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 9"-502-M Fe>c wl-wi-w Laa ldf No. V1C1 -7 '1052570 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 #. .......... .... ........ ......... ...... ........................ 0 ..... a .... a ....... ..... ..... ........ ....... sees .... 00.4.. .... .................0 MMdMue 0" Rnmm Membrane FSar MMO•MUO (PIA) TOM co"mm E OCIL omm Pe.TLm rmw LTar Ohdcoure COWAWoad: vwkmm b A9EC. ANC feK .furl OaWr►rr• ears a ake ftow Q Fewd (J rMk . tMlt.T..lr•rrOr+ DeWT1nIe• � �/L-o�^ /�i I a. a.orr4rr • FamreFNF0= 19ATI03 Form 121T03jda ' I ' I 1 I (N89'S5'C !82.98'1 ' S89053'57"E 171.98" 1 34.09' SO°43'45"E X47.24' I ' N O? .�. • y ' U � m m L7 A Mmm� z? >o �. C I zp .ZCIM��Z7 V . In ' : p 0 `)---'------- L X PA `... X W ° , osrN P ii• I r tie ' '•,'' °� \ e Ll y rn e/.o• 13t 1 6Z L5.Lg5 n ,4ge =E ml, to Eg 0 WAY 0 0 S 0 0 0 NORTH �1 �g O P P c a 0 I ^ mGx 9998 •-s +r.. Z7 Nm co Lu o m y Tha v Cb N Imp ; c� Ui yIr ' rli �1 Cis Ac 1� A• Z rl, I x 4Ir D •lrs �I , � 1 ; �C 1 O 1 p �' \m\ P a D I nl \ S43°51'15 "W r`� � ( � �\ � � .' 18.31' j / � A O I \� ,. �1) h (, 111 \ . I i r\ .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