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HomeMy WebLinkAboutMANN #2 BLK 6 LT 6 Name Phone(si Permit No. No. of ~edrooms ~EGAL DESCRIPTION TANKS MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT DISTANCES  SEPTIC ABSORPTION TANK FIELD WELL LOT LINE FOUNDATION AS-BUILT DIAGRAM (Show location of well, septic system, property hnes, foundafion, driveway, water bodies, etc.) Material TYPE OF SYSTEM [] TRENCH x~ BED [] W. DRAIN [] OTHER Depth to pipe botlom from Tolal depth Irom original grade original grade ~), ~/ FT /,,~ FT' Fill added above original grade ~.. ,t' FT Gravel length zz/~f) FT 7~ 0 $(} FT Total absorption area 81~ FT Gravel depth beneath pipe Gravel widlh Distance beJween lines ~i, FI Pipe material Date Installed WELLS Number gl lines Soil rating Installer ~PRIVATE [] OTHER fldentifv) Classification (A.B.C) Total Depth FT Cased to Installe~ Date Installed: REMARKS: /~(t')6k/tl)jJ~ ; Inspections Peflormed bYl ~(/~- L' ~C/' I /~' ~? ~-~ cedily that this inspe~ion was peHormed according to all Municipal and Stats guidslinss in effect on Ihis date: /- ENGINEER"S SEAL ; : '! 72-013 (3/85) INS~PECTION REPORT MUNICIPALITY OF ANCHORAGE, BUILDING SAFETY DIVISION INSPECTIONS (907) 563-3464 3500 EAST TUDOR ROAD INFORMATION (907) 786-8211 FOOTING ~ ELEC. TEMP. ~ ~ PLBG, UNDGR. ~OUN~ON _ U .~.c, s~v~_ U BOND BEAM ~ ~ ELEC. ROUG~, , ~ PLBG. ROUGH FRAMING ~ ELEC. FINAL d~ ~ GAS TEMP. ~ GAS ~ INSULATION ~ ~ ~ OTHER ~;~" ' ~ MECHANICAL SHEETROCK ~ ~ MECH. FINAL STRUCT. FINAL ~ ~ F~RE FINAL ~ PLBG. FINAL OTHER ~ ZONING ~ OTHER ~O NONCOMPLIANCE OBSERVED ~ CORRECTIONS ESSENTIAL AS COMMENTS EXPLAINED BELOW ,/ ' INSPECTOR ' '"' DATE W~N CORREC'~IONS ARE MADE, PLEASE CALL FOR INSPECTION. 8,-0021Rev../871 DO NOT REMOVE THIS NOTICE ALASKA F1UIBOFlm rlTAL COFITROL $1 BUIC $, IrlC. ~nqineeHnq $ {~nuJr0nmenlal Studies P. O, Box 340668 Anchorage, Al< 99534-0668 (90?) 3?9-5553 *** FA× (90?) 2?6-8?05 January 36, 1990 Municipality of Anchorage Department of Health & Human Services 835 L Street, 5th Floor Anchorage, AK 99501 RE: Lot 6, Block 6, Mann Subdivision #3 I,~ q RECEIVED Today, Alan Wlen and I shot elevations on the sewer system and curtain drain at the above lot. For future reference, the center of the window ledge at the northeast corner of the garage has a relative elevation of 104.05 feet. Here are the relative elevations: Location Garage Window ledge Bed surface Bottom of gravel Curtain drain Upstream monitor tube top elevation water level Downstream monitor tube top elevation water level Elevation (ft) 104.05 103.33 100.05 105.55 95.65 104.39 94,59 Separation between system bottom and water level= 100.0§ 94,59 = 5.46 feet MOA code requires 4 feet separation distance. On Janaary 19, 1990, I measured the water level under the bed at 95.9 feet. Six days later the water level has dropped 1.4 feet. The curtain drain still has slightly over I foot of hydrostatic head. The elevation of the water was 100.4 feet when the test hole was dug. The water table was dropped 5.8 feet. It worksl When the excavator exposed the old bed the rock was clean. It does not appear that it was ever used, The old septic tank was lower on the inlet side tban on the outlet side. The pipe from the tank to the field was disconnected' so water ran into the gravel by the field and probably not into · the bed. The house has been vacant for several years, so' <A,~.~ ~v-)vo ~ tvu~I 2~cf~553 the rock was not contaminated. It was mixed with native $oll and used above the sand as a dike material. It is well over 4 feet above the water table. As the system meets all requirements of the MOA code, please issue the health authority. Sincerely yours, (//Ler~f/y C. R~;id, Jr. Ph~/, PE, Pf-Zesident LCR/sr UI::'E,N ¢:~N.O !;l (}!ii;Iii; tEXE;A',/,'::~f;I:iJN D!',! i!:i¢'~l'"lti!!: ;O(q':/:, ill::;: HiiiiZO~j t::.;!;:!1::!, i:~i:;;!i:i.'ll:i;l',,l ~ 1::; I, i..t,, i',!i.l!i'i );diii: E::(;it'II:::'(:E:; '1H:O '1"O 9!5% cd',l;O '.:i;E~ !. I. I:-','I!,Yl" ;i: F.l!ii Vll I:,.' I I::: ;!; Ii;i;) I:'I;;~ ;!; Eli;.' Itl] '~:;dJ ;I. 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(;:i (::id! 5~; .~::'~ ALASKA [1UIBOIqm [1TAL CO[1T[ OL $1 I UICg$, IrlC. ~,~,;lin~¢rin,:l 6 I~n~ironm~ntol $lu~lics SPECIFICATIONS FOR ELEVATED BED WASTE~qATER TREATMENT SYSTEM LEGAL DESCRIPTION: LOT 6, BLOCK 6, MANN SUBDIVISION 1.0 8ENERAL 1.1 The Drawings, sheets 1 'thru 6, shall be part of this specification. 