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Home My WebLink AboutKNIK HEIGHTS BLK C LT 2OI 02. '.,_ MUNICIPALITY OF ANCHORAGE . '7',~''%%,~,,¢,,.,,~.,,~2~,~''¢I~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ~ ~ ENVIRONMENTAL ENGINEERING DIVISION ~ 825 L Street - Anci~orage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~ ~, PH°NE ~,,M~ ,/-, ~ ./. '1::~'77];' :~,./~~ .,. ,..:.,,,, ;// //, ~ // / t ' , . . ~ ~UPGRADE ~M)d LING ADDRESS ~EGAL DESCRIPTION ..; -~ . ~.. , , _ LOCATION NO. -- V~le~l'r'/ ¢ Abs°rptj°'~rea Dwelling / PE~I?NO, ¢ ¢' :"~ .&.5 ~;f,/ 6. "7 ~ ..... Y' .' I~ Manufacturer ,' "]~' d ~. MaterJa)-~ ,¢'~-/ ~ . Nc. of compartments i~< '/ ~ ,~..~ L:: ~ ~L)/-~ .~ .. .~- ~ .. i~ ~ . Liq. cap~ci2~qallons Inside length Width Liquid depth ~ /, :, ¢, , IF HOME.DE:,, ~ ~ [ DISTANCE TO: Well Dwelling PERMIT NO. / Foundation. ~ / Nearest 19~ lig~: PERMIT ?.~t; ( ~, .// ' ) / / ,::; ~-'~t..:) ~""'/ ~ DISTANCE TO: Well . ; ~_ ~"~'/' u E TJqDC]] widl[)', Distance b~tween lines ~ Z~ Nc. of lines ..... Length ct each'Un.e / 7otai length of tines . , ? - ~ ~ Top of tile to finish grade / / Material beneath tile ./.. Total effe¢i~e~so/plion Crea ~ ,t_/ ~*¢ inches L.),~.. 1~:¢~. .... Length Width Depth PERMIT NO. ~ DISTANCE TO: ¢ Class Depth Driller Distance to lot line PERMIT NO. ~ ~ Buildin9 foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: ]IP~ MATERIALS / / ~ --r -- / "/ ill ~.]' ) /,;~./ ~-' ....X .... 7~' / ................. ~O L ~EST RAT'ING. ~,, / ~STA~L~m ~ ~ ~ ~REMAR~SVI ~' __ MUNICIPALITY OF ANCHORAO~ DEPT, OF HEALTH & ,,q., ~VlRONMENTAL PROTECTION ¢ .. N 0 V ~ 2 ~ - .;,..~; . .,'~? RECEIVED " '"' /- ~ ,...] :.:,. .-. '~,~ ,~ ~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT L~GAL DESCRIPTION LOCATION DISTANCE TO: Manufacturer ~ Liq. WellF HOMEMADE: DISTANCE TO: Inside length NO. OFBEDROOMS No. o f~,,~pa r t merits Liquid depth Dwelling PERMIT NO. Manufacturer Liquid capacity in gallons D,ST^NCETO: we"Il,cC ¢-- I Lenath of each line finish grade · · J th IMaterial Foundati~/ f/ I Nearest;~i~ ~ Tota?; t o ,ne, inches MateriaJ'be~eath tile inches Distanc~.~ ytween lin'es Total PERMIT NO, Length Type of crib ;rib diameter Well DISTANCE TO: Depth Building foundation DISTANCE TO: Depth Crib depth Total effective absorption area Building foundation Nearest lot line Driller Distance to lot line PERMIT NO. Sewer line Septic tank Absorption area(s) OTHER MATERI~ ,:~A P,~_P R OV F-]D (~,) / DATE LEGAL DEPI=tRTMENT O, HERLTH FINE:, EN'v'IRONMENTFIL I ]TECTtON 825 L STREE]'., FINCHORFtGE., RK 95~5C4t 264-4728 PERFIIiF NO: FtF'PLICFINT: - , RD[:,RE:SS: F:IqNTF]F:T PHONE: I_EGFIL~ .[:,ESCR I F': LOT _,I~E: I"IFI::-:: BEDF.:OOMS: 84. C44::L2 k.~,,. ~¢:~ :1.,. c, 4 RFtY CUNI'.,I I NGHFIM SRR BOX ::L588-C FINCHORFIGE., FtI< 7;45-5266 SLIB[:,I'¢ISION: KNIK HEIGHTS SECTION: ~.,' TOHN::,HIF: :L2N HI_.Fi.E=, .. 43:5Ci0 (SC!. FT. OR .... ~" LOT: 2 BLC,Z:K: C RFINGE: ]:1.,.I DF FILN::, FI'v'FIIL.FIE:LE TO 'T'OU IN I],ESII]NING '¢OUR SEF"T'IC: LISTED E:ELOH FIRE THE ~ " ] "' ' _ _ E,E:,I FITS '¢OUR _,ITE. SYST~FI. CHOI3SE I'HE FIF'TION THFIT ' '-~ '-- DEPTH TO PIPE BOTTOM <F'r. ) 4. 0 4. 0, 4. 0 GRFI',,,'gL DEPTH (FT. ::' ;-2. 0 0. 5 ~L. 0 TO'T'F/I~ DEPTH (FT.) 6. C4 4. 5, 5. GRFt'v'EL WID"FH (FT. ::' 2. 5 22. O. 5. GRRVEL LENGTH (FT.) :1.57. 0 :+::~: 43:. 