HomeMy WebLinkAboutBIRCH TREE ESTATES BLK 2 LT 8
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: -.~'/4/C~q02,~/-;/ PID Number: ¢I71WW
Name:
~oH~ C. ~ ~T~ ~. ~F~=o~ Wastewater System: D New ~ Upgrade
Address:
~Z~o ~ /~7 ~ ~v~. ABSORPTION FIELD
~CHO~"~, ~ ~/~ ~No. ofB~rOoms: ~ Deep Trench ~ Shallow Trench ~Bed ~Mound ~Other
Total Depth from original grade:
LEGAL DESCRIPTION s°""~""~: ~.7 ~/sq. ~t. ~.~'
Lot: Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township: I Range: ] Section: Fill added above original grade: Gravel length:
~~ - ~I ~ t Ft. ~ Ft.
~New ~ Upgrade Gravel width: Number of lines:IlDistance between lines:
WELL:
/~ Et. ~ ~*~ Ft.
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Driller: ~ ~, Date Drilled: Static Water Level: Installer: ~ Date installed:
I Pump Set at: J Casing Height Above Ground: TANK
Yield: I ¢ GPM Ft. I* 5 Ft.
SEPARATION DISTANCES ~ Septic ~ Holding ~S.T.E.P.
To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~~~ T~
Number of Compa~ments:
Surface / ~
Lot / ~ Size in gallons: I Man~cturer:
Line ~ /~ / ~ ~' ' ~ /~
"Pump on" level at: J "Pump off" level at: J High water alarm at:
Foundation /~ ' ~7 , /~ t = : ~ ~#I ~"I
Cu~ain ~0~ ~ ~ ~ ~ Pump Make & Model Electrical Inspections pedormed by:
Drain ~ ,~/ ~
Remarks: BENCH MARK
'Location and Description:
T~ -
J Assumed /00, ~ ~j,
Elevation:
Inspections performed by: z..~. Rivar. Ala,k. ~S~ Dates: 1st
Department of Health andHum ices approvpl
Reviewed and approved b ~ Date: /
/
72-013 (Rev. 9/91) MOA 25
Permit No.Sw940224 Page 2 of 2
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.IRCH TREE ESTATES, BLOCK 2, LOT 8 PID No.: 01714141
104 1i f--104.1'.
.................................. co'~ .......... c'o~ ...................... i ........................................... ~ ....................................... ~"~--il'l"f-" ..................... ?"ll"f"~:i ......... ~ .........................................
, -uo.( , Ma ~ / IMPERME~B~ B~IER~ ~ otI S, X ~ 11° ~IM~ BARRIER
94,1~ ,,no O*L I ~9~.9' i (MTIa l~J 1'~ / ~ - (MTaaMT4)
sw~ I :: ~ MT2/ :' / [~ DIST, PIPES ~D WI~
......................................... i....~ ........... [ ....... i ........................................... :: ..................... Z ................. ~..,.,....~.~...,.,..../ ........... J .............. a'L.~E..s~..~o.~..o~.~n ................
~ M~.~ --~. I ~ UNDER DIST. PI~E~.
SAND
N.T.S.
&93.9' WATER FOUND 6-9-94
10' U~IL ESMT
NEW PRESSURIZED
UTION BED
1500 GAL.
S.T.E.P.
LOT 8
ON
AN AS-BUILT ~SURVEY DRAWN BY:
GASTALD! LAND SURVEYING
IT 15 THE RESPONSIBILTIY OF THE CONTRACTOR
TO VERIFY EASEMENTS, REQUIRED SEPARATION
DISTANCES, AND PROPERTY LINES PR[OR TO
CONSTRUCTIOI~.
N
SCALE
WELL
ROBEF(T C. COWAN
CF. -8801
72-013 A (1/93) '
11-~-1994 07:13 90756384~3
PARKWAV ATRIUM BLDG P.03 '
DEPARTMENT OF NATURAL IISOURI~"
D:ws:o. OF WA .
WATER Wll,I. IP.~OIO "
D~H TO ~ATm W~ LWEU
, D p~Ora~ ~ o~t~ hole
~p~ of opaning~: ~ te ~ ft
GROUT TYPI; .-- ~
De~ from , ~ft
D~O~tT M~HOD:
~L OISnF~EO UPON C~.~ON?~Y-- a .0
CONTRACTOR INFORMATION: REMARKS:
Signature of AuthOriZed Rispreientazwe PO BOX 7722116' . , ,.
