HomeMy WebLinkAboutWOODBOURNE BLK 1 LT 12 Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~-~ f-~2 ~ ~' O~~'' ~-~ P1D Number:
Name:
~¢[[ ~ ¢%. Wastewater System: ~New ~ Upgrade
Address; [~ ~ ~{¢~0~ ~~'~ ABSORPTION FIELD
Phone: '~--~ , --JNo'o~d~oo~s: I OOeepTrench ~ShallowTrench DBed ~Mound
D Other
SoiJ Rating: I Total Depth from original grade:
LEGAL DESCRIPTION D.~ GPD/Sq. Ft.
Lot: Block: SubdN~ion: Depth to pipe bosom from original grade: Gravel depth beneath pipe
To..,,,.: J.~n,o: Iso~tion: Fiiladdedaboveodginalgrade:,.O Ft. Gravollength~~O Ft.
WELL: ~New Q Upgrade ~ . GraveJwidth: Number of lines: JDistance~eenlines:
~, O F~. /, D .t.
Classification (Private, A,B,C): Total Depth: Cased To: ~.1 'Total absorption area: Pipe material:
Driller: Dat~Drillyd: Sta~Water Level: Installer; Date in lied:
Gasing Height Abo~e Ground;
!Yield: ¢ GPM Ft.J %0 ~,. TANK
SEPARATION DISTANCES ~Septic B Ho[ding : S.T.E.P.
From Tank Field Statio~ Tan~ Sewer Li~es~ ~ ~ ( ~ ~O
~ ~ Mat°rial: .
W*~ t O0 ¢ 10O t N [00 ~ ~ ~ ( Number of Compa~ments:
s.~ao~ ~o~+ [~ I~ LIFT STATION
Water
Foundation
Remarks: BENCH MARK
Location and Description:
ENGINEER'S SEAL
Inspections pedormed by: Dates: 1st ~t~ ¢
Depa~ment of Health and,Huma~ Se~ices approval ~.,.
Reviewed and approved by: Date:/2 -7-~
72~13 (Rev. 9/91) MOA 25
2 2
Permit No. SW990124- Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 54-5-,~74~
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: LOT 12 BLOCK 1 WOODBURNE SUBD. PID No.: 015--351-18
208 .
C.0.2 14.3' 28.4' I00.1' 97.1'
TC.O.1 20,2' 23,15' 100.7'
~ ~ TC,O,2 25.9' 26.50' 100.3'
~ ~ C03 30.0' 28.0' 100.2' 97.3'
~ C,0.4 23.5' 38.5' 99.25'96.25'
~ C,0,5 94.0' 72.5' 100.2' 96.20'
F
MARK A B ORND, PIPE
ELEV. ELEV.
C.0.1 14.0' 29.3' 100,1' 97.1'
C,0,2 14.3' 28.4' 100.1' 97.1'
TC.O.1 20,2' 23,15' 100.7'
TC,O,2 25.9' 26.50' 100.3'
C03 30.0' 28.0' 100.2' 97.3'
C.0.4 23.5' 38.5' 99.25' 96.25'
C,0,5 94.0' 72.5' 100.2' 96.20'
MT 63,6' 51.5' 99,8'
IVI'VV I,~Kll./IN~ I1~¢,
PO. ~o!e 110378 · 10330 Cid Seward Hi0hwa!,'
(g07) 349.8535
ANCHORAGE, At.ASKA 99511
P.O1
PERMIT# SW990'124
DRILl.lNG LOG
Owner_ BELL HO[~ES r INC Use of
L~aflon (ad~ ~; Tew~hip, R~, ~tion, E ~own; or diet.ce ma~ roa~
LOT ~2~ ~LOCK ~, WOODBOURNE: 8201 GINA~I C~R
ANCHORAGE, AK
i Size of c~/a~---~6-'"--~'"DePt~h o:~ ~o] e ~ 9 feet C~ed to 9 5.0 7 feet
:Sta~c w~ter level 2~_~ (~"~{~1~) ~ 1~ aur~ace. FLn~h of we~ (check one) o~n ~d ( ~
~ of ~awdo~] from static ~L:.~ q{f :" AS BUILT NOTES: 1 ) WELL DRY GROUTED W1['H 1
, ~: .... . t. B~NTONITE CH~PS
' + 20 ' ~EPTEM~E~'~ 999
~om~d su~ace ~ ~ formation~ ~netrated, size of materlal, colo~ ~d har~es~
0 .TO 3
3 .TO 54__
54 .TO_ 62
63 ' .TO. 90
90 _TO. 95
9 s
_TO_
.TO_
I--CUSTOMER
);
it,
SACK
TOTAL P, 01
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 / WATER SUPPLY PERMIT
Initial
Date Issued: Jun 07, 1999
Expiration Date: Jun 06, 2000
Permit Number: SW990124
Legal Description: WOODBOURNE BLK 1 LT 12
Design Engineer: 0088 Anderson Construction & Eng'g
Owner Name: Bell Homes, Inc.
