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HomeMy WebLinkAboutPARADISE VALLEY BLK 4 LT 35Paradise Valley Lot 35 Block 4 #020-411-01 Municipality of Anchorage Page I of ~'~ 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 Permit Number: ,~/~'~.ct O-,¢1 '7 RID Number: Name: ~ I',' ~,.~. ~ ~ ~ ¢¢~ ~ ~. ~'~ Wastewater System: ~New U Upgrade Address: P.O. ~.,.~ ~11'~,~- ABSORPTION FIELD Phone: No. of B~drooms: ~ Deep Trench ~hallow Trench B Bed B Mound Q Other LEGAL DESCRIPTI ON Soil Rating: Total Depth from original grade: ,~, Subdlv~ion: }epth to pipe bosom from original grade: Gravel depth beneath pipe - " 0,_5 ~t. Township: [Range: I Section: (~ Fill added above original grade: Gravel length: Number of lines: ~ Distance be~een I~nes: WELL; ~ New C Upgrade era~e~ width: ~ Ft. II ~ Ft. Classification (Private, A,B,C): Total Depth: Cased TO: Total absorption area: Pipe material: Date Drilled: Static Water Level: Installer: Date installed: Yield: ~ GPM I ~O, rCtM Pump S~at: Ft. [Casing HeightAb0ve Ground:¢~ Ft. TANK SEPARATION DISTANCES ~ s~tic u Hot~i.g ~ S.T.E.P. TO Septic Absorption Lift Holding ~ublic/Priva1¢Manufacturer: Capacity in gallons: Sudace Water I¢0 f I~ * ~ + LIFT STATION Line ~ ~ i ~ ~ ~ D~a~. H4:/~ ¢I t~ ¢ ~ I Remarks: BENCH MARK I ~ f~, E~ NEEB'8 SEAL Inspections pedormed by: '*~%, Dates: 1st 2nd q Depadment of Health and Human Se~ices approval . vi ed ¢¢ ' ////~/ 72-013 (Rev. 9/91) MOA 25 £5 0 36 / £EPLACE&{~T TRENCHES / 35 Well 50 75 lO0 SCALE: I' = 50 FL TOBBEN SPURI(LAND P.E. 205 W 15TN. AVENUE ANCH. AK, 99501 (907) 279-,5916 x, EN SPURKLAND PARADISE VALLEY BLOCK 4 6217 ROMANIA DRIVE MICHELSOHN AND DAUGHTER LOT 35 !0 /34 SEPTIC SYSTEM AS BUILT DATE: OCT. 12, 1999 SHEEk 2/5 GRID.. 5558 PE£NI? # 2L,/990£/7 PiP II 0~.0 411-01 PDVO435~DI./6 ~ 4-INCH INSULATION STANDARD DRAIN FIELD 1-1/4 PVC P/ITH 1/8" HOLES AT 50" TOTAL LENGTH 50 FT TOTAL DEPTH 2 FT TOTAL ROCK DEPTH .5 FT TOTAL COVER 5 FT. 96.8~ AlP, COMPRESSOR kiln BIOCYCLE 6000 95~ 0 0 0 o o o u SILT £ARRIER 0 0 0 0 0 0 0 0 O GoO OoOo~ ~ INSULATION ND S£ALE 88,$ G~/ ~7 7/8/99 TESTHOLE 10 FT. DEEP L£GEA P. TOB£EN SPURKLAND ~£ 205 WIS& Ave Ak 99501 PARADISIz' VALLI2Y BI( 4 LOT 35 WASTEWATER SYSTEM SCHEMATIC MICHELSOHN AND DAUGHTER I. PRIMARY TREATMENT, SEPTIC TAN/< 2. AERATION TANK 5. CLARIFICATION TANK 4, DISCHARGE TANK $. SOIL ABSORPTION BENCH kiARK TOP RIO£K = Ihh. O0 £~ SEPTIC SYSTEM SCHEMATIC DATE: OCT. 12, 1999 SHEET: GRID: 5558 PERMIT// SW990217 PID NO 020-411-01 PDVO4555. DWG T.SPURKLAND P.E. 203 W. 15th. AVE. SUITE 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 Jeff Poet Municipality of Anchorage Division of Environmental Health Department of Health and Social Se~wices 820 1 Street Anchorage, Alaska 99501 April 24, 2000 Subject: "Pink Sheet" Lot 35, Block 4 Paradise Valley I obtained a smweyed As built of this property today. Copy is enclosed. A legal replacement site can be located up hill from the present drain field as shown on my revised drawing. This replacement is based on a determination made by the Teclmical Review Board on April 18, 2000 which specified that the BioCycle system can use a loading rate of 4 gallons per square foot per day in soils rated at 5 rain per inch. In this case the required drain field will be a 5 x 30 field. Such a field can be placed as I have shown. Yours Tobben Sl~urkland P.E. 04-24-2E~00 E~¢._~PId FROI'I C-ee.t. uehKiX, chenh[te:~.ign TO 2?E~68~3 P.Oi .