HomeMy WebLinkAboutT12N R3W SEC 24 SE4NE4NW4SE4
/"~, MUNICIPALITY OF ANCHORAGE /--%
DE :ITMENT OF HEALTH AND HUMAN SER ES
, Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Na~e DISTANCES
~ - TANK FIELD WELL
~, , AS-BUILT DIAGRAM (Show location ol well, septic system, property Imnes, foundatmon.
SEPTIC ~ HOLDING ~l ~
TYPE OF SYSTEM ~
~ TRENCH BED ~ W. DRAIN ~ OTHER ~c~L~l~- ~'~q
Depth to pipe bottom from Total depth from origLnal grade
original grade ~/~ ~ FT '~ O FT
~ FT /c~) FT
WELLS
~PRIVATE ~ OTHER fldentifv)
REMARKS:
Inspections Pe~ormed by:
Health Depa.ment Approval: . V ...... Date:
72-013 (3/85)
· OEF'AR'[I~IIEI'4T 14EAL,.TH AND ENVZRi]:tNM[i:]'TFA[ .... ~C)TECTIC)N
S;~?.5 L. SI'RE::ET~ ANCHORhGE, AK ':¢950
~ ~- -,>/,=. ENGINEEI::~ED DESIGN ,
~ 0 i 03
CONTAC:T FIHONE ~.
HANS SCHWAIGER
4859 KLff)REANOF:'
ANC~HOfbqGE, AK
',56:3-6846
99507
! am fami!J, ap ~,',~ith Lhe ~"equiPemen'Ls f'oi"
~or. th by 'k.i~e Mun:i. cipa].ity c)!: AnchoPage
I ~,,;i'].]. ins'La] ]. k. he sys'[.(.~m :ir'! ac:c:opdanc:i.!:,
[..CFI': NiA BLCK]<: N/A
RANGE: 3W
(MOA) arid the State el,~' Alaska,,
~J.'[.l"i all MOA ,:::c!d!.:~s a!'-.,!::l
]: ,'...'~:[,] ]. adh(~)i~[, 'I:Q a].]. k'IOA arid [iikLa'l:.e (:)-!' A].aska r'.eclui!~e)mer'i'L!_~ [(::!p '!.he se'l:, back
}Z f::' A L]:[:'T ~; T AT }] [:)N ]:~ IN!3'I'AI...LED IN Ah! AREA COVE:RED BY MOA BUiL,.i)]:NG CODE:S,
THEIx! (I) AN E[.ECI'RICAL f::-'[~'RPiIT AND ]:NSPECT]:ON MUST BE OBTAINED~ (2.) AS.-"BU
WILL[.. NOT BE APF:IROVED WI'I"HOU'[ AN EL[~:C;T[~]:[CAL ZNSFIEC]-ION RE]::'OR"F; AND (3)
~.~. , .~ _.~ ....................... : ................
7'
AncAorage
P.O.,r/~'~h( 196650
ANCHORAGE, ALASKA 99519-6650
(907) 264-~$'X1~
TONY KNOWLES,
MAYOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
January 9, 1987
Hans Schwaiger
4859 Kupreanof
Anchorage, Alaska
99507
Subject: T12N R3W Section 24 SE¼ NE¼ NW¼ SE¼
On-site Sewer & Well Permit ~860372
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1986.
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent to
this Department for documentation of the installation and to
close the permit.
If a private engineer inspected the installation of the on-site
sewer system the original as-built inspection report (three part
form) must be sent to this office for review and approval, and
for documentation.
If there are any further questions, please call this office
at 264-4744.
Sincerely,
~obinson
Program Manager
On-site Services
RWR/ljw
eric: copy of permit
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: fZ/:~t~; ~z4~lO~ DATE PER
LEGAL E}E~CR PT ON: ~'~ l/q I ~J~ ~fl /~/'~r~ 5.~.t/u, Township, Range, Section:
SLOPE
10 ~,~,J /~ WAS GROUND WATER
ENCOUNTERED?
