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Home My WebLink AboutPEG LT 20B Municipality of Anchorage Page I of 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: .~u,}~ '10 2:=t¢~ PID Number: O ~1 - O"77.'- ~ Name: ~t~ ~A~ ;~ Wastewater System: D New ~ Upgrade Address: ~Sl~ ABsORpTION FIELD Phone: ~ ~ . ~ ~ D Deep Trench ~ Shallow Trench ~ Bed ' ~e~t~leM ~A~ Total Depth from o[iginal gra~e[ Lot: ~0 ~ Block: Subdivbio~ Depth to pipe bottom fro~original grade: Gravel depth beneath pipe Township: -- IRange: _ ~Section: -- =illaddedaboveori~inalgrade:3,~,. ~1 Ft. Gravellength: ~1 Ft. Number of lines: ~ Distance between lines: WELL: E~t%~New ~ Upgrade Gravelwidth: ~ 8t Ft, 8 I 30 Classification (Private, A,B,C): Total Depth: ~ Total absorption area: Pipe material: ~ ~o ~riller: ~Drilled: Static Water Level: Installer: Date installed: ~G IPump Set at: Icasing Height AbOve GrOund: ' TANK PM Ft. Ft. SEPARATION DISTANCES ~ Septic D Holding ~ S.T.E~P. To Septic Absorption Lift Holding =ubll¢/Private Manufacturer: Capacity I~allons: From Tank Field Station Tank ~ewerLInes ~0~ ~ J 500 Wel~' !00I+ leO~+ jOOi~ ~ ZSl+ Material: ~ea~ Number of Com~ments: Su,ace LIFT STATION Water I0~ t ~ ) oOl~ I OO I~ ~ Line ~1~ ~ ~ Size in gallons: I Manufacturer: Remarks: ~t~ ~ ~ ~~E BENCH MARK Location and Description: I Asaumed Elevation: Inspections pedormed by: S & S EN~IN=E.IN6 %~/~~"'~---~ ..... Department of He~~d p~man Se~ices approval -- '-~ - Reviewed and approved bY: ate://-/?- CF 72-013 (Rev, 9/91) MOA 25 PERMIT NO. SW970299 PAGE 2 o~' 2 Municip, g_.Li~¥~o. F Anchoro, oe DIE?ARTMENT OF ~AL/id AND HUMAN 8FRVICES FNVIRON~ENTAL SERVICES DIVISION P,E], ]]ox 196650 eAnchor(~ge, A[c~sko, 99519-6650eTe!,eohone: 343-4744 ON-SITE WASTE. WATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 2OB, PEG SUBDIVISION P.I.D. NO. 051--072--74 ST1 ST2 92.3' ~soo ca[ 92.1' S.T.E.P. 8YSTeu PROFILE VIEW N.T.$, ORIFICI~ O~T3 OL~ SCH 40 F~C LAT£.~.S OR[F~C£ SPAC£O 27 O.C MT40 50' A , B , T1 41.5 22.0 T21 4S.5', I 29.0:1 IH I 46.5 I 50.5 I IT1 56.5' I IT21 52.0' I 44.5'1 IT5 50.0' 49.0' IT4 48.0' 57.0' NEW 1500 S.T.E.P. TANK NEW BOTTOMLESS-~ SAND FILTER ~ blT~ -- -- '-~tdT4 A?H I ~ 2.]MT2 EXISTING 4 BDRy HOUSE (PLYWOOD WALLS) IMPERMEABLE (PLYWO00 TOP VIEW N.T.S. ULA'nON FILTER COV[R BARRIER., w~cs) WELL 1" = 40' ~T~ = BOITOML£SS SAND ,g3.3' WATE.I~ FOUND 90.7 B.O.H. PROFILE VIEW ORADE LINES (LEVEL) ROBERT C. CE -880l N,T.S, NO%/-- 12--97 WEI) 11:59 HEAVENLY LIGHTS ELECT CO 575 5894 491 Willow Street · Wasilla, Alaska 99654 Phone# (907) 373-3893 · l~ax# 373-3894 P.01 l November 4, 1997 William Fuller C/O Vista Real Estate Attn: Lola Pedersen 16635 Centerfield Drive Eagle River, AK 99577 REFERENCE: Lot 20B; Peg Subdivision Dear Mr. Fuller, Construction of the on-site wastewater disposal system located on the reference property per S & S Engineering design is essentially completed. The system is operational however a requirement that the intermittent sand filter be covered with top soil and seeded can not be accomplished due to winter conditions (topsoil is not available). Tweed Excavating will return to the property in the Spring, 1998 to add topsoil, final grade and seed the intermittent sand filter and other disturbed areas. This is not to be construed as a requirement to perform other landscaping and it will be up to the home owner to provide sufficient water to the areas to insure growth. The wood board fence located along the east property line will be repaired to the extent possible considering age and deterioration of the existing materials. If we may be of further service, please contact us. Sincerely, Richard S. Shaf~ Tweed Excavating RSS/gk cc S & S Engineering CoPy PAGE 1 OF MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH A_ND HUM_AN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 A/~CHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM {UPGRADE) PERMIT PERMIT NUMBER:SW970299 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:FULLER WILLIAi~ H & DOROTHY P OWNER ADDRESS:21917 GLACIER RD CHUGIAK, ALASKA 99567 DATE ISSUED: 9/09/97 EXPIRATION DATE: 9/09/98 PARCEL ID:05107274 LEGAL DESCRIPTION: PEG LT 20B LOT SIZE: 41885 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 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 A_ND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18A2~C72) AND DRINKING WATER REGULATIONS (18AAC80) . 