HomeMy WebLinkAboutTONJESS ESTATES BLK 2 LT 12Ton jess Estates Block 2 Lot 12 #051-832-19 Municipality of Anchorage Community Development Department Page 1 of 3 On -Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP141304 PID Number 051-832-19 0 New ✓❑ Upgrade Name: Aron Crowell & Dee Hunt Address 25145 Schaff Drive Chugiak, AK 99567 Phone Number of Bedrooms 3 ABSORPTION FIELD ❑✓ Deep Trench 0 Shallow Trench ❑ Bed ❑ Mound ❑ Other Soil Rating 1.2 GPD/SF Total depth from original grade LEGAL DESCRIPTION Subdivision Block Lot ,Tonjess Estates 2 12 Depth to pipe invert from original grade 1.9 R. 9.9 Ft. Gravel depth beneath pipe 8 Ft. Township Range Section Fill added above original grade 0-1 Ft. Gravel length 25 Ft. SEPARATION DISTANCES Gravel width 3 Ft. Beds: Number of Lines From To Septic Tank Absorption Field Lift Station Holding Tank Sewer Line Total absorption area 400 Ft2 Number of trenches One Well >100' >100' N/A N/A >25' Distance between lines Ft. Dist. between trenches Ft. TANK E Septic 0 S.T.E.P. 0 Holding 0 Other Surface Water >100' >100' N/A N/A Lot Line >5' >10' N/A N/A Foundation >5' >10' N/A N/A Curtain Drain None Noted NA Manufacturer Anchorage Tank Capacity 1,000GaI. Material Steel Number of compartments Two LIFT STATION Manufacturer Capacity Gal. Remarks Flow Diverter Valve Installed and Existing Absorption Bed Tied in for Future Use. Existing Septic Tank Decommissioned in Accordance with Municipal Code. Pump on level at in. Pump off level at in. High water alarm at in. Pump make and model Electrical Inspections performed by Installer G & R Excavating Inspector A Harala Inspection dates: 15` 9/3/14 2m 9/4/14 e 9/5/14 4" PIPE MATERIAL House to tank DTank to 3034 D3034 draingeltl Drainfield F810 CO/MT D3034 BENCH MARK (Assumed elevation) 100.0f Location and description Garage Slab. COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Conditional Approval: Date Approve� '� // Date Inspection Re T1-1-12.doc �0' 1'941 ,`Q:•• 9►i • e s'* 491a• MICHAEL E. ANDERSON . <r ®' ,• CE -4381 0'D • Z. S ./S -••4c"` ►al PRO rEssv30\:i.e ktnnt ,p� Municipality of Anchorage Permit Number: OSP141304 DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 N TONJESS ESTATES SUBDIVISION LOT 12, BLOCK 2 , Qn 31,453 SF N1O NOTE: Existing Septic Tank Decommissioned in Accordance With Municipal Code. A B 12.7' 17.9 28.7 29.2 C5 39.5' 50.5' S1 S2 C4 M1 16.9' 15.3' 25.1' 26.2' tp Lot 9 Well\ 100' Radius TH 1® C5 Existing Absorption Location Unknow Bed Located in Trench Vents, H and Robert Joh :-d. Exact Unknown. M1 4 51 1 7 1 LEGEND: C4 — Clean Ou TH — Test Hole M1 Monitor T be FSV — Flow Sp$tter Valve 81 — Septic Vent Vents in R ation to New se Corner son Survey. Page 2 of 3 PID NO.: 051-832-19 Existing_ Well NOTE: Drawing Not Completed From Surveyed As Built. Locations are Not Exact. 5• Rp ialcV 4j�9—tfh),4 04%MICi E. c 0 N CE -4381 .04 73 PLAN AS BUILT SCALE 1" = 30' Miinicipality__ofAnchorage Page 3 of 3 DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report Permit Number: OSP141304 PID No. 051-832-19 N U U Finished Grade W 94.0 > N NM 0 co 00 LL Existing Finished Ground .....IIIL 000 Gallon Septic Tank 89.6 87.5 9.4 90.1 8 Existing Grade 85.6 Geotextile Fabric Drainfield Rock 77.6 71.5 No Groundwater 8-21-2014 25' (Trench Length) PROFILE AS -BUILT No Scale 85.6 On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP141304 Tax Code Number: 05183219000 Work Type: Septic Upgrade Permit Effective Dates: September 03, 2014 to Design Engineer: ANDERSON ENGINEERING Subdivision: TONJESS ESTATES Site Legal Address: TONJESS ESTATES BLK 2 LT 12 G:1462 September 03, 2015 Owner/Address: CROWELL ARON L & HUNT DEE C 25145 SCHAFF DRIVE CHUGIAKAK 995675721 Lot Size in Sq Ft: 31453 Total Bedrooms: 3 Site Mailing Address: 25145 SCHAFF DR, Chugiak Vr;ay 2:y0 This permit is for the construction of: Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Date: q��—/y 9 3 /Il Issued By: �� .or Date: MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-832-19 Property owner(s) Aron Crowell and Dee Hunt Mailing address 25145 Schaff Drive Chugiak, AK 99567 Site address 7-343-7904 BMITTAL AUG 5 2014 Same Legal description (Sub'd., Block & Lot) Tonjess Estates, Block 2, Lot 12 Legal description (Township, Range & Section) Lot Size 31,453 Sq. Ft. Number of Bedrooms Three (3) APPLICATION IS FOR: (& all that apply) APPLICATION IS