HomeMy WebLinkAboutMANN BLK 5 LT 1Onsite File
#020-481-01
Municipality of Anchorage
Development Services Department .~ ~:
Building Safely Division
On-Site Water and Wastewater Program, 4700 S, Bragaw St.
P.O, Box 196650 Anchorage, AK 99519-6650 Page of
www.cLanchorage.ak,us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit,Number: _.~,~r (~) ~)~.~ 7Z.//. PID Number: _~) 2.. C> -', O,.~ J-- (~ 7
^~d'"'I~O~ 4 I0/~a..5 4 lx)~_.J~,. ~ ABSORPTION FIELD
Soil Raling: Total Depth from odginal grade:
LEGAL DESCRIPTION O
Number of ~ines: D,stance i~etween I,n_e::
Driller: Date Drilled: StabC Wale~' Leve~: Installer:
SEPARATION DISTANCES m septic [] Holding [] S.T.E.P. ~ther:
To Septic Absorption Lift Holding 3ublicJPdvate
· [)ed x,eh ct;To ?¢0 ,,.
Engineer's Stamp
,Inspecti°ns performed by:xJ, .w_) } ZSC_.../~45y~'~ Dates: 2"d~'~1st (~ '-- ~ ~~~, ' ~.
Development Services Departmont Appro~ ~'
S~f030274
AS BU.[LT PLAN
°~--- ~e77 LOT 2
$..x $2'. leach f~eld, 0.8' elf ---;~ /TH ,
m ~e
A C02 98.6
A MT I 79.1
B COl 83.5 ~ ~. ~
B MT2 78.1 ~ .~, ~ ~
3~ES SIZE~ORE & ASSOCIATES
CIVIL ENGINEERS & SURVEYORS
SIf030274
AS BUILT DETATLS
g°~7__.~.
~ , ' ..~ ' ' - ~ ~ ~ 1~-~ 6~ ,~d~ .~, ~.~
3~ES SZZEMORE & ASSOCIATES
C~V~L ENGINEERS & SURVEYORS
RightF&x
8/6/2003 10:48 PAGE I/1 RightFax
Inspection Report
Municipality of Anchorage, Building Safety Division
4700 South Bragew
INSPECTION! VOIGE 343-8300
Agdresa
legal
Subdlvlllon
Comments or Dlroctlone
INSPECTIONI FAX (907)249-7777
Brick's Electric: Bill
5601 E 162ND AVE
INFOI 343-7952
BK5 LT 1
MANN
Permit 03-8623
Phone 345-:1436
Mike
440-9351 Bill
Inspection Date 8/7/2003 AH
Early A.M,??? Owner is Mike Bbnch~rd co~ct phone #:1. Tank lid is
unlocked. Thanks
Inspection J~a~o E~ctrlcal I~lnspocUon N
"'""[~NO NONCOMPLIANCE OBSERVED
[] CORRECTIONS ESSENTIAL AS EXPLAINED BELOW
[] WILL RE-EXAMINE AT NEXT [] DO NOT CONCEAL UNTIL REINSPECTION
INSPECTION
r
COMMENTS~; (for Inspector use only)
~nspector Dete~
MUNICIPALITY OF ANCHORAGE
Deve/oprnent Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Jul 28, 2003
Expiration Date: Jul 27. 2004
Permit Number: SW030274
Legal Description:~iN"BLi~ 1.15' LTl' 1i !i7
Design Engineer: 0027 James Sizemore & Associates
Owner Name: Michael Blanchard
Owner Address: BOX 110185
ANCHORAGE, AK 99511-0000
Parcel ID: 020-051-07
Site Address: 005601 162ND AVE E
Lot Size: 45000 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. Ail 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.
IssuedBy: ~)~_~_/_: ~ ~
Date:_.~~
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 SEWERJVVELL.P- ERMIT_APPLICA. TION
FOR A SINGLE FAMILY DWELLING
Permit Number SW~ ~0~74[
Propertyowner(s) //~(.1~'"', /J//',; ,J~/~..- .,~
~ilin~address (2) ~ I~g ~ B ! ~ L'~ ~V~ Zip Code
Legal description (Lot, Block & Sub'd.)
Legal description (Section, Township & Range)
~: ~- m ~ - Acres/Sq~ Number of Bedrooms
Lot Size ~ .I ~
ooo .,
THIS APPLICATIO~ IS FOR:
Sewer Only [] Well Only r-]
Sewer and Well [] Water Storage []
Sewer Upgrade [~
THIS PROPERTY CONTAINS:
Hot Tub [] Jacuzzi ~
Swimming Pool [] Water Softening Unit []
Therapy Pool []
I cedify 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.
