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HomeMy WebLinkAboutTONJESS ESTATES BLK 3 LT 17Onsite File L Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191351 PID Number: 051-832-06 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New © Upgrade Name Steven & Marita Lerwick ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed �ound Site Address 25260 Schaff Drive Chugiak, AK ❑ Other Phone Number of Bedrooms Soil Rating depth f original grade 4 GPD/SF JTotal Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Fl. Subdivision Block Lot Tonjess Estates 3 17 Fill added above original gr a Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft SEPARATION DISTANCES To Septic Absorption ! Holding Station Sewer Total aXorption area Number of trenches Dist. between trenches From I Tank Field (Lift I Tank Line � Ftz Ft. Well 100'+ 71��> TANK 9 Septic ElS.T.E.P. [ED]Holding El Other Manufacturer Greer Capacity 1250 Gal. Surface water 100'+ Material Number of compartments I Lot Line 5f+ ( NA plastic 2 Foundation 10'+/ LIFT STATION Manufacturer Capacity Remarks Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank Tank to 3034 drainiield 3034 Jr's Septic Services Drainrield cotMT3034 Inspector Pannone Engineering Services BENCH MARK (Assumed elevation) 494.0 ft Inspection es: 1"9/3/2019 2a 9/4/2019 Location and description 3N 4" Bottom Trim @ A ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date OF Ti -I cry I . r'.tr....�. t<.`.,L Septic System f-- Approved` Note: this approval does not include well permit requirements.���`�" rRo„ n�m�f�rai Lo 0 �0 00 Q3 -Ic Kz(ncnv>z;0 Zc�Jl��Z��FT1 �oorOPx�m� °czoc�inO�C CNnrn `sad � r��C��WD(n m t(A � Z�DtDNO 0 OmX*Dzz_!v y ry-mA�DO� O O m c�ri - _.. �mr'!T rrrl z �C�Oci omo I n OO N :� m -Izz Z 0 O D onD z m m m D — z S 1 Z ;rl (n� 0 rn O m ;u O rn E n � fTi v m\ r \ \a O ? FOUNDATION CLEAN OUT(E) MANHOLE CID \ na U \ �� �\ �-, i C, N-�� I MT co \ oT \ \ �\ J D i `� m m y z CLEAN OUT ro �\\ \ \\ i N \; W �� \ \ \ 1 \– \ _O N r a I m ( DOUBLE CLEAN OUT \ J \ ��a >�0 \ 1 \ \ \ >-a \ I \ \ \ rm'rn OA \ z \♦ Oj C \ \ DIm I_D A- --5a -511 C)N \ \\\ \ o, NOTES: PANNONE ENG SVC, LLC P.O. BOX 1807 PALMER, AK 99645 PHONE 901) 745-8200 FAX 907 745-8201 =S OFA(, \sj ���P•' ;f9f� REVISIONS DATE 9/5/2019 RECORD DRAWING SCALE TONJESS ESTATES B3 L17 STEVEN & MARITA LERWICK 252 %*' *I j I'•$•leven .'�o none/ �� �1+1i` 60 P.I.D. NO 051-832-06 -DRAWN ACP SITE PLAN CHUGIAK, ADRIVE SHOTP709�351 \\ MUNICIPALITY C}FANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 Permit Number: OSP191351 Work Type: SophoTankUpgoade Tax Code Number: 05183286000 Site Legal Address: TONJESS ESTATES BLK 3 L 17 GA 462 Site Mailing Address: 252S8SCHAFFDR, ChuQiok Owner: LERVV|CKSTEVEN E&MAR|TAA Design Engineer: PANNONEENGINEERING SERVICES This permit is for 'the construction of: El Disposal Field Z Septic Tank 0 Holding Tank 0 Privy Effective Date Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 8/19/2019 8/1812020 R Private Well 11 Water Storage All construction shall beinaccordance with: 1. The attached approved design, 2. All requirernents specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (1BAAC73)and Drinking Water Regulations (1OAAC8O) 1 The Wastewater code requires inspections during the installation. The engineer shall notily the Development Services Department per AMC 15.65.Provide notification bycalling (SO7)343'7QO4(24/7)� 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall beeither m. Opened and Closed onthe same day, ur b, Covered, sealed, and heated (uprevent freezing Received By: Date-, 4 MUNICIPALITY OF ANCHORAGE Community Development Department -343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-832-06 Property owner(s) Steven & Marita Lerwick Mailing address