HomeMy WebLinkAboutVOYLES BLK 2 LT 3
Municipality of Anchorage Page / of ~
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION ~"¢./,L.~
Address:
LEGAL DESCRIPTION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 /
On-Site Wastewater Disposal System and/or Well Inspection Report,
Permit Number: ,.~,v ~0~../,~' PID Number:
Wastewater System: ~;'New [] Upgrade
ABSORPTION FIELD
Lot: Block: Subdivision:
_Township: //~/~/ t Range: ///~ Seotlon:
WELL: ~-New [] Upgrade
Classification,,i~f/j,/,~t ~"~(Private' A,B,C): I To~l¢~ ¢"'~Depth: Ft. Cased/~' ~"T°: Ft.
Yield: ~ ~ GPM I Pump~/~Set at: Ft. I Casing He[gM. Above Ground:Ft.
SEPARATION DISTANCES
To Lift
From Station Sewer Lines
~/~
Well
Surface
Water
Lot
Line
Foundation
Curtain
Drain
Remarks:
Post-It"' brand fax transmittal memo 7671 I # of pages
co., co.
Fax ~ Fax fl
E] Deep Trench "~Shellow Trench E] Bed [] Mound [] Other
Total Depth from original,grade:
Depth to pfpe boaom Irc original grade: Gravel depth beneath pipe
¢' ~ ~,. 3 ~ ~,.
Fill added above original grade: Gravel length:
FANK
J~(Septic [] Holding [] S.T.E.P.
Manufacturer: Capacity in gallons:
Material: Number of Compartments:
LIFT STATION /7//,4
.~¢ i Size in gallons: Manufacturer:
"Pump on" level at:
Pump
High water alarm at:
~pections performed by:
BENCH MARK
Location and Description:
Inspections performed by: ¢/4 ~o Dates: 1st
2nd ,¢¢~3/?q
Department of Healtl~ Humaf~vices approval
Reviewed and approved by~'~ ,~~ Date: ~A.-"~/~..c
6(t"~/~'/~
Assumed ElevafiTo0 f 0 0
ENGINEER'S SEAL
~-~ ,~ , ~'~
12-013 ($/gl) MOA 25
Permit No. '-} ~ ~/?~ ;;/~ Page
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Bo× 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: ._~0~"~-¢% Z.O'r ~ (,~£~,&Z:._ ~..
10' UTILITY
EASMENT
ELEVAT]BNS ~ m~ or ,~LL CASIN~ -,
(NOT TO SCALE) ~u~T[~v = lOO.OO' ~m
SV/ING VIES
h - D = 33.7
A E = 76,7
B F = 49.6
SCALE I" = 60'
ENGINEER'S SEAL
' CE-6736
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" StreeL Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
(ENGINEER'S SEAL)
pE, FOHMED POR: ~U¢51'~¥ DI41't5-1'O t~Vl5 ~I~ACEH~F ~¢A DATE PERFORMED;
LEGAL DESCRIPTION: "~0"~~ '2~//~, Township, Range, Section:
2
3-
4
5
6-
7
8
9
10
11
12
13
14-
15-
16-
17
18
19
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
DepLh Io Watsr After D~_~T~
Monitoring? Date:
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
I a H~7 lo:oH,r!,
~o,o HiN
[0,0 HIN
20-
PERCOLATION RATE [/-~ (minutes/inch} PERC HOLE DIAMETER __
TEST RUN BETWEEN
FT
COMMENTS
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 {Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE:
SULLIYAN WATER WELLS
DATE - ~tar~ - E~de~
PERMIT NUMBER
AIN~ OF FORMATION:
From ,
~_Ft. to Ft,_
From
Ptom~
o~ wi;u-' '/rPi
LEVEL OF W.~.TER F r.
MI$CL. [NFOliMATION: "i~ ', ', '
'1
I ' '
Fro~ .... Fi-to__
From~ _Fl. to _Ft,
From~FLto .... Fl
From .....
From .... F~ to ....
Fromm- ~FL go ..... FI
From ....
