HomeMy WebLinkAboutCINERAMA TERRACE BLK 2 LT 5AOnsite File
5
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,(.,) C~?O ~,~--t '~ PIDNumber: C:) ~-¢~.'~
Name:/~ ~ ~ ~:~ 7 ~ ~P ~ Wastewater System: ~New ~ Upgrade
Address:
ABSORPTION FIELD
Phone: ~4~ ' tT~ I [,o. of Bedrooms~ ~ Deep Trench ~hallowTrench ~Bed ~Mou,d ~Other
Total Depth ?om original grade:
LEGAL DESCRIPTION ~og,a~i.,~ . ~ ~S,.,,. 5 · E '
Lot: ~ Block~~; ~Subdiv~i°n: T~ Depth to pipe~ bottom¢ ~ from~ original grade: FL Gravel depth~ bene[~ ~ pipe Ft.
TOW.Ship:~ ~ JRange: ~W ISect`O': I FiHaddedaboveoriginalgrade: Ft. Gravellength:/~ Ft.
'1
Number of lines: 0istance baleen lines:
WELL: D New D Upgrade Gravelwidth: ~ FL
' Classification (Private~,B,~:~_ ~ Total Depth: Cased To: Total absorption area: Pipe material:
Driller: Date Drgled: Static Water Level:Ft. Installer'~tZ~ ~; Date instal~,d:
Yield: Pump Set ~ ~ Casing Height Above Ground:
~P~ .t. Ft. TANK
SEPARATION DISTANCES ~Septic D Holding ~ S.T.E.P.
To Septic Absorption Lift Holding )ublic/Private ~anufacturer~ ' Capacityin galrons:
From Tank Field Station Tank Sewer Lines ~ ] ~ ~
Wel~ ~ ~ ~ ~ Material:~+~ ~/ NumberofCompa~ments: ~
SudaCewater '~ ~ ~ LIFT STATION
Line ~' /~ ~A ~ M4 Size nufacturer:
Drain ~ ~ ~ ~ Pump~a~& I~oldoal
Remarks:' ~ ~p~i~ ~ ~ ~ BENCH MARK
ENGINEER'S SEAL
~P~- ~- ~"%.%5~ ,~
Inspections pedor by: ~O~ E.._¢?~..,.,''''~,~z~ ~:,:'~
partment of Heall~nd Human ~e~ces approva~ ~,~ ~, ::,z,
Reviewed and approved by: Date: '17:
72-013 (Rev. 9/91) MOA 25
SW970323
AS BUILT PLAN
FROM TO DIST.(FT.
CO1 Pt. A 43.7
CO1 Pt. B 24.8
MT1 Pt. A 44.8
MT1 Pt. B 23.2
STCO1 Pt. A ,89.5
STCO1 Pt. B 85.6
CO2 i Pt. A 117.8
CO2 Pt.B 116.4
MT3 Pt. A 72.9
MT3 Pt. B 67.2
STCO2 Pt. A 71.8
~, STCO2 Pt, B 76.7
MT2 Pt. A 117.4
MT2 Pt. B 115.2
I
JAMES SIZEMORE & ASSOCIATES
CIVIL ENGINEERS & SURVEYORS
FROM TO DIST.(FT.
CO1 Pt. A 43.7
CO1 Pt. B 24.8
MT1 Pt. A 44.8
MT1 Pt. B 23.2
STCO] Pt. A 89.5
STCO1 Pt. B 85.6
CO2 Pt. A 117.8
CO2 Pt. B 116.4
MT3 Pt. A 72.9
MT3 Pt. B 67.2
STCO2 Pt. A 71.8
STCO2 Pt, B 76.7
MT2 Pt. A 117.4
MT2 Pt. B 115.2
Page ~'~ of .~
Municipality of Anchorage
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
72-013 A (Rev. 9/91) MOA 25
MUNICIPALITY OP ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT
Initial
Permit Number: SW980397
Legal Description: CINERAMA TERRACE BLK 2 LT 8
Design Engineer: 0027 James Sizemore & Associates
Owner Name: Randy & Crystal Lipps
OwnerAddress: 12761 OLD SEWARD HIGHWAY
ANCHORAGE, AK 99515-3509
Date Issued: Oct 06, 1998
Expiration Date: Oct 06, 1999
Parcel ID: 020-033-17
Site Address:
Lot Size: 75083 SQ. FT.
