HomeMy WebLinkAboutHIDEAWAY LT 5AHid.,
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LOt 5A
#050-523-01
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
NAME . . ,,,/: P.ONE
LEGAL DESCRIPTION
Well / Absorption area Dwelling PERMIT NO,
DISTANCE TO:
~. ~ Manufacturer ~aterial ~o. of compartmen
~iq. c~paciW in ~allons ...........
/~O ~h uulwe~wAuE: Inside length Width Liquid depth
~ Well Dwelling PERMIT NO.
DISTANCE
TO:
~ ~ ~ Manufacturer Material Liquid capacity in gallons
Well ,/ Foundation Nearest lot line PERMIT NO.
~ DISTANCE TO:
~~ Total length of~i.ne% Distance between lin~,,
_~Z No. of lines Length of each]ine~ Trench width
P ~ ~ ~ Top of tile to finish grade / Material beneath tile -- Total effective absorption area
Length Width Depth PERMIT NO,
u~ DISTANCE TO:
~ Cla~ ~ ~ Depth Driller Distance to lot line PERMITN0.
~ ~ DISTANCE TO: Building foundation ~ewer line Septic tank Absorption area(s)
OTHER
SOIL TEST RATING~ O'~ ~r~I* t~ ~
INSTALLER
REMARKS
MUNICIPALITY OF ANCHORAGE
825 Street, ~chorage, AK. 9501
264-4720
Z~ * * * HANDWRITTEN PERMIT * * *
Permit ~ ,
.~D,~ ON-SITE SEWER PERMIT
Applicant:_ . Mailing Address:
Location: P~one Number:
Legal Description: Z(D~~~.~, ~ ~/~ Lot Size:
Type of Soil Absorption System Is/~
Trench: Drainfield: ~ _~Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: _~ Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is~.
DD~TH LENGTH ~'7~. GRAVEL DEPTH ~WIDTH
- ~ I~ ._ ~ .~
The length dimension is the length(in feet) of th~Cren~r drainfield. 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 minim~ depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
~ ~ REQUIRED SEPTIC(~D-i~G) TANK SIZE = /~O GALLONS ~ *
Permit applicant has the responsibility to inform this department during the
installation 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.
Minimum 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
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a co,nuDity 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
avai:Lable to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 $ 3 * * *
I certify that:
1) I ara familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
2) I will install the system in accordance with codes.
3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more th~ 3 ~droo~. /$
Signe~[: ~q~~ ~,,~~_ Issued by :~~~~y~ n/ // ~
A~licant Date: ~/~/~
SWP/024 (1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 254-4720
SOILS LOG - PERCOLATION TEST
[] SOILS LOG
"~'"- PERCOLATION
TEST
5
6
7
8
9-
10
11
12
13
14
15-
16
17,
18-
19.-
20-
SLOPE
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE (/ ~ (refutes/inch)
/%.
72-008 (6/79)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P,O, Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILYDWELLING
Parcel I.D. p ~O - ~' ~- 3 - o I
115 GENERAL INFORMATION
· Complete lo. gal description ~ Lo t
Location (site address or directions)
Current Property owner(s) Andy Rembert
Mailing addrass 11411 OZd
Lending agency
Expiration Date: !.,
SA; Hideaway S/D
25317 Black Pine Rd.
Day phone
q(~r.r, A~ 00~77
Day phone
Mailing address
Real Estate Agent Cindy Lindblom Day phone §94-ql 25
Mailing Address Greatland Realty 11411 Old Glen Hwy EaF, le River AK
Unlessotherwiserequested. HAAwillbeheldbyDSDforpickup. ~ 2 ~
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
3
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
~ Individual Holding tank ~E]
Community On-site
[] Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State o! Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system Is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(ara) in compliance with all appllcable Municipal and State codes, ordinances,
and regulations in effect at the time of installation. ~ & ~ bNGINEERING
Name of Firm :707. ~-"'cI'' I~lv~. L~ Reed No. 20-
Address Eagle River, Alad~a
Engineer's Printed Name
5. DSD SIGNATURE
~ Approved for ~
Disapproved.
