HomeMy WebLinkAboutFOREST RIDGE BLK 2 LT 10
Jun 13 22 09:08p Anchorage Well & Pump Ser
9072430742 p.1
MUNICIPALITY OF ANCHORAGE
Development Services Department) Phone: 907-343-7904
On -Site Water & Wastewater Section � �/ Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number:
Parcel Identification Number- 017_112_$9
Date of Issue: _
Legal Description Block Lot Property Owner Name & Address:
REGER CORTLAND JON & MICHELLE ELIZABETH
FOREST RIDGE 2 10 11 5214 MANYTELL AVENUE
ANCHORAGE, AK 99516 11
Pump Installation Date: os - os - 2022
Pump Intake Depth Below Top of Well Casing: 70
Pump Manufacturer's Name:
Pump Model:
BERKLEY
B7P4JP07221-02
Pump Size: 175 hp
Pitiless Adapter Burial Depth: 10
Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer:
Well Disinfected Upon Completion?
Method of Disinfection: PELLETS
Comments:
Pump Installer Name: _
Company:
Mailing Address:
feet
feet
MARTINSON
k Yes ❑ No
ANCHORAGE WELL & PUMP SERVICE
7640 KING STREET
ANCHORAGE, AK 99518
907-243-0740
State:
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
~.. Municipality of Anchorage Page ~/of 2-
' ~'" 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: ~qseo"z,~ PID Number:
Name:Wastewater System: ~New D Upgrade
~"': ABSORPTION FIELD
Phone: INo*ofae~ooms: DDeepTrench ~ Shallow Trench O.Bed ~Mound ~Other
Township: I Range: I Section: Fill added above original grade: Gravel length: ,
SEPARATION DISTANCES ~eptic ~ Holding ~.T.E.,.
su,~c, LIFT STATION
Lot Size in gallons: ~ Manufacturer:
'Pump on" level at: ~ "Pump off" level at: ~ High water alarm
Remarks: BENCH MARK
-,..... ENGINEER'S SEAL
Department of H and Hu Seduces appr~ . ,.
Reviewed and approved by Date: ~
Permit No. SWq'~nnTR
Page
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
Legal Description: FOREST RIDGE, BLOCK 2, LOT 10
PID No.:01711 289
COl CO
..... 6.5 ~. :
92. ' ,~o c... .6'
89.2',--j
I,{TSpT.2'
89.2'/
89.2'
· 79' NO WATER FOUND
A B
COl 27.5 13
kiH 27 14.~
bfl'l 38 51
14T2 2'7 18.~
1~'3 46.5 57X
I~T4 39.5 33.[
I,{T5 56.5 64..'
MT6 53 48..~
4 BDRL{.~
MOUSE BI
A
NEW DRAINFEI~~
~,,,--NEW 1500 GAL. S.T.E.P.
72-013 A (2/91) MOA 25
· .,* M-W DRR. LUqG, ~n¢.
,?' P.O. ~0:( 110378 · 10330 Old Sew~r~
(907) 349-6535
ANCHOPAGE, ALASKA ~511
· .~ev~n '~ C¢c/~Z!~ J~v~ · ..Usc
~ . .': ~0~ : ....
~oc~tio~ (nS~r~ oL Township, ~ge, ~ctlon, ~ ~ow~; or ~ce m~
,'.'".,., ~o~.]0 ~k, 'Z ~o~est ~t. dge, A~c~o~e
S~e o~ c~g~ 6" - 95.52
' ' . Depth of Hole__J~ ' ~eet . ' C~sedt~ ' -~eet
Static water level ' '~ ~ 'iL. {~ :~ s~iace. F~!s~ oi well (c~eck one) open en
low) lanS' ' ' '~ '
Screen ( · ); Verfotated,(~.
Describe sct~n or ~tfotatIo~' ~ · ~ ~
P.o;z
(x)i
~- ..., . · hours with
Well pumping test at 10 ga~!nS.l~ ~) (minute) for - -
of d~awclown lrom static l[~'~el,',;."l*a '{ :~ ~
I~t 'f:,~; ' ;:~ ,%~ Built' !lo,e: !*~e!l dry. grouted
Date ot completion July 9~19~. '.i ~ ~ 5entonite. chip
enviroplu$
· ..; ':,,. :. · ~' Witt LOG ~ ,
! ~- ~:. "~s '~/'t6rmatlo~ ~netrated, size of material, cclor and hardne[s
Gige dtt~ll
~roun~surface .- . , ._.
o
2 17
!7 56 B:~ · occ~icnat boulder~
TO
56 77
TO
77 92
_ ~ ,~0_
92 96
TO.
