HomeMy WebLinkAboutT12N R3W SEC 15 LT 67A MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 hftp://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP251119 Work Type: Septic Upgrade Tax Code Number: 01505303000 Site Legal Address: T12N R3W SEC 15 LT 67A G:2436 Site Mailing Address: 9601 CARLSON RD, Anchorage Owner: ALASKA SEWELL 2017 TRUST Design Engineer: FIRST WATER CONSULTING This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 5/9/2025 5/9/2026 37890 0 Disposal Field Z Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall 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 (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day; or b. Covered, sealed, and heated to prevent freezing Received By: L4=' C Date: Issued By: Date: `' 4 Septic Tank Holding Tank Privy Well MUNICIPALITY OF Development Services Department On -Site Water & Wastewater Section � ct__ ON -SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 015-053703 Property owner(s) ALASKA SEWELL 2017 TRUST Day phone Mailing address 9601 CARLSON ROAD ANCHORAGE, ALASKA 99507 Site address 9601 CARLSON ROAD ANCHORAGE, ALASKA 99507 Legal description T12N R3W SEC 15 LOT 67A Number of Bedrooms 4 Engineering Firm FIRST WATER CONSTULTING Building Permit Number APPLICATION IS FOR: (Z all that apply) Absorption Field El X] r_1 El F� Not Applicable F-01 APPLICATION IS AN: Initial 0 Upgrade Renewal ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Permit/Rush Fees: I K Date of Payment: I Z Z' 5-Z Permit No. OF 2 Mq Waiver Fees: Date of Payment: Waiver No. Phone: 907-343-7904 Distance: 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / firstwaterAK@gmail.com ! !! April 28, 2025 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC SYSTEM UPGRADE PERMIT LEGAL: T12N R3W SECTION 15 LOT 67A The property owner has requested we obtain a permit to upgrade the failed septic system of the above referenced lot. We propose to install one deep trench and 1 500-gallon HDPE deep-burial STEP tank to serve the existing 4-bedroom residence. The design is based on the recent test hole conducted on April 16, 2025. No groundwater was observed at test hole excavation or monitoring. The slopes are flat at the proposed upgrade location. The fence in this location and an existing shed is to be moved prior to construction. This is a very tight area with separation challenges and the easement, property lines, etc…must be staked by a professional surveyor prior to construction. There is also a storage/utility extension attached to the house that is on a concrete slab with no foundation as noted on the design and 5’ separation is to be maintained. The lot and area are served by private water. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251119, Curtis Townsend, 05/09/25 30 . 3 ' 36.9'5. 9 ' 1.0' 18 . 0 ' 54.3'8.2'13.0' 9. 8 ' 6.9' 20 . 3 ' 36.3' 4.1'49.8' 6" PIPE SHED SHED 4BR RESIDENCE GENERATOR EL E C . GAS FE N C E FIRST WATER CONSULTING T12N R3W SEC 15 LOT 67A DESIGN CALCS: NO SLOPES >25% WITHIN 50' OR PRIVATE WELLS W/IN 100' OF PROPOSED SEPTIC SYSTEM. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251119, Curtis Townsend, 05/09/25 30 .3 ' 36.9'5. 9 ' 1.0' 18. 0 ' 54.3'8. 2 ' 13.0' 9. 8 ' 6.9' 20 .3 ' 36.3' 4. 1 '49.8' 6" PIPE SHED SHED 4BR RESIDENCE GENERATOR EL E C . GAS FE NC E FIRST WATER CONSULTING NO WELLS WITHIN 100' OF PROPOSED SEPTIC TANK OR EXISTING FIELDS. DESIGN DETAILS: T12N R3W SEC 15 LOT 67A Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251119, Curtis Townsend, 05/09/25 13030 Sues Way - Anchorage, Alaska 99516 Tel. 907-350-9566 firstwaterAK@gmail.com SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: T12N R3W SEC 15 LOT 67A PERFORMED BY: FWCS / FWC - I CURTIS HUFFMAN CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE & MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. 