HomeMy WebLinkAboutOVERLOOK ESTATES BLK 3 LT 1
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3 BR HOUSE
NEW 1250 GAL POLY
TANK
NEW DUAL
CLEANOUTS
100' WELL
RADIUS
OVERLOOK ESTATES BLOCK 3 LOT 1
A
B
C
DEF
DECK
BM +100.0' TOP OF DECK
82.3
4.8' COVER
1250 GAL POLY TANK
76.7576.92 71.9
C&M ENGINEERING SERVICES
907-854-5558
SITE PLAN
LEGAL DESCRIPTION:OVERLOOK EST BLOCK 3 LOT 1
OWNER:HOWELL DATE: 9/9/21 REV: 0 DRAWN: CB REF:
SCALE: 1" = 20'
CHARLES G BALZARINI
CE-13854R
E
G
I
S TEREDPROFE S S I O N A L E N GINEER
LEGEND
CLEANOUT
MONITOR TUBE
3/23/24
SCHEMATIC SETCION, NTS
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: OSP211306
Work Type: SepticTank Upgrade
Tax Code Number: 06804115000
Site Legal Address: OVERLOOK ESTATES BLK 3 LT 1 G:0465
Site Mailing Address: 27438 PARAMOUNT DR, Eagle River
Owner: HOWELL RUSSELL B & KATHRYN E
Design Engineer: C&M ENGINEERING SERVICES
This permit is for the construction of:
Effective Date
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
��z�ent
De]�arCment
7/30/2021
7/30/2022
39193
❑ Disposal Field 2 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:
Date:
Issued By: Date: O 2
3
ON-SITE SEPTICANELL PERMIT APPLICATION
Parcel I.D. 068 041 15
Property owner(s) Howell
Mailing address
Site address 27438 Paramount Dr
Day phone
Legal description (Sub'd., Block & Lot) Overlook Estates Block 3 Lot 1
Legal description (Township, Range & Section)
Lot Size 39,193 Sq. Ft. Number of Bedrooms 3
Phone: 907-343-7904
Fax: 907-343-7997
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) El
(w/wo ADU)
Septic Tank
0
Upgrade ED
Duplex (D) ❑
Holding Tank
ElRenewal
❑
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
C&M ENGINEERING
(Signature of property owner or authorized agent)
Permit/Rush Fees: Waiver Fees:
Date of Payment: .i Date of Payment:
Receipt Number: 0�4�Lfb Receipt Number:
Permit No. 0 SJ°,2 113 0 6 Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
C&M ENGINEERING SERVICES
Ph: 907-854-5558
Municipality of Anchorage
Onsite Water & Wastewater Program
4700 Elmore Rd Anchorage, Ak 99507
RE: Proposed Septic System Modification for Overlook Estates Block 3 Lot 1
Dear Reviewer,
The above referenced property is currently served by a 4 bedroom septic system installed in 1980s. The
Tank is over 30-years old and is need of immediate replacement.
We are proposing that the existing tank be replaced with a new 1250 gallon moa approved septic tank.
As shown on the plan, the tank will be greater than 10’ from the house foundation.
The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover or a minimum of
4’ of cover without insulation.
The repair must be performed by a moa certified installer in accordance with MOA requirements.
Repair of the proposed system will not negatively impact adjacent lots.
Upon completion of the installation, a record drawing will be submitted showing the location of the new
tank, leach field, well, and other applicable features.
Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854-
5558 or by email cgbalzarini@gmail.com with any questions or concerns.
