HomeMy WebLinkAboutT14N R1W SEC 23 E2NE4SW4NW4 & NE4SE4SW4NW4T14 RIW
Sec. 23
E2 NE4 SW4 NW4 &
NE4 SE4 SW4 NW4
#050-521-21
Municipality of Anchorage ne
• Development Services Department ,o
Building Safety Division
Onsite Water & Wastewater Program, 4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us (907) 343-7904 Page 1
of 3
Onsite Wastewater Disposal System and/or Well Inspection Report
Permit Number: SWO10184 PID Number. 050-521-21
Name:
LES TIMS
Wastewater System: ❑New ■Upgrade
Address:
25202 McINTYRE ROAD * EAGLE RIVER, AK 99577
ABSORPTION FIELD
Phone: No, of Bedrooms:
(907) 694-6112 4
❑Deep Trench ■Shallow Trench Dead ❑Mound ❑other
LEGAL DESCRIPTION
Sell Ruling:
1.2
Total Depth from origiml grade:
GPD/Sq.
rt 9-10 FL
Lot: C 0 : slop: i /
Depth to pipe bottom from origlnol grade:
Gravel depth beneath pips:
Amu, y
4.61-5.61
Ft. 4.39 FL
Township: T1 4N Range: R1 W Section: SEC. 23
Ful added above original grade:
Gravel length:
1.53-2.94
rt. 50 Ft
WELL: E] New El Upgrade
Gravel width:
5
Number of liner.
1
Dlelance between luras:
—
pt,
Ft,
Clesenicabon (Private. AB.C): Total De
Cried To:
Total absorption area:
Pips material:
ft
Ft.
500 so. rt.
D 3034/ F-810
Griller. Data Drilled:
Static Water Loveb
Installer.
Dale ineWllad:
Ft.CCC
CONSTRUCTION
6/29/-7/2/2001
Yleltl:Pump
Sat At:
Cooing Height Above Ground:
TANK
GPM
R.
FL
SEPARATION
DISTANCES
. Septic O Holding ❑ S.T.E.P. ❑ Other
To
Septic
Absorption
Lift
Holding
Public/Priwh
Manufocturer.
copwig, in gallons:
From
Tank
Field
Station
Tank
sewer Linea
ANCHORAGE TANK
1 1250
Well
100'+
100'+
—
—
25'+
Material:
STEEL
Number of oomportmerde:
2
Surface Water
100'+
100•+
—
—
—
LIFT STATION
Lot Line
5'+
10'+
—
—
—
Size in gallons:
Manufacturor.
Foundation
5'+
10'+
—
—
—
Rump an' Iwai aump t: at:
High water alarm ah
Curtain Drain
NO
KNOW
Pump Make I:
EMcbleal Inspections performed br.
Remarks: — EXISTING SEPTIC SYSTEM WAS
BENCH MARK
Location and Description:
ABANDONED PER UPC
TOP OF GARAGE SLAB
-�• 1
-Der--p s�.,�l�'l�K-
Assumed Elevation:
loo.00
ENGINEERS SEAL
�p060��
0
Inspections performed by: AWWC, INC. Dates: 1st 6/29/2001
2nd 7/2/2001
�OQ
3rd 7/2/2001
P : f ey .. �... esti;'
C 7953
Department of Health and Human Services approval
Vi •, ;poop
.p
Reviewed and approved by: • / Date: �� it d f
0
der, Jorof ..... °Qac
OQ4pO���p
(Rev. 72/00)
PERMIT NUMBER
SW010184 : AS -BUILT DRAWING
--A--B \
/
I
/ ST1 55.50 51.22
ST2 61.76 54.45
DBL1 69.03 59.42
DBL2 70.48 69.79
C01 126.38 75.16
MT1 128.11 76.56
CO2 158.36 121.45
MT2 1159.141121.12
APPROXIMATE LOCATION
OF CREEK--\
PARCEL ID NUMBER:
050-521-21
EXISTING SEPTIC SYSTEM
ABANDONED PER UPC
/l
/f
f
l
Icio i'o Cw'
` NEW 1250 GALLON
EXISTING I SEPTIC TANK
4 BEDROOM
HOUSE DBL1
DBL2
B
/ NEW DRAINFIELD�
(j I
1 r
o
__ _--------f-----__
30' ROW EASMENT J,
— — — — — — — — r — — 10' GAS EAS ENT ® —
7/6/2001
srs;sRx,xsr�c- DRAWN BY:
ALASKA WATER & WASTEWATER C.J.G.
