The URL can be used to link to this page

Home My WebLink AboutKASILOF HILLS BLK 2 LT 2Kasilof Hill Block 2 Lot 2 #015-161-28 - Jevelopr?nt Services Department \ BuildIny Safety Division / } On -Site rs4 ai r r+, WaStewater proorcm 1�t=�' 47FaStreet '/� P.O.O 30o, 9 : _96650 Mark Begich Anchorage, All 99519-6650 Mayor ;90734;-7904 - Pump Installation Log Well Drilling Permit Number: SW Date of Issue: Parcel Identification Number: Legal Description Property Owner Name & Address: A 'CGCG Pump Installation Date: Pump Intake Depth Below Top of Well Casing V6 feet Pump Manufacturer's Name: Pump Model: ,�G Pump Size % hp Pitless Adapter Burial Depth: U feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Completion? U Yes ❑ No Method of Disinfection: ,.� Comments: Anchorage Pump & Wall San Pump Installer Name: 330 Past 78th Avenue Anchorage, Alaska 99 518 Phoma: 007-24a-074.10 Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. MUNICIPALITY 01=ANCHORAGE %® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION _ 825 L Street - Anchorage, Alaska 99501 Telephone 204-4720 �- ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE NEW • / I r'7_ ❑ UPGRADE MAILINGADDRESS LEGAL DESCRIPTION LOCATION V NO. OF BEDROOMS 3 c Absorption area Dwelling mm '37 DISTANCE TO: �t�� t f- 2 Manufacturer Mater al/ w Ea..11 _�� _ _l.Ji-. _ Licl. ca acity in gallons �-� IF HOMFEIIADE: Inside length Width �_ -- PERMIT NO. T _ No. of comparunents n7 _: Lictuicl depth -- Well Dwelling DISTANCE T0 z : Z_--- - Q Manuf rer ate-r-ia -.- ._ PERMIT NO. I , .- iC` uid c•rp �i y �I ty in gallons � p -JDISTANCE TO: Well _ 7_ tet, Foundation Nearest lot ine PERMIT NO. _ a f--- No. of lines Length of each tie, i -- Total length of Ii q s Trench width - - �/-- —(n_ inches Distance bet eon lines I_ Top of tile to finish grade F; Material beneath tile h` -'T Total offer, ive absopoop alea G� 14+i4s -) 1--� Length Width �� Depth _-.�_ PEiRMIT NO. m Q f- w Lu Type crib _ _ _ _�L Crib diameter _ Crib depth Total effeci vE: absorption ai ea- i DISTA TO: Well f -{3n" din fou odatioi y Barest lot lin -- el ss Depth Driller Distance to lot line PER P.4T NO. w DISTANCE TO: Building foundation Sewer line Septic tank Absorption area (sl OTHER T- -- - - - PIPE MATERIALS i SOI L TEST RATING j lPeYLLER---- C REMARKS t C) I I �® DATE APPRO�V�ED��s LEGAL 13AWTA IX jDillin(D w1mimZ 13ox 13000 SWAM 110uWE: A ANCHORA(;mp AII.AsKA 0 502 344-771.4 SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF 2.. DRILLED AT THE RATE OF PER FOOT. PROPERTY OWNER.t1Qy�2 �LC�A LOCATION OF WELL SITE— 3iY. `.�. S=h�'�� -- MUNICIPAL.IIY OF ANC11pRAC7E DRILLER — N�n�r nF_IIEALTH & ENVIRONPIENTAL PROTECT-- IZ)1-- WELL LOG: 0-._-_23' 5�,U-tr- .f- n.e a>!,rzire.t rrl;th jeVeAat 4mG-U--- 23......41' CrjaAAe (7nn.cr(?- t F, AMC,,) dreAcack- Plan 47 to 50 deet. 50-2,` ' !1a urat.e.2. p�radt.tc#ion �ILot,r2n,r unt,1A 780 to 190 �,eet. ,4 9hanA0a1)c. t�).,qe )ck, 6hou•.Ln.g. a"Lea.------- _. R.14o about 7/2 %7" to an. a.'r.ea .Aom 798 to 207 -deet. 72om 27/+ -to 222 Deet ,,h.owr_7 — 1/2 %C2. 7'o tcL� toa ten p.h oduc;tion. 4h.awt d. 4h.a.,7 1 1/2 %I.'' tL Uh- an. il7r th use. 175 den ', of trrr,.teJ �.tand cher in c�c.o .rz 3/4 hwt4e SuJ�me�ro.t.C,t Pwa.,- �h.at�C.d he tn,6tab'c?,d 1$ .rent a ba -mat.. 300 9OA of t,valtpJe 2n /Lei,eJLur .U7. c-l�,r:r..nt. 1.0 CaLi pelt -'rio=t. 2500 to 3000 na.(� al waste.7- o.tra i. Ca.GLe. pe 2!f h. s_% , ; �r.e .Pi,, ,( Th.an.l: �'ou. JeJu�, i."u-ch .�� ...,.9„�-'�..q'w...� �...., _�•-11�.,�� BrAn,LP_. C.1-o-u.A a� Ra1Lp"A MUM 71: Q :E . 