The URL can be used to link to this page

Home My WebLink AboutSOUTH LAKEWOOD HILLS #1 BLK 6 LT 5 GR/'~"~ER ANCHORAGE AREA BORG(" / DEPARTMENT OF ENVIRONMErdTAL QUALITY 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION SEPTIC TANK: / MAILING ADDRESS J~X ~:~- ~J~) ~,,~1/'~, PHONE LEGAL DESCRIPTION DISTANCE FROM WEU LIQUID CAPACITY ~ NUMBER OF MATERIAl '"~'Jk(-'(q,K '-~J"~ '~ ~/~Z /~'~d~qO COMPARTMENTS GALLONS. INSIDE LENGTH '-'-"-- INSIDE WIDTH LIQUID ~ DEPTH____ SEEPAGE SYSTEM: NUMBER OF PITS. LINING MATERIAL NEAREST LOT LINE SEEPAGE PIT: OUTSIDE DIAMETER ~ OR WIDTH ~-~ , LENGTH J (~ , DEPTH DISTANCE FROM WELL /~O / TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) BUILDING FOUNDATION SQ. FT. TILE DRAIN FIELD: DISTANCE FROM WELl NUMBER OF LINES ABSORPTION AREA DEPTH: TOP~'~NISH GRADE , FOUNDATION , N~ , OF LINES .DISTANC~ TRENCH WIDTH IN. TOTAL EFFECTIVE SQ. FT. LENGTH OF EACH LINE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE-- WELL: TYPF/~IJJ. ~ILL~2~ , DEPTH. NEAREST LOT LINE /0 'J- . SEWER LINE ,J~ ! DISTANCE FROM ~ ~ WATER /~-~/ ,BUILDING FOUNDATION. ,~O 'L_~ _SAMPLE_ , NEAREST SEPTIC ,__,~-~ ~ SEEPAGE /C~ ! OTHER /~'~o/~ , TANK , SYSTEM , CESSPOOL. -- , SOURCES DATE APPROVED d, G.A.A.B. GREASIER ANCHORAGE AREA BOR H DEPARTMENT OF ENVIRONMENTAL QUALITY 3500 TUDOR ROAD POUCH 6-650 ANCHORAGE. ALASKA 99502 SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT LEGAL DESCRIPTION INSTALLATION OF: SEPTIC TANK ~.~ SEEPAGE PiT ~ i DRAIN F~ELD ~ , OTHER FINANCED THROUGH TO BE INSTALLED BY FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL iNSPECTION BY THE HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION. ~ ' MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK ~OUNDAT,ON TO SEEPAGE P]T SEPTIC TANK TO SEEPAGE PIT WALL f ELITO E T'OTA K 5'6 EE A EP'T SEPTIC TANK, ., SEEPAGE PIT TO RIVER, LAKE, STREAM. -, DRAIN FIELD ~_X~CAVATI (~_N ~ F~ET ~jJ~LTJ3JJ~LD/STJJ/~RFFI $01L. GRAVEl. BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION, TYPE, DIAGRAM OF SYSTEM I CERTIFY THAT [ 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. DEPAR'I'HENT OF ENV!ROIt!~'EHiAi_ QUALi 3500 TUDOR ROAD ANCHORAGE, ALASKA 995,02 CASE # Performed For $ohn Spano Legal Descrintion: Lot 5 Block__ This Form Renorts Soils Log Date Performed3 August, Subdivision XX Percolation Test 1972. ~enth Feet Soil Characteristics The Gm-Gw had a high cobble and. coarse sand content with l a few boulder sized Ch and M1 bodies present but these were of an erratic nature and accounted for less th~n 5% of the total sediments. soil 2~ 3-- to 5Gw 7-- 9--~--~ 1 ~Gm Was Ground Water Encountered? No ~?o^ Iq Yes, At what Depth? Readin~ Net Time Denth to H20 Net D~om Percolation Proposed Depth of CdM!~ENTS: Date Gross Time Rate n' ~, :,1 Inst~-~i~on: Seen, aqe Pit ? f~'~J,,,, Field _..?_ ........ Inlet q ~'enFH--t-J ~¥F~}~ F,f Pit f'~ Trench 14 feet ........... ~.~ ................. , .......... ~ ..... 