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HomeMy WebLinkAboutSAMPSON ESTATES BLK 4 LT 26Sampson Estates Block 4 Lot 26 #051-822-16 Su1OM1 I I A AUG 0 7 2015 Municipality of Anchorage Community Development Department Page 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: OSP141265 PID Number: 051-822-16 ❑ New ✓ 1 of 3 Upgrade Name: WalterTusten ABSORPTION FIELD ❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other Address P.O. Box 5617 Fort Richardson, AK 99505 Phone Number of Bedrooms 3 Soil Rating GPD/SF Total depth from original grade Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Sampson Estates 4 26 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines FL SEPARATION DISTANCES To From Septic Tank Absorption Field Lift Station Holding Tank Sewer Line Total absorption area Ft2 Number of trenches Dist. between tenches Ft. Well >100' >100' >100' >75' >25' TANK o Septic • S.T.E.P. IN Holding ■ Other Manufacturer Anchorage Tank Capacity 1,000GaI. Surface Water >100' >100' N/A N/A NA Material Steel Number of compartments Two Lot Line >5' >10' N/A N/A LIFT STATION Foundation >5' >10' N/A N/A Manufacturer Capacity Gal. Curtain Drain None Noted Remarks Tank Only Replaced Under This Permit. Pump on level at in. Pump off level at in. High water alarm at in. Existing Tank Decommissioned in Accordance With Pump make and model Electrical Inspections performed by Municipal Code. Installer Stuart Gilbert PIPE MATERIAL House to tank D3034 Tank to D3034 drainfield Drainfield CO/MT Inspector A. Harala BENCH MARK (Assumed elevation) 100.Oft and description Garage Slab Inspection 1. 8/11/14 - rdLocation ection 8/12/14 3" 4,n COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Conditional Approval: Date ntririnWri •".s1•OF•q:g1ft, �,`Q;.• ; g4.918 �... •...........rite 1/4Y # •••*1 / MICHAEL E. ANDERSON .• r vI f'. CE -4381 • ......`4.:: sr T fly•.•R-7-ij..•`ar I4.1 �i�111..... Or* Approved /ia 73,,i-- bate - g Inspection Rep bft_1-1!12. Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 PID No.: 051-822-15 38 SAMPSON ESTATES SUBDIVISION LOT 26, BLOCK 4 41,446 S.F. 0 rn Page 2 of 3 Permit Number: OSP141265 O A B 51 21.2' 14.5' S2 25.6' 20.5' / / Existing Septic Tank Decommissioned in Accordance with Municipal Code. LEGEND S1 — Septic Vent CO — Clean Out M1 — Monitor Tube TH — Test Hole FCO — Foundation Cleanout Ni 41111.: 1/4-4 49th PM i• C," 1�n u".ur7 MICHAEL E. ANDERSON i II %I, '., Na- CE -4381 ' NOTE: As Built Not Completed from Surveyor As Built. Locations are not SITE PLAN Excat. SCALE 1"=40' Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report Permit Number: OSP141265 PID No. 051-822-16 Page 3 of 3 1 97.8 U U m (`ten 5 U 92.5 ,000 Gallon Septic Tank 92.3 Tank Only Replaced Under This Permit. Existing Tank Decommissioned in Accordance with Municipal Code. PROFILE AS -BUILT No Scale isgsommaiii OF 44 sir4 $ I49th • I tE •m.MICHAEL E. ANDERSON L g-, 1163. .: u. w -,p NO. NO. �_III IIIII FESa\w4•• On -Site Water and/or Wastewater 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: OSP141265 Tax Code Number: 05182216000 Work Type: SepticTank Upgrade Permit Effective Dates: July 25, 2014 to July 25, 2015 Design Engineer: ANDERSON ENGINEERING Subdivision: SAMPSON ESTATES Site Legal Address: SAMPSON ESTATES BLK 4 LT 26 G:1560 Owner/Address: TUSTEN WALTER L & LIZABETH T PO BOX 5617 FT RICHARDSON AK 995050000 Site Mailing Address: 23711 GOLIATH DR, Chugiak Lot Size in Sq Ft: 41446 Total Bedrooms: 3 This permit is for the construction of: N 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: Issued By: Date: MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division On -Site Water & Wastewater Program Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-822-16 Property owner(s) Walter and Lizabeth Tusten Mailing address P.O. Box 5617 Fort Richardson, AK 99505 