CONSULTANTS, INC.m -- SCALE: l
6901 OEBARR ROAD, SUITE 2B' ANCHORAGE, AK 99504' PHONE (907)337-6179' FAX (907)335-5246
1"=50'
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
LES TIMS (907) 694-6112 2 OF 3
LEGAL DESCRIPTION:
NE 1/4, SE 1/4, SW 1/4, NW 1/4; SECTION 23, T14N, R1W,
TYPE OF WORK:
AS -BUILT DRAWING OF SEPTIC SYSTEM UPGRADE
n
=T=
r _
e y A. Gar ess:
G
4 �ed'Orofessiof%0\
��40000�a
APPROXIMATE LOCATION
OF CREEK--\
PARCEL ID NUMBER:
050-521-21
EXISTING SEPTIC SYSTEM
ABANDONED PER UPC
/l
/f
f
l
Icio i'o Cw'
` NEW 1250 GALLON
EXISTING I SEPTIC TANK
4 BEDROOM
HOUSE DBL1
DBL2
B
/ NEW DRAINFIELD�
(j I
1 r
o
__ _--------f-----__
30' ROW EASMENT J,
— — — — — — — — r — — 10' GAS EAS ENT ® —
7/6/2001
srs;sRx,xsr�c- DRAWN BY:
ALASKA WATER & WASTEWATER C.J.G.
CONSULTANTS, INC.m -- SCALE: l
6901 OEBARR ROAD, SUITE 2B' ANCHORAGE, AK 99504' PHONE (907)337-6179' FAX (907)335-5246
1"=50'
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
LES TIMS (907) 694-6112 2 OF 3
LEGAL DESCRIPTION:
NE 1/4, SE 1/4, SW 1/4, NW 1/4; SECTION 23, T14N, R1W,
TYPE OF WORK:
AS -BUILT DRAWING OF SEPTIC SYSTEM UPGRADE
n
=T=
r _
e y A. Gar ess:
G
4 �ed'Orofessiof%0\
��40000�a
PERMfTNUMBER: AS -BUILT DRAWING PARCEL ID NUMBER:
SWO
SWO10184 050-521-21
TOP OF TANK A
INLET = 89.76
INVERT OF BUNG
AT INLET = 89.19
FILTER FABRIC
INSULATION -
FINAL GRADE _
99.24-99.29
NEW 1250 GALLON
SEPTIC TANK
TOP OF TANK AT
OUTLET = 89.86
INVERT OF BUNG AT
OUTLET = 89.11
FINAL GRADE _
90.52-92.65
ALASKA WATER & WASTEWATER
CONSULTANTS INC
ORIGINAL GRADE
= 88.71-89.71
INVERT OF PIPE
= 84.10
—BOTTOM OF
TRENCH = 79.71
7/6/2001
DRAWN BY:
C.J.G.
6901 DEBARR ROAD, SUITE 2B' ANCHORAGE, AK 996D4 • PHONE (907)337-6179 • FAX (9D7)338-3246 N.T.S.
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
LES TIMS (907) 694-6112 3 OF 3
LEGAL DESCRIPTION:
T14N, R1W, SECTION 23, NE 1/4, SE 1/4, SW 1/4, NW 1/4
TYPE OF WORK:
PROFILE AS -BUILT DRAWING OF SEPTIC SYSTEM UPGRADE
P •,J ff G ne s;...
m CE 53 e,
'Ofn �Fa
MUNICIPALITY OF ANCHORAGE
Development Services 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
Upgrade
V.Zllo! q 4XA.Th^'
&/r, 0/,v I
Date Issued: Jun 12, 2001
Expiration Date: Jun 12, 2002
Permit Number: SWO10184 Parcel ID: 050-521-21
,, "tg" t4 8W4NW4 & NE4SE4SW4N1N4 v
Design Engineer: 0041 AK Water & Wastewater Consultant Site Address: 025202 MCINTYRE RD
Owner Name: LELAND L. & ALYSSA RENE TIMS Lot Size: 326700 SQ. FT.
Owner Address: 25202 McINTYRE ROAD Total Bedrooms: 4 Permit Bedrooms: 4
EAGLE RIVER , AK 99577 -
This permit is for the construction of:
g Disposal Field K Septic Tank Holding Tank [—] Privy 0 Private Well Water Storage
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 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:
Z:��w'Date: jp —12 —0/
Municipality of Anchorage
• �` Development Services Department °z
Building Safety Division LI
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.anchorage.ak.us
(907)343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. DSD " SZ % — V Permit Number SwO/oW
( SLAVO t. t kV5sn RtmE TIms
Property owner(s)
Day phone 694-6112
Mailing address (1) c/o SHARON MINSCH wf REMAX PROPERTIES
51Tt: ZrZOZ M 4Z"'fY91 RCRD
Mailing address (2) 16600 CENTERFIELD DRIVE * EAGLE RIVER. AK Zip Code 99577
Legal description (Lot, Block & SuVd.) NE 1/4. SE 1/4, SW 1/4, NW 1/4,
Legal description (Section, Township & Range) SECTION 23, T14N. R1 W.