5 ~ee~ Gm-Gw ~ 15~ ~m ~/b~m~ 1 foo~ Gm A~ g2~_~_q ~t/bd~m Test Performed By }>e, roCo ..................... Data Certified 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 Parcel I.D. # GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing add~ess Lending agency Mailing address .,'~z~. Agent z~,~. ~'¢,~ Address '-~':¢ '""/~" Day phone ~¢Z -~¢~Z ~e~¢~G ~ ~-/~ ~'~/~ay phone ~ -~ ~ Day phone ~¢~-~'~ Unless otherwise requested, HAA will be held for 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well NOTE: oickup. Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site 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 validati'on 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 structu re 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 ~.~.--...~ 2"%'. Address ¢'¢~,0 ~ ~'~F.¢/,¢ ~.. Engineer's signature _ Phone_ Date _~'~ DHHS SIGNATURE //'/' Approved for 'T"/L//:~ -F'4~' bedrooms. Disapproved. Conditional approval for _. 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 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~)25(Rev. 1/91) B~ck MOAt21 Municipality of Anchorage SEP 'J 4. '}~ /~'~ DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 ° Health Authority Approval Checklist Legal Description: Z,~ ~',-~'/~P~'~,u~,~ ~,-~,~'~-~.~:~ Parcel I.D.: A. WELL DATA. Well type /,~,~ ~'.-~ ,~ Log present (Y/N) ,4/ Total depth 1~' ~ / Sanitary seal (Y/N) If A, B, or C. attach ADEC letter. ADEC water system number Date completed Cased to ~'o ~.~/, Casing height (above ground) Wires properly protected (Y/N) Date of test Static water level Well production FROM WELL LOG g.p.m. AT INSPECTION g.p.m. WAT E 2.A/%L E S LTS: Coliform Date of Sample: Nitrate ~, Z Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~¢~,~ Foundation cleanout (Y/N) ' Date of Pumping Tanksize /o~o ~"-~Number of Compartments ~ Cleanouts (WN).__ ,Y' Depression (Y/N) "J High water alarm (Y/N) Y C. ABSORPTION FIELD DATA . - ~ ' ~o¢~:~,~f~.ll,~-r, ,,. ,~ ~/,o/~ ~.~,~ ~,,'A Date installed Length / ~ / Width Effective absorption area Date of adequacy test Soil rating (g.p.d./fF or ?/bdr.m) / ~ Gravel thickness below pipe Monitoring Tube present (Y/N) ~/ Results (Pass/Fail) ~,~-~' System type d,~-~' ~ ' Total depth /5.4 Depression over field (Y/N) ~ For 3' bedrooms Fluid depth in absorption fie!d before test (in.); Fluid depth /~ '~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) Immediately after ~?/gal. water added (in.): Absorption rate = ~/"~-'~ _g.p.d. If yes, give date -- 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cyele~ E. SEPARATION DISTANCES Size in gallons "Pump on" lev¢ at* F. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 6~ ' Absorption field on lot "'4'¢// Public sewer main Sewer/septic service line ~5'- ~',,~z/' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation '¢/~ /~-/ Property line Water main/service line ,,ZS-'~/,~Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water Curtain drain ENGINEER'S CERTIFICATION I certify that I have determined thru in conformance with ~OA HAA guidelines in effect on this date. Engineers Name ,~2,,~,¢,~.-¢,~¢T'. Date '{. S- On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station ,~-z~P-u¢¢T~'ve I at* Absorption field - ¢¢-¢-~/"/ Wells on adjacent lots Building foundation ~o'~-/- Water main/service line ~'~ Driveway. parking/vehicle storage area ~ ~,~:,o, /~., z-~ ~'/~- ~-- Wells on adjacent lots /o o '~-/~' HAA Fee $. .