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Home My WebLink AboutVALLI VUE ESTATES #2 BLK 3 LT 30Valli Vue Estates #2 Lot 30 Block 3 #015-341-38 ~ , MUNICIPALITY OF ANCHORAGE ....~ · DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ,r ENVIRONiVIEN"i'AL ENGINEERING DIVISION 825 L Street- Anchorage. Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MUN ICIPA~I~i~ ANCHORA~E[~[NEW - ' ................ ~OTECTiv,4 LEGAL DESCRIPTION 2/~N 2 '] lUS~ I ~Well ~. bsorption area Dwelling PERMIT NO~ kJq. capacit Jn gallons inside length Width Liquid depth ~ II, Foundation i Nearest lot line PERMIT NO,~ "o. oflines , Length o~¢h line Total I':~tZ' lines_ Tren~ ~th . inches Distance between lines Total effective absor tion area ~ Topoftiletofinish~a~e¢~j~j~_~ ~g ~1 Material beneath tile ~J*O inches ¢~ Z ~ '~: Length ~ Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot llne PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(si 72-013~ PERMIT NO. RPF'L i CRNT LOCRT I BN LEGRL DEPRRTMENT ~ HERLTH RND EN',,,'IRONMENTRL ,~OTEC:TION _.TREET, RNTHnRRGE. BK. J:2 264-47RC~ 0~-~. Z T~ ~...-]~ F'~F.~ Z T 71 ¢1'-,o '- RNDERSON BRZS BO,. 694 E. RE[:, TREE CIRE:LE LOT g8 BLK Z~ ',/RLLI VUE SIJB LOT SIZE ~.~L, ,_,~.1 '-]ITJl IRRE FEET TYF'E OF :,;_ilL HE,_,uRFTIuN SYSTEM '-' TRENC:H · . ". ' ..,. =, L ~.:R~INI..~ ,::SQ FT,."BR)= M~'3XIMI_IM NI_IME, ER OF BEDROOMS = '> '- THE REQLtIRED _I,:.E OF THE _,uIL RES]RPTION SYSTEM I_. :2;---"5 C, EPTH=: 12 L_E~-~GTH= -~-2 n_SRR"./E [_ [:,EPTH= .-~t. 5 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT tS THE DISTRNCE BETWEEN THE SURFRCE OF THE GROUND 8ND THE BOTTOM OF THE EXCBVRTION (IN FEET). TNERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). F'ERMIT HPPLI_.BNT HRS THE RE~FuN~IBILITT TB INFORM THIS DEPRRTMENT [,IIRING THE INc, TMLLRFION IN_FECTIuN_ OF RNY HELL_, BDJBCENT TO THIS FECPERT'¢ FIN[:, THE NUMBER OF RESIDENCES TI-IRT THE WELL WILL SERVE. ~ __ ~¢- '- ' -' - ' ''',,'~ BY ERRP'FTI LING OF BNY _T--TEM WITHOLIT FINRL IN--FEL. TION RND HFPEL,HL THI_, DEPRRTMENT WILL E,E --,UE, JEL. T TO PR_-¥SEE_TIZN MINIMUM DISTRNCE BETWEEN R NELL RND RNY ON-SITE SENRGE DISPOSRL SYSTEM IS 100 FEET FOR R PRIVRTE WELL OR !50 TO 288 FEET FROM A PUBLIC NELL· DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVR'FE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. · - "--- t '-=~- ~ ::L PEF-:[-'I I T E::--'F' I RE.--. DEL--:-E~-IBE[-i.: r-', ' ,,R', -.EETIFT THRT ~ ~ ,= ,--~- I RM FRMILIRR NITH THE ..E..]LIREME~;~FS ~FL4R flN-'-~TE _,EWER_-, RND WELLS H--, SET I FORTH BY THE MUNICIPRLITY OF RNCHORRGE. 2: I I,.IILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. ]:: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN 3: BEDROOMS. _., I ~NE[ __ ]_ .............. BPPL I CFtNT RN[:,ERSON BROS. ISSUED B'~~~ ~--~ ...... E:'FI ' E - -r-~ --~- -~-~- ~- - - i Il i SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825'L. Street, Anch¢irage, Alaska 99501 264-4720 -SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR= 'EGAL DESCR,PT ON: 1- , 6- 10- 11- -~12 - · 13- 14- 15- 16- 17 18- 19- SLOPE NO. 1732-E June 22, 1968 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Readir~j Date Gross Net · Depth to Net Time Time ' Water Drop I COMMENTS /'~ /~)0 7' ~5~ PERCOLATION RATE TEST RUN BETWEE~N ET AND (minutes/inch) FT 72*-008 (6/79) :1 ~MUNICIPALITY O F~,...