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Home My WebLink AboutASPEN HIGHLANDS #2 BLK 2 LT 8 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 Name: D~O~O~. &~ ¢ ~4~l~Y~ Wastewater System: ~ew D Upgrade Address; I~ ~/~/ ~,, ~ ~5/U ABSORPTION FIELD Phone: ~ No. of Bedrooms: ~'~ ~~ 5 ~eepTrench ~ Shallow Trench ~Bed ~Mound ~Other LEGAL DESCRIPTION SoilRating: ~p GPD/Sq. Ft. Total Depth from ~i~rade: Lot:~ ~BI°ck: ~ ~/~ ~Subdiv~i°n: ~ ~ Depth to pipe boEom f~O~inal grade: Ft. Gravel depth bene~./pipe Ft. Township:~ ,Range:/ Fill added above~ri~na)grade: Gravel length: Number of lines: Diet. ce ~n IJn~: WELL: ~New ~ Upgrade Gravel width: ~ Ft, / I ~ Ft. ! Clarification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Drilled: S~tic Water Level: Installer: Date installed: Yield; I Pump Set at: I C.ing Height A.ve Ground: ¢ 6P. 3~ Ft. 3 Ft.TANK SEPARATION DISTANCES ~eptio u Holding ~ S.T.E.P. TO Septic Abso~tion Li~ Holding ~Prtvate Manufacturer: Oapaci~ in gallons: Sudace Water ~/~) ~ ~/~ LIFT STATION LineL°t ~ ~ / /~ / / ~ / Size in gallons: ~ Manufacture~ I Foundation /~. /~/ ~/~ "Pu m p on" level~~'i at: I High water alarm at: Cu.ainDrain ~/~ , , ~ ~ Pu~del ~Electri.llnsp~tionspedorm. by: Remarks: ~&~ CN~N~ ~ ~ BENCH MARK ] A~umed Elevation: Depadment of Heal~ and Human Seduces approva~ Reviewed and approved by: Date: 4 -/~-¢,~ 72-~13 (Rev. 9/91) MOA 25 Permit No..-- 5}.~ '~ d o 3.~j' Page 2 of 2 Municipolity of Anchorege DEPARTMENT OF. HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaske 99519-6650 · Telephone: 545-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: ASPEN HIGHLANDS .2 L8 B2 PlO No.: -- 10'x25' ANCHOR EASEMENT 1500 GAL SEPTIC TANK WELL SWING TIES A-C = 6B,3 B-C = 18,4 A-D = 70,7 B-D = 18,8 ELEVATIONS (NOT TO SCALE) RE'lIAR AT SOUTH LOT CORNER ASSUMED ELEV = 93,3e' ! 0-1' AODED RM. ORIGINAL GROUND 0 NIO0.O0 [] - TEST HOLE · - MONITOR ~dBE o - SEWER CLF-.~OUT + - WD..L ~ -- - EASEMENT ~- NEW EEACHRELD ~- E~ISTING ~HRELD SCALE 1"=5,0{ ./4/16/97 ,. /'; ~GINEt~'R'S SEAL ........... PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW960335 DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES OWNER NAME:DOOROS GEORGE P & MARILYN M OWNER ADDRESS:13000 MIDORI DR ANCHORAGE, AK 99516 DATE ISSUED:10/03/96 EXPIRATION DATE:10/03/97 PARCEL ID:01701337 LEGAL DESCRIPTION: ASPEN HIGHLANDS #2 BLK 2 LT 8 LOT SIZE: 42125 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: 5 THIS PERMIT IS FOR THE CONSTRUCTION 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 (iSAAC80) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 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: THIS PERMIT IS APPROVED FOR A DEEP TRENCH ABSORPTION SYSTEM HOWEVER, IF DURING CONSTRUCTION THE TRENCH WALLS CAVE IN, A SHALLOW WIDE DRAINFIELD MAY BE INSTALLED AS DESIGNED. ISSUED BY: /I- RECEIVED BY: ~ ~ P.O. Box 77,3294 Eagle River, .Alaska 99577 694-5195 :FAX 694-FAXS Dote: Total If you h.ave please call uestiOr us at 694-5195. iheet. I~' any pages Eagle River Engineering Services Louis Butera, P.E. P.O. Box 773294 (907) 694-5195 tel Eagle River, AK 99577-3294 (907) 694-3297 fax September 27, 1996 Jim Cross, P.E. Manager, On-Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Aspen Highlands #2 Lot 8, Block 2 Narrative & Permit Application Dear Mr. Cross: The proposed well and septic system will have very limited impact on adjacent properties for the following reasons: 1. The surrounding lots are large, allowing sufficient room for septic sites. 2. Immediate neighboring septic systems are all +30' distance. 3. Reserve space is adequate, due to absorption capacity. 