The URL can be used to link to this page

Home My WebLink AboutUPPER EAGLE RIVER ESTATES BLK 1 LT 2A 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 On -Site Wastewater Disposal System Permit Permit Number: OSP241257 Work Type: SepticTank Upgrade Effective Date Expiration Date: Tax Code Number: 05078122000 Site Legal Address: UPPER EAGLE RIVER ESTATES BLK 1 LT 2A G:0056 Site Mailing Address: 20114 EAGLE RIVER RD, Eagle River Owner: PATTERSON MICHAEL J & DIANE J Design Engineer: FORGE ENGINEERING This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy 8/28/2024 8/28/2025 Lot Size in Sq Ft: 46721 Total Bedrooms: 4 ❑ Private Well ❑ 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. Qovered-seafed and heated to prevent freezing Special Provisions: • Locate missing pipes in the field and repair as necessary. Reeefved-14� T Su/e, or 2 Issued By: tel/ Date: Date: �� ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 050-781-22 Property owner(s) Diane Patterson Day phone (907) 242-1983 Mailing address 20114 Eagle River Road, Eagle River, AK 99577 Site address 20114 Eagle River Road, Eagle River, AK 99577 Legal description (Sub'd., Block & Lot) Upper Eagle River Estates Block 1 Lot 2A Legal description (Township, Range & Section) Lot Size 74,052 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (Z all that apply) Absorption Field F] Initial EJ Single Family (SF) RX (w/wo ADU) Septic Tank E RX❑Upgrade Duplex ❑ (D) Holding Tank R Renewal❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: 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: Date of Payment: Receipt Number: Permit No. 02 q Permit App_::-: I Waiver Fees: Date of Payment: Receipt Number: Waiver No. August 8, 2024 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Upper Eagle River Estates Block 1 Lot 2A - 20114 Eagle River Road Septic Tank Replacement Dear On-Site Services Engineer: The owner of the above lot has a septic tank that has reached its end of useful life, so we are submitting this permit application for its replacement. The attached site plan identifies the location of the home as well as the wells and septic location. No conflicts exist between this proposed system and any other wells or septic system, whether on this lot or adjacent lots. We are replacing the septic tank with the same size designed for 4 bedrooms. The new septic tank will be a minimum of 100’ from all wells and surface water. Please refer to the attached plan for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241257, Deb Wockenfuss, 08/28/24 Benjamin Schiller CE 12592REGISTEREDPROFESSION A L E N GINEER 1"=50' APPROX LOCATION OF EX 75' LONG ABSORPTION TRENCH TO REMAIN IN SERVICE CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND 2CO UPPER EAGLE RIVER ESTATES, BLOCK 1 LOT 2A FEET 0 50 100 EAGLE RIVER ROAD 4-BDRM HOME SEPTIC PLAN 8/8/24 15' UTILITY EASEMENT 15' UTILITY EASEMENT 10 ' U T I L I T Y E A S E M E N T SHED EX 1250 SEPTIC TANK TO BE DECOMMISSIONED PER UPC NEW 1,250 SEPTIC TANK EX. CO LOCATE MISSING PIPES AND REPAIR AS NECESSARY Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241257, Deb Wockenfuss, 08/28/24 EAGLE RIVER ROAD UPPER E A G L E R I V E R ESTAT E S S U B D I V I S I O N BLOC K 1 Taylor L. Dosch No. 189892 R E GISTEREDPROFESSIO N A L L A N D S U RVEYOR DETAIL: HOUSING FOOTPRINT DETAIL 2 NAME MAILING ADDRESS LEGAL DESCRIPTION LOCATION MUNICIPALITY OF ANCHORAGE 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 REP(~T PRONE / '~ ~ ~.-T~'-~'~' ~¢~L~-~(.~;,¢~-¢~..~ ~ UPGRADE Weg j I Absorptio~re~ Dwelling DISTANCE TO: ~' ~- -~'q"'~'~ Material / No. of compartments Liq, in gallons IF HOMEMADE: Dwellin21nside length Width ~ Liquid de t~.~.~.~ DISTANCE TO: Well IJ/A PERMIT NO. Manufacturer Material / Liquid capacity in gallons ~Nea rest y(~ in~4~ ~/ Trench w d~.