~ ~)0~ (~)O Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHOP~.GE MEMORANDUM SEPTIC SYSTEM ADVISORY HEALTH AUTHORITY APPROVAL NO. ~ ~ S 0 ~ q~ Prior to a recent adequacy test on the septic system for this lot, ~4 inches of standing water was observed in the absorption field. This indicates that approximately ~ % of the absorption area is inundated. Aithcugh this system passed the adequacy test, the remaining life expectancy may be limited. This advisory must be attached to all copies of the subject Health Authority Approval. Douglas T. Kenley P.E. 8f76 9960E Puffin Drive, Palmer, Alaska 99645 (907) 746-~076 WELL AND SEPTIC ADEQUACY TEST Legal: Lot 6, Block 5, South Lakewood Hill Addition #1 Subdivision Applicant: Ronald Hess Date of Test: 1-Sep-98 System Data: Tank Volume {gallons): Number of Bedrooms: 1,000 Absorption System: Crib 3 Depth of well (ft.): 165' Static Water Level {ff.): 130.5' Absorption Required (150 gal X #bedrooms) 450 Depth of Casing {ft.): Hei~lht of Casing (inches above ~lround): Unknown 16" Time Net Time Meter Incremental Total Flow Well Delta Well Monitor Delta Monitor (min.) Reading Volume (gal.) (gpm) Level Level (ft.) Tube Level Tube Level (gal.) (gal.) (ft.) (in.) (in.) 11:21 6,906 130.1 99 11:30 9 6,935 29.0. 29 3.2 135.5 -5.4 99.75 0.75 11:40 10 6,979 44.0 73 4.4 132.8 2.7 101.5 1.75 11:50 10 7,011 32.0 105 3.2 135.9 -3.1 - 102.5 ~1 12:00 10 7,050 39.0 144 3.9 137.3 -1.4 102.62 0.12 12:20 20 7,125 75.0 219 3.8 137.1 0.2 104.5 1.88 12:40 .20 7,200 75.0 294 3.8 137.5 -0.4 104.5 0 1:00 20 7,280 80.0 374 4 138.5 -1 107 2.5 '1:30 30 7,380 100.0 474 3.3 134.5 4 107.5 0.5 2:30 60 7,590 210.0 684 3.5 138.1 -3.6 3:21 51 7,810 220.0 904 4.3 137.8 0.3 3:40 132.1 5.7 103.5 -4 6:00 100 -3.5 System Passed X System Failed Additional Comments: *Water flow was diverted from septic system to the open field to finish test on the well. The well production rate averaged 3.7 gpm over the duration of the four hour test, SEP 14 '98 09:23 HI RON HESS TIME TRAUE~ER,S TCA 90? 346 82?2 ISAACS PUMPING SERVICE,INC, 6218 Quinhagak Streel Anchorage Alaska, AK 99507 TO: 907 248 5?74 PO1 Invoice DATE INVOICE 9/8/97 23211 BILL TO HESS,~-ONALD I IOI WILDWOOD DELVE ANCHORAGB.ALA'~KA 995 Iff INVOICE DATE DATE SERVICED HYDRO jETT DATE OERVICED 9-597 DESCRIPTION HYDEO JF, TT DRAIN FIELD LOCATION o/s/g? RATE AMOUNT 235.00 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PN.. I'ECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 GENERAL INFORMATION (a) Legal Descriptio0 (include lot, block, subdivision, section, township, range) .' ..' Location (address or.directions) //;'o / Business (b) Applibant Name ,~-/f4~ ,~.~ Telephone: Home .~Y~ . Appl!cantAddress' ///1~/ ~./IL/~tCll(J /~. ,/~5~, (c) Applicant is(check one): Lending Institution []; Owner/builder~; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e} Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family'[. Multi-Family [] Number of Bedrooms 3 Other WATER SUPPLY Individual Well ~ Commu'nity [] Public [] 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~ Public [] Community [] Holding Tank [] 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) 5. ..ENGINEERING FIRM PROVIDINg' INSPECTIONS, TESTS, FILE SEARCH, D~..A 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 obtaieed 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 Address Date Engineer's S~ Approved fo7 ~/~/uL.