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Home My WebLink AboutKASILOF HILLS BLK 4 LT 22Kosiloff Block 4 Lot 22 #015-131-10 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 MAILING ADDRESS p.o, t_3ox LEGAL DESCRIPTION LOCATION PHONE ~ NEW 3y~ ~/)/ (~] UPGRADE Well Absorption area DISTANCE TO: I / ¥ ~'~ Manufacturer f, Liq. capacity in gallons ~ ,.~.~.~^~ Inside /1~1~ ~ I r nUlVl~lVl/~U~: length DISTANCE TO' ~Well Dwelling ' I Manufacturer ~We]l /~ ,, DISTANCE TO:I ~7~ No. of lines ..~ Length of each line Top of tile to finish grade /~ / Material beneath tile /~r~ Length Width -- Depth Type of crib Crib diameter Crib depth --~ Well DISTANCE TO: 8ailding foundation Class ~ ~ Depth Driller ~ISTANCE TO: Building foundation Sewer line NO. OF BEDROOMS OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER F~ /'~.z REMARKS 7 Material W dth Material ~;.~'7~f Nearest lot line Foundatioq i (~1 "(.o ~-~ ~ -" " ';:~ Io 4- Total length of lines Trenc~ width I O/ /~O inches inches PERMIT NO,~ ¥'0 't &~ No. of compartments Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. Distance between lines Total effective absorption area PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line PERMIT NO. Absorption area(s) Septic tank ( ../,.~ .- APPROVED DATE LEGAL ' DEPAR"FMENT OF HIEALTI"J AND ENVIRONMIENTAL. PRO]"ECTION 825 L SI"I:REET, ANCHORABE.~ Al'.:: 99',501 264-4720 PERMIT NO: DATE ISSUED: AF'PL I CAI',IT: ADDIRESS: CONTACT PHONE I_EGAL. DIESCF~IP I_[)T SIZE: MAX BIEDROOMS: 840489 06/20/84 FE,]ES DEVEI_OPMENT P.O. BOX 11-2009 ANCHORAGE ~ Al':.': 995 '.}';49.-8 C) .I. 1 SLJBDIVISION: KASIL. OF HILLS SECT'ION: 15 TOWNSHIP: 58046 (SQ.FT. OR ACRES) lEE b, L- IF:"-" E: F,: Ihdl :E ]-~ LOT: 22 BLOCK: 4 RAN(3E: 3W Listed belc~¢ ape the op'Li~ns availab].e 'Lo you in des;iigning youP ~se:ptic system. Choose the option that best f:i. ts youp site. Ir_CED DEPTH TO PIF'E BOT'¥OM (FT.) 4.5 GFIAVEL DEPTH (ET'.) 0. TO'I~AI_ DIEF:'TH (FT.) 5. GRAVEL WIDTH (FT.) 15. GRAVEL.. LENGTH (I=T,) 29, (31:~AVEL. VEILLIME (CI..I. YDS. ) :1.6. TANK SIZE (GALS) 1,000. S[III- RATING (SQ.FT. /BR) 96 4 0 1 0 5 0 5 0 51 () 14 .1. .1., 000 0 '~"~' 96 e~ 'T'ANK MUST HAVE A'T' I_EAST TWO COMF'ARTMENTS I cert. ify tha'L: 1., I am familiar with 'Lhe requirements fc)r on-site. ':sewers and we].l~ a~s set forth by the Municipal:i. ty c~¢ Anchorage (MOA) and the State oF Alaska. 2~ I will im~tall the system in accordance wit. h all MOA codes and r'egulat.:i.c)ns, and in c:ompliance with 'Lhe de~ign criteria of this per'm:i.t. 3. I will adhere to all MOA and State (:~{' Alasl.::a requirements fc)r' the ~et back dis'Lar'lces from arty exis'l:.ing well, wastewa'Ler d:i. sl::)osa]. ~syst. em [~l" public sewerage system on 't.h:ls or any adjac:errl:.. (:~r' near'by 4. I unders'Land tha'L t. his petrel'l: :[s valid fc~r a I~xifllLtrfl 0~' :5 bedr, ooms arid any enlargement will r'eqt.t:i.l-e an additiorJal ]:Fr A I....IFT' STAT'ION IS INS"I'ALLtED .'t;N AN AREA COVERED BY MOA BUII_DIIqG CODliES, 'T'HEN (.1.) AN EL.ECT'F'~];[;AL. F'ERMIT AND INSF'ECTION MUST BE; OBTAINED; (2) AS-BUIL.]"S W]:LL. NO'I' BE APPROVE.]D WITHOUT AN EI.~ECTRICAL INSF'IECTION IRIEPOF~T; AND (3) THIE EI...li~CTRICAL WORK MUST BE DONE BY A LICENSED IELECTIRICIAIxl. S :1: GNED DATE: APPLICANT: FEJES DEVEI~OF'MENT ISSUED BY DEP~RTMENT OF HEALTH ~ND EN¥I~ONMENT~L PROTECTION 825 L. STREET~ laNCHORlaGE, laK 9950± 264-4720' PERMIT NO: [:,laTE 1:5:SI_lEE:,: 840489 ENG I NEERE[:, [:,E:51GI'.,I .06,.-"20,.-"E 4 laF F L.I L. ttN r: laDE:,RE:5:5: C:ONTRCT PHONE: FEJE:5 DEVELOF'MENT P.O. E:OX tt.-2009 laNC:HORlaGE~ RK 99511 ~:49-801& LEGRL DE:SCRIP: :SUBDIVI:SION: KR:SILOF HILLS ' LOT: 22 BLOCK: 4 :SECTION'. t2;..: TOHN:SHIP: t~N' RFINGE: ~1.,.1 LOT :SIZE: 58C446 (:sg!. FT. OR FtCRE:5:.', ; I CERTIF~¢ THRT: :1.. I laM FlaMILIlaR HITH THE REG~UIREP'/ENT:5 FOR ON-:SITE '.F, EHERS laN[:, HELL:5 la:5 :sE'r FORTH B'¢ THE MUNICIPlaLIT'¢ OF laNCHORlaGE (MOla) laND ]'HE ':.]TRTE OF' laLlaSKR. 