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Home My WebLink AboutNORTH WOODS UNIT 3 BLK 12 LT 6 Municipality of Anchorage Page _~._~ of DEPARTMENT OF HEALTH AND HUMAN .SERVICES ENVIRONMENTAL SERVICES DIVISION' P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-47.44 On-Site Wastewater Disposal Systdm and/or Well Inspection Report Permit Number: .~ H,J q b ~ o~ PID Number: Name: ~Upgrade c~o~, ~V ~ ~ ~4~/~ WastewaterSystem: D New Address: ~ ~ ~~ ~~ ~ ~7~ ABSORPTION FIELD Phone: ~ No. of Bedrooms: ~o~A~ ~. ~'I ~ D DeepTrench ~ShallowTrench D Bed D Mound ~ Other LEGAL DESCRIPTION soil Rating:/. ~ GPD/Sq. Ft. Total Depth~from. ~°riginal/grade: Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth beneath pipe 'Township: Range: ~ Section: Fill added above original grade: Gravel length: I Number of lines: Distance betw~n lines: ~ New ~ Upgrade Gravel width: ~ Ft. / '~ Ft, Classification (Priva~~ Total Depth: Ft. Cased To: Ft. Total absorption area:~ SQ. Ft.: Pipe~material: ~ ~/~ Yield: Pump Set at: Casing He~ GPM Ft. ~X ~ ~/N¢¢ TAN K SEPARATION DISTANCES ~Septic ~ Ho~ding ~ S.T.E.P. To Septic Absorption Lift Holding Public/Private Man~cturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~ ~ Mate~al: Number of Compa~ments: su,~c~ ' ~ LIFT STATION Lot ~/~ Size in gallons: J M~er: "Pump on" level at: "Pump off" ie~h water alarm at: Foundation ~'~ -- ~ __ ~ump Make & M°del I Electrical 'nspecti°ns Ped°rmed bY:~ Cu~ain Drain Location and Description: I Assumed Elevation: ENGI~AL Department of Heal~ and Human~Services approval Reviewed and approved by_ Date: ~-/-~[ 72-013 (Rev. 9/91) MOA 25 WASTEWATER DISPOSAL SYSTEM LOT 6, BLOCK 12, NORTH WOODS III PRE-EXISTING BLUFF LINE CREATED BY FILL GREEN --- S.T, 0% I ~ ~E~ FCD o A B 3 BDRM SFD )~BM DISTANCES A - C = 11,0 B - C = 62,4 A - D = 48,4 B - D = 77,4 A - E - 75,1 B - E = 48,1 A - F = 75,3 $ - F - 4¥,0 hWATER GARDEN DRIVE NBTES: i. EXISTING SEEPAGE BED RETAINED FOR FUTURE USE. 2. D]VERTER VALVE INSTALLED TO ALLOW FLOW : TO EITHER ABSORPTION SYSTEM. 3, USED 4' PVC SEWER DIVERTER VALVE, MODEL DV84. 4, BENCHMARK IS TOP OF SILL AT BACK DOOR, ~REPARED FOR: ROY CROSS/CAROLYN MCPHEE-CROSS C/O REMAX OF EAGLE RIVER EAGLE RIVER, ALASKA 99577 KND E'NGINEERING B0441 PTARMIGA~/SLVD EAGLE RIVER, AK, 99577 (907)696-6HI/Fax (907)696-8]]] WASYEWAT iDi SPBSAL SYSTEM LOT 6, BLOCK 18, NORTH WBBDS III PRBFIKE VIEW o EX]STING J,O00 GAL SEPTIC TANK W 5' M]N, FINISHED GRADE UNCLASSIFIED FILL FABRIC ANB 2# ]NSULAT]BN~ SCREENED RBCK 60' BOTTOM OF TESTHOLE ~l BOTTOM OF TESTHOLE fib 2' MIN. PREPARED FOR', ROY CROSS/CAROLYN MCPHEE-CROSS 23005 GREEN GARDEN DRIVE CHUGIAK, ALASKA 99567 KND ENGINEERING 20441 PTARMIGAN BLVD EAGLE RIVER, AK, 99577 (907)696-61]l/Fo, x (907)696-811] DATE: 7/19/96 SCALE: bITS AS-BUILT INSPECTION PAGE 3 OF g MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PERMIT NUMBER:SW960200 DESIGN ENGINEER:KND ENGINEERING OWNER NAME:CROSS ROY LEE & OWNER ADDRESS:23005 GREEN GARDEN DR EAGLE RIVER, ALASKA 99577 PARCEL ID:05173215 PAGE 1 OF 1 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT DATE ISSUED: 7/16/96 EXPIRATION DATE: 7/16/97 LEGAL DESCRIPTION: NORTH WOODS UNIT III BLK 12 LT LOT SIZE: 27000 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST 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 (iSAACS0) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS RECEIVED BY: DATE: DATE: 'MND ENGINEERING 20441 PTARMIGAN