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HomeMy WebLinkAboutHIDDEN HILLS BLK 1 LT 11Hidd n Hills lock I Lot 1 1 011-121 -36 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. Mark Begich Mayor ~,.~, et.-/ Division W o::."e~ .& 4700 ~rogow Street P.O. ~ox 196650 Anchot-o~c, AK ¢951~-6650 (907) 343-7904 Well Drilling Permit Number: SW Pump Installation Log Date of Issue:~--4& Parcel Identification Number: ,5¸ Legal Descriptio ,n Pump Installation Date: q. ~ Pump Intake Depth Below Top of Well Casing: ] ~ feet Pump Manufacturer's Name: Pump Model: 329(.. Pump Size ~ hp Pitless Adapter Burial Depth: ] (.7 feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: ~k) Well Disinfected Upon Completion? ~es [] No Method of Disinfection: ~_~¼ ~0¢'v~,%¢.. Comments: Property Owner Name & Address: Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. , Municipality of Anchorage Page i of ~' 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: G ~,/C~pO ~) PID Number: Oil-12.1- 3 6 N~.: '%~~ ~ ~ ~ ~ Wastewater System: D New ~Upgrade Address: ~il ~O~'~' ~ ~ ABSORPTION FIELD Phone: No. of Bedrooms: ~ ~ ~ Deep Trench ~ Shallow Trench ~Bed ~Mound ~Other Total Depth from original grade: LEGAL DESCRIPTION SoilRating: t' ~ GPD/~:Ft:- Lot: ~ ~ ~ B~ ~.~ [ ~ ~Subdiv~i°n: ~ ~ ~ Depth to pipe bottom from ~l°riginal grade: Ft. Gravel depth beneath pipe. T_ / Ft~ Township: ~ Range: Section: Fill added above original grade: Gravel length: o - I ~. '~ ~ ~. WELL: ~ New ~ Upgrade Gravel width: Number of lines: Distance belween ~ine~ ~ Ft. ~ ~ Ft. Classification (Privste, A,B,C): Total Depth: Cased TO: Total absorption area: Pipe material: Driller: Date Drilled: Stadc Water Level:Ft. Ilnstaller: ~ Date installed: j ~/~2~ Yield: Pump Set at: C~t~ g Heighl Above Ground: SEPARATION DISTANCES ~S,,~ic ~ Holding ~ S.T.E.P. TO Septic Absorption Lifl Holding ~ublic/Pdvate Manufacturer: Capacity in gallons: From Tank Field Stabon Tank S .... Lines ~/~ ¢ l~ '~ ~ I ~ Surface w~t~, N o ~1 ~ LIFT STATION Lot ~ ~ Size in gallons: Manufacturer: Line ~ JO Foundatio~ .~ ~ ~ ~ ~ ~ "Pump on" level at: "Pump off" level at: High water alarm CurtainDrain ~ 0 ~ b~ Pump Make & Model Electrical Inspections performed by: Remarks: BENCH MARK ¢~ '~4 ~Yl'~ ~ ~ & Location and Description: Inspections performed by: ~ Dates: 1st ¢ ~ ' Department of Health and ~~ervices approval 'b:,',t,-~"~,, ." :" * Reviewed and approved ~4_ ~ Date:~~ ..... '.:'~, ~, ....... 72-013 (Rev 9/91) MOA 25 49th BEi~ SPURKLA BENCH WANK REPLACE 1000 GAL lANK INSFALL TRENCH 50 FT LONG 15 F? DEEP N~ OF ROCK 0 85 50 75 ,?CALD I~'= SO/FL SW/NGflES. AC 56.4 BC 41 AD $8,2 BD J9. J AE 65 BE S! '. AF 62.5 44 OUI£ T CIP, CL E / 125 I50 / TOBBEN SPURKLAND P.E. J J II 205 W 15TH. AVENUE ANCH. AK. 99501 _(907) 279--~91 ~, LOT 11 HIDDEN HILLS 6311 OUIET CIRCLE DANIEL ?ALBERT J J SEPTIC SYSTEM AS BUILT DATE: OCT. 21, 1996 SHEET: 2/5 GRID: 2222 ?tanc/ar'c/ ?r~nch : 35' L on9 7' Serxer rocl~ 6' Covem ~ YT SCALE 0 co Founda't','on Cleon out 0 1000 9o! Sepbr toni< D/VE£TE£ VALVE ZD200 ~'-~Doub[e £{eon Du~s SILT Cleonoui:s /~ Hon,'~om 88. 6 IE 89. 