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HomeMy WebLinkAboutT12N R3W SEC 17 N240' OF S570' OF W150' OF E600'T12N R3W Sec 17 N240' 5570' W150'E600' 016-061-12 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES f Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name C L 0! I,16 DISTANCES FROM TO TANK ABSORPTION FIELD WELL Address Address WELL 7. j -f- Phone(s) 52-7- I i 52- Permit No. 1003 -7 No. of Bedrooms LOT LINE ' + (, i/I LEGAL DESCRIPTION Lot Block Subdivision . FOUNDATION I Township, Range, Section �• , • I�= AS -BUILT driveway, DIAGRAM (Show location of well, septic system, property lines, foundation, water bodies, etc.) TANKS EL rj J C &L He i s' M -09 ✓1 r1 v �)} r ❑ SEPTICHOLDING Manufacturer Capacity in `rgallons Material No. o Compartments TYPE OF SYSTEM []TRENCH ❑ BED ❑ W. DRAIN ❑ OTHER Depth 16'We bottom from original gra F Total depth from original grade FT ! I " J Fill added above final grade Vol depth beneath pipe FT Gravel length FT Gravel width FT Total absorption area T Distance between lines FT .,j Number of lines Soil rating SO FT ipe material Installer Date Installed WELLS ❑ PRIVATE ❑ OTHER (Identifvl I S I Classdicauon (A,B,C) Total Depth FT Cased to FT fnstallei Date Installed: / REMARKS: 'nee_ -� f1 ti�il "le -1 zr j fir/ [A IC✓r �Gcr �h' cA 1t 1�. / / / J (Ifroi t, ^C, - 1 ro(__ . 71 To _ ideico ides Scale: L, Inspections Date: T F {C�tl(�E�R $ SEAL Performed by: ) O performed according to all �= Date: y 1 ot:_ o _ f _ (j 1{l � i vsm?4-(— Lw bm-p etas, "Six, l7ic wPSI � Jcertify that [his inspection was A� tt % Municipal and Slate guidelines in el� / elect on this date: t � Health Department Approval: —,� &'"'"�'•t 72-013 (3/85) 5901PKC 8E0 Lee /Zev-4'OE' Y ' e/r itiu r �! ded tyO e Atjhr �- awE�e n Ab" s4+nc� , Sew` a tuell 3 .Urn 05 250 = 7=Y> >✓ /, S = //2 5 3Lx3o=9aa f X/2= 2,fo \ 7/'? -o D v / Viwg(Qt cp jJ/ I Fcle/G--j-5 : s A=b 01, ��� rP Se 3 BD2X,, 1-(ovj�E ate! /ecg"Ineef � ekCJ'i j hft e 35'd' --'P a E i4. ,L- o l e-(,',0 �Z 4 7((f N / Cee�lYt� - x o o a %rn SPc{, n.•�tr/6.�r` /7//6�2�2/ 600 moi! W ��`,<- � -� 4 � • a � a� SPcf. /9�Zo-YGrPucE .U. 330 /¢ !`kPsrc� e Pe�,P.l-e 64 :G isa/ n F'�-e Al 2ao 'flreu�e �o�r�% S`C774IN /Sc tl�e ale S Zoo' ra fit. �Fc/J rt `1 NOTE: All Dimensions And Locations Must Be Field Verified Prior To Construction SEWER SYSTEM LOCATION PLAN IAT BLOCK SUBDIVISION rr 5 Tom_ _w SECTION/TOWNSHIP/RANGE {CS`�o t' seof• i7 r/ SCALE-// NOTE- ­At } / / i� / a-�u/vf��, /� The Accuracy OC Location Of Exisiting And •� r / :t "pa Proposed Property Corners, Hells, and Septic �r/ ��/ J-/ - c- ry DRAWN BY� Systems Indicated Is Not Exact. Oimens ions NORTH d --e Indicated Nave Been Determined By Use OC Cloth #, i°grim+ r ;4 �I - Tape and/or Municipal Records, And Not By 1. l:.Q: '•eft a:'RS&T ^M Surveying Techniques HI. :r .f� i! YX �x ' fiF ox, PREPARED FOR, P�/'Y4 Consu Zing ` Tneers; DATE, 1016 SHEET ` OF HOLDING TANK: Minimum TaF-- Size: 2�000 gallons. A high water alarm must be installed on the tank and connected to the residence, Depth to top o� holding tank < 4.0 �eet requires insulation over tank. WELL: Log must be submitted to Municipality o� Anchorage Department o� Healih and Human Services within completion, |Hl� SYSlEM MUST BE INSTALLED IN ACCORDANCE WITH THE APPROVED ENGINEER'S DESIGN AND ANY DEVIATION THEREFROM MUST HAVE DHHS �PPRGVAL PRIUR TO CONSTRUCTION. THIS PERMIT IS FDR A 3 BEDROOM SINGLE FAMILY RESIDENCE ONLY AND EXPIRES ON 12/31/89" THE EXIST- ING CRIB MUST BE PRQPERLY ABANDONED` INSTALLATION OF A LIFT STAT�UN REQUIRES THE APPROPRI/TE ELECTRICAL INSPECTION" I CERTIFY THAT: �amiliar with the requirementc {or onsite sewers and wells as set forth by the Municipality o� Anchorage (MOA) and the State c Alaska, 2. I will install the system in accordance with a1l MOA codes and regulations� and in compliance with the design criteria o� this permit. 