The URL can be used to link to this page

Home My WebLink AboutCURRIN LT 5 Municipality of Anchorage Page J of--~ 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: -~',J '~ C)I':~-c~ PID Number: (~ IT -~t -17-o Name: Wastewater System: D New ~Upgrade Address: ~t~ c~ c~. ~ ~/~ ABSORPTION FIELD Phone: I No. of Bedrooms: ~ I ~~I ~ ~DeepTrench D Shallow Trench ~ Bed D Mound D Other LEGAL DESCRIPTION ~o,, Rating: Total Depth from original grade: ~ · ~ GPD/Sq. Ft. / ~ Lot: Block: Subdiv~ion: Depth to pipe bosom from original grade: Gravel depth beneath pipe ~ ~ ~ .~' ~ Ft. ~'~ Ft. Township: I Range: I S~tion: Fill added above original grade: Grovel length: I I ~ ~ ~ Ft. ~' ~ Ft. WELL: D New ~ Up~ ~Gmvel width~ ~ Number of lines: Ft. ~ I ~ Ft. Cl~sification (Private, A,B,C): ~ Cas~ To: ~Total abso~tion area: Pi~ material: ~ Ft. Ft. ~ ~* ~ SQ. Ft. ~/~ /~ Driller: ~ Date Drilled: SaticWaterLevel:Ft. Insta~r:~ ~ ~ Datein~l~/~ SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. To Septic A~o~tion Lift Holding Public~ri~te Manufacture~ Capacity in gallons: From Tank Field S~tion Tank ~wer Lin~ ~ ~ O~ TA~ ~ ~ ~ Material: Number of Compa~ments: Sudace ~ LIFT STATION Water 1 ~ l ~0~ LOt ~ Size in ga,Ions: ~ Manufacturer: ~ Line ~1 ~0~ Foundation /~'~ '~,~ -- "Pump on" level at:~' level at: I High water alarm at: Cu~ain Drain ~r~ ~ ~ IEle~ri~[ Ins~i°ns ped°~ed by: Remarks: BENCH MARK Location and Description: I A~umed Elevation: Inspections pedormed by: ~,~~~ ~ Dates: 1st ~[~ Depa~ment of Heal~}and H~man Se~ices approval Reviewed and approved by: Date: ~-/~-~7 ~,:,;., ~0F~ss~' 72-013 (Rev. 9/91) MOA 25 CURRIN CIR, AS-BUILT WASTEWATER ABSORPTION SYSTEM Currin Subd, NOTE~m 1) EXI~TINO TRENCH ~ED HA~ FAILE~, ~E~A~E LEVEL IN THE ~E$ ~A~ 15 TO lB INCHES ~ 5/31/97. ~) REPLACE~ EXISTING TANK ~ITH NE~ 1500 ~ TANK LOT 6 NEIOBDRS ,L IS LDCATE~ PPRQX, 180' FROM SYSTEM. LOT 4 EXIST. BE9 SEPTIC SYSTEN SEE NOTE t INST~LLEI~ VALVE & CLEAN-BUTS, NL~m/ UPGRADE I)EEP TRENCH 6.5' EFF,, 10' .F, ~ 1,500 g SEPTIC TANK SEE NOTE LOT E THIS AREA IS UNI)EVELDPE]L ]]ESIGN' tC~, A B FC --- TI 30~3 19.4 TE 38,9 I)C 40~) 31~ I)V 4EA C1 27,3 19.6 CE 53,7 5~B NT 5~,1 5%9 E1 54,4 46.6 EE 6~,9 Drawing C,\Vork\5-CLIRRIN.D~/G GRIFFIN RDA~ # Perc Rate = 3 MIn/Inch Soils= 125 sF/br 5 Bedroom House 625 SF Rqd As-Bul[~, 6.5' EFFec~clve. 10' To,a[ ]]ep~h 3' ~tlde, 50.5' Long To~al AbsorPD;Ion = 656.5 PREPARED FOR, Rober~c Mackey 5120 Currln Circle Anchorage, AK 99516 (907) 271-5880 Pannone Eng. Svc, P. 0. BOX 142025 ANCHORAGE, ALASKA 99514 272-B21B, PHONE & FAX OATE, 8-E4-97 I AS-BUILT SCALEm AS-BUILT DETAILS el~ ~ASTE~ATER ABSORPTION SYSTEM Lot 5 Currin Subd, z p- c~ W UPGRADE PLAN , I P~nnone Eng. Svc, W P. 0. BOX 142025 ANCHORAGE, ALASKA 99514 272-B21B{ pHONE & FAX DAT£, 8-25-97 / NUT TO SCALEI AS-BUILT PAGE 1 OF MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW970170 DESIGN ENGINEER:STEVEN R. PANNONE OWNER NAME:MACKEY ROBERT C & LOUISE N OWNER ADDRESS:5120 CURRIN CIR ANCHORAGE, ALASKA 99516 DATE ISSUED: 7/03/97 EXPIRATION DATE: 7/03/98 PARCEL ID:01734120 LEGAL DESCRIPTION: CURRIN LT 5 LOT SIZE: 56553 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD 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 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) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BYi ~ Steven R. Pannone, P.E. Consulting Engineer (907) 272-8218 P.O. Box 142025 Anchorage, Alaska, 99514 {907)272-8218 Fax June 8, 1997 Municipality of Anchorage Dept. of Health & Human Services On-Site Services Section P. O. Box 196650 Anchorage, Alaska 99519 Subject: Lot 5 Cumn