HomeMy WebLinkAboutT14N R2W SEC 12 LT 17
" Municipality of Anchorage Page 1 of 3
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 Ins. pection Report
Permit Number:. SW970077 PID Number: 05027302
Abig, ail F. Dunning Wastewater System: [] New %ii, Upgrade
P.O. BOX 773682 Ea¢le River ABSORPTION FIELD
Phone: Nc. of Bedrooms: ' I~ Deep Trench ~ ~hallow Trenc~ ~ Bed ~ Mou~d ~ Other
LEGAL DESCRIpTIoN Soil Rating: Total Depth from odgin~ g~d.:
.6 eP0/so. ~. 12
17 4 n. 8
Town~i~: J Range: J Section: Fill added above odginal grade: Gravel lengm:
14N J 2W J 12 5 ~t. 63.5
WELL: D New ~ Upgrade G~velwidth: Number of lines:
2 ~,.J One N/A ~.J
P~4,~ Ft.: m. 1 ,O]6 so. re. ASTM D3034 ·
m. ~, Barr 5/97
Well 103' 130' N/A N/A >20' Steel 2
Sudace
Water >100 >100 N/A N/A N/A LIFT STATION - N/A
tine :>1 0 ' >.10 ' N/A N/A ~?~,
>50' >80' N/A N/A N/A 'Pum, o." level a~ ' j "Pump o,~ I.ve, au ' t High wat.t ala. a~
Foundation
Omin None Doted Dn lot
I
: BENCH MARK
Remarks: ~o ~o~k ~as accomplished o~
Garage
se~o ~a~k a~d c~&b c~usbed
~nspections pe~ormed by: 2 Stuart Gilbert Dates: ls~~ ~ ' *' ,:'*~ .... o ....
Depadment of Heaffh ~d Human ~e~ces' a ?,, .... ¢
RevieWe and approved by: . ate: '~*~'*~'~" - '
Permit SW970077
PID No. 05027302
Page 2 of 3
SYSTEM AS BUILT
SCALE 1" = 40'
NOTE: .~LL LINES' UNDER DRIVEWAYS/PARKING
COVERED WITH 4" INSULATION.
'%
ILS`
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:SW970077
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NANE:DUNNING STEPHEN G & ABIGAIL F
OWNER ADDRESS:P.O. BOX 773682
EAGLE RIVER, AK. 99577
DATE ISSUED: 4/29/97
EXPIRATION DATE: 4/29/98
PARCEL ID:05027302
LEGAL DESCRIPTION:
T14N R2W SEC 12 LT 17
(EAGLE RIVER RD.)
LOT SIZE: 90750 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
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 (18A3tC80).
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
THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIO/
RECEIVED ~'f~ ~7
April 24, 1997
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 17, Section 12, T14N, R2W, S.M.
Septic System Design
Impacts to Adjacent Properties
RECEIVED
APR ~ 4
D MUnicipali
ept. Health [Y~°f,._Anchora
Dear On Site Services Engineer:
We hereby apply for a permit to construct a septic system on Lot 17,
Section 12, T14N, R2W, S.M. to replace the existing system which has
failed The attached site plan and backup documentation identify the
location of the new septic system proposed to serve the 4 bedroom house
on the lot. Testholes placed in the area of the proposed absorption trench
revealed a silty gravel with a percolation rate of 30 minutes per inch. No
groundwater was noted during the monitoring period nor is any present
now,
The existing septic tank and absorption crib will be crushed and
backfilled. The existing absorption trench which was added in 1974 will
be abandoned in place. During excavation for the testholes we found the
distribution pipe from the crib to the trench completely blocked with
sludge. No effluent had been draining to the trench for many years and the
trench is clean. Materials used to .construct the trench, however, do not
meet current requirements.
A Class C Well existing to the east- of this lot and the septic system will
be constructed outside the 150' protective radius. All other separation
distances will also be maintained.
The surface of the lot is fairly flat with only minor slopes from east to
west. Drainage patterns on the lot will be maintained after construction.
Steel pipe sleeves will be placed where the new line crosses under
driveways and parking areas. Insulation will be placed above the steel
pipe sleeve to prevent freezing of the delivery lines.
