HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES #1 BLK 3 LT 12
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP221229
Work Type: Septic Upgrade
Tax Code Number: 05065105000
Effective Date:
Expiration Date
i»ent
o
Department
7/14/2022
7/14/2023
Site Legal Address: MOUNTAIN VALLEY ESTATES #1 BLK 3 LT 12 G:0758
Site Mailing Address: 4240 JOHNNY DR, Eagle River
Owner: MORGAN ERIC M Lot Size in Sq Ft: 94350
Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 5
This permit is for the construction of:
Q Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By:
Issued By: eZ7�k,,,W�
7/14/22
Date:
Date: /Z
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 050-651-05
Property owner(s) MORGAN ERIC
Mailing address 4240 Johnny Dr
Site address same
Day phone 280-7956
Legal description (Sub'd., Block & Lot) MOUNTAIN VALLEY ESTATES #1 BLK 3 LT 12
Legal description (Township, Range & Section)
Lot Size 94,350 Sq. Ft. Number of Bedrooms 5
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(M all that apply)
Absorption Field
Fx_1
Initial ❑
Single Family (SF) 0
(w/wo AD U)
Septic Tank
0
Upgrade El
(D) El
Holding Tank
❑
RenewalDuplex
❑
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: % 5� 5_ Waiver Fees:
Date of Payment: 6 a3a0, 2 Date of Payment:
Receipt Number: 0 060)�D Receipt Number:
Permit No. 0 S'P Q Q 1 a 2% Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
SteveEng.com
Steve Eng, PE, PH
907-694-7028
SteveEngPE@gmail.com
Date: 7/13/22 Number of Pages: 1
To: MOA On-Site Services
Subject: MOUNTAIN VALLEY ESTATES #1 BLK 3 LT 12
Septic System Upgrade- Steep Slope
The owner desires to upgrade the septic system. A new soils test reveals no bedrock near the
surface. The design calls for a new trench and a new septic tank. Slopes and easements are
depicted on the drawing. The terrain is generally a flat slope at the trench site, and sloping
toward the east. The system design size is a single family at 5 bedrooms.
A cut-bank exists to the east of the trench, closest point is 40-feet. The cut-bank disappears
gradually to the north. Although the slope is greater than 25% at this point, where the slope
changes to over 25%, the drop in surface height is less than ten feet below the invert elevation of
the horizontal drainpipe.
The property is vegetated with brush & grass below the slope. The property line down-gradient
of this point is over 100-feet, with gradual slope the entire distance.
The trench width is narrow, as recommended in the steep slope code. Natural vegetation will
remain undisturbed below the steep slope. For these reasons, the short cut-bank slope should not
affect this project or performance of the septic system.
Thanks-Steve
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221229, Deb Wockenfuss, 07/14/22
SteveEng.com Mtn Valley Est #1 B3 L12
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: This is an existing 5-bedroom, single family home. This is a
developed subdivision with large lots. A new trench is planned + new 1500 gallon septic
tank. The existing septic system to be decommissioned. No adverse impacts are expected
from trench/tank upgrade. No conflicts to the other lots will take place by this septic
system construction upgrade. A new soil test reveals SM w/gravel. An application rate of
1.2 GPD/FT². Trench Length = 625 FT²/5 x 2 = 63 trench, 5 effective. A new 1500
gallon septic tank will be installed; Decommission old tank per UPC. No easements in
the area, private water wells serve these lots. A 9 trench depth requested due to
monitored groundwater @ 13 Above ground building to be moved 5 to east per
drawing. Slopes & cut-bank as depicted in Plan view.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water
Regulations and Wastewater Regulations.
Two compartment, New 1500 gallon septic tank. Install Double Cleanouts.
Decommission old tank per UPC. MOA-Spec Material Under Tank.
10 minimum between the tank to house, property lines, 5 between tank & trench.
3 of cover or insulation is required for trench; 2 Minimum thickness for insulation
can substitute for 1 cover.
Tank & solid pipe must be set on well compacted, stable soil.
4 inch diameter cleanouts with airtight caps are required 1 to 4 from foundation
wall, prior to any 90 degree bend in 4 inch line, in each tank compartment, and two
adjacent opposing cleanouts between the tank and the absorption field, not more than
10 from the tank positioned to provide cleanout access towards the tank and towards
the absorption field.
All cleanouts must extend to at least ground level.
In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
Trench to be placed level, minimum of 4 to groundwater, 6 to bedrock from drain-
rock.
Drain rock to be ½ to 2 screened, distributed uniformly throughout the trench.
Perforated pipe to be installed level with perforations down.
Silt barrier (filter fabric) to be installed above the drain rock.
Smeared trench sides must be raked or scarified before drain rock placement.
The finish grade must be mounded to promote drainage away from trench.
Insulation must be placed over any pipe installed under driveways or parking areas.
Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789,
ABS ASTM D2661,
Sewer Service Line is minimum 2% slope.
Septic Tank to be pumped every two years or when required.
Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal)
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221229, Deb Wockenfuss, 07/14/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221229, Deb Wockenfuss, 07/14/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221229, Deb Wockenfuss, 07/14/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221229, Deb Wockenfuss, 07/14/22
Municipality of Anchorage Page [ of ___
r)EPARTMENT 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
Permit Number: ddt ~ ('-") ~::Z)~,~O3Li PID Number: _~/-~ ~ - ~z~'
N~: ~ka~O~ ~~ Wastewater System: ~ New U Upgrade
Address: ~ ~ ~ I~~;~~, ABSORPTION FIELD
Phone:
oo s, ~ Deep Trench ~ShallowTre~ch ~Bed ~Mound ~Other
LEGAL DESCRIPTION so, Rating: Total Depth fro~ original grade:
GPD/Sq. Ft. ) 7
Lot: ~ Bloc~ ,. __. Spbdivision:~ ~ Depth to pipe botlom Item original grade: Gravel dept~eneath pipe
'l O W n, h ' p:, + ~I" n o=,~ ~ection:~'--" FillaOOeOabovo~inalgraOo: Gravellength: -
. Ft. 48' Ft.
Grave~: Numbe~f lines: Distance between li~es:
WELL: B New Q Upg ~¢~ ~t ¢, Ft. ~'% Ft.
Classification (Private, A,B.C): Tota~ Cased To: Total absorpti Pipe material:
~ Ft. Ft. SQ. Ft.
Driller: ~ Date Drilled: Static Water Level:Ft. _1%~¢¢ ~.~ ~: Date installed:~_
'7~GPM I"umpSotat: Ft. CasingHeightAboveGround:Ft. TANK
SEPARATION DISTANCES u Septic ~ Holding U S.T.E.P.
To Septic Absorption Lift Holding ~/Private Manufacturer: ~city gallons:
Well JO8t J 5~' ~O8/ ~ / ~ Maleria~ Number of Compartments:
Surface/
~ Water +~%' ~1~' ~t~' +~ LIFT STATION
Lot Size in gallons: Manufacturer:
"Pump ~" level at: "Pump off" level ~t: High wa[er alarm at:
Curtain ~ '
~. Drain ~ ~ +~1 ~Or :Pump Make & Model~ Electrical Inspections performed by:
Remarks: ~ t~o G ~tF~ 5T>~0¢ /N~t~ BENCH MARK
Locabon and Descr~pbon:
Assumed ElevatiO~
Inspections performed by: ~s~4~ ~¢ Dates: 1st
Department of He~ and Human Services approval
Reviewed and approved by: Date:~'//~/____'__ :~,~
72-013 (1/91) MOA 25
Permit No.
7_ 7_.
Page of
Municipality of Anchorage
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 ~nspection Report
72-013A{2/91) MOA 25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW910234
DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC.
OWNER NAME:CARRINGTON SHARON
OWNER ADDRESS:P.O. BOX 772038
EAGLE RIVER, AK. 99577
PAGE 1 OF 1
DATE ISSUED: 8/09/91
EXPIRATION DATE: 8/09/92
PARCEL ID:05065105
LEGAL DESCRIPTION: MT VALLEY ESTATES #1 BLK
T 12
3 L
LOT SIZE: 94350 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
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 (iSAACS0).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAl, PROVISIONS
RECEIVED BY:
ISSUED BY: //.~'~___~~/~'~-~
DATE:
DATE:
'~ 4-o)ooo s ~
ENGINi
S]:TE PLAN DETAILS-~PROPOSED ABSORPTION SYSTEM
LOT 12~ BLOCK 3, MOUNTAIN VALLEY ESTATES SUB
PREPARED FOR:
SHARON CARRINGTON
'P.O. Bo'~ '77~o58
EAGLE RIVER, Ali, 99577
SCALE: i" : 100'
DRAWN BY (:AL
CONSTRUCTING ENGiNEERS3A6-2000
9601 BUDDY WERNER DR 694-9098
ANCHORAGEr AI(~ 99516
DRAWING // 91-'$2-07-'1A
ABSORPTION AREA CALCULATIONS: 4 Bedrooms x 150gpd/bedroom = 600 gpd
(soils rating : 1.2 gpd/sf) 600 gpd / ]..2 gpd/sf = 500 sf area
500 sf/(W + 2D) for W = 5', D = 3' = 46 ' trench
Mini. mum trench length = 46'
IMPACT ON ADJACENT LOTS: Th.ks lot is served by an existing prJ. vate well. The
private well on I.ot 11, the lot J. mmedJ, atley North of this lot, will not be
J. mpacted by this installation. There is no development on Lot 13, the lot
immediately adjacent 'to the South. The private well on Lot ].9, Block 5, is
more than 200' from the proposed upgade.
ENGINEER'S SEAL
SITE PL}UN D}'.~A1LS--PROPO$~,D ABSORPTION SYS.~kr.t
LOT 12, BLOCK 3, MOUNTAIN VALLEY ESTATES SUB
PREPARED FOR: SHARON CARRINGTON
Po gow "7'7Zo58
EAGLE RIVER~ AK, 995'?7
hOT TO SCALE DRAWN BY CAL
CONSTRUCTING ENGINEERS346'-2000
9601 BUDDY WER}IER DR 696-'9098
DRAWING # 91-S2-07-1A
LOT I2, BLOCK 3, MOUNTAIN VJLLLEY ESTATES sUB
PREPARED FOR: SHARON CARRINGTON PO BOX 772038
' 2
EAGLE RIVLR, AKt 995']7
,gCALE: 1" = 50'
DRAWH BY CAL.
