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HomeMy WebLinkAboutNORTH SLOPE #2 BLK 5 LT 4North Slope #2 Block 5 Lot 4 #050-581-07 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. Municipality of Anchorage Page of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: --5V/ 98(9/ 80 PID Number: OSO • -:5'9/-0 7 Name: Cqp. L/S07CL� Wastewater System: 2R New ❑ Upgrade Y P9 Address: P.O. &Z �2•70a10 ABSORPTION FIELD E - L _ ' l/JE)o- AILI 9597 0.2/0 Phone: �• S/_ S i '7 No. of Bedrooms: 3 ❑Deep Trench Shallow Trench ❑Bed ❑Mound ❑Other LEGAL DESCRIPTION Soil Rating: / O. Total Depth fro moriginal grade: �-t'J (� GPD/Sq. Ft. /,J Lot: Block:�" / Subdivision: W") Depth to pipe bottom from original grade: / Gravel depth beneath pipe ...7 I UQ.%/y S10?6- c + / Ft. D. S Ft. Township: Range: Section: Fill added above ori mal grade: Gravel length: _ — .3. Ft. / 0 8B' 0) ` O"= /('8/ Ft. WELL: ®New El Upgrade Gravel width: 5 Number of lines: Distance between lines: 1 - Ft. c,) /O Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area:/ Pipe material: pj�/vwrc -5,-)0 Ft. /9Ft. 4/0 / SQ. Ft. M303`/ r5'/0 Driller: scl LL Date Drilled: '71d Static Water Level: %93 Installer: w&C Date installed: -3d _9d' /uAs✓ 9/99 Ft. Yield:Pump Set at: Casing Height Above Ground: TAN K 3 GPM 6(14P_,10 6J / / Ft. a Ft. SEPARATION DISTANCES 0Septic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ,/ �/ Alit oPllgc //a.4�f:- /000 WeIF /00 /f /U0 _ – / f Material: STCC1 Number of Compartments: 12 WateSurface r /00 rf /00 a- LIFT STATION Lot / / /d} Size in gallons: Manufacturer: Line 5 Foundation / 13 / 1 •� o "Pump on" level at: p off" level at: High water alarm at: Curtain / C�'!" / 0 PMake de ump l Electrical Inspections performed by: Drain Remarks: �' OF MO4- BENCH MARK Location and Description: SI Ht) lnfTALV✓zJ v„„oh.-t --f&AA = To. o%eol✓cleE'TE' /+7- lj?a0(--- BOOP-, - - Assumed Elevation: /OU E go L 4` O� h oat lN6II4Cr.K1jMtP 17034 Eagle River Loop Road, No. 204 ✓ „ ti' 1 !p Inspections performed g ,Alaska 99577 Dates: �'-a/-9& p yFa Ie River, r 2nd `�`� �� E't� ROBERT C. COWAN tfce-seoi Department of Health and Huma Services approval Reviewed and approved by: 42n-n_�X_ 11PCIA Date: C-32 72-013 (Rev. 9/91) MOA 25 PERMIT NO. SW980180 PAGE 2 OF 3 MunicipaUt of Anchora e DEPARTMENT OF HEALTH AND HUNfAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 0 Anchorage, Alaska 99519-6650 0 Tele hone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 4. BLOCK 5. NORTH SLOPE P.I.D. NO. 050-581 —07 LOT 1 LOT 3 NEW 1000 GAL. `\1�� LOT 2 SEPTIC TANK c FCO 3 £by DBLI HOUSE \ DBL2 • STI A ` TH #1 ST2 NEW DRIVEWAY \ C01" NEW ELL \ TH #2 �`: WELti gA�1�s C033 \?�, `•�`\ �\\•j`; LOT 5 ` ,ore\ • �tj� 2 SCALE 1" = 40' > ENs co \ \ LOT 4 r ` NEW .TRENCHES ......, g ROEERT C. COWAN R �@ 3 6i 'ti CE - 8801 ?`a v A PERMIT No. SW980180 PAGE �J OF 3 MuricipaUt of Archora e DEPARTMENT OF HEATH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 0 Tele hone 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 4, BLOCK 5, NORTH SLOPE #2 STI 92.0' ST2 FINAL GRADE INSULATION NEW 90.0' 1000 GAL 89 8• S.T. col = 91.9' FINAL GRADE CO2 = 91.5' MTI CO2 / P.I.D. No. 050-581-07 SR B C C01 = 88.3' CO3 = 85.7' CO2 = 88.5' z,„ C04 = 85.8' J ST2 40.5' 21.0' - MTI = 87.8' 5 1 MT3 = 85.0'-/ MT2 = 88.0' MT4 = 84.9' FD .� M.O. ,J. A,?^FWpA 001 s A ,• i3 MT1 A80.9, 34.0' - 0O2 WATER FOUND 114.5' - MT2 73.4' B.O.H. 113.5' - P.I.D. No. 050-581-07 = 88.0' = 87.9' N. T. S. A B C FCO - 15.0' 11.0' ST1 38.0' 14.5' - ST2 40.5' 21.0' - DBL1 41.5' 23.0' - DBL2 42.5' 24.5' - FD 54.0' 78.0' - 001 35.5' 35.0' - MT1 34.0' 34.0' - 0O2 88.5' 114.5' - MT2 88.0' 113.5' - 0O3 57.5 67.0' - MT3 1 57.0 67.0 - 004 1113.0' 137.0 - MT4 113.0 136.5 - = 88.0' = 87.9' N. T. S. FROM DISOTELL CONSTRUCTION FAX NO. : 1 907 6960215 Dec. 03 1998 10:26AM P2 (IT '49r-ffin by DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 670272, CHLIGIAK, ALASKA 99567 . TELEPHONE 686-2759 OWNER OF LAnND i0JSO 1 E[L L"k"4 I ADDRESS _Ih 442< 1 '7 o d r 0 l� 2 LEGAL DESCt21PTION A) ZAT H � t) 09 &g S � , r I - t ro PERMIT NUMBER Date of issue J -17-� 0,50 B a TAX INDENTIFICATION NUMBER Is well located at approved permit location? Qj-"s ❑ No Method of Drilling: ZP<r rotary O cable tool Depth of well: _ Casing Type Wall Thickness, $"Ci inches Diameter �,� d inches, depth (�'� feet Liner Type: Casing Stickup Above Ground= . -_ _.. _� ... feet Static Water Level (from ground level): feet Pumping lever feet after hrs. pumping gpm Recover Rate: 3 gprn Method of Testing: _419. Well Intake Opening Type: Q Open End 954Yren Hole 0 Screened, Start feet Stopped feet Q Perforations Start _feet Stopped feet Grout Type: &olume d a 4115 Depth: from feet, to feet Pump Intake Depth: Pump Size hp Brand Name Well Disinfected Upon Completion? !G}.h%s Q No Method of Disinfection: C111o,R1.J4 0(� f e"i Comments: Art, E 0A4to4O -7 Id BORE HOLE DATA Driller's Name 0Ja< 47JAO16. /'%eco -i Ccrg� 6r4AJ': ri Ad��Ca49_d/ 9.4g4rtrgrJ � 00 c1c17ii;q.f- 1-4,6,00Ct- 6A4-1 s/ DEC 17 1999 MUOicipality Of Anchorage ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority- Municipality of Anchorage: Department of health & Human Services and/or Department of Environmental Conservation_ MatSu Borough: Department of Environmental Conservation. 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 AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW980180 DESIGN ENGINEERS & S ENGINEERING OWNER NAME:DISOTELL CARL OWNER ADDRESS:P.O. BOX 770210 EAGLE RIVER, ALASKA 99577-0210 PARCEL ID:05058107 LEGAL DESCRIPTION: NORTH SLOPE #2 BLK 5 IT 4 LOT SIZE: 64298 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE 1 OF 1 DATE ISSUED: 6/16/98 EXPIRATION DATE: 6/16/99 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 PROVISIONS: RECEIVED BY: _�U/ Z'�� DATE: C V ( 7 _ �7 a ISSUED BY: 1 DATE: 1/ '—'/7-7B nG ROBERT C. COWAN, P.E. March 16, 1998 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 HEALTH AUTHORITY APPROVALS MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 SEWER&WATER MAIN EXTENSIONS Anchorage, AK. 99519 REFERENCE: Lot 4, Block 5, Northslope S/D Addn. #2 SEWER & WATER INSPECTION Request you issue a permit to drill a well and install a septic system to serve the proposed three bedroom house on the referenced property. ENGINEERING STUDIES Two test holes were excavated and percolation tests were The approximate AND REPORTS performed. location of the test holes are located on the attached site plan. At the time of excavation groundwater was encountered in test hole #1 at 5.5 feet and WELLINSPECTION no groundwater was encountered in test hole #2. After seven day groundwater & FLOW TEST monitoring, the monitoring tubes were checked and water was found to be at 4.5 feet in test hole #1 and at 6 feet in test hole #2, respectively. SITE PLANS This property has enough area for a future septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring wells, septic systems or ROAD DESIGN drainage patterns by the installation of the proposed septic system. There are no points of contamination within the proposed well radius which can be seen SOILTEST on the attached site plan. If you require additional information, please contact us. PERCOLATION Sincerely, y STRUCTURAL& Robert C. Cowan, P.E. MECHANICAL INSPECTIONS RCC/jhn Enclosure ON SITE WASTEWATER DISPOSALSYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 1 z Fa pj~fir Z �ti%� dl) oaa N , pali ` 3 % .•• F- R: oo��d 0 // U co s n y i z y • U C?' t woLJJ J wU' 1a. r w V k-: oLL� ��Ft'% C• p'' N zr_� m .� �Q .�' o rx o z 4 z o CL U 3 O vi �C, z Q z�C]Q Q 'O Mo E- E wazo a00, Y 03 O o W JO E p LAF a a A 2 o Olox a Z zE d � � rn i,F- c a Q�+j OJ < ii ii ii Q Z Q 0 z Li U) C) oz 0 U 5z 820 OY aga4 OZ lC� 0' = i Z 04 W, OF- oww aa,. Uara ON u U< r worn OV W� s wwa•mOHWz WF- V1W n O " zazv),5D V1a O— V) a og<M L61 aN oz u HaOor a O d'Q Q ww> mr0 d O w v~- W (L d O O M J a• WFMrewvwizZ O O � o� 1 -yl z HUO3_aJ 2 V~JmWUl O LA zzm OwtV FV] OO,pEMHW Q�r � Z IFUH A � W a vw z d.z.] ] o v~i v=ia 1-V) Q a�'` W m �C`7Z w Cii E--4CL yy-1 U p n�i v� Q W V1'=Z. �r W I- O Yd -1 F. H Z E A .r c O0in U W 00 Ohm' tCDr*� W0> vZ �Wa CqN' II 0 11 W OZU OJ oaf L N� Z. a�> W�r'e II to N �wO�n $ .aF0 no �"� 4! 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W.T.S. DETAIL PROFILE SCALE V W ri % � • �. 1.11 S Z O�Opa I+i s< L7 �O fe�o b o ~i 1.5' - 2' DEEP (REMOVE ALL ORGANICS) d m 3 i MIN. m cnrREMO6VE o z 0 TO GROUNDWATER � zD r 0N. COVER r- 0 !- 0 0 � 0.5' EFFECTIVEm r �o ox z � � ' DEEP 7. ORGANICS) 0 lu�0 a yM r � m TO GROUNDWATER "' w 0 � �"' r om Aa 2' MIN. COVERC) rn b I 0.5' EFFECTIVE c co d z C m A 0 Lo Z �.y D O � D O r tN r O rTl Or O G m (n p o z N _BOO o• W n D 3' MIN. COVER 00co c=� L `tel•' ZOp o!: on "� z 0 o z i 1\L :�z►" PERFORMED Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST Dl so72�1,L I LEGAL DESCRIPTION: ORGANICS 1 w M_ w- 2 3- 4- 5 4 rj Vt/r )r/ 6 6M/511 /t 7 `r I //r'/ or 4� /r 9 .�, 10- 11 0 11 �G 12 13- 14- 15- 16- 17 314151617 18 19 20 COMMENTS DATE PERFC nwnship, Range, Section: SLOPE SITE PLAN WAS GROUND WATER , %O ENCOUNTERED? S IF YES, AT WHAT L O DEPTH? P E Depth to Water Aft - I P - - _ -Bate: (0 _9_9s Reading Date Gross Time Net Time Depth to Net Water Drop 9 9 / / & /' // 3-3 /o 8" a" a17E2 1/ 110 to" -Add so /Q /u/w ff ;v PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER =' 11 TEST RUN BETWEEN FT AND FT PERFORMED A & S ENGINEERING I p1� "'vj�?""��^'sg CERTIFY THAT;THIS TEST WAS PERFORMED IN 17034 Eagle River Loop Road No. 204 1 / ACCORDANCE IS �TFATIFA"�"CIPAL GUIDELINES IN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) 99 DATE: ( `� F OF q Municipality of Anchorage t DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 •�• SOILS LOG — PERCOLATION TEST . ___... _.�...,. •. a• as P ROBERT C. COWAN, f Q q CE -8801 ,t*• CARL �f. PERFORMED FOR: �150'i•ELL. DATE PERFORMED:' ��- �,.-.Ig —15" LEGAL DESCRIPTION: L -•o -r P�"CAC, ,j Township, Range, Section: p pOr{-(ja SLOPE/j� {4DpfJ; 2 SLOPE SITE PLAN 1 .�. w w I�R%Arstcs 2 3 s•� 4- 5 Q• ' 7p 6 �- 7 gy . 8 9 10-` �0 12 13- 14- 15- 16- 17- 18- 19- 20 314151617181920 COMMENTS GMAm IF YES, AT WHAT DEPTH? Depth to Water After 1 Monitoring? Date: Reading Date Gross Net Time Time Depth to Water Net Drop P F—so x PeIZ10 I Z 2498 12: So 6tZu '7 2:55 5 3 I:Da 711 V14 4 1 :05 -7 114 11 1/4' d PERCOLATION RATE 22 (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN 4 FT AND 5 FT S & 5 C1mvilmcercnw PERFORMED BY: 1.7034 Cagle River Loop Road No. 2041 CERTIFY THAT THIS TEST WAS PERFORMED IN WIFF�� �LRRTtAlaska 99577 ACCORDANCE LyA AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) Municipality of Anchorage 1w . •S,r� t DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 �•• °� .,: ,. ,,, „„,,,,,;, ,,,, SOILS LOG — PERCOLATION TEST...;. _,.,...,..;,. F y ROBERT C. COWAN �• e- Vii,°•� E - 8801 f ^v q `��� PERFORMED FOR: LkEx- DISO-m—w— DATE PERFORMED,, - 7:111-18,'�'�'�.` LEGAL DESCRIPTION "T 6LOGK S Township, Range, Section: . 1E44;r Y OK -r4 SLOPE 51p Z• SLOPE SITE PLAN aeunz ~/wµ N 2 l =0 3 Qi 4 '�+ 1 5 01 7 8 11a 9 0 } 10 WAS GROUND WATER YDS ENCOUNTERED? i 11 s IF YES, AT WHAT L DEPTH? �• O 12 P E Depth to Water After I 13 Monitoring? 