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HomeMy WebLinkAboutSUETAWN ESTATE LT 1Sue Tawn
Estates
Lot 1
#051-501-19
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
C5.NEW
}
1 O U`!q B C `Xi/ld n
❑ UPGRADE
MAILING ADDRESS
13 L WDccit=%,o 1 �i a i t;'i 1� r✓ �j
LEGAL DESCRIPTION
v
LOCATION
NO. OF BEDROOMS
1= r Do n -' /Q', `4 (N)
3
Well
Absorption area t
Dwelling
PERMIT NO.
'
Uy
DISTANCE TO:
- 4_^± 1
P z
w
Manufacturer
ANCAOr JIL aF
Material
S'tcE1-
No. of compZtments
w
Lin. capacity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
�
DISTANCE TO:
Well
Dwelling
PERMIT NO.
Uz
Oz F
Manufacturer
Material
Liquid capacity in gallons
Well
Foundation
Nearest lot line
PERMIT NO.
w=
DISTANCE TO:
W u ZNo.
of lines
Length of each line
Total length of lines
Trench width
Distance between lines
H z w
inches
FTop
tile to finish -
Material beneath tile
Total effective absorption area
of grade
p
inches
Length '
Width I n
Depth 4`
PERMIT NO.
w
-s
G
cs
w1jQ
91
Type of crib
Crib diarr1etep_1
/Y�rU
Crib depth. Aj%/J
Total effective absorption area ,fa
w Q
rn
DISTANCE TO:
Well _7 D
Building foundation
Nearest lot line p
I t'f'-F
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
w
�
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
s
PIPE MATERIALS
T il'c.ai rJ$�atj
SOIL TEST RATING
INSTALLER
_
U'c�>a%` EX 8cr�43�
46 Gf
REMARKS
1Aj5w_/,4-t,oAj Burg TAIjej. J6iji aiAJ
w
.A
a"
e
P I�f_ iE h Z 13 ' i ` 415 FILLZ:
/U5P5cr€ edY <.rOAAM c'A4C'
r
.7- C�,4024
y
I g.
0 U SIC
t
ELL.
APPROVED DATE LEGAL -
t✓ t, WCs `7/321 E� tP I AJ/i4 SU4 _tAu+A, ESirlrEg 7fSM JZIL.t See 14
72-013 (Rev. 3178)
3S `
IMKJNI 11 iE� I F�64L-_ I -V7V C3F� A4PQC114C3FR4NC4E_='
DEPARTMENT OFHEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501
264-4720
V3V4_-E3'][1FK=" fH!K=7tWE7FR In W~UEK&_.L_
PERMIT NO: 840519
DATE ISSUED: 06/28/84
APPLICANT: KORPI CONTRACTING
ADDRESS: 13250 RIDGEW0OQCIRCLE
` ANCHORAGE/ AK 99516
CONTACT PHONE: 345~0920
F�EEIF�U��-r
LEGAL DESCRIP: SUBDIVISION: SUE TAWNESTATES LOT: it 1
SECTION: 15 TOWNSHIP: 15N RANGE: 1W
LOT SIZE: 3"6A <SQ"FT" OR ACRES)
MAX BEDROOMS: 3
BLOCK: NA
Listed below are the options available- to in designing'yoac septic
system. Choose the option that best fits your site.
~- -.____~___`- __^~~-_~__
'-
-I- 14z F=! 1%140 F"- r_9 F-- 131 V___�
~�
DEPTH TO PIPE BOTTOM (FTA 4.0 4^0 4^0
GRAVEL DEPTH (FT,) 4"0 3.5
TOTAL DEPTH (FT") � 8"0 4.5 7"5
GRAVEL WIDTH (FT") 2"5 17.0 5^0
GRAVEL LENGTH (FT") 47"0 41^0
GRAVE[ VOLUME (CU^YDS") 19"5 21.4 30^3
TANK SIZE (GALS) 1�00O.0 ** 1v000°0 **`
SOIL RATING (SQ,FT,/8R) � 125 125
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS' `��-//
-
1" I am familiar with the reqairements|for on-site a
-site sewers ndwells asset
forth by the Municipality of Anchorage (MOA) .and the State of Alaska.
2" I will install the system in accordance -with all MOAcodesamd regulations,
and in compliance with the design criteria of this permit.
