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HomeMy WebLinkAboutFOX HILL BLK 2 LT 4Foxhill Block 2 Lot 4 #051-073-10  Municipality of Anchorage ....?.,~, .'. Development Services Department."'"" ~:"-': ' Bu~ing Safety Division On-Site Water and Wastewater Program, 4700 S. Bragaw SL P.O. Box 196650 A~chorage, AK 99519-6650 Page · ~vw.d.anchorage.ak. us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number:. ~'[/JO00~'~ PID Number:. "-~Jofi~y [/U)O~Vl,R~ WastewaterSystem: ~-lNew I~JUpgrade PO goy ?.~ ABSORPTION FIELD LEGAL DESCRIPTION s~..~ · FI, Well: [] New [] Upg ,, f210 ~~.. ~. ~ TANK SEPARATION DISTANCES ~ septic [] Ho/ding ~-1S.T.E.P. [] Other.. To SepticAbsorptJor Lift Holding Publlc~Pdvat~ ,. ll5' ~16' I~H' 25~+ "':/./OPE s.~,=w.,, lOCI/. 100~. IO0~- ~ / LIFT STATION V S,z* ~,~,o~'. ,-- 6,' ~rc~,--4~ P.C~6 $~ BENCHMARK Inspections pe.ormed y: ...... uates: 2~ ~-~3-O0 Development Se~ices Depa~ment Approval Reviewed and approved by: Date: PERMZT NO SW000286 PACE 2 OF 4 Municip. o[i-I; oF' .A. ncho?gg.e . DEPARTMENT OF HEA~TH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION · P.O. Box 196650 e.,Anchor'clge, Alaska 99519-6650 · TeleDhome: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEOAL LOT 4, BLOCK 2, FOX HILL P.LD. NO. 051-073-10 LOT 5 LOT 6 LOT 3 I I I ,/ CE-8801 PER),IIT F;O. SW000286 PACE 5 OF 4 Hunicipa[it oF An c h o r'~.cj?. DEPARTMENT OF HEA~_TH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION · P.D. Box 196650 ~._Anchorage, Alaska 995Ig-6650eTelephone~ 343-4744 ON-SITE WASTEWATER UISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LECAL LOT 4, BLOCK 2, FOX HILL P.LD. NO. 051-073-10 GRADE ST1 ST2 INSULATIO ELECTRICAL CONDUIT DISCHARGE PIPE 803 NEW 1000 GAL. TO SAND FILTER POLY. TANK 80.4' A B FCO $4.5' 10.0' ST1 88.5' 69.0' ST2 94.5' 75.0' MH 98.5' 79.0' FV1 116.0' 87.0' FV8 128.5' 96.0' MT.3 119,5' 84.5' C01 182.5' 172.0' MT1 191.0' 182.0' C02 204.5' 189.0' MT2 198,5' 181.0' Ill 550 GALLON FAT ALBERT WITH PUMP ASSEMBLY PERMI? NO. SW000286 PAGE 4 OF 4 Municioc[itv oF .A. mch. orogp. DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 eAncho~age, AlaskQ 99519-6650® Telephone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 4, BLOCK 2, FOX HILL P.[.D. NO. 051--073--10 GRAVITY BED C01E~ HMT2 MT1H NC02 FINAL .... /'-~~~~2" INSULATION ~ MT 24" FILTER SAND "PEA GRAVEl 18' X 20' SAND FILTER 82.5 WITH GRAVITY DISCHARGE ROBERT C, COWAN, RE, ROBERTA. SHAFER. RE. Date: CIVIL ENGINEERS (907) 694-297g FAX(907) 694-121 ~ 80~LTEST Municipality of Anchorage DEPARTMENT OF EEALTH AND HUMAN SERVICES 825 L Street P.O. Box 296650 ~nchorage, Alaska 99519-6650 REFERENCE: The septic inspections for the referenced property were performed on ~nd ~-~-~. Prior to submitting the On-site Wastewater Dlsposal System~nd/or,Well Inspection Report we are waiting for the ~-~H;~$ufV~ to be completed. - If we may be of further service please contact us. Sincerely, 17034 NORTH EAGLE RIVER LOOP · SUITE 204 ,, EAGLE RJVER, ALASKA 99577 MUNICIPALITY OF ANCHORAGE Depa~ment of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Aug 08, 2000 Expiration Date: Aug 08, 2001 Permit Number: SW000286 Legal Description: FOX HILL BLK 2 LT 4 Design Engineer: 0003 S & S Engineering Owner Name: Johnny Womac Owner Address: PO Box 670183 Chugiak, AK 99567-O183 Parcel ID: 051-073-10 Site Address: 021828 WOODCLIFF DR Lot Size: 43559 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. Ail requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Issued By: ~ ~, ~,b / / ROBERT C. COWAN, P,E. June 27, 2000 CML ENGINEERS (907) 694-297B FAX (907) 694-*12 ! 1 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 4, Block 2, Foxhill It is requested that you issue a permit to upgrade an existing system to a pressurized septic system (Intermittant Dosing Sand Filter) with a 1000 gallon Premier polyethelene septic tank and lift station to serve the existing 3 bedroom house on the referenced property. A test hole was excavated and a percolation test was performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation on 5/19/00 water was found at 4 feet. After monitoring until 5/27/00 the test hole was found to be dry. We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent pmpertieso If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/jhm Enclosure 17034 NORTH EAGLE RIVER LOOP * SUITE 204 * EAGLE RIVER, ALASKA 99577 DESIGN CRITERIA: smucruR~s, ~AS£USNTS. OR ~r~ 3 BDRM = 450 GPD SHOWN ON THIS SITE P~N ARE ROBERT C. ~OHNSON 450/0.5 = 900 SQ. ~. R~Q'D BED CRITERIA: ~1 (go7)eg~-~mt 1 60' / EXISTING PRO~SEO 1000 ~LLON ~ WORK. ' / ~ ~NDONEO) / 1000 ~LLON ~ ~ LI~ STATION IN 550 I ~ l - ~ d< ~- "' > rj<~F--~ ~rm Z 12~wo _z°O~n"r n ~'-oF-m ~o0- OZZ ._i _~w~ ~ Z (.D '-I- (D o3W O~-- .J o~ CS] W · ~ ~~ - Z =-/ / / / / / \ \ \ \ \ --\ / 1 0 b_ n xz 0 © ~- I OxJn ri b-.'~-~' 0- 0._ '-- Z < / / / / / / / / / / / / / / / / ,OS = ,,l qlV£3G NV'Id ~t£1S CO ~ INSULATION '~ OUTLET [m~.~ 1000 GALLON POLYETHYLENE TANK 550 GALLON FAT ALBERT WITH PUMP ASSEMBLY "~' LOT 4, BLOCK 2. FOXHILL S/D ].ll.M. R.C.C. 8-1-00 4 OF 7 PHON[i (907)694-2979 FAX~ (907)694-i211 ~[NAL ~~~~ GRADE ~ ~ CO MT MT CO 2" INSU~TION O~IGINAL __ GRADE ~ FILTER FABRIC] 4" DISTRIBUTION PIPES ~ID WITHIN SEWER ROCK. 6" UNDER ~ 2" OVER DISTRIBUTION P~PES ~ PROFILE OF GRAVITY BED FILTER FABRIC LOT 4, BLOCK 2, FOXHILL S/D J.}I.M. R.C.C. 8-1-00 5 OF 7 4" SOLID MANIFOLD ¸60' CO MT 0 © FROM INTERMITTANT DOSING SAND FILTER BED DETAIL meeting LOT J,H.M. (U~£ FLEX TOP OF LI~E) / .