HomeMy WebLinkAboutSKYLINE VIEW BLK 2 LT 1Skyline View
Block 2
Lot 1
#051-192-26
"`" T`� MUNICIPALITY OF ANCHORAGE
' • On-Site Water&Wastewater Program ai
�a+� PO Box 196650 4700 Elmore Road
i ,..c,, , Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
!J ' httpa/www.muni.org/onsite
N�.c_H ON pVf. I)(..pa1'IIt cn1.
On-Site Wastewater Disposal System Permit
Permit Number: OSP191116 Effective Date: 4/23/2019
Work Type: SepticTank Upgrade Expiration Date: 4/22/2020
Tax Code Number: 05119226000
Site Legal Address: SKYLINE VIEW BLK 2 LT 1 G:1051
Site Mailing Address: 19375 DOGWOOD ST, Chugiak
Owner: BEVERLIN DONALD SAM Lot Size in Sq Ft: 16050
Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 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
..----` 10,7___
v s
Received By: - ` Date: 2 ,
r •
Issued By: �' L.A i . • Date: on
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. 051-192-26
Property owner(s) Beverlin Day phone 980-8866
Mailing address 19375 Dogwood Rd
Site address same
Legal description (Sub'd., Block & Lot) Skyline View BLK 2 LT 1
Legal description (Township, Range & Section)
Lot Size 16,050 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Initial ❑
Absorption Field II] Initial Family (SF) x(w/wo ADU)
Septic Tank ❑ Upgrade v� 8 9 �0 , Duplex (D) ❑
Holding Tank Renewal ti �,
,1 ultiple Dwellings n
Privy (SF and/or D)
Private Well ❑ a APR 1 2013 n
Water Storage ❑ w
THIS APPLICATION INCLUDES A WAIVER REQU ST FO .
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
40111
(Signature of property ow er or authorized agent)
Permit/Rush Fees: a25 Waiver Fees:
Date of Payment: t l iq1 i9 Date of Payment:
Receipt Number: 0244/ Receipt Number:
Permit No. OLSPPINo Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Apptication.doc
TF-�I M
ENGINEERING SteveEng.corn
Steve Eng, PE, PH
907-694-7028
SteveEngPE@gmail.com
Date: 4/17/19 Number of Pages:
To: MOA On-Site Services
Subject: Skyline View Block 2 Lot 1
Septic Tank Failure
The subject septic tank has failed-a new tank will replace the old one. The existing trench appears
to be working OK. Please issue a permit so the tank can be replaced. The existing trench will
remain. Please review as soon as possible.
If there is need for additional information or clarification please give me a call.
Thanks-Ste
\ORTI-�I M
ENGINEERING SteveEng.com Skyline View Block 2 Lot 1
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: This is an existing 3-bedroom home. Most of the neighboring
lots are developed. The current septic tank has failed- the trench still functions. These lots
are almost half-acre and are served by the private water wells. No adverse impacts are
expected from tank replacement. The easements are depicted on the lot. The slope is
indicated in the area of the septic system.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water
Regulations and Wastewater Regulations.
• New 2- compartment, 1000 gallon septic tank. Watertight couplings on inlet& outlet.
• 5' minimum between the tank and trench. 10' to property lines.
• 4' of cover or insulation is required for tank; an equivalent of 1" insulation for l' foot
soil cover. Minimum of 2' soil with insulation. Tank& solid pipe must be set on well
compacted, stable soil.
• 4" 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.
• 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)
Y OFTr
CA �
41.6
�e
'- e,Sievctl'r,". Eng e (V
• :L
,w;
�''�;is ",���
r
DESIGN NOTES:
1. Existing Trench Remains In Place.
2. Sewer Service Line minimum 2% slope.
3. Replace Septic Tank/Decommission Old Tank Per UPC.
Connect New Tank To Existing Trench.
4. Lots Served by Private Water Wells.
5. No Conflicts Within 200'.
6. Check Condition Of Sewer Service Line— Replace If Necessary.
7. Add Double Cleanouts Before Tank If No FCO.
New 1000 Gallon
Septic Tank w/DCO's
Decommission Old
Septic Tank
PER UPC
Lot 8
No Conflict
Utility Easenen I —
Flat Slope Flat Slope
Y
I+,
C
a)
E
n I a• Flat Slope
O d
W
ce
Lot 9A
o s I +, No Conflict
o Well Flat Slope
rn O
0
a
Lot 2 I
No Conflict
Flat Slope
NORTHRIM s•P�c-.°F.k' SKYLINE' VIEW
ENGINEERING *~.49m ► •*\ ; DESIGN
SteveEng.com BLOCK 2 LOT 1.
PO Box 770724 Sl;, dif LAYOUT
Eagle River, Alaska 99577 0 WASTEWATER UPGRADE
907.694.7028 REPLACE SEPTIC TANK ''t 4/17/19 2 of 3
Foundation Cleanout
Tank Cleanouts
. 7
Fin ade Opposing Cleanouts Between Septic Tank & Trench
•dr o/
4 Foot Cover
or Equal
I''" `�� r---..-
1000 Gallon To Trench
SEPTIC TANK
MOA-Approved
lid Pipe
Match Elevations To
DESIGN NOTES Existing FCO & Line
1. Use Existing Trench.
2. Septic Tank & Solid Pipe to be Placed on Compacted,
Stable Soil, Free from Boulders.