CONSTRUC!~ING ENGINEERS346-2000
9601 BUDDY WERNER DR 69~9098
~CI{ORAOE, AKf 99516
DRAWING # 91-S2-07-1A
Municipality of Anct~orage
DEPARTMEN'r OF HEALTH & HUMAN SERVICES
825 "L" Street, Anch(?age, Alaska 99302-0650
SOILS LOG PERC( LA~iiON TEST
PERFORMED FOR:
LEGA
2
3
4
5
6
8
9
10
12
13
14
15-
16 -
17
1 9 --
2O -
('~-;,:~.'¢"Y"I"~,~'-~TT;~__~L ....................... DATE PEREORMED:
7-
SLOPE SITE PI_AN
WAS GROUND WA'FEll
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
~lmilering7 Dale: -'. -
Time Time
Readm9 Date ~ Water ' Drop
1C2,.-,., ,A
IOta
PERCOLA'rlON RATE 5 'Z~__ (l,~a~uts$/IflOh)~)E[]O HOLE DIAMETER
?ESTRUNBE'IWEEN __~*~__ FfAiXlD ___~--
IViuldcipality ot Anchorage
DEPARTMENT OF Hb~AL'FH & HUMAN SERVICES
825 "L." Street, Anchorage, Alaska 99502-0650
SOILS LOG --- PERCOLATION TEST
PERFORMED FOR:
SLOPE SITE PLAN
2
3
4
6
7
1 1
1 2
'17
2(I -
COMMENTS
WAS GROUND W/',TER
ENCOUNI'ERED? ..... LVO ___
IF YES, AT WHA'F
DEPT}I?
Del)th Io Water filler
Reading
Date Gross Net Depth to
Time Tim~, Wet0r
';--
PERCOLATION RA1E _____
TEST RUN BETWEEN
oq~v~ o~ ~</~T~:
Net
Drop
PERFORMED BY: ¥". ~' ~',~f~'~.~L~ I ...... __~ .~_."~---- CERTIFY 7HAl' THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STA~E AND MUNICIPAL O JIDELINESIN EFFECT ON qH,s ~A'r~. PAr~: ...... 71~O' )~) .......... = ......
72-008 (Rev 4/'85) '~-~T' ~t.~ ¢~ ~' ~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONIVIENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME ~- ~'~ PHONE /
IMAI LI~A~DR ESS , ~- '
LEGAL DESCRIPTION
LOCATION '~=~ ~_ ' ' ' ' NO ~F BEDROOMS 1~
Wellz ~ ~ Absorption a~ / Dwolling I PERMIT NQ.
~: Z Manufacturer ~ .~ ..... ~ I Material ~- I No. of compartments
~ Liq~ca~cit~in gallons r ............. Insideaeneth Width Licuid depth
i
D~ Manufacturer /~. I Material I Liquid capacity in gallons
~ / I We Foundation Nearest lot line ~ERMIT NO
~ / DISTANCE TO: I / ~ ~ '
;E~ I I /~ I inch~, I
~~ ~ Top of tile to finish grade // IMaterial beneath tile Total effective absorption area
~ , inches
Length ~,. / Width ~/ / D~ ~ ~,)/ (~ [~/ IPERMITNO.
~ ~" /~ :~ ~ ~/ b ~,~. /~ P,~bI
~lTypeof cr b Crib diameter Crib depth I Tota effect veabsorpti~area~t.
u~ ~ W II
~ ~ e ~ ~-~ ~ Building foundat onz I Nearest ot ine z ~
DISTANCE TO: (/ ~ ~[),~ iH /~ -.~-
~ Class~ . ~ Depth _ Driller ~ Distance to lot line- I PERM T NO
~ ~ ~ ~ ,~ . · . - [ · .
~ DISTANCE TO: ~ld n~foun~at ~ Sewer I ne Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
REMARKS
APPROVED
72-013 (Rev. 3/78)
DAT[
.. MIJN:! C I PlaL I T¥ OF laNE:HC',~..., ~GE
[:,EPRRTMENT OF HERLTH RND ENVIF.'.ONMENTRL F'RCTECTION
,=' , ,~. ,:)..=;Fi.'L
P"".'.=, L _,TF..EET., RN':H]RRGE FIK
2G4-4.720
C,I'-,I--S ]: TE '~=;EI.,-IER .~: t.,JIELL F'IEZF-." I',1 :[ T
PERMIT NO:
DlaTE I SS .lEE:.,:
RPF'L I C:RNT: RLC:FtZRF.: L. ORF ';,',
RC:,E:,F.:ESS: SR 2: BO,'-,",
ERGLE F.'. I VER., 8K
6L~. 4-2440
F:ONTFIC:T f~ H_INE:
99577
LEGFIL [:,ESCRIP: SUB[.',IVI:BION: MOUNTlalN ',,,'FILL. EST#:.'L LOT: i:::"
SECTION: ]:~ TO!4N'-]HIP: ±4N RFINGE: 1. H
LOT SIZE: 2R (~,Q. FT. OR FtCRES)
MAN BEDROOMS: Z.:
E:LOC:I<:
LISTED BFI_OI.,.I FIRE THE UFTION=, RVRILRE:LE TO '¢OU IN DESIGNING 'T'OUR =,EF]'I..
S"r'STEM. CHOOSE THE OF'T ION THlaT BEST FITS ¥OLIF.'. SITE.
DEPTH TO PI~E"E:OTTOId <FT, ~
GRRVEL DEPTH <FT. >
TOTRL DEF'TH <FT. >
.GRRVEL NIDTH (FT. >
GRRVEL LENGTH (FT.)
