HomeMy WebLinkAboutCHANDELLE ACRES LT 24
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
IPHONE-f I [~NEW
NAME 5 l ar
LEGAL DESCRIPTION
/5-M .
~Z Manufacturer~
~ Liq. capacity in gallons .. ........ Ins~~ ~~ Liquid depth
' ~ ~ PERMIT NO.
~ -- ~ Manufacturer Material Liquid capacity in gallons
DISTANCE TO: ~ W~ ~ / , Nearest lot line
.... ' I ' e~ofi , .~S Trench width Dista~een lines
~ ~ Z No. of Hnes Length o~ line Total
~ ~ / ~ ~ ' Total ef~ive abs~tion~ea
~ Top of ti~e to finish ~rade ~ Mat.rialBeh.athtile ~/~ inches
Length Width Depth PERMIT NO.
~ ~ Type of crib Cri~diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
m DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO,
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
REMARKS
72-013 (Rev. 3/78)
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FIF'F'L I CFINT' · .~r~::, ~ r,~ ................
1 .=,::,I...,E ..... ,;::, r, .. DI::tTE '
SOILS LOG
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS 50
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
I-Z.
SI~-i
5o-4(_
NO. 1732-E
June 2~, 1968
SLOPE
WAS GROUND WATER
ENCOUNTERED?
PERCOLATION
TEST
SITE PLAN
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
:~,~,~¢ Ch - ~" -
~/h :.'?)0 ~ ~)o ~,~ 7" i'
5h50,n '5o~ 9" I"
PERCOLATION RATE 'J~ (~ (minutes/inch)
TEST RUN BETWEEN ~ ''~ FT AND ~ ~;) FT
CERTIFIED B,: ~% 4~';~ DATE:
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.
~.t,~~-[AL SERVICES DtVISIOH
RECEIVED
1. GENERAL INFORMATION
Complete legal description
Lot 24; Chandelle Acres
Location (site address or directions)
23737
Chandelle Drive
Property owner
Mailing address
Chu,~iak, AK
Farideh Soto Day phone (707)
172 Ald~rbrook Drive Santa Rosa, CA 95404
528-4468
Lending agency
Day phone
Mailing address
Agent Don McKenzie/ Don M~Kenzie Real Estate Day phone
Address 13135 01d Glenn Hwy. Suite 100 Eagle River, AK 99577
694-9035
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
NOTE:
Individual well
Community well Y, XX
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:
XXX
Individual 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
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 $ & s EN~IN;;~ Phone
170~ Eagle River L~ R~d No. ~
Address
Engineer's signature
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.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage ERWiC=C~0Nlcip^Lit~
DEPARTMENT OF HEALTH & HUMAN S ,,,
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744~ ~,,?
Health Authority Approval Checklist
RECEIVED
Legal Description: LoT 'Zq ~ C~44/M40~t._c~ P~c~ Parcel I.D.:
A. WELL DATA
Well type
If A, B, or C, attach ADEC letter. ADEC water system uumber
Log present (Y/N) Date completed
Total depth
Sanitary. seal (Y/N)
Date of test
Static water level
Well production
e~of sample:
Cased to Casing height (above g~
Wires prope~Y/N)
FROM WELL LOG / AT INSPECTION
Nitrate Other bacteria
Collected by:
Bo
SEPTIC/HOLDING TANK DATA
Date installed ~ /,~,/~ t~ Tank size
Foundation cleanout (Y/N)
Date of Pumping.
loC> a.~ Number of Compartments 7__ Cleanouts (Y/N).
Depression (Y/N) /'4 High water alarm (Y/N)
Pumper 3 i:L Po ~°lrd 6
Co
Date installed .~/i'~
Length (,,0 Width
Effective absorption area q (,,
Date of adequacy test 3/{~ /
Fluid depth in absorption field before test (in.):
Fluid depth q7 J' (ins.) Minutes later:
Peroxide treatment (past 12 months) (Y~
Soil rating (g.p.d./ft2 or ft2/bdrm) Zg"/
Gravel thickness below pipe
Monitoring Tube present(Y/N) )/
Results (Pass/Fail) ~)~5
g,.r~/S ~.~
System type
1~ I Total depth
Depression over field (Y/N)
For ,~ bedrooms
Absorption rate =
]~io¢~dIf yes, give date
.g.p.d.