96
.TO~
TO_ .. ~,.
'.,'Yl")-i Ok.' li'lcJP{-'O'Jl~i'{,~l: };I.EC¥I:IC,",L 'O 0
3-- 0 .{ J3 .
...! .... 3 1,
1/
· i
.i
~ .
I
l~.3 }'III t.{',')tlf:.Cl~iI-'l, lf~HCl-'- O[:SI:[iUI.',L,,. [ 3 i',OI;~{;C'flO,'lC:
· ~:.*,{.l.t. 1 ~{ c [,
I~ 3 I~IILL .~}:EXAtt]'i'}I: AY HI-,'XI' INGPEI'.:tlOI{ i. 3 Ifil NOT
PAGE
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
PERMIT NUMBER:SW930076
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:NORCOL INVESTMENTS
OWNER ADDRESS:3911 EASTWOOD LOOP
ANCHORAGE, AK 99514
DATE ISSUED: 4/28/93
EXPIRATION DATE: 4/28/94
PARCEL ID:01711289
LEGAL DESCRIPTION:IiFOREST RIDGE BLK 2 LT ' 10
LOT SIZE: 50488 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / 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 343-4329 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:
Srl'E PLANS
PERCOLATION
TEST
June 13, 1993
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
{unlcipality of Anchorage
)EPARTMENT OF HEALTH AND HUMAN SERVICES
325 'L' Street
%0. Box 196650
%nchorage, Alaska 99519-6650
CIVIL ENGINEERS
(907) 694-2979
FAX 694-121 t
RECEIVED
JUN 2 2 1995
Mumc~pahty ot Anchorage
Dept. Health & Human Services
~FERENCE: Forest Ridge Subdivision, Block 2, Lot 10
~equest you re-issue permit ]SW930076. This permit was
£ssued on April 28, 1993, to drill a well and install a
septic system to serve the proposed four bedroom house on the
=eferenced proper~y. The permitted design has been revised
ko show three shallow pressurized distribution trenches be
£nstalled in place of the permitted pressurized distribution
bed.
~wo test holes were excavated and percolation tests
performed. The approximate locations of the test holes are
located on the attached site plan. The monitoring tubes
within the holes have been checked and found to be dry.
This propert has enough area for a septic upgrade which can
be seen on the attached site plan. We do not anticipate any
adverse effects on neighboring properties by the installation
)f the proposed septic system.
you have any questions, or require additional information
[or your review, please contact us.
ct A. Shafer, P.E.
17034 NORTH EAGLE RIVER LOOP * SUITE 204 · EAGLE RIVER. ALASKA 99577
LEGAL FOREST RIDGE SUBDIVISION, BLOCK 2, LOT I0
DRAWN L. $. ULSHER IcKD' R~.S. I
REVISED 6/21/,°3
DESIGN CRITERIA· - .......... ' '
u~,~/~~'/~.u: .. .~ ~/,~
4 BDRM = 600 GPD_ 5' WIDE
600 * 0.45 =1334 sq. ft. REOO 3'EFFECTIVE
//
/
LOT 7
I
I
II
ALT.
pROPOSEr.
~,.OPo~o ' ! 1
,~$$ORPTtON [ /
PRESSURIZED DISTRIBUTION SYSTEM..
PUMP = 20 051 05HH - 5 STAGE (-30 GPM)
3 LATERALS - 46'LONG EACH'. I0
I0 I~-.~s/L4r (5' O. CJ - 30HOLES TOTAL = I!
~" ' DIA. HOLES FACED DOWNWARD
I ~t" DIA. LATERALS
~' SO?JO M.4NIFOLZ)
4 J~DRM
HOUSE
LOT I0
pROPOSED
PLAT 86-178
I00' SEPTIC SE T~A CK
A/E SUPPLIES 150208
LE°ALFOREST RIDGE
DRAWN I eKD.
I ~;_ III _SHI:'I? I
Y O O O O
L --
F-
v
SUBDIVISION, BLOCK
R.A.S. J DATE6/21/93
0 0 0 0 0
1 1/4" DIA. LA
r-
_~/4" HOL~S (5' O.C.)
DETAIL
MT
J
'~---'~'~FROM $.T.E.P.
~"~'---Z' DIA. SOLID MANIFOLD
PROFILE
INAL GRADE
II
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
REFERENCE~ FOREST RIDGE SUBDIVISION, BLOCK 2, LOT 10
GENERAL
1.
e
The scope of this project includes the installation of a
1500 gallon Septic Tank Effluent Pumping (S.T.E.P.)
system and three five foot wide pressurized distribution
drainfields to serve the proposed four bedroom residence
for 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 from soil settling. On all leachfield mound
systems, the property owner shall be responsible for
ensuring a satisfactory vegetation growth over the
mounded area.
