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HomeMy WebLinkAboutKASILOF HILLS BLK 4 LT 1611of0 . Hills LijS -3i i � 6Az -1/'? 0 Z' 5- Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3 ON -SITE WASTEWATER INSPECTION REPORT Permit Number: OSP241134 PID Number: 015-131-16 Dwelling: H Single Family (SF) n with ADU [I Duplex (D) 0 Two Single Family Project: n New nN Upgrade Name BILL JOLIN A RPTION FIELD Trch E]Wide Trench El Bed ound ren0 c ED D Trench Site Address 10601 REZANOF CIRCLE, ANCHORAGE, AK Other Phone Number of Bedrooms Soil Rating '***%** original grade 907-727-5771 3 /S,,ITotal !::�Ft. LEGAL DESCRIPTION Depth to pipe invert from original'4% Ve 0-*' N. Gravel depth beneath pipe , Ft. Subdivision Block Lot KASILOF HILLS 4 16 Fill added above originalh Ft. Ft. Township Range Section Gravel width �� Ft. Beds: Number of Lines Dls',,� en lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total orption area Number of trenches Dist. between ches From Tank Field Tank Line Ft' Well 100'+ EXIST. - - 25+ TANK [I Septic [I S.T.E.P. [I Holding [I Other Manufacturer GREER TANK Capacity 1250 Gal. Surface Water 100'+ EXIST. - - - Material PLASTIC Number of compartments 2 Lot Line 51+ EXIST. - - NA Foundation 10'+ EXIST. - - rIFT�ATION ManufactueF`*�. Capacity Gal. I , Remarks CONFIRMED 5-FOOT SEPARATION DISTANCE FROM NEW TANK TO DRAINFIELD. OLD TANK Alarm location HAULED OFFSITE. Tank to PIPE MATERIAL House to tank EXIST. D2661 drainfield Installer OWNER Drainfield EXIST. CO/MT D3034 Inspector GEG CONSULTANT, JODY MAUS BENCHMARK (Assumed elevation) 100.00 it Inspection 1st 7120/2024 Location and description dates: 2 nd TOP OF DECK AT CORNER"B" 3rd 4th ON -SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp o F Conditional Approval: Date _IksN 4 . ... . . ..... ...... . . . ........ ...... Septic System A. Gor ess.: VA of C E`Q� — Approved Date Note: this approval does not include well permit requiremen(s. rofes k #AEcca" (Rev 05/02/18) PERMIT NUMBER: PARCEL ID NUMBER: OSP241134 RECORD DRAWING 015-131-16 WELL o r r `�\ C;ipnc // \\ -.J \ \ d. EXISTING 3-BEDROOM HOUSE f A B C� MH 48.6 16.8 42.1 ST1 52.8 18.9 43.0 DBL7 54.6 19.9 43.4 DBL2 55.6 20.5 43.6 C01 100.2 60.3 67,6 MT1 100.E 61.0 68.8 ION IN l— EXISTING PRESSURIZED SEWER LINE LIFT STAT HOUSE TO TANK 9 I m —NEW 125 GREER PLCZFm A / EXISTING DRAINFtELDS, PASSED SEPTIC ADEQUACY TEST ON 5/29I2024. NEW CLEANOUT AND 2" MONITORING TUBE INSTALLED ON SOUTH END OF WEST TRENCH ARFA� I \ KASILOF HILLS; �\ I BLOCK 4, LOT 17 \ \ 1 \, \ GARNESS El`+GINEERIN+G GROUP, �,s.,w.�,J�.,{�._.��.,��,_...���.�t�wENGINEERING � SALES � CONSULTING ­,­,w�,���; aras a zuooR aono, suite tag �radscc nussw Qe+atse tson a��birs wEesire: +_g,rs, PREPARED FOR: PHONE NUMBER: PAGE NUMBER: BILL JOLIN 907-727-5771 2 OF 3 PROJECT/LEGAL DESCRIPTION: DRAWN BY: KASILOF HILLS; BLOCK 4, LOT 16 J.L.M. Aw lip TYPE OF WORK: DATE: RECORD DRAWING OF SEPTIC TANK UPGRADE 7/25f2024 LICENSE`, ESS�����•♦ #AECC884 �����'�: PERMIT NUMBER: EDRAWING A ��v I PARCEL ID NUMBER: OSP241134 015-131-16 'FINAL GRADE TOP OF MANHOLE = 103.16-103.24 (MH1) = 104.12—i TOP OF TANK @ INLET = 100.06- INVERT OF BUNG @ INLET = 99.31— NEW 1250-GALLON GREER PLASTIC SEPTIC TANK NOTE: PER OWNER, APPROXIMATELY 24 INCHES OF SOIL COVER WAS ADDED OVER THE TANK AREA AFTER OUR INSPECTIONS AND FINAL GRADE SHOTS. TOP OF TANK @ OUTLET = 100.06 -2" OF INSULATION PER CONTRACTOR VERT OF BUNG @ OUTLET = 99.20 w+ ' •••. GARNESS ENGINEERING GROUP, Lid ; * ♦; ENGINEERING, SALES -CONSULTING 3701 E. TUDOR ROAD. SUITE 101 • ANCHORAGE, AtASKA' PONE (9071337-6179' ATSSIM, wwwgwrassawjmenM.cart OLn �' . • • ........................... PREPARED FOR: PHONE NUMBER: PAGE NUMBER: 0 � % e . G ness r BILL JOLIN 907-727-5771 3 OF 3 ♦ C 7 53 PROJECT/LEGAL DESCRIPTION: DRAWN BY: I♦♦♦ [�•.