(Sig~ture"J' of pr-operty owner or a~tthorized agent)
Permit Fees: ~, '~"~ (''')
Date of Payment:
Receipt Number:
(Rev. 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
PROBABLE IMPACTS TO ADJACENT PROPERTIES
A) WELLS
The proposed BioCycle Wastewater Treatment System proposed for this lot provides
better treatment of the wastewater generated on the lot than the timber crib that has been
in place for 35 years. The impact to the well on this lot and to the well on the adjoining
lot should therefore be reduced.
B) WASTWATER SYSTEMS
The BioCycle Wastewater Treatment System gives excellent treatment to onsite
wastewater. There should be no adverse effect on adjacent systems.
C) RESERVED SPACE/SURFACE AND SUBSURFACE
There is sufficient space on this lot for this replacement system. The protective radius
around the well is adequate.
D DRAINAGE
Disturbed areas will be graded so as to prevent ponding of water and not adversely affect
drainage.
°~-- ~e~ LOT 2
$ x',46 ft. Leach FfeTd, 0.5 eff. o~ TH I
..... ~~_~
Exi:st Timber ICrib,'. b,~,, ~ ,~,o'T~ ~'o~
Rea)ye To~ F~11
I · ~locyclei .
w~t~ unclass~f~e~ ~ _~ ~. r~at~e,t:~,~t
~Ex~,st~ng ST, Re~ve~
~,. , w~~o ,.~
~;, o,~,,~ _~~jLOT 1, BL 5, MANN SUBD.
PROPOSED SEPTIC UPGR~E
',,,'.'.,..,.~ SITE PLAN
~ES SZZE.ORE ~ ~SS~ZATES
TEC SO~-~4e:~4S~
~. BY 3FS ~. 8Y 2S DA~: ~LY 13, 03
~LE: 1~. ~ ~'
t;e'e 5'x ~' /Ze~c4 F'i ei¢-
r--A~ Fl' X--SF_~ v
Municipality ot Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:
DATE PERFORM
J~:me* F. ~'xcmom
SITE PLAN
3
4
5-
9
10
11
12
13
14
15
16
17
18
19
2O
WAS GROUND WATER
ENCOUNTERED?
IF YES. AT WH AT.z..7,
hole
Reading Date Gross Net Depth to Net
Time Time Water Drola
' ' ~: ~: ~ ; ~0~' ~ ~
"E"COLA.,ON RA.E !¢, $ ,.,nu,e~,.c., .ERC.OLE D,AME.~. (e"
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.anchoraqe,ak.us
(9o7) 343-79o4
Soils Log - Percolation Test
Date Performed:
5-
6-
7-
8-
9-
10.I
12-¸
13-
14-
15-
16-
17-
18-
19-
20-
-Site Plan'~ ~ '-
I,I
WAS GROUND WATER
ENCOUNTERED?
MonltoHng?~ ~
Reading Date Gross Time Net Time Depth lo Water Net Drop
, ',,, .~.~ ?_:_~.~. "~/~
~.;o ? .~-~ ~ ' '1'"
tf
PERCOLATION RATE ~ ~nutes/Inch) PERC HOLE DIAMETER
TEST RUN BE'~'WEEN t ~ FT AND ~) FT
WASTEWATERDISPOSAL SYSTEM
LOT 1, BL. 5 MANN SUBD.
1.0 General:
1.1 The scope of this project consists of installing a "Bioeyele" aerobic treatment
unit which will discharge the treated effluent into a 5' x 46' leach field. The
system replaces a septic tank and seepage pit. The existing tank and seepage
pit shall be properly abandoned by pumping, crushing and removing the tank,
and removing the top ofthe seepage pit and backfilling with soil.
1.2 The 1250 gallon "Bioeycle" aerobic treatment unit shall be supplied by
BioCycle Alaska.
1.3 The Bioeycle supplier shall be responsible for setting the control and alarm
floats and verifying their proper operation.
1.4 The contractor shall be responsible for obtaining any necessary electrical
permit and inspections.
2.0 Soil Absorption System
2.1 The soil absorption system shall be a 5' x 46' shallow trench with an effective
depth of 0.5'. The bottom of the trench shall be level and the trench will be
located as shown on the site plan. Care shall be taken to maintain separation
distance from the system on Lot 2, immediately to the North.
2.2 A cross section of the trench is shown in the design.
2.3
Approved filter fabric shall be placed over the top ofthe sewer gravel. 2" of
blue board insulation, covered with 2' feet offill shall be placed over the filter
fabric.
