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HomeMy WebLinkAboutMCKINLEY VIEW ESTATES BLK 2 LT 20 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~'~ '~/ ~.7;~ PIDNumber: ~/ Name: . Wastewater System: ~ New [] Upgrade : ABSORPTION FIELD Phone: ~o. o~ B~rooms: ~7~ --~-~ ~ U Deep Trench ~ Shallow Trench ~Bed ~ Mound D Other LEGAL DESCRIPTION So..~.n.: ~o~, ~/~X- GPD/Sq. Ft. ~ / , Lot: Block: Subdivision~ Depth to pipe bottom from original grade: Gravel depth beneath pipe ~ O ~ ~,~/~ ~ ~. /, ~ Ft. ~'~ Ft. Town,hip: Range: Sec~n: Fill added above original grade: Gravel length: /~ / ~ /- ~ Ft. ~0 ' Ft. Number of lines: Distance ~een lines: WELL: ~ New ~ Upgrade Gravel ~ ~ / Ft. ~ I~ ~ ~ ~ Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: ~" ~ Ft. ~ Ft. /~ SQ. Ft. Driller: Date Drilled: Static Water Level: Installer: Date installed: Yield: : GPM PumpSetat: ~ Ft. CasingHe~AboveGround:Ft. TANK SEPARATION DISTANCES ~= Septic ~ Holding ~S.T.E.P. To Septic Absorption Lift Holding PuNic/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~ ~ ~ Material: Number of Compartments: Well ~o ' ¢ ~' ~v~ ' ~ ~/~ ' ~./ SurfaCewater ~ ~. / LIFT STATION Lot / size in gallons: Manufacturer: Line ~ 10 / ~ / ~ / /~. ~.--~ ~ ~-/- Foundation ~ /~ / ~ / ~ / "Pump on" lev~ at: "Pump off" level at: High water alarm at: Curtain Pump Make & Mode[ Electrical Inspections performed by: ~-~ ~ Drain ~/~ ~ / ~ //~ ~p~ BENCH MARK Remarks: ~., /. ~ ~ ~ ~ ~/ ~, Location and Description: Assumed Elevation: Inspections performed by: ~, ~,f, Dates'. 1st ~,/~/ ~ %:~. ~ :. ~*;~'d7 ' .... , /" Department of Hea~ an~ ~uman Services approval ~,8ovieweO and approveO by: Date: /~ 72-013 (1/91) MOA 25 Permit No. ~o ~ t <D \ 3-'1 Page Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report - MONITOR TUBE EASEMEN~ ' o -- SEWER CLEANOUT KEYBOX ~ - WELL .... EASEMENT ELEYATIBNS , (NO! fO SCALE) ~ WATER VALVE ]~BX ASSUMED ELEV = lO0+O0' a' ADDED FILL 72~013 A (2/91) MOA 25 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW910137 DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES OWNER NAME:ERICKSON STEVEN D & ALISON R OWNER ADDRESS:PO BOX 77120~ EAGLE RIVER, AK 99577 PARCEL ID:05179224 DATE ISSUED: 6/06/91 EXPIRATION DATE: 6/06/92 LEGAL DESCRIPTION: MCKINLEY VIEW ESTATES B2 L20': SEC 4, T15N, R1W, SM LOT SIZE: 32650 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVI S~NS: RECEIVED ISSUED BY: DATE: DATE: / / · ~ TAN ,,,,,,,, ,, ,,-,,,~ ~//' ,~ ?~/ EXISTING '<~, ~~~//-2.21...x..~ ~2~ ~ ~x"~x.. ~ 10' DroJnage Los .... t "//" NO KNOWN CURTAIN DRAINS ,:~ ~// ~ - TEST HOLE ' · - MONITOR TUBE o - SEWER CLEANOUT + - WELL EASEMENT ,-. .': -' :.t ,', ,., SEPTIC SiTE PLAN ,:' :: :"" LEOAL: McKin~ey View Estetes Lot 20, Elk 2 '" " ' ' ' OWNER: ERICKSON .:,.:,.,..-:.,. .., CONTRACTOR: N/A lOB ~ 90 1221 DATE: 05/23/911 SCALE 1" : 50' EAGLE RIVER ENGINEENING SE~WCES ' ' ' ~0. ~ox 77~4 EACLE NIVEN, A~. 99577 EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294. EAGLE RIVER, ALASKA 99577 Phone 694-5195 //~;;~__lease reply [] No reply necessary SIGNED EAGLE RIVF' ENGINEERING SE,,.., iCES P. O. Box 773294 EAGLE RIVER, ALASKA 99577 Phone 694-5195 JOB ~. SHEET NO.- CALCULATED BY CHECKED .