HomeMy WebLinkAboutSAND LAKE #2 BLK 7 LT 175and Loke
Block 7
Lot 17
#011-132-20
Heat. / and Environmental Protec~.)n
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
279-2511, x 224, 225
INSPECTION
LDCAT,ON ia
REPORT ONLSITE'£EWAGE DISPOFSAL SYSTEM
SEPTIC TANK:
DISTANCE
FROM WELL_ MANUFACTURER
INSIDE LENGTH_ ~ INSIDE WIDTH__ -------
NUMBER OF
MA'FERIAL ~'~ ~-/ COMPARTMENTS
LIQUID DEPTH ' LIQUID CAPACITY //(J~7~)GALLON5.
T-tLE D,,A, I
DISTANCE I':ROM WELL b~F~FOUNDATION__~3-- ~
9 of Lines _~_~ DISTANCE BETWEEN LINES
ABSORPTION AREA_~
DEPTIt: TOP OF TILE qO FINISH GRADE
SEEPAGE PIT:
Log Crib Rings
BUILDING FOUNDATION.
NEAREST LOT LINE__ I B/ TOTALOF LINELENGT~:~'% /
/-J//~__TRENCH WIDTH)__~__ IN. TOTAL EFFECTIVE
SQ. FT. LENGTH OF EACH LINE ~ /
DEPTH OF FILTER
,~ / MATERIAL BENEATH TILE__2~ IN. ABOVE TILE ~"/
IN,
DIAMETER _ OR WIDTH .... LENG'FH .., DEPTH
Crib Size :i DIAMETER___DEPTH_ , DISTANCE FROM: WELL I
TOTAL EFFECTIVE
NEAREST LOT LINE ABSORPTION AREA (wALL AREA)
SQ. FT.
Well ~;~9~ ~
Class: Depth:
Well Distance To: Lot Line
Bldg: Sewer Line:
Pipe Materials:
# of Bedrooms:
Installer: .j ,~ ,,,,~ Y. ,~
Remarks:
~ ~/*,~ ~ ~- ~ · ~,,~1~
~,/~
· %.~, WATER WELL LOG
FOSS DRILLING
1336 Ingra Street
Anchorage, Alack. 99%01 RECEIVED
I'NVIE~NMI:N I AL PK~I bg,.I I~lXl
NOV g1977
SIZE OF CARING ~ "DEFrH OF HOLE~4/~PTo
STATIC WATER LEVEL /~ FT. YIELD.~.~__GAL.PER.MIN. WITH
PEET OP DRAWDOWN.
REMARKS
DATE COMPLETED / D - / G ' ~ .'7
PUMP TO BE SET AT /~""~) !
PT ·
So P
to
PERFORMED FOR:
LEGAL DESCRIPTION:
)EPTH
FEET)
1
3
7
8
12
2O
COMMENTS
PERFORMED BY:
72-008 (7/76)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99502 276-2221
SOILS LOG- PERCOLATION TEST
[] PERCOLATION
TEST
7
DATE PERFORMED: "~ -- I ~¢- --"7 "7
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
FT AND
(minutes/inch)
FT
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
Parcel I.D.
GENERAL INFORMATION
Complete legal description I_ O
Location (site address or directions)
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FoRA SINGLE FAMILY DWELLING gElYSUE
Expiration Date: ~- ~" (::) ~
Current Property owner(s)
Mailing address
Lending agency
Day phone
Day phone.
Mailing address
Real Estate Agent
' lD'a~f phone
Mailing Address
Unless othe~vise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: .~
TYPE OF WATER SUPPLY: '
Individual Well [~
Individual Water Storage []
Community Class ~ Well [-I
Public Water System []
TYPE OF WASTEWATER DISPOSAL: ~
Individual On-site
Individual Holding tank []
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 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Ce~ficates of Health Authcdty 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. (Certificates may be reissued for a pedod 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~F INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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 wsstewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type cf structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Address ~o~ ~ )~ ~
Engineers Pdnted Name I ~ ~
5. DSD SIGNATURE
~ Approved for ~
Disapproved.
Conditional approval for
Phone
Date
· .~;~ ......... ·
~ ' ;',-'::?: '-.t ' ·
,.~..¢..~-~-,~ :... · ........ ST,~,.~.,
bedrooms. ;; .;v. '-~ .~.. ........ -. - · ,.~
bedrooms, with the follo~n~ ~tipulat[on~:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date: ~ - ~'- <~ ~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw SL
P.O, Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage, ek.us
(907) 343-7904
Legal Description:
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Well type ~
Date completed IO.t<.?~
Totel depth g~g fL
Date of test
Static water level
Well production
IfA, B. or C provide PWSID #
Sanita~/seal (Y/N)
FROM W~LL LOG
lo. i~ · "/~7
t'lrO g,p.m.
