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Home My WebLink AboutHERITAGE PARK BLK 1 LT 22 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 IP~H°NE .. I MAI LING ADDR;~S LOCATION /I ..~ ,' Well~ ' Absorption area IF HOMEMADE: Well Inside length Dwelling NO. OF BEDROOMS No, of compartments Liqui ~ep~h Foundation PERMIT NO. Manufacturer Material Liquid capacity in gallons DISTANCE TO: Length WeU/2 Lenqth of each/line Nearest Trench wfd.,~2~ ~.' ~ inches '"~¢-~ inches Tota %_~..gAo fill n e s Material beneath tile Depth Distan~F/~ lipes Total ~,~¢o~/ption area PERMIT NO. Type of crib ;rib diameter Crib depth Well Building foundation DISTANCE TO: Class Depth Driller PERMIT NO. Building foundation DISTANCE TO: Sewer line ITotal effective absorption area Nearest lot line Distance to lot line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOl L TEST RATING ' INSTALLER REMARKS APPROVED 72-013 {Rev. 3/78) DATE LEGAL PERMIT NO. DEF'RRTMENT ~_..,~HERLTH 8ND ENVIRONMENTRL Ym'OTECT!ON 825 ~L~ STREET., RNCHORRGE, RK. 99501 264-4728 ~2~-~--SITE ~..E~4EF: F"EJRhl Z T ( 8~0287 RF'PLICRNT LOCRTION LEGRL DEVCON ENT. INC. 54±i OLD SEWRRD HWY. LOT 22 BLK ± HERITRGE PERRK SU LOT SIZE 56±-±082 999999 SQLIRRE FEET TYPE OF SOIL RBSORPTION SYSTEM IS: TRENCH MR~IMUM NUMBER OF BEDROOMS SOIL RRTING (SQ FT?BR)= .85 THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS: THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRtNFIEL[). THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN 'THE SLIRFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTRLLRTION INSPECTIONS OF RNY WELLS RDJRCENT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. T~4C, (2) I ~-~$F'EE:TI £~-4'_~] R~:E ~:E~;~L~I ~:E[:, BRCKFILLING OF RNY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DiSTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS ±00 FEET FOR R PRIVRTE WELL OR ±50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PR!VRTE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MRY RF'PLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. t CERTIFY THRT · 1: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND HELLS RS SET FORTH BY THE MUNICIPFILITY OF RNCHORRGE. 2: I WiLL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. ~.:. I UN[.,E~]TRN[., THRT THE ON-=nITE L-nEWER SYSTEM WRY REQUIRE ENLRR]EMENT RESI[:,E~S REMCm[:,E~]~NCLUDE MORE THRN 3: E:E[:,ROOM~. RF'F'L IE~NT E:,~Z:ON ENT. I NC. IF 'THE V4. 0 k,,~../,, '~,.~/' ~[ SOl LS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESOR,PT,ON: I.. '2.- ? OUer-bo~er~ 1 3 ~ 4 7 8 12 13 15 ........ · ..... , '-'." ' 16 19 ~,'5 ,' ..~. 20 COMMENTS [] PERCOLATION TEST DATE PERFORMED: '~ --/ Z --~ SLOPE (~SITE PLA'N WAS GROUND WATER ~JO SL ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? ~OU FLT ~ AVl Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND __ FT CERTIFIED BY: ~,,.~_--~//',.-".--,~'~" DATE: 72-008 (6/79) ~ ComOct~ce Municipality of Anchorage' Development Services Department Building Safety Division on-site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak, us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 0 5"0-%:,,~1 {'".5"'0 GENERAL INFORMATION Complete legal description Location (site address or directions) /~7,=,.~ HAA# 0/.../L 0 ~-,,.~7 Expiration Date: ~ _ ,~ jr _ 0.5r''' Current Property owner(s) Mailing address Day phone Lending agency Mailing address Real Estate Agent Mailing Address Day phone Unless otherwise requested, HAA will be held by DSD for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Public Water System [] [] TYPE OF WASTEWATER DISPOSAL: Individual On-site [~ Individual Holding tank [] Community On-site [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority ApproVal (HAA)·based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year'with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. " 4. STATEMENT OF INSPECTION BY ENGINEER Se 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 Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater'disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Address ,/7~ Engineer's Printed Name~ DSD SIGNATURE J,,/ APproved for ~ Disapproved. Conditional approval for .. bedrooms, with the following stipulations: bedrooms. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow AdviSory X Maintenance Agreements 'Supplemental Engineer's Report Other Original certificate Date: (Rev. 01/02) Municipality of AnchOrage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O.' Box 196650 Anchorage, AK 99519-6650 r~ .www.ci.anchorage.ak.us (907) 343-7904 ! i HEALTH AUTHORITY APPROVAL CHECKLIST Legall~,iscriplion://'/~-~(~'~C~' /~-/~/'~';/'°'r"~'~-,~ ~z0~~ [~ Welltype ~; ~lfA, B, orCprovidePWSID~ , ~ '. ;/WelIL6 'i ' " " ' / ..... , . ,- , / .... I, Date c6~pleied ' '-.' Sang, seal (YIN) ~ : ' es properyr (~iN ' .,; ',~ ., .: /~": .: ..,, : , Totald?th ': .ft. . ~asedt0 '. ft. : '~ ,;asingheight(~l 9reground) , in. . ,, · , . . ..~ / :~ , .,.. ,, ., FRO~ELLLO~ . ': '..';..-:., . ' 'AT INSPECTION ~ ./ '-~ ' Dateof, test'~ - ' ,'" .: . /: ;?'" ; · . ~l: - . ,, . ' . -. r S~ , ,. ~ - Stabc.,,water, level~.,.z~ / ::~' - ~-: ~. ~./// ~.I': ',. __: - .... ~,:., ft,. ? I ~ ' '' , ' Well production '/ ::' :_ :z g ~. ' '' ' r ~ , : ' '; ' m ' Coliform', /~ Colonies/10~l. i' - rog.Il. ,: :',. Other ~ ' colonies/100 mi. Arsenic:/ ~ .m~l. ~ ~ . ~ Sampe: , i~ .C( I 1 SEPTIC/HOLDING .TANK DATA ~'. Tank ~ype/Materia~fC~4C~ Date installed ~/~3 ' ........ Tank size [Q6o,.,~g~l:~ '7,,?;~ Number of Compadments ~ ~ ~'~ C eanOuts (Y/N),: ~ Foundatio~'C~eanodl~(Y/N) ~,'~; DepreSsion over tank (Y/N) '~i:~: H gh water ~ a~m (YIN) Date of pumping ~/~'1~0 ~ :,;t. Pumper 4 '; ,' - - ' ' r - ' '',, , ::' ~' ABSORPTION FIE~D DATA ::''; "' ' ~ ~ :'~ ~' : '.", . ' [ ~ ,~-".~ : · ' ~: ~ · ~ I': Date ,nst~,ed,///!~/~ ?So,¢at,~g (g.p.d./~' o~ ft%d~m) ~: System type ~g ~' :~' ~'~.':~,5 ..... '"L~,?:'~ ': ~,, :: ~ ~' t. pipe: Length '.,~ ~ -fl.:.' ,;,~ - - Wdth - ~, fl.' Gravel below . ~ ft. ; '~ ' ' ' · ' ' 2 ,'lz,' . ,:. ' . Totaldepth ,~.f$. Eff..absorpt,onarea~C~ ft Mon,tor,ngtube- .~ Depression over field Date of;adequacy/est /. ~ ' :: ResUlts (Pass/Fail) ::~' ~ ~ For ~ bedrooms Fluid depth in absorption field before test ~ imr Wate~ added ~ga "i ~ .... New depth ~O in. ..... . . ~ Q ' . . . 4; . ] ,: .'.ElapsedT~me~QJm~n. - Final fluid de pth ~ in .l ' ' AbsorPt on rate >~ ~0 ~ ODd ,,"~: 'i:Any rejuvenatian treatment (past 12 mo.) (YIN & type) ; ~~ ':~ Ify s 'give date D. LIFT STATION Date installed / "Pump on" level at, TL_ in. Datum / ~ SEPARATION DISTANCES Size in gallons "Pump off' level at Cycles tested .,/ Manhole/Access (Y/N) -,/' ~ r ~i~eht :~i~ rm a~a~:i ~v~ nt s ? SEPARATION DISTANCES FROM,WELL ON LOT TO:" Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer/septic se~ne _ , SEPARATION, DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main Water service line ,/0 Wells on adjacent lots ~///'/~ · SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /(~' ~ Building foundation //0 ~' Water Service line /0 ~'''- Surface water //d O Curtain drain ,xJ//',,~' ~ · Wells on adjacent lots F. COMMENTS Water main /4) '* Driveway, parking/vehicle storage conformance with MOA HAA guidehnes in effect on this date.' Engineer's Pr in ted Name Date HAA Fee $ Date of Payment Receipt Number (Rev. 12/01) Date of Payment Receipt Number ASBUILT o~,wzu~u ~ a.~bUUlA'l'~:S LAND SURVEYING 694-08 I HEREBY CERTIFY .THAT I HAVE SURVEYED THE SC~E: FOLLOWING DESCRIBED' PROPERTY: /~-~' ~~' AND ~AT NO EN~OACHMENTS EXIST.