HomeMy WebLinkAboutMCMAHON BLK 2 LT 1McMahon Block Lot 1 #017-041-23 Municipality of Anchorage Page of Z 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: `)q 1101 1 ci PID Number: nhi -- ini-j \ 5 Name:—�'A Wastewater System: ) 'New El Upgrade �o n n�e'er Address: ZZ0 Cleveland -0-(Z01 ABSORPTION FIELD Phone: i/ Z No. o4f8 edrooms: Deep Trench LJ Shallow Trench 11 Bed El Mound Other LEGAL DESCRIPTION Soil Rating: D' � Total Depth from original grade: ��' � F'T_ GPD/Sq. . Ft Lot: Block: Subdivisio�ny C/ "f cl Am Depth to pipe bottom from original grade: 3• $ Ft. Gravel depth beneath pipe � Ft. Township:��yy /G Range: W g 3 Section. �J Q Z8 Fill added above original grade: 4M /-3 Gravel length: Ft. T� Ft. WELL: XNew ❑ Upgrade Gravel width: Numberoflines: / Distance between lines: Ft. Ft. Classification (Private, A,B,C): Total Depth: /01 Cased To: /0/ Total absorption area: 1 Pipe material: 1P VC, Yi va+e, Ft. Ft. - , 000 SQ. Ft. Driller: lite; rdlil n € G14W, I�IeD Date grilled: � Static Water Level* 7��n Installers aAn ,w,ir�- Co. Date installed: 3�5�I9 Yield: 115 Pump Set at:: Casing Height Above Ground: ve 00 TANK GPM ! Ft. ✓ Ft. SEPARATION DISTANCES XSeptic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacture y7 ) 1 (j7 K Capacity in gallons: /ZSO From Tank Field Station Tank Sewer Lines ��LL1lll Well 2-S' / l30! N6� Nd� aJ�� ,VA/� Material: �L 7 Number of Compartments: Surface Water N�. �/� �V Arm !V t` /V IV LIFT STATION Lotze / t0 An,- Size in �4allons: Manufacturer: Line / "MQ� / �O /(HVAC Foundation 5' 0' ✓ n/ - /V A m /(/ AJai �V Pump on" level at: "Pump off' -level at: High water alarm at: Curtain/ Drain ��� � ' Am - J*+ /V / Pump Make & Model "` Electrical Inspections performed by: BENCH MARK Remarks: Location and Description: `o f/ t/ n !R /Z !/ bi'rck 23' ea,s4 of easf _r -'Y4 o-� Krause Assumed Elevation: /00 ENGINEER'S SEAL OF Dates: 1st Inspections performed by: ° y .^� 2nd3/khj:10a 000° Department of Health and Hu a Services app Vol.,$.a.baay. a ° EAUSMAN ARLE V. ° °' Reviewed and approved by: �' % Date: CE d 1393 ^�.. o°Ooo.......°°°P.sa ww 72-013 (Rev. 9/91) MOA 25 Nof� ///--3o/ 72-013 A (2/91) MOA 25 co, �! ijR l vE OV ;,r _- Woo o ooa0 00000 sod• e4�0000000aa 0694,000 NAM o SARI@ V. Atrsmm ° CE -1393 )� n F �f.LY`(fav�1 C.1��r IC I�Oa@' FJ Z 2 Permit No. Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report '/� �32- Legal Description: i PID No.: r Co N 98- Co Co Ai vi N9 Z 98) e theJ %�g111, in N9le: No wils win ,41St"riV• �ntij W"�s er1T lets( 0,v5'oF level 844, it off ' Na vJafer __ L� l � Bia�loor Ivo' !�I ABZ AB( co 1 /p' 16, �'� 5'r, l5' r5' s I col sTZ 2-2! r5� BDR� CoZ 25, 16 Dwk!_GII/6- Go3 26 _ �3co2 Mwl 39'2-71250 Z A$Z c r 39' �3` 30' GkL, TgNt� co0 s G88'1 r ENGINEER'S SEAL Nof� ///--3o/ 72-013 A (2/91) MOA 25 co, �! ijR l vE OV ;,r _- Woo o ooa0 00000 sod• e4�0000000aa 0694,000 NAM o SARI@ V. Atrsmm ° CE -1393 )� n F �f.LY`(fav�1 C.1��r IC I�Oa@' FJ FPDI•I FiPIIE ERILLVA' LOCATION OF WELL _.. ... ___ Fk< 110. : 907 345 IS'Ll•' Har. 2' 2DOS 11:1314.1 Pl STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION OF WATER WATER WELL RECORD aoRCUGH sueolm." LOT Ilteat SeCTION nTRs E[crioN TOVNKNIP PAMS 641700 AN OE ONI Owl I LOCATIONISKETCH: WELL OWNER: DEPTHS MEASURED FROM:❑caslrg top Oground surface WELL DEPTH: DATE OF COMPLETION Depth of hole: �9— % ft !