HomeMy WebLinkAboutCONIFER HEIGHTS BLK 3 LT 21
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
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
N.~: ~~ ~~~/~ ~ Waslewater System: ~New ~ Upgrade
~ ~ ~ ~~:/~~ ~~ ~ - ABSORPTION FIELD
Phone:
_ ~, ~Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other
Lot: Block: Subdivision: ¢ Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township:~/~ I Secti>~ F,,I added aboveoriginalgrade:~/~ Ft. Gravel length:~ ' Ft.
WELL: ~ew D Upgrade ~ave~ ~pth: ~ ~mb~r of,~es: 0,,ta~cebet~e~ines;
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe m~terial:
Driller:~~ ~~] Date Drilled: ~Static Water Level: Installer: Date installed:
Yield: ' Pump Set at: / ] Casing Height Above Ground:
SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P.
To Septic Absorption Lift Holding Public/Prwate Manufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~ ~ ~~~,. ~
5~W~V( Materiah Number of Compartments
Surface LIFT
Remarks: BENCH MARK
Location and Description:
I Assumod
Department of Health and Human Services approval ~ cE-
Reviewed and approved by: ~~ Date:
72-013 (1/91) MOA 25 /
Permit No. cJj ~ ~ ~ ~
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
Legal Description: ~o~ ~--'~, ~ IF~ H'T.~
F
72-013 A (2/91) MOA 25
Permit No.~ ~ 0 .~.~,~ ~ 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
Legal Description: ~.~."7",=~? .z~.-~"- 3 ~,~,,.,-/~-,~' ,,,~-,/,~'//~,~,/~'~ PID No.:
THOM A. FISCHER
CE - 6793
72-013 A (2/91) MOA 26
ALASKA E[1UIROI'IITIErlTAL CO[1TROL SI RUICES, Ir'lc.
· (~nqineerinq ~, (~nuironmcnlal Studies
P. O. Box 240668
Anchorage. AK 99524-0668
(907) 279-5553 *** FAX (907) 276-8706
LOT 21, BLOCK 3, CONIFER HEIGHTS SUBDIVISION
September 24, 1990
This is the last of the lots on the east side of 6riffith
Street to be developed. The surrounding lots all have
houses that are served by septic systems and wells. The
slope of the ground at the upper part of the lot is 18
percent sloping to the west. In the area of the future
system the ground slope changes to 8 percent. There is a
low spot near the northern corner of this lot where the
culvert crosses the road and dumps onto Lots 7 and 8, Block
2. Lots 7 and 8 are undeveloped, and are heavily treed.
The wells in this part of the subdivision are generally in
the range of 200 feet deep and yields are from 5 to 15
gallons per minute. Since this is an area with a relatively
good water system the placement of the new well within 50
feet of the neighbor's well should have very little impact.
In all probability, at a pumping rate of 5 to 6 gpm, for the
short periods of time to meet dousehold needs, the drawdown
influence will not reach the neighbor's well.
The sewer systems in this vicinity seem to be properly
spaced. There is no apparent conflict between the sewer
systems and the reserve areas on Lot 22. The impact of this
sewer system on Lot 8 is nil, as the 100 foot radius to the
sewer system would place it in the 10 foot easement from the
lot line on Griffith Street.
There is a dedicated drainage easement that ranges between
Lots 12 and 18 and 21 and 22. This easement comes off the
end of Ponderosa Drive. I have walked the easement, and can
find no evidence of any stream beds or water, even in this
period of high rain fall.
The owner of Lot 13 commented that the removal of trees on
Lot 21 has improved his view. He does not feel that the
height of the house will impact his view across Cook Inlet.
The culvert located at the low spot on Grtffith Street will
convey any runoff from this property. The removal of the
trees may increase some runoff in the northwest quadrant of
the lot. However, the vegetation on the west one-third of
the lot, except for the road, has not been disturbed.
In my professional opinion, the construction of this house
and well and existing and future sewer systems will not have
any harmful environmental impact on the surrounding lots.
ALASKA eFIUIRO[lmeFITAL COFITROL SE RUICE $, IFIC.
o ~nqimrinq ~- ~nuironmcnlal Studies
SPECIFICATIONS FOR A TRENCH-TYPE WASTEWATER DISPOSAL SYSTEM
LEGAL DESCRIPTION: LOT 21, BLOCK $, CONIFER HEIGHTS SUBDIVISION
1.0 GENERAL
1.1
The Drawings, sheets I thru 6, shall be a part of this
specification.
1.2 All materials and workmanship shall meet the
requirements of the Municipality of Anchorage,
Department of Health & Human Services (DHHS), the
conditions of the permit, and all applicable rules
and regulations currently in effect.
1.3 Ail elevations and depths are advisory, and are to
be verified or modified in the field by the
engineer or inspecting agency.
