HomeMy WebLinkAboutGREENLAND BLK 6 LT 3Onsite File x� k i r 5 S d � � t N n` a" ;F015mmI714=22 � •� � �T AI uispccuun mvporn_i-1-iz.eoc Municipality of Anchorage TU _.o X019 Community Development Department Page 1 of 2 On -Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite - (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191023 PID Number: 015-171-22 ❑ New E Upgrade Name: Paul & Marie Maiden ABSORPTION FIELD ❑ Deep Trench F-1 Shallow Trench ❑Bed ❑Mound Address 4700 E 113TH Ave ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SFJ Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Greenland 6 3 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well 100+ TANK Il Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Anchorage Tank Capacity 1000G,1. Surface Water 100+ Material Number of compartments Lot Line 5+ Steel 2 NA Foundation 5.7 LIFT STATION Manufacturer Capacity Curtain Drain 50+ Gal. Remarks Pump on level at in. Pump off level at in. High water alarm at in. Pump make and model Electrical Inspections performed by Installer PIPE MATERIAL House to tank3034 Tank to drainfield 3034 A+ Home Services Drainfield CO/MT 3034 Inspector Pannone Engineering Services BENCH MARK (Assumed elevation) 466.Oft Inspection ist 3/8/19 dates: 2" 5/20/19 Location and description 3"' 4th sw Bottom House Trim COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp Conditional Approval: Date �Gt�FA�,��� Steven 'R. 'f�annone Approved %CE 8149 Date uispccuun mvporn_i-1-iz.eoc t / I 55 / l 1 E 113TH Ave 470 _ 460 _ _ z/ WOOD RETAINGING WALL ' WELL / 4 I / I I REMO SEPTIC TANK(E) PER V / ALL MEASURMENTS =1.0' A B T1 8.5 40.8 T2 8.9 46.7 DC1 9.8 48.7 DC2 10.0 49.5 MOA C 65 �� 2 L GRAVEL DRIVEVdAY 110.7 lm J 38R SFD A `�i WELL E 5.7 DE K I / '— 52.51 / INSTALLED 10004 SEPTIC TANK W/ DCO AFTER CONNECTED TO WELLJE EXISTING DISCHARGE PIPE DRAIN FIELD E �/ C 1/ —, — —eV-- — \rte C — ( — f� SCALE: 1 "=5' PROFILE SCALE: N.T.S NOTES: PA ONE ENG SVC, LLC Dote RECORD DRAWING P.O. BOX 102954 ANCHORAGE, AK 99510 �' ' • 6/28/2019 PHONE (907) 272-8218 FAX (907) 272-8211. Scole • 1" 50' "' • P.I.D. NO GREENLAND 136 L3-171-22 PAUL & MARIE MAIDEN ,even :'�annORe' PERMIT NO. DRAWN ACP CE8149 4700 E 113TH AVE OSPI91023 ANCHORAGE, AK 99516 Ff59,. Sheet 2OF2 W 5 4.0 !> Q0 0 0 40 5-7 Dw w J0 I w Nw U U oU SCALE: 1 "=5' PROFILE SCALE: N.T.S NOTES: PA ONE ENG SVC, LLC Dote RECORD DRAWING P.O. BOX 102954 ANCHORAGE, AK 99510 �' ' • 6/28/2019 PHONE (907) 272-8218 FAX (907) 272-8211. Scole • 1" 50' "' • P.I.D. NO GREENLAND 136 L3-171-22 PAUL & MARIE MAIDEN ,even :'�annORe' PERMIT NO. DRAWN ACP CE8149 4700 E 113TH AVE OSPI91023 ANCHORAGE, AK 99516 Ff59,. Sheet 2OF2 Lot 4 O M C C C a u c r C C o C c L (E E 113th Avenue O co S89053'20"E 100.00 20' ALLEY (Not built) — — — — — — — — — — — — — — — — — — — EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT ARE NOT SHOWN HEREON FB 19-2, pg 28 UNLESS OTHERWISE NOTED. FB 04-5, pg 22 O O O a) w 0 0 O O O z BE Lot 2 5391 SCALE: V= 30' t PX, ' OF 49 th00 nA e •. biI obeth L. 'Nalotko : o �s� • • 8036 - LS • • • ��� ' tai RECERTIFIED 3-19-19 L- , r- AS -BUILT NO CORNERS SET THIS DATE I hereby certify that I have performed a Mortgagee's inspection of the following described property: LOT 3, BLOCK Q. GREENLAND SUBDIVISION Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alaska this 10th day of August 2004. FRED WALATKA & ASSOCIATES, L.L.C. 907-248-1666 Engineers and Surveyors MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite Permit Number: OSP191023 Work Type: SepticTank Upgrade Tax Code Number: 01517122000 Site Legal Address: GREENLAND BLK 6 LT 3 G:2636 Site Mailing Address: 4700 E 113TH AVE, Anchorage Owner: MAIDEN PAUL J & MARIE L Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms iveRr yI)CI)artill e11t 2/8/2019 2/8/2020 Sii4 ❑ Disposal Field Z Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: Date: Date: �1 Y 3 CKANS MUNICIPALITY OF ANCHORAGE Community Development Department -343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWERIWELL PERMIT APPLICATION Parcel I.D. 015-171-22 Property owner(s) Paul & Marie Maiden Mailing address 4700 E 113th Ave ANCHORAGE, AK 99516 Site address 4700 E 113th Ave Day phone Legal description (Sub'd., Block & Lot) Greenland B6 L3 Legal description (Township, Range & Section) Lot Size 18,000 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank ❑X Upgrade X pg ❑ (D) ElRenewal Holding Tank El Renewal❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 0.)-A! Date of Payment: L4 l lq Receipt Number: ncrgo�✓(a Permit No. (05 P i�j i'. QZ3 Permit App_ -'-:. :'-.,:c, Waiver Fees: Date of Payment: Receipt Number: Waiver No. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191023, Rebecca Carroll, 02/08/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191023, Rebecca Carroll, 02/08/19 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 PHONE NEW ,�^ /�� (5p RY J /"' C z- L 6 77- ❑ UPGRADE MAILING ADDRESS LEGAL DESCRIPTION - LOCATION NO. OF BEDROOMS I/ 3 P 5 el 1--18 Well Absorption area Dwelling PERMIT NO. ., O DISTANCE TO: a Z Manufacturer Material No. of compartments N Liq. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth n y DISTANCE TO: Well Dwelling - PERMIT NO. Z O Z Q 3: — b Manufacturer _ Material Liquid capacity in gallons 0 w2 DISTANCE TO: Well � Foundation - Nearest lot line PERMIT NO. r �0 ®° 0' Qt) LL!UL z No. of lines Length of each line Total length of lines Trench width Distance between lines F Z L / p 4c p j® inches 1... Top of tile to finish grade Material beneath tile Total effective absorption area D ? °• 4 iz-'A%r/ f' /7,0 C & ? Z inches % z 19 4 Length Width Depth PERMIT N0. W ae~. Type of crib Crib diameter Crib depth Total effective absorption area W N Well Building foundation Nearest lot line DISTANCE TO: ® J Class DepthDriller t Distance to lot line PERMIT NO. rAl 1vl uac. G'.9 AA.C449A QAj r�, 17 1 LU DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS G2` Hl'E` G,t7• �'OJH -a' 1v Pe-AS ?'/c Je) ;n. { 0(17 @f rflv/c •/)GASTlc Pehr. SOI L TEST RATING -32.,S C, INSTALLER 17w1v is A ° d REMARKS t �1l(�CN WAS lNS'iA[.Le--,b !r S" rd � r.Wle WX X ll-.V7 tl 4 1r CO 6 - Id-eq All y r, 4'Nr o �1y\ /%! / i •! {.') �. ,, °� / y -U rk �t i V ).� !� a>V y" p onn^aCDa aeoa p}»•ryr>!>}>}oa ca a CF 54$4 • �` ma ,s•(� a}••• f� ° Q � L6 aQ• APPROVED DATE LEGAL 70ma 10,.11 a1vv1 MUNICIPALITY OF ANCHORAGE acs Department Health and Environmenta" "rotection - 825 Street, Anchorage, AK. ,y501 264-4720 Permit # U�jC `-J`( # ae HANDWRITTEN PERMIT # ��— WELL AND/OR ON-SITE SEWER PERMIT Applicant: (�,7A4i2Y �. �Y1�LL�{4 Mailing Address: Location: Phone Number: Legal Description: L 3 13(o Gfzs-mac (A -_J _ Lot Type of Soil Absorption System Is: Trench: J_' Drainfield: Seepage Bed: Maximum Number of Bedrooms: 3 Size: Holding Tank: Soil Rating(sq.ft/br) y3_� '�-�i`{f 1 The Required Size of the Soil Absorption System Is: DEPTH /0 LENGTH 10FJ ( GRAVEL DEPTH 6 ' _ WIDTH _ 0 / 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(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = D U GALLONS # Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED # # Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 u 3 " I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that 3 bedrooms. Signed: af, J514-tQ A i a t SWP/024(1/81) Issued by:�_�'� Date: Permit #' 820005 January 31., 1.983 TO: Permit- Applicant Subject: Lot 3 Block 6 Greenland Subdivision A permit issued by this department for an individual well. and/or on-site sewer_ system has expired as of December 31, 1982. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal Ordinance. If you have drilled the well-, a well log needs to be sent to this department for documentation of the installation date and to close the permit. If a private engineer inspected the installation of the on-site sewer system, please have: them send us the as-builts for our files and documentation. If there are any further_ questions, please call this office at 264-4720. Sincerely Robert C. Pratt, R.S. Acting Program Manager Sewer and Water. Program RCP/ljw enc: Copy of Permit SWP/057 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD THE DEPTH OF H TRENCH OR PTT IS THE DISTHNCE BETNEEN THE SURFHCE OF THE GROUND HND THE BOTTOM OF THE EXCHVRTION (IN FEET) THERE IS NO SET W7DTH FOR TRENCHES TH� �RHVEL D�PTH [S THE MINIMUM DEPTH OF GRHVEL 8ETWEEN THE OUTFHLL PI�E HND THE BOTTOM OF THE EXCHYHTION (IN FEET) ������ ���� PERMIT HPPLICRNT HHS THE Rf::SPONSI8ILITY TO INFORM THI� DEPHRTMENT DURING THE INSTHLLHTTON INSPECT[ONS OF HHY WELLS HDJHCENT TO THIS PROPERTY HN� THE NUMBER OF RESIDENCES THHT THE WELL WILL SERYE BHCKFILLING OF HNY SYSTEM NITHOUT FIN�L INSPECTION HND HPPROYHL BY THIS DEPHRTM�NT NILL BE SUBJECT TO PROSECUTION MINIMUM DISTRHCE BETNEEN H NELL HND HNY ON~SITE SEWHGE DISPOSHL SYSTE� IS 100 FEET FOR H PRIYHTE NELL OR 13G TO 200 FEET FROM H PUBL[C WELL DEPE�DING UPOM THE TYPE OF PUBLIC HELL MINIMUM DISTHNCE FRUM H PRIVHTE NELL TO H PRIVHTE SEWER LINE IS 23 FEET HND TO H COMMUNITY SENER LINE IS 75 FEET NELL LOGS HRE REQUIRED HND MUST BE RETURNED TO THE DEPHRTMENT NITSI� ]0 DHYS OF THE WELL COMPLETION OTHER i: M, MHY HPPLY SPECIFICHTIONS HND CONSTRUCTI0N DI�GRHMS HRE HVHILHBLE TO INSURE PROPER INSTHLL9TION il If�' I CERTIFY THHT 1 I HM FHMIL1HR QITj THE REQUIREMENTS FOR OH~S[TE SENERS HHD WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE 2� I NILL INSTHLL �HE SYSTEM IH HCCORDHHCE HITH THE CODES ]� I UNDERSTHND THHT THE ON^SlTE SEHER SYSTEM MHY REQUIRE ENLHRGEMENT IF THE RESIDENCE IS REMODELED TO lNCLUDE MORE THHH ] 8EDROOMS �dYrY,�YrJYYIVrJi'�YiIV�YlVltiluY t`�' �l IY�f�. _. ENGINE'. }NG AND SI RVEYING 212 E. INTErRNx TIONAL AIRPORT ROAD PERCOLATION ANCHO�R(4GE, ALAS KAI99502 TEST PktON E 218:3,7.73'_ i R, PERFORMED FOR: DATE PERFORMED: .7 ` LEGAL DESCRIPTION: > /�/i. ! C' 1 -✓/'v 11 •" DEPTI-I SLOPE � SITE PLAN r� 7Y/ (FEET) 1 - - 2- 3- �j 4- 6- 7- 8- 9- 10- 11 .12- COMMENTS WAS GROUNDWATER ENCOUNTERED? IF YES, AT WHAT DEPTH? S AV o L 0 P E Date 1 r ;� 13- Depth to Water Net Drop 14 -- 15- q 17 V 18 •Y off e flalph IS lokela 19 � —f•i a __._----�..---____i---I'_---III COMMENTS WAS GROUNDWATER ENCOUNTERED? IF YES, AT WHAT DEPTH? S AV o L 0 P E Reading Date Gross Time Net Time Depth to Water Net Drop q V � —f•i a __._----�..---____i---I'_---III Reading Date Gross Time Net Time Depth to Water Net Drop q V PERCOLATION RATE %rl ?/;v //, Li � (minutes/inch) TEST RUN BETWEEN FT AND _Z__ FT PERF0HMFD ;/ J �.� (. �, tj j j CERTIFIED BY:_AL�L --•-`DAT MUM X, . ..... :1 T" "Ir" 1E.11 ll:-: 1001 ��"::-'Ic W'2�11��� DEPARTMENT OF HEALTH ANDPROTECTION 825 L STREET, ANCHORAGE, AK 99501 " � 264~4720 PERMIT NO: 840791 DATE ISSUED: 09/18/84 APPLICANT: GARY MELLOTT ADORESS: 1741�M SR »Ax ANCHORAGE, AK 99516 CONTACT PAONE� 345~7338 LEGAL DESCRIP: SUBDIVISION: GREENLAND LOT: 3 BLOCK: 6 SECTION: 22 TOWNSHIP: 12N RANGE: 3W LOT SIZE: 18000 (SQ,FT^ OR A(:;RES) I that: 1miliar with the r�quirements for on ... site sowors and wolls as set forth by the Municipality of Anchorage (MOA) and the State of Alaska" 2" I will install the system in accordance with all MOA codel.