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Home My WebLink AboutPARADISE VALLEY BLK 4 LT 23A-1I LoT' / i 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 NAME PHONE E~NEW MAI LING ADDRESS LEGAL DESCRIPTION ~ C Il. LOCATION ~O, OF BEDROOMS Well Absorption area Dwelling ~ PERMIT NO, DISTANCE TO: ~O~ ~ MeT IN 5 NoT IN ~ Z Manufacturer Material No, of compartments ~ ~ Liq. capacity in gallons Inside length Width Liquid depth ~ IF HOMEMADE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O ~ ~ Manufacturer Material Liquid capacity in gallons Q Well Foundation Nearest lot line ~ PERMIT NO. --~ Z ~ ~ ~ No. of lines / Length of each~line Total lengt~o~nes Trench width~ O inches Distance between lines ~ Top of tiJe to fin]sh grade Material beneath ti]e Total effective a~n area Q ~ F ~ g ~ inches Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth TotaJ effective absorption area ~ Well Building foundation Nearest lot line m DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. ~ BuiJding foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PiPE MATERIALS D ~oBq ~, INSTAELER ~ REMARKS APPROV~~ ~/ATE LEGAL 8~ 72-013 (Rev. 3/78/ ~'~, MUNiCiPALiTY OF ANCHORAGE , ~,' · :~--lJ~ ~'--a..~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROT=CTION ~(~ ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE ~NEW ~N~ ~ ~ ~oN ~ ~ ~ UPGRADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS DISTANCE TO: ~ell A~sorotion area D~ellin~ Pfi~MIT ~0. ~ ~ Manufacturer Material ~o. of compartmant~ ~ ~ Liq. capacity in gallons Inside length Width Liquid depth IF HOMEMADE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O Z ~ Manufacturer Material Liquid capacity in gallons ~ Well Foundation Nearest lot line PERMIT NO. ~ ~ DISTANCE TO: No. of lines Length of each line Total length of lines Trench width Distance between lines inches -- ~ ~ Top of tile to finish grade Material beneath tile Total effective absorption area Q inches Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class ~ Dep~ ~ Driller~ ~ Distancet~tline,~ PERMIT, s_ ~o~NO ~m DISTANCE TO: Building foundation~o Sewer lin~/~ Septic tank I I ~ Absorption area(s) I OTHER PIPE MATERIALS ~ ~ INSTALLER [ IO ~ ~ APPROVED DATE LEGAL 72-013 (Rev. 3/78) WELL LOG --. Da~ Drllledl . , 6-23-8~ Static Water Level feet Gallons Per Minute Co~rsd VerDon P~r~dise Valley Lot 23 B].k.4 1% Draw Down N/A feet Total Feet of Casing 224 Ty~e Material Drilled: //O/feet 83 to 160 Cemented Crav, l 224 fe~t to 36~ Bpdrogk to f~2~ 83 feet to 368 feet to Hefty Drilling S.R.A. Box 1553 H Anchorage,Alaska 99507 MUN I C I PFII...][ T'¥' OF' F.:INCHORF:I(':iE C, Ef:'RRTHEN~ OF NEI:::IL. TH RND CNVIF.'.ONMEI'4Tf::~L PROTECTION ,825 L STREEI', RNCI...IORFiGE, RK :.q. 950:1 264.-4720 PERMi]' NO: E:,FKFE '[ 'SS' .. Eli:,: FIF'F'f... I CFIN'T ' FtE:,I.'.:,R E S': S - tj]T '..:.]; I ZE: M 1:::t;,.,: BE[:,F.%~Of,IS - CONRRD F. VEF;'.NOR .':'ii;RFt BOX ]i:55:.t. t.3 I'.,I C H 0 R. FIGi;:~:., FtK 95~5:1. 5 S45-...6540 SLfBDI',,,'ISIOi'4: PRRRD!SE '¢F:iLLEY S';EC:T II:]N: 2L::I.. TO!.qI'-,ISHIP: 22::t..74 (Si;~. FT. OR FICRES) 3: LOT: 2_"Z, BLOI]:I<.:: 4 RFtNGE ' 3:14 I....I:~';]"E[:, E:EI...OI.,.I FIRE THE: OF'TICd',tS FI',,,'FtILFIE:I_.tE TO '¢f3U IN r.)ESIGNINI3 but. F: SEPTIC S'¥'STEM. CHOO:E;E: THE ".: PT I ]I'.,I 'T'FII::t"F BEST 1:..': I T:S '¢OLtR S I "I'E. [:,EPTH TO P I Pt:].:.' BOTTOM ( F"F. ). 4.. E:i 4. 5 · 4. 0 GRF!:,,,'EL Df.."..:F'"I"!...f (i::'T.) 6. !5 R. 5 3:. 