PO Box 770132 Eagle River, AK 99577 Site address 25260 Schaff Drive Chugiak, AK Day phone Legal description (Sub'd., Block & Lot) Tonjess Estates B3 L17 Legal description (Township, Range & Section) Lot Size 51,453 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑x (w/wo ADU) Septic Tank NUpgrade ❑X (D) El Holding Tank ❑ RenewalDuplex ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: a� CrIv 5 Waiver Fees: Date of Payment: g Date of Payment: Receipt Number: C09 G Receipt Number: Permit No. O SPI9 1 351 Waiver No. Permit App_-'-:. . ..:c Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191351, Rebecca Carroll, 08/19/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191351, Rebecca Carroll, 08/19/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191351, Rebecca Carroll, 08/19/19  ~ MUNICIPALITY OF ANCHORAGE ~' ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT N AM E ,~..,,~'~ ..~[ ~ [ ~PHONE I ~.~.,o..I ~.o~=-. ,..,~.,..,~ .,~,~ Manuf~turer .~ / QJ .___ ..... Material Liquid capacity in ~llon, _ Length W*dth ~pth PERMIT NO. Ty~ of crib Cri~ di ~ib depth Total elf~tiw e~orption area DISTANCE TO: Well / ' Building f~ndation Near.t lot line Cla~~epth Driller Distance to lot line I PERMIT NO. Building foundation Se~r line Septic tank I Absorption area(s) DISTANCE TO: ,,'~'-.~EW r-IUPGRADE OTHER PiPE MATERIALS SOIL TEST RATING ,j~Z'~ ~ DATE LEGAL ---z PERHIT DRTE ISSUED: 1,1Ur..I T C 'r~",F~I_T T'~' OF RI'-,IC:F"'~RRGIS DEPFtRTMENT c,' HERLTH RND ENVIROI'.,IMENTRL ~.-~OTECTION 825 L STREET, RHCHORRGE, RK 99501 264-4720 Ot'.l--5 1' TE ~E;EL'iER 'PERI'I T T 840011 APPLICRNT: RDDRESS: COHTRCT PHONE: S&S ENGIHERRING ERGLE RIVER, RK 99577 694-2997 LEGRL DESCRIP: LOT SIZE: MRX BEDROOMS: BLOCK: LISTED BELOW RRE THE OPTIONS RVRILRBLE TO'YOU IH DESIGNIHG YOUR SEPTIC SYSTEM. CHOOSE THE OPTION THRT BEST FITS :YOUR SITE. TREI'~ICH BEE:. 14. [;.ER I t4 DEPTH TO PIPE BOTTOH (FT.) 4. 0 4. 0 4. 0 GRRVEL DEPTH (FT.) 6,~_.0 0. 5 3. 5 TOTRt~ DEPTH (FT. > 10. 0 4. 5 7. 5 GRRVEL WIDTH (FT. > 2.5 16. 0 5. 0.. GRRVEL 'LENGTH (FT. > ~.~,..~ 32. 0 37. 0 GRRVEL VOLUME (CU. YDS. > 17. 4 IS.'9 27. 4 SOIL RRTIHG (SQ. FT./BR) 85 85 85' ** TRNK HUST HRVE RT LERST TWO COMPR~,TME/.ITS' I CERTIFY THRT: l., I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEHERS RHD WELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE (MOR) RND THE STRTE.OF RLRSKR. 2. I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH RLL MOR CODES RND REGULRTIONS, RND IN COMPLIRNCE WITH THE DESIGN CRITERIR OF THIS PERHIT. 3. I WILL RDHERE TO RLL MOR RND STRTE OF RLRSt(R REQUIREMENTS FOR THE SET BRCK DISTRHCES FROM RHY EXISTIHG WELL, WRSTEWRTER DISPOSRL SYSTEM OR PUBLIC SEWERRGE SYSTEM ON THIS OR RNY RDJRCEHT OR HERRBY LOT. 4. I UNDERSTRND THRT THIS PERMIT IS VRLID FOR R MRXIMUH OF 4 .BEDROOMS RND RNY ENLRRGEMEHT WILL REQUIRE RN RDDITIONRL PERMIT. WILL NOT BE RPPF ELECTRICRL WOR SIGNED INERRING ISSUED BY qSTRLLED IH 8H RRER COVERED BY MOFI BUILDING CODES, 'PERMIT RND INSPECTIOH MUST BE OBTRIIqED~ (:2) RS-BUILTS' .FiN ELECTRICRL INSPECTIOIq REPORT~ RND (3:) THE BY R LICENSED ELECTRICIRN. DRTE: DRTE: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG [] PERCOLATION TEST 7- 11- 12- ' 13-r ~ 14-- 16- 16- 17- 18- 19- 20- PERFORMEOFOR' OATEPE.O.MEO: SITE PLAN WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT DEPTH? Gross Net Depth to Net Date Time Time Water Drop Reading (minutes/inch) TEST RUN BETWEEN COMMENTS "' ' PERFORMED BY: ~; .~ ~.- ~ . '' ' 72-008 (6~9) '~'~ FT AND FT · . .;..: i. P.O. BOX 272, CHUGIAK, ALA'SK~A 97~? · TELEPHONE 688-2759 SULLIVAN WATER WELLS OWNER OF LAND /'~g,~ "~) DEPTII OF WEL KIND OF CASING /,,PO ~EGALDESCRIPTiON Zo7 17 DATE-Started I/]~/t~" Ended PERMIT NUMBER KIND OF FORMATION: ' ~ ri.,,, .-.9. ri. ,,.,,/&e,~,~,,~.