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: THIS PERMIT IS ISSUED FOR THE CONSTRUCTION OF A RECIRCULATING TRICKLING UPFLOW FILTER SYSTEM. AS A CONDITION OF THIS PERMIT, THE OWNER OF THIS SYSTEM AGREES TO MAKE ARRANGEMENTS FOR THE SYSTEM TO BE SAMPLED ONCE A MONTH FOR A MINIMUM OF 12 CONSECUTIVE MONTHS AFTER BEING PUT IN USE. THE ATTACHED PROPERTY OWNER AGREEMENTS BECOME A PART OF THIS PERMIT PACKAGE. ~~_~ zmo ~ ~ -- 0 0~0 z~ z~z O0 ~m~mm · Z NO WELLS/SEPTIC . W~TH~. ZOO'+ OF PROPOSED WELL/SEPTIC ~ ~ I 3_7~ ~Z~ , n ,~l f. F~ 0 ~ ~- ,.--~. ~o~' , ~-~ .- ~ PEG STREET ~ ' ,~. ~,.'., : ~ ..c~-~ N.T.S. 8GALE PROFILE Ii N.T.S. ~GALE CROSS-SECTION DETAIL '1 PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT /~r DEPTH? ~ p Depth to Water Alter Monitoring? ~'~' Date: lO-lq-q? SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop 3 ~: 2G 2~ V2" 2 '/z u ~ ~: ~ ~" - PERCOLATION RATE '2.~"* (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND "~ FT COMMENTS PERFORMED B~ & .~ F-NC.I kll~_~l~ I~J/~~'~ 1734 a ACCORDANCE.WIg~3 ~L ~¥Aq~"Y~I~I~OI~I~I~I~LI~tJ~L~INES tN EFFECT ON THIS DATE. =agra K~ver, Alaska 99577 72-008 (Rev. 4/85) CERTIFY THAT T~IIS TEST WAS PERFORMED IN DATE: :~O //~ /'~7 PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11- 12- 13- 14- 15- 16- 17- 18- 19- 20- Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORMED:' ~ --~1 ..,. Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? DEFT.? Depth to Water Alter .~ Monitoring? ,~" Date: Reading Date Gross Net Depth to Net Time Time Water Drop ,./ PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN,,~t FT AND '~ F'~ COMMENTS PERFORMED BY: ~'~'~'"- ---, ~.~tl;~--- ~,vtrr'' ,'~p ~Oa~l NO, 204i .... ACCORDANCE WlT~[t ~'~~~L GUIDELINES IN EFFECT ON THIS DATE. CERTIFY THAT THIS TEST WAS PERFORMED IN DATE: , '~ /:~ ~r~/~ ~ 72-008 (Rev. 4/85) ) MUNICIPALITY OF ANCHORAGE '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 ] Well ~ Absorption area Dwegin9 PERMIT NO. DISTANCE TO: ~ Manufacturer ~ /~ ~///~ Material No. of compartments Liq. capacity in ~allons Inside length Width Liquid depth /O~ If HOME'DE: ,,,~ ' DISTANCE TO: Wag~/// Dwelling PER M ITN O. O ~ ~ ~anufacturer Material Liquid capacity in gallons Q Wag Foundation Nearest lot Hne PERMIT ~ No. of lines Length of Distance between lines ~ -- Top of tile to finish grade Material beneath tile Total effective absorption area Lengtb , Width Depth, ~/ ~L PERMIT ~O ~ ~ ~ Type of crib Crib diameter Crib depth Total effectJve absorption area OTHEB PIPE MATERIALS ~' ~ 5~ _ SOIL TEST RATING ~--¢/O~ 72-013 (Rev. 3/78) MU~-~ ][ C. ][ V)AL ][ T~' OF ~IP,~Ig:H!EhF~P~GE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 8~5 L STREET, ANCHORAGE, AK 99501 264-4720 PERMIT NO: 840690 UPGRADE DATE I,~,:~UE:D: 28 / l._/,~4 AF'PL I CANT: ADDRESS :" - CONTACT PHONE: STRATA % S&S ENGINERRtNG EAGLE RIVER, 694-2979 LEGAL DESCRIP: SUBDIVISION: NA LO]": ,-~(:)B BLOCK: NA SECTION: 4 TOWNSHIP:' 15N RANGE: 1W LOT SIZE: 42000 (SQ.FT..OR ACRES) I certi£y that: ' wells as set 1. I am f'amiliar wi'~Eh the requirements £or ~n-site sewers and ~orth by 'the Municipality o£ Anchorage (MOA) ~nd~ {he State o£ Alaska. .'-.~. I will install the s;ystem in accordance with all MOA c~des and regulations~ and in compliance with the des~ign criteria o£ this permit. .