3" I will adhere to all MOA and State.�of Alaska requirements For the -set back
distances from any existing well, wastewater disposal system or public
sewerage"system on this'or any adjacent or nearby lot"
4^ Iunderstand that this permit is valid for a maximum of 3 bedrooms and
any enlArgement will require an additional permit.
^ �
'
IF A LIFT STATION IS INSTALLED IN AN AREACOVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT ANDINSPICTIQN MUST -BE OBTAINED; (21 AS-BUILTS
WILLNOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED DATE:
APPLICANT:
ISSUED BYDATE: ~
�
,/
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-0720
SOILS LOG - PERCOLATION TEST
PERFORMED
LEGAL DESCRIPTION: LO 1 1
(
MI
SArv6 Yyy slcr
INpiST, Sig �
1 OVaa�iGS
z GM 5//�rY SANpY GKAvPc
CJev13e
�p 5/AA/6Y 6RAvE1-
4� detl5e wfOrSf/jNewtl
5 !• wilts Huw1-Ev�US co�o6�p5
a 14 60u1de45 4o av
7 !, a.51 ILDI 0'(A IasQ�bt�l
810
9-
10 -
SLOPE 10
SLOPE
P SOILS LOG
Wo' 1 1
❑ PERCOLATION
TEST
DATE PERFORMED:
n/i�. An TP//`5 G/`PPK
11 I _ WAS GROUND WATER S
SM 51[ i Y SAtiA ENCOUNTERED? 140 L ^ 0
O d
12 �ftn5e� k+Or$�r brow e
y.NCI H -I IF YES, AT WHAT
DEPTH?
13-
14-
15-
16-
17-
3141517 i" ' % lI,I
18-
19-
Leroy
8 19 Leroy C. Reid, Jr.
s • No. 2251-E
P•
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
r
,o
a y'
i
20 F `0• . ��
�PROFES`i -i' PERCOLATION RATE
n I' / _ `� t• TEST RUN BETWEEN
PERFORMED BY: �d1A2//7 RO-C &A $1-l-OQ t% CERTIFIED BY:
72-008 (6/79)
FT
j WATER WELL RECORD
�./ STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological a Geophysical Surveys
! Drilling Permit No.
LOCATION OF WELL (Please complete either is, Ib or Ic.) A.D.L. No.
'Mia.8orough Su9tliviaio Block Ib. 1/4 at re. Section No. Township NC( Range -E0 Merldian
ii�cf %IBW� a� Iesti
DISTANCE AND DIRECTION Irk ROAD INTERSECTIONS 3. OWNER OF WELL: Mr. Colin Korpi.
Suetawn Sub., Chugiak, Ak. Address: SR Box — S
Anchorage, Ak. 99507
Street Address and Area of Wall Location
2. WELL LOG Feet Below
- Surface
Material Type Top Bottom
q, WEV:.,7)EPTH: (final)
88 ft
5. DATE OF COMPLETION
— �_ — 84
Boulders, sand, gravel 0
8
6 ❑Cable tool XNotcry ❑Driven ❑Dug
[]Auger E] Jetted C3 Bored C] Other
Gravel sand silt 8
35
Grey sand and gravel 35
70
T. USEXn Domestic ❑ Public Supply ❑ Industry
❑ Irrigation ❑ Recharge ❑ Commerical
❑ Test Well ❑ Other:
Gravel sand brown silt 70
88
water
8. CASING: ❑ Threaded UWaldad
dicm._6 in. to_88_ft. Depth Weight 17 lbs./ft
dlam. in. to ft. Depth Stickup ft.
9. FINISH OF WELL:
Type: Diameter:
Slot/Maah Size: Length:
Set between ft. and ft.
Sackfilling Gravel pack
10. STATIC WATER LEVEL: Artesian.
❑ Above or ❑ Below land surface Date
Equipment used:
(N OF ANC
OEPT' OF ROTECT N
11 . PUMPING LEVEL below land surface and YIELD
ft. after _hra. pumpingg.p.m.
after _hrs. pumping g.p.m.
ENV)R
1QRft.
IE.GROUTING Well Grouted: ❑ Yes ❑ No
Material: ❑ Neat Cement ❑ Other:
13. PUMP: (if ovailoblo) HP
Length of.. Drop Pipe ft. capacity 0 -p.m.
