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Home My WebLink AboutT12N R3W SEC 15 SW4SE4NE4SE4 W60' OF E90' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMEN'rAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTION REPORT NAME PHOI~IE NEW LEGAL DESCRIPTION LOCATION -- - NO. OF BEDROOMS ~ M DISTANCE TO; Well Dwelling ~ ~ ~ No. of lines ~ ~ Trencb width Distance between lines ~ PERMIT NO. ~ DISTANCE TO: B~ildi~d~t~ Sewerlin~ ~ Septictank/(20 ')' /O~ ~ ~ ~ , Absorption area(si OTHER PIPE MATERIALS SOIL TEST RATING /I REM~KS 72-013 (Rev, 3/78) - ( PERMIT IqO: 8406} DATE Z SSLJED ~ 07/2.0 APPL I [',AIq'l": ADDRESS ,", CONTACT PHONE ROSS CONSTRLJCT I ON 10360 SCHNEI"FI~I:~ DRIVE ANC'HORAfgE~ AK 995:L6 LEGAL DESCRIF' L. OT SIZE:.. LOT LOCATION.., MAX BEDROOM.S ~l SLIBDIVISI[IN.. NA L. OT: PARC S[~:CTIOt',I: 15 'I'OWNSHIF:': I:~N kANGE. 19S00 ([~G..FT. OR Al]RES) 104'l'H OFF' BIRCH 'l"X CODE 4 16 FJLOCK: NA I_i:~ted below are the op'Lien~:~ available 'Lc) yell in designing system. Choose the op'Lion that bes'L Fits you~ site. yeur sep'L:i.c . DEPTH *TO F'IPE BOI*TSM (FT.) 4.0 4,,0 4.0 GRAVEL. DEPTH (F'T,,) 5.0 0. TST~L DISPTId (FT.) 9.0 4,,5 7. GRAVEL WIDTH (F'I'*.) 2.5 19.0 5.0 E'iRAVEL LENBTH (IZT.) 4Zl.,, ~ _ GRAVEl_ VOLUNE, (CU. YD~. ) 22.4 24,, 6 ~',=' - TANK ~ ,:~IZE (E~ALS) 1,R50.r~ .~:.~. 1,~50.() *,~. . c- . . · ' 1, ~.,.zO. 0 '~"2' SOIL RATIN8 (oQ.F']. /DR) 110 110 110 · ~* TANK MUST HAVE Al* L.EAST TWO COMF'ARTMENT.S ]: certify that: 1. I alii fami],:i,~H- with the Peqt.tipel~a,l.lts for err-site sewers arid we].].!~ as set fol"Lh by 'Lhe Municipality of Anchorege (MOA) and 'l:.he State oF Alaska. 2. I will install the system :i,n ~ccord[:u]ce wi'l:.h all MOA codes and r'egu].a'tions, and in cc~mplianoe wi*Lb 'Lhe design cm"iteria oF this permit ' " ,.,3. I will adhere to all Iq[IA arid c, orate of' Alasl.::a r'equirements Fop the set back distances From any existing well, wastewater, disposal system or' public s~pwepage system on this or ~lFty acl~acen'l: op near, by loL. 4. I Lt]dePstarld tha'L 'Lhis pea'mit is valid FoP a maximLl~ oF 4 b¢~dP~o~; and any eFllap(~elll~].[ wJ. ll P~qLliPl~ an additional pmPmit. ]:F A I_IF'l" STATION I8 IN~'I"AI..J.,J:ZD IN AN AREA COVERED BY MOA BUILDING CODE8~ THEN (1) AN ELECTRIC;A[ PERMI]" AND 1N,~I-EC]].ON MIJST BE OBTAINED; (~) AS-BUiLTS WILL NOT BE APPROVED WITH(JUT AN ELEECTRICAk INSPECTION FqSF'OF~T: AND (3) THE ~ ECTRICAL W[IRf~.~8~ BE DIXIE BY A lICENSED El ECTRICIAN. S I GNED ' . · DATE: APFr'L..I CANT: ROSE{ CONSTRUCT I ON PERFORMED FOR: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. 8treat, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST I~ SOILS LOG ~ ¢o Go / E] PERCOLATION TEST LEGAL DESCRIPTION:~~ 1 2 3 4 5 6 7 8 9 10 11 12 13- 14- 15- 16- 17- 18- 19 2O COMMENTS._ PERFORMED BY: 72-008 (6/79) _'r ~ WAS GROUND WATERN ~ ENCOUNTERED? O P E IF YES, ATWHAT DEPTH? Gross Ne! Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~JI~,~$AL !~::~ WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geolo§icel 8~ Geophysi¢ol Surveys __of__of--of -- S[~] wE[] n~"ll~'~ff~ $, OWNER OF WELL: I~OSS Con~t ........ O 28 6. ~ Cable foe, ~aot~ry C] Driven ~ Dug , _. 99 100 O ,.,. w.,, ~ 100 180 8. CASING' 0 Threaded ~ Welded 180 183 .,o~. 5 ,.. to~.,. ..... 183 213 ..~. ,. ,~ f,. &-~ra~el 213 219 s. sm,sso~ gravel 219 228 __ Typo: m. STATIC WATER LEVEL: fi. / / . ~ Above et ~ 8clew land surfoce ~ ft. after hrs. pumpla9 ~.m. Materiel; ~] Neet Cement ~ Other: .... L.eagth of Drop Pipe fL cepocity .D~lling & Ent _ AA~5327_ _gr~ay .da ~n- siLt-~ ,,,, ,, ,, g_rave__ll ~e~l--yl se~ p hard -cemented silt w_/~rav~e_~ gravely.