BLVD. EAGLE RIVER, AK 99577-8736 (907)696-6111/FAX (907)696-8111 July 3, 1996 Municipality of Anchorage Dept. of Health & Human Services, On-Site Services Section P. O. Box 196650 Anchorage, Alaska 99519-6650 Subject: Lot 6, Block 12, North Woods III - Sewer Upgrade Gentlemen: Recently we performed an adequacy test on the sewer system serving the above residence. This system was able to accept 450 gallons of water in a little over 4 hours. However, since the water level in the monitoring tube was 10.5% we were unable to pass the system. On June 27, 1996 we excavated into the bed and concluded that the system had been operating above the top of the lateral pipe for some time. We then excavated two testholes adjacent to the system. The results of these tests and percolation tests are attached. We have designed a wide drainfield to take best advantage of both the drop from the septic tank and the excellent shallow soils. Although groundwater did not appear during the monitoring period, our experience is that the presence of groundwater is likely during seasonal fluctuations. The existing septic tank will be exposed and inspected during the installation of the new field; a replacement tank will be installed if the original tank is damaged.. The new tank, if necessary, will be installed at roughly the same elevation as the original to allow for gravity disposal into the trench. Additional fill will be imported to provide at least minimum cover over the system. This lot is served by public water. There is no public well within 200' of the proposed installation, nor any private well within 100'. There are no known curtains drains within 50' and no surface water within 100'. This upgrade will have no adverse effect on neighboring lots. If you have any questions, please contact me at 696-6111/FAX 696-8111. Respectfully submitted, ring Kenneth M. D attachments: On-Site Well and Sewer Application Wastewater Absorption System Details/Site Plan Soils Log/Percolation Test WaSTEWATER DISP[BSAL SYSTEH LOT 6, BLOCK ]2, NORTH WBB~)S III VACANT SEWER BLUFF L][NE CREATES BY FILL ~ ~ ~oy. BDRM SFD N WATER GREEN SEWER BES1GN 3ETATLS 1. 3 BORN X ]50 GPO = 450 GPD FLOW. 450 GPB/I,~ GPO PER SQ. FT. - 375 SO FT. ABSORPTION. 3, 375 SQ. FT,/5' ~/]DE X ,78 R,F, (LS' GRAVEL) = 58.5' LONG. 4. TOTAL DEPTH [SF FIELD IS 5 EXISTING SEPTIC TANK TB 3E INSPECTED FOR INTEGRITY AND REPLACED IF DAMAGED. REPLACEMENT TANK WILL BE 1,DO0 GALLONS AND PLACED AT SANE ELEVATION AS ORIGINAL 6 ADDITIONAL FILL ¥1]LL BE PLACED OVER DRAINFIELD TD CREATE MINIMUM R4~ COVER. INSTALL R' HD BURIAL FOAM INSULATION E]VER DRA]NF]EWLD PREPARE3 FOR: ROY CROSS/CAROLYN MCPNEE-CROSS C/O REMAX OF EAGLE RIVER EAGLE RIVER~ ALASKA 99577 KND ENGINEERING 20441 PTARMIGAN BLVD EAGLE RIVER, AK, 99577 (907)696-GJ~l/Fcx (907)696 8111 Municipality of Anchorage DEPARTMENT Of HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: C~ ~'O[~ ~P~¢~ ~ DATE LEGAL DESCRIPTION: ~o ~ ~ ~LO~ J~ ~0 r~ Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS ~/~ ~ SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED7 s IF YES, AT WHAT ,~d (~ DEPTH?. _ P E Depth to Water Alter .~ Monitoring? Date: /' ! Gross Net Depth to Net Reading Date Time Time Water Drop I I,,~,~-'14o 11 '~ '- ~I/S ~ ~/~ . ~.,~ II ~g I ~/~ PERCOLATION RATE __ tminutes/inch~ PERC HOLE DIAMETER La. ,'/'/7 . / TEST RUN BETWEEN ~ FT AND ~ ¢ FT ACCORDANCE WITH ALL STA~ND MUNICIPAL GUIDELINES IN EFFEOT ON THIS DATE' DATE: 72-008 (Rev. 4/85) WAS PERFORMED iN Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: L~' ~ ~J/L' 12-- 1~c'7~'w~.t- Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13- 14- 15- 16 17 18 19 20 COMMENTS ~,~ ~,,~_~ .