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HomeMy WebLinkAboutT15N R1W SEC 18 LT 100T15N RIW Sec. 18 Lot 100 #051-172-29 Municipality of Anchorage Page —L of Z DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Is Anchorage, Alaska 99519-6650 0 Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: PID Number: C6,1 -/7Z-7_9 Name: Wastewater System: 0 New 06 Upgrade Address: A-- ABSORPTION FIELD Phone: 6P1r — T 3 o y No. of Bedrooms: a,r XDeep Trench 13ShallowTrench O Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: Total Depth f7,original grade: d- GPD/S . Ft. Lot: Block: Subdivision: Depth to pipe bottom from odgimdr Gravel depth beneath pipe � �Ft. s_ Ft. Township:/5n/ Range: 1W Section:' Fill added above original grade: Gravel length: D Ft. 7e Ft. WELL: fx./..0 New ❑ Upgrade Gravel width: 3 Number of linea: Obbna be ween lures Classification (Private, A,B,C): Total Depth: To: Ft. Total absorption area:Pipe 'W/ 14 Ft. material: Ft. 6� D. Ft. �'t7�•+ ?. 3N FFI D Driller. Date Orllled: Spee Water Lever.. Installer. Data installed: _ Ft. 4•/Ps ,U4�r 6 Yield: r Pump Set at: Casing Height Above Grourt. TANK GPM Ft. Ft. SEPARATION DISTANCES )I septic ❑ Holding ❑ S.T.EP. To Septic Absorption Litt Holding lWPrwa% Manufacturer Capacity in gallons: From Tank Paid Station Tank Sawer Livros /rvJ Well'/-')- 57 t0o Y'd-f.., Material:fre�/ Number of Compartments: Surface7�/�� Water t/oP T/sv LIFT STATION Lot Line fSize to /c, /'/,v in gallons: Manufacturer. Foundation ,`,15' / yU .� "Pump on" level at: Pump oft" leve High water alarm at: Curtain Drain Pump Modal Electfi spections performed by: Remarks: - BENCH MARK nn - ,Location i.✓i/'s. and Description: -e.r vr,'W r4fC wa/.k w-o,v ALE a: Assumed Elevation:Ft ENGINEERV SM OF A� ��•••aa.eaaw s� "� p%te 4. Inspections performed by: ��f= j Dates: 1 s 149-2�i��so./j9 ��«...a. 2nd 6—r1-99 /•• .....».»....» Department of Health and Human Services approval Louis A. elders t �; i C 67H .� �� �'•.Nwaaawf Reviewed and approved by: Date: 7 61 - I t%� 72-013 (Rev. oral) MOA 25 Permit No. SW990123 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196656 Anchorage, Alaska 99519-6658 Telephone: 343-4744 On -Site Wastewater Disposal Systemand/or Well Inspection Report NO SEPTICS +100, Legal Description: LOT 100, T15N, R1W, SEC 18 PID No.: 051-172-29 FD MON 101AI 0 m FD REBAR NO WELL +100' 1018 ADRIAN AVENUE / 33' BLM ROAD RESERVATION �+ T— (WEST - 330.00) X00 \EXISTING � WELL BLM s LOT 100 EIST O 1500 GAL SEPTIC TANK i 2% FD MON (EAST - 330.00) EXISTING MONITOR TUBE 22� ■ \WING TIES 0!A -C = 24.6 + B -C = 50.3 Lv A -D = 31.1 8-O = 60.2— A -E = 32.4 B-E = 61.9 A -F = 46.0 N B -F = 71.3 o A -G = 38.7 A 37.4 z -H = 8-H = 65.2 A -I = 36.0 B -I = 65.8 A -J = 37.2 B -J = 67.3 A -K = 34.6 8-K = 66.5 A -L = 100.2 8-L - 135.3 A -M = 104.8 B -M = 139.9 EIST O 1500 GAL SEPTIC TANK i 2% FD MON (EAST - 330.00) EXISTING MONITOR TUBE 22� ■ - TEST HOLE - MONODR TUBE o - SEWER CLEANOUT + - WELL - LEACH FIELD - EASEMENT o r qp- WELL SCALE 1' = 60' NO SEPTIC +30' NO WELLS/SEPTIC oo� U00 �� OF �4 ELEVATION 0IGIN G ��0� $o��P 0 (NTS) 98.4El .T, "'49TH ye .................... a ...... ................ tANN TOP Or RE CORNER OQ '. LOUIS A. BUTERA 94.9 .6 4.6 U.6LIF CONCRETE VALK Q ir••. CE -6736 2G Asv - :DSD ELE� `89.6 7 a- MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On -Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Permit Number: SW990123 Legal Description:'V15N R1W SEC 18 LT 100 Design Engineer: 0024 Eagle River Engineering Services Owner Name: Bruce Powers Owner Address: PO BOX 770258 EAGLE RIVER , AK 99577-0258 L -°tilq . sL`, 0 rh Date Issued: Jun 04, 1999 Expiration Date: Jun 03, 2000 Parcel ID: 051-172-29 Site Address: 019718 ADRIAN AVE Lot Size: 108900 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: ❑✓ Disposal Field ✓❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage 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 (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: Date: 6�1 f Date: .4-99 Eagle River Engineering Services Louis Butera, P.E. P.O. Box 773294 (907) 694-5195 tel Eagle River, AK 99577-3294 (907) 694-3297 fax SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM LEGAL: Lot 100, T15N, RIW, Sec 18 5/18/99 A. GENERAL 1. The well and septic plan are for a single family residence only. 2. The drawing and or site plan shall be a part of this specification. 3. All materials and workmanship shall meet the Anchorage Department of Health and State Department of Environmental Conservation requirements. 4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. 5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage, Department of Environmental Conservation requirements. 6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi -family wells. 7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. C. SEPTIC TANK 1. Septic tank construction shall be a minimum of 1250 gallon steel two compartment tank approved by the Municipality of Anchorage. 2. Septic tank is to be installed level on compacted base material. 3. All connections are to be made with caulder couplings. 4. The existing tank is to be pumped, removed and disposed of properly. 5. New tank to be provided with 2 cleanouts after tank and a diversion valve to old leachfield C. TRENCH 1. The trench is to follow the natural land contour to maintain uniform total depth of the trench bottom_ 2. The bottom of the trench shall be level, plus or minus 1.5". 3. The total depth of the trench excavation is not to exceed 9', referencing the ground surface at the uphill side, at any point. 4. The effluent line within the trench shall be laid level within 0.03'. 5. The trench gravel is to be covered with typar fabric material. 6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed over the leachfield. Mound if necessary 7. The area over the trench is to be finish graded to prevent ponding of surface water runoff. 8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS: TOTAL DEPTH= 9' GRAVEL DEPTH = 5' under pipe, 2" over pipe TRENCH LENGTH= 75' TRENCH WIDTH = bucket width SOIL RATING = 0.8 GPD/112 BEDROOM CAPACITY= 4 SEPTIC TANK = 1250 gallons Twenty-four (24) hours notice required for all inspections. \1999\99-013-spe EAGLE RIVER ENGINEERING SERVICES P. 0. Box 773294 EAGLE RIVER, ALASKA 99577 Phone 694-5195 JOB- Lof'/oo %/sN.