0f.. I -1-ows 13H Q T41 f? i 1 TV! M�� DEPARTMENT OF HEHLTH HND ENYIRONMENTHL PROTECTION STREET/ GNCHORHGE/ HK. 99501 264-4720 u( / �"T �TH 1,1M 1101 to, ASK Fw? rel X T PERMIT NO ( 810975 ) HPPLICHNT RODNEY CREW PO BOX 10-2201 99511 277-9618 LOCHTION GLRZHNOF STREET LEGHL L 2 B 2 KHSILOF HILLS S/D LOT SlZE 42000 SQUHRE FEET TYPE OF SOIL HBSORPTI8N SYSTEM IS� TRENCH MAXIMUM NUMBER OF SOIL RHTING (SQ FT/BR)� 125 THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS: �� too �K I .. �ERE �� 10, THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE BETWEEN THE SURFHCE OF THE GROUND HHD THE BOTTOM OF THE EXCHVHTION (IN FEET)_ THERE IS NO SET NIDTH FOR TRENCHES THE GRHYEL DEPTH IS THE MINIMUM DEPTH OF GRHvEL BETWEEN THE OUTFHLL PIPE HND THE B()TTOM OF THE EXCHYRTION (IN FEET). p. _q ��JOE. N2 0- Fit 1441102 S; 1: W Ey! — Vt. d�� PERMIT HPPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THIY� INSTHLLHTION INSPECTIONS OF HNY WELLS HDJHCENT TO THIS PROPERTY HND THE NUMBER OF RESIDENCES THHT THE WELL WILL. SERVE. �� BHCKFILLING OF HNY SYSTEM WITHOUT FINHL INSPECTION HND HPPROVHL BY THIS DEPHRTMENT NILL BE SUBJECT TO PROSECUTION MINIMUM DISTHNCE BETWEEN H WELL FIND ANY ON~SITE SEWHGE DISPOSHL SYSTEM IS 100 FEET FOR H PRIVHTE WELL OR 150 TO 200 FEET FROM H PUBLIC NELL DEPENDING OPON THE TYPE OF PUBLIC NELL MINIMUM DISTANCE FROM R PRIVATE WELL TO H PRIVHTE SEWER LINE IS 25 FEET HND TG H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS FIRE REQUIRED HND MUST BE RETURNED TO THE DEPHRTMENT WITHIN ]0 DHYS OF THE WELL COMPLETION OTHER REQUIREMENTS MHY 8PPLY. SPECIFICHTIONS 8ND CONSTRUCTION DlHGRHMS HRE HVHILHBLE TO INSURE PROPER INSTHLLHTION. 104 EYE Too M :1: W �'Poo" _111[� HFE.::!�_._T �1 E_. o. 1 TH 1 t - 111 A W E i tl::: EEO :1 I CERTIFY THHT 1 I 8M FHMILIHR NITH THE REQUIREMENTS FOR ON -SIVE SEWERS HND WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE 2� I WILL INSTHLL THE SYSTEM IN HCCORDHNCE NITH THE CODES. ]� I UNDERSTHND THHT THE ON~SITE SEWER SYSTEM MHY REQUIRE ENLHRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THHN 4 8EDROOMS SIGNED /l �� / ~�-�-----~------~---~`~~~~��~~��~~��~ e1� //��L��/Y HPPLICHNT RODNEY CREW �� ` ISSUED BY___~-__. ........ ~~........ ............ ..... ..... ... ..... _.DHTE/]�»� 'AUNICIPALITY OF ANCHORAGE Department Health and Environmental rotection 825 L Street, Anchorage, AK. 99501 �) 264-4720 # # # HANDWRITTEN PERMIT # WELL AND/ ON-SITE SEWER PERMIT Applicant: 0A yre' ly LAT Mailing Address: Z d, Location: �� '� � i Phone Number: Legal Description: ., 6\s/2 -or ,��Lot Size: Type of Soil Absorption System Is: Trench:_ Drainfield: _ Seepage Bed: Holding Tank: Maximum Number of Bedrooms: Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is: DEPTH/ � LENGTH � � ` GRAVEL DEPTH � �'�"`J1 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(HOLDING) TANK SIZE _ IZ ra _ 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. # TWO(2) INSPECTIONS ARE REQUIRED # # Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet 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 31, 1 9 3 1 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 understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that 3 bedrooms. Signed: Issued by: a Applicant Date: SWP/024(1/81) (ii' cif al ell and �Ct�ri� iiarn, rtt . tt<;�.c;r ;,zc3tt W"CLI AND/OR ON-WfC- s' {f 4 } � s App i.cant { ' ] t�� ^� _ � I� ma_ _za(f 11� 04ceC3o I FAeg �3 1) , a s LegE1 S,,t J..iesso L` 3J,?h loo t ' ...__. -*._ :..._. ... f -.a .. . f �e Lot! st ��6'+r� : `"pts cit SojA Akif3<➢e:pH ou 'yotoi% t ; rL'ronc h. _ rs 1)ra i)7C.6,et.d "Iciej�aq ;i�'Attmm Nujilbo!. `ot T3eiC t C1k;�ttt .. 00 i t. I;dtII}q(:-0(1, 2°3 }}aV) t}Ic Regfit?-)"(3d O)iz , Cit' Llvi 2=4)2.1. Ab,,3oxpLimu �iysten IS: (t -PTI t ; ) j } �, �}Ci1 ii_t.'f ._ . I # , � f { � 1� I1 r� 4 Hi _ f_ W I DT]i E, `lot, t oligt1i enrV:}I{ l) te-et) of, t:}1 }'•.teric'n o!v Wl ial d-, 9 ylu`?_11 t'] f2I' )�.rJ, ;,O Olp (,J1:3taric.- lbe; wee+ 11 it114 a13t}:aco vi the gr,:tt_lltd;:: t: i1 Cs bot l -x- i ok, i. -w -I t§krgav-ih: or, { kt1 feel -0 l�di;',.L'ft 1:1 110 cwlt fds.t3l}t f{7i `ill*- va_Vol depk-}I tia t & cn.m)Xmun Aepl-b of tjravml- bc:}'.t e -e rw tbo okALNOLL iin F; 11£ }. trY} Rif! t}l'. F 1if=_37i-'ava;i:on ( J_)"i i`a":'.'f,� o 1. o-rfit:'i_ i qp). tc:.xnt !1cii: t,}its VC -t 3'pC1T7 Sib— SAIty to liifo)°!Ti ('Aiilii -Dq the 2.tl s:i ily, �..l at,. ilob .ITAOp4o-'Ni.Ac'n*; of any iY€ lls :a C.}j•:-is'.'4,mit. t o t_}l.l.? Property awl 0)44 nuirih G' T `_: . ' t .. - mc.kcill.ing {,t ;niv sp3tom wi.htiout. filial .