=,A/. r,om__rt, io F,.t&/~/,,_lu, q__ .. Ft. to~ ~-, Ft.' ~' ~'-J fl (' '~'~ ~& ~' From __ Ft. to Ft. From __ Ft. to From Ft. Io From Ft. to ~'~-°~'~¢ r ~ rt. to From~Ft. Io From Ft. to Ft. Ft- Ft Ft. Ft. __FI. to Ft. FLto Ft. Ft. Io Ft. FI. to Ft.' FL to FI: FI. to Ft. FI. to Ft. Ft. to Ft. Ft. to FI From~F~ to Ft. Fro~ -~'~ &' Ft. to 27 Ft. ._... From .'.~ ~r FI. fo '< / : FL FMm ~[ Ft. to ~ '-FL From : ' Ft. to ' Ft." From'_?O FC to CC-~7' .FI. "From __FL.to FL From Ft. to ' Ft. From Ft. f" ' Ft.__' ~'~m ' 'FI. to ' Ft. F~0m ' Ft. t~FI. F[om FI. to ' Ft. From Ft, to FL From From From From · From ]~rom F~om From MISCL. INFORMATION: · ~,~ / ToT~. ~c..; 064;5 .'. teXior MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 051-832-06 Certificate of On -Site Systems Approval Expiration Date: '^' Z 7 1. GENERAL INFORMATION Complete legal description TOnjess Estates B3 L17 Location (site address) 25260 Schaff Drive Current property owner(s) Steven & Marita Lerwick Mailing address Real estate agent PO Box 770132, Eagle River 2. TYPE OF DWELLING: n Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Private Well Water Storage Community Well Public Water System Waiver request for. 0 Day phone Day phone TYPE OF WASTEWATER DISPOSAL: 0 Private Septic R ❑ Holding Tank ❑ ❑ Community ❑ ❑ Public Sewer ❑ Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 5J -U Waiver Fee $ Date of Payment 16-1/9 Receipt Number 032.A6 COSA# 6-15Cl9lgly Date of Payment Receipt Number Waiver # Distance: 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system In accordance with MoA COSA guidelines and regulations. The reported results describe 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 soil condition, ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. 6. DSD SIGNATURE System #1 Approved for __V_ bedrooms System #2 Approved for bedrooms Disapproved Phone (907) 745-8200 Date 1 qd,?d �� of a� gs>ili 49 TH Steven R Pannone �F ICE 8149 AW 0o ssioat��= Conditional approval for bedrooms, with the following stipulations: '•�f6lllrr�'. By: ...L_ Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the Stale of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory l Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet i Legal Description: Tonjess Estates 133 L17 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA H Well log is filed with Onsite (or attached) Date drilled 01,6184 Total depth 100 ft Cased to 42 ft ® Sanitary seal is functioning correctly ❑® Wires are properly protected Casing height (above ground) 19 in. Date of flow test for COSA 7123/18 Static water level at beginning of test 39.5 ft. Comments B. TANK DATA Age of tank(s) 0 years Tank type/material Plastic Measured operating fluid level in septic tank 0 ® Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA Which system tested (date installed) 2/24/84 H ALL standpipes present per record drawing Total measured depth from grade 8.3 ft (max) Measured depth to pipe invert from grade 3.3 ft (min) ❑ N/A — pressurized field 0 Monitor tubes go to bottom of effective. If not, state depth into effective Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 051-832-06 Structure served by this system Well production at time of t*_1 gpm Water storage tank volumelons Well disinfected for coliform test? Yes ❑✓ No N-1 Coliform bacteria is Negative Nitrate 6.51 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L © Arsenic less than MRL (ND) Collected by PES Date of Sample 818/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 7/23/18 Results ❑✓ Pass For 4 bedrooms Fluid depth prior to test 0 in Water added 600 gal New depth 0 in Elapsed time 200 min Final fluid depth 0 in Absorption rate 600+ gpd Any rejuvenation treatment (past 12 months) unk