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T15N R1W SEC 8 LT 123
T15N RIW Section 8 Lot 123 #051-154-08 Municipality of Anchorage Page / of Z_ DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 i Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: _ AV U 011 2 PID Number: _ O5/ -/5z/ -09 Name: 7CHQ . L 4 1) L612/1 //q 1— Wastewater System: New ❑ Upgrade _— Address: ABSORPTION FIELD k A Z J vLr CAI mak', , ic', -- ----- Phone: No. of Bedrooms: ��� ❑Deep Trench ❑Shallow Trench Read ❑Mound ❑Other LEGAL DESCRIPTION Soil Rating: a F Total Depth from original grade: GPD/Sq. FI. ___Z� 4 —_ Lot: Block: — Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe Township:—TTIIII R—anger ', / Section: � C1 FIII added above original grade: Ft. Gravel length: 133 Ft. WELL: ❑New ❑Upgrade _ Gravel depth-WiDrH Number of lines: Distance/between lines: Classification (Private, A,B,C) Total Depth: Cased 1"0: Total absorption area: Pipe materiel: l/A%E Ft. I Ft. L� Z J SQ. FL 451--' 3 3 V L vo —.mss-- _ Driller: — Date OrJl led: Static Water Level: L/v✓1r� l0/9 L FL Installer: Date installed: 6-7A�f _® �4/95 Yield: Pump Set at Casing Height Above Ground: J GPM (/'1fi %�ll�� F= — {-- Ft. TANK — SEPARATION DISTANCES ❑Septic E) Holding _ To Septic Absorption lin Holding PWatiaMrivale Manufacturer. I /j /� CeUecily in gallons: From Tank Field Station 1'enk Sewer Lines Well plA // 3 / /00 7 NIA f p > Material: — —ems- Number Co_mpparbrents- Surface / A / / IV I A Nle /� / /JJ,� LIFT STATION Water --— Line /•ll A f Ja0/ Na0 IV14 /,30' Size in gallons: Manufacturer: PI TiWK 0kj,1V c4 Foundation �I//i ?)Cj' ZUl !/l/ NlA -Zi4r20 — "Pump on" level at: Pump off' level at: High wa}er alarm at: Lf3 " �fOr' y� Curtain Drain �llA NIA /\t/A i�lA NIA Pump Make& Model os/mos-zoo=gym —= Electrical Inspections performed by: 1,L �CTi2 r� BENCH NIARK Remarks: ---------- ------------ Location and Description: ILOF 1 1,LG 541gI ----- ------- Assumed Elevation: O �o�e ----Lao—, _tet — ---- ENGINP--rI S SEAL r F i '1' : n Inspections performed by: Dates: FJ Ci 2nd // 2 Z, °o A, -r. r Loc A r!t n (7 G' `'`' + Department of Heal td Hu(�ervices appro alNT�°°° Her ` Reviewed and approved by: � � �' � �- Date7" ��' / k", 72-013 (1191) MOA 25 Permit No. Page _--_— el -I- Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 9 Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description_ 3 JAYNAWK D IVk— EE 4 c 50' PA -N ROW RESERVE 0 0' —E — 0 [22 HOUSE OUSE_ ✓Zrn� II R 1250 STATION �� W/LIFA S I D 2' PVC 1-1/4' PVC ti A z < a _I f1 `\ aN A \IO•s3r OED 'J+ p oto E <I El El I I A < N 89'5]'00' E M 2130.00 LLLVATII❑NS (NOT TO SCALE) GROUND AT J---- 'FANK 97„5�, 1:2• ADDED FILL TANK 72019 A 12/911 MOA 25 PIDNo.: SWING TIES A -C=43 D - C = 25.5 A - D = 63.3 D - D= 46.9 A-E =91.3 D - E = 68.3 SCALE I”=100' i • - MONITOR TUBE 0 - SEWER CLEANOUT ¢ - WELL - - - - EASEMENT ATOP SSUHEDWELL EL.EVHEAD 100.00• �EAL o n* .9TH ORIGINAL - 00 ... GROUND Tl LEVEL @ 98:� - -- 35PSI INSULATION �IIITIIIr/G\✓T @ 91.9' nO LOUIS A. BU TERA ty 0 e.2s• YY ,/ 89'91 , cis CE -6736 LLLVVV TF � NT GRAVEL LAYER 97.4' 1I \ pROFES51ON4 FVR 09 191 09:13x. RI %t1:IX IA III ULE RM Halmar Eleotric 1?n Dox 1864 Palmer Arx 91645 PH. 7456883 , 696•-8883 To: Eadie VenLtirea VO Box 1822 MIcIlo River AK 99577 o,1 :Site Sower ]Lift; Station. VM DKe: 04-06-94 1213: Lt :1;23 section. a Cbug.-Lak AIC. '['111:1 is to ae1:t.ItY 1*,U.fet on sotwer Lift ;if:5.t;T.on at, eahove Residence has been wired in AGcorSl+ MO with the HatiOna7. Electrical Code. All eleotrical test: have met manufactures spocificati.ons. by DOC Co. dna SULLIVAN WNFEll WE 14LS P.O. BOX 676272, CHUGIAK, ALASKA 99567• fEL15PHONE(I6e•2706 OWNER OF t/ANII'• ADDRESS J—/Y v -&---j -I.L._`',t..q]�!:____%C LEGAL DESC;RIPTION_ DA'f IF. - Slatted _ Endtd FF AMI INUMBER KIND OF FORMATION: DEPTH OF WELL to STATIC LFVEL OF WATER Ft. 1HRAW&WNFT. From --Ft, _ GALS. PER HR -- /1L.._�L__ s- KINI) OF CASfN(; to. From —0 _Ft. Cru -- - -Fr.._ f_r_ �,7..'I r bi d L Frotn.m r .Ft. FL_ Zis a !Q -n— _-- Fronl_-Ft. to ��tI {{'-'� i "s Frorn'T'.._-.Pato.17,_.