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Home My WebLink AboutHIGHLAND HILLS #2 BLK 2 LT 2Highland Hill Block 2 Lot Z #050-382-33 Municipality of Anchorage Page ~--.-~of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O, Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: .~"qqo ,non.: LEGAL DESCRIPTION WELL: fl New Fl~ll~rade Ft. SEPARATION DISTANCES Welt' Sudace Water Lot Line Foundation Curtain Drain Remarks: Inspections pedormed by: PID Number: O I~D -' ?x~,~.-- ~ % Wastewater System: D New ~l(Upgrade ABSORPTION FIELD Deep Trench ~,Shallow Trench r't Bed ;'1 Mound ri Other Soil Rating; Total Depth from original grade: Gm~l Septic [3 Holding $.T.F_P. Capacity in gallons: LIFT STATION ~ ,, c~ d,._ '""P °n' '' ": I BENCH MARK Dates: 1st Department of Health and Human Services approval Reviewed and approved by: ~~' ~ Date: /- 20-~ ENGINEER'S :*, ' "'o' ...... ' ,:,.: ,.:? ,_', .,-,: · '"~.:- .. I BIOCYCLE 6808 5-VIDE T£ENCH AC 84.$FT TOTAL LENGTH TOTAL ~EPTH .5 FT F1L TE~ ~AND ~DCK DEPTH .~ FT 3 FT ~ ABANDDNE~ EXI2T. TANK AND D~AINFIELD I I ILE; 11' = 58 FT. I I TOBBEN SPURKIAND P.E. 203 W ISTH. AVENUE ANCH. AK. 99501 (gO7) 279-$916 IIIGtlLAND tlILL$ //2 BLOCI{ 2 LOT J MILE .5.1 HIGHLAND ROAD, EAGLE RIVER TED STANFIEID SEPTIC SYSTEM AS BUILT DATE:. OCT. 21,'.19£9 SHEET: 2/3 GRID: SW 658 PERMIT # SIg990373 PID # 8S§-382-33 HLHO2022.DJVG 4-INCH INSULATION 1-I/4 PVC W/TH 1/8' HOLES M' $0' 5 X 40 DRAINFIELD .5 Fl' TOTAL DEPTH I FT SAND BLANKET .5 FT EFFECTIVE ROCK CPP PAL~ER 2 FT COVER /-- AIR UN.rS · ¢, ~. ,, ..e. 7 ... ----IIF:tll=llg-tll=lll=tll~,lll~.---~l,l~-ii~.t ,... -~ · NO SCALE BIOCYCLE 6000 t~ -- 97 LEGEND: I. PRIMARY TREATMENT, SEPTIC TANK 2. AERATION TANK $. CLARIFICATION TANK 4. DISCHARGE TANK 5. SOIL ABSORPTION BENCH MA£K: DOOR fRESH HOLD ASSUI~EO ELEK I00. OO FT [OBBEN 5PURKLAND P.--E. 203 WlSth Ave Anchoroqe Ak 99501 279-5916 IIIGtlLAND tlILLS //2 BI{ 2 LOT 2 BIOCYCLE WASTE WATER SYSTEM STANFIELD WASTEWAr£R SYSTEU SCH£UAr/c DATE: 0C1'. 21, 1999 SHEET: $/$ GRID: SW 5~ PERMIT # 2V990373 Piti # o$o-~2-$$ HLHfl£O£3.DWG PROPERTY OWNER AGREEMENT FOiR TIIE MAINTENANCE OF AN ON-SITE WASTEWATER DISPOSAL SYSTEM This a~eement, dated._~/., q/ 199..~_, is made between the Mrmicipality of Anchorage Department of .[!ealth and Human Service:; (DHH$) a~d the property owner(s) of: This agreement is made for the purpose of maintai~g an on-site wastewater dispos~ system on the subject property. The property owners agree to th, e following: Submit to the Municipali~ ~,f Anchorage, on an annual basis, an inspection and operation statement from a tegistered professional engireer. This inspection and operation statement shall verify that the engineer has inspected all effluent and ~ pumps, timers, and alarms, ,nd that any deficiencies have been repaired and tl~t the system is functioning as desi..med. (Signature) (Printed Name) (Printed Name) ............................... N:~arize Here ................................ who is perso~mlly known to me ~ whoge identt.:'! I proved on the basf. s of ~. ~ L. · ~hose identi:: I proved on the bart/affirmation of ~~f~/~ . a credible w,tness t of the abo~y document, and he/she acknowledged t~t he/she signed it. ~ ~NOT~Y: ~ ~ bX~c ~ ... .. ~ Hy commission expires ~ ~. ~ ..... .q~, CARCEL ELECTRIC INC. 10410 FINLEY CIR. * ANCHORAGE, AK. 99516 907~34E'4030 * 907-346-4032 ~ Mr. Tobin Strtckland: Qec. 7, 1999 Carcel Electric wired the Bio-Cycle located at Mile 5.1 Highlan'd..rd., Highland ~ills, #2 subdtvision~ Lot 2, Bk2, .£agle'R&ver AK. Owner~ Ted Stanfield, installed Oct. 11th. This ~10vCycle was wired per the 1999 National'Electrical Code. If you have any questions please givelme a:'ea11. Steve Cloud General Manager. MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P,O. Box 196650. Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Oct 01, 1999 Expiration Date: Sap 30, 2000 Permit Number: 8W990373 Legal Description: HIGHLAND HILLS #2 BLK 2 LT 2 Design Engineer:. 0007 Tobben Spurkland, PE Owner Name: Ted Stanfield Owner Address: PO BOX 772822 EAGLE RIVER, AK 99577-2822 Parcel ID: 050-382-33 Site Address: Lot Size: 66407 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] SepticTank [] Holding Tank [] Pdvy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsuriace soil absorption system under construction during freezing weather must be either:. A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. Biocycle - This permit is for a Biocycle system. Issued By: Date: IO.l. T. ?U KLAlqD ?.E. 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 9950 I (90'/) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 2 BLOCK 2 HIGHLAND HILLS ~. TED STANFIELD Municipality of Anchorage Department ofttealth and Social Services 825 L Street Anchorage, Alaska 99501 September 15, 1999 We are submitting an application for the upgrade of the septic system for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements ofthe lot, of which only the septic system is subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following: Ground Water at 5 fl Assume Ground Water at 4 fl Use BioCyclo with 5-wide trench Soil Rating. From Test 09/02/99 1.5 min/in = 2.4 gal per sq.ft/day No. of Bedrooms 3 Required Area per Bedroom: 150/2.4 = 62.5 sq.fi. Total area required: 62.5 x 3 = 187.5 sqfi Length Required: 187.5 / 5 -- 37.5 fl USE -~Lr q~ ~.~ SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 40 FT TOTAL WIDTH 5 let TOTAL DEPTH .5 FI' FILTER SAND I FT ROCK DEPTH 0.5 FT COVER 3 FT BIOCYCLE 6000 The installation of this septic system will not prevent development ofadjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. · ' The proposed septic system will not change the general slope of the area. Ponding ~nd/or concentration of surface - 4 mnoffwill not result from this inshallation. LDT 3 LOT £ LDT 3 LOT 17 LOT 18 ~ LDT I £5O 300 I I IOOSgO SPURKIAND P.E. 203 Pt 15TN. AVENUE ARCH. AK. 9950t (907) 279-3916 I{HGIIIANB IdllE $. t HIGHLAND ROAD, EAGLE RIVER TED STANFIEID SEPTIC SYSTEkt DESIGN DATE: SEPT. 14, 1999 SHEET: I/$ GRID: SY/ 558 PERMIT # SW990XXX PID # 050-388-23 HLHO£OPl, DWG '' t m m ~ m m m DIOCYCLE 6000 S-WIDE TRENCH TOTAL LENGTH 4~ FT TOTAL DEPTH .$ F F FILTER SAND ! FT ROCK DEPTH .$ ET COVER $ FT ~ ABANDON EXIST. TANK AND DRAINFIELD IFell ~5 I I ~5-I'~ §~ ~ 75 lt~ Is6 ILE~ 11' = 50 FT. I I ........- ~ ~ '49~h I~% ~ ;TF ~....~~~.....~ I I TOBBEN SPURKLAND ~£ 20~ W ~SrH. AVENUE ANCH. A~ 99501 (90Z) 2Z9-~9I~ IIIGtlLAND tlILLS //2 BLOCI{ 2 LOT I I I MILE 5, I HIGHLAND ROAD, EAGLE RIVER TED STANFIEID SEPTIC SYSTEW DES/ON DATE: SEPT. 14, 1999 SHEET: 2/3 GRID: SW 558 PERMIT # St/990XXX PID # 050-38~-33 HLHO2022,D~/G SAND BACK£1U. 4-INCH INSULATION ~'-t/,/ PVC mrH MS'/¥oL£s Ar 5 X 4~ DRAINFIELD .5 Fl' TOTAL DEPTH I Fl' SAND BLANKET .5 Fl' EFFECTIVE ROCK $ Fl' COVER LEGEND: I. PR/WARY TREAI'WENI', SEPI'IC TANK 2. AERATION TANK $. CLARIFICATION TANK 4. DISC/lARGE TANK 5. SOIL ABSORPTION TOBBEN SPURKLAND P.E. 205 Wl5lh Ave Anchoraqe Ak 99501 77g-3916 tlIGI1LAND tlILI~ //2 BI{ 2 LOT 2 BIOCYCLE WASTE WATER SYSTEM STANFIELD IwAsr£wAr£R srsr£u SCH£UAr/C DATE: SEPT. 16, 1999 SHEEI.: 3/3 GRID: SW 5~ PERMIT # SW990XXX PID fl ~ HLHD£O£3.DWG Munl;li:allty of Anchorage DEPARTMENT O~ .tEALTH & HUMAN SERVICES 825 #L" Street, A~mhorage, Alaska 99502-0650 SOILS LOG - PERCOLATION TEST LEO^~. DESCRmT~ON= Lo[' ~,1~V,~, 14;~k~,.~ Township. Range. Section; ,~ ' H:tl5 SLOPE SITE PLAN 10 - WAS GROUND WATER ENCOUNTERED? I S 11- L IF YES, AT WHAT {~ 0 DEPTH? p 12- E 17- 1~- 19- 20- Net Dec)th to Net / ~"* {m,i~ule~/mch PERC HOLE DIAMETER . PERCOLATION RATE __ TLST RUN BETWEEN , ~ FTAND .--.~' FT '' ::' DISCLAIMFR' C, rn~ndwatPr r~ndit~nn~ tndiratPd ar~ fnr the dates shown only· Past and future presence &nd/or depth of gro[ndwater can not be predicted · from these observationS. PERFORMED BY: 7~- ~ ..__ I ~'~ ~3~ . ~ CERTIFY THAT THIS TEST WAS PERFORMED IN · ACCORDANCEWITHALLSTATEANDMUNiCIPALObiCELiNESiNEFFECTONTHiSDATF. DATE: ~//~/g~ 72-008 (Rev. 4/85) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTFCTION ENVIRONMENTAL ENGINEERING DIVISION 825 L ,Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPFCTION REPORT NAME MAI LING AD~ES8 LEGAL DESCRIPTION LOCATION Well ~/~ Absorption area t Dwelling DISTANCE TO: Z~ Msnu faaturer Liq, ~allons IF HOMEMADE: Inside length Width .... DISTANCE TO: Well ,/~/1 Dwelling Manufacturer DISTANCE TO: ]Well No. of lines Length of Top