~ inches Distance bet~V4ine~ NO. of Ii.es ~ Length ~.,l~e~h~ ne Top of tile to finish grade Length Type of crib DISTANCE TO: DISTANCE TO: Width Crib dianleter Well , th Building foundation Material beneath tile Depth Total eJ:fective ab.s~ptio~ area PERMIT NO. ;rib depth Total effective absorption area Building foundation Nearest lot line Driller Sewer line Distance to lot line Septic tank PERMIT NO, Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS APPROVE~ ~ 8 E"~GtNEERIN~ .......... J~H. 694 2070 DATE LEGAL PERM IT NO: DATE I SGUED". APPL I CAN'¥: ADDRESS: CON'T'ACT PHONE: LEGAL DESCR IF': L~OT SIZE: IdAX BEDROOMS: ~'-IL~-.,~ ~: £} I F"~-~L. ][ -l'"'~v" OF~ DE.FA~-,TMENT OF HEALTH AND ENVIR~NMENTA PROTECTIGN 825 L STREET, ANCHORAGE., ~64 -47~ . 850434 AK 9950 %,)~-~<~ ENGINEERING JOSH PALISTER GRB- 196-X EAGLE RIVER, AK 995'77 694-2979 -' -' E,.~TA [E,.~ L. OT: 2A BLOCk.. sUBDIVISION: UF'PER b..l~. -~ " ~" ' ' "' SECTION: :U7 TOWNSHIP: 14N RANGE: 1W 4o7~1 (SQ.FT. OR ACRES) 4 Listed below are the options available 'to you in designing youe septic, system. Choose the option tbat best ~its your site. [.EF 1H TG PIPE BGTTOM (FT.) ,-.~, GRAVEL DEPTH (F'T.) 4.C~ 0.5 3.0 TO-I'AL. DEPTH (F'T.) 9.0/~ 6. 8 bRAgE. L WID]]H (FT.) GRAVEL LENGTH (FT.) ~5.0~ 41.0 70.0 GRAVEL VOLUME (CU.YDS.) 31.3 / 33.5 45.4' SOIL RATING (SQ. FT./BR)' ~ 'T'ANK MIJST HAVE AT LEA,)T TWO COMFARTMb-N]S -I certify that: 1. I am familiar with tl~e-requirements ~or on-site sewers and. wells as set ~ortb by the Municipality o{' Anchorage (MOA) and the State e~ Alaska. I will in,tail the system in accordance"with al, 1 MOA codes and reg~lation~ . and in cempliance wi+h the design criteria o~ this permif .... 3. I w~].]l, adhere te ail MOA and State. ol Alaska requirements rcm the set back distances ~'rom any exist:i, ng we].].~, wastewater dispesal system o~' public sewerage system on this or any adjacent or' nearby lot~ 4. I understand that this per. mit is valid for a maximum o~' 4 bedrooms and any en].argenent will requi~'e an additicJna], permit. IF A L. IF'T' GTATiGN IS INS'I'AI...[.ED IN AN AREA COVERED BY MOA BLILDING CODES, THEN (1) AN ELEC'I"RICAL PERMIT AND INGPECTIGN MUST BE GB'I'AINED'~ (2) AS-BUIL"t'S p' ,'' INSPEC- ON REF'GRT~' AND (3) THE WILl... NOT BE AF'PROVED WITHGUT AN EI..,E...,[RICA~ ELECTRICAl-- WORK' MUST BE DJ)NE BY A LICENSED E....~CI'RI[',IAN. ................ AF, F>LI[]AN'f: % S&3 ENGIN:ERINB ;0S1'4 PAL~TEF DEPARTMENT OF NEALTH AND ENVIRONMENTAL PRGTECTION 825 L STREET, ANCHORAGE, AK 995(}1 ;264-4720 PERMIT NO DATE ISSUED. .7/.~/8~ APPL I CANT: ADDRESS: CGN"f'ACT F'HONE: ADEPT C[)NST INC SR 177 EAGLE RIVER, AK 694-6550- 99577 LEGAL DESCRIP: SUBDIVISION~ UPPER E.R. ESTATES 'LO]'~ 2A SECTION: 17 TOWNSHIP~ 14N ~ANGE: 1W LOT SIZE: 466900 (SQ.F'T'. OR ACRES) MAX BEDROOMS: -3 BLOCK~ 1 L. isted below are the options available to you i~] designing your .septic system. Choose the option tba'L best fits your site. DEPTH TO PIPE BOTTOM (FT.) 5.0 6.0 5.0 GRAVEL DEP]"H (FT.) 4.0 0.5 3.0 TOTAL DEPTH .(F'T.) 9.0 6.5 8.0 GRAVEL. WIDTH (FT.) 2.5 ' 19.0 5.0 GRAVEL L. ENGTFI (FT.) 57.0 .36.0 ~.~ 0 GRAVEL. VOLUME (Cu. YDS. ) o= * -, ~.~. 8 25.4 .~,4.. 4 TANK sIZE: (GALS)~ 1~000.0 ~ 1,000.0 ~* '1~000.0 ~ SOIl_ RATING (SQ.FT. /BR) 150 150 15] ~..~ TANK MLIST HAVE AT LEAST '¥L~O COMPARTMENTS I certi£y that: 1. I am {amiliar with the requirements for on-site sewers and wells as set ¢orth by the Municipality oF Anchorage (MOA) and the State oF Alaska. 2, I will install the system in accordance with all MOA codes and regulations, and in compliance with {he design cr, itepia oF thi~ permit. 