- ~ '~/a* FILTER SAND 8' - 3/8' PEA ~ND F~..TER PERIMETER SUPPORT I/2' Pt. YWOOD SHE:lETS BLOCK FOXHILL R.C.C. 8-1-00 60F7 CE-8801 MOUNDED SO~L COV[R 2' SAND LEVELING LAYER l (UNDERDRAJN TO BE: I. ND FLAT) 20' ~vC B~CKnU. SAND 2' INSULA130N +35 PSI BURtAL RAT~D SIDE VIEW 18' X 20' SAND FILTER w/ GRAVITY DISCHARGE UND£ROI~AtN DETAIL ($07)694-1211 LOT 4, BLOCK 2, FOXHILL S/D J.It.M. R.C.C. ~-1-00 FLEX CONNECTOR I-~/4" 0~A. FLi'XI~LE I~'C HOSE I' oR 1-1/A' 0~. m BOOT (THE ~T ~GE ~ BO,OEO TO 30 M~L LINER) 7 OF7 TOP VIEW i ~ 1 8' : SHIEL~O -- ,0 MIL PVC UN£R / OR£NCO MODEL U 15" CONTRACTOR IS REQUIRED TO OBTAIN UTILITY LOCATES PRIOR TO ANY EXCAVATION WORK. -- MONITORING TUBE PVC BOOT O EFFLUENT FROM SEPTIC TANK ~y 1-1/4" DCA. PVC 1-1/4' D~A. MANIFOLD P~ MIN. TRANSITION r~OM TO DIFFUSER UNE (USE FL~X CONN[CTOR) 3/4'-2'* JACK[TEg~ INSUL. HOPE PIPE B" INSUI~13ON AROUND PER]ML'T£R OF FILTER TO DRNNFIEI.D -- 4' DL~. CLASS 12S SLOTTED PVC PIPE (CUT I/4' wIDE SLOTS 2-1/2' DEEP AND AT 4' O.C.) fLUSHING VALVe: AND ENCLOSURE 18' X 20' SAND FILTER WITH GRAVITY DISCHARGE ALL PORTIONS OF SYSTEM Ex~cT O,,C,S~ONS *aD OCS,G, WITH LESS THAN 3.5' OF PAe*a,~d[TC~ ,N TH[ F'~LO. ~ COVER REOU~RE INSU~TION. CON~NS. · . --'"'~ ~,_~ ~..,~""' ...... ~.,o,.' .~,-~'-""~ ~,, . Mumcipahty of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES so..s .oo ' RCOU'noa'rEST 2 3 4 5 6 7 8 9. 10- 11 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES. AT WHAT DEPTH? Depth to Water JUter Monitoring? Reading Date Gross Net DePth to Net .~<,~/~'~/~-/~ Time Time Water Drop PERCOLATION RATE / ~ ~)~0 (m,nutes/*nch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND .~FT PERFORMED BY: S & S ENGINEERING I ~ CERTIFY THAT Tk)IS TEST~ WAS PERFORMED IN 17034 Eagle River Loop Road No. 204"-' ~' ' ' ~/~. ACCORDANCE WITH i~Ti~I~i~I~JI~j~GUIDELINE$ IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) ROBERT C. COWAN, P.E. CML ENGINEERS (907) 694-2979 FAX (907) 694-1211 ROa,D DESIG~ INTERMITTENT DOSING SAND FILTER SPECIFICATIONS (Bottomless) Lot 4, Block 2, Foxhill Subdivision June 30, 2000 GENERAL STATEMENT OF WORK The work and plans covered by these specifications consist of furnishing all labor, materials, tools, transportation, and equipment necessary to complete an Intermittent Dosing Sand Filter system as described herein and on the attached drawings. All work under this project shall comply with current Municipality of Anchorage (MOA) Regulations. 3 Bedroom House 450 GPD Use 10' x 36' Bottomless Sand Filter and absorption area (360 S.F. required) Sand filter to be constructed on accepting soil with all organics removed. SITE INVESTIGATION The Contractor must carefully examine the project documents, have full knowledge thereof, have investigated the site, and be satisfied with the conditions affecting the work. Conditions include, but are not limited to those bearing upon transportation, disposal, handling and storage of materials, availability of labor, water, electric power, roads, and uncertainties of weather, physical conditions at the site including all underground utilities, the conformation and condition of the ground, the character of equipment and facilities needed preliminary to and during prosecution ofthe work. The Contractor must be satisfied with the character, quality and quantity of surface and subsurface materials or obstacles to be encountered. Any failure by the Contractor to become acquainted with the available information will not relieve him/her from responsibility ofperforming the work as stated in these specifications and drawings. Location of utilities will be the contractor's responsibility. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 * EAGLE RNER, ALASKA 99577 Page 2 Lot4, Block 2, Foxhll! S~D June 30, 2000 SEPTIC TANK / LIFF STATION / AIR COMPRESSOR General The work under this section consists of the performance of all operations pertaining to furnishing and installing the septic tank/lift station, air compressor and piping to the sand filter. B. Materials 1. Tank a. Septic tank shall be a two compartment tank ofat least the minimum size indicated on the drawings and MOA approved. b. First compartment shall have a separate 4" pump-out riser. The second compartment shall have a separate 4" pump-out riser. 2. Manhole Riser or Lift Station Tank a. An additional second compartment manhole riser shall be capable ofbeing equipped with the following: 1. A junction (Nema 4x) box or equal, bonded or attached to the pump basin. 2. UL listed electrical cord grips, installed in the J-box. -OR- b. An additional tank (M.O.A. approved) may be provided for the effluent pumping assembly and the items in (a.) above. Effluent Pumping Assembly, Controls, Alarm & Piping a. Effluent pumping assembly shall be of approved materials, including the following: I. A 110 volt or equal U.L. Listed effluent pump. Page 3 Lot4, Block 2, Foxh[l! $/D June 30, 2000 2. High-density PVC cylinder housing the pump, with level controls and screen, serving as a baffle to prevent the screen from clogging. 3. All piping shall be PVC or other non-corroding material. b. Pump controls and alarm system shall be an approved system with the following options consisting of: 1. Event counter 2. Elapsed time meter 3. Program timer 4. 10 watt heater 5. Remote alarm panel option with a minimum of 80 DB sound pressure at 24", operating temperature 30AC to 65AC, continuous sound to be located in the home. 6. Oil-tight visual alarm with push-to-silence feature. Automatic audio-alarm reset. 7. 15 amp motor rated toggle switch, double pole, double throw with three positions; manual (man), automatic (auto) and center (of0 (H.O.A.). 8. Nema 4x-rated, fiberglass, or equal, enclosure with hinged Covcr. 9. All controls to be installed as per manufacturer's recommendations. 10. Control panel to be installed on outside wall of home within sight ofseptic tank/lift station. Piping from the septic tank to the sand filter is to be I 1/4" PVC schedule 40 solvent weld piping properly bedded as described in Materials Specifications and sloped to drain back to the lift station. Insulation board 2" thick and 2' wide centered over pipe is to be placed where soil cover is less than 4' depth over pipe. Page 4 Lot4, Block 2, FoxhlllS/D June 30,2000 d. The air line from the house to the filter is to be HDPE arctic insulated pipe 3/4"-2" SDR- 11. The compressor will have a gauge (0-10 psi) and be installed in a heated area, crawl space, or garage. 