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Home My WebLink AboutPETERS GATE BLK 1 LT 12Onsite File Peters Gate Block 1 Lot 12 #051-541-05 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201041 PID Number: 051-541-05 Dwelling: ❑® ,Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑® Upgrade Name ALBEE JOHN M & JUDY L ABSORPTION FIELD ❑ epTrench El Wide Trench ❑ Bed ❑ Mound Site Address 25057 Sierra Mesa Cir Chugiak ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 PD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from origina ode Gravel depth beneath pipe Subdivision Block Lot PETERS GATE 1 12 Ft. Fill added above original gradevel Ft. length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distabetween lines Ft. SEPARATION DISTANCES To Septic I Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between -nches From Tank Field Tank Line FC Ft. Well >100' NA I NA NA TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1000 Gal. Surface Water >100' NA NA NA Material Number of compartments Lot Line >1Q' NA NA NA NA plastic 2 Foundation > Q' NA NA NA FT STATION Manufacturer Capacity Remarks 2" INSULATION OVER TANK Gal. Alarm location Elec ' a 'stalled by Installer PIPE MATERIAL House to tank 3034Tank to 3034 drainfield JRs Septic Drainfield Co/MT3034 Inspector Curtis Townsend BENCH MARK (Assumed elevation) 100 ft Inspdecct Sn 15t 6/4/2020 2nd 6/6/2020 Location and description 3'd 7i25i2Q6 41" CONCRETE PAD AT POINT B ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: DateAO �.• :� �� . ........ . P � 2. ....� �� Date' �1 Septic System9�6au Approved Isaa Date �F• c'�lF •No.CE11964 �aV® RF Note: this approval does not include well permit requirements. PROFES (A" k acv vo,v- iUJ J J w Z 0 J Z 0 Of �o w � Z Aa- E� LJ ZU)� i EXISTING 65' x 5' x 24" EFFECTIVE DEPTH TRENCH DOUBLE CLEANOU NEW 1000 GAL SEPTIC TANK UNSUBDI VIDED STA TE PARK THERE ARE NO STEEP SLOPES WITHIN 50' OF THE PROPOSED TANK. T SCOPE OF WORK 4j 1. PLACED NEW 1,000 GALLON SEPTIC TANK J AND TIED INTO EXISTING ABSORPTION / SYSTEM. THE TANK WAS PROVIDED WITH MINIMUM 20" 0 MANWAY RISER SERVING THE FIRST COMPARTMENT. 2. ALL CONSTRUCTION WAS IN ACCORDANCE WITH ALL REQUIREMENTS SPECIFIED IN SEPTIC AREA ' ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65. c//PQ E T NEIGHBORING WELL IS > 100' FROM PROPERTY LINE As Built Drawings Prepared for r ILU11 �P •,•••... • q��s�i�i JOHN AND JUDY ALBEE .•��E O ••••. 25057 Sierra Mesa Cir Chugiak, Alaska 99567`?�''+ •'' 9 0 PETERS GATE BLOCK 1 LOT 12 49 " - *� OSP201041 ............. ...................... f ....................................... EKLUTNA ENGINEERING, LLC DATE: 7/28/2020 :;CURTIS TOWNSENDx [BRAWN: CLT I� N 19162 MOUNTAIN ROAD �� o7C 1904 2 1/904 r CHUGIAK, ALASKA 99567�j•'•••• ....,. D 5 SHEET ' a• (907) 355-9820 PA 051-541-0 1" = 40 2 OF 3 ' �+'i,��;��.�� NOTES: 1. DIMENSIONS ARE RECORD PER PLAT 74-146. 2. UTILITIES OTHER THAN THOSE SHOWN MAY EXIST. 3. THIS SURVEY DOES NOT CONSTITUTE A BOUNDARY SURVEY AND IS SUBJECT TO ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. UNDER NO CIRCUMSTANCES SHOULD ANY DATA SHOWN BE USED TO ESTABLISH ANY FENCE, STRUCTURE OR ANY OTHER IMPROVEMENTS. 4. ALL VISIBLE ABOVE GROUND FEATURES OF THE EXISTING SEPTIC SYSTEM WERE LOCATED AT THE TIME OF SURVEY AND ARE SHOWN HEREON. LOT 11 UNSUBDIUIDED STATE PARK % ) 'S 12' X 12' (l 2ND STORY 124.5'± CANTILEVER 4.2'X7.' SHED i CONCRETE - PAD 3' PALLET-/\ FENCE 5. GRAVEL DRIVEWAY NOT LOCATED AT TIME OF SURVEY DUE TO SNOW COVER. ASBUILT - NO CORNERS SET THIS DATE L 16j 87 R, I HEREBY CERTIFY THAT I HAVE PERFORMED S��RR60 R1087-Of?95 OO' A SURVEY OF W4 1, LOT 12, BLOCK 1, PETERS GATE SUBDIVISION, PLAT N0. 