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Home My WebLink AboutTHUNDERBIRD HEIGHTS #3A BLK 7 LT 4Onsite File Thunderbird HI*!ghts #3A Lot 4 PID# 051-581- 11 LNO from MOA ROW for the trench in the Utility Easement required prior to COSA . 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 On -Site Wastewater Disposal System Permit Permit Number: OSP241304 Work Type: SepticTank Upgrade Tax Code Number: 05158111000 Effective Date: Expiration Date Site Legal Address: THUNDERBIRD HEIGHTS #3A BLK 7 LT 4 G:1865 Site Mailing Address: 24412 THUNDERBIRD DR, Chugiak Owner: JOHANSON GREGORY L Design Engineer: FORGE ENGINEERING This permit is for the construction of: 9/23/2024 9/23/2025 Lot Size in Sq Ft: 27530 Total Bedrooms: 4 ❑ Disposal Field Q 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. Open and Closed on e sable -day -,-ate b. ,Covered, sealed, and heated prevent freez1bg-, Special Provisions: 1. The beginning of the field is to be located prior to construction and a cleanout added. 2. A LNO from MOA ROW for the field in the Utility Easement is to be issued prior to COSA approval. Issued By: Lz= Date: c/ Date: 2�� -�— MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907 -'i43-7904 Development Services Division Fax: 907-343-7997 On-Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-581-11 Property owner(s) Gregory Johanson Day phone (907) 862-1233 Mailing address PO Box 671854, Chugialk, AK 99567 Site address 24412 Thunderbird Drive, Chugialk, AK 99567 Legal description (Sub'd., Block & Lot) Thunderbird Heights #3A Block 7 Lot 4 Legal description (Township, Range & Section) Lot Size 27,530 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Single Family (SF) Initial D Absorption Field (w/wo ADU) Septic Tank Upgrade EX-1 Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy EJ (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: 122_ � Waiver Fees: Date of Payment: zal-'_C4 Date of Payment: Receipt Number: t2476 Receipt Number: Permit No. 5P 2 � 1-30Li Waiver No. Permit App_::-: - , September 3, 2024 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Thunderbird Heights #3A Block 7 Lot 4- 24412 Thunderbird Drive Septic Tank Replacement Dear On-Site Services Engineer: The owner of the above lot has a septic tank that has reached its end of useful life, so we are submitting this permit application for its replacement. The attached site plan identifies the location of the home as well as the septic location. Since this property and all adjacent lots are on a public water system, no conflicts exist between this proposed system and any other wells or septic system, whether on this lot or adjacent lots. We are replacing the septic tank with the same size designed for 4 bedrooms. The new septic tank will be a minimum of 100’ from all wells and surface water. Please refer to the attached plan for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241304, Deb Wockenfuss, 09/23/24 Benjamin Schiller CE 12592REGISTEREDPROFESSION A L E N GINEER 1"=30' DECOMMISSION EX. 1250 GAL SEPTIC TANK CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND THUNDERBIRD HEIGHTS #3A BLOCK 7, LOT 4 FEET 0 30 60 NOTE: THIS PROPERTY AND ALL SURROUNDING LOTS ARE ON A COMMUNITY WATER SYSTEM. THU N D E R B I R D D R I V E 4-BDRM HOME SEPTIC PLAN 8/30/24 15' UTILITY E A S E M E N T APPROX LOCATION OF 37' ABSORPTION TRENCH FCO NEW 2CO NEW 1250 GAL SEPTIC TANK FIND AND REPAIR/REPLACE CLEANOUT WATER LINE CONNECTION AND APPROX WATER LINE ROUTING TO