4. Air Compressor a. Air compressor shall be a T~IOM^S LINEAR SERIES model number 5060-A or 5070V-A or M.O.A. approved equal. CONSTRUCTION SEQUENCE In order to insure proper installation, the system is recommended to be installed in the following order: I. Sewer line from house to tank II. Septic tank/lit~ station III. Sand filter IV. Final grading CONSTRUCTION 1. Construction Instruments Contractor shall provide instruments such as transits, or levels, for establishing proper elevations and levelness of pipe or materials. 2. Pipe Laying All pipe shall be laid with material free of large or sharp rocks and organic matter. Each section of pipe shall be handled carefully and placed accurately. The spigot end shall be fully inserted pointing in the direction of flow and glued in place to make a water tight seal. Each section of pipe shall be properly supported to insure true alignment and an invert which is smooth and free from roughness or irregularity. At all times, when work is not in progress, open ends of pipe and fittings shall be closed so that no undesirable substance will enter the end of the pipe or fittings. Page 5 Lot 4, Block 2, Foxhi]l June 30, 2000 3. Bedding of Pipe for Sewer Lines The pipe should be bedded with materials free of large or sharp rocks and organic matter, compacted. Native materials may be used as back fill material above the pipe, provided it is free of large rocks and organic matter. All lift stations shall be installed in accordance with the manufacturer's recommendations and standards. Electrical installation is to be in accordance with the National Electric Code (latest adopted edition) by a licensed electrical contractor, with M.O.A. inspection where required. IfMOA inspection is not required, a licensed electrician is to provide a letter to the Engineer stating that the system meets or exceeds all applicable codes. 4. Excavation Excavate to proper depth to allow gravity flow, install tank level, tolerance 0.05 foot, on undisturbed or compacted classified sand fill material. Create a level sand surface over the tank and add 2" burial foam +35 PSI directly over tank. Mound unclassified soil over tank with a minimum of 2 feet of cover. /Inti-flotation weights may be required in areas of shallow ground water. 5. Connections All connections to be as per MOA requirements, PVC 3034 piping with Caulder or equivalent couplings for inlet riser pipes. All tank connections are to be completely water tight. SAND FILTER The work under this section consists of the performance of all operations pertaining to furnishing and installing the sand filter. A. Materials I. Sand Filter a. The Contractor shall provide a washed sand to meet ASTM C-33 Concrete Sand Specifications with the additional requirement that all but I% of the materials passing the #100 sieve be removed. All sand shall be approved for use by the Page 6 Lot4, Block 2, FoxhillS/D June 30,2000 Municipality of Anchorage (M.O.A.). Ifthe sample does not meet specifications, all sand will be removed and replaced. b. The Contractor shall be responsible for providing pea gravel that shall be a washed material containing no fines (0% passing the #100 sieve) and a maximum size of 1/4 diameter. c. The Contractor shall provide the manifold assembly. The manifold assembly shall be of approved materials with orifice shields and flushing assembly. All drilled holes to be cleaned of burrs and pipes flushed, prior to assembly. Flushing valve to include riser to finish grade. Lateral distribution piping is to be laid level (@ :t 0.05'). d. Side walls and top of the filter box to be insulated with 2" direct burial polystyrene insulation. e. The Contractor shall be responsible for providing filter fabric. f. Air coil in sand filter to be geoflow WF16-4-24 150 LF placed 6" above bottom of sand. Construction of Sand Filter The sand filter construction is to follow procedures as outlined below, as applicable to this design. Pea gravel and filter sand are to be hand leveled to proper depth (tolerance within 0.05 feet) in filter, taking care not to allow mud or fine soil material into the filter or gravel layer. This would include any soil material picked up by excavation machinery buckets while loading specified material The Contractor should estimate filter material volumes such that allowance is made for wastage of material in contact with the ground at site. The area over the sand filter to be finish graded with a minimum of 2 feet ofcover and to prevent ponding of surface water mn off. Side slopes shall not exceed 3:1. The Engineer will reject any sand or pea gravel that does not meet specifications or is contaminated in transit or while handling. If such material is placed in the filter, all soil material may be required to be removed and replaced with new material. CONTRACTOR / INSTALLER PROPERTY OWNER AGREEMENT FOR TIIE MAINTENANCE OF AN ON-SITE WASTEWATER DISPOSAL SYSTEM lids agreement, dated ~'t~lt, / ~ 2000, is made between the Municipality of nchorage Department of t~alth and tluman ~eervices (DIIIlS) and the ro crt ~ P P Y owner(s) of: Lot 4, Block 2, foxhill Subdivision This agreement is made for the purpose of maintaining an on-site wastewater disposal system on the subject property. The property owners agree {o tl]e following: Submit to the Municipality of Anchorage, on an annual basis, an inspection and operation statement from a registered professional engineer. This inspection and operation statement shall verify that the engineer has inspected all effluent and air pumps, timers, and alarms, and that any deficiencies bare been repaired and that the system is functioning as designed. (Signature) (Signature) Johnny l./oraa e (Printed Name) (Printed Name) (Notarize Ilere) - tl, 71v : !' NOTARYPUB.L. IC / [ Sandra IC Hemphill ......... ._. .... I'1P~-09-2001 11:~9 S~S E~GIi'EERING 90? E;94 1211 P.I~ 900 S. Gmrlthom 8t Wa.~ta AK 99~54 TOTAL. NAME MAILING ADDRESS LEGAL DESCRIPTION LOCATION MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OFf WELL INSPECTION REPORT PHONE /~115 f~xbdl'¥/,StOm Dwelling I DISTANCE TO:__ b I' ,vt.lt"l/e} Absorption area Manufacturer ~ Material Liq, capacity in gallons ............ Inside ' No. of hnes ~ ~Length of each .. ~ / Top of tile to finish grade ~ ~ Ty~e of crib Crib di .... ter &~ DISTANCE TO: W~II ~ I Building foundatioh DISTANOE TO Material Foundation t 'Nearest lot line Total length of lines.,.