HomeMy WebLinkAboutGRECIAN HILLS BLK 4 LT 1 ',,-.J MUNICIPALITY OF ANCHORAGE i 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 NAME PHONE [~NEW MAI LING ADDRESS LEGAL DESCRIPTION LOCATION OUR O~J~Well ROGiO,c/O~.~ Absorp~n ~rea DISTANCE TO: Manufacturer ~nC ~ir{,allo s ~ X~ ...... Inside length DISTANCE TO: lWell Dwelling Manufacturer Well DISTANCE TO: Length of each No. of lines Top of tile to finish grade Foundation Width line Total length of lines Material beneath tile Type of crib I DiSTANCE TO: Class ' TO: DISTANCE ;rib diameter Depth Building foundation Depth Crib depth ~ _ Building foundation ~"~ Sewer line I [] UPGRADE Dwelling Material Material Nearest]otline Trench width inches inches Total effective absorption area NO. OF BEDROOMS _ '7 1 "/ No. of com~,rtments Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. Distance between lines Total effective absorption area Nearest lot line Distance to lot line PERMIT NO. Absorption area(s) Septic tank 'E MATERIALS OTHER ql APPROVED U "~ ~ DATE LEGAL L I ~ ~-~'E-~,'~ ~,',~.~s .r,z~ r~3~J WATER WELL RECORD STATE OF A~ASKA DEPARTMENT OF NATURAL RESOURES Division.of GeoIo§icDI ~ GeophysicolSurveys Drilling Permit No. LOCATION OF WELL (Pleole complete either Io~ lb or lc.) A.D.L, No. IC.JJDISTANCE'AN~ DIRECTION FROM ROAD INTERSECTIONS 5. OWNER OF WEL~."./. Street Address end Area of Well Locofion 2. WELL LOG Feet Surface Below 4. WELL DEPTH: (final) 5~TE OF COMPLETION ~ Threoded diom. tn. fo fl. Depth Sflckup fl. 9. FINISH OF WELL: SIot/Me~ Size: L*ngth ~ Set between ff. and ft. , ~_~ ' ".P~G LEVEL below lend .urfac. end YIn. ~-- ~ O ft. after bra. pumping g.p.m. -- ft. after .~hrs, pumping g.p.m. I~.GROUTING Well Grouted: ~ Yel/~No Materiel: ~ Neat Cement ~ Otb'er: ~ ~{ ~ IS. PUMP: (If available) HP LengtA of Drop Pipe ff. capacity g.p.m. REMARKS: 16, WATER WELL CONTRACTOR'S CERTIFICATION: 15, Wafer Temperofure o ~ F ~ C DEPARTMENT OF HIEAL.TH AND ENVIRONMENTAL PFIOTECTIOI~ 825 L STREET.., ANCHOFIAGE, AK 9950:[ 264-4720 F'ERMI T NO,', DATIE ISSUED: 84 ')7 :[ '7 08123184 AF'F'I_ I CAN'I": A.D[. REx, . CONTACT PHOI'.]E: SN I I:RLEY AK I N SRA BOX '7--K AIqCHORAGE, At< :338-3366 99507 t..EGAL DESCRIF': I_OT SIZE: MAX BEDROOMS: SUBDIVISION: GRECIAN HILLS SECTION: 25 'TOWNSHIP: ,11.1491 (SQ.F]". OR ACRES) 2 LOT: ,1. BLOCK: 4 12N RANGE: 3W , Listed below ape tine opti(.~ns available to yClLI iii designing your' system. Choose the option that best fits yoLm site. tE~ E' D DEPTH 'TO PIPE BOTTOM (FT.) 2.0 .~.~ GRAVEL DEPTH (FT.) 0.5 'TOTAL. 'DEPI'H (FT.) 2,, 5 GRAVEL WIDTH (FT.) :I.'7.0 GRAVEL. LENGTla (FT.) 31~'0 GRAVEl.. VOLUME (CU. YDS. ) 19.5 'TANK SIZE (GAl._S) . 1,000.0 -~.[. SOIL RATING (SQ. FT. IBR) 172 '~'.~ DEF:'TH TO F'IF:'E BOTTOM 3.5 FT. REQJIRES II',ISULA'I'IOIq · ~'~'~' DEPI'H TO PIPE BOT'TOId < 4,0 1::1'. MAY REQUIRE A I._IFT STATION ~'~' 'TANI< MUST HAVE AT I_.EAST TWO COMPARTtdEIqTS I centit'y that: :1,,, I am familiaP witl"~ the r'equiveme~ts fop oh-site sewePs and wells a~s set ~oPth by the Municipality o~ AnchoPag~i (MOA) and the State oi' Alaska. 2. I will ins'[.ail the system in accovdanc, e wit. h ail MOA c:odes and Pegulat.:i. ons, and in compliance ~itfl the design c~itePia oF this pePmit. 3. I will adbePe to ali MOA and State o¢ Alasl<a vequivem~mt.s fop the set bacl< distances t'Pom any existing well, wastewateP di'sposal system op public sewePage system ~m~ this on any adjacent oP neaPby lot.. 4. I under'stand t. ha'L this pePm'it is valid ~ov a maximum oF 2 bedrooms and any enlaPgement will. PequiPe an additional pePmit. IF A LIF:T STATION IS INSTAl_LED IN AN AREA COVERED BY MOA BUILDING ,..OD,~,..), THEN (.1.) AI",I EI...IECTRICAL F:'ERM]:T AND ],t..:~FEI..,TION' ,.,lc" , "' ' MUEN" BE OBTAINED; (2.) AS-BUILTS WI'' NOT BE AF'F'I-~OVED WITHOUT AN ELECTRICAL " ...... ].N~.I EO] I,..,N REPORT; AND (3) THE EI..ECTRICAI... WORI< MLJST BE: DONE BY A LICE:I',ISED EL. EC]"tRICIAN. , ,, .., .: , ..-'., .' <.' 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: 1 2 3 4 5 6 7 ~o b'n~ ) ~oa~cJ y 12 13 14 15 16 17, 18- 19- 20- SLOPE // 72-00B (6/79) DATE PERFORMED: z/ :- ,/o']' I ~)/-L~ SITE PLAN I I I I~;~¢*1 I I' I I WAS GROUND WATER y~.~. SL ENCOUNTEREO? O P IF YES, AT WHAT / E DEPTH? ~'-~-~q / O. 0 ~-17~g¥ ~.0' Gross Net Depth to Net Reading Date Time Time Water Drop /q /O o, TEST RUN BETWEEN COMMENTS 5' ~ FT AND "~ t,~__~ FT z..'2 9'? ' ,q,.~_~ ~-'> 11.8 1200 West 33rd Avenu( Suite B ANCHORAGE, ALASKA'~/g503 Phone 561-5040 CALCULATED BY-- CHECKED BY SCALE DATE DATE ALASKA ENVIR(; ',NTAL CONTROL SERViC~, INC. 1200 West 33rd Avenue Suite B ANCHORAGE, ALASKA 99503 Phone 561-5040 CALCULATED BY ~ CHECKED BY S C ALE. *~'~ 7~' OF DATE 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 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) (b) (c) Location (address or djrec,,tions) ApplicantName'..~',~'LE~'~ t"~n/,~/$ Telephone:Home -,~F~'''- ~/>~ Business Applicant Address ~/ ~f~ ~ ~ ~/'I ~ ~ Applicant is (check one)J,Len~ing Institution ~ ;' Owner/builder~; Buyer D 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-Familyt]~' Multi-Family I-I Number of Bedrooms ~ WATER SUPPLY Individual Well~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department $~'"Environ'mental Cons;rvation 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 I of 2 72-025 (11/84) 5.~ ENGINEERING FIRM PROVIDIN"G~NSPECTIONS,~ TESTS, FILE SEARCH, D/~i"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 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./'~"~ ~ ~'~/_.5~ ./.~7'u Name of Firm Telephone Address /,~'~ ~/ ~'~x'~/ /'f~'~ 5~/'7~' ~ Date DHEP APPROVAL Approved for _~-~.~-~'~2 bedrooms by 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) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: Z~'~'-/ WELL DATA Well Classification Well Log Present~) Total Depth 72~ / Cased to Static Water Level ~ / If A, B, C, D.E.C~. Approved (Y/N) Date Completed /¢-~.-¢'-,¢"¢ Yield Casing Height Above Ground Electrical Wiring in Conduit (Y~) Separation Distances from Well:/. / To Septic/Holding Tank on Lot (~ /O~z To Nearest Edge of Absorption Field on Lot /~"& Depth of Grouting Pump Set At Sanitary Seal on Casing (Y~) Depression Around Wellhead (Y~) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Line ,~//~ To Nearest Public Sewer Cleanout/Manhole /J//+ To Nearest Sewer Service Line on Lot Water Sample Collected by /¢'~'L~ /¢' ,¢4//g'Tvf ; Date Water S a m ~~'/~/~ ¢'~-"7~'~.~-~, SEPTIC/HOLDING TANK DATA Date Installed /,¢'-~"-~:~¢ Size Depression over Tank (Y~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) ,4///9 Separation Distances from Septic/Holding Tank: To Water-Supply Well /¢~/ To Property Line To Water Main/Service Line Course /~¢Z~ No. of Compartments Foundation Cleanouf(~N) Date Last Pumped /,¢7-~/~-0~ ,~/,/4- ;for Temporary Holding Tank Permit (Y/N) / To Building Foundation ~) To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026(11/84) 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 DEPT. OF HEALTH & ENVIRONMENTAL PROTECTioN /-7~.~ ~ _ ~_ Type of System Design ~' ~ ~;~j~hVf~i~l --~' 2"' '~ ~. Depth of Field Gravel Bed Thickness Standpipes Present~N) Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ~) //~"~ / To Building Foundation To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Property Line To Existing or Abandoned System on /' ; On Adjoining Lots /'~ C- To Cutbank (if present) //~' To Driveway, Parking Area, or Vehicle Storage Area LIFT STATION Dat; In~sta te~ Dimensions Size in Gallon~- /(¢/////} Manhole/Access (Y/N) "Pump On" Level at ~'74-.~~ "Pump Off" Level at High Water Alarm Level at ~Vent (Y/N) Tested for ~~..~ Pumpin cles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments Company ,/¢'~L-~' MOA No. ¢~'~, -0~¢ Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 [11/84) TO BE COMPLETED BY MATER SUPPLIER ,DATE COLLECTED TIME C~LLECTED I TYPE OF SYSTEM MONTH DAY YEAR ~ ~ ;~0 [-1 PUBLiC,INDIVIDUAL I.D. HO. (PUBLIC SYSTEMS) CTRCLE CLASS A B C t~Residential} NAME OF SYSTEM ' zoT! ~q'( ~/ ~,~FL'//~'¢/ /~LL~ TELEPHONE NUMBER SYSTEM ADDRESS CITY STATE ZIP CODE , LOCATIO, WHERE SAMPLE WAS COLLECTED 'COLLECTED BY:(SIGNATURE) .,.~ ~ OTHER(Spec~¢y) ~ THIS SAHPLE A CHECK SAHPLE TO A PREVIOUS NON-CONFORH]N6, S~NPLE? ~ YES ~NO PREVIOUS COLLECT~ON DATE AHAL~S~S REQUESTED (IF OTHER T~A~ TOTAL COL]FORH) SE~D REPORT TO:(PR~NT FU~L N~ME,ADDRESS AND ZIP CODE ADDRESS -/Z:'~ '~ ~ ~" ' FOR LAB USE ONLY RESUBMIT SAMPLE Sample rejected because: CHECK ONE OR MORE Sample too long in transit. Sample should not be over 30 hours. Sample received too late im week Not in proper container Leaked out Insufficient information provided. Please read instructions on form. [] Other (Specify) RECEIVED FROM /'~75 ,/~/~/ /')'£x/ DATE /~-/~-~ ~ TIME ANALYT I/GAL METHOD: [~MEMBRANE FILTER [] FERMENTATION TUBE Date & Time Started ~,1/~/~ Date & Time Completed ~ LABORATORY RESULTS Analyst .~~_~_~ [] Other Bacteria [] Test unsuitable because: [] Confluent Growth [] TNTC SATISFACTORY [~ UNSATISFACTORY [] BACTERIOLOGICAL WATER ANALYSIS RECORD FOR LAB USE ONLY  TOTAL COLIFORMS '-I FECAL COLIFORMS ~] OTHER Membrane Filter: Direct Count .mm Verification: LTB Final Membrane Filter Results Reported By BGB Date Coliform/lOOml Coliform/lOOml Time A.M. P.M. READ SAMPLE COLLECTION INSTRUCTIONS ON BACK OF FORM SHEET NO OF CALCULATED BY. CONTROL SERVIC % INC. 1200 West 33rd Ave~o~. Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 CHECKED B'~ ~CALE DATE DATE 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 '/~ '- GENERAL INFORI¥1ATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ///zL~£~'?4/ /~-'/O,~//¢~ Telephone: Home Business ~'~' (C). Applicant is (cfieck one): Lending Institution I-I; Owner/builder []; Buyer []; Other~ (explain); (d) Lending Institution _ Telephone Address (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 ~ Other WATER SUPPLY Individual Well~ Community [] Public[] Note: If corem unity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status, SEWAGE DISPOSAL OnsitetJ~. 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 72-025 (11/84) ENGINEERING FIRM PROVIDING 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 Approval shows that the on-site water supply and/er wastewater disposal system is safe, functionat 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 flies and from my investigation and inspection, the on-site water supply and/er wastewater disposal system is Jn compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~ ~¢¢/~/~. ~,~/7'~¢/-- 5'~-~, //J¢" Telephone ~¢/" ~/6 Address /~¢¢ ~ ~ ~//'~ ~ ~/~// /~ ¢~*~ DHEP APPROVAL Approved for .