2. I. WILL .IN:STlaLL THE S'¢?I'EM IN RCCORDRNCE WITH laLL MOla CO[:,E:5 RND REGULlaTION:5., "' laND IN CONPLIlaNCE HITH THE DE:SIGN CRITERIR OF THI:5 PERMIT. 3:.. I HiLL laDHERE TO FILL MOla RND 'STRTE OF laLR'..TKla REL.]UIREMENT:5 FOR THE :sE'r BlaCK [:,I'=;TRNCES FROM RN'¢ EXISTING WELl_., HR:STIEWRTER [:,I:SPOSlaL :5~¢:STEM OR PUBLIC :SEHERlaGE S'¢S]'EM ON THI:5 OR laN'r' la[.',JlaCENT OR NElaF.:B'¢ LOT. IF: la LIFT ':-]TlaTION I:5 IN:STFILLE[.', IN lan RRER COVERED E:"r' MOla BUILDING CODE:5, THEN (i) lan ELECTRICRL PERMIT RN[." IN:SPECTION MU:ST BE OBTlaINE[:'.~ (2) RS-BUILT:5 WILL NOT BE RPPROVE[:' b. IITHOLtT RN ELECTRICRL INSPECTION REPOR'T.~ RND (]:) THE ELECTRIClaL 1.40RK MUST BE DONIE B"r' R LICEN:SE[:' IELECTRICIlaN. :51GNE[:, FFLIL.~NT: I .::, .-,LIE[. E:'T' FE JES .Ek~.¢ ELOPP1EN'I~.-~ /o o MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 826 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG /~ PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: oL 1 2 3 4 C~ 5 DATE PERFORMED: SITE PLAN 10 11 12 13 14 15- 16 17 18 19 20 COMMENTS PERFORMED BY: r~¢,,¢ ¢'7 WAS GROUND WATER ~ ~ S ENCOUNTERED? ~'~ O L O P E IF YES, ATWNAT DEPTH7 Gross Net Depth to Net Reading Date Time Time Water Drop ~o~ _ . 5~ ._ /la ' ,s PERCOLATION RATE ~/'~ (minutes/inch) TEST RUN BETWEEN ~ I/~ FT AND ~ FT y'F 8 ~* 2~- CERTIFIED BY: DATE: 72-008 (6/79) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTFCTION PERCOLATION /, TEST 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SITE PLAN 10 11 12 13 14 15 16 17 18 19 20 COMMENTS PERFORMED BY: 72-008 (6/79) ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Wate, r Drop G 0 L,~ION RATE :es/inch) .~ ~RLIN BETWEEN AN[~ ~-~ 7 ~z~_~m ; .., ~ ~ ~ ~ ~ , ~ ~' ~._ ~ ~ ~ ,. , ,~ ''~ , CERTIFIED B~,;. ~,L~.~I;' ~ ' ' · ;,, DAT __T~ 7 ~' ',,'~:~ ~:,~- ~ F,' .: ' ~' , ', .' ~:~t~.-'~ .....,..,~: ALASKA ,,UIRO me TAL CONTROL" ~nq,n~¢rinq 6 ~nulronm~'nlol Slurries InC. TH ~ 1 2 3 4 § ? 8 9 10'- 11 12 13 14 15- 16- 17 18 19 20 Subdivision Supplemental Soils Information. LOT LOT TH TH DEPTH ', 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 l0 19 20 - 20 1200 UJ~I 33~'d Au~nu~, ~uil~ B · ~nc~oroq~. ~lo~k~ 99503 · [907) 276-~36~ LO1 T H 1 2 3 4 6 7 9 12 ~3 17 ALASKA ENVIRONMENTAL CONTROL SERVIC' ' INC. 1200 West 33rd Avenu. Suite B ANCHORAGE, ALASKA 99503 Phone 276-1361 SHEET NO CHECKEO BY SCALS OF ~' DATE _ ', q G' r" C a.F, ALASKA ENVIRONMENTAL CONTROL SERVI¢ ',, INC. 1200 West 33rd Avenb~ Suite B ANCHORAGE, ALASKA 99503 Phone 276-1361 SHEET NO OF CHECKED BY DATE SCALE ALASKA u, iUIBOFImeF1TAL COFITBOL Se dlC S, IFIL ~ngi~¢¢rJn§ 8 ~nuironmenlal $1udies SPECIFICATIONS FOR DRAINFIELD AND BED SYSTEM - LOT 22 ELK 4, KASILOF HILLS SUBDIVISION 1.0 GENERAL 1.i THE DRAWINGS SHALL BE A PART OF THIS SPECIFICATION. 1.2 ALL MATERIALS AND WORKMANSHIP SHALL MEET THE REQUIREMENTS OF THE MUNICIPALITY OF ANCHORAGE, THE CONDITIONS OF THE PERMIT, AND ALL APPLICABLE RULES AND REGULATIONS CURRENTLY IN EFFECT. 1.3 ALL EXCAVATIONS AND DEPTHS ARE ADVISORY AND ARE TO BE VERIFIED OR MODIFIED IN THE FIELD BY THE CONTRACTOR. 1.4 IT IS THE RESPONSIBILITY OF THE OWNER OR INSTALLER TO OBTAIN ALL NECESSARY PERMITS, EASEMENTS, OR WAIVERS REQUIRED FOR INSTALLATION OF THE SYSTEM. 2.0 SEPTIC SYSTEM 2.1 THE SEPTIC TANK SHALL BE A UPC APPROVED TWO COMPARTMENT TANK, SET LEVEL, AND INSULATED WITH AN OVERLYING LAYER OF 2 INCH BURIAL TYPE POLYSTYRENE. THE SEPTIC TANK SHALL REST ON UNDISTURBED SOIL. 2.2 INLET AND OUTLET PIPING SHALL BE FITTED WITH WATER- TIGHT CALDER COUPLINGS. PIPING SHALL BE 4 INCH SOLID PVC SLOPED A MINIMUM OF 1/4 INCH PER FOOT, WITH A MINIMUM OF 4 FEET OF COVER. IF LESS THAN 4 FEET, USE 1 INCH OF POLYSTYRENE FOR EACH FOOT OF COVER LESS THAN 4 FEET. 2.3 CLEANOUTS SHALL BE INSTALLED WITH CALDER COUPLINGS, CAPPED WITH AIR-TIGHT JIM-CAPS (OR EQUIVALENT), AND EXTEND A MINIMUM OF 3 FEET ABOVE GROUND LEVEL. 2,4 THE SEPTIC TANK SHALL BE A MINIMUM OF 5 FEET FROM THE HOUSE FOUNDATION, AND A MINIMUM OF 5 FEET FROM THE DRAINFIELD. 