3, I will adhere to aIl MOA and State o� Alaska requirements �or the set back distances [rom any existing well� wastewater disposal system or public sewerage sysiem on this or any adjacent or nearby lot" 4" I undersiand that this permit is valid �or a maximum o[ 3 bedr�oms" I also understand that the capacity oe total system is 3 bedrooms and any enlargement will require an additional permit" Signed: TE: (Owner> RICHARDpGUNTHER Issued By: DATE: ^~ MUNICIPALlTY OF ANCHORA6� Department o� Health & Human Services 825 L Street, Anchorage, Alaska ON~SITE HOLDING TANK & WELL PERMIT Permit Number: 890237 Upgrade Date Issued: 1O/18/89 Engineer Designed O�ner Name: RICHARD GUNTHER Day Phone: Owner Address: 2441O O/MALLEY ANCH, AK 99516 Parcel Id: 016-061'i2 Lot Legal: Subdivision: NONE Lot: 9999999 Block: 999999 Section: 17 Township: 12N Rangex 3W TRACT NEG" Lot Size 360OO (sq.�t^ or acres) Max Bedrooms: This Permit: 3 Total Capacity: 3 HOLDING TANK: Minimum TaF-- Size: 2�000 gallons. A high water alarm must be installed on the tank and connected to the residence, Depth to top o� holding tank < 4.0 �eet requires insulation over tank. WELL: Log must be submitted to Municipality o� Anchorage Department o� Healih and Human Services within completion, |Hl� SYSlEM MUST BE INSTALLED IN ACCORDANCE WITH THE APPROVED ENGINEER'S DESIGN AND ANY DEVIATION THEREFROM MUST HAVE DHHS �PPRGVAL PRIUR TO CONSTRUCTION. THIS PERMIT IS FDR A 3 BEDROOM SINGLE FAMILY RESIDENCE ONLY AND EXPIRES ON 12/31/89" THE EXIST- ING CRIB MUST BE PRQPERLY ABANDONED` INSTALLATION OF A LIFT STAT�UN REQUIRES THE APPROPRI/TE ELECTRICAL INSPECTION" I CERTIFY THAT: �amiliar with the requirementc {or onsite sewers and wells as set forth by the Municipality o� Anchorage (MOA) and the State c Alaska, 2. I will install the system in accordance with a1l MOA codes and regulations� and in compliance with the design criteria o� this permit. 3, I will adhere to aIl MOA and State o� Alaska requirements �or the set back distances [rom any existing well� wastewater disposal system or public sewerage sysiem on this or any adjacent or nearby lot" 4" I undersiand that this permit is valid �or a maximum o[ 3 bedr�oms" I also understand that the capacity oe total system is 3 bedrooms and any enlargement will require an additional permit" Signed: TE: (Owner> RICHARDpGUNTHER Issued By: DATE: ° ' ' '^` MUNlCIPALITY OF ANCHORAG� Department o� Health & Human Services B25 L Street, Anchorage, Alaska 995O1 343--4720 ONSITE SEWER & WELL PERMIT {�\���2�~] m-�u /���`" ' Permit Number: o 237 Upgrade `~/� Date Issued: /U/18/89 Engineer Designed Owner Nam RICHARD GUNTHER Owner Addres 2441O O'MALLEY / ANCH� AK 99516 Parc : 016-061~12 Lot Lamals Subdivisi : 9999999 Block: 999999 Section: 17 12N Range: 3W Day Phone: acres> MaTotal Capacity: 3 SEP T c tank capacity: 1,000 gallons" Each septic tan s tments. Depth to top of septic tank(s) < 4.0 fee�/reou���s ins����ion ove�*��nk(s). g mu submitted toARApality o� Anchorage Department o� Health 7HIS SYSTEM THE APPRO�FD ENGINEER/S D MUST HAVE DHHS APPROVAL PRID S FOR A 3 BEDROOM SINGLE FAMILY RES ON 12/31/89^ THE EXIST� ING CRIB MUST BE PROP D, INSTALLATION OF A LIFT STATION REQUIRES THE E ELEC NSPECTION. - ~-~----��^- 1 ���|1FY |M�| 1. I am te sewers and wells as set forth and the State o. Alaska" 2, I wil all MOA codes and regulations; and in compliance with th this permit, 3. I will adhere to all MOA a requirements Kor the set back distances any existin disposal system or public sewera�e system on this or arby 1ot, It. I understand that this permit maximum of 3 bedrooms" I a1so understand that the c::apac:j I a S f th. a Lotal system is 3 bedrooms and any e larojeHREMA ill PRCIUMM an additlonal permit" Signed: DATE: (Ower F:,' RIC ' Issued By: DATE: �`^-=-~-^^------ �------r--��--- cr,b EK�a{2G{e vert ofd Co"rP �t-ggipJ�F,-e n &C 'any 1 5 BS91,�t. 2-Ko>rs�E I e tue,l 35 dPeP 41Z f ro 3� I Sewer I 20 3 3 8.k 250 = 750 �'/,S= //2 5 r->'3' a4 at 3a k3a = 90-0 , fol ✓✓x<a4- J 1 lav (c Pte/0 --- C9 I -- Orn er.',O�cIL �cuvt-�kef' Som{, f% W Q :.• - v a an Sec-. /7 �Zo �LrpurE X1 330 f¢ a ,E /So% fT.PareAl24o'f'Gteu�e.�i.�P6� P P 6 /Sofa, iliPuteS Z¢0' {, /�t. J�e��dnR/I/ NOTE: BEo SECTIar� All Dimensions And Locations Must Be Field Verified Prior To Construction SEWER SYSTEM LOCATION PLAN � w4.'