HomeMy WebLinkAboutEAGLE PARK BLK 3 LT 2Eagl Pork Block 3 Lot 2 #050- 782-16 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://Www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201156 Work Type: SepticTank Upgrade Tax Code Number: 05078216000 Site Legal Address: EAGLE PARK BLK 3 LT 2 G:0056 Site Mailing Address: 20718 MELODY LN, Eagle River Owner: RIVERA LOURDES M & Design Engineer: NORTH RIM ENGINEERING This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft: Total Bedrooms: ��cnr `0: Departmenr 618/2020 6/8/2021 W01r10 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall 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 Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: __ 4 �e 6/8/20 Date: Date: rd rd MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTICIWELL PERMIT APPLICATION Parcel I.D. 050-782-16 Property owner(s) MURRAY DAVID Mailing address 20718 Melody Ln Site address same Day phone 980-6232 Legal description (Sub'd., Block & Lot) EAGLE PARK BLK 3 LT 2 Legal description (Township, Range & Section) Lot Size 39,975 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) El � (w/wo ADU) Septic Tank 0 Upgrade El Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: ' Distance: I certify that the above information is correct. 1 further certify that this Js in accordance .with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees:o� oZfJ / I g• �"J� Waiver Fees: Date of Payment: ( ' lew ;16 Date of Payment: Receipt Number:��[ ?3 D Receipt Number: Permit No. 0SP a a 1 i5-% Waiver No. r. GADevelopment Services\Building Safety\On Site Water and Wastewater\FormslClient FoMQYJA, �?plicafion.doc 25% DISCOUNT APPLIED SteveEng.com Steve Eng, PE, PH 907-694-7028 SteveEngPE@gmail.com Date: 6/4/20 Number of Pages: To: MOA On-Site Services Subject: Eagle Park Block 3 Lot 2 Septic Tank Failure The subject septic tank has failed- a new tank will replace the old one. The existing seepage trench appears to be working OK. Please issue a permit so the tank can be replaced. Please review as soon as possible. This is a large lot with no nearby neighbor conflicts. If there is need for additional information or clarification please give me a call. Thanks-Steve Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201156, Rebecca Carroll, 06/08/20 Eagle Park Block 3 Lot 2 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: The current septic tank has failed- the seepage trench still functions. This lot is over an acre. No adverse impacts are expected from tank replacement. The easements are depicted on the lot. The slope is indicated in the area of the septic system. No conflicts to neighbor properties. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations.  New 2- compartment, 1250 gallon septic tank. Watertight couplings on inlet & outlet.  5 minimum between the tank and trench. 5 to property lines & 10 to house.  4 of cover or insulation is required for tank; an equivalent of 1 insulation for 1 foot soil cover. Tank & solid pipe must be set on well compacted, stable soil.  No large rocks for tank bedding. Plastic/fiberglass tanks require special bedding per MOA- sand or pea gravel.  4 diameter cleanouts with airtight caps are required 1 to 4 from foundation wall, prior to any 90 degree bend in 4 inch line, in each tank compartment, and two adjacent opposing cleanouts between the tank and the absorption field, not more than 10 from the tank positioned to provide cleanout access towards the tank and towards the absorption field.  