3. I will adbepe f..o all MOA and State ~{ Alaska requirements ¢~p the set back distances ~rom any exi'sting'well, wastewatep disposal system op public sewerage system on this op any adjacent or nea~by l~t. 4, I understand .that this permit is valid ~op a maximum o~ 3 bedrooms and any enlargement will pequir~e an additional per'mit. IF' A I...IF'T STATION IS INS]"ALLED IN AN AREA COVERED BY MOA BOILDING CODES, THEN (1) AN ELECTRICAL PERMI,T AND INSPECTIOIq MUST BE O~]"AINED; (2~ A~;-BUIL]"S WILL NOT BE APPROVED WITHOUT AN ELECTRICAL. INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. APPL,ICANI"~ ADEPI~ONST INC . MUNICIPALITY OF ANCHO, ,,~GE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: 1 2 3 4 5 6 7- 8- [] PERCOLATION TEST SITE 10 11 12 13 14 15 16 17 18- 19- 20- COMMENTS N~. 1457-l~ ~. ~h~ TIll ~ ~ ..-i · ~ Ti~e Water Drop PERCOLATION RATE TEST RUN BETWEEN FT AND .(minutes/inch) FT PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4- 6- 7 8 9- ' SOILS LOG MUNICIPALITY OF ANCHORAGE [] PERCOLATION DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST 825 L. Street, Anchorage, Alaska 9BBO~ 264-4720 SOILS LOG - PERCOLATION TEST SLOPE SITE PLAN L / / 10- 11 13~,~ 14- 15- 16- 17- 18- 19- 20- WAS GROUND WATER //~ ~ ~ ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE /'~/////~' (minutes/inch) TEST RUN BETWEEN , ET AND . FT B '//"~/ / COMMENTS PERFORMED BY: , 72-008 (6/79) 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) (b) (c) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name '~"~ '~,z~'-'t~'~-=IL- Telephone: Home Lo~- ~.~ob~Z~ Business ~:~-~ Applicant Address '~,,O. I~,c:::,~' "lrll"Z-.~ 'E~,~n'~--- ~--~k/~.¢--- ~.¢.'L.,¢,.~¢.~,. ¢'lct~"l'-/ Applicant is (check one): Lending Institution []; Owner/builder,S..; Buyer []; Other [] (explain); (d) Lending Institution ,/~L.. '~z:,~.:.-i~-qc. ~D'C.-q-~/,.~ Telephone Address (e) Real Estate Company and Agent f'"'&~--~ Address Telephone (f) ..l~,~-the HAA to the following address: --S&S~NGJNEEEING- SRB 19~( EAGLE RIVER, AK 99577 TYPE OF RESIDENCE Single-Family~ Multi-Family [] Number of Bedrooms ~ 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 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) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE 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 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 inspect~r~. ........ & ~ ENGINEERING Name of Firm $~ R J~6X Telephone Address ~GL~ MAY I 4 1986 Date Approved for //~) ~ '~ bedrooms by ./)'~/~:;/ / '-)~' ¢-<-~,4~'~ Date '\, L~' Approved ×/~ 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 professional engineer's work. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MO.~,i; · G~IEALTH AUTHORITY APPROVAL (HAA) · ~, OF ~'~Ct~OYJ~' ·CHECKLIST - FEBRUARY 1984 [~V .,.,~...~ Legal Description: WELL DATA Well Classification If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/~' Static Water Levei Casing .Height Above Ground ...'Electrical Wiring in C~nduit~/N) Cased to /--/-o ;~ Date Completed .];:~-F_.- /~/¢2~ Yield Depth of Grouting ~ Pump Set At ~ ~ Sanitary Seal on Casing Depression Around Wellhead (Y~ f ~ Separation Distances from Well: ' ' TO Septic)Holding T~nk on Lot /!,5~ ' ; On Adjoining Lots ~ ' ~'To ·Nearest Edg~ of Absorption Field on Lot / ~ z~ / ; On Adjoining Lots /~, '-', ', To Nearest Public Sewer Line To Nearest Public Sewer · :- ,Cleanout/Manhole To Nearest Sewer Service Line on Lot water SamPle Collected by ~ ~ ~ ~ ~t,~'~=~/__/~,Jd~ ; Date / Water S~imple :rest Results ~,'~'"'/-/5'F=~'~-"~'-~/2-~¢ Comments B. SEPTIC/I.I~L-DiNG TANK DATA Size /~'~ ~) No. of Compartments ~-- Foundation Cleanout~3'N) _ Date Last Pumped /J~ /-4'/~ ; for Temporary Holding Tank Permit (Y/N) Date Installed ~' ~ - ~E~,_~ Standpipes ~YN) Air-tight Caps ~/N) Depression over Tank (Y~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) '-/~ Separation Distances from Septic/.