HomeMy WebLinkAboutHERITAGE PARK BLK 2 LT 14Pitage
Pa k
Block
Lot 14
#050-211-66
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/OR WELL INSPECTION REPORT
4AME
MAI LING ADDRESS
LEGAL DESCRIPTION
LOCATION
DISTANCE TO: Well
Manufacturer
L q. capacity in gallons IF HOMEMADE:
DISTANCE TO: Well ~/,/
Manufacturer
Well
DISTANCE TO:
NO. Of lines / Length of eac,~e!
Top of tile to finish grade
Length Width
Type of crib Crib diameter
Well
DISTANCE TO:
DISTANCE TO:
Absorption ~.~a
~ nsfde le_.._ngth
IDwelling
Foundation
Total leng~o~ I~nes
Material beneath tile
Depth
depth
Building foundatfon
Building foundation Sewer line
[~,N EW
[] UPGRADE
Dwelling
Material
Width
Material
Nearest lot lin2(~)
Trench wid~i~) inches
~_~/ inches
4
PERMIT NO,
No. of compartments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMIT NO. E,,~
Distance between lines
Total effective
PERMIT NO,
Total effective absorption area
Nearest lot line
Distance to lot line
Septic tank
PERMIT NO.
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
DATE
Department -f Health and Environmenta' Protection
825 ~-l' Street, Anchorage, AK. ~9501
264-4720
Permit 9 '~/~:. ***HANDWRITTEN PERMIT*** .
WELL AND/OR ON-SITE SEWER PERMIT ~/ - ~ ~
_ _ .. ., -~/ I/
Location: Phone Number: ~ ~-Z-~
Legal Description: ~/~ ,Z~ /~/~/~S~?-L~ i~~/ LOt Size, --
Type of Soil Absorption System Is:
· _ Seepage Bed: Holding Tank:
. Trench: X Drainfield:
Maximum Number of Bedrooms: ._~ Soil Rating(sq.ft/br)
The Requ~'red Size o the Soil Absorption System Is: ~
DEPTH /~ LENGTH ~/ GRAVEL DEPTH ~/' WIDTH
The length dimension is the length(in feet) of the trench or dralnfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation (in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /2~ GALLONS * *
Permit applican~ has the responsibility to inform this department duri:g the
i~stallation inspections of any wells adjacent to this property and the number
'of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection .and approval by this department
will be subject to prosecution.
~inimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30. days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
, * * * PERMIT EXPIRES DECEMBER 31~ 1 9 o° 3 * * * /
I certify that: .
(!) I am familiar with the requirements for on-site sewers and weELIs as
set forth by the M. Dnicipality of Anchorage.
(2 I will/~nstall t~,system in accordance with codes, i
(31 I u~l~er~t~nd ~he on-site sewer system may require enlargement if~
th~re~i~c~emodeled to include more that 3 bedro~s.
~p~ica~ f Date: '-- 1.~25
SWP/024 (1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
2
3
4
7
8
10
~2
~7
18
20-
SiLT
SLOPE
DATE PERFORMED:
SITE PLAN
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
!
PERCOLATION RATE /~//~ (minutes/inch)
COMMENTS ~ , TEST RUN BETWEEN ·B/,~v~// ~ Y////~/'~FT AND
PERFORMED BY: S ~ ~_~_~(~"l[~l~ CERTIFIED DATE~
72-008 [6/79)
•
• 9 1.0-" Nr,c
Municipality of Anchorage
On-Site Water and Wastewater Program
(907) 343-7904 E 20' 'sly p '�f
y
4.
A.,
Certificate of On-Site Systems Approva . <,
Parcel I.D. 050-211-66 Expiration Date:
1. GENERAL INFORMATION:
Complete legal description HERRITAGE PARK; BLOCK 2, LOT 14
Location (site address) 19525 Laura Lee Circle*Eagle River 99577
Current Property owner(s) Sarah Smith Day phone 350-3726
Mailing address
Real Estate Agent Karen Dannenbrinq Day phone 360-8438
2. TYPE OF DWELLING:
Single Family (wlwo ADU)
El Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ® Public Sewer ❑
WaiverNariance request for: Distance:
Received by: /re‘ Date: o �7
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ - P Waiver Fee $
Date of Payment �J l II. 1.t 1 Date of Payment
Receipt Number 69,01 (eG Receipt Number
COSA# 1 -1 \ 0, \ Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by myseal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on pro`iredures 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 wastewatertisposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm: Garners Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101-Anchorage,Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: V 1 /a-
64oQopQ4
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system OF q CN
in accordance with the guidelines and regulations established by the Municipality of Anchorage and � .••"'"•...r� non
industry practices. The reported results describe the condition of the system/s on the date/s of the O '- v UQ
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or ":1 " 49TH "••=_.'