• 32 ` •'�: KASILOF HILLS; BLOCK 4, LOT 16 J.L.M. t♦, Pp'•�.... �����,+++ TYPE OF WORK: DATE: i� 'S,:, RECORD DRAWING OF SEPTIC TANK UPGRADE 7/25/2024 #AECCB 4 + 8360W eighbor's driveway 1 ' LOT 15 200.00 1°3q,f3giiE I 1 1 30 _- --- 90 Wire fence 1 LOT 8 Well p _ ..... _ 1 2.00 1 76. O 0 36,0 `© Oa N 3 Story 1 Frame N (- N House 4 0 se 2 o -i Z 2.co 11 N rn '� 26.0 A 1 Cn 1rn N a 4.0 O 0---Manhole 1 m deck 1 Zt m o L©l- 16 1 vent (tyP) O O � r Septic Wire 1 1 Wood fence fence °O ° LOT 7 �. with conc. posts 1 200.00 LOT 17 1 30 gavel driveway crosses Lot 17 REVISED 9 01-2d Adde s tic-iVnt RECERTIFIED 7-31-242� �' AS -BUILT N CORNERS SET THIS DATE '% OF 44 1' 1 hereby certify that i have performed a Mortgagee's inspection • .... , in accordance with ASPLS Standards of the following LOT 16 BLOCK 4 ff A,Cj^• ,S'rr Cry. '.-q �� described property: KASILOF HILLS SUBDIVISION „r 4gth •. f * . rt � Anchorage Recording Precinct, Alaska, and that the • • • • 00 improvements situated thereon are within the property lines and do not overlap or encroach an the property lying � Y." ...: 00 p • r. b lizaeth L. Walatka . j ,s adjacent thereto, that no improvements on the property lying c� kl A, adjacent thereto encroach on the premises in question and j �'F • 8036 — LS • • r ,,. that there are no roadways, transmission lines or other SCALE: 4 = 40' ,� '0 q•�• • •��o � visible easements on said property except as indicated ssratu4 `�"" %\ Dated at Anchorage, Alaska Z this 24th day of ,TUNE , 2011. EASEMENTS OF RECORD, OTHER THAN 9 " 2_ THOSE SHOWN ON THE RECORDED Fb 24-3, pg 37 FRED WALATKA 8 ASSOCIATES, L.L.C. PLAT ARE NOT SHOWN HEREON Fb 11-3, pg 63-64 8E 907-248-1666 Engineers and Surveyors UNLESS OTHERWISE NOTED. F & G This drawthg is a representation of conditions found at the time the mortgage location survey was performed. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained on this drawing shaft not be used to establish any fence, structure or other improvements unless otherwise noted. This drawing shall only be used for a single property transaction. Use of this drawing by the original client or by others at a later date without the consent of Elizabeth L. Walatka is a violation of Federal Copyright law. Unless gross negligence is discovered, the liability extent of the preparer is limited to the amount of fees collected for services in preparation of this product. MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 hftp://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP241134 Work Type: SepticTank Upgrade Tax Code Number: 01513116000 Site Legal Address: KASILOF HILLS BLK 4 LT 16 G:2541 Site Mailing Address: 10601 REZANOF CIR, Anchorage Owner: JOLIN CHARLES W Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms: t.)epartIne I1r 6/24/2024 6/24/2025 30000 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ 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 (24/7). 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 By: Date: Ir la 2 Issued By: Date: y -AJ_ ON -SITE SEPTICMELL PERMIT APPLICATION - C, 47 Parcel I.D. *-M-1 6 Property owner(s) BILL JOLIN Day phone 907-727-5771 Mailing address 10601 REZANOF CIRCLE, ANCHORAGE, AK 99516 Site address 10601 REZANOF CIRCLE, ANCHORAGE, AK 99516 Legal description (Sub'd., Block & Lot) KASILOF HILLS; BLOCK 4, LOT 16 Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (Z all that apply) Absorption Field Fj Initial ❑ Single Family (SF) r4 (w/wo ADU) Septic Tank RX Upgrade RX Duplex (D) ❑ Holding Tank R Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well EJ Water Storage R 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: Waiver Fees: Date of Payment: I i Date of Payment: Receipt Number: Receipt Number: Permit No. L( Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241134, Curtis Townsend, 06/24/24 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241134, Curtis Townsend, 06/24/24 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241134, Curtis Townsend, 06/24/24 L m c � 0a)3 0`0 E O O 0 (n 4- cu cu = c L 7 r- O -0 o O L _ > '0 3 aa)) O a) ,s o. o, a-CU CU E a L (B � CO Q Q O U) ". 