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HomeMy WebLinkAboutKNIK VIEW ESTATES BLK 3 LT 26 Municipality of Anchorage Page / 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 Name: Z~o Y ~/~ ~ Wastewater System: ~ New: ~ Upgrade Address:h-o, 8¢~ ¢ v¢0¢¢ ABSORPTION FIELD No. of Bedrooms: Phone: ~¢-~O~¢ ~ D Deep Trench B Shallow Trench ~Be~ ~Mound ~Other Lot: Block: Subdiv~ion: Depth to pipe bosom from original grade: Gravel dep{h beneath pipe Township: Range: Section: Fill added above originsl grade: Gravel Number of lines: Distance belden lines: ~lassification (Private, A,B,C): Total Depth: .¢ased-Tb% Total absorption area: Pipe materiel: / )riller: . - .... Date Drilled: StaticW~ter Level: Installer: D~te installed; Yield: ......... -. . ~ Pump Set at: Casing Height Above Ground: SEPARATION DISTANCES ~ septic u Holding ~ S.T.E.P. F~o~ Tank Field Station Tank Sewer Lines ~/JC~ O ~ ~ ~t~ /' ~ ~ 0 Web /¢0(/ /¢0r¢ /00~ ~ ~ Material:5 %CE L Number°f C°mpa~ments: Sudace r / Water /a¢ / i00 f lde~ LIFT STATION Lot Line ~' / ' L/ / Size in gallons: Manufacturer: -- Foundation '~ / ~/ /~/ "Pump on"¢¢level//at: "Pump~off" level//at: 7[, High waterz/¢ alarm//at: Pump Make & Model I Electrical InsPections pedormed by: Remarks: BENCH MARK Loc~tion ~nd Description: Assumed Elevation: Depadment of Heal~ and H~an So.ices approval ~' ¢'' Reviewed and approved by: Date: 2 -/7-~ 72-013 (Rev. 9/91) MOA 25 PERMIT NO, SW980365 PAGE 2 OF 3 ~uQi~ ip ~l,i~ y...o. ~ Anchor~qe DEPARTMEN/ uI- HI:::AL/H AND HUM'AN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 eAnchoraoe, Alaska 995~9-6650·TeLephone, 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT b~.G^L LOT 26, BLOCK 3, KNIK VIEW ESTATES P.LD. NO. 051--04.5--28 RANKIN ROAiD 3' SEC. LIN.E EASEMENT~ ~ 10' ELEC. __& TF,,L~COlVi. ~/ / A~ox. WAT~ /~ / ~.~ IALT SITE I 3 LOT 28 ~~ LOT 12 NEW BED sca~ P~,R~r~ NO. SW980365 PAGE ~ OF ~ Municip. o, Li-t;.. _y_..oF Anchoro, ae ; DEPARTMENT OF HEALTH AND HUiVFAN SERVICES ENVIRONMENTAL SERVICES DIVISION P,O. Box 196650 ®Anchorage, ALaska 99519-6650®Tetephone~ 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEOAL LOT 26, BLOCK 5, KNIK VIEW ESTATES P.].D. NO. 051--045--28 A B FCO 24:§' 44.0' ST1 25.0' 45.5' ST2 27.5' 47.5' MH 28.5' 48.0' MT1 45.5' 55.5' MT2 46.0' 90.0' 2" INSULAT[ON: SEWER ROCK 99.2' MT1 100.1' % "-98.1' --g5.6' 95,6' 15' 89.6' WATER FOUND §8.1' BOH PRESSURE DIST, BED: 3 LATERALS ~ 36' LONG EACH 10 HOLES/LAT· (4' O.C.) - 30 HOLES TOTAL 3/16" DIA. HOLES FACED DOWNWARD 1" DIA. LATERALS 2" DIA. SOLID MANIFOLD SOUTlt FORK CONSTRUCTION P,O. BOX 770567 EAGLE RIVER, ALASKA 99577 (907) 694-4351 FAX (907) 694-1122 Re: Electrical connections - septic lift station Lot 26 Block 3 Knik View Estates To Whom It May Concern: In October, 1998, the electrical portion of the septic lift station installation on the above referenced property was performed by Jeff Foster of Silva Services. Mr. Foster's license number is #19970386. Please call if you have further questions. Sincerely, Dan Janke South Fork Construction MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 995'19-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Date Issued: Sep 17, 1998 Expiration [:)ate: Sep 17, 1999 Permit Number: SW980365 Legal Description: KNIK VIEW FSTATES BLK 3 LT 26 Design Engineer: 0003 S & S Engineering Owner Name: LeRoy Alderman Owner Address: P.O. Box 670054 Chugiak, AK 99567- This permit is for the construction of: [] Disposal Field [] Septic Tank ~] Holding Tank Parcel ID: 051-043-28 Site Address: Lot Size: 40000 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 [] Privy [~] Private Well [] Water Storage 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 ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). : 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: Date: Date: HEALTH AUTHORITY /LPPROVALS SEWER & WA'r ER MAIN EXTENSIONS SEWER & WATER rNSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & ELOWTEST SITE PLANS ROAD DESIGN SO]LTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM DESIGN ROBERT C. COWAN, RE. ROBERT A. SHAFER, RE. September 11, 1998 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 26, Block 3, Knik View