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SKYLINE VIEW #1 BLK 2 LT 2A
Skyline View #1 Block 2 Lot 2A #051-191-56 Municipality of Anchorage "• Development Services Department Building Safety Division ,..... ori -Site Water and Wastewater Prerram.4700 S. Braganr SL P.O. Box 196650 Anchorage. AK 99519-6650 Pagef 0f� wvnv.ci.anchorage.akus (907) 34}7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: 5W 060 PID Number. 51" Iq I— 5 Name.6,41 PO L +k -O Wastewater System: tKNew ❑ Upgrade Aeana: 911 f t �i k�✓« 99577 ABSORPTION FIELD (�G��c% PI•ara-. /�` � / p^�' Numsad9am .3 o rJ ( 13 Deep T r ht(Shid. 7,..h 05M 0M.4 OcIMr WRablq I DP Total repo ham WVal pada: LEGAL DESCRIPTION • ,Fr F.. Z?Ae:ak tot: 1ld LE4 0,90 n pp baba, hom WV" 73h' GWM depd, bfnsad, pope: Ft Tcw,uaip: Ra^M: see FA ah'ed abew anprW 78da: .1— 1 G.avai LwVA ['•�/ F1. / FI. Well: New ❑ Upgrade GrwM w.dc Marbfrdenee ( Dotanobet~1hee: Ft. Ft. e:a it:A o (P ate. A• e. c): Total D a CaeM I a � Total abaerptw, area: � � Pe»� . 1303 lO C�trI/•I'VT' 01'/ 1;4C T��O` S .2S Fl hL. AJ C!IZ 6i•�i Oa1a Fs:aeed: 5-..I / _CR Y:eld: ump5r / GPM/roWr] FL FWA »FL TANK SEPARATION DISTANCES b(Septic ❑Holding ❑S.T.E.P. OOther. To From Septic Tank Absorption Field Lift Station Holding Tank PutrKIT'dwat Steer Line �aC9fe' capacdy. G/•hc/ -A- 1I000 Gal wfe 1 Ar I `�`I` �L t .". S�eCi N. ••td Can:ur..arla. surlau Wuu 1 + ' I + LIFT STATION ^�.,1t aa. I ` 8 I $�2f. I.IiIMAa[GVK. LotUre WI �, 7 jV 'Pump an' MvN at 'P,Kp Htn wa1K alarm at Fwmdatcn h n N. Pump Mane s Mc E:apYfal hspec:iene perrtarnW br Cochin Drain Rem.ke: .SOILS LOa✓faSTR^�T TN.t0J4NdrT BENCH MARK lcofw ertl ofscyxrt nn j � Refh f -r,uArG14 6-x Ghv*r7o,� - V/ru/ft.a r! L I 11` 11,v I SO 70 W I a.L. ^+.0@P—O;,14100 na5ca Ft # � 11EvE• Engirr�e'pt$Rcjh + i S S S ENGINEERING f Inspections performed by:17034 Eagle River Loop Road. N6�0+{ 1" S-1 / �uot r E"Ie River, Alaska 99577 pd r NLc7 4 P—'Lr�• Development Services Department Approval 7t 1 ROBERT G COWAN �j� ��\; CE -8801 Reviewed by: Date: Z oZ �s= and approved 0 PERMIT NO. SW020060 PAGE 2 OF 3 Munic-ipalit of Anchorage DEPARTMENT OF HEATH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.0 Box 196650 •Anchorage, Alaska 99519-6650 • Telephone 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 2A, BLOCK 2, SKYLINE VIEW #1 P.I.D. NO. 051-191-56 --------------- — - — - — - — - — - — - - — --------------- SKYVIEW AVENUE a 3 0 C O, NEW 3 BEDROOM HOUSE << A NEW jb5O GALLON TBI _ a - DECK Q SSPlC!-, N1 FCO IT2 �. j CO2 r8L'' G � N DBL �: •• y k, I71 1 ., STI IV y ST2 01 DBL1 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ----- ____EXISTING _ _ _ _ _ _ _ _ _ _ EXISTING 10* UTILITY ESIT. EXISTING 10' UTILITY ESIT. --------------------------------------------- SCALE. I' - 40' LOT 2B �� '"� C COWAN T ROBERT ryll``o�s� CE -8801 �\�i•� PERMIT No. SW020060 PACE 3 OF 3 Municipalit of Anchorage DEPARTMENT OF HEATH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 •Anchorage, Alaska 99519-6650 • Televrene 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 2A, BLOCK 2, SKYLINE VIEW #1 P.I.D. NO. 051-191-56 A B C ST1 ST2 100.7' 20.0 FINAL GRADE 26.5 56.0 — ST2 30.0 767'NEW 1000 95.4' 3t.5 65.5 — DBL2 GALLON 71.0 — C01 36.0 73.5 SEPTIC TANK MT1 35.0 72.5 CO2 CO1 — 74.0 MT2 55.0 — b1T2 CO2 MTl CO1 = 101.3' CO2 = 99.9' FINAL GRADE C01 = 95.3' SR I CO2 = 95.3' MT2 = 92.4' MTl = 92.4' N. T. S. ��`?.�•...... vttl�. NO WATER FOUND ; 85.4' B.O.H. L tt T, ROBERT C. COWAN / �i'�g\ CE -8801 I1��i!