3. Sewer Service Line is Minimum 2% Slope & 3' Cover.
4. Water-Tight Couplings.
5. See Specification Sheet.
6. All Work To Conform to Municipality of Anchorage (AMC)
Requirements & Specifications.
7. Decommission Old Septic Tank Per UPC.
8. If No FCO, Install DCO's.
NORTHRIM 44 .1t
ENGINEERING >:�P-- SEPTIC TANK PROFILE SKYLINE VIEW
SteveEng. corn 3'* :49m •
Po Box 770724 �....• Stove Eng � •
tt BLOCK 2 LOT 1
Eagle River, Alaska 99577 ��
907.694.7028 'ti' ri a TANK REPLACEMENT Dote.4/17/19rim" By: SE rcaI.
' 1• = 5 3 of 3
I SE
. N
" N.
I
I
LOT 9
1 LOT 8 ; CHNNUNK FENCE
I S 89'59'00-E 150.01' Ti '
� LOT
! 1 S4 ---1 T _____ _
z 16.173 s.f. ' N
14o .8' X32.0'
8Q CARPORT N
4410 1
O ` 96.6' 0
s-
28.3 ` `� CLFJWOUTS
�_ • s 3.0' X 14.3' r�
•
Q DR CANT \ y LOT 9
O STORY o
COVER \ONE
WOOD N I m
0 PO FRAME \ !
a 12.0' Kt
(' 'oao / RESIDENCE DECK \
N t
Q I /WELL265, l
100' PROTECTIVE
WELL RADIUS ..,^r
N 89'59.0O144 150.81'
30.00' LOT 2
1
( 1 `
1
10' UTILITY CASEMENTS l
TEMPORARY TURNAROUND EASEMENTII I
TO BE VACATED If ROAD tS EXTENDED
PLOT PLAN _ AS BUILT X SCALE 1" ' 30' GRID NW 1159 Project No. 07-117
Lang & Associates, Inc. 11500 Daryl Avenue. Anchorage. Alaska 99515-3049
(907) S22-6476 Phone
Registered Land Surveyors (907) 522-4625 Fax — F' q `�.,
cianglsOalaska.net — . .. --4SII
kgianglst?ataska.net / j i�P.• •1 '•.,;„1
I hereby certify that I have surveyed the following described property: 49 .I� '*--.711, Q
LOT 1, BLOCK 2. SKYLINE VIEW SUBDIVISION (PLAT No. P-506) �:.
Anchorage Recording District. Alaska. and that the Improvements situated thereon are i w•• • ••
within the property lines and do not encroach onto the property adjacent thereto. that
no improvements on the property lying adjacent thereto encroach on the surveyed ,.. : . i
KENNETH •.
premiss and that then an no roadways. transmhslon lines or other visible I .
easements on said property except as Indicated hereon. 'sI ' . LS— ;02
2Tu , 200 . at Anchorage. Alaska 11.4. • •''�'Ii •''•p
Dated this the Day of �\ plyti,V'
It Is the responsibility of the owner to determine a the xxrseence edofany
easubdivision plaits,
covenants. or restrictions which do not appear
MUNICIPALITY OF ANCHORAGE
A 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 ❑ NEW
Lz � r�
UPGRADE
MAIL-INGDRESS
LEGAL ESCRIPTION
/ 92 SGcL' G / iV
LOCATION `1516
/ 6 l ` /1)/ �^
NO. OF BED$�OMS
Wel'/06)
t� /
Absorpti n�reY
/% Dwelli__.,.
PE I/ 0 7�7 ,
�
Uy
DISTANCE TO:
G✓
r- r�
Y�
Manufacturer /`
Ma iG
No, of co partme`
//
wQ
Com— G�
WH
Lim]' idallons
!J
IF HOMEMADE:
Inside Iengk§ _.
Width
Liquid depth
� �, Z
Ll TAN
TANCE T0:
Well
Dwelling
PERMIT NO.
�
T4
Manufactu
Material
Liquid capaci�-g ons
I VV
Foundation
Nearest lot line
-PERMIT NO.
iu x
DISTANCE TO:
wU.. 7
No. of lines
Length of eac ne
Total length of lines
Trench vyi�}
Distance between lines
�/ inches
pS
cc
Top of rile to finish grade
terial beneath rile
Total effective absorption area
(3
inches
Length
Width
Dept
PERMIT N0.
w
Q F-
Type of crib
Crib diameter
Crib depth
effective absorption
area
w
—
w
N
DISTANCE TO:
WeJ
Building foundation
Nearest lot line
_
s
Depth
Driller
Distance to lot line
PE 0.