0 GRFI',/EL VOLUHE ,::CU. Mg, S. ) 2:6. ]: 3:5. I~ TRNK SIZE (GRLS) 1., 50Ct g~ *:'~: ~.., DOEr 0 SOIL R~'Fi'.NG (SQ. FT. /BR) , :L25 f25 t25 :+; :+: GRFI',,,'EL LENGTH :::, ,'5 FT. RE~¢gJIF. E_, I1UL'TIFLE RUNS (IqOT E,.,L. EED]N~ ,.'5 F"T'. EFIL:H) TRNK hlUST FIR',/E RT LERST TWO COHPRRTHEt',ITS I CERTIFY THFIT: I Flr'l FI:fl','IIL..IFIR HITH THE REQUIF.:EMEI"STS FOR ON-SITE SEHERS I-aN[:,'WELLS FIS SET FORTH BY THE IdUNICIPFILITY OF FINCHORF~GE (FIOFI::, FIND ]"HE S'TFITE OF 2. I WILL IN'.:~]"FILL 'THE SYS"rEM IN FICCORDRNCE WITH FILL MOR CODE'_'-:: FIND REGULFITIONS., FIHD IN COMPLIFINCE 14I'FH THE DESIGN C':RITERIFI OF THIS PERMIT. Z.'.. I !.,.IILL FIDI.-IEF. tE TO RLL MOFI RND STRTE OF FILFISKFI REQUIREMENT'-'; FOR THE SET BRCK [:,ISTFINCES FROH FINY E:SISTING WELL., WRSTEWFITER [:,ISPO:SFIL SYSTEFt OR PUBLIC SEI.,.IERFtGE SYSTEH ON THIS OR FIN'¢ P]DJRCENT OR NEFIRB'T' LO'f, 4. I tJNDERE]TRND THRT THIS PERI',IIT tS VFILI[:, FOR R I',IFI',,-.','II',IUI','I OF 5 BEDROOMS FIND FINY ENLFIRGEMEI'.,IT WILL RID~UIRE FIN FIDDITIONFIL PERFIIT. IF:' FI LIFT STFtTION IS INSTFILLED IN RN ~RER CO',/ERE[:, B"r' I"IOFI BUILI)ING CODES, THEN! ,..:iL.., FIN ELEC'fF'.ICFIL FERHIT FIN[:, IN,~EC. TION I'IU=-:T BE OBfFt.[NE[.b (2) .O:7~-BUILT5 HILL INOT E:E RPFc~.O',/E[:, klITHOUT RI4 ELErC:/TRICFIL INSPECTION REPORT.~ RI'q[:, ,:..5.:, THE El EC'i'F'i}FIL FlOl:Td<. M ~T BE ~E:,OI'.,IE Be F L//1/CENSED ELEF:TRICIRI",t. /C~- ISS_~.[: E,T ~ ,' -_~._ COBWIN 8,-. AS...._DCIATES, INC. CONSULTING ENGINEERS 432! GRAPE PLACE SUITE 204 ANCHORAGE, ALASKA 99504 (907) 561-6151 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 10 11 12 13 SLOPE DATE PERFORMED: /c.,-, , /-.' _ //', SIT~ PLAN WAS GROUND WATER ENCOUNTERED? DEPTH? O P E 14 15- 16- 17 18 19 20 OOMMENTS Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN :,~-.5~ FT AND -~'. ~z,~ FT PERFORMED BY: 72-008 (6/79) DATE: / ? I I MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SI'rE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) LOT 2_ _SLOCK g. KA/I[. t-/~f~#.T.¢ .-s-/,/,R, _ T/2/V R,31g --,<F~c, z 7 Location (address or directions) ! 2 qzto -~ t¢ ~L f3u~/E RD. (b) Applicant Name R47 Telephone: Home 3Z/~ -5-~'~' Business ApplicantAddress 12q50 .%HELB¢~N~ 4,D ~¢¢ 4~ Y¢~/b (c) Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain); (d) Lending Institution ,. Telephone ~ Address ~ ~~ (e) Real Estate Company and Agent Address ~~ (f) Telephone Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family J~' Multi-Family [~] Number of Bedrooms Other WATER SUPPLY Individual Well [~' Community [] Public F1 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation 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 and status. Page 1 of 2 72-025 (1~84) 5. , ENGINEERING FIRM PROVIDINL~ INSPECTIONS, TESTS, FILE SEARCH, DAiA AND INFORMATION · As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name o'f Firm ~ ~.~ //V'~*, Telephone ~---~"~/~ ~ ~ Address __/~O~/ ~¢ ,~,~2~ ~ ~ / ~ ~ ~> DHEP APPROVAL Approved for ~ Approved v,~ Disapproved Conditional Date /r~/~///~ ~'' Terms of Conditional Approval CAUTION 'The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered Jn the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPALITY OF ANCHOR G D~?f. OF I-tEAI.'[H & ~ALTH AUTHORITY APPROVAL (HAA) ENV}RONMI~N'FAL PROTECTION CHECKLIST - FEBRUARY 1984 264-4720 I]I:C :_. 