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HomeMy WebLinkAboutBROADWATER HEIGHTS TR D BLK 1 LT 18 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: SW 930463 PIDNumber: 05013133 Name: Chuck Knecht/ Susan A. Dunn Wastewater System: r~ New [] Upgrade Address: P.O.Box 770997 ABSORPTION FIELD Phone: 696 - 4633 I NO. of Bedrooms: 3 [] Deep Trench ~Shallow Trench [] Bed [] Mound [] Other I LEGAL DESCRIPTION sci, Rating: 1.2 Total Depth_from_o. riginalb.b, grade'. GPD/Sq. Ft. Lot: .1. 8 B~ck: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe Broadwater Hts. 3 . 5 Ft. 2 . 0 Ft. Township: I Range: I Section: Fill added above o(~iginal g rede: Gravel leng~ 14N 2W i Ft. Ft. WELL: [] New [] U pg rede Gravel width: 5 ..... Ft. Numberlof lines:,I DistanceNAbetween lines:Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Ft. Ft. 5 1 5 SQ. Ft. PVC Driller: Date Drilled: Static Water Level: Installer:E S k imo Se rv. Date installed: 5 -- 2 0 - 9 4 Ft. Yield: GPM I Pump Set at: Ft. I Casing Height Above Ground:Ft. TANK i i SEPARATION DISTANCES [] Septic [] Holding {~:S.T.E,P. To Septic. Absorption Lift Holding ~ublic/Private Manufacturer: Anchor age Capacity in~l~(~:. From Tank Field Station Tank Sewer Lines Well- , , , , , Material: Stee 1 Number of Compartments: 2 Surface Water 4 '+ 4 '+ 4 '+ NA NA LIFT STATION Lot Size in gallons: I Manufacturer: Line 10'+ 6' 10'+ NA NA 161I O.R.E.N.C.O. Foundation 1 0 ' + 10 r + NA NA NA "Pump on" level at: I "Pump off" level at: High water alarm at: 44', 4fl~ 45" Curtain Pump Make & Model Electrical Inspections performed by: Drain NA NA NA NA NA ~.0osi05hh Vic Menichetti #107484 Remarks: * Served by Community Water BENCH MARK Location and Description: Top of Rebar N.W. Corner Lotl8, Blk 1 I Assumed 3 00 Elevation,:0 ~ ENGINEER'S SEAL Inspections performed by: Sr±c ?, Yug'les~ad Dates: 1st 5-12-94 2nd 5-20-94 ...... ': Department of Health~rRd... ____H rvices approval 72-013 (Rev. 9/91) MOA 25 Permit No. SW 930463 Page 2 of 3 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 Legal Description: L18r Bi, BROADWATER HE;IGHTs PIDNo.: 05013133 t~I~ O JE C T BENCttMAt~I( ~ TOP REBAR, NORTHWEST CORNER LOT 18 LOT 1 1 ASSUMED ELEV. = lOJ. O ~ (VACANT,) CONT. INT. = 2' ANCHORAGE TANK~ 5' WIDE X 2' DEEP X .55' LONG 1250 GAL. SHALLOW TRENCH LOT 19 LIFT TANK SYSTEM S.A.S (VACANT) c/o (TYP) ALTERNATE SYSTEM, TANK 7' CLR. TO BE REL OCA TED_REPLACED__%/ CAPPED MONITOR TUBE S;A,.,q. '.GRAVEL ROAD ~I AD~ ~EPTIC SWING T DETAIL LOT 18 29, J44 10' UTILITY EASEMENT N 87°48,30" 72-O13 A (2/91) MOA 25 Permit No. $~g 930463 3 3 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 Legal Description: Al8, B1, Broadwater Heights PID No.: 05013133 /~-- CAPPED CLEANOUTS (TYP) / / THREADED CAP BURIED I' ~ CAPPED MONITOR/-'-WI~~5 X 30" REBAR GUARD ~ ~ TUBE-----:7 / c~ ' / l ~ ToP OF nLL PIPING I ~ 1/2"T0 2 1/2"/ I I DIA SEWER ROCK~ ' · ~ ~ ~ WATER ............ NEW 1250 GAL. LI~ PIPE ELEVATIONS SHOWN ARE --' ~" TANK SYSTEM TO TOP OF PIPE 17 HOLES (I/4" DIA) ~ 36" O/C (HOLES UP) W/ FLOW DISPERSERS. INSTALL LEVEL THREADED CAP BURIED 1'NI----' /r-- I 1/4" DIA. PERF. PIPE (TYP) 11/4" DiA. SOUD W/ ,5X$0" REBAR GAURD / /' (HOLES UP) PVC PIPING--~ ~ ~/ INSTALL LEVEL ,- 55' ~ ...... ,,t~-- 'i:..