HomeMy WebLinkAboutT15N R2W SEC 25 LT 28A Municipality of Anchorage Page
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: ~L~q~OO~l PIDNumber: O.~-/- 2, ~'/- /~,~
Name: ~..~ ~_.~..~,~..~[, O~ ~. ~.. ~. Wastewater System: D New ~Upgrade
Address: ~ ~ ~'~ ~ ~ ~ ~'~ ABSORPTION FIELD
Phone: ~ ~ -~ ~ IN°'°fBe~°ms:
~ Deep Trench ~ Shallow Trench ~ed ~ Mound ~ Other
Total Depth from original grade:
LEGAL DESCRIPTION S°ilRating: J.~ GPD/Sq.F'.
Lot: Block: Subdivision: Depffi to pipe bogota om original grade: Gravel depth beneat~ pipe
Township: , ~ I Range: ~ I Seclio.: *~ Fill added above original grade: Gravel length:
Gravel ~h: . Number of lines: IDistance ~een line~:
WELL: ~r;~2tD New ~ Upgrade ~ ~'~v~ /7 ~t, ~ ~I
C~assification (Private. A,B.C}: Total~ ~Depth: Ft. Cased To: Ft. Total absenta:. ~ SO. Ft. Pipe~material: ~)
Driller: Date Drilled: Static Water Level:Ft. Installer:~ ~ ~ ~=~ D~te installe '~ I m~
Yield:GPM IPump Set aE Ft. ICasing Height Ab°ye Gr°und:Ft. , TANK
SEPARATION DISTANCES ~s~pt~ ~ Holding D S.T.E.P.
Capacity in Ions:
To Seplic Absorption Lilt Holding Public/Private Manufacturer:t~t/~ ~ { ~ ~
From Tank Field Statio, Tank Sewer Lines ~,~ O~
Matedah Number of Compa~ments:
Surface LIFT STATION
Water ~ ~/~ ~/~
LineL°t [~l.' ~OI ' ~ --]1[ ,I Size in gall°ns: I Manufacturer:
FoundatioR 7ol ~l I ~ ~ ~]B "Pump on" level at: I "Pump off" level at: IHigh water alarm at:
Cu~ain ~ __ ~ -- Pump Make & Model I Electrical Inspections pedormed by:
Drain ~/~
Remarks: BENCH MARK
coeation and Doscription:
Assumed Elevation:
ENGINEER'S ~EAL
Ihspections performed by: ~F Dates:lst ~/~/$ * * ' :
Department of Health and Human Services approval ~,~, ~-,.. ~'.. . ..
Reviewed and approved by: ~ ~~ Date / '~'~',~-, '*
72-013 (1/91) MOA 25
Permit No. ~ ~ ~{ I (:~ ~3 I
Page ~ of ~
Municipality of Anchorage
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
PID No.:
2-5%
Z
con flTcts +200*
Ou[~Buildiog1
Devotions
~oo'
FIELD
20~ Utility Eosement
N00'06'301' E 150.00
o~ ~
No con[l[ct$
+200'
- TEST HOI~E
o - SEWER CLEANOUT
- WELL j
72~J13 A (2/91) MOA 25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF 1
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW910081 DATE ISSUED: 5/03/91
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAME:SECRETARY OF HUD
OWNER ADDRESS:222 WEST 8TH AVENUE, BOX N-64
ANCHORAGE, ALASKA 99513
EXPIRATION DATE: 5/03/92
PARCEL ID:05128163
LEGAL DESCRIPTION: T15N R2W SEC 25 LT 28A
LOT SIZE: 44613 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1o 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 (iSAAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY: /~'~J
ISSUED BY: ~~ ~, '
DATE:
Louis Butera, P.E.
Registered Civil Engineer
April 29, 1991
John Smith, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Lot 28A, T15N R2W Sec. 25
Narrative
Dear Mr. Smith,
The proposed septic upgrade will have very limited impact
adjacent properties for the following reasons:
on
1. The area has large lots of 1.5 acre minimum size allowing
sufficient room for well site~
2. Immediate neighboring septic systems are all +30'
distance.
3. Reserve space is adequate, homes are existing with many
upgraded already.
4. Drainage will not be effected and is not a major
consideration in our design.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
P.O. Box 773294 . Eagle River, Alaska 99577 · Telephone (907) 694-5195 · Fa.x (907) 694-3297
5EGAL:
LOT 28At
SPE?!FICATIONS FOR ON-SITE SEPTTq SYSTEM
T15N, R2W, Sec. 25
GENERAL
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this
specification.
3. All materials and workmanship shall meet the Anchorage
Department of Health and State Department of Environmental
Conservation requirements.
4~ Ail soil tests are advisory to the design and are to be verified
or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified
or modified in the field by the contractor to meet Municipality
of Anchorage, Department of Environmental Conservation
requirements.
