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HomeMy WebLinkAboutT15N R1W SEC 5 LT 33 M110' '7~'~'~ : MUNICIPALITY OF ANCHORAGE ~ ~'m'l~ .------------------~ ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT [] UPGRADE LEGAL DESCRIPTION LOCATION / ] / NO. OFBEDROOMS Well ~ I Absorption Dwelling ~ ~ Manufacturer Material No. of compartments Liq. ca~allons IF HOME.DE: Insid~ Width Liquid depth ~ ~ DISTANCE TO: Well ~[ /,~ Dwellin9 PERMITNO. O ~ ~ Manufacturer/' ~/~ Material Liquid capacity in gallons Q Well ~undation Nearest lot line PERMIT NO, / ~ ~ No. of lines Length of each line tal length of lines Trench width Distance between lines ~ inches ~ -- Top of tlle to finish grade Material beneath tile Total effective absorption area Q inches ~g ~' ~ Cdb depth~ Total effective absgr~o~ ~ ~ DISTANCE TO: Well/~ / Building '~a~on Nearest lot line /O / ,' Class ~ V J <__~J/~i.~[Z Driller Distance to lot llne PERM,TNO. OTHER ~ ........ PiPE MATERIALS ~ ENVI[ON~N AL ROI OTIC ....... Mt~ICIPALITY OF ANCHOK..JE DEPARTMENT OF HEfLTH AND ENVIRONMENTfL PROTECTION 825 L STREET~ RNCHORAGE¢ AK 99501 264-472¢ PERMIT NO: DRTE ISSUED: 848452 06712/84 RPPLICRNT. RDDRESS: CONTRCT PHONE: LEGRL DESCRIP: LOT SIZE: MRX BEDROOMS: C?O S & S ENGCG R & S CONSTRUCTION SRB ±96X EfGLE RIVER, RK 99577 SUBDIVISION: NB LOT: ±/2 ~ BLOCK: SECTION: 5 TOWNSHIP: 15N RANGE: ±W i. 25R (SQ. FT. OR fCRES) NB LISTED BELOH RRE THE OPTIONS AVRILABLE TO VOU IN DESIGNING YOUR SEPTIC SVSTEM. CHOOSE THE OPTION THfT BEST FITS VOUR SITE. BE[:, DEPTH TO PIPE BOTTOM (FT.) 3.5 mm GRAVEL DEPTH (FT.) 0.5 TOTAL DEPTH (FT.) 4.0 GRAVEL WIDTH (FT.) ~9.0 GRAVEL LENGTH (FT.) 36.0 GRfVEL VOLUME (CU YDS.) 25. ~ TANK SIZE .(GALS) i, 000. 0 ~ SOIL RRTING (SQ. FT. ?DR) ±50 mm DEPTH TO PIPE BOTTOM < 4 0 FT. MAY REQUIR~ f LIFT STATION ~ TANK MUST HAVE AT LEfST TWO COMPfRTMENTS I CERTIFY THRT: ±. I BM FRMILIfR WITH THE REQUIREMENTS FOR ON-SITE SEWERS fND WELLS RS SET FORTH BY THE MUNICIPfLITY OF fNCHORAGE <MOA) AND THE STfTE OF ALRSKf. I WILL INSTALL THE SYSTEM IN RC.L. URBfNUE WITH fLL MOl CO£.E_. AND RE=LLfTI - AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. 3. I WILL RDHERE TO ALL MOA fND STATE OF ALfSKf REQUIREMENTS FOR THE SET BfCK DISTANCES FROM RNY EXISTING WELL~ WfSTEWBTER DISPOSAL SYSTEM OR PUBLIC SEWERfGE SYSTEM ON THIS OR ANY ADJfCENT OR NEfRB9 LOT. 4. I UNDERSTfND THRT THIS PERMIT IS VfLID FOR f MfNIMUM OF ~ BEDROOMS AND ANY ENLARGEMENT HILL REQUIRE fN fDDITIONAL PERMIT. IF R LIFT STATION THEN (i) BIN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; WILL NOT BE BPPR~¢E[:, ~4~[HOUT AN E~ECTRIC~L INSPECTION REPORT; ELECTRICAL WOR~, , , ,,,,, ,~LI$'T//~¢'ONE BY/¢~ LICENSED ELECTRICIAN. SIGNED~_~_ _ ............. DRTE: APPLICRNT: C?¢!¢S~-~- S ENGCG. R & S CONSTRLICTION ISSUED BY IS INSTRLLED IN RN RRER COVERED BY MOR BUILDING CODES, (2) RS-BUILTS RND (~) THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~ SOILS LOG [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 5 6 7 8 9 10 11 12 13 14 15 16 17, 18- 19. 20- SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND COMMENTS ~1~ y]'~ ~.-[ I~(~1 TO ~li~,~ ~ ~~ ~ -- FT 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 CER'r F CATE OF HEAL'tH Au'rHOR TY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Middle ½ of Lot 33; Sec 5; T15N; R1W Location (site address or directions) 22319 Davidson Drive Chugiak, AK Property owner Bob Juettner Mailing address P.o. Box 671390 Day phone Chugiak, AK 99567 Lending agency Mailing address Agent Address Day phone Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. 