~._~\.. bedrooms by~"~ Approved u/.J~ Disapproved Conditional Terms of Conditional Approval CAUTION 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 profes§ional engineer's work. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range.) Location (address or directions) · ///o/ (b) ;P¢ic;nt Name ,~~amt/lc'j': ' ,///"'¢$Y Telephone: Home 3¢6-,2--03~' Business .5~¢- ApplJc~r~tAddres§ /])Ol',/,'df/_,~/d~]) '~_. /¢~¢//./ /'~. ?~-¢*~/~ (c) Applicant is (check one): Lending Institution []; Owner/builder,~; Buyer []; Other [] (explain); (d) Lending Institution Address Telephone (e) Real Estate Company and Agent Address Telephone (f) TYPE OF RESIDENCE Single-Family~ Multi-Family [] Number o~ BeOrooms Other WATER SUPPLY Individual Well~ Community [] Public [] : Note; If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISP, OSAL : Onsite~[, Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (~ 1/84) Page 1 of 2 ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FiLE SEARCH, DATA AND INFORMATION AS certified by my seal affixed hereto and es 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 numbe~: 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. ~"'~/'-.5'~ ",9/0 Name of Firm //~ 5 Telephone Address Date DHEP APPROVAL ~ Approved for ~ bedroomsb~2~='-~ j~~e Approved __ Disapproved Terms ofConO,t,onalApproval ~ ~ CAUTION 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 ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. ].200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 SHEET NO OF CHECKED BY. DATE · ~' 'CH'EMICAL & GE°LOGICAL LABORATORIES OF ALASKA, INC. ~I~ ^- '@07'5622343 5633 B Street ~ Drinking Water Analysis Report for Total Cohform Bacterm TO BE COMPLETED BY WATER SUPPLIER [] PUBLIC WATER SYSTEM I-D-# I I I I I I "~ ~L PRIVATE WATER SYSTEM , Phone No. Name Mailing Address _~vje// /Cz'. ¢¢~0 3 State Zip Code City Mo. Day Year SAMPLE TYPE: Routine ~ Check Sample (for routine sample with lab ret. no. [] Special Purpose .) [] Treated Water )~ Untreated Water SAMPLE NO. LOCATION 3 l TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~atisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received Analytical Method: Membrane Filter * No. of coloniesll00 mi. Time Collected Lab Ret. No. Result* Collected ~//?~ ~ E~ - _ Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Coiltorm1100ml Membrane Filten Direct Count. Verification: LTB. BGB_ Filter Results O~ __ _ . CoiJtormll00ml F inalMembrane ~~/ Date TNTC = Too Numberous To Count OB = Other Bacteria ALASKA e[1UlROllmellTAL CO ITROL ~n§in¢¢rin§ 6 ~nvironmcnlal $1u~lies SEI UICI $, IrlC. RONALDHESS lll01WILDWOOD DRIVE ANCHORAGE ALASKA 99516 S~,T,ER-RONALD HESS 03/17/86 RONALDHESS lll01WILDWOODDRIVE ANCHORAGE ALASKA 99516 60104 LEGAL:SOUTH LAKEWOOD HITJ~ BLOCK 6 LOT 5 ADEQUACY TEST FOR SEWER SYSTEM ADEQUACY TEST DATE-03/13/86 TIlE TYPE OF ABSORPTION SYST]5~ IS A CRIB WITH AN UNKNOWN AREA. THE SYSTEM IS CAPABLE OF ACc~F~ING 450 GALLONS OF ~%'£~ PER DAY. THE SURGE CAPACITY OF ~ SYSTEM IS 690 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 3 BEDROOM HOME. SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1000 IS ADEQUATE FOR THIS 3 BEDROOM HOUSE. THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON 9/10/85 . THIS REPORT DOk~ NOT VERIFY THE INT~ITY OF THE PIPING FOR THE SUPPLY OR WASTEWA'.'