1.2 All materials and workmanship shall meet the requirements of the Municipality of Anchorage, Department of Health & Human Services (DHtlS), the conditions of the permit, aad all applicable rules and regulations currently in effect. 1.3 Al]. excavations and depths are advisory, and are to be verified or modified in the fleld by 'the Engiueer or inspecting agency. 1.4 It is the responsibility of 'the property owner or iustaller to adhere to approved design for tile installation, to maintain the specified separation distances and to have the appropriate inspections. 1.5 It is the responsibility of the property owner or installer to report to tile engineer any observed conditions which would put the system in violation of state or Municipal regulations. 1.6 If thc installation is not inspected by an AECS engineer, AECS will not be responsible for the installed system. An engineer at AECS should be consulted prior to construction, to determine the number of inspections that will be required and ~o explain what these inspections will invo].ve. 2.0 SEPTIC TANK 2.1 If there is an existing septic tank it may be used if it meets the capacity requirement for the residence and the approval of DIItlS. 2.2 The septic tank shall be a UPC-approved two--compartment tank, constructed of 12 gange steel with bitumastic coating aad set level on undisturbed soil. If 'the tank is buried at a depth of 4 feet or less, it must be insulated with an overlying layer of 2 inch burial type polystyrene rigid board iusulatlon. 2.3 The septic tank shall be at minimum of 5 feet from 1412 WGs~ 33R~ ~VGBUG · &nchoR~qe, &l&ska 99503 · (907) 279-5553 the house foundation, and a minimum of 5 feet from the absorption area. 2.4 The septic tank and bed shall be a minimum of 100 feet from any private well or body of water, 150 feet from Class "C" wells, and 200 feet from Class "A' or "B" wells, unless otherwise specified. Less than the requlred separation dlstance must have prior approval to waiver by DHHS or Alaska Department of Environmental Conservation (ADEC). 2.5 Piping shall be fitted with a mechanical watertight calder coupling on the outlet and inlet of the septic tank. Piping shall be 4 inch solid PVC ASTM D-3034 or cast iron, sloped a minimum of 1/4 inch per lineal foot. If the piping is buried at a depth of 4 feet or .less, it must be insulated with an overlying layer of 2 inch barial type polystyrene rigid board insulation. 2.6 2.7 Cleanouts shall be installed as designated and capped with air-tight rain caps (Jim Caps or equivalent), and extend a minimum of I foot above ground level. If a lift station is required, it shall be a combination lift station septic tank per Anchorage Tank and Welding, Inc. design. Specifications and design drawings are on file with the Muncipality and the engineer. 3.0 SEEPAGE BED 3 I The sand, if specified, shall have a size distribution which meets tbe requirements of ~OA Code 15.65.077. 3 2 The gravel for the bed shall be 0.5 to 2.5 inch, screened rock with less than 3 percent passing the No. 200 sieve. All substitutes must have prior DHHS approval. 3 3 The bottom of 'the excavation shall be level and raked with the backhoe blade to insure tbat the bottom has not been compacted during excavation. 3 4 The distribution pipe shall be perforated 4 inch rigid PVC with a minimum crush strength of 1500 pounds aud shall meet the approval of DHHS for ase as drainfield pipe. Ail pipes shall be laid level, and spaced according to the drawings. 3 5 Monitor standpipes shall be placed as shown in the drawings. They shall be 4 inch rigid PVC ASTM D--3034, or cast iron. Tile section shown with holes may be either drilled 0.5 inch holes on 6 inch centers on opposing sides of the pipe, or a section of regular perforated sewer pipe may be clamped to the solid section with a no-hub coupling or solvent joint. The perforated section of the monitor tube shall be located in gravel only. the portion of pipe above the sewer rock shall be solid. A rubber raincap (Jim Cap or equivalent) shall be placed over the top of the pipe. 3 6 Filter fabric is required. 