Conditional approval for
Phone GQ y'-~- ? 7~
Date
..... -
bedrooms, b. ~,~ ~.- ....... ~,.,~. ~
bedrooms, with the follow~ng stipulations
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: / O - /'~'- 0 /
Municipality of Anchorage
Development Services Department
Building Safely Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box lg6650 Anchorage, AK 99519-6650
w~w.cLanchoroge.ak.us
(.07) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
LogalDescription: ~r ~'~ ~ F'~'l~,,d'/~ ~/~PamellD:
A. WELL DATA
Well lype~]~l~.~..V ~""'~-
Date comple~/~,~
If A, B, or C provide PWSlD # ~
Sanitary seaJ (Y/N) ~/
c~sa~te I~rl ~.
Totaldepth I"~'1 ft.
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well production
WATER sAMPLE RESULTS:
Coliform (~) colonies/100 mi.
Date of sample:
Well Log (Y/N) ?//'
Wires properly protected (Y/N) Y
Casing height (above ground) [-~-tL In.
g.p.m.
IO]5-/Ol
O colonies/100 mi.
B. SEPTIC/HOLDING TANK DATA/
Tank size I ~ gal. dumber of Comparknents '~
Foundation cieanout (Y/N) Y Depression over lank (Y/N) ~
Dateo, pumping 6 J tl } O '
Date installed ~
Cleanouts (Y/N) "'/
water alarm (Y/N) hJ/~3,
High
/
C. ABSORPTION FIELD DATA ----~ ~-'~'
Date installed
Length .~ ff. Width Gravel below pipe
Totaldep~ ~ fl. Eff. abso~n~a~ MonitorinL~ ~
Dateofad,uacy~,~['~[O' Resul~ (Pa~Fa~)~
Fluid depth in ~s~pfion field before ~st~ in.
Elaps~ Time: ~O min. F~I fluid ~ ~ in.
Depression over field
For ~ bedrooms
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Water added_.~gal. Now depth ' ~ in.
Absorption rate >= d~"'O g.p.d.
~ 0 If yes, give date
D. LIFT STATION
Date installed
/
"Pump on" level at_/__in.
Datum /
E. SEPARATION ~ISTANCES
Size in gallons
"Pump off' level at in.
Cycles tested
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanldlift,,,6ta~ on lot. /
Absorption field on lot /
Public sewer main
S~sepfic service line
On adjacent lots
On adjacent lots
/00 /'/'
Public sewer manhole/deanout
Holding tank
SEPARATION
DISTANCES FROM SEPTIC/HO~ TANK ON LOT TO:
Building foundation ~ -/r' Property line ..~.~_~"' Absorption field ~ /''/'-
Water main t,.{/A Water service line / ~/../.. Surface water
Wells on adjacentlots IO0
Property line
Water Service line I O 1 4, Surface water / O~
Curtain drain ~ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
t 0 & Building foundation / I~ I
-~. Water main
Driveway. paddng/vehicla storage
F. COMMENTS
o. E" ,.EER'S CE..F,CA.O.
I ~ that I he~ dete~ ~m~h field
m~w of Mun/dpe/ m~Ms ~at the a~ s~e~
~n~an~ ~ MOA H~ /n e~
HAA Fee $
Date of Payment
Receipt Number
(Rev. lA'00)
~00. oo
0 11¢'77
Waiver Fee $
Date of PaYment
Receipt Number
90'7 694 1211 P.~./O~
CT&E Ref. e 1016gS3001 Clfent
Olent N~ne S &SF~ce~ i~duted Date/Time 10/11/2001 9:10
l'r~-t Name/~ LSA. Hidel,~,V S~D C~lkc~ed Dntt/Tlmt 10/05/2001 15:!5
C~nt Saa~e ID L~A: Hi~nv~y ~ Received DtteFr~me 10/05/2001 17:05
M~'i~ ~1c~n8 Water Tedmlcn! Director Steghen C.
P~,~nem. ~s~ts PQL th,~t~ Mehea ~ D~te Date Init
0.500 mi/L F. PA 300.0 (cIO)
SCL
To=! CoJ~*cnn 0
~l/I ~OmL, $MI8 97~n (<1)
Parcel I.D. #
1 ..... GENERAL'INFORMATION
.3::: Comp ere legal desert ption
P.O.-Box 196650 Anchorage, Alaska 99519-6650
· '~ ~ ~ r 343--4744
_~ CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
MUNICIPALITY OF ANCHORAGE
!,:.'.DEPARTMENT OF HEALTH & HUMAN SERVICES
.. Division of Environmental Services
On-Site Services Section '
Lot 5A~'Hid~y S~v~on
;l~:2.~Locatio~l (site ad~lress or directions) : NHN D~ann
g,b;':·'- '..· :,.;~?~¢ ;.,.:' · .