Day phone Site address 23711 Goliath Drive Chugiak, AK 99567 Legal description (Sub'd., Block & Lot) Sampson Estates, Block 4, Lot 26 Legal description (Township, Range & Section) Lot Size 41,446 Sq. Ft. Number of Bedrooms APPLICATION IS FOR: APPLICATION IS AN: pg all that apply) Absorption Field Septic Tank Holding Tank Privy Private Well Water Storage ❑X 0 Initial Upgrade Renewal Three (3) TYPE OF DWELLING: Single Family (SF) (w/wo ADU) Duplex (D) ❑x C Multiple Dwellings 0 MITid 'mt JUL 2 1 2014 THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number c7 go G Permit No. OSPiW (ZSPrc Permit App Waiver Fees: Date of Payment: Receipt Number Waiver No. ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 522-6779 (FAX) July 20, 2014 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: Lot 26, Block 4, Sampson Estates Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The septic tank on Lot 26, Block 4 Sampson Estates Subdivision has failed and must be replaced. We are therefore requesting a permit be issued for the construction of a new 1,000 gallon steel septic tank to serve the home. The attached Site Plan and backup documentation identify the location and configuration of the existing septic system and the location of the new tank. Also identified on the plans is the existing well on the lot. The new septic tank will be placed at the same location as the old tank and is not in conflict with neighboring private wells. The existing tank on the lot will be properly disposed in accordance with Municipal Code. The existing absorption system will remain in place for continued service. The ground surface on the lot slopes at shallow grades to the southeast in the area of the septic tank. The tank will be constructed near the location of the old tank and in conformance with Municipal requirements. If the tank is constructed in accordance with our design the following statements apply: 1. The tank, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. The tank, 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 tank, if constructed as designed, will have no adverse impact on reserve Lot 26, Block 4, Sampson Estates July 20, 2014 Page 2 of 2 space, either surface or subsurface, on any lots located in the area. 4. The tank, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, /� Jt, Michael E. Anderson, P.E. Attachments SAMPSON ESTATES SUBDIVISION LOT 26, BLOCK 4 41,446 S.F. Decommission Existing Septic Tank in Accordance with Municipal Code. Place New 1,000 Gallon Septic Tank and 2 — Post Tank Clean Outs. Tie In Existing Absoorption Bed. 0 t ca 0 LEGEND S1 — Septic Vent CO — Clean Out M1 — Monitor Tube TH — Test Hole FCO — Foundation Cleanout 49th s f. MICHAEL E. ANDERSON # ,4 No. CEa381 .p r Go' j SITE PLAN SCALE 1" = 40' NAME MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT T+ Co s"flitc-h'Or) MAILING ADDRESS LEGAL DESCRIPTION LOCATION Z -30,c ZSv�yf 'In, 996i'S PHONE 4 7j& -z 5r m o'K -NEW El UPGRADE L o /- Z6 la/or-4 j/ -5-2.77/!?S Ov7 Cr- e e NO. OF BEDROOMS 3 I- 1- 2 CL LUa DISTANCE TO: Well /Ofd Absorption area Dwelling PERMIT NO. Manufacturer Material No. of compartments `' • Liq. capacity in gallons /BO® IF HOMEMADE: Inside length Width Liquid depth 6 Z -1 a2 � DISTANCE TO: Well - Dwelling PERMIT NO. F Manufacturer non Material Liquid capacity in gallons w = z DISTANCE TO: Well 115 / Foundation 2 to I Nearest lot line ,) or PERMIT NO. y 9/o Z j LL F Z w No. of lines 2Length of each line 3y s - Total length of lines r Trench width inches Distance between lines /. )/Z t v o Top of tile to finish ade in ,o' , _ `�- .;ate, r F�-ec<"�I_- `,sf-,.T' / o Material beneath tile f/y- Z' CA e-tLe1 g r4Veij 6 inches J Total effective absorption area 7 w C7 Length Width \_ Depth- PERMIT NO. <1- w o. Crib w Type of crib Crib diameter depth Total effective absorption area DISTANCE TO: Well Building foundation Nearest lot line W Class Pr; vale Depth a � Driller J i..o,1A ,14Y1-' Distance to lot line 7I0' PERMIT NO. DISTANCE TO: Building foundations8 i Sewer line ,__. Septic tank (CO t Absorption weals) /15 t OTHER PIPE MATERIALS //� ell 0 /7 S%7 333 SOIL TEST RATING 2o5P/ INSTALLER 5+-ve- SkA.99S RE ARKS Ha IIII 0,� �® �d01S3j � MUNI IN N ■ uaa�� ,. 