do Q
encroachments may exist that were not identified during the evaluation. The operational life of all wells 0 , * D
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, 0'1 , Q
A
groundwater levels (that may fluctuate during the year), quality of construction (materials and 4 n,
workmanship),and the water usage of the family utilizing the system/s. These conditions can vary, and O. �.-�../.,' ✓ 0
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the Qn ,Je
system/s; therefore, GEG makes no warranty(express or implied) regarding the future performance of Vn mS
V E-7953 k
�,p
the well or septic system. GEG makes no representation whether an alternative well or septic system O s �1 r.•• .�c¢Q
can be installed on the property in the event either of the current systems fail to perform adequately in �QfP 'L/L.'4 / T He'd
the future. The content of this report is for the sole benefit of the person/party that retained GEG to �Q °profess ono o
perform the evaluation. Reliance upon the information provided in this report by any other person or ���OopaQ
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
System #1 Approved for 2 bedrooms
System #2 Approved for bedrooms
Disapproved (-IC tial;,
Conditional approval for bedrooms, with the following gtulations:
ON-SITE G;
WATER AND
WASTEWATER
PROGRAM
By: L t.,,.. Original Certificate Date: S G -I 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 Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet_10-10-12.cloc
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description HERITAGE PARK: BLOCK 2, LOT 14 Parcel ID: 050-211-66
A. WELL DATA PUBLIC WATER
Well type If A, B, or C provide PWSID# Well Log (Y/N)
Date completed Sanitary seal (Y/N) Wires properly protected (Y/N
Total depth ft. Cased to ft. Casing height(abs - •round) in
FROM WELL LOG AT I -' CTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RES
Coliform colonies/100 ml. Nitrate mg./L. Collected by:
enic. ug./L. Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL Date installed 9/17-20/08
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping 9/23/16 Pumper SANITARY PUMPERS
C. ABSORPTION FIELD DATA *DEPTH BELOW EXISTING GRADE NORTH/SOUTH
Date installed 9/17-20/08 Soil rating •.p.d./i'or ft`/bdrm) 1.2 System type DUAL SHALLOW TRENCH
Length 20+20=40 ft. Width 5.0/5.0 ft. Gravel below pipe 4/4 ft.
Total depth'10.4+19.9+ft. Eff. absorption area 400 ft- Monitoring tube YES Depression over field NO
Date of adequacy test 5/3/17 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0/0 in. Water added 14.4/2115 gal. New depth 2/9 in.
Elapsed Time229/184min. Final fluid depth 0/4 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date -
-CONDITION OF 1983 TRENCH WAS NOT EVALUATED, BUT THE SUMP APPEARED TO BE DRY ON 5/3/17
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at • wa er alarm level at in
- .• Cycles tested Meets alarm& circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO. PUBLIC WATER
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main ••• sewer manhole/cleanout
Sewer/septic service line Holding tank
containment areas Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO
Building foundation 5'+ Property line 5'+ Absorption field ~5'+
Water main 10+ Water service line 10'+ Surface water 1004
Wells on adjacent lots 100+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 5'+ Building foundation .•'10'* Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
"IN 2008 JEFF POET GRANTED VERBAL WAIVER FOR 5'FROM EAST LOT LINE AND 5'FROM OLD TRENCH TO NEW
SOUTH TRENCH.TANK IS PARTIALLY UNDER LOW LYING DECK THAT SITS ON GROUND SURFACE(SEE ATTACHED PHOTO).
ST1 AND ST2 ARE ACCESSABLE. "SEPERATION TO 1983 TRENCH IS UNCERTAIN.
""MEASURED 10.5' FROM FOUNDATION TO CO1 ON 5/16117
G. *aaaaa■%�
ENGINEER'S CERTIFICATION • S
c.
1 certify that 1 have determined through field inspections and • 9 ! ��
review of Municipal records that the above systems are in •• �•• ..•,;
conformance with MOA COSA guidelines in effect on this ."
date. s c• Jeff Gojness; ;
§g peer's Printed Name JEFFREY A.GARNESS feel �., 711/43*9
SIi6//4 4 ' ESS\ ,•'
LICENSE lit
MAECCBB4
(Rev. 10112112)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES·
Division Of Environmental Services
On-Site Services Section
P.O. Box196650 Anchorage, Alaska 99519-6650
' 343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING'
GENERAL INFORMATION
Complete'legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailin. g address
Day phone
Agent ,,~/,.,'//~z~, ~2~,.~4 Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
T~'PE OF WASTEWATER 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.
