HomeMy WebLinkAboutGATEWAY TO THE PARK BLK 1 LT 7Onsite File
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Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page of
ON -SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211198 PID Number: 067-611-20
Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade
Name
KRISTEN LABRECQUE
ABSORPTION FIELD - EXISTING
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
1920 MOUNT KILIAK CIR, EAGLE RIVER
❑ Other
Phone
Number of 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
GATEWAY TO THE PARK 1 7
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
Ftz
Ft.
Well
100'+
--
25'+
TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER
Capacity
1000 Gal.
Surface Water
100'+
--
Material
HDPE
Number of compartments
2
Lot Line
10'+
--
NA
Foundation
10'+
__
LIFT STATION
Manufacturer
Capacity
Gal.
Remarks S.T. INSTALLED 100'+ TO EXISTING "CREEK"
CREEK BELOW BERM & 100'+ SURFACE RUN TO
Alarm location
Electrical installed by
SEPTIC — ADDRESS W/ ANY FUTRE COSA
Tank to
PIPE MATERIAL House to tank 3034 3034
Installer FRS
drainfield
Drainfield CO/MT 3034
Inspector FWCS
BENCH MARK (Assumed elevation) 100 ft
Inspection15` 10/14/21 nd 10/15/21
Location and description
3rd 4ch
BOTTOM OF CORNER TRIM
ON -SITE WATER AND WASTEWATER SECTION APPROVAL
'�`�O��'
Conditional A roval: Date
..- '=:tQ,�
*: 49 TH ....�:*fir/
• •
' " " " " " ' ' %
Septic System
Approved -
, :
% Curtis Huffman
10280991••AW
Date l2- �' 2oz3+�isj'•,.CE2
•,�����/
F....••
PROFESSIO W
Note: this approval does not include well permit requirements.
(Rev 05/UZ/18)
PID:067-611-20 PERMIT: OSP211198
SMALL,
S�FAAf
\ 'CREEK' IS BELOW BERM & HAS -A 10V+ SURFACE
RUN TO SEPTIC SYSTEM. NEW TANK WAS INSTALLED
100'+ FROM EXISTING CREEK PER THE DATE NOTED &
\ THE MOA SEPTIC TANK UPGRADE PERMIT.
\ �O. \
lj1 \ 11.5'
-A
�jA S�!
o
\ T
A—C=35,9'
B—C=42.7'
A—D=40,2'
B—D=46.5'
A—E=42,4'
B—E=48.2'
BM: BOTTOM OF
CORNER TRIM
LOT 7
BLK 1
WELL
O
25.5'
24.0'
GRAVEL
DECK W DEW
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24.0' 22.1'
FCO
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INSTALLED
1000-GAL HOPE SEPTIC TANK
'
WITH NEW DCO.
�
� 1
SEPTIC SECTION
GATEWAY TO THE PARK 131, L7
PREPARED FOR:
KRISTEN LABRECQUE
1920 MOUNTAIN KILIAK CIRCLE
EAGLE RIVER, AK 99577
FIRST WATER CONSULTING
13030 SUES WAY
ANCHORAGE, AK 99516
907-350-9566 firstwaterAK@gmoil.com
3UPPORT SERVICE
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DATE:
1/20/2023
SURVEY:
JLS
DRAWN:
FWCS
SCALE:
1 " = 30,
SCALEI NTS
* 9 TH
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CE 128991
1/20/2023e AV
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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.muhi.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP211198
Work Type: SepticTank Upgrade
Tax Code Number: 06761120000
Site Legal Address: GATEWAY TO THE PARK BLK 1 LT 7 G:1005
Site Mailing Address: 1920 MOUNT KILIAK CIR, Eagle River
Owner: LABRECQUE KRISTEN
Design Engineer: FIRST WATER CONSULTING
This permit is for the construction of:
Effective Date
Expiration Date
ent S,
n n
r v
Department
Lot Size in Sq Ft:
Total Bedrooms:
6/10/2021
6/10/2022
35413
❑ 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. Opened and Closed on the same day, or
b. 'Covered, sealed, and heated to prevent freezing
Special Provisions:
** Show the creek on the record drawing.
Received By:
Issued By:
Date:
Date: 6 /O Z
f 11
3
* r
Development Services Department
On -Site Water &Wastewater Section
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 067-611-20
Property owner(s) KRISTEN LABRECQUE Day phone
Mailinq address 1920 MOUNT KILIAK CRICLE, EAGLE RIVER, AK 99577
Site address 1920 MOUNT KILIAK CRICLE, EAGLE RIVER, AK 99577
Legal description (Sub'd., Block & Lot) GATEWAY TO THE PARK 131, L7
Legal description (Township, Range & Section)
Lot Size 35,413 Sq. Ft. Number of Bedrooms 3
Phone: 907-343-7904
Fax: 907-343-7997
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF)
Z
(w/wo ADU)
Septic Tank
El
Upgrade Q
Duplex
❑
(D)
Holding Tank
❑
Renewal ElMultiple
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.
Ignature or property owner or autnorizea agent)
Permit/Rush Fees: Waiver Fees:
Date of Payment: '7 0 Date of Payment:
Receipt Number: 0j "i 0 LJ 0 Receipt Number:
Permit No. d sips If 1 ?8 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
June 4, 2021
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: GATEWAY TO THE PARK BLOCK 1, LOT 7
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 1000-gallon HDPE tank per the
attached design to serve the existing 3-bedroom residence. 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
OSP211198, Deb Wockenfuss, 06/10/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211198, Deb Wockenfuss, 06/10/21
i MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON~ITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME IPHONE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS ~-~
Well Absorption area D~lling PERMIT NO.
DISTANCE TO:
~ Z Manuf~turer ~ Material No. of com~ments
Liq, capaciW in gallons Inside len~h Width Liquid depth
J /O ~ ~ IF HOME.DE:
~ ' DISTANCETO: Well Dwellin~ / PERMITNO.
O Z ~ Manufacturer Material Liquid capacity in ~llons
Well Foundation Nearest lot line PERMIT NO.
i Z DISTANCE TO:
~ J ~ No. of lin~ Length of each lin~ ~ Total length of lin~ Trench width Distance ~t~en lines
/
~ Top of tile to finish grade
I
inch~
Length Width ~pth PERMIT NO.
Tg~ of crib ~rib diameter ~rib d~p Total eff~ti~ absorption ar~a
m Well j Building fou~ation N~rest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS ~, ~ LL
SOIL TEST RATING
INSTALLER
REMARKS
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK
264-4720
ON--SITE SEWER & WELL
PERMIT NO:
DATE ISSUED:
84c)554
07/10/84
APPLICANT:
ADDRESS:
CONTACT PHONE:
BRAD DICKEY CREATIVE HOUSING INC
SR BOX 1615
EAGLE RIVER, AK ~577
6~4-~259
LEGAL DESCRIP:
LOT SIZE:
LOT LOCATION:
MAX BEDROOMS:
SUBDIVISION: GATEWAY TO THE PARK
SECTION: ~ TOWNSHIP: 15N
55415 (SQ.FT. OR ACRES)
EAGLE RIVER ROAD
5
LOT: 7 BLOCK: 1
RANGE: 1E
Listed below are the options available to you in designing youp septic
system. Choose the option that best fits your site.
DEPTH TO PIPE BOTTOM (FT.)
GRAVEL DEPTH (FT.)
TOTAL DEPTH (FT.)
GRAVEL WIDTH (FT.>
GRAVEL LENGTH (FT.)
GRAVEL VOLUME (CU.YDS.)
TANK SIZE (GALS)
SOIL RATING (SQ.FT./BR)
TRENCH (~ceI BED W. DRAIN
5.0 ** -~- &. 4.0 4.0
8.0 ~. c, 0.5 5.5
11.0 q C 4.5 7.5
2.5 ,,~. T' 1 ~. 0 5.0
29.0 ¢~. (~ 56.0 49.0
22.8 ~ 25.5 56.2
1~000.0 ** /aoo 1,000.0 ** 1,000.0 **
150 ~ ~ 150. 150
** DEPTH TO PIPE BOTTOM < 5.5 PT. REQUIRES INSULATION
** DEPTH TO PIPE BOTTOM < 4.0 FT. MAY REQUIRE A LIPT STATION
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
I certify that:
1. I am familiar with ~he requirements for on-site sewers and wells as set
forth by the Municipality of Anchorage (MOA) and the State of Alaska.
2. I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
5. I will adhere to all MOA and State of Alaska requirements for the set back
distances from any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot.