~,,, I wi].], adhere to ali. MOA and State o£ Alaska ~'equirements £~r the set back distances £rom any existing well, wastewater disposal system or public sewerage system an this op any adjac:ent nv nearby lot. IF: A L. IFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING [.ODEo~ ~ c:-._.'q . '- THEN (i) AN ELEC]"RILCAL PERMIT AND INSPECTION MU~.~ BE OBTAINED; (~) ~.' ~UIL1S WILL NOT BE AF'F'RGVED WITHOLJT AN ELECTRICAL' INSPECTION REPORT; ANI) (3) THE EL.E~TRICAL WORK MUST BE DONE BY A,LICENSED ELECTRICIAN. SIGNED ~ '~' ~ / ,/ "~ ' ~)AI'E: ~., /~ ~/ APPLICANT: STRAT~ ~' ~ .-- . MUNICIPALITY OF ANCHORAGE i 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 [] UPGRADE [Weil/~ / IAbsor~re~ Dwelling27 / PER Z Manufacturer No. of compart~ 0 ~ ( Manufacturer /~ Material Liquid capacity in gallons / ~ Top of tile to finish grade Material beneath tile Total effective absorption area ~ Type of crib Crib diameter Crib depth ~~ ~ Total effective ab ' re ~'~ ~ DISTANCE TO: 'Well /~ / , BuilOin~ati~ Nearest lot llne XX" ~ Class Depth Driller Distance to lot llne PERMIT NO. ~ Building foundation ~ Sewer line Septic tank Absorption area(si ~ DISTANCE TO: OTHER PIPE MATERIALS ! ~ ~ / / REMARKS * ~ ~ ~ 72-013 (Rev. 3/78)= DE[:'FIF,:TI',tENT OF HEFIL]"H HF, L EN',,/IRONPI,EN]'RL.. F'F'ZI'E]I"IZN -',"", hq ,-' , ............ 99501 ,:,,_-.._ L .:,TF. EE'~. dlq...H..F,H_~E. FIE ;2' 64 -. 4 ;:~ 2 ¢3 F'ERf'!I T NO: [:,FITE Z :5:.;.,.. ES,: FIF'F'L I CFII'.JT: FID[:,RES:5: - - i'..FFFIF T F'I--IL- FIE - S'T'RFFITFI INC. F;: '.S&S ENOINEERIi.4G EFIGLE FFI. i'v'E:F'.., RI-( 99577 L.EGI!:IL..[:,ESC:R I F': LOT SIZE: I"IFI>:; E:E[:,FF:00MS: SUB[:,IVIL:.iIOt'.~: l'-,!l:::l LOT: BLM 20B ':':;ECTtON; 4 TOI-,.INSHIP: t5N RRNGE: i!-,.I ,~2000 (SQ. Fl". OR FIE:FF:E:~,) BLOC:K: NR L. ISTED E:EL.OI4 RRE 'THIS O[:'TiONS ~I',,,'RILFIBLE 'l-O YOU IN DESIGNING YOUR SEPTIC S'-/STEP!. CFIOOSE THE OF'TIOIq THI':IT BEST FiTS '.fOUR SITE. :+::+: DEF'TH TO PIPE: BOTTOI'"I < .7..':. 5 FT. F'.EQUIF'.ES INSULRTION :+:,l-: D[iPT[I TO F'IF'E E',CITTOI-'I, .:::: 4.. O FT. hlFIY RELT]LIIRE R LIFT STFITION :+::+: -FFINI< i"ILIST I~.IIa',,-"E I::1'I" LEFIST THO COi"iPFti,';;'.TI"tENTS CIEF:T I F:'Y THRT: i. I FIM FF:ff'!:I:LIFIF: HITH THE REQUIREi"!ENTS FOF:: ON--SITE SEi4ERS FIND HELLS RS SET FORTtl BY THE I~II.]NZCIF'FIL. IT'.~.' OF FfiNCHORF!GE (i"iOFI) FIND THE STFITE OF FILFISKR. ;2. I HIL. L.'INS};TRLL. 'TH[ S'¢STEP1 IN F;CCOR[:,RNCE HITH FILL MOt~ CODES RND REGULFITIONS, FIN[:, iH COMF'L. IRNCE HI'TH THE DESIOH CRI-['ERIFI OF THIS PERMIT. 3:. I 14ILL FIDII,ERE TO FILL. P!OFI FIN[:, STFITE OF RL.F:ISI<F~ REQUIF:EI'dENTS FOR THE SET E:RCK DISTIaNC:ES I::F:OH I:it'-,1"*" E',:-:;ISTIHG HE!_L, HFISTEHFITER DISPOSFIL SYSTEM OR F'UE:LIE: SEHERFIGE: SYSTEf'I ON THIS OR RNY RD,)'RCENT OR NERRE:'¢ LOT. I UNDERSTRN[:' THF!T THiS F'EF4HZT IS ',,,'FIi._.ZD FOR FI Plla2;IFILIM OF 3: BEDROOMS RND RNY ENL. RRGEHENT NZL.L REQUIRE RN.FIDE:,ZTZONRL. F'ERMZT. IF'Fi L. IF:'T'STFFI'iOi'.,i IS iNS]"FILLE:D iN R!',i I:iREFt COVERED B'-/ I'IOFI 8U!LC, ING TFIEI'.,! (::L) Fllq ELEE:TIq:iE:F:IL PEFF:['II'T' FIN[:, INSF'EE:TION MUST BE OB'TRINED.~ 42) klILI... NOT BE [:IF'PF,::OVED NITHOUT lqN EL. ECTR!E:FIL INSPECI"iON REPORT.~ RND b:LECTRiCFIL, i-,.!ORi-::: HUST B[i DOI'4E BY F! LICENSED ELECTRICIRN. H_, E, LI I LT_, ,:: 2:) THE S :[ GIqE[:' FtF'F'L. I CI::iNT: T. S:E';UED F "," [:'ATE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTE(~TION 825 L, Street, Anchorage, Alasl~8 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 4 7- 8- 9- 10- 11 13- 14- 15- 16- 17- 18- DATE PERFORMED: ~ __ SLOPE SITE PLAN WAS GROUND WATER HO I~ ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop ,~ MUNICIPALITY OF ANCHORAGE i 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 "EW LOCAT ON NO. OF BEDROOMS Manufacturer Material No. of compartments ~ Liq. capacity