STATEMENT OF INSPECTIONiBY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below,'l verify that my
investigation of this Health Authority Approva! application shows that the on;site water supply
and/or wastewater dispersal system is safe, functional and adequate for the n~mber of bedrooms
and type of structure indicated herei~:l ~urther verify that based on the information obtained from
the Municipality of Anchorage files and from my i.nve, s~igation and inspection, the on-site water
supply and/or wastewater disposal system !s in .compli~n.ce w!th all Municipal and State codes
ordinances, and regulations in effect on the date of this inspection.'
'- Phone. ~ -'/,~ 73
Name of Firm
Englnee~ssignature ~"':~~ ':
bedrooms.
DHH8 SIGNATURE
. [/'~Approved for
Disapproved.
Conditional approval for
bedrooms, with the
· ....
~.~; ON-SITE
~ WATER AND
Additional Comments
Date ~ /- ~) /
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 DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before e certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street. Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
A. WELL DATA
wen type ~ ~'/-~-
Log present (Y/N)
Total depth
If A, B, or C. attach ADEC letter. ADEC water system number
Date complated ~
~ ~lght (al3ove ground)
Wires properly protected (Y/N).
FROM WELL LOG
AT INSPECTION
Date of test
St~ water level
Well production
O. SEPTIC/HOLDING;lANK DATA
Date installed ~ Tank sl2e /~
Fouedatlon cleanout (Y/N) .)/ Depms$len (Y/N) ,4/
Oate of Pumping /.~/,~/~e Pumper ~.,~'.
g.p.m.
Number of Compartments ,~ Cleanouts (Y/N)
High water alarm (Y/N)
C. ABSORPTION FIELD DATA
Date Installed ~ Soft rating (g.p.d~ o~
Length .~' /' · Wic~h .~ 0 /' Gravel thickness below pipe
Effective absorption area ~//~ Monitoring Qbe present (Y/N) /
Oate of adequacy test ~/~/,//~/ Results(Pass/Fail) /~'.~-<~/
Ruld depth In abeof13tlon field before test (In.);_,~ Immediately after ~ gal. water added (In.):
Fluid depth ~ '/
(Ins) Minutes later: (/,,~ Al~soq:)tlon rate - ~.i~d.
Peroxide treatment (past 12 months) (Y/N) /~/f~ I1 yes, give date --'---- ~
System type
~ ~ ~' Total depth
. Depression over field (Y/N)
72-O26 (Rev. 3/96)*
D. UFT STATION
Date installed Size In gallons ,
Manhole/Access (Y/N) 'Pump on" level at' , 'Pump off' le~
High water a~arm level at* *Datum __ . ~
Cycles tested ~ ~ ~
E, SEPARATION DISTANCES ~
SEPARATION DISTANCES FROM WELL ON L~.~.~O:
Septlc/holdlngtankoniot .~,~o/~''~ On a(~jacent lots e~' '
Absoq311on field on lot ~ On adjacent lots__
_Pub~~ eewer manhole/cleanout
Pul~c
Semi, er/eeptk~ service ,ne Uft station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~'" Propertyllne ~'~ ,' / AI3soq3tlonfleld
Water maln/service #ne /~,~" .Surfacewater/clralnage
Property line
. Sudace water
SEPARATION OISTANGE FROM ABSORPTION FIELD ON LOTTO:
//,' Building foundation /~2 Water main/service line
/'(P ~ ~' Driveway, parking/vehicle storage area
Curtatndraln/'~ /<~,~ 7~ ~-x/.~7~- Wells on adjacent lots ~'~ ~
72-026 (Rev. 3/96)*
Receipt Number ~:~"~
Waiver Fee $
Date of Payment
Receipt Number
F. ENGINEER'S CERTIFICATION
....
/ certEy that I have determined thru field inspections anti review of Municipal re~3~that tJ~f~_~, are
in conformance wlth MOA HAA guldellnes in effect on thls date. ~.e~..'~ ~ .,, ,~-~' '.'flu
_ d,.._
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. #
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~\\- Jnl,-~ HAA# ~'~
Lot 14; Block"2; H~r'~ag~ Park
Location (site address or directions)
19525 Laura Lee Drive
Eagle River, AK 99577
Property owner Wayne and Ruth Ta.q.qart
Mailing address 19525 Laura Lee
Day phone 694-6138
Lending agency
Mailing address
Day phone
Agent Lorie Crowder/ REMA× PROPERTIES Day phone 694-~n~
Address 16600 Centerfield Drive, Eagle River, AK 995713
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water ~xx
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
XXX
72-025 (Rev. 1/91) Front MOA#21
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 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 inves_tigation 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 _~ ~z ~ =~,,. .......... ~ Phone ~/~'~ "Z ~ ~ F
Address ~3.~?gJe Rlv.r L~p R~~ ~'
.