Lot Size 109.905 Acres/Sq.Ft.
326, 700
THIS APPLICATION IS FOR:
Number of Bedrooms 4
Sewer Only 0 Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade ❑
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal codes.
ALASKA WATER & WASTEWATER CONSULTANTS, INC.
Permit Fees:
Date of Payment: � t 16 l
Receipt Number: %C�g
Waiver Fees:
Date of Payment:
Receipt Number:
ALASKA WATER & WASTEWATER
CONSULTANTS, INC.
May 28, 2001
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On -Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Septic Upgrade Design for NE 1/4, SE 1/4, SW 1/4, NW 1/4, Section 23, T14N, R1 W,
To whom it may concern:
The existing 4 bedroom house is served by a private well and septic system. The existing septic
system is not documented. The existing drainfield was excavated in order to document the
dimensions of the drainfield. During the excavation, the drainfield was found to be in a state of
failure and needs to be upgraded. A test hole was excavated south/southwest of the existing
septic system. The proposed septic system will be designed around the 30 foot radius of test hole
91. We are proposing that a 1250 gallon septic tank and a five foot wide drainfield be installed.
Comments regarding the proposed design are summarized as follows:
1. SOILS: See the attached logs which shows the soil classifications, groundwater monitoring,
and the percolation test results. It is our opinion that the insitu sandy soils should act as a sand
filter and that, an application rate of 1.2 gallons/day/ft2 should be used.
2. TRENCH DESIGN:
a. Percolation Rate: <1 minutes/inch
b. Allowable Application Rate: 1.2 gallons/day/ft2
c. Number of Bedrooms: 4
d. Design Flow: 600 gallons per day
e. Minimum Absorption Area: 500 ft2
f. Total Depth: 10 feet (max.)
g. Effective Depth: 4 feet
h. Width: 5 feet
I. Reduction Factor: 0.5
i. Minimum Length: 50 feet long
j Effective absorption area = 500 112
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed
upgrade.
4. TOPOGRAPHY: As can be seen on the design, the proposed drainfield is to be installed at
the base of a cutbank slope. The area for the proposed drainfield ranges from a 5 to 10 percent
slope running from approximately north to south. There is a small cutbank downhill from the
trench; but the system will be installed deep enough so that a 25 percent slope from the top of the
distribution line to 50 feet downhill of the drainfield will not daylight at any point. Given the
porosity of the soils we do not anticipate any concerns with the effluent migrating laterally. The
trench is to be installed parallel to slope contours.
We are unaware of any adverse impacts this installation would have on adjacent wells or septic
systems. If you hav7 any questions, please contact us at 337-6179, or 244-9612. Thank you for
your assistance.
M.S.
NOTE: Attached is a site plan drawing, a design drawing, a soils logs, and a 7 page construction
specification letter which are all part of the design package for this septic system.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
\ x
ROBERT VERNON LOWE HOMESTEAD
\
/ \ d
Jy \
EXISTNG
4 BEDROOM
1
\
HOUSE
J
PROPOSED SEPTIC UPGRADE
t
(SEE DESIGN PAGE 2 OF 2)
I
t I
I
!! r
GROLL S/D;
LOT 3, BLOCK 2,
McINTYRE 5/D; \
t /
t
NO,WEILS FOUND WITHIN
100 + OF THE PROPOSED
TRACT A
\\ ��(( /
SEPTIC SYSTEM. CONTRACTOR
1
�`\ 7�/
TO FIELD VERIFY WELL
PRIOR TO CONSTRUCTION.
t`
1� CREEK
t
l
__ _ _
1
EXISTING —1—
CSYSTEM
!
SYSTEM
TH#'1-
f
1
1
t_®1__—__®__
/t
®�®_ m m---_--,
'_^ _,_
ALTERNATE SITE
/ t
\'
r
t `o
TRACT B; McIN7YRE S/D
I j
! I ! 1 NO ENCROACHMENT CONCERNS
I
DATE:
5/28/2001
DRAWN BY:
ALASKA WATER & WASTEWATER
C.J.G.
Ste:
CONSULTANTS, INC.
