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HomeMy WebLinkAboutSUMMIT ESTATES BLK 3 LT 1 Lot 1 Block 3 #015-071-31 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211097 PID Number: 015-071-31 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name AMY K. LARSEN ABSORPTION FIELD - EXISTING EJ Deep Trench E:1 Wide Trench El Bed E:1 Mound Site Address TH 5740 E 98 AVENUE, ANCHORAGE ❑ Other Phone Phone 7�� f Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot SUMMIT ESTATES 3 1 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 Ft' Ft. Well 100'+ -- 25'+. TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1250 Gal. Surface Water 100'+ -- Material HDPE Number of compartments 2 Lot Line 10'+ __ NA Foundation 101+ __ LIFT STATION Manufacturer Capacity Gal. Remarks Existing tank removed and new tank placed in same location w/ no effect to the existing field. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034. Tank to 3034 Installer PCN drainfield Drainfield CO/MT 3034 Inspector FWCS BENCH MARK (Assumed elevation) 100 ft Inspection Vectiot 4/14/2021 4/15/2021 Location and description 2nd 3`d 4'h BOTTOM OF SIDING ON-SITE WATER AND WASTEWATER SECTION APPROVAL e e� Conditional Approval: Date �AW .....�:* L� "" '•••'••••• Septic System Approved % �•,• Curtis Huffman - Date����s�F�•.4n5/202J.•��C� CE 128991 i �AW iROFESSIO-� Note: this approval does not include well permit requirements. kr-,Vv uzvu// 1 Of PID: 015-071-31 PERMIT: OSP211097 N89 59'00"E 120.00' A—C=33,1' B—C=24,9' A—D=34,8' B—D=29,1' A—E=35,5' B—E=31.0' A—F=37,5' B—F=34,6' 10' UTILITY ESMT N89 57'30"E 120.00' rMH CO DCO NEW MT INSTALLED FINAL GRADE 4.3' INTO i EXISTING SUMP NOT LOCATED 98.45 J THE 5.8 'ED UTILITY CONFLICTS PREVENTED —\ / EXTENSIVE EXCAVATION 1,250 -GALLON HDPE TANK SEPTIC SECTION SCALE, NTS SUMMIT ESTATES BLOCK 3, LOT 1 PREPARED FOR: AMY K. LARSEN 5740 E 98TH AVENUE ANCHORAGE, AK 99507 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 firstwaterAK©gmail.com EXISTING FIELD SUPPORT SERVICES: WCSalp,OF ALS �� 9TH '�Kl C — DATE: 4/16/2021 SURVEY: JLS rtis Huffman wx DRAWN: FWCS r CE 128991 w SCALE: 1" = 30' 4/16/2021R� PAGE: 1 OF 1 %Mssiov M LL N DRIVEWAY N -' rn c 2x14.5' 2x20' � CANT CANT 6' 27.9' 28.0 24.0' EXISTING w EXISlANG Z O 35R o_ HOUSE N w GARAGE 'o. o O Z b O OC,d 280, � 21.9' 0 O 32.6' PRO B DEC � W O D CK FCO � O W LOT 2 C) BILK 3 STAKED 100' � _ LOT 1 '-'-WELL RADIUS � _ CA BLK 3 PRIOR CONST.O� MH ® E O CO F NEW MT CA D bo DCO INSTALLED APPROX. J / EXISTING EXISTING MT DECOMMISSIONED EXISTING FIELD S.T. & INSTALLED NEW 1250 -GAL HDPE SEPTIC TANK WITH NEW DCO. I A—C=33,1' B—C=24,9' A—D=34,8' B—D=29,1' A—E=35,5' B—E=31.0' A—F=37,5' B—F=34,6' 10' UTILITY ESMT N89 57'30"E 120.00' rMH CO DCO NEW MT INSTALLED FINAL GRADE 4.3' INTO i EXISTING SUMP NOT LOCATED 98.45 J THE 5.8 'ED UTILITY CONFLICTS PREVENTED —\ / EXTENSIVE EXCAVATION 1,250 -GALLON HDPE TANK SEPTIC SECTION SCALE, NTS SUMMIT ESTATES BLOCK 3, LOT 1 PREPARED FOR: AMY K. LARSEN 5740 E 98TH AVENUE ANCHORAGE, AK 99507 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 firstwaterAK©gmail.com EXISTING FIELD SUPPORT SERVICES: WCSalp,OF ALS �� 9TH '�Kl C — DATE: 4/16/2021 SURVEY: JLS rtis Huffman wx DRAWN: FWCS r CE 128991 w SCALE: 1" = 30' 4/16/2021R� PAGE: 1 OF 1 %Mssiov MUNICIPALITY OY- ANCHORAGE 0 n -S i to VVater & Wastewater Prog r am RO f 156954 4704 €IM6ft ROM Anchorage, Ala6ke 9N19 -N50 Phom: (907) 343-7904 Fax: (P07� 343-7907 h*JAv vw.Fmnf.argron On -Site Wastewater Disposal System Permit Permit N umber: 0SP211 {09 Work Type: SepticTo n k U pgrade Tax Code Number. 0150713100 Site Legal Address: SLIM M IT ESTATES K K 3 LT 1 x:2437 Site Mailing Address;. 