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HomeMy WebLinkAboutTRANQUILLITY HEIGHTS BLK 1 LT 32ATranquility Height Block Lot 32A #014-151-76 NAME MAILING ADDRESS LEGAL DESCRIPTION LOCATION MUNICIPALITY OF ANCHORAGE DEPARTMENT OF REALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 T01ephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT i Manufacturer ~ ~)..r~ ¢ Liq,DiSTANcECapacity in TO:gall°ns w21F HOMEMADE: DwellinglnSide length ~NE~.~ ~I~RADE NO, OF BEDROOMS PERM,TNO. Liquid depth PERMIT NO. Manufacturer Liquid capacity in gallons Foundation Material Near~s-~ot line Trench width Depth DISTANCE TO: Well NO. of lines ~ ///), I Length of ~ach.~ir)~..( · op ot ti e to finish gra~o Length PERMIT NO. PERMIT NO. Type of crih Crib diameter Crib depth Total effective absorption area Woll Building foundation Nearost lot line DISTANCE TO: Class Depth Driller Distance to lot llne Building foundation Sewer line Septic tank DISTANCE TO: OTHER PIPE MATERIALS SOIL TEST RATING REMARKS LEGAL WATER WELL LOG FOSS DRILLING ASSOCIATED 909 CHUGACH DR, #5? ANCHORAGE, ALASKA 99505 WELl, OWNER William Co Plunder USE OF WELL Domestic WELL LOCATION Lots 52 and 55 Block 1 Tr~lquility Heights Subdivo SIZE OF CASING6" DEPTH OF HOLE 85 FT. CASED TO STATIC WATER LEVEL 37 FT. G, Po Mo 8 WITH REMARKS 85 FT. 46 FT. OF DRAWDOWN. DATE COMPLETED 8/18/79 PUMP TO BE SET AT 84' O to56 Till; grey color and hard P6 to 7__~2 Alluvium; grey color, medium hardness 72 to 84 to Silt~ ~and~ and gravel; grey color, with water Sand and graveli grey color, with water to to to to to tO to__ to RECEIVi:L) PERMIT NO. DEPFIRTMENT OF HEERLTtt ~ND EN',tlRONMENT~L PRO'rECTION ~.6200 SG~ APPLICANT NILLIAM C PFUNDER 9499 BRFIYTON LCICATION 3640 E, 72ND AVE LEGAL L. 3~ BLK i TRflNQUILTY FII'5. LOT SIZE TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH MRXIMUH NUMBER OF BEDROOMS = Z SOIL RFITINQ <SQ FT/BR)= THE REQUIRED SZZE OF THE %OIL RBSORPTION S~STEM ]'HE LENI3TH DIMENSION IS 'THE LENGTH (IN'FEET?.' OF' THE TRENCH OR DRFIINFIELD. Tt4E DEPTH OF A TRENCH OR PI]' I5; TME DISTANCE: BETI4EEN TIlE SURFRCE OF' THE GROUND RND THE BOTTOM OF THE' EXCAVATION (IN FEET). TFIERE IS NO SE]' HIDTH FOR TRENC:HES. THE GRAVEL DEPI'M IS THE MINIMUM DEPTH ,OF GRAVEL BETHEEN THE OUTFFILL PIPE AND THE BOTTOM OF THE EXCRVPITION (IN FEET). PERMI'F APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALL. FFTIOI'..I IHSPE.'CTIONS OF ANY HELLS RDSRCENT TG THIS PROPERTY RND THE NUMBER OF RESIDEt',IC[:-;S THAT THE HELL HILL SERVE. 1-141C) ,:: 2 ) I i~iSI:::'EC':T I OIJIS AREE REZI_.'1!.IJ I REED ......... BFICKFILLIN6 OF RNY SYSTEM HITHOUT FINAL INSPECTION AND BPPROVRL BY THIS DEPARTMENT 14ILL BE SUBJECT TO PROSECUTION. MINIMUM DIS'FAN£.':E BETHEEN A HELL fiND FtNY ON-SITE SEWAGE DISPOSRL SYSTEM IS :E.~B} FEET FOR R PRIVRTE 14EL,L; OR t50 'TO 208 FEET FROM R PUBLIC WELL DEPENDING UPON THE TMPE OF PUBLIC HELL. WELL L, OG~S RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT NITHIN 2<O DBMS OF THE WELL COMPLETION. OTHER REE~tJIREMENTS NRY ~PPLY. SPECIFICRTIONS FiND CONSTRUCTION DIRGRAMS RRE R'~,'RII,.flBL. E TO INSURE PROPER INSTRLLRTION. I CERTIFY Tt4AT :!.: I tim FF~IILIRR WITH THE REQUIREMENTS FOR ON-SITE SEI4ERS RND HELLS RS SET FORTH BY THE ML.INICIPRLIT9 OF ANCHORAGE. 2: I HILL INSTRLL THE SYSTEM IN RCCORDRNCE HITH THE CODES. ~: I UNDERSTRND THRT THE ON,..-S~TE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF 'file RESIDENCE~IS REMODELED~tlC:LUDE MORE I'HRN ~ BEDROOMS. RP~L~.FtFFt' ~II_LFI~M i::: PFUNDER ' ..... ................................... ..... ................ SOILS LOG PERFORMED FOR: MUNICIPALITY OF ANCHORAGE DEI~.ARTMENT OF HEALTH AND ENVIRONIV~EN'rAL PROTFCTION Pouch 6-650, Anchorage, Al~ka 99502 276-222~ SOILS LOG - PERCOLATION TEST Sheri Plunder PERCOLATION TEST ASI No. 02479 DATE PERFORMED: 6/19/79 LEGAL DESCRIPTION: Lot 33, Block 1, Tranquilit~ Heighta 1 2 3 4 § 6 7 8 9 10 11 12 13 15 17 18 19 20- COMMENTS No Overburden. Sandy Gravel w/Silt (GM) BEown 2.5' Sandy Gravel w/Silt (GM) & Cobbles to 6" Gray ToDo SLOPE WAS GROUND WA'rER S ENCOUNTERED? N 0 ~ i P E IF YES, AT WHAT DEPTH7 SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop 9:52 6/19/79 0 0.08' 0 10:02 " 10 min 0.13' .05' 10:12 " 20 " 0.16' .03' 10:22 " 30 " 0,19' ,03' 10:32 " 40 " 0.21' .02' 10:42 " 50 " 0.23' .02' 10:52 " 60 " 0.25' .02' 16.0' PERCOLATION RATE ~2 mJ. nu~caa/J_noh(minuteslinch) TEST RUN BETWEEN ~ ° 0 FT AND 9.2 FT PERFORMED BY: D. Shellenberqer CERTIFIED BY: S. Sbracler DATE: 6/20/79 72-008 (7/76) MUNICIPALITY OF ANCHORA~I.: M'mJNIO'rpALITY Of' A~CHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MEMORANDUM %t0V 8'jgsg DATF.: TO: FROM: SUBJECT: RECEIVED Nove~mber 7, 1989 Tom Wolf AWWU Construction and Planning Supervisor Jerry T. Weaver, Jr. DEDP Planning Supervisor S8858 Tranquillity Heights Subd. Lot 32A Thank you and your staff for meeting with JoAnn and myself today concerning this case and the need for sewer extension. As we discussed, we will arrange another meeting with the Department of Health to establish consistent application of the subdivision regulation concerning the extension of sanitary sewer vs. the use of an on site system. In this particular case, Since the applicant has a recently approved septic system pe~it (Sep~ 1989) I am not requiring the extension of Sanitary sewer. I hope when we meet again with the come to some resolution as to when sanitary sewer or allow the use of 0epartment of Health, we can to require the extension of an on site system. cc John Smith DHHS PRELIMINARY PLAT APPLICATION OFFICE US~ Municipality of Anchorage DEPARTMENT OF COMMUNITY PLANNING ~ 'c~. / Box 6650 VER~FY OWN _i ; ;. :, Anchorage, Alaska 99502-0650 ': ' , -.~:. ~ .', Please fill in the information requested below. Print one letter or number per block, Do not write in the shad~' - ,z ~b[ocks, ...., 0. Case Number (IF KNOWN) 1. Vacation Code ce ,';: -~::.;:' ,.,":' New abbreviated legal description (T12N R2W SF-C 2 LOT 45 OR SHORT SUB BLK 3 LOTS 34). ~ '~ [/-I ob1131 ~14 I~ I, I~ ~1~1, I,. LI , ITbl Isl, l~l I ... ,..'~:'~';. ' ' 3. Existing abbreviated legal description (T12N R2W SEC 2 LOT 45 OR SHORT SUB BLK 3 LOT 34) full legal on back page. t_lob113kl. Ist~l Tt,l~i~l~¼ ,~.~-, -r ~ ¢ ~ 11111t' / IIIIII 4. Petitioner's Name (Last- First) Illlllll'lllllllllllJ Address ~-'/l/'~ ~. '72- City /~c~,¢-.¢¢-.~ state 5. Petitioners Representative ~/~'~ IIII Address- ~00~ ~", ~)IV~o~J) City /~t'-!ctL~Z-"z¥¢-.~ State Phone No. Bill Me_ Phone No. ,,~'2-2-- t ~1( Bill Me 6. Petition Area 7. Proposed 8. Existing 9. Traffic 10. Grid Number 11. Zone Acreage Number Number Analysis Zone Lots Lots 12. Fees "~ ~'O' O0 13. Community Council ~¢ c,, ,_'-,/ X ufD ~//'~ B. I hereby certify treat (I am)(I have beenauthonzedto act for)theowner of the property described aboveandthat I des~reto subdivide it in conformance with Chapter 21 of the Anchorage Mumc~pal Code of Ordinances. I understand that payment of the basic subdivision fee is nonrefundable and is to cover the costs associated w~th processing this applicabon, that d does not assure approval of the subdwis~on. I also understand that adchtional fees may be assessed ff the Mumc~pahty s costs to process this application exceed the basra fee. I further understand that ass~gne8 heanng dates are tentative and may be have to postponed by Planning Staff, Platting Board, Planning Commission, or the Assembly due to adrmmstrat~ve reasons. Date: ':¢ 8858 OCT 2198,9 Signature f 'Agents must provide written proof or authorization. C. Please check or fill in the following: 1. Comprehensive Plan -- Land Use Classification ~N Residential Commercial Parks/Open Space Transportation