� and regulations, and in compliance wi.th th.c design critE?ria E![ this pepmit^ 3" I will adhere to all MOA and St,�.ite of Alaska require0gnts for the set 6ack distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot.. SIGNED APPLICANT:�GARYh4Eu�TfT ^ ISSUED BY ^ \ ^ So UJ eA —�YDu� Dj DATE �� j'Inciflor Deij I -Ing, Well Lot; Lot ), Alk 6 Greenland Subdivision 0 - 12 band & Gravel 12-28 brown clay 28-45 Brown Clay Gr�ixel. V5-60 Gray Clay Gravel 6o-69 Gravel A Water Bailed 10 GPM 40' Water in well. 69 U 6" Cassln,,, Anchor DrAlling Sidney P, MIR1,11C., iv I i OF 1 ] MUNICIPALITY OF AZ Development Services Department On -Site Water & Wastewater Section Parcel I.D. 015-171-22 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date:. I _' — 2- d 2-0 Complete legal description Greenland B6 L3 Location (site address) 4700 E 113th Ave Anchorage, AK 99516 Current property owner(s) Paul & Marie Maiden Day phone Mailing address Real estate agent Same 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic Q Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 5�5_0 Date of Payment 9l a� 119 Receipt Number (N9 ii a7G COSA # (j 5Glq JU59 Waiver Fee $ Date of Payment Receipt Number Waiver # 6. 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, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) 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 (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. 6. DSD SIGNATURE 2 System #1 Approved for 3 bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for Phone (907) 745-8200 Date 09/27/19 bedrooms, with the following stipulations: vt^ ilk (- J �� NJTYQFr�i�/�/� VV F m 5�0 BY—taw Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) bas&bhl9 'it representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet CSA Checklist Legal Description: Greenland B6 L3 Parcel ID: 015-171-22 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA © Well log is filed with Onsite (or attached) Date drilled 8110/84 Total depth 69 ft Cased to 69 ft © Sanitary seal is functioning correctly X Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 2/11/19 Static water level at beginning of test 29.7 ft.. Comments B. TANK DATA Age of tanks) 318119 years Tank type/material S.'WS'""' Measured operating fluid level in septic tank 48 WE Standpipes/foundation cleanout per record drawing Date of pumping N/A D. ABSORPTION FIELD DATA Deep Trench Which system tested (date installed) 915183 01 ALL standpipes present per record drawing Total measured depth from grade 9.0 ft (max) Measured depth to pipe invert from grade 3.0 ft (min) ❑ N/A — pressurized field Q Monitor tubes go to bottom of effective. If not, state depth into effective R Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Well production at time of test 7.13 gpm Water storage tank volume n/a gallons Well disinfected for coliform test? ❑ Yes ❑✓ No X Coliform bacteria is Negative Nitrate 0.711 mg/L ❑ Nitrate less than MRL (ND) Arsenic PENDING ug/L ❑ Arsenic less than MRL (ND) Collected by Pannone Engineering Services Date of Sample 9/6/2016 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 2/11119 Results ❑✓ Pass For 3 bedrooms Fluid depth prior to test 18 in Water added 450 gal New depth 26 in Elapsed time 90 min Final fluid depth 18 in Absorption rate --4ou gpd Any rejuvenation treatment (past 12 months) n/a If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' 0 Yes if No 5.7 Community Sewer Manhole/Cleanout > 100' 0✓ Yes if No ft M Yes if No ft Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' 0 Yes if No ft Absorption Field on Lot > 100' M Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50'[]✓ Yes if No ft M Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' EJ Yes if No ft M Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No 5.7 ft Surface Water > 100' Q Yes if No ft Property Line > 5' Q Yes if No ft Wells on Adjacent Lots: Wells on Adjacent Lots: Absorption Field > 5' Yes if No ft Private Wells > 100' F,71 Yes if No ft Water Main > 10' 0 Yes if No ft Community Wells > 200' [Z] Yes if No ft Water Service Line > 10' P/ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ✓0 Yes if No ft If absorption field is under driveway comment below Property Line > 10' Fl Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' El Yes if No ft Community Wells > 200' Yes if No ft Surface Water > 100' ✓0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet SGS Ref.9 1195223001 Client Name Pannone 1311(y. Srke. Project Name/# =1700 E 113th Ave Client Sample 11) -1700 1:_. 