74-146, ANCHORAGE RECORDING DISTRICT, ALASKA, . .. • • • • • . q.0_�1 AND THAT THE IMPROVEMENTS AS DEPICTED HEREON EXIST AS SHOWN IN RELATION TO THE PROPERTY LINES. EASEMENTS OF RECORD OTHER THAN THOSE SHOWN ON RECORDED PLAT No. 74-146 ARE NOT SHOWN HEREON UNLESS OTHERWISE NOTED. DATE: 7/27/2020 FB: 2020-1 GRID: NW 1262 DRAWN: DMR SCALE: 1" = 60' I FILE: 20-003AB • Dayna M. unfelt No. LS j 1 322 '1�lF9FpP'7I L��' ,NOSp2 i �l>,�AOfESSI0NA1.`a � PETERS GATE 2 0 LOT U LEGEND N SCALE 1" = 60' Q SUBDIVISION In PLAT 74-146 C WELL µ —STORY LOT 12 -- L J L FRAME HOUSE BLOCK 1 WITH WALKOUT I BASEMENT / GARAGE 12' X 6' 2' 'Z 2ND -STORY ^� ARCTIC ENTRY �� 2 0 LOT U LEGEND N SCALE 1" = 60' Q FOUND REBAR iS) SEPTIC VENT `WJ WELL - GUY WIRE -- L J L POWER POLE I TELEPHONE PEDESTAL - ( III - —OVERHEAD UTIUTY LZ MENDER SURVEY 6 MAPPING 2890 S BARNYARD CIR., WAS61A, AK 99654 DAYNA RUMFELT (907)301-5177 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-8850 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201041 Work Type: SepticTank Renewal Tax Code Number: 05154105000 Site Legal Address: PETERS GATE BLK 1 LT 12 G:1262 Site Mailing Address: 25057 SIERRA MESA CIR, Chuglak Owner: ALBEE JOHN M & JUDY L Design Engineer: EKLUTNA ENGINEERING, LLC" This permit is for the construction of: ❑ Disposal Field d Septic Tank ❑ Holding Tank ❑ Privy Effective Date Expiration Date: do �0entz S' Q, n i Department Lot Size in Sq Ft: Total Bedrooms-- El edrooms: 3/12/2020 3/12/2021 65340 ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (2417). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received B� Issued By: n Date: 9 �j /� Date: 3 i �C oc oz 0 3 9po &_Q�4 Development Services Department „! ne: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-541-05-000 Property owner(s) Mike Albee Mailing address PO Box 670758 Site address 25057 Sierra Mesa Cir Chugiak Legal description (Sub'd., Block & Lot) PETERS GATE BLK Legal description (Township, Range & Section) Lot Size 65,340 Sq. Ft. Number of Bedrooms 3 Day phone 907.244.7234 1 LT 12 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field E] Initial F] Single Famil SF) Q (w/ o ADU) Septic Tank Q Upgrade 0 pg Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify tha�the above information is correct. I further certify that this is in accordance with applicable Mu icipal Codes. 10 (Signatut`,e of property owner or authorized agent) Permit/Rush Fees: 996- Waiver Fees: Date of Payment: 3 % I 1 /01O g6 Date of Payment: Receipt Number:05P:261()(_(1 �� o7- & 35 � Receipt Number: V Permit No. 5 P :2 U 1() (_(1 Waiver No. GADevelopment Services\Building Safetyl0n Site Water and WastewaterTorms0lent Forrns\Permit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201041, Rebecca Carroll, 03/12/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201041, Rebecca Carroll, 03/12/20 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 ! J~rN EW MAILING ADDRESS LEGAL DESCRIPTION LOCATIO~ ~0, DISTANCE TO: /0 ~ ~ ~< Z Manufacturer ~g~ Material~ Liq. capacity in gallons Inside length Width Liquid depth /OO O IF HOMEMADE: ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. ~ -- ~ Manufacturer Material Liquid capacity in gallons Q Weld Foundation Nearest lot Dine ~ PERMIT NO, ·~ ~ DISTANCE TO: / O ~ ~O widt~ ~inches~ ~ Distance between lines ~Z~ N°'~°f lines~ Length of ~oeach Dine~ ~ Total length of Dines~o Trench ~ Top of tile to fin,sh~raOe~ . ~~'~ M.ter,aIBen.athtHe ~inch.s Total effective a~t~ area ken,th ~idth Depth P~MIT ~0. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area m Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE MATERIALS SO~L TEST INSTALLER REMARKS DATE LEGAL 72-013 (Rev. 3/78) MUNICIPALITY OF ANCHORAGE Department ~f Health and Environmental 7rotection 825 Street, Anchorage, AK. ~501 264-4720 * * * HANDWRITTEN PERMIT * * * Permit ~_~ W~ND/OR QN-SITE SEWER PERMIT Location: Mailing Address: Phone Number: Legal Description: ~ / ~! ~ ~~L~ Lot Size: Type of Soil Absorption System Is: Trench: Drainfield: ~ Seepage Bed: Holding Tank: Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br) /~_(~ DEPTH The Required Size of the Soil Absorption System Is: ~ ' LENGTH ~'~ GRAVEL DEPTH ~ Z~ ' 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(HOt~TNS) TANK SIZE = /~73~ 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. * * * TW0(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection.and approval by this departme~ will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fe( 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 1 9 8 3 * * * 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/u~rstand that the on-site sewer system may require enlargement if /%he re~idence~i~...o~eled to include more that 3 bedrooms. ~ppl~cant "J ~'Y " ' ~ Date: '~/~ ~[/~ SWP/024 (1/81) 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 LEGAL DESCRIPTION: SLOPE 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O COMMENTS PERFORMED BY: 72-008 (6/79) WAS GROUND WATER ~/~5 ENCOUNTERED? O P IFYES. ATWHAT 8y~.-~,x E DEPTH? ! Gross Net [ Depth to Net Reading Date Time Time Water Drop ~T z: oz Ibm;ri. : W ' PERCOLATION RATE TEST RUN BETWEEN 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST 6 -:~ 7 8 /0 10 11 12 13 14 15 17 18 19 20 COMMENTS PERFORMED BY: 72-008 (6/79) C. Reid, Jr. No. 2251.E WAS GROUND WATER ~ tS. ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net I Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BE~EEN Certificate of On -Site Systems Approval Parcel I.D. 051-541-05 Legal description PETERS GATE BLK 1 LT 12 Site address 25057 Sierra Mesa Cir Chugiak Current property owner(s) Albee Expiration Date: /",7 Z -d2 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: Z `J This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject systems) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory X Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 051-541-05 Complete legal description Peters Gate Block 1 Lot 12 Location (Site address) 25057 Sierra Mesa Circle, Chuigiak, AK 99567 Current property owner(s) John & Judy Albee Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 3 yrs - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ 2J7 0 Waiver Fee $ Date of Payment 3 2 3Z?OZ3 COSA #_ (9SC 231(959 Date of Payment Waiver # COSA Application—June 2022 Peters Gate Block 1 Lot 12 051-541-05 21 0.354 24+ Forge Engineering 1/25/23 49" 3/10/23 JR's 7/24/83 5.5 N/A > 450 Benjamin Schiller, P.E. (907) 522-7773 Well Nater Advisory Certificate of On -Site Systems Approval # OSC231058 Subdivision: Peters Gate, Block: 1, Lot: 12 This well's productivity was determined to be 0.07 gallons per minute. The minimum well productivity required under (AMC 15.55) for a 3 -bedroom residence is 0.31 gallons per minute or 150 gallons per day per bedroom. Although the well production does not meet this requirement, water storage has been provided to meet minimum code requirements. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. F MaiUng Address P O $ox 196650 *Anchorage, Alaska 1946650,1.,1 W w muni org MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date .5;/'/? i/~ 5' GENERAL INFORMATION (a,~ Legal Description (include lot, block, subdivision, section, township, range) _..zq,._~:t_,.