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Home My WebLink AboutEAGLE RIVER VALLEY RANCHETTES LT 6A 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: ~c).~5'Ot"]O PIDNumber:. O~O ,,~ I~ Name: I<~,T~ ~ V'~w~ ~;'~.c.~-~z Wastewater System: D New ~Upgrade ~ ABSORPTION FIELD Phone: ~./~ ~No. of B~m,:~ ~ Deep Trench ~ShallowTrench DBed DMound DOther WELL: ~x,~r,.~ New ~ Upgrade Gmvelwidth: 5 ' Num~r of line,: Ft I ~ Ft SEPARATION DISTANCES ~Septic D Holding a S.T.E.P. Well' ~ ~ ~ ~ ~ t Material: ~ Number Of Compa~ments: Drain ~ ~0~ '¢ ~N, Remarks: BENCH MARK ~ CO N ~ . Depadment of Health and Human Se.ices approval Reviewed and approved by: ~ ~ ~ DatO:~-~/-~J' SW950170 2 2 P~Vlfllt It~. Page PAGE Mun{c{pal{ty 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 UCOA- LOT 6A, EAGLE RIVER VALLEY RANCHETTES~[nNNnpI[T bL" 05022124 Legal Descn~]on: co, co~ i i /09.4' { ' ' { ~-99.d' } ~ ~ , FINAL iCRADE-- { ~ l MTco/ .................... · .............................. * ......................................... i ...................................... ; ........................................ ~ ......................................... ~ ........................................ ~ .................. g2~t~. __.: .......................... ~ ...................................... ~ ~ ~ ~s8.~' WATS~ FOUND ~ ~ [ 7-~0~95 MAN ~ WAR RO~D ~ ~~ ~ Fco 4' 57' RAVEL i ~T1 12' 59' ~RIVE , { ~ ~T2 19' 60' { ~ LOT 6A UO2: 23' 62' EXISTING ~ ~ ~05 '42' 80' 4 BEDROOU ~ Uo4 ~71' 66' NEW 125o GAL HO,~,SE ~ ~T2~T1 70'46'~41' SEPTIC TANK~ ~ ..................................... [ ......... ~, ...... ~ ................................... .~! ..................................... ..?' ~ ~.,~ o~c. I MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519'6650 PAGE I OF i ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW950170 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:TINCHER KEITH A & VIVIEN W OWNER ADDRESS:18708 MAN-O-WAR RD EAGLE RIVER, ALASKA 99577 DATE ISSUED: 7/20/95 EXPIRATION DATE: 7/20/96 PARCEL ID:05022124 LEGAL DESCRIPTION: EAGLE RIVER VALLEY RANCHETTES LT 6A LOT SIZE: 17955 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIOn_ , RECEIVED ROBERTC. COWAN, RE. ROBERTA. SHAFER, RE. CML ENGINEERS (907) 694-2979 FAX (907) 694-121"1 ROaD DF. SIGN SOILTEST MUNICZPALZT¥ OF ANCHORAGE Pepa~:bne.nt of Hea~ and Hu~anSeruic~6 P.O. Box 196650 An~o~9~, AK 995~9 REFERENCE= Lot 6A; Eagle River te6t hole wa6 excavated and a per,oral, ton te6t perfo~u~ed in the area ;the p~opo6ed upgrade. The approx, tmatz location of the te~t hole Z6 located on ;the attached 4ite plan. the ~J~e of exeaua~Zon, ~a~er ma~ e~cou~ered a~ 14 {ee~ and after 6eue~ d~y grovel ~a~er monolog ma~er ~z6 ~ou~d a~ 9.5 {ee~. A~t~ched Z~ the propo6eE upgrade de~lgn. O]e do not a~pa~e a~ adverse effec~ on neZghbo~Z~j ~e~t~, 6epic 6y6tem6 or d~u~ge pa~er~ by the in~CLon of the 6ep~Zc 6y6t~. Zf Vo" requJ~e addd;tiona~ info,'u~za, td. on, please co~t~c~ u~. Sincere.tV, Robt.