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Home My WebLink AboutWOODRIDGE BLK 1 LT 6WOODRIOGE Block 1 Lot 6 #020-093-03 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 — ^' NAME/ PHONp /Ly NEW �7 A- JGk nS ue.� 34'16y- 3 ❑UPGRADE MAILING ADDRESS /')—vo r :? 6 , /1, rf (z LEGAL DESCRIPTION Wv,d!'Jje L.4- 6 %j /ucM / Ec rfl1J n-3 U LOCATION Ufai 0 NO. OF BEDROOMS "T DISTANCE TO: WellAbsorption area Dwelling — PERMIT NO. O y /O��— ul ZQ Manufacturer Ci fa(r- Material No. of compartments v NF Lid. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth V_9 DISTANCE TO: Well Dwelling PERMIT NO. Iz H Manufacturer Material Liquid capacity in gallons o1 LU Well Foundation Nearest lot lin DISTANCE TO: /p/ 23 Z� PERMIT NO. 6'S'-n1C)3�V PF w Z No. of lines Lyeng� h of each li e Total length of lin s Trench width (,.11 Distance between lines F?cc / 6 --/ fr 3P ( 7- Z� Inches !f 6 ¢ H Top of tile to finish grade Material beneath tile Total effective absorption area p 2— hio, d -&9- (-, inches 4- °7�—Cf Length Width Depth —'��— PERMIT NO. or U Q F o- — Type of crib Crib diameter Crib depth Total effective absorption area w DISTANCE TO: Well Building foundation Nearest lot line Class //�� Y' Ucd DISTANCE TO: Depth Building foundation Driller Sewer line 0 / i Distance to lot line PERMIT NO. Septic tank Absorption areals) -- OTHER - PIPE MATERIALS 7 -;,305;1 c/ $ — SOIL TEST RATING /ZSCi %L— INSTALLER .5 - 4,-', 5 9 REMARKS 'Ke/vi yTrs a —A6 ell vs > IEli -- — `F,PPROVED DATE LEGAL 72-013 (Rev. 3/78) -� —-— % 1.. IRA Hi�Y::1;�Ca�.r�C��"^'^�"'Y"�-'�� A.IVC,7�OlE;A.IGEn L•��,A�S1�iA►��" 1201 RON" St _ ............_____-. 7344-7714 SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF 33V r!!!>c � ,r ��D66R66IL9�L�gqEDAT THE RATE OF 823,00 _— PER FOOT. CJw4" ?" 325 A . 't'Ft01 *Y OWNER ChA#,U ;whrwon T.O. # 102071 99510 AWA 40"s LOCATION OF WELL DRILLER ARAMd&_ " WELL LOG: A _-71?I C11A.. ....' GL, 6 BLk. 1 lJood 14e Sub. 18-�' f�as�.d wn. A cted_qtew�.t. ldat wa.E�.�iaL ea 43--350' Be44eek. A are� ha.td eedUentoty tom. drod41 GTe te4 1�r ld wn o vet min twa f. a LC Eh�e wn� dN+re to A ;7!a�t%+r Q.tnqwl�tlwaA wait" y.t&U* rE/te�e ataao F4!* �+ 315--350' Alma. Motet ptadur.P.tan, l ri kyr e, a g±ract 345 Vito. Otte& *e44,&* Porto" "I/WCAt; AEhe t 44ell" 4!9A � A 345-350' UqU track .into loud &A4& bedrock. " tot" I#aU t p wdu.c tlan e4 1440 gattww 4A a 24 hoot. 44w 4 1*mK• heat.. toater 4ecovaW t4 back .to wa Azn 30 ?A 4Wl.Pwe. 320,44 .iii C"&4 at 1.6 gaLLww pest• %t. Ovat 500 ga.Uamo o. wait" An AP Thaw 4hag ld ag 4et the .tate a� {dew Pet m4julte.. �•lttr lIL _.titl..�tltl:/tW.� ga" WaltfA .C.O d e UU.tt4 "`i`7" AX &U"k4 4 W44 411.E %A lie4,4 Am the. dtUA..ted .to the bottoms and dn4 dww" 4" Me :seer P4oJm,&4 .thee to -14 wen batbr t wa ttA Ptadeu t4aa 50 ;e 100 alone 4 @A dean. 7'04a.0 C64.t o f AtUt4 tq• at. thio 44= 44: 8:23.00 pert 4 X 335 A. ;-7495.00 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. .:' WRITE: CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF THANK YOU VERY MUCH. BERNIE CLAUS OF RAMPART DRILLING WQ: DATE_ RptU30th, 1985 SERVICE CHARGE OF I/.