GRRVEL VOLUME (CU. gD$. )
· TRNK SIZE (GRLS)
SOIL RRTING (SQ. FT./BR)
m:+: [:,EF'TH TO PIPE E;OTTOI'"I .C 3:. 5 FT. F..EL..!LIIRE_, Ilqz, ULMTILN
:+::+: [:,EPTH TO PIPE BOTTOM '{ 4, 0 FT. MR"r' F.E.'UIRE R LIFT STFtT.~nN
:+':+: TRNI< MUST HRVE RT LElaST TNO COMPRRTMENTS
I CERTIF"r' THFIT:
t. I FtM FlaMILIFIR NITH THE F.:EQ.IIREMENTS Fr'~R ON-SITE _,EHI_F.._, FIN[:, HELLS las SET
FOR]'H B'-r' THE MUNII]:II'~RLIT'¢ OF lalq]:HORRGE '~h'lOla) FIN[:, THE STlaTE OF RLRSI<R.
~.o .... I HILL INSTRLL THE :EA"STEM IN F'tCCI]IR[:,RNE:E NITH RLL Mr]FI F:FE)E'=; laND F..EUULHTILN=,.,
laND IN COMPLIRNCE HITH THE [:'E':;IGN CRITERIFI OF THIS F'EF.'.MIT.
E, ML.F.
S. I NILL la[:'HERE TO RLL I'10R RND STRTE OF RLFISKla F.'.EC..!UIRIEMENTS FOR THE '...=,ET" .....
'~ ¢- ' f" '- -'" '- ~' '=, :' - ' ' '"" '-' "~~"- ' , ' I ' '1-'
E.Z_-,THN..E:, FROM RN'¢ I=,..,I..-:,TIr4b NELL, Hla_TEHHTEF.. DI-,PO=,I-IL -:,~_~IEI't ErF..'
_,EHEF.:RL~E _,Y_,TEfl CIN THIS OR laN"r' RE:,JFtCENT UF.. NEFIRE:"r' L. OT.
4. I LNDERSTFIND THFIT THI'---, F'EP, MIT I':; ',,~laLI[:, FOR la MFI::~;IMUM OF _", .... BE[,ROOM_-,'" ' '- '- FIND
FIN¥ ENI..FIRGEMENT WILL REQUIRE lan FI[:,DITIONlaL PEP. MIT.
'- ' I=, INSTFtL~.ED IN RN FIREFI CO',,,'ERED
LIFT --,TIdTION' '-
c .... ':,) RS-EIUI LTS
,'1) RN ELECTRIE:RL PERMIT RNE:,' IN_,FEL. TION MUST BE FE:TlalNEr).~ ,,,:..
NOT BE RFFF..J~E[. NITHOUT FIN ELE_.TRIE:laL :[N=,FEL. TION F. EFuF..r., laNb (~-:':, THE
IF'R
THEN
H ! LL
ELECTRIClaL WORK MIJST BE--.~[:,ONE B'¢ Fl./LICENSED ELECTRICIRN.
?~¢"¢/ '~ [~4-W D~ILLING, Inc.
P.O, Box 10-378" 10300 Old Seward Highway
(907) 349-8535
ANCHORAGE, ALASKA 99511
DRILLING LOG
Well Owner__C~d'LIU-l';C'tlOi'l~ ,l']7.l & S !AT-lC :'1 Use of Well
Location (address of: Township, Range, Section, if known; or distance main road .......................
~' c~ 1"]1 ~,~ '
Size of casing. .(:," .Depth of ttole__.. 10]. feet Cased to__ 0:.],_:L ...... feet
Static water level '?:£~ ..... ft. (idgbVe) (below) land surface. Finish of well (check one) open end ( );
Screen ( ); Perforated ( ).
Apr' J ,,:,.fi't! i'].;1,qE;{x: J,[;i(?'A'
Describe screen or perforatiom 7[~sLaJ.].ed bO' oJ~' ,'~" ,,.,,~ *~" '
Well pumping test at_ .[~._gallons per (~O~Y) (minute) for_.~..._~hours with ..... JS?)i ................ ft::
of drawdown from static level,
Date of cornpletion_~&~ff_~:~~
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
.'.FO .... 53
.TO.
........... TO
.TO.
.TO.
2'0.
TO.
.TO_L
NWWA Certified Contractof'
Certificate No's. 814 & (073
3 -- CONTRACTOR
l.:.. t ~iFi" E: I::.; EdEL. Cd.,J IqRE:_' THE: Ii)l:::"]' ]10hii:~; I- [. [,L E TO "~;' '"1 :il l'ii [::,E~; i Ii:iN 11: I'.,IG "r' '" I1:;-' SIEF:'"t" ]1C
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fi'E? ]'[:,E:H.".:li;i: 1. Z I:;;:E:I'"IOI:::,E:L[~:I:::, '1.'C I I'.,IE:I...IJ[::,IE I"IE6;.':[~: THI'::I?.,I E~
t:::'ERH I 1" !:IF'Fi'L. :[ CI::'IhI'T' I-II:::IZ THE I E .',F . I,I , [ E, I1. t '1 ~- TEl !'I'.,IFOI:~:H I:::'liii:R'.i~;E~t'.,ll'.,IEi:l... [',
THE :I:I'.,t:!!:;TI:':ILL.t:IT:t:EJ?.,I ;i:l'.,l'..'!;l::'E:l:::TI(;;d'.4::ii; (::11:::' RN'.¢ HIEL..L..Z i:::II%:rRE:EN'T TO "l"l...l:[:i.~; r::'I:~:OF'IERT'T' F:tI'.,IE:,
THE H. f,1l~: I?P OF F..:E:ZI E:,E:NE:[!!::!i; THFIT THE I.,.tEL. L.. I.,.I :[ L.L..