1 13(h Ave Matrix Drinking Water sample Remarks: Printed Date/Time 10/04/2019 16:29 Collected DatelTime 09106%2019 10:30 Received Date/'Time 09%06/2019 10:50 Technical Director Stephen C. Ede Allowable Prep Analysis Parameter Results LOQ Units Method Container (D Limits Date Date Init Metals by SCP/MS :arsenic ND Waters Department 'notal Nitrate/Nitritc-N 0.71 I Microbiology Laboratory iv. Coli NePative `fetal Coliform Negative 5.00 ug/l. EI1200.8 B ('.10) 09/11119 10!03119 BR -17. 0.200 mgA- SA921 4500NO3-E C (x:10) I 100nt1, Stvi21922313 A 1 100mL SN1219223B A 09/09//19 I:w 09106119 A.1, 09/06119 AJ, 2 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. 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 Parcell.D. 015-171-22 HAA# bQ USQ!� 1. GENERAL INFORMATION Expiration Date: I If — 16 Complete legal description GREENLAND SUBDIVISION;• LOT 3 BLOCK 6 Location (site address or directions) 4700 E. 113th AVE * ANCHORAGE AK 99516 Current Property owner(s) JOHN WHISMAN Day phone 346-5238 Mailing address 4700 E. 113th AVE * ANCHORAGE AK 99516 Lending agency Day phone Mailing address Real Estate Agent Day phone Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: 3 TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual On-site 0 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. 4. 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, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 1 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 JEFFREY A. GARNESS, P.E. Engineer's Printed Name Phone 337-6179 Date __s is Z A Engineer's Comments: oo6ovo0 In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, a OF Q 4 conscientious engineering analysis of the system in accordance with ADEC and MOA moo! 4 DSD Guidelines & Regulations. The reported results described the performance of the 00 �OQ system under the conditions encountered at the time of the test, and separation D distances measured to readily identifiable features. The operational life of all wells and D* 9T �%D septic systems depend on the local soils condition, groundwater levels that may a O Fluctuate during the year, and the water usage of the family being served by the system. Q These conditions are outside the control of the evaluator of the system. Satisfactory test i- ' fr ' me s. results do not guarantee future performance of the system, nor do they guarantee that 9 there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide QO � •. E 7953 any warranty or future estimate of how long the system will continue to meet the 4�0 a .......... 1V14 operational requirements of the ADEC or MOA DSD. The content of this report is for ��4d Pro f essto°°cam the sole benefit of the owner listed above. Any reliance upon or use of this report by any Oppppo�4 ____ other person. or party is not authorized,. nor will it confer any legal right w_ a. soever_.__... 5. DSD SIGNATURE Approved for bedrooms. Disapproved Conditional approval for bedrooms, with the fllowing stipulations: 4 V Attachments: HAA Checklist (/ Manitenance Agreements Septic System Advisory Supplemental Engineer's Reort Well Flow Advisory Other • rr\vvrv\m By:�Original Certificate Date: — Q — (Rev. 12101) jymnicipanty or Anchorage Development Services Department,'°; Building Safety Division rQ , On -Site Water &Wastewater Program ( ox '66 0 A chora`ge A� 99519 6650 � �` c anc orage ak us FDI l"(a'�I ITl-J11D 1-TV""'/�DOt]nY'y.•n'i"' I"i irrn�gra- -.. ' � ,yA�Well Log (Y/N) YES innQin� s properly protected (YIN) YES o/ ivy iyow 10/y24/2002 - g p.m:_ 6.72 9 P.M w a rvw niesl100 ml. Nitrate 0.106 mg /L Other bacteria` 0 colonies /100 ml Date` of sample: 8/5/2004 Collected by: GEG Ltd. „"� W Dateinstalled 6/10/1984 Nnmher nf-hftTh�rfrvicri+c i nu.Za .a_...,.zh• ...rn ,:, i wig r���u uA1H I'BELOW EXISTING GRADE e � 5 1:983 Soil rating (g.p d /ft�o /bdr �?