HomeMy WebLinkAboutSPRING HILLS ESTATES BLK 1 LT 8Lo'T'
"ry MUNICIPALITY OF ANCHORAGE
On-Site Water&Wastewater Program �
-,,, PO Box 196650 4700 Elmore Road - '
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.org/onsite 1160* r
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On-Site Wastewater Disposal System Permit
Permit Number: OSP181363 Effective Date: 10/15/2018
Work Type: SepticTank Upgrade Expiration Date: 10/15/2019
Tax Code Number: 01505146000
Site Legal Address: SPRING HILLS ESTATES BLK 1 LT 8 G:2436
Site Mailing Address: 9521 SPRING HILL DR, Anchorage
Owner: ROBBINS TETYANA S Lot Size in Sq Ft: 49228
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 5
This permit is for the construction of:
❑ Disposal Field El Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage
All construction shall 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 shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: mT.4.-- Date: 'i 1 / V
Issued By: law, Cqtiixs9 Date: 0 Al, 0 8
MUNICIPALITY OF ANCHORAGE
/r'
Development Services Department .
j Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 015-051-46
Property owner(s) MIKE ROBBINS Day phone
Mailing address 9521 SPRING HILL DR
Site address same
Legal description (Sub'd., Block & Lot) SPRING HILLS ESTATES BLK 1 LT 8
Legal description (Township, Range & Section)
Lot Size 49,228 Sq. Ft. Number of Bedrooms 5
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑ Initial ❑ Single Family (SF) ❑
(w/wo ADU)
Septic Tank Upgrade Duplex (D) ❑
Holding Tank ❑ Renewal c, 5 7 8 9
uttiple Dwellings n
Privy ❑ de�,'• °'( ,,/:,, and/or D)
Private Well • 1
OC r i (I [0)$
Water Storage ❑
ti
THIS APPLICATION INCLUDES A WAIVER REQU • , I -:
6899
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 215.0 V p Waiver Fees:
Date of Payment: I O/iDI2OIB Date of Payment:
Receipt Number: Gh er,K!I DCO l Receipt Number:
Permit No. 05P1813(0 Waiver No.
G:1Development Services\Building Safety1On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Oct. 10,2018
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage,Alaska 99519-6650
Fax 249-7847
Re: Septic tank replacement permit
Legal: SPRING HILLS ESTATES BLK 1 LT 8
To Whom it may concern:
This is a request for a permit to replace the existing septic tank due to failure. A new 5 bedroom tank(1500
gallon)will be installed per the MOA guide lines,depending on the depth of the old tank. The old tank is a
1250 but will be replaced with the larger 1500 gallon unit.
rte.,it*
The surrounding properties will not be impacted by this How -septic permit.
Please call me if you have any questions.
Sincerely WA/6(
Michael N. Anderson. I'.l:.
4661 Natrona
Anch, Ak 99516
Ph 727-8864
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A• MICHAEL N. ANDfRCN • ;.') •-TTI NL 4r4".• /`�
SURVEY CERTIFICATION imoiss x*� Prepared by
••••� of 4 ',`• Robert E. Johns, Jr. & Assoc.
;;,•,1;j1,.,I.•„r,,,•,y.•.•,•. . P�• ''.• Professional Land Surveyors
......w..-.•••••.••r••,•...•..1 I 4 6' ♦ 842 E. 12 Me r•.••"W16011 4 4•'""""' a , `• I •• . • ,� ANCHOR ACE, ALA AVE.VE. 99 SOI
A•...mk=old•...•r.......q ••�
.•.•.1...••.•rte i•.•+•+..+•..• xr / • RK Lot S.F. R.c. Plat Ill• No.
O € th = , Sc�I.:1 50'
Fa/Mt:A-11CM AS—BUILT 0 i . i .Uro G ,(�.cr W e
I.•r+t c a..*..MHAy^eh 04 I / ` Dat• Surveyed:
....... ••�..,. 1 9-20-07 REI 67.
r..w•..«r...�••...jr
............11144 rr.•r•�..-...... V.' P rOBE' . JR. .. Ir 'Jot* Drown: 2436
t rtd: W.0.