~//~ SCALE DATE May 23, 1991 John Smith, P.E. Manager, On-Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Lot 20, Block 2, McKinley View Estates Narrative Dear Mr. Smith, The proposed septic upgrade will have very limited impact on adjacent properties for the following reasons: 1. There is a community well system in place so there are no well setbacks considerations allowing adequate room for upgrades on all lots. 2. Immediate neighboring septic systems are all +30' distance. 3. Reserve space is adequate, homes are existing with many upgraded already. 4. Drainage will not be effected. Existing drainage is directed down a drainage channel on North property line. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. P.O. ?,ox 77:/29,! ~' t,',agIe River, Alaska 09377 , %]cphone (907) 6!)445195 o Fax (!}07) (i94 32!)7 /. · ~ TANK -..../ LEACH FIELD DEVELOPMENT NO KNOWN OU~TAIN D~AINS ~ - TEST HOLE · - MONITOR TUBE o - SEWER CLEANOUT ~ - WELL EASEMEN[ SEPTIC SITE PLAN L~AL: McKinley View Esta[es Lot 20, BIk 2 OWNER: ERICKSON CONTRACTOR: qOB ~ 9o-1221 DAYE: 05/23/91J SCALE 1" = 507 ~ EAGLE RIVER ENGINEERING SERVICES ~ P,O. Box 773294 ~ EAGLE RIVER, AK. 99577 LEGAL: SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM LOT 20, BLOCK 2, McKINLEY VIEW ESTATES A. GENERAL The well and septic plan are for a single family residence only. The drawing and or site plan shall be a part of this specification. All materials and workmanship shall meet the Anchorage Department of Health and State Department of Environmental Conservation requirements. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. All excavations and depths are advisory and are to be verified or modified in the field by the contractor to meet Municipality of Anchorage, Department of Environmental Conservation requirements. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. B. BED 2. 3. 4. 5. 6. 7. The bed is to follow the natural land contour to maintain uniform total depth of the bed bottom. The bottom of the bed shall be level, plus or minus 1.5". The total depth of the bed excavation is not to exceed 2' referencing ground level at test hole #2. The bed gravel is to be covered with typar fabric material. Soil or combination of soil and extruded board insulation to a depth of 4' or equivalent is to be placed over the leachfield. The area over the bed is to be finish graded to prevent ponding of surface water runoff. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS: TOTAL DEPTH = 2' GRAVEL DEPTH = 6" BED LENGTH = 37.5' BED WIDTH = ~4~;3'd( SOIL RATING = 0.5 GPD/Ft2 BEDROOM CAPACITY = 3 SEPTIC TANK SIZE = 1,000 gallons NOTE: NOTE: Lift station required if grade not met to house foundation level. Shallow flow lines to insulated. Twenty-four (24) hours required for all inspections. Tom Fink, Mayor N mxicipality of A xchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 November 27, 1990 Louis Butera, P.E. Eagle River Engineering Services P.O. Box 773294 Eagle River, Alaska 99577 Re: Lot 20, Bk 2, McKinley View Estates Dear Mr. Butera: In response to your November 14 letter, this office conducted a site visit and inspected the drainage easement which exists between lots 20 and 21, Block 2, McKinley View Estates. Based on our inspection, it appears that the drainage easement is used only to carry break up and/or rainfall event surface