EAGLE RIVER AK $9677.2.115
11-22-1994 8T:12 98?5630453
PARKWAY ATRIUM BLDO
ION ~EPOBT
P. 82
HUt't lC I~"AL'I."1 ¥ 1.11? ANC. I.IOR~, BUILD lNG BAI'ETY .... JO() £A~T TUDOB ROAI)
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TYBIi Ol~ IN~iI"I~¢T.'[(~N:"" ""
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(.'OMH [:NT~;
PERMIT NIIMBER:SW940224
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:PETERSEN JOHN C & HEATHER E
OWNER ADDRESS:5290 E 147TH AVE
ANCHORAGE, ALASKA 99516
PAGE 1 OF 2
DEPARTMENT OF HEALTH ~ H~ SERVICES
~.o. BOX z~6650, 8~S "~" ST~SST, ~OOM 50~
~CHO~GE, ALAS~ 99519-6650
ON-SITE WELL ~ WASTEWATER DISPOSAL SYSTEM PE~IT
DATE ISSUED: 7/06/94
EXPIATION DATE: 7/06/95
PARCEL ID:01714141
LEGAL DESCRIPTION: BIRCH TREE ESTATES BLK
8
2 LT
LOT SIZE: 28414 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT:
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 (24 HOURS)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
TH~.~.S~--,U8~.,~ THE. ,~~,~;F~R ~?::BE ~A:: CL~E~ COURSE
0N-~{~E.~ USED OR ~ST BE OBT~I~M-A ~-APPR0~ED
~SOO~CE.
RECEIVED BY: '",~-'.~..,',.J,
ISSUED. BY: ~
ROBERT SHAFER, P.E.
ROGER SHAFER, P,E.
June 14, 1994
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 'L' Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Birchtree Estates Subdivision; Block 2; Lot 8
Request you issue a permit to drill a well and install a septic system
to serve the proposed four bedroumhouse on the referenced property.
Test holes were excavated and percolation tests performed. The
approximate location of the test holes are located on the attached site
plan. At the time of excavation water was encountered at 3.5 feet in
both test holes and after seven day ground water monitoring water was
found at 1.5 feet.
This property has enough area for a future septic upgrade which can be
seen on the attached site plan. We do not anticipate any adverse
effects on neighboring properties by the installation of the proposed
septic system.
If you have any questions, or require additional information for your
review, please contact us.
Since
SOIL TEST
PERCOLATION
. E.
TEST
R~S/LSU/jk
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
Z
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I
w
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1 O' IL ESMT
NYqd 311S
z
L~J
O3O
91¥130 'S'I'N
PERFORMED
LEGAL DESCR IPTIO N:~'!
1
2
3
4
5
6
7
8
9
10
11
12
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15
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18
19
2O
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT &St OL
DEPTH? p
E
Depth to Water After
Monitoring? Date:
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water ~ ~.4~'~
I¢.; 0"+¢,,, -- 0
:. 07 t ,, fi'O," ¢ ~ w."
;1o t" 6'fi- ~'
PERCOLATION RATE [ ~-' (minutes/,nch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~-~.=~AND ~ FT
COMMENTS t~'~-{:~ "/ ~'~ ,~-'¢-'~ F ~. ~I~¢~D.. ~ ~
S & S ENGINEERING
~ ...... , ~, ..... RTIFY THAT THIS TEST WAS PERFORMED IN
PERFORMED BY: E~G~~ ...... , ~,aa~u 77a//
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINE~E~ ON THiS DATE· 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:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
ENGINEER'S SEAL)
DATE P
// ~~~.~
Township, Range, Section: '
SLOPE ~ITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT ~)
DEPTH? %,~t P
E
Depth to Water After
Monitoring? Date:
Gross Net Depth to Net
Reading Date
Time Time Water ~ ~tS',~ ,..
> 22 ( ,, ,%" -~ I'/z"
; g) i" ..qO 't'~"
PERCOLATION RATE __ (minutes/tach) PERC HOLE DIAMETER
~.$
TEST R~N BETWEEN ~Z_~.~F.T AND~_ FT
S & S ENGINEERING
~ .~-'~- · .... ,&."vo ~Aa I~ERTIFY THAT THIS TEST WAS PERFORMED IN
PERFORMED BY17034 -~---§I; ,.D='' ~. =---' - --=
ACCORDANCE ~I~,I_~"~ANeaI~,~tJ,;'~,P^L GU,DEUNE~'C~N TH~S DATE. DATE'.
72-008 (Rev. 4/85)
ON-SI~ ~tt~lt DISPOSAL S~STEM
CONSTRU6~ION PRACTICES
and
MATERIAL SPECIFICATIONS
~: Birchtree Estates Subdivision; Block 2; Lot 8
1. The scope of this project includes the installation of a 1500 gallon
septic tank effluent pumping (S.T.E.P.) system and a pressurized
absorption bed to serve the proposed four bedroom residence located on
the referenced property.