Well Log (Y/N) ~"/
Wires pmpedy protected (Y/N)
Casing height (above ground)
AT INSPECTION
g.p.m.
in.
WATER SAMPLE RESULTS:
Coliform ~ coloniss/100 mi. Nitrate ~1[..~ mg.fl.
Arsenic: mg./I. Date of sample:
SEPTIC/HOLDING TANK DATA
TankType/Materta, '~'?]~(;I g~-*/
Tanksize J~c~ gal. Number of Comparm~ents ~-
Foundation cleanout (Y/N) _,~ Depression over tank (Y/N)
Date of pumping II I ~-'2 ~ O ~ Pumper
Other bacteria ,LJ colonies/100 mi.
I
Date installed
Cleanouta (Y/N)
Pt/ High water alarm (Y/N)
C. ABSORPTION FIELD DATA
Date installed
Lengt~ '~ "7.-. ft. Widm --~ fL
Systam type "~"'/~-
Gravel below pipe
Totaldepth /cO ff. Eff. abeorpttonareaS~ft2 Monitodngtube ~'/ Depression ovor field ~/
Date of adequacy test For -~ bedrooms
Fluid depth In absorption field before test / in. Water added ~-~ ~'~al. New depth ! ~ in.
Elapsed TIme: o')-cO min. Finalfluiddepth /~ in. Absorpfionrate >= /-~/,~ C:) gp.d.
A~y rejuvenation treatment (past 12 mo.) (Y/N & type) J~'l If yes, give date I'//
D. UFT STATION
Date installed
'Pump on' level at in.
Datum
E. SEPARATION DISTANCES
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankJliff station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cteanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~ ~' Property line I D 1' Absorption field
Water main r~/A Water sewice line ~.~ ~ surface water
Wells on adjacent lots 1 ~ ~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~'
Water Service line ~- ,~ '~
Curtain drain ~'~ I O
Building foundation /'~ ~ Water main ~'~//%'
Surface water P-I I C~ Drtv~my, parting/vehicle storage
Wells on adjacent lots J 00 '~
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems ere in
conformance wfth MOA HAA guidelines in effect on this date,
Engineer's Printed Name t o~1,~
I
Date ?-~ a.~./ "~ I~ ~ ~-~J'L
HAA Fee $
Data of Payment.
Receipt Number
(Rev. 12~01).
Waiver Fee $
Data of Payment
Receipt Number
I~.Y-~3-~)2 CZ:28~1 FROg-CT,LE Efl',/It~I~HTAL SRV
r_._ C
'T&E ErrdronmefTl~l Services Inc.
9CTSEt5301
Cf& £ Rtl. It 1022873001
CI)enl ~ame To~b~n Spu~klnnd P.E.
P~et-t Nan~.'a 8316 Elad~¢o~
Oleat Sample ID 8316 Endicott
M~rtx Dr~ Water
Ordered By
I~WSID 0
Printed Date/Time 05/23/2002 11'.20
Cnlhs:led Date/Time 05/21/2002 8'.30
Rteelved Dnte/T~me 05/21/2002 17:00
TerknkM Dl~ectnr St ep~'~
R~I e~d By~
PQL Unl~ Mctl~d Limits D~tc 1~ Inlt
0.~00 U
0.200 mg/L I~pA ~00.0 (<101 05/21/02 JDT
'l'c~l Cohform 0
co!/lOOmL SMI8 922~B
05/21/02 KAP
MAY-Z3-02 C2:28~ FROI~I-CTAE EIIVIR~,bENTAt SRV
9CTSEIS~61 T-955 P,O~/e3 F-46~
I'_~ s,r~ Re~L~
Sand Invoi~
SAMPLE DATE:
SAMPLE TYPE:
~/~Routine
; '~ Repeat Sample
"- (referto lit] no..
[] Treated Water
~ Untreated Water
,,)
Method: ~embra~o FIWar
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.cLanchorage.ak.us
{907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
1.