water. However, because our inspection occurred after freeze up, there is still a possibility that surface water, unrelated to a specific event, may flow within the easement area. We will be happy to reinspect the site after break up and make a final determination as to whether surface water is present within the drainage easement. Sinc_erely,/ ~ ogram Manager, On-site Services Kids Are Our Future PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 g 10 11 12 13 14 15 16 17 18 19 20 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 82§ L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? O P E IF YES, AT WHAT /,~ / DEPTH? Dross Net Depth to Net Reading Date Time Time Water Drop I PERCOLATION RATE ~',~ (minutes/inch) TEST RUN BETWEEN 4/' FT AND '~.-~-~ FT COMMENTS Eagle [river Enginocrlng Servic0$ ~ DATE: 'g~';;~-~' .. PERFORMED BY: p ~, Rn'x77329-1 CERTIFIED BY: Eagle I}iver, Al( 99577 694,-5195 72-008 (6/79} MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 82§ L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: DATE PERFORMED: LEGAL DESCRIPTION: ,~"~Z" ,~o ~5=/',~' ,2. 1 2 3 4 5 6 SLOPE SITE PLAN 7 8 9 10 WAS GROUND WATER 11 .'OUNTERED7 12 IF YES, AT WHAT/,/,~v DEPTH? 13 14 15 16 17 18 19 20 PERCOLATION RATE S L O P E Gross Net Depth to Net Reading Date Time Time Water Drop f ////5' I~;/~- '~ .... 4'-?'~ '-x %% .2 t/,'//'~' 1/; 9'7 Xo ..... ~; ? '~ 3 TEST RUN BETWEEN ~, o/ 1 . (minutes/inch) ~", FT AND .5-- FT COMMENTS PERFORMED BY: 72-008 (6/79) Eagle Riv0r Engin0edng Services F. 0. Box 773294 Eagle River, Al( 99577 69-'~5195 CERTIFIED BY: DATE: 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: LEGAL DESCRIPTION: 77/3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O SLOPE DATE PERFORMED: //> '//~ ~ SITE PLA~ WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop i n/~v I/.'-~7 s,~.-~.~ ~':/~ :2 ~'J~ I/',: 1 .~' ..... ~ ~ '~ " / ~¢ PERCOLATION RATE TEST RUN BETWEEN ~'~ ~( (minutes/inch) ~'J-FT AND z/' FT COMMENTS Eagle River Eng[neer)ng Services ~/'~"~.~_.~ ,~-/...~.~,,//~,~ PERFORMED BY: P I'1 ~',' 773~g,! CERTIFIED BY: ~ DATE: . . Eegle Pffver, At( gg577 69~-5195 72-008 (6~79) 77// , SENT DY:ADEO ANOHORA~E ;10-16-91 ; 1~:24 ;ANQHORABE/WE~TERN D0* 694~[~;~ 2 DEPT, OF ENVIRONMENTAL CONSERVATION ANCHORAGr: DISTRIOT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 WALTER J. HICKEL, GOVERNOR (907) $63-6775 October 14, 1991 FOR: Eagle River Engineering PWSID: ~ My review of the records on file In this office reveals that the McKinley.View Estate~ S~ Class "A" Public Water System is in compliance with the provisions of 18 AAC 80.060, State of Alaska Drinking Water Regulations. Sincerely, ,/) Byron Roys Environmental Engineer 8R/cf /~--.~/~ -~ ,., HOMESTEAD RD. I I (W. HOMESTEAD RD.) NW 1459 14 * 21 ~orth Muaicioality Area Boference Mao~B 20 ~ 22 28 ~ COPYRIGHT 1989 JMR Parcel 1. .D.# MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES ~ ^~cHO~AG~ Division of Environmental Services ~, Ow .,~-~ [~/~$~O~ On-Site Services Section 99519-66.~~/~°~ P.O. Box 196650 Anchorage, Alaska 343-4744 APPROVAL FOR A SINGLE FAMILY DWELLING .AA# ./-/,e GENERAL INFORMATION Complete legal description Location (site address or directions) r~?/.~,~.'.'.'.