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Home My WebLink AboutT12N R3W SEC 22 LT 22B Jan_05.2023 09:44 AM Anchorage Well & Pump Service Inc 9072430742 MUNICIPALITY ITY O4 ANCHORAGE #5322 P 1/ 1 Development Services Department Phone. 907-343-7904 Cin -Site Water & Wastewater Section Fax: 907-343-7997 Dump Installation Log Well Drilling Permit Number:..._._._..... _ ._..._... _.. .._ Date of Issue: Parcel Identification Number. 015.141.68 Legal Description Block Lot Property Owner Name & Address: TOMISSER WILLIAM P & GALINA l T12N RM SE=C 22 22B 4705 E 112TH AVENUE ANCHORAGE AK 99516-1611 Pump Installation Date: 01 . r... 04 - 2023 Pump Intake Depth Below Top of Well Casing: 152 feet Pump Manufacturer's Name: MYER Pump Model: 3NFL72-8-P4-02 Pump Size: .. . 75 ----hp Pitless Adapter Burial Depth: 12 I Pitless Adapter Manufacturer's Name: I fatless ,Adapter Installer: feet MARTIN ON Well Disinfected Upon Completion? X Yes ❑ No Method of Disinfection: PELLETS Comments: Pump Installer Name: _ ANCHORAGE WELL & PUMP SERVICE Company: 7640 KING STREET ANCHORAGE, AK 99518 Mailing Address: 907-243-0740 State: Zip: Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. San_05.2023 09:44 AM Anchorage Well & Pump Service Inc 9072430742 MUNICIPALITY OF ANCHORAGE #5322 P 1/ 1 Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section 4 W Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: Parcel Identification Number: 015 141 6$ Date of Issue• Legal Description Block Lot IProperty Owner Name & Address: TOMISSER WILLIAM P & GALINA I T12N R3W SEC 22 22[3 4705 E 112TH AVENUE ANCHORAGE AK 99516-1611 I Pump Installation Date: 01 _ 04 - 2023 Pump Intake Depth Below Top of Well Casing: Pump Manufacturer's Name: MYERS Pump Model: 3NFL72-8-P4-02 Pump Size: '75 hp Pitless Adapter Burial Depth: 12 I Pitless Adapter Manufacturer's Name: I Pitless Adapter Installer: 152 feet feet MARTINSON IWell Disinfected Upon Completion?Yes ❑ No Method of Disinfection: PELLETS Comments: Pump Installer Name: _ ANCHORAGE WELL & PUMP SERVICE Company: 7640 KING STREET ANCHORAGE, AK 99518 Mailing Address: 907-243-0740 State: Zip: Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. Municipality of Anchorage Page I of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report. Permit Number: ~L-L~C~ ~t"~-~'~ ~ PID Number: '~ ~ ~ ~ Name: k~ ~ I ~ Wastewater System: a New ~pgrade A~,.~: ~0~ ~. LL~~ ~. ABSORPTION FIELD Tot~ Depth from original grade: ' LEGAL DESCRIPTION Soil.afl.g= ~' ~ GPO/Sq. Ft. . LOt: ~ SIock: SUbdiv~ion: ~ to pi~ ~B~m from odginal grade: Grav~ depth ben.th pipe Towns.ip: tX~ Range: 5~ 8~i°n:z~ ~4 FiUadd. aboveodginalgrade: Gravetlongth: 0 New U Upgr arave~ width: ~' ~ Ft. J M Ft. Cl~ification (Pfiva~~ ~. Ca~ To: Ft. Tot~ ab~rption~ ~area: SQ. Ft. ~o~[~.Pipe ma?Hal:~D~I ~ Drifle~ ~ ~ Ft, ' : C~ingHe[ oveGround: ~ GPM Pu~p 8etat: Ft. ~ TANK SEPARATION DISTANCES ~eptic 0 Holding ~ S.T.E.P, To 8epti= A~rptlon Uff Holding ~[blieP~ate Manufacturen ~ Capaci~ in gallons: Su~aceWemv I~/~~l~e'-~)Jo"~' ~ ~ ~'~tt¢' """"~': 5~%L1~ STATIoNNUmber Of Compa.monts:~ ~/ t~ ~, t~/ "Pump on" level aC. ' ' lev ' ater a a~ ac' Foundation Remarks: [M~~ ~ ~S~I~ BENCH MARK L~tion and D~cription: Assumed Elevation: ~ Pt, ENGINEER'S :~% BREN~ P. EATON Bepartment of Health~ Huma.