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HomeMy WebLinkAboutLAMPERT ESTATES BLK 2 LT 7 Municipality of Anchorage Page J' 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: .~'f,'J ~ ~ o'~'/iZ., PID Number: O,~i ,.-""/9 1 - lC'l~J~ ~'He:c. oocJ Wastewater System: [] New I~ Upgrade Address: P, o , 60~ &'7 ~ o~ CHu~,~ A~ ~ ABSORPTION FIELD No. of Bedrooms: ~Phone: ~ ~ ~ ~ ~ ~ Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRI PTI ON so, Rating: ~, ~ GPD/Sq. Ft. Total Depth fro~¢iginal grade: Lot: ~ Block: ~ ~ ~Subdiv~i°n: ~ Depth 1o pipe bottom~ original grade: Ft. Gravel depth~ibeneath pipe Ft. Township: Range: Section: Fill added above original grade: Gravel length: ~ -~ I '~ I ,~ Ft. ~q ~t. WELL: B New ~ Upgrade Gravelwidth: I Number of lines: Oistancebetweenlines: ~e~t~ ~ Ft. J ~ Ft. ~lassification (Private, A,B,C): Total Dep~ ~T~ Total absorption area: Pipe material: ~riller: ~/ Date Drilled: StaticWater Level: Installer: Date installed: Yie~ I Pump Set at: Casing Height Above Grou,d: TAN K ~ GPM I Ft. Ft. SEPARATION DISTANCES ~ Septic U Holding ~ S.T.E.P. TO Septic Absorption Lift Holding =ublio/Private Manufacturer: Capacity in gallons: From Tank Fie~d Station Tank Sewer Lines ~ ~ ~ ~ ~ K ~ O Material: Number of Compadments: Sudace Water lOOt+ ~¢omp ~ ~ ~ LIFT STATION Foundation ,~' 5, t* -- -- -- "Pump on" level at: ~~ I -igh water alarm at: Cu~ain Drain Remarks: BENCH MARK Location and Description: Assumed Elevation: I Co ,O Inspections performed by:s&8 ~UmU.~.IN6 Dates: 1st 2-A~-q~ ~ ~¢~ 17034 Eagle Eiver Loop ReaS, No. 2~ 2nd ~-~-~'3 ~,o~,~c. cow,, Department of Healt~¢nd ,H~man S~rvices approval "9 ~'"~ ?'. Reviewed and approved by: Date: ~ -2~'-~7 "'- <~' ...... 72-013 (Rev. 9/91)MOA 25 PEnMm' NO SW960372 PAOE 2 OF 2 HunicipeLiiy o-F Anchore9e DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICE8 D~VISION P,E]. Box 196650® Anchoro, ge, AI.o, sko, 99519-6650®Tetephone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LIneAL LOT 7, BLOCK 2, LAMPERT ESTATES S/D P.].m NO. 051--791-08 A B FCO 17,0' 26.5' ST1 27.0' 25.5' ST2 32.5' 25.0' DBL1 35.0' 25.5' DBL2 37.0' 26.5' FD 65,0' 56,5' C01 60.0' 62.5' C02 91.5' 96.0' MT1 95.0' 93.5' C03 98.5' 89.0' C04 75.0' 69,0' SCALE 1' = 40' NEW 1000 GAL. SEPTIC TANK EXISTING CRIB (E~,ACT LOCATION OF SIDEWALLS UNKNOWN) PLOW (FD) DRIVE ST2 &m co WATER LINEj MAINTAINED 10' HORIZ. DISTANCE FROM SEPTIC SYSTEM NEW C02 ST 1 ST2 F}NAL NEW 1000 GAL SEPTIC · TAN K 89.5 SCALE 1" = 40' MT CO C03 = 97.8Q C02 = 97.8" NO WATER FOUND 82,0' B.O.H. C03 = 92,5' C02 = 92.5' SW960572 2 2 Permit No. Page of Municipality of Anchorage 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 LOT 7, BLOCK 2, LAMPERT ESTATES S/D 051-791-08 Legal Description: PID No.: FCO 17 O' 26.5' ST1 27 O' 25.5' ST2 52 5' 25.0' DB_L1 ,35 O' 25.5' -DBL2 ~/ u; zo.o'_ EXIS]'ING CRIB~ FD 65 O' 56.5' C01 60 O' 62.5' ¢; ,,-,~.~,~,,,,.~.~_ ~ C02 88 O' 90.5' NEW 1000 GAL. ~,v~,.o,¢,v) \ NEW TR~NCFI MT1 82 5' 84.0' SEPTIC T~,NK CO5 75 O' 69.0' ~ ~ LOW DIVIDER\ I I N ~1 O ~'~~ ~1 ~ ~ ~ Li~/ ~1 m0 ST t ST2 ~- FINAL GRAD~ MT CO NEW ~- ~.. , .. ~.~ ~oo( CX~ ~ % / /,5~ ',, ' SNP' 10 8' ~ COl 9~.~' ~ / ~,~,~,ay COg 92,5' 4./ .