Loading...
HomeMy WebLinkAboutNORTH WOODS UNIT 4 BLK 15 LT 12 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~L,~ ~OO74 PID Number: Name: No,mt-kuuo,~J.~ 1¢~4. Wastewater System: ~New ~ Upgrade Address: ~ ~. ~[ ~ ~ ~ ~ ABSORPTION FIELD Phone: No. of B~rooms: ~ Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRIPTION so,, Rmingo. 3 Total Depth fro~ original grade: ,~ot ~ ~ Block: Subdivision' Depth to pipe bottom from original grade: Gravel depth bene~h pipe Township: J Range: Section: Fill added above original grade: Gravel length: WELL: ~ New ~ Upgrad~; Gravel width: ~ Numberof lines: Oi~t~ncebetween~ines: ~ (~a~) Ft. ~ ~' Ft. Classification (Private. A.B C):~ ~ ~~Cased To: Total absorption area: Pipe material: . . ~ / Ft. ~t. ISTo Se, Ft. Driller: ~ ~' / Date Drilled: Static Water Level: Installer: Date installed: J Casing Height Above Ground: YieJd~ I Pump Set at: ' ~ GPM I Ft. Ft. TANK SEPARATION DISTANCES eSe.tic ~ Holding U S.T.E.., TO Septic Absorption Lift Holding ~ublic/Private Manufa~rer: Capacity in gallons: From Tank Field Station Tank Sewer Lines Number of Compartments: w., Surface ~ Wate~ *~ ~' +~' LIFT STATION LineL°t ~ _' ~ Foundation ~ ' I~ ~ ~ "Pump on" ~evel at:~ level at: High water alarm at: CurtainDrain ,~* +~' -- P~ JElectricallnspectionsperformedby: Remarks: M~ 5Y5~ '~s~'~ F~ BENCH MARK Loc~ion and Description: I Assumod Elevation: EN~'~¢EAL Inspections performed by: ~~, Department of H es app va Reviewed and approved by: ~ v ~2 72-013 (Rev. 9/91 ) MOA 25 Permit No. ~/9~00~, Page Z, of Z., Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: PID No.: O~1 °6~r°l 1 ENGINEER'S SEAL 72-013 A (2/91) MOA25 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930074 DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC. OWNER NAME:NORTHWOODS INC OWNER ADDRESS:709 W INTERNATIONAL APT. RD ANCHORAGE, AK 99518-1123 PARCEL ID:05106401 PAGE 1 OF 1 DATE ISSUED: 4/27/93 EXPIRATION DATE: 4/27/94 LEGAL DESCRIPTION: NORTH WOODS UNIT IV BLK 15 LT 12 ~ LOT SIZE: 24049 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: THE ATTACHED APPROVED DESIGN. 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). THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS 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 THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY: .... DATE: DATE: HENRY WILSON 9601 BUDDY WERNER DR.: ANCHORAGE, AK 99516 (907) 346-2000 Consl En ngineers CHARLES A. LANDERS HC83 BOX 192-A, MYRTLE DR. EAGLE RIVER, AK 99577 (907) 694-9098 April 15, 1993 Municipality of Anchorage On-Site Services Division PO Box 196650 Anchorage, AK, 99519 Attn: John Smith, P.E. re: Submittal for Septic Permit, L12 B15 Northwoods Sub Gentlemen: Attached are plans for a new wastewater absorption system for the subject lot. The lot previously has had two soils tests performed which are the basis for the design. Although we were not the engineers which performed the tests, these tests did meet the MOA requirements for water monitoring. The soils tests do not indicate a presence of ground water, but the owner is wishing to be most conservative' and considering the history of ground water issues in the subdivision, he wishes to install a bed system. Although the normal requirements for area around the test hole require 60' diameter coverage, and since the test holes indicate consistent soil characteristics on the lot, we ask for approval as shown on Drawing 93-Sl-05-4. If you have any questions, please contact me at 694-9098. Respectfully submitted, Chuck Landers Constructing Engineers ABSORPTION SYSTEM DESIGN 7' AI. SZTE PIP-N--PROPOSED ABSORPTION SYSTEM DETAZLS OF BED ABSORPTION SYSTEM LOTI2: BLOCK 1~, NORTH~OODS SUB, ED FOR. PAUL MEYERS 688-1236 PO BOX 670485 CHUGIAK, AK, 99567 =I~' ~UCXZNG ENGINEERS346-2000 BUDD~ WERNER DR 694-9098 I ~CHORAGE, AK, 995~6 DRA~N BY CAL 4-10-93 