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Home My WebLink AboutKASILOF HILLS BLK 8 LT 10 Nov_11.2022 01:46 PM Anchorage Well & Pump Service Inc 9072430742 #2944 P 1/ 1 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: Parcel Identification Number: 015 132 05 Date of Issue: - Legal Description Block Lot Property Owner Name & Address: CHRISTENSEN CHARLES S & BLAIR M KAILOF HILLS 8 10 645 G ST #650 ANCHORAGE, AK 99501-3437 I Pump Installation Date: 11 - 90 - 2022 Pump Intake Depth Below Top of Well Casing: 255 feet Pump Manufacturer's Name: BERKELEY Pump Model: B7P4M 10231-02 fPump Size: .00 hp Pitless Adapter Burial Depth: 12 feet Pitless Adapter Manufacturer's Name: MARTI NON 11Pitless Adapter Installer: IWell Disinfected Upon Completion: L 'Yes ❑ No Method of Disinfection: PELLET'S I Comments: I Pump Installer Name: _ Company: I Mailing ,Address: City: ANCHORAGE WELL & PUMP SERVICE 7640 KING STREET ANCHORAGE, AK 99518 9017-243-0740 State: zip: Attention: The pump installer shall provide a pump installation log to On4site within 30 days of pump installation. Address ~(s) .... t~No ~ ~--]No ol Bedroo~s MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Heallh Division 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT DISTANCES ~"~ TO SEPTIC ABSORPTION __F~O M ~ TANK FIELD WELL LOT LINE r'?~! ~. ~ j~l .~/~ SEPTIC ~ HOLDING TYPE OF SYSTEM ~TRENCH ~ BED [~ W. DRAIN [] OTHER Total depth from original grade FT ('~1 G~avel deplh benealh,p~pe {~ FT ~ FT ~ SO FT D WELLS X PRIVATE Classd~catrorl (A,O.C1 [] OTHER fldentifv) 1ora Deplh Cased .[ REMARKS: FT scale: I ' ~ 7ZO Inspecbons Performed by ~_ ~-: : ~-~' ~ce~ y a rlis~speciion was pedormed according to all Municipal and Stale guidelines in eflec,~ __ __ __ ~Z - ¢/ ~ O : __ E.NGINE E R'S SEAL '- ~. q~¢\\ , //):/ ER. SYSTEM 'LOCATION PLAN ~ 4~ '" ' M~OT~ m /~ .~~ DIMENSIONS INDICATED HAVE ?~R~ ~n,~. uo~,n ~ '~7~ ~ =~ ..-.-~x~ '= .." ' .:~ · '-~:~ :~ ~,e,~eo eom L~::i]~oti':~r6~ .: ..... :.: ..... : .....::: / ~ ~ J _ LEGAL OESCRIPTION:~OW [¢ SCr ~ Township, Range, Sect,on. ~//~. N U ~ C21 ~ [.~ St. OPE SITE PLAN ,...q r"o. Uc J , -f-r~c-( x', /+ -- gr'^-r~/ ~'i/4'; ~-o,.e .C~nJWASGROUNOWATER ENCOUNTERED? iF YES, AT WFIAT DEPTH? 0¢¢h to Water ~eu / ~onit~ri.g~ ~)~Y 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O _ / _ Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE __ (m,nutes/~nclg PERC HOLE DIAMETER __ TEST RUN BETWEEN .FT AND FT COMMENTS ~ -- ' .... , / ~ '/ , ( / ACCOROANOE WITH ALL S,A~EANDMUNICI'AL~UiDELINE/I'(~E~(~ THIS DATE. 72-~8 (Rev. 4/85) M-W DRILLING, Inc. P.O. Box 110378 · 10330 Old Seward Highway (907) 349-8535 ANCHORAGE, ALASKA 99511 DRILLING LOG Well Owner WARD WHITMORE Use of Well Location (address of: Township, Range, Section, if known; or distance main road _ T.n~- ID h]k_ R K~siloff Hills Domestic Size of casing Static water level Screen ( ); Perforated ( Describe screen or perforatlo~ .