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HomeMy WebLinkAboutR & R BLK 3 LT 24'cx0- 331- VO Mark Begich Mayor Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www. mu ni.orq/onsite (907) 343-7904 Pump Installation Log Well Drilling Permit Number: SW Parcel Identification Number: E(.O `331-10 Date of Issue: Legal Description IG^i'1\ f3 L2. Property Owner Name & Address: SY / lra',n /Yoli,,; o,) 1g333 Sfa1c4;/( Pump Installation Date: 5^_ u (^ r 6 Pump Intake Depth Below Top of Well Casing: Pump Manufacturer's Name: Rec J "ked. Pump Model: 1.5-62.,1 %Si6 Pump Size )1 -hp Pitless Adapter Burial Depth: . (0 feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Completion? r Yes ❑ No ?a !'/Z Method of Disinfection: Comments: G7d t� c c 2: vcne, A K feet Zpr Pump Installer Name: Coif C0-1-4 ANCHORAGE WELL & PUMP SERV. 330 EAST 76111 AVENUE ANCHORAGE, AK 99518 PHONE: 907-243-0740 AWPS.COM Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. Anchorage Page of 2. Municipality of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report PID Number' 04033//0 Permit Number: sWg30401 Name: ess/6- N. /4,4z_ r_ j- Wastewater System: Ig New ❑ Upgrade Addreaa: /7// ? CG/20N4-Do ABSORPTION FIELD .Shone., EA6-Z.E 12.f Vf✓ /Z , k 99x77 No. of Bedrooms: 3 (-Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: 0. 6, GPD/Sq. Ft. Total Depth from original grade: 7 Lot: Block: Subdivisiori:� Z / 7 F /Z 5�/.) Depth to pipe bottom from original grade: /. SFt. Gravel depth beneath pipe S. 6 -Ft. Township: —. .� Range: -- Section: -- Fill added above original grade: / Ft. Gravel length: '7 S Ft. WELL: New ❑Upgrade Gravel width: 3 Ft Number of lines: / Distance between lines: — Ft. Classification (Private, A,B,C): & Total Depth: Z2O Ft. Cased To: (fl? r Ft. Total absorption area: 72$ SQ. Ft. Pipe material: FP'o PELF AsrAs P2°39 P.Y.c. j2/VAi Driller: I/e� S"v4`(v/4) WA%t� Date Dried: y 9N Static Water Level: z- FL Installer: l/714,1/swill CONST • Date installed: 'l - f - 9 `i Yield: 3 GPM yy��ELLS Pump Set at: UK -JJ Ft. Casing Height Above Ground: 2- Ft. TANK SEPARATION DISTANCES -Septic ❑ Holding ❑ S.T.E.P. To From Septic Tank Absorption Field Litt Station Holding Tank Public/Private Sewer Lines Manufacturer: A,uc,1O ,o -E TAN 1e- Capacity in gallons: /000 Material: Number of Compartments: Welt' /22' /2St 25 5 -re cz- 2- Surfac 'i- ' LIFT STATION Water /00 /00 I-- LotSize , •: •.s: Manufacturer: Line /0 '+ /O i- "Pump on" level at: "Pump off' lev: .. High water alarm at: Foundation -7' 2.31 - Pump Make & Model Electrical Inspections performed by: Curtain NO/tie f«p W /J Drain Remarks: BENCH MARK Location and Description: TOP Of /'vU'vaA'Tip.0 FOOT//U6- @ (VORTN -S-/.DE Or' Nor/So. Assumed Elevation: J /00.00 ENGINEER'S SEAL ^a to 'ycl i4 r3�_ 43 'z r r l 3 J 17034 Eagle River Loop Road, No. 204 River,Alaska 99577 Dates: 1st s"7(-99 ; u .^'•( „ t. "' n o."s a 0 4i Inspections performed by: Eagle 2nd r, -/-9ii ., r '•-..�_,s.�,,•�n-t Department of Health and Human Services approval Mg /�� C`�- Date: 9'26 ' 9'/ ` 3.rt A. $1104u - • ,. r iJ., ,J Reviewed and approved by: ��l a, C.•p 79-n19 IRay. 9/911 MOA 25 Permit No. SW930401 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report R & R SUBDIVISION, BLOCK 3, LOT 3 06033110 Legal Description: PID No.: CO1 CO2 r 97.6' 6 NEW 1000 GAL SEPTIC TANK A B FCO CO1 CO2 CO3 C04 MT 24.0 25.0 29.0 39.0 54.0 50.0 29.0 31.5 37.0 39.0 101.0 98.0 FINAL GRADE 92.5' ♦ 80.5' NO WA'T'ER FOUND NEW 1000 GAL. SEPTIC TANK SCALE C' = 40' NEW TRENCH 72-013 A (1/93)' 0 b. 2 7. 94 0' ri1V1 :I.4_yE!4 S C0 AK 9J 7 2 rjt4 5 2 5 F' From : R A VRANCKRERT SAND POINT PHOE No, 94.173E1:5SS65 Jun, 24 1994 1:52A11 fol ,Jq 3 0401 10, (1,1ertifid Ortilitto by DOC Ca, am SULLIVAN WATER WELLS C.h. B4>t trtJ . 