~t/~Immediately after '~o gal. water added (in.): __
MUNICIPALli'~ gl- ^N~.t~c
ENVIRONMENTAl. SERVICE,5 DIVISION
Do
LIlT STATION
Date iustalled Size
Mauhole/Access (Y/N) ~_..~'"'~ump on" level at*
High w~t* *Datum
Q~.Wc~s tested
RECEIVED
"Pump ofF' level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
egew'e'/'~r/septic service line
· On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
t I
Building foundation .5. ~ Properly line I 0 q' Absorption field
Water main/service line I o ~ -t- Surface water/drainage Ioot 4'- Wells on adjacent lots 'Zoo t +
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation q.-~ ~
Surface water I 0 o ~ 'P
Curtain drain 14 / tX
Water main/service line I o at
Driveway, parking/vehicle storage area
Wells on adjacent lots '2o~t 4 Property line
F. ENGINEER'S CERTIFICATIOn'?
! cert!./]v that I have determined t,~hrufield inspections and review of Municipal records that theab~3~v~stems are
in conJbrmance with MOA H~' guidelines in effect on this date.~ ~ .
Date ~1' "iver, Alaska 99577 Vy/¢/,
HAAFee $ ~/ ~ Waiver Fees
Date of Pay,nent ~ ~ff/-- ~ Date orPayment
Receipt Number ~ O/Dff ) Receipt Number
Rev. 8/95 OSS: haa.wk.doc
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
Parc. el I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Day phone
Mailing address
Agent
Day phone
Address
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:
Individual 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 David R. Damon P-F- Phone
2.*'.~ ~ 0 Donalar St.
Add ress ':h,~,31 p!, Alaska 995~,~
Engineer's signature ~/~'~--"'~ .~Y'~-~'~,~?r~"~~%- Date
DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The M,,r~icipality 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 tY21
Legal Description:
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Well type /
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
Date completed
Cased to
FROM WELL LOG
?
ADEC water system number ~'-
Driller
Casing height
Wires properly protected (Y/N)
MUNICIPALITY OF ANCHORAGE
AT INSPEC'[Itl0~DNMENTAL SERVICES DIVISION
Date of test
Static water level
Well flow
,~¥ 0 6 199;~
RE E!VED
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service Line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Nitrate Other bacteria
Date of sample:
Collected by:
Date installed ~'/~.//~'~
Cleanouts (Y/N) ~/
High water alarm (Y/N)
Date of pumping
B. SEPTIC/HOLDING TANK DATA
Tank size / ~ Compartments
. Foundation cleanout (Y/N) Y Depression (Y/N)
./~///~" Alarm tested (Y/N)
~/~'~..~ P u m per .7",~ ",~ /~~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /~/'///-- On adjacent lots /L'///~ Foundation .5- ~/~
To property line ,z~ Absorption field
Water ma~/service line
Sudace water/drainage /~
72-026 (Rev. 7/91)Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
High water alarm level
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
Length d o
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
-5~///.~/~' .~ Soil rating ~'
Width ~ ' Gravel thickness
~ 4:~ Cleanouts present (Y/N)
~ Date of adequacy test
~,~2~ ~ for
Peroxide treatment (past 12 months) (Y/N)
System type
If yes, give date
Total depth
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots ~//~/- Property line
/
~ :~ To existing or abandoned system on lot
Wellon lot '~'//,'-~
To building foundation
On adjacent lots
Surface water /~2/__.2/~ Driveway, parking/vehicle storage area
Curtain drain
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.
HAA Fee $ /
Date of Payment''--~- 2- P.~
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
D. R. DAYTON, P.E., R.L.S.
~~~ Chugiak, Alaska 99567
20210 Donalar
(907) ~~
696-2417
May 5, 1993
ADEQUACY TEST
Legal Description: Lot 24, Chandelle Acres Subdivision
Date of Test: April 29, 1993
Septic Tank: 1000 gallon, 2 compartment, steel tank (DHHS Records)
Absorbtion System: 60' long x 3' wide x 8' effective depth trench (DHHS Records)
Soils Rating: 287 sq, ft. per bedroom (DHHS Records)
Requirements: 3 bedroom - 450 gallons per day
Test:
473 gallons of water were injected into the absorbtion trench
with a total rise in the liquid level in the trench of 0.66 ft.
After injection was stopped, the liquid level drawdown was meas-
ured at timed intervals. The results were plotted on a graph of t~me
versus gallons absorbed.
Results:
The septic system absorbtion trench is currently functioning
adequately for a 3 bedroom home.
