HomeMy WebLinkAboutSKYHILLS PH 3 BLK 3 LT 305kyhills
Block 3
Lot 30
#011-122-62
Municipality of Anchorage Page t of 4
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section 825 'L' Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorageak.us (907) 343-.4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW010164 PID Number:. 011-122-62
The Petersen Group, Inc, Wastewater System: New
3820 Lake Otis Pkwy., Suite 204 Anch., AK 99508 ABSORPTION FIELD
562.1170 Four {4) Deep Trench
LEGAL DESCRIPTION 12 GP~e 12
3 30 Skyhills No. 3 5 F,. 7
0 ~,. 41
Well: Publlc Water 3 r,.
F~. ~,.574 re ASTM D3034 PVC
F, Sanders & Sanders 6/26/01
SEPARATION DISTANCES Ig septic D Holding D S.T.E.P. [] Othen
Tank Field Station Tank ~ [~e Anchorage Tank 1,250
w~ N/A NIA N/A NIA N/A Steel Two (2)
s~.w.,, ·100' ·100' N/A NIA ~ / LIFT STATION - NONE ON LOT
t~,~ >5' >10' NIA NIA
>5' ·10' N/A NIA
c~. ~. None Noted "~ ~ ~ ~ ~ ~"'*~'
n,~,,, BENCH MARK
Garage Floor Slab
Inspections performed by: MEA Dates: 1" 6/26/01
2"~ 6/26101
Department of Health and Human Services approval ~.C~-. CE.4381 .°
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Municipality of Anchorage
DEVELOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK 99519-6650 - 343.7904
On-Site Wastewater Disposal System or Well Inspection Report
Page 2 of 3
Permit Number SW010164
PID No. 011-122-62
THA '
/
FOUR
BEDROOM.
HOUSE
A B
Sl 13.5 15.9
S2 12.2 22.2
, C4 53.1 67.3
MI 53.4 67.6
C5 38.5 41.5
LOT 30
PLAN AS-BUILT
SCALE 1" =40'
· Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number:. SW010164
Page 3 of 3
PID No.: 011-122-62
n_ 13'
100.7~ ~ o
95.3-./
93.3
99.0
PROFILE AS-BUILT
Scole: 1" m 10'
MEMO
TO: Jeff Post
WITH:
MoA/Building Safety/On.Site Water & Wastewater Program
DATE:
FROM:
2119102
Mike Andemon~
SUBJECT:
Lot 30, Block s, Skyhill$ Subdivision No. 3
Septic System As-Built
Certificate of Health Authority Approval
MESSAGE:
The absorption trench serving the ssptic system on Lot 30, Block 3, Skyhills No. 3
was placed parallel with ths lot line to provide more room for the construction of
the house on the lot. The lot topography is virtually fiat in the area of the new
trench which would allow placement in either dirsction. We Inspected the area
prior to construction o! the trench and verified little or no drop over the surface of
the lot In the area of the absorption trench.
Please let me know if additional information is required before the Certificate of
Health Authority Approval can be issued.
1 "=40'
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SKYHILLS SUBD., PHASE ,3
LOT 30, BLOCK 3
40,041 S.F.
LOT 30
, AS-BU ILT
· ' JD'F A. OASTALDI, R~L$.
4726 WEST 881H AVE:NI,~
N~ICHORAGE, N.A~KA 99502
PHONE
2222 I/~1/20o2
F.8. ,JOB. NO.
01-08 . $i-rS3303
MUNICIPALITY OF ANCHORAGE
Development Sen/ices Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Jun 05, 2001
Expiration Date: Jun 05, 2002
Permit Number: SW010164
,Legal Description: SKYHILLS PH 3 BLK 3 LT 30
Design Engineer: 0014 Anderson Engineering
Owner Name: DAVID EIBECK
Owner Address: 8301 SKY MOUNTAIN CIRCLE
ANCHORAGE, AK 99516-
Parcel ID: 011-122-62
Site Address:
Lot Size: 40041 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
Ail construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastawater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By: ~
Issued By: ~
Date:
Data:
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 995196650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/VVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Permit Number SW O l O I g~t
Property owner(s) 1'he Petersen Group, Inc.