04/24/2025 DEPTH FEET OG SOILS 1 ORG/OL 2 3 4 5 6 7 8 GM/sp 9 10 11 12 13 14 15 16 17 18 19 20 BOH Reading Date Gross Time Net Time Depth to Water Net Drop 4/24/2025 30 min 6” 2 13/16” 30 min 6” 2 14/16” 30 min 6” 2 14/16” PERCOLATION RATE 11 (MIN / INCH) TEST RUN BEWTWEEN 6 & 7 FT PERC HOLE DIAMETER 6” PRE-SOAKED PRIOR TO TEST & ALL READINGS TO THE 1/16TH. GROUND WATER ENCOUNTERED: NO IF YES, AT WHAT DEPTH: NA DEPTH TO WATER AT MONITORING: DRY DATE: 4/24/2025 TESTHOLE # 25-1 DATE PERFORMED: 4/16/2025 SEE SITE PLAN FOR SLOPE & LOCATION COMMENTS: VERIFY GROUNDWATER MT AT TIME OF CONSTRUCTION PERFORMED FOR: BRAD SEWELL 04/24/25 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251119, Curtis Townsend, 05/09/25 30.3' 36.9'5.9' 1.0' 18.0' 54.3'8.2'13.0' 9.8' 6.9' 20.3' 36.3' 4.1'49.8' 6" PIPE SHED SHED SHED RESIDENCE GENERATOR ELEC. GAS LEGEND FOUND 5/8" REBAR, 2" ALUM. CAP EDGE OF GRAVEL DRIVEWAY/PAD UTILITY PEDESTAL DECK FENCE OVERHEAD UTILITIES POWER POLE EDGE OF ASPHALT RECORD DATA PER PLAT #78-283 4" PLASTIC PIPE WELL TIMBERLINE SURVEYING AND MAPPING 17035 BARONOFF AVE EAGLE RIVER, AK 99577 907-242-5320 ryan@timberlinealaska.com FILE NO.: 25.055 SCALE: 1" = 30 FEET DATE: 3/31/2025 SHEET: 1 of 1 MOA GRID: SW2436 SCALE: 1" = 30 FEET(11"x17") 30'0' 60' AS-BUILT OF: ADDRESS: 9601 CARLSON RD, ANCHORAGE, AK LOCATED IN: ANCHORAGE RECORDING DISTRICT LOT 67A, SECTION 15T12N, R3W, S.M.PLAT #78-283 Municipality of Anchorage Page / of ~- DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL, SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 e Telephone: 343-4744 (;)n-Site Wastewater Disposal System and/or Well Inspection Report Name: Wastewater System: B New ~ Upgrade Address: ~¢0~ ~A~¢'~. ~9~/~ ABSORPTION FIELD Phone: No. of Bedrooms: ~..~¢~ ~; ~DeepTrench. ~ Shallow Trench ~Bed ~Mound ~Other LEGAL DESCRIPTION Sol, Rating: Total Depth from original grade: Lot:~ Block: Subdiv~ion: Depth to pipe bottom from original grade: Grave] depth beneath pipe Township:~]Range:~] Secti~ Fil, added above original grade: Gravel [ength: WELL: ~ New ~ Upg~ Gravel width:~ t Ft. Number of lines:~ ~ Distance belween lines:~ Ft. Classification (Private, A,B,C): Tot ~1.~: ¢ eased To: Totat absorption area: Pipe material; ~'~ GPM PumpSetat: Ft. CasingHe,ghtAboveGrou;~ TANK SEPARATION DISTANCES ~Septic U Holding ~ S.T.E.P. To Seplic Absorption Lilt Holding Public/PrivateManufacturer: Capscity in gallons: From Tank Fietd Stsfion Tank Sewer Lines Material: Number of Compadments: s~ LIFT STATION ~ I ~ "Pump on" level at: ~ level at: I High water alarm at: Foundation 1 Remarks: ~¢A~¢ '~ ~'~. ,, BENCH MARK ENGINEER'S SEAL Department of Health and Human Services approval Reviewed and approved by: ~- ~' Date: //'b -q~ 72-013 (Rev. 9/91) MOA 25 Perml~ No, SW970874 P,IJ], No, AS- UILT WASTE~/ATER ABSORPTION SYSTEM Lot 67A, S15, T12N, R3W TH1 DESIGN, .............................................................................................................................................................. f ~'c. -~ l]r~wlmg C,\Work\67A$15,I)WG This Upgr o. de PREPARED FOR, Brad & Susan Sewell 9601 Carlson Road Anchorage, Al( 99516 (907) 777-6606 Pannone EnO, Svc:, P, O, 3OX 148085 ANCHORAGE, ALASKA 99514 878-8818, PHI]NE & FAX qTD' 10--m-97 i ] AS-BUILT gALE, 1'=50' I Soils= 125 s?/br 5 B[:olroo~ House 650 SF Rqcl, 504 SF Exist, AS-BUILT~ 3,5' Eggective 8' Tot~[ Depth 3' ~/Ide, 30' LonQ Ne~ Absorption = 810 sC ota~ Absorption = 714 sC = 1,14 MIn/Inch AS-]~UILT gETAILS A:BSBRPT~ON SYSTEM S15, T1PN, R3W '~ TH1 ', T2 15,7 37,8 [!~,'~'~ "" 36,~ E~ 83,0 30,0 E3 42,6 42,4 E4 42,5 5~,0 CS 11,2 44,4 C4 40.1 50,0 MT 2~,4 45~7 F- 3,5 IJJ ~nn Drawing C~\Work\87AS15,l]~/G 1AD N¥3-13 J d PREPARED FORI Anchor~§e, AK 99516 (907) 777-6606 Pcnnone Eno, Svc, P, 0, BOX 142085 ANCHORAGE, ALASKA 99514 878-8818, PHONE & FAX DATEI 10-31-97 NOT TO SCALE AS-BUILT Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 82,5 "L' Street, Anchorage, AJaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 3 4 5 6 7 8- 12.