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Home My WebLink AboutVALLI VUE ESTATES #2 BLK 6 LT 10 Municipality of Anchorage Page 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 Name: ~ .d~., (~-~'~r'-J~ ' Waslewater System: ~ New ~pgrade Add~ I ~~ ~ ~lp ABSORPTION FIELD Phone: INo. o~rooms: ~epTrench D Shallow Trench ~Bed ~Mound ~Other LEGALDESCRIPTION So,...n,: ~. & GPD/Sq. Ft. Totai Depthfromoriginal}~d~: Township: ~ Range: ~ Section: Fill added above original grade: ~ Gravel length: Grave~l~~1Ft. Number of Iines::~D~stance~e eon lines:. Ft. WELL: New Upgrade Classification (Private. A.B.C): Total Depth: Cased To: Total absorption area: ~ Pipe material: Drgler: Date Drilled; StaticWaterLevel:Ft. ~ ~. Yield: Pump Set at: Casing Height Above Ground: TAN K GPM Ft. Fl. SEPARAT'O N D'STANCES ~eptic~,~¢) Holding . S.T.E.P. To Septic Absorption Lift Holding ~ublictPrivate Manufacturer: Capacity in gallons: From Tank Field Statio~ Tank Sewer LinesJ- --~-- Well ~0~ ~O'& ~ -- ~ Material: Number of Compa.ments: Surface A~ Water ~ I~ ~ ~ ~ LIFT ST Line Foundation ~1 [~ ~ -- -- "Pump on" ,eve,~"Pump oR" level at: I Hig. h water a,arm at: Cu~ainDrain ~ ~ ~ ~"~ 3umpM~de' IElectricallnspecti°nspeH°rmeoby: Remarks: BENCH MARK Location and Description: ENGINEER'S SEAL S & S ENGINEERING t~~ ., ¢: ~ Inspections performed by: ~7034 Eagle River Loop Road, NO~s: ls ~. ~.~7~; Department of Health and Human Services approval ,~ Reviewed and approved by: ~ ~ Date: ~-2/- ~ ,~ ,,u-::?.-~ ' -.~.- 72~013 (1/91) MOA 25 ' Permit No. ~wq.~f~gR.~ Page Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION of 2 P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description:V^Lf.f ¥]]E RURDTVtRtON ~2: Rt.OCJ( 6. t.~T lo PID No,:0! 55! !5_~ C01 C02 EXIST. 9~.5 91 1250 GAL ' S.T. FINAL MTc03 /95' · 77.1' NO WATER FOUND NEW TRENCH UTIL. ESMT. 4 BDRM HOUSE -EXIST. SUCH THE 1250 INTEGRITY ABANDONED IT MAY BE USED IN SEPTIC TANK A B FC0 29.0 24.0 CO1 56.7 I 25'5 I C02 62.0 32.5 I C03 104.3 78.5 C04[ 63.5 I Z4'01 MTI e°.5 I 45.°1 DV 64.5 35.6 SCALE -APPROX. WATER ~JNE 40' ENGINEER'S SEAL 72-013 A (Rev. 9/91) MOA 25 PAGE 1 OF 1 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:SW930283 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:GAGNON BRUCE E & OWNER ADDRESS:6721 ROUND TREE DR ANCHORAGE AK 99516 DATE ISSUED: 8/10/93 EXPIRATION DATE: 8/10/94 PARCEL ID:01531153 LEGAL DESCRIPTION: VALLI VUE ESTATES #2 BLK T 10 6 L LOT SIZE: 21555 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 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: Ao OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS RECEIVED BY: ISSUED BY: DATE DATE:/~./~/(~ ~ ~ August 2, 1993 ROBERT SHAFER, P.E. ROGER SHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTHAUTHORI3Y APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER&WATER INSPECTION ENGINEERINGSTUDIES ANDREPORTS WELL INSPECT[ON & FLOW TEST SITE PLANS ROAD DESIGN Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street Anchorage, AK 99519-6650 REFERENCE: Valli Vue Estates Unit #2, Block 6, Lot 10 ~e request you issue a ~ermit to uDgrade the existing septic system serving the four bedroom house on the reference~ )roDerty. ~n adequacy test was performed on the existing system and the ~bsorption capacity of the system was found to be adequate for a three bedroom house. Municipal approval of the system ~as for a three bedroom house in 1974. ~o test holes were excavated and percolation tests )erformed. The approximate location of the test holes are _ocated on the attached site plan. The monitoring tube within the test holes have been checked and found to be dry. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your review, please contact us. Sincere~ SOI[~ TEST PERCOLATION TEST Shafer, P.E. STRUCTURAL& MECHANICAL INSPECTIONS ~lsu ON SITE WASTE WATER DISPOSAL SYSTEM OESIGN 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 1" '= .40' SCALE IUPGRADE I. 0 r- ~ ~ Zmmm 0N-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Valli Vue Subdivision Unit %2, Block 6, Lot 10 GENERAL: 1. o The scope of this project includes the installation of a leachfield trench to serve the four bedroom residence located on the referenced property and excavation of the existing 1250 gal septic tank to verify its integrity. If the integrity of the existing septic tank is poor the existing septic tank is to be excavated, pumped, crushed, and abandoned in place and a new 1250 gal septic tank installed. Construction shall be in accordance with the approved site plan and design drawings; Municipal permit with any special provisions or conditions; and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. o Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. Page Two Valli Vue Subdivision Unit #2, August 2, 1993 Block 6, Lot 10 o A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft· from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. MINIMUM MATERIAL SPECIFICATIONS: Any septic tank constructed by a manufacturer. proposed for installation must be Municipally approved septic tank The following septic system Anchorage: pipe materials are approved for use in installations in the Municipality of Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. o Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. 6. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. Page Three Valli Vue Subdivision Unit #2, August 2, 1993 Block 6, Lot 10 7. When sand is being used as a filter material, it's gradation specifications must conform to AMC 15.65.060D. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed- up) before gravel (sewer rock) placement. o Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. o Monitor tubes shall be of four (4) inch diameter and installed approximately in the locations shown on the design. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. Page Four Valli Vue Subdivision Unit #2, August 2, 1993 Block 6, Lot 10 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: o The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. o The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre- construction meeting will take place on-site. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERPORUEO FOR: ~>~Z~Lc_P_ ~-Ca~C~O~ DATE PERFO LEGA' DESC.,FT,ON: I/~ [J'~?~ LoT/0: ~ r~ Township, Range, Sec,~on: SLOPE SITE PLAN 2 3 7 8 9 WAS GROUND WATER I0 ENCOUNTERED? E Depth t0 Water A,er 14- 15- 16- 18- 19- Gross Net Depth to Net Reading Date Time Time Water Drop ;IO io ~Yff / '/~" :~S 1o 5% Il:o~ ~O ~" 20 - 2? '" PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER ) ¢ TEST RU BET, WEEN ~ T AND ~ FT, COMMENTS "-~.~ ~ ~ "r~" ~?~,~- ~2 ~ ~ ~ ~"' PERFORMED~03~ ....... ~,'~ ~1,~' ~OO~ "~a~ ~O. ~0~ //~~,FyTH~TTHJSTESTWASPERFORMEOJN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELI~FFECT ON THIS DATE, DATE: 72-~8 (Rev. 4/~) ~ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ~[~.