- 1 gpm H20 cemented silt ~gra~ cemented silt, lenses __ _ 2~ to~3 ~R~ laska Now~Well/V.~rn2~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Parc~Z 16~ Section 15~ TI2N, R3W~ S.M. Location (site address or directions) 5701 East 104th Avenue Property owner Mailing address Lending agency Mailing address. Terrance Smith 10 Spenc~.~ B~ird Day phone MA 02543 Day phone 346-2910 Agent Rclph Nobrcga / Vista B&tter Hom~ & GardenSDay phone 562-6464 Address 3000 "C" Stre~, Suite 101. Anchorage,, AK 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 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. TYPE OF WASTEWATER DISPOSAL: Individual on-site X×X Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. SEWER&WATER MAINEXTENSIONS SEWER&WATER INSPECTION ENGINEERING STUOIES ANDR~PORTS WELL INSPECTION & FLOW TEST SITE PLANS ROBER¥SHAFEP P ! RGGERSHAFER PE January 13, 1993 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES Attention: Robbie Robinson 825 L Stre~ P.O. Box 196650 Anchorage, Alaska 99519-6650 RECEIVED JAN 1 199 Mumc pa v of AnchoraQe :'~ept. 'iealth ~ Human Serv~ca~ REFERENCE: Parcel 16; Section 15; T12N, R3W, S.M. Dear Robbie, On behalf of the referenced property owner and their rc~ estate r~pr~s¢,ntativ~, we request you issue the attached H~alth Authority Approval replacing the Approval issued D~eember 21, 1992. The purpos~ of th~ new Approval is to delete the advisory comments pertai~ng to the marginal productivity of th~ w~ll. Subsequent to our w~ flow testing of December 15, 1992, the w~ll was further perforated and d~velop~d by Alaska Now-Well/Vern's Dr~ng & Enterprises (s~ let~ attached). A new flow t~st was p~rfo~d on th~ w~l January 11, 1993 (data also at~aehed). W~ have found the w~ll to currently produce 1.4 gallon~ per minute. If you have any questions, or r~quire additional information for your review, please contact us. Sincerely, SOIL TEST S~RUCTURAL& MECHANICAL INSPECTIONS ROGER J. SHAFER, RJS/tv Attachments P, Eo ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 ?034 Eagle Rivet Loop Road Eegle River, AlaakaggS/? ** IELL FLOW lEST DATA StlEEI LOCATION OFWELLILegat Deacdptlon): ~/~.~L WEt. L DEPTH: Z~,:~ FT. CASING: DATE DRILLING COMPLETED: ~;~/~d-~ STATIC WATER LEVEL (Top o! Casing): 13..~ ROBERT A, SHAFER CIVIL ENGINEER 694 2979 FT. SCREEN: DRILLER: V~)~ ~/~1~ Comments: ~L)~L/-- ~* U~E///L~' ~/~O/~UCES /,'~ 6PILL Flow is not Guaranteed Subsequent Variations Can Occur. ELAPSED TIME SINCE DEPTH TO DRAWDOWN/ PUMPING CLOCK PUMPING STARTED/ WATER, FT. RECOVERY RATE, OPM REMARKS TIME STOPPED, MIN. 20 25 40 60 ~0 ( I hour) -?:oo oo z~g 7r I,~ Pump ~o'T q: ~0 120 (2 hours) --- ~0~ ~ I, ~ _W~TE~ 180 (3 hours) EO2 ~ /, ~ .... Alaska Now-Well/ Yern's Drilling &.T~nterprises 12241 Avio~n-St. Anchorage, Alaska, 99516-2136 January 4, 1992 Ref: Work: at 5701 104th. x,.~...rwaspurnped frorn wel~, tlsen power shut off. The water pump and water pipe was tnen removed from the well. ~ '-" 81 ~,~, ~ r,e formation at I 8(., to 183' was perforated. Tl~e water flow, · ~'~ bailing, was above !/2 gpm, but not up to the 1 gpm. The formation at 60' to61' 6" was perforated. The well was then bailed to remove the debris, and tocheck flow. The flow wasupabove 1 gpm The pump was then installed in tl~ewell. The water was pumped from the well, and then tirned for recovery, and then measured as it was pumped fcom the well. Tne recovery was measured at 1.3 gpm. It is possible that th~'elow will increase as the well is being pumped to clear the formation. The well will have to be pumped until t~e water clears, before pumping into the pressure tank and house. $incePely, Vernon L. Nowell ALASKA NOW-WELL VERN'S ORIt. LING& ENTERPRISES 12241 Avi0n Street ANCHORAGE, AK 995!6-2136 (907) 345-4417 TAX i !40L, i TOTAL All claims a.r~d returned goods MUST be accompanied by this biJL CThank¢~ou MUNICIPALII'Y OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legaldescription p~,Q£ 1~: S~.e;tJ.¢Jn 15_, T/~.J~L, R3W, S.M. Location (siteaddressordirections) 5701 East 104t~ Auenue, A~oho&~ge, AK Property owner Mailing address T~,~a~,eQ. Smith Day phone 346- 2910 10 Spencer Baird ~oad, Woods Hole,, MA 02543 Lending agency MaiLing address Day phone o Agent Ralph Nobrega/VISTA BE'F~ER HOMES & GARDENS Day phone 562-6464 Address 3000 C Stree. t #101 Anchora,q~ Alash~ 99503 Unless otherwise rectuested, HAA will be held for pickup. NUMBER OF BEDROOMS: 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. TYPE OF WASTEWATER DISPOSAL: Individual on-site X×X Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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. ! 703a E ' · -~gle ,~ver Loop ~oad No, 204 Name of Firm Address Engineer's signature DHHS SIGNATURE ~/~ Approved for ¢¢ bedrooms. Phone Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Additional Comments ~:~ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a centificate is issued. The Municipality of Anchorage is not responsible for errors or omissions ~n the professional engineer's work. 72-925 (Rev 1/91) 8ack MOA ~t21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: I~"l/~cEL' IG ~'/ff' '~/&/~ ~$~ -%,/vt, Parcel I.D. ('~ A. WELL DATA Well type Log present ~(.~N) Total depth ~.Z-~ Sanitary seal ~/N) If A, B, or C, attach ADEC letter. "/'~ ~ Date completed Cased to FROM WELL. LOG ADEC water system number Driller Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /(20' Absorption field on lot Public sewer main ~oIJE Sewer service line ,Z~/¥- ~ ;~ -~' / Casing height / ~- ~' Wires properly protected fJ~/N) ~'.~' g.p.m. AT INSPECTION g.p.m. ~ ; On adjacent lots //0 ~ ; On adjaceat lots /O0~ Public sewer manhole/cleanout /~O,dd t~/'?ESE'/,/T' Petroleum tank ,,L~.),,f./~' WATER SAMPLE RESULTS: Coliform_ O~loornl Nitrate 0,10 m~/I Date of sample: 17_/13/~/7--- Collected by: Other bacteria O//co~l B. SEPTIC/HOLDING TANK DATA . Date installed_ ~'/Z~- /j'~L /~' Tank size / 7_.~'0 '~'"~ __ Compartments Cleanouts ((~/N) (//C,"5 _ Foundation cleanout CN) ~'~ Depression (Y~ High water alarm (Y/~ ~0 Alarm tested (Y/N) ~/~ Date of pumpmg /~/~/~ ~'_ Pumper ~ ~o~g ~-~V/~:~S SEPARATION DISTANCES FROM SEPTIC/~;]~ TANK TO: Well(s) on lot__ / CO Cf- On adjacent lots /'0~/4- Foundation / (¢ / _Absorption field Water main/service line ~'~-~ To property line /t¢(/' Surface water/drainage 72-026 (Rev 7/91) F(ont CONTINUED ON BACK PAGE Manufacturer Size in gallons ~ ~ Vent (Y/N) "Pump on" level at s-~'~- ~off" level at High water alarm level J~ ..... ~ Cycles tested SEP~;)N-DISTANCE FROM LIFT STATION TO: ~./.Weq I on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~/Z t./~¢ /' Length ~r'~ / Width -~0~ Total absorption area . '~(~Ot Depression over field (Y~) Results (pass/fail) Peroxide treatment (past 12 months) (Y~[~ Soil rating /lO ,/~/(~ System type_ Gravel thickness ' Total depth Cleanouts present ~yN) Date of adequacy test /~////_~ for If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot /00 To building foundation On adjacent lots Surface water AJo~ Curtain drain A)OA)E' K,U0f, WJ On adjacent lots ) OO ¢+ Property line To existing or abandoned system on lot Cutbank /Jo,dE /g?