77 DIVERTE£ VALVE ZD 200 x, IE 90. I0 81.4 · £{ oF' Septic Roche 81.4 NL7 SCALE /?ENCH MA£,¥, BOTfOW SIDING ASSUME/) ELEV ]00.00 TIIB]}EN SPURI<LAND P.E. ~03 \415L. h Ave Anchoro. ge Ak: 99501 LOT I.I IflygD£y IIILLS SEPTIC SYSIEM SCttEMAI/C P£OPOSED CONSTRUCTION SEPT]£ SYSTEH AS SU~LT DATE; OCX 21, 1996 SHEET: GRID, ~ Municipality of Anchorage Department of Health and Human Services 825 "L" Street RickMystrom, P.O. Box 196650 Anchorage, Alaska 99519-6650 Mayor October 23, 1996 Tobben Spurkland, P.E. 203 West 15th Avenue #203 Anchorage, Alaska 99501 Subject: Waiver Request for Lot 11 Block 1 Hidden Hills Subdivision Waiver Request #WR960059, PID #011-121-36, I-IA960435, SW960340 Deal' Mr. Spurkland: Your request for a waiver of the required 10 foot separation between an on-site wastewater disposal system and a lot line has been approved. The approved waived distance is 2 feet from the absorption field to the property line. This approval applies to the existing on-site wastewater disposal system lot line separation only. Any future upgrade to the on-site wastewater system will require all separations be met or another approval from this department. If there are any questions or concerns regarding this waiver, please call our office at 343- 4744. SincerelY/') A James P. Williams Civil Engineer On-site Services JPW/ljm:Talbert MUNICIPALITY OF ANCHORAGE Depar-~ment of Health and Human Services On-site Services Section Waiver Review Worksheet WR~ WR960059 PID~ 011-121-36 Date Received: October 21, 1996 HA# HA960435 Permit ~ SW960340 Legal Description: Lot 11 Block 1 IIidden Hills Subdivision Engineer: Tobben Spurkland, P.E. 203 West 15th AVenue #203, Anchorage, Alaska 99501 Applicant: Daniel Talbert Waiver Requested: Lot line waiver of 2 feet from the absorption field to the __ property line. Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: Vm List Conditions or Reasons for above: Wai'~er is NOT Granted: By: the of Reviewer Rec ~: 02370/3048 Amount: $ 115.00 Date Paid: October 21, 1996 T.SPURKLAND P.E. 203 W. 15th. AVE. SUITE 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 Municipality of Anchorage Department of Health and Social Se~wices 820 1 Street Anchorage, Alaska 99501 October 21, 1996 Subject: HAA and As Built Lot 11 Hidden Hills Lot Line Waiver Gentlemen; We are submitting an HAA and a set of As Builts for this property. The septic system was replaced on October 19, 1996. As shown on the permit application the trench was installed within 2 feet of the south property line. The separation distance to the old trench could not be obtained with the new trench between the old trench and the residence. A lot line waiver fee of $115.00 is enclosed. Yours T. Spurk[~nd P.E. 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 (UPGRADE) PERMIT PERMIT NUMBER:SW960340 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:TALBERT DANIEL J & ROSALIE C OWNER ADDRESS:6311 QUIET CIR ANCHORAGE, AK. 99516 PARCEL ID:01112136 DATE ISSUED:10/08/96 EXPIRATION DATE: 10/08/97 LEGAL DESCRIPTION: HIDDEN HILLS BLK 1 LT 11 LOT SIZE: 10120 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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 (iSAACS0) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 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: 1.) ENSURE THE REQUIRED SETBACK DISTANCE BETWEEN TRENCHES IS MET AS REQUIRED BY AMC15.65.060.A1D 2.) A PROPERTY LINE WAIVER REQUEST WILL BE REQUIRED IF THE PROPOSED TRENCH IS INSTALLED LESS THAN TEN FEET FROM THE PROPERTY LINE ($115~0 FEE). RECEIVED BY: ~ ISSUED BY: DATE: DATE: ~i_ o~Jl ~,~lF,c3[~x4~2aL.~D? ~.