HomeMy WebLinkAboutBEEDE BLK 1 LT 7 e 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 IPH°NE [~NEW
MAILING ADDRESS
LEGAL DESCRIPTION
OF BEDROOMS
~ Well ~ PERM~O
~-- DISTANCE TO: I ~OT ~ IAbs°rpti°}~a Dwel~g ~
~ ~ ~ M~nuf~ ~,r~ ~ Mat~a~ No.compartments
Liq. ea~a~ty in ~allons Inside length Width Liquid depth
Z~ ~ IF HOMEMADE: ~
~ ~ DISTANOE TO: Well Dwelling PERMIT NO.
W~ PERMIT NO.
~ Foun0ation ~earest lot tine ~ ~/
~-- N°' °~i~ C Length ofea~ ¢line" Total length of lines .~ Trench width~ ~ ~n~h~s
~ Top of tile to finish grade . Material beneath tile ~ Total effective ~sorDtion area
~ ~~ in ches
Length Width Depth PERMIT NO.
~ ~~ ~eter ~ ~ib de~h~~ Total e~s~tion are~
~ ~ell ~ ~foundation ~st lot line ~
~~~ ~epth Driller Distance to lot line ~[~MIT ~0.O//~--/
~ DISTA~C[ TO: Buildin~ foundation Semer line Septic tank Absorption area{s)
SOIL TEST RATING
INSTALLER
I ,I
V DATE LEGAL
' ,
72-0' (Rev. 3/78) ~
FIF'F'L I CF!NT L t NE:,R ~:: (3RR r' KI..tT I L ;2:9Z2 !,JENTF.!ORTH ~: ,.' ~....'
LE3F~L. L7 BZ E=EEE:,E /: LOT S ZEE '~:5'.9E4 .
TYF'E OF SOIL RE'FOF4'P'T'ZON .'5'~ S'T'Ert I:5- 'T'REHCH
F,'.FIXIM..M NJFIBER CF BEE:,ROOMS = ]: '.~")IL RA'TING ,::S;;~ F".',..'E,R::=
... z x.:,f E.H IS'
THE RE: ':)L ! RED SIZE OF THE SOIL FIBSORPTION '-'"-"-'
THE LENGTH [:, Z MENS I ON ZS THE LENGTH ,::ZN FEET') OF 'T'HE 'TRENCH OR E:,RRINFIELD.
THE DEF'TH OF R TRENCH OR P Z'T' ZS ]"HE [:,ZSTRNCE E~ETP.IEEN THE SURFFIE:E OF THE
GROUN[:, RNE:, THE BO'TTOM OF THE EXCR',,,'RTION ,:: ZN FEE]").
THERE ZS NO SET 1.4ZE:,TH FOR TRENCHES.
THE GRR',,,'EL DEF'TH ZS THE r,'IZNZMUM E:,EF'TH OF GRRVEL. E]ETI.4EEN THE OUTFFIL. L.
FIN[:, THE BOTTOM OF TFIE EXCFIVFITZ(]N ,:: ZN FEET).
PERM !'T RPPL ICF:tN'F HI=IS THE RE'..=.;F'ONS I8! L IT¥ TO !NFORM 'FHI S [:,EF'RRTMENT E:,URI NG THE
tNSTFfL[..FI]'ION !NSF'ECTIC~N:5 OF FII"PT' HELLS RDJRCENT TO THt:~.; PROF'ERTY FIND THE
h,IUME~EF.: OF' RESIDENCES THR'T' THE !.qELL. HILL SERYE.
................. T' 1--~! MS::, ,:'.: ;';? ::~ :I. Ih,ti :.~.'; F' ~'.:'~E E: ]F" ][ C~ !'-,I E; F:lt liT: E IF'.;.: EE .~]::! Ell ;J': F,;,', E': E;,
E~ACKFILLING OF FINY F;Y:~;TEM 14ITHOLr'[' F!NFIL INSPEC]":[ON FIND FIPPRO',..,'RL. BY THIS
[:,E:PRRTr'IENT HILL BE ':-:;UEL~ECT TO PF..~OSECUTION.
r,'tZNIMUH [:,!STFINCE 8ETI,.tEEN R HELl... FIND, FIN"r' ON-SI'TE SEI.qFIGE DISPOSFIL. S'¢STEM IS
::LOO FEET FOR R F'RI',,,'RTE WELL OR :L50 TO 200 FEE:]'' FRO!"! R F'USL!C t,.tlEL. L. DEPENE:"If"~.G
I...IPC'~N THE TYPE OF F'UBL. IC t.4ELL.
