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HomeMy WebLinkAboutGOLDEN VIEW HEIGHTS LT 5BGolden View Height Lot 020-042 -98 Municipality of Anchorage Page I of 2. 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: .~Wc~qOdCt7 PID Number: 477~00 ~'?---c/? Name: Wastewater System: ~ew D Upgrade Address: ABSORP~ON FIELD ~c~o¢~-, ~ q¢¢/GI ¢ U Deep Trench ~ShallowTrench ~Bed UMound ~Other L E G A L D E S C R I P T I O N Soil Rating: Total Depth from original grade: /. 0 GPD/Sq. Ft. : ~ ' Lot: Block; Subdiv~ion: Depth to pipe boltom from original grade:~ GrAvel depth beneath pipe Township: Range: Section; Fill added above original grade: Gravel length: ¢ Ft. /~O Ft~ WELL: ~ New ~ Upgrade Gravel width: Number of lines: Distance between lines: ~ Ft. ~ /~ Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: ~¢/O ~¢M~. Driller: j Date DriJled: Static Water Level: Installer: Date installed: Yield: Pump Set at: ' I ~a'sing Height Above Ground: SEPARATION DISTANCES ~septic u Holding U S.T.E.P. TO Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~HO~ ~&D~ ~O Well' //6/ I /~/ ~ ~ ~ ~ Material: Number of Compa~ments: Surface '¢ '¢ LIFT STATION Water /Od /OO I i i Lot ~~utactumr: Line /0~+ tO ~ Foundation ~Z ~ ~-~ i ~ "Pump on" level at: ~mp-~at: High water% alarm at: Cu~ain Pump Make & Model Electrical Inspections perform~ Drain - - WO~6= ~d u~ ~ ~% Remarks: BENCH MARK Loc~tion and Description: Assumed Elevation: / oo,¢ ~, ENGINEER'S SEAL 17034 Eagle River Loop Road, No. 2~ · Inspections performed by: ~ ~lvar~ Alaaka 99577 Dates: 1st ~ ~/- ?~ 2nd C~ ~z ' ?? ; ~ Department of Health a~ , I uman'~rvices approval~ ' I ~ ' ' ;'~ ' ' ' .... l: ; Reviewed and approved by: :~¢¢:::::- Date: ~( Permit No.SW940097 Page 2 of 2 Municipality of Anchorage 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 Legal Descripti(:~.LDEN VIEW HIEOHT$ SUBDIVI$10N LOT 5B PID No.: 02004298 CO1 95 4' C02 .-.i-,~ ,%%'~-';.-.~-. ...... ~; ....................... -"ti'Il ................ ~-tlt-I ~.T.S. :. 85.5' ~!...' . ~ ~ ' '......................' '. ___..._ :.183 0,./ i....... · 79.5' WATER FOUND 9-12-93 ^ B 14 ~co ~6,o 8.5': CO1 31.5 27.8 C02 38.5 34.$ C03 64.0 58,5 C04 56.5 62,5 0'05 'fO'~;(~ '~2'.0 C06 85.5 95.~: MT1 56.5 63.5 MT2 104.0 91.0 MT3 86.0 96.8 $c^b~ f' 4 40' 72-013 A (1/93) ' P.OI ~reent Paa,~inO Perco~'~t required for DEC eeptic filter 054 O0 85-1 60-90 -- 25-50 0-t~ -- ~?~ .. ('Mark 1,.i (P/~'v ......... Fr.om : ALPINE DRILL 9(]'7 ~45 0282 IONISK~'TCH; W[d.. OWNS:R: [35 [Ow /'~) ,~4,4 f .. RECEIVED dUN 2. 9 1994 Drage Dept, Health & Human Services DEPTH 'fO STATIC WA'('E~ LF.WEL: .-~,:L~-It bMov LISE O~~ WELL: O,,~pth$ of opSnl:'~£~s: ............ to ............ ft G~VEL PACK ~ YP[: ................................ Vo!um~ u~d: Dept. GROg1' YYPE; Volume: Depth: from ............... ]~ to O~V~LO~'MENI' ( Z Duration: WELL DISINFECTED UPON COMPLETION? , ';". I ' ' ~ " ~" ' / . / .. ,. .;~ ,, ";i..,.::.~ ~;S<...~',.,.~f -" '-."" . ;'/,~*'~'~"' ,/ "-":" '. ~:"'"~" . '::', '"'.". PAGE 1 OF 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHOP~AGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT ~ER:SW940097 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:ABEGG KRISTEN M OWNER ADDRESS:6446 WEST CIRCLE ANCHOP~AGE AK 99516~5019 DATE ISSUED: 4/26/94 EXPIP~ATION DATE: 4/26/95 PARCEL ID:02004298 LEGAL DESCRIPTION: GOLDEN VIEW HEIGHTS LT 5B LOT SIZE: 29233 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION 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 C~tAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 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: SYSTEM MUST BE CONSTRUCTED BY DHHS PERMITTED CONTRACTOR. A 2 FOOT THISK SAND FILTER MATERIAL WILL BE INSTALLED BETWEEN 4 AND 6 FEET BELOW EXISTING GP3dDE. THE SAND USED IN THE FILTER LAYER MUST BE A CLEAN COURSE SAND WITH 4% OR LESS MUNICIPALITY OF ANCHOP~AGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHOP~AGE, ALASKA 99519-6650 PASSING THE #100 SIEVE AND 2% OR LESS PASSING THE #200 SEIVE A SEIVE ANALYSIS ON THE SAND MUST BE PROVIDED WITH THE AS-BUILT INSPECTION REPORT. RECEIVED BY: DATE: ISSUED BY: -~t~ c~,'~ DATE: PAGE 2 OF 2 ROBERT SHAFER, P.E, ROGER SHAFER, P.E. April 5, 1994 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST Municipafity of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 'L' Street P.O. Box I96650 Anchorage, Alaska 99519-6650 REFERENCE: Golden View Heights Subdivision, Lot 5B Request you issue a permit to drill a weft and install a septic system to serve the proposed four t~edroom house on the referenced property. Test holes were excavated and percolation tests performed by Jeffrey A. Garness. The approximate location of the test holes are located on the attached site plan. At the time of excavation water was encountered in test ho/es one and two at 9.5 feet and 10.5 feet respectively, and after seven day water monitoring water was found at 9 feet and 10.5 feet respectively. This property has enough area for a future septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, please conta, lSincorolY or require additional information for your review, Shafer, P.E. STRUCTURAL & MECHANICAL INSPECTIONS RAS/LSU/Isu ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP · SUITE 204 ° EAGLE RIVER, ALASKA 99577 ~o~ 0~ ND SONG DRIVE rL UTIL ESMT ~,SE 8 ~ 8 I .o6 ~ ~_ NVqd qlIS PERFORMED FOR: LEGAL DESCRIPTION; FEET) ~ 4 8 DEPARTMENT OF HEALTH & HUMAN SERVICES ~ , 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS I. OG -- PFRCOLATION TEST ~¥,fJ¢,.~.*.O~.~T :, ~1 - ~~ · __ / ~6.~ ~/p Township, Range, Section: SLOPE SITE PLAN Gross Nel Depth Io Net Reading Dale Time Time Water Drop ~. ~/,q~s ,,/~ i ~.'~ ,-,//.~ ~-'~" 14 15 16 17 18 20 - " :~ ~::>// PERCOLATION RATE .Z~ l (minules/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~- © FTAND 5. ~ FT ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINE~ IN EFFECT ON THIS DATE' DATE: PERFORMED FOR: LEGAL DESCRIPTION: DEPTH '1 4 5 -- 6 7 8 9 10 12 13 14 15 16 17 18 19 20 ~OMMENTS Municipality o! Anchorage ~ DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST ~ 'T'Iz~ BI~,V-F-~ DATE PERFORMED: L-O'T" ~'~..) ~°uPF-'a°vl%/,,D Township, Range, Section: N/> :' SLOPE WAS GROUND WATER ~% ENCOUNTERED~ ~ IF YES, ATWHAT ~. ~ SITE PLAN DEPTH? ~onilorln9? L Oro$~ Net Depth to Net Reading Date Time Time Waler Drop PERCOLATION RATE ,.-,.~% (minutes/inch) PERC HOLF DIAMETER TEST RUN BETWEEN ' ' FT AND FT ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and It/IA TERIAL SPECIFICATIONS REFERENCE: Golden View Heights Subdivision, Lot 5B GENERAL: 1. The scope of this project includes the installation of a 1250 gallon septic tank and a five foot wide drainfield to serve the proposed four bedroom residence for the referenced property. Construction shaft be in accordance with the approved site plan and design drawings; Municipal permit with any spe¢ial provisions or conditions; and aft applicable State and Municipal Wastewater Disposal Regulations. The contractor shaft be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shaft be responsible for final grading areas subsequently depressed from soil settling. On aft leachfield mound systems, the property owner shaft be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK IN$'rALLA TION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shaft include two 4" cleanouts for pumping access. The septic tank shaft be sufficiently bedded to prevent settling or shifting of the tank. Afl standpipes on the septic tank shaft extend a m/n/mum of 12 inches above final grade. Page Two Ge/den View Heights Subdivision, Lot 5B April 5, 1994 Septic tanks installed with less than 4 ft. of cover shaft be insulated. A foundation cleanout shaft be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shaft be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shaft be located on undisturbed soil not more than 10 ff. 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 shaft 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 shaft 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 barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter and installed approximately in the locations shown on the design. The portion of the monitoring tube extending through the gravel shaft 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. Page Three Golden View Heights Subdivision, Lot 5B April 5, 1994 MINIMUM MA TERIAL SPE¢IFItA TION$: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes ASTM D3034 (PVC) Yes ASTM F810 (HDPE-) Yes ASTM D2662 (ABS) Yes Yes Yes No 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 permeable nontoxic silt barrier (Typar 3401, M/raft 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, it's gradation specifications must conform to current M.O.A. or D.E.C. requirements. Page Four Golden View Heights Subdivision, Lot 5B April 5, 1994 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 be 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. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at/east 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 act/v/t/es. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no I/ability to the owner or to others for acts or omissions of the contractor or any other persons perfom?ing work on this project or the failure of the contractor to carry 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/OWNER • • Municipality of Anchorage •`f t ' On-Site Water&Wastewater Program (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 020-042-98 Expiration Date: 12-t 1. GENERAL INFORMATION Complete legal description GOLDEN VIEW HEIGHTS S/D; LOT 5B Location (site address) 15800 WIND SONG DRIVE, ANCHORAGE,AK 99516 Current Property owner(s) REBECCA POLLIS&SEAN WARNKEN Day phone 310-0628 Mailing address 15800 WIND SONG DRIVE, ANCHORAGE,AK 99516 Real Estate Agent CAROLE MARVEL W/DWELL Day phone 884-8912 2. TYPE OF DWELLING: • Single Family (w/wo ADU) ❑ Duplex I I Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well U Individual On-site U Individual Water Storage n Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for N/A Distance: - Received by: Date: COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ 55-6 v Waiver Fee$ Date of Payment Io`I( Date of Payment Receipt Number D5(itqh Receipt Number COSA# (5CIq i Z3S Waiver# 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 Certificate of On-Site Systems 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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E.TUDOR ROAD, SUITE 101 *ANCHORAGE,AK,99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date b/�3/1f`J Engineer's Comments: In conducting this evaluation,GEG provided an engineering evaluation of the well and/or septic system in accordance with the .��iS`\ig 1 guidelines and regulations established by the Municipality of Anchorage and industry practices.The reported results describe the * c OF ,r '•e condition of the systems on the date/s of the evaluation.Separation distances were measured to readily identifiable features. �� '\ 4 vh Hidden defects or encroachments may exist that were not identified during the evaluation.The operational life of all wells and septic *_\ •'••'••• �0 systems depend on a variety of variables including,but not limited to,soil conditions,groundwater levels(that may fluctuate during 4 •• • �. the year),quality of construction(materials and workmanship),and the water usage of the family utilizing the system's.These : i 'N t-* conditions can vary,and are outside the control of GEG.Satisfactory test results do not guarantee future performance of the ■ , i.. 0 .. system's;therefore,GEG makes no warranty(express or implied)regarding the future performance of the well or septic system. • •• GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the �,,,;;;, ,j current systems fail.The content of this report is for the sole benefit of the person/party who retained GEG.Reliance upon the �%U ; •'��• • information provided in this report by any other person or party,including but not limited to subsequent property ° '. G a rn•SS ••: �v q purchasers,is not �0 •/ CE- ' ��i authorized.In short,GEG disavows any legal duty to anyone other than the person/party who paid for this report. ,{ • V\ i 6. DSD SIGNATURE ♦•♦C 4-•pROFESS\...\P:4•• VLICENSE 41*ivimmillo• i0 System #1 Approved for I bedrooms. System #2 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: — By 1 I tt // "00 MF –r q Original Certificate Date: ^� The Municipality or Anchorage Develop,emt Services Division(DSD)issues Certificates of On-Site Systems Approval(COSA)based only upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTCHMENTS: - * . COSA Checklist X Nitrate Advisory , Septic System Advisory Arsenic Advisory Well Flow Advisory Other `� _ ' �� � �� (Rev.10/12/12) COSA Checklist Legal Description: GOLDENVIEW HEIGHTS S/D; LOT 5B Parcel ID: 020-042-98 If more than 1 septic system on lot: COSA Checklist# 1 of 1 Structure served by this system 1 A. WELL DATA ■❑Well log is filed with Onsite (or attached) Well production at time of test 4.7+ gpm Date drilled 5/3/94 Water storage tank volume NONE gallons Total depth 126 ft Well disinfected for coliform test? ❑ Yes 0 No Cased to 70 ft Coliform bacteria is Negative • Sanitary seal is functioning correctly Nitrate 0.292 mg/L ❑ Nitrate less than MRL (ND) 0 Wires are properly protected Arsenic ug/L ❑ Arsenic less than MRL (ND) Casing height (above ground) 12+ in. Collected by GEG, Ltd. Date of flow test for COSA 5/30/19 Date of Sample 5130,20,9 Static water level at beginning of test 18.7 ft. Comments B. TANK DATA C. LIFT STATION Age of tank(s) 25 years ❑ Required maintenance completed Tank type/material STEEL Age of lift station years ❑� Standpipes/foundation cleanout per record drawing Lift station material Date of pumping 10/26/2018 Comments: OPERATING LIQUID DEPTH IN ST1 =47.75" /OPERATING LIQUID DEPTH IN ST2=50.5" D. ABSORPTION FIELD DATA SHALLOW 5-WIDES Which system tested (date installed) 6'1-2194 Adequacy test date 5/3019 ■❑ ALL standpipes present per record drawing Results E Pass For 4 bedrooms Total measured depth from grade 4.5 ft(max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade 3.4-4.2 ft(min) Water added 608 gal ❑ N/A—pressurized field New depth 0 in ❑ Monitor tubes go to bottom of drainfield. If not, state Elapsed time 0 min depth into effective SEE COMMENTS ❑■ Code-required soil cover over field Final fluid depth 0 in Absorption rate 600+ gpd ❑ System presoaked NO (Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) date of test) N/A If yes, enter date Gallons introduced gallons Comments/Deficiencies:TESTED WEST TRENCH ONLY.EAST TRENCH REMAINED DRY THOUGHOUT TEST.MT1 ON EAST TRENCH ONLY EXTENDS 3 BELOW INVERT OF DISTRIBUTION LINE COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot> 100' Community Sewer Manhole/Cleanout> 100' ['Yes if No ft Q✓ Yes if No ft Neighboring Tank > 100' 11 Yes if No ft Private Sewer/Septic Line>25' Q✓ Yes if No ft Absorption Field on Lot> 100' illYes if No ft Holding Tank > 100' Q Yes if No ft Neighboring Absorption Fields> 100' Animal Containment> 50' Q Yes if No ft Q✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Q Yes if No ft Z Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations> 10' Q Yes if No * ft Surface Water> 100' Q✓ Yes if No ft Property Line > 5' ['Yes if No ft Driveway/Parking > 0' E✓ Yes if No, comment Absorption Field > 5' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' Q Yes if No ft Private Wells > 100' Q✓ Yes if No ft Water Service Line > 10' Q Yes if No ft Community Wells > 200' ['Yes if No ft From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Q Yes if No ft Driveway/Parking > 0' Z Yes if No, comment Property Line > 10' [' Yes if No ft Wells on Adjacent Lots: Water Main > 10' Z Yes if No ft Private Wells> 100' Q✓ Yes if No ft Water Service Line > 10' I✓ Yes if No ft Community Wells> 200' I✓ Yes if No ft Surface Water> 100' Q✓ Yes if No ft F. ENGINEER'S COMMENTS *5'+ TO DECK o�o�00\\' G. ENGINEER'S CERTIFICATION o OF A ��Q I certify that I have determined through field inspections and review �'` • �; 00 of Municipal records that the above systems are in conformance with Q�•a C * D MOA COSA guidelines in effect on this date. 0 Q D f 'I • J e f^n' ,. a rr e-s:• O0 . 00 '• ! E-7 09. . Li .pf, ••.o !3 � ,c' �4Q��rofessooCOSAChecklistyellowsheet #AECC884 \0000 MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT • F r�"1. 907-343-7904 On-Site Water and Wastewater Section Fax: 343-7997 www.muni.org/onsite Septic Tank Advisory Certificate of On-Site Systems Approval #0SC191235 Subdivision: Golden View Heights Lot 5B Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 25 years old. Typical replacement costs range from $6,000 to $9,000. This advisory must be attached to all copies of the subject Certificate of On-Site Systems Approval. This is an example of what the metal of a 20 year old steel tank MAY look like. •-*.,., y r ` r Vity : • z a r44,'* 1 '; ,..,..5,;_.! • f\ .. • j A ti 3 � Mailing Address: P.O. Box 196650*Anchorage,Alaska 99519-6650 *www.muni.org N89459 ?z'� zoo-. - ---------------- `, io 're-4,filer: y4 sr'T/airy � :.,i. of M V• t. • rig 1:: - ;• , :If4 B: is 11 ►,i • , • °fri'TI . c ! �, . ,. P _ /0 Uli► /sem` - - _.._ \ \ ,� pf iUl_L ti� i 04 a 0 c k, di k \o ; k, \/- 'iv i, �/-. SO ( \/6� I . V c I sir • / 4,111 0 0 I it;'b ' ".; pilt I I .: • r 60064111 i �v ",Sy'SS'E /06 Pc t 1 /9Ze jr. 7,47GST7 d'/. S// 9 , ; ' f72 -' ',1;', ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 694-0829 I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE= FOLLOWING DESCRIBED PROPERTY: " ' 3a QF A r It tt iaill-�/ vl�yi,,,:rr-vys so©<' /a7-,;-",•;"' DATE: a�� .. .,•.'��S` �, AND THAT NO ENCROACHMENTS EXIST EXCEPT AS isAr �•. -. ! INDICATED. IT IS THE RESPONSIBILITY OF THE �� 9� i* 43_" = OWNER TO DETERMINE THE EXISTENCE OF ANY GRID: -00... ''' EASEMENTS, COVENANTS, OR RESTRICTIONS .�za8 ��, ••;:;�; It _ GGA WHICH DO NOT APPEAR ON THE RECORDED SUBDI- V. Dwne Mirk Seward VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB' �` .•. 1S-6918 . �,F0 ANY DATA HEREON BE USED FOR CONSTRUCTION so-09 �1 , •., •.� ( #' OF FENCE LINES, OR FOR ESTABLISHING BOUND- '�� ••.• �"�" ARY LINES. DRAWN t���� •f•' ..e2-';---r" MunicipalitY of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 E!more Road P..O. Box 196650 Anchorage, AK 99519-6650 / vWCvV.~ U ru .o~ g~ uFl~ ~.~ (907) 343-7904 CERTIFICATE FOR A OF ON-SITE SYSTEMS APPROVAL SINGLE FAI','llLY DWELLING Parcel I.D. 020-042-98 1. GENERAL INFORMATION Expiration Date: /!' g -/! Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent M~iling address GOLDENVIEW HEIGHTS 15800 WIND SONG DRIVE * STEPHANIE MARTIN 15800 WIND SONG DRIVE S/D; LOT 5B ANCHORAGE, AK * 99516 Day phone 545-8150 · ANCHORAGE~ AK * 99516 Day phone ANNA SCHULMAN W/ PRUDENTIAL Day phone 677-9067 3801 CENTERPOINT DRIVE, #200 * ANCHORAGE, AK * 99505 Unless' otherwise 'requested, COSA will be held by DSD for pickup. NUMBEROF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well · Individual On-site · Individual Water Storage [] Individual Holding tank [] Community Class Well [] Community On-site [] Public Water System [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for 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 COSAs upon request to homeowners. Certificates of On-Site Systems 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 samples. (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. 4. STATE,¥.'ENT OF !NSPECT!ON BY ENGINEER As certified by my sea/afT?xed hereto and as of the validation date shown be/ow, I verify that my investigation, based on procedures outlined in the Certificate of Qn-Site Systems Approval Guideiines for this application, ;~a~t~v~a,=, d~s~o~a .......... shows ~,~a~ '~ ' ~,,e'~ u,~-o,~" ~'~ water supply and/or ..... *^, ~ . ~ ~ system it ,.~,f~)~ ~.¢,~, functional ~d adequate for the number of bedrooms and type of structure indicated herein. I fu~,Ser verify that based on the lfiiOl~lOfi OU~II I~U I1 UlII U ~ fvlU ,l~[p~Jl~ O, ~n~,ffo, ~ge files and ~m my investigation end 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 GARNESS ENGINEERING GROUP, Ltd. Phone 357-6179 Address 5701 Eo TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.Eo Date Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue, to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal.figl~t whatsoever. DSD SIGNATURE ~ Approved for L~ Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: t.,~o,~, C Septic System Advisory Well F/ow Advisory (Rev,~~Wj' - .~.rsen.c Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: Ao Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: GOLDENVIEW HEIGHTS S/D; LOT 5B Parcel ID: WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) 020-042-98 YES Date completed 5/3/1994 Total depth 105 ft. Date of test Static water level Well production 9 WATER SAMPLE RESULTS: Coliform (~ colonies/100 mi. Arsenic: ~ ~ ug./L. SEPTIC/HOLDING TANK DATA Sanitary seal (Y/N), YES Cased to 70 ,ft. FROM WELL LOG 5/3/1994 36 .ff. g.p.m. NitrateJ~) J~ mg./L. Date of sample: Tank Type/Material SEPTIC/STEEL Tank size 1250 gal. Number of Compartments Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 7/7/2011 9 ff. 5.15+ .g.p.m. YES 12+ in. Collected by: 7/7/2011 GEG, Ltd. Date installed 6/1-2/1994 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Date of pumping -~-/~ ~/I' ABSORPTION FIELD DATA [*BELOW EXISTING GRADEI Soil rating ~r ft2/bdrm) 1.0 Date installed 6/1-2/1994 (30' & 90') Length 120 TOTAL .ft. Depression over tank (Y/N) NO High water alarm (Y/N) Pumper. A+ HOME SERVICES N/A System type DUAL TRENCH Width 5/5 ft. Gravel below pipe 0.5/0,5 Total depth .4.1/4.6 ft. Eft. absorption area 600 ft2 Monitoring tube YES Date of adequacy test *'7/7/2011 Results (Pass/Fail) PASS Depression over field NO For 4 bedrooms Fluid depth in absorption field before test 0 in. Elapsed Time: - min. Final fluid depth 0 Any rejuvenation treatment (past 12 mo.) (Y/N & type) **;30' TRENCH WAS 100% FULL AT TIME OF TEST. Water added 600 gal. New depth 0 in. in. Absorption rate >= 600+ g.p.d. NONE KNOWN If yes, give date - TESTED 90' TRENCH ONLY. D. LIFT STATION Date installed "Pump on" level at in. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Size in gallons Manhole/Access (Y/.(.~_) f "Pump off" level ~ High water alarm level at Cycles tested. Meets alarm & circuit requirements? 100'+ Septic tank/lift station on lot Absorption field on lot 100'+ Public sewer main N/A Sewer/septic service line 25'+ Animal containment areas 50'-I- .in. On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout Holding tank N/A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property ine 5'+ Water main N/A ' Water service line 10'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'-I- Building foUndation. 10'+ Water service line 10'+ Surface water 100'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ Absorption field 5'+ Surface water. 100'+ Water main N/A Driveway, parking/vehicle storage 10'+ F. COMMENTS 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 COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS / Date "7 I'Z.-~ / I / COSA Fee $ Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Parcel I,D. # 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 MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISIOF JAN 2 ? 19.9-7 RECEIVED 1. GENERAL INFORMATION Complete legal description Location (site address or directions) /~OO ,4,¢_ ,'446 Property owner ./(-~%t ¢% lr'~ '~.~ Day phone Mailing address Lending agency Mailing address Day phone Agent ~:~'~//' /----~¢6c~/'/ Dayphone ~57-0//~' Address .~¢,~¢,-X /5~//;q Z~O ~~ ~~e~ 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- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: '-' · · Individual on-site X 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. 72-02§(Rev. 1/91) Front MOA#21 J 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, ordinances, and regulations in effect on the date of this inspection. Name of Firm KND i:.~;,.,o,,,;.,, Phone ~ ~ -~;//// 20441 Ptarmigan Bvd. Address ~ ................. EngineeCs signature ~yt~ Date DHHS SIGNATURE ' ,,/~/Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By:/~" / ~ Date .2.-.~-7~F --,- ;:,; '?. :.' ~, ..? ./ - _ '~rhe MuniciPality of A~h°rage Depa~ment of Health'and Human Se~ices (DHHS) i~ues Health Authori~ 'Approval ce'~ific~t?":baS¢ only upon the representations given in paragraph 5 above by an independent profe~ional engin~r register~ in the State of Alaska. ThC DHHS does this as a cou~esy to purchaseB of hom~ and their lending institutions in order t° ~tis~ ce~ain federal and state r~uirements, Employes of DHHS do not conduct inspections or anal~e data before a ce~ificate is i~ued. The Municipali~ of Anchorage is not responsible for erro~ or omi~ions in the profe~ional engin~ffs work. · : ' 72-o25(Rev. 1/91) Back MOA~Y~I :: MUNiCIPALiTY rNW~oN~4~Nr^L Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division : 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343,¢.744 Health Authority Approval Checklist Legal Description: Parcel I,D.: (~(.-)C~¢~-¢~ A, WELL DATA ,, // Well type ////¢7¢/~'/~Y/~¢¢ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date compJeted Total depth /,~ ' Sanitary seal (Y/N) Y Cased to '~) Casing height (above ground) Wires properly protected (Y/N) Date of test Static water level Well production FROM WELL LOG g.p.m. AT INSPECTION g.p.nl, WATER SAMPLE RESULTS: Coliform (~ Nitrate ~ Date of sample: ¢~/~ ~/ Collected by'. B. SEPTIC/HOLDING TANK DATA Date installed ~'/¢¢ Tank size Foundation cleanout (Y/N) Y' Depression (Y/N) /V' Date of Pumping //~//¢¢ Pumper /~'-~ C. ABSORPTION FIELD DATA Date installed (¢/~4/ Soil rating (g.p.d./fF Length /,~_~t ~.~,~t Width Gravel thickness below pipe Effective absorption area ~_¢ ~) O Monitoring Tube present (Y/N) Date of adequacy test //~.O/~ 7 Results(Pass/Fail) Other bacteria Number of Compartments ~ Cleanouts (Y/N) High water alarm (Y/N) /, O System type 5'~-~.0 , -~ Total depth ~¢, __ _ Depression ever field (Y/N) For _ ¢ bedrooms FMd depth in absorption field before test (in.); ~__ Immediately after ¢¢?'~gal. water added (in.): depth ¢ (ins) Minutes later: ,2,x2 Absorption rate = ~¢'¢~:~'tL g.p.d. Fluid Peroxide treatment (past 12 months) (Y/N) /V' If yes, give date 72-026 (Rev. 3/96)* LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /~D t.~ Absorption field on lot /O O 'Jo On adjacent lots On adjacent lots Public sewer main Sewer/septic service line /00 ~4 Public sewer manhole/cleanout Lift station /V/-~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation /~) /'+ t Property line /0 '+ Absorption field /0 Water main/service line ~--*~'/~ Surface wateddrainage /~O ~ _ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /O / .b Building foundation /'L~) /'/' Water main/service line Sudace water /O~ /4- Driveway, parking/vehicle storage area Curtain drain A~o,?~/{'//,?~u.~/') Wells on adjacent lots /c/-.~) ENGINEER'S CERTIFICATION ,. I certify that I have determined thru field inspections and review of Municipal recor~d~t(~i~ aj~jTVb_~t~tems in conformance with MOA HAA guidelines in effect on this date. ~;~ .,.~ · ~.. ~...~ ~ Signature Date HAA Fee $ ~ '" ~ Date of Payment Receipt Number c::~'~,~ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Parcel I.D, # OZO--0 ~ _C/~ Complete legal description Heights S/D DEPAFITMENT OF HEALTH & HUMAN SERVICES_ . Division of Environmental Services .:~ . On-Site Services Section ' ' ' P.O. BoX196650 AnchOrage'Alaska 99519.665 i ..!." 343.4744 :CERTIFICATE OF HEALTH AUTHORITY i APPROVAL FOR A SINGLE FAMILY DWELLING Lot 59; ' 'Ool'den View Location !s te address or directions) 'Kristen M. Abegg Property. owner Day phone Ma!lingaddres§ e/o Jack Nh±re 3201 C St., .