LEEBuilding
ISTANCE TO:
foundation
Sewer line
Septic tank
Absorption areas)
OTHER
PIPE MATERIALS
SOIL -TEST RATI G-
1
INSTALLS
i'T
N'1
U✓
"4�
REMA KS
_
��t�`� 1
r
6-90
Xv-
tn4 "bort A. Shrierlot
APPROVEDI�L� rr DATE LEGAL
72-013 (Rev. 3/78) r
�11',dl 11�'. 3: 10" 9% U :11 -11- V CO H:7 oil, 011 ED 1 -110 R: got CA! ERI
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET/ ANCHORAGE, AK 99501
264~4720
C-11 P,41_~!!.El; Y~IF , �'hil �H-�: 11- 11 :1,. -
PERMIT NO: 840859 UPGRADE
DATE ISSUED: 10/08/84
APPLICANT: LINDA PARKER
ADDRESS: % S&S ENGINEERIN8
EAGLE RIVER, AK 99577
CONTACT PHONE: 694-2979
LEGAL DESCRIP: SUBDIVISION: SKYLINE VIEW LOT: 1 01-01K g 2
SEmION: 16 TOWNSHIP: 151\1 RANGE: 1W
LOT SIZE: 16050 (SQ^FT. OR ACRES)
I certi�y that:
1" I with the requirements �or on�site sewors and wells as set
forth by the Municipality of Anchorage (MA) and the State of' Alaska"
2" I will ,install the system in accordance with all MOA codes and reguloil, ions�
and in compliance with the design criteria othis perm:1.t.
3" I will adhere to all MOA and State Of Alaska requirements for the set back
distances from any existing well, wastewater disposal s;stem or public
sewerage system on this or any adjacent or nearby lot,
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODESv `
THEN (1) ().N ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AWOL) ILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; ('iND (3) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN"
SI8NED kJ DATE: /0
IPA,
APPLICANT: I A KER
ISSUED BY
� r
pug '
/ 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
NAME o/7/L
/REPORT
PC�J
EW
❑UPGRADE
MAILING ADD ESS
'
LEGAL DESCRIPTION
LOCATION ��"� �7
NO. OF BED_R90MS
DISTANCE T0:
Well
Absorption area
Dwelling /
L{:
PERMIT N(�..
�/�
F
F- Z
Manufacturer
Material CC rr //
No. of co T partments
N
Liq. capaFity in alms
1 C�
IF HOMEMADE:
Inside length
Width
Liquid depth
�----
pUZ
DISTANC O:
Well
-
Dwelling
--"_
PERMIT NO.
�--- -�� --
O b
Manu cturer /
_
l -
Mate'ial--� -`
"Liquid capaci� in gallon'
O
w a
DISTANCE TO:
Well
Foundation
Nearest Io lin
�1- �(�
PERMIT NO. C,
J u. z
ti z w
No. of lines
r) ��
Length of eacJl line
oL (
Total length of lines
U2
Trench width
3�� inches
Distanc b en lines
/ij
CCFTop
of tile to finish grade
Material beneath tiler-�t-
.inches
Total effective abs ion rea
Lu
Length _
Width
Depth
-
PERMIT NO.
LLI
TV crib
Cri iometer
Cri epth �/
Total of ective abso ptton
area
—�
W
N
DISTANCE TO:
Well
Building founcation
Nearest lot line
.j
Us�
Depth
Driller
Distance to t Ijn�
MIT NO.
w
DISTANCE TO:
Building foundation
Sewer line
Septic to \�
LAbsorptinarea(s)
CC
OTHER
PIPEM/A�TERIIALSS //may
- ,r -t -i
_Mi
I
y�
SOIL TEST RATING
l'Q v
INSTALLE
REMARKS
I
ut
t'
APPROVZD)
_
DATE LEGAL
/T
72-01FL1'kev.3/78) v
PI Ly T41 X 921 1:-VAL. 10
DEPHRTMENT HEHLTH
825 'L' STREET,
���� ����_�����
PERMIT �O ( 811145 )
HPPLICF)NT CHARLES L. MOWRER
KIN P07 f"I 01.W Inv fit PIT Go
HND ENVIROHHENTML 0![EIC:/1:L9� � �`'/��S n/
HNCHORHGE/ HK. 91950j. �� «/
y
������
/uos �|
�� x������n
PO BOX 647 ER688^^]23�|y,
LOCHTION DOG WOOD
LEGHL L1B2 S�YLINE
TYPE OF SOIL HB5ORPTION
VIEW �/D
SYSTEM IS
LOT SIZE
TRENCH
22000
G'! In., FEET
MHXIMUM NUMBER OF
BEDROOMS � ]
SOIL RRTING (SQ
FT/BR)�
100 UL
THE REQUIRED SIZE
OF THE SOIL R8SORPTION
SYSM IS�
TE
0
«
�Q to, -1 , I!. � - 11:- � �14 all -N- 1-0 — -11L. "10 fit IT! 1=1 "w" FE RE_. IITT�� -'I] - 1-1 : 1 A
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE BETWEEN THE OF THE
GROUND AND THEBOTTOM OF THE EXCHVHTION (IN FEET).