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LL W (L— c cC vp?a s -Soo 0 ECCt o > 0 8A.2 0-8 20,0 0 A I'D ji It C-i M�a aE�W:6 -ro , A w R z LL A W;v z 6 o 0 W w0 x cr w -, 0 LU �- Z W 0 Z I.- 0 z zmw WWR 2 lu uj w0 W < u� fl-: 3! MUNICtP/~,I ITY OF ,'\NCllf)RAG!} DEPARTIVIENT OF IlEAl TII & IzklVIRONIVIFN']A~ PROTEC[ION ENVIRONMENTAL ENGINEERING DIVISION 825 LStreet -Anchorage, Alaska 99!701 TelmfllOn~: 264-4720 ON-SITE SEWAGF DISPOSAl_ SYSTEkq AND/OR WEI. I. INSPECTiOhl If!SIAl D?,,1 i !iH i)Z',i:) :[ V :[ :iii~ ]: E)N :', I':::AD :[ [ .[:)F::' Ii :[!_ I.% '.~!HE(::::T :[ I:]N ~ :!. ;:f!;2d. 'I"C!WNE;H :[ F" ':': ,, '7~:::JF:~ (!ii, G! ,, I:::'T' ,, [)F:;'. ('ff]l::~[!{:!!i~) I.; SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O COMMENTS PERCOLATION TEST SLOPE SITE PLAN ?< i~ WAS GROUND WATER ,/<,j. ~ S ENCOUNTERED? L O P E IF YES, ATWRAT DEPTH? 72-008 (6/79) ?' Gross Net Depth to Net ' breading Date ? q Tirne Time Water Drop /J ~ (minutes/inch) PERCOLATION RATE TEST RUN BETWEEN FT AND FT CERTiFiED~,~~''/' 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 PERFORMED FOR: Robert Hammond ,j DATE PERFORMED: 7/16/82 LEGAL DESCRIPTION: Lot 16, Block 4, Kasilof Hills Subdivision SLOPE FIBROUS PEAT w/ORGANIC SILT Brown SILTY SANDY GRAVEL, GM wet ,. ! ~/' '~./ ~. ,~.i'/ ., ,, ..' ./-.~ /~, ;) ~' ~ ,,,; ,.! Brown SILTY SAND, w/trace GRAVEL SH, moist SITE PLAN lO 11 12 13 14 15 16- 17- 18- 19- 2o COMMENTS Grey SILTY SAND w/GRAVEL, SM moist TOTAL DEP1 ENCOUNTERED? · No DEPTH? to 12.5 feet ' ~ ~ ~ 7/16/82 [ I I I I I I Gross Net Depth to Net Reading Date Time Time Water Drop i 7/16/82 11:19 0 ~4" 0 2 7/16/82 11'4g 30 mi~ 5g" 5" 3 7/16/82 12:19 30 min ~ry 3" 4 7116182 12:20 -,- ~.~.-/4" -- 5 7/16/82 12:49 30 m'in ;5" 2-3/4" !,~6'7 7/]6/R2 1:19 3(3 rn'in ~7-5/R" 2-5/g" 7/16/82 1:49 30 min 50-1/2" '/'~ ;CA 7/16/R2 2:19 3(3 min ~4" 3-1/2" ~,~ 7/16/82 2:49 30 min 57-1/4" 3-1/4" ;.~ 7/16/82 3...1.9 30 mir ~1-3/4" 4-1/2" PERFORMED BY Roy McDonald/Mark Hal 1 RUN BETWEEN ~0--/FT AND ' tl .0 F~ .... i" /)"¢;;';' i', CERTIFIED BY: Oohn N, Lambe OAT~:JU3~ 30~ 1982 II-p__ 5 E LOT 14 W N LoT 15 w N LoT SCALE: L_OT I CF..N'T-I~F_Ti~.R. = I0 FEET /8 JM LAMBE AND ASSOCIATES, INC, Soils Laboratory and Geotechnical Engineering Job no, Appr, Date__ SITE PLAN PLATE AIVIBE AND ASoOCIATES GEOTECHNICAL ENGINEERING , IN[;, AND TESTING John M. Lambe. P.E. 7127 Old Seward Iliflhway o Anchora.qe, Alaska 99502 907-349-6531 March 29, 1985 Municipality of Anchorage Department of ltealth and Environmental Protection 825 "L" Street Anchorage, Alaska 99501 Attn: RE: Susan Oswalt Lot 16, Block 4, Kasitof Hills tlarms Sewer Application NOIID]IO~d lVJ. N]Y~NOalAN~ ~ HJ.1V3H 40 flf)~'~OHDNV ~O A$11¥~IDINA~/ Oear Ids. Oswalt: Thank you for your courtesy of March 29, lq85. You are correct in that our Soils Log for Lot ].6, Block 4, Kasilof Hills Subdivision indicates that the percolation test was run between 5.0 and 1]. feet. This is incorrect. The percolation test data on that form inJicates that the test was run at between 54 inches and 62 inches below the surface or at approximately 5 feet below surface. The percolation test results indicate a high percolation rate. Recognizing the possibility of layers of less Silty material within the SM deposit, we would suggest a rating of 250 square foot/bedroom 'For this site. We trust the foregoing summarizes our conversation of March 29, 1885. Si ncerel y, II~te Drilled~ Blk. 4 Lot 16 Kasi !of Subd. Static Water Level ,~ feet Gallons Per Minute Draw Down ~/~. feet Total Feet of ~asin~ 2n Material