4. Drainage will not be affected and is not a major consideration in our design. We are submitting calculations, site plans and specifications for both a deep trench and a shallow trench. An attempt will be made to install the system as a deep trench, however, if the trench walls will not hold, we wish to have the option of converting to a shallow trench system without having to inform the Municipality for approval at the last minute. The material is a sand with 75% passing the #10 sieve, so the application rate and trench design are based on our grading the soil as a sand (SP) material. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION SEP 2 7 1996 RECEIVED \1996\96-080A-NAR.DOC · :DF-EP TRENCH :DESIGN ......... /~~ ~_~"~"o ~ / / .il DEVELrlpP. ENT J ¥ F~C~,.~~/ / $ [] TEST HOLE w~-L WELL -~ - WELL ~ WELL EASEMENT NO SURFACE WATER i PROPOSED LEACHFIELD NO KNOWN CURTAIN DRAINS I1~- EXISTING LEACHFIELD W E L L,/S E P T I C S I T F P LA N LEGAL: ASPEN HIGHLANDS #2 LOT 8~ BLK 2 OWNER: N/A CONTRACTOR: HAGMEIER ~'°' ~°= ~=~ "~;t~"-- .... '" <'' EAGLE RIF£~, A~. 99577 (907) 694-5195 PAX: (907) 694-32,97 SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM LEGAL: Aspen Highlands//2 Lot 8, Block 2 09/27196 Ac GENERAL I. The well and septic plan are for a single family residence only. 2. The drawing and or site plan shall be a part of this specification. 3. All materials and workmanship shall meet the Anchorage Department of Health requirements. 4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. 5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage requirements. 6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi-family wells. 7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. 8. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. 9. Any remaining open test hole excavations shall be filled. Bo SEPTIC TANK 1. Septic tank shall be of MOA approved design, 1,500 gallons minimum. Co TRENCH 1. The trench is to follow the natural land contour to maintain uniform total depth of the trench bottom. 2. The bottom ofthe trench shall be level, plus or minus 1.5". 3. The total depth of the trench excavation is not to exceed 14' at any point. 4. The effluent line within the trench shall be laid level within 0.03'. 5. The trench gravel is to be covered with typar fabric material. 6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed over the leachfield. 7. The area over the trench is to be finish graded to prevent ponding of surface water runoff. 8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS: TOTAL DEPTH = 14' GRAVEL DEPTH = I0' under pipe, 2" over pipe TRENCH LENGTH = 38' TRENCH WIDTH = 3' SOIL RATING - 1.0 GPD/ft2 BEDROOM CAPACITY = 5 SEPTIC TANK = 1,500 Twenty-four (24) hours notice required for all inspections. fo,- /o' m.,I : I,Z.<' \1996\96-080a-spc.doc aloe' SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM LEGAL: Aspen Highlands//2 Lot 8, Block 2 09/27/96 mo GENERAL 1. The well and septic plan are for a single family residence only. 2. The drawing and or site plan shall be a part of this specification. 3. All materials and workmanship shall meet the Anchorage Department of Health requirements. 4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. 5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage requirements. 6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi-family wells. 7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. 8. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. 9. Any remaining open test hole excavations shall be filled. SEPTIC TANK 1. Septic tank shall be of MOA approved design, 1,500 gallons minimum. TRENCH 1. The trench is to follow the natural land contour to maintain uniform total depth of the trench bottom. 