HomeMy WebLinkAboutGLENN VIEW ESTATES WEST PH 1 BLK 1 LT 10Glenn View
Estates West
#1
Block 1
Lot 10
#051 - 793 - 10
_'
' Municipality of Anchorage .7,.
_""rf
�� Development Services Department :;rfry:
Building Safety Division
On -Site Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW010477 PID Number: 051.793-10
of
NKappen Homes. LLC
Wastewater System:
i.:4 New ❑ Upgrade
Address:
17034 Eagle River Loop. Suite 201. E R.. AK 99577
ABSORPTION FIELD
Phone: Number of Bedrooms:
622.5585 4
0 Deep Trench ® Shanow Trench 17 Bed 0 Mound 0 Other:
LEGAL DESCRIPTION
Soil Rating:
0.6 GPDIFte
Total Depth front original grade:
5.0 FI.
Block: Lot: Subdivision:
1 10 Glenn View Estates West Phase 1
Depth to pipe bottom from original grade:
2.72.2.71 FI.
Gravel depth beneath pipe:
2.28 - 2.29 FL
Township: Range: Section:
Fill added above original grade:
0.87-0.14 FI.
Gravel Length:
144 Ft.
Well: IN
New II
Upgrade
Gravel width:
5 Ft.
Number of lines:
2
Distance between lines:
10 FL
Classification (Private, A, B. C):
Total Depth:
Ft.
Cased to:
FL
Total absorption area:
1028+ Fre
Pipe Material:
D3034 & F810
Dnner.
Date Drilled:
Static Water Level:
FL
Installer.
Red Dog Masonary
Date Installed:
8/12/02 -
Yield:
GPM
Pump Set at:
Fl.
Casing Height Above Ground:
Ft.
TANK
SEPARATION DISTANCES
C• Septic • Holding ■ S.T.E.P. ■ Other.
To
Septic
Tank
Absorption
Field
Lift
Station
Holding
Tank
Public/Private
Sewer Line
Manulact se :
Anchorage Tank
Capacity:
1250 Gat.
Well
200'+
200'+
NA
NA
25'+
Material:
Steel
Number of Compartments:
2
Surface Water
1004
100'+
NA
NA
LIFT STATION
Lol Line
5'+
10'+
NA
NA
Size:
Gal.
Manufacturer
Foundationin.
5'+
10'+
NA
NA
'Pump ori level at:
'Pump oho level at:
„
High water alarm at:
h
Curtain Drain
NA
*50'+
NA
NA
Pump Make & Model
Electrical Inspections performed by:
Remarks:
*none known
BENCH MARK
Insulation over field and tank
Tand Description:
LoTop
Top of porch
Assumed t.evalwn:
100 FL
Engineer's Stamp
... 0 .�F'A�g�
S11
j T't ?a} L ,• *,�,
,• N•• ••••••••.sops •.u- •
IS
Inspections performed by: KND Engineering, Inc. Dates: 15t 8/12/2002
2nd 811312002
• � ,.
j ; Kenneth M. Duf!u• W j
, •• CE 7116 r
�0 `!�'••a ••. �c,„!
,19eo a•••.•aa.N••\"4-..
•,a1O..\4 4114.
Development Services Department A proval 34 (1/11/03
�� /
Reviewed and approved by: //�{/��]� ori P Date: £ /2.--Lv 3
(Rev. 12200) / O
A -C=12.2'
B -C= 25.8'
A -D= 20.4'
B -D= 33.4'
A-E= 26.4'
B-E= 24.1'
A -F= 36.2'
B -F= 35.7'
A -G= 93.9'
B -G= 52.9'
A -H= 97.2'
B-H= 58.8'
A -I=61.3'
B -I=26.6'
AS -BUILT SYSTEM DETAILS/SITE PLAN Permit SW010477
GLENN VIEW ESTATES WEST S/D, LOT 10, BLOCK 1 PID#051-793-10
DRIVE
EXISTING 1. BDRM
HOUSE
`aE
c
A
•
0
EX STING 1250 GAL
SEPTIC TANK
•
99-1/10
Lot 10
Zr
MONITOR TUIE.
NXR aXMQIT
97.5..
