HomeMy WebLinkAboutHALL LT 12AHoll
Lot
#051-092-65
Municipality of Anchorage
Development Services Department "-"; ~A"'
On-Site Water & Wast°water Program, 4700 Soulh Bragaw SL
,.o.
www.cLanchomge.ak.us (907) 343-7904 Page I of
On-Site Wast°water Disposal System and/or Well Inspection Report
Permit Number SW990266 PID Numbam 051--092--65
N°m4:RON HALL Wast°water Syetem: · New I-I Upgrade
21024 SCENIC DRIVE * CHUGIAK, AK 99567 ABSORPTION FIELD
No, of I~edrooml:
Ph°ne:(907) 428--6,~91 4 13Delp Trench ElSh~ltow Trench IBed lUou~d lOth°r*
LEGAL DESCRIPTION .2.0 ~ ~ -1.5 - 2.5~
2.5 - 3.5
WELL: · New [] Upgrade 12
PRIVATE 160 ~ 117 ,. 360 ~. r~ o-=o~4/ r-S~0/SCH. 4O ~VC/H~
SULLIVAN WATER WELLR 8/10/99 45 ~. A+ HOME SERVICES 17/2000
3.o ~ UNKNOWN ~ 2+ ~ TANK
SEPARATION DISTANCES =s.,~= =.o~=.g ~.~.~...
~o s~pu= ~or~Uon U~t Ho~ng .~"~'~ ANCHORAGE TANK 1500
Well 100'+ 100'+ 100'+ - 25'+ STEF'L 2
s~,o=o ~oto~ ~oo'+ ~oo'+ ~oo'+ - - LIFT STATION
~t Un° $% 10'+ $'+ - - 1500IANCHORAGE TANK/ORENCO SYSTEMS
F'aundef~on 5'+ 10'+ 5'+ - -- TIMER TIMER 46"
C~,o~n 0.~n .¥~ ~.OW ~=0 0~, OS ..~ I~1~' l;~t~ ~I~c~'~C ~'nC.
~e.~ar~=: .so~ro~ss ~.~.~rr~.~ s~o r~L~. (~s~ BENCH MARK
· '1'O BOTTOM OF' EXCAVATION. 2.66 FEET OF U.O.~ TOP OF CMU FOUNDATION
SANO ~L'rER N)DED. Bo'FroM OF S.T.E.P. TANK = 90.36
FINAL GRADING, INCLUDING TOP SOIL AND SEEDING. TO 99.7
Inspecfions performed by: AWWC, INC. Dates:lst 6/17/2000 (~'"-; ...... '~"'~;[ .....
5th 4/19/2001
Department of Health and Human Services approval ItO~'~". ¢~-t *~...'"'~"~'~
R~viewed and approved b Dote: ~.r--./. ~ /
Heavenly Lights Electric Inc.
900 S. Grantham St
Wasilla AK 99654
To whom it may concern:
The lift station at lot /2 ~ block ~-'~t t sub division
was-,a,~d.by,a I~scensed electrician, in
acco dance w~th current nabonal Ele~:'t'~'~'~e. Under penalty of perjury, I ced[fy
this information to be true and correct.
John Roudebush PresidentJSecmtary
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R0, HALL (g07) 428-6~91 2 0F ~ [ [~,~ [;', ~. 0~mess:
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AS-BUILT OF NEW WELL LOCATION AND SEPTIC SYSTEM
sw,,o=66 AS-BUILT DRAWING ,ARCELIO NL,~BER:0,51
- 9~,7~ (AV~.)
CONSULTANTS, lNG.
LOT 12A; T15N, RlW, SECTION 8 ..-'"'
PROFILE AS-BUILT OF SEPTIC SYSTEM (BO~OMLESS ISF) °fe's~°e--~&~
07/17/00 M0N 06:04 FAX 688 $075 -, l~on & Barb Hall &Klds . ~ ~001
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04/13/01
FR! 0S:20 FA/ 088 5075
Ron & Barb Hall & Kids
~]001
MUNICIPALITY OF ANCHORAGE
Deparlment 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 I WATER SUPPLY PERMIT
Initial
Date Issued: Aug 10, 1999
Expiration Date: Aug 09, 2000
Permit Number: SW990266
Legal Description: HALL LT 12A
Design Engineer:. 0041 AK Water & Wastewater Consulta
Owner Name: Ron Hall
Owner Addrass: PO Box 670955
Chugiak. AK 99567-
Parcel ID: 051-092-65
Site Address:
Lot Size: 45460 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
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.