AN: TYPE OF DWELLING: Absorption Field Initial Septic Tank Upgrade Holding Tank ❑ Renewal Privy ❑ Private Well ❑ Water Storage ❑ ❑ Single Family (SF) ❑ (w/wo ADU) Duplex (D) Multiple Dwellings (SF and/or D) 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. *Ltd E Com, (Signature of property owner or authorized agent) Permit/Rush Fees: 60 — Waiver Fees: O Date of Payment: D/514 Date of Payment: Receipt Number: /�©Q3 Receipt Number: Permit No. LJSP(6fq Waiver No. Permit App_9-1-12.cloc ON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK99524 522-7773 677-7766 (FAX) August 5, 2014 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 Elmore Road Anchorage, AK 99519-6650 Subject: Lot 12, Block 2, Tonjess Estates Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer The existing septic tank on Lot 12, Block 2, Tonjess Estates Subdivision has failed and must be replaced. We are therefore requesting a permit be issued for the upgrade of the septic system to accommodate the three-bedroom home on. The attached Site Plan and backup documentation identify the location and configuration of the existing and proposed septic system. The existing septic tank will be decommissioned in accordance with Municipal Code. The existing absorption bed will be left intact and connected to the new system with flow diverter valve for future use as needed. Also identified on the plans are the locations of the existing well on this and adjacent lots and adjacent septic systems. No conflicts exist between the proposed septic system and the wells on this or adjacent lots. Protective radii are shown to the adjacent wells. Drainage arrows are shown indicating the current drainage pattems. The drainage patterns will be maintained after construction. The test hole placed on the lot indicated Well Graded Gravel with Sand (GW/SW). No groundwater was noted and none developed during the monitoring period. The percolation rate in the soil was found to be 4 minutes per inch. We have designed the new trench with an application rate of 1.2 gallons per day per square foot. We are proposing to place a 24' long by 3' wide absorption trench with an 8' effective depth. The total depth of the trench will be 10'. The ground surface on the lot slopes from east to west in the area of the absorption trench. The trench will be placed parallel to the slope as shown on the attached drawings. A minimum of 100' will be maintained between all components of the septic system and the proposed well and from any surface water in the area. Lot 12, Block 2, Tonjess Estates August 5, 2014 Page Two If the system is constructed in accordance with our design the following statements apply: 1. The system, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. 2. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. 3. The system, if constructed as designed, will have no adverse impact on reserve space, either surface or subsurface, on any lots located in the area. 4. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattem will be maintained. Sincerely, p n a 6L2 Michael E. Anderson, P.E. Attachments TONJESS ESTATES SUBDIVISION LOT 12, BLOCK 2 31,453 SF SCOPE OF WORK: Decommission Existing Septic Tank in Accordonce With Municipal Code. Ploce New 1,000 Gallon Septic Tank and 2 Post Tank Cleonouts. Ploce Flow Diverter Valve and New 24' Long x 3' Wide x 8' Effective Depth Absorption Trench. 24' Long x 3' Wide x 8' Effective Depth Absorption Trench. Lot 9 Well\ 100' Radius \ 1 LEGEND: TH — Test Hole CO — Clean Ou MT — Monitor Ire FSV — Flow Sper Volve SV — Septic Vint / CO CO 1,000 Gallon Septic Tank S� SV 2C0 7 Existing_ Well NOTE: No Groundwater within 100' of the Septic System. No Excessive Slopes within 50' of the Septic System. 0 -�PP i t�fl�flAh.1,h / 49th 4-•i irati SPO, MICHAEL E. ANDERSON; Ent • #C"` • No. CE ' ,-4391 � SITE PLAN SCALE 1" = 30' LOT 12, BLOCK 2, TONJESS ESTATES SUBDIVISION DESIGN FACTORS: Three Bedroom Home Perc. Rate: 1-5 Min./Inch Application Rate: 1.2 GPD/SF SYSTEM REQUIREMENTS: Deep Trench System 1,000 Gallon Septic Tank 8' Drainfield Rock 3 Bedrooms * 150 GPD/Bedroom = 450 SF Absorption Area 450 SF/1.2 GPD/SF/16 SF/LF= 23.44 LF Trench Length THEREFORE: Decommission Existing Septic Tank in Accordance with Municipal Code. Place New 1,000 Gallon Septic Tank and Construct 24' Long x 3' Wide x 8' Effective Depth Absorption Trench. Flowline Elevation to be 2' Below Original Ground Surface Total Trench Depth to be 10'. Provide 3' of Cover Over Absorption Trench and 4' of Cover Over Septic Tank. Place Flow Diverter Valve to Connect Existing Bed for Future Use. 1'6" 3' Geotextile Fabric 4" Perforated PVC (Holes Down) Drainfield Rock TYPICAL DEEP TRENCH SECTION ,.