3 NOTE: Individual well XXX 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: xxx 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. ?2-O25(Rev. 1/91) Front MOA#A1 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 Approvat 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 invest_~ation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with ali Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature Phone Date -)//~'/E ? REQUEST YOU ISSUE A FULL HEALTH AUTHORITY APPROVAL AT THIS TIME. ON THE CONDITIONAL APPROVAL HAS BEEN COMPLETED. TA~K HAS BEEN REPAIRED. DHHS SIGNATURE [J'~ Approved for '~ Disapproved. Conditional approval for bedrooms. ALL WOP~ REQUIRED THE BROKEN CLEANOUT ON THE SEPTIC 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 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. Legal Description: MUNIClPALIT'~ 0,': AINCHOY,~.GE mVI,ONM~N'r^L Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN. SERVICES ~JAR 1 ,~ 199 Environmental Services Division 825 L Street, Room 502° Anchorage, Alaska 99501° (907)34~I~4~E i YED Health Authority Approval Checklist I~=~o~-~ .,~ .~,= J.o'r'~, ~ec~/~'5~), ~'l~Parcel I.D.: O A. WELL DATA Well type Log present (~1) Total depth Sanitary seal ~1) If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to FROM WELL LOG 10,5' Casing height (above ground) I~" e- Wires properly protected (~) ~'~ AT INSPECTION Date of test Static water level Well production -'-.% g.p.m. I .5 g.p.m. WATER SAMPLE RESULTS: Coliform Nitrate 0 .<~ Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~'/'~q Tank size Foundation clean,gut (~) ?'~s Depression ('~. Date of~P~rppmg ,, , ~:19~',:'~,, Pumper __ C. ABSOrPTION'FIELD DATA .¥, ~: Dat~*ifi~{~ll'~d ' G/qq ....... ~'I. Soil rating (g.p.d./ff~ or~ Len~:; '~.r~q Widt~ ~ P I~' Effecfi~e~ab~orption are~ ~ ~ Date of adequacy tost ~ -~w High water a arm (Y/I~ Number of Compartments. ~ ' Cleanouts~/~N) Gravel thickness below pipe Monitoring Tube present~_J~N) System type O, ~ ~ Total depth __ Depression over field Results (~ail) /P.4. s For -~ Fluid depth in absorption field before test (in,); ~" Immediately after~7~) gal. water added (in.): Fluid depth 0" (ins) Minutes later: PeroXide treatment (past 12 months) (Y~) Absorption rate = If yes, give date bedrooms ~)~* 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) 14igh water al~ E. SEPARATION DISTANCES on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: ~holding tank on lot Absorption field on lot Public sewer main i Or~~ f- On adjacent lots On adjacent lots Public sewer manhole/cleanout Sewer/septic service line 35 "~ Lift station ' SEPARATION DISTANCES FROM~HOLDING TANK ON LOT TO: Foundation ~' r 4- Property line /O ~ 4- Absorption field Water main/service line Surface water/drainage IO¢'~- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water Curtain drain Building foundation (~' ' +- Water main/service line Jo0'+ Driveway. parking/vehicle storage area Wells on adjacent lots /Oo '~ ENGINEER'S CERTIFICATION I certify that l have determined thru field inspections and review of Municipal records~.o.'.~.v~.~s are .,,. ~..;.,,. : .... in conformance with MO,¢ H,A,4~guide~ines in effect on this date. f ~4,~ '""~.,?.~_~ Signature ~t~ ~ ,~, HAA Fee $. ~% ¢r-~ , ¢'~ Waiver Fee $ , Date of Payment Date of Payment Receipt Number ~¢F,~ ~'* ~--~Z D,~~--) Receipt Number 72-026 (Rev. 3/96)* 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. # © 3'~ / - 4) ~ ;~ - ;~ ~_ HAA # ~c~ ('~-~L~ 1. GENERAL INFORMATION \ \[~)~ Complete legal description Middle ½ of Lot 33; Sec 5; T15N; R1W Location (site address or directions) 22319 Davidsop Drive Chugiak, AK P~operty owne~' ' Bob Juettner, Mailing address ~ P:o. Box 671390 Lending agency Mailing address Agent John Levy/ HRT Realty Chuqiak, Day phone AK 99567 Day phone Day phone 244-3722 Address Unless otherwise-requeSted, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: xxx If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~)25 (Rev. 1791) Front 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 Address Engineer's signature S & S ENGINEERING 17U~4 Eagle I(iver Loop Koad NO, 204 Eagle River, Alaska 99577 Phone REQUEST YOU ISSUE A CONDITIONAL HEALTH AUTHORITY APPROVAL TO REPAIR LOCATED ON THE FIRST COMPARTMENT OF THE SEPTIC TANK. WORK TO COMPLETED NO LATE THAN 15 JUNE 1997. - CLEANOUT DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: _ 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 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 engineers work. 72-O25(Rev. 1/91) ~ack MOA#21 ROBERTC. COWAN, RE. ROBERT A. SHAFER, RE. CIVIL ENGINEERS SEWER&WATER INSPECTION ENGINEERINGSTUDIES ANDREPORTS WELL iNSPECTION & FLOWTEST SITE pLAN~ ROADDESIGN $OILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS July 7, 1997 (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Middle ½ of Lot 33; Sec 5; T15N; R1W RECEIVED JUL 9 1997 Municipality of Anchorage Dept. Health & Human Services A Conditional Health Authority Approval (HAA) was issued March, 1997 for the referenced property. All work required for the Conditional HAA has been completed. The broken cleanout located on the first compartment of the septic tank has been repaired. Please issb~ a' fullHealth Authority Approval at this time. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E.. i. RCC/gk 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 ROBERT C. COWAN, RE. ROBERT A. SHAFER, RE. SEWER&WATER INSPECTION ENGINEERINGSTUDIES /~ND REPORTS WELL INSPECTION &FLOWTEST ~OAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS March 28, 1997 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Middle 110' of Lot 33; Sec 5; T15N; R1W Request you issue a Conditional Health Authority Approval on the referenced property to repair the broken cleanout located on the first compartment of the septic tank. Work to be completed no later than 15 June, 1997. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/gk 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 CT&E Environmental Services Inc. Laboratory Division 200 W. Pmxar Orive Drinking Water Analysis Report for Total Coliform Bacteria ~,ohoragn. ~K ~s: 8-1 605 READ INSTRUCTIONS OPl REVER~E SIDE BEFORE COLLECTII¥G SAMPLE Tel: {907) 562-2343 tVffOST BE COMPLETED B---~ WATER SUPPLIliR PUBLIC WATER SYSTEM I.D.# ~ I I I ] PRIVATE WATER SYSTEc'VI 0 SendRe~ult$ 0 Sendlnvoice 17034 Eagle River Loop Read, No. 2.0~ S & $ ENC. INEERING i~°mPmY ~q~¢ 17034 Eagle Rtver Loop Road, No. ~ ~au ........ , Alaska ~vavx Month Day Year SAMPLE TYPE: '~ Routine 0 Treated Water 0 Repeat Sample (for routine sample '~ Untreated Water with lab ref. no. ) O Special Purpose Time Collected Collected By 7__:So e~ e. Fax: (907) 561-5301 TO BE COMPI,~''~D BY LABORATORY Analysis shows this Water SAMPLE to be: -O__ - Satisfactory 0 UnsatisfactOry ' O Sample over 30 hours old, results may be unreliable O Sample too long in ransit: sample should not be over 48 hours old at examination to ndicate reliable results. Please send new samole via special delivery mail. Date ixecei e ~ AnalOsis Beg~P . ~ Anal~ical Meth0~ Membrane Filter o MMO-~G Number ofcolonies/100 mi. r ~ h R~L No. Result* Analyst Sent to A.D.E.C. Anch Fb~ Jun Faxed Date: Time: -- Client notified of unsatisfactorY results: [] BACTE~OLOGIC.~ WATER ~N.