Subdivision Septic Upgrade Permit FAILED SYSTEM Gentlemen: My firm was contacted to conduct a Health Authority Investigate of thc well and septic system serving this lot for a pending refinancing. The existing system was completely inundated with liquid. The fluid levels were approximately 12 roches above the lateral pipe. I informed the owners that the system was in failure. The owners requested my firm investigate the possibility of installing a replacement system. A single test hole was excavated on May 31, 1997. The soils report and a percolation test result is attached. Ground water was monitored for seven days. No groundwater or bedrock was encountered in the test hole. The lot is approximately 1.I3 acres in size. Lot 5 slopes to the northwest at a rate of approximately 3 to 5 percent. The proposed installation will be located on the southwestern portion of the lot. The existing field will be reused. A diverter valve will be installed between the two fields. The septic tank will be verified during the installation. It will be reused if found competent, and replaced with a 1,500 gallon tank outside the well radius if found to be deteriorated. Double clean-outs will be installed down stream from the tank. The proposed location is greater than 100 feet away from the existing well serving this property and 25 feet from the water service lines. The surrounding wells are located greater than 100 feet from the proposed installation, The proposed installation will not affect the future development of the surrounding or existing lots. See the attached design. If you have any questions about the proposed installation, please contact me at 272-8218 AtteSts: C:~WOP, K~5-CUmUN.001 ' - t~'ff ~ '~71~i ·~, CURRIN CIR. DESIGN ~ASTEWATER AI)SORPTION SYSTEM Lot 5 Currin Subd, NOTES, 1) EXISTING TRENCH BEI) HAS FAILEI), SEWAGE LEVEL IN THE I~EI) WAS 15 TO lB INCHES ON 5/31/97. E) VERIFY INTEGRITY OF EXIST. 1ESOg SEPTIC TANK. REPLACE TANK WITH NEW 1500 g TANK OUTSIDE THE 100' WELL LnT ~ RAI]IUS IF FOUND LEAKING, NEIGBORS IS LOCATED 180' FROM SYSTEM. LOT 4 EXIST, liE9 SEPTIC SYSTEH SEE NI]TE I INSTALL IIIVERTER VALVE ~ CLEAN-OUTS, PRI]PDSEll ]}EEP TRENCH 53 6' EF'F,, 9' EXZST, leSOg SEPTIC TANK SEE NOTE ~ J LOT 2 THIS AREA IS UNI~EVEL[]PE]}/ Drawing C~\Vork\5-CURRIN,D~/G GRIFFIN ROAD -~x ~%.~..' ...... -..'~ 97~ I ~ FDR~ '~~ ~Robep~ N~ckey "~~~~ I Anchorage, ~K 99516 DESIGN, Pert R~e = 3 Nih/Inch SoiLs= 125 s~/br 5 I~edroom House 625 SF Rqd ]]esl n~ 6,0' E??ec~clve 3' _ong To~l Absopp~on = 636 s~ P:nnone Eng, Svc, P. D. 9DX 142025 ANCHORAGE, ALASKA 99514 272-8218, PHONE & FAX DATE, 6-~-97 I ]]ESIGN -~CAL£m 1m=60' I DESIGN DETAILS ~/ASTEV/ATER ABSORPTION SYSTEM Drawing Cm\Vo~k\5-CURRIN.DV~ I _- "~,. _,t_ ":-.."~% ~~ .................... ':'~'~ PREPARED FOR~ [ ~Stewn R. Pnnnonm~ · / ~ Robert M~ckey ~ wm~-.-~'i~- Anchor~Qe. AK 99516 I .qmim~$$,' P~nnone Eng, Svc, I.I P, O, BOX 142025 ANCHORAGE, ALASKA 99514 872-8218~ PHONE & FAX DATEm 6-1-97 NOT TO SCALE] DESIGN PERFORMED FOR: Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG m PERCOLATION TEST LEGAL DESCRIPTION: 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 DATE PE. Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? " p E Depth to Water After Monitering? '~) ~"~ Dale: SITE PLAN I I I I Gross Net Depth to Net Reading Date Time Time Water Drop 5/3r ~:~s- '" ,~ ~/~ - - .. ,t~, ( ~/~ ~/~ PERCOLATION RATE TEST RUN BETWEEN ~¢~ FT AND ~' FT COMMENTS --~"~- ~ PERFORMED BY: ~ '(~- ~)~,AJ~.J ~),~t,/~ ~ I ~ 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) ~ 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 IPHONE ~ _ ~ UPGRADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS ~ ~ D,STANCE TO: ]~~ I Ab'°rPt'°~'~ D~ellingp~~d. PERMIT NO.