5740 E 98TH AVE, Anchorage Owner; LARSEN AMY K D-usign EnginLae r. FIRST WATER CGNSLILTIN(� This }permit Is for the construction of: Effecfiva Date-. Expiration Date: Lot Size in Sq Ft Tatar Bedrooms; 4)912021 41912022 16175 ❑ Dispos@l Field © Sepllo Tann ❑ Holding Tank ❑ Pdvy ❑ Private WalI El Water Storage All constructlen shall be In accorda nee with: 1. The amched approved design, 2. All requirements specified in Anchorage Muniripal code Chapters 15.55 and 15-65 and the Mate of Alaska VlateWater Disposal Regulations (1S AC72) and Drinking ',+1latw Regulations (1WC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Develepn-ieigl Services Department per AMC 15.65, Provide notification by calling (907) 343-7904 (24Y7). 4. From Octobef 15 to April 16, a subsurface 9011 absorption SyStam under construction during freezing weather shall be either: a. Opened and Closed on the $arra day, or b. Ccrvered, sealed, and heated to prevent freezing Received By: Issued By: vru V9/2021 Data: Date - --- -- --I UNICIPALITY--OF ANCHORAGE b� Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 015-071-31 Property owner(s) AMY LARSEN Day phone Mailing address 5740 E 98TH AVENUE, ANCHORAGE, AK 99507 Site address 5740 E 98TH AVENUE, ANCHORAGE, AK 99507 Legal description (Sub'd., Block & Lot) SUMMIT ESTATES 133, L1 Legal description (Township, Range & Section) Lot Size 16,175 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank 0 Upgrade M (D) El Holding Tank ❑ Renewal ElDuplex Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A 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: t a a 5 Date of Payment: /642 0 4 1 Receipt Number: '70( 0yy Permit No. 05e x1109`-1 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / firstwaterAK@gmail.com April 3, 2021 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: SUMMIT ESTATES BLOCK 3, LOT 1 The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic tank on the above referenced lot. We propose to install a 1250-gallon HDPE tank per the attached design to serve the existing 3-bedroom residence. The existing tank is within 1’ of the existing field per MOA records and field observations. The existing tank is also 7.5’ from grade in loose material per recent observations of a monitoring tube installation. If it is determined at construction that field integrity cannot be maintained, the tank will need to be placed within the 100’ well radius and a waiver will be requested. This waiver if needed will be justified due to the improved HDPE material of the tank and the fact that the septic tank is down gradient and on the opposite side of the house from the well. The lot and area are served by private wells. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211097, Rebecca Carroll, 04/09/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211097, Rebecca Carroll, 04/09/21 , ' 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 MAILING ADDRESS LEGAL DESCRIPTION PHONE~ ,.~3~ Z~- ~NEW F~UPGRADE D,ST^NGETO: IW""IO Z I Ab'°rpti area Dwe"' Z ~ N L q, capacity~ in gallons IF HOME,DE: Inside /length W dth ' NO. OF~DROOMS No. of~..~mpar tments Liquid depth Well DWelling PERMIT NO. DISTANCE TO: Manufacturer Liquid capacity in gallons Material Nearest lot line Trench~idt 36 ~ ~'~inches Fou ndatior~, Total len th of lines DISTANCE TO:Well No. of ,~e, fi L.ngth Top of tile to finish grade Length Width Type of crib Crib diameter Material be~j~ee ? (~ ~! / inches Depth PERMIT NO. Distance between lines PERMIT NO, Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: /..~ / Driller ~1o~ line NO. DISTANCE TO: APPROVED LEGAL 72-013 IRev. 3/78) ANC HOP.,. DR.ILLING PERMIT NO. ~U~ ICI ~HLI OF A~ ~HL~r~.AGE DEPflRTMENT OF HEflLTH fiND ENVIRONMENTRL PROTECTION 825 ~L~ STREET, RNCHORflGE.. BK. 99501 264-4729 ~4ELL R~4D Clf-~--SITE SE~4E~: PERMIT ( 82084& ) fiPPLICRNT LOCRTION LEGRL MIKE & DlflN~ GflRD LiB~ SUMMIT EST 6t~5 E TUDOR ~30 99507 LOT SIZE ~8-25i2 999999 SQURRE FEET TYPE OF SOIL RESORPTION SYSTEM IS: TRENCH MRXIMUM NUMBER OF BEDROOMS SOIL RflTING <SD FT?BR)= 85 THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS: [)EF'TH= ii LEI'-.IGTH= :1. '_:~- GRR%-'EL DEPTH=. 