Loading...
HomeMy WebLinkAboutGREAT LAND ESTATES #3 BLK 4 LT 10 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE [] UPGRADE NAME MAI LI N~?,/D~D~ R ESS~, C ,z, =L EGA L DESCRIPTION LOC^T,O DISTANCE TO: Well /V/~l~ Absorption area~- Manufacturer ~_~ ~ L q. capacity in gallons DISTANCE TO: IF HOMEMADE: Well DISTANCE TO: Well Length ~P.~)li ?e No. of lines / f. Top,.~of til~ to finish grade Length Dwelling M a t e r ~' _~ .~.~ NO. OF BEDROOMS ~ No. of compart~nents ~.~ IWidth Liquid d eJ~t h Material Foundation ~,.~_.- ~ Nearest lot line.~ / Total ~i~es Trench wi~lr~ ~- /~rl' inches Depth th tile Type of crib Crib diameter Crib depth inches Well DISTANCE TO: Building foundation Building foundation Sewer line DISTANCE TO: PERMIT NO, Liquid capacity in gallons , P E R M I;F,N~ -- ~_~-~,~ Distance between Pines ~/~ Total effe~jve abso[p.~J,~n area PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line Septic tank PERMIT NO. Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING I NSTAILLER REMARKS 7~-0)/3 (Rev. 3/78i DATE LEGAL PERMIT NO. [:,EPRRTMENT '. J' HERLTH RND ENVIRONMENTRL',_._~:OTECTION 8:25 '"L'" STREET., RNCHORRGE., MK. 995Et;L :264-472F~ ( 8~:F~599 ) SF--.::2 BOX '"'"".=i';' _. p_,_.. .... F'I ONEEF.: '-~T 99.567 56'1±-44:22 FIPPL I F:FINT F.:F'tL~N~D 141EF~B I CK i LEGflL L:.LE~ B4 GREflTLFtN[:, ESTfiTES LOT SIZE 9'99'99La. SL--.!Ut=IRE FEET TVF'E f-iF '.EOi'L RES]F.'PTt3N S'¢STEM IS: [:,RRINFIELD MRXIMi_IH NUHBER OF BE[,R SOIL F.:RTING ,":,R' FT,.'"BF.:)= 1_...._ THE REQUIRED SIZE .3F THE SOIL. RBSF~F.:F'TI]~-f ;,,=,TEIt IS: [:, E F' -f' H = 5 L E t-,~J G T H = 7 -a ,_3 F: Fl "..-' E i ...... [:, E F' T ia = J. THE LENGTH DIMENSION IS ]'HE LENGTH (IN FEET:) OF THE TREi'.,ICH OR DRRINF!EL.D. THE DEPTH OF R TRENCH OR PIT IS TIqE [)tSTFINCE BET[4EEN THE SURFRCE OF THE GROUND Ri'.,tD THE BOTTOM OF THE E::.:',CR',,,'RTION (IN FEET)· T H E T E: E f-~ C: f-~ k4 1: E:, T H 1: S 5. ~Z~ ~Z'~ C~ F- E E T. THE GRR'v'EI_ DEPTH IS THE MINiMLIM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE E:,.-';CR',,,'RTtON (IN FEET:). F-:EG:.,L[ 1: F4E2[:, '_=;,EF' T 1: C: TRf-~=:: "= Z ZE= ""L~--~ ¢~--=~ L~HLL. L PEF.:MIT RF'F'LiCFINT HI=IS THE F.:ESPONSIBtI_ITV TO iNFORM THIS [:,EPRRTMENT [)URII',,tG TFIE INSTRLLRTION INSPECTIONS OF RI',i'-/ b. IELLS RDJRCENT TO THIS PF.:LF .... T'r RND THE i'-~IjMBER r'~F RESIDENCES THRT THE i4ELL NiLL SERVE. T !i....] C" ,:] 2 ::" 1: !'-.~ S F' E C: T 1: C" f-4! S F-II F: E F-: E G':.