Prope~owner,"?;J°h~*a~{ Co~e~n D~mann
5.?Ma lng address ..... P.O.. Box
Lending age[~&y./. ' ';
AK
AK
Day phone · 696-3505
Day phone
- ~ ~;" NUMBER OF BEDROOMS,
...... ' ............................................ : ., ....-. ....... : ,'.;-8~: eL': ~:;:;~' ;;'.L ;-''..:'':
~. ./'-' '~,%;-'-L',.:. :.-. - ¢ -./:..;.
-. 3, '.}~',~PE OF_WATER SUPPLY: _.,..., ............... ;.; - - -.? .:;..;¥.: ... :-:-
' :' ...; {Y:,:/~:;:lndividaal well -",.. XXX .,,.,' .. -,.., : . ',
.:,_'...(.NOTE: l ":.'/f.bommuni~ell system, pmyide.lw~]~en confirmation fro~ State.~D~ a~est-'
~. , ing to the legali~ and status 'of system. I ''; ' ,~' ~
~.?': -- -- -----, ',J,'~¢M..)~ L3 ~:-::~,' ~.'...'~ .....
::~..YNOTE: If &~muni~;¢astewator system, provide Wri~On Confirmation from State' ADEC .
.~..::.. affesting to the legali~ and status of system.'
- 5. STATEMENT OF INSPECTION BY ENGINEER i.. · ' - ' - L ~* '
As certified bY my seal':affirm(ed he~.eto 'and as'°f'tl~'e'~alidation ~ate shown below, ! verify
~my
investigation of this Health Author ty Approval application shows that the on-site wate~ ~ply
and/or wastewater disposal system is safe, functional and adequate for the
and type of structure indicated herein. I further verify that based on the information =rom
the Municipality of Anchorage files and from my inves.t~ation and inspection, the on-sii
supply and/or wastewate~'disposal system is in compliance with all Municipal and Stat~E~des,
ordinances, and regulatio~i's n effect on the date of this inspection. · '
Name Of Firm ........ Phone ' ~'~/~ ~ ~_c,/
$&$ENGINEERIN~ ~ : ,..
Address 17034 Roa~i Ne.: '. ~"~.
Eagle R
'Engineer's signature
... :,~... - , Condmonal approval'for ..... :.b~rooms, with the fOIIowmgstlpul s.~:_::::
" . ....... "':'Additional Comments -' '
. {.:. :':,,,~, '~ ",,, .,/ .., .z.~. . ,, ....... ~,"
:,:' ~,[,\r.7-~/_,,,, '::, .4' l/ _./1~--i'-- -' "~""'"'::" ".'. "-.~,~ ~_ ¢:~,.~"
.: ~x: ~- '~~' '-:; ~ <~: ~ ' '.. ' ;' · ":" ' '1 ' ' ' ~ '>'-~ ' ' ' ~'~ '2
"~': ~ I ~:. .': ~"~ ":' ' ~:' ' '"' ' ' · ' '--"'
L:', ' ~J e' ''
· , ~ ,.. Th~Mun~cipah~ 0~nchorege Deper[ment of Health end Humeri Semces (DHH8) roues Hee th
',-~,:APgrovA~Oe~if ~Jes .bas~ only upon the representations gwen ~n paragraph 5 above by an ndependent.
.g . .. . , .~ ~ . . . - . - . ~,,~.=~ .....
:~ ~rotess~onal e,qG[~e? reglster~ ~n the State of Al~ka. The DHH8 does th~s
~an~t~elr lending mst tut ons in order to ~tm~ ce~am f~e~l and state requ remand. Employes of DH~]~o not
.. conBuct ~nspect ons or aha ~e data before a ce~flcate ~s msued The Mun c paliW of Anchora~e'~s,~;; not
.responsible for errom or omissions in the profe~onal engln~ffs work.
72-025 [Rw. 1/gi) ~ck MOA ~1
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type 'iPAu~*-Cr~
Log present(~N)
Total depth
Sanitary seal (~N)
~..~ ~- ~ ~¢._~.~ ~ Parcel I,D.
if A, B, or C, attach ADEC letter. ADEC water system number
Date completed (& .'7.-o-~5 Driller -.~'~,-~
Cased to \~ ~' Casing height
Wires properly protected (~'N)
FROM WELL LOG AT INSPECTION
lC', o .g.p.m. (~,2-~- g.p.m.