� (NO SCALE) a.... NOTE: Grade Area Over Trench to Drain Away. Minimum 6' Separation From Bedrock. Minimum 4' Separation From Groundwater. Minimum 100' Separation From Private Wells in the Area. Minimum 100' Separation From Surface Water or Streams. • 41.4444s249th s -V MICHAEL E. ANDERSON INE ♦ ��': �. SNo. CE -4381.' r��� MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 4700 BRAGAW STREET ANCHORAGE, AK 99519-6650 DEPTH (feet) 1 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: Lot 12, Block 5, Tonjess Estates PERFORMED FOR: Dee Hunt/Aron Crowell DATE: 8/21/14 PROJECT No • PARCEL ID#• TECHNICIAN: A Harala 2 — 3 4 5 6 7 8 9 1011 12 13 14 15 16 17 18 19 20 TEST HOLE 1 OB/OG GW/SW WELL GRADED GRAVEL WITH SAND B.O.H. WAS GROUND WATER ENCOUNTERED? IF YES @ WH DEPTH OF WATER AFTER MO DATE OF MO SLOPE No 444 2 49th� '•�$ el ..` 0A 1 MICHAEL E. ANDERSON ? z Professional Engineer, Stamp: SITE PLAN See Site Plan LT DEPTH? ITORING: None 0 IITORING: 8/30/14 tC DATE READING GROSS TIME (MINUTES) NET TIME (MINUTES) DEPTH TO WATER (INCHES) NET DROP (INCHES) TEST HOLE PRESOAKED PRIOR TO TESTING: 8/21/14 1 11:36 .75" 2 12:06 30 8.25" 7.50" 3 12:07 .50" 4 12:37 30 8.00" 7.50" 5 12:38 .75" 6 1:08 30 8.25" 7.50" PERCOLATION RATE: 4 0 (MIN/INCH) PERC. HOLE DIA. 12 (INCHES) TEST RUN BETWEEN: 4 FT. and 5 FT. COMMENTS. TEST HOLE PRE SOAKED PRIOR TO TEST. TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS DATE: 8/30/14 4 .. • MUNICIPALITY OF ANCHORAGE • 1 r \\ ► (i I ` - 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 NAMEPHONE N' Ca. lia_ ctn .94 ;Soy KNEW ❑ UPGRADE MAILING ADDRESS r O So)c 77Z 793E -71,_R; ve�j AK 99577 LEGAL DESCRIPTION TOnJess g-sfu4rs J Of /Z B/0k2- LOCATION P.'S c.Y.e.-k-- NO. OF BEDROOMS v Y w1Manufacturer N I- DISTANCE TO: Well /OPj Absorption area '}/• Dwelling $' PERMIT NO. 9Vo?$2_ 6 Material .S-{ee-1 No. of compartments 2 Liq. capacity in gallons HOMEMADE: Inside length Width Liquid depth IF t] Y JOX S — < gll Dwelling PERMIT NO. DISTANCE TO: Manufacturer Material Liquid capacity in gallons TILE GRAINFIELD TRENCH DISTANCE TO: Well /yD Foundation 3D• Nearest lot line I �• PERMIT NO. 8t% oy yZ No. of linesLength 3 of each line f 2$ Tete4-leogth-effines el Ie. Ji 31' e. T.rwidth 8 .17 • laeieee Distance between lines Top of tile to finish grader 5 Z Materia l ber��ath tile Ved to inches Total effective absorption area 5Z7$f SEEPAGE PIT Length Width Depth PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area DISTANCE TO: Well Building foundation Nearest lot line J J 3 Class vr;vecit.. Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER /oB I wail PIPE MATERIALS Y"evc 69%57/1 D3 030 ee4s774D 2721 SOIL TEST RATING •1 0 O f No/h, INSTALLER 54e-ve- b k 3 a 11 REMARKS • F m aF� A / F.I•.• 4se/as /0 1 . ••A'°rs ' •.•••'i b�` a 1 L ra ,:h#0 r • . • d .'TH ,' n 11 1111 ` 1\ • 16 I/. .� C‘C /r s ••••' -..4. d's , '''ESS `;�.w'•" 21it�t cor�ts e`d,tFs•C4- ice • Z...r 4 fes•) A P VEDi DATE LEGAL le,18te5 //I� /2'2-88y %onus. sv.n-�zs o4 (J /ockZ 2-013 (Rev.3/ K6 U4Be.ife" v-6- //,2 LOCATION OF WELL (Please complete •Ilh.r lo, Ib or Io.) r,..,'\ WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological Q Geophysical Surveys Drilling P.rmll No. A.D.L. No. 0 Borough Subdivision Tonjess Lot (2- Blocs 2— Ib. 1/e Qtrs. —of_et—of ^ Section No. Township ND sO Range ED w0 Meridian 1�. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS Street Address and Area of Well Location 3. OWNER OF YELL: Mr. Kit Callahan Address: P.O. Box 772993 Eagle River, Ak. 99577 2. WELL LOG Feet Delow Surface 4. WELL DEPTH: (final) 240 S. DATE CF COMPLETION 15 84 --,— ft. .10 - - Material Type Top Bettors band, gravel, silt 0 30 c. 0 Cable taolXX Y' a pry p Driven ❑ Dug --Grey—rozk .-01-15D- 0�YAuger 0Jet ed ❑Bored Other: Grey and greenstone, water 100 120 T. UAX omeelic p Public Supply 0Industry s0 120 LOU 0 Irrigation 0 Recharge 0 Commerical Greenstone and water 200 210 0 Test Well 0 other: Grey rock and greenstone 210 240 0 CASING: 0 Thr.aJ.dXXM Welded diem. 6 In. to.3.2,_ ft. Depth Welgh117 Ibs./ ft. Com. In. to It. Depth Stickup 11. 