Total Bedrooms: 5 Permit Bedrooms: 5
This permit is for the construction of:
[~ Disposal Field [~ SepticTank ~ Holding Tank [] Privy
Private Well [~ Water Storage
All construction must be in accordance with:
I. 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 DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 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.
The following special provisions.
Must have 2' of approved sewer rock under perf pipe.
(VACANT>
LOT 5
NORTH
(UNDEVELOPED)
\~ROPUSF~HOUSE
LOT 8, BL_K ~ CINERANA TERRACE SUBJ}IVISION
PROPOSED g/ELL ~ SEPTIC SYSTEM
SITE PLAN
JAMES SIZENORE ~ ASSOCIATES
ANCHORAGE, ALASKA
TEL: (907)345-157~ FAX~ (907)345-~6~9
DR~'N BY, RRL ~ BY, JFS ~ 0(~-09-S7
iSCALE, ]'=100'__ IGC, ~SHEET, 1 OF i
LOT ~
LOT 3
(VACANT)
LOT $
\\~R OFOSE~' HOUSE
/LOT " /
NORTH
REPLACEMENT
TRENCH LOCATION
PROPOSED 5'x97,5'x4'd
EFFECT[V£>
GALLON
LOT 8, BLK 2 CINERAMA TERRA---~--SUBgIVISIDN
PROPOSED ~/ELL ~ SEPTIC SYSTEM
~ SITE PLAN
JAMES SIZEMORE ~ ASSOCIATES
ANCHORAGE,
3R~N BY~ RRL ~ --
KD B~ iFS
SCALE, ~._i~ ~ 06-09-97
~SHEET, 1 o~ ~
James Sizemore & AsSociates
Civil Engineers &
Surveyors
6410 Switzerland Drive
(907) 345-1572
WASTEWATEK DISPOSAL SYSTEM
LOT 8, BLOCK 2 CINERAMA TERRACE SUBDMSION
0.0 GENERAL
0,1 The scope of this project consists (~finstatlation ora 1500 gallon Septic Tank
and a five foot wide by 97.5 feet long absorption trenches containing 2.0 feet
of sewer rock.
0.2 Construction shall be in accordance with the approved site plan and design
drawings, Municipality of Anchorage permit with any special provisions or
conditions. Deviations from the approved design drawings shall be
coordinated and approved by the engineer conducting the inspections.
0.3 Ali construction procedures and material used to construct the system shall
comply with Municipal and State regulations.
0.4 Unless specifically agreed otherwise, the homeowner shall be responsible for
finish grading areas at[er the system is constructed and soil is compacted and
mounded over the wide trench disposal field and the Septic Tank.
1.0 SEPTIC TANK
1.1 The 1500 gallon septic tank shall have two compartments and shall comply
with Municipality of Anchorage Requirements. The tank shall include two 4"
cleanouts for pumping access.
1.2 The septic tank shall be set level and shall be bedded as necessary to prevent
settling or shifting of the tank.
1.3 All pipe connections t(~ the septic tank shall be made with waterproof
mechanical couplings. A cleanout shall be installed upstream of the tank
within 5 feet of the house foundation. A double cleanout shall be installed
downstream, within 5 feet of the septic tank. The first cleanout downstream
of the septic tank shall clean toWard the drainfield. The second cleanout shal/
be to clean toward the septic tank.
2.0 SOIL ABSORPTION DRAINFI~LD
2. I The soil absorption drainfield shall consist of a5 x 97.5' x 4.5' deep trench
with a total of 2.0 feet of sewer rock; 1.5 l[. beneath the perforated drain pipe.
2.2 The bottom of the excavated trench shall be level within +/- 2". And
compacted or smeared surfaces shall be raked to allow for proper infiltration
of effluent. This includes both the sides and bottom of the trench.
2.3 Sewer rock shall be 0.5 - 2.5", screened gravel with less than 3% passing the
# 200 sieve.
2.4 Cleanout pipes and monitor tubes shall be 4" diameter and installed as shown
on the plans. The portion of the monitor tube extending through the sewer
Rock shall be perforated. All monitor tubes and cleanout pipes shall have
Waterproof caps conforming to Municipality of Anchorage Specifications.
