HomeMy WebLinkAboutT12N R4W SEC 11 E2NW4NE4NW4NW4
.... · ' Municipality of Anchorage Page of __
' DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
.~me: ~f I~ PU~ Wastewater System: ~New D Upgrade
Phone: ~ NO. of Bedrooms:
~ ~ Deep Trench ~hallow Trench 0 Bed ~ Mound 0 Other
LEGAL DESCRIPTION soi,.~,i..: ~,~ GPD/Sq. Ft. Total Depth from original g~e:l
~~~' ' ' Depth to pipe bottom from o~n of. grade: Gravel deplh beneath pipe
lOwn*hi~: ~~. ] ~an~e: ~ ~ Section: Il Fig aOOed a~ovo od~inal ~ra~e:~ Ft. Gravol Ion~t~:~.~l ~t.
WELL: O New ~ Upgrade Gravelwidth: ~ FL ~I ~ Ft.
Clas di at~on Private. A.B.C)~ To[al Depth: Cased TO: Tolal absorption srea:
Yield: Pump Set at: Casing Height Above Ground:
'SEPARATION DISTANCES ~ Septic ~ Holding ~ S.TE.P..
To Septic Absorp~io~ Lilt Holding Public/P¢ivate Manufacturer: . Capacity in gsgons:
Fro~ Tank Field St alien Tank Sewer Lines
Well ]l~/ ~l~' ~ /~ / 71~O' ]Matorial:~ Numbor°fC°mpadmont°:
Foundation ~, ~, / 5 / ~ "Pump oW' level water alarm at:
C~T~?~n ~k g~ X Pump~ I Electrical Inspections pe'ormed bY: ~
Remarks: ~ /~ ~(~(~ /~ BENCH MARK
Location and Description:
Department of Health and Human Services approval
Reviewed and approved by: ~1 ~('~ Date:/O/~/~
72-013 (Rev. 9/91) MOA 25
'Pea)mit.No. '~'~ ~?~'¢~' P~ge
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
of
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Pe~mitN~, ~'~/ ~2,~,~ Page
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
of
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
72-013 A (Rev. 9/{)1) MOA 25
PAGE
1 OF
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920202
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NAME:DUL PEGGY J
OWNER ADDRESS:3636 W 78TH AVE
ANCHORAGE, AK 99502
DATE ISSUED: 7/29/92
EXPIRATION DATE: 7/29/93
PARCEL ID:01224204
LEGAL DESCRIPTION: T12N R4W SEC 11 E2 NW4 NE4 NW4
NW4, SM
LOT SIZE: 49500 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD 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 OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
1
SPECIAL PROVISIONS
RECEIVED BY: ~
July 27, 1992
Municipality of Anchorage
Dept. of Health & Human Services
Environmental Services Division
825 "L" Street, Room 502
Anchorage, Alaska 99501
Subject:
E1/2NE1/4NW I/4NW 1/4NW 1/4S 1 1 T1 2NR4W
Septic System Design
Impacts to Adjacent Properties
Dear On Site Services Engineer:
The property owner on the referenced property wishes to upgrade her
existing septic system. I have prepared the attached design in conjunction
with this request. The existing septic tank and seepage crib will be
crushed, backfilled and abandoned in place·
1 bare reviewed information available on lots adjacent to the subject
property and have conducted an onsite investigation. The terrain of this lot
gently slopes at a 0% to 2% slope in a north-south direction. The slope is
virutally flat in the east-west direction. Soils encountered in the testholes
located on the lot were consistent well graded and excellent for an onsite
septic system. All systems on adjacent lots are at least 200' from the new
system.
The system, if constructed as designed, will have no adverse
impacts on the wells currently in use or to be placed in the future
on lots located in the area.
The system, if constructed as designed, will have no adverse
impact on existing septic systems in the area or those to be
constructed in the future.
The system, if constructed as designed, will have no adverse
impact on reserved space either surface or subsurface on any
located in the area.
lots
The system, if constructed as designed, will have
impact on drainage patterns in tile area.
Sincerely,
Michael E. Anderson, P.E.
JOB
'"' ROCKFORD CORPORATION
P.O. Box 111706
ANCHORAGE, ALASKA 99511 CALCULATEDBY.
(907) 344-4551 CHECKED BY.
FAX (907) 344-2130
SCALE
OF.
DATE
DATE
;&~ichael E. Anderson
4381 -E
ROCKFORD CORPORATION
P.O, 8ox 111706
. ANCHORAGE, ALASKA 99511
(907) 344-4551
FAX (907) 344-2130
JOB
SHEETNO,
CALCULATEDBY
CHECKEDBY
OF
DATE
DATE
SCALE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage. Alaska gg502..0~60
SOILS LOG .-- PERCOLATION TEST
AFOHMED FOR: UL OATE
L~GAL OESCmPT,ON:? ~Z. AJEI/~ y? 1~gJ'/,.ll~Ll'/¥Township, Range. Section:
1
2
3
4
5.
