HomeMy WebLinkAboutNORTH WOODS BLK 4 LT 19- 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: ~'~CJ~'~) L~
Name: ~ ~ ~~ ~ WastewaterSystem: ~ New O Upgrade
Phone: ~--~0~ '1 ' :3 =D.pTrench ,ShallowT.nch ~Bed =Mound =Other
WELL: O New
IPumpset at: pt. I Casmg ~e'gm ~ove Greu;::
SEPARATION DISTANCES
Wel~ ~ ~ - . ·
Lot
,o~..,,o. D~' 17' 2)'
cu~,. N r~
Remarks:
TANK
i'1 Septic t-I Holding 1'I 9.T.r-.~,~OC ~l~.
LIFT STATION
s'i'~;~'~': I"'"~'~"''~' ~:~¢ w/~
"Pump on" level et: "Pump off" level al: High water alarm
~.vs" I ,~.'~" I ~,.as"
BENCH MARK
~ po,~
Dates: 1st q.-13-q~
2nd ~~~Z'tlq
17034 Eagle River Loop Road, No. 204
Inspections pedormed by: Eeqle River. Alaska 99577
Department of Health and Human) Services apprqva!
Reviewed and approved by: '~.~/'~l../~.~ Date:
PERMIT NO. SW980428
PAGE 2 OF
Munlcip. oH~ o?
DEPARTMENT OF HE~_THAND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 eAnchorc~ge, AIo. sk~ 99519-6650eTetephone' 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
L~CAL LOT 19, BLOCK 4, NORTH WOODS S/D P.[.D, No. 051-741-02
I
lOX15 I
Anchor Esm~
P£~IT No. SW980428
un~op, ct · o Anchor'oge.
DEPARTMENT OF HE~_TH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 eAnchor~ge, Al(lsk(i 99519-665Oe Tetephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LECAL LOT 19, BLOCK 4, NORTH WOODS S/D
PJ.D. NO. 051--741--02
MANHOLE
J1 A B C
L FCO - 48,5' 10.0'
BIO - 4;5.0' 41.5'
BIOCYCLg ~,rl 52,0' 40.7' -
UNIT ~r2 44.0' 23.0' -
~Ir 3 83.0' 43.5' --
~,~r4 85.5' 52.5' -
TBM: TOP OF GARAGE SLAB
....... ASSUMED 100.0'
MT2- - MT~._]MT~ = 10~'.0',
/ IMT2 = 105.0
__~ /FINAL GRADE
.................................... /2" INSULATION
SR A
NO WATER FOUND
MT2 = 100.0 ~"-MT$ = 100.0' B.O.H.
MT4 =
MT4 -_ MT I._]MT 1 = 10'LO'
/ IMT4 = 107.0'
~ /FINAL GRADE
102.0' MTI = 101.0'
. CARCEL ELECTRIC INC.
10410 FtN~.EY CIR. · 'ANCHORAGE, AK. 99518
90?-346.4030 · 907.34~.4032 ~
Tweed Excavating
17034 Eagle River rd. #202
Eagle River, AK 99577
To whom ~t ma~ concern=
RECEIVED
AUG lO 1999
Munlcip.~lity ot Ancl~orage
Dept. Health & Human Services
~ul¥ 14,-1999
Cagcel Electrlc wired the Bio-Cycle located et 22733 Nc~enna
Lot 19~ Bk-4, Northvoo~ls Sub., Chugiak RK. '
This Bio-Cycle was wired per the 1996 National Electrical
Code. If you have any questions please give me a'call%
Thank you,
Steve Cloud
General ~ana~er
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box '196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
L~ te Issued: Nov 04, 1998
Expiration Date: Nov 04, 1999
Permit Number: SW980428
Legal Description: NORTH WOODS BLK 4 LT 19
Design Engineer:. 0003 S & S Engineering
Owner Name: Robert A. Shafer
Owner Address: PO Box 773303
Eagle River, AK 99577-3303
Parcel ID: 051-741-02
Site Address:
Lot Size: 24854 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
[] DisposalField [] SepticTank [] Holding Tank [] Privy
[] 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 Ddnking Water Regulations ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours pdor to each Inspection. Provide notification by calling
(907) 3434744 ( 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.
5. The following special provisions.
This permit is for a BioCycle
Received By:
Issued By:
September 9, 1998
ROBERT C. COWAN. RE.