~'£_~',VF Water main/serviceline Driveway, parking/vehicle storage area _ ~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. 17034 Eagle i~iver Loop Road NO. 2~ ~¢' *'~2 Signature F~!wr, ~ka ~9~7~ ROGER ~. HAA Fee $ / "7'¢ Date of Payment .ecei¢ Number Waiver Fee: $ Date of Payment Receipt Number 72 026 IRev. 3/91) Back MOA 21 WATER WELL ADVISORY HEALTH AUTHORITY APPROVAL NO, ,'~/'~ ~~'~ During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Lot ~ Block of ,~]~c.~--'7-~,A/~- ~.~V~/ Subdivision, the well's productivity was determined to be ~,~JY gallons per minute. The minimum well productivity required by this department (AMC 15.55) is 150 gallons per day per bedroom. On this basis, the minimum well flow requirement for a 3 bedroom residence is ~,3/ gallons per minute. Although the subject well currently meets the minimum well production requirements, all parties concerned are advised that the production capacity of the well may fluctuate and that water conservation measures may be required during periods of low production capacity. Measures which can be taken to minimize the impact of a low production well are: 1. Installation of a storage tank (300 to 500 gallon) to serve as a reserve source during times of maximum water usage. 2. Restriction.of noncritical water uses such as, washing cars, lawn and garden watering, etc. Installation of water saving devices on faucets, showers and toilets. Conservative use of laundry facilities and dishwashers. This advisory must be attached to all copies of the subject Health Authority Approval. $ & $ ENGINEERING 7034 Eagle River Loop Road Englo River, Alaska 9~577 ~ELL RECOVERY T~IST FORI~ TEST PROCEDURE 1. Draw water down to pump. 2. Shut pump off (15-30 min). -record time1 -record meter1 3. Turn pump on. 4. Water @ pump/shut pump off. record time2 record me'for2 5. Calculate gpm recovery: (Pump Off) (Pump On) (Pump Off) ~EST DATA Trial Pump Time Meter G.P.M. "Off Off Off ~:~/~ ~3 ~,~~ / "' 2 On Off /o:l~Jz Off Off 10:41:3o 33~3,0 ~gg,~ ~.~ Off /m:4l:~ ~G3,0 IZ,~/ Off Off off Off Ii: Off 11:43;~o ~$~,5- ~,~3 ~'~/ Off I/: Off // off Off ? Flow ,s not Guaranteed ,'~.~ Subsequent Variations -: :' ca. Occur. CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEI-~RING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 569-2343 ANALYSIS RESULTS for INVOICE ~ 61567 Chemlab Ref.# 92.6796 Sample # I Matrix: W~TER FAX: (907) 561-5301 Client Sample ID : PARCEL 16S,15 T12N R3W PWSIO : UA Collected : 12/13/92 0 20:00 hrs. Received : 12/14/92 % 08:45 hrs. Client Name ::3 & S ENGINEERING Client Aeet ::~NSENOP BPO# : Req~ : Ordered By :]{. SHAEER PO# :NONE RECEIVED Analysis Completed : 12/14/92 Send Reports to: l)S & S ENGINI~ENING Parameter Results UMts Method Allowable Limits NITNATE-N ND(O.IO) mg/1 EPA 353.2/300,0 lO Sample ROUTINE SA~'LE COLLECTED BY: Remarks: i Tests Pe~fozmed S~o Special Instruetion~ Above UA-Unnva~lable ND- None Detected '" See Sample Remarks Above NA- Eot Analyzed LY=Les~ Than, GY~G~oator Th~n MUNICIPALITY OF ANCItORAGE DIVISION OF ENVIRONMENTAL HEALTtt DEPARTMENT OF I~ALTH AND ENVIRONMENTAL PROTECTION APPLIC~flON FOR t~ALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date a) Legal Description (inclnde lot, block, su~division, section, township, range) Location (adJress or directions)_ b) Applicants Name ~)~ C~C3~ ~T] Tele~Qne - H______ojne__. Business Applicants Address (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address (f) Telephone Mail the HAA to the following address: 1-1 o & 2o T~R_e of Residence Sing ie--Femfly Number of Bedrooms Individual Well 5~ Other (describe) Community [--~[ Public Note: If commnnity well system, must have written con£1rmation from ths State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Dis~o_s~a_l. Onsite ~f: Public :7] Community [~_~ Holding Tank 'Note: If community well system~ must have written confirmation from the State Department of Envirom~ental Conservation attesting to the legality and status° [Page 1 of 2] 5o .E.