� BOREHOLE DATA: Depth Depth of casing /_L/ / 5 Material Type and Color From To '. DEPTH TO STATIC WATER LEVEL: f7 0 h below EX4v of casing ❑ Around surface f Dace „�• METHOD OF DRILLING: .0 air rotary O cable tool ❑other USE OF WELL, 13 domestic ❑irrigation ❑ monitor z*,r 2,- ❑ pt*& supply O other _.) C �" CASING STICK-UP- 7 . tt. Otam: tn. tozQl h .�'.��.%IAvac+�✓ :s'Z�fJ ��% Casing type_ in. to YO!—ft WELL MAKE OPENING TYPE: © open end ❑ screened 13 perforated ❑ open hole Depths of openings: to h SCREEN TYPE: Diam: in. Slot/Mesh Size: lugth: It GRAVEL PACK TYPE- YPEVolume Volumeused: Depth to top: GROUT TYPE: \ Volum¢: Depth: from h to h DEVELOPMENT METHOD - Duration: PUMPING LEVEL AND YD: rsDumDig? _gpm PUMP INTAKE DEPTH: h Horsepower: WELL DISINFECTED UPON COMPLETION? MM ❑ NO CONTRACTOR INFORMA ON' , REMARKS: PLEASE MAIL WHITE COPY OF LOG:70: atO tl ! DNRIDNISION OF WATER PO BOX 772116 EAGLE RIVER AK 99577.2116 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 FJ/v y3 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW940013 DESIGN ENGINEER:POLARCONSULT OWNER NAME:HAGMEIER JOHN C & JUDITH A OWNER ADDRESS:2204 CLEVELAND #201 ANCHORAGE, ALASKA 99517 PARCEL ID:01704123 LEGAL DESCRIPTION: MCMAHON BLK 2 LT LOT SIZE: 29809 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 1 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: I DATE ISSUED: 1/26/94 EXPIRATION DATE: 1/26/95 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED ISSUED BY DATE:ZY DATE: 2 /- / 4 polarconsult alaska, inc. ENGINEERS • SURVEYORS • ENERGY CONSULTANTS January 12, 1994 DHHS, Environmental Services, On-site Services P.O. Box 196650 Anchorage, Alaska 99519 Attn: Permit Review Officer Re: Design and Construction Approval for On-site Sewer System at Lot 1, Block 2, McMahon S/D. Dear Sir or Madam: Please accept the following design for review and permitting. The proposed system does not affect the current use of the adjacent properties and will have minimum future impact. If you have any questions, please give me a call. Sincerely, Matthew Korshin POLARCONSULT Attachments: On-site Sewer/Well Permit Application Site Plan, Sheet 1 of 4 System Design Calculations, Section, Sheet 2 of 4 Percolation Test, Sheet 3 of 4 Percolation Test, Sheet 4 of 4 4e�Alo $44A Check for Permit Fee 1503 WEST 33RD AVENUE • SUITE 310 • ANCHORAGE, ALASKA 99503 PHONE (907) 258-2420 • TELEFAX (907) 258-2419 PRODUCT 217-1(&*Sh )205-1(PWW) 0. IN., GMMMm. 01471. To OrdffPMTOLL FRE I-MMMO polarconsult alaska, Inc. 1503 West 33rd Avenue • Suite 310 ANCHORAGE, ALASKA 99503 (907) 258.2420 Fax (907) 258-2419 JOB G / ,B Z /" lcMahon S/29 SHEET NO. OF Z CALCULATED BY DATE CHECKED BY DATE SCALE PRODUCT 207-1&0sr,aets)20�1(Paaaed)®,[M.Ghon,MM.01471. To Order PHONE TOLL FREE I�00.225d'f80 Of' At"S �� ° k 0;% GINEER'S ........ 42k °.° - d YM �F �s • 00 a• •oeeeee ooe• ..� Z e Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES ®@ ••® ••••°•®•••• 825 "U' Street, Anchorage, Alaska 99502-065039 MW V. AUSMAN ° SOILS LOG — PERCOLATION TEST ���°••� 17�' r pram -o PERFORMED FOR: vYtn c� e—le—r DATE PERFORMED: LEGAL DESCRIPTION:_ Lal 1, 81k 2 11%lcMgiM Township, Range, Section: —r12 -N, R3W, S215 DEPTH SLOPE SITE PLAN (FEET) 2 1 10. 