ADVANCED WASTEWATER TREATMENT SYSTEM blAINTENANCE AND
REPAIR AGREEMENT
I~IEMORANDUM OF UNDERSTANDING
BETWEEN MUNICIPALITY OF ANCHORAGE
THI Mt!McSk frDtrM OF Uflm!RS 'Als-DINc;' made and 6n-/6i~ed into as of' this y 7 .......
day of D"a-.z. ~/ 20c.3, by and between/t/,,~.~,,~r_ /I. ~.~.~,~,d.~.,r~, herein the
"OWNER," and th~' Municipality of Anchorage, herein the "MUNICIPALITY." In
consideration of' the mutual covenants contained herein, the parties to this Memorandum of
Understanding a~ee as follows:
1. ADVANCED WASTEWATER TREATblENT SYSTEMS. Municipality grants
permission to Owner to utilize and operate an Advanced Wastewater Treatment System
(AWWTS), described as ~ i~ ~ ')'r__. ] ~
Anchorage, Alaska.
2. Definitions.
Alteration. Any change to the desi~ or function of an AWWTS that
includes the installation or removal of any parts, components or pieces
not included in the original construction permit and design. Prior to
performing any alterations to an Aww'rs the owner must obtain a
wastewater Disposal System Construction Pe,,,it from the Municipality
pursuant to Anchorage Municipal Code (hereinafter, "AMC") 15.65
Certificate of On-Site Systems Approval. An approval by the
Mt, nicipality of existing water and wastewater disposal systems given at
the time of property sale and title transfer in accordance with AMC
Page I o~5
15.65. These approvals certify that the systems are adequate for the
homes that they support and meet the codes that were in place at the time
of system construction. ... .....
" C.' '" 'Damage.' .'Any maa-made or natural change in a sS, stem that would.
inhibit the system from performing as designed.
D. blaintenance and Repair. The scheduled and as needed replacement of
existing parts, components and pieces of an AWWTS that were included
in the ori~nal design which would allow the AWWTS to continue to
perform as designed.
~, E.' Permit (Const.r. uction). An On-Site Wastewater Disposal System
Construction Permit as defined by AMC 15.65.
F. Permit (Operating). An Advanced Wastewater Treatment System
:' Operating Permit. An annual permit, issued by the Municipality, that
allows the Owner to operate an AW~VTS, upon meeting all requirements
· ' "6f this a~eement, the conditions of the O'perating~ Pem~it, the.
requirements of the On-Site Wastewater System Construction Pemfit
and all relevant provisions of AMC 15.65. ~
3. Fee. Owner shall pay to Municipali.ty an annual fee of (~
(S ~_~ .00), payable on or before the issuance of the operating permit and annually
thereafter. The annual fee is due on or before the anniversary date of the approval by the
Municipali .ty of installed system.
Page 2 0£5
4. Term. The term of this Memorandum of Understanding shall be for the life of the
Ag/g/TS. The term begins on the date of approval by the Municipality of the installed system
and shall continue while the AWWTS system is in use or operational or until the property, is
s0id or title is {ransfe~-ed by OWner-a-nd a 'new'certificate'of oh site approval i$'.i-'.'aued to tile -'
new owner or transferee of the property.
5. Alterations, Installation and Removal of Additional Equipment. Owner agrees not
to make any alterations, removal of parts or additions to the AWWTS without a Construction
Permit from the Municipality.
6. M:iintenance and Repairs. '
A. Throughout the term of this Memorandum of understanding, the Owner shall
maintain AWWTS in good repair. In addition, it shall be the responsibility of the Owner
during the term of this Memorandum of Understanding, and any extensions or renewals
thereof, at the owner's sol~ expense, to pay for any and all: (1) repair(s), (2) maintenance, (3)
adjustment(s), (4) replacement costs, and (5) inspection costs. Further, owner agrees to
comply with all applicable ordinances, laws, regulations, roles and orders for the AW~VTS.
B. Owner agrees to provide the Municipality a written schedule of routine
maintenance and repairs which have been performed on the system pursuant to the teims and
conditions contained in the Owner's AWWTS Operating Permit. This schedule shall be
submitted to the Municipality annually upon the renewal of the permit. The schedule of
maintenance and repair contained in the Owner's AWWTS Operating Permit is:
_ Page 3 of 5
C. Owner acknowledges that the fine schedule for failing to maintain and repair an
AWWTS are codified in AMC 14.60.