❑ Salim. ❑ Jet ❑ Centrifical ❑ Other
14. REMARKS: Production of 10 GPM
and flows at 2 GPM artesian
16. WATER WELL CONTRACTOR'S CERTIFICATION:
y,�� 15. Water Temperature ❑ F ❑ C
Thia.,gagnusolnd J.l;Yi' �upsod,i'tion and this report is True t4 the f�,O�tpo („my knowledge and belief;
1�1 Registered BB.u%ssiiness..LLNo.. IIA r, Contract License Number
Address: P.O. Box 770504 Eagle Rivers Ak. 99577
july a
' Signed h1w 74LOats:
Authorized Representative
Form 02-WWR (11/81) Copy Distribution: WHITE-Slote OGGS, PINK-Drillor, CANARY -Customer
.tlaJtfc/
Municipality of AnchorageI/ �� 6 �
• -� Development Services Department ,•s_
Building Safety Division
On -Site Water and Wastewater Program ; 6., <I.
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. 051-501-19
1. GENERAL INFORMATION
HAA #_ 050D.') -I
Expiration Date: a —
Complete legal description _Lot I- SnP Tavn FgtAtPv
Location (site address or directions) 19125 .i A A m i n P RL Fn g l P River
Current Property owner(s) Ralph Layva Day phone 242-5276
Mailing address
Lending agency
Mailing address
Day phone
Real Estate Agent Kathy Geraci Day phone 694-9125
Mailing Address _11411 Old Glenn Hwy. Eagle River AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well Ey
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank ❑
Community On-site ❑
Public Sewer ❑
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. 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm
Address
Engineer
S 6 S Engineering
Phone 694-2979
ver, AK 99577
Date
Sc'
CIO • A. cam
5. DSD SIGNATURE ;��� tai
✓ Approved for 3 bedrooms. R �•r�
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Or
\�NO4 ..,...... ti
Additional Comments : WATER AND
.. � ur ;STEWIlTER •
PROGRAM
Mr r'�M S � 06'5
�JJJJIJJJI)11�``
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineers Report
Well Flow Advisory Other
By: VC>Original Certificate Date:
(Rev. 01102)
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.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LT I't Sub 7>4oju 64nnys Parcel ID: D61- So 1 - 19
A. WELL DATA
Well typevlhTL`
Date completed 317/0
Total depth M ft.
If A. B, or C provide PWSID #= Well LogbN)L-Shm wt @
Sanitary sea] ([9N) J95 Wires properly protected (YIN) Ni} Cy�1
Cased to _t�ft. Casing height (above ground) 19'=+ in.
FROM WELL LOG AT INSPECTION
Date of test ! I o s
Static water level AMM144.) ft. ft.
Well production g.p.m. 3. g.p.m.
WATER SAMPLE RESULTS:
Coliform O colonies/100 ml. Nitrate ?I* b mg./I. Other bacteria O colonies/100 ml.
Arsenic: — mg./I. Date of sample: 1111Vos Collected by: SO -S 5X*.wezt04
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material 5e T1 c- ISTS6(. Date installed -1 31 s
Tank size ICdb gal. Number of Compartments : Cleanouts 67N) yCS
Foundation cleanout(LVN) -q&;, Depression over tank (Y/S? I� High water alarm (Y& Ju0
r
Date of pumping _�� Pumper ZY ZSf 0wFttJ4.
C. ABSORPTION FIELD DATA
Date installed 7 3 Soil rating (g.p.d./ft2 or ftz/bdrm Sc'12System type P�E�
t �
Lengthft. Width ft. Gravel below pipe 0.5 ft.
t
Total de pth_5 ft. Eff. absorption area 630 ft' Monitoring tubeY6S Depression over field NO
Date of adequacy test__.,51,qDS Results as ail) 'F*65 For-3—bedrooms
Fluid depth in absorption field before test !E_ in. Water added_55 Ijal. New depth in.
u
Elapsed Time: l �i_O min. Final fluid depth
_JL in. Absorption rate >_
Any rejuvenation treatment (past 12 mo.) (Y49)& type)
Nm
L90t- 9.p -d.