9. FINISH OF WELL: MUNICIPALI FY- OF ANL.AUMGE DEPT. OF --:EMT# & Type: Diameter: ENVIRONMENTAL PROT CTION Slot/Mesh Stye: Length: Set between 11. and It. f� l.]� JAM 2 3 iY` i 5 Daekfillinq G,.y.l Doak 38 � 1 0 8" R eEiv D 10. STATIC WATER LEVEL: ff. /15/ 5 L c ' V Deft 0 Above or X Tdow land surface Equipment used: 11. PUMPING•LEVEL below land surface and YIELD ft, after hrs. pumping g•p•m• ft. otter hrs.' pumping • g.p.m. - 12.GROUTING Will Grouted:' 0 Yes 0 No Material: 0 Neot Cement Other: 13. PUMP: (if acailobl.) HP Length of Drop Pipe ft. capacity g. p.m. 0 Subm• 0 J.' 0 Centtrifical 0 Other 14.REMARKPrOduct10T1 of z GP'1 16. WATER WELL CCNTRACTOR'S CERTIFICATION: 15. Water Ternperolui. 0 F C Toil. well was drilled under my jurisdicllon and the repot l is True to 1•w best o1 .my knowledge and belief; Magnuson Dxilling ':AA 5385 Regiaered Business Hon,. Contract License Number A'�dre:.: P•0. Box 770504 Eagle River, Ak. 99577 e�--�.— Oct. 19, 19'84 Aathorlsed Representative Form C2•WWR (Il/el) Copy Distribution: WHITE- Slate DGGS, PINN 'Driller, CANARY -Customer 4 c N a: N 0 • a e F1LiJ'1 a c a P a'�E_ I TY �� 441,411-IDff� Cie DEPARTMENT OF HEALTH -AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 QN—E a TO= E tE Fi L' w1=1 _L F'8•^F ' 1 a T PERMIT NO: 840942 DATE ISSUED: 11/09/84 APPLICANT:. ''ADDRESS: CONTACT PHONE: LEGAL DESCRIP: LOT SIZE: I MAX BEDROOMS: KIT CALLAHAN P 0 BOX 77'993 EAGLE RIVER, AK 99577 694-5102 SUBDIVISION: TONJESS ESTATES LOT: 12 SECTION: 2 .TOWNSHIP: 15N RANGE: 1W 1A (SQ.FT. OR ACRES) BLOCK: Listed below are the options available to you in designing your septic.. system. Choose the option that best fits your site. DEPTH TO PIPE BOTTOM (FT.) GRAVEL DEPTH (FT.) TOTAL DEPTH (FT.) GRAVEL WIDTH (FT.) GRAVEL LENGTH (FT.) GRAVEL VOLUME (CU.YDS.) TANK SIZE (GALS) SOIL RATING (SQ.FT./BR) IIID 5.5 0.5 6.0 17.0. 31.0, 19.6 1,000.0 ** 115 w_ Drar.l 5.5 1.5 7.0 5.0 54.0 20.0 1,000.0 115 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS' 1 ** • ,I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2.. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements for the set back distances,from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. 4. I understand that this permit is valid for a maximum of 3 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES; THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST DE OBTAINED; (2) AS-DUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED DATE: APPLICANT: 'KIT CALLAHAN ISSUED BY � ` � DATE: 8- 9. eci PERFORMED FOR: A34,6,?e, LEGAL DESCRIPTION: i •4- ,..o3 • MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L Street, Anchorage, Alaska 99501 2644720 SOILS LOG - PERCOLATION TEST S �iA5S 1 �t+i,si'rKc+IM DEPTH (FEET) L"t , 1 !gid a re)-) r i t• SLOPE Ole 6 - Anil i 4- C /4t /4),•••• 10- 11 Sµn1.1 4 6, -Ave( 6t/G// &—Iesq/(aw-GP) l / Jto(rnr.., 12- 13- 14 - 15 16 17- 18- 19- 20 - COMMENTS Rec. cane- .i .6'e,! 1 a l WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? DATE PERFORMED: SOIILS__ LOG gtT//09SZ2— ❑ PERCOLATION TEST !/Y -/V SITE PLAN Wr /1 4a �--a Hs roc` 1.6 5// , t i SckA FF O 0 V !S• 20 Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE TEST RUN BETWEEN sysie at (minutes/inch) FT AND Tot -4./ rent ..4'k "a.,it .tSed a•-e.t c"r•. 13encc PERFORMED BY: 68f -'-e a -q 72-008 (6/79) CERTIFIED BY: FT De#,Vii, ,Z 7v S/yyQ DATE: !{ eI{ v MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 .. CERTIFICATE OF HEALTH AUTHORITY. APPROVAL FOR A SINGLE FAMILY DWELLING Parcel l D # O3-.'9 1. GENERAL INFORMATION " Complete legal description • Lot- 12; Block 2;-Tonjess Estates HAA #:• Hh. • 97L /.9'f • • Location (site address or directions) 25145 Schaff Eagle River, AK e • Property owner ;Michael & Wanda Clancy 'Mailing address •-D• ' ,'.ending `'Mailing address - Box 672134 Day phone Chugiak, AK 99567 688-6094 Day phone Agent -Ro1f.Milton/ Partner's Real Estate Day phone Address Unless otherwise -requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 'TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: XXX If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer • XXX NOTE: If community wastewatersystem, provide written confirmation from State ADEC attesting to the legality and status of system. 72.025 (Rev.1/91) Front MORIN 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 of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further 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 in with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S & S ENGINEERING Address 1/u34 Eagle River Loop Road Ao. Eagle River, Alaska 99577 , Engineer's signature Phone 6'1 1- -9 7 DHHS SIGNATURE Approved for bedrooms. Disapproved. Date 6 /a 3/9 7 •rc�a �►�� OF ��1� �'C�,' • .ti c>1 I1I 441 6ROBERTLG EOYAN lc�sr� CE -8801 ; �lti1i 1>1Ti►SO. .4.1"w Conditional approval for bedrooms, with the following stipulations: Note: The well for this property meets existing State and Municipal Codes. There are nitrates present. It is suggested that aperiodic testing be performed to insure the wells continued suitabiliaty. Nitrate concentration is 5.26 mg/1. EPA miximum concentrations is 10.0 mg/l. More information on nitrates is avotl.-£rov the nn -Sire cervieeq Prngram. i1NAA, 343-4744. Additional Comments By: :. • Date 6— 2 3 - CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given In paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate Is Issued: The Municipality. of Anchorage is not responsible for errors or omissions in the professional engineer's wo rk 72-025 (Rev.1/91) Back MOA 121 Municipality of Anchorage r. DEPARTMENT OF HEALTH & HUMAN SERKIEESE I V E D Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (I -74 Health AuthorityApproval Cheg,jnlcipality of Anchorage pp Health & Human Services Legal Description: Loi r X RUCK 2 7a AJ $5 t 57. • Parcel ID.: 0 S / — Y 3 A --1 A. WELL DATA Well type Pig Log present SYN) %E Total depth a'to If A, B, or C, attach ADEC letter. ADEC water system number Date completed / D 4" 13 Cased to 3 a 7 • 04' Casing height (above ground) 14 Sanitary seal ®1N) )' i s Wires properly protected/N) Y[ S FROM WELL LOG AT INSPECTION Date of test /0 //r/ sal SIig/97 '46 - Static water level 3 8 S V. 6 Well production 0 • S g.p.m. S g.p.m. ac rc,r /4L-li#AA+L IrNOCA s✓/EA,l.I'# 4/ WATER SAMPLE RESULTS: e4 M. A,v qi.$ ie N P.C. Coliform 0 Nitrate S. 4, Other bacteria i Date of sample: SIT/ 9 7 Collected by: S 7..44 7 C,Led,tr F 4 /'+ . AN44,e,..,, B. SEPTIC/HOLDING TANK DATA Date installed / a`• / g'1 Tank size )0(10:7 Number of Compartments a Cleanouts iygYN) )'E J Foundation cleanoutfi/N) 7 E 5 Depression (Ye N v High water alarm (Ye N o Date of Pumping " Y /•1 7 Pumper a' - R • P 4., r, -46- C. e4C. ABSORPTION FIELD DATA' Date installed I ti / Soil rating (g.p.d./ft' orMa/bdrmj 1 i 3` System type 8E 0 Length 3I ' Width ' 7 Gravel thickness below pipe 0, S Total depth °1 Effective absorption area • Cr Monitoring Tube present etN) Yas Depression over field (Ye ^' o Date of adequacy test b //I/9 7 Results ail) PAs 5 For bedrooms Fluid depth in absorption field before test (in.); 0 Immediately after'r`o gal. water added (in.): q 7" 3:a Fluid depth 3-S' (ins) Minutes later. 1-a 40 Absorption rate = `" C 3 0 g.p.d. Peroxide treatment (past 12 months) (Y/N) ^' ° ^' 'CNC 44 ' If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at* "Pump off" level at" High water alarm level at* `Datum Cyc E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 70 o On adjacent Tots 1 0 o 14- Absorption field on lot / 0 0 .4- On adjacent Tots v o f Public sewer main /'4 Public sewer manhole/cleanout "A Sewer /septic service line a. s' + Lift station N /4 SEPARATION DISTANCES FROM SEPTIC/HOLDINGTANK ON LOTTO: Foundation 8 1 - Property line / 0 �+ Absorption field S �4 Water main/service line /43 t Surface water/drainage / do * Wells on adjacent lots 100 SEPARATION DISTANCE FROM ABSORPTION FIELD -ON LOT TO: Property line / 0 + Building foundation/0 "' Water main/service line /0 ' Surface water 70 0 ' f Driveway, parking/vehicle storage area a S Curtain drain N o' 4- K Na w Pi F. ENGINEER'S CERTIFICATION Wells on adjacent lots 10 0 14. I certify that / have determined thru field inspections and review of Municipal records ' ' r_ ' s are in conformance with..f A�IAA guidelines in effect on this date. Signature/''M /� • K Engineer's Name d j t,1 T C. C0 w 9 •v Date `�a3/97 HAA Fee $ Date of Payment l- `c�-c, Receipt Number 1.