7 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF ~ TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCBVRTION (IN FEET). THERE 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>. ~:EC~UIREC, SEPTIC TAN)( SIZE= i0~0 GALLOr4S PERMIT RPPLICRNT HflS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTBLLRTION INSPECTIONS OF RNY WELLS RDJRCENT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. T~.~O (2) I r~SPECTI~]~S ARE RE~!LiI R:ED BRCKFILLING OF tiNY SYSTEM WITHOUT FINRL INSPECTION fiND RPPROVRL BY THIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTfiNCE BETWEEN R WELL fiND RNY ON-SITE SEWRGE DISPOSAL SYSTEM IS i00 FEET FOR R PRIVRTE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTflNCE FROM fl PRIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET fiND TO R COMMUNITY SEWER LINE IS ~5 FEET. WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS WRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTBLLRTION. PERr-~ I T E.'"--~F' I RES DEC:E~4BER --~i.. I CERTIFY THRT l: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS fiND WELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE. ~ I WILL INST~LL THE SYSTEM IN 8CCORDRNCE WITH THE CODES. ~ I UNDERST8ND THRT THE ON-SITE SEWER SYSTEM M~Y REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN ~ BEDROOMS. SIGNED: RPPLICRNT MIKE & DIRNR GRRD V4. 0 ~vnz~ TO z~ e~ 21{~.4st In,ternational Airport Rd, Suite 204 ANCHORAGE. ALASKA 99502 (907) 278,3773 SOILS LOG -- PERCOLATION ·TEST LE_,GALOESCJ31PTION: L,O'T' J · [~'L~)~'-~-, .'~ SLOPE :~-' :1o' : 112 ': . 13 - 15- 16- 18- 2O SOILS LOG [] PERCOLATION '-EST SITE PLAN WAS GROUND WATER -:NCOUNTEREO? O F YES. AT WHAT DEPTFI? Gross Nat ' DepthTo ' Not Reading Date ,' · · ,' Time · Time · Water Drop PERCOLATION RATE (minutes/inch COMMENTS TEST RUN BETWEEN :T AND , F- MUNICWALITY Development Services DepartmentPhone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015.071-31 1. GENERAL INFORMATION Expiration Date: Z jq— 2j Complete legal description SUMMIT ESTATES BLOCK 3, LOT 1 Location (site address) 5740 E 98TH AVENUE, ANCHORAGE, AK 99507 Current property owner(s) AMY K. LARSEN Day phone Mailing address Real estate agent 5740 E 98TH AVENUE. ANCHORAGE. AK 99507 2. TYPE OF DWELLING: ® 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 ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 55 O Waiver Fee $ Date of Payment q—(1—Z( Receipt Number q (}�d COSA # (?) 1� c a Date of Payment Receipt Number Waiver # Distance: 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Address 13030 SUES WAY, ANCHORAGE, AK 99516 Phone 907-350-9566 Engineer's Printed Name CURTIS HUFFMAN, PE Date 4/14/2021 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & FWCS 6. DSD SIGNATURE System #1 Approved for --3— bedrooms System #2 Approved for bedrooms Disapproved OF •44:4`�ll i g�P TM.... .....:..r� Ir Curtis Huffman CE `'srF�• 4/14,/271••���'�V Conditional approval for bedrooms, with the following stipulations: a \A1h qt, -v,'ATER AA ,Z PROOKAM a� IQ 7N� >>>>))))))»>�• r . I Original Certificate Date: z 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 X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other Legal Description: SUMMIT ESTATES BLOCK 3 LOT 1 Parcel ID: 015-071-31 If more than 1 septic system on lot: COSA Checklist # _of _ Structure served by this system A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 1982 Total depth 69 ft Cased to 69 ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 4/2/2021 Static water level at beginning of test 42 ft. Well