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MOUNTAIN VALLEY ESTATES BLK 1 LT 18
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HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES BLK 1 LT 18Mountain
Valley Estates
Block 1
Lot 18
#050 - 641 - 17
Heal
"UNICIPALITY OF ANCHORAGE
and Environmental Protec )n
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
264-4720
INSPECTION REPORT ON-SI-i'E/SEWAGE DISPOSAL SYSTEMf(%
NAME. - _ 1J �II�h� 1 -o -MAILING ADDRESS Ger:bt ' it ((►.�31.1 ?PHONE y, -9I 2
LOCATION�!-�� � L EGAL DESCRIPTION L. tlrl�' Uq.11ey S
SEPTIC TANK:
wax?
FROM WELL_ /QO 4' MANUFACTURER
(2 Pax MATERIAL _`e '
INSIDE LENGTH INSIDE WIDTH
NUMBER OF
COMPARTMENTS
LIQUID DEPTH LIQUID CAPACITY"GALLONS.
TILE DRAIN FIELD7t:14111)41291"
DISTANCE FROM WELL Lwat FOUNDATION_�O + NEAREST LOT LINE OF LINE
TOTAL LENGTH
# of Lines
DISTANCE BETWEEN LINES A/A* TRENCH WIDTH IN. TOTAL EFFECTIVE
ABSORPTION AREA cs 0
SQ. FT. LENGTH OF EACH LINE
DEPTH. TOP OF TILE TO FINISH GRADE 14'
SEEPAGE_: PIT:
DEPTH OF FILTER -`
MATERIAL BENEATH TILE _(0v___IN. ABOVE TILE
L IN
DI METER
OR WIDTH_ LENGTH__, DEPTH
Log Crib Rings Crib Size: DIAMETER __DEPTH_ _ DISTANCE FROM: WELL
TOTAL. EFFECTIVE
BUILDING FOUNDATION NEAREST LOT LINE ABSORPTION AREA (WALL AREA)
SQ. FT.
Well '?V?.`)? 7
Class: 15na. Depth:
Well Distaince To: Lot Line L
Bldg: 140 Sewer Line:
Pipe Materials: Was.. .
# of Bedrooms: 3
Installer : N MDp C ons4 .
Remarks: sohi $54(
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DATE 9'1-5:1413 APPROVED
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DATE 9'1-5:1413 APPROVED
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RPA I PIEA -F CHF INR Ihm IcaH'
ov-yrimpiE TIE HEALTH AND ENVIRONMENT --F$TATIA-ITTFcOPM__
STREET, ANCHORAUE, Al. J9501
PA FEU [1:::111P.A1 11E" "=::V.:;!! IF" 11-.11 1. -11
TIERMIA-Ra ,77160 in;.no pnk
1,PPLICMIr 11111.T5 BULITWIT ONGEN. . E.R.
. //WAS
LOCATION BIRDSONG DR.
17.1a114.: LA . ITE v our y --ETE
E SOIL -A BSC R -SYS1"EF.11 s : TRENCH -
-LOT-SIZE- 51000 -SQUARE 17E1'
TWNIMUM -NUMBER-OF -BEDROOMS z SOIL -RATING
111E -REQUIRED sIZE u1,- THE suiL ABSORPTIoN- sYSTEK IS:
CD .. ILA 11,;;!:11-11%,..," O.__
-THE LENGTH-DTMENSTON- IS THE LENGTH (IN FETETY OF THE TRENCH OR DM:WHET:b.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND HND THE EOTTOM JAE EXCAVATION <IN FEET).
THERE IS r' SET WIDTH FOR IskTIKME.
THE GRAVEL DEPTH IS THE !J II DEPTH OF GRAVEL BETWEEN THE OUTFALL -PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
11 F." 11 _IL H..: 7 .. .
F." FA C.: !KARI w.3 IF" H H".4 in -F I CD PA -- .......... -- •
A PACKAGE PLANT MAY BE INSTALLED AT THE PERMITTEE'S OPTION SUBJECT TO THE
FOLLOWING CONDITIONS:
I. EITHER A CLASS I OR II NSF APPROVED PLANT MAY BE t11 111
2. H CLOATNUOJS MAHIM'IANCE AGREEMENT IS 1- 1111 IF A MAINTENANCE
AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED TO ENLARGE THE suIL
ARsoRPTION EYSTFM AND/OR YOH MAY BE UE:JEET TO PROEFTliTOW
1- JA ifj <H2-2! :':)1 P-4 V-- 1E= F J. ci P-4 JA F=. 1GA! H,1La›
BAGKEILLING or ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL. BY THIS
DEPARTMENT WILL BE SUBJECT TO 1 il11111.':01.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR FI PRIVATE WELL OR 200 FEET FOR 1 PUBLIC WELL:
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ZO DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APH...Y SPECIFICATIONS AND cuNSIRUcTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATIOK
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREMENTS t'''i: uN-SITE SEWEks AND WELLS AS SET
FORTH BY 11-11- MUNICIPALITY OF ANCHORAGE:
2: I WILL INSTALL THE SYSTEM IN AccuRDANCE WITH THE CODEa
-I-TRIXETAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BETIROMe&
APH T :::::II, T AMOS ..II. I NGTON
:NqUED RY
D A T
- 3 7
;:u';=CIP<ALLT'Y OF NC O:RAC
D,o>rtme of :.f.alth and Environ_aantal ? tecti_on
Pe_rfor:::ea for
SOILS LOQ
PERCOLATION TEST
Amos Bullington
Date Performed 8/24/77 •
Legal Description Lot 18, Block 1, Mountain Valley Estates
- 4j.
