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Home My WebLink AboutT13N R1E SEC 4 E2E2NW4SW4NW4 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Name: ~T~I._ /'-1~ N ~,~C t_ Wastewater System: ~ New ~ Upgrade Address: ~O~c~._.~t~. ~ ~DeepTrench B Shallow Trench ~Bed QMound ~Other LEGAL DESCRIPTION Soil Rating: O ~ Total Depth from original grade: ' GPD/Sq. Ft. LOt:~ ~2~ ~'( BIock:o~ ~0 ~ 0'~ ~ O~' Subdiv~ion:~ Dedh to pipe bottom from original__g~:~ Ft. Gravel depth beneath pipe ~, Ft. Township: I Section: Fill added above original grade:~ Ft. ~f )7~ ~) IRange: &:(-~- j.~. Gravellength: Ft. WELL: ~(New B Upgrade Gravelwidth: ~ ~ Number of lines:5 Distancebetweenlin~: Pipe material: Classification (Private, A,B,C):~ fl~,k) ~'~ G; Total Depth:~ O ~_ Ft. Cased To:~_ 0 t Ft. T°tal absorpti°n area:~5~ SO. Fl. , Date installed: Yield: Pump Set at: Casing Height Above Ground: SEPARATION DISTANCES n Septic U Holding ~S.T.E.P. TO Septic Absorption Lift Holding ~ubtic/Prival Manufacturer: Capacityin gallons: SudaCewater {00'P ~'-F (~"t LIFT STATION Lot Size in gallons: Manufacturer: Foundation j~, j~j, ~, ~ "Pump on" level at: /~"~" I ~,''Pump off" level at: I High water alarm at: Remarks: BENCH MARK Location and Description: 04' ENGIN~8~S SEAL 17034 Eagle River Loop Road, No. 2~ Inspections performed by' ~=leRlver, Ala,ka995~ Dates' 1st ¢- IO'-q~ ,~,,,.,;~,'~ 79-013 (Rev, 9/91) MOA 25 sn~? ~o. SW970417 ~^s~ 2 oF 3 Plunicip, o,U~... _y_..o~ Ancho~qe DEPARTMENT OF HEALTHAND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.B. Box 196650 ~Ancho~cge, Atcsk~ 99519-6650~Tetephone~ 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT L~6a~ E~ ~, N~, S~, N~, 8SC. 4, TISN~ R1B P.LD. ~0. 050-771-0~ PERMIT NO SW970417 PAGE _ 3 OF . 3 ~unicip. o,H~ oF Anchor'o, oe DEPARTMENT OF HEALTHAND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P,B. Box 196650 OAnchoro. ge, Ataska 99519-6650 · Tetephome: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL El/2, E¼, NW¼, SW¼, NW¼, SEC. 4, T13N, R1E P.I.D. NO. 050--771--01 89.%/ FINAL ST1 95.0' 1500 GALLON S.T.E.P. TANK ST2 95.1' /?INAL INSULATION * MT1 =104.6' * MT2=105.1' xx.x GRADE DEEP TRENCH * USES TBM2 * MT1=93.8' ~ * MT2=93.8' · NO WATER FOUND * 87.8' B.O.H. GRADE A B C ;CO 19.0' 21.5' ST1 50.0' 25.0' ST2 36.5' 30.0' MH 58.0' 51.5' MT1 153.5' 153.5' MT2 191.0' 186.5' * CO1 =99.8' * C02=99.8' STAMP OWNER OF LAND ADDRESS by DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 BORE HOLE DATA PERMIT NUMBER ,¢ ¢ , Dateoflssue / ~ '~ ".f. TAX INDENTIFICATION NUMBER ' '~"<- ~ ¢ '' Is well located at approved permit location? [~ Yes [] No Method of Drilling: ~ air rotaw ~ cable tool Depth of well: ?~ ~ ~ Casing Type, /,,,',,',' Wall Thickness ~ ,.~,, inches Diameter ¢, inches, depth ~, , / feet Casing Stickup Above Ground: ' feet Static Water Level (from ground level): j; > ! feet Pumping level: feet after hrs. pumping gpm Recover Rate: ,..< ,. i gpm Method of Testing: Well Intake Opening Type: [~ Open End [] Open Hole ~1 Screened; Start feet Stopped__ feet [] Perforations Start .feet Stopped feet Grout Type: /!~ :..~ t, .... ,,, ' "¢/'' Volume ,,~,~ ()~.ii' '~ Depth: from ('., feet, to Pump Intake Depth: Pump Size. .hp Brand Name Well Disinfected Upon Completion? 0 Yes [~ No feet feet DEPTH From Driller's Name ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. MatSu Borough: Department of Environmental Conservation, ENGINEERINGSTUD1ES AND REPORTS WELL INSPECTION & FLOWTEST ROAD DESIGN SOIL TEST PERCOLATION TEST July 13, 1999 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICE 825 L Street PO Box 196650 Anchorage, Al(. 