1.4
It is the responsibility of the property owner or
installer to adhere to approved designs for
installation, maintain the specified separation
distances, and have the appropriate Inspections.
1.5
It is the responsibility of the property owner or
installer to report to the engineer any observed
conditions which would put the system in violation of
state or Municipal regulations.
1.6
If the installation is not inspected by an AECS
engineer, AECS will not be responsible for the
installed system. An engineer at AECS should be
consulted prior to construction to determine the
number of inspections that will be required and to
explain what these inspections will involve.
2.0 SEPTIC TANK
2.1
If there is an existing septic tank, it may be
used it if meets the capacity requirement for the
residence and the approval of the MOA.
9..2
The septic tank shall be a UPC-approved
two-compartment tank, constructed of 12 gauge
steel with bitumastic coating and set level on
undisturbed soil. If the tank is buried at a
depth of 4 feet or less, it must be insulated with
an overlying layer of 2 inch burial type
polystyrene rigid board insulation.
2.3 The septic tank and trench shall be a minimum of
100 feet from any private well or body of water,
150 feet from Class "C" wells, and 200 feet from
Class "A" or "B" wells, unless otherwise
specified. Less than the required separation distance
must have prior approval or waiver by ADEC or MOA.
2.4 The septic tank shall be a minimum of 5 feet from
the house foundation, and a minimum of § feet from
the absorption area.
2.5
Piping shall be fitted with a mechanical
watertight calder coupling on the outlet and inlet
of the septic tank. Piping shall be 4 inch solid
PVC ASTM D-8034 or cast Iron, sloped a minimum of
1/4 inch per lineal foot. If the piping is buried
at a depth of 4 feet or less, it must be insulated
with an overlying layer of 2 inch burial type
polystyrene rigid board insulation.
2.6
Cleanouts shall be installed as designated and
capped with air-tight rain caps (Jim Caps or
equivalent), and extended a minimum of ! foot
above ground level.
2.7
If a lift station is required it shall be a
combination lift station septic tank per Anchorage
Tank and Welding, Inc. using an ORENCO lift station
design. Specifications and design drawings are on file
with the Municipality and the engineer.
3.0
ABSORPTION AREA
8.1
The gravel for the trench shall be 0.5 to 2.5
inch, screened rock with less than 3 percent
passing the No. 200 sieve. Ail substitutes must
have prior DHHS approval.
8.2
The bottom and sides of the excavation shall be
raked with the backhoe blade to ensure that it has
not been compacted during excavation. The bottom
elevation shall be level.
3.3
Monitor standpipe(s) shall be placed as shown in
the drawings, and shall be 4 inch rigid PVC ASTM
D-3054, or cast iron. The section shown with
holes may be 0.5 inch holes drilled on 6 inch
centers on opposing sides of the pipe, or a
regular section of perforated sewer pipe clamped
to a solid section with either a no hub coupling
or a solvent joint. A rubber rain cap (Jim Cap or
8.4
3.5
3.6
3.7
equivalent) shall be installed over the top of the
pipe.
The distribution pipe shall be perforated 4 inch
PVC with a minimum crush strength of 1500 pounds
and shall meet the approval of DHHS for use as
drainfield pipe. If the system is a pressure
distribution system see Section 5.0. Ail distribution
pipes shall be laid level.
Trenches may be paralleled, but must have a
minimum separation distance between the trenches
of 10 feet or 2 times the gravel depth (which ever
is greater). 75 feet is the maximum allowed
linear length of any trench.
If the final grade over the trench is less than 4
feet above gravel, insulation is required, using
burial type polystyrene rigid board insulation.
There shall be I inch of insulation for every foot
of soil less than the required 4 feet of cover,
but there must be at least 24 inches of soil cover
even though insulation is used. The solid pipe
extending from the septic tank to the drainfield
shall also have a minimum of 4 feet of cover or an
equivalent layer of insulation to prevent freezing
of the line.
The gravel shall be covered with a layer of nonwoven
engineering cloth.
4.0
INSPECTIONS
4.1
A minimum of two inspections are required for the
installation of the trench. The first inspection
will be of the open excavation to assure that the
system is installed in the proper soil strata,
correct depth and meet minimum specified design
parameters.
4.2
The second inspection will be after placement of
the gravel, monitor standpipe and distribution
pipe to verify proper installation and position
prior to backfill.
4.3
The inspection of the septic tank installation can
be incorporated with any one of the above listed
inspections.
4.4
The lift station will require either an MOA electrical
inspection or certification by a licensed electrician,
5.0
depending on whether the building code applies to this
part of the city.
PRESSURE DISTRIBUTION SYSTEM
5.1 The lateral and header pipes are to be Schedule 40 PVC
or ABS in the sizes indicated on the drawings.
5.2 The laterals are to be level within plus or minus one
inch.
