HomeMy WebLinkAboutTHUNDERBIRD HEIGHTS BLK 3 LT 14Thund
rbird
H
ights
Block 3
Lot 14
#051-721-25
~ ~ MUNICIPAL,TrOt ANC.ORACE ~. ~,--- ~::)~.~ ~'
DE,ARTME.TO~.EA.T.~ENV,RONMENTAL,ROTECTION L.-~-~ ~-'
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 2644720 ~,~,~_.,Z[~.J~¢,.- ~ '
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE ,-
[] UPGRADE
LEGAL DESCRIPTION
LOCATION I NO. OF BEDROOMS
DISTANCE TO: ~/~.
Manufacturer ~a~...~r.~..' Materia,~l~...~ No. of compartment$~
DISTANCE TO: Well
Material
Total le~l~ ~.J i~e, Trench~wldth
Material beneath tile '~.--~L
PERMIT NO.
Liquid capacity in gallons
PERMIT NO.
PERMIT NO.
< I- Type of crib Crib diameter Crib depth Total ef fecti~e absorption area
uJ Well Building foundation Nearest lot line
u~ DISTANCE TO:
~ Class Depth ~ Driller Distance lo lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer hne Septic tank Absorption area(s)
OTHER
INSTALLER
APPROVED DATE LEGAL
PERMIT HO.
MUNICIPALITY OF Ar`ICHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL.PROTECTION
825 'L' STREET~ ANCHORAGE, AK. ~501
2~4-4720
ON--SITE SEWER PERMIT
( 800102 > I
APPLICAIIT O.S.K. CONST. SRA ~105 A-~ PALMER
LOCATION THUNDERBIRD DR
~OT l ....
LEGAL 4 BLH ~ THUND£RAIRD HITS: LOT SIZE
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
745-255~
SQUARE FEET
MRXIMUM NUMBER OF BEDROOMS = 4
SOIL RATING (SQ FT?BR)= 85
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DEPTH= ~ LENGTH= $5 GRAVEL DEPTH=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET> OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET>.
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET>.
REQU I RED SEPT I C TAr`IK S I :::'E= ::1.250 GALLONS
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS RDJRCENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THRT THE WELL WILL SERVE.
TI~IO ( 2 > I NSPE~:;T I Or-IS RRE REQU I RED
BRCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND RPPROVRL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSRL SYSTEM IS
100 FEET FOR A PRIVRTE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC ~IELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS ?5 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERMIT - EXPIRES DECEt'IBER :~:l., :L980
I CERTIFY THAT
l: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
APP/~IC~IT /~. S. K, CONST.
performed for: d'~ ~-~'
la ol~c. -,L~-r- /,y'
M.D.G.';- 'ENGINEERING
/ground Velar ~'~-~
deplh I t')°---
.15-
17-
18'
date
Ig-
~- . . . ·
20' ' · perc. rate '.,~/4.- .-...,-.-~,~,~. m./m.
.' between ,_~
;ornm~
· ~·'~'~,'..,.*"~.~,,.'
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 I.D. # C~5 I- '7'7-1-
1. GENERAL INFORMATION
legal
description
Location (site address or directions) Z.4~j ~ "l-~,.~'c~,;,.J ~ "~r~O~.
Property owner
Mailing address
Lending agency
Mailing address
Agent ~
Address ~ ~1~
Unless othe~ise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
~PE OF WATER SUPPLY:
NOTE:
Day phone
Day phone
Day phone
Individual well
Community well
Public water
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
H~lding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
5. STATEMENT OF INSPECTION BY ENGINEER
Name of Firm ~---~n~<~-~ ~,<.'~,-,~
Address ' ,~<~.~-~ ~ ~--~c. "~. ~>95"~"'+
As certified by my seal affixed hereto and asof the validation date shown below, I verify that my
investigation of this Health Authori.ty 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.
Phone
Engineer's signature
DHHS SIGNATURE
Approved for
Disapproved.
bedrooms.
Se
Conditional approval for
Date
...' ~_ ~r
'~"v ~
bedrooms, with the following stipulations:
Additional Comments
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.
Parcel I.D. it
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
GENERAL INFORMATION r ' '
Complete legal description ' "",',',',',',','~'~,'/~; ~P'i'~',d
Location (si!e ~a.ddress or directions)
'"' ','Property 0wne'r;
"Matli~g address ,.