production at time of test 6.4 gpm Comments B. TANK DATA Age of tank(s) NA – NEW TANK years Tank type/material SEPTIC / HDPE Measured operating fluid level in septic tank NA ® Standpipes/foundation cleanout per record drawing Date of pumping NA D. ABSORPTION FIELD DATA Which system tested (date installed) 10/17/1982 ❑ ALL standpipes present per record drawing* Total measured depth from grade 13.6 ft (max) Measured depth to pipe invert from grade 9.3 ft (min) ❑ N/A – pressurized field Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ® No ® Coliform bacteria is Negative Nitrate 4.21 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) FSE: Collected by FKS Date of Sample 4/1/2021, - C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: Adequacy test date 4/2/21 Results E Pass For 3 bedrooms Fluid depth prior to test 3 in Water added 450 gal New depth 38 in ❑ Monitor tubes go to bottom of effective. If not, state depth into effective *4.3' into the 5.8' ED Elapsed time 75 min depth 4 in Code -required soil cover over field Final fluid d— ❑ System presoaked Absorption rate 450 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) If yes, enter date Gallons introduced gallons –NEW MT INSTALLED. Comments/Deficiencies: *EXISTING SUMP / MT NOT FOUND FES_, 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' ® Yes if No Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No ft Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' Water Service Line > 10' ® Yes Animal Containment > 50' ® Yes if No ft ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ®Yes if No ft ® Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑ Yes if No *2+/- ft Private Wells > 100' ® Yes if No ft Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft Water Service Line > 10' ® 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' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No _ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' Water Service Line > 10' ® Yes if No ft Community Wells > 200' Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS ® Yes if No ft ® Yes if No *Original tank was installed within 2'+/- of existing field New tank installed in the same location with no effect on existing field. G. ENGINEER'S CERTIFICATION l 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. low 'A TH Curtis Huffman F�, • CE 128991 •��Awo� PROFESSI NP��-•�'�� E 98th AVE c>J 0 0 N89°59'00"E 120.00' WELL ^' m AMEN DRIVEWAY PA T 2'x14.5 2'Y20' CANT CANT 26.6' 27.9' 28.0' Z EHOuSE c EGARAGE o p Z o o p pD, 24.0 21.9' O O 32.6' ZPRO 2 W ® DEC O W p DECK �7 O C7 O —. MH I D wP LOT 1 ®® e SEPTIC W BLK 3 `ENT (tm) v 10' UTILITY ESMT N89'57'30"E 120.00' 50.0' ' ANCHORAGE RECORDING DISTRICT, ALASKA AS-BUILT OF: NOTE: Pavement locates are approximate SUMMIT ESTATES due to deep snow and ice conditions. LOT I BLOCK 4 PLAT P-628®® SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a 0 F 4Z I%% y �D LAjgj) physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance should Cb 49TH any information on this drawing be used for construction offences, ®....................... x t-' structures, improvements, or for establishing boundary lines. 1r U a C EXCLUSION NOTES: It is the owners responsibility to determine ,g ..............................� V1 r the existence of any easements, covenants, or restrictions which J N L. SCHULLER. � ,Q. �' 0 R do not appear on the recorded subdivision plat. a� ! LS-10408 .....` o^, J ® 1831 Talkeetna Street WORK ORDER NUMBER: DATE: SCAB E-HAIL• ® @ �% !� p. '�t�•. j.