Loading...
HomeMy WebLinkAboutT12N R4W SEC 11 W2SW4NE4NW4NW4TI2N R4W W2 SW4 NE4 NW4 NW4 #012-24-203 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~Vq/ c~'ZD2'~) PID Number:_ ¢IZ~ '~":~¢~N~D ~ ~6~ ~ Wastewater System: D New ~Upgrade Address~ ~ ~. 7~~ ABSORPTION FIELD Phone: ~_ 1~ INo. of B~rooms: ~DeepTrench ~hallowTrench BRed BMound ~Other Total Depth from original grade: LEGAL DESCRIPTION so,,.~i.g: l.O G~D/S~.F~. ~,~ Lot:~ ~ ~~BIock~ ~W~ ~'~ubdivisi°n: Depthtopipebottomfromodginalgmde:~,~ Ft. Graveldepthbeneathpipe~. ~ Ft.  Fill added above original grade: Gravel length: ~  Number of lines: ] Dislance b tween lines: WELL: ~ New D Upgrade Gravelwidth: ~'~ Ft. I ~ Ft. Classification (Private, A,B,C): Total Depth: Ft. Cased To: Ft. Total absorption~ ~area: SQ. Ft. Pipe mate~ Dar installed: Driller: Date Ddlled: Static Water Level: Installer: Yield: GPM ] Pump Set at: Ft. ICasing Height Ab°ye Gr°und:F,. TANK SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding Pub[ic/PHvate Ma~ffacturer: ~ Capacity in gallons: Well I O [ 10 J Materia~ ~ Number of Comparlments:z su~f~c~ ~ LIFT STATION Line ~ ~ J ~ Remarks: ~ ~ ~ ~V~ BENCH MARK ENGINEER'S SEAL Inspections performed by: ~l~.c ~o~,~ Dates:lst_~/ZG/~ ~ 49,~ g'-"r?~"r t '"'~ .,"~-,~,.-' ..... ' Department of Health a~a~ Se~ice~approval ~,,. c~. 7~4~ Reviewed and approved by: ~ e: '~g0~ESS~ 72-013 (Rev 9/91) MOA 25 Perr~it No. ~V,/ q ,'~O ~,~ Page ,Z~ of 2. Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: 72-013 A (Rev 9/91) MOA 25 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW920238 DESIGN ENGINEER:MICHAEL BRODIE, P. E. OWNER NAME:BRAKER BERNARD J ESTATES OWNER ADDRESS:P. O. BOX 100326 ANCHORAGE, ALASKA 99510 DATE ISSUED: 8/18/92 EXPIRATION DATE: 8/18/93 PARCEL ID:01224203 LEGAL DESCRIPTION: T12N R4W SEC 11 W2SW4NE4NW4NW4 LOT SIZE: 52800 (SQ. FT.) NUMBER OF BEDROOMS: 2 THIS PERMIT: 2 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL 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 WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS 2. 3. INSTALL MONITORING TUBE IN EACH TRENCH SEGMENT TO BOTTOM OF GRAVEL. % RECEIVED BY: ~,~',lA~ INSTALL TWO POST-TANK CLEANOUTS. CLEANOUT REQUIRED AT EACH END OF EACH TRENCH SEGMENT. DATE: DATE: ~ ~rz~o : zZZ(~ ~ k 10' OFFSET TO ~~ PROPERTY LINES ,/ / ~ ] "'.,~ _j ~ ~o' o~SET ~o I ~ 895846 W ~, ,, I ,~ CIOWL ENGINEERS ALASKA TESTLAB Pro~eet Name COMPUTATIONS Client Name Prepared by: Date ] Checked by: W.O. # Sheet ~_ of ~' ' Project Name COMPUTATIONS Client Name Prepared by: Date W.O.# Sheet Checked by: Date CIOWL ENr~INEERS ALASKA TESTLAB Project Name C;OMPUTATIONS CllentName Prepared by: Date Checked by: W.O.# Sheet Date 9- 10- 11 12 13 14 15 16 17 18 19 20 Municipality of Anchorage I DEPARTMENT OF HEALTH & HUMAN SERVICES ~,,,,~,,~,,,;~,; 825 "L" Street, Anchorage, Alaska 99502-0650 ~ ~./;% CE- 7442 SOILS LOG -- PERCOLATION TEST {~ ~-.,. ...:.~ DATE PERFOR"ED: ~d~ ~ Township, Range, Section: '~lZ/kJ ~ ~H~/, .~>~cl J/,~,'~ SLOPE WASGROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Oepth t0 Wale[,Aller / , / Monitoring? ~o c~.tV. Date: SITE PLAN Gross Net ~.~/_~ Depth to Net Reading Date Time Time Water (~t~) Drop ~ " 'l J~w J,,t c 0'~ (-" I SO" ~" ~ " ~" ~' ~" ~ ,, PERCOLATION RATE (~)' ~'' (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~' FT AND --~ ET COMMENTS PERFORMED BY: /~, k"j~ ~o.D~ ~ I CERTLFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) Probable Impacts Narrative Legal Description: Parcel 6, T12N, R4W, Sec. 11, S.M. The disposal field will have no impacts on lots to the west of Huckleberry Street or to the south of West 78th Avenue. However, the three parcels to the north, northeast, and east will be partially impacted. The disposal field is to be located in the northeast comer of the subject lot and a 100 foot arc surrounding this system will not be available for the placement of a drinking water well. The placement of the on-site wastewater disposal system on the subject site does not render any of the adjacent parcels undevelopable. Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: -SVv/ ~ IO-:~::'~. PID Number: Name: '~Jpgrade ~ ~ ~, ~ ~,~ Wastewater System: D New Address: ~ W, 7~ ABSORPTION FIELD Phon~/q_/~ ~ NO. of Bedrooms:~ ~Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other Total Depth from original grade: LEGAL DESCRIPTION S°ilRaEng: /,O GPD/Sq. Ft. Block: ~ ~ Subdivision: 9epth to pipe bottom f~om original grade: Gravel depth beneath pipe ~o,: ~..~ ~ )~ ~ )~ ~ 2'N ~'/~1~ ~')~1 ~ ~,. o, ~ ~,.  ~ Fill added above original grade: Gravel length: Townshi~/z~ Range: ~J~ISecti°n: // ~ ~00~ Ft, ~ Ft. WELL: ~ New ~ Upgrade Gravel.~ WIO~ Numberoflines: ]Distance~nlines: Classification (Private, A.B,C); Total Depth: Cased To: Total absorption area: Pipe material: ~t. ~t. 3~b. ~ s~. Drgle,: DateDdlred: StMicWaterLevel: I,staller: ~0 ~/~/ Date installed: . Yield: GPM ] Pump Set at: Ft. I Casing Height Above Ground:Ft.TANK SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding )ublic/Private Manufacturer: Capacityin allons: From Tan* Field Station Tank Sewer Lines A-~ ~ we~ /o ~ /o ~ Mateda~%~ Nu~b"r of Co~pa~me.ts: Sudace ~ LIFT STATION Water LineL°t ~ ~ Size in gallons: .I Manufacturer: Foundation /O~ /¢~ "Pump °n" level at: I "Pump °fl" level at: ] High water alarm at: Cudain ~ ~ Pump Make & Model J Electrical Inspections peHormed by: Drain Remarks: ~¢~ -~ .~ ~ BENCH MARK Location and Description: ~, ENGINEER'S SEAL Inspections peflormed by: /~> ~,6 Dates: 1st ~w,~199/ Department of Healt~%~man: S¢~ices'approval Reviewed and approved by: Date'. 72q)13 (1/91) MOA 25 PermltNo. SV'/4I'fD'507- Page ~- of Z. Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report LegalDescription: ~p__c~_. ¢., '%'/Z,',J ~-/¢W' -%~ II PIDNo.: ©lZZqZo.~ 12-013 A (2/91) MOA 25 PAGE 1 OF MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW910302 DESIGN ENGINEER:DUMMY COMPANY 'LLOL~L OWNER NAME:BRAKER BERNARD J ESTATES OWNER ADDRESS:P. O. BOX 100326 ANCHORAGE, ALASKA 99510 DATE ISSUED: 9/24/91 EXPIRATION DATE: 9/24/92 PARCEL ID:01224203 LEGAL DESCRIPTION: T12N R4W SEC 11 W2SW4NE4NW4NW4 LOT SIZE: 52800 (SQ. FT.) NUMBER OF BEDROOMS: 2 THIS PERMIT: 2 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL 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 WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: 1. ENGINEER MUST VERIFY NO BEDROCK TO 15.3 FEET FOR INSTALLATION TO 9.3 FEET. 2. PROPERLY ABANDON EXISTING SEPTIC TANK AND ABSORPTION RECEIVED BY: ISSUED BY: ~ ~ DATE: DATE: DOWL ENGINEERS ALASKA TESTCAB ProJect Name COMPUTATIONS I w.o.#4.5~ ~/~ CZ Client Name Sheet I of -~ Prepared by: Date [ Checked by: Date I GM~IBNIE3N~! 1/WOO ENGINEERS T E S 1' L k B Project Name COMPUTATIONS Iw.o. ~ ~Y~o3 Sheet -~ of .~ Client Name Prepared by: Date Checked by: Date PERFORMED FOR: DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Slreet, Anchorage, Alaska 99502~650 SOILS LOG -- PERCO~TION TEST / LEGAL DESCRIPTION: (FEET~ 3 4 5 6 7 8. 12 14 16~ 17- 18- 20 Township, Range, Section: SLOPE 'T/Z/d, II SITE PLAN Oeplhto Warn' ~fler. ; M~tuing? N~ ~/~,'TIE. Z-Date: ~'~J-¢ll WAS GROUND WATER ~JC) E- 7E,¢h ,~,~. ENCOUNTERED? DEPTH? , pO J Gross Net Depth to Net Reading Date Time Time Water Dro~ ~/' 8-27-q~ 5c>" ':/." I" ~" 'a'- z?-ql a.