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HomeMy WebLinkAboutDENALI VIEW BLK 2 LT 1Onsite File Denali View Block 2 Lot 1 #015-461-18 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP21358 PID Number: 015-461-18 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name RICHARD JABLONOWSKI ABSORPTION FIELD ❑ Deep Trench E] Wide Trench ® Bed E] Mound Site Address 8641 SULTANA DR, ANCHORAGE ® Other ADVANTEX Phone Number of Bedrooms Soil Rating Total depth from original grade 4 2 GPD/SF 1.5 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 1 Ft. Gravel depth beneath pipe 0.5 Ft. Subdivision Block Lot DENALI VIEW 2 1 Fill added above original grade VARIES 2.1-2.15 Ft. Gravel length 20 Ft. Township Range Section Gravel width 15 Ft. Beds: Number of Lines 3 Distance between lines 5 Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 300 FtZ -- -- Ft. Well 50'+ 50'+ __ 25'+ TANK ® Septic ❑ S.T.E.P. ❑ Holding ® Other ADVANTEX Manufacturer GREER TANK Capacity 1500 Gal. Surface Water 50'+ 50'+ -- Material HDPE Number of compartments 2 Lot Line 5'+ 5'+ __ NA Foundation 10'+ 10'+ -- LIFT STATION Manufacturer ORENCO Capacity 1500 Gal. Remarks DECOMMISSIONED EXISTING SYSTEM & INSTALLED NEW ADVANTEX SEPTIC SYSTEM w/ INSUL. Alarm location BASEMENT Electrical installed by CAPSTONE Installer A+ (BED/POD) & DENALI EX (TANK) PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Drainfield 3034 CO/MT 3034 Inspector FWC BENCH MARK (Assumed elevation) 100 ft Inspection ddates: I5` 10/19/21 2nd 7/26/22 Location and description 3 I 7/27/22 41h 7/28/22 TOP OF AX20 POD ON-SITE WATER AND WASTEWATER SECTION APPROVAL �, "�`.• ••'�:4 ►,l Conditional Approval: Date .� 0•• Septic System •••• •••••••••• �� Approved - �•, Curtis Huffman Date klslFR•, a/23/2z •-��c,��.. PROFESSION.: Note: this'approval does not include well permit requirements. kwv VJN 1 10) OSP211358 PID: 015-461-18 N1 SCALE, 1'1= 30' A -C=45.7' B -C=52,1' A -D=46.3' B -D=55.0' A -E=48,4' B -E=58.6' A -F=47.8' B -F=59.2' A -G=44,3' B -G=59.4' A -H=31,4' B -H=54,8' A -I=31.9' B -I=55.8' A -J=36.6' B -J=61.1' A -K=52.5' B -K=70.9' A -L=42,1' B -L=67,1' A -M=41.0' 20-L X 15'W BED (300 SF) - 2'OG PER MOA. INSTALLED CONSERVATIVELY 300+ SF (SQUARE FEET) AT -1.5 ORIGINAL GRADE (OG). REMOVED ALL BIOMATTED INSTALLED 1500-Gj L MATERIAL & ADDED REQUIRED ANCHORED HDPE Tj NK MOA SAND. ALL SEPARATIONS 100.10 FINAL GRADE 100,15 VERIFIED ON SITE ... I.E. INSTALLED FIELD 98.00 FIELD TO SEPTIC TANK OF 5' MT T MATH A+ EXCAVATOR, MOA & FWC. TH21-1 INSTALLED PER MOA PERMIT W/ Cp M 1, ORG/01- 93.42 1500–GAL ANCHORED CONVERSATIONS W/ REBECCA SEWER ROCK 96.50 96.50 HDPE TANK v CARROLL AT MOA. TM22-07 C� O CIo Mei ttDH -P SEPTIC SECTION H C SCALE, NTS 100' WELL CO RADIUS , LANDSCAPING / LOT 1 INSTALLED AX20 POD. BLOCK 2 85_.00/ SUBSEQUENTLY v cK FALL 2022 o DENALI VIEW BLOCK 2, LOT 1 SUPPORT SF®RVICES: 2 CP PREPARED FOR: RICHARD JABLONOWSKI & W OF AL Apr - G,�tcr L 30.5 0 x � \ o Z5 FCO \ 'LG1 RADIUS`r o BM: TOP OF POD FCO DFCO MT CO MT CO 99.91 oVrFR MH AX20 POD MFi 100.10 FINAL GRADE 100,15 98.00 INSULATION rFILTER FABRIC & INSULATION ORIGINAL GRADE /— TH21-1 7.50 DO AETAPPROX. 