6. It is the responsibility of the owner to obtain all necessary
permits or easements.
7. The excavation is to be exactly in the area shown on the site
plan, any deviation requires engineer approval.
8. It is always recommended that a surveyor locate the nearest lot
line position and the location of any easements.
B. BED
1.
2.
3.
The bed is to follow the natural land contour to maintain
uniform total depth of the bed bottom.
The bottom of the bed shall be level, plus or minus 1.5".
The total depth of the bed excavation is to be at a maximum of
6' . Removing soil to 8' and replacing with 2' sand layer
meeting State specification per 18 AAC 72.
4. The Sgwer lihe is to completely replace the existing sewer line
that leads to the existing tank. The existing tank is to be
abandoned to code.
5. The bed gravel is to be covered with typar fabric material.
6. soil or combination of soil and extruded board insulation to a
depth of 4' or equivalent is to be placed over the leachfield.
7. The area over the bed is to be finish graded to prevent ponding
of surface water runoff.
8. The septic tank and leachfield must not be closer than 100' to
any existing private well, 150' to any class "C" we~]~,~,~q~ 200
feet to any community well .....
RECOMMENDED LEACHFIELD DIMENSIONS
TOTAL DEPTH = 6' (max) GRAVEL DEPTH 1'
BED LENGTH = 44' BED WIDTH = 17'
soil Rating = 125 (sand material)
Bedroom Capacity -- 4
Septic Tank Size = 1250 gallons
Sand Filter = 2' depth. Remove and replace existing soil as required.
Existing septic pit is to be abandoned per code. This will require
permission and entry onto neighboring property.
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
DATE PERFORMED:
SOILS LOG
PERCOLATION
TEST
4-
5-
6-
7
8
9
10
11
12
13
14
15
16
17
18
19-
20-
SLOPE SITE PLAN
f
WAS GROUND WATER
ENCOUNTERED?
E
IF YES, AT WHAT /~7/
DEPTH?
,¢/..., -,/~
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~--~ / (minutes/inch)
TEST RUN BETWEEN ~7/ FT AND --~ , FT
COMMENTS
PERFORMED BY: f'~c~,~J' ~;~' -- '~ '7/
72 008 (6/79)
MAT-SU TEST LAB, INC,
Soils -- Concre(e -- Water
Ficld and I,almratory Testing Services
- P.O. Box 871868 · Wa$illa, Alaska 9£687 · (£07} $78-3005
PROJECT NUMBER: 391015 DATE: 4-3-91
PROJECT NAME: adec septic sand
TEST HOLE: SAMPLE: DEPTH:
SIEVE % PASSING SPECS: COMMENTS
3 IN.
2 IN. Sanpledelivered to MS]L
1½ [-N. o~ 4-3~91 '~ ' '
1 IN-
.. ~ ~..
3/4 tN.
½ IN." ' ' " '.' ': * ~ Specs:'
Cu = 2.8 · ~4
3/8 IN. ' Cc = 0.8 : '---! '
'[/10- 97 ...... 85-100
~/30
t/4o~ 43 25-50
ENVIRONM~NrAt
1/50 M$00
,,/8o RECEIVED
//200 !. L ~' 5 Munic~a ~v ot AdCt~orage
Dept, 1
Reviewed By:
DEPT. OF ENVIRONMENTAL CONSERVATION
April 12, 1991
WALTER J. HICKEL, GOVERNOR
p.o; Box 871064
Wasilla, Alaska
99687-9998
(907) 376-5038
Mr. John Waters
Quality Sand and Gravel
P;O Box 1456
Palmer, Alaska 99645
RE: Sand Filter Material; Specification Review
Dear Mr. Waters:
This is in response to your submittal, received in this office on
April B, 1991. It is assumed that this analysis is a second
testing of the sands you are stockpiling for use in sand filters
for soil absorption systems; I have completed my review of your
submittal and find that the Department has no objection to the sand
that this sieve analysis was performed on, being used in sand
filters.
In order to retain the Department's non-objection, a sieve analysis
on a representative sample taken from your stockpile will need to
be submitted to this office for every 1000 cubic yards stockpiled.
A similar submittal will need to be made next year, by April 15,
1992, if you intend to obtain the Department's non-objection to
your sand. This non-objection is for use in sand liners, which are
constructed in the Mat-Su Borough;
It is emphasized that this letter of non-objection is for sand used
in wastewater disposal systems, which are less than or equal to
1000 square feet in size; Systems larger than 1000 square feet may
require a separate sieve analysis every 1000' square feet; however,
this is the concern of the owner/developer, not the supplier/source
of the material;
Thank you for your eooperation with this Department; If you have
any questions, please do not hesitate to contact me.