*
,
1 - _ loo,
......... .. .............I
6901 DEBARK ROAD SUITE 2B • ANCHORAGE. AK 99504 •PHONE (907)337-6179 •FAX (907)538-3246
/
..
PREPARED FOR PHONE NUMBER:
PAGE NUMBER:E;
LES TINTS 694-6112
1 OF 2
f e Gamess.� ✓✓✓�/
C 953 , • ��1d
LEGAL DESCRIPTION:
SECTION 23, NE 1/4, SE 1/4, SW 1/4;
NW 1/4,
rof
TYPE 04WORRIW,
SITE PLAN FOR SEPTIC SYSTEM UPGRADE
Bio���>'
�`�O ession
I
5
1
I 1
APPROXIMATE LOCATION ' INSTALL DOUBLE
1
OF CREEK CLEANOUTS
\
EXISTING t PROPOSED 1250
/
\
4 BEDROOM GALLON SEPTIC TANK.
HOUSE WILL REQUIRE A
DEEP BURIAL TANK
INSTALL DOUBLE
CLEANOUTS
EXISTING SEPTIC SYSTEM TO J
BE COMPLETELY ABANDONED {
-- — —
00 CO
PROPOSED NEW DRAINFIELD.
EXCAVATE A TRENCH THAT IS t rTH1
10 FEET DEEP BY 5 FEET WIDE
BY 50 FEET LONG. ADD 4 FEET
OF CLEAN, WASHED SEWER
DRAINROCK. INSTALL TRENCH ALTERNATE SITE
PARALLEL TO SLOPE CONTOURS
_-y— _ y
— — — —. — — — — -- — — — — —t —I ----
30' ROW EASMENT /
— — — — —
—90'
GAS ENT
TOP OF
1 % / SMALL CUTBANK
(APPROX. LOCATION)
DATE:
O
5/28/2001
000
0
q ��Q
DRAWN BY:
C.J.G.
.
ALASKA WATER & WASTEWATER
�0
SCALE:
CONSULTANTS, INC.
* •. 9*
""•"'•
6901 OE9ARR ROAD, SUITE 26 ANCHORAGE. AK 99504 •PHONE 907)337-5179 `FAX (907)338-3246
-
1" — 50'
' ' .. "" ".....
D
PREPARED FOR: PHONE NUMBER:
PAGE NUMBER:
LES TIMS (907) 694-61 12
2 OF 2114
fr G s:'
ODO�i ,•.• 955 ,•• �oOQQ
LEGAL DESCRIPTION:
NE 1/4, SE 1/4, SW 1/4, NW 1/4; SECTION 23, T14N, R1W,
®
44�eaY'�ofessio�o��o�
�04ofess%c
TYPE OF WORK:
DESIGN OF SEPTIC SYSTEM UPGRADE
I ALASKA WATER & WASTEWATER
CONSULTANTS, INC.
6901 DEBARR ROAD SURE 28 • ANCHORAGE, AK. 99504 • PHONE (90 7)337-6179 w FAX: (907)338-3240 • WEBSITE: akwwo.aam
LEGAL DESCRIPTION: T14N, R1W, SECTION 23, NE7/4,SE1/4, SW1/4, NW1/4,
PERFORMED FOR: LES TIMS DATE: 5/19/01
DEPTH _ _ ORGANICS
(feet) 'nP o TEST HOLE 1
i'oo e
7
Sao
DRY
SOIL
CLASSIFICATIONS
GM TO
1 t
2
GW/SW
9
"oov
MOSTLY SAND
1 t
WITH LARGE
10
/
BOULDERS AND
GW
�000
ORG
// tl
PER�p'CER
lON °F
GP
ML
pp ;.qa0
TM#7
GM
CL
4
1> - 0a
GC
OL
SW
MH
SP
CH
5—'
oov
SM
OH
SC
7
12
13
vo
15
>aD
.roo
�•'Qni;D°C
17::'D°£
`SOD
16'h °
B.O.H.
19
DEPTH TO
GROUNDWATER
oov
DRY
5 19 01
DRY
GM TO
1 t
. =rao°
GW/SW
9
"oov
MOSTLY SAND
1 t
WITH LARGE
10
/
BOULDERS AND
�000
SOME SILT
12
13
vo
15
>aD
.roo
�•'Qni;D°C
17::'D°£
`SOD
16'h °
B.O.H.