in gallons Inside length Width Liquid depth IF HOME.DE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO, O ~ ~ Manufacturer Material Liquid capacity in gallons a Well Foundation Nearest lot line PERMIT NO, ~ ~ No. of lines Length of each lin~ Total length of lines Trench width Distance between lines ~ inches ~ Top of tile to finish grade Material beneath tile Total effective absorption area ~ Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: Driller · ¢ Distance to I t line PERMIT NO. ~ DISTANCETO: Buildingfoundatio~ Sewerline /~ Septictank ~) ~ Absorptionarea(s) OTHER 72-013 (Rev. 3/78) ~ // by DOC Co, dba P,O, BOX~72, CHUGIAK, ALASKA 99567 * TELEPHONE688-2750 OWNER OF LAND ADDRESS ?~o LEGAL DESCRIPTION DATE- Started " ' ;' Ended · PERMIT NUMBER DEPTH OF WELL / STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR / KIND OF CASING -' KIND OF FORMATION: From /' Ft. to · Ft. From :' Ft. to ::.~ Ft. From ~ / Ft. to "; Ft. From Ft. to FI, From ? ;i~ Ft. to '? :)' . Ft..', ~ ~ ;, ,; r',.~,~ ,,: :' ~. From_ ~' :? Ft. to %' 7" Ft. ,-,,/.'~ - From Ft. to__.Ft, From Ft. to Ft. From Ft. to__.Ft From Ft. to__ Ft From___Ft. to__.Ft From __ Ft. to__.Ft From Ft. to__.Ft From Ft. to Ft. From Ft. to Ft From__.Ft. to.__Ft. From Ft. to.__Ft From__Ft. to FI, From__.Ft. to Ft. From__Ft. to Ft From Ft. to Ft. Frmn Ft. to Ft. From Ft. to Ft. From__FI. to __Ft. From Ft. to___Ft. From Ft. to Ft From Ft. to Ft From__Ft. to___Ft From FI. to Ft. From FI, to Ft. From Ft. to Ft. From Ft. to Ft MISCL. INFORMATION: DRILLER'S NAME : ',-::-:. ' •;-lc." Municipality of Anchorage `s' On-Site Water and Wastewater Program - (907) 343-7904 _ Certificate of On-Site Systems Approval Parcel I.D. 051-072-74-000 Expiration Date: IJoV 01 2 v 1 1. GENERAL INFORMATION Complete legal description Peg L2OB Location (site address) 21917 Glacier Vista Rd Chugiak, AK 99567 Current Property owner(s) Thomas & Carol Elliott Day phone 907-688-2572 Mailing address P.O. Box 672547 Chugiak, AK 99567 Real Estate Agent Brad Wilson Day phone 907-441-7178 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well E Individual E Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: , Received by: Date: �- / I( COSA to be released to the en ' eer,unless otherwise r nested by the gineer. ' �� d� � 7,-7-��77 / COSA Fee $ 52 co Waiver Fee $ Date of Payment 11.20/1 7 Date of Payment Receipt Number akt 332 (0cl Receipt Number COSA# OSC 111U1 `-r b Waiver# 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, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Alaska Rim Engineering Phone 907-745-0222 Address 9131 E. Frontage Rd Palmer, AK 99645 Engineer's Printed Name Norman Gutcher Date 9/22/41Kt�a 44. OF ..n/ p �� •^e•••C•Y•te T.�1 �B •• . ) � 6 P ® e4.9 TH ` , 6. DSD SIGNATURE , 1 !qv;..,;;•,e„ n System#1 Approved for bedrooms rn= Norman K:Gutcher System #2 Approved for bedrooms AQ 9F• ••••••e••' 4 Disapproved @�`�®eR,O�� " Conditional approval for bedrooms, with the following stipulations: HiV c• 014 S1TE G�` . \v A1ER AN ER 1> W� � W PRS Rp,M By: IR C&uce'U Original Certificate Date: Val /18 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet f - - If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system C&&tuf tate of On-Site Systems Approval Checkll st Legal Description: Peg L2OB Parcel ID:051-072-74-000 A. WELL DATA Well type Private If A, B, or C provide PWSID# N/A Well Log (Y/N) Y Date completed 5/84 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 100 ft. Cased to 40+ ft. Casing height (above ground) 45 in. FROM WELL LOG AT INSPECTION Date of test 6/17/97 7/20/17 Static water level 76 ft. 72.7 ft. Well production 6.3+ g.p.m. 6'4 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 0.661 mg/L Arsenic <MRL ug/L Date of sample: 8/16/18 Collected by: Brandon's On Site Services B. SEPTIC/HOLDING TANK DATA Tank Type/Material Steel / Anchorage Tank10/30/97installed 10/30/97 Tank size 1500 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) Y Date of pumping 10/13/17 Pumper Sanitary Pumpers C. ABSORPTION FIELD DATA Date installed 10/30/97 Soil rating (g.p.d./ft2 or ft2/bdrm) 1 .2 Soils System type Bed Length 20 ft. Width 18 ft. Gravel below pipe 0.5 ft. Total depth 3.5'-4' ft. Eff. absorption area 360 ft2 Monitoring tube Y Depression over field N Date of adequacy test 7/20/17 Results (Pass/Fail) Pass For 4 bedrooms Fluid depth in absorption field before test 1 .5 in. Water added 604.9 gal. New depth 3.5 in. Elapsed Time: 15 min. Final fluid depth 1 .5 in. Absorption rate >= 604.9 g p d Any rejuvenation treatment (past 12 mo.) (Y/N & type) Non Known If yes, give date Non Known D. LIFT STATION Date installed 10/30/97 Size in gallons 1500 Manhole/Access(YIN) Y "Pump on"level at 41 .5 in. "Pump off' level at 40.5 in. High water alarm level at 48.5 in. Datum Bottom Of Tank Cycles tested 3 Meets alarm&circuit requirements? Y E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100Y+ On adjacent lots 100'+ Absorption field on lot 1001+ On adjacent lots 100'+ Public sewer main 25'+ Public sewer manhole/cleanout 100 + Sewer/septic service line 25'+ Holding tank 1001+ Animal containment areas 1001+ Manure/animal excrete storage areas 1001+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation + Property line 45+ Absorption field 100 + Water main 101+ 101+Water service line Surface water 1001+ 1Wells on adjacent lots 100 + ABSORPTION FIELD ON LOT TO: Property line 101+ Building foundation 101+ Water main 101+ 1CYWater Service line + Surface water 100 + Driveway, parking/vehicle storage 10+ Curtain drain 501+ Wells on adjacent lots 100+ F. COMMENTS G. ENGINEER'S CERTIFICATION ns- .44I%., I certify that I have determined through field inspections and of„t ,.' ` A �``_, - p review of Municipal records that the above systems are in ; 0y ; t^ ; A conformance with MOA COSA guidelines in effect on this date. •R' a `ti,�..}..1.:1.. k 4:t Engineer's Printed Name /14/^/NoNrJ l� Cru / I'%e 1,701 .4<'-(1 e----e ; r ✓f i'/V., Nononn 1:.C;o! her .J. Date il. / *a's L...-/1) COSA canary sheet_2-6-15.doc :N'1UNICIPALITY OF Al+ICHORAOE+Community Development Department•On-Site Water&Wastewater Progran:. P: 907-343-7904•F: 907-343-7997+P.Q.Box 196650 Anchorage,AK 99519-6650•http:i/www.muni.org/buildiu Intermittent Dosing Sand Filter Maintenance Log OwnerC°\r0 �S[-.C� Street Address 9 ":tt t 1 G) ac\ er vi 610.. PhoneLegal Desc.PI. G 1.,4- aQ ( PID Septic Tante: -Sludge level ; inches -Pumping: required g� q uired es co Pumping completed !;' ; no Absorption Field: - 1 -Liquid level ' inches -Flushing valves per approved design :&;; • -All flushing valves opel� . , distribution lines flushed, and flushing valves closed ;o; no Lift station: •Pump basket cleaned ;gas no -4 •Biotube effluent filter cleaned es no -Timer float setting 66 inches -High level float setting 57 inches -Reference point,Top • lSQc-- -Pump on `c C% seconds -Pump off minutes -Cumulative lifetime cycles 3 7 ij -Cumulative run time 1 Z5`',: � 0ars -Operation satisfactory 02) no Air System: -Air pump filter cleaned es no -Air pressure psi -Date of latest install or rebuild 0. •Air system operation atisfact ry not sat stictory Alarm System: .-�— •Dedicated electrical circuit, 'y yes_ no S ,?� -Audible and visual alarm inside dwellingna� Lr� •Float setting inches -Alarm system operation satisfactory not sati i ctary Comments: A a...moi ... .��\- vt-ek . w 6Q- /3t) AofR Pap, , Us ) ... Maintenance Provider: Technician L-r'`.'C`K`y" je- \5 �� (1 Date of maintenance vt/�I o Company L. 