Sincerely,
Environmental Engineer
RK:Jlf
Well.~
¥
100'
1',100'09'00" E 1 50.00
10' Utility Easement
2-5~.
---- Septic system
110" from Iotllne
~-- No other
confllcts +200'
2~
lOO' cn
Abandon
e
No conflicts
+200'
House
Out-Building
Drive
20' Utility Easement
NO KNOWN CURTAIN DRAINS
NO SURFACE WATER +200'
N00'06'30" E 150.00
No Conflicts
+200'
SEPTIC SITE PLAN
LEGAL: Lot 28A, T15N, R2W, Sec. 25
OWNER: H.U.D. Properties
CONTRACTOR: N/A
JOB # 90-125 J DATE:
12/11/901 SCALE 1" = 30'
A
EAGLE RIVER ENGINEERING SERVICES
P.O. Box 773294
EAGLE RIVER, AK. 99577
(907) 694-5195 FAX: (907) 694-8408
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 g9519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O 5' / - 3. cj' I - 6 3
1. GENERAL INFORMATION
Complete legal description ' Lot 28A, Section 25~
Location (site address or directions)
Expiration Date:
?C15N, R2t~,
16240 Shims Street
0101~o
Current Property owner(s) Larry Smith Day phone 564-1812
Mailing address 16240 Shir~s Street, Chu,~iak, AK 99567
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Un/ess otherwise requested, HAA will be held by DSD for gickup.
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 the representatlcns given in paragraph 5 by en 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 prope~es served by a private or Class C well and may be reissued with
r, ew 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 fcr 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 outiined 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.
S & $ ENGIN£ERING
Name of Firm r~n't4 Fn~_l. I~;v.,- Inn? !~n~
Address Eagle River, Alaska 99577
Engineer's Printed Name Robert
DSD SIGNATURE
~ Approved for ElL
Disapproved.
Condiiional approval for '~
Phone 6
C. Cowan, ?.£. Date ~/~ 5//0 ,
.,[ttI!(.(~//Ot,. ....-. ¢¢ (..),- ~/ ~..
,,?~b.. ...... 'i..... 'e,,; t,
X -- , ........ ,
~";.,,~L" "..'"~?-.. ,¢'o/' .,-z~J',.:.'.~'~,
O -S TE
~%'., ..'Z-',$' '~, ~'". .~',e'
bedrooms. ~ '. ...... .' ~%~-~ '
/J)JJJJJ ;) I~~1'
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
lvlaintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: Z/L - .~,- O I
Municipality of Anchorage
Department of Health and Human Services
Division of Environmental Sewices
On-Site Services Section 825 'L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-4744
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
.A. WELL DATA
Well type~ If A, B, or C provide PWSID # ~
Parcel I.D.:
Well Log /V'~:~
Wires properly protected
Casing height (above ground) I~.. in.
AT INSPECTION
Date completed 4/¢~-7'~
Total depth ~'~'/ It
Date of test
Sanitary.seal
Cased to ~ It
FROM WELL LOG
Static water level
Well production
g.p.m
It
z:~, / g.p.m
WATER SAMPLE RESULTS:
Coliform C) colonies/lO0 mi
Date of sample: ~__/~--~ /
/
B. SEPTIC/HOLDING TANK DATA
Nitrate /. ~.~ mg/I Other bacteria c3 colonies/100 mi
Tank Type/Material
S & S ENGINEERING
17034 EagJe River Loop Read No. 204
Eagle River, Ala~ka 9'9577
Collected by:
Date installed ~ Tanksize /~.-.~ gal Number of Compartments __
Cleanouts ~ ' Foundation cleanout
Date of pumping /~/~/~ O
Depression over tank ,R/' ~ High water alarm /V/~
Pumper ~-~A~' ~C
C. ABSORPTION FIELD DATA
Date installed ~.~_..~ Soil rating (O.P.d./ft2 or It2/bdrm) /' ~ System type_.~-~
Length x~ ft Width /:~Z. ft Gravel below pipe ~:~.~'ft
Total depth ~' It Effective absorption area.Z"Z~ft; Monitoring tube._~__ Depression over field
I I
For 4- bedrooms
Fluiddepthinabsorptiorifialdbatoretest// ~ in Wateradded ~/gal. Newdepth ~- in.
Elapsed Time: ~ min Final fluid depth _~/ in Absorption rate >= .~ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)/~X/~' ~/~f/~/~/' If yes, give date
72-02~ (Rev. 01~00)'
D. LIFT STATION
Date installed _~ in
gallons
"Pump on" level at~//"in "Pump off' level at'
Datum /,/ Cycles tested
E. SEPARATION DISTANCES
in
Manhole/Access
High water alarm level at in
Meets alarm & circuit requirements
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewe~/septic service line
SEPARATION DISTANCES FROM WELL ON LOT TO:
,/~)0 / ~ On adjacent lots
/~)0 '-/" On adjacent lots
~,//A Public sewer manhole/cleanout
~. ~'- '/~- Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~' ' 4.