0111/r81t,14, ALAKKA OW/ i 'rl:l.tr 1vaNN EL6wn OWNER O11 LAND I.... DEPTH OF WI: LL, �..a 1-f STA1'It' I.FVI I t!!' WAnk 1 I . r C LEGAL DESCRIPTION �W • ar4� ._�L�LL}�1, ._ DRAW )014'NET, DATE •Eterta _._._.. - Fngtltf . l''''/61 c L$ 1'c€ Hit e,i PERMIT NUMBER ..., _. ___ ..... .........« t..,.d.,,a..i.„,... „ KIN!) (11 CAIN( . ,,.trl1:...k.C. .. KIND OF FORMATION: - Frorn. -Et In ..,.Ft. :! a/4.0„4-..._ _.(..rc.r', li.._ From a From_ Et to 1't, Ft -- 1°- 1°- e, I. � r FL if) b! _1_- rt i_� ! �' bfl . �_ � i� �c.iF{it Iri �._. n. lrt�.. ._ , rt. From. Ft loR1 Ft. _ %�✓�?t�:rsC� _ css;t.- I torr rt. to -Front .._4.- Ft. to-1�� __}t _/:, 1&'_.G.A- 6K,c c1,1_. 11.,/ 4', ),6..er4- fltrom ./,;‘)S1.- pt to 1 7 '' Ft. 6i k .c,'..k.tw.i`=.....4.g.r. _ (1. 4 ($4,1_____ _ i ( u, t t .. . Prom./..7___Ft, lu,J 1.,i .Pr.__A.4i tlig,'>Cr/._..„6_,t+ai'i">) FrOl,i ft 10 .....ry....b'E.__ rronifl ..Fr.li,2,1 Ft. ,c,..�C�eZL1��, .-ri.WJ- i Firdo----._.___Ft 1.,.„ .... .._....F .-. R� � Ft ,..06b_ <:%� r 0 Ytutn Ft. to. -�i?V_ r?hi-._37"-&1..),--Irom......w.,...-FI,:c....-.---F1.-- =W.___ ,; --k: tr-___..... Front ..Z_,)41. Ft i rt „g.k._1,,J.. .__..... Pram, ..._ k E tv_ . tt. I-1 _. .....': cTS.....-_.,...._• (,1 <2 _:.G IFraa+ FY. to rt.-_. return._..-----_ Fi. ti . ,.,. ,.,iit. id- t--_-- __,) i 1 a.." ":`r From Pr to Ft - Prom_ .____.rr,ra..- ...Ft... ..._. f't to - {h --ro ai 0 Froln.---- --FI. 1110 41,-.• Vt• x... From -- - - IPL Io _ _-Ft. _ From t"t to _ !Fran® _Pi tc�.�_. ,.Ft. _._. W_ From ___._-Pr M1SCL. INFORMATION; 4$,�E� �ra�11'!a/ J/141444 lei Frum_a_ _._rt.th...��,. FNMA __.... _Ft . ro From,-_ I t. t 4 ' l t.. 141 744 ra rit c:--Ja•�r, PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT DATE ISSUED: 9/29/93 EXPIRATION DATE: 9/29/94 PERMIT NUMBER:SW930401 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:HALL JESSIE H JR OWNER ADDRESS:17118 CORONADO EAGLE RIVER, ALASKA 99577 PARCEL ID:06033110 LEGAL DESCRIPTION: R & R BLK 3 LT 2 LOT SIZE: 46405 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD / WELL SYSTEM 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 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY: �t DATE: 7/2<? /9.7 ,1 _6 C DATE: C:_. HEALTH AUTHORITY APPROVALS SEWER 8 WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ROBERT SHAFER, P.E. ROGER SHAFER, P.E. September 25, 1993 unicipality of Anchorage EPARTMENT OF HEALTH AND HUMAN SERVICES 25 'L' Street .0. Box 196650 nchorage, Alaska 99519-6650 EFERENCE: R & R Subdivision, Block 3, Lot 2 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 equest you issue a permit to drill a well and install a septic system to serve the proposed three bedroom house on the referenced property. Test holes were excavated and percolation tests performed. The approximate location of the test holes are located on the attached site plan. The monitoring tubes within the test holes have been checked and found to be dry. This property has enough area for a future septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your review, please contact us. Sincerely, ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN A. Shafer, P.E. S/LSU/lsu 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 LL O 1- 4 N =y � d c U w J w J z 0 oM >U(n2 U Q et Lu Ld0n=www CK H CC Z_ O Z?,. Z LO 0-I OH Z N J w r(Y H 0 0 H O J w Ld w Q LLJ w> CO I- p 0 Q Q H w In — Z U PNCC 0ZwaSOX Qcn ZOW _JLi.-. wzvi 5NNZ — Ld 0 J W� w Q O 1Y J Q I— Li O m w)- w U O D O Q D 1 I U r Q Z H U (n wZ /— - cn>au) '- Qom 0 z F — O O I 0 U 0 w Ln 0 H d S i ONEHILL ROAD Oo O v (J < 00a - z0 Q H LL_ p2 V_ 0 H O 0 0 Cl -0 OM U � C Loh- Z w\ II0II W '--4- (4UO I I CO E-, W uj Z 0 a✓ 00 m _J Q w J F4 MV) CMN al 0 Z 0, -~� 1000 GAL SEPTIC TANK Z9 t J S 0 0 U a j 4 'Nb ' b jo& 31VJS NVld 31IS 017 Page Two R & R Subdivision, Block 3, Lot 2 September 25, 1993 5. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. 6. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: 1. Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed - up) before gravel (sewer rock) placement. 2. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. 3. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. 4. Monitor tubes shall be of four (4) inch diameter and installed approximately in the locations shown on the design. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. 5. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. Page Three R & R Subdivision, Block 3, Lot 2 September 25, 1993 MINIMUM MATERIAL SPECIFICATIONS: 1. Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). 5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. 6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. 7. When sand is being used as a filter material, it's gradation specifications must conform to current M.O.A. or D.E.C. requirements. Page Four R & R Subdivision, Block 3, Lot 2 September 25, 1993 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: 1. The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. 2. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre - construction meeting will take place on-site. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: SSI 4pt/_(__ LEGAL DESCRIPTION: La`1 IJ� g- 4 I` 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 r. Jab The lit ai s NNW at S�) Township, Range, Section: bRC, 6411 COMMENTS (.lsi- 9 / Pp 125NCi"I SLOPE WAS GROUND WATER ENCOUp/'t"ERED? IF YES, AT WHAT DEPTH? Depth to Water Allern Monitoring? YfL AID S L 0 P E Dale. 61/2-41", SITE /2 - SITE PLAN Reading l Date Gross Time Net Time Depth to Water Net Drop 9'p0 — y),1i" — •.10 10 Ag,,,, S%- sc�, ,, :ao ,I 6 y vs,, :3�6)y 4 S/g" Yo l . 7 348 5/8" PERCOLATION RATE 6 /�(m(minutes/inch) PERC HOLE DIAMETER " TEST RUN BETWEEN ti -S P 5`-5 FT w/ 1 EF -H RJ S ENGINEERING PERFORMEgAf$ Oe ®, TU FGGC-0k) CERTIFY THAT THIS TEST WAS PERFORMED IN � ACCORDANLEWtlt PHd�Lhc MaAlEaA9SZt!°1NICIPAL GUIDELINE- EFF' CT ON THIS DATE. DATE 72-008 (Rev. 4,85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG - PERCOLATION TEST PERFORMED FORS\•=4551.E.— Ru.-, LEGAL DESCRIPTION: 3 4 - 12 P FIE T D 19- 20 - COMMENTS (ENGJNEERS SEAL); DATE PERFORMED: Township, Range, Section: O2G 3.(,4, SLOPE WAS GROUND WATER 1 ,, ENCOUNTERED? �_ IF YES, AT WHAT DEPTH? S L 0 P E Depthto Water Alter Montt/ ( Monitoring? gale• T� PLAN Li `E Reading Date Ifo 1 Gross Time Net Time I__ Depth to Water Net Drop PERCOLATION RATE TEST RUN BETWEEN (minutes inch) PERC HOLE DIAMETER AND SFT S & 5 ENGINE PERFORMED BY170034 Eagle RiveraLoopj1zoad nr nAA 1 CERTIFY THAT THIS TEST WAS PERFORMED IN E9577 ACCORDANCE WIa7Hl ALL SRiveTATE ANBD MUNICIPAL GUIDELINES IN EFF CT ON THIS DATE. DATE 72-008 (Rev. 4185) 0 E- E GEM .CHNICAL a DEVEL.. E NI CO. Russell Oyster 694-27740%L L6N r Earl Ellis Soils & Foundations �' 0 688-2280 Land Development Box 90, Davis St., Eagle River, Alaska 99577 �� 694-2774 or 688-2280 Performed for: Name: Mr. Donald Combs Tel, Noo 694-..9389 Mailing Address: Star Route Box 9-239 Eagle River, Ak. 99577 Legal Description: Lot 2 of Block 3 of R & R SubdivisionDgEklattl_ AArtOeristi_C$ 0 1 ML - Silt topsoil with roots and organics. 275 sq. ft./Br. 2 5 6 8 10 GP -GM - Silty Sandy Gravel with cobbles and boulders to 24 inches. Material very loose. 