Mailing address (1) 3820 Lake Otis Parkway~ Suite 204 Anchorage~ AK 99508
...... :,-,§ address (2) 8~0] ~(Y ~OU~T/tI~ Cl~
Day phone 502.t170
Zip Code ~'~1~
Legal description (Lot, Block & Sub'd.) Lot 30, Block 3, Skyhills Subdivlslon No. 3
Legal description (Section, Township & Range)
Lot Size 40,041 SF
AcreslSq. Ft.
Number of Bedrooms Four (4)
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
[] Well Only
Water Storage
Jacuzzi
Water Softening Unit
I cedify that the above information is correct. I further cedifythat this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit Fees:
Date of Payment:
Receipt Number: '~,~)
(Rev. 12~00)
Waiver Fees:
Date of Payment:
Receipt Number:
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
MEMORANDUM
DATE: June 4, 2001
TO:
FROM:
Dan Roth
Mike Anderson, P.E~
SUBJECT:
Lot 30, Block 3, Skyhills No. 3
Septic System Design and Permit Application
I have revised the design for the proposed septic system for Lot 30, Block 3, Skyhills
No. 3 to reflect placement of the absorption trench beneath the fill and organic material
on the lot. Please review the revisions and if acceptable issue the permit for
construction of the new septic system.
May 14,2001
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject:
Lot 30, Block 3, Skyhills Subdivision No. 3
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:.
The owner of Lot 30, Block 3, Skyhills Subdivision No. 3 intends to place a new 4-
bedroom home on the lot. We are therefore applying for a permit to construct a new
septic system on the lot to serve the proposed home. The subdivision is Currently
served by the Municipal water system. The attached Site Plan and backup
documentation id .entify the location and configuration of the new septic system and the
parameters used n the des gn It also shows the location of the new water service line..
Also identified are the location of the test holes and the alternate septic site. Existing
drainage patterns are shown and will not be altered by the development of the lot.
Two test holes were placed on the lot during the fall of 1999. Soils were found to be
well to poorly graded sands with minor amounts of silt. Percolation tests in the material
indicated rates between 2 and 3 minutes per inch which is consistent with the rates
· achieved on the lots surrounding this lot. No groundwater was found during the
excavation and none was found during the monitoring period. We are therefore
proposing to place an absorption trench 40' long by 3' wide with a 7' effective depth to
treat the septic effluent. The distribution pipe will be placed at 5' below the surface for a
total depth of 12'. The trench will be placed under the fill and organic material on the lot
which extends to nearly 5' below the surface.
The ground surface on the lot slopes as shown on the attached Site Plan with slight
grades from we.s.t to east. A steep bluff is found at the easterly portio.n of the lot. The
septic system w~ll be constructed a minimum of 50' from the edge of th~s bluff. The new
absorption trench will be constructed parallel to the contours of the surface in
conformance with Municipal requirements. Grading will be accomplished to assure
surface drainage is away from the new trench. The existing drainage pattern on the lot
will not be affected during development.
If the system is constructed in accordance with our design the following statements
apply:
1. The system, if constructed as designed, will have no adverse impact on the wells
Lot 30, Block 3, Skyhills Subdivision No. 3
May 14, 2001
Page Two
in the area or those to be constructed in the future. The subdivision is currently
served by the Municipal water system.
2. The system, if c. onstructed as designed will have no.adverse impact on existing
septic systems in the area or those to be constructed m the future.
4.
Sincerely,
The system, If constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Michael E. Anderson, P.E.
Attachments
· 'N COURT ..... ..... "'-..
