Loading...
HomeMy WebLinkAboutVALLEY VIEW TERRACE BLK 1 LT 17 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 REPORT GRADE LOCATION Well DISTANCE TO: ~-z~ Manufacturer ~_~C ~ DISTANCE TO: ~ell I A~s°rPt'°n ar~ / Dwelling/ DISTANCE TO: No. of lines / / We"/6 t I L,ngth of,. Foundat~(~ ¢ Matera beneatht e Top of tile to finish grade ;Length Width Type of crib Crib diameter Well DISTANCE TO: DISTANCE TO: foundation Depth Cri~d~pt h > Building foundation Driller Sewer llne Width Material inches NO. OF BEDROOM~ No. of ¢omp~ments Liquid depth PERMIT NO. Liquid capacity in gallons lines PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line PE F~.~ Sept c tank Absorpt on area(s) OTHER PIPE MATERIALS INSTA .~ Brillin[l ng By DOC Co. dba SULLIVAN WATER WELLS P.O. BOX272, CHUGIAK, ALASKA 99567 · TELEPHONE688-2759 OWNER OF LAND ADDRESS ~ t3 LEGAL DESCRIPTION ~ 1'7 t(~f/~' DATE- Started ~t,/g'~]~ Ended '~' PE~IT NUMBER ~O DEPTH OF WELL /~bC;} STATIC LEVEL OF WATER FT /O,')'~ t ,tz,~-- DRAW DOWNFT GALS. PER HR KIND OF CASING KIND OF FORMATION: From t) Ft. to c~ Ft. From ;~I., Ft. to ~ ,~ · Ft. From ,c,) ~ Ft. to ({"~ Ft. From ~'J,4 Ft. to '~$~ Ft. ,From ??; Ft. to ]c;'~] Ft. From /~?,'~9' Ft. to ! ~ q ,Ft. From __ Ft. to Ft. From/'.-':'~/- Ft.'to /~'/L~ Ft. From Ft. to Ft. From__.Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Fr. From __Ft. to_ Ft. From __Ft. to Ft. From Ft. to Ft. Fi. to Ft Ft. to_ Ft. From Ft. to Ft, From Ft. to Ft. FromFt. to Fi Ft. to Ft Ft. to Ft. r-~,~)From From From From From From From From Ft. to. Ft. Ft. to Ft. From ~Ft. to Ft. From Ft. to Ft. From Ft. to __ Ft MISCL. INFORMATION: DRILLER'S NAME t~g' . :: l ~ .............. DEPFIRTMENT OF' HEFILTH FIND ENMIRONMENTFIL PROTECTION 825 L STREET., FINCHOF..'FtGE., Fti.( 995E~it ;264-,4-72E~ FIPPL.!CFiNT: C,.-'O S & S ENG'"G. SOUTH FORK FIE:,DRESS: SRE: :1. S': 6::.:; ERGt_.E RIMER., FII'.( DS~577 CONTFIC:T F'HONE. 5~4-2'379 L. EGFIL DESC:RIP. SUBDt',,,'ISION: YFILLEY MIEN TERRFICE LO'F: ::L7 SECTION: SIZE: 6FI (SQ. FT. OR FICRES) BE[:,ROOMS: BLOCF.:: i L ISTEF: EIE[_.O[:] FIRE THE ...F]I..i'iI:, F FIILFtBLE TO :¢1-111 I~'~ ['E':;,t3i'.4ING :TI-tUF, SEF'TIC S'T'STEM. CHOOSE THE OPTION THFIT BEST FITS '.POUR SITE. DEPTH TO PZPE BOTTOI' (FT ::, GRFI',/EL DEP-FH <FT. TOTFIL DEPTH (FT. ' , _:~H EL LENGTH (FT.) 47. GRRMEL MCILUME (C:U. '¢B:S. SOIL RFITIHG ,::SCL FT. ,..'E:R) :+: Ill: TFINK ll:IlJ:ST I."IFI:'":E FIT LEFIST TI''tO cOt'"IPFiRTMENTL/'' \\ '[ CERTIFY" THFIT : il I FII'I F'RI'dlLIRR MITH THE REQUIREMENTS FOR ON--SITE SE'klERS RND !4ELLS RS SET FORTH B'T' THE i''IUNICIPFII..IT"¢ OF FINCHORFIGE (MOFI) RI'4D ]'HE STFITE OF FILRL=;KFI' ;2 I 14IL.t-- INSTFILL 'THE S'T'STEf'! IN FtCCORDFINCE I''tITH FILL i"lOFi CODES FIND REGULFITIONS'' FINE:' iN COMPLIFINCE WITH TNE DESIGN CRITERIFI OF THIS F'ERMIT. ]: I klILL FIDHERE TO FILL PIOFI FIN[; STRTE OF FILFISKFI REL':.~.UIREHEI'-]TS FOR THE SET 8RCI< E:,ISTFINCES FROH RN"r' EXISTING NELL, WFFISTE!-4FITER DISPOSFtL S?STEM OR PUBLIC SENERFIGE S'T'STEH ON THIS OR FIN'¢ RDJFICENT OR NEFIRB"r' LOT. 4 I LINDERSTFIND TFIFIT THIS F'ERHIT IS MFILID FOR Fi MFtl,,'.':,ti"IUI"I OF 2 BEDROOMS RND FIN'¢ ENLFIRGEMENT I.,.IILL REC!UIRE FIN FFIDDITiOI']RL PERf'IIT. ~F FI LI'FT STF:KI"I]I~'~ IS iNL::;TFILLEE:' II",l FIN FIREFI C:O'¢ERE[:' E"¢ MOFI E:LtILE:,Ii'.]