�II
1250 GAL II
II—_ ll= .;
SEPTIC 1=11=11
TANK-
94.1 94.is-41"li
TANK1=1 u
u
i.3 * 95.11 I ,_ 91.89 91.90 II
,I
= =11=11=
SCALE' NTS
KENNETH Y. D
CE -7118
ss10l' .a►'
•
FINAL GRADE
SEWER ROCK
TRENCH 1
FINAL GRADE
KND
u
SCALE' 1' = 50'
VNIXS
CLEAPOJT
VARIES
SEWER ROCK
TRENCH 2
72'
PREPARED FOR:
REX TURNER
ARCTIC DEVCO, INC.
P.O. BOX 3489
PALMER, ALASKA 99645
SCALE' NTS
FIELD BOOKS
COMPUTED:
I'm"' LANG
DR" VBG
STAXNO:
u'Ea® KMD
Amu"' LANG
DATE•
2/17/03
DWG. FILE:
ftlD NW1459
ADHD "'r: 01110.DWG
doe Na: 01110
ENID ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER. AK 99577-8736
(907)898-8111/FAX (907)898-8111
GREEN GARDEN DRIVE
• I2.07'
• 330.0'
LOT 11
S 89'59'03'W 240.35'
LOT 10
40.001 3.f.
LIE/TIC CLEANOUT?
1414'
30.0'
- 16' TELECp1 e
ELECTRIC EA1E1OfT
N e9'59'03'E 240.12'
LOT 9
0
FOUNDATION AND SEPTIC ONLY
PLOT PLAN _ ASBUILT X SCALE I. ' +3. GRID NW 1459 Project No. 01-183
Lang & Associates, Inc. 11500 Daryl Avenue, Anchorage, Alaska
ReRegistered Land Surveyors 907 522-6476 Phone
9 Y 9073 522-4625 Fax
1 hereby certify that 1 have surveyed the following described property:
LOT 10. BLOCK 1. GLENN VIEW WEST SUBDIVISION (PLAT No. 2000-42)
Anchorage Recording Dlshtct. Alaska, and that the Improvements situated
thereon are within the property lines and do not encroach onto the property
adjacent thereto. that no Improvements on the property Tying adlacent thereto
encroach on the surveyed premises and that there an no roadways, transmission
lines or other vlsIbie easements on sald property except as Indicated hereon.
Dated this the 3D4I' Day of avf3<JT , 2002 • at Anchorage. Alaska
It 1s the responsibility of the owner to determine the existence of any easements.
covenants, or nsMations which do not appear on the recorded subdivision plot.
99515
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
Initial
91-12. p2 e :c
q -l3" °L /63' 5:e
Date Issued: Dec 05, 2001
Expiration Date: Dec 05, 2002
Permit Number: SW010477 Parcel ID: 051-793-10
Legal Description: GLENN VIEW ESTATES WEST PH 1 BLK 1 LT 10
Design Engineer: 0070 KND Engineering Site Address:
Owner Name: Turner Construction Lot Size: 40001 SQ. FT.
Owner Address: PO Box 3487 Total Bedrooms: 4 Permit Bedrooms: 4
Palmer , AK 99645 -
This permit is for the construction of:
❑✓ Disposal Field Q Septic Tank ❑ 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 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: /OA/
Date: /010
Parcel I D
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
6s/-7,73 -/D
Permit Number SW D D 4 7 7
Property owner(s) Turner Construction Day phone 242-4555
Mailing address (1) PO Box 3487, Palmer, AK
Mailing address (2)
Legal description (Lot, Block & Sub'd_) Lot 10, Block 1, Glenn View Estates West ?/4 Y - 1
Legal description (Section, Township & Range)
Lot Size 40.On1 Acres/Sq.Ft. Number of Bedrooms 4
Zip Code 99645
THIS APPLICATION IS FOR:
Sewer Only ® Well Only
Sewer and Well 0 Water Storage
Sewer Upgrade 0
THIS PROPERTY CONTAINS:
Hot Tub 0 Jacuzzi
Swimming Pool 0 Water Softening Unit
Therapy Pool 0
o
o
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.