~ C. ~owan, P.E. RCC/gk E~c~o6u~e 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 I LEGAL LOT 6-A, DRAWN D.H.L · DESIGN CRITERIA: iC-]II'IEERJlI~ 4 BDRMS = 600 OPD SOILS = 1.2 GPD/SO.FT. 600/1.2 = 500 SO.FT. REO'D. REDUCTION FACTOR = 0.64 TRENCH DESIGN: 5' DEEP 2.5' EFFECTIVE 5' WIDE 64' LONG EAGLE RIVER VALLEY RANCHETTES IcKD' R.C.C. IDATE 7-10-95 ISNT. 1 OF1 STRUCTURES, EASEMENTS, OR ENCROACHMENTS SHOWN ON THIS SITE PLAN ARE AS SHOWN ON IT IS THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY EASEMENTS, REQUIRED SEPARATION DISTANCES, AND PROPERTY LINES PRIOR TO CONSTRUCTION. MAN 0 WAR ROAD CONTRACTOR IS REQUIRED TO OBTAIN UTILITY LOCATES PRIOR TO ANY EXCAVATION WORK. LOT 7B INSTALL EXISTING 1000 .~P~oTIC TANK N COMPLETELY EXISTING SYST£ A~ANOON COMPL[-r~.Y OVERHEAD ALL PORTIONS OF SYSTEM WITH LESS THAN 3.5' OF COVER REQUIRE INSULATION. EXISTING 4 BEDROOM HOUSE MT UTIL ESMT ALT. LOT 6C LOT 6A 'OSED 1250 GAL TANK FENCED )POSED TRENCH NOTE: THIS PROPERTY SERVED B3 PUBLIC WATER LOT 6B CLIENT ,E.FORMED ~=OR: /"e,'.,'/, LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16- 17 18 19- 20- COMMENTS Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street. Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST CE-880; WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPT., ~el~ la Wale~ Nl~r ~te: ~Z -3' ~S E Moail~ing? Gross Net Depth to Net Reading Date Time Time Water Drop ~ : ~ / ~ ~ ~ I ~/~ ~ ~: i~ ~ 9'/~ ! PERCOLATION RATE "~ (minutes/tach) PERC HOLE DIAMETER TEST RUN BETWEEN ~'' FT AND S & $ ENGINEERIt~ _/~//. / PERFORMED BY: ~'~r~ -~=~!-' ~~ve" I eep ~=d ~. ~0~1 ~ CERTIFY THAT THIS TEST WAS PERFORMED IN /. a 995~ ~ ' ACCOROANCE WI~~UNIC PAL OM 0EL "ES N EFFECT ON T"IS DATE. DATE: ? /h /~ ~ / 72~ (R~. ROBERT C. COWAN, RE. ROBERTA. SHAFER, RE. ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CML ENGINEERS (907) 694-2979 FAX (907) 694-1211 Lot 6-A, Eagle River Valley Ranchettes July 10, 1995 The scope of this project includes the installation of a 1250 gallon septic tank and leachfield trench to serve the four bedroom residence located on the referenced property. The existing septic tank is to be excavated, pumped, crushed, and abandoned in place. The existing leachfield is to be excavated, pumped, crushed, and abandoned in place. e Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 0 The contractor shall be responsible for obtaining any necessary underground utility locates. e Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Se Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INST~T.T.RTION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. me The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. ® Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP , SUITE 204 ° EAGLE RIVER. ALASKA 99577 oo Page Two Lot 6-A, July 10, Eagle River Valley Ranchettes 1995 e e Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the llne between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INST~.?