The URL can be used to link to this page

Home My WebLink AboutMELINDA VIEW ESTATES LT 4A '~ ~"~ MUNICIPALITY OF ANCHORAGE ,~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTE~ AND/OR WELL INSPECTION REPORT NAME ¢ I;;~/~ , IPHONE MAI El N,,G ADDRESS J~-.~ L ~ESCRIPTIONEG~LD '~~ (~l~ ~'~-- ~(:~B¢ ~ LOCATION NO. OF BEDROOMS I ~e~ , Absorpti~a;a Dwelling , PE~ ~NO. ~ ~Z Manufacturer ~ '~ Materialt~~ N°' of compart~nts_ ~ ~ Liq. capacity in gallons Inside length Wid Liquid depth ~ IF HOMEMADE: ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. 0 ~ Manufacturer .~ Matoria] ~ ' ' gm~llons m Well ~ ~ Foundation { ~ / Nearest lot lin~ PERMIT NO. ND. of lines ~~ % ~C inches inches Total e~orp~rea EenDth of ea~ , Total length~e~ ~ ~ ~ Top of til grade .~o~nish Material beneath tile Length Width Debth PERMIT NO. 4 ~ Type of crib Crib diameter Crib dep~ ~otal effective absorption area ~ Well ~ Building foundation ~est lot li~ ~ DISTANCE TO: ~ ~~ Depth Driller Distance to lot line PERMIT NO. m Building foundation Sewer line " ~eptic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE MATERIALS SOl L TEST RATING R EMAR KS .~ ~ ~'.~ ' ,!I '- : --.i 72-O13 (Rev. 2/78) ~-,~ DRILLING, [nc. P.O. Box 110378 · t0330 Old Seward Highwsy (907) 349-8535 ANCHORAGE. ALASKA 99511 85-259 *Log Amended I0/30/8~ Well Owner DERUNG LOG Rmy Kinard .Use of V~el] Domest ftc Location (addr.~s of: Township, l~mge, Seetion, if known; or distance main road L4, Bi Melinda View Subd., Anchorage Size of casing___~" Depth of Hole___/ 30n___feet Cased to_ l 1 n_ R feet Static water Ievel___~.S ft. (ahllY~/ {below) land surface. Finish of welt (check one) open end ( ); Screen ( ); Describe~lor .... 'Z~'ro{,s of slo~ perf~$w/4slo~s per ft. per ro~ from 85'-80' Well pumping test at.__3 gallp~s of dxawdown :from s~tic Date of completion_. 10/7/85 from __o_TO 2 -- 2 TO 40 40 50 ____TO 50 55 TO 55 75 75 85 _TO_ 85 100 _ ~__TO _ 10_0_TO _110 110 120 __TO_ 120 TO 195 195:_TO' 229 229 300 TO TO __ _TO (minute) for 1 hours with__ 100% WELL LOG df formations penetrated, size of material, co~u~ gravel silty sand (wet) -~r~owrt..silt~y sand {wet) % gpm. DEPT '~NCHo '"~ IAL p~,OT£~TiOAI Gray bedrock *Production/~h o~O~~erf, 2'~+__ G~tg{ }{W~rA Certified Contractor Certificate No's. 814 & 973 Tan bedrock Gray bedrock *Cumulative production @ 229 was 2~ GPM F.'ERMIT NO: DA'TF.': ISSUED: 0 9 / 0 3 /8 5 AF:'PL I CANT: ADDRESS: C'ON'I'ACT PNONE: WRAY W I<INARD 7045 GEMINI DRIVE ANC'HORAGE, Al< 995()4 2'76- 10 11 ~..=u.~.-_ DESCRIF': LOT SIZE;: LOT I_OCAT.I:ON: MAX BEDF~OOMS: SUBDIVISION: MEI_IIqDA VIEW SECT !(])lq: :35 TOWNSH I F': 12N 52608 (SQ. FrT. OR ACREES) JGANNE OFF 144TH 4 LOT: 4 RANGE: 3W .:~L. OCI ..... NA L. isted belctw are the: optic)n~.~ available 'Lo you zn designing yeur septic syst. em. Cheose t. he opt. ion that best fits youP sit.e. I)EF~'T'H 'TC] PIPE BOT]"OM (I:3T.) GRAVEl... DEPTH (F'T'.) TOTAL DEF:'TH (F"r'.) GRAVEl-. WID'I'H. (FT.) .GRAVEL I_ENGTH (FT. GRAVEL VOLUME (CU. YDS,, ) TANK SIZE (GALS) SOIL RA'T'ING (SQ.F:'T,,/BR) 4.0 4.0 4.0 8. () 0.5 3.5 12.0 4.5 7.5 2.5 16. () 5.0 21.0 32.0 36,. 