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4
:
5
42.401 sq. fL
7
SKY'HILLS
'10
40.182
33
31
40..350 ~q. fL
~8-3-A
28:'
N89'~3'28'£ 768.34'(R)
174,12' .... J
LOT 30, BLOCK 3, SKYHILLS SUBDIVISION
PHASE 3
~ Alterna
~O~/ THA
Line,,
THB
Four'
Bedrdom .
Home
NOTE:
Maintain 10' Separa[z~
Between Water Service
and Ail Components of Septic
System.
Depth
./
SITE PLAN
SCALE1"=40'
LOT 30, BLOCK 3, SKYHILLS SUBDIVISION NO. 3
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Four Bedroom Home
Perc. Rate: 2-3 Min./Inch
Application Rate: 1.2 GPD/SF
Deep Trench System
1,250 Gallon Septic Tank
7' Drain Field Rock
4 Bedrooms X 150 GPD 11.2 GPDISF = 500 SF of Absorption Area
500 SFI14SF/LF = 35.7 LF Trench Length
Therefore: Construct an Absorption Trench 40' in Length by 3' Wide With 7' of Drainfield
Rock Beneath the Distribution Lateral. Distribution Lateral to Be Placed 5' Below Existing
Ground. Total Depth of Trench to Be 12' from Existing Surface. Mound Over Trench if
Necessary to Provide Minimum Cover of 3'.
NOTE:
TYPICAL DEEP TRENCH SECTION _-"?~-Y.'"
-- (NO SCALE~ -- -- '~ ~ ~." 4
Grade Area ~er Trench to D~,n Away. ,'
.... ' ......
Minimum 6 Sepamtlo. From B~r~k. - '~~-~N ·
Mmlmum 10 Sepa~flon ~ro~ Lot Line. ~
Minimum 4' Se~tion From Groundwater.
Performed For:. Bob Klein
Legal Description: Lot 30. Block 3 Sk_v Hills Phase III
SLOPE
6
8
9
10
11
12
13
14
15
16
17
18
19
Fill Area
GM
Debris
· ,~; OF AL~:'
,-~/',~" ..... ;"~G','.
Munlclpah~
of
Ancho~ge
Depa~ment of Health & Human Sewices ~'.'~_[~7;E~ [ ~;O~,~" :~ ~
825 L S~t. Anchorage. AK 99502~650 ~ ~ .. CE - 4381 ..,~- ~
SOILS LOG - PERCO~ON TEST 4~. ~¢?.. .." %~ ~
Date Pedo~ed: ~ I~~
OG/PT
Fine Sand
Some Silt
Bottom of
Hole
No
SITE PLAN
2% - 5%
None
10110199
Was Groundwater
Encountered?
If Yet, What Depth?
SP Depth to Water
After Monitoring
Date:
Reading Date Gross Net Depth To Net
Time Time Water :Drop
I 29-Sap 13:06 .5"
2 13:16 10 3.5" 3"
3 13:17 .5"
4 13:27 10 3.5" 3"
5 13:28 - .25"
6 13:38 10 3.25' 3"
Parc. Rate: 3.3 MinJlnch Parc. Hole Diameter: 6"
Test Run Between 6 Ft. and 7 Ft.
Comments: Percolation Cavity Presoaked Prior to Testing.
Performed By: ~ I, MJ~3acLE-~3d~D~ Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 10/25/99
Performed For: Bob Klein
Legal Description: Lot 30. Bl~ck 3 Sky Hills. Phase I1!
SLOPE
........