IssuedBy; "~~ ~. ~'~
Alaska Water & Wastewater Consultants, Inc.
6901 Debarr Road, Suite 2B ~Anchorage ~Alaska 99504
Phone (907) 337-6179 ~ Fax (907) 338-3246
Consulting Engineers
July 27, 1999
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Reft Well and Septic System for Lot 12A, Section 8, T15N, RIW
PROPOSED BOTTOMLESS INTERMITTENT SAND FILTER SYSTEM
To whom it may concern:
1. GENERAL: The proposed 4 bedroom home will be served by a private septic system and a
private well. A test hole was excavated on the referenced property by Eagle River Engineering
on 6/24/92. Groundwater and impermeable soils was encountered at 5 feet in the test hole. On
6/1/99, our company had a test hole excavated and found groundwater to be at 4.5 feet and
impermeable soils at 7 feet. The lot is generally flat and it is our opinion that the groundwater
level and impermeable soils stratum is constant. Given these site constraints, we are proposing
that a Intermittent Sand Filter (ISF) system be installed. The soils are summarized as follows:
2. SOIL CONDITIONS: Attached is a log which shows the soil profile, and the pemolation
test result. The soils below the organic layer are a GM to GM/SM material (with cobbles) to a
depth of 7 feet (bottom of the test hole). Groundwater was encountered at 4.5 feet during the
excavation of the test hole. After 7 days, water was found to be at 4.5 feet. A percolation test was
performed between the depth of 1.0 feet to 4.5 feet and found the rate to be <1 minutes/inch.
3. TRENCII DESIGN: Bottomless Intermittent Sand Filter (1SF)
a. Percolation Rate: <! minutes/inch
b. Allowable Application Rate for ISF: 2 gallons/day/ft2
c. Number ofBedrooms: 4
d. Design Flow: 600 gallons per day
e. Minimum Absorption Area: 300 ft2
f. Effective Depth below pressure pipes: 3+ inches
g. Width: 12 feet
h. Length: 30 feet.
i. Effective absorption area = 360 tt2 (>300 ft2 OK)
j. Air Supply: Thomas Industries, Model 5070, "Anchorage Tank".
k. Air Supply Line: "Wasteflow" emitterline, 1/2 inch I.D, "Anchorage Tank".
I. Sand Material: M.O.A. Approved Sand Filter
m. Pea Gravel: 100% passing 3/8' sieve, less than 20% passing the 1/4' sieve, and
less than 1% passing the #8 sieve.
We are proposing to excavate down to a depth of 2.0 feet (maximum), place a minimum of 6
inches of sand, install the air supply line, and cover it with 1.5 feet of sand. On top of the sand,
we will place 6 inches of 3/8 inch pea gravel, with the pressure laterals midway in the layer. We
will use a conventional lift station (Anchorage Tank), equipped with a programmable timer so
that flow can be intermittently dosed to the ISF.
4. MATERIALS AND CONSTRUCTION PRACTICES: The materials used, and the
construction practices will comply with DHHS' "Intermittent Sand Filter Design, Installation &
Maintenance Manual". The contractor should read this document prior to construction. Copies
are available at the Municipal Onsite Services office (Sth floor, 9th & L St.).
5. SURFACE WATER: There are no surface waters within 100 feet of the proposed septic
system.
6. TOPOGRAPIIY: The referenced property is generally fiat; in short, there are no slope
concerns.
7. CLOSING: I am open to any suggestions from your department that would be an
improvement to the proposed system. I am una~vare of any negative impacts that this installation
would impose on adj,~cent wells, or septic systems. Ifyou have any questions, please call me at
337-6179.
