HomeMy WebLinkAboutR & R BLK 3 LT 1
Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~L,V---/ ~q~ (¢ L// PIDNumber: O~O - '~75J-O
Name:
~'~-'~)v~.~ ~'¢~,/,~ v~ Wastewater System: [] New ~Jpgrade
Address:
72-,'5¢/ k/.i t,~ ~__,~ ABSORPTION FIELD
Phone: No of Bedrooms~ --r~. Deep Trench [] Shallow Trench [] Bed [] Mound [] Other
L E G A L D E S C R I PTI 0 N so, Rating Total Depth from original grade:
GPD/~q. Ft
Lot:/[BI°ck:~"~ ~_S ~c~tt/n~'Subdivisi°n: Depth to pipe bottom from original grade: Ft. Gravel. depth beneath pipe Ft
Township: / Range: e io Fill added above original grade: Gravel length:
Ft. Ft
WELL: [] New [] Upgrade Gravelwidth: Number of lines: Distance between lines:
Ft Ft.
Classification (Private. A,BC) Total Depth: Cased To Total absorption area: Pipe material:
Ft Fl SQ Ft
Driller: Date Drilled: Slalic Water Level: ~lnstaller: Date installed:
Ft.
__=Yi.~l~: GPM Pum~SetaL F, O~sin§HeighlAboveGrou~:: '-- TANK
S E PARATI O N D I STAN CES ~'~'eptic [] Holding [] S.T.E.P.
I From ~ank F,eld Stat,on Tank S ...... L ....A-~.~- "~,.-~, t~. ~ ~
Well J~,O --Material: ~ ~ Number of Compartments:
Surfaco
Water ~'~ '4 "~. LIFT STATION
Lot Size in gallons: Manufacturer:
Line
"Pump on" level al: "Pump off" level at: High water alarm at:
Foundation I
Curtain NJ, l Pump Make & Model Electrical Inspections performed by:
Drain
Remarks: BENCH MARK
"~----~ r~l~.L.~. '~.,.,¢ ..¢.~.-f..,-./~'~ ~ ~--~.~'*,.~-¢~ Location and Description: ~ ~ ~"~.3 L-.L~:~/~U (~
~ ~ ~ Assumed Elevation: ~-
ENGINEER,S SEAL
2nd
Department of Heal~ and Human Seruices approval
Reviewed and approved by: ~ /~' ~ Date: 4-/_4-~ .,, .
72 013 (Rev 9/91) MOA 25
S f E IYA £~ ~£l VE
94r~
TOP FOUN~O
]000 GAL. SEPTIC TANK
ANCHD. QAGE ~NK
SCALE: I~ ~ SO FT,
TBBBEN SPURKLAND P.E,
203 t¢ 151-H, AVENUE
ANCI4, AK, 99501
L£T ] 8L£CK 3 ¢ & R S/~
fREVDl~ NcD£NAL~
9239 HIGHLAND P£A~, EAGLE £IVEA~
SEPTIC SYSTEM AS BUILT
DARE: AP~°IL 9, 1994
SHEEI', ~/~. GRID, Sk/ 255
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW940064 DATE ISSUED: 4/06/94
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. EXPIRATION DATE: 4/06/95
OWNER NAME:MCDONALD TREVOR
OWNER ADDRESS: 0504510800088
PARCEL ID:06033109
LEGAL DESCRIPTION: R & R BLK
3 LT 1
LOT SIZE: 46399 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
SEPTIC TANK 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 (iSAACS0).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY: ~~
DATE:
LOT ~
R[PLACE CDLLAPSED
~ooo ?~ ~~ ~
N
~o 7~ ~oo 1~1 Eo
$CAL& 1' = $0 FT,
HILAND ROAD
TDBBEN SPURKLAND P,E.
803 V/ 15TH, AVENUE
ANCH, AK, 99501
LDT I BLOCK 3
TR[VBR NcDDNALD
9239 HIGHLAND P£A~ [A6L[ RIVER
SEPTIC ~YSTEN PLAN
DATE, APRIL ~ 1994
SHEET, I/1 GR~D,£M
oGRE"-ER ANCHORAGE AREA BO['
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
UGH
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION__
SEPTIC TANK:
DISTANCE
FROM WELL
'4
MANUFACTURER .~"~'~i'(' .~ ~/~.