:[1::: I:::1 L..]:F'f' Z'f'Ir-'IT:[OI",I :1::~!; :[l'.ii:%;'FFtl....I....l!E[::,., I:::ll",l [J:L.EC:-f'J;;::[(:::I:::tL. I::'E:RI'I:t:T I:II",IE:, .T.I'.,I:~!;f~'L'iC:T:[Ed'.,t I"IU:.~;T
ErE t)[!l"f'¢:l :J:l'.,l!:!i:ti:,. I:::1~!;-...!!!',!...111; L..'1.':!i; E:i::iI'.,II'.,ICr1.' E',E F:iI:::'F'R q',,,'E'l') H il: 'll..IOI...l'l" FiN [:~:L..E3Z:TR .f, C:I:I[_ :[ hI:i.~;F'Ei:CT :[ O1",1
F;:E:F'Ii3R'I". TI"ItE EiL.tEC:Tlai:]:Ii::I::IL. I.'.tOl~:l'::: h'II...IZT !~:lii.": [::'OI",IE I!!!:'~" !:::1 t...IE:IEt",ICE;IED [!~L..If!(:::'i"I;;::[C:[I::II",I.
MUNICIPALITY OF ANCHORAGE
Department Health and Environmenta~ rotection
825 ~ Street, Anchorage, AK.
264-4720
* * * HANDWRITTEN PERMIT * * *
Location: ~> ~"[~ Phone Number:
Legal Description: >[':' '~ ~I~4 CS": ice:
Type of Soil Absorption System Is:
Trench: Drainfield: Seepage Bed: /~ Holding Tank:
Maximum Number of Bedrooms: ,(~ Soil Rating(sq.ft/br)
The Required Size of the Soil AbsorptioD System Is:
GRAVEl_ DEPTH~
W~DTH
The length dimension is the length(in feet) of t~e trench o~ d~ainfield, The
depth of a trench or pit is the d±stance between the surface of the ground and
the bottom of the e×cavation(in feet), There is no set width for trenches,
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the e×cavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SiZE = ./~P~? GALLONS * *
~ermit applicaat has the responsibility to inform this department du~ing the
installation inspections of any wells adjacent to this property and the number
of residences that the.well will ser~e,
* * TWO(2) INSPECTIONS ARE REQUIRED * * *
BacAf±l].ing of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well, Hinimum distance from a private well to a private sewer line
is 25 feet and to a co~unity sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER ~1~ 1 9
I certify that:
(l) Z am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) Z understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 bedro~
SWP/024(1/81)
PEF:.H t T NO.
DP-F'FIRTMENT r HEFIL. TH FIND ENVIRONMENTFIL OTECTIEIN 8;-25 '"L STREET., FtNCNOF~'.I.~ISE., RK.
,:: E:]:Ell.'-'l]:','~l ::,
RF'F'L..'( CRNT
LOC':FIT I ON
LEGFIL.
JOFIN GROSS
LJ.2 B3: MT. ',,,'FILLE'T' ESTFITES
PO BOb', :1. t6t E.R. 694-.9t38
LOT SIZE 9E1EiEJE1 SQt.IRRE FEET
TYPE OF' SOIL RBSORPTION SYSTEM IS: TRENCFI
MFI',:-:;IMLIH NLIHBEF.: OF E:EDROOHS = _.].':
SOIL RFITING (SQ FT,,"BF.:)= 85
THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS:
[:, E F' 'T H =-~ -'t ;7.:: I_ E P-.t (.~ 'T Fi =: 2 ~"; ,.'3: F=: F4 "...' E I_ [:, E-': F=" -r l-I =--.
TFIE LENGTH DIHENSION IS THE LENGTH (IN FEET) OF ]"HE TREI'.4CH OR [:,RFIINFIELD.
TFIE DEPTH OF FI TRENCH OR PIT IS THE DISTRNCE BETHEEN THE SURFFICE OF' THE
GROLIN[:, FIND TFIE BOTTOM OF THE EXCFI'v'FITION (IN FEET).
I'FIERE: 12"; NO SET NIDTH FOR ].'RENCHE':::.
TNE GRR',,,'EL [:,EF'TN iS ]''FIE MINIMUM [;,EPTH OF GRFI',,,'EL BETWEEN THE OUTFRLL PIPE
FIN[.,, ]''HE BOTTOM OF THE: E,'.',',CFI',,,'FITION (IN FEET).
F'ERI'"I~.T RF'PLICRNT HFIS ].'HE: RESF'ONSIE:ILITY TO INFORM THIS [:',EPRRTHENT DURINi] THE
INSTRLLFITION INSPECTIONS OF RF,I'¢ HELLS RDJRC:ENT TO THIS PROPEF.".T~r' RN[:, THE
NUHBER OF RESIDENCES THFIT THE NELL HILL SERVE.