All cleanouts must extend to at least ground level.  In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.  Insulation must be placed over any pipe installed under driveways or parking areas.  Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661,  Sewer Service Line is minimum 2% slope.  Septic Tank to be pumped every two years or when required.  Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201156, Rebecca Carroll, 06/08/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201156, Rebecca Carroll, 06/08/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201156, Rebecca Carroll, 06/08/20 t DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 2~720 ~ ON~ITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME P ONE ~ EW ~ O~ DISTANCE TO: Wel: l ~ OweUin. PERMIT NO, ~ DISTANCE TO: Well/~O Foun~ -- ~ ~Pth PERMI$ . . Clas~ ( ~ ~ :~ Driller Distance to lot Ira. PERMIT NO. ~ DISTANCE TO: Building foundation ~ewer line Septic tank Absorption area(s) Permit # Applicant: ..~UNICIPALITY OF ANCHORAGE Department .~ ~ Health and Environmental"~rotection 825 L Street, Anchorage, AK. ~501 264-4720 * * * HANDWRITTEN PERMIT * * * WELL AND~ ON-SITE SEWER PERMIT Location: ~., ,~;;~.,_' Phone Number: ~.~.~ Type of Soil Absor~pti. on.System !~: -- Trench: I/Dra~nf~eld: Seepage Bed ~ Holding Tank: Maximum Number of Bedrooms: Soil Rating(sq.ft/br) c~/~g,~' The Required Size of the Soil Absorption System Is:' DEPTH //',~' LENGTH //g . GRAVEL DEPTH Z./,~' 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 = , /~"5-~ GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection.and approval by this departmen' will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee' 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 DECEtCBER 31, 1 9 8 3 * * * I certify that:' (1) I am familiar with the requirements for on-sit~ sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand t~at the on-site sewer system may ~equir~ enlargement if , the residence Ks remodeled to include more tha~ ~ bedrooms. S igne~:~/~,~/~/~-~~ Issued by ~ o ~y3~ ~ / pncant' . - --© - Date. ~"/' >" / ~'/~',.,~ · SWP/024(1/81) SOILS LOG , MUNICIPALITY OF ANCHORAGE j~/ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST SOILS LOG - PERCOLATION~ PE.PORMEDPO* ~×cnt~nq, ~-nq~ee~ t~-OATEPERPORMED:.QL~tiJ__q0___~__ t SLOPE SITE PLAN 11 12 13 14 15 16 WAS GROUND WATER '~L~ O ENCOUNTERED? SL IF YES, AT WHAT PF 19- 20- Gross Net Depth to Net Reading Date Time Time Water Drop / qm~ /o ,,//o .05 5 q:~ /o .~r .oq DATE:~ ALASKA t r ol menTAL COI~TROL SI~RL~S, IrlC. ~PERCOI~,TION._TEST DATA SH£ET ADDRESS' DATE ZIP CODE LEr..~,L LOCATION TOTAL OEP~ OF "OLE ~,~ ft. ZONE ~STED~ ft TO ~.~ ft TH J TEST HOLE DIAMETER READING # CLOCK TIME NET TIME DEPTHDATbI4 TONET DROP RATE (mtn/tn) FINAL PERCOLATION RATE . "r~ (min/tn) (~/"J O' SQUARE FOOT/BEDROOH L// _._,:~:.. . -....~+.. PERFORMED BY ~ ~ ~'~'~ ~..,~~.. 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,ak,us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE 'FAHILY DWELLING Parcel I.D. 050-782-16 1. GENERAL INFORMATION Expiration Cate: 7 - ~ O -'(:~ ~-- Complete legal description EAGLE PARK SUBDMSION; LOT 2, BLOCK .3 " Loc. at[on (site addressordirections) 20718 MELODY LANE * EAGLE RNER, AK 99577 Current Property owner(s) Mailing address Lending'agency Mailing address Real Estate Agent Mailing address CAlL WEAVER Day phone 552-5103 20718 MELODY LANE * EAGLE RIVER, AK 99577 Day phone TIM RrI'I'AL w/ RE:MAX PROPERTIES Day phone 2600 CORDOVA STREET * ANCHORAGE, AK 99503 244-4472 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well 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. 