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FOX HILL BLK 1 LT 7
Foxhi'*11 Block I Lot 7 #051 �073 � 25 Municipality of Anchorage Page / 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 Permit Number: ,_~'~ ~/' ~ O ,.~ OD PID Number: O..~/-¢ '~ .~ ~' N~: ~/ ~/~L /~5' WastewaterSystem: ~New ~Upgrade ~r~,: ~oo /~ ~o~ ;~,, ~ ~o~' ABSORPTION FIELD .~U~ ~- c ~/~ e4 9~.5'9 o _ - J No. of Bedrooms: Phone: (~0~ (¢¢~ ~/~I ~ g Deep Trench D Shallow Trench ~ Bed D Mound a Other Total Depth from original grade: LEGALDESCRIPTION SollRatlng~), ~ ~GPM/Sq. Ft. / ,_ ¢/ ~ubdiv~lon: Depth to pipe botlom from original grade: Gravel depth benealh pipe Lo~,. ~ ,,oc~: / ~-o~ //~z ~ ~,: F~, O,: F~. ~ownship: Range: Section: Fill added above original grade: Gravel length: , _ Gravel widlh: / Number of lines: Distance belween liees: WELL: D New ~ Upgrade/ /~ v- /~ Fi, ~ '~ Ft. Classilication (Privale, A,B,C): Total De~/ ~ased To: Total absorption area: Pipe materka]: / -Driller: ~ ~ ~ Date Drilled: Static Water Level: Installer: Dale Jnst~lled: ~GPM JP~ps~t~t: Fi, CasingHe[ghlAboveGmu.d:Ft, TANK SEPARATION DISTANCES ~Septic g Holding D S.T.E.P. To Septic Absor~tion Llfl Holding PubJlc/Prlvato ManuJacJurer: Capacity In gallons: From T~nk Field Statlo~ Tank Sewer Li.e8 ~'C ~ O ~/~ ~ ~' '~ ~ /~ / MaJmlah Number of Compartments: weu- /~o~ /~ ~ -~ jd/ ~.~ Surface Water /~0/ ~ /~ ~ LIFT STATION~ Lot / / Size In gallons: Manufacturer: CuHalRDraJR ~ / ~/ ~m~el J Electrical inspections pedormed by: ~ 2 BENCH MARK ~emarks: ~F~47/~ /~ m 4~c' , Location and Description: Assumed Elevation: /~ Inspections performed by:.~ale_ River.. Alaska 995~ Dates: 1st 2-JJ ~P~'- '~' ,O~,RT C. COWiNg' '"~ ................/>~ .... Department of Health and Huma~ Se~ices approval . ,~ .-, and .pp o d by: ..... t:':-':' 72-013 (Re¥. 9/9~) MOA 25 PERMIT NO. SW980500 PAGE 2 OF 5 _ .[',luQi_cipg,.iLit:.y.p..F Anchoro, ae DEPARTMbN/ UI- HbAL/I-I AND HUMAN SERVICES ENVIRONHENTAL SERVICES DIVISION P.O. Box 196650 ·Anchorage, Ate. sko, 99519-6650·Tetephome~ 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 7, BLOCK 1, FOX HILL SUBDIVISION P.I.D. NO. 051-073--25 100' WELL RADIUS ~Co~ FCO o EXISTING WELL LOT 8 SCALE t" = 40' RQB~RT C, COWAN CE - 8801 PERMIT NO SW980300 PAGE ~.~ OF 3 Municip. c~l, it: oF A~cho~e DEPARTNENT OF HEA~THAND HUMAN SERVICES ENVIRONNENTAL SERVICES DIVISION P,O, Box 196650 ~Anchon~e, AL~sk~ 99519-6650 · TeLephone~ 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LBOAL LOT 7, BLOCK 1, FOX HILL SUBDIVISION P,LD. NO. 051--07,3--25 ST1 ST2 9 1250 GAL , MT1 CO3 C02 CO1 MT2 97.§'-~ 96.§' 98.1' MT3 C05 C04 A B C :CO 8,5' 24.0' - ST1 12,0' 28.0' - 5T2 18,5' 33.0' - DBL1 21.0' 34.0' - :)BL2 21,5' 33,5' - 301 29,0' 25,5' - 9T1 37,5' 36.0' - ,?.02 32,5' 31,0' - VlT2 - 28.0' 49.5' ~03 - 35.5' 57.5' ~AT.3 - 25.0' ..39.5' 304 - 20.0' 42.0' 305 - 25,5' 38,0' 97.1' ~-~--INSULATION ,-97.8' ~/~- FINAL & WATER FOUND 87,§' 85,9' B.0.H. GRADE MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 995~9-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade \ f)CY'l Date Issued: Aug 12, 1998 Expiration Date: Aug 12, lg99 Permit Number: $W980300 Legal Description: FOX HILL BL.K 1 LT 7 Design Engineer: 3 %,~) ~--~. Owner Name: Richard Williams Owner Address: PO Box 671671 Chugiak, AK 99567-1671 Parcel ID: 051-073-25 Site Address: 021849 WOODCLIFF DR Lot Size: 40000 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: L~ Disposal Field [] Septic Tank [~ Holding Tank [] Privy Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. Ail 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 (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Date: IssuedBy: ~'~~,,, C d~'~d Date: HEALTH AUTHORITY A~PROVALS SEWER&WATER MAIN EXTENSIONS SEWER &WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & F LOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM DESIGN ROBERT C. COWAN, RE. ROBERTA. SHAFER, RE. July 28, 1998 CIVIL ENGINEFRS (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 7, Block 1, Foxhill Subdivision Request you issue a permit to install an upgrade septic system to serve the three bedroom house on the referenced proI)erty. A test hole was excavated and percolation test performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation 7/7/98 water was encountered in the test holes. After seven days of ground water monitoring water was found at 9'. We do not anticipate any adverse effects on neighboring wells, septic systems rese~xe areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any hture development on any of thc adjacent prope~ies. If you require additional information, please contact us. Sincerely, Eobe~t C. Cowan, RCC/mg Enclosure 17034 NORTH EAGLE RIVER LOOP . SUITE 204 · EAGLE RIVER, ALASKA 99577 ',1" = 40' ! DESIGN I DETAILS 0 0 �tv o z � �7 O n a X O D m :> Lzj d r' z vzi Cb m -� a o r a z ri H d O �-3 bd � O Q rn .g2 + � o 0n 4� 3 0 wcnotr>N) ►� �j >o�+ cn in Crj m r�m� m dr�md^�� LettOomr*m O - mm va. ZM O\ 0 1-x-1 n 14 m m �. �%\ W ►-4 C�1t p W d co II 0 II O m� \ \ °'C)Co \-moo H W Q O =*i 1-1 H cta O"J G \ 1 �.�. TJ �+ '°.i° z d cS• m H � O C� f o C, tz O �—I t3jMz0 Wm 0'd�� m m�� ;DOZVZ H > trj n z th z z o d o 0 Dnpr CURTAIN D a DRAIN 0 wcnotr>N) ►� �j >o�+ cn in Crj m r�m� m dr�md^�� LettOomr*m O - mm va. ZM O\ 0 1-x-1 n 14 m m �. �%\ W ►-4 C�1t p W d co II 0 II O m� \ \ °'C)Co \-moo H W Q O =*i 1-1 H cta O"J G \ 1 �.�. TJ �+ '°.i° z d cS• m H � O C� f o C, tz O �—I ;DOZVZ _4 A oocQ m 3 th Drm Dnpr 1 �L A l Z a `4,4 �, �� ZN 0 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 6 8 10 11 12 B ,0~ /'~ 13 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth ID Water After Monitoring? DATE PERFOR~*~ ,.