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HomeMy WebLinkAboutSUSITNA VIEW ESTATES BLK 3 LT 2 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP221466 Work Type: Septic Upgrade Tax Code Number: 02009133000 Site Legal Address: SUSITNA VIEW ESTATES BLK 3 LT 2 G:3336 Site Mailing Address: 17016 ARIES CT, Anchorage Owner: KENNY MICHAEL T 8, VALERIE J Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: Effective Date Expiration Date p�cnt- .S J 'r u llepartfncnr Lot Size in Sq Ft: Total Bedrooms: 12/27/2022 12/27/2023 21706 Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: S�� To C �? Issued By: Date: Date: % Z 2 V2-0 2- 3 Municipality of Anchorage AJ --- Department P.O. Box 196650 0 4700 Elmore Road Anchorage, Alaska 99519-6650 0 (907) 343-7904 0 Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Division On -Site Water and Wastewater Program * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV221074 Permit#: OSP221466 PID#: 020-091-33 Legal Description: Susitna View Estates Block 3 Lot 2 Engineer: Jeffrey Gayness, PE Applicant: Jeffrey Garness, PE Your request for a waiver of the required 100' horizontal separation from the septic field to well has been approved. The approved separation distance is 80'. In addition, your request for a waiver of the required 10' separation from field to lot line has been approved. The approved separation distance is 1'. In addition, your request for a waiver of the required 50' horizontal separation from the absorption field to an excessive slope has been approved. The approved separation distance is 30'. This waiver approval applies to the Existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department ❑The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected adjacent property. ® Adjacent properties are not affected by this waiver. .................. 0 M N S E N ....................... ■ ............................. ■ 1 Waiver is Granted: X Waiver is not Granted: Date: I Z Z 2,7-L Z Approved by: V— Name of Reviewer .................................. a M N U 0 N ....... ■ ............................. ■ 1 **** VARIANCE/WAIVER REVIEW **** MUNICI A I T OF ANCHORAGE Development Services Department P p Phone. 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 020-091-33 Property owner(s) MIKE KENNY Mailing address 17016 ARIES COURT *ANCHORAGE, AK Site address 17016 ARIES COURT *ANCHORAGE, AK Day phone 907-227-3993 Legal description (Sub'd., Block & Lot) SUSITNA VIEW ESTATES; BLOCK 3, LOT 2 Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (2 all that apply) Absorption Field 0 Initial ❑ Single Family (SF) (w/wo ADU) Septic Tank 0 Upgrade M (D) ❑ Holding Tank F] Renewal ❑ Renewal Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: DRAINFIELD TO SLOPES GREATER THAN 25%; DRAINFIELD TO WELL; DRAINFIELD TO LOT LINE so; eo; Distance: 1 certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 545' Date of Payment: 1/hob'?— Receipt /hoI2zReceipt Number: oS7 3s3C� Permit No. as 190a d' )q Waiver Fees: l l 8'D Date of Payment: Receipt Number: OS �383�. Waiver No. OS V 2Z 1 61 I G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221466, Curtis Townsend, 12/27/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221466, Curtis Townsend, 12/27/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221466, Curtis Townsend, 12/27/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221466, Curtis Townsend, 12/27/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221466, Curtis Townsend, 12/27/22 8504E 30 Lot 3 °0 x'`33"�, CD 0 d 030 �y( Rock ret. wall (typ) -,, Q UI 2.3 OH i 'CO o N l \ Septic vent d (typ) © 28.0 0 I o 4.0 OH ® Ct O O( 00 Z Lot 2 �, 0 4.00 O LL v co 16.0 25.0 et 2 Story Frame 0 ; t ` i 27.3 :,:. House with UJ Basement deck w6 20.7 :_ .