3 7 Insulation is required, using burial type polystyrene rigid board insulation. There shall be 1 inch of insulation for every foot of soil less than the required 4 feet of cover, but there must be at least 24 inches of soil even though insulation is used. The solid pipe extending from the septic tank to the drainfield shall also have a minimum of 4 feet of cover or an equivalent layer of insulation combined with soil. 3.8 The side wails of the sand and gravel shall be lined with visqueen. 3.9 The sade slope of the mound shall be sloped 1 foot vertical to 3 foot horizontal. 3.10 The top and sides of the [)ed shall be planted with a white clover and red rescue mix, or with Kentucky bluegrass. 4.0 INSPECTIONS 4.1 This bed will require a minimum of foul? inspections. The first inspection will be of the open excavation, to assure that 'the system is installed in the proper soil strata, correct depth and meet minimum specified design parameters. 4.2 Tile second inspection will be performed after sand fill is installed, but prior 'to placement of gravel and distribution pipes. This inspection will w~rify that 'the fil'ter is properly installed, that it meets specifications and that it fulfills the intention of the design. 4 3 The third inspection will be after placement of gravel, monitor standpipes, and distribution pipe, to verify proper installation and position of pipes prior to backfill. 4 4 The fourth iaspection will be after' final backfill and gradiag to ensure that adequate soil cover has been provided over 'the bed. 4 5 The inspection of the septic ta,]k installation can be incorporated with any one of the above listed inspections. 4 6 The lift station will require either an MOA electrical inspection or certification by a licensed electrician, depending on whether the building code applies to this part of the city. ALASKA ENVIRONMENTAL CONTROL SERVICES, INC.- SHEET NO / OF CALCULATED BY DATE CHECKED BY DATE_ SCALE ) .c~ ' ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. JOB SCALE '/ ~'' / ~ 2 ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. SHEET NO. [ OF CALCULATED BY. /* '~"J DATE CHECKED BY DATE- SCAL~ © Z / = Z "q '-'! Fa 0 H PERFORMED FOR: ~"~'~,~' "~'--I'o ·; e'e"~. ~::~ I[[~EER'S SEAL) Municipality of Anchorage ~/4~ 825 "L" Street, Anchorage, Alaska 99502-0650 ' SOILS LOG -- PERCOLATION TEST . DATE LEGAL DESCRIPTION: Township, Range, Section:~-///t2 SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 2O WAS GROUND WATER ENCOUNTERED? /~£ I~i IF YES, AT WHAT / O DEPTH? fleplh to Waler Alter Monitoring? ,:,'~,/' Dale: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND __ FT COMMENTS [~L~ g'O,/~' C¢~ /[~) l~ rlff.~. ~)~4 e/~.~47'l(e~] ~2-go/ ~-~e~ C~¢"O~i~~ ~l/~ )~v~b. PERFORMED BY: /-" ~ '~ I /"' /d~e '-'~' 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) NAME 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 MAILING ADDRESS LEGAL DESCRIPTION PHONE ,~ EW [] UPGRADE LOCATION NO. OF BEDROOMS compartm~ts / Liq. capacity in gallons ~ IF HOMEMADE ~ Inside length ~Width _ ~ Liquid depth ~,~i DISTANCE TO: IWell . , ] IDwelling PERMI~~ ~ Manufacturer ]~ M~terial Liquid capacity in gallons ~O~~ ~ DISTANCE TO'~ . I We Foundation Nea~es~lot line PERMIT NO. ~ ND. of lines Length of each line ~ :Fotallengtb of lines Trench width Distance between lines Topoftdetofmish grade z~ Materialbeneat~ inches Tota~~ area ~ ~ ~ Type of crib [ Crib diameter Crib depth -' / .... Total effective absorption area~ ~- ~ ~Clas~ ~]~Bepth Drille~ Distaace to lot line PERMIT NO. ~ / DISTANCE TO Building foundation Sewer line Septic tank I Absorptioa area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTALt. ER REMARKS DATE LEGAL / 72-013 (Rev, 3/78) )~)IEF'AR]"MENT OF HEAI.,."I'H AND ENVII;?ONMIENTAI,,,, PROTE[:FFION 825 I.., STREET, AI~[]"I(]F~AGI~:~, AK 99501 ,'.,.~ 64,~-- 4727 () F'ERIq I 'T' :(.)Al E:. 1 ,.,~,..IUEL 85 ::;4'7" IENG I NEIEF(ED DES I GN (: 8 l(: ,'..':! 18,,.~ &F'F:'L. ]: A D D I::;; E S !3: C!]N"rAc]' F;'HOI',IE: L. IEGAI.... DESCR I F': I..OT 'S I ZE ,", []/0 S &. ENG'G HARDI...,D GI::d]SS SRB 196X EAGL.,li~: RIVER, Al'c: 99577 694"'"29'79 ) SUE:iD I V I S I ON ~ MANN SEC'f' I ON: ~::,~; 'I"OWNSH I I:::': 1 :l, lxl 4-5()00 (SQ,,F"I'. OR ACRES) LOT: 6 RANI3E: 3W BLOCI<: 6 I...,D'I- I.,,,I:.