~,~~F'¢ Township, Range, Section: SLOPE SITE PLAN Dale: doss Net Depth to Net Reading Date Time Time Water Drop / .r 72" 2_ /,I 2 ',go pa j~O~l~b 1,.5- /' ~ '/ /, ~ / ~¢/./~ ~ ~ / ~,X~p~ 7 ~,, ~ , ~,'oz'pm /o~/~ ///~" ~" 14 15 16 17 18 19- 20 - ~0/¢¢ //9 r*~ PERCOL~TI~ RATE ~. ~ tm,nutesnnchI PERC HOLE DIAMETER TEST RUN BETWEEN FT AN _ FT COMMENTS /, . , PERFORMED BY: 17034 ~=.l. PI .... ~ ..... J ' ~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ~t~%~~UIDELINES IN EFFECT ON TH'S DATE. DATE: 72-008 (Rev, 4~85) ROBERT C. COWAN, RE. ROBERT A. SHAFER, RE. ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN E~TENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW T EST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSAL SYSTEM DESIGN REFERENCE: Lot 7, Block 1, Foxhill Subdivision July 28, 1998 GENERAL: The scope of this project includes verifying the integrity and replace 1250 gallon septic tank if necessary. Excavate existing bed by removing bio-matt and level with sand to 4' depth. Add on 5' wide leachfield trench to existing bed to serve the proposed tbrec bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed fi'om soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval fi'om the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufactm'er. Construction shall include two 4" cleanouts for pmnping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 Page Two Lot 7, Block 1, Foxhill Subdivision July 28, 1998 All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. 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. fi'om 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. Two flow dividers shall be installed sending 3/4 flow to longer trench and remaining 1/4 flow to shorter trench. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: 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. 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. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt ban'ier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. 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. 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 Lot 7, Block 1, Foxhilt Subdivision July 28, 1998 MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipal approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: T~vpe 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. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). 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. 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, its gradation specifications must conform to cmTent M.O.A. or D.E.C. requirements, which ever requirement applies. INSPECTIONS: Typically there will be a minimmn of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: Page Four Lot 7, Block 1, Foxhitl Subdivision July 28, 1998 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. The second inspection must be conducted after the placement of the silt ban~ier, 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. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S l~ngineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MA L NG-AD'DRESS ~ . LEGAL DESCrIPTiON LOCATION Well¢ ~STA~C~TO: ~ /¢¢ Manufacturer Inside length IF HOMEMADE: Well Li~ DISTANCE TO: DISTANCE TO: Well No. of lines Lengt ~ of each Top of tile to finish grade IPHONE (J~ NEW /?, / Material Width NO. OF BEDROOMS PERMIT NO. No. of compartments Liquid depth PERMIT NO. Material Liquid capacity in gallons Foundation Nearest Jot line PERMIT NO. Total length of lines Trenc~ width inches Distance between lines Material beneath tile Total effective absorption area inches Length Type of crib Crib diameter Crib depth /.f- DISTANCE TO: _ Class Depth Building Driller DISTANCE TO: Sewer line /l-~'l ~, &0//~( PERMI~J'gO, Total effective absorption area Nearest lot li,e /¢; ~ Distance to lot line PERMIT NO. Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER R EMAR K8 DATE Tr,A,.,t*ftrb Drittino 1,1'xg by DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2759 OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE - Started Ended PERMIT NUMBER KIND OF FORMATION: From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to -Ft. From From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: DEPTH OF WELL STATIC LEVEL OF WATER FT DRAW DOWN FT. GALS. PER HR KIND OF CASING From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. toMU�'16FALiTY (9F 04GHraRAGE From EPT. O` F: L Ft. to V ' �rdia4cPdi.'a� ��'T�r iI iN From Ft. to Ft. 8 M6 From Ft. to Ft. From nn `,► Ft. to Ft.Kf� IV ED From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft DRILLER'S NAME I ROBERTA. SHAFER 1986 CIVIL ENGINEER 694-2979 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERINO STUDIES AND REPORTS Municipality of Anchorage Department of Health and Human Services 825 L Street Anchorage, Alaska 99501 ATTENTION: Susan Oswalt WELL INSPECTION & FLOW TEST SITE PLANS MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION JUL 'Z ','. REFERENCE: Lot 7; Block I; Foxhill Subdivision An on-site wastewater disposal system was installed on the referenced property under permit ~840099 on July 31, 1984. Inspections were performed and are documented on an inspection report on file in our office. This report has not been submitted for record due to non-payment of fees associated with the work. Since ¢, . ROAD DESIGN SOIL rEST PERCOLATION TEST STRUCTURAL MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN SRB 196X EAGLE RIVER, ALASKA 99577 D[!:F'FII:TT'HI!i:NT Cfi:::' I'I!::~:F:IL. TFH FII",IE:, ENV]:F~:ONI"IEi:NTI':IL., I:::'Fi:CFFT;iC:T]:[::U'-,} :E:;i?.!if:i L. 