HomeMy WebLinkAboutDEER PARK #1 BLK 2 LT 5Deer Park #1
Block 2
Lot 5
#051-042-62
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201399 PID Number: 051-042-62
Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade
Name
CHAD HAMMOND
ABSORPTION FIELD - EXISTING
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
22722 OAK KNOLL DRIVE, CHUGIAK
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
DEER PARK #1 2 5
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft'
Ft.
Well
100'+
__
25'+
TANK ❑ Septic ® S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER
Capacity
1250 Gal.
Surface Water
100'+
--
Material
Number of compartments
Lot Line
10'+
--
NA
HDPE
2
Foundation
10'+
__
LIFT STATION
Manufacturer
GREER / ORENCO
Capacity
1250 Gal.
Remarks
Alarm location
HALF BASEMENT
Electrical installed by
CHAD HAMMOND
Installer CHAD HAMMOND - OWNER
PIPE MATERIAL House to tank 3034 Tank to 3034
drainfield
Drainfield CO/MT 3034
Inspector FWCS
BENCH MARK (Assumed elevation) 100 ft
Inspection ection 1M 10/11/20 2nd 10/12/20
Location and description
3m __ _4h_ _ _ _ _
BOTTOM OF WINDOW SILL
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Conditional
• ��
Approval: Date
3
TH
� • • • • • • ....... 'W
Septic System
Approved
�•,• Curtis Hufman
-
•: 4
CE 128991
Date j 1 o�J 0�0�` b
/''• •'�C� ,®
I 11/9/202Q.AXW
PROFESSIO�.,
�
Note: this approval does not include well permit requirements.
/D_" !1G1I\O/40\
PID: 051-042-62
PERMIT: OSP201399
A -C=25.5'
B -C=47.0'
A -D=30.0'
B -D=45.2'
A -E=56 5'
B -E=46 0'
N89 44'33"E 345.00'
�O
FCO
D C
MH MH
NEW 1250—GAL
HDPE STEP TANK
r, NEW MT
1
r1,6 G�
OF'
1000—GAL.
WATER STORAGE
IN BASEMENT
NO WELL ON LOT
SEPTIC SECTION
GRAVEL
D/W
GRAVEL
D/W
SCALE; NTS
DEER PARK #1 BLOCK 2, LOT 5 SUPPORT, SERVICES: - ' kN\
PREPARED FOR: ���� AZ 4 1
CHAD R. HAMMOND
22722 OAK KNOLL DRIVE 4 1c. 6
�* 9 TIH*
CHUGIAK, AK 99567
FIRST WATER CONSULTING DATE: 11/9/2020 rtis Huffman /
SURVEY. DMS 20201 �'f�, CE 128991
13030 SUES WAY DRAWN: FWCSAf
11/21/202
ANCHORAGE, AK 99516 SCALE: 1" = 30' 1 ��
907-350-9566 firstwaterAK@gmoil.com ��__�
EXISTING
COs
CO
E
EXISTING
C1
NEW
FIELD SHED
MT
• (RECENTLY
MT MOVED)
CO
8.0'
PER MOA
RECORDS
nd SHED
NOT VISIBLE
N89 44'33"E 345.00'
�O
FCO
D C
MH MH
NEW 1250—GAL
HDPE STEP TANK
r, NEW MT
1
r1,6 G�
OF'
1000—GAL.
WATER STORAGE
IN BASEMENT
NO WELL ON LOT
SEPTIC SECTION
GRAVEL
D/W
GRAVEL
D/W
SCALE; NTS
DEER PARK #1 BLOCK 2, LOT 5 SUPPORT, SERVICES: - ' kN\
PREPARED FOR: ���� AZ 4 1
CHAD R. HAMMOND
22722 OAK KNOLL DRIVE 4 1c. 6
�* 9 TIH*
CHUGIAK, AK 99567
FIRST WATER CONSULTING DATE: 11/9/2020 rtis Huffman /
SURVEY. DMS 20201 �'f�, CE 128991
13030 SUES WAY DRAWN: FWCSAf
11/21/202
ANCHORAGE, AK 99516 SCALE: 1" = 30' 1 ��
907-350-9566 firstwaterAK@gmoil.com ��__�
o
O%<� .moi
?1SRtlll T
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY: AND THAT NO ENCROACHMENTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES.