-%TION~ Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sldewalls of the excavation become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soll backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. e Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. oo Page Three Lot 6-A, Eagle River Valley Ranchettes July 10, 1995 Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIM~MMATERIAL SPECIFICATIONS: me Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. m The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 0 Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the %200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements. oo Page Four Lot 6-A, Eagle River Valley Ranchettes July 10, 1995 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. e The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. o The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. Page Five Lot 6-A, Eagle River Valley Ranchettes July 10, 1995 S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER 18547 18607 18631 18709 18727 18809 18827 18847 18548 18610 18634 18710 lTD 16C /6D /5C 18730 18808 WHIRLAWAY 18828 18846 14B lid 13C · ,.18547 18609 El] 7,4 185§1 18607 1862'; 1872918807 18827 V MAN O' WAR 18847 18708 6C ez _o 6B 5A 18828 r) 2 ..... 6D 5C 18631 18713 18733 18809 18827 I 18848 50 CITATION ROAD GRrATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT ~': 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING .~, LOCA,,ON Z;/ /. Z Zg .. / EGALOESC.,PT,ON / SEPTIC TANK: DISTANCE FROM WELL ,~ ~'~/ ~,~/.,~.~,~/ NUMBER OF / MATERIAL COMPARTMENTS. LIQUID CAPACITY ~ GALLONS. INSIDE LE~ INSIDE WlDlfi _DEPIH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF FITS LINING MATERIAL NEAREST LOT LINE / OUTSIDE DIAMETER__OR WIDTH ,~"/e''~ LENGTH *'/,c"~ , DEPTH ~ ~/'~/ff~,,~'"'7" ~/',~,~ . DISTANCE FROM WELL, ~ ~/ . BUILDING FOUNDATION ~OTAL EFFECTIVE ABSORPIlO~ AREA ~ALL AREA) SO. Fl. TILE DRAIN FIELD: DISTANCE FROM WELl NUMBER OF LINES ABSORPTION AREA. DEPTH: TOP OF TILE TO FINISH GRADE , FOUNDATION DISTANCE BETWEEN LINES SQ. FT. LENGTH OF EACH LINE ., NEAREST LOT LINE .TRENCH WIDTH DEPTH OF FILTER MATERIAL BENEATH TILE TOTAL LENGTH , OF LINES IN. TOTAL EFFECTIVE IN. ABOVE TILF WELL: TYPE ~jk~../ /, ~,r'~ I/. ! 7"/~ S / DISTANCE FROM WATER · DEPTH . BUILDING FOUNDATION. _SAMPLE NEAREST SEPTIC/' SEEPAGE LOT LINE ,. SEWER LINE. , TANK , SYSTEM , CESSPOOL. DIAGRAM OF SYSTEM DISTANCES: , NEAREST OTHER , SOURCES GREATE NCHORAGE AREA ROUGH IIEALTil DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 279-2511 Case No. ~ · SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT NAME OF APPLICANT RESIDENCE ADDRESS J.D. Crow APPLICATION TO INSTALL: SEPTIC TANK TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH Self MAILING ADDRESS 8007 Seward H~HONE NO. .z~'t c h 99502 LOCATION OF INSTALLATION Man 0 War X , SEEPAGE PIT X , DRAIN FIELD ,OTHER TO BE INSTALLED BY Dan C. 