............ -li" L-~t C, ( 2 ::, Z ~'-.~ S; F" E: C: T 1' O i'-.I :_:.; F~ i:;.:.: [':'. F.-: E.Z. Lz.~ L" :[ lf.~:: E:
E:IZtCKFILLING OF RN'¢ SYSTEM NITHOUT FINRL INSPECTION RND FIPPRO',,,'RL B'¢ THIS
DIEF'FIRTMENT P]ILL BE SUBJECT TO PROSECUTION.
HINIHLIH [.~ISTRNCE 13ETHEEN R WELL. RND RNY ON-SITE SEHRGE DISPOSRL SYSTEM IS
2. EIE1 FEET FOR R F'RIVRTE WELL OR ±SE1 TO 2E1E~ FEET FROM FI PLIBLIC P.IELI_ DEPEN[:,ING
UPON THE TYPE OF PUBLIC WELL.
MINIHUM DISTRNCE FROH IR PRI',/RTE HELL TO FI F'Rt'v'FITE SENER LINE IS; 25 FEE]" FIN[:,
TO R COHt"'IUNITY SEHER LINE IS 75 FEET.
HEL.L LOGS RRE REQIJIRED FIN[:, MUST BE RETURNED TO THE: DEPRRTMENT P.IITHIN L~;El DRYS
OF TItlE 1.4ELL. COMPLETION.
OTHER REQUIREMENTS MFIY FIPPLY. SF'EE:IFICRTIONS RND C:ONSTRLIC]'ION DIFIGRFIMS RF..:E
FI',,,'RILRBL. E TO INSURE PROPER INSTFII_I_RTION.
F' E R B'"I Z T' E:- ::-:: F" 1' F-: E: S [:, E ,..]: E--] f"l E: E F: Z:: t .. ::L 9 E.' ]-~::
I CER].'IF'¢ THFIT
· 1: I RI'"I FRI','IILIRR HITH THE REQUIREMENTS FOR I]N-SITIS SEHERS RND NELI._S RS SET
FORTH B'-r' THE MLINICIPFILIT'¢ OF' RNCFIORFIGE.
2: I P.III_L INSTRLL. THE SYSTEM IN RCCORDFINCE NITH TNE CODES.
]:: I UNDERSTRND TNRT THE ON-SITE SEWER SYSTEM HR"r' RECiUIRE ENLRRGEMENT IF THE
RESI[:,ENC:E ~S~'.EMC,?ED ?3 INCLLI[:,E ME, RE TFIRN ~: E:E[:,RC, C,M~.
....... ...... ......................
='L. ICFINT JGHN GROSS
, -_
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: /.- I '~' r:~ ~.-~
SLOPE
SITE PLAN
10
11
12
13
14-
16.-
17
18
19--
20-
COMMENTS
/
G 2 ) ' c-, >
WAS GROUND WATER V ~,~,,5 SL
ENCOUNTERED? O
P
IF YES, AT WHAT /' E
DEPTH? "7 '
v2~ --- I t)
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~'~ (minutes/inch)
TEST RUN BETWEEN
72-008 (6/79)
FT AND FT
CERTIFIED B~~'((/
U 3',"
~Permit ~: 820060
January 31, ].983
TO: Permit Appl. i. cant
Subject: Lot 12 Block 3 Mountain Valley EsEa~es Subdivision
A permit issued by this department for an individual ~ell
and/or on-site sewer system has expired as of December 31,
1982.
Permits are issued on a calendar year basis, as stated on
the-permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log needs to be sent
to this department for documentation of 'the installation
date and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files and documentation.
If ther'e are any further questions, please call this office
at 264-4720.
Sincerel~
Robert C. Prattt R.S.
Acting Program Manager
Sewer and Water Program
RCP/Ljw
enc: Copy of Permit
SWP/057
L..::!,;2 IEC~: HT. , 't..::; I!!Z'T'FITF:Z
THE:.:: L. fii:HG"I",LI [::,:!: HE:NE;:£ OH I E; 'T'!.'!E:
TH[ii: [>.E:F:'TH OF:' ¢::~ "I'F~;E:i'.,IC:H OF.'! PIT tE; TH,E:
GFi'.OLIh,II) FIN[::, THE: E~O"I"TOi"! OF TH!:~ !ii:;:':',CFI',,,'F:!T
'T'HI~I:;i:E: I::5 i'.,IO :~;E:'[' I.,.!]:E:,TFI F'O,qi:
T!..I..r':i: G!:,:".FI,',,/E:L !'::,E:F'TFI :1: Z 'TI...!f-~: I"1 :[ J",! ]: I"!Uh'l bF.'i:F'TH
FIND 'FI-'!E: E',O"I'TOH OF' THE: E:::.:;CF~',,,'FC[' :[ ON ,:: i
rf'.I'::'T'F'It [ FT"Oi'.,! ]:H':PF"'T:I:~'.~1'::: r'd::: FIN"r' I,IF'I I':: I::I!.::,..:rFIC!:2.,Fr TO "['Hi:i~: ::,:,-:,,:.~:,...u c,U.. THE:
i'.,IL.I.UE',!ZFi OF' F~:E:!:,IE:,!i~:N(::F~:E; T,LIFIT THE: !,.I~'.:'LL.