. r` 3 LOT BLOCK SUBDIVISION SECTION/TOWNSHIP/RANGE CPQ �eGl-• /7 77 le 5: /a It . �)'R SCALE- / NOTE - The Accuracy Of Location Of Exisiting And Proposed Property Corners, Wells, and Septic �0 DRAWN BY, Systems Indicated Is Not Exact. Dimensions / NORTH I.Wi ca[ Slave n eton. ined By U OByCloth Tape and/or municipalRecords, AnWet *iSurveying Techniques £ PREPARED FOR- ,• H DATES /Q /6 SHEET ` OF r Municipality of Anchorage iyk of T DEPARTMENT OF HEALTH & HUMAN SERVI&f 825 "L" Street, Anchorage, Alaska 99502-065F;; ; w SOILS LOG — PERCOLATION TEST§.e PERFORMED FOR: AceaE�`I LEGAL DESCRIPTION: L4 &J" Township, Range, Section: E T (FEET) I PL, eX 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS Al WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water Atterq Monitoring? / SLOPE L t� S O P Q E Date: /� 1 Ay,,„ .;' 1tZNpGINEER'S-SEAL) rY�9e OFE .ali'�h// SITE PLAN PERCOLATION RATE 2'3' (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEVN -"� FT AND �� FT �/ 7iS �d1f l iGi.O'->� �/� /711h, n4 PERFORMED BY: 1 �ERTIFY THAT TfHIS T ST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELI S IN EFFE N THIS DATE. DATE: 72-008 (Rev. 4/85) Dep" to Water PERCOLATION RATE 2'3' (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEVN -"� FT AND �� FT �/ 7iS �d1f l iGi.O'->� �/� /711h, n4 PERFORMED BY: 1 �ERTIFY THAT TfHIS T ST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELI S IN EFFE N THIS DATE. DATE: 72-008 (Rev. 4/85) 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 SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW930219 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:EVANS ELIZABETH & OWNER ADDRESS:2441 OMALLEY RD ANCHORAGE, ALASKA 99516 PARCEL ID:01606112 LEGAL DESCRIPTION: T12N R3W SEC 17 TR NEG l LOT SIZE: 36000 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE 1 OF 1 DATE ISSUED: 7/14/93 EXPIRATION DATE: 7/14/94 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 343-4329 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: RECEIVED BY: / DATE: y�(�I���� ISSUED BY : (S�zurr-� DATE: ' T lzacr A _ d n G-tlilsl.l suP, .gRA1+��6 LaSuu!T ..— F�1 b�� S5�•00`•� IS000 -.� to' UEI CLaG 1lSL EA IfMrtlt o w Fou�.,o �b "teo- – FouNoSJ9 Yadea_� a Q0.4 T0.5 a a GLac. GA�IfNONr St1mvwe Po1.9 ,� aovr c, O L k(AkvT O 6/ 4 fv sl rn3ck tf �jf L N I D2Naw. ( nr po � �r 0 yrs %o k� O / j oar a, s �' >oQ, Qh TCLwT t��Z _ I � •i,% 0 � CaRLwN Sub- - WC:LL +e �wea�ooN FLaNeu r 1 SriT5fpk3o>RN6eo_ ��—o��e ��� 1- Y � S S9 = SS'•oo" W a 15La oo --�- I::� S� PI 0 O 0 N Te44;T Py- Z �u sug 'J'o F13Nc+r wvNo 51i Ra6Aa. >q; t-AMTa5 ANC) ISo44vS PLI6GrZkPTl;j14 l iro �..oM Tµ•l3 51-'�TLON C.OM.L �(L_Zo 21 THKNGO `N L3.T Coco _ Puzor oN Smr.TLON LANG) ZO - TL++st-AQ9 NORTH °530 F471;T -. - TO T*9 7oLNT OF 15uwNNlQcj I TL+r,.NLG LAST I FaLsT� T46Nca NORTH Zoo Fv�T, TNanlc-e WuST ISo I`•I FL'L,'T� T1+ISNGI� SOUTH Z40 Flt 1lT TO TS+s F'F7LNT OP f'jaC71NNINfa. d'MAU.EY .. iCoAP OT AZaA = 5Co 000 5 . (� ► ry e459 -`T714 0 (to 0 1p / /Z' 1/2 horsepower submersible pump should be installed 500-5 50 ft. + X INCH WATER WELL DRILLED -- -----OUT TO THE DEPTH OF 6 feet. 'harge for 600' onl1t, MILLED AT THE RATE OF' 23/22 $ . PER FOOT. Steel easing seated to 291. aPERTY OWNER '4r. %hne Marteasen 345.,4545 RECEIVED CATION OF WELL SITE Lt. Alk. Nub. NOV 10 1993 ILLER EOrnie Claus of Rampart Drilling Works, Mumcipal ty of Anchorage Dapk Rgalth A Wumin cangd.^w e Water Well wav drilled during the aridpart of the summer & will i crease L4 LOG! by about6C,. ur3ng we seasons. Increase with use is about 90%, J .- . 