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 from the
Municipal Health Department.
SEPTIC TANK INSTA?.?.%TION~
o
A septic tank is to be constructed by a certified septic
tank manufacturer. Construction shall include two 4"
clean,uts for pumping access.
The septic tank shall be sufficiently bedded to prevent
settling or shifting of the tank.
All standpipes on the septic tank shall extend a minlmum
of 12 inches above final grade.
Page Two
Forest Ridge Subdivision,
June 13, 1993
Block 2, Lot 10
4. Septic tanks installed with less than 4 ft. of cover
shall be insulated.
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 llne, shall be to clean
toward the leachfield. The second cleanout shall be to
clean toward the septic tank.
Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/D~AINFIELD INSTA?3'~TION~
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
barrier covers the entire gravel surface before placing
backfill.
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.
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
Forest Ridge Subdivision,
June 13, 1993
Block 2, Lot 10
MINIMUM MATERIAL SPECIFICATIONS~
Any septic tank
constructed by a
manufacturer.
proposed for installation must be
Municipally approved septic tank
0
The following pipe materials
septic system installations
Anchorage:
are approved for use in
in the Municipality of
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.
Insulation shall be at least 2" thick extruded direct
burial polystyrene (Dow Chemical Company Styrofoam HI or
equal).
o
Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
0
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.
0
Ail leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the %200 sieve.
When sand is being used as a filter material, it's
gradation specifications must conform toAMC 15.65.060D.
Page Four
Forest Ridge Subdivision,
June 13, 1993
Block 2, Lot 10
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=
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.
o
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.
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:
LEGAL DESCRIPTION: ~T IO!~d~-~, ~'~"7 ~)/D~_'~ownship, Range, Section:
~ SLOPE SITE PLAN
5
6
7
8
9-
10-
WAS GROUND WATER ~..~
ENCOUNTERED?
f,,.~
11
12
13
IF YES. AT WHAT
DEPTH?
Depth ~o WMer Afle,rT~r?
Gross Net Depth to Net
Reading Date Time Time Water Drop
· ~ ' ~:oo ~,,. % '/~," w~"
~'.~ ~ .. ~ ~2" ~/~*,
~t~ ~" 5'/~ ~I~
14.
16-
18-
20 6 ~''
PERCOLATION RATE "~ Irmnutes/mchJ PERC HOLE DIAMETER
TEST RUN BETWEEN--~-.~ AND ~:~'~' FT
~MMENTS ~ ~'-~ l't"~ __,. ~/''
PERFORMED BY' 17~ ~1. ~l~-- g .-- ---, ..... i /~ ~/ ~ CERTIFY THAT THIS~ES~W~S PERFORMED
,cco,~anc~~~au~u'=eune~t on t.,s uat~. uate: --/ - ~ ~
72~ (Rev. 4/~)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG ~ PERCOLATION TEST
PERFORMED
LEGAl. DESCRIPTION:~'OT/O( '~-! ~/"/E:~f ,t~tl~"~TOwnship' Range. Section:
1
2
3
4
5
6-
9-
10
WASGROUNDWATER
ENCOUNTERED?
SLOPE SITE PLAN
11
12
13
14.
15-
16
17 -
18-
19
20
[.o,H.
IF YES. AT WHAT ~
DEPTH?
E
Moniteri.o? P~Y OaI~
Gross Net Depth to Net
Reading Date Time Time Water Drop
~S ~o ~' S~" ~"
PERCOLATION RATE ~'~) (minutes/tach) PERC HOLE DIAMETER
TEST RUN BETWEEN
Municipality of Anchorag
On -Site Water and Wastewater Program, Ov
(907) 343-7904
JAN
4J
Certificate of On -Site Systems A of
Aj
Parcel I.D.017-112-89 Expiration Da 6 8 L
1. GENERAL INFORMATION:
C T
Complete legal description Forest Ridge; Block 2, Lot 10
Location (site address) 5214 Manytell Avenue *Anchorage, AK 99516
Current Property owner(s) Scott Tweedley Day phone 907-290-1057
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
Z Single Family (w/wo ADU)
❑ Duplex
F-1 Multiple Dwellings (Single Family and/or Duplex)-.