<<. = O CNUI O W C) < .1� 30 N79°�$`24n1A�" � � 47.15 � Well rub 30 r Lot 1 AS-BUILT NO CORNERS SET THIS DATE pC 1 I hereby certify that I have performed a Mortgagee's inspection AWf• OF in accordance with ASPLS Standards of the following �^, • ° 's'r described property: LOT 2, BLOCK 3 49th°.y SUSITNA VIEW ESTATES ® * . •. *,40 Anchorage Recording Precinct, Alaska, and that the ° improvements situated thereon are within the property lines and do not overlap or encroach on the property lying ° ° • ° ° • • adjacent thereto, that no improvements on the property lying . Elizabeth L. Walatka . oo tv adjacent thereto encroach on the premises in question and `Pxx • • 6036 - LS • • �Q m. that there are no roadways, transmission lines or other rr— .. visible easements on said property except as indicated SCALE: — 40o • • '`3^e��_®" hereon. p pe Y p �s����Dated at Anchorage, Alaska this 7th day of September , 2022. EASEMENTS OF RECORD, OTHER THAN 2-0 THOSE SHOWN ON THE RECORDED FRED eA v ASSOCIATES, L.L.C. PLAT ARE NOT SHOWN HEREON BE Engineers and and and Surveyors UNLESS OTHERWISE NOTED. FB 22-1, pg 69 907-248-1666 This drawing is a representation of conditions found at the time the mortgage location survey was performed. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained on this drawing shall not be used to establish any fence. structure or other improvements. This drawing shall only be used for a single property transaction. Use of this drawing by the original client or by others at a later date without the consent of Elizabeth L. Walatka is a violation of Federal Copyright law. Unless gross negligence is discovered, the liability extent of the preparer is limited to the amount of fees collected for services in preparation of this product. SGS Ref.# 1226177001 Client Name Garness Engineering Group, Ltd (GEG) Printed Date/Time 10/25/2022 7:18 Project Name/# 17016 Aries St. Collected Date/Time 10/07/2022 16:00 Client Sample ID 17016 Aries St. Received Date/Time 10/07/2022 16:32 Matrix Drinking Water Technical Director Stephen C. Ede Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 B (<10) 10/11/22 10/13/22 HGS Waters Department Total Nitrate/Nitrite-N 2.86 0.200 mg/L SM21 4500NO3-F C (<10) 10/24/22 EBH Microbiology Laboratory E. Coli Negative 1 IOOmL SM21 9223B A 10/07/22 M.A Total Coliform Negative I IOOmL SM21 9223B A 10/07/22 M.A 2of5 MUNICIPALITY OF ANCHORAGE · . DEPARTI~-~JT OF HEALTH & ENVIRONMENTAL PRO'L_~/rION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage~ Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME [] UPGRADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION ~z NO. oE BEDROOMS Material IManufacturer ~ ~'~- Width Liq. capacity in gallons Inside length / Z $-O IF HOMEMADE: DIST~ NC£ TO We Dwelling Manufacturer Material ken each line ~-~1~ I Ne. of lines ~. I g~fl ~'~ Total length of lines I Trench width Top of tile to finish grad ~ · Width Depth Length Type of crib Crib diameter Crib depth Well DISTANCE TO: Depth Building foundation DISTANCE TO: Class OTHER PiPE MATERIALS SOl L TEST RATING INSTALLER Building foundation Driller PERMIT NO. No. of compartments,~.~ Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO,~ [-~oI Distance between lines / ~ inches Total effective ab orption area inches ~'~ ~ ~ ~' PERMIT NO, Total effective absorption area Ne. arest lot line Septic tank Absorption area(s) Distance to lot line PERMIT NO. : Sewer line REMARKS 7-Ac. t""/' ~1~ ? ~.~ d~ - ~ '~ ~ ~ ~t s -;t-~ 72-013 (Rev. 3/78) DATE LEGAL DIEI::'~:~F:CTI'fEN]" OF HIE¢fi_TI'I ~ND E~NVII:~ONME]qT'F~L. SDE:; L :S'T'FU~EEET ~, ANCHCtF~'./~E~E 2.64,-"4.720 1", I C;H,~!EL. I<ENNY 1'70:I. 6 ¢fi::i]:!ES COURT A !g ,'..':: I. ~ C.' F:i: (-~, GE[. ./..~ K 995 L. i3T !3 'J: ZFZ :.' L_OT LOC¢~ 1." i E)N ~ i..i,,-, v B E D,"u.I ......... )B L.(-~C h::" ~ 'l'C)T(~d_ OEF'TH (F:"I',, ~ / 0 .*0 !.(). O GR(4VIEL 14]:DTF! (F:T. ~, ~/ 2. ~ EiI:;'.¢::6..qEL LENGTH (F'"I-. , & ~. 