HomeMy WebLinkAboutMOUNTAIN MANOR BLK 3 LT 3
www.sullivanwaterwells.com
Pump Installation Log
Well Drilling Permit Number: SW Date of Issue
Parcel Identification Number:
Legal Description Property Owner Name & Address
Mountain Manor Block 3 Lot 3 Karl Westerlund
18888 Jamie Drive Eagle River, AK 99577
Pump Installation Date:
3-4-20
Pump Intake Depth Below Top of Well Casing:
190 feet
Pump manufacturer’s Name:
F&W
Pump Model:
4F07P05305S
Pump Size:
1/2 hp
Pitless Adapter Burial Depth:
10 feet
Pitless Adapter Installer:
Unknown
Disinfected Upon Completion?
yes no
Method of Disinfection:
Chlorine 50 PPM
Comments:
Pitless Manufacturer: Unknown
Pump Installers Name:
Sullivan Water Wells
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
er ifie rilling
DOC Co. OBa
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS ,
LEGAL DESCRIPTION
DATE - Started
PERMIT NUMBER
Ended
I)EI'Ttt OF ~,ELL
SF XTI(' LEVI~L OF W \TI:R Fr.
1)1{,\% DOWN F'I.
GALS. PER HR
KIND OF ('ASING ; =
KIND OF FORMATION:
From
From
From
From
From
From
From
From
From
From
From
From
From
From
From
From
From__
Ft. to ~
Ft :' ~ : ; ~ ' '-!: ' Fronl ,__ Ft. to ..... Ft.
Ft. to
Ft ' , ":: L- -:~ From____Ft to___Ft
Ft. to,
__Ft. to
Ft. to
Ft. to.__
Ft. to~
Ft. to__
Ft. to
Frmn_____ Ft. to____ Ft.
_ D~,:r r.~F HEALTH &
From I' t .....
ENvI~C'?*M~N I ~k r~,~ ....
From___Ft. lo
From Ft, to Ft
Ft. to: Ft.,'
From Ft. to
__.Ft. to ___Ft. . ~ : ' , ', From Ft. to
Ft. to __Ft. . From_ Ft. to Ft
Ft. to ...... Ft. From Ft. to _Ft ......
MISCL. INFORMATION:
DRILLER'S NAME
2 &~.q.'.' ::t. '?'?. C,
C::I~ II'",,.11 ...... '~!!!!:il; i:II:: "II" I!ii!!!i: IL,..,!I IE!iii:: L... II ....... IF::" II!ii!i!i: if::::;;:: f1'""!! ::11:: "!1
f c> i" '!. l"i k)":,, I:.l"i,;.:;, !"lLu'q:i.c::i.l::)at].:i.'k.'?' i::',f' /:~nc:l"lc)r'a(;'l(,.;:, (I¥1C)i:?~) and k.h(;.:,, '..i:;l:a'ke (::)1: ~%:l.a~ii~!-::a',.,,
;':?. :[ ;,~:i.].]. :i.~'~;;~;'k,::':'~].}. 'k.l"'~(~.) s~;'y'~;;;'k, em :i.n ,':~(:::(:::(::~l".(::l;;~l'"~:::~..:;, ~.,~:i.'t'.h a].] I"IC)(.~ (:::~::)~::le~;;; and
ar'id :i,n (::: c)ml::) ], :i~';d'/c:e ~,x~:i.'kh 'k.l'q~:a ch~e~;;;:i.~,ti"i (:::~". :i.I. (.):.)i', :i.,':'~ (::) I:.t'l :i.~{[; J::),):,:,)l'~Fli:i'i'. ,,
:]~;,,:[ k~:i.].], aCit"~(.?::,l"~:'~ 'l'.c, a].J. I'l[J(.~ avid ~[~k.a't'(.~:.:, (::~{ (.~:l.a~;I.::a r'eqL~:i, ven'~(.:....,v~t'.~ii; ~(::)~' 'k.h(.~ ~;e'i:. I:::,~(:::1.::
(::1 :i. ~[.'l:.,':'~.l"i[:::e~ [' (::)['~ any (~:~,>( :i. ~;'l:. :L r'l,::~] ~,,~[~.::, .I ]. ~, ~,,~a.~;t:. (.:e~,.~,:~tt.(:~,~". (::1 :i. ~H:)(::~;a :1. ~;'y'~i~;'k.~:,.:,m c)v I::~ul::) ]. :i. ~:::
~;;(:.)y;,.~:;:)r.a~)jie ~;;'>:~ii;'('..(.;'.)m (::~r"~ 'k.h:i.E; (::H- ,;;d"l'i &td..~a(:::~.;.)l"~'l:.. (:::,1" Fi,:.;:~aPl::)'y' I.(::)'k.,,
........
