Loading...
HomeMy WebLinkAboutHILLCREST BLK 6 LT 4On -Site Water System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP141171 Tax Code Number: 01627136000 Work Type: Well Initial Permit Effective Dates: June 17, 2014 to June 17, 2015 Design Engineer: Subdivision: HILLCREST Site Legal Address: HILLCREST BILK 6 LT 4 G:2432 Owner/Address: BARBOSA RAFAEL 1211 CONTRARY CT ANCHORAGE AK 995152125 Site Mailing Address: 1211 CONTRARY CT, Anchorage This permit is for the construction of: N Disposal Field N Septic Tank N Holding Tank Lot Size in Sq Ft: 8400 Total Bedrooms: 3 N Privy Y Private Well N Water Storage 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 (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received Issued By: MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program Parcel I. D. Property owner(s) Mailing address _ Site address i ON-SITE SEWE EL ERMIT APPLICATION Legal description (Sub'd., Block & Lot) D. i Legal description (Township, Range & Section) Lot Size ot/d D Sq. Ft. Number of Bedrooms _ APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (0 all that apply) Absorption Field ❑ Initial 1K Single Family (SF) S1 Septic Tank ❑ Upgrade (w/wo ADU) ❑ Holding Tank ❑ Renewal Duplex (D) El Privy El SUB y Multiple Dwellings Elr+BMi I IA� (SF and/or D) Private Well 0 1 Water Storage ElJUN 0 g 2014 THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that�peatS veI rmatio is correct. I further certify that this is in accordance with agent) Permit/Rush Fees: Waiver Fees: _ Date of Payment: 62/3 CAS h Date of Payment: Receipt Number: I_74SJR Receipt Number:, Permit No. O5piq I'l I Waiver No. Permit App_9-1-12.doc 9 0 1 Ik., Imim- n k, i 0.00 -s, 3 sago y�ze,w baa C)O/ i$ -W DRILI-MG, Inc. P.O. Box 110370 0 10330 Old Seward Highway 20 (907) 349-13535 � ANCHORAGE, ALASKA 99511 DRILLINO MO Well of Weli l;�. Location (address of: Township, Range, Section, if luaown; or distance main road---- Size oa _Size of: casing CaJJepth of Bole U _feet Cased toi.�" feet' Static water level—_? `1—__ft. (6.138Vb) (below) land surface. Finish of well (check one) open end Screen ( ); Perforated ( )> Describe screen or perforation_ _a_Uaua Well pumping test ai_agallokis poi' 11i6ifr) (minute) for ?____Jaours with t0()i U. of drawdown from static bevel, Date of completion_�� 'U'VE yL LOU MUNICIPALITY OF ANCHORAGE Depth in feet from ENVIRONMENTAL PROTECTION ground surface Give details of formations penetrated, size of. material, color and hardness _a_TO— —TO a _ -------z? —1:_2_—TO__fa2 62 mn 71 77 i, —TO 4,% TO TO^—_ TO TO TO TO— TO TO, TO__ NWWA Certified Contractor Certz£icab No's. 811 & 973 3 — CONTRACTOR 1-01-1141 1 ET I T"acho~XA-V 13 H=* H H - 11 ILAi������ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264�4720 PERMIT NO: 850730 DATE ISSUED: 12/04/85 APPLICANT: NINO DUARTE . ADDRESS: F:1 C) BOX 2844 ANCHORAGE�. AK 99510 CONTACT PHONE: 522�1428 , ~ LEGAL DESCRIP: SUBDIVISION: HILLCREST LOT: 4 BLOCK: 6 SECTION: 17 TOWNSHIP: 121\1 RANGE: 1W LOT SIZE: 8400 (S(A"FT" OR ACRES) l certy that: 1. I am [amiliar with the requirements for on~site sewers and wells as set forth by the Municipality of Anchorage (HOW and the State cd Alaska. 2, I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria o[ this permit^ 3. I will adhere tp all MOA and State o[ Alaska requirements [or th(..� set back distanc [ g well, wastewater disposal system or public sewerag t t any adjacent or nearby lot, SIGNED DATE: d;v.�.,-.. .^~^�__~_�~~~_~__� APPLICANT: NINO ^ lSHUEJ) B DATE: °^ABHOI GR 'ER ANCHORAGE AREA BOROL I DEPARTMENT OF ENVIRONMENTAL DUALITY 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM » MAILING -2�j NAME ��`�/s 1�G7-G���� ADDRESS PHONE c LOCATION_/��'�>����' gL DESCRIPTION 3EPLT-- TANK:--�l���Tfi✓� /f/G.���r��'�v - DISTANCE FROM WELL •��,/ / 71i, ��� MATERIAL_ ����/�/�U✓j' NUMBER OF COMPARTMENTS �'�1, /rr'�v/I/�v/r' !