4. I understand that this permit is valid for a maximum of 5 bedrooms and
any enlargement will require an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (5) THE
ELECTRICAL WOR~.MUST BE DONE/IB~ LICENSED ELECTRICIAN.
SI GNED _~_~~ DATE:
APPLICANT: BRAIY~KEY CREATIVe/HOUSING INC
ISSUED BY ~ .... /~.,. ,,,, ~-- DATE:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
SLOPE SI~ :E PLAN
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
,,
PERCOLATION RATE W/ ~ (minutes/inch)
i ,!
TEST RUN BETWEEN FT AND
~ FT
,, M-W DRILUNG, Inc.
P.O. Box 10-378 * 10300 Old Seward Highway 84-224
t · · (~
ANCHORAGE, ALASKA 99511
DRILUNG LOG
We]] O~ner DICKEY, BRAD Use of Well Domestic
Location (address of: Township, Range, Section, H known; or d~tance ma~n road Lot 7, Block 1 Gateway To The Park Subd.-Eagle River
Size og casing
Static water level 71
Screen ( );
Depth of Hole
ft.
Perforated (
93 feet Cased to 93 feet
(below) ]and surface. Finch of we]] (check one) open end ( X
).
Describe screen or perforation
We]] pumping test at 20 gallol~s per of drawdowh from static level.
Date of completion JulM /2. 1~
(minute) for 1 hours with
WELL LOG
);
Depth in feet from
ground surface
0 TO 2
2 TO
4 TO
~ .TO ~8
48 .TO
59 .TO 81
81 .TO. 89
89 .TO 93
_TO · · **
_TO.
.TO.
· ';i: ..TO.
.TO
Giv~ ~ of formations penetrated, size of material, color and hardness
Fill
Stl~ gravel
~Xt~ g~-avel - loose
SJAt~ gr~el~ ~ardpan
Sil~ g~ravel - loose
Waterbeari~g gravel
3--CONTRACTOR
'Parcel I.D.
ivxunicipality of Anchorage'
'Development Services Department
Building Safety Division
On,Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 'Anchorage, AK 99519-6650 -
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
/Y67E//,,to
GENERAL ,INFORMATION
Complete,legal=desc, riptiOfi ~,,:
Location (site ~ddress'or di[.ections
~ Mailing address
Lending agency
HAA#
Expiration Bate:
~',~'~'/~/G-~ Day phone .~"?/-/-
Day phone ~
Mailing address
Real Estate Agent
'Mailing Address
Day phone
Un/ess otherwise requested, HAA will be hem by DSD for pickup.
2. NUMBER OF BEDROOMS: ~
e
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 I'-I
Community On-site "' I--I
Public Sewer r-I
The Municipality of Anchorage DeveloPment Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent profesSional civil
engineer registered in the State of Alaska. Certificates of Health Authority ApProval are required fo{ the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. 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. (Certificates may be reissued for a period of up to one year with valid water samples.)
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.
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 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.
Name of Firm
Address i ~') z/~./ vF'i,~J ~-~:
Engineer's Pdnted Name.
DsD SIGNATURE
,/-
Approved for
Disapproved. ·
Conditional approval for
Phone
~ ~ '... ..' '
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist .. ~
SePtic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
By:
(Rev. 01/02)
Odginal Certificate Date:
i ' : MUnicipality of Anchorage
evelopment Services Department
I ' I Buil,ding'S~fety Division '
On-Site W,.4te'r & Waste~ater Program
'~ 4700 S6dth Bragaw St.
p20. Box 196650 Anchorage. AK 99519,6650
· www.~:i.hnchorage.ak.us : !
(907) 343-7904 .
: = HE, ,LTH AUTHORiTY APPROVAL CHECKLIST
, . t
LegalDescription:i I ' ~__.~e~Ot,~ i "~' ,7)-/1.~ '~a.2"~., .,~ ..~., L';':I~: ParcellD:
A. WELL DATA
Well type '-~ ¢~.~.~ If Al: B. or 9 Provide PWSID #
Date completed ;'7 '-"/.2. ~ ~o:~/ t Sanita'ry seal (Y/N) ~ )'"~..5
Total depth ¢~.~ ~.fl. , I Cased to. ,~.~' ft.
' FROM ~WELL LOG
Dfite of test I' ! ~7"-{ ih~-: ~
Static water level ,"1' { ft.
