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HomeMy WebLinkAboutTURPIN #1 BLK 5 LT 3ATurpin I Block 5 Lot 3A #006�096�21 /L v r 3 A ) /,714-' BIG -/ DIPPER �U A[ ITWnMITV APPPOVAI /� /-/ /V 4� 61 DRILLING W�* 7529 E. 6th Avenue e July 21, 1984 Celia %Century 21 --Sleeper 8050 old Seward Hwy. Anchorage, Alaska 99502 Dear Celia, 0 Anchorage, Alaska 99504 0 (907) 333-6435 The following information is your copy located at Lot 3, W1/2, & Lot 2, Block of Anch. This should be retained improvements to your peropety. IM ct: pa :5 K To 6 Feet Silty Gravel > rn z 0:� 13 Sand < Co Gravel r7l 20 Silty sand, gravel 23 Gravel 28 Silty 0 6 10 13 14 20 23 28 30 34 35 47 50 53 61 73 77 83 88 90 91 115 132 148 156 Feet drilled of the well log for the property 5, Ist Addn to �urpin Sub, Muni as your permanent record of WELL LOG To 6 Feet Silty Gravel 10 Gravel 13 Sand 14 Gravel 20 Silty sand, gravel 23 Gravel 28 Silty sand, gravel 30 Sandy silt 34 Silty sand, gravel 35 Silt 47 Silty sand, gravel 50 Gravel 53 Sandy silt, gravel 61 Sand, gravel 73 Silty sand, gravel 77 Gravel 83 Silty gravel 88 Sandy silt 90 Sand 91 Silty sand, gravel 115 Sandy silt 132 Sandy water 148 156. Silt, Sand, gravel gravel(nTER) 15 LONS RYJL-MJXUNX� Sfatic -water level 89 feet STATEMENT and cased @ $20.00 per foot $3,120.00 Thank you for specifying BIG DIPPER DRILLING for your water well needs. This will entitle you to one chance in the drawing for two round trip airline tickets to Iiawaii. The drawing will be in December. Sincerely, ei 'Ie 7�� C. R. KRON Owner Licensed* Bonded Insured Anchorage POU ~.,~1 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit 9: Handwritten Permit January 31, 1985 TO: Permit Applicant SUBJECT: Lot 3, W½ Lot 2 Block 5 Turpin Subdivision #1 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984o Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as-built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincere ly, Keith E. Bandt, SupeYvisor Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 MUNICIPALITY OF ANCHORAGE Department,/~ Health and Environmenta]~rotection 825 Street, Anchorage, AK. '_2501 264'4720 * * * HANDWRITTEN PERMIT * * * Permit ~ WELL ~~- .-~£~ PERMIT Location: Z~,~ ~/~ ~3 ~/~ Phone Number: Lega~ Description: . ~ Lot Size: Type of Soil Absorpti'on System Is: Trench: dfD Drainfield: ~ _ Seepage Bed: ~ Holding Tank: ~aximum Number of Bedrooms: ~ Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is: ~ ~ WIDTH r--........ DEPTH ~ LENGTH GRAVEL DEPTH '"' ' The length dimension is the length(in feet) of the trench or drainfieldo The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = ~,,/,/2~ GALLONS Permit applicant has the responsibility to inform th~'s department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection.and approval by this department . will be subject to prosecution. ~inimum distance between a well and any on-site sewage disposal system is 100 feet ~or a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 * * I certify that: (!) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. . (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more th~t/~bedrooms. Signe~: . Issued by Date:. SWP/024(1/81) Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval Parcel I. D%�'621'k4' Expiration Date: 1. GENERAL INFORMATION Completedegal description Turpin #1 Block 5 Lot 3A Ldqation (site addres o(3331 E 6th Ave Current Rr6perty owner(§i,,. clayton afterburn 'PO Box 1036 Willow, AK ..M.alling address "iReal Estate Agent 2. TYPt,OF DWELLING: Fx Single Family (w/wo ADU) F] Duplex [I Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 04 Day phone 360-1149 Day 0 9 2 0 1'^ IV 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual El Individual Water Storage Holding Tank 1-1 Community Class Well Community F-1 Public Water System Public Sewer nX COSA Fee S 5 -;Lt, - Date of Payment LL, Receipt Number -7 vp COSA #. lqoq 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 in�pectign, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and.State codes. ordinances, and regulations in effect at the time of installation. Name of Firm C&M Engineering Address 30840 Prudhoe Bay ave Engineer's Printed Name Charles Balzarini 6. DSD SIGNATURE _7K_ System #1 Approved for bedrooms System #2 Approved for bedrooms 114"Proved Phone 854-5558 Date 9/9_QQ16 �CQF A4- III## io 40 0 �ie a ffaktrei�ni: �� 10KE, 0 CE - IARM 0 Wo - WOW .4 Ni�'" I . .