✓//��� T/�id/J LIQUID LIQUID CAPACITY / UO _GALLONS. INSIDE LENGTH C�- INSIDE WIDTH " DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS LINING MATERIAL NEAREST LOT LINE _ TILE DRAIN FIELD: DISTANCE FROM WELL NUMBER OF LINES —OR WIDTH LENGTH , DEPTH DISTANCE FR BUILDING FOUNDATION , TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) STANCE BETWEEN LINES ABSORPTION/rY(EA SQ. FT. LENGTH OF EACH LINE NEAREST LOT LIN TRENCH WIDTH SQ. FT. TOTAL LENGTH OF LINES TOTAL EFFECTIVE DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE WELL: DISTANCE FROM DEPTH �� WATER TYPE �' � BUILDING FOUNDATION. /� ` SAMPLE iV�yF NEARESV-"'` i NEAREST '`�`P SEPTIC SEEPAGE"��� OTHER '` -/- 71 LOT LINE �` SEWER LINE ', TANK :: , SYSTEMLZZ �_ CESSPOOL SOURCESd�_ DIAGRAM OF SYSTEM DISTANCES: �vr 41 >� • ur« "_,r fy 8 u ju o' �! DATE �`�--s//� APPROVED GREAI ER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3500 TUDOR ROAD POUCH 6-650 ANCHORAGE, ALASKA 99502 TELEPHONE 279-8686 SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT i NAME OF APPLICANT INSTALLATION LOCATION .� 1_EGAL DESCRIPTION _. L/G C //I/ ���_ >� INSTALLATION OF: EPTIC-TANK _ TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH PERMIT NO. MAILING ADDRESS Ili PHONE - SEEPAGE PIT V' 0A DRAIN FIELD OTHER TO BE INSTALLED BY ��`� 1L> 71 ' A SOIL TEST RESULTS NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED L FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE TYPV - MINIMUM DISTANCES, REQUIREMENTS -r FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT SEPTIC TANK TO SEEPAGE PIT WALL i SEPTIC TANK SEEPAGE PIT TO NEAREST LOT LINE, WELL TO SEPTIC TANK DRAIN FIELD WATER MAIN TO SEPTIC TANK DRAIN FIELD P / EP G,E AREA SIZE L "%i DRAIN FIELD DRAIN FIELD i SEEPAGE PIT ALSO CONSIDER AREA WELLS. / SEEPAGE PIT SEPTIC TANK, SEEPAGE PIT , DRAIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. / j HEALTH AUTHORITY OR LICENSED DESIGNER TYPE DIAGRAM OF SYSTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE L' APPLICANT'S SIGNATURE'" ✓�/%``T �/ �'.�C"-/iZ�T-�-�" - v n MUNICIPALITY OF ANCHORAGE A Department of Health & Human ServicesDIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # LALD Q1 \ — JL HAA # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) S Location (address or directions) (b) Property owner Mailing Address ATelephone : (home) .S^Z o W 7%4-�L I� (c) Lending Institution SAM t:S Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here if hold for pick up.) List contact person and day phone number below: $0 %L4. N t lFt�- 3 3 -7 - I. 1 2. TYPE OF RESIDENCE Single -Family Number of bedrooms 3. WATER SUPPLY Individual Well Community ❑ Public ❑ WJ Business E4I"jn.tJv Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ❑ Publicx Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 5. 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 le, N % EfIEX- GtJ G"t PCR' R11JGlephone Address Date 10 — / r u l PI 1Z f Engineer's Seal B. DHHS APPROVAL. / Approved for 2� bedrooms by �t tc ! r Date Approved Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 7180) Back Page 2 of 2 C9 n MUNICIPALITY OF ANCHORAGE (MOA) Are Health Authority Approval (HAA)CHECKLIST - FEBRUARY 1964 343-4744 Legal Description: 1 4 6 A. WELL DA� Well Classification Well Log Present (Y/N) Date Completed If A, B, C, D.E.C. Approved (Y/N) -1�A Yield Total Depth Cased to Depth of Grouting — Static Water Level — z ® Pump Set At A Casing Height Above Ground 7� Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: / To Septic/Holding Tank on Lot "I A // qq ; On Adjoining Lots tj` To Nearest Edge of Absorption Field on Lot l� 1A ; On Adjoining Lots A To Nearest Public Sewer Line >2-01 To Nearest Public Sewer Cleanout/Manhole v To Nearest Sewer Service Line(5 // on Lot — p Water Sample Collected by ' ell� ;Date Water Sample TestResultsN- k 5 4=Ae. ro A -y Comments 8 NLas N % ,.fir 0. B. SEPTIC/HOLDING TANK DATA aLot f CL xx tsw CIL- Date Installed Size No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High -Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPT C/1 To Water -Supply Well To Property Line To Water Main/Service Line To Stream, Pond, La Comments