3- Date Gross Time Net Time Depth to Water Net Drop 4 4- ■■■EEN■R■■ — - — — G ■■emmmmlffl — 3 — 6- 6 1/6 "in ■E■■ 3/1y M 7 7 1 /Z Min :L eIvn I y8" %// 8- 1 s� 3 r"Irl 2r' $ 9- min ONION .2 10- 1012t 8 min rnrn Z l mril yrmn. 3'Y' I" 12- /6 min mmimmo■■NI■■ t 13- 3 ■■■iiiENNEN 14 14- 16 16 17 °; .. _. 'JAA5 +he dc, 18 GOH NO wo-I 19 20 COMMENTS WAS GROUND WATER A /C ENCOUNTERED? NV IF YES, AT WHAT DEPTH? Depthto Water Aflen Monis _ 1 /1 7/9i Monitoring? � Date: ■■■■■■■11■■ Date Gross Time Net Time Depth to Water Net Drop RESD4 ■■■EEN■R■■ — - — — G ■■emmmmlffl — 3 — Z 1/6 "in ■E■■ 3/1y M MM=9 :• ■■NIN11 1 /Z Min :L eIvn I y8" %// 1 min 3 r"Irl 2r' $ 0111111111000 min ONION .2 la116 8 min rnrn Z l mril yrmn. 3'Y' I" 8 /6 min mmimmo■■NI■■ 3 ■■■iiiENNEN ■■ICA■■■■■■■ Reading Date Gross Time Net Time Depth to Water Net Drop RESD4 ► 6 — - — — G O rnin — 3 — Z 1/6 "in I rnr;t 3/1y 3" 3 1 /Z Min :L eIvn I y8" %// 1 min 3 r"Irl 2r' $ 5,g„ min / min .2 la116 8 min rnrn Z l mril yrmn. 3'Y' I" 8 /6 min 3 rrn'n 3 �. PERCOLATION RATE 8 (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN 7 FT AND Qv FT PERFORMED BY: J00Arc S a �� I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: I zz/H 72-008 (Rev. 4/85) e Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: Jnn Aka rA4 e4— DATE PER VF pas wo 001OV6o0 a as a o a`®a 1ARlL= W. AU3MAN LEGAL DESCRIPTION: �07 �� /lam Z, MC/ ,AAur_ Township, Range, Section: % 12A1, 93W) SZB DEPTH SLOPE SITE PLAN ( FEET) I j—TTT"1 2 Date Gross Time 3- Depth to Water Net Drop PkZD#W- 16 — 4- 4 — 5- 567 16 0 min, — t — 6- jb Zmin• Zmin, 7 I MIDI. 2 m in, B�6 �� 3 /b •• 8- 6 (o in. mil. 101146 I " 9- 91012 10- 1114 12- 13 13- hy rhi . ' 14- 1415 /(o min- 2 wlin, l yel I / r, 15- 16- 1617 17- 18 18 $oH N Waite 19 20 COMMENTS Tl��'Z WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? AD S L O P E Depth to Water After / Monitoring? Dirl Date: i 94 Reading Date Gross Time Net Time Depth to Water Net Drop PkZD#W- 16 — — — 16 0 min, — t — jb Zmin• Zmin, 3 I MIDI. 2 m in, B�6 �� 3 /b •• 6 (o in. mil. 101146 I " 1114 8 hy rhi . ' /(o min- 2 wlin, l yel I / r, PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND 1 FT PERFORMED BY: Polaria"+ I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE 1171,P1 72-008 (Rev. 4/85) MUMCWAUTY OF Development Services Department On -Site Water & Wastewater Section Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval -y P, Parcel I.D. 017-041-23 Expiration Date: O Q l (� 7 v2— d 1. GENERAL INFORMATION Complete legal description MCMAHON BLOCK 2, LOT 1 Location (site address) 3600 MC MAHON AVENUE, ANCHORAGE, AK 99516 Current property owner(s) K.M. & FRANK MEEDS TRUST.... Day phone Mailing address Real estate agent MC MAHON AVENUE, ANCHORAGE. AK 99516 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Private Well Water Storage Community Well Public Water System 4 Day phone TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Holding Tank; ❑ ❑ Community ❑ ❑ Public Sewer. ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 5n - Lf ( a •SD Waiver Fee $ Date of Payment (.9 Iq I a-0 Date of Payment Receipt Number 3()QI57a- Receipt Number COSA # 05C �26 ia(,05' Waiver # COVID_ 19 -M� DISCOUNT ApPLIL 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, 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 6/18/2020 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & Fks 6. DSD SIGNATURE /�- System #1 Approved for —1— bedrooms System #2 Approved for bedrooms Disapproved �.