~, r- ~ ~" ~ - - '-.'~,- :,., - ~ ~ -: - .--- ANCHORAGE TANK 1250 GAL. [ L".'-: ,~* '::~"",.',.':'..'-.. "'"'. .;_.L~.~zJ LIMITS OF SYSTEM ................ ~ EXC, LIFT TANK OR (SOL,D). ~,~.~ CAPPED CLEAN-~ 72-O13 A (2/91) MOA 25 Rick Mystrom, Mayor Municipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 July 28, 1995 Howard C. Holtan, P.E. U.S.K.H. 2515 "A" Street Anchorage, AK 99503 Dear M_~~: I have enclosed a copy of the As-Built Inspection Report for L 18, B 1, Broadwater Heights Tract D. In reviewing pages 2 and 3, you will note that many of the dimensions and notes on the drawings are of such small scale and poor clarity that they are not legible. This problem will compound if these drawings are microfilmed and then used by the public on the microfiche machine. Please resubmit pages 2 and 3 with larger font sizes and clearer dimensions so as to be easily read by the general public. Thank you for you prompt attention to this matter. Sincerely, Program Manager On-Site Water Quality MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF 1 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930463 ~VIf~ ~>~/~%/: DESIGN ENGINEER:ACUMETRIX CORPORATION OWNER NAME:DUNN SUSAN A OWNER ADDRESS:il627 BIRCH HILLS DR EAGLE RIVER, ALASKA 99577 DATE ISSUED:ll/02/93- EXPIRATION DATE:il/02/94 PARCEL ID:05013133 LEGAL DESCRIPTION: BROADWATER HEIGHTS TR 1 LT 18 D BLK LOT SIZE: 29344 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: THIS PERMIT IS FOR THE CONTRUCTION 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 (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 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: MAXIMUM TRENCH SHALL BE 7.5 FEET FROM T~ ORIGINAL GROUND DEPTH OF THE BOTTOM OF THE PROPOSED ABSORPTION SURFACE. ~unicipaJit¥ Human serg~ces Dept. Health & April 13, 1994 Municipality of Anchorage Department of Health and Human Services Box 196650 Anchorage, Alaska 99519-6650 Subj: Revised Septic Design Permit No. SW30463 Lot 18, Blk 1, Tr. D, Broadwater Heights Subdivision Attn: Daniel J. Roth/Robbie Robinson Gentlemen, Find enclosed revised site and section plans for the subject project. Per your on-site inspection of April 12, these plans show a 5 foot wide by 2 foot deep by 55 foot long "Shallow Trench" Soil Absorption System. A 500 gal. lift station has been added "down stream" from the septic tank to allow for even distribution of the effluent into the S.A.S. A waiver for minimum separation distance from lot lines is hereby requested. The purpose of this waiver is to allow for maximum utilization of the level terrain at the upper (eastern) edge of the property. Inspection of the adjacent lots indicated that the terrain consisted of slopes less than 25% for the majority of the properties. Therefore, this waiver will have no undo effect of the placement of any future new or alternative systems on these lots. ~ubmitted, an, PE Enclosures Howard C. Hol an, P.E. 4900 Palmer. Wasilla-Fiigttway - Suite 3 Wasiila, Alaska 99654 October 16, 1993 Municipality of Anchorage Department of Health & Human Services Environmental Health-On-Site Services 