Foundation Cleanout (Y/N) Date Last Pumped ;for remporary Hol Tc OLDING TANK, o Building Foundation To Disposal Field -- r Drainage Course 72-026 (Rev. 7/88) Front Page 1 of 2 nk Permit (Y/N) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTI To Water -Supply Well To Building Foundation Lot To Water Main/Service Line Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present Date of Last Ade cv Test To Stream, Pond, Lake, odor Drainage Course o Property Line On Adjoining Lots To Driveway, Parkir Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments To Existing or Abandoned System on To Cutback (if present) Dimensions Manhole/Access (Y/N) T "Pump Off' L_e etWc "Check Permitted Bedroom Rating Against HAA Request" nt (Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or nformed to all MOA and HAA guidelines in effect on the date of this inspectio - Signed Company ��N rtl7.�- C�i'+.1 G-tr✓C Engineer's Seal Date MOA No. ��® dA® 0 f 11 Receipt No, Receipt No. Date of Payment -al Waiver Fee: $ Amount: $ % Date of Payment 72-026 (Rev. 7/88) Rack Page 2 of 2 KEKNIEFEL ENGINEERING 8441 Miles Ct., Anchorage AK. 99504 (907) 337-1121 • Fax (907) 338-1874 H. F.Ah.TH....A.UT.H.QRTTY .......RE.SULTS...... AND .......AN.AL.Y5.1.$ Date of Testing: September 17, 1990 Legal Description: Lot 4, Block 6, Hillcrest Street Address: 1211 Contrary Number of Bedrooms: Two (2) ---------------------------------------------------- Well Flow Test: Static Water Level 2.0 Average Flow Rate: > 9 gpm Results of Water Quality Analysis: .......,,.$,a,.ti.s.fac.I.ta..ry. Total Coliform ---- 0 colonies Nitrate -N -- 0.6 mg/l (10 mg/l allowable) ------------------------------------------------------- Results of Septic System Adequacy: MOA Sewer System --------------------- The well produced at above the 9 gallon per minute 'level for the entire test period. An aquifer at the approximate 25 foot depth never allowed the water to be drawn down below that level. The electrical conduit was properly installed to the well casing, the ground around the casing was re -graded to provide proper slope, and the well had a sanitary seal. A.G........ t.hp....time. ...t7f...... 'te.sting.....1ho, wQll.........was .....c.apab..).eQ Qf.......pr.Qduging...aro (a. .r .�h..an ..1 hr�:�........g�1.JQn.5 T�Pr. m.1..n.u1o_..f.Q.r....a......_f.Qur........h.Qur...p..p..r.iP..G�, thereby meeting both the FHA and MOA minimum requirements. The system was tested in accordance with MOA policy and regulations in force at the time of this test. NORTHERN TESTING LABORATORIES, INC. 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-277-0378 • FAX 274-9645 907-479-3775 •FAX 479-0547 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY CLIENT ❑ PUBLIC WATER SYSTEM I.D. # PRIVATE WATER SYSTEM NAME r/LY�� Mailing Address ^ / iwtl-1 __ A q City State Zip Code SAMPLE DATE: U � 1 � _/u Phone Mo. Day Year Purchase Order No. SAMPLE TYPE: [Routine ❑ Treated Water ❑ Special Purpose ❑ Check Sample (for original contaminated sample with lab reference no. Sample Time No. Location Collected 7 1 IL11 Ca,�i1tMi-y j Z,' J .�ti 2 3 4 5 6 7 8 9 10 Signature of Representative ❑ Untreated Water Collected by Laboratory Hof. No. ( Li'1i l Q/) Q/ n Lj. FOR LABORATORY USE ONLY GHAflCE PflEPAIa iflANSMITfAL SPECIAL INSiflUCT10NS MAIL TO 13E COMPLETED BY LABORATORY Received at: (; Anch. ❑ Fbks. Date Received IIn Time Received I V� Next Sample Due �— COMMENTS: SATISFACTORY ( s l UNSATISFACTORY U RESAMPLE R OTHER BACTERIA OB TOO NUMEROUS TNTC TO COUNT Direct Verification Coo- LSB Bell Final Result-Cn,,,ments ZZ)--— --f-- `�J}\� *No. of Total Coliform Colonies per 100 mis. Reported by Date NORTHERN TESTING LABORATORIES, INC. 2505 FAIRBANKS STREET ANCHORAGE. ALASKA 99503 907 277 8378 • FAX 274-9645 3330 INDUSTRIAL WAY FAIRBANKS. ALASKA 99701 907456-3116 • FAX 456-3125 Kniefel Engineering 8441 Miles Court Anchorage AK 99504 Attn: Robert Kniefel Our Lab #: A105103 Location/Project: - Your Sample ID: 1211 Contrary Sample Matrix: Water Comments: Method Parameter