~_9_~ Approved 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 oi 2 ALASKA i iFOIROFIIll FITAL COFITROL (~(lineerin§ 6 Enuironrnent~I $1uclies 0 ' 985 February 18, 1985 Department of Health and Environmental Protection 825 L Street Anchorage, Alaska 99501 RE: Lot 1 Block 4 Grecian Hills AECS made a site evaluation of the subject property on 2/13/85. The occupant stated that the road over the system is temporary and is being utilized only for moving in; she designated the area east of the residence as the permanent driveway. Traffic was noted as crossing over the absorption area and between the monitor standpipes (see attached diagram). The monitor standpipes were probed and found to be 1i.47' and 12.84' from the top of the pipe to bottom of the system. After subtracting pip~,,heigh~t abovegro~nd and 1' for the bed absorption area,,-~a~roximately ~9~'feet of ~'~li is Pr~se~ over the system. "-'-': : ...... , - This office feels that the 9 feet of backfill Will aid in preservation of the system, but that an alternate driveway, preferably avoiding the absorption area, should be established. If this office can be of further assistance, please contact us at 561-5040. '"'~"{ppr ove d: Suite B. Anchoreqe, Alesko 99503 .(907) 56t-504'0 ALASKA B'HUIROFIITleFITAL COFITROL SEI iUIC $, FIE J~n§in¢¢rm§ 6 ~,~uironmcntal Studies October 8, 1985 Municipality of Anchorage 825 L. Street Anchorage, Ak. 99501 Re: Lot 1, Block 4, Grecian Hills Subdivision On 10/7/85, we inspected the above referenced lot to remove the conditionals from the Health Certificate. The abandoned well has been covered with backfill so the casing is not exposed. The driveway has been moved to the west and is more than 10' from the absorption area. (See attached diagram). From this inspection, we feel that the subject property has now met all requirements for the Health Authority Approval. If you have any questions, please contact us at 561-5040. Sincerely, Alan Wien Engineering Technic ian 1200 J. Ucs! 33rcJ J~ucnu¢. 5uii¢ B' A,choracl¢. Alaska 99503 ,(907) 561-5040 ,.~ICIPALITY OF ANCHORAGE DIVISION OF E~iRONMENTAL }tE.,ALTH DEPAF,%!~E~NT OF HE~ALTH AND E~VIROIqFiENTAL PROTECTION AJ?PLICATION FOR tIEALTH AU~t{OR%TY A~?PROVDJ~ CERT~FICATE.~ Io C~anerai Information Application Date (a) Legal Description (include lot, b!Qck~ subdivision, se.c. fiou~ tow~ashlp, range) (b) Applicants Name Applicants Address (c) Applicant is (check one) Lending Institution (d) Landing Institution Telei!!~one ~_ . Address Real Estate Co. & Agen~ Address <f) Telephone Mail the MAA to the follo~.z%ng address: ~TMep~of Residence Single-Family ~ ~umber of Bedrooms Individual Well [~ M~.~i ti=F emil y ~ Other (describe) Community F~ Public · con~iz~na~.~on from the State Note: If communi~y %~I1 system, must have written Department of Environmental Conservation attesting to the legality and status° ~nstte_ :,<~ Public .~--~ Community ~ Molding Tamk [h~. Note~ 7.f community well system, mus~ have ~itten cogitation from ~he State Department of Environmental Conse~ation attesting go the legality and status. [Page ! of 2] E~n~ineering Firm ProvidinLI~n__s~pections, Testsz_F__File Searcj~ Data and Yn~o:,~,~ ~ As certified by my seal affixed hereto and as of the valida'Cion da~e shown ba!.o%,, ~ verify tha~ my inves~Igatio~ of' this ~{ealth Authority Approval shows that the o[%-~sit~e water supply amd/or wastewater disposal system is safe, functional and adequate for ~he ~umber of bedrooms and type of structure indicat£<t herein°, t further verify tha~'.