�• • w•• ��'•- A B C FCO 20.0 — ST1 26.5 56.0 — ST2 30.0 62.5 — OBL1 3t.5 65.5 — DBL2 34.5 71.0 — C01 36.0 73.5 — MT1 35.0 72.5 CO2 56.5 — 74.0 MT2 55.0 — 72.5 08/07/2002 14:48 3453287 Job No.: 02-120 M W DRILLING, INC PAGE 02 M -W Drilling, Inc. P.O. Box 110378•Anchoroge, AK 99511♦ •907-345-4000 • 907-345-3287 Fax* Project No.: NIA Permit No. SWO20060 Groundwater Well As -Built & Lo • Well Owner, Pochatko, Paul do Danae • Use of Well: Domestic • Legal Description: Skyline View #1 Block 2 Lot 2A Eagle River Alaska Construction •Hole Depth: 240' •Casing Size: 6" •Cased To: 120.56' *Material. A53Steel •Drill Method: Ab Rotary Perf. ♦ Well Completion- Open end X Screen Perforated _ Method. •Sereen/Perforationdncrlption: None • Groat Notes: (1) Sack- No. 8 bentonite granules • Notes: • Well Dewtopm nt. Method: Air surge Notes: • Static water level (SWI) 85' (above) (below) top of caring (IOC). • Well yleld test at 1.5 gallons per tw&ute (CPM)/ ) for i hours with 100% of drawdown (DD) from static level (SWI). *Method.- Airlift • Date efcorrrpkdon: MMay2002 4NmpInstall. W.II T nit Depth in fat from top of essinr, Detaits of formations penetrated, size of mnteri4 color and hardness. 0 TO 2 Casing stickup 2 TO 7 fill and topsoil 7 TO 22 Gravel with large cobbles 22 TO 112 Boulders and cobbles: occasional SLayel 112 TO 115 Gravel and cobbles: small layer of clay mixed in 115 TO 120 Boulders and cobbles 120 TO 240 Bedrock: gray black, silt -stone argillite, few small water seaps in s oradic fractures TO TO TO TO TO TO TO TO TO 1C—CerttuedC oatractca PODEnr c. cowAN. PE. n0DEnTA. SI IAFEn. P.E. CMLENGINEEnS (907)694-2979 S — Q Date: FAX(907)694.1211 pC �} 01 ICALIIIAMIIDIIIIY MPI MRS F1unicipality of Anchorage smnSwAIEn DEPARTMENT OF HEALTH AND HUMAN SERVICES MM""IEN5101a 025 L Street P.O. Box 196650 Anchorages Alaska 99519-6650 .smntwmn EarEctldl Lotaf% UCLA k4l,'rre VsI REFERENCE: ew-# twPIEEISNOSMUIES ANOnEP001S The septic inspections for the referenced property were performed on 5-I'7- ba and 5-1 7-0a Prior to submitting the On-site Wastewater Disposal System�I and/or Well Inspection Report we are waiting for tl:e 49-bL 1 ff SLf YPV to be wcEEEarEclla, completed. SILOWIESI If we may be of further service please contact us. S1IE PIAM Sincerely, /I _/ 42 &// "OADDESIG" N Robert C. Cowan, P.E. SMInt PfnCOIAIKA IESI SInuCILML& womo AI EaPECIl01a aI9IE wAtlEwAlEn OUPomsysm" us"I 17034 Ilonf l I EAGLE mvEn LOOP 4 SUM 204 • EAGLE WHEW. ALASKA 09577 S- /7-02 @ /2: 3a MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT Initial Permit Number: SW020060 Legal Description: SKYLINE VIEW #1 BLK 2 LT 2A Date Issued: Apr 11, 2002 Expiration Date: Apr 11, 2003 Parcel ID: 051-191-56 Design Engineer: 0003 S & S Engineering Site Address: Owner Name: Paul & Denae Pochatko Lot Size: 45796 SQ. FT. Owner Address: 9811 Chatham Circle Total Bedrooms: 3 Permit Bedrooms: 3 Eagle River. AK 99577 - This permit is for the construction of: [✓ ! Disposal Field ❑Q Septic Tank ❑ Holding Tank ❑ Privy ❑✓ Private Well ❑ Water Storage 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 DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (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: Issued Issued By: Z Date: ',//j 1 /0 2 - Municipality of Anchorage • Development Services Department Building Safety Division i On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE SEWERIWELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. b5j - N I - S O Permit Number SWOZOO60 Property owner(s) P AUl- ' 't> EN AE P 0r, a ATk 0 Day phone (09 to • -A 2.--1 Mailing address (1) Oi%\\ CN ASW A M C1 Ru E Mailing address (2) 6A6lee- RSV EQ NIASY, A. Zip Code ol°IS3: a: Legal description (Lot, Block & Sub'd.) 1-o% Za. N\oc%2 ) S kyNlrJ-y\Ul SID Legal description (Section, Township & Range) Lot Size 4-66 6%q— �1ere /JQ.Ft. 116-'7 9loG THIS APPLICATION IS FOR: Number of Bedrooms 3 Sewer Only Well Only ❑ Sewer and Well ® Water Storage ❑ Sewer Upgrade ❑ THIS PROPERTY CONTAINS: Hot Tub ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ I certify that the above Information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. 