HomeMy WebLinkAboutROSEBUD HILLS BLK 1 LT 7 " 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: SC',-' p7OO ~$' PIDNumber: O/ 7'~,~!3 ~
Name: ~7 ~ Wastewater System: ~ New D Upgrade
Address:
/z~o~ ~ n~ ~ ~, ~ ~e~/~ ABSORPTION FIELD
No. of Bedrooms:
Phone: ~ . ~_~ ~ ~ ~ DeepTrench D Shallow Trench O Bed D Mound D Other
Total Depth from original grade:
LEGAL DESCRIPTION SoilRating: ~,~- GPD/Sq. Ft. J~* It
D:~c'~: Subdiv~ion: Depth to pipe bo~om from original grade: Gravel depth beneath pipe
Lot: 7 ~ ~oz¢~ 8, IIz E. ~ ' Ft. ~. Z Ft.
Township: ~ Range: ~ Section: Fill added above original grade: Gravel length:
1,~ Ft. ~ ~ ~ ~ I0 ~ Ft.
I
I
WELL: Nob D New ~ Upgrade Gravelwidth: Number of lines: Distance be~een lines:
~ ~'~' Ft. ~ ~ O Ft.
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption ares: Pipe material: ~-~/O
Ft. Ft. t ~ ~ SQ. Ft. 0-30 ~ Non .
Driller: Date Drilled: Static Water Level: Installer; Date installed:
Yield: GPM IPump set at: Ft. ICasing Height Ab°ye Gr°und:Ft. TANK
SEPARATION DISTANCES ~Septic ~ Holding D S.T.E.P.
To Septic Absorption Lift Holding Public/Private Manufacturer: Capscity in gallons:
From Tank Field Station Tank Sewer Lines ~ ~ ~ ~ {
Material: Number of Compa~ments:
Welk ~e e /
w~t~ ~to~' >too ~ - - MFT ~T~TIO~
Line Lot ~0' ~ ~' ~ . Size in gallons:,I Manufacturer:
Foundation ~ q ~ ~ ~ -- .- - "Pump on" level at: "Pump off" level at: High water alarm at:
Cu~ain Pump Make & Model I Electrical Inspections pedormed by:
Drain .... --
I
Remarks: ~ys~e~ i~//~ ~ ~~ BENCH MARK
Location and Description:
Assumed Elevation:
ENGINEER'S SEAL
Inspectionspedormed by: ~' ~ ~ Dates: 1st "/7/97~~~e~
2nd ~/7 197 ~ ,~-~o~o,':: ~, ~ .~,~, ~:'
Department of Heal.and ~u~an~Se~ices approval ~2~:% c~. sz~,, ~,.
Reviewed and approved by: _ Date: ~- 2~-G~ ~-t~z:b$:c,~?t;,,~
72-913 (Rev. 9/91) MOA 25
I
PAGE 2 OF 3
PERMIT NO: SW970025
PID NO: 01738134
TBM ,,,%
1000 GALLON
SEPTIC TANK
DOUBLE C.O. ~
'H' .D.
- E-
52' LONG 77. H.
SOIL ABS. M.T.
TRENCH
'T' ~ 'F"
M.T.
rep I,ac em e,~ P.. '"G"
NOTE: THIS IS NOT A SURVEYED P~T.
LOCATIONS OF FEATURES WITH RESPECT
TO PROPERTY LINES ARE APPROXIMATE
RIDGEVIEW
DRIVE
NOTE: PER CONVERSATION
WITH KEN DUFUS ON 8/13/97
THE RESERVE AREA FOR
THE LOT 8 SEPTIC SYSTEM
IS LOCATED EAST OF THE
PRESENT SYSTEM ON LOT 8
APPROX. SITE FOR
PROPOSED WELL
SWING TIES:
FROM: COR. "A" COR. "B"
TO:
S.T.C.O. "C" 56' 48'
S.T.C.O. "D" 57.5' 53.5'
DBL. C.O. 'E' 59' 57'
TR. M.T. "F" 71' 83.5'
TR. C.O. "G" 92' 107'
TR. C.O. "H" 73.5' 58.5'
TR. M.T. '1" 84.5' 84'
TR. C.O. "J' 95' 101'
50' LONG
SOIL ABS.