ROBERTA. SNAFER. RE.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
lVlUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 19, Block 4, North Woods Subdivision
Request you issue a permit to install an innovative (BioCycle) system to serve the
proposed three bedroom house on the referenced properD'.
One test hole was excavated and a percolation test was performed. The approximate
location of the test hole is located on the attached site plan.
At the time of excavation, ground water was encountered in the test hole at 10 ft. After
seven day groundwater monitoring, the monitoring tube was checked and the ground
water level was found to be at 8.5 feet.
We do not anticipate any adverse effects On neighboring wells, septic systems or
drainage patterns by the installation of the proposed septic system. The construction of
this system will not prevent any future development on adjacent properties.
This subdivision is serviced by a Class "A" water system.
If you require additional information, please contact us.
Sincerely,
/;:t2
Robert C. Cowan, P.E.
RCC/srj
Enclosure
17034 NORTH EAGLE RIVER LOOP * SUITE 204 * EAGLE RIVER. ALASKA99577
PHON[I (g07)694-2~79
Z
Z
s.r.d, r.c.c. I rev~se~ ~o-~-~1 ~ or ~
STRUCTURES. CASEMENTS. OR ENCROACHMENTS
~IIOWN ON Tiffs SITE PLAN AR[ AS SIiOWN ON
WILLIA~ FL[~ING
~. D ISTANC,S. AND PROPERTY LINES PRIOR '0.
CONSTRUCTION. ~ ~x~
/,??, /' , ,
OGTAIN UTILITY
, , F
78' LONG (2039') j
~IOCYCLE UNIT
SlT~ ~
PROPOSED FI~ ~ ~ ~
DESIGN CI{I'I'EI{h\:
3 BDRM = 450 GPD /
SOILS -- 0.4.5 GPD/SQ.FT. /
450/0.45 = 1000 SO.FT. REQ'D./
AREA/2 FOR BIOCYCLE = 500 S,Q. F'T.
500 x 0.78=.390 SO. FT.
/
~TRENCI.I CRITERIA:
4' DEEP
1.5' EFFECTIVE
5' WIDE
78' LONG (2039')
ALT. CI¢.ITERIA:
4' DEEP
1,5' EFFECTIVE
5' WIDE
Z
3 BDRM = 450 GPD
SOILS = 0.45 GPD/SQ.FT.
450/0.45 = 1000 SQ.FT. REQ'D.
AREA/2 FOR BIOCYCLE = 500 SQ. FT.
500 x 0.78 =$90 SQ. FT.
PROPOSED WATER
SERVICE LINE
'TI:~E NCH CRITERIA ,o .-
4' DEEP
1.5' EFFECTIVE DRIV
5' WIDE
78, LONG
~ ~ROPOSED DRAINFIELD
ALT. CRITERIA: BIOCYCLE UNI
4' DEEP
1.5' EFFECTIVE ~ ~ .
200' WELL RADIUS .............
~STRIBUTIO~--~~[] ........... ~ ~'"'' ~l ALT. S~ITE
PUMP = MYERS M~40 (~60GPM)
2 LATERALS ~ 5g LONG = 50 GPM/LAT.
56 HOLES TOTAL = 1.65 GPM/HOLE
1/4" DIA. HOLES FACING DOWNWARD
1 1/~" DIA. LATERALS ~L~ PoR'rlo~s or
HOLE SPAGING = 2.0' ~rm I.~ss tn~ as' or /
COVER REqUiRE INSUl~'rlo~.
'"~" I,()T 19, III,OCK ,1, NOR'i'll WO01)~ ,'-;/1)
S.R.J. R.C,C. 9-1-98 3 OF
SIDE VIEW
5' WIDE SIIALLOW TRENCII
I)ISTRIBUTION SYSTEM:
PUMP = MYERS ME40 (~60GPM)
2 LAIERALS ~ $9' LONG = 30 GPM/LAI.
$6 HOLES IOrAL = 1.65 GPM/ItOLE
I/4' DIA. IIOL[S £ACING DOWNWARD
I I/4' DIA. LAIERALS
IIOLE SPACING -- 2.0'
'"* I,OT 19, IH,{}(;I{ ,1, NOI~.'I'II XY()OI)~
S.R.J. R.C.C. 9-1-98 4 OF
BIOCYCLE WASTE WATER TREATMENI SYSTEM
5.94"
COVER
7.6'
(2.~,~)
I
i--2.95"
/
/
6.97'
~////////////////////~ ,
..,--
X-SECTION
TANK
5,94"
PERFORMED FOR:
Municipality ol Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
13-
14-;
15-
16-
17-;
18-
194
20-
Township, Range. Section:
SLOPE
SITE PLAN
ENCOUNTERED?
IF YES. AT WHAT
DEPTH? /O
Mon,0ring? ..r ////'"Date,: C,,, /Z..
· - Gross
Readihg Date Time
/
6
"7
S
L
O
P
E
PERCOLATION RATE
· '[EST RUN BETWEEN.
?n ~. >~ .-' ~-/' I,/,,. s~.
6 l 4'
I
Net DeDth tO Net
Time Wate~ Dr(~D
Cd IO;~°h ~ ~" I*~
{mlnutes~nchl PERC HOLE DIAMETER
S & S ENGINEERING '/ /
17034 Eagle River Loop Road No. 204
FERFOPMED BY; E=gle River, Ala3ka 295,77 I///~"~'3. . ~ CER'[IFY '[HAT '[HIS '[EST WAS PERFORMED IN
ACCCf~DANCEWITHALLSTATEANDMUNIClPALGUIDELINESINEFFECTON'[HISDATE. DATE: '
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage. Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: ~" ,"~ ~
1 -
,,R ,,7 '
LEGAL OESCRIPTION:~'- 4~ '~""/d~/ ..~ ,~ / ~, /~,,.',~ .e'~'~.o'_w.'r~ship, Range, Section:
ELOPE
WAS GROUND WATER
ENCOUNTERED?
x S
/ L
IF YES. AT WHAT /~. 0
DEPTH? p
De,th to Water Ntor ·
Monitoring? , /': Oat~.
Gross
Reading Date Time
Net
Time
.'.,,/
13-
14-
15-
16-
17-
18-
19-
SITE PLAN
I
Oe[3th to Net
Water Drop
,~ '~7~, " l/A,"
~ " i~,
g-' /~
~" /"
20 - ,~/-; ~,,- /, .x,: ~ ~z'=.-/-I~; ~' ~..J
PERCOLATION RATE .'~*'~ tm.nutes/sncr~l PERC HOLE DIAMETER
TEST RUN BETWEEN '~ FT AND ~ FT
COMMENTS
5 & S ENGINEEEING
1 ' ' ' '
7034 E,~jI. R,.~r Loop Koad No. 204. , -- -'// ~
PERFORMED BY; Eagle River, Alas~ca g9~77 I ' '[~' / ~' -: ~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: I I / ~ / ~ ~
72-008 (Rev. 4/85)
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
ROBERTC. COWAN. RE.
ROBERTA. SHAFER. P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
REFERENCE: Lot 19, Block 4, North Woods Subdivision
August 4, 1997
GENERAL:
The scope of this project includes the installation of an "innovative" Biocycle
Wastewater Treatment System and two drainfield trenches to serve the proposed
three bedroom residence to be located on the referenced property..
Construction shall be in accordance with the approved site plan and desi~
drawings, M.O.A. permit xvith any special provisions or conditions, and all
applicable Municipality Wastewater Disposal Regulations.
The contractor shall be responsible for obtaining any necessary underground
utility locates.
Unless specifically agreed otherwise, the property owner shall be responsible for
final grading areas subsequently depressed from soil settling.
Contractors installing wastexvater disposal systems must be familiar with
construction practices in this area and either be certified by the Municipal Health
Department or have been previously certified under the D.E.C. certification
program. Oxvners installing their own systems must also receive prior approval
from the M.O.A.
ABSORPTION TRENCII/DRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The
bottom &the excavation shall be within 2 inches of level. If the sidewalls ofthe
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 betxveen the final gravel layer and the native soil
backfill. Ensure the silt barrier covers the entire gravel surface before placing
backfill.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 ,, EAGLE RIVER, ALASKA 99577
Page Two
Lot 19, Block 4, North Woods Subdivision
August 4, 1998
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.
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.
MINIMUM MATERIAL SPECIFICATIONS:
Any septic tank proposed for installation must be constructed by a Mm,icipally approved
septic tank manufacturer.