~ based on the information obtained from the ~anicipali~y of A~chorage files and from my investigation and inspection~ the on-site w~ter supply and/or wastewater disposal system is in compliance with all Municipal and State codes~ ordinances~ and resu!a~ tions in effect om the date of ~his inspection° Name of Firm ~ ~ ~e~ ephone ~ / ~J~f3 9~ (ENGINEER SEfuL ) Approved for ,:~ bedrooms By Approved ~ Disapproved ~ Conditional CAUTION THE MUNICIPALI%~f OF ANCHORAGE DEPARTMENT OF HEALTE A~ID ENViRO~%~NTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON T~YE REPRESEh~T~ ATIONS GIVEN IN PAtLA~GRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENG!~ER P~G!STERED IN THE STATE OF zkLASKAo T~IE DHEP DOES TRIS AS A COURTESY TO PURCIL~SERS OF ~ObiES AND ThlEIR 13ZNDING INSTI'!qJTIONS IN ORDER TO SATISFY CERTAIN FEDERAL ~ND STATE REOU~RE~ MENTSo ~PLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ~;ALYZE DATA BEFORE A CERTIFICATE IS ISSUED° THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR MP, RORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK~ (DHEP SEAL) RR4/ej/Di8 [Page 2 of 2] 7~19-84 ae OF (MOA) armO TY PROWL CHECKLIS~ - FEBRUARY 1984 Legal Description: Well Classification ~/~;V/~/~'~' Well Lcg P~esent ~) Total Depth ~2-~ Cased to Static Water Level Casing Height Above Ground Electrical wiring in Conduit ~/N) Separation Distances f~cm Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot~¢/~-3 To Nearest Public Sewe~ Line '"'"1 © 'ig85 Cleancut/Manhole ~//~ To Nearest Sewer Service Line on Lot ; On Adjoining Lots /dD ; On Adjoining Lots To Nearest Public Sewer Water Sample Collected By Water Sample Test Results SEPTIC/HOLDING TANK DATA Date Installed /~,/~/~ Size /d~rO ~ Standpipes ~) Air-tight Caps ~N) Depression over Tank (Y~ Date Last Pumped No. of Cc~%~a~tments ~ Foundation Cleanout ~/N) Pumping/Maintenance Contract on File (Y/N) ~/~ ; for ~/~ Holding Tank High-Wate~ Ala~-,~-, (Y/N) 4/~ ' Tempora~ Holding Tank Permit .(Y/N) 4~ Separation DiStances f~am SePtic/Holding Tank: To Water-Supply Well ~ /0~/ To P~operty Line 3~ To ~ter ~i~Servi~ Lir~ To Building Foundation To Disposal Field To Stream, Pond, r~ke, c~ Major D~ainage [Page 1 of 2] Receipt ~ Date Paid: Amount: 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorpt%on~ Strata Type of System Design ~.~ Date.Installed /D/~/~/ Length of Field Width of Field /~' Depth of Field ~- Gravel Bed Thickness Square Feet of Absorption Area ~'?A ~]/ Standpipes P~esent ~) Depression over Field (Y~ Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance f~cm A~sorption Field: To Wate~-SupDly Well ~- /~3 To P~cperty Line _ To Building Foundation ~ 30 To Existing or' Abandoned System on Lot ~// ; On Adjoining Lots 5'~ ~ ~ To Water Main/Service Line ~/~ To Cutbank(if present) To St~eam/Pond/Lake/c~ Major D~ainage Course ~/~ To D~iveway{ Parking A~ea, c~ Vehicle Storage Area ~N£~)/~{ ~V£~ D. LIFT STATION ~ta~lfed . Dimensions Size in~~ . ~ Manhole/Access "P~f~ On" Level at~_ . ~ / /~Pum~ Off" Level at.. High Water Alarm Level at~ / I~ Vent (Y/N)2 Tested for ~ Pumpi~ Adequa~t Test. Electrical Codes (Y/N) Comments . , . . ..~"~ Meets MOA ** Check Permitted Bedrccra Rating AGainst HAA Request ** I certify that I have checked, verified, or. conformed to all 'MOA HAA Guideli~,n?s in effect on the date of this ins~%e~ction. Signed Date ~ -~- F~" ~ ~'. .... ,, ~, . KB1/d5/s [Pa~ 2 of 2] 2-15-84