11 s
IF YES, AT WHAT ~
12 ,_~p/~.~ J~ ~ DEPTH? p
Deplh to Water After
13 Monitoring? Date:
15¸
16-
17-
19-
20-
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE __
(minutes/inch) PERC HOLE DIAMETER __
TEST RUN BETWEEN __ FTAND FT
COMMENTS
PERFORMED BY: 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)
FIPF'L:[C:I::II"4T ~.;.[~- ,1 .... tl:...lllJ ....... r:'o BOX ~r~l.-..2,.-'t ~;13. ~;Ti::ITtCIN
LOC:I::IT f. (:tN COBRI:I '_:.:;'r
L. EEiFfL 5E;t/4 l'-,1[~:1,.."4 1'.41.4:1..,.'4 SE:L./4 524 T± LOT 5ZZE ::1J.3S5C-~0 5C!URI:;:.'E FEET
T?F'E 0[:: '::;OIL FIE:E;OI?.IiTI'IOI'q 5'.,-'STEi'.I IS: "rEi~.:i"4C:,LI
MI::IX_Ti"IlJM NLIME:ER ELF:' BEE:,F::OCIMS -"= 3
5OIL f;;:FITII'qG ,::SQ FT/E=Iq:>= '_1.25
THE I::?.EC!LIi[:?.E:[) ':'F,!ZE 1_3F 'T'I-IE :iF, OIL RBSOI:;?.PTtOI"4 ':2.r'STEM IS:
THE LEI",IGTH DIMEN:5ION I5 TI'IE LENGTH KIN I':'EE'I") O1::' THE TF?.EI"4CI-I CIE [:,I:.'::I=IINFIEL[:,.
TIlE [:,E[:'T[I OF I::1 TREI'-4C:H OE [':'IT I5 THE DI'.'7;]'FIhlCE B[F['!.,.IEEN ]',LIE SUI:;iiF'I::tCE OF THE
GROUND FIND TI. IE BOTTOI"I OF' 'fiE: EXCf::IVFt'['IOI"4 (IN FEET).
TI.ERE Z5 I'.,EI SET I,,.IIDTH FOl.?. T[:?.Ei'.~CI.IES.
TI'IE GF'.FI',,,'EL [:,EI:"TH I'.:.':; TIlE ["IINIi"IUi'4 D[::PTH OF: GI:;?.r:i',,,'EL E:ETklEEi'.4 'ride OUTF'I'::IIJ... F'IF'E
FIN[> THE E~OTTOi'4 OF THE EXCFi',,,'FIT ]: ON ,::Ii'.,l FEET::,.
F:'EF:t'I ]; '1' FII::'PL. ! CFIN"r HR:E; THE RESPOI'.4:::; Z E: t L ~: T'.,.' TO ]: NFOI?.M 'TI..I 1:5 DEPFIRTHENT DUI',:.'. I big THE
Ztl'3TF:iLLFffIO?.,I INSI::'ECTZOI'.,E:; OF' FIt'.,l'.r' I-,.IELI_$ F]D..TRC:ENT TO TH_T5 F:'F:OF'E:RTh-' I=IND THE
NUhlECR OF EES]:[:,ENCE5 'I"I. II=IT TI.IE I.,.tELL k!ZI....L 5EE',,,'E.
BFE:I.<F' l LL Zi',ll3 C:ll::: FIl'-,l'.r' S'.r'STEM kl I'f'HOLIT F ZIqFIL ]:t'.,ISPECT 10['4 FIND F:IPPRO',,,'RL E:'T' TH~( S'
DE]r::'FiI:;?.TME[NT I,]II_L. E:E: :~:;IJB.irEC:T TO F'F;:OE;ECUTZOt'.4.
M ]:['.,I I HUM [:,]: 5;TFihti::E E:ETkEEIq Fl I.,fEI..L FIND F:iI'.4',.' OI'.4-...E!;:[ TE %E!.,.IFiGE D I SF'OSFIL S'¢S'?EM I'.-:;
:L(i~ FEE1- F'O[;?. FI F'r;?.Z',,,'FI-t'E I.,.IEL. L.~
:1_5~i TO 2E11:3 FEET [:'ROf,1 FI F'UE)EZC: I.,.IELL DEI:::'ENDZNG UF'ON TI.IE T'.r'F'EE F'iF I::'LIE[L. IC: I.,.I[ZLL.
1.4EI...L LOGS FlEE I';;:EI~)UIF:E[)
OF' THE !.4ELL COMI::'LETZOI'.4.