2. Construction shall be in accordance with the approved site plan and
design drawings, Municipal permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater Disposal
Regulations.
3. The contractor shall be responsible for obtaining any necessary
underground utility locates.
4. Unless specifically agreed otherwise, the property owner shall be
responsible for final grading areas subsequently depressed from soil
settling. On all leachfield mound systems, the property owner shall be
responsible for ensuring a satisfactory vegetation growth over the
mounded area.
5. Contractors installing wastewater disposal systems must be certified by
the Municipal Health Department for system installations. Owners
installing their own systems must also receive prior approval from the
Municipal Health Department.
SEPTIC TANK INSTALLATION:
1. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts for pumping
access.
2. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
3. All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
4. Septic tanks installed with less than 4' of cover shall be insulated.
Page Two
Birchtree Estates Subdivision; Block 2; Lot 8
June 14, 1994
5. A foundation cleanout shall be installed one to four feet from the
building foundation. In the line between the tank and the leachfield
there shall be two adjacent cleanouts (unless an effluent pumping system
exists within the septic tank). These cleanouts shall be located on
undisturbed soil not more than 10' from the tank. The first cleanout,
in line, shall be to clean toward the leachfield. The second cleanout
shall be to clean toward the septic tank.
6. Final grading over the septic tank shall be such that a positive slope
exists away from the septic tank.
PRESSURIZ~MO~3NDSY~ INSTALLATION:
1. Any peat or organic matter must be removed from the elevated mound site.
2. The bottom of the basal bed area as well as the top of the sand filter
is to be within two inches of level.
3. The distribution piping is to be of P¥C (ASTM D3034 or equal). All
joints are to be solvent cemented.
4. The side slopes of the top layer of the mound system must not be steeper
than 33% (3:1).
5. The top of the mound shall be covered with a minimum of 6 inches of
topsoil and vegetated sufficiently to prevent erosion.
6. The distribution pipes are to be embedded in sewer rock. Care should be
taken to backfill in such a way as to prevent damage to the piping
system.
7. Silt barrier material must be installed between the final gravel layer
and the native soil backfill. Ensure the silt barrier covers the entire
gravel surface before placing backfill.
8. Backfill over the final gravel layer must not be less than twenty-four
(24) inches. Insulation must be installed when the backfill depth is
less than thirty-six (36) inches.
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be constructed by a
Municipally approved septic tank manufacturer.
Page Three
Birchtree Estates Subdivision; Block 2; Lot 8
June 14, 1994
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Type of Pipe Perforated
Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be approved by the
inspecting engineer.
3. Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Company Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Fernco, or equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140/N, or equal)
must be installed between the final leachfield gravel layer and the
native soil backfill.
6. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel
with less than 3% passing the #200 sieve.
7. When sand is being used as a filter material, its gradation
specifications must conform to current M.O.A. or D.E.C. requirements.
INSPf~TIONS:
Typically there will be a minimum of three (3) inspections required during the
installation of the wastewater disposal system. These inspections will occur as
follows:
1. The first inspection must be conducted after the excavation of ditches,
pits, trenches, or beds and before the installation of any gravel. A
septic tank may be set in place, but may not be backfilled before this
inspection.
2. The second inspection must be conducted after the placement of the silt
barrier, gravel, distribution lines, standpipes, cleanouts, and
insulation, but before the placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Page Four
Birchtree Estates Subdivision; Block 2; Lot 8
June 14, 1994
Often there will be more than these 3 inspections required, especially with the
installation of multiple trenches, sand filters, pressurized distribution
systems, etc. Thus, the inspecting engineer is to be contacted at least 24
hours prior to the start of construction. If necessary, a pre-construction
meeting will take place on-site. The inspecting engineer will not coordinate,
direct or control in any way the contractor's activities.
The owner shall contract with the contractor to perform the work outlined in
these specifications and plans and in accordance with the attached M.O.A.
permit. There will be no contractual arrangement existing between the
contractor and S & S Engineering. S & S Engineering shall be the owner's
representative and will inspect the work as stated above to document the
contractor's activities. Final acceptance of the contractor's work rests with
the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or
omissions of the contractor or any other persons performing work on this project
or the failure of the contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer will not be
responsible for the construction means, methods, techniques, sequence,
procedures or the safety precautions incident to this project.