�W.... % ......... Curtis Huffman f �F� CE 128991p •`�AM PROF SSI H��+` r Conditional approval for bedrooms, with the following stipulati���((((((f��� C L J WATER AND m 7v;�,ATER o r-- By: *� ('— Original Certificate ii Date:-/- 17- 20 20 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�r Legal Description: MCMAHON BLOCK 2 LOT 1 Parcel ID: 017-041-23 If more than 1 septic system on lot: COSA Checklist # —of _ Structure served by this system _ A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 4/1/1994 Total depth 101 ft Cased to 101 ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA 5/15120 Static water level at beginning of test 79 ft. Well production at time of test 5.5 gpm Comments B. TANK DATA Age of tank(s) 26 years Tank type/material SEPTIC / STEEL Measured operating fluid level in septic tank 50.5" ® Standpipes/foundation cleanout per record drawing Date of pumping 5/15/2020 D. ABSORPTION FIELD DATA Which system tested (date installed) 3/15/1994 ® ALL standpipes present per record drawing Total measured depth from grade 14.6 ft (max) Measured depth to pipe invert from grade 7.6 ft (min) ❑ N/A — pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ® No ® Coliform bacteria is Negative Nitrate 13.1 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) Collected by NES Date of Sample 6/10/2020 & 7/6/2020 C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: SEE MOA TANK ADVISORY Adequacy test date 5/15/2020 Results N Pass For 4 bedrooms Fluid depth prior to test 63 in Water added 800 gal New depth 74 in Elapsed time 1380 min ®Code -required soil cover over field Final fluid depth 60 in— ❑ System presoaked Absorption rate 600 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) If yes, enter date Gallons introduced gallons Comments/Deficiencies: NES E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ® Yes if No Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No ft Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' Water Service Line > 10' ® Yes Animal Containment > 50' ® Yes if No ft ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ®Yes if No ft ® Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No _ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION ,••...,...c5'��� 1 certify that I have determined through field inspections and review ��Q'•. • r� of Municipal records that the above systems are in conformance �0j.•� •;'� �� with MOA COSA guidelines in effect on this date. '. pl.... .... .. ......... •. .. .... ........:.� �.• Curtis Huffman •; �c •. CE 128991 �kFlo lk�,�'�'®����� Nitrate Advisory Certificate of On -Site Systems Approval # OSC 0201265 Subdivision: McMahon , Block: 2 , Lot: 1 A water sample revealed a nitrate concentration of 13.1 milligrams per liter (mg/Q. 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 relativequality 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. Ma�l�ng Address P O Box 196650 *Anchorage, Alaska 99519 66501,,_, W mum org From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. ^ � Ma�Ung Address P �O Box 196650 *Anchorage, Alaska 99519 6650 * vvuwir muni org �� Septic 'Tank Advisory Certificate of On -Site Systems Approval #OSC 201265 Subdivision: McMahon Blk 2 Lot 1 Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 26 years old. Typical replacement costs range from $8,000 to $11,000. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 20 year old steel tank MAY look like. Municipality of Anchorage _v 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 FORA SINGLE FAMILY DWELLING f Parcel I.D. 017-041-23 COSA# QS C I a123 Y 1. GENERAL INFORMATION Expiration Date: I ":�), ,,c - % Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address MCMAHON S/D; BLOCK 2, LOT 1 3600 MCMAHON AVENUE * ANCHORAGE, AK * 99516 JULIA DOUGAN Day phone 227-0221 3600 MCMAHON AVENUE * ANCHORAGE, AK * 99516 Day phone JANELLE PFLEIGER W/ REMAX Day phone 242-0076 110 W. 38TH AVENUE, #100 * ANCHORAGE, AK * 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 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 may be reissued fora 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. 1 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 JEFFREY A. GARNESS, P.E. Engineer's Comments: in conducting this evaluation, GEG, LID. 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 ofthe 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 bedrooms. Disapproved. 337-6179 gy,......... ss. ...O rrC 79 3 � . profess'%O �0000o�� 2 ON-SITE -� WATER AND Conditional approval for bedrooms, with the following stipulations:� PROGRAM Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: _Original Certificate _Date: (Rev. 11/05) Municipality of Anchorage ' Development Services Department Building Safety Division On -Site Water & Wastewater Program s' 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: MCMAHON S/D; BLOCK 2, LOT 1 Parcel ID: 017-041-23 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 4/1/1994 Sanitary seal (Y/N) YES Total depth 101 ft. Cased to 101 ft. FROM WELL LOG Date of test 4/1/1994 Static water level 70 ft. Well production 15 g.p.m. WATER SAMPLE RESULTS: Coliform O colonies/100 ml. Arsenic: NQ ug./L. B. SEPTIC/HOLDING TANK DATA Nitrate &• .z ?mg./L. Well Log (Y/N) YES Wires properly protected (YIN) YES Casing height (above ground) 24+ in. AT INSPECTION 6/9/2012 Date of sample: 6/8/2012 Tank Type/Material SEPTIC/STEEL Wel 7.07+ g.p.m. Collected by: GEG, Ltd. Date installed 3/14-15/1994 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (YIN) YES Depression over tank (Y/N) NO High water alarm (YIN) N/A Date of pumping 12/26/2011 Pumper DENALI PUMPING C. ABSORPTION FIELD DATA Date installed 3/14-15/94 Soil rating ( .p.d./ft rft2/bdrm) 0.6 Length 72 ft. Width 2 f System type TRENCH Gravel below pipe 7 ft. Total depth * 13.6 ft. Eff. absorption area 1000 ft2 Monitoring tube YES Depression over field NO Date of adequacy test 6/9/2012 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 53 in. Water added 600 gal. New depth 65 in. Elapsed Time: 120 min. Final fluid depth 55 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed "Pump on" level at in. E. SEPARATION DISTANCES Size in gallons "Pump off' Manhole/Access water alarm level at Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ Animal containment areas 503+ On adjacent lots 100'+ 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 P 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 t certify that 1 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 JEFFREY A. GARNESS Date 4 1/ �L1f 2 COSA Fee -S `l g o. — I Date of Paymentla 0A / Receipt Number a Lig IY-4 (Rev. 11105) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage e 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 # 121234 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 2, Lot 1 of McMahon subdivision. This inspection revealed a nitrate concentration of 8.22 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. Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 017-041-23 1. GENERAL INFORMATION Complete legal description McMahon Blk 2, Lot 1 ;fit,C-lam HAA # 65 f7IN Expiration Date: a-20— O,S Location (site address or directions) 3600 McMahon Dr. GG51to Current Property owner(s) Estate of Chester Darrell, Jr. Day phone 336-2123 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address c/o Helena Collins, 3600 McMahon Dr. Ken Jelenek REMAX Properties Unless otherwise requested, HAA will be held by DSD forpickup. 2. NUMBER OF Day phone Day phone 257-0196 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well El 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 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 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. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seat 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 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 -she 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 Watkins Engineering, Inc. Phone 349-1851 Address P.O. Box 110443, Anchorage, AK 99511-0443 Engineer's Printed Name Cindy W. Ellis Date 6. DSD SIGNATURE ✓ Approved for _—Ik— bedrooms. Disapproved. Conditional approval for Additional Comments bedrooms, with the followin 3-Z4.os Note: The well for this property meets existing State and Municipal Codes There are nitrates present It is suggested that periodic testing he to Insnrn the wells rnntinned sni►ahility. Current nitrate concentration is 8.28 mg11 EPA maximum concentration Is 10.0 mg&_Mnrn Information on nitrates is available from the On -Site Services Program, at 143-7004_ Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By; Original Certificate Date: -3 " 3 U ` 0 5� (Rw.o,Az) Municipality of Anchorage • Development Services Department Building Safety Division On-Sfte Water & Wastewater Program 4700 South Bragaw St. P.O. Box 198850 Anchorage, AK 99519-850 www.muni.org/onsfte (907) 343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: McMahon, Btk 2, Lw 1 Parcel ID: 017-041-23 A. WELL DATA Wen typePr+ Date completed 4nim Total depth 101 ft. Date of test Static water level If A. B, or C provide PWSID S Sanitary seal (Y/N) Y Cased to 101 ft, FROM WELL LOG 4/1/94 70 ft. Well production 15 9 -p.m. WATER SAMPLE RESULTS: Conform 0 colonies/100 mi. Nitrate 8.28 mg.A. Arsenic: NA mg.A. Date of sample: 3"6m B. SEPTICIHOLDING TANK DATA Tank Type/Material •1061 Tank size 1250 gal. Number of Compartments 2 Well Log (Y/N) Y Wires property protected (Y/N) Y Casing height (above ground) 24+ In. AT INSPECTION 3/15/2005 73 7.3 ft. Other bacteria 0 oolonies/100 ml. Collected by: Cindy Ellis Date installed 3/14/94 Cleanouts (Y/N) Y Foundation cleanout (YIN) Y Depression over tank (Y/N) N High water alarm (YIN) NA Date of pumping 3/16/05 Pumper A+ Home Services C. ABSORPTION FIELD DATA Date Installed 3/14/34 Length 72 ft. Soil rating (g.p.d.W or f?/bdrm) 0_6 . 