-Ind appt:oval i.✓i_l..J. .>I sitb.)ecr° U. ,rte ci ll i.c3iY. 6''}ini'(fiun d:f_si aac botwoem `l SitAJ and anyC)1A"' 31, t; i�4iV��a sl`S.'+'iS-7O it�. sy-)tem AV, LOO =zvcli { ti1_ . ta): raft i_ 20CI f&t: c. Pion a � ubl to ;Nell dopen't,� oq ��pou thO >t t> }iii} Lic ($oU. Min.bCima c :i ,cltlt-y Vom i; pr7_v,-t,-, will to a p5!,j ,.1:A--Icjw''r )_:i7 } fd Z5 por? t: s±t'a to a is{}titlttl)-f11� y Qiego!, l ?, e if, `71i Eoo�- l`?ell hl``IgC tIVA i �ss�113:i` and atria#. b-e� re t1,k):Ytc*t tee, tn71 _s S' tthln .#U dWVC. Of t�hc- S14 X11 tJ4;;Ctk:r f`r,quixom` nt"I faay 4ivp,1_V. ::=andt't:Jll;a�i^tic"i ].C?Il t7.11!��c�t11� :"%Vft ay.s.i.l.ablc ho 1Ftf3uurpl=Of)ar((33 aiil[[7 ¢f`+1 f�[�}fiCZFf`. { 7 $ } S-�i�tMI i S�ilP i (1-7 L .A.t'tf It1g.! .414, r5ii.t'itl t }i. E3 i_(:!{ltli-J" tT'tf.t)} h i Cat 5311''t> ;t'€4r?t;:-', an t:C')yth by Ow C•iUM—,":ip€il h}r of AJAR110i dqa. { (2) 1. 1Yt].3 Lt1:A-akL One- ov,*ten CIl _3<3tz{}k'.{1afw°! ;'iit"n t:_C7Ceo� ( 3) T 011 Mt:P o3(-.'wau `q'31 --,:n may t:`f3quixt', cmili'Sf_l,Me t t .q /� swill, •0?7 s. ( 1/ 8.Ll K= C0�1S-_ F JCTION IES T LA3 E A PERFORMED FOR: Rodn LEGAL DESCRIPTION: THIS FORM REPORTS Crew - Lot 2 Block B Visual Soils Examination DEPTH SOIL rC7CT r)Fq(.RIPTinN 2 NOTES I8O( V' 48TH AV S' E 1C( ANCHORAGE, ALASKA 99503 248-1333 _DATE PERFORMED_ 6-1-81------ Subdivision_Kasilof Hills 0 Percolation Test 81-1561 Sandy Silt NO 2' — Silty Sandy Gravel (GM) — 4' --�J�Qo Gravelly Sand (Sid) o - 16' _ -- - I8O( V' 48TH AV S' E 1C( ANCHORAGE, ALASKA 99503 248-1333 _DATE PERFORMED_ 6-1-81------ Subdivision_Kasilof Hills 0 Percolation Test 81-1561 BOTTOM OF HOLEty WA GROUND WATER EN No IF YES, WHAT DEPTH --�J�Qo -- o - LEGEND Y.inney R. B ter °�� _ a- cPT 0'00 3650' - C• 0 _ _ _ . -- q 8 S - Sample token �G9�10SgtO�� ' - - - - -- -- GENERAL SITE SLOPE ts - Frozen zone ' - Water table 0 p _j - I ;— TIME NET TIME I DEPTH TO H 0 NET DRAI'N'AGE 2 ! ji LU cr) DRAINAGE REQUIREMENTS' 125 sf/bedroom POPOSED INSTALLATION . O SEEPAGE PIT DRAIN FIELD O OTHER 3MMENTS , IL ST P RFORYFO BY. Kevin Braun pu -- - Kinney R. Baxter GAF E: 6/2/81 J - - - I 77H. -(A- -t - E �11„ BOTTOM OF HOLEty WA GROUND WATER EN No IF YES, WHAT DEPTH --�J�Qo -- - LEGEND Y.inney R. B ter °�� _ - Perc zone cPT 0'00 3650' - C• 0 _ _ _ . -- q 8 S - Sample token �G9�10SgtO�� ' - - - - -- -- GENERAL SITE SLOPE ts - Frozen zone ' - Water table I ==ADING DATE GROSS TIME NET TIME I DEPTH TO H 0 NET DRAI'N'AGE 2 ! _=COLATION RATE _ .: DRAINAGE REQUIREMENTS' 125 sf/bedroom POPOSED INSTALLATION . O SEEPAGE PIT DRAIN FIELD O OTHER 3MMENTS , -- - -- --- ST P RFORYFO BY. Kevin Braun DATA CcRTIF IED BY Kinney R. Baxter GAF E: 6/2/81 Parcel I.D. 015-161-28 1 r V i_ .nor Municipality- of Anchorage On -Site Water and Wastewater Program) 3� (907) 343-7904 0 i C� Certificate of On -Site Systems Approval Expiration Date: � --` —1 z GENERAL INFORMATION Complete legal description Kasllof Hills, Block 2, Lot 2 Location (site address) 11100 Glazanof Dr. Current Property owner(s) Steve & TWlla McClung Day phone Mailing address Real Estate Agent 11100 Glazanof Dr. Anchorage, AK 99507 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone CI 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual Z Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Received b Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ �-iU' 00 Date of Payment 1215) 110 Receipt Number 22� �D COSA# 0S(,, P 2?� Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER wW . As certified by my seal affiii ed 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 disposalsystemis (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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions. are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sale benefit of the ownerlisted above. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Alk. 99510 Engineer's Printed Name Steven, R. Pannone Date 11/29/2016 6. DSD SIGNATURE System #1 Approved for bedroomsStever ❑nnane . f System #2 Approved for bedrooms �+4 , CE -8149 Disapproved (��EDHzp}�g�jpNP� Conditional approval for bedrooms, with the following stipulations: By ^� �� "� \ Original Certificate Date: 12— L —! 