* "O'w Conditional approval for _ bedrooms, with the following Original Certificate Date:9 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the ropresontations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Septic System Advisory Well Flow Advisory COSA bl.� hoeLf � C Nitrate Advisory'' Arsenic Advisory Other Jlf more than I septic system is on the lot: COSA Checklist # Structure served by this system Certificate of On -Site Systems Approval Checklist L,(q T 3/1 0V& -016q -Li Legal Description: )-c-/iZZTA/ t/ ( 3 (; - - Parcel ID: AOEP� - A. WELL DATA Well type If A, B, or C provide PWSID Well Log(qN) A'-5 Date completed 71-' V1 4W Sanitary seal ON) Wii res.properly protected&) Yes Total dipp!�L�-ft. Cased to L% -ft- Casin g height (above ground) in. FROM WELL LOG Date of test. Static wat e r level. Well production 9 -p -m - WATER SAMPLE RESULTS: AT INSPECTION 9 -P.M. Coliform AIC�- colonies/100 mL Nitrate mg/L Arsenic ug/L. Date of sample: Collected by: 6iM .- B. SEPTICIHOLDING TANk DATA W14) Pr,/)3 1,7-c- 3 EC�R X - Tank Type/Material Tank size gal.- Number of Compartments Date installed Cleanouts (Y/N) Foundation cleanout (YIN) — Depression over tank (Y/N) High water alarm (Y/N) Date.of pumping', Pumper A C.' ABSORP-f[dW FIELD -DATA Date installed Length ft. Soil rating (g. p.d./fe or ft2/bdrrn) Width System type ft. Gravel below pipe ft. Total depth. — ft. Eff. absorption area fe Monitoring tube — Depression over field Date of adOqacy test Results (Pass/Fail)­ For bedrooms Fluid depth�in�:db;s6.rption field before test— in., Wateraddled gal. New. depth_ in. Elapsed Tin*? - min., Final fluid depth — in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date 1), LIFT STATION /t-/)4 (-'TC Date installed "Pump on" level at Datum Size in gallons in. "Pump ofr'level at E. SEPARATION DISTANCES WELL ON LOT TO: Cycles tested — Manhole/Access (Y/N) in. High water alarm level at — in. Meets alarm & circuit requirements? Septic tank/lift station on lot A& On adjacent lots Absorption field on lot All A On adjacent lots f Public sewer main +7Y Public sewer manhole/cleanout (00 Sewer /septic service line Holding tank z Animal containment areas go Manure/animal e xqrete storage areas SEPTICIHOLDING TANK ON LOT TO: A1,14 - Building foundation Water main Property line Absorption Water service line Surface water Wells on ?djacent,lots ABSORPTION FIELD ON LOT TO:' Property line Building foundation,_ Water main Water Service line Curtain drain Surface water Wells on adjacent lots Driveway, parking/vehicle storage F. COMMENTS .tv LA/Et-C -t 75 t40501-12 ZA-' A (lAvL-r 1IZ,q FIC7 S 94 DR*0 Lro, VAcl I -r D t -,A5 - VE A 2 r- re g) r* er72%P-1 G. ENGINEER!S CERTIFICATION i certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effi)ct on this date. Engineer's Printed Name CH4(UZ5 OAL2-11'z2�,OT- Date 1.6 COSA yellow sheet-2-6-15.doc Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Arsenic Adviso Certificate of On -Site Systems Approval 4 osc161409 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 5, Lot 3A of Turpin #1 Subdivision. This inspection revealed an arsenic concentration of 11. 1 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (NICL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health inforrnation and can therefore be used to gauge the relative quality of water from private wells. information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.or&onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. 8443J Tract D N89055'06"E 102.36 15' Utility, T & E, Gas & San. Sewer Easement - — — — — — — — -- — — — — — hed she;7�_ r — — — — — — — -- C) to 10.1 � I deck FUL 38.0 1 1/2 Story UU 4 Frame House 4 04 N E 1/2 Lot 4 ..;;T Lot 2 10�0 38.0 00 Lo Grave zo C) driveway 0 0 oWell Lot 3A C 4. _J Plastic fence/ N89*53'26"W 102.26 C� E. 6th Avenue ..... A4 49th 00 ....... 00 00 00 00 00 00 %Fred Walatka.*ff 00 3255 S 'Mo Frsslota"- SCALE: V= 30' EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT ARE NOT SHOWN HEREON. FB 16-8, pg 23 BE AS -BUILT NO CORNERS SET THIS DATE I hereby certify that I have performed a of the followino described DrODertv: L( Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alaska this - 25th day of August .2016 FRED WALATKA & ASSOCIATES (907-248-1666) Engineers and Surveyors Municipality of An��g� Development Services Department Building Safety Division all . - 0 On -Site Water and Wastewater Program 4700 South Bragaw St. 5 A 9TT P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ek.