MUNICIPALITY OF ANCHORAGE
DE ':ITMENT OF HEALTH AND HUMAN SER ES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
Address
Phone(s) I ~r~t No No~ Bedrooms
LEGAL DEECRIPTION
LOt ~ Block Subdiws,on
TANKS
~ SEPTIC ~ HOLDING
TYPE OF SYSTEM
L~TRENCH ~] BED [] W. DRAIN [] OTHER
De,)th to p~pe bottom tronl lotal depth from original grade
orig,nal grade /2~FT o/ FT
Fdl added above ongmal grade Gravel depth beneath pipe
,~ ..9".~.. F T
gO FT
so FT ,
DISTANCES
WELL
SEPTIC
TANK
ABSORPTION
FIELD
WELL
LOT LINE
FOUNDATION '~ill~_~-/ ~ /o' ~ ~"dJ /
AS-BUILT DIAGRAM (Sbew Iocahon of well, sepac system, property hnes, Ioundabon,
drweway, water bodies,
Installer
WELLS
[] PRIVATE [] OTHER (Identify)
Class~hcaUon (.,A, B, C/
Date i n st alle,,~,~
FT
REMARKS:
~ o~ ?~c~c.l~ I/~.. 4~.{;~¢~t 'r~
Scale:
Inspections Performed by:
eagle Rr~er Engineering Services
P~ O. UOX //3294
Date: Eagle River, AK 95577 ~
~// o/~ ~ 6~-5195
I ~,z.~ /'"'~~~ cedity that this inspection was performed according to all
Municipal and State guidelines in eflect on Ih~s~atn: '~/'g~ ':"t'/°¢
Health Department Approval: .-- . Date: 10 --2 ~-- ~
DE!]::~AR'FHE]q F HEAI..'[H ~.~d',lD ENV I RONMEN'TAI .... ~O]'ECT' ](' N
~.y..-'hL !i~] I::~lii]iiilT', !...ih~(,rl .} ". i.-i :.'~c. !, A!< :...?, :..1 !~ ~,~.,~ro~.~...~-
Ei;AE)L. Ei: I::~' ]; 'v'Ei]::;'. ~, Al'::;
St.JBD I V I S :1: (::)lq: MOLJNTA :1: N MANOR
'.:iii;E:C ]" ]: 01",1: 6 10WI',.ISI"I I P: 14 hi
(SE!,, F'T',, OR AC;RES)
z[ :t . C)
:I 000 ,'" '"~
'~ t.. ~ f .,.~ !ii~ t a t e~'", 'i A .I. a !i!~ I.'.: ~'..'~
~..~., bv '[:h(::.., Muri:i.(::::.p,a]:i.{y (::,'[ ..rlchor'ag(~e (MOA) ar'id ......... ....