Engineer's s~gnature /~/ ~ Date
DHHS SIGNATURE
Approved for "7~-~--'~:(~) bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
~~ ~ 'Date
By: ~
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. Employees of DHHS 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.
72-025 (Rev, 1/91) Back MOA #21
Municipality of Anchorage /~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
~.~ ~_- ~-~,-~f,~-~_ Parcel I.D.
~.~ ~ cb
A. Well Data
Well type .~ 0~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Date completed Driller
Total depth Cased to ~t
Sanitary seal (Y/N) Wires_~cted (Y/N)
WELL LOG~'~ AT INSPECTION
FROM
Date of test ~~
Static water level
Well flow ~ g.p.m, g.p.m.
Pum~.~ __~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~ ~ ; On adjacent lots
Absorption field on lot ~-~ ~ ~ ''~ ; On adjacent lots
Public sewer main Public sew~ut
Sewer service line ~m tank
WATER SAMPLE RfiS~I '~
Coliform ~ Nitrate Other bacteria
Dat~e: Collected by:
B, SEP,'FIC/HOLDING TANK DATA
Dare.installed \ ~ ~'5
Cleanouts ~) ~,~
High water alarm (YN~
Date of pumping
Tank size \ '7.--~-'b Compartments '7._-
Foundation cleanout~/N) ~ Depression (¥~) ,~'~
~ Alarm tested (Y/N) /'~ [,~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ,TO:
Well(s) on lot '7.~, ~:, ~ ~ On adjacent lots
To property line ~o ~ ~ Absorption field
Sudace water/drainage '\ ~ '~
Foundation
Water main/service line
72-026 (:3/93)* Front CONTINUED ON BACK PAGE
C, LIFT STATION
Date installed
Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at "Pump off" Level at
High water alarm level ~d'-~'~
Meets MOA electrical codes (Y/N)
SEPARATION DIST~N TO:
We IIT~n I~"~t On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed ~.~ ~o '~ Soil rating (GPD/Ft2)
Length /-~ I ~ Width '~ ~ Gravel thickness
Total absorption are~.~ ~o<:-~'/' Cfi------' Cleanout present ~[~/N) ~/'
Date of adequacy test '~ ~ / E-.53 Results:;~Jail) ¢'~.<¢ 5
Water level in absorption field before test ~
Ceroxide treatment (past 12 months) (Y,~
/ /-Jo '"~ ~('z~¢-~ System type
~'¢ ~ Total depth
Depression over field (Y~
for ~ ~ ~Bedrooms
After test
/
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
On adjacent lots
Property line
To building foundation
On adjacent lots
Sudace water
Curtain drain
To existing or abandoned system on lot
Cutbank "J' IA" Water main/service line
Driveway, parking/vehicle storage area /~ /
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
$ & S ENGINEEEIh
Signature 17034 Eagle R~
Engineer's Name ~/.,
Date ~ ~
/
HAAFee$ /'~/? ~d'/'2~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
~te of thiS: til$~ection.
APPLIC. L-.'T. FILLS OUT UPPER HALF" ')NLY
· / Phone
PropertyCL~er ,.~//,-///~,~C'7'-/~L C~),A/.("-~'/(2 ~ ~/ ~/~L./
MailingAddre~ t~ ~L~, .~. ~/~. ~~ ZipCode~ ~
Buyer
Address Zip Code
Phone
Lending Institulion
Add~ess Zip Code
Phone
Address ~FCZ [~ ~ ~ d ~ ~ Zip Code ~/- ~--'~
Street Locati~ ~ f~ ~ ~ ~ J~/~ ~ ~ / ~ ~
Type of Residence
ultiple Family No. of Bedroo~.
~ Other
Water Supply
~ Individual A~ACH WELL LOG. A well Icg is required for all wells drilled since June 1975.
~ommunity For wells drilled prior to that date, give well depth (attach Icg if available).
~ Public Utility
Sewer Disposal Year Individual Installed: /¢~ ~
~lndividual
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED·
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
(/~ APPROVED BEDROOMS ~ 'CONDITIONS OF APPROVAL
(~ DISAPPROVED
( ) CONDITIONAL APPR. OVAL2
DATE J ~ /~/'~/~//~"-~
BY·
Soils Rating Date ~we~lnstalled Well To Absorption Area Well Log Received
~/~ Well to Tank Septic T~k Size
72-O23 (3182)