Lendin'g ag,encz.-
Ma~hng address - ·
Ageht "' ~'' :'
Address
Day phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: /'~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: 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 ..
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
. 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 Ea le River En in h,.
Address P,O. B~ :7732(~. E,.~,. l?~,e,., AK
Engineer's signature ~~"'"'~-" Date ~'~
· I,/ Approved for FO Id/~ bedrooms·
Disapproved.
__ Conditional approval for bedrooms, with the following stipulations:
Additional Comments
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 courtesyto 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 ts issued. The Municipality of Anchorage is not
responsible for errors or omissions In the professional engineer's Work.
RECEIVED
Municipality of Anchorage JUN 1 5 J99~J~
DEPARTMEN.T OF HEALTH & HUMAN. SERVICES -
Environmental Services Divis,on ~aP,,v,.rn,
825 L Street, Room 502 · Anchorage, Alaska 99501 ·
Health Authority Approval Checklist
LegaJDescripfion: -~u,J¢~.~,'~',~ ~/=.,,~T; /-/~ ~'~ ParcelI.D,: ~-J-~.,~
Well type If A, B, or C, attach ADEC letter. ADEC water system number
Cased to CaD--bore
Sanitary seal (Y/N) ~"~ _ Wirier'properly protected (Y/N)
AT
INSPECTION
Date of test
Static water level ~/~
Well production g.p.m, g.p.m.
B. SEPTIC/HOLDINGTANK DATA
Date installed ~-/~-~'C) Tanksize /ZS',O Number of Coml~,,ents ~. Cteanouts(Y/N) ~-~
Foundation clea~out.(y/N) . ~'~.; Depression (Y/N) /V~J High water alarm (Y/N) --
DateofPu~rll3~l~l":'~'-/~'f~' ': Pumper ~-'~
c. ADSO;t~O. REU~ 0ATA '.
'"" ~l~~
Datein~t~ll'e~l'''7-/~: ' Soilrating (g.p.dJfForft=/bdrm) ~ ~"/~-Systemtype
Length '.-~",C Width Gravel thickness below pipe ~-?'~ Toteldepth
Effective ab$oq:~l~ Da area' ~¥~' ~"~ ~' Monitoring Tubff. present (y/N) ~'~-~ Depression over field (Y/N)
-*,.. ~
Date of abequacy test e"-/~-f~' Rasulte(Pass/Fail) /~o.~5 For ~/l~-'z' (~) bedrooms
Fluid depth in absorption field before test (in.); ~ Immediately after~'¥/ gel. water added (in.):
Fluid depth 7 (ins) Minutes later: .~ Absorption rate = ~ ~ ~ .,c'- g'P'd'
Peroxide treatment (past 12 months) (Y/N) If yes, give date .
72-o26 (Rev.
Date installed Size In gallons
Manhole/Access (Y/N) *Pu .nlp-on~leve ~'~~*Pump off* level at'
High water alarm level at* ~- *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: C~'~,~'~,~,/'~'~'
Septic~olding tank on lot On adian,~
Absorption field on lot On adjacent lots
Public sewer main ~ Public sewer manhole/cleanout
S~.e~.~e~ ~ line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~" / Property line ~'/¢:~ ~' Absorption field
Water main/sen/ice line P/~ · .Surface water/drainage
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Surface water
Curtain drain
H~ Building foundation '/ C/'~ ~~,,--,~ Water main/sewice line
4'/~o · Driveway, parking~hicle storage area
~ /~',A ~ Wells on adjacent lots -/- '2.~,~ /
R ENGINEER'S CERTIFICATION
· HAA Fee $ ,~ Z~, ~
Receipt Number '~'0 3 (/'776)
Waiver Fee $
Date of Payment
Receipt Number
72-o26 (Rev. 3/96)*
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescdption: LI415~ T~,~C~.~j~.~, ~1-,~ Pamell. O. 051- '77..t-'Z.s
A. Well Data
Well type pu~-~(.. ~'q"E~', B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Date completed / Driller
Cased to J Caslng height
~e~properly protected (Y/N)
FROM WELL LO~,x/ I AT INSPECTION
Static water level
Well flow
g.p.m.