3 f amu o6� rozs ispw==="11�VIMioa me�mrrrr� ,5,•se4. ls•ar••a....u mop .• Ii PI090R01,a0 1.,,„ liggRairfaiSillill1111111111121RIO. 0a�s Be g BERI iiMIII s #fp�I% , =��• l IN AP ED DATE LEGAL .1t--/ /U/y4/ ;0/2 . s -/ .e 4.� A Lo )" Z6 %�/vG/t -S.-awe-salSC(.6ea<i vfslap) iset, e L 7 3 (Rev. 3/7 1 i/ ` "' PlIJINI :I CI: IP14-4�11-11ENFI:01P-P If • DEPARTMENT OF~lEALTHAND-ENVIRONMENTAL Fr--NTE'TION , 825 L�jTREET: ANCHORAGE, AK 264~'4/20 C3IN_�'T IL ����-F. PERMIT NO: 840962 DATE ISSUED: 11/28/84 APPLICANT: ADDRESS: CONTACT PHONE: LEGAL DESCRIP: LOT SIZE: MAX BEDROOMS: SKAGGS CONSTRUCTION P.O. BOX 670690 . CHUGIAKv AK 99567 688-2831 SUBDIVISION: SAMPSON SECTION: 3 • TOWNSHIP: 15N 40000 (SQ^FT. OR ACRES) 3 LOT: 26 RANGE: 1W BLOCK: 4. 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) 7FR1EU-'44=11-1 4.0 -2"O 6.0 113.0 ** 26.2 1,000.0 ** 150 4"0 4.0 0,5 2.0 6.0 19,O^`~-` 36,0 25.4 1,000"O ** 150 5,0 63"0 29^2 1,000,0.** 150 ** GRAVEL LENGTH > 75 FT" REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT EACH) ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS` 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. I understand that this permit is valid for a ~" maximum � 3 bedrooms and any enlargement will require an additional permit. :F A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING rODES �HEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OSTAINED; (2) AS-B�vILTS 'n DLL NOT BE APPROVED WITHOUT AN F|ECTRICAL INSPECTION REPORT; AND (3) E L .ECTRICAL WORK MUST• BE DONE BY A LICENSED ELECTRICIAN" !IGNED PELICAN -1g SKACcr', C, TRUCTION SSUED BY DATE: DATE: � �^4�� //:;20/8 � MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: S/k CL3 c3 S C'ori��-�u c:im ova LEGAL DESCRIPTION: _5airyiJPSor\ .�;.�1j(I;v. 11 "ck. 4 L -o+ Z% I SLOPE 7- 8- 9— O-.61; Pec�f 4 7=3,o': S/1 /61,1 3,o-io.o': 5P/C-1- c/ i 4- v vv.74 • .c.* (No Gr e• w,[f wa.i 11 — 12- 13- 14— t ND 15— 7`,®a"saO`4�1,� I 16 — ove �i/ eeae. p{ ` CO 07".Vk.,'" f;p, eo y� e44e Oaf e�Hj'ae cote aseeea^ .� 1 qp� ea..ee4•••4;4_04 B 1 ice J. Corwin 1.•.441'1° . � ee o. CE -5283 e �, .jo 20 -��9r0 ee•veeaa`" �(m % ' 70FESS\O'a11t' COMMENTS 9' 0 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? SOILS LOG PERCOLATION TEST DATE PERFORMED: //—Z.O —0y S //o 0 P E SITE PLAN bri I-1 /B a 0 N r 6 Reading Date Gross Time Net Time Depth to Water Net Drop ,c, I /l -Z(7 0:440 0: So /0m„7. .5 t3 ,yo , /o �Hz_0 �0 43 ;3.00 70 4,/,i, , zip . /o Ly�0 ES .•i0 /07h,}7, „So ,S[/ •Oy PERCOLATION RATE /8.5 TEST RUN BETWEEN 3• S FT AND S4,75 ,-aiyd re* 205' 0/6dr-rn Re�omme.n i best Sj v PERFORMED BY: M , DKeefe. 72-008 (6/79) 3,u`. b^fw 3,o' a+,ct I o , p' (minutes/inch) FT CERTIFIED BY: BATE: 7(-2-% 0 `�. ALL ALASKA rn lit, rn s Q le ® to, a Q nal Spl C.7 wg AO 153Nz cati V ISEI o eg O 0 ¢r.; o I-.8 0 em 0 a WE SERVE ,DEPTH OF WELL STATIC LEVEL OF WATER FT.... DRAW DOWN FT......7 00.%.eat.;, 4e GALS. PER HR 10-20-84 {.14 is4.4 E-. � w I o 0 5-r. a1 a3 ar RA ro al ro 3 5.4 34 a). ro 5a 0 0 E- 0 0 0 fAi E-; W w a a 0 0 0 0 0 O 0 0 0 0 0 0 O [M. - E- F h E- {5- F 1- H 1- WELL - SITE DATE -.STARTED o- �r •-1 N 0 0 0 0 0 0 0 0 0 0 0 a a a a x a a a a a a w w w w w w w w w MISCL. INFORMATION: rut • • • 0 t7 DRILLER'S NAME 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.