~ qO ~ Z Manufacturer ' Mat~;~ No. of compartments Liq'~~gall°ns IF HOME.DE: Inside length~ Width ~ Liquid depth ~ ~ell Foundation ~earest lot line Pfi~MIT ~0. m ~ DISTA~ ~ ~ ~--~ No. oflines Length of each li~ ~f~ ~ ~ m ~ ~ Trench width Distance between lines -- z ~ ~ inches ~ ~ Top of tile to finish gra'de Material b~n~th [ile ~ ~e absorption area Q inches ~ LengtW~' Width /~, Depth ~, PERMIT~ ~ ~ Type of crib Crib depth .~I~ ~/~ Crib diameter ~[~ ~/~ Total effective a~o~ea ~ Well ~~ B~ding founda~on Nearest lot line DISTANCE TO: P~o~ /I ~ Class~ ~ Depth ' Driller ' Distance to lot line PERMITNO. ~ DISTANCEt TO: Building found~ Sewer line ~ Septic tank Absorption area(s) SOIL TEST RATING INSTALLER /~ ~ ~~--~---0-/j ~ ~ " ' REMARKS I ~ ~ ~ ~' ~ t .... ~s~~ ~u~d oor~'~k ~'~' '~ ~ '""' .... ~,1 ....~, ..... ,,.~ / 72-013 (Rev. 3/78) P E R M I T NO: DATE ! :i.'3SLJED: A F'F:'L.. ! CANT .,% r'~ T) ~:(' c: c: CON'TACT F:'HOI',ilE: CL..ARI< CONSTF<tJCT I,'.')N I:.". O, BOX :t 1074 1 ANCHOI-?.AGE, AK 995! 1 344-'722:3. 12N :'Ar,~', ZW Listr.-.'.-d belaw are the ,:;p'l:.ic.~n,:~ ava~.;!.ab!e 't.c~ ',/c)u ~,.r".. des:i, gning y,:.~ur' septic --~x.,sTem. Clnoose the opt. i.c)n +hal- best. fits vou. r ':'If'" ,IF;;:: EET. NI IE:::; IF..-{ I::3: liE!-'..:: ][Z> ~.,~,~ ,,, ]]},, IF;,". ~:~ % ~",dl 1,., F'IF:'E B(]'I'TC)M (FT' DEF:'TH '"n . . GRAVE! .... DE:PTH (F'l'.) TOTAl.. DEF:'TI-t (FT.) ,,,~- ............ WIDTH fFT ) :3 f:~ '1~ I , · GRAVEL. I ..... I".1,.::,, -I (F"T.', r.'::ni,,",~:-':~ VOI_IJHE ~'RIJ YDS ', TANK,.:<-':; .,.'r ,..'7 ;_~:" (GALS) ¢:,"~'r, RAT'ZI',IG '.:SQ,, F-T. /~R.) TANK MUST' HAVE AT ...... ~. wi ]. 1 ~n~+ al ]. thce system in :~:~c::c:c:)rdanc:(e u',¢i'* h .::~]. ]. MC)A r'¢'~des ...... r, ... s e v,} e r a ~ ~ s'/s't, e m any enlargemen't w'ill r,c~qu:i.r'¢ ali add:~.tJ.(3na], pc-;pm:i.t S I G N E D AF'PL ! t..,,-~,q f: ....... t.,! ...... B'-," Municipa ty of Anchorage PO L._.~4 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit ~: 840973 January 31, 1985 TO: Permit Applicant SUBJECT~ LOt 5 Curr~n Subd~v~si0n A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. 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 and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Keith E. Bandt, or Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 DEPARTMENT OF I-IIEAL..'TI'4 AND ,-.N.,- .,.,',011ME:h,, .~L F'FtO]'EC'I'ION EP'~ L STREET, ANC:HC)RAGE.,, AK 9950 1 264-"4720 PERM I T NO: f]ATE I c,~ ~ .- ,D,DUE£: APPL I CAN'T: ADDRESS: PHONE: DI~,I--S ][. 1-E SEWE:F< 840973 12/03/8/.1- CL. ARK CONSTRUCTIC)N P 0 BOX 110741 ANCHORAGE, Al'::: 99511 .-r. ~. ~_ .7-~. ~..-r. L. EGAL DESCRIP: SUBDIVISION: CURRIN LOT: 5 BLOCK: NA SECTION: 27 TOWNSHIF': 12N RANGE: :!,W LOT SIZE: 1..5A (SO.FT. OR ACRES) MAX BEDROOMS: 4 ; Listed below are the optians available ta yciu in cles:Lgn:i, ng your septic: system. Chao~e the option that best ells your si'Le., DEF:']]I...I, TO PIPE BOTTOM (F'l-.) 3.0 .w.* . / 4.0 ~ 3,, 0 ~ GRAVEL. DEF']'H (FT.) 4.5 0,,5 ~ 3,,5 ]'OTAL DEPTFI (FT.)' 7.5 4.5 .] 6.5 .~F, AgEI_ WIDTH (FT.) ~_.~ 27.0 / ~.L) GRAVEL LENGTH (FT.) ' 123.0 ** . 54.0 J 1].9~0 ~ · :x.-~ DEPTH TO PII-'E BOTTOM < 3.5 FT. REQUI:IRES INSUL. ATION ..:x-.DEPTtq TD PIPE BOTTOM < 4.0 FT. MAY REQUIRE A I_IFT STAT ZON · '~ GRAVEL LENGTH > 75 FT, REDU~RES MULTIPLE IRUNS (NOT EXCEEDII;IG 75 Fl'. EACH) '~-* TAI'qK MUST' F'!~VE A'T LEAST TWO CDMF'ARTMENTS I certify that: I. I am familiar with the r'equiremep, ts f'ar' on--si, re '..