Day phone
3. NUMBER OF BEDROOMS:
.4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual
Individual Water Storage
El
Holding Tank
0
Community Class Well
0
Community
0
Public Water System
0
Public Sewer
0
WaiverNadance request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5-56
Date of Payment 02 0
Receipt Number
COSA #
Date:
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'. Gayness Engineednq Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507 I
Engineer's Printed Name: Jeffrey A. Garness Date:
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 the Municipality of Anchorage and 00000
industry practices. The reported results describe the condition of the system/s on the date/s 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 04:"_1
and septic systems depend upon a variety of variables, including but not limited to, soil conditions,
groundwater levels (that 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 th
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of O • • G
the well or septic system. GEG makes no representation whether an alternative well or septic systemO _P re A. Garn ss.:
can be installed on the property in the event either of the current systems fail to perform adequately in Q
the sole any 44���re Gd )—
t future. report
benefit the
person/party that retained
�Performthe evaluation. Reliance upon information provided his report by otheper on o
�4 af'rofessio�o\ o
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right ���O000�oo
whatsoever.
#AECC884
6. DSD SIGNATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the
� ST /V® rn
" ►tp
JJlJ����s V 7 \
By: Original Certificat ® -2 0 W
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 G Nitrate Advisory _
Septic System Advisory Arsenic Advisory _
Well Flow Advisory Other ��
Legal Description: FOREST RIDGE; BLOCK 2, LOT 10
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 719193
Total depth 98 ft
Cased to 95.52 ft
FOR Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 11129/19
Static water level at beginning of test 15.5 ft
Comments
B. TANK DATA
r
Age of tank(s) 26.5 years j N
Tank type/material sTEpr""I
Measured operating fluid level in septic tank 25
FOR Standpipes/foundation cleanout per record drawing
Date of pumping 7/11/2019
D. ABSORPTION FIELD DATA
Which system tested (date installed) 612511993
❑ ALL standpipes present per record drawing
Total measured `depth from :grade 6.9' ft (max)
Measured depth to pipe invert from grade ft (min)
❑ N/A — pre ssurizedAeld
❑ Monitor tubes go to bottom of.effective. If not, state
depth into effective "
Parcel ID: 017-112-89
Structure served by this system
Well production at time of test 6+ gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? Yes i7 No
ffr`C�0'liform bacteria is Negative �� o G C_ a
Nitrate 0.91 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L [`Arsenic less than MRL (ND)
Collected by G EG D\,) q v4%e l,C� �!✓
Date of Sample 1/8/20
C. LIFT STATION
❑ Required maintenance completed
Age of lift station 26.5 years
Lift station material STEEL
Comments: SEE ATTACHED MAINT LOG
Adequacy test date 11/2912019
Results Q✓ Pass For 4 bedrooms
Fluid depth prior to test •25130,27 in
Water added 636 gal
New depth •26130129 in
Elapsed time 120 min
❑ Code -required soil cover over field
Final fluid depth `25130,27 in
❑ System presoaked Absorption rate 600+ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NO
date of test) N/A
Gallons introduced N/A gallons If yes, enter date
Comments/Deficiencies:.3 TRENCH TYPE DRAINFIELD - WATER INTRODUCED THROUGH LIFT STATION
**AS STATED ON 10/14/16 COSA IT IS UNKNOWN IF 3' OF SOIL COVER OVER THE
DRAINFIELD; MT 2 & MT 4 DO NOT APPEAR TO BE SET DEEP ENOUGH
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
Community Sewer Manhole/Cleanout > 100'
ft
❑✓ Yes
if No
ft
❑✓ Yes
if No ft
Neighboring Tank > 100'
M Yes
if No
ft
Private Sewer/Septic Line > 25' ❑✓ Yes
if No ft
Absorption Field on Lot > 100'
M Yes
if No
ft
Holding Tank > 100' ❑✓ Yes
if No ft
Neighboring Absorption Fields
> 100'
Animal Containment > 50' ❑✓ Yes
if No ft
❑✓ Yes
if No
ft
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
ft
Surface Water > 100 0 Yes
if No ft
Property Line > 5'
0✓ Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
❑✓ Yes
if No
ft
Private Wells > 100' ❑✓ Yes
if No ft
Water Main > 10'
✓❑ Yes
if No
ft
Community Wells > 200'✓Q 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' ❑✓ 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
Water Service Line > 10'
❑✓
Yes
if No
ft
Community Wells > 200' ❑✓ Yes if No
Surface Water > 100'
✓❑
Yes
if No
***80 ft
F. ENGINEER'S COMMENTS
*WR#16117 - 26 YEAR OLD STEP TANK AND DRAINFIELD ARE LIKELY APPROACHING THE END OF THEIR USEFUL LIFE
**MET CODE AT TIME OF INSTALLATION - SEE ATTACHED PHOTOS
***SEE ATTACHED LETTER REGARDING SURFACE WATERS
G. ENGINEER'S CERTIFICATION 0000600 O�
1 certify that / have determined through field inspections and review Q. of Municipal records that the above systems are in conformance with
J -.g.:. 14 �A ��i
MOA COSA guidelines in effect on this date.