't ,5 5 ery � S J - I Signature Date 22, A?? ie 1DSF Maintenance Log_040313.cloc Invoice Michael N. Anderson, P.E. Civil/Structural Engineering and Construction 4661 Natrona Ave. Anchorage, Alaska 99516 Phone 727-8864 Fax 345-1391 August 24, 2018 THOMAS& CAROL ELLIOTT PO BOX 672547 CHUGIAK, AK 99567 Re: Septic Repair Legal: PEG LT 20B Description Excavation Services Provided: 1. Excavate sand filter system to install or expose the 8 missing blow-off pipes which are required by the MOA for the COSA. Total due this Invoice $ 2,500.00 Co mfle,kcl / 5/f B' 641,01.0 Sen+) ti i � oc • f, ' • t,f f1 ' of • I • 3 . ,,s/ _ 3Yr SII !: .1 .reit! . . t k a� f� % . ,1 . likltiotth_. /r-e ‘ - {,0 0 e, Q° • �. ry0 . h `fl •v r: \I o� h floi. • . i\I i /1/fi" i mw � � i' . os•�', •`�so • , �1�, Y _j� r Fe a. •1 . • 0 • e 1• w ,3..zd'.�/A7 ox,wyr, Lk i c"s<OC•• r4 '. . .ytlt.4.07".40r.4?"; ••a - 'KW!? yW!?rrr.cPW lir' ,/,4e2,-0d • • • Ufa C��Triere,/,774-I,.11 �.� AS 6U!LT SEFIARD & ASSOCTATRS LAND SURVRYTNG 694-0829 I HEREBY CERTIFY -THAT I HAVE SURVEYED THE SCALE'. , FO, LOWING DESCRIBED PROPERTY: '�� 4.:":„ or 4 °°t ANO THAT NO ENCROACHMENTS EXIST EXCEPT AS �S7' iriA..••• • 6/ "•t ff. MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGREEMENT, herein the"AGREEMENT" made and entered into as of this v2,)-- Day of AA.00, s-4- of 20 11? , by and between La`Tr\ ,(11Q i er- and [Aar° , herein the"OWNER,"and the Municipality of Anchorage,herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as located at(legal description) ?'L L . 2. Maintenance, Repairs and Alterations. (Owner is required to read, understand and initial each section) 47117 Throughout the term of this Agreement, the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. h-- It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to $600). Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, ``ll repairs or permitted alterations to the system. �D`P Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. 05/18/2018) Page 1 of 3 64,711_--Owner acknowledges that the Municipality may request records of maintenance and repairs from the manufacturer's representative or maintenance provider. OX:_-. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS. The Municipality will give at least 24-hour notice. I ' /y�jl`�-=-- Owner agrees that any sale or transfer of title of the property will not occur without a new �',fJ /r Certificate of On-Site Systems Approval. %� i-- Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the Owner's AWWTS. /, ,lig Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system,or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof,or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7. Severability. Any provisions of this Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev. 05/18/2018) Page 2 of 3 OWNS' By: ' �� ' <— --� (signature) Date: Icj /I (print name) STATE OF ALASKA ) ) ss. THIRD JUDICIAL DISTRICT ) The foregoing instrument was acknowledged before me this . day of Al,t 4t6t- 20 l 6, by Le% , K! e' • ARY PU ICFO' AL MYRTLE SJ.LEWIS-MOSBY M Commis ion expir s: ,, " . ,pJ .1 Notary Public 1 State of Alaska My Commission Expires Feb 21,2021 MUNICIPALITY: n Q By: .0COCULOC (signature) Date: a123/I ICQ)Oe e CA arra(I (print name) Title: (rev. 05/18/2018) • OWNER: • By: % "1—li7` (signature) Date: 55'3a"J I ✓o/ C.- gk/ty(print name) STATE OF ALASKA ss. • THIRD JUDICIAL DISTRICT ) The foregoing instrument was acknowledged before me this 9aday of Po.g31 6-t . 201$, by i-love la— y 14.42;o if,� MYRTLE S.J.LEWIS-MOSBY N ARY ; BLIC f O LASKA 1 Notary Public M Commission expires: ,V,,41,tiv4 c9.0a 1 1 State of Alaska 1 My Commission Expires Feb 21,2021 MUNICIPALITY: 0 By: .) / (signature) Date: $'/23/1 ROo2 0.Co.. Cwe ro l (print name) Title: (rev. 05/18/2018) 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # O~"'l -o'7~. 