Sincerely,
Charles Balzarini, PE
7/10/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211306, Deb Wockenfuss, 07/30/21
3 BR HOUSE
DRIVEWAY
10' UTILITY EASEM
E
N
T
NEW 1250 GAL POLY
TANK POSITION TO ELIMINATE
90-DEG UPSTREAM OF TANK
NEW DUAL
CLEANOUTS
INSPECT LINE COMING
INTO TANK FOR DAMAGE
DEMOLISH OLD TANK PER
MOA REQUIREMENTS
100' WELL RADIUS
OVERLOOK ESTATES BLOCK 3 LOT 1
C&M ENGINEERING SERVICES
907-854-5558
SITE PLAN
LEGAL DESCRIPTION: OVERLOOK ESTATES BLOCK 3 LOT 1
OWNER: HOWELL DATE: 7/10/21 REV: 0 DRAWN: CB REF:
SCALE: 1" = 30'
CHARLES G BALZARINI
CE-13854RE
GISTEREDPROFES S IO N ALENGINEERLEGEND
CLEANOUT
MONITOR TUBE
7/10/21
SEPARATION DISTANCE NOTES:
THE PROPOSED SEPTIC TANK IS GREATER THAN:
100' FROM ANY PRIVATE WELLS
200' FROM ANY PUBLIC WELLS
100' FROM ANY SURFACE WATER
10' TO ANY PROPERTY LINE OR FOUNDATION
5' TO THE DRAINFIELD
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211306, Deb Wockenfuss, 07/30/21
Lot 1, Block 3,
Overlook Estates Subdivision
As Built
Land Surveying
Land Development Consultants
Subdivision Specialists
Construction Surveying
AEC# 173042
S4
Group
124 E 7th Avenue
Anchorage, Alaska 99501
(907) 306-8104
mail@S4AK.com
03/26/2024
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES /~-'
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
Addre~ '1 I TANK FIELD WELL
Township. Range. Section
%~ ~1 ~W: ~ 2% driveway,AS'BUILT DIAGRAM (Showlocation ofwell, septic system, propedylines, foundatiOn,water bodies, etc.)
,anulact .... Capacityingallon, ,~/ '~ -- _ S,
TYPE OF SYSTEM
Depth to pipe bottom 'r~m "~ Total depth fro~o~ginal grade
original grade ~1 FT FT
Gravel depth beneath pipe
Gravel ,ength¢~ FT ~ ~ FT ~ ' 9 ~ ~ ¢ ( ~"
CC
Total absorption area )istance between lines
Numbe, O' lines / ~oi,,~,i.~ Pipe --aterial
In~tatler ~j~ ~(~ ~ Date Installed ' - ' '
WELLS
~ PRIVATE ~ OTHER (Identify}
nstaller ' ' / ~'~'~""~:~ ~ ~. A:~'DU~LI
Scale: ~.~ 5 .... ~%~'S SEAL ','
Inspe~dormed by:
I S & S ENGINEERING
17034 ~a.l* "i~e~ ~ "°"" ~- ~
72-013 (3/85) ,
~..~ Z T Y C] ~ R
Day ~ I,L, ~...
6 9 4- 5 7 9 7
t._(::)'1:.. Leg a :i. ,~ !iih_d::)d :i. v :i. s :i. on: OVIERLOOK E,%'T. l....c)t: ]. B ]. (:)(::: I<: :5,
Sect:i. on: 25 "[o~.~r":ship~ 14N Range: IW
!...crL S:i.?:e 39:1.9[~; (sc:i, ~"I:.~, c)r" acr'.es)
Plax Bedr. ooms: 'l"his !:::'er'.m:[t: 4 To'Lal C;apac:ity~ 4
,,~,::.., : l...c:i(:i must !:m:, submit'l'..ed 'Lo Munic:i.i::~al:i.'Lv o'f Anchor'age Dej:!ar'tmenC of l.-lea:l, th
al]C! ~-"]LU¥'ic-tr] [{(.DP\/:I.(::(.:.-':'S ~li'khJ. l] 3() c[~'..':~.WD; ,:::t~' t,'.c('DJ.].