( B O3628PGO 31 Agreement to Allow Easement to Property Anchorage Recording District This agreement is between Michelsohn & Daughter Coustruction Inc. owner of Lot 35 Blk.4 Paradise Valley Sub. who is a corporation licensed in the State of Alaska. Lot 35 Blk.4 Paradise shall be known as the Don~lant property. And Michael J Wrabetz and Crystal Wmbetz, a married couple who own Lot 34 Blk.4 Paradise Valley Sub. Lot 34 Blk.4 Paradise Valley Sub. which shall be known as the Servient property. Michael J Wrabetz and Crystal Wrabetz agree to give an easement oil lot 34 blk.4 Paradise Valley Sub. an area 6ft.by 6ftin dimension, located on tile west property line surrounding the existing well casing which currently supplies water to lot 35 blk.4 Paradise Valley Sub. The purpose of the easement is to allow the owners of lot 35 blk.4 Paradise Valley Sub. to use and maintah~ a well for rite purpose of supplying water to lot 35 blk.4 Paradise Valley Sub. If for any reasons the well is abandoned and a new well has to be drilled it will be the responsibility of the owners of lot 35 blk.4 Paradise Valley Sub. to relocate the well in its entirety onto lot 35 blk.4 Paradise Valley Sub. This agreement shall become effective after signing by all parties mid recorded with the State of Alaska. The agreement shall become part of and remain part of the Warranty Deed for lot 35 blk.4 Paradise Valley Sub. The agreement shall become null and void upon abandonment of the current well or die written agreement of the ow~ers of both properties. Owner of D~operty (date) Miche~6hu & Dar~Const hie. By it{President x-N Owners oftServient Property _(date) Michael J Wrabetz Crystal Wrabetz Notary Block for Owner of Dominant Property Signature; STATE OF ALASKA ) ) SS: THIRD JUDICIAL DISTRICT ) Tbis is to certify that on the day of ,2000, before me, the undersigned Not,my Pubhc in and for the State of Alaska, dilly commissioned mid sworu as such, there personally appeared Panl Michelsolm Jr., known to me as fire President of a Corporation, and he acknowledged that he executed the foregoin, g instnanent as a free mid volnntary act and deed of said corporation for file uses mid purposes thoretitt~tated, and oil oath stated that he was authorized to execute said instnunent. In witness whereof, I have hereonto set my hand and affixed my official seal tlk8 Agreement to Allow Easement to Property Page 1 BKO3628P~O~32 Notary Block fro' O~vner of Servient Property Signature; STATE OF ALASKA ) THIRD JUDICIAL DISTRICT ) This is to certify that on the(-~ day of ~.x,~ , 2000, before ine, the undersigned Notary Public in and for file State of Alaska, duly commissioned and sworn as such, there personally appeared Miclmel J. Wrabetz and Crystal Wrabetz, known to me as husband and wife, and riley acknowledged that they executed tile foregoing instrument as a free and voluntary act and deed of said lmsband and wife for the uses and purposes therein stated, and on oaflt stated fl~at he was authorized to execute said instalment. -. In wimess whereof. J,~¥~/hereonto set my hand and affixed my offic, ial~al the day and year ' hereinabove written. >,x?\\x~lSg/fl///,~ ~ My commission expires ~ Return recorded agreement to: Michael and Crystal Wrabetz P.O. Box 111904 Anchorage, Alaska 99511-1904 020932 ',' ,:'~> ^ '-' RECORDh~u DISTRICT ,C& REO'UESTED ~\%~ Agreement to Allow Easement to Property Page 2 ........................ J ~ CORREOIO~g ARE ~DE, PI. EASE eL FOR INSPECTION DO NOT REMOVE ~HIS NO~'CE. MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box '196650, Anchorage, AK 995'19-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT Initial Date Issued: Jul 27, 1999 Expiration Date: Jul 26, 2000 Permit Number: SW9902'17 Legal Description: PARADISE VALLEY BLK 4 LT 35 Design Engineer: 0007 Tobben Spurkland, PE Owner Name: Michael Wrabetz Owner Address: PO Box 211325 Anchorage, AK 99521- Parcel ID: 020-411-01 Site Address: 006217 ROMANIA DR Lot Size: 27982 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: [] Disposal Field [] Septic Tank [] 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 15.05 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AACS0 ). 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. 5. The following special provisions. THIS PERMIT ISSUED FOR THE CONSTRUCTION OF AN ALTERNATIVE BIOCYCLE WASTEWATER DISPOSAL SYSTEM. THE ATTACHED PROPERTY OWNER MAINTENANCE AGREEMENTS SHALL BECOME A PART OF THIS PERMIT PACKAGE. Received By: ~~/~~ ~'~' Date: Issued By: Date: 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 35 BLOCK 4 PARADISE VALLEY MICHELSOHN AND DAUGHTER Municipality of Anchorage Department of Health and Social Services 820 1 Street Anchorage, Alaska 99501 July 8, 1999 We are submitting an application for a well and septic system installation for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the well and septic system is subject to this pe~xnit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following: Ground Water ~ 6 ft. Use Standard 5-Wide Trench with BioCycle Unit Soil Rating. From Testhole 06/18/99 5 min/in = 2.4 gal per sq.ft/day No. of Bedrooms 4 Required Area per Bedroom: 150/2.4 = 62.5 sq.ft. Total area required: 62.5 x 4 -- 250 sqfl Rock Depth 6 inches Total Trench Length 250 / 5 = 50 fl SYSTEM CONFIGURATION STANDARD 5 WIDE TRENCH TOTAL LENGTH 50FT TOTAL WIDTH 5 FT TOTAL DEPTH 2 FT ROCK DEPTH 6 INCHES COVER 3 FT BIOCYCLE UNIT The installation of this well and septic system will not prevent wells and septic systems from being installed on the adjacent lots. There are no developed or natural'surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. / / 4'::J Lh / 17 £C~LE~ 1~ -~ ~0 FL 18 TOBBEN SPUN/(LAND P.E. 205 W ISTH. AVENUE ANCH. AK. 9950! (907) 279-5916 [ PARADISE VALLEY BLOCK 4 6217 ROMANIA DRIVE MICHELSOHN AND DAUGHTER LOT 35 SEPTIC SYSTEM DESIGN DATE: JULY 8, 1999 SHEET: 1/5 GRID: 5558 PII) # XX PDVO4351,D~/6 FT ,?6 £ FT TOTAL £5 50 75 SCALE~ 1~ 50 FL 10 24 TOBBEN SPURKLAND P.E. 205 ~/ 15TH. AVENUE ANCH. Al(. 99501 (9071 Z79-5916 IPARzlDISE VALLEY BLOCK 4 6217 ROMANIA DRIVE MICHELSOHN AND DAUGHTER LOT 35 SEPtiC SYSTEM AS BUILT DALE: OCT, 12, 1999 SHEET: 2/5 GRID: 5558 PE£MIT # SIF990£17 PlO /4 020 411 01 PDVO435£,DiF6 £s o 36 SPflN6 TIES: !0 'x 75 I00 ~ SCALE: 1" : 50 FL 34 SPURKLAND .~ ISO ~ \ / TOBBEN SPURKLAND P.E. IPARADISE VAL££Y BLOC'I( 4 LOT 35 SEPTIC SYSTEM AS BUILT 205 W IST/'L AVENUE ANCH. AK. 99501 6217 ROA~ANIA DRIVE DATE: OCT, 12, 1999 (9071 279-5916 IdlCHELSOHN AMD DAUGHTER SHEET: 2/5 GRID: 5558 PERMIT # SI,/990£17 PID fl 020-411-01 PDVO435R. Db/6 SANG £ACKFILL 7-+ 4-INCH /NSULAtON AIRCO~iPRESSO£ STANDARD DRAIN P/ELD I-ii4 PVC FILTH I/$" HOLES AT TOTAL LENGTH 50 FT TOTAL DEPTH 2 FT TOTAL ROCK DEPTH .5 FT TOTAL COVER 5 FT. SILT £ARRIER BIOCYCLE 6000 INSULATION NO SCAL£ OW 07 7/8/99 TESTHOLE FT. DEEP LEGEND: I. PR/MARY TREATMENT, SEPTIC TANK 2. AERATION TANK 5. CLAR/F/CA tON TANK 4. DISCHARGE TANK 5. SOIL ABSORPTION TOBBEN SPURKLAND P.E. 205 Wl5lh Ave Anchoraqe Ak 99501 279-,~976 PARADISE VALLEY BI( 4 LOT 35 WASTEWATER SYSTEM SCHEMATIC MICHELSOHN AND DAUGHTER JSEPtC SYSTEM SCHEMAtiC DATE: JULY 8, 1999 SHEE~ 5/5 GRID: 5558 PERMIT ~ SW9900XX PID NO XX PDVO4555. DWG PERFORMED FOR: Munl:t~.'allty of Anchorage DEPARTMENT OF -~EALTH & HUMAN SERVICES 825 "L" Slreet, Auchorage, Alaska 99502-0650 SOILS LOG- PERCOLATION TEST 1 2 3 4- 13- 14- 15- 16 17 18 19 2O DATE PER ~ORMEO: Township, Range, SecUon: SLOPE WAS GROUND WATER ENCOUNTERED? SITE PLAN _.