uo ._ 7—
J e Ga ess:
CE 7943
av
COSA Checklist yellow sheet �Q d pr o f e s slonoo�
#AECC884 ���OOoo��
ft
ft
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
On -Site Water and Wastewater Section
Septic Tanis Advisory
Certificate of On -Site Systems Approval #OSC 201034
Subdivision: Forest Ridge B 2 Lot 10
907-343-7904
Fax: 343-7997
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this property is 26 years old. Typical replacement costs range from $8,000 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 20 year old steel tank MAY look like.
'``x' ,. K g" z`'s
Ma�f�ng Address P b zBax 196650 Anchorage; blask� 995191 6650 *`www muni org r
01/0712020 11.29 8686770 APLUS "''WIN
�Pp�ICHOpAOE
X+e PAWV WO, MutAICI
� pkeot790
Phone' 907-34W3.7904„�,.•�•+s a�� y�� Fax: 907-3,�:?'..7997
ament
peveloprnent Serve D ater $eCtion fir),
on -Site Water & Wastew Vault
o-�� �f�'�` Lift MP
P, �`� Maintenance Log
Addreset s i ID
Sire P
Leg�Oesc_
s�Q
Phonepumping completed1,
required
1 el �-'nohes-pumping,
•Sludge lev
_M,ent filter cleave confirmed
Lx TPump basket cleaned .Proper float s>n
•Control floats
cleaned
.operation satisfactory visual alarm inside dwelling Y�, -
-Audi[�lb and -
la
Ma electrical alarm circuit
.Dedicated + aaii f$.o-
-Alarm system operation
w�wnhA ����«� 1.IE�ay T1Q
nnection .Weep hole fi�ncti0r%
-Ground water Intrusion at riser to tank 00 c ►+
ene'tration� es
Properly Secured
-Ground weEP-T Intrusion around Pipe p Insulated
•Manhole lid: FuR�%oval CY9”
03Mredinspections and rraaintenance complied �-�
anufacturer requ�
.All
m j E/ � .....................
l-.�p......_�N ... --
cl" ,.1.� l -.._lav••• -....
7
...................
V� ................................. ............................................. ......1 ............. .......-- --. .....
I .... I..... ....
......
................................
.............. ....................................... ............... ...............
Date of maintenance_..__
Technician
Company
Signature ��
~ .... :..."-~'F~:~'=,-~.-.,,--- ~:_~'~"'~'"'~. . MUNICIPALITYOFANCHORAGE ........ "~,,'::".,~'-= ·" "' '. ....
· : ':'.,,.~5:,.~'.~.. [."'~h' DEPARTMENTOFHEALTH[HUMANSERVICESF..';~i~' ' - ..
' . '.' Complete legal descnpbon I.~ 10
:.......~.~ .~._,_ ,.,a,,,nu .,
...... Agent Day phone-'~-
.._: '~.~ Unless otherwise requested, HAA will be held for pickup ..... ~_;?.*:. ~_:.~ ~.~. ......... ....... _..~.>, ,~._ ..,.
..... : ....... ~.-...~,~..-,,.-,.---- Communltywell .............. _..~..;.._- .......... r ~.,,.=,,.,~.;..,
.,~. ~....', NOTE: :..~commun~rywe~sy~em, prowuewrmencon~rma,on~r~m.~a~e,~L/c~m~es~: := ~ ...
. '~'~'..': . Ing to the legality and status of system. : - ~..~:; :>~-'~. ~ ~ t ·
4. · .TYPE OF WASTEWATER DISPOSAL: ~ ' -- 7.' :x~" · - ~,, .. ~.~ ,.....
.............. ...... ? - : ~ ..... ; *-*''7. ~:'. '* ~1~, ', ' ''~" -1~ ~'-''
Ity ' · *
,;[~,..,~ ,., . ~ .. . Cor~lTlUn on-site ....... ,.-.. ........ , ....... .~. ~ .
~" ~" ' ~' '~ ~'*'?*' Publi(~ sewer .... ...... ~ ........ - .... ~ '~ ~' "~- :' ~" *~:' "'
NOTE: If communlt~ wastewa~er system, provide written confirmetion from Sta~e
attesting to the legality and status of system.