165 sq. ft./Br. PERCOLATION DATA Net Time Net Dro 10 1 1 8" PERCOLATION RATE 20 1" 30 1" 10 Minutes/inch 40 1" 11_ 50 1" 60 1.11=165 sq. ft./Br. 16 3ottom of pit Ground Water Encountered: Yfl Proposed Installation: SeemP t_ Comments: Pdij...,_)cX_._... If yes s what depth —__ proin Field xx Performed by: Date: 25 July 1976 MUNICIPALITY OF ANCHORAGE 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. 060 331 10 1. GENERAL INFORMATION Complete legal description R&R Block 3 Lot 2 Location (site address) 19333 Stonehill Current property owner(s) Nouvion Mailing address Real estate agent 2. TYPE OF DWELLING: F-1 Single Family (w/ADU) F-1 Duplex R Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Expiration Date:. I -,' ' '2 q -2-6 ZZ Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic El Water Storage 11 Holding Tank F-1 Community Well El Community F1 Public Water System El Public Sewer 1-1 Waiver request for: NONE Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee$ Date of Payment_ 1011q1z I Receipt Number n?Z2q I JD COSA # 0.5c,2-1 1 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. Name of Firm C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 10/18/21 OF A� -kk ,low 49 TH 6. DSD SIGNATURE ... .. . ... ...... �0_ System #1 Approved for bedrooms .. ...... .. jl! t;HARLES G BALZARINI �o . ',,- " W System #2 Approved for bedrooms 67 CE -13854 Disapproved Conditional approval for bedrooms, with the following stipulations: WAST!1_-_-VVATER Z_ FJHU(3KAM J. SFN N'\ By: 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 SahC A�, COSA Checklist blue sheet ��M �� Legal Description: R&R BLOCK 3 LOT 2 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA FEI Well log is filed with Onsite (or attached) Date drilled 4/94 Total depth 220 ft Cased to 68.4 ft RE Sanitary seal is functioning correctly RM Wires are properly protected Casing height (above ground) +12 in. Date of flow test for COSA 10/17121 Static water level at beginning of test 80 ft. Comments B. TANK DATA Age of tank(s) 27 years Tank type/materia I SEPTIC STEEL Measured operating fluid level in septic tank 49 01 Standpipes/foundation cleanout per record drawing Date of pumping 10/19/21 D. ABSORPTION FIELD DATA Trench Which system tested (date installed) 1994 F01 ALL standpipes present per record drawing Total measured depth from grade 7.9 ft (max) Measured depth to pipe invert from grade 3,5 ft (min) F-1 N/A — pressurized field F] Monitor tubes go to bottom of effective. If not, state depth into effective 4.4' N Code -required soil cover over field El System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 060 331 10 Structure served by this system 1 Well production at time of test 3 gpm Water storage tank volume NA gallons Well disinfected for coliform test? El Yes MR No FE1 Coliform bacteria is Negative Nitrate 1.32 mg/L El Nitrate less than MRL (ND) Arsenic_ ug/L MR Arsenic less than MRL (ND) Collected by C.Balzarini Date of Sample 10/17/21 C. LIFT STATION El Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 10/17/21 Results 91 Pass For 3 bedrooms Fluid depth prior to test 3 in Water added 450 gal New depth 0 in Elapsed time 0 min Final fluid depth 0 in Absorption rate 450 gpd Any rejuvenation treatment (past 12 months) NA If yes, enter date NA E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Lj�j Yes Community Sewer Manhole/Cleanout > 100' ry7( Yes if No ft M Yes if No ft Neighboring Tank > 100' [Z] Yes if No ft Private Sewer/Septic Line > 25' 177� Yes if No ft Absorption Field on Lot > 100' El Yes if No ft Holding Tank > 100' 0 Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' 0 Yes if No ft F/1 Yes if No ft if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' F71 Yes if No ft n,/ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Yes if No