~o~iees approval ~'¢~"uh'~h'.. CE-012O ...~.'~ Reviewed and approved by: Date: //~¢~-- %~¢ ~OFE%~ Distances (feet) ' CO1 ST1 ST2 CO2 CO3 BRV CO4 CO5 MT J~ HouseA 11,2 7.2 11.3 14.0 14.9 15.3 25.4 64.3 63.3 ,C House B 35.7 47.3 51.6 54.6 54.9 55.1 44.4 84,3 82.3 / 22A ~ I "~ LOT I ............ N 89-$4'~i- £~ ~ <~LOT 22A ~LL I X 3e~.7~ / J~ ~EN PUMP~ CH. VALUTA y ~ CO2 C03, & VAL~ (BULL RUN) ~ LOT 22C LEGEND ~ + WELL LOT 22C SEP~C AREA ~ TEST HOLE o EXISTING STAND PiPE TO LOT 22C ~LL ~ EX, TRENCH DRAINFIELD NOTES: ~ NEW TRENCH DRAINF~ELD NO NEIGHBORING WELLS +100' o NEW CLEANOUT NO SURFACE WATER +100' NO KNOWN CURTAIN DRAINS PAGE 2 OF 5 ~ NEW MONITOR TUBE SEPTIC PLAN ASBUILT OWNER: KEN SMITH .~ .. :~ .... /.:...~ DATE: 11/07/95 SCALE: 1"= 50' ~:~~ ~ 8RENT ~. EATON ..'~,:¢~ B ENT P. EATON, P.E. 5801-A WILSON STREET '~{E¢~';~:.:;;~(;~ ANCHORAGE, AK 99505. PM. 229-5777 BOTTOM OF SIDING ASSUME ELEVATION = 200' 192.4' 195 4' 192 4' t /BULL RUN VALVE --2L.--~_L~ V 192'7"~1 ~. ? /194,6 ,191.5 101.1' SEPTIC TA~JK [~ ~ . ' ~ .o 7~' (EXISTING) ~ 188.6 / . . o Z ~o~ ~¥'188.6'/ o o %~' ~188,5' I + ~ 177.6' 177.5' 177.~' PAGE 3 OF 3 SEPTIC PROFILE ASBUILT ~, .~v OWNER: KEN SMITH ........... DATE: 11/07/95 NOT TO SCALE~P. EATON BRENT P. EATON, P.E. v,'~., c~-~2~ ..'~ 3801-A WILSON STREET ANCHORAGE, AK 99503 PH, 229-3777 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW950373 ~ ...... ~PANY ~ DESIGN ENGINEER:~K~:- ..... OWNER NAME:SMITH KENNETH J SR & OWNER ADDRESS:4705 E. 112 TH AVE. ANCHORAGE, AK 99516 DATE ISSUED:il/03/95 EXPIRATION DATE:il/03/96 PARCEL ID:01514168 LEGAL DESCRIPTION: T12N R3W SEC 22 LT 22B LOT SIZE: 54435 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 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 (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0) . 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. IS SUED BY:/~~~ DATE: DATE: BRENT P. EATON, P.E. CIVIL ENGINEEI~ 5801 A Wilson Street * Anchorage, Alaska 99505 * Phone 229 5777 October,~, 1995 Jim Cross, P.E. Manager, On-Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Subject: Lot 22B, NWl/4, S22, TI2N, R3W Dear Mr. Cross: The proposed septic system will have very limited impact on adjacent properties for the following reasons: The surrounding lots are large, allowing sufficient room for septic sites. 2. Immediate neighboring septic systems are all +60' distance. 3. The design is an upgrade to an existing, surcharged system. Drainage will not be affected and is not a major consideration in my design. I will be on site several times throughout construction of the proposed improvements should there be any change in below ground conditions that would require a design modification. If you have any questions please call me at 229-3777. Brent P. Eaton, P.E. C:~BPE\DOCUMENT~SMITH~NARR I)OC BRENT P. EATON, P.E. CIVIL ENGINEER 5801-A Wilson Sired * Anchorage, Alaska 99505 · Phone 229-3777 BPE Project No.: 95-04/- Calculated_By: Date: Oct.'