From__. Ft. Io
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 WE~ ~ WASTEWATE~ DISPOSAL SYSTEM PE~IT
PERMIT NUMBER:SW940218
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAME:JOHN GRAYBILL
OWNER ADDRESS:P.O. BOX 670358
CHUGIAK. AK 99567
DATE ISSUED: 7/01/94
EXPIRATION DATE: 7/01/95
PARCEL ID:05106465
LEGAL DESCRIPTION: VOYLES BLK 2 LT 3
LOT SIZE: 48522 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MTJST BE IN ACCORDANCE WITH:
2.
3
4
THE ATTACHED APPROVED DESIGN.
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).
THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 (24 HOURS)
FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
REC .IVED BY:
ISSUED BY:z~--~~
DATE:
Louis Bulera, P.E.
Registered Civil Engineer
June 29, 1994
Jim Cross
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Voyles, Lot 3 Blk 2
Narrative
Dear Mr. Cross:
On behalf of our client, Turner Construction, Inc., we are re-applying for a septic construction
permit. The application incorporates design modifications agreed to in our meeting of June 28,
1994. We are still requesting a variance of the code 50' distance to the top of a slope break of
25 % or greater. The distance from our proposed primary field to the slope change averages 40'.
Slope after the break ranges from 45-65 %. The sloped area is completely vegetated and has
large birch and spruce trees. Based on our past experience, the soils information, and other
conditions at the site, we feel the proximity to the sloped area will not cause surfacing or other
effluent disposal problems. Due to the configuration of the lot, driveway and house location
along with the required well setback, the planned location is the best usable area.
The proposed septic upgrade will have very limited impact on adjacent properties for the
following reasons:
2.
3.
4.
The surrounding lots have sufficient room for septic sites, and the subdivision
adjacent to the west is served by community water.
Immediate neighboring septic systems are all +30' distance.
Reserve space is adequate, due to absorption capacity and lot size.
Surface drainage will not be affected and is not a major consideration in our
design.
Due to our client's construction schedule and your prior staff design review, we are requesting
an expedited review of this permit submittal. If you have any questions please call our office
at 694-5195.
Sincerely,
Louis Butera, P.E.
\C:\WPWIN60\WPDO CS\ 1994\94-029 B .NAR
P.O. Box ?73294 , Eagle River, Alaska 99577 · Telephone (907) 694-5195 · F~x (907) 694-3297
SPECIFICATIONS FOR ON-SITE SEIrrlC SYSTEM
LEGAL: VOYLES LOT 3, BLK 2
.GENERAL
1. The well and septic plan are for a siugle family residence only.
2. The drawing and or site plau shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health
requirements.
4. All soil tests are advisory to the design and are to be verified or modified itl the
field by the engiueer.
5. All excavations aud depths are advisory and are to be verified in the field by the
contractor to meet Municipality of Anchorage reqnirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements
aud to locate any adjacent multi-family wells.
7. The excavation is to be exactly in the area shown on the site plan, any deviation
reqnires engineer approval.
8. It is always recommended that a surveyor locate the nearest lot line position and
the location of any easements.
DRAINFIELD
1. Tile drainfield is to follow the natural land contour to maintain unifor~n total
depth of the drainfield bottom.
2. The bottom of the drainfield shall be level, plus or minus 1.5".
3. The total deptb of the drainfield excavation is not to exceed 5.0' at any point.
4. The drainfield gravel is to be covered with typar fabric material.
5. Soil or combinatiou of soil and extruded board insnlation to a depth of 3' or
equivalent is to be placed over the leachfield.
6. The area over the drainfield is to be finish graded to prevent ponding of surface
water runoff.
7. The septic tank mid leacbfield mnst not be closer than 100' to any existing private
well, 150' to any Class "C" well, or 200 feet to any coinmunity well.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH = 5.0' GRAVEL DEPTH = 3.0'
DRAINFIELD LENGTH = 87' DRAINFiELD WIDTH = 5'
SOIL RATING = 0.8 GPD/ft2 BEDROOM CAPACITY = 4
SEPTIC TANK = 1,250 GALLONS
Twenty-four (24) hours notice required for all inspections.