5.3 Ail joints are to be solvent welded.
5.4 There shall be 2.5 inches of rock over the top of the
headers and laterals.
5.5 The holes In the pipe are to be properly sized and
spaced.
5.6 The holes shall be clean with no cuttings still
attached to the pipe or left free inside the pipe.
5.7 Holes may be reverse beveled if it does not increase
the outside hole size.
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
1200 west 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
JOB
SHEET NO,
CALCULATED
CHECKED BY
DATE
DATE.
SCALE
PR0eqJCT 204-1 ~lnc., Gfoton. Mas~. 01471
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
JOB
SHEET NO ~'
CALCULATED BY
CHECKED BY
SCALE / ~'~'~
o~
DATE.
DATE.
Z
0
H
H
H
bJ
z ~i
Z
0
HZ
!-0
01...
rr,~
,,~ I--
..JlO
OZ
011.
~0
'1
II JO.
nH
.0.
m H
°
0
o -o,~/
/ x ~ ~ - ,..~~ ~.: ..... ~~ ~ .
, ~ ...- ~ .' ~ ~ - ~ ·
~. . - · I ~' ~.' ~ ~ .4~ ~ ~. f . '... '· . ~ , ~
.. .' .' _ I ' '.,,~ ~' : ~' ' ~ ~.~-." '.... ' -- . .~ ' ~
~ .. :: - .: _~ ~., = ~ ..-,-~.,,~.:>u'l~
~r~- .: r:' ./.--:.7 "~',~ilI
1' ~/' ~" '
~.~, . ~ '
~ ~ [.~ ' . ~ . ..'
'""'-..~..~,,~O~ r ~q~O.~~-''''
..~.~
/ VI5 0 N ,
~~..,~. , --.....~.~
/
/ '~2'.. ..... .."-~,
5'
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:LO'T'~.~. I ~ ~
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
O?YT H
_ ~"v'"'~
il 1
mI H.
Ii~....,
Il
II,
/~,wnship, Range, Section: 7~'_/Z,~ /~,~ uJ ~'~.~"~ /,~
SLOPE SITE PLAN
,~ ... ~%OU'N D WATER
L REID, J~ ~ ~ S
.+~ ~ATWHAT
~i~ ~:h 'o Water After
PERCOLATION RATE //. ~ (minutes/inch} PERC HOLE DIAMETER ~" //
TEST RUN BETWEE~N ~ FT AND '-~ FI
COMMENTS s,,,t. ?,,r~,5 .4-'/' /?o _~,~. ~5/_a;~?~' ~?_,,/-/ ~. s~ ' -~ /~'
PERFORMED BY:.'~"~/~'. '"' ~ ~,J/~'"/A/ t ~ .~~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
Reading Date Gross Net Depth to Net
Time Time Water Drop
,., d;n.;!-/~'-f/_. ~.'o~/~:~ /_,, ,~,Z.,,,'//.~'z. ./'7
'* ,:--'; t,:~:~ - ~?'/. <,"
i, .~:_i,)5,:¥~ : ,;..,). i.'i.'
~' :~:4~ 1~:~3 .,,,7'/. <"~'_/z..
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" 8tFeet, AnchoFage, Alaska 9950~-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION: ,~ Z/ g 3 Co.,,~-e/-/~., ?,(J-.~ Township, Range, Section: ~'-/,~t)
SLOPE SITE PLAN
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
S
L
Depth to Water After
MvOnitoriag? br,~, Dar,, ~',,~ ~,/~ o
Gross Net Depth to Net
Reading Date
Time Time Water Drop
~ ~/,.
PERCOLATION RATE
(minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~FTAND --FT
PE.FORME~ BY:.4 ,/"~e., ~' ,
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE: ~,//'*'/~0
/ unicipality
of
Anchorage
P.O. BOX 6650
ANCHORAGE, ALASKA 99502-0650
(907) 264-4:,'t::,1:~x 4744
TONY KNOWLES,
MA YOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
February 9, 1987
John Hagmeir
1399 West 34th Avenue, Suite 103
Anchorage, Alaska 99503
Subject: Lot 21 Block 3 Conifer Heights Subdivision
On-site Sewre and Well Permit #860018
A permit issued by this Department for an individual well and/or on-site sewer
system has expired as of January 24, 1987.
Your permit expired on the date of issue basis by authority of Municipal ordinance
existing at that 'time. A new permit must be obtained from this Department for
any well and/or on-site sewer system not installed by the expiration date. The
new permit will come under the calendar expiration date as per the new Waste-
water Ordinance (effective May 20, 1986).
If you have drilled the well, a well log needs to be sent to this Department
for documentation of the installation and to close the permit.
If a private engineer inspected the installation of the on-site sewer system the
original as-built inspection report (three part form) must be sent to this office
for review and approval, and for documentation.
If there are any further questions, plesae call this office at 264-4744.
