HomeMy WebLinkAboutHIGHLAND HILLS #2 BLK 2 LT 8Alis [}
NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
82.5 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAILING A D D R2F..SS
LFGAL DESCRIPTION
LOCATION
I I Well Absorption area
t~: DISTANCETO: I A~.~7~1~-4 1 /o'
~ ~ Manufacturer
Liq. c~paciw ii, gallons I
'~_[~7-~ ~- c J, , ........... ~U~: j Inside length
DISTANCE TO: J Well ~ / Dwelling
-"~ Well F oun clat io~;~.(_
DISTANCE TO: ~.~...,~¢1_./i..~.I Tota, ,ength of~' ~es
~ Length of each/line
No, oflines / .~ ~¢ ~__ ~-5I
Top of tile to finish grade ~
. I Material beneath tile
Width
Type of crib Crib diameter
Well
DISTANCE TO:
Building foundation
DISTANCE TO:
Depth
Crib depth
Building foundation
~Driller
Sewer line
OTHER
PIPE MATERIALS
SD IL TEST RATING
/
I NSTA L~JR
REMARKS
APPROVED
PFIONE
J Dwelling
Widtb) 7
Material
[Nearestlotline__ //-q ~.~
Trench wi?~O inches
NO, OF BEDROOMS
PERMIT NO.
No. of compartments
Liquid
PERMIT NO.
Liquid capacity in gal/ohs
Distance between lines
Total effeativ& absorpBgn area
PERMIT NO,
~:~N EW
[] UPGRADE
Total effective absorption area
Nearestlotline
Distance to lot line
PERMIT NO,
Absorption area(s)
Septic tank
DATE LEGAL
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysicol Surveys
LOCATION OF WELL
~'~J Borough Subdivision
7~5J O,STA.C.A.O
Street Address and Area of
Drilling Permit No.
(Pleose complete either Io, lb or lc.) A.D.L. NO.
Lot[~BIock~-~bJ.~ I/4qlrs. Section No. Township N[] Renge EEl Merldion
.?? J ' ,, L~.~_°f-°f-°f- SE] W~
ROAD
Feet Below 4. WELL DEPTH; (final) 5. DATE OF CO~LETION
~ ~ ~=..~ ¢~ ,~ '[~ ' ~[[J. 6r ~ Cable fO01 ~] Rotary ~ Driven ~ Dug
~;-) . ¢~ ~ ~ubllc Supply ~ Industry
.-~.~. 'f, ¢~;~' '~j. ~,:' ~-'.'-' ~ Irrigation ~ Recharge
.... ~¢, h.L~ ....... ,-" ?'(J // ~') ~ Te~t Well ~ Other:
' '"~' ) ""''; ' / 8. CASING: ~ Threaded ~ Welded
ID. STATIC WATER LEVEL:
---- ~ Above or [~ Below land surface Date
~'[' ?(']?ft afler ~ :~ hr~. pumping g.p.m.
~N~O~ ~ ~.~OUT~ W~H ~.~: ~ Y~ ~ No
~NVI~ONMENTIL PROIE~ ~ ~. PUMP: {if ovoiloble) HP ': ,'
~['*~ ~ ~ ~ Lan,th of Drop Pipe ~__f,. copecily ~g.p.m.
15. Water Temperature ~o ~ F ~ C
WELL LOG
Material Type
16. WATER WEL~. CON'¥RACTOR'S
¥')i~Y''F:' "cc~
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:
1
2
3
4
5
6
7
8
9
10
11
12
13
SLOPE SITE PLAN
N... S
WAS GROUND WATER (.."~~
P
E
ENCOUNTERED?
