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HomeMy WebLinkAboutPARADISE VALLEY BLK 4 LTS 41A & 42Pctrcidise VoIIey Block 4 Lot 41,4 #020-411-34 On -Site Water and/or Wastewater System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP161100 Tax Code Number: 02041135000 Work Type: SepticTank Upgrade Permit Effective Dates: May 12, 2016 to May 12, 2017 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Subdivision: PARADISE VALLEY Site Legal Address: PARADISE VALLEY BLK 4 LTS 41A & 42 G:3538 Owner/Address: SCHOCK WADE G & MAILER KAREN 18111 SPAIN DRIVE ANCHORAGE AK 995164023 Site Mailing Address: 18111 SPAIN DR, Anchorage Lot Size in Sq Ft: 56378 Total Bedrooms: 1 This permit is for the construction of: N Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April.l5, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: / t, j Date: C Issued By:/ �/� . ��jtY�/f Date: 5� MUNICIPALITY OF ANCHORAGE Community Development Department ~--~ Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On-Site Water & Wastewater Program ~ Parcel I.D. ~ -~// -~ Prope~yowner(s) ~ ~~cL~e~, aayphone Mailing address /~/If ~t,~ ~ ~ Site address ~r,, ~,~-.' Legal description (Sub'd., Block & Lot) Legal description (Tqwnship, Range & Lot Size '5-G, ~ ;) ¢ Sq. Ft. Section) '- Number of Bedrooms APPLICATION IS FOR: ([~ all that apply) Absorption Field [] Septic Tank ~ Holding Tank [] Privy [] Private Well [] Water Storage [] APPLICATION IS AN: TYPE OF DWELLING: Initial [] Single Family (SF) [] (w/wo ADU) Upgrade [] Duplex (D) [] Renewal [] Multiple Dwellings [] (SF and/or D) THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number: Permit No, I~¢'~1 (¢ Waiver Fees: Date of Payment: Receipt Number: Waiver No. Permit App_J- :.: L..;c ¢ Michael N. Anderson, P.E. Civil/Structur~ Engineering&Construction 4661NaronaAvenue Anchorage, Alaska 99516 Phone 727-8864 Fax 345-1391 May4,2016 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: Paradise Valley Blk 4, Lot 4lA, Tax ID 020-411-34 To Whom it may concern: This is a request for a permit to lower the existing septic tank which was installed in 2008. The drain pipe f'rom the house keeps plugging at the tank entrance therefore the tank needs to be lowered. Nothing will be changed except to lower the tank for better flow. This permit will not impact any of the neighboring properties, see attached site plan. If you have any question please call me. Sincerely~ Michael N. Anderson, P.E. EXISTING WELL / ~ WADE SCHOCK AND KAREN MAILER ~2~'~ .............. %~,77'. PARADISE VALLEY, BLOCK 4, LOT 4lA ~.,"-~".... /t '~.' Anchorage, Alaska ~ ~ 49~ ~ MICHAEL N. ANDERSON, P.E. ~....~:~.~,~,~,,: ........ :...~ 4661 NATRONA AVE ~.~MICHAEL N. AN~E~SON~w (~0~) v~v-88d4 / ~ (90v) 34~-~9~ ~2~ ~.c~ ~ SCALE: 1"=100' MAY 4, ~016 "~~'~"~/ffo~ ;I ~ ~,, ! ~. MUNICIPALITY OF ANCHORAGE D~, ~TMENT oF HEALTH AND HUMAN SEE ~S Environmental Health Division ~ 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-81TE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT .~ DISTANCES ~/~ ¢ ~F~ ~S'~ ~ TO SEPTIC ABSORPTION WELL ~dr~FROM ~ TANK FIELD Phone(s) I Permit No. No. of Bedrooms LEGAL DESCRIPTION Township, Range, Section AS-BUILT DIAGRAM (Show location o¢ well, septic system, property hnes, foundation, //~¢ ~] / / d ..... ay, water bodies, etc.) TANKS i ~ SEPTIC ~ HOLDING ~a~u~acturer Capaoty m gmlo~s Material No. of Compa~ments TYPE OF SYSTEM ~' ~o ~ 4 ~TRENCH ~ BED ~ W. DRAIN ~ OTHER Depth'to p,pe bottom from Total depth ~rom original grade original grade ~- 0 F1 ~. 5 FT ~ rill added above original grade Gravel depth beneath p~pe Gravdlength_ ~' ~ FT Gravelw'dth ~,~ FT ~. Number ot hnes ~ Soil rating P,pe material 4It ~ ~ ~ p/p~ ~J-T WELLS ~ ~.~ _ ~ PRIVATE ~ OTHER (Identifv) nstalle, Date~nstalled: ~ :0; ~r BEMABKS: I ~T~/g O. ~H~~Z/S&. ceMily thal this inspection was peMormed according Lo all Municipal and SLate guideliues in effect on this date: Health Depadment Approval: ~ .. Date Drilled: Static Water Level Draw Down WELL LOG 5-16-86 40 ft, Legal Description Gallons,Per Minute Total Feet of Casing Lot 41 Blk. 4 Paridiase Valley 8 Type Material Drilled 0 Feet 2 ft. 40 ft. 70 ft. to 2 Over burden to 40 Gravel w/clay to 70 clay to 150 bedrock to to to to to to to to HEFTY DRILLING 3540 AKULA :DRIVE ANCHORAGE, AK 99516 (907) 345-0593 .,% . F;'ERM I 'T' NO: ][)AYf'E ISSUED: 85()() 14 01111185 APPL. I CAN'T': ADDF~ESS: CON"r'ACT F:'HONE: LIEGAL. DESCR IF:': L.O T S I ZI:J:-': MAX BIEDROOMS: BRAD Al,ID Fi'.ENEE WEST 4420 BERING ANCHORAGE, AK 99503 56.1.-4836 SUBDIVISION~ PARADISE VALL..EY SECTION: :1.1 'TOWI~ISHIP: ~:[N 250C;0 (SQ,.I:'T. OR ACRES) 3 LOT: 41 ELL)..,I .... RANGE: 3W L.i. sted below ape the'._, e?Lions ava:Llab].e 'L(n you in designing your sep'L:i.c sys'Lem. Choose the option that best Fi't.s your si'Le,, DEPTH 'T'O PtF'E BJ]TTOM (I:ZT.) [~)RAVIEI... DEPTH (F'T, TC.)TAL. DEPTH (F::]"~) GF"4AVEL. W I D]"I'"I (I:rT, 'GRAVEL LE:NGTH (I"-'T,) GRAVEL. VE]L. UME (CLJ, YDS, ) TANK SIZE (GALS) SC)IL RA'T'ING (SQ,FT, /BR) '~'~s 'T'ANK MLJS"I:' HAVE q'f' LEAST TWO CC.,M, AI,,I,,E..III,.~ I c:ertJ Fy tha'f..~ ]... I am {'ami].iar with 'Lhe r'equ:i, rements ~'of on.-..si'Le sewersll and wells as set Forth by the Munl(:J. pa].ity oF Anchorage (MOA) and ~he State 2. I wi].l ins't:.a].], the system in acc:cH'dance wi'U] ali TI(IA cc:~des and r'e(gLt].a'L:i, or'~i~, and in comp].:Lance ~,,~J,'(.l"i the design criteria oF this permit, 3. I will adhere) to all MOA and S'Late (:~¢ A].a~ika r'equiremer'vE~ ~'c}r the set back dist:ances From any ex ist :i.i](:j ~/48:i. ]. ~, **~asiL(.D~,¢a'Ler' disposal, sys't:.em or' pub ]. ic ~E, wer'ag(~.~ systen'! on 'LhLs or any adjacent or near'by 4 t unders'L~nd that 'tLhis p~H'ffiJ, t :L~ raj. id ~'or a rl~aX:LFdL(n'~ OF 3 bedr'ooms and any enlargement t,~J.].l r'equ:Lre ar] addJ. t.J. cH']a~ perm:i.t., IF A LIF'T' S'I"AT!LqN IS INS'I'ALLED IN AN Ai::;'.EA COVEEREED BY MOA BUIL. DtNG []ODES.,, THEN (:I.) AN IELEC]]:;'.IC;AL. F'ERMI]" AND ]:NSi:::'ECTION ~'ltJ.']