'Lot 17, Section 12, T12N, R2W, S.M.
April 24, 1997
Page Two
If the system is constructed as designed the following statements can be
made:
The system, if constructed as designed, will have no adverse impact
on the wells in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact
on existing septic systems in the area or those to be constructed in
the future.
The system, if constructed as designed, will have no adverse
impact on reserved space, either surface or subsurface, on any lots
located in the area.
The system~ if constructed as designed, will have no adverse impact
on drainage patterns in the area. The current drainage pattern will
be maintained.
Some surface grading may be required to assure a minimum of 100'
separation between surface water and all components of the septic
system. Grading and filling will not impact the current drainage patterns.
Sincerely,
Michael E. Anderson, P.E.
Attachments
LOT 17, S. 12, T14N, R2W, S.M.
AREA MAP
SCALE 1" = 100'
12
18
GRID NW 52
150' PROTECTIVE
RADIUS
;EXISTING TRENCH
TH #1
FOUR BEDROOM HOME
EXISTING WELL
NOTE:
EXISTING SEPTIC TANK AND CRIB TO
BE CRUSHED AND FILLED WITH
SAND.' EXISTING DRAINFIELD TO BE
ABANDONED IN PLACE.
ALL PIPING UNDER DRIVEWAY TO BE
SLEEVED WITH 6" STEEL PIPE. 2"
OF DIRECT BURY INSULATION TO BE
PLACED ATOP PIPE.
SITE
SCALE 1',' = 20'
LOT 17, SECTION 12, T14N, R2W. S.M.
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Four Bedroom Home
Perc. Rate: 30 Min./Inch
Application Rate: .6 GPD/SF
Deep Trench System
1,250 Gallon Septic Tank
8' Drainfield Rock
Crush & Backfill Tank & Crib
4 Bedrooms X 150 GPD / .6 GPD/SF = 1,000 SF of Absorption Area
1,000 SFI16 SF (Sidewall Area) = 63 LF Length of Trench
Therefore: Construct a Deep Absorption Trench With
Length. Distribution 'Pipe in Trench Placed at 4.0'
Ground Surface.
One Lateral 63' in
Below the Original
NOTE:
TYPICAL DEEP TRENCH SECTION
(NO SCALE)
Grade Area Over Trench to Drain Away.
Maintain Setbacks From' Wells in the Area
Existing Trench to be Abandoned in Place
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:.
DATE PERFORME
LEGAL DESCRIPTION: ~-el' J~ "l-Jq/~J~ ~Z.21,,~ ~/~... Township, Range, Section:
ELOPE SITE PLAN
4-
5
6
8
9
10
11
20-
COMMENT~
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
aa~;fi~? .~J'o ,,/~'
Gross Net Del~h to Net
Reading Date Time Time Water Drop
/~: .~' ~o /Z '1~ " I '1~ "
IZ: ~- II"
'iF ~ I: I.~ ~0 I~." /"
I:;~° d"
PERCOLATION RATE "'~ (minutes'inch) PERC HOLE DIAMETER
T~ST.U..~WE;N /' '/~' . ~ AND 7 '/~ ~
ADDO.o^.CE W,TH ^~ STA.E A.D MU.,O,F~ GUID"' ,.ER ,N EFFEO. O.'.,S OAT~ DAT~' ' q/Z¢/q7
72-00~ {Rev.
Munir.,ipallty of Anahomge
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR.- ASI~Y
1
2
3
4
5
6
?-
8-
9-
10-
12-
13-
14-
16-
17
19-
20-
COMMENTS
DATE PERFORME!
~=.. I~.Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
SITE PLAN
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Dr~o
'~ ~ '~/~?/e~ /= ='~ /~/~." --
~tiS. IW.~'/&"
3O
PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BE-TWEEN ~ f/~' FT AND '~ I/Z'~' FT
ACC0ROA.CE ~T. A" ~ATE A"=%.,C,.A' ~-.,O~,.E~,. E.~ECT O. T.,S =A.~ OAT"'' ~//~/e '~
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: Lot 17, Section 12, T14N, R2W, S.M.