..•_.....— ....r........._ ♦ • 4 .0 A" 10-01-07 7260
•� ••
FINAL STRUCTURE AS-MALT •
l 1114.01 IL r--I..b•�,--r'«' •♦•••c,• '••........••••fah:." L'°°' t'°°v>ptla•,: Lot S Block 1
• ..w.•. 14.4.40.4":=.•.•• 41 P'Of•..10^d`4 Spring Hill Est
•....•..r«.....r_.•1•.•. .1S111111111.6411
••••••.•...r.
I,o LAT PANTY SURVEY TYPE SYMBOLS
❑ fCt1fOATKJM AL-•✓tULT • SET REBAR DRAINAGE ��::- -?:-'*•::': :-1 ASPHALT
O nm.... tlwin•
cA• muLT O FOUND REBAR .6-.....--0. 1 -WOOD FENCE •-•-�l CONCRETE
o PLOT RAN .. .A -11UILT...LAT WRAY...TCROGRAu+ry (1-0611) ASSUMED REV. x—af UETAL FENCE �� WOOD IXC
AS-WALT.. .NO CORe�i SET 0 RLfSIMIS.E 0S LFAILT—114 4LRlYLi_xl
PLOT PLANS & LOT SURVEYS NOTE:
IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO ONLY THOSE (1APROVEIaENTS ABOVE GROUND AND VISIBLE WILL BE
CONSTRUCTION. TO VERIFY PROPOSED BUILDING GRADE RELATIVE CH O`MN. FCNC(C. WELLS. GET'Tlc CLC ANOUT3, 31 DC WALK 3. DRI VCWAT3.
TO FINISHED GRADE AND UTILITY CONNECT ONS AND TO DETERMINE ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW
THE EXISTENCE Of ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PREVENT 504E IMPROVEMENTS FROM BEING SEEN AND LOCATED.
WI-IICH DO NOT APPEAR ON THE RECORDE;,> SUBDIVISION PLAT. _ ALL DISTANCES ARE r ECOR.D UNLESS OTHERWISE NOTFD
UNDER NO OIRCULSTANCES SHOULD AN AS-BUILT BE USED FOR CCNSTRUCTCN OR FOR ESTABUSH!NC BOUNDARY OR FENCE UNES,
THE SURVEYOR TAXES RESPONSIBILITY FCR THE INITIAL TRANSACTION ONLY ANO ASSUMES F:NANOAL UABNTY ONLY FOR THE COST OF THE SURVEY.
USTEO OtSTANCES PREVAIL OVER SCAJNG. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
j- .
MUNICIPALITY OF ANCHORAGE ._ ..� ..r.
:fi;.:, . DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL_ ENGINEERING DIVISION
:_,
`✓�1 825 L Street-Anchorage,Alaska 99501 Telephone 264-4720
�' ON-SITE SEWAGE DISPOSAL. SYSTEM AND/OR WELL INSPECTION REPORT
NAME 11/ "�.. ..�.�•_��_ -___________�._ -_r __._.W.�— PHONE il
NEW
/ 1.r TZ-V' CO,t/S.,-, a.71e —• Iiii71-^Iti 7 ❑UPGRADE
MAILING ADDRESS
/_3z Us W. 79 77// _ 4j/G// 4/z- 9 -c--./ Y.-- -
LEGAy DESCRIPTION
LOCATION NO.OF BEDROOMS
,S�'P -,�C , /,--I-4 ;MS/v'E / - rs1/ /
Well) /j, �sQ(//e[:}�bsorptionrj�rea bwellin3,/ PERMIT NO.
DISTANCE TO: i"r,�> off ) / b l i_ / /�a '10 8C'o
u
i-2 Ma1iufacturerMaterial, No.of ompartments
CL �nr,Jl-.N. ?A/1C.. - 7.L 7 —�
o Llq.capacity in gallons IF HOMEMADE: 'Inside length Width Liquid depth
------ / ..r-if
Well �'�' Dwelling PERMIT NO.