CRAWLSPACE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241304, Deb Wockenfuss, 09/23/24 PLOT PLAN ___ AS BUILT _X_ SCALE _ 1 50__ GRID _ NW 1865_ Project No. J24 -1561A1 P.O. Box 210005 Lang & Associates i n c Anchorage, Alaska 99521-0005 (907) 522-6476 Professional Land Surveyors jonathan®langsurvey.com o ken®langsurvey.com I hereby certify that I have surveyed the following described property: LOT 4, BLOCK 7, THUNDERBIRD HEIGHTS ADD. No. 3A (Plat No. 81-264) Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the Zb Day of _CS 6 0 ;Tat Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. JONAT A C. LANG o� 04 �Fo LS -9944 44�OR0FESSIONN- �AQ� State of Alaska AECC963 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 ~' DISTANCE T0: I Wel~¢ ~ I A~r~°~area Dwollin~ ~ ~ Liq, c~t~llons IF HOME'DE: Inside ,ength Width Liquid depth No. of line i bo.,~4,.~ [ rot3,~f, lines Tron~¢th inches Distanc~ I~nes ~ ~ Top of til2~to finish grade¢ Material beneath tile ~ inches ;;;~eCsorption area OTHER (Rev. 3/78) PERMIT NO. ( BPPLICANT LOCBTION LEGAL ,... Mien l C i ~AL I T"'¢ OF R r413 ~-~!R RGE DEPRRTMENT HEALTH AND ENVIRONMENTAL , ~OTEC:TION 825 'L' STREET.. ANCHORAGE, AK. 9950& 264'4720 : O~4--SITE SE~IER PER~dIT 82079~ ) SKBGGS CONST PO BOX D 99567 L4 B? THUNDERBIRD HTS LOT =,I~E g99999 =,QJARE FEET TYF'E OF _,OIL RBSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS SOIL RATING (SQ FT/BR)= 110 THE REb]UIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: ' ' DEPTH= 1~---"~ LE~'-,~GTH= ~ GRAVEL [:~EPTH= 6 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF B 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 END THE BOTTOM OF THE EXCRVRTION (IN FEET). /2.....,f'-¢ REG~UIRE[) SEPTIC: TRt4I( SIZE= ~ ~]RbbOt-~S 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. T~40 .:: 2 ;-~ I i'4SPECT I (:~NS ARE REQI I I RE[::. -BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND RPF'ROVRL BY THIS DEPARTMENT WILL BE 'SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL 8ND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR B 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 R COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS 8ND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F'ERMIT EXPIRES [)ECEMBER ~I .. I ~82 I CERTIFY THAT 1: I BM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL I~BLL THE SYSTEM IN ACCORDANCE WITH THE COBE~. ~: I U~IBERS~'I~ THRT THE ON-SITE SEWER S~STEM MflY" ~'~.EQUIRE ENLARGEMENT IF THE RESIDENCE /S/REMODEL¢)TgilNCLUDE MO~,E~' THAN ~ BEDROOMS. ~ SIGNED: ............. iSSUED BY~~--~ O & E ENG,NEERING & DEVELO~ ,VlENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster Earl Ellis 694-2774 SOIL, LOG 688-2280 Performed for: Name: -~;;>~:~J~-"/ /~ ~/<:~'~'4~ ~'>,~?'~,~-~'c:~f>~,/ Tel. No. ~-~'~ '~'~ / Mailing Address: Legal Description: Depth (feet) Soil Characteristics --~ PLOT PLAN '12 __ 13__ PERC. TEST 14~ 15__ 16__ Ground Water Encountered: Yes Proposed Installation: Seepage Pit Comments: No/~ If yes, what depth. Drain Field ~ ,~ APPLIC i~IT FILLS OUT UPPER HAL/mr'ONLY P~operty Owner Phone T & D Construction Mailing Address BOX 2524, Palmer, Ak Zip Code 99645 745-2731 Buyer T & D Construction ,:996'45~:~:;-: 745~2731 Address BOX 2524. Palmer Ak Zip Code 99645 745-2731 Phone Lending Institution A.las[ca. Pacific Bank 99501 276-3110 P. O. Box 420 Zip Code Address Phone Realty Co. & Agent Totem Realty/William J. Schlegel Ad~ress 724 Eo 15th Avenue Zip Code 99501 272-0571 Legal Description Lot 4 Block 7 Thunderbird Heights