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Home My WebLink AboutREED LT 2 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211033 PID Number: 051-102-11 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name MICHAEL & KARLA BELLER ABSORPTION FIELD - EXISTING ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 23128 HOMESTEAD ROAD, CHUGIAK ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot REED 2 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line FtZ Ft. Well 200'+ -- 25'+ TANK z Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal. Surface Water 100'+ -- Material HDPE Number of compartments 2 Lot Line 10'+ -_ NA Foundation *$'+ __ i LIFT STATION Manufacturer Capacity Gal. Remarks *OUTSIDE SOIL BEARING PRISM. .4" INSULATION. Alarm location Electrical installed by Installer JRS PIPE MATERIAL House to tank 3034. Tank to 3034 drainfield Drainfield CO/MT 3034 Inspector FWCS BENCH MARK (Assumed elevation) 100 ft Inspection V1 4/26/2021 2nd 4/26/21 Location and description 3`d 41h BOTTOM OF SIDING ON-SITE WATER AND WASTEWATER SECTION APPROVAL A�l iAlPe� Conditional Approval: Date ' �:� *:49TM .....:*� " " "' • • • • Septic System ; Curtis Huffman Approved - �� 'c��,/•,• �C(�l u�a Date CE 128991 ..•��`�/r 11/30/21. . • ��.w li;'°ROFESSIO0 Note: this appr al do s not include well permit requirements.\\��lt�� ,f[CV LIU/UL/ 1 O) PID: 051-102-11 PERMIT: OSP211033 O?v�' O WOOD FENCE e WATERLINE NE PORTION OF LOT L, FCO 0 0� 0 Io / z�2 LOT 2, REED SUB. A -C=10,9' FCO B -C=30,4' ® C S.T. & INSTALLED A-11=14,8' CO 4. B -D=32,0' A -E=17,8' HDPE SEPTIC TANK 3 B-E=33,5' E \NDATIO1 TANKTOFOU EXISTING & OUTSIDE SOIL BEARING It FIELD PRISM APPROX. LOC OF WATERLINE DECK m �G• 3BR° 12.5 HOUSE 5.0 Lc3 SEPTIC SECTION SCALE, NTS REED LOT 2 PREPARED FOR: MICHAEL & KARLA BELLER 23128 HOMESTEAD ROAD CHUGIAK, AK 99567 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 firstwaterAK@gmail.com ®JLI \ V 1liLJ. ®®®® -00 ® k OF AL�gs C ,t9 TH i e DATE: 11/30/2021 SURVEY: HOLT � rtis Huffman 4 CE 128991 w DRAWN: FWCS 11/30/21 cs4' SCALE: 1'r = 20' � N, �FESSIOI��' DECOMMISSIONED EXISTING MH ® C S.T. & INSTALLED CO D NEW 1000—GAL HDPE SEPTIC TANK 3 DCO E WITH NEW DCO. EXISTING It FIELD %N'ft l 89 59' W 83.64 H CO rDCO / 98.81 (FINAL GRADE 96.13 1,000—GALLON 5.38 HDPE TANK EXISTING FIELD SEPTIC SECTION SCALE, NTS REED LOT 2 PREPARED FOR: MICHAEL & KARLA BELLER 23128 HOMESTEAD ROAD CHUGIAK, AK 99567 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 firstwaterAK@gmail.com ®JLI \ V 1liLJ. ®®®® -00 ® k OF AL�gs C ,t9 TH i e DATE: 11/30/2021 SURVEY: HOLT � rtis Huffman 4 CE 128991 w DRAWN: FWCS 11/30/21 cs4' SCALE: 1'r = 20' � N, �FESSIOI��' HOMESTEAD ROAD._____ N8959' w83.64 MUNICIPALITY OF ANCHORAGE 0 n -Site Ylfate r & 1Nestewaw Prog rare PO Bax 14ffiso 4700 Elmore Road Anchorage, Rlaska 92519 5D PhOnt: [947] 343-7944 Fax; M7) 343-7997 http: A%%y x_muni.org1ansbff 0n -Sita Wastewater DIsposal System Permit Perinit Number: 4S P211033 Work Type: epticTank Upgrade Tax Code Number, 05110211000 $4e Log al Address REED LT 2 GA3.5g $11to MailIng Adldmss: 23128 HOMESTEAD Rb. Chugiak Owner: DELLER MICHAEL H & KARLA K Design Engineer, FI FAST WATER CONSULTI N G This perm It is for the construc;tI#n of: Effective Date, Expiration Gate, Lot Size in $q Ft; Tota I Bedrooms: �zenx L �it.