% PER MONTH WILL BE ASSESSED ON PAST DUI. ACCOUNTii.° PILJPA jE to ic 0,001R. 7K I'v" u to eNvaqvi iuHnnown DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTIoN 825 L STREET, ANCHOR0GE, AK 99501 264-4720 C3 P4~E3 I - :F Q Q HIE 14 EKE V71 10 �Q L. L. F"VEFIVI 1 0 pERMIT NO: DATE ISSUED: APPLICANT: ADDRESR: ARMOMMMIMIM LEGAL nESCRIP: LOT SIZE: MAX BEDROOMS: 8501�3 04/16/85 CHARLI R^ JOHNSON 1200 E. 76TH" AVE. 01214 ANCHORAGE, AK 99502 349-65(".)5 SUBDIVISION: NODDRIDGE: SECTIpN: 3 TOWNSHIP: 11N 40153 (SQ^FT. DR ACRES) 4 LOT: 6 9LOCK: 1 RANOU: 7W Listed below are the options available to you in dosigning your septic system" Choose the option that best fits your site. �ITTET 1,110 131212 ul I) FT CA I P, If DEPTH TO PIPE BOTTOM (FT.) 4.0 4.0 4.0 GRAVEL TH (FT, 3^5 O^5' 3.5 TOTAL DEPTH (FT.) 7"5 4^5 7.5 GRAVEL WIDTH (FT.) 2"5 20. C? 5,0 GRAVEL LENGTH (Fl ,> 72,0 38.0 . 54.O GRAVEL VOLUME (CU"YDS^) 26"7 2B^2 40.0 TANK SIZE (GALS), 1,250.0 in 1,250"0 ** 1,250,0 ** SOIL RATING (SQ.FT./nR) 125 125 125 ** TANK MUST HAVE AT !EAGT TWO COMPARTMENTS I certify that� 1.^I am familiar with the requirements for on-site lowers and wells as set forth by the Municipality oF Anchorage (MOA) and the State of Alaska" 2. T will install the system in accordance with all MOA coOes and reguIatiuns, and in compliance with the design criteria of this permit. 3" I will adhere to all MOA anti State Af Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot" 4^ I understand that this permit is valid for a maximum of 4 bedrooms and any enlargement will require an additional permit, IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA 8UILDING CggES, THEN (1) AN ELECTRTCAL PERMIT AND INSPECTION MUST 8E 09TAINED; (2) AS-BUILTS WILL -NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPgRT; AND (3) THF ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN, ' SIGNED APPLICANT: ISSUED BY L'3" SOILS LOG MUNICIPALITY OF ANCHORAGE �. ❑ PERCOLATION DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 1; TEST 625 L. Street, Anchorage, Alaska 99501 264.4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: G��,%.. T�pN/tZL— ,J/, _DATE PERFORMED: LEGAL DESCRIPTION:_( / 11 - ��v - P T� 1 L AIVII �lniws 2 3 4 / 6ucwK�lMOrs1/ u4rf%u �wti.'G 6 ` . 7 8 � 9 ';r'ely 10 f J SLOPE SITE PLAN 51 11D legit ` WAS GROUND WATER S W t )r ENCOUNTERED? �,.I,( O 0 12 y OYtj -41 / E .' IF YES, ATWHAT / 13 �" �s. -�L SalUvard G��(J-5,5 DEPTH? P 14- 15- 16- 17 4 151617 18- 19- 20- Reading 81920 Reading Date Gross 'rime Net Time Depth to Water Net Drop 5U PERCOLATION RATE FT AND /!, PERFORMED BY: IIP/n v1(5 k,<' _CERTIFIED I3Y 72-008 I6/791 (minutes/inch) FT DATE: Municipality of Anchorage Development Services Department =: ' ►`: Building Safety Division On -Site Water 8 Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 020-093-03 HAA#_0 n ZZj 1. GENERAL INFORMATION Expiration Date: Complete legal description WOODRIDGE SUBDIVISION; LOT 6, BLOCK 1, Location (site address or directions) 5100 WOODRIDGE DRIVE * ANCHORAGE, AK Current Property owner(s) WINTHROP FOWLER Day phone 278-9133 Mailing address 5100 WOODRIDGE DRIVE * ANCHORAGE. AK 99516 Lending