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F:I[)HEI:;.'.~.~ "!'O FILl... l',iOF::l I::llq[)STF:I'T'I~ OF l:::ll...l:::l:~ii;~(FI Fi'.I!~i:(i:!I...I:[I:;i:[!iiFIEi',,IT:!!!; I:'Cff~'. TH[ii: SET I::.i~F:IC:I.( I:) :[ I~:];'T'I::'iI",!(::IE!!; !::'l:;i:Oi"! FIf'.,l'.d E~:i;.:i :t: :i:;"l" J.' 1'4(!i I.,.lliii:!....! ...... I,.IF:I'.:ii;TI!~],.II:::I'T'EI:;i: D :1.' '.ii!;l:::'Cl~:~;F:ll... :i~;'~.':iii"t"[~:l,I, O1~: F:'LtlF:fl.... ~[ C: :ii;E:'.l.,.lE[l~:Fl[:iili:.:: :5"~.':E;'Fi!~:I"I I'~)i'.,[ "i"l'-'l :[ :!i; I::)l;i: F:tI",I'T' I::Ii::,J'FICEiff'4T CiFi: lq[ii:t:::ll:;:l!ii',"d I....I:::IT. ,'4. :t: IJN[)EI:~'.:!~;TFII",I!:) 'FI"IF:IT 'l"H :[ :!]; I::'I]~:F~:i'"1:1: T :1: S ',,,'F:IL :1: I:) [:::l:)l:~'. FI PIN;:';', :1: I"IIJH OF:' 2.": 1.3EI.'::,I:;.':(3OHS F:It'.,ID !:::IF,I~'~'' E:NI....F::I[~'.GEHEi:I",IT !.,.I :i: LL.. F;':'.i:!!:(.:.!I.t :[ I:~:E 1:1i"4 i:::IDD ! T ]: CINI::IL. I::'EFi:H ~ T. SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~,~ ¢,f SLOPE [] PERCOLATION TEST DATE p ER FO R M E D: 4.~? ~//~¢"'- (~::~ ¢~ j f b ~' lb 10 11 13-- 14 15 16 17 18 19 20 ) WATER TERED? j '~ ? Gross Net Depth to Net ~ding "t ~ ate Time Time Water Drop PERCOLATION RATE (minutes/inch) ¢ , TEST RUN BF,/rWEEI'¢' ~._~_~ FT ANJ~ FT .. ,.'%" :.; '],OI?X ....... ( ' "'"' - 72-008 (6/79) Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval Parcel I.D. 051-073-25 1. GENERAL INFORMATION: Complete legal description FOXHILL; BLOCK 1, LOT Expiration Date: OJ .27 �2 O a O Location (site address) 21849 WOODCLIFF DRIVE, CHUGIAK, AK 99567 Current Property owner(s) ZACHARY AND ELIZABETH KUGLER Day phone 223-5609 Mailing address Real Estate Agent 21849 WOODCLIFF DRIVE CHUGIAK AK 99567 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3- 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ q -5,0 + y �` 5 b (pus H ) Waiver Fee $ _ Date of Payment �r 5 1 aC) 10 � C)2'0 Date of Payment Receipt Number 139 C) 6a ©T15(116 Receipt Number COSA # OS G 20 13 7 3 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: Gamess Engineering Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101- Anchorage; Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: :1- In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system j: Al"�L� in accordance with the guidelines and regulations established by the Municipality of Anchorage and�� , . • industry practices. The reported results describe the condition of the system/s on the date/s of the r✓ �r 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 —it � and septic systems depend upon a variety of variables, including but not limited to, soil conditions, �✓ I groundwater levels (that may fluctuate during the year), quality of construction (materials and 3� ' 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 if(� Jefir;� } ,C ess. system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of 0. SCE 7953 the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG too perform the evaluation. Reliance upon the information provided in this report by any other person or ```la�tic5~c party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. #AECC884 6. DSD/ SIGNATURE VSystem #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the foll of owin` ,4 ul t�r� ITE 45 SEF By: 9&cajuz g 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 Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other I o-rx Q_Qe QAV i Sar+ X COSA blue sheet_10-10-12.doc Legal Description COSA Checklist FOXHILL; BLOCK 1, LOT 7 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA Parcel ID: 051-073-25 Structure served by this system I 0 Well log is filed with Onsite (or attached) Well production at time of test 7+ gpm Date drilled *4/84 Water storage tank volume NONE gallons Total depth *121 ft Well disinfected for coliform test? ❑ Yes No Cased to *121 ft ❑■ Coliform bacteria is Negative ❑■ Sanitary seal is functioning correctly Nitrate 4.35 mg/L ❑ Nitrate less than MRL (ND) ❑■ Wires are properly protected Arsenic ug/L 0 Arsenic less than MRL (ND) Casing height (above ground) 18 in. Collected by GEG,LTD. Date of flow test for COSA 7/14/20 Date of Sample 7/13/20 Static water level at beginning of test 92 ft. Comments *PER 1986 HAA IN MOA RECORDS. WELL LOG IN MOA RECORDS IS NOT LEGIBLE. B. TANK DATA FT STATION Age of tank(s) ,'22 years ❑ Requir aintenance compl Tank type/material STEEL 'IN ST1 (50.5 IN sT2) Age of lift station ye Measured operating fluid level in septic tank 49'5 Lift station material 0 Standpipes/foundation cleanout per record drawing Comment Date of pumping *7/13/2020 D. ABSORPTION FIELD DATA BED (*MT1/MT2) Which system tested (date installed) 91 23/7998 Adequacy test date 7/14/20 0 ALL standpipes present per record drawing Results ❑✓ Pass For 3 bedrooms Total measured depth from grade 5.1 ft (max) Fluid depth prior to test *2'5/0 in Measured depth to pipe invert from grade 3.6 ft (min) Water added 850 gal ❑ N/A — pressurized field New depth *5/5 in 0 Monitor tubes go to bottom of effective. If not, state Elapsed time 1065 min depth into effective Final fluid depth *1.5/0 in XCode-required soil cover over field Absorption rate 450+ gpd ❑ System presoaked (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NONE date of test) Gallons introduced N/A gallons If yes, enter date Comments/Deficiencies: 'MT3 (NORTH MT) REMAINED DRY THROUGH ENTIRE TEST. MAX LIQUID LEVEL WAS BELOW INVERT OF DIST. LINES. COSA Checklist yellow sheet 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' ❑ Yes if No Community Sewer Manhole/Cleanout > 100' p✓ Yes if No ft 0 Yes if No ft Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25'[Z] Yes if No ft Absorption Field on Lot > 100' F71 Yes if No ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' [✓ Yes if No ft Q✓ Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' [✓ Yes if No ft ❑✓ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No *51+ ft Surface Water > 100' 0 Yes if No ft Property Line > 5'❑ Yes if No ft Wells on Adjacent Lots: Wells on Adjacent Lots: Absorption Field > 5' Q✓ Yes if No ft Private Wells > 100'✓0 Yes if No ft Water Main > 10'✓❑ Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Water Service Line > 10' ❑✓ 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' Q✓ 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' Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Surface Water > 100'✓❑ Yes if No ft F. ENGINEER'S COMMENTS *MET SEPARATION DISTANCE REQUIREMENT AT TIME OF INSTALL. G. ENGINEER'S CERTIFICATION I certify that 1 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. COSA Checklist yellow sheet #AECC884 MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904 On‐Site Water and Wastewater Section Fax: 343‐7997 www.muni.org/onsite Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org Septic Tank Advisory Certificate of On‐Site Systems Approval # OSC201373 Subdivision: Fox Hill Block:1, Lot: 7 The septic tank for this property is 22 years old. The average life for a steel septic tank is 20 years. Typical replacement costs range from $7,000 to $11,000. 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 30 year old steel tank MAY look like. Municipality of Anchorage Development Services Department Building Safety Division · On-Site Water and Wastewa~er Program 4700 Soulh Bragaw St. P.O. Box ig6650 ,~knchorage. Al( 995t9-6650 www.cLanchorage.ak. Us (907) 3,l~-7g0,t CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-073-25 'l. GENERAL INFORMATION · Completelegalde~cfiption Lot 7; Rlo~ 1., Location (site address or'directions} 2].849 Woodc].i££ ':Current Propedyowr~r(s) Ale× & Dan Morton ' .Mailing address 21849 Woodcliff Dr. Lendin~ agency Mailing address Expiration Date: if / ~/~.~ ~n,,-ht I 1 Fh~hr)ivt ~4 nn Drive Day phone Chuviak. AK Day phone 688-5763 99567 Real Esiate Agent Laura Patton Dayphone 257-0191 . Mailing Address 2600 Cordova St Ste. i00 Anchorage, AK 99503 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Public Water System Well TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual. Holding tank Commundy On-site [] Public Sewer The Municipality of Anchorage Developmenl Services Departmenl (DSD) Issues Certilicales of Health Aulhority Approval (HM) based only upon the representations given In paragraph 5 by an Independent professional civil engineer registered in the State of Alaska. CerJilicates of Health Authority Approval are required for Ihe Iransfer of lille (except between spouses) for propedies served by a single family on-site wastewaler disposal and/or water supply system. DSD also issues HAAs upon request Io homeowners. Certificates of Health Authority Approval are valid for 90 days from lhe dale of issue for properties served by a private or Class C well and may be reissued wilh new waler sample results less than 30 days old. (Cerlificales may be reissued tot a period of up to one year with valid water samples.) Cedific~h3s are valid for one year'for propedies served by Class A or B wells or a public water system· The Municipality of Anchorage Is not responsible for errors or omissions In the professional engineer's work. 4, STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as o1' the valldafion da{e shown below, I verify that my Investigation, based on procedures outlined In Ihe Health Authority Approval Guldeltnes 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 ~udher verity fha{ based on the Information obtained from the Municipality of Anchorage files and from my Investigation and Inspection, the on-site water supply and/or waslewa~er disposal system Is{are) In compliance With a~l applicable Municipal and Stale codes, ordinances, and regulations In effect at Ihe time of Installation. NameofFirm S & S EngineerinR Address 17034 N. EaRle River Loop Ste. Engineer's Printed Name Robert C. Cowan 5. DSD SIGNATURE L.-"" Approved for ,5TM Disapproved. Conditional approval for Phone 694-2979 204 Eagle River, AK 99577 Dale ~/~/o 7_ · . &~ .. . ...a"~ ~ F~'...':. ...._J,.~j?...'. '~ bedrooms. %~,~> ~ ........... ;:.~ ~ bedrooms, with Ihe fallowing slipulalions: Additional Comments Attachments: HAA Checklist Septic Sys{em Advisory Well Flow Advisory X Maintenance Agreements Supplemenlal Engineer's Report Other Orig;nal Certifica,e Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastevmter Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchomga.ak.us (S0?) 343-?g04 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: WELL DATA Well type ~ To,-~ dep=/~'.= '~. If A, B, or C provide PWSID # ~ Well tog (Y/N) ~ sectary =e~ (Y/N) Y' Var~ pmper~ protected (Y/N) "/ Cased to '~fl.' Casing height (above ground) /I:~" Date of test FRO ~f~,/_~,~L LOG Static water level ~ / ft. Well production ~;) g.p.m. in. AT INSPECTION LoZ_ ft. ~'. O g.p.m. WATER SAMPLE RESULTS: Coliform (~) colonies/100 nd. Date of sample: B. SEPTIC/HOLDING TANK DATA .Tank size ( ~,3.~ gal.' 'L Number of Compartments ~" / ':: Foundation cleanout (Y/N)~*~ Depression over tank (y/N) · Date of pumping O~. Pumper '~1:;~ C~. ABSORPTION FIELD DATA Nitrate .