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HomeMy WebLinkAboutALPINE TERRACE BLK 4 LT 4 015 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~W ~~ PID Number: OI ¢ ~.~4 3I Name; V14~IZVI~J E. ~ ~~.l~ A. ~~ Wastewater System: ~New ~ Upgrade Address: II ~ C~)~. ~.,~~ ABSORPTION FIELD Phone: ~-- ~ ~ ~ ~_~No. ~f BeSoms: XDeep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRIPTION soi, Rating: Total Depth from original grade: t' ~ GPD/Sq. Ft, Lot: Block: Subdivision: Depth to pipe bottom fro~rigina~ grade: Gravel depth beneath pipe/ Township: ~ Range: ~ Section: Fill added above original grade: Gravel length: ~ ,t. ~,2. ¢ ,t. WELL: ~New ~ Upgrade Gmve~ width: ~ .~ Ft. Numberj of lines: Distance~between lines:Ft. Classifi~tion (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: ~ Date D.rillad: Static Water~,l~ ~staller: Date ins~alled~6 Yield:~ GPM I ~~ ~ Height Above Ground:. ~, ~ Ft. co~, ~, TAN K SEPARATION DISTANCES ~Septic U Holding ~ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank S .... Lines ~' ~ I ~ ~ ~ ~ Material: Number of Com~rtments: Su~faoe -- -- -- ~ LIFT STATION Water [ OQ~ I ~* ~ Lot ~ ~ ~ Size in gallons: ~ Line ~ ~ {~ Foundation ~, [~ -- -- -- "Pump on" level at: I "Pump off" I~ter alarm at: Curtain Drain ~ ~O*f ~")~ ~ ~ PumpMake&M°de' IElectrical'nspecti°nsperf°rmedby:~ Remarks: ~H~- NEW ~~ W¢~ I~A~[~ BENCH MARK Location and Description: ~ Assumed Elevation: , ~. ¢.% Marvin E. Brownell Department of Health and Human Services approval '*'t ¢~:'*~''':'''.....-m Reviewed and approved 72-013 (Rev. 9/91) MOA 25 W p- Z (/) Z Z z ~ M-W DRILLING, Inc. P,O. Box 110378 · 10330 Old Seward Highway (907) 349-8535 ANCHORAGE, ALASKA 99511 93 ~135 DRILLING LOG Well Owner ~darvin Brownel! Use of Well Dome s tic Location (address of: Township, Range, Section, if known; or distance main road Lot 4 Blk. 4 Alpine Terrace Size of casing 6 . Static water level 2 ] Screen ( ); Describe ~e~..~ Well pumping test of drawdown from static Date of completion July 16 Depth in feet from ground surface 0 TO 2 .TO 4 4 .TO 6 6 TO 73 73' TO' 74 74 77 TO 77 <.,9 ~O. 89 92 TO. 92 .305 TO. TO. TO. .TO .TO Depth of Hole 305 feet Cased to 92,35 feet ft. ( ~v) blow) land surface. Finish of well (check one) Perforated ( ),, (minute) for Note: open end ( X 89-86 & 75-72 ]- hours with 100% Well Dry Grouted with ]. Enviroplug chips sk WELL LOG penetrated, size of material, color and hardness ); ft. !avel .~n,micipalit¥ oi AnchOrage Dept. HeaRh , Small 'Water Seap~_ In Sporadic Certi[ied 1 -- CUSTOMER PAGE 1 OF 2 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 AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930057 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:BROWNELL MARVIN E & DANIELE A OWNER ADDRESS:3621 W. 79TH ANCHORAGE AK 99502 DATE ISSUED: 4/13/93 EXPIRATION DATE: 4/13/94 PARCEL ID:01524318 LEGAL DESCRIPTION: ALPINE TERRACE BLK 4 LT 4 LOT SIZE: 59900 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: 5 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 (iSAAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS 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: PERMIT IS APPROVED FOR OWNER CONSTRUCTION. OWNER IS EMPLOYED BY WILDER CONSTRUCTION. DURING CONSTRUCTION WILL VERIFY SOIL TYPE TO A DEPTH OF 16 FT. MONITORING TUBES MUST BE EXTENDED FULL DEPTH OF THE TRENCH. ASTM 3034 MUST BE PAGE 2 OF 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 USED FOR ALL CLEANOUTS AND MONITORING TUBES. WELL MUST BE LOCATED AT LEAST 100 FEET FROM ANY SEPTIC TANK OR DRAIN RECEIVED BY: ; } '/ ~. DATE: Brownell Design and Construction 3621W. 79th Ave. Anchorage, Alaska 99502 (907) 243-4077 March 26, 1993 MOA DHNS P.O Box 19-6650 Anchorage, Alaska 99519 Attn: Mr. Dan Bolles RECEIVED Ref: On-Site Wastewater Disposal System Design and Permit Application-New Subj: Lot 4, Block 4, Alpine Terrace Subdivision Gentlemen: The purpose of this letter and the attached documents,is to design and apply for a New On-site Wastewater Disposal