,:::,, I ~;.i J .I .it sL,:: .~. ] 'l.h(.? system :t.n ~'aE:c;(:)r'(::lar"~c:(.))) ~A~:i't:.h al. ]. MOA (:::(::)ch.:.:.)s and
a, r'..::~ :t. ~"i E (::)('('~l:] ]. :i ~?:~ ri (::: 6? ],,,.~ :i 'k, h '~: h (? c:J E.)!E. J. ~:J r'i ~::: r' ~ t (~ r' :i..:?:~ "', ~: ~: I"l :k ~i~ [:::, ~) r' fY~ :i 't:. ,,
3,, I w:i:l:l a(::ll'-~e:.:,r'(.:? !(::) a:t:L MOA al'iCJ ~?L.¢:ttE, (:]~' A].(¢:t~E.l-::a P(.:.:.)CIt..t:}PE::CR6~,r~'(.~;~ ~'(::)P 'l.. l", ,:.:.))
(:I :i ~:~ k. a~ r'~ c (:.? ~. i: r (:::, m a r'~ y (~.:.) x :i .~;~ t: :~. I'] (~.1 w 6:, ]. ]. ~, L,9 a s t 6) ~t a t ~) i". cl :i s I:] ~:::, s a ]. s './s 't'. (.:.:.:, m ,::::, i'.
I I:;: A L. :1: F'T S't AT' ]: [::)f'..l ]: !ii!; :[ tqS'T'AL..!..liii:D I I',I AI',I AREA i::::OVEI::;:E;D BY MOA BU I L..D ]: NG CODE:S,
THEi]'..I ( :1. ) AN E]..IECTI::~]:CAL.. PERM:I: T' AFl.() ]:IxlSF'EC]'ION MIJSI' )3E OB'T'AIIqE~:'t}; (2) AS--'E~UILTS
W]:I....I.. F.H:] i' BIE AF:'t:::'Fd?,q~].:) WI]'HOt. FI' AN E}]....EC f'I::~'. ]: CAL.. INSPE:C]']:OIq !::~E]::'E)R]'; AND (3) ]"HE:
Al:::'l::'t ] C;Ah.I 1 ;', DAV ;1: ;[~', T.d~]::d:~",'
EAGLE RIVER ENGINEERING SERVICES
Lou Butera P.E.
P.O. Box 773294
Eagle River, Alaska 99577
Telephone (907) 694-5195
~ay 28, 1986
Mr. Steve Morris
Civil Engineer, On-site Services
Municipality of Anchorage
P.O. Box 196660
Anchorage, AK 99519
REF: Lot 3, Blk 3, Mountain Manor
Dear Mr. Morris:
The enclosed application is submitted for issuance of a septic
construction permit for a 4 bedroom home useage on the above referenced
lot.
The application for permit uses a soil log dated 4/30/84 which
was performed by myself for Hamman Construction. We are requesting
that you waive the new requirement for a ground water monitor as the
test hole was excavated before the requirement and I believe that this
area does not have a ground water problem. The design we are
specifying places the wide drainfield well above the bottom of the
test hole in order to make use of the soil layer with a 126 rating.
The lot does have some +25% slope area however as shown on the profile
drawing the septic is located on a natural bench and is sufficiently
setback from the slope break.
If there are any questions or if additional information is
required please feel free to contact me at 694-6195.
Sincerely,
Lou Butera, P.E.
Encl: soil log
site plan
specifications
profile
EAGLE RIVER ENGINEERING SERViOES
P.O. BOX 775294
EAGLE RIVER, ALASKA 9957'7
694-'5195
SPEOIFIGATIONS FOR ON-SiTE SEPTIO SYSTEM
LEGAL: Lot 5, Block 5, Mountain Manor
A. GENERAL
1. The drawing and or site plan shall be a part of this specification.
2. Ali materials and workmanship shall meet the r-equirements of
the Anchorage Department of Health and State D.E.C,,.
¥. All scsi tests are advisory to the design arid are to be
verified or modified in the field by the engineer.
4 All excavations and depths; are advisory and are to be verif'ied or
modified in the field by the contractor to meet MOA, D.E.O r'equire~''
ments.
5.. It is the responsibility of the o~ner to obtain all necessary
permits oF easements and to locate any adjacent multi-family wells.
6. The excavation is to be exactly in the area shown on the site plan
any deviation requires engineer approval..