(Signature of property owner or authorized agent)
Permit Fees: $ 320
Date of Payment: 111'0'0
Receipt Number: 0/3c? 32
(Rev. 12100)
Waiver Fees:
Date of Payment:
Receipt Number:
D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
November 29, 2001
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: New sewer permit — Glenn View Estates West, Block 1, Lot 10
Gentlemen:
The owner has requested we proceed forward to obtain a septic permit on the subject
lot. On April 19,1999 we dug one testhole for the proposed system. The results of the
test are attached. The general slope of this lot is from east to west at a grade of
approximately 0 - 10%. We have designed our system utilizing the testhole we
excavated for the 4 -bedroom house, which is proposed for this lot. The lot will be
served by public water. We propose to install a 5' wide shallow trench. Water was not
encountered during the excavation or monitoring.
There are no public or private wells within 200' of our proposed system location except
as noted. There is no surface water within 100' of the proposed system and there are no
known curtain drains within 50'. We do not expect there to be any adverse effect on
adjacent lots by the development of this system.
If you have any questions, please contact me at 696-6111/FAX 696-8111.
Respectfully submitted,
IKHD Engineering
Kenneth M. Duffus, P.
Attachments: On -Site Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
WELL & WASTEWATER DISP❑SAL SYSTEM DETAILS/SITE PLAN
GLENN VIEW ESTATES WEST S/D, LOT 10, BLOCK 1
Lot 26 \ \ Lot 11
NO PUBLIC WELLS VITHIN 200' OF
PROPOSED SYSTEM
NO PRP/ATE WELLS WITHIN 200' If
PROPOSED SYSTEM EXCEPT AS HOTEL
NO SEPTIC SYSTEMS WITHIN 200' IF
PROPOSED WELL EXCEPT AS NOTED.
9-..•.
*#
' �iCE -7118
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Lot 10
0
z
'wool
Lot 9
Lot
Lot 8
ROSS VOYLES
DESIGN DETAILS
4 BDRM X 150 GPD = 600 GPD
600 GPD/.6 GPD PER SQ. FT. (17.78 MIN/IN.)= 1,000 SQ. FT
(1000/5'(W)) X .70(RF) (2.0' GRAVEL) = 140 FT. TRENCH
USE 2 TRENCHES - 70 (L) X 5' (W) X 2.0'(B)
Total depth of system Is 5.0' from original grade.
Total depth of gravel below distribution pipe Is 2.0' .
NOTES:
1. USE 1250 GAL SEPTIC TANK, INSULATE IF <4' OF COVER.
2. INSULATE TRENCHES WITH 2' HD BURIAL FOAM.
3. CONTRACTOR WILL ENSURE MINIMUM 2% SLOPE INTO SEPTIC TANK.
4. ADDITIONAL FILL WILL BE ADDED OVER SYSTEM TO ACHIEVE
MIN. 3' COVER IF REQUIRED.
5. CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT
WELLS, SEPTICS, LOT LINES, FOUNDATIONS AND ALL OTHER SETBACKS.
PREPARED FOR:
REX TURNER
ARCTIC DEVCO, INC.
P.O. BOX 3489
PALMER, ALASKA 99645
Scale: 1'= 100'
PAGE 1 OF 2
FIELD BOOKS
COMPUTED:
°°"N°ARw LANG
DRABN VBG
STAIONR
CHECKED: KMD
ASBUI.T: LANG
DATE 11/20/01
DWG. FILE
CR1D NW1459
ACRD FBF` 01110.DWG
J8N°4 01110
'END ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)896-6111/FAX (907)696-8111
KNi]D
Lot 25
EEPDC/
Lot 24
\/
\/
Lot 23
NO PUBLIC WELLS VITHIN 200' OF
PROPOSED SYSTEM
NO PRP/ATE WELLS WITHIN 200' If
PROPOSED SYSTEM EXCEPT AS HOTEL
NO SEPTIC SYSTEMS WITHIN 200' IF
PROPOSED WELL EXCEPT AS NOTED.
9-..•.
*#
' �iCE -7118
'/
sstoa►l' .�
P1
PI
eft
_.. laa
Lot 10
0
z
'wool
Lot 9
Lot
Lot 8
ROSS VOYLES
DESIGN DETAILS
4 BDRM X 150 GPD = 600 GPD
600 GPD/.6 GPD PER SQ. FT. (17.78 MIN/IN.)= 1,000 SQ. FT
(1000/5'(W)) X .70(RF) (2.0' GRAVEL) = 140 FT. TRENCH
USE 2 TRENCHES - 70 (L) X 5' (W) X 2.0'(B)
Total depth of system Is 5.0' from original grade.