14.5 Date: 14 15 16 17 18 19 20 2a 6n PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN '•5 FT AND 3 s FT COMMENTS S & S ENGINt:PKINv PERFORMED BY17 034 gagl Rffiver861U Loop Road NO. 204 IY42��� CERTIFY THAT THS TES WAS PERFORMED IN ACCORDANCE 19A W%K'V9fA7EeAND RUCI GUIDELINES IN EFFECT ON THIS DATE. DATE: �� lei I 72-008 (Rev. 4/85) HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSALSYSTEM DESIGN S&S ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Lot 4, Block 5, Northslope S/D Addn. 42 March 16, 1998 GENERAL: ROBERT C. CIVIL ENGINEERS (907)694-2979 FAX (907) 694-1211 The scope of this project includes the installation of a 1000 gallon septic tank and 2 - five foot wide drainfields to serve the proposed three bedroom residence or the referenced property. 2. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The contractor shall be responsible for obtaining any necessary underground utility locates. 4. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: 1. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 3. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99677 P.E. Page Two Lot 4, Block 5, Northslope S/D Addn. #2 March 16, 1998 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. 5. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. 6. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed -up) before gravel (sewer rock) placement. 2. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. 3. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. 4. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. 5. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. Movr Dpi L �Cpc+FYI�� �5 i2 £C2��2rL id P Sn /z G 4,0 y6i 0),,c MINIMUM MATERIAL SPECIFICATIONS: 1. Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. Page Three Lot 4, Block 5, Northslope S/D Addn. #2 March 16, 1998 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pip Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). 5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. 6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. 7. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements, which ever applies. INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: 1. The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. 2. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property. Page Four Lot 4, Block 5, Northslope S/D Addn. #2 March 16, 1998 Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre -construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/OWNER MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 050-581-07 �• GENERAL INFORMATION HAA # Complete legal description Lot 41 Block 5 Northslope 02 Location (site address or directions) NHN Harca Property owner Carl Disotell ( Mailing address Po Box 770210 Day phone 694-5797 Ea le River, AK 99577 Lending agency Mailing address Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2• NUMBER OF BEDROOMS: 3 3• TYPE OF WATER SUPPLY: Individual well xxx Community well Public water " NOTE: If community well sysfem Ing to the le alif r provide written confirmation from State ADEC attest - 4 and status of sysfem. 4- TYPE OF WASTEWATER DISPOSAL: Individual on-site xxx Holding tank Community on-site _ Public sewer NOTE:if co—� mmunity wastewater system attesting to the legalit ° provide written confirmation from State ADEC 72-025 (Rev. 7/91) Front MOA x27 - Y and status of system. Municipality of Anchorage • Development Services, Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www. ci. a nch orage. a k. us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. g - Sd"/ - D HAA # ®4 053?j Expiration Date: 1. YGENERAL INFORMATION Complete legal description Location (site address ordirections) yaz spy Current Property ownet(s) Day phone. 7A - ay.1 Mailing address s Lending agency Mailing address -- Real Estate Agent Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. Day phone Day phone 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site IX Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services 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 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 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. ame o irrn - ,E .F -.use - E 5u Phone �/-.r/s3-" Address Aaep�/ Engineer's Printed Name Da 5. DSD SIGNATURE Approved for 3 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory oRnr,RQM JJ .,� o�tvrs��r�,,� Maintenance Agreements Supplemental Engineer's Report Other By. Original Certificate Date: i (Rev. OM2) AIN Muni>t �p �ofAn horagem� gf B4i (�11 Development,, ices bepa` rtrtmentt r ;li Building Safety -'Division On Site Wafer &as'fewater urogram s s T r r 4Tt outL8ragaw BOX nC wv�W of anchorage ak us 3 � b HEALTH /�UTHOR'I7Y APPROVAL CHECKLfSi�" ' kE Z senptiori .cr hl _14? . J Parcel ID OSCJ- ✓ 8y-0 AT"A __ 77., N v�sr� If A B or C provide PWSTD # Well Lo N) Jre:.5 ipTeTe anitary seat &JN)5Wires properly protected z0 ft Cased to /,1 ft _. Casing height (above �2in'. FFCdNI WELL L(7G� AT1N� � e ater level / �3 ft.' /s2 ft. 9'P m 3 , / g p.m. colonies/100 ml Nitrate�O I Mg. Other bacterra �_ colonies/100 mL m Date of sample �V y Collected by C I{nA ep uRT aS j e atena s �� Date ins"tared^jr �y8 /endo gal Number of Compartments. Cleanouts1 1) iiES n cleanout�N) Depression over tank (YM _,_ve . High water alarm`' (Y4 /.ter ampmg �24%ny Pumper 's /ZJS PL4^PtAY4 61 TfOI�FibDC7"�C _�. _e.. tle g Soil rating p.d./ or ft2/bdrm) d eA System type aft Width Gravel below pipe O.6 ft. ft Eff: absot tion area Io z M � � ... �iM6 �, , Monitoring tube E'1''15epression over le equacytest%ayfdh Res�ritsFail) f3s For 3 bedrooms - 5 F6 field before tesr' m." Water addba-'s gal New depth in. rie mm Final Mdde fh"� m Absorption rate > "` ym D g.p.d. P nationi'reatment (past 12 mo) (Y�& type) k D. LIFT STATION ... Date installed g�os `� Manhole/Access (Y/N) Size n "Pump on" level at _ in. Pu evel at _ in. High water alarm level at in. . ..... ..... .. ..-....._..... Datum Cycles tested Meets alarm 8 circuit requirements? ... . _...... N. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/444ta£e0 on lot f fee ' On adjacent lots rlecp Absorption field on lot fi°°' On adjacent lots Public sewer main + �S' Public sewer manhole/cleanout Sewer /septic service line ' Holding tank oo' SEPARATION DISTANCES FROM SEPTIC/Heil t TANK ON LOTTO " Building foundation /S Property line f? Absorption field is Water main -r re' Water service line +101 Surface water f r°o' _. Wells on adjacent lots 1 t00' _ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /,Z ' Building foundation 3.2 ' Water main Water Service line -t Surface water + t0d ' Driveway, parking/vehicle storage 3' Curtain drain ! So " Wells on adjacent lots '+1 °° �.V._ F. COMMENTS ..OF S A� G. ENGINEER'S CERTIFICATION .* 1 certify that I have determined through field inspec%ons and' `••- """"' review of Municipal records that the above systems are in ...... ... ....... in effect on this date. CiIRISTOPHERR•WOOD conformance with MOA HAA guidelines m `CE10387 Engineer's Printed Name / v2�sroPr�e�%oA .rte c '� Date Waiver Fee $ HAA Fee $ �. f �g 69 Date of Payment Date of Payment _ Receipt Number ,20, Receipt Number (Rev. 12101) I" 6W ASBUILT I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE FOLLOWING DESCRIBED PROPERTY:DAf AND THAT NO ENCROACHMENTS E. EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS GRID: WHICH DO NOT APPEAR ON THE RECORDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB: ANY DATA HEREON BE USED FOR CONSTRUCTION OFFENCE LINES, OR FOR ESTABLISHING BOUND- - -� ARY LINES. DRAWN: d � a ASBUILT I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE FOLLOWING DESCRIBED PROPERTY:DAf AND THAT NO ENCROACHMENTS E. EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS GRID: WHICH DO NOT APPEAR ON THE RECORDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB: ANY DATA HEREON BE USED FOR CONSTRUCTION OFFENCE LINES, OR FOR ESTABLISHING BOUND- - -� ARY LINES. DRAWN: oil QG �ll 6 j v .w SGS Ref.