Drilled: 0 feet 12 fwet MUNICIPALHY OF ANCHORAQE DEPT. OF I{EAI.TFI & ENVIRONMENTAL PXO'fECTION I~E. 6 5 1986 P, E. C E IV [! I) to ProducioT J. ~.o.m. near bottom. to to Hefty Drilling S.H.A. Box 1553 H Anchorage, Alaska 99507 ~,- Municipality of Anchorage Dovolopment Services Department Building Safety Division On-Site Water and Wastewater Program 4700 EImore 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. '©iff, i31; 16 1. GENERAL INFORMATION. Complete legal description Location (site address) Current Property owner(s) Mailing address Expiration Date: Lending agency Mailing address Day phone Real Es~te Agent ' ~! :'. : :' . Unless ,ofh, erwise~reque~ted, :COSA will be held by DSD for pickup. NUMBER oF E~]~DROoMs: ,~.,,~ · ~,..,~"(" , TYPE OFWATER SUPPLY: Individual' Well" Individual Water Storage Community Class ~ Well Public Water System Day phone TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding Tank Community On-site Public Sewer [] [] [] The Municipality of Anchorage Development Services Department (DSD) issues Cedificates 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 dispos"al 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 sample results. (Certificates may be 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. 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. NameofFirm -~.~,~r~/,~2 Z,-~/'~,~,/7 Address Zo.~ w,/~V~. ~7~ ~o~, ~o,~ ~ Engineer's Printed Name /~5 ~¢/¢~/~¢-i DSD SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. Phone ~,~- Date · ~,."~'~-~\\ OF. ..., ,~. ....... ."~.~ ti, bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory (Rev. 11/05) X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other ,~C~~original Certificate Date: 7 "/~ - it Municipality of Anchorage Development Services Department Building Safety Division Water & Wastewater Program On-Site 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 . www. muni.Org/onsite (907) 343~7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: ~1'/~/ ~t'J}5 B/J~ I~ L~r~]~, Parcel ID: 015-{31- A. WELL DATA Well type Date completed Total depth ~00 f. If A, B, or C provide PWSID # -- Well Log (Y/N) ~' Sanitary seal (Y/N) "/ Wires properly protected (Y/N) ~' Cased to ~.O~' ft. Casing height (above ground) + I~ in. 'z3 ft. O, ~_ g.p.m. FROM WELL LOG Date of test Static water level ,/-~ ft. Well production ~ g.p.m. WATER SAMPLE RESULTS: Coliform /I/'~0- colonies/100mL Nitrate ~,.~'~ mg/L Arsenic: J~D ug/L date of sample: B. SEPTIC/HOLDING TANK DATA Tank Type/Material .//3t:J~ Tank size ]000 gal. Foundation cleanOut (Y/N)' "/ Date of pumping sJ~{~ Depression over tank (Y/N) Pumper C. ABSORPTION FIELD DATA COllected by: Date installed Cleanouts (Y/N) High water alarm (Y/N) _/V" Date installed 6. ~.~ Sail rating (g.p.d.m~ or~ t50 .Length ""' ~ fl. Width ~ ff. Total depth 5,~ ft. :Eft. absorption area ~50~ft2 Monitoring tube . Date of adequacy test ... G/~IJ/ ... Results(Pass/Fail) Fluid depth in absorption field before test I~ in. Water added .~0 gal. Elapsed Time: ~r:~ min. Final fluid depth ~ in. AbsorPtion rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) Systemtype Sk~,l[~ '~r_k Grovel below pipe ~-. ft. Depression over field /V~ FOr ~ bedrooms New dePth J~in. ~50 g.p.d. Ifyes, givedate ~ - D. LIFT STATION E. Dateinstalled ~r''''' Size in gallons .,,,"' Manhole/Access (Y/N) ,.., '~Pump on" lev~'"~n. "' Pump off" level at ~n. High water alarm level at Datum .- Cycles tested / Meets alarm & circuE~~ts~' SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot }COY Public sewer main Sewer/septic service line Animal containment areas ~O On adjacent lots On adjacent lots. liDO -P Public sewer manhole/cleanout ,/V/~ Holding tank Manure/animal excrete storage areas . Property line 5 ~ Absorption field Water service line Surface water SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation .~ + Water. main /VIA I0~' Wells on adjacent lots 100~ Property line Water Service. line Curtain drain 5D'-{' COMMENTS SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: J,OI¥ Building foundation tO'4' Water main JO'+ Surface water JOO'~- (/Ii. 0.) Driveway, parking/vehicle storage CN,0~ Welts on adjacent lots tOO JO t-i. (Rev. 4/10) .F. A ' ' ' / I ~ that I have datelined ~gh reid ,nspectionsand review of Munici~l re~ords t~ ~e.a~ve systems are in ' ~.forma.~ w,b MOA COSA guMel,~. ,. e~ on this date. Engineer's Printed' Name LA~ ~0~¢ ~ ' COSA F., ~0 -- Wai~er F~ $ Date of Payment ~ ~-- ~ ~ Date of Payment, .~ipt N.m~ O~ 5 qq~ R~ipt Num~ Municipality of Anchorage Community Development Department Development Services Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On-Site Systems Approval # 111236 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 4, Lot 16 of Kasilof Hills subdivision. This inspection revealed a nitrate concentration of 6.87 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On- Site Systems Approval. 0 CO (DO AA0988 NOBO~Z5';Zl"W 0'01~ 0 o 0 150.00 NOBO?_5,?_i,,W 150.00 lU o o Z LU lU 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 Parcel I.D. # O 1 5 -- CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ]'~/ --lJo HAA# ~fi~ C'f L~O L_k-l,)__. 1. GENERAL INFORMATION Completelegaldescription L_o'7' /(~! ~k~ ~ P~'o_.,~l~ ~; ll~ Location (site address or directions) Property owner Mailing address _ Lending agency Mailing address_ Day phone Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: .~ 3. TYPE OF WATER SUPPLY: NOTE: Individual well ~/ Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site 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. NameofFirm '--~'¢--~ -~"~-[~"(~ "-~'~; Phone. Address ~¢~¢¢/ /S~ ¢ ~% Engineer's signature Date o DHHS SIGNATURE ~--- Approved for ..~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date The Muni¢Ipali~ of Anchorage Department of H~alth and Hurnan Se~ice$ (DHH$) issue~ H~lth Authorib/ Approwl Oer~ifi¢~t~s b~ed only upon ~he mpm~nt~tion~ ~iYen in paragraph § ~bow by an independent professional engineer m~i~tered in the Stat~ of Alaska. Th~ DMH$ do~ ~hi$ ~s ~ courtesy to purchasers of horn~ and their lendin~ institution~ in order to ~ati$~/¢~rt~in federal ~nd ~t~te requirements. Emplo¥~ of DMM$ do not ¢onduct inspections or analy~e data b~fore a certificate i$ issued. Th~ IVluni¢ipali~ of Anchora~ i$ not responsible for errom or omissions in the professional en~in~Fs work. 72-025 (Rev. 1/91) Back MOA t¢21 WAr£~ER WELL ADVISORY HEALTH AUTHORIT'f APPROVAL NO. /~/~ During a recent Health Authority Approval on-site inspection and test of the potable water supply ,well on Lot /d~ Block of ~.2}~/~ /-~'>/~' Subdivision, the well's productivity was determined to be © /.9~ gallons per minute, The minimum well productivity uequi~ed by this department (AMC 15,55) for a ~ bedroom residence is d,}'.~gal!ons per minute. Although the subject we!! currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction noncritical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of t'he subject Healti~ Authority Approval. Note: The well for this property meets existing State and Municipal Codes. There are nitrates present, it is suggested that a periodic testing be performed to insure the wells continued suitability. Nitrate concentration is 5.2 mg/1. EPA maximum concentration is 10.0. mg/1. Municipality of Anchorage Department of Health and Ftuman Services HEAL'FH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Parcel I.D. Well type ~ Log present (Y/N) "/' Total depth L¢¢O Sanitary seal (Y/N) "/ If A, B, or C, attach ADEC letter. ADEC water system number Date completed /~" tT- d~2','~' [:)riller ¥~r~ ~:'~'/ Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG / AT INSPECTION Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line / I " g.p.m. /- SEPARATION DISTANCES FROM WELL TO: ~ ~O+ [iAUNICIPALITY OF ANCHOP,.AGr: I~NVIRONMENTAL ,SERVICES DIVISION g.p'.