EAGLE RIVER
ENGINEERING SERVICES
P. O. Box 773294
EAGLE RIVER, ALASKA 99577
Phone 694-5195
VOYLES Lot 3, Block 2
C.H. o^~ 76_/29/94
L.B. 06/29/94
SCALE
Four Bedromn Siugle Family Dwelling- REVISED 06/29/94
Wastewater loading:
Soil Absorption Rate =
Required Absorption Area
for a 5' wide trench L =
Reduction factor for 3.0' gravel
Use 87' x 5' trench, 3.0' gravel
4 Bedroom Capacity = (4BR) (150 GPD/BR) = 600 GPD
8/9 min/inch = 0.8 GPD/ft2 application rate
= (600) + (0.8) = 750 ft2
750 + 5 = 150'
= (150) (0.58) = 87'
TANK
4 BR = (4-3) (250) + 1,000 = 1,250 gallons minimum
Leachfield Dimensions:
Gravel Depth = 3.0'
Gravel Length = 87'
Total Depth = 5.0'
C:XWPWIN 60\WPDOCS\I994\94-029 B.CAL
E
~ TEST HOLE
NO SURFACE WATER PROPOSED LEACHFIELD
+100' TO SEPTIC ~ ~ - EASEMENT
NO KNOWN CURTAIN DRAINS
WELL A~D ~EPTIC SITE PLA~
LEGAL: LO[ 5 BLOCK 2 VOYLES SUB.
OWNER: N/A
CONTRACTOR: TURNER CONSTRUCTION, INC.
,o~ ff ~4 o2q D~,U: ~/:v/~ I' sc~c~ 1" = 40'
i EAGLE R/VYR, A/(. 99577
(907) 694-5195 ]7'AX: (907) 694-3297
Municipalily ol Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEt.~AL DESCR PTION:
1
2
3
4
~ 0 ~,. ~1,) 56
7
8
9
10
11
12
13-
14
15
16
17
18
19-
20
COMMENTS
DATE PERFORMED:
3../ [.. ~j ~ 2.. Township, Range, Section: '"7~¢.¢",,~ / ~'
SITE PLAN
SLOPE
Gross Net Depth to Net
Reading Dale Time Time Water Drop
2.. ,,
PERCOLATION RATE ~' r~~ (minules/inch} PERC HOLE DIAMETER . ~ ''/
1EST RUN BETWEEN - ~" FTAND ~ FT
li-46TALJ.,, I.'Z-6" t'IC 'lo,t: [['
-- ~ .~..~-~ CERTIFY THAT THIS TEST WAS PERFORMED IN
PERFORMED BY: ~../~/~-.J', I
ACCORDANCEWI1HALLSTA]EAND MUNICIPAL GUIDELINES IN EFFECT ON'IHIS DATE. DATE:
72 008 (Rev. 4;85)
(ENGINEER'S SEAL)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, ARchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
Township, Range, Section: '7-/5-/p/ /:'/bu.' .~t.,:.. ~
SLOPE
SITE PLAN
10
11
12
13
14
15
16
17
18-
19
20
was GROUND WATE,~
ENCOUNTERED?
IF YES, A F WHAT
DEPTH?
D~plh Io Waler After ~
Oate
Time
Depth to Net
Water Drop
PERCOLATION RATE ~ (mmules/inch) PERC HOLE DIAMETER
~ EST RUN BETWEEN '~' ~FT
COMMENTS ~(~-JJl ~h~,S'l'AII J ~1'1~.t¢ ..... , ~l - FTAND
ACCORDANCE WITH ALL STA1 E AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE
72-008(Rev 4i85~
CER]IFY THAT I'HIS TEST WAS PERFORMED IN
DA'rE: __~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Di.¥ision of Environmental Services
On-Site Sen/ices Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I,D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
051 -064'-65
1, GENERAl. INFORMATION
Complete legal description Lot 3; Block 2; Voyles Subdivision
Location (site address or directions)
21844 Chandelle Drive
Chugiak, AK
Property owner
Mailing address
Lending agency
Mailing address
Paul & Deborah Alleman
21844 Chandelle Circle
Day phone 688-1 423
Chuqiak, AK 99567
Day phone
Agent Dave Aquino/ Jack White Real Estate Day phone
Address
762-3120
tJnless otherwise requested, HAA will be held for pickup.
NU~IBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
XX
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. YYPE 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~O25 (Rev. 1/9~) 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 o/f/this inspection.