['/w see /8 SHEET NO. el OF CALCULATED BY L /C DATE CHECKED BY DATE-- .) IO PR00.GT3W.1®k, pours Ya omit. NO SEPTICS +100' ADRIAN AVENUE /1�133� BLM ROAD RESERVATION-/ \��\ (WEST - 330.00) WELL EXISTING — WELL BLM 101A ' LOT 100 I EXISTING HOUSE ° ABANDON 9u O1• EXISTING PROPOSED SEPTIC TANK N SEPTIC TANK CO o FO REBAR I � n w BULL RUN VALVELn f� M 97.1E y n.L> NO WELL rPROPOSED +)mac I LEACH +100' b'Fl EI.O (�( <n p a Z 1018 Z 900 B7'n EXISTING NO SEPTIC rn MONITOR +30' n TUBE FD MON (EAST - 330.00) ® - TEST HOLE • - MONITOR TUBE NO WELLS/SEPTIC c - SEWER CLEANOUT - WELL NO SURFACE WATER — — - EASEMENT NO KNOWN CURTAIN DRAINS - PROPOSED LEACHFIELO EXISTING LEACHFIELD SEPTIC UPGRADE SITE PLAN LEGAL: LOT 100,T15N, R1W, SEC 18 ®®��� OF A(gopo OWNER: BRUCE POWERS CONTRACTOR: BARR of * : 4.9 TH '* ...................... JOB 99-013 1 DATE: 5/13/99 SCALE 1" = 60' EAGLE RIVER ENCINEERINC SERVICES'..LOUIS A. BUTERA P.O. Box 773294 4�-s,�'. CE -6736 .'n EAGLE RIVER, AK. 99577 0�?ka `Cl (907) 694-5195 FAX. • (907) 694-3297©aiNrESS10000000 e, Municipality of Anchorage DEPARTMENT OF HEALTH &HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 •'•;• °° S SOILS LOG — PERCOLATION TEST �,e'4 �ufluters CE573s �6 —, -- . PERFORMED FOR: /4c.r/ Oe^'h" `'r•'�j /���^' CEJ DATE PERFORMED: 7 LEGAL DESCRIPTION: Lo T/eo Township, Range, Section: j /s,v /2 / w p �y SLOPE SITE PLAN Re i— 1 ' 2- 3- 4- 51 34 5 r^ ff>e3 /'he/ `wept' 7 1 14 far is- 16 - 516 I br 17 t8 19 20 WASGROUNDWATER Gross Time ENCOUNTERED? —YDS Nett Drop S IF YES, AT WHATL i/ / 'S/iZ p DEPTH? I - •. E Depth to Water Alter Monitoring? /3 Date: S// 77 15�1 Reading Date Gross Time Net Time Depth to Water Nett Drop S d...r I - •. y; yr y 32 3 bac y, 27• 90 37 PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER 6 1 �l TEST RUN BETWEEN FT AND S- FT COMMENTS %la Ae J is -i ,r/ t G L war PERFORMED 8Y: I ®/ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: -5--Is-g7 72-008 (Rev. 4/85) �6 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 /J P-0 PHONE ❑NEW /CHA,QD UVE'•2 S Joe- 2/ 58 CKUPGRADE MAILING ADDRESS P. O. SOX SyC, CfltJC//�K, 1lf c.qV,, ,9 994--,.7 LEGAL DESCRIPTION - Lor /,00, LOCATION - NO. OF BEDROOMS UNe Well Absorption area DISTANCE TO: �Q J`� 5'�•7 Dwelling I 7 PERMIT NO. 790 3678 P M F Manufacturer G ee �.z Material No. of compartments 6 &� L Liq, capacity in gallons IF HOMEMADE: Inside length Width Liquid depth DMZ DISTANCE TO: Well Dwelling - PERMIT NO. _ H Manufacturer Material - Liquid capacity in gallons LU Z Well i DISTANCE TO: /L 2 Foundatio -1 i Nearest lot e,� PERMIT NO. s J LL No. of lines Length of ea line ! Total len th of)ines Trench width Distance betwee Ines _ZW ~ C H Top of tile to finish grade Material beneath the inches Total on area ct45Q, -41 60 inches. 0 ,'�7 w Length Width - Depth PERMIT NO. U M F wa Type of crib Crib diameter Crib depth Total effective absorption area DISTANCE TO: Well Building foundationce ftd� Depth Driller Distanto lot line PERMass IT NO.DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) ) OTHER .PIPE MATERIALS P v.e. PwE SOIL TEST RATING / S© INSTALLER 8, P. 4N 7-4 e RA/ sA!!: zs REMARKS OF A' L% .. g r , ir.,�P .••• ••.a —v�1 ..* ,4 .. .......`.. 0.0...� ?� Earl P.• EllisAt 00. CA APPROED-. DATE - LEGAL 816/79 Lor /Do, S,eC, !8, i !d -N, A?