~ o:~ 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 1 1 HIDDEN HILLS DANIEL TALBERT Municipality of Anchorage Department of Health and Social Services 820 1 Street Anchorage, Alaska 9950 l October 1, 1996 We are submitting an application for the installation ora well and septic syste~n for this lot. Tl~e submittal consist of ttu'ee (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the well and septic system are subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following: No Ground Water or Impervious Layer to 19 ft. Use Standard Trench Soil Rating. <2 rain/in = 1.2 gal per sq.fl/day No. of Bedrooms 3 Required Area per Bedroom: 150/1.2 = 125 sq.ft.. Total area required: 125 X 3 = 375 sq ft Outlet Existing Tank 6 feet below ground Testhole depth I9 feet Bottom Rock At 13 feet Top Rock At 6 feet Rock Depth 7 feet Total Trench Length 375 / 14 - 26 ft Replace Existing Tank SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 30 FT TOTAL WIDTH 2 FT TOTAL DEPTH 13 FT ROCK DEPTH 7 FT COVER 6 FT i000 GAL SEPTIC TANK DIVERTER VALVE TO EXISTING TRENCH The installation of this septic system will not prevent wells from be installed ou the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Proposed trench will be iustalled adjacent to south lot line. Lot line waiver is required, N 50 o 50 100 /50 SCALE; 1" = ~00 F?. L DS l CIP, CL E OUIE 7' £If~CL E £XISTINC IMPRO V~>I£NTS t'TOE]BEN SPURKLAND P.E. LOT 11 HIDDEN HILLS DAN/EL TALBERT SEPTIC SYSTEM DESIGN DATE: SEPT. 50, 1996 SHEET: I/.~ GRID: 2222 / 49~h :BE~ 3PURKLAF REPLACE 1000 GAL TANK INSTALL TRENCH 30 FT LONG I$ FT DEEP N 7 ET C2UIET CIA~CLE LLTT 25 ~] ~LDT £~ LOT 27 50 75 1~5 150 SCALD ~"'= 50/;~. PROPOSED IMPROI/EMENTS I'TOBBEN SPURKLAND P.E. A2 h~ .7 A1KS. TH9 ~ ¢oV1E N U E ~,(907l 279-3gl 6 Z, OT 11 HIDDEN z;II££S 6511 OUIET CIRCLE DANIEL TALBERT SEPTIC SYSTEM DESIGN DATE: SE?L JO, 1996 SHEET: 2/5 GRID: 2222 Foundot/on C/eon out ?f~ndord ?rench : 30' L on2 7' Sewer root< 6' Cover /VD SCALE JO00 9o/ Septic DIVERTER VALVE ZD200 (~)]?oub/e C/eon Plon/~-or ~ 6' Co vet '~ DIVERTER VALVE ZD 200 /-- Ex/st. Ground 5' Min Cover SILT 7 F~ of' Septic BocA: SCA L E 6 fl /000 goL sept,'c fan/< ?ENCH MA£X ASSUMED ELEIX /00,00 'FB99EN SPURI<LAND P,E, 203 WlSth Ave Anchonoge Ak 99501 LOT 11 HIDDEAf HILLS SEPTIC SYSrE~ SCHEWA?IC PROPOSED CONSTRUCTION SEPTIC SYSTEH DESIGN DA'rE: SEPT, JO, 1996 SHEET: ~/~ GRID: ~c~P~ Municipality of Anchorage DEPARTMENT OF HEAL'TH & HUMAN SERVIC;FS 825 "L" Street, Anchorage' Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEER'S SEAL) P~R"ORMED POR: 'YAL1D~T'; 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20- Township, RaFigel Sec[ion: SLOPE SITE PLAN s L IF YES, AT WHAT O DEPTH? p E Oeplh Io Waler Monilc, rlng7 ~-~ Oate: Cleading Date Gross Net ... -.~ Depth'~,o~ Not Time ~ j ~'1 Time ¥~,t I ~'1 Water ,l~.l/ Drop ~/~_~J~ ~.... ~ ,, .rEST RUN BETWEEN -- (mrnutes/inch) PERC HOLE DIAMETER ~ F'r AND 7 /~.~'__ FT PERFORMED BY: ~"--""~ I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATF. DATE: 72-008 (Rev, 4/85) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT MAILING ADDRESS LEGAL DESCRIPTION LOCATION .,%H ON E NO. OFBEDROOMS [~UPGRADE Well , I Absorption area DISTANCE TO: Manufacturer.~ Liq, ?~t~i n gaIIonsDiSTANCE TO: We~IF HOMEMADE: DwellinglnSide length DISTANCE TO: Well N~'~ i~ No. of linest ] Length ~a¢ I?e Tot al Ion gt h'o~li~les Topof tileto finish grade ~ / ateria Beneat~ tile Length Width Depth Dwelling Material Width Material IN~arest IoT~e [-trench widt,5 ~ inches PE~IT NO. No. of co~artmeC~ts- Liquid depth PERMIT NO. Liquid capacity in gallons PER¥~T~O. Distance b.~tween lines ~//~' Total ef~ct~e a~sor~tion area PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PI~E~F~MAT ER IA LS SOl L TEST F~ATING.~ INSTALLER RE-MARKS R-~-~"~) DATE LEGAL F'EI:;i:I"I I T N(], F:IF'F'L. t Cf::II'.4T I...OCFFI' 1 ON LEGFd .... ..... IE.,E. CLFliR L::!LI I E"f' C I Fi%I._E L.. l::L E: :L H I[:'[:'EN H IL. LS C, IEF'FtF:'T'HENT OF' HIEFII...TH FIN[:, IF:[',',,, IROi'.,I'"IENTF:II... F:'I;%)TECTION '~] ""~ ;~.