GENERAL INFORMATION
Complete legal description ~
Location (site address or directions)
Current Property owner(s)
Mailing address
Lending agency
Expiration Date:
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Un/ess otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: .~
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
[] Public Sewer
The Municipality of Anchorage Deve!opment 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 of/)Jaska, Certificates of Health Authority Approval ere 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 fype of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage flies and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm I o b J~.~,,~ V ¢~.1. ~. 'i'~- I~- Phone ~-.-'7~ - ~ ~ / (~
Address ~ I~-~ H~
Date ~ ~0/~
Engineer's Printed Name
5. DSD SIGNATURE
~ Approved for
Disapproved.
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Cedificate Date: ! ,?.. ,-. / ~ - ~0 I
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Andlomge, AK 99519-6650
wvnv.ci.anchorage.ak.us
(SO?) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOT tl,
ParcellD: OI1,- I~-~l.)
WELL DATA
Well type [~
Date completed ID. I ~' 'TI
Toteldepth ~V~' ft*
Date of test
Static water level
Well production
If A, B, or C provide PWSID # ..
Cased iD .t'f~ ..
FROM WELL LOG
~o '~4.77
g.p.m.
Well Log (Y/N) ~/
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
g.p.m.
In.
WATER SAMPLE RESULTS:
Date of sample: % ~ I 3. ~ i
Other bacteria ~'~ ~) colonias/lO0 mi.
B. SEPTIC/HOLDINGTANK DATA
Tank Type/Material ~
Tank size I~'~"~ gal. Number of Cempadments ~
Foundation cleanout (Y/N) %/ Depression over tank (Y/N) I~
Date of pumping t~ ~..'1 II~' I Pumper
Date installed ~' ~' 7 '7
Cleanouts (Y/N) y
High water alarm (Y/N) ~
Co
ABSORPTION FIELD DATA
Date installed ~-~J "] '/
Length 5 ~-- ft.
Total depth ~ ff.
Date of adequacy test
Soil rating (g.p.d./fl2 ~ ~/bdrm) ! ~.~,
wiath .-5 ft.
System type
Gravel below pipe
Eft. absorption area ~..~_~ft2 Moniaxing tube .~ Depression over field
I(l~ll~, ( Results(Pass/Fall) "~ For :~7:) bedrcoms
Fluid depth in absorption field before test ' ~ in. Water addedT~gal. New depth J/~ in.
Elapsed Time: ~v~D min. Final fluid depth ~7 in. Absorption rate >= /~,~E:~ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type). ~ If yes, give date
D. UFT STATION
Date installed
'Pump on' level at in.
Datum
E. SEPARATION DISTANCES
'Pump o~ at in. ~tsr alarm lovel at
C~es tested /./' Meets alarm & dmult requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift stain on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
Off adjacent lots ~ 0'~ J'
On adjacent lots I0~ 4'
Public sewer manhole/deanout
H ding
,,%
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:.
Building foundation 4,¢5~ Property line I D ~ Absorption field
Water main r,l.~ Water service line ~- ,:~ ~' 8udace water
Wells on adjacent lots ~ ~ J~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line --L
Water Service line .,% ~_~
Curtain drain l"[I 0
Building foundation /-//t~ Wa~' main H/~c
Sun'ace water I',11 I~ Driveway, paddng/vehlde storage
Wells on adjacent lots 1L~¢:) ~'
F. COMMENTS
HAA Fee $ ~
Date of Payment
Receipt Number
(Rev. 1~)
ENGINEER'S CERTIFICATION ......, , . t. _ ~.
I~thatlha~dete~ln~thm~hfleldi~pe~e~ ' ~ .~?:~ : : ,~ '..'~,
review of Mun~l m~ ~at the a~ s~ am ~ ~, .~'~',.'-,' .?"~'*: '~ ~
Wa~er F~ $ //~ ~
Receipt Number J'~
T.SPURKLAND P.E.
203 W. 15th. AVE. SUITE 203
ANCItORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
Municipality of Anchorage
Development Services Department
On Site Water and Wastewater Program
4700 South Bragaw St.
Anchorage, Alaska 99519
December 13, 2001
Subject: Waiver Request
Lot 17, Block 7 Sand lake//2
PID # 011-132-20
Gentlemen;
We are applying for a lot line waiver for the septic system serving this lot The north end of the drain field is located
6 feet more or less from the north lot line This situation has existed for 25 years with no detrimental effects on the
adjacent lot.