Owner Address: 18622 Guillemot Cimle
Anchorage, AK 99516-
Parcel ID: 015-351-18
Site Address: 008201 GINAMI ClR
Lot Size: 104706 SQ. FT.
Total Bedrooms: 4 Pe(mit Bedrooms: 4
This permit is for the construction of:
[] Disposal Field [] SepticTank [] 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: C.~ ~~
Date:
Date:
MICHAEL N. ANDERSON, P.E.
14250 N. Goldenview Drive
Anchorage, Alaska 99516
(907) 345-3377~FAX 345-1391
May 24, 1999
Municipality of Anchorage
Dept. of Health & Human Services
On-Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519-6650
Subject: Lot 12, Block 1, Woodbourne Subd.
Gentlemen:
On April 21, 1999, several exploratory testholes were dug on the above property. We found
shallow water on holes closest to the eastern side of the lot, but good soils and a deeper
water table along the southwestern side of the lot. In addition, there are two testholes which
were dug in August of 1996 by Alaska Water and Wastewater. We intend to install the
sewer system around our testhole 99-4 and use one of the previous testholes for the reserve
area. Copies of these testhole results are attached.
This development will be for a 4 bedroom, single family dwelling. Although the percolation
test for testhole 99-4 was 1.5 minutes per inch, we propose to adjust the application rate to
0.8 gpd/sq.ft, to ensure longevity of this system. We will install two 35' shallow trenches
with a maximum depth of 6.0'. A splitter will be used to evenly divide the flow.
There is a platted drainage along the southern side of the lot. However, during the spring
melting period we observed that water actually drains into the cul-de-sac from southwest to
northeast and then appears to be absorbed underground along the eastern portion of the lot.
This contention is supported by our testing on the eastern side of the lot. There is no surface
water within 100' of the system.
The development of this lot does not appear to have any adverse impact on either Lot 11,
which is now vacant, nor Lot 13, which is developed.
If you have any questions about this request, kindly contact me at 345-3377.
Sincerely, -- I ,
Michael N. Anderson, P.E.
WASTEWATER DISPBSAL
SITE PLAN
LBT ]2, BLOCK L Wl]I]DBOURNE SUBD.
SYSTEM
N 89*57'45 £ 205.07
N
/
5Z
LOT ]1
LDT
]3
PREPARED FI]R:
STEVE BELL
ANCHDRAGE, ALASKA
INSET SCALE 1'= 50'
995
MICHAEL N. ANDERSDN, P.E.
]4250 N, 6DLDENVIEW DRIVE
ANCHDRAGE, ALASKA 995]6
WASTEWAT R A]}SBR]BTIBN SYSTEM
D£STGN ]DETAILS
LIST 12~ SLEEK L WBB]D]BBURNB SUS]D,
]DESIGN PARAMETERS
l, 4 BEDRISBMS X ]50 GPD 600 GPD
2, 600 GPD/0,8 GPD PER SO. FT, - 750 SO, FT.
3, INSTALL SHALLOW TRENCH WITH TnTAL DEPTH
OF 6,0' AND 4' OF GRAVEL BELOW PIPE.
4. 750 SQ. FT./5' X R.F. 50X 75' LENGTH OF LINE.