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a
12 - o
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14 -.
A
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16-.•
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18 --
20 --
Red -broom silt w/organics (ML)
Brown, well -graded, sandy gravel (GW)
85 ft. /bdrm.
Total Depth = 17 feet
No water table encountered
AVERAGE ABSORPTION AREA REQUIRED FROM SOILS LOG = 85 ft.2/bdrm.
Date
Net Time _
Depth
Net Drop
_
Percolation Fate
minute
CFIAMPION DRILLING COMPANY, INC.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 0-5-0 HAA# 65035-5-
GENERAL INFORMATION
Complete legal description"/i!T4J VALLI-SST
Location (site'address or directions) 4/9''// girt/sou
Current Property owner(a)Atn, o S %3Ultnq fo„ Day phone ‘c9?—cz/7c
Mailing address . .P0'((1'-ifloa3 EP61s-kwe, t\(L- gel 53
Lending agency # Day phone
Mailing address
Real Estate Agent Eva. LoK¢,•� ' / f n Day phone,l�Q— 4/ 7(
Mailing Address fruchit licl/V isia n i� �e _ Rivtc
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: .3
Expiration Date: / O — 7- 0 5'
BLOCI; / Lor
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
a
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one.year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. 1 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effectefeat the time of installation.
V
Name of Firm / 6 r &AG% EA 9.
Address / 7.23 7 herr AGfj Cart.
Engineer's Printed Name Stein,
5. DSD SIGNATURE
✓ Approved for 3 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Phone C70-702,
Date 7/22/ OS
Additional Comments
11
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: 7,
(Rev. 01/02)
Original Certificate Date: 7- a 7 - oS
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.clanchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: 414 Til/ V.IL [�S/ ,Ei f ' g / L la Parcel ID: Ci 6-O - 4 el /- /7
A. WELL DATA /
Well type / If A, B, or C provide PWSID # _ Well Log (Y/N) N
Date completed X77 . Sanitary seal (Y/N) Y Wires properly protected (Y/N)
Total depth r3 ft. Cased to t a ft. or $eciextjasing height (above ground) Q in.
FROM WELL LOG AT INSPECTION
Date of test -^ 7/7/65
Static water levet ft. 72.4 ft
-
Well production g.p.m. 3- g.p.m.
WATER SAMPLE RESULTS: '/
Coliform 0 colonies/100 ml. Nitrated /9
mg./1. Other bacteria ,, /0 colonies/100 ml.
Arsenic: — mg./I. Date of sample: 71/05 Collected by: /1/O4 Roti. F_ni.
8. SEPTIC/HOLDING TANK DATA
Tank Type/Material Gr« rl src& Date installed /777
Tank size /000 gal. Number of Compartments 2 . ` Cleanouts (YIN) 1/
Foundation cleanout (Y/N) / Depression over tank (Y/N) !Y High water alarm (Y/N)( N/4
Date of pumpingS•0 Alotineeper %/2i/es
C. ABSORPTION FIELD DATA
Date Installed /977 Soil rating (g.p.d or ftp/bdrm) 5,3- System type TesacH
I Length Z•15- 11 Width _ 3 ft. Gravel below pipe s ft.
I q
1 Total depth I ft. Eff. absorption area 24° ft2 Monitoring tube Depression over field A/
Date of adequacy test 7/7/65 Results (Pass/Fail) AMU' For 3 bedrooms
Fluid depth in absorption field before test i. 5 in. Water added Qgal l- New depth S in.
Elapsed Time:/20 min. Final fluid depth 0 in. Absorption rate >=
..�' SO g.p.d. t
Any rejuvenation treatment (past 12 mo.) (Y/N & type) /JA/k If yes, give date
1
i
A
{
D. LIFT STATION
Date installed
'Pump on" level at
Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /CB /4 -
Absorption
fAbsorption field on lot /136'r
Public sewer main N/4
Sewer /septic service line /60)1-
Size
O0 *
Size in gallons
'Pump ofr level at in.