~., ii Trench wi,dth Material beneath tile "bepth Crib depth Building foundation Nearest lot line Driller Distance to lot line Sewer line Septic tank inches ~]'N EW [] UPGRADE NO. OFBEDROOMS PERMIT NO. Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. Distance between lines Total effective absorption area PERMIT NO, Total effective absorption area PERM(I}TtNO, ( b 't c, f't:7 Absorpt on area(s) OTHER PIPE MATERIALS .~N aO~ ,¢ Z7zq SOIL TEST RATING iNSTALLER REMARKS / LEGAL ' "' ' ' 't~!1'11' Lo -4, 'z, Fox h tLs 1711:::'1::'l.. I I]:l:lJ~.,I ]' ('i:0 J'.,lTlZll]:'J" L.OT 'Z: I Z~::: L..OT: 4- Eiq_OCl<: 2 I::i~F:ll",l(a[i!:: ::U,.I :J: C.[!iFUt" :1: I::'~'r' T'HF::!'[': 1.. I F:II"I F:'I::IM):I...IF:IFi: I.,.II'!'H THE P. Ei:(~:!UIF~:I:ZM[ii:NT:; I:::'OFi: ON-':::IT~ '.ii~[!i:141L-]B::Ei IqFrl[:' I'"IEL. L.:~: I::IS [::O[ii:T'H EJ"r' 'T'H[~: hlUl',l i C I F:'F!I-I ]"V 01:: FIi'.,!CHO[~'.I':IG[::: ,:: MOF:I ::~ I:::IN[:, THE ZTFITFZ OF' I::II_FISI<FI. ?.. I I,.!):L.I~. IN'::$TFiI_!.. TI".t[.~: :i;"r':E;TIZM I1",1 ]::ICI]:OF[:[:q:::IJ~',IC:E t.,.I!TH F:IL.L MOI::I C0[:,[i.::i~: I::tI",IC, F:ff',iD :!: i",[ C:OI'IPL. i r:liq(:::l~: I,.I I 'T'I.I Ti. 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[.,.lOF:ili< J'lL.l:i:"l' .......... .......... SOILS LOG __ MUNICIPALITY OF ANCHORAGE // [] PERCOLATION ~ · DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: 5'7~EV/~-/~ L, ~'/I~/~"~'S d~_~,,b'577Zd&7/O~'~J DATE PERFORMED: *~--3~")"-c¢'~'/' LEGAL DESCRIPTION: I0 11 12 13 14 15 16 17 18 19 2O __. END COMMENTS PERFORMED BY: 72-008 (6/79) %5, SLOPE SITE PLAN WAS GROUND WATER S ENCOUNTERED? , yE~ L 0 P IF YES, AT WHAT / E DEPTH? ~ Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN ~"'tT AND . FT ~¢. ~OILS LOG ~-~ -.~ MUNICIPALITY OF ANCHORAGE ///~ Q ~ %~. ~ PERCOLATION i/®'~"~i/ DEPARTMENT OF HEALTH AND E NV, R ONMENTALPROTECTION TEST ~-~1~1~//? 825 L. Street, Anchorage, Alaska 99501 264-4720 '~ SOILS LOG - PERCOLATION TEST PERFORMED FOR: 3TCVE~ L, SKA(-;-C*5 (olU'j;"/'t).C,~.?'lOAJ DATE PERFORMED: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16- 17 18 19- 2O SLOPE SITE PLAN /--'T, B Ro/.oW ND COMMENTS ~/~"/~ PERFORMED BY: '~'OL) WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop 4"H?.O 2 --:2 '4'. ,¢ ~ ')-;'53 10 o, 5~o C), oo PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN ~' ~ FT AND 4° ~ / FT 72-008 (6/79) COIRWIN & ASSOCIATES, INC. CONSULTING ENGINEERS 4321 GRAPE PLACE SUITE 204 ANCHORAGE, ALASKA 99504 (907) 56),-6151 April 4, 1984 Mr. Greg Drummond Dear Mr. Drummond: We have completed the soils investigation of Lot 4, iBlock 2, Fox Hill Subdivision. The purpose of the investigation was to determine the suitability of the sub-surface soils for construction of an on-site septic system. Two soil tests were performed on two seperate days. The first test hole was dug on the east side of the Lot:. A percolation test was run but, yielded unsatisfactory results. The second hole was dug on the northwest corner of the property. The soils encountered were suitable for construction of a system. We used the backhoe to explore the extent of the gravel. A ground water level of six (6) feet was observed. It is our recom- mendation that a mound type system be used. It is the best suited and economical configuration for ~he conditions encoun- tered. We feel that due to the limited extent of the subsurface gravel that the mound be placed 'ten (10) feet from each property line in the northwest corner of the property. The only other parameter effecting the design was that 'there may have been an established drainage course on the low lying adjoin- ing property. I visited with Robert Robinson of DHEP, on Monday, April 2, 1984, and he assured me 'that there was no established drainage course on the adjoining property. Mr. Robinson also indicated 'that the area we chose would be satisfactory for construction of a mound system as far as DHEP was concerned. Before final acceptance will be granted by DHEP, the water level must be monitored in the test hole at least seven (7) days after the test hole was dug. The results will be recorded on the soils log at 'that time. Thank you for the opportunity to work with you on this project. If you have any questions, please do not hesitate to call. Sincerely, CORWIN & ASSOCIATES,/INC. 'i'od Sherman TD:kjh Enclosures C:ORWIN 8x ASSOCIATES, INC, CONSULTING ENGINEERS 4321 GRAPE PLACE SUITE 204 ANCHORAGE, ALASKA 99504 (907) 561-6151 SPECIFICATIONS FOR ELEVATED BED ALTERNATIVE WASTEWATER TREATMENT S~STEM FOX Hill Subdivision, Lot 4, Block 2 1.0 General 1.1 The Drawing, Sheet 1 of 1, shall be a part of this Specification. 1.2 Ail materials and workmanship shall meet the require- ments of Anchorage Department of Health and Environ- mental Protection Permit. 1.3 Ail excavations and depths are advisory and are to be verified or modified in the field by 'the Contractor as directed by the Engineeer. 2.0 Seepage Bed 2.1 The gravel for the bed shall be screened to the sizes indicated; 0.5 to 2.5 inches. 2.2 2.3 The bottom of the excavation shall be raked with the backhoe blade to ensure that the bottom has not been compacted during excavation. The bottom elevation shall be level plus or minus 2 inches. An observation pipe shall be placed as shown in the drawings. It shall be Rigid PVC, ASTM The section shown with holes may be either drilled-~.5 inch holes at 6 inch centers on opposite sides of the pipe or a section of regular perkorated sewer pipe may be clamped to the solid section with a no hub coupling or solvent joint. A rubber rain-cap (Jimcap or equal) shall be placed on the top of the pipe. 2.4 If insulation is required, the insulation shall be Dow Extruded Blue Styrofoam Board insulation board o~ the thickness shown on 'the drawings. 2.5 The top and sides of the bed shall be planted with a White Clover and Red Fescue Mix or Blue Grass. 2.6 The septic tank or bed must not be closer than 100 feet to any existing well or body of water. 