THER� IS NO SET WIDTH FOR TRENCHES
THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF CARMEL BETWEEN THE OUTFHLL PIPE
HND THE BOTTOM OF THE EXCHVHTION (IN FEET).
�M R 1� V-1 III: QV 3: Z:�� fi�:_ I n:� It�����
PERMIT HPPLICHNT HAS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE
�NSTHLL�T�OW �NSPECT���� OF F11101., WELLS TO E
NUMBER OF RESIDENCES THAT Tra WELL WILL SERVE.
I. �11-, 1 1C.*) �_'j, JC Ii. to" Q oil Q- X Ell 011 W A lot M Fit 147 Q 1-1 1 & M fix ��---
BRCKFILLING OF HNY SYSTEM WITHQUT FINIAL UNSPECTION HO,D HPPROVHL BY THIS
DEPHRTMENT WILL BE SUBJECT TO PROSECUTION
MINIMUM DISTHNCE BETWEEN H WELL AND MAY ONNSITE SEWAGE DISPOSHL SYSTEM IS
1�0 FEET FOR H PRIVHTE HELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTHNCE FROM R PRIVHTE NELL TO H PRIVATE SEWER LINE FE�T HND
TO H COMMUNITY SEWER LINE IS FEET.
NELL LOGS HRA EREQUIRE� HND MUST 8E RF�:T1JF:O1ED TO THE DEPHRTMENT WITH11'-f ]0 DAYS
OF THE WELL COMPLETION
OTHFR REQU1REMENTS MY HPPM SPECIFICATIONS RND CONSTRUCTION DIHGRAMS HRE
HVHILHB�E. TO IPROPER INSTHLLHTfON1.
1: _T,
I CERTIFY THHT
1 I HM FHMILIHR WITH THE REQUIREMENTS FOR ON-SITE SENERS HND WELLS HS SET
FORTH BY THE MUNICIPHLITY OF HNCHORHGE
2� I WILL INSTHLL THE SYSTEM IN HCCOR"HNCE WITH THE CODES
]� I UNDERSTHND THHT THE ON�SITE SEWER SYSTEM PIFW REQUIRE -ENLHRGEM IF TWE
REMODELFED TO INCLUDE MC)REE THHN
S] .` .....
F�PPLICHNT `HH ~~ / M[||RER /D/�(~//
ISSUED BY �y �.. // ~DHTE�~�/�//.+�-(V��1.
--'- -�7- -----������������
PERFORMED
1 SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 2644720
SOILS LOG — PERCOLATION TEST
LEGAL DESCRIPTION: Z'
DEPTH
1
�7 <
2 - �g
3 lr
4 <)
V
5 - �•�
a.
6- / j f
I/a /Q j JLC,
7 -
9
10 wN
WAS GROUND WATER �� S
ENCOUNTERED? L
12 I ;y
IF YES, AT WHAT
DEPTH?
13
G
SLOPE
"P
DATE PERFORMED:&57 {
,/% r'Lt)
SITE PLAN
r
Reading
Date
Gross
Time
14
Depth to
Water
Ro(anrt A. S4of
PERCOLATION RATE _(minutes/inch)
1457-E
15 -
xv
O'
16-
49/
17-
f
117
" f kle
0�.`r E
18-
a
19
SITE PLAN
r
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE _(minutes/inch)
TEST RUN BETWEEN - FT AND - FT
20 •
iN1
PERCOLATION RATE _(minutes/inch)
TEST RUN BETWEEN - FT AND - FT
COMMENTS
PERFORMED BY: CERTIFIED B
72-008 (6/79)
DATE:C s-ocnr
Trv,iftrb 43ritting lxg
by
DOC Co. tlba
SULLIVAN WATER WELLS
P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2759
OWNER OF LAND DEPTH OF WELL
ADDRESS STATIC LEVEL. OF WATER FT.
LEGAL DESCRIPTION
DATE - Started Ended '
PERMIT NUMBER
KIND OF FORMATION:
Ft. to
From
Ft. to -
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to ' --
Ft.
From
Ft. to
Ft.
E D
From
Ft. to
Ft.
From_
Ft. to -'
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft..
From
From
Ft. to
Ft.
Ft. to
From
Ft. to
Ft.
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
MISCL. INFORMATION:
DRAW DOWN FT.
GALS. PER HR
KIND OF CASING
From
Ft. to
Ft.
From
Ft. to
MUNICIf+LITY OF ANCHORAGE
From
Ft. to
ENVIn Ft':..1...=..:
From
Ft. to_t
m 1f9C,7
FromFt.
to__lZg_M_V_
From
Pt. to
E D
From
Ft. to
Ft.
- From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
Froin
-Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to_
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft
DRILLER'S NAME
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 6 r I ' I q Z-2 COSA # I0 CC01
Expiration Date: T — 2 lP — /O
1. GENERAL INFORMATION
Complete legal description Lot 1; Bbck 2; Skyline View Subdivision
Location (site address) 19375 Dogwood Rd.