SLOPE
8-
9
10,
11
13-
14
15
16
'17,
18-
~9
20
WAS GROUND WATER
ENCOUNTERED? /~/~7
SITE PLAN
137,
S
IF YES, AT WHAT L
DEPTH? , pO
E
Del3~ t~ Wall: N~', / /
Reading Dire Grin! Net Depth tO Net
Time Time Wirer Dto~
~/ 7//? Z:/O ~ -- ~ ,, ~
~ Z:~ I~ 7 ~ /, ~ ~ /,
~ Z ~ ~O /0 I~ " ~,/~ ,,
PERCOLATION RATE ~ (minuleUinrdl) PERC HOLE DIAMETER _,, ~ //
TEST RUN eETWEEN ,~ FT AND ~' FT
Municipality ol Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVtCE~
825 'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
13
14
DATE
Township, Range, Section:
ELOPE
WAS GROUND WATER
ENCOUNTERED? ,/~
IF YES, AT WHAT
DEPTH?
15
16¸
17-
18-
19
2O
PERCOLATION RATE 4.// (minuleUin~) PERC HOLE DIAMETER .
/7/D TEST RUN BETWEEN -~ FTAND ~ FT
~ /~/Ft $ p.rt.~ $ 0 A/~-~-a P£/O R. 'TO -r-~- <."r~
Parcel I.D. #
1.
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
GENERAL INFORMATION
complete legal description ~ t/t_
Location (site address or directions)
L)
Property owner
Mailing address
Lending agency
Mailing address
-'~_e ~ c[ ,~ "J~ Day phone
Day phone
T
Agent [ ~-~-~'-J~ ~'~ Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY:
Individual well
NOTE:
Community well
Public water -., ¢.,. ~,
community well system, provide written confirmation from State AD~ES~tlt~t-
lng to the legali~ and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
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.
72-025(Rev. 1/91) Front MOA#21
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,
NameofFirm I ~ J¢~.¢_~ ~)u¢~.-{-o...~ 7, L~. Phone
Address ~0
Engineer's signature
6. DHHS SIGNATURE
· approved.
· '"'~'"~ Conditional approval for
' "', ' ~ Addltlgnal Oomment~
bedrooms.
bedrooms, with the following stipulations:
By: / Date
The Municipality of Anchorage Department of Health and Human Services (DHH$) 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, . ' . .:-~. :. · '
T. SPURKLAND P.E.
203 W. 15th. AVE. SUITE 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
Municipality of Anchorage
Division of Enviromental Health
Department of Health and Social Services
820 1 Street
Anchorage, Alaska 99501
Feba 22,1995
Subject: HAA
El/3, NWl/4, NE1/4, NWl/4, NWl/4 SEC. 11 T12N R4W
Gentlemen;
An HAA was issued for this property last week. Unfortunately I was told that the residence was a
two bedroom unit, and I market it so on the application. This morning the Real Estate Agent
informed me that the appraisal shows it to be a three bedroom house. I have included a new
application form reflecting a three bedroom house and request that the previous application be
voided.
Yours
Tobben S~l~land P.E.
MUNICIPALI.'~Y OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES_
...... Division of Environmental Services
- - . -: On-S te Serv ces Sect on
P.O. Box 196650 Anchorage, Alaska 99519-6650
....... ~ .... : 343-4744
' ' ' ' ' '~ CERTIFICATE OF HEALTH AUTHORITY
~ - ' APPROVAL FOR A SINGLE FAMILY DWELLING
I.D~
Parcel
: HAA #
1, GENERAL INFORMATION -
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Day phone ~_L/(~ _~
Day phone
Agent
Address
Day phone £?£--o~/ '
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: : :>:: ~L_ : .....
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
If commumty well system, prowde written confirmabon from State?~DEC~,. attest-
to the legality and status of system. . .-~,l~,~.',~ ...,,,~\qq,b.:,.
lng
NOTE:
4. TYPE OFWASTEWATER DISPOSAL:
/
Individual on-site ~"
' Community on-site .......... ?5'. ,-= .....
..... , Public sew~r:-:~,- -~ ':??-' ';-~" "'
72-025(Rev. 1/91) Front, MOA~21
NOTE: - If community wastewater system, provide written confirmation from State ADEC : ~
attestin o the lega and status o em. - -. -.~- '---. -. -
5., STATEMENT OF INSPECTION BY ENGINEER ' "'
As certified by my seal affixed hereto and as of the validation date showr~ belOw, I verify that my
investigation of this Health Authority Approval application shows that the on-site water sbpply
and/c r wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verifythat 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 ~s in compliance ~vith all Municipal and State codes,
ordinances and regulations in effect on the date of this inspection.