__,.:; (~-~-~, ¢~. !:~/~,,_/¢ / z.o~- i~2- ~., i/ ~-~ ~ Locabon (address or directions) (b) Applicant Name -Z),,,~ ,,~,]~,.,-,~,-~,~ Telephone: Home ,¢,?,D :/'z/~'~ Business :Z ApplicantAddress Po z}~:~..Z?/~-~ ~- g ./~',~,/ Ic /~, v¢,- /),( ~/ ,¢ .~'- E' ~- (c) Applicant is (check one): Lending Institution [] ' Owner/builder ~t.; Buyer [] · Other [] (explain); __ (d) Lending Institution /x;)/4,. ~_.~-~",,, ~z-'/~ /,.¢;. · _ Telephone (e) Real Estate Company and Agent ___ - Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family~ Multi-Family [] Number of Bedrooms ..5 Other WATER SUPPLY Individual Well F' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL '~ Public [] Community [] Holding Tank [] Onsite 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 72-0~5 (~,~4) 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 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 regulations in effect on the date of this inspection. Name of Firm Address / 2 Date 5-/// Telephone Engineer's Seal Approved for '"'---~ bedrooms b - ate Approved '~,.,.. Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engine.er registered in 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 requirements. 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. Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MAY 3 2 1985 Legal Description: Well Classification Well Log Present (Y/N) '1~ $ Total Depth ~O,5" Cased to Static Water Level ~'0' Casing Height Above Ground Electrical Wiring in Conduit~'~l~l) V Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line t'J Cleanout/Manhole Water Sample Collected by' Water Sample Test Results Comments · F,-o,~, A~cS c,~l~c~,.. If A, B, C, D.E.C. Approved (Y/N) Date Completed ~ - lo - ~ Yield 2- I' (~J~o~-~ Depth of Grouting ~1,.~,~ ~- s.] Pump Set At r[~,~ 4- ~"~1 Sanitary Seal on Casing CN) Depression Around Wellhead (YO ., ./7~ ,./~/j[;~ · On Adjoining Lots ~oo + 1~-~'~'* ~-; On Adjoining Lots ~ o o' '-~ To Nearest Public Sewer To Nearest Sewer Service Line on Lot [',J ~ ;Date 5- ~.Y - ~.E B. SEPTIC/HOLDING TANK DATA Date Installed :7/~ff /~ Size ~o o No. of Compartments Z Standpipes CN) '1~-~ Air-tight CapsCN) 1¢~ Foundation Depression over Tank (Y/N) ~ ~ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ~o :~4f ' for Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holdino Tank: To Water-Supply Well , o~ To Property Line -- ~' To Water Main/Service Line Temporary Holding Tank Permit (Y/N) ~'J ^ Course t oo' 4 To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments~ F~o,,* ~ec.~ ,',~&¥,, Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~ - zH ~ Width of Field -'k 60" Square Feet of Absorption Area Depression over Field (Y/~. Results of Last Adequacy Test Type of System Design Length of Field ¢ G o Depth of Field ;~ ~ ~ Gravel Bed Thickness Standpipes Present~)N) Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot (,,q To Water Main/Service Line ~ ~ ~ + To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments'~' -I='r~ /+Ecs ~,,s?~-,~,~ To Property Line --r To Existing or Abandoned System on · On Adjoining Lots $ o '-~ To Cutbank (if present) D. LIFT STATION Dimensions ~ Manhole/Access (Y/N) Size in Gallon-'s'"~s~......,.......~ "Pump Off" Level at "Pump On" Level at ~ High Water Alarm Level at '"""'-~ ~ Pumping Cycles during Adequacy Test. Meets MOA Tested for ~---~ Electrical Codes (Y/N) Comments J ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed '~ ~,~' Date Company ~ E~ ~ [~- MOA No. Receipt No. '~ ~ ~ ~ ~ Date of Payment ~ -~-~ Amount: $ ~ E* Engineer's Sea Page 2 of 2 72-026 (11/84)