Current Property owner(s) wells Fargo
Day phone
Mailing address
Lending agency
Day phone
Mailing address
Real Estate Agent Diane Sheer r Keller Williams
Day phone 854-0007
Mailing Address
Unless otherwise requested. COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well IZI
Individual On-site
❑�
Individual Water Storage ❑
Individual Holding Tank
❑
Community Class Well ❑
Community On-site
❑
Public Water System ❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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 Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply andlor 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 S & S Engineering Phone 694-2979
Address 15861 S. Birchwood Loop Chugiak, AK 99567
Engineer's Printed Name Roberta sharer
5. DSD SIGNATURE
_1.G Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
40
By: ` Original Certificate Date:__
.(Ran IW51
Municipality of Anchorage
• '� Development Services Department =
/ Building Safety Division
- On -Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE S
QYSTEMS APPROVAL CHECKLIST
Legal Description: /---)-r /j �JGOCA- O� ' 3/4n t3 S Parcel ID: 0S f' No? -A/o
A. WELL DA A
Well type _ pfd VA. B, or C provide PWS` I/D # = Well Logol) )`'_
Date completed f1 /� / Sanitary seal�N)%C-S Wires property protected�f) 'I VS
Total depth 1:2�ft. Cased to=2; _ft. Casing height (above ground) f - ' in.
FROM WELL LOG AT INSPECTION
Date of test 1 13 /D
/
Static water level P7 3 r ft. mos ft.
Well production g.p.m. (o g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate -14 mg/L Other bacteria C7 colonies/100 mL
Arsenic: ug/L date of sample:I u 1 'v Collected by: `tea SJtrwEkJKXo
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material 5(-]>77L S7 -15-t-( Date installed` I�
Tank size _ CCO gal. Number of Compartments o2 Cleanouts&) YES
Foundation cleanouu6m) L`'-" Depression over tank (Y® too High water alarm (Yis.
Date of pumping O Pumper.
C. ABSORPTION FIELD DATA
Date installed 11 Ii, Soil rating (g.p.d./f 2 ftZ/bdrm 1.0 System type�A
Length ON , ft. Width ft. Gravel below pipe f:5— ft.
Total depth ft. Eff. absorption area Wft' Monit tube Depression over field 96-
Date of adequacy test f v Resul (Pa /Fail3g For a bedrooms
Fluid depth in absorption field before test 0 in. Water added LR"�al. New depth:3::L in.
II
Elapsed Time: L min. Final fluid depth in. Absorption rate >= 4150-r g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y�?type) - If yes, give date —
D. LIFT STATION �11�
Date installed 1!1
'Pump on' level at _ in.
Datum
E. SEPARATION DISTANCES
Size In gallons
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
/
Septic tank/lift station on lot /06 �-
Absorption field on lot /00,1
Public sewer main 16
r
Sewer /septic service line d5 4—
r
Animal containment areas So +
in. High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
i
On adjacent lots 4� 4
Public sewer manhole/cleanout
Holding tank N In
r
Manure/animal excrete storage areas ICO -4-
SEPARATION
h
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Building foundation /0 a- Property tine 1Q -,L Absorption field S 4-
r
Water main t4 Water service line !27 -I- Surface water /dam
r
Wells on adjacent tots /CYC
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
I I
Property line /n -A Building foundation /b '1' Water main
Water Service line /� rl Surface water /i)
r
Curtain drain A3e x)t= ekVxOAt Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that 1 have determ*
review of Municipal records
conformance with MOA COQ/
Engineer's Printed Na ar/�r
Date Z Z
COSA Fee $ / D
Date of Payment
Receipt Number 0
(Rev. 11/05)
v
rough field inspections and
the abovesy qms aye in
dings in Affe o thrs 4t6.
r
Driveway, parking/vehicle storage
Waiver Fee $
Date of Payment
Receipt Number
r]
k VACOO
1461'4
in.