6.-- DHHS SIGNATURE
· :' Approved for
~..
· ~.-'ii .... ' : ' Disapproved.
-- Conditional approval for
bedrooms, with the following' stipUlafionsi:
- : --The Municipality of Anchorage Department of Heaith and Human Services (DHHS) iSs[~"'Health'Au'tl~0rity
. ,-Approval Certificates based 0nly upon the representations given in paragraph 5 above byan independent
~;' ?'i< professional engineer registered in the State of Alaska. The DH HS doss tl~is as a courtss~to purchJ~sers of h'0m~S- '
- 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 s not '.',:
· responsible for errors or omissions in the professional engineer's work. '~ "," ~ .,,~ :~: ~;,. .....
.. . . . , . . ;~..~,~.~
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type
Log present (Y/N) ~.1,
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level1
Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number '~/.z~
Date completed [ qG ~-~ Driller
/
Cased to ?~ ~ ~ Casing height
/
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot / ! LO ~
Absorption field on lot [ ,~ O -~
Public sewer main j O~ ~'
Sewer service line 7~ ~
Wires properly protected (Y/N) ~'/'
AT INSPECTION
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample: ¢-~/~/c~ ~
Nitrate Other bacteria
Collected by: -~ % .-
B. SEPTIC/HOLDING TANK DATA
Date installed ~//~/~ Z-
Cleanouts (Y/N) '~/
/
High water alarm (Y/N)
Date of pumping
Tank size /~ ~ C~ Compartments
Foundation cieanout (Y/N) ?/ Depression (Y/N) /%/
Alarm tested (Y/N)
Pumper A~/~/~q /~,S
/
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface wateddrainage
On adjacent lots "~ ~2 ~
Absorption field ~ !
Foundation ,~
Water main/service line
CONTINUED ON BACK PAGE
72-026 (3/93)* Front
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (WN)
"Pump off" Level at
.Cycles tested
Meets MOA electrical cedes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed ~l~
Length ~ /, ~ Width
Total absorption area ~ ¢ ~
Date of adequacy test 2/75 ) 0¢ ~:~
Water level in absorption field before test '~-'~ ~.?
Peroxide treatment (past 12 months) (Y/N) /%"I./
Soil rating (GPD/FF)
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail)
System type
Total depth
Depression over field (Y/N)
for
After test ~/-~-
/
If yes, give date
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ] ~ O -~ On adjacent lots ¢~¢c~ ~ Property line
To building foundation
On adjacent lots
Surface water '~.
Curtain drain
Cutbank
Driveway, parking/vehicle storage area
To existing or abandoned system on lot
'~. ¢ ~ ~ Water main/service line
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.
HAA Fee $ '~-~-
Date of Payment
Receipt Number
72-028 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
T. SPURKLAND P.E.
203 W. 15th. AVE. SUITE 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax 007)-276-6013
Municipality of Anchorage
Division of Enviromental Health
Department of Health and Social Services
820 1 Street
Anchorage, Alaska 99501
February8,1995
Subject:
HAA
El/2, NWl/4, NE1/4, NWl/4, NWl/4, SEC. 11, T12N R4W
Gentlemen;
On February 6, 1995 we applied for an HA without the required lab results for the water. We
received the results today and they are included with this letter.
Yours
Tobbe~
RECEIVED
MUnicipality o~ A;icho~age
Dept. Health & Human Services
T.SPURKLAND P.E.
203 W. 15th. AVE. SUITE 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
Municipality of Anchorage
Division of Environmental Health
Department of Health and Social Services
820 1 Street
Anchorage, Alaska 99501
February 6,1995
Subject: HAA
El/3, NWl/4} NE1/4, NWl/4, NWl/4 SEC. 11 T12N R4W
Gentlemen;
We are submitting an HAA for the property located at 3636 Strawberry Road without the results
from the water quality test. Water samples were turned in to ChemLab on Feb. 3, and the results
are expected back by mid week and will be forwarded to you then.
Closing of this property is scheduled by the 15th. of this month. In order to expedite the processing
of this HAA, I request that you accept this submittal.
T~b~eS-~~
RECEIVED
FEB 6 19 5
MUnicipa~ :y o All
Dept. Health & Hum~c.~°ra~e
CT&E Ref.# 95.0491~1
Client Sample ID 3636 STP~WBERRY
Matrix WATER
CT&E Environmental Services Inc.
Laboratory Division
Laboratory Analysis Report
Client Name TOBBEM SPURKL~-ND, P.E. WORK Order 12436
Ordered By Printed Date 02/07/95 ~ 14:38 hrs.
Project Name Collected Date 02/03/95 @ 16:30 hrs.
Project~ Received Date 02/03/95 ~ 16:56 hrs.
PWSID MA
Technical Director
STEPHEN C. EDE
Sample Remarks: SD~4PLE COLLECTED BY: T.S.