7 (Signature of property owner or authorized agent) 17034 Eagle River Loop Rc Eagle River, Alaska 99577 Permit Fees: SSr0 • J Waiver Fees: Date of Payment: `t/ V /0 Z Date of Payment: Receipt Number: o i$ o f 3 Receipt Number: (Rev. 12100) S& IEkTNNITW"7y APPnOVALS SEWERS WATER MANEXTENSIPB SEWEnA WATEn MPECTp4 [WG NEEMGSTUNES ANDREPORIS WELL MPECTM & RPV TEST SITE PLAtis ROADOE.SK'Y SPL TEST PEIICOLATK TEST STTIUCTLNAL 6 MECHANICAL MPEOT " ONSITE wASTEWATEn DISPOSALSISTEM DESK A0R#c ti., 2002 MUNICIPALITY OF ANCHORAGE Development Services Department P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 2A, Block 2, Skyline View S/D #1 nOBERT C. COWAN, P.E. CIVIL ENGINEERS (907)694-2979 FAX (907) 694.1211 It is requested that you issue a permit to install a septic system to serve the proposed three bedroom dwelling on the referenced property. A test hole was excavated and a percolation test was performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation 11/28/01 water was not found. After at least seven days of ground water monitoring the test hole was found to be dry. We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent properties. If you require additional information, please contact us. Sincerely, V7 N Robert C. Cowan, P.E. RCC/jhm Enclosure 17034 NORTH EAGLE RNEn LGOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 DESIGN I 1 •• _ a WILDWOOD — N ra o j A Or G m Z m pRMw�ro H O N 0o Z I 7C -_ A n mI Oyoo� <yy I _ i~mm ypC A .'• < I CNK•• mL^• N m m O-Ic7�tmm f .tmmr-1 •�i�Osy � I K"v 002E O Cc+l <ya Y •A Monmom K>n G to A oy�tjF m^ z>,a ox K y -i> V3 l m V. V.0 ON Mwo mZ> ~ �� P 1•• J 1131 Odo <c :0;1 KN nl m m n X Z . • r � SITE PLAN DESIGN 1" = 30' S( AIG S n 0FD I xF. I� p r :o mgr inn^ ONZ CyO t I = n� r�i>N 0 m wung :+ iUl ZO � G -nVo b cw� m moi I m o Z O ANWm •-3 A V!W C AS, [+10 � 0-9 In s CA g D Z O Z 2\S, WNA,T+ •-•� 7z z (n ,C-) > vim, --3 ZV n D m my m D r - T O r > m > v a V g •.GC; N Hf 1; h CN PROPOSED '� N 3S i -1-1,3/\ Or n t` O m O DRIVEWAY I I r •. C ai i Ln foo r� iII -� m m z LII c) o Z�;� �I rO 1z�z� , C m (- 0 `ayKm m�m N ` C > Omr �A n� C �4o<mm X x z .� O�>s� Ln 0 .� z ZG ' m••a'i ocvi O O m yOmt7 yx T. r -r O z m O O (n ` ^•yzC z+r m o�>N M 0 =r m {Z Z ZTOO = C\n l i �' lett JAN -16-2002 1246 S&S ENGItEERING Int 1/)M:k. : 907 694 1211 P.03/03 SOILS PERCOLATION TEST Performed for _ Tim Ronin Date Performed;_�L Project 51,y]]ne Vi w fD Nl B2 n •TESTHOLEt1 ZOM-01 1f 11 12 13 14 15- ORG - black rootmat, red - Brown overburden CP/GW -brown, sandy gravel W/ cobbles to 3' mobture Increasing w/ depth HOLE PRESOAKED PRIOR TO TEST SEE ATTACHED SITE PLAN FOR BOLE LOCATION r "Croundwaterencountered? No What depth? NA pthtowateraftermonttodW. NA Date., 04/25/01 E lationRate, (min/inlPere Hole Diameter 6'un Between _3 filet and 4 feet L Kenneth M. Duffus, certify that this test was performed in accordance with all Siete and Municipal guidelines in effect on this date. YLtif'qt.l xi S&A Ing ROBERT C. COWAN P.E. CML ENGINEE1tS (907)694-2979 FAX(907)694.1211 EEAUIIAUT11p1�TY ON-SITE WASTEWATER DISPOSAL SYSTEM APIl"ALS CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS SEWERS WATER MW O(TENSKM REFERENCE: Lot 2a, Block 2, Skyline View Subdivision 41 March 22, 2002 SERER a WATER INSPECTION GENERAL: 1. The scope of this project includes the installation of a 1000 gallon Premier ENGINEETM,GSWEXES polyethylene (IIDPE) septic tank and a new trench to serve the proposed three AI,DREronrs bedroom residence located on the referenced property. 2. Construction shall be in accordance with the approved site plan and design WELLNSPECTION drawings, Municipal permit with any special provisions or conditions, and all anaWlEsr applicable State and Municipal Wastewater Disposal Regulations. 3. The contractor shall be responsible for obtaining any necessary underground SITE PWJS utility locates. 4. Unless specifically agreed otherwise, the property owner shall be responsible ROADDESIGN for final grading areas subsequently depressed from soil settling. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Flealth Department for system installations. Owners installing their 50 E ZEST own systems must also receive prior approval from the Municipal Health Department. PENCOLVION SEPTIC TANK INSTALLATION: TEST 1. A septic tank is to be constructed by a certified septic tank manufacturer. STIT)CM4141 Construction shall include two 4" cleanouts for pumping access. WCHNACAL INSPECTIONS 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. DIME WASiEWATEn 01SPOSALSv51Eu DESIGN 17034 NORTH EAGLE nNEn LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 Page 2 Lot 2a, Block 2, Skyline View SID #1 March 22, 2002 3. 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. 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 fl. from 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. 6. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCII/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. 2. 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. 4. 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. 5. 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 3 Lot 2a, Block 2, Skyline View 31D #1 March 22, 2002 MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipal approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pine Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (IIDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam III or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). 5. A permeable nontoxic silt barrier (Typar 3401, Mimfi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. 6. 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 current M.O.A. or D.E.C. requirements, which ever requirement applies. 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: Page 4 Lot 2a, Block 2, 3kyline View 3/D #1 March 22, 2002 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. 2. 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. 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 die failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering'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 � -►.�! ori::^=: = ='=,�Y On -Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I .D. 051-191-56 1. GENERAL INFORMATION Complete legal description Skyline View #1 Blk 2 Lot 2A Location (site address) 23032 Skyview Ave Current Property owner(s) Brennen & Kristi Will Expiration Date: 1 - J Z ©Z / Day phone Mailing address 23032 Skyview Ave. Chugiak, AK 99567' Peal Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class _ Well ❑ Public Water System ❑ Waiver/Variance request for: 3 TYPE OF WASTEWATER DISPOSAL: Individual Holding Tank ❑ Community ❑ Public Sewer ❑ Received by: Date: COSA to be released to the engineer, unless otheRvise requested by the engineer. COSA Fee 12. 50 couto Date of Payment 10 - q -20 Receipt Number 1 COSA# 056201550 Waiver Fee $ Date of Payment Receipt Number Waiver # Distance: 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 ARCTERRA CONSULTING, INC. Phone 696-6111 Address 20441 PTARMIGAN BLVD„ EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 10/5/2020 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the' evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future _rft.'9k,1%, occupants or can ArcTerra guarantee that no unseen �.� 0'E A.i� � 1 encroachments, deficiencies or discrepancies exist, 6. DSD SIGNATURE System #1 Approved for bedrooms. System ##2 Approved for bedrooms. Disapproved. rte 1ENNETH D tF1S Conditional approval for bedrooms, with the following stipulations: J M v� r� y1J 1 iJ�71�� l By: _ _ 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 X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COS,A blue sheet 10-10-12.doc Legal Description: CSA Checklist Skyline View #1 Blk 2 Lot 2A If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 5/14/02 - Total depth 240 ft Cased to 120 ft ❑ Sanitary seal is functioning correctly Q Wires are properly protected Casing height (above ground) 36 in. Date of flow test for COSA 9/30/20 Static water level at beginning of test 111 ft. Comments Age of tank(s) 18 years Tank type/materia[ Septic/Steel Measured operating fluid level in septic tank 49" ❑ Standpipes/foundation cleanout per record drawing Date of