� System type DEEP TRENCH ""i7ik"—'3uevxdbr'ButaWk.@`�aV.mew,',SW`:+`3ef.£:.eAis+u34x.'2'.'v.uU.cCno-nrt�.si�:mwa" eN3 i.Y4 ;"arbu?�, ft Width 2�5 ft. Gravel below pipe 6:0 ft ' P ftz . Monitoring tube YES Depression over field NO q Y , , , Results (Pass/Fall) PASS For 3 bedrooms i inabso�ption field be ore test 46.7 in.m- Water added 6?2 .gal New depth 60-25 in me" 0 min. Final`ftuid depth 57.25 In gbsorption rate ?- 450+ g p d — nation treatmenf(past 12 mo.) (Y!N &type} NONE KNbWN` If yes give date uiwuus:k...xkx.;:- t f. ... ,.a Size in ga lons Manhole/Ac-- Pump offl _ in. High water alartnTevel at in V, s Cycles tested Meets alarm & circuit requirements? , S.� RU ms are in on this date. Date of o� 0 e Gar r /f 1,10 009. E 79 eDO u. 44t ^ed Pio f ea 11%0 0\ r' 4.w.... —.J� x¢`ihi :. ✓k�iK t��"# .sP.k �,4...e'; ..._ o� 0 e Gar r /f 1,10 009. E 79 eDO u. 44t ^ed Pio f ea 11%0 0\ r' '11/2004 WED 13;39 FAX 907 248 1978 JORNSON CONTROLS, INC, E. //3 Ah AVE- So/ VE' So' Wl_ m IA/AL-1 c ;;tell 0 p oc �j2tV� t� w 5 S9°53 ZD AG -LEY _Z_ — AS -BUILT NO CORNERS SET THIS DATE . iia �'u ,•+�, id'('l. '$R:1�. <S Y, 1,r+A'" :MENTS OF RECORD, OTHER THAN &01/001 539( i hereby certify that I have performed a Mortgagee's inspection of the following described property: --�=� 7 B� ,840 (7-l'E-=. ni LN nJa j; �,p; r.). Anchorage Recording Precinct, Alaska, and that the tmprovemems situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that.there are no roadways, transmission lines or other visible easements on said Property except as indicated hereon, Dated at Anchorage, Alaska this day of A UG4 .r zo G �_ FRED WALATKA & ASSOCIATES a MUNICIPALITY OF ANCHORAGE V / DEPARTMENT OF HEALTH & HUMAN SERVICES V DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property Owner Telephone: Home Mailing Address (c) Lending Institution nlC Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the followina address: or: Check here 0, if hold for pick up. List contact person and day phone number below. /I✓ANS � �. /d��f ,�G/--�6 z S 2. TYPE OF RESIDENCE Single -Family Number of Bedrooms _ 3. WATER SUPPLY Individual We)]Z� Community ❑ Public ❑ f12�-Ds 9O. u � Business 5X/ —O6Z,5 Note: If cornmunity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite }u Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (Rev 81861 Fronl 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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 date of this inspection. Name of Firm `cf�r�s �Telephone Address Date ?Y77 Engineer's Seal ��P��•OFIA�gs�� 1 1. 1•IIIi •• Y •IIIn.Or �aY111 •I II�Y �.u'Mi4i.p� M1 • Dale R. errell �J •• No. AFF I.1 QQ`� '��OFESSIONP 6. DHHS APPROVAL Approved for ` �3 edrooms by < -4V2?/Ao„w Date Approved Disapproved Conditional Terms of Conditional Approval CAUTION 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. Page 2 of 2 72-025 tRev 8186) Back MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISIQMUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (MAA) J U i.- 31 1987 CHECKLIST - FEBRUARY 1984 264-4744 A. WELL DATA Legal Description:' Well Classification '' r;r " '" If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N)—Date rCompleted / y`' Yield Total Depth 61111- Cased to % Depth of Grouting N ?: / Static Water Level � i > � Pump Set At – Casing Height Above Ground Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot On Adjoining Lots To Nearest Edge of Absorption Field on Lot SOC ' On Adjoining Lots — ZOL" To Nearest Public Sewer Line ZI lel To Nearest Public Sewer Cleanout/Manhoearest Sewer Service Line on Lot Water Sample Collected by 14'Z f; Date Water Sample Test Results Comments /✓/r i� ::•'.