}[;ATIOIq',~ ~()I¢32EN VIEW DRIVE :t: c e r. t :i, f y 1:,1"1 a'L: :t.,, t am Fami].iar~ wi'Lr'~ the r'equir'ements roi~ c~n-site sewers; and wells as set f'onth by 'Lhe Mun:[cipality of .Aricl'w,)r'age (MOA) and 'Lhe State of Alaska,, :,:':'.,,.' I will :i. nsta].l 'Lhe system in acc;ondar'lc:e wi'Lb all MOA c:c)cles ~:u'ld I*egula'L:i,~:ms, and in compliance wi'Lb {['le design ct'it'.er'ia (:if this per'm~'L, 3,, t w:i, ll adl"m:,pe 'Lo al J, MOA and State c~f Alaska r'equir'em~:ants rcm t,l"m~ set. back dis'lt, anc0:¢s fr'om any existing well, wastewa'Ler, disposal sys'Lem [:)1" pub],ic sewer'age system on :Lhis c)i- ZF:' (.~ LIF::'T S"I'AT:[OIq IS INSTAI.,.,L, ED IN AN AREA COVERIED DY MOA BUIL.DING CODIES,., THEIq (1) AN EI....ECTRICAI.... I:::'EERHZT AND INSF:'ECT]:ON MUST ]3E (:!D'FAZNED~ (2) AS-BU:I:I...TS NII....I... NO"I' BE AI::'PFd]VED N~'FI.,,IOLI"[' AN EL..ECTI:r(ZCAL INSF'IECTZON REPORT~ AND (3) THE IEL. IE[:FFF~I CAI.... N(]RK I"JUST BE DONEE BY A L.:I:CENSED EL.E[;TRICIAN SIGNED (~r'r: L,): CANT: [:;/[:~ S ,~ ~EI'4G' G HAROLD MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~ SOILS LOG [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18, 19- 20- SLOPE qRONM~NT^L PROT~CTI©N DATE PERFORMED: P~ -~,.'~,- '~-~ SITE PLAN IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN FT AND (minutes/inch) FT COMMENTS $ & t:~ I?iGINET~J':~INC~ PERFORMED BY: g(~,~ $.,'~8)'.' CERTIFIED BY: ~FI. 094-2979 72-008 (6/79) SUBJECT: COMPUTATION SHEET OF MUNIC'IPAi, IT¥ OF ANCHORAGE D~PT, OF HEAl, TH ~,NVIRONMF~NTAL PROTECTION RECEIVED. ~OMPUTATION SHEET -,,:, ,.~LE I:~IVE,q, ALASKA 9~577 PH. 694-2979 DALE: SHEEr CKD OF ,I V SUBJECT: ,.,OMPUTATION SHEET DATE.: SHEET BY OF / ROBERFA. SHAFER SPECIFICATIONS FOR ELEVATED BED ALTERNATIVE WASTE WATER TREATMENT SYSTEM I. GENERAL A. Ail excavation & depths are advisory and are to be verified or modified in the field by an engineer. B. All materials & workmanship shall meet the requirements of Health and Environmental Protection permit. II. LIFT STATION III · The stock material for the lift station shall be either galvanized steel (ASTMA-4444-76) or aluminum culvert capable of burial to ].0 feet. The 36 inch pipe :for the lift station shall have a welded water tight bottom of the same thickness & composite as the culvert· C. The top cap shall be rain tight & fastened with screws· All electrical fittings & connections in the lift station shall meet the requirements for a water tight service. E. The sump pump shall be capable of delivering approximately 10 gpm at a head of 20 feet. Fe The sump pump shall be suspended not less than 6 inches off the bottom of the lift station with a chain, or nylon line or set on a steel grate. SEEPAGE BED A. The gravel for the bed shall be screened to sizes of ½ inch to 2½ inches. Be The berm around the seepage bed shall be constructed of impermeable material, and on a slope of 1 foot vertical per 3 feet horizontal. C. The bottom elevation of the bed shall be plus or minus 2 inches. The insulation required shall be dow extruded blue .styrofoam insulation board of the 2 inch thickness, or equal. SRB 196X EAGLE FUVER. ALASKA 99577 CIVIL ENGINEER 694-2979 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 AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Location (site address or direction s)., - Pr~'perty°wner '~i~Ah'\ V/D%'A'~'- Dayphone Lending agency ~ M~iiing address_· Day phone__ Agent - - ' ' Day phon e 3, TYPE OFWATER SUPPLY: ...... ' .... Individual well Corn munity well Public water ' . .- NOTE: If community WelI system, provide wri~en confirmation from S~ate AD~C attest. . mg to the legality and status of system. - 4. TYPE OF WASTEWATER DISPOSAL: Individ ual on-site " ·Holding tank'. .... Community on-site · ':'-'-: .¥. Public sewer NOTE: If community Wa~teWater system, ¢ro¢id'e ' -" ..... 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 o n-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. EngineeCs signature ~ ~ . Date Additional Comments · _:.' .,, ~: '.- .~ ~~' ........ · ~.: '. . ~"':. 'i.-':.:-''--~ . '; "... ~ - .. ~ 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 this as a courtesy to purchasers of homes and their iehding 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. lf91) Back MOA f¢21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~¢~/~; A, Well Data Well type '-~ Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number ~¢/A Date completed ~, ¢. 