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/he~h~j tank on lot
Absorption field on lot \
Public sewer main
Sewer service line
; On adjacent lots
;On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
~.
~>
o C
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample:
B. SEPTIO/H~L-'BtN~ TANK DATA
Date installed
CIeanouts ~) 7
High water alarm (Y/~_
Date of pumping
Collected by:
Tank size /¢ o o
Other bacteria O
$ & S ENGINEERING
17034 ~gle River Leop-ReoS-I'.'c,. 204
Eagle River, Alaska '~9577
Compartments 2--
Foundation cleanout l~'N)
y Depression (Y/jL~A ,J'
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HeL-BtNG-TANK TO:
Well(s) on lot ~. c~_-~ On adjacent lots
To property line \%-~ ~ Absorption field
Surface water/drainage ~ O c~
Foundation
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTAN~E~M LIFT STATION TO:
On adjacent lots
Manufacturer
Manhole/Access (Y/N)
"Pump on" level at "Pu~ at
Surface water
D. ABSORPTION FIELD DATA
Date installed ~ - t, ¢ ~5
Length ~ '
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y~
Soil rating (GPD/Ft2) '~c~,p~/l~¢~ System type
Width ¢- ~ Gravel thickness '2- ' Total depth ¢'. ¢- '
~, ¢~ ¢ c.,,~.~, Cleanout present I~N) ~/ Depression over field (Y/~j~
,~ '~-'~ -'~.¢~ Results~_~fail) ¢¢,,4~5 for
~ ' After test /5'-"
~o ~ E.- F'~ ,'-( ,3 If yes, give date
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
On adjacent lots ) oo ~ ~L Property line
/0/+
To existing or abandoned system on lot
Cutbank '"//~- Water main/service line .
Surface water
Curtain drain
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certi~ that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 f3/93)* Back
,¢ %.-'
I o RO~ -~
~ : '], E,~T C. COWAN ~¢~ ~
~¥ ', ~ ;-f: ;~'~'d,~
Waiver Fee $
Date of Payment
Receipt Number
0~×24×95 COMMERCIAL TESTING ~ 90?6941211 N0,810 U02
10:02
cT&~ Ref.~ 95,0680-1
C1£¢]%c Sample ID bSA HIDEAWAY S/D
CT&E Environmental Services Inc.
Laboratory Division ~
Laboratory Analysis Report
Client Name S & s ~NGXNEgRIMG WORK Order 12781
Ordered By R-J.S. Printed Dare 02/21/95 ~ ll:~ hr~-
Projec~ Nam~ ColLected Date 02/17/95 ~ 12:30 hr~
~rojeot~ Received D~e O2/~7/95 ~ 16:00 hr~,
PWSID UA
Techaical Director STEPHEN C. ~DE
Sample Re~ark~; ~OUTINE SAMPLE CODLECT~D ~Y; RA~.
QC Allowable Ext.