~.3~mgJI. Other bacteria ~ colonies/100 mi. C~dby: ~'~ ~ Date Instelled ~/~'- ~ / '~1 ~ C~eanoute (Y/N) ~' High water alanm (Y/N) "~ ~/,~/~,~ Soil rating~r ~/bdrm)~). Or'- Dam installed ,.an,~'~,~'~:~ ft. w,~th/~"//o' ft. Tote, dep~ 4 ft. E..e~so~tion=-- 4'~> ~oni,orin~ Fluid depth in abso~aon ~eld ~f~ test ~ ~. Wa~r add~ ~al. Elape~ Tiree: ~ min. Fin~ ~u~ dep~ ~ in. ~aon rate >= ~y rejuvenation ~a~ant (~st 12 ~.) ~ & ~) ~ System type Gravel below pipe ~;)o ~" / Depression over field For ~ bedrooms New depth ~) in. '~ %~.~ g.p.d. If yes, give date D, UFI' STATION DatUm / E. SEPARATION DISTANCES Size in gallons 'Pump off' level et Cycles tested Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tenk/li~..s~n on lot /0 C~ /'~ I Absorption field on'lot / O o '/'- Public sewer main /~ S~"/~ptic sewice line · *~..~ SEPARATION DISTANCES FROM SEPTI~ TANK ON LOT TO: Building foundation ~' On adjacent lots / ~ "~-' On adjacent lots Publlo sewer manhole/deanout ~ / '"~ Holding tank Property line ~ '~' Absorption field ,~ '~' / Water sesvice line ,/~) "/" Surface water /QO Water main "~'/~' Wells on adjacent lots /~O /-''- SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: ProperS/line /O Water Sewice line Curtein drain '~' I Building foundation /' 0 ~- Water main su ace / 0 0 +'- Driveway, parking/vehicle storage Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and rev/ew of Municipal recon:/s that the above systems are in conformance ts/Eh MOA HAA guidelines in effect on this date. Engineer's Printed Name RO~J~-4/- C. Cok/8, °ate HAA Fee $ Date of Payment Receipt Number (Rev. 12/00) .. Waiver Fee $ Date of Payment Receipt Number ,~t~. CT&E EnvlronmentalSe~ceslnc. CT&E Ref.# 1024424003 Client Name S & S Engineering Project Neme/~ Client Sample ID Matrix Drinking Water Ordered Ely ~'WS~D 0 Sample Remarks: All Datt~TIm. are Alaska Standard Time l'rlnted Date/Time 07/22/2002 14:49 Collected Oate/l'lme 07/16/2002 19:00 Recdved Date/Time 07/17/2002 11:10 Technltnl Director Stepbe~l~de Released By Waters DeDar tmenb Total Nittate/Nitrlte 2.55 PQL UnlU Method mg/L EPA 300.0 AHowa~le Prep A~aly~s LL, nh~ D~t¢ Date Init 07/20/02 JDT Hic~:obiolog~ Laborabo~ Totnl Col/form col/100mt. SMI8 9222B (<11 07/17/02 KAP PAGE DRIVER INVOICE DATE OF ,~ERV1CE TIME Last Pump Other ~ Pump Septic Tank w/up to 3 Backwashes [] Pump Holding Tank [] Extra Time I Backwashes Required [~ JR's recommends your next pumping in ~. ,~.~ AUTO [] We wiii call o~ send a re.minder at thai time. ' Standpipe(s) needs repair; missing / crimped I broken I no caps Only one standpipe on septic tank Tank appears to be./.5"~' gallons I crib leach ~7/ . Quantity Description Gallons pumpecl- Septic System Extra Time I Back'washes Other; Amount Total Amount Due: $ Payment Terms: 30 days from invoice (:late - 1.5% per month late fee '$25 charge for all returned NS~= checks Municipality of Anchorage 4 Department of Health and Human Services � Division of Environmental Services On -Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FORA SINGLE FAMILY DWELLING Parcel I.D. 051-073-25 Complete legal description HAA#C``���C' Expiration Date: Lot 7, Blockl, Foxhill Subdivision Location (site address or directions) 21849 Woodcliff Current Property owner(s) in r h r i G t P n S P n Mailing address 21849 Lending agency Mailing address Real Estate Agent Mailing Address Day phone 277-2788 Woodcliff Drive, Chugiak, AK 99567 Day phone Day phone Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System r/X1 420 TYPE OF WASTEWATER DISPOSAL: M Individual On-site 1X11 ❑ Individual Holding Tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 2-025 (Rev. 01,'00)' 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 Health Authority Approval Guidelines for the Health Authority Approval application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. S & S ENGINEERING Name of Firm 17034 Eagle River Loon t2ead tete 2Q4 Phone v Ci ( —,)`9 7 Address Eagle River, Alaska 99577 Engineer's Printed Name 6. DHHS SIGNATURE V Approved for 3 bedrooms. Disapproved. Date S /L o ° Conditional approval for bedrooms, with the following stipulations. Additional Comments Attachments: HAA Checklist Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By f Original Certificate Date: % Expiration Date: ` o Reissue Date: 75-025 (Rev. 01 00)` RECEIM Municipality of Anchorage IAW#AY 7 7 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MUNICIPALITY OFA 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 3ZffQFWAL SERVICES DIVIS1r Health Authority Approval Checklist Legal Description. 1*yVH14-1- SXD Parcel I.D.: Off/ —07-3— Z5— A. WELL DATA Well type Pte! ✓•q—/� If A, B, or C, attach ADEC letter. ADEC water system number Log presen"( /N) Yes Date completed 4 Total depth / z0 /-7 , Cased to 4v 4- Casing height (above ground) Sanitary sea6N) Ye:�s Wires properly protectefo/N) _ z Es FROM WELL LOG AT INSPECTION Date of test Zi /O Static water level Well productiong.p.m. 7� l% g.p.m. WATER SAMPLE RESULTS: Coliform 0 Nitrate a . I Other bacteria O Date of sample: -2-- Collected by: Loop Ftodd No. 204 •,r.