Estates Subdivision CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 Request you issue a permit to install a septic system to serve the three bedroom dwelling on the referenced property. Two test holes were excavated and percolation tests performed. The approximate location of the test holes are located on the attached site plan. At the time of excavation 08/4/98 water was encountered in the test hole. After seven days of ground water monitoring the test hole reflected water at 7 feet. We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent prope~lies. If you require additional inlbrmation, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/mg Enclosure 17034 NORTH E4,GLE RIVER LOOP · SUITE 204 ' EAGLE RIVER, ALASKA 99577 : I" = 60' SCALE SITE PLAN DESIGN / / / / / 0 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION:~T ¢~-(o /~/-~. ~ Township, Range, Section: DEPTH 2 '5. 3 t :~ 4 $ 10 14 17 18 2O COMMENTS SLOPE WAS GROUND WATER .~.< J 7,~ ENCOUNTERED? SITE PLAN 7 LZ oL P E IF YES, AT WHAT DEPTFI? Deplh to Water Alter Monilorino? Reading Date Gross Net Depth to Net Time Time Water Drop ?/t.,~,,.~,~~/,-//,~ ¢ o :).?'6.. - PERCOLATION RATE ~'~J Immures/inch) PERC HOLE DIAMETER TEST RUN BETWEEN /~ FT AND __ FT PERFORMED BY: 11034 Ea~lle ,iver Loo~ Roa, N0. ,~ O/~ ~ CERTIFY THAT. THIS TEST WAS PERFORMED IN EaCe River, Alaska 99,511 - ' ACCORDANCE WITH A~L STATE AND MUNICIPAL GUIDEt. INESIN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) PERFORMED FOR: /--I~,,/~O '~' Zo T ~ LEGAL DESCRIPTION: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15- 16- 17- 18- 19- 20- COMMENTS SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water Alter Monitoring? ~7 Date: Reading Date Gross Net Depth to Net Time Time Water Drop o - '?" - /.~' i0 to /~,~ 7" ~ ', PERCOLATION RATE (mmnutes/inch) PERC HOLE DIAMETER __ TEST RUN BETWEEN ~ '/~' FT AND__'~//~ F7 PERFORMED BY: 1703., EaglehlaskaRlver Loopy¢5~Road No. 2~ - ' ~ CERTIFY THAT T~IS T~ST ~AS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECTON THIS DATE. DATE: ~* / II ~ ~' 72-008 (Rev, 4/85) ON-SITE WASTEWATER DISPOSAL SYSTEM ROBERT C. COWAN, RE. ROBERT A. SHAFER, RE. CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WEL~ INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ONSITE WKSTEWATER DISPOSAL SYSTEM DESIGN REFERENCE: Lot 26, Block 3, Knik View Estates Subdivision September 11, 1998 GENERAL: CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 The scope of this project includes the installation of a 1250 gallon SiT.E.P. tank and an absorption bed to serve the proposed three bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible roi' obtaining any necessary underground utilily locates. Unless specifically agreed otherwise, the property owner shall be responsible lbr final grading areas subsequently depressed fi'om soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satiafactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department fol' system installations. Owners installing their own systems must also receive prior approval fi'om the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufactm'er. Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tartk. All standpipes on the septic tank shall extend a minimum of 12 inches abovc final grade. 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet fi'om the building foundation. In the line between the tank and the leachfield there shall be two adjadent cleanouts 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 Page Two Lot 26, Block 3, I~'fik View Est. S/D Sept 11, 1998 (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than i 0 ft. fi'om the tank. Tl~e first cleanout, in line, shall be to clean toward the leachfield. The second cleanou~ shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. LEACHFIELD BED INSTALLATION: Excavate the proposed Bed Area to the depth shown on the design. The bottom of the excavation shall be within 2 inches of level. If the bottom of the eXcavation becomes smeared, it must be raked or scratched (ruffed-up) before gravel or sand placement. Ifa sand layer is required, place sand over entire excavation to the required depth shown on the design. The top of