~umc~pa.~ o~ anchorage ~ ~.~.~-
· Depa~ment of Health & Human Se~s
825 L Skit. Anchor~o.
SOILS LOG - PERCO~ON ~ST
Date Petered: ~/~~
S~E P~
1
11
12
13
14
15
16
17
18
Fill Area
GM
Debris
OG/PT
Fine Sand
Some Silt
SP
Was Groundwater
Encountered? No S
If Yet, What Depth? L
Depth to Water O
After Monitoring None P
Date: 10/10/99 E
2% - 5%
Reading Date Gross Net Depth To Net
Time Time I/Vater Drop
I 29-Sep 14:10 .5"
2 14:20 10 5.5" 5"
3 14:21 .5'
4 14:31 10 5.5" 5"
5 14:32 .25"
6 14:42 10 5.25' 5'
Bottom of
Hole
Perc. Rate: 2 Min./Inch Perc. Hole Diameter: 6"
Test Run Between 6 Ft. and 7 Ft.
' Comments: Percolation Cavity Presoaked Pdor to Testing.
Performed By: ~ I, ~ Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 10/25/99
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 30, BLOCK 3, SKYHILLS SUBDIVISION NO. 3
GENERAL:
The scope of lhis project includes the procurement and placement of a
new 1,250 gallon septic tank at the location shown on the site plan.
Work also includes the construction of a new 40' long X 3' wide X 7'
effective depth absorption trench at the location shown. The
distribution line in the trench will be placed at 5' below the existing
ground surface. Total depth of the trench will be 12' below the existing
ground surface. All components of the septic system must be placed a
minimum of 10' from the water service line to be constructed on the lot.
Construction shall be in accordance with the approved site plan,
design drawings, Municipal Permit with any special provisions or
conditions, and all applicable. State and Municipal Wastewater
Disposal Regulations.
The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the
location of all lot lines.
Unless specifically agreed otherwise, the contractor shall be
responsible for final grading areas subsequently depressed from soil
settling. Property owner shall be responsible for revegetation of
affected areas unless specifically agreed otherwise.
Contractors installing wastewater disposal systems must be certified
by the Municipal Department of Health and Human Services for
system installations. Owners installing their own systems must receive
pdor approval from D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
1. A new 1,250 gallon septic tank must be be procured from an approved
source and installed at the location shown.
A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4' cleanouts for pumping
access.
3. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
4. All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct
burial insulation.
A foundation cleanout shall be installed one to four feet from the
building foundation. Two cleanouts are required between the tank and
the drainfield.
* Lot 30, Block 3, Skyhills Subdivision No. 3
May 14, 2001
Page 2 of 3
7. Final grading over the tank shall be such that a positive slope exists
away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown on the
design. The bottom of the trench shall be within 2" of level.
Distribution piping must be placed level with perforations down atop a
level bed of drainfield rock. Rock should then be placed over the pipe
to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between the drainfield
rock and the natural soil backfill.
e
Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated.
Contractor shall verify the septic tank and drainfield are a minimum
100' away from any pdvate water wells in the area, 150' from a Class
'C" Well or 200' from any community well.
Direct bury insulation must be placed over the distribution system if
less than 3' of backfill depth is available. Finish grade over the trench
must be mounded to prevent settlement or depressions.
Grade area surrounding the absorption trenches to drain away.
A minimum 2' of accepting soil is required below the drainfield rock for
a 5' wide trench. Contractor shall verify this condition prior to
placement of the rock. All pockets of unacceptable materials must be
removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a municipally approved septic
tank manufacturer.
The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated
and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and
ASTM D2662 or A.B.S. (perforated and solid).
Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Femco, or equal).
'Lot 30, Block 3, Skyhills Subdivision No. 3
May 14, 2001
Page 3 of 3
5. A permeable geotextile fabdc (Typar, Mirafi or equ.a,I) must be installed
between the final drain rock layer and the native so~l layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing
the #200 sieve.
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These
inspections must be conducted under the supervision of a professional
engineer registered in the State of Alaska. The first inspection must be
conducted after the excavation of trenches, beds or pits and before the
installation of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement of the
geotextile fabric, gravel, distribution piping, standpipes, cleanouts and
insulation. No backfill should be in place at the rime'of'inspection.