pumping 10/11/2020 Parcel ID: 051-191-56 Structure served by this system 1 Well production at time of test 1.6 gpm Water storage tank volume na gallons Well disinfected for coliform test? ❑ Yes Nc Q Coliform bacteria is Negative Nitrate 2.32 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L [Z Arsenic less than MRL (ND) Collected by ArcTerra Consulting Date of Sample 9/30/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: NA D. ABSORPTION FIELD DATA Which system tested (date installed) 5/17/02 Adequacy test date 10/1/20 ALL standpipes present per record drawing Results ®Pass For 3 bedrooms Total measured depth from grade 8'5 ft (max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade 5.5 ft (min) Water added 500 gal ❑ N/A — pressurized field 0 New depth in ❑ Monitor tubes go to bottom of effective. If not, state 10 depth into effective Elapsed time min 0 Code -required soil cover over field Final fluid depth in ❑ System presoaked Absorption rate 450 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) Gallons introduced gallons If yes, enter date Com ments/Deficiencies: 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' ® Yes if No fit 7 Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sever/Septic Line > 25' ® Yes if No ft Absorption Field on Lot > 100' ® 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' ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ® Yes if No ft Private Wells > 100' ®Yes if No _ Water Main > 10' ® Yes if No ft Community Wells > 200' Yes if No. 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 ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION .l certify that l 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 ft li, If, ft • Municipality of anchorage On -Site Water and Wastewater Program (907)343-7904 Parcel LD 051-191-56 Certificate of On -Site Systems Approval Expiration Date: Z2 " 1. GENERAL INFORMATION Skyline View #1, Block 2, Lot 2A Complete legal description Location (site address) 23032 Skyline Avenue Chugiak, AK 99567 Current Property owner(s) Richard & Abby Pochatko Day phone 232-1357 Mailing address P.O. Box 1971 Palmer, AK 99645 Real Estate Agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3, NUMBER OF BEDROOMS: Three 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well M Individual El Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by:! % / 4 f d L-� " Dater. COSA to be released to the engineer, unless othermse /.quelled by the engineer. - COSA Fee $ 5'2-� Date of Payment .741 S// 5 Receipt Number 6-10a01 �l COSA# 05Ci 6 I �-(Pq 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 Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. 6. DSD SIGNATURE System #1 Approved for 3— bedrooms System #2 Approved for _ bedrooms Disapproved Phone 522-7773 Date 1 Conditional approval for bedrooms, with the following stipulations: BT r— Fri �� Original Certificate Date: 1 Z Lit 5 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 Slate of Alaska. The Municipality of Anchorage isnot responsible for errors or omissions in the professional engineer's work. - - 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet ° c If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system Certificate of On -Site Systems Approval Checklist Z Legal Description: Skyline View #1, Block Lot 2A Parcel ID: 051-191-56 A. WELL DATA Well type Private If A, B, or C provide PWSID # Well Log (Y/N) Y Date completed 5/14/02 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 240 ft. Cased to 120 ft. Casing height (above ground) >18 in. FROM WELL LOG AT INSPECTION Date of test 5/14/02 11/25/15 Static water level 85 Well production 1.5 WATER SAMPLE RESULTS: ft. 89.6 ft. g.P.m. 1.6 g.p.m. Coliform 0 colonies/100 mL Nitrate 2.35 mg/L Arsenic ND ug/L Dateofsample: 11/25/15 B. SEPTIC/HOLDING TANK DATA Collected by: And. Engineering Tank Type/Material Septic/Steel Date installed 5/17/02 Tank size 1,000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (YIN) Y