the sand layer must be within 2 inches of level. Sewer rock shall be placed uniformly throughout the entire bed. Perforated distribution pipe must be installed level with perforations down. Gravel depth below the perforated pipe shall be a minimum of six (6) inches. Gravel depth above the perforated pipe shall be a minimum of two (2) inches. The total gravel depth tltroughout the entire bed shall be a minimum of twelve (12) inches. The perforated distribution pipes must be no more than six feet apart. The distance between the outermost perforated distribution pipes and the sidewall of the absorption bed must be no more than tl'u'ee feet. Silt barrier material must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before Placing backfill. Monitor tubes shall be of four (4) inch diameter, installed at the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending tl'n'ough the gravel depth shall be perforated six (6) inches below the bottom of the horizontal distribution lines. The monitoring tube should not extend below the bottom of the gravel surface. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finished grade over the bed must be mounded to prevent tlie formation of a depression after settling. Page Three Lot 26, Block 3, Iqaik View Est. S/D Sept 11, 1998 MOUND SYSTEM INSTALLATION: 1. Any peat or organic matter must be removed fi'om the elevated mound site. The bottom of the basal bed area as well as the top of the sand filter is to be within two inches of level. : The distribution piping is to be of PVC (ASTM D3034 or equal). All joints are to be solvent cemented. The side slopes of the top layer of the mound system must not be steeper than 33% (3:1). The top of the mound shall be covered with a minimum of 6 inches of topsoil and vegetated sufficiently to prevent erosion. The distribution pipes are to be embedded in sewer rock. Care should be taken to backfill in such a way as to prevent damage to the piping system. Silt barrier material must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Backfill over the final gravel layer must not be less than twenty-fora- (24) inches. Insulation must be installed when the backfill depth is less than thirty2six (36) inches. MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: T_y. ge of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Page Fora' Lot 26, Block 3, Knik View Est. S/D Sept 11, 1998 Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. When sand is being used as a filter material, its gradation specificatiOns must conform to current M.O.A. or D.E.C. requirements. INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tai~ may be set in place, but may not be backfilled befbre this inspection. The second inspection must be conducted after the placement of the Silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. Page Five Lot 26, Block 3, Knik View Est. S/D Sept 11, 1998 The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure: of the contractor to can'y out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER MUNICIPALITY OF ANCHORAGE 4 �! Development Services Department _ Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 051-043-28-000 Legal description KNIK VIEW ESTATES BLK 3 LT 26 Site address 21944 RANKIN RD Chugiak AK 99567 Expiration Date: 3/20/2025 Current property owner(s) FLESHER TIMOTHY E &CRITES-FLESHER LILIAN A X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for Comments or advisories: bedrooms, with the following stipulations: Original Certificate Date: 3/29/2024 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory X Arsenic Advisory Other COSA Approval—June 2022 MUNICIPALITY OF ANCHORAGE Development Services Department '�` p p Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I. D. 051-043-28 Complete legal description Knik View Estates Block 3 Lot 26 Location (site address) 21944 Rankin Rd. Chugiak, AK Current property owner(s) _Tim FieGhpr Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units n Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: © Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 25— - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS n Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ ) Waiver Fee $ Date of Payment G% Y Date of Payment COSA # 6sc, Waiver # COSA Application—June 2022 3 10 UNMP LITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT On -Site Water and Wastewater Section www.muni.org/onsite Septic Tank Advisory Certificate of On -Site Systems Approval # OSC241081 Subdivision: Knik View Estates Block:3, Lot: 26 907-343-7904 Fax: 343-7997 The septic tank for this property is 25 years old. The average life of an asphalt coated steel septic tank is 20 years. Typical replacement costs are $10,000 or more, not including engineering, surveying or MOA permitting fees. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. 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 AUTHORIIY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # O51-O43-28 1. GENERAL INFORMATION Complete legal description Lot 26, HAA# '¢i/~., ~!C\ , : Block 3, Kr~ik View_~Estates Location (site address or directions) NHN Rankin Road Property owner Mailing address MC21/Leroy Alderman PO Box 670054, Chugiak, AK 99567 Day phone 229-8059 Lending agency Mailing address Day phone Agent Address ,. Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well Community well Public water xx¢ ~'- NOTE: TYPE' OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. ×xx If community wastewater system, provide written confirmation frorrl State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA If21 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/orwastewater 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 $ & $ ENGINEERING 17034 Eagle I~iver Loop Road No. 204 Ea.gle River ALaska 99577 Phone Date DHHS SIGNATURE ~ Approved for 2 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 th is as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees 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. 72~25 (Rev. 1/91) Back MOA ~21 Municipality of Anchorage FEB 2 2 19 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MUNICIICALIIY 825 L Street, Room 502. Anchorage, Alaska 99501' (907)E~l~l)¢~-O~/4z[i~TAt' SE~VK. Health AUthority Approval Checklist ,; A. WELL DATA Well type ¢ ~-~ ~ ..r ,4 If A, B, or C, attach ADEC letter. ADEC water system number : Log present (Y/N) Date completed ~--'~ Total depth Cased to __ ~~t (above ground) Sanitary seal (Y/N) ____ ,..~.~A/ifes properly protected (Y/N);~. FROM WELL LOG ~ AT INSPECTION Date of test / Static water level Well production j g.p,m, g.p,m. WATER SAMPLE RE~: Coliform Nitrate Other bacteria Ddt e: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed /0/0%'7/~ ~ Tanksize ) ;~...c-o Number of Compartments '~ Clea~0uts~'N) Foundation cleanout ~/N) "/ ~ J Depression (Y/U-~ ~'/ O High water alarm CN) '7' Date of Pumping '~/4 ~ "~ ~'-J Pumper '- C. ABSORPTION FIELD DATA Date installed )0/G /¢/,~' Soilrating ~g.~5,_-d'.'~'~/orfF/bdrm) O¢~,r Systemtyp~. Length ,3 I~ Width ~ ~ Gravel thickness below pipe (0. ~- Total depth Effective absorption area ~ ?0 /~r ~- Monitoring Tube present ~/N)¥*J Depression over field (Y~I} '~ o Date of adequacy test .~,~ (/4 - /'/'~"'/ Results (Pass/Fail) For -~ bedrooms Fluid depth in absorption field before test (in.)i .~.~ I.~m. me_gCc, tety"a~ gal. water added (in.): Fluid depth (ins) Minut?~tator:~'-~ Absorption rate = : g.p.d. Peroxide tre~a..tmer~past 12 months) (Y/N), If yes, give date 72-026 (Rev. 3/96)* ::; LIFT STATION Date installed ) Manhole/Access ¢:¢~ N ) High water alarm level Cycles tested Size in gallons // "Pump on" level at* *Datum ,'~ o ~- "Pump off" level at* ',7 ~, E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/sept~ec~'hne On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation -/ Property line ~ /o Absorption field Water main/service line / 0 ¢- Surface water/drainage / ¢ 0 Wells on adjacent lets D. 0o + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Surface water Curtain drain Buildine foundation ~ ~ Water main/service line f -/- Driveway, parking/vehicle storage area ~< ,~ 0 ~J ~ Wells on adjacent lots '~ 0 O ENGINEER'S CERTIFICATION in conformance with MOA H~4 guideJines in effect on this date. Signature Engineer's Name ~0&~7 ~. ¢0¢/,,~ Date ~/ ~ / R ~ HAA Fee $_ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number