GENERAL:
SEPTIC
The scope of this project includes furnishing and installing
a new 1,250 gallon septic tank. Work also includes the
construction of a new deep absorption trench a total of 63'
in length with an 8' effective depth. The existing septic
tank and absorption crib will be crushed and backfilled. The
existing absorption trench will be abandoned in place.
Construction shall be in accordance with the approved site
plan, design drawings, Municipal Permit with any special
provisions or conditions, and all applicable State and
Municipal Wastewater Disposal Regulations.
The Contractor shall be responsible for obtaining all
underground utility locates and for the layout of the septic
system and verification of the location of all lot lines.
Unless specifically agreed otherwise, the contractor shall
be responsible for final grading areas subsequently
depressed from soil settling. Property owner shall be
responsible for revegetation of affected areas unless
specifically agreed otherwise.
Contractors installing wastewater disposal systems must
be certified by the Municipal Department of ,Health and
Human Services for system installations. Owners installing
their own systems must receive prior approval from D.H.H.S.
before beginning system installation.
TANK INSTALLATION
A new 1,250 gallon septic tank must be procured from an
approved source and installed at the location shown on the
Site Plan.
Lot 17, Section 12, T14N, R2W, S.M.
April 24, 1997
Page Two
2. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" ¢leanouts
for pumping access.
3. The septic tank shall be sufficiently bedded to prevent
settling or shifting of the tank.
4. All standpipes on the septic tank shall extend a minimum of
12 inches above final grade.
5. Tanks installed without 4' of cover shall have a minimum of
2" of direct burial insulation.
A foundation cleanout shall be installed one to four feet
from the building foundation. Two cleanouts are required
between the tank and the drainfield.
7. Final grading over the tank shall be such that a positive
slope exists away from the septic tank.
DRAINFIELD CONSTRUCTION:
The drainfield shall be constructed to the dimensions shown
on the design. The bottom of the trenches shall be within
2" of level.
2. Distribution piping must be placed level with perforations
down atop a level bed of drainfield rock. Rock should then
be placed over the pipe to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between
the drainfield rock and the natural soil backfill.
Monitor tubes must be 4" in diameter and installed at the
locations shown on the design. The portion below ground
must be perforated.
Lot 17, Section 12, T14N, R2W, S.M.
April 24, 1997
Page Three
Contractor shall verify the septic tank and drainfield are a
minimum 100' away from any private water wells in the
area, 150' from a Class "C" Well or 200' from any community
well.
Direct bury insulation must be placed over the distribution
system if less than 3' of backfill depth is available. Finish
grade over the trench must be mounded to prevent
settlement or depressions.
7. Grade area surrounding the absorption trenches to drain
away.
A minimum 2' of accepting soil is required below the
drainfield rock for a 5' wide trench. Contractor shall verify
this condition prior to placement of the rock. All' pockets of
unacceptable materials must be removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a Municipally approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C.
(perforated and solid), ASTM F810 or H.D.P.E. (perforated, but
not solid) and ASTM D2662 or A.B.S. (perfo.rated and solid).
3. Insulation shall be at least 2" thick extruded direct burial
polystyrene (Dow Chemical Co. Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
Lot 17, Section 12, T14N, R2W, S.M.
April 24, 1997
Page Four
5. A permeable geotextile fabric (Typar, Mirafl or equal) must
be installed between the final drain rock layer and the
native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with' less than
3% passing the #200 sieve.
INSPECTIONS:
A minimum of two inspections are required by Municipal
Ordinance. These inspections must be conducted under the
supervision of a professional engineer registered in the State
of Alaska. The first inspection must be conducted after the
excavation of trenches, beds or pits and before the installation
of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement
of the geotextile fabric, gravel, distribution piping,
standpipes, cleanouts and insulation. No backfill should be in
place at the time of inspection.
Contractor shall provide a copy of all field survey layout and
construction notes for use in preparing the certified as-built
of the completed system. :
121
GREF' R ANCHORAGE AREA BOR;' ' IGH
of Environment Quality
Department
3500 Tudor Road
Anchorage, Alaska 99507
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME STeUE 'J)~v. wi'l,t~ MAILING ADDRESS PHONE
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH
MANUFACTURER
INSIDE WIDTH
COMPARTMENTS -
LIQUID DEPTH
LIQUID CAPACITY J 000 GALLONS.