825 L Street, #502 Anchorage, Alaska 99501 Reft New On-Site Wastewater System - Lot 18, Block 1, Broadwater Heights Subdivision Gentlemen: This letter is to request approval of the design of a new on-site wastewater disposal system proposed on the referenced property. The system has been designed for a 4- bedroom, single-family dwelling in accordance with Municipality of Anchorage Wastewater Regulations. Please find attached a copy of the system plans and soils percolation tests results. The property is served by an approved community water system. Please call if you have any questions or you require additional information. Sincerely, _~ Hbward C, Holtan, P.E. CE-3063 attachments: PROPOSED 3 BED. RECEIVED APR 1 3 1994 __ unmipah[y o'1 A, tchorag~ ~ept. Health & Human Servi~es~ GRAVEL ROAD PR OJEC T BENCHMARK CORNER LOT 18 ASSUMED ELEV. = 1 0,5.0 CONT. INT. = 2' LOT 19 (VACANT) ALTERNATIVE SYSTEM, TANK TO BE RELOCATED/REPLACED 1250 GAL, SEPTIC TANK cio (T~P) RECEIVED LOT I I APR 1 3 1994. (VACANT)_ Municipality oi Anchorage Dept, Health & H. uman Services 5' WIDE X 2' DEEP X 55' LONG SHALLOW TRENCH S.A.S. -- 500 GA. "QRENCO" MODEL A-I LIFr STATION OR EQUAL E,.¥1E~. G2rMDE (rfP) CAPPED MONITOR TUBE 103.3 3 BED- ROOM ~u.,3130.3 \ ..... : . %-~.~,:~...-',~ .... ,..*. ,~6.,, .iL"".'.'.'.'i ~...' \ .'1.7 w.v. N 87'48%t0" ADJ. SEPTIC 240 + LOT 12 ....... ..... ( 29,54'4 ~. " "',, 254. 10' UTILITY EASEMENT L (~ T I S~'PTIC NOTE.' THIS LOT SERVED BY CITY WATER NOTE: SCALE: 1" = 50' SHT I O? 2 ALL BEARINGS AND DISTANCES SHOWN ARE RECORD, UNLESS NOTED OTHERWISE. LOT: BLOCK: SUBDIVISION: ~N OA D ~¢:A TE~*~ HEIGHTS PERMIT NO. SW 9,ZO46Z 27-'_7-C' ~z:~LM ~ (MUNICIPALITY OF ANCHOa~A GE) 4-900 PALMER-WASILLA HWY., SUITE 5 WASILLA, AK 99654 (907) 376-8~00 FAX (907) .376-9629 )ATE: 4/12/94 SCALE: NOTED dOB NUMBER: 95-07.09 DRAWN: DESIGN BY: CHECKED: rs t4 ~5 '%0 ~,' I9 · ' ";:'.:2'_-~.-.7 .......... ,' 2 ....... z,J ArIFC qf~lCf~lir?o.~ It? ~f~,c..f 0~? ~ltis d~ltC, I.)AfF; CORPORA Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 7'/~'. /"~ 1 2 3 4 10 11 12 13 14 15 16 17 18 19 2O ·, ~:,~ DATE PERFORMED. .,- , .~ _ -~/ COMMENTS /L/a ¢/_- ~2 d.$ Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT L O~ DEPTH? /y~- p E Depth to Water Monitoring? J.~,,.~ FEE.~ Date: SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop 1o" ;~-~T-?~i ~.oo ~o / 5" ~_,. ..... - ~- z~--. ~'~1 ~-~o z - -- /o~ o~-z ~'-- ?~ I ~':' .~ 2_ 3~ /5'" 5" PERCOLATION RATE ~ (m~nutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~// FT AND ~ ET ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES tN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) CERTIFY THAT~IIS ~ST WAS PERFORMED IN DATE'. ~--'~/~'/'~' / / PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST ~:"o I ~ ~ Howard DATE PERFORMED: LEGAL DESCRIPTION: 1 2 3 4 6 7 8 9 10 11 12 Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTER ED? S IF YES, AT WHAT DEPTH? // p E Depth lo Water After Monitoring? tJ,O F"W Date: SITE PLAN 13 14 15 16 17 18 19 2O ~z,4 y COMMENTS -r//-~¢~- ~/~/~ C4/~ Reading Date Gross Net Depth to Net Time Time Water Drop ?" 8'--z~-?