3.0 ENGINEERING INSPECTIONS
3. I A minimum of four engineering inspections wilt be required during
construction of the system. One after the septic tank is set prior to/ts backfill,
one after excavation of the absorption trench prior to placement of sewer rock,
one after placement of the sewer rock and the distribution piping, cleanouts
and monitoring tubes are in place. The final inspection shall be after filter
fabric is placed; the trench and the final grading are complete.
3.2 The contractor shall coordinate with the engineer at least 24 hours prior to
start of construction. If the contractor des/res, a site visit with the engineer prior
to start of construction can be arranged.
PROBABLE 13/fPACTS TO ADJACENT PROPERTIES
A) WELLS
The proposed wastewater disposal system is designed in accordance with current
Municipality of Anchorage Wastewater Disposal Regnlations. The proposed
drainfield will be constructed in accordance with these regulations. The separation
distance fi.om wells On adjacent properties is greater than 100 ft. Therefore n6
unacceptable impacts are expected on the'wells located on adjacent properties.
B) WASTEWATER SYSTEMS
The new drainfield wilt be constructed with oo · ·
aacd~e,~n~t!ot~s. Soils te.sts have shown the soilgw°'~d~s~e~-aratm~n d~s. tance fi.om systems on
· ~w~me rot an on-me disposal system *h~J~"--~.'~ me system ~s to be constructed is
- , .... ~,re there should be no unacceptable
~mpacts of adjacent wastewater disposal systems.
C) RESERVED SPACE/SURFACE AND SUBSURFACE .
The lot on which this system will be constructed has ample space both surface and
subsurface accommodate this upgrade The proposed drainfield should not affect
adjacent properties. '
D) DRAINAGE
The location of the drainfield will not interfere with any drainage. The area disturbed
during construction of the field will be graded and sloped so as to not pond water. There
fore this system should not adversly affect adjacent properties.
Rick Mystrom,
Mayor
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
http://www.cJ.anchorage.ak.us
343-4744
September 18, I998
Randy H & Crystal L Lipps
12761 Old .Seward Highway
Anchorage, Alaska 99515 3509
Subject: Lot 8 Block 2 Cinerama Terrace Subdivision
Permit #SW970323, PID #020-033-17
The subject permit, issued September 18, 1997 by this office for a
single family well and/or on-site wastewater system, has
expired as of September 18, 1998.
A new permit must be obtained from this office for a well
and/or on-site wastewater system NOT installed by the
expiration date.
If you have drilled the well, a well log must be sent to
this office for documentation of the installation and to
close the permit.
If a licensed Professional Engineer has inspected the
installation of the on-site wastewater system, the original
as-built inspection report must be sent to this office for
review, approval and documentation. Ail inspection reports
must be submitted within 30 days of construction completion.
When applying for a new permit, the fees are: $320.00 for an
on-site wastewater permit; $120.00 for a well permit and
$440.00 for a combined on-site wastewater and well permit.
ave any questions, please call this office at 343-4744.
~Y' ~
J~mes ~C~oss, P~ E
Program Manager
On-site Services
enc: Copy of Permit
cc: James Sizemore & Associates
PAGE
MUNICIPALITY OF ANCHQRAGE
DEPARTMENT OF HEALTH ~L~TD HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW970323
DESIGN ENGINEER:JAMES SIZEMOORE & ASSOCIATES
OWNER NAME:LIPPS THOMAS &
OWNER ADDRESS:12761 OLD SEWARD HIGHWAY
ANCHORAGE, ALASKA 99515
DATE ISSUED: 9/18/97
EXPIRATION DATE:
PARCEL ID:02003317
LEGAL DESCRIPTION:
CINERAMA TERRACE BLK
2 LT 8
LOT SIZE: 75083 (SQ. FT.)
NUMBER OF BEDROOMS: 5 THIS PERMIT: 5
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
THE ATTACHED APPROVED DESIGN.
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).
THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED A~TD CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
THE FOLLOWING SPECIAL PROVISIONS.
1 OF
9/18/98
SPECIAL PROVISIONS:
James Sizemore & Associates
Civil Engineers &
Surveyors
6410 Switzerland Drive
Anchorage, Ali 99516
(907) 345-1572
WASTEWATER DISPOSAL SYSTEM
LOT 8, BLOCK 2 CINERAMA TERRACE SUBDIVISION
0,0 GENERAL
0.1 The scope of this project consists of installation of a 1500 gallon Septic Tank
and a five foot wide by 97.5 feet long absorption trenches containing 2.0 feet
of sewer rock.