~..,' , I,E:;Z~:~;'''L "' L:!;TF.:EI::'ET., RI'.,tCHOF:'.I::IEiE:5F!K. ,' ',:3]:OE;40 ::, '"¢~/1"' L~L~ ]:'2'E)l EI...IREI'::;FISF'FICE '78-1::1 ' I F;.E. NCH "F'¢PE OF 'FDIt.... 1::ISSORF'TION .: ~:: TEll I:E;: - .'- MFIXtHLIM i",IIJHE~E:R OF EE[:'ROOHS = 7.": SIZE OF' TFIE SOIl_ FtE:~;ORF'TION S"r'STEM T'HI!.::: LE:NGTH t}IHEI",iSION IS THE LENGTH ,:lIN FEET) (IF: THE TRENE:H OF..' [:,FrFIINFiEL[:,. THE [:,EF'TH OF F! TF:.EhlCH OF:: F'tT IS THE DISTFff-,ICE: E',E:.TI.,.tEEi",I THE SURFRC:E OF '1"HIE GROUND FIND THE E',OTTOM OF' THE EXE:FF,,'FtTION (.' I i",l F'EEt"::,. T'HE,~;:E IS NO SET WI[:,TH FOF.: TRENCHES. THE' GI::::Ft',,,'EL. [)EF'TH t S THE I'"11 i'.,I I HUM [:,IEF'TH OF: GRFI',,,'EL BETWE'EN THE CILITFI:::ILL. F:' t PE FIhlD THE BEFf']"OH OF THE E',=.,;CF:¢,,,'FFf'I ON ( I N FEET ::,. F:'EF::I'I I "F F:IF'PI_. I E:I::Ii'.,IT I.-II::IS T~--IE RI:2?,F:'OI'.,IS l E: I L I 'T"¢ 'r~'o :[ NF:ORM "['H I '--"4; I}EPRRTHENT DUR I I'"IG ]"HE I I'"IST'FIi....L3:FF I Oi'4 I i'"iSPECT I Oi'"t2T Oi::' FIN"r' !-,.IEL. L.~.; FII}JRCEht'T TO TH I S F'[~' :]PEF.:T"r' RN[:' THIE -.':,EF., E. i',tlJhlE~ER OF F.:ESIDEN(]ES 'f'HFI]" THE I.,.IL::L.L WILL ' ...... "'" E~I-':ICI.::]::'tL.I....iI'.,t(]~ OF' F'll'.~"r' ?¢'STEM I,.IITHCdJT FII'.,IFII_. INSF'EC"f'ION I=ff',![:, FIF'F'F::O',,,'FIL. E'~.., THIS I}EF'FIR]"HENT I.,.tILL. BE SUI3JEC¥ TO F'F.:L]SEE:IJTION. i'l I I'.,i I HUH E:, I '.2;TI::II'.,tCEE E:E]"I.,.ilEEN t::~ !.,.IELL RN[:, FIN'Y OI'.,t-S I 'I"E SEklFtGE I1::, I '.'.:.:,l::'OSl:~l_ ~5"r'S'TE:M l' iOE~ FEET' F'OF.: I::t F'Rt',,,'FITE WE:LL. OR :LDO TO 200 FEE]' F'RCd"I I::1 PIJE:L..IC: 1.4EL. L. DEPEN[:,tI",IG UPON TFIE YYF'E OF' PUBLIC WEI._L.. i'lti'.,]II'liJM [:,ISTFff',ICE I'"':ROH R I::'RI',,,'I::I]"E: I.,.IELL TO FI PRI',,,'FITE SEWER LINE IS ;2'.5 FEE:T F:IN[:, TO FI COMMUNIT'¢ SIEWER LINE IS '75 FEET. WELL. L. OGS FIRE f;i:EQUIRED Fff',t[:, idU'.:-;T BE RE]'URNE[:, TO THE DE.I::'FSUFI"IIENT I,.I].'THIN ]:0 OF THE WEL. L COIdI::'I...IETION. OTHEF: F.'.IEL::!U i REMEN]"Z"; I'IFI"," Fd:'F'L.'~':. SF'EC I F I E:FtT IONS FII",ID CONSTR:UCT I ON D I FIGI:;.:F~HS I":I",,'R I LI::tBLE ]"0 i NSIJRE PROF'ER I I",ISTRL. LFIT I O1",t. :( _.EP.~II r THFI'F :L: I FII'"I I::'FIMILIFIR I.,.ttTFI THE I';.:Eg!IJlREI'"IIEN'R:5, F(]F:: ON-SITE SEI.,.IEI:~':S I::IN[:, I.,.IELL. S FIS SET FORTH E, ~' T'HE MI...II'-,I I C t F'FIL I "f"¢ OF FII'.,ICHORRGE. ,.-:. I I.,.III.~L It'.,ISTFtLi. THE .: ~.:: I1:11 I1'-,I FICE:CdE:C, FII'.4CE' t.,.II i'FI THE 2.'.: I UI'.I[:,ERS]"F:IhI[:, THI'":t'f THE Ot'.4-S!]"E SEI.,.IEF;: S"r'~;TEM I"lt::!'T' REQUIRE E?',IL. FIRGEME:]",IT IF THE F.:ES I [:'EI",ICE I S REHODELED T '] i NCI. JJDE I"tF F.':E THFIN 2 BEDF;'.O01"I:i:2;. .~., . ~ /7,, .., .4':~;;' S I GI'.,IE[:, · F:tF'F'L. IE:RNT /'~.~I"E'v'E CL..I:::III:;~: f Y> ~ " "/:.~,L .... SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 I1 12 13-- 14 15 16 17 18 19 20 COMMENTS SLOPE ~ITE PLAN 72-008 (6179) WAS GROUND WATER /~/'~:, ~ ENCOUNTERED? -- O P E IF YES, AT WHAT ~__ DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (nlinutes/inch) TEST RUN BETWEEN FT AND FT CERTIFIED BY: Date Drilled: Static Water Level !75 feet WELL LOG Gallons Per Minute Drmw Down ~'?^ feet Total Feet of Casing ~ype Material Drilled: 0 feet to 11 sat~ · 1~ feet to qr, Hefty Drilling S.R.A. Box 1553 H Anchorage,Alaska 99507 Parcel I,D. # 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 12.