0 4S2. ~¢ GFi'.AVEI. V[)L..Ut~IE (CU,. YDS. '~ 'TANK SIZE (EiF~L..E;) /.~O ~:, ()oo,. c") .,..~ SOIL IRCYI"IIIB (SD..':'I-. /BFi'.) i74 Z MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Ataska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: 'To.t,4 LEGAL DESCRIPTION: ~ ~.%~ ~' ~'~O. 1 2 3 4 5 E~ 6 7 8 9 10 11 12 13 14 15 16 17 18 19- 20- COMMENTS a~ &*, '/ fl~ ~( ,'¢ PERFORMED BY: ~ ¢'"- >~ 72-008 (6/79} DATE PERFORMED: ,~ /2../ ~ ~' SLOPE SITE PLAN WAS GROUND WATER S ENCOUNTERED? ~(0 LpO E IF YES, AT WHAT / DEPTH? PERCOLATION RATE/T tt%~'~ ( /'/ ~'//~- FT TEST RUN BETWEEN FT AND Gross Net Depth to Net Reading Date Time Time Water Drop t 33s~ lo /,77- , ~3 q 3~'f - ~" / q~F to I,~' ' ~ CERTIFIED BY: ~ ~/~'~~t DATE: WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological ~ GeophysicaISurveys Drilling Permit No. LOCATION OF WELL (Please complele either Io~ lb 9r lc.) A.D.L.~Io. Io~.JBorough Subdivision Lot Block ~ '/4qtrs. Sect[on NO. Township,[~ Range E[~ Meridian Susit~.~ sO wO ~JD STANCE AND DIRECTION FROM ROAD INTERSECTIONS 5. OWNER OF WELL; ' Micnae! Ad~ress: 17016, Aries t, ouz ....... s,~, ~ ~,~ A~ of w~u Lo~,o, .. ~nch., Ak 99516 Fee, Below 4. WE~PTH: [f,n~') 5. DATE OF COMPLETION WELL LOG Surfcce ff. ; ~) -- ~ Meterio~ Type To~ Barf om (;ray el.ay d Rocks 35 45 0~..,~ 0~""'~ ~so~.~ ~:rown clay, ~,-ravel & 12tt]e O Irri;~tlo, O Rechcr;e O Commerie~ water 47 59 ~ Test Well ~ Other: ]]~/'k brow~ sa~ld~ O].~V ~ 8. CASING: O Threaded ~[Welded water, 2 gal~ per nlin. 59 70 di~m. 6 i.. to 72 ft. Depth Weight 17 '?ad'cock 7o 130 diam. in. ~o ft. Depth Stfckup 9, FINISH OF W~LL: Type: Dlametor: Slot/Mesh Size;. Lenglh: Set between ft. and 8ack filling Grove[ pac~ '~'~O.~ ,o. Sr*T,C w*~. ~W~: 23 .. ~ ~ I /85 ~/ ~ '~/ ~ Date f~/~ ~O~ /,~ O Above or ~ Below land surface .~ .. Q.~ q~. ~/,~/~ ~ft. after .~hrs. pumping Sommerville Well..i)]?i]_..] lng A13785 ....... . I 1140 .Pol~:~r i)r~ r, Anchorage, AK 99516 Anchorage POUCH 6-650 ANCHORAGE, ALASKA 99502 (907) 279-2511 GEORGE M. SULLIVAN, MA YOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (825 "L" Street) September 26, 1977 Mike Kenny Box 4004D Anchorage, Alaska 99509 Subject: Permit Expiration Dear Mr. Kenny: A permit issued by this department for well and/or on-site sewer installation on Lot 2 Block 3 Susitna Estates Subdivision has expired since the issue date exceeds one (1) year. In the event you still plan to install the well and/or on-site sewer system, a new permit is required. The original soil test may be used to obtain a current permit. If the well has been drilled, a well log should be sent to this department to document the installation date. If you have any questions regarding the above matter, please do not hesitate to contact this office immediately at 264- 4720. Sincerely~ Sanitarian RCP/lj h PERI'lIT NO. 25~0 E.' TUDOR RD.., FtNC~ORRGE., RK. ~50,.' . -', i~ "' KENN'~, BOX ~OEI4.D - RNCHORRGE ~FPLI_.RNf ,MIKE . LOCRTION RRIES STREET LEGRL L2 B~ %IJSITNR ESTRTES LOT _I~E 22800 S6ILIRRE F'EE'T' TYPE OF SOZL RBSORBTZON SYSTEM ~S: TRENCH MRXIMLIM NUMBER OF BEDROOMS = ~ SOIL RRTIHG (Sg. FTcE, R]- t80 THE REQUIRED SIZE OF THE SOIL RBSORPTION SVSTEM E:,EF"TH= ~ LE~-~GTH= 46 ISRR'-¢'EL E)EF THE LENGTH DIHENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIEL. D. THE DEPTH OF R TRENCH OR PZT IS THE DISTRNCE BETNEEN THE SIJRFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET NIDTH FOR TREN_.HED. THE GRRVEL DEPTH IS THE MZHIMUM DEPTH OF GRRVEL BETNEEN THE OUTFRLI_ PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). F'RC:K~R~3E F'LR~T FCEE!!J I REE:' EITHER R CLRSS I OR II NSF RPPROVED PLRNT HRY BE ZNSTRLLE[:'. R CONTZNUOUS MRINTENRNCE RGREEMENT IS REQUIRED, IF R HRINTENRNCE RGREEMENT IS NOT KEPT CURRENT YOU NR~~ BE REE~UIRED TO ENLRRGE THE ~LIL.. 8BSORPTION SVSTEM RND/OR ~OU MR¥ BE _,UBJEbT TO PKO_,EuUTIUN. I~' ~ F" ~cc f S¥CTEM Z~ I1~[) THE LENGTH IS _~. 