Pump level1
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
SEPARATION DISTANCES FROM WELL TO:
,~n adjacent lots
~) ~ ; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform Nitrate...) h
Dateof sample: f --
Collected by:
Other bacteria
g.p.m. I'-rl
B. SEPTIC/HOLDING TANK DATA
Date nstalred ,3',.,'t-',, ~ ~)[:',o Tank size 1%$0
Cleanouts (Y/N) ~ Foundation cleanout (Y/N)
High water alarm (Y/N)
Date of pumping
7_.
Compartments
Depression (Y/N)
I',J ~ Alarm tested (Y/N)
7-9~ ~ .~ ~'~ Pumper ~-~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot r4
To property line
Sudace water/drainage
On adjacent lots , ZcDo' Foundation
Absorption field ~' ' Water main/service line
* loc)'
72-026 (3,~3)°Fmet CONTINUED ON BACK PAGE
C. LIFT STATION
Date Installed
Size In gallons
Vent (Y/N) 'Pump on' level a/t.~
High water alarm level tJ
Meets MOA electrical codes (Y/N)~
SEPARATION DISTANCE~FROM LIFT STATION TO:
Well on lot On adjacent lots
~s
'Pump off'Levelat
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ~-uL~
Length. ~,<;/ Width
Total absorptlo~ area 5 4o ~:
Date of adequacy test '7- 90- 9-5
Water le,~el in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/FF)
Gravel thid~ess 7_
Cleanout present (Y/N)
Results (pas~a~)
4
O-
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /"J P~
To bullding foundation~- IO°
On adjacent lots 4. Ioo/
Surface waler -t--t oo'
Curtain drain +5o'
System~pe
Total depth
7 Depression over field (Y/N)
~,,~s s for
Nter test 0 -
If yes, give date
Bedrooms
On adjacent lots '+Z~ / Property line 4- Z~"
To existing or abandoned system on lot
Cutbank .~lt:~ ' Water main/service line
Driveway, parking'vehicle storage area ~-/["'
E. ENGINEER'S CERTIFICATION
I cern'fy ~at I have checked, vedtied, or conformed to all MOA and HAA guidelines
Signature
Engineer's Name
Date
HAA Fee $ /~CO O0
Date of Payment ~- ~7/'~ ¢--~
- Receipt Number C>~/.~ ~/0~
72-028 (3'1)3)°
Waiver Fee $
Date of Payment
Receipt Number
TIME
INSPECTION APPOINTMENTS
TIME
DATE RECEIVED
TIME
DATE DATE DATE
INSPECTOR
INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHOr~A~
ULFI. OF h~U. TH &
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION
j. DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825LStr.t-Anchoraee, Ala~k, 99501 OCT 2 1 ~0.
ENVIRONMENTAL SANITATION DlVlSlONTelephone 264-4720 RECEI.V. ED.
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts Der page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing.
PHONE
MAILING ADDRESS
PROPERTY RESIDENT (if different from above) PHONE
MAILING ADDRESS /~.~7---~ ~ ~ ~
4. REALTOR/AGENT
MAILING ADDRESS
PHONE
PHONE
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
~ SINGLE FAMILY
I--I MULTIPLE FAMILY
7. WATER SUPPLY
i'--I INDIVIDUAL'
15~ COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE**
I--I PUBLIC UTILITY
N~M~ER GE~EDROOMS
I'-I One i'-I Four [] Other
[] Two [] Five
[~ Three [] Six
ATTACH WELL LOG. A well log is required for all wells drilled
since ,June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
/~...1 YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
.THIS SIDE FOR OFFICIAL USE ONLY . , .
NUMBER OF BEDROOMS
[] ONE I-1 THREE [] FIVE
[] TWO [] FOUR [] SIX
[] OTHER
WATER SUPPLY
I-'1 INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
I-'IINDIVIDUAL/0N -SITE
[]PUBLIC UTILITY
Connection Verified
F'-ISeptic Tank or r-]Holding Tank
Size:
give dimensions:
TYPE OF TANK
PERMIT NUMBER
DATEINSTALLED
INSTALLER
IfTankishomemade $OILS RATING
MANUFACTURER
TOTAL ABSORPTION AREA
4. DISTANCES
WELLTO:
Absorption Area to nearest Lot Line
5. _COMMENTS
MATERIAL
Sept,cJHotding Tank IAP$olption Area
ISewer Line
· I Nearest Lot Line
DATE
[~PPROVED FOR ,.'~ BEDROOMS
I'"1 CONDITIONAL APPROVAL (letter must accompany certificate)
t-"l DISAPPROVEDJBY /~
72.010 (Rev. 6/79)
Parcel I.D. O~/- ?-.'~-/- ~
1. GENERAL INFORMATION
Complete legal description
Municipality of Anchorage o
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program ·
4700 South Bragaw SL A
P.O. Box 196650 Anchorage. AK 99519-6650 ~<1~-,,,,,,,
www.ci.anchorage.ak.us I It i ~ ~ ,~ '"',,J
CERTIFICATE OF HEALTH AUTHORITY APPR(~JJAL "~
FOR A SINGLE FAMILY DWELLING.=
Expiration Date: / / ~ ~-'-
Location (site address or directions)
Current Property owner(s)
Mailing address
Lending agency
Day phone
Day phone
Mailing address
Real Estate Agent
Day phone ~ ~ ~-¢~/','
Mailing Address .,4,.-~.,/-.,,,-.~.)-,._ .