of tile to finish grade PHONE ] I_~ ~ ~1~-} [] UPGRADE NO. OF BEDROOMS Length 'Z-~ ! Width Type of crib Crib diameter Crib depth Well DISTANCE TO: Building founc DISTANCE TO:: ng OTHER Sewer line PIPE MATERIALS , LLER REMARKS PERMIT N No. of compartments Liquid depth PERMIT NO. Material Liquid capacity in gallons Nearest lot Pine PERMIT NO. length of lines Trench width Distance between lines inches Material beneath tile Total effective absorption area inches Total effective absorption are~_l~ Nearest lot line Oistance to lot line PERMIT NO. Septic tank Absorption area(s) AL PERMIT 1"40. DEPFIRTMENT OP' I"tEf::IL. TH FIND EN',,,'IRONMEI'.ITRL '""]OTECTION ,'.:-":2.5 '" STF.:EET., flNCHORFtGE., ilK. 9:. .j"l~ 264-4-720 mE, fP-~ -- :S Z -F E ::5 EC ~..4 tE F..: F" E IF..: CF"1% T' ,:: 8_-'.':0079 ) RPPL I C FII",IT L 0 C I::1 '¥' I 0 N LEGFIL SOU'FFI FORK CONSTRLIC:TION PO BOX 5e]7 E.R. 995'?7 L2E:2 HIGHLFIND HILLS LOT SIZE T"r'F'E OF' SOIL FIBSORPTION S"r'STEM IS: DRRINFIELD MRXIMUM HUME,'ER OF E:EB, ROOMS= ~: 999999 SQUf'-'IRE FEE]' SOIL RFI]"ING ,::SQ FT,/BR)= :L50 THE REQUIRED SIZE OF THE SOIL flE:SOF.:PTION SYSTE]"I IS: THE LEi",IGTH [:'IMEi",ISZON IS 'THE LENGTH '::IN FEET) OF THE TRENCH OR DRFtINF'IELD. THE [:'EPTH OF Ft TRENCH OF..' F'IT IS THE DIS"I'RNC:E BETMEEN THE c;UF..'FFICE OF' THE GROUN£:, RN[:' THE BOTTOM OF THE EXCFtVRTION '.'.'IN FEET). TIdE GRR',,,'EL C'EF'TH I'-"; THE MINIMUM DEPTH OF QRFI',,"EL BE'TI4EEN THE OUTFFII...L. PIPE fiN[:' THE BOTTOM OF THE E,'.4C:I=I',/FtTION '.'.'IN FEET). PERi'lIT FIPPL. ICFII",IT HI'aS THE RESPONSIBILIT"r' TO IIqFOF.':M ]"["lis [:'EF'FtRTMEI',IT DUI;.'.II",IG THE II',ISTRL. LflTIObl INSPECTIONS OF' FIN"r' I.'.IEL. L.S RDJFICENT TO THIS F'ROPERT"¢ FIN[':, THE I",IUME',ER OF RESIDENCES TI'IRT THE bIEL. L I-'.IILL SER',,,'E. .......... -r ~-.,11 ~:.:~ ,:.' 2 ::, :E. ~"-,~ ~'; F' [E C: T 1: E} f'.41 "_=.; F~ 1:,1: [-E F..: [E G:.~ EJ % If;..: [:.:.:. E',RE:KFILLIN6 OF' F:II'.,!'¢ SYSTEM I,.IITHOLIT FINFIL INSPECTION FIND RPPROg'flL BY THIS DEF'FIRTMENT WILL BE SUBJECT TO PROSECUTION. I','tINII,1UM [.',ISTI.aNCE BETMEEN Ft NELL RND fiN'r' ON-SITE SEI4RGE [:,I.SF'OSFII_ S"r'S"FEM IS :J. 00 FEET FOR R PF..'I',,,'FITE WELL OR ±50 TO 200 FEET FF-.'OM fl F'UBLIC I.'.IEL.[.. [:'EF'ENC,:[NG UPON THE T"r'PE OF' PUBLIC [4ELL. MINIMUM DISTiaNC:E FROM FI PRI"/RTE 1.4ELL TO R PF.:I'v'RTE SEklER LINE IS ;-:!5 FEET laND TO F~ COMMUNIT'¢ SEWER LINE IS 75 FEET. ATHE:R REL.]UIREMENTS t'If:l"r' RF'PL'¢. SPEE:IFIC:flTIONS RND CONSTRLICTION [:,IFIGRfZlMS FIRE R","RILIZlBLE TO IblSURE F'ROPER IN'"7, T'RLLRTION. I CERTIFY THRT ::L: I FIM FflI','IILIF4R !.,IITH THE REQUIREMENTS FOR ON-SITE SFb. IERS RI'.,ID I.,IELLS FtS SET FORTH B'.r' THE MLINII]:IF'FILIT'.r' OF flNCHORFIGE. 