12' silty sand coarse gravel with con, .from 9 to 12 feet. Weathered rock fragments. (conglomerate) to (broken rock) showing 6 o ?2' Cap rook. A true sedimentary► rock on top of broken rock fragments. I2 A Wesilty red gravel of coAglomerate. (Rock fragments,) - 6551 Bedrock. A hard sedimentary rock material. C:Asing seated to 29 ft. 181 to 183 ft. showed a granular tTpe rook producing close to )/3 gpm, *water production was UP to 3/4 l ; from thin areas of LseurOS in granular rock. .om.350 to 55Q ft, water yield increased to A total of 1 1/2 gpm, 9U gph, iter full drew down & long duration pumping. t(Dfer four hours.) .om 635 to 643 ft, water production during drilling increased aignificantly. appeared to be a false reading due to bigh pressure pnauma�lcs. This area, hpaevers slightly porous = a granular type rook producing a good poteaw al of water. Water production inoreaaed possibly just over one gpm, total to slightly over 2 i/2 gpm,-150 gpu after full draw clown & after long ration pumping over four hours. Short duration pumping after draw down, VQV6r7 shows very clock to 3 1/2 gYm. (Ilrst two to three hours of pumping.) ttor recover, is back up to 40 ft, of surface. increase with use is 30%* - 2r INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. 200'm# $23.00 x 200 ft, $49600-00 200'- 600': $22.00 x 400' ;g& $t7b .00 iTE CHECK PAYASL9C TQ RAMPART DRILLING WORKS FOR THE SUM OF $13,1+2+,00 600.00 + $8000400 03t400,00 + sa P: $24, 00 THANK YOU V1=RY MUCH. n. The integrity (hardness) off the be oc s very g BERNIE CLAMS OF RAMPART DRILLING WORKS •� August 29 1.993 TOTAL F.01 ------- ----------------------------------------------- A �Ifl 4 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID # 92.0040440 IABORATO RIES ANALYSIS REPORT BY SAMPLE for Work Order # 18395 Date Report Printed: NOV 25 89 @ 14:12 Client Sample ID:GUNTHER RESIDENCE - 2441 O'MALLEY RD PWSID :UA Collected NOV 21 89 @ 13:00 hrs. Received NOV 21 89 @ 14:00 hrs. Preserved with :AS REQUIRED Analysis Completed :NOV 22 89 Laboratory Sup exvi c -STEPHEN C. EDE Released By Special TRACK NEG, SEC 17, T12N, R3W, OUTSIDE SPIGOT. Instruct: HOLD UPON COMPLETION FOR P/U. Chemlab Ref #: 8620 Lab Smpl ID: 1 Parameter Tested ----------------------------------- NITRATE-N Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY T.F. MOORE. Client Name FLATTOP TECHNICAL SRV Client Acct FLATTOT P.O.# NONE RECEIVED Req # Ordered By : T.F. MOORE Send Reports to: 1)FLATTOP TECHNICAL SRV 2) Matrix: WATER Result Units Method ------------------------------------------ ND(0..10) mg/l EPA 353.2 1 Tests Performed See Special Instructions Above UA -Unavailable ND= None Detected See Sample Remarks Above NA= Not Analyzed LT=Less Than, GT=Greater Than Allowable Limits ------------- 10 j�), � 7`�O7' CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. — TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 4 •�°•ro^•• Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER jWATER SUPPLIER TO BE COMPLETED BY LABORATORY [11 PUBLIC WATER SYSTEM I.D.# I I I I 1 II A I s shows this Water SAMPLE to be: ® PRIVATE WATER SYSTEM Flaf rkhnic.w( Sei^v,Et,r 3 1� —/35s Name Phone No. !'l53 o Edo J f Mailing Address AnCAo cionp A 99S 1 e City State Zip Code SAMPLE DATE: ! 2 O S 8 9 Mo. Day Year SAMPLE TYPE: 19 Routine N Check Sample (for routine sample with lab ref. no. R 6z0 - 2 ) ❑ Treated Water ❑ Special Purpose ® Untreated Water SAMPLE Time Collected NO. LOCATION Collected By 1 2`1`(1 O'/`TalCr-y R/ 3--(0"" 2 I r. N71 Sec 17 T/ZN� R3i4r 3 4 5 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE nay Satisfactory ❑ Unsatisfactory ❑ Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received Analytical Method: Membrane Filter No. of colonies/100 ml. Lab Ref. No. Result* Analyst I 9- U m U m U m U m BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count Verification: LTB A Og°h Coliform/100mi Final Membrane F•Iter Results Coliform/100ml Reported By Date X;X — Time: ,� a.m. p.m. TNTC = Too Numberous To Count OB = Other Bacteria Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS FOR A SINGLE FAMILY DWELLING Parcel I.D. b I 1 o- W I -19 COSA# DgD5 1. GENERAL INFORMATION Expiration Date: II—al-07 Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address T12N R3W SEC17 N240 S570, W150, E600 2441 O'MALLEY ROAD ' ANCHORAGE AK 99507 LISA & JAMES ACRE Day phone 350-1019 - 2441 O'MALLEY ROAD " ANCHORAGE AK 99507 Day phone GEORGIA STUMBAUGH w/ STEWART TITLE Day phone 274-2562 2601 DENALI ST. • ANCHORAGE AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well 0 Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site 