!"IlNIMUM DISTFINCE FrROH FI F'F.:I',,"FI]"E [4EL. L TO Ft PRI',,,'FITE SEi,.tER L. INE IS 25 FEET
'TO FI COMr,IUNITY SEt.qEF..: L II'.,IE IS, 75 FEET.
HELL LOG':'] 8RE REf.]LIIF.'.ED AND I',tLI:~.];T BE F.:ETLIF.:NE[:, TO THE DEPARTMENT t,.i!]'HIN ::~:;;i.~
OF 'T'HE 1.4ELL COMF'L. ETION.
OTHEF.'. REC!UtREMENTS r,!RY RF'PL.Y. SPEC:[F"rE:A'TIC~NS AND C:ONSTRL!CTION DIRGRFIHS RRE:
R',,,'RZLFIBL. E TO !NSUF.:EE PROPER ]:NSTRLLFITION.
I CERTIFY 'THR]"
±: I RM FRMI[...IRR HI]"H THE REi('::!UIF.:EMEI'4TS.'; FOR ON-SITE SEP]ER5 RN[:, I.,.IELL:'..:.; R:i~; :~.i;t.:.!;T
FORTH BY THE MUNIC!F'FILI. TY OF FiNCHORFtGE.
2: I I,.IIL. L INSTRL. L THE SYSTEM IN RCCORDRNCE WITH THE CO[:,EL:;.
3: I UN[:,ERSTFIND THFIT THE ON-SITE SEWER S'.r':5'T'EM t"!RY REQUIRE ENLFIRGEr"tENT iF' THE
RESIDENC'E IS REHODELED TO I NCLU[:,E MOF..'.E 'T'HRI';f 3 BE[:,ROOrPS.
:51 (3 N E [::, ·
FIF'PL I CF~NT L..,]:,f]IE:,R & GF!RY I<UT .'[ L
I ':.'.:;, :ii~, ., El) E:'T'. ............................................................................................................. ~
~ l.E~((~lH pll'~fI'l~,.-,JFsl',~ }!- 1HE LENO1H <)N FEEl.', [,F 1Hi- 1F~NC:H CJFI [~F'I=IJI-~FtFI.P.
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:
LEGAL DESCRIPTION: LO~T '1I 12 I~ !
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
· 18
20
SLOPE
L
ENCOUNTERED? ~ O
P
E
IF YES, AT WHAT
DEPTH?
2225-E
~NE25.197t
SITE PLAN
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS
PERFORMED BY: ~U ~t~.~~)
I
CERTIFIED BY: . DATE:
72-O08 (6/79)
,!
JRN TO:
Division of Geological and Ge slcal Surveys (DGGS~
3001 Porcupine Drive (Teleph,ne: 277-6615)
Anchorage, 'Alaska 99501
WATER WELL RECORD
Orllllng Company Name
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
U.S.G.S. Local rio.
Drilling Permit No.
LOCATION OF WELL ] Please complete either la, lb, or 1.c,,,. A.U.L. mo.
la. Borough Subdivisionl Lot Block lb. Fraction I Section No. Township Range Meridian
~ ~ : ~I N/S E/W
,' i '~ ,. / / /
lC. Distance and D~rection from Road Intersections ~). OWNER OF WELL: ~".' ~,: .'
Add res s:
Street Address and Area of Well Location _
2. WELL LOG Feet Below b,. WELL DEPTH: (completed) Surface Elevation) Date of
Comp1 et ion
Surface ~. :
Material Type Top Bottom ,,'. ]~ ft.
