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HomeMy WebLinkAboutNORTH WOODS UNIT 4 BLK 16 LT 4 . ' 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: ~'r~¢l ~ O I"/'~ PID Number: C)~ I - O/ol~ - Name:'~HO~~ ~.. ~ ~A~ ~N~m~ Wastewater System: ~New ~ Upgrade Address: ~"~ ~ ~w~ ~..~K ~ ABSORPTION FIELD Phone: ~'~ '--~OO No~of~drooms: D DeepTrench ~Shallo~Trench D Bed D Mound D Other LEGAL DESCRIPTION so, Rating: O, ~, GPD/Sq. Ft. Total Depth from origin~l~ - grade: Lot: Block: . ~ubdiv~ion: Depth to pipe boEom from original grade; Gravel depth beneath ipe Township; I Range: I Section: Fill added above original grade: I Gravel length: ~,5) Ft. ~ I ~ Et WELL: ~t ~w ~ Upgr~ Gravel width: Number of lines: Distance between lines: Classification~.~(Private, A,B,C): ~ ~Ft. Cased To: Ft. Total absorption~e~:~ SQ. Ft Pipe material: ~l~ Driller: ~ Date Drilled: Static Water Level: ~ installer: Date installed: Yield: ~ ~ Pump Set at: Casing Height Abo~e Ground: TANK , ~ G PM Ft. Ft. SEPARATION DISTANCES ~*septic D Holding ~ S.T.E.P. To Septic Ab~rption Lift Holding ~ublic/Privat~ Manufacturer: Cap~cityin gallons: From Tank Field Station Tank Sewer Lines ~ ~t~O¢ A~ '~t~ J Number of Compa~ments: SudaCewater ic~l~ i~c~ ~ ~ ~ LIFT STATION Lot ~ Size in gallons: I Manufacturer:~ Foundation ~ t J ~ t ~ ~ ~ "Pump on" level at: ~. High water alarm at: Cu~ainDrain dO,~~ ~ Io~J~ · ~tectrical Inspecti°ns Pe~°rmed bY: Remarks: ~Al~¢& ~o ~¢¢~ BENCH MARK Location and Description:  Assumed Elevation: Department of Health and,~umam~ Se~ices ~pprova~ '~,"~. ,.",~ Reviewed and approved by:.~¢¢~ ¢ /k~J J,~ Date: [17,,~' ' 72-013 (Rev. 9/91) MOA 25 Permit No. SW960179 2 2 Page of 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 _ LOT 4, BLOCK 16, NORTHWOODS S/D UNIT#4 PIDNo.: Legal uescription: 051 -064- 16 LOT 4 ~ v / A B ~~ · s~r x DBL2 28.0' 22.5 C01sc~ r' = ~o' 42.5' 17.0: / / MT1 42.5' 17.5: ~~ / co2 to2.o' 8o.o' SPRUCE LOOP ' ~ CO1~= ~00,8' - , MTtlCO~ / ST1 S, T2 -- FINSL GRADE~ MT~I~02/ 72-013 A (Rev. 9/91) MOA 25 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORMEI LEGAL DESCRIPTION: ~-~'~r L~f--~,~t'~L-K-" t.~,~O ['~ ~) ~% -~ ~ TownshiP,sLoPERange, Section: SITE PLAN I 2 3- 4 5 6 7 8 9 10 11 12 13 14 15 16- 17- 18- 19- 20- COMMENTS WAS GROUND WATER t ENCOUNTERED? ~- ~' IF YES, AT WHAT L DEPTH? pO E Depth to Water .A~er~. I Monitoring? ~ ~' Date: \ 0 ~ ;7~'~ -.~:1L~ Reading Date Gross .Net Depth to Net Time Time Water Drop PERCOLATION RATE __ TEST RUN BETWEEN ~ (minutes/inch} PERC HOLE DIAMETER __ '~ FTAND ~' FT PERFORMED BY: 117034 Ea~le River Loop Road No. 204 ~ '- ?'/_~..,.~ ~ ~;f"~ CERTIFY THAT T, HIS TEST WAS PERFORMED IN Eagle River, Alaska ~577 .... ! 0 / -~ ~ / ~' ~ ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ( '¢ ,' 72-008 (Rev. 4/85) ROBERTC. COWAN, RE. ROBERTA. SHAFER, RE. HEALTH AUTHORITY ~'PROVALS SEWER&WATER MAIN ID(TENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANJCAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM DESIGN Date: CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 RECEIVED JUL 30 1996 Municipality of Anchorage Dept. Health & Human Services REFERENCE: The septic inspections for the referenced property were performed on '?-Z~.-~ and 7-2~-qg . Prior to submitting the On-site Wastewater Disposal System and/or Well Inspection Report we are waiting for the /~,,~ r~o~ to be completed. If we may be of further service please contact us. Sincerely, Robert C. Cowan, P.E. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 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:SW960179 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:NORTHWOODS INC OWNER ADDRESS: PAGE 1 OF 1 DATE ISSUED: 7/10/96 EXPIRATION DATE: 7/10/97 PARCEL ID:05106416 LEGAL DESCRIPTION: NORTH WOODS UNIT IV BLK 16 LT LOT SIZE: 39604 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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 (iSAAC80) . 