~, 1995 Legal: Lot 22B, NWl/4, S22, T12N, R3W Test Hole No. 1 Single Family, 3 Bedroom Dwelling Deep Trench Subsurface Wastewater Disposal Field Water use at 150 gallons per bedroom = 450 gallons Percolation Rate = 25 minutes per inch Wastewater application rate = 0.6 gallons per day per square foot Required absorption area = 750 square feet Gravel depth = 13 feet Required length = 29 feet Total Excavation Depth = 15 feet C:~BPE~DOCUM ENT~SMITH/CALC.DOC LOT 22A SEPTIC AREA//~' ~'~. I1~0' ~ N J 3~9.78 / ~ , . ~UUND~RY I 0 I ~ ~ ~ EX. SEPTIC TANK APP. L~ION ~" / ~z I ~ ~ /REMOVE ~ REPLACE W/NEW 1000 GAL~ ~ m /~~X AFTER C/O'S, INSTALL ~~VE ~ ~m' x v INSTALL DOUBLE CLEAN~ ~ OmLE~ ~ ~ / mm,~ ' ,(o~X CONNECT TO EX. AND NEW TRENCHES , LOT 22B LOT 22C LEGEND ~ + WELL LOT 22C SEPTIC AREA 'a TEST HOLE NOTES: ~ o EXISTING STAND PIPE NO NEIGHBORING WELLS +100' TO LOT 220 ~LL ~ EX. TRENCH DRAINFIELD NO SURFACE WATER +100' ~ ~ PROP. TRENCH DRAINFIELD NO KNOWN CURTAIN DRAINS o PROPOSEB CLEANOUT (CO) EXISTING TRENCH TO BE VALVED OFF · PROPOSED MONITOR TUBE UNTIL FURTHER NOTICE TO DHHS SEPTIC SITE PLAN DESIGNONLY OWNER: KENSMITH DATE: 10/26/95 SCALE: 1" = 50' 5801-A WILSON STREET ~{~¢'~ ......... ANCHORAOE, AK 99503 PH. 229-3777 PERFORMED FOR: LEGAL DESCRIPTION: 2 3 6- 7 10 11 12 13 14 15 16- 17- 18- 19- 20- r~ ~.<.,~. ........ ~ ~, ~,,-- DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 I~.~ ~~:~; SOILS LOG -- PERCOLATION TEST ~ v0~... CE-9126 ,,..~ ~ ~ [~ DATE PERFORMED: )%~~ ~ ~ Township, Range, Section: ~W ~2 A~ ~.[~} ~¢~ SLOPE SITE PLAN ) ' WAS GROUND WATER ENCOUNTERED? S DEPTH?IF YES, AT WHAT I',..~ / ~ pO L E Deplhto Water After /_ Monitoring;' I~[~ Gross Net . Net Depth to Time ~,~1~ ~)R, eading Date Time ~.~," .~ Water (~t~,~ ,~ ~ tt~ ~.~ ? lo Io tq~ lO - [ ;~,~,m ~..~! PERCOLATION RATE ~'~ (minutes/inch} PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND ~ FT COMMENTS ~-~ ~)/ *~ ~ ~:~)l~--~ ~ ~ ~ _L.?~.~ ~---~-~*. ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) BRENT P. EATON, P.E. 5801-A Wilson Slreel. * Anchorage, Alaska 99505 * Phone 229 5777 BPE Project No.: 95~ Calculated By' E · ¢.¢, Date: Octobe:r~, 1995 Legal: Lot 22B, NWl/4, 822, T12N, R3W SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM A. .GENERAL The well and septic plan are for a single family residence only· The drawing and or site plan shall be a part of this specification. All materials and workmanship shall meet the Municipality of Anchorage Department of Health & Human Services requirements. All soil tests are advisory to the design and are to be verified in the field by the Engineer. All excavations and depths are advisory and are to be verified in the field by the Installer to meet Municipality of Anchorage requirements. It is the responsibility of the owner to obtain all necessary permits or easements and to locate all adjacent multi-family wells. The excavation is to be exactly in the area shown on the site plan, any deviation requires Engineer approval. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. B. DEEPTRENCH 2. 3. 4. 5. The bottom of the trench shall be level, plus or minus 0.1 feet. The total depth of the trench excavation shall not exceed 15 feet, The sewer line shall be level, plus or minus 0.03 feet. The trench gravel is to be covered with geo-textile material. Insulation board (2" Thick) shall be placed over the drain tile, over which a minimum of 2 feet of soil shall be placed. The area over the trench is to be finish graded to prevent ponding of surface water runoff. The septic tank and leachfield must not be closer than 100 feet to any exising private well, 150 feet to any Class "C" well, or 200 feet to any community well. Note: Twenty-four (24) hours notice required for all inspections. C:~BPE~ DOCUM EN~SMITH~SPEC.DOC GREA ,ER ANCHORAGE AREA BORL JGH Department of Environmental QuaJity 3330 C Street Anchorage, Alaska ggs03 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE ? FROM WELL ' INSIDE LENGTH NUMBER OF MANUFACTURER C~¢~¢--~ MATERIAl ~-~'~4~-~/ COMPARTMENTS-~'¢~ INSIDE WIDTH % LIQUID DEPTN __ _ LIQUID CAPACITY/~GALLONS. DISTANCE FROM WELL NUMBER OF LINES /f,'~m / LINE ,~0 / TOTAL LENGTH~,~_.~p// / _FOUNDATION- __NEAREST LOT _ OF LINES DISTANCE BETWEEN LINES TRENCH WIDTH~ IN, TOTAL EFFECTIVE ABSORPTION AREA ~C~'~-O ~ SQ. FT. LENGTH OF EACH LINE ~7/ DEPTH: TOP O,F'TILE TO EINISH. GRADE ~ '/ DEPTH OF FILTER MATERIAL BENEATH TILE__ ~ /~-~, ABOVE TILE IN. WELL: TYPE ~¢7-'_~t2¢S/~ I/~dNSTRUCT~ON BUILDING FOUNDATION_ CESSPOOL _ APPROVED DEPTH NEAREST NEAREST SEPTIC SEEPAGE LOT LINE SEWER LINE TANK__ SYSTEM OTHER SOURCES -. DISAPPROVED REMARKS - DISTANCE FROM: INSTALLED BY: SEWER LINE DEPTH: PIPE MATERIAL' LOT SLOPE: _ DIAGRAM OF SYSTEM i"IF::iV,][i"IiI,N t'-,![.Ji"tfL::t[I:;~ OF f:~ffZ[)f;~:13([[ll"'lS :-:: Ti-ii!i: I...i'!i:BI(iiTH f);[ I"II.i{NS ]; Oi",I ]i Ei; '1 I II~i[ I _tz'?'1 ':iTl-I ,:i ]; N FEiE'£' :;, 'qF TI'"I[:; Tl:;i:lii[i",li2H Oi:,~[ [)t:RF::I ;[ t'.,11:::' ]; ELD. "f'tli!i D~ii:F:'TH OF I:;:1 't'l:;i:ii;l'.,li2il O1.;i: t':')F[' ;[:i:; 'TI'Iii![ [;, ]; S'I"F]N~Z;E I:]i:llKl"l.,.lf~]!3",l TI'lIE SI..II:;~:I:::'F:tC;E:; EtI:' THE:] ~3i:,~:Oi...iNi) F:iND t'HE( t!;:OT'i"OI'"i OF '[HI:Fi Ei[~:':iCt::I',,,'I::'IT]3;:ff',t 'i'lli:i[!:;'.~; i['.ii; NO SE'T' I,i:!:[::,'i'I"I F:'OI:;i: '['HIE (~ii:;~ff;l',,,'l~[l_. i;/)[;i;i:::'-['l'"l ];S TH[:[ I"I][i'.,1Ii"1t..1i-'1 DEPTH OI::: ([:]1:;[~I::1~,,,'[~!;[.. 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Itr::IT :il.: ;[ F::Ii'"I J:::'l:;iJ'"l]i[.]]t:::lt~]'. t4]["I'H '1'I'IE FR~;(i:!LIII:;i'.I-~ii'"ItE. i",I'T'.il; I:::'O1:;~'. ON'.'".~i;/l;'[lii] SEi.,.II:Et:RS F::Ii",!D I.,.IE[Lt..S I:::I~FJ; i:::'i2i;:T~l !ii',"r~ 'f'!I1~] I'"II..IN]3Z;]H:::'I::'iI..]F/"'T' [TIF ;;~:: ]; !'