agency Day phone Mailing address Real Estate Agent DON McKENZIE REMAX PROPERTIES Day phone 694-4200 Mailing address 16600 CENTERFIELD DRIVE * EAGLE RIVER, AK 99577 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Municipality of Anchorage ' Development Services Department Building Safety Division OnSlte Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.enchorage.ak.us (907) 343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: WOODRIDGE SUBDMSION; LOT 6. BLOCK 1. Parcel ID: 020-093-03 A. WELL DATA Well type PRIVATE If A. B. or C provide PWSID# N/A Date completed 4/30/1985 Sanitary seal (Y/N) YES Total depth 350 ft. Cased to 350 fL FROM WELL LOG Date of test 4/30/1985 Static water level 30 ft. Wag production 1 9.p -m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 0.20 mg./L. Well Log (YIN) YES Wires property protected (Y/N) YES Casing height (above ground) 31 In. AT INSPECTION 3/17/2003 31 ft. 0.78 g.p.m. Other bacteria 0 colonies/100 mi. Arsenic: N/A mgJL. Date of sample: 3/17/2003 Collected by: AKWWC. INC. B. SEPTIC/HOLDING TANK DATA Tank Type/Material GREER/STEEL Date installed 5/29/1985 Tank size 1250 gal. Number of Compartments 2 Cleanouts (YIN) YES Foundation cleanout (YIN) YES Depression over tank (Y/N) NO High water alarm (YIN) N/A Date of pumping 3/17/2003 Pumper MCDONALD'S PUMPING C. ABSORPTION, FIELD DATA Date installed 5/29/1985 Soil rating (g.p.dlftbr E 125, System type BED Length 42 ft. Width 21 ft. Gravel below pipe 0.5 ft. Total depth 04.5+ ft. Eff. absorption areal_ ft' Monitoring tube YES Depression over field NO Date of adequacy test 3/17/2003 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth In absorption field before test 0 in. Water added 806 gal. New depth 2 in. Elapsed Time: 16 min. Final fluid depth 0 in. Absorption rate >= 600+ g.p,d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed "Pump on" level at in. Datum E. SEPARATION DISTANCES Size in gallons High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/deanout N/A Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 106+ Surface water 100'+ Wells on adjacent lots 1000+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehide storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION L v� I certify that I have determined through field inspections and (, review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. e r A. Gam ss:' Engineer's Printed ame JEFFREY A. GARNESS 953 t; fi.�°^° Of ..... • Datea x,04 —�+— ofee°to� HAA Fee $J 15• Waiver Fee $ Date of Payment 5/+ �p�q3 Date of Payment Receipt Number �lDj�'�1 Receipt Number (Rev. 12101) Municipality of Anchorage Development Services Department Building Safety Division ,., 61 On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchoraga.ak.us (907)343-7904 Water Well Advisory Health Authority Approval # 030227 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block 1, Lot 6 of Woodridge subdivision, the well's productivity was determined to be 0.78 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 4 -bedroom residence is 0.41 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. MAY -28-2003 WED 09:46 AM GEICO DIRECT 1 907 258 7958 P. 02 ss.