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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
I C~%N E W
MAILING ADDRESS
Z.q ~S" X?~,~..,"J Ro"-~.-
LEGAL DESCRIPTION
LOCATION
I Well [ Absorption area ~..O I Dwelling
DISTANCE TO: //~
Manufacturer ~'~ ~'/' I Material
WiDth
NO. OF BEDROOMS ~
PERMIT NO. fl~&~3J~,,,,
No. of compartments
Liq. capacityj 2-5-oin gallons WellIF HOMEMADE: Inside length Liquid depth
DISTANCE TO: Dwelling PERMIT NO.
Manufacturer Liquid capacity in gallons
Foundation
Total length 'nas
Material beneath the
Material
Nearest lot line /~
~ ~nches
DISTANCE TO: Well
No.o,,in
Top of tile to finish grade
Length W~dth
Type of crib C[ib diameter
Well
DISTANCE TO:
Class Depth
DISTANCE TO: Building foundation
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSIALLER
Depth
REMARKS
DATE
inches
PERMIT NO.
72-013 (Rev. 3/78)
Total eifective absorption area
/ '~'"p 7.-
PERMIT NO.
Crib depth TotaJ effective absorption area
Building foundation Nearest lot line
Driller Distance to lot line
Sewer line
Sebb. .n,,
LEGAL
AMUNICIPALITY OF A. NCHORAGE_
Department' 'f Health and Environmente'-%Protection
· ~ 825 ~ Street, Anchorage, AK. ~9501
: " 264-4720
'. /..-...~ i.,-~- ~*- ~ H~WRITTEN PERMIT ~ ' ~
Applic~t: ;~.~ ...... r_ ..~ ailing Address~,/~XJ~M ~
Location, "-'F'-'- f .~ ~L~one Numar: ~
Legal Description, L ~ ~--~~,/S ~. Lot Size: "
Type of Soil Absorption System.Is:
Trench: Drainfield: ~ Seepage Beds ~ Holding Tank:
Maximum Number of Bedrooms: ~ Soil mating(sq.ft/br)
The Required Size of the Soil Absorption System Is: ·
DEPTN C,
LENGTH ,~ GRAVEL DEPTH WIDTH
The length dimension is the length(in feet) of the trench or 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 minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
' ' REQUIRED SEPTIC(HOLDING) TANK SIZE
Permit applicant has the responsibility to inform ~his department during the
installation inspections of any wells adjacent to this property and th~ number
of residences that the well will serve.
~ ' ~ TWO(2) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection.and approval by this departmer
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 re(
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 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 '
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will instaI1 the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
· . the residence--is ~emodeled to include more that/Shbedrooms.
S lgne~ .~_/~.~ Issued by: ~~ ~
MUNICIPALITY OF ANCHORAGE
...~,-.. Department~'~825~ ' Street,Health andAnchorage,Environmenta~--~rotectionAK, ~.3501 ~'
-' 264-4720
Per'it $ ~~ * * * HANDWRITTEN PERMIT '* * *
~ON-SITE SEWER PERMIT ~?~.
Location: Phone Number: =~ 7~- 7 ~-~./
Legal Description: LF~~~_ ~ Lot Size:
Type of Soil Absorption. System Is: / t~ '
Trench: Dramnf~eld: _ Seepage Be~!. ~ / Holding Tank:
Maximum Number of Bedrooms: .~ Soit~tzng(sq/ft/br) /~
The Required S~ze of the~oil ~sorpti~n System Is: '
The length dlmens~on i~ t~e length(~n fe~t) of ~e_ trench or dra~nf~eld. The
depth of a trench or p~t ~s t~e ~stance ~etween'the surface of the ground and
the bottom of the.excavatmon(~n ~et).. There is no set w~dth for trenches.
The gravel depth ms the minim.um tepth Of gr~vel between the outfall pipe and
the bottom of the excavation(~n ' ~ ~
. * *.REQUIRE~ TANK IZE = ~ GALLONS * *
Permzt app. lzca. nt he,the responsibi ,ty t~ Snform this department during the
instal.lat~on ~nspect~ons of any wel ~adj~ ~nt to this property and the nun~er
of resmdences that t~ well F' 1 serve ·
.th.~. i~ e~ J ***
. . ' '.¥ TWO(2)"[N,SPECTIO] ARE REQUIRED
Backfzll~ng of any sys~.~m withoUtflnal inspection .and approval by this department
wi.ll be subjec~ to p~os~e~tion. ~
Minimum d. istance between a~well and a%y on-site sewage disposal.system is 100 feet
for a private well .or.150 .~ 200 feet ~rom a.public well depend, zng upon the.type
of public well. Minimum d..l~tance f.ro.m~a.private well to a private sewer line
is 25 feet and to a.c.omm.u.n.it~sewer lin~ is 7.5 feet. Well logs are requir.ed
and must be returned to this d~partm, e.n.t ?.ithin 30 days of t. he w.ell completion.