-:,, ,. B. SEPTIC/HOLDING TANK DATA Date installed ZG`� Tank size � Number of Compartments z Cleanout&N) 7 �� Foundation cleano (/N) Depression(Y/N) A619 High water alarm (Y/N) Date of Pumping Pumper C. ABSORPTION FIELD DATA Date installed 2� l Soil rating (g.p.d./ftz or ft2/bdrm) �� System type�� Length G�,.S Width /� %� Gravel thickness below pipe l/ Total depth Effective absorption area (22 Monitoring Tube presen6A-i;!5 N)��Depression over field (� Date of adequacy test �F Results (Pass/Fail) For ��� bedrooms Fluid depth in absorption field before test (in.); -� Immediately after gal. water added (in.): Fluid depth � (ins) Minutes later: Absorption rate = g.p.d. Peroxide treatment (past 12 months) (Y/N) /E Ar f yes, give date VIS 72-026 (Rev. 3/96)'` /A/ �/�Z� � �� � � Sly VIS � D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 100/_14- Absorption field on lot /O L' / ,-- Public sewer main %`✓ Sewer /septic service line 2 f �4— On adjacent lots On adjacent lots "Pump off" level at* Public sewer manhole/cleanout Lift station /V• /14 AV ,{- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation Property line Absorption field Water main/service line Surface water/drainage Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ! 0 Building foundation O 7�-- Water main/service line Surface water / C -V /'- Driveway, parking/vehicle storage area Curtain drain _VOIVe— 16VCTVAI Wells on adjacent lots F. ENGINEER'S CERTIFICATION O Z) I certify that / have determined thru field inspections and review of Municipal recor ' i tQ5bqire-tems are in conformance with MOA HAA guidel'nes in effect on this date. Signature t �!'"--� `►�: .rt °. <� r`� Engineer's Name ! ` d Al -e % - ��7 �.�A.✓ �3 -o ROBERT C. COWAN Date 3-46/00 � n�,••% CE -3301 tea �L'•. -- ' :�' �,.� HAA Fee $ 3D -Z> Date of Payment 7 Receipt Number 6:2 72-026 (Rev. 3/96)'` 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 Parcel I.D. # CERTIFICATE OF HEAt. TH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 0~-/ 0-~3 -~- HAA# I'~'~'~~'~?~/ 1. GENERAL INFORMATION Complete legal description L-o Z- '7 ,~ Loc,< Location Property owner Kt~..~.,;,~' ~,~,. j ,+,~ .r Mailingaddress ~'z. c1-¢~;¢ ~,/?,¢ Ld,~,¢ o,~ Day phone( Lending agency Mailin, g address Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well 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 Holding tank Community on-site NOTE: Public sewer If community wastewater system, provide written confirmation from State AD£C attesting to the legality and status of system. 72-025 (Rev. 1/91) Fronl MOAiI21 o 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 flies 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 ENGINEEEING Phone ~ Name of Firm ~.70~4 ~,,~ River Loop I~oad No. 204 Eagle River, Alasl(a 99577 Address , .? Engineer's signature '~A~)/- ¢ ~&~ Date DHHSi SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with th-e following stipulations: 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 sstisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before ~ certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineeKs work. 72-0'25 (Ray. 1/91) Back MOA #21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES,~W/~L.~ Environmental Services Division 825 L o otreet, Room 502 · Anchorage, Alaska 99501 * (907) 343-4744 Health Authority Approval Checklist LegalDescription: /.-07' 7 ~[.oc~ / Fox tt,.L 5'//.) ParcelI.D.:O~/*-0'7] A. WELL DATA Well type /o/~ Log present (~/N) YE Total depth If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~-} / 9' ~/ Cased to L/0 '¢- Casing height (above ground) Sanitary seal (~N) Ye J Wires properly protected (~/N) )"8' J' Date of test Static water level FROM WELL LOG AT INSPECTION :~O g.p.m. 5~'. O '~- Well production g.p.m. WATER SAMPLE RESULTS: - Coliform O Date of sample: i(>/ y~ ¢1 SEPTIC/HOLDING TANK DATA Date installed gl/~- f¢ / ~ (¢ Nitrate Tank size )D- _$~ 0 Collected by: Number of Compartments Other bacteria O s s Eagle River, Alaska 99577 '~ Cleanouts ~/N). Y~ -~ Foundation cleanout(~N) Y~ )' Depression (Y/~q~. ~' f) High water alarm (Y/~ /~ Date of PUmpihg ~/~ ~'~. "' _ Pumper C. ABSORPTION FIELD DATA Date installed q/¢ ~ / ~ ~ Soil rating ~~r fl~/bdrm) 0 .'~ System ~pe ¢ ,o P Length~ ~ />_Width ~ ~ Io Gravel thickness below pipe O- &' Totaldepth · Effective absorption area (; ~ 5- rr ~Monitoring Tube present~) Y ¢ Y Depression over field (Y~ Date of adequacy test ~ / 4~ - ,~ · u-, Results (Pass/Fail) For Fluid depth in abso~tion field before test (in.); ~~affer gal. water added (in.): Fluid depth _~~ Absorption rate = g.p.d. Peroxide trea~t 12 months) (WN) If yes, give date bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles te~st.~d ._-~-- .... Size in gallons "Pump on" ,evel at* ~"~evel at* .~.---¢ -'*D-~t u m E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot / o o -,~ Public sewer main Sewer/septic service line ~;z_.~- On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation / 0 Property line ~ 5' Absorption field Water main/service line /o ¢- Surfacewater/drainage /po ~ Wells on adjacent lots £ /oo SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Surface water Curtain drain Building foundation ~ co Water main/service line Driveway, parking/vehicle storage area / ¢¢~.-0~ ¢.~ Wells on adjacent lots / 0 0 ENGINEER'S CERTIFICATION I certify that l have determined thru field inspections and review of Municipal in conformance with MOA H~ guidelines in effect on this date. Signature ~ Date HAA Fee $ Date of Payment ~/~ ~/~ ? Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number ~t~.- CT&E Environmental Services Inc. CT&E Ref.# 985916001 Client Name S & S Engineering Project Name/# N/A Client Sample ID Lt 7 Blk 1 Fox Hill Matrix Drinking Water Ordered By PWSID Sample Remarks: Client PO# Printed Date/Time 10/14/98 16:10 Collected Date/Time 10/08/98 18:00 Received Date/Time 10/09/98 14:35 Technical Director: Stephen C. Ede Released By~~ Parameter Results PQL Unfts Allowable Prep Analysis Nethod Limits Date Date [nit Total Coliform Nitrate-N o 1.67 col/lOOmL SN18 9222B 0.100 n~/L EPA 300.0 10 max 10/09/98 RMV 10/09/98 10/09/98 GCP A VAP -0 COMM Wd GA�Mll %7%AM C, 7— V V at wal 0 CAW& Sw/c CAvr ISO 4A • 0 1 IMP I RAVI Sm. 4 xf-t I= Vi RVEY SYMLS LaT SURVEY SU• TYPE BO......... rovmw%om AS.