~" ct" I" PERCOLATION RATE O. ~' (mlnutes~mch) PERC HOLE DIAMETER ~' // TEST RUN BETWEEN ~ FT AND '~ FT COMMENTS PERFORMED BY: ~'~ L ! ~ I ~lt/-/~,,~ ~-e,~ ~- CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; ~ ~"' ~ I Probable Impacts Narrative Legal Description: Parcel 6, T12N, R4W, SM The disposal field will have no impacts on lots to the west of Huckleberry Street or to the south of West 78th Avenue. However, the three parcels to the north, northeast, and east wil/be partially impacted. The parcel directly to the north of parcel 6 will be restricted from the placement of a well in approximately the southern 40 feet of the site. A 30 by 40 foot section in the southwest corner of the parcel to the northeast of parcel 6 will be restricted from the placement of a well. In addition, the northwest quarter of the parcel to the east of parcel 6 will also be restricted from a well. The placement of the on-site wastewater disposal system on parcel 6 does not render any of the adjacent parcels undevelopable. GREA,ER ANCHORAGE AREA BOR~,dGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE FROM WELL MANUFACTURER INSIDE LENGTH INSIDE WIDTH MATERIAL LIQUID DEPTH NUMBER OF COMPARTMENTS LIQUID CAPACITY GALLONS. SEEPAGE PiT: NUMBER OF PITS ~ DIAMETER--OR WIDTHS,/ LENGTH/~',! DEPTH ~ / LINING MATERIAL ~'/~' ~") CRIB SIZE: DIAMETER ~/DEPTH ~ / DISTANCE FROM: / TOTAL EFFECTIVE BU.D~NG ~OUNDAT~ON.R.~ ~ NEARES~ LOT UNE /~/ . ADDITIONAL ABSORPTION WELL ABSORPTION AREA (WALL AREA) ~ SQ. FT. WELL: BUILDING ~,/ NEAREST NEAREST SEPTIC FOUNDATION ~/~ LOT LINE SEWER LINE TANK CESSPOOL OTHER SOURCES APPROVED DISAPPROVED REMARKS DISTANCE FROM: SEEPAGE SYSTEM DISTANCES: INSTALLED BY: t5~-~ // ' LOT SLOPE: REMARKS: DIAGRAM OF SYSTEM IlL APPROVEI G.~J BA.A.. ~ ~J 'l ~ .L~ .~-~'~ ...... . GEE/ :.R ANOHORAGE ARWA BOF UGH /,'"' 1~,., , ~. ~.~,'/ ' , SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT OTHER * FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. ~ SEPTIC TANK SIZE MIRII~IUM DISTANCEB, REQUIRENIENT~ FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE pIT SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK ~, SEEPAGE PIT TO NEAREST LOT LINE. WELL TO SEPTIC TANK DRAIN FIELD ~ WATER MAiN TO SEPTIC TANK DRAIN FIELD SEPTIC TANK, , SEEPAGE PIT. TO RIVER, LAKE. STREAM. OF DRAIN FIELD, / ,SEEPAGEP'T. , SEEPAge PIT , DRAIN FIELD CAST IRON INTO AN[3 OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 iNCH DIAMETER CAST lEON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AiRTiGHT REMOVABLE CAPS. GF~AVEL BACKFILL I CERTIFY THAT [ AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO, 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. 'ATE GREATER ANCHORAGE AREA BOROU?~ Department of Environmental QuA /ty 3330 "C" Street Anchorage, Alaska 99503 SOILS LOG - PEROLATION TEST Performed for~¢~ ~-.~er- Legal Descrip~~k~ ~ ~.-~' t~ ~ ~o.) This form reports: Soils log ~z Date Performed__~- ~!-~$~ Percolation test Depth Feet 2- 3- 6- 7- 8- 9- lO- ll - 13- 14.- Was ground water encountered? If yes, at what depth? Reading Date Gross Time Net Time Percolation rate minute. Depth to Water Net Drop -Proposed installa~-{on: Seepage Pit Drain Field !)epth of I~let ........... . Dept~i--~-o--b-o~--c~-~-])it or trench COI,1[.1EItTS~._ 0 / Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and 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 FAMILY DWELLING 012-24-203 Parcel I.D. t Expiration Date: '1.' GENERAL INFORMATION w~/~. ~1~ NC ti+ .I)tu~/ulu I~ Completelegaldescription ~--, ~ T12N, R4W, Loc~tion (site address or directions) Current Property ownerCs) E s t a t e 3655 W. 78th of Brenard J. - Mailing address Lending agency HAA# ttt OiO040 Section Dynamic BrakerDayphon~61-7600/Harvey rrickett Day phone Mailing address Dynamic/Harvey prickett Real Estate Agent Mailing Address 3111 c 2. NUMBER OF BEDROOMS: Day phone ~61-7600 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 (HA,A) 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 from the date of issue for properties se,wed 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 cna year for properties served by Class A or B wells or a public water system. The Municipality of Anchcrage is net responsible for errors or omissions in the professional engineer's work. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verity 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 ef bedrooms and type of structure Indicated herein. I further verity 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~.h~ 17034 Eagte R~ver Loop Road No. 204 Name of Firm _~=!e ~!¥"r, ~.._t.. ~7577 Address Engineer's Printed Name 5. DSD SIGNATURE Approved for Disapproved. Conditional approval for Phone Robert C. Cowan. P.E. bedroom~ O~-$11E WATER WASTEWATI ,.. PROGRAL~ bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: ~ --20 -- O/ (Rav. I~CO) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Sm'th Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 wvM.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST LogalDescription:P#~-¢(L G ) ~t(.w,. I/ ) T',3~, Ryk/ ParcellD:OI;~-3. y-'3*O3 WELL DATA Well type t Date completed '~ Total depth I0o 4. fl. If A, B, or C provide PWSID # sanM~ ~al I~N) v~ ~ Casedte. ~fO~ It. FROM WELL LOG Date of test Stefic water level ~ It. Well production .~/ gp.m. WATER SAMPLE RESULTS: Coliform O colonies/100 mi. Nib-ate ~.5'. mg./I. Dateofsampte:;l~,//O, ~ ~&/o/ Coltectedby: B. SEPliC/HOLDING TANK DATA Tank Type/Material ~ ~.,~ ]', ~ / Tanksize/OeO gal. .~ Number of Comparl~ents ~ beta of / , / ° c. DATA Well Log (Y~. ~ o wir~ pmpeW protected (:~N) Xe/ AT INSPECTION ~- ~ g.p.m. tn. Length fa 3) ff. Other bacteria O colonies/lO0 mi. S & S EHGINEE]UNG 17034 Eagle Ri~ Leap Read Ne. ~4 Date installed c~eanou~ (~N) High water alarm Depression over tank (Y4~ /~ e Pumper R ~ /-/dm · / System type £~/4c L-. ~ 'Gravel below pipe O. S"' fl. Soil rating (g.p.dJ1t~ or ft2fodrm) )- o WVlth 5'. ,~ It. Eft. absorption erea'~¥~.5"~ Monitoring tube Ye.,f /~/e I Results~Fail) t~'~$ Total depth "[ '~- It. Date of adequacy test Fluid depth in absorption field before test ~'~ in. Water added~'~"~ gal Elapsed Time: v/~. min. Final fluid depth ~'/-~ in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Abserption rate >= Depression over field ,/v ,2 For ~* bedrooms New depth IA'Yin. ~ e ~ g.p.d. a: ,,,~ ~,,,/ If yes, give date D. LIFT STATION Data installed Size in gallons. Manhol~.~___.~ 'Pump on" level at __ in. 'Pump off' I~..~_..~. High watar alarm level at Datum .......~"'"'~CC~ ~ted Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/fiff staflo~ on lot J~o '~' Absorption field on lot I 0 ,~ -+- Public sewer main ~//a sewer/septic service line ~- .~ "/" On adjacent lots On adjacent lots Public sewer manhole/oleanout Holding tank /v' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundaflo~ ..v / e o Property line 5- Water main /~ / ,4 Water service line Wells on adjacent lots / 0 D 4 I0 '~ Absorption field Surface watar SEPARATION DISTAN(~E FROM ABSORPTION FIELD ON LOT TO: Proper[71ine lO ~.~ Building foundation I0o Water Service line )O '~- Surface water I O 0 ~- Curtain drain ~ ~ ~ ,t. , ~,v.~,,-, ' Wells oll adjacent lots /'~ · 4 Watar main /~ / R D~n. my. parking/vehicle storage F. COMMENTS G. ENGINEER'S CERTIFICATION I certify 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 "~0~ ~,~/'- C . Date ~./, ~./ O / HAA Fee $ Date of Payment Receipt Number (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number