�r�e a:.o;f •• vlvyJ \• � �rn . ca.c1' It co 3`. oZIcZ AVEC L I 1 lo' ,url LITY t:6MT'. Il �� 4 Aai.voow covr. I N � I I 0 .7z.2 I • .1t17'40'RI'r 179.£11' J00 NO.: B0c24 8p' v ZONED : QBC'.eY L'PL7.47'�' i�IO�ssaG FIELD BOOK: CLIENT I JOHN3oN SCALE:1'-d0 PLOT PLAN: TS -BUILT; % GRIO: 'J'b'!-I DRAWN BY:VJS I CHECKEDf120 1. FIR BY: FaRBES ENGINEERS, INC . ANCHORAGESTALASKA 99501 I'NERGY CERTIH THAT 1 HAVE.StRVEVEO'1 k•FOLLOWING DESCRIBED PROPEI 'Y. LOT Qa ,BLK. 1, W0007Fi1CT$E'.}$UDC71VISIoi4, AHC4CRAGE RECDA01011 DI STRICT.AK.. IM THAT THE IXPPDVE14ENTS SITWIEI •THEPEDN ARE WITHIN THE PRCPFATY LINES ANO 00 NOT E1,;ROACM ON THE PROPERTY LYING IAJACENT TMERETO: THAT NO IMPROVEMENTS ON P:OPEFTY LYING ADJACENT THERETO ENCROACH 0114 THE THE PREMISES IN WEST ION AND THAT THERE. ARE NO ROADWAYS. TRANSMISSIIyI LINES OR DINER VISIBLE EASEMENTS ON SAID PROPERTY Exam AS INDICATm HEREON.*. DATED IVIS 2P^''JtY OF MAY ,19,614, ANCHORAGE, *ALASKA. IT IS INC RESPCKS:BILITY OF INC OWNER /R BUILDER, PRIOR TO CONSTRUCIC•4. TO VERIFY PRCPDSED BUILDING GRADE 14CLATIVE III F111 -5H GRADE AND UTILITY C011ECt"ONS A:10 TO DETERMINE THE E%:3T£NCE OF ANY EA3171EN-A& COVENANTS OR RESTRICTI0M8.101:CH 00 NOT APPEAR OV In RECOROEO SUBDIVISIDH PLA'. ,..rr+..,c.-. r.. _..arc:•.�+•r'.•.�.� i 1. GENERAL INFORMATION Application Date ? -- �' ^ Y-6 (a) Legal Description (include lot, block, subdivision, section, township, range) �lvodr'd�e• QL 6 r // /V R 3 W'' Location (address or,0irectl�ns) ..w o, (b) Applicant Name CAar(ie' of fon _ Telephone: Home Business 3y�—/_Z_ 3_ Applicant Address Po BoK 'yI 2 Yy 3 AM-41--y'r- (c) Applicant is (check one): Lending Institution ❑ ; Owner/builderC ; Buyer ❑ Other ❑ (explain); (d) Lending Institution AY- Mw �ttI—Telephone Address (e), Real Estate Company and Agent Address Telephone — (f) Mail the HAA to following address: 2. TYPE OF RESIDENCE Single-FamilyfA Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well Community C7 Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsill Public El Community ❑ Holding Tank 11Note: I community well system, must have written confirmation from the Slate Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 /2-025 n1/84) 1, Application Date ? -- �' ^ Y-6 (a) Legal Description (include lot, block, subdivision, section, township, range) �lvodr'd�e• QL 6 r // /V R 3 W'' Location (address or,0irectl�ns) ..w o, (b) Applicant Name CAar(ie' of fon _ Telephone: Home Business 3y�—/_Z_ 3_ Applicant Address Po BoK 'yI 2 Yy 3 AM-41--y'r- (c) Applicant is (check one): Lending Institution ❑ ; Owner/builderC ; Buyer ❑ Other ❑ (explain); (d) Lending Institution AY- Mw �ttI—Telephone Address (e), Real Estate Company and Agent Address Telephone — (f) Mail the HAA to following address: 2. TYPE OF RESIDENCE Single-FamilyfA Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well Community C7 Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsill Public El Community ❑ Holding Tank 11Note: I community well system, must have written confirmation from the Slate Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 /2-025 n1/84) 5. ENGINEERING FIRM PROVIDINI. ASPECTIONS, TESTS,FILE SEARCH, DA'. 