# 1046456001 Client Name Eagle River Engineering Project Name/# North Slope #2, Lot 4, Block 5 Client Sample 1D North Slope #2, Lot 4, Block 5 Matrix Drinking Water sample nemarkS: All D2tea/Time% are Alaska Standard Time Printed Date/Time 10/19/2004 9:10 Collected Date/Time 09/30/2004 13:45 Received Date/Time 09/30/29J04 14:26 Technical Director , SteOld C. Ede Parameter Results P L Units Allowable Prep Analysis Q Method Cnntainertb imits bate Dale lnit Waters Department Nitrate -N Microbiology Laboratory Total Coliform 0.100 U 0.100 tng/L EPA 300.0 u coV100mL SM20 92228 13 (<=10) A (<=1) 10/02/04 AB 09/30/04 DKC 9P9-3 EO/Z0'd EE9-1 10£9199106 S33IA83S AN3 S3S 'IS3 3'813-PIONd P1d9P:10 PO -61-01 JRs Pumping PO Box 773415 Eagle River, AK 99577 (907)694-6454, ..Ir-—,.,._... ' Bllling--Infom_ation Eagle River Engineering 10421 VFW Rd Ste 2DI Eagle River, AK 98577 (907)504-5195 Job Description: 1000g P.O. Number: Terms: Net 30 Salesrep; Nikole Map Book: Service Agreement Number; 014822 Order Date: 23Sep-2004 Service Data: 24 -Sep -2004 12:00 am Technician: Tony Job Type Repeat M Gw _ __ _ _ ap t 145- . Job Slie Information ... Cross Streets: Pmdhoe Bay Avenue —..-_.. _ Chris Jotn 8i Sue Will (home owner) Job Comments: Last §ery 04/13/02 1100g 4244 Hama Street .Checked and pumped tank - levels normal Eagle. River, AK 99577 (907)1194-3382 Tax Percent: 242.2717 0 Service Type as x 2 Men _ Tex SapuC Service Under 2K 1 No No Extension Actual Additional Location Comments: Three story gray w/green metal roof Tank 0 left - rear of home Diagram: r:/u . HE ffDW •>,1,a3kk • rfo • Gallons Planned: 1000 Gallons Actual: Hose Length; Double Tank: r; _ Pump System: Baffles Inlet: Eames outlet ❑ ter.... NonTaxable Total Taxable Total Tax Total Grand Total Customer agrees to the terms and conditions printed on the back. THIS IS A BINDING AGREEMENT. Signature and TBIe of Customer Represaniative Date Accepted by JRs Pumping Date Accepted For your added convenience we accept American Express/ DlcoveryfAse and Master Card payments over the phone, After 30 Days 1.5% Will be Charged or THERE WILL BE A DELIVERY $25.00 For NSF Checks Rwhimad RECEIVED Municipality of Anchorage DEC 17 199 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MUNICIPALITY OFANCH 825 L Street, Room 502 • Anchorage, Alaska 99501 • (9MVF�MMSERVICES DIVISION Health Authority Approval Checklist Legal Description: L'9 'r I GL 0 C K 0 _- Parcel 1. D.: C g C S "" A. WELL DATA Well type 101: I v'`1 i vz- If A, B, or C, attach ADEC letter. ADEC water system number Log present (l�/N) Y�LI Date completed /x `I `1 �� Total depth Sanitary seal 6YN) 'yri Date of test i Cased to 1 5 y Casing height (above ground) Wires properly protected OY N) FROM WELL LOG Static water level ) q 3 Well productions WATER SAMPLE RESULTS: Coliform 0 Date of sample: 1a,! /O/`l B. SEPTIC/HOLDING TANK DATA Nitrate Y & S AT INSPECTION i 9.131m. g.p.m. Other bacteria C S & S ENGINEERING Collected by: 17034 Eagla River I nasty Rand Nn_ 204 Eagle River, Alaska 99577 Date installed z `f Tank size � 0 c C Number of Compartments a Cleanouts &t/N) "" J Foundation cleanout(YaN) Yrz S Depression (Y/W /" O High water alarm (Y/fly Date of Pumping ti /11 /v Pumper C. ABSORPTION FIELD DATA �r �yr�lx � 2) 2 0.c f'z ��� Date installed Soil rating g.p.d./ft or ft /bdrm) System type Length ' Width 5 Gravel thickness below pipe C7 * Total depth Effective absorption area '� i� C r g Monitoring Tube present &/N)_)L/ Depression over field (YC�3 1v c Date of adequacy test "JI,4 - N `t Results (Pass/Fail) For bedrooms Fluid depth in absorption field before test (in.); Fluid depth (ins) Minutes late Perot de.treatrneht (past 12 months) (Y/N) 72-026 (Rev. 3/96)" Immediately