~n~_ineerin~_ Firm Providing~_~Inspections, _ __~Tests File Searc.h~ ...... Data and Information As certified by my seal affixed hereto and as of the validation date showe 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 M~nicipality 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 regula- tions in effect on the date of this inspection° Date Telephone (ENGINEER SEA1,) //~w / ~ 5 ~' i ' ~ ~'~,,~1 ~o. 22:!5. E ' DHEP A~jproval Approved Disapproved Condition~ Terms of Conditional Approval CAIYfIOM THE MUNICIPALITY OF ANCHORakGE DEPARTMEhrf OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES IIEALTH A[r~HORITY APPROVAL CERTIFICATES BASED SOIf'iLY UPON T!tE REPRESENT- ATIONS GIVEN IN PARAGR3LPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN TIlE STATE OF ALASEA. THE DREP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL f~>]D STATE REQUIRE~ MENTS. EMPLOYEES OF DHEP U0 NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSHEDo THE MIIMICIPALITY OF ANCHORAGE IS NOT PO~SPONSIBLE FOR ERRORS OR OMISSIONS IN t~IE PROFESSIONAL ENGINEER'S WORK° (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEAL'i~{ AUTHORITY APPROVAL (HAA) CHECKLISI' - FEBRUARY 1984 Legal Description: Well Classification _~ ~ Well Log Present (Y/N) Total Depth ~R ~ . Cased to _ Static Water Level ._ /~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances f~c~n Well: To Septie/]~ml~3. Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewe~ Line If A, B, Or C, D.E.C. Approved(Y/N) N/~ Date Completed _, 8/~/~ Yield '~5~/,~,; ~2~ __ Depth of G=outing. ~/ON~:- Pump ~t At ~, ~ ~ ~ ~ '/ Sanitary ~al on Casing (Y~)~ ~preesion ~ound ~llhead (Y~) ~ ; On Adjoining Lots I~ loc ~ ; On Adjoining Lots To Nearest Public Sewer Cleancut/Manhole ~ O ~ ~m_ To Nearest Sewer Service Line on Lot Water Sample Collected By ~--~,~ ; Date Water Sample Test Results Comments SEPTIC/H~i~G TANK DATA Date Installed ~D/~/ _ Size_ /~ No. of Compartments 7~'~ Standpipes .~Y~) ~ Air-tight Caps (Y~) ~ Foundation Cleanout (Y~) ~p~ession o~ Ta~ (Y~) ~ Date ~st P~d ~ ~/ Pu~ing~aintenan~ Contract on File (Y~) ~/~ ; for Holding Tank High-Wate~ Ala~ (Y~) ~/~ '~a~,y Holding Tank Permit .(.Y~) Sep~ation Distance f~ ~ptie~olding Tank: To Water-Supply Well ~ To Property Line ~Q To Water Main/Service Line Course N O N Corm~nts To Building Foundation ]~:~ TO Disposal Field Id) To Stream, Pond, Lake, Or Major Drainage Date Paid: Amount: [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption A~ea Depression OVer Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field ~'~ Depth of Field / O Gravel Bed Thickness ~ Standpipes Present (Y/N) Date of Last A~quacy Test Separation Distance from Absorption Field: To Water-Supply ~%11 To Building Foundation Lot NO~4~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To D~iveway, Parking Area, or Vehicle Storage Area Comments ; ~9 + To Property Line ~D + ~ ~; To Existing or Abandoned System on ; On Adjoining Lots ~ ~- ~/(9 ~ To Cutbank(if present) NoN D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dinmnsions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Corf~ents ** Check Permitted Bedroom Rating Against HAA Request I oertify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. Signed Company KB1/d5/s [Page 2 of 2] Date 2-15-84