-I-cc&, HAA# __~-~c~i,< GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner _~-¢~,L~P~'~., -~Ahlt~.. L Mailing address ~, '¢// Lending agency Mailing address Day phone Day phone Agent Address phone ~-&,,2- (¢~-~-~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water 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 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. NameofFirm '-~-~1 ,,~,-~/--.~,~v,_o~ -"~.J~., Phone 'J2'7c?-'3c~/~' Address ~O~ L~' /~(--4d ~ ~o ~ Engineer's signature DHHS SIGNATURE [¢~ Approved for ~-~ff~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: 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 DH HS 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 MOAlY21 Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICESK, Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 3~,~-~7~ 1996 Health Authority Approval Checklist copt. Health & Human Serg'ice8 ko'T!~ JCJ~P)..~t\J l~J~.k% ParcelI.D.: ~J/~ ¥ If A, B, or C, attach ADEO letter. ADEC water system number Date completed ~, ~" Cased to / ~¢,,~ easing height (above ground) '~'/,~ I1 FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HO~-DING-TANK DATA Date installed Foundation cleanout (Y/N) Date of Pumping Wires properly protected (Y/N) y AT INSPECTION g.p.m. ~ g.p.m. Nitrate /, ~ 14,¢~/ Other bacteria r'"J J,~ Collected by: _Tanksize /~) Number of Compartments :/~ Cleanouts (Y/N)~/ '~ Depression (Y/N) ~'-~ High water alarm (Y/N) Pumper C-//'' C. ABSORPTION FIELD DATA Date installed JO~lc[l? ~, Length ?>Oi Width Effective absorption area /.1/'(~0 ~ Date of adequacy test. [~//~- Fluid depth in absorption field before test (in.); Fluid depth ,-/ (ins) Minutes later: ~ Peroxide treatment '(past 12 months) (Y/N) Soil rating (g.p.d./fF or4~-bdr-m) /~/'?-- System type %-~¢.4,4' Gravel thickness below p~pe ~7 I Total depth Monitoring Tube present (Y/N)_.~ Depression over field (Y/N) Results (Pass/Fail) _ ~t.¢-> For_ ~ bedrooms Immediately after """gal. water added (in.): Absorption rate = (~/' If yes, give date g.p.d. 72-026 (Rev. 3/96)* Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at* "Pump off" level at* High water alarm level at* *Datum Cycles tested 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: I ~ ¢~-S / Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: I Foundation '~/,~¢1-- Property line ~ 10 Absorption field Water main/service line .>~'"O Surface water/drainage ~./t~ On adjacent lets On adjacent lots Public sewer manhole/cleanout Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ,~ ! Building foundation /¢/~ ! Water main/service line Surface water ~' / 0-¢--) Driveway, parking/vehicle storage area Curtain drain ~/~) Wells on adjacent lots ~>/0-0 F. ENGINEER'S CERTIFICATION . I certify that I have determined thru field inspections and review of Municipal reco(dsthat the above systems are in conformance with MOA HAA guidefines in effect on this date. s,, .tur. Date ~ ~, [~ ~ HAA Fee $. Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ //¢;~"7'~-t-) Date of Payment Receipt Number CNVIRONMI~NTAL SERVICES DIVISION Municipality of Anchorage OCT 0 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division R~CEi 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist ~,~.LLLf-.~/ L-©'T' '~1 ParcelI.D.: Legal Description: A. W[=-:LL DATA Well type ~ Log present (Y/N) "// Total depth / ~oO ¢~)- Sanitary seal (Y/N) y FROM WELL LOG Date of test ~ -~" C~ ~ Static water level _ /c--d- ~' Fa/- Welt production / ~ WATER SAMPLE RESULTS: Coliform ¢ If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to } ~ O {¢~.~- g,p,m. Casing height (above ground) Wires properly protected (Y/N) "-/ / AT INSPECTION g.plm, Date of sample: (::/~ ,/~,, c~ ~ B. SEPTIC/HOLDING TANK DATA Date installed / 0/¢l~/~ ~__ Tank size Foundation cleanout (Y/N) _ Date of Pumping Nitrate /-(¢ H'~'~) /l Other bacteria Collected by: '~Y.