MATERIAL
INSIDE LENGTH
INSIDE WIDTH
LIQUID DEPTH
NUMBER OF
COMPARTMENTS
LIQU,D CAPACITY /~/~ GALLONS.
SEEPAGE PIT:
NUMBER OF PITS / DIAMETER '''~2' £ OR WIDTH
-' - , LENGTH /~,! DEPTH 9/.
LINING MATERIAL ~6J'*¢/¢-% CRIB SIZE: DIAMETER ¢ DEPTH ¢" DISTANCE FROM:
BUILDING FOUNDATION ~Z/I NEAREST LOT LINE /~/~',,,F- TOTAL EFFECTIVE
ADDITIONAL ABSORPTION
WELL I/1/0t
ABSORPTION AREA (WALL AREA) ~ SQ. FT.
WELL:
TYPE ¢;//~Y CONSTRUCTION J ~4.~ ~//g(.., Y DEPTH
BUILDING gl~/ NEAREST
FOUNDATION LOT LINE_ '2L/` NEAREST '- "¢- SEPTIC
SEWER LINE /~ --, TANK
CESSPOOL
OTHER SOURCES_
APPROVED__ - DISAPPROVED
DISTANCE FROM:
SEEPAGE
SYSTEM
REMARKS
DISTANCES:
INSTALLED BY:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form No, LQ-031
DIAGRAM OF SYSTEM
APPROVED/~'~/4t /(~ ~
GRE:ATE:R ANCHORAGE AREA BOROUGH
D'~'PARTMENT OF' ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE:, ALASKA 99503
TELEPHONE 274-4561
SEWAGE DISPOSAL SYSTEM w APPLICATION AND PERMit
PERMIT NO.
'EGALDESCR,PT,ON
INSTALLATION OF: SEPTIC TANK
PHONE
SEEPAG~ PIT.
TYPE AND SIZE OF FACILITY TO BE SERVED __.~ )'~'~ ~ . /
FINANCED THROUGH TO BE INSTALLED BY
SOIL TEST RESULTS
FINAL INSPEC'I"ION: 24 HOUR NOTICE REQUIRED, BACKFILLING Oi~ ANY SYSTEM WITHOUT FINAL INSPECTION BY THe
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
BEPTIC TANK SIZE TYPE. ~'/~' - AREA BIZE TYPE
MINIIV~IJ~VI DISTANCES, R~(~UIREMENT~
FOUNDATIOH TO SEPTIC TANK
/
FOUNDATION TO SEEPAGE PIT ~
, DRAIN FIELD
/
BePtlC tANK TO SEEPAGE Pn' WAhl ____ / ~
SEPTIC TANK
-, SEEPAGE Pit
TO NEAREST LOT~/L NE.
, DRAIN FIE~D
., SEEPAGE PIT
SEPTIC 'rANI(, , SEEPAGE PIt ~/~/___., DRAIN FIELD
TO RIVER, LAI(E, Stream.
CAST IRON INTO AND OUT OP SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION ~ PEET iNTO UNDIS'rUrBED SOIl.
G R:AVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
DIAGRAM OF' SY~'rEM
I CERTIFY THAT I AM FAMILIAR V~/ITB THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM lB IN ACCORDANCE WITH SAID CODE.
Civil lSnoh~ovrs
229 EAS'F 51st. AVZ. FLO. o',,- - -,
-- ~u,~ 60~7 - ANCII()~AGk, ALASKA 99503
'IELEF'FIONE 907 2'/9--0:183 1El EXO(-}() 35319
JAMES W. FiOO! F", P. E.
MALCOLMA. ME ~Z [~S,P,E,,I_.,S.