Cycles tested
Manhole/Access (Y/N)
High water alarm leve t in.
Meets alarm & circuit equirements?
On adjacent lots ADD
On adjacent lots
Public sewer manhole/cleanout
Holding tank /1//4
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: '
r
Building foundation S 't Property line /0 /f Absorption field
r �
Water main /V//}' Water service line f Q * Surface water MO f
Wells on adjacent lots MI 0 /4"
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line / 0 if
Water Service line M 14 -
Curtain
Curtain drain if/4k
F. COMMENTS
Building foundation /a 'f Water main NIA
` /f
Surface water /00 /� Driveway. parkinglvehicle storage L __iL_
Wells on adjacent sots /00 1+-
G.
t
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Sr64/E EAIG
" Date 7/.22/45
q o . op
HAA Fee $
Waiver Fee $
Date of Payment 0''9" C)"diz/ as Date of Payment
Receipt Number 113/8 Receipt Number
(Rev. 12/01)
y ar7 coo 'a✓ _cro, et.
458 Ul LT
Art a
VII
1 HEREBY CERTIFY THAT 1 HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
LZiyr�yy.%gLlErjEly�lS"Lor /se B,f:/ •
AND THAT NO ENCROACHMENTSeEXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES.
•
7
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SEWARD &
SCALE= i
•
DATE:
GRID=
re✓6soci
FB:
/07 r7
DRAWN:
.oaf
ASSOCIATES LAND SURVEYING 694-0829
.. .�
Du.n. Mirk Seward
!LS -6918 ' _.A'
Mat -Su Test
CHEMISTRY Water
Lab of Alaska
Quality Testing
Email: plat-sutestlab(drogershsa.eom
-
Mile 3.2 Palmer-Wasilia Hwy.
Midtown Community Business Park
Phone: (907) 7453005
P.O. Box 2749
Palmer, Ak. 99645
Fax: (907) 7453010
Client: North Rim Engineering
17237 Bear Paw Circle
Eagle River, Ak. 99577
Attn.:
Client ID: Lot 18 Block 1Mtn. Valley Est.
PWSID #:
Source:
M.S.T.L.#: 51518
Sample Matrix:
Comments:
Date Arrived: 7/12/05
Report Date: 7/15/05
Sample Date: 7/12/05
Sample Time: 1100
Collected By: N.R.E.
Method Parameter Units
Results
MDL
Date Prepared
Date Analyzed MCL
SM 4500-NO3-E Nitrate -N mg/L
SM 4500-NO3-E Nitrite -N mg/L
Total Nitrate/Nitrite mg/L
Legend: MRL = Method Report Level
MCL = Max. Contaminate Level
B = Present In Method Blank
E = Estimated Value
N = Above MCL
D = Lost to Dilution
esow- d
4.19
0.52
4.19
0.50
0.05
0.50
7/15/05
7/15/05
7/15/05
7/15/05 10.0
7/15/05 1.0
7/15/05 10.0
Re. • ed By Jon Paul Campbell
Lab Manager
Mat -Su Test Lob
190774E3012
07.'13/06 C7sO2pn P. 003
Matsu Test Lab of Alaska
Vila 3.2 Palmnr-Wanilla tlwy
Midtown Community Business Park
P.O. Box 2740
Palmer, Alaska 99044
Phone: 745-3005 Fax: 748-3010
Drinking Water Analysis Report
Total Coliform Bacteria
LCfient:: G` t^et
1 Address:
PWSID# applicable):
v,`-� � e d �
,t. fi ti 51h,U� a Z Paid.
Ph ot7rr #: t o2 ' rax #: b i
'' " --This Section to be cOFripfeted by Sampler.
Legal Description of Property: 44.77u �4LLg'1 es -t- B f L 1 i
G ttY'
Sample Site Location:
Fel' 'ct -J
(I.E : kncnen sink. baUvoom snit, outside hose bit)
Time Sampled: 1 i d 0 Date Sampled:%/(Z(os Sampled by: AJdrill Beth tot
✓-
Delivered to Lab By: MJC1 fafrt— Es 5
t
Sample Type: Routine Treated:0 Untreated:[] Repeat Sample #:
This Section to Be Completed by Lab
Analysis Results:
QSatisfactory
❑Unsatisfactory
❑Sample too long in transit (greater than 30 hrs.)
'Request resample.
