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HomeMy WebLinkAboutT12N R3W SEC 33 LT 187T12N, R3W, Section 33 Lot 187 #018-282-15 =S3SOddnd S3I1I3Iln 881 W g .,4+��!►�r 0 8I38nd (INd kVAGVOd 803 a z .:4 � i'0Wef�o �i 1N3W3SV3 NnIIVAa3S38 ,E8 O_ •..�.p: ,•0 0 In AV 1 i 00 AV .. N00.08'00"W 280.00' 4) PQ m ID 00 • a: W O/ / D Oo fi 41 `tt `,• � � ` : J \8': v a F C rr�i'►�`� y -4 N oo p, „"d p d�0 04 y,� 0,04 m i . ° as ca p 0 m 0 4-) $4 ��" m®� yd 0 U °van '•;� d d m m °' m a a a m O b .o M coH � } N .d '0O ro a asp V a • i° .r ems v Ci yy Z OD 4 ON d 10 cq °� go"a'U LaJ ! n- ON W i , co ..� p w O la .-�. M 0 do � o �� oo44egqo4)� 04)0N q0 ir)GO° o aC v'mco (INm a0�a a� am H 'adm �a0ir,aa0w"'���� do F- 01) I Ld j x •-'p„'0 ��>,adm0 °mctF a m _ a „ ¢CL jLijy to�o5 W— Np,oU dd ZZ� 3 �* .d�0� "'W�p+0� �00 0 o¢� O `"A0o 4)14 q Ho q� �aai a W d=W G4Q a= ,QUO j¢� 3 d ,00.0s wQW n w O U') 0 SwF o cv J i i i I i I i S00°07'47"E 280,02' 981 H-19  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 Page t/ of v.'v,~v,ci.anchorage.ak.us (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: C-~.o ct~ ~ Lq ¢~ PlO Number: ©L~ - ~-~'2.--1%-- N .... ~, e. tQ~ ['~ [~-, Wastewater System: ~ New ~ Upgrade LEGAL DESCRIPTION / ~ ~. ~..~e 1~;~ // ' F,. Well: ~:~ '~"~n5 ~ New ~ Upgrade ~-, ~') Ft. {I ..... FL SEPARATION DISTANCES ~septic ~ Holding ~ 8.T.E.P. ~ Other: ~ Msnuf7 ..... ~ ~ ~:~ -~ Capac~ To Septic Absorption LiQ Holding Public/Private Tank Field Station Tank Sewer Line ~' . ~ O~ J~Z ~() Gal. '~ZO~ '5C~ [/ "Pumpon"levelat: "~le~t High~teralamat: Rem.~s: BENCH MARK Engine~r'~ [t~mp Depa~ment of Health and Human Services approval ~%~,. cE-9~9 ~.viow~,n~.pprowd by: ,~ ~ U. ~ D,t.: ~'m ~-~ O ,,:,~,~_ .~--"'.'."' ~,-~ 2 2 Permit No. SW990298 Page .of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 345-4744 On-Site Wastewater Disposal System and/or Well inspection Report Legal Description: T12N R5W SEC55 LOT 187 PID No.: 018-282-15 -BLM 166- 329.81' S89'59'47"E 35' pR~L-'cRVATION~,,. EASEMENT I -BLM 188- 250 GALLON TANK- ~ e~~ ~TH~)~ .... ~SECON~ARY~ I S FSTEM ,' ,,,,. f/ x 329.83' N90'O0'O ~ / GRND. PIPE % MARK A 8 ~ R A B B I T C ~/E E K R 0 A D - ELEV. ELEV, --~ ~ ~ ~ ~ ~-¢ C01 48.2' 32.1' 99.2' 97,3' C02 35,6' 51,3' 99.3' 97.5' TC01 36.1' 55.0' 99.5' TO02 40.1' 59.9' 99.5' C0,3 42.~' 60.5' 99.8' 96,4' C0,4 46.0' 60,8' 99.8' 96.4' C0.5 88,4' 59.4' ~99.5' 95.5' MT 65.9' 58.0' ~ 99.8' BENCH MARK tS GARAGE S~B ELEVATION 100' ASBUlLT SCALE: 1"=80' ~~ 95.4 TANK o o~o~( DRAIN ROCK °~ , GRND. PIPE MARK A 8 ELEV. ELEV, C01 48.2' 32.1' 99.2' 97,3' C02 35,6' 51,,3' 99.3' 97.5' TC01 36.1' 55.0' 99.5' TO02 40.1' 59.9' 99.5' C0,5 42.1' 60.5' 99.8' 96,4' C0,4 46.0' 60,8' 99.8' 96.4' C0.5 88,4' 59.4' 99.5' 95.5' MT 65.9' 58.0' 99.8' MUNICIPALITY OF ANCHORAGE Department of Hea#h 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 PERMIT Initial Date Issued: Aug 23, 1999 Expiration Date: Aug 22, 2000 Permit Number: SW990298 Legal Description: T12N R3W SEC 33 LT 187 Design Engineer: 0088 Anderson Construction & Eng'g Owner Name: Jeff Holt Owner Address: PO BOX 2821 DEMING, NM 88031-2821 Parcel ID: 018-282-15 Site Address: Lot Size: 108900 SQ, FT. Total Bedrooms: 4 Permit 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 ( t8AAC72 ) 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. Date: Date: Michael N. Anderson, P.E. 14250 GoldenviewDr. Anchorage, Alaska 99516 Ph 345-3377 Fax 345-1391 Date August 20, 1999 Municipality of Anchorage Department of Health and Human Services On-site Services P.O. Box 196650 Anchorage, Alaska 99519-6650 R}'CEI i/ED AUG 20 1999 Mu/~ici Dali~ .... 