Well production , , ~ g.p.m. ~';~
WATER SAMPLE RESULTS: i
Coliform; ~ff': ''~ ' .... e',,.~. 5;
· ~ colomes/100 mi. Nitrat £ t mg./I.
Arsenic: ' ~ Img./I. i Date of sample:
SEPTIC/HOLDING 'TANK
~ma~'Material ,-'.. ,~7"~'~'t_
Taqk size It 000 gal. NumlJer'ofCompartments
Foundation cleanout (Y/N)'~S ~Depress~o,n over tank (Y/N) ~J0. ~ ' ' · ' t .~1 .
Date of pumping ! ~- .g- O~ I~: , Pumper ' ~'-tq., ~
Well Log (Y/N) :
Wires properly protected
Casing height (above ground)
AT INSPECTION '
ft.
g.p.m~
Other bacteria
Collected by:
Date installed
Cleanouts (Y/N)
High water alarm (Y/N) i; I
in.
i : ·
Date installed "7' ~ W ~.- ,R~/S{Oil
rating :(g.p.:d./ft~ or ft~/bdrm) 150 ~Z~/~W.. S~/stem type
ength ,~' ft- ! ;':: :Width' ~..¢J' ft. - Gravelbelowp~pe,,
Total depth lO. ~ ft. i Eff. abs0rption'area .qsp, "ft~ Monitoring tube.
Date of adequacy te~;t ~,,;.. ~ I Results (Pass/Fail) ~ '
Fluid depth in absorPtion"field before test ~lin. Water added~5o gal.
Elapsed Time: J~ min.; Final fluid depth.'l;::ff,..'¢ in. Absorption rate >=
Any rejuvenation treatme'nt (past 12 mo.) (YIN & type)
· ft.
Depression 6{/er field
For ~ ~ bedrooms
N~v~ depth ~i~
g.p.d.
If yes, give date
,7_ Col0nies/100 mi.
':' ;'{I
D. LIFT STATION
Date installed
Size in gallons
·
~n.. "Pump .off" level at
Cycles tested
E. SEPARATION DISTANCES
sEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/~ on lot II~ t .. .
Absorption fie d on lot' Io~0 ·
.~Acces~ (Y/N)
in. J [ High Mater alarm level at
Meet alarm & c~ cmt reqmrements?
On adjacent lots J ~ fO0 t
On adjacent lots
I i
Public sewer main il i' .' '/'' lOG/: Or~/~z~,~..) Public sewer manhole/cleanout
Sewer/septic ser~ic(~ line ~,~ ~ i : 'Holding tank /'~.//~.-
' i;. ~' · .~ SEPTI(~/HOLDING TA~K': ON LOTTO:
SEPARATION DISTANCES FRC~jM
Building foundation~ ;:)'-t , P~ope'rty line'' ~o t , i Ab~sorption: field
:. i :"' ' ! surfaCet w;ter
Water main ~ lOC) I. , I; Water service line' ~ ~ '
Wells on adjacent Jots ! -t- I00 ' j
I "T
SEPARATION DISTANCE FROM ABSORP, TION FIELD ON LOT TO:
Property line ~. (o ~ 'Building foundation ~"3 ~ Water main .I- Ia0
Water Service lin~; ~ ' i 'r'
. . ,~'O. i Surface water . lO0 storage
Curtain drain~ .~',,~b.r-~NVells~°n adjacent lots! ~'~ IO(3 '
- ~i '
COMMENTS ,; cL~4~.~.
G. ENGINEER'S CERTIFICATION: :.i"'
I certify that l have determinedthrough 'fiel~ insp~c'tiO~s and
review of Municipal records that the above ~ystems are in
conformance w!th~MOA' HAA g'ui~lelines'in e, ffect on this date.
Engineer's Printed Name C~,~-I~'rot='ftF-/~- Cz;.'u,Ooo~
Date ,..K~-I~'"O q l':' i,' :: ' ;,; ' ;.
~' lot') '
in.
HAA Fee $
Date of Payment
Receipt Number
(Rev'. 12/01)
Waiver Fee $
Date of Payment
:Receipt Number
,11
APR-23-2004 (FRT) 14:42
I~PR--2;~=O4 FEI
EAGLE RIVER ENGINEERING
12:03
SEWAR~ [ I~;SOI: LAN~
(FAX)907 694:3297
IRV 90?