___.FL._ __•'%��S� i`'y�LJcL i..,pYS4rom_—Ft.to�_TFt.__,�___���-- From —.'r�-�t .Ft. to—W—Ft. " 0 iSt. j Fran_,—_Ft. to --Ft r/U c 7 From 51- to Ft., . .......... -- .rd Flom.aj_Ft.to.-C_.fl. r'r9-"}_---_..F._. From— Ft. lo_, -_,--Ft._ Frmn---,,^Ft-to—__Ft. ` r•J t5 TC" From _ ft. t(;—. Ft. Trom - L !F Fl. to �� ft. s _-�':•. t'... KJ From_.. -Ft. From—Ft. to Ft. from Ft. to--fl— o—_fl._From_—Ft,to—__eFt. From --Ft, to—- Ft.� � � From_..`.Ft,to._.--Ft._ Frmn--FL to. Ft. _.___—..._ From ----_Ft. ta_-_ to.—.__FL_ _—_--T FYomt.to—_Ft.— From, ,,_Ft. to Ft. FlotnFt• lo— _ft._— --- Fro k -----_ft. to --Ft. � � Frout__Ft. to._ _ Ft.__ _ from -Ft, —F r I V / P MISCL. INFORM A7(ON: t.rAPR 1 2 19921 Municipality of Anchorage Dept. Health & Human Services { r _ DRILLERS NAME PAGE 1 OF 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825."L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930412 DATE ISSUED:1.0/06/93 DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES EXPIRATION DATE:10/06194 OWNER NAME:HALE MITCHELL D & DEBRA A OWNER ADDRESS:8822 JULY CREEK EAGLE RIVER, ALASKA 99577 PARCEL ID:05115408 LEGAL DESCRIPTION: T15N R1W SEC 8 LT 123 LOT SIZI"": 108900 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL 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 OE' ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHIIS 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: / �H THE SAND USED IN THE FILTER LAYER MUST BE A CLEAN COURSE S.q_N12 SAND WITH 4% OR LESS PASSING THE #100 SIEVE AND 2% OR LESS t est PASSING THE #200 SIEVE. A SIEVE ANALYSIS MUST BE PROVIDED ON THE SAND USED OR SAND MUST BE PROVIDED BY AN APPROVED SOURCE. 60G'cr RECEIVED BY: ISSUED BY: DATE: _LC DATE : / -��� EMSTO °h/aye Enalue"elms &IFTIP100 Louis Butera, P.E. Registered Civil Engineer September 29, 1993 John Smith, P.E. Manager, On -Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Lot 123, T15N R1W Section 8 Narrative Dear Mr. Smith: The proposed septic upgrade will have very limited impact on adjacent properties for the following reasons: 1. The area has large 2.5 acre lots allowing sufficient room for septic sites. 2. Immediate neighboring septic systems are all +30' distance. 3. Reserve space is adequate, due to good soil absorption capacity. 4. Surface drainage will not be altered and is not a major consideration in our design. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. \1993\93-059A.NAR P.O. Box 773294 • Eagle River, Alaska 99577 • Telephone (907) 6945195 • Fax (907) 694-3297 JAYHAWK DRIVE 50' PATENT ROW RESERVE ro o v o N A PROPUSE < }r WELL S1 F PRIVATE / TH WELL +100' IIIIr �a N L Q'tOf�JS� a O1250 I � n� 1250 TANK D N ,-'W/LIFT STATL A tri c - z Z 2' PVC 4�rq A — TH`— F 1-1/4' PVC < £ C1 TI430 kL .0 W d rq < �3i roW PROPOSED z7 ^o• 18'x32' DED < rq I I / O 0 .0 PRESSURE PIPE CLEANDUT�,.u..., 0 TEST HOLE o MONITOR TUBE _ o SEWER CLEANOUT NO SURFACE WATER 1-100' + - WELL ++++Ft++IT+ -- PROPOSED LEACHFIELD NO KNOWN CURTAIN DRAINS EASEMENT WELL. & SEPTIC SITE PLAN LEGAL: LOT 123, T15N R1W SEC.8 _ OWNER: MITCH_ & DEBBIE HALE _- CONTRACTOR: N/A JOB —#-9-3-059F—DATE: 10/04/931 SCALE 1" == 60' EAGLIT RIVER ENGINEERING SERVICE'S P.O. Box 773 EAGLE' RIVER,, AK 99577 (907) 694-5195 FAX: (907) 694-3297 OF q(gs��ei i k 49LH *0 0 ,. s 0_..sem— i 00p LOUIS A. 13UTERA 0,'s, CE 736 \?�! p 111 \\�lk%,V '� - JAYHAWK DRIVE 50' PATENT ROW RESERVE 000000 0 0°. aµ... PRESSURE PIPE CLEANOUI NO SURFACE WATER +100' NO KNOWN CURTAIN DRAINS WELL &: `.SEPTIC SITE PLAN 0 - TEST HOLE • - MONITOR TUBE o - SEWER CLEANOUT ¢ - PROPOSED o- — PROPOSED LEACHFIELD WELL SITE EASEMENT ", oma, I IOD A I v o m I I PRIVATE 3 s WELL TH WELL +100' yW 4O�y I a o 1250 TANK n �W/LIFT STATION 1-1/4' PVC =I /2' PVC 2 ® � w�WC A oI < TFI2 mku ® k4 d x rb 88 'm I 0-, I I I I I 000000 0 0°. aµ... PRESSURE PIPE CLEANOUI NO SURFACE WATER +100' NO KNOWN CURTAIN DRAINS WELL &: `.SEPTIC SITE PLAN 0 - TEST HOLE • - MONITOR TUBE o - SEWER CLEANOUT ¢ - WELL o- — PROPOSED LEACHFIELD - — - - EASEMENT LE:GAI_: LOT 123, 1-15N R1W SEC.8 OWNER: MITCH & DEBBIE HALE CONTRACTOR: N/A _ JOB # 93-059 DATE=: 09/29/93 SCALE: 1 60' EAGLE RIVER ENGINEERING SERVICES E.O. Bo:c EAGLE RIVERER,, AK. 99577 (907) 694--5195 FAX: (907) 694-3297 �7 ;* .49TH ��1 *I LOUIS A. BUTERA CE -6736 11 Fo I I � pROFESSIONN�'�� EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294 EAGLE RIVER, AK 99577 (907) 694.5195 'JOB Lot 123, T15N R1W Section 8 SHEET CALCULATED CHECKED OF_ DATE_ 09/93 _ DATE \1993.