7.00 97.00 1, ORG/01- 93.42 1500–GAL ANCHORED –2.5' 4.00 SEWER ROCK 96.50 96.50 HDPE TANK TOP OF TANK GM/SM GRND.WTR. SEPTIC SECTION o 4.,V10/29/2021 SCALE, NTS OR 93.60 PER OWNER: 13 LANDSCAPING / BOF{ SOIL ADDED 85_.00/ SUBSEQUENTLY FALL 2022 DENALI VIEW BLOCK 2, LOT 1 SUPPORT SF®RVICES: PREPARED FOR: RICHARD JABLONOWSKI & SUSAN ROGERS wirs OF AL Apr - G,�tcr ANCHORAGE, AK 99516 FIRST WATER CONSULTING 13030 Sues Way Anchorage, Alaska 99516 (907)350-9566 firstwaterAK@gmail.com DATE: 08/24/2022 rtis Huffman ,-Q: SURVEY: JLS CE 128991 �P Alf DRAWN: FWCS 8/24/2022 e.A SCALE: 1" = 30'Fssio��' MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP211358 Work Type: SepticlzpgEk Upgrade Tax Code Number: 01546118000 Site Legal Address: DENALI VIEW BLK 2 LT 1 G:2741 Site Mailing Address: 8641 SULTANA DR, Anchorage Owner: JABLONOWSKI RICHARD & Design Engineer: FIRST WATER CONSULTING This permit is for the construction of: Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy Effective Date Expiration Date: t»cnt s Department Lot Size Size in Sq Ft: 40445 Total Bedrooms: 4 ❑ Private Well ❑ Water Storage All construction shall 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 shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing C0*za: a0' x 15' bed @ 2, �k TD; _PNV_' V7��Z'�� CO'S.Q �a. CAA q, � 4- `i M75 (0- _IPln L '_8 1 ► ( 2 2- Received By: Date: Issued By: Date: ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 015-461-18 Property owner(s) RICHARD & SUSAN JABLONOWSKI Day phone Mailing address 8641 SULTANA DRIVE, ANCHORAGE, AK 99516 Site address 8641 SULTANA DRIVE, ANCHORAGE, AK 99516 Legal description (Sub'd., Block & Lot) DENALI VIEW B2, L1 Legal description (Township, Range & Section) Lot Size 40,445 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field x C01 Initial ❑ Single Family (SF) ❑ (w/wo ADU) Septic Tank El Upgrade Fx� Duplex ❑ (D) Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. gnature of property owner or autnorized agent) Permit/Rush Fees: 9,25 j' 0 .Co Waiver Fees: Date of Payment: 23 ao� Date of Payment: Receipt Number: a A -3 (o 15 Receipt Number: Permit No. 6S F:2 1 1 3 5Fs- Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc W# 1 FFS[ } C O N S U L T I N G V . 13021 Montego Circle, Anchorage, AK 99516 907-350-9566 / FirstWaterAK a,gmail.com April 27, 2022 Municipalities of Anchorage On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC SYSTEM UPGRADE PERMIT LEGAL: DENALI VIEW BLOCK 2, LOT 1 The new HDPE Greer tank was installed and anchored per the MOA permit last fall by Denali Excavation and it was found at that time the septic field was saturated and within 100' of the surface water to the north. We had discussions with Tom Varney of Anchorage Tank, Denali Excavation, the owner and MOA staff and it was determined to complete the tank install and install Advantex components this summer 2022. We did a test hole at that time, which results are attached. Attached also is the design change from a tank to a complete septic system. We have asked the owner to complete the attached MOA AWWTS and will get it back to you with the MOA septic permit fee. The slopes are moderate at 5%+/- at the proposed upgrade location. The lot and area are served by private water. The design will not impact any of the neighboring properties and will be 50'+ to any surface water or private wells. Please contact us if you have any questions. Sincerely, w Curtis Huffman, P.E. Attachments: 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / firstwaterAK@gmail.com August 18, 2021 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: DENALI VIEW BLOCK 2, LOT 1 The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic tank on the above referenced lot. We propose to install a 1500-gallon HDPE tank per the attached design to serve the existing 4-bedroom residence. The lot and area are served by private wells. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211358, Rebecca Carroll, 08/25/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211358, Rebecca Carroll, 08/25/21 DESIGN CALCS: 4 BDRM X 150 GPD = 600 GPD 600 GPD/2 GPD/SF, = 300 SF SAS 300 SF / (15' BED) = 20 FT. TRENCH USE 1 TRENCH - 30' (L) X 15' (W) X 0.5'(ED) TOTAL DEPTH FROM EXISTING GRADE, -1' FROM ❑G USED REDUCED APPLICATOIN RATE CAN INSTALL 20' BED VS 30' LONG IF PRESSURIZED WITH PUMP BASIN USE; 75 LF 1 1/4' PVC WITH 3/160 HOLES @ 2,5' SPACING (TYP) OR 4' W/ COs NOTES: STAKE PROPERTY LINE & WELL RADIUS PRIOR TO CONSTRUCTION NO SLOPES >25 o WITHIN 50' OF PROPOSED I(�FIELD. I I ' N jn O OJ to N µ N ' I ' w 10 � I N'� ' ON O CO zo IU v ' I 0 r x I 30' I i I N89 56.45'E 130.09' (150.00' R) 10unun mar GRAVITY -FED FIELD IS ASSU COS AT THE END OF EACH E PIPE & MTS AT EACH CORNE DIED & INSTALL STRIBUTION R OF 30'L X 15'W BED. � N Z 0 MAY PLACE Flf3D ` 0 O phi UP HU WAN w YESHM TD AVD®MT Eli NEW SYSTEM EC+ PCD To 'SMAIS+' g SURFACE WATER LOT 1 REMOW a REPLACE OMMO FEW Few P1To �CONNST. VM A /6' X XY BED. New NEWF HDPE a AN oo P W/ PUMP PUMP FP BA5D1 F RMDENAU TANK RISTALIM DY � EXCAV. ,x L� NEW Yr. TIM -1 yr / �IIATr ROAMMC A!>0 YW SAF®d DD MT BED AS DESIp7 f N MAY PLACE Flf3D ` CD phi UP HU WAN w YESHM TD AVD®MT E7D L6 MN PCD &DEUR SIAM Mile LOT 1 Few P1To �CONNST. .L BLOCK 2o a ,x L� G'_ PAYED D/W / Y MELE NEXNBORS ® PAVED D/kl N8955'59"E 147.19' (147.11• R SULTANA DRIVE CA 0 LOT 2 BLOCK 2 SEPTIC AREA NO WELLS qITHIN 1 00'OF NEW ODPE SEPTIC TANK DENALI VIEW BLOCK 2, LOT 1 ®SERVICES: PREPARED FOR: OF At,4 RICHARD JABLONOWSKI & SUSAN ROGERS �� V` 8641 SULTANA DRIVE '7 ANCHORAGE, AK 99516 'C * 9 TH FIRST WATER CONSULTING Jlt`'i,, DATE: 4/26/2022 rtis Huffman 13030 SUES WAY SURVEY: JLS r n CE 128991 AO DRAWN: FWCS4/26/22 ANCHORAGE, AK 99516 SCALE: 1" = 50'ssto��' 907-350-9566 FirstWaterAK©gmoil.com PAGE: 1 OF 2 Ell DESIGN DETAILS: REMOVE AND REPLACE EXISTING FIELD WITH A NEW 15' X 30' BED USING MOA APPROVED SAND. AND ADD A AX20 POD THAT WILL BE GRAVITY FED TO THE FIELD. IF ELEVATIONS CANNOT BE MAINTAINED ADD ANCHORED LIFT STATION TO BED. ADD COs AT END & START OF FIELD IF NOT PRESSURIZED WITH SUMP BASIN & IF PRESSUIRZED JUST ADD MTS. INSTALL PER AMC 15.65 & 15.55 ,,,BEDDING, SEPARATIONS, MATERIALS,,. N N N W � W N 00 N O co Z o G-. REMOVE & REPLACE EXISTING FIELD WITH A 15 X 30' BED, 0 o & INSTALL AN AX20 POD I I W/ PUMP BASIN IF REQ. 0 0 REMOVE BIOMATT ADD MOA SAND & BED AS DESIGN / MAY PLACE FIELD UP HILL WAN 30' TESHOLE TO AVOID BIOMATT. LOT 1 BLOCK 2 PAVED D/W DENALI VIEW BLOCK 2, LOT 1 PREPARED FOR: RICHARD JABLONOWSKI & SUSAN ROGERS 8641 SULTANA DRIVE ANCHORAGE, AK 99516 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 TH21_1 MT CP Co MTt l\ EXISTING MT FirstWaterAK©gmail.com NEW HDPE SEPTIC TANK INSTALLED BY DENALI EXCAV. NEW MTs I ® MT O ;O 7s DCO mr- O Cl Cn N J O -P Cn STAKE WELL Uw RADIUS V�N PRIOR TO_),OX' W � X � <+ 2.5 \ FCO $ 5 ��G� 1'x•0 X yoGSt�` o LOT 2 BLOCK 2 SEPTIC AREA N W WELLNEIGHBORS ® PAVED D/W SUPPORT®SERVICES: OF Ator C 9TH DATE: 4/26/2022 rtis Huffman 04 SURVEY: JLS CE 128991 DRAWN: FWCS 4/26/22v$ SCALE: 1" = 30,r'Esslo��' PAGE: 2 OF 2 N II NEW SYSTEM 50'+ TO "SWAMP" SURFACE WATER REMOVE & REPLACE EXISTING FIELD WITH A 15 X 30' BED, 0 o & INSTALL AN AX20 POD I I W/ PUMP BASIN IF REQ. 0 0 REMOVE BIOMATT ADD MOA SAND & BED AS DESIGN / MAY PLACE FIELD UP HILL WAN 30' TESHOLE TO AVOID BIOMATT. LOT 1 BLOCK 2 PAVED D/W DENALI VIEW BLOCK 2, LOT 1 PREPARED FOR: RICHARD JABLONOWSKI & SUSAN ROGERS 8641 SULTANA DRIVE ANCHORAGE, AK 99516 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 TH21_1 MT CP Co MTt l\ EXISTING MT FirstWaterAK©gmail.com NEW HDPE SEPTIC TANK INSTALLED BY DENALI EXCAV. NEW MTs I ® MT O ;O 7s DCO mr- O Cl Cn N J O -P Cn STAKE WELL Uw RADIUS V�N PRIOR TO_),OX' W � X � <+ 2.5 \ FCO $ 5 ��G� 1'x•0 X yoGSt�` o LOT 2 BLOCK 2 SEPTIC AREA N W WELLNEIGHBORS ® PAVED D/W SUPPORT®SERVICES: OF Ator C 9TH DATE: 4/26/2022 rtis Huffman 04 SURVEY: JLS CE 128991 DRAWN: FWCS 4/26/22v$ SCALE: 1" = 30,r'Esslo��' PAGE: 2 OF 2 First Water CONSULTING : 13030 Sues Way - Anchorage, Alaska 99516 Tel. 907-350-9566 firstwaterAK &gmail.com SOILS LOG -PERCOLATION TEST LEGAL DESCRIPTION: DENALI VIEW B2 L1 DEPTH FEET OG SOILS ORG/OL 1 2 3 GM/SM 4 5 6 7 8 9 10 11 12 13 BOH 14 15 16 17 18 19 20 .... ....