O'I"HEI:;?. F:EL:]IJ:[I;i:Ei',EF(rs MR'.r' FIPPL'¢. SPECIF]:C:FII"IOhI'_::: FIN[;, COI'.,E;TF~:UCTZO['.,I [) ]: [.3GF4'.FiM:E; FIRE
FIVIq:[L.FIECE TO :[['.4%IJRE F:'F?.OF'EF,' L(N:'E;TI:-iL.Lf::IT:[OI'.,L
l
t:
FOF:TH B'T' THE i"ILIitIC:[F'RL:[I'h" OF: 1:II'4CHOF'.FIGE
2:: :[ I.,.I]:LI._. ]:I'4::.;TFII_L "I'I-tE 5'¢'3TE1'¢1 ZI'.4 FIC:CORDFII'.~CE I,.l:[]"ld THE CODES.
2: I UI",IDE[?.STFIi",I[) THF:ff THE ON--SITE '.E;EI.qE[:~'. SYSTEI"I i"El"r' REC!UIRE Ei"&FIIRGEMENT Z F THE
F::ESI[:,EHCE I5 F.::EI"IODE;L. ED TO ZI",ICLUDE PIORE THF:II',I _'3.,: BEDF::OOMS.
'_E; l C~;I',,'~:~ E:,: ............ ~_.~ ........ ~ ......................... FhLFL.[CIMT P':.UE,~=I-~.7 M. ~::TI~:.I:~LE;'_~,
:I ~ .... :~: ~ :~ ...............................
C[~:RT I F'¢ TI' ll::l-r
_T. RH F'I:::ti',IZLZFIR I*!ITI...] -I'HE REC!IJIF'.E?'IEi'.4T5 FOR IDN--.SI'T'E 'L=,EHEFE; FiI'.,I[:, HELL_.5 I:::l~; '..'~;ET
F EF-.i~I I T NO.
RPPLtCRNT
LOCRTION
LEGRL
ROBERT M STRRUSS P 0 BO)--',' :l. 0-27~; SOUTH STRTION 3-.::49-±22:D
COBRR STREET
SE±?4NE:t,,"4NH±24SE:t.,.."4S24T:~2NR]~:W LOT SIZE :~08Ea00 SQLIRRE FEE]'
TYPE OF SOIL. BBSORBTION S'¢STEM IS: '¥RENCH
HBNIMIjM NUMBER OF BEDROOMS
SOIL. RFITING (SQ FT,,'BR)= 125
]"HE REQUIRED SI2E OF THE SOIL I~BSORPTIOH S'¢S'f'EM IS:
l[:;. E F' '1- Fi = :1. El ~_ FZ P-.~ ~.3 "¥ H = ::-=; l-T-_' ill F.: F~ %-' E L. [;. El F' -F F~ == ~;
THE LENGTH [:,IblENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRII"~F'iEL.[:,.
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETHEEN THE SURFRCE OF THE
GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRMEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL F'IF'E
RND THE BOTTI]M OF THE E)',:CRMRTION (tN FEE]").
8FICKFILLING OF. FIN9 S'¢STEM HITHOUT FINFIL INSPECTION 8ND RPPRO',,,'RL. BY 'T'NI2:;
DEPBRTMEN'T HILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTFINCE BETWEEN R HELL. RND FIN"? ON-SITE SEHRGE DISPOSI~I_ S'¢STEM IS
t00 FEET FOR Ft PRI~"RTE WELL OR 200 FEET FOR B PUBLIC WELL.
WELL LOGS RRE REQUIRE[..' RND MUST 8E RETURNED TO ]'HE DEPRR'FMENT HITHIN ]:0 DRb'E;
OF THE HELL COMPLETION. -
SPECIFICFITIONS RND CONSTRUCTION DIRGRRMS RRE 19,,,'RILRBLE "FO INSURE F'ROPER
I NSTRLLRT I ON.
I CERTIF'¢ THRT
±: IRM FRMIL. IRR WITH THE REQUIREMENT_; FOR ON-SITE SEHERS I-]ND WELL~S RS SIE"I"
FORTN B'¢ THE MUNICIPRLITb' OE RNCHORBGE.
2: I HILL INSTRLL THE S'¢STEM IN RCCORE:,BNCE WITH ]'HE CODES.
~: I UNDERSTRND THRT THE ON-SITE SEHER SYSTEM MR'¢ F,'Et;!UIRE ENLRF;,'GEMENT Il:' THE
RESIDENCE IS REMODELED TO INCLUDE NORE THRN ]: BEDROONS.
I-tF'F'LICFtNT ROE:ERT M STRFII_ISS
.., , .... ~,-~ ' . . : . .