\93-059A.CAL FIEMsM Ii, IJ Ws)MI (Pd j J6EllstIrn.E?t',' l0a 014l To WAI 1WEIOR [SEE I EA26S SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM LEGAL: LOT 123, T15N R1W Section 8 A. GENERAL 1. The well and septic plan are for a single family residence only. 2. The drawing and or site plan shall be a part of this specification. 3. All materials and workmanship shall meet the Anchorage Department of Health requirements. 4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. 5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage requirements. 6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi -family wells. 7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. 8. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. B. SEPTIC TANK 1. 1,250 gallon Orenco Systems lift station/tank with 20 -OSI -05 HHF pump. 2. Receipt from licensed electrician to be provided to engineer for wiring of lift station. C. BED 1. The bed is to follow the natural land contour to maintain uniform total depth of the bed bottom. 2. The bottom of the bed shall be level, plus or minus 1.5". 3. The organic soil layer is to be completely removed to gravel surface (est. 2' level) and backfilled, if necessary, with material graded SP so that the total depth of the bed excavation does not to exceed V at any point. A V septic gravel layer is to be installed over the sand with 1-1/4" PVC pressure effluent piping at 2" below top of gravel. 4. The bed gravel is to be covered with typar fabric material. 5. A combination of soil and extruded board insulation to an equivalent depth of 4' is to be placed over the leachfreld. 6. The area over the bed is to be finish graded to prevent ponding of surface water runoff. 7. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS: TOTAL DEPTH = 1' GRAVEL DEPTH = V BED LENGTH = 32' BED WIDTH = 18' SOIL RATING = 0.8 GPD/ft' BEDROOM CAPACITY 3 SEPTIC TANK SIZE = 1,250 with lift station NOTE: Leachfield piping to be 1-1/4" PVC with 1/8" holes spaced 16" OC, installed face up with orifice shields installed. Twenty-four (24) hours notice required for all inspections. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 4 825 " L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR:- I r( fi YDATE PERFORMED: LEGAL DESCRIPTION: 41 I Z2;) c0K6ANIG PIAT, IaPSaL 1 _�wNSii.T, FES RocK 2 3 - GP�GP-6� 4 - [ SANby 6RA\jE1. w''lmrncESIFT YAPLISS To awll'H SILL q'er -F 5, 5 MANY RA (.C- q 9. • rEw Go13gLE .► �" 6 7' p• P,•. s ;0_ .•- a] 10 11 12- 2 Deta Net Depth to Time Water Net Drop 13- 1604-.'00 0 14- Na.... wre..� .,.. 15 Qne�..ty.......>•. 17 19 19 i, Range, Section: SLOPE WAS GROUND WATER `IBES ENCOUNTERED? i IF YES, AT WHAT DEPTH? Depth to Water Aller Moniloring? 6' 3 Dale; (ENGINEER'S SEAL) 15 NAR -I\./ SITE PLAN 111 FieedinD Deta Gross Time Net Depth to Time Water Net Drop _ i� 1604-.'00 awl 20 L—I PERCOLATION RATE 01l (minutes/inch) PERC HOLE: DIAMETER �— I I q� TEST RUN BETWEEN FTIAND 3 Ff COMMENTS Il-tKMA D pili t VC, �oNITa2, TL.IfSE. To E� ------ PERFORMED BY: �iL- E�LrJ -- Imo._ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) (ENGINEER'S SEAL) . (a� Municipality of Anchorage c t DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR:_!' U 01m► — — —DATE PERFORMED: 9S 9S LEGAL �DESCRIPTION: C*rl 1-� I(i-J ��Z- I'(�'�i�C�P-6ANIGHATTop501V- Sl�f F&w p_OI'K 2- 3 - -3- 4 C 5- �v 7 s'o o 8 11 12 13 14 15 16 17 18 19 t r 6P/6P-6d SWDY 61?I ell T11 -i' = $"OT UAR�65'twlrN SIV1° S�*\)OAS LOOSE Als"t 41 (MAWY{311 ( Rtctc, FEw,F e,' FEw 4 I$ 6w� A 1 ' Township, Range, Section: -rI5 N1R IQ SLOPE SITE PLAN WAS GROUND WATER ��r•J, ENCOUNTERED? S IF YES, AT WHAT '2,J I LO DEPT IT? I P E Depth to Water Aller Monitoring? _ 6'p Oale: Reading Date Gross Time Net Time Depth to Water Net Drop II — 11I 1.36'N u 20 t— I / It PERCOLATION RATE -1— (minutes/inch) PERC HOLE DIAMETER„iv TEST RUN BETWEEN _ 2 FIAND 3 —FT COMMENTS IN"trAU-ep IkI1'4W(- 110H"rOR, 1l.JgF- TO Ids PERFORMED BY: CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE. 72-006 (Rev. 4t85) i O Municlpallly of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 j 1SOILS LOG — PERCOLATION TEST PERFORMED FOR: !�� ��I'tVL+ 22 —_ —_ DATE PERFORM LEGAL DESCRIPTION: ✓� V.7 Township, Range, Section: 115 N/ �N1 --7 SLOPE SI E 1"1 Kr.KP rYI--- '" 1 r--.—r—r� 1 4M O RL,aNI G�>I I T� TOPSOIL. GP 5ANDY6RAVELr MA(-E611.T VAPIES To"WITR'SII,-r" DENSER 3EI.ou 71 hANYROCIf- k {yll t1kN(k6" sLr�uu�us. 10- WAS GROUND WATER ENCOUNTERED] 11 - S IF YES, AT WHAT / 6I 1. DEPTH] C)' 0 12_ E 13- Depth to Water Alter Moidloriny7 _ '51 / Dale: (ENGINEER'S SEAL) Reading Date Gross Time 14 Depth to Water Net Drop 16- � 0 B�pC00 n:ytr-y�T i A. n o Let�ls 9ate.� 17 - ©,. o ° 2 I-7o1j:yoHb HIN_ i6 � 19- Depth to Water Alter Moidloriny7 _ '51 / Dale: (ENGINEER'S SEAL) Reading Date Gross Time Not Time Depth to Water Net Drop 2 I-7o1j:yoHb HIN_ i6 � 3 I I 171�j_52. 0 MIN 8 /jam fIr— 2ff�TIF— 2U l—I II q J PERCOLATION RATE 16 in _ Imutos,inch) PERC HOLE DIAMETER �i 1 I q' TEST RUN BETWEEN t'.5 _ FT AND 95.6 —FT COMMENTS _INs�gl.l.�p 1LI. � I y(., j�oHI-roll 1tjBF- To —_ PERFORMED BY: CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72.008 (Rev. 4755) .10 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 1. D. JS I—] �5 --0:9 HAA # 1. GENERAL INFORMATION Complete legal description Location (site address or dii Expiration Date: 7-- j `7 - 0 3 Current Property owner(s)` 1 i'J?j r', a/ '16- L ' Mailing address :CJ'� j.�tL�. „»;1 Lending agency Mailing address Real Estate Agent Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. Day phone t)qq - 7 � 1's Day phone Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site fx Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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 5 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 need water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with va!id 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 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 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Eagle River Engineering Services Phone & 4-- 5105 �F(3 Boa 7TJ age River, AK 99577-3294 Address Engineer's Printed Name u / i A, P-Suie ra— Date Ll D� 5. DS, D SIGNATURE V Approved for bedrooms. Disapproved. Conditional approval for Additional Comments Attachments: HAA Checklist X • Septic System Advisory Well Flow Advisory iJ ENGINEER'S, STAMR a aSY14 �yJne c bedrooms, with the following stipulations: I v r A MIC'ITP �rc> WA ER A.ND sr• SArr1CTc1N4�GR PROGRAM �i�� ��, V I Jc • . Maintenance Agreements Supplemental Engineer's Report Other 5 t�!' �' -.��! Orginal Certi�icatw Date: Li' i .2 Y �— (Rev. 42/00) 0 Municipality of Anchorage GE_ 8V Development Services Department Building Safety Division S - On -Site Water & Wastewater Program 5 ° ` T Y 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST 1� Q Legal Description:U4 ��3 X15 AJ 2 10, See. Parcel ID:os — 151 -os A. WELL DATA Weil type &`Q.kti If A, B, or C provide PWSID # -A)b Well Log (Y/N) � Date completed 101013 Sanitary seal (Y/N) Wires properly protected (Y/N) Total depth L ft. Cased to & —/ft. Casing height (above ground) �in. FROM WELL LOG AT INSPECTION Date of test lobby Static water level 15 ft. Well production 3 9 -p -m- �. (/� 9•p -m - WATER SAMPLE RESULTS: Coliform colonies/100 ml. Nitrate < fl.� mg./i. Other bacteria _4 colonies/100 ml. Date of sample:" " D 3 Collected by: L . i3�f�va f4s lt_C�ir rig.v5� cCi .