(�:?.E'' a Anchorage, Alaska 99508 MAY 16, 2021 1 "=30' BchullerCak.nat A P 21-026-2 DRAWN BY CHECKED BY CRID NUMBER: BOOK, �®~ofessioncN o'er (907) 227-1455 office JLS SW2437 210136 ��®��® (907) 274-4992 fax Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanchorage.ak,us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ParcelI.D. O1~-o7/¢ ~1 1. GENERAL INFORMATION Expiration Date: Complete legal description t-~t Location (site address or directions) Current Property owner(s) '~ ~ Mailing address ,-~'TLf~ ~' , ~:~/'"~/~0_ · Lending agency Day phone Day phone Mailing address Real Estate Agent Mailing Address Day phone Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community CIass Public Water System Well TYPE OF WASTEWATER DISPOSAL: ~ Individual On-site E~ [] Individual Holding Tank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health AuthorityApproval (HAA) based only upon the representations given in paragraph 5 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. 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 sample results less than 30 days old. 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. 72 025(Rev. 01/00)* 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 Health Authority Approval Guidelines for the Health Authority Approval application show 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. [ 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Address Engineer's Printed Name DHHS SIGNATURE ,,~ Approved for 3 Disapproved. Conditional approval for __ Phone bedrooms· bedrooms, with the following stipulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: ~- - / '7- ~ ,/ Original Certificate Date: Reissue Date: 72-025 (Rev. 01/00)' ""'EC EIVE D '- Municipality of Anchorage Department of Health and Human Services NOV 0 3 2000 Division of Environmental Services On-Site Services Section 825 "L" Street Room~( ................. P.O. Box 196650 Anchorage, AK 99519-~NMENTAL sERVICES DIVISION www.ci.anchorage.ak.us (907) 343-4744 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. 'WELL DATA Well type Date completed Total depth L )-F I L:5 5 L)NH/T EsTA:TIZ If A, B, or C provide PWSID Cf t~,g;t,, Sanitary seal ft Cased to /¢ FROM WELL LOG Date of test Static water level Well production I -~ g.p.m WATER SAMPLE RESULTS: Coliform ~ colonies/100 mi Date of sample:~ I o/~.,/ B. SEPTIC/HOLDING TANK DATA Tank Type/Material Date installed J°//?/8.2_ Tank size- Cleanouts ~' FoundatiOn cleanout Date of pumping ~'/~z.~/~-~ C. ADSORPTION FIELD DATA ff Parcel I.D.: Well Log ~ Wires properly protected Casing height (above ground) AT INSPECTION '~' g.p.m Nitrate .2.'~ ~ mg/I Other bacteria ¢ colonies/100 mi Collected by: I ~ ~ , ST'E- ¢. L_ Ic,'oo gal Number of Compartments Depression over tank ~ High water alarm Pumper Date installed v°/tllSZ--- Soil rating (g.p.d./ft2 or ft2/bdrm) 8¢o System type Length ,~ ft Width ~ ft Gravel below pipe "7Or ~ . Depression over field For ~ * bedrooms Water added '7~Z) gal. New depth Total depth lO ft Effective absorption area~P, fF Monitoring tube Date of adequacy test l°/~t'~/oo Results (Pass/Fail) "~ Fluid depth in absorption field before test ,-~'~) in Elapsed Time: min Final fluid depth Any rejuvenation treatment (past 12 mo.) (Y/N & type). in. in, Absorption rate >= z//~SZ) g.p.d. .If yes, give date v/ 72-026 (Rev. 01/00)* D. LIFT STATION Date installed at.~ Size inoff".~vegall°ns/..,.// "Pump on" level in "Pump~l at __ in Datum /'/ cY,~ctested E, SEPARATION DISTANCES Manhole/Access j High water/8 rl~m level at Meets..a~rm & circuit requirements __ SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots '/~ / ¢ o On adjacent lots ~ / ~ O Public sewer manhole/cleanout Holding tank ~//~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main Drainage Property line ~' Water service line Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line .';> ~ o Building foundation ~ D Water Service line ~ ~-...-"~ Curtain drain I"ll ~ COMMENTS Absorption field Surface water t.