~ ~,':~-o :~' / -~" '7' - ~'- z ~- %,'~'zo ~ - ~., ~..e~3 ~:~ ~o ;3 - ~,, PERCOLATION RATE TEST RUN BETWEEN · '~' ~ (minutes/~nch) PERC HOLE DIAMETER ¢ FT AND ~ FT PERFORMED BY: ~:)(~'~t~-/)"~?4~'://''~'~-. I ~ --~'/f~ CERTIFY THAT TH~TES~/WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: //~//~.//9= / 72-008 (Rev. 4/85) -FOP REBAR, NORTHWEST r~k'],u,.~ipality of Anchorage CORNER LOT 18 Dept. He~a'"l~"~ ~uman 8ervicea ASSUMED ELEV. = 10~ LOT I I (VACANT) LOT 19 (VACANT) l~E/,~ (C~_y%P)ED (I 1 IN BED) I ~ 0 . ' ' ~'/ ;'.v. N 87048'3©. txx ' , uo.~7 THIS LOT SERVED BY CI~ WATER SCALE: ~" = 50' NOTE: ~r ~ o~' 2 ALL BEARINGS AND DISTANCES SHOWN ARE RECORD, UNLESS NOTED OTHERWISE. LOT: BLOCK: SUBDIVISION: Z~R OAD ~A TER ~rEI'G~rTE T/ON ~ 4900 PALMER-WASILLA HWY., SUITE .3 WASILLA, AK 99654 (907) 37B-BBOO FAX (907) `376-9629 APPD: DATE: JOb NUMBER: DESIGN BY: 95-07.09 CHECKED: TIC ?LA (MUNICIPALITY OF ANCHO. HA G'E) SCALE: NOTED DRAWN: epf RECEIVED NOV ;~ 9 199;) MunicU:~ality o! Anchorage Dept. Health & Human Services NEW $ BEO. HOUSE LOT 19 (VACANT.) 50' 'HOUSE " '"'LOT 1',3 TEST HOLE ~2"'"~ '" l'lOiOZ $ WA TE R VALVE O' UTILITY EASEMENT 8 7o48'50" W LOT 1 7 '"b MIT * 120.69 LOT I 1 (VACANT) ADJ. SEPTIC --200' · * 126,2B 254.65 LOT 12 \ \ \ \ ADJ. SEPTIC PLA N NOTE.' THIS LOT TO BE SERVED BY CITY WATER. SCALE: 1" = 50' NOTE: 5W? ! Of' 2 ALL BEARINGS AND DISTANCES SHOWN ARE RECORD, UNLESS NOTED OTHERWISE. LOT: BLOCK: SUBDIVISION: BROAD WA TER HE£GHT~_~ 4900 PALMER-WASILLA HWY., SUITE 5 WASILLA, Al( 99654- (907) 576-8800 FAX (907) 576-9629 APPD: DATE: dOB NUMBER: DESIGN BY: 93-07.09 R.M. CHECKED: ~£P ?lC £LM ~V- ('MUNICIPALITY OF ANCHO~ GE) SCALE: NOTED DRAWN: epf Tom Fink, Mayor Ntuni pality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 April 14, 1994 Howard Holtan, P.E. Acumetrix 4900 Palmer-Wasilla Highway Suite 3 Wasilla, Alaska 99654 Subject: Waiver Request for Lot 18 Block 1 Tract D Broadwater Heights Waiver Request #WR940017, PID #050-131-33, SW930463 Dear Mr. Holtan: Your request for waiver of the required 10 foot separation between a septic system and a lot line has been approved. waived distance is 5 feet. The This approval applies to the existing septic system lot line separation only. Any future upgrade to the septic system will require all separations be met or another approval from this department. Cincerely, ~ Civil Engineer On-site Services ljw~7 MUNICiPAL!TY 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 Parcel I.D. # 050-131-33 HAA# HA940074 1. GENERAL INFORMATION Complete legal description Lot 18 Block 1 Broadwater Heiqhts Tract D Location (site address or directions) 11627 Birch Hills Drive Property owner Mailing address Lending agency Mailing address Agent Address Chuck Knecht Day phone 242-8490 (Mobile) Day phone Day phone , Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: ,1 Four (4) NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer Individual well Community well ..,.,,,,,~ [~[~/,,, ,,,,, , ,,~....,,, ..'