~ 7.D~%,,Cq Time Time Water Orop 'p/~ ~r_ 5c /~. __ ~,o DISCLAIMFR: Past and future presence &nd/or from these ~e~¥at]ons. PERFORMED BY; ! ,~ ~ PERCOLATION ,'ATE ¢ 7 (m,nulesl,nch} PERC HOLE OIAMETER ~) t/ TLS, RUN.ETWEEN 2 FTANO'2 pT Groundwater r&~tions indicated are for the dates shown only. depth of groundwater can not be predicted CERTIFY THAT THISTE T WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUlL ELINES IN EFFECT ON THIS DA~fF DATE: ¢~" ~'7~/Cq 72.008 (Rev. 4/85} PR©PERTY OWNER AGRE~E~T FOR ~ MAINTIgNANCE OF AN ON-SITE WASTEWA~i]~R DISPOSAL SYSTEM AThi~agteem~ent, dated_t.~.~. ~~ _199_q, t~ made between the Mlmicipalit of ncuorage t~epartmem or ~ea~m and Human Services (DH}IS) and l[~e ,,,',, ..... Y owner(s) off: This agreement is nlade for file purpose ofraahl~inlng an on-site wastewater disposal system on file subject property. The' property owners agree to th, e following: Submi[ to the Municipality el~ gmchorage, on an atonal basis, an impection ~nd operauon statement from a registered professional engineer. This k~spectiou and operation smtemem shall verify that the engineer has inspected all effluent ~nd. air pumps, timers, and alarms, and thor any deficiencies have be~m repaixed and that the system is functior~ng as design~. (Signature) (Printed Name) ............................... Notarize llere ~% ........................................ personally appeared before me~ who i~ personally known ~o me whoOe identtt~ the bmsis of -- %,ho se bath/affirmation R/ck My~rom Mayor MaaicipaJity of' Anchorage Department of Hea th and Human Services 25 L Sfieet P.O. Box 196650 Anchorage, Alaska 99519-6650 http:/A'aw¢.ol, armhorag¢,a k,u¢ Borehole Data: Soil Type, Thickness & Wat~ Strata Stick-up 0 2 silt 2 7 gt'~ vally silt 7 f 2 silty cebbly .qravel 12 63 sand 63 70 silty cobbly gravel w,,'bfdrs '70 105 ~ill 105 173 gravelly ,silt 173 197 beOrock 197 287 H20 DP;.rm..it Nu,,m. ber: #SW_9~90~&,7~7 Dateoflssue: 7-27-99 Parc I ' · te~tarted,?_52.~ Datelqna,,i~o,,.a,~:r.n-W~ .... ~ . .. e Identification Number: · ~,~7~- ----t~'~'--~-'-'~'~ IS W~] lO~ ' , ~ ...... "~'~'~'. Legal Description: p~.....,, .... .;, ...... ated at approved permit location?'~J y~ '[2] No Property Owner Name & Address: ~ic-h~"/~oh'-/~:-~"~ghte'rTM.... 750 ~ Dimond #fO0 A Anonorofle Ak. ,99515 · Depth (£t) · Method.ofDH~ljng [~a~r rotm~y From To 265 275 cable tool Casla~ type: Wall Thickness: ,.25~0. inches 'Diameter: 6 ~clles D ' ~ epth: ~.2_.~0~ feet Liner type: Diameter:--~ inches Depth: ....... tee.~ asmg stmkup above ground: ,~ feet Static water level (fkomground level): 786 feet ' Pan!ping level: 2~87~fe¢;t after _2 hours pumph~g .O_' gpm Recovery Rate: § gpm Method.of.Testing: a.~/~ W~II lntake~Opeainff.,Type: [.~Open End · 'D~ Open Hole ~]]J Screened Start ........ tout Sto~;ped [-.]Pertbrations Start. fca Stopped fe~.t Grout Iype: ~gnto~ig.~_8.. Depth: Start 0 feet Stop[~d k~et Pump: Intake Depth 'Weql'Disinfeeterl'JdP°aCompletimi? ~ Yes~j No Method .of. Disit~lL~tion: Comments: Well Driller: A/pine Drilling ¢ , :;/pnsest P.O. Box 110496 Anchol~ge At( 99571 a ned the proper!,, 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.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 0~0~ ~t1-01 Expiration Date: GENERAL INFORMATION Complete legal description Location (site address or directions) Current Property owner(s) Mailing address 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 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. 