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL " i FOR A SINGLE'FAMILY DWELLING Parcel I.D.- 00 HAA # A 0100 (o :7 –of Expiration Date: 1. GENERAL INFORMATION,, Complete legal descdp�jon B —1 0 Eat N # Location (site address or directions) A ve Current Property owner(s) Celcej 11 e ir- Day phone Mailing address I;:: L, it, AA4_�- Lending agency r�s-L A kyiericoL4 Day phone Mailing address Real Estate Agent tj r 0. It-- 2 Lk V, Day phone ;L5 7 – o 14 Mailing Address e le '911,00 '-do vo Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site El Individual Water Storage El Individual Holding tank El Community Class Well El Community On-site El Public Water System n Public Sewer 19 The Municipality of Anchorage Development Services Department (DSD) 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 Naska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. 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 may be reissued for a period of up to one year with valid water samples.) 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 respons'ble 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 of the validation date shown below, I verify that my Investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system ls(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 frorn 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 4D b 11),e,;,t P F_ , t I Address zlos Awe-& A-14 Engineer's Printed Name lks V� �\JY OF ON-SITE WATERAND WASTEWATER 5. DSD SIGNATURE PROGRAM Approved for bedrooms. '�,,'�o Phone �7q-Bqlb, qJ50 / Date EN'GINEERS n:z Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other Original Certificate Date: By: (Pw. 12 0) Municipality of Anchorage Development Services Department Building Safety Division On-Sfte Water & Wastewater Program 47W South Bragaw St. P.O. Box 196650 Anchorage, AK 9951M650 www.dznchorage.ek.us (907) 343-79N . HEALTH AUTHORITY APPROVAL CHECKLIST LegaiDescription: 1-6-1 3A 15V.15 'T%)Q1PII�A0j Parcel ID: 00 6 - 6%* A. WELL DATA: well type R— if A, B, or C provide PWSID # Well Log (Y/N) Date completed Sanitary seat (Y/N) Wires property protected (YIN) Total depth iE&—ft- Cased to L.IELIL Casing height (above ground) in. FROM WELL LOG Dat a of test 7/v A- q - Static water level 91? — ft. Well production 15' — g.p.m. WATER SAMPLE RESULTS: Coldorm —0— colonies/1 00 rrJ. Nitrate mgA. Dateofsample: 4115-14C�11 Collected by: B. SEPTICIHOLDING TANK DATA Tank Type/Material _ Tank size _ gal . Number Of CompaV/ents Foundation cleanout (YIN) _ Depress' er tank (Y/N) _ AT INSPECTION sq g -p -m - Date of pumping C. ABSORPTION FIELD DATA Date Installed I Other bacteria -nhj colonies/1 00 mi. Date Installed Cleanouts (YIN) High water alarm (Y/N) Soil rating (g.p.dJft2,4r ft2A)drm) _ System type Length ft. Wfidth ft. Gravel below pipe ft. V' Total depth ft. Eff. abso;rpbon 2 ft' Monitoring tube Depression over field Date of adequacy test Results (PassJFail) 7 Wate For bedrooms Fluid depth in absorption field befo test _ in. Water added_ gal. New depth— In. Elapsed Time: _ min. Final fluid depth _ In. Absorption rate >=_g.p.d. Any rejuvenation treatment (Oast 12 mo.) (Y/N & type) — If yes, give date 'I D. LIFT STATION Date installed Size in gallons — i Manhole/Access (Y/N) "Pump on' level at _ in. 'Pump off" level at High water alarm level at — In. .1 8�: Datum Cycles tested Meets alarm & ckcuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAtft station on lot Absorption field on lot I`41A Public sewer main SO Sewer /septic service line —x>�,>� N On adjacent lots - I / 'oo on adjacent lots — "A Public sewer manholeldeanout JC0+ Holding tank NlAr SEPARATION DISTANCES FROM SEPTICIHOLDING K ON LOT TO: I Building foundation Property line Absorption field Water main WatWu se line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSOF Property line Building Water Service line Surface Curtain drain FIELD ON LOT TO: adjacent lots Water main Drivoway, parking/vehicle sWrage F. COMMENTS G. ENGINEEITS CERTIFICATION so C;1 ge % I certify that I have determined through field kMP8e0n3 and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect an this date 12^ Engineer's Printed Name ig- Date al, EO HAA Fee $ C) Waiver Fee $ Date of Payment Date of Payment Receipt Number. Receipt Number (Rev. 12100) 011-22-01 15:34 FROM -CTE ENVIRONLENTAL A ME Environmental services Inc. 56153GI T-068 P.02/03 F-533 Waters laspartment Nitritc-N 0.500 u 0.5()o trigil, EPA 300.0 Microbiology Laboratory