�:.`.~:.. • • Curtis Huffman CE 128991 . •'c`�c�,�� ��B�FAF�pROOL2. �.+�Aw PERFORMED FOR: RICHARD JABLONOWSKI TESTHOLE # 21-1 DATE PERFORMED: 8/27/21 GROUND WATER ENCOUNTERED: YES IF YES, AT WHAT DEPTH: 8' DEPTH TO WATER AT MONITORING: 4.4' DATE: 10/29/2021 SEE SITE PLAN FOR SLOPE & LOCATION COMMENTS: VERIFY GROUNDWATER MT AT TIME OF CONSTRUCTION Reading Date Gross Net Time Time Depth to Water Net Drop 8/28/21 30 min 6" 1 1/16" 30 min 6" 1 1/16" 30 min 6" 1 1/16" PERCOLATION RATE 28 (MIN/ INCH) TEST RUN BEWTWEEN 2 & 3 FT PERC HOLE DIAMETER 6" PRE-SOAKED PRIOR TO TEST & ALL READINGS TO THE 1/16TH PERFORMED BY: FWCS / FWC - I CURTIS HUFFMAN CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE & MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 10/29/2021 F- - � 30' I N 89'56' 45"E 130.09' (150.00' R) ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: DENALI VIEW SUBDIVISION LOT 1 $LOCK 2 PLAT 77-153 SURVEY CERTIFICATE: 1, John L. Schuller, Have conducted a physical survey of this properly as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance should any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to detemrine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. JUNE 25. 2021 1 1"=30' 1 achulleraak.nat 21-06,5 7 am MEM 77 SW2741 210201 SULTANA DRIVE * = FND 518" REBAR AL'k,>r �fi�R 49, H -JOHN L. SGC�H/H 1L ER.- o` 1� LS -10408 a c� r1►r°fessionot �"o� w 0 4 xi CL � fir` � � n r 'q 1831 Talkeetna Street Anchorage, Alaska 99509 (907) 827-1455 office (907) 274-4992 fax MUNICIPALITY OF ANCHORAGE  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME 'PHONE I~NEW MAI LING ADDRESS LEGAL DESCRIPTION LoT/ / ~Aocl4 ~ ~N~I ~1~ LOCATION NO. OF BEDROOMS DISTANCE TO: NOT I~1 NOT Material~ ~'~ No. of com~t~ ~ Manufacturer ~ ~ ~ ~ ~ Liq, capacity in gallons ~ Inside length Width Liquid depth ~ IF HOMEMADE: Well Dwelling ~ PERMIT NO, 9 ~ ~ DISTANCE TO: O ~ Manufacturer Material Liquid capacity in gallons Foundation Near.sI ~t ¥. Pe~MIT~N~NO. q~= DISTANCE TO: WNoT~I' I~I ~OT ~ ~ No. of lines Length o~a~line Total length of lines Trench width Distance between lines ~ inches - ~ ~ Top of tile to finis~ grad~ ~ Material beneath tile ~/ Total effective absorption area Length Widt~ Depth PERMIT NO. ~ p Type of crib Grib diameter Grib depth Total effective absorption area m Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class ~ Depth Driller Distance to lot line PERMIT NO, ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER ~,~ [--~ ~ ~ I PIPE MATERIALS I SOIL TEST RATING INSTALLER REMARKS ~ / . ~ % - . APPROVED DAT~ LEGAL 72-013 (Rev. 3/78) Box 1369, STAR ROUTE A ANCHORAGE, ALASKA 344 SIX INCH WATER WELL DRILLED AND CASED OUT .TO THE DEPTH OF 370 DRILLED AT THE RATE OF ~22.00 PER FOOT. ~e l~-,o,t. 300 CZ ortho ~ & [l~. g, Lcd, 2zl~,Lorra~,ok.,L 276-5261 34,4-5893 PROPERTY OWNER LOCATION Of WELL SITE DRILLER WELL LOG: 0 .... 11 '~ $,td. tq. ~an, d~ ave,uz,tC¢.~ 1.6 9add.a~ a.~ ~a,f,e,t. pe~ ¢,L ~ e.,e~e. R,bou, t. 500 9x:zdd, an~ ,et. an.ct 1,'ti,. Ch,e tra4,oe .ou, lmre~,t,b. Le. pum¢ .droud, ct he ,lr~~ ,t.a 350 CZ. 2880 ¢a, bLan~. a.u'a. LZa, b. le.. p,ea. 24. /'~u,t. ~ ¢.,.t.a,~. / "x~c~'~tl N~U~ "'~nl OF HEALTH & _.. t-'~:'. ,,',,.:~,rT AL p?,OT ECT~,ON Co.,,t, 0¢ ~4X, tZX~: t122.00 p.e,,r CZ. × 300 CZ: ~I6600.00 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUMf/OF '~'00.!0 '~ BERNIE CLAUS OF RAMPART DRII.