T ' :
DISTANCE FROM WELl
NUMBER OF LINES
ABSORPTION AREA
FOUNDATION
DISTANCE BETWEEN LINES
SQ, FT. LENGTH OF EACH LINE
DEPTH OF FILTER
DEPTH: TOP OF TILE TO FINISH GRADE
TOTAL LENGTH
OF LINES ~/01
NEAREST LOT LINE
TRENCH WIDTH ~6' IN. TOTAL EFFECTIVE
MATERIAL BENEATH TILE
IN. ABOVE TILE .IN.
WELL:
TYPE
BUILDING
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST NEAREST
LOT LINE__ SEWER LINE_
OTHER SOURCES
DISAPPROVED
DEPTH
SEPTIC SEEPAGE
TANK-- SYSTEM
REMARKS-
DISTANCE FROM:
DISTANCES:
DIAGRAM OF SYSTEM
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form PW¢027
DATE~
GreaTER ANCHORAGE Area BorOUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-4561
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
PERMIT NO.
INSTALLAT ON LOCATION~__~~L~' ~ /~ '~/ 7
LEGAL DESCRIPTION
INSTALLATION Of: SEPTIC TANK SEEPAGE Pit
TYPE AND SIZE OF FACILITY TO BE SERVED %~!~
FINANCED THROUGH TO BE INSTALLED BY
SOIL TEST RESULTS
COMPLETION DATE ANTICIPATED
DRAIN FIELD .
PHONE .
NOTE: THIS PERMIT IS NOT VALID WITHOUT BOIL TEST
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK U~/
FOUNDATION TO SEEPAGE PIT ~//~ / DRAIN FIELD
SEPTIC TANK TO SEEPAGE Pit WALL ~/~f/
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC: TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH R GULATiONS REGARDING INSTALLATION.
TYPE
DIAGRAM OF SYSTEM
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, ~ ~~
.., _.,._...,...... .
Performed For (~/i~ 7~/~
Leoat ~escrintion: Lot
This Form Renorts Soils Loq
One ~est t~ '~orth a thousand opJmons
PZ~ ~,,~" Date Performed ..
Block ~ubdivision
Percolation Test
Depth
Feet Soil Characteristics
1
2
3
4
7__
Ground Water Encountered?
Yes, At what Depth?
I Readinq Date Gross Time Net Time Depth to H20 Net Dron
Percolation Rate Hinute ~-.
d' ' Prorosed Installation-: See~aae Pit Drain Field
t Depth of Inlet Depth To Bottom Of PitxO? Tr~enc
Test Performed By 1~ r~"cA Data Certified BY:__~-~
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. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
05027302 HAA# ~[ ~-~C~ -~ [~-)% \..~)
1. GENERAL INFORMATION
Complete legal description
Lot 17, Section 12, T14N, R2W
Location (site address or directions) 17041 Eaqle River Road
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Abiqail F Dunninq Dayphone 694-2250
P.O. Box 773682 Eagle River, AK 99577
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
4 '~
NOTE:
Individual well XXX
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
XXX
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (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
Address
Engineer's signature
Anderson Engineering
Phone
P.O. Box 240773 Anchorage, AK 99524
563-7155
May 27, 1997
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 regis~[ered in the State of Alaska. The DHHS does this as a courtesyto purchasers of homes
and their lending institutions in order to satisfy eertain federal and state requirements. Em ployees of DH HS 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.