'. - : .... : .... · .' . "*-I*~ : : , '. ,.: t'.t ' -
" ;~-; ' ' ~ ~ ' ' ' : ":'L ' :
· , : : - ~,.{ . ~-~r~ ~r a ~/~ -- ~ - --
- ' · T ' '. ' - ..' :' ~ '- ~ ~/~r/ ~/ ~ ..... r.'*'~; .... :'--
, · i ~: .... ~ ~. ~ · : .... ·
...... - ' ~,' 'i..,.[ '~ '~ ~; ; .... ?: ...... ·
' - ' · : "_ .~ ' .~o~ ~a~ ~~i :]'..i ;.ZZ:..'
....................... .._.._., ....... .
.. ' . "' . ~ ' ' ~ . · ;--- '. ;' ~ ' " : ' "' - ~.~ :~ -----~ z~~* ~
!
; ......· ~ -~~ ,,~ ....... ~ .
I~ MA~Ca 77 ' ,
· /
PLOT PLAN
//,,CA/ r~, Z? 41
ENgiNEERING
ANCHORAGE, ALASKA, fl'ilS /~ DAY 0F./~.,4~-~¢..- "197~7
24, 1978
~77104
Robert ~. Strauss
Post office Box 10-276
South Station
Anchorage, AlaSka 99502
Permit Expiration
A permit issued by this department for well and/or on-site
sewer installation on T12N R3W Section 24 SE% NEb NW~
has expired since the issue date exceed~ one(l) year~
In the event you still plan to install the well and/er
site sewer system~ a new permit is required. The original
soil test may be ~sed to obtain a current permit.
If the well has been drilled, a well log should be s~nt
to this department to doc~ent the installation date.
If you have a~y ~aestions regarding the above matter, please
contact this office ~m~ediately at 264-4720.
Sincerely,
Les N. Buc~lolz~
Senior Environmental Specialist
December 29, 1978
#780070
Robert M. Strauss
Post Office Box 10-276
South Station
Anchorage, Alaska 99511
subject: TI~N R3W Section 24'SE~ NE¼ NW~ SE¼
A permit-'issued by th~s department for well and/or
sewer system has expired.
P~rmits are issued on a calendar year basis, as stated
on the permit, by authority of Municipal ordinance.
If you have drilled the well, a well log should be
sent to this department to document the installation
date.
If there are any further questions, please contact
this office at 264-4720.
Sincerely,
Les N. Buchholz, R,S.
Senior Environmental Specialist
LNB/ljw
enc: copy of permit
,,ATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysical Surveys
Drilling aermlt No,
OF {Please either lo, to lc.) A.D.L. No
I~.lBorough Subdivision Lot Block ~b~.I '/4qt,{. I Secfion NO. Townsh[PN[~. Reag, ED Meridian
~,ree, Addres, Grid Area of Well Location
Feet Below 4. WELL D~PTH: (final) ~. DATE OF COMPLETI~ '
~ I~.GROUTING Well Grouted: ~ Ye* ~No
~.~.,~~(~_~This well w~s dr~ d u~ ~y jurls~lction nd this rep0rl is Irue ,o~7the be of m ~n~edge end belief;.
BESSE, E PS & POTTS
IV,~'NICI:P^LITY OF ANCHORA~.-~
:DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
~OCT · 21986
RECEIVED
October 2, 1986
Mr. Robbie Robinson
Municipality of Anchorage
Deparment of Health and
Environmental Protection
825 "L" Street
Anchorage, AK 99501
Re: SE 1/4, NE 1/4, NW 1/4, SE 1/4, Section 24, T12N, R3W, SM
Septic Design
Dear Mr. Robinson:
A monitor tube was installed in the test hole on the
above-cited lot on Thursday, September 25, 1986.
The seven-day groundwater monitoring period was completed on
Thursday, October 2, 1986, and no groundwater was encountered.
Very truly yours,
mgk/smh
ENGINEERING, PLANNING, SURVEYING
2220 E. 88th Ave./Anchorage, Alaska 99507/Telephone 907-349-6451/344.1352
"Providing a quality personalized service to those building Alaska's future"
d.O, = q. cct~,,~ Oo'r
'- i
9?3
h
LEGEND
NOTES:
1. IT SHALL BE THE RESPONSIBILITY OF THE BUILDESOROWNER TOVERIFY THAT
BUILDING LOCATION SHOWN MEETS ALL SUBDIVISION COVENANTS AND ZONING
ORDINANCES.