3.0 BED OR FIVEWIDE DRAINFIELD SYSTEM 3.1 THE GRAVEL FOR THE BED SHALL BE SIZED BETWEEN 0.5 TO 2.5 INCH AND FREE FROM SILT OR SAND. 3.2 THE BOTTOM OF THE EXCAVATION SHALL BE RAKED WITH THE BACKHOE BLADE TO INSURE THAT THE BOTTOM HAS NOT BEEN COMPACTED DURING EXCAVATION. THE BOTTOM ELEVATION SHALL BE PLUS OR MINUS 2 INCHES WITHIN LEVEL. 3.3 THE DISTRIBUTION PIPE SHALL BE 4 INCH RIGID PVC OR POLYETHYLENE. THE PIPES SHALL BE LAID LEVEL. 3.4 TWO OBSERVATION PIPES SHALL BE PLACED AS SHOWN IN THE DRAWINGS. IT SHALL BE RIGID PVC, ASTM D-3034. THE SECTION BELOW GROUND LEVEL MAY BE EITHER DRILLED 0.5 INCH HOLES @ 6 INCH CENTERS ON OPPOSITE SIDES OF THE PIPE OR A REGULAR SECTION OF PERFORATED DISTRIBUTION PIPE MAY BE CLAMPED TO THE SOLID SECTION WITH A NO HUB COUPLING OR SOLVENT JOINT. A RUBBER RAIN-CAP (JIM-CAP OR EQUAL) SHALL BE PLACED ON THE 1200 Wes133rd Auenu¢.Suile BoAnchoroq¢. Alosb gg503°[g07) S61-50~O TOP OF THE PIPE. 3.5 THE GRAVEL SHALL BE COVERED WITH A LAYER OF UNTREATED BUILDING PAPER OR A NONWOVEN FABRIC (SUCH AS MIRAFAR FIBRETEX 200 GRADE, POLY-FILTER X, OR EQUAL.) 3.6 IF INSULATION IS USED RATHER THAN MOUNDED BACKFILL, THE INSULATION SHALL BE DOW EXTRUDED BLUE STYROFOAM BOARD OR ARCO GEOFOAM EMBANKMENT INSULATION BOARD OF THE REQUIRED THICKNESS (1 INCH PER FOOT OF SOIL LESS THAN 4 FEET OVERLYING THE BED). 3.7 THE TOP OF THE BED SHOULD BE PLANTED WITH A ~{ITE CLOVER AND RED FESCUE MIX, OR BLUEGRASS. 3.8 IT IS CRUCIAL THAT CARE BE T~(EN IN CONSTRUCTION OF THE BED TO ENSURE PLACEMENT INTO THE PROPER SOIL STRATUM FOR PROPER OPERATION OF THE SYSTEM. WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological a Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either to, Ib or Ic.) A.D.L. No. la. Borough Subdivision Lot Block Ib. 1/4 qtrs. Section No. Township NEI Range ED Meridian —of—of—of S1:3 WE Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL: `� n�1 d;wO""• Address: Street Address and Area of Well Location , 2. WELL LOG Feet Below 4. WELL DEPTH: (final) 5. DATE OF COMPLETION Surface Material Type Top Bottom ft. 6, E] Cable tool Rotary F] Driven EJ Dug ❑ Auger E]Jetted 0 Bored 0 Other: 7. USE: Domestic EJ Public Supply Industry Irrigation El Recharge Commerical E] Test Well [] Other: 8. CASING: E] Threaded F] Welded diam. in. to ft. Depth Weight Ibs./ft. diam, in. to ft. Depth Stickup ft. 9. FINISH OF WELL: Type: _ Diameter: slot/Mesh Size: Length: Set between ft. and ft. Backfilling Gravel pack 1 r �,0 & Q 10. STATIC WATER LEVEL ft. P� , r D Above or l_.J Below land surface Date Equipment used: 11 . PUMPING LEVEL below land surface and YIELD ft. after hrs. pumping g.p.m. ft. after hrs, pumping g.p.m. 12.GROUTING Well Grouted: O Yes F� No Material: D Neat Cement ❑ Other: 13, PUMP: (if available) HP Length of Drop Pipe ft. capacity g.p.m. 0 Subm. ❑ Jet ❑ Centrifical ® Other 14. REMARKS: 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Water Temperature ° � F El C This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Registered Business Name Contract License Number Address: Signed: Date: Authorized Representative Form 02-WWR (11/8I) Copy Distribution: WHITE -State DGGS, PINK -Driller, CANARY -Customer C: N G) w r 0 Z 0 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DMslon of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage. AJas~,a 99519-6~50 (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING Parcel I.D. # '015-131-10 1. GENERAL INFORMATION Complete legal description KASILOF HILLS SUBDIVISION: LOT 22. BLOCK 4. Location (site adriress or directions) 10600 REZANOF CIRCLE ANCHORAGE. AK 99516 Property owner BRAD CAMPBELL Day phone (907) 346-1921 Mailing address. Lending agency Mailing address Agent Address ': -' c./o PEGGY ~ ~"rEWART PACIFIC RIM Day phone (907) 762-5497 · ' ' '~" . Day phone Unless otherwise requested, I~IAA Will be.held for pickup. NUMBER OF BEDROOMS: 3 · ' ,' TYPE OF WATER SUPPLY: ~ - . ' ' Individual well xxx Community well Public water NOTE: If community well system, provide wrftten confirmation from State ADEC a~test- lng to the legality and status of system. 