&LIN6 ~ERVICE CHARGEOF 1~% PER MONTH WILL BE ASSESSED . DEPARTMENT OF HEALTH AND EN ON ~AL F'~OTE6' 82.5 L STREE]', ANCHORAGE.,, AK 99501 ,-' 64-47.-' ¢ OINl'--~--::~ ! 'I"E ,~:iE::WER .~-.~ WELL PE!FR~ I T PERM I T NO: DATE ISSUED: 84c.)6~ HAND WRITTEN /.-.6/84 APPL I CANT: ADDRESS. - CONTACT PHONE: RICHARD JABLONOWSKI 1820 CONGRESS CIRCLE ANCHORAGE~ AK 99507 176-5261 LEGAL DESCRIP: LO]' SIZE: SLIBDIVISION: DENALI VIEW SECTION: 24 TOWNSHIP: 40445 (SQ.FT. OR ACRES) LOT: 1 BLOCK: 12N RANGE: :F.,W I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set # forth by the Municipality o¢ Anchorage (MOA) and the State of Alaska. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria o~ this permit. I will adhere to all MOA and State of Alaska requirements {or the set 'back distances £rom any existing well.~ wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. IF' A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA B[JIL. DIN6 CODES.~ THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL. NOT BE AF'F'ROVED WITHOUT AN ELECTRICAl.. INSPECTION REPORT; AND (5) THE: ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED APF'L I CANT :'~ I CH~;'~;LONOWSK I - o-'-'¢ / MUNICIPALITY OF ANCHORAGE Department :. Health and Environmental ~rotection 825 _, Street, Anchorage, AK. 3501 ~0 ~' 264-4720 Permit ~ ~30~x * * * HANDWRITTEN PERMIT * * * WELL AND/OR ON-SITE SEWER PERMIT Applicant: p,~C~ ,~.~6~$~i... Mailing Address: 3~O2 Location: 7'--~'.)._/t/ ;~-,-,7~.~d ~'~'.~.. a"-~ Phone Number: Legal Description: ~-I ~l~ b~4n.~_~i&~ ~ Lot Size: _~/~,,.~- Type of Soil Absorption System Is: Trench: Drainfield: Seepage Bed: / Holding Tank: Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br) ~/~ The Required Size of the Soil Absorption, System Is: DEPTH ~/~ LENGTH ~O~'-~' GRAVEL DEPTH o~- WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). · * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~-O GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. · * * TW0(2) INSPECTIONS ARE REQUIRED * * * Backfilling Of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. · * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the r~es~dence is remodeled to include more that 3 bedrooms. Date: "In the event that a lift station ]s 'lnetalled an elect;ical permit and inspection must u~ ~~ SWP/024 (1/81) obtained. As-builts cannot be approved til the electrical inspection is received in this office. The electrical work must be per- formed by a licensed electrician? Permit UNICIPALITY OF ANCHORAGE Department ~ Health and Environmental ~rotection 825 L Street, Anchorage, AK. 99501 264-4720 * * * HANDWRITTEN PERMIT * * * WELL AND/OR ON-SITE SEWER PERMIT Applicant: ~,'~ .~6~J~$~... Mailing Address: Location: T.{~ ~,~ ~ ~ Phone Number: Legal Description: L~% / ~lk ~ ~~i~3 ~ Type of Soil Absorption System Is: Trench: Drainfield: Seepage Bed: Maximum Number of Bedrooms: _ ~ Lot Size: ~/~, / Holding Tank: Soil Rating(sq.ft/br) ~2~/~ The Required Size of the Soil Absorption~ System Is: DEPTH ~ ~ ' ~ LENGTH ,,..~$_-z/ GRAVEL DEPTH o<~' WIDTH ,-~'//- The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = ?~'~ GALLONS * * Permit applicant has the responsibilitY to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this departme~ will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fe~ for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER ~1~ 1 9 ~ 3 * * * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that 3 bedrooms. Signe':~.~~0 (~,_.~_.~ ~--I~ Issued by:~/,~. Y/~~f... _ ?~i.~'~,,~ Date: "In the event that a lift station lS ln~tal~ed an elect,~cal permit and inspection must un.~."'