✓S. B. SEPTIC/HOLDING TANK DATA Tank Type/Material ,q_ ,e/Date installed Tank size I gLS0 gal. Number of Compartments Cleanouts (Y/N) Foundation cleanout (YIN) .Depression over tank (Y/N) High water alarm (Y/N) MA__ Date of pumping t/— /5" D 2 Pumper S 0y'^i= C. ABSORPTION FIELD DATA o Date installed ), Soil rating (g.p.d./ ? M) O System type �� Length _3 ft. Width _—', ft. Gravel below pipe ft. Y Total depth ft. Eff. absorption area�7ft2 Monitoring tube Depression over field k)_ Date of adequacy test y—c C Results (Pass/Fail) For bedrooms Fluid depth in absorption field before test 11-5 in. Water added gal. New depth />5 in. Elapsed Time: min. Final fluid depth 1�S in. Absorption rote >= 11 0 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) - ;y I,� If yes, give date D. LIFT STATION Date installed i "Pump on" level at&a in. r1 Datum uvll n i� r'� Jai1K E. SEPARATION DISTANCES Size in gallons 1 "Pump off"level at' -/O in. Cycles tested -(- SEPARATION DISTANCES FROM WELL ON LOT TO: I Septic tank/lift station on lot r Absorption field on lot i 11,F) /, Public sewer main �1 H. Sem !septic service line +'Wr Manhole/Access (Y/N) 1 High water alarm level at _{f _ in. Meets alarm & circuit requirements? i On adjacent lots + r On adjacent lots -j ldlJ Public sewer manhole/cleanout f) f Holding tank I A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line + Absorption field r7 f +r�©fit Water main Water service. line Surface water Wells on adjacent lots f SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: r Property line + L 00 Building foundation c35 Water main + I Q) ee�l1 { r Water Service line Surface water } Driveway, parkinglvehicle storage f Yio v«.t Curtain drain Wells on adjacent lots k t F, COMMENTS fl2 c:err g"' G. ENGINEER'S CERTIFICATION I certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. / aaaaa � Engineer's Printed Name luiS �,Cc1� ';gym c3'>STAAi4fs '� Date G1— 1 ! r— '?) HAA Fee S_ �� 7Lj . ©c Waiver Fee $ Date of Payment �f / �7��.J Date of Payment Receipt Number J7J ( I �c' ' Receipt Number (Rev. 12100) 05/15/2002 14:37 9076943093 GREAT LAND REALTY PAGE 02 �r?r 1olr7 coo "6' •ow. a �lei! /Z*• N ,fW tq ' Nb 1 a APR-15-2003(TUE) 1253 EAGLE RIVER ENGINEERING (FAX)907 694 3297 P.003/ow hrm-ur-n IK1 o-41 KL[Ilm lA LIA7LC C1YCK rm PW. wic=VUi Y. vej" .. . t '•NOt•-T7'mY • U �� So �Ab/�Ms+v/!!� r •� 1 � 1 •w AS�LT 98ii8D 6 ASJOC2AT>LS S1ND WRf;ETIAC 94- 2 I HEREDY CE7MrY TMAT t NAVE SJRYEYED THE POLLM NH Dcsot ED PROPFRfY+ t�w►�u'irJseac vrisr.iit.�/�if!. '• ANO 7w No E%A04CI fE1Rt DOST t7tLE} r A' be CKrm rf IS THE MCDKNMLITT oR THE MUM TO asl"Rt W THE onsTDM OF AMY iA&S ADRs. GOVCMAUn, OR aesTnitT>ONs W"M DO NOT AFFM ON TME Iti COAtJED wAgl- Y amw PLAT. NND6R MO m=Wwrims me" AWT bm 3iERt w 6E trAm FOR CDNB Rt7C om OF MM LINT, OR FOR t8Vzt.NM4w =M- SCALEI �~• h► +•t hs ++. OF•A(�t� �P: , S,Y � : y:'asz„ :7 • ' ^f...... •. • �. `...� ..• s..•r ; ••r f7� t oi• •, LS -091 : ,• a' t ' • . , ,,. .. p E, ��444ov otIR .► �i�s1 m =! X90'/ Municipality- of AnchorageO l �•� Development Services Department okooq`' c, 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 343 7ge.ak.us (907)343-7904 �+ CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D.051- ISS!—Gg HAA# 7 Expiration Date: -7 - 3 0 - O 1. GENERAL INFORMATION Complete legal description to+ 1q3—TISIU, f2 ( (A) i `SEGS Location (site address or directions) a13a--_a \JatiftC1WP< l,rl tib �(1� V Current Propertyowner(s�lnl x LaL I'en�rrr{P✓l_%e+ti Day phone (o'Rg-:5`(-7 1 Mailing address PD bnx (0-7 10'7 1) CA u-.5 IAS A' A of S &-i aaa-�xa Lending agency Al w4-iyz one_� "� Day phone��' Mailing address 1400 L,) Q.vAsorn f�'TtC fLQ e-&'je, A- - Real Estate Agent ro✓oQ�ltlo rtcl R PCL'1+�— Day phone &94-q I PS- Mailing SMailing Address 11411 (04 6;I,0 v7r1 P t.Jt-� , P03lP I� Lie e- A -K. Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3L 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well IR Individual On-site 9 Individual Water Storage ❑ Individual Holding tank 0_ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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 5 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 less than 30 days old. (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 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 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect, at the time of installation. Name of Firm Eagle ]River Endineerin services Phone (r�4 _51Qj Address P.O. B= 773294, Eagle River, AK 99577.3294 Engineer's Printed Name Ltw (S Date4. R• i � � 'ti 1, ` �": ' �.'�+ tars.• M EOGIN�ER'S X} Loi; A. Eelera 5. DSD SIGNATURE' ',`�r� gin, CE -6736 s i� Approved for 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory <n—,v �0� zz. P--e'� �\11 OFAPr�+'%. J?• ON-SITE ��c'= �� WATFR AND m WASTEWATER : PROGRAM ��/i�llJl nt•Nt Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: �4' 3 0 - 0 -2- i Municipality of Anchorage • Development Services Department Building Safety Division Onsite Water & Wastewater Program 4700 South Bragew St. P.O. Box 196650 Anchorage, AK 995195650 www.cl.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lof 1113 715 13) k l 00 SL ---0113 Parcel ID:C5 f - 15 4 -o K A. WELL DATA Well type �Jek K A B, or C provide PWSID # Well Log (Y/N) Y Date completed '�J3 Sanitary seal (Y/N) - Wires properly protected (YM) _ Total depth ft -51t- Cased to �� ft. Casing height (above ground) } n. FROM WELL LOG AT INSPECTION Date of test I O f cl 3 Static water level IS ft. 3 ft. Well production g.p.m. 1.6 g.p.m. WATER SAMPLE RESULTS: Coliform _-4) _colonies/100 ml. Nitrate 0, X mg.A. Other bacteria —0— colonies/100 mi. Date of sample: 43 1 yJ'r Collected by: L ,94A!�" Al zt, A.J B. SEPTIC/HOLDING TANK DATA Tank Type/Material Ste e.( Date installed t t tri 3 Tank size 11150 gal. Number of Compartments -2- Cleanouts (Y/N) K Foundation cleanout (Y/N)) Depression over tank (YM) _ Q_ High water alarm (Y/N) /V f �T Date of pumping §*N- y/J 1 Pumper SR f C. ABSORPTION FIELD DATA _p Date installed 11 Soil rating (g.p.d./ftr or !L'{irdrrn) L g System type Length 33 ft. Width ft. Gravel below pipe 14 ft. Total depth 1 ft. Eft. absorption area(Q;LJ_ft= Monitoring tube -Y-- Depression over field li Date of adequacy test Results (Pass/Fail) arr For 3 bedrooms Fluid depth in absorption field before test / S— In. Water added YSagal. New depth S in. Elapsed Time: 0 min. Final fluid depth I -S' in. Absorption rate >= '6'J -,P g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) r✓ 14 If yes, give date "— D. UFT STATION Date Installed 111ql� Size in gallons 1,9L50 'Pump on" level at'L3_ in. "Pump or level at JqQ in. Datum Py+n r" d -Jan (( Cycles tested ID E. SEPARATION DISTANCES Manhole/Access (YM) Y High water alarm level at q in. Meets alarm ti circuit requirements? Xew SEPARATION DISTANCES FROM WELL ON LOT TO: 1 Septic tanklliR station on lot /rA�) 1 On adjacent lots -I j C� Absorption field on lot 113, On adjacent lots Public sewer mala N)& Public sewer manhoie/deanout n/ twver /septic service line 42 3O r Holding tank Al IA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: r + r r Building foundation a Property line /00 Absorption field L r r Water main N A Water service line f3D Surface water + r Wells on adjacent lots + I QO SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: r J Property line 4'1W Building foundation :;�s Watermain Water Service line -F-,—Y) r Surface water + 100 r Driveway, parkinglveNde storage +3Q r1uY'l e J Curtain drain 0.pparee f Wells on adjacent lots +i on F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspecOons and review of Municipal records that the above systems are in conformance with MCA HAA guidelines In effect on this date. Engineer's Printed Name LOu tS --�wff'_V4, Date_ L/—Z]—oa HAA Fee $ Date of Payment Receipt Number (Rev. 12100) C77-75.00 Waiver Fee E yfa-(16 a ,{ Date of Payment g(�# • Receipt Number y ay9 Y �1 .. of Ce�,(a,. *!'49b 14► 4 Louis A Huhn �; CE -4736 t O �. � Jn i4.�ws•.pN � 1'�� NB9 Ji Oa 6 .' =BD•O •� 9 Nd'J'TT F 56170 N7z !' )' FOAL ' ASSUILT SM&RD d A3.90CTATLS LAND-'tMV7:LCG 694-0825 1 HEREBY C'✓ZTIPY THAT 1 HAVE SURVEYED THE;, FOLLOWING DESCRIBED PROPERTY, �• - £OF A(�•�) BGsI.nT/23 Jse: Ofi1.