TRENCH
LOT 8
LOT 7 ROSEBUD HILLS
SEPTIC SYSTEM INST.
AS-BUILT INSP. REPORT
FLATTOP TECHNICAL SERVICES SCALE: 1" = 30'
14530 ECHO STREET DRAWN BY TFM
ANCHORAGE, ALASKA 99516 AUGUST, 1997
'PERMIT NO: SW970025
PAGE 3 OF 3
PID NO: 01738134
INV.
88.3
1000 GALLON
SEPTIC TANK
INV.
88.0
1.5' FILL
"~
ORIGINAL ''
GROUND i',
ELEV. 93.4'
INV. 87.5'
BOTH ENDS
OF BOTH
TRENCHES
SEWER
GRAVEL
BOTTOM
TRENCH
ELEV. 78.3
T.H. #1 M.T. DRY
~.,,~.,~'~_'~_~,~,~,. ~'~ 8/7/97 ELEV. 69.4'
~..'
~.~ ~..?~..~ .... ~.~
LOT 7 ROSEBUD HILLS
SEPTIC SYSTEM INST.
AS-BUILT CROSS-SECTION
FI~TTOP TECHNICA~ SERVICES NOT TO SCALE
14530 ECHO STREET DRAWN BY TFM
ANCHORAGE, ALASKA 99516 AUGUST, 1997
WATER WELl. RECORO
WELL DEPTH' , / ~.. DATE OF COMPL~
r ' : DEPTH,TO STATIC WATER L~ELt ' .::
GRAVEL PACK TYPE:
~:.,/~,,,:~.,. . ....
'. NOV 4 1998 D~ELOPMENT M~IHOD~
PUMP INTAKE DEPTHt , ft Horsepowert
{MATION; REMARKS; ":
~' · ' / , Z? ", ' ,' ".~;'~- ...: .' ','.;
.... .. . ..... · ~ ...... ~",~= ',~- ~ ,',~
~ .... ' · :, ............... · . .. .... ..n. ,~. ~; .... ·
Ted NU ~E:G8 866~'0E'~°0 ESSO S~ L06 qqI~ ~NISqU :
PAGE 1 OF 1
MUNICIPALITY OF A/NCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW970025
DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES
OWNER NAME:HANSEN ALLAN B & HENRIETTA
OWNER ADDRESS:5701 RIDGEVIEW DR
ANCHORAGE, ALASKA 99515
PARCEL ID:01738134 '~ ~ "' ' ~'~
DATE ISSUED: 2/21/97
EXPIRATION DATE: 2/21/98
LEGAL DESCRIPTION:
ROSEBUD HILLS BLK 1 LT 7
LOT SIZE: 56333 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL 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 (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 lIND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVEDBY:
DATE: ~//7 / g7
DATE: ?-- 2 ! --
CWIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS
THEODORE F. MOORE, P.E. 14530 ECHO ST.
PH: (907) 345-1355 February 10, 1997 ANCHORAGE, ALASKA 99516
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dem' Sirs:
The purpose of this letter is to provide the required design narrative in support of our application for a
permit to construct wastewater disposal facilities on Lot 7, Block 1, Rosebud Hills, located at 5701
Ridgeview Drive. Soils logs, perc test results, a site plan, design drawings and specifications are enclosed
for your review.
The proposed system will be constructed in the vicinity of test hole # 1. As can be seen from the soil
log, the native material between 11 feet and 24 feet is a silty fine sand with a measured perc rate of 60
minutes per inch. Using the soil application rate of 0.45 gpd/sq, ft. specified in the wastewater ordinance,
this 3 bedroom residence requires a total absorption area of (3 x 150)/0.45 = 1000 square feet. The
proposed 2 parallel 50 foot long trenches with 10.5 feet of sewer gravel between 5.5' and 16' below
ground level has 1000 square feet of effective absorption area in the designated absorption stratum. The
additional sewer gravel in the trench above 11 feet will protect the installers from the danger of sidewall
collapse and will provide an unquantifiable amount of supplementary absorption area.
The topography of the lot slopes in the vicinity of the proposed construction slopes down towards the
west at approximately 5%.
The proposed project will have no significant impact on present or future water supply and wastewater
disposal systems serving adjacent properties, nor will it have any significant impact on reserved space-
surface and subsurface, or on drainage. ~,
Please give me a call at 345-1355 if you have any questions on this submittal.