ozw1uUJ N HJJUui
SCALE:
DATE:
GRID:
FB:
DRAWN:
l
b
G�
Q
LAND SURVEYING 694-
At
94-
7 H��?
0 . _
4 w Dvene ME k •w d � o
` LS -6 f ��►
n
M U N IC IPAUTY OF ANC H0RAGE
00 -she water & Mate water Pr -09 ram
PO W 4-9695a 47OG ElmDru :goad
Anchorage, Alaska 9951 650 Plone; �9D7) $4VY004 Fay {917 343-n97
rNWfvnrrr_ m u M. uVo ns I�e
On -Site Wastewater Disposal System Kermit
Permit Number: OSIS 1 399
Work Type: 8e'pI1oTankUogmde
Tax Code plumber- 05 1 U262000
Site Legal Address; DEED PARK #1 BLIP 2 LT 5 G:11558
Sita Wailing Andress: 22722 OAK KNOLL DEQ, Ghtiglak
Owner; '-1A1r1MQND CHAD R
Design V-ngineer. FIRST WATER C0N5UL71NG
Thal 1)ormit is far the conMrUWCM Of:
❑ Cizp,sFd Field M Si�ptln Tank 13 HoMing Tank ❑ PrlvV
Effective Date;
Expiration Date:
Lot Size In Sq Ft
Twat Bed rooms:
912W2020
'EV28f2021
40441
❑ Pr"-vata Well 13 Water Storage
All construction:0all be in ancordaracewRh:
1, Tne:aftauhed appruued design.
2- All requirarnents speciLled In Anchorage Murtioipal node Chaptem 15.55 and 1 M8 and the State of Ataska
Wastewater Disposal Regulations ('IOAAG72) and D inking Water Regtj latlons (1&AAC;$0)
3_ The wastmaEter code inquires irrspectlons -during the installation. The englnesT shau -nobly Vhe Ue�-aloprTwnt
Services Dapairtm nt per AMC 15.55. Provide notfication by calling €907p 343-7904 (2417),
4, From CcWber 16 t0 Aprll 15, a su bsurface toil ab&orptlon systern under mristrLaorr during ffwzi q g weath e, -
shall
rshalll be either
a. Opened and Closed on the same may. or
�- Covered, sealed, and heated to prevent freezln;I
Reoelved ByIwo-ed By:
-
9812020
Dale:
3
13030 Sues Way, Anchorage, AK 99516
907-350 -9566 / firstwaterAK@gmail.com
September 23, 2020
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: DEER PARK #1 BLOCK 2, LOT 5
The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic
tank and lift station on the above referenced lot. We propose to install a 1250-gallon HDPE
tank with lift station to serve the existing 3-bedroom residence. The owner has heavy equipment
experience and plans on performing the installation. Please see attached MOA Septic System
Owner-Installer Agreement. Per the owner, the well has been decommissioned and the rough
location is shown. The property is served by water holding / storage system. The area is served
by private and community water systems and the design will not impact any of the neighboring
properties. Please contact us if you have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201399, Rebecca Carroll, 09/28/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201399, Rebecca Carroll, 09/28/20
/ FIRST WATER CONSULTING
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On -Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WATER SUPPLY PERMIT
Upgrade
Permit Number: SW990003
Legal Description: DEER PARK # 1 BLK 2 LT 5
Date Issued: Jan 19, 1999
Expiration Date: Jan 19, 2000
Parcel ID: 051-042-62
Design Engineer: 0048 Poiarconsult Alaska, Inc. Site Address: 022722 OAK KNOLL DR
Owner Name: Alaska Housing Finance Corp. Lot Size: 40441 SO. FT.
Owner Address: 4300 Boniface Total Bedrooms: 3 Permit Bedrooms: 3
Anchorage , AK 99510-1020
This permit is for the construction of:
❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑✓ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72 ) and Drinking Water Regulations (18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 (24 hours). ( Not required for a Water Supply Permit only).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
5. The following special provisions.
The existing wells are to be decommissioned as per AMC 15.55
Received By:
Issued By:
�,�, C meala�
Date: �!0
Date: 1-19-99
MUNICIPALITY OF ANCHORAGE
DI�RTMENT OF HEALTH AND HUMAN SER ES RAD
i Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ! 0 Z ��
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION RE T
NAme DISTANCES
O 14 F S E P TO SEPTIC ABSORPTION
r FROM TANK FIELD WELL
Ado,e55
Tr -3 �tJ /EST i ALy G '! 01 WELL
Vnonnts) Permit
No. No. of beorooms
iZ7 -!n 7 t 7n IF7 3
LEGAL LOT LINE �C /7 /z
ws or uaionOa
lot bKKh Subdms�on
r� 2 n E R PATS K c-- -,r = FOUNDATION
iownsnip. Range. Section
r CSE / AS -BUILT DIAGRAM (Snow location o: wen. aep:tc system, properly lines, lounoabon,
L-/ o"'ewa, walw boo." e1cI
TANKS TTiI I I IKTF_
❑ SEPTIC ❑ HOLDING 1e 1 \ y
Manulddorer Gapacily in gallons
Matenn, No Or Compartments
TYPE OF SYSTEM Eli
I \\\\ �' \\►o.
❑ TRENCH ❑ BED W. DRAIN ❑ OTHER V u 4\
Low%to p`pc bottom iron, lora: tiepin nom original graav i.. t I0 \ \
0,.g.nw grade
FT 5 FT z \ \
Fal adocd aWve ungmat graav Grave: a•ptn peneam pipe I 7A \
FT FT a \
Graves
"n911, FT
whdlh
y \ \
Iota: absorption are, I cisidnce between lines \
UV
ir+QFTj FT
�� \
Numbt•r a ones Still rating Pope mater,ai I 9 -BE E \
/%5 SOFT ASTM Y i 10 \
m5:depr Date IN18t �\ W
�Asl-1vsl-_ ►o a7 7
WELLS I le
❑ PRIVATE El OTHER (Identify)
utspa I_
UaSO�L4e1Wn IA.b.CI la: LWilt Cased to I a
FT FT ——_
ms:mien Date Instanvo
ta' UTILITt-E�f.
N 00. OS' YO' V 166.97'
REMARKS: OMC KNOLL DRIVE _
OF- -- - --� -
Scale:
ENGINEERS SEAL
Insp coons Performed by`^!'k
wta T f
1• I . T X117/1'7
tIf < I le. 614 If rod.(. that this inspection was perlorMed according t all ,' 1j•,f 1 2225-E:
�a
Municipal and Tate guidelines in elled on this date ' 1 .. • L
.e
Health DepaAment Approval: ,z S
'2.013 (3,85)
I1 U N 1 C I f' A L 1 l Y O F A N C H i l Q AV C, E
linpartment of Hualt.h 4 Human hprvrca
825 L Streat, Anchorage. nlasFa 99501 --4720
O N -- 5 1 T E S E. W F R r E f< r L l
cr �iL Nurnbr•: 87f�2E12 LJpgrode
i"to lszuo d: 10/21/B7 Lnginv:.!er Designed
bL
10-a�-fid
SPLU-&-erucl
04,t.: r Nome: GROH I PRICE PRICE Day Phone:
CR:ncr F:ddwwws: 550 WEST- 7TH AVENUE 272-6474
ANCHORACU, AI:. 99501
P,rcel Id: 051-042-39
a=ction: 4 Township: 15N Flange: 1W
Lot. Birc 40255 Qq.ft. or ocrcas.)
tl_ l:kqlro;:;:r._: Ihic PerrmiL: I IMUI Lapacity: _
t"_f 11': In1k: Minimum i ote:E septic tank capacity: 1.000 q d rnnc. Each septic
r,l nd.,:nt- h ern; at LeaKt. 2 eompartmontc. Depth Lo top of _s;:pUc tanl (w) K 4.0
'i- '=-i ..1 '. I'!'.-3 insulation over tunl (s).
,{.jr�c•,.-it:fT 1-:..:._.."StFIUii._1>� j�:T'°, r.l'dTf_Ird..�F'LC;II(1Pi, lV ENri{P) f -R ,___.;
"`• r" : ^ANJ F ILT,T"T' R[G!Ul[wD
�yr��,aLE.TO: �:� FEtI"f'ROM "KaE{buhh`IlUlf f�lE_LI)'AN�'_hENrHUr_ Idllfl
I an famr l iar with Lhe requirement., for ori -site sew;ars and well=_ as sot
forth I_,v tho Municipality of Anchorage (MOA) and the KLate of Alaska.
E will install the system :n accordance with all MUA codas and regulations;
_nd in compliances with the deoign criteria of this perniL.
will ndhe,re to all MnA and State of Alanka requirpr',:ants for the set back:
distenunn from any existing well, wastewater dispo=bl system or public
_a,weragn s,stem on this or any adjacent or nearby lot..
t =&Pretancl that this permit_ is valid for a maximum ofybedrooms. I
.lau and rstand that the capacity of the total systa=m it 3 bedrooms aqd
any onlarcl:_,ne„t. will require an additional permit.
DALE:
Vwi is r ) f. � 1I I!i •"< f'IoI ..r_. r'f:ILJ
IO -2 1-0p
'
Municipality
of
Anchorage
October 22, 1987
r-*.
P.O. BOX .96650
ANCHORAGE. ALASKA 99519-6650
(907) 343-4200
TONY KNOWLES,
MAYOR
DEPARTMENT OF HEALTH f HUMAN SERVICES
Tobben Spurkland, P.E.
203 West 15th Avenue
Anchorage, Alaska 99501
Subject: Design Parameters of Permit Number 870282
Lot 5 Block 2 Deer Park Estates iR. N1
Dear Mr. Spurkland:
Pursuant to your request, this letter will outline the design
parameters for the absorption system permitted for construction
on the subject lot.
The design of a bed with a sand filter for the subject permit
was a result of Title 15 Chapters listed below:
Chapter 15.65.040 Section H, Article 1., 2., 3., 4., 5
Chapter 15.65.040, Section H, Article 4
Chapter 15.65.060, Section A, Article 3
Chapter 15.65.060, Section F
Chapter 15.65.060, Section A, Article 2
In addition page 239 of the E.P.A. Design Manual for Onsite
Wastewater Treatment and Disposal Systems is used as a guide.
If you have further questions please do not hesitate to contact
me at 343-4744.
Sincerely,
&a �. 4�-g
Daniel .7. Roth
Civil Engineer
On -Site Services
cc: Gus Andress, P.E., Manager
On-site Services/Water Quality Programs
n
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650 "
SOILS LOG — PERCOLATION TEST
(ENGINEER'S SEAL)
clF.n'`��lal
1, 'j -L,
PERFORMED FOR:11ZO��C7G �,c.S £ RICE DATE PERF&MED:*.Ai�7,
LEGAL DESCRIPTION: Loo 5,g K2F–ep- PAP V Township. Range, Section: TtJ ,
P
ESTAr� SLOPE SITE PLAN rr
1 �e SIL Ty
C��-f�✓kL
-,-2
Y
3-49 01 C rl-E A N G 2 /i V E L
GM
4
51 o
G V/
6 �
7 . e , saMc�y S; hE
10
it
12
13
14
15
16
17
18
19
20
140 1- I:
WATER
ENCOUNTERED? l ,
1�
S
IF VES, AT WHAT L
O
DEPTH? P
E
DepthMonis tri Water Alter
MoniN�
Monitoring? Oats
PERCOLATION RATE (mmulevinchl PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
COMMENTS �Yr5 r1ty r 9 N AfAi f/1/p i X11L 1, IFRF L1F/Vi e0A17-A 1"A7-1cAI
r
PERFORMED BY: •F7,& ICERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EF ECT ON THIS DATE. DATE: �T � q e
72-008 (Rev. 4,85)
IN
I; SO 25 0 25 SO 75 I00 125
I \
I so. \
l
NOTE,
PUBLIC WATER
GRAPHIC SCALE. I• - 50'
4 ti
9
,1l "B.
W \
1,007
INST&L, ?
a 52 L.F.\5' WIDE TRENCH
w 4' TOTAL\DEPTH
J 12. OF ROCS(.
00 = 2-4'CLEAN TS.
v~i CO 1-4',M
ZONITOR_
i: 1
REMOVE
4' CLEAN OUT
ABAI IDON
EXISTING
DRAINEIELD
IMT APPROX. LOCATION\
EXIST. DRAINEIELD. \
�r \
Jfi►T� \
Sc* e�
C
\ I3 -BEDROOM HOUSE \
10' UTILITY ESNT,
N
M
a
w
a
e
N
Ul
CD
OAK KNOLL DRIVE
TOBBEN SPURKIAND P.E. LOT 5, BLOCK 2, DEERPARK ESTATE4I SEPTIC SYSTEM DESIGN
203 W. 15TH. AVENUE SEC. 4, T15N, I JW DATE, SEPTEMBER 10. 1987
ANCHORAGE. ALASKA GROK EDGERS S PRICE SHEET, Irl SEPTEMBER.
(907) 279-3916
municipelty
P.O. 6C>'-1966_';0ANCHG..,GE, ALASKA 99519-600
(907) 343-4200
Anchorage MAYOR OWLES.
'� MAYOR
�i
DEPARTMENT OF HEALTH 5 HUMAN SERVICES
September 16, 1987
Tobben Spurkland, P.E.
203 West 15th Avenue
Anchorage, Alaska 99501
Subject: Application for Sewer Upgrade Permit for Lot 5 Block 2
Deer Park Estates 4V
Dear Mr. Spurkland:
As a result of the attached ground water studies performed by
us in Northwoods Subdivision, which neighbors Deer Park
Estates, one of two things will have to be observed to
accurately determine where the ground water table is; 1) You
can monitor the water table once a week through the end of
October which has been determined to be one of two high water
periods during the course of a typical year; or 2) we can add a
minimum of 1.5 feet to the already determined 8 foot water
table in the test hole which would adjust the maximum depth the
absorption field could be placed into the ground at 2.5 feet.
Since it has been determined that the existing absorption
trench is encroachin ukonn— c round„ iter table,an entire
upgrade of Lne adsorption field will have to be performed to
bring this septic system into compliance with Municipal Codes.
If you have any questions please direct them to me by calling
343-4744.
Sincerely,
LiRoth
�%�
Daniel J.
Civil Engineer
On -Site Services
cc: Gus Andress, P.E., Manager
On Site Services/Water Quality Programs
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BED CROSS-SECTION
oR I
DEPTH of
tXcAvAT 1 o N
_ i.
C -i p` I •� f GOA RSE
o .� •• ° •�° C„RAINEO
• / � / �/: /s jO �i . ittATrv� So1L
SILK
GARR IEfi
/ /�';� -' / `�• �/ sly
SEl�/E R
ftoLK
SAND FILTER SPECIFICATIONS
Sieve Size (mm) Percent Passing by Weight
#4 (4.75) 100
010 (2) 75 - 100
060 (0.25) 5 - 75
#200 (0.074) 0 - 15
0
NBC WATER
e
REMOVE
Ilk
30 23 0 23 30 73 l00 123
\ GRAPHIC SCALD V - 30'
I
T,P
2
oI\ ifs o.
v
to
W I \ \ (f�F
ABANDON
EXISTING
DRAINFIELD
0F Ai"
*' 49TH YV
i... ........�.
�..�t.. .... .a... •-v.
JUNE 25?1971 ; `A{4%-'
�•
\—A T6. V
U 'y°'
F.\ 3' VIDE TRENCH
TOTAL DEPTH
12' SAND F LTER
12' OF ROCK \
2-4'CL 'AN 0llt\S,
1-4'&MONITOR.
APPRIIX LOCATION\ Qv
EXIST. DRAINFIELD.
S -.t~ \
41 v \ N
\ I e
3 -BEDROOM HOUSE \
\ I\ W
a
Y
m
°o
Z
1
30' UTILITY ESMT.
N 00. 05' 20' V 166.37'
OAK KNOLL DRIVE
TOBBEN SPURKLAND P.E.
LOT 5, BLOCK
Z DEERPARK ESTATEW/
SEPTIC SYSTEM DESIGN
203 V. 15TH. AVENUE
ANCHORAGE, ALASKA
SEC.
4. T15K R1V
11
DATEa OCTOBER 18, 1987
(907) 279-3916
GROH._EGGERS
S PRICE
SHEET, 1/1 GRID
r � .
I MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
I ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264.4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME/? �j
VQII /l Li/ /� /f Li/ �C�/ l�
PHONE
3.31-77F47
(iC�NEW
❑UPGRADE
MAILINCLADDRESS
3820 Pvlr/'(i(( Lh. 4hc/.
LEGAL DESCRIPTION
tof f' 2 Purh ES W-
e. -r afrfr Sub I
LOCATION
Nah(Dr. Oele j (reek
NO.OF BEDROOMS
3
OY
DISTANCE TO:
Well/00,,
L �S y
Absorption area 12
L �S /
Dwelling 12
PERMIT g2llgq
//
wQ
Manufacturer
�re(r
Material
No. of compartments
~
N
Liq. capacity in gallons
c0
IF HOMEMADE:
I^side length
Width
Liquid depth --
6 Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
J t7$
O Z F
Manufacturer
Material
Liquid capacity in gallons
DISTANCETO:
Well / r
Foundation .,
Nearest lot line A [�
i J
PERMIT NO / / mss.
`'
No. of lines
•
Length of each line
•�. •
Total length of lines
• Trench width [
60Inches�LTop
Distance between lines
lw�
of the to finish grade �
4
Material beneath the
Total effective absor tion area
p
2'/ inches
6 r/2
Leryth
Width
Depth
PERMIT NO.
Type of crib
Crib diameter
Crib depth
Total effective absorption area
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
y i
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption areals)
OTHER
PIPE MATERIALS
%
L + P1 rC
O
SOIL TEST RATING
00 ftYpedreot.
INSTALLER
T R fas ka
REMARKS
re Ajet
rai
el
rilry OfCi/
level,i
tiof
/veE 4,11e of
_11V.?,
2 y
APPROVED DATE LEGAL
- n I, L
/— 3 v� Pork! t fil.
)/ J rfI f (1 o
72-013 IRev. 3/78)
DEPARTMENT HEALTH AND ENVIRONMENTAL . .OTECTION
825 'L' STREET. ANCHORAGE, AK. 99501
254-4720 ��qf
lJEL L- FitJG OFa—'o I TE 1EWEFR F•EFZP1 I T
PERMIT NO. ( 821189 )
APPLICANT VAN BUILT BUILDING 3820 PATRICIA LN. 337-7789
LOCATION PETERS CREEK
LEGAL I LT. 5 SLK. 2 DEER PARE: S/D lam_ LOT SIZE 9P9999 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM DRAINFIELD
------------
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SQ FT/BR)= 100
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
C•EnF irtA== a L_E"viGTH= 4I" C3FZFA':fEL C•EF"TH= sal
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR. PIT IS THE DISTANCE BETWEEN THESURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVRTIOW (IFJ F
THE TF?Et•.ICH lJ I LATH 11-7 i. 4=1��F-+ FEET.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAT - F 'FJ TH_r� rnITFF+L{ joy RE
AND THE BOTTOM OF THE EXCAVATION CIN FEET).
F:El U I FZ":EC- cEF'T I C T1=1fJ1C '7, I .-'E_ ►_+�=y�_� i�FiLL��IJ�
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
IFJSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
Nt"BER OF RESIDENCES THAT THE WELL WILL SERVE.
--- Ti -10 C � ] I " -F ECT 11_lrJ�7, F=l F<:E FEC, lU I F E=- E>
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTAFJCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM Is
100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC'_ WELL DEPENDIN13
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER. LIFJE IS 25 FEET AND
TO A COMMUNITY SEWER LIFJE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER. REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F EFRM I T E? -4F1 I F:E'S CtiECEMBEFZ: 2r1s 1_-82
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REOUIREMENTS FOR. ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
I WILL INSTALLS THE KYSTEM IN ACCORDANCE WITH THE CODES.
I UNDERSTAND T T TH ON-SITE SEWER. SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REFG ED �T INCLUDE MORE THAN 3 BEDROOM
f/ r' Pd7
S I GFJEC> :r,l�------------- _
APPLICANT AN BUILT BUILDING
ISSUED BY'1 �r r=----------CrATE ,�I__ � _ - V4.0
!~ flI SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 0 PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264.4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: VA" A ujr r Tau s fi tm ts-, C, / . DATE PERFORMED:_
LEGAL DESCRIPTION: 1- rz Dee-, P, a Cla ArIcit \s O H 0 1
SLOPE SITE PLAN
r= tr /4L jI I1I I I I Ar ry (7 /
1
z GP
3-
4
4 f
5
6
7in11.1 GM
s
9
10
11 WAS GROUND WATER S "l -
ENCOUNTERED? Y ES L
O
12 P
IF YES, AT WHAT E
13 �'---GP.OUNO WAVER DEPTH? 13
14
:1a • G P
15
16
17
18
19
20
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE (minutest
TEST RUN BETWEEN FT AND FT
PERFORMED BY: AA -Ac OAr LAIjrr CERTIFIED BY:
72-008 (6/79)
DATE: .//—Zr—PL
polarconsult alaska, inc.
ENGINEERS • SURVEYORS • ENERGY CONSULTANTS
January 14, 1999
MOA ONSITE SERVICES
Attn: Donna Mears
825 L. Street
Anchorage, Alaska 99501
Subject: Notice of intent to install water holding tank.
22722 Oak Knoll Drive, Chugiak
Deer Park Addn. #1, Lot 5, Block 2
Dear Ms. Mears:
RECEIVED
IAN 14 1999
MUNICIPALITY Of ANS,., _ •�bt
ENVIRONMENTAL SERVICES DIVISION
Pursuant to our previous conversations, this fax is to serve as notification for the installlation of a
a water holding tank at the subject property. The proposed tank will serve as the sole source of
water for the property.
The water storage tank is needed since the on-site water wells are insufficient to provide potable
water to the residence. The water storage system will consist of a bladder tank, booster pump,
the required controls, and a fill port. The system will be designed in accordance with MOA
requirements and will be placed in basement of the structure.
As a part of this project, the two onsite water wells will be decomissioned in accordance with
MOA requirements.
Thank you for you assistance
Since y,
David Ausman,
Project Engineer
1503 WEST 33RD AVENUE • SUITE 310 • ANCHORAGE. ALASKA 99503
PHONE (907) 258-2420 • TELEFAX (907) 258-2419
02-09-1999 02:07PM FROM Polarconsult Alaska
polarconsult alaska, inc.
ENGINEERS • SURVEYORS • ENERGY CONSULTANTS
February 9, 1999
TO 3434786 P.02
RECEIVED
FEB 9 1999
MOA ONSITE SERVICES Pf rH"Ith d Human orate
Attn: Donna Mears Services
825 L. Street
Anchorage, Alaska 99501
Subject: Notice of Completion. Water tank installation and well decomissioi ing.
22722 Oak Knoll Drive, Chugiak
Deer Park Addn. #1, Lot 5, Block 2
Dear Ms. Mears:
Pursuant to our previous conversations, this fax is to serve as notification of completion of a
water holding tank at the subject property. As a part of this project, the two onsite water wells
were decomissioned in accordance with MOA requirements.
Thank you for you assistance
Sinc ly,
David Ausman, PE
Project Engineer
1503 WEST 33RD AVENUE • SUITE 310 • ANCHORAGE, ALASKA 99503
PHONE (907) 258-2420 • TELEFAX (907) 258.2419
TOTAL P.02
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 ^L^ STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW970298
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:GRINDER GEORGE H & JULIE A
OWNER ADDRESS:22722 OAK KNOLL DR
CHUGIAK, ALASKA 99567
PARCEL ID:05104262
LEGAL DESCRIPTION:
DEER PARK # 1 BLK 2 LT 5
LOT SIZE: 40441 (SQ. FT.)