~ Well pumping test at 3+ gai~ ~'~'~ (~ (minute) for of drawdown from static l~eii~ ii! Date of completio~ WELL LOG Depth in feet from ground surface 0 TO. 1 1 .TO. 16 16 .TO. 3 3 Depth of Hole 300 feet Cased to 35 feet ::,:;; . 60 ft. (aY:~I~)[:. !below) land surface. Finish of well (cheek one) open end ( J/ ] hours with 100% G[V'~id~ai~s Of formations penetrated, size of material, color and hardness ~'S'C STICKUP ~'~L~ HARDPAN - DRY ' 33 .TO. 300 TO ¸TO. ¸TO. ¸TO. TO_ TO. __TO .TO TO ); ft. ~D~0C~: Sporadic Fractures with small water seaps. __ .TO 1 --CUSTOMER Municipality of Anchorage Development Services ,Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Ancho~'age, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH 'AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.'D. 015-132-05 1. GENERAL INFORMATION Expiration Date: Complete legal description Location (site address or directions) Current Property owner(s) Mailing address ' Lending agency Mailing address Real Estate Agent Mailing address 10500 WARD WHITMORE KASILOF HIII-~ suBDIvISION; LOT 10,. BLOCK 8 STROGANOF DRIvE * ANCHORAGE, AK 99511 Day phone 952-4272 HEATHER Day phone HUDSON W/ REMAX PROPERTIES Day phone 257-0161 2600 CORDOVA* ANCHORAGE, AK 99503 Unlessothe~ise~queste~ HAAwillbeheld~DSD~rp~k~. 2. NUMBER OFBEDROOMS: 4 3. TYPE OF WATER SUPPLY: ih--d~~e_ll Ii .Individuai ~vat. er. storage , ,/' Co~r~unity (~'lass Well D ;' ::~ ~ Public Water SyStem TYPE OF WASTEWATER DISPOSAL: IndNldoal-Orl~ite Individual Holding tank community on-site Public Sewer The' Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil . engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 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. 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 Health Authority 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 bedreoms 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 °fFirm GARNESS ENGINEERING GROUP, Ltd. · Address; 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Phone 337-6179 Date Engineer's comments: In conducting this evaluation, GEG, Ltd. attempted to Provide ~ 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 e valuator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there ara 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 con!ent of this 'report ~s for the sole benefit of the owner li~ted above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal rfght whatsoever. DSD SIGNATURE bedrOoms. Disapproved. Conditional approval for bedrooms, with the fi.lowing stipulations: Attachments: HAA Checklist -~ · t~nGRAM · : ...- ' ~/././;,','~CN I ~.', ox' Manilenance Agreements .,.