2. The bottom of the trench shall be level, plus or minus 1.5". 3. The total depth of the trench excavation is not to exceed 14' at any point. 4. The effluent line within the trench shall be laid level within 0.03' 5. The trench gravel is to be covered with typar fabric material. 6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed over the leachfield. 7. The area over the trench is to be finish graded to prevent ponding of surface water runoff. 8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS: TOTAL DEPTH = 14' TRENCH LENGTH = 38' SOIL RATING = 1.0 GPD/ft2 SEPTIC TANK = 1,500 GRAVEL DEPTH = 10' TRENCH WIDTH = 3' BEDROOM CAPACITY = under pipe, 2" over pipe 5 Twenty-four (24) hours notice required for all inspections. &,-- ,.;,:,,, 7,,."./ .?.ZV. ::<' X 1996X96-080a-spc.doc ,¢0r EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294 Eagle River, Alaska 99577 (907) 694-5195 ERES Project No.: 96-080 Calculated By: LB Date: 9/24/96 Legal: ASPEN HTS #2 LOT 8 BLK 2 Single Family 5 Bedroom Dwelling TEST HOLE Deep Trench Subsurface Wastewater Disposal Field Water use at 150 gallons per bedroom = 750 gallons Percolation rate = 0.4 minutes per inch Wastewater application rate = 1 gallons per day per square foot Required absorption area = 750 square feet Trench width (W) = 3 feet Gravel depth (D) = 10 feet Required length = Required absorption area / 2 / D Required length = 750 / 2 Required length = 38 feet Total Excavation Depth = 14.0 feet / 10 SINGLE FAMILY ON-SITE WORKSHEET ERRS PROJECT NUMBER: 96-060 CALCULATED BY: LEGAL DESCRIPTION: ASPEN HTS #2 LOT 8 BLK 2 NUMBER OF BEDROOMS: 5 WATER USE PER BEDROOM: 150 PERCOLATION RATE: 0.4 DEPTH TO GROUNDWATER: 20 DEPTH TO IMPERMEABLE LAYER: 20 ANTICIPATED DEPTH OF COVER: 4 MOUND OR BED SYSTEM LB GALLONS MINUTES PER INCH FEET FEET USABLE SOIL STRATA FEET TOTAL USABLE DEPTH: USABLE SOIL STRATA DEPTH: 0.7 GAL/SQ.FT 1071 SQ.FT 89 FEET 71 FEET 14 10 WASTEWATER APPLICATION RATE: ABSORPTION AREA REQUIREMENT: MINIMUM BED LENGTH 12 FEET WIDE BED 15 FEET WIDE BED TRENCH SYSTEM WASTEWATER APPLICATION RATE: 1 GAL/SQ.FT ABSORPTION AREA REQUIREMENT: 750 SQ.FT SHALLOW TRENCH OPTIONS DEEP TRENCH OPTIONS 5 FEET WIDE TRENCH 3 FEET WIDE TRENCH EFFECTIVE REQUIRED TRENCH EFFECTIVE REQUIRED TRENCH DEPTH (FT) ENGTH (FT) DEPTH (FT) ENGTH (FT) 1 131 4 94 2 105 4.5 83 2.5 95 5 75 3 88 5.5 68 3.5 81 6 63 4 75 7 54 8 47 9 42 DESIGN SPECIFICS FIELD SYSTEM: GRAVEL DEPTH: TRENCH OR BED WIDTH: LENGTH: TOTAL EXCAVATION DEPTH: D 10 3 38 14.0 (B=BED, S=SHALLOWTRENCH & D=DEEP TRENCH) FEET FEET FEET FEET 5' V]DE ~3PT~F1NAL NEIGHBOR SEPTIC 10'x25' ANCHOR EASEMENT NB DEVELOPMENT DESIGN APPROX PROP HSE SEPTIC TANK PROP WELL WELL WELL NO SURFACE WATER NO KNOWN CURTAIN DRAINS WELL/SEPTIC LEGAL: ASPEN HIGHLANDS OWNER' N/A CONTRACTOR: HAGMEIER WELL SITE PLAN #2 LOT 8, BLK 2 EAGLE RIVER ENGINEERING A P.O. Box 773294 EACLE RIVER, AZ<. 99577 (907) 694-5195 FAX: (907) [] - TEST HOLE · - MONITOR TUBE o - SEWER CLEANOUT ~ - WELL EASEMENT PROPOSED LEACHFIELD ~- EXISTING LEACHFIELD SER VICES 694-3297 WELL SPECIFICATIONS FOR ON-SITE SYSTEM 5' WIDE OPTION LEGAL: Aspen Highlands #2 Lot 8, Block 2 09/27/96 Ae 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. GENERAL The septic and well plan is for a single family residence only. The drawing and/or site plan shall be a part of this specification. All materials and workmanship shall meet the Anchorage Department of Health (MOA- DHHS requirements. All soil tests are advisory to the design and are to verified or modified in the field by the Engineer. All excavations and depths are advisory and are to be verified in the field by the Contractor to meet MOA-DHHS requirements. It is the responsibility of the Owner to obtain all necessary permits or easements and to locate any adjacent multi-family wells. It is the responsibility of the Contractor to secure all utility locates prior to construction. The excavation is to be exactly in the area shown on the site plan, any deviation requires Engineer approval. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. Any remaining open test hole excavations shall be filled. Bo SEPTIC TANK The septic tank shall be of MOA approved design, 1,500 gallons minimum. Ce 3. 4. 5. 6. o LEACHFIELD The leachfield is to follow the natural contour to maintain uniform total depth of the trench bottom. The bottom of the leachfield shall be level, plus or minus 1.5". The total depth of the leachfield excavation is not to exceed 7' at any point. The effluent line in the trench shall be laid level within 0.03'. The leach gravel is to be covered with typar fabric material. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed over the leachfield. The area over the trench is to be finish graded to prevent ponding of surface water runoff. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200' to any community well. RECOMMENDED LEACHFIELD DIMENSIONS: TOTAL DEPTH = 7' GRAVEL DEPTH = 4' under pipe, 2" over pipe GRAVEL LENGTH -- 75' GRAVEL WIDTH = 5' SOIL RATING = 1.0 gpd/ft2 BEDROOM CAPACITY = 5 SEPTIC TANK SIZE = 1,500 gallons Twenty-four (24) hours notice required for all inspections \1996\96-080b-spc.doc 09/25/96 EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294 Eagle River, Alaska 99577 (907) 694-5195 ERES Project No.: 96-080 Calculated By: LB Date: 9/24/96 Legal: ASPEN HTS #2 LOT 8 BLK 2 Single Family 5 Bedroom Dwelling TEST HOLE Shallow Trench Subsurface Wastewater Disposal Field Water use at 150 gallons per bedroom = 750 gallons Percolation rate = 0.4 minutes per inch Wastewater application rate = 1 gallons per day per square foot Required absorption area = 750 square feet Trench width (W) = 5 feet Gravel depth (D) = 4 feet Required length = Shallow trench factor * Required absorption area / W Shallow trench factor = (W + 2) / (W + 1 +2 D) Shallow trench factor = 0.50 Total Excavation Depth = 7.0 feet Required length = 75 feet 133_-I O'Z :H.Ld30 NOIZYA¥OX3 9¥.L01 1333 SZ. :HJ. ON3I /33J 9 :H/C]IN~ O:lB EIO HON:I~J. J. aaJ ~ :HJ. clqC] 9aA¥~J~ (HONa~IJ. d330=O ~ HONa~IJ./WO99¥HS=S '(]aB=B) S :IAla.LSAS C]931J SOIJIO3dS NglS3Q B9 :~3AOO 30 HJ. d30 (33J. VdlOlJ. N¥ :W3AV'I 39BV31/;l~3d~l O/H/d30 :~J3J.¥~C]NrlO~I90J. HJ. d3C] :3/¥~J NOI.L¥'IOO~J3d :I,NOOWO3B ~J3d 3Sfl ~J3£VAA :S~00WC]38 JO W381~Ii3N ~ >llB 9 .LO1 ~# S.LH N3dSV :NOI.LdlWOS3(3 9VE)39 :,kB 03J. VlflOlVO 0g0-96 :~3BI/~IgN J. O3fO~ld S3~3 J.:I:IHS~I~JON~ :IllS-NO AqlI~IV-I :I19NIS Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS DATE PERFORMED: Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? S IF YES, AT V1/HAT DEPTH? p E Depth to Water After Monitoring? d Dale: Gross Net Depth to Net Reading Date Time Time Water Drop .~,,~ ,~ -_~ _7 ~',~,,,~ ~.;, ,, ....... ; ,'~ I ?-z.~. /y..~,o ~ '~r~ ~- ~" ~ / /~,'~2 Z '~" ~ ' ~" ~I (~,'~y ~, ~! ', ~" ~" PERCOLATION RATE~' / (minutes/inch) PERC HOLE DIAMETER ~" TEST RUN BETWEEN 7 FT AND ~;~ FT PERFORMED BY: /~,,.TN I /~"~ ~ CERTIFY THAT THtS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) 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~UTHORITY AISPROVAL FOR A SINGLE FAMILY [}WELLING Parcel I.D, # 1. GENERALINFORMATION Location (site address or directions) P~operty owner Mai!lng address .'Lending agency Mailing address., Agent ,~ lA Address Day phone 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 ~" Gommunity on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and statUs of system. ' 72-025 (Rev. 1t91) Front MOA#21 STATEMENT OF INSPECTION BY ENGINEER As certified bY my'seal affixed hereto and as of the validatiOn date shown below, I verify that my investigation .of this Health Authority Approval application shows that the on-site water supply and/or waStewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ' Address Engineer's signature ~,~~----~'~--- Date DHHS ? SIGNATURE Approved for .,~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Mun]ci~)_~ality of AnC'~h"." orage Department of Health and Human Services (DHHS) issues Health Authority ~Approval C~ificates',"$as~d only upon the 'representations given in paragraph 5 above by an independent professional engine~r i'egistered in the State of Alaska. The DHHS does th~s as a courtesy to purchasers of homes ,-,, ~.~.... .... . ~,;:~,'-'...-. and their, lending mst~tubons 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-O25(Rev. 1/91) Back MOA#21 Municipality of Anchorage APR 1 6 1997 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division R~.4~ly E D 825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) Legal Description: A. WELL DATA Health Authority Approval Checklist /il/eS,,4/.~..v,~l,r :#~-,1.~ Z~ ~,,~Parcel I.D.: Well type Log present (Y/N) .,~ · Total depth ~z~,..~- Sanitary seal (Y/N) ,~re/~,~-~ If A, B, or C, attach ADEC letter. ADEC water system number Date completed / ~ ..1_ ~ - P ~) Cased to /~ ? / Casing height (above ground) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test /- ;;;2 f - ~ ~ ~/,4 ~,~ ~,~ ~,.~ ~// Static water level /5-?" Well production ~ g.p.m, g.p.m. WATER SAMPLE RESULTS: Coliform ~ Date of sample: /W-// ?' ? Nitrate ~z, &- ~ ,.,~ ~/~_ Other bacteria Collected by: ~'/~ E'J' B. SEPTIC/HOLDING TANK DATA Date installed //- :~;z-'/4, Tank size /~-~ j Number of Compartments -.~ Cleanouts (Y/N) ,)/ Foundation cleanout (Y/N) ,Y Depression (Y/N) ~-' High water alarm (Y/N) ~/4' Date of Pumping /v'~,,,~ 7~~,~ Pumper ABSORPTION FIELD DATA Date installed / ~- 3.:z - Length ' ~"/'Y' Width Effective absorptiOn area 7? Date of adequacy test Soil rating (~._g_.p.d./ff~r fF/bdrm) ,/,4) System type 7-~-~,vc A Gravel thickness below pipe ?' Total depth Monitoring Tube present (Y/N) ,~. Depression over field (Y/N) __ Results (Pass/Fail) ,,o,=,, ~- For bedrooms Fluid depth in absorption field before test (in.); ~ Immediately after ~ gal. water added (in.): Fluid depth --'- (ins) Minutes later:. Peroxide treatment (past 12 months) (Y/N) Absorption rate = '" 75-~ .g.p.d. If yes, give date 72-026 (Rev. 3/96)* 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 -/-/~ Absorption field on lot -/--z, Public sewer main Sewer/septic service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation lb ~ Water main/service line On adjacent lots '/'~ ~" On adjacent lots '/-/~a ~ Public sewer manhole/cleanout Property line ~ / ¢/~ t Surface water/drainage "Pump off" level at* Absorption field SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /~ Building foundation /? / Wells on adjacent lots Surface water '/'/~ / Curtain drain ~//,~ ENGINEER'S CERTIFICATION Water main/service line are Driveway, parking/vehicle storage area Wells on adjacent lots ~/oo / I certify that I have determined thru field inspections and review in conformance with MOA HAA guidelines in effect on this date. Signature ~ Engineer's Name ,/--~- ~ ~,~. Date .' '~'~/--~.' ~ ~' ? HAA Fee $ ~~r' ' ~ ' Date of Payment '~,~' /~ 7 Receipt Number ~':~_~,~' /FF--) ~ ,~ 72-026 (Rev. 3/96)* · Waiver Fee $ Date of Payment Receipt Number