Sincerely,
W Robinson
Program Manager
On-site Services
RWR/lj w
enc: copy of permit
of
P.O. B, , 196650
ANCHORAGE, ALASKA 99519-6650
(907) 264-4111
TONY KNOWLES,
MA YOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
June 23, 1986
John Hagmeier
1399 West 34 Avenue, Suite 103
Anchorage, Alaska 99503
Subject:
Lot 21 Block 3 Conifer Heights Subdivision
On-site Seewr & Well Permit #860018 - Issued January 24, 1986
On May 20, 1986, The Anchorage Assembly approved a new ordinance
regulating on-site wastewater disposal systems (septic systems).
Ail septic systems constructed after the effective date of this
ordinance are subject to the provisions of this ordinance.
Our records show that you currently hold a permit for the installation
of a septic system. We strongly urge that you contact this office
prior to constructing your system. Any changes in the code that could
impact the construction requirements of your septic system will be
identified and brought to your attention. Please contact the
Environmental Services Division at 264-4720.
Thank you for your cooperation.
Sincerely,
Susan E. Oswalt
Program Manager
On-site Services
SEO/SSM/ljw
F:'Ei:RM ]: ]' NO:
DA'Tlii: ISSLJE:D::
A F:' F::' I..,. I CANT
A D D R E S S:
CONTACT F:'HOI",Ili!::
0 1/24/,:16
SUBDIVISIOIq: COIxli:F""[::F:~ 1'4EIGHTS
SECT :1: C]N: :1.:3 'I"OWIqSH I P: :[ 21'4
::!;9405 (SC,!, F::"T',, C]R AC;IRES)
4.
LOT:,,."~ 1
RANGE: 3W
]E. LLIL,~ .... 3
L.'is'Led I::ie].ciw ar'e i:.he optic:ns avai:l, ab].e 'Lo you in desigr'~:i, ng your' sep't..:i.c:
syst:.em. Choose i'..he Cll:)tic:,Ft thai: best f:its ye)ur. ::i. te,,
"'IF IF:R: E: th,,.ll E:]~" IF.41 :IE.~ EE:: ]t::) It~,,,P ,., :Il:ii, !1::::;;." ~f-'::'.~h ]1:: II"ql
DE:I:::"T'H 't"O 1:::' :1: F::'E BO'TTOM (F:"I".) 4.0
C')Fur..~vli'::I .... DIE:I:::"I"I"] (Ii:iT.) 7. ()
TO'T'AI... DI:ii:I:::'TH (F:'T ,, ) 1 1.0
f:'3l::h::~VE:t .... W I D"I"H (I:::'"1".) :.:2 II [~J
GFd..VqEEI .... t....liEI',IGTH (l:::"l" ,, ) 5 '.l.. ()
GRAVE:I .... VCtI....UMI!ii: (CU,, YIJS,, ) :.];5.5
'T'ANI< S I Z E: (G(,,~I,,.E~) 1: 2.5CI. 0 ,x-~.
SO Il ....RAT' ]: NG (SQ. F:'"I",, /BR) :1,77
GRAVEl .... I_I:i:I'qGTH > 75 FT ,, RE:C,!U I RES MLJL.'I" :1: I::' t... l:::: RUNS (IqC:)'T' E X CEE:D :t: NG 75 F'T ,, Ei:A[:2"i )
TAI:II< MUST HAVE AT LEAST 'I"WO COMF'ARTMIE:Iq]"S
if. cer'tiFy 'LIffa'L:
:t:,, I. am familiar' wi't.h 'Lhe r'ectuiremer'~ts for' Ol"~-.si'Le sewers and we:l. ls as set
foi"'Lh by the Mur'l:i.c:ipa],:Lty of Anc:hor'age (MOA) and the Sta'l:.e of Alasl.::a.
2. :1: will ir'tstall the system :i.n ac:coPdarice with all MOA codes anti r'equlat:i, cH"ts~
and :i.n comp 1 lance with 't, he design c:r iter :i.a of i:.h:i.s perm:it.
3,, :1: wi:l, 1 aclher'e to all MOA and State (:)f Alaska r'equir'ements for'. 't. he se't. back
d:i. star'ices fr'cm', any ex:i.s'Ling we].1, wastewater' d:i. sposal sys'Lern or pul::)1ici
sewerage sys't, en~ on th:i.s or' al']y adjac:en'L <::ir' near'by Icj't..
zj.,, ]: Ltl"lCJEer'.::t. ar'lcl 't,h~::t'~. th:i.s perm:i.'k is v~lid For' a maximum of 4 bedr'ooms and
any er'~:l, ar'gemeF~t ~i],l r'equire an adcliticmlal per'mit.