~ I o Water main Driveway, parking/vehicle storage Surface water N. ~ r~ Wells on adjacent lots 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 HAA guidelines in effect on this date. Engineer's Printed Name '"'~- ~ po ,r ~..-~.,. ~ ~ Date 1 o/ct'-//~ HAA Fee $ ~.~,¢H¢, ~---- I) Date of Payment Receipt Number ~ ~' / ~ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 01/00)* s~te address or d~rechons) Individual on-site '~':"~:"~:" ~' '¥ " 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, 1/91) Front MOA #21 ,x~r NSPEcTION '" " "~ 5. STATEMENT' I BY ENGINEER)" ,~ i~,~' ~ ~t!~C~ ~ ~ ~ ~- As ce~ified by ~y seal affixed hereto and as of the vahdaflon date shown below, I ven~ that my investigation of this Health Authori~ Approval application shows that the on-site water supply and/or wastewater dispo~l system is ~fe, functional and adequate for the number of bedrooms and ~pe of structure indicated herein. I fu~her veri~ that based on the information obtained from the Municipali~ of ~e ?les~a~'f~m. my~inv~ii~ati~a~ insp~tion, the on-site water:. supply and/or Wast~{~i~o~i ~ste~"i~ ih d'0m~li~nce'wi{h ~11 Municipa! a~ state cod~s, ;';~.~.. .......... ;.Engin~ssignature ~~ ~ ~ . Date ~ / ','. '~% for ~ bedrooms :.w~th .the ;follow ~g~t~pulabo s.. 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 errom or omissions in the professional engineer's work. Municipality of Anchorage MUNICIPALITY OF ANCHor^G= ~ DEPARTMENT OF HEALTH & HUMAN SEP~I,~EN~'^LSERViC~S OlVl$1~lJ]~ Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343j~7~4,~ ]~)9~ Health Authority Approval Checklist LegalDescdpQon: L, alc2,~ t3/~3~ _Cw~,~;h E. cf. ParcelI.D.: RECEIVED A. W-ELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) . IfA, B, or C, attach ADEC letter. ADEC water system number Y Date completed t c) ~ ~ Cased to ~ ' Casing height (above ground) ~ ~ '~ ~' Wires properly protected (Yt2q) ~f · FROM WELL LOG AT INSPECTION ~9~a ,~/~'/06' I,,c' g.p.m. ~-. '75 g.p.m. ~,.(7 mq/-,~ J Collected by: Other bacteria Nitrate Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 col /too m ( Date of sample: 5"/ ~ / / 9n~ B. SEPTIC/HOLDING TANK DATA Number of Compartments ~ Cleanouts (YfN) High water alarm (Y/N) t~, A. Dateinstalled 1o /17 / ~ ~ Tunksize I OOO,ff Foundation cleanout (Y, qq) Y Depression (Y/iq) DateofPumping .~/tb-/9~ Pumper Soil rating (g.p.d./ft2 or ftZPodnn) /~ ~"~ae~System type Gravel thickness below pipe 70" Total depth Y Monitoring Tube present(Y?N) y' Depression over field (Y/N) H Results (Pass/Fall) Pt~xj' For ~q bedrooms C. ABSORPTION FIELD DATA Date installed tc~ / 17 / Length E ~' Width Effective absorption area Date of adequacy test 3'7 Fluid depth in absorption field before test (in.); q~.5" .a Immediately after-7~ gal. water added (in.): ,,, d,s)'?;p~ Fluid depth qa }doe's(ins.) Minutes later: ~r- Absorption rate = ~ q.~O g.p.d. Peroxide treatment (past 12 months) (Y/N) IM If yes, give date b/. A D. LIP'I' STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: / Septic/holding tank on lot t 0.5- ' -ko c o Absorption field on lot I t3' ' Public sewer main t~. ~. Sewer/septic service line ';> g3-' Size in gallons "Pump on" level at* *Datum "Pump off' level at* ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation :~O~ Property line .gG" Absorption field Water main/service line ~> ~ 5' ~ Surface water/drainage ~ too ' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Surface water '~ to o Curtain drain Mo/, o F. ENGINEER'S CERTIFICATION lO0t Property Line PO' / Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots '> (oo ~ Waiver Fee $ Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.doc I-IAA Fee $ Date of Payment Receipt Number Engineer's Name Date l'~)/ ~ I certify that I have determined thru field inspections and review of Municipal rego;'db 'that th,~,'~'b'oye~ ~,stems are m conformance wtth MOA HAA guldehnes m effect on thts date. ,,:~'. - ;= ; ~ ':: 7; , Signature~,J,~ 7/-. '/~& ~ ..,.'