Depression over tank (YIN) N High water alarm (Y/N) _ Date of pumping 12/11/15 Pumper Royal Flush Pumping C. ABSORPTION FIELD DATA Date installed 5/17/02 Soil rating (9.p.d./ftz or ftZ/bdrm) 1.2 GPD/SF System type 5' Wide Length 44 ft. Width 5 ft. Gravel below pipe 3 ft. Total depth 8.5 ft. Eff. absorption area 379 ft, Monitoring tube Y Depression over field N Date of adequacy test 11 /25/15 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 461 gal. New depth 3 in. Elapsed Time. 60 min. Final fluid depth 0 in. Absorption rate — 450 g P d Any rejuvenation treatment (past 12 mo.) (Y/N & type) _ N If yes, give date D. LIFT STATION Date installed "Pump on" level at Datum _ Size in gallons _ in. "Pump off' level at Cycles tested _ Manhole/Access (YIN) in. High water alarm level at Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot > 100 On adjacent lots > 100' Absorption field on lot > On adjacent lots >100 Public sewer main >75' Public sewer manhole/cleanout >100' Sewer /septic service line >25' Holding tank >75 Animal containment areas >50 Manure/animal excrete storage areas >100' SEPTIC/HOLDING TANK ON LOT TO: , Building foundation > Property tine >5' Water main >10, Water service line >10' Wells on adjacent lots _ > 100' ABSORPTION FIELD ON LOT TO: Property line >10 Building foundation >10, Water Service line > Surface water >100' Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that I 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. Engineer's Printed Name Michael E. Anderson, P.E. Date 12/12/2015 COSA brown sheet 10-10-12.doc Absorption field >5' Surface water >100' Water main >10' Driveway, parking/vehicle storage > 10, in. OF .44 Ill 4.G TH �j1°eo eammwmo°.......... . � ? VMICHAEL E. ANDLRSON' �� J m CE -438? ;; ,� Municipality of Anchorage hw,� Development Services Department -/f Building Safety Division Onsite Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 *,P&s W✓r CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-191-56 COSA # Q R Q j 3 Expiration Date: 8 —1 0 g 1. GENERAL INFORMATION Complete legal description SKYLINE VIEW #1 BLOCK 2 LOT 2A Location (site address) 23032 SKYVIEW AVE CHUGIAK, AK 99567 Current Property owner(s) PAUL & DENAF POCHATKO Day phone Mailing address Lending agency " Mailing address Real Estate Agent Mailing Address IN s • . r • `;'j1.7 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well 19 Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Day phone Day phone TYPE OF WASTEWATER DISPOSAL: Individual On-site 19 Individual Holding Tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of Onsite Systems Approval (COSA) based only upon the representations given in paragraph 4 by an Independent professional civil engineer registered In the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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. (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 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 of the validation date shown below, I verify that my Investigation, based on procedures outlined in the Certificate of On -Site System Approval Guidelines for this application, shows that the on-site water supply and/or wastewater dispo ystem is (are) safe, functional and quate for the number of bedrooms and type of structure indicdt i I further verify that based formation obtained from the Municipality of Anchorage files an vesligation and i the on-site water supply and/or wastewater disposal system is(, in co I * e with all apounicipal and State codes, ordinances, and regulations in effect at the time of insiadation. Of FirmPhone _868-3792 Address 20441 PTARMIGAN BLVD. EAGLE RIVER AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date x/13/2008 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. 