~z- .~ SLOPE WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT DEPTH? ~ P E SITE PLAN Monitoring? Gross Net Depth to Net Reading Date Time Time Water Drop I ~.- ~z- ~ / ~ '5' '7 -- /~//~.- PERCOLATION RATE J' ~ TEST~UN~ETWEEN /': __ (minutes/inch) PERC HOLE DIAMETER __ FTAND .2._, ~' FT /t ACCORDANCE WITH ALL STA~ND MUN'~I~A-L GUIDELINES IN EFFECT ON THIS DATE' DATE: 72-008 (Rev, 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST ,r~L,o ~-~. / :z-_ Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS SLOPE WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? P E Depth to Water After Monitoring? Date: SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop ~._ 5'-~ 7 ..~ ,5//.>. i, /F/ PERCOLATION RATE '~O (minutes/inch) PERC HOLE DIAMETER -- TEST RUN BETWEEN d~. O FT AND ~, Z) FT PERFORMED BY: ,~//~//J) ~.//~,/~/'/'~_~'-.'~/~'['~' I ..... ~ CERTIFY THAjT T~IS TEST WAS PERFORMED IN ACCOROA.CE W,TH ^,. SdEAND M.N~' GU'DEL'NES'" EFFECT O' TH'S DATE. DATE: '/ 72-008 (Rev. 4/85) ',' MUNICIPALITY OF ANCHORAGE M0h S'T 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 MAI LING ADDRESS LEGAL DESCRIPTION LOCATION NO, 0 J Well Absorption area Dwelling PEFMILNO' ~ DISTANCE TO: Corem ~ ~ ~r)+ b uii,F ~ Manufacturer G¢~C¢ Material S~~ No. of co~artments ~ Liq. capacity in gallons Inside length Width Liquid depth ~¢~ IF HOMEMADE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O z ~ Manufacturer Material Liquid capacity in gallons ~ Well Foundation Nearest lot line PERMIT NO. ~ ~ Top of tile to finish grad~ Material beneath tile Total e~ective ~bs~rptiop are~ ~ Length ;~ }~d~c~ Depth ~ inches PER~T N~ < h Type of crib Crib diameter Crib depth Total effective absorption area ' ~' ~ ~ilOing ,oun~tion ~t l,2/ , ~/~ / ~ DISTANCE TO:~ , ~ ~ ~ ~ ~ ~ ~ ~ ~, ~ Class Depth ~ ~ c~riller Distance to Jot hne ~PE~MLTN% ~ /' / ~ DISTANCE TO: ~l~ing foundation Sewer line ~eptic tank Absorpt~o~areg(s) . / OTHER PIPE MATERIALS I< '1 SOIL TEST RATING '¢ ~ ~ INSTALLER ~ REMARKS J i i ~/ co. I 72-013 (Rev. 3/78) MUNICIPALITY OF ANCHORAGE Department~f Health and Envlronmenta"~-~rouection 825 Street, Anchorage, AK. ~9501 264-4720 · C P * * * HANDWRITTEN PERMIT * * * Permit ~ ~~ ~0N-SITE SEWER PERMIT Applicant: . ~/' Mailing Address: Location: . ,~ hone Number: Legal Description: ~."~"',1~ ~/;~"~' ~/~%~"~-~-- LOt Size: Type of Soil Absorption System Is: Trench: Drainfield: Seepage Bed: ~ Holding Tank: Maximum Number of Bedrooms: 5 Soil Rating(sq.ft/br) /~- The Required Size of the Soil Absorption System Is: / __--- DEPTH ~ LENGTH ~_~--C)' GRAVEL DEPTH ~'- WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). · * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~O~ GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. · * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. · * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * * Z certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more tha~32edro~-~ SWP/024 (1/81) Date: [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 26~. ~.720 SOILS LOG-- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPT,QN: ~-'~ Z~ ';~'' ~ SLOPE [~/PERCO LATION TEST Russell L Oyster No. 4286-E 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O DATE PERFORMED: h~ 'SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES. AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE 1O m~U/*t}~.