WALTER J. HICKEL, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
(907) 349-7755
May 7, 1993
Mr. David Dayton
S U BJ ECT:
Lot 24, 23737 Chandelle Drive
Chandelle Acres Subdivision
Class "A" Public Water System, PWSID 213807
Dear Mr. Dayton:
I have completed a review of this office's files concerning the monitoring status of the
above-referenced Class "A" Public Water System and found the following:
The last satisfactory Total Coliform Bacteria Sample results was submitted
to this Department on April 20, 1993. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last inorganic Chemical Contaminants Sample results were submitted
to this Department on November 27, 1992. This does meet the provisions
of 18 AAC 80.200(a), of the State Drinking Water Regulations.
o
The last Radioactive Contaminants Sample results were submitted to the
Department on January 28, 1993. This does meet the provisions of 18 AAC
80.200(a), State Drinking Water Regulations.
The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC)
were submitted to this Department on June 21, 1992. Based on analysis
of the previous VOC samples results have been satisfactory. This does
meet the provisions of 18 AAC 80.200(s), State Drinking Water Regulations.
Issuance of this letter does not imply that the above-referenced Class "A" Public Water
System is in compliance with other provisions of the State Drinking Regulations. Unless
otherwise noted, this letter is valid for 30 days and is for the specified legal description
noted above only.
If you have any questions on the above information, please do not hesitate to contact this
office at 349-7755.
Sincerely,
Michael Lu
Environmental Eng. Asst. II
STATE OF ALASKA
DEPARTMENT OF ENVIRONMENTAL CONSERVATION
APPROVAL OF ON-SITE RESIDENTIAL WATER AND SEWER SYSTEMS
PROPERTY DESCRIPTION
Lot, Btock& Subdivision or U.S. Survey
Certificate Issued for Application No.:
This approval does not constitute a guarantee of any kind, explicit or implied, as to the performance
of the water supply and wastewater disposal systems.
WATER SUPPLY
A recent water sample was tested and found to meet Department of Environmental Conservation drink-
ing water standards for total coliform bacteria.
Name
WASTEWATER DISPOSAL
The domestic wastewater system was:
[] inspected by the Dep.artment of Environmental Conservation and found to be in compliance with
applicable requiremen'ts,, of 18 AAC 72;
[] inspected by a Professior~l. Engineer who certifie§"ihat the system complies with applicable re-
quirements of 18 AAC 72; ",,
[] installed by a Certified Installer w~ifies that the system complies with applicable requirements
of 18 AAC 72; or
[] tested by a Professional Engineer who ce~rtifies that the performance of the system is satisfactory
specified 18 AAC 72.
and that the system c_~pli'es with the min~um separation distances in
//
This approval is v,~fd for a [] single family [] mu'~-family unit with a total of bedrooms.
/
Name Title ] Date
18-0404 {Rev. 8/85)
DISTRIBUTION: WHITE--BANK/LENDING INSTITUTION; CANARY--APPLICAN'I~ PINK--DEPARTMENT
MUNICIPALITY OF AN(
DIVISION OF ENVIRONME]
DEPARTMENT OF HEALTH AND ENVIR~
APPLICATION FOR HEALTH AUTHORITY
1. General Information
(a) Legal Descriptioq (includ.~e lot, block, sub
Location (address or directions)
(b) Applicants Name ~,~7CO;'
Applicants Address /~ O ~ O/~ ~'~ -- /
(c) Applicant is (check one) Lending Instituti,
Buyer ~ ; Other ~ (explain);
(d) Lending Institution
Address ~5--
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. Type of Residence
Single-Family~--~
Number of Bedrooms
3. Water Suppl~-
Individual Well~-~
Multi-Family t i Oth,
Community~----~ Publ
Note: If community well system, must have writ
Department of Environmental Conservation attes
4. Sewage Disposal
Onsite~.. Public ~-~ Community ~
Note: If community well system, must have writ
Department of Environmental Conservation attes
[Page 1 of 2]
HORAGE
TAL HEALTH
tI~[EN~rAL PROTECT ION
APPROVAL CERTIFICATE
Application Date ~:~ ~ '2~_'~ [ ~'~
[tviston,.p.section, township, range)
,lephone - Home Business b
,n F'~ ; Owner/builder.~. ;
Telephone
~.r (describe)
:eh confirmation from the State
;lng to the legality and status.