Street Locatic~ Thunderbird Dr. Type o~ Residence Single Family :~ Multiple Family No. of Bedrooms 4 [~ Other Water Supply ~ Individual ATTACH WELL LOG. A weg Icg is required for all wells drilled since June 19Z5. For wells drilled prior to that date, give well depth (attach Icg if available). ~ Community Public Utility Sewer Disposal ~ Individual Year Individual Installed: !982 · (~ Public Utility When Connected to Public Utility: [~ Holding Tank NOTE: THE INSPECTION PEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Insp~tor · Insp~tor Insp~tor Insp~tor Field Notes: ~UNICIPALI~ OF ANCHORAGE S E P g ~'~/982 gECE! E 72-O23{~J~) , / / ? ? I EASEMENTS OF RECORD, OTHER THAN · THOSE SHOHN ON THE RECORDED PLAT, ARE NOT SHOWN HEREON. . ~ ~ ~-~, ,.~ ,,~ ,~ .~ %.? LOT SURVEY CERTIFICATION LOT ~ BLOCK .7. THUNr)ERRIRD HEIaH~S, A~)q.'"'3A(g1-264). ANCHORAGE- R~CORDING DISTRICT pREPARED BY; DOW_ NG '8,:-ASSOCIATES ' : I.Residence ' '804 EAsT '15~h Av.e,'Sui~e 2. ' / ' ~ ' ANCHORAGE1 ALASKA 99501 LEGEN;D: "v~r~ ~'/~,p,,,'~,cz- REVISIONS F,B. I GRID: DATE BY ?~/A' ADEQUACY TEST LOCATION: ~"¢;~' '~"~"~'~- 7/ ~-~,.,'¢,~'z,~,/Z¢/'//4,,-~ ¢'~./-,z NO. of BEDROOMS' DATE' ~/~'t//~'0 TESTED BY; ~- TANK SIZE, RESULTS PASS .~'x FAIL__ LOAD: 150 GALLONS X ~ BEDROOMS SEPTIC TANK LIQUID LEVEL METER CUMULATIVE FLOW SEPTIC TANK /~ S.A.S. /~ COMMENTS TIME READING VOLUME RATE· LIQUID LEVEr SEPTIC TANK LEVEL S.A,S. /.' os" 9 7~o o ~ o ~ la ;5~~ .¢/¢.~. 0 Z.'a~ IO Z ~l ~1 7,¢ o i~'-~¢ o 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. ci.ancho rage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. Expiration Date: GENERAL INFORMATION Complete legal description ~n7-4/' ,J~¢.~ ~,' ~/0~/~0 Location (site address or directions) ~/~ ~L/~/~ Mailing address ~(~ Lending agency Mailing address Day phone Real Estate Agent Day phone Mailing Address ,, Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked uP bY: '/'~J ~- ~'~,,?'-.~ /1 f~ //o Ioo NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] Individual Holding Tank [] Community On-site [] Public Sewer The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (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. 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. I further verity 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. :5 & 5 ~.~ ,.~,~ .~: ..RI ,~O tTO.~,~ .:;~g,e ~i',,~r Loop Road No. 2~ ~ q ~ - ~C~ ~ 0 Name of Firm =~,,~ ...... ~ m. ~l.,!,~ - 99577 Phone Address Engineer's Printed Name DHHS SIGNATURE / Approved for L/. bedrooms. Disapproved. Conditional approval for Date 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: ~2 _ ~ . .~O I Original Certificate Date: ~ - ~ ~ ~ c Reissue Date: 75 025 tRey 01 00,' ·.. hora e Environmental Services uivis~on" c~.~ ~ Mun,c,pal,ty of Anc . DEPARTMENT OF HEALTH & H~A~ , 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: ~-d,,' ~(~- '~)' 'Z~-/''~#'~--~ ~'1~/7~' ~ Parcel I.D.: 0~? A. WELL DATA Well type Log present.(Y/N) Total depth Sanitary seal (h~/N) Date of test Static water level Well production Date of sample: IfA, B, or C, attach ADEC letter. ADEC water system number Date completed ~ Cased to Casing heig Wires pro~j~protected (Y/N) FROM WELL LOG~AT INSPECTION g.p.m. Nitrate Other bacteria Collected by: g.p.m. B. SEPTIC/HOLDING TANK DATA Date installed ~ Tank Foundation,cleanoq~) size 1 Z~")"~ Number of Compadments ~' Cleanouts~r/N) ~'~' Depression, (Y~_~ /%-/4~) High water alarm (Y/N) /~f'//~- Date of Pumping ~;/'3~ / 0 o Pumper "~/~ d; C. ABSORPTION FIELD DATA Date installed_ ¢//¢/~ ~- So; rating ~ Length ~ Width 5 Gravel t~ickness below pipe' ~ Total depth Fluid depth in absorption field before test (in.); ~ Immediately affer¢~al, water added (in.): Fluid depth (ins) Minutes later: ~ Absorption rate = _g.p.d. PeroxMe treatment (past 12 months) (Y/N) ~D~~ If yes, give date ~ 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) / High water alarm level at* ~.