System for Lot 4, Block 4, Alpine Terrace Subdivision. The lot is situated in an area that is underlain with a well graded sandy gravel, as shown on the attached soils logs. The test pits for the primary and alternate deep trench subsur- face disposal fields were excavated with a Cat 436 loader/extenda hoe on 3/14/93. Pictures of the pits are on file for further review. The pits were dug to 14 and 12 feet deep with no indication of a water table. After the test pits were dug and soils examined, a depth was selected at which the drain tile might lay. Then,adjacent pits were dug to the proposed drain tile depths. This was the level that the percolation tests were performed. The results of both tests were 1.32 min/in, and 1.27 min/in. This represents trench application rate of 1.2 gpd/SF. The house that is proposed for the lot is a four bedroom, but there is a room that is scheduled to be an office which might be converted to a bedroom in the future. Therefore, the operational capacity of the field shall be (5 b.r.)(150 gpd) = 750 gpd. The drainage area of the sides of the trench shall be 750 gpd/1.2 gpd/SF or 625 There is 5'+ of good drainage gravel below the proposed invert of the drain tile. Use 4.5 feet of drain gravel below the invert - the trench length shall be 625 SF/2(4.5) = 69.44', use 70' trench. Refer to the attached sketch for typical cross section of trench. The alternate site for the future drain field requires the same 625 SF of trench area and the same depth of drain gravel, there- fore, the same trench length can be used. The drainfield shall essentially parallel the contour lines, therefore, the trench shall be canted accordingly. The site plan shows the location of all known wells and septic systems within 200 feet of the proposed project. There is no in- dication that the proposed septic system will impact any was- tewater systems in the area. Sincerely, Marvin . , P.E. /CLJ I ~ ~',-. Z X Ld [] o . I Zo °? / b_ W O_ Ld :! 7 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 LoT/+ Township, Range, Section: SLOPE 10 WAS GROUND WATER ENCOUNTERED? 14 15 16 17 18 19 2O s L IF YES, AT WHAT i~,,.j/~' 0 DEPTH? p Depth lo Water After_ _ / /~ ~~E Monitoring? ~ Date: ,_% Gross Net Depth to Net Reading Date Time Time ~1~. Water II~J. Drop + ~Lo ~: ~$'. ~o ~o ~Zfl :30 COMMENTS ~ ~--~ PERFORMED BY: Fao~'')ldl~' U''' ~''~ ~,~0 t~.~l,d.¥T~, ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) I PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~'~ ET AND ~ .ET I I ' CERTIFY THAT THIS TEST WAS PERFORMED IN Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED LEGAL DESCRIPTION:~ i~ I A~IN~- ~~ownship, Range, Section: ~0~ SLOPE SITE PLAN WAS GROUND WATER Sl,4~14"¢~' $[I-.'('~'~' S~,~<S~ENCOUNTERED? t IF YES, AT WHAT S~t-~" 10~l~l,~. r~v~. DEPTH? L ~'. tJ~ Depth Io Waler Aller,,~ Monitoring? I')~. (:~ I,?.~ Date: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O DATE PER FORMED: Gross Net Depth to Net Reading Date Time Time V~l~l Water t I,J. Drop -~H-? o S~ 5:40: ~ G" PERCOLATION RATE j .~,1 (minutes/inch) PERC HOLE DIAMETER ~_~ t, TEST RUN BETWEEN 4'05 FT AND 5.5 .FT COMMENTS E_,,.rg..t " .., '~Ol~l,,~.Lf.,,. 0~"~%~,t,~ ~ (~%.L[['1~. .... CERTIFY THAT THIS TEST WAS PERFORMED iN PERFORMED BY: ACCORDANCE WITH ALL STATE AND MUNICIPAL' GUIDELINES IN EFFECT ON THIS DATE. DATE: ~/~.~/~,7f ~ 72-008 (Rev. 4/85) 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 015-243-18 1. GENERAL INFORMATION Complete'legal description Lot 4;Block 4; Alpine Terrace Subdivision Location (site address or directions) Property owner Mailing address 11865 Circle Drive Anchorage, AK Marvin & Daniele Brownell Dayphone 11865 Circle Drive Anchorage, AK 345-8733 99516 Lending agency Mailin. g address Agent Address Day phone Day phone Unless otherwise requested, HAA will be hel~ for pickup. NUMBER OF BEDROOMS: ~' ~ TYPE OF WATER SUPPLY: Individual well Community well Public water XX NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XX 