~'~ /~:~--~?~? Number of Compartments y Depression (Y/N) _Pumper o~- Cleanouts (Y/N) High water alarm (Y/N) f%/ C. ABSORPTION FIELD DATA Date installed / ~ Soil rating (gc.d,/ft~ or ft2/bctrm) t,.-~O System type 14¢..44 c-/~ _ Length ¢(~ ¢ Width ~ '~);J'~- Gravel thickness below pipe ~, ~ Total depth /,,¢,'f¢ ~./~ Effective absorption area /-//.~'/~ ~:z. Monitoring Tube present (Y/N)_~ Depression over field (Y/N) ~ Date of adequacy test <7/~/¢¢¢ Results(Pass/Fail) ,.~,~r~ For .~:~3 bedrooms Fluid depth in absorptien field before test (in.); Immediately afterT~O gal, water added (in.): ¢? ~ Fluid depth {¢ ! ~?-- (ins)Minutes later: ,~,,"~. ~. ¢%_ Absorption rate= ~, ¢~'O glp.d. Peroxide treatment (past 12 months) (Y/N) /"/ If yes, give date 72-026 (Rev. 3/96)* LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at* "Pump off" level at* High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot I O.~ t- ~...~ Absorption field on lot Public sewer main ~'~ Sewer/septic service line ~'¢'~ ~- On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station IO~h SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation "~ ,.~, t Property line ') ~ ~ ._ Absorption field ~ t Water main/service line ~ ~5 Sudace water/drainage ~'~ Wells on adjacent lets SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water Curtain drain Building foundation ~ ~ ~ Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots ~, F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in/effect on this date. Signature '~'. ~ Engineer's Name I"~¢~,~¢~/~_.~/~O~'F--¼¢-' ' ' o '" o~ '-~. I.~' HAAFee $ ~¢)~'¢f'~ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 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 Location (site address or directions) Property owner "~- t C~ Mailing address ¢~o}<- °/il ~_-~ Lending agency .?.o/~¢=- ' Mailing.a~ddress '" Day phone 'Z'~t'~ - g) 'O~ '~.. Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water 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 NOTE: 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 STATEMENT OF INSPECTION BY ENGINEER As certified by myseal 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/orwastewaterdisposalsystem 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. NameofFirm ~I~F~ ~'~-gJ~AcJ Co~su~."~l,J~ Address 5o~ W .,-'----[~ ~ ~/,.~ Engineer's signature {X~__,):~ " DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: .~O H-~q_ ~I/t 11"~u Date (~//i/~ 7_~ 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 DH HS 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. 72q325 (Rev. I/9~) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L Il ¢., I t'[~00E¢ ¥1tLLC~ ~,t. il¢ Parcel I.D. A. WELL DATA Well type 1~'40~V~ Log present (Y/N) Total depth Sanitary seal IfA, B, orC, attachADECletter. ADEC water system number Date completed cf'~'~(~) Driller I~pTY Cased to i~C>I C~ Casing height ~...~. I Wires properly protected (Y/N) ~ (~ Date of test Static water level Well flow Pump level FROM WELL LOG ~-,~.~ ~;~ g.p.m. AT INSPECTION (o- Z, ~1 - ~ ~. ® MUNICIP/\Li IY C)~ ANCI IORAGE IiNV-h~)F!MENIAL S!~RVI{:i% DIVISION i 1_o0 ~-i~ (~ g,p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot I O Public sewer main hJ Public sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform %.&~' ~&F¢~-'r~ Y Date of sample: Nitrate ~AT igF^(_¥o/~¥¢''~'-~ Other bacteria Collected by: C',A¢-L., /V~,~tl ~ El. SEPTIC/~ANK DATA Date installed IO~ Z"L- ~) ~ (~'~ Tank size [ooo ® Cleanouts (Y/N) ~ (~ Foundation cleanout (Y/N) ~(~ High water alarm (Y/N) ~/A, Date of pumping ~ -~.._Ic~I'Z-L Dm~ra/NL.t Compartments Depression (Y/N) J~ (~) Alarm tested (Y/N) /4 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot II'L'+ © ~+(~ To property line 1'~ Surface water/drainage ~/,~ On adjacent lots I~,C~'+ (~ Absorption field ~ ' ® 72-026 (Rev. 3/91) Front MOA 21 (~ ~-O ~ Foundation ~ c5 Water main/service line ,® CONTINUED ON BACK PAGE C. LIFT STATION Date installed N,'//z~ Size in gallons Vent (Y/N) ~ "Pump on" level at High water alarm level 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 Date installed I O - ~--~-- - Length ~ I (~) Width Total absorption area 'dr~O Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) Soil rating I~'0 ~ ' (~ System type to Gravel thickness Total depth ___ , Cleanouts present (Y/N) I ~ ~u~At~o~l~ Date of adequacy test ~-~-~ ~ for ~ bedrooms ~o © If yes, give date Well on lot To building foundation On adjacent lots Surface water Curtain drain SEPARATION DISTANCE FROM ABSORPTION FIELD TO: ~ (~) On adjacent lots I I~~r © Propertyline To existing or abandoned system on lot Cutbank ?--oo'+ To ~(~ · Water main/service line Driveway, parking/vehicle sto~age area ~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines Signature Engineer's Name Date '7- G ~ HAA Fee $ Waiver Fee: $ Date of Payment ?- ~- ~ ~ Date of Payment Receipt Number ~ ¢ 2¢ ~ ~ ¢ ~ Receipt Number this inspection. I0 ..... CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. TC:LEPHONE (907) 562-234:3 56,33 B Strut Anchorage, Alask~t gggt8 Drinking Water Analysis Repert for Total Coliform Bacteda TO BE COMPLETED BY WATER SUPPLIER [] PRIVATE WATER SYSTEM Fable No. Mo. O,y Year SAMPLE TYPE: [] Routln- [] Check Sample {for routine sample with lab ref. no. .) [] Treated Water [] Special Purpoae I~ Untreated Water gAMPLE Time Colleal~d No. LOCATION Nc~ 2, ~ 7.. Colle~b~d By I 3 I 4[ READ INSTRUCTIONS BEFORE COLLECTING SAMPLE TO BE COMPLETED BY LABORATORY Analysis shows this Water 8AMPLE to be: [] Unsatisfactory El 8ample too long In transit; 8ample should not ~ over 30 hours old al 0x~mlnslbn to ind~ate reliable resume. Please send new sample via special dollve~ mail, Anal~l~l Method: Membrane FlEer ' No. el colonies/lO0 mi, BACTERIOLOGICAL. WATER ANALYSIS RECORD Membrane Filler: Direct Count Vorlllcatlon: LaB Fe~I Coliform Conllfmatlen Flail Membrane Filter Reaulte Reported ~y r[7~ Analyat TNTC = TOO Numerous To Count OB = Other Bacteria BGB PART ONE OF TWO REHAINDER TO FOLLOW C~llform/100 mi Collform,/lO0 mi CHEMICAL & GEOLOGICAL LABORATORY A DIVISION Off COM~IER~IAL TE~TINQ & ENQINEERING CO. 5683 ~ ~TREEI ANCHORAGE, ALASKA ggSI8 TELEPHON~ (UU/) 502'2848 FAX:(807) ~61-5001 ANA~Y$I~ ~EBUL~ ~o~ INVOIC! t 553~2 P~ID UA J~N 29 }2 { $6~21 ~. BPO} : PO! ~RONE ~ECEIVZD Ozd~zud By ~C ~ k P~ze~te[ Results Up. its ~thod Allo~bl~ L~rttti MIIBATI-H ~,6 m~/l EPA 353,2 10 PF. oNT VI l~l,,J MUNICIPALITY OP ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPtkRTMEb~ OF HEAL'i%! AND ENVIRONMENTAL PR~ECTION APPLICATI~ ~R [~EAL%~ F~ORI~ ~PROVkL CE~iq]FICATE 1, C~a]. Infom~ticn Application Date ~:_~=~!..% k ~ (a) I~al ~sc~iDtion (inclu~ lot, block, subdivisicn, section~ to~nship, range) Locatign (add~ol~s o~.,di[ections) (b) Applicants N~ ~ '~ ~ (j? 'A ' ~ . ~.~<i } ~C Applicants Address (c) Applicant is (check: one) Lending Institution (d) Lending Institutio~ Addre s s (e) Re)a! E!-tate Co. & Agent Address Te le phor~e 2, ~!~ylre of Fesiden~ Nun~r of Bedroe~ns Other ~escribe) Individual Well'~[ Cor~nity t~ i~b].ic ~i~. Note: If c~munJ, ty ~.