0 Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below,/ verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) 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 riles and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SURE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LID, attempted to provido a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines 8 Regulations. Tho reported results described the performance of the system undor the conditions encountored at the time of the test, and separation distances measured to readily Idonlifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outsido the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do the y guarantee there are no hidden defects or encroachments. GEG, LTD. can therefore not provident any warranty or future estimate of how long the system will continue to meet the operational e ADEC port Is for the sole bereft of the owner irements of listed above, Any reliance uponnOrr use tent fof thithis s report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE _,//' Approved for _3 bedrooms. Disapproved. Phone 337-6179 Date Vu/17 /D:iL 0000aoopp *.:.... . ....... ........ 0� i G •. f r y A..... 0 ness.: � QO°p. CE -7 53 :p 6 app04pf�q,oto, giant, .'tY OFa, Conditional approval for bedrooms, with the flowing stipulations: Attachments: 0-1 i: ON-SITE WATERAND ; rn= WASTEWATER PROGRAM ''etNTSEN�s���\l COSA Checklist Septic System Advisory Arsenic Advisory Well Flow Advisory Maintenance Agreements Nitrate Advisory Supplemental Engineer's Reort Other <:: Original Certificate Dater_ Z (Rev. IV05) Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196850 Anchorage, AK 99519.86W www.muni.org/onsite (907) 343.7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: T12N R3W SEC 17 N240 5570 W150 E600 Parcel ID: O 1 Ce - B 6 I - 12- A. WELL DATA *PER 1989 HAA **SEE ATTACHED INVOICE FROM HARROW PUMP AND WELL SERVICES Well type PIRMATE If A, B, or C provide PWSID# N A Date completed '1968 Sanitary seal (Y/N) YES Total depth 0151 ft. Cased to "51 + R. FROM WELL LOG Wail Log (YIN) NO Wires property protected (YIN) YES Casing height (above ground) 72 in. AT INSPECTION Data of test 1013 y 8/1/2007 Static water level R. 33 ft. Well production N� g.p.m. 2.59 g•p.m. WATER SAMPLE RESULTS: NT) 00 Coliform _ CT{(1_ colonies/100 ml. Nitrate mgA. Other bacteria _a_ colonies/1 mi. Arsenic LS_q ug./L. Date of sample: 7/27/2007 Collected by: GEG Ltd. B. SEPTIC(HOLDING TANK DATA Tank Type/Material HOLDING/STEEL Date installed 11/13/1989 Tank size 3000 gal. Number of Compartments 1 Cleanouts (Y/N) YES Foundation cleanout (YM) YES Depression over tank (YIN) NO High water alarm (Y/N) YES Date of pumping 7/30/2007 Pumper ANCHORAGE CESSPOOL PUMPING C. ABSORPTION FIELD DATA HOLDING TANK Date installed Soil rating (g.p.d./ft or ft'Ibdrm)— System type Length ft. Width ft. Gravel bApe— Total pe ft. Total depth R. Eft. absorption area_ R' Monitorin _ Depression over fteld Date of adequacy test Rea ail) For—bedrooms Fluid depth in absorption fieldbefo — in. Water added —gal. New depth —in. Elapsed Time: Final fluid depth — in. Absorption rate >-9•p•d• venation treatrnent (past 12 mo.) (YIN & type) If yes. 9n• date D. LIFT STATION Date installed "Pump on" level at _in. E. SEPARATION DISTANCES Size in gallons 'Pump off Manhole/Access water alarm level at Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAiR station on lot N/A On adjacent lots 100'+ Absorption field on lot N/A On adjacent lots 100'+ Public sewer main N/A Sewer /septic service line 25'+ Public sewer manhola/deanout - N/A Holding tank 75'+ Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTI OLDIN ANK ON LOT TO: Building foundation 5'+ Property line 50+ Absorption field N/A Water main N/A Water service Ane 10'+ Surface water 100'+ Wells on adjacent lots 75'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: HOLDING TANK Property line Building foundation Water main Water service line Surface wate Driveway, parkingNehicie storage Curta' Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION I ceMly that I have determined through field inspeclions and review of Municipal records that the above systems are in conformance with MOA COSA guidelines In effect on this date. Engineer's Pri ted Name JEFFREY A. GARNESS Date a7-*la2 COSA Fee S LI3 U.V U Date of Paymentf� /% / 7110 7 Receipt Number J `j (Rev. 1 VMS) Waiver Fee Date of Payment Receipt Number Municipality of Anchorage • ^tel Development Services Department Building Safety Division .,. On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.orglonsite (907) 343-7904 Arsenic Advisory Certificate of On -Site Systems Approval 0 070324 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block , Lot of T12N R3W Section 17 N240 S570 W150 E600 Subdivision. This inspection revealed an arsenic concentration of 25.9 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsiLe) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. 3qo l . E. TUDO2 P—f> AAROW PUMP & WER SERVICE, LLC P.O. Box 110496 Anchorage, Alt 99511 Office: (907) 346-9355 - Fax (907) 333-8976 Eagle River: (907) 622-9335 CUSTOMER VQ%1=#9JAM �r L OMWOO E NR 07800 JOB SITE J 1 ICEDATE Itc01 QUANTITY WELL DEPTH SWL CHLORINATED PUMP DEPTH DESCRIPTION SA PERISON PRICE AMOUNT S ri r - / 1 1 1 LABOR HOURS RATE AMOUNT TOTAL MATERIAL �Clc� d TOTAL LABOR WORKORDEREFT DATE COMP. TOTAL LABOR PAY THIS AMOUNT Thank You SIGNATURE (I Hereby Acknowledge the Satisfactory Completion of the Above Described Work and agree that 9 above work Is not paid for In 90 days I agree to allow Aarow Pump & Well Service, L.L.C. the right to remove unpaid for equipment and charge for labor already performed & labor to remove unpaid for equipment.) TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 11.5%. PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS. OrwiI lt}nQ E s m l . Fmd 3/8' rebor Pulled out of prnd 6 _CS M'I FT I U �G N o, U I < o I I o v7 Tract B-2 Green Sub'd I n. (5 0 a w L o_ is I a, l0 L7 I a. NOTES 9 I. Easements of record created after date of filing of record plat are not shown. From Owner supplied plot plan Metes and Bounds Description Tract A Green Sub'd N89055'00'E 150.00'(R) / 3eA 4t w 00 000,Fhy QDp Q �P 3/8' rebar SE From the section corner thence west 600 feet on section line*, thence north 330 feet to the POB, thence east 150 feet; thence north 240 feet; thence west 150 feet, thence south -240 -Ft. to -the POB. 3' 2nd ,P7C Oh t septic System Cleanouts 4' above ground %f o\ �O '7P ® 5WIty LOT Meter 36,258 s.f. 0.8 Acres Tract B-2 Green Sub'd P,F OFAt4%14 %*�49�5*' �c ROBERT T. KERN / �},'•, Nu Boa -s ,: � '41o�'•••......•'wo \ \ �`EsSIONM- ,.4, Ilk Itis...•. SURVEYOR'S CERTIFICATE I HEREBY CER77FY THAT I HAVE SURVEYED THE PROPERTY AND FACIU77ES DESCRIBED HEREON AND THAT THE IMPROVEMENTS AND VISIBLE ENCROACHMENTS SITUATED THEREON DO NOT ENCROACH ON ADJACENT PROPERTY. THAT IMPROVEMENTS ON ADJACENT PROPERTY DO NOT ENCROACH ON THE SURVEYED PREMISES AND THAT THERE ARE NO OTHER VISIBLE EASEMENTS OR RIGHTS—OF—WAY, EXCEPT AS SHOWN HEREON. ROBERT T. KEAN, R.L.S. J94J—S DATE EXCLUSIONS NO DATA HEREON SHOULD BE USED FOR POS1770NINC ADD177ONAL STRUCTURES, FOR BUILDING FENCES OR FOR LOCA77NC BOUNDARY LINES. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENT OR RESTRIC77ON THAT DOES NOT APPEAR ON THE RECORDED SUBDIVISION PLAT AND TO VERIFY THAT ALL IMPROVEMENTS MEET ALL SUBDIVISION COVENANTS AND ZONING ORDINANCES. N240' of Fmd 3/8' rebar Food condition 9.2'x8.4' Wooden Shed on Blocks N A O 0� A Fmd 3/8' rebar Flush with prnd. LEGEND Tract B-2 Green Sub'd — — EASEMENT LINE - FOUND 5/8' REBAR ® WELL LOCA17ON •na POWER POLE —P— OVERHEAD POWER LINE FENCE As -Built S570' of W150' of Section 17 of E600' (Per MOA Property Appraisal Div.) LOCATED WITHIN THE SECTION 17, T12N, R3W, S.M., AK ANCHORAGE RECORDING DISTRICT PREPARED FOR: ISCALE: ISURVEY DATE: James Agre 2441 O'Malley Road Anchorage. Alaska 99309 PREPARED BY: 1" = 40' DATE 08/03/07 W.O./F.B. W07112 KEAN & ASSOCIATES CHECKED BY: GRID: 8827 Old Seward Hwy /101 Anchorage, Alaska 9931e RTK SW2533 v 0 a 3 v X I N r O Q U Q 0 .o N O >. 