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 COSAbluesheel � - . - If more than 1 septic system is on the lot: COSA Checklist # of I Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Kasilof Hills, Block 2, Lot 2 Parcel ID- 015-161-28 A. WELL DATA Well type Privato If A, B, or C provide PWSID # Date completed 10%5/1981 Sanitary seal (Y/N) Y Total depth 225 rt. Cased to 225 ft.. FROM WELL LOG Date of test 10/5/1981 Static water level Well production. 50 ff. 1.5 g.p.m: WATER SAMPLE RESULTS: Coliform /P colonies/100 mL Nitrate 3. O� mg/L Arsenic /l/J� ug/L Date of sample: 11/28/2016 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above. ground) 12+ in. AT INSPECTION 11/29/2016 43 ft. 3.0 g.p.m. Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 9/23/1981 Tank size 1,250 gal. Number of Compartments 2 Cleanouts (Y/N) Y Depression over tank (/Y/N) N High water alarm (Y/N) N Pumper 4 h 4 'O,- !, sei� cpm Foundation cleanout (Y/N). Y Datebf pumping C. ABSORPTION FIELD DATA Date installed 9/23/1981 Soil rating (g.p.d./ft2 or ft2/bdrm) 125 SF/BR System type Deep Trench Length 36 ft. Width 3 ft. Gravel below pipe 7 ft. Total depth 9.8* ft. Eff. absorption area 504 ft2 Monitoring tube Y Depression over field N Date of adequacy test' 1 1 /29/2016 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 0 in. Water added 600 gal. New depth 0 in. Elapsed Time: 150 min. Final fluid depth -0 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100+ On adjacent lots 100+ Absorption field on lot 100+ On adjacent lots 100+ Public sewer main 75+ Public sewer manhole/cleanout-100+' Sewer /septic service Ilne 25+ Holding tank 100+ Animal containment areas 50+Manure/animal excrete storage areas 100'+ SEPTIC/HOLDING TANK_ ON LOT TO: Building foundation 5+ Propertyline 5+ Absorption field 5+ Water main 10+ Water service line 10+ Surface water .100+ Wells on adjacent lots. 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water main 10+ Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 110tH Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS "Monitor tube appeared to not reach bottom of field. Field has sufficient cover.. Survey As -Built on File. G. ENGINEER'S CERTIFICATION 1 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. Engineer's Printed Name Steven Pannone Date 11/29/2016 COSA canary sheet_2-6-15.doc .A N..... Teri �� 0dnndne CE -8149 :.i =^ 7 - Municipality of Anchorage 'r Development Services Department Building Safety Division , On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-161-28 COSA# X15 C 1 a ! a//� 0 1. GENERAL INFORMATION Expiration Date: / _ co — / 2 Complete legal description KASILOF HILLS S/D; BLOCK 2, LOT 2 Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address 1110 GLAZANOF DRIVE * ANCHORAGE, AK * 99516 CHARLES & JAN TOOLE Day phone C/O AGENT /&el2l2ll Day phone MIKE MULNEAUX W/ REAL ESTATE BROKERS OF AKDay phone 3300 C STREET, #200 * ANCHORAGE, AK * 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 297-2912 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates maybe reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 GARNESS ENGINEERING GROUP, Ltd. Phone Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name Engineer's Comments: JEFFREY A. GARNESS, P.E. In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for AL bedrooms. Disapproved. Date 337-6179 ON-SITE WATER AND Conditional approval for bedrooms, with the following stipulations: VVrw pORAM pR Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Nitrate Advisory Other By: f Rev.`�ros� Original Certificate Date: 7 — / & " �a Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6550 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: KASILOF HILLS S/D; BLOCK 2, LOT 2 Parcel ID: 015-161-28 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N A Date completed 10/5/1981 Sanitary seal (Y/N) YES Total depth 225 ft. Cased to 225 ft. FROM WELL LOG Date of test 10/5/1981 Static water level —50 ft. Well production 1.5 —9 P.M. WATER SAMPLE RESULTS Coliform C) colonies/100 ml. Arsenic: t\J Oug./L. B. SEPTICIHOLDING TANK DATA Nitratel T,mg./L. Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION Date of sample: 7/2/2012 Tank Type/Material SEPTIC/STEEL Tank size 1250 gal. Number of Compartments ? Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO Date of pumping O X Pumper / ACIOCrILu 7/6/2012 2.22 9.p -m. Collected by: GEG, Ltd. Date installed 9/1981 Cleanouts(Y/N) YES High water alarm (Y/N) N/A C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE TO BOTTOM OF SUMP Date installed 9/1981 Soil rating (g.p.d./ft2or /bdrm 125 System type Length 36 ft. Width TRENCH Gravel below pipe 7 ft. Total depth *9.6+ ft. Eff. absorption area 504 ft2 Monitoring tube **YES Depression over field NO Date of adequacy test 7/6/2012 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 0 in. Water added 670 gal. New depth E in. Elapsed Time: min. Final fluid depth 0 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date **SUMP EXTENDS 81" INTO 84" EFFECTIVE DEPTH. NOTE: APPROXIMATELY 3' OF THE TRENCH HAS 2.5-3' OF SOIL COVER (IN AREA OF SUMP). REMAINDER OF TRENCH HAS 3+ FEET SOILOVER. D. LIFT STATION Date installed Size in gallons Manhole/Access (YM "Pump on" level at in. "Pump off" level High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lI t station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ Animal containment areas 50'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Holding tank N/A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that i have determined through field inspections and T �* review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. ..:... a es Engineers Printed Name JEFFREY A. GARNESS X00 9, E-7 53 Date4p�a�a '7�II I? Fo°v 1 .2 44na profession' � COSA Fee S `-f—i U Waiver Fee $ Date of Payment 7 hl /ia Date of Payment Receipt Number 011?52C Receipt Number (Rev. 1 1105) LI 0 1 72a 203.E A K 591 p ECL C)t 27e 0 G° EX N, l ST/NO Np N g Z S7,,Z7TUAZE Ut _ 4 z7= m ° 1 SEP77C 9.P.g 'o ,o o iN l 20- e • o � �Y l� 1 1 !4� L)TILm i�voi° ESKvtT WEST LOT I o . e. o..u�saumwa.ia Lar 2 , Block 2 Kasi /o /Ion e c ea,I. Anchorage Recording District, Alaska Button. Easements of record other than Mose Chown on �_u' sad --LS 1192 the Dldt of -record are not a�own hereon unleu F. e a• �4 LOT SURVEY CERTIFICATION LEGEND nared �eaFopo,..........PP I nereby cernry that I have sarveyca the property snows dna described Q5 Brass or Aluminum capped monument recovere&`:ti'e:%-B''Q; nereon, and that the improvements situated thereon are within the prop- O Iron pipe and/or robot recovered. a3�5-� arty lines and do not overlap or encroach on adjacent property and that O 2 x 2 hub 6 tack fe COVefed )o improvements on adjacent property overlap or encroach on the Premises • 5/B x u30"b react set this survey n Question and that there are no roadways, utility line., or other visible aasements on sold property.... pt as Indicated hereon Scale a Date R QQ Prepared by: R L. BUTTON I8 " Registered Lond Surveyor (907)279-6200 5/9W Eighth Ave. Anchorage Alcska 9950/ Ref. 2i F. B. No, Property of: 44 -5�o MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES M Division ion Site Services EnvironmentalSecServices ENVIR i OFANCNO MGE on SERVICFS pIVIS1 P.O. Box 196650 Anchorage, Alaska 99519-6650 �V 343-4744 MA 2� 1997 CERTIFICATE OF HEALTH AUTHORITY RECEIVED � ` j} APPROVAL FOR A SINGLE FAMILY DWELLING l V E�/ Parcel I.D. # DIS - / 61- 2. g HAA If 1. GENERAL INFORMATION Complete legal description Lo -r z,yi=z� lis)) of W1('L_5 Location (site address or directions)11 1 O0 Prop( rty o;✓ner��! r`1� Su w S f?; . ,u{ --- Day phone - _34-I_S+1 Mailing address A66 -)e Lending agency �� Day phone Mailing address �f Agent J�V wtkCClk1e ,espy Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF 13EDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 4 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: X Individual on-si 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. 