NUMBER OF BEDROOMS: 2 THIS PERMIT: 2
THIS PERMIT IS FOR THE CONSTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
DATE ISSUED: 9/09/97
EXPIRATION DATE: 9/09/98
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
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 P"""
RECEIVED
ISSUED BY
DATE:g- //-
DATE:
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Development Services Department '
On -Site Water &Wastewater Section
Phone: 907-343-7904
Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051-042-62 Expiration Date: ss:,2
1. GENERAL INFORMATION
Complete legal description DEER PARK #1 BLOCK 2, LOT
Location (site address) 22722 OAK KNOLL DRIVE, CHUGIAK, AK 99567
Current property owner(s) CHAD HAMMOND
Mailing address
Real estate agent
Day phone
22722 OAK KNOLL DRIVE, CHUGIAK, AK 99567
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Private Well
Water Storage
Community Well
Public Water System
3
Day phone
TYPE OF WASTEWATER DISPOSAL:
❑
Private Septic
®
Holding Tank
❑
❑
Community
❑
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ q S0 V I Waiver Fee $
Date of Payment 1 i a a a� Date of Payment
Receipt Number `� f Receipt Number
COSA 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY ANCHORAGE AK 99516
Engineer's Printed Name CURTIS HUFFMAN PE Date 11/10/2020
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to ,�,�►
these various and dynamic characteristics and are outside the control of the evaluator of the l
well and septic system. Therefore, any estimate of how long a system will function satisfactory ®ig�Q:•'. •„���
for current or future occupants or guarantee that no unseen encroachments, deficiencies or �d
discrepancies exist can be given by First Water Consulting & FWCS 0 49 i ........ �0
6. DSD/SIGNATURE Curtis Huffman
J System #1 Approved for bedrooms VIP, 128991
�A�
System #2 Approved for bedrooms ��FgFOpOfESS10NESS00..
Disapproved
Conditional approval for bedrooms, with the following stipulations:
OF
-SITE G�
WATER AND
By: Original Certificate Date: 11 a3 aCAC
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations 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. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist
Legal Description: DEER PARK #1 BLOCK 2, LOT 5 Parcel ID: 051-042-62
If more than 1 septic system on lot: COSA Checklist #
of
Structure served by this system
A. WELL DATA – WATER STORAGE
Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume 2 X 500 gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date of Sample
Comments __________________________________________________________________________________
B. TANK DATA
Age of tank(s) NEW years
Tank type/material STEP / HDPE
Measured operating fluid level in septic tank NEW
Standpipes/foundation cleanout per record drawing
Date of pumping NA
C. LIFT STATION
Required maintenance completed
Age of lift station 0 years
Lift station material HDPE
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 11/6/1987
ALL standpipes present per record drawing
Total measured depth from grade 3.6 ft (max)
Measured depth to pipe invert from grade 2.6 ft (min)
N/A – pressurized field
Monitor tubes go to bottom of effective. If not, state
depth into effective NEW MT INSTALLED
Code-required soil cover over field*
System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Adequacy test date 9/9/2020
Results Pass For 3 bedrooms
Fluid depth prior to test 0 in
Water added 450 gal
New depth 0.5 in
Elapsed time <1 min
Final fluid depth 0 in
Absorption rate 450 gpd
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Comments/Deficiencies: *Per owner – no known freezing issues.
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well) NA - WATER STORAGE
Septic Tank/Lift Station on Lot > 100’
Yes if No
ft
Neighboring Tank > 100’ Yes if No
ft
Absorption Field on Lot > 100’ Yes if No
ft
Neighboring Absorption Fields > 100’
Yes if No
ft
Community Sewer Main > 75’ Yes if No
ft
Community Sewer Manhole/Cleanout > 100’
Yes if No
ft
Private Sewer/Septic Line > 25’ Yes if No
ft
Holding Tank > 100’ Yes if No
ft
Animal Containment > 50’ Yes if No
ft
Manure/Animal Excreta Storage > 100’
Yes if No
ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Property Line > 5’ Yes if No
ft
Absorption Field > 5’ Yes if No
ft
Water Main > 10’ Yes if No
ft
Water Service Line > 10’ Yes if No
ft
Surface Water > 100’ Yes if No
ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No
ft
Community Wells > 200’ Yes if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10’ Yes if No
ft
Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No
ft
Water Service Line > 10’ Yes if No
ft
Surface Water > 100’ Yes if No
ft
If absorption field is under driveway comment below
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No
F. ENGINEER’S 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.
11/9/2020
November 12, 2020
Brent W. Western
First Water Consulting Services
13021 Montego Circle
Anchorage, AK 99516
Brent,
# I am the electrician that did the electrical on the septic. My electrical is per NEC.
• The alarm for the septic is located in the basement next to the electrical panel.
• There have never been any freezing problems in the field.
Chad Hammond
ALASKA DEPARTMENT I OFLABOR
ELECTRICIAN joURNEYI+1MAN
Issued = Expires .
11126#2019 Y t'.09/1812021
CHAD-R'HAMNIO
22722 OAK#(�10LL DRIVE
CHUG{AK AK 99567 '
WGT DOB HGT
185 03/22/1975 511 Dr.,Tamlka L Ledbetter
3055WA
MUNICIPALITY OF ANCHORAGE
• ^• DEPARTMENT OF HEALTH til HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
�A/PPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# 05 -0)1a -&Z HAA# �4zog4
1. GENERAL INFORMATION
Complete legal description _Z;'45G2 P 2K 4f y r cc r 6-
- nuc Z
Location (site address or directions) 21Z4'7_2 can►c IcNoL-t.- DF,� .
Property owner Af1FG Day phone 330-g21 -
Mailing address 3-01 E. IS) 2212— RD. QwLH . el- 015 0
3
Lending agency Day phone
Mailing address
Agent
Address
Day phone
Unless otherwise requested. NAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
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.