5 TOTI"-'II... DEF'TI'"I (i::T.., J..~Z,. 5 5. 0 7. 5 GRW,/EL l.,.lI[:,Tt...l ,::t::'T. ::, 2. !5 22. 0 5. 0 GRFtVEL. L. ENG]"H ,::F:"F. ':, 5::L. E~ 4:']:. 0 72. 0 GRR',..,'EL. ',,,'OLIJHE (CU. "r'[:':']!;. ':' .]~3:. El 2.']5. 0 5L~:. TRI'.,IK SIZE (GFILS::, d_., 00El. El :+::+: :l.., OEIO. 0 :+::+: ::L., 000. 0 SCI t L RI:IT I NG ,:: '..'.-'.';Q. F:?F. ,-."E:R ) 220 2R9 22F't C':EF.: T I F:'"r' TFII:::tT: .'.i... I Fli'"i FfiMII...IF!F":: HI"t"I"t THE REQUIIREHEI",t]":5 FOR OI",I~:SI"FE SEWERS RND 1.4ELL. S FtS '_-SET FORTH E-Fi-' THE HLtNICIPFtL.:t:T'¥: OF FINCHOF..'RGE (HOFI:.:' FINE:' THE STFITE OF RLFIS;,KFI. 2. :[ P.IILi.. II",iSTF:!L..L. ']"FIE: S'¢'.STEH IN F"tCCOR[:'FINCE 1.4ITH FiLL MOFI (:::ODES; FIND REGULFITZONS., fiN[) t i'.t COHF:'L 1FtNE:E 1.,~ t TH THE DES I li::,N CR I TEF.: l Ft OF ]"H l Lc., F'ERM I T. ].. i I.'.IZLL FIDHEF.':E TO RL.L t-'!OR t::IND S'f'.C::fTE OF' HLI-_,.t'...H R. Eg!LIZF'.EMENTS FOR "I~HE SET BH~.I'.. DISTRNCE:S I::'RE*f'I FtN"r' EXISTING I.,.!E:LL., t,.IFtSTEHFITER DI~POL-SRL S"r'STEi'"I OR PUBLIC :SE!.,.IERRGE ':'!.";"P:];]"F']'"I ON THIS OF:: FIt",f"¢ F!DJFICEi",IT OR i",IEFIRB"¢ LOT. 4. i UhlDERSTRt",tD TFtFKF TFi I S PERM I T I S ",,'RL. I E:' FOR R i"lFIX I MUM OF' "_:i: BEDROOMS FIND RN'T' ENL. RF:tC:iEMENT i.,.1Z L.L. F:E(.::!U :[ RE F¢'.I RDD I T I ONFIL PEF.:M I T. IF FI LIFT S'T'FtTIOt",I IS tNL::;TFtL. L. ED IN RI'4 F:tREFt COVEI:;?.ED BY MOR BUlL. DiNG CODES, ]"HEN (:;L) FIN Et...ECTRIC:FtL F::'ERHIT RI",ID iNSF't::':C"T'ION HUST BE OEKI"FtII",IE:[.".~ (2) FIS-BLIILTS I.,.IIL. L. NOT BliE RPi::'RO',,,'ED HITHOU"II' RN ELECTRICF:IL INSPECTION F.::E:POF.'.T.~ FIND' '.'::.']:.'." 'THE ELECTR I CF:IL !.,.IORi< i"IU:S"t" E:E' B'¢ R L. I C':ENS;ED EL. ECTR I C I FIN. / ,, .................. I-- L:.:, t GNEi} FtPPI .. I ": Ft."IT ' CON.[~:FI[:, I StL-] _lEE:, MUNICIPALITY OF ANCHORAGE DEPARTIVIENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG-- PERCOLATION TEST SOILS LOG . PERCOLATION TEST LEGAL DESCRIPTION: DEPTH 2 i.m 3 mi{ 4 5 6 7 8 o / 13- 14-/m 15 16 17 18 19 20 COMMENTS ? SLOPE SITE PLAN WAS GROUND WATER INO S ENCOUNTERED? L O P IF YES, AT WHAT E DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN ~o~ ~: ~/ u l ~e~ c~.~,~,~ ~: ~OA 5T ~'3 -O~H 72-008 (6/79) J~O. 75 (minutes/,~/. // 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 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 23 Block 4 Paradise Valley Subdivision - Tt2N R3W Section 11 Location (address or directions) 6412 Italy Circle (b) Applicant Name Conrad Vernon Telephone: Home 345-6548 Business Applicant Address (c) Applicant is (check one): Lending Institution []; Owner/builder:[]:; Buyer []; Other [] (explain); (d) Lending Institution First Alaska Mortgage Telephone Address Chef Haley (e) Real Estate Company and Agent Heritage Home Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family [~[k Multi-Family [] Other Number of Bedrooms three (3) WATER SUPPLY Individual Well [~x 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 [~xx 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 (11/84) Page 1 of 2 ENGINEERING FIRM PROVIDi :INSPECTIONS, TESTS, FILE SEARCH, ~\~, 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 Date Engineer's Seal This department has received written confirmation from the engineer regarding the Conditional Approval of March 18, 1986. This has been corrected and reinspected and this property is now fully approved. Approved for three(3) bedrooms by Approved ×x×× Disapproved Conditional Terms of Conditional Approval Date May 15, 1986 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 Ataska. 