~L~ SW~/024 (1/81) obtained. As~builts cannot be approved til the electrical inspection is received in this office. The electrical work must be pe~ ~rm~ by a licensed el~trician.~ SOILS LOG ) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERCOLATION TEST 3 4 7 8' z 8 11 12 13 DATE PERFORMED; SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? SITE PLAN I i - Gross Net Depth to Net Reading Date Time Time Water Drop +~,zo i 0 :lq ,5~ · 4 tqz¢ IO:~q ,51 PERCOLATION RATE ~__ .e3 3 (minutes/inch) 14 15 16 17 18 19 2O . . / . TESTFJUN BET~EE~J~, -3 . FT~,AND, ._~.'6 FT 72-008 (6/79) MUNICIPALITY OF ANCHORAGE o Development Services Department s Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel 1. D. 015-461-18 Legal description Denali View Block 2 Lot 1 Site address 8641 Sultana Dr, Anchorage Ak Current property owner(s) Richard Jablonowski Expiration Date: X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for Comments or advisories: 1-4-2023 bedrooms, with the following stipulations: Original Certificate Date: 10-4-22 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 Arsenic Advisory Other COSA Approva"une 2022 MUNICIPAUTY OOiF ANCHORAGE Development Services Department 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. 015-461-18 Complete legal description DENALI VIEW BLOCK 2, LOT 1 Location (site address) 8641 SULTANA DRIVE, ANCHORAGE, AK 99516 Current property owner(s) RICHARD JABLONOWSKI & SUSAN ROGERS Day phone 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: ® 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: ❑ Steel ® Plastic ❑ Concrete ❑ Fiberglass Age <1 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ® AWWTS ® Bed ❑ Deep Trench ❑ Wide Trench ❑ 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 $ o� iib Date of Payment el 11 iaaZ 0 a�b�� b COSA # 062Z 2 f L.Q?, Waiver Fee $ Date of Payment Waiver # COSA Application.doc • Legal Description: DENALI VIEW BLOCK 2 LOT 1 Parcel ID: 015-461-18 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) Water storage tank volume NA gallons Date drilled 8/1984 Total depth 370 ft Well disinfected for coliform test? ® Yes ❑ No Cased to 56 ft ® Coliform bacteria is Negative ® Sanitary seal is functioning correctly Nitrate 4.01 mg/L ❑ Nitrate less than MRL (ND) ® Wires are properly protected Arsenic ug/L ® Arsenic less than MRL (ND) Casing height (above ground) 24+ in. FWi5 Date of flow test for COSA 8/11/2021 Collected by & 907 WATER WELLS Static water level at beginning of test 61 ft. Date 8/16/2022 & 8/24/2022 (TESTS: SGS & AWL,) Well production at time of test 1.1 gpm Comments 907 CHLORINATED WATER SYTEM AND TOOK NEW, ATTACHED COLI. B. TANK DATA Measured operating fluid level in septic tank NEW Date of pumping NA — ADVANTEX <1 YR ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) NEW FIELD ® ALL standpipes present per record drawing Total measured depth from grade 3.65 ft (max) Measured depth to pipe invert from grade 3.15 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) N If yes, enter date C. LIFT STATION ® Required maintenance completed Age of lift station years Lift station material Comments: NEW ADVANTEX SYSTEM Adequacy test date NA — NEW Results ,❑ Pass Fluid depth prior to test _ in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 6 in Effective depth used 0 in Effective depth remaining 6 in Comments/Deficiencies: CO/MT AT EXISTING GRADE. NEW 4BR ADVANTEX SYSTEM. US COSA Checklist—July 2022 copy 2.docx 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' ❑ Yes if No *50+ ft ® Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No *50+ 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 ❑ 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 *50+ ft Tank to Property Line > 5' Field to Property Line > 10' Water Main > 10' Water Service Line > 10' F. ENGINEER'S COMMENTS ® Yes if No ft ® Yes if No ft ® Yes if No ft ❑ Yes if No *50+ ft Wells on Adjacent Lots: Private Wells > 100' Community Wells > 200' ❑ Yes if No *50+ ft ® Yes if No ft If tank or field is under driveway comment below *MAY MEET CONVENTIOANL SEPARATIONS, BUT SYSTEM MEETS CATIII SEPARATION DISTANCE REQUIREMENTS. G. CERTIFICATION & 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, 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 FIRST WATER CONSULTING Phone 907-350-9566 Engineer's Printed Name CURTIS HUFFMAN PE Date Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. 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 in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. 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, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & FWt 5 COSA Checklist—July 2022 copy 2.docx 9/20/2022 At V.� ..k•.. . .T •• ....�. Curtis Huffman � 4i ! �c�`•% CE 128991 c�`�lF • . 9/20/22. • •� .W ...... O PROFESSOW MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and entered into as of this ISS Day ofS T,n{�,ItY1�Cjc_y' of 20 ZZ, by and between =ij�rc`t��Q�14(t ,herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as AN ADVANTEX SYSTEM located at (legal description) DENALI VIEW BLOCK 2, LOT 1_ _ 2. Maintenance, Repairs and Alterations. 1 (Owner is required to read, understand and initial each section) 4 Throughout the term of this Agreement, the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. It shall be the responsibility of the Owner during the term of this Agreement to a for a P �' �' pay all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to $600). Owner agrees that only maintenance and repair personnel approved by the Municipality AA1h or the manufacturer's representative will inspect and make any necessary maintenance, NVArepairs or permitted alterations to the system. 'Owner acknowledges that regular maintenance AWWTS g g nance of an A reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. 05/18/2018) Page 1 of 3 1� v Onwner acknowledges that the Municipality may request records of maintenance and repairs from the manufacturer's representative or maintenance provider. ` Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. agrees to grant the Municipality reasonable access to test and inspect the AWWTS. The Municipality will give at least 24-hour notice. 'Owner agrees that any sale or transfer of title of theropertY will not occur without a new p Certificate of On-Site Systems Approval. wner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing `"guidelines for the construction, maintenance and repair of the Owner's AWWTS. Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constituk!e a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7. Severability. Any provisions of this Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev. 05/18/2018) Page 2 of 3 STATE OF ALASKA ) ss. THIRD JUDICIAL DISTRICT ) Dater e) The foregoing instrument was acknowledged before me this day of�� 202-2, by _ M(IYCk t\)?jkQn PRf N TARY P LIC FOR ALASKA �'`;'••'' ''•a My Commission expires: =n,r®V MUNICIPALITY: By: (signature) (print name) (rev. 05/18/2018) PUBLIC:* * Date: ff " 26 - Z Z Title: Page 3 of 3 T,LC N00'03'15"W 270.46' (270.13' R) �tiJ�� co u� 32.8' V30 �� o o nz m 0to ui z � �V) in CD x x x ¢ � ¢ '4N 'd' W � D N Z J to to CQ / _1, ,pCh ,L'i O CD O v>> LnX/X � J � 'y o �N 0O>� x O % I- W > .. s �q 3 �0 2� 3 ✓ a• O r F, C6 Or •' O J `- CV v U p W : SA W D] a Q Q a o E+I u a oLli� 0,3 LO z Lo 00 0 Y o z cn 3 4s N _ o o°� c o "U, �96 6�Z x y � � 80 _ �� C, ® ,0 •� t. bA O 6 R z ch 65.A o� ..gpN) ' «9"N3o�'-p; · MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 1. General Information Application Date .,,N~ (a) Legal Description (include lot, block, subdivision, section, township, rang.e)/ Location (address or directions) (b) Applicants Name Telephone, - Home g2 ~ -17 ?