,:.~ I
'l"Hli]i:b.I (:1.) AN I:::L. IEC'I'RICAI .... I:::'ERMI"I" AND :t:NSF'E:CT]:OIq I'~US'T' BE: OBI'A]:NI:J!:D~ (:2.) H,::'-BUII...I,:::
W.I.L.L.. NO'T' BE AI"I"Id.J\,I:.D WI]"HOUT Alxl EL.E:CTI::~ICAI.. INSPECTIOIxl I=EEPC)FCI'; AND (3) 'T'HE'.
liJi:L,E:CTI::~ :1: CAI .... WORI< MUST BE DE)NE I.:: f ~:.', L I CE:I':ISIED E.::l....liii:C]'R I C I AN
AF::'t:::'I.... I CANT: .... '" ', ..... : .:' '
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
LEGAL DESCRIPTION: LO-I~ I
DEPTH
II
6
9
II !
10
I 1
12
13
14
17
18
19
2O
COMMENTS
~d//¢'~',~ /¢~,wnship, Range, Section: '~ /~.~ ~ :¢Z.~'~ t~
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth lo Water Alter
Monitoring? Date:
Gross Net Depth to Net
Reading Date
Time Time Water Drop
,d~. / I-/¢'Yrf, ~:~/.~:/,~ /o /¢//,/ ,~'~/,~'k.- ,/'7
PERCOLATION RATE //~' 4 (minutes/inch) PERC HOLE DIAMETER
TEST RUN.ETVVE~N 4'¢' FT AND -¢' FT
l ?O ~¢. ~s-~ ~)z~y ~# ,z, y' / "~
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE: //-//'~
72-008 (Rev. 4/85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:~~O
LEGAL DESCRi PTION:~.~"~P
.H~,wnship, Range, Section: ~'
SLOPE SITE PLAN
(~ro~$
Time
Reading
~MENTS / ~ ·
Net Depth to Net
Time Water
CERTIFY THAT THIS TEST WAS PERFORMED iN
ORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
8 (Rev. 4/~)
)~
/3 3B..LS
9L' tOZ
O~'9ll
3,0£,30 oOS.
H.LI.-J~ lBO
,OF A.I.. ~I
~,~,..
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM PERMIT
PERMIT NUMBER:SW910061
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:HAGMEIER JOHN C
OWNER ADDRESS:2204 CLEVELAND STREET
ANCHORAGE, ALASKA 99517
DATE ISSUED: 4/16/91
EXPIRATION DATE: 4/16/92
PARCEL ID:01509302
LEGAL DESCRIPTION: CONIFER HGTS BLK 3 LT 21
LOT SIZE: 39405 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT:
4
THIS PERMIT IS FOR THE CONTRUCTION OF:
WELL 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 (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
DATE:
DATE:
CON I FER H£1&HTS SUI~D.
L 0 T Z I BL K. 3 /":
/
L C~A },,,/
LOT
I~ I
30'
EX, 19TIKIG
I I
I I
I
L
AS BUILT ~ hereby certify that I have surveyed
.... the property depicted above and that
GASTALDI LAND SURVEYING no en6roachments exist except as indi-
Jeff A. Gastaldi,R.L.S. cared. It is the responsibility of th.
3030 Bettles Bay Loop owner to determine the existence of a~¥
Anchorage, Alaska 99515 easements,covenants or restrictions
Tel. 907-344-4272 which do not appear on the recorded
subdivision plat. Under no circumstan-
,,, ces should any data hereon be used for
GRID DATE construction or for establishing boun-
¥. B. JOB NO.
~-O ~, ~C~ORAG:]3 RECORDING DT$~RTC~,
· ~'U N I C 'I.P ,L I ~T Y ','D F -'A 'N O. R A ~ E
'
..: ... epaptm~r~.~ of Health-' &.'Human Se;-vices' '
~ .825 L Stpeet;~ "~nchorag~.~' A'l'aska ~501 54J-4720
O N -.S I T E S E'W E R &'"~W E~L ~ '. P E R M I T
~a~e I~u~d: 10/02/90 .Engide~r Designed, ·
C>~n~r Name: JOHN HAGMEIR . D~v F'h~n~;~
At',ICHCRAGE, ' Al< ~'~ i Z
/
F'arc~l Id: O'= ' ~ -'
,. Lot Legz~l: Subdi,~si,~n: CONIFER HEIGHTS Eot: 2~ ~c~.=:~
S~cti~n: 1.3 'fc~'n~hfp: 1~,: .-Rang~: ~;~
'.Lot"~' · ¢~
.:;>~ Bedr. ooms~ ]'hie F'<~r~it: ~'4· ~ Total 6apaGity: 4
:'TIC TANt.::: I1ini. m,u~ tCt.~,l ~ept~' tank 'capsc'ft~: 1'250-gal Ions.