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 dale of this inspection. 91 Name of Firm /%ECS Telephone ✓5-61 SO L/0 Address / 20o w ;.3.3 /f., CA or., A (ate t y?J-Z:)3 Date DHEP APPROVAL(�� Approved for !�'611,R, bedrooms by _ Approved X Disapprove Condition Terms of Conditional Approval M0 NUVA OK Date V 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 DFIEP 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 riot 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 (11/04) MUNICIPALITY OF ANCHORAGE (MOA1 HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1964 MUNICIPALITYDEPr. OF ANCI-IORAGE ENVI ONMEOF HEALTFI & NTAL PROTECTION 264-4720 (p ►r^ p Legal Description.. E 1 G Crp- I ��/D-L S4, 3 T/zIO 3WT A. WELL DATA Well Classification ��'y" If A, B, C. D.E.C. Approved (Y/N) 'yg Well Log Present OI) Date Completed — W__34 I_YgsJ— Yield 6o 1'14 Total Depth 350 Cased to 36-5 — Depth of Grouting _ Static Water Level 3 0 _ Pump Set At — Casing Height Above Ground -- `2,x Sanitary Seal on Casing6N) Electrical Wiring in Conduit PN) - Depression Around Wellhead (Y/� Separation Distances from Well: To Septic/Holding Tank on Lot —L�— To Nearest Edge of Absorption Field on Lot /0 To Nearest Public Sewer Line SVA Cleanout/Manhole — 'V 13 _ Water Sample Collected by Po,, I A �S Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA ; On Adjoining Lots G7 /00 ; On Adjoining Lots 67- /00 — To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date 6`30-86' Dale Installed S Ly Size /2 5_"i StandpipesfN) Air -tight CapsaN) Depression over Tank (Y/6Q Pumping/Maintenance Contract on File (Y/N) /`/d Holding Tank High -Water Alarm (Y/N) — A'd Separation Distances from Septic/Holding Tank: To Water -Supply Well /0 9 To Property Line 3 To Water Main/Service Line Course 6T /00 Comments Page 1 of 2 72-026(11/84) No. of Compartments — ;7 FoundationCleanoutZo, N) Date Last Pumped _ ;for /v1 Temporary Holding Tank Permit (Y/N) To Building Foundation / To Disposal Field 3— To Stream, Pond, Lake, or Major Drainage Ooodn !�((Je 131 Z G C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /;_1 r Type of System Design 19eQ Date Installed 5/Zq SS Length of Field _ Width of FieldZ / Depth of Field Gravel Bed Thickness 3 � S Square Feet of Absorption Area 68 P_ '(f Standpipes PresentA Depression over Field (Y/W Date of Last Adequacy Test Results of Last Adequacy Test _ IV4- Separation Distance from Absorption Field: To Water -Supply Well to / To Building Foundation — 2. 3 Lot N r+ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION To Property Line aO ; On Adjoining Lots To Existing or Abandoned System on CST 30 To Cutbank (if present) 6 /00 Date Installed Dimensions Size in Manhole/Access (Y/N) "Pump On" Level at _ "Pump Off' Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** 2-0 Cycles during Adequacy Test. Meets MOA I certify that check d, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Sign _ Date 8 �6 Company J�FCS MOA No. sr `I`6 0 L Receipt No. -bg 4 qy 6 Date of Payment 2-H-84 Amount: $ t° Page 2 of 2 72-026 (11/84)