P. 001/001
P.IB1
i_ASBUILT .SEW_AR__~ & AS$OCIA_I~ iAND SURV]~YING 69&-0~."
! HERE~ CERTIFY THAT ! HAVE SURVEYED THE ~ ~E ~ _~ 1-- ~_ ' '
FOLLOWING DESCRIBED PROPERTY,
INDIOA ~/'~/~ ~ ~ ~ .~ '$
~m~_~ER~iE~TH~ ~IST~m OF ~Y Imm, .... :.-.;~.~.~...~/~
I E~TS, COVENANT8~ OR E~I~IONS I ~/~/ ~~.~
W.I~ ~ NOT PFA~ ~ ~ u~~ e~
~ .......... .,~ , ~wJ~
ViS
~Y DATA H~N BE US~ FOR CONS~U~ION I
ARY LINES. - ....... I D~WN:
Parcel I.D. #
1.
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
067-611-20 HAA# '~''~ C~ L\ (~ ,~C~
GENERAL INFORMATION
Complete legal description
Gateway ,to the Park
Lot 7, Block 1
Location (site address or directions)
NHN Kiliak Circle
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Dean & Teresa Sundmark
P.O. Box 375. Homer. AK 99603
Northland Mortgage/Trish Kostner
Day phone 235-5188
Day phone 694-7872
11421 Old Glenn Hwy., Eaqle River, AK 99577
N/A Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
3 ~
Public water
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
NOTE:
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72q)25 (Rev. 1/91) 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 inves_ti_gation 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 Eagle River Engineering Services Phone 694-5195
Address .P.O. Box 773294, Eagle River, AK 99577
Engineer's signature
Date
DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
bedrooms.
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 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.
72~)25 (Rev 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORrFY APPROVAL CHECKLIST
Legal Description: ~,~73~F,,,M,¥ ~'a "/"//~ /~#J~d-. Pamel I.D. O~ll~ ~
Well D~
Well type ~IV~/~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
.)/~ Date completed ~)?~ ~/~0/3/' Driller
~ ~ / Cased to ~ ~i Casing height
,V~ Wires propedy protected (Y/N)
AT INSPECTION ~ i
y//
g.p.m..
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot //~ /
Absorption field on lot /
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
h/go '
/00
z
WATER SAMPLE RESULTS:
Coliform (~ Nitrate
Date of sample: ~ '/'//~ ~/<~ ~
Collected by:
Other bacteda
B. SEPTIC/HF~-em~m TANK DATA
Date installed ~'2//1./'/~' ~ Tank size /, ~ Compartments
Cleanouts (y/N) .Y~"~ Foundafion cleanout (Y/N) )/~ Depression (Y/N)
High water alarm (y/N) /*J///~ Alarm tested (Y/N) .,~J/~
Dete o, pumping Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot //5
To property line
Surface water/drainage
On adjacent lots ~ / OD / Foundation
Absorption field ~.~, i Water m:;..--Jservice line
Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTAN.GE, A~M LIFT STATION TO:
Well ~ On adjacent lots
Manufacturer ~
Manhole/Access (y~......-.-'''''~
~ste'~p' d off" Level at
Surface water
D. ABSORPTION FIELD DATA
Date installed ~ '?/? g / ~
Length ~ ~' / Width
Total absorption area '/--/'~ ~' Cleanout present (Y/N)
Date of adequacy test ~/'/'/Z-~/~ Results (pass/fail)
Water level in absorption field before test ~/~),~"//
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/FF) /~) '¢~/Z~,~. System type
Gravel thickness ~,P / Total depth /,~ / ~ /
Y~'~ Depression over field (Y/N)
~2/,z} 5 _~ for --~ Bedrooms
After test ./~
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
!
Well on lot
To building foundation
On adjacent lots ~- ~ /
Surface water
On adjacent lots ¢- / L)~ ! Property line ,,Z//..~.~ !
~ ~ i To existing or abandoned system on lot /~.1J ,~
Cutbank /~/~ Water-ma~/service line ~::~J /
Curtain drain /~/~/~
/~(~ / Driveway, parking/vehicle storage area "~-~
E. ENGINEER'S CERTIFICATION
I cert/[y that I have checked, vedfied, or conformed to all MOA and HAA guidelines tn eff~ ~t~ ~s mspectton.