- ~7 ~8 20 COMMENTS . SLOPE DATE P~'F( Township, Range, Section: ~'~ ~:~ SITE PLAN WAS GROUND WATER ENCOUNTERED? //~) C) S L IF YES, AT WHAT ._ O DEPTH? p Depth lo Water Alter Monitoring? -t~Q"~' Date: IO/t,~.~ Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE t. I /~ (m,nutes/,nch) PERC HOLE DIAMETER TEST RUN BETWEEN ~:~ _ FT AND ~ FT PERFORMED BY: S.~"~:)~ ~'~'~. ~- , I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE: /~///~/'¢::~ ~ 72-008 (Rev. 4/85) ]PAGE 1 OF MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW970274 DESIGN ENGINEER:STEVEN R. PANNONE OWNER Nf~ME:SPOHNHOLZ CLIFFORD W & MARY A OWNER ADDRESS:9601 CARLSON RD ANCHORAGE, ALASKA 99516 DATE ISSUED: 8/26/97 EXPIRATION DATE: 8/26/98 PARCEL ID:01505303 LEGAL DESCRIPTION: T12N R3W SEC 15 LT 67A LOT SIZE: 37890 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: 2 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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 (182LAC72) AND DRINKING WATER REGULATIONS (iSAAC80) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 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. \o-\ SPECIAL PROVISIONS: AT THE TIME OF CONSTURCTION ENGINEER SHALL PERFORM 7 DAY GROUND WATER MONITORING TO A MINIMUM OF 14 FEET DEEP AND SUBMIT IT WITH THE AS-BUILT INSPECTION REPORT. RECEIVED BY:~~ -- ISSUED BY: D TE : Steven R. Pannone, P.E. Consulting Engh]¢¢r (907) 272-8218 P.O. Box 142025 Anchorage, Alaska, 99514 (907)272-8218 Fax July 25, 1997 Municipality of Anchorage Dept. of Health & Human Services On-Site Services Section P. O. Box 196650 Anchorage, Alaska 99519 Subject: Lot 67A, S15, T12N, R3W Septic Upgrade Permit Gentlemen: My finn conducted a Health Authority Investigation on the referenced lot in Ma>, of this year. At that time, the system was determined to be adequate for a three bedromn house. The new owners would like to upgrade the system to five bedrooms. Attached is the proposed design to upgrade the system. The upgrade will be attached to the existing system, and is located inside a testhole excavated in 1993 by Ted Moore. No groundwater or bedrock was encountered in the test hole excavated in 1993~ The lot is approximately 0.86 acres in size. Lot 67A slopes to the west at a rate of approximately I to 2 percent. The proposed installation will be located between the existing system and the east lot line. A new 500 gallon septic tank will be installed between the existing tank and the existing leach field. The existing 1,000 g septic tank was installed in 1993, but will be verified during the installation. It will be reused if found competent, and replaced with a new 1500 gallon tank outside the well radius if found to be deteriorated. Double clean-outs will be installed down stream from the tank and between the P, vo tanks. Tile proposed location is greater than 100 feet away from the existing well serving this property and 25 feet from the water service lines. The surrounding wells are located greater than 100 feet from the proposed installation. The proposed installation will not affect the filtm'e development of the surrounding or existing lots. See the attached design. If you have any questions about the proposed installation, please contact me at 272-8218 Sincerely, Attachments: C:\WORK\67AS [ 5.001 ~lp~wlng Z PREPARED FOR, Brad ~ Susan SeweLl 9631 Carlson Road AnchoraQe, AK 99516 (907) 777-6606 Pannone EnO, Svc, P, D, BOX 142025 ANCHORAGE, ALASKA 99514 272-8218, PHONE & FAX ~TE' 7-84-97 ] NOT TO SCAI E DESIGN Municipality of Anchorage 'Page I of 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: __..