ft Surface Water > 100' Yes if No ft I Property Line > 5 Lj�j Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Yes if No ft Private Wells > 100' F71 Yes if No ft Water Main > 10' Yes if No ft Community Wells > 200' n,/ Yes if No ft Water Service Line > 10' F71 Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' 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' Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' F71 Yes if No ft Community Wells > 200' Yes if No ft Surface Water> 100' E] Yes if No ft F. ENGINEER'S COMMENTS TANK IS OLDER BUT LEVELS NORMAL. RECOMMEND PRO -ACTIVE. REPLACEMENT IN THE FUTURE. ALL SEPTIC PIPES VERIFIED DURING CONSTRUCTION. NO DECK SUPPORTS WITHIN 5'OF SEPTIC TANK G. ENGINEER'S CERTIFICATION i certify that / 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. 10/28/21 COSA Checklist yellow sheet k 49 TH ... .. .. .. ....... ;0, ... ....... — C ARLE G BALZARINI ;t' %,w CE -13854 . - *�', , Ar z e2o PROFEW Septic Tank Advisory Certificate of On -Site Systems Approval #OSC 211629 Subdivision: R&R Block 3 lot 2 Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 27 years old. Typical replacement costs range from $9,000 to $12,OGO This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 20 -year-old steel tank MAY look like. de, Municipality of Anchorag On -Site Water & Wastewater Program (907) 343-7904 0/ 6 8 CERTIFICATE OF ON-SITE SYSTEMS APPRO L Parcel I.D. 060-331-10 1. GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address Real Estate Agent R&R; BLOCK 3, LOT 2 19333 STONEHILL DR. Expiration Date: 5 f C, DON & ETHANN OLDHAM 1933.3 STONFHII J DR. RANEY HARDMAN Day phone 242-0337 2. TYPE OF DWELLING: • Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System W aiverNariance request for: N/A 3 Day phone 440-7257 TYPE OF WASTEWATER DISPOSAL: Individual On-site ❑ Individual Holding tank ❑ Community On-site ❑ Public Sewer • Distance: — Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: 2/3�1lQ COSA Fee $ S-010 Date of Payment 1 %l& Receipt Number 619.- S(1, COSA # 05GI 6 ! o l g 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. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 *ANCHORAGE, AK, 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by (he Municipality of Anchorage and industry practices. The reported results describe the condition of the system's on the dates of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation.The operational life of all wells and septic systems depend on a variety of variables including, but not limited to, soil conditions, groundwater levels ((hat may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system's. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system's; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on (he properly in the event either of the current systems fail. The content of this report is for the sole benefit of the person/party who retained GEG. Reliance upon the information provided in this report by any other person or party, including but not limited to subsequent property purchasers, is not authorized. In short, GEG disavows any legal duty to anyone other than the person/pady who paid for this report. 