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HomeMy WebLinkAboutSOUTHPARK #2 BLK 1 LT 24 r ~ MUNICIPALITf · ~ MUNICIPALITY OF ANCHORAGE D£PT. OF HEALTH &  ' DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIONENVIRON,~ENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL DESCRIPTION LOCATION Well Dwelling DISTANCE TO: ~ /~GI ,To [~..;~ ~ '~ M,~nu facturer Liq. capacity in gaUon$ IF HOMEMADE: Width r Well DISTANCE TO: Manufacturer WeU Foundation / Nearest lot line · DISTANCE· TO: Length of th of linesv No. of hnes ~ inches ) of tile to finish , I ~.~ ~ inches Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. PERMIT NO. Type of crib Crib diameter Crib depth Total eflecti~e absorption area Well Building foundation Nearest lot line DISTANCE TO: Building foundation line Septic tank DISTANCE TO: OTHER PiPE MATERIALS G INSTALLER 72-013 (Rev. 3~78) DATE LEGAL I-lkll~l I C I t-'Al_ I ]"Y 0I:' ~-~NCI-IOIR f-'~{]JE DEF)AR'TMEN'[ OF }.IEAL][.{ AND ENVIRONMENTAL PROTECTION ~]25 L STREET, ANCHORAGE, Al.': 99501 264 -4720 F'ERMIT NO: 850155 bAlE ISSUE[): 05/06/85 AI~[ILICANT: ADDRESS: COHTAC] PHONE: FOREMAN CONSTRUCT ION P.O. BOX 112177 ANCHORAGE, AK 99511 Z79- 1790 LOI' SIZE: MAX BEDROOMS: SUBDIVISION: SOUTH F'ARK ~ LOT: 24 SECTION: 5 TOWNSHIP: 1.1N RANGE: 5W .5A '(SO.FT. OR ACRES) 4 BLOCK: 1 Listed below are the options available to you in designing your septic system. Choose the option that best ~its your site. T RENCI-! B E[) ~. DRAIN [ ) [~ I :' T ~ ~' 0 PIPE BOTTOM (FT.) 3.0 ** 4.0 4.0 GRAVEL DEPTH (FT.) 9.0 0.5 1.0 IO['AL DEPTH (FT.) 17.0 4.5 5.0 GRAVEL WIDTH (FT.) 2.5 20.0 5.0 I]RAVFL LENGTH (FT.) 45.0 58.0 88.0 ** GRAVEL VOLUHE (CLJ.YDS.) 59.6 ~8.2 24.5 1ANI:] SIZE (GALS) 1,250.0 ** I~50.0 *m 1,~50.0 m* ~i~lL RATIHG (SO.FT. /BR) 200 125 125 DEF'TH TO PIPE BOTTOM < 5.5 FT. REQUIRES INSULATION DEP]H TO PIPE BOTTOM < 4.0 FT. MAY REQUIRE A LIFT STATION GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) 'lANK MUST HAVE AT LEAST TWO COMPARTMENTS 1 certify that: 1. I am {amilia~ with the requirements onlsite sewers and w~lls as set ~orth by the Municipality o~ Anchorage (MOA) and the State el Alaska. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria o~ this permit. 5. I will adhere to all MOA and State oF Alaska requirements ~or the set back distances £ro~ any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. 4. I understand that this permit is valid for a maximum oF 4 bedrooms and any enlargement will require an additional permit. IF' A ] HEN WiLL NOT BE APPROVED WITHOUT AN ELEClRICAL INSPECTION REPORT; E~LIZC'T~<II]AL ~JO['~[:~ MUST BE BONE BY A LICENSED ELECTRICIAN. LIFT STA]ION IS INSTALLED IN'AN AREA COVERED BY MOA BUILDING CODES~ (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS AND (3) ]HE 51GNEI) J-IF IF'J. I CANT: ! S3UED BY DALE: FOREMAN CONSTRUCTION F'DRMI T ~,J. · ~, ATE IS{SUED: ~]50155 05/06/85 qc'F'!.ICANT: FOREMAN CONSTRUCTION ADD~i'E!]'S: F'.O. BOX 112177 ANCHORAOE, AK 99511 C:)M'rACT PHON~: 27~- 1790 L.[X:~AL DESCRI2: SUBDIVISION: '~UTH PARI< SECTION: 3 TOUNSI~IF': i. 2F SIZe: .SA (SO.FT, OR ACRES) M2Y BEDROOMS: LOT:~_,'~? BLOCI::: ,~ !_.it~t(:~d bolow arc' the options avl:ii, able trj you in designii:[: '~c_~u, =¢.--;2~"-ic s,.ctc~r.. Choose ~he option that bcst fit~ your site. :<ZF'TII TO PIPE BOTTOM (FT.) 3.0 '~ 5~,nvr£1_ DEF'TH (F'¥.) 3.0 TOTAL DEPTH (FT,) d,O r;f'AV:ZL WIDTH (FT.) 2.5 t;I::AVEL pENGTH (FT.) 8~.0 '*~ C, RAVE[. VOLUME (CU.YDS.) 27.3 '-(,)~':' SIZE (G~LS) 1~250.0 ~. SC]It. RATING (SD.F]'. /DR) !25 4.0 4 · 0 0.5 !. 0 4.5 5.0 20.0 5.0 58.0 99.0 20.2 2'4.5 250.0 *~ 1,250.0 :[25 125 ** i)EPTH TO RIPE BOTTOM .4'3.5 Yr. REQUIRES INSUL. A]'IO,~ ~ ,~ DEPTH TO F'ZPE BOTTO,~_I ~_]]j__H ._ _.~y.~'< 4~ FT.~fAY REQUIRE, A~fF~ 73 FT, ~' 7A,NK MUST HAVE AT L~/~T ~C} (%)MF'~,:TI~- -,---.- ...... .... ¢ ............. 1.. I ,urn {ami,i~r with th~ ~ equsr[h~dnts top on-site ~"o¢~h by {he Runicipali{~ c¢ Anc,bQ~ag,~: (MOA) ar, d t!~ ~,: of Alesda. 2. i ,,;ill [nst~ll tho syst~n in acc~:rdancn ~;ith all M'2f :~W )z; ,and r'~gu]at~onz~ ond in comp].~anc~ ~,:ith tho de:;ig,; criteria 3. I will adhePe to all MOA and !';tatc~ ~3¢ Alacl:a Penguin. ;': :~ :tn tc,~ thc 5~t bach distanc]s ~rom any exi:ting well, w~stewatoc ;~ispc~: · ;,:tom or publ~c .}, und~r<~tand that this pcmmit is valid for ~, re.I: i~:~:, ,')~ 4 b(:.drc~,~:~ ~nd zny enlarg~:~en[ will require en addLtional pormi~. ~[- A I.IFT STATION IS INSTALLED IN AN AREA COVERED DY MOA EUII.DIMO (]ODES, -'HIM (1) AN ELECTRICAL PERMIT AND INSPECTION MUST PE OErT':IM[~D; (2) AS-QUILTS. WILL MOT BE Ar:'F:'ROVED WITHOUT AN ELECTRICAL IIqSF'ECTIEN RS~'~}F:'T; AND (3) THE 'I.~%TRICAL ~ORI'::.MUST DE DONE BY A LICENSED ELECTRICIAN. ,'IF'FLICANTi FOREMAN CONSTRUCTION ~.~. ~t:, D DATE: DEPT. 0 F,~--------~q~. ~,,~. ENVI~ONME~~ SOILS LOG PERCOLATION TEST ~N 0 9.1986 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: 1 2 4- 5- 6 7- 8- 9- I0 11 12 13 14 15 16- 17- 18- 19- 20- DATE PERFORMED: ~ ~.~.~~ SLOPE SITE PLAN '\ WASGROUNDWATER ENCOUNTERED? IF YES. AT WHAT DEPTH? Reading Date Time Time Water Drop z_ ,, ~z'..~s- ~.., :~'~ THOM CE-6793 PERCOLATION RATE "~ ~ (minutes/inch) TEST RUN BETWEEN ¢~ , FT AND ~'~ FT COMMENTS MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVl RONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264~t720 SOILS LOG - PERCOLATION TEST SOILS LOG ' [] PERCOLATION TEST PERFORMED FOR: ~o~ ~r~ f~ ~./~ DATE PERFORMED: LEGAL DESCRIPTION: I 4- 5- 6 7- 8- 9- 12 20- SLOPE COMMENTS 72-008 (6/79) WAS GROUND WATER S ENCOUNTERED? qo ~ P E IF YES. AT WHAT ~ DEPTH? SITE PLAN Gross Net Depth to Net Date Time Time Water Drop PERCOLATION RATE ,(minutes/inch) TEST RUN BETWEEN ~ FT AND ~ FT >'/.( (, ..,/ CERT,F,ED.~ ::"l, x DATE:?~-':' • • c,C QOi Municipality of Anchorage On-Site Water and Wastewater Program ` . 1,11111111 : (907) 343-7904 SA F ET Y Certificate of On-Site Systems Approval Parcel I.D020-501-14 Expiration Date: l ©— Zd— 1. GENERAL INFORMATION Complete legal description Southpark #2 Block 1 Lot 24 Location (site address) 4721 Southpark Bluff Dr. Current Property owner(s) Sara & Chad Weber Day phone Mailing address 4721 Southpark Bluff Dr. Anchorage, AK 99516 Real Estate Agent Day phone 2. TYPE OF DWELLING: Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual Q Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System Q Public Sewer ❑ WaiverNariance request for: Distance: r Received b Date /z?I I c'".? • COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ 6..Ss Waiver Fee $ Date of Payment (a /2$ 119 Date of Payment Receipt Number ii Q(p9-7� Receipt Number COSA# 06 (. 17 136U 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. In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system.These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 2 Engineer's Printed Name Steven R Pannone Date 06/ 2018 . OF 44kkk 1 0*: gTM 9*#1 6. DSD SIGNATURE 0i_____, 2, ��� 2' Lei K System #1 Approved for l bedrooms �� •Seven R. Pannone: 6-A.•. CE-8149• System #2 Approved for bedrooms s • �r Disapproved ��k -`PROFESSO\--4 - Conditional approval for bedrooms, with the following stipulations: +---&I S e-PVC- ." --avi,114 S i'S 0 Id t A ve,t,o,ep 0 _e.-6.te ct � mt flyt�.S L.� -�- (S .4.0 (A40-w. � p v,, ` Q or-ot, -*°4-1/4)-P6" -Qa1,,4)-Po' c tits' e�+.,sis.: , c4o rp tF�u�^e a tivt r AO r•uM i e(c,(, S e� 4�v t s i v s o ��` N • �iAI-�E� P�FR U C) ‘1\11 PS RPS _;-<.> VROG r' 4n-4l c),,, \r" , c•��''Nt` By: �.� ( Original Certificate Date: —zo —1.P 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 er�^�Advisory( �A "6 Well Flow Advisory Oth , IA-C Ot S t(ky r COSA blue sheet. '- / If more than 1 septic system is on the lot: COSA Checklist# 1 of 1 Structure served by this system 1 Certificate of On-Site Systems Approval Checklist Legal Description: Southpark #2 Block 1 Lot 24 Parcel ID:020-501-14 A. WELL DATA Well type Public If A, B, or C provide PWSID# Well Log (Y/N) Date completed Sanitary seal (Y/N) Wires properly protected (Y/N) Total depth ft. Cased to ft. Casing height(above ground) in. FROM WELL LOG AT INSPECTION Date of test Static water level ft. ft. Well production g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Arsenic ug/L Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 6/5/1985 Tank size 1250gal. Number of Compartments 2 Cleanouts(Y/N) Y Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N Date of pumping 6/22/2018 Pumper A+ Home Services C. ABSORPTION FIELD DATA Date installed 6/5/1985 Soil rating (g.p.d./ft2 or ft2/bdrm) 200sf/br System type Deep Trench Length 52 ft. Width 3 ft. Gravel below pipe 9 ft. Total depth 12 ft. Eff. absorption area 936 ft2 Monitoring tube Y Depression over field N Date of adequacy test 06/22/2018 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 0 in. Water added 600 gal. New depth 0 in. Elapsed Time: 1440 min. Final fluid depth 0 in. Absorption rate >= 600+ g.p.d. N Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer/septic service line Holding tank Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10+ Property line 5+ Absorption field 5+ Water main 10+ Water service line 10+ Surface water 100+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water main 10+ Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS Survey on file. G. ENGINEER'S CERTIFICATION .44.7 OF At 14 I certify that I have determined through field inspections and oe0).- `.,'" 'IF review of Municipal records that the above systems are in %*;49TH /\ ••*V conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Z__4 Steven Pannone i'•:S even •.•0annone Date 06/26/2018 1,1'9.• CE-8149• . COSA canary sheet_2-6-15.doc MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT j e 907-343-7904 On-Site Water and Wastewater Section ` ; Fax:343-7997 www.muni.org/onsite '' Septic Tank Advisory Certificate of On-Site Systems Approval # OSC180304 Subdivision: South Park #2 Block:1, Lot: 24 The septic tank for this property is 33 years old. The average life for a steel septic tank is 20 years. Typical replacement costs range from $6,000 to $9,000. This advisory must be attached to all copies of the subject Certificate of On-Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. - „. , : r r rti7J 7 v'v. .w'SOt c. .3ti * ' Ic 4 r At% .,r t , << , V� 0 • $- r •'. i a`' - sy- z7,..-- .- S iiiir lie Aqk'. 8�F::' ` 3a , kms'. l i' w ,'.:a6y -. Mailing Address: P.0. Box 196650*Anchorage,Alaska 99519-6650 *www.muni.org Municipality of Anchorage · Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I. D.._c~.~='z-4--' GENERAL INFORMATION Complete legal description $outhpark #2 Block ~., Lot Location (site address) 672zSouthpark Bluff Drive Expiration Date: Current Property owner(s) Steven 8, Anissa Riley Mailing address Day phone Lending agency Mailing address Day phone Real Estate Agent Mailing Address Dan Wolf/Keller Williams Day phone 865-65:t2 Unless otherWise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4, TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [~ [] Individual Holding Tank [] [] Community On-site r-~ [] Public Sewer [--] The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone Engineering Services, LLC Phone 272-82:1.8 Address P.O. Box ~oo2~.7, Anchorage, AK 995~o Engineer's Printed Name Steven R. Pannone, P.E. Date ~o/~5/2o~o Engineers Comments: in conducting an adequacy test, [ attempt to provide a thorough, conscientious engineering analysis of the system irt accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. PES can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized nor will it confer any legal right whatsoever. 5. DSO SIGNATURE V'""' Approved for ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Descriptionr A. WELL DATA Well type Public Date completed Total depth ~ Southpark #a Blocka., Lot 2~ IfA, B, or C provide PWSID #~ Sanitary seal (Y/N)~ Cased to ~.ft. FROM WELL LOG Date of test Static water level ~ Well production WATER SAMPLE RESULTS: Coliform colonies/100 mL Arsenic: ~ ug/I B. SEPTIC/HOLDING TANK DATA Tank Type/Material Steel Tank size ~.2~e gal. Foundation cleanout (Y/N) Y Date of pumping ,.1~.,1:~o.,o C. ABSORPTION FIELD DATA Parcel ID: o:~o-5o~.-~.~ g.p.m. Nitrate mg/L Date of sample: ~ Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION in. Other bacteria Collected by: ~ g.p.m. Date installed Number of Compartments _~ Depression over tank (Y/N) N Pumper A+ Home Services ~ colonies/100 mL Date installed ~.h h. e86 Length ~ ft. Width :l Total depth ~ ft. Eft. absorption area 9:/6 ft2 Date of adequacy test =olaFlao[o Results (Pass/Fail) Fluid depth in absorption field before test 7* in. Elapsed Time: =..Ao min. Final fluid depth 7* in. AnY rejuvenation treatment (past 12 mo.) (YIN & type) N CleanoutS (Y/N) Y High water alarm (Y/N) N Soil rating (g.p.d./ft2 or ft2/bdrm) 2ooSFIBdrm ft. Monitoring tube Y Pass System type Deep Trench Gravel below pipe 9 Depression over field N For _~ bedrooms Water added6a8 gal. New depthS_~* in. Absorption rate >= 600 g.p.d. If yes, give date LIFT STATION Date installed "Pump on" level at~ Datum in. E. SEPARATION DISTANCES Size in gallons "Pump off" level at~ Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field 'on lot Public sewer main Sewer/septic service line Animal containment areas in, Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation lO+ Property line lo+ Water main lo+ Water service line 25+ Wells on adjacent lots ~.0o+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Absorption field 5+ Surface water lOO+ Property line 3** Water Service line lo+ Curtain drain None Known COMMENTS Building foundation ~o Surface water ~.oo+ Wells on adjacent lots lOO+ * Monitoring tube appears to extend 6' into 9' field ** WR#: 020086 ENGINEER'S CERTIFICATION Water main lO+ Driveway, parking/vehicle storage Ao+ 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. EngineeCs Printed Name. Steven R. Pannone~ P.E. Date COSA Fee $ Date of Payment. Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number in. Lot 23 1, ~J~ drawin~ In no~ to be modified fo~ ~e e~ :a .p~Ot plan 'wi.thout. th~ W~RLeh O~n Sen:~ ,10' T..ELE.. & ELEc. L ~ 6, S'OU THP:ARK BLUFF DRIVE AS'BUI:LT Lot 24, Bloak 1'~ Southpa,rk Subdivision Add. No. '.2 Dr]~ LAND &: CON$~[RUCTiON SURVEYORS-PLANN£R'$-ENSINEERS ~40 W~ B~sbn Boulevard, Su'/.Le 200 Phc'ne: 562-5~1 ~_h~her~g~, ~a~ko 995~3 F~: 561-6626 Steve 'RiJey Lo~ '25 SUR..~'~, I~.ER"I1~¢AI~N; LAH..~E.(LFt has. c~e. duc~d a phgaica ,,u. rvoy,of .lb. ,p~c~eny as sh~n .~ ~is dr~g a~d c~es tha~ EXrLU~I~ARY 'NO~: I[ iS l~ .owners' Ke~o~uiblUt~ to ~te~a the O~te; g4qrcb 22, 2010 s~:e: ~ =513 Municipality of Anchorage Development Services Department Building Safety DMslon On-Site Water and Wastewater Program 4700 South Bmgaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.munl.org/onsite (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 020-052-24 HAA# ~'~ Expiration Date: 1. GENERAL INFORMATION Complete legal description South Pad( #2, Block 1, Lot 24 Location (site address or directions) 4721 South Park Bluff Drive Current Property owne~(s) Holly Grimm & Ronald Caldwell Day phone 349-4721 Mailing address 4721 South Pan~ Bluff Drive; Anchorage, AK 99516 Lending agency Day phone Mailing address Real Estate Agent Mailing Address Mary Tutterow, Dynamlc Properties 3111 C Street; Anchorage, AK 99503 Day phone 261-7600 Unloss otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage .- Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: Individual On-site . Individual Holding tank [] Community On-site [] Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon Ihe representations given In paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of rifle (except between spouses) for pmportes served by a single-family (m-sEe wastewater disposal and/or water supply system. DSD also Issues HAAs upon request to homeownem. Certfmates of Health Authority Approval are valid for 90 days from the date of issue for propertes served by a pdvate or Class C well and may be reissued with new water sample results. (Certfloates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. e STATEMENT OF INSPECTION BY ENGINEER '* As ce~fied by my seal affixed hereto and as of the validation date shown below, I verify that my Invesl~ation, ' based on procedures outlined in the Health Authority 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 lype of stnJcture Indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Wafldns Engineering, Inc. Address P.O. Box 110443; Anchorage. AK 99511-O443 Engineer's Printed Name Cindy Ellis · 5. DSDSIGNATURE Approved for ~/ Disapproved. Conditional approval for Phone 349-1851 Date 12-3-03 bedrooms. bedrooms, with the following stipulations: Additional Comments By: Attachments: HAA Checklist ~. Septic System. A,dvisory. Well Flow A. dvisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage. AK 99519-6650 www.muni.org/onsite (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: South Park #2, Block 1. Lot 24 Parcel ID: 020-052-24 A. WELL DATA WeJ~Public - ~ ~J~' If A, B, or C provide F;WSIO # Well Leg (Y/N). ' Date C°m~ Sanitar~ seal (Y/N) Wires properly protected (Y/N) Total depth ft~Cased to ..~E. Casing height (above ground) FROM ~ AT INSPECTION ~ Date of test '~..... ~ Well production WATER SAMPLE RESULTS: Coliform colonies/100 mi. Arsenic: mg./I. SEPTIC/HOLDING TANK DATA Tank Type/Material Steel Tank size 1250 gal. Foundation Cleanout (Y/N) Yes Date of pumping 9-16-03 ABSORPTION FIELD DATA Nitrate mg./I. Data of sample: Number o~ Compartments 2 Depression over tank (Y/N) No Pumper A+ Home Services g.p.m. O~ colonies/100 mi. Collected b~ ~ Date installed 6-5-1985 Cleanouts (Y/N) Yes High water ~fatt? (Y/N) N/A Date installed 6-5-1985 Soil rating (g.p.dJ'ft2 ?r lt2/bdm~) ,200 Length 52 ~ ft. Width ,3 ~ ft. Total depth 12 ff. Eft. absorption area 936 ~ Monitoring tube yes Date of adequacy test 8-15.2002 ~'Results (Pass/Fail) Pass ,;: Fluid depth in absorption field before test 28.5 In. - Water added 733 gal. Elapsed Time: 21 min. Final fluid depth 55.75 In. Absorption rate >= 600+ Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN Eyes. give date, System type Trench Gravel below pipe ,9 Depression over field No For 4 bedrooms New depth ~s in. g.p.d. O. ST^TIO, ~ Size In gallons Manhole/Access (Y/N) 'Pump on" level at ~igh water alarm level at in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO' Absorption field onlot__ ~ lots Public sewer main ~lic~~ Sewer/septic service line Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Water; main 10'+ Property line 10' Water se~ice line 10'+ Absorption field 5'+ Surface water 100'+ Property line 3' +/- Water Service line 10'* Curtaln d~ain NONE KNOWN F. COMMENTS Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABsoRPTIoN FIELD ON LOT TO: Building foundation 12' · Surface water .100'+ Wells on adjacent lots 100'+ Water main 10'+ Drfveway, parking/vehicle storapa SePtic adequacy test performed by Alaska Water/Wastewater Consultants, Inc. on 8-15-2002. 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 HAA guidelines in effect on this date. Engineer's Printed Name Cindy Ellis Date ~12-3-03 Date of p?Yment ! .; Receipt Number (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number N 89'57'24" E 175.41' ..t.~' SEC. LINE ESMT. LOT 24 LOT 25 LOT 23 [AND &; CONSTRUCT)ON SURVEYORS-PLANN£RS-ENGINEER$ 4,10 'WEST BENSON E~LVD. ~ 105 (fox) 561-S626 ANCH~ACE, ALASKA 99505 (907) 562-5291 pCT. 29. 2002 t 1 -~ LEGEND: SE.[ FI~D LOT 24, BLOCK 1, SOUTHPARK SUBDIVISION ADD. NO. 2 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 WWN.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 020-052-24 1. GENERAL INFORMATION Expiration Date: Completelegaldescdption SOUTH PARK SUBDIVISION ,~2; LOT 24., BLOCK 1 Location (site address or directions) 4721 SOUTH PARK BLUFF DRIVE · ANCHORAGE, AK Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address KEVIIN HOWARD Day phone 345-4295 4721 SOUTH PARK BLUFF DRIVE * ANCHORAGET AK 99516 Day phone NIEL THOMAS w/ COLDWELL BANKER Day phone 2525 "C" STREET * ANCHORAGE, AK 99503 562-7653 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4. 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community on-site Public Sewer The Municipality of Anchorage Development Sewices Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for propeffies served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ at, or pdor I · to closing for the engineering sen/ices provided. I 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I vedfy that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER &: WASTEWATER CONSULTANTS. INC. Phone Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 337-6179 Engineer's Comments: In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough. conscientious engtheedng analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results desc#bed the performance of the system under the conditions encountered et the time of the test. and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate durtng the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AKWWC, Inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authortzed, nor will it confer any legal #ght whatsoever. DSD SIGNATURE ~ Approved for '~ bedrooms. Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: ..... ~ ; WASTEWATER . - Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other Odginal Certificate Date: Municipality of Anchorage Development Services De partment Building Safety Division On-Site Water & Wast*water Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 995196650 www,ci,anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: SOUTH PARK SUBDMSION ~2; LOT 24r BLOCK I Parc,liD: 020-052-24 A. WELL DATA PUBLIC WATER SYSTEM Well type If A, B, or C provide PWSID# Well Log (Y/NJ Date completed Sanitary seal (Y/N) ~/N} Total , '~-'- -.. Cased to ft. Casing height {above ground} FROM WELL LOG AT INSPECTION Date of test / / WATER SAMPLE RESULTS: .In. Coliform - colonies/100 mi. Nitrate - mgJL. Other bacteria - colonies/100 mi. Arsenic: - rog.IL. Date of sample: - Collected by: - B. SEPTIC/HOLDING TANK DATA Tank'Type/Material STEEL Date installed 6/5/1985 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N} YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping ' 6/6/2002 Pumper. CHUC_,ACH PUMPING ,. *BELOW GRADE AT NEW MONrI'ORING TUBE. C. ABSORPTION FIELD DATA NEW bi~.F.L MT DRIVEN INTO TRENCH ON 8/15/2002 Date installed 6/5/1985 Soil rating Or ft~bdrm) 125/237 System ~ype BEEP TRENCH Length ' 52 - ff. Width ' 3 ff. · , Gravel below pipe 9 ff. Totaldepth' o11.s 'ft. Eft. absorption area 936 fi2 Monitoring tube *YES Depression over field NO Date of adeq~acy test 8/15/2002 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 28.5 in., Water added 733 gal. New depth 58.25 in. Elapsed Time: ,, 21, min. Final fluid depth 55.75 In. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (yiN & type) NONE KNOWN If yes, give date - D. LIFT STATION Date installed Size in gallons ~ . _ ,n. Da...~F~tu~ Cycles tested Meets alarm & circuit requirements?. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main PUBLIC On adjacent lots WATER SYSTEM ~nholeldeanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Properly line. 5'+ Absorption field · .5'+ Water main 10'+ Water sen/ice line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT.T_O: _1 . Property line :'6 +-/- Building foundation ~ ~ Water main 10'+ Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle Storage ~ 10'+ Curtain drain NONE KNOWN Wells on adjacent lots. 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's PrintedName Date JEFFREY A. CARNESS Waiver Fee $ Date of Payment Receipt Number ALASIG WATER & WASTEWATER November 6, 2002 Municipality of Anchorage Development Service Department Building Safety Division On-Site Water & Wastewater Program P.O. Box 196650 Anchorage, Alaska 99519-6650 Reft Lot Line Waiver for Lot 24, Block 1 South Park Subdivision #1, 4721 South Park Bluff Drive. To whom it may concern: We request that your department issue a 3 foot lot line waiver from the west property line to the existing drainfield. I am unaxvare of any adverse impacts this waiver would have on adjacent wells or septi~ systems. If you have any questions, please contact us at 337-6179. Thank you for your ass~hn~. 'er y, 6901 Debarr Road, Suite 2B * Anchorage, AK 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akxx~'c.com Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage. AK 995194650 www.ci.anchorage.ak.us (907) 343-7904 Waiver Review Worksheet WR#: p20086 PID#: 020-052-24 HA#:020572 Permit~: Date Received: 1%7-02 Legal Description: South Park Subdlvlston #2 Block 1 Lot 24 Engineer: Alaska Water & Wastewater Consultants, Inc. 690t De Bart Road, Suite 2B Anchoraqe, Ak. 99504 Applicant: .Kevln Howard Waiver Requested: 3 feet separation absorption field f~o lot line. Criteria: Geology A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Points: Total: Waiver is Granted: t--"'/ Waiver is not Gmnte~ List Conditions or Reasons for above: C-~N'a w(6 iff'Reviewer Ret#: 11-7-02 Amount: $!50 Date Paid: 1111412002 Municipality of Anchorage lhdlding Siffc/y Division Anchorage Ali. America City 20O2 11/14/2002 Alaska Water & Wastewaster Consultants, Inc. 6901 DeBarr Road, Suite 2B Anchorage Ak. 99504 Subject: Waiver Request for 3 feet distance absorption field to lot line Waiver Request #WR020086 Parcel ID #020-052-24 South Park Subdivision//2 Block 1 Lot 24 Dear Engineer: Your request for a waiver of the required 10 feet horizontal separation from the absorption field to property line has been approved. The approved separation distance is 3.0 feet. This waiver approval applies to the existing absorption field to property line separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, Jeffrey W. Poet Engineering Technician On-Site Water & Wastewater Program 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 1. GENERAL INFORMATION (a) Legal Description (include lot. block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~0~'~-'{-- "~-~-~e~phone: Home ~ 40~~] Business ~ Applicant Address ~~ ~~ ~ ~11 (c) Applicant is (check one): Lending Institution ~; Owner/builde~; 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 Singte-Family~ Multi-Family Number of Bedrooms. Other WATER SUPPLY Individual Well I'-I Community~ Public I-~ Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite~:) Publicl~ Community[] Holding Tank I-I Note: I! community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. 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/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. NameofFirm J,-O~ttl'l~,~.,~t~_'"~_- ~,:...I,~r'-~.i?'j.:.'"Z'_~e.A Telephone Address ~ ~ (::,CC', C"~'..~.-"~' ' g'h F~l~-~' ,~:"'- Da,e Engineer's Seal Approved for, ~.~"/7_ ~edrooms by .F~"~I Approved /,~,,) Disapproved Terms of Conditional Approval Conditional, Date 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 engineers work. Page 2 of 2 WELL DATA Well Classification MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 I~UNJCIPALITY OF ANCHOP-AG'~ DEFT. OF HEALTH & ENVIRONMENTAL PROTEC'I'ION 9 1986 264 ,=0 IV ED Legal Description: Well Log Present (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separabon Distances from Well: To Sepbc/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line CleanoutJManhole Water Sample Collected by Water Sample Test Results Comments If A, B, C, D.E.C. Approved (Y/N) Date Completed Yield Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; 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 ~>/.~-"/~::~_~'"8ize Standpipes (Y/N) '~.~--'~ Air-tight Caps (Y/N) 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 To Property Line ~,~" To Water Main/Service Line Course ~.~ No, of Compartments ~"~ ~---~ Foundation Cleanout (Y/N) ~T'-----~ Date Last Pumped ~.3~'~..,~ ;for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond. Lake, or Major Drainage Comments Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~~'-- Width of Field ,~.c, h Square Feet of Absorption Area (~-~-' Depression over Field (Y/N) ["~3,~ Results of Last Adequacy Test ~ ~ Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line Type of System Design Length of Field '~'-'~ Depth of Fie,d Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line '¢~ / To Existing or Abandoned System on ; On Adjoining Lots ,~;:~ ~ ~ To Cutbank (if present) 4[~) "' Comments D. LIFT STATION Date Installed Dimensions Size in Gallons __ .-.M~ole/Acc,e.,ss (Y/N) "Pump On" Level at _J "P~mp Off' Level at . High Water Alarm Level at J / Vent (Y/N) ~J Tested for / mp Meets MOA Electrical Codes (Y/N) ./ ~ ~cy Test. Comments / *' Check Permitted Be~J.ccom .qa~g Against HAA Request ** Signed '"~j~~ Date . Ii / ~'/~ ~ Company '~'~;;'5,,~cD~,,~.-_~--(~' '* ~OA No. ReceiptNo. ~ I~(~"~ Date of Payment I Amount: $ (r~ ~'3c~-'' Page 2 of 2 72-026 (t 1,841 Engineer's Seal