.! 1( LL ]i t",i':'b;TI:::IL.L. TI"!I'F; ?r'S'i"li:!]'"I ~ t",I t:::I(~;[];(]I:,~ff)FINfZ;;E l.'J ;[ TI'I Tt"llil 2; I Iti",IDHt':i'.Fi;'i'!:':tI~',!D THI:::fT Tl'lli; Ot'-,l-'"J::iI ITl; SEI.,!Et:;i'. S"r'S"rfJ!]'l i'"ll:::f'~" l:;i'.l~[(;:!lJ]Hq:l:i:i E]",!!...I:;:II;irlFiE!;t"ItEt",!'T' II':' 'I't'iE t:;;'.I[:!:~;];DF[I",i([:E IS 1:;i:!!3'"tOtl)13..~i:~D -l'fqi ;tZI",ICLUDI!Z~ i"IOI:RfFZ THF:IN ~!i: DRILLING, INC. DRILLING LOG Well Owner ,,,.m~ . ,.h .rz..~ Use of Well L°cati°n (addresl °f: T°wnship' Range' Secti°n' if kn°wn; °r distance main r°ad Size of camng ':' Depth of Hole Static water level '"-- ft. (l~b~dg'~) Screen ( ); Perforated ( J.o,'; feet Cased to -' '>.~. ~ / feet (below) land surface. Finish of well (check one) ). (minute) for 1 hours with ID(L: Describe scree~ or perforation Well pumping test at '.!() gallons per (h~ii~) of drawdown from static level. open end ( k ); f~ Date of completion '/ . :~-, WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness TO _TO _TO _TO · ':;'J _TO _TO 6o ~b _TO ~;b _TO '~50 ~' 'f) _TO. LbO _TO. .TO. .TO .TO .TO_ Sit%v '.~ nd ~'",, .il r]~'/- ?];I ;;<,'U ~vv vvn CeriSiSea Contractor Certifieato No's. 814 & 973 2 -- STATE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section ·" P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D.# {~\_~_ 1. . GENERAL.INFORMATION Complete legal description L..- CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA # ~ ~-~ ~(~ Location (site address or directions) /-{'~)~ ~. I1~T~ Prope~ owner -K~ ~[~ Day'phone Mailing address :(~P~ ~ '-[L¢~ k~ Lending agency Day phone Mailing address A~en{ - Day phone Add~ess '' '.. _.: Unless otherwise requested, HAA will be held for pickup, i....._.....~.{- 2. NUMBER OF BEDROOMS: J - . -!Y-~.c- 3. ~PE OFWATER SUPPLY ... ....... ' Individual well ~ . -'Pub, c water . 'NOTE If community well system, provide written confirmation from State ~DEC attest- ~'-~ ; · lng to the legality and status of system. ~ ~ ~ ~ , ~ : ?' 4. ~PE OFWASTEWATER D SPOSAL: % · '1 ...... Individual on-site ~ · . '¢g.,,.~ J ~ [,$ ~,," ,.-, . ..:, .., :- - . ' ' .Holding tank . ._ ' Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA~21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by n~y seal. affixed hereto and ~ 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 wastbwater 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 Engineer's signature ...- Phone DHHS SIGNATURE /~ Approved for "~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Comments The Municipality of Anchorage Departm(Cnt of ~Jealth 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 A~ ~,ska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev, 1/91) Back MOA ¢21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-47'~Q Health Authority Approval Checklist ~m /~ ~o~ A. ~LL DATA ~'/~ Well type ~ . Log present (Y/N) ~ Total depth 1 ~' ~ t Sanitary seal (Y/N) "/ / If A, B, or C, attach ADEC letter. ADEC water system