0 16.6 :19.0 26.7 25(). 0 .~.~ 1,250.0 .~.~. 1,250.0 .x..x- 83 83 83 · x-~ TAIqK MUST HAVE AT I_EAST TWO COMIZ'ARTMEIqTS I certify t. hat: 1. I am Familiar with the requirements £or on-site seweps and wells as set. Forth by the tdunic::ipality of Ar'ichonage (MOA) arid the State of Alaska. 2~ I wili instaI1 t. he system in accordance with all MOA codes and pegu].ations, and in compliance with the design cniteria oF th:is permit. 3. I will adher, e to all MOA ancl Stat. e of Alaska pequirements ¢op tine set back distances ~pem any exist, lng we].]., wastewater- disposal system on public sewepage syst. em on this or' any adjacent cm neapb'y lot. 4. I under'stand t. hat. this permit is valid rot a maximum eF 4 bedpooms and any enlargement, wi].~, require an additic~nal permit. IF A LIF:'T STATIOIq IS INSTAL. LED IN AN AREA COVERED BY M[)A BU!LDIIqG CODES, THEN (1) AN EL. ECTI~ICAL PE:RMIT aND INSPECTION MUST BE OBTAINED; (2) AS-BLJIL_.TS WILL NOT-BE AF'F:'ROVED WITHOLJT AN ELECTRICAl-.: INSPECTIOIq REPORT;. AND (3) TI4E ELECTRICAL WORI< MUST BE DONE BY A LICENSED IELECTF~ICIAN. . . ................ : .......... APPLICANT:'WRAY W~::~NARD ./ AS-BUILT CERTIFICATE: I hereby certify that I have surveyed the following de,ctS..bed and that n~~ts exist excep~ as inulcate~ EXCLUSION NOTE: it 'is the responsibility of th~-owner to ?~%~m£ne..the ~£~tence of,'~y .ea~,em~nts.~ co~naBt~-0 or restr~ot~,on~ ~h/£Oh ao ~t appear'. On the recorded su~iV~s~on pl'at'. Under ~o o~r=umst~oe~ should' any 'data hereon be ~s~ fo~ con~Ot~on~:o= f~= e~t~l~sh~ng ~unda~ or fence lines. AGUA FEIA SL VEYOES A~chor~ge~ Aiesk~ ~:J~9505 .~76 ~ 6151 O~te - '~-.,- ~co ie !'''= r'~ PERFORMED FOR: LEGAL DESCRIPTION: 1 2-- 3 4 ? 8 MUNICIPALITY OF ANCHOR,~ClPALiTY OF ANcHo - DEPARTMENT OF HEALTH AND ENVIRONMENTAL I~EK~i.T~I~NrH ~'~ 925 L. Street, Anchorage, Alaska 99501 2~J~.~NMENTAL PROTECT[Oi~ SOILS LOG - PERCOLATION TEST APR ~ ;[ 1.Q..R~ SLOPE SOILS LOG PERCOLATION TEST SITE PLAN I0 11 _----12 13 14 15 16 17 18 19 20 COMMENTS PERFORMED BY: THOM A.. FISCI CE- 6793 ,," IFYES, ATWHAT ~E ~.~__ ~ DEPTH? ~ Gross Net Depth to Net Reading Date Time Time Water Drop t z_'.oo ---- Z', _.____ ATION RATE I (~D t~'~') (minutes/inch) TEST RUN BETWEEN ~ FT AND ~ FT CERTIFIED BY: 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. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot ~, Melinda View Estates Location (site address or directions) Off 1 Zl~th 14600 ]oanne Cgrci'¢ (Rabbit Creek Road) Property owner Mailing address Lending agency Mailing address. Wrav Kinard Day phone 14600 .}canne Circle , Anchoraqe, Ala~<a 99516 Day phone 786-8631 Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: NOTE: Individual well X 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 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 Gilfilian En~ineerin.~, Inc. Address 255 E. Fireweed Lane. , Suit e 102 , Engineers signature .