IF YES, ATWHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water' Drop
14
15
16
17
18
19
2O
COMMENTS
PERCOLATION RATE
TEST RUN BETWEEN
PERFORMED BY: ,.,~F~B 196){
72-008 (6/79)
CERTIFIED
/t.~//~ (minutes/inch)
FT AND FT
I...0 T' S 1 Z ,... :',
!.h,,, BE:)DH:OOHS~:
St. Ji:.:;D :1: V I S I E)N i~ H :!: ())il..!l..Ah!)} l[ ]: I...I..S
SE!:CT :[ ON: 28 'I'ONN!!!:H :!: I:::' :', 141',1
E:i:::.!;?.:5;?. (S(:~! ,, FT. OR ACRES )
3
ii)RAVE:L. L.E]qi!}FI"H (I:::'"I",,)
GRA'v'Ei:I.... VC)L..U!'"IEil (C)U,~ Y:(}S. )
RAT :I: N!::ii ( SC~t ,, I:::"T ,, /)::')R )
c: (::,! r' t. i {' y '!'. h a t. ',',
:!.,, :[ ?a~i~ · (?(.tm:i. :!. i?.'.tp ?,!it. II '!.'.h,,.::.~ r,E:),,.:;!L,,.:i.j.,;::.:.)ri.!~:.::)~t..ii~; '[ (::)r' ,:::)l'.,...~i:i'!'..c~ ~s(~:,x!,'.'.)P.~i~
{'ciPt. h by t.l~0:.:, Mun:Lc::i. pal:i.t.y c),-" (.~d'ic:llc.,l~.~ii.:.:!(i? (J?I(]A) .:':]r'i:;l t. hc..) ~i!!;t..:':~i.:.,:::.:,
;7:'.~]: ~,.',!:i.:!.:l. ir'~st, aI]. 'l.:.in:....! .?.i~'y'.:irL. c.!iit :i.n .:'acccll~d.an,':::,'...:, ~.,~!:i.'Lh all MOA
and :i.n coral::) :1. :i.L.?~rlc:(::.', t,,.,':i, th t. hc:, d(a!!~:i, gn (::~' :i 'l:. (:.::, t, :i...:L c),':.' tl"~ :i.:s j::)c:,r',i:i.t. ,,
3, :!: L,,;:i.!l adh,'.):)r'.c.! t.,:::~ .:':.tl]. MC)A ?:.~.r'ld St. at.,):) ,:::i.J Al?:t~iil.::a r'.(.:?c!u:i.~'.e!m,:ant, s .?c~r. ti'h:,:., ~si...?t back
s(.:)w*(m'"a(.:..tc.:, sys'Lc)m (::)~'1 'Lh:i..~s c)P any .::':v.::l..i.:'.':t,::::~:~.tr'it. (::)r' r~(.??:~u',l::~y :Lc?i:.,,
4,, :I: url!:J!~.:.u'-st.aricl 'I:.h,'~tt. t.h:L!s p,::'~r'm:i.t. :i.s va1:i.d ,~'(:::,r' .~t m..:u.,':i.i'~'ii..Lm o'.," 3
ai~y ,'~:.,J"l:L.:::tJ'!?:m'~c.)nt ?,~:i. ll P,:'.?~c?,..~ir,,:~.:.~ an ,::':u:h::!it.:i. cJnal ?:!l'.m:i.t.~
...... . ....... ]'l',IS'l'(.'d I :::") ]:N AI'.I ""'"'" )'::l!l'l't '""TI'.E.] ~'"' ........ ""'
· .,d:,..~ (::;/::)'-,.,.'l!!:l::;:l!ii:):) E:Y i"I(:)A
'1"l tl!i!]',l ( 1 ) AN llii:l., E:C'T'R I il]Air. I:::'I!i!',RM i1: 'I" ~:1: N!!~I::'E!:CT I E)N MUS'!' Bti!: (]EFTA ]:
............ J ........ :.hi .... .,.U,~,.... I"'l~.~,' , [)~ h, t:::. /~:.,'Y A I.~., !xl!:~)]) E:LJ:i':'"T'F~' ]' C ' ~1',
................
'. ........ '.i,i} BY ~z~ c~L-"-~- D A'I"Ii: ,,', ~/ ~'~
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13.-
14--
15
16
17
18
19
2O
COMMENTS
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
' SLOPE SITE PLAN
WASGROUND WATER NO
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to
Reading Date
Time Time Water
Net
Drop
TEST RUN BETWEEN FT AND FT
PERFORMED BY:
CERTIFIED BY: ~,~
72-008 (6/79)
6189 1077
el
•
•t _�` Municipality of Anchorage
On-Site Water and Wastewater Program JULaUL 2 J
(907) 343-7904 S „< T T .�
S
Certificate of On-Site Systems Approval `` or 6 e L 9
Parcel I.D. 050-382-63 Expiration Date: J Q —471-1 7
1. GENERAL INFORMATION
Complete legal description Highland Hills #2. Block 2, Lot 8A.