nmnber I~/~. Date completed Cased to L b 2- '7 ! Casing height (above ground) I, Wires properly protected (Y/N) 7 Date oftest Static waterlevel Well productiou FROM WELL LOG AT INSPECTION ! / WATER SAMPLE RESULTS: Coliform O Nitrate Date of satnple: [(_ --'/_ c) ~ O- ) O Other bacteria O Collected by: '~ {:Z~3,"U ~]~T-c::~ B. SEPTIC/ItOLDING TANK DATA Date installed Foundation cleanout (Y/N) Date of Pumping C. ABSORPTION iqI~LD DATA Date installed Number of Compartments ~- Cleanouts (Y/N) . Depression (Y/N) 1~ High water alarm (Y/N) 1--3. O Pumper Soil radug (g.p.d./ft2 or l~2/bdrm) di3- (o System type ~ Len~h Wid~ ~ ~ ~ Gravel t~c~ess below pipe ]0' ~ Total depth Effective abso.tion area ~ 5.[ Mo~toring Tube present.m) ~ Depressiou over field Date of adequacy test [ [ ~& ~ Results eass~ail) ~ For ~ bedrooms Fluid depth in absorption field before test (in.); 1-.3'/t¥ Immediately after 8//b gal. water added (in.): I'd/~ Fluid depth b3/~c (ins.) Minutes later: M'/Pc Absorption rate= Iq//~ g.p.d. Peroxide treatment (past 12 months) (y/N) ~ If yes, give date g.t/fl[ I Do LIFT STATION Date installed Mauhole/Access (Y/N) High water alarn~ level Cycles tested Size iu gallons ~'~ "Pmnp on" level at* }..,)/Pc "Pump off' level at* *Datuln iM/Pr E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: I t' Septic/holding tank on lot __J O~ [ \ ~ Absorption field on lot [~6 / (d~ ~[~t Sewer/septic se~ice line [ [ O t / Lift station ~ ~ SEP~ATION DISTANCES FROM SE~IC/HOLDING TANK ON LOTTO: Building foundation Prope~y line ~ ~ / Absorption field ' / Water maiWse~ice line ~ ~O Surface water/drainage ~ ~ Wells on adjacent lots : Oil adjacent lots ; Oil adjacent lots Public sewer uianhole/cleanout SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Snrface water Cartain drain. ! Driveway, parking/vehicle storage area ~ Wells on adjacent lots [ ~9 Property line F. ENGINEER'S CERTIFICATION Signature~~- ~. ~~"X Engineer'sNanle g~ ?. ~ ......................................... ; ................................................................. ~~ ........... HAA Fee $ ~ ~ Waiver Fee $ Date of Payment ReviS/95OSS:haa.;vk.doc O ¢ /~Z(~ Date of Payment Receipt Number In I ze' 1 - ��. I ASW SLE F�.W �j I O Nee .z of W�DPLiGNT� I _ mesMi �s•�oo orie N LL V 1 `_• o° K �� —I SViz. til �z Eza.i;: LoT iZ nlu( I4 Sk.c.LL O I Z V ` N 840 58' S3 'o-/ 3z4.9a' Foy, .rte i�e'eev.i2 `Fi D 5/5 QE3� S -BUILT CERTIFICATE: hereby certify that I have surveyed the following described roperty: 5'/r- 0 '/c eitavr. LaT 2Z. $F,- ZZT ZN, iz3 r✓ S • &c. nd that no encroachments exist except as indicated. EXCLUSION NOTE: It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. Under no circumstances should any data hereon be used for construction or for establishing boundary or fence lines. G4Ti1 Y� I ' ERALD B.°KURTZ }; LS•6297 T Govr. L6r ZZ, `st -z AGUA FRIA SURVEYORS 9024 VANGUARD DRIVE Anchorage, Alaska 99507 349-4688 Date ,�,-, - e> -i I Scale I"= 1 Grid ZL3 1%0.61-19 s 1 f 07 -oz I