paral%eter Re¢~lt~ Qual Unit8 Me~hod Limic~ Oa~e Da~e ~Dit
See Speuial In~ruc%~ns ~Lbove UA - Unavailable
See Sample Remark~ Above NA = U¢~ ~alyz~d
U~detected, Rsp~T~ Value ls ~he prac=ical ~an~ifica~ion liml~, LT = ~ T}%=n
Secondary dilution. GT ~ Greater Than
2~ ~. Polter O~{ve, A.ohe,a~~ AK 995~ 8-~ ~05 -- Tel: (907) 582.2343 F.x; (907) 5~-~30~
5NVI~ON~EN/AL 7ACIUTI~S IN ALASKA, CALIFORNIA. ~LOR~OA. ;LUNOI$. ~ASY~ND, ~ICMIGAN, ~lS~OuRI, NSW J~RSEY, OHIO, ~EST VIRGINIA
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICFS
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # ~ -%,~ O~ HAA# ~. f'~ ~ OC> (2) (or,~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 5A Block 2; Hid6away Subdivision;
Location (address or directions)
Hideaway Court
(b) Property owner Alaska USA Federal Credit UT~lhone: (home) Business
Mailing Address P.O. Box 196613 Anchoraqe, Alaska 99517-6613
563-456?_
(c) Lending Institution Telephone
Mailing Address
(d) Real Estate Company and Agent
Add ress
USA F&d~-~¢ C".¢dit U,~Lon ACT,Y: Ron McAlpi~
(e)
Telephone 563-4567
Mail the HAA to the following address: (or check here r~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCF
Single-Family E~x' Number of bedrooms 3
3. WATER SUPPLY
Individual Welh[Z Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site E~x Public [] Community [] Holding 'l'ank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
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~¢'; .,MUNICIPALITY O.F ANCHORAGE (MOA)
' . ~¥~
~'¥'!"~'~ '"~ '2 ~'~'~ Legal Description: ~.z-~"f' ~- '~"
Well Classification ~_,'~ ff 1~ l~ ~;~ If A, B, C, D.E.C. Approved (Y/N) .._
Well Log Present (Y/N) ~ Date Completed ~ "~ o -~ _Yield
Total Depth (~/ Casedto./~ ~ Depth of Grouting
Static Water Level 3 I '
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
Comments
; On Adjoining Lots 1 O0 /-'
! 00'?- ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole ~/~
~ ~- .:S /~"J ~/'~ ~,.~£/N ~ 'Date
· "%' t LJ ' ~ -
B. SEPTIC/HOLDING TANK DATA
Date Installed ~
Standpipes (Y/N)
Depression over Tank (Y/N) _
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
I t")oO No. of Compartments
Air-tight Caps (Y/N)_ ~1 Foundation Cleanout (Y/N)
~ Date Last Pumped ~- ~ ~ ~/O
k~/'tq ;for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDiNG TANK:
To Water-Supply Well
To Property Line
To Water Main/Service Line /
To Stream, Pond, Lake or Major Drainage Course __
Comments_ ¢'~b ,°¢~t'~ ~L
To Building Foundation
To Disposal Field
If
%-'+
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ - / - ~.~
II
Width of Field (¢ O
Type of System Design
Length of Field ~
Depth of Field ~. ~- '
.... Gravel Bed Thickness
Square Feet of Absortion Area (¢ O0~ (-/~ L_(~. Statndpipes Present (Y/N)
Depression over Field (Y/N) A) Date of Last Adequacy Test
Results of Last Adequacy Test .~.~'7~1~¢P,c-'~0¢'1't - ~
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation ~ '4'
Lot fd/¢
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
f
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present) ?d/J3r
i00
D. LIFT STATION
Date Installed ~
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request ....
I certify that l have checked, verified, or conformed to all MOA and HAA guidelines i~n.~eft'~ ~.'~'~...te
inspection.
S & S ENGINEERING
Company
Date E aCeRiver, Al aska~9 ~_ ~-~. ~~_~,., ,,. ....... ,
MOA No.
o, 1437
~/ 7/~' a¢¢ Receipt No.
Receipt No.
Date of Payment
Amount: $
72-026 (Rev 7/881 Back
Waiver Fee: $
Date of Payment
Page 2 of 2
FEDERAL TAX ID # 92-0040440
ANALYSIS REPORT BY SAMPLE for Work Order $ 19781
Date Report Printed: FEB 15 90 @ 16:59
Client Sample ID:LSA 2 SE, }IIDEAWAY LAKE $/D
PNSID :UA
Collected FEB 8 90 @ 14:05 hrs.
Received FEB 9 90 ~ 16:45 hrs,
Preserved with :AS REQUIRED
Client Name : S & S ENGR
Client Aect : SNSENGP
P,O.~ NONE RECEIVED
~eq ~
Ordered By : R. SNAFER
Analysis Completed :PEg 12 90 Send Reports to:
Laboratory Superv~or~z..:__STEPHEN C. EDE I)S & S ENGR
Released Ey 2)
Special
Instruct:
Chemlab Roi ~: 900066 Lab Smpl ID: 1 Matrix: WATER
Allowable
Parameter Tested ~esult Units Method Limits
NITRATE-N 0.42 ms/1 EPA 353.2
Sample SAMPLE COLLECTED BT R.D.J.
Remarks:
I Tests Performed ' See Special Instructiono Above UA=Unavailable
ND= None Detected "See Sample Remarks Above
NA= Not Analyzed LT~Less Than, GT=Greatoz Than