72-025 )Rev. 1/91) Front MOA #21 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 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. N aska YYator IX Name of Firm 8471 Bmokridgp Cir Address nel-9 AK0'g5a Engineer's signature 1� 6. DHHS SIGNATURE Approved for 2 �y bedrooms. M Disapproved. Conditional approval for Additional Comments Phone 337'6/79 Date bedrooms, with the following stipulations: WTla 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 engineers work. 72-025 (Rev. 1/91) Back MOA #21 F^, I e Nvltl' Municality of nchorage • DEPARTMENT OF HEALTHA& HUMAN SERVICES lkq 6 Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 34 .44 1199? /oN Health Authority Approval Checklist (`�e41 Legal Description: QIP Zj 1U° s M ups Parcel LID.:— O 1.5 6 A. WELL DATA Well type PV`T If A, B, or C, attach ADEC letter, ADEC water system number N Log present (Y/N) ys_� Date completed tds- B / Total depth 27,5' Cased to 7-7,5 Casing height (above ground) IZ�1 Sanitary seal (Y/N) Wires properly protected (Y/N) yF,.S FROM WELL LOG AT INSPECTION Date of test Static water level 50 5U `- Well production _ �• S g.p.m. / a° + g p m Fol/' pLOU M1'j-'-e-S Gco C�k4W NJ /%�i-kW �QW nJ WATER SAMPLE RESULTS: � 10o f2r--16- - -' KZof ag MIMN S = 2.0 GPM RMtovf� Coliform �� Nitrateq•'� - Other bacteria Date of sample: ="T kO 'It Collected by: B. SEPTIC/HOLDING TANK DATA Date installed 9 f3/ Tank size IZ50 Number of Compartments �Z-_ Cleanouts (Y/N) Foundation cleanout (Y/N) _ Y Depression (Y/N) NO High water alarm (Y/N) PJ Date of Pumping e/gl `76 Pumper 1 4 ft'4E C. ABSORPTION FIELD DATA Date installed / 8 --Soil rating (g.p.d./ft2 or ftz/bdrm) /Z5- _ System type-T`P_F- I -I Length 36 Width 3 Gravel thickness below pipe _Total depth /Z Effective absorption area 504- Monitoring Tube present (Y/N)'PDepression over field (Y/N) NQ Date of adequacy test - It NCJ4 Results (Pass/Fail) P'4s For _ `� bedrooms Fluid depth in absorption field before test (in.); .24 Immediately after_ gal. water added (in.): SY Fluid depth o�%e I� (ins) Minutes later: 02 Absorption rate =. 60Q g.p.d. Peroxide treatmentast 12 months Y/N (p ) ( ) No nw If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm le) E. SEPARATION DISTANCES on" *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer /septic service line ons "Pump off" level at* On adjacent lots On adjacent lots � IDo / Public sewer manhole/cleanou Lift station . � 4 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 2,drI+ Property line 451+ Absorption field ✓� P /�sPr Water main/service line n, t> 10 Surface water/drainage Wells on adjacent lots aG fmsrrc-- S)Pa4 I+oNsp- SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water >AW Curtain drain 100 I r Building foundation 3G Water main/service line �1D oPPos�a� s�D t+oaSE Drivewa arkin9 /vehicle storage area /+ NarJf< IWowrj F. ENGINEER'S CERTIFICATION Yr P r _ Wells on adjacent lots I00 /certify that i have det , ined r fie inspections and review of Municipal records th"eObouo sy, ms are in conformance w' H ideli es in effect on this date. f° Signature9 �� e" a Engineer's Name l' �f U 9 • ga4 °_ �sl I / � �Ci f Y A. �YU�II 4 Date c -M; [-3 �J. G 9 r HAA Fee $ c� r� Waiver Fee $ _ Date of Payment ir�Y� ) Date of Payment Receipt Number ICU �/ Receipt Number 72-026 (Rev. 3/96)* O C T �: 2 — 9 s m U-4 1 4 0 5 P q. r- t r, c, k., r c, c k ... T i n cj o. I I � . �' . 0 p,W n i i rk1uw1Wf"M ti t i -0 , no& Lo , Ib ORA N9 QZ mC SURVEYOK TWO N Wl fUR'tY $l NVINAIO n3-A41LY -nNAl wywtwm Ai-M,ML1 ftbT PLM &S-00 �I i i m �•k w 7 Y,r 'V �! 4 Y 8 Lo , Ib ORA N9 QZ mC SURVEYOK TWO N Wl fUR'tY $l NVINAIO n3-A41LY -nNAl wywtwm Ai-M,ML1 ftbT PLM &S-00 �I i i m �•k w 7 Y,r 'V yo arra,��- yV,wu,}'1' AH m al. AEsm Amm MIN. 11 9 NE& _ .. 1HC nUn�t. Robsrt E• JOhn.sr Jr, , Asso Profo ulonal Land $urvoyora �a 'ate 12Al.&W 0000 nic. Frm, 1" 40' 9•1OR93 f d Ml J _ WA LOT 2• BLOCK Z,� KASILOF }SILLS SUMVISION �! v ho b� ,W� W 1a� � ,` . � •. R It •'( . ol yo arra,��- yV,wu,}'1' AH m al. AEsm Amm MIN. 11 9 NE& _ .. 