~k'mu~t have· e.% l'east "2 .cOmp&~tments. DePth t.o top oF ~ep'ttc tank(s~ < 4,0 "
)t.:...P~qui~e~ 'iOsUlatlc'O.. O~P :&~n;: (~) , .;.'..""-": .'-3;' .; . . ''-' '
:Lc keg. mus.t.be..Subat,tt~d to' Ountcipa.!lt¢.'~¢'A.n~ho~'age Departr;ent o¢ Healt~-.'..,..
t .Huma~ ':S~Pg'ices: ~i'thio.¢.~O '~a.~'s' '0¢ 'i~el ~' "E'~¢'l~t'~on;.'% ; - '
' '·71 '¥ ;..'..: . ..'r~ ,"~.'..,'~ '-. ';.' ,.'< ' ..... .. ',~ ¢ .., ~.:-;;.-',., .?~..'..~ ,- : . ·
iS PERMIT.EXP. IRE~ 12{~.t/?O'AND VALID F'OR']~ SINGLE FA~LY HOME.
'.ISTRUCT PER ENGINEE~t8. ATTACHED .DESIGN, '"''" '
:ORM ~,H,H.S, PRIOR ,I'O.'INSP~CTIONS B~ ENb'INEER~ 'IF'AFTER ..
'ICE' HOURS, CALL ~43-4~81 AND LEAVE A' MESSAGE.
;E~T ZFY ~HA~: . ...
· I .~m familiar, with 'the ~equi ~ '
rements .~o~:.on-site se~ers and ~elI~ a~ ~et '.
'.Forth by the Muntc~pal%(y oF Anchgrage'.(HOA)' and the State or Alaska. "'~'''
I ~ill .install the '~Ystem.'in accord~n'C~.With' all MOA codes and. ~egulatiSns,':.'.
and in cc. mpliance.~ith'the design c~it~i'a'.o~ ,this.p'ermit. " ""
I ~il. 1 adh~r'e to'al];.~OA and' State o~'~i~%ka'requirement~ Fop the ~ back: 7'-.....~.
di. st. ancu~ {ru~.an'y existing ~eli,. ~a~te~]~ter-~i~posaI.s~,~t.~m. or p~bllc :"'",
I und~p stand '%hat thi~.permik is valtd [~.~..a.'maximUm o'~ 4 bedrooms, I. .....
.aiso under,'rand that-the capacity.of th%.'.total, system is 4 'bed~oum~ ~nd'-
any enlargement ~ill requ~pe an addltt6~l permit, . ·
'.' , -'.'.... '., '.', .' . '.-.::.'.t '.,....... "'
'- ...... ET: ' · ·
<o~mer ).. a~ ~Ae~Z~R. ' ,-.J. f . / . .'~'.': .' d..
u~d ~y: _ _ :~
I 'a ~£T T6~T'~'TO 'ONI $O~U ~OH~
CONTROL SERVICES, INC.
! 200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO. // OF .... ~
CALCULATED BY- / " /
' ~,.,,', OATE q .,'~ ~/~ ~ '
CHECKED 8'Y- DATE .. ,
ALASKA ENVIRONMF. NTAL
CONTROL SERVICr. '~INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(~07) S~-S040
JOB,, L St
SHEET NQ.
CALCULATED BY,
CHECKED, By
BCALE~ ~*
DATE
FRO~ ~EC$ INC. "~'x 01.24.1991-.~3:52
P. 8
Z
-4
~.
r
Z
b
3,0£
C)
£~i£T ~66T'~"TO
'2NI ~H I,I~UJ
PERFORMEO FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Township, Range, Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
L
IF YES, AT WHAT 0
DEPTH? ~
P
Oepth to Water Alter
Monitorl
E
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch) PERC HOLE DIAMETER
;OMMENTS
TEST RUN BETWEEN FT AND -- ET
?. 7:,__~. 7-/~- ,z,~.~ y-, E,,~ ~, .&~ ~/~.ca
S~ ~ OF AStJ~SKA
DEPA/~TMENT OF NATUR3%L ~ESOI/RCES
DIVISION OF GEOLOGICAL AND GEOPHYSICAL SURVEYS
WATER WELL RECORD
LOCATION OF WELL
BOROUGH SUBDIVISION LOT BLOCK SECTION QTRSI~!~ C I TOWNSHIP RANGE MERIDIAN
DIRECTIONS:
WELL DEPTH: DATE OF COM]~LETION
MEASURING POINT: [] top of casing Depth of hole: ~,~ ~%,~ ft
Dground surface Dother: Depth of casing:~o~'? ft ~' -~$~-
BO~HOLE DATA: Depth STATIC WATER ~L: /{/~ ~ ft. Date L<
Material type and color From To
~ ~THOD OF DRILLING: ~air rotary
:~ :~ '~ USE OF WELL: '~domestic
x~ Y . · ~. ,<, . f~ CASING: Stick-u~ ~ ft. Diam: ~'~. in
d'_ ':-:~ ./ .4, /~'z_ WELL INTAKE: ~ open end ~screened
~ ~,~ ~,~. ~"~ ~ open hole
~_~ ~ perforated
"-,/xJ. SC~EN T-YP.~j Diam: in
~. ~.~,,~,,~ . · ..............