~ ~v' f130 IlS' PID Number: O I._qO,E 30 ~ Name: · TA~ ~ Upgrade b SPoil N HoL% Wastewater System: D ~ewoNLy CLIFFO~ Address: q¢ol CA~L~o~ RoAb, ~NC~ ~K qqSoq ABSORPTION FIELD Phone3Z~" iS~} [NoolB~lrooms: ['] Deop Trench ~ Shallow Trench [3Bed ~Mound ~Other LEGAL DESCRIPTION ~°" '~'i"": Total Depth Item original grade: GPD/Sq FI Lot: /- ~ A Block: Subdivimon: Deplh Io p~po botlom Item original grad0: Gravel depth beneath pipe Ft WEI. L:~vi51~ D New ~ Upgrade Gravelwidth; Numboroflines: O[slancebetweeMines: ~, dLPINE ENT~RP¢iSES ~/t/q3 TAN~ Yield: I Pump Sel al: I Casing Helghl Above GPMI FiI ~, TAN K SEPARATION DISTANCES ~Soptic ~ Holding D S.T.E.P. Iooo '12Ot ~T[E~ We[[ w~ >1oo LIFT S'rATION Line I Remarks: ~e~c M~ ~ I~ ]~ll¢~ BENCH MARK Ioy ~ p~ ~,~r,~.t~ ~ ~ ..... Ioo.o .r~, ~ I~/~S ~¢C¢~ ¢' ¢t~ g~/ , ENGINEER'S SEAL / / Mspsctions performed by: gZgZ'ToP TEC~ ~C5 _ Dates: lsL ~/I ~e 2nd __ ~~ ~ Department of He Huma S approval (~ ,. ,,~:¢,:o~ }:. ,.,,oo,~,.. ~' ~. CE-358.2 Reviewed and approved ate: ~ ~,.'4S,.' ........ " PermitNo. 5%¢' q30115- Page "~ of ~ Municipality of Anchorage DEPARTMENT OF HI-'ALTH AND HUNIAN 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 Legal Description: ~O% 6'7 A ,SEC IS- T izN, F'.%~' PIDNo.: 015'0,5'3o3' oR, I 6. Poo~ '~ b./EL L LoT 70 'To C.o..1~ I CoRNERs B /~LL boCA T 19.N ~ Flattop Technical Serv~.ces 14530 Echo Street Anchorage, AIaska 99~ LoT &8 NE[,,/ lO00 6AL ~E'i::'T JC ENGINEER'S SEAL CE . 3589 ,' ',,, ,,,' Permit No, ~h/ 93© I1~- Page 3 of 3 Municipality of Anchorage 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 Legal Description: LoT PID No.: f qS' No I~RIzoNTAL. SCALE ENGINEER'S SEAL ..~.~.,.~.... ,. ·., ~, ~,,%. 72-013 A [Rev 9/91) MOA 25 PERFORMED FOR: ~Idto~5 Techn{ca] Services 14530 Echo Street DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOIL8 LOG -- PERCOLATION TEST CLIffFORb SPoHNHoL~. ~%', CE-3589 % DATE PERFORMED: ~ Il 193 LEGAL DESCRIPTION:j:~L I~ 1 PT' 2 3 5 6- 8 9- 13 '~ 14- 15 16 17 18 19 20 COMMENTS CLEAN, FiNE ¢~IND Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? NO 0: s IF YES, AT WFIAT OL DEPTH? p E Daplh lo Waler After Mogilorino? Dale: __ /K, T/2/V, SITE PLAN Reading Date Gross Net Depth to Net Time Time (H,N~) Water Drop~ ~ '~ ~3 lb ~6:32 0.~ 2o ~ 2 5~ PERCOLATION RATE ~ (minuteshnch) PERC HOLE DIAMETER TEST RUN BETWEEN '~.e _ FT AND ~,~'~ FT PERFORMED BY: fi?/dI~OP TECH SI/C5 _ i ,~".~_~ ~O-e~<~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECI ON THIS DATE. DATE: 72~008 (Rev, 4/85} PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW930115 DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES OWNER NAME:SPOHNHOLZ CLIFFORD W & OWNER ADDRESS:9601 CARLSON RD ANCHORAGE AK 99507-4325 DATE ISSUED: 5/21/93 EXPIRATION DATE: 5/21/94 PARCEL ID:01505303 LEGAL DESCRIPTION: T12N R3W SEC 15 LT 67A LOT SIZE: 37890 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: SEPTIC TANK 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: SOIL AND PERCOLATION TEST MUST BE PERFORMED TO CONFIRM LOCATION OF REPLACEMENT SITE LARGE ENOUGH FOR A 3 BEDROOM SYSTEM. RESULTS FROM TESTMUST BE PROVIDED WITH AS-BUILT INSPECTION REPORT~ , -- ISSUED BY: ~j6[~ ~ m~ DATE DATE: L.&T ~80' ~oT p~r~ 70 /_o7' PAoPoX~ ccp~.r~Ap~ ~¢tI~ Technlecd Services 14530 Echo Street Anchorc~ge, Alc~skc~ IDA-T~ .' S' /93 Municipality of Anchorage Page DEPARTMENT OF IqFALTH 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: 12~, ~: PID Number: (-~]~/~ - (~'~ -~ _ CLIFFOR~ 5Po. HN UOL% Wastewater System: D New ~Upgrade Address: %o~ ca¢~so~ ~oab , 2~4, 41~ ¢~z0~ ABSORPTION FIELD Pho~:~. /~ ' INo el B~room7 fiJ Deep Trench ~*F* Tg~/*~P ~ShallowTr nch OBed OMound Other Soil Rating: ~, Iq~ Total grade: LEGAL DESCRIPTION , ¢ ~E~ ~ OepU¢irom original 200 "/~P~h ~,,s~ 9,~ / Lot Block: Subdivisiom Depth [o pipe bol~om from original 9¢ade: Gr~vel deptb beneath pipe 1 ownship: [ Range I Secbon Flit added above original grade: Gravel lenglh: SEPARATI ON DISTANCES ~:; Sol)tic t! Holding E; Sl.E P Well ~2o~ wa,~, >¢oo' LIFT STATION Line Dram Remarks: PE~Fo~b 'T~H~ U~Ab~ BENCH MAR~H,A-. ENGINEER'S SEAL nspections performed by":: ~, - _ ..... ~rt~ates: 1st ..... Anchorage, Al~sl(.