-,..'~HO RAG E DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION CITIZEN COMPLAINT [] JUNK CAR [] NUISANCE ~,~WAG E []AIR [] WATER [] NOISE [] HOUSING ~ PUB FAC LOCATION OF PROBLEM DETAILS OF COMPLAINT VIOLATOR'S NAME (If known) ADDRESS PHONE o79-o96o 70-006 (Rev. 1/78) DO NOT TAKE ANONYMOUS COMPLAINTS c>, IG9. ~.63 , d~,-.i'4 ?m I n~reby certify that I have su~teyed the following described property, Lot .~[,..Block. '-P 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. # ~/,_c~'..~)~// - ~.¢,~' HAA # ~'+l~( i,'( r ,~ '[ GENERAL INFORMATION Complete legal description Location (site address or directions) ~¢' -~ '~,¢' /~-~" /"~- Property owner ~'~o!~. ~ {/',~,.,-~ ~,_._.,--~ ti, / ,'¢.._ ~¢'; .. ~¢r%_,.T&~-- / %~ . L.-~-~*-¢7c-~% Day phone ~ ~-' Mailing address ~.~ ~ , F'~e~:~ !~.L~ ~ Lending agency Mailin_g address Agent ,')q ~L ~/J Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 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: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-O25 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of tile 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 ('--' ,~ ~ s ~'~'u ¢-- ~ ~ ,-~3 ~ '~ ~ I ¢, ~-~-,v'5 Phone Address c/Gal Engineer's signature /'/~' /~ 4/~¢~,,~-._. Date DHHS SIGNATURE Approved for L1L Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DH HS 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. RECEIVED Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES APR 17 20 Environmental Services Division MUNICIPALLY' OF ANCI~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907)~1~. S~RWCFS Health Authority Approval Checklist LegalDescription: (~o ['~ t-Jh~l ~ L~'<~'~ ParcelI.D.: A. WELL DATA Well type A IfA, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Date completed Cased to Casing height (above ground) Sanitary seal (Y/N) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well production g.p.m, g.p.m. WATER SAMPLE RESULTS: Coliform Nitrate _ Other bacteria Date o[ sample: Collected by: B. SEPTiC/HOLDING TANK DATA Date installed ~u/~ ~ ~ Tank size Foundation cleanout (y/N) ~ Date of Pumping IZ.~O~ Number of Compartments ~' cleanouts(Y/N)__ Depression (Y/N) /'J High water alarm (Y/N) Pumper ~ + l~rO~'t~- $~R,u'[C~;5! C. ABSORPTION FIELD DATA Date installed ,~o~ ~ O~'~ Length '-~ ~ ~ Width ~ Gravel thickness below pipe Effective absorption area ~O 5; F Monitoring Tube present (y/N) ~ Date of adequacy test ~. - I ~ - ~3 O Results (Pass/Fail) [~'¢~--5~ Soil rating (~ or ff~/bdrm) ~,~' System type ~. I Total depth I . Depression over field (y/N) For :FOol7-. .bedrooms Fluid depth in absorption field before test (in.); Fluid depth O (ins) Minutes later:. 