D. Owner agrees that only maintenance, repair personnel certified by the
Municipality will inspect'and' make any nec~:$s~y~ maintenance,' repai~ .or-pc~mittcd '"' -"
alterations tO 'the systems.
E. Owner a~ees to grant the lVlunicipality reasonable access to test and inspect the
AW~VTS upon 24 hours written notice.
F. Owner a~ees that any sale or transfer of title of the property will not occur
without a new Certificate of On-Site Systems Approval.
G. Owner a~ees that the relevant provisions of the standard specification
guidebook for AWWTS is the governing professional guidelines for the construction,
maintenance and repair of the Owner's AWWTS.
7. Nonwaiver. The failure of either party at any time to enforce a provision of this
Memorandum of Understanding shall in no way constitute a waiver of the provisions, nor in
any way affect the validity of this Memorandum of Understanding or'any part. hereof, or t.h~
right of such party, thereafter to enforce each and every, provision hereof.
8. Amendment.
A. This Memorandum of Understanding shall only be amended, modified or
changed by a writing, executed by authorized representatives of the parties, with the same
tbrmality as this Memorandum ot"Understanding was executed and such writing shall be
attached to this Memorandum or Unc~rstandmg as an amendment,
Page 4 of 5
For the purposes of any amendment modification or change to the terms and
conditions of this contract, the only authorized representatives of the parties are:
A~ehorage: Purchasin~ Officer
C. Any attempt to amend, modify, or change this contract by either an
unauthorized representative or unauthorized means shall be void.
9. Jurisdiction: Choice of Law. Any civil action arising from this Memorandum of
Understanding shall be brought in the Superior Court for the Third Judicial District of the
State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and
obligations Oft.he parties under this Memorandum of Understanding.
10. Severability. Any provisions of this Memorandum of Understanding decreed invalid
by a court of competent jurisdiction shall not invalidate the remaining provisions of the
Memorandum of Understanding.
OWNER: NIUNICIPALITY:
By: ~-'"//.~ ~- ~ ~' By:
~__~~~. ' Title:
Date: .~/.~.~'~_ Date:
STATE OF ALASKA )
) SS.
THIRD JUDICIAL DISTRICT )
The foregoing instrument was acknowledged before me this1~.~ day of by · offbehalfof
of
NOTARY PUBLIC FOR ALASIC-k
Page 5 of 5
R;~h..d'~ASSiGNMEN"i'v~.AACodc Addcndum AMC I $.65 [~¢0O-O2$7]',Mcmurunudm ur Undcrstanding Vcrslon Vi.doc
Page 6 of 5
Municipality of Anchorage
Development Services Department
Budding Safety Division
On-Site Water and Waste,~'ater Pr.ogram
" 4700,South Bragaw St. '"
P.O. Box 196650 Anchor, ge, AK 99519-6650 www. ci. anchorage, ak. us
' ' (907) 343-7904
CERTIFICATE OF HEALTh ~u ~ r, OR~ I Y ArrRvv~L
.... "" "I-OR~ ;'51~I-GLE t:AMiLY D'~ErI.:iN"G
,-. ; ..... . .ExpirationD. ate: // -/,~... - O-~
1. GEN ERAL II~P, dlRMATION. ' -~,'~ ~ '
Complete legal descfiptidn:;(
Lomtion (s~e~ddress or direction)}~'' '
5~ h~, ' 'J-.,, "; : .t-' ·
Current PropeNy.owner{s)
Mailing address B~ I't.Oi TBj q¢511..
Lending agency ... Day phone
.. Mailing address
Real Estate Agent
Dayph~ne
Mailing Address
Unless otherwise reqqested, I-/AA w~l be he/d by DSD for pickup.
NUMBER OF BEDROOMS: ~'
TYPE OF WATER SUPPLY:; '
Individual Well -. ~ '
Individual Water Storage []
Community Class Well []
Public Water System []
· 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 4 by an independent professional civil
engineer registered in the State of Alaska. Certifimtes 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 r-re
valid for 90 days from the date of issue for properties served by a private er Class C we!l and may be reissued with
new water sample results. (Certificates may be reissued for a pedod et up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or 13 we!Is 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 validaUon date shown below, I verify that my investigation,
based on' procedures ouUin;s'd in the Health Authority Approva! Guidelines for this application, shov,'s that the on-
site water supply and/or v,,ast~water,disposal system is(are~ S~fe, ~h'ctic~nal and adequate for tho number Of
bedrooms and type of structure indicated herein. I further verify th~.t bas. ed on. the !nformation obtained from the
Municipality of Anchorage files and from my investi~ab.'~n..'.Gnd .inspection, the on-site water supply and/or
5. DSD SIGNATURE·
wsstewater disposal system is(are) in co.mpiiance with .all .apprL~. b!.e.' Municipal and State codes, ordinances, . .."....-.~'
and regulation{ in;~ffect at the time of installation... ' · .;-.'.. '."?..-..":':' ' ": '~' · · ' .... .- .?.'."