QC Allowable Ext. Anal
Parameter Results Qual Units Method Limits Date Date Init
Nitrate-N 0.10 U mg/L EPA 353.2 10. 02/06/95 CMR
See Special Instructions Above UA = Unavailable
** See Sample Remarks Above NA = Not Analyzed
~ = Undetected, Reported value is the practical quantification limit. LT = Less Than
~= Secondary dilution. GT = Greater Than
200 W. Potter Drive, Anchorage, AK 99518~1605 -- Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA
Parcel I.D. #
1.
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
GENERAL INFORMATION
Complete legal description
Location (site addreSs or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Add ress
Day phone '-~ ~q- ~q~
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well ~4
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:
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.
72-025 (Rev. 1/91) From MOA #21
STATEMENT OF INSPECTION BY ENGINEER .. , ..
As certified by my seal affixed hereto and as of the varidation date shown below, I verify th'At 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 5ased 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 /Z]f.,~ ~ i..-'-ilSO.,J /~/5 ,'~)~.,-'/LI~, Phone
Address PO, gO,~ 2~077J5 /'~ 6~40rL~-
Engineer's signature '¢/~0/*.-0~,~_,, ~--~ L/~¢,,c],_.....-~ .
Date
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
'%,
bedrooms, with the following stipulations:
Additional Comments
By: ..~O t--h~ ~/[d ,'T/--/' 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. Em ployees 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 t~21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
Parcel I.D.
A, WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
Y
ADEC water system number
Date completed / ¢]~' ~ Driller r
Casedto 3q~ ~
Casing height.
Wires properly protected (Y/N)
FROM WELL LOG
Date of test d~-3 ~l,aOv,) ~
#
Static water level
Well flow g.p.m.
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot //D ~
Absorption field on lot /,~) t
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
~ Z.O~)/
WATER SAMPLE RESULTS:
COliform ,~4 e.,cM~a T'/F/~ Nitrate ~J' j~, Other bacteria
Date of sample: ~--/~f4,-'~/~Z* Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~/~/q~'
Cleanouts (Y/N) ~
High water alarm (Y/N)
Date of pumping
Tank size_ IOO 0 ~13 ¢.. , Compartments
Foundation cleanout (Y/N) Y' Depression (Y/N)
/~ Alarm tested (Y/N) /~/A
~O~l ~T-I1,4JC-T/O*J Pumper /~ )~'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
TO property line
Surface water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (Rev. 7/91)Front cONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length b I ~.'
Total absorption area
<~/,'~/q~-- ~ Soilrating /,Z- (~)//-"77~Systemtype
Width '¢"- Gravel thickness -~ / Total depth I /
5'~30 ~ I~ ¢'- ~ Cleanouts present (Y/N)
Depression overfield (Y/N) ,~ Date of adequacy test /~l~'-I/J
Results (pass/fail) P/~ ~-~ for ~ ~ bedrooms
Peroxide treatment (past 12 months)(Y/N) /X//~ If yes, give date
-)6 r-¢o p..cd).
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot / ~ 0 On adjacent lots '~' Z~O Property line
To building foundation u/~ ~ To existing or abandoned system on lot
On adjacent lots
Cutbank d
Surface water /'~ O rJ 6" Driveway, parking/vehicle storage area
Curtain drain /%JO/'J E''
E. ENGINEER'S CERTIFICATION -~X.~$'r"IM
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
HAA Fee $
Date of Payment
Receipt Number
72-02S (Rev. 3/91) B~ck MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
· ? , CHEMICAL & GEOLOGICAL LABORATORY
,i"~ A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 3 STREET ANCHORAGE, ALASKA U9518 TELEPHONE (U07) 562-2343
ANALYSIS RESULTS fat INVOICE $ 53888
Chef, ab Rof.~ 92.2206 Sample ~ i Matrix:
FAX:(907) 561-5301
WA?ER
Client Sample ID ; 3636 STRAWBERRY
?WBID · UA
Collected . MAY 20 92 ~ b~.
Received : MAY 20 92 ~ 12:15
Preserved with : AS REQUIRED
Client Name :ANDERSON ENGINEERING
Client Acer ANDENGE
BPO~ ; PO~ :NONE RECEIVED
Req~ :
Ozdezed By MIKE ANDERSON
Completed : MAY 20 92
Laboratory Supe~¥i~9~ ; STEPHEN C. EDE
Send Repor~ to:
1)ANDERSON ENGINEERING
?arame~e~ Results Unite Method Allowable Lim[[s
NITRATE-N ND(O.iO) mg/1 EPA 353.2
Sample ROUTINE SA}~LE COLLECTED BY:
NA~ Not Analy~ed LT~Less Than. gT=o~ater Than
~SSS Member of the SGS Group (Soci~t~ G~n~rale de Surveillance)