~}~O N0 ~A'i'ER F0U ID ¢~"~,% CE-8801 82.0' B,O,H. ,~, ,, .,,' 72-013 A (Rev, 9/91) MOA 25 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE f~%'-r, __ 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:SW960372 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:BLESSE FREDERICK G & DOROTHY OWNER ADDRESS:22535 LAMPERT CIR CHUGIAK, ALASKA 99567 DATE ISSUED:12/03/96 EXPIRATION DATE:12/03/97 PARCEL ID:05179108 LEGAL DESCRIPTION: LAMPERT ESTATES BLK 2 LT 7 LOT SIZE: 19300 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 1 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD 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 (18AAC80) . 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: RECEIVED BY: ISSUED BY: DATE: DATE: ROBERT C. COWAN, RE. ROBERT A. SHAFER, RE. CIVIL ENGINEERS HEALTH AUTHORITY APPROVALS S~¢ER & WATER MAIN EXTENSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ONSIfE WASTEWATER DTSPOSAL SYSTEM DESIGN November 11, 1996 (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 7, Block 2, Lampert Estates Subdivision Request you issue of a permit to upgrade the septic system serving the proposed three bedroom house on the referenced property. A test hole was excavated and percolation test performed in the area of the proposed upgrade. The approximate location of the test hole is located on the attached site plan. At the time of excavation no water was after seven day ground water monitoring, tube was found to be dry. encountered and the monitoring Attached is the proposed upgrade design. This property is served by a Community Water System. We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/gk Enclosure MUNICIPALI rY OF ANCHOP, AGE ENVIRONMENTAL SERVICES DIVISION NOV IL i99(; 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 F 1" =4.0' 80ALE SITE PLAN mO O 10' UTIL. ESMT. LAMPERT PROPOSED $ BDRM HOUSE O~ <r~ CARPORT ~ ~zO DESIGN 7'__ ~> © 7t27 120 F ~o -<-<~ m~ z Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 ~ c~'" 0,(~ 2 3 4 7 $ 10 14- 16 17 18 19 2O i~Ayv~,,~T ~.,¢~T.ownship, Range, Section: SLOPE WAS GROUND WATER p.., ENCOUNTERED? S IF YES, AT WHAT DEPTH? E SITE PLAN Deplh l0 Water A~e,r., Monitoring? ~ ~'~'/ Dale: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~ ~.~ (m~nutesnnch~ PERC HOLE DIAMETER TEST RUN BETWEEN L~ FT AND '~ FT COMMENTS PERFORMED BY: 1~O.~,~. ~'a~j,~ R~vur Loop ~oa~ i~o. 2~/ : " CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCEWITH~I~y~A~X~GUIDELINESINEFFECTONTHISDATE. DATE: J l / { ~ / ~ ~, 72-008 (Rev. 4185) ROBERT C. COWAN, RE. ROBERTA. SHAFER, RE. HEALTH AUTHORI I%' APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER &WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELt. INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILIEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM DESIGN ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 REFERENCE: Lot 7, Block 2, Lampert Estates Subdivision November 8, 1996 GENERAL: The scope of this project includes the installation of a five foot wide drainfield to serve the proposed three bedroom residence on the referenced property. The existing septic tank is to be excavated to verify integrity. If the integrity is poor, the tank is to be pumped, crushed and abandoned; and replace with a new 1000 gallon septic tank. An adequacy test has been performed on the existing crib and will absorb more than 300 gallons per day. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wast·water Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from -the Municipal Health Department. ~EPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 Page Two Lot 7, Block 2, Lampert Estates Subdivision November 8, 1996 3e All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between 'the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (roughed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill· Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Page Three Lot 7, Block 2, Lampert Estates Subdivision November 8, 1996 Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when · the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIMUM MAT~:RIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in 'the Municipality of Anchorage: ~¥pe of Pipe Perforated Solid Cast Iron ASTM D3034 (PVC) ASTM FS10 (HDPE) ASTM D2662 (ABS) Yes Yes Yes Yes Yes No Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between 'the final leachfield grave], layer and the native soil backfill. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the %200 sieve. When sand is being used as a filter material, its gradation pec~flcatlons must conform to current M.O.A. or D.E.C. requirements. Page Four Lot 7, Block 2, Lampert Estates Subdivision November 8, 1996 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. Page Five Lot 7, Block 2, Lampert Estates Subdivision November 8, 1996 S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, 'techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER GRE/ ANCHORAGE AREA BOI;' ""'H Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION. SEPTIC TANK: DISTANCE FROM WELL 8/L. MANUFACTURER '-~¢~. MATERIAL INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH 5/~C¢ (~/.~ NUMBER OF COMPARTMENTS "')-- LIQUID CAPACITY /~0~--2] GALLONS. SEEPAGE PIT: NUMBER OF PITS / LINING MATERIAL ~___ BUILDING FOUNDATION ADDITIONAL ABSORPTION DIAMETER ~;~' / OR WIDTH 3¢f, LENGTH 2~),/' DEPTH CRIB SIZE: DIAMETER ~;::~ DEPTH ~ DISTANCE FROM: WELL NEAREST LOT L NE2?¢ TOTAL EFFECTIVE ..ABSORPT,ON AREA IWALL AREAl SQ. FT. WELL: ~r~/~fZ/4 ~ ~r TYPE BUILDING FOUNDATION CESSPOOL APPROVED .--CONSTRUCTION NEAREST LOT LINE OTHER SOURCES DISAPPROVED DEPTH DISTANCE FROM: NEAREST SEPTIC SEEPAGE SEWER LINE __ TANK , SYSTEM .. REMARKS DISTANCES: REMARKS: Form No. LQ-031 DIAGRAM OF SYSTEM T PEANOS,ZEO .C'L,T TO BESE.VED ...... ..... ' SOIL TEST RESULTS COMPLETION [)ATE ANTICIPATED , OTHER NOTE: 'rHIL~ PERt~IT I~ I',IOT %t/~LID ~,IITHOIJT ~X;:III. tEST FINAL It-IBPECTION~ lil4 HOUR NOTICE REQUIRED, BACKFILLING OF ANY ~¥,~TE~,'I WITHOUT FINAL. INI3PE~TIOH II~Y THE HEALTH DEPARTg~IENT AUTHOI~ITY WILL BE SUBJECT tO PRO~ECUTIOP~. SEPTIC TANK SIZE TYPE,~_~,~O~J~J~'~C'I~/~teSEEPAGE AnEA SIZE TYPE IMtlNIMUM DII~IT/%NCEI~, ~,~IiEQUIFtEI~IEI~ITS 5 ft. 'rANK TO SE[PAGE PIT WALL ~ 15 ft~ TO NEAREST LOT LINE. DRAIN FIELD __ /~('~ / WATER MAIN TO SEPTIC TANK . 10 ft. ALSO CONS,OE. AREA WELLS. SEEPAGE P,T 10_ f__t .... 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 PI'T' FITTED WITH AIRTIGt4T REMOVABLE CAPS. {~P. AVEL I]A~KFILL CONFOI:IM TO ~IOROUGH REGULATIONS REGARDING INSTALLATION. [ t on 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 APPROVAL FOR A SINGLE FAMILY EJWELLING Parcel I.D.