!Fl" BE OBTAINED~ (:;:'.) AS-BLtIL_TS MILL N[)]" BE AF:'F:'ROVE::D- NITHOU'T' C:~N E.:.LIECTF;'.ICAL INSPECT]:DN REI:::'OF~T~ AND (:5) ]"HE IEL. EC:TR]:CAL. NORK MLtST BE DC)I',IE!: BY A L]:C;ENSED ELEC]"F',:ICIAN,, AF'PL. ICANT: BRAD AND RI:ENEE NEST ..... ......... E~G~INC. 7125 OLD SEWARD HIGHWAY ANCHORAGE, ALASKA 99502 (907) 349,6561 PERFORMED FO R:_~__~_ SOIL LOG SOIL LOG t '~ PERCOLATION TEST PERCOLATION TEST _2--~_ BEDROOMS ,OB NUMBER: ,~,-f-o_~_~_ ..... 2_.. DATE PERFORMED: ~-~ ..... LEGAL DESCRIPTION: 2 · .'~ '~/ 5 O - I, 0 ' ,S(LT' ~ aTI-/ 2248-E SLOPE SITE PLAN ~L SP P WAS GROUND WATER S L ENCOUNTERED? ~ 0 o P E LCrT $ rz_E, W E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Waler Drop .~ ,~ -"---.... DEPTH PERCOLATION RATE ..... (minutes/inch) (FEET) TEST RUN BETWEEN ....... FT AND COMMENTS *'~--~-I~-(-~)~A~b *JJ~(.~Cl/~& ,~V,-~7'"~.,'~ /M ....... ~,J~.M (~,O ~ ~5,.5- ......................................................... PERFORMED BY: ................. CERTIFIED BY ........................... DATE: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVlCES Division of Environmental Services On-Site Services Section P,O. Box 196650 Anchorage. Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF ~IEALTH AUTHORITY APPROVAL FOR A S NGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description L c~-~-- ~ I ~[ ~-, ~ Location (site address or directions) I I~'111 .<:;~a[¢,, (~/--, '- ' ~:~ pr~-Pert¢owner'~'?_~F~ ~ ~~ (~~ Dayphone~ ~.: Agent ~m(l~ ~ %~(( Day phone Address ~ ~oV ~_ Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DIS POSAL: Individual c n-site Holding tank Community on-site NOTE: Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025,Rev. 1/91) Front MOA#21 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 obtai ned 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 ,~l~,'r~',~ C~,~.~.~ocr/,-.~ j/~'.~,O. LC~'/:'~"'~r Phone Address 77~,_~ I.-/ICHZ,~,vzg~/ ,O,'~,¢-~ ,~NCR~,q/'4~.. AL;q<;~JQ / Date DHHS SIGNATURE '/~ A~3proved for ~,~.z:;~ .. bedrooms. DisapProved. - Conditional approval for bedrooms, with the following stipulations: /~'Additional Comments Note: The well for this property meets existinq State and Municipal Codes. There are nitrates present. It is ....... ~-~..~ +~=+ = p~;~ testing ~ ~,=~'~=~'m~ +~ ~ ~h~ w~ll~ continued suitability. Nitrate concentration is 9.6 mg/1. EPA By: ~ ~,~g Date /- &~- 7~ Pr:llII[N[ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA F21 Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST If A, B, or C, attach ADEC letter. Date completed Cased to -7 0 ~ FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I ~(~:) -F-{-. Absorption field on lot Public sewer main Sewer service line t,,J/~ ADEC water system number ~-[ (~- ~; ~) Driller Casing height Wires properly protected (Y/N) ~ AT INSPECTION ; On adjacent lots ; On adjacent lots 0 V~---~ Public sewer manhole/cleanout Petroleum tank /kl'/ I(oO --F+. IC¢o -Fi-. WATER SAMPLE RESULTS: Coliform ¢ Date of sample: ( _ jo( Nitrate Collected by: Other bacteria /',,) ~r~ ~--~ B. SEPTIC/HOLDING TANK DATA ~.//~.¢~ Date nste~ ed/ '~/'~- "~'(~ Tanksize J(~O(') cacti . Cleanout~'(,Y/N) ~i~-% Foundation cleanout (Y/N) ,.41 Compartments ~ Depression (Y/N) H'igh wat~ ~1ar m ::Date of;p'~,~C)ing S~ARA¥J~N DIe'ANdEs FROM sEpTIC/HOLDING TANK TO: Well(S) on Jo~ To proporty lino Surface water/drainage Alarm tested (Y/N) Pumper I~O -~CFoundation Water main/service line /xJ//~. 