~3 LuEE=,., ' '= P - ' - " (2::' -'- ' I ~,, THEN ('_i.)' FIN EL.ECT,~2'TI"':FIi. PERi'"!IT RND IH'i:_;PEiTIZN I'dU_,T -,E uETPIi'IED. PI.:,-BUI_T- ['TILL NOT E,E HPFF_ E[ ktlTHL]IJT RN ELEC'TRIC:FIL IN_-,Fb. uTI_N RE.F_RT., FIND THE E,E. [)L-IF,IE IR LIE:ENSE[:, ELEIi:TI.';.:IRIFiN. DFITE [)FITE: SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -- PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18 19 20 SLOPE COMMENTS PERFORMED BY: 72-008 (6/79) ENCOUNTERED? O P DEPTH? DATE PERFORMED: SITE PLAN Gross Net Depth to Net ;'~F[~ading Date Time Time Water Drop PERCOLATION RATE ~ /~ (minutes/inch) RUN BETWEEN ~ FT D TEST ,", 8B OX,. FT PERFORMED FOR: LEGAL DESCRIPTION: 4 5 6 7 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 SLOPE SITE PLAN 1 1'~ ~ 12= 13- 14- 15- 16- 17 18 19 20 COMMENTS PERCOLATION RATE ~ ~' (minutes/inch) TEST RUN BETWEEN ~F'~FT AND FT Reading Date Gross Net Depth to Net Time Time Water Drop 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.# L(~) 1. GENERAL INFORMATION Com ,.e~?~ ! .e,g¢:¢l. ~sc ri ptio n Lot 17; Block I; Valley View T~rra¢~ Location (site address or directions) NHN Low~ T~ra¢~ Property owner Mailing address Lending agency Mailing address Frank Boone P. O. Box 772782 Day phone Eaql~ Riv~_r, Alaska 99577 Day phone 696-4392 Agent Mike L~wis PHH/HOMEOUITY 400 East Las 0o,¢~.~ Bo~vard Address Sui~ #_~00 b , Irvi. ng~ Texas 75039 mess otherwise requesreo, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well XX Community well Public water Day phone 214-506-8808 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 XX 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 (Rev. 1/91) 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 ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. $ & $ ENGINEERING 17034 Eagle River Loop ~[oa~ Eagle River, Alaska 99577 Name of Firm Address Engineer's signature DHHS SIGNATURE 42(/.~ ApproVed for /~,'¢-~(~.~_) bedrooms. Disapproved. CohSitional approval for Phone 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. 72~)25 (Rev. 1/91) Back MOA #21  Municipality of Anchorage Department of, Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~>'~' \/~ ~-~-t/-~ ~/'&~L~'L4~ ' ~ ~'~ _ Parcel I.D . . A. WELL DATA : Well type ~¢--"~J ,¢,fl'¢~- If A, B, or C, attach ADEC letter. AD~E.~ater system number Log present ~5'N) V Date completed ~ Driller Totaldepth ~/-~C>' ~: Casedto 17\ ~ ~" Casing height Sanitary seal (~N) V Wires properly protected ~N) V FROM WELL LOG AT INSPECTION Static waier level I ¢);5~ I ~ ~ ~ g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot \ C~r=> d-- ; On adjacent lots lDO Absorption field on lot ~,Z~ b ~''' ; On adjacent lots ~. C>c~ ~,F Public sewer m~.in J~ I/'~'~ Public sewer manhole/cleanout ~ sewer service line .~-S" ~' ~ Petroleum tank '.'Z--~" t .F WATER SAMPLE RESULTS: Coliform ff'~ &~w~/~oo~. ~/Nitrate Date of sample: ~ ~ l Lo ~ ~ Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts ~_~N) High water alarm (Y~_~ Other bacteria & $ ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Date of pump!ng Tank size ~::o (_~,~'L~ Compartments Foundation cleanout (~N) ~/ ~ Depression (Y~.~ Alarm tested (Y/N) /~/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~ c~ ' '~ On adjacent lots To property line '! ¢> AbsorptiOn field Surface water/drainage J~PO ~ ~' Foundation Water main/service line ~ ['''~ 72-026 (Rev. 7/91) Front · coNTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA elec~ __Manufacturer Manhole/Access (Y/N) ~ "Pump on" level at ~evel at ~cles tested Surface water D. ABSORPTION FIELD DATA Date installed I o--It, Length '~'~" [ Width Total absorption area Depression over field (Y~) Results ~i~fail) Peroxide treatment (past 12 months) Soil rating \ '7-.