If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' M Yes Community Sewer Manhole/Cleanout > 100' [j✓ Yes if No ft 71 Yes if No ft Neighboring Tank > 100' Q Yes if No ft Private Sewer/Septic Line > 25' M Yes if No ft Absorption Field on Lot > 100' [Z] Yes if No ft Holding Tank > 100' ❑ Yes if No ft Neighboring Absorption Fields > 100' M Yes if No ft Water Main > 10' Animal Containment > 50' F/� Yes if No ft 0 Yes if No ft ✓V Yes if No ft Water Service Line > 10' M✓ Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway comment below Community Sewer Main > 75' Yes if No ft M Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' M Yes if No ft Surface Water > 100' Q Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: 0 Absorption Field > 5' if No Yes if No ft Private Wells > 100' M Yes if No ft Water Main > 10' Q Yes if No ft Community Wells > 200' ✓V Yes if No ft Water Service Line > 10' M✓ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' 2 Yes if No ft If absorption field is under driveway comment below Property Line > 10' El Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' Yes if No ft Water Service Line > 10' F-71 Yes if No ft Community Wells > 200' 0✓ Yes if No ft Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. q , /9f11 COSA Checklist yellow sheet n LEGEND: -N I ADDED 5EPTIC. PIPE MEASURED DATA 12.5' RECORD DATA N 90'00`00" W i RECOVERED 5/8" REBAR o / A HOR F� DR�vo a29"E PPV PEDL R�sO so op LOT 17 51,453 Sq.Ft. ao � 10x30' ANCHOR < EASNENT(TYP) 0• WELL''••••.... yO o cr '°• r a •.., a0 A\CCr Aa1............ LOT 16 < 'A °o. C/O A, /P Qp DECK I I MULTI STORY WOOD HOUSE (2' EAVE TYPICAL) R� LOT 18 3p, NOTES 1. ALL BEARINGS, DISTANCES AND AREAS SHOWN ARE RECORD, UNLESS NOTED OTHERWISE. 2. THIS SURVEY IS PREPARED IN ACCORDANCE WITH THE ASPLS MORTGAGE SURVEY STANDARDS. EXCLUSION NOTE: IT IS THE RESPONSIBILTY OF THE OWNERS TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APEAR ON THE RECORDED SUBDIVISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDRY OR FENCE LINES. MORTGAGE SURVEY CERTIFICATE• I HEREBY CERTIFY THAT I, OR SOMEONE UNDER MY DIRECT SUPERVISION, HAVE PERFORMED A MORTGAGEE'S INSPECTION ON THE FOLLOWING DESCRIBED PROPERTY: LOT 17 BLOCK 3 TONJESS ESTATES AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. aaasnp 2019 A/�°'°es LOT: 17 BLOCK: 3 GEOMATICS LLC (SUBDIVISION: 49ttt1� '\ °d TONJESS ESTATES "oo DATE: JOB No: F.B. No: SECTION 2 TOWNSHIP 15N RANGE DIV e So :......................................... 9� IZ% 19 19-04.11 19-01 o r� _Te ry L. Nicodemus o SEWARD MERIDIAN SCALE: DRAWN: CHECKED: PLAT No. 82-59 1" = 50' TAN TLN MAP No. °°�9''•. No.9106-S �� °°FD Seo RECORDING DISTRICT PALMER NW1462 og °9pnong��n�pp%� ` MORTGAGE SURVEY 25260 SCAFF OR, EAGLE RIRER, AK 99577 DEVELOPMENT SERVICES DEPARTMENT Cin -Site Water and Wastewater Section www.muni.org/onsite --� Nitrate Advisory Certificate of On -Site Systems Approval # OSC191414 Subdivision: Tonjess Estates B 3 L 17 907-343-7904 Fax: 343-7997 A water sample revealed a nitrate concentration of 6.51milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. ss'B� 655 A�icfa ems X9565 �artiinMINIMUM �` From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend , using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. MOMOV..ting d Les>y�o 16 50 Aina rg�Alas a51�665� Www m"Mnrt�rg� Parcel I.D. 1, GENERAL INFORMAIION Complete!egaldescription 'Lot 17, Block 3. Location (site address or directions) 25260 $cha ff Municipality of Anchorage o Development ServiCes 'DePartment ' ..... .. Building Safety Division . · . · On-Site Water and Wastewater Program. '- - :'. 