�a111 72-026 (Rev. 3/96)" Waiver Fee $ Date of Payment Receipt Number JUN -20-97 1f::ti9 FROM=MW/DPW OFFICE ID, 563 5389 PACE 4/5 Cr iii Environmental Services Inc. • a J'Sa CI &E Ref./,` 972283002 • Matt PON Client Nanta SG Technical Printed Udell -one 05/12/97 13:05 Projed Narce';l NIA CateredDate/Time 05/08/97 09:21 Mot Samp4.L 1 : L12,B2 Tonjeac Est. Bea ived Dote/raw 05/06/97 09:55 Matrix Drinking Water Ta aita1 Dtmtor: Stephen C. Ede Orduzd By p'VVSID 0 Bel"Sed DJ Sample Rtrr:W.i Cf&E Miat bin:.;; y- DrinauE Water Program certification wttut is provisional as of 4/6/97. allowable Prep Anatysis Parameter Rasutts POL Units Nettrod Limita Date Date snit Nitrate -N 5.26 0.500 ap/L 3N1$ 4S00-N055S 10 ons 05/09/97 JUL Total Calton-. i OR N/0 m J COL/IOU NL SN18 92226 05ID8/97 RAH /'�6.� '. -----...2.4", t r : 4,1/4_ ,or.,k+t, ss&8 "E Cinee zmq '�aE AIAs FIEUTMALfiiDPor APPROVALS SEWER/WATER &MTN EXTENSTOS SEWER & WATER INSPECTION ENGINEERING STUDIES ANDREPOR1S WELL INSPECTION &FLOW TEST SITE PL fIS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WASTEWATER OSPOSAL SYSTEM DESIGN ROBERT C. COWAN, P.E. ROBERTA. SHAFER, P.E. ADEQUACY TEST FORM CLIENT: t" 1 \ C-4 Ike -G. a-Aca-V'4 CIVIL ENGINEERS (907)694.2979 FAX (907) 694-1211 DATE: (o-lLI—cj7 LEGAL DESCRIPTION:. L. t22 7_ rot1.3-` SS EST. 0 OF BEDROOMS: '1y SEPTIC TANK/FIELD SEPERATION TO WELL: Ot71 TYPE OF ABSORPTION SYSTEM: P2GD SEPTIC TANK SIZE: ) pop ABSORPTION FIELD DATA: Depression over field (j; IJ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: /oit RECEIVED SEPTIC DATA: LIFT STATION: Driveway, parking/vehicle storage area: Curtain drain: Foundation: ala to f� JUN 2 4 1997 Date of pumping: UK Pumper: M i ipality ul n,.cno aye Foundation cleanout (Y/N): y Depression (YIN „ ].lept. Health & HUrtlall Serviol "PUMP ON" level at: High water alarm level: "PUMP OFF" level at: 5s -c- p i az.,ZA•.M c , 3ALtC- TIME METER READING GALLONS ADDED LIQUID LEVEL (TOTAL) 1 •OMMIENT_S__ S.T. M.T. AM.T. Hr2" c5" 1 1" de -4-r1= — 4-7" 1',30eri o'' -- 1-.ePM +l Lin 1 " 4-1.' •"4-',3orA .tat L Sop 1" }ell" 1" 4.0 I S ham\ -/QJ Q. IZIn 7" -7," 1' -Z- L'—is-011 2 1‘3or- 35-, _ 3,s_ _y_',_. -3.S 11" l5 OOIR-- P ..C.,o M ow-rJnA-t- to o " 1-1fk-T'-.^- V or VMS E Slate 1- S3E__ 1 /JJ4 Ate. l z_b t,3 r.... -tp.'. c 1 _mirk 4 wt -r-1- --rZ.1 k -A -Z— ,13 S r--,7— r P�6z t<<,b3 oM.Ig.- I .r r--ocwDe_, awl d, 17v- Cr, RESULTS: IFAIL: FP%JS EXPLANATION: 3 TESTED BY: THIS SYSTEM IS NOT GUARANTEE.[) AGAINST SU 10011? C. COWAN Etir,ILu 17034 NORTH EAGLE RIVER LOOP • SURE 204 • EAGLE RIVER, ALASKA 99577 N g J Z � • tan .4 Arm r tii_••''i . l IL N 0 3 cr 0 o' 1 0"'r 1011sM.sJ/N llowskailbrip • itemposhiq 1110461114 mressing i-On1111 __ 0 3 cr 0 o' 1 0"'r 1011sM.sJ/N L . Y Immemo•rq ••••••••••••••••- - ____adm. _..», ; r CO1 PT 1T1 39tld 'f 9NI833NI9N3 S (INV S ttZtb69L06 8111 L66t/6Z/90 MUNICIPALITY OF ANCHORAGE • DEPARTMENT, OF HEALTH &HUMAN SERVICES '. `Division'ot Environmental,Services r s On -Site Services Section;`:' t' •' ; ' P O BoO96650a Anchorage, Alaska•J 99519-6650 , !a -r. ,,343-4744• ' CERTIFICATE OF; HEALTH AUTHORITY . PPROVALFORASINGLEFAMILY:DWELLING ` t Y I{• ,�t� L f 'Y,.l {•.+1 . arcel l D # ��1 h: 11 .... > HAA# ..WQCli�(>�L',= •`GENERALz INFORMATION omplete legal description Location (site add s ( ress or,directions)1,2 5145 ; Schaff•:Drive.; Chuq> ak r • AK 99567 Property owner Michael Clancy Dayphone ,.688.7-6094,_(h)::,, ••. ,, ..., -( ,,•. : r .ail ,,!127978471..;,(w):', Mailing address ' : 225145,' Schaff,.Drive;,. Chugiak'._:iAK;�:'.99567, ":':` .. Lending'agency ' _ ; . Day phone' Mailing address _ . • gent .. , <' Address Unless otherwise requested, HAA will be held for pickup: NUMBEFf OF BEDROOMS: .5;131 , '1 7• , TYPE OF WATER'SUPPLY • ,Individual Well xxx- Community.weli Public water'' TE If.community wellsystem, provide written,confirmatlon from State ADEC attes .ing'.to the legality,and'status;of;system. ;` , TYPE,OF,WASTEWATER'DISPOSAL:; • Individual on-site Holding tank Community;on'stte'. NOTE: ' .If community wastewatersystem, provide written confirmation from;State ADE ' attesting to the legalityIand status of system 2-025 (Rev. 1/91) Front MOA 021 • • w. 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 of this Health AuthorityApproval application shows that the on-site water supply and/or wastewater disposal system is safe, functional`andadequate for the number of bedrooms and type of structure indicated herein: l furtherverify 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 in compliance with all M_ unicipal and State codes, ordinances, and regulations in effect on the date of this inspection S 8 S ENGINEERING -Z./� 7 9 Name'of.Firm Phone ` G 9 `f 17034 Eagle River:Loop Road No. • ` .!Address Eagle 1214e% Alailrn 9g' . Date3 /' .: : , _Engineer's signature ACV �, �k 1 i M OF ,..2 'L• -,i.YT7 '•c•.