V0
14
wqfE�Al
SGS Ret.N
Client Name
Project Name/N
Client Sample ID
Matrix
Sample Remarks:
1100109001
S & S Engineering
Lot 1 Block 2 Skyline View S/D
Lot I Block 2 Skyline View S/D
Drinking Water
Printed Date/rime
Collected Date/rime
Received Datefrime
Technical Director
01/21/2010 11:00
01/11/2010 14:50
01/11/2010 15:55
Stephen C. Ede
Allowable Prep Analysis
Paramettt Results LOQ Units Method Container II) Limits Date Date Inil
Metals by ICP/MS
Arsenic 5.00 U 5.00 ug/L EP200.8 C (<10) 01/12/10 01/20/10 NRB
Waters Department
Total Nitratc/Nitrite-N 4.24 0.100
Microbiology Laboratory
Colony Count 0
Total Coliform 0
Fecal Coliform 0
m&I SM204500NO3-F B (<IO)
col/IOOml- Sh1209222B
col/IOOmL SM209222B
col/IOOmL SM20922213
A (<200)
A (<I)
A (<I)
01/19/10 LCE
01/11/10 KAR
01/II/10 KAR
01/11/10 KAR
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FORA SINGLE FAMILY -DWELLING
Parcel I.D. 667— /U--.2'
1. GENERAL INFORMATION
Complete legal description
-Location (site address)
COSA# �lO -
Expiration Date:
9
ST_
Current Property owner(s)Air Ar. P /�1�1Jo.�rai� . Day phone � -' eyZ 9
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
3
Day phone
Day phone 2t/e1— 1q3 a
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Is
Individual Holding Tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of Onsite Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-familyon-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems 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 Certificate of On -Site Systems 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. ZVQ, 7"!-+ , / Phone _ JV ;74&d:,Address �—(�ipl % •7Q _7o U
Engineer's Printed Name C 77Ectf 6AJC Date �d6 Q
it
';, i+ t _
5. DSD SIGNATURE f r •. Srww w.Ems re 6256
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
ON-SITE •:
Attachments:
COSA Checklist X Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other
By: Original Certificate Date:_3 -- 3 — 0_7
(Rw. 11105)
Municipality of Anchorage
^� Development Services Department ,
Building Safety Division `
On -Site Water & Wastewater Program `
4700 Bragaw Street
P.O. Box 198850
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:t; r !j&je, Vre$
Slack o? L .f l Parcel lD: O SJ- J 9�Z -2, (o
A. WELL DATA
Well type P
Date completed �el
Total depth?,,Z-ft.
K A, B, or C provide PWSID # _
Sanitary sea[ (YM)
Cased to � R.
FROM WELL LOG
Date of test
"' Zlkldol
Static water level ft.
Well production �� g p•m•
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate 3. S ( mg/L
Arsenio QLZ-y mgfl Date of sample: J&0%aT
B. SEPTICIHOLDING TANK DATA
Well Log (YM) _
Wires properly protected (Y/N) �/Z—
Casing height (above ground) 2!!y in.
AT INSPECTION
d7
/,? . ft.
S05 g.p.m.
Other bacteria d colonies/100 mL
: �(3r^�h
Collected byfes+ & •
Tank Type/MaterW CRe4Z1 S7WZK Dale installed
Tank size ld 0 U gal. Number of Compartments Z Cleanouts (Y/N) —
Foundation cleanout (Y/N) Depression over tank (Y/N) ,AL High water alarm (Y/N) Ail
Date of pumping &Z
OCZ(7 Pumper ✓- R `S
C. ABSORPTION FIELD DATA
Date installed Lrl � / A� Soil rating (q.pA4 or fte/bdrm) Ids System type 40466(0 % RE"1 C r -f
Length ft. Width 3 ft. Gravel below pipe _� ft.
Total depth // ft. Eff. absorption area "ft, Monitoring tube __y__ Depression over field N
Date of adequacy test 0 Results (Pass/Fail) L�`r For 3 bedrooms
Fluid depth in absorption field before test C in. Water added5L5 gal. New depth/ in.
Elapsed Time: 0 min. Final fluid depth 7 in. Absorption rate >= ys o g•p•d•
Any rejuvenation treatment (past 12 mo.) (Y/N & type) Lirik_ If yes, give dale
D. LIFT STATION Nlof
Dale installed Size in gallons I Manhole/Access (Y:ulremenE
"Pump on" level at in. "Pump off"evel at n. High water alarm lein.
Datum Cycles tested Meets alarm & circuit
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot /00 r,, -
Public sewer main
r
Sewer /septic service line
Animal containment areas /,041 f
On adjacent lots /Q a Y-
On adjacent lots /45,0 r-01—
Public sewer manhole/cleanout .U1�
Holding tank /t//-4
Manurelanimal excrete storage areas a a �F
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
r
Building foundation /O +` Property line lG *' Absorption field
Water main AIA Water service line Surfacewater COQ r�
Weiss on adjacent lots 1D41,f
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /d f Building foundation Ort Water main 4/��/
Water Service line 14� Surface water IOO t r Driveway, parking/vehicle storage
Curtain drain 11A) re- Wells on adjacent lots /CJC r
F. COMMENTS
G. ENGINEER'S CERTIFICATION•.�y�j
I certify that l have determined through field inspections and r..•
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date. ...........
Engineer's Printed Name s 1 6 y�i tp -PE 6256 •`�c``AV�
Date
CO • A
COSA Fee
Date of Payment 1/�j
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
ANALYTICA
GROUP
Northrim Eng
Attn: Steve Eng
17237 [sear Paw Circle
Eagle River, AK 99577
907-694-7028
Fax: 907-694-7026
Client Sample ID:
Sampling Location: 19375 Dogwood St.
Client Project: Northrim Eng
Sample Matrix: Aqueous
COC #:
PWSN:
Residual Chlorine:
Comments:
Analytica International, Inc.