::U;!~i,:.:.l F:'E::E-':T F:'OF: F'! ~f, .... i'1. ~. I,IZ OF: :'t '~:O "1"O :i;::O¢~i I='='F."I" !::'F?OH i:::1 :' ,E', 'i' !.,.!FL.L..
....... i'"' OF:' I='I. IE~L.. ]: f:: I,.!I:=LI
iJl:::'Ol'.,I TF.i~i( . ~ .: .........
.vl"l,.,l:rl','. li',1 !:::,]:E;Tf::IHI:i::!i~: F'F~i:ff,1 FI F'F;I',,,'i:::IT~!:_ I,l~::...L. ........ TO I=I !::'1:;~:~ "- I';::. 'E;.!=,,!I:!:F: L. I I',IE: I !~; :...% .... ......... ~:~::'[: ..... !
'FO FI C Ffi',iHIJNT. TV E; E !.,.! ~:~: F: I... I NE: :[ '.:!:; ?:'!:5 !:::'E:.E:T'.
!h:::~.{...L I '."G'/: Fif;..:l:~: i:.;'.f.:i:~:i:!l..l:[l';i'.i.;~:[::, f:il'.,l~:, I','!l...t?[ I:!:',:~: F~:E:"f"LII::;tI'.,!!_::[) TO THE: E:,E:F'i::iF;:'f'HE:!'.,!T !.,! I T,LI ]: !'..~ ':!!:::~ F,F;~'.d'.:;
OF' 'i',~.~.t.';: !,.b~!:LL.
OTH!i!!:F.: F:E):~.!U I' I::i:EjHE:NTZ !'"lF~'.r' .............. ::IF'F:'[ ..... FF'I=T:: :!: I::'~ C!~'F :[ OI"X-~; I::~N[::, :::OI'..k:.":TF:I ICT i !:')H ! ........... '," '::a =:~:::'.
FI',,,'Ft I I. FIE ..,..E' 'T'CI ): b,l~;I...IF~h~;: F'F;.:OF'[ii:Fi: I h,kii;TF:IL.L!::FT' Z
:1.: ! FIH FFII"!ZL..IfqF: !.,! :!: "r'!'l THE:
F'OF.'ITH E',"r' THE: !'"!LIH]:CIF'FIL.]JT"r'
;;;i:: ~i: !,.!IL.L !N'.:i;TF:!L.L. THE:
::i~:: ! LIH[>E:Fi:::ii;TF:!N[::, THFF'f THE:
,r'~:f~ti!;i[>!i!~i",ff:::l~i': I';5 RE:HO!>E:L.E:E:, TO
L~'~f:;F:'i.. :[ CF:iHT ..2[~
SOILS LOG
MUNIClPAI. ITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROI'ECTION
82.5 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
6
7
8
9
10
11
.12
13
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
14
15
18
17
18
19
20
COMMENTS
Reading Date Gross Net Depth to Net
Time Time Water Drop
"'
.....
PERCOLATION RATE (minutes~ "
TEST RUN BETWEEN F TAND F T
72-OO8 (6/79)
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
.Parcel I.D. # _~-..~)_.~.¢~_-(~)~-~ · NAA# ___.~C~
\
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
Day phone
Unles~ otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~r~
TYPE OF WATER SUPPLY:
Individual well
Community wel!
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system. ~
TYPE OF WASTEWATER DISPOSAL:.
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
s~uewwoo leUO!~!pp¥
:suol~elndp, s BU!MOIIOJ eq~, H~.!M 'suJooJpeq
'9
bI::I=iNI!DN~] A8 NOI.LO=IdSNI =lO J..N=IIN:I.LVJ. S 'S
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L'~¢~ /~°'~r'~'~t~l'~ (-~>')' Parcel I,D,
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
If A, B, or C, attach ADEC letter.
Date completed
Cased to._..___~O
7
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Public sewer service line
ADEC water system number
f'vl ~'~ I _~ ~q- Driller
Casing height ::'-'~ ~'
Wires properly protected (Y/N)
AT INSPECTION
44~ ~,C-.
6,0
g.p.m.
Z
0 ~ r~ L.LJ
; On adjacent lots
; On adjacent lots ~-~ co
Public sewer manhole/cleanout M. f~.
Petroleum tank
WATER SAMPLE RESULTS:
Coliform P' Nitrate
Date of sample:
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed Tank size
Cleanouts (Y/N) Foundati~ic,_cleanout (Y/N)
High water alarm (Y/N) ~/ Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot I o A' On adjacentlots
To property line +so' Absorption field
Surface water/drainage -+-I Oo'
Compartments .
..---'--~~;io n (Y/N)
Foundation
Water main/service line
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons ,
Vent (Y/N) "/
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer ~,,-~ ~.~-o~ "t~r,-¢4
Manhole/Access (Y/N) Y
"Pump off'~ level at.
Cycles tested ~'
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot Io~' On adjacent lots
Surface water +toO'
D. ABSORPTION FIELD DATA
Date installed
Length 4-'~' Width ~"
Total absorption area
Depression over field (Y/N) ~J
Results (pass/fail) ~ ~
Peroxide treatment (past 12 months) (Y/N) ~ ~
Soil rating 1'7-' ~P&l~°¢ System type
Gravel thickness '~ ' Total depth
Cleanouts present (Y/N)
Date of adequacy test
for __ bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots -4--t oo' Property line
To existing or abandoned system on lot
Cutbank ~b' 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
Date ~-&~
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev, 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONP~NTAL HF, ALTIt
DEPAR%~ENT OF ~ALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAl, CERTIFICATE
1. General Information Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(e) Applicant is (check one)Lending Institntion ['--2 ; Owner/builder.~[.;
Buyer ~ ; Other I7[] (explain>;
Address ....