~ L[ 1: F-: E [:, BRCKFILLiNG OF FIN'./ S'-/STEM WITHOUT FiNI=iL INSPECTION RN[) RF'PF.:O',,,'RL B"r' THIS DEF'RF.'.TMENT 14ILL E:E SUBJECT TO F'F.:OSECUTION. MINIMI..tM DISTRNCE BETNEEI",I Fl. NELL RND FiNV ON-SITE SEHRGE B, ISF'OSRL SYSTEM IS :LE~F~ FEET FOR R PRIVRTE 14ELL OR ±5~3 '1'0 2E~E~ FEET FROM R PUBLIC NELL DEPENDING UPON ]'HE T'¢PE OF PUBLIC WELL MINIMUH [:,ISTRNCE FF:OM R PRIVRTE 14ELL TO FI PRIVRTE SENER LINE IS 25 FEET RND TO R COMMUNITV SENER LINE IS 75 FEET. NELL LOGS RRE REC!UIRE[) RND MUST BE RETURNED TO THE DEPRRTMENT NITHiN ]:E~ DRVS OF THE NELL, COMPLETION. OTHER RELT~.LIIREMENTS I"/R'¢ RF'PL'~', SPECiFICRTIONS RND CONSTRUCTION DIFIGRRMS RRE FI',,,'FtILRBLE TO INSLIF.:E F'F.'ZPEF.'. !NSTRLLF!TtON. I _.EF..TIFT THRT i' t RM FRMiLiflR NiTH THE F.'.EC!LIiREMENT5 FOF.: ON-SiTE SEI.,.tEF:S fiN[: ~ T FORTH B'T' THE MLINICIF'FIL!TV OF FtNC:HOF.".FIGE. . ~,~) :2: I b.IILL INSTRLL THE S"/STEM IN RCCL3RDRNL-:E NITH .,T, HE CO[:'~=.. t UN ::,ERSTRr'ID THFIT THE ON-SiTE S [4ER Svs'rEM RE,:-.!UZ4 'F-CI. :GEMENT ZF THE F.'ESiDEi'.,ICE TS I~E'"ODELED s t nNEC,: - · RPF'L t CFINT ROLRN[:' ¢~'I ERZB I CK t iSSUED E'¢_ ...... ~7" PERMIT NO~ c,...-:.,.~ "'L "' ~ ........ ...... STREET., RN-:HC~'RGE, 264-4728 ( 8]:E~52:8 ) RPPLICFINT ROLFIND HIERZBICKI SR2 BOX 6Z-':57 PIONEER ST 9:9567' 56t-4422 LOF:FIT I ON LEGFIL L±t-'"4~GF.:ERTLRND ESTRTES LOT SIZE '~'.9'~'~'.9 St_.]URRE FEET T"r'PE OF SOIL RBSOF.:F'TION S"r'STEM IS: [:'RRINFtEL[:' MRXIMLIM NUMBER OF BEDROOMS SOIL RFITING ,::SQ FT,."BR)= ±Z;5 THE REQUIRED SIZE OF THE SOIL FIBSORPTION SYSTEM IS: THE I..ENGTH DIMENSION IS THE LENGTH ,::tN FEET) OF THE TRENCH OR DRFIINF!EL[:,. THE DEPTH OF FI TRENCN OR PiT IS THE DISTFINCE E:ETHEEN THE SURFFICE OF THE GROUND RND THB BOTTOM OF THE E:,.::C8',,,'FITION ':.'IN FEET). T H E i- F~: E ~~~ C: ~.-~ L.~ ][ [:. T H ][ S 5 _ E1E~ El F E E THE GF.'.FI',.,'ELDEPTH IS THE MINIMUM DEPTH OF GRFI',,,'EL BETWEEN 'THE OUTFFILL PIPE FIND THE E:OTTOM OF THE E',:-::CR',..'FtTION (IN FEET). PERMIT FIPF'[..ICRNT HRS THE RESPONSIBtLIT'¢ TO INFORM THIS DEPRRTMENT DURING THE INSTRL. LFITION INSPECTIONS OF FIN'.'? WELLS FIDJFICENT TO THI'=; PROF'ER.T'¢ FIN[:, THE NUMBER OF RESIDENCES THFIT THE HELL. WILL SERVE. BFICKFILLING OF FINb' SYSTEM ~4ITHOLIT FINFIL INSPECTION FIND RPPRO',,,'FIL B'¢ THIS [:,EPRRTMENT HILL BE SUBJECT TO PROSECUTION. MINIMLIM DISTRNCE E:ETHEEN FI HELL FIN[:, FIN'¢ ON-SITE SEHFIGE DISPOSFIL S'~'STEM IS iE~E~ FEET FOR FI PRIVRTE HELL OR ±5E~ TO 2E~E~ FEET FROM R PUBLIC .