'Bell 24 hr adv notice PERCOLATION TEST RESULTS ANTICIPATED DATE OF COMPLETION ~or final Inzp BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT THIS IS TO SERVE AS J.D. Crow , PERMIT TO INSTALL A Sewa_me System AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED 2 Bedr99[~ · SEPTIC TANK SIZE 1000 Gal TYPE Ste~l SEEPAGE AREA288sq* TYPE 2 Perf Concrete rings DIAGRAM OF SYSTEM DI~ANCES: 1. Septic tank to 1 Bldg 5' 2. seppage area 15' 2. Seepage area to 1. Bldg 20' 2. property line 20' 3. conform to all re5 regarding and CZ p~pe H~alt~.~l~{h~rity I certify that I 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. DATE APPLICANTS SIGNATUR~E ,' ~ ~4~'~, ~¢-'~----~ ^pti1 ~3, 1974 Veterans A4~inistratlon 429 O. Street Anchorage AK 9~577 Gentle,iCh: ~en enclosed diagram sho~s a IySte~ similar to ~hat ts ~equircd to meet local specifications. A systea such as UJts constructed on aR~ lot in Eagle River ¥~11e~ Ranchettes Subdivision could be expected to fJnctlon satisfactorily un- ttl publlc se~er ts available. P]ease notlf~ the undorstgned at the Ea~le River office tf you ~ish further assistance. Vet7 sincerely, John R. Lee, R.S. Eagle River District Sanitarian sr Enclosure :'(~' ' MUNI¢IPAUTYOFANCHORAG£",-~:~.-:: ,.~. DEPARTMENT OF HF_~,LTI~ & HUM~,N SERVICES . . Division of Environmental Services ..... , .... · . On,Site Services Section ...-~ .,; '- _. P.O. Box196650 Apch0mge.'Alaska .99519-6650 ............... CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING INFORMATION *:,ComPlete legal d~cripii0n Lo:~ 6A T Location (site address:or directions) lglOg M~zn 00J~,~ ', NOTE: If community .wastewater system, provide written confirmation from State'ADEC ..... attesting to th.e legality and status, of system."- ';~ ..,' ;,-" - --* --.--~..' .,'-' Pr.'o, I~e~'Y owr[,er ' "Ke'~t-A ~ FZu~z~ TZncA~. Day phone ~94-~4~ ::.-,Mailing addre~ ' '~glOg ., . :--.....:~.~?.,..~;~.., ..-.- =.~,..- , ........... Da_y phone :;.'"':-':Mailingad~re~ '' 1500 ~. B~on Au~ 4~ ~oo~ An~o~e, A~ Day phone - · . -.2. -.NUMBEROFBEDROOMS: 4 .. . . . ,-.~ ,, .. -'-~ .- }3.'?~'~PE OFWATER SUPPLY: -' ·: ' " · ~ ~: - · - .... ~ ...... ' ,~ -' . ' '...'.~ ...... , ~*' .:... ~.. ,.* ,..~.....-, ... ·., Indw~dualwell .... ~ ... m ~ ..... NOTE: If communi~ well system, provide wri~en confi~ation from State ADEC ~est- - - '* ' ':" ...... lng to the legali~ and status of s~tem. ' .........- .,,,' .. --'.,- I.~, ~ '.. "~:.." . Indvdualon ste - - . · . .~ :-. ..... - .... .... *,., ; .... 'Commun ~on-site .... : ................ ~'~:' ' '~ .... J,: : STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validatio~ 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 venfy that based on the'nformat*on 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. ****. ..... $& S ENGINEERING Phone ~; c/'/,,/_ ~.~' 7'~ Name of Firm I vu.~l P.~jle Rivm' Lo¢~ Road No. 204 . * Eegle Rlv~, Alaska 99577 Address ....... .. 6..~DHHS SlG~TURE ' ". Disapproved. · · -.- .. · -,' ....: .,. .., ~... ~.~.-~,,.. -. - - . "~ ~: ~nditional ~pm~l for ~r~ms. wi~ ~e following~ipulations: - - .... ... ~_~ .,.- .. , ,..~. - .. Additional ~mmen~ ,.*.-- ,* ~ ~-. ': "I'.L*, '..