8~, E-~ Driller ~/¢'1~¢ ~/¢? Cased to ~*~/¢;:~ Casing height '~,~ FROM WELL LOG Date of test Static water level Well flow Pump level1 /k/~¢ ~'~4ot¢:¢ 1,1 SEPARATION DISTANCES FROM WELL TO: Wires properly protected (Y/N) Septic/holding tank on lot Absorption field on lot Public sewer main ~./"',Z~ Sewer service line AT INSPECTION g.p.m. .._% g.p.m. ,,~,, ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of samp,e'. Nitrate ¢) ~ Other bacteria Collected by: '~'~; -% B. SEPTIC/HOLDING TANK DATA Date installed /' Cleanouts (Y/N) ,~ High water alarm (Y/N) Date of pumping /-?/¢ I' .,~ff '~'?~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Tank size / ¢.5~P ¢'.'*~¢0 Compartments r~ ~ J Foundation cleanout (Y/N) ~/ Depression (Y/N) Alarm tested (Y/N) Well(s) on lot / / .~ On adjacent lots ~ ! ~ Foundation ~ To property line '.. ¢~ Absorption field /~.. Water main/service line Surface water/drainage /~ ¢ ~/¢2 ~'~¢,r ~¢-t'" ~)'~'*~1 CONTINUED ON BACK PAGE 72-026 (3/93)~ Front C. LIFT STATION Date installed I ' ~ ~ · ~ 0 Size in gallons Vent (Y/N) y High water alarm level Meets MOA electrical codes (Y/N) 500 "Pump on" level at Manufacturer /-~,L. dC¢/-/ v.~ Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot I ¢,~ On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed /' ¢. ~' ~ (~ Soil rating (GPD/FF) . / ~-¢ System type )"~0¢ Length t~ 0 Width I oI Gravel thickness ~.¢ I~ Total depth Total absorption area ',/~ Cleanout present (Y/N) y Depression over field (Y/N) Date of adequacy test ~/~/¢[ ¢* Results (pass/fail) ~> for ~,.~ Bedrooms Water level in absorption field before test '~,~-~,/ After test I1¢~ 't Peroxide treatment (past 12 months) (Y/N) ~"1 If yes, give date ~///% SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot [ ~ ~ To building foundation On adjacent lots ) Surface water ~ e v~ .-e.~. Curtain drain '~-~ On adjacent lots '~'~ / ~O Property line To existing or'abandoned system on lot Cutbank ~'~ o ~,! ~ Water main/service line Driveway, parking/vehicle storage area ,~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number CT&E Ref.~ Matrix Client Sample ID CT&E Environmental Services Inc. Laboratory Division ,f. arjj.~-.~.~fj.~j~jfjjjjffj~~~~~ 95.1 15- Laboratory Analysis Report L6 BLK6 ~ Client Name TOBBEN SPURIC~J%ND, P.E. WORK Order 13610 Ordered By Printed Date 04/04/95 ~ 14:16 hrs. Project Name Collected Date 03/31/95 ~ 12:50 hrs. Project~ Received Date 03/31/95 ~ 16:30 hrs, PWSID UA Technical Director STEPHEN C. EDE Sample Remarks: SAMPLE COLLECTED BY: T.S. WITNESSED BY J.S. Qc Allowable Ext. knal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 0.86 mg/L EpA 353.2 10. 04/03/95 CMR See Special/Instructions D~bove UA = Unavailable Undetected, Reported value is the practical cf~an~ificaticn l:mit. LT = Less Than Secondary dilution. GT = Greater Than 200 W. Potter Drive, Anchorage, AK 9951 8-1 605 -- Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA  MUNICIPALITY OF ANCHORAGE ~ · Department of Health & Human Services ~ , . DIVISION OF ENVIRONMENTAL SERVICES ...... 343-4744 - ~. ; .; , 'cERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # 4~) ~ c2 ~ ~ ~' / - / '7 HAA # /~L¢~ c:) ~o o &~ 1. GENERAL INFORMATION (M.ust be'Completed prior to submittal) (a) Legal DescriptioQ,~r,~pJ, pde 10t, block, subdivision, section, township, range) Locati~re~¢~ ,~ (b) Prope~¢~¢ -~t ,. ~. (c) Lending institution Mailing Address Telephone: (home) Telephone Business (d) Real Estate Company and Agent Address Telephone Mail the HAA to the following address: (or check here~ hold for pick up.) (e) List contact person and day phone number below: TYPE OF RESIDENCE Single-Family./~E~._ Number of bedrooms WATER SUPPLY Individual We I I)li~' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. · ' "" ' SEWAGE DISPOSAL On-site'~ 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, 72-025 (Re',', 7/08} Page 1 of 2 E~ JO ~ S6ed .... ')~JO~ s,JSSu!I~Ue leUO!SSsJoJd sql, u! SU0JSS!LUO JO SJOJJS JOJ Slq~SuodseJ ~OU S! Sl~eJoqouv JO XHled!o!un~ sql 'penss! s! sleo!;BJeo e eJojeq elep SZXleUe Jo suoBosdsu! ~onpuoo ~ou op SHHO ~o sseXOldLU3 'StUSLUeJ!nbsJ stets pue leJeps~ u!eHeo ~Js0,es 0t JepJo u. suo.lnLtsu. I~u]pusl :J!eq~ pue SeLUoq JO sJsseqoJnd o~ XssHnoo e se s!q~, seop SHHQ sqJ. '~>lSel¥ ~o e~etS eqt u! psJsls!