~ j.,/.;.;; ,. ~ ~ ~ ~. Supplemental Engineer's Reorl Other Septic System Advisory Well Flow Advisory (Rev. 12J01} Original Certificate Date: Legal D?scription: · Municipality Of Anchorage Development Services Department, Building Safety Division · On-Site Water & Wastewater Program 4700 South Bragaw St. · P.O. Box 196650 Anchorage, AK 99519-6650 .. www.ci.anchorage.ak.us (907) 343-7904 ' HEALTH AUTHORITY APPROVAL C_,HECF, LIST KASILOF.HILLS SUBDIVISION;" LOT 10r BLOCK 8 ' Parcel ID: 015-132-05 Nitrate 0.01 mg./L. Date of sample: ,4/30/2004 WELL,DATA ~ Well t~p~I' PRIVATE IfA, B, or C provide PWSID# N/A Date :c~r~'pleted 7/3/1990 Sanitary seal (Y/N} YES Total C{el~{h. 300 ff. ' , Cased to ..... FROM WELL:LOG · . Date 'of test 7/3/19 9 0 ,~:: Static ~ter level 60 producbon .. 3+ g.p.m. WATER,SAMPLE RESULTS: Cohform' ~ colonies/100 mi. Arsenic: ~ ~[N/A mg./L. SEPTIC/HOLDING TANK DATA : ' Tank ~/Material SEPTIC/STEEL Tank~s~z~~ 1250 gaL . .. NumberofCompa~ments. 2 "~:~t(WN) FoundatiOn cleanout (WN).YES DePression over Date of.~ump~ng 10/19/2003~ Pumper. ABSORPTION FIELD DATA · ,:!! ~ Date installed ' 8/24/1990 Lengih ],i 50 ff. Date installed 8/24/1990 Cleanouts (Y/N) YES NO High water alarm (Y/N) N/A ISAACS PUMPING SERVICE Total depth. *9 .ft. Eft. absorption area 600 ft Monitoring'tube YES · ' · 4'3°'2004 f /' -' 'PASS' ua[e or adequacy [est / / ~..:. - Results'(Pass ~-a')__. :' i:;'~ ' :: , ' t FlUid d.,el~t? in absorption, field before test -: 61 in. '1 Wa!er added,765 gal.'. Elapsed ~Time?67.5min. Final fluid depth 65 in. Absorption rate >= Any reju¥.enation treatment (past 12 mo.).(Y/N & type ) · * 'AT RECOVERY TIME OF ~,080 MI NONE KNOWN If yes, give date LEVEL IN TRENCH .WAS 60 INCHES System type DEEP TRENCH Gravel below pipe 6. .ft. Depression 'over field NO ..For 4 bedrooms New depth 73 in. 60O+ ' g.p.d. Well Log (Y/N) YES Wires proPerly protected (Y/N) YES Casing height (above ground) 12+. in. AT INSPEC:I'ION ,V3o/2oo4- 60 .ft. 2.99 g.p.m. Other baCteria_,~ colonies/100 mi. Collected by: GEG~ Ltd.: - ~'BELOW ,~I~N~ CRADEI · ~, Soil rating (g.p.d./ft2or~ 150 -Width · t2 ft. D. LIFT STATION Date installed · : "Pump on" level at E. SEPARATION DISTANCES :.'. ' Size in gallons ~ ' ~ 'in. "Pump off" m. . : High water alarm level at ', Cycles tested Meets alarm & circuit requirements?. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station bh lot ' 1 oo'+' AbSorptio~ field on lot 100'+ On adjacent lots ' On adjacent lots' · 100'+ ¸in. ' ' ' 100'+ Public sewer main N/A Public sewer manhole/cleanout "; Sewer/septic service line" 25'4- ,',~" : Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANKON LOT TO: 'Building foundation ' ' 5'+,, Propertyline - 5'+ Absorption field' Water main N/A · .. - Water service line 10'4. .Surface water Wells on adjacent lots 100'+ . ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: 100'+ Building foundation ~' '10'+ Surface water 100'4. Property line ' 10'+ Water service line 10'+ Curtain drain' NONE F. COMMENTS ~ ~ KNOWN , Wells on adjacent lots 100'+ Water main N/A' Driveway, parking/vehicle storage · 10'+ G. ENGINEER'S CERTIFICATION · i certify that I have determined through field inSPections and ..review of Municipal records that the above systems are in conformance ,with:MOA HAA guidelines in effect on this date. Engineer's Printed Name ' JEFFREY A. GARNESS / ! "Date '~'/l,/O~" " '-'-, · HAA Fee $ -'- /1/~)'~'-.' Date oi Pa~,ment ~//o~/O~l ReCeiPt Number O~ I q-~,,'2~ (Rev. 12/01) Waiver Fee $ ":Date of Payment' · Receipt Number" HaW 11 04 lO:27a ~. .~ . Butler & Butler, Inc. 907-27B-1584 ~', ~ " ~...~,~ .. ~, ~S~M~NTS OF H~HD, OTH~ THAN ~'u~SSION~ ~ THOSE SHOWN ON ~E RECORDED ~%~~ ' P~T ARE NOT SHOWN HEREON. p.2 NO CORNERS SET THIS ATE ! he. teby cel'tify that ! have l~e.t~orr~ecl a ~iorfmgee'$ Lu- ~ect. ion. c~ ~e. ~ollowir~_ ~ desc:ibecl property: ./-~," I~ ~ ~'/,~. ,~ / R'~/'~,~ //'/ll~r ~c~,~,, _A~??o~..ge .Re.co..rding P-~:inct.;..Ala~..a, and that the improve- ~oe~s s~uatea ~nereon. are w~trun me property lines and do ._ ..ov_~eriap~o~,e. ncroacn, cn the property 1.yzng adjacent there- ~, ~na~.no -.m=..rC-vem. e~. ts o--- property lyzng adjacent thereto encroac, n on ~r~e prermses in question and that there are no roadways, transmission lines or other v/slble easements on said property except as indicated hereon. . Dated at Anchorage, Alaska FRED VSALATICA & ASSOCIATES Engineers and Surveyo~ 05-11-04 11:51AM FROM-CT&E ESI, SGS EflV SERVICES 9075615301 T-275 P.OZ/03 F-88Z ...... SGR Ref.# Client Name Project Name/t/ Client Sample ID Matrix 1042276001 Garness Engineering Group, Ltd. 10500 StroganoffDr. 10500 StroganoffDr. Drinking Water Sample Remarks: All Dates/Times are Alaska Standard Time Printed Date/Time 05/10/2004 15:07 Collected Date/Time 05/05/2004 14:10 Received Date/Time 05/05/~04 14:40 Teelmical Directo,r.....~ Step,/r/i'~ F'~'~f'- C. Ede Allowable Prep Analysis Parameter Results PQL Units Method Container ID Limit~ Date Date Init Waters Department Ni~ratc-N 0.100U 0.100 mg;L EPA300.0 B (<=10) 05106104 JMP Microbiology Laboratory Total Coliform col/100mL SMlg 9222B A (<=l) 05105104 DKC 05-11-04 11:51AU FROU-CT&E ESI, SG$ ENV SERVICES 9075615301 T-275 P.03/03 F-88Z SGSICT&E ENVIRONMENTAL SERvIcEs Drinking water Analysis Report for Total Coliform Bacteria' READ INSTRUC31ONS ON REVE. RSE SIDE I~EFORE COLLECTING SAMPLE MUST BE COMPLETED ElY WATER SUPPLIER 200 W. pOTTER DRIVE 'ANCHORAGE, ALASKA gg51B Tel: 907-562-2343 Fax: 907-561-5301 Lab Ref No. SAMPLE COLLECTION: . ~o ~u e~ ame as ~l~or ~he~ · TO BE COMPLIED BY ~BD~TORY Sample Receivln~: .__ . SAMPLE TYPE: HMO-MUG [P/A) RESI. II.T',~: Seatto ADEC: . . ANC FB.K Date/Time:... ' . , ~Ba~tertoloR'lcaI Water A,nalvsls Recol%l; Allaly, l~ Beg_art: Analyst: Analytical Method: Me~brane Filter NIMO-MUG (P/A) I · ' B~gnalum ,,~ MEMBRANE FILTER Direct Counl: Verffication: ~c4o~iez/10OmL Sent to C11afll: ,~ Satisfactory []. Unsatisfactory Form I~ FW- 0053 12/17/03 5-- 3--04; 13:32 ;CT and E AWWC SGS/CYE .E.f~I~iRONMENTAL SERVICES Drinking Water Analysis Repot[ for ·Total Coliform B~cteria RP-_~,D INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE MUST.BE COMPLETE.D BY WATER SUPPLIER, .