¢~~,//~"'~ bedrooms. DHHS SIGNATURE Approved for Disapproved. Conditional approval for Phone 277-2021 Anchora~e~ Alaska 99503 Date · bedrooms, with the following stipulations: Additional Comments I L. ~;Nll/[*]~L 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 MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot AA Melinda View Est. Parcel I.D. A. WELL DATA P rivat e Well type Log present (Y/N) Yes Total depth 300 ft. Sanitary seal (Y/N) Yes If A, B, or C, attach ADEC letter. ADEC water system number N/A Date completed 10/7/85 Driller M-W Drilling, Casedto 110.8 ft. Casing height 14 inches Wires properly protected (Y/N) YPs Inc · FROM WELL LOG Date of test 10/'7/85 48 feet Static water level 3 Well flow Pump level Unknox~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Over 100 feet Absorption field on lot Over 100 feet Public sewer main AT INSPECTION 10/7/92 46.3 feet g.p.m. 5.6 g.p.m. Unknown Sewer service line ; On adjacent lots Over 100 feet ; On adjacent lots Over 100 f¢¢t Public sewer manhole/cleanout None visible w/in 100 ft. Petroleum tank Over 2.5 feet N/A Over 100 feet WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml 9/2/92 Date of sample: Nitrate 0 rog/1 Collected by: Other bacteria None Robert S. Gilfilian B. SEPTIC/HOLDING TANK DATA Date installed 9/4/85 Tank size 1250 gal Compartments 2 Cleanouts (Y/N) Yes Foundation cleanout (Y/N) Yes Depression (Y/N) No High water alarm (Y/N) No Alarm tested (Y/N) N/A Date of pumping 9/12/92 ~ Pumper Isaacs PumPing SEPARATION DISTANCES FROM'~EPTIC/HOLDING TANK TO: Well(s) onlot. 107 feet Onadjacentlots 100 + feet Foundation 13 feet To property line 55 + feet Absorption field 7 feet Water main/service line 25 + feet Surface water/drainage N/A 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 "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D, ABSORPTION FIELD DATA 9/5/85 Soil rating 150 Date installed Length 40 feet 6OO Total absorption area Depression over field (Y/N) No Results (pass/fail) Pass Peroxide treatment (past 12 months) (Y/N) System type Width 36 inches Gravel thickness 7 ft. 6 tn. Trench 12 ft. 6 in. Cleanouts present (Y/N) Date of adequacy test for 4 (four) If yes, give date Total depth Yes 9/3/92 lq/A bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellonlot 100 + feet To building foundation On adjacent lots 30 + feet Surface water N/A Curtain drain N/A Onadjacentlots over 100 + ft Propertyline 30 feet 13 feet To existing or abandoned system on lot N/A Cutbank N/A Water main/service line 50 + feet Driveway, parking/vehicle storage area 30 + feet E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA date of this inspection. HAA Fee $ Date of Payment Receipt Number 72-028 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number 8O WELL FLOW TEST Lot 4 Melinda View Estates 70- 60- 50- > ~ 30- 20- 10- 0 0 15 3O 45 6O TIME (min.) 75 90 I--"~WATER LEVEL FLOW RATE GILFILIAN ENGINEERING, INC. Professional Environmental Consultants Main Office: Mat-Su Office: WELL