If yes, give date
5umF t�trnp tx�st.bE t}2�}u9C
15 F34r,*"
D. LIFT STATION
Date installed
"Pump on" level at_ in.
E. SEPARATION DISTANCES
Size in gallons
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
r
Septic tank/lift station on lot too k
r
Absorption field on lot too
Public sewer main t2Y}'
Sewer /septic service line 26 Il
High water alarm level at in.
Meets alarm & circuit requirements?
1
On adjacent lots 104D 4--
r
On adjacent lots 1 bb �-
Public sewer manhole/cleanout ALD sle
Holding tank /J P
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
r �S3 r Absorption field IBI'+"
Building foundation /$ Property line P
Water main lJ A-, Water service line Ib Surface water
I
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line INS r Building foundation AS t_ Water main N p`
1
Water Service line ID 1 4'- Surface water I dd i- Driveway, parking/vehicle storage 10 -F-
Curtain drainon adjacent lots _jo0 Ia—
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined G
review of Municipal records that
conformance with MOA HAA gu
Engineer's Printed
Date
[7
field inspections and
eve systems'�a'�rre�1.n
I in ofied on mr�rdefs
HAA Fee $ q an CO
Date of Payment 7/��
Receipt Numberl o P�"� �l _ �'Am
(Rev. 12/01)
Waiver Fee $
Date of Payment
Receipt Number
b i A. s;dw •• "r •.
ti. 1474 j
05-19-05 05:10PY FROM-CHE ESI, SGS ENV SERVICES
—Ss$ -
SCS Ref Of
Client Name
Project Name/N
Client Sample ID
Matrix
Sample Remarks:
1052571001
S & S Engineering
Lot 1 Sue Tawn Est
Lot I Sue Tawn Est
Drinking Water
9075615301 T-768 P.02/04 F -0O3
All DatesMmes are Alaska Steadard Time
Printed DateMme 05/192005 11:50
Collected Date/Clme 05/122005 13:45
Received DateMme 05/122005 16:31
Technical Director Stephen C. Ede
Alloasblc Prep Analysis
Panrtieter Results PQL Units Method contains ID Limits Date Date fait
Waters Department
Nitrate.N 316 0.100
Microbiology Laboratory
Total Colifumm 0
mg/l. EPA 300.0 B ("10) 05/12/05 JIB
col/100ml. SM209222B A (�1) • 05/12/05 TLF
05-19-05 04:47PM FROM-CTiE ESI, SGS ENV SERVICES 9075615301
SGS/CUE ENVIRONMENTAL SERVICES
Drinking Water Analysis Report for Total Coliform Bacteria
aeAo rralla,crwrr. orr lavol.e eaxt eQorK coLLserew e�IePLa
MUST BE COMPLETED BY WATER SUPPLIER r
❑Rl�t]�1NATb1.tTfTtslq
L—W/A' MZ
t1'tRJr
p SW011a.w p wid er4ara p 5" n..w
SAWPLE C OLLECTNON: _ _
12 0
rrr I" TAW
Tnwpard ���
fa Labor. � as oa0e w cow..
TO BE COMPLETED BY LABORATORY
BamPle @>c*Mnw
'Lim,
0Rom a Semple
T-753 P.03/04 F-999
200 W. POTTER DRIVE
ANCHORAGE, ALASKA 99M1S
let
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Laa ldf No. V1C1
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pa.ro mv"
13 Tromd Waw
E3 U,Ibeeaawaw
(refer to Nb m L
Spedld Purpop
Ode ❑eampha.w30Muaarq ❑ RUSH SAMPLE
Tema PorM mq be unrna
Term ❑4emawdw Phorrw'
Ddvely McOiad: Fa FA toneaw Fax #.
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.01
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date a/P41-
i
(a) Legal Description (include lot, block, subdivision, section, township, range)
L.p
Location (address or directions)
(b) Applicants Namee_-01_iA) J-\6,0, Qj Telephone - Home3K-_.WzqusM.ness
Applicants Address] 3 a Srf `dna i �D f�e.l., Pnn,� n, g 12 ff's-16
(c) Applicant is (check one) Lending Institution ; Owner/builder
Buyer E�] ; Other E::j (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. Type of Residence
Single -Family 1,_�4 Multi -Family Other (describe)
Number of Bedrooms
3. Water Supp
Individual Well �z Community = Public M
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 54 Public 1=3 Community F__T Holding Tank Q
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]
'6)z� SUL Y/ieo'li f -=5 c.