E. IT IS THE RESPONSIBILITY OF THE BUILDER TOVERIFY ALL ELEVATIONS WITH
RESPECT TO ALL UTILITIES.
9. THI~ PLAT REPRESENTS THE PARCEL OF PROPERTY DESCRIBED BELOW TAKEN
FROM THE RECORDED PLAT DESCRIBING THAT PARCEL,INSTRUMENTB
RECORDED PRIOR TO OR AFTER THE PILINS OF THE RECORDED PLAT
DRAWN DY: KNi L
BESSE, EPPS 8~ POTTS
zz~o E.88thAVE. ·
ANC,..O~GE, ~
DATE: ]-_Z+_RI'IFLBBK: '"
I
~"'~'~ MUNICIPALITY OF ANCHORAGE ~.
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description {include Jot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name 1 5 dAt eP Telephone: Home
Applicant Address ~
Business
(c) Applicant is (check one): Lending Institution []; Owner/builder ~; Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~ Multi-Family [] Other
Number of Bedrooms ~f¢ (~)
WATER SUPPLY
Individual Well*'~ Community [] Public
[]
Note: If community well system, must have written confirmation from the State Deeartment of Environmental Conservauon
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite~' Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality andstatus.
72-025 {11/84}
Page I of 2
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eql u! SUO!SS!LUO JO sJoJJe Jo~ elq!suodseJ lou s! eeeJoqouv Io ,il!ledlo!un!ml eql 'penss! s! @lBo!l!lJe9 e eJojeq elep aZ,ileUB
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pau!elqo uo!lemJo~u! e~l ua pasBq ]eql ~lpea Jeqpn~ I 'u!eJeq paleg!pu! emlomls
alenbap~ pub leuo!lounj 'ales s! ma]s~s igsods!p Jaleaelsea Jo/puB ~lddns ]al~M ells-ua aLII l~ql SMOqS leaoJddv X]!Joqlnv
qlleaH s!ql 1o uo!lee!lseAul Am ]eLll ~llJea I 'MOleq UaOVS alep ua!lap!lea aql 1o SB pub olaJeq PeXUle leas ~m iq pa!~!~eo sv
NOIJ. V~I:JO..4, NI aNY Viva 'HOIJV3S 3-11:J 'SJ. S31 'SNOliO::IdSNI ~9NIC]IAOI:]d IAlJ::ll-i EINII:I~]~]NION'a 'g
MUNICI~AI.ITY OF AN~ICIPALITY OF ANCHORAGE (MOA)
DEPT. OF HEALTH & HEALTH AUTHORITY APPROVAL (HAA)
ENVIRONMENTAL' PROTECrlONI
CHECKLIST- FEBRUARY 1984
¢ 1987
RECEIVED
264-4720
Cased to
If A, B, C, D.E.C. Approved (Y/N)
Date Completed lO '~-7~'7- ~:~ Yield
I?--~ ~ Depth of Grouting ~
Pump Set At U ~J~0LdtJ
[~..~t Sanitary Seal on Casing (Y/N)
x~I~ Depression Around Wellhead (Y/N)
Well Classification
Well Log Present (Y/N)
Total Depth
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
I
-F I~O ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot J¢ [qO* ; On Adjoining Lots --F [00 !
To Nearest Public Sewer Line --I-~'~ / To Nearest Public Sewer
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
NO
Date Installed
Standpipes (Y/N) ~-~
Depression over Tank (Y/N)
SEPTIC/HOLDING TANK DATA (~LJ
OC-'T' ~(~ Size J"'~O No. of Compartments
Air-tight Caps (Y/N) '~--~ Foundation Cleanout (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well '+' I(~O ~'
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
To Property Line
To Water Main/Service Line
Course -F ('~0
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72 026(11/84)
Soils Rating in AbsorPtion Strata
Date Installed 001" ~;~
Width of Field ~' ~! r'n
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation .+
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
¢ D¢-¢~ Type of System Design '~::~1'~
Length of Field ,~¢,1 ~, .
Depth of Field
Gravel Bed Thickness
t- Standpipes Present (Y/N) '~
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
..ff lOt
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~J2;;~h~,& Date 4 '~'~'7
Co m pa ny '~:~.~? J~_ ii ~ ~;~ ~e'~:~ MOA No."
Receipt NO. ~O/ [0~e~
Date of Payment ¢-- ¢~ 7
Amount: $ / ¢¢~ Engineer's Seal
Page 2 of 2
72-026 (1 ~/84}