The following pipe materials are approved for use in septic system installations in the
Municipalit3' of Anchorage:
Type o f Pipe Perforated Solid
Cast Iron Yes
ASTM D303-1 (PVC) Yes
ASTM F810 (HDPE) Yes
ASTM D2662 (/kBS) Yes
Yes
Yes
No
Yes
Use ora type of pipe other than listed above must be approved by the inspecting engineer.
Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Swrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder. Femco, 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.
All leachfield gravel (server 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.
Page Three
Lot 19, Block 4, North Woods Subdivision
August 4, 1998
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 max, be set in place,
but may not be backfilled before this inspection.
The second inspection must.be conducted after the placement of the silt bah'let,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the properD.'.
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 o~vner 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. 5; & S Engineering shall be
the o~vner'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.
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 Engineefing'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
PROPERTY OWNER AGREEMENT
FOR TItE MAINTENANCE OF AN
ON-SITE WASTEWATER DISPOSAL
SYSTEM
This agreement, dated August: 17 1999, is made between the Municipality of
Anchorage Department of Health and Human Services (DHHS) and the property
owner(s) of:
Lot 19, Block 4, Northwoods Sutxlivision
This agreement is made for the purpose of maintalnlng aa on-site wastewater disposal
system on the subject property.
The property owners agree to th, e following:
Submit to the Municipality of Anchorage, on an annual basis, an inspection and
operation statement from a registered professional engineer. Th.is inspection and
operation statement shall verify that the engineer has inspected all effluent and air
pumps, timers, and alarms, and that any deficiencies have been repaired and that the
system is functioning as designed.
(Sigmmre)
(Signature)
Troy K. Laird
..NOTARY..
~gZg 'X V "[(~.~x~'xsSN'o t ar = e Here)
Teri D. taird
(Printed Name)
~".':.Cyc]e,~LASKA W^STEW^TE~
TREATMENT
SYSTEM S .'.
?~ ~}3 McM~m~s ~lve ,13630 ~ R~
'
· .. .,' I. - DEPARTMEN'[OF & HUMAN SERVICES .
.... Division of Environmental Services .
.... ,-~: :..- ...... · --~" ': :On-SiteServicesSe~ti6n ..... '. '*~'
· '.:., ,...- ,.. ........ ·. P.O. Box 19~50 .~ Anchorage. Alaska. 99519~650 ~; ~ .:.. · ." '- .
,':: :~ .~.-.~,~.~.)~:~, ./,~ ,, · '.~': -.:'.', .... ~343~7~. : , . ~ .... ~ ......
. ';-,',': -.- ~ .. ,, ., CERTIF CATE OF H~ETH A~THORI~., - '
' ' ~ ...... '-"'7 ' APPROVAUFOR A SINGLE FAMILY DWELLING ' ~ ": /
1." GENERAL INFORMATION .,. ~ .,: ~'~'=:1 ~?.: ~.¢~ ~,.~a ~.'~ ~: :.c=~; , -
oca.~gn,(site~address or d~recho, s) ;~
. ~ B[O~owner;T.he. ~homas~Co./Eike ..~ho=as, ¥ .-~ Da..hone.
· =.~ Lending agency = · ~ '- ~- ' ...... ' - ' ....... Day phone
~a ngaddress x ~
Ageht,- ~" ' ~ ...... ,' ' ' ~'' *[D~yphone - '"
Address ":' "' ' '
less oth e u t ~ill Id ic **. ~". ~ .
~ NUMBER OF BEDROOMS: ~ : ~ : .,: * '
"' Individual well''
c0mmbniW well: ,.
Public water XXX
NOTE: If communi~ well s~tem, provide wri~en confi~ati~n from State ADEC a~est-
;.... ',- !ng to the l~ah~ and s~atus of system. . .. :: , . :~, . :;. · ~.,~
4. TYPE OF WASTEWATER DISPOSAL:
XXX
NOTE:
Individual on-site
-- '(3ommunJty on-site . ...
" " ' Public sewer ' "~ ,'; :"-
If com~nunity wastewater system.'proc'ide written confirmation from State ADEO
attesting to the legality and status of system. '
5. STATEMENT OF INSPECTION BY ENGINEER
'.As certified by,~. y ;:eal affixed hereto and :~s of th~ validation'date shown below, I verify that my
investigation 6f this'Health Authority A. pproval app-lication- shows that the ~n"site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure in~:licated herein. I furtherverify that based on th~informationobtained from
the Municipality of Anchorage files and fro.m, my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in comphance.with all Mumc;pal and State codes, ·
ordinan, ces, and regulations In effect on the date of this inspection. · * * '. ' - ' .