~ ','-., 71< ' · . ~l'he I~um~l~ali~ Ot~.~cl~ore~e I~:mrtment of H~alth ~nd Hum~n ~rvk:~ .(DHHS) i~u~ I.-~lth Authonht ":-.'~pmval C~rtlfi.c,,".~:,b~.~d only upon the representations given In paragraph 5 a.b?e by an Independent ~Br~f~i~fiai ~'n'~i[~r'~i~ered in the State of Al~k~.Tl'~ DHH$ do~ thI~ ~ a ¢ourt~ to pumh~m of hom~ [r~ the'i'~ t~ndin'g Ir~titutions in orderto satisfy certain federal and state requirements. En~Joyees 6f DHHS do not c6ndu~ Insl:~'flons or analyze data I~fore a ceffifi~te Is I,~J~d. ~ Municipality of Anchorage is not r~on~ible ~or ~rrom or omi~lon~ In ~'~ prof~ional ~n~In~r'a ~ork. · - .... Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT GA, F_.,~.~' A, Well Data Well type Leg present (Y/N) Total depth Sanitary seal (Y/N) Parcel I.D. O'=~O~,~ I~ I[~, or C, attach ADEC letter. ADEC water system number .Date completed Driller .Cased to Casing height. .Wires propedy protected (Y/N). FROM WELL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: SeptioT,,,;J;,,~ tank on lot ~c)o/~ Absorption fie~d on lot =~:)/,~ Pubiio sewer main Sewer service line g .p.m. ATINSPEC~ON ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanoul. Petroleum ta~ WATER SAMPLE RESULTS: Coliform Nitrate .Other bacteria Date of sample: Collected by:. B. SEPTI~ TANK DATA Date Installed ' "7- ~-/-q~ Tank size 19 ~ OAC~"S Compartments. Cleanouts(~lN) (-/'e-~ '?" Foundationcleanout(~N) ~*/,~r'~ Depression(y~ High water alarm (Y~ '/,,~o Alarm tested (Y~) Date of PUmping t,J/~ - /,/-~'~ sy~.-r~'~,/ ' Pumper -- SEPARATION DISTANCES FROM SEPTIC/HC)L-~iINGTANK TO: Well(s) on lot 2oo '," On adjacent lots -- Foundation To property line '~ 5 ' Absorption field Iq ' .Water main/service line ~o %- Sudace water/drainage Ioo '-~ · ~.o2e (~3). ~ra~ CONTINUED ON BACK pAGE C. UFT STATION Date Installed ManufaCtUrer Size in gallons Ma'nhOlelAcc;ss (Y/N)'- Vent (Y/N) Hig~ water alarm level cycles t~sted~ ~- Meets MOA electrical codes (Y/N) ~. -, SEPARATION~' ' ' ; ~* ' '~' .'' Well~ - On adjacent lots ' Surface water D. ABsoRPTIoN FIELD DATA Length /~"J ~W'~h ' ~ ' .Gravel thici~ness Total abSOrption area'. ~oo 9~ - CleanoUt Present ~ Date o{ adequacy te~ ~//~- "~'~" 5,~.~ ReSUlts (pas~ai]) Water level In abso~lon lield before test '-' Peroxide treatment (past 12 months) (Y/N) sEPARATION DISTANCE FROM ABSORPTION FIELD TO: Systemtype ,3H,~-~ 're~,,¢~ Total depth (~ ~' Depression over field (Y~) /',/o ' for ,/ Bedrooms : If yes, give date .300 ~-~- On adjacer~ lots /,,'/.~ ~mp~ line To existing or abandoned systemon Iot- Cutbank ~-0 ' +- .... Water ma~sewice line Driveway, pa~ng/vehicle storage area W? ' Well on lot To building foundation On adjacent lots Surface water I00 Cu~lain drain E. ENGINEER*S CERTIFICATION ~is inSpe c~on. I cer~lhat I have checked, vedfled, or conformed to a]IMOA andHAA guide/inesin eff~_~~,~([ · ,: , ., -- ,. , . HAA Fee $": ! ~' r./f~ '; ' ' Waiver Fee $ · ' ~ ' ' * Date of Payment ~>/dc~/,~''~ '''-- Date of Payment ' - Recelpl Number ,~./'~','~'~//~.// Recelp~ Number