~ 9ghee Department of Health and Human Services approvalv .~,,~o~cr~ Reviewed and approved by: gO.. ~ Date: [//r/~ ~ ~'~":'~, .~/ ........ . ,..~,,* ~%"?, ..~ __ ' Permit No. ___~/~ Page ~ __ of ~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O, Box 196650 · Anchora§e, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: ~L~o-r- 6'7 /I · 6E¢ IS'~_.~J'zN~.~k/ PID No.: LOT V/ELL .LOT ~8 5£PTic SEPI',C S¥Sl-g. tq NOTE: Tfhs Is NoT Ague' YlP?Ro×iMA'r E, Flattop Technfcal Services 14530 Echo Street Anchorage, Alaska OP TE@HNI:CAL , CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVA~ON & ANALYSIS THEODORE F. MOORE, P.E. 14530 ECHO ST. PH: (907) 345-1355 October 15, i992 ANCHORAGE, ALASKA 99516 John Snfith M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 Dear Mr. Smith: The purpose of this letter is to provide a description of the adequacy test and related measm'ements we made per your suggestion in order to document the previously undocumented upgrade to the wastewater disposal system serving the residence of Clifford Spohnholz on Lot 67A, Section 15, TI2N, R3W, S.M. On the basis of our field measurements, we have filled out the enclosed On-Site Wastewater Disposal System Inspection Report, insofm' as possible. To assist in your review and evaluation, we are also enclosing a copy of our adequacy test data sheet and copies of relevant backup documents describing the construction of the original two-bedroom system. According to documents on file at DHHS the original two-bedroom wastewater disposal system was installed in July of 1975 and consists of a 1000 gallon Gmer septic tank followed by 38 lineal feet of soil absorption trench containing 9 feet of sewer gravel. The soil rating used in the design was 200 square feet per bedroom, and the original trench has a reported absorption area of 504 squm'e feet, so it was actually sized for 2.5 bedrooms. According to Mr. Spobnholz, backed up by a September 1992 letter from Ken Ellsworth, an undocumented seepage pit upgrade to this system was installed in September of 1979. This upgrade consisted of a 900 gallon perforated steel tank bedded in an unknown quantity of sewer rock. Our enclosed inspection report shows the location of both the original mid the upgrade to the system, and all parameters that were measurable at this time. The total depth of the upgrade is 9.5 feet, which is less than that of the original system and greater than 4 feet above any known water table. The seepage pit upgrade is configured to operate in series after the original n'ench is completely full. To assess the adequacy of the both portions of the system, on October 12 we added a total of 1200 gallons of water to it, while monitoring fluid levels in both po~xions of the soil absorption system as well as in the septic tank. The house was occupied at the time of our test, and the septic tank had been pumped by Roto Rooter on October 6, so was only half full. The original ~rench accepted 700 gallons of water without any measurable rise in the fluid level in the sump which was several feet below the level of the horizontal distribution pipe. We then switched the hose to add another 500 gallons of water directly into the upgrade seepage pit. This seepage pit was initially dry, and the addition of this much water caused the water level to build up to a maximum depth of 12.25". After the flow of water was stopped, the fluid level in this seepage pit alone receded at a more than adequate rate for a 3 bedroom residence. Based on our inspections anti test data, I believe that the existing system can safely be approved for a three be<h'oom residence without concern as to imminent failure or potential contamioation of drinking water sources. Please feel fi'ee to give me a call if you have any questions on this report. Sincerely, Ted