It Ls always recommended that a surveyor locate the nearest lot line
position and the location of any easements.
8. DRAINFIELD
The drainfield is to follow the natural land contour to maintain
uniform total depth of the trench bottom.
2. The bottom of the trench shall be level, plus or mi.nus 1.5".,
S. The total depth of the trench excavation is not to exceed 6' at ally
point
A ~idp trench design is specified so the leaohfield remains.
The trench gravel is to be covered with typar fabric material.,
Soil or combination of soil and extruded board insulation to a depth
of 4' or equivalent, is to be placed over the drainfield.
8. The area over' the bed ie to be finish graded to p~event ponding
of surface water runoff.
9,, The septic tank and leachfield must. not be closer than 100 feet to
any existing private well, 150' to any Olase "0' well, or 200 feet
to any community
L. EAOHFIEI_D DIMENSIONS
TOTAL DEPTH: 6'
GRAVEL.. DEPTH:: 5.5'
TRENCH LENGTH:: 54'
REQUIRES
1.5'mounded soil
~ITE
*septic site plan only
~oai$ A, Buterq ,Z
· CE-6736
'70;O0
septic site plan only
CLA SJ ,~
EAGLE RIV
ENGINEERING SER~,¢ES INC.
P. O. Box 773294
EAGLE RIVER, ALASKA 99577
Phone 694-5195
JOB /--'~ 3
SHEET NO
CALCULATED BY
CHECKED BY
SCALE
OF
DATE
LOT 3, BLOCK 3, MTN. MRNOR
LOT PROFILE FOR SEPTIC PERMIT
N.T.S,,
EAGLE RIVER ENGINEERING SERVICES
Lou Butera P.E.
P.O. Box 773294
Eagle River, Alaska 99577
Telephone (907) 694~$195
June 23, 1986
Mr. Steve Morris
Civil Engineer, On-site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, Alaska 99519
MUNICIPALITY OF ANCHORAGe:
DFPT, OF HEALTH &
ENVIRONMENTAL PROTECTION
RECEIVED
REF: Lot 3, Blk 3, Mountain Manor
Dear Mr. Morris,
As per your request, I have installed a ground water monitor into a
previously excavated test hole on the above-referenced lot. After 7
days of monitoring, there is no indication of ground water at the test
hole location. Monitor tube depth is 13'
If there are any questions or if additional information is required,
please feel free to contact me at 694-5195.
Sincerely,
Lou Butera, P.E.
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:, , >/¢q ~'~/'~ ~-~
LEGAL DESCRIPTION: Zof '~
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19.
20-
/
SLOPE
WAS GROUND WATER
ENCOUNTERED? ,,/~/~
IF YES, AT WHAT
DEPTH?
SITE PLAN
,~-,"'~,.""~'~ ~ss Net Depth to Net
Reading
· , ~,'~,-'_ a01:' '~(rL~~ Time Water Drop
41~- .,...
~,~, I ,uN"RATE / ;~ ~ ':~,~'r-- ~ (n~m~ter,/inch)
TEST RUN BETWEEN FT AND
CERTIFIED BY:
72-008 (6/79)
ANCtt()RA(~E, Al A,.~KA c c~,~l ,~
(,90i') 264-4 I
DEPARTMENT OF HEALTH AND ENVIRONMENTAl PROTECTION
Permit t~: 840268
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot 3 Block 3 Mountain Manor Subdivision
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1984.