FLOW TEST DATA FORM Location Lot 4 Melinda View Estates Project No.: Test Dar October 7, 1992 Tested By: 255 E. Fireweed Lane, Suite 102, Anchorage, Alaska 99503 (907) 277-2021 · FAX (907) 274-8683 5751 Mayflower Court, Wasilla, Alaska 99654-7880 (907) 376-3005 · FAX (907) 373-5686 192101 Robert S. Gilfilian ITEM WELL LOG MEASURED Total Well Depth* (ft.) 300 Well Static Level* (ft.) 46.3 Well Casing Material NA steel Well Casing Diameter (in.) 6 Casing Height Above Ground (in.) NA 14 Well Yield (gpm) SEE BELOW Well Pmnp Type (submersible, jet, other) NA Submersible Fype of Well Cover NA Sanitary Seal P[Inlp Wire Condition (In Couduit) NA Yes Surface Draiuage Around Well (10 ft Radius) NA Yes :::::::::::::::::::::::::::::::::::::: ::'::ii::iii:: i::iiiiiiiiii ii iiiiiiiiiii::iiiiii ii ii i::iii::::::!i ::::::::::::::::::::::::::: ?::: ::.....)?...:%.....~::?.?......?....?..~?:?:~??.:~3.i~¥~.~.~.~.~.~::...7~i~i~.~g..:g~!i.~!!~.~.~5~}:¥$¥~.~ ~ ~ ~ ~ ~ ~ ~!~ ~!!~i~ ~i~53i~i."~i.'~5~ .............................................................................................. ~:~.:.~ ......... ~ ............. ~...~....~..~..~( ......................... ~...,.~ .......... ~:~ TIME ACTUAL CLOCK FLOW RATE WATER LEVEL* COMMENTS (min.) TIME (gpm) (ft.) 0 1254 0 46.3 Start Well Flow 5 1259 5.5 53.3 15 1309 5.7 60.5 30 1324 5.7 65.3 45 1338 5.4 68.3 60 1354 5.5 70.4 End well flow TIME ACTUAL CLOCK WATER LEVEL* COMMENTS (miu.) TIME (ft.) 0 1354 70.4 5 1359 63.4 15 1409 58.6 27 1421 55.7 Average Sustained Well Pump Rate** (gpm): 5.6 Maximum Drawdown (ft.): 24 * Measurements Taken From Top of Pipe (TOP) ** Average of Flow Rates Measured at Times of 30, 60~ 90, 120. 150, 180, 210, 240 (minutes) MAT-SU TEST LAB Soils - Concrete - Water Field and Laboratory Testing Services 5751 Mai, flower Court, Wasi#a, Alaska 99654- 7880 Phone (907) 376-3005 Fax (907) 373-5686 CLIENT: Gilfilian Engineering, Inc. ADDRESS: 255 E. Fireweed //102 Anchorage, AK 99503 PHONE # 277-2121 ACCOUNT #: DATE: 09/02/92 COST OF TEST(s):. ~22.00 PAYMENT: CHECK # CASH REFERENCE NO: 392300 001 TESTING REQUESTED: Nitrate LEGAL/PROJECT NAME: Lot 4 Melinda View Estates (GEl 192101) PRIVATE: X PUBLIC (LIST STATE ID NO.): DATE RECEIVED: 09/02/92 TIME RECEIVED: 1700 DATE SAMPLED: 09/02/92 TIME SAMPLED: 1155 SAMPLED BY MSTL/RSG Analysis Performed: Level Detected MCL Nitrate ND(0.10) 10 mg/I mg/I = milligrams per liter ND = none detected MCL = maximum contaminant level NOTE: This analysis was performed by: Mat-Su Test Lab If you have any questions concerning the above results, please call me at 376-3005. ~/z3' ~'/)<~P>c L/~v 09/04/92 Che ry~'id~ltz, Water isor Date MAT-SU TEST LAB, INC. ,[ Soils -- Concrete -- Water Field and Laboratory Testing Services P.O. Box 871~68 o Wasilla, Alaska 99687 ? (907) 376-3005 DRINKING WATER ANALYSIS FOR TOTAL COLIFORM BACTERIA fiPPLICANT INFORMATION: Name: <::.1 l,-~ 0 y Moiling Address:_ /Z?Z',//~, Sample Information: Legal Description: LeT' Phone: (pO I<') State I. D. No.'