after gat: water-a6Te-d`(in.) Absorption rate = g.p.d. If yes, give date CT&E Environmental Services Inc. znt,L Laboratory Divisionr®®®��®,®®®®®®®®®®r�it�iiiiirrw4►,orwir��iw�iiiitie 200 W. Potter Drive Drinking Water Analysis Report for `dotal Coliform Bacteria Ae c rag e, K 99618-1 sos READ INSTRUCTIONS ON REVERSE' SIDE BEFORE COLLECTING SAMPLE Fax: 1907► 561.5301 MUST BE COMPLETED BY WATER SUPPLIER 0 PUBLIC WATER SYSTEM I.D. f* PRIVATE WATER SYSTEM ❑ Send Results © Send Invoice VrIp'yrKn1 mmvco� mpaym ne ana>rawmc fogy /ozi/ one um cr I,es um er 'vl os M&M (( ny sum �p e Send Results O Sendlnvoice (amwnY . -0nLClAme 17034 Engle River Loop Reed No. 2H Mallnlx a River, Alaska 98977 tlY SWIC 4p COO SAMPLE DATE: l(_I; F-712 ME ,1 Month Day Year - SAMPLE TYPE: j9 Routine 0 Treated Water Cl Repeat Sample (for routine sample ❑ Untreated Water with lab ref. no. ) ❑ Special Purpose Time Collected SAMPLE LOCATION Collected By L -r Y 81�r ICL�/.�Vf�l Please Frim Comments: I U tib CUMNI b EU I3Y LAtiUKA I'UKY Analysis shows this Water SAMPLE to be: Satisfactory Unsatisfactory o Sample over 30 hours old, results may be unreliable ❑ Sample too long in transit: sample should notbe over48 hours old at examination to indicate reliable results. Please send new sample via special PIN ry mail. Date Received Time Received 1.7 Analysis Began 9,,r Analytical Method: }i( Membrane Filter o MMO-MiJG ' Number of colonies/100 ml. Result* Analyst Fbks Jun 0 FAxed Date: Timc: Client notified of unsatisfactory results: Cl 0 Phoned Spoke with Foxed Date Time: _ BACTERIOLOGICAL MATER, ANALYSIS RECORD MMO-M(JG Result: Total Collform _ E. Ceti Membrane Filter: Direct Count 0 Colonies/100 mi Verification: LTB _ BGII � —COLIF Fecal Coliform Confirmation _ Final Membrane Filter Results Q „ coliform/100 mi Reported By ��� Date _ Z J Time bl >'J brs Nlarnbor of 00 5BU Oroup IS"iolb G6n6ralo de Survoillanco) ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA. FLORIDA. ILLINOIS ftie,avl ANn UIIl WIr:AN Fxrecnuel ue+.1 TNTC- Too nrureerous To Cougr OB -Orsi. 84crerra TOTAL P.02 AL. CT&E Environmental Services lne. CUE Ref -ll Client Name Project Name/tt Client Sample W Matrix Ordered BY PWSW 987168002 S & S Engineering NIA Lo14 Bk5 North S1opC Drinking Water Parameter Resuttti Nitrdte-N 0 Client POA Printed Date/Time 12/15/98 00:08 CollectedDate/Time 12/10/981430 Received Date/Time 12111/9$ 10:OU Technical Director: Stephen C_ 8de Released By allowable Prep Analysis PqC unias Method CimicS Dare Dace Init 0.254 0.900 mq/4 EPA 300.0 10 max 12/11/98 12/11/98 SCC M� DEC 17 1999 Nlurticipalityof lara(:c-101 aCA8 Dept. Health a V111man Ser,%ficee Municipality of Anchorage • Development Services bepeFtment Building Safety Division On -Site Water and Wastewater Program A 4700 South Bragaw St. P.O. Box 196650 Anchorage, Ak 99519-6650 www.cl.anchorage.ok.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. 050-581-07 HAA# i�A0,20/&Z Expiration Date: 8 f 9 ro Z 1. GENERAL INFORMATION Complete legal description. Lot 4; Block 5; North Slope f/2 • 4 Local F'(sileaddressord'irections) 4244 Harka St. Eagle River, AK 99577 Current Pr.operty owners) `Sharon McRee Day phone 694-3362 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address same Day phone Day phone Unless otherwise requested, NAA will be held by DSD for pickup. ? � �rt._ S -1N1 o'Z- 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Individual On-site 0 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 the representations given In paragraph 5 by an Independent professional civil engineer registered in the Stale 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 properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (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 yalidation date shown below. I verify 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. 