CONTRACTOR/INSTALLER
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
01714141 HAA #
1. GENERAL INFORMATION
Complete legal description
Lot 8; Block 2; Birchtree Estates
Location (site address or directions)
Property owner
Mailing address
John Peterson
5290 E. 147th
5290 E. 147th Ave.
Anchorage, AK 99516
Day phone
Avenue Anchorage, AK 99516
Lending agency
Mailing address
Agent Chris
Add ress '
Day phone
Peterson/ Peterson Group
Day phone 242-1082
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
4
Individual well xxx
Community well , ~
Public water 'i?' '
If community well system, provide written confirmation from State ADEC at~est- ,,,' i'
ing to 'the legality and status of system. ''~ , ","
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
STATEMENT OF INSPECTION BY ENGINEER. ,
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verifythat 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 ail Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm s & s ENGINEERING Phone (~ c//./_ ;).? -~ ~
17034 Eagle River Loop Road No. 204
Address Eagle River, A. las .k~ 99.5Z7
Engineer's signature ~/~J(~_.~/-~_-.-/q------ Date /¢ /a.i /~'~lr~
DHHS SIGNATURE
'~(~' Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with
,., c:~' ... ..~ ... ~'~
..'.'
the following stipulations:
Additional Comments
Date
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 DHH$ 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.
~(IRe~.l~j1) Ba~ MOA~.i
MUNICIPALITY OF ANCHORAGE
£NVIRONMENTAL ~SERVICE5 DIVISION
Municipality of Anchorage OCT 2 1 199(~ /~
DEPARTMENT
OF
HEALTH
&
HUMAN
SEF V,OE E C E V E D
Environmental Services DivisionJ
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
LegalDescription: L~- ~ t3~k :L 8~.~7~e.( ~$~-~7~J' ParcelI.D.: O1'7 -~/- V/
A. WELL DATA
Well type
Log present (~/N)
!
Total depth
Sanitary seal (~/N) ',/r~ $
If A, B, or C, attach ADEC letter. ADEC water system number
Date eom pleted ~ / '~ -//~/~/
Cased to I 5' ~/ Casing height (above ground)
Wires properly protected (~/N)
!
Y~$
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
FROM WELL LOG
AT INSPECTION
I
) 5' g.p.m. G. H
g.p.m.
Coliform O Nitrate
Date of sample: ) O / I ;;~ / ~J (~
B. ~HOLDING TANK DATA
Date installed IO/~-~'/'f¥ Tanksize I~-~
Foundation cleanout (~t/N) ¥
Date of Pumping 't'0/*! /c~
C. ABSORPTION FIELD DATA
O. ~ "/ '7 Other bacteria
Collected by: $ & $ ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Number of Compartments
Depression (Y/(~ ~ o High water alarm {~N)
Pumper ~ ---/- )./0~.,4~ $~.Nvl¢t ~'
Date installed / o/,~ ~-//,~ Y ', Soil rating ~or ff~/bdrm) (P. '7 System type /'') "'~''' ~
Length ~'- ~' Width .... ; ) ~ Gravel thickness below pipe O. 5" Total depth -~, ~
Effective absorption'area ~ ~ '/o ~,.* z Monitoring Tube present (~N) Y~) Depression over field (Y/{~ "'-' ~2
Date of adequacy test I0 /~ ~ / q ~ Results (Pass/Fail) /04- $$ For ~' bedrooms
Fluid depth in absorption field before test (in.);
Fluid depth ~"/~ (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Immediately after'7'7'Y gal. water added (in.): ~)'~ )'
Absorption rate = (0 oo ~c .g.p.d.
If yes, give date
72-026 (Rev. 3/96)*
LIFT STATION
Date installed 1 0 / ~- 5'- / ~] ~
Manhole/Access ((~)/N) ~'~ J'
High water alarm level at* ~' 0
Cycles tested ~'~ +
Size in gallons
"Pump on" level at*
*Datum 'r o
"Pump off"level at* ~' /o
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
/
holding tank on lot /0
Absorption field on lot
Public sewer main
Sewer/septic service line -7 5- /-~-
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM~HOLDING TANK ON LOT TO:
/ ! ·
Foundation I $ . Property line 5" 5~ Absorption field 5"
Water main/service line 5-o + Surface water/drainage /o o Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
!
Property line ! 3 Building. foundation ;;) -3 Water main/service line 5"o
Sudace water ~ o o --H Driveway, parking/vehicle storage area
Curtain drain ~v 0 ~,~. ~: ,,-o ~., ~ Wells on adjacent lots
HAAFee $ ~t~)'
Date of Payment
Receipt Number
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records ~s, tems are
inconformance~th~~/~ui~_ine_ffectonthisdate.
",..',h ,
Signature · ~-, u--~
Engineer's Name
Date
Waiver Fee $
/~/~/~ Date of Payment
~ ~? ~D~ ) Receipt Number
72-026 (Rev. 3/96)*