Moore, P.E. cc: Clifford Spohnholz GREI .R ANCHORAGE AREA BOR SH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM · /, - PHONE LOCATION LEGAL DESCRIPTION SEPTIC TANK: DISTANCE , ~ ~,~.._ NUMBER OF j FROM WELL /¢O*~- MANUFACTURER ~/-'/_"~-'~'_t~-~ MATERIAL ~'/. COMPARTMENTS INSIDE WIDTH LIQUID DEPTH INSIDE LENGTH LIQUID CAPACITY_~g}¢ GALLONS. TILE DRAIN FIELD: DISTANCE FROM WELL ¢/~f~f'¢- FOUNDATION /~__1¢~ NEAREST LOT LINE /~i~C TOTALOF LINES LENGTH___~g/ NUMBER OF LINES__/ DISTANCE BETWEEN LINES ~_/,J~ TRENCH WIDTH $~*IN. TOTAL EFFECTIVE ABSORPTION AREA___',~O ~/ SQ. Fl'. LENGTH OF EACN LINE DEPTH: TOP OF TILE TO FINISH GRADE ~'~ / DEPTN OF FILTER _ MATERIAL BENEATH TILE ~ I~ABOVE TILE ~"/ __IN, WELL: TYPE ~:1//4¢.~2, DEPTH AREST N~ // BUILDING NE ~§EPTIC SEEPAGE FOUNDATION____ LOT LINE __, SEWER [~%~ANK __ SYSTEM ' ~ ' CESSPOOL .... OTliE R SOURCES APPROVED DISAPPROVED REMARKS __DISTANCE FROM: DISTANCES: INSTALLED BY: SEWER LINE DEPTN: ......... PIPE MAT E R I AL: .~,-..~--~/~ LOT SLOPE: REMARKS: Form LQ-032 DIAGRAM OF SYSTEM G.A,A.B. ~ GRE/ ER ANCHORAGE AREA BOP UGH SE~A~c~S~EM -- APPLICATION AND pERMIT NAME OF APPLICANT ~/'- /~':'~'~2/?/~ ~'--~' ~) ~ '~._~/b~/~ L ~ MAILING ADDRESS iNSTALLATION OF: :3 qV- ~ VT.L-~ SEPTIC TANK SEEPAGE PIT ., DRAIN FIELD , OTHER TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH SOIL TEST RESULTS COMPLETION DATE ANTIC[PATE/~ FINAL INSPECTION: 24 FLOUR NOTICE REQUIRED, BACKFILLING OF ANY SYSTEM WITNOUT FINAL INSPECTION BY THE BEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE TYPE SEEPAGE AREA SIZE ~ TYPE / / 0~0 ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK DRAIN FIELD SEPTIC TANK, .~-~/~ --, SEEPAGE Pit SEEPAGE PIT , DRAIN FIELD_ 4 INCH DIAMETE~ CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. DIAGRAM OF SYBTEM I CERTIFY THAT I AM FA~41LIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO 28-68 AND THAT THE ABOVE ACCORDANC~ w,T, SA,D COOE. ../1// /~(~ X ~ m e GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMEI~ITAL QUALITY 3330 "C" STREET ANCHORAGE, AL/~,SKA 09503 TELEPHONE 274-4§61 SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT PERMIT NO TYPE AND SIZE OF FACILITY tO be SERVED FINANCED THROUGH TO BE INSTALLED BY OTHER NOTE: THl~ PERMIT ]5 NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 NOUR NOTICE REQUIRED. BACKFILLING OF ANY SYETEM WITHOUT FINAL INSPE(:TIO~ BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE ~{) ~ TYPE E ~ FOON A 'ON TO SEP,,O TAN _ FOUNDATION TO SEEPAGE PIT sePTIC TANK TO SLEPAgE Pit WALL SEPTIC TANK ~<~ ~ , DRAIN FIELD TO NEAREST LOT LINE. YVATER MAIN TO SEPTIC TANi< id SEPTIC TANK, J~ , SEEPAGE pIT~<~ ALSO CONSIDER AREA WELLS, · SEEPAGE Pit DRAIN FIELD_ CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURI~ED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTight REMOVABLE CAPS. CONFORM TO BOROUG;RE~UJ-ATI~::f.NG 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. vo.~ .o. ~o .... GP~TER A~iCPORAGE AREA BOROUGti Depa ,ent of Enviro~mental Qua!ity 3330 "C" Street Anchorage, Alaska 99503 Perfcrmed forMr. Oliffe~i 3pchnholz, ~63:~ Carlson Rd. Da~e performed Nay 1~, ,1~75 Legal Oescriptiorm: l'h~ form r~ports: Soils log X Depth Feet q / IN/, I .'¥ ~ . :. ..:.. ..... ...: ..:.~.-: ~.-::'.. .. . .. ~.. ~ 10- 11 ll' - Varies evenly betweenl 50% 8p= Poorly graded Smlds(15 50% Sm,- Silty Sands (2!50) 12- !3- 16 i,ias ground water encountered? If yes, at what depth? Reading Date Gross Time Net Time Depth to H20 Net Dren ::: ......................................... : ....... I ............................................................................... 