1986 ' Legal Description: L. 2 ~ WELL DATA RECEIVED Well Classification Well Log Present C/N) Total Depth /I ~ / Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (~/N) Separation Distances from Well: To Septic/Holding Tank on Lot tO,/~/~'//~'~'1~ If A, B, C, D.E.C. Approved (Y/N) /t/'//~ Date Completed Yield _ Cased to / / ~ / Depth of Grouting ~/~ '~,/ / ~ Pump Set At gN~Ol~ ~ ¢.~ / Sanitary Seal on Casing ~N) Depression Around Wellhead (Y~} / M.F / ;On Adjoining Lots To Nearest Edge of Absorption Field on Lot __/ZO /4- ; On Adjoining Lots / ¢ C} / ~'- To Nearest Public Sewer Line /'~/~ To Nearest Public Sewer Cleanout/Manhole /'~//~ To Nearest Sewer Service Line on,Lot / .~/~ Water Sample Collected by _/~,~/~/'~/ /~/,/~'/~/ ~"/¢~(~.~) ;Date Water Sample Test Results _~ ~ ~.~,~/~C B. SEPTIC/HOLDING TANK DATA Standpipes ~)N) Depression over Tank (Y~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /~///~ Separation Distances from Septic/Holding Tank: TO Water-Supply Well To Property Line / To Water Main/Service Line Course /OO Size Air-tight Caps CN) No. of Compartments Foundation Cleanout Date Last Pumped N//t'/ ;for '//V'///-)' Temporary Holding Tank Permit (Y/N) //~',~ __ To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed '"~/~J~ Width of Field Square Feet of Absorption Area Depression over Field (Y(~ Results of Last Adequacy Test /V'//~ Separation Distance from Absorption Field: TO Water-Supply Well ~ 20 / "1/' To Building Foundation Lot To Water Main/Service Line ~-~ l ~/~. ..... DEPT. OF HEALTH & ENVIRONMENTAL PROTECTIO' n~r' 4 1988 ~ ~ ,~ rf,l~lo~4~tem Design KELI::Tv Length of Field Depth of Field ~/~ Gravel Bed Thickness Standpipes Present ~N) Date of Last Adequacy Test To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~'~ TO Property Line To Existing or Abandoned System on ; On Adjoining Lots TO Cutbank (if present) /V'// Icc) / ¢' Dm LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions /~" Manhole/Access (Y/N)// //~ "Pump~ ~ / /LI ~'-Vent (Y/N) ~'V///~ / ~ Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments /'~ ** Check Permitted Bedroom Rating Against HAA Request ** I certify that leave q, hc"¢kcd, veri, fie. d, or c.¢nformed to all MOA and,HAA guidelines in effect on the date of this inspection. Signed ~~'~/~'Date / Company ¢'/~-~ //~, MOA No. Receipt No. 2.,¢>¢/ ,'¢~'¢ ? Detect Payment Amount: $ ~, ~ Page 2 of 2 C,O, ALASKA alUIROI meRTAL COF1TFqOL $614ulC8S, lilt. Er,§in¢¢rir, q $ ~rluironmcald Slugies 12/03/86 O I;;AN KRiJMM 670:1 DOWNEY F[NCIi LANE ANCHORAGE ALASKA 995~ 6 SE],LER RAY CUNNINGItAM JEAN KRUMM 6701 DOI~/NEY FINCII LANE ANCHORAGE ALASKA !)953 6 60632 MUNICIPALF[Y OF ANCHORAGE DEP1. OF Y[EALTki & ENVIRCN,M~NTAL Fr<OF!~Ci ION A FI,ON TEST NAS PERFORMED ON TIlE WEI,L. 934 GALLONS OF klATER NAS PUMPED AT A RATE OF 3.89 GPM OVER h DURATION OF 4.25 HOURS. THF.. DRAI~IIONN WAS 5.7 ' ~JT['[II h RECOVI';RY TIME OF ]5 M~N[J'FES AND THE STATIC NATER LEVEl, NAS 78,1 FEET. T[IE ~{EI,I, IS .&¢I,;QUA'I'E FOR TtIIS 5 BEDRO0~ }IOME. 1200 L[~¢sl 33rd Aucnu¢, Sui;¢ B ~' Anchorcqe. Alaska 99503 .