Cclifo", 0 ccllj(�)rnl. SM1892223 10 max 02, 1 SAI I SCL 02,151ul SKV, 1010759001 Client PO;; Pre -Paid Colisf.NO3 CT&F. Ref.0 'robben Spiukland P.E. printed Daleffline 0212212001 9:10 client Name Collected Datel'I'line 02/1512001 13;15 Project Narnef# Turpin 41 Received VatetTime 0115/2001 16:30 client Sample ID Lot 3 A Block 5 Technical Director Stephen C. Ede Matrix Ordered By Drinking Water 01 Released By PWSID Sam,& Remarks; Resells PQI� ulits Method lainits Date Date Waters laspartment Nitritc-N 0.500 u 0.5()o trigil, EPA 300.0 Microbiology Laboratory Cclifo", 0 ccllj(�)rnl. SM1892223 10 max 02, 1 SAI I SCL 02,151ul SKV, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 1. GENERAL INFORMATION 2. ApplicationDate Aarch 12,1986 (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 3A, Block 5, Turpin Subdivision, First Addition Location (address or directions) 1 6331 East 6th Avenue, Anchorage, Alaska (b) Applicant NameCal!.4_j__St4) �,,. Telephone: Home337--7453 Business Applicant Address (�'Jjj T��.qf- 6tli A17pnuo. Anch=arre, Ak q_95 0 A (c) Applicant is (check one): Lending Institution El Owner/builder Buyer El ; Other 11 (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address Telephone Mail the HAA to the following address: 6331 East 6th Avenue, Ancho Telephone e. Ak 99504 TYPE OF RESIDENCE Single-FamilyEJ Multi-FamilyE] Other Number of Bedrooms I 3. WATER SUPPLY individual Well 12 Community 11 Public El Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite 11 Public 0 Community 11 Holding Tank El Note: if communitywell s . ystem, musthavewritten confirmation from the State Departmentof Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Barnard Engineering Telephone 274-5235 Address 203 West 15th.Ave. , Anchorage, Ak 99501 Date March 12, 1986 6. DHEP APPROVAL Approved for bedrooms by Approved A I Terms of Conditional Approval Q 1 14 N10el-01 CAUTION Engineer's . 'Vv U R. Bmnard 754-E The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 6 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 DHEP 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 79-W� 111 IR41 MUNiciPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA� HEALTH AUTHORITY APPROVAL (HAA) MAR 14 CHECKLIST - FEBRUARY 1984 264-4720 RECEIYED, Legal Description: n Subdi,Tisic4n, F11-st Addif:inn A. WELL DATA Well Classification Ind i vi dual If A, B, C, D.E.C. Approved (Y/N) — Well Log Present (Y/N) YeS Date Completed Julv 21 F 19 8 6 Yield Total Depth 1-56' Cased to 15 6 Depth of Grouting nnnc-- Static Water Level 89' — Pump Set At 140' Casing Height Above Ground 31 — Sanitary Seal on Casing (Y/N) Yes Electrical Wiring in Conduit (Y/N) Yes - Depression Around Wellhead (Y/N) No Separation Distances from Well: To Septic/Holding Tank on Lot NA On Adjoining Lots To Nearest Edge of Absorption Field on Lot NA , On Adjoining Lots Nj To Nearest Public Sewer Line 80' — To Nearest Public Sewer Cleanout/Man hole 150' To Nearest Sewer Service Line on Lot 60'+ e� Water Sample Collected fA� �wner j Date Ael-Ae, z!r 91 /a lvl� Water Sample Test Results 5�4 7_-J A -,C. T_,9 A!� Comments B. SEPTIC/HOLDING TANK DATA NOT APPLICABLE Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Size — Air -tight Caps (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) — Separation Distances from Septic/Holding Tank: To Water -Supply Well To Property Line To Water Main/Service Line Course Comments No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field — To Stream, Pond, Lake, or Major Drainage x fl-� L Page 1 of 2 L MIT C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field NOT APPLICABLE Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course - To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed - NOT APPLICABLE Size in Gallons — "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments - Type of System Design Length of Field Depth of Field Gravel Bed Thickness — Standpipes Present (Y/N) — Date of Last Adequacy Test To Property Line To Existing or Abandoned System on On Adjoining Lots — — To Cutbank (if present) — Dimensions — Manhole/Access (Y/N) — "Pump Off" Level at — Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, ified or con rmed to all MOA and HAA guidelines in effect on the date of this inspection. D Sigi . l2c= ate M_arjah_J_2_,__19_3_6_ CompanyBarnard EnqJnP(-rin(YOANo. Not: Appl J nahl P. Receipt No. 7 7 7 % Date of Payment C)F Amount: $ Engineer's Seal Page 2 of 2 72-026 (11/84) F011 R. Barnord