.ti,h:~],-..ll ........ PER ,.:.,tE .... [[ t". AF:'F:'FRC!VIED .................. lq(:.l'l']:!:::"Y' DHHS F'F.:]:C)R 'T'O
,:'/, '", ...[ ,'.' ~,)[~r~
i:,..i.,I, :[tqSPE[;'I'ION, THIS t::'IERMIT ZS.."'~:',.,,~,~c'n,, I:::OR "['HIE F'LANNE:D 4
S:[I',IGLIE I::'AM]:I_Y D41~'L.L]:NG C)IqL..Y AND EXF".:RES 01"4
((:)v,u"m?P) T'
(::;IE R"I" :i: F' Y T H A"I":
2. :I'. ~,~,:i.:l.:!, :i.n.stall the csystem :i.r'~ acc:or'dar'~ce v,.',i'Lh al:[ MOA cc!des .¢:~tl"~('.:!
al']d J.r"~ (:c)ff~[)].J. ar!cc-:, v,~i'l:..h thG:, dE,~J..q.'l'! c:f'::;.t(~::!'iL~ Of th:i.s
:3,, :i: ~iJ.:!.:l.a(::lher'(.:-:~ t.~::~ a].]. M[]A ar!d .~!H:.a't:.e~:~ c),*' Alaska r'eqLt:i.r'emer'~t.s 'for' 't. he set back
c,r' any adjacerrL c:-r' near'by lc, t.,
ePm:i.t J.s valid for' a max:i, mum of 4 bedr'c, oms,,
}'1~x.-' .,:::apac:i.'Ly (3{ {. h,'.:.;:, 'Lota]. s'ystem 5.~i 4
DATE;
/ --
E R F:' R Z Z IE S
SCALE
/.
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:~ ~~ ~ ~ DATE
LEGAL DESCRIPTION: ~' ~ O~~~wnship, Range, Section:~,~b~ ~ SLOPE
1
2
3
5
8
9
WAS GROUND WATER
10
ENCOUNTERED? ~'"'""~
s
11 L
IF YES, AT WHAT '"') ~ ~./' O
DEPTH? /~/~'c~- ~' p
12 __// .~/~,--E
13 '~-' t~onitorin,? ¢~'"- /
/
Gross Net Depth to Net
Reading Date Time Time Water Drop
14
15
16
17
18-
19-
:o-
PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER __
TEST RUN BETWEEN ~ FT AND FT
COMMENTS / /
PE O .. · ~Y/ ! / /.~"- ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDE CT ON THIS DATE. DATE:
72-008 (Rev. 4185)
by
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK,-ALASKA 99567 · TELEPHONE 688.2759
OWNER OF LAND ~/,.~DT'~'L4. C az,,]~ ~"'
ADDRESS f/) ' /~' "]70,~.../0 ~
LEGALDESCRI~ION ~O~ I i~K 3 0~ Z~o~ ~
DATE - Started Ended ~
PE~IT NUMBER ~q ~ / ~ 1
DEl'TH OF WELL /O~0
STATIC LEVEL OF WATER Fr.
DRAW DOWN FT.
GALS. PER HR j6~0
KIND OF CASING 6 ~
KIND OF FORMATION:
From 0 , Et. to c~ Ft.
From ~'~ Ft. to ~ Ft.
From. ~ Ft. to [~ Ft.
From Ft. to Ft.
From' Ir' Ft. to .~0 Et,
From Ft. to Ft. ~0 ~.~
From.~ Et. to ~6 Ft. ~0
From ~& Et. to ~& Ft.
From Ft. to Ft.
From ~ Et. to' ~J Ft,
From' Ft. to Ft.
From~J Et. to t~ Ft.
From I0~ Et. to IoY Et.
From Ft. to Ft.C~
From I0~ Et. to I I~ Ft. ff~R0
fromm/0 Et. to /&O Et'.
From Ft. to Ft..
From;
From __
Frmn
From
From;
From
From
From
From
From__
From
From__
From
From ,__
From
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From'
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Ft. to,__
Ft. to
Ft. to
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Ft.
Ft.
Ft. to FL.
~Ft. to _
Ft. to Ft.
Et. to__Et
Et. to Ft.
Et. to Ft.
Et. to Ft.
Ft. to Ft.
Ft. to. Ft.
Et. to Ft.