(907) 561,5040 CONTROL SERVI(' , INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 SHEET NO OF ' CALCULATED BY J TI~ DATE ~_ CHECKED DY DATE. ~D^LE I '% 30' _J/JELL P.O, BOX 6650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWI ES. MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES December 5, 1985 Dennis Roe Alaska Environmental Control Services, Inc. 1200 West 33 Avenue, Suite B Anchorage, Alaska 99503 Subject: Lot 2 Block C Knik Heights Subdivision Waiver of Required Separation Distances Between the Septic System of Lot 2 and the Well on Adjacent Lot 1:WR85-05 Dear Mr. Roe: The Department acknowledges that the septic system on Lot 2 has been installed within 100 feet of the well on the adjacent Lot 1. Apparently this well was not considered during a Department inspection on August 21, 1984. A site visit, conducted on December 3, 1985, by John Kennedy and I revealed that the orientation of the leachfield as shown in the inspection report(August 21, 1984) was incorrect. Please see the corrected version enclosed. I have evaluated the separation distance involved between the well on Lot 1 and the septic system on Lot 2 in order to determine if a waiver of these separation distances would be appropriate in this case. Well logs and soil tests in the area were examined. Because the water table is relatively deep and protected by layers of silt and other slowly permeable strata, waivers to the required separation distances were granted. These waiver evaluations were performed using the State of Department of Environmental Conservation guidelines. Waivers for the separation distance between the well and septic tank and the well and absorption bed were granted to 84 and 90 feet respectively. Please note that the State had previously granted a waiver to 82 feet for the distance between the well on Lot i and the septic tank on Lot 1. Dennis Roe December 5, 1985 Page Two This waiver will be valid for the existing septic system on Lot 2 only. Any upgrades of the absorption field or septic tank invalidate this waiver. Sincerely, Stephen So Morris Civil Engineer On-site Services SSM/ljw BIG DIPPER DRILLING 7529 E. 6th Avenue June 20, 1984 * Anchorage, Alaska 99504 * (907) 333-6435 Ray Cunningham SRA Box 1588-C Anchorage, Alaska 99507 The following information is your copy of the well log for the property located at Lot 2, Block C, Knik Hts, Anchorage, Alaska. This should be retained as your permanent record of improvements to your property. WELT. LOG 0 To 3 Feet 3 15 15 25 25 28 28 35 35 48 48 56 56 59 59 80 80 90 90 101 101 110 110 116 Soil Sandy silt Silty sand, gravel Gravel Coarse sand, gravel Fine sand, gravel Silty sand, gravel Gravel Silty sand, moist gravel Water, fine sand, gravel Dry sandy silt Sand, gravel Water 15 GALLONS PER MINUTE Thank you for specifying BIG DIPPER DRILLING for your water well needs. This will entitle you to a chance in the drawing for two round trip airline tickets.to Hawaii. The drawing will be held in December. Sincerely, C. R. KRON Owner Licensed · Bonded · Insured MUNICIPALITY OF ANCHORAGE ~EpARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONIVIENTAL 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 lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~e~t~r~jq ~'*~: Telephone: Home Applicant Address /~ (c) ¢~z ,p--_ ~',J~K* Business ,dx', / Applicant is (check one): Lending institution D; Owner/builder~; Buyer ~; Other ~ (explain); (d) Lending Institution __~=2,..~- . , :,-¢,, ~. ,..