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed /'J/~ Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~;).~-'~- Length ,~ ~. ~- Width ~,..~- Total absorption area Depression over field (Y/N) Results (pass/fsil) Peroxide treatment (past 12 months) (Y/N) Soil rating System type -~-F'~'_,'~¢_~'% Total depth ~'. ~ Gravel thickness ._~, Cleanouts present (Y/N) Date of adequacy test for ~ 0 If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water _ f"J/f~t Driveway, parking/vehicle storage area .~) -F~-. Curtain drain hJ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. J HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number Box 196650 Ana~o~ ,M~ 99519 0N-SZ~B $¥S~MA~PROVAL REOUgS~ 41, Block 4~ Paradise valley Subd~v£n~on ~l~roval is r~cjuested on nubJecb property for the I:m~osee of y~r da~ ~n ~986. The ade~acy tent wan co~uct~ ~ ~o0o~da~o~ with ~ec~at~onH ~n 'In Sltu Temt~ of ~-8ite s~r Sye~' (~ld, 1982), ~x~ that ta~ had been ~d tn advance of the ~est~ng. ~t the t~ of the t~ had b~en fully =ef~Ll~ wit~ d~st~c w~at~. ~ntroduc~ ~nto ~he 9e~io ta~k vent at a rate ~c~g 4 continuous perl~ of 170 minutes. The ~ater ~evel ~ the cheer roes a~fox~ately 318 to 1/2 ~oh during the f~st 20 minutes of the ~nting, and maintal~that le~ f~ t~ duration of the test. Water wan ine~uc~ fr~ t~ houee~ld su~ly, which ~ndicaten that the the teat, ~d ;~ ~ditioal t~n duri~the test, at ~rl~s exceed~g 30 m~flutea. ~nttial fl~waa measug~ ak 3.8 9~. eub~e~ent fl~o ~anured at 4.3 g~. ~e fiflfll wan afte~ the ~aoy test ~as de~, a~ a Nltrate-N~t~n 1~el o~ 9.6 m~liigr~ ~ L By ~ of th~s letter, I ~ ~tl~ the ~o~ ~hat Ntt~o~n level ~ Just b~el~ w~h~n the re=~fld~ I~L~B of m~ll~gf~ ~g liter. I ~ rec~ing to t~ h~ that the ~11 ~ ~tored on t ~nthly basin for Nitra~-Nit~fl a~ ~n~ zeeLden~ o£ ~he household beeches l~egnaet, unless said resident ~e ~asu~ on slo~ w[~h a rag ~a~. st~cture~ w~th~n 200 f~ o~ the ~11. T~O has ~n no ~lld~ on ~hLu s~ec~ h~e. ~he new ~ se~a and th~s s~e~ h~e. O~stance be~en t~ new h~ s~c s~ ~d syst~ i~ on the f~ sl~ of the new h~. T~ w~te= well Off SubjeCt h~ is constructed ~ a shal~ pLt. ~e~ pit 18 adJacen~ to a 8t~p b~, ~d a 4-~cn_p~ ~it tO daylight a~r~tely 20 feet aw~y. pit, ~d It ~s ~ain f~ly. ~ ~l~ w~S. ~d le oov~ed with a et~l plato. c~a~c~ed oo=re~iy, wL~h a s~l~. ~n relocated sin~e the or~gl~l cona~c~ofl~ and sYated t~t they ~Yend 2o ~aiee 2he ~11 In my ~niOn, the ~11 ~d the ee~kc ayat~ oonst~otL~ ~th offer ade~ate e~tar~ p~otect~on ~ their presen~ condition, and I he=eby r~eet appr~al Ho ~ha~ ~he re~lnancing can ~oc~ w~thou~ delay. Tb~ ~u. sketch of separation distances sketch of ~ll const~uction wate~ analye£s results £0'd 3NI33I~ ~ NOIlOf]~JlSNO3 ~:lC:T I~l-I £6--~--Nt~£ INVOICE ~,,~ ~ P.O. BOX 112688 PHONE 345-2513 Job Address N©- 50441 SEWER AND DRAIN CLEANING SERVICE ANCHORAGE. ALASKA 99511-2688 ROTO-ROOTER SERVICE CALL H RS @ STEAM THAWING HRS. @ TRIP CHARGE H FIS. @ OVERTIMECHARGE HRS. @ ADDITIONAL LABOR CHARGE v~MPING SERVICE (GAL.) HYDRO-J ET SERVICE HRS. @ HRS. @ CUSTOMER ORDER# .