! \
! ~'~'-- ~' ~0 LOT 4. SEC. 8
i ~, / LOT 5, SEC. 8
/ .... ~ T15N, RlW.
I
LOT8
~ '/ VALL~ AVENUE
LOT 22B. SEC. 8
T15N. RlW LOT 21, SEC. 8 ~ T15N, RlW,
(C~EE ACRES) L~I~: ~? ~ ~ [ LOT 20. SEC. 8
T15N; R1W; SECTION 8; LOT 12A
SITE P~N FOR THE PROPOSED WELL LOCATION AND SEPTIC SYSTEM .............. :.,,:
RON HALL (907)
THE AZR C[3~4PRE$$rlR SHALL ~E I. fl3CATE~] VITNIN
S~L ~ ]/2 I~H ~I~ HDPE (1 PZECE), ZN~TED VITH ~/
I~H r~H PZ~ VR~ ~3 VALe),
OEPTH ~ 3 FEET. //
1.25 INCH HDPE ~E SLOP~ ~K TO !1
U~ ~A~N FOR D~E OF UN~ NO (6/24/92)
PROPOSED ~--~T~.~
pROPOSED O RN~'~'AY
WEE NOTES) ~'
I I 1500 GALLON *~ ~' ~'
S,T.F-P. b~YSTEM
I I
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PROPOSED
:' WELL
ALASKA WATER AND WASTE, WATER CONSULTANTS, INC.
5g01 DE,ARE ROAD SUIT~ 28. ANCHORAGE, AN ggs04
PHONE.: (907) ~57-617g/FAX: (907) ~58-~246
/
/
T15N; RlW; SECTION 8; LOT 12A
OF WORK:
DESIGN OF' PROPOSEO WELL LOCATION AND SEPTIC SYSTEM
FOR: PHONE NUMBER:
RON HALL (907) 428-6591
7/27/99 J.L.M. I = 40' 2 OF 5
P~N VIEW
~'~ PROFILE VIEW
~S~ WA~ A~ WAS~WA~ CONS~TA~S, ~C.
~E OF WORK:
BOnOU~ESS INTERmnENT SAND FILTER
~Te7/27/99 D~WN ~:j.L.M. N.T.S.
FOR ~ MAINTENANCE OF AN
ON-SITE WASTEWATF. R DISPOSAL
SYSTE~
Anchorage Depar~me~ of H~lth .ca Hurn~,n Serw, c~ (DHHS) e.d the property
This agreem~ Ls made for the propose of maimalnlag an.on-slrc was~ewazer disposal
sysmm on the subjecz propenT.
The l pe.m, ow. . agr th, e foUowing:
Submit to the Municipality of Anchorage, on an .nmml basis, an/nspe~tion and
operation smtemem f~om a registered professional engineer. This inspection and .
Opel"'eltiOI1 ~ $h:~11 vez~fy thai: the cngineer?~ i~spected all effiuen~ ~.rl air
pumps, ~m.r~, and alarms, and that any deficiencies have b~-"n repaked a~d rl~ the
sys',em is P;-_~onlnZ as desired.
~ N~mc)
(P~-'"~ Nm~)
--Notarize Here ----
personally appeared befor~me,
who is personally k~owu to me ~ ~ ~/__ . ~~t
whose identity I provid on the bath/affirmation of
, a credible witness
(,,] ~ ryPublic
.AL&SKA WATEII. &: WASTEWATER CONSULTANTS, INC. _~'~'~'~"-%~mO.F.. ~ { ~.
e~o~ D~ ~o~. su~ :B · ~C.Oe,~. ~X. ~0,~e.,..~X.:... ,~'x~-.ri'"~
ISOIL LOG -PERCO~TION TESTI ~
~ ~c.~o.: ~s.: .~w: s~o. ~: ~ ~ r./-'" .~,.,.~ .............
P~FOR~ED FOR: ~N ~'- ~
DA~ P~FORMED: 6/1/99 ~h~
~z ...