Contractor shall provide a copy of all field survey layout and construction
notes for use in preparing the certified as-built of the completed system.
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 FAMILY DWELLING
Parcel I.D. 011.122.62
i.
Expiration Date: ~ o .~, O - O ?,
GENERAL INFORMATION
Complete lega! description Lot 30, Block 3, Skyhills Subdivision No. 3
Location (site address or directions) Sky Mountain Circle
Current Property owner(s) The Petersen Group, Inc.
Day phone 562.1170
Mailing address
3820 Lake Otis Parkway, Suite 204 Anchoraqe, AK 9
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested. HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
Four (4)
3. 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 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 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. Certificates of Health Authority Approval are
valid for 90 days frcm 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 seat affixed hereto and as of the vaIidation date shown below, I redly 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 vedfy that based on the information obtained from the
Municipalit7 of Anchorage files and from my investigation and inspection, the on-sita 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 Anderson En.qineerinq
Address P.O. Box 240773 Anchoraqe, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
5. DSD SIGNATURE
~ Approved for L.~
Disapproved.
Conditional approval for
bedrooms.
Phone 522.7773
Date 2/5/02
'. ~.~,. OF,..AI
~ ~7: , ~. ,-.'~ '
~;;&~.~ ..... .t....~ .....,.
~'. CE-~81 . :-~'
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 Certificate Date:
Bo
Legal Description:
WELL DATA
Well type
Date completed
Total depth
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(9O7) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Lot 30, Block 3, Sb/hill; Subdivision No. 3
If A, B, or C provide PWSID #
Sanitary seal (Y/N)
Cased to ft.
FROM WELL LOG
ParcellD: 011.122.62
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform colonies/100 mi.
Date of sample: -..
SEPTIC/HOLDING TANK DATA
Tank Type/Material Septi~;teel
Tank size 1,2~ gal.
Foundation cleanout (Y/N) Y
Date of pumping
ABSORPTION FIELD DATA
Date installed 6/26/2~1
Length 41
Total depth 12 ft.
Date of adequacy test
g.p.m.
We, Log (Y/Ni
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
in,
Nitrate mg/I.
Collected by:
gp.m.
Number of Compartments 2
Depression over tank (Y/N) _N.
Pumper N/A
Other bacteria
colonies/100 mi.
Fluid depth in absorption field before test __ in.
Elapsed Time: __ min. Final fluid depth __
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Date installed 6/26/200t
Cleanouts (Y/N) Y
High water alarm (Y/N) N
Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 GPD/SF System type Deep Trench
ft. Width 3 ft. Gravel below pipe. 7
Eft. absorption area 574 ft2 Monitoring tube Y Depression over field N
Results (Pass/Fail)
Water added gal.
~n. Absorption rate >=
N If yes, give date
For bedrooms
New depth in.
gp.d.
D. LIFT STATION
Date installed
'Pump on" level at __ in.
Datum
E. SEPARATION DISTANCES
Size in gallons
'Puml~ o~ level at
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanldlift station on lot NIA
Absorption field on lot N/A
Public sewer main N/A
Sewer/septic service line N/A
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
On adjacent lots N/A
On adjacent lots
Public sewer manhole/cleanout N/A
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5'
Water main >10'
Property line >5'
Water service line >10'
Absorption field >5'
Surface water >t00.
Wells on adjacent lots >100.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
.. Property line >10'
Water Service line >10'
Building foundation >10'
Surface water >100'
Water main >1~
Ddveway, parking/vehicle sto~age >25'
Cuffain drain Npn~ Noted
Wells on adjacent lots >100.
F. COMMENTS
Lot is served by AWWU wp~ system.
G. ENGINEER'S CERTIFICATION
I certF~y that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Michael I~. Andemon, P.E.
Date 2/~2~2
Data of Payment
Receipt Number / ~ 7 b ~' ~ ~,
(Rev. 12/00)
Date of Payment
Receipt Number