DRA{iING # 9~-SI-05-4 ABSORPTION S¥STE~ DESIGN DETAILS ABSORPTION AREA CALCULATIONS: 3 Bedrooms x 150gpd/bedroom = 450 gpd (soils rating : 0.3 gpd/sf) 450 gpd + 0.3 gpd/sf = 1500 sf area Bed design: use 30'W x 50'L bed (minimum) w/ 5 ea 4" perf pipes @ 6' centers, each 44' in length. IMPACT ON ADJACENT LOTS: This lot is served by a public water system. The proposed absorption system is located such that there is no adverse impact to any adjacent lot. There are no wells, private or public, within 200 of the proposed system. DESIGN DETAZLS--PROPOSEDABSORPTiON SYSTEM BED ABSORPTZON SYSTEM LOT 12, BLOCK 15, NORTHWOODS SUB, PREPARED FOR: PAUL MEYERS 688-1236 PO BOX 670485 CHUGIAK, AK, 99567 NOT TO SCALE CONSTRUCTING ENGINEERS346-2000 9601 BUDDY WERNER DR 694-9098 ANCHORAGE, AK, 99516 DRAWN BY CAL 4-10-93 DRAWING # 93-S2-05-4 ~1 DEPTH? ~ ~ f7 lB , ~ ~-~r~T ON THI~ DATE. DATE: DEPAR.TMENT OF HEALTH & HUMAN SERVICES LOG -- PERCO~TION TEST OA~E PERFORMED: SLOPE SITE PLAN I 2 3 4 6' 6- 8 g 10 11 12 13 14 16 16 17 18 COMMENTB WAS GROUND WATER ENCOUNTERED}' IF YEE, AT WHAT DEPTH}' Oeplh lo Wmf Mar,~,,~,,,/ Reading Date OrOll Nil Oal~th to Nat Time Time Wltlt Drop PERCOLATION RATE "~"'~ (m,nuta~'tncn) PERC HOI, E DIAMETER ..... TEBT .UN BETWEEN ~FT AND ~F~ ~,~ ~ ~ ~0~/~)~ ~ ,,~'.~ /~. ......... .... PIII~FORJ,AED BY: /'~yg,Y _ ~' (A')/~ ...... I~ ..~ CERTIFY THAT THIS TE$? WAS PERFORMED ACCORDANCE WiTH ALk STATE AND MUNICIPAL GUIDELINE5 IN EFFECT ON THIS DATE, DATE; I I' ~ ~'~ ~ I P.O. b~9( 6650 ANCHORAGE. ALASKA 99502-0650 (9071 2o ~411, T('./;'~ Y K?,70 WL E S ,,Is, v p/~ DEPARTMENT OF HEALTH & HUMAN SERVICES January 10, 1986 TO: Permit Applicant Subject: Permit # 850343 Lot 12 Block 15 North Woods Subdivision #4 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1985. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the instal.lation of the on-site sewer system the original as-built inspection report(three part form) must be sene to this office for review and approval,and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Susan E o Oswalt Program Manager On-site Services SEO/ljw eric: Copy of Permit Perm~!' Depar~en~ .~ Health and Environmenaa£ 825 Street, Anchorage, AK. 264-4720 * * * HANDWRITTEN PERMIT * * * WF.I~L AND/OR ON-SITE SEWER PERMIT Type of Soil Absorption System Is: Trench: / Drainfield: Seepage Bed: Holding Tank: Maximum Number' of Bedrooms: ~ Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is:' DEPTH,~' ~D'~/i~"G ' LENGTH . · RAVEL DEPTH 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 * * ?ermit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number )f residences that' the well will serve. · * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection.and approval by this departm~ ~ill be subject to prosecution. ~inimum distance between a well and any on-site sewage disposal system is 100 f~ for a private well or 150 to 200 feet from a public well depending upon the typ~ Df 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. Dther requirements may apply. Specifications and construction diagrams are ~vailable to insure proper installation. * * * PERMIT EXPIRES DECEMBER ~1~ I 9 8~'~* * * I 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 that 3.bedrooms. Signe~: Issued by: ~- Applicant Date: SWP/024 (1/81) PERM I T NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT F'HO NE: -EGAL DESCRIP: _CT SIZE: ~AX BEDROOMS: DEPARTMENT OF' HEALTH AND ExIVIROIXIMENTAL PROTEC.TION CC) ~-\,~ 8'25 L. STREET~ ANCHORAGE~ AK 99501 ~ 4-4Z~0 S~ZWER F'EF-4:r~i I l- BALTIC BUILDERS P.O. BOX 774089 EAGLE RIVER, AK 688-3751 995'77 SUBDIVISION: NORTH WOODS #4 SECTION:.) '.~ TOWNSHIP: 15N 24049 (SO. FT. OR ACRES) LOT: 12 BLOCK: 15 RANGE: 1W -isted below are the options available to you in designing your septic system. Choose the.option that best ~its your site. -FRENCH )EPTH TO PIPE BOTTOM (FT.) 4.0 ~RAVEL DEPTH (FT.) 10.0 'OTAL DEPTH (F'T.) 14.0 ;RAVEL WIDTH (FT.) 2.5 iRAVEL LENGTH (FT.) 60.0 ~RAVEL VOLUME (CU. YDS. ) 58.4 ANK SIZE (GALS) 1.