4307 Arctic Blvd.
Anchorage, AK 99503
Phone: 907-258-2155
Fax: 907-258-6634
Report Date:
7/30/2007
Receipt Date:
7/10/2007
Sample Date:
7/10/2007
Sample Time:
10:30:OOAM
Collected By:
TE
Flag Definitions:
MRL = Method Reporting Limit
MCL — Maximum Contaminant Limit
D = Present also in Method [clank
11= Exceeds Regulatory Limit
M = Matrix Interference
J = Estimated Value
D = Lost to Dilution
00= RL higher than MCL; target not detected
TNC = Too Numerous to Count - result rejected
CF - Confluent Growth - result rejected
TCNG - Turbid Culture No Growth - rejected
LabN: A0707103 -02A
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
92228 (Aqueous) - Membrane Filtration MF Test was conducled by: Analytica -Anchorage
Bacteria, Other <MRL CFU/IOOmL 1.0 7/10/2007 7/10/2007 PL
Total Coliform <MRL CFU/IOOmL 1.0 1 7/10/2007 7/10/2007 PL
Labfl: A0707103 -02B
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL 1%ICL Method Date Date Analyst
4500-NO3E (Aqueous) - Nitrate Test was conducted by: Analytica - Anchorage
Nitrate as 3.51 mg/L 0.50 10 7/13/2007 7/13/2007 AJ
Lab#: A0707103 -02C
Analysis Method Prep Prep Analysis
Parameter Result Units Flags MRL MCL Method Date Date Analyst
00.81200.8 (Aqueous) - Family Well Water to
Arsenic 0.624 ug/L 0.15 /0
Reported by: Claire Toon, Page 2 of 2
Laboratory Project Manager
HWS
200.8 7/17/2007 7/18/2007 KS
30.00'
I 1
LOT 8 LOT 9
1 �CHAINUNK FENCE
� —LOT—1
1.41 \
\14.8' X 32.0'
CARPORT
RA\ 96.6'
-
26.3Y
T.
CE
d-
av sea.
X 14.3' CLEANOUTS
12.0' X 12.0\1
DECK
LOT 2 10' UTILITY EASEMENTS 1
PORARY TURNAROUND EASEMENT I I
BE VACATED IF ROAD IS EXTENDED
PLOT PLAN _ AS BUILT X SCALE 1' - 30' GRID NW 1159 Project No. 07-117
LOT 9
Lan &Associates inc. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049
9 (907) 522-6476 Phone
Registered Land Surveyors (907) 522-4625 Fax v pF qL
kglonglaftlasko.net / jelongle0alasko.net ��`.• " ""• '9S1�
I hereby certify that I have surveyed the following described Properly: '
LOT 1, BLOCK 2, SKYLINE VIEW SU80MSION (PLAT No. P-500)?:` 49m
Anchorage Recording District. Alaska, and that the Improvements situated thereon aro ....
within We property Iines and do not encroach onto the property adjacent thereto, that I
no Improvements on the property lying adjacent thereto encroach on the surveyed .....
premises and that there are no roadways, transmission lines or other visible j$ ' KENNETH .
easements on sold property except as Indicated hereon. LSI—I5 02
Dated this the I' ii,Day of Tuve . 1,00. of Anchorage, Alaska J,,
It Is the responsibility of the owner to determine the existence of any easements, HAL
��EZSS5SII0O
covenants, or restrictions which do not appear on the recorded subdivision plat.
I
r ._ - ,..::�:-...�-«..�� --..- ,-;-:�_. ,. -, _ e ...a.� .—. > �-:� �s=Y��.wK .::.i,nY, > .�:u-: . —. _�.. �.a.s/ail �.•Sazr.+•iva'mw�e�z ,F�..�i3LA7r—�Jfs� .vlv,sa;v�[-�ui1
MUNICIPALITY OI'' ANCHORAGE
DIVISION OF ENVIRONMENTAL llr�,,ALTH
DEPA-RTMENT OF HEALTH AND ENVIRONLiENTA.L PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date
(a) Legal Description ( ny.lude I t, blo k, subdivision, section, township, range)
Locatio (a(Ldress or
>> directions)
l /,
)^J
%
-s _�
!'�
(b) Applicants Name Telephone ,home _ _ Business
Applicants Address --_.___
(c) Applicant is (check ,one) Lending Institution Owner/buil.der ;
Buyer Othez (ex lain);
(d) Lending Institution Telephoil
Address
(e) Beal. 1satal:e Co. & Agent.._._._..
Address 1,K_
Telephone(f)
Mail .tail r_he IL1A to the following address:
2.. T%_ of Residence
Single -Family Multi -Family Other (describe)---,--e_�w-^._---__._._
Number of Bedrooms
3. Water Supp11
Individual. well Community _� Public I
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 I'X I Public C�� Community E—Holding Tank El
Note: If community well. system, must have written confirmation from the State
Department of Environmental- Conservation attesting; to the legality and su.-Atus.
[Page 1 of 2]
5
6
Engineering F_i_rm ProvidinTT.nspections, Tests File 5ear.ch, Da tam 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 dale of this; inspection.
Name of Firm
Address
a�lef? .f x
Date
Telephone,__
YA+s rytkRS },.