STATEMEI~ ............... ~,
OF INSPECTION BY ENGINEER := ~ ;'-...
' '
As cert~fl~l by my so~l affixed hereto and es of the vahdabon date shown below, I. ve~ 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 fo[, ............ the*number of I~lrooms'-' ' -: " - '- "'" '
')i=i L :.;:, i;:: and typ~ of structure Indic.~ted herein. I further verier that bera~ on the information obtained from
: {~':.*::~, ."~ ;: . the Mumcipality of ,A. nchomge files and from my lnvestigabon and Inspection, the on-site water.
':~-?,~; *~:*:- *.7~ .. supply and/or wastewater d~sposal system is in compliance w~th all Municipal and State codes
~. -, ........ .~..-:ordnances andr uabonslneffectonthedateofthlslns ion ........ ~ ~t-~-.~,~
~ Approved for 4 bedrooms.
· ' r3i~.annrnvnel
:~...: ......... .~ .....
· ....... Conditional approval for
..... ~ ~ . - ,,,,~/~ . .
: ~.?:' ~: ;~<~: Additional ~mmen~
. ' : '.' t/, ?.
bedrooms, with' the .~ollow!ng ~.fip?~tions: '
' ;";':~'} The Municipality of Anchorage Department of Health and Hum'an S~i~:~(D~I$) I~u~s Heaitli'A~thorlty
-..' ~. ;: ~ Approval Certificates based only upon the representations given in paragraph 5 above by an Independent
,' professional enginear registered In the State of Aleska, The DHHS does thls 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 lor errors or omissions in the professional engineer's work,
Legal Description:
A. WELL DATA
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
Lot 10, Block 2 Parcel I.D.:
Forest Ridge subdivision
017-1128
MUNICIPALI1Y OF ANCHORAGi~
ENVII~NMENTAL SERVICES DIVISION
FEB 0 7 1996
RECEIVED
Wclltype Private IfA. B, orC. attachADECIcttcr. ADECwatcrsystcmnumber N/A
Log present ~ Yes Date completed 7/9/93
Total depth 98 ft.
Casodto 95.5 ft. Casing height (abovc ground) 12" +
Sanitary seal ~rN) Yes
Wires properly protected (~IN) Yes
FROM WELL LOG
AT INSPECTION
Date of test
7/9/93
17 ft. BGS
2/2/96
13 ft. BGS
Static v,'atcr lcvcl
Well production 10 g.p.m. 5
WATER SAMPLE RESULTS:
Colifoml Nitrate
Other bacteria
Date of sample: 2/2/96
Collected by: Chris Ri~io
B. SEPTIC/HOLDING TANK DATA
Date installed 6/93 Tank size
Foundation cleanout (~ Yes
1500 Number of Compartments 2 Cleanouts (Y/N) Yes
S.T.E.P. ,
DcpmssionO~) 'No ' High water alarm l~N) Yes (on lift stn.)
Date of Pumping Pumper
C. ABSORPTION ~ELD DATA
3 ea, 5 ft wide
Dateinstallcd 6/28/93 Soilmting (g.p.d./fi'-orft"/bdrm) 0.45 GPD/Systcmtype Drainfield Trenches
SF
Length 156 ft. Width 5 ft. ' Gravel thickness bclow pipe 3 ft. Totaldepth 6 ft.
C: .'_,
Effective absorption area 1333 sqftlVlonitoring Tube prescnt(~, yes. ?prcssion over field (YO No
Date of adequacy test 2/2/96 Results {l~)Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test (in.); 3.5 Immediately afier 900 gal. water added (in.): 6
Fluid depth 1320 Minutes later: ~. 5 (in.) Absorption rotc = 900 '{- g.p.d.
Peroxide treatment (past 12 months) (y(~) N ffyes, give date N/A
D. LIFt STATION
Date installed 6/28/93
Manhole/Access (~rN) Y 24" t~
High water alarm level at* 45"
Cycles tested 4+
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot 100+ ft..
Absorption field on lot 100+ ft..
Public scwer main N/A
Sev.,er/septic sc~Ace line N/A
Sizein gallons 1500 Gal. S.T.E.P.
"Pump on" level at* 43" "Pump oW' level at*
Bot.tcca
*Datum Lift Station
: On adjacent lots 100+ ft..
; On adjacent lots 100+ ft..
Public $ev.'er manhole/cleanout N/A
Lift station 100+ ft..
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation 11 ft. Property line 10+ ft. Absorption field 5+ ft.