Co , Sent to State: Yes _t w
ChromogenicIFluorostenic Method Results:
A Total Coliform Present (P)/Absent (A)
Lab I.U. #: c5 /6 V--
r� E. Coli Present (P)/Absent (A) 9 Q g
Date Received: 7/ 40� Time Received: 1 tt 30 Received by: !, `
Date Test Begun: 7/R Time Test Begun: _ /GJo Analyst:
Date Completed: 7/13 Time Completed: /G.h Analyst:
Refer to Back Side for Instructions
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTIECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL l=�la-
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date November 11, 1986
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 18, Block 1, Mountain Valley Estates T13N,R1W, Sec. 8
Location (address or directions)
Eagle River
(b) Applicant Name EiMOS Bullington Telephone: Home 694-36.5 Business 659-8591
Applicant Address P.O. Box 771623 Eagle River, Alaska 99577
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder K1; Buyer ❑ ; Other 0 (explain);
(d) Lending Institution First National Telephone 694-2103
Address P .0. Box 770548 Eagle Rivers Alaska 99577
(e) Real Estate Company and Agent N/A
Address N/A
Telephone N/A
(f) Mail the HAA to the following address:
picku by engineer
2. TYPE OF RESIDENCE
Single -Family 0 Multi -Family 0 Other
Number of Bedrooms 3
3. 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 0 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 (11/84)
5. ENGINEERING FIRM PROVIDING 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 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 Telephone
Address EAGLEBLVER_ENGINFFRINI; SFRVICES
Date 1///&/Er‘ EAGLE RIVER, AK 99577
P. 0. BOX 1/3294
694-5195
6. DHEP APPROVAL
Approved for 3 bedrooms by
Approved , Disapproved
a�di, pp
`1f cee h nr C'
el (.;j ,<:° e: > 0
-;z �.., �rtglr�er s feel (gyp
io n ,, I r5).''__ a e> .1
7 40�iave 4.JG"`v'9ecce�,. ,'�¢,n ,
v
iyA ouou.. o>aaoe . onone c�
f�4 1"� o Louis A. Butera ��
©sia
;- 'ee CG67. 6 ^.�N A'
Conditional
Date //-2/RCit'
Terms of Conditional Approval
FiWe
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
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
NOV 2/79986
RECEIVED
A. WELL DATA
Well Classification s /614 /
MUNICIPALITY OF ANCHORAGE (MOM)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: j o f & / /--?//c- j
//,6,7 fs /te r ,773 /-✓ le/ by c_ -
If
If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) ,y Completed % 9 7 7 Yield �. r�
A...)Date
Total Depth -, -..0Y- Cased to�y�" �se"""-/Depth of Grouting 'L'``
Static Water Level >> " /e/N %/2 012 4 s"" S Pump Set At 8 3 <
Casing Height Above Ground27
, Sanitary Seal on Casing (Y/N) /
Electrical Wiring in Conduit (Y/N) i
Depression Around Wellhead (Y/N)
res yrs(
/✓
Separation Distances from Well:
To Septic/Holding Tank on Lot //5 / ; On Adjoining Lots/oa
To Nearest Edge of Absorption Field on Lot /moo ; On Adjoining Lots //v6.2
To Nearest Public Sewer Line 10 To Nearest Public Sewer
Cleanout/Manhole /U To Nearest Sewer Service Line on Lot //t-
Water Sample Collected by 1ys/& /`' " 5""tee " f ; Date //ll 34=96
Water Sample Test Results � ,s c
Comments r Ve//
/a -✓lc _1 f!-‘,>->-.
G✓��"yam,
C. -v^
B. SEPTIC/HOLDING TANK DATA
Date Installed /777 Size /uv° 5 / No. of Compartments ;.Z
Standpipes (Y/N) /
Air -tight Caps (Y/N)
Depression over Tank (Y/N) /✓
Foundation Cleanout (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High -Water Alarm (Y/N)
p//,‘
Date Last Pumped
Separation Distances from Septic/Holding Tank:
To Water -Supply Well //-5
;for 'mak
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Property Line r/'D To Disposal Field
To Water Main/Service Line /o / To Stream, Pond, Lake, or Major Drainage
Course
/1//,,
Comments
Page 1 of 2
72-026111/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 7
Type of System Design
Length of Field �6
i
Width of Field Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area
o
5-7
Standpipes Present (Y/N) i
Depression over Field (Y/N) it) Date of Last Adequacy Test ii//.3A-
Results of Last Adequacy Test fi sf Ifo
Separation Distance from Absorption Field:
/
To Water -Supply Well
To Property Line *�o
/
To Building Foundation (26To Existing or Abandoned System on
• On Adjoining Lots 3 t
To Water Main/Service Line t/o / To Cutbank (if present)
Lot '�76t
To Stream/Pond/Lake/or Major Drainage Course /%
To Driveway, Parking Area, or Vehicle Storage Area too
Comments
D. LIFT STATION /�J
Date Installed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
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 r; MOA No S
Receipt No. 500/ —moo/r.
//—ZG
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
6,5-: 0
Eagle River Engineering Services
P. 0. Box 773294
Eagle River, AK 99577
694-5195