'Tealth ~'1~~, AnChoran~ ~erwoe Subject: BLM Lot 187 To Whom it may concern: This a request for a new four bedroom septic system permit on the above lot. The lot size is 2.5 acres with an existing well as the plan shows. The existing well has no records but the owner did have the well tested for flow, depth, and volume and I will include that data in the asbuilt. The soils were gray sandy gravel with no water observed after the seven day monitoring period. The perc rate was 1 minute per inch which translates into a trench length of 42 feet with 6 feet affective depth. No surface water was found and the lot slopes away to the south. The system will be more than 50 feet away from the 25% slope to the north. This new system will not prevent future wastewater and well development on the adjoining lots. The existing systems on the surrounding lots appear to be performing adequately. Please feel free to call with any questions concerning this system at 345-3377. Michael N. Anderson, P.E. I -BLM 168- r-TEST HOLE (TH) Ii PROPOSED55' PRESERVATION EASEMENT ¢.---./30' RADIUS 4 BEDROOM RESIDENCE--x. /" ', : -BLM 186- I ~ / "', ~'~) EXISTI~O' ~ ~-- ,o~F_ ~O~l°: ~ i WELL RADttJ'S~.% ~../'~.~;. ,=,.k. I L. 0: ~ I [ -BLM 188- * 329.85' Ngo'oo'oo"E / _.l. I ~ ~ - R A B B I T C R E E K// R O A D - ~MOUND OVER DESIGN CRITERIA: ~GRADE 4 BDRM = 600 GPD SOILS = 1.2 GPD/SQ, ~, -~' OR ,~l % ~FILTER FABRIC 600/1.2 = 500 SQ. ~. REQ'D ~ TRENCH: ~ 9.0' DEEP 6' EFFECTIVE OM 2.0' WIDE ~20'~RAIN ROCK ~2' LONG SEPTIC DESIGN PREPARED FOR dEFF HOLT ~4~., . ..y~ LOT 187 ...... MICHAEL N. ANDERSON, P.E. 14250 N. GOLDENVIEW DRIVE (907) 345-3377 / FAX (907) 545-1391 SCALE: 1"=60' JULY 16, 1999 PRESERVATION EASEMENT /" ;ECONDARY / SYSTEM DOUBLE I250 GALLONG TANK SEPTIC DESIGN PREPARED FOR JEFF HOLT LOT 187 BLM SUBDIVISION PREPARED BY MICHAEL N, ANDERSON. P.E. 14250 N. GOLDENVIEW DRIVE (907) 545-5577 / FAX (907) 345-1391 SCALE: 1"=,30' WELL RADIUS ,~.~. · A .',~ ~% ~ICI'IAEL N, ANDERSON JULY 16, 1999 ~A~~ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOI~ATION TEST PERFORMED FOR:~ e ¢"~'J~ LEGAL DESCRtPTION: ~b'~ 2 3 4 5 6 7 8 9- 10- 11 13- 14- 15- 16- 17- Township, Range, Section: SLOPE 19- 20- WAS GROUND WATER ENCOUNTERED? IF YES, AT WHA'r DEPTH? /7~?E Oep~ lo Water Afl.er, Monilonng? ~,f C~ ~Oate~ SITE PLAN I N Gross Net Oel3th to Net Reading Date Time Time Water Drol3 ~',,~ ;., ~e~-~f ~;~" / PERCOLATION RATE ~/ (m~nutes/~ncr~) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND ~ FT .~OMMENTS ~U, ¢ ~ ,I PERFORMED BY: ~'~J /~ I CERTIFY THAT,~HIS TEST WAS PE'RFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/851 MUNICIPALITY OF ANCHORAGE Efwfmpqnfou!Tfswjdft!Efqbsunfou Qipof;!!):18*454.8:15 Po.Tjuf!Xbufs!'!Xbtufxbufs!Tfdujpo !!!!!Gby;!!):18*454.8::8 Dfsujgjdbuf!pg!Po.Tjuf!Tztufnt!Bqqspwbm PTD372366 603803138 Parcel ID 129!.393.26 Expiration Date: Legal description U23O!S4X!TFD!44!MU!298 Site address 26235!MPD!MPNBO!MO Current property owner(s) !IPMU!KFGG!'