2.7 The gravel shall be covered with a layer of untreated building paper or a non-woven fabric such as Mirafi  ibretex 200 grade, or Poly-Filter X or equal. 2.8 ~he distribution pipe shall be 4 inch Riqid PVC or Poly- ethylene. The pipe shall be laid lew=_l.' 2.9 The berm around the seepage bed shall be constructea~ on a slope of 1 foot vertical per 3 foot horizonal. I I I III .. ! 2G' ,.'1,4,.'1T,~,~/,A L. .I PLAN VIEW ~'AND PiPE TO ,SEPTIC TA/VH J, Cgrw~n ,. Ct z .... r~ · ..COL/L) PV.C P/PE P, ~, C PIPE. TEl) PiPE .DINQ /PAP/SR ~ UNDI~T'UR~ED ~ CZ P-A N ~A VEL .= 15' fl SECTION A-A N,~,S. NOTES I, GRADE AREA TO DIV~E, RT 3URFACE WATER A~IiY ~o~ ~UN~ z. SOIL ~T/N~. ~ 7~/~ .3 ~o ~oo~ . PREPARED FOR'. FOX HILL. Ot?AtVlV iZY ~ ~. O/-IEQffEO BY T~ NO. D~ re; AP,~. &z ~°OALE: ~I~EET / OF I SUBDIVISION LOT- 4--'BLOCK 2 )'i)I~?r'.~F~:'T'I¥11EN'f' O1:::'.. HE'.rqL. TH ,.)t' I''l ~r'~"~ IEI'"IV iii I::/E)N?IEilN'i"r~.~ L. I:::'F'r]T..:i~c"r' ;[ 2 d~ 4...... 4.'? 2 0 l[:::::ll II',,,t ........ :liE!l; % '"IF: lEE:!p,,,li Ili!!E 11....... I! ...... !F::" 1E!!iE II:::;;:: !1',,"!I % '"'il"' ~!3 x!. ()?/-l. 7 :1. :1. l :1.:i:.!; DOC CO. dba SULLIVAN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 LEGAL DE~CRI~OM DATE · Sta.ed PERMIT NUMBER t DEPTH OF WELL __/OO 7 ,;,t ,, ~'"~ATIC LEVEL OF WATER FT. g O DRAW DOWN Fr, GALS. PER HR ::--~) zik O O KIND OF CASING <7~"OO. .... : '.:..~. From From From From-- From From From From From From From From From From From From KIND OF FORMATION: Ft. to 4 Ft, Ft. to 4 Ft. · Ft, to Ft. to_L© / Ft. to Ft. to , Ft. Ft. to.__Ft. __ Ft. to.__Ft. Ft. to Ft Ft. to.__Ft, Ft. to Ft Ft. to Ft Ft, to Ft, FI. to Ft, Ft, to Ft, _ Ft. to.__Ft. __ Ft. to Ft From__Ft. to Ft.. From__Ft. to' Ft From Ft. to Ft From__Ft. to__Ft From__Ft. ~o Ft From__ Ft. to__Ft From Ft. to Ft From__.Ft. to__ Ft From__Ft. to Ft. From Ft. t o.__Ft From Ft. to Ft. From Ft, From Ft, to Ft, From Ft. to Ft, From Ft, to .... Ft. From Ft. to Ft. From FI, to.__.Ft, MISCL. INFORMATION: DRILLER'S NAME __ ,"-; ~'...c. ! .., ............ MUNICIPALITY OF ° HCHOAOCE 0% j Development Services Department On -Site Water & Wastewater Section Certificate of On -Site Systems Approval Phone: 907-343-7904 Fax: 907-343-7997 Parcel I.D. 051-073-10 Expiration Date: I '(-,-" —1 q 1. GENERAL INFORMATION Complete legal description FOX HILL BLOCK 2, LOT 4 Location (site address) 21828 WOODCLIFF DRIVE, CHUGIAK, AK 99567 Current property owner(s) JOHN C. HUGHES Day phone Mailing address Real estate agent PO BOX 672222, CHUGIAK, AK 99567 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 4 S,5 -C) Waiver Fee $ Date of Payment 312 q ti g Date of Payment Receipt Number ,A31AW Receipt Number COSA# bbaq 13C43 Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm ANDERSON CONSTRUCTION & ENGINEERING Phone 345-3377 Address 4661 NATRONA AVENUE, ANCHORAGE, AK 99516 Engineer's Printed Name MICHAEL N. ANDERSON, PE Date 7/26/2019 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by FWCS and Anderson Construction & Engineering. 1_�__- 6. DSD SIGNATURE 4C_ System #1 Approved for —4— bedrooms OF .AZ4, *:49TH p MICHAEL N. ANDERSON: L No. CE 9469 1-.7/26/19...' 10 \ nssloos System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the following stipulations: �VgST o pRoe� r� �o RVICEII��`\\ By: �- Original Certificate Date: — 1,7 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: FOX HILL BLOCK 2 LOT 4 Parcel ID: 051-073-10 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 5/1984 Total depth 101 ft Cased to 40+ ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 5/4/2019 Static water level at beginning of test 66 ft. Well production at time of test 3.9+ gpm Comments B. TANK DATA — 8/23/00 - 1000 GAL Age of tank(s) 19 years Tank type/material HDPE Measured operating fluid level in septic tank 47 ® Standpipes/foundation cleanout per record drawing Date of pumping 5/14/19 Structure served by this system Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ® No ® Coliform bacteria is Negative Nitrate 3.49 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) Collected by F krS Date of Sample 7/15/2019 C. LIFT STATION — 550 GAL ® Required maintenance completed Age of lift station 19 years Lift station material HDPE / PLASTIC •I1owl VI D. ABSORPTION FIELD DATA — IDSF W/ 60'L x 15'W x 0.5'ED — 0.5 GPD/SF = 900 SF Which system tested (date installed) 8/23/2000 ® ALL standpipes present per record drawing, Total measured depth from grade 3.4+ ft (max) Measured depth to pipe invert from grade 2_9 ft (min) ❑ N/A — pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective Adequacy test date 5/15/2019 Results � Pass For bedrooms Fluid depth prior to test 0 in Water added 800 gal New depth 2 in Elapsed time 1400 min ® Code -required soil cover over field Final fluid depth 0 in ® System presoaked Absorption rate X000+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) If yes, enter date Gallons introduced 1540 gallons WES Comments/Deficiencies: COSA Checklist.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ® Yes if No Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' Surface Water > 100' ® Yes Animal Containment > 50' ® Yes if No ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ft ft ft ft ft ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No. Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No _ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No —ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 4Z,4 I certify that I have determined through field inspections and review OFts of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. �. *:49TH A '.MICHAEL N. ANDERSON No. CE 9469 7/26/19 .. COSA Checklist.docx PftFESSIO1;N ft ft Michael N. Anderson, P.E. Civil/Structural Engineering and Construction 4661 Natrona Ave. Anchorage, Alaska 99516 Phone 345-3377 / Fax 345-1391 Support Services Brent M. Western 907-440-4601 August 6, 2019 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SYSTEM SIZE 3-4 BEDROOMS LEGAL: FOX HILL BLOCK 2, LOT 4 On-Site Staff, Per our telephone conversation, the referenced property’s septic system is adequate up to 4 bedrooms based on the soils with a conservative application rate of 1 GPD/SF for an IDSF and the size of the tanks (1000-gallon tank with 550 lift station). The existing bed post IDSF is rated ate 0.5 GPD with an effective absorption area of 900 square feet. An application rate of 1 GPD/SF with the IDSF for 4 bedrooms would requires 600 square feet. Please contact Brent M. Western or me if you have any questions. Sincerely, Michael N. Anderson, P.E. MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and rw entered into as of this J 5 Day of _ of 20_ja, by and between Qt< �p� ►'1 � ��Q_vV f—y herein the OWNER, and the Municipality of Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365..In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as T 'DIS F located at (legal description) 2. Maintenance, Repairs and. Alterations. (Owner is required to read, understand and initial each section) Throughout the term of this Agreement, the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to $600). Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. 05/18/2018) Page 1 of 3 $IA_ Owner acknowledges that the Municipality may request records of maintenance and repairs from the manufacturer's representative or maintenance provider. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS. The Municipality will give at least 24-hour notice. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. 11.•x' Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the Owner's AWWTS. Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system; or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver, The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7. Severabilitv. Any provisions of this Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev. 05/18/2018) Page 2 of 3 ER..:`` B (1 J Tnnc,(signature) Date: Z� AN0NK K.. 61ARU�print name) STATE OF ALASKA ) ) ss. THIRD JUDICIAL DISTRICT ) The foregoing instrument was acknowledged before me thisaPWay of , 20J� , by l..aa. TARY PUBLIC FOR ALrA�SKA =AOberman My Commission expires: � a3 MUNICIPALITY: By:(signature) _(print name) Date: Title: (rev. 05/1.8/2011;) Page 3 of 3• • - Nva �j�_..-,�.---�''� -- � � ^ o� _. .. '�-v .. _. .----`� �. Municipality of Anchorage Department of Health and Human Services Division of Environmental Services 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 .CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. O~"/- D',7-~, -/~ NAA# ~/~:~' (') ! O ". Expiration Date: ~ · 1'.' ' GENERAL INFORMATION '.." Complete legal description /~'JT" 4: .~l.[p(..kc ~ ~ ]'~X I-F /~-I.~ . ;"' Location (s,te ad~d';;ss'or directions) ~'1 "-CurrentPropertyowner(s) ~/.4--~',x/'/ · Mailing address Lending agency Mailing address Day phone e Real Estate Agent Mailing Address Day phone Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: Well TYPE OF WASTEWATER DISPOSAL: NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System El Individual On-site [~ r-1 Individual Holding Tank [] [-I Community On-site [] [] Public Sewer t-I The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health AuthorityApproval (HAA) based only upon the'representations given in paragraph 5 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. 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 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. 72-025 (Re,/. 01/00)° 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 the Health Authority Approval application show that the on-site water supply and /or wastewater disposal system is safe, functional and adequate for the number cf bedrooms and type cf 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. $ & 8 ENGINEERING 17034 Ea~lo R~ver Loop Reid NO. 204 Name of Firm E,~-I,. P~v,,,-. ,~t~I<~ ~9577 Phone Address ' ' ' Engineer's Printed Name R06~,.7 ~ (~{;)~'/l~v" Date ........ ' .... I ,':'. 6. Dn~,u.~nun='-"- - '-' .... ~ ~' PROG~M ' " ~ . .'.. · ~% - , · ~ · Aooroved for ~ bedrooms., ~'-... ,, .. ~,, , . _... D~sapprov~d. , .. -, ~~,~ , 1:'- ..--- ..- ',,' . .,, '.,.. ;~, ~ . ,.-JJ~ )~, ,.~ ., . · . Cond~honal approval for" bedrooms, ~ following stipulations. Additional comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Expiration Date: Original Certificate Date: Reissue Date: 72-025 (Rev. 01~0)' MnnicipaUty of Anchorage Development Services Department Building Safety Divisio~ On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 wv~w.ci~x:homge.ak.us (~07) 343-7~04 HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Total depth /O/fi. If A, B, or C provide PWSID # "~ Casing height (above ground) ~ in. Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~ colonies/100 mi. Date of sample: ~-/~.~ / 0 I FROM WELL LOG AT INSPECTION fl. B. SEPTIC/HOLDING TANK DATA Nitrate Otherbac~r~ ~ colonies/lOOml, Foundation cteanouf~N) ~_.~ Date of pumping Tank size //~)00 g~. Number of Compartments CtsanouL~/N) Depression over tank (Y~"/K,/'O High water alam~N) Pumper C. ABSORPTION FIELD DATA Date instelled ~ Soil rafi~ ~/bdrm)/~), ~' System type ~'D ,~::~ ~7~ Length //~/~) ft. Width /~' ff. Gravel below pipe ~- ~' fl. Total depth ~, ~' ft. Eff. absorptionarea~4ff'~) ~ Monitoringtube_~__ Depression over field Date of adequacy test //~'C~/ Results (Pas~Fail) Fluid depth in absorption field bef~ gal.' Elapsed 'i'ime.' ~.~.;..~inal fluid depth in. Absorption rate >= Any rejuvenet~n treatment (past 12 mo.) (Y/N & type) If yes, give date For bedrooms New depth in. g.p.d. O. UFT STATION oate , il 'Pump on' level at ~J~ in. -Pumpofl"levalat G~/ in. Datum T~ '0~ E. SEPARATION DIS'i'ANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot ~/0~)/~('- Absorption field on lot Public sewer main Sewer/septic service line /00 Manhole/Access{~)N } .__~'"~ High water alarm level at --~ ~ Meets alarm & dmult requirements? /~'~ in. On adjacent lots /'OO On adjacent lots / O~) /4-- Public sewer manhole/cteanout /'V'/~' Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Absorption field property line ~'~c. Water service line /0/'/" Building foundation /0 ~'./--' / Water main . Wells on adjacent lots //O~ t~_ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Water Service line / ~) /./.