~YSIS ~CO~ E. Coil ~ ~ MMO-MUG Result: Total Coliform BGB COLIFI~M_ ~ Membrane Filter: Direct Count Verification: LTB. Fecal Coliform Confirmation Final Membrane Filter Resultz Reported By ate Phoned Spoke with Date: - Time: -- Coliform/IO0 mi Faxed Co~me.ts: PAB-'[ ONE OF ~ ~TwO-T 0 FOLLOW MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1o General Information Application Date (a) Legal~ ~Descripti°n~ ~5- ~ (include~/~l°t',tY bl~; ~su~divisi°n'6~ ~ ~'secti°D~//O township,~ range) Location (address or direction~) (b) Applicants ~ ~,5 ~ ~ezepnone - aome Business (c) Applicant is (check one) Lending Institution ~; ~er/b~lder~ ; (d) Lending Ins:i:n:ion ~ '~" ~t~O ~ Telephone Ad~ ss (e) Real Estate Co. & Agent Address 0 Telephone (f) Mail the HAA to the following address: ~pe of Residence Single-Family~ Number of Bedrooms Water Supply 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 Disposal Onsite~ Fublic~ 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] Engineering Firm Providin~ Inspections~ Tests~ Pile Search~ Data 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 wsstewater disposal system is safe~ functional and adequate for the number of bedrooms and ~ype 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 wmter supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect .0D ~he date of this inspection. Name of Pirm Address Date Telephone D~EP Approval Approved for ~ bedrooms By Approved ~ Disapproved __ Terms of Conditional Approval Conditional CAUTION TH~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF MEALTH A~ND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT~ ATIONS GIVEN IN PA!RAGPJkPH 5 ABOVE BY AN INDEPENDENT PROFES~SIONAL ENGINEER REGISTERED IN T~ STATE OF ALASKA. ThIE DHEP DOES THIS AS A COURTESY TO pURCHASERS OF HOMES AND THEIR LENDING i~NSTITUTIONS IN ORDER TO SATISPY CERTAIN FEDERAL, AND STATE REQULRE- MENTSo 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. (DHEP SEAL) RR4/eJ/D18 [Page 2 of 2] 7-19-84 ae MUNICIPALITY OF ANCHOP, A~E ~ /"~'~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MUNIcIPALZTY OF ANCHORAGE (MOA) H~T. armo~ ~PROV~ (mi MAR J c~ - F~ ~ R E C E I V E D £ Well Lc~ present[~/~, Date Cc~leted ~ /~ / ~pth of ~outin9 Casing ~ight ~ G~nd / ~ / ~+ Sanit~ ~al on ~sing~ ~p~ation Distan~s ~ ~11: / To ~st ~ of ~s~tion Field On ~t,,/~ ~ ; ~ Adjoining ~ts Wate~ S~le Colle~ed . ~ / Be SEPTIC/HOLDING TANK DATA Date Installed ~4/~ ~' Size /~O~ No. of C~ga~tm~nts standpipes (~) Ai~-tight Caps (~/ . Fou~dation/7/./Cleanout (Y/N) Depression ove~ Tank (Y~ Date Last P~m~ed ~u~' ,,. pumping/Maintenance Contract on File (Y./N)/J/~; for Holding Tank High-Wate= Ala=m (Y/N)/~//~ Tempo=al~y Holding Tank Permit (Y/N)~J~ Separation Distances f=fzn sePtic/Holding Tank: · 'To Wate=-Supply Well /~ ~ ~ To Building Foundation /¢ / To Property Line /~ ~-~ To Disposal Field /~' TO Water Main/Se=vice Line /63 (~'~ To stream, Pond, Lake, c= Major D~aina~e Cou~e /3 ¢ ~J ~- Cu~ents Receipt % Date Paid: Amount: c~% [Pa~e 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date .Installed ~.~./~' Width of Field /d~ Square Feet of Absorption A~ea Depression over Field (~ Type of System Design Length of Field Depth of Field ~ravel Bed Thickness ~:,/&'~o~-~'~ Date of Last Adequacy Test Results of Last Adequacy Test /J/~b Separation Distance f~cm A~sc~ption Field: To Water-Supply Well To Building Foundation Lot /~ ?~Yi To Water Main/Service Line To St~eam/Pond/Lake/c~ Majo= Drainage Course To D~iveway, Parking Area, c~ Vehicle Storage Area Co~nts /~l~O ~ To P~operty Line /0 r ~ ! TO Existing or' Abandoned System cn ; On Adjoining Lots ~o ¢ ~ /~ ~ To Cutbank(if present) /%30 ,~3~c D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Cora~ents Dimensions Manhole/Access (Y/N) "Pump Off" Level/at . Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA ~quest ** I certify that I have checked, verified, or eonfc=m~d to all MOA on the date of this insD~c~ic/n. Signed ..... ¥~_ ;%~%S~-% ~v" Date Company i':, = ., ........... No. KB1/d5/s Ln effect [Page 2 of 2] 2-15-84