~ SYSTEM. FLOW TEST ON WELT, W~.T. FLOW DATE-03/13/86 A FLOW TEST WAS PERFORMED ON THE WR.¥,T.. 690 GALLONS OF ~7A'1'~ WAS PUMPED AT A RATE OF 6.9 GPM OVER A DURATION OF 1.6 HOURS. THE DRAWDOWN WAS 12.9 ' WITH A RECOVERY TIME OF 30 MINUTES AND THE STATIC WA'.u.~.~ LEVEL WAS 119.5 FEET. THE W~LT, IS ADE UATE FOR THIS 3 BEDROOM HOME. ~'%.~:~[Jgsl 33r~J Avenue, Suilg J~ o AncMaqe, Alosk. 99503.(907) 561-50/40 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 E D Legal Description: .~&~-.5'" z¢/~¢£~ ~ - MUNICIPALITY' OF ANCHORAGE DEPT. OF HEALTH & ENVIRON/',4ENTAL PROTECTION WELL DATA Well Classification ~:~/~/¢/'/¢~''~'¢ If~ A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y~-z Date Completed ¢¢~/.~¢,~0~/ Yield Total Depth ,/(~'" Cased to ~'~" ¢- Depth of Grouting ,~/'~' Static Water Level ~ //¢.~4" '~ Pump Set At Casing Height Above Ground ~ Sanitary Seal on casin (g~N) Electrical Wiring in Conduit (Y~_ Depression Around WellheadCN) Separation Distances from Well: To Septic/Holdin~ Tank on Lot '~ ~':~"! ; On Adjoining Lots' To Nearest Edge of Absorption Field on Lot ,/O~ / ; On Adjoining Lots To Nearest Public Sewer Line ,'¢'/)~* To Nearest Public Sewer Cleanout/Manhole ,4,//~ To Nearest'sewer Service Line on Lot Water Sample Collected by /¢'~'~ /¢' ~f'//~¢' ; Date Water Sample Test Results SEPTIC/HOLDING TANK DATA Size f¢~'Z) ~,~ No. of ComPartments Foundation CleanouGN) Date Last Pumped ~-/~) ,4//¢~'- ;for Temporary Holding Tank Permit (Y/N) Date Installed Standpipes~) Air-tight Cap (,~'~) Depression over Tank (YN~ 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 To Building Foundation '~'//~) / To Disposal Field '~¢' ~ To Stream, Pond, Lake. or Major Drainage Page 1 of 2 72 026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata //(-~¢~ ~/~7' Type of System Design Width of Field ~"¢?~" Depth of Field ¢ "~'~,.m~m~ Gravel Bed Thickness Square Feet of Absorption Area ~ ~/v/~"*J'~/'4/Standpipes PresentCN) Depression over Field (y~r~ Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ,/¢'~ To Property Line /~ '~'- To Building Foundation ;~/,~,-,~ / (/'*/&'~ ~¢)-,¢'l,/b/IP~..) To Existing or Abandoned System on Lot ,M'//~ ; On Adjoining Lots ~'~'O To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Cutbank (if present) LIFT STATION /~j/~/ /~'J//~ Dimensions ' ' Ga,,ons ~ Manhole/Access (Y/N) ~_ "Pump On Level at ~mp Off" Level at _ _ High Water Alarm Level a~) ~eS~r~cfa~rccc~ses ~umping Cy~AdeqN) ~,~,.,~uacy Test. Meets MOA Comments ~ Page 2 of 2 72-026 (11/841 ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I/~.~hpe~d, v.~r~ied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~¢..l;---~. /t...// Date ~ ~/¢~ ¢¢'1~ Company ~ MOA No. ~ ~ ~ Receipt No. ~ '~ ~'7 S ~ ~,.,,",.,,,~.O.~ Date of Payment ~' I:'~ ~"'~' ~"¢' ~ "%'~ Amount: $ ~,;~% ~ ~ ~z~ J~' ~