-?" S , 7 •tel•.•' 4•4.ltl. R s obort A. S'tdr hI / d '• No. 14.57-E ' ' i‘•-..1.,4". re • :DHHS SIGNATURE ;'. °�4k�ESSr' !re •T Approved for.: --bedrooms. Disapproved: • 6. Conditi•on•al approval for • bedrooms, ,with, the following stipulations: • Additional Comments Date CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority A . •pproval'Certificatesbased'only upon the representations given in paragraph 5 above by an independent; • professional engineer registered In the State of Alaska. The DHHS does this as a courtesy to purchasers of homes • and the( . r. 'r lending institutions in orderto satlsfycertainfederal and state requirements. Employees of DHHS•donot conduct inspections or analyze data, before ‘a.certificateOs issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work • • • 72425 (Rev. 1/9” Back MOA a21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: 1. -o -f 1 Z- g► -+LZ- �o�rF�s �5r' Parcel I.D. A. Well Data Well type ?tz t.l e i1 _ If A, B, or C, attach ADEC letter. ADEC water system number l'`ft, Log presentN) Total depth Z`tol Sanitary seal ) Date of test Static water level Well flow Pump levell y Date completed 1 o - 1 S - frIt Driller I 1.Josa.l g 0A- Cased tk Cased to 32 F�.t?-• Casing height 12 FROM WELL LOG ‘t•-•%5-941- Wires 0-%5-94 -t) Wires properly protected (SFIN) AT INSPECTION -21-cl 1 D,S g.p.m. S 2 + g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot /ao' /eit) fF Public sewer main "J 1/4 r Sewer service line 2 s - ; On adjacent lots ; On adjacent lots /0o / 00 �- Public sewer manhole/cleanout Petroleum tank ` I} 2S WATER SAMPLE RESULTS: Coliform Nitrate 3. ag Other bacteria Date of sample: Collected by: : S B. SEPTIC/HOLDING TANK DATA Date installed 11Y - S 1 Tank size 1 00o Compartments Z Cleanouts PN) I Foundation cleanout0/N) y Depressign (Y High water alarm (Yi fi Alarm tested (Y/N) ,i(A Date of pumping 'i — / / - 91- Pumper -T/Q , Gossjo v r., SEPARATION DISTANCES FROM SEPTICMOLDING TANK TO: Well(s) on lot /o' On adjacent lots / a Foundation To property line /a / Absorption field /0 Water main/service line /0 A Surface water/drainage /06 72.028 (3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at 'Pump off" High water alarm level - ested Meets MOA electrical codes (Y/N) SEPARATION • ' CE FROM LIFT STATION TO: Well on lot On adjacent Tots Surface water D. ABSORPTION FIELD DATA Date installed 1 Soil rating (GPD/Ft2) US / System type Cie- 7 Length '> > Width \ 1 ` Gravel thickness 0,5- Total depth Z,; - Total ,; - Total absorption area S-7-7 Cleanout present ON) I Date of adequacy test 4-2-1-9 f- Result fail) /7i11%5 Water level in absorption field before test 0 - After test 0/r (41)Peroxide treatment (past 12 months) ( AWL (A.L J J If yes, give date ,t(,_ (PIM Depression over field (Y/) .l for 3 Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot L /Do On adjacent lots /ao Property line /6 To building foundation /o t y To exiting or abandoned system on lot r'�� On adjacent Tots 3 0 Cutbank ��.a- Water main/service line /0 Surface water Curtain drain (Do rF i/ - Driveway, parking/vehicle storage area 2.f E. ENGINEERS CERTIFICATION I certify that I have checked, verified, or confo ed to all MOA and HAA guidelines in effect on the date of this inspection. S Engineer's Nam SEN • Date Eagle River, Alaska 99577 S,3 %i/ Signature & IN HM Fee $ 3a V Date of Payment Receipt Number 72-026 (3/93)• Back Waiver Fee $ Date of Payment Receipt Number SINCE '908 Commercial Testing & Engineering Co. Environmental Laboratory Services®`rrtr.r.r.era-w-c-r►c©dzrzw-d-arznezw®crr-crs%z-..^rcrcmc LABORATORY ANALYSIS REPORT CT&E Ref.