Related 2. Comprehensive Plan -- Land Use Intensity Special Study 3. Environmental Factors (if any): a. Wetland 1. Developable 2. Conservation 3. Preservation Marginal Land Commercial/Industrial Public Lands/Institutions Dwelling Unite per Acre Alpine/Slope Affected b. Avalanche c. Floodplain d, Seismic Zone (Harding/Lawson) D. Please indicate below if any of these events have occurred in the last three years on the property. Rezoning Case Number Subdivision Case Number Conditional Use Case Number Zoning Variance Case Number Enforcement Action For __ Building/Land Use Permit For Army Corp of Engineers Permit E. Legal description for advertising. Alpine/Slope Affected Industrial Special Study F. Checklist 30 Copies of Plat Reduced Copy of Plat (8'/2 x 11) Certificate to Plat Fee Tope Map 3 Copies Soils Report 4 Copies Aerial Photo Housing Stock Map Zoning Map Water: Sewer: / Private Wells "~ Private Septic Waiver Community Well Community Sys. Public Ublity Public Utility Municipality of Anchorage On-Site Water and Wastewater Program (907) 343-7904 Certificate of On-Site Systems Approval Parcel i.D. 014-151-76 Expiration Date: 1, GENERAL INFORMATION Complete legal description Tranquility Heights, Block 1 , Lot 32A Location (site address) 3710 E 72nd Ave. Current Property owner(s) KTAC Properties LLC Day phone Mailing address 200 W 34th Ave. #961 Anchorage, AK 99503 Real Estate Agen[ Day phone 2. TYPE OF DWELLING: [] Single Family (w/wo ADU) [] Duplex [] Multiple Dwellings (Single Familyand/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: Individual Well [] Individual Water Storage [] Community Class __ Well [] Public Water System [] TYPE OF WASTEWATER DISPOSAL: Individual [] Holding Tank [] Community [] Public Sewer [] Waiver/Variance request for: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: Distance: COSA Fee $ Date of Payment Receipt Number COSA 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 fur[her redly that based on the information obtained from the Municipality of Anchorage files and from my [nvestiga§on 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 ~t 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 ail 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 controt 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 Phone (907) 272-6218 above. Name of Firm Pannone Engineering Services LLC Address P.O. Box 1.~00217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone 6. DSD SIGNATURE System #1 Approved for '~ bedrooms System #2 Approved for __ bedrooms Disapproved Conditional approval for Date 6/4/2015 bedrooms, with the following stipulations: B Y:/~'~/J"¢~'~~''~/,/.~ __ Origina' certificate Date: The[q,~/u~iciPality Of Anchorage Development Services Divisioe (DSD)issues Cer[ifTcates 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. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory x Nitrate Advisory' Arsenic Advisory Other COSAbluesheet_.r '- :,~ c If more than 1 septic system is on the lot: COSA Checklist # ~ of ~ Structure served by_this system 0 Certificate of On-Site Systems Approval Checklist Legal Description: Tranquility Heights, Block 1 , Lot 32A Parcel ID: 014-151-76 A. WELL DATA Well type Private ifA, B, or C provide PWSID # Date completed 8/.18/'1979 Sanitary seal (Y/N) Y Total depth 85 ft. Cased to 85 ff. FROM WELL LOG Date of test 8/18/1979 Static water level 37 ff. Well production 8 g.p.m. WATER SAMPLE RESULTS: Coliform Neg colonies/100 mL Arsenic ND ug/L Nitrate 0.436 mglL Date of sample: 5/22/2015 we,I Log (YiNJ.Y Wires properly protected (Y/N) Y Casing height (above ground) '18+ in. AT INSPECTION 5/13/2015 37 ~. 3+ g,p.m. Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tanksize 1,000 gal. Foundation cleanout (Y/N) N Date of pumping ¢k,J~ Number of Compartments 2 Date installed 8/30/1979 Cleanouts (Y/N) Y Depression over tank CY/N) N_ High ~vater alarm (Y/N) ___ Pumper A+ Home Services } J~0?