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 m~y be reissued with new water samples. (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. Municipality of Anchorage Development Services Department Building Safety ONIslon On.Site Water & wastewater Program 4700 South Bragaw St. P.O. ~ox 196650 Anchorage, AK ~951~6650 vww.cLsocfiemge.ak.us (gO7) ~.3-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: F~.~LE pARK S/D; LOT 2, BLOCK 3 Parcel ID: 050-782-16 Co WELL OATA Well type pmvA'n[ If A, B, or C provide PWSID~ N/A Date completed UNKNOWN Sanitary seal (Y/N) YES Total depth UNKNOWN, ft. Cased to 40+ ft. FROM WELL LOG Data of test Static water level Well production ft. g.p.m. WATER SAMPLE RESULTS: Colltonn ._~ colonies/100 mi. Arsenic: N//A mgJL. SEPTIC/HOLDING TANK DATA Well Log (Y/N). Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION ,/ 5/2oo2 91 ft. 2.45 g.p,m. Nitrate ~'' ~ ~r~gJL. Other bacteria Date of sample: 4//15/2002 Collected by: NO YES Tank Type/Material STEEL Tanksize 1250 gal. Number of Compartments 2 Foundation deanout (Y/N) YES Depression over tank (Y/N) NO Date of pumping 4/11/2002 Pumper ABSORPTION FIELD DATA 330 & Date installed 10/19B3 , Soil rating (g.p.dJff=on~ 268 Length 74 ft. Width 3 ft. Totaldepth 12 ff. Eft. abso~tion area 1184 Its Monitodegtuba YES Date of adequacy test 4/15/2002 Results (Pass/Fail) PASS Fluid depth in absorption field before test 48 in. Water added 810 gal. Elapsed Time: 960 min. Final fluid depth 50 in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~) colonies/100 mi. AWWC, INC. System type DEEP TRENCH Gravel below pipe IS lt. Depression over field NO For 4 bedrooms New depth 60 in. 600+ g.p.d. NONE KNOWN If yes, give date - 12+ in. Data installed 10/1983 Cleanouts (Y/N) YES High water ~,larm (Y/N) N/A JR'S PUMPING I 'I :i I~.~ph S. Domna ~ 3 CT&E Ref,# Client Name Project Name~ Client Sample ID Matrix Ordered By PWSID 1021950001 Ali Water & Wastcwatcr Consultants Inc. Eaalc Park S/D; Lot 2, Block 3 Eagle Park S/D; Lot 2, Block $ Drinking Water Sample Remarks: Results PQL Units Method All Dates/Times are Alaska Stln~ll;d Time l'rlnted Datetl'lme 04/22/2002 9:34 Colletted Date/Time 04/17/2002 8:18 Received Date/Time 04117/2002 1~:00 Technical Director Stephc~,Ede Allowable prep A~alysi$ Limits Date Date Init Wa:ers Department Nit~ate-N 5.88 0.200 mg/L EPA 300.0 (<10} 04/17/02 Microbioloo'Y Laboratory Total Coliform 0 eol/I OOmL SMI8 9222B (<1) 04/17/02 KAP 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 Parcell. D.# 059 ?~2 i5\ 1. GENERAL INFORMATION Complete'legal description Location (site address or directions) Property owner Mailing address Lending agency Mailin. g address Ralph & Donna Ray . Dayp~one C/O Prudent~al Vista Eaole R~ver Day phone 696-8484 Agent Eva Loken/Prudential vista Dayphone 689-6477 Address "16635 Centerfield Drive Eagle Riverr 'AK Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 ~ 3. TYPE OF WATER SUPPLY: Individual well XX Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest-. lng to the legality and status of system. - 4. TYPE OFWASTEWATER DISPOSAL: Individual on-site XX Holding tank Community on-site Public sewer NOTE: If commun!ty 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 d~te. ~.~his inspection. Name of Firm ~ A~f~sJ~a W.