.. Gel Date Collected;' Z'71 Sample Type: ~Routine Time Collected:. 7/~-~ Collected By: [-]Check Sample [~Treated ~Untreated [] Fecal ANALYSIS .RESULTS THIS SECTION TO BE COMPLETED BY LAB S atisfactory Unsatisfactory [~ Sample Rejected:I--lOver 30 Hours In Transit ~-~TNTC:C(~onies Too Numerous To Count r~--j Confluent G.rqwth RECOMMEND R ESAMP~.{~ Final Membrane Filter Results:O :'~. Colonies/l~l DateNo. of Positive Tubes fr.om,five_[I fl~-/ 10 ml Portions;/~-l--By: ~/~j~f~/~/,,r~ / . AnJiysi's' C°mpleted: /~I~Rep°rted .... ;MPN:~p~ lO0.ml MICROBIOLOGY LABORATORY RECORD-COLIFORM ANALYSIS ~/.~l~f.~~?/t~,/~/~Time Received: J41~O Lab Date Received: ~!/'~'~/-/'""~Time Test Started''[~'~~D! Analyst: Date Test Started: . TEST METHOD TEST RESULTS ' ~ATE/~IME/ANALYST. ' Membrane Filter .p~rect Count: 0, ,Colonies/lO0 ml ~/.~ ~--~ ~'~(-~ (MF) Verification: LTB ,BGB / Presumptive Tube # (LTB) 24 Hr. 48 Hr. Confirmatory Tube # (BGB) 24 Hr. 48 Hr. Completed Plate # Tested EMB 24 Hr. Tube # LTB 48 Hr. REFER TO BACK SIDE FOR INSTRUCTIONS GILFILIAN ENGINEERING, INC. Professional Environmental Consultants Main Office: Mat-Su Office: 255 E. Fireweed Lane, Suite 102, Anchorage, Alaska 99503 (907) 277-2021 · FAX (907) 274-8683 5751 Mayflower Court, Wasilla, Alaska 99654-7880 (907) 376-3005 · FAX (907) 373-5686 INVOICE NO. 4336 Mr. Wray Kinard 14600 Joanne Circle Anchorage, Alaska 99516 September 8, 1992 PROJECT NAME: Lot 4 Melinda View Estates PROJECT NUMBER: 192101 SERVICES: Conducted Adequacy test on septic tank/soil absorption system, analysis of water for total coliform bacteria and nitrate for the Municipality of Anchorage. TOTAL DUE THIS BILLING $ 415.00 A 1.5% PER MONTH SERVICE CHARGE WILL BE APPLIED TO ALL PAST DUE ACCOUNTS - NET 30 DAYS. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Appl,cation Date Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name ("~ 1¢'1'~"~ Telephone: Home Business'~7 Applicant Address _~,~--'~, ~ II- [ 87G ; Applicant is (check one): Lending'Institution []; Owner/builder, S; Buyer []; Other [] (explain); GENERAL INFORMATION (a) (b) (c) (d) Lending Institution ~'~/ Address Telephone (e) Real Estate Company and Agent Address Telephone (f) Mail the H~A/~ to the following address: TYPE OF RESIDENCE Single-Famity~) Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY I'ndividual WeJ~ 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 [] Page 1 of 2 Holding Tank /// Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. ENGINEERING FIRM £ 'VII)lNG INSPECTI ~; As cert!hed by myseal a f~i~ed hereto a .... ONS, TESTS, FILE SEARCH, DATA ~ ...... Authority Approval shows that the on~si'i; as ot the validation date o~, ....... ,-~l~u INFORMATION for the number of bedrooms and type of structure indicated herein. I ¢Udher Veri~y that based on the information obtained . . . ~-~wn ~elow, I venfy that my ~nvest~gahon o~ this Health Water Supply and/or WasteWater disposal system is ~afe, functional and adequate from the Munm~pahty of Anchorage h/es and from my