~, <_ ~%~h~.~ ,, Slot/Mesh Size: Length: ft
x' Set Between__ and ......... f~ ....
G~VEL PACK ~TY'PE~ ..........
Vol~e used: -'-b-~h-,-~o -~Op:
~ ~ ~ Depth: from .......... ~f'~fU~' ......... .ft
~]Ot%OU~ ~' ' ' Duration: J
~ ~ <:~) ft after ~ hfs pumping gpm
P~ INT~E DEPTH: ft Horsepower:
Date Pump Installed
CONT~CTOR ZNFO~TION: WATER CHEMISTRY S~PLE TAKEN? ~ yes D,no
. ," 4': ,,<' ~ ' Well disinfected upon completion? '~yes ~no
Reg~'~tered Business Name~;,"
Signature of Authorized P~presentative
Date
PLEASE MAIL WHITE COPY OF LOG WITHIN 45
DAYS TO'.
//PO BOX 77-2116 ~
DEplti~Ti~ENT OF NAT~ i~EsoUI~CES
DIVISION OF GEOLOGICAL AND GEOPHYSICAL sUrVEYS
WATER WELL RECORD
)ROUGH
SUBDIVISION
SECTION
TOWNSHIP
RANGE
MERIDIAN
IONS: /
SURING POINT:
[]ground surface
BOREHOLE DATA:
type
,[]top of casing
[other:~
Depth
:olor.
Dept.
CONTRACTOR iNFO~MA~TION: ~ ' ' , '
Date
WELL OWNER:
W~LL DEPTB:
Depth of nu~ .~-~------
Depth of casing:~--~---ft
DATE OF COMPLETION
Date~
STATIC WATZ~ ~VZL: / ~ ~7 f t.
METHOD OF DRILLING: ~air rotary
~cable tool [ o t he r: ____----~-------------
USE OF WELL: ~dOmestic ~irrigatiOn[~mOnitOr
[]public supply ~other'
;lNG: stick-u~ft'
~¢'? open end
WELL INTAKE: ~ perforated
to
. ~ in
D~am: (~ ~
[]screened
[6pen hole
D iam: ~f
SCREEN TY2E ~_~.
~i-, ~.-?~-~-__ Length
Slot/Mesh ~z~.~~_
Set Between____-----
PLEASE MAIL
DAYS TO:
PACK"'TY'PE~--
GRAVEL
Volume used:_/
Volume:~
GROUT TYPE:,~_______ft
Depth: fr°m---------____.--T--~_
DEVELOPMENT METHOD:~~~/
Duration:_
pUMPINGLEVELAN/~YI~:pumping~____-gpm
~_~ft a fter_~_~
pUMP INT~E DE~TH:--------ft HorSepower:-----
Date pump in~talled~
WATER CH~ISTRY S~PLE TAKEN?,
WHITE cOPY OF 'LOG 'wITHI~
DGGS .'
PO BOX .77-2116"
EAGLE RIVER, AK. 995771''~
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
Parcel I.D.
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner Jol. t~ DIz. t.14,q
Mailing address S4~'
Lending agency
Mailing address
Agent
Address
Day phone 2'/¥
Day phone
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.
72-025 (Rev. 1/91) Front MOA ~t21
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 further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm F'/-/} T'Fo P TEC
Address I H~'30 ECHO
Engineer's signature
DHHS SIGNATURE
~ Approved for
Phone
Date ~,/av/%~_
bedrooms.
DisapProved.
Conditional approval for
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. 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~)25 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health &Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:./,oT 21~ B/-I( 3 j Co~ F'[I~ ~T$ Parcel I.D.
A. WELL DATA
Well type ~'~VATE
Log present (Y/N) ~/
Total depth 2 35
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
Date completed
__ Cased to .l o'7
ADEC water system nUmber
L{ /:zS /~j l Driller
Casing height 3O
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
AT INSPECTION
g.p.m. ~ ~.L/ g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main ~ ~oo'
Sewer service line )1oo
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank NoNE
WATER SAMPLE RESULTS:
Coliform 0 co(
Date of sample:
Nitrate
Collected by:
Other bacteria C? ¢ol {/oo ~ ,~
FLATTOP ~.cft ,~c$
B. SEPTIC/HOLDING TANK DATA
Date installed
CleanoutS (Y/N)
High water alarm (y/N)
Date of pumping
Tank size 1250
Foundation cleanout (Y/N) Y
Compartments 2.