6. DSD SIGNATURE System #1 Approved for 3 bedrooms. System #2 Approved for Disapproved. Conditional approval for bedrooms. Date 11 2 J r'6 bedrooms, with the following stipulations: \\( OF�;� ON-SITt m WAND v+tAS1 t=vATER R PROGRAM By: Original Certificate Date: 3 _1 Cr The Municipality or Anchorage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatations 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. ATTCHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory (Rev. 10112/12) Nitrate Advisory Arsenic Advisory Other 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: A. WELL DATA Well type PRIVATE R&R; BLOCK 3, LOT 2 Parcel ID: 060-331-10 If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 4/1994 Sanitary seal (Y/N) YES Wires properly protected (YIN) YES Total depth 220 ft: Cased to 68.4 ft. Casing height (above ground) 12+ in FROM WELL LOG AT INSPECTION Date of test 4/1994 1/20/2016 Static water level 72 ft. 72.9 ft. Well production 3 g.p.m. 2.5+ g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate " mg.IL. Collected by: GEG. Ltd. Arsenic: N 0 ug./L. Date of sample: 1/20/2016 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size 1000 gal. SEPTIC/STEEL Number of Compartments 2 Foundation cleanout (Y/N) YES Date of pumping !%Z I % to 16 C. ABSORPTION FIELD DATA Depression over tank (0N) NO Pumper JR'S PUMPING Date installed 5/31/94-7/1/94 Cleanouts (Y/N) YES High water alarm (Y/N) N/A *BELOW EXISTING GRADE Date installed 5/31/94-6/1/94 Soil rating orft2/bdrm) 0.6 System type DEEP TRENCH Length 75 ft. Width 3 ft. Gravel below pipe 5.5 ft. Total depth *8+ ft. Eff. absorption area 825 ft2 Monitoring tube **YES Depression over field NO Date of adequacy test 1/20/2016 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 610 gal. New depth E in. Elapsed Time: 3 min. Final fluid depth E in. Absorption rate >= `' .450+ - g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give date **MT ONLY EXTENDS 4.84' INTO EFFECTIVE D. LIFT STATION Date installed Size in gallons "Pump on" level at in. "Pump off' level Datu Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: 100'+ Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer /septic service line 100'+ 75'+ 25'+ Animal containment areas 50'+ Manhole/Access (YIN High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank 75'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Water main Property line 5'+ Absorption field 5'(ASSUMED) 10'+ ( Water service line 10'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Water service line 10'+ Surface water 100'+ Curtain drain NONE KNOWN F. COMMENTS Surface water 100'+ Building foundation 10'+ Water main 10'+ Driveway, parking/vehicle storage 10'+ Wells on adjacent lots 100'+ G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Pr nted Name Date l Zcj,I(o (Rev. 11105) JEFFREY A. GARNESS b a VA y A. Garness. CEr 79 m0 -ft (ovefe fp,-of ession:\ v �Opoo�a Block 2 Lot 1 12.0.x12.01 SEPTIC PIPE DECK SEPTIC PIPES ROW -CANT -- - 9.7' Tract 2 46,405 s.f. 10.0'x10.0' 21.8'x23.3' .0'x30.3' BALCONY 10' UTILITY EASEMENT PLOT PLAN S 89'56'30W 309.41' —ate— —ore—arc—arc— Ott —aA—ate— EVE — EVE -..- STONEHILL DRIVE A5 BUILT X SCALE 1' = 60' ORID SW 255 Protect No 15-351/A1 Lang & Associates, Inc. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049. (907) 522-6476 Phone gyp© % Registered Land Surveyors (907) 522-4625 Fax OFq kenOlangaurvey.oam / JonathanOlangeurvey.aom �,�,.••• 1 hereby certify that I have surveyed the following described property: p+`;' LOT 2, BLOCK 3, R&R SUBDIVISION (PLAT 76-246) P / 49 Anchorage Recording District, Alaska, and that the Improvements situated thereon a within the property lines and do not encroach onto the property adjacent thereto, th no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as Indicated hereon. Dated this the i tell Day of ihacnanPnbr- at Anchorage, Alaska It Is the responsibility of the owner to determine the existence of any easements, covenantee. or restrictions which do not annenr nn the recorded subdivision Dint. 