§sJ Jssu!l~us leUO!SSSjoJd ~uepuedspu. u~ Xq SAOqB ~ qdeJl~eJed u! USA!I~ suop, etusssJdsj sql uodn ~lUO psseq psleo!J!Jso le^oJdd¥/q!Joq~n¥ qtleSH senssj (SHHQ) seo!^JsS ueLunH pu~ qtleSH Jo tUeLuHeds(::] SeeJoqouv ~O Xt!l~d!o!unl~ :.. leUOB!puoo leAojddv leuo!l!puoo JO SLU,I@/ pe^oJddes!O ~, pe^oJddv Xq SLUOO~peq =~,¢¢/JOJ pe^oJdd¥ 'l¥^Obldd~ SHHQ '9 euoqdele.L ?G/ sseJpp¥ ~ ~2-~7 ~ cu~!:l jo euJeN · 'uoRoedsu! slql jo elep eql uo loejje u! suo!~,elnSeJ pue 'seoueu!pJo 'sepoo pue led!o!un~ lie qIF~ eoue!ldLuoo u! s! Lue~s/,s leSOdsip ~e~e/~e~seM ~o/pue Xlddns ~e~e/~ el!s-uo eq~ 'uo!~oedsu! pue uoBee!~se^u! XLU ~uo~J pue sel!J eee~oqouv Jo AHledio!unlhl eq~ LUO~J peu!e~qo uoBeuuJoJu! eq~ uo peseq ~eq~ ~JHe^¢eqlJnJ I 'u!e~eq pe~so!pu! e~nlon~s ¢o ed41 puc SLUOO~peq ;0 ~eqLunu eq~ Joj e~enbepe PUUleuoBounj 'ejes s! LuelsXs lesods!p ~ele~e~,se/~ ~o/pue Xlddns Jelet~ e~,!s-uo eql ~,eq~, s~oqs le^oJddv ~;Hoqlnv qlleeH s!q~ jo uo!~e6!lse^u! XLU ~eql ~Jpe^ I '/~oleq u/~oqs e~ep uo!leP!le^ eq~ jo se pue o~e~eq pex!j~e leSS/,LU Xq PeijiHeo sV NOIJ. VlNeO4NI aNY vzva 'HOUYaS 3'11.-I 'S.L$:~J, 'SNOIJ. O~dSNI DNIQIAOEId INblld DNIId:B3NIDN:a 'g Parcel I.D. # MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) LocatLc~(ad d¢,(~ bT,directions) Ma n~es~"C .:¢ ~ (d) Rea'l Estate Company and Agent Telephone: (home) Telephone Business ~ Address Telephone (e) Mail the HAA to the following address: (or check here,,~3~if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family/l~ Number of bedrooms 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If commgnity well system, must have written confirmation from the State Depa[tment of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site,J~' Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legaitty and status. 72-025 (Rev. 7/88) Page 1 of 2 ~ ~.o ~ eaed 'HJOM s,Jeeu!6ue leUO!SSe~oJd eqj u! suojss!uJo Jo sJoJJe Joj elq!SuodseJ ~ou s! eBeJoqou'~, ~o ,~!led!o!u nlAI eq/.penss! s! eleo!j!lJeo e eJojeq ~jep ez,qeue Jo suoBoedsu! ~onpuoo ~ou op SHHQ ~o see,~oldLU~] 's~ueLueJ!nbeJ re, els pue leJepe~ u!elJeo ~jsp, es o~ JepJo u! suoBnu~su! 8u!puel J!eqj pue SeLUOq JO sJeseqoJnd o~ ~sepnoo e s~ s!q~, seop SHHQ eq.L '~selV ~o el~S eq~ u! peJejs!8@J Jeeu!Due 18uo!sse~oJd ~,uepuedepu! ue ~q eAoqe ~ qde~Se~ed u! ue^!8 suo!~jueseJdeJ eqj uodn ~lUO peseq pe~eo!~!Jeo le^oJddv ~poqlnv q~,leeH senss! (SHHQ) seo!^JeS ueLunH pu~ qlleeH ~o lueLUp~d@Q eS~Joqouv ~o Xql~d!o!unl/~ eq.L . ..~ ~" ~'-~C¢)' leAOJddVleUOil!pu(io,ostuJe.L ~ leUO!~!puoo pe^oJddes!a pe^oJddv o Z¢-- ~ -~ el~C] ~ .-~.-~,~/ ,~q sLuooJpeq~Jo, peAoJddv 'IVAO.ddV SHHQ '9 E-~j.._F_f._..~/~ ~ euoqdele.L ~tT* 5-2~/ LUJ!:3 ~0 euJeN 'UO!lOedsu! s!til jo e~p eql uo loej~e u! suoB~lnDeJ pue 'seoueu!pJo 'sepoo e~elS pue led!o!unR lie ql!M eou~!ldtUOO u! s! tue~s,~s lesods!p JeleMelSeM Jo/pue,qddns JeleM elis-uo eql 'uo!joedsu! pue uoijeSBSeAU! XuJ uio~j pue sel!~ e6eJoqou¥ jo X~!led!o!unR eq~ tuoJj peu!e~qo uoRmuJoju! eql uo peseq leq~,~jpeA JeqlJn~ I 'ujeJeq pe~eo!pu! eJnlonJls jo edXj pue stuooJpeq jo JequJnu eqlJo1 e~enbepe pueleUOBOunj 'eels s! tuels,~s lesods!p j@~eMe~SeM Jo/pue Xlddns JeleM el!s-uo eql leql SMOLiS leAoJddv ,qpoqlnv qlteeH s!ql jo uo!l~S!lse^u!/~tu leql,~Pe^ I 'MOleq UMOqS elep uoReP!leA eql Jo se pue oleJeq pex!JJe leeS,~tu ,~q Pe!~!lJeo sV NOI£¥1NIJO4NI (3NV ¥£¥a 'HOI=I¥~S ~'114 'S.1.$~£ '$NOI£O~dSNI 9NIC]IAO~J,t ItltJI4 9NII~NIgN~ .g Well Classification ~//'¢' Well Log Present Total Depth ,/Z~ ¢ Cased to Static Water Level ~ ' Casing Height Above Ground Electrical Wiring in Conduit~',)N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments .,,t,?,~ 1. MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: .?. Date Completed /-7'0 ' Depth of Grouting If A, B, C, D,E.C. Approved (Y/N) Yield ~,, 7 ~., P/d Pump Set At Sanitary Seat on Casing ~N) Depression Around Wellhead (Y/~ ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole /¢//! B. SEPTIC/HOLDING TANK DATA Date Installed /¢/&/¢5'- Size Standpipes(C~/N) Depression over Tank (Y/~ /O¢o No. of Compartments ~ Air-tight Caps ~¢0/N) Foundation Cleanout ~/N) Date Last Pumped 5'w ,4/0,/~ z. Pumping/Ma nteR. cnee~C'dg.t'aet on F e fY/N~ /,v,//¢ ' for Holding Tanl~-F~ieh~,'~C.t~l"At'~r,' .¢~-fi-'~) ,,~/~ Temporary Holding Tank Permit (Y/N) 4///] S EPARATIONDfSTA~B$,~M'~.E"~TIC/HOLDI NG TANK: '.. To Building Foundation Property L~he ' ,,~ ,/¢..