1IM1 ft. System type deep trench Gravel below pipe 7 ft. Total depth 13_7 ft. Eff. absorption area 1008 IF Monitoring tube Y Depression over Reid N Date of adequacy test 3/15/)5 Results (Pass/Fa1Q PASS For 4 bedrooms Fluid depth in absorption field before test 30.5 in. Water added 997 gal. New depth 47 in. Elapsed Time: 188 min. Final fluid depth 38_5 in. Absorption rate >= 800 g.p.d. Any rejuvenation treatment (past 12 mo.) (YAV & type) None known If yes, give date D. LIFT STATION Date installed NA 'Pump on' level at _ in. Datum E. SEPARATION DISTANCES Size in gallons Manhole/Access (Y/N) 'Pump ofr level at _ in. High water alarm level at in. Cycles tested Meeta alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/11111 station on lot 117 Absorption field on lot 190 Public sewer main 100+ Sewer /septic service line 115 On adjacent lots 100+ On adjacent lots too+ Public sewer manhole/cleanout 100* Holding tank NA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5 Property One 48 Absorption field 5 Water main 100+ Wells on adjacent lots 100* Water service line 50+ Surface water 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 25 Building foundation 13 Water main 100* Water Service One 50« Surface water 100+ Curtain drain None Wells on adjacent lots 100* F. COMMENTS G. ENGINEER'S CERTIFICATION 1 car* that ► have determined through field Inspecdons 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 Cindy W. Ellis Date 3-Z4-06 HAA Fee Date of Payment `814''/05 Receipt Number �5014q (Rev. 12/01) Driveway. parldng/vehicle storage 25+ Waiver Fee Date of Payment Receipt Number 49TH 10dY YI(:.Ellls Q W W E] v in r V W `a N ❑ ❑ L MCMAHON AVENUE N 90000'001IW 1 1 5.00' a We 17-21"E 145.071 THE INFORAMTION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES OR EASEMENTS AND IS HOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES OR FENCELINES. EASEMENTS OF RECORD. OTHER THAN THOSE SHOWN ON THE RECORDED PUT. ME NOT SHOWN HEREON MLESS INDICATEO) NOW ANY FENCELINES SHOWN ME LOCATED APPROMWELY AND ME HOT TO BE USED TO DETERMINE PROPERTY LINES OR LOCATE STRUCTURES. ANY PAVING SHOWN MAY BE APPROXIWTE DUE TO SNOW CONDITIONS. m O 0 O N W v N P) ❑ 0 0 II . OF.A y�pp0 s .�, G SHANE A. HOLT. Ip w LB -691 4 i G AS -BUILT SURVEY (NO CORNERS SET THIS DATE ) 1'•70' 1 HEREBY CERTIFY THAT 1 HAVE FERFORMED A MORTGAGEE'S INSFECTION OF THE FOLLOWING DESCRIBED PROPERTY. LOT 1. BLOCK 2, WNIAHON SUB. ANCHORAGE RECORDING DISTRICT. ALASKA AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ME WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE, ALASKA THIS 167H. DAY OF MARCH 2005 . HOLT LAND SURVEYING BBI. FB 11)40 TEL. 345 5510 MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES y} Division of Environmental Services Mei On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # C� M!1 - X2) HAA # A Q 9 1. GENERAL INFORMATION Complete legal description LI / 321 !'/271/, R 3 W, Se c. 2- 8 -7%3-0 Location (site address or directions) 5- Car''La'Y- °'F t-tcrro-V✓ "k PC/. , ovvld /I C1t1ah'n. Ave. Property owner 1AnL, m4 ( Q2 Day phone Mailing address '���L1 �La r Q nrf Q , nL2 Lending agency Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: ZI 3. TYPE OF WATER SUPPLY: Individual well X Community well Public water Day phone Day phone 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: 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 H21 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. Name