Total depth of gravel below distribution pipe Is 2.0' .
NOTES:
1. USE 1250 GAL SEPTIC TANK, INSULATE IF <4' OF COVER.
2. INSULATE TRENCHES WITH 2' HD BURIAL FOAM.
3. CONTRACTOR WILL ENSURE MINIMUM 2% SLOPE INTO SEPTIC TANK.
4. ADDITIONAL FILL WILL BE ADDED OVER SYSTEM TO ACHIEVE
MIN. 3' COVER IF REQUIRED.
5. CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT
WELLS, SEPTICS, LOT LINES, FOUNDATIONS AND ALL OTHER SETBACKS.
PREPARED FOR:
REX TURNER
ARCTIC DEVCO, INC.
P.O. BOX 3489
PALMER, ALASKA 99645
Scale: 1'= 100'
PAGE 1 OF 2
FIELD BOOKS
COMPUTED:
°°"N°ARw LANG
DRABN VBG
STAIONR
CHECKED: KMD
ASBUI.T: LANG
DATE 11/20/01
DWG. FILE
CR1D NW1459
ACRD FBF` 01110.DWG
J8N°4 01110
'END ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)896-6111/FAX (907)696-8111
WASTEWATER DISPOSAL SYSTEM DETAILS
GLENN VIEW ESTATES WEST S/D, LOT 10, BLOCK 1
KND
FLAT
10'
PROPOSED 4 BDRM
HOUSE
10'
CO
MT e-
cn
J
a
M
CO
-e-
D
PRO°DSED
ZABEL Z200 /
FLOW DIVIDER
1
RESERVE F
w
CO
12'
FCO
MT
0
10'
fif , 1
�.� . • TN %\
AVO,DEssV30'
-e- MT
CO
2-5%
jT
PROPOSED 1250 GAL
SEPTIC TANK
PREPARED FOR:
REX TURNER
ARCTIC DEVCO, INC.
P.O. BOX 3489
PALMER, ALASKA 99645
#99-I/10
5-9%
Lo
Scale: 1'= 20'
PAGE 2 OF 2
FIELD BOOKS
COMPUTED:
9"N" LANG
06AVBG
STAIO"1..
p1EO'11:t MAD
Air: LANG
DATE:
11 /20/01
NC. FIE:
ac NW1459
ACAe` 01110.DWG
46", 01110
NB ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-8111/FAX (907)896-8111
ND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
SOILS PERCOLATION TEST
Performed for: Arctic Devco/Turner Construction
Project: Lot 10, Block 1, Glenn View Estates West TEST HOLE # 99-1/10
Depth
Date Performed:
4/19/99
2-
3-�j i
0 t4'
t
5- ,6-
.(
�y4}V� fi
7- ti
9-',l..
re ;
10- F�l
11- S`; ^Wq
12-i :17 } Silt increasing on bottom
!y Jw/density.
13- B.O.H.
Org — soft, black, root mat
SM on bottom loose
Loose & soft on top
Redish bm to grey bm
SM/GM — Med dense,
W/ gravel & silt, dry
14-
15-
16-
17-
18-
19 -
HOLE PRESOAKED
20- PRIOR TO TESTING
SEE ATTACHED SITE PLAN
FOR HOLE LOCATION
Was Ground water encountered? NO
Depth to water after monitoring? DRY
• What depth? N/A
Date? 05/15/99
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
1
4/19/99
2:05
-
7"
-
2
2:35
30 min
54/16"
112/16"
3
"
2:36
-
7"
-
4
4:06
30 min
5 5/16"
111/16"
5
'
4:07
-
7"
-
6
437
30 min
5 5/16"
111/16"
7
8
9
10
11
12
•
Water
Added
Percolation Rate 17.78 (min/in) Perc Hole Diameter 6"
Test Run Between 3.0 feet and 4.0 feet
I, Kenneth M. Duffus, certify that this test was performed in accordance with all State and Municipal guidelines in
effect on this date.