4. TYPE OF WASTE~VATER DISPOSAL: Individual on-site xxx Holding Tank Community on-site Public sewer NOTE: If community wastewater system, provida wdtten confirmation from State ADEC lng to the legality and status of system. 724325 (Rev. 1/91)Front MOA ff21 C~mputer Version · I. Note; Alaska. Water. and Wastewater Consu. ltants, In.c,. shall be paid $1,110.00 at, or prior to, closing mr the engineering serwces pro~aea. 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 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 Investjgation and Inspection, the on-site water supply and/or wastewater disposal system.Is In compliance w~th all Munlc.~l and State codes, ordinances, and regulations In effect on the date of th~s Inspection. . · : .. . I ! ~vi , Name of Firm 'ALASKAW~ -.'Rf8 WASTEWATERCONSULTANTS, INC. Phone ~907) 337-6179 Address 6901 DEBARR/~O~ )./Si ~('E ~/~ At~CHORAGE. ALASKA 99504 system In accordance with ADEC and ~ Jt4 D IHS Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readi~, identifiable features. The operational life of all wells and septic systems depend on the local soils condition, ground water levels that may fluctuate dudng the year, and the water usage of the faml~ being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance . ?... of the system, nor do they guarantee that there are no hidden defects or encroachments. AWWC, Inc. can therefore not provide any warranty,~Yor future estimate system wilt continue to rneot the operetiona/ requirements of tho AD[(1.?I ~lJ~l, ~r, ....... The content of thls report ls for the sele benefit of the owner liste~. ~b~{/l>.?y~t .~.r. ~ ; re,ance upo use ot thfs re o, eny other pe on or ". : ..... nor will lt confer any lecjal right whatscever. ~ ~"'~ .* ON- ., ~ 6.' DHHS SIGNATURE ~'~ I~'.. ~/ ...' ~.~,~' · . Conditional approval for beflYo~q~'~th I~,~ ng stipulatiohs: Note: Tile ~ ell fm ih4 p~ upci i.~ mc~;~ ~:.d~i.[ug $1alc uuu A, AUnlClpal t.,uuc3. '['4crc arc uiLrutc~ present. It is snggested that periodic testing be performed tn in~,re th~; well~ cnn/la.ed ~nltaMIity. Current nitrate concentration is 6.52 rog/1. EPA maximum concentration is 10.0 mg/l. More information on nitrates is available trom On-Site Services, CPD~ 343-4744. Additional Comments. Date 2-20-0/" The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority Approval Certiticetes based only upon the representations given In paragraph 5 above by an Independent professional engineer registered In the State of AJaska. 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 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 ~1 Comlmter Vemlon Legal Dasorlption: A. WELL DATA Well Type pRIVATI~ Log present (Y/N) Total depth Santimy ~eal (Y/N) Date of test Static water level Well production WATER 8AMPL~ RF~U~: Col~orm Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Envffrmmentel 6endcos Division 825 'L' Street, Rm 502 Anchorage, Ateska 99501 (907) 343-4744 Health Authority Approval Checklist KASILOF HILLS S/Di LOT 22~ BLOCK 4, Parcel I.D.: 015-131-10 ff A, B, or C, attach ADEC letter. ADEC water system number N/A Y[:S Date completed 6/13/1984 Cased to 29' (TO BEOROCK) Casing height (above ground) 12'+ ~ YES FROM WELL LOG 6/13/1984. Date of ~ampla: 1/2¢J/2001 SERTIC~IOLDINO TANK DATA Dateinstelled 7/15/1984 Tankslze Foundation deonout (Y/N) YES Date of Pum." g f- 31-Ol C. ABSORPTION FIELD DATA Date Ins~ed 7/13/198¢ Leno~ 33' Wla~ 1 ,~ g.p.m. Wires properly protected (Y/N) AT INSPECTION 1/19/=om 4,6 Nltmte~Othor bactorte.~- Collected by:. A.W.W.C.