Units -------------------•------------------------------ EPA 300.0 Nitrate -N mg/l i Reported By: Francois Rodigari Anchorage operations Manager. Report Date: 09/21/90 Date Arrived: 09/14/90 Date Sampled: 09/14/90 Time Sampled: 1230 Collected By: Kniefel Flag Definitions U = Below Detection Limit DL Stated in Result B = Below Regulatory Min. H = Above Regulatory Max. E = Below Detection Limit Estimated Value Date Result: Flag Analyzed ------------------------------- 0.5 U 09/20/90 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND E=NVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 2614-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) / P, Location (address or directions) / (b) Applicant Name - /bit O 6LaLLt<- Telephone: Home Business _ Applicant Address _ t �o ���iv c(.cz FPO V6; --— (c) Applicant is (check one): Lending Institution ®; Owner/builder d Buyer El ; Other ® (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: 2. TYPE; OF RESIDENCE; Single- FamilyO Multi -Family D Other Number of Bedrooms _ Telephone 3. WATER SUPPLY Individual Well Community C] Public D Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite ❑ Publicr Community © Holding Tank ED Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) t� (66( [t< licac "1 5. ENGINEERING FIRM PROVIDINu 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 / Name of Firm ���- -�, =K�, -Telephone _—���, -- c��C q Address —�� G!'. "?�"� �lG/ Date OF A o° 7 TZ n o a fp 00gy4 '000 0000008^ b�000® B• •9x09 9bp° b c oo4 y C. Reid, NO. 7257•E ,94 ��.° Engineer's Seal OP�OFESSIO ,,e DHEP APPROVAL... .. Approved for bedrooms by f-` — jY ate Approved —_�T Disapproved --- — Conditional -- Terms of Conditional Approval CAUTION 4 The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) 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 requirements. Employees of DHEP 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. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAOR MUNICIPALITY OF ANCHORAGE (MOA) DEPT, OF HEALTH & HEALTH AUTHORITY APPROVAL (HAA) INVIRONMENTAL PROTLCTION CHECKLIST - FEBRUARY 1984 UCu 06 264-4720 Legal Descriptio -7n: A. WELL DATA Well Classification!" ll't r%u�e If A, B, C, D.E.C. Approved (Y/N) Z104 Well Log Presen(Y N) — Date Completed — 6r. --_7–P55_ _ Yield /5 �Pkrtl Total Depth —_ ( Cased to 'R// Depth of Grouting ti Static Water Level Casing Height Above Ground Electrical Wiring in Conduit(Y N) Separation Distances from Well: — Pump Set At Pmt°l6-"e`"� Sanitary Seal on Casin[ /N) _ Depression Around Wellhead (Y/c To Septic/Holding Tank on Lot ; On Adjoining Lots ��1�'��� To Nearest Edge of Absorption Field on Lot — t/ ; On Adjoining Lots 4/4- r To Nearest Public Sewer Line '�; T % To Nearest Public Sewer / Cleanout/Manhole Com% .4� 0 To Nearest Sewer Service Line on Lot _-426 — Water Sample Collected by rn vC ; Date (0 Water Sample Test Results cy- Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Size Air -tight Caps (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 To Water Main/Service Line Course _ Comments Page 1 of 2 72-026(11/84) No. of Compartments Foui Date I09t Pumped Cleanout(Y/N) for Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width 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 To Water Main/Service Line To Stream/Pond/Lake/o ajor Drainage Course _ To Driveway, Parki Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments 11cvf<? Type of System Design Length of Field Depth of Field Gravel Bed Thickne :S�ta�nipes Present(Y/N) of Last Adequacy Test To Property Line To Existing or Abandoned System on On Adjoining Lots To Cutbank (if present) /Access (Y/N) "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** 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. Signed {= Date —q-95 — Company f Et ,:; c_ MOA No. 's Receipt No. (q t OF Ak✓��Fj� Lq x� •.00a�O g�� h3f kI Date of Payment c�� �n 5 cry o C-2 An Amount: $ @� ;° e ,.: oo �3 Engineer's Seal f006B0000�• 0 �1 Page 2 of 2 72-026 (11/84) Ieroy Reid, dr.(�, No. 2251-F I