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051-793-10
1. GENERAL INFORMATION
Expiration Date: Lp—!9 2dZ y
Complete legal description GLENN VIEWESTATES WEST PH 1 BLK 1 LT 10
Location (site address) 22818 GREEN GARDEN, CHUGIAK, AK 99567
Current property owner(s) JOESEPH AND KAREN FURRER Day phone
Mailing address
Real estate agent
22818 GREEN GARDEN, CHUGIAK, AK, 99567 USA
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
®
Public Sewer
❑
Waiver request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date:
COSA Fee $ 5 5 D Waiver Fee $
Date of Payment b a b
Receipt Number t 19 ao1
Date of Payment
Receipt Number
COSA # 0 5 C2, � 13 1 ,2, Waiver #
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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name CURTIS HUFFMAN PE Date 6/27/22
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
6. DSD SIGNATURE
XSystem #1 Approved for _�/_ bedrooms
System #2 Approved for bedrooms
Disapproved
*� �TM ....�:* �d
. • Curtis Huffman i
-,q % CE 128991 • ik��
���di�pROF S ONP\F��.r
Conditional approval for bedrooms, with the following stipulations:
AQQ` p,oly OFr(ri
CATERA hi nm
VVA
PR
ATER z
fl
1
7'SERVIGtis
By: 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 State 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
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other 4-u& Aqo�J;Sict
Legal Description: GLENN VIEWESTATES WEST PH 1 BLK 1 LT 10 Parcel ID: 051-793-10
If more than 1 septic system on lot: COSA Checklist # _of _ Structure served by this system
L DATA — PUBLIC WATER
❑ Well to s f led with Onsite (or attached)
Date drilled
Total depth _ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) _in.
Date of flow test for COSA
Static water level at beginning of test _ft.
Comments
B. TANK DATA
Age of tank(s) 20 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 50"
® Standpipes/foundation cleanout per record drawing
Date of pumping 6/17/2022
D. ABSORPTION FIELD DATA
Which system tested (date installed) 8/12/2002
® ALL standpipes present per record drawing
Total measured depth from grade 5.2' / 5.3 ft (max)
Measured depth to pipe invert from grade 2.8' / 3.5 ft
(min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective 2.4'ED & 1.8'ED (W / E TRENCHES)
® 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:
Well production at time of test _gpm
Water storage tank volume_ gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate _mg/L ❑ Nitrate less than MRL (ND)
Arse is ug/L ❑ Arsenic less than MRL (ND)
Collected
Date of Sample
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _ years
Lift station material
Comments:
Adequacy test date 6/18/22
Results M Pass For 4 bedrooms
Fluid depth prior to test 10" / 5 in
Water added 600 gal
New depth 13" / 8 in
Elapsed time 1380 min
Final fluid depth 10" / 5 in
Absorption rate 600 gpd
Any rejuvenation treatment (past 12 months) N
If yes, enter date
E. SEPARATION DISTANCES
.from Private Well on Lot to: (Please enter distances if less than required or if community well)
❑ Yes
Septic Taii-OLStation on Lot > 100'
Community
Surface Water > 100' ® Yes if No
Property Line > 5'
Sewer Manhole/Cleanout > 100'
if No
❑ Yes
if No ft ❑ Yes
if No
Neighboring Tank > 100' ❑ Yes
if7 ft Private Sewer/Septic Line > 25' ❑ Yes
if No
Absorption Field on Lot > 100' ❑ Yes
if No ft ``� ;,o ding Tank > 100' El Yes
if No
Neighboring Absorption Fields > 100'
Animal Containmen+> 50' ❑Yes
if No
EJ Yes
if No ft _
Manure/Animal Excreta Stor ivy
if No
Community Sewer Main > 75' ❑Yes
ge
if No ft ❑ Yes
N -a
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
❑ Yes
if No *5+
ft
Surface Water > 100' ® Yes if No
Property Line > 5'
® Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes
if No
ft
Private Wells > 100' ® Yes if No
Water Main > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Water Service Line > 10'
® 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'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No
_ ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
*INSTALLED PER MOA CODE AT SEPTIC TANK INSTALLATION.
G. ENGINEER'S CERTIFICATION
l certify that l 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.
Noll
r :*-49 TH
.. ....
.. ...*Huff
..........