4700 South BragawSt.' - ' : - P.O. Box 196650 Anchorage, AK 99519-6650 ' ' ':' ' ' · www.cl.anchorage.ak.us: "- '" (907) 343-7904 . . CERTIFICATE OF HEALTH AUTHORITY.. APPROVAL. .... "' FOR A SINGLE FAMILY, DWELLING ' - .... -051-832-~06 HAA# /-'~r~ Expiration Date: Current Property owner(s) Phillip Butch Day phone 688-1434 Mailing address PO Box 672191, Chugiak,' AK 99567 Lending agency Day phone Mailing address Real Estate Agent Mailing Address Un/ess otherwise requested, HAA will be held by DSD for pickup. 4 NUMBER OF BEDROOMS: Day phone 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 (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. J STATEMENT OF INSPECTION BY ENGINEER · As certified by my seal affixed hereto and az of the validation date shown below, I 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 Is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the ti,me of installation. S & S ENGINEERING ' Name of Firm 17034 ~'=~e 1p=.,~,,; I cop Address Eagle River, Alaska 99577 Engineer's Printed Name . Robe]:t. c. Co.an, 5. DSD SIGNATURE ~ Approved for. 'ilL . .Disappr°ved' ConditiOnal approval for bedrooms. Additional Comments bedrooms, with th~ following stipulations: ~ : WASTEWATER': ~ ; Att;~chments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Cedificate Date: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist LegalDescription: L..~ ~'~ "~0~r3"~.-~ [.f~'4T~L~ ParcelI.D.: A. WELL DATA We, Log present ~N) Total depth If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to t~ Z.~ FROM WELL LOG Date of test Static water level Well production g.p,m. Casing height (above ground) Wires properly protected,l~2N) ~ AT INSPECTION g.p.m. WATER SAMPLE RESULTS: Coliform O Nitrate Date of sample: H/~1/~1 SEP3'IC/HOLDING TANK DATA Date installed t~1%~ Foundation cleanout~l~N) ~ Date of Pumping ~'~"&l Pumper ::~'~--- ~--~ ~. ~' -/ Other bacteria O Collected by: S & S I~IGINEERING I~ ,'..,.; .~agle River Loop Road NO. 204 Eagle Eiver, Aladca ~9577 Tank size ~ ~ Number of Compartments Z.. Cleanouts (~) ~/ Depression (Y~. ~ High water alarm (Y/N) **i'/3)A ABSORPTION RELD DATA Date installed :l~t~~ · ' *~ -~oilrating (g.p.d~Forff~/bdrm) ~- Systemtype 'T~.~.5£d- Length ./~.a[ ,~ Width /,/O EffeCtive absorption area ,~'t/~ Date of adequacy test Fluid depth in absorption field before test (in.); Fluid depth ~-? (ins) Minutes later: Peroxide treatment (past 12 mo~ths) 72-026 (Rev. 3/96)* Gravel thickness below pipe (,' · Total depth Monitodng Tube present~/N) ~/ Rasults ~tail) /O · Depression over field (Y~ For /'/ bedrooms Immediately after ~1 ~/gal. water added (in.): Absorption rate - ~3.p.d. If yes, give date D. UFT STATION Date installed Manhole/Access (Y/N) High water alarm level at' Size in gallons 'Pump on" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELLON LOT TO: Septic/holding tank on lot Absorption field on lot - Public sewer main Sewer/septic service line ~'D I-L On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDINGTANK ON LOTTO: . Foundation ~- i .L Property line /,3 ~ ~' Absorption field Water main/service line ~ I~ Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /D . Building foundation /o Surface water ' /5' Curtain drain /04 I'~ W~tls o;q adjacent lots Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots /oZ) I ~ F. ENGINEER'S CERTIFICATION I certify that I have determined thru f/eld inspections and review of Municipal ~.~...,~,tl~Et ff~{~..~stems are · In conformance with MOA HAA guidelines in effect on th~s date. ~ c~..~ ~ ~.~.'.?/'~ Date &// /0 I ~)"~",'?.. , ,..."~,~,~' Waiver Fee $ Date of Payment Receipt Number HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* ~.,..-.--~.,-,~t~-.o~,.,,~ ..-~,.--~...~, ,-. i ,,.,, t MiiNi~iPALITY {3F ANCHORAGi~ ...... ';:&';;,~",;;;~,; ~:;~ o/', .*~[~ 4.~ .~ Depadment of Health & Human Se~lce~ ~ ¢i: ~g~:,.