!DPSSJOF Y5 The On-site system(s) is/are approved for bedrooms Conditional approval forbedrooms, with the following stipulations: Comments or conditions: Op!dpnnfout tffubolbhfbewjtpsz Curtis Townsend 803403137 By:Original Certificate Date: This Certificate of On-Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Service Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's submittal. ATTACHMENTS: !!!!!!Y COSA ChecklistWell Flow Advisory Absorption Field AdvisoryNitrate Advisory Tank Age Advisory Arsenic Advisory Other MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 COSA Application_Apr2025.doc Certificate of On-Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. Complete legal description Location (site address) Current property owner(s) Day phone 2. ON-SITE SYSTEMS SIZED FOR BEDROOMS 3. TYPE OF WATER SUPPLY: Private Well serving # dwelling units Other Non-public well as regulated by MOA Water Storage Community Well or Public 4. TYPE OF WASTEWATER DISPOSAL: Private Septic Private Septic serving 2 dwelling units Holding Tank Community Septic or Public Sewer 5. SEPTIC TANK: Steel Plastic Concrete Fiberglass Age ______ - See advisory if steel or fiberglass older than 20 years 6. ABSORPTION FIELD: AWWTS Bed Deep Trench Wide Trench Seepage Pit Waiver request for: Distance: Expedited review requested: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ Waiver Fee $ Date of Payment Date of Payment COSA # Waiver # COSA Checklist.docx COSA Checklist Legal Description: T12N R3W SEC 33 LOT 187 Parcel ID: 018-282-15 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Unknown Total depth *136 ft Cased to *136 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 5/28/26 Static water level at beginning of test Artesian Plug Well production at time of test 3+ gpm Water storage tank volume None gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 0.647 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date 5/28/26 Comments *Per MOA/COSA Docs B. TANK DATA Measured operating fluid level in septic tank 48" Date of pumping 5/27/26 Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. DISPOSAL FIELD DATA Which system tested (date installed) 9/21/1999 ALL standpipes present per record drawing Total measured depth from grade 10.7 ft (max) Measured depth to pipe invert from grade 3.8 ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes (MT) go to bottom of effective (ED). If not, state depth into effective 6.8’ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date 5/28/26 Results Pass Fluid depth prior to test 41 in Water added 600 gal New fluid depth 54 in Elapsed time 1440 min Final fluid depth 40 in Absorption rate 600 gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) 84 in (MOA 7’ ED) Effective depth (ED) used 42 in (Missing ED + Final Fluid Depth) Effective depth remaining 42 in Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots & appears approximately 2 inches of ED is missing – not measurable. Pre-tank clean out was buried and not found. COSA Checklist.docx E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Disposal Field on Lot > 100’ Yes if No ft Neighboring Disposal Fields > 100’ Yes if No ft Sewer Line/Main > 100’ Yes if No ft Sewer Manhole/Cleanout > 100’ Yes if No ft Sewer Service/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required) Tank to Foundation > 10’ Yes if No ft Field to Foundation > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main/Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 07/14/2026 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 or NO 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 & 07/14/26 MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907-343-7904 On-Site Water and Wastewater Section Fax: 343-7997 www.muni.org/onsite Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org Septic Tank Advisory Certificate of On-Site Systems Approval # OSC261255 Subdivision: T12N R3W SEC 33 Block: , Lot: 187 The septic tank for this property is 27 years old. The average life of an asphalt coated steel septic tank is 20 years. Typical replacement costs are $15,000 or more, not including engineering, surveying, MOA permitting fees or site restoration. Steel septic tanks utilizing "Coal Tar Pitch" coatings are subject to corrosion as the steel reacts to water and rusts. These tanks have a finite lifespan buried in the ground. These tanks can become structurally compromised and pose a health risk. They could collapse and/or leak untreated wastewater directly into groundwater. In the interest of protecting public health and the environment, the Municipality of Anchorage Development Services Department has issued Policy W.05 Standard of Care Regarding the Inspection of Steel Septic Tanks when Performing COSA Inspection. Please request a copy of this policy from the Department if interested. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. Municipality °fAnchorage Department of Health and Human Services Division of Environmental Servicesr: - On-Site Services Section 825 "L" Street Room 502 P,O. Box 196650 Anchorage, AK 99519-6650 www.ci.ancho rage.ak.us (907) 343-4.744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL' FOR A SINGLE FAMILY DWELLING Parcel I.D:~', ~ '- 1; GENERAL'INFORMATION Complete Ibgal description · ' Location (site address or directions) . Current Properti,.:0wr{er(s) ~--~ Mailing address __ Expiration Date: Lending agency Mailing address Day phone Real Estate Agent Mailing Address DaY phone Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 3. TypE oF WATER SUPPLY: Individual Well · Individual Water Storage · Community Class Public Water System TYPE OF WASTEWATER DISPOSAL: ¢~' IndividuAl on:site [] · Individual Holding Tank Well [] Community On-site b~ public Sewer The Municipality of An~h0rage Department of'Health and Human Services (DHHsi i~sUes C~difi~ates of Health AuthorityApproval (HAA) based only upon th~ representations given in para'CaPI~ 5 by an ir~8~Pendent professional 8ivil engineer: registered in the State of Alaska. Certificates of Health Authority Approval are required for the '{~:ansfer of title (except between spouses) on propedies 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 propedies 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)* = STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed here{o andas of the validation date shown below, ~ 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 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. Name of Firm Address Engineer's Printed Name DHHS SIGNATURE' ' ' Approved for LC. bedrooms. Disapproved. Conditional approval for __ Phone Date "'~/~ ~/~/'¢~.¢~ ¢~ ~,.. CE~ 9409 . .