19
DEPTH TO
GROUNDWATER
DATE
DRY
5 19 01
DRY
5 2 01
1 t
I /
DATE
READING
CLOCK
TIME
NET TIME WATER LEVEL NET DROP
(MINUTES) READING (INCHES)
�
1 t
I /
1 t
� 1
/
// tl
PER�p'CER
lON °F
TM#7
SITE PLAN
51z�
------------------ / - --------------------------
f
DATE
READING
CLOCK
TIME
NET TIME WATER LEVEL NET DROP
(MINUTES) READING (INCHES)
5 GP��o�s
EQ
laMN���S
�N
PER�p'CER
lON °F
51z�
PERCOLATION RATE <1 (MIN./INCH) PERC. HOLE DIA. 6" (INCHES)
20 TEST RUN BETWEEN 5.5 FT. AND 6.0 FT.
COMMENTS: THE INSITU SANDY SOILS SHOULD ACT AS A SAND FILTER.
PERFORMED BY ALASKA WATER & WASTEWATER I, JEFFREY A. GARNESS, CERTIFY THAT THIS AS PERFORMED
IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE:
Municipality of Anchorage
• Development Services Department
Building Safety Division E
On -Site Water & Wastewater Program
4700 Elmore Road �.
P.O. Box 196650
Anchorage, AK 99519-6650 l~
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-521-21 COSA# 1 C I �L 6.s
1. GENERAL INFORMATION Expiration Date: 3
Complete legal description T14N. R1W, SECTION 23, E2 NE4.SW4 NW4 & NE4 SE4 SW4 NW4
Location (site address)
25202 McINTYRE ROAD
* EAGLE RIVER, AK
99577
Individual On-site
Current Property owner(s)
ROBERT AND MELINDA STOREN
Day phone
694-6112
Mailing address
Lending agency
Mailing address
25202 McINTYRE ROAD * EAGLE RIVER AK 99577
Day phone
Real Estate Agent JAY OSBOURNE W/ REAL ESTATE BROKERS OF AK Day phone 345-4663
Mailing address 3300 C STREET #200 *ANCHORAGE, AK 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems
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 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.
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 Certificate of On -Site Systems 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 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.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, LED, attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSDSIGNATURE
Approved for Z_/ bedrooms.
Disapproved.
337-6179
Date 1Z c-/((
Conditional approval for _ bedrooms, with the following stipulations:
Attachments
COSA Checklist ✓ Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitr Advisory Other
By Original Certificate Date:
(Rev. 11105)
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)3437904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: T1 4N, R1 W SECTION 23 E2 NE4 SW4 NW4 & NE4 SE4 SW4 NW4 Parcel ID: 050-521-21
A. WELL DATA *SEE ATTACHED REPORT.
Well type PRIVATE If A, B, or C provide PWSID# N/A
Date completed UNK Sanitary seal (Y/N) YES
Total depth *5U4 -ft. Cased to * -7 T ft.
FROM WELL LOG
Date of test NO WELL LOG
Static water levelft.
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml.
Arsenic: ND ug./L.
B. SEPTIC/HOLDING TANK DATA
Well Log (Y/N) NO
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
*7/13/10
44.1
4.7 q. p. m.
*PERFORMED BY DOUGLAS KENLEY, P.E.
Nitrate 0.13 mg./L.
Date of sample: 10/16/11
*FCO IN GARAGE
Tank Type/Material STEEL/SEPTIC
Tank size 1250 gal. Number of Compartments 2
Collected by: GEG, Ltd.
Date installed 7/2/01
Cleanouts(Y/N) YES
Foundation cleanout (Y/N) *YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping 04Z25/2011 Pumper JR SEPTIC PUMPING
C. ABSORPTION FIELD DATA *BELOW FINAL GRADE
Date installed 6/29-7/2/01 Soil rating.p.d./ r ft /bdrm) 1_2
Length 50
Width
System type TRENCH
Gravel below pipe 4.39 ft.
Total depth*10.5-12.9 ft. Eff. absorption area 500 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test **7/13/2010 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 0 in. Water added 847 gal. New depth 0 in.
Elapsed Time: _ min. Final fluid depth 0 in. Absorption rate >= 600 g p d
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NO If yes, give date
**PERFORMED BY DOUGLAS KENLEY, P.E.
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N
"Pump on" level at in. "Pump off level High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+
Public sewer main
Sewer /septic service line
Animal containment areas 50'+
On adjacent lots
Public sewer manhole/cleanout
100'+
Holding tank N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
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 COSH guidelines in affect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS '
Date t 2 f3 / 11
COSA Fee $ y c
I
Date of Payment
Receipt Number.
(Rev. 11/05)
Driveway, parking/vehicle storage 10'+
Waiver Fee $
...........................
Date of Payment
Receipt Number
CE-
3-Z(.� .r+'', FS�4
MAGNIFICENTI MOUNTAIN
TRACT 88-1 SLOPES SUBD. TRACT 88-2
N90'00'00"E 330.00'
FOUND
DONALD C.
REBAR
�---25' SLOPE
'
EASEMENT
�r
L
O
W112 NE1/4 rn
25'
SW1/4 NW1/4 0
SEC. 23, T7 4N, o
R I W, S.M. o
0
0
z
NOTE.
SEPTIC SYSTEM SHOWN
BASED ON AS -BUILT
PROVIDED BY ALASKA
WATER AND WASTEWATER
CONSULTANTS, INC.
DATED 7/8/2001.
DENALY SUBDI'OSION
TRACT Al
FOUND
ALCAP
E112 NE1/4 SWI/4 NW/4 &
NE1/4 SE1/4 SWI/4 NW1/4
SEC. 23, r14N, R1 W, S.M.
FOUND
BRASS CAP
C
STREAM rL
EXISTING
BUILDING
�c0i
02
PAVED T2
DRIVEWAY
330.94'
BLOCK 2, LOT 1
GROLL SUBDIWS/ON
BLOCK 2. LOT 2A
BLOCK 2, LOT 3
LWIM SURVEY CER nRCAT10NF'
: i
ADJACENT PROPERTY LINE RODNEY P. KINNEY ASSOCIATES, INC. HAS 'S • O
• A'L�,i)
PROPERTY LINE CONDUCTED A PHYSICAL SURVEY OF THIS //�Q'•' s'�
PROPERTY AS SHOWN ON THIS DRAWING AND 49 1`
WELL THAT THE IMPROVEMENTS SITUATED THEREON //''•
ARE WITHIN THE PROPERTY LINES AND NO ""' "' ' "' """"
ENCROACHMENTS EXIST OTHER THAN NOTED.
GRAPHIC SCALE .. .....
100 D 50 100 EXCLUSION NOTES: Kevin M. smith o`' /
IT IS THE OWNERS. RESPONSIBILITY TO ,�;'ae,'•. 9234
DETERMINE THE EXISTENCE OF ANY EASEMENTS, q,
COVENANTS, OR RESTRICTIONS WHICH DO NOT �`� ! e
IN T)
1 inch = 100 ft. APPEAR ON THE RECORDED SUBDIVISION PLAT.
IIEMPKA
E1/2 NE1/4 SW1/4 NW1/4 AND AS -BUILT
NE1 /4 SE1 /4 SW1 /4 NWt /4
I1IMP.M l➢11NdalnOF SECTION 23, T14N, R1W, SEWARD MERIDIAN, EAGLE RIVER, ALASKA 12/05/11 FIGURE 1
DONALD C.
SCHROEDER
'
ADD. 1
TRACT 4B
0
O
rn
rn
BLOCK 2, LOT 1
GROLL SUBDIWS/ON
BLOCK 2. LOT 2A
BLOCK 2, LOT 3
LWIM SURVEY CER nRCAT10NF'
: i
ADJACENT PROPERTY LINE RODNEY P. KINNEY ASSOCIATES, INC. HAS 'S • O
• A'L�,i)
PROPERTY LINE CONDUCTED A PHYSICAL SURVEY OF THIS //�Q'•' s'�
PROPERTY AS SHOWN ON THIS DRAWING AND 49 1`
WELL THAT THE IMPROVEMENTS SITUATED THEREON //''•
ARE WITHIN THE PROPERTY LINES AND NO ""' "' ' "' """"
ENCROACHMENTS EXIST OTHER THAN NOTED.
GRAPHIC SCALE .. .....
100 D 50 100 EXCLUSION NOTES: Kevin M. smith o`' /
IT IS THE OWNERS. RESPONSIBILITY TO ,�;'ae,'•. 9234
DETERMINE THE EXISTENCE OF ANY EASEMENTS, q,
COVENANTS, OR RESTRICTIONS WHICH DO NOT �`� ! e
IN T)
1 inch = 100 ft. APPEAR ON THE RECORDED SUBDIVISION PLAT.
IIEMPKA
E1/2 NE1/4 SW1/4 NW1/4 AND AS -BUILT
NE1 /4 SE1 /4 SW1 /4 NWt /4
I1IMP.M l➢11NdalnOF SECTION 23, T14N, R1W, SEWARD MERIDIAN, EAGLE RIVER, ALASKA 12/05/11 FIGURE 1
v 30 11 08:01a Dadt( 3388078
l►4N,(LIW�4�Sf1U�2Sw1F�q�j�WrW NL%j�
AAROW PUMP & WER SERVICE, LLC
P.O. Box 110496
Anchorage, AK 99511��
Office: (907) 346-9355 • Fax (907) 333-8976
Eagle River: (907) 622-9335
CUSTOMER
WINA CE
No. 9213
JOB SITE
J L
NVOI r fi7E / /
WELL DEFTH
ML
MLOFItJATEj
PiJrdP DEPT j
SA.LE� N —
J -.•, �' Pte- fay
QUA
DESCRIPTION
PRICE
AMOUNT
_.._..__..-----
G/P!/_ �: �. �:—..C�3L'h�•, t ,./ham___ �- ``-'�, �: ln,e.. f.