-:ewers~-and wel.].s a~..~ siet £or'th by the Municipality 0¢ Anchc)rage (MOA) and 'Line State of Alaska. 2. I will :Lnstall 'Lhe system in accordance wi. th all MOA codes and regp:Lat:Lans, and in compliance with the design criteria oF this permit.. k .....se'k back 3. I will adhere to ail MOA and State of Alaska r'eqL~irement.~; lap ..k~ distances ¢r'am any existing well, wastewat, eP disposal system or public se~,.¢erage system an this or any adjacer~t or near'by lot. 4.. I understand t. hat this permit., is raj. id ¢ora maximum o{ 4. bedr'o~ms: and any enlargement will. require an aclditi(anal permit. IF A I_..TF"T STATION IS ,c: ,, c ., IN,.,TA,_I_.,..:D IN AN AREA r-n~¢.r...c.r..r~ BY Mr';,~ ~":,'~"~ ~',~',,i,:: r-nnp-c: ~ ~..~.~ ~ ..' ~' -], ,--J:~ '1~ C' ",C"~' T" ~-u~-.~ (1) AN ,_I_ECTI.:[CAL. FE:.-',MIT AND ............ ] ..... iFc_t.,T,.dN MiJST BF FIB-FA]'Mrsf]''.~ .~9~ ..... .~c:._~.-., ~4 ...... U I I...]'c"' .... ~. :, .c'. _.,:'. "::, ,-..,'~ IxqS::'E[C"r'I,.qtx R ...... I.F; ANT.) ~.::!) "r'..,-' W'r LL IxlOT' ~.:,E AF'F'ROVED W I THOUT AN ,....L~_C T t,. I ,-,,-L ,,~::L:. r', :"' " , f.,I::. EL. ECTRICAL WEIRK MUST BE r~n~, '- BY L ,'m:"~,,::~::q ~!::~ ..c-.m-~-c.,' · ....... 4E. A I ......................... [CIAN. - ~ r..,l r-.- AF',-", .... C~-;dxlT: CLAF;..'K CON:.:,Tc.U,.~ T I [.,I I DEF'ARTMENT OF HEALTH AND ~ '~ =" ~ ~' ~_N~ I ~.E,'tqM~:NTA~ F'ROTECTION .... ~ '-'~ ANCHORAGE:, ~ ~'' ~..~,'... ~501 254'-"472() ,~ ,:RMIT NO: DATE ISSUED: ---. S I 'T' E SEE ~ ~-7_ F~ 840973 HAND WRITTEN 12103184 F' E-~ F;: M I "f APPL I CANT: /'~ P,'r')[..-~,E: c; (':-' . CONTACT PHONE: CLARK CONSTRUCTION P El BOX 110741 ANCHORAGE, AK 99511 344-7223 L. EGAL DESCRIF': SUBDIVISION: CtJRRIN LO]': 5 BLOCK: NA SECTION: =,. TOWNSHIF': 12N RANGE: 3W L. OT SIZE: ~..5A (SQ.FT. OR ACRES) 1. I am familiaP with the nequinement~ fop on-s~ite sewe¢~ and we].l~ a~ set for'th by the Municipality of Anchorage (MOA) and the Sta'k.e of Alaska. 2. i will install the s~ystem in accordance with a].l IdOA c:c3des and r'egu].ation~s, and in compliance with the design c~ite~'ia o¢ this permit. ' 3. I-will. adhel-e to all MOA and State o~' Alaska r'equirements for the set back distances ¢~'om any existing well, wastewaten di~posaI sy's~.e~ or' public se~,)erage system on 'Lhiss o~' any adjacent of near'by lot. IF.A LIF'T STATION IS INSTALl_lED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBT~-.II..,b~, AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSF'ECTION REPORT; AND (3) THE ELECTRICAL WORK IdUST BE DONE BY A LICENSED ELECTRICIAN. S I GNED APPLICANT: CLARK CONSTRUCTION DATE: ISSUED BY :DATE ,. 264-4720 Pe~it ~ ~o~ * '~ *,,,., ~HA DW IT~P,~.__MIT * * * ,, .L A ...... .,~-~,i ,,..,F_6r_x PERMIT Applicant: ~//~Y ~/~-- ' Mailing Address: MUNICIPALITY OF ANCHORAGE Departmen' of Health and Environment ~ Protection 825~L Street, Anchorage, AK.~'99501 Location: Legal Description: ~~-~ Type of Soil Absorption System Is: Trench: /j-Drainfield: r Maximum Number of Bedrooms: DEPTH Phone Number: 3(-t~-/--7~ , (~//.,~..,~.4~J Lot Size: Seepage Bed: Holding Tank Soil Rating(sq.ft/br) ~7~- The Required Size of the Soil Absorption System Is: :7'~'- LENGTH /~ GRAVEL DEPTH'._.~~ WIDTH The length d~ension 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 ~xcavation(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 : /Oq'~'~ 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 inspect~n and approval by this departmen will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee 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 diagra/~s are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 * * 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 underst~d that the on-site sewe,,5~e ~s.