5. DSD SIGNATURE Vf Approved for 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checidist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other By: —&G&_ Z W- Original Certificate Date: , i - a/ q' O (Rat IiM) ii Municipality of Anchorage i Development Services Department f' Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SKYLTNE VIEW 81. BLOCK 2. LOT 2A Parcel ID: 051-191-56 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID # _ Well Log (YIN) y Date completed 5/14/2002 Sanitary seal (Y/N)Y 0 Total depth _20 ft. Cased to'i4offt. FROM WELL LOG Date of test 511412002 Static water levet 85 ft. Well production 1.5 g.p.m. WATER SAMPLE RESULTS Wires properly protected (YIN) y Casing height (above ground) min. AT INSPECTION 4/29/2008 107 ft. Coliform ,-Q_colonies/100mL Nitrate 1.33 mg/L Other bacteria.gcolonies/100 mL Arsenic: JSP mgll Date of sample: 04/29/2008 Collected by: ArawA B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date Installed 5/17/02 Tank size 1000 gal. g.p.m. Number of Compartments 2 Cleanouts (YIN) XFoundation cleanout (YIN) y Depression over tank (YIN) rL High water alarm (YIN) N_Date of pumping 4/29/08 Pumper, unitary C. ABSORPTION FIELD DATA Date installed 5/17/02 Soil rating (g.p.d./fe or fe/bdrm) LZ System type Shallow Trench Length _UflL Width .5 ft. Gravel below pipe 1ft. Total depth &S ft. (bottom of effective) Eff. absorption area 3af? Monitoring tube Y Depression over field IY Date of adequacy test 4129108 Results (Pass/Fail) PASS For 3_bedrooms Fluid depth In absorption field before test _Q., in. Water added,fi�L gal. New depth -2-in. Elapsed Time: 10 Final fluid depth 0 in. Absorption rate >= 4$4g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) N -If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on' level at_in. `Pump off" at_in. High water alarm level at_in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot loo'+ Public sewer main 751+ Sewer /septic service line 25'+ Animal containment areas 501+ On adjacent lots 1001+ On adjacent lots 1001+ Public sewer manhole/cleanout 1001+ Holding tank 1001+ t Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 51+ Property line _51± Absorption field 51+ Water main 101+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 1001+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: i Property line 10'+ Building foundation 10'+ Water main 101+ Water Service line 10'+ Surface water 1001+ Driveway, parking/vehicle storage 10'+ Curtain drain 50'+ (None Known) Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and J0 x t'4 TH k review of Municipal records that the above systems are in •.� •• ••• conformance with MOA COSA guidelines in effect on this ••,,,,,,;,• i date. Engineer's Printed Name KENNETH M. DUFFUS I,I f �F9 ., �cf 4-0 Date 0511,*008 1�\'*170FESSt`�4� COSA Fee $430.00 Date of Payment 15 1310 Receipt Number 10 ?7 ^15,6, (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number SCS ReEN 1081725001 Client Name ArcTerra Engineering and Surveying Project ;dame/N Skyline View NI 132, L2A Client Sample ID Skyline View NI D2, L2A Statris Drinking Water PIVSID 0 Sample Remarks: All Dates/rimes are Alaska Standard Time Printed Date/rime 05/13/2008 9:42 Collected Date/time 04/29/2008 18:00 Received Date/time 04/30/2008 10:15 Technical Director Stephen C. rale Allowable Prep Analysis Parameter Results PQL Units Method Container ID Limits Date Date snit Metals by ICP/MS Arsenic Waters Department Total Nilmte/Nilrite-N Microbiology Laboratory Colony Count Total Coliform recal Coliform ND 5.00 u8/L EP200.8 C (<10) 05/07/08 05/12/08 TK 2.33 0.100 mgfL Sh1204500NO3-F D (<10) 05/06/08 LCP 0 col/100mL SN1209222B A (<200) 04/30/08 DLC 0 col/100mL Sts1209222R A (<I) 04/30/08 DLC 0 col/100mL SN1209222U A (<I) 04/30/08 DLC m a 30 O � � WILDWOOD DRIVE I M z ,m b• Ca sJM. Ye.. rwu. NxVMN Yw N w». SBS Engineering a.n..t rrt. aMowmW. ial ..vil�W «a .a scut woo Municipality of Anchorage • �-- Development Services Department " Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. '"' "• P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-191-56 HAA # Z:lA��20��� = • '"- Expiration Date: 1. GENERAL INFORMATION Complete legal description Lot 2A; Block 2; Skyline View #1 Location (site address or directions) corner of Skyview Dr. and Wildwood Dr. Current Property owner(s) pant & Dnnae Po ha ko Day phone 696-4271 11 Mailing address 9811 Chatham Cir. Eagle River,AK 99577 Lending agency Mailing address Real Estate Agent Mailing Address Day phone Day phone Unless otherwise requested, HAA will be held by DSD for pickup. ��„� %� - 1�,.