F~. ::;~: ...:>~5 :; . . 6~ .:: .:-~'~ ...... ::"~ ....... :~/ /.~ a ?:' 6. USE: ~Oo~stlc ~Publ lc Supply ~ Industry
:- : ~ ~ Irrigation ~Recharge ~Co~rclal
~Test ~ell ~ Other:
' ~ ' 7. CASING: ~ Threaded ~.Welded
' ' :': in. to ' ft. Depth Weight lbs/lC.
i6t'to > ] ft. Depth
8. FINISH OF WELL:
Type: z ::~::~k=/ Dla~er:
51ot/~esh 5~ze: Length:
Se~ be~en f~. and fi,
Fi~ings;
~. STATIC WATER LEVEL: : ft.
~ A~ve ,~eelow land surface
Type of Measure~nt:
10. PUMPING LEVEL below land surface
DFPT. OF HF/'~TH ~ ]~.~ f~. after r,,= hrs. pumping --g,p.m.
ENVIE, A'JMZ/':A. Y;;O: E_ Ti] ,4 -- ft. after -- hrs. pumping -- g.p.m.
1). WELL H~D COMPLETION: ~ tn Approved Pit
J U L S !9',)2
Pltless Adapter ~ inches above grade
Haterlal:
13. PUMP: (If avallabie) HP ~' ~,
Length of Drop Plpe ~.~ :~;[~: ft. ca,city g.P.~
Type: ~ Sub~rsible ~ Rec iProcat ing
~Jet ~O~her:
lq. REHARKS:
5. ~ATER ~ELL CONTRACTOR'S CERTIFICATION:
This we)t ~as drilled under my jurlsdlction and this report is true ~o the best of my knowledge and belief:
Registered Bus lness"Na~e Contract License Number
Authorized Representatlye
Form 02-~R Copy Distribution: WHITE - State 0~S, PINK - Dri~ler, CANARY - Customer
CERTIFIC p
- ,/
Application Date
GENERAL INFORMATION MUST BE COMPLETED' PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Prope.y Owner ~ ~4~g~[ Telephone: Home ~ y~X ~,ro l' Business
Mailing Address
<c) Lending Institution ~/.¢..4.,t~ ~/ Z _.¢~ c, 4 Te ephone
Mailing Address ¢~, ,/~";.~ ,~ ~ ~ ¢~'~ ~ ~¢
(d) Real Estate Company and Agent ~'~,~ r~ ~'~
Address ~ ~ - ~ ~
Telephone ~ ~ ~- ~ ~-~
(e) Mail the HAA to the followine address: or: Check here ~, if hold for pick up.
List contact person and day phone~number~.~below~~.~
- /
TYPE OF RESIDENCE
Single-Family ~*
Number of Bedrooms
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.
SEWAGE DISPOSAL
Onsite/J~' 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.
Page 1 of 2 72-025 (Rev 8/86~ Front
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by m~/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
Address
Date
Telephone
Engineer's Seat
DHHS APPROVAL
Approved for .~__~!-~ .~,,~ )bedrooms by
Approved ,;~ Disapproved
Terms of Conditional Approval
Conditional
CAUTION
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.
Page 2 of 2 72-025 (Rev 8/861 Back
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
MUNICIPALITY OF ~rr~,~l(T)~{~JTHORITY APPROVAL (HAA)
' DEPT. OF HEALTH ~.HECKLIST- FEBRUARY 1984 ~
ENVIRON/vtENTAL PROTECTION 264-4744
JAN 198
RECEIVED
Legal Description: _ _ _ - ~J~l - -~
If A,.B, C, D.E.C. Approved (Y/N) I~I'
Date Completed ' ~,/{~, ~,~2 Yield 7~p~l,l
I~' Depth of Grouting NO N~
Well Classification '~
Well Log Present (Y/N) ~"
Total Depth ~ ¢ Cased to
Static Water Level ,~ ~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances fi'om Well:
To Septic/Holding Tank on Lot
,,%
Pump Set At ~, ~ 7'7'0
Sanitary Seal on Casing (Y/N) ~
Depression Around Wellhead (Y/N) ~l~
; On Adjoining Lots ~ /~'~
To Nearest Edge of Absorption Field on Lot ~J~r2__ · On Adjoining Lots ~' /~"~
To Nearest Public Sewer Line 1~ {~ I~ I~' To Nearest Public Sewer
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
~ 0 J"J J~' To Nearest Sewer Service Line on ~_ot
~,=~' ;Date I/1
6 I. q
B. SEPTIC/HOLDING TANK DATA
Datelnstalled Jl.lq,~l Size ~,~-J~-- No. of Compartments 'T~O
Standpipes (Y/N) 'rl, l~ Air-tight Caps (Y/N) y Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~1 Date Last Pumped I /J ~!~'~
Pumping/Maintenance Contract on File (Y/N) I~/~. ',for I~/~e~,
Holding Tank High-Water Alarm (Y/N) J~'/~'~ Temporary Holding Tank Permit (Y/N)
N
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
NON
TO Building Foundation '~ '~
To Disposal Field I ~
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026 fRev 8/86/ Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed Il ' I
Width of Field
Square Feet of Absorption Area
Depression over Field' (Y/N)
Results of Last Adequacy Test ~'~'~,~,~
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field ,~,
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
7
To Property Line ,
To Existing or Abandoned System on
On Adjoining Lots ' ~%
To Cutbank (if present)
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 during Adequacy Test. Meets MOA
Comments
** Check' Per'mitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to ail MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ ~ Date 11/,
t
Company MOA No.