-,,~r, :u:~;~('" Address Telephone (e) Real Estate Company and Agent / Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family ~ Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Well [~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 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 and status. Page 1 of 2 z, 02.~ <~ 8.~) Authority Approval shows that the on-site water supply and/or wastewater d sposa' s,,ste -n~ ss ~, .... ~unc~on~l"' ' ~m:~'"~h::~,~: ,. :.~:,~::,, for the number of bedrooms and type. olstructureindicated herein. I further verify that based on the inlormm~o~ . ' from the Municipality of Anchorage files and from my investigation and inspection, the on-site water SUpply ~md,', wastewater disposal system i~_~ compliance with all Municipal and State codes, ordinances, and regulations in effect the date of this inspection. ~ Name of Firm /~ ~ ¢'~ ~ ~p_hone~_ ~?~/~ D~O cfc Address ~~ Ef/~F '''~//, ~d,~'d/,2.~/. ~'~-g~':~ Date _~ ([- ~ /- ~ ~- ,,, ~ ..... ' ~ ."1,-~.-~, ~, ' Approved Approved ~ , DisapVvedW Cond~nal Terms of Conditional Approval Date CAUTION The MLIncipality of Ancl~orage Department of Health and Environmental Protection (DHEP) issues Health ~uthority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska, The DIdEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 (1 h84) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: t MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION Well Classification Well Log PresenGN), Total Depth [/'~ Cased to Static Water Level Casing Height Above Ground __ Electrical Wiring in Conduit Y~PN) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E,C. Approved (Y/N) Date Completed ~,-L~,(~-- ~5'~ Yield //~ ' Depth of Grouting Pump Set At /',-% Sanitary Seal on Casing~,l) Around Wellhead (Y/~/ Depression / ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~f* /o'~') ' To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by _ Water Sample Test Results Comments ; On Adjoining Lots ,,'~'/~ To Nearest Public Sewer /(//~ To Nearest Sewer Service Line on Lot ~-~-~"P B, SEPTIC/HOLDING TANK DA'rA Date Installed Standpipes~N) Air-tight Caps Y~) Depression over Tank (Y//~4) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: Size /-~("~O No. of Compartments C%~)~ Foundation Cleanob~N) Date Last Pumped /'(//G - -%~'~-~ ¢¢'*'/ '~'~ Temporary Holding Tank Permit (Y/N) To Water-Supply Well ~'~- To Property Line To Water Main/Service Line Course Comments (~/2 To Building Foundation To Disposal Field To Stream. Pond, Lake. or Major Drainage Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/G)/ Results of Last Adequacy Test Type of System Design Length of Field .G- Depth of Field ~'- Gravel Bed Thickness Standpipes Present Y~4) Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ~7- To Building Foundation ~7" Lot /(-/~- To Water Main/Service Line __ ~'~- To Stream/Pond/Lake/or Major Drainage Course f To Property Line Tq Existing or Abandoned System on ; On Adjoining Lots "~./~ 7- To Cutbank (if present) To Driveway, Parking Area, or Vehicle Storage Area D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/~N'~''~''~ t'~ ~ Off" Level at ~'/ (/'~,'~ Vent (Y/N) /~ Pumping Cycles during Adequacy Meets MOA Test. ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have check¢¢, verified, or conformed to all MOA and HAA g ui~elines in effect on the date of this inspection. Signed ~-~ ~-f'~E6~ Date Co.['npany /~': ~ --/% c MOA No.