[4ELL DEPENDING UPON THE T'¢PE OF PUBLIC HELL MINIMUM [:,ISTFINCE FROM R PRIVFITE HELL TO FI F'RIVRTE SEHER LiNE IS 2.5 FEET FIND TO FI COMMUNIT'¢ SEHER LiNE IS 75 FEET. WELL LOGS FiRE REI]'4UIRE[:, FIND MUST BE RETURNED TO THE DEPFIRTMENT HITHIN ]:C~ DFI'T'S OF THE HELL COMPLETION. OTHER REQUIREMENTS MFI"¢ RPPL"r'. SPECIFICFITtONS FIN[:' CONSTRUCTION DIFIGRFIMS FIRE R',,,'FIILFIBLE TO INSURE PROPER INSTFILLFITION. I CERTIF'¢ THRT i: I FIM FFIMIL. IFIR HITH THE REQUIREMENTS FOR ON-SITE SEHERS FIN[:, HELLS FIS SET FORTH B'¢ THE MUNICiPFILIT'¢ OF RNCHORFIGE. 2: I HILL INSTFILL TNE S'¢STEM IN RCCOR[:,RNCE HITH THE CODES. ]:: i UNDERSTRND THFIT THE ON-SiTE SEWER SYSTEM MFIY REQUIRE ENLRRGEMENT IF THE RESIDENCE tS REMODELED TO INCLUDE MORE THRN 3: BEDROOMS. .... c h SIGNED' ............... ~= ¢~' RFPLZC:~NT ROL.~B~ HZERZE:Z Z:f:::Z ~ ~' ISSI_IED E'Y ...... [,HT O & E ENC~,'r~IEERING & DEVELOi-~vlENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Performed for: SOIL LOG Mailing Address: ~]// 2. / / ~/~/~/t/' ,~ y / Legal Description: Earl Ellis 688-2280 Tel. No. ~ Depth (feet) 0 6__ 7__ 8__ 9,' 10 Soil Characteristics PLOT PLAN 12__ 13__ PERC. TEST 14__ 15__ 16__ Ground Water Encountered: Yes ~ Proposed Installation: Seepage Pit Comments: Performed by: . No If yes, what depth Drain Field ©? POUCH 6 650 ANCHORAGE. ALASKA 99502-0650 (907) 264-4111 TONY KNOWI_ES. l/ PARTMEN[OF HEAl l iI,'.NO ENVIRONMENTAL PROTECTION <Permit ~: 820277 ~January 31, 1983 TO: Permit Applicant Subject: Lot 10 Block 4 Great Land Estates Subdivision A permit issued by this department for an individual well and/or on-site sewer system has expired as of December 31, 1982. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal Ordinance. If you have drilled the well, a well log needs to be sent to this department for documentation of the installation date and to close the permit. If a private engineer inspected the installation of the on-site sewer system, please have them send us the as-builts for our files and documentation. If there are any further questions, please call this office at 264-4720. Sincerel~ Robert C. Pratt, R.S. Acting Program Manager Sewer and Water Program RCP/ljw enc: Copy of Permit SWP/057 PER~'[ T NCL F~P PL. :.r. CF!NT L. OCF:i'T }'[ ON L.EGRL THE LE!'q(3]"H DIMENS;,r. oN :IS THE LEF,iEiTH ,:::(N FEET) OF:' 'THE TRENCH OR DRF~ THE DEPTH OF Fi TRENCH OR F'!T IS THE OIS'TFiNCE E:E'T'NEEN THE %URF:'FiCE OF' THE GROUND FIND THE BOTTOM 01::' THE E;:':;CFfv'Fi'T'ZON (ZN FEET). THERE ]:S NO SET k!iDTH FOR 'T'RENCHE:~;. THE GRR',/EL DEPTH ]:S THE MZN:i:~'iUi"I DEPTH OF GRRVE~:L. EcEff'!.4EEN THE OUTFFiLL. F"~F:'E RN[:, THE E~OT'TOM OF THE E',:<CF!',/RTION 4]:!4 FEET). h!ZNZMUi',! DISTRNCE BE'!"k!EEN R kiEL. L. F~ND Rhi¥ ON-S:!:"FE SEI.,.iRGE D]::E;F'O:E:FiL. L¢~Z* FEET FOR i::i PRZ',/F:iTE I.,.iEL.L OR :i. 5E~ TO 2Eil~i FEET F:'I;;:CiPi I::1 PUE:L. IC WELL UPON THE 'i"'.¢PE OF PUE:L.:[C NELL. MiNIi'!Lff'! DiSTFiNCE FROM FI F'RIVF!TE NEL..L. TO R PRIVFi'I"E SE:!4ER LZNE iS 2~;J FEET TO FI C(:ff'1ifiUNi]".? SE!.,.iER LiNE IS 75 FEET. [,IEL. L I...OGS RRE F:EG!ijlRED FIN[)MUST BE RETURNE[> T'O THE DEPF~RTrdENT NZTHi!'-,i OF THE !4ELL COi'iF'L.E]":[ON. OTHER F;'.EQLIZRE!qENTS; MF!"r' RPF'L¥. SF:'CC/I:FZCFITZONS RND C:CJi'4STRL~C'T':[EiN R',/RILF!E:L.E 'T'O ZNSi...IRE PROPER IF!:STRL. LRT): February 16, 1982 Whom It May Concern John Kennedy Lot 10, Block 4, Greatland Subdivision Mr. Wierzbick states that he will not be able to meet the minimum distance requirements of one hundred (100) feet between the proposed location for his well and septic system. Based on this information the department will not be able to issue a permit for installing an on-site septic system on the subject property. John Kennedy Code Enforcement Officer ROL. flN[::, I.,.! ! Ei:;;'.ZE', ! E:k: I C[--II.~iG I .NK., FtK 9956? 688-2589 SIJB[:, I ',,,' I ~ t.0i'¢ ' GREF!TLNh4E:, ESTFITES 'E E "i T f. Oi'.,i ' :].k'.'~ T '~ i.,Ih,lSH I F' ' 2. 85F't ,:1 :E;Q., F'T. '3F~' F:l i:~";;'E:E'; 1:, E:, Iii F.: I H E:' Fl LtiIT: F.:RN GE ' ::L ELI_-ICK' :.r. C:E:r.~'.TIF'.¢ THNT i. .1; NM FFiHtL.'[FIR i,.IITN THE: RE:QUIREZi',tENTi~..:, FOR ON-:5ITE'SEWERS NND HELLS FIS SET FORTH E¢'r' THE' f'IUNtC!F:'RLiT'?' OF NNCHOi:%NGE '::HON> FiND THE STFFFE OF 2. Z HILL. Ii"4STRLI.. 'T.~iE: S'.FSTEN :[!",} FIE:E:OF;;'.[::,NHCE H!TH FILL MON CO[:,ES FINE:' REGULNTION$, FIND t N' COHF'L. :[ FINCE !.,.! ! 'T'H THE: [::,E:..:.; I GI",I CR I TEN i N OF' T'H I S PERI"11 T. .i:. I I,.i:[L.L. FI[>HERE TO NLL. HON Nh,i[:' STRTE:' OF FI[...FISK¢ REQUIF.'.EHENTS FOR THE SET BRCk: [:,! STFINCES F'ROH F:P,F'r' E';':', Z ST' I h,lG .k!EL.i. .... i.,.IFI:E';TEWRTER D Z SF'I3SRL :P'¢?T'EM OF'.': PUE',L I C :F_.,EHEF.-:NGE S'¢:E;TEH Obi TH:iS OR NN'T' ND3'NCE:NT O!::~'. NENF-.'.EW LOT. ._8 '..i .,. , .. . S]:GNE:C, ~ .~' · [:,I:T1-E: IQ'" FIF'F'L. Z 3Ni'.rr: i:;;'Fil. NH[> i,.i Z E,q:ZE; ii: ,.!'