~t~ ~ Phone En inee?;si na[ure f ~r~,~ '' Date Engineering Semtces Prow 6. DHH8 SIGNATURE ~ · .r?ove- .. .,. Di~pproved. ~ Conditional approval for ~drooms, with th~ following stipulations: per~o~ed ~o insure ~he weZls continued suitability. Cu~ren~ nitrate ~ore ~n~o~a~ton on nt~ra~es ~s available from ~he On-stYe SedUces Pro,ram, DH~S, 343 57~. By: The Municipality of Anchorage Department of'Health and Human Se~ices (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. Municipality of Anchorage APR DEPARTMENT OF HEALTH & HUMAN SER~,~ Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 A. WELL DATA w,, type Log present (Y~) Total depth Sanitary ee~) Health Authority Approval Checklist ~J<~ ~.~ ~:3/~__ ~?6~f'~ Parcel I.D.: 0,50- If A, B, or C, attach ADEC letter. ADEC water system number Date completed - (./F)~/'[dJ~JY'l Cased to ~(.) Casing height (above ground) Date of test Static water level ~ Well production ,~J WATER SAMPLE RESULTS: Coliform ~ Nitrate SEI~'iC/HOLDING TANK DATA FROM WELL LOG Wires property protectec~)N) AT INSPECTION // g.p.m. J'~' 0 g.p.m. Date installed /F__P Foundation cleanout ~/N) Date of Pumping ABSORPTION FIELD DATA Dam installed / / Langm '7/'/ Tank size /'~ ~ 0 Number of Compartments ~ Claanoute {~I~1) y y Depression 0f~_~ ,/J H~gh water alarm (Y/N) Soilrafing (g.p.dJfFo~fff/bdrm)~Systemtype d~, ~L~'¢nC_~ Grovel t~ickness below pipe ~ / Total depth Date of adequacy test /;II/~Z Reeu~a,I) /gg :.~ For ~ bedrooms :3'. Fluid depth in absorption field before test (in.); ~'~.~ ~ mmedlately after 13*7-~gal water added (in.]: Fluiddepth ~_/../~1 (ins)Minutes later:.. "'/~ Absorption rate = (.O&)~ fi.p.d. Peroxide treatment (pest 12 manths) (y~.~ ,z~/f) y] ~/C~ z?CO/,[ if yes, give date : ' ...... ' 72-026 (Rev. 3/96)° UFT STATION ~ Date installed ~.--'""~ze in gallons. Manhole/Access (Y/N) / ~mp on" level at* "Pump off' level at' High wa~ *Datum C~le~"teste d E. SEPARATION DISTANCES Absorption field on lot Public sewer main Sewer/septic sswice line SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /~)O ~ On adjacent lots ,/OO Y- On adjacent lots /t~ ~ '/- Public sewer manhole/cteanout ,~,//~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation .~ '/' Prope~/line /~ -/ Abso~tion field Water main/sewice line /~ '/- Surface water/drainage / ~O '/- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /~ ~ Building foundation / Water main/sewice line /0 "~ Surface water /~0 -/-- Driveway. parking/vehicle storage area ,_5 ~ .~- C.r,,n d=. F. ENGINEER'S CERTIRCATION I certify that I h~r~e~, ii~ ~ld inspections and rev/e, -. OF Date '~t'/~'-~l "HAA Fee $ ~ ~ "¢'n~ Waiver Fee $ Date of Payment Receipt Number 72-028 (Rev. 3~96)* MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES. Division of Environmental Services On-Site Services Section P.O. Box196650 Anchorage/Alaska 99519-6650 343-4744 Parcel I.D. # 1. 'GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~.~"~3 -7~.-'/~, HAA ~. ~ ~ Location (site address or directions) Property owner Mailing address Lending agency Mailing address P,0. 8ox I?~87 Day phone 9~I07 Day phone Agent Lee/ REI4AX I:'ROPERT~ES Address £600 Co,dove[ $.~tec~, Su.~ ;00 A~ct~o~c~qe, Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual well XYJ( Community well Public water .... Day phone ~57-0149 AK 99505 NOTE: If community weJ~ S y-stem, pro~,~de wri'tten confirmation from State ADEC attest lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: · Individual on-site · ~.' ~. Holding tank '~ corn ity c~ sit · - mun n- e · · '.', Public sewer NOTE: If community wa tewater system, provide written confirmation from State ADEC ' ting lity yste ........ ' " 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 furtherverify 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. ........ Phone ~ q ~ - ~_c/'79 Date ~r~ms, with the following stipulations: -- ...~-. 6. DHHS SIGNATURE ':::,o.~Z----* ...... '-'-.' Approved for .bedrooms. Disapproved. , , :., ., Conditional approval for By:. Additional Comments The Municipality of Anchorage Department of Health and Human Senflces (DHHS) Issues Health Authority - ! .: Approval Certificates based only upon the'i~epr~htations given in paragraph 5 above by an Independent ~' ' professional engineer registered In the State of Alaska- The DHHS does this as a courtesy to purchasera °f h° .roes ~ * · and theirlending institutions In order to satisfy certain federal and state requirements. Employees Of DHHS do not -- - conduct Inspections 'or'ailaly'ze data before a ~ertiflcate'ls Lqsued. *The Municipality of Anchorage. Is ,~!,o.t/:.:.,: .. ~ r~ I the profe~i ngi .......... responsible for e rs or omlsslo n onale near'swod<. ~:. ............. .-- :.'~!::,-L{..~.. .,':. · .7: .:' ,.' .- ... . .. · . . ' , ,..~.... Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~..-c,T' ~ ~ '~ G~.~t..~ {:::)~.~x._s~ Parcel I.D. Well Data Well lype ~;:)lz-~J ~,~'-E..- If A, B, or C, a~ach ADEC le~er. ADEC water sy~em nu~er ~ L~ presem ~ ~ Date ~mpleted ~ Driller - 0 II Total depth ~ ~ ~ ~ Cased to ~ o ~ ~. Casi~ height ~ San~a~ seal ~) ~ ~res property prote~ ~) ' ~ Stat~waterlevel ~ ~ ~ ~ ~ we,,,,w Pump level1 '' ' J ' SEPARATION DISTANCES FROM WELL TO: Seplic/holding tank on lot Absorption field on lot t Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout. Petroleum tank WATER SAMPLE RESULTS: Coliform C, Nitrate z~ 71'1 Date of sample: I ~ -' 17. -1 ~ Collected by: Other bacteda C) B. SEPTIC/HOLDING TANK DATA Date installed Io -~,'~ Tank size t ~'5'"'b Compartments Cleanouts (~N) ,..{ Foundation cleanout (~N) ~ ', Depression (Y/I~. -- ' "~1 '-, x., High water alarm (Y~) t-[ Alarm tested.(¥/N) ~ ~ -. -. Date of pumping t~) .- t'l -'t ~ _Pumper · ~'---~, :~----~-.~. Pc, o/... SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: '- t ' '~, \ Well(s) on lot ~ ~o tir To property line I a Sudace water/drainage On adjacent lots .Absorption field /~,~ /~' Foundation .,.~' .Water main/service line CONTINUED ON BACK PAGE . SEPA~TION TO: ~ *' . ' ' On adjacent lois' C. UFT STATION " Date Instatled ManufaCtUrer * Manhole/Access (Y/N) Size in ga,ohs Vent (Y/lq) 'Pump on' level at ~ High water alarm level C~yclesl~sted Meets MOA e~ztrical ~:les (Y~) ~ water D' ABSORPTION FIELD DATA Date installed Length ;~ ~' Total absorption area Date of adequacy test Soil rating (GPD/F.F) '"5'"50 '2.G~ ystem type ~ ~ Gravel thickness Total depth Cleanout present {~7N) ,,~ ' Depression over fieId (Y/I~) Result~ail) ~'~<,5 for ' ~ ': "/?"' · Water level in absorption field before test Nter test Peroxide treatment (past 12 months) (Y;~ tjo,JF-- ~Z.,Jo~,,J I! yes, give date ' sEpARATION DISTANCE FROM*ABsORPTION FIELD TO: Well on lot ~ o o On adjacent lots 'lo ~' ~/' P~operly line To ~ilding foundation' On adjacent lots' ".30 f ~' Sudace water Ioo ~ "' · Curtain drain E. ENGINEER'S CERTIFICATION TO existing or abandoned system on lot Cutbank ~/k Water main/service Iine Driveway, parkingNehicle storage area I ¢ergfy g~3t I I~,ve checked, verified, or confon"ned to gl~ MOA and HAA Engineer's Name Date Waiver Fee $ Date of P-';yme~ Receil~ Number