99519-6650 Reference: TI3N, R1E, Section 4, El/2, El/2 ,NWl/4, SWl/4, NWl/4 Dear Sir, As uoted, the placement of the primary trench was moved to allow the relocation of the onsite well with its required 100 foot radius. On June 11, 1998 a joint inspection was conducted by Robert Cowan and Dan Roth. The present site for the primary trench was approved at that time. It was noted that the soils remained constant throughout the length of trench and the movement of the trench would cause no adverse effects to this property or surrounding properties. Therefore, additional soils testing was not performed. IF you require any additional information, please contact us at 694-2979. Sincerely, Robert C. Cowan, P.E. RCC/skh 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA ~9577 ROBERT C. COWAN, P.E. CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 19076886??7 RISING SON ELECIRIC PAGE ~]1 Rising Son Electric P.O. Box 670687 Chugiak AK, 99567 (907) 688-6777 )uly 9, 'I999 5 & 5 Engineering 17034 Eagle p,iver Loop p`oa4 EagJe p,iver, AK 99577 To whom It May Concern; /'his letter is to conri'pm that Kevin Hombuck[e, owner of'p,isin9 Son Electric, EJectdca[ Administrator license number 1284., Specialty Contractor license number 25396 and Alaska Business license number 256608, has hooked up the li~ station at Misty Mountain ~cor C & T Construction. Should you have any questions about this job or you require additional information, please do not b,esitate to call me at the telephone number listed above. 1 hal~k you. chana M. I4ornbuckle Of rice Manager SEWER&WATER ~IN EXTENSIONS ROAD DESIGN SOILTEST ~ROBERTC. COWAN, RE. ROBERTA. SHAFER, RE. Date: CIVIL ENGINEERS (907) 894-2979 FAX (907) 694-1211 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 BECEIVED JUL 27 1998 Municipality Ot Anchorage Oept. Health & Human Services REFERENCE: The septic inspections for the referenced property were performed on ~-/0--~ and ~-/0-91 · Prior to submitting the On-site Wastewater Disposal System and/or~ell I~spection Report we are waiting for the ~ ~z~,z~:o be completed. If we may be of further service please contact us. Sincerely, ¥ Robert C. Cowan, P.E. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW970417 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:HONADEL TAL OWNER ADDRESS:1211 BUSINESS BLVD. EAGLE RIVER, AK 99577 DATE ISSUED:12/31/97 EXPIRATION DATE:12/31/98 PARCEL ID:05077101 LEGAL DESCRIPTION: T13N R1E SEC 4 E2E2NW4SW4NW4 LOT SIZE: 108900 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS {18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ~f)/ ×' >: ~ '~ DATE: DATE: ROBERT C. COWAN, P,E. SEWER&WATER MAIN EXTEhSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES AND AEPORTS WELL INSPECTION & FLOWTEST SiTE PLANS ROAD OESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS December 15, 1997 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 J2ONMEN'fAL SERVICES DIVI$1L 0lC 7199'/ RECEIVED REFERENCE: E 1/2, E 1/2, NW 1/4, SW 1/4, NW 1/4, Section 4, T13N, R1E Request you issue a permit to drill a well and install a septic system to serve the proposed four bedroom house on the referenced property. A test hole was excavated and percolation test performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation no groundwater was encountered and after seven day groundwater monitoring, the monitoring tube was found to be dry. This property has enough area for a fi~h]re septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. There are no points of contamination within the proposed well radius which can be seen on the attached site plan. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/jm Enclosure 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 1". = 80' SITE PLAN DESIGN SCALE 1'i = 40' DESIGN DETAIL -- SCALE ~ ~ ~ ~ ~ ~ mm ROBERT C. COWAN, P.E. SEWER&WATER INSPECTION ENGINEERING STUOIES AND REPORTS WELL INSPECTION & FLOWTEST ROADOESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 REFERENCE: E 1/2, E 1/2, NW 1/4, SW 1/4, NW 1/4, Sec. 4, T13N, R1E December 15, 1997 GENERAL: The scope of this project includes the installation of a 1250 gallon septic tank and a leachfield trench to serve the proposed four bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal peirnit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. 17034 NORTH EAGLE RIVER LOOP o SUITE 204 · EAGLE RIVER, ALASKA99577 Page Two E 1/2, E 1/2, NW 1/4, SW 1/4, NW 1/4, Sec. 4, T13N, R1E December 15, 1997 A foundation cleanout shall be installed one to four feet fi'om the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 fi. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt ban'ier must be installed between the final gravel layer and the native soil backfill. Ensure the silt ban'ier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipal approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Page Ttn'ee E 1/2, E 1/2, NW 1/4, SW 1/4, NW 1/4, Sec. 4, T13N, R1E December 15, 1997 Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). A pmxneable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. When sand is being used as a filter material, its gradation specifications must conform to cun'ent M.O.A. or D.E.C. requirements, which ever requirement applies. INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may he set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property. Page Four E 1/2, E 1/2, NW 1/4, SW 1/4, NW 1/4, Sec. 4, T13N, R1E December 15, 1997 Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressttrized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to can'y out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORME~ LEGAL DESCRIPTION: El./?-, ~ Y?-, ~ ~"/,-f ,-~J ~/~/,f~¢~r~-°wnship, Range, Section: 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 SLOPE WAS GROUND WATER ENCOUNTERED? S SITE PL~.N & DEPTH? p E Depth to Waler Afler Menitorino? OIL~ Date: l~,' I['q~ Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~ 0 (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~°'~ FT AND '~.~' FT COMMENTS , · CERTIFY THAT THIS TEST WAS PERFORMED IN PERFORMED BY: ~-703'! Ec~!: ~'¢a, ~p Roafi No. 20~' ~ ' ~ ACCORDANCE WITH AE~N&~¢~I~UIDELINES I" EFFECT ON THIS DATE. DATE; j ~/ / ~/ 'l 7 72'008 (Rev. 4/85) Ta~Honade[ 121 ~[0 Bus. BVld Ste6,246 Eagle River, AK June 3, 1998 RECEIVED Ms Donna Mears Health and Humane Services Municipality of Anchorage 835L Bt Suite~02 Anchorage, AK dUN 3 5 1998 Municipality of Anchorage Dept. Health & Human Services Dear Ms r~ rs, Per 'our phone discussion in reference to the proper procedures for the installation ~nd permitting of an owner installed septio systemj:lam submitting this letter of intent. Asthe owner of TI3N R1E 8ec4 permit flSWgT0417 I have installed a septic system per design parameters provided by 8&8 Engineeringv~The project was inspected for proper installation by 8&S Engineering on three occasions throughout it's course. Please call if any additional information is needed 689 7808. Sincerely, Tal Honadel MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Bo~ 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D.