~nce i~e~de~d to inc'l~d~YSm~ may rethat ~~o~rgement if /~licant Date- U ~~ ~ ~ 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 LEGA' DESCR,PT,ON: L~'- /5/K ~ SLOPE SITE PLAN 10 11 12 13 14 18 20 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? S L O P E Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN ~ FT AND ~ FT ~-008 (6/79) ALASKA EnUIROIlmeI1TAL COI1TROL SeRolCe$, IF1C. ~ncjineerinq g ~nuir0nmentol Studies Janurary 24, 1985 Department of Health and Environmental Protection 825 L Street Anchorage, Alaska 99501 Subject: Lot 5 Currin; T12N, R3W, Sec 27 MUNICIPALITY OF ANCHORAGI~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTIOi'~ ~AN 2 ~ 1985 RECEIVED Attached is the soils log for the subject property. The excavation for aa-site septic system was not within 10 ~eet of the original test hole. The soils in the excavation was examined and visually rated. The system was re-designed accordingly. The soil wa8 examined a minimum of 4 feet below the excavation to verify proper separation from ground water. If this office can be of further assistance, please contact us at 561-5040. Sincerely, L. D. Montgomery j"--/ 1200 J.Ues! 33rd Auenue, Suite B, Anchorage, Alaska 99503 *(907] 561-5040 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -- PERCOLATION TEST ~ SOILS LOG PERCOLATION TEST PERFORMED FOR: DATE PERFORMED: SLOPE SITE PLAN I- l I II1 & l! ! 10 11 12 13 14 15 16 17 18 19. 20 COMMENTS PERFORMED BY: ~o~ oo~ 772-008 (6/79) WAS GROUND WATER S ENCOUNTERED? rto L O P E IF YES, AT WHAT ~ DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION / O (minutes/i~c~ Y 6 ~)- TEST RUN BETWEEN FT AND O///~'-' FT M 'W DRILLING, Inc. P.O. Box 10-378 · 10300 Old Seward Hlghw,,y '-~* ANCHORAGE, ALASKA 99511 85-125 DRILLING LOG Well Owneraot,- m .,-~ e~.,.~ .... ~ ~ ..... Use of WeH.-~----- Location (address of: Towmh]p, 1R~mge, Section, if ]mown; or distance maf~ roar] L 5, Currin Subd. Size of casing 6" r~epth of Hole 2/: 2 ' feet Cased to 2/: !. 7 feet ~ Static water level 220' ft, ~ (below) land surface, Finish of well (check one). open end ( X ); Screen. ( ); Perforated ( ), Describe screen or perforation, Well pumping test at 20 gallons per of drawdown from static l~vel, ' ": Date of completion June 12 ~, , ,, Depth in feet from " ........ ~ ground surface Give det_ait~ None (minute) for 1 hours with 100~ WStL LOG 6f 'formations penetrated, size of material, color and hardness 0 TO 2 2 TO 6 6 TO 48 48 ..TO 63 63 TO 103 103 .TO 119 119 TO 121 __!_2J~_TO 148 148 TO 161 161 TO lan TO~N~ ~05 TO 2~9 .TO 230 · 230 TO 2~2 .~0. & sand It4UIVICiPAi ;~, OF -- . . ~,. at:PT. ~). ~NCHO~ - ;'~ur~CrlOhl ;Silty: Gravel ' JUN :~ . : ,"& '.! hard.., oa~..!/ W~ter gr~ve! Water gravel NWWA Certified Contractor C~..~__..,!~.ic x, , o~, o 1 -- CUSTOMER ALASKA ENVIRONMENTAL CONTROL SERVICEe INC. 1200 West 33rd Avenu~.~,uite B ANCHORAGE, ALASKA 99503 (907) 561-5040 JOB L_. ~' SHEET NO. -- CALCULATED BY CHECKED BY SCALE OF DATE DATE {~'F L L 7q' \ \ \ 2q,5" f7' ~_0' 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 Parcel I.D. CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location(site address or directions) Lending agency Mailing~ a~ldres§ Agent Address Day phone '~-/--~'-~ O Day phone Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: I nd ividual on-site "~ Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information 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'-'~A,u,~o/u~ ~-~ ~vc_ Phone ~-~-~.