JAMES i I. I/i_-- LI.MAN, P.F,
22, 1973
Gcolos'kts
....... L and Surt'oyor6-
RAI_Pl I R, IdI61.1ACCIO
~'g('J ..... ED
u !973 . if/I
', ........ ~x~i~c o~ a~ R & H No. 3665]
Hr, Donald Combs
4915 ['/esi: 84th Avem;e
Anchorage, AK
Test Hole m~d Soil Tog Rapo):t for SauJ. tary
R 6: R Subdiv!?,.c,n
Deal: z,.. Combs:
fle ara submitting herewith thc,. Cast bor:ing results and our comu~artt:s
rega~tdJ.ug soil (ondSticr).; encountered aL the subjoct site. This
investigation was performed in accordance with your request of
August J.6~ 1973, and those procedures outl:i_ned in a .letter dated
September ].3~ 1971 by Mr. Rolf Stricklnad of the Greater Auchorago
Area Eouough Departmaat of Environ ertal Qual:ity~
A single test hole was~ put down within thcz Block 3 area fo~t the
pt Cpo:~e og defin:[.ng ged(~:~'[ su. bsurf,oc~ ~;o['. conditions fo}: the
posed s~m[to.ry system. Excavation was accomplished ~.::~l:[t a trzc
laourH'ed b~]c. lchoe and Lbo t~:st hole was exl. am'e 1 t:o a tol:al ~ -
c.epth
]4.5 feat belLow g:cound r,,cfac:e. The fin. al log prepared : ' the
, - "-
~lo.l.e has bean iucludad in Drawing A---0 L.
l.ia af)prec::[ate [)eJn~ given, th:is ol)pockun[ty i:o be '': sa:,-'v:[ce to yot~.
TI[ - L
O, 0
MUNICIPALITY OF ANCHORAGE
Department
Development Services De
p pT Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 060-331-09
Certificate of On -Site Systems Approval
Ow Date, 11/b3/Z3
Expiration Dat
Legal description R & R BLK 3 LT 1
Site address 7732 HILAND RD
Current property owner(s) ERICKSON CHERYL ANN &RALPH W L
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
Original Certificate Date: 6/5/23
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent. professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory X Arsenic Advisory
Other
COSA Approval_June 2022
MUNICIPALITY OF ANCHORAGE
Development Services Department 1a Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 06033109000
Complete legal description R & RBLK 3 LT 1
Location (site address) 7732 H I LAN D RD
Current property owner(s) ERICKSON
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone 406-4846
3. TYPE OF WATER SUPPLY: 0 Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: 0 Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 29 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench W Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ -Sy Waiver Fee $
Date of Payment ��Z�e-lo -7� Date of Payment
COSA # O- G 2 Z 116 0 Waiver #
COSA Application—June 2022
COSA Checklist
Legal Description: R & RBLK 3 LT 1
Parcel ID: 06033109000
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 1973 Total depth unk ft
Cased to >51 * ft
❑■ Sanitary seal is functioning correctly
❑■ Wires are properly protected
Casing height (above ground) 36+ in.
Date of flow test for COSA 6/14/22
Static water level at beginning of test 47.9 ft.
Comments * MOA file
B. TANK DATA
Measured operating fluid level in septic tank 50
Date of pumping 8/17/23
❑ Required maintenance completed, if AWWTS
Comments: Steel, 29 yrs
D. ABSORPTION FIELD DATA
Which system tested (date installed) 8/22/73
❑■ ALL standpipes present per record drawing
Total measured depth from grade 12 ft (max)
Measured depth to pipe invert from grade unk ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
❑■ Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Comments/Deficienci
COSA Checklist June 2022
Well production at time of test 6+ gpm
Water storage tank volume0 gallons
Well disinfected for coliform test? ❑ Yes ❑■ No
❑■ Coliform bacteria is Negative
Nitrate 2.51 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑■ Arsenic less than MRL (ND)
Collected by NRimEng
Date 8/4/23
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 6/14/22
Results g Pass
Fluid depth prior to test 65
Water added 450 gal
New fluid depth 72 in
Elapsed time 30 min
Final fluid depth 65 in
in
Absorption rate 450 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 108 in
Effective depth used 65 in
Effective depth remaining 43 in
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
■0 Yes if No ft ❑■ Yes if No
Neighboring Tank > 100' R■ Yes if No ft Private Sewer/Septic Line > 25' *Yes if No
Absorption Field on Lot > 100' ❑■ Yes if No ft Holding Tank > 100' ❑■ Yes if No
Neighboring Absorption Fields > 100' Animal Containment > 50' ■❑ Yes if No
ft
ft
ft
ft
■0 Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' W Yes if No ft M Yes if No ft
❑ N/A— Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
■❑
Yes
if No
ft
Surface Water > 100'■❑
Yes if No _
Tank to Property Line > 5'■❑
Yes
if No
ft
Wells on Adjacent Lots:
Field to Property Line > 10'
■❑
Yes
if No
ft
Private Wells > 100'
❑■ Yes if No _
Water Main > 10'
❑■
Yes
if No
ft
Community Wells > 200'
Fm -]Yes if No_
Water Service Line > 10'
❑■
Yes
if No
ft
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
li
ft
ft
G. CERTIFICATION & STATENJENT 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm NorthRim Engineering
Engineer's Printcd Name Steve Eng
COSA Checklist June 2022
Phone 694-7028
Date 3/3/23
+P�� of Al No
Ar �I
s *: 49 r o
�... ..