Other requirements may apply. ~pecifica~ons and construction d~agrams are
available to insure proper instigation/
· * * * PERMIT EXP"IRE'f' DECEMBER 31, 1 9 8 3 * * *
I certify that:
(1) I am familia~ with the requirements for on-site sewers and wells as
(2)
(3)
SigneR:
SWP/024 (1/81) electrical permit and Inspection must be
obtained. As-builts cannot be approved un-
til the electrical Inspection is received In this
office. The electrical work must be per-
formed by a licensed electrician."
set forth by the Municipality of Anchorage.
I will install the system in accordance with codes.
I understand t.hat the on-site sewer system may re.~uire enlargement if
the residence ~s remodeled to include more th~~s.
~ Issued by:
Applicant
Date: .
"In the event that a lift station Is Installed an
PERFORMED FOR:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 ~L, Street, Ancho~'lge, Alaska 9950l 2644720
SOILS LOG - PERCOLATION TEST
DATE PERFORMED:
SOILS LOG
PERCOLATION
TEST
~/3o/~
4
5
W/$O/','1¢ 6R,,~V~L. TRACE;
SLOPE
1
11
13-
BLoc,~ [g
SITE PLAN
Iii I I"-F~°I' I [11 I
~;J:~,l! I I I I I I ~1 ~t
I', I b,l~ ~1~ I, I1~1
IIIIlllllll
WAS GROUND WATER
ENCOUNTERED? ~/~- SL
IF YES. AT WHAT
DEPTH?
14-
15-
16-
17-
18-
19-
I01tN [. SWRNSON.~
Time Time
Depth to
Water
Net
Drop
20-
PERCOLATION RATE V
· TEST RUN BETWEEN ~ FT AND ~ FT
Box 1369, STAR I~OUTE A ANcHoRAGE, ALASKA 99502
344-?~'14
SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF
DRILLED AT THE RATE OF ~ PER FOOT.
~. & /~; ~. Z~ ;Oa~Oa 349-3790
PROPERTY OWNER
LOCATION OF WELL SIT
DRILLER Be.tn.~ C~
WELL LOG:
205 )%eZ
22---68'
68--122'
122-176'
3/4 t{o,t,~e l'u,,~.p. ,~h.ou.,Lfl, I~e.~..~, ,be ~ 04. 175 ,fit.
Co,~t o~ ~),,,,L,I.4X/~: $23.00 p,e,t. ~ X .205 ,fi~.: ~4715.00
good ,~.~e,u~e
H0tDato~ WtN~NNO~IINq~
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLE'rlON OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF ~4715.00
THANK YOU VERY MUCH.
DATF Se.p,,t ~.3-t~, 1984
SERVICE CHARGEOF lY.% PER MONTH WILL BE ASSESSED ON PAST DUE:ACCOUNTS.
BERNIE CLAUS OF RAMPART DRILLING WORKS
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
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner '~'~"'
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone ~.~¢-
/~/Jc/4 , /rl~t
Day phone
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.
4. TYPE OFWASTEWATER DISPOSAL:
NOTE:
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.
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.
Name of Firm C-~,-.~-lr,-uc.-t-~, ~,,5'_ ,,-,~<. Phone
Address (:~:~o! ~ ~~ ' ~
Engineefssignature /~~~ Date 2'~'
DHHS SIGNATURE
,.~ _ Approved for .~. bedrooms.
Disapproved.
Conditional approval for
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 DH HS 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.
Permit No.
Page I of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 e'Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description:
I~ ~,'1"~
LoW I&
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L ~ I~ -r'.=~l.~ ~-'~t..~u~ Parcel I.D.
A. WELL DATA
Well type Pr~,~'~(~, If A, B, or C, attach ADEC letter·
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date completed
?_o5'
Cased to
ADEC water system number
Casing heig'ht
Wires properly protected (Y/N)
FROM WELL LOG
Date of test ~-.~4
Static water level ' (;.$' ' '
Well flow ~
pump level 1'7.~ ~ .~
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot 4-I,co'
Absorption field on lot .I- too~
Public sewer main /'/J"'
Sewer service line · 7S'
AT INSPECTION
,~.~,t.'~Z MUNICIPALII~ OF ANCHORAGE
7-i¢~'[7,OiIMENTAL SEI;~VICES DIVISION
~,.
RECEIVED
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
g.p.m.
~A
· Petroleum tank
WATER SAMPLE RESULTS:
coliform, ~ Nitrate
Date of sample: g-Z,o-'9 ~.
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date Installed 9- ~ z~,Sd- Tank size
Cleanouts (Y/N) ¥ Foundation cleanout (Y/N)
High water alarm (Y/N)
Date of pumping
Compartments
~ ~ Depression (Y/N)
Alarm tested (Y/N).
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot -t- too' On adjacent lots + ~ c)o ' Foundation·
To property line ~ZO~ Absorption field ~ ~ Water main/service line
Surface water/drainage ~ ~00'
72-026 (Rev. 7/91) Fm~l
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
': * ' Mariufacturer
. , . ,- ... ·; · , - '/A~,.~o~.~oo °~)~-" ,
Size in gallons . ' ~Manl~01e (y/N ~ 7- ~..
., ,,....-- · / ,..,./'..;= ..', '..~,
Vent (Y/N) - ' 'Pump on" level at "Pump off" Ira}el at
High water alarm level ~ . Cycles tested
Meets MOA electrical codes (Y/N)
,SEPARATION I N IFTsTATIC~N TO:
Well on lot
D. ABSORPTION FIELD DATA
Date installed ~'IZ "~
'Length'" :5"~ -/'~i'dth'
Total absorption area' I Z.'7 ~ $C' ""
Depr[ession ove.r field (Y/N)
U3 Y I:.~-i.:.'~ .',~.
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
On adjacent lots Surface'water
Sell ratin' g I~ ' ' ~/ System ~pe~
Gravelthickness ~ ~ ' Totaldepth ~.O
C'~an°u~esPin'~Y/N) .~
/for ' "' ' ' ~ ~
Results (pass/fail) ~/~.~;~ ~ bedrooms
Peroxide treatment (past 12 months) (Y/N) /'J / If yes. give dat~ : ~
Wellon lot *1~ On adja~t lots *'~ Prop~.yline & ~ :
To building foundation . ~ / To existing or abandoned system on lot ~
b ~ Water main/se~ice line
On adjacentlots +~o' ank
~ DrivewaY~ parking/vehicle storag~area ~ ~* ' '
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
Signature
Enginee?. Name ~--cl,~' ~°~-'3 b'O"~r"'"'"l:) '/
Waiver Fee: $
Date of Payment
Receipt Number
HA,~ Fee $ /~"~ '"'~"~'
Date of Payment ~'.-~/' -'q ~
ReceiptNumbe, °'~.~7 ~.Z7/~)
EASEMENT
The Grantors, Daniel W. Beardsley and Mary Ellen Beardsley,
Husband and Wife, ~hose address 11480 Bro~der Avenue, Anchorage,
Alaska 99516, for and in consideration of mutual benenfits do hereby
convey and ur arrant to Daniel W. Beardsley and Mary Ellen Beardsley,
Husband and Wife, whose address is 11480 Browder Avenue, Anchorage,
Alaska, an easement for septic system purposes upon, over and across
the following described land ounned by Grantors within the Anchorage,
Recording District, Third Judicial District, State of Alaska, to wit:
Lot Three (3), Block Eight (8), of TRAILS END SUBDIVISION, according
to Plat P-604, filed in the Anchorage Recording District, Third
Judicial District, State of Alaska.
PROPERTY BENEFITTED BY THE EASF~IENT. The easement shall be
appurtenant to and for the benefit of the following described real
property:
.Lot Eight (8), Block Eight (8), of TRAILS END SUBDIVISION,
according to Plat P-604, filed in the Anchorage Recording
District, Third Judicial District, State of Alaska.
GRANTEE'S RIGHT TO USE. The Grantee shall have the right
to use the easement for construction, operation, maintenance and
r~pair of a septic system for the benefit of Lot 8.
IN WITNESS ~HEREOF,
this ~%~J~day of October, 1992.