- %�� 0 - n B. SEPTIC/HOLDING TANK DATA Date Installed �O" /P'f2' Size rbc / — No. of Compartments Z _ Standpipes (Y/N) Y Air -tight Caps (Y/N) l Foundation Cleanout (Y/N) �� 7 Depression over Tank (Y/N) — Date Last Pumped Pumping/Maintenance Contract on File (Y/N) for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well To Building Foundation / To Property Line To Disposal Field�i To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course Comments //2;i Page 1 of 2 72-076 fRev 8/861 Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field '4 Type of System Design Length of Field Depth of Field Gravel Bed Thickness Square Feet of Absorption Area 12 Standpipes Present (Y/N) Depression over Field (Y/N) nDate of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: y To Water -Supply Well /o 6 -1-; To Property Line 0 To Building Foundation Lo To Existing or Abandoned System on Lot ////" : On Adjoining Lots To Water Main/Service Line �D /1r To Stream/Pond/Lake/or Major Drainage Course _ To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments To Cutbank (if present) ,-1 /7 Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Date Company MOA No. Receipt No. —�10 --0 U/ �(f, OF Date of Payment ` CL/ 1WAA c��•••e°•��� A Av o Amount: $ 00 IV* Enn Page 2 of 2 72-026 (Rev 8'861 Back _J a w•n•o Dale R. nrrell 9� say°. No. 2055-E �F ••°j �t>rs. 89FQp..,.°..,*� .s. ®4 `d BES � q �+�r}� �'y yiT���+ BESSE, EPPS � PUTTS A/® 9l 110A dA• AAAV.eO •' 2720 FAST 88 AVINUF, ANUiORAGE r AK 99507 (907) 349-6451 Q G°(1'. Oole R. Morrell e Pn'VAa No. 2055-E WATER WELL TEST $���•pRm OF[S$��N�`� � Lute._/ -- j. Subdivision: Lot: Block: G; Client's Name: r�vr r y-llyi Address: Tester: �f7�1� /�1�; axy Initial Reading on Meter: go3 , / _ _,._-..._.. TIM GPM GALL CNS A VOLUME GA(,r-k-(i-s TCIT L VOLUME '- /i% ° 2 ,, /o• � — // t;w l/% 5 0 r� — t1O f_„ � : J JT, -/O -&U CI°� ur<4!<((JIEdr� ,✓I�IP�P�'- So el 7- ?, C NORTHERN TESTING LABORATORIES, INC. 600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS. ALASKA 99709 907479-3115 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907277.8378 Besse, Epps, & Potts 2220 E. 88th Avenue Anchorage, Alaska 99507 Attn: Andy Potts Source: L3, B6, Greenland Sample ID#: A071587-17 Parameter Unit Nitrate -N mg/L Result HW Date Arrived: 7/15/87 Time Arrived: 1240 Date Sampled: 7/15/87 Time Sampled: 1200 Date Completed: 7/15/87 ADEC MCC* 10 e�� ------------------- Reported By: Date: 7/16/87 Carol J. Garrison, Vice -President * MCC = Maximum Contaminant Concentration NORTHERN TESTING LABORATORIES, INC. 600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS. ALASKA 99709 907-479 3115 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907.2778378 Quality Control Report Client: Besse, Epps, & Potts ID#: A071587-17 Listed below are quality control assurance reference samples with a known concentration prior to analysis. The acceptable limits represent a 95% confidence: interval established by the Environmental Protection Agency or by our laboratory through repetitive analyses of the reference sample. The reference samples indicated below were analyzed at the same time as your sample, ensuring the accuracy of your results. Sample# Parameter Unit Result Acceptable Limit EPA WS378-6 Nitrate -N mg/L 0.88 0.84 - 1.02 Reported By: Date: 7/16/87 ---------------- ------------------------------ Carol Carol Garrison, Vice --President MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF UFALTII AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE I. General Information I" Application Date �•' /%'m {> f (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or. directions) �='�l✓S %� � ;�_' � 1, s'!� (b) Applicants Na.n;e— �� c(�l r .�,; j Tel hone Home_ Business_ ;1`. 1!