~) ~?r,~r0 /~,-. Mailing address Lending agency Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. NUME~ER OF BEDROOMS: ~'~ ~/ TYPE OF WATER SUPPLY: Individual well Community well Public water RECEIVED MAY D Munic/Pality of ~nc ept. Health ~_ ~,. horaa~ "human Sery_~i~ee~ NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front MOA#21 STATEMENT OF INSPECTION BY ENGINEER. As certified by my Seal affixed hereto and as0f 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. Address Engineer's signature D..s SIG.ATURE ~"-- APproved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Tile 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 doe§ thi§ a§ a Courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-O25 (Rev. 1/91) Back MOA ~21 Legal Description: A. WELL DATA Total depth Sanitary seal (Y/N) Date of test Static water level Well production WATER SAM ~P,I.,E"RESU LTS: Coliform Municipality of Anchorage ~tUN~C~P^UTY OF ANCUO~j~i~ DEPARTMENT OF HEALTH & HUMAN SERVlL~NMF-N'~At-$~P'VlCFS pi Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 3~7~ 1997 Health AUthority Approval Checklist R E ~ E [ V ~ D ~2~ Parcel I.D.: B, or C, at(ach ADEC letter. ADEC wat~¢yctem number Date completed Cased to AT NSPECT ON FROM g.p.m. Casing height (above ground) Wires properly protected (Y/N) g.p.m. N it rate Other bacteria Date of sample: SEPTIC/HOLDING TANK DATA Date installed -,)'-~l7 ~{ Tanksize Foundation cleanout (Y/N)--/V" Depression (Y/N) Date of Pumping /~¢~y/?/ ~,:~z_ Pumper Collected by: Number of Compartments ~ Cleanouts (Y/N) /V' /tO/ High water alarm (Y/N) ABSORPTION FIELD DATA / Date installed ~]Z_~L-~ ¢~ ,'~ S.oilratino,~pd/ftorft/bdrm)~-~'~ystemtype~~' Length ,%F) Width ~ Grave th ckness be ow p pe ~ Tote dept~ Effective absorption area / ¢ © ~ Monitoring Tube present (Y/N) ~ Depression over field Date of adequacy test ~/5~/I~/~ ¢7 _ Results (Pass/Fail) ~'%-'~ For ~ ! / Fluid depth in absorption field before test (in.); Fluid depth ~ 1~-~'~ (ins) Minutes later:. Peroxide treatment (past 12 months) (Y/N) Immediately after~'-,~jal, water added (in.): Absorption rate = ~'~"~ g.p.d. If yes, give date bedr. oo~ 72-026 (Rev. 3/96)* LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested Size in gallons "Pump on" level at*_ ¢0 "Pump off" level at* RECEIVED E. SEPARATION DISTANCES Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line SEPARATION DISTANCES FROM WELL ON LOT TO: ,v'//'/, On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING _T,~NK ON/~TO: Foundation (~-'~ Propertyline 722 ~ %~Absorption Mu~iclpaiity ct Anchorage · . ealth & Human,Services I',,l /~: ..... lSurface water/drainage '¢';t ~- ~ Water main/service line Lc_.,~.~) _ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT T.O: Properly line / 0 Building foundation ~, ~ Water main/service line Sudace water ~ ~~~~~e storage area_ Cu~ain drain /~/~ Wells on adjacent lots /V/~- F. ENGINEER'S CERTIFICATION I certify that I have determined thru ~fjeld inspections in confqr~e with MO/~ ~AA gui~lines in effect on this date. Signature ~ ~._~ j ~f L.~~ ~ Engineer's Nam ~ i ~ Waiver Fee $ Date of Payment Receipt Number are 72-026 (Rev. 3/96)* ~ ,; '. CERTIFICATE OF HEALTH AUTHORITY .... /'";?:'?" ~' ';'"~" ~ ";'~ '"' ~,PPROVAL FOR A SINGLE'FAM LY DWEL~LIN~ 5Z- Parcel I.D.~ 0 792-24' '" 1. GENERAL INFORMATION -- .