~ Gravel thickness Cleanouts present ~'/N) Date of adequacy test for l~ ~ If yes, give date System type Total depth ¥- bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~. o ~, ~ ~'' On adjacent lots \ OD ~4-- Property line. To building foundation To existing or abandoned system on lot On adjacent lots ~c~, ~ ~' Cutbank ~ I/~ Water main/service line ~ ~-'r Surface water ~(2r2 ~ ~- Driveway, parking/vehicle storage area ¢- ~'' t ~ Curtain drain ~ I/'~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature $ & S ENGINEERING 17034 Eagle River Loop Road NO, 204 Eagle River, Alaska 99577 Engineer's Name Date HAA Fee $ / Date of Peyment 4~/(~-~ /q~--, Receipt N,mber ~ '~ ¢/:J~D ,;~ ~2-7~.~,) ) 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number Parcel I.D. # MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (M~Jst be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 17; Block I; Valley View Terrace Subdivision Location (address or directions) Lower Terrace Street, Eagle River, Alaska (b) Property owner Dan & Carol Moran Mailing Address P. 0. BOX 772934 (c) Lending Institution Mailing Address (d) (e) Telephone: (home) ~;q~-3577 Business Eagle River, Alaska 99577 Telephone Real Estate Company and Agent PPH/Homequity Attn: Address 1855 Gateway Blvd. Suite ~850 Concord~ Telephone (415) 246-6568 Lorna Osor~o California 94520 Mail the HAA to the following address: (or check here~ if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eagle R';¥er Loop ~agle River, Alaska 9~577 2. TYPE OF RESIDENCE Single-Family E~x. Number of bedrooms 3. WATER SUPPLY Individual Well [~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Departmen( of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 Name of Firm 5. 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 end 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. Telephone c~ ~'~'~'~-~-~' ~ ~' ~, :;. ! ::~ River Loop koad No. 204 Address Date 6. DHHS APPROVAL ~~ Approved for J bedrooms Approved ~ Disapproved Conditional Terms of Conditional Approval Y~¢)'/*'2''Z'~/-'~ Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 72-025 (Rev 7/88)B~c~ Page 2 of 2 MUNICl~ ANCI'Cd~I~31PALITY OF ANCHORAGE (MOA) ~ ENVlRONJ~j_ J~ViCE$ DIVHt~Ntth Authority Approval (HAA) ~,,~v~ CHECKLIST- FEBRUARY 1984 JUl 'D 1990 343-4744 Legal Description: /--o-/' / ,"7-7- ~ ~1o~'.,1</ I RECEIVED A. WELL DATA We, Classificat 0n t Well Log Present (~.~)/ ,,~ Date,Completed Total Depth /z-/O Ca,r` sedto /P/'8'D/epthofGrouting __ Static Water Level / / ~ * '/' Pump set At Casing Height Above Ground --~-~" Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Hcldh,";g Tank on Lot / To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments If A, B, C, D.Eic. Approved (Y/N) ~//~,~ Yield ~.'--, Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On AdjOining Lots ! Od) ' '1- [00"1- ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole B. SEPTIC/HOLDING TANK DATA Date Installed / o -II~ t34 Size Standpipes (Y/N) c1 Depression over Tank (Y/N) / c~oO ~-I No. of Compartments Air-tight Caps (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well / DO /+ To Property Line / O /~ To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments ~ ~,,P "/~-~ ~o ~,¢'/t0~ c1 Foundation Cleanout (Y/N) Date Last Pumped Z¢ - ! - ~' O AJ./~ ;for Temporary Holding Tank Permit (Y/N) To Building Foundation TO Disposal Field 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata _ [ .~-- ~" ~'~/~ Date Installed ,! O -- / I - ~ Width of Field .~ © Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test F'~-Type of System Design Length of Field Depth of Field / Gravel Bed Thickness statndpipes Present (Y/N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well / To Building Foundation Lot hg To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line [ O /~ To Existing or Abandoned System on ; On Adjoining Lots .~O / + To Cutback (if present) /d/~ IOO' Comments D. LIFT STATION Date Installed "% Dimensions Size in Gallons ~, Manhole/Access (Y/N) "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. 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, S & S ENGINEERING .~. Company Eagle River, Alaska ~957~ Date of Payment ~'~ - ~/'~ Amount: $ / / ~' 72-026 (Rev 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSP'ECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date / ~___~11 -,~ [o GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, towns_.C:&p, range) Location (address or directions) (b) Applicant Name ~--~c~ ~.~C>~...,/~_~ Telephone: Home ~/~PM-P-'%~-V~' Business Applicant Address p.O, /~g::~ ~- ~/5'~' ~_~, ~,~'c... ~'~:~-- (c) Applicant is (check one): Lending Institution [~Owner/builder []; Buyer []; Other [] (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address Terephone (f) k~the HAA to the following address: SR B 196X EAGLE RIVER, AK 9~577 TYPE OF' RESIDENCE Single-Family [~MultJ-Family [] Number of Bedrooms Other WATER SUPP~,..~/ 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. 4. SEWAG~J~I~OSAL Onsite-E~]' 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 inspection. Name of Firm S & S ENGINEERING Telephone ~ .~,~ ~' .~? ~' SR B 196X Address EAGLE RIVER, AK Date O.EP APPRO A' ~ '~ /z ", . Conditional Approved '~; .,,, ;:~ ,;,Disapproved Terms of Conditio, nal Date /2 -23 ,F CAUTION The Muncipallt~ 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 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: ~.-~/.'~ I~cO~lc. / WELL DATA Well Classification · Well Log Present(~'~) Total Depth // ~);gO ' Static Water Level Casing Height Above Ground Electrical Wiring in Condui (t~N) Separation Distances from Well: Cased to /O 7 If A, B, C, D.E.C. Approved (Y/N) Date Completed 7z/~:~ ~' Yield Depth of Grouting C4 ~ Pump Set At ~ ~ Sanitary Seal on Casing (Y~) Depression Around Wellhead (Y~_~ To Septic/U,~.',d:,,q§ Tank on Lot 1~20 ~Z TO Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments 'v,,/c=~cx_ ~'~c_~,v' /'~.'~T ,~'-~.v:,¢~,,~¢>/5 ' O ; On Adjoining Lots ; On Adjoining Lots /0~ ~')/'~ TO Nearest Public Sewer ~ / ~ To Nearest Sewer Service Line on ~ '~ ~ ~rt~/~ ¢ ; Date /~//~E ' V' I / B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes ~'N) Air-tight Caps Depression over Tank Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: /m -// - ~ Size / (~c~.~ No. of Compartments ~ Foundation Cleanout (~YN) Date Last Pumped / Z~-/3- ~ · ~//~ . ; for ~ Temporary Holding Tank Permit (Y/N) ~ /Oo/ -~ /+ To Water-Supply Well To Property Line To Water Main/Service Line Course / ¢0 To Building Foundation -~ To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 MuNICIPALHY OF A~:'':W?:!r'GF DEPT. OF HEALi'~ ,~. ~NVJROHMENTAL pROi,:C ~,~N RECEIVED 72-026(11184) C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata /~- ~7/,~).~ Date Installed /¢> -[/ -~'¢~ f¢¢ Width of Field ;~ou Square Feet of Absorption Area Depression over Field (Y(~_rT.~ Results of Last Adequacy Test ~ Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot N'/ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~' )LCoc~ ~c~ Type of System Design Length of Field ,~,.~ / Depth of Field ,I~ / Gravel Bed Thickness c~/ Standpipes Present ~,N) Date of Last Adequacy Test To Property Line /0/-d-- To Existing or Abandoned System on ; On Adjoining Lots ~b'~L To Cutbank (if present) D. LIFT STATION Date Installed , Size in Gallons "Pump On" Level at //,Cf / 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 Ich a~,e,c, hecJ~,.wrified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection "~ ~:t'~I~EER/NG ' Signed ca ~ Company ~OA No. Receipt No. ~ ~/ ~ate of Payment Amount: $~, ~ Page 2 of 2 72-026 (11/84)