~ (minutes/inch) TEST RUN BETWEEN ~ FT AND FT ~ '~' MUNICIPALITY OF ANCHORAGE DEPARTMENT oF'H'E/~'~.~r~'~ I~ U'~-~ERVICES_ ::~.':~,,':, Division of Environmental services : ~ ~}On~Site Se~ices Section .......... :"~95i9.6650 Parcel I.D. # ~-q' / - 7 ~ ,~ 1. GENERAL INFORMATION ~plete legal description. P.O. Box 196650 · ;'~ ':;CERTIFICATE OF HEALTH'AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ' HAA # ~o~ati6~~ (sit~ add'~ess or directions) . DaY phone address _.~dinn' agenc address Day phone Public sewer :: ': ~ ~ · ' %,i '/?/4 NOTE: If community wastewater system, provide written confirmation from State ~D£C ' , attesting to the lega/i~ and status of system. '. 72~ (R~. 1/91) Front MOA~I ~' .. ;~, =' STATEMENT OF INSPECTION BY ENGINEER "; As certified by my seal affixed hereto and as of the validation d;~e shown below, I verify that my investigation of this Health Authority Approval application 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. Name of Firm :~ ~-A,)Z:) '~-~,~ ~',,~ ~_~,~ . Date. DHHS Ken,eib ~. Cot a rooms ~.~; ' Date ,~'-/' ,,, ~' ~',... . ,'.~.~* ;- The Munm~pahty.of Aqchorage Depa~ent of Health and Human Se~ic~ (DHHS) i~ues Health AuthO~ ,~,pprov~l'~ifi~{~S 5a~ only upon the representations given in paragraph 5 above by an independent profess~on~ engm~r r~i~e~ in the State of Alaska. The DHHS does this as a cou~to purchasem of hom~ and their lending Jnsti~tions in order to ~tis~ ce~ain federal and state r~uirements. Employ~ of DHHS do not conduct inspections or anal~e data before a ce~ificate is issued. The Municipali~ of Anchorage is not responsible for errom or °minions in ~e profe~ional engineefs work. 72~25(Rev. 1/91) ~ack MOA~21 Healt~ Legal Description: A: WELL DATA Well type Log present (Y~) Total depth AT INSPECTION WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: ; Colle dby: B. SEPTIC/HOLDING TANK DATA : .... Date installed :~6-,~.- ~)~ Tank si~e ,//o ~ O' Number of Compartments -~-'_ · Cleanouts.(Y~ Z' Date of adequacy test _ AJ~t4.J Fluid depth in absorption field before test (in.); Fluid depth A (ins3 Minutes lfifei': Peroxide treatment (past 12 months) ('~/N) Results (Pass/FaiD ~ For If yes, give date ~" S Sewer/septic I~uilding fotmdatioti Surface water Curtain drain F. ~ adjacent lot~, Engineer's N~m~ MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLiCATiON FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. Genera~ Information Application Date 7~/~.~ (a) Legal De~crij~tio6 (include lo.t, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name ~ Applicants Address Telephone - Home Business (c) Applicant is (check one) Lending Institution ~ ; Owner/builder ~--~ ; Buyer ~--~ ; Other ~-~ (explain); ' (d) Lending Institution Telephone Address Address Telephon~.~ ~ 't/c~'~ ~" /c~b'~ ~ I~,E'~M*..ZS**,.~/ e, ~.. (f) Mail the HAA to the following address: 2. Type of Residence Single-Family~ Number of Bedrooms 3. Water Supply Individual Well~--~ Multi-Family Other (describe) 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 Di p,p.o sa.~. Onsite ~ Public ~ Community ~ Holding Tank ~ Note: If community well system, mus~ have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. .En$ineerin$ 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 ' Address Date DHEP Approval Approved for~.