O 0 2 DISTANCE TOS..---�'��
O Z Q Manuf -war.-- Material Liquid yin gallons
W II /od I l(' tf/e4?) Foundation Nearest lot line PERMIT NO.
I
- DISTANCE TO: /46/0 t".77') - - -- -
tli tJ No..p f lines Length of each line Total len�lth of lines '-rank-,width �a.l) Distance between lines
H J Ai,' ;--)- N ?'3/�j `[�.lS' A/f� 7/. ' x43/ •iaeles S i
t.f Top of tile to finish grade Material beneath tile Total effectivepbsorption area
'77)T,4L D&i7—/ i c.,. 7' 4-0ii inches ��•1ir
Length WidDepth PERMIT NO.
w
aI- Type of crib Crib diameter Crib depth Total effective absorption area
wa
-
w Well Building foundation Nearest lot line
co DISTANCE TO:
J Class1av Depth Driller Distance to lot line PERIy11 Nv.ceri O
u' DISTANCE TO: Building foundation Sewer line. Septic tank Absorption area(s)
OTHER
��r -- •aa ff . to • u�
7.___
r PIPE MATERIALS - R �..� iY- `l— - -
C'/,~sr' i,(.'04/ 4 r ri!-V,:. ; 0303 r../ .2.) —I =-
SOIL TEST RATING A _7,1AINSTALLER -- /au7 0 3 lV- Lr( 1`
6'146 .)(C/1-0. ......Mo
/? r
REMARKS _ - U _ , --
r1) x l=r-n,n //L G/z...' •I -6 1 '1' 1 , , i —i.e. ----_7
fi — _.....
'y ct1Eu ,v o G E'r /A/ - ■ :0 1 A —-a
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S'Fm•,t.-c:r0 Se 0,5 a rt..r_- /_i. 2.o ' -
2. A_ v- .7- AIf- )4/5rrt t-41 e2) n/?.” _ I .
AI, i). 5'7zy2..
ti LLE oar ,era tf.,, -- GI - - -
�•U�1n/e7q.r-Io,J /}-n/ Zz ...eta. /
El
62) 'D��77�t.�/cam -rU cG•�ZL (:).</ /o'T '/ ,s /OZ` ------ -.-
-
- MIw
tot/ ;/D/5, I — .r _ .
/5f )ylll lac. -C:L>. ------ �- �. -
APPROVED DATE LEGAL
,/4 -/L...A..-- (i,�4..;7(-ft- /v / , / h / ,-C-,g-e./,✓ti '
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MUNICIPALITY OF ANCNORAGE
DEPARTMENT OF HEAl. TH & ENVIRONMENTAL PROTECTION
ENVIRONMENI'AI. ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTION REPORT
iPHONE
PGRADE
MAILING ADDRESS
/ c.,
DESCRIPTION
....
LOCATION
Weli 2~: ' ~-~ ~l/G-~bs otp t i o~:~ rea Dwelling_.
DISTANCETO: I ~;)~O~ I 16~g ' I /5'
Manufacturer
~' ~ &-, fl IF HOMEMADE:
W~I[ /~)~ / ~/'//~} Foun~atio,~ Nearest lot line
DISTANCE TO:
No, of lines Lenq~h of each line
Top of tile to finish grade
Length Width
Type of crib Crib diameter
Well
DISTANCE TO:
Class~ Depth
~ Building foundation
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
Total I~_~_of lines
Material beneath tile
Depth
/-.o v-' 9' /,s
C~ M' bz-~- 6~ .-%~/~
NO. OF BEDROOMS
¥
PERMIT NO.
~"-/o o~o o
Liquid depth
PERMIT NO.
Liq~allons
PERMIT NO.
Distance between lines
Total effective .absorption area
PERMIT NO.