2: I I.,.IILL Ii'.,tSTRLL THE S'¢STEM IN FICC:ORDflNCE I.,.IITH THE CO[:,ES. ]:: I UNDERSTFIN[:, THflT THE ON-SITE SEbIER S'¢STEM MFI"r' REQUIRE ENLF:IF.:GEMEi",IT IF THE F.:ESIB'ENCE IS REMO[:'ELED TO INCLLIDE MOF.:E TI'"IflN .".:.:: BE[:'F,'.OOM.S. FIF'F'LI?__:FtNT SC)UTM FORK CONSTF, UCTIAN /.. _._/,., 1 POUCH 6-650 ANCHORAGE, ALASKA 99502-0639 (907) 264-4111 TONY I~NOWL£S M4YOll DEPARTMENT Or HE,',I I li ^ND ENVIRONMENTAL PROTECTION ~Permit %: 821165 .January 31, 1983 TO: Permit Applicant Subject: Lot 2 Block 2 tlighland tlills Subdivision A permit issued by this department for an individual well and/or on-site sewer system has expired as of December 31, 1982. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal Ordinance. If you have drilled the well, a well log needs to be sent to this department for documentation of the installation date and to close the permit. If a private engineer inspected the installation of the on-site sewer system, please have them send us the as-builts for our files and documentation. If there are any further questions, please call this office at 264-4720. Sincerel~ Robert C. Pratt, R.S. Acting Program Manager Sewer and Water Program RCP/ljw enc: Copy of Permit SWP/057 PERMIT NO. RPF'L I CFlNT LOCIRTION LEGFlL SOUTH FOR. K C:ON2;T. L2 B.':" HIGHLRND HILLS PO BOX 567 ERGLE RIVER LOT SIZE D~4~DL~'..=.~'.5~ SQURRE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: DRRINFIELD I"IRXIMUM NUhlBER OF BEDROOMS = _-.-': SOIL RRTING (S6~ FT/BR)= ±50 TNE RE(.:!UIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS: [:." E'~ F" 'T H= 5 L. E I'-,I t3 T H == ?_.1 _---~.: 13 R I::~ '..-' E IL_ [:. E F" ]- [-t == ]:: THE LENGTH DIMENSION IS THE LENGTH ,'.;IN FEET) OF THE TRENCH OR [.',RFIINFIEL[:,. THE DEPTH OF Ft TRENCH OR PIT IS THE [.',ISTFINCE BETWEEN THE SURFFlCE OF' THE GROUND FIN[.,, THE BOTTOM OF THE E)..',CFI'¢FITION (IN FEE'['). THE GF.:FIVEL [:'EF'TH IS THE MINIHLIM [:,EPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE FIN[:, THE 80TTOH OF THE EXCR',,,'RTION (IN FEET). PERMIT RPF'LICRNT HR2; THE RESF'ONSIBILIT¥ TO INFORM THIS DEPFIRTMEN"I" DUF.:ING THE INSTFlLLRTION INSPECTIONS OF RNY WELLS R[.',JRCENT TO THIS PROPERTY RN[:, THE NUME;ER OF RES I[:,ENCES THFlT THE WELL. HILL SER'v'E. E:FICKFILLING OF RN'¢ S'¢STEM WITHOUT FINRL INSPECTION RND FIPPRO',/FIL F:Y THIS I)EPFIRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM [:,ISTFINCE BETWEEN FI WELL RND FlNY ON-SITE SEI.4RGE [:,ISPCISBL SYSTEM IS :;LO0 FEET FOR R PRIVFlTE WELL OF.'. 150 TO 20E~ FEET FROM FI PUBLIC WELL DEPEN[:,ING UPON THE TYF'E OF PUBLIC WELL MINIMUM [:,I:STFINCE FROM FI PRI'¢FlTE WELL TO R F'RIVRTE SEWER LINE IS 25 FEET FIN[.,, TO F:I COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MFlY FIPPLY. SPECIFICRTIONS RND CONSTRUCTION DIFiGRFIMS FIF.'