~000.0 ** (]IL RATING (SO. FT../BR) 397 BED W. DF~IN 4.0 4.0 0.5 3.5 4.5 7.5 27.0 5.0' 52.0 129.0 ** 52.0 95.6' 1~000.0 ** 1,000.0 ** 307 597 ** GRAVEL L. ENG'I"H > 75 FT. REQUIRES MULTIPLE RUNG (NOT EXCEEDING 75 FT. EACH) *~ 'TAI',tI< MUST HAVE AT L..EAST TWO COMF'"''AR ........ TMEN ~S certify that: 1. I am (amiliar with the requirements ~o~ on-site sewers and wells as set ~orth by the Municipality of Anchorage (MOA) and the State o( Alaska. 2. I will install th~ system in accordance with all MOq codes and regu].at~ons~ and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements ~'or the set back distances ~'rom any existing well, wastewater disposal system or public sewerage ~yStem on this or any adjacent or nearby lot. 4. I understand that this permit is valid ~or a maximum of' 3 bedrooms and any enlargement will require an additional permit. A L. IFI' STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES~ ~EN (1) AN ELE(]TRICAL PERMI~ AND INSF'ECTIO~ MUST BE OBTAINED; (~) AS-BUILI"S ~U... NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (5) THE .EC'T'RICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. ___ , ..... ~ .......... DATE: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 g Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST ~SOI LS LOG [~'~PPERCOLATION TEST PERFORMED FOR: '~t~['--"~'"~.C--~ LEGAL DESCRIPTION: ! J~'~ 1 2 3 § 7 10 12 ~3 17 20 COMMENTS PERFORMED BY: 72-008 (6/79) DATE PERFORMED: ~ SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT )EPTH? Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE (minutes/inch) TEST R~UN BETWEEN ~'~ ALASKAN ENGINEERS AND SURVEYORS P.O. BOX 875144 · WASILLA. ALASKA 99687 ~. (907) 376-3667 Bus. PERCOLATION TEST DATA FORM PERCOLATION TEST DATE: LOCATION: 1~>~. ~ '~L ~,~,-' · ~S~ ~0~E ~0.: PERCOLATION TEST BY: ~-L~--c~' DEPTH~ INCHES SOIL TEXTURES · . _ Drop In Pe~cola~ . Time Measure- ~ ~qater tlon Rate, Interval ment Level- Minutes TIME Minutes Inches Inches Per Inch REMARKS PERCOLATION RATE = MINUTES PER INCH. / llnlCllilalltyo 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit ~: 840248 January 31, 1985 TO: Permit Applicant SUBJECT: Lot 12 Block 15 North Woods Subdivision #4 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984o Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for dOcumentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as-built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Si.ncerely, ~~Ba~or Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 PERMIT NO: DI=ITE ISSUE[:,: KiPPL I C'FINT: f'"~ D D R E 'Z','."_-',: CONTACT PHONE: LEGAL B,E:.SCR I F:': DEPARTMENT Oh FIERLTH AND ENVIROf',IMENTFIL h?;~:OTECTION 825 L STREET., ANCHOF.:RGE., RK 9950::L 254-4720 84 ~;.'!~ 2,4-8 04,..";.z-: 7 / 84 L.O]" S I ZE: MR:=": BEDROOMS: S;"I-E;',,,'Ei;I~,I L... SKAGGS C:ONST.. P.O. BOX E;';'~'06:;9 ¢S88""'2831 : ::' ', ' ': - NCIF.!THI.,.I00[:' ':";LIB 'ii' ..... LIE,[. I, I.., I L fi: - SECTION: 3 TOt. qNSHtF': i5N 24045~ ,::SD. F'T. OR F:tCRES) LOT': RANGE BLOCK: L. ISTED BELO.t,.I F:IRE THE OPTIONS AVFIILABL. E 'T'O YOLI IN DESIGNING YOUR' SEPTIC '..S'.r'STEM. CHOOSE THE OPTII.']N THAT BEST FITS '¢OUR S;ITE. DEPTH TO PIPE BOTTOM (FT.) 4 0 GRR',,,'E[.. DEPTH (FT.) ~_'.S~ 5 TOTAL. DEPTH <Ff'. ) 4. 5 GRFtVEL WIDTH ,::F'T. ) 2':.-".. ~:~ GRAVEl... LENGTH ,::FT. ) 45. 0 GRRVE-L VOLt..IME (CU. 5.'DS. ) 7Z;8. 2.: TANI< SIZE <GALS) ::t.., 080. 0 '.iSOtL. RATING ('.i..:]t.q. FT. ,.."BF.'..':, 228 4. .I.. 5.0 5.0 t]:2. 36;. 000. 250 GRAVEL LENGTH .> 75 FI". REQUIRE::.-]; MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) TANK MUST HAVE RT LEAST TI40 COMF'I:::IRTME]'.