+; .0iW !/�! . OATL' rQ.•......... �9d` 4 ••• AND THAT NO EXIST EXCEPT AS q�B/�Y' �'� e:�s moi' ED. R&CATIT IS THE RESPONSIBILITY OF THE i.�;• 4$t� LN :•? j . OWNER TO DET ERMINE THE EXISTENCE OF ANY GIDS �.... •• EASEMENTS, COVENANTS, OR RESTRICTIONS ivs✓ir'T1 • .......... WWOi DO NOT APPEAR ON THE R£LORLED SUBDI- a. -t. . VISION PLAT. UNDER No CIRCUMSTANCES SHOILD F$ ;�. LS-D91B ANY DATA HEREON W USED FOR CONSTRUCTION yY 9./ HA'�'•.... .• l OF FENCE LINES, OR FOR ESTABLISHING BOUND- DRAWN, �\ "`*a�tt^.a �•�"� ARY UNCS. ,p..�f *!vim•.*" 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. # _ 051-154-08 1. GENERAL INFORMATION Complete legal description HAA # U, c,�.:--% Lot 123, T15N R1W Section 8 14 Location (site address or directions) --_ 21322 Jayha7vvk Drive, Chugiak Property owner Mitch & Debbie Hale v Day phone 688-4901__ Mailing address P.O. box 771997, Eaqle River, k 99577 _ Lending agency SPaN-1P Mortgage _ Day phone s -sem Mailing address 4300 B Street, Anchorage, AK 99503_ Agent Vista Real Estate Lori :rouse _ Day phone 689-6464 Address 16635 Centerfield Drive, Eagle River, AK 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well X Community well -- Public water -- NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site — X 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 (Pev 1/91) Fmm 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 Eagle River Engineering Services Phone 694-5195 Address Engineer's signature 6. DHHS SIGNATURE Approved for 3 Disapproved. Conditional approval for Additional Comments 0 bedrooms. — Date 3 r n bedrooms, with the following stipulations: Date -f— CAUTION 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 courtesyto purchasers of homes and their lending institutions in orderto 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 x21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVg'4RAurvOFAN*lomUE Environmental Services Division 10MMM SERVICES DIVISICO-k,DD� O 825"1_" Street, Room 502 • Anchorage, Alaska 99501 • (907) I-AAY 4 IAAY 0 6 1996 Health Authority Approval Checklist R E CT I V E. D Legal Description: 1101 /Z31/'�Al ,e -/W S« S—_ Parcel I.D.: O 1�/-� S y ` (V _ A. WELL DATA Well type _&l P�%C_ If A, E, or C, attach ADEC letter. ADEC water system number Log present (Y/N) yG5 —_ Date completed Total depth __Kqz� — Cased to _ iP Casing height (above ground) Sanitary seal (Y/N) Date of test Static water level Well production FROM WELL LOG /D WATER SAMPLE RESULTS: Coliform �- Wires properly protected (Y/N) _�-- AT INSPECTION g.p.m. --- 47 g.p.m. Nitrate 0-/0 N7 C:y�-__ Other bacteria _'01- —_ Date of sample: _ `j/9 �� _ Collected by: B. SEPTIC/diOL-DING TANK DATA. Date installed P43 Tank size 0 7 _ Cleanouts II // �� Number of Caxipar[ments � (Y/I� Foundation cleanout (Y/N) _ L(- Depression (Y/N) ��_ High water alarm (Y/N) _ /✓1 _ Date of Pumping _2 j�%i0 Pumper C. ABSORPTION FIELD DATA Date installed 422L— OIL- Soil rating (g.p.d./ft2-0r-R%dnh) O _ System type T Length _� Width _�_ Gravel thickness below pipe _ l Total depth _ 4L - Effective absorption area —62106t Monitoring Tube present(YIN)_,V ES, Depression over field (Y/I� ��0 Date of adequacy test Results (PasslFail)> For _ ."i-- bedrooms Fluid depth in absorption field before test (in.); 0 Immediately afteryfo gal. water added (in.): /• OP" Fluid depth _ 0_(ins.) Minutes later: _/ P Absorption rate = _ ' Ys o g.p.d. Peroxide treatment (past 12 months) (Y/N) _ NO If yes, give date D. LIFT STATION Date installed ///m Size in gallons /l 130 Manhole/Access (Y" WS "Pump on" level at* 1 " "Pump off' level at* -iii% High water alarm level at* Cycles tested E. SEPARATION DISTANCES *Datum If, 1rm -r soak SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/hel&ng tank on lot _ 104 ; On adjacent lots Absorption field on lot //3 ; On adjacent lots �nO Public sewer main 11/14- Public sewer manhole/cleanout I-///1 / Sewer -/septic service line 1-30 Lift station /00 