Signature ~~ ~
Engineers Name
Date ..~/o~-/~
HAA Fee $
Date of Payment
.ece pt .umber
Waiver Fee $
Date of Payment
Receipt Number
Parcel I,D. #
1.
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
067-611-20 HAA# ~ ~c'~t~/5 ~ ~'~
GENERALINFORMATION
Completelegaldescription
Gateway to the Park, Lot 7, Block 1
Location(siteadd~ssordirections)
NHN Mt. Kiliak Circte~ Eagle River
Property owner Janice M. Snvder Day phone 694-7345
Mailing address HC 83, Box 2494, Eagle River Rd., Eagle River, AK
Lending agency N/A
Mailing address
Agent N/A
Address
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3 '~
3. TYPE OF WATER SUPPLY:
NOTE:
Individual well X
Community well
Public water
If community 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 X
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Re~. 1/91) Front MOA~21
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 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,
Name of Firm Eagle River Engineering Services
Address p_o_ Rnw 77qPg4: F. agl~ River. AK
Engineer's signature ~
ordinances, and regulationsin effectonthe date ofthisinspection.
Phone
99577
DHHS SIGNATURE
,/P(/_ Approved for ~,?_)bedrooms.
Disappr6Ved.
__ ,Conditional approval for
694-5195
bedrooms, with the following stipulations:
Additional Comments
By: .....
Date
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-O25 (Rev 1/91) Back MOA ~t21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
If A, B, or C, attach ADEC letter.
Date completed
Cased to
Well type
Log present (Y/N) ~'~
Total depth
Sanitary seal (Y/N) ~'~'
FROM WELL LOG
Date of test
Static water level ~ /
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot // '~ j
Absorption field on lot / ~''g) /
Public sewer main '"~/"/'~
Sewer service line ~'0 ~
Parcel I.D.
ADEC water system number
~3 '~///~/o°~ Driller
~ ~ / Casing height
Wires properly protected (Y/N)
g.p.m.
AT INSPECTION ~ ~ ~
g.p.m. ~ o O
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~) ~ Nitrate O. 5 ~t/~ -
Date of sample: 0 ~/~' ~///~ 2 ~ Collected by:
Other bacteria
B. SEPTIC/N~L'~ff, I~' TANK DATA
Date installed ~ ~///-//~.Z/. Tank size ./. ~ Compartments
Cleanouts (Y/N) /V~' 4~ Foundation cleanout (Y/N) Y~ ~ ~ Depression (Y/N)
High water alarm (Y/N) /4,//.,~ Alarm tested (Y/N) ,/~//,"~
Date of pumping /O/;~/c~ / ~ Pumper 5.'f/~/? ~;'~,~'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on l~t ././~ / On adjacent lots
TO property line- ', ~"i0' ~;" Absorption field
Surface water/drainage ~*'-/~)~) /
Foundation ---~ '~' /
Watermai~/service line /~ ~ /
72-026 (Rev. 7/91) Front ' ' CONTINUEDoN BACK PAGE
C. LIFT STATION
Date installed Manufacturer ~
Size in gallons Man~)
Vent (Y/N) "Pump on" level at ~.~-'~ "Pump off" level at
High water alarm level ..~.~~ Cycles tested
Meets MOA electrical codes
SEPARAT~ROM LIFT STATION TO:
Well o~j3-fSt On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed (~ ']//~/~'~
Length ~ ~ ! Width '--~ (~/'
Soil rating / ~ 0 ~-~h~ ~
Gravel thickness //~ /
Total absorption area ~ ~
Depression over field (Y/N)
Results (pass/fail) //~
Peroxide treatment (past 12 months)
Cleanouts present (Y/N)
Date of adequacy test
for
System type
Total depth /~, ~ /
~//~-~ ' bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot / ~"~'
To building foundation
On adjacent lots '7/...~) /
Surface water /00 /
Curtain drain
On adjacent lots ~'- /O~) / Property line
~' ~ ! To existing or abandoned system on lot
Cutbank /'///} Water ~/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
HAA Fee $ /~' ~ Waiver Fee:
Date of Payment ~ - ~ Date of Payment
Receipt Number ~:~ 7 ~ ~Z J ?~? Receipt Number
MUNICIPAUTY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PR°TECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-472O
Application Date
GENERAl. INFORMATION
(a) Legal Description (~,,k~le I~, 1~3¢k, ~i~. ~tion. tow~hip, range)
(b) A~nt ~ ~ T~ne: ~ Bumn~ ~
(c) Appli~nt is (ch~k one): Lending Institu~on ~; Owner/build~ ~; Buyer ~; Othe~ (explain);
(d) Lending Institution
Telephone
Address
(e) Real Estate Company and Agent ~"-/,,,,-_.~z_. ~.~I"I-F- ~"~'"'~. -- ~ ~L~A'I'JL'~'~J
(f)
Address ~E.. ,~'d~-~__... t J, ~.~
Telephone ~'~'~ -
~HAA to the following address:
TYPE OF RESIDENCE
Single-Family J~ Multi-Family []
Number of Bedrooms
Other
WATER SUPPLY
Individual Well~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite,~ 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.