,
Real Estate Co. & Agent
(e)
Address
Telephone
Telephone
(f) Mail the }{AA to the following address:
0
T_~pe of Residence
Nut, bet of Bedrooms
Other (describe)
Puhli
Note: If community well system, must have written cor~firmation from the State
De.p,~rtment of Environmentai Conservation attesting to the legality and status.
NgC~: If community well system, must have written coufirmation from the State
Department of Environmental Conse~ation attesting to the legality and status.
[Page ~ of 2]
5. .E~n~i~neerin.~ Firm Providing_ In_~s~pections, Tests, File Searchz Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, l
ve.rify that my investigation of this Health Authority Approval shows that the on-site
wa%er supply and/or wa.~tewater~' disposal system lo° °oafe, functional and adeqnate for
the number of bedrooms and type of structure indicated herein. I further verify that,
based on the information obtained from the Manlcipality of Anchorage files and from my
ihvestigation and inspection~ the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Approved Z~~ Disapproved
Terms of Conditional Approval
· CAUT]
TIlE MUNICIPALITY O1. ANCHORAGE DEPAR~,~ENT 0F HEAL'IH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES" BASF, D SOL~,L~ UPON THE REPRESENT.-,
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. TIlE DHEP DOES THIS AS A COURTESY TO PORCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CF, RTAIN FEDEILAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DtlEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF z~NCHORAGE IS NOT RE~dPONSIBLE FOR ERRORS
Og' OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DItEP SEAL)
RRA/ej/D18
[Page 2 of 2]
ae
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY. APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
(1 A! D;J'd
Well Classification
Well Log P~esent (Y/N) ~/<~-j
Total Depth !.~)[ / Cased to
NOkLD]LO~d 1VLNflW~NO~IAN]
H±lVaH JO 'ld]~
f ' V
Legal Description:
A, B, ~ C, D.E.C. ~p~o~d(Y~) ~/~
If
Date ~le~d Z4 ~q
Static Wate~ Level ~.~ I
Casing Height Above Gzrc~nd
Electrical Wi~ing in Conduit (Y/N)
Separation Distances f~cm Well:
To Septic/Holding Tank on Lot
Pump Set At
Sanita~.y Seal on Casing (Y/N)~
Depression A~ound Wellhead (Y/N)/~
; On Adjoining Lots~ ~OC) /
To Nearest Edge of Absorption Field on Lot I I ~ ' ; On Adjoining Lots
To Nearest Public Sewe~ Line /q/~ To Nearest Public Se~
Cleanc~t/Manhole A[/~ To Nearest Sew~ Service Line on Lot
Wate~ Sample Collected By ~ 6 ~ ; Date
Cc~t,fents
Be
SEPTIC/HOLDING TANK DATA
Date Installed ~ ~t)/~ ~4 Size I Dd)O ~A L No. of CQ~pa~tments ~_
Standpipes (Y/N) ~ ~_~5 ai~-tight Caps (Y/N) '~ Foundation Cleanout (Y/N) ~-~ _
Depression ove~ Tank (Y/N) /(JO Date Last Pumped AJ/~ N~J $%(~7~.
Pumping/Maintenanc~ Contzact on.File (Y/N) A//A; fo~ /%),//%~
Holding Tank Sigh-Wate~ Alarm (Y/N) /{J,/ Z%. Tempo~a~y Holding Tank Permit (Y/N)~//~
Separation Distances f~om Septic/Holding Tank:
To Water-Supply Well [O~' To Building Foundation 4~-O/
To Property Line ~ "'~(..Q'
TO Water Main/Service Line /~/~
Course /tJ/.~.
To Disposal Field
To Stream, Pond, Lake, c~ Majo~ D~ainage
Com~nts
[Page 1 of 2]
2-15-84
C.. ABSORPTION FIELD DATA
Soils Pating in Absorption Strata
Date Installed & ~0~- ~ ~/
Width of Field t~
!
Square Feet of Absorption A~ea ~ 75
Depression over Field (Y/N) /~ O
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To te -Sup ly Il To Property
To Building Foundation ~ ! To Existing or Abandoned System cn
Lot ~/~ ; On Adjoining Lots
To Water Main/Service Line AJ/~ To Cutbar~(if p~esent)
To St~eam/Pond/Lake/c~ Majo~ Drainage Course
To D~ive~way, Parking Area, c~ Vehicle Storage Area
/.
Depth of Field . ~/
Gravel Bed Thickness ~"
Standpipes Present (Y/N)
Date of Last Adequacy Test
Conm~nts
O. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water AlarmLevel at
Tested for
Electrical Codes(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
Conments
** Check Permitted Bedroom Rating Against HAA Request
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection. ~i~
Signe Date c~3dm~/~/ ~ ~% ~ ~
- f,
Company ~'~_ ~ C~/V~//U~cr~=7~.~C /,~d'_. MOA NO. ~?-~'~-OL)~L ~~'~%~$m~ ~'~ ~
[Page 2 of 2] ~~~-
2-15-84