~ INC. g.p.m. 10P0 Number of Comperlmente 2 Cteanonte (Y/N) Dapr~ssloI1 (Y/N) NO High water alarm (Y/N) N/A *MT1/m2 Soil rating (g.p.dJ1t2 o~) 96 System type 15' Gravel thickness below pipe {}" Total depth Effective absorption ama 495 SC~. FT. Monitoring Tube present (Y/N) YES Depression over field (Y/N) Date of adequacy test 1/19/01 Results(Pass/Fall) PASSED FOr 3 Fluid depth ~ absorption field before te~t (in.); Fluid depth 6"/5' (ins) Minutes laten Permdde trealn~ent (past 12 months) (Y/N) NO · 4"/1.25" Immediately alter 639 N~ption ram = NONE KNOWN If yes, give date Bedrooms gal. water added (ln.):l 4,50+ D. UFT STATION [*INSPECTION WAS DURING WINTER CONDmONS] E. SEPARATION DISTANCES SEPARATION DISTANCES FROM W;I I ON LOT TO: Septic/holding lank on lot. 100'+ Absorpfion field on lot 100'+ Publio sewer main N/A Sewe#se~o eewlce line 25'+ Properl~ line · Sur[ace water Curtsln drain .On adjacent lots 100'+ On adjacent lots lOO'+ Public sewer manhole/cteanout N/A U~ $lafiOI1 N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundafion 5'+ Pmpe~y line 5'+ Water main/service line 10'+ Surface water/drainage *100% SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: 10'+ Building foundation .100'+ NONE KNOWN At~sorpfion field 5'+ Wells on adjacent lots 100'+ 10'+ Driveway, parldng/vehlcte storage ama 1 o'+ Wells on adjacent lots 100'+ Water maln/sendce line 10'+ Waiver Fee $ Date of Payment Receipt Number, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING \~_~ - \('3 HAA# ~ ~ ~?~"'~ 1. GENERAL INFORMATION Complete legal description LoT 22, Location (site address or directions) I0 (~oo A/~cf/. Property owner Y~ 6 ~E'f N£c5o~ Mailing address Lending agency Mailing address Agent N. A-. ( t~¢ ~m~n¢~) Address Day phone ~ox 2q Oo"l l ~NC/~., A~ 5E~I E NOR~ Day phone _C-G q~ - c~32J 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. TYPE 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. 72-025 (Rev. 1/91) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein, lfurtherverifythatbasedontheinformationobtainedfrom 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 ali Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~'LA'rTDP TccH S~/cs Phone ~ qS-' / 3 5~'5~ Address IL~530 EcHo ~T. ,,~FJCF/, ,,~K ~S-/(o Engineer's signature DHHS SIGNATURE Approved for Disapproved. bedrooms. Conditional approval for Date '7/' /~/93 bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The 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 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: LoT 22, A. Well Data Well type ~'I~IvA¥~ Leg present (Y/N) ¥ Total depth ~'o Sanitary seal (Y/N) BL/( L/, KA$//oF' ~ILL~ ParcelI.D. 0/"~-- /'~/ ~ /o If A, B, or C, attach ADEC letter. ADEC water system number Date completed (~/15/8¥ Driller AL Casedto 29' ('BCb~o¢~<"~ Casing height Wires properly protected (Y/N) Y Date of test Static water level Well flow Pump level1 FROM WELL LOG AT INSPECTION 15' g,p.m. > ~', '2. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /2:5 Absorption field on lot Jcl~ Public sewer main Sewer service line MUNIC!PAI.IIY OF ANCHCmAGE ENViRONMENTAl,. SERVICES DIVISION RECEIVED ; On adjacent lots ~./oo' ; On adjacent lots '>/oo Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform OCc'([IoO~ Date of sample: Nitrate 'Y, "t ? ,-,,~,/.¢_ Other bacteria Collected by: ri, SEPTIC/HOLDING TANK DATA Date installed 7 /1~/8~¢ Cleanouts (Y/N) "'/' High water alarm (Y/N) k\. ,~. Date of pumping Tank size /ooo ~AL Compartments Foundation cleanout (Y/N) 'Y' Depression (Y/N) Alarm tested (Y/N) N,,,q 7/.~ / ?.3' Pumper N SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 12~~ To property line ~ 70 Surface water/drainage On adjacent lots ~/oo Foundation ¢ ,9o/ Absorption field '7¢ Water main/service line ~ $o ~/o0" 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) "Pump on" level at Manufactu ret Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed 7ItT/St( Length 55' Width 15't Total absorption area ~.¢ F(L Date of adequacy test '7/2/~/~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/FF) 1.6 GPP//F{z Gravel thickness (¢" Cleanout present (Y/N) Y Results (pass/fail) Nor, Ir k-N0~/r4 System type Total depth Depression over field (Y/N) for After test If yes, give date N ,/~, N Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 195 To building foundation f'75' On adjacent lots ~ ._¢'o Surface water ;~, ~ o o Curtain drain No~qE O[~ERt/Eb On adjacent lots '~ /oo Property line To existing or abandoned system on lot Cutbank N,/~ · Water main/service line ~ /oo Driveway, parking/vehicle storage area '>/oo ' E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidefines in effect on the date of this inspection. Signature ~ ~. ,7~ Engineer's Name '7%¢o¢,¢o,"¢ /='. /~o,.-~ Date ::T',~ (~.' ( ~.., /? 9~ HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back ENVIRONMENTAL LABORATORY SERVICES ~,~cE ,~0~ REPORT of ANALYSIS Chemlab Ref.9 :93.3178-1 5633 8 STREET ANCRORAGE. AK 99518 Client Sample ID :L22 B4 KASILOF HILLS NORTH HOSE BIB TEL: (907) 562-2343 Matr ix : WATER FAX: (907) 561-5301 Client Name :FLATTOP TECHNICAL SRV Ordered By :CHRIS Project Name : Project~ : PWSID :UA WORK Order :67876 Report Completed :07/07/93 Collected :07/02/93 @ 09:45 hrs. Received :07/02/93 @ 13:15 hrs. Technical Director:ST~?~E]~. ,EDE / Released By :~C ~F_---- Sample Remarks: ROUTINE SAMPLE COLLECTED BY: CHRIS. QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 4.47 mg/L EPA 353.2/300.0 10 07/07 LLH See Special Instructions Above UA = Unavailable See Sample Remarks Above NA = Not Analyzed Undetected, Reported value is the practical quantification limit. LT = Less Than Secondary dilution. GT = Greater Than Member Of the SGS Group (SociC,~ G~n~rale de Surveillance) ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# ..~)~-.~-~.%\- t('-') 1. GENERAL INFORMATION Complete egal description /_.O;- /3 00 ¥ Location (site address or directions) Property owner Day phone ZTcO-ZZ'J"/ ~/~ ;"' *'~',,~ Lending agency _A/'/~'? ~::~,'~t¢ /~o/¢'r~"¢ ._TA,I~, Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS; ~ TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE 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. 72-O25 (Rev. 1/91) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ,..~'~"/_//y' _(~.o/?j-/_///-/'~/)~' Phone _ o°~,~5'--4 ~~~ Date EngineeCs signature DHHS SIGNATURE /~ Approved for~'~("~) bedrooms. DisapProved. Conditional approval for bedrooms, with the following stipulations: Additional Comments ~/~.,,~..4"~-/~,,'--~¢-~ ?~-'~ -'~'"-~ ~ ,~"~ ~. ~ By:-/X]~~ / ~' ~'z~.X~_~-'~- .., 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 ~HHS. 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 ~1 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LaT2~/°~OcX ,¢,~/z,~/¢~¢.~ Parcel I.D. ~) / -~-' A. WELL DATA Well type Log present ,~N) Total depth ,,~"~ Sanitary seal (Y/N) _ If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~-~ '%/,~'- ~¢ _ Driller 4/z;:'/,9¢' Cased to~ ~o IB~D~ZCasing height Wires properly protected (Y/N)M~JiCiPALii y ~ ANCHORAGE Date of test Static water level Well flow Pump level FROM WELL LOG /4' 3¢' g.p.m. ENVIRONMENTAL SERVICES DIVISION AT INSPECTION OCT Dr:, c SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /'~.g (,~u/'~¢'~' ~3~,'/~ · On adjacent lots Absorption field on lot .22~ (. ~.~'-/~,'/t- ;On adjacent lots. Public sewer main ,,~/-? Public sewer manhole/cleanout Petroleum tank Public sewer service line WATER SAMPLE RESULTS: Coliform (2J/,, Nitrate ~ / z'z'~.~/ff Other bacteria ~ Date of sample: /0 '-/~f_~ - ~/ Collected by: ,.~,/'-/'_.~',/v~'/--g'.~;' /?~'~ B. SEPTIC/HOLDING TANK DATA Date installed ~ -/_~ ~ Tank size Cleanouts (Y/N) ~ Foundation cleanout (Y/N) High water alarm (Y/N) Date of pumping /'(-~ '-/~2 ~ ~/ Compartments IDepression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /~ Onadjacentlots t~'O (.~'u/'veq¢~:mi?t)Foundation To property line ~ ~ Absorption field ~8 ~7~/~g ~Water main/service line Surface water/drainage 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Manufacturer Size i~ ga Ions ~-~.~, Manhole/Access(Y/N) Vent (Y/N) "Pump-~,~CL~vel at "Pu_~p-~rff~el at High water alarm level ~ Meets MOA electrical codes (Y/N)____~ ~---~ SEPA/~DIS:~E"FROMRATION LIFT STATION TO: -Well--on lot On adjacent lots Surface water ....... --~-.