1 ~ '~' ' Pit x . : ProDosed house to have 1 'b~droomlReoo~end trench or p~t -~6-~:[p'i~-~'O 'lower strata _ ~ M-W DRILLING, Inc. P.O. Box 110378 · 10330 Old Seward Highway (907) 349-8535 ANCHORAGE, ALASKA 99511 85-254 Deepening Clifford Spohnholtz Well Owner. DRILLING LOG Use of Domestic Location (address of: Township, Range, Section, if known; or distance main road T.67, ~C 15~ TlPN: R3W; ~.M. S~ze of casing. Static water level Screen ( 6" 240 Depth of Hole feet Cased to ;~8 _+ feet 189 ft. (h~. !below) land surface. Finish of well (checkone) X open end ( ); (minute) for_ 1 hours with ); Perforated ( ~ ? : Describe screen or t3erforatibn ":/~ ! '~ None Well pumping test at~--40__gall~S per 0~) ] 00% ' of drawdown from' staticlevel, · '~¥. ~; ' · Date of comnletion 9/18/85' ~'~ : ;" : WELL LOG Depth in feet from . : ground surface Give details of formations penetrated size of material, color and hardness 0 E~i~t ing Well . 218 Water ·Gravel __~O 218 ~O 240 __~O .TO TO __TO. __~O TO __TO __TO __TO TO ~O 1--CUSTOMER /0 - L/- 7 00L .jZI '- ~.~./d-I/[FU / ,SO/t] U- c: L. Pr y (//AIZD R,:wv ) I-)ID ,t/o'f. i/U.~'7-~-L.(_ pb{ t?l P MUNICIPALITY OF ANCHORAGF. 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 HAA # 1. GENr.'RAL. INFORMATION Complete legal description ~_c~'T'- ¢-.Z L-~t £ Location (site address or directions) Property owner Mailing address Lending agency Mailing address Day phone Day phone Agent .2,Z~.~ ,.'u ~,,~ ¢ 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 NO'T'E: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site 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. 5. STATEMENT OF INSPECTION BY ENGINEER. As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address ~'~, ¢. ~o~2 EngineeCs signature_,~'~ Phone A ~ Date /¢//~/,/~ ~z D,~ SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulatJons: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DH HS 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. Municipality of Ancl~orage ~) E C E I \/~ r~ DEPARTMENT OF HEALTH & HUMAN SERVICE8'~ -- ~ ~ Environmental Se~ices Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 3~¢-~74~ 1997 Municipality of Anchorage Health Authority Approval Checklist Dept. Health & Human 8erylces Legal Description: A. WELL DATA Well typeqp¢2 t ~,a.''r-~' Log present (Y/N) Total depth _~ ~-~ Sanitary seal (Y/N) Date of test Static water level Well production if A, B, or C, attach ADEC letter. ADEC water system number Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Date completed Cased to q t~ ~ FROM WE"LL LOG ~ i ~-/ /~ ¥ g,p.m. WATER SAMPLE RESULTS: Coliform ~ ~ -- Date ef samp a:_ I j Nitrate J,~.~7' /,, (~ ~ Other bacteria -- c) Collected by: .S · ~-,~.a..),,oo,,t,, t_~ B. SEPTIC/HOLDING TANK DATA Date installed /??3/.,¢,//d~Tank siZe ./¢~/Squ Number of Compadments ~ / ~ Cleanouts (Y/N)_~__ Foundation cleanout (Y/N) ~ Depression (Y/N) _ ~ High water alarm (Y/N) Date of Pumping A ) C. ABSORPTION FIELD DATA Date installed '~/~5'//~/tt (~i"-/- Soil rating (g.p.d./fta or fF/bdrm) ~:~. ~-~ System type. q5 '1'- Length ~'/~,o' .W dth ~ /Z, Gravel thickness below pipe '7' / 3 ..~__ Total depth /C~.-)- / ~ Effective absorption area ,5,-o~'/:~! t.) Monitoring Tube present (Y/N) '-(_ Depression over field (Y/N) / Date of adequacy test '-5-½~Vle~'-/~'~c~/Results (Pass/Fail) <~::~.'.~ For ~- bedrooms Fluid depth in absorption field before test (in.); ~ "--- Immediately after --:-_gal, water added (in,): ~- Fluid depth (ins) Minutes later: Absorption rate g,p,d. Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date. '"---- 72-026 (Rev. 3/96)* LIFT STATION Date installed Manhole/Access (Y/N) ~/"~"~u I:~e¢-I~ ~,t Highw~~ / '/~ ~//~*Datum _ _C~le~ tested ' "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /.~,..~-t Absorption field on lot //! ~--- Public sewer main ./L//~ Sewer/septic service line / CO-f- · On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~ I Property line '2. ,.~ ~' Absorption field Water main/service line .~,.~,w _Surface water/drainage /¢¢ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / ~ t Building foundation /~/ Wells on adjacent lots Water main/service line Surface water / Curtain drain F. ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area Wells on adjacent lots /~;~G ~ I certify that I have determined thru field inspections and revie in conformance with MOA HAA guidelines in effect on this date. Sign atu re__..~ .~-~"~ Engineer's Name Date HAA Fee $ Date of Payment Receipt Number 72-026 (Rev, 3/96)* Waiver Fee $ Date of Payment Receipt Number 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. # ~-~/'~'"~:~.~' ~--(:~:::>-~ HAA# ~-~., ~¢'/~'~-, ~'~ /'L~[ 1. GENERAL Complete legal description Location (site address or directions) Mailing address Lending agency Mailing address Day phone Agent Address Day phone_ Unless o(herwise requested, HAA will be held for pickup. NUIVIBER 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. TYPE OF WASTEWATER DISPOSAL: Indiv: ' oi -sit,.; HoJdi¢. tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC atiesfing to th,,? legality and status of system. 72-025 (Rev. 1/91) Front MOA ~21 5. STATEMENT OF INSPECTION BY ENGINEER. As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm~/~¢~oM~cz- ~.. ~",./~ Address "~'-c~,E~cP,~ /q20~-.5"~ ! A,vc, l,L ~ Ak Engineer's signature. .... ~--~- ~ Phone Date DHHS SIGNATURE 0/'~ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72~25 (Rev. 1/91) Back MOA #21 Municipality of Anchorage A~ DEPARTMENT OF HEALTH & HUMAN SERVICES .R E C LE I V ~, Environmental Services Division ., .... 825 L Street, Room 502 · Anchorage, Alaska !;)9501 · (907) 343Jlj~44 ~ 1997 Mui'licJna i,, ol .... Health Authority Approval Checklist ept, Health & Human ~'Je, Legal Description: L¢~/4~TI;~-t. P-3t,cf ~t~'- Parcel I.D.:~/L~:; _-,- c, ,.~%.~ A. WELL DATA ~ ~L4Jt~c~ ~[~,¢ff~,~. ~%~ Well type ~[u ~%~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) -~ ~¢ Date completed Total depth ~~ Cased to ~ ~ Sanitary seal (Y/N) ~' I--ROM WELL LOG l~c~ e40 Nitrate Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION g.p.m. ~' ~ g.p.m. Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform -- Q) Date of sample: B. SEPTIC/HOLDING TANK DATA I ~ "P~,~- Other bacteria Collected by: -<;, P--- ,~;~A,,'~,/Jo~.~ ~ Date installed ~ q_~J _Tank size Foundation cleanout (WN) "d Depression (WN) Date of Pumping ~,]'2~/qr¢- Pumper. C, ABSORPTION FIELD DATA "TT,)_¢.,~,c~ · ~'~tT' Date installed ~/'~-,Y'-./ t 0~.o~ _Soil rating (g.p.d./fFor ft2/bdrm)_ Length _ "'~¢ ~/ Width 7~ 6" Effective absorption area Date of adequacy test _,¢',/~q J ~ :~ Number of Compartments ~a_. Cleanouts (Y/N).__ ~-..t. High water alarm (Y/N) '"¢[~ _ System type '"c~o~- Gravel thickness below pipe_ ci'~ _ Total depth Monitoring Tube present (Y/N) "E" Depression over field (Y/N) Results (Pass/Fail) ~"c~,5~ __ For -~ bedreoms 72-026 (Rev. 3/96)* Fluid depth in absorption field before test (in,); I$1"l q'_' Immediately after_d.~U)gal, water added (in.): Fluid depth_~l'/ 1%" (ins) Minutes later: ~q/~.5 Absorption rate = q,~'~' g.p.d. Peroxide treatment (past 12 months) (Y/N) ,t),ME.,¢c~,.~¢../ If yes, give date '~'~' D, LIFT STATION Date installed Manhole/Access (Y/N) "Pum~ "~J High water alarm level a~ ~ *Datum Size in gallons "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /'~.,/~ Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation .~ ~ Property line 'Z-(:~ t Abso[ption field ! Water main/service line ~.,S.=A- Surface water/drainage ./~-e Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO; Property ne. /¢J~ Surface water / ¢~J¢ Curtain drain ~' ¢0''¢ Building foundation / ¢ Water main/service line ~'~- '~' Driveway, parking/vehicle storage area ~'0 ~ Wells on adjacent lots / ~¢ ~' F. ENGINEER'S CERTIFICATION I certify that I have in conformance with MOA HAA guidelines in effect on this date. Signatur~ ~ Engineer's Name ~7-'~,J ~r~./,J Date ,~'/~/~/~ :7: HAA Fee $ ~- Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number