Water main/service line 25+ ft.. Surface water/drainage 100+ ft.. Wells on adjacent lots 100+ ft..
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation 19 ft..
Surface water 1004- ft..
Curtain drain None Kncmna
F. ENGINEER'S CERTIFICATION
Water main/service line N/A
Drivcx~y, parkingA'chicle storage area
Wells on adjacent lots 100+ :El:.
50+ ft.
33"
tn conjormance wt~h flOA ttflA gufi~ines in effect on this date. r~'Cg~x~.~· ........ ::.',ff6'~][[
~F~ $ ~ '~ WaivcrFce$
Date of Payment ~- 7- ~ Date of Pa)~cnt
R~ipt Num~r / ~~/~ Receipt Numar
Rev. 8/95 OSS: ~.xvk.d~
CT&E Environmental Services Inc.
Laboralory Division ~,'~'~'~'~'~"~'~"~"~'~"~'J"~'~'~"'~'~'~
Laboratory Analysis Report
ChemLab Ret. #:
Clienl Sample ID:
Matdx:
Liras Sample liD:
Client Name:
Ordered 6y:
Project Name:
Project #:
Saml~le Remarks:
96.0372-01
Lo110 BIk 2 Forest Ridge S/O
drfrskin~ waler
£nvironmenlal Management Inc.
Chris Simon
Collected: 2/2/98 1420
Received: 2P, J96 1835
Client P.O.:
WORK Order:
Report Pdnted;
Releas.d E~y.' ,.,~.,~, ~,~.
Project Manager:. /MTT
Meth0d-Analyte Units OCOuaL Result Ext. Cate Comp. Date Initials
E~d o! Sample
EPA 353 2 mg/~.. U 0.1 2/5196 2/5/98 BMW
200 W. Potter Drive..Anc.__horage....,AK 99518-1605 -- Tel: 190"/) 562-2343 Fax: (907) 561.5305
02.'08..'96 1,'?:05 CT*~E E~! A~,~HOF~AF_.~E -, ~4i59 HO.~'?.~
.~T~__..~' CT&E Environmentet Se,v;<:,, Inc.
ChemLab Ret'. #:
Cl~ent Sample ID:
Mat[ix;
Urns Sample ID:
Client Name:
Ordered By:
Project Name:
Project #:
Sample Remar~cs:
96.0372-02
Lot 10 Blk 2 Forest Ridge S/D
drinking water
Env;ronmental Management Inc.
Chris Simon
Collecled; 2,/2~6 1420
Received: ?./?./~ 1635
Client P.O.:
WORK Order.
Report P~mcd: M.~ ~,~'
Released By:
Project Manager:
Method-Analyte
Units QC Qual. Result Ext. Date Comp. Date
Total Coliform
SM92222B colonlesll00 mi
0 2/3/96 2~/~6
End of Sample
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. # 01'7-112-89
HAA# HA930728
1. GENERAL INFORMATION
Complete legaldescription Lot 10 Block 2 Forest Ridge Subdivision
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Colony Builders Dayph0ne 244-6233
2340 Loren Circle Anchorage, Alaska 99516
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Four (4)
Individual well xxxxxx
Community well
Public water
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:
XXXXXX
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 ~'egulations in effect on the date of this inspection.
Name of Firm S & S Engineering Phone 694-2979
Address 17034 Eagle River Loop Road, Suite 204, Eagle River, Alaska
99577
Engineer's signature
Date
DHHS SIGNATURE
xxxx Approved for four(4)
__ Disapproved.
__ Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
By:
Additional Comments This department has received written confirmation
from the engineer regarding the Conditional Approval of 12-1-93.
~-C~'--~ ......... U/~;)e ~ ............ ~- ......... been
compl'~ted by the e~inee, r.. The subject property meets with
/___f ~ ~'[ t/~?~J!'! 'Date June 15t 1994
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.
SOft. TEST
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
15,
1994
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
DEPARTMENT OF HEALTH AND HUMAN SERVICES
At, n: Jim Cro66
P.O. Box 196650
Anchorage, AK 995~9
RECEIVED
dUN 1 4 199
Munic~Pah~
Dept. Health iY filu~n_¢horage
~,-an Services
REFERENCE: Lot I0; Block 2; Forest Ridge Sabid~ui6ion
On 12/I/93 Voua o{{lce ,O,6aed a Cond. Z:~omzl HeaLth Au,:tJ'to.,M, tV Approva~
(H.A.A.) {o~ ,the re{eaence prope,~y. The condZ,~o~ o{ ,th,O, approuaZ
~equJxed depres~ion~ be ~if, led oven the ~ep,tJ.c ~nk and ~i~t ~az,t/.on
and {i.m~ B~adi~ o{ the ~ept,/,c ~y~tern a~.e~t.