MiSCL. INFORMATION:
I
To
DRILLER'S NAME
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COSA Checklist_June 2022
COSA Checklist
Legal Description: Parcel ID:
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
COSA Checklist_June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F.ENGINEER’S COMMENTS
G.CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Phone
Engineer’s Printed Name Date
C&M ENGINEERING
CHARLES BALZARINI, PE 4/15/24
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MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # (~[ ~?~- C~ \ - ~,~.~ HAA# ~¢~,1 ~ ~c~'~L-\°~c~'
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Lot I; Block 3; 0ve~ook Estates
Location (address or directions)
Paramount Drive
(b) Property owne'~" C~rl Disotell
Mailing Address P.0.Box 770210
(c) Lending Institution
Mailing Address
Telephone:(home) 694-5797
Eagle River, Al~ka 99577
Telephone
Business
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here ~(if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 Eagle RTver Loop Road
Eagle R vet, Alaska 99577
2. TYPE OF RESIDENCE
Single-Family [~3X Number of bedrooms 4
3. WATER SUPPLY
Individual Well []X Community [] Public []
Note: .f community well system, must have written confirmation from the State. Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirm'ation from the State Department of Environmental
Conservation attesting to the legality and status.
72~25 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by myseal affixed hereto and as of the validation date shown below, I verifythat my investigation of this ·
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional .end adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm 17U~4 F..agi~, ~,~;cr L~ ~d Nc. 3~ Telephone
Ad dress Eagle River, Alaska 995~
Date
6. DHHS APPROVAL
Approved for/~f*~-+) bedrooms by
Approved /~ Disapproved
Terms of Conditional Approval
Conditional
Date
The Municipality of Anchorage Department of Health and Human'Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registere~ in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS 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.
72~25 (Rev. 7/88) Back Page 2 of 2 ·
A. WEL, DATA R E C £ I V E D
Well Classification 3, tO ~; fl~'_ ~ ?v~t l ~
Well Log Present (Y/N) y Date Gompleted ~/~
Total Depth [~0/ Cased to ~Og-~Depth of Grouting
MUNICIPALITY OF ANCHORAGE (MOA)
lUNiCiPA.,Health AUthority Approval (HAA)
..... ~u ~K~I~I~,~E a R UARY 1984
"~,~,~NTA]~ SE~RWC~s D~,4~744
..... j:d~g Legal Description: ~0~;
If A, B, C, D.E.C. ApProved (Y/N)
Yield [ ~O o~J~
Pump Set At L) (~/'
Sanitary Seal on Casing (Y/N) ~
Depression Around Wellhead (Y/N) /NJ
Static Water Level (¢ '~
Casing Height Above Ground
Electrical Wiring'in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ./ O0 -/-
To Nearest Edge Of Absorption Field on Lot ! O0 ~
; On Adjoining Lots /
; On Adjoining Lots / O0 "4-
To Nearest Public Sewer Line ~/~ To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ~
Water Sample Collected by
Water Sample Test Results
Comments -~, O A c~/td~i
B. SEPTIC/HOLDING TANK DATA
Date Installed ~' ~f Size I,Q~O
Standpipes (Y/N) Y Air-tight Caps (Y/N)
Depression over Tank (Y/N) /~
Pumping/Mainten. ance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N) ~/1/~
No. of Compartments
~ Foundation Cleanout (Y/N)
Date Last Pumped
'for
Temporary Holding Tank Permit (Y/N) ~/~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments ~_,~)
To Building Foundation
To Disposal Field
fO0 't
72-026 (Rev. 7/88) Fronl Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~/~-- ~ ~ -
Width of Field B(2 '
Square Feet of Absortion Area
Depression over Field (Y/N)
Type of System Design
Length of Field ~-Z¢ ~
Depth of Field ~
Gravel Bed Thickness z~
Statndpipes Present (Y/N)
Date of Last Adequacy Test
Results of Last Adequacy Test
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 A. rea .
; On Adjoining Lots $¢ ¢::E-
To Cutback (if present)
/OO
To Property Line ( 0 / ¢
To Existing or Abandoned System on
Comments
D. LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test.
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 and HAA guidelines in effect on the date of this
inspection.
S & S ENGINEERING
Signed
1/034 Eagie Rivu~ L,~i;, R,~,~ I'~io. 204
Company Eagle River~ Alaska 99577
MOA No. ~- /~F~¢~
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2