1HC nUn�t. Robsrt E• JOhn.sr Jr, , Asso Profo ulonal Land $urvoyora �a 'ate 12Al.&W 0000 nic. Frm, 1" 40' 9•1OR93 f d Ml J _ WA LOT 2• BLOCK Z,� KASILOF }SILLS SUMVISION MA`i'-23-1994 CIO! 20 179E ESI ANCHORA=GE 911 CT&E Environmental Sorvicres Ina, CME Rcf,# Client name Project Name/N Client Sample in Matrix Ordered By i'WSM 9/2506001 AK Watar &, Wastewater Smi;xs 11100 Glazanof dr, 11100 Olazanof dr.. Drhildnb Water Client PON Printed Date/Time 05112i97 19:18 Collected Dati'T3me 05/20/97 13:15 Received Date/Time 05/20/97 13:30 Technical Diractor! Stephen C, Ede Relel5etl By CME Mlerohi0ogy Drinking Water Program Certification Mms is provisional as of 4/8/97. Mkow 14La Prey, Analysis �aramete�� Kesul;s POL knits Method nits Date Dace ini^ N`trace-N 4,97 0.500 mg/L sM18 45U4•903F 10 mer, 05/<1,97 d8L 70181 Cul i form ' 06 W/0 CGU COL,/100 ,IL 51110 92228 05/2P/97 NM9 0.9 MUNICIPALITY Or ANCHORAGE DIVISION OF ENVIRONMENTAL 111?Al,'P;3 DEPARTMENT OF FEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HLIALT11 AUTHORITY APPROVAL CERT.'IFICAM 1. General. Information Application Date qan��' �' ,'ak`•5- (a) Legal. Description (include lot, blo:.k, subdivision, section, township, range) Location (address or directions) 1 i f (1O f1- 6TH e ef"? E5I- bf' KrQ (b) Applicants Name .Sc...4!lr;4 �vkrerr Ck TelePl3oRO, Home Business �r Applicants Address ica) App i.r..[. ant ti; (check; one) Lending Institution �� Owner/builder Buyer I ; Other 1=-1 (explain); .� n R =-n�. �__a . _._._ rm =__ t.._•_� T - (d) Lendl.ng Institution TelOPhone (e) Real Estate Co. & Agent Address Telephone (f) Mail the 11AA to the following address: 2. XyZc o Res Ldence Single -Family I—�- }� Multi—Family r -7j Number of Bedrooms —pa `l - a o Water Sup -22 Individual Well Community ED Other (deserlbc)_`� Public j Note: If community yell. system, must, have written confiimatior, frov's the State Department, of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite � Public r:—_1 CommuniCy 1=11 Holding Tank Note: If community well system, must have written corz._r-i.rmat.ion from th", Stare Department of Environmental Consorvat.ion attest:in.- to the lcFa.lity and status. [Pape l of 2] 5. IanaatneeEj;q Firm Pr•ovict 7ns�ec to=t.oras, Tests i c...bcaar ef+ I 9 ,�A Infoa�aaa.ation As certified by my seal affixed hereto and as of the validation date shown below, - verify that my Investigation of this Health Authority Approval shoo that the on sine water ;supply axed/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 Manicipa i ity of Anchorage files and from my i,.avestigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal i,,: -.,d State cedes, ordinances, arta regula- tions in effect on the date of this inspection. Name of Firm �n('LI ftr /�F'C6 ? N !4' rvtccC` �. —� z a. i,'eloph(a"r.'era,� AddiC'u s s ''a . 11 /_'---x, ? lip D.°7 tE�_f .n`v. [..� ��,�. 1 e..a—„s,.,.n.--�_,.,�.ae,.-��_,---o-..,=--�•-® /„ ) a ^ c � o � �./°. . 6. DREP Approval Approved for Approved O Terms of Conditional, "r �`. a r:.. 0 as neonano (ENGINEER SEAL) !1 i/ f/:.!.✓ �..f �l ^/� i ” . VIA (fit (. .�J •1 f3''!7 bedrooms B Disapproved Conditi.ona-1 ApProval•,_T___ _.-_-. CAi TION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES 1T1?,.BETH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE RFrPESENT-•• ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN 1NDEPENDEN:i PROC+EBIONFt.L ENGInu."a REGISTERED .IN THE STATE OF ALASKA.. THE DHEP DOES THIS AS A CO(>RTrSY. TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERT'A!N FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPPCTTON3 OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHOP.AGE TS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL,) RR4/ej/DI8 [P -age 2 of 2 ] 7-19-84 MUNICIPALITY OF ANCHORACE MUNICIPALITY OF ANCHORAGE (MOA) DEPT. OF HEALTH & HEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL PROTECTIOty CHECKLIST - FEBRUARY 1984 FEB 2 rJ, 1985) Legal. Description: r) 1-24 110 � c", J A. WELL ARTA s� �—A_- -V-- hecurfo.