.E FI'v'RILFIBLE TO INSURE PROPER INSTFlLLF~TION. I CERTIFY THFlT l: IRM FRMILIFlR WITH THE REC~LIIREMENTS FOR ON-SITE SEWERS RN[) WELLS RS SET FORTH BY THE r,IUNICIPRLITY OF FINCHORFIGE. 2'.: I WILL INSTRLL TNE SYSTEM IN RCCORDRNCE WITH THE CODES. Z.':: I UNDERSTFlND THFlT THE ON-SITE SEWER SYSTEM MR"r' REL::-!UIRE ENLFlRGEMENT IF' THE RE'-:;IDENCE IS REMO[:'ELED TO INCLUDE MORE THFlN ~: BEDROOHS. ,,~ SOILS LOG PERFORMED FOR: LEGAL DESCRIPTION: 2 3 4 7 8 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST SLOPE [] PERCOLATION TEST DATE SITE PLAN 10 11 12 13 14 15 16 17 18 19 2O - (¢'/d/<'f~ Om/'/,j WAS GROUND WATER ~ i/~.2 /~ S ENCOUNTERED? 7r~'~ L O IF YES, AT WHAT DEPTH? ~ Reading Date Gross Net Depth to Net ,kz~ Time Time Water Drop PERCOLATION RATE (minutes/inch) COMMENTS 72-008 (6/79) TEST RUN BETWEEN FT AND / CERTI Fl ED ~/~'~" :/ 1/ FT ,:SULLIVAN WATER WELLS ?ERMIT NUMBER' :: - ,, , ,,? , · .... ~IND OF FORMATION:? . ~rom 0 Ft.'t0'~:'?~~ Ft;i':i':!~,.i~.;~;~;,~.~e'~/~-~ From From ?. ' Ft. to:.~'~ . Ft',.,'~'~e;::~ :;~ a~' r,~,: ~ ~0 From From Ft. t0??;~ :,. From Ft,-ioa.:,'.".r From Ft. tO;,-', Ft.~ From, Ft. 'to d~;: .: ~ Ft; ..... From Ft/t~ ~,? 'F~;: -, , .- - : DEPTH OF'WELL - ~ STATIC LEVEL::OF WA~ER:.FT. GALS. PER HR KIND OF O~iNG Ft, From_ __ Ft.-t0..':-, , Ft. From___ F From , Ft, to, ,, ..~Ft,. '.,' .. From , . Ft. to';.- :.~Et, From , Ft,[rO,;. ; ~Ft, .. 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[~ 'E 'f'l:E' '1: '~ .:::IL :I: I',ISF'ECT :[ O1',1 "" ~ I T~: .'P'"" '"~?" / / I':IP I:::'L ]: CFII",IT ' .......... ~ ........ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Sot.~h Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.d.anchorage.ak, us (907) ~3-7904 CERTIFICATE OF H -EALTH AUTHORITY APPRO~,%L FOR A SINGLE FAMILY DWELLING Parcel I.D. GENERAL INFORMATION Complete legal description LOT' Location (site addres~ or directions) Current Proper~y owner(s) "~; ~.~o;" Mailing address Expiration Date: Lending agency Mailing address Real Estate Agent ~'~c, oj.~/' /]4~o 'r~-; 5 Mailing Address Unless otherwise requested, HAA win be held by DSD for ~c/ckup. 2. NUMBER OF BEDROOMS: ~ Day phone 3. TYPE OF WATER SUPPLY: ' Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer [3 The Municipality of Anchorage Development Services Department (DSD) Issues Ce.'+Jficates of Health Authority Approval (HAA) based cnly upon the representations given in p~ragraph 4 by an independent professional civil engineer registered in the State of ~aska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-~mily on-site wastewater oisposal and/or water supply system. DSD also issues HAAs upon request to homecwners. Ce~ficates of Heafth Authority Approval are valid for 90 days from the date of issue for properties served by a priv,~te or Class C we!l and may be reissued with new water sample results. (Certificates may be reissued