1 further verily 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 S & S Engineering Phone 694-2979 Address 17034 N. Eagle River Loon Eagle River, AK 99577 Engineer's Printed Name Robert C. Cowan Date t// /o Z 5. DSD SIGNATURE Approved for 3 Disapproved. 3/ c/t,aoeERT C. CE 8801 COWAN Y bedrooms. f•r� =�' Conditional approval for bedrooms, with the following stipulations: J . •ON -S WAS ER ANO : M Additional Comments p'• ROGfiAM 1����/J/1)11I1111�1(: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other BY •� 4 + Original Certificate Date: (P.. 12A0) Municipality of Anchorage • Development Services Department Building Safety Division On-site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196850 Anchorage, AK 99519.6650 www.d.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lor 4 814 4E S` ivdprn f L"00C 0$ Z Parcel ID: 0 S40 -S`9 / —0 7 A. WELL DATA Well type Y3r vAIC Date completed _7,6Lq/qg Total depth 3 � ft. Date of test Static water level Well production If A, B, or C provide PWSID # Sanitary seal 4aGiN) YE S Cased to '40Y ft. FROM WELL LOG /ig A !s3 ft, WATER SAMPLE RESULTS: 3 Coliform _0 —colonies/100 ml. Date of sample: s+ /'-& � /0'Z Well 1-091 N) Y E S Wires property pvtected4'N) Y" J Casing height (above ground) -;L Y 'f' In. AT INSPECTION } oa 2gS' ft. 3.6 9— p.m- Nitrate 0•'' Srmg.A. Other bacteria 0 colonies/100 ml. Collected by: s A& ENGINEERING 17034 Eagle RhW Loop Rad No. 204 B. SEPTICIHOLDING TANK DATA Eagle River, Alaska 99577 Tank Type/Material 5CO rc.I S' -EEL Date installed Tank size / 000 gat.Number of Compartments Cleanouts&N) Y t I Foundation cleanout &) YE Ss Depression over tank (Yt) , o Date of pumping 'Y/A6/Ox Pumpr S /e S High water alarm (YAW N O C. ABSORPTION FIELD DATA S NA��o w Date installed g U /? Soil rating g.p.d. or f 2fodrm) 6 System type *Rt�(:wt t Length 9F 4- V-()' ft. Width S ft. Gravel below pipe 0- S ft. Total depth S— ft. Eff. absorption area $y 0 fir Monitoring tube Y t S Depression over field & 0 Date of adequacy test �S/o Results kjjail) For 3 bedrooms Fluid depth in absorption field before test bAY in. Water added y3 - gal. New depth 3 in. Elapsed Time: I H min. Final fluid depth 0R7' in. Absorption rate >= 815-0 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N r N t Kraw,-' ,-' If yes, give date — D. LIFT STATION Date installed "Pump on" level at _ in. Datum E. SEPARATION DISTANCES Size in gallons "Pump off Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100 r Absorption field on lot /00 Public sewer main N 14 High water alarm level at in. Meets alarm d eucu t requirements? On adjacent lots On adjacent lots Public sewer manhole/deanout r/1A Sewer /septic service line .' r �-, Holding tank NSA SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation 13 Property line 7 Absorption field Water main i✓ /4 Water service line 10 i' Surface water /,JO -0 Wells on adjacent lots _/O C f SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: i Property line a Building foundation a Water main N 1A Water Service line / 0'+ Surface water / 0 0 + Driveway, paddnglvehide storage /c 4 Curtain drain AJ -,t Kw# w w Wells on adjacent lots / 00 4 F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and Pit/ review of Municipal records that the above systems are in f..� conformance with MOA HAA guidelines in effect on this date. E . Engineer's Printed Name 9d B,t A7- C_ Cp,.4,,, !A\ 18CE .8801 COWAN Data S- A -z- HAA HAA Fee $ 3 -)SS ° Date of Payment S///0,21— Receipt Number (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number id;.• A `, a t •' '' '? I Of o • `r'p 14 i Nk I F. r ., 1 n q A C S O f Y AA YA ( IrA w n.o3.g�ga :z n n —G A a an I e n ' Y n C SYaA fiIt Y 1 Mr JAA R Tl�u �•yv m�C o.a�a" IRi''f� wYa 3idmo., F-, T I ,',oI�O a a7 c£ncavl � c. 3 tri+^ T