Location (site address) 5941 Hiland Road.
Current Property owner(s) Eric Gingrich Day phone
Mailing address 5458 Bent Oak Drive. Sarasota, FL. 34232
Real Estate Agent Day phone
2. TYPE OF DWELLING:
• Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received byL -� ilOr I� I Date: P/4/1 7-
COSA to be released to the engineer, unless otherwise reques ed by t e gineer.
COSA Fee $ 2-� Waiver Fee $
Date of Payment 1 I?-1 ( Ii Date of Payment
Receipt Number 03c (p el Receipt Number
COSA# OSC 1?3\C1 Waiver#
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 9n-,,Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater
disposal system-is (are) sgfe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information' ibtained 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.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.The reported results describe 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 soil
condition,ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system, nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 7/26/2017
*: i� * /
6. DSD SIGNATURE 1'•• .4410P ... d
System #1 Approved for 3 bedrooms 16 •S{even 1i. ISonnone
( System #2 Approved for bedrooms Y#445
CE-8149 1
Disapproved �� OFESStic :J:r
Ce
nditional approval for
bedrooms, with the following stipulations:
cS Z lS rS -2_ Yl
3 ...,,,,..
Ps 2 c iU-earl a- 4 , `"h;
I ON-SITE 1
WATER AND
r WASTEWATER ;,y
� PROGRAM
''').,.,r-,-„,r,c. .
L--,iJ
By: � - Original Certificate Date: 7" y /7
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
?C
Well Flow Advisory Other
COSA blue sheet S • -
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: Highland Hills #2. Block 2, Lot 8A. Parcel ID: 050-382-63
A. WELL DATA
Well type Private If A, B, or C provide P L ID# Well Log (YIN Y
5/6/1985s.
V
Date completed Sanitary seal (YIN) s \I Wires properly protected (YIN) ;
Total depth 273 ft. Cased to 46 ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 516/1985 7/18/2017
Static water level 120 ft 110 ft.
Well production 1 •0 g p m 1 .1 g.p.m.
WATER SAMPLE RESULTS:
Coliform Neg colonies/100 mL Nitrate 2.88 mg/L
Arsenic 14.3 ug/L Date of sample: 7/18/2017 Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 5/8/1985
Tank size 1000 gal. Number of Compartments 2 Cleanouts (YIN) 'a 1
Foundation cleanout)(Y/N) Y Depression over tank (Y/N) N High water alarm (YIN) N
Date of pumping q{r 1- f--i PumperOV--\ neikr9•
C. ABSORPTION FIELD DATA
Date installed 5/8/1985 Soil rating (g.p.d /ft2 or ft2/bdrm) 150 SF/bdrm System type Deep Trench
Length 33 ft Width 2.5 ft Gravel below pipe 7 ft
Total depth 11 .5 ft Eff. absorption area 462 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 7/18/2017 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 52 in Water added 458 gal. New depth 62 in.
Elapsed Time. 350 min. Final fluid depth 52 in. Absorption rate >= 450+ g.p.d.
No
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes. give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100+ On adjacent lots 100+
Absorption field on lot 100+ On adjacent lots 100+
Public sewer main 75+ Public sewer manhole/cleanout 100+
Sewer/septic service line 25+ Holding tank 100+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+
Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
4 'VFW()Oil 4C1 DO CAQCOYICa, LpcA .e ck i 'n Cl r un h Dust, .
G. ENGINEER'S CERTIFICATION .��' q
r'�• �q.•sly
/ certify that I have determined through field inspections and P
review of Municipal records that the above systems are in * 49 j t �-.*�V
conformance with MOA COSA guidelines in effect on this date. o•.•.• •• ��r�p� • • 10
StevenPannone
Engineer's Printed Name r••.�leiei W.•
r156Morie.• e
Date 7/26/2017 0 .:• CE-8149 ....01.
COSA canary sheet_2-6-15.doc
•
• Municipality of Anchorage .. L�:
rt�
Development Services Department
Building Safety 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
Arsenic Advisors'
Certificate of On-Site Systems Approval # OSC 171319
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 8A
of Highlands Hills #2 Subdivision. This inspection revealed an arsenic
concentration of 14.3 micrograms per liter (ug/L) for the property's well
water sample. The Environmental Protection Agency (EPA) has established
a maximum contaminant level (MCL) of 10.0 ug/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. Information on
arsenic is available from the On-Site Water and Wastewater Program
website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
I
•
I"1 f -.:
`�
o
F
V� V ` r V r b . i
M ---'' 1 1 6( • 0 1 ii)
b. ' . • p iI‘)
e- \ 1 I 1 1 1 I.• i t
o, L 11 IPI s\ !