7 Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* Immediately after&'OOgaL water added (in.): Absorption rate = ~ Goo q.p.d. If yes, give date D. LIFT STATION /,JET' 0~-~ Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at* "Pump off" level at* High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: ,~J O Septic/holding tank on lot _ On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer/septic service line Liffstation SEPARATION DISTANCES FROM SEPTIC/I*I(Yc~.NG TANK ON LOTTO: Foundation + 5 Property line ~' ~' t Absorption field ~ 5' Water main/service line + t 0 .Sudace water/drainage + ~ o 0 Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line, + 3 Building foundation + f o Water main/service line Surface water +lDo ' Driveway, parking/vehicle storage area +*~ ~ Curtain drain 1' 1 eow Wells on adjacent lots -{-, 'Zc, o F. ENGINEER'S CERTIFICATION I certify that I have determined in conformance with MOA HAA guidelines in effect on this date. Signature ~/J~/~'~' ~"~"' Engineer's Name g, H, UOI C3 o~ ~ ~ o~ S T, ~ ~ ar~ Date "{" ~ (' ' o 0 HAAFee $ ~'~ Date of payment ~/) '-~/"~ Receipt Number ~z)--(~?~_ L/ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* . MUNiClPALiTYOFANCHORAGE ,... !'::: j~'~-:.- :. :'.'_ ._ :. ~. 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 FORA SINGLE FAMILY DWELLING ,," - ._-, ' 1.' GENERALINFORM;ATION ' 4 Location (site address or directions) ' .'. 'Prop~rtyOWner" '~-~l('c~/~ ~---- ~ Z-~-~. /V~, ~:~'¢~-~Day phone Lending agency' Ma'!-Iing'~ddress. YAgent ' : ~'' '-- · Day phone Day phc .":., Unless otherWise requested, HAA wdl be held for pmkuD, . ' ~.: · 2: '~'uM'BER OFBEDRooMs ( ~bU~ -.' ': . :: ~ ~ .. :. 3. TYPE OF WATER SUPPLY: Individual well .---"'.' :' ' ' comm~nity~ll .... ' ......"' : Pu-Iic--ate-b w r NOTE: If community well system, provide written ~)nfi~mation from State AbEc'attest- ~ :;' Z:',.. · - . ing to the legality and status of system. -' : ,. -,, o, w%%,0.,,;,:o,,,: /-. .. .. ' ~::~':~.2: :., ' .... .'." ' : · -' ' - · ~'~ . ',~t::,,'X¢' Pubho sewer ,. -:...,.- ...... -,, :::,,.-~:: *¢; --~*/'7: ,-.~4,¢~, t,. . ~ , ~: :-<~.?.. ,.., .. . :. :).. . .. --'- - NOTE: If C~mmuni~ wasteWater system, provide writer confirmation fro~.S{ate ADEC a~esting to the legali~ a~d status of system. . -'.:-:,.: 72*025{Rev. 1/91) Front MOA#21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wasmwater disposal system is in compliance .with all Municipal and State codes, ordinances, and regulations iri effect on the date of this inspection. Name of Firm Co/.JS'~/ ~'.,~J~/'~..5', Phone c~/'/~ -CoO O ~gineeCs signature DHHS' sIGNATURE -T%~ r ' ~".':' A~r0~ed f~r bedrooms ...... ,~. . . ... · -:-.~Disapprove ' ' ' ' -'.... ' .'. ':' Conditional approval for bedrooms, with the following stipulations: Additional Comments ,,The MuniCipality o~,,~;nc'horage Department of Health and Human Services (DHHS) ~ssues Health Authority "~.~'-' ..... 'i/"ert fic~t~ I~'ased on ~t Upon the representations gi¥~rl in Paragraph 5 above 15~ an independent ..._c.~,;.,~,~;... ~.,..~,,4~ r,=nistered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes ~'r~s~?,,~, ~ .(: \-~,, ,~. .... ~ - . . ..... ~ ~n orderto sabs certain federal and state requirements Emp oyees OT ummS do not ~h'd their lending ihstitutions ' ' fY ' · 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 ~ork ~'~ :, · .' Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: s/q) Tt'Z-t'ot A. Well Data Parcel I.D. If A, B, or C, attach ADEC letter. ADEC water system number ~' ! o ~, o 5' Well type Log present (Y/N) Date completed Driller Total depth Cased to Casing height Sanitary seal (Y/N) FROM WELL LOG g.p.m. Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 4- ~. oo Absorption field on lot 'f- ~ oo ' Public sewer main + 'g.o~ ' Sewer service line -+ ~.oo ' Wires properly protected (Y/N) AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank . 7_0o WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ,/4 o ~ ! ff X' I Cleanouts (Y/N) ~/ High water alarm (Y/N) Date of pumping Tank size ! 'z.-5 o ,~ Compartments Foundation cleanout (Y/N) F Depression (Y/N) , Alarm tested (Y/N) ~ '~ Pumper /~ '/''/¢o~¢ ~ ~'/~'/¢-E.¢ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /,////4- To property line '/- 5- ' Surface water/drainage On adjacent lots Absorption field /~'//,4- (/-/Loo) Foundation ~ ~ 4- 5- ' Water main/service line 72-026 (3/93)* Fronl CONTINUED ON BACK PAGE C. LIFT STATION '~' /..2o 7- ~' .5 ~"~, Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Z', ~..~? d/¢¢/: z Date installed ~ ~ ~f f?~/' Soil rating (GPD/Ft2) (~' ~/~/~ System type /'~¢-~c-/U Length . ~ ~"' Width ~ ~'" Gravel thickness ,~ ' Total depth _ /'~ ~ Total absorption area C~ ~/'C~ Cleanout present (Y/N) Y Depression over field (Y/N) /v'/ Date of adequacy test ~ "~'~- ¢~ Results(pass/fail) Water level in absorption field before test O Peroxide treatment (past 12 months) (Y/N) /~'0 ,/~/'-/'-55 for .~-~2 C-'/E., Bedrooms After test z/' ~' If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ,,t,//'~ To building foundation 7~/(2 ' On adjacent lots /' Z o ' Surface water 'c/DO ' Curtain drain ¢' / ¢~ ' On adjacent lots ~ ~2o Property line To existing or abandoned system on lot Cutbank ,z/~¢ ' Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all M, OA and HAA guidelines Signature HAAFee$ ~'~,~ Date of Payment "~/.=¢/,. Receipt Number ¢~d~ Waiver Fee $ Date of Payment Receipt Number 72-026(3/93)" Back MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH B/qD ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATS 1o General Information Application Date (a) Legal 5ascription (include lot? block, subdivision, section, township, range) Location (address or_direct~ons) ~ _ (b) Applicants Name 8¢ra/J ~, ~F'OZZ)~ Telephone - HomeS¢~-/~/FBustness (c) Applicant is (check one) Lending Institution ~ ; ~er/b~lder ~ ; (e) Real Estate Co. & Agen~ ~ ~/~ Address ° Telephone (f) Mail the HAA to the following address: ~esidence Single-Family~--~ Number of Bedrooms Multi-Family Other (describe) Note: If community well sys~em, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Sewag~ Di~ Onsite~ 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] E~ineerln~, Firm Providing Inspections,_ Test~t~le 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 %zastewater 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 w~ter 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 Firm L)~°~9S~¥0~'~/~ ~5 /~- ~-~ ~}6~ Telephone ~q~'ZO~ Date DREP A~ Approved for ~]ZZ~ bedrooms Approved~ Disapproved Terms of Cdnditioual Approval (ENGINEER SEAL) By Conditional CAUTION THE MUNICIPALITY OF ANCHORAGE UEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER ILEGISTERED IN THE STATE OF ALASKA° THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND T~IR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE~ MENTSo EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED° TttE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS 0R OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK° (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 MUNICIPALITY OF ANCHORAGE (MOAi~ HEALTH AUTHORITY APPROVAL (HAAi CHECKLIST - FEBRUARY 1984 Well Classification ~ Well Log P~esent (Y/N) Total Depth Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances f~om Well: To Septic/Holding Tank on Lot To Nearest Edge of Absc~mption Field on Lot To Nearest Public Sewer Line Cleancut/Manhole Water Sample Collected By Water Sample Test Results MUNICIPALITY OF ANCHOP. AGE DEPT, OF HEALTH & ENVIRONMENTAL PROTECTION If A, B, c~ C, D.E.C. Approved(Y/N) Date Completed Cased to Pump Set At Depth of Q~outing Yield~ Sanitary Seal on Casing (Y/N) Dep~essionA~oundWellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date B. SEPTIC/HOLDING TANK DATA Date Installed t~U6? /?~J Size I 'L~O ~ No. of Ca,ua~tm~nts Standpipes (Y/N) y Air-tight Caps (Y/N) y Foundation Cleanout (Y/N) X Depression over Tank (Y/N) AJ Date Last Pumped "~c~ ~ /~ ~-~ Pumping/Maintenance Contract on File (Y/N) ~ ; for Holding Tank High-Water Alarm (Y/N) /t//~- Temgorany Holding Tank Permit (Y/N) Separation Distances f~om Septic/Holding Tank: To Water-Supply Well To P~aperty Line +~l To Water Main/Service Line Course '~/~ To Building Foundation To Disposal Field Counts To Stream, Pond, Lake, c~ Majo~ D~ainage Receipt ~ Date Paid: Amount: [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date .Installed Width of Field Square Feet of Absorption Area Type of System Design 'l Length of Field 3 ~ i Depth of Field ; Gravel Bed Thickness 3- ~ Standpipes Present (Y/N) Depression over Field (Y/N) ~3 Date of Last Adequacy Test Results of Last Adequacy Test /%~~J+~'~O~ ~ ~/~' Separation Distance frc~ Absorption Field: To Water-Supply Well d-2~9o To Property Line 'k3 To Building Foundation ~ /o ' To Existing Or Abandoned System cn Lot ~2/~ ; On Adjoining Lots + ~d To Water Main/Service Line ~ ~ ~ To Cutbank(if present) /J/~ To Stream/Pond/Lake/c~ Major D~ainage Course + To D~iveway, Parking Area, c~ Vehicle Storage A~ea Comients Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA l%~quest I certify that I have checked, verified, or eonfur,~d to all MOA HAA Guidelines in effect on the date of this inspection. Signed KB1/d5/s [Page 2 of 2] 2-15-84 APPLICf" IT FILLS OUT UPPER HAL "ONLY td~opertyO~;ner ~.~cp /~,~t/Z~o- ~-~i /~-~ ~../~ j/~ ~ ~ Phone ~ailino~ddre~ ~'~ ~O ~ ~C~O A ~O~-7 ~ ~ ZipCode Buyer ~ ~ ~ ~ ~ ~ [~F~O ~ ~ Address Zip Code Lending Institution ~ ~ /~1 ~ ~ ~ 0 ~ ~ ~ ~ ~ ~ Phone Address Zip Code RealtyCo.&A~nt ~A~ ~/c ~ /~ /~/~ ~ ~C~ Phone Address ~ ~ '~O~ ~O~ ~/~O~ A~ ZipCode ~'~ Street Locati~ ~'~ f~ ~ ~ ~ [V e ~ ~ Type of Res[~nce ~ Single Family ~ Multiple Family NO. of Bedroo~ ~ Other Water Supply ~ Individual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. ~Community For wells drilled prior to that date, give well depth (attach log if available). ~ Public Utility Sewer Disposal ~ Individual Year Indiv~ual installed: ~ ff~ ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector MUNICI 'ALr[Y O~ AN(JH(JF. ALCE ( PROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* DATE Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size 72-023(3/82)