# GENERAL INFORMATION Complete legal description Lot 7; Block 2; Lampert EStates Location (site address or directions) Lampert Circle Chugiak, AK Property ow'her i ·Finis Sheldon 'Mailing address :.?.0. Box 671087 Lending agency Mailing address. Agent Address ._ Day phone 688-3263 Chugiak, AK 99567 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank community on-site XXX NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. ~" XXX 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 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 complian(~e with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm s & s ENGINEERING Phone .' 17034 Eagle River Loop Road NO, Address ;;al.lie River, Alask~a,.~,~577 DHHS SIGNATURE Approved for -.~ ' bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments :~e Municip~,'iity of An'~horage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates'[~ased only upon the representations given in paragraph 5 above by an independent profeSSional engineer registered in the State of Alaska. Th.e 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) Back MOA#21 ~NVlRO~mr^g ~VlC~S Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES RECEIVE Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type Health Authority Approval Checklist Lo-r -'/~ I~,-~t..~. "2.~. L.~,~¢~r~l- ParcclI.D.: O~l- '"/'~'~ F----~-~r.; "A* If(;a~B, orC, attach ADEC letter, ADEC water system number 21 0~¢l'/ Log prcscut (Y/N) Date completed Total depth Cased to _ _ Casing height (a,~.~gmmrrff''~~ Sanitary seal (Y/N) ~'l)rotected (Y/N) ~- INSPECTION Date of test ~ ~ production g.p.m, g.P.m. WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: ~ Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~, - ~- q'l Tank size Foundation cleanout ,Date of Pumping ' '/~ g~ Pumper C. ABSORPTION FI~.]LD'DATA Ieee Nuinber of Compartments '7-- Cleanouts (~I). ~'%.q. Depression (Y~ ik) o High water alarm (Y/I~ ~ o Date installed "/"~-'/~t3~!~-ql S0il rating (~ or ft2podrm) O. (o System tyl, c Leugth 2o /Z* Width Gravelthickness below pipe ¢-'/$' Total depth 12 Effective absorption are}i ~28~0¢ Monitoring Tube present(~)_ ~¢5 Depression over field (Y~ g* Date of adequacy test q, ~1 - ~ Results ~Fail) ~ ~ For ~ 2 bedrooms Fluid depth in absorption field before test (in.); 0° hmnediately ~ter~oOgal. water added (iu.): ql~ Absorption rate = J<ao~4 If yes, give date I ~.Oe,~o~ Fhdd depth ~0~ (ins.) Minutes later: Peroxide treatment (past t2 mouths) g.p.d. mo Lllrr STATION Date installed Si~ ~ Manhole/Access (Y/N) "Pulgpqm""-]~l at* High water alarm level ~ *Datum "Pump ofF' lcvel at* SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: (""_.or4ff~ 0dl-ry Septic/holding tat~k ou lot : On adjaceut lots Absorption field on lot On adjacent lots Public sewer mare _ ~ sewer manbole/cleanout Se~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation I%t Property line .~o~ Absorption field Water mai~ffservicc line 10'4- Surface water/drainage 100% Wells on adjacent lots 'Z.moI + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ~.,~ q- Surface ~vater Jo o I & Curtain drain ~J o,4~- ~dooJ~ Water mailffservice line I o Driveway, parking/vehicle storage area Wells Oll adjacent lots '2oo iq. Property line F. ENGINEER'S CERTIFICATION .: ..... I certify that I have determined thru field inspections and re~ leu of 3/hmicipal records L~ ~e~:~ are ' ' , ' ~ ' ~ o. ........ , ?~t m coqJormance wRh MO/J HyL4 suiclelinex in qfJ~ct on this date. ~ ~.~' ' ' ... ~ b HAAFee $ 3~ t ~ Waiver FeeS Receipt Number ~ / ) ReceiptNumUer / Rev. 8/95 OSS: haa.wk.doc