . 202.1 j My comn,tsston Was x.14,2021
MUNICIPALITY:
By: (signature) Date: .�r Z 3 -/
(print name) Title:
05/31/2017 04:44 8686770 APLUS PAGE 06
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no ■■M■ MMR III MiIi. ill. ■Ai I
11 ii I M l ilii ■ M ■ i• ■■ iI ■ PU IS ■
I III IN i■i■ Milli I RIM Mill • 0
Advarirrexe Field Maintenance Report AnchorageTank
Annual Inspection 907-272-3543
opornta
Property 0w0 T na00 Larry BettsShane Harvey Conine see Add�ass (907)980-1676
16357 Mountain Breeze Drive, Anchorage AK 99516 ��� Date a�t �
Co""�1D f Pod
11 RTU 12/15/2016
ion
AX Site ID a RTU 131953
AX137605 1 OSP151056 422165
Retrieve O&M Info Measure Sludge/Scum
own
Daily flow
Sludge S_ _ —
1St Compartment Currgnt Previous Current Previous
Recirc ratio
Ti _ /?J ,t
mer settings 2nd Compartment Current Previous Current Previous
Inspect/Clean Advantax Filter Inspect Clean
Odor: .EirkiOm,ai ❑Pungent Laterals/Orifices-'-" ""t''
Perform Field Sampling/Observations 8lomat: Normal ❑Excessive Pod Bottom -- •
NTU(16 e NTUs) pH(6-9) DO(2-6) Briddging/Ponding: None/Mlnor ❑Excessive Intake Vent
/a-OC
9. 1 Inspect/Clean Discharge Pump System
JJ VV 11 Inspect inspect Clean
Odor of Sample Rlser/Lid CI no CI CITypical Zi Musty ❑Earthy ❑Moldy
Splice Box El Pump ❑ ❑
Non-typical W$uHlde ❑Cabbage ❑Decay Float cords [-i�
Oily tnm in pw ❑Yea eNo
d5 Inspect/Service Other System Components
inspect Clean
Foam in tank ❑Yes /�No Inspect Clean
Check Control Panel Disinfection Equipment C� .nt / '� Olsperaal t.aterals/OTt ice�� '�^
ReeirC Amps Discharge AmPa Observations t/v^
L
Additional Services R `dared
— — ❑Cleaned textile ahem? ❑Replaced UV items?
Audible and visual alarms zoK ❑Replaced/Used other Items?
Dial tone(telemetry only) C Yes,rel No Parts Used:W=Warranty,B e Billable(✓appropriate selection)
inspect/Clean Pump System w 13 Item Number Description
InClean
Fliser/Ud "P:irr
Splice Box
Float Cords
Floats rU Final/Safety Inspection -+
tSV reinstalled '[_I�Sda bolted on
Pump vrrJ •n
Control
,Z 0 �anlfakJ reconnected;flush valves closed Control panel reactivated
Biotube Pump Vault ✓ ( Summary/Recommendations
El XJ System performing;no further action needed ❑Tank needs pumping
Recirculating Splitter Valle —
El Call for service ❑Other?
Comments
Date �1/ttcf /7
Signature -
Fax Completed form to 1-666-884-7404