~T~-.:; I CERTIF'¢ TI-IRT: :.!... I AM FAMII_IRR WI].'H ]'HE REQUIREMENTS FOR ON-SITE SEWERS AND P.IELLS RS SE]'' F'ORTH B'¢ THE MUNICIPRLIT~' OF ANCHORAGE (MOl=t) AND THE STR'TE OF FILASKA. 2. I t4ILL INSTALL. 7'HE S;'-r'STEM IN ACCORDANCE I.,.IITH ALL MOA CODES; AND REGULATIONS., AND IN COMF'LItqNCE I.,.tITH THE DESIGN CRITERIA OF 'THIS F."ERMIT. ]% I 14It._t... ADHERE TO AL.[.. MOA RNt'., '.S'TRTE OF' ALASKA REQUIREMENTS FOR THE S;ET BACK DISTANCES Ir:ROM I::tf.,l'¢ EXIS;TIf.4G NELL, I,.IRSTE.WFITER DISPO:'.:;RL S"r'STEM OR PLIBLIC SEI.4ERRGIE S"r'STEM ON THIS OR AN'~" ADJACENT OR NERRB'¢ LO'f': 4. I UNDERSTRI'-,ID THI::tT THIS; PERMIT IS VI:::IL. ID F'OR R MAXIMUi'd OF ]: BE[:'ROOMS AND FIN'¢ ENLARGEMENT klILL RE6!UIRE FIN R[:,DiTIONRL PERMIT. IF' R LIFT STATION IS INSTALLE[:' IN AN AREA COVERED BY MOR BUILDING CODES;, THEN ':.'l) AN ELECTRICAL: F'ERMIT AND It'..ISF'ECTION MUST BE OBTRII",IED.~ (2) AS-BUILTL-] 4ILL. NOT BE RPF'ROVED P.tITFIOU].' FiN ELE:CTRICRL INSPECTION REF'ORT.~ FIN[:, (~:) THE STEVEC3. 55-': ,GOS" - CONST.(,A SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERCOLATION TEST .E.PORMED POR: LEGAL OESCR,P~,ON: ~'/- /2 ~/~ /5-- SLOPE SITE PLAN DEPTH (FEET) 6- 7 8 9 10- 11 1'2- 14 16 17 18 19 20 COMMENTS WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop ,~;.~ /~ . V3' .o~/ PERCOLATION RATE -~ -~ · ~ [minutes/inch) TEST RUN BETWEEN __~.~ FTAND 4~f , FT 72-008 (6/79) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # 1, CERTIFICATE OF HEALTH AUTHORITY. APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day.phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA~21 5. 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 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 ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. ] Name of Firm C4~-~,~-~_~-~ ~-~e_~ Phon~- ~~.~9~ Address Engineers signature /~'Z~~ Date DHHS ~IGNATURE J Approved, for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: The Municipality of Anchorage Department Of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in th~ 8rate 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 DH H8 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 professionul engineer's work. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~-~% 15~5 ~c,~-~o,~ //~J~-4 Parcel I.D. A, Well Data ©cj I oG Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to FROM WELL LOG Driller Casing Wires properly protected (Y/N) .g.p.n AT Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: .g.p.m. Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line Date of sample:.//// · On adjacent lots ; On adjacent Pots Public sewer manhole/cleanout Petroleum tank Nitrate Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size I o o o ~ Compartments Foundation cleanout (Y/N) ¥ Depression (Y/N) k) r~ Alarm tested (Y/N) ~ <- ~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~J ~ To property line ~' Sudace water/drainage On adjacent lots Absorption field Foundation Water main/service line 72-026 (3/93)'Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) Manufacturer ~'~ Manhole/Access (Y/N)_~ ~" Level at ~sted Surface water D. ABSORPTION FIELD DATA Date installed ~"~,t_'~ ts.~ Length ~'1 -~ Width Total absorption area ~ 57~° ~'~ Date of adequacy test ~g'~J Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/FF) o. :~ System type ~' ~'~ Gravel thickness ~ Total depth Cleanout present (Y/N) '/ Depression over field (Y/N) Results (pass/fail) -- for A),~ After test ~ ~ If yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Sudace water Curtain drain ~- ~ co ' On adjacent lots -+Z~oo' Property line ~ ~ ~ To existing or abandoned system on lot Cutbank +~ co~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I ce~'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date ~ _ HAA Fee $ / Date of Payment Receipt Number 72-d26 ~* ~ck Waiver Fee $ Date of Payment Receipt Number