HomeMy WebLinkAboutGREAT LAND ESTATES #3 BLK 3 LT 8
i MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
$25 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEB/AGE DISPOSAL SYSTEM AND/OR B/ELL INSPECTION REPORT
NAME
~ UPGRADE
MAI LING ADDR~S
LEGAL DESCRIPTION
LOCATION
WC ~¢~ C~ee ~ NO, OF BEDROOMS
DISTANCE TO: ] Well Absorption Dwelling PERMIT NO.
N ~ Manufacturer
~ < Liq, ~ Material ~'ff~ /
~ ~ ~ ~ ~_ ~ No. of compartments
capa~allons IF HOMEMADE: Inside length / Width Liquid depth
DISTANCE TO: Well Dwelling PERMIT NO,
Manufacturer Material Liquid capacity in gallons
D Well Foundation Nearest lot line PERMIT NO,
~ DISTANCE TO: /00 r ~ / ~ /
~ ~ ~ No. of lines Length of each line ] Total length of I~nes Trench width ~ Distan een lines
~ ~ Top of tile to finish grade ~ Material beneath tile
~ ~ .~~ ¢ ~ / Total effective absorption area
Length Width Depth
~ PERMIT NO,
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ DISTA~C[ TO: ~ell Buildin~ foundation ~earest lot Nno
~ Class De~th Driller Distance to lot line CE~MIT ~O.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
SOIL TEST RTING , ~ ~
iNSTALLER ~ ~ '
~ ~;~ ~e ~ ~ LouisA, 8ufera ~ ~g ~. % ~
APPROVED DATE LEGAL
~oF ~ ~,~ ~ -~ , ~_ , ,
MILE,,501/2 PARKS HWY
892-7950
'JOE GIELAROW KI
DRILLING CO.
LIFETIME ALASKAN SERVING ALASKA
P.O. BOX 772847, EAGLE RIVER, A!..ASKA 99577
)WNER OF LAND ...... ~co.~=..&..D~bbAe..El~m~.~g ...........................
~DDRESS p.o.Box 773887 EAgle R±ver,Ak. 99577
YELL - SITE
)ATE - STARTED ...... 6Z2L]~ ................................................................
)ATE - ENDED 6~22~85
DEPTH OF WELL ....~..~....~..t;., ..............................................
STATIC LEVEL OF WATER FT ...... .~.Q.Q....F..~.t...~...n....h..9..1..e.,
DRAW DOWN FT ...... .9...5.~....e..s..t.., .........................................
GALS. PER aR ..... .3...O..0...~.a..t..E..P..e..r..:....h..r..:....e...s..t.... .............
raND OF C~SINO ?.3....Et........o..L.6.....%"........e~.h..:...~.~O... .......
~ND OF FORMATION:
FROM ...........O ......... FT. TO ........~ .......... FT..~g~.~ ........
FROM ...........
FROM ..: ........ 65 ....... FT. TO ........
FROM ........... ~3 ....... FT. TO
FROM ........... 62 ....... IT. TO
FROM ........... 22 ....... FT. TO
........ 6Z .......... FT..k~Q~k .................
........ 22 .......... FT..~r.~..EOf~k/water
..... 105 .......... FT..~.ock .................
FROM ........ A0~ ...... IT. TO ..... llZ .........FT..~c~t~r.e~..<o. ck/water
FROM .........!~Z ...... IT. TO ......~ ......... FT..~§~.r.O~.~ .................
FROM ........ ~ ...... IT. TO ......~Z ......... IT..~.~.~..~p.~/water
FROM ..~ ...... ~Z ...... IT. TO ..... i~ ......... FT..~.O.E~.~ .................
FROM ...................... FT. TO ...................... FT ....................................
FROM ...................... IT. TO ...................... FT....; ...............................
FROM ....................... FT. TO ....................... FT .............
FROM .............; ......... FT. TO ........................ FT ............
FROM ..~M0~,4L, tev.,Er. TO ........................ ~ ............
DEo~" ~. oF ANCHo~o
FROM ~V~ ~ & ............. ~ ............
............ ...................... ............
FROM ..................... ~. TO ........................ ~ ............
...........
....................... ...................
FROM ....................... ~. TO ....................... ~ ...........~
FROM ....................... FT. TO ........................ ~ ............
FROM ....................... ~. TO ....................... ~ ............
FROM ....................... ~. TO ....................... ~ .............
FROM ....................... ~. TO ........................ ~ ............
,IISCL. INFORMATION:
Hang pump 10' off bottom.
No septic on site at time of drilling.
No warranties or warranties implied.
DRILLER'S NAME .................. .l~ OX~ ~tD,,.~,~ ~, ~.~.li .............................................
PtSRM I ]-' NO:
DATE: ISSIJED:
DEPAfRTMENT~.L HEALTH Al'ID ENVIRONMENTAL i ,:[]TEC]"ION -nc~j~.
' 264-47;7.() " ' (-¢,, ~-~ ~,,~
"'It'"' E~: ~= ..... . ~ ......... '
AF:'PL ]. [, 41,11:
C£..Iq 1A~[, 1 PI-,IOtilE,,.
()6 / 12/85
DEB(]RAH J. F'I...EMING
F:'O BOX 77:5736
[<Af3LE R I VER, AK ':?95'77
694'""7976
I-EGAL DESCRIP," SUBDIV]':SIOb~: G'REATLAND ESTAT'ES
SEC'I'ION: 10 T'OWNSHIF': 15N
(..CFI' SIZE: 90605 (SQ,F'T, OR ACRES)
LO]" LOCA]]:ON~ GREA'r'L:AI'4D CIRCLE
MAX BEDROOMS:
RANGE: 1W
l_isted belc)w ar'e the options available t.o you ir'f des:i, gning your septic
system, Choose the Opt, ion that best ~i'Ls your' site.
,DEPTH T'O'PIF:'IE BO'I"TGM (FT.)
· GI:~AVEL DEPT'H (F:]".)
]"OTAI_ DEPT'H (F:"1-4)
GRAVEL WID'TH (F"T,)
GRAVEL LENGTH (F'T,)
GRAVEL. VOLI,JME (CU. YDS.
TANI< SIZE (GALS)
St::)]:(_ RA'I"[NG (SQ~.FT, /[JR)
*'~-~ I'ANI< MUST HAVE AT' LEAST TWO COMPAR'I'IqENT'S
I certi{y that:
1., I am familiar, with t. he ~'equirements for' 'on-site sewers and wells as set
forth by t. he Municipality of AnchoPage (MOA) and the Stat. e of Alaska.
2. I will install the system in ac. coPdanc:e with all' MOA codes and ~egulations,
and in compliance with the design c['itePia oF this pe['mit,
3. I will adhere t.o all MOA and State o~ Alasl<a requirements for the set back
distances fPom any existing ~ell, wastewat, eP disposal'syst, em or' public
sewerage syst~em on this or any adjacent or. nearby lot.
: zl.~ I under'stand that this permit is valid for a maximum o( 3 bedr'ooms and
any enlargement, will r'equir'e an additional permit.
IF: A LIFT STATION IS INSTALLED IN.AN AREA COVERED. BY MOA BUll_DING (]ODES;,
THEN (1) Alii ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT' BE APF'ROVED WI'I"HOUI" AN EL.ECTIRICAL INSF'IEC'I"ION REF'ORT';. AND. (3) ']"HE
[<L. ECTRICAL. WORK MUST BE DONEE BY A LICENSED ELEC]"RICIAN.
DATE
AF:'PL Z CAN]': ~BOF, t/~I-4) ~, FL..EM ]: N~'~ -
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION [] PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720 f~'.~'~~-~-"~
so.s ,oG- .ERCO'ATION TES'~ ~S
DATE PERFORMED:
COMMENTS
SLOPE SITE PLAN
WAS GROUND WATER ~JO ~
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
RATE
TEST RUN BETWEEN
FT AND -- FT
PERFORMED BY: ~::~-~ ~ ~
CERTIFIED BY:
DATE:
72-008 (6/79)
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
Parcel I.D.# ~-)~\ -
1. GENERAL INFORMATION
Complete legal description
Lot 8;
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
19911Qui~t Way
Chu~iakt AK
D~b F£~ming Day phone 688-~859
P.O. Box 670269 Chu~iak, AK 99567
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well XXX -
Community well
Public water
NOTE:
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on;site
Public sewer
XXX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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, fun'ctional 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.
S & S ENGINEERING
Name of Firm 170~4 ~.agJe EJvel' ~-~ad No, 304
Phone
DHHS SIGNATURE
Y Approved for -~
Disapproved.
Conditional approval for
bedrooms.
bedrOoms, with the following stipulations:
Additional 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 ~,d independent
professional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of 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.
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~ ~;A-V-''~ /_..~-dp~-ft..~i:) -~<.~ Parcel I.D.
A. WELL DATA
Well type '~\1 ~ If A, B, or C, attach ADEC letter.
Log present ~/N) ~ Date completed
~"~ ~ Casing height
Wires properly protected (~N)
AT INSPECTION
Total depth \ ~'
Sanitary seal Y~N) "{
Cased to
FROM WELL LOG
Date of test (,p ~ "~:7.- ~ ~'-
Static water level \ dc, \
Well flow ~ c>
Pump level \ ~" ~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot \~-~
Absorption field on lot
Public sewer main ~\~'
Sewer service line
WATER SAMPLE RESULTS:
Coliform ~ Nitrate~
Date of sample: L~
g.p.m.
ADEC water system number
b, ~ 7.'7.-- ~ ~, ~- Driller
'~. t.~, g.p.rn,~
; On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
B. SEPTIC/HOLDING TANK DATA
Date installed L. ~ ~>~"
Cleanouts ~)N) ~
High water alarm (Y/~
Date of pumping
Other bacteria ~
S & S ENGINEERING
17034 Eagle River Loop ~oad Ne, ~z6,i
Collected by:
Tank size \
Foundation cleanout ¢~/N)
River, Alaska 99577
Compartments
Depression (Y~I,~
Alarm tested (Y/N)
~--"~L-~'~ Pumpe~ '~'_~,' ~..~'~t::'~',~-~,"
Well(s) on lot \ k~ ~
To propertyline \C)
Surface water/drainage
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
On adjacent lots ~ c:,c> Foundation
Absorption field \ ~ .Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
Manufacturer
Manhole/Access (Y/N) ~
"Pump on" level at .-~-'"~ump off" level at
High water alarm level .-----'""-'"""~Cycles tested
Meets MOA electrical code~
SEP~NCE FROM LIFT STATION TO:
W'~11 on lot Surface water
On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length ~ t ~ Width ~- I
Total absorption area
Depression over field (Y~ ¥~
iesults~ail) ¢ Jk~-~
Peroxide treatment (past 12 months) (Y~)
Soil rating \'?~<~ lt~¢~-
Gravel thickness "~.~ ~
Cleanouts present ~/N)
Date of adequacy test
for "~
~ ~ ~.,_.k. ~_~ If yes, give date
System type
Total depth
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot \
To building foundation "~"7~\
On adjacent lots
Surface water \
Curtain drain i~ ~-
On adjacent lots \ ~,=' ~ ~ Property line
To,existing or abandoned system on lot
Cutbank ¢'\ ~' Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
Signature/certify that~dl have checked,
Engineer,sN~1461 ,~~
Date
to all MOA and HAA guidelines in effect
HAA Fee $ // ',7 ~) ,¢¢;E"D
Date of ayme.', ¢-
eceipt um er ¢ ? ? Z /¢'¢, 7 /1
Waiver Fee: $
Date of Payment
Receipt Number
· "" ~' ~ CT~E ENUIRONMENTAL LAB SERUICES ,' NO. 194 D02
06715/93' 11:~8
ENVIRONMENTAL LABORATORY 8ERVICE~
~=~c. ....... R~RT of ANALYSIS ~6~3 B STREET
Chemlab Ref,~ :.3.2 120-1
Matt ix ~
Client'Name :S & S ENGIN~R[NG WORK Order .:6~077
Ordere~ By :R, SHAF~ Re.ri Complet~ ;0~/14/93'
Collecte~ ~06/10/93 ~ 15t20 hrs.
Project Name : Received :06/1~/93 8 15:48 hfs
Project~, : Teci'~nica~ D~ rector:
QC Allow~le Ext. ~nal
Par~et~r Re~ult~ Q~I units Hethc~ [,[mits Date ~ate Init
............................................. .......
Ni~rate-N
See Special Instruction~ Above NA = Not /%nalyzed
See S~ple Remarks A~ve
Undetectea, ReD0rt, ed value tS the practical qu~ltification li~it. [,T = [~ess Than
' GT = Greater Than
Secondary dilution.
'i
~,,~sr~s Membel: of the $G$ Group (Soci¢t6 G~n6rala de Surve]l!ance)
'~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date 12/17/85
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 8, Block 3, Greatland Estates
T15N, R1W, Sec. 10
Location(addressordirections)
Quiet Way
(b) Applicant Name Scott Fleming Telephone: Home 688-2859 Business 694-7976
Applicant Address P.O. Box 773736, Eagle River, Alaska 99577
(c) Applicant is (check one): Lending Institution I-I; Owner/builder 1~1; BuYer []; Other [] (explain);
(d) Lending Institution
Address
Telephone
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF. RESIDENCE
Single-Family [~ Multi-Family []
Number of Bedrooms 3
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.
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM PROVIDINt iSPECTIONS, TESTS, FILE SEARCH, DA', 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 Approval 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 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 Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm Telephone
Address
Date
Engineer's Seal
ENGINEER'S ORIGINAL STAMP
AND SEAL ON FILE WITH DEPT.
OF HEALTH AND HUMAN SERV.
DHEP APPROVAL
Approved for Three(3) bedrooms*by
Approved Y3( Disapproved
Terms of Conditional Approval
NOTE:
~ Date 1-22-86
Conditional
This approval based on applicant's certification that well is actually
located on this lot. See attached Notice of Indemnity.
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)
iP.-'¢E O ? 6 2
376
NOTICE OF INDEMNITY
AGREEMENT RE: SURVEYING ERROR
In consideration of-the Agreement of the MunicipalitY
of Anchorage to issue health authority approval for water and
septic systems servicing Lot Eight (8), Block Three (3),
GREATLAND ESTATES SUBDIVISION, Unit No. 3, the undersigned
owners give notice that they have agreed 'to i~demnify the
Municipality of Anchorage, its agents, successors and assigns
for questions or errors of survey of such facilities serving
the lot, and their respective locations vis-a-vis rights of
way, boundaries and easements. Nothing in this notice should
be interpreted to indicate' Ghat the described systems do not
meet or exceed Municipal requirements established under Title
15.55 and 15.65 of the Anchorage Municipal Code (known as water
well and wastewater standards) and relating to design,
installation, performance and separation requirements.
DATED this ~Z day of January, 1986, at Eagle River,
Alaska.
DEBORAH J.(JFLEMING (/
Owner v w
STATE OF ALASKA )
) SS.
THIRD JUDICIAL DISTRICT )' '
THIS IS TO CERTIFY that on the
ay of January,
1986, before me, a notary public in and for the State of
Alaska, duly commissioned and sworn as such, personally
appeared SCOTT T. FLEMING and DEBORAH J. FLEMING, known to me
to be the individuals named herein, who acknowledged to me that
they executed the foregoing instrument freely and voluntarily
for the uses and. purposes mentioned therein, and that the same
was their act.
IN WITNESS WHEREOF I have hereunto" set.'"my hand and
official seal on the day and year last above
It ;' ~' '." :; ~: '[;. ~ · Notary Publl~:~:f~]~ff
[)IS f RlOl ~?'"
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date 12/17/85
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 8 Block 3, Greatland Estates T15N
R1W See.lO
Location(addressordirections)
Quiet Way
(b) Applicant Name Scott Fleming Telephone:Home 688-2859 Business 694-7976
Applicant Address P.O. Box 773736, Eagle River AK. 99577
(c) Applicant is (check one): Lending Institution []; Owner/builder'S]; Buyer []; Other [] (explain);
(d) Lending Institution N/A Telephone
Address
(e) Real Estate company and Agent N/A
Address
Telephone
(f) Mail the HAA to the following address:
pickup
TYPE OF RESIDENCE
Single-FamilyTJ~] Multi-Family []
Number of Bedrooms 3
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
attestin9 to the legality and status.
Page 1 of 2 72-025 (11/84)
ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA J A 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 Approval 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 verity that based on the information obtaine.d
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wasteweter disposal system is in compliance with ail Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm EA6LE R!VER~4,]G!NEERING S~ER Telephone
Address EAGLE RIVER, AK 99577
P. 0. BOX 773294
Date 694 5195
Eng~,~eer's Seal
C:E. 6 ;"3~$ °
Approved for ,~'~ bedrooms bY .
Approved ,~ Disapproved Conditional
Terms of Conditional Approval
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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
~ UNICIPAI'ITYd:~I;~(~'E B R UA R Y 1984 DEPT. OF ~'A~f-~ 264-4720
ENVIRONMENTAL P.~OTECTION
Legal Description:
OEO l 7 1985
WELL DATA
Well Classification ,~ ~'~-,4 ~-~'
Well Log Present (Y/N)
Total Depth 1/-¢ ¢" ~ Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
.RECEIVED
If A, B, C, D.E.G. Approved (Y/N) ,'~'J,~'~
Date Completed ~'/¢' ~-/'¢ ¢' Yield
..~-3" Depth of Grouting
Pump Set At /'~,~;"""""""""'~
Sanitary Seal on Casing (Y/N)
/Y Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments ,2.,.,~ ~/?
; On Adjoining Lots ~','~'~
~/~" ' ; On Adjoining Lots "/¢'~'
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date /~ .-//~"/~¢
B. SEPTIC/HOLDING TANK DATA
Date Installed ~"&
Standpipes (Y/N) /Y
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well /Oo ~
To Property Line '¢'1~ ¢
To Water Main/Service Line
Course ,"~¢'~ ~,¢;¢Z,.' /~,~ '
Size XOoo ,.¢~ ? No. of Compartments
Air-tight Caps (Y/N) _ 2V Foundation Cleanout (Y/N) ,Y
Date Last pumped
; for
Temporary Holding Tank Permit (Y/N) ,,~J/.4
To Building Foundation /'~ ·
To Disposal Field
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/N) ~
Results of Last Adequacy Test //~'¢ ,-¢
Separation Distance from Absorption Field:
To Water-Supply Well /'¢'~ '
To Building Foundation :~ r
Lot ,/b-'¢-.~¢~
Type of System Design
Length of Field z,,,/ /
Depth of Field ? ~
Gravel Bed Thickness :~ ~"
Standpipes Present (Y/N)
Date of Last Adequacy Te~t
To Property Line ¢ :~ o~
To Existing or Abandoned System on
; On Adjoining Lots 3 ,~
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Cutbank (if present)
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"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 _,-- ~ ~'¢ ~'~¢-~ ~"~:~ Date
Company /~---?¢ .~ -£
Receipt No. ~'~
Date of Payment ~ ~ _ C) c-
Amount: $
Page 2 of 2
72-026 (~ 1/84)
MOA No.
Seal