-~ D, ABSORPTION FIELD DATA Date installed 6 Length ~'L?"' ,~3 Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating .?J~ System type ~ Gravel thickness ¢' ~ Total depth Cleanouts present (Y/N) Date of adequacy test .¢ -2/-~/ for ~ bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: //scok~{ /~o~ ~ , /f~col¢,c/ /,"~ml Well on lot ~¢O kZa~VOu ~'-~/t] On adjacent lots ~ (,J~da~'~J~roperty line To building foundation /~/(~,'vs~ ~-~//~o existing or abandoned system on lot On adjacent lots ~ Cutbank ~ Water main/service line Surface water ~ Driveway, parking/vehicle storage area ~0 Curtain drain E. ENGINEER'S CERTIFICATION ...... ~'?-~%'Z:~/",'~-','~.. . I certify that I have checked, verified, or conformed to all MOA and HAA gu~dehnes ~n ef~,.e.d~r~ t~edate of,,(hts inspection. Signature Date /'~ '/(,,' 91 ¢, HAA Fee $ // '7¢¢, ~ Date of Payment Receipt Number .,:><~ Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343 FAX:(907) 561-5301 ANALYSIS REPORT BY SAIdPLE fez WORKotdor$ 39205 Date Report Printed: OCT 14 9t @ 09:48 Client Sample ID:L22 E4 KASILOF HILL PWSID :UA Collects? OCT 10 91 ~ 12:30 hrs. Racoived~,~0CT i0 91~/i5:30 hrs. Preserved wiX~A~ REQUIRED Client Name :HENSLEE, STEVE Client Acct :HENSSC BPO { PO # NONE RECEIVED Ordered By :STEVE ]tENSLEE Analysis Completed :OCT 11 91 Send Reports to: Laboratory Superry~l~llEN C. EDE 1)HENSLEE, STEVE Released By :~~ ~ 2) Chemlab Ref ~: 915427 Lab Smpl ID: I Matrix: WATER Allowable Parameter Tested Result Units Method Limits NITRATE-N 4.i rng/1 EPA 353.2 lO Sample Remarks: ROUTINE SABLE COLLECTED BY: S. NENSLEE. Tests Performed ' Soo Special Instructions Above UA-Unavailable None Detected "See Sample Remarks Above Hot Analyzed LT-Lo8s Than, GT-Greator Than Member of the SGS Group <Soci0t0 Gbn~rale de Surveillance) LOT 22 lWO STORY HOUSE LEGEND: I 5/8" REBARR SET ~) FND O PLASTIC MONUMENF SET-~ FENCE- x-- x -- DVERHANG ~/OOD DECKS- CONCRETE- ASPHALT- EASEMENT LINE- SEPTIC STANDPIPES- WATER WELL- ELEV (DATUM ASSUMED)~ 3RDERED BY:I SAULA MOUNT JOY LAND & CONSTRUCTION SURVEYORS-PLANNERS-ENGINEERS 440 WEST BENSON BLVD. # 10,3 ANCHORAGE, ALASKA 99503 562--5291 (F)561-6626 ~RK CRDER NUMBER: 91-L 428 GRID NUMBER: 2541 LEGAL DESCRIPTION:I/~x ~ ____ ~ U I I~ F LOT 22, BLOCK 4, KASIL. OF HILLS Io~)~:T. 8. 199/ ISCAriOt'=40' EXCLUSION NOTE: It is the owners' responsibility ~ /~ to determine the existence of (]ny easements, covenonts, or restrictions which do not oppeor on _ / .... Ithe recorded subdivision plat. , Gentlemen: The following items are: Enclosecl Sent ~ via ( ) Ret~ort ( ) Sp,.eclfloation ( ) Cost Estlmate ( ) Progress Est. ( ) Tesl Result ( ) Blank Form ( ) Test Sample (,~) Other These data are submitted: ( ~X ) At your request ( ) For your aotlon ( ) For your approval ( X: ) For your flies ( ) For your review ( ) For your information General Remark,=: ~_.~.4-- z~.~ ~,a',~c w~'~'~ ~~~~. /r///a ~R~ O/~Eo w/~ m~. ~u~p ve~ truly yours, GO-4 00/68) OCT ~9 '91 11:17~M H~RDIMG L~WSOM ~SSOC ........... -' '±--p.~'~ ..... . ~\M · M Q R A N D U M TO: FRDM: SUBJECT: B, Hmnelee, 8KLH Conm~.~tm~%m~L Aastlof Hill~ 8ubd, Lot 88, Blook 4 Oh-site Potmblm Water Well 0,,~ 2 9 19,)l the ~vmnin8 of 88 October 1991w Mr Harper vmri~ies %he well meets current MOA guidelines and requipements~ Thm ~aslMg for the subjmot well b~d~ock for the fir~ 87 Feet below bhe ground surface ~hrou~h which thm was ~ivmn. A~ 87 fe~t ~he emsi~g ~et rm~umml and ~he well was ~¢: M~. Dave Harper, Alpine Drtllin8 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONf~NTAL HEALTH DEPARI?.