*i;C'~J~.cDIVlSlON OF ENVIRONMENTAL SERVICES "l;A~; ? ;,~ ~ ~'~' CERT FICATE OE INSPECT ON FOR H~LTH AOTHORI~ APPROVAL '~, T .':- 'ON-SITE S~ER AND WATER FAC L ~ FOR S NGLE FAM LY DWELL 1LGENERAL INFORMATION .(Must be completed prior.to submittall ~ '~ ~ -' .... ( . ,-, F .:. ,. Legal Description (include lot. block, subdivision, section, township, range) ..... 2~'5'.7:)}¢x~._ :'~'~: '~6ngess Estates, 'Lot 17, Block 3, -T15N, RlW, Sec. "- L6catJ0n (address or'directions)_.: .... : ......... ......... =25260 -Shaff'Drive'- ; · "'~- .% (1~) Property owner,Mark &'. Para [Obrien ......... · -' Mailing Addr%~s - Lily Street,. Anchorage, (c) Lending Institution N/A Telephone: (home) 3 3 7- 3 ! 5 0 Business Telephone ' ' · ; Mailing Address "'-' · "''~' '-- ........................................................ ...... : ............ ........ ........... · '(d) R~ E Ag ''' -' ' ' state Company and ent -'-. %.-- ..Address ' · '~ ' ' -.-. .... Telephone ........ :~.... __~. ~ ~..~__ ~__.:. ........ .=x .~ =.t.~ ........ ~,,, ,- ~,., .... ~ ....... ' ~(e] M~il the'HAA to the following address: (or check here D, f ho d for pick up ) "'~ ~%~.-"/~ ...... 0,¥.~. ..... ;., ,~ Llst contact person and day phone number below: ' - .... ' 'c ~ .;~ ~...~O .",~ .... ~'- ..... . ~,- . . : :' ~. ,.,., ..%: ..... ::..:.,.~ .. .... ' .... ~ ' Num:-"ber ...... ~f bedrooms ......... .. ~ 3.'WATER S~PPLY=:; ..... ~=:.¢";.: .... ', - ..................... ¢?, ndvidualWelB_-,, ,.Communed . PublicD .... . ' . ." . ~ . . : ';.-:.. ~;:~ · · ....,,,--~ -.: ,Nole:..If communlt well s stem-must have,w tten conf rmafion,from,theState Depa~ment of. E6vlronmental ~.: ..,~;,'.. - - Gonse~atlon attesttng tO m legall~ aRQ sis[us. ~' Nole: ~f community well system must have wrttt~n ~onfirmation from the State Depadment of Environmental Conse~at on attest ng to the legall~ and status . n~¢~,~m) ...... Pagelof2 -._-.-..- - 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ""' AS certified by my seal'~f.fl~ed hereto and as of the validation date shown below, I veriil~'t h~'t .my investigation of this Health Authority Approval/shoves that the on-sit~ watei' suppl~ and/o~ wastewat~r, disposal system ts safe,' functional and adequat6 for the number of bedrooms'and ~pe of structure indicated herein. I fu~her veri~ that based on the information obtained from the Municipality of Anchorage files and from my investigation and.-- ' inspection, the 6d~site'wht~r ~fipply~nd/0r'wastewater disposal system Is In compllafic~'~ith all Municipal and. -: State codes, ordinances, and regulations In effect on the date of this Inspection;.[ff~ ~.-~.r.r .,~Nameof. Firm ~1~ E~ ~g~g S~i~ ,.Telephone (907) 594-5195; '"- '-.' - ..-..~ Address - P.O. ~x.773294, ~gle ~,-~. 99577,~,* ...... ~ ~ ~ ........ =~,, T~r~-'~'C? r . , '". ._ ' · , ' ~-~--'--'~ ~~c~ ' =': . ............. .. , ....... . ..... - . ........ ' 6. DHHSAPPROVAL ~: '..; : ' .'; ~''. ......... -. '.; ' Approved ~x '~' 6isappr~ved Conditionel. Terms of O0nd'Rio.al · ,.-Note:' :.' 'The,well for this prope=ty meets..existing State ," _. , and. Mu~c~ga~Codes,. , There are 'n~t~s.,p~e~'~nt. I~is suggested · "-~h~t '~&~-~6~¢~t'es'tin~'b~ pe~'fo~ed' ~'~' i~ur'~ the '~ll's ~0ntinued ';" '" }".-~ v~., ~suig~l~,~J Nitrat~.[.~oncen~ation~iS~l~..'~mg/1; _l. EPA_maxim~2.h._' ~: .'.' .... concentration is 10.0 mg/1. · ' ' ' · - · ' - . ·, , :. - .- ...... ' -.., ." ' ' < ..... .=.. ,..%',,-. ~ Y.lqqU[~ ~KTA%Y : .- . . ..,: . ...; ; ~3,I,U~.. ~' -~ ...... . The Municipali~ of Anchorage Depa,ment of Health and H amen So'ices ~D~ ES) issues Heal~ 6u%ho[i~ 6p~r?~v~l, ... ' ~} cor?catod based 0~ly upon tho represontations givon in paragraph $ ab?o by an independont ~rof~si~a~ en~ '-:}~~:'r~*torod In th~ 8tats of ~la*ka. ThO DHHS doo~ thl~' a~ a e6~e~, t~'pUreh~*er~' o[ h~m~'and them · ~.~ .. ........ Pa~o2o~2~ .