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: /'-/
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
E]~ Individual On-site
Individual Holding tank u
[] Community On-site []
[] Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval ere required for the transfer of
title (except bet~,veen spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures out~ined in the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein, I further verity that based on the information obtained from the
Municipality of Anchorage flies 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 or Firm ~..a~]e ]:~.J.?c~' ~.~z,--~[ucex;,,,~ ~e- -_A_ Phone
Address P.O. Bo~ 2732o~, E,~{~ R,,~. A E oe,=;7-/.~?~ $
Engineer's Pdnted Name /-.-~,,.,,~ ,.C.-A..,~ Date
5. DSD SIGNATURE
Approved for L.~
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Sox 196650 Anchorage, AK 995'19-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Parcel ID: ~5'-/-
WELL DATA /~,//~ /~,~.~,~. ~,,~,..
Well type ~ If A. B, or C provide PWSID #
Date compte~d Sanitary seal (Y/N)
Total depth'.,~__fl. Cased to ~ft~
FROM WELL LOG
Date of test ~
Static water level ~ ft.
Well production ~ g.p.m.
WATER SAMPLE RESULTS~
~,t~or(~sa_~ple.' celonies/,00~L ;J~tec~edby: mg./I.
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
In.
g.p.m.
Other bacteria
colonies/100 mi.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material .~ V-~ /
Tank size ,/2 5'-~ gal. Number of Compartments
Foundation cleanout (Y/N) ~' 'Depression over tank (Y/N)
Date of pumping /4'- '~ - 4, ~_ Pumper :3"~ ~-
Date installed '~-
Cleanouts (Y/N)
High water alarm (Y/N)
ABSORPTION FIELD DATA
Date installed '7-/%P,-, Soil rating
Length ~c'5-
Total depth 5~. & ft.
Date of adequacy test
Fluid depth in absorption field before test
Elapsed Time: ~P min.
ft. Width 2~" '~.
Eft. absorption area ~. '/4t2 Monitoring tuba __
Io - I,~- ~-3.- Results(Pass/Fail)
O in. Water added ~o~ gal.
System type Tr~',~l
Gravel below pipe c,~ ft.
Depression over field ~
For z~' bedrooms
New depth /"/ in.
o'"~,~ g.p.d.
Final fluid depth ,~ in.
Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (YIN & type) ,,~,~ If yes. give date
D. LIFT STATION
Date installed
'Pump on~4~'~ in.
D~dm
Size in gallons
"Pum~ in.
Cycles tested
Manhole/Acce.~.~_/
High ~t~rm level at
Meets alarm & circuit requirements?
in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /~'/~
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots ,'~"/~'
On adjacent lots ~'/~'
Public sewer manhole/cteanout
Holding tank .,~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Water main
Property line 2,~ ' Absorption field ~'~'~'.
Water service line ,' ,,-," Surface water ;/,'~'
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~ o '
Water Service line
Building foundation -' ~ ' Water main ~' ~ '
Surface water ~' t= ~, · Driveway, parking/vehicle storage
Curtain drain
Wells on adjacent lots *,~,~ '
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 MOA HAA guidelines in effect on this date.
Engineer's Printed Name ,~',,..;' ~P~ ~'--
,.
Waiver Fee $
Date of Payment
HAA Fee $ ~_~g .~o
Date o¢ Payment t~I ~ ~ ,~"~.
Receipt Number ~.:~ 67~ ~p~.
(Rev. 12/00)
Receipt Number