~.P 1 ~ J~)94 RECEIVED ; On adjacent lots _ ; On adjacent lots ~..'-,, ~-~ Public sewer manhole/cleanout h///~ Petroleum tank hi JO '/ WATER SAMPLE RESULTS: Coliform /~ Date of sample: ' ~/5//~ ¥' Nitrate 5~. ~- Other bacteria Collected by: I , ~.'., B. SEPTIC/HOLDING TANK DATA Date installed I"/I.fS/c~_~Z~ Cleanouts (Y/N) '~/ High water alarm (Y/N) / Tank size Foundation cleanout (Y/N) Date of pumping '/~'~ ~(I I'~'~"'{ Compartments ~"-' Depression (Y/N) Alarm tested (Y/N) N Pumper A~t~/4, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I I D .t- ¢' On adjacent lots To property line ;~'Of° Absorption field Surface wateddrainage h,t JO ~' Foundation ¢~,o Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION [""~ Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Ler~gth ~t~..+ ,_2. j ~ Width T0ial absorption area ~ Date of adequacy test ~'/r2-'~/~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/Ft2) ~1 ~ O ) Gravel thickness Cleanout present (Y/N) Results (pass/fail) ,,/ ~"- Total depth ~ Depression over field (Y/N) . h~ for -.~ Bedrooms After test ~f if yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots '"2 I o-£.p Property line To existing or abandoned system on lot Cutbank ~ L~' © Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certi~ that I have checked, verified, or conformed to afl MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date HAA Fee $ ,....~O4'.) ~ Date of Payment _~O~/~¢/-.// Receipt Number ~O,~o~. Waiver Fee $ Date of Payment Receipt Number CT&E Ref.// Client Sample ID Matrix ClientName Ordered By Project Name Project# PWSID Commercial Testing & Engineering Co. Environmental Laboratory Services w.a~.~'.a~'.~:~'.~'.~.a~j.~-j.~.~-,~-~-~.a~-j~jtjjj~j~j~ 94.4488-3 1614 KASILOF H1LLS WATER TOBBEN SPURKLAND, P.E. TOBBEN SPURLKAND UA LABORATORY ANALYSIS REPORT WORK Order 81864 Prhttcd Date 09/07/94 ~ 11:39 tits. Collected Date 09/01/94 ~ 14:00 In-s. Receiv ed Date 09/01/94 ~16:10 lu's. Technical Director STEPI~N C. EDE Sample Remarks: ROUTINE SAN~LE COLLECTED BY: T.S. Qc Parameter Results Qual Units Method Allowable Ext. Anal Limits Date Date hilt Nitrate-N '5.2 mg/L EPA 353.2/300.0 10 09/02/94 CMiZ * See Special l~stmctions Above ** See Sample Remarks Above U = Undetected, Reported value is the practical quantification linfit. D = Secondary dilution. UA = Unavailable NA = Not Analyzed LT= Less Than GT = Greater Than 5633 [3 Street, Anchorage, AK 99518-1600 --Tel: {907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) LOT 16; BLOCK 4; KASILOF HILLS, SUBDIVISION: Location (address or directions) 10601 Resano f (b) Property owner Mailing Address Steve & Bonnie HaJu~s Telephone: (home) 346-3270 Business P.0.Box 102348, Anchorage, Alaska 99510 (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent JACK WHITE COMPANY ATTN: Kay England Address 3201 "C" Street, Suite 100, Anchorage, Alaska 99503 Telephone 563-5500 (e) Mail the HAA to the following address: (or check here~ if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eaale_EL~ar i E,*gle River, Alaska 99577. 2. TYPE OF RESIDENCE Number of bedrooms%3 Single-Family E~X 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site~;~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified bymysealaffixed hereto and as of thevalidationdateshown below, I verify that myinvestigationofthis Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional end 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 Date S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Telephone 6. DHHS APPROVAL Approved for Approved __ Disapproved Conditional Terms of Conditional Appr. oval /¢'/-n/~'.",./~: /?