0.2 Construction shall be in accordance with the approved site plan and design
drawings, Municipality of Anchorage permit with any special provisions or
conditions. Deviations from the approved eslgn drawings shall be
coordinated and approved by the engineer conducting the inspections.
0.3 All construction procedures and material used to construct the system shall
comply with Municipal and State regulations.
0.4 Unless specifically agreed otherwise, the homeowner shall be responsible for
finish grading areas after the system is constructed and soil is compacted and
mounded over the wide trench disposal field and the Septic Tank.
t.0 SEPTIC TANK
1.1 The 1500 gallon septic tank shall have two compartments and shall comply
with Municipality of Anchorage Requirements. The tank shall include two 4"
cleanouts for pumping access.
1.2 The septic tank shall be set level and shall be bedded as necessary to prevent
settling or shifting of the tank.
1.3 All pipe connections to the septic tank shall be made with waterproof
mechanical couplings. A cleanout shall be installed upstream of the tank
within 5 feet of the house foundation. A double cleanout shall be installed
downstream, within 5 feet of the septic tank. The first cleanout downstream
of the septic tank shall clean toward the drainfield. The second cleanout shall
be to clean toward the septic tank.
2.0 SOIL ABSORPTION DRAINF]ELD
2.1 The soil absorption dralnfield shall consist ora5 x 97.5' x 4.5' deep trench
with a total of 2.0 feet of sewer rock; 1.5 fi. beneath the perforated drain pipe.
2.2 The bottom of the excavated trench shall be level within +/- 2". And
compacted or smeared surfaces shall be raked to allow for proper infiltration
of effluent. This includes both the sides and bottom of the trench.
2.3 Sewer rock shall be 0.5 - 2.5", screened gravel with less than 3% passing the
# 200 sieve.
2.4 Cleanout pipes and monitor tubes shall be 4" diameter and installed as shown
on the plans. The portion of the monitor tube extending through the sewer
Rock shall be perforated. All monitor tubes and cleanout pipes shall have
Waterproof caps conforming to Municipality of Anchorage Specifications.
3.0 ENGINEERING INSPECTIONS
3.1 A minimum of four engineering inspections will be required during
construction of the system. One after the septic tank is set prior to its backfill,
one after excavation of the absorption trench prior to placement of sewer rock,
one after placement of the sewer rock and the distribution piping, cleanouts
and monitoring tubes are in place. The final inspection shall be after filter
fabric is placed; the trench and the final grading are complete.
3.2 The contractor shall coordinate with the engineer at least 24 hours prior to
start of construction. If the contractor desires, a site visit with the engineer prior
to start of construction can be arranged.
PROBABLE IMPACTS TO ADJACENT PROPERTIES
A) WELLS
The proposed wastewater disposal system is designed in accordance with current
Municipality of Anchorage Wastewater Disposal Regulations. The proposed
drainfield will be constructed in accordance with these regulations. The separation
distance from wells on adjacent properties is greater than 100 ft. Therefore no
unacceptable impacts are expected on the wells located on adjacent properties.
B) WASTEWATER SYSTEMS
The new drainfield wilt be constructed with good separation distance from systems on
adjacent lots. Soils tests have shown the soil where the system is to be constructed is
.acceptable for an on-site disposal system, therefore there should be no unacceptable
impacts of adjacent wastewater disposal systems.
c)
RESERVED SPACE/SURFACE AND SUBSURFACE
The lot on which this system will be constructed has ample space both surface and
subsurface c¢ommodate this upgrade. The proposed drainfield should not affect
a
adjacent properties.
D) DRAINAGE
he locatlon of the dramfield will not interfere with any drainage. The area disturbed
during construction of the field will be graded and sloped so as to not pond water. There
fore this system should not adversly affect adjacent properties.
:\ Municipality of
Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
FOR:
LEGAL DESCRIPTION:/~ :¢J ~,~;~)~/~J~ l,k~; Township, Range, Section:
3
4
5
6
7-
8-
9
10
11
12-
13-
14-
15
16
17
18-
19-
20-
COMMENTS
SLOPE SITE PLAN
ENCOUNTERED? .
IF YES, AT WHAT
DEPTH?
Moniterin~?
Reading
Date
Gross
Time
I,"/
f ri
Net
Time
PERCOLATION RATE ~ ~) (m utes/inch) PERC HOLE DIAMETER .