Y" '~ ' ....
Engineer's Printed Name~
· .. ., .... .,~..-~ ,,.. ,; ,~../.~-'~.~.'.'?'. . ,- . ". ~ - . . ·
.. ... . ...-.,.: .....
· · .. .... ~,~ ·
· . "..· .. '~._.~:.~;:';,'-:..:~:.~.u..:.-.:,'? .,...-. ~ .,
. .,
s,:mth the foil?rang stipulati¢
: ';'..'; ~'~::...7;.;.,',.~ ' ~:-. ~::;. ;-:; ~.. :. -, ~ · '
· . . ..' ...:'.:..'.' '...,. .... . .. -..~..'.. ..,...-,, .....,..-.
"Disapproved. ' · ·
~ - -.Cond'iti~)~al appm~,al'for '~ ......... ':.:.bedr6omS
Attachments:
HAAChecklist... '. '
Septic System Advis'ory:' .
Well Flow Advisory
""' Maintenance Agreemehts
8uppien~ental Engineer's Report
·Other
Original Certificate Date:_
(Rev.
Municipality of Anchorage
Development Services Department
; Building Safely Division
On-Site Water & Waslewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L-
A. WELL DATA
Well type ¢~/~¢~'~ If A, B, or C provide PWSID #
Date completed/,~"'J'~ . ' Sanitary seal (Y/N)
Tota ; epth "77. i,.. Castro,'77
FROM WELL LOG
Date of te~t
Static water level '"" · ~ I ft.
Well production
WATER SAMPLE RESULTS:
Coliform C~ colonies/100 mi. Nitrate ,,~..".mg./L
Arsenic: mgJI. Date of sample:?~/(~
B. SEPT~C/HO'D~.G TANK DATA
Tank Type/Material
Tank size ~/~) (~gal. Number of Comparlments
Foundation cleenout (Y/N) ~.. Depression overtank (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Parcel ID: (~)'~(~)-~]--Z~7
Well Log (Y/N) /'
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
Other bacteria '~ colonies/100 mi.
Date installed .~ '"-'"
Cleanouts (Y/N) Y
High water alarm (Y/_N)
Date installed ~IL,~'''- (~
Length 5~:~ ft. Width ,,'-~ ." ft.
/
Total depth J,"'~0 ft' Eft. absorpli.~n, are¢'2T/~ ,,ft'' Monitoring tube__
Date of adequacy test t~-- Results (Pass/Fail)
Fluid depth in absorption field before test in.
Elapsed Time: min. Final fluid depth
Any rejuvenation treatment (past 12 mo.) (YIN & type)
Soil rating (g.p.d.lft2 or ftt/bdrm):~_'~)~'/c'Cl~/~ystem type ~ ¢~__.~ '[-r"~,,
Water added gal.
in. Absorption rate >=
Gravel below pipe, ~)i~ ft.
Depression over field Jr/
For ."~ bedrooms
New depth in.
~ g.p.d.
If yes, give date
LIFT STATION (F.,¢~/'~ ~
Date
at~ ~
"Pump on" level "Pump off' leve~ ,~t ~in.
Datum J~--'~ ~J~ Cycles tested ~. T~
Manhole/Access (Y/N) ~
High water alarm level at
Meets alarm & circuit requirements?
in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot I (~ ~ ,,-~
Absorption field on lot
Public sewer main
Sewer/septic service line ~ I
On adjacent lots
On adjacent lots
Public sewer rnanhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation. ~ L~ . .. Property line J~/'~'.~ j'
Water main ; _
Wells on adjacent lots '~' t OC cwater servi,? line
Absorption
Surface water ~~__--~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LpT TO:
Propertyline [~'~ ! Buildir,gfoundation_"~.~-~' Watermain ~ ~'~:2 £
Water Se~ice line ~ Sudace water Driveway. parking/vehicle storage
Cudain drain ~ ~ Wells on adjacent lots
~OMMENTS J~OO ~1 ~Te~f~ ~~~ 0~ ~
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this dat~.
Encnee 's Printed
Date ~ -.-, '~--.-'-~;:7 ~
Fee s
Date O~ Payment
Receipt Number
(Rev. 12/01)
Date of Payment
Receipt Number