Receipt No. ~- i~ l ~007
Date of Payment ! --/~ "-~ ~
Amount: $ [?¢ ~
Page 2 of 2
72-026 (Rev 8/86) Back
Engineer's Seal
203 W. 15th AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
TELEPHONE: (907) 279-3916
LEGAL:
LOCATION:
OWNER:
RESIDENCE:
WELL:
SEPTIC SYSTEM.:
DATE OF LAST PUMPING:
DATE OF TEST:
SEPTIC SYSTEM ADEQUACY TEST
Lot 7, Block 1, Beede
14440 ~cho
Robert McNeal
Single Family, Four Bedrooms
On Site, .ResideD~i~l
FROM MUNICIPAL RECORDS:
TANK: Anchorage Tank, Steel, 2 Comp.
ABSORPTION SYSTEM: Trench
ABSORPTION AREA: 340 sq. ft.
SOIL RATING: 85
INSTALLATION DATE: November 19, 1981
January 14, 1988. Isaacs Pumping
January 12, 1988
TEST PROCEDURE: System was inspected and' measured. Tank was
found with one foot of cover and a liquid
depth of 48 inches. Trench has 2.5 feet of cover. Sump had 2
inches of liquid.
550 gallons of clean water was added to the clean out between
tank and trench at a constant rate of 7 gpm while the water
levels in the tank and sump were monitored. Tank level did not
change, level in sump rose 9 inches. Infiltration rate was
monitored for 20 minutes. During this time the water level in
the sump dropped 3 inches, indicating that the the liquid was
draining from the trench.
TEST RESULT: This system meets the code requirements of
the Health and Social Services Department of the Municipality of
Anchorage.
NOTE The operational life of all septic systems depends on the
local soil conditions, groundwater levels that may fluctuate
during the year, and the water usage of the family being served
bY the system. These conditions are outside the control of the
evaluator of this septic system. We can therefore not give any
estimate of how long this system will function satisfactory for
current or future occupants.
CONSULTIN(3 ENG!NE[}Ig
203 W. 15th AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
TELEPHONE: (907) 279~3916
RESIDENTIAL WELL INSPECTION
LEGAL:
LOCATION:
OWNER:
TYPE OF WELL:
Lot 7, Block 1, Beede
14440 Echo
Robert McNeal
Sinqle Family, Residential
WELL 'LOG AVAILABLE: ' Yes
INSTALLATION REQUIREMENTS MET:Yes
WELL YIELD FROM WELL LOG:
7 Gallons Per Minute
PUMP YIELD FROM TEST:
7 Gallons Per Minute
DATE OF INSPECTION:
January 12, 1988
TEST PROCEDURE: Well was pumped at a constant rate while the.
drawdown was monitored with an acoustic probe. At the beginning
of the test water level was found at 31 feet below top of casing.
At a pumping rate of 7 gallons per minute the water level dropped
to 57 feet after 80 minutes of pumping. A total of 550 gallons
were pumped. The well recovery rate was monitored for 15
minutes. The well recover to 31 feet during this p~riod, a 100%
recovery.
TEST FOR E.COLI AND TOTAL NITROGEN: Water was tested for E.Coli
and total nitrates on
E.Coli 0. Total Nitrates 1.4mg/1.
Max. allowable Total Nitrates 10mg/1.
TEST RESULTS: This
Municipality of Anchorage.
well meets the
requirements of the
THIS WELL WILL PRODUCE MORE THAN 3 GALLONS PER MINUTE
THAN FOUR HOURS
FOR MORE
The Municipal requirement for well flow is 150 gallons of water
per bedroom per day. This well exceed this requirement. The
assessment of the condition of the well applies only to the
conditions as of the day tested. The flow rate may change due to
subsurface conditions that may not be observed from the surface,
and changes in the land use and other factors that may impact the
aquifer feeding the well.
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)
(b) Applicant Name ~¢~ ~fif Telephone: Home
(c) Applicant is (check one): Lending Institution ~ ' Owner/builder ~; Buyer ~; Other ~ (explain); .
(d) Lending Institution Ce~q~"n,4..rf /','(o¢"~c~,~,,~ Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [] Multi-Family
Number of Bedrooms
Other ". r
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.
Page 1 of 2
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 t11 84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm
Address
Date
Engineer's Seal
DHEP APPROVAL " /. ~
Approved for ~ ~(~'/"/'.,~ bedroom~ by ~_.,5/'¢'//~../~/e-~/-,'~-'- -- ~ Date
Approved -~ Disapproved Conditional
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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description:
~UNiCIPALITY OF ANCHORAG~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
WELL DATA
Well Classification p/,,i uct ~ if A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) ~' Date Completed ~' ,/ I~ / ~ ~ Yield
Total Depth ~,yt Cased to I
Static Water Level ~' I '
Casing Height Above Ground .~O"
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole N, ,4.
Water Sample Collected by . '"r
Water Sample Test Results
Comments ~
'~' ~' Depth of Grouting ~b~-.
Pump Set At ~ ! '
Sanitary Seal on Casing (Y/N) ~
Depression Around Wellhead (Y/N) .
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
;Date
N
SEPTIC/HOLDING TANK D~i~A
Date Installed ~ Size I ~ ~! "~o. of Compartments ~,
Standpipes (Y/N) ~' Air-tight Caps (Y/N). ~ Foundation Cleanout (Y/N)
Depresmon over Tank (Y/N) N
Pure ping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Su pply Well
To Property Line ~ ~0'
To Water Main/Service Line /~, ~1.
Course
Date Last Pumped
'for
Temporary Holding Tank Permit (Y/N)
N
To Building Foundation ~'? I
To Disposal Field J~:
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 11 / I'~ /
Width of Field .~ '
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot N'/~.
TO Water Main/Service Line
Type of System Design
Length of Field '~ ¥
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~'* ~. ~
TO Property Line ~ /
To Existing or Abandoned System on
; On Adjoining Lots ~ ~'0 t
To Cutbank (if present) ~1,~.
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 during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~'~'-~ ~. ~ Date ~//7'/~'~'
Company ~'(.zxJ~/ ~',~_.¢~,,,,a~g' ..('u, Ct' MOA No.
Receipt No. ~O/b
Date of Payment
Amount: $ {~,o ,~_~---''
Page 2 of 2
72-026 (11/84)
Engineer's Seat
APPLI(" 'T FILLS OUT UPPER HAL NLY
Mailing Addre~ Zip Code
Address ~~ ,~t,~,~ [ Zip Oodo
~ealty Co. & A~nt Phone
Address IM O ~O ~ Zip Cole
Street Locatl~
Type of Resl~nce ~?'
~lngle Family
~ ~ultlpl~ Family ~ No. of Bedroo~ .~ .~
~ Other --
Water Supply
~ndividual A~ACH WELL LOG. A w~l log Is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach log if available).
~ Public Utility
Sewer Disposal
~dividual Year Indiv~ual Installed:
~ Public ~ility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
D..~./~t ' _...~ ~,,~"/'~" Date Date Date
Inspector Insp~tor Inspirer Insp~tor
Field Notes:
(~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAP~OVED
( ) CONDITIONAL APPROVAL*
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
72.023 (3/82.)