SEPARATION DISTANCES FROM SEPTIC/1,16bDING TANK ON LOT TO: Building foundation 7 Q Property line '21"/M Absorption field Water.main/service line f- ( Surface water/drainage 'i'/00 Wells on adjacent lots /X SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation t / Property Line �-/GYM Water main/service line Surface water /-/0() Driveway, parking/vehicle storage area r zn / �ION� / Curtain drain Wells on adjacent lots -/ co F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records that the above sys6hs are in conformance with MOA HAA guidelines in effect on this date. Signature l /s Engineer's Name Cy�[j(T%!2/-i ,`Engine'eting`SeaPHete%ria Cc -6736 Date S/a 56 HAA Fee $ AZ I a Date of Payment 6 /y� Receipt Number _lo/ /c 5v z / Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number 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 Eagle River Engineering Services Phone 694-5195 Address P.O. Box 773 le River AK 99577 ` Engineer's signature Date m av p 5A Ij�•'k�gy 4:.: t�sf b'oe 6. DHHS SIGNATURE PRorE4`��°4�} 'rr Approved for bedrooms:` Disapproved:: Conditional approval for bedrooms, with the following stipulations: d Additional Comments By 7/�(/ d _ Date 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 orderto 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 engineers work. '� 7M25 Rev. V81) Back MOA N21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: GD1 /1-3 1- /Z/w SECS _Parcel I.D. OS/ OP A. Well Data Well type P1211//4fY If A, B, or C, attach ADEC letter. ADEC water system number /y��! Log present (Y/N) YES _Date completed �U/9 3 Driller _S vl� L- / vn-1'\1 _ Total depth t 5 / __Cased to /0 1 ___Casing height 1,12 Sanitary seal (Y/N) YE5 _Wires properly protected (Y/N) YC -S FROM WELL LOG AT INSPECTION '0 2 n Date of test a /9 aW � 7a Static water level _ TTI y Well flow 3 g.p.m. g.p.m. Pump levell (INKNDw/ I u� R 0 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /00 Absorption field on lot On adjacent lots _ -/dU 3 —;On adjacent lots /- ZiM Public sewer main N,/1- _Public sewer manhole/cleanout_ 5//9 3 �! i Sewer service line Petroleum tank _moi -a /lye ell/tE1-/ WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: - 01/0 Collected by: �W- � _ 13. SEPTIC/14014tNG TANK DATA Date installed _ // / 2 93 Tank size 42--50 6,Y1.5 _Compartments_ — Cleanouts (Y/N) _ YES _Foundation cleanout (Y/N) yl --s Depression (Y/N) /JD _ High water alarm (Y/N) LY14 _Alarm tested (Y/N) =�/�/-) _ Date of pumping l3 - NEw✓ _Pumper &-, _ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Wells) on lot On adjacent lots _Foundation To property line 91, / 00 _Absorption field __Water m/service line f so _ Surface water/drainage/ 72-026 (3/93)• Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer /�,iYd// lxlvle ✓� Size in gallons /2 50 Manhole/Access (Y/N) Y&5 Vent (Y/N) YCS "Pump on" level at g-3 / "Pump off" Level at /f0 " High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Cycles tested I—gln - New Well on lot /00 On adjacent lots t /00 Surface water D. ABSORPTION FIELD DATA Date installed //�/2�93 Soil rating (GPD/Ft2) d. System type /3�0 Length 33 Width / 9 Gravel thickness / Total depth / Total absorption area /4.7 4z' Cleanout present (Y/N) YSS Depression over field (Y/N) /C-5 Date of adequacy test N/w Results (pass/fail) P/9 S 5 for 3 Bedrooms Water level in absorption field before test 'V14 After test 4bg Peroxide treatment (past 12 months) (Y/N) N%/9 If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 11-31 On adjacent lots Yc- To building foundation 3 Property line -� /Od To existing or abandoned system on lot /V/4 On adjacent lots f 30 Cutbank Water main/service line Surface water Curtain drain E. ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area t 30 I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in inspection. A L Signature 2 Engineer's Name GQt /s /3U%CR 14 P. E • 4+.01 io„ Q U, ct Date , po HAA Fee $ 0 00 ° r-� Date of Payment Receipt Number 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number