~F~~ o.~,cs reTEST HOLE ~1 I
GM TO GM/SM :~'~ GW I°RG
3 WITH COBBLES :3~:~ GP~1 )ML (8/24/92) ~
GM ICL
~0~
6 , SC
7 , DEPTH TO DATE ,~ ~ L
3ROUNDWATER
~ 4.5' 6/1/99 ])
4.5' 6/8/99 ~ ~ / ~ s~
SITE P~]
' = 00~
10
11 DATE READING CLOCK NET TIME WATER LEVEL NET DROP
TIHE (HINGES) RE. lNG (INCHES)
12
13
19 PERCO~TION ~TE <1
20
(HIN./INCH)/~ PERt. HOLE DIA. 6~ .(INCHES)
TEST R~ BETWEEN 1.0 FT. ~D ~ .5 FT.
COHHENTS: SOI~ C~SlR~ TO BE IMP~M~ AT
P~FORMED ~ ~ WA~ ~ W~A~ I. ~ ~~ , C~ ~T
~,~ w~ .~o.~ ,..cco.~c~ ~ ~ ~.~/~, ~.,c,.~,~u.~
0~-1~-I99~ I~:~PH F~Otl £.R. £n~lneerir~ ~vc~. TO
~n~i~ Of ~chorlp
DEPARTMENT OF H~L~ & HUMAN ~EflVICE8
82S 'L' Strut, ~ch~ge, Aluka ~2~
801LS LOG -- PERCO~TION TEST
LEaA!.DESCI~PTION: ~,~-/2.,4 7'/%J~ t~t~ ,Ct. F Township, Range. Section: T/~,~ ~/~, ~.~& ~
~f
4
WASGPOUNDWATER
PLAN
J A
11
14
15
16
17 ~-
RUN BETWEEN .
PERCOLATION iRATE ~ (m~n~l~,4m~d~) P~RC HOLE DLAMETER , ,~ '"'
C~RTiPY THAT THI~ TEST W&$ PF..qFORMED iN
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
925 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAILING ADDRESS
LEGAL DESCRIPTION
Well Absorption area ~,~ I Dwelling ~d'~'~. / -L
Manufacturer Material
DISTANCE TO: 70 .~ / ~ Poundatlon N*~ IOt~
aDPG.ADE
NO. OFBEDROOMS
Liquid depth
PERMIT NO.
Liquid capacity in gallons
Tota~c~a~rption area
No. of line~
Top of tile fish grade
Length W~dth
Type of crib
DISTANCE TO:
DISTANCE TO: Building
inche~
PERMIT
Crib depth
Building foundation
Nearest lot line
OTHER
PIPE MATERIALS
iNSTALLER
~EM.~RKS
Septic tank
PERMIT H0.
tlU~,~ T C I PRL I T'T' OF R[-ICHORRGE
DEPARTMENT OF HERLTH AND ENVIRONMENTAL PROTECTION
825 'L' STREET, ANCHORAGE,
° 264-4729
I,!ELL Rt'.iD Ot-,I--S 1' Ti SEI.qER PER£'I 1' T
( 828-?46 )
APPLICANT CALVIN MOORE
LOCATION ,
LEGAL Ti5N RiW SEC 8 LOT 12
5400 DAVIS HIGHHRY
LOT SIZE
108900 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: DRAIHFIELD
MAXIHUM NUHBER OF BEDROOMS
SOIL RRTING (SQ FT?BR)= 100
THE REQUIRE[, SIZE OF THE SOIL ABSORPTION SYSTEM IS:
Er.EF'TH= 4 LEf46TH= 42 6RR%.'EL Er.EPTH= 2
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETHEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THE TF.'Ef-~CH I,.I I Er, TH T S 5. ¢Z~C'Z~_-~ FEET.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL DETHEEN THE OUTFRLL PIPE
AND THE BOTTOM OF THE E×CRVRTION (IN FEET).
SEPT I C TflNK S I ----"-E= :2888 6FtLLOf4S
PERMIT APPLICANT HRS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIOHS OF ANY HELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE HELL WILL SERVE.
TI40 ( 2 ) I I'-ISPECT I Or*IS RRE REQU I REEf.
BACKFILLING OF ANY SYSTEM WITHOUT FINRL INSPECTION RND APPROVAL BY THIS
DEPflRTHENT HILL BE SUBJECT TO PROSECUTION.