T. Spurkl~//d P.E. \.
Municipality of Anchorage
Building Safety D~x'aston
P.O. Box 196650 * 4700 S. Bragaw Street
Anchorage, ~daska 99519-6650 * (907) 343-8301
h ttp:/]xc~vw.ci.anchoragc.ak.us
~cpartment o~
Public Works
Tobben Spurldand, PE
203 West 15th Avenue, Suite 203
Anchorage, AK 99501-
December 13, 2001
Subject: Waiver Request forSAND LAKE #2 BLK 7 LT 17
Waiver # WR010101 Lot Line Request for Parcel ID 011-132-20
Dear Engineer:
Your request for a waiver of the required 10 feet horizontal separation of the on-site wastewater
disposal system to the lot line has been approved. The approved separation distance is 6 feet.
This waiver approval applies to the current on-site wastewater disposal system and lot line
separation only. Any future upgrade to the on-site wastewater disposal system and lot line will
require all separation distances to be met or another waiver approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office at
343-4744.
Engineering Technician III
On-Site Water Quality Program
MUNICIPAUTY OF ANCHORAGE
.Department of Health & Human Services
On-Site Servlcee
WF~: 910101 PID~: 911-132-20
Date Received: 12.13-01
Legal Description: Sand Lake #2
Waiver Review Worksheet
I-IA~: 010632 Permit~:
BIk. 7 Lot 17
Engineer. Tobben SDurkland
203 We~t 15"~ Avenue. Suite 203
Applicant: ~
Anchoraae Ak, 99601
Waiver Requested: Absorotlon Field to Proeertv Line of 6 feet
Criteria: 1.
2. Special Conditions: .
3. Other:.
Geology
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
Points:
Total:
WaiverisGranted: J
Llst ConditionsorReesonsfor above:
Waiver is not Granted:
Date: I,~- /~-O /'
Re<~: 12-13-01 Amount: 1'16.00
Date Paid:
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
CERTIFICA-r:E OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ~)1[-
HAA #
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Day phone
Day phone
Mailing address
Address ~ 7. ¢ 0 ¢-. ¢ ~
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: --~
TYPE OF WATER SUPPLY:
Individual well ~
Community well
Public water
NOTE:
Day phone ~_.2 - /2.7_. ?-
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
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 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.
NameofFirm ~J¢,~-1 ~v-~-,-~¢~ ~'~
Address _ ~L~"~ ~ /. ~ ~'¢
Engineer's signature ~'-~ ~
Phone
DHHS SIGNATURE
/~ Approved for "7-'/'¢'rc~-~edrooms.
Disapproved.
Conditional approval for
Date
bedrooms, with the following stipulations:
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 a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72~25 (Rev. 1/91) Back MOA ~21
Legal Description:
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Parcel I.D. Oil-
A. WELL DATA
Well type "~
Log present (y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
ADEC water system number
Date completed [O- ~q. ~7'7 Driller
Cased to ~ ~ Casing height
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
Date of test [O' ~.c{. 7'7 b'/~ *?~
Static water level ] ).."~ //'7
Well flow /'t® g.p.m. 7
Pump level /SO '/~'O
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot [ 00
Absorption field on lot ~, ~ I.[
Public sewer main ~'~//A
Sewer service line ~' .~C)
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
Other bacterJa
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~F~ '?~l- '~7
Cleanouts (Y/N) y
Tank size J ~
Foundation cleanout (Y/N)
Compartments .,2.
Depression (Y/N) ~
High water alarm (Y/N)
Date of pumping '-~.,_~,~ ~ ~ ~ ~ 7_ Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot J~
To property line ~-~
Surface water/drainage
Alarm tested (Y/N) ~/~
Onadjacentlots .'>1~ Foundation
Absorption field ! O Water main/service line
72-026 (Rev, 7/91) Front
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
8, 31.77
Soil rating ! ~L5 System type
Gravel thickness ¢-~ Totat depth
Cleanouts presen~ (Y/N)
Date of adequacy test /¢ ' ,/~' ¢,,~---
for
If yes, give date __
Date installed
Length '~2.. Width
Total absorption area
Depressian over field (Y/N) N
Results (pass/fail) '"~
Peroxide treatment (past 12 months) (Y/N)
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot I I ~
To building foundation
On adjacent lots
Surface water
Curtain drain
¢.5
On adjacent lots /~ l(::~o Propertyline
To existing or abandoned system on lot
Cutbank ~'~¢-- 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 effect on the date of this inspection.
Signature
Engineer's Name
Date
HAA Fee $ /7
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number