*~, ".,,,~:~, To Disposal Field .5- / To Water MaliCe,Sd?vice I~ne' "__' To Stream, PonS,, Laird or.Ma]0(~E~r~ainage Course ,~/O O / Comments 72-026 (Rev. 7/88} Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /.///b//~..t' Width of Field ~g Square Feet of Absortion Area Depression over Field (Y/~.~ Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot A J/, ,zCp.f ///')¢ //~r/ 2-0 ~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field ¢// Depth of Field /,X' / ./,,7 ¢a'.;,.,¢/ Gravel Bed Thickness / / Statndpipes Present ~'N) Date of Last Adequacy Test ,~.~. To Property Line /O',' To Existing or Abandoned System on ;On Adjoining Lots ,~//¢ To Cutback (if present) /d~ / D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Dimensions / Manhole/Access (Y/~_.~ ~"' "Pu rj:~f;~rff'~evel at '~'"~ Vent (Y/N) Tested for Meets MOA Electrical Co.~deC~N¢) Comments / Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA g~m~l~,~ t~n the date of this Signedinspacti°n' r--'~~~/' ~,~.~,~., . .,/ ~..~.~,,.' ,~.~¥I,~, Company - -- ~¢~' ~ ¢"""~'~ ~'~ngineer's Seal Date ¢ [ ~- 0 *'~ ~O MOA No. ~: ~ Receipt No, r"~--- / Date of Payment Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 MUNICIPALITY OF AN~',~ DEPT. OF EN¥1RONMENTAL PRO~ RECEIVED A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST. FEBRUARY 1984 343-4744 Legal Description: Well Classification _ Well Log Present (Y/~} ~ Total Depth /~ Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (C/N) SEPARATION DISTANCES FROM WELl_: To Septic/Holding Tank on Lot //~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by P¢/:-~' Water Sample Test Results Comments .. Date Completed .-'~ ~/~ ! Depth of Grouting / If A, B, C, D.E.C. Approved (Y/N) Yield ~' ¢ ~'/~?'/ Pump Set At /.~t Sanitary Seal on Casing _~.Y.~N) Depression Around Wellhead (Y(~) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ? z// B. SEPTIC/HOLDING TANK DATA Date Installed /~ 2'-~ ¢~ Size I2'¢5~ No. of Compartments Standpipe~i~/N)_ ~ Air-tight Caps (~N) Foundation Cleanou~,(~N) Depression over Tank (Y(~ ~ ~ Date Last Pumped ~/t'~' . Pumpi~g~l~te~nce Contact on F e (Y/N) W~ 'for ~ aOl~,pg ~an~ ~,~}.~er Alarm (Y/N) 1,~ Temporary Hold~ng Tank Permit (Y/N) ?' ..~¢PARS~.¢"t DI,~*}~.~ZS FROM SECT C/HOLD NG TANK ~; TO Water-Supp y W~i['¢'~, //~ T~ F~roperty, Line T~ StFeam .ROhd ~L~ke or Major Drainage Course To Building Foundation To Disposal Field //~' 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /- Width of Field / Depth of Field /f Z. Gravel Bed Thickness d?, '; Statndpipes Present ~hN) Date of Last Adequacy Test Square Feet of Absortion Area Depression over Field Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: />o Type of System Design Length of Field ~ / To Water-Supply Well To Building Foundation To Water Main/Service Line /d y- To Stream, Pond, Lake, or Major Drainage Course /~d '¢ To Driveway, Parking Area, or Vehicle Storage Area 5;' 7'~ To Property Line .To Existing or Abandoned System on ; On Adjoining Lots '/¢ To Cutback (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at · ~/~ Tested for Meets MOA Electrical Codes (~N) Comments P¢'/'/~:;// '-/~//tJ/( L // 7 Dimensions Ma n h cie/Access (~Y~'N) "Pump Off" Level at ~// Vent ~/~.~N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that l have checked, verified, or conformed to ail MOA and HAA guidelines in e~f~,~'~~f~thlS inspection, ~.,~../ ~7 ~.,'/ Signed .. ~---' Company ~ Date -- ~ Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 ALASKA FIUIROFImE F1TAL COFITROL SeRUlCe$, IllC. ~nqin¢~rinq 6 J~nuironm~:nlal Stucli~s P. O. Box 240668 Anchorage, AK 99524-0668 (907) 279-5553 MUNICIPALITY OP ANClffOp_~p~ D~:PT. OF HEALT ENVIRONM ...... H & *** FAX (907) 276-8706 ~'~/~L PROTeCtIoN Department of Health & Social Services Municipality of Anchurage 825 L Street, Fifth Fluor Anchorage, AK 9950~ ATTN: Susan Oswalt RE: Lot 6, Block 6, Mann Subdivision #2 Dear Ms. 0swalt; In my report of January 26, 1990, I reported the separation distance between the water level and the bottom of the system as 5.46 feet. On April 23, 1990, it was 4.96 feet. The upstream~_wa~t~er level is 9.55 feet and the downstream level is~'~5.09. ~ There is only 0.46 feet difference across ( ~ the curka~i~;l~d-r~ain as opposed to 1.06 feet in January. The snow is all