MINIHUH DISTANCE BETWEEN fl HELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
3.0A_ FEET FOR R PRIVATE HELL OR ~.50 TO 200 FEET FROM R PUBLIC HELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
HINIMUM DISTANCE FROM A PRIVATE 14ELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEHER LINE IS 75 FEET.
HELL LOGS ARE REQUIRED AND HUST BE RETURNED TO THE DEPARTMENT HITHIN ~0 DAYS
OF THE HELL COMPLETION.
OTHER REQUIREMENTS MAY AF'PL¥. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PER['1 I T E×P I RES Er.ECEI"IBEI~:
I CERTIFY THAT
I AM FAMILIAR WITH THE REO. UIREMENTS FOR ON-SITE SEHERS AMD HELLS RS SET
FORTH BY THE HUNICIPRLITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE HITH THE CODES.
3: I UNDERSTAND THAT THE ON-SITE SEHER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
e
_ . . . . .
V4.
0
/"DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
PERCOLATION
. TEST
825 L. Street. Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: ~ ~"/~ ~'/'~/~/~ ~
LEGAL DESCRIPTION: // /// 2 /~
1
2
3
4-
5-
6-
7-'
8-
SLOPE
10-
124
13/__
14-
15-
16
17l
18
19
20
72-008 (6/79)
WAS GROUND WATER
ENCOUNTERED?
IP YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
/
PERCOLATION RATE ~///~' (minutes/inch)
Di,~/Z~t//~/~.~EST RUN BE~EEN FT AND
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wssfewater program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.snchorage.sk.us
(9o7) 343-7~4
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D. '
051-092-~ ~.~
GENERAL INFORMATION
Completelegaldescription LOT 12A; T15N, R1W, SECTION 8[,J-J ~L.~-"~t
Location (site address or directions) 21024 SCENIC DRIVE * CHUCIAK, AK.
Expiration Date: ~ - / - O I'
' RON HALL ' Day phone 428-6.391
· Cun'ent Pr~party o~er~s)
Mailing eddre~..,.
Lending agency
'P.O. BOX 670955 * C~UGIAK, AK 99567 ' '
· .."~ '; " " ' ' ' ' Day phone.
Mailing address
Real Este{e Agent
. Mailing address
Unless o~erwl~e requested, HAA wfll be held by DSD for plckup.~
2. NUMBEROF BEDROOMS: 4
'. Day phone.
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTE'WATER DISPOSAL:
Individual On-site ~ ·
Individual Holding tank E]
Community On-site
u
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given In poragmph 5 by an Independent pmfesalonal 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 slngle family on-site wastewater disposal end/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,) Cer'dficates are valid for one year for pmpartiee served by Class A or B
wells or a public water system, The Municipality of Anchorage Is not responsible for errors or omlsslons In the
professional engineer's work,
Note:Alaska Water and Wastewater Consultants, Inc. shali be pald ~30~9~ a& or prior I
to closing for the engineering services provided. '
I
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validaUon date shown below, I ye#fy that my
InvesEgaUon, based on procedures outlined In the Health Au~ Approval Guidelines for this applica#on,
shows that the on-site water supp~ 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
informs#on obtained from the Municipali~ of Aschorage files and from my Investtgaffon and inspection, the
on-site water supply and/or wastewater disposal system Is(are) in compliance v/4h all applicable Municipal
and State codes, ordinances, and regulations In effect at the time of Installation.
Name of Firm ALASKA WATER &: WASTEWATER CONSULTANTS, INC.
Phone 357-6179
Address ~ 6901 DEBARR ROAD. SUITE 2B * ANCHORAGE. AK 99504 - '
Engineer's Printad Name JEFFREY A. GARNES$, P.E. Date" "~'/2.$'/0!
Engineer's Commen ' .............. ' ' "·
Wstam under lhe cono?flona encounteead st a~e flme of ~he ~es~ and aeparaffon
the acx~ benefit of the o~,w~r 8s,'ed above.'Any re#ance upon or uae ~ ~,~/s report by any
5. DSD SIGNATURE
I,"'/ Approved for L/[ bedrooms.