for a pedcd of up to one year with valid water samples.) Ce~ficates are valid for one ye~,r for proper~Jes served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or cmissions in the professicnal engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewatar disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage flies and from my investi(Jation and inspection, the on-site water supply and/or wastewater disposal system is(are) in complinnce with ail applicable Municipsl and State codes, ordinances. and regulations in effect at the time of installation. Address ~D ;~ tV/ /~ ~ /~,¢..~ ~ Engineer's Printed Name --/ o/~b-~,~ S~,,.,"!,.,'....(¢.,a~,~ bedrooms. DSD SIGNATURE Approved for ~ Disapproved. Conditional approval for Phone 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: '~/~ ~-/0 ~_.. Municipality of AnchOrage Development Services Department Building Safety Division Or~lte Water & Wastewater Program 4700 South Bragaw SL P,O. Box 196650 Anchorage, AK g9519-6650 www.cLanchorage.alc us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST A. WE]J. DATA Well type I~ If A, B, or C provide PWSID # Totaldepl~ I00 lt. Casedt~ ~ ft. FROM WELL LOG pete o~ ~t / static water level Wefi production (~ g.l~m. WATER '~a~IPLE RESULTS: Coliform ~ colonies/lO0 mL Nra'ate ~ mg./L Amenlc: ~ mg./I. Date of sampla: q/lille,. Parcel ID: 050- '~-':~..~ we, Log (Y/N) Wlres property protected (Y/N) Casing height (above ground) . .~ in. AT INSPECTION Ol~er bacteria B. SEPTIC/HOLDING TANK DATA Tankeize ~r~oo gal Number of Comparlments ~ Foundation deanout (Y/N) ¥ Depression over tank (Y/N) ~ .....,._..,,, . Fluid dept~ in abeoq3tion field before test ~ in. Water added gal. Elapsed Time: /~' min, Final fiuid dept~ ~> in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~ colonies/100 mi. Date Installed I~/I//q~ Cleanoute (y/N) Y High water alarm (y/N) Y Gravel below pipe O, ~ ft. Depression over field /V' For ~ bedrooms New depth ~ in. Absorption rate >= ~'0-O g.p.d. If yes. give date / D. UFT STATION "Pumpon'levelat ~.$ in. 'Pump ofl' level at ~'*~in. E. SEPARATION DISTANCES Manhole/A._-~_ ss (Y/N) High water alarm level at Meets alarm & circuit requirements? in. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankJiiff station on lot 10[, Absorption field on lot JO~ Public sewer main Se~er/septic service II~e I00 On adjacent Iote "/ ~00 On adjacent lots ~ ~00 Public sewer manhole/deanout Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation .~S Water main ~ ~O Wells on adjacent lots ~'{00 Pmpe~'y ilne ~0 Water sewice line SEPARATION DISTANCE FROM ABSORPTION FIELD ON LoT. To: Property ilne tO Building foun.dation I $ water Sen'ice line > ,~ O Surface water ~(/O Curtain drain AJ Wells on adjacent lots 7100 F. COMMENTS G. ENGINEER'S CERTIFICATION I cerUfy that I