% Well Classification {'rlvat6 If A, B, or C, D.E.C. A.pproved(Y/N) Well Log Present (Y/N) i _ Date Completed /cr 14-1491 _ Yield IS m Total Depth 2; Cased toa Z„ Deptho Grouting Static Water Level. 37,y Pump Set At Un1-v Casing Height Above Ground Sanitary Seal on Casing (Y ) Y Electrical Wiring in Conduit (Y/N) V" Depression Around Wellhead (Y/N) At Separation Distances from Well: - To Septic/Holding Tank on Lot ^= [y3 Y}�; On Adjoining Lots '9 too To Nearest Edge of Absorption Field on Lot fJ"7 Pf On Adjoining Lots '-,� (oo To Nearest Public Seiner Line Nt4- To Nearest Public Sewer Cleanout/Manhole Al, 4, To Nearest Sewer Service Line on Lot W✓I-. Water Sample Collected By f" jal-6?p %Pc�i Serc_; Date //I Water Sample Test Results �cxkrrtar� Carments B. SEPTIC/HOLDING TANK DATA Date Installed F / e 3 /,0/ Size j _'W / No. of Canpartments Standpipes (Y/N) `i Air -tight Caps (YM) ; Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped e/y /6S- Pumping/Maintenance Contract on File (XLN) YA, ; for Holding Tank High -Water Alarm (Y/N) N A- _ 'temporary Holding Tank Permit (Y/N) _ Separation Distances from Septic/Holding Tank: To Water -Supply M11 e;:�: to3 To Building Foundation 12 Y Ft _ To Property Line _ _ ,;'G P To Disposal Field - S Pf ,per A--b,r,/l To Water Main/Service Line fN•A. To Stream, Pond, Lake, cr Major Drainage Course qooe Comments [Page 1 of 2] 0= o"_As+ 1p Z4's 0 0 2-1584 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 13'16y(r. Type of System Design _D&ep °rrellcg Date Installed 912-3 fC9/ Length of Field 36� fl- Width fWidth of Field 3 Depth of Field 1z s'f Gravel Bed Thickness 7 f Square Feet of Absorption Area -15-0y Standpipes Present (Y/N) Y Depression over Field (YIN) N Date of Last Adequacy Test All) Results of Last Adequacy 'lest N A Separation Distance from Absorption Field: To Water -Supply Vb ll I/-/ To Property Line 10 To Building Foundation 36 -f� To Existing or Abandoned System on Lot N /} ; On Adjoining Lots '-;;, loci To Water Main/Service Line N /} To Cutbank(if present) /2 f1` To Stream/Pond/Lake/or Major Drainage Course N /3. To Driveway, Parking Area, or Vehicle Storage Area — h Comments D. LIFT STATION Date Installed Size in Gallons M,AI "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Comments J Dimensions Manhole/Access (YIN) "Pump Off" Level at Vent (YM) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request I certify that I have checked, verified, or conformed to all MOA HAA Guidelines iri.', t on the date of this inspection. °0 ()F AA Signed T. Date cry /ZI /&3 - Company Fluh/-)p Teeh �@rvicxt MOA No. KB1/d5/s [Page 2 of 21 �A°° .°' .•i•.�° i• a °i ��..i.°it 4 '. THEODORE I'. MOORS a - if t�� ^a�•. CE -3589 •' w4 At J', •.,. •.•' 4P 2-15-84 r— Time APPLI NT FILLS OUT UPPER HA' ONLY Property CUwner ( 04"LIV �. 1�-.' "i !=' !-r C--7- /c i�l / d�; [, Phone Mailing Address ' 1 �' X - Zip Code Buyer /-c-'- _ ,- ..-,(l; )n Address ! ,-' r. '--- �+ c_: -.r. Zip Code Lending Institution j. J 1:: �� -.(_ /ji7 i� ; i Phone Address Zip Code Realty Co. & Agent Inspector Phone Address Zip Code 'CONDITIONS OF APPROVAL Legal Description /_ .. { �/ /moi .", / L i� 1--- �✓ ! C_ l '.� //",_ Street Location /U / / /l) Type of Residence _Single Family Multiple Family No. of Bedrooms -� ;-? f..= -r.=- ❑ Other Date Sewer Installed Water Supply Well Log Received \U,, 3Y-IndividualATTACH Well to Tank WELL LOG. A well log is required for all wells drilled since June 1975. ❑ Community For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility Sewer Disposal; .f / / -,W ,Individual Year Individual Installed: = ❑ Public Utility When Connected to Public Utility: _ ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Dae Date Date Date JJ Inspector Inspector Inspector Inspector Field Notes: (ogj� APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' -'6 2 - DATE _ BY: _ t, Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received \U,, Well to Tank Septic Tank Size 72023 (3182)