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 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 sy~-~ i~ca~ ordinances, and :regulations i~¢~l~ecdoa~ Name of Firm Address / / // Engineer'~ signature (/ Alaska Water & Wastewater Consultants, Inc, Shall be PAID ? l leO or prior to, closing for the ' Engineering-Services Provided, i~ance with all Municipal and State codes, is inspection. fries, I~lC. rite 2B Phone ~/~'/// '504 Date DHHS SIGNATURE Disapproved. Conditional approval for bedrooms. bedrooms, with the f?!lowing stipulations: Additional Comments Date :J/-/0 ~/ 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 ragistered in the State of Alaska. The D H HS does this as a co u rtesy to pumhasers of homes and their lending institutions in orderto 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 net responsible for errom or omissions in the professional engineer's work. Municipality of Anchorage NOV 0 8 3990 ~ HUMAN SERV,,{,~,~,S^~i~ o~ ^r~c~o~Ge DEPARTMENT OF HEALTH & o~wsl Environmental Services Division ~.v~,o~t~z^~s~v~cEs 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type PRIVATE Log present (Y/N) Total depth 505' Sanitary seal (Y/N) Health Authority Approval Checklist ALPINE TERRACE S/D; LOT 4, BLOCK 4, Pamel I.D.: If A, B, or C, attach ADEC letter. ADEC water system number 015-2¢3-18 Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: 11/3/99 B. SEPTIC/HOLDING TANK DATA Date installed 11 ./R./~.~ Tank size Foundation cleanout (Y/N) YES Date of Pumping 11/3/99 C. ADSORPTION FIELD DATA Date installed ~ 1/6/g3 YES Date completed 7/16/93 Cased to 92.35' Casing height (above ground) YES Wires properly protected (Y/N) FROM WELL LOG AT iNSPECTION 7/16/93 !,1/13/99 81' 116' 3.0 g.p.m. ~.7 N/A 1'-{- YES g.p.m. ~_~?1~ m~../I Other bacteria 0 Collected by: A.W.W.C., INC. 1 Ann Number of Compartments 2 Cleanouts (Y/N).__ Depression (Y/N) NC) High water alarm (Y/N) N/A PumperOLD McDONALD'S PUMPING YES Soil rating (g.p.d./fF or ft~/bdrm) 1.2 System type TRENCH Length 70' Width 2.5' Gr,~a)~l thickness below pipe 5.(¥ Total. depth 10' Effective absorption area o ube present (Y/N) YFS Depression over field NO Date of adequacy test 11/3/99 Results (Pass/Fail) I~A~ For ;K: ~ ~'" bedrooms Fluid depth in absorption field before test (in.); 0" Immediately after 700 gal. water added (in.): 1' Fluid depth 0" (ins) Minutes later: ~0 Absorption rate = 600+ g.p.d. Peroxide treatment (past 12 months) (Y/N) 0 E N If yes, give date - 72-026 (Rev. 3/96)* D. LIFT STATION ~ Date inetalled _ _ - ~ Manhole/Access (Y/N) ~* "Pump off'level at* High wate~ *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: 100'+ Septic/holding tank on lot 100'+ On adjacent lots Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Public sewer manhole/cleanout N/A Sewer/septic service line 25'+ Lift station N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 5'+ Property line 5'+ Absorption field 5'+ Water main/service line 10'+ Surface water/drainage 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: 10'+ Building foundation 10'+ Water main/service line 100'+ 10'+ Property line Surface water Curtain drain 10'+ 100'+ NONE KNOWN R ENGINEER'S CERTIFICATION , I certify that l h~et~i~' · inconfotmanr wi~D~_.~uk signature E"gineer,s Name Date Driveway, parking/vehicle storage area Wells on adjacent lots .Id inspections ~ lines in effect on this date. JEFFREY A, GARNESS are HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number ~0V-08'99 09:34 FEOM-CTE ENVIEONMENTAL ,~t~_,,,CT&EEnvironmentalServiceslnc. T-696 P.OZ/O6 F-538 CT&E Rcf.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID ffample Remarks: 996151~02 AK Water & Wa~tewatet Cona~taat~ Inc. N/A .nipine Terr LoT 4 Blk 4 Drinking Water 0 Printed Dare,Time 11108199 09:23 Collected Date/Time 11104199 10:05 Re~elved Da~e/Time t1/04/99 10:05 Technic~l Director.: Stephen C. Ede Toter Cotiform 0 cot/lO0mk 0.500 mg/L AItouabte Prep Anatysls ~e~hoa Limits Date Date S~18 02226 11/0~/99 dDT EPA $00.0 10 max 11/o~/~ 11/0~/90 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 GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address %%<;( 0AN' 'LE : bJk)F" ay phone Lending agency ~ v~C., Day phone Mailing address 4-'~O ~,J, ~"L~O~-~, IA-V), /~,,,4. t-I. Agent T-f="A'~ C0vt--~t ~ ~~ Dayphone Address ~ O ~, ~~ ~, ~C~. 