.k i WATER WELL RECOED~~. STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Seological ~ Geophysical Surveys : Drilling Permit No. ,OCATION OF WELL (Please complete either la, lb or lc.) A.D.L. No. laJf Borough Subdivision Lot Block r~l ]/4 qt rs. section No. Township N [~ Range Er-J Meridian Anch" ~reatland lO 4~'_pt_or__ot__ s~ w~ Ic. JJDISTANCE ~?ION FROM ROAD INTERSECTIONS ~. OW,~, O~ W~, ROland Wierzbickf Address: SR 2 Box 6357 Pioneer St Ak. 99567 Materiel Type Top Bottom Gravel and olay 8 20 7. USEx~Deme*lic ~ Public Supply ~ Induslr, Silt and ~ravel 30 52 ~ Test Wall ~ Other:' Damp gravel 52 55 s. CAS,,m O V~'~ X~w.u.~ Gravel, sand silt water 55 70 d~am.b_ln. fo__~/~ ft. Deplh Weight 17 lbs./ft. Gravel and boulders 70 75 dlom, in. to~ ft. Depth Stlckup~ ft. 9. F(NISH OF WELL: Set between ft. and ft. BaokfllJin~ Gravel .... Akt~qO~E IO. STATIC WATER LEVEL: E~I~ON~NT~ p~O [~llUl~ ~ Above or Date Equipment :~ II. PUMPING LEVEL below land surface end YIELD g.p.m. I ~,GROUTING Well ~routed: I~,PU~P: (If available) HP ~engt~ ef Drop Pip~ ,~.,z~,~s: Perforations from 55-70 Production of 5 GPM I~. Water Temperalure , o Magnuson Drilling AA 5385 Form O2'WWR (11/81) Copy Oislribution: WHITE-Stole DGGS, PiNK-Driller, CANARY-Customer MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Descrip~tion (in~ude lo~,/block/ s~b~ivision, section, township, range) Location (address or directions) (b) Applicants NamJ // / zZZZ Z ' Tel _ hone - Home Applicants Address 5~ ~ ~O ~ ~ ~ ~2 ~~/~ (c) Applicant~is (check one) Lending Institution ~--~ ; 0wner/builder~ ; Buyer ~ ; Other ~--~ (explain); (d) Lending Institution zlJLY~ Telephone Address (e) Real Estate Co. & Agent Address e Telephone (f) Mail the HAA to the following address: T~of Residence Single-Family~ Number of Bedrooms Multi-Family Other (describe) 3. Water SupR~z Individual Well ~ Community ~ Public Note: If community well system, must have %~itten confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposa~ 0nsite ~ Public ~ Community.~ Holding Tan~ 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] 'Engineering Firm A~ certified by my verify that my water supply and/or the number of bedrooms Inspections, Tests~ File Search, Data and Information affixed hereto and as of the validation date shown below, I Ltion of this Health Authority Approval shows that the on-site :ewater disposal system is safe, functional and adequate for type of structure indicated herein. I further verify that, based on the information obtained from the Municipality of Anchorage files and from my t~vestigation 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 effect On the date of this inspection. Name of Firm Address Date DHEP Approval Approved for ~ bedrooms Approved Disapproved Terms of Conditional Ap*proval Telephone Conditional CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRO~iENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 .