Depression (Y/N)
Alarm tested (Y/N) /~ ,,~,
Pumper I $/~A~ .~
N
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot '~ 1~5~ Onadjacentlots '~.lo0'
~ -~ ~ (~/~11
Topropertyline ~ (~0 Absorption field ?-~
Surface water/drainage
Foundation -~'
/'/'/~ter main/service line
2.5 +
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Man u factu rer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed 12
Length ,EH Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail) P/~JS
Peroxide treatment (past 12 months) (Y/N)
Soil rating O.~ ~;PI)/~' System type
/
Gravel thickness "7 Total depth
Cleanouts present (Y/N) "/
Date of adequacy test ~ / Ii
for ur bedrooms
KNowN OF If yes, give date IN ,A,
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~
To building foundation
On adjacent lots ~ 30
Surface water
Curtain drain
On adjacent lots ~/oo Property line 1:2
12 To existing or abandoned system on lot N,/~,
Cutbank ~' 50 Water main/service line ~' 25
Driveway, parking/vehicle storage area
20'
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.
Signature
Waiver Fee: $
Date of Payment
Receipt Number
Engineer's Name 7~¢.~c.~o,'F_ F./~,,o,-~'
Date
HAA Fee $
Date of Payment
.eceipt Number
72-026 (Rev. 3/91) Back MOA 21
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Lega, I Descr..[p.tion~..o~ ci (~c_~de lOt, block, subdivision, section, township, range)
(_ol- Z ,,
Location (address or directions)
(b) Property owner
Mailing Address
(c) Lending institution
~61D:'elephone ' (home)-'-'-----' Business ~,48 -~'7 '~:;~
Telephone
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here,,~C'if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family,,J;~ Number of bedrooms
3. WATER SUPPLY
Individual Well,,~[;' Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site,,~t;a' 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.
72-025 (Rev. 7/88) Page 1 of 2
ENGINEERING 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 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 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 g.f this inspection.
Name of Firm ~ .~r. ~_~/',~'-T'~-~ ~-_-.~,~---~l:'~ephone ~-~4:¢r._~'-- 7 ~-..,(~"7
Date ~/q /~ '. , .
neer's Seal
6. DHHS APPROVAL
Approved for ~ bedrooms by
Approved /~ Disapproved
Terms of Conditional Approval
Note:
Conditional
The well for this property meets existing
State and Municipal Codes. There are nitrates present. It is
suggested that a periodic testing be performed to insure the wells
continued suitability. Nitrate concentration is 5.3 mg/1. EPA
maximum concentration is 10.0. mg/1.
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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. 7/88) Back Page 2 of 2
A. WELL DATA
Well Classification
Well Log Present (Y/N)
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST- FEBRUARY 1984
Mun::s~p;i.,.tiiV of Ar~chorago
DopL Health & Human '," '
oervlces
If A, B, C, D.E.C. Approved (Y/N)
Cased to'Z~O'7 Depth of Grouting ~/'~
167 ' Pump Set At Z~ '
Sanitary Seal on Casing (Y/N)
Total Depth'~"~'
Static Water Level
Casing Height Above Ground
Electrical Wiring in 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 I C:)C:~ -'r"
Depression Around Wellhead (Y/N)
To Nearest Sewer Service Line on Lot
Water Sample Collected by ~ k,~ ~.-~,'t"~o,~crrc~--
Water Sample Test Results
;On Adjoining Lots
/
! ~¢-.~_r.~ ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
't-
B. SEPTIC/HOLDING TANK DATA
Date ,nsta ,ed
Standpipes (Y/N) ~--~ Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
No. of Compartments ~
~ ~ Foundation Cleanout (Y/N)
Date Last Pumped t,,5~
;for t'~ !~z:¥
Holding Tank High-water Alarm (Y/N) ~'~ / ¢r Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line (,:~.C:~- /
To Water Main/Service Line '2,,~
To Stream, Pond, Lake or Major Drainage Course
Comments
To Bullding Foundation
To Disposal Field
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~
Width of Field -- '2~'~-O !
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
-756
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot ~.~ O t~i~-
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~
v~ ~/~ ~ Type of System Design
Length of Field
Depth of Field -7
Gravel Bed Thickness '7
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ~,~-~
To Cutback (if present)
D. LIFT STATION
Date Installed ~ Dimensions
Size in Gallons / / Man hole/Access (Y/N)~
"Pump On" Level at / / "Pump Of~l at
High Water Alarm L.~at / ~,e'ht (Y/N)
Testedfor / / ~ /~ Pumping Cycles during Adequacy Test.
Meets MO~,l~ctrical Codes (Y/N) / ~,/ '
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, ~conformed to all MOA and HAA guidelines in effect on the date of this
inspection..,¢
Company
MOA
No.
g~neer s Seal
Receipt No. c~,~ °t'-'~ Receipt Nol .
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Waiver Fee: $
Date of Payment
Page 2 of 2