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING i-CEIVLV I1.1N 0c 1999 ..tNk_trkuir ur ANCHORAGE N IRUNAALN1AL SERVICES DIVISION i/tc.E,.,Ce ,p rig Parcel I D # 060-331-10 HAA # 1. GENERAL INFORMATION Complete legal description Lot 2, Block 3, R & R Subdivision Location (site address or directions) NHN Stonehall Road Property owner Marjorie Hall Day phone 694-8817 Mailing address PO Box 773244, Eagle River, Ak 99577 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 - 3. TYPE OF WATER SUPPLY: Individual well Community well Public water XXX NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer xxx NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA 1121 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 inspection. Name of Firm S & S ENGINEERING Phone `i — 67 17034 Eaale River Loop !load No. 2'4 Address EaaJe River, Alaska 99577 Engineer's signature17..- 6. DHHS SIGNATURE v Approved for l /-/PES bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: / /c1 1 Date Additional Comments By: Date (7 - ( � CAUTION 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. 72-025 (Rev. 1/91) Back MOA x21 JUN 0 1999 Municipality of Anchorage rvrUNIUPALI1Y OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN sa\ackgallAi SERVICES DIVISIO Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: Ln'\ --6 n'Z Y-. 3 r.4 e Ie Parcel I.D.: btpc, (t A. WELL DATA Well type Pe -01 A --CE- If A, B, or C, attach ADEC letter. ADEC water system number Log present/N) '/ Date completed 14"1 ql r rr rr % Total depth � Cased to 6 k Casing height (above ground) /d Sanitary sealON) `/ Wires properly protected 6N) y FROM WELL LOG AT INSPECTION Date of test -61,'f ri ,2 1 1 Static water level 12.i 7 yl Well production 5,o g.p.m. LI • Z g.p.m. WATER SAMPLE RESULTS: Coliform 0 Nitrate I L G`' 1L Other bacteria Date of sample: •- 2 3 -91 Collected by: O B. SEPTIC/HOLDING TANK DATA Date installed /-I 4 Tank size 1 ✓0 U Number of Compartments 2 Cleanouts jN) l/ Foundation cleanout ON) \f Depression (Y/60 High water alarm (Y/N) `,Ifr Date of Pumping 6-19 Pumper V _ . eUM.P I rs -i C. ABSORPTION FIELD DATA Date installed 7 -1 -1 Soil rating (g.p.d./ft2 or ft2/bdrm) b, to System type 72(vrJc.4-( Length 75 ' Width 3 / Gravel thickness below pipe S, 5.-- Total depth 2''SY Effective absorption area �°�� Monitoring Tube present10VN) Depression over field (Y,b) 'N-) Date of adequacy test 5-'13 .-5 cl Resul •.Fail) f/V3 For 3 bedrooms Fluid depth in absorption field before test (in.); O u Immediately afterGg/ gal. water added (in.): Fluid depth 6 (ins) Minutes later: U Absorption rate = 4/6-0 9•p d• Peroxide treatment (past 12 months) (Yg /)udr` (--A'° Ai If yes, give date ij/"} 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at* _ imp o evel at* High water alarm level . * *Datum s tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holdingSeptic/holding tank on lot tZZ On adjacent lots lav;k Absorption field on lot \ ?2'> On adjacent lots Public sewer main Public sewer manhole/cleanout Inv r. -- Sewer /septic �� Lift station SEPARATION Ui ;i'.;. L FROM S� EnG/HOLDING TANK ON LOT TO: Foundation — l Property line I0r� Water main/servic line ?n `-fr Surface water/drainage PPO 1 ,r SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: 4- Property line Building foundation 3 Absorption field Wells on adjacent lots /moo 14. Water main/service line /r .f U Surface water / Driveway, parking/vehicle storage area Sb Curtain drain r /x Wells on adjacent lots /00 ( F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal in conformance with MO I H4�,guidelines in effect on this date. Signature Engineer's Name I 403 t-tr C, 0) 4/� Date 40 a �) records 4t% fiku �urV�iy a.' 10 T • ROBERT.C..COWAN r o; o • CE - 8801 /' >- s are V .e, HAA Fee $ 3 t7f7 (-)0 Date of Payment bu 1 Receipt Number CI" 9 o 9 C 72-026 (Rev. 3/96)* �vcy 