Crib depth Total effective absorption area
Building foundation Nearest lot line
Driller Distance to lot line
Sewer line Septic tank
orption area(s)
DATE LEGAL
72-013 (Rev. 3/78)
IP'tl IL]l IP',,.I1 ]:IIi ,L~7; ]E F:" ~1~:::~, IL.... ]l'.'. '"'Il'"' "¥" C} II::::' ~s'-"~l, ti'"4t C]: II'.dl I['_"'ll IF:~?,: ~,..r:.?~ 'L!E~ lES:
Dli~]::'ARTI'dliEI',IT (II::: I'.]IE]AI_..'TI'I AND I~iI',IVIRONME:'IqTAL..PRC]TEECTION
~1f25 L STRI~:Ii:.]", AI",IC, I'ICIRAGi~: :, AK 9950 1
2.6 4'-" Zl.'720
C]? II",,,ll .......... '.liEf; ~.:: '-Il'"' IEi!] .liEii: lEE'.] II,all lES] IF;i,". ~!~-~; II,~,JI IEE] IL.... II. .... F" E!:'] IF:;',,". !I'-ql ][] '"It""
~:] 4 () 800
() 9 / :L 9 / El 4
A F:' F' L I C.; A N T:
A D D R E S ~iil:
C(]Iq"I"At]T F:'HONI~i]:
HT,, VIEW COI'qS'I".
:1.205 W. 79TH. AVIS
ANC.'HOI'~,:AGE ~,AK 995()2
3zI. 4....,76676
I....li;:G Al.. DIE!iiE:R I P:
L(]'T E~I ZE~:
MAX BliF:DROOMS:
SUBD :l: V ]: S ]: ON ': SF:'t:~':I: NG H ]: I....I_..S
SEC]"I ON: :L 5 'T'OWNSH :l: I::',",
I.,,,?.SA (SQ, F:'T, C)R AC;RES)
4
LILT: 8 BL.OCI<:
RAN(SIC.r. ~, 3W
I....ist~:.!d l:)e].cm; ar'E! 'L h (,'..'.! q:~tic~ns ava:i.].able 'Lo yc)u :Eh des:i, gri:i, ng yc~up r,~iep:l:.:i.c
· syst(.:..~m,, (]hc:)os~..? 'l'..['i~ opt,:i.c)n tl'~at best ¢ its y(~ur' site.
DE~F:"T'H "1"0 PIPE'. BOTTOM (I:::T.)
GFd.'~VIEI.... DISF:'TH (F:'T.)
"I"OTAL. DEF:'TI'~ (F:"I",,)
E)FdYdEL. WIDTI'~ (FI".)
GRAVE:I..., LENGTH (FT,)
GI:;'.AVI~]_VCII...LJME (C, LI. YDS, )
'T'AIqK E~IZE (E.')AL.S)
SC)]:I_ RAT]:NB (SQ,, F'T,. /BR)
,~,",~- DEF:"T'I-] 'T'[] F:'II:::'I!!! BOT"FOM < :];,.,,.~ F:'T,. F~IEiE~L.I:I:I:~:E'.:S INSLJLA'I"IC.)Iq
,x.,,x. DE:F:'TH "FO F""IPIE~: BC)'T"?OM < 4.0 FrT. HAY F~IE(:;!U):IRIi'Z A L.:I:F'T ,S'I'A"I':CC)N
· ~"'t~,' GRAVEl_ L. ENG'I"I'] > 75 I:::'T,. REQLIII::;:ES IqLJL. TIF'LE RLIIq,9, (I',IOT EXE]EE]OII',IG 75 F'T., EEAC',H)
,¢',~'~' TANK MLJST HAVE AT I.,,EAST TWO C[)MF'ARTME:'NTS
I cePti,~'y t, ha'L:
~.,, I am I'ami:l.:i. aP wi, th '1:.1"~,~ PE2qLI:J. PE.~ffI~.~n'J:.'.,~; ~'CIP c)r]'-"~Bi'~.,(~~. D(DWE.~I'~:]i ~,.]~l'](:J ~,~!(¢Jl],!~ii a~.s
I Fr A
'l"Hli!:"lq
WILl..,
EI_ECTR I (:)Al.,. NJ]RI< I'q!..IEFI'
SIGNED-' ~' ~
AF'F::'L.,:[C;AIqT~ ~ V~ CONST.