~CE~ AS ~~ ~ .' ~_ ...~ INDICA~D. IT IS THE RES~NSIBILI~ OF THE - * : 4~~ "~ ~ ~ OWN~ TO D~ER~INE THE EXISTENCE OF ANY GRID: '"':'~ ....... ~~ WHICH DO NOT ~PEAR ON THE RE~D~ ~BDI- VISION PLAT. UNDER NO CIRCUMSTANCES S~ FB: ~f~", [S-59~8 ~ ."~ ~Y DATA H~EON BE USED FOE CONSTRUCTION ~~ ~t7%~.'.. .."%~ OF FENCE LINES, OR FOR EST~LISHIN~ ~ND' DRAWN~ '%?~~' ARY LINES, Parcel I.D. # 1. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Servicbs Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING O6o-- ;2. ll- 5'0 ~,C PALITY OF ANCHORAGE :MENTAL SFP, VICES DIV SiON AUG 0 4 1997 , ECEIVED GENERAL INFORMATION ComPlete legal description Location (site address or directions)' Property owner Mailing address Lending agency Mailing address Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water Day phone 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 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. . Name of Firm . Phone Address I Engineer's signature Date . DHHS SIGNATURE Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 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~)25 (Rev. 1/91} 8ack MOA #21 Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (WN) · · · ,~C~?AL~'['~ OF ANCHOR Mun,c,pahty of Anchorage ~u~t _.. s~v~c~s ~ DEPARTMENT OF HEALTH &' HUMAN SERVIC~'~.O~'~'~'' ,(~ Environmental Services Division ~G 0 ~ ~99 ~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343z~744 Health Authority Approval Checklist ~ ~ C ~ ~ ~ ~9 If A, B, or G, attach ~DEG lottOr. ~D[O wator systom numbar Date completed Cased to FROM WELL LOG g.P:m. Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Date of test Static water level Well production WATER SAMPLE RESULTS: g.p.m. Coliform Nitrate Other bacteria Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed Ill~'/~'~ Tank size Foundation cleanout (Y/N) "/ Date of Pumping ~'///~"7 C. ABSORPTION FIELD DATA Date installed t'1'~' 1~'~ Length ~. ~ ~ Width 3 Effective absorption area ~- (,, ~/ Date of adequacy test 7'z ~/'~ '~ Collected by: Depression (Y/N) Pumper Number of Comaartments ~ Cleanouts (Y/N) ~/ High water alarm (Y/N) l~l Soil rating (~.~J~,,~d./..~-or fF/bdrm) Gravel thickness below pipe Monitoring Tube present (Y/N) ~/ Results (Pass/Fail) '~ Immediately after ~;,O0 gal. water added (in.): Absorption rate = ~ ~'~2 g.P.d. If yes, give date Fluid depth in absorption field before test (in.); Fluid depth .~ ~" (ins) Minutes later: ~O Peroxide treatment (past 12 months) (Y/N) 5' System type ~',4,z,~/ ~,! Total depth /~' Depression over field (Y/N) For ~ bedrooms 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* Cycles tested *Datum SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer/septic service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation /--/--'~ / ' Property line ~, 1 ~ Water main/service line ~' ,,2~~ Sudace water/drainage t-4 I o SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ?/o Building foundation & ~ Surface water /'~ lo Curtain drain J'~ [0 Absorption' field ~ Wells on adjacent lots Water main/service line ~' ,,~ ' Driveway, parking/vehicle storage area Wells on adjacent lots ~l//~r ENGINEER'S CERTIFICATION I certi~/that I have determined thru field inspections and review of Municipal records that the above ~ystems are in conformance with MOA HAA guidefines in effect on this date, Signature ~-"- ~ Engineer's Name I ~ ~ ~ ,' ~.Lo. ~,, l~ HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DMSION OF EN%qRONMENTAL HEALTH 1. General Information Application Date (a) Legal Description~(include lot, blDck, subdj~isign, section, township, range) / Locat io~/6~ddm~ s~ or . f- y~-L' ~' directions) ® (b) Applicants Name Applicants Address ~¢/~ ~/~ / (c) Applic~ant~is (check or~) Lending Institution ~; C~ner/builde~; Buye~ ~ ; Othe~ ~ t (explain); (d) Lending Institution (e) Address Telephone Real Estate CO. & Agent Type of Residence S ingle-Family~ Number of Bedrooms Multi-Family Other (describe) Water Supply Individual Well ~-~ Co,m.,ni ty~ Public ~~ Note: If c~t~'~nity w~ll system, must have written confirmation frcm the State Depa=~m~nt of Envirop~rental Conservation attesting to the legalit~ and status. Is the ~11 adequate fo_~ the number of bedrooms specified in this HAA (Y/N) Sewage Disposal Onsite~ Public ~--~ Community ~-~ Holding Tar~ ~ Is the wastewater disposal system adequate f~ the number of k~drocms (Y/N) [Page 1 of 2] 2-15-84 5. ~ngineering FiL~m Providing Inspections, Tests,I Data and Information I certify that L,~l~-~hecked~ verified, or conformsd to all biOA HAA Guidelines in effect on the/d~te Signed 6. DHEP Approval Approved fo~ Approved ~ (ENGINEER SEAL) bedrooms- Disapproved ~ Tea~-t-~ of Conditional Approval The Municipality of Anchorage Department of Health and Environn~ntal Protection dces not guarantee the continued satisfactory ~erformance of the water supply and/or the wastewater disposal system. This approval indicates that, as of the validation date shown above, based on the data and information furnished by an engineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func- tional for the number of bedrccms and type of str. uctu~e indicate.d. (EttEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] 2-15-84 ae MUNICIPALITY OF k.~,, '%~.2 [;.:PT. OF HEALTH & M~CIP~I~ OF ~C~GE (MOA) Date ~leted Yield ~pth of G~outin~ ~ ~t At Sanit~'~al on ~sing (Y~) Elec~ical ~ing in ~n~it (Y~) ~- .... ~, ~ssion._. ~ound ~l~ead (Y~) Well Classification ~i-I~.L~ P~esent (Y/N) Total De'~'"~-. Cased to Static ~ater Level "*_~ Casing Height Above Ground ........ , Separation Distances f~cm Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption F.ie-i~ To Nearest Public Sewe~..~Li?~b C leanout/Manhole/ ..... Water Sampl~p.--C~ilected By Wate~/Sa~le Test Results -~nts · ..... , bn~Adjoining Lots on Lot , On ~.oining Lots To Nearest ~'~l.b ~..q~seWer To Nearest Sewer Service Line oh~-~ot ; Date ~'~-~. SEPTIC/~I~ TANK DATA Date Installed //h~/~ ~ Size /~) ~) ~ No. of CQt~atctments ~ Standpi~s ~. ~. Air-tight Caps~~ F~ndation Clean~t ~ ~ession ove~ Ta~ (~) Date ~st P~d ~'-~ L~ P~ing~intenan~ ~n~a~ ~ File (Y~ ; fo~' ~ Holding Ta~ High-Wate~ ~a~ (Y~) ~" Te~a~ Holdi~ Tank ~t (Y~) /' ~p~ation Distan~s ~ ~pt~c~olding Ta~: ~~ To Water-Supply ~ 11 ~/~/U ~ ~ ._ To ~ilding F~ndation · To ~o~ty Li~ /~ To Dis~sal Field_ q~ / To ~ter Main/~vi~ Li~ ~~: TO S~e~, ~nd~ ~e, ~ ~jo~ Draina~ ~/~ Couzr se __ / [Page 1 of 2] 2-15=84 C. ABSORPTION FIELD DATA Soils Rating in Absorntion Strata Date Installed /~//~ )~ ~/~ Width of Field ~.'~ 6 // Square Feet of Absorption A~ea Depression over Field ~ Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes i~esent ~) Date of Last Ad~=quacy Test Separation Distance from Absorption Field: / To Water-Supply Wall ~//6z~' ~/ To P~operty Line /~ f To Building Foun~tion /~ ~ / To Existing or ~ndo~d System Lot ~~ ; ~ Adjoining ~ts ~'} 7~ TO Wate~ Main/~vi~ Line ~ ~7~/~ To ~t~( if pre~nt) To St~e~ond~ke/~ Majo~ ~aina~ C~se To ~iveway, Pa~king ~ea, o~ Vehicle St~a~ ~ea D. LIFT STATION Date Installed Size in Gallons "Pump O~" Level at High Water Alarm Level at Tested fo~ Electrical Codes(Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles duming Adequacy Test. Meets MOA Coitm~nts ** Check Permitted Becl~oom Rating A~aihst HAA Rmquest I certify that~'~I~ave checked, verified, o~ conformed to all MOA HAA Guidelines in effect on the date""of p~~%ion.~t [ Comp~n~ z/ _~ . MOA No. ~. [Page 2 of 2] ~ '~i~'!~'~!~i',' '~' ~ ' '~ 2-15-84