~ · _ .................. ~ ....... .. ~ . ..... . .. . . ~ · . .. . ...... ; ... ~ .~..~ ~..j~. -.~ ,' · ~ MUNICIPALITYOFANCHORAGE (MOA) . :Z'~'~: .... :- "; ;. ' ' . . (."~[{~',~., . Heal~b~th~rltyAppmval(HAA) '~A~ OF ~~- FEBRUARY 1984 "' : ~UG ~ ~ ~9~0 ' ' .Legal Description: _ . '.- " ' ':~ ECEIVED ' A. WELLDATA , '" ; ' ' ' '~ "'." ':~ ': Well Classification . ~,~<.~.:, ..,. . ~ ' - '"' 'IFA, B, C, D.E.C: Approved (Y/N) ":"' '" .... *" "' Well Log Present (YIN) ~ Date Completed Total Depth {P~ ~ Cased to ~ / Depth of Grouting Static Water Level ~' ~ ~ ~/~ PumpSetAt ~/' Casing Height Above Ground -- Electrical Wiring In Conduit (Y/N) · SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot /~o · To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line - Yield .~.~ ~-,~.- 7~':~,'.,..t' ,~'~;o Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) '" " · 'Lots · , On Adjoining " ; On Adjoining Lots ~'~'~' · To Nearest Public Sewer CleanoutJManhole · To NeareS{ sewe~; Service Line 0n LOt ~ ~'" Water Sample Collected by ; Date Water Sample Test Results '"'~/"~-~"~'~' "l: '/~';'/-"~'~--' Comments B. SEPTIC/HOLDING TANK DATA · ' Date Installed ~"-F'5/ · Size ~Z.~-'.~ No. of Compartments Standpipes (Y/N) )" ' Air-tight Caps (Y/N) ,Y Foundation Cleanout (Y/N) ~' Depression 0,~er Tank"(Y/N) '~ ............ Date L~t PU~pe.d ~'/,'~' ~'"~ P~Jmping/Maintenance Contact on File (Y. !N) ; for Holding Tank High-Water Alarm (Y/N) "~"~ ' ;Tempoi'ary Holding Tank Permit (Y./N) ' ~"'~ SEPARATION DISTANCES FROM SEPTIC/HOLDING T,~NK: ' - To Building Foundation To Disposal Field ' ' '"- ~'T To Water,Supply Well /,m~ To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments 72-02~ (Rev. 7/88) F~t Page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /~'~ * Width of Fielc~ "~' '"' ' ' - Square Feet of Absortion Area ~':~'":" ' *" ~"'~:' Typ~0fSystem Design ' r :Length'of Field -.~-~' '* ' ' · ' Depth of Field /'~ ~ · : ,~.~ ~, %x. Gi;avel Bed Thickness '~" Statndpipes Present (Y/N) ~'Depresslon over Field (Y/N). /;" Date of Last Adequa~;y Te,st Result~ofLastAd~quacYT~st ~. ,' ~.,~$,-.-&.-'~.,L, ,,a~/e. SEPARATION DISTANCE FROM ABSORPTION FIELD: pply W ' To Prope~y Line ToWater-Su ell /~ ~ ' ' ' ~ ~ ' ' '" ' To Butlding Foundation /~x~ , I L :,~ ' ~-v~:,. ~..' ,,.: :, ,,','- To Existing or ASand~ned Sys~eTM on · Lot ~/~ ':" :' "~ :~' -'; On Adjoining Lots :: X ~l:r' To Water Main/service Line ' ' ~',"~" .... ~ To Stream, Pond, Lake, or Major Drainage Course TO Driveway, Parking Area, or V, ehicle Storage Area Comments To Cutback (if present) D. LIFT STATION /./,//ac ,. ~ ( ' Date Installed .... "" ~ · - Size in Gallohs "Pump On" Level at . _ High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments r ' ' '' ;;: Dimensions ---,,.,_', ,,, Manhole/ACc~(wN)', ~ "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted BedrOom Rating Against HAA Request*~*' I certify that I have checked, verified, or conformed to all MOA and H,~.A guidelines in effect on'the date of this nspection." ~, , . , ~., ,';, .... -,, ~-'?~ i' ,-, ',~'~'. r~F-~ ' Signed ~~~ ...... ,, .... uompany E~¢e River [n~lnCUlhu 8~,,~=~ ...... ¢~ ~TH ~':~ . ~. ~J ~'~ ' .... ~/~e/9 ~ +' "P' O. BOx 773294 .... ~/...~.;~.~....,Eng,ne~s Seal Date ~/' /' , [ag~eniverAKgSSZr , ' ~ "~~,;: r ' Amount: $ / ~ '" D~te of Payment ~ (n~. ~ ~ page 2 of 2 ' ' ' A Eagle River Engi,neering Services · ' 11940 Bus~nei~':Blvd, Su~te #205 P.O. Box 773294 Eogle Rive'r, Ak. 99577 % Owner: Oo~t,.~-. Dote: Type of test: El Well Flow Test [3 Septic Test Only DJ Well & Septic Test [3 Other: Meter Monitor Well Tonk GPbt Time Reodlng Level Level Level 12:O.L._~51oo.d ' 9~" ' ' q.oo 13:~5 GG~Io.O ' ~5 .... PSI 694-5195 Fax 694-3297 Remorks' __1 I ......... J ............ J /. L ~ ...... ] ................ J J ............. ! ...... 1 ..... J ................. J___ 1 ....... J .......... l NOFIlHEFIN TESTING LABORATOFIIES, ~ ~a ~P,~ K~; ~TR~ET ANCHORAGE. ALASKA Drinking Water Analysis Report fbr Total Coliform Bacteria TO BE COMPLETED BY CLIENT .~ ,~,~LIC WATER SYSTEM'.~'." I I I'-I 'Ill I~PRIVATE WATER SYSTEM ' ? ' ' :.. ~,,,~- . ~. C g. *-~ Purpose Purchase Order No. I-I Treated Water · /[~Un~rea, !ed Water Check Sample (for original contaminated sample with lab reference no. COMMENTS: SATISFACTORY ~) UNSATISFAC i URY U RESAMPLE R OTHER BACTERIA OB TOO NUMEROUS · TNTC TO COUNT 6 7 8 10 Signature of Repres~ FOR LABORATORY USE ONLY 'No. of Total Colifcrm Colonies pe~ 100 mis. TO OE COMPLETED BY LABORATORY Received at: ~ Anch. [] Fbks. Date.eceiv.d /'~:5' ~ GY'J Time neceived // Next Sample Due MUNICIPALITY OF ANCMORAGE DMSICN OF ~;IRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRCNMENTAL PROTEL-£1ON APPLICATION MOR HEALTH AUI'HOP. ITY APPROVAL (~RTIFICATE 1. General Infcrmaticn Application Date ~; Owner/builder.~, · Telephone Address (e) l~al Estate Co. & AGent Address Telephone Type of l%~sidenne Sirgle-Family ? Number of Bedro~s Multi-Family ¥ Other (describe) 3. Water Supply Individual Well ~ C~.,~nity ~ Public ~-~ Note: If ua,.~.~ntty ~11 ~s~m, ~st ~ ~tt~n ~ti~ ~ ~ S~te ~nt ~ ~viror~ntal ~tt~ at~sti~ ~ ~ ~galfty ~ ~atus. Is ~ ~11 a~a~ f~ t~'~r of ~ ~cified in ~is 4. ~ Di~al O~i. ~ ~blic ~ ~nity ~ ~lding Tark ~ Is ~ ~s~water dis~al sys~ ~ f~ ~ ~r of ~ ~Y~) [Page 1 of 21 2-15-84 Engineering Firm Providing Inspectic~, Tests, Data and Infc~mation I ~rtify that IJ~a~Checked, ~3z~ified,? oonfc~m~d to all M~A HAA Guidelims in Nar~ Of Ffrm T~leph~ Date 6. DHEP Approva 1 App~o~d for Approved ~ ( ~'~GIN~ S~AL) Disapproval ~--~ Conditional Terms of Conditional Apt~oval The Municipality of Anc~aGe Dapa~tm~nt of H~alth and Envir~ntal Protection not Guarantee th~ continued satisfactory perfc~mance of th~ water supply and/c~ the wastewater disposal system. This approval indicates that, as cf the validation date shown ahoy, based cn the data and info~.ation furnished by an engineer z-egiste_-ed in the State of Alaska, the water supply and wastewater disposal system is safe and func- tional fo~ the rnmber of badrocms and type of structure indicated. (D~, SEAL) 7. Mail the HAA to the followirg address: KS21d51s' [Page 2 of 2] 2-15-84 A, ~.r.r. r~TA Stati~ h~ter [e~l ~ ! Casing Height Above Ground Elect=ical Wiring in Conduit (~/N) Well ~lassificaticm ~, ~. Well Log Present ~/N) Total Pepth /~O ' Cased MUNICIPALITY OF ANCHORAGE (~3A) HEAL~ A~OR~TY APPROVAL (HAA~ ~I~ - F~Y 1984 ~p~ of ~ti~ ~nit~ ~al ~essi~ ~ ~l~ad (Y~ separation Distances f=cm Well: B. SEFrIc~ TANK raTA Standpipes ~N) Aid-tight Caps ~/N) Fcundatton Cleanout Dep=ession over Tank (Y~J) Date Last Pu~e/d Pumping/Maintenance Cc~tract c~ File (.Y/~)~ Holding Tank High-Ware= Alarm (Y/N)/V/~ Tempcra.-y ~olding TaPJ~ Permit (Y/N) Separation Distances f~c~ Septip/Holding Tank: To Wate=-Supply Wall /~9 ~z~' To Building Foundaticn To .ter Main/Se=vice,Line /¥/~- To St=~a~, Pond, Lake, ~ Major DrainaGe Course C~tatt:2ts ' ' [PaGe 1 of 2] 2-15-84 Co ABSOt~'I'ION FIELD [I~TA Soils Rating in Absorption Strata Width of Field ~// Square Feet of Absorption Area Dapression over Field (Y~ - ~esults of ~ast ~egu~c~ ~st Le.gth of zieid ~9 /-~ Depth of Field /~) / Gravel Bed Thickness ~ Statics ~e~nt ~) .. · To D=iveway, Parking Area, c~ Vehicle stc=aG~ A~ea D, LI~T STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested fc~ Electrical Codes(Y/N) ** Check Be~dtted Bec~o~a Rating ;~Jainst HAA ~equest ** I ca~tify that I/4~.~e~ 9ke. d7 verified, c~ confcz~sd to all MOA in effect on the date of~this/~r~p~. , , . , Co,~any ~/ / MOA Nd. KBi/d5/s [Page 2 of 2] 2-15-84