:5
(ENGINEE:R SEAL)
1 Fn •, Na, ids%•F. r
DHEP Appy§j 09
Approved for P���_�� bedrooms By UaOhw
z �- —
\f
Approved /X Disapproved Conditional.
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 PROFZSSI:ONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF H9MES 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/DI8
[Page 2 of 2] 7--19-84
N
pp. .npF'IPALITY OF ANCHORAGE .
Ei T. OF HEALTH &
MUNICIPALITY OF ANCHORAGE (MOA) EI"vI,<i: I �' NTAI_ PROTECTION
HEALTH AUTHORITY APPROVAL (HAA) OC •1 'i '��(�
CHECKLIST - FEBRUARY 1984
A. WELL DATA Legal Description: L"
Well ClassificatipqIf A, B, or C, D.E.C. A proved(Y/N)
Well Log Completed Yield
Total Depth Z
J
% Cased t Depth o£ Grouting
Static Water Level — � 3 ( Pump Set At L_C C -
Casing Height Above Ground Z� Sanitary Seal on CasincY
Electrical Wiring in Condui t6
Y Depression Around T%b llheadl((Y
Separation Distances from Db11:
To Septic/ -Tank on Lot /00 ` On Adjoining Lots
To Nearest Edge -of sorption Field on Lot 00 On Adjoining Lots O 0
To Nearest Public Sewer Line To Nearest Public Sewer
Cleanout/Manhole /J To Nearest Sewer Service Line on Lot /O
Water Sample Collected By_�o� S �C7G l�Pe�/ ; Date_ �� Zg
Water Sample Test Results
Comments xJ Lo i�J
B. SEPTIC/HSG TANK DATA
Date Instaln(Yw
/ �� 8 ( `d U Size No. of Ccmoartments 2_
Standpipes ,Air -tight Caps (Y Foundation Cleanout (Y()W
Depression over Tank ( ) Date Last PP d
Pumping/Maintenanoa Contract on File (Y / -q ; for N
Holding Tank High -Water Alarm (YW Temporary Holding Tank Permit (Y ems}
Separation Distances from Septics Tank:
To Water -Supply Well To Building Foundation �50_
To Property Line To Disposal Field 5- (
To Water Maim/Service Line ZD 7L To Stream, Pond, Lake, or Major Drainage
Course dtl `p -
Comments
Plk
G 1. DY -f �i /NS�� C� � � r � /� �•. �'� �, ��� ,� .;. �.
Receipt
Date Paid:
Amount:
[Page 1 of 21
2-15-84
/Uo /
rz--
C. ABSORPTION FIELD LUTA
Soils Rating in Absorption Strata Type of System Design Glc
Date Installed l/ ( g / _ Length of Field Z� _
Width of Field �j l� L` Depth of Field / Z
Gravel Bed Thickness
Square Feet of Absorption A. ���� Standpipes Present (Y
Depression over Field (Y Date of Last Adequacy. Testi
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply G%b11_ /(�� To Property Line
To Building Foundation To Existing or Abandoned System on
Lot )V6k1%` ; On Adjoining Lots ,1Y11-4- Za f
To Water Mwi-A/Service Line /O 7/-- To Cutbank(if present) /Vl
To Stream/Pond/Lake/or Major Drainage Course Pi d5
To Driveway, Parking Area, or Vehicle Storage Area
COITents /Ulf d'J
D. LIFT STATION
Date Installed
Dimensions
Size in Gallons Manhole/Access (Y/4)
"Pump On" Level at "/Pump Off" Level at
High Water Alarm Level at / _ Vent (YM)
Tested for Pumpi g Cycles during Adequacy Thst. Meets MOA
Electrical Codes(Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request "
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection.(w a � ()h At.. Ife 4
Signed Date
ani
Company 31V��IaA ' 4a'5'T` MOA o.
KB1/d5/s
Robert A. 5fiafv� d` 41 ;i
[Page 2 of 21---4g•...,�����p�
Time
Time e
Date
Date
Date
D
Inspector
Inspector
Inspector
Comments
Conditional Approval
Date Sewer Installed
Permit No.
Septic Tank Size /coo C-)
A (
Holding Tank Size
Soils Rating
Well To Absorption Area
Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner OVA (N (f ( Tim Phone
Mailing Address
Buyer
Address/soo,e y i. e
Lending Institution-- appOt�,c�T— Phone
Address
^�
Realty Co. & Agent Phone
W pu-
Address
FS
Legal Descriptlon Q
Street Location
Type �q€ Residence
C] Single Family
❑ Multiple Family No. of Bedrooms
_❑ Other
Water�upply —
tt55 Indlvidual ATTACH WELL LOG. A well log is required for all wells drilled since June
❑ Community 1975. For wells drilled prior to that date, give well depth (attach log if
❑ Public Utility available.)
SewaawDisposal
C7 Individual Year Individual Installed:
❑ Public Utility When Connected to Public Utility:_
❑ Holding
NOTE: THE INSPECTION FEE MIDST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.