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent
to this Department for documentation of the installation
and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, the original as-built inspection report
and the yellow copy must be sent to this office for review
and approval, and for documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
Keith E. andt, SupeYvisor
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SWP/057
PERMI'T' NC:
[:,F::! Tt!:.'-. I S S U E~,E:,:
I I [. L. J .. L..:::,.:::,:
..... H"I"F:I" T t:::t'"I '" I"!E:
E;L. OF':K:
t_ I :'T,'TE[:, E:E!:I_OI4 !:::II:RE THE OF:"T' IONS ", I- t I.._ IE L..t::: TO "r' ": ~ :1: I",t E:'EE!; I GI",I I BIG "r'OIJR SEPT
::, '~., I L..I L CJ"iO(]:i!!;[!i: "t"1"11!~: OPT'I Zd",J "r'Hl:::t]" IJ3E:!!!',T I::r ]: "t":!~, '.r'l'2 UJ:;." ~; l
[>EF:'TH ]"O F' I F'E E:OT'T'Cff'I ,:: I:::'T'. 1:,
Gi:~'.F:fv'EL. [>E!]::'TH ':: F::'T. >
'T'OTIaL.. [:,Ei:PTH '::F"'T'. >
GRt:::IVE]_ I.,.t I E:,TH ':: FT'. >
GF'4~I::I',,,'EI.... Lli!!:i",IG'T'H < I:::'T.
GRI::rlVE:L.. ',/OL.I.Ji'"IE!: '.:C:U.
TI'":II",II< :!!; l :;!:.:Iii: ,:: (]il:::lL..~i!i; >
5;CI I I.... I:;iff::lT' I J",J(] ':: :E;Q. I:::'T. ,."'EiJR
I C:IE]:;;:T I F:'"r' T]'"I!:::IT:
I. I I:::It'"1 I:::'!:::IMILtI:::II:;: I.,.IIT'H TH!Z I:~?.E:QU]:REMI~I'-,IT'ii.~i I::'O1~: C:~i",l'"-:!!!::l:"l"t":_:' :F::EI.,JER'.':~ FIND I.,.I[L...L..:i~: F::IS :i::E"r'
F:'ORTH E:'-r' THE M.I...tN ].' C l t::'F:IL.. :[ 'l-'.r' OF' F::INC:HOF~::F:I(.~iI!!: ,:: I',101:::t .':, F:li'.,t[:, 'THE STF:i]"[.~: OF:' IZlL..F:ISI<Fi.
2. I I.,.I ILI_ :I: NE!:'T'FiL..L.. 'T'HI!i~: S'./ST'EM I N I:::IC:CC~RIDFiNCE .kl :[ TH I:::tL.I_ MOi::I CO[':,ES I:::IN[:, F..:E?.GUL~FfT'I OI'.,tS.,
FiND I N COMF:'L.. I FII",IC':E I.'.I :[ TH THE [:'E::E; I Gl",t C:R I TER l Ft OF:' TH I :'2; PERi"11 ]".
3. :[ t411_1.... F::I[>HERE "1"O FII_L.. MO!::I l::tlq[:' :~;TFfTE O1:':' I::ILFISI<FI I:RE:.'::QUIREMEI",IT:~: F:'OI:~i: THE
[> I :.:T,'T'I::tNCE:!!i; I:::I;[:OM I:::IN"/ E::':: I :ii;TI I",IG HEi:L.I. ..... ,L'.II:::IE;TEI.'.IFTT'E:I'T:'. [." I '.-3F'OSFIL S"r'~T'EM OR F'UE:L 1' C
SEt.,.IEt::::F:II:'.:iE !::?'r'i!~;]"E]"l ON TH tS OR F:ti",l"r' FI[:',]'FICEN'T' O1:':'.' I",!ElaRB'~" EOT.
I I.JlqDE:R:i!!:TI:::II",ID TI"IFtT TH ]: S F'IZRM I T I :i~, VI:::tL ].[ [:' F:'OR I:::I I"11:::1::':', 1 I'"11...11"1 OF: Z.': E:E[:'ROOMS FII",I[':'
I:::IN"/ ENI_I:::!I:[i:GI!]]"IEi]'-,I]" I.,JtL..L. l::i:l?~(1)l...llI;i:J~ FIN I:::I[:'[:'ITIONF::IL. I::'l:'~]::~ff"llT.
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:
/ / ,/ // SLOPE
DATE PERFORMED:
SITE PLAN
DEPTH / /
(FEET)
'/'"
2
3
4
5
6
7
8
/
9 -~
10
~.~: r: 49~.