-T~ C. ABSORPTION FIELD DATA Date installed 8/30/1979 Soil rating (g.p.d./ff2 orff2/IJdrm) Length 68 ft. Width 3 Total depth 4'2A~. t OW ~I~ Y Eft. absorptioh area ~ Monitoring tube Date of adequacy test 5/13/2015 Results (Pass/Fail) PE~SS" _ Fluid depth in absorption field before test 0 in. Water added.450 Elapsed Time: 1440 min. Final fluid depth 0 Any rejuvenation treatment (past 12 mo.) (Y/N & type) No 290 SF/BR System type Deep Trench ft. Gravel below pipe 8 ft. DePression Over field N For -3 bedrooms gal. New depth 0 in. in. Absorption ra[e >= 450+ g.p.d. If yes, give date D. LIFT STATION Date installed 8/30/1979? "Pump on" level at 8 in. Datum Bottom .of Tank Size in gallons Unknown "Pump off" level at 3 in. Cycles tested Unknown* MadholelAccess (Y/N) Y High water alarm level at 16 Mee~ alarm & circuit requirements? Ye~ SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100+ Absorption field on lot 100+ Public sewer main 7'5+ Sewer/-septic service line 25+ Animal containment areas 50+ SEPTiC/HOLDING TANK ONrLOT TO: Building foundation 5+ 10+ Water mare Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Water Service line 10+ Curtain drain 50+ On adjacent lots 1 DO+ On adjacent Jots 100+ Pu blic sewer manholelcleanout lO0+- Holding tank 100+ Manure/animal excrete storage ai;eas 100+ Prooerty line 5+ Water service line 10+ Absorption field 5+ Surface water 100+ Building foundation 10+ Surface water 100+ Wells on adjacent lots 100+ Water main 10+ Driveway, parking/vehicle storage 10+ F. CO!~MENTS ~,tMoaitOr ~ubb'd6es nbt extend to botto~ of field. Bottom ~of M'l%appears to be 41" off'bottom of field. *Tested by A+ Home Services. G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspection~,~and review of Municipal records that the above systems a~e in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Steven. R~ Pannone Date 6/4/2015 COSA canai~ sheeL2-6-1 &doc Pannone Engineering Services EEC Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve~, panenRak.com June 08, 2015 Municipality of Anchorage Development Services Department On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, Alaska 99519 Subject: Tranquility Heights, Block 1, Lot 32A Ladies and Gentlemen: 1. Septic Test: On 5/13/2015 we did a well/septic test at 3710 E 72nd Ave. What we found was a well and septic system attached to a trailer which has not been used in over 10 years. The septic system consists ora 1,000 gallon tank, a small pump vault, and a 68'x8'ED deep trench. We presoaked the drainfield then started our test. During our test we introduced 450 gallons from the well, into the septic. The monitor tube that we were using was 41 inches offthe bottom of the drainfield. This only puts the monitor tube 55 inches into the top of the drainfield. The monitor tube was dry before we started our test and did not accumulate any water during our test. It is our opinion that this septic system is working adequately for a future 3 bedroom residence. 2. Well Test: From the well log, it shows the well 85 feet deep with a static level of 37 feet and able to produce 8 gallons per minute (GPM.) Prior to our test we found the static level to still be 37 feet. During the first 20 minutes of our test, the water level in the casing drew all the way down to the pump. At this point we were producing 6.4 GPM without any drop off in production. The well can produce over 6.4 GPM. 3. Conclusion: The test results showed that the well and septic were both operating adequately for a 3 bedroom residence. After our test, the trailer was removed so both the well and septic are disconnected from use and power. Once a new structure is built, they will be reconnected and ready for use. Sincerely, Steven R. Parmone, P.E. ' Owner/Civil Engineer Attachments: Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 Physical: 332 1/2 East Manor Ave, Anchorage, AK 99501 lelephone: (907) 272-8218 FAX: (907) 272-8211 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.