of Firm — Address 150 o/Cir(ZWa/-t- Phone ZS8'2520 Engineer's signature 6. DHHS SIGNATURE Approved for Disapproved. M Conditional approval for Additional Comments bedrooms. Date 5/19 �:I ^70 00 90000000 0 got ijf ea . •0/e'ea 0 0000 1400 �! EARLE V. AUSAMH ra �- Cli - 1393 bedrooms, with the following stipulations: 111TIC 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 engineer's work. 72-025(Rev.1/91) Back MOAk21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LI , 132 SAD Parcell.D. A. Well Data Well type Prl ei4o- If A, B, or C, attach ADEC letter. AD/EC water system number Log present (Y/N) t Date completed 1///9-fDriller Alplu Drdl/ A 9 &4�_nk-Zs Total depth !'D/ ?1577- v Sanitary seal (Y/N) 1 Cased to /4/ FT Casing height 3 �T Wires properly protected (Y/N) i/ FROM WELL LOG Date of test ZM/ A y Static water level 7o Well flow 5 9•p•m• Pump levell SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot /25' X30' AT INSPECTION o Nod ? _ g.p.m. 91; z r T1 _ 0ro c 1 o �' X77 rn <w �liV / o On adjacent lots — +J On adjacent lots O Public sewer main No -n4 Public sewer manhole/cleanout Ncr� Sewer service line Ah Petroleum tank Nrli-p- WATER SAMPLE RESULTS: Coliform D Nitrate 6 2�1 �' �Z Other bacteria � Date of sample: 5-4 / `� Collected by: /111/�ii;t B. SEPTIC/HOLDING TANK DATA Date installed 3/ly/9y Cleanouts(Y/N) Y. Tank size /I ZSa 6--a/ Compartments Z" Foundation cleanout (Y/N) y Depression (Y/N) High water alarm (Y/N) IVIA Alarm tested (Y/N) A1114 - Date of pumping lAv Tank Pumper IVIA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well's) on lot X25 / On adjacent lots f/�� / Foundation 5 To property line 51 , Absorption field 2-0 / Water main/service line 7� Surface water/drainage /Vane_ N 72-026(3,93)• Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed / V P_LA__ Manufacturer — Size in gallons Manhole/Access (Y/N) — Vent (Y/N) - 'Pump on" level at High water alarm level = Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA "Pump off" Level at — Cycles tested — Surface water — Date installed 3/ 9Y Soil rating (GPD/Ft2) �' System type _ ��P nc Length 72- Width 2 Gravel thickness Notal depth . /D, S Total absorption area /i ODD Fr / Z, Cleanout present (Y/N) I Depression over field (Y/N) N Date of adequacy test /Vol �� %red Results (pass/fall) for Water level in absorption field before test ' test Peroxide treatment (past 12 months) (Y/N) Alrne- If yes, give date = SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot J 30' To building foundation 30 On adjacent lots 56 r On adjacent lots /00 F=T Property line To existing or abandoned system on lot /Voll_ r �G Bedrooms Cutbank N� Water main/service line //vn-e _ Surface water A� Driveway, parking/vehicle storage area 33/ Curtain drain /VU'S e - E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. �r fA`.J�1y�r Y Vll � S A' 17 v 4'd •rF, AI U4 HAA Fee $ kW Date of Payment _� _a:�, - (A 'A Receipt Number a,�C1D3 72-026 (3/93)' Back ,Cx> Waiver Fee $ Date of Payment Receipt Number cea�, Signature:,.6!!.<��':..4.4na�' Engineer's Name / 5/ 9A,1 (990onru,oti g4K�nono°GP<' WW 1i. AUMM ' Date :,a L ! . Vs U � ° ° CE y39� . rye`iiT +l?F ° u` 004)cl,n c,'o HAA Fee $ kW Date of Payment _� _a:�, - (A 'A Receipt Number a,�C1D3 72-026 (3/93)' Back ,Cx> Waiver Fee $ Date of Payment Receipt Number