-~'~/~ Address Engineer's signature- SIGNATURE Approved for Disapproved. bedrooms.,, DHHS ¥ 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. 72-025(Rev. 1/91) Back MOA#21 RECEIVED DEC 22 lg98 Municipality of Anchorage -MUI~C-LP~,LITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN 8J~xlF~[,~TAL SERVICES DIVISIO Environmental Services Division 825 L StreeJ, Room ,502 · Anchorage, Alaska ggs01 · (go?) 84:3-4744 Legal Description: A. WELL DATA W-ell type~-lPE t o Log present (Y/N) Total depth Sanitary seal (Y/N) Health Authority Approval Checklist (~c)~-"P--I,'~ ParcelI.D.: C:,l~- 3W'-/~ If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to ~- fi/. -7 Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~ C_~- Date of sample: / B. SEPTIC/HOLDING TANK DATA Date installed ~//~/~ ~ Tank size Foundation cleanout (Y/N) Date of Pumping ' C. ABSORPTION FIELD DATA Date installed <~'/f/ FROM WELL LOG Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION g.p.m. ~ -t-' g.p.m. Nitrate Collected by: Other bacteria ~ ~ --'-" /,s- c~ Number of Compartments ~__ Cleanouts (Y/N)__ Depression (Y/N) ~ High water alarm (Y/N) Pumper /~ -t'J~l o,'v/ ~ Soil rating (g.p.d./fF or fF/bdrm) Immediately after ~ Absorption rate = Length ~c) ,_~ Width ,~ c~ Gravel thickness below pipe Effective absorption area ~;,~,---~ Monitoring Tube present (Y/N). Date of adequacy test /~J~.u.~ ~//~/t~-7 Results (Pass/Fail)"~A-~,S Fluid depth in absorption field before test (in.); ~ Fluid depth "-- (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) c~. ~ System type -'C) -/-- Total depth /m ~ Depression over field (Y/N) For ~-- bedrooms gal. water added (in.): .g.p.d. If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed , / Size in gallons ....-- Manhole/Access(Y/N) (/~"Pu~ High water alarm level a.~~~ ~tum E. SEPARATION DISTANCES "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /.~C~ t Absorption field on lot /~/ Public sewer main ~"~/~ Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation / ?' ~ Property line ~ ~ I Absorption field ~; Water main/service line ~,O ~ Surface water/drainage /c~o --r- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line z"/O ~ Surface water /c~ '+- Curtain drain g' 0c9 ~'- Building foundation /7 ~ Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots /o F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal recor~ystems are in conformance_ with MOA HAA guidelines in effect on this date. ~:~'~~('~'"'~ /t ',,/I- ~t,~""-'~_..-~ Signatur~~~ Engineer's Name Date l'~ / I -~ / q ~ H~ Fee $ ~~ z ~ Waiver Fee $ Date of Paymen.t /~/~ W2 Date of Payment ~'~~(q~ '~). Receipt Number Receipt Number 72-026 (Rev. 3/96)* DEC-~0-88 14:35 FRq~'FE ENVIK~NI~NTAL 5615301 T-2T8 P.02/05 F-424 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) .¢"/~ o ~¢~..,,e,",,.,J Property owner Day phone Mailing address Lending agency Mailing address Agent Address Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. 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. 724)25 (Rev. 1/91) Front MOA ~21 .... 5. STATEMENT OF INSPECTION BY ENGINEER J 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 Phone Address ~~'~~~ Date ~ '(~ '~ Engin~fs signature I I A ' .... DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. 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. /24~5 (REV. 1/91) Back MOA il21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ ~ ~ ~~"'~-~ ~.,~',cJ. Parcel I.D. A. Well Data Well type ,'~.~"~.