5. INSTALL. NEW 1250 GAL. SEPTIC TANK.
6. INSTALL 2 TRENCHES, LENGTH 35' EACH.
7. INSTALL SPLITTER TI] EVENLY DIVIDE FLBW.
8. INSULATE TRENCHES WITH 2" HDPE.
PREPARED FOR:
STEVE BELL
XXXXXX
ANCHORAGE, ALASKA
XXXXX
MICHAEL N. ANDERSON
14~50 GI]LDENV]EW DRIVE
ANCHORAGE, ALASKA 995J6
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTTON: ~ 't/''/'~' "~'/'~'
~ "~ MICHAEL N. ANDERSON
~¢~~ownship,'Range, bec' :
1
2
3-
4-
5
6
7
8
g
10
19
13
'14
t§
t7
lO
20
COMMENTS
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
y
S
) L
IF YES, AT WHAT /f'~;: pO
DEPTH? '
Deplh to Water After / ~/
Monitoring? / ~' -' Date:
Reading Date Time Time Water Drop
PERCOLATION RATE '/""~.! ,) PE~Z ~'//
TEST RUN BETWEEN ~' ~ FT AND J~r {'~ FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~/'~'//~ ~
72-008 (Rev. 4/85)
• c,
0
• '"° Municipality of Anchorage 5 6 7 8 9 u P?
On-Site Water and Wastewater Program 4,
(907) 343-7904 A F E T Y
LT:
aNcV ZO/g
rYa
Certificate of On Site Systems App
Parcel I.D. 015-351-18 Expiration iitez. wti I a Oil l
b 8L9 `'
1. GENERAL INFORMATION:
Complete legal description WOODBOURNE; BLOCK 1,LOT 12
Location (site address) 8201 Ginami Circle*Anchorage,AK 99516
Current Property owner(s) Claude Elowe Day phone 947-9693
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: Date:
/V2//6
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 5 24 Waiver Fee $
Date of Payment 1(1z1q Date of Payment
Receipt Number 61260657 Receipt Number
COSA# Q 5CJ i 6x'9' Waiver#
"f"
•
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,
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.
Name of Firm: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101-Anchorage,Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: 101?//15
oo000�,4
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o' OF A C
in accordance with the guidelines and regulations established by the Municipality of Anchorage and
industry practices. The reported results describe the condition of the system/s on the date/s of the 0P. QO
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or • �•
: / /\
encroachments may exist that were not identified during the evaluation. The operational life of all wells � 4• T •
/ •_
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, 0.•.•.•' ` /
groundwater levels (that may fluctuate during the year), quality of construction (materials and
workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and 9... .. .. . . Q
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the f f - Gar ess:'
•
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of Op CE-7s • QQD
the well or septic system. GEG makes no representation whether an alternative well or septic system v04 •. �ce4
can be installed on the property in the event either of the current systems fail to perform adequately in p �, ••••.1 D .31 •1. (sAo
the future. The content of this report is for the sole benefit of the person/party that retained GEG to %Z"Protes so' z
° '
perform the evaluation. Reliance upon the information provided in this report by any other person or 000'
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
ON-SITE ��
System #1 Approved for 1 bedrooms ' WATER AND
System #2 Approved for bedrooms :=.-.1.q1 WASTEWATER o
Disapproved
. PROGRAM O
�A 5
Conditional approval for bedrooms, with the fo16Uyirtg t l tions:
By: 1 .S ' l/'�.0\ Q11 Original Certificate Date: J\l c�V a f 001 E
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the 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 Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other •
COSA blue sheet 10-10-12.doc
•
If more than 1 septic system is on the lot:
COSA Checklist# of_
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: WOODBOURNE; BLOCK 1, LOT 12 Parcel ID: 015-351-18
A. WELL DATA *ARTESIAN WELL WITH PLUG
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 9/20/99 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth 99 ft. Cased to 95 ft. Casing height(above ground) 18+ in.
FROM WELL LOG AT INSPECTION
Date of test 9/20/99 10/3/18
J
Static water level 25 ft. ft.
60S
° Well production 6 g.p.m. 5.6+ g.p.m.
(s1 WATER SAMPLE RESULTS:
V Coliform NE 6- colonies/100 ml. Nitrate0'`1 y mg./L. Collected by: GEG, Ltd.
LArsenic: N 1 ug./L. Date of sample: I (;I 13/
5` ,� LI Ove v 1
B. SEPTIC/HOLDING TANK DATA CONDITION OF 19 YEAR OLD STEEL SEPTIC cep-f,4 '7•12.)-44
TANK IS UNKNOWN ?r ID1 e
Tank Type/Material SEPTIC STEEL Date installed 6/29/99 1 1
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N)AYES Depression overtank (Y/N) NO /High water alarm (Y/N) N/A
Date of pumping t o 1 T I �`C) Pumper Alk c. IO Jv c.. t A S PIA on.O!1
b--
C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE AT MONITORING TUBE
Date installed 6/29/99 Soil rating kp.d./ft r ft2/bdrm) 0.8 System type TRENCH
Length 75 ft. Width 5 ft. Gravel below pipe 4.0 ft.