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- ~~ ~ ISSUED BY~~ ROBERT C. COWAN, RE. ROBERT A. SHAFER, RE. July 3, 1996 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ONSITE WASTE'WATER DISPOSAL SYSTEM DESIGN MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 4, Block 16, Northwoods S/D Unit Request you issue a permit to install a septic system to serve the proposed three bedroom house on the referenced property. A test hole was excavated and percolation test performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation water no was encountered in the test hole and after seven day ground water monitoring, the monitoring tube was found to be dry. This property has enough area for a future septic upgrade which can be seen on the attached site plan. This property is served by a Community Water System. We do not anticipate any adverse effects on neighboring wells, septic systems o~ drainage patterns by the installation of the proposed septic system. If you require additional information, please contact us. Sincerely, Ro eft C. Cowan~ P.E. RCC/gk Enclosure 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 50' SITE PLAN DESIGN ~GALE 0 --460 r- o¢)6~ 0 ~'-r'm £o PERFORMED FOR: LEGAL DESCRIPTION:. ROBERT C. COWAN, RE. ROBERTA. SHAFER, RE. CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 Lo'r ~l1 ~ Lo ct4, ! /- ~A0~ DATE PERFORMED*:"~ Township, Range, Section: SITE PLAN 10 11 12 13 14- 15 16- 18- 19- 20- COMMENTS WAS GROUND WATER ENCOUNTERED? $ L IF YES, AT WHAT O DEPTH? ~ p E Depth to Water After Monitoring? D~e-/' Date: Reading Date Gross Net Depth to Net Time Time Water Drop Il PERCOt. ATION RATE _. ~__~____ (minutes/inch) PERC HOLE DIAMETER ~' TEST RUN BETWEEN '~' ~' FT AND ~' ~' FT PERFORMED BY: 'I. 7~4 ~J~, ~;,~ L~t~ ~,~acJ ~, -~ I .. CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE wJr~I~Bi~exTf, ht~J~AL GUIDELINES IN EFFECT ON THIS DATE. DATE: '7 / ~"/ q G, 72-008 (Rev. 4/85) ROBERT C. COWAN, RE. ROBERTA. SHAFER, P.E. ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PE~OLAT~ON TEST STRUCTURAL & MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSAL SYSTEM DESIGN ]ENERAL: 1. 2e e e Se Lot 4, Block 16, Northwoods S/D Unit #4 JUly 3 ,1996 The scope of this project includes the installation of a 1000 gallon septic tank and a leachfield trench to serve the proposed t~r,~ bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. ~EPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 2. The septic 'tank shall be sufficiently bedded to prevent settling or shifting of the tank. e Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 ° EAGLE RIVER, ALP~KA 99577 Page Two Lot 4, Block 16, Northwoods S/D Unit #4 July 3, 1996 / 4. //Septic tanks installed with less than 4 ft of cover shall ~ .... be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Se Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock) placement. me Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Page Three Lot 4, Block 16, Northwoods S/D July 3, 1996 Unit Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIMUM MATERIAL SPECIFICATIONS: me Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron ASTM D3034 (PVC) ASTM F810 (HDPE) ASTM D2662 (ABS) Yes Yes Yes Yes Yes No Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). e Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. e Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the %200 sieve. 7e When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements. Page Four Lot 4, Block 16, Northwoods S/D July 3, 1996 Unit ~4 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. e The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. Se The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. Page Five Lot 4, Block 16, Northwoods S/D July 3, 1996 Unit #4 S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER 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. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 051-064-16 GENERAL INFORMATION Complete legal description HAA# ~q4 c~(~C'/7~l Lot 4; Block 16; North Woods Subdivision #4 Location (site address or directions) Sheltering Spruce Property owner Mailing address Thomas Co. 8510 Solar Drive Anchorage, Day phone A~ 99507 346-4025 Lending agency Mailing address Agent Address Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well Community well xxx 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. xxx 72~025 (Rev. 1/91) Front MOA#21 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 ~hat 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. S & S ENGINEERING Name of Firm ;7c34 E:~!