� R/y-4 w z 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site If 9] Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ 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 Alaska. 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 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 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 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 Municipalily of Anchorage riles 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 S & S Engineering Phone 694-2979 Address 17034 N. Eagle River Loop Ste.204 Eagle River, AK 99577 Engineer's Printed Name Robert C. Cowan Date '? �a c / o z � OF 5. DSD SIGNATUREy r 4 ROBERT C. COWAN CE .8801 4— Approved for bedrooms. I/t; Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional CommentsON-SITE �. ,A 1A Tr" ,N" - WASTFWATFR Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: + Original Certificate Dale: ,p, ,I/Ofll Municipality of Anchorage Development Services Department `± ` - Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:L�� S/G��L/h/F V(/(r��parcellD:OSI—/�l/—SG A. WELL DATTAAi Well type O 1' ' !` ,f If A, B, or C provide PWSID # _ Date completed J / 4/0Z, Sanitary seal (YIN) Total depth Vat Cased toAT_ft FROM WELL LOG Date of test S /14 c&— Static & -Static water level ft. Well production g.p.m. WATER SAMPLE RESULTS: Well Log (Y/N) 7 Wires properly protected (Y/N) y Casing height (above ground) 18 n. AT INSPECTION ft. Coliform _ Lcolonies/100 ml. Nitrate 4-Slmg.A. Other bacteria colonies/100 ml. Date of sample: :71:0410Z, Collected by: QS B. SEPTIC/HOLDING TANK DATA Tank Type/Material 45tT/c, s7r-r, Date installed O Tank size IWO gal. Number of Compartments 07� / Cleanouts (Y/N) Foundation cieariout (Y/N) % Depression over lank (Y/N) /v/ High water a!arm (Y/N) _ ,Date of pumping /` 1 �� Pumper �— ti •, C. ABSORPTION FIELD DATA �7 Date installed (/Soil rating , .p.d./ft' r ft'/bdrm)_?/ System type SR-A� "T'J Length ft. Width� ft. Gravel below pipe 3 ft. Total depth ft. Eff. absorption area 3Tq ' /rtft' Monitoring tute y Depression over field N/ Date of adequacy test Results (Pass/Fail)1/R S For 3 bedrooms Fluid depth in absorption fiel/before _ in. Water added_ gal. ew depth_ in. Elapsed Time: _min.d depth _in. Absorption ra;es, g.p.d. Any rejuvenation treatment (YIN & type) Ifgive date D. LIFT STATION Date installed d � "Pump on" level at in. Datum E. SEPARATION DISTANCES Size in gallons Manhole/Access (YIN) `Pump off' level at _ in. High water alarm level at in. Cycles tested Meets alar & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAiftanon on lot /00 "r Absorption field on lot /,00 ffi Public sewer main A i f S er /septic service line On adjacent lots _Joe) T"" On adjacent lots /0(0 Public sewer manhole,/cclean'out Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: r 1 1�J� .{— Building foundation S 4- Property line Absorption field Water main / A_ Water service line r� Surface water / DO r f Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT r TO: �.l Property line LQ .r Building foundation O '{"Water main r Water Service line 10 r'rSurface water /00 •f— Driveway, parking/vehicle storage I r Curtain drain b�E %/pHtJ Ielis on adjacent lots � F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field Inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines In effect on this date. Engineer's Printed Name R D $ t r.T C. Cow,#✓ 5/110/0 Z Date HAA Fee $ 3 % S - + J Waiver Fee $ Date of Payment 01 / �0 Z Date of Payment Receipt Number O a 9 9 8 3 `3 r Receipt Number (Rev. 12/00) a N IYl .lt'KI ;w f .