"C.~l It:::E) ~]y
,"'or"Lh by 'Line., Municipality of Anchor'~gc.~ (MOA) and th~ State c)f' Alaska,,
I ~i].]. insta].l 'Lh~ system il"~ a(::c:(]r'dar~c::e with a:l, 1 MOA cc)des and
I w:i.].], adhePe '{'..o a],:l. MC)(~ and S't:,ate (~I' A:l, asl<a r'equiP~:~mE~rYt,.s for' the set bac:k
di!~!;'f.,al'H::c.]s t' Porn any ex J.s'L J. ng t,-~e:l. 1 ~, was'l:.~wa'l:.eP dispc]sa], syst. em oP
sewer'age system Ol"J t,h:i.~; (:m ar)y acJ.ja(::eri~ of' i~c~ar'by
I um'idem's'[.and that this i:]epmit :i.s valid Fop a maximum oJ' 4 bedr'ooms arid
PERFORMED FOR:
LEGAL DESCR ~PTION:
1
2
3
4
5
6
7
8
i~IUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 284-4720
SOILS LOG- PERCOLATION TEST
'¢;
D PERCOLATION
TEST
OATE,ERFORM.O
SITE PLAN
10
11
12
13
14
15
16 C,
17
18
19
20
COMMENTS
PERFORMED BY:
72-008 (6/7 .g)
ENCOUNTERED?
O
P
DEPTH?IFYES'ATWHAT ~ / E
Gross Net Depth to Net
Reading Date Time Time Water Drop
rv~-W DRILLING, Inc.
P.O. Box 10-378 * 10300 Old Seward Highway
(907) 349-8535
ANCHORAGE, ALASKA 99511
DRILLING LOG
Well Owner ,'1~, Yl.;i j ~:/' ~ ;I ~,!'~/;._'~:~ L', ) [:~ :i '~ ~ 'V'~, .~,~ ( ;~ ~ l: ! :. Use of Well J om~¥;~ '?:'~ 'r
Location (address off Township, Range, Section, ff ~own; or distance main road
Size of casing.
Static water level
Screen (
.Depth of Hole
]:,';0 ft.
); Perforated (
Describe screen or perforation
Well pumping test at ;I 0 gallons per ('h'our);:
of drawdown from static level.
Date of completion 0c.'.L,:>i~:,: 2:)~ ],9;J-/~. _
)J.' feet Cased to ](iJ..2 feet
(below) land surface. Finish of well (check one) open end ( ~'r
).
(minute) for ] hours with ].riO'.(
MUNICIPALITY OF ANt~IO~,AOB
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
WELL LOG
);
ft.
Depth in feet from
ground surface
Give details of formations penetrated, size of material, (l~l~ ~r~tl~
¸TO.
3--CONTRACTOR
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL N~AI,TH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICA~
1. General Information
Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions) -
(b) Applicants ~ame /:t':-:~L.,~ :D/'t"°ST~'~_Te:l. ephone - l-lome Business
Applicants Address
(c) Applicant is (check. one) Lending Institution ~ ; Owner/builder
Buyer ~; Other ~ (explain);
(e) Real Estate Co. & Agent
Address
(f)
Telephone
Mail the HAA to the following address:
g~3 z c- ~- }o/c-/~-. ~/z~-~
2. T~e of Residence
Single-Family I~
Number of Bedrooms
3, Water
Individual Well'~
Multi-Family~__~
Other (describe)
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 Dis 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 lega].ity and status.
[Page 1 of 2]
l~neerin~ Firm Providin8 Inspections, Tests~ File Se~l~ Data and Information
As certified by my seal affixed hereto and as of the vtjlidation date shown below, I
verify that my investigation of. this Health Authority Approval sho%m that the on-site
water supply amd/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 Municipalitt of Anchorage files and from my
investigation and inspection, the' om-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State c~les, ordinances, and re§ula-
tions in effect on the date of this inspection.