Water main ,/~/A
Drainage /~/,/,'~
Property line '~ '~''- Absorption field
Water service line /O ~- Surface water /OO/-f--
Wells on adjacent lots
! C)/.~- Surface water / OO '.t--- Driveway. parking/vehicle storage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Properly line / 0/V'-' Building foundation //0 ~-- Water main
Water Service line
Curtain drain'/ /'/'/I/~X/,/-,(~z/7~,</ Wells on adjacent lots //~-~--
F. COMMENTS
G. ENGINEER'S CERTIRCATION
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
Date 3/3, 3/0,
HAA Fee $
Date of Payment
Receipt Number
g/o/
Waiver Fee $
Date of Payment
Receipt Number
72-0ge (Rev. oI/oo)'
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
Parcel i.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Lot 28A, T15N, R2W, Sec. 25
Location (site address or directions) 16240 Shir~ Street, Chugiak
Property owner H.U.D.
Mailing address 222 W. 5th Avenue; Anchorage; AK
Lending agency N/A
Mailing address.
Day phone
99513
Day phone
2~i-4314
Agent Sandv Hjelmsted/ Associated Brokers
Address ~4{~ W qAfh Avenl]P. ,q%]ite ], An~hnr~9~; AK
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Day phone 563L3333
99503-%g07
Indiv!dUal well x
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
x
4. TYPE OFWASTEWATER 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 (Rev. 1/91) Front MOA #21
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. 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.
Name of Firm Eaqle River Enqineerinq Services Phone 694-5195
Address P.O. Box 773294, Eagle River, AK 99577
Engineer's signature
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following
stipulations:
Additional Comments
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 DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Em ployees of DH HS 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 engineeds work.
72~025 {Rev. 1/91) 8ack MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:~''~ ~ .4 Z-/.¢',~' ~ ~.~,~ .~,-~5" Parcel I.D.
Log present (Y/N) ~J
Total depth ~"// ~¢'~-
Sanitary seal (Y/N) Y
A. WELL DATA
Well type
Date completed / ? ? ~' "¢""~- Driller
Casedto ~'4/~' ,*,- ¢¢,~'~o~ Casing height.
Wires properly protected (Y/N)
If A, B, or C, attach ADEC letter, ADEC water system number
FROM WELL LOG AT INSPECTION
Date of test ,,V/../' ///~ ?../~ o
Static water level ~" 3~- t
Well flow f g.p.m. ~ ~
!
Pump level 0 z/-.~ '
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot /~*- ~
Absorption field on lot /'~ / /
Public sewer main /'""~
~ sewer service line {z~ /
z
g.p.m.~ E,
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank ,~'¢~,e ~,~,~-~,~'
WATER SAMPLE RESULTS:
Coliform ~
Date of sam pie: 5"-.~- ~'./'~
Nitrate ~ 3 ~,,/,- Other bacteria ~'
Collected by: ~--~-~' ~-~,-'~-~
B. SEPTIC/HOLDING TANK DATA
Date installed ,/~/ ~--~0~t I Tank size
Cleanouts (Y/N)
High water alarm (Y~)
Date of pumping
./..~.r-~ ~:.~- Compartments ~'
Foundation cleanout (Y/N) ,v Depression (Y/N)
Alarm tested (Y~D.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /
To property line
Surface water/drainage
On adjacent lots ~'/¢¢¢" Foundation 7~ '
Absorption field /¢ '~ Watermain/serviceline -~/'~"
72-0~6(Rev. 3/91}Front MOA21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed /~-¢/'/ /¢z~"e1~
Length 4/¢ / Width / 2 '
Total absorption area _ 7'¢,~ ,¢
Depression over field (Y/N)
Results (pass/fail) /¢¢
Peroxide treatment (past 12 months) (Y/¢
Soil rating /~'-..~ d/,~.../,~'-' System type
Gravel thickness ~ '"" Total depth
Cleanouts present (Y/N) /~'
Date of adequacy test "~'"¢~""
for
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /~/ On adjacent lots ~"/¢'~ / Property line
To building foundation o/// To existing or abandoned system on lot
On adjacentlots ~' ;"'~ ~ Cutbank ,'//,~ Watermain/serviceline
Surface water "~.,~ Driveway, parking/vehicle storage area ./""¢
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on
date of this inspection.
Signature
Engineer's Name ~-'~-, ,':,' ~':'~"~,
Date
HAA Fee $ ./~, ¢0
Date of Payment ~ ,///¢ /
Receipt Number ~,,~ ~/~¢~'
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number