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-822-16 1. GENERAL INFORMATION HAA# YJ/ `_J'�?3�aZ� Expiration Date: 1 -' d " O Complete legal description SAMPSON ESTATES SUBDIVISION; LOT 26, BLOCK 4; Location (site address or directions) 23711 GOLIATH DRIVE * CHUGIAK, AK Current Property owner(s) DAVID CALDERONE Day phone 688-2237 Mailing address PO BOX 672237 * CHUGIAK, AK 99567 Lending agency Day phone Mailing address Real Estate Agent VALESA LINNEAN w/ REMAX PROPERTIES Day phone 242-5665 Mailing address 2600 CORDOVA STREET * ANCHORAGE, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site Individual Water Storage n Individual Holding tank Community Class Well ❑ Community On-site Public Water System ❑ Public Sewer n n 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 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 iNSPECT{ON 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. 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 all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Address 6901 DEBARR ROAD, SUITE 23 * ANCHORAGE, AK 99504 Engineer's Printed Name _ JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & 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 operation& 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 are no hidden defects or encroachments. AKWWC, Inc. 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 is 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 X Approved for 3 bedrooms. 'Disapproved. Conditional approval for Phone 337-6179 Date bedrooms, with the fltowing stipulations: This absorptinn fip1r1 is under-sizPr1, but it e assed the adequacy test. Attachments: HAA Checklist Septic System Advisory Weil Row Advisory Manitenance Agreements Supplemental Engineer's Reort Other (Rev. 12101) Original Certificate Date: (toiii((i((J k\Ltr ��\or °``HryMr�i ON -S. c s'', WATER AND • PROGRAM n f h r J ' f ST 0 =3 ora a •Iii aT„rfl�e'$ Depa a. Buff g a QIIsian On Sue r & UUaslewater Program •H 71 50 th BragaW St PO Box 196650 nphorage, AK 99519-6650 .wyrww ct anchorage;ak us (9r.....4.4::":1;.:6:.;:•17.:.17::.....-::- 907).43 7904. H€EALTH : AUTHORITY APPROVAL` CHECrKLIST Legal Description SAMPSON ESTATES S.OBDIV1510N, LOT 25, BLOCK 4; Parcel ID WEL'DATA V1? tl type t?RIVATe tf A B or C :provide PWSID#`` N, ate completeri 10/20/84 Samtar�rseal (,1 /I�f.) YES Total,depth 220 ft (Cased to 220 R0M FELL tOG 10%20/84.. 195 ft,;. Date:;of.test Statrcwater level Wen;production WATER SAMPLE RESULTS Coliforrrt 0 coloniesll0001 Ptrsenic SEPTICIG�CI LDINLG TANi1K W • Tank hype/Material Tank size 1000 gad Fouriaation cleanout (Y/;N). 'f Date:of fslampirsg 12/30/02. A .6,5177:822.16 Well Log --(WN) : YES Wires prbperiy protected ( /N) YES Casi tg height (above ground) 12+ AT INSPECTION, 1.2:/30/02 1.76 :3:85 ;'. Nitrate 1;57 mg.L Other bacteria 0 cplonies/100 m1.:" Date of sample 1'-2/30/02 STEEL:`.' umberof Com•partment•s 2 •resston:•over tank:(Y/N) ~_ Pumper :,'; ASSORPT`IQN I+IELD•DAT W5/88 Sort rat�n dlft2or bcJrm 20.5', BED Date installed ; `(g P Syste:: fype Len th 0 Width 18 ft. Gravei::below�pipe Total;depth *4 25 ft Eff• absarptioa areal* X7 0 Ytz Mor itonng,tube YES Date of adequacy test : " t 2/30/02 Resutts (Pass/Fart) PASS Water added, 73ga1 Collected by., AKWWC, ;I:NC Clearouts (YIN) High water alarm (Y/N) CHtJGA'H .PUMPING `'' i*BELOW= EXISTING. GRAI7-EI Fluid depth in, absorpton field before test•• DRY u Elapsed Time 312 min Final fiord'depth' DRY m.' {ny refuvenatib treatment (past 12 mo) (YIN &type) egression over field For 3 bedrooms N:ew depth 4 in Absorption rate,>= 450+ g p d: NONE. KNOWN Ifyes, e date +$ , , ' n giv ONLi�I{7 0 Sq ft OF DRAMS:ELO 'gF9 I:PE D. LJFT STATION. Date installed Size in gallons: "Pump.on" level at in. "Pump off' IPA%GiI Datura Cycles tested E.' SEPARATION DISTANCES' 'SEPARATION DISTANCES FROM WELL ON LOT TO: Septietank/lift station on lot Absorption field on lot Public sewer main Manhole/Acc s (Y/N). ` High water alarm level at • Meets alarm'& circuit requirements? 