Total depth *7.5+ ft. Eff. absorption area 750+ ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 10/3/18 Results(Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 15 in. Water added 1017 gal. New depth 27 in.
Elapsed Time: 120 min. Final fluid depth 19 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) NONE KNOWN If yes, give date -
Cr
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at wa er alarm level at in.
_ _ • Cycles tested Meets alarm &circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
'4.75 FROM EDGE OF ST1 TO FOUNDATION WALL-SEE 2003 COSA
loom ii%
*• 4 1
G. ENGINEER'S CERTIFICATION .... � ..O.. •,!
I certify that I have determined through field inspections and 4 •
review of Municipal records that the above systems are in p i
conformance with MOA COSA guidelines in effect on this • •:— ••1If •
■
date. -y A. Garn-ss:'&
♦ Gi 2•
Engineer's Printed Name JEFFREY A.GARNESS •1�:��;,•..,D 3/5�'� �C�:
Date [011/1/b 14� PROFESS\_P•.••
LICENSE ,Iii�"���4
#AECC884
(Rev. 10/12/12)
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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. # (P¢~-- ~'5'/- /~ 'NAA# /Lf~E~4:~'~
ComPlete legal description ~ ~ t ~ ~(o c~ [ ~
Location (site address or directions)
Property owner
Mailing address
Day phone. ~-~-/~-- -Z."~ 5-~--"
Lending agency
Mailing address
Day phone
Agent,, Day phone
Address
o
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:. zi~
TYPE OF WATER SUPPLY:
Individual well ~
Community well
Public water
NOTE:
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
If community well system, provide written confirmation from State ADEC attest-
NOTE:
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.
72-025 {Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage 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 · h/I, ~'~'~ ¢,f/XJ, /,n c~-~' ~ ~ Phone ~
fin~[neor's si~naturo . . . Dato
DHHS SIGNATURE
~( Approved for 4
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date /2- 7--77 __
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 i,'; not
responsible for errors or omissions in the professional engineeCs work.
724)25(Rev, I/91) B~ck MOA~21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description: L..d-~
Parcel I.D.:
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
If A, B, or C, at, ach ADEC letter. ADEC water system number
Date completed ~/'Z, of~ ~
Y
Cased to c~ ~-', --~
FROM WELL LOG
I -
g.p.m.
Casing height (above ground)
Wires propedy protected (Y/N)
AT INSPECTION
g.p.m.
WATER SAMPLE RESULTS:
Coliform ~j//~ [ Nitrate
Date of sample: 7 ~ ~
B. SEPTIC/HOLDING,,/_,.,,_TA,N~ DATA
Dateinstailed C//~z''~/~[~ Tanksize
Foundation cleanout (Y/N)
Date of Pumping ~,~.~ ~ Pumper
I, O ~ Other bacteria p
Collected by:
!
Number of Compartments ~.... Cleanouts (Y/N) .
Depression (Y/N) I~ High water alarm (Y/N)
C. ABSORPTION FIELD DATA
Date installed
Length '~ ~'- ! Width
Effective absorption area "':~;--~ ~ Monitoring Tube present (Y/N) y
Date of adequacy test ~,[-e ~ Results (Pass/Fail)
Fluid depth in absorption field before test (in.); ~,[ e~,.3
Fluid depth ~¢r,~,3 (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Soilrating (g.p.d./fForfF/bdrm) (..-~,~:) Systemtype
Gravel thickness below pipe /-~! Total depth ~'~:~
. Depression over field (Y/N)
For ~-~ bedrooms
Immediately after C/~ gal. water added (in.):
Absorption rate = (-~{~"~ g.p.d.
If yes, give date
72-026 (Rev. 3/96)*
D. LIFT sTATIoN
Date installed Size in gallons
Manhole/Access (Y/N)
High water alarm level at* / *Datum
Cyoles~
SEPARATION DISTANCES
"Pump off" level at* __
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation =,~' Property line 5"'~ ¢ Absorption field [0
Water main/service line /~) "{- Surface water/drainage .,'~ '-I- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Surface water
Curtain drain
Building foundation ~. '7'/ Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots ( oc~ ~
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records th.~~,_~/~stems are
in conformance with MOA HAA guidelines in effect on this date.
....
S g n atu re ~f~ M,/~
Date ( ~/~/~ ¢
HAA Fee $.
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number