/"P~-/,,-,.-'~ T¢,~.7"I~.,~, Note: The well for this property meets existing State and Municipal Codes. There are nitrates present, however, it is suggested that periodic testing be performed to insure the wells continued suitability. Nitrate concentration is 8.1 and 8.6 mg/1. EPA maximum concentration is 10.0 mg/1. The Municipality of Anchorage Department of Health and Human Services(DHHS) issuesHealthAuthorityApproval cerificated 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 ordertosatisfycertain federal and state requirements. Employees of DHHSdonotconductinspections or analyze data before a certificate is issued. TheMunicipalityofAnchorageisnot responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 ~; ,.,MUNICIPALITY OF ANCHORAGE (MOA) (~,~(~/: :;: ' Health Authority Approval (HAA) .~ CHECKLIST- FEBRUARY 1984 A. WELL DATA Well Classification _ Well Log Present (Y/N) Total Depth 343-4744 Legal Description: Date Completed _(~ -/ ~ Cased to ¢to'~ Depth of Grouting If A, B, C, DE.C. Approved (Y/N) Yield Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) ~ SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ~ ~O 7"- To Nearest Edge of Absorption Field on Lot Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments ~ ; On Adjoining Lots { OO '/- ; On Adjoining Lots { OO 7'- To Nearest Public Sewer Cteanout/Manhole B. SEPTIC/HOLDING TANK DATA Date Installed /~ ~ ° ~ ' -/~ '~:) S~ze Standpipes (Y/N) ~ Depression over Tank (Y/N) f o ~c¢ No. of Compartments ,2~ Air-tight Caps (Y/N) ~/ Foundation Cleanout (Y/N) r,,) Date Last Pumped _ ~- I ~ ~ Pumping/Maintenance Contact on File (Y/N) /,)/~ ; for -- Holding Tank High-Water Alarm (Y/N) /J/~ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Building Foundation To Disposal Field To Water-Supply Well , ( too ' To Property Line ( o ~ To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments '~-,¢'"~'~;:> 72-026 (Rev 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field ~ Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field ~ ;:Z. ) Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Property Line ~ O To Existing or Abandoned System on ; On Adjoining Lots .;~O "/-- To Cutback (if present) To Water-Supply Well / (9 0/'~ To Building Foundation Lot /d [~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION '~ Date Installed Size in Gallons '~. ^ "Pump On" Level at High Water Alarm Level at "~.~ Tested for Meets MOA Electrical Codes (Y/N) Comments ~ ~ -.-q--~ ~oo'~. '~,fl¢-~ of Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effeF,~t.~i~ il~.e, of this inspection, Receipt No. ~ Receipt No. ~" "' Date of Payment //- ~ ¢ ~ ~ Waiver Fee: $ Amount: $ /~" ~ ~ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. MJALYStS REPORT BY SANPLE for Work Order 8 18324 Date Report Printed: NOV 21 89 8 09:32 Client Sample ID:L16 B4 KASILOPF HILLS PWSID :UA Collected NOV 17 89 fl 16:00 Received NOV 17 89 fl 16:30 his. Preseryed with :AS REQUIRED Client Nal. e : S & 8 ENGR Client Acct: SNSENGP P.O.~ }lONE RECEIVED Req ~ Analysis Completed :NOV 20 89 Send Reports to: Laboratory Super¥is,oz ;STEPHEN C. EDE 1)$ & S ENGR Special Instmet: Chemlab Ref ]: 8581 Lab Smpl ID: 5 }4atrix: WATER Allowable Parameter Tested Result Units [,te t hod Limits NITRATE-N 8.1 la(j/1 EPA 353.2 10 Sample ROUTINE SAMPLE Remarks: SAI4P5E COLLECTED BY RJS I Tests Performed ' See Special Instructions Above UA=Unavailable }ID= }]one Detected "See Sample Remarks Above NA= }lot Amalyzed LT-Less Than, GT=Gzeater Than CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~'6~'o~'o.~,~'J% FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order ~ 18412 Date Report Printed: NOV 27 89 @ 12:18 Client Sample ID:L16 B4 KASILOF HILLS PWSID :UA Collected NOV 22 89 ~ 11:20 hrs, Received NOV 22 89 ~ 13:30 hrs. Preserved with :AS REQUIRED Client }tame : S & S ENGR Client hcct : SNSENGP P,O.