~" . :'"':'!~, 2' : 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) ~' 7 ~'o E. Property owner ~ PATE¢ ,~ 3 ~A~l£ HOL 1'¢~ Mailing address 5~ME Day phone Lending agency ~K t~erdE MoRTgAGE' Day phone Mailing address Agent N,,4. ( R~/:~,~c~) Day phone. Address 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well ~'/ Community well Public water If communify 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 Pub!lc sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/95) 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 wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. NameofFirm FLA'Ffo¢ TEC~. ~l/C$. 3'4~ 13~5- Address Engineer's signature D ,H~,.SIGNATURE Approved for Phone Disapproved. Date Conditional approval for 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 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(Rev. 1/91) Back MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: Lo'f I., ~Lk' ~, Seal/fliT EST, ParcelI.D. A. Well Data Well type Log present (Y/N) '7' Total depth Sanitary seal (Y/N) Y If A, B, or C, attach ADEC letter. ADEC water system number Date completed 1~2Z Driller Cased to (~1 ' Casing height Wires properly protected (Y/N) Date of test Static water level -- Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot f Absorption field on lot I I0 Public sewer main >. Icc ' Sewer service line FROM WELL LOG AT INSPECTION '712o1, 1 ~' .g.p.m. >' 3 g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout ~./oo ~/oo Petroleum tank NoNE WATER SAMPLE RESULTS: Coliform O ca///o(,, CZ- Date of sample: 7 ~2o1~3 Nitrate ,',~e/~ Other bacteria ,,/ Collected by: F/~/i T'fOP T£c H B, SEPTIC/HOLDING TANK DATA Date installed lo/Il/~ Cleanouts (Y/N) ~' High water alarm (Y/N) N.A. Date of pumping 5/2~ )~ Tank size I0oo ¢4 ~ Compartments Foundation cleanout (Y/N) ¥ Depression (Y/N) Alarm tested (Y/N) N.A - Pumper ~oTo- N SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot Jo3 On adjacent lots> I co Foundation :~2 To property line ~-o ' Absorption field I ~ Water main/service line Surface water/drainage > lc)o' CONTINUED ON BACK PAGE 72-026 (3/93)* Front C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" Level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length 23t Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Ne 1.7 a ~q/~C- Soil rating (GPD/Ft2) Width 3 ~ Gravel thickness 70" 2~,'~ F¢ Cleanout present (Y/N) Y '7/2~/~3 Results (pass/fail) F4 <55 ~'o After test System type Total depth Depression overfield (Y/N) N for .~ Bedrooms .5/ KN 0 ~,~ If yes, give date N,~ - SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot lib' On adjacent lots To building foundation Ho' To existing or abandoned system on lot On adjacent lots Surface water .-~ 1oo Driveway, parking/vehicle storage area ¢ .5-0 Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines ir, the date of this inspection. Signature Engineer's Name Date 7 / CE-3589 ..' HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $. Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SiTE SEWER AND WATER FACILITY 264-4720 Application Date o// 07/ 3/ 6/so/ee GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lc-f' ! Location (address or directions) (b) Applicant Name~ ~ / ; Te~ephone~ Home ~ 4-.~-'7 ~:~7 Business Applicant Address 4-Z I [ ~:L~-~-¢~ !'~F ; ~¢r~ ~I6(.¢~ i C3:~ c~ ~)~¢. (c) Applicant is (check one): Lending institution []; Owner/builder,~; Buyer []; Other [] (explain); (d) Lending Institution Address Telephone (e) Real Estate Company and Agent Address (f) Telephone Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family,[~? Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well,~ Community [] Public [] Note: if community well system, must have written confirmation from the State Departmbnt of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite/~ Public [] Community [] Holding Tank [] Note: If corn munity 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 {11/841 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 r?, Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe. functional and adequate for the nu tuber 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 'MC 14-~ l't='c~,,A-r~-"¢~ ~--~'_ ~,,SG-~t,&~?~.'~Z~-~-~ Telephone ~ z~ -'~ Engineer's Seal Approved for .,~ bedrooms by Approved .,~ Disapproved Terms of Conditional ApP'[oval Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do 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 Well Classilication MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: L~'~" IfA, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Total Depth ~:> <:7 Cas.~,~ed to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Date Completed ~ ~ ~ ~ Depth of Grouting Separation Distances from Well: Yield 1'4 ~t,-;'~~- Pump Set At "~,c)'X"T'°'/vN Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot [ ~, O,, G To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments ; On Adjoining Lots ; On Adjoining Lots J _~-~::>~-~.~- To Nearest Public Sewer t,.A'c:>t..~,~' To Nearest Sewer Service Line on '~"-"~¢~:=,,,~ .¢,., l~'~%c-t4'c-~e ; Date B. SEPTIC/HOLDING TANK DATA Date Installed ~. ~;:)J j-~ /~37.8ize ~ (~)0 NO. of Compartments Standpipes (Y/N) "~ Air-tight Caps (Y/N) "1~'-'-'-'-'-'-'-'-~ Foundation Cleanout (Y/N) Depression over Tank (Y/N) ~,\O Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ~"~/¢4' ; for /^ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line ,~O To Water Main/Service Line Course Temporary Holding Tank Permit (Y/N) ~'~ To Building Foundation To Disposal Field ~.~'.--~ ~ ~¢'g~c~- ~.~'~'- To'Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72 026(11/84~ ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) (~-~(::~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ~ I C').. ,~ / To Building Foundation z~.-(~'.'~ Lot ~-~,~, t-~ ~'- To Water Mai n/~l~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ¢/~'~/~ Type of System Design Length of Field 'Z. ~ / Depth of Field I ~ ~ Gravel Bed Thickness '"7 Standpipes Present (Y/N) "'~ Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~--'~::~ "~-' To Cutbank (if present) D. LIFT STATION Date Installed ./~ Dimensions ~ize in Gall. cna //Manhole/Access (Y/N) 'Pump On' Level at /'/ / "Pump Off" Level at High Water Alarm Level at / Vent (Y/N) Tested for ~/ / ~____ Pumping Cycles dur. j.I;~ Adequacy Test. Meets MOA / Electrical Codes (Y/N, / ~'..~.~ ~~_-- Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that ~becked, v~rmed to all MOA and ~AA g uideli nes in effect on the date of this inspection. Signed ' ~ ~.~ ~ Date &/ Company ~.~ ~(~. MOA No. Receipt No. __ ~/4 Date of Payment ~-- ~ Amount: $ .~70 ~ Engineer's Seal Page 2 of 2 72-026 ¢1/84) APPLI~..~HT FILLS OUT UPPER HA[._~ ,.!ONLY . Property Q~wner p~/~ ~ Phone Buyer / Address ~ ~ ~ [ ~/L ~'~/ P ~'~ '~ ~;~ Zip Code Phone Realty Co. & A~nt Address Zip Code Type of Resi~nce Single Family ~ Multiple Family No. of Bedroo~ ~ Other Water Supply . ~ Individual ~_~ L~ ~ ~.. A~ACH WELL LOG. A W~l log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available). ~ Community ~ Public Utility Sewer Disposal When Connected to Public Utility: ~ Public Utility ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Date Inspector Time Time Inspector Field Notes: ~ ~4UNIC~PALITY OF gECEIVED ~} APPROVED BEDROOMS~ ) DISAPPROVED ) CONDITIONAL APPROVAL" ~ATE , ;~-IIT,E.~ Soils Rating Date Sewer Installed Well To Absorption Area Well to Tank Well Log Received Septic Tank Size