Sincerely,
Ted Moore, P.E.
MUNiCiPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
FEB ! 0 1997
RECEIVED
LOT 2, CbNTbUR o
SEPTIC LOT 1, CONTOUR ACRES, ADDN. #2
ACRES, ADDN. #2 SYSTEM
O
LOT 6
(VACANT)
CONSTRUCT
2 PARALLEL
50' LONG SOIL
ABS. TRENCHES
WITH 10' SEWER
GVL. BELOW PIPE
SITE FOR
SIMILAR
REPLACEMENT
TRENCHES
LOT 4
BLK. 2
FDN. ',
C.O.
5%
,, T.H.
,' #2 ,'
INSTALL
1000 GALLON
SEPTIC TANK
RIDGEVIEW DRIVE
SEPTIC "-
SYSTEM '
TRACT A, BLOCK 2
ROSEBUD HILLS
LOT 8
, (VACANT)
FLATTOP TECHNICAL SERVICES
14530 ECHO STREET
ANCHORAGE, ALASKA 99516
-- --FEET~ --
HOUSE
LOT 7, BLK. 1, ROSEBUD HILLS
PROP. WELL AND SEPTIC SYSTEM
SITE PLAN
1 INCH = 50 FEET
DRAWN BY TFM
FEBRUARY, 1997
NOTE: THIS IS NOT A SURVEYED PLAT.
ALL LOCATIONS SHOWN ARE APPROXIMATE.
20 0 20 40 60 80 100
,/ 4" DIA. D-$034 \ DBL. ~ M.T.~
~ J CONSTRUCT 2 PARALLEL
~ ~ BELOW DIST PIPE. BOTTOM OF
~4" DIA. ~ TRENCH AT 16' BELOW GROUND
o.o.
PLAN VIEW
SCALE: 1" = 10'- 0"
-- MONITOR TUBE
_L 12"
3
ORIG. GND ....
6 INCH
4" DIA. D-3034 --
1000 GALLON
SEPTIC TANK
FABRIC
- 2 1/2" GVL.
OF EXC.
SECTION "A - A"
SCALE: 1" = 8'- 0"
LOT 7, BLK. 1, ROSEBUD HILLS
SEPTIC SYSTEM INSTALLATION
PLAN AND CROSS-SECTION
FLATTOP TECHNICAL SERVICES
14530 ECHO STREET
ANCHORAGE, AK, 99516
SCALE: AS SHOWN
DRAWN BY: TFM
FEBRUARY, 1997
Flattop Technical Services
14530 Echo Street, Anchorage, AK99516
Phone (907) 345-1355
Lot 7, Block 1, Rosebud Hills S/D
5701 Ridgeview Drive
Wastewater disposal system installation
Specifications
1.0 General:
1.1 The scope of the project consists of installation of a I000 gallon septic tank and construction of
two parallel 50 foot long soil absorption trenches containing a total of 10.5 feet of sewer gravel.
1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor
deviations from these drawings may be allowed or required by the engineer conducting the inspections.
All constmction procedures and material specifications shall conform with Municipal and State
requirements. All separation distances shall be in conformance with Municipal requirements, unless
specifically waived.
1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work around any
buried utilities.
1.4 The contractor shall provide adequate cover material and rough grading over all system
components to ensure that proper drainage is achieved after settlement and that there are no residual
depressions. Insofar as possible the contractor shall minimize damage to trees and existing lawn areas.
1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after
the soil is compacted, as well as placement of topsoil and reseeding all areas disturbed by the construction.
2.0 Septic Tank:
2.1 The new 1000 gallon, 2 compartment septic tank shall be Municipally approved and shall be set
level on undisturbed soil. Each compartment shall be equipped with a watertight manhole cover and a 4"
cleanout. If the tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial type,
rigid insulation.
2.2 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The
waste line from the residence to the septic tank shall have a minimum slope of 1/4'" per foot, and the waste
line between the tank and the soil absorption system shall have a minimum slope of 1/8" per foot. A
cleanout shall be installed within 5 feet of the building foundation, and a double cleanout shall be installed
within 5 feet downstream of the septic tank.