melted over the bed and ~he curtain drain area. There is still some snow near the road. There is little water leaving the curtain drain oatfall. This indicates that the water levels are stabilized. Please remove the cunditional from the attached t[ealth Authority. Thank you. LCR/sr Sincerely yours, PhD, -'I~E, DEE CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order # 18963 Date Report Printed: DEC 21 89 @ 17:07 Client Sample ID:L6 B6 MANN S/D O/S TAP PWSID :UA Collected DEC 20 89 @ 14:30 hrs. Received DEC 20 89 @ 16:30 hrs. Preserved with :AS REQUIRED Client Nams : A E C Client Acer : AKECSRP P.O,~ NONE RECEIVED Req ~ Ordered By : Analysis Completed :DEC 20 89 Send Reports to: Laboratory Supervlsq~ jSTEPHEN C. EDE I)A g C S Special HOLD UPON COMPLETION FOR PICK UP. Instruct: Chemlab Ref ~: 8983 Lab Smpl ID: 1 Matrix: WATER Allowable Parameter Tested Result Units Method Limits NITRATE-N 0,77 mE/1 EPA 353.2 10 Sample ROUTINE SAMPLE. SAMPLE COLLECTED BY A. WEIN. Remarks: 1 Tssts Pezformsd * See Special Instructlon¢ Above UA-Unavailable ND= None Detected '* See Sample Remarks Above NA= Not Analyzed LT-Loss Than, GT=Greatez Than MUNICIPALITY OF ANCHORAGE · DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ALASKA eF1UIROFlmeFITAL COFITROL ~n(jin¢¢rin§ $ ~nuironmcnlel $1udics SERUICSS, IFIC. 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 72-025 (11/04} ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA~A 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 of Firm Aziz Engineering Company -- Telephone 3~9-2557 Address 9024 Vanguard Drive Anchorage, Alaska 99507 [)ate July 29, 1986 Engineer's Seal DHEP APPROVAL Approved for Approved 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 in the State of Alaska. The DHEP does tbis 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 ANCHORAOF: DEPT, OF HEAL~?I & ENVIRONMENTAL PROJECTION :, 1986 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 RECEIVED LegalDescription: Lot 6, Block 6 Mann Subdivision, Addition No. 2 A. WELL DATA Well Classification A If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Yes Date Completed 8/8/85 Yield Total Depth 120' Cased to 6"/#0' Depth of Grouting N/A Static Water Level 8' below ground surface Casing Height Above Ground 4, .5 ' Electrical Wiring in Conduit (Y/N) Yes Separation Distances from Well: To Septic/Holding Tank on Lot . J, 1 ~- ' 2.5 gpm Pump Set At 120' Sanitary Seal on Casing (Y/N) Ye~ Depression Around Wellhead (Y/N) No ; On Adjoining Lots tOO' + To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line N/A Cleanout/Manhole N/A Water Sample Collected by Water Sample Test Results Comments 112' ; On Adjoining Lots 100' + To Nearest Public Sewer To Nearest Sewer Service Line on Lot N/A Harold C. Gross, Owner ;Date 7/23/86 Satisfactory, Northern Testing Laboratories, 1nc., see attch. B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) No Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) N/A Separation Distances from Septic/Holding Tank: To Water-Supply Well 11//-' To Property Line ~ ] 0+ To Water Main/Service Lin e N/A Course N/A Comments 10/16/85 Size 1000 gal No. of Compartments 2 Yes' Air-tight Caps ('C/N) Yes Foundation Cleanout (Y/N) Yes Date Last Pumped New No ; for Temporary Holding Tank Permit (Y/N) N/A To Building Foundation _ 8~ To Disposal Field 5 ' 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 10-16- _8~' Width of Field 26' 2 150 fi Square Feet of Absorption Area 1066 SF Depression over Field (Y/N) No Results of Last Adequacy Test N/A /Bt Type of System Design Length of Field L~[ , Depth of Field 1.5~ deep/2 2' Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test Mounded seepage bed sand/ 2' cover Separation Distance from Absorption Field: To Water-Supply Well 112 ' To Building Foundation 20~ Lot N/N To Water Main/Service Line N/A To Stream/Pond/Lake/or Major Drainage Gourse To Driveway, Parking Area, or Vehicle Storage Area 20' Gomments Yes New To Property Line 10 ' + To Existing or Abandoned System on ; On Adjoining Lots N/N To Cutbank (if present) N/A N/A D. LIFT STATION N/A ; ~ ' ' '~ " ': .... 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 Date Company MOA No. Receipt No. <~)0,'/ OO/' F Date of Payment ~'/.-~)/~:~ ~;' Amount: $ ~' ~'"""' <:~ ~ Page 2 of 2 Engineer's Seal 72-026 (11/84)