~--------- G/::9,~-l%~ (~/",,J DATE PERFOF :' LEGAL DESCRIPTION: r ownshlp, Range, on: SLOPE SITE PLAN 2 4. ~/S ~o L~ 7 8 9 10 - WAS GROUND WATER ENCOUNTERED7 /~O 11 S IF YES, AT WHAT 32 DEPTH? p E Depth 10 Waler A~er ~o 13 Monitoring? V~[~ Date: ~2~/~ I Reading Date Gross Net Depth to Net Time Time Water Drop Iot%~ ? "-" : qo Io ~/~" 14 15 16- w., ~O.H, 18' 19 20 t PERCOLATION RATE I(~ (minutes/inch) PERC HOLE DIAMETER ~ /t TEST RUN BETWEEN, ~ . FT AND {~ FT o,~ PERFORMED BY: '~7~ ~qle Rlvo~ .o0~ ~o~ No, ~ CERTIFY THAT THIS TEST WAS PERFORMED IN 72-~8 (Rev. 4/~) GRF 'ER ANCHORAGE AREA BG tJGH ~.~d~/ Department of Environmental Quality ~ 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME "~¢)/,~l~72 ~ ~-£~,~/g/-(~ MAILING ADDRESS LOCATION ~::~¢CZ,,t./4:) 7'-.,'~b~' LEGAL DESCRIPTION SEPTIC TANK: DISTANCE FROM WELL /t///~l MANUFACTURER INSIDE LENGTH INSIDE WIDTH NUMBER OF / MATERIAL ~//~.~/r~-'~,~./~ COMPARTMENTS LIQUID DEPTH LIQUID CAPACITY / .:~-.,~--O .GALLONS. SEEPAGE PIT: NUMBER OF PITS / DIAMETER __ OR WIDTH LINING MATERIAL~,~?-~ /~,~ ¢ ~"~,"d~g~-- CRIB SIZE: DIAMETER__ ,,~,/-/.- ~, / .'* BUILDING FOUNDATION , NEAREST LOT LINE__.. LENGTH /~, [DEPTH DEPTH DISTANCE FROM: WELL TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) .SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE CONSTRUCTION BUILDING NEAREST FOUNDATION LOT LINE CESSPOOL OTHER SOURCES APPROVED / DISAPPROVED NEAREST SEWER LINE REMARKS DEPTH DISTANCE FROM: SEPTIC SEEPAGE TANK __ SYSTEM DISTANCES: INSTALLED BY: /~Z) PIPE MATERIAL: {~/)&'7' -~'~/¢ LOT SLOPE: REMARKS: DIAGRAM OF SYSTEM DATE G.A.A.B. GREATER ANCHORAGE AREA Borough DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. SEWAGE DISPOSAL SYSTE~ ~ APPLICATION AND PERMIT INSTALLATION LOCATION ~'///__~, DRA[N FIELD T R SOil TEST RESULTS COMPLETION DATE ANT,CIPATED FINAL INSPECTION: 2A HOUR NOT~CE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTIVIENT OF ENVIRON~v1ENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROS~L~TION. SEPTIC TANK TO SeEPAge PIT WALL SEPTIC TANK ,~/ SEEPAge PIT DRAIN FIELD .//'~ 0'./~~// DRAIN FIELD /~) SEEPAGE pit ~/~.~O//~<~ ' ALSO CONSIDER AREA WELLS. SEEPAGE PIT /~ / CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOil. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. CONFORM TO BOROUGH REGULATIONS REGARDING [NSTALLAT[0N. I CERTIFY THAT [ AM FAMILIAR With THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS ]N ACCORDANCE WITH SAID CODE. GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY Case 3330 "C" Street ANCHORAGE, ALASKA 99503 Performed For Legal Descrip~io'n: LoT i0 Block This Form Reports Soils Log~ Percolation Test Soil Test Must Be Logged To 4' Below Proposed Seepage System Depth Feet Soil Characteristics Was Ground Water Encountered? If Yes, At What Depth? Reading Date Gross Time Net Time Depth to H20 Net Drop Percolation Rate Minute Proposed Installation: Seepage Pit~o Drain Field Depth of Inlet Depth to Bottom of Pit or Trench COMMENTS: ~-~[ ~ ~ ~o.~ ~-~-~ ~m~ 2g~g~ Date Certified BY:_ Test Performed BY '~ ~ "~k-q-~5-~,~_ -----~-- Date: /:-~artment of Environmental Quali%~ ~Vater and ~Sewer Questionnaire Date &-~- -75' , Time SUbdivision {)'~/~'-{-Zgc~ ~ ~s~/~g ,Block , Lot /~ Mailing Address: QUestions: 1. }Iow many bedrooms are now in your house? 2. How many bedrooms were in the house at the time of purchase? 3. Were the basement bedroom walls "roughed in" at 'the time of purchase? 4. Was the basement bathroom plumbing "roughed in" at the time of purchase? 5. Did the realtor or builder inform you that you would have to enlarge the existing sewer system if you finished the basement bedroom (s)? ~ 6. If on a public water supply, do you always have an adequate supply of water? i/e $ 7. Is the pressure always adequate? [~/~e 8. Who was the builder? ~t~r ,A--~7~.~?