~Tank: To Water-Supply Well ] ! ,~ TO Building Foundation / To Property Line /~ "4- To Disposal Field To Water Main/Service Line / o ~ To Stream, Pond, Lak~, or Major Drainage Comments · Page I of 2 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y,(~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well / To Building Foundation ~p 2 Lot / ~-/-') ¢'~'~f)- Type of System Design Length of Field '~'~ Depth of Field c~ Gravel Bed Thickness /¢ Standpipes Present (~/N) Date of Last Adequacy Test To Water Main/Service Line / o 14' To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line / To Existing or Abandoned System on ; On Adjoining Lots ~'~ To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) ~'Pump Off" Level at / '~--~/Tf-I _ Vent (Y/N) ,' / ' Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certif'~t~t~ ~l~]~ied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signe~ ~ .... Date Comp~.~R~ MOA No. Receipt No. ,,~-~20'' 4 Date of Payment ~ Amount: $ Page 2 of 2 72-026 (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) r (b) Applicant Name '~;'-~.-~t-[. ~;;'~ ~,,~'1-¢~-eL-- Telephone: Home [~¢~ Z~f~6¢ Business /~"//- ~'~' Applicant Address ~, (:D. ~:~::~X ql~-'/...~d¢ _ ~:¢~'~. ~.¢'~,4._; ,¢~ (c) Applicant is (check one): Lending Institution []; Owner/builder~L~Buyer [] ;.Other i--I (explain); (d) Lending lnstitution ~ f:2,,¢.~-~,~"~c..- IL~E::Yz:C~/'.~Telephone Address 4~:~.~. I .~-~-_. (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 ~f' Other WATER SUPPLY Individual Well/l~- Community [] Public [] Note: Jf 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 corn munity 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) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE 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 Hea~th 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 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 ¢ - ~- -~ . , Telephone Address SR~ 196x Approved for ~__~_~ ~ bedrooms b ~ Date Approved 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 professional engineer's work. Page 2 of 2 WELL DATA Well Classification Well Log Present Total Depth q/?/ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (~N) Separation Distances from Well: To Septic/Huldi~,u Tank on Lot MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: MUNICIPALITY O~ ANCHORAGE DEP?, OF HEALTH & ENVIP, ONMENTA!- PROTECTION Ocw-/z- ¢--¢~.~. ¢.~,r~¢~I v ~,t¢, ('~F~tv A'CE..'~, Ii A, B, C, D.E.C. Approved (Y/N) Date Completed Z/~_~ ~/~'76- Yield Cased to ~ ~_/L. Depth of Grouting ~ /~ '~-..~ ! Pump Set At ~- ~ ~ ~.~ /r Sanitary Seal on Casing(~N) Depression Around Wellhead (Y,~ ; On Adjoining Lots /~)(:~ 74' To Nearest Edge of Absorption Field on Lot ./50 / ; On Adjoining Lots //¢O To Nearest Public Sewer Line '~//~ To Nearest Public Sewer ~7~ Cleanout/Manhole /'~ f ~)- To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results ~ --r,/~/¢- ,~ ¢ ~-J,~-~ ? B. SEPTIC/HOLDING TANK DATA Date lnstalled ~l'~ I Standpipes¢/N~ Depression over Tank ~) Size Air-tight Ca ps ~)'4~ 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 W~tec-Maiz~Service Line ~O Course Comments ~ u, ,%-t'¢__~..~ ~..~o-¢ No. of Compartments ~ Foundation Cleanout ~ Date Last Pumped .//'/'/~4- ~A-- ;for ~ Temporary Holding Tank Permit (Y/N) To Building Foundation ~- I TO Disposal Field To Stream, Pond, Lake, or Major Drainage Page I of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed (~:)/.~ ! ~ Width of Field ~,~ Square Feet of Absorption Area Depression over Field (Y/~.~ Results of Last Adequacy Test b 0o Type of System Design Length of Field t]~-~ Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) / ',~ Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot TO Water Me~/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ,,~¢,.2/.// ~'~ To Property Line \ To Existing or, Abandoned System on ; On Adjoining Lots /~'"~ To Cutbank (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. L'° m pany[~agle ~,tver, Receipt No. '%?O Date of Payment Amount: $ ~ Date MOA NO. (~.)~O Page 2 of 2 72-026 {11/84)