-'~"'"~' Log present (Y/N) ,)/ Total depth ,~"~"~,~ ~'~' Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~/'x'/'~,,,'~,5''' Driller ~ Cased to ,~'~'/, ,~' ,~'~' Casing height Wires properly protected (Y/N) AT INSPECTION ,~ g.p.m. /'1/ g.p.m. FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /-~ ~' Absorption field on lot / ,9"~' / Public sewer main ~,~ Sewer service line //¢~ / ~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: ,-~,'~". /'~'~ / ~ f~/ ~. "/,~' Other bacteria Collected bYc~ '.~ ~ - f B. SEPTIC/HOLDI ,NG TANK DATA Date installed '~/'/~//;'~',6'~" Tank size /,g-.~'~ Cleanouts (Y/N) )/ ,~ .Foundation cleanout (Y/N) High water alarm (Y/N) Compartments ,~ ,Y' Depression (Y/N) Alarm tested (Y/N) ~ Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /..4, ?,'~./, . On adjacent lots To property line ..~/. ,~"~' Absorption field Surface water/drainage ,'~"~' ~"~' Foundation Water main/service line ~/'Z~ ,",,~'~- 72-oas (a/m)'Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level ,.I/4 Meets MOA electrical codes (Y/N) SEPARA~vvett~lot On ad;OaceNntTO~s Manufacturer Manhole/Access (Y/N) Surface water. D. ABSORPTION FIELD DATA Date installed ../,,~,~.Z Length ,~',,~,~',,z'. Total absorption area Date of adequacy test Water level in absorl~ion field before test Peroxide treatment (past 12 months) (Y/N) / P~,.~"' Soil rating (GPD/FF) ~-~ ~ * System type Width / ~ / Gravel thickness /,~-- ''/ Total depth ~'.~,~ Cleanout present (Y/N) Y' ' Depression over field (Y/N) ,~/' ff./6'.'~ '-/ Results (pass/fail) Da ~ for /-/ Bedrooms t · Nter test /v' If yes. give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot, To building foundation .~/~-,,z. On adjacent lots / ~,~ ~ ,z",,~ Surface water Curtain drain On adjacent lots / ~-'o ",4-,,~ Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in eff~_e~~~,l~i,s/nspec~o. - . - Date HAA Fee $ ~ ~ ~ Waiver Fee $ Date of Payment ~"- / ~- ~4/__ , Date of Payment R.ce .umber [4 J Recei..umber 72-o26 (3/1~)' B~ HUSTON.XLS Doul[las T. Kenley Civil Engineer State of Alaska C.E. 8176 SEPTIC SYSTEM ADEQUACY TEST Legal Description Applicant Date of Test SYSTEM DATA Tank Volume Number of Bedrooms Absorption system - :~..'~.-3 ............. Absorption required (1 .~daily flow) - TEST DATA TIME FLOW VOL. TANK LEVEL TUBE LEVEL COMMENTS (gp,m) (gals) System Passed J,,/' Sysytem Failed Comments Page I HUSTON.XLS Douglas T. Kenley Civil Engineer State of Alaska C.E. 8176 SEPTIC SYSTEM ADEQUACY TEST Legal Description Applicant Date of Test SYSTEM DATA Tank Volume Number of Bedrooms Absorption system Number of Bedrooms Absorption required (1.5 dally flow) TEST DATA TIME FLOW VOL. TANK LEVEL TUBE LEVEL COMMENTS System Passed Comments J '~'~ -~'~-,,--'. Sysytem Failed Page 1 SINCE t908 CT&E Ref.# Client Sample ID Matrix Client Name Ordered By Project Name Project# PWSID Commercial Testing & Engineering Co. Environmental Laboratory Services w~'~r~'j~'j~-~,j~'jsj, ar~r~'jf~,j~jjjjjjjj~~ LABORATORY ANALYSIS REPORT 94.4160-1 LOT 5 CURRIN SUBN WATER DOUGLAS KENLEY,P.E. DOUGLAS KENLEY UA WORK Order 81374 Printed Date 08/16/94 ~ 16:32 hrs. CollectedDate 08/14/94 ~21:20 hrs. Received Date 08/15/94 @ 11:00 hrs. Technical Director STEPHEN C. EDE Sample Remarks: ROUTINE SAMPLE COLLECTED BY: FRED W. KENLEY. QC Parameter Results Qual Uni~ Method Allowable Ext. Anal Limits Date Date Init Ni~ate-N 0.48 mg/L EPA 353.2/300.0 10 08/15/94 CMR * See Special Instructions Above ** See Sample Remarks Above U = Undetected, Reported value is the practical quantification limit. D = Secondary dilution. UA = Unavailable NA-- Not Analyzed LT= Less ~han GT= Greater ~lmn 5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA ARCTIC SPECIALTIES AND SUPPLY Serving Alaskan Engineers with Well and Septic Adequacy Tests and Soil Percs slnoe 1986 \ ,' Legal .