& Business , Telephone ~-o 7~-'~'t:~ Applicants Address ~& g/ 5~%r~%~¥~ ~_ (c) Applicant is (check one.) Lending Institution ~--~ Buyer ~ ; Other ~ (~plain) (d) Lending Institution Address ~S~,/~'~ c (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single-Family.~-'[, Number of Bedrooms 3. ~ater Supply Individual Well~ Multi-Family ~--~ Other (describe) Community ~-~ Public ~-~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal 0nsite ~ 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] En~ineerin~ Firm Providing Inspections~ Tests~ File Search~ Data and Information As certified by my seal affixed hereto and as of the validation date shown~below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wast.water 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 wast.water disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Address Date DHEP Approval Approved for Approved ~ Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ~NCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOIiELY UPON THE REPRESEWI'- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/eJ/D18 [Page 2 of 2] 7-19-84 ae MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Cased to Well Classification Well Log P~esent (Y/N) y Total Depth ~ 70 Static Water Level kO casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Legal Description: .~(~- I :~%(O-. If A, B, c~ C, D.E.C. Approved(Y/N) Date Completed Pump Set At Av~, ~~ Yie ld_~7~ Depth of Grouting ~O N ~ Sanitary Seal on Casing (Y/N))/ Depression Around Wellhead (Y/N) ~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~l~ ; On Adjoining Lots .... To Nearest Public Sewer Line NO N ~ To Nearest Public Sewer Cleanout/Manhole NO ~ ~ To ~Nearest Sewer Service Line on Lot Water Sample Collected By Water Sample Test P~sults , C~=~ents B. SEPTIC/HOLDING TANK DATA Date Installed .]~)~.~ IC~'.'/ Size I~O No. of Compartments Standpipe (.Y~) 7~ ai~-tight Caps (Y~) ~ Foundation Cleanout ~ession o~ Ta~ (Y~) ~ Date ~st P~d ~ ~ P~ing~intenan~ Con,act ~ File (Y~) ~ ; for Holdin~ Ta~ High-Wate~ ~a~ (Y~) N/~. ~ra~y Holding Tank Permit (Y~) Sep~ation Distance ~ ~ptic~olding Tank: To Water-Supply ~11 ~ ~ ~ To ~ilding Foundation To ~o~rty Li~ ~ To Dis~sal Field To ~ter Main/Se~vi~ Li~ ;O + To S~e~, ~nd, ~e, ~ ~jor ~aina~ cou= N C~nts [Page 1 of 2] Receipt # Date Paid: Amount: ~ 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 3 U~ J ~ ~ ~ Width of Field ~ ~ Type of System Design Length of Field ~ ~ ~7 Dept~ of Field .~ ', ~-~ · ~;/I Gravel ~d Thickness ~ ~ Stan~i~s ~esent (Y~) ~te of ~st A~qua~ Test ~ ~ ~/~ Square Feet of Absorption A~ea I ~ ~ ~ Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply W~ll v- To P~operty Line ~ 7 TO Building Foundation ~ ~ To Existing or Abandoned System cn Lot ~ ~ ; On Adjoining Lots ~O To Water Main/Service Line I 0 ~ . To Cutbank( if p~esent) To Stream/Pond/Lake/or Majo~ Drainage Course To Driveway, Parking A~ea, o~ Vehicle Storage A~ea Ccnm~nts ~. ~ STAT~O~ N 0 N ~ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested fo~ E le ctr ical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy; 'I%st. Weets MOA Con~ents ** Check Permitted Bedroom Rating Against HAA Request I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. Signed ~ Company Date //' ~OA ~o. ,~ ~'~?-o ~! KB1/dL/s [Page 2 of 2] ~. No. 2225-E 2-15-84