~;^s~ ~ ..o~ ~,~',.vo,o'. - ' - ~o~, iff _~, TOTAL FOOTAGE CLEAN ED OR THAWED BLADES USED LINE CLEANED '/'J O B NOT GUARANTEED FOR FOLLOWING REASON WORK ACCEPTED BY ,.J MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Prope~y Owner ~ Mailing Address I ~ I1I (C) Lending Institution Mailing Address Business (d) Real Estate Company and Agent Address ~O Telephone (e) Mail the HAA to the followina address: or: Check here¢, if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family~ Number of Bedrooms WATER SUPPLY individual Well]~ Community Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 IRev 8/86) Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the vatidation date shown below, I verify that my investigation of this Health Authority Approval shows that the ori-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein, t 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 disposat system is in compliance with/~i Municipal and State codes, ordinances, and regulations in effect on Name of Firm ~... _.,~--v \~ Telephone Address Date '/~/~"~ Seal DHHS APPROVAL Approved for Approved ~ Disapproved Conditional Terms of Conditional Approval Date ¢- -~'-~'"~' CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 fRev 8/86) Back MUNICIPALITY OF ANCHORAGEMuNiCiPALiTY OF ANCHORAGE (MOA) DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL [HAA) CHECKLIST - FEBRUARY 1984 RECEIVED WELL DATA 264-4720 Well Classification ~'"'~ Well Log Present (Y/N) y Total Depth ~/~"'~ Cased to 7~.. Static Water Level Casing Height Above Ground Electrical Wiring n Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot ,~, To Nearest Public Sewer Line Cleanout/Man hole Water Sample Collected by Water Sample Test Results Comments If A, B, C, D.E.C. Approved {Y/N) Date Completed '~/~/~' ~, Yield Depth of Grouting ~ 0 N/,.~ Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots J ,.~--,O : On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on "t~, .C_W,. ' Date B. SEPTIC/HOLDING TANK DATA Date Installed ¢~/~' Standpipes (Y/N) '~ Depression over Tank (Y/N) Size 10"~ No. of Compartments '~/'J~' ~'~ Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) ~' ~. Date Last Pure pad ~,//'~ J~ "~' ~ 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 ; for J~/~l~ Temporary Holding Tank Permit (Y/N) J~'/~ To Building Foundation J O To Disposal Field i ' To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 72-026¢ 1/84] C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field 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 Type of System Design Length of Field ~-~I~o 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 Water Main/Service Line ~ I O To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Cutbank (if present) D. LIFT STATION NoNE Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, ol;,conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~r'~~ Date~ ! Company MOA No. Receipt No. ~ ~0'1 ~ ~ I~)''~''' Date of Payment /- ~-'~(::~ -- 0cX 7 Amount: $ /~..)~ , CJ ~ Page 2 of 2 72-026 (11/84) Engineer's Seal