- /O a '*'- Surface water Building foundation Surface water /_ Water main Driveway, paddng/vehlcle storage / Curtain drain/1/~'/.-/~,,//~,~/ Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems ere in conformance with MOA HAA guk~llnes in effect on this date. Engineer's Printed Name Date 3/I Waiver Fee $ Date of Payment Receipt Number /0 02-27-01 17:10 FROM-CTE ENVIRONI, ENTAL ~tr~ CT&E Envlronment,l Services Inc. 5515301 T-192 P.02/09 F-755 CT&[ Ref.~ 10109~001 Client Name S & S F~gineering Project Nam~ N/A ~ent Sample ~ ~t 4 BZoc~ 2. Fox Hi~ ~ ~tdx ~ Wate~ Ordered By Sample Client PO~ Printed Date/Time 07./27/2001 12:12 Collected Date/Time 02/23/2001 14:~;0 Receivrd Date/Time 02/23/2001 17:15 Technical Director Stephen C. Ede Relensed By .~ff~~ Nim~e-N R~m PQL Units A~ownble Pre~ Analysis Limlt~ Dam Date 1.25 0.500 mg/L EPA 300.0 10 max 02/23/01 ~ic:cohiolo~-~ Labora~oz7 To~ Coliform 0 col/100mL SMI8 9222B 02/23/01 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR FIEALTH AUTHORITY APPROVAL~\~'~t - C~(._~ \L~ OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) .'Applicant 'Name ¢~,¢d,.~. ¢¢' -11,,~ I,~R Telephone: Home Applicant Address _~,O ~ ~,[¢C::~ ~ .Z~.5~~_..) /~----, (c) Applicant is (check one}: Lending Institution ["1; Owner/builder]~L; Buyer E']; Other 17] (explain); Business 'TE:~ - ~'~'~- ~1 ~'~=[" t~L¢C~ (d) Lending Instituti9n __~¢~"Y"~'~ _ Telephone -" (e)'-~;al Estate Company and Agent ~~ '~ ~ S & 5 BGINEERING 2. TYPE OF RESIDENCE , ' ..... ' ..... "~ ~.",' ;, ~;Single-Family J~ Multi-Family El Othe¢ .- ' · ' : :-' - ' ' '." , ' . '.-':! '/'":';';',Z." ~ ' ' ' 3, WATER SUPPLY '. ,.,.'.....,.. Individual Well~- Community [] Public [] .: ..... .,' "¢ ' "' ' ' - .... r:' ' Note: If community well system, must have written confirmation from the State Department of Environmental Conservation :"" attesting to the legality and status, .-','" - "' ":'.;"~i-. ~ ' ~ "' ' ' ' ' ' ' 4. SEWAGE DISPOSAL . . · , .-,, . · . Onsite ~(- Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status, · ' 4 Page 1 of 2 72-025 (11/84) ENGINEERING FIRM PROVIDI, , INSPECTIONS, TESTS, FILE SEARCH. DATA AND iNFORMATION As certified by my seal affixed hereto and as of the validation date shown below, t 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. Name of Firm S & SENGINEERING 17034 Eagle River Loop Road No. 204 Date Telephone & '. '.....'"- Appr?ved for _, bed ¢' ' '; .... '*" ¢ / ' Disapproved Conditional ' - Conditional Approval . ~'. 'The Muncipality of Anchorage Depa~ment 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 cou~esy to purchasers of homes and their lending .':-;: - institutions in order to satisfy ce~ain federal and state reauirements. Employees of DHEP d o not conduct inspections or analyze dale before a ce~ificate is issued. The Municipality of Anchorage is not responsible for errors or omissions m the professional engineer's work. Page 2 of 2 72-025 ('i 1/84) WELL DATA N0113~10~ 'IVLN~NNO~IAN~I MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) 1 13:'i° CK'%'"-%"UA"Y'96" Legal Description: L-c:rT "~ If A, B, C. D,E.C. Approved (Y/N) Well Log Present ,(~/N) Date Completed <¢/~-' Yield . Total Depth \o~~ Static Water Level Casing Height Above Ground Electrical Wiring in ConduitS;tN) Separation Distances from Well: To Septic/~4el~j Tank on Lot Depth of Grouting Pump Set At Sanitary Seal on Casing (:~N) Depression Around Wellhead ~c::~::,' ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot '~'¢"~¢ ; On Adjoining Lots To Nearest Public Sewer Line ~[~ To Nearest Public Sewer Cleanout/Manhole ~I/2 To Nearest Sewer Service Line on Lot Water Sample Collected by -/2 ~-~ /~..h_%/~~ f',~Gt ; Date Water Sample Test Results ~/¢'¢1'~ ~ Comments ~ ,¢¢ .~,I;:;L)~Z-- ~I(=::L.-~- F~I~z;~ ~ ~=~¢~.~V4E;27) B. SEPTIC/H4~'=t~I~'G TANK DATA Date Installed '7 - ¢-~ -¢'~ Size Standpipes ~i~/N) Air-tight Capsd,..~N) Depression over Tank Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/.laa~iLcg Tank: No. of Compartments Foundation Cleanout(~)N) Date Last Pumped t4//% ;for Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line TO Water Main/S~vice Line Course Comments To Building Foundation '¢--~ I To Disposal Field ~'~ '¢ To Stream, pond, Lake, or Major Drainage Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~ ~'~'~ Width of Field ~ Square Feet of Absorption Area Depression over Field (Y/(r~p_ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design '~:~;;~ Length of Field ~ Depth of Field Z¥ ..~ / Gravel Bed Thickness C:::' ~:~ Standpipes Present ~) Date of Last Adequacy Test To Property Line ; On Adjoining Lots To Existing or Abandoned System on To. Cutbank (if present) / Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Bequest ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Date //~ /~'7 MOA No. ~ "~'~-'~¢ ~ $ & $ ENGINEERING S ~e,~d~ Eagle Ri;vet L~;~p R~ld No. 204 Receipt No. (o~ Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) 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 264-472O Application Date GENERAL INFORMATION (a) Legal Description (include lot, b.J.lock, su. bdivision, section, township, range) Location (addresa or directions) 5 '('--.e,t/-¢_~ _~Telephone: Home (b) Applicant Name Business Applicant Address =,I~,(~, L~,~, (-¢""~0~O (C) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer r']; Other~'"(explain); (d) Lending Institution,J~¢,4/~l( ,~],'f/Jt ~'t( Address 7/4 e /Y,~777~ Telephone _~" ? -,~/7 (e) Real Estate Company and Agent Address (f) Telephone Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family ~Multi-Family Number of Bedrooms Other WATER SUPPLY /- Individual Well ~-~J/' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4, SEWA~,~POSAL Onsite L.~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) 5. 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 Name of Firm ~--~0/'"'/,4./}~ ~/~f , . Telephone ~ :~[5 f Address --~~f~/(&~ ~ ~. ~, ~ ~ ~'~' ~ ~- ~Z., . [ ~' ~ ~),'~%. 7'~ CE-~283 ¢"~ Engineers Seal Approved for .,f~r_,,~-~C,_~Q,.