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. 4. TYPE OFWASTEWATER 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 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. NameofFirm ~(l~ua~: ~')lc~t(~,,5 ~ C0~'~'t. Phone ~4-~ ~'~ Address ~.' ~O&~ ~//~~..~ ~e~ ~ c~(/.2 Engineer's signature ~/q 4.- DHHS SIGNATURE /~. Approved for Disapproved. Conditional approval for bedro°msl Date STAMP bedrooms, with 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 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 ~Y21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: L-cT ~L (1)1.,~C~ /t¥1.~1~ ~'E-VL., ParcelI.D. (~)15 "Z~r'~]{~ A. Well Data Well type ~ ~[~,'P c. If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed '7//~ ~/~J ~ Driller Total depth '~c..) S Cased to ~ ?- ~ 5" "' , Casing height 7- '" Sanitary seal (Y/N) Iq, Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test '7/~{~/~/~ //" ,,~/ MUNICIPALITY OF ANCHOI'~GE Static water level 'Z,~/,~ ~ LO~,~ (~), ~.~. ~NVIRONMENTAL SERVICES DIVISION Wellflow ~ g.p.m, g'~ 1 2 1994 Pumplevell ~.~/..~1~ ~E£o~ O..C'~. ,/ RECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot J "'Lo fl'" Absorption field on lot J ~0~' "J' Public sewer main Sewer service line ~"~/,~ ; On adjacent lots J '7_"'J ,4- ; On adjacent lots J 10 Public sewer manhole/cleanout l~J/f'~ Petroleum tank WATER SAMPLE RESULTS: Coliform /~ Date of sample: J//l o/~j ~., Nitrate O. J 0 ~'"~/L. Other bacteria Collected by: Y'V%A~V [~ 3~'LO ~ A B. SEPTIC/HOLDING TANK DATA Date installed ~ /~'/q ~ Cleanouts (Y/N) LI; High water alarm (Y/N) Date of pumping ~//~ Tank size J~ ~, Foundation cleanout (Y/N) Alarm tested (Y/N) Pumper Compartments Depression (Y/N) SEPARATION DISTANCES FRO~OLDING TANK TO: Well(s) on lot J )--o "-4j. " On adjacent lots J Z.o ~ To property line ~ ~ '-.t- (o~ Sudace water/drainage Foundation Absorption field Water main/service line 72-02e (3/e3)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) ~elat High water alarm level Meets MOA ele~s (Y/N) Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed I t/~/~ $ Length ~ 0 /' Width On adjacent lots ~ Soil rating (GPD/FF) {, Gravel thickness Sudace water. Systemtype ~E~O "T'~n,~..~¢l-J Total depth ~ 0 Total absorption area ~?..~ SF' Cleanout present (Y/N) Date of adequacy test ~J/~/~ Results (pass/fail) Water level in absorption field before test ~/~ Peroxide treatment (past 12 months) (Y/N) ~J//~ Depression over field (Y/N) ,"~///%' for After test If yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I ~ ~ ,Ar To building foundation On adjacent lots Surface water Curtain drain On adjacent lots t ?--'7 Property line To existing or abandoned system on lot Cutbank /~J//A Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that l have checked, verified, or conformed to all MOA and HAA guidelines in p~_'~r~_~.e. ~~ Signature ~ ~ ~;~ Engine,s Name ~~ E. ~~.cC ~o~ ~'.~~}I~ ~?~. ~** CE 5936 HM Fee $ ~=~J ~ o Waiver Fee $ Date of Payment /'~/~-~/' Date of Payment Receipt Number ,~- ~"%-' ,,7~/7 ~) ~') Receipt Number 72-025 (3/93)' Back LoT ~. TO / 'X PLOT PLAIT ~ AS BUILT __ SCALE I% 4o' GRID JOB No l']Itreby certify that l']mve sumeyed the following d.cribe4 property: ~o~ Rtcordin~ D~, ~askm, and tha~ Iht improvtm~ situated thereon ~r~ ~t~n ~e prope~y lln~ an~ do not encroac~ onto t~e prop~ty ~djacent t~ereto, t~at no ~~ on ~e ~op~ ly~ adjacent thereto encroac~ on th( surveyed premises and ~at there er~ no r~dweT~s ~anmission lints or other visiblt easements on said proper~7 ~cept ms h~catcd h~on. ~ rl~o~ whic~ do not appear on tht rzcorded subdivision plat. 1731 George Bell Circle Anchorage, Alaska 99516 (g07) 346-6476 ~," ~:L~ ",'Z- ~, ~.. 49-~, ...