/W, 9,.tl 72-013 (R 3/78) ev. ION r7i OF 7�'I MUM MU" I C I F"F4L I TY OF= FiNCvHC:)MFiC3E DEPARTMENT O"RLTH AND ENVIRONMENTAL QMECTION 825 BEET, ANCHORAGE, RK. 99 264-4720 17 NVS ITE !sEwE:m P EF�M I T NO. C 790358 ) T RICHARD D. POWERS BOX 54 CHUGIAK 688-2158 RDRRIN'LN I L100 T15N RIW S.1B LOT SIZE 108900 SQUARE FEET SOIL RBSORBTION SYSTEM Le.TRENCH NUMBER OF BEDROOMS 4 SOIL RATING CSO FT/BR)= 150 E REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: EF"TH= 9 L.EP4C3TH= Era. C3FZFi%{E L E?EP TH= Z5 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). REQU I MME> SEPTIC TF "K �3 I 2!E= 1.Zt5O OaF L_L_O"- 'ERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE 1UMBER OF RESIDENCES THAT THE NELL WILL SERVE. --- TWC:e' <;2> I hJSF"EGT I O"S; FiF2E REC�U I FZECa --- 3ACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS )EPARTMENT WILL BE SUBJECT TO PROSECUTION. IINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS L00 FEET FOR A PRIVATE WELL; OR L50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. )THER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE IVAILABLE TO INSURE PROPER INSTALLATION. P EF M I T F=XFz' I RF=Sy E l-=0eME3aM :33.r I CERTIFY THAT L: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS -ORTH BY THE MUNICIPALITY OF ANCHORAGE. ?: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. C: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE 'ESIDENCE IS REMODELED TO LUDE MORE THAN 4 BEDROOMS. iIGNED:---- - - --------- -------- APPLICANT RICHARD D. POWERS SSUED BY Iso?S3 AND WELLS AS SET ENLARGEMENT IF THE V3. 2 a.�ivcs= ITVA 0 & E GEOTAHNI CAL Et DEVELGOAENT CO. -• Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 4ussell Oyster Earl Ellis Soils t SOIL LOG baa -2280 Soils B foundations Land Development Performed for: Name: K/cNA/LD peWw-'2S Tel. No. 6g8 -2/S -V Mailing Address: &y S',-, �ur✓�/�K tea. 995"7 Legal Description: LOT loo , S,Ec. /8, W,!!! - Depth (feet) Soil Characteristics 0 1 /U/L. --5/,L 7—-7o 2 3 4 i 6 4 S� C0t3/31. 8 �EtEfE To ! �iei Awe PcaT 06VAI I Ata —Se4� 11 12 S/tt 14Al0 z,S o 13 /,cep 7- 15 15 16 YS `"Z,9 -ST gle IAt rh `21n'%7 ti �6 Ground Water Encountered: Yes ✓No— If yes, what depth/a3�i r Proposed Installation: Seepage Pit Drain field Comments: Performed by: I'— r, I Date: — � 17034 Eagle River Loop Road ROBERT A. SHAFER A A Eagle River, Alaska 99577 CIVIL ENGINEER t A 694.2979 • r >R ,Q'r A'vCe_ r PROJECT: ��(7 �F� DATE OF TEST: LOCATION OF WELL (Legal Description): orf" 1 00 �� 1® WELLDEPTH:. V,L. FT. CASING: q"�)-l' FT. SCREEN:—�_ 4 DATE' DRILLING COMPLETED: ISIS _ ( DRILLER:_ STATIC WATER LEVEL (Top of Casing): 21 FT. GATE: �1-1-SS CLOCK ELAPSED TIME SINCE DEPTH TO DRAWDOWN/ PUMPING f TIME PUMPINGSTARTED/ WATER, FT. RECOVERY RATE, GPM REMARKS STOPPED, MIN. I •,40 0 Z V. �7 45 4:0l" AZN Z• 2`.00 10 ' B •� �( ••.. 1 •. O s - 15 t %1{ 2 20 60 (0 hour) �'�, lo" 25 30 U 0 1 Start 150 RECOVERY 4 t 0 a'le q 15 i .4 4 Comments:�J� t'f1F oc q o p(tlpca�r—� r Flow is not Guaranteed Subsequent Variations" Can Occur. V. �7 45 4:0l" AZN Z• 50 �j ' B •� �( ••.. 4-4 55 71�n 60 (0 hour) �'�, lo" 17 �,.•.° t _�.. ifif 150 RECOVERY 4 t 0 a'le q 15 i .4 4 Comments:�J� t'f1F oc q o p(tlpca�r—� r Flow is not Guaranteed Subsequent Variations" Can Occur. 