- [] PUBUC WATER SYSTEM ID# ,. j~/;IVATE WATER SYSTEM ~end Results., ~end Invoice N~te~:.~yste m N a me/C ompa ny N.'t ma =~' . ~DT-GID? '" ~,~ailm g Address SA~PLE COLLECTION: Month ~Y Year ;5615301 # 2/ 2 "200 W. POTTER DRIVE · ANCHOP, AGE, ALASKA 9~518 Tel: 907-562-2343 Fax: 907-561-5301 I ~h R~f kln. 10421 93 I SAMPLE TYPEi " ~Routine [] Treated Water [] Untreated Wa~... Time: ~:.~4~) AM ~.~o.) [] Repeat Sample PAn~d Na~ ~e ~ · T~ns~ed ~a ' to La~y: me as cofle~or Other: ~ TO BE (~OMPLETED BY kABORATORY Sample Receivin.q: Date: Time: Temp: Delivery Method: Received By: c..~-(--'~"' Printed Name Comrr~nts: · [] Sample over 30 hours oM; Results may be unreliable ~ 48 HourWalver [] :RUSH SAMPLE Phone #: Fax #: Held For Confkmatio- For~~_ .lions Bact~.ri olo.qical Water Analysis Record: ; Jse~{t to ADEC: ' I~O-MUG (P/A) RESULTS: I ANC FBK JUN An=ly.Js lB°gan: C('/ ~/~t~ ( ~ I [Z") Total Coliform: JDatefT]me: Analy~ : AnalytJca~l Method: Isent to Client j Phoned I---I Faxed I-'"1 O-3teFims: ' S )eke with: . r-~ Membrane Filter I-~ MMO-MUG (P/A) ME. MBRANE FILTER RESULTS: Direct Count -ri~3-t_ o~ Cobnles/lOOml Verification: 'I.B~B~i~.~g-~%~C I--1 Saiisfact~ry ..,~..~ [ EC:~ .. ~ Unsatisfactory ( j II~I'C - 'Too Numerous te Ceu~t - '~ignature ~' - .. -. ,. / .. ,- .. I "~ For~#FW-O053 ~0/24/O3~ \~petra\public\DOCUMEN~FORMS~Vl[cro\Coti Form.xls · :"! / ~..: .................. ' ...... J.; . ....~ ..... : .................... 05-06-04 OZ:IgPU FROU-CT&E ESI, SGS ENV SERVICES 9075615301 T-228 P.02/03 F-786 · I SGS Ret# Client Name Project Name/# Client Snmple ID Matrix 1042193001 Garness Engineering Group, Ltd. Ka$ilofHills LI0, B8 Kasilof Hills L10, B8 Drinking Water Sampl~ Remarks: All Dates/Times nrc Alaska Standard Time Printed Date/Time 05/05/2004 15:25 Collected Date/Time 04/30/2004 15:10 Received Date/Time 04/30/2004 16:11 PQL Units Melhod Allowable P~ep Analysis Container ID Limits Date Date Init Waters Department Nitratc-N O.lOO U 0.100 mg/L EPA 300.0 B 05101104 JMP Microbiology Laboratory Total Coliform TNTC OB col/lOOmL SMI8 9222B A (<=1) 04/30104 DKC 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 GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Mailing Address ~d; / (c) l_ending Institution Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here ~-Id for pick up.) List contact person and day phone number below: Telephone: (home)¢"/'//,,~ Business Telephone ~7~ Single-Family ~ Number of bedrooms 3, WATER SUPPLY ~' Individual Well iD" 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 IRev. 7/88) Page 1 of 2 ~ ,to ~ ebed ')po/~ s,Jeeu!Sue leUO!SSe~oJd eq~ u! suo!ss!uJo Jo sJoJJe JOj elq!suodseJ ~ou s! ebeJoqou¥ jo ,OJled!o!unlAI eLI11 'penssf s! e~eo!Ji~Jeo e eJojeq e~ep eZXleUe Jo suo!],oadsu! ~onpuoo ~ou op SHHQ jo seeXoldLu3 's~ueLuej!nbeJ e],e~s pue leJepej u!elJeo/,Js!