".-"'Name of Firm - s & s ENGINFE~lN~ ..... Phone
En eer's s atu e' '.' "" Date
..... · ' Disapproved.'-:":'~ .............
COnditional approval f(~r
Additional Comments
'bedrooms,-.Wlth the following 'sfipulabons:
"The Municipality of A..nchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only uPOn the representations given In paragraPh 5 above by an Independent
professional engine' registered in the State of Alaska.The DHHS does this as a courtesy to purchasers of homes
and their le~ding Institutions In order to satisfy/certai n federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before · certificate is Issued. 'The Municipality of Anchorage is not
re~nsible for errors or omissions in the professional engineer's work.
Municipality of Anchorage .~ o~ ~~
DEPARTMENT OF HEALTH & HUMAN SERVIC~;;~.~.~.~
Environmental Services Division ~.~'~"-
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
LegalDescriptlon:LoT Iff E,L~ck ~ /U~g?I¢~o~).~ ParcolI.D.: 05'/ -'191 --0 ~
A. WELL DATA /~ ,.,~c.~ (_ I.~
Well type
If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Date completed
to Casing h~
Cased
w.~c<~e-~ protected (Y/N)
FROM WELL~ AT 17$PECTION
Well production
WATER SAMP~
g.p.m.
Nitrate Other bacteria
Collected b/:
B. SEPTICfllOLDIflG TANK DATA
Datelnstalled -//$/=1~ Tanksize ;~-eo
Founcl~tioncleanout~lN) ~/~ ~' Depmssion(Y~
Date of Pu'mping ~'/~ '-~¢.~ Pumper
C. ABS0RP~ION F1EID DATA
Number of Compartments
Date install~l ~/I 3 t q o/ ,~i.I rating~[~or fff/bdrm)
Eff~ ~m~on ~a~y ~r
Da~ of adequ~ ~t ~ /4 ~ ~ ~
g.p.m.
(~ .¥5-' System type
Gravel thickness below pipe j' ~' Total depth 5"
Monitoring Tube present ~) Y~ $ Depression over field (Y/~). ~" 0
Results (Pass/Fall) For ~ bedrooms
Fluid depth in abeorptlon field before test (in.);.
Fluid depth (ins) Mln~.~atl~''~''~-.
Pemxide~th~)
Imrserllntgly ~,ftur gal. water added (In.):.
Abeorption rate = g.p.d.
If yes, give date
72-026 (Rev. 3/g6)*
UFT 8TAI'ION
Date ,,~led
ManholeJAcc~N)
High water alarm level
Size in gallons
"Pump on" level at* 'ld re
*Datum
}5-0 0
'Pump off level at' I 7 ~/~/ ~'
Cycles te~ed
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot On adjacent lots
Abeoq3tion field on lot ~
Public sewer main /~/Public sewer manhole/cleanout
Sewer/septic s~eo~.e11~ Uff station
,O~o cycL4.
SEPARATION DISTANCES FROM SEPTIC2HOLDIIqG TANK ON LOTTO:
Foundation ~ 7 Properly line / ~o Absorption field
Water main/service line /0 'f Surface waterldraJnage' ]o0 ~
SEPARATION DISTANOE FI:IOM ,I~BOR~I'ION FIELD OH LOT TO:
Property Hne ) ~ Building foundation ) ~'
Wells on adjacent lots
Water main/saUce line
Surlace water / o 0 4- Driveway. parking/vehicle atomge ama '/
Curtain drain /~ a,v~, ~¢,~o~v~ Wells on adjacent lots '~ 0
F. ENGINEER'S CERTIFICATION
., c,,,,,o,,,,e,,ce w~ ~,o~ ,~ ,,,.,,,:,o,,,,,,. ,,, .,,~ on .,,s ,,,,,,, Z'~;"
Engineer s Name /r~ ~w6~'4- r' /~'' C o/,o/f,o
.,, / , [.~\ ma, c. e~,. I,~Z
oat. -,,, / '~'~ '~:,,.. "-"°'
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72..02~ (Rev. 3/96)*