8 FEET. ' "%~ ~I-~M ~-1SED THE LENGTH I~ 42. e FEET. IF R CL8~ ._ 1¢S _ E:RCKFILLIHG OF RN,¢ SVSTEf,I W/THOUT~TI~D RPPRO'¢RL E:*' THIS WELL LOGS RRE REQLIZRED ~MU~~~'TO THE ~ OF THE NELL COMPLETZOH. ¢ - ~ ND cON~TRUCTIO DIRGRRH~ RRE R',/RILRBLE TO ~NSUR. E PROPER =PECZFZCRTZON- R _ . ~l . -. · PEg:D1 I T ',/RL I D F~3F: ~2FtE 5"ERg: FF:Oi'4 I CERTIF'¢ THRT =,EHER_, RND NELLS RS t: I RM FRMZLIRR NITH THE REEqUIREMENTS FOR ON-SITE ~ FORTH ~'Y' THE flUNICIPflLITY OF flNCHO~RGE. 2: I NILL IHST~LL THE S~'STEM IN flCCORDflNCE NITH THE CODES. ~: Z UNDERSTRND..THRT~THE ON-SZTE SENER 5YSTE~ MA'¢,,~IRE ENLARGEMENT RE,~i[,ENC:E ~D~D TO INCLUDE MORE THRN - BEDKuun='. SET THE ~ GREATER ANCIIORAGL AREA UOROUu.., Department of Environmental Quality , 3330 "C' Street Anchorage, Alaska 99503 SOILS I,OG -- I)EROI,ATION TEST Performed for Legal Descripti This form reports: Soils log. vercola~mn ~es~ ~.. 0 5 ~ 13- Was ground water encountered? , /~Z~)_.__ If yes, at what depth? __ Reading Gro{s Time Net Time ]Depth to W.a_tep Net Drop ~-~-~' 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) Applicant Name ~/~ ~e¢,m~ Telephone: Home Applicant Address /7¢/~¢ A~"~ ~z, ~P~(~e'-~2 (b) Business ~¢~'~ (c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain); (d) Lending institution Af~ Address '~m,~ ~' j~V~¢¢,¢,~$~'~'~. (e) Real Estate Company and Agent Address Telephone Telephone (f) MaiJtheHAAtothefollowingaddress:~,,~,[[ pFC-- .~'.' ~ -- ~c~'L..- ~/£.~)l~q TYPE OF RESIDENCE Single-Family,~M ulti-Famity 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. 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 72-025 (11/84) ENGINEERING FIRM PROVI INSPECTIONS, TESTS, FILE SEARCH, A 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. Telephone Name of Firm ~ Address [~ ~' ~ -- Date /~-~Y- ~ DHEP APPROVAL ' Approved for -//-/4~- bedrooms by Approved ~ Disapp~d Conditi~ Terms of Conditional Approval //-4- 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 2 MUNICIPALITY OF ANCHORAGe] MUNICIPALITY OF ANCHORAGE (MO~'T"'Ei'-,~VIRONMF-NT,'L PF:CTECTIOJ'I HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: WELL DATA Well Classification ~r'l Ca r' Well Log Present,N) Total Depth /~f~ Cased to Static Water Level ~'~ ~ Casing Height Above Ground Electrical Wiring in Conduit (~) Separation Distances from Well: ff A, B, C, D.E.C. Approved (Y/N) Date Completed ~ ~('('- ~.~- Yield ~'- Depth of Grouting Pump Set At Sanitary Seal on Casing(~N) Depression Around Wellhead (Y~ 37,- TO Septic/Holding Tank on Lot /~7 I ./~ :~jo. ' On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~-~- /~:~2 ; On Adjoining Lots ~.~ To Nearest Public Sewer Line ~/~- To Nearest Public Sewer Cleanout/Manhole /~//~F To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments ; Date B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes ~)N) Air-tight Cap~N) Depression over Tank (Y~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) ./~/~ Separation Distances from Septic/Holding Tank: TO Water-Supply Well /0'7 / To Property Line /'~'~" To Water Main/Service Line Course ~-T. /,Z ~'~ '~'~.-~'~F, Io. of Compartments ~ Foundation Cleanou~N) Date Last Pumped .--~-/~, /fY//- ; or Temporary Holding Tank Permit (Y/N) ,~' 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/~ Results of Last Adequacy Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation /~- Lot 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~N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~,' To Cutbank (if present) ~,,~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions ,~ Manhole/Acc~/N) "~Off" Level at /~ ~,~./ Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have,checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed (~ ~ k~ Date Company ~.~-~-"*-d ~¢ MOA No. Receipt No. &~ ~ ~ Date of Payment ~ 0 -~ -~ Amount: $ ~d~ ,~'/ ~ e~ Page 2 of 2 ~a~ ~ Reld, Jr..' ~,~