~ bedrooms Date Approved ,.,2~ Disapproved ___ Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DFIEP) issues Health Authority Approval certificates based solely upon the representations g~ven in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. · Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 L,~_~Description: MUNICIPALITY OF ANCHORAGE DEPT, OF HEALTH & ENVIRONMENTAL PROTECTION 1985 RECEIVED Well Classification _ ~'~--AJ ~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present,N) c~/~¢~.~ Date Completed ~/¢¢'¢~., Yield Total Depth ~O~, I _ Cased to ~ c.~ I Depth of Grouting (~ ~--.~.~v~_ Static Water Level ~:2C~ Pump Set At :2.' Casing Height Above Ground _ Sanitary Seal on Casing~N) Electrical Wiring in Conduit~N) r.~/~,~ Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot [ CO ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot '~..E~ '.;~' ; On Adjoining Lots To Nearest Public Sewer Line. /~)/A- To Nearest Public Sewer Cleanout/Manhole ~-'[/A- To Nearest Sewer Service Line on Lot Water Sample Collected by 'T~ ~k~~ ; Date Water Sample Test Results %¢C'~;~ "~'~"1 Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes ~N) Depression over Tank (Y/~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: _~. O ~ O ,~¢z_,[ No. of Compartments -Z__ Size Air-tight Caps(C~N) c~'~ ~%p Foundation Cleanout~N) ~ Date Last Pumped ~ ~'~ ~ - ; for ~ Temporary Holding Tank Permit (Y/N) ~ To Water-Supply Well ~,~ f..~i To Property Line To Water Main/Service Line Course To Building Foundation ~}, I To Disposal Field _ ~ ~ ~ ! To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 7/~/$/8 Width of Field J z~, Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation ~---~ Lot ~:~ ~ '¢~7b ¢.,~,.~. Type of System Design Length of Field Depth of Field ~'~-~-~ ~ Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test I To Property Line 30 To Existing or Abandoned System on ; On Adjoining Lots '-ct- ~c.~O To Water Main/Service Line "+- "2-..~ C'~ ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Cutbank (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhol6 (Y/N) Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check P~ I certify th~ Signed Com Receipt No. Bec Rating Against HAA Request ** verified or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Date .. , , ~ MOA NO. ,.~,)'--~* ¢'~- 0..~ Date of Payment Amount: $ z'/.~ Page 2 of 2 72-026 {11/841 MlrNICIPALITY OF ANCHORAGE 'DIVISION OF ENVIRONMJ~.NTAL REALTH DEPARTMENT OF HEALTH AND ENVIRONbfENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVA~L CERTIFICATE 1. General Information Application Date (a) Legal Desqription (include ,lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name ~q~ ~(2~ Telephone -_ Home Business ~'~i Applicants (c) Applicant is (check one) Lending Institution /~ ; Owaer/builder ~ ; Buyer ~--~ ; Other ~ ( explain); __.~0KtU~{C~ (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. ~y~ of Residence Single-Family~ Number of Bedrooms Water Suppl~ Multi-Family ~. Other (describe) Note: If ~community well system, must have written continuation from the State Department of Environmental Conservation attesting to the legality and status. Sewage Disposa~ Onsite .~. Public [__----~ Community ~--~ Holding Tank ~_~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page l of 2] 5. Engineering Firm Providin~ 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 regula- tions in effect on the date of this inspection. Address 57 /,:"' ,- \, , .... Approved ~ Disapproved __ Condition~ __ Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES MEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. ~IPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE I$ ISSUED. THE MUNICIPALITY OF ANCHORAGE I$ NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH ALrI~ORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 WELL DATA Well Classification 1 ~i V · Well Log P~esent q/N). ~ Total Depth !d)l' Cased to Static Water Level ~O1 Casing He ight Above Ground Elect~?ical Wiring in Conduit Separation Distances from Well: Legal If A, B, o~ C, D.E.C. Approved(Y/N) ~-- Date Completed ~/~ Yield Depth of Grouting. Pump Set At U~0wN Sanitary Seal on Casing Depression A=ound Wellhead To Septic/Holding Tank on Lot. I~)~' __; On Adjoining Lots + I CXD To Nearest Edge of Abso=ption Field on Lot ~ ; On Adjoining Lots + To Nearest Public Sewer Line ~ ! ~ To Nearest Public Sewer Cleancut/Manhole ~l~ To Nearest Sewer. Service Line on Lot __~ Water Sample Test Results ~/~{JrtL C nts B® SEPTIC/HOLDING TANK DATA Date Installed 7/Z¢/~ Size !~O (14 No. of Compartments Standpipes (Y/N) I~ Air-tight Caps (Y~) '¢~ Foundation Cleanout (Y/N) Depression over Tank (Y/M) ~D Date Last P~d ~03 / Pumping/?4aintenanoe Contract on File (Y/N) N ~ ; for Holding Tank High-Water Alarm (Y/N) ~/~ 'I~mpora~y Holding Tank Permit (Y/N) Separation Distances f~om Septic/Holding Tank: I To Water-Supply Well I0~)' To P~operty Line ~O' To Wate~ Main/Se_~vice Line sou=se TO Building Foundation ~ To Disposal Field 1~7~' To Sbzeam, Pond, Lake, o~ ,Major D~ainage Comments [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption A~ea Depression over Field (Y/N) Results of Last Adequacy Test Length of Field Depth of Field 2-0 Gravel Bed Thickness ~(~ Standpipes P~esent (Y/N) Date of Last Adequacf Test Separation Distance from Absorption Field: To Water-Supply Well ~ To P~operty Line ~(~ To Building Foundation ~1 To Existing or Abandoned System on Lot N/~ ; On Adjoining Lots ~ ;C)O~ To Water Main/Service Line +~(~O~ To Cutbank(if present) ~/~ To St~eam/Pond/Lake/o~ Major D~ainage Course + IQ0 To DFiveway, Parking Area, o~ Vehicle Storage Area ~ Con~nts D. LIFT STATION Date Installed ~-~---~ Dimensions Size in Gallons /// High Water ~a~m Level at Tested fo~/__~. ~ . Elect~i~ Codes (Y/N) Commefs k Manhole/Access (Y/N) X~Off" Level at Vent . (Y/N) Pumping Cycles ~cy Test. Meets MOA ** Check Permitted Bed~oom Rating Against HAA R~quest I certify that I have checked, verified, oF conferred to all MOA HAA Guidelines in effect on the date of this inspection. Signed [¢~ ~/~(~ /O3~ Date [Page 2 of 2] 2-15-84