/ 117 Applicants Address Al ", r/ j' %.S /! (c) Applicant is (check one) Lending Institution �m 9 O�-nxer/builder Buyer E7; Other E-1 (explain);��----- (d) Lending Institution T� —Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. Type & Residence Single—Family 570 Number of Bedrooms 3. Water Supply Individual Well E] l Multi --Family Id Community E---4 Other (describe Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. fie. Sewage Dismal Onsite 1:—El Public �� Community =1 Holding Tank E7 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. (Page I of. 21 5, Engineering Firm Providing Inspections, Tests, File Search, Data 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 regula- tions in effect on the date of this inspection. Name of Film Telephone Addr.es5 -74 Date�s or /j L '1 (ENGINEER SEAL) ^S r eee.yl4e a. ,. D I I 6. DHEP Approved for bedrooms y �r " Approved Iv Disapproved n Al Conditional Terms of Conditional Approval_. CAUTION THE MUNICIPALITY OF ANCHORAGE DEPAR'T'MENT OF HEALTH WD ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY O PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP 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 ENGINE'ER'S WORK. (DHEP SEAT,) RR4/ej/D18 [Page 2 of 2] 7-19-84 MUNICIPALITY .Op ANCH%AGL DL'PF- 'OF HEALF11 ENVIRONMENTAL Pt 7F;CT10 l !SSPMUNICIPALITY OF ANCHORAGE (MOA) MurJICIPAUTY OF ANCHORAGE HEALTH AUTHORITY APPROVAL ( HAA) ,ONt IN HEALTH PRO & EIJVI!:ONIJi�.NfAI PRO(EOTI9i4' RECEIVED CHECKLIST - FEBRUARY 1984 SEP "!2 A. WELL DATA 1. Well Classification / &A✓V//a udL, If A, B, cr C. D.E.C. Approved(YM) Well Log Present (Y,/N) i Date Completed /O - $ y Yield 2" �P/? Total Depth_ _ �_ - Cased to G 7� Depth of Grouting __,!LA Static Water—Leve Zq / Pump Set At C d ` Casing Height Above Ground /'G Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/Ni Separation Distances from well: To Septic/Holding Tank on Lot 1(72- � / On Adjoining Lots 64 - To Nearest Edge of Absorption Field on Lot /pS ; On Adjoining Lots /_001 To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole �A� 4 To Nearest Sewer Service Line on Lot $'U�y�• Water Sample Collected By Gf/n.y ,T M e -4i v l70.11; Date -" 2 j- L? ®, Water Sample Test Results-, 1,6 g a Lq po A.T. Comments X L)n1,av OWA, iLzsr uvAs' RVN O v 7/1e7 c h,1i1V ie-sr4t,1,60 Alv4 11 r41(1W4?b T/✓d7 /f L. ,,Lf YIC-40 AA11 J�S'r1I'Mfe-j 22OF/li. B. SEPTIC/HOLDING TANK DATA Date Installed 6--/0-gl/ Size /000 No. of CGRIPartments Z. Standpipes (Y/N Air -tight Caps LY/N) Y Foundation Cleanout (YM) % Depression over Tank (YM) Al Date Last Pumped A Pumping/Maintenance Contract on File (Y/N) ; for I(/Q� �® Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Tebll /0 7To Building Foundation To Property Line _i 31 To Disposal Field To Water Main/Service Line 3ca` To Stream, Pond, Lake, or Major Drainage Course Comments v? mac. d [Page 1 of 21 2-15p84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 3 fIWAA .DJ° Type of System Design 1'/L 0/ Date Installed f -- .r - 63 Length of Field /()g, Width of Field 0 "�' Depth of Field 147 Gravel Bed Thickness G ' Square Feet of Absorption Area I Z,96' Standpipes Present (Y/N) k Depression over Field (YIN) iV Date of Last Adequacy Test 4,4 Results of Last Adequacy 'lest Al Separation Distance from Absorption Field: To Water -Supply Wbll /O r To Property Line /0 To Building Foundation y0 To Existing or Abandoned System cn Lot A1,4 ; On Adjoining Lots ? O To Water Main/Service Line •i, o' To Cutbank(if present) 1v 1 To Stream/Pond/Lake/or Major Drainage Course 11114 To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at Dimensions Manhole/Access (YM) "Pump Off" Level at High Water Alarm Level at Vent MIN) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes(Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or, confor-ed to all MOA HAA Guidelines in effect on the date of this inspection. Signed �- Date �'-•/ ��`/) .-� {� C� /!� �� �� aia3� fnt,�`ksc•trne ncr3tl r�� �y y 6x/,,.y T /yft/,eri a.. Co an MOA No. S7�y sf �. •, . ��, �� n KBl/d5/$ yc cr -'�e,o n<aese..u.ros.. e..u.• • F �; r'•`. Be e•./.• •r. u.•e ore rn� 544.4 [Page 2 of 21 , ^v�-.15-84