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) MUNI MAY 1.4 1986 DEPARTMENT OF HEALTH AN Re:Conditional Health~Authority ~Approva~, L0t ~2-3,/-Blo~k 4 ~ Paradize Valley . Madame; On March 18, 1986 a conditional approval was given for subj~eQit- ~ lot. The conditions'~ for the ~proval have been met. The standpipe to the trench has been Please furnish this office wit? Yours cc City Mortgage, Cher ~Haley 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 Application Date ~"~ ~-- ~ GENERAL INFORMATION (a) (b) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name C.~H. la&~ ~ff.~a.~. Telephone: Home '~' ~ -~-~ ~ Business Applicant Address (c) Applicant is (check one): Lending Institution []; Owner/builder [~'; Buyer []; Other [] (explain); (d) Lending Institution ~';'¢~' ~.//~ta,¢~, {e) }:leal [:state Company anO Agent Address Telepho. ne (f) Mail the HAA to the following address: 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:!l~ community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 72-025 (11/84) ,ENGINEERING FIRM PROVID/-~INSPECTIONS, TESTS, FILE SEARCH, ~-'~ 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 hereinr. 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. NameofFirm T~'~4"I g~,l'¢'~'La'4'~ P~" Telephone Address ~ '~ ~'~ Engineer's Seal DHEP APPROVAL Approved for ':~,~'(2~'bedrooms by Approved ': Disa,,,~ro~ed~ . . Terms of Conditional Approval Conditional Date 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 72-025 (11/84) WELL DATA MU NICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 ~UNICIPALITY OF DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MAR ]. ? RECEIVED Well Log Present (Y/N) Y Date Completed Total Depth ~i~t~ ~ Cased to ~t'~, Static Water Level ~ ~['/ Casing Height Above Ground Electrical Wiring ~n Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot y, Yield Depth of Grouting Pump Set At ~I~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) it7 To Nearest Edge of Absorption Field on Lot ~' O ~ To Nearest Public Sewer Line Cleanout/Manhole : On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot Water Sample Collected by __ Water Sample Test Results Comments tee 'f ; Date SEPTIC/HOLDING TANK DATA Date Installed ~ Size _~ No. of Compartments T Standpipes (Y/N) 7~'O Air-tight Caps (Y/N) y Foundation Cleanout (Y/N) Depression over Tank (Y/N) M Date Last Pure ped ~ Pumping/Maintenance Contract on File (Y/N) I~/~ : for Holding Tank High-Water Alarm (Y/N) Separation D stances from Septic/Holding Tank: Temporary-Holding Tank Permit (Y/N) ~/~,~ To Water-Supply Well To Property Line To Water Main/Service Line Course To Building Foundation ~ To Disposal Field ~ To Stream, Pond. Lake, or Major Drainage Comments Page I 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 Lot ~O 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 Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test /0 To Property Line ~;~ To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrica~ Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify t h~,~ chec_ke~d_, v~erified,~conformed to~lT_O~a, nd HAA guidelines in effect on the date of this inspection. Signed W' - --' - ' -- Date / Company MOA No. Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) Engineer's Seal MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL h-~ALTH DEPARTMEN~ OF HEALTH 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) (b) Applicants Name ~dg~fA~ ~ ~-.~OIW Telephone - Home Business Applicants Address (c) Applicant_tis (check one_) Lending Institution ~ ; Owner/b~'~ ; (e) Real Estate Co. & Agent Telephone Address Telephone (f) Mail the HAA to the following address: 2. T_~of Residence Single-Family~ Number of Bedrooms 3. Water Suppl~- Individual Well ~ Multi-Family~--~ Other (describe) 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] I 5. En~ineerin~ Firm Providi~$ Inspections, Tests, File Search~ Data and Information e 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 regula- tions in effect on the date of this inspection. Name of Firm / ~ ~ ~ F ~ ~*~ ~ Telephone Address ~0 ~ ~ Date 7~ ~/{~°K DHEP Approval Approved for ~ bedrooms Approved ~x Disapproved Terms of. Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. 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. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 ae MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITY OF ANCHORA(~IJ DEPT. OF HEALTH & ENVIRONMENTAL PR~OTECTIO~ RECEIVED Legal Description: LOT ,,9,~ ~,~ ~,~4~O~ Well Classification ~ If A, B, ~ C, D.E.C. ~o~d(Y~) ~/~ ~11 ~ ~e~nt .(Y~) ~ ~te ~leted &. ~ ~. ~ ~ Yield /.~,~ NON " Depth of G~outing Sanitary Seal on Casing (Y/N) %/ Depression Around Wellhead (Y/N) ~ ; On Adjoining Lots l O~2) JO(~ ; On Adjoining Lots To Nea=est Public Sewer Total Depth ~ ~ Static Water Level Casing Height Above Ground , ~,0 Electrical Wiring in Conduit (Y/N) %/ Separation Distances f~cm Well: To Septic/Holding Tank on Lot J J "J TO Nearest Edge of Absorption Field on LOt To Nearest Public Sewer Line ~//% Cased to ~ ,~. ~ Set At IV/A C leanout/Manhole Water Sample Collected By Water Sample Test Results C~{~{~nts To Nearest Sewer Servioe Line on Lot ;Date ~h//~~ Be eTA Date Installed ~/~/~%/ Size '/0"~ Standpipes (Y/N) ~ Air-tight Caps (Y/N) ~/ Depression over Tank (Y/N) ~ Date Last Pumped No. of Cu~a=tments ~ .. Foundation Cleanout (Y/N) ~W . Pumping/Maintenance Contract on File (Y/N) ~/~ ; for W//~ Holding Tank High-Water Alarm (Y/N) ~_/A Temporary Holding Tank Permit (Y/N) ~/A Separation Distances f=om Septic/Holding Tank: To Water-Supply Well ~ I 7 To P=operty Line To Water M~in/Service Line co se Counts To Building Foundation ~ To Disposal Field ~ To Stl~eam, Pond, Lake, c~ Major D=ainage [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absoz~ption St=ara Date Installed ~//~/,~ Square Feet of Absc~ption Area Dep=ession ove= Field (Y/N) l~sults of Last Adequacy Test Type of System Design Length of Field ~ (~ Depth Grail ~d ~ick~ss ~ ~ of Separation Distance from Absorption Field: To Water-Supply W~ll ~O~ To P=operty Line ~ To Building Foundation ~) To Existing or Abandoned System Lot N(~ ~ ~ ; On ~x~joining Lots ; ~,~ + To Ware= Main/Se=vice Line ~/~ To Cutbank(if present) ~//-% To Stream/Pond/Lake/c~ Majo= D~ainage Cou=se ~/~ To D=iveway, Pa=king Area, c~ Vehicle Storage Area ~ ~ C~m~nts D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Ware= Alarm Level at Tested fo~ Elect=ical Codes(Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) . Pumping Cycles du~ing Adequacy Test. Meets MOA ** Check Pe=mitted Bec~ocm Rating Against HAA l~quest ** I certify that I hay? checked~, verified, or confo~-~d to all MOA HAA Guidelines in effect on the date of this lnspec~f'~. / , Signed Date -- ~. ~o." "..~.~2~ Company ~ ~'Z~ MOA No. [Page 2 of 2] 2-15-84