72q325 (11/84)
Page 1 of 2
5. ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DAtA AND INFORIII~TIOI~I *~
As certified by my seal affixed hereto and as of the validation date shown below. I ve~afy that my m~l~gation of th-ts Health
Authority Approval shows that the on-site water supply and/or wastewater clisposal system ~ ~ ftJ~ and adequate
for the number of bedrooms and type of structure indicated herein. I further verafy that ba~ed on ~ info,,marion obtained
from the Municipality of Anchorage files and from my investigation and inspection, the Ott-61te wate~ supply and/or
wastewater disposal system is in compliance with ail Municipal and State codes, or¢hrtan¢~ ~ ~egulations in effect on
the date of this inspection.
Name of Firm
~ & ~ E_~GIHEERIN~
Address
Date
Telephone
Approved for ~./¥ ~ bedrooms by/v/,
Approved '~ Disapproved
Terms of Conditional Approval
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
72-025 (11/84)
WELL DATA
Well Classification
Well Log Present (I~N)
Total Depth ~.~ r
Static Water Level
Casing Height Above Ground
Electrical Wiring in ConduitS/N)
Separation Distances from Well:
To Septic/I-~ank on Lot
MUNICIPALITY OF ANCHORAGE (Mt~A)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
NIUNICIPALh-Y OF ANCHoP, AG,~
DEPT. OF HEALTH
ENVIRON, VIENTAL P~CTECTION
~-~, ~', If A, B, C, D.E.C. Approved (Y/N)
Date Completed ."T'IJ'L. /~l;;~t.~ Yield
Cased to ~ "~ ~ Depth of Grouting
Ti ' Pump set At
'~o~ Sanitary Seal on Casing~)'N)
Depression Around Wellhead
.,//~.- ' ; On Adjoining Lots
~ ; On Adjoining Lots
To Nearest Public Sewer
To Nearest sewer Service Line on
~"~ ~' ~.)~--~ (~'~"~-" ; Date
To Nearest Edge of Absorption Field on/Lot
To Nearest Public Sewer Line Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/~ TANK DATA
Date Installed "//.~
Standpipes ~VN)
Depression over Tank (Y/I~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/.l=i~Tank:
TO Water-Supply Welt /
To Property Line i~ ~'~
To Water Main/service Line
Course 1~ / ~
Size _/~ No. of Compartments ~--
Air-tight Caps ~N) Foundation Cleanoul~/N)
Date Last Pumped ./_~ --~' ~ ~""
, for ~
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field ~.Z.-
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y~[~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
f
To Water-Supply Well
To Building Foundation /-'~.~ !
Lot
To Water Main/Service Line //P x~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness (.~
Standpipes Present (~N)
.~Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots '~3
To Cutbank (if present)
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
nhole/Access (Y/N)
1~ /,a "Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed -- -- ~:;i'IIN" Date
Compar~.~! ~ ~,~,~',-* .~.~1~_..~, _ ~
MOA No.
~ ~ ......
Receipt No. ~~
Date of Payment I 0 ~ I q -~_~
Amount: $ ~
Page 2 of 2
72-026 (11/84)
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIROh~fENTAL HF~TH
DEPARTMENT OF HEALTH AND ENVIRON~NTAL PROTECTION
A~PLIC~TION FOR HF~TH ADTHORITY ~PPROVAL CERTIFICATE
1. General Information
Application Date
section, township, range)
(a) Legal Description (include lot, block, subdivi~s~ton,
Location (address or directions)
Applicants Address
(c) Applicant is (check one) Lending Institution ~ ; Owner/builder..~. ;
Buyer~-~ ; Other~--~ (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the HAA to the following address:
Type of Residence
$izgle-?&mily~
Number of Bedrooms
Water Supply
Individual Well~
Community
Public~-~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Sewage Disposal
Onsite~ 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.