Name of Firm Alaska Wa, t~ ,~ & Wa~t/~,~ate, r/I Phone
7320/E~st ~2~ :ster/H~.~ c~rcie
Address ,~'nchbr~/~ A~rl~995[04 ,
ALASKA WATER & WASTEWATER SERVICES
SHALL BE PAID $650.00 AT CLOSING
' FOR SERVICES ~R4E-P¢n~E~.PERFORMED.
bedrooms,
DHHS SIGNATURE
L"/ Approved for
Disapproved.
Conditional approval for
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.
72-025(Rev. 1/91) Back MOA~21
, I:CEIVED
Municipality of Anchorage AUG 0 3 1998
DEPARTMENT OF HEALTH & HUMAN SERVICES t~,~J
Environmental Services Division .~UNICIPALI'rY OFANCHOP, AGE ~.~
825 L Street, Room 502· Anchorage, Alaska 9950~l[¢~N¢~s-~s pwlslo~
Health Authority Approval Checklist
Legal Description: LeT' -~, ¢~-0~,. Z.~ '~o'¢~-¢s ~ Parcel I.D.:
A. WELL DATA
Well type
Log present (~N)
Total depth
If A, B, or C, attach ADEC letter. ADEC water system number
"f/P-, -¢ Date completed
Sanitary seal ~N)
t
Cased to J
Casing height (above ground)
Wires properly protected (~1)
Date of test
FROM WELL LOG AT INSPECTION
Static waterlevel
Well production ~.O
WATER SAMp~;E RES~TS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed ¢;/..~qq Tank size
Foundation cleanout (~/N)
D at e o f P u m pi n g o~J~/¢'~)
C. ABSORPTION FIELD DATA
Date installed
Length ftc Width
Effective absorption area ~7'~~
Date of adequacy test
g.p.'m, lB, I g.p.m.
Nitrate l'%¢ f~/'~' Other bacteria
7320 East Chester Hts. Circle
Anchorage, Alaska 99504
Number of Compartments ~ Cleanouts
Depression (Y~ /~ High water alarm (Y~
Soil rating ~ orJCCbdr-m)
Gravel thickness below pipe
Monitoring Tube present i~N)
Results ~
~ System type
'~ Total depth
Depression over field (Y(~ ~ o
For ¢r bedrooms
Fluid depth in absorption field before test (in.); q'L. lo" Immediately afterql-g gal, water added (in,):
FMd depth~; 6 (ins) Minutes later: 2.2...g. Absorpti?n rate = ¢oo+' _g,p.d.
Peroxide treatment (past 12 months) (Y(~).IkJ0 ' If 'yes, give date ~
72-026 (Rev. 3/96)*
/
D. LIFT STATION
E. SEPARATION DISTANCES ,
SEPARATION DISTANCES FROM WELLON LOT TO:
Septic/holding tank on lot I co 14.-
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots I
Public sewer manhole/cleanout ~/~,
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation .,,'k ~t .~.
Property line q.C;t Absorption field '~ ~o~
Water main/service line Io~e Surface water/drainage leo Lf- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line II Building foundation ~Zt Water main/service line IoLP
Surface water '~ o et 4- Driveway, parking/vehicle storage area '¢H'o I
Curtain drain ~¢~4r~ ~.¢0¢d Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
' ¢~"fy that' h, Ne Ce~i~4u field inspections and review of Municipal
in conerma~e ~it~ ~¢~A ~ide/ines in effect on this date·
Signature
Mate f 15 ~ / -/~
HAA Fee $
Date of Payment
Receipt Number .~
72-026 (Rev. 3/96)*
· Waiver Fee $
Date of Payment
Receipt Number
SCALE I%.~o' GRID J~'~JJ-~D_9 Project No, ~,~4~'[Z~_~_
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. #
1.
CERTIFICATE OF HEALTH AU'~HORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
051-064-65
GENERAL INFORMATION
Complete legal description
Voyles Lot 3, Block 2
HAA# Fl q q q,3
Location (site address or directions)
NHN Chandelle Drive, Chugiak
Property owner John Graybill
Mailing addressP.o. F~x 670358. Chnglak. A~'
Lending agencyN/A
Mailing address.