~ bedrooms Approved~__ Disapproved Terms o~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 PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURC}~SERS 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 Classification ~ Well Log P~esent (Y/N) Total Depth Cased to Static Water Level Casing Height AbOve .Ground Electrical Wiring in Conduit (Y/N) Sepa~a.tion Distances f~c~ Well: To septic/Holding Tank on Lot ~(30 ~- Legal Description: If A, B, c~z C, D.E.C. Approved(Y/N) Date Cc~Npleted Yield Depth of Grouting. Pump Set At Sanitary seal on Casing (Y/N) Depression A~ound Wellhead (Y/N) ; On Adjoining Lots To .~Ne:arest: Edge of Abs°r~tion Field on Lot ~ ~-- ; On Adjoining Lots To Nearest-P6bl~ie .S~wer Line To Nearest Public Sewer Cle~Cu'[/Manhole- To Nearest Sewer service Line on Lot Water Sample Collected By ~ Date Water Sample Test Results Cr~t~tents S E PT I C/Ja~I~:--TANK DATA Date Instal 1.e~d ,~/~/~ '~ Size /~.~ No. of Compartments ~ Standpi~s ~ ~Ai~-tight Caps~ Foun~atio~ Cleanou~) ~p~ession ~~-~')~ ~te ~st ~d ,~//~ , ~ Holding Ta~ High-Wate~ Ala~ (Y~) ~/~ ~ra~y Holding Tank Permit (Y~) ~p~ation Distan~s ~ ~ptic~olding Tank: To Water-Supply ~11 ~ ~ To ~ilding Foundation /~ / To Property Line ~ dD To Water Main/Service Line Course Comments To Disposal Field ' ~ ~' TO Stream, Pond, Lake, c~ Major D~ainage Receipt Date Paid: Amount: [Page 1 of 2] 2-15-84 Ce ABSORPTION FIELD DATA Soils Rating in AbsorptioN Strata Date Installed ~j~, Width of Field Length of Field ~ / Depth of Field . ~-zz Gravel Bed Thickness Square Feet of Absorptio~/~/~ea S~ ~_ _ ._ Standpipes P~esenF(~Y~ Depression over Field (Y~/ Date of Last Adequacy TestY/ Results of Last Adequacy Test /L/ / ~ Separation Distance from Absorption Field: To Water-Supply W~ll ~.~ ~-- To P~operty Line ~ To Building Foundation ~ ~D ~- To Existing or Abandoned System on Lot /3 /~%- ; On Adjoining Lots ~ ~ To Water Main/Service Line ~ ~ To Cutbank(if present) To Stream/Pond/Lake/c~ Major Drainage Course /0 To Driveway, Parking Area, o~ Vehicle Storage Area ~ Coparents D. LIFT STATION Date Installed Dir~nsions Size in Gallons / / MaD~ole,~ccess (Y/N) On" Leve~ at '~/~_/~ ~mp Off" Level at High Water Alarm Level at //-- Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Electrical Codes(Y/N) C~nts Meets MOA ** Check Permitted Bectrocm Rating Against HAA Request I certify that I have checked, verified, o~' conformed to all MOA HAA Guidelines in effect on the date of this inspection. Signed Company KB1/d5/s [Page 2 of 2] ApPLIFJ' !NT FILLS OUT UPPER HA -'.i ONLY Property Owner~ ~tJ ~(~,~'~'~ C.'-)~ (,~ '~-- ' Phone Buyer Address Zip ~ode Lending Institution Phone Address Zip Code Realty Co. & A~nt Phone Address Zip Code Street Locatim ~ ~)X~[/ Ty~ ~esl~nce ~ingle Family' g Hultiple Family No. of Sedrooms g ~ther Wat~ Supply ~' ~ividual A~ACH ,WELL LOG. A w~l log is required for all wells drilled since June 1975. ~mmunity For wells drilled prior to that date, give well depth (attach log if available). ~blic Utility ~r ?sposal ~ ~ Public Utility When Connected to Public ~t~it~ ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Dar ~.~ Inspector Inspector Inspector Inspedtor MAY&5 1983 "P..,~t 'COND,T,ONSOF ( ) CONDITIONAL APPROVAL* Soils Rating Date Se~uer Installed Well To Absorption Area Well Log Received ~f~'_~.~ Well to Tank Septic Tank Size 72.023 (31~)