17
4°'
20 -
/971 ,~ ,,~
COMMENTS S
WAS GROUND WATER/J//'/~ S
ENCOUNTERED? L
O
P
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
TEST RUN BETWEEN FT AND -- FT
PERFORMED BY: ]_. %Z.~ ;~'"z-'~L
72-008 (6/79)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
ii/10/86
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 3~ Block 3~ Mountain Manor T14N R1W Sec. 6
Location (address or directions)
Skline Drive~ Eagle River
n/a
(b) Applicant NameDavid Berry Telephone: Home 688-3249 Business
Applicant Address 1698 Blue SprAce Lane, Eagle River~ AK 99577
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other E] (explain);
(d) Lending Institution n/a
Address
Telephone
(e) Real Estate Company and Agent
Address
n/a
Telephone
(f) MailtheHAAtothefollowingaddress:
pickup by Enxineer
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.
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.
72-025 (~ 1/84)
Page 1 of 2
ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DATA 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 flies 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 E~.6LE R!VER FN6INFFRING SERVICES Telephone
EAGLE RIVER, AK 99577
Address,/~//,¢~,/ P.O. BOX,//3294
Date 694-5!95
s Seal
DHEP APPROVAL
Approved for '~/~/,,~L6-, bedrooms by
Approved /.)~ [')isapproved Conditional
Terms of Conditiohal 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 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-o25 (11/84)
MUNICIPALITY OF AN~I~'I~PALITY OF ANCHORAGE [MOA)
DEPT. OF HEALT~I~ALTH AUTHORITY APPROVAL (HAA)
ENVIRONMENTAL PROTECTI~ECKLIST - FEBRUARY 1984
264-4720
NOV 1986 ~g., Description:
RECEIVED
WELL DATA
Well Classification /~" ~'~'-/-~ If A. B. C. D.E.C. Approved (Y/N) '/'~'?'~
Well Log Present (Y/N) ~ Date Completed ~,,,,",¢'d Yield
Total Depth ~oo" Cased to ~7'~//'~" Depth of Grouting /u/,/'~;
Static Water Level z¢..? ,'/5~/~,.¢ ~,.,~'~- /-,,~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
/
To Septic/Holding Tank on Lot ,//--~
To Nearest Edge of Absorption Field on Lot
TO Nearest Public Sewer Line _/~',/~
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Pump Set At ~ x"~-,~-
Sanitary Seal on Casing (Y/N) Y
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Aajo~mng Lots
To Nearest Public Sewer
· '~',//4 To Nearest Sewer Service Line on Lot
~5~ ~ ,~',~"~'-"~.~' :Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date installed
Standpipes (Y/N) /~/ Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N) ~/-/~'
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well //--~ /
To Property Line ~'~J /
To Water Main/Service Line ¢-/~
Course ~-/0o ~
Size ,/~'~%~"/ No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped "~'"¢¢"'
; for
Temporary Holding Tank Permit (Y/N)
TO Building Foundation ~-~-- /
To Disposal Field ~ / -¢
To Stream, Pond, Lake, or Major Drainage
Comments
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/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ,//~"- /
To Building Foundation /¢2 /
Lot
To Water Main/Service Line Y-/'~ /
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field -g'o
Depth of Field 0*5'"
Gravel Bed Thickness ~
Standpipes Present (Y/N)
Date of Last Adequacy Test ¢-/~-~-~' (:¢-,-,.r-~--,-~c ./-/,-~,
To Property Line /,5'-
To Existing or Abandoned System on
; On Adjoining Lots Y--~ /
To Cutbank (if present)
Comments
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~~"--'-' Date
Company ~'/~"~'J" · MOA No.
Receipt No. ~, OO / ~
Date of Payment //-/~'~'
Amount: $ ~', ~ ~;~ /~--¢.~,~ ~
Page 2 of 2
72-026 (11/84)