Grantors have signed this easement
RECEIVED
HARY//ELLEN BEARDSLEY, GRAntOR
OOT 2 7 1992
Municipality of Anchorage
Dept. Health & Human Services
ACKNOt[/LEDG)IENT
STATE OF ALASKA )
)
THIRD JUDICIAL DISTRICT )
z
THIS IS TO CERTIFY that on the Y day of October, 1992, before
me the undersisned, a Notary Public in and for the State of
Alaska, personnally appeared Daniel ~. Beardsley and Mary Ellen
Beardsley, knoura to me to be the inde~ntical persons who ~
executed the foresoins Easement and they acknowledsed to me that
they sisned the same as their free and voluntary act and deed,
with full kno~ledse of its contents, for the uses and purposes
.therein mentioned.
IN WITNESS~HEREOF,
affixedd my official seal
I have hereunto set mu hand and
the day and ~ear above written.
My Cc~ ~ission Expires:~--//~/~"
RECEIVED
OCT 2 7 1992
Municipality of Anchorage
Dept. Health & Human Services
ENCROACHMENT AGREEMENT
1203-24A
Grid 2641
THIS AGREEMENT, made and entered into this day of
__, 1992, by and between CHUGACH ELECTRIC ASSOCI~-~ION, INC.,
an Alaska non-profit electric cooperative membership corporation
of Anchorage, Alaska, hereinafter called "First Party" and
Daniel and Mary Ellen Beardsley of Anchorage, Alaska, hereinafter
called "Second Party", WITNESSET}! THAT:
W~EREAS, First Party occupies an easement on the
east side'6f. Lot Three (3), and the west side of Lot Eight (8),
Block Eight (8), Trails End Subdivision, Anchorage Recording
District, Alaska; and
WHEREAS, Second Party proposes to install a septic
system line across the easements as shown on attached Exhibit
"A", an plot plan of said Lots Three and Eight (3&8), Block Eight
(8).
NOW, THEREFORE, for and in consideration of their
mutual agreements and other good and valuable consideration, the
receipt of which is hereby acknowledged, First Party, for itself,
its successors and assigns, waives its objections to Second
Party's encroachment on the said easement for the purpose
mentioned, subject to the following conditions:
1. Second Party will hold First
liability for any injury or damage to any
which may result from such encroachment.
Party harmless from
person or property
2. The said encroachment will be without prejudice to
First Party's full enjoyment of any and all rights it may have in
and to such easement.
3. Any facilities or property of First Party which
are damaged or destroyed as a result of such encroachment will be
repaired or replaced at no cost to First Party.
4. Second Pgrty will comply with all applicable
RECEIVED '
OOT 2 ~ 1992
Municipality ot ~mc~orage
Dept. Hqalth & Hum.an Servic. e~
HgNICIPALITY OF A~CHORAGE
DM$ION OF ENVIRONMENTAL ~EALTIt ~'
DEPARTI~.NT OF HEALTH AND ENVIROB~ENTAL PROTECTION
"A~T~ICATIOe FOE ~TE AUT~0alTY APrAOVAL CERTIFICATE
lm~omatiou Application Da~e .1-/2.~/~ ~ '
Description (include loc, block, subdivision, section, township, range) .; .
· - .(e)
"Location (address or directions)
_.. 3q%~tl'71
-- (b) Applicants Name~ ~ ..Jo6n$~,-, 'L-exepeoue -some Business 5¥~ /~'~1
Applicants Address
' ' (c) Applicant )is (check;~ne) Lending Xnstitution ~; Owner/builder ~;
'- ......... 4 .~ '?,':"2' ',¢~
Le~i~ InscicuCi~h ' '1 ~/
.....
~d4ess -
Address
Telephon~ ~ ~
Hail the HAA to the following address:
2.:Type of Residence
Single-F~ntlyF'~
'Number of Bedrooms
~atar Supply
Individual Well~r~
Hulti-F~m!!y ~
Other ,(describe)
CommuniLT~--~ Public~--~
Note: l~ community ~a~ll system, must have written confirmation from the State
,. '.Department of Enviroomental Conservation attesting to the legality and status.
.'4;' ~ewa~e Disposal
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the lesality and status.
[Page 1 of 2]
. $~ Ensineertn8 Firm Providing Inspections, T~sts1 File Searchl Data and Tnformat~on
~.: . i..cerCi£ied by my seal affixed hereto ~n~ as of the validation date sho~u below, I
[ . . verify that my Investigation of this Health Authori~y Approval aheva ~ha~ ~he on-site
' '" water supply and/or ~mstewater disposal aystem is safe, funcCiona/ and adequata for
~. , ~he number of bedrooms and ~ype of structure indicated herein.. ! further verify that~
. .. b~Sed on the ~nforma~ion obtained from the Fanicipali~y of Anchorage files and fro~ my.