. Public water xxxxxx ,~,:,, .,,. If community well system, provide written confirmation fror~,:~'tate A~EG'bttest~-', ing to the legality and status of system. XXXXXXX ' ~<~ "(~ ~'' 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. Name of Firm Acumetrix Corporation Phone 376-8800 Address 4900 Palmer-Wasilla Highway, Suite 3 Wasilla, Alaska 99654 Engineer's signature Date Howard C. Holtan, P.E. The orignial Certificate has been lost or misplaced. This is a reconstruction of the~, Certificate by the On-site Services Program to assist the property owner(s). If there are any questions, please call our office at 343-4744. DHHS SIGNATURE xxxx Approved for four (4) Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: 'Additional Comments Date November 3, 1995 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. 72-025 (Rev. 1/91) Back MOA ~21 Legal Description: Lot WELL DATA This Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICR~ C E IV E D Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 34:~t 2 1995 Municipa ity of Anchorage Dept. Health & Human Services Health Authority Approval Checklist 18, Blk 1, Broadwater Htq~arcell. D.:05013133 Lot Served By Public Water System If A. B. or C. attach ADEC letter. ADEC water system number Date completed Cased to FROM WELL LOG g.p.m Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Nitrate Other bacteria Date installed 5/20/94 Tanksize 1250 Foundation cleanout (Y/N) YES Date of Pumping N/A ABSORPTION FIELD DATA 5 ,/~0 / 9 5 Date installed Length 5 5 ' Width Effective absorption area 515 Date of adequacy test N/A Fluid depth in absorption field before test (in.); Fluid depth (ins.) Minutes later: Peroxide treatment (past 12 months) (Y/N) g.p.m. Collected by: Number of Compartments 2 Cleanouts (Y/N) YE S Depression (Y/N) NO High water alarm (Y/N) YES Pumper N/A Soilrating (g.p.d./ft:orft2/bdrm) 1.2 Systemtype Shallow Trench 5 ' Gravel thickness below pipe 2 ' Total depth 5.5 ' sq. fl~lonitoring Tube present(Y/N)YES Depression over field (Y/N) YES Results (Pass/Fail) For bedrooms Immediately after gal. water added (in.): Absorption rate = . g.p.d. If yes, give date D. LIFt STATION Date installed 5/20/95 Yes Manhole/Access (Y/N) High water alarm level at* 45" Cycles tested E. SEPARATION DISTANCES Size in gallons 40" "Pump on" level at* 161 "Pump off' level at* *Damm Date of Payment Receipt Number Rev. 8/95 eSS: haa.wk.doc Date of Payment Receipt Number I certify that I have determined thru field inspections and review of Municipal recor~,'~ ~s. ysterns are in conformance with/'iC~A JfAA guideli~in effect on this date. : . __ Engineer'sName..How~rd C. Holtan/ CE-3063 Date / O/~.~O/~' c" ............................................................................................... la .~2;..A~. ~Aq.,, ~:.,%,~%.%k.f t, ........... HAA Fee $ Waiver Fee $ Water main/service line 2 5 ' + Driveway, parking/vehicle storage area 10 ' + Wells on adjacent lots N/A Property line Building foundation 10 ' + Surface water 100 ' + Curtain drain N/A ENGINEER'S CERTIFICATION 10'+ SEPARATION DISTANCES FROM WELL ON LOT TO: This lot on Public Water system 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: Building foundation 10 ' + Property line 10 ' + Absorption field 10 ' + Water main/service line 2 5 ' + Surface water/drainage 10 0 '-+ Wells on adjacent lots 100 ' + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: