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Home My WebLink AboutBENITO BLK 3 LT 12Onsite File Benito Block 3 Lot 12 #050-272-12 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENV'IRONMENTAL 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: ~,L5 °t°~ ~3 :;;ZL~.~. PID Number: ~ ~ ' ~ ~ Name: ~ ~ ~ ~ Wastewater System: ~ New ~pgrade Addres~cO~ ~'~'~'~'~ ~~ ABSORPTION FIELD Phone:~~ No.~Bedrooms: ~eepTrench ~ Shallow Trench ~Bed ~Mound ~Other LEGAL DESCRIPTION so, Rating: Total Depth from origina~ grade: /~ ~ GPD/Sq. Ft, LOt; /~ Block: Subdiv~ion; Depth to p~pe bottom from original grade: Gravel depth beneath pipe ~ ~/~ ~ '~ Ft. ~ ~ ~ ~ Ft. Township: Range: Section: Fdl added above origin~ade: Gravel length: WELL: ~¢~Z~ew ~ Upgrade Gravelwidth: ~ Fb / ~ Ft. Classification (Private, A,B,C): Total Depth; Cased To: Total absorption area: Pipe material: /~ ~/ Ft. ~ Ft. ~ Sa. Ft. Yield: Pump Set at:J Casing Height Above Ground: g GPM ~gx~'~ Ft,~ '~ Ft. TANK SEPARATION DISTANCES ~,t,o ~ Herding ~ S.T.E.P. TO Septic Absorption Lift Herding 'ublic/PrivateManufacturer: Capacityin gallons: Number of Compa~ments: Waif /~ ~ / /~/ ~ ~/~ ~/~ ~'~/ ~ateriar:~ Sudace Water /~ ~'~' ~Z~ ~* ~¢¢¢~ LIFT STATION LOt ~ ~../ Line ~ ~ / / ~ / ~ ~ ~ Sizein gallons: Manufacturer: evel at I High water alarm at: Foundation ~ ~ ~ ~, ~// ~ ~ "Pure on"level at' ' "Pu f Cu~ainDrain ~ ~ ~/~ ~ ~ P~ Electrical Inspections pedormed by: Remarks: BENCH MARK ~ ~;~ ~.. ~ Assumed Elevation: Inspections performed by: /~¢~ ~" ~/ Dates: 1st ~/~7 Reviewed Permit N®. Page 2 of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650,, Telephone 345-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: LOT /2, BLOCK 5, BENITO SUBDIVISION. PID No.: eee eee [[ JO ~ I0~ ,¢'9~ 9'6E ENGINEER'8 SEAL Permit N~. Page 3 of 5 State of Alaska DEPARTMENT OF ENVIRONMENTAL CONSERVATION P.O. Box 1064 · Wosillo, Aldsko 99687 · Telephone 576-5058 Application for On-Site Water and Sewer System Approval Legal Description: LOT 12, BLOCK 3, BENITO SUBDIVISION PID No,: W h () ENGINEER'S SEAL x~ .....;'?:~,_ i MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Aug 09, 1999 Expiration Date: Aug 08, 2000 Permit Number: SW990262 Legal Description: BENITO BLK 3 LT 12 Design Engineer: 0069 Douglas T. Kenley, PE Owner Name: George Founds Owner Address: 17206 Foothill Drive Eagle River, AK 99577-8145 ParcellD: 050-272-12 Site Address: 017206 FOOTHILL AVE Lot Size: 11339 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [~ Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Cede 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 (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. .Douglas T, Kenley, P.E. 9960 E. Puffin Ddve, Palmer, Alaska 99645 (907) 746-1073 July 30, 1999 Mr. George Founds, Owner Lot 12, Block 3, Benito Subdivision 17206 Foothill Avenue, Eagle River, Alaska PERCOLATION TEST RESULTS AND GENERAL SITE INVESTIGATION REPORT The design presented is an upgrade system to replace a failed absorption crib. The new system will be placed on the rear of the lot east of the old system, using a new 1,000 gallon tank and deep trench. The old crib and tank were both found within the 100 foot radius of the well. The old system was installed in 1974, a year after the 100 foot requirement for the absorption area and tank was in effect. No remarks are made on the well inspection report as to a waiver being granted. Therefore, a new tank will be placed outside of the well radius. The old crib cannot be used as an alternate absorption system in conjunction with the new trench without a well waiver from the Municipality. The test hole and pemolation test were performed on the 23rd of July, 1999, by Fred W. Kenley. The test hole log reports finding water at 15.8 feet from grade, which amounts to 12 inches of water from the bottom of the test hole. The total depth of the test hole is 16.8 feet. The test hole log is attached to this report. The design is based on the assumption that the new system will be placed so that the bottom of the gravel is at least 6 feet above the elevation of the bottom of the test hole. This will put the bottom of the gravel at least 4 feet above the present water level in the test hole. The test site had adequate percolation rate to support the existing three-bedroom residence. Subsurface soils were found to contain some 30-inch diameter boulders and gravel with sand and some silt ovedain by 12 inches of surface organics. The percolation rate used for the design was found to be approximately 4 minutes per inch. The test hole was pre-soaked for a period of 4 hours, The application rate of 1.2 GPD/SF was used in the calculation, with 10 feet added as a conservative factor. The tank is to be positioned such that it could also serve an alternate system in the event the designed system fails in the future. Page 2 July 30, 1999 The proposed system will have nO measurable impact on reserve space, surface or subsurface, or on drainage to adjacent lots. Please consider this report as a request for review and approval of the attached design drawings for a replacement on-site wastewater, disposal system If there should be any questions concerning the percolation rate or characteristics of the site, please call me at (907) 746-1073 or 243-5372. Sincerely, Douglas T. . PE#8176 z m o ~ 2 ?z~~ o~ ~°Oooo ~ '~d 'Ag*lN~,f '.L gv-E)fioa NOISIAll3EIrl8 OIINiilE] '8 )tOO'll:l '~l. .LO'I ~ ~ ~ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION:~'o~"L~? ~"--~ DATE PERFORM~)~~ Township, Range, Section: SLOPE SITE PLAN 1 2 3 4- 5- 6 7 8 9 10 11 12- 13- 14- 15- 16- 17 18 19 20 COMMENTS WAS GROUND WATER ENCOUNTERED? S DEPTH?IF YES, ATWNAT /,~,; ..,~/~T/, ~)p E Deplh to Water After ..~ x Monitoring? ~',~", ,e~ Date: Reading Date Gross Net Depth to Net Time Time Water Drop '~ :7' ~ x~,,~'.,o ~ " ?" ~ ,, ~ ~ - 7., _ /_~ .¢'/..-~ /7/ PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER __ TEST RUN ~ETWEEN ~/'-~ ' ~T AND W- F~ 72-008 (Rev. 4185) GRE"rER ANCHORAGE AREA Bor'nUGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME H P,~,eL. D LOCAT,ON MAILING ADDRESS LEGAL DESCRIPTION PHONE SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH MANUFACTURER INSIDE WIDTH MATERIAL NUMBER OF COMPARTMENTS ~-- LIQUID DEPTH_ .LIQUID CAPACITY. /~ GALLONS. SEEPAGE PIT: NUMBER OF PITS LINING MATERIAL DIAMETER OR WIDTH__ CRIB SIZE: DIAMETER , NEAREST LOT LINE BUILDING FOUNDATION ADDITIONAL ABSORPTION LENGTH.__, DEPTH DEPTH DISTANCE FROM: WELL TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) SQ. FT. WELL: TYPE ~"~lf, i I-I- ~1: BUILDING FOUNDATION CESSPOOL APPROVED_ CONSTRUCTION NEAREST NEAREST , LOT LINE , SEWER LINE , OTHER SOURCES DISAPPROVED REMARKS DEPTH SEPTIC , TANK DISTANCE FROM: SEEPAGE SYSTEM DISTANCES: INSTALLED BY: LOT SLOPE: REMARKS: J Form No. EQ-031 DIAGRAM OF SYSTEM DATE fl~ ~,/~7~/ APPROVEI ' , .A.A.B. GReaTeR AnChORage ARea Borough DEPARTMi~NT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 · TELEPHONE 274-456 ! SEWAG1E DISPOSAL SYSTEM -- APPLICATION AND PERMIT PERMIT NO. NAME Of APPLICANT INSTALLATION LOCAT,ON MAILING ADDRESS PHONE INSTALLATION OF: SEPTIC TANK SEEPAGE PIT DRAIN FIELD OTHER SOIL TEST RESULTS ~,~t THI IT IS NOT VALID WITHOUT SOIL COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCES, REQUIREMENTS DIAGRAM OF SYSTEM C FOUNDATION TO SEPTIC TANK '~ FOUNDATION TO SEEPAGE PIT SEPTIC TANK TO SEEPAGE Pit WALL SEPTIC TANK TO NEAREST LOT LINE. DRAIN FIELD ., SEEPAGE PIT , DRAIN FIELD WELL TO SEPTIC TANK DRAIN FIELD SEEPAGE PIT /~l ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK DRAIN FIELD SEPTIC TANK, . ., SEEPAGE PIT TO RIVER, LAKE, STREAM. SEEPAGE PIT /~' ,DRAIN FIELD C~AST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. LICENSED DESIGNER I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. FORM NO. EQ-0t 6 October Z~, 1974 Alaska State Bank 310 £. Northern Lights Blvd. Anchorage AK 99503 SL.JBJECT: Lot 12, Block 3, Denito Subdivision. Dear Sir: The subject lot is not available to public sewer, and it ts not economically fa&siDle to serve the lot with public suwer at this time. The sevmr system, if installed to local speci¢tcation$, should provide ade- quate sewane disposal until such time as public sewer is avallahle. The water supply, whicf~ ~ust We an individually drilled well p&aced at l~ast lO0 feet froth the. sm.~er systen~, should provide a potable supply of water if installed to state and local spactftcattons. Sincerely, John R, Lee, R.S, Eagle P. tver District Sanitarian ~lRL/sr September 20, 1974 Veterans Administration 429 O. Street Anchorage AK 99501 SUBJECT: Lot 12, Block 3, Bentto Subdivision. Dear Sir: The subject lot ts not available to publlc sewer, and tt ts not economically feastble to serve the lot wtth public sewer at this ttme. The sewer system, t~ tnftalled to local spect¢tcatlons, should provtde ade- quate sewage dtsposal unttl such ttme as publlc sewer ts available. Th~ water supply, whtch must be an fndlvtdually drtlled well placed at least 100 ~e~t from the sewer system, should provide a potable supply o~ water Installed to state and local specifications. Sincerely, John R. Lee, R.S. Eagle River Dtstrtct Sanitarian JRL/sr March 2~1, 1974 Alaska State Bank 442 West 5tn Avenue Anchorage AK 99501 SUBJkCT: Lot 12, Block 3, Bentto Subdivision. Dear Sir: , The subject lot is'not available to public sewer or a public water supply. For this reasOn the sewer must consist of a septic tank-soil absoeptton ordance with Borough Ordinance # 28 - 68. /Installed system installed in. accj ~ .... ,6^. ,,H~factorilv until public sewer is in this manner it snoula TU,,U~,v- ...... available. Water will have to be through an individual drilled well. If constructed to our specifications. "!,.t should provide potable water. If you wish further inf~rmatt°n, or clarification, please contact this office. Very Sincerely. john R. Lee, R.S. Eagle River District Sanitarian sr MUNICIPALITY OF ANCHORAGE Development Services Department Phone: (907)343-7904 On -Site Water & Wastewater Section Fax: (907)343-7997 Certificate of On -Site Systems Approval OSC251339 Parcel ID 050-272-12 Expiration Date: ` (v Legal description BENITO BLK 3 LT 12 Site address 17206 FOOTHILL AVE Current property owner(s) WALIGURA ASHLEY NICOLE X The On -site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or conditions: No comments By: Original Certificate Date: 8/15/2025 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Service Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's submittal. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory 14_ Arsenic Advisory Other MUNICIPALITY OF ANCHORAGE 4A, Development Services Department s Phone:907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 05027212000 Complete legal description BENITO BLK 3 LT 12 Location (site address) 17206 FOOTHILL AVE Current property owner(s) WALIGURA 2. ON -SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 907-440-2175 3. TYPE OF WATER SUPPLY: FN Private Well serving #_1_ dwelling units R Other Non-public well as regulated by MOA El Water Storage F] Community Well or Public 4. TYPE OF WASTEWATER DISPOSAL: � Private Septic E] Private Septic serving 2 dwelling units E] Holding Tank R Community Septic or Public Sewer 5. SEPTIC TANK: OR Steel [:] Plastic E] Concrete F-1 Fiberglass Age 26 _ See advisory if steel or fiberglass older than 20 years 6. ABSORPTION FIELD: R AWWTS E] Bed ro-1 Deep Trench E] Wide Trench R Seepage Pit Waiver request for: Expedited review requested: R Distance: By applying for this entitlement, this property is subject to inspection by municipal On -site staff to verify the accuracy of the information provided. COSA Fee $ 5 SO Date of Payment &W2� COSA # 005131q Waiver Fee $ Date of Payment Waiver # COSA App1icaUon_APr2025.doc COSA Checklist Legal Description: BENITO BLK 3 LT 12 Parcel ID: 05027212000 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA F0 Well log is filed with Onsite (or attached) Date drilled 5/16/74 Total depth 81 ft Cased to 40+ ft M Sanitary seal is functioning correctly ❑E Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA 7/24/25 Static water level at beginning of test 73 ft. Comments B. TANK DATA Measured operating fluid level in septic tank 51 Date of pumping 8/5/25 ❑ Required maintenance completed, if AWWTS Comments: D. DISPOSAL FIELD DATA Which system tested (date installed) 8/17/99 R ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade 6.5 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. R Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: Well production at time of test 6+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes Al No OR Coliform bacteria is Negative Nitrate 3.56 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L X Arsenic less than MRL (ND) Collected by NRim Eng Date 7/24/25 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 7/24/25 Results 0 Pass Fluid depth prior to test 24 in Water added 450 gal New fluid depth 28 in Elapsed time 30 min Final fluid depth 24 in Absorption rate 450 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 66 in Effective depth used 24 in Effective depth remaining 42 in COSA Checklist_May2025.docx E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100' Z Yes if No ft Neighboring Tank > 100' Z Yes if No ft Disposal Field on Lot > 100' R]Yes if No ft Neighboring Disposal Fields > 100' 0 Yes if No ft Sewer Line/Main > 100' [E]Yes if No ft, Sewer Manhole/Cleanout > 100' Z Yes if No ft Sewer ServicelSepflc Line > 25'Z, Yes if No ft Holding Tank > 100' Q Yes if No ft Animal Containment > 50' Yes if No ft Manure/Animal Excreta Storage > 100' rvl Yes if No ft Q N/A —served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required) Tank to Foundation > 10' 21 Yes if No ft Surface Water > 100' R Yes Field to Foundation > 10' P-1 Yes if No ft Tank to Property Line > 5' Fv�' Yes if No ft Field to Property Line > 10' M-1 Yes if No ft Water Main/Service Line > 10' 21 Yes if No ft F. ENGINEERS COMMENTS Wells on Adjacent Lots: Wells > 100' EMMUZZMMIM if No ft R] Yes if No ft Fv�l Yes if No ft If tank or field is under driveway comment below G. CERTIFICATION & ,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, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on -site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm NorthRim Eng. Engineer's Printed Narne — Steve Eng COSA Checklist May2025.docx Phone 694-7028 Date 8/4125 ,W Vr - AV CI) Steve Eng 0 CE-6256 At AV 4%& 4W 4 8'/ 4/2 519" MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT �k "� 907-343-79(�4 On -Site water and wastewater Section ,f Fax: 343-7997 www.muni.org/onsite Septic Tank Advisory Certificate of On -Site Systems Approval # OSC251339 Subdivision: BENITO Block:3, Lot: 12 The septic tank for this property is 26 years old. The average life of an asphalt coated steel septic tank is 20 years. Typical replacement costs are $15,000 or more, not including engineering, surveying, MOA permitting fees or site restoration. Steel septic tanks utilizing "Coal Tar Pitch" coatings are subject to corrosion as the steel reacts to water and rusts. These tanks have a finite lifespan buried in the ground. These tanks can become structurally compromised and pose a health risk. They could collapse and/or leak untreated wastewater directly into groundwater. In the interest of protecting public health and the environment, the Municipality of Anchorage Development Services Department has issued Policy W.05 Standard of Care Regarding the Inspection of Steel Septic Tanks when Performing COSA Inspection. Please request a copy of this policy from the Department if interested. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904 On‐Site Water and Wastewater Section Fax: 343‐7997 www.muni.org/onsite Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org Septic Tank Advisory Certificate of On‐Site Systems Approval # OSC201433 Subdivision: Benito Block:3, Lot: 12 The septic tank for this property is 21 years old. The average life for a steel septic tank is 20 years. Typical replacement costs range from $7,000 to $11,000. This advisory must be attached to all copies of the subject Certificate of On‐Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. 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~l HAA# 1. GENERAL INFORMATION. Complete legal description Locatio.n..(si~.e address or directions) ~'~'.¢-,¢¢ ~--~,~-~.~.,~.~ ...~,~' Property.owner' .' ~'¢/~-~- '~'¢~'~'¢ Day phone address' L~ ~ ~.~ ~, ~ ~,~, ~ -'..Mailin~" ': .... '"' '~ Lending .agency ' ~;~ Day phone Mailin~ addross. '~-'~ ~' Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: --~ TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 'TYPE OF WASTEWATER DISPOSAL: NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 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 (Re?, 1/91) Front MOA#21 gECEIVED Municipality of Anchorage AUG DEPARTMENT OF HEALTH & HUMAN SERVw,~o 19 1999 Health Authority Approval Checklist LegalDescription: ~- ×~, ,~,.~..~ .~9,~..o,..~ ,~_~,.~.,~>~Xl~arcel i.D.: A. WELL DATA Well type ~'~/U~,~ IfA, B, or C, a~ch ~EC leaer. ~EC water ~stem n~er Log present ~ ~ Date completed _ ~/~¢~ ~ To~ dep~ ~/~ C~ed to ~ ~ ~/ ~ ~ C~ing height (above gro~d) s~ s~ ~ ~ __ Wires properly protected (Y/N) ~ __ Date of test Static water level Well production WATER SAMPLE RESULTs: Col/form .~ Date of sample: ~/~? SEPTIC/HOLDING TANK DATA FROM WELL LOG AT INSPECTION g.p.m. ~ Nitrate ---- g.p.m. Other bacter/a _ Collected by: /a~-'~, ~, Date installed / :r z Tank size /,~ o"~7 N ---------___ Umoer of Compartments ~,~ Cleanouts (Y/N)__~ Foun~t{on cieanou~-(Ya,~) ~ --' - _ ~ Depression (Y/N) ~ __ High water alarm (Y/N) ~ Date of Pumping A~'/~. · · Pumper C. ABSORPTION FIELD DATA Dateinstafied~ ~ Soil rating (g.p.d./l~2orl~2/bdrm) -/~ ;E. S ste Length ,9/~ ~ ~ Y m type --~--------___.~Width ~ ~/ Gravel thickness below pipe ~ .5~/Total depth /~ Effective absorptmn area' ~'~ ~ Momtonng Tube present(Y/N)__~____~/Depression over field (Y/N) Date of adequacy test Fluid depth in absorptiOn field before test On.); ~ Imm~ater add · .: Fltud depth__.______~(ins.) Mi~ /0//,~ ed (in) __ ~ _ Absorption rate = P~n~te treatment (past 12 months) (Y/N) ~ ~ ~g.p.d. ~------------___ If yes, give date