:• • Curtis Huffman
���Fci�T • ' • b 27/2991
kkF, PROFESS aNV���'�'
ft
ft
ft
ft
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Septic Tank Advisory
Certificate of On -Site Systems Approval #OSC 221312
Subdivision: Glenn View Estates West Ph 1 BLK 1 lot 10
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks The septic tank for
this COSA / property is 20 years old. A leaking septic tank may be a source of contamination
to the aquifer. Typical replacement costs range from $10,000 to $15,000
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of a 16 -year-old septic tank in failure and should be replaced.
Parcel I.D.
Municipality' of Anchorage
Development Services 'Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muniorg/onsite
(907) 343-7904
Vv
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
051 -'13 -in
1. GENERAL INFORMATION
Complete legal description
COSA# 0100(6Q
Expiration Date' 3 - 2 7- OR
GLENN VIEW ESTATES WEST SUBDIVISION ;1; LOT 10, BLOCK 1,
Location (site address) 22818 GREEN GARDEN DRIVE • CHUGIAK, AK
99567
Current Property owner(s) CHRIS EDERLE Day phone 529-0069
Mailing address 22818 GREEN GARDEN DRIVE * CHUGIAK, AK 99567
Lending agency
Mailing address
Real Estate Agent
Mailing address
Day phone
Day phone
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
. 3
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 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, 1 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. 1 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 ell applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
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, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines 8 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 am 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 Ls 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
tee Approved for 3 bedrooms.
Disapproved.
Conditional approval for
Date 1/2
•3./24,A7 oA�F�t
:.;79
FitteJSITE Ge5 WATER AND : T^_
WASTEWATER :
PROGRAM : s
bedrooms, with the fllowing stipulations: % Q' .z_••• ••••
'�
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
By:
(Rev.,,/0S)
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
Original Certificate Date*
3 -Q7-°7
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onste
CERTIFICATE OF ON-SITt0itMS APPROVAL CHECKLIST
Legal Description: GLENN VIEW ESTATES WEST SUBDIVISION 11, LOT 10. BLOCK 1 Parcel ID:
A. WELL DMA
Well type If A, 8, or C provide PWSID# _ Well Log (Y/N)
Date completed Sanitary seal WN ' Tres property protected (Y/N)
T Cased to ft Casing height (above ground)
FROM WELL LOG AT INSPECTION
PUBLIC WATER
Date of test J�
Static water level / ft
Well production
WATER SAMPLE RESULTS:
g.p.m.
Coliform colonies/100 ml. Nitrate m•J
ft
g.p m
in.
colonies/100 ml.
Date of sample. Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEEL Date installed 8/12/2002
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) NJA
Date of pumping 3/23/2007 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA
61:144014 btodEt
Date installed 8/12/2002 Soil rating e.p.d. ' or ft'/bdrm) 0_8 System type TRENCH
Length 144 ft Width 5 ft. Gravel below pipe 2.29 ft.
Total depth +6. ft. Eff. absorption areal 028+ft' Monitoring tube YES
Date of adequacy test 3/22/2007 Results (Pass/Fail) PASS
Fluid depth in absorption field before test'tDRY in. Water added 11071 gal.
Depression over field NO
For 4 bedrooms
New depth 17 in
Elapsed Time: 214 min. Final fluid depth 14 in. Absorption rate >= 600+ g p d
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date —
•"TESTED THE SOUTH TRENCH. NORTH TRENCH WAS DRY ON 3/22/07
D. LIFT STATION
Date installed
"Pump on" level at in.
Datu
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main ublic sewer manhole/deanout
Sewer /septic service line Holding tank
Ani - • r mment areas Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Size in gallons Manhole/Access (YIN
"Pump oft" leve = High water alarm level at in
Cycles tested Meets alarm & circuit requirements?
PUBLIC WATER
On adjacent lots
On adjacent
Building foundation 5'+ Property line
5'+ Absorption field 5'+
Water main
10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water service line 101+ Surface water 1001+
Curtain drain NONE KNOWN
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Wells on adjacent lots 200'+
I 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.