72-025(Rw.1/91) From MOA921
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. l Iurtherverify 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 ?O�.4 2coNSyc.T Phone Z5'g- Z y -Z0
Address
Engineers signature
6. DHHS SIGNATURE
X Approved for 3
Disapproved.
Conditional approval for
Additional Comments
M
bedrooms.
Date IZZ"of lEa
bedrooms, with the following stipulations:
Date Z —4-0c
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage Is not
responsible for errors or omissions in the professional engineers work.
72-025(P. uvn e.a MOA V1
RECEIVED
Municipality of Anchorage JAN 28 2
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division MUNICIPALITY OF AN
825 L Street, Room 502 • Anchorage, Alaska 99501'- (907)r�41" seavlers
Health Authority Approval Checklist
Legal Description: 'DEFQ PA4',- # /- 40rg" B.c Z Parcel I.D.:
A. WELL DATA /11/,3
Well type
Log present (Y/N)
Total depth
Sanitary seal (YIN)
Date of test -
Static water levet
AOP120016'4t'2 .
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to
FROM WELL
Well production
WATER SAMPLE RESULTS:
Coliform
Nitrate
g.p.m.
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Other
g.p.m.
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed U"&l Tank size laaO Number of Compartments Z Cleanouts (Y/N)--4v—
Foundation cleanout (Y/N) /V Depression (Y/N) IV High water alarm (Y/N)
1O
Date of Pumping q Pumper RA1G</. GJRr6•e°�`liJfJ.
pv wr!/GO .
C. ABSORPTION FIELD DATA
Date installed /0/2 9L/9� Soil rating (g.p.dJftZ or ftZ/bdrm) fro_ System type SNAG LoyJ TRE'OG�
/
Length S e Width S r Gravel thickness below pipe Total depth y' J
Effective absorption area Monitoring Tube present (Y/N)_y Depression over field (Y/N) A/
Date of adequacy test Z&A Results (Pass/Fail) �%S,f For 3 bedrooms
Fluid depth in absorption field before test (in.); O Immediately after-J:S-7gal. water added (in.): _Q
Fluid depth O (ins) Minutes later: Absorption rate - i y50g.p.d.
Peroxide treatment (past 12 months) (Y/N) A/ If yes, give date
72-026 (Rev. 3/96)'
D. LIFT STATION
L1wK,
Date installed Size in gallons
Manhole/Access (Y/N) v "Pump on" level at* ZO "
High water alarm level at" .Datum $orro.�s
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding
Absorption field on lot
Public sewer main
On adjacent lots
On adjacent lots
�r'1�
"Pump off" level at' /6 1,
manhole/cleanout
Sewer /septic service line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation %/O / Property line _> /O Absorption field % / o
Water main/service line it/ Surface water/drainage >/O0 r Wells on adjacent lots % /Gb
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line i /O Building foundation i / C2 Water main/service line 1W,92
Surface water % /0 O Driveway, parking/vehicle storage area %/a
Curtain drain 41,114 Wells on adjacent lots /00
F. ENGINEER'S CERTIFI ATION �w
1 certify that 1 have
(etlr inedodeline
spections and review o/ Municipal record�;�t3�V�sy�&'are
in conformance wio OF
HAA gin elfecton this date. �/
Signature ;;��
Engineer's Name _/r4r/rO
HAA Fee
Date of Payment o
Receipt Number Od-% 3 / C
72-026 (Rev. 3/96)'
Waiver Fee $
Date of Payment
Receipt Number
�.".`f
P' .. �. _....... i
P4 T�� DAVID E AUSNAN••,••� 0
CE -8843 1��'` `1 y�7 ,, • ..............J
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Time
APPL16'AN 1
t UPPER HAI-'- ONLY .
Time
.__ .
.,.,
Property Owner \ N
p j1{ ") -
one
Mailing Address
P ,\
, ZIP Code
Beyer
Go i t. Adi� --
Address
Zip Code
Lending Institution � �. N --
Phone
Address
'CONDITIONS OF APPROVAL
Zip Code
Date Sewer Installed
Really Co. d Agent
Well Log Received
Septic Tank Size
Phone
Address
Zip Code
Legal Description
Street Location
i Type of Residence
Single Family
Family
rE� l—4
Family
MultiO Other
No. of Bedrooms
\.. J t,.v r\ a0 — 7
Water Supply
Individual
ATTACH WELL LOG. A well log Is required for all wells drilled since June 1915.
Community
For wells drilled prior to that date, give well depth (attach log If available).
❑ Public Utility
I S wer Disposal
Individual
Year Individual Installed:
Public utility
When Connected to Public Utility:
i ❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
inspector
Field Notes:
( PPROVED BEDROOMS
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL-
DATEs.���
'CONDITIONS OF APPROVAL
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well to Tank
Well Log Received
Septic Tank Size