~-~i~, - 9. Who was the home purchased from? OTHER COMMENTS: 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 Parcel I.D. # 01531153 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Valli vue' Estates Subdivision #2, Block 6, Lot 10 Location (site address or directions) Property owner Mailing address Bruce Gagnon Same 6731 Round Tree Drive Anchorage, Alaska 99516 Day phone 276-1700 Lending agency Mailing address Day phone Agent Bonnie Mehner/JackWhite Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well · - Community well ×x 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 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 fil~ my investigation and inspection, the on-site water supply and/or wastewater di.d.d~po~al syste~Cis in compliance with all Municipal and State codes, ordinances, and regulati/or~/s in effect.pKthe date of this inspection. Name of Firm ../",~/~"~/// Phone 4~"'/'~Z,~2 '~' ,~"~GINEERING Address ~'~--- --./ .... II~,J~e I:agl~-Alvel' Loop I~oa~t ~0. ")0~ / sign~t~rr~d-~.gle~ Rive,, Al.,k* 99~77 Date ~/2~/ Engineer's DHHS SIGNATURE ~X~ Approved for '~- Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 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 engineer's work. 724Y25(Rov, I/91) Bsck MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: V//~-/,~-I ~/(/~ ~',~-?'~--/~,q'"~d:f'~-Parcel I.D. Wall Data Well type ~--4~-'~ ~ . Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B. or C, attach ADEC letter. ADEC water system number Date completed ,,,-'/ Driller / Cased to //' Casing height W res~erly protected (Y/N) Date of test FROM WELL LOG/ AT INSPECTION Static water level Well flow / g.p.m. Pump level1 SEPARATION DISTAN SC/~FROM WELL TO: Septic/holding tank on lot '~' ~ ; On adjacent lots Absorption field on lot ~:~O' ~ ; On adjacent lots Public sewer main Public sewe~anhole/cleanout Sewer service line Petr~um tank WATER SAMPLE RESULTS: Coliform Nitrat~~__ Other bacteria Date of sample: ,/ Collected by: B. SEPTIC/HOLDING TANK DATA Cleanou~N) '"~/ Foundation cleanou,t~N) ~ Depression (Y,/~ High water alarm ('~/~) ,~//~. Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/ ...... NC TANK TO. · Well(s) on lot ~/1t~ . On adjacent lots ~--~O '--~ Foundation To property line ~/ L~ / Water main/service line l~) t'~ Absorption field Surface water/drainage MUNJCIPALJYY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION g.pAr0.G 2 0 199;5 RECEIVED 72-026 (3/93)' Front CONTINUED ON BACK PAGE C. LIF'r STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level ~ ~ Meets MOA electrical codes (Y/N) _ SEPARATION ~LIFT STATION TO: Well on lot ~ On adjacent lots D. ABSORPTION FIELD DATA Manufacturer ~ ~ "Pump off" Level at Cycles tested Surface water Date installed ¢'11 Length [¢'~ / Width Total absorption area Soil rating (GPD/Ft2) ~, ~¢ System type Date of adequacy test /'~/-/~ Water level in absorption field before test Peroxi~.e treatment (past 12 months) (Y~-~ Sl--PARA%rlON DISTANCE FROM ABSORPTION FIELD TO: Gravel thickness '~-.'~ / Total depth Cleanout presen,~) "7-/ Depression over field (Y~ Results (pass/fail) ,O~'z'~2 ~'~S¢;~PCor ~ After test h'-)/~' If yes, give date,,.-} Bedrooms Well on lot ~ ( Te building foundation On adjacent lots Surface water Curtain drain On adjacent lots ~ ' ~ Properly line To existing or abandoned system on lot Cutbank 1..~l o ~.~.~' Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION Signatur Engineer s ~//~NGINEE.i.6 -~//¢7034 Eagle ~Eive" L°°P R°ad No. 204 Date ~¢' HAA Fee $ ~O0 Date of Payment Receipt Number I (;edify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection, Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Bsck