-IIIIII 0 SET REBAR DRAJNACE fI VRVCWRT 0 FOUND-RMAR a a e yjOOD FENCE CONCRETE PLoi Pi.Am ... As-IIIII ;'L0j SJWVICY ... 7MMAPM AssumED ELEV. JIt x w mETAL FENCE WOOO DE4 HLUI I'LANb & LUI a6Pr%vr-l-;P IT 15 THE pEspoNsISJUTY-OF THE BUILDER OR OWNER, PRIOR TO CONSTRUCTION. TO VERIFY' PROPOSED BUILDING rR^oe RELATIVE TO FINISHED GRADE AND UTIUTY CONNECTIONS AND TO DETERMINE THE EXISTENCE Or ANY EASEMENTS, COVENANT'S OR RESTRICTIONS ICH 00 NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. SURVEY CERTInCknoN 00T PLAN Ar CF I AWv a -wk -4 .m —o oba,aa 49 FOLINOATION AS -BUILT 0 hwM1Mw• a, Nie1.1 -d "0 .4 %A- .... .........urt wee, ... tm E. J JR. -1 v A' FINAL 5MCTURE AS -01I 412 —S 4c. r I, A— E. '- �' -wqv .. 1. .... r'4 dw now 0 ei 0 w4 ONLY THOSE IMPROVEMENT'S ABOVE GROUND AND VISIBLE WILL SC SHOVI FV4C3= WIELL.4"ft SEPTIC CLEANOUTS. SIOEWALKS, ORIVEWAYS. ETC., ARE: SHOWN IN THEIR APPROXIMATE LOCATION, ONLY, SNOW MAY PRCV1114T SOME IMPR40VIEMrNTS FROM SCINC SEEN AND LOCATED. ALL DISTANCES ARE RECORD, UNLESS OTHER"SE NOTCO. Prepared by Robert E. Johns,Jr. & AS:Soc. Professional Land Surveyors 80.2 L 4 AVE. ANCMORACE. ALASKA 99501 soclo.60 0 1 Rae. Lot S.F.I pvlc. clot rle 140, vt = Date Surv%Yed: joravm by. ichackea by. LOT 7, BLOCK 1 FOX RILL SUBDIVISION k 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 Lot 7; Block 1; Foxhill Subdivision Location (site address or directions) 21849 WoodcZi(~ Dr~ve Property owner Mailing address Lending agency Mailing address_ Agent Address Richard Williams Day phone P.O. Box 671671 0hu.gd~b.~ Ata~ 9q567 City Mortgage - Anchorage 0ffic~. Day phone Day phone 688-7353 wk: 384-0774 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well 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 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. XXX 72-025 (Rev. 1191) Front MOAg21 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/orwastewaterdisposalsystem is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverifythat 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 Address Engineer's signature $ ~. ~, 17034 Eagle River Loop Road ~!z ~h.c.- ~*.[a:!-.= 99577 Phone Date The conditions of have been met. DHHS SIGNATURE Approved for""'¢/~,"~'/~'~_~) bedrooms. Disapproved. Conditional approval for the Health Authority Approval issued October 8, 1992 bedrooms, with the following stipulations: Additional Comments Date 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 DH HS does th is 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) 8ack MOA RECEIVED DE(] 9 1992 Murlloq3ah~y o[ Aiioiqor'sge Dept. Health & Hu/~c~i~ST PORN LeGAL DESCRIPTION: HEALTH AUTHORITY APPROVALS SEWER S WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION ~ FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL& b~ECHANICAL INSPECTIONS ON SITS WASTE WATER DISPOSAL SYSTEM TIME DATE OF TEST: . , \'~- NUMBER OF BEDROOMS: SEPTIC TANK SIZE: TYPE OF ABSORPTION SYSTEM: TOTAL VOL. !~L (Gal.) AM.T. METER READING ROBERT SHAFER, P.E. ROGER SHAFER, P,E. CIVIL ENGINEERS (go?) 694-2979 FAX 694-1211 COMMENTS RESULTS: 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. # ~/~ -~-'~ %- ~,~ 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Lot 7; Block I; Foxhill Subdiv~ion; Location (site address or directions) 21849 Woodcliff Driv& Property owner Mailing address Lending agency Mailing address Richard Williams Day phow~e 688-7353 384-0774 P, O. Box 671671 Chugiak, Alaska 99567 City Mo~t~g~ge ~ncfiorage Office Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well 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 Holding tank Community on-site Public sewer NOTE: XX 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 #21 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/orwastewaterdisposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverifythat 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 $ & $ ENGiNEERhNG 17034 Eagle River Loop Road No. 204 Address Engineer's signature 6, DHHS SIGNATURE Phone Approved for bedrooms. Disapproved. /- Conditional approval for . ./'~'/-,,--.¢¢~...~.-~ bedrooms, with the following stipulations: 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 certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72~)25 (Rev 1/91) Back MOA ~21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: _~--c~-r" '~ ~-%--~.-- / ('/""~ ~ ~v-~/i:> Parcel I.D, d?.~/_~ A, WELL DATA Well type I~;'¢.~%) ~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (~N) Totaldepth Sanitary seal Date completed ~t'-'q-~ Driller Cased to \"~ "1 '~ Casing height Wires properly protected ((~N) ~ Date of test Static water level Well flow Pump level FROM WELl. LOG AT INSPECTION '~::;). D g.p.m. "7.~'~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot \ pc;> Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank _ WATER SAMPLE RESULTS: Coliform z:~ 4' '~' '/o~ .~, Date of sample: ~ ~\L,, -~"L. B, SFPTIC/HOLDING TANK DATA Date installed '7 .-'~ I -'b~¢ Cleanouts ~}~-~N) ~/ ~ High water alarm (Y~, Date of pumping ( Nitrate_ \?? ~5/,,t. Collected by: Other bacteria & $ ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Tank size \crt>c;> (.~p<t~ -- Compartments 'Z- Foundation cleanout~/N) _ ~/ - . Depression (Y/~ r-~ ~-J Alarm tested (Y/N) ~g/4 ~'¢~Z..