7
Legal Description:
A. WELL DATA
Well type Private
Log present (Y/N) N
Total depth 80 '
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform 0
Date of sample: 5/1 9/97
B, SEPTIC/HOLDING TANK DATA
Date installed 5 / 97
Foundation cleanout (Y/N)
Date of Pumping New
C, ABSORPTION FIELD DATA
Date installed 5/97
Length 63.5 ' Width
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division ~[ ~4~!4Y4~ D
825 L Street, Room 502 · Anchorage, Alaska 99501 · (
Health Authority Approval Checklist 'JUN 2 1997
Municipality of Anchorage
Lot 17, Sec. 12, T14N, R2W Parcell.~..ept. l~"~anServices
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Unknown
Cased to 80 ' Casing height (above ground) 1 8"
¥ Wires properly protected (Y/N) ¥
FROM WELL LOG AT INSPECTION
Unknown 5 / 19 / 97
Unknown
Unknown g.p.m.
-67 '
7.2
Nitrate
g.p.m.
1.93 mq/L
Collected by:
Other bacteria 0
Stuart Gilbert
Tank size 1 , 250 Number of Compartments 2 Cleanouts (Y/N)
¥ Depression (Y/N) N High water alarm (Y/N) N
Pumper Construction
Y
Soil rating (g.p.d./ft2or fF/bdrm) .6 System type Deep Trench
2 ' Gravel thickness below pipe 8 ' Total depth 1 2 '
Effective absorption area 1 , 01 6 SF Monitoring Tube present (Y/N) Y
Date of adequacy test New Const o Results (Pass/Fail) Pass
Fluid depth in absorption field before test (in.);
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
Immediately after
Absorption rate =
If yes, give date
Depression over field (Y/N) N
For 4 bedrooms
gal. water added (in.): 0
>600 .g.p.d.
D. LIFT STATION - H/A
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E, SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot > 1 00 ~
Absorption field on lot > 1 00 ~
Public sewer main > 1 00 '
Sewer/septic service line > 20 ~
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at*
On adjacent lots > 1 00 '
On adjacent lots > 1 00 ~
Public sewer manhole/cleanout > 1 00
Lift station Hone on Lot
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation > 1 0 ' Property line > 1 0 ' Absorption field
Water main/service line > 2,0 ' Surface water/drainage > 1 00 '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line > 1 0 ' Building foundation > 1 0 '
Sudace water > 1 00 ~
Curtain drain Hone on Lot Wells on adjacent lots
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections
in conformance with MOA HAA guidelines in effect on this date.
Signature
Engineer's Name Michael E. Anderson
Date May 27, 1997
>10
Wells on adjacent lots > 1 00 '
Driveway, parking/vehicle storage area
Water main/service line > 20 '
>5'
>100'
systems are
HAA Fee $ ?¢L.~, (_~..)
Date of Payment (,:~ . ~ c~-~
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
., ~.~ -
a. Bac~i~ //
b. . . '
,,, c. Casing Size
d, Distance from well to closest exlstinz
'~ .[ 5' P~°PerTY L~ne ,'~¢* · . . '
~ ~ ~ 6. Other sources of poss~le contamination, i.e., c~eeks, lakes~
~ houses, barn, drainage ditch, etc..... · ~:'
~ ~ ~ _ ~. /.~/ 'Jr .,~
I b. Septic tank capacity in gallonsf (~ 50~ / ,~~
c. Name of septic tank manuf'actume~ ,
.1. If "~ome made" show dla~am on reverse- -~si~his fo~m.
d.' Dzsposal f~eld oP seepage pit size and t~e ~ ~ ,. ,
/
1, Distance to pPope~-.~ne ~ ~ to house fo~dati ~ .*.
e. Perco~l~ti~ Te%~t 'results ..... .
f. Percolation Test performed by . .
~ Use the reverse.szde of this form to show dia£ram. Dlafra~ should include
~.~he ~oilowing information: ~operty lines;.well location, house locatzon,
~k~rtz¢ tank location, disposa~ area location, location of percolation
an~.. direction of Eround slope.
9. The lnforma~ion on this form is true and correct ~o the best of my knowledge.
Signazure of Applicant
Date Signed
"T,O, BE FILLED OUT BY HEALTH DEP,ART{.JENT PERSONN,EL
~e above described sanitary facilities are hereby approved, subjec?..to the
.......... ~.~611~owing con~ions:
Conditions :. .
The above described sanitary facilities are disspproved for the following
reasons:
'-~App~-ovat is valid for one year fgl&owing the date of approval.
- CPJ:cw