-- ~;""" Laop Road No. 204 Phone (~, ~f ~/ - ~,.':? 7 ¢~ Address Eagle River, Alaska 99577 ~ Engineer's signature ~,~ Date / //~'; / ~ ~' REQUEST A RELEASE OF THE CONDITIONAL HEALTH AUTHORI~f ALL CONDITIONS HAVE BEEN MET. S TIME.© Approved for ~--~? edrooms Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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 the State of Alaska. The DH HS 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. 72-025 (Rev. 1/91) Back MOA ¢Y21 Parcel I.D. # MUNICIPALITY 0f ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE[ FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot 4; Block 16; North Woods Subdivision ~4 Location (site address or directions) Sheltering Spruce Property owner Mailing address Thomas Co. 8510 Solar Drive Chuqiak, AK Anchorage, Day phone 346-4025 AK 99507 Lending agency Mailing address Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well Community well ×xx 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. xxx 72-025 (Rev. 1/91) Front MOA #21 ; 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 all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S 8, S ENGINEERING Phone ~' 17034 Eagle River Loop Road No. 204 Address Ea_ale River. Alaskn 99q77 ,,, Engineer's signature ~.~.Y Z ~./~.~_ .,~ Date 6. DHHS SIGNATURE APproved for bedrooms. Disapproved. Conditional approval for '~ bedrooms, with the following stipulations: 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 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 (Jertificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-o25(Rev. 1/91) Back MOA#21 Legal Description: A. WELL DATA Municipal i DEPARTMENT OF HE I ~"~!RONIvjENTAL EnVirOnmental Services Division 825 L Street, ,Room 502- Anchorage;Alaska 99501 · (907) Health Authority Approval,Checklist ~ ~ ~ ~C~ J~ ~z~5 ParcelI.D.: 01~ Well type C~-~S ~A ~ If A, B, or C. attach ADEC letter. ADEC water system number 'Z J ~Oo ~ Log present (Y/N) ~'-'"~ Date completed Total depth Cased to Sanitary seal (Y/N) Casing height (above ground) Wires prop.er y protected (Y/N) Date of test Static water level Well production FROM WELL ;LOG WATER SAMPLE RESULTS: Coliform - Nitrate Date of sample: -- B.'~EPT[C~HOLDING TANK DATA Collected by: AT INSPECTION Othe ~ bacteria Date installed "/-'Z~-~(,, Tank size I Ooo Number. of Compartments 'Z~ . Cleanouts(~N) Foundation cleanout (~) ¥E,$ Depression (Y~ - t~ e High water alarm (Y~ I~° Date of Pumping ~E'I,~J Pumper -- -~..~. C. ABSORPTION FIELD DATA Date installed "'/',~?,~1- ~,(- Soil rating ~or ~/bdrm) Length ' , ~ ~'~i._ Width ~.. ~ t ~ Gravel thickness below pipe Effective absorption area ~,/~;;~ M(~nitoring Tube present (~)N)~/¢~ Depression OVer field (Y,~ /'JO Date of adequacy test Results (Pass/Fail) ' For ,~ bedrooms Fluid depth in absorption field before test (in.); Fluid depth (ins) Minutes later: --"--"- Absorption rate '= Peroxide treatment (past 12 months)'(Y/N) ' "'--- . If yes; giv~ date 72.026 (Rev. 3/96)* Immediately after ~ gal. water added' (in.): g.p.d. ~N Date installed Hi eve~ i *Datum E, SEPARATION DISTANCES Pump off level a SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Pubiic sewer manhole/cleanoUt Sewer/se Lift station SEPARATION DISTANCES FROM[~HOLDING TANK ON LOT TO: Foundation '7 Property ne ~ Absorption field -Water main/service line I 0 Surfacewater/drainage lee Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ~' I~t Surface water leot ~'' Curtain drain F. ENGINEER'S CERTIFICATION Building foundation I~, ~ Water main/service line I o I~. Dr vewa¥; park ng~teh c e storage area ~ ~3 ~ . Wells bn adjacent lots 500 ~ I certify that I have determined thru field i~spections and review Signature Engineer's Name are Date HAA Fee $ ~ Date Receipt 72.026 (Rev. 3/96)* Waiver Fee $ Date of Payment Jmber