# 94.1661-3 Client Sample ID L12 BLK2 TONJESS EST Matrix WATER Client Name S & S ENGINEERING RUSH Order 77540 Ordered By RIS Printed Date 04/18/94 @ 08:47 hrs. Project Name Collected Date 04/15/94 @ 15:00 hrs. Project# ReceivedDate 04/16/94 @ 11:30 hrs. PWSID UA Technical Director STEPHEN C. EDE Released By: Sample Remarks: ROUTINE SAMPLE COLLECTED BY: RAY. Parameter QC Allowable Ext. Anal Results Qual Units Method Limits Date Date Init Nitrate -N 3.88 mg/L EPA 353.2/300.0 10 04/16/94 CMR * See Special Instructions Above UA = Unavailable •• See Sample Remarks Above NA=Not Analyzed U = Undetected, Reported value is the pmctical quantification limit. LT= Less Than D=Secondary cfilution. GT=Greater Than 5633 B Street, Anchorage, AK 99518-1600 — Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) T,2 je Lc -4- / Location (address or directions) Pe-frr^s C—rw& (b) Applicants Name K. (7,7/4, /,a„ Telephone - Home Business Applicants Address PO -772,91'73 ”5-77 (c) Applicant is (check one) Lending Institution El ; Owner/builder MI ; Buyer f[ ; Other ` (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following. address: Vo(' err cc -v.? /K,/ �`ti--r2 v -�-4C 2'2577 2. Type of Residence Single -Family Multi -Family J Other (describe) Number of Bedrooms _ 3 3. Water Supply Individual Well Community j Public Note: If community well system, must have written confirmation from the State •Department of Environmental Conservation attesting to the legality and status: 4. Sewage Disposal Onsite Public 11 Community Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further 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 in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. i Name of Firm Ccwit, E 4.SS0C+e,�'4,.Sa1.� Telephone PF A4 Mi Y .� LL'� Address /�V9 / . /Gcl/n.- Sci , ,� •0.741,••.' 7Y,7a.ii Q //. JJJ iii Date %" .-3'tis a't 4 3►1 •'.*it 4EI INE ME)) 1 '% , CE -52E7 I o 6. DHEP Approval L��� 4b �oF'•' Approved for bedrooms By Approved .X Disapproved Terms of Conditional Approval 1 Date Conditional .S- /-(e/s/ CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DEEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: MUNICIPAL{." DEFT. OF ENVIRONMENTAL F::.:Tt:•-:TICN JAIL231985 RECEIVED Lof /Z 13/ock2 T+•iac_s Well Classification Pr;Va. le- If A, B. or C. D.E.C. Approved(Y/N) Well Log Present (Y/N) Date Completed /o -,S- 8i Total Depth 21401 ' Cased to 32' 46 Depth of Grouting Static Water Level s8''". Pump Sat At Casing Height Above Ground q" Sanitary Seal cn Casing (Y/N) Yield Electrical Wiring in Conduit (Y/N) Depression Around tnbllhead (Y/N) nl Separation Distances frau Well.; To Septic/Holding Tank az Lot • /;./91 Co Adjoining Lots To Nearest Edge of Absorption Field cn Lot /55-' ; Co Adjoining Lots • too' To Nearest Public Sewer Line — To Nearest Public Sewer Cleancut/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected By ..1. oirec Date /-Z/-e5 Water Sample Test Results 4; 541. c.Awy Caunents #: ret fcnnLLAN.e., rl",fr. ,�.-:U.- ; we -11.i . 8. SEPTIC/HOLDING TANK DATA Date Installed /Z -?S -S' Size /coo ya.F. No. of Compartments Z Standpipes (Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) }/ Depression over Tank (Y/N) N Date Last Pumped Pumping/Maintenance Contract cn File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) Temporary Bolding Tank Permit (Y/N) Separation Distances frau Septic/Holding Tank: To Water -Supply Wall /081 To Building Foundation 8' To Property Line > iQ' To Disposal Field e.fi' - Aj Q,rur To Water Main/Service Line — To Stream, Pond, Lake. or Major Drainage Course Comments Receipt 1 t 7 p Date Paid: Amount: L (Page l of 21 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 115 sOr Type of System Design Date .Installed r 2 - zs - tsi Length of Field -31' Width of Field 17' Depth of Field C Gravel Bed Thickness 1' Square Feet of Absorption Area Sal Standpipes Present (Y/N) Y Depression over Field (Y/N) /1 Date of Last Adequacy lest — Results of Last Adequacy Zest 5,1,54.4.4., tO.�1,0 Separation Distance frau Atiscrpticn Field: To Water Supply Well 156-' TO Property Line > i b' To Building Foundation 30' To Existing or Abandoned System as Lot n o„e ; On Adjoining Lots — To Water Main/Service Line - To Cutbank(if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, cc Vehicle Storage Area Convents D. LIFT STATION none Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) Maw On" Level at "Pimp Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Zest. Meets MaA Electrical Codes(Y/N) Contents ** Check Pew' tted droan Rating Against HAA Request ** I certify on the da Signed Company KBl /d5/s =t iormarr I hadecked, verified, or conformed to all pecticn. [Page 2 of 2] Date /-Z3 �S NOA No. „ f7- -2/S MOA HAA Guidelines in effect 40• ...... ` 0 : e - J. Corrin ; ua/ t C '. • CE -5283 .. �� rt It a•........•.• • C., do 14. R4FFC N.41' 2-15-84