~es o~ JepJo u! suoRnlRsu! l~u!pual J!eq~ pue saLuoq jo sJeSeCl3Jnd o~ Xse~Jnoo e se s!q~ seop SHHQ eq.L 'e)fsel¥ jo e~elS eq~ u! paJe~s!SeJ Jeeu!lSue leuo!ssejoJd ~uepuedepu! ue/,q a^oqe S qdeJSeJed u! ue^!8 suo!le~ueseJdeJ eq], uodn/~lUO peseq peleo!~peo le^oJddv X~!Joq~n¥ Lt~leeH senss! (SHHQ) seo!^Jes ueuJnH pue q],leeH ~o ~uecuiJedeQ el~eJoqou¥ ,to X~!led!o!un~ eqj. leUOB!puoo le^oJddv leUOB!puoo to suJJe.L pe^oJddes!C] /~ pe^oJdd¥ /,q scuooJpeq~,Joj pe^oJdd¥ lYAOtJdd~ SHHCl '9 lees s,Jeeu!bu3 Well Log Present (Y/N) Z' Total Depth '~E:Et_) Cased to Static Water Level ~/) Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: ~ MUNICIPALITY OF ANCHORAGE (MOA) ~ ,(x~,~i~'~ Health Authority Approval (HAA) /~]%~ ¢~x~ ° ~¢,q x°t~ 343-4744 ~ Legal Description: A. WELL DATA cV~ ' Well Classif.*~~ ~ ~ Fe. I, A, B, C, D.E.C. Approved (Y/N) ~ Date Completed ~*~'d)~-- Yield ~,,~I;~7 Depth of Grouting _ ~ Pump Set At ~'?~z/P~ SanitaW Seal on Casin~ (Y/~) ~ Depression ArounO WellheaO (Y/~) ~ To Septic/Holding Tank on Lot ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot z/'¢''¢'/ ; On Adjoining Lots To Nearest Public Sewer Line /~'72~ To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by . .*~'7/7J~"~'~'~,,'~?~'7~ '.2.. t ,' Water Sample Test Results Comments B. SFPTIC/HOLDING TANK DATA Date Installed Od~>~//~°'//~E7 Size /~--5~"E~ No. of Compartments Standpipes (Y/N) ~ Air-tight Caps (Y/N) ~" Foundation Cleanout (Y/N) Depression over Tank (Y/N) /~ Date Last Pumped /~'~---'/~¢~ Pumping/Maintenance Contact 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 '7 To Water Main/Service Line ~ ¢'~-'~:~ 1 To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation ;¢2.~ To Disposal Field /~/' 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 SEPARATION DISTANCE FROM ABSORPTION FIELD: Type of System Design Length of Field Depth of Field ~'~ / Gravel Bed Thickness ~;'~ '7/2~ ~ Statndpipes Present (Y/N) Date of Last Adequacy Test To Water-Supply Well / To Building Foundation LOt ,/~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line ¢~,~ / To Existing or Abandoned System on ; On Adjoining Lots ~" .~O / To Cutback (if present) '/~, Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Dimensions Manhole/Access ~' "Pu. mC~f' Level at J Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/Nog,,''''i Comments **Check Perm.~t,t~ ~=Bedroom/ating Against HAA Request** I certify that/.)¢¢~ check~'.Ccv~rified, or conformed to all MOA and HAA inspection//.,~ Signed ~///~"~' - -'~'/6'~ Company on the date of this Engineer's Seal Receipt No. ,¢'~'- ~)'~ ~ Date of Payment Amount: $ 72 026 (Rev 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2