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # OGo _' 3 I - J0 1. GENERAL INFORMATION HAA # \A cc'1 to \�� Complete legal description Lot 2; Block 3; R & R Subdivision Location (site address or directions) NHN Stonehill Rd. Eagle River, AK Property owner Jessie and Marjorie Hall Day phone 696-8646 Mailing address P.O. Box 773244 Eagle River, AK 99577 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well XXX Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer XXX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev ' 91 ( = r. MC.: X21 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 inspection. S & S ENGINEERING Name of Firm 17034 Eagle River Lnop Rnad kin 404 Phone C % - `% 7 `% Address Eagle Riivve�err, Alaska 99577 Engineer's signature 7/7 6. DHHS SIGNATURE X Approved for 3 bedrooms. Date �S 9 E •'')t'1-7 io vi •t ROBERT C. COWAN r •�� r • ; Cc „ •8o1 '�-p+�` Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By A/,P Date 1 - 25— 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. 72-025 (Rev. 1/91j Bacx MCA 421 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: /---07' Z /3(.4e 3 R 40 %O Parcel I.D.: -0/".5.33 /to r o m G, ew Cid �L -2 A. WELL DATA ®®�*s(• I N Well type pg.,../.r If A, B, or C, attach ADEC letter. ADEC water system number JE A '411o G Log present ON) y Date completed 1/- 5 `i ,n -F Total depth a' o / Cased to be ' S y Casing height (above ground) /Z Sanitary seal N) .s./ Wires properly protected ai=/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well production WATER SAMPLE RESULTS: 7 2' 3,D PoT- 1,V-;o csP.- g.p.m. / g.p.m. Coliform 0 Nitrate j.1\ Other bacteria D Date of sample: 1-/-61 /1/-22 -n Collected by: B. SEPTIC/HOLDING TANK DATA S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Date installed 7 --1 -' I Tank size lex O Number of Compartments 2— Cleanouts Foundation cleanout 1 'N) Depression (Y® ,S High water alarm (YIN) Date of Pumping t .- -1...W t2 -Pumper C. ABSORPTION FIELD DATAr Date installed 1- 1-� `I Soil rating (g.p.d./ft2 or ft'/bdrm) t' System type vl DN)y Length 73— Width 3 Gravel thickness below pipe SS Total depth Effective absorption arca 9225 Monitoring Tube presenlaiN) / Depression over field (Yap .(6 t y,[- PP -r - Date of adequacy test AIM "3 r° ash Results (Pass/Fail) For bedrooms Fluid depth in absorption field before test (in.); - Inunediately after —gal. water added (in.): Fluid depth ms.) Minutes later: Absorption rate = — /g.p.d• Peroxide treatment (past 12 months) (Y/N) J�-/ If ycs, give date ,//.4. / 4 D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* sled Size in gallons „Pump on" lev E. SEPARATION DISTANCES *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Se tic bolding tank on lot Absorption field on lot Public sewer main /22 las t /J/A, Sewer /septic service line ; On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station 1c>0 /'4 /op i4" SEPARATION DISTANCES FROM(SEPTIC7HOLDING TANK ON LOT TO: Building foundation 7' Water main/service line Property line 119 / Absorption field /o (4- Surface water/drainage 14- Wells on adjacent lots /oa / SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation 023' Water main/service line Surface water /06 / -{- / 0 „`" Driveway, parking/vehicle storage arca Curtain drain de,14 I ' J0 h1 wt Wells on adjacent lots F. ENGINEER'S CERTIFICATION So �'L /0041' Property line /o 1 certify that 1 have determined thru field inspections and review of Municipal r in conformance with A, )A 1M -1A guidejines in effect on this date. Signature Engineer's Name let}. “2 T C Date ecords thag \ `4P HAA Fcc $ Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.doc 360 'd L - Waiver Fee $ Date of Payment Receipt Number