2 0 E 0 0 Q N n N 0 n O 0 t` O O N .11 MUNICIPALITY OF ANCHORAGE • T Department of Health & Human Services - DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # 016-061-12 HAA# HA890497 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) T12N R3W Section 17 Tract Negative Location (address or directions) 2441 O'Malley Road (b) Property owner Richard Gunther Telephone: (home) 344-8855 Business Mailing Address 2441 O'Malley Road Anchoraget AnchorageAlaska 99516 (c) Lending Institution (owner finance) Telephone Mailing Address (d) Real Estate Company and Agent Esther Bum ardner Address 5740 East 172nd Avenue Anchorage, Alaska 99516 Telephone 345-10 (e) Mail the HAA to the following address: (or check here ❑, if hold for pick up.) List contact person and day phone number below: Moore - 345-1 2. TYPE OF RESIDENCE Single-FamilyKP�c Number of bedrooms three (3) 3. WATER SUPPLY Individual Well 13x Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ❑ Public ❑ Community ❑ Holding Tank ax Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1. of 2 5. 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 Ted Moore, P.E. Flatto Address 14530 Echo Street, Anchor Date Teci)%jWfi e4ervices , Alaska 99516 345-1355 Engineer's Seal 6. DHHS APPROVAL hree �1�"�� July 27, 1990 Approved forDate t—�drooms by Approved XXXXXX Disapproved Conditional Terms of Conditional Approval This department has received written confirmation from the engineer Flattop Technical Services, that the Conditional Approval of 12-14-89 has been completed and now meets with Municipal codes. This property is now approved. The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 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 not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 CIVIL & ENVIRONMENTAL ENGINEERING • ENERGY CONSERVATION & ANALYSIS THEODORE F. MOORE, P.E. PH: (907) 345-1355 Susan Oswalt M.O.A. DHHS P.O. Boz 19-6650 Anchorage, AK 99519 Dear Ms. Oswalt, J my 23, 1990 14530 ECHO ST. ANCHORAGE, ALASKA 99516 MUNICIPALITY OF ANCHORA(A DEPT. OF HEALTH & ENVIRONMENTAL PROTECTIOII Wt 2 31,990 RECEIVED Per your request I have reinspected the final grading over the holding tank on Tract Negative, Section 17, T12N, R3W, and am able to inform you that the necessary grading work has now been done and there is no longer any depression over the holding tank. Sincerely, Ted Moore, P.E. MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services y r DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # Cmn - Hila l - 1- - HAA # t,1� RlIA 91 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) i ra cf A(c czfi �z St c f-ron /7 T/ Z N R a w Location (address or directions) / 0, (-t•al/ev Ra< (b) Property owner (etictrcQ Gc<n d er Telephone: (home) 3yy-965S Business Mailing Address 2Yy/ O /-ta11-e 9,96-/C (c) Lending Institution Al, A (Gwncr finance Telephone Mailing Address (d) Real Estate Company and Agent ES -�'er- 0",) 6urd'?e'- Address S7 to t 7 2/4-ve / /Ic-60 . z e f%k 995 �6 Telephone (e) Mail the HAA to the following address: (or check here ®, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single -Family CS Number of -bedrooms — 3. WATER SUPPLY Individual Well 9 Community ❑ Public ❑ Note: if community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ❑ Public ❑ Community ❑ Holding Tank I!W Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 Z to Z a6ed PPO (eea Aee) ezo-zL ->IaoM s,aaau!6ue leuo!ssaloid agl ui suo!ss!wo ao saoaaa aol alq!suodsaa lou si 96eaogouy to Al!ied!o!unyy agl'panss! si aleo!lpiso a aaolaq elep azAleue ao suo!loodsui lonpuoo lou op SHHQ to saaAoldw3 'sluawaa!nbei alels pug leaapal u!eliao Als!les olaapio ui suo!lnl!lsui bu!pual a!agl pue sawoq to saasegoind of lsolinoo a se s!ql saop SHHd agl 'e>!sely to 91e1S aql ul 109aals16aa aaau!6ue leuo!ssaloid luapuadapu! ug Aq anoge 9 yde.ifted u! UGA16 suo!leluasaidaa eq; uodn Aluo paseq poleo!l!aao Ienoaddy Al!aoglny glleaH sonss! (SHHa) sao!AJOS uewnH pug gl!eOH to luawliedad a6eaogouy to Al!led!o!unW aql / '} lenoaddy Ieuo!l!puoO to swaal leuo!l!puoO panoaddes!Q panoaddy aleQ aV fq swooapa �- - cyl Aol pertea dy � ldAOaddV SHHQ '9 ®gym NaTA'% t4 • 0 U; 3 IeaS s,aaau!6u • :3JCCl'i6E�£ 'j ?NCQWHl •• � �.... o... •.,... P Of ©.. •.......... •........... ot Ae' • 4r C✓ z 1 '�'4 68 6l L 2 r' alga I s66 �l d mJOy� 7�S o y�� O�Sh J ssaaPP`d auogda!al �»��as ����vyoa� `:ff 29)_—j wa!A to aweN -uo!loadsui s!ql to alep aql uo loalla ui suo!leln6ai pue 'seoueu!pio 'sapoo alglS pug Ied!ownVI Ile gl!M eoue!!dwoo ui s! walsAs !esods!p aaleMalseM ao/pue AIddns aaleM al!s-uo agl 'uo!loodsu! pue uo!le611sanu1 AW woal pug sol!l a6eaogouy to Aj!Ied!o!unyj aql woal pau!elgo uo!lewaolul eql uo paseq legl tl!JOA aaglanl I •u!aaaq paleo!pui ainlonils to adAl pug swooapaq to aagwnu agl jol alenbape pug leuo!lounl 'ales si welsAs lesods!p aaleMalseM jo/pue Alddns aaleM al!s-uo aql legl smogs Ienoaddy Al!aoglny glleaH s!ql to u01le61lsanu! Aw legl Al!aaA I 'Moleq uMogs alep uo!lep!IeA aglto se pue olaaag pax!lle leas Aw Aq pa!lpiao sy N0I1VWa0:INI aNV dlt/a `HOUV3S 3'114 `S1S31 `SN01.L03dSN1 ONIOIAOUd WHId ONId33NION3 '9 r Jai\C.iiQ��l-\C IIGIpP JIc`S �y(1(VlPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343 4744 Legal Description: %c Cf- Alen. Se r f ryn ! 7 r 12 At, R 3 cv A. WELL DATA Well Classification Pr("°c If A, B, C, D.E.C. Approved (Y/N) 1Y, Well Log Present jY/N) N Date Completed 1968 der ocvner Yield > 2,0 M rne� /1/z 1/69 per a Afr- - Total Depths ' Cased to rs"' Depth of Grouting All A. Static Water Level Su Casing Height Above Ground 12" Electrical Wiring in Conduit (Y/N) i SEPARATION DISTANCES FROM WELL: Pump Set At (,in 6r. �:=- 6y/ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) M To eke/Holding Tank on Lot SS, �V C' 0. ; On Adjoining Lots* > 160 To Nearest Edge of Absorption Field on Lot N, A • ; On Adjoining Lots > 100 ` To Nearest Public Sewer Line N, A• To Nearest Public Sewer Cleanout/Manhole Ai, A • To Nearest Sewer Service Line on Lot > 2•s. ` Water Sample Collected by T F1.7 ; Date 1(/ 2-1 /69 12• Sahs'�acymrr - Ocok rin or o /3• non-odefec1V'Qe 'nfit�is. Water Sample Test Results orrytnar sc�e hue -r TiYrc o ray .en well 11M Comments * shacl-c or Sinaf/ (o/- M soc'A once harms CA cuelr d- cf- r�xso' huf ne(N+er hal h2en yune¢eonal _4:cir peter O yirr. A sXet1locv eLgirecrion n,gtb( Corr er ogoft,n Fs fAe cx1i4?ePon� cess cx�/ it /o caA��E 9�` froom, f�ir�Pl/, B. SEPTIC/HOLDING TANK DATA N(ecu Fell CQr-Weor on f Ais (cvf naf connrc A-e� rny(o sF as r� � sm, weir hSI-ee( la A- ce,tlo-lecl c7 An t M12. well s er�y Kt�+ �mse , Date Installed H / 13/81P Size :aeNo. of Compartments Standpipes (Y/N) 1' Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Y Depression over Tank (Y/N)y`. Date Last Pumped Al, A. (neW ) Pumping/Maintenance Contact on File (Y/N) G(n !c for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well &-S" r•51To Building Foundation To Property Line > 10 1 To Disposal Field To Water Main/Service Line > 2S' To Stream, Pond, Lake or Major Drainage Course coo 32, N, Y Comments �anlr bactcF+lly� wr/� �ar/i41/cr frozen sol/ - mil/ seffle r"vre ext if yAaws Sel(et- haf .nacre arrrq!?%ewr &?f f -o hawe_ ercazux{er ,,-ed 4-fnu1 r«ofrnf s°e4rnmfr '90 72-026 (Rev. 7188) Front Page 1 of.2 C. ABSORPTION FIELD DATA AI- A Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Ta,7 (rJ Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present(Y/N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well To Building Foundation Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Property Line On Adjoining Lots To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION /V, A. Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments To Existing or Abandoned System on To Cutback (if present) Dimensions Manhole/Access (Y/N) "Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection./ ���s,vsagVA Signed J/�ea(�e %hew c <0� OF° A4,1 �b Company Flat -1011 Tecti.i ecur S'U qr �, ,ti • /i.To-i-�Engineer's Seal Date Nom 27 /989. 12-/IZ/6% s+...°........°...°.°°°°...°. MOA No. 69 ® :•THEODORE F. 'ADORE Receipt No.� Receipt No.'a'e�ef��®� Date of Payment �7�� �! / Waiver Fee: $ Amount: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2