1. GENERAL INFORMATION Complete legal description Lot 2OB: Peg Subdivision Location (site address or directions) Pr.operty owner i'."Mailing address 'Lending agency "Mail.ing address Day phone 21917 Glacier Rd. Chuqiak~ AK 99567 · 376 Lone Elk Rd. Spear Fish, SD 57783-8645 Day phone Agent 5ola Pedersen/ Vista Real Estate Address Day phone __ 689-6458 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: e NOTE: 4 Individual well xxx Community well Public water 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 NOTE: XXX Public sewer 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 ? 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. S & S ENGINEERING Name of Firm 17~,34 F. aU',~ ,%,e, Loop ,'~,~,,; ;,;o. 264 Address Eagle River, Alaska 9~5,,77 Engineer's signature Phone 6'""~y ~~¢/ 7.'~ ... Date It /'>"/cf 7 Se DHHS SIGNATURE ' ,,~ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date///- 2~- ~'7 The Municipality of Anchorage DePa.rtment 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 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~CZl Municipality of Anchorage D DEPARTMENT OF HEALTH & HUMAN SERVICES' E C E IV E Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 3~(~7'~ 1997 Municipality of Anchorage Health Authority Approval Checklist Dept. Health & Human Services Legal DescriPtion: L,o'~ ~o~, ~ ~OEG, ~"~.(3[ ¢151o,',} Parcel I.D.: -0-/2. -'7,/ A. WELL DATA Well type ~)¢,,~,JAI'E. . If A, B, or C, attach ADEC letter. ADEC water system number ~/~, Log present (Y~)) I'J'o Date completed ¢- V-. Total depth Cased to H'ol '~ Sanitary seal ~/N) 'l/E. ¢, Casing height (above ground) Wires properly protected ~N) Date of test Static water level Well production FROM WELL LOG WATER SAMPLE RESULTS: Coliform Date of'SamPle: B, sEPTIC/HOLDING TANK DATA Date installed Io. o n Tank size Foundation cleanout (~N) Date of pumping C. ABSORPTION FIELD DATA Date: iflStalled I o Leng,t.h ~O' r '~ Width Effective.absorption area [ Date of adequacy test /"J Pumper g.p.m. AT INSPECTION g.p.m. Nitrate O o ~ 15 Other bacteria 1 Depression (Y/N) Collected by: S& s ENGINEERING 17034 Eagle River Loop Road, No. 204 Eagle River, Alaska 99577 Number of Compartments ~ Cleanouts (~r/N) High water alarm (~N) Fluid depth in absorption field before test (in.); Soil rating ~or fF/bdrm) 1. Z(so~System type _~',~n I I t i ~ Gravel thickness below pipe ~-~ Total depth Monitoring Tube present (~N) ¥,~ Depression over field (Y/~ /'J o Results (Pass/Fail) - ' For L/L bedrooms ~ Immediately after -- gal. water added (in.): Fluid depth ~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) Absorption rate = .g.p.d. If yes, give date 72-026 (Rev. 3/96)* D= LIFT STATION Date installed Manhole/Access (~N) High water alarm level Cycles tested Size in gallons I ~'o "Pump on" level at* ~f Z "Pump off" level at* . *Datum SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: I Se ptic/holding tank on lot I oD 4- Ioo + Absorption field on lot Public sewer main Sewer/septic service line I On adjacent lots Joo 4- On adjacent lots ~ oo '{- Public sewer manhole/cleanout t,,]/.~. Lift station ) Oo ~ 'f' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: 14- 15 Absorption field Foundation Zo '5 Property line ---- Water main/service line ~ °~ ~' Surface water/drainage J o~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: ~ '~o ~ ~ Water main/service line I t Building foundation Property line Surface water t Ioo 4- Curtain drain I~o~ ~-.~ o~J~ ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area Wells on adjacent lots I certify that I have determined thru field inspections and review of Municipal in conformance with M. OA HAA~guideli. nes in effect on this date. Signature ~/~Y//w/~' ' Engineer's Name Date ! I / I ~. / ~/"7 HAA Fee $ Date of Payment_ Receipt Number Waiver Fee $ record~ms are Date of Payment Receipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ~2~CHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date'-/~:// ~/C ~/ Legal Description (%nclude lot, block, subdivision, section, township, range) (a) Location (address or directions) (b) Applicants Name <c) (d) ~sines$ Telephone - Home Applicants Address Applicant is (check one) Lending Institution ~--q ; Owner/builder~ ; Buyer~ ; Lending Institution /t/~ /G~/~ / Telephone Address (e) Real Estate Co. & Aggnt Address (f) Telephone Mail the HAA to the following address: 2o ~ of Residence ' Single-Family'~--~ Number of Bedrooms Multi-Family~ O~her (describe) 3. Water Supply- Individual Well~~ Community~ Public~ Note: If community well system, must have w~.ttten confirmation from the State Department of Environmental Conservation attesting to the legality and status° 4. ~ewage Disposal Onsite~ Public~ -Communtty~--~ 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] Engineering 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 varify 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 DHEP Approval Approved for__~ Approved _/~ Telephone bedrooms Disapproved Terms of Conditional Approval CAUTION Tt~ Mb~ICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONb~NTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENt- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED %N 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 REQUIRE- MENTS. ~IPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE ~ONICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN ~ PROFESSIONAL ENGIHEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 ae Well Classification Well Log P~esent (Y/N) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: If A, B, c~ C, D.E.C. Approved(Y/N) Date Cc~pleted S:/~ ~/ Yield Total Depth /~9! caSed to Static Water Level 7~ / Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances f~om Well: To Septic/Holding Tank on Lot TO Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line / 1oo Pump Set At Depth of G~outing. "'~ Sanita=y Seal on Casing (Y/N) .y Depression Around Wellhead (Y/N) ~ ; On Adjoining Lots /~ ; On Adjoining Lots /u~ To Nearest Public Sewer Cleancut/Manhole ~/~¢~ To Nearest Sewer Service Line on Lot Water Sample Collected By ~),~-~ ; Date Water Sample Test Results ~ .~- ~ Cc~wents B. SEPTIC/HOLDING TANK DATA Date Installed ~/~ g ./~ ~ Size 7 ~ f'7~ NO. of Compartments ~ Standpipes (Y/N) .~/ Air-tight Caps (Y/N) / Foundation Cleanout (Y/N) Deim,-ession over Tank (Y/N) /~/ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) .h//~; for Holding Tank High-Wate~ Alarm (Y/N) /~//,~- Temporary Holding Tank Permit (Y/N) Separation Distances f~om Septic/Holding Tank: To Water-Supply Well /~w ~- To Building Foundation ~--o / To Property Line /~ ~- To Water Main/Service Line CourSe To Disposal Field ~ % To Stream, Pond, Lake, c~ Major Drainage [Page 1 of 2] 2-15-84 Ce ABSORPTION FIELD DATA Soils l~ating in Absorption Strata ~ 5- ~ Type of System Design /~/ Date Installed ~'i/~'~ ~,,~,~ ~( Length of Field ~ q- Width of Field ~ ~ I~-/ f+, /~/~ Depth of Field ~ ~ Gravel Bed Thickness ~ Square Feet of Absorption Aazea ~-~Q- Standpipss P~esent (Y/N) Depression ove~ Field (Y/N) fl.~ Date of Last Adequacy Test Results of Last Adequacy Test /~/~ ~ ~, Separation Distance f~om Absorption Field: To ~ate~-Supply W~ll -/~/~ ~ To P~ope~ty Line /~ -~- To Building Foundation ~5-~~ ~- To Existing or Abandoned System on Lot /ZOr~e~ ; On Adjoining Lots ~ ~ ~- To Wate~ Main/Service Line ~-~+ To Clltbank(if p~esent) To St~eam/Pond/Lake/o~ Majo~ D~ainage Course ,v/~ To D~iveway, Pa~king A~ea, o~ Vehicle Sto~a~e A~ea ~ /~ ~- C~ments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Wate~ Alarm Level at Tested fo~ Electrical Codes(Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Corm~nts ** Check Permitted Bedrccm Rating Against HAA t~equsst ** I certify that I have checked, verified, o~ conformed to all MOA HAA Guidelines in effect Signed ~/. ~ Date Company "~/~.~.,~ ~laoCZlO~ MOA NO. KB1/d5/s [Pa~e 2 of 2]