�1•rrncr�r 212021 V22M22 11166 ❑ Disposal Field 0 Septic Tank ❑ holding Tank ❑ Pdvy ❑ Frigate Well ❑ Water Storage All con atru ctian s Mall be in acoordan re wlth: I . The attached approved design_ 2. All requirements specified in Anchorage Ithunicipal code Chaplers 15.55 ami 15.65 and the State ofAla ske Wastewaler Disposal Regulatiiom (I8AAC72)and drinking Water Regulatlons (18AAC80) 3. The wastawater code requires Inspectlons during the instaltatron. The angineer shill noti[y the Development Services Department per AMC 15,65. PfaMa r7oNcation by calliri� X997) 343-7904 (24f7), 4, From OctobeT 15 to Apri 1 15, a subsu rFace sail absorption eyatem under constru ction du ring freezing wither shall be either_ a. Opened and Closed on the same day, or b. -Covered, seal , and healed to prevent freezing Spec-leiI Frovisions, *" The water line is to be localed prior Io-ronstructien. If the waterline is wiihln IV of the septlo. system and requires a desfgnchange, construction of the system will stop Rending On-:$ ite review andapproval, Received BY_ Date; Issued By: bate-, =2021 3 MUNICIPALITY F ANCHORAGE Development Services Department f` Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-102-11 Property owner(s) MICHAEL & KARLA BELLER Day phone 907-351-6870 Mailing address PO BOX 671647, CHUGIAK, AK 99567 Site address 23128 HOMESTEAD ROAD, CHUGIAK, AK 99567 Legal description (Sub'd., Block & Lot) REED LOT 2 Legal description (Township, Range & Section) Lot Size 11,166 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank ElUpgrade FXDuplex (D) ElHolding Tank ElRenewal ElMultiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 0 ' 25 Date of Payment: 2 ZIO Z Receipt Number: 71`3115 Permit No. 05PZ 110 3 3 Waiver Fees: Date of Payment: Receipt Number: Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / firstwaterAK@gmail.com February 13, 2021 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: REED LOT 2 The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic tank on the above referenced lot. We propose to install a 1000-gallon HDPE tank per the attached design to serve the existing 3-bedroom residence. The lot and area are served by a Class A Water System (Dawn Water). The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211033, Deb Wockenfuss, 02/22/21 FIRST WATER CONSULTING REED LOT 2 NO WELLS WITHIN 200' OF PROPOSED SEPTIC TANK LOT & AREA SERVED BY CLASS A WATER SYSTEM - DAWN WATER Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211033, Deb Wockenfuss, 02/22/21 . ' ' ' ��L If' -11* 01 H=' ��1[7.J1�d-2!11 jr-3� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 PERMIT NO: 860082 DATE ISSUED: 04/01/86 APPLICANT: FINIS SHELDON ADDRESS: P.O. BOX 67-1087 CHUGIAK, AK 99567 CONTACT PHONE: 688-3434 LEGAL DESCRIP: SUBDIVISION: REED LOT: 2 BLOCK: NA SECTION: 9 TOWNSHIP: 15N RANGE: 1W LOT SIZE: 11152 (SQ.FT. OR ACRES) I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulations and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage adjacent or nearby lot. SIGNED DATE: ___________________ APPLICANT; FIN SHWDO1,,1 ISSUED BY ��_ ' DATE: �~� °- -----C�'-------------��--------------- --------------- I'p ^a tw!/ /up . �p.~- o�&=�_9 , A_ '` -I- sz''t� u�Iw_".- i. X ^4~ W>e-i., � A / g5��`^'�-�+`~°^`�~'f`�� - ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite [3 ANCHORAGE, ALASKA 99503 (907) 561-5040 / JOB (' ~ ~'~ SHEE~' NO MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEIVI AND/OR WELL INSPECTION REPORT Address LEGAL DESCRIPTION TANKS "~ SEPTIC [] HOLDING TYPE OF SYSTEIVl TRENCH ~ BED L~ W. DRAIN [] OTHER / FT ,~0 FT Total at)SOf[)t~Ol~ erda WELLS FT FT RIVATE ~J OTHER (Identify) Ciass,h~-~ (~--B~;~ 7ola~ Depth Cased to "~r~e~ .... Dale Instadod REMARKS: FT DISTANCES SEPTIC TANK Municipal and Stale guidelines in ellacl on Ibis dale: ABSORPTION FELl] Health Department Approval: WELL WELL ,~/dT' /,,~ LOT LINE ..