# ~5(~° -]ql CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete'legal description E. t[~, ~. ~/L ) ~LO~/~ ~ ~(~) ~/ ~ ; /~/'--/ ~ 5~CL~ }'~1.~'' ~-, I ~ Location (site address or directions) ~J IJc/g ~,'5-~ Cr~LLr~'O,,r, '~' Property owner Mailing address Lending agency Day phone Day phone Mailin. g address Agent Address 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. TYPE OF WASTEWATER DISPOSAL: 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-O25(Rev. 1/91) Front MOA#21 STATEMENT OF INSPECTION BY ENGINEER As cectified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approvar 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. Address Engineer's signature $ & $ ENGINEERING Name of Firm 17C~4 ~'-u;- ~,;ver L~op Aead- Eagle River, Alaska 99577 Phone Date ~/'//~/.~ ~' DHHS SIGNATURE I,.-'~ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Addition~ 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 DH HS 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. < -CEIVLU Municipality of Anchorage dUI 1 2 3999 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MUNICIPALITY OF ANCHO~ RoNMENTALSERVICE$ 825 L Street, Room 502° Anchorage, Alaska 99501° (9~'~t 343-4744 Health Authority Approval Checklist A. WELL DATA Well type ~(i ~/~L't~~ If A, B, or C, attach ADEC letter. ADEC water.system number Log present(~N) '"~ Date completed, (~ '-\~ -~i ~ Total depth ','~ ~'~ ~ Sanitary seal (~/N)y~'~ O/ Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform O Date of sample: --~-b," Cased to ~o~0 ~ FROM WELL LOG Casing height (above ground) Wires properly protected ,~N) g.p.m. AT INSPECTION g.p.m. Nitrate O. D~ Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~" ~)~':'~{ ~ Tanksize Foundation cleanou~l) Date of Pumping /g/'~ C. ABSORPTION FIELD DATA Depression (Y Pumper ~ z~- Number of Compartments ~-:;),, Cleanouts (~)N) j~ High water alarm J~/N) Date installed /~,- i;~.-'~i~~' Soilrating (g.p.d./ft~orfF/bdrm) O,~ System type T'D¢-? ,5 ? Length /.x. '.~ ~:~.~tb Width ,~-, ~ ~'(.~-i~ Gravel thickness below pipe (-¢~ l~.e--P Total depth J i -~-~'t~ Effective absorption area '~ -.~ns~'~gMonitoring Tube present((~.N) y~-~ Depression over field (¥J~'~ Date of adequacy test j~/~ Results (Pass/Fail) ~/r~ For ' /"}' bedrooms Fluid depth in absorption field before test (in.); ~//~ Fluid depth /~/)'} (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) ~,-~/~ Immediately after~/~ gal. water added (in.): Absorption rate = /-.3/.,~ g.p.d. If yes, give date /~/~ 72-026 (Rev. 3/96)* LIFT STATION Date installed Manhole/Access ¢~N) I/~.. ~' High water alarm level at* Cycles tested Size in gallons "Pump on" level at* //.~// *Datum "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot /~ ~ / "/- Public sewer main Sewer/septic service line ~.~ On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station /f¢~) / '~- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation / ¢ /Property line '~/-~/~ Absorption field / ~¢'~ / Water main/service line /~ ¢'~' Surface water/drainage /~/~)~/¢/' Wells on adjacent lots ¢/~Y? (~- SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /~ / Building foundation / tl~/// Water main/service line Surface water /~(~) ~'/~- Driveway, parking/vehicle storage area Curtain drain i~f>IO.r:_ ~¢(',~d~ Wells on adjacent lots /(?(') F. ENGINEER'S CERTIFICATION I cerIifj, in conformance with MOA HAA guidelines in effect on this date. Signature 5 & $ ENGINEERING Engineer's Name 17034 Eagle River Loop Road NO. 204 Eagle Rivey, Al~ka ~9577 Date HAA Fee $. ~ f-~") ' ~TJ Date of Payment '"),//'~,/~.: Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)*