3.0 Soil absorption system:
3.1 The soil absorption system shall be constructed by excavating two parallel 50 foot long soil
absorption trenches to a total depth of 16 feet below original ground level.
3.2 The bottom of the trenches shall be level. Any compacted or smeared surfaces shall be raked to
allow proper infiltration. Sand for leveling or serving as filter material shall comply with Municipal
specifications.
3.3 A total of 10.5 feet of approved sewer gravel shall be placed in the bottom of the trenches with the
perforated distribution pipes laid level such that the pipe inverts are no less than 10.0 feet above the bottom
of the sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing the
#200 sieve.
3.4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on
the design drawings. The portion of the monitor tube extending through the sewer gravel shall be
perforated.
3.5 Approved filter fabric shall be placed over the entire top surface of the sewer gravel. A minimum
of 2 feet of soil cover is to be placed over the filter fabric. If the soil cover thickness is less than 3 feet,
two inches-of rigid, burial type insulation is to be placed over the entire top surface of the gravel, in
addition to the filter fabric.
3.6 The top surface of the cover material shall be raised a minimum of 12 inches higher than the
surrounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill
slopes shall be no steeper than 3:1.
3.7 Unless specifically agreed otherwise the homeowner shall be responsible for arranging to have the
site finish graded after the backfill material has stabilized, and for placement of adequate topsoil and seed
to promote rapid revegetation of all areas disturbed by the construction.
4.0 Inspections:
4.1 A minimum of 4 engineering inspections will be required during the course of the project: (1)
initial stakeout with the contractor to establish the location of the system and to discuss the plans,
specifications and construction procedures, (2) after the native material has been excavated to expose the
infiltrative surface to ensure that it is level and at the right elevation, and conforms with the soil test
information, (3) after the sewer gravel is in place and the distribution pipes have been laid and connected
up to the septic tank, but prior to placement of insulation or filter fabric, and (4) after rough backfill and
grading is complete. The septic tank requires one inspection after it is set level and the piping connected,
but prior to backfill. This inspection may be incorporated with any of the above inspections.
4.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in
advance to ensure the availability of the engineer.
TEST HOLE
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
DEPTH
(feet)
24
B.H.
COMMENTS:
FLA'I-rOP TECHNICAL SERVICES
14530 ECHO ST,
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
Lot 7, Block 1, Rosebud Hills S/D
September 25, 1996
Cathy Kerr
Pt.
SM silty loam
ML Gray gravelly silt
dense, damp
SM Very silty fine sand
Gravellier between
11' and 12'
Siltier near bottom
SLOPE
)
55 Ii
'~ ~ T.H.
#1
T.H.
#2
RIDGEVIEW DRIVE [~-
Depth to Groundwater Date
No Groundwater 9/25/96
Monitor tube dry 9/26~6
Monitor tube dry 10/3/96
Clock Net Time Percometer Not Drop
Date Reading Time (minutes) Reading (inches)
9~25 12" Presoak
9~26 Resoak
Start 11:11 7 1/16
#1 11:31 20 6 11/16 3/8
Add water 11:32 7 3/8
#2 11:52 20 7 3/8
#3 12:12 20 6 5/8 3/8
PERCOLATION RATE 60 (minutes/inch) PERC HOLE DIAMETER 8"
TEST RUN BETWEEN 12.5 FTAND 13 FT
Test hole dug using a track mounted auger. Split spoon samples observed at 5' intervals.
PERFORMED BY FLA'I-rOP TECHNICAL SERVICES. I ,'~ "~4¢,-o..,<_ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: [~/__? /~0~
TEST HOLE# 2
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
DEPTH
(feet)
COMMENTS:
FLATTOP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
Lot 7, Block 1, Rosebud Hills S]D
September 25, 1996
Cathy Kerr
Pt.
SM silty loam
ML Gray gravelly silt
Softer drilling below 7'
Similar to T.H. #1
SLOPE
Depth to Groundwater Date
No G~oundwater 9/25/96
Monitor tube dry 9/26/96
Monitor tube dry 10/3/96
SITE PLAN
55 II
~ RDGEVIEW DRIVE ~
SM Silty fine sand
Similar to T.H. #1
Clock Net Time Percometer Net Drop
Date Reading Time (minutes) Reading (inches)
9/25 12" Presoak
9/26 Resoak
Start 11:11 6 9/16
#1 11:31 20 6 3/8 3/16
Add water 11:32 6 3/4
#2 11:52 20 6 9/16 3/16
#3 12:12 20 6 3/8 3/16
PERCOLATION RATE >60 (minutes/inch) PERC HOLE DIAMETER 8"
TEST RUN BETWEEN 4.25 FTAND 4.75 FT
The perc test data shown on this sheet applies to a separate perc test hole located 9 feet south of test hole #1.