LABOR
HOURS
RATE
AMOUNT
TOTAL MATERIAL
TOTAL LABOR
WORK ORDERED BY
DATE COMP. I
TOTAL
LABOR
PAY THIS AMOUNT
Thank You
SIGNATURE
(I Hereby Acknowledge the Satisfactory Completion of the Above Described Work and agree that if above work is not paid for in 90 days I agree to allow Aarow
Pump & Well Service, L.L.C. the right to remove unpaid for equipment and charge for labor already performed & labor to remove unpaid for equipment.}
TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE.
SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS.
-- Municipality of Anchorage
i !f
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. COSA # OSC 16 1 3 �/
Expiration Date: /0 '
1. GENERAL INFORMATION
Complete legal description T1414, R1 W, Sec. 23, E2, NE4, SW4, NW4 & NE4, SE4, SW4, NW4
Location (site address) 25202 Mcintyre Road, Eagle River, Alaska 99577
Current Property owner(s) Paul and Sue Bischoff
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Audrey Mason, ReMax of Eagle River
11525 Old Glenn Hwy., Eagle River, AK 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
✓❑
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Day phone
Day phone
Day phone 622-3344
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 On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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 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 Certificate of On -Site Systems 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 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.
Name of Firm Douglas T. Kenley, P.E.
Address 9806 E. Northstar Dr., Palmer, AK 99645
Engineer's Printed Name
Douglas T. Kenley
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Phone (907) 746-1073
Date 7 � 2L � to
maw
OF
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other _
By: Original Certificate Date:
(Rev. 11105) _
Municipality of Anchorage
• Development Services Department
Building Safety Division v
On -Site Water & Wastewater Program
4700 Bragaw Street i4
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: T14N, R1 W, Sec. 23, E2, NE4, SW4, NW4 & NE4, SE4, SW4, NW4 Parcel ID: -ems
A. WELL DATA
Well type Private If A, B, or C provide PWSID # _ Well Log (YIN) N
Date completed UNK Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 54+ ft. Cased to 40+ ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test UNK 7/13/2010
Static water level
Well production
WATER SAMPLE RESULTS:
UNK ft,
UNK
1
Coliform 0 colonies/100 mL Nitrate 0.1 mg/L
Arsenic: -,40- mg/I Date of sample: 7/13/10
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
44.1 ft.
4.7 g.p.m.
Other bacteria colonies/100 mL
Collected by: F Kenley
Date installed 7/2/01
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y` Depression over tank (Y/N) N High water alarm (Y/N) NIA
Date of pumping 7/19/2010 Pumper JRs Pumpers
C. ABSORPTION FIELD DATA
Date installed 6129-7/2/01 Soil rating (g.p.d./ftz or ff/bdrm) 1.2 System type Trench
Length 50 ft. Width 5 ft. Gravel below pipe 4.39 ft.
Total depth 10.5-12.9 ft. Eff. absorption area 500 ft' Monitoring tube Y Depression over field N
Date of adequacy test 7/13/2010 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 0 in. Water added 847 gal. New depth 0 in.
Elapsed Time: min. Final fluid depth 0 in. Absorption rate >= 600 g,p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
II]S1111I;1111&1110aii[a]:I
Date installed Size in gallons _
"Pump on" level at in. "Pump off' level at
Datum Cycles tested _
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO
in.
Manhole/Access (YIN) _
High water alarm level at
Meets alarm & circuit requirements?
Septic tank/lift station on lot 100+ft. On adjacent lots 100+ft.
Absorption field on lot 100+ ft. On adjacent lots 100+ ft.
Public sewer main N/A Public sewer manhole/cleanout N/A
Sewer /septic service line 25+ ft. Holding tank N/A
Animal containment areas 50+ ft. Manure/animal excrete storage areas 100+ ft.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ ft. Property line 5+ It. Absorption field 5+ ft.
Water main N/A Water service line 25+ ft. Surface water 1100+ ft.
Wells on adjacent lots 100+ ft.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10+ ft. Building foundation 10+ ft. Water main N/A
Water Service line 10+ ft. Surface water 100+ ft. Driveway, parking/vehicle storage 5+ ft.