~ bedrooms, with the following stipulations. --~.., . .Addltional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements · Supplemental Engineer's Report ,' "i Other ...... - ..... " Expiration Date: ~ "~ ~'- 0 0 Original Certificate Date: Reissue Date: 75-o25{Rev. 01/00)' Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room . P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 Legal Description: HEALTH AUTHORITY APPROVAL CHECKLIST Parcel I.D.: A. WELL DATA Well type ~¥-'~,0,~- ~ If A, B, or C provide PWSID # Date completed ~,~,~,~¢t Sanitary seal Total depth ~ 'b(,, ft Cased to I ~C¢ ft FROM WELL LOG Date of test /., ~o~:,~ 6(*'°~ Static water level ~ ft Well production ,.,.-/'/' g.p.m WATER SAMPLE RESULTS: Coliform ~__colonies/1 O0 mi Nitrate ~,~o, '?'~¢1 mg/I / Date of sample: ?;/~/o(_) Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material ~-5 (- ~-~ Date installed ¢( /'z- //-l "f Tanksize ~'2-5'(2 gal Cleanouts ~/ Foundation cleanout 'Y' Date of pumping /',.~ c Well Log Wires properly protected Casing height (above ground) /¢~/' in. AT INSPECTION t ~ ft g.p.m Other bacteria / colonies/100 mi Number of Compartments '2. Depression over tank /~ High water alarm Pumper C. ABSORPTION FIELD DATA Date installed ':t/? I/R ~"t Soil rating (g.p.d./ft2 or ft2/bdrm) It ~ System type I?ength ¢~/~ ft Width ~ ft Gravel below pipe '~', c, ft Total depth /¢',~ ft Effective absorption area ~,¢~ ft2 Monitoring tube Y' Depression over field Date of adequacy test -~- Results (Pass/Fail) ~ For "y/' bedrooms Fluid depth in absorption field before test -~-~- in Water added ~¢gal. New depth .~-~'in. Elapsed Time: ~ min Final fluid depth. ~ in Absorption rate >= ¢--~g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) ¢,(~-), .If yes, give date __ 72-026 (Rev. 01/00)* D. LIFT STATION Date installed "Pump on" level at in .L'~ump-ofl* eq~vvel at __ D~!u~ ~ Cycles tested E. SEPARATION DISTANCES Size in gallons ~~----ManlTol~A~s in High water alarm level at SEPARATION DISTANCES FROM WELL ON LOT TO: Septictank/lift station on lot / Absorption field on lot / O Public sewer main ~ Sewer /septic service line {c~ in Meets alarm & circuit requirements On adjacent lots / o(a r /_ On adjacent lots / ¢:,~ '../- Public sewer manhole/cleanout ~/// Holding tank '////¢, SEPARATION DISTANCES FROM SEPTIC/FIOL-DI~'G TANK ON LOT TO: Property line ~"o~ Water service line ~'}'o Wells on adjacent lots Building foundation Water main Drainage ¢¢/¢o ¢.¢ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line z~ c .-/~ Water Service line Curtain drain h/ Building foundation '~ Surface water f 0 (~ Wells on adjacent lots F. COMMENTS Absorption field ~-/' O t / Surface water / ¢o //- Water main ~'/.-¢' Driveway, parking/vehicle storage 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 ~, t-~,~¢ l ~.[ ,'¢,~ ~1 ~.~ 4 ~,q Date '~/X~ ~/,/'~, o HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 0~/00)* Well NO, Measuring equipment AQUIFER TEST DATA Page .... Tlme Data Water Le,,~l Data Discharge Data Pump on: Date ~ Time ~ (to) I~/ How Q measured ~ e.'~ ~' Comments on ~c~ers Pump elf: Date ~13 Time ~(~) Static water level D e plh o~'p"~air lin e ~ Durationofaquifertest: Measutingpeint hal,u, TOP. Previeus~'~ing?Yes No ,~ aifectingtestaata Pumping '~ k,r-~ Recede y '"-- Eleval[on of measuring point Duration "'-'-' ~ ~ ~ · ~ ~ Water ~/~ ,,,~ ~' I F~¢ 57~ 170~7 ~:~ 77' ~' ,,;,~ I ,q 3~ i I I J [ I ! I i Address County ,~C k State /~ lq