PERFORMED BY FLA'I-rOP TECHNICAL SERVICES. I ~7~J_~..~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: t ¢' [.? t/ ~ O/
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/'7- ~g- J~gt/
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailin. g address
Agent
Address
uay phone
Day phone
e
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-O25(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 verifythat 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 Phone
Address
Engineer's signature
Date
DHHS SIGNATURE
V Approved for *-/"//-///~E- bedrooms.
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 IRev. 1/91) Back MOA #21
Municipality of Anchorage '-'
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division , !','VIRONM[NTAL 5[:RVICES
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
Health Authority Approval Checklist
A. WELL DATA
Well type 1~_
Log present (Y/N) y
Total depth t t./~'~
Sanitary seal (Y/N) ~//
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to
FROM WELL LOG
Date of test
Static water level
Well production
Casing height (above ground) ~-- 7
Wires properly protected (Y/N) 5/
AT INSPECTION
g.p.m.
WATER SAMPLE RESULTS:
Date of sample: ~
B. SEPTIC/HOLDING TANK DATA
Date installed '~/'7 / ~7 Tank size
Foundation cleanout (Y/N)
Date of Pumping
Nitrate
~,/e( ~/L~. Other bacteria
Collected by:
Number of Compartments Z- Cleanouts (Y/N)_TZ~.~
High water alarm (Y/N) 1,~1
~:). q~"- System type / ~ ~
?. ,~- Total depth /~', /
· Depression over field (y/N) 1'"~
bedrooms
C. ABSORPTION FIELD DATA
Date installed ~ [~ I~ ']
!
Length ~ ~-~!~. Width
Depression (y/N)
Pumper
Soil rating (g.p.d./ft~ or fF/bdrm)
Gravel thickness below pipe
Effective absorption area ! g' ~2~ Monitoring Tube present (Y/N) '"/
Date of adequacy test J~ ~ ,L ~ ~ ~ Results (Pass/Fail) / For ~
Fluid depth in absorption field before test (in.); ' ~ Immediately after ~gal. water added (in.):
Fluid depth ~'/ (ins) Minutes ater: ~ Absorption rate = ~'/ g.p.d.
Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date ~
72-026 (Rev. 3/96)*
D. LIFT STATION ~- V/-.~-
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
~ E, SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ! O 1~
Absorption field on lot i 1 ~'
On adjacent lots
On adjacent lots
Public sewer main ~"~///~
Sewer/septic service line "Z ~ O
Public sewer manhole/cleanout ~"~/~'~'
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ,~ ? Property line 50 t ~ Absorption field
Water main/service line ? J~ c~ Surface water/drainage. ~'''J /o Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water
Curtain drain
Building foundation /-/r 7 Water main/service line /% S~,~
Driveway, parking/vehicle storage area ~ ,2. ~'-'
Wells on adjacent lots ,~ / ~
ENGINEER'S CERTIFICATION
· . ,
I certify that I have determined thru field inspections andhire;;etw of Municipal records that the above syster~¢ a e
in conforrnance with MOA HAA guidelines in effect on this d, te.
Signature ~ -
Engineer's Name t ~ ~---~
HAA Fee $ ~'~
Date of Payment
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
CT&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
986058006
Tobben Spurkland P.E.
r }.1... r
Lt 7 Rosecloud Hills
Drinking Water
0
Sample Remarks:
Client PO#
Printed Date/Time 11/04/98 11:04
Collected Date/Time 11/01/98 12:10
Received Date/Time 11/02/98 08:00
Technical Director: Stephen C. Ede
Parameter
Results PQL Units Nethod
AlLowable Prep Analysis
Limits Date Date Init
Total Coliform
Nitrate-N
o
3.19
cot/lOOmL SH18 9222B
0.100 mg/L EPA 300.0
lO max
11/02/98 KAP
11/02/98 11/02/98 GCP