* `
‘ --st:-.. „,}
s
.•-•.... gfpe:/ l ;,I . .
\._,V 4. i .C.e.
: [ 1
KOS
ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 694-0829
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE" i ,�,�
FOLLOWING DESCRIBED PROPERTY: :/..°
p� ���
-"/ �HICSs60." ,U/ri 2"477- A `z - DATE": Pi _ ... ,q�,��
AND THAT NO ENCROACHMENTS"EXIST EXCEPT AS .77, .••- ! ..- 9
INDICATED. IT IS THE RESPONSIBILITY OF THE z�� v(':• TH ' •Y 4.
OWNER TO DETERMINE THE E ISTENCE OF ANY GRID- .� '°^
SEMENTS, COVENANTS, OR RESTRICTIONS ,,tvySB v .•
/ H DO NOT APPEAR ON THE RECORDED SUBDI- --- Q . Duane MerE a d - 0
1r...gON PLAT. UNDER NO CIRCUMSTANCES SHOULD FS' ,�o�� �¢. L5—S --�- •A'
ANY DATA HEREON BE USED FOR'CONSTRUCTION "'4,.•'�� ,v SJ
OF FENCE LINES, OR FOR ESTABLISHING BOUND- '�'% �}ar- • -. 0C.•
ARY LINES. DRAWN! •-, ���etmt►��
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
Application Date __ --~,~"~
1. GENERAL INFORMATION
(a)
(b)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name ~'~ ~" /
Applicant Address
Telephone: Florae :~g~'~/~'-5-2 ~, '? Business
(c) Applicant is (check one): Lending Institution [_3; Owner/builder.~'; Buyer []; Other [] (explain);
(d) Lending Institution ~/~'/~ ..... Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE Of RESIDENCE
Single-Family~ Multi-Family
Number of Bedrooms
Other
WATER SUPPLY
Individual Well ~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservatien
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite [~ Public El Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and stalus.
Page 1 of 2 ~2 0xs(~ ~4~
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
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 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 ___ J'~l.~ ~!iVE~F4V61NEERtNa~ERt/10ES' _ Telephone
Address ____ FJ~GLE RIVER, AK_99577
P, O, ~OX 773294
Date §94--5'195
Engineer's Seal
Approved for (.-~,/~..J'~L__bedroom 'Date
Approved_ /"~ Disapproved_ -- Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DFIEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirer'nents. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality ol Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
MUNICIPALITY OF ANCHORAGE
DEPT, OF HEALTH &
ENVIRONMENTAL PROTECTION
1985
WELL DATA
If A, B, C, D.E.C. Approved (Y/N)
Date Completed ~?/~/~-5"' Yield
Cased to Z/E,' _~,¢,~j¢ Depth of Grouting ,4'/'.,~'~
Pump Set At /-'¢'"~"~*~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead. (Y/N)
Well Classification
Well Log Present (Y/N)
Total Depth ~ '2 '~"
Static Water Level /~.g--¢"
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N) _ Y
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Commen!s
B. SEPTIC/HOLDING TANK DATA
Date Installed ~/~
Standpipes (Y/N) __/V Air-tight Caps (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
To Property Line /~ 'y-
To Water Main/Service Line ;~5- '
Course
Size /,¢g,o d-.. /' No. of Compadments
Foundation Cleanout (Y/N) /v-
Date Last Pumped /'~'~'c..~
;'for
Temporary Holding Tank Permit (Y/N)
To Building Foundation ~;.)o"
To Disposal Field /o"
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 5~/
/~-~-
Width of Field "~o "'
Type of System Design
Length of Field
Depth of Field
// /
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 Building Foundation
Lot /7./' ~'~., ~
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Gravel Bed Thickness ~"
.2. ~ Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line __ /
To Existing or Abandoned System on
; On Adjoining Lots 3~¢~ /-'
To Cutbank (if present)
Comments
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Vlanhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
SigneJ~~' Date
Company ,~'-~'~, ~;"¢-¢'-,;--$ MOANo.
Receipt NO. 23
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)