Please be advised ,that ~ o{ Jane 13, 1994 {bla~ g~.ding Md been
complied aM ~e ~ Md be~ ~op ~o~ aM ~eeded. Pep~aio~ ~
A. SHAFER, P.E.
17034 NORTH EAGLE RIVER LOOP * SUITE 204 ',' EAGLE RIVER, ALASKA 99577
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
1. GENERAL INFORMATION
Complete legal description
Lo:t I0~ ~och. ~; Fo~.t. P. Zdge Su. bclZuZ~Zor~
Location (site address or directions)
e
Property owner
Mailing address
Lending agency
Mailing address
Agent
· Address
Day phone
Day phone
£44-6~$$
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
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
· Holding tank
Communiiy 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 inves.t~ation and inspection, the on-site water
supply and/or wastewater 'disposal system is in c~3mpliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm $ & ~ ?,~,~._-..~.c- ..-'~'-~ Phone
Ad r 17034 Eagle Rlver.l-~o. ~ Ro~O. 204
d ess . ., ~¢.~ ~?~-r~-
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 Certificate~ 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
· - arid their lending institu~t!ons in order to satisfy certain federal and state requirements. Ernployees 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.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescdption:~--~O,~3.,.~ ~f"/JE~'7 ~tb0~.'~T/"F' ParcelI.D. ('~1~ IIP,
A. Well Data
Well type ~{ u~'Ti~ If A, B. or C, attach ADEC letter. ADEC water system number
Log present {~/N) ~/~-~> Date completed ~'1~ I~ Driller
Total depth c~, Cased lo c~.~,,..~ ' Casing height
Sanitary seal ~/N) Y Wires propedy protected (~/N)
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG AT INSPECTION
~0 g.p.m. ~ g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic~olding tank on lot
Absorption field on lot
Public sewer main ~'//)-
Sewer sen/ice line
; On adjacent lots /(~0 '/
; On adjacent lots [Od '/,"
Public sewer manhole/cleanout
Petroleum tank ~/,1~ . - /~J/~
WATER SAMPLE RESULTS:
Coliform (-P _Nitrate
Date of sample: l(
(~/U~)~TEc'TEO. Other bacteria
Collected by:
B. SEPTI~TANK DATA ~
Date Installed G- ?.~ Tank size J.~ ~3AL ~.?.E.l~Compartments ~
Cleanouts ~) ~ Foundation cleanout ~) ~ Depression)
High water ala~ ~) ~ Ala~ tested ~ ~a
Date of pumping ~ -- ~ 7~ Pumper ~/~' ~
SEPARATION DISTANCES FROM SEPTmC~ TANK TO:
Well(s) on lot I~)G'/" On adjacent lots
To property line [O' [ Absorption field
Surface water/drainage (06 ~/C
~2-026 (3/93)' Fe~qt
(~o'/-' Foundation It
Water main/service line
CONTINUED ON BACK PAGE
C. UFT STATION
Date Installed
Size in gallons ~.~(3 ~ .~.'-(~ F:;, ~,
Vent ~/N) .Y 'Pump on' level at
~ ·' 'Pump off' Level at ..~ "' ~ '~ ~ E
Cycles tested "~/~ i , ~ ro ~ ~
High water alarm level ~..~'
Meets MOA electrical codes (Y/N) ~//
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot ~x~ (/- On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed ~ -,~-~
-' - Lengtl~ /.5"~ / Width
Total absorption area I .~"5
Date of adequacy test )~///~-
Water level in absorption field before test ~//~ ~ ~)~
Peroxide treatment (past 12 months) (Y/N) ~/~ -
Soil rating (GPD/Ft~) ~,c/~
.Gravel thickness
Cleanout present ~ ~x'~ · ~.
Resu~ (pasCall)
~ A~er test
If yes, g~e date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
.System type
.Total depth f~ '
Depression ever field (Y/N)
for ~ Bedrooms
Well on lot
To building foundation
On adjacent lots c~-,~
Surface water ((~) ~/- Driveway, parldng/vehicle storage area ~. 0
Curtain drain
Eo ENGINEER'S CERTIFICATION
I certify ~hat I have checked, vedfied, or conformed to all MOA and HAA guidelines in effec~ .~.,~.~! '~h~. inspection.
~' / /r~'~."7~--~-. , ....... ~..
Date ...........
HAA Fee S ~?
Date of Payment
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)' Back