~ 'Suite 100, Anchorage, AK 99503 ~ Lending agency Day phone /Mailing address_ 22Q-52R7 Agent Address :' Day phone Unless otherwise requested, HAA will be held for pickup. -; ' . ~. ',', : ;.i.;"i : 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual well xXX Community well NOTE: Public Water · . ., %??/', ,,. If comm~nitT' well system, provide written confirmation from State AD£C atte~ lng to the legality and status of system... TYPE OF WASTEWATER DISPOSAL: Individual on-site ..... '. Holding tank Community on-site NOTE: X ,Public sewer -. - If community wastewater system, provide written confirmation from State ADEC 72.025 [Rev. 1/91) Front MOA ~21 :" attesting to the legality and status of systemp;,,: ' '* ' ?'" ' ':"' 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 furthe~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. Name of Firm s & $ ENGINEERING Phone ! 7034 Eagle River Loop Road No. 21)4 ' Address Eagle Rive.; A,~?b., ??=~,-,~ ..- E ngineeCs signature ¢//'~_~~~ ~,~_~.c..-_-- Date 6. DHHS SIGNATURE ~ Approved for __ Disapproved. bedrooms. bedrooms, with the following stipulations: Conditional approval for :-~dditiOn~l Comments .-, 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 . c°n~luct inspections o~ analyze data before a certificate is issued. The Municipality of Anchorage is not ' :-'~'-" :i re~po'nsible for errors or omissions in the professional engineer's work. ' .... :, ',,_ ' .' : :ii:i-i:::. .! '. ,,. :: ' i'"": !'!' ' "¢ i' ":":" "',-. " .. :"" "'- " ~ ¢ ' " '.:';'::"'.. · :" i, '72-025(Rev, I/91) Back MOA¢21 -;.¢'.-, . . _. :.; .; ,,.. , ,.. , . · :'."",:..~.i ;;:.,- . :~-,:. · . ........ : . - . Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A, Well Data Well type Log present (((((~N) Total depth / Sanitary seal ON) If A, B, or C, attach ADEC letter. ADEC water system number /t.//,,~ Date completed ~/,~ / ~"~r- Driller ~JCl/.JE /.)~lLL/tJ(~ ¥ ~'~/"J~, Cased to ¢~ ' Casing height ! Wires properly protected(~N) FROM WELL LOG Date of test Static water level ~::~ Well flow Pump level1 g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/-ho,~Id~,-~g-tank on lot / I ~ / Absorption field on lot /'¢/ ~ Public sewer main /'~.~- ~¢' Sewer service line AT INSPECTION ; On adjacent lots /00 ; On adjacent lots /00 Public sewer manhole/cleanout Petroleum tank ~o~E WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Collected by: Other bacteria B. SEPTIC/HOL-DtN~ TANK DATA Date installed Cleanouts(~N) High water alarm (Y~'~ Date of pumping Tank size Foundation cleanout(~) Compartments Depression (Y~) Alarm tested (Y/N). Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDhN6-TANK TO: Well(s) on lot To property line Surface water/drainage On adjacent lots Absorption field Foundation ~ Water main/service line /© 72-026 (3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level ~ ..-----"'"~Cycles tested Meets MOA electrical codes (Y/N) _ SEPARATION DIS~OM LIFT STATION TO: On adjacent lots ABSORPTION FIELD DATA Manufacturer Manhole/Access (Y/~.~-~ ~ off" Level at Surface water Date installed Length /~2(3" Total absorption area ~_¢oz~ ~ Cleanout present~) Date of adequacy test ./L)/~ ~c¢~ .~'¥.~ 7'~'.-~ Results (pass/fail) Water level in absorption field before test Peroxide treatment (past 12 months) (Y/~) ~ (/~ Soil rating (GPD/Ft2) /, Width .~' / Gravel thickness System type ~f/~f. Lo~ Total depth ~:~ Depression over field (Y~ for '"~///g- Bedrooms After test /tY///j' If yes, give date /--J///~r SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /zC/L/" To building foundation On adjacent lots Surface water ~ On adjacent lots ~ /-/- Property line ('o To existing or abandoned system on lot Cutbank /t/z~'~~- ~'~O(=S~J~FWater main/service line /O Driveway, parking/vehicle storage area -~ Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guideline~of this inspection. f.i,?O.,,'~. ~1:-8801 ," ... ?/ HAAFee$ t~¢~, Date of Payment <::~¢- Reoe,pt N.mber Waiver Fee $ Date of Payment Receipt Number