~ ~ Pumper ~'~'_~_ ~$£/~5~:) ~- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: / Well(s) on lot 1~¢ To property line Jo Surface water/drainage On adjacent lots / ~O ~ ~ Foundation ~ / ~' Absorption field /2. ' Water main/service line Jo ~¢' 72-026 (Rev. 7/91) Fronl CONTINUED ON BACK PAGE C. LIFT STATION Manufacturer "Pump on" level at Date installed Size in gallons Vent (Y/N) High water alarm level ~ Meets MOA electrical codes ~ SE~ROM LIFT STATION TO: MC'bll on lot On adjacent lots Manhole/Access (Y/N) ~ ~~level at Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed Length ~'~ -- .Width Total absorption area ~¢I Depression over field (Y/~? Results ~:faif) Peroxide treatment (past 12 months) Soil rating ~" ~'/[~::~. Gravel thickness ~ ~ Cleanouts present o/N) Date of adequacy test for -i~r~f¢--¢-~ (,?.) ~ ~ If yes, give date System type ~¢'P Total depth 4-~ bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot To building foundation On adjacent lots Surface water Curtain drain .~¢2 On adjacent lots ~oc~ Property line [ ~ To existing or abandoned system on lot Cutbank *J/,~. Water main/service line I ~ ~ 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 eff¢ot-pnt.the.qlate of this inspection. $ & S ENGINEERING Signature 1~034 Eaule l~iv,~r I nn~, o~..~ ~,_ ~, Eagle River, Alaska 99577 Engineer's Name Date HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number Client 8~mpl* ID LV B1 EOR HILL UA HITBAIE-N 1,3 ,~/1 EPA 353 2 Ig ROU?IHE BASLE COI, LEC~ED BY: BAY, Not Ar~lyz~d ~1~ Mm'nbe,' of the $05 Group (So¢{¢t~ O4nOr6{~ de @urveHiance) S & $ ENGINEERING 17034 Eagle River Loop Road No, 204 Eagle River, Alaska 99577 OCT 08 '92 11:57 AH DAYTOH SE~ER & DRAIN SVC 907 3388180 Po~e 1 DAYTON SEWER & DRAIN SER¥ICE P.O. BOX 141792 ANCHORAGE, ALASKA 99514 FACSIMILE TRANSMITTAL TO: Compa n y ~'a× NumbeF MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEAL'rH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date Septembqr 26, 1986 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 7; B!o~k ].;~'~h-i4-1 S~Lvsi~ Location (address or directions) (b) Applicant Name Bruce Phau Telephone: Home Business 786-6364 Applicant Address ~D_i_t:.ec~L.BaELk ~f Alaska (c) Applicant is (check one): Lending institution []; Owner/builder []; Buyer []; Other [] (explain); (d) (e) (f) Lending Institution united Bank of Alaska *~,, Telephone Address 440 East 36th Avenue, Anchor~qe, Alaska Real Estate Company and Agent none Address Telephone 786-6463 99503 ~,~he HAAtothefollowingaddress: S & S Engineering SRB 196~ Eagle~iver, A]~S!~a 99577 TYPE OF RESIDENCE Single-Family ~1 Multi-F~Jf~/,EJ Number ol Bedrooms Other WATER SUPPLY Individual Well [] Dommunity ~ Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [] 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. Page 1 of 2 72-025 (11/84) ENGINEERING FIRM PROVIDIh,.~ INSPECTIONS, TESTS, FILE SEARCH, D~,,A AND INFORMATION As certified by my seal affi×ed 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. Name of Firm I~ & § ENGINF4ERING Address ~ ~ ~ t~{~)( Telephone Date Approved for ~~/~ b e d roe m s b~~~o,~te Approved ~.-~.~ Disapprove~ Conditional ~'~ Terms el Condilional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DFIEP 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. Page 2 of 2 72-025 (11/84) ....... ,rill. lit OF ANCH~ DEPE OF HE-' uRAG~ · ,~LTH & MUNICIPALITY OF ANCHORAGE (MOA/ E~IRONM~NTAL PROTeCtIoN HEALTH AUTHORITY APPROVAL (HAA) ~T ~ 3 ~ CHECKLIST- FEBRUARY 1984 Cecal ~escdption: ~ ~ ~ / ~ WELL DATA Well Classification../~¢~:2//~''¢¢¢ ;/~ If A, B, C, D.E.C. Approved (Y/N) "~" te m leted z.~/~ Z/ Well Log Present~'/~l) ____ Da Co p / / " Yield~'?,'~ Total Depth .¢~--"~ ~ Cased to /~ / ' Depth of Grouting ~-~ Static Water Level ~ ~' ~ Pump Set At Sanitary Seal onCasin (g~) Depression Around Wellhead (Y,~ ,/¢:20 t./.. ; On Adjoining Lots Casing Height Above Ground Electrical Wiring in Conduit (~N) Separation Distances from Well: To Septic/~ Tank on Lot To Nearest Edge of Absorption Field on Lot /"~O t./_ ; On Adjoining Lots //O O To Nearest Public Sewer Line ~'J /~'¢ To Nearest Public Sewer Cleanout/Manhole "~//~ To Nearest Sewer Service Line on Lot Water Sarnple Collected by '~ & S ENGINEERING ;Date 7/ZZ/ ~ B 196X Water Sample Test Results .~-~G ~ ~'r~ ~ . ~ LERIV~[~. AK 99577.. Comments ¢f../d~ ~/{ -/~j,"O¢.,,,~ ~¢ ~.-d .¢ ~ ,'? ~',,~,~",~ , /~, SEPTIC/~ TANK DATA Date Installed Size No. of Compartments Standpipes ~)' Air-tight Caps (~N) Foundation Cleanout~N)~) Tank (Y/~ Date Last Pumped /J .('~/.O ~ /t/o -~' Depression over / ,/~ Pumping/Maintenance Contract on File (Y/N) tr*'` ; for "'"--' Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/He/~ Tank: To Water-Supply Well To Property Line /~) r,../_ To Water '~'Service Line Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field __ Course To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11184) ABSORPTION FIELD DATA / Soils Rating in Absorption Strata ~,~- /4~//~¢~./ Type of System DeS~n/ Date Installed 7/,~/ /~' g/ / Length of Field _ ~ Width of Field / /F / / Depth of Field Square Feet of Absorption Area Depression over Field (Y,~.~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ~//O ~' To Building Foundation ~ Lot Gravel Bed Thickness Standpipes PresentON Date of Last Adequacy Test To Water I~¢~Service Line /~ ¢ '/' To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments / To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) /t2 ~. x,~,~" D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) ~///~p Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Bating Against HAA Request ** I certi~' ~~I ~t~vt~i~e~l~l~l e ified, or conformed toall MOA and HAA guidelines in effect on the date of this inspection. Signe~J~ .~, Date /O ~/:~ - Com~l ~ ~l~ . ~¢ MOA No. Receipt No. ~/ ~ 0 ~ ~ of Amount: Page 2 of 2 72-026 (11/84)