mvest~gahon and ~n~pect?n the on ~te wate~ supply and/or the date of this inspection. wastewater d~sposal system is in COmpliance with all Municipal and State Codes, ordinances, and regulations in e~ect on Name of Firm ~~ Address ~ ~ -~ phone ~ Date 6. DHEP APPROVAL institutions in Order to ...... or.Alaska. The DHEp does t~'v'n ,n paragraph 5 a ove{b .HEp! issues Health u/horit - o,=.sr ce - nl b A analyze data before a c "y .rta,n federal and stat $ as a COurtesy to ur ~_"~n independent prof · ertlhcatels iss,,,~,4 -,-~ .. e reclutrements ~_, P chasc~ of h,~ .... . esslon~l professional engineer's Work. . of,-..~..orage rs not resnono~-,-, not co~duct inspectJon. .... ~ne MUnicipality ,~.~,.~' '-'-P.~Oyees of DHEP do -.,,..,,_c.~ and their lendjn Page 2 of 2 .- o,u~e rot errors or omissions in th"; 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 03A!333 1 Legal Description: WELL DATA NOLID~J.O~J 'IVINat,'~JOlllN~J Well Classification If A, B, C, I~.E.C2Approved (Y/N) Well Log Present (Y/N)--~ Date Completed ~ O '~'"~///~ Yield Depth of Grouting ~ /~ Pump Set At Sanitary Seal on Oasing (Y/N) Depression Around Wellhead ; On Adjoining Lots ~ / ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on, ct ~~ ; Date ~ Total Depth ~.~OO f Cased to Static Water Level 4~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: Io7 To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field/~/~ Lot To Nearest Public Sewer Line ,~/ Cleanout/Manho e ~J/i Wate¢ Sample Collected by Water Sample Test Results Comments SEPTIC/HOLDING TANK DATA Date Installed ~' ~ ~ ize [¢~'~2~ No. of Compartments '~ Standpipes (Y/N) ~ Air-tight Caps (Y/N) ~.~-'~%-_ Foundation Cleanout (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ~ t',,-~ To Property Line ?;;~,~'~ ~''~''''' To Water Mai~ Course ~ ! ~ Comments · ~ Date Last Pumped ~ ;for ~/~ Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page I of 2 72-026(11/84} ABSORPTION FIELD DATA Soils Rating in Absorption. Strata Date Installed Width of Field Standpipes Present (Y/N) Date of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ! ~, ~'" To Property Line To Building Foundation I""'~ ~ Lot ! TO Water Main/~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Existing or Abandoned System on ; On Adjoining Lots ~'~'~ To Cutbank (if present) Comments D. LIFT STATION Date Installed _...,..........~ Dimensions .// Size in Gallons / /~/lan hol'e/Access (Y/N) ~ "Pump On" Level at / / "Pump Off" Level at ~ High Water Alarm Levey / Vent(Y/N) ~ Tested for / / Pumping Cy~,J,,9~uring Adequacy TesL Meets MOA Electrical Coy(Y/N) / ~ ** Check Permitted Bedroom Rating Against quest ** I certify that I ha~e checked, verified, or conformed to all MO~ and~HAA guidelines in effect on the date of this inspection. Signed~~"'~'' ~ ..'~-~'Date ?/ ~¢'/~¢-g~ Company ~,¢,~'~'~'f~g::l~ ¢¢J~ MOA No. ReceiptNo. ~.(~::~\~ L-~".'.) Date of Payment O~. ~ \ (~_ ~ Amount: Page 2 of 2 72-026 (~ 1/84) ineer's Seal ., YHONt A. FISCHI %,, CE- 6793 o,*".~ ~ ;,, -... ...'