- ~ Complete legal description Hc~le~ View gstates~ ~ot 20, Bi~ 2 · 15N AlW Sectlo~ 4 ~ B~o~ ~ive, ~a91e Location (site address or directions) Pro perty owner .~.v.n & A]]~.~on Erickson Dayphone 694-5326 Mailing address P.O. Box 771207, EaGle River, AK 99577 Lending agency N,/A Day phone Mailing address Agent N/A Day phc ne Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well x Public water NOTE: ing to the legality and status of system. If community well system, provide written confirmation from State ADEC attest- 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual o n-site X Holding tank Community on-site . - Public sewer 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 .... sluewwoo It]UO!l!ppv :suo!lBInd!is BU!MOIIO,t eLI1 ql!M 'SUJOOJpeq JO} IBAoJddB leUO!l!puo~) 'peAoJddBs!Q 'SLUOOJpGq ~-- Joj peAmddv ~ :]tlR~'~NIDIS SHHa '9  eJnl~u§!s s~eeu!§u:l LLq66 )IV '.xa.,',T~I ~TB[?Et 'Iz6E£LL xo[t *O*&- sseJppv ~ t:I=I=INIDN=1 Ag NOI.LO~idSNI dO .J.N=IINgJ. VJ.S 'S Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ,/,/C.,~./,xzZ.~Y I//~lo t5:57?., Z~oT' ZO Z~L/~: ZParcel I.D. A. WELL DATA Well type ~f ¢ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed Driller Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Cased to Casing height Wires properly protected (Y/N) ×/" AT INSerTION Absorption field on lot W ; On adjacent lots FROM WELL LOG Pump level SEPARATION DISTANCES FROM WEL~: Septic/holding tank on lot ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Public sewer main Sewer service line J WATER S~E RESULTS: ./D~te of sample: Collected by: Nitrate Other bacteria B. SEPTIC/HOLD!.N'G T~NK-DATA Date installed DC,//ZZ,/? / Tank size /~ ~0 Compartments Cleanouts (Y/N) ~ Foundation cleanout (Y/N) ~' Depression (Y/N) High water alarm (Y/N) -'%//~ Alarm tested (Y/N) Date of pumping z¥//} - /t/~.l,,t/ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /V///~ On adjacent lots To property line ~' Absorption field Surface water/drainage Foundation Water.ma-i,~service line 72-026 (Rev. 7/91) 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) I,~50 "Pump on" level at Manufacturer Manhole/Access (Y/N) )/ -¢0" "Pump off" level at Cycles tested SEPARATION DISTANCE FIROM LIFT STATION TO: Well on lot .... ,A///,¢ On adjacent lots D. ABSORPTION FIELD DATA Date installed ..... 0 Length Jr0 ' Width Total absorption area /~ ?.,OO /cZ Depression over field (Y/N) Results (pass/fail) _ _,P/~;$ Peroxide treatment (past 12 months) (Y/N) ¢ ~'0g) ' Surface water ___/v'/,4 Soil rating O'z~ Gravel thickness ~.~ ' Total depth Cleanouts present (Y/N) Y Date of adequacy test for System type If yes, give date ..... ~./~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot zV'//~_ '1'o building foundation On adjacent lots ~)ff Surface water /V/,,~_ Curtain drain _ /t///~ On adjacent lots /' ~.00 ' Property line ..... /~) ' To existing or abandoned system on lot __Cutbank ,-~/,~ Water mair+/service line__~/?~Li .... Driveway, parking/vehicle storage area /'~ bedrooms E. ENGINEER'S CERTIFICATION ! certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this ~nspection. Signature _ ~ '-/~-J¢ Engineer's Name 13ate .... 1~¢/¢/ HAA Fee $ Date of Payment Receipt Number 72-026 (Rev, 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number