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. # HAA #��� 1. GENERAL INFORMATION Complete legal description r i o Tis 1v A2 i --� .r -r-<' Location (site address or directions) 0/9 71e -4111, <', A�� Property owner 'Z5�1ce f� - r Day phone y -i3 Mailingaddress 7? -f5-4 Fir /C'�� y9T7-� Lending agency obnSkrnorcLac Day phone -7 //-2_ 4 Mailing Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 1-/ 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site X 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.1191) Front MOAM21 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 forthe number of bedrooms and type of structure indicated herein. I furtherverify 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 EagleRiver Engineerit Ser"M phone Coq— $ ! s �E%113�4, a River, AR 99g?.M Address Engineer's signature Date �_C — 55 6. DHHS SIGNATURE _ice Approved for ED UR bedrooms. M Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments i A fes/. /�rJjL Date 7- G UITic 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 (Pe .1Ni) Back MOA V1 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 a Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: Lir /oc) . 7/5.+✓ A/u/ Oce f8 Parcel I.D.: 051-/7L-29 A. WELL DATA Well type % , ✓4rrr If A, B, or C, attach ADEC letter. ADEC water system number /'r 1A Log present (Y/N) Al Date completed J751 �f— sir *rr. Total depth /A,d KroOaN Cased to a N *" " Casing height (above ground) Z/ /5S'P P..E'Lava rf 4s r see sq t Sanitary seal (Y/N) Wires properly protected (Y/N) y Date of test Static water level Well production FROM WELL LOG 1111A WATER SAMPLE RESULTS: Coliform el Nitrate AT INSPECTION '7--1-91 g.p.m. 3 / g.p.m. a • 5 —51� Other bacteria Date of sample: Ce�-Z8-99 Collected by: G/ci�f B. SEPTIC/HOLDING TANK DATA Date installed / f 2 9 Tank size iSv v Number of Compartments JI, Cleanouts (Y/N)� Foundation cleanout (YIN) Y Depression (Y/N) ry High water alarm (Y/N) N ta Date of Pumping T—k Pumper — C. ABSORPTION FIELD DATA Date installed /5 %S Soil rating (g.p.d./ff2 of4t4b&m) & C- System type 7 re"`� Length IA—Width -7 r Gravel thickness below pipe 5- Total depth S Effective absorption area 74 n Monitoring Tube present (YIN) Y Depression over field (Y/N) N Date of adequacy test No✓ 'y r "e Results (Pass/Fail) For — be Fluid depth in absorption field before test (in.); Immediately after= gal. water added (in.): i Fluid depth — (ins) Minutes later: — Absorption rate = — g.p.d. Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)' If yes, give date — D. LIFT STATION N `q Date installed Manhole/Access ) _ High wat farm level at* Cvcles tested Size in gallons "Pump on" level at* *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot //-I ` Absorption field on lot Public sewer main N !A "Pump off" level at* On adjacent lots */4e _ On adjacent lots r -/O" ` Public sewer manhole/cleanout /✓ 1A Sewer /septic service line + .a r' Lift station N /A -y SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation �2 T- Property line Ads—, Absorption field S - Water main/service line 1W ' Surface water/drainage -.Awa ' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line "-6 Building foundation 2fo / Water main/service line Surface water f�DO ` Driveway, parking/vehicle storage area ' Curtain drain Al la Wells on, adjacent lots R ENGINEER'S CERTIFICATION 1 certify that f have determined thru field inspections and review of Municipal recm: in conformance with MOA HAA guidelines in effect on this date. °� , ••"°••••yM�� 4 Signature Engineer's Name .��� > �w fora ••� Date S HAA Fee $ �6,9' .mom Date of Payment D 7— ,!�, /L / `f Receipt Number 7 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number are