~.. ~ FOUNDATION AS-BUILT DIAGRAM tShov,, ~ocaho~, el weJl, sepac system, p~oper~y hnes, Ioundal~on, d~lveway, water bodies, Date: ENGINEER'S SEAL 72-013 (3/85) ...... ) 3; ,, 5 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: (ENGINt~AL) /0 ..->.z -~5'~ COMMENTS 50/L~' ,~/~-:;~'~ PERFORMED BY: /~:~: ~':~ /~:: I ' : " .... CER, IFY THAT THIS ~EST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECTON THIS DATE. DATE: 72-008 (Rev. 4/85) WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? p E Deplh to Waler After ~onitorinD? Date: Reading Date Gross Net Depth to Net Time Time Water Drop / /~:/. /o >,/,v' ,. ,/r: ,/? I~/~) ,~7 PERCOLATION RATE//-'~'? / ¢,utes/,nch)/~PERC HOLE DI~ER TEST RUN BETWEEN ~ FTAND. Township, Range, Section: '7~/~X ,,~/ SLOPE SITE PLAN MUNICIPALITY OF ANCHORAGE Development Services Department �1 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-34 7A 7 Certificate of On -Site Systems Approval Parcel I.D. 051-102-11 Expiration Date: (r q- 1. Z 1. GENERAL INFORMATION Complete legal description REED LOT 2 Location (site address) 23128 HOMESTEAD ROAD, CHUGIAK, AK 99567 Current property owner(s) MICHAEL & KARLA BELLER Day phone Mailing address Real estate agent PO BOX 671647, CHUGIAK, AK 99567 2. TYPE OF DWELLING: E Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic Water Storage ❑ Holding Tank ❑ Community Well ® Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Dista Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ c6- 9 O Waiver Fee $ Date of Payment Date of Payment Receipt Number 7� 5 5� Receipt Number COSA # 05 2 10 H 5 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 2/13/2021 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & FWCS 6. DSD SIGNATURE 2 XSystem #1 Approved for 3 bedrooms System #2 Approved for bedrooms Disavoroved .r- Tt-I r • • ' Curtis Huffman . • . ' . CE 128991 .•�4�� PROF S ONa,��' Conditional approval fo� bedrooms, with the following stipulations: Original Certificate Date! 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 Legal Description: REED LOT 2 Parcel ID: 051-102-11 If more than 1 septic system on lot: COSA Checklist # _of _ Structure served by this system _ A. WELL DATA - CLASS A WELL ❑ Well log is filed with Onsite (or attached) Date drilled Total depth _ft Cased to _ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) — in. Date of flow test for COSA Static water level at beginning of test _ft. Comments B. TANK DATA Age of tank(s) NEW TANK years Tank type/material SEPTIC / HDPE Measured operating fluid level in septic tank NEW ® Standpipes/foundation cleanout per record drawing Date of pumping NA D. ABSORPTION FIELD DATA Which system tested (date installed) 10/17/1986 ® ALL standpipes present per record drawing Total measured depth from grade 3_9 ft (max) Measured depth to pipe invert from grade 3.4 ft (min) ❑ N/A – pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective Well production at time of test _gpm Water storage tank volume_ gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate _mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by. Date of Sample C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: NEW TANK INSTALLED Adequacy test date 2/12/21 Results 0 Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 500 gal New depth 0.5 in Elapsed time 1400 min ®Code -required soil cover over field Final fluid depth 0 in ® System presoaked Absorption rate 450 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) Gallons introduced 2000 gallons If yes, enter date Comments/Deficiencies:. FES E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' IN Yes if No Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft ❑ Yes if No Neighboring Tank > 100' ❑ Yes if No ft Private Sewer/Septic Line > 25' ❑ Yes if No Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' ❑ Yes if No Neighboring Absorption Fields > 100' From Absorption Field on Lot to: (Please enter distances if Animal Containment > 50' ❑ Yes if No ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' M Yes if No _ ft Manure/Animal Excreta Storage > 100' Water Main > 10' Community Sewer Main > 75' ❑Yes — if No ft El Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ft ft ft ft ft ® Yes if No ft Property Line > 5 IN Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑C Yes if No ft If absorption field is under driveway comment below Property Line > 10' M Yes if No _ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells >' 100 _ ®Yes if No ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. 2 7H .. .... ....L .^.... Curtis Huffman b �FG'��•. CE 128991��i/� �i ft 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 HAA # 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Day phone Lending agency Mailing address Agent Address 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. 5. STATEMENT OF INSPECTION BY ENGINEER Address 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 (egulations in effect on the date of this inspection. Name of Firm ¢__~,.o~¢-~,~ ~ ~'~E.--74:--'~-¢~ Phone ~'~o~fi' Engineer's signature ~:Y DHHS SIGNATURE --~',~_ Approved for Disapproved. Conditional approval for 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 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. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Parcel I.D. A. WELL DATA Well type IfA, B, orC, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed Driller Total depth Cased to Casing height__ Sanitary seal (Y/N) Wires properly protected (Y/N) FROM WELL LOG AT Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot __ Absorption field on lot ~.._)v ; On adjacent lots ; On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer service line Petroleum tank WATER SAM~ RESULTS: Coliforn Nitrate Other bacteria sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed I Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size ~ OO(::) Compartments Foundation cleanout (Y/N) Y Depression (Y/N) ~ Alarm tested (Y/N) IXJ/~ .A.-,m&(~6"P bet"r~z~zo,,~ O-.~¢,~--'¢~ Pumper I",,/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage On adjacent lots Absorption field 'PI dip' Foundation ~ Water main/service line -F'%0 ' 72-026 (Rev. 7/91) Fronl CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) ~ Vent (Y/N) "Pump on" level at ...._.-~'~level at High water alarm level ~,,~...~,.~-~Cycles tested Meets MOA electrical codes (Y/N) ~ SEPARATION DIS~F..A~T STATION TO: We~crF6~ot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed I Length -z'~O ' Width 4-s o Total absorption area Depression over field (Y/N) Cd Results (pass/fail) Soil rating 8~ Y~: /~;~:Jv¢-, System type Gravel thickness ~ ~ ~ 'e' ¢'=5'Total depth Cleanouts present (Y/N) Date of adequacy test for Peroxide treatment (past 12 months) (Y/N) ~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot h¢ ~ If yes. give date bedrooms On adjacent lots F/~ ('-Hoe*) Propertyline To building foundation Z.l' To existing or abandoned system on lot On adjacent lots '* ~' Cutbank 4- ~ oo' Water main/service line -P ~o ' Surface water +~:o' Driveway, parking/vehicle storage area J~ Curtain drain ~- E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in:eEect on,the date of this inspection Engineer's Name ~, HAA Fee $. Date of Payment 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number