100'+ On adjacent lots: 100'+ 100'+ On' adjacent Tots ` 100'+ N/A .. . :Public sewer manhole/cleanout N/A '•:. Sewer /septic- service -fine 25'+ Wilding tank . N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING •TANiK•ON LOT -TO: 'Building foundation' 5'+` 5 + Absorption field• Properfyline Water main N/A Water service line 10'+ .. •.,::.. Surface water Wells on adjacent.lots: •" ..100'+ SEPARATIONDISTANCE FROM,. ABSORPTION FIELD ON LOTTO:. 10C+ Property: line 10 +.;..:... Building foundation 10+.:. .. Water. main N/A Water service line 10'+ Surface water 100'+ Driveway, parkinglvehicle storage 10'+ Curtain drain :'<NONE :.KNOWN Wells on adjacent lots 100'+. F. COMMENTS • 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 WA HAA guidelines in effect on this date. Engineer's Print d me Date 111 o 3 HAA Fee $ 375-w JEFFREY A.GARNESS Date of Payment I -13-0A Receipt Number 3003 `' E (Rev. 12/01),. 40400 !rG• Y�..e.r-ey A. Ge- .esu.O C: - .' o ;:f • yrs�• �" rte ..... �G LG Ofe 93IO�`'�j Waiive1-Fee.S5 Date of Paynent.' RecefptNumber • 01-07-03 12:09 FROM-CT&E ENVIRONMENTAL SRV 9075615301 aE. CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix PWSID Sample Remarks: Parameter CT&E Environmental Services Inc. r � 1028675001 AK Water & Wastewater Consultants Inc. Sampson Est L26 B4 Sampson Est L26 B4 Drinking Water 0 Waters Department Nitrate -N Microbiology Laboratory r- M1 Results T-338 P.02/03 F-207 All Dates/Times are Alaska Printed Date/Time Collected Date/Time Received Date/Time Technical Director Released By Standard Time 01/06/2003 15:54 12/30/2002 16:00 12/31/2002 12:35 Stephs .� Allowable PQL Units Method Limits 1.57 0.200 mg/L EPA 300.0 Total Coliform 0 (<=10) col/100mL SM18 922213 (<=1) Prep Date Analysis Dare Imt 12/31/02 JS 12/31/02 SKW Dec. 30. 2002 3:03PM REMAX PROPERTIES ,•� . No, 4703 P, A I, • D' THIS DATE • rtiiy that I have performed aMortagee's in- ection of the following described property: L o f Z 4� /Uck4 SP.i.,p5Oka Lc1,174ci.tes ef• " ' •9141311 I �" h„ i EASEMENTS OF:RECORD, OTHERITAAN,,k,,,j;„�; • THOSE SHOWN • ON THE RECORDED '• ' PLAT ARE NOT SHOWN HEREON, R. `�/a��5 PM FW Anchorage Recording Precinct, Alaska, and that the improve- ments situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent there- to, that no improvements on:property lying adjacent thereto encroach an. the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alaska thie Y3.4.1'._ day ofriicavi a FRED WALATKA & ASSOCIATES Engineers and Surveyors • Parcel I D # 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 HAA # 4414 fed 13vc33 1. GENERAL INFORMATION Complete legal description Lot 26; Block 4; Sampson Estates Subdivision Location (site address or directions) 23711 Goliath Property owner Dorothy Towner Day phone Mailing address Lending agency NORWEST MORTGAGE Day phone Mailing address ATTFNTTr1N• Mary sassara Agent Jeri.Deming/AREA COLDWELL BANKER Day phone 561-2488 Address 4105 Tudor Centre Drive, Anchorage, Alaska 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Public water XXX NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer XXX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA 921 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 compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature 6. DHHS SIGNATURE 5 & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River:.