~, / ~' Cycles tested ~~ Size in gallons "Pump on" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot On adjacent lots Absorption field on lot ~ Public sewer main ~~sewer manhole/cleanout Sewer/septic service line -/ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~'-/'/-- ~" /''~ Property line Absorption field Water main/service line Z~~'''- ¢/'~Surface water/drainage /¢¢~ /¢- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: (' (~/,.-/- Building foundation /~) Property line Surface water /~)~) Curtain drain F. ENGINEER'S CERTIFICATION Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots ~///4 /o Z / HAA Fee $_ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Location (address or directions) (b) Property owner '~A-,,d ~)E:o,,~,,~¢~-,-- Telephone: (home) (~' 35'7..E- Business ~%z-~z.? Mailing Address /~ (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here~, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family ~ Number of bedrooms 3. WATER SUPPLY Individual Well [] Community.~(. Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site.~, 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. 72-025 (Rev. 7/88) Page 1 of 2 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 th is 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. NameofFirm --~N~o ~ .~A~'-~'T'O,,j [~,,~, Telephone Address /-/LL 7~ /~.,<. /~,~ ~,,¢¢¢,~'/,,¢/~ / Engineer's Seal Approved for b y ,~-,,~"~'~'"~' ~¢ ~ Approved Y Disapproved,z -- Conditional Terms of Conditional Approval I The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph $ 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. 7/88) 8ack Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: /,ct WELL DATA ,/~¢;4/~ Well Classification ~ ~ ~ -- ~-~ ~ ~,Z,,./--,¢, :~ ¢-~ If A, B, C, D.E.C. Approved (Y/N) Date Completed Depth of Grouting Well Log Present (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: ' To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments Yield Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ,/ ; Date B. SEPTIC/HOLDING TANK DATA Date Installed ~//9//,¢Z- Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) Air-tight Caps (Y/N) No. of Compartments ~' Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANW. 71'o Water-Supply Well To Property Line To Water Main/Service Line 3o~ /~,¢- To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation /Z To Disposal Field 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~,,//~,/~'Z- Width of Field :~c-" Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation / Lot To Water Main/Service Line /o ,-,-- To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field -~ '~ Depth of Field /¢ / Gravel Bed Thickness ? 2- '/ Statndpipes Present (Y/N) Date of Last Adequacy Test Y To Property Line ,'/~ To Existing or Abandoned System on ; On Adjoining Lots /'~ ¢' To Cutback (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA inspection. Signed company Date UOA No. effect on the date of this Engineer's Seal Receipt No. Date of Payment Amount: $ 72-028 (Re~. 7/88) Back Receipt No Waiver Fee: $ Date of Payment Page 2 of 2