~ENT OF HEALTH AND ENVIROB~,~ENTAL PROTECTION APPLICATION FOR }H~ALTI{ AUTHORITY APPROVAL CERTIFICATE 1. General Information (a) Legal Description (include lot, block, subdivision, section, to~mghip, range) Location (address or directions) (b) Applicants Name/-~-~fE_% /pz~w~_AD~g~z- Telej~hone - Home Applicants Address Bneineee (c) Applicant is (check one) Lending Institution Buyer ~ ; Other ~ (explain); (d) Lending Institution Address Owner/builder [~ ; Tel'e~ne (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: i . i,l,: (., 2. T~_p~ of Residence Single-Family ~ Number of Bedrooms Individual Well ~ Multi-Family~ Other (describe) Community~ Public~----~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. S__e,~a~e Disposal Onsite ~ Public ~ 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] .~Engineering Firm Providers ~nspections~ Test~s, File Se_aj.~_~_ Data and InformatiO~ [~'~ ~ system is in compliance ~th ~1 Municipal and State codes, ordinances, and regula-: tions in effect on the date of this inspection. Name of Fir~.~-C ~ , ~ ,' Telephone ~g.._ ~0 ~. Address~_:g 0 ~ DHEP Approval Approved for Approved ~ Disapproved Conditional Terms of Conditional Approval CAUTION Tt~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF I~ALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESEWf- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER HEGISTERE~ 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 FEDEIL4L A~D STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. ~ MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN %~iE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/DI8 [Page 2 of 2] 7-19-84 WELL DATA Well Classification Well Log P~esent ~N) Total Depth ZUNICIP~LIT~ Or ~CHO~GE (MOA) 786~, C: ~ 190 HEALTH A~ORITY ~PROV~ (H~) NO~3~ZO~d 3VIN]'>~NO~IAN~ CHECKLIST - FEBRU~Y 1984 ~ H~W~H ~O 'lda~ ]~V~OI-IDNV dO ~lWdlDlNg~ Legal Description: _~3~'Z'Z ~ . If A, B, or C, D.E.C. Approved(Y/N) ~/~ Date Co~leted ~ ~/~ ~ Yield Card to~ ~c~ ~ ~pth of Groutin~ ~x)A,'~ Static Water Level I~' Casing Height Above Ground Electrical Wiring in Conduit (~N) Separation Distances from Well: Pump Set At Sanitary Seal on Casing Depression A~oundWellhead (__Y~ To Septic/Holding Tank on Lot . I.c~51 ~'~ ; On Adjoining Lots . ~/O To Nearest Edge of Absorption Field on Lot j ~/~ t 21); On Adjoining Lots To Nearest Public Sewer Line _ /d/% To Nearest Public Sewer Cleanout/Manhole_ /~/i~ To Nearest Sewe~ Service Line on Lot ! Wate~ Sample Collected By Ji) (~_j ~ ; Date /$/~ ~//~ Water Sample Test P~sults Comments~K' ~S~D to /~£i)~oc~ I~-,( ~1 , f ~ ~ l o%.~ ~') &&~ ~ ~.s~ b~,~; >'),~',~ t o&~t~¢ B. SEPTIC/HOLDING TANK DATA Date Installed ~//S/~q- Size t,(DO~ No. of Compartments ~ Standpipes ) Air-tight CapstaN) Foundation Cleanout~N) Depression ove~ Ta~ ~Y~) ~te Last Pu~d ~/~ __ P~ing/Maintenan~ Contract on File (Y~)~/~. ; for ~ Holding Tank High-Wate~ Ala~ (Y/N) ~/~ ~rary Holding Tank Permit (Y~)~/7~ , / Separation Distance ~ ~ptic~olding Tank: To Water-Supply ~11/~~ ' ~'5 To ~o~rty ni~ ,.) ~ To %~ter Main/Se~vi~ Line ~/~ __To Building Foundation I~ I' To Disposal Field ~6~7 To Stream, Pond, Lake, or Major D~ainage [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Pating in Absorption Strata Date Installed 4/!_~/ ~- Width of Field I,.~ t Square Feet of Absorption Area Depression over Field .(Y~ Results of Last Adequacy Test ~6 U3 / Type of System Design Length of Field 3~ ~ Depth of Field ~t Gravel Bed Thickness ,.~ ' f; / Standpipes Present _~N) Date of Last Adequacy Test To Building Foundation Lot .~j/~- To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Conn~nts p~-~ lg B-~o~ r- ~,'.) /9~ F,'~o Separation Distance from Absorption Field: To Water-Supply Well ;~8~ To P~operty Line _, ~0 + /-6/ ~ ~') To Existing or Abandoned System on ; ~ Adjoining Lots ~ 3~ / ~7/t~ To Cutba~(if pre~nt) D. LIFT STATION i~ ~i r ~/~s Date Installed ' t Si~ in Gallons ~ MapJ~ole/Ac~e~s (Y/N) "Pump On" Level at xx~ "Pump/QfC" ~vel at__ High Water ~ ~vel at ,..~ / Vent (Y~) Tested for ~ __ ~~les during Adequa~ ~st. ~ets ~A Electrical Co~s (Y/N) / ~ CobaLts / ~ ** Check Per~tted ~dr~ Rating Against ~ ~quest I ~rtify that I have checked, verified, or ~nfor~d to all ~A ~ ~i~%ines in effect on the date of this ins~ction. ~'~ O[ ~%%% Signed ~ Date /~. 9 ~. KB1/d5/s '~m~ ~ / ~"~ ,z,~ ~% L~ C. Reid, Jr , ~;~%? 2-15-84