%ND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ~NALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/~j/D18' [Page 2-of 2] 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALqlI4 AUTHORITY APPROVAL CHECKLIST - FEBRUARY 1984' MUNICIPALITY OF ANCHOP~A~E DEPL OF HEALTH & ENVIRONMENTAL PROTECTIoN OCT 1 9 lg z, RECEIVED Well Classificatio]~ ~ ~ ' ' ~-- ~ ~-- ( ~pth of ~outing~ Total ~p~h ~ ~ ~d to Static Wate~ ~1 ~ ~ ~ ~t At ~ ~ ~ Casing ~ight ~ G~ound ~ ~ ~ Sa~lt~ ~al oQ Ca~l~g~~ ~p~ation Distan~s f~ ~11: "Z'~/ ~% To ~ptic/Holding Ta~ ~ ~ ./~c~ ; ~ ~joini~g Lots To ~a~st ~ of ~so~ption Field on ~t ~ ~ ~ Adjoining ~ts To Newest ~blic ~ Line ~ //g To ~est ~blic Wate~ S~le Colle~ed Bye" ~ ~~//~ ~te ~ -- / --~ Wate~ S~le Test ~sults __ ~ ~/~d ~ ~ c/~ ~_ ' Standpi~)~ '--__~i~-tight Cap~ Fo~ndatiog ~p~ession ove~ Tark ~.~ ~te ~st P~d /~ ~ P~ing~intenan~ ~n~a~ on File (~¢. ; fJ~ ~~ Holding Ta~ High-Wate~ Ala~ !Y~/~- ~,a,y Holdl~ Tank ~p~ation Distan~s ~ ~ptic~oiding Tank: _ To ~ilding Foundation / To Water-Supply ~11 /~ --~ TO ~rty ni~ ~ /~ ~ To Dis~sal Field To Water Main/Se~vi~ Line ~ /~ To S~e~ Pond, ~e, ~ 5~jor ' [Page 1 of 2] 2-15-84 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field ' _.~ Square Feet of Absorption_A~ea Depression over Field Results of Last Adequacy Test Length of Field Depth of Field · Gravel Bed Thickness ~O Standpipes P~e se nt~_( .Y'~)' Date of Last Adequacy Test Separation Distanc~ from Absorption Field: To Water-Supply We 11 //.~ ~ '-- . ~ ! To P~operty Line /~ /~ To Building Foundation · .' To Existing or ~andoned System cn Lot //t~/~ ; O~ Adjoining Lots . ~/3' ~/~ ~z To Water--~Main/Service Line ~ 7~ To Cutbank(if p?e,sent) ~o St~eam/Pond/Lake/o~ Major Drainage Course /~ / //~ To D~iveway, Parking Area, c~ Vehicle Storage Area ~c~ ~ Con~ents Test. Meets MOA LIFT STATION Date Installed Dimensions Size in Gallons / ~ Manhole/Access (Y/N___! ! ! 0~" Level at /A / //'/~Pump Off" Level at High Water Alarm Level at~'%'~1 /.//t~ Vent (Y/N)' Tested for Pu~ing Cycles du~ing Adequacy Electrical Codes(Y/N) ' Co~nents Check Pe~mi'tted/Bedroom Rating Against HAA Request I certify that I/h/a~e~h~c~.d~ verified, o~ confo~msd to all MOA HAA Guidelines in effect o n t [Pa~e 2 of 2]