DHEP A~.proval
Approved for /~Lf/? bedrooms
Approved ~ Disapproved
%
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTA.L PROTECTION
(DHEP) ~SSUFS HEALTH AIY~EORITY APPROVAL CERTIFICATES Bj;.CED ._SOIi, LY UPON THE REPRESENT"
ATIONS GIVEN IN P~RAGRAPH 5 A~OVE BY AN INDEPENDENT p~,OFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DEEP DOES THIS AS A COUR:Z'CSY TO PURCHASERS OF EOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTA-,iN FEDERAL AND STATE REQUIRE-'
MENTSo EMPLOYEES OF DHEP DO NOT CONDUCT iNSPECTIO~i~$ OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICEPALITY OF ANCHORAGFJ IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN TH}', PROFESSIONAL ENGINEER'S WORK.
(DEEP SEAL)
RR4/eJ/D18
[Page 2 of 2]
7-19-84
~LL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (MOA;
HEALTH AUI~ORITY APPROVAL (HAA)
CHECKLIS'f - FEBRUARY 1984
Well Log P~esent (Y/N) ,y
Total Depth / $/ Cased to
Static Water Leval / ~oO '
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation ]Distances frcm W~ll:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
"' igSg
Legal Description:
If A, B, ~ C, D.E.C. ~p~o~d(Y~)
~te ~leted Oo~ LSt ~ ~['~ Yield
~pth of ~outing
Pump Set At
Sanitary Seal on Casing (Y/N)/
Depression A~ound Wellhead (Y/N) AJ
; On Adjoining Lots i 7_0
' ~' ; On Adjoining Lots (
To Nearest Public
Cleaneut/Manhole ~/~ To Nearest Sewer Service Line on Lot
Water Sample Collec~ced By d'o~3~. ~1,~ ; Date ,~[-
Water Sample Test Results /rT-T/?c/~/3
B. SEPTIC/HOLDING TANK DATA
Date Installed /a~//~ ~ Size / LD-o No. of C~a~tm~nts Z_ '
Standpipes ~/N) /v Air-tight Caps (Y/N) y Foundation Cleanout (Y/N! ~
Depression ove~ Tank (Y/N) AJ Date Last pumped /t)//~ ~ /J~xg
Pumping/Maintenance Contract on File (Y/N) /J ; for
Holding Tank High-Water Alarm (Y/N) /t/~ Temporary Holding Tank Permit (Y/N) ~/~ .
Separation Distances f~cm Septic/Holding Tank:
To Water-Supply Wall I 0.5-
To Property Line _ ~0'
To Water Main/Service Lir~
Course /'70'
!
To Building Foundaticn /~
To Disposal Field Io, ~ '
To Stream, Pond, ~ke, c~ Major D~ainage
Receipt 9
Date Paid:
Amount:
[Pa(3e 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date .Installed /0
Width of Field
Square Feet of Absorption Amea
Dep=ession over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field ~/3
Depth of Field ~
Gravel Bed Thickness ~
?Z~3,~, Standpipes P~esent (Y/N) y
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /~0 ' To P~operty Line ~ O
To Building Foundation ~-~+ To Existing or Abandoned System cn
Lot n~//~ ; On Adjoining Lots + /00'
!
TO Water Me. Service Line ~O + To Cutbank(if present)
To Stream/Pond/Lake/c~, Major D~ainage Course 170'
To D~iveway, Parking Area, or Vehicle Storage Area
CoJ~ents -Z~-f/~ 7~/~x~/ /~-a~/~/~ f ~ ~ ~/% C/ ~ ~)
lled Dimensions
~cess (Y/N)
Size in
"Pump On" Level at~'~-~// "Pump Off" Level at
High Water Alarm Level. t:~'~'~ ~ Vent (Y/N)
Electr~~s (Y/N)
e~ts
Meets MOA
** Check Permitted Bedrcxxn Rating A~air~t HAA Request **
I certify that I have checked, verified, or confor~ed to all MOA HAA Guidelines in effect
on the date of this inspection. ~,.~>:..~'%.%.~%
[Pa~ 2 of 2] ,:~ ..~.>..~.~%~~
2-15-84