# L31cl-I'.SI-~ A~3' 'Lp_Y~ i HAA#_ ~gq~q~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) '-3'7i0 7Z''d (b) Property owner .,~ L,~%' ~-)~ ~/.~",~'1 Telephone: (home) Business ~40~' "-Z 758 Mailing Address (c) Lending Institution Mailing Address ~,1 (d) Real Estate Company and Agent Address h/ 'Telephone 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, WA'rER SUPPLY Individual Well.~ Commuoity [] Public [] Nole: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality 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 legality and status, 72025(Rev 7/88) Page 1 of 2 ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Nameof Firm ~ ('?~¢-~:,//.,.' ¢ /~ ..~?¢.%'- Telephone Date /L~(.,,~ ~? , / , ,.<~, Engineer's Seal 6. DHHS APPROVAL Approved '~ ___ Disapproved Conditional Date Terms of Conditior~al Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 72-025 (Rev. ?/88) Back Page 2 of 2 ~ MUNICIPALI'rY OF ANCHORAGE (MOA) N~,j~J~A'g)[y OF ANCl-~fl~Aathorlly Approval (HAA) ~NV~fALS~ViC~tLIST- FEBRUARY 1984 ...... '~ 343-4744 P, '- ~ 989 Legal Description: J_.oT ~ ~ .~.~ RECEIVED A. WBLL DATA Well Olassifioation ~ I~ ~7 If A, B, O, D.E.O. Approved (Y/N) Well Log Present (Y/N) I Date Completed _:?1/~/7~ Yield Total Depth ~S- Oased to_ ~75'- Depth of Grouting ~. ~ Static Water Level _~.'.'.'.'.'.'.'.'..~.~ ' Casing Height Above Ground _ ~.~ Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot Pump Set At L~¢- ~ Sanitary Seal on Casing (Y/N) ~/' Depression Around Wellhead (Y/N) ; On Adjoining Lots ~/Oo ; On Adjoining Lots To Nearest Public Sewer Line ~ /)'~- To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot -~-~-© ~ Water Sample Collected by /~, ;Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~/~0/7/~' .Size ~/~:)C'~';)/~_(_ No,, of Compartments Standpipes (Y/N) k//' Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) 2_ Foundation Cleanout (Y/N) Date Last Pumped ~/Z/~<~ ;for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well /C',~:~ ~ To Building Foundation jL%/ / To Property Line ::~ /(') ' 'A'~-J~ To Disposal Field .5~ ' To Water Main/Service Line ~/~ To Stream, Pond, Lake or Major Drainage Course .~ ~ Comments'~ ~/~/. '7~q ,'/ed -/O ~ e- ]~,//~(;/ O ~, ~8~ o,~A 72-026(Rev 7/88) Front Page 1 of 2 ABSORPTION FIELD DATA Soils Rating in Absorption.., Strata Date Installed ¢/.~o ./) ¢¢ Width of Field Square Feet of Absortion Area )t (''~¢/~' Depression over Field (Y/N) /~,l Results of Last Adequacy Test ¢'~/'~7-15 SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well / ~ ~ To Building Foundation ~/~ ~ To Water Main/Service Line %-~ / To Stream, Pond, Lake, or Major Drainage Course k~ To Driveway, Parking Area, or Vehicle Storage Area //~-jr',~ Type of system Design Length of Field ~ ~ ~ Depth of Field '~ /Z. t Gravel Bed Thickness ¢ I Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line /O ' ~ ~ To Existing or Abandoned System on ; On Adjoining Lots ~- ~7_ ~ ~ To Cutback (if present) /(,[ 1,,~ / D. LIFT STATION Size in Gallons .~'-(.)~ ~.~o~ ! "Pump On" Level at'~ ,~, ~1 High Water Alarm Level at-'~' '~ ~¢ ~ Dimensions Manhole/Access ,,Pump Off,, Level at_ Vent (Y/N) Tested for' --~%~ ,-'~ -- ~----~yC /e ~ Pumping Cycles during Adequacy Test. Meets MOA, Electrical Codes (Y/N) -~ **Ch~ck Permit~d Bedroomgating Against HAA Request** I certify that [LaCe ohecke~ified, or conformed to all MOA i nspection./~///~ // / ' a ndHAA ,lines in effect on the dafe of this Signed //,;~ ~ ~~'~- Date ~ ¢ / Engineer's Seal MOA No. ¢ - Receipt No. Date of Payment Amount: $ 72-028 (Rev. 7~88) Back Receipt Waiver Fee: $ Date of Payment Page 2 of 2