Holding Tank ~
:eh confirmation from the State
:lng to the legality and status.
e
Engineering Firm Providin~ Inspections~ Tests
As certified by my seal affixed hereto and as
verify that my investigation of this Health Au
File Search, Data and Information
~f the validation date shown below, I
~.hority 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 J.%dicated herein. I further verify that,
based on the information obtained from the Mun.£cipality of Anchorage files and from my
investigation and inspection, the on-site wate~ supply and/or wastewater disposal
system is in compliance with all Municipal and~ State codes, ordinances, and regula-
tions in effect on the date of this inspection~
Name of Firm ~fS~'~c--~ ~--~{~1~7~¥-~/ ~--~C_. Telephone
bedrooms ~..~,.~ ~ ~- .~?: ~ ~ Da~e
DHEP Approval
Approved for '~
Approved ,~
Terms of Conditional Approval
Disapproved
CAUTION
Conditional
IiEALTH AND ENVIRO~NTAL PROTECTION
[CATES BASED SOLELY UPON THE REPRESENT-
~DENT PROFESSIONAL ENGINEER REGISTERED
A COURTESY TO PURCHASERS OF HOMES ~ND
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIF
ATIONS GIVEN IN PARAGRAi~H 5 ABOVE BY AN INDEPE
IN THE STATE OF ALASka. THE DHEP DOES THIS A
THEIR LENDING INSTITUTIONS IN ORDER TO SATISF f CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT. CONDUCT I~SPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNIolPALITY OF~NCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S W0~K.
RR4/ej/D18
[Page 2 of 2]
(DHEP SEAL
7 -19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AU%~O~TY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
ae
Well Classification
Well Log P~esent (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electzical Wiring in Conduit (Y/N)
Sepazation Distanoes f~cm Well:
To Septic/Holding Tank c~ Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
C leanout/Manho le
Water Sample Collected By
Water Sample Test Results
If A, B, c~ C,
Date Completed
Pump Set At
NOIZD~IO~d
]~'v'~iOHDNV aC)
D.E.C. Approved(Y/N)
Yield
Depth of G~outing
Sanitary Seal on Casing (Y/N)
Depression A~ound Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Neazest Sewer Service Line on Lot
; Date
S' ys m IQ Z-1%-8'°7
B. SEPTIC/HOLDING TANK DATA
Date Installed ~'-19-~4' Size ~000 ~_.,I NO. of Cc~a~tm~nts ~
Stan~ims (Y~) y~ Air-tight Caps (Y~) ~e$ F~n~tion Clean~t (Y~) 7~
~ession o~ Ta~ (Y~) ~o ~te ~st ~d ~.~.
P~ing~inte~n~ ~n~a~ ~ File (Y~)N.~, ; f~ ~ ·
Holding Ta~ High-Wate~ ~a~ (Y~)~.~- ~a~ ~ldi~ Tank ~t (Y~)~.~..
~p~ation Distan~s ~ ~ptic~old~ng Tank:
To ~te~-Supply ~11 ~. ~, .... To ~ilding F~ndati~ ~;
To ~o~ty Li~ ~7,~' To Dis~al Field ~
To ~ter ~im~vi~ Li~ ~' To S~e~, ~nd, ~e, ~ ~jor ~aina~
[Page 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption St=ata
Date Installed ~-~-8~
Width of Field ~ ~
Square Feet of Absarpticn Area
Depression over Field (Y/N)
Type of System Design
Length of Field ~O
Depth of Field I '7-
Gravel Bed Thickness 8'
~ ~ Standpipes P=esent (Y/N)
Date of Last Adequacy Test
Results of Last Adequacy Test /%/
Separation Distanae frc~ Absarption Field:
To Water-Supply Well ~J .A. To P=operty Line
To Building Foundation Z~D' To Existing or Abandoned System
Lot ~. ~%. ; On Adjoining Lots ;~-~ ~
To Water Main~ Line ~C; To Cutbank(if present)
To Stream/Pond/Lake/a~ Majo~ Drainage Course N./% .
To Driveway, Parking Area, ar Vehicle Storage Amea 70'
84-oz8o _
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adeqaa~ Test.
~eets ~DA
Cc~ents
** Check Permitted Bed~oc~ Rating Against HAA Request
I ceFtify that I have checked, verified, or confarm~d to all MOA HAA Guidelines in effect
on the .date of this inspection. _...:,.'~'%'t~,.._
Company
KB1/d5/s
[Page 2 of 2]
._~.~L.' A '"..Y-~ '~,
June 22, 19~ ...~,~
2-15-84