Engineer's Printed Name JEFFREY A. GARNESS
Date 3lZ6/o•-7-
Driveway, parking/vehicle storage
10'+
COSA Fee $ 4 3G� . 0 0
Date of Payment .5 ' a 7 - 0 7 Date of Payment
Receipt Number 1 3 2 1 Via
Receipt Number
(Rev. 11/05)
Waiver Fee $
,)li5'FA?_l S
Municipality of Anchorage
Development Services Department
Building Safety Division •
••
On -Site Water and 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 ID. 0S1-793-10
1. GENERAL INFORMATION
Complete legal description Glenn View Estates West Ph1 61 L10
Location (site address or directions) 22819 Green Garden Drive, Chugiak, AK 99567
Current Property owners) 1 ara Srhwartz Day phone 688-6757
Mailing address 22819 Green Garden Drive. Chugiak. AK 99567
Lending agency _Summlitiortgage, Chric Day phone 646-8700
Mailing address 205 F. RPnsnn Rivd SultP 101, Anrhnragp, AK 99503
Real Estate Agent Susan Westland PrularkWhitp Day phone 689-6520
Mailing Address 16635 rpnterfield Drive, Eagle River, AK 99577
Unless otherwise requested, HM will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
HAA # D5D.5'a
Expiration Date: 7- 18 - D (p
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
❑ Individual On-site
O 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 4 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. (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 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 time of Installation.
Name of Firm KNI) FN(;INFFRING Inc. Phone (907) 868-1791
Address 20441 Ptarmigan Rlvri., Eagle River, AK 999771
Engineer's Printed Name_Kenneth M Duffus
Engineer's Comments:
This Investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the
condition of the well and septic applies only to the
conditions as of the day tested. The flow and absorption
rates may change due to subsurface conditions that
may not be observed from the surface, changes In
land use, local soil characteristics, groundwater levels
that may fluctuate during the year and the water usage
of the family being served by the system. The operational
life of all well and septic systems are subject to these
various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system.
Therefore, KND can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can KND guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
5. DSD SIGNATURE r'�
Approved for T bedrooms.
Disapproved.
By:
Date 7/12/2005
i 49L
i..r .. e •
1,;�•
t•w4,
Ken.0`p, e
Conditional approval for bedrooms, with the following stipulations: �� A�r
�'1/4ttttt.�f�-Tr
irr
•
.'C=
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
� � : WATER AN
'ATER
•, AROG�RAM
%
lop//lijj .lull/',
Supplemental Engineer's Report
Other
Original Certificate Date. 7-- /8 - O,S
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.cianchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description. Glenn View Estates West Ph1 81 L10 Parcel ID: 0 51- 7 9 3 -1 Q
A. WEU. DATA
Well type Public 11 A, B, or C provide PWSID #_ Well Log (Y/N)
Date completed_ Sanitary seal (Y/N) Wires properly protected (WN)
Total depth ft. Cased to ft. Casing height (above ground)
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft.
Web production g.p.m
WATER SAMPLE RESULTS:
ft.
g.p.m.
Coliform _colonies/100 mi. Nitrate mg./I. Other bacteria _ colonies/100 ml.
Arsenic: mg./I. Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel (Anchorage Tank) Date installed 8/12/2002
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) X_pepression over tank (Y/N)1'LHlgh water alarm (Y/N) ft
Date of pumping 6/28/05 Pumper JR's
C. ABSORPTION FIELD DATA
Date installed 8/12/2002 Soil rating (g.p.d./ft2 or fl2/bdrn) 0.6 System type Trench
Length 144 ft. WIdth 5 ft. Gravel below pipe 2.2 8 ft.
Total depth 5 ft. Eft absorption area 1028+ft2 Monitoring tube y Depression over field N
Date of adequacy test 6/28/04 Results (Pass/Fail) Pass For bedrooms
Fluid depth in absorption field before test 9/15 In. Water added 720/430 gal. New depth 17/20.5 in.
Elapsed Time: 170/255 min.Final fluid depth 14/18.5 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed NA
Size in gallons Manhole/Access (Y/N)
Pump on level at in. `Pump off" level at in.High water alarm level at In.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/deanout
Sewer /septic service line Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line _51_±
Water main 101+ Water service line 1 01+
Wells on adjacent lots 200'+
Absorption field 5 ' +
Surface water 1 00'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 1 0'+ Water main 1 0'+
Water Service line 10'+ Surface water 1 00'+ Driveway, parking/vehicle storage 25'+
Curtain drain 50'+ Wells on adjacent lots 200'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems ars In
conformance with MOA HAA guidelines In effect on this date.