~ NONE RECEIVED Req ~ Ordered By : R. SHAFER Analysis Completed :NOV 22 89 Laboratory Superfv~s~ ,_//~PHEN C, EDE Send Reports to: 1)S Q S ENGR Special Instruct: Chemlab Ref ~: 8636 Lab Smpl ID: 3 Matrix: WATER Allowable Parameter Teeted Result Units Method Limits NITRATE-N 8.6 mE/1 EPA 353.2 lO Sample SMILE COLLECTED BY R.D.J, Remarks: i Tests Performed ' See Special Instructions M)oYe UA=Unavailable ND~ None Detected "See Sample Remarks Above NA= Not Analyzed LT-Less Than, GT:Greater Than MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CFRTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date /2/2"/ GENERAL INFORMATION Legal Description (include lot; block, subdivision, section, township, .range) Location (address or directions) (b) Applicant Name/27{~/4'J,.5' , Telephone: Home ~2 ~,~- d' '~,)".~ Business ApplicantAddressfa /,~>¢ /O2_..,~,¢~.¢, /,.-?~J~.z'.,/, ~¢¢)/.¢ ~'~,j-/o (c) Applicant is (check one): Lending Institution []; Owner/builder'S'; Buyer E'I; Other F'l (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family'3 Multi-Family [] Number of Bedrooms .~ Other WATER SUPPLY Individual WellJ~' Community[] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite~" Public [] Community [] Holding 'rank [] 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 72-025 (11,84) ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA~A AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this H~alth 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 ~ & S ENGINEERING Telephone ¢/¢2,¢'-Z-¢7 ~' Address Sl~ B 196X Date Fff, AGLI-'" RIVER, Al(: 99577 DHEP APPROVAL Approved for bedrooms 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 engineer 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 72-025 (11/84) WELL DATA Well Classification Well Log Present Total Depth _~¢o¢ Static Water Level Casing Height Above Ground ..'3~t~ Electrical Wiring in Conduit (~/N) Separation Distances from Well: To Septic/Holding Tank on Lot /' Co To Nearest Edge of Absorption Field on Lot __ To Nearest Public Sewer Line _ Cleanout/Manhole Water Sample Collected by ~ Water Sample Test Results Comments '~ )~OV~ ~/c~T~.-~ MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 19§4 Cl l l. l 2§4-4720 Legal Description: L~'£ /~ ~"-cl~- ~ HllV~H gO 'ld~d Date Completed ~ ' / ~ - ~ Yield Cased to ~D/ ~ Depth of Grouting ~' /C~ Pump Set At ~,/~- Sanitary Seal on Casing ~N) Depression Around Wellhead (Y~ ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on (.~,',,ZL~J,.-'~'IP~m,'~C.'.~ ; Date /_~- -/ B. SEPTIC/HOLDING TANK DATA Date Installed L¢-/.5*- ,'-~5~ Size /o¢o No. of Compartments Standpipes ((~'N) Air-tight Caps ((~N) Foundation Cleanout f(~/N) Depression over Tank (Y~ Date Last Pumped /,,4~ Pumping/Maintenance Contract on File (Y/N) /'" ; for Holding Tank High-Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course ,,'CO / To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed (,, -/¢~~ Width of Field ~ Square Feet of Absorption Area Depression over Field Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well /oo r_/, To Building Foundation Lot ~/I~ To Water Main/Service Line /0 /-¢' To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field Gravel Bed Thickness Standpipes Present ,~/N) Date of Last Adequacy Test To Property Line /0 To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) ZJ/~j Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Company ~,,~j~7~[j(~/~MOA No. Receipt No. i (.,.~C.) \ -- (--?-)~ ~,,.'2~ Date of Payment Amount: $ i ~..Cc'-) Comment ,//~' /-~9~.¢,.~P) /¢2,,~,,~ % / ** Check Permitted Bedroom Rating Against HAA Request** I certify thaLI ba~,gD¢&~¢~verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. ~ ~ ~ aN~INEERING Sig ned 5i( ~ 'i 96X Date /2~/'fi/~/~ ~ 72-026 (11/84)