%laska 99577 Phone Approved for bedrooms. Disapproved. Conditional approval for Additional Comments i By:/ t_ iltnilaAnctLm % Q M Date bedrooms, with the following stipulations: /-7 Date /�i� 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 work. 72-025 (Rev. 1/91) Back 'MOA 921 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:° Zk-0 Spawthso S. -6A -Parcel I D A-r-BZZ-r' A. WELL DATA Well type P(Z\\IKCi If A, B, or C, attach ADEC letter. ADEC water system number ala Logpresent&N) i Date completed \o, -2o -46h Driller -Pr‘..k kwtprrtS Total depth Z2® Cased to Z'Zo ` Casing height Sanitary seal 'N) Wires properly protected 05/N) y FROM WELL LOG AT INSPECTION Date of test 10 - Zo -1'6¢ 1- \\ -°\'' Static water level ?' t \11--' Well flow 14-1 o gpm 4.Lo- gpm Pump level OV-- UtL SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ido ' ; On adjacent Tots \ oo‘k A- Absorption field on lot \ OO ' ; On adjacent lots 1 opt k Public sewer main AN Public sewer manhole/cleanout A A Sewer service line 2S 1 Petroleum tank 25 WATER SAMPLE RESUI TS: 0 tet,, Coliform Nitrate Other bacteria Date of sample: 11 �c\ 3 Collected by S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 B. SEPTIC/HOLDING TANK DATA Date installed \2-61-e4 Tank size \ op Compartments Z Cleanouts ('N) Foundation cleanout69N) _I Depression (Y/g High water alarm (Y,) Alarm tested (Y/N) 'SIA Date of pumping 1 - 9 —j� Pumper 3:2.- C.--e-ssnouL- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \,-o' On adjacent lots \ Foundation 5 I } To property line Or - Surface water/drainage 72-026 (Rev. 7/91) Front Absorption field 1_91/4 1 Water main/service line \ o CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" level at Cycles tested Manufacturer High water alarm level Meets MOA electrical c SEPAR Y/N) N DISTANCE FROM LIFT STATION TO: ell on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed V2 — S''39" Length Total absorption area Depression over fie�� t- Date of adequacy test \ — \\ `O3 Result ( ail) pp<ss for I/2' %�� ���o� If yes, give date 1A. Peroxide( treatment (past 12 months) (Y �� 6F - SEPARATION 1�\`0 �\v0 to tAa,•Sk�o�,,,Su. \JSr� g -tea- -ca T�s�1�c, o PJt-P� SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots 1 to jr Property line Width (&` Soil rating Zas A1190— System type Gravel thickness Lo„ Total depth 4.5 Cleanouts present �Y)/N) l M bedrooms Well on lot To building foundation lot On adjacent lots Surface water Curtain drain Cutbank To existing or abandoned system on lot Water main/service line Driveway, parking/vehicle storage area t b` AA E. ENGINEER'S. CERTIFICATION 1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effffegsoLtse' t of this inspection. S & S ENGINEERING ga � � '$ �� Signature 17034 Eagle River Loop Read No.204 py.OWSZOd0P ® T®°t3°fl e Eagle River, Alaska 99577 Engineer's Name RQ°0 0000 6.000 0e 1 a 1Sa R©GER J SHAFER a t a Date `— \` _�� V� ,°0° No. 295 �0 fie', °eo 5®° 84�, �����i'ROFESSI®��� t®®®®®®®� HAA Fee $ OG Date of Payment Receipt Number ,,/// c 2/ f CS 5,3'o2./ Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 Chemlab Ref.# :93.0147-3 Client Sample ID :L26 B4 SAMPSON EST. Matrix : WATER Client Name :S & S ENGINEERING Ordered By :RAY Project Name Project# PWSID :UA REPORT of ANALYSIS Collected :01/11/93 @ 14:30 hrs. Received :01/12/93 @ 16:20 hrs. WORK Order :62261 Report Completed :01/13/93 Technical Director :STEPHEN C. EDE Released By : j fie.- G — Sample Remarks: ROUTINE SAMPLE COLLECTED BY: RAY. Parameter QC Allowable Extract Analysis Results Qual. Units Method Limits Date Date NITRATE -N 1.36 mg/1 EPA 353.2/300.0 10 01/13/93 01/13/93 • See Special Instructions Above " See Sample Remarks Above U = Undetected, Reported value is the practical quantification limit. D = Secondary dilution. UA = Unavailable NA = Not Analyzed LT = Less Than GT - Greater Than f1SGS Member of the SGS Group (Societe Generale de Surveillance) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION X/16Fe (a) Legal D cription (include lot block, sec:on, township, rang) c>1- G �rr3 Location (a ress or directions) (b) Applicant Name Telephone: Horne l gS- i/7 Business 4-'74 9S (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ; Other 0 (explain); Applicant Address 6'• 0770 % 7d (d) Lending Institution Address (e) Real Estate Comp y and Agent Address Tune (f) Mail the HAA to the following address: S<F-S Telephone V99Y Z , J 9x9-5-77 -1464,e.e.ex. 2. TYPE OF RESIDENCE Single -Family Multi -Family 0 Other Number of Bedrooms sJ 3. WATER SUPPLY Individual Well xC Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. i1 4. SEWAGE DISPOSAL1 Onsite* Public 0 Community 0 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 72-025 (11/84( 5. ENGINEERING FIRM PROVIDIN_. INSPECTIONS, TESTS, FILE SEARCH, DA k.+ AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this He,alth 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 regulations in effect on the date of this inspection. Name of Firm Address Date S & S-ENCINEERING SR a 196X EAGLE RIVER, AK 99577 6. DHEP APPROVAL 1 (___S) Approved for c-t,C19-Qbedrooms bDate Approved k Disapproved Terms of Conditional Approval Telephone Tp/§2o Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP c16es this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. 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. Page 2 of 2 72-025 (11/84) 4. 4) (s v ,` A. WELL DATA 4Q_V Well Classification r MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description- <-- ZL' aA « fj/)- 1On) S7, If A, B, C, D.E.C. Approved (Y/N) 4-)/4 Well Log Present&N) Date Completed /0 *-2-4) -85Yield 0. 5- (Pv- f Total Depth 2.2-0 r Cased to ?2O Depth of Grouting r— Static Water Level 7-.5-' Pump Set At 6-4A r Casing Height Above Ground 3 Sanitary Seal on Casing Om) Electrical Wiring in Conduit (9/N) Separation Distances from Well: To Septic/Holding Tank on Lot 700 Depression Around Wellhead (Y/60 //S- • On Adjoining Lots /i . To Nearest Edge of Absorption Field on Lot • On Adjoining Lots To Nearest Public Sewer Line &IA To Nearest Public Sewer Cleanout/Manhole •U/A_To Nearest Sewer Service Line on Lot 5 4 Water Sample Collected by 3 +S C 706-)k.) eVZ_l106- • Date /r2s-86 Water Sample Test Results Comments /OD/ -f Sf/ 7f S/. -C To 7 B. SEPTIC/HOLDING TANK DATA Date Installed / -- -- 93 - Size / COO No. of Compartments Standpipes ON) Air -tight Caps CY%N) Foundation Cleanout Depression over Tank (Y0 Date Last Pumped Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) tu//9" Separation Distances from Septic/Holding Tank: To Water -Supply Well /00 To Property Line 'c' for Temporary Holding Tank Permit (YIN) rJi4 7 To Building Foundation /Z To Disposal Field To Water Main/Service Line /0'4 To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ZOS- 46/ Date Installed Width of Field %o Square Feet of Absorption Area Depression over Field (/f Date of Last Adequacy Test L6.5S7/d) 2-Y -5. Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness 661) 34 , Standpipes Present (ON) Separation Distance from Absorption Field: To Water -Supply Well // 5 To Building Foundation Lot ID/ lc To Property Line /0 To Existing or Abandoned System on • On Adjoining Lots To Water Main/Service Line To Cutbank (if present) fr")/d1" qik To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area KO' Comments D. LIFT STATION Date Installed ///4_ Dimensions Size in Gallons J� 1 Manhole/Access (Y/N) "Pump On" Level at"Pump Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify thgt Lha ENGINEERING or conformed to all OA and HAA guidelines in effect on the date of this inspection. Signed SR B 196X Date CompamEAGLE RIVEK, AR 99577 00I 00l Amount' $ b3-7 Receipt No Date of Payment MOA No. Page 2 of 2 72-026 (11/84) "6 -on 3 hart A. SIvorkt e 44." "e No. 1457-E .a k. �° Cdr t `F ,,•Ay• n�4D MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE Application Date - 1. General Information (a) Legal Description (include lot, block, subdivision, section, township, fad 2!0 ./ocl' 2.vi _ o• u6.;v/ /st Location (address or directions) p � (b) Applicants Name -Rh c Applicants Address o V ZS Zq (c) Applicant is (check one) Lending Institution Buyer ; Other I (explain); Tele hone - Home