Engineer's Printed Name Kenneth M. Duffus
Date 07/12/05
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/01)
elick`=�4
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and 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
•}:_
HAA# "H (:)30
Parcel I.D. 051-793.10
1. GENERAL INFORMATION
n '
.:Complete legal description GLENN VIEW ESTATES WEST PHASE 1. BLOCK 1, LOT 10
Expiration Date: $ — 1 2 — 0 3
Location (site addressor directions) GREEN GARDEN DRIVE, CHUGIAK. AK 99567
Current Property owners) KAPPEN HOMES, LLC Day phone 622.5585
Mailing address 17034 EAGLE RIVER LOOP. SUITE 201 EAGLE RIVER. AK 99577
Lendin%agency ,,, Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: '
Individual Well , • 0 Individual On-site El
Individual Water Storage 0 Individual Holding tank 0
Community Class Well 0 Community On-site 0
Public Water System ® Public Sewer 0
'The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 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. (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 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 time of installation.
Name of Firm KND ENGINEERING, INC Phone (907) 696.6111
Address 20441 Ptarmigan Blvd., Eagle River, AK 995
Engineer's Printed Name Kenneth M. Duffus
Date 5/8/03 -
* 4NGH ' S•'f*II
r, ...'. •.. •••i•• •.• :•• •A
.•
c 01
5. DSD SIGNATURE /; ���Kenneth
M.CE uU, 14 o
�L
.1-7Approved for "7 bedrooms. 44 •,.••• c5
Disapproved. ,� 10\vaN+��lo
Conditional approval for bedrooms, with the following stipulations:`
Additional Comments
C
ON-SITE , c
WATER AND . R'=
• . : WASTEWATER
PROGRAM ;
si
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
By: (, �, - 11) 10-P Original Certificate Date: 5 ' / 2 ' O 3
(Rev. OVC2)
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.cl.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: GLENN VIEW ESTATES WEST PHASE 1. BLOCK 1. LOT 10 Parcel ID: 051-793.10
A. WELL DATA
Well type Public if A, B. or C provide PWSID # _ Well Log (Y/N)
Date completed _ Sanitary seal (Y/N) Wires properly protected (YIN)
Total depth _ft. Cased to _ft. Casing height (above ground)
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m g.p.m.
WATER SAMPLE RESULTS:
Coliform _colonies/100 ml. Nitrate _mg.A. Other bacteria _ colonies/100 ml.
Arsenic: mgA. Date of sample: _ Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Seapc/Steel ANCHORAGE TANK Date installed 8112102
Tank size j280 gal. Number of Compartments L Cleanouts (Y/N) y
Foundation cleanout (WN) Y....Depression over tank (Y/N) y High water alarm (YM) N
Date of pumping JN/,-NE,N(JANIS Pumper
C. ABSORPTION FIELD DATA
Date installed $112102 Son rating (g.p.dJft2 or ft2/bdrm) 0.6 System type Trench
Length 144 ft. Width § ft. Gravel below pipe 2.28 ft.
Total depth ft. Eff. absorption area 1028+ ft2 Monitoring tube Y Depression over field N
Date of adequacy test NA • NEW SYSTEM Results (Pass/Fail) Pass For 4_ bedrooms
Fluid depth in absorption field before test _ in. Water added _ gal. New depth _in.
Elapsed Time: min. Final fluid depth _in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes. give date
D. LIFT STATION
Date installed NA
"Pump on" level at _ in.
Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
Size in gallons
Manhole/Access (Y/N)
"Pump off" level at _ in.High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
On adjacent Tots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5y'+ Absorption field 5'+
Water main 10'+ Water service line 10'+
Wells on adjacent Tots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+
Water Service line 10'+ Surface water 100'+
Curtain drain 50'+
F. COMMENTS
Wells on adjacent lots 200'+
Surface water 100'+
Water main 10'+
Driveway, parking/vehicle storage 25+
G. ENGINEER'S CERTIFICATION
I certify that / have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Kenneth M. Duffus
Date 518103
•qE OF 44%f
y/fix=• , � '••f*�I
F. NN e1Me N.Nge /N•N •• •
i a
TT Kenneth . ufr:,•i/ty���
firthiv IGigYfet. S ,;s
ar
HAA Fee $375.00
Date of Payment
Receipt Number
(Rev. 1vol)
t7slotia3
.c 3 SO ego
Waiver Fee $
Date of Payment
Receipt Number