Curtain drain None known toexmt Wells on adjacent lots 100+ft.
F. COMMENTS: `FCO is located inside the garage
G. ENGINEER'S CERTIFICATION A • Mi " ` VV4
I certify that I have determined through field inspections and + • c > , ••
review of Municipal records that the above systems are in • DaIOtABT KINI.EY.
conformance with MOA COSA guidelines in effect on this date. rr ' ,• +� j
Engineer's Printed Name Douglas T. Kenley p ` •....• .,
Date / / /�
COSA Fee $ `i ! o Waiver Fee $
Date of Payment Z&aa /l /) Date of Payment
Receipt Number Receipt Number
(Rev. 11105)
In
Municipality of Anchorage
® y 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
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-521-21 HAA#dk 0lL� j(p
f. GENERAL INFORMATION
Expiration Date: /0
aJw ry /�fsL�y swryl�wyy
Complete legal description T14N
R1W, SECTION 23
41E�SE-1-/-4—SW
�_
Individual Water Storage
❑
Individual Holding tank
Location (site address or directions)
25202 MciNTYRE
ROAD * EAGLE
RIVER, AK 99577
Current Property owner(s) LES TIMS Day phone 694-6112
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
25202 MCINTYRE ROAD * EAGLE RIVER AK 99577
Day phone
SHARON MINSCH w/ REMAX PROPERTIES Dayphone 694-4200
16600 CENTERFIELD DRIVE * EAGLE RIVER, AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. Ta PE OF WATER SUPPLY: -TYPE OF WASTEWATER DISPOSAL:
Individual Well
[
individual On-site
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
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 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.
Note: Alaska Water and Wastewater Consultants, inc. shall be paid $1,050.00 at, or prior
to closing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, l 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 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 fs(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC.
Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this eualuafion, AWWC, Inc. attempted to provide a thorough,
conscientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the fest, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. AWWC, Inc. can therefore not provide
any warranty or future estimate of how long the system will continue to most the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Phone 337-6179
Date -7 le 7 /0/
MINNIMMMMI
e
f y A. Gayness;
jC —7953
caa
PrEc°o
n_e ao
Conditional approval for bedrooms, with the filow! ng stipulations:
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Manitenance Agreements
Supplemental Engineer's Reort
Other
sem` ON-SITE,,
WATER AND
41JASTEWATER :
PROGRAMA
gy: Original Certificate Date: %' - b
(R.'. 1&00)
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
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
rYy#NEY* StoYq t NJ&C .AJ - Alt YM fF_ YVr St✓Yy AlWx
Legal Description: T14N, Riw. SECTION 23, Parcel ID: 050-521 -21
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A
Date completed UNK Sanitary seal (Y/N) YES
Total depth 53'+ ft. Cased to 40'+ ft,
FROM WELL LOG
Date of test UNK
Static water level UNK ft.
Well production UNK g,p,m,
WATER SAMPLE RESULTS:
Well Log (Y/N)
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
5/29/01
39
7.6 +/-
Coliform 0 colonies/100 ml. Nitrate 0.5 mg./L. Other bacteria 0 colonies/100 ml.
Date of sample: 7/9/2001 Collected by: AWWC, INC.
B. SEPTIC/HOLDING TANK DATA *INSIDE GARAGE.
Tank Type/Material
STEEL
Tank size 1250 gal. Number of Compartments 2
Foundation cleanout (Y/N) `YES Depression over tank (Y/N) NO
Date of pumping
NEW
C. ABSORPTION FIELD DATA
Date installed 6/29-7/2/01 Soil rating .p.d./ or ft2/bdrm) 1_2
Length 50 ft. Width
5
Date installed 7/2/01
Cleanouts (YIN) YES
High water alarm (Y/N) N/A
System type TRENCH
ft. Gravel below pipe 4.39 ft.
Total depth 10.5-12.9 ft. Eff. absorption area 500 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test NEW Results (Pass/Fail)
Fluid depth in absorption field before test _ in.
Elapsed Time: min. Final fluid depth
Water added _ gal.
For—bedrooms
New depth in.
in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at in.
E. SEPARATION DISTANCES
High water alarm level at
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on
Public sewer main
100'+
100'+
Sewer /septic service line 25'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
10'+
Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 5'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
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 Print d N e JEFFREY A. GARNE55
Date 0,
HAA Fee $ : SG1O . CDO
Date of Payment 7,& 7A
Receipt Number 7&99
(Rev. 12100)
Waiver Fee $
Date of Payment
Receipt Number