c Steve Eng 0
1 CE -6256
N4 3/3%2
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907-343-7904
On-Site Water and Wastewater Section Fax: 343-7997
www.muni.org/onsite
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org
Septic Tank Advisory
Certificate of On-Site Systems Approval # OSC231160
Subdivision: R&R Block:3, Lot: 1
The septic tank for this property is 29 years old. The average life of an asphalt
coated steel septic tank is 20 years. Typical replacement costs are $10,000 or more,
not including engineering, surveying or MOA permitting fees.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
This is an example of what the metal of a 30 year old steel tank MAY look like.
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P,O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A S NGLE FAMILY DWELLING
Parcel I.D. #
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Day phone
Day Chone
Agent b,./~4 ~t ';i~ ~,~ ~i~ ~.~
Address - 7(¢~
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
Day phone
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
Holding tank
Community 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. 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 informat[on 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.
NameofFirm l'--¢~,~._~ ,_~u¢~,_L~(~ ~-E Phone ~?~-,'S~/~
Address ~11.0 ~ ~ I ~ ~d M Z o '~
Engineer's signature '~ - ~ Date l l/~4/"t~f
DHHS SIGNATURE
Approved for ,-~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
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. Em ployees 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.
72~25 (Rev. 1/91) ~ck MOA ~1
Legal Description:
A. WELL DATA
Well type ~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
RECEIVED
Municipality of Anchorage NOV 2. ~ 19~
DEPARTMENT OF HEALTH & HUMAN SERV CES ~u [~j,~l~l)
NICIPALITY OF A
Environmental' Services Division ENViRoN/dE.NT^L ,~ E 8VICL~"~i~r~, ~
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 "-~o u~w~loN
Health Authority Approval Checklist
Parcel I.D.:
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to ~ .~ !
FROM WELL LOG
Date of test
Static water level
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform ¢ Nitrate l,
Date of sample: It//~/~i& Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~/~y Tank size
Foundation cleanout (Y/N)
Date of Pumping l l~ '7/~._g...
C. ABSORPTION FIELD DATA
Date installed ~/?- 'z---/'7 %
Length l ~2 Width I r~
Effective absorption area ~ ~'~
Date of adequacy test / ~/U / fie
Fluid depth in absorption field before test (in.);
Fluid depth 7,~ (ins) Minutes later: ~._~
Peroxide treatment (past 12 months) (Y/N)
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
g,p.m.
Other bacteria
/4,-~ Number of Compartments ~ Cleanouts (Y/N) .
Depression (Y/N) Ix.I . High water alarm (Y/N)
Pumper ~,t~ ¢~,,---~
/
Soil rating (g.p.d./fF or fF/bdrm) ~ ~
Gravel thickness below pipe ~
Monitoring Tube present (Y/N).__~___ Depression over field (WN)
Results (Pass/Fail) ~ For ~
System type
Total depth
Immediately after ~'~ gal. water added (in.):
Absorption rate = ~ ~J~ ~ g.p.d.
If yes, give date
bedrooms
7~
72-026 (Rev. 3/96)*
LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at*
"Pump off" level at*
High water alarm level at*
*Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
.... ,,-,u ....... TANK ON LOTTO:
SEPARATION DISTANCES FROM
Foundation ~ Property line ;>/O Absorption field ~-~
Water main/service line ~> ~ O Surface water/drainage ~'"~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line ~ / ~ Building foundation c~- -~
Surface water
Curtain drain I-~ / ~
Water main/service line
Driveway, parking/vehicle storage area ' ~
Wells on adjacent lots ~> ! ~
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records that the'above systems are
in conformance with MOA HAA guidelines in effect on this date.
Signature
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment.
Receipt Number