[Page 1 of 2]
5. En~ineerin~ Firm Providin~ 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 Authority Appcoval shows that the o~-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 ~
investig~tion and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in e.f. fect on the date of this inspection.
Name of Firm
Telephone
Address
(ENGI~ER
D~P Approval
Approved for
Approved ~ Disapproved
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES NE. ALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAi~ 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DflEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES A~ND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE P. EQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. TflE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SF~)
RR4/ej/D18
[Page 2 of 2]
7-19-84
- J~IpAL'J'Pi' OF ANCHO~'GZ
D[l~%. OF HF. ALT~; d.
,S£t:'_ ! 8 '1B84
RECEIVED
A®
Well Log esentl
Total Depth ~-~ / Cased to
Static Water Level
Casing Height.Above Ground ,_~
Electrical Wiring in Condui~/~
Separation Distances f=cm Well:
To Septic/~3-Tank cn Lot
Leg a_~ Description-
If A, B, cr C, D.E.C. Approved(Y/N) /
Datef~.~C~,~leted ~ ~/~
~ ' ~p~ of ~ti~ --
Sanit~ ~al ~ ~si~~
~essim ~d ~l~ad (~
; On ~djoining Lots ~./~4/~2~o/
To NeareSt Edge:' of ~tion Field ~ ~t /~ / ; ~ ~joi~ ~t~ ~~
To ~est ~blic ~ Li~ ~ /~ To ~est ~blic ~r /
~/~ ~ ~est ~ ~rvi~ Li~ ~ ~t
Wate~le ~lle ~ed ~~~( ~ ~/~/~
Water S~le Test ~sults ~ ~ ~/~/~c ~m~
B. SEPTIC/HOLDING TANK II~TA
~5~r Cleanou (~
Standpipes((Y~ / .~Air-tight Ca~/~ F~n~t i~
~essi~ Ta~ (~ ~te ~st ~d ~ ~ ~
~i~in~ ~n~a~ ~ File (Y~ ; f~ ~
Holding Ta~ High~ate~ ~a~ (Y~) ~/~ ~~ ~ldi~ Ta~ ~t (Y~) ~
Separation Distances frcm Septic/Holding Tank:
To Water-Supply Well //~
TO l~_'operty Line /~ 7/-
To Water Main/Service Line ~o
c se /oe /
/
To Building Foundation ~ ~
To Dispcsal Field ~ ~- /
TO Stream, Pond, [mke, c~ Major D~ainage
Receipt ~ ~',~(~/
Date Paid; ~- _f?./~ .(/
Amount: ~
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 7/~ 9/
Width of Field / ~D /'
Square Feet of Absorption/~ea
Depression over Field (~/
Results of Last Adequacy Test
Length of Field
Depth of Field
~ravel Bed Thick~ess
Date of Last Arl~quacy Test ,~
Separation Distano~ from Absorption Field:
To Water-Supply Well /~ '~ To P~operty Line ~/d~ ~
To Building Fouodation ~ / To Existing or Abandoned System on
Lot /~//~ ; On Adjoining Lots ~ ~ ~7~= U
To Water ~e~rvice Line 39 7/ To Cutbank(if present) ~,/F~-
To Stream/Pond/Lake/or Majo~ Drainage Course /~;O f
To D~iveway, Parking A~ea, c~ Vehicle Storage A~ea ~-~ ~
C~nts
D. LIFT STATION
Date Installed . / Dimer.-~ions
Size in Gallons ~ /~/~Manhole/Access (Y/N)
"Pump On" Level at ~ V ~"Pump Off" Level at
High Water Alarm Level at
Tested for
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
W~ets ~F3A
Electrical Codes(Y/N)
Comments
** Check Permitted Bedrocm Rating Against HAA Bequest **
I certify that I have checked, verified, c~r conformed to all MOA HAA
on the date of this inspection.
Signed
Com~any~
: l/dS/s .....
[Page 2 of 2]
2-15-84