~- ' investi~a~/on and inspection, the on-s~e ~ter supply and/or ~ms~ewater disposal
,~ syscom is in compliance vlth all Hun~cipal ~na State codes, ordinances, and resula-'
tions in effect on the date of th~s inspection.
Telephone
. Ter~ of Conditional Approval
CAUTION
TEE fIDNICIPALITY OF ANCHOP. AGE DEPAR~IENT OF HEALTH AND E.N~IRO,NM~ITLa. L PROTEC~ION
(DEEP) ISSUES HEALTH AUTHORITY API~OVAL CEI~TIFICATES BASED SOLELY UPON IH~- REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT I~OFESSIONAL ENGIL'EEit REGISTERED
IN T~ STATE OF ALASKA. ~il~ I~EP DOES THIS AS A COURTESY TO PURCHASERS OF EOHBS
THEIR LENDING IITSTITUTION~ IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
HENTS. t2tI~LOYEES OF IltEP DO NOT CONDUCT INSPECTIOI~ OR ARALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE HUNICIPALITY OF AI~CHORACE IS NOT RESPONSIBLE FOR ERRORS
O~ CItIS$IOFS IN THE PROFESSIONAL F. NGINEER~S
(DHEP SEAL)
off 2]
7-19-84
WELL DATA
~."~ ~JNIcIPAUp( OF
AN~HOP. AGE
DEPT. OF H~ &
Legal Description: ~/Is ~ ~ - ' ~
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classification If A. B. C. D.E.C. Approved (Y/N)
Well Log Present~'Y~) ~'-~ Date Completed ,,~.p*~ 23 /? E,Y Yield
Total Depth 20."' ' Cased to ~ Depth of Grouting ~/.4
Static Water Level " '-' ' ' ~'
/vA
/ ~o G /'/-/
Casing Height Above Ground
Electrical Wiring in Conduit~N)
Separation Distances from Well:
To Septic/Holding Tank on Lot'
Pump Set At /',,*~,~,'~' /~-~' -
Sanitary Seal on Casing~lN) ~e ¢
Depression Around Wellhead (Y(~ '~ ~
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot. /Of" ; On Adjoining Lots /'~ ~'~
To Nearest Public Sewer Line /v',4 To Nearest Public Sewer
Cleanout/Manhole A/4 To Nearest Sewer Service Line on Lot
Water Sample Collected by ,"~,~'{,.,'~',' ~,.e,'/ & P"'I/' ; Date .~- - / - ~5'
Water Sample Test Results &'.'1~'.~"~¢'~',~
Comments
B. SEPTIC/HOLDINGTANK DATA
Date Installed .~pf /2./~ Size
Standpipes~) ~¢$~'~ Air-tightCaps~N)
Depression over Tank (Y/~/
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course ~o~ ~ ~
/Z $-'o No. of Compartments
Foundation Cleanou,}~N)
$
Date Last Pumped
4/,4 ; for
Temporary Holding Tank Permit
To Building Foundation /o /Ct,'
To Disposal Field mc, ·
To Stream. Pond. Lake, or Major Drainage
Comments
Page I of 2
72-026(11~84)
C- ABSORPTION FIELD DATA
~,~oP~y o~ ~c~o~
~PT. OF H~L~ &
k AY g
Ty~ of System Design ~'~
Lenglh of Field ~ 3 '~
~plh of Field ~ ~ /
Gravel ~ Thickne~ /~"
Standpi~ Pr~en~N) ~
Dale of L~t Ad~uacy Test ~ ~
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area 72
Depression over Field (Y/~
Results of Last AdequacyVTest
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation 2.
Lot /V' A
To Water Main/Service Line /0
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line I )- ~'
To Existing or Abandoned System on
; On Adjoining Lots ~0~'~'
To Cutbank (if present) A/,t
D. LIFT STATION
"Pump On' Level at
High Water Alarm Level at / ~Ve~Y/N)
Tested for _ ..~'~/ pump~n~~~d~uacy Test. Meets MOA
Electrical Codes (Y/N)
Comments ~ ~"~'~"'"~
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~'~'"'~ ,Z~.~',_ ~ Date 5--// '~' 2 / ~ ~
Company ~ ~E~ MOANo. 5T ~5- o~
Engineer's Seal