- ,,., ' ~."/~ Owner Phone Client Test Phone Date T,D,B.T.P. L,L,A,B, $,U. A,T,P. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) ~/zo cu R. N ciR., f t cH. AK. (b) Applicant Name ",~HN' C~.-it~l'J~i( Telephone: Home 3 /"1/('/' 722-3 Business 3 Applicant Address P,O,i'80 ( 1107 /! / NCH (c) Applicant is (check 0n~): .Lend. lng Institution [] · Owner/builder I~'; Buyer []; Other [] (explain); (d) Lending Institution ., Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family I~° Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Well~[ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page I of 2 ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND IN'FORMATION 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 of this inspection. Name of Firm '~ C ~ -~ I ~ (~, Telephone ~/- ,~'~ YO Date Approved for /~--~'/--.~,-~ Approved ,~k'/ Disapprov~d~d ' ~-~'~.-~-L.~-//~:::~_~Di~te Conditiona'l Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations 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 requirements. 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. Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) NtUNICIPALITY OF ANCHORAC-{:HECKLIST- FEBRUARY 1984 DEPT. OF HEALTH & 264-4720 ENVIRONMENTAL PROTECTION Legal Description: L'~~' 'T 12. N f~3U] ~,~A¥ t 5 1986 RECEIVED i IVDi u~ DuP, L Well Classification If A, B, C, D.E.C. Approved (Y/N) Well Log Present (~N) Date Completed Total Depth ~ Cased to 2. (1/ I, 7 Static Water Level 2 ~_0 · Casing Height Above Ground Electrical Wiring in Conduit (~)/N) Separation Distances from Well: To Septic/Holding Tank on Lot I00/-/- ! TO Nearest Edge of Absorption Field on Lot I / To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results C u F~ f{ ml ,5/0 .SEC., Z7 ~l/J_ Z,/ ~'-~" /_ Yield ~:~- (? ~ P~ Depth of Grouting ~/~ Pump Set At gN~~ Sanitary Seal on Casing ~/N) Depression Around Wellhead (Y/~ · On Adjoining Lots · On Adjoining Lots ~/~(/~r/'Jr To Nearest Public Sewer To Nearest Sewer Service Line on Lot ,~,.~, ~ ~ I 7"(_. J"JU(.~ 'Date ~//.'~/,~ /00"/' /00 ''/- i O0 'Jr- Comments B. SEPTIC/HOLDING TANK DATA Date Installed I/2q/~,&~'' Size I ~.,,S"O No. of Compartments ~-- Standpipes aN) Air-tight Caps (~N) Foundation Cleanout i~N) Depression over Tank (Y/~) Date Last Pumped . .A/'/)z) ~ Pumping/Maintenance Contract on File (Y/N) //~//OF ;for /U//ot, Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well / O~ To Property Line ~ ~' · To Water Main/Service Line Course ! 0 0 / Comments ~ -~'E.~' C ~'/~ 'I"/F/C Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage ~ A ~ cc. u P~,vc Y Page 1 of 2 72-026(11/84) v C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field 15-0 Square Feet of Absorption Area .~._"~ Depression over Field (Y~) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation J,~ /~' Lot /00 TO Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field ,-,.~.~ / Depth of Field Gravel Bed Thickness Standpipes Present {~N) Date of Last Adequacy Test . To Property Line / / / To Existing or Abandoned System on · On Adjoining Lots / O0 ' ~ . To Cutbank (if present) /00' P Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes ( CommentS Dimensions/././~'/ Manho~s (Y/N) ~,.,.,.~P~rnp Off" Level at ~ Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have c,J~cked, v~rifiecl,, or conformed to all ~OA anzd HAA guidelines in effect on the date of this inspection. Signed 0~-~~''~ Date F/_~q/~J~'~ ' Company / [ ~I~':;C~..~, ]J}/C, MOA NO. ~'~-O'~''~q Receipt No. ~ ~ ~ ~ Date of Payment =~/~ ~ Amora: S Page 2 of 2 72-026 ( 11/84)