TEST RUN BE'I*WEEN ~rO ETAND ~45 ET
Depth to Net
Water Drop
72-008 (Rev. 4/85)
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMEO FOR:
9
10
11
12
~ ;:~/~ DATE PERPORN
~,~/~ .~nship, Range, Section:
SITE PLAN
SLOP
WAS GROUND WATER ~, ]f/I
ENCOUNTERED?
/v('/
13
14
15
16
17¸
18-
19-
20-
COMMENTS
S
IF YES, AT WHAT
DEPTH? p
I~enilorin§? .
Dross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE nutes/inc ) PERC HOLE DIAMETER
TEST RUN BETWEEN .~C.O FT AND 3r 5 FT
PERFORMED BY:- ~- ~ ~'~"~'~'fZ~ L,~./~'~----~ff~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELI~ IN EFFECT O~THiS DATE· DATE: ~ ' ~
72-008 (Rev.
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 SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description /](~ l-~'~
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Dayphone ,~C~.~ ._../ 7~/
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
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~)25 (Rev· 1/91) Front MOA #21
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 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:[urther verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm ,]~/~F'/~_.~ S/'-'~/r~' ~-- ,~L~.~''~C~' Phone ~"~ --/'~7~.
EngineeFssignature~~~~ Date ~ --~
DHHS SIGNATURE
~/ Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
Date
The Municipality of Anchorag~D~partment of Health and Human Services ,_,..iHS) issues Health Authority
Approval Certificates based '(~r~ly upon the representations given in paragra~.¢] 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 inspeciions 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.
724Y25(Rev. 1/91) B~ck MOA#21
AUG 16 1999
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVIC~L~C[P^LITY Of ANCHO~.~
Environmental Services Division ENVIP, O~,IMENTALSERVICES DJVi~
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
Well type
Log present (Y/N)
Total depth
Health Authority Approval Checklist
Or ; /
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to
Sanitary seal (Y/N)
FROM WELL LOG
Date of test
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Static water level
Well production
WATER SAMPLE RESULTS:
g.p.m.
g.p.m.
Coliform
Nitrate
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Dateinstalled/O/'~/~'~~' Tanksize ~/~ ~::)O Number of Compartments
Foundation cleanout (Y/N). Depression (Y/N)
Date of Pumping ½~J/~ Pumper
Other bacteria
~--~ Cleanouts (Y/N)
High water alarm (Y/N)
S~ystem type ~%J~//g~..)~'J/"~.~C~7
Gravel thickness below pipe f' 5 Total depth ~. ,~ :
Monitoring Tube present (Y/N) 7 Depression over field (Y/N) ~
Resu For .bedrooms
C. ADSORPTION FIELD DATA
Date installed /~/7/~
Length J ~)O / I
Width ..
Effective absorption area ~ ~
Date of adequacy test
Soil rating (g.p.d./ft2or fF/bdrm) ~, '~
Fluid depth in absorption field before test (in.);
(ins) Minutes later:
Immediately after gal. water added (in.):
Absorption rate = g.p.d.
If yes, give date
Fluid depth
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed ~
Manhole/Access (Y/N) ~on" level at* _
High water ala~ *Datum
Cycles tested.
"Pump off" level at*
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: , //~_~.~/
Septic/holding tank on lot ~ On adjacent lots _
On adjacent lots
Absorption field on lot ·
Public sewer m~in :
Sewer/septic ~ervice line-
sEpARATiON DISTANCES FROM SEPTIC/HOLDING TANK
Foundation 7,~:-~ .~/x~ . Property line
Water main/service line J~, _Surface wateddrainage _
Public sewer manhole/cleanout _
Lift station
ON LOT TO:
Absorption field
/~'(~'~VVells on adjacent lots_
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line / ~-~'~ I Building foundation _/~;~- ~'~ Water main/service line ~'~
Surface water /V ~ ~ ~ Driveway, parking/vehicle storage area ~
Curtain drain /~A ~ ~ ~ Wells on adjacent lots _~ /'~.~O /
ENGINEER'S CERTIFICATION
· ' ~a~)~ stems are
I certify that l have determined thru field inspections and review of Municipal record_s.~.~
in conformance with MOA HAA guidel~,es in effect on this date. ...~-~.,.~. ~
Signatur
E,,u; .........
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*