72025 (Rev 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 ot 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. Address ~-,~ ~ i.~/ /.~ I,L-'/-t ~ .~-0 '.~ Engineer's Printed Name "'"~-~,, ~,~2 -,:' ,-1 -~ ~ o, ,-.- ~. ~,,,. ~ ~,¢. Date DHHS SIGNATURE Approved for_ ~ bedrooms. Disapproved, Conditional approval for ENGINEER'S ,.-~---~ n STAMP 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: 4~' -/-/~ ¢ O Original Certificate Date: ~-- ~ 0 o Reissue Date: 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.anchorage.ak.us (907) 343-4744 HEALTH AUTHORITY APPROVAL CHECKLIST ,tECEIVE[ MAY 0 1 000 BAUNJCIPALIT¥ OF AHCHL)I(AG~ · ~mr"NMENTA~. $t~RVICF~ pr,-' Legal Description: A. WELL DATA Well type Date completed Total depth ~7~' ft Date of test Static water level Well production If A, B, or C provide PWSID # . Sanitary seal Cased to ~.t..'--~ ft FROM WELL LOG ft g.p.m Parcel I.D.: ¢ ;zo -. 5///- o/ Well Log ~ Wires properly protected ~ Casing height (above ground) ~ in. AT INSPECTION WATER SAMPLE RESULTS: Coliform ~_~_colonies/lO0 mi Nitrate ¢&~-/ mg/I Other bacteria / Date of sample: ~///~7/,¢-~ Collected by: ft g.p.m colonies/100 mi B. SEPTIC/HOLDING TANK DATA Tank Type/Material '~/O C ~g / ~' Date installed ~/~/'.~/¢¢ Tank size Cleanouts ~ Foundation cleanout Date of pumping C. ABSORPTION FIELD DATA Date installed ¢¢/¢/;~/'¢~ Soilrating(g.p.d./ft2orvtfPcr,~t'm),~,/-'/ Length .~0 ft Width .,~ ft /~b¢.2 gal Number of Compadments Depression over tank Pumper System type Gravel below pipe O, ~ft Total depth ~ ft Effective absorption area,.~.6'D fF Monitoring tube~ Depression over field. / Date of adequacy test /"//~ Results (Pass/Fail) / For ¢//bedrooms Fluid depth in absorption field before test /in Water added Elapsed Time: ~ min Final fluid depth / in Any rejuvenation treatment (past 12 mo.) (Y/N & type). ~al. New depth /in. Absorption rate >= ~/'g.p.d. If yes, give date 72-026 (Rev, 01/00)* D. LIFT STATION Date installed ¢~;~/¢ "Pump on"level at ~,~ in Datum E. SEPARATION DISTANCES Size in gallons J~' ':~ "Pump off" level at ~j~_.in Cycles tested Manhole/Access '~/ High water alarm level at ,¢.,¢./~ in Meets alarm & circuit requirements SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanldiift station on lot I D~ Absorption field on lot Public sewer main Sewer/septic service line 7~ On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Building foundation ~z.'~ Property line Water main 'N//A- Water service line Drainage '~¢ ¢.¢,~¢~/;~/f Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ¢¢-(~ Water Service line Curtain drain F. COMMENTS Building foundation Surface water Absorption field Surface water Wells on adjacent lots 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 Date ~//~?/¢-~ HAA Fee $ ~ Date of Payment ~:'-///~ Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev, 01/00)* ~l~tr~m, CT&E Environmental Services Inc. CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered B.y PWSID 1001802001 Tobben Spurkland P.E, 35/4 Paradix Valley 35/4 Paradix Valley Drinking Water 0 Sample Remarks: Client PO# Pre-Paid ColisfNO3 Printed Date/Time 05/03/2000 10:31 Collected Date/Time 04/27/2000 7:45 Received Date/Time 04/27/2000 8:15 Technical DirectoI Stephen C. Ede EP300 Nitrate: Laboratory Control Sample was outside acceptance criteria (112%). The re-analysis confirmed the original mn. ^llouable Prep Analysis Parameter Results PQL Units Method Limits Date Date Init WATERS DEPT 4.51 0.500 mg/L EPA 300.0 (<10) 04/27/00 SCL MICRO LAB Total Coliform 6 OB, No Coli col/lOOmk SM18 9222B 04/27/00 JOT