Disapproved.
Conditional approval for __
. ..
~. ON-SITE . ~_
· ~-' WATERAND -~: m=~
.Le.I ..... ~ [ WASTEWATER :' ~
.
~ Attachments: .
·HAA Checklist
Septic System Advisory
Well Flow Advisory
· Manitenanca Agreements
Supplemental Engineer's Reort
Other
Ortglnal Certificate Date:' .~-/- ~ /
Municipality of Anchorage
Development Services Department
On-Sits Water & Westamvater Program
P.O. Box 196650 Anchorage, AK gg51g-6650
A. WELL DATA
HEALTH AUTHORITY APPROVAL CHECKLIST
LOT 12A; T15N, RlW, SECTION 8 ParcellD:
051-092--1~
Wlill'ly]3e PRIVAT[ ffA, B. orGprovldePWSlDft N/A
Date completed 6/26/2000 Sanltsp/~ (Y/N) YES
Totaldepth 160 fl. Casedto 117 It.
FROM VV~ i LOG
6/26/2000
45
Well pmduc~on 3.0
WATER SAMPLE RESULTS:
Data of sample: 4/19/2001
.g.pJn.
well Log (Y/N)
W~es pmpe~ protected (y/N)
Casing belght (above ground)
AT INSPECTION
g.p.m.
A~VC, INC.
SEPTIC/HOlDING TANK DATA
Tank Type/Matarlal STEEL
Tank size 1500 gal. Number of Compartments 2
Foundation deanout (Y/N) YES Depression over ta~ (Y/N) NO
Data of pumping NEW Pumper
ABSORPTION FIElD DATA
Data installed e/~7/2~oo
Length 30 ft.
Total depth =2.06 It. Eft. absorption oroa 360 fit Monitoring tube YES
Date of adequacy test NEW Results (Pass/Fall) -
Auld doplh In ebeorptJon field before test - In. Water added - gal.
Elapsed TIme: - min. Final fluid depth - In.
Any rejuvenation treatmont (past 12 mo.) (Y/N & type) -
.~ colonies/100 mi.
Depression over tleld NO
For 4 bedtoums
Newdeplh - In.
Absorption rata >~ - g.p.d.
If yes. give data -
Goll mtlng (l[~or fttredrm) 2.0 System M3e BOTTOMless
W1dlh 12 .It. Grovel below pipe 0.25
2+ In.
Data Installed 6/17/2000
C;eanouta (Y/N) YES
High watar alarm (Y/N) N/A
D. UFT STATION
Data Installed 6/17/2000
'Pump on" level at TIMERIn.
Oatufft BOTI'OM OF TANK
F. SEPARATION DISTANCES
Size In gallons 1500
'Pump off' level at TIMERIn.
Cycles tested NEW
SEPARATION DISTANCES FROM WELL ON LOT TO:
~eplic tank/lift ~talion on lot 100'+
AbsorplJon field on lot. 100'+
Public ~war main N/A
Sewer/septic ~ewlce line 25'+
High water alarm level at 46
Meets alarm & circuit requirements?
On adjacent lots 100'+
On adjacent lots 100'+
Publl= sewer manhota/ctaanont
Holding tank N/A
Proberty line 10'+
Water esndce line 10'+
Curtain drain NONE KNOWN
F. COMMENTS
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO.'
Building fonndafion 5'+ . Property line ,5'+
Water main N/A Water eswk:e Ilne. 10'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO.'
Bulldingfoundal/on .10'+
Surface water 100'+
Wells on adjacent lots. t 00%
AJ~ field. 5'+
Surface water 100'+
Water main
Driveway, parldngNetdclc ~orage 50'+
G. ENGINEER'8 CERllFICATlON
I cerUfy that I have determined through field Inspec~es and
review of Munlclpal reon~s ~ the above systems are In
conformance with MOA HAA guidelines In effect on U~s date.
Englneel's Prl~ Na~pte JF_~H~EY A. GARNESS
Date ~
HAA Fees
Data of Peymont
Receipt Number,
Waiver Fee $
Data of Payment
Receipt Number,