99567
Day phone_694-5195 (msq)
Day phone
Agent N/A
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well X
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community well stem, provide ntten confirmation from Sta~, e AbE a t- ":' :
the legality and status of system. ' ; ' ~' :
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 affi×ed 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. ~ further verify that based on the information obtained from
the Municipality of Anchorage files and from my invest, i_gation 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 Eagle River Engineering SerVices Phone 694-5195
Address P.O. '
Date
Engineers signature
DHHS SIGNATURE
,~,._ Approved for
Disapproved.
Conditional approval for
bed¢ooms.
bedr00msl with the following stipulations:
-/ ,~'?",\%/i ~. ~o- mhe well for this property mee_~s exl_.stl, nq
,"~'~ ',~ddit)o~t, CQm,,m_en-ts-~--~.~.'~o~.es There are nitrates pre~ent. +~ l~_~s
~C ,' ~~?T~-~itrate 6once~tration is 5.5b mg/l. ~*- ·
:/ / ~inue~ suitability · '~ , ,
'~ ,' ~'~'U~- ,..~ ~.~' ~ S' 10.0 'm~/l~ .:
responsible for errors or om ssions in the professional engineer's work.
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
' ' ' er to satisfy certain federal and state requirements. Employees of DHHS do not
andtheirlendmg~nstltut~°ns~.n°rd .... ~-^'^,'- a certif cate is ssued. The Munmlpahty of Anchorage ~s not
conduct Inspections or analyze ~ata u~,-,,,~ ' ' '
Municipality of Anchorage
Depar[ment of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~?O~-¢G /.0~ ~ ~L-~ ~- 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. ADEC water system number
,V¢' .~ Date completed ~2 ~/~z/ Driller
/~/! Cased to / ~'/ /
Casing height
~/~-~ Wires properly protected (Y/N) ~/~'~
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well flow .~ g.p.m.
Pump level1 [.//z/K/'/DI4)/~/ /
SEPARATION DISTANCES FROM WELL TO:
Septic/AoffJirfg tank on lot ~/0~ /
Absorption field on lot 7
Public sewer main
Sewer service line ;~'./t¢(~ /'
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE BES~ILTS:
Coliform ~ Nitrate
Date of eamp,e:
.5; ¢o /~¢¢, //--.
Collected by:
Other bacteria
S. SEPTIC/H~bDtNG TANK DATA
Date installed (~2/0;/~ Tank size /~ F(~
Cleanouts (Y/N) )/g~ Foundation cleanout (WN)
High water alarm (Y/N) /~//~
Date of pumping ///,4 ~
Compartments ,~
,¢L¢~ Depression (Y/N) /'/0
Alarm tested (Y/N) ,,A//,/~
Pumper ./'V//~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ¢' /(~ ! On adjacent lots
To property line L]¢2 / Absorption field
Surface wateddrainage /y/A
/
Foundation
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION ,/~/~
Date installed
Size in gallons
Manufacturer /
Manhole/~..~. "Pump~at
Vent (Y/N) "Pump on" level at
High water alarm level ~_..-,-'"'~Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTAN..G~-F~OM LIFT STATION TO:
Well on [pt-'''''''''~ On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed (~//) ~/¢L//
Length ¢(~ ? Width
Total absorption area "~ "~
Date of adequacy test ,.4//,~
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/Ft2) 0, cc System type ~;_///¢/../.~
~F' / Total depth ~ /
~ Gravel thickness ~ /
¢Cleanout present (Y/N) ?~> Depression over field (Y/N)
Results (pass/fail) /P/¢ ~' S for "~ Bedrooms
/V//~ After test
/,//~ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /- / O~ /
To building foundation
On adjacent lots ¢ .~ (-,) /
Surface water
Curtain drain ./-//~
On adjacent lots ¢'/~..~ / Property line
,~ ~- / To existing or abandoned system on lot
Cutbank ,,,V,//¢ Water main/service line ¢ ~ /
Driveway, parking/vehicle storage area //~) /
E. ENGINEER'S CERTIFICATION
Signature
Engineer's Name
Date //-
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect..oR, tho,date of this inspection.
HAAFee$. ~00 ,~O
Date of Payment //- / - c~ ,z-/'~
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back