~1]. system, must ha~ vmitten confirmation fT~ the State L~part~nt of ~]viron~ntal Conservation attesting to the legality and status. Is the ~11 adequate fo~ the nLm~l~r of ~dr~ s~cified in this K~l ~) Is the wastewater dis~sal system adequate for t~e ~r of ~dro~us ~/N) [Page 1 of 2] 2-15-84 5. ~p_qineering_ Firm Providinq_I3'.!_s~_gt.io__ns, ll)sts, Data and Information I c~n:t].fy that I have checked, verified, or conformed to all MOA ~%A C~idel].ne.s in effect, on t~a date of this inspection° S ig~e d Adck-ess \, :' . [)}. ,.' '' '. ': i_,[ i 'ii. i S igr~.d by h', ,, \,,,, ,, Date -~ ( ENGINEER SEAL) DHEP A~.pr ova 1 Approved for ~- l~.¢lr oc~ Terms of Conditional Approval '£he Hunicipality of Anchorage Department: of Health and Environmental Protection dces not guarantee the c~ntinued satisfactory .pe[,fo~mancm of t]'~. wate~ supply and/or the wastewater disposal system° 1his approval i~dicates that, as of the validation date shown above., based on the data and information fuunished by an engJ.~er registered J.n the State of Alaska, the %cater supply and wastewater disposal, system ].s safe and func- tional for the number of bedrocms and tying) of structL~e indicated. ( DHEP SEAJL) 7. Mail the HAA to the follc~wing adouess: KS2/d5/s [:Page 2 of 2] 2-15-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) Well Classification Well Log P~esent Q/N) Total ~p~ /3~ =' ~d to Static Water ~1 Casing ~ight ~ Ground Elec~ical Wiring in ~nduit ~p~ation Distan~s ~ ~11: To ~ptic/Solding Ta~ '136 £ g NOIID~IO~d 1VIN~V~NO~IAM:I CHECKLIST - FEBRUARY 1984 ~wo NV O ¥ If A, B, ~ C, D.E.C. ~p~o~d(Y~) ~./~_~-~._ Pump S~t At Sanitary Seal on Casing ~/N) Depression A~ound Wellhead (Y/~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /~ '7, ~- ~; On Adjoining Lots To Nearest Public Sewer Line! ~/~ . To Ne.a~est Public Sewer Cleancut/Manhole ~[/'t~ TO Nearest Sewe~ Service Line on Lot Water Sample Collected By ~ D ; Date Z//~/~ ~ Water Sample Test Results ~$~ B. SEPTIC/HOLDING TANK DATA Date Installed I0" ~.7-~'~ Size I:[)0O No. of C~,%~auzt_rmnts StandpiFes ~N) Air-tight Caps ~yN) Foundation Cieanout Pu~ing~intenan~ ~n~a~ ~ File (Y~) . __; rot_ ~.~. . - - Holding Ta~ High-Wate~ Ala~ (.Y~) ~/~ . ~ra~y Holdi~ Tank Permit (Y~) '1 ~p~ation Distan~s f~ ~ptic~lolding Tank: TO Water-Supply Well I/ ~, TO P~operty Line ~' To Water Main/Service Line Cours~ A//f~ Comments , (~O~>~-jC ~L TO Building Foundation ~'7 ~ To Disposal Field ~ z To Steeam, Pond, Lake, c~ Major Drainage [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed {D-~.A' ~'.~ Width of Field Square Feet of Absorption A=ea Dep=ession ove= Field (Y~ Results of Last Adequacy-~st _ Type of System Design Length of Field ~ ~ / Depth of Field I I~>/ Gravel Bed Thickness ...~/ Standpipes P~esent ~N) Date of Last Adequacy Test /~//t Separation Distance from Absorption Field: To Weter-Supply Well I~'], ~-' TO P~operty Line ~%0 / TO Building Foundation ~/[/~ To Existing or Abandoned System on To Water Main/Service Line }3 ~ TO Cutbank(if present) ~//~ To St~eam/Pond/Lake/o~ Majo~ D~ainage Couttse To D~iveway, Pa=king Area, o~ Vehicle Sto~age Area ~ ' Conm~nts '~f)£~%~¢~ ~ /%~O~ .-~1'~(/~~- D. LIFT STATION Date Installed ~/~ Size in Gallons ~/~ , "Pump On" Level at ~1//~//~ High Water Alarm Level at Tested for ~/~ Electrical Codes(Y/N) ~/~ Con~ents / Dirre ns ions ¢/& Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request certify that I have checked, verified, o= confo=n~d to all MOA HAA Guidelines in effect on the date of this inspection. Signed KB1/d5/s [Page 2 of 2] 2-15-84