Business -7/S'Z73/ (d) Lending Institution Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: ; Owner/builder Telephone 2. Type of Residence Single -Family Multi --Family Number of Bedrooms 3. Water Supply Individual Well Community I Public 1----i Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Other (describe) 4. Sewage Disposal Onsite t5ZI Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Community Holding Tank [Page 1 of 2] 5. Engineerin: Firm Providin; Ins,ections Tests. File Search Data and Information As certified by my seal affixed hereto and as of the validationls dadate e shoshatntbebelow, 1 ite verify that my investigation of this Health Authority App 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 verd ify that, based on the information obtained from the Municipality of and/or nchorage fires ands from my investigation and inspection, the on-site water supply system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Telephone 6110/'645/ Name of Firm COnA/7 e ['Ca �sw OF A •..... 6. DHEP Approval Approved for bedrooms Disapproved Approved (E r,;ERs ., 44 9F4) •••••.•...d��<A qa 14 •..ROFESS\O 'L-- Terms of Conditional Approval By Condition CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) 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 ORDER TO ISFEDERAL STATE REQUIRE- MENTS. EMPLOYEESOODHEPDO NOTCONDUCT INSPECTIONS OR DATABEFORE 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 23 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 A. ELL DATA Well Classification Pre'va/e. If A, B, or C, D.E.C. Approved(Y/N) Well Log Present (Y/N) i Date Coirpleted 9i} =� -V1i- Yield lcoryi, Total Depth 0 4 Cased to 2" _- Depth of Grouting `"- Static Water Level z451 - Pump Set At Casing Height Above Ground .31 Sanitary Seal on Casing (Y/N).Y Electrical Wiring in Conduit (Y/N) }' Depression Around Wbllhead (Y/N))/ Separation Distances from Irbil: To Septic/Holding Tank on Lot /00' ; Qn Adjoining Lots > /ate' To Nearest Edge of Absorption Field on Lot //5' ; On Adjoining Lots >/oo' To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Lire on Lot Water Sample Collected By a, < ,:t ; Date PT P-` Water Sample Test Results �; �y Comments B. SEPTIC/HOLDING TANK DATA Date installed /Z-6--9 Size /0042 pi. No. of Compartments 2 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 on File (Y/N) — ; for Holding Tank High -Water Alarm (Y/N) -- Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well WO' To Building Foundation 12' To Property Line 710' To Disposal Field V To Water Main/Service Line To Stream, Pond, Lake, cr Major Drainage Course > (a0' Comments [Page 1 of 2] Lo�� �ltgtgc( 2-15-84 C. ABSORPTION FIELD MTA Soils Rating in Absorption Strata Date Installed Width of Field /Z -s -e ZoS 4%/3R Type of System Design ,g, Square Feet of Absorption Area 7Z0 aed Length of Field 9o/ 3'6" Depth of Field ' i rtt Gravel Bed Thickness /' Standpipes Present (Y/N) Y Depression over Field (Y/N) N Date of Last Adequacy Test — Results of Last Adequacy Test — Separation Distance from Absorption Field: To Water -Supply call //,E .To Property Line >10' To Building Foundation Z(' To Existing or Abandoned System on Lot ; On Adjoining Lots — To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage To Cutbank(if present) Course > V)9' To Driveway, Parking Area, or Vehicle Storage Area > 10' Comments D. LIFT STATION lso-e� Date Installed Dimensions Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Comments Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MDA ** ** Check Permitted Bedroom Rating Against HAA Request I certify .Oft I hay on the dare of this nspection. Signed ///' Date /2-/�'i-o# Company ,424 Air checked, verified, or confur«d to all MOA HAA Guidelines in effect KB1/d5/s [Page 2 of 21 MOA No. .578# -NNS .OF E8p P.^• ®V °..17 °°.. ....,.< 3 . .e� . CE-5233a1� 44 2-15-84