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 regula-
tions in effect on the date of this inspection.
Name of. Firm Al/-C/,MC Telephone QJ �iO�h�1
Address 12oc) /11 -3 A'vc/1o2 Ii GF _ Oa 1, <>
Date
(ENGINEER SEAL)
6. DHEP Approval
Approved for bedrooms By
Approved Disapproved
Terms of Conditional Approval
CAUTION
0
Conditional
�` e ✓ . Vr
C. Reid, Jr..F�«i'.
7)ate� �3 ° 3 e/
THE 14UNICIPALITY 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
A. WELL IATA
MUNICIPALITY OF ANCHORAGE (MOA) AUG 29 4°
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
-rXA •I I AzwjyA .S06 tAw.0 esrMr�,
Y-Isni fi')44 sz.. +S
Well Classification/iuAT- If A, B, cr C, D.E.C. Approved(Y/N)
C)�
Well Log Present N) Date Completed T� Yield id 6i?rA
Total Depth ego Cased to 98" Depth of Grouting U v hnit tJnJ
Static Water Level A77AsiAA) Pump Set At L)/Vl1A)C)WN t')o
Casing Height Above Ground 2 r Sanitary Seal on Casing Y }
Electrical Wiring in Conduit (Y/N) AJ /) Depression Around Wellhead (Y
Separation Distances from Well:
To Septic/Holding Tank on Lot 11't On Adjoining Lots jDU
To Nearest Edge of Absorption Field on Lot / 27 ; On Adjoining Lots /oc-
To Nearest Public Sewer Line A-) /tom To Nearest Public Sewer
Cleanout/Manhole �/ To Nearest Sewer Service Line on Lot Z�IA
Water Sample Collected By 301 G- ; Date � z 2i -
Water Sample Test Results SAtiSFActo,zV
Ccmmnte�) AIZYrS!ARJ �i�u�nnu.w�;.w OSR w[I( l01
B. SEPTIC/HOLDING TANK DATA
Date installed 7/312$4 Size /,Ono No. of Compartments 2 -
Standpipes (YDN) Air -tight Caps jJ!N) Foundation Cleanout �[Q)
Depression over Tank (UM Date Last Pumped /,I.
Pumping/Maintenance Contract on File (Y i) ; for �yZA _
Holding Tank High -Water Alarm LY/N) 6?& Temporary Holding Tank Permit (YIN)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well I /'7 ��' To Building Foundation t i
To Property Lire 15.3 To Disposal Field
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course /Vl/
Iu.rJ�l
Comments joi!`1jp,;;,,�.,..�„�Ua,e, _
�s OU
Vt 'U"�
[Page 1 of 21
2-15-84
-,A � is r,.vY&s
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ! 2S n Type of System Design Dish
Date Installed ?A" 4 Length of Field 35 !
—r -
Width of Field lei Depth of Field 4•, 5'
Gravel Bed Thickness ©,S'
Square Feet of Absorption Area /.3Cj ai Standpipes Present CSN)
Depression over Field (Y*) Date of Last Adequacy Test
Results of Last Adequacy 'lest ZJZ
Separation Distance from Absorption Field:
To Water -Supply till ) 217 J To Property Line _ 4.5' ! _
To Building Foundation 28 To Existing or Abandoned System on
Lot /U/J4 On Adjoining Lots j 3o i
To Water Main/Service Line, A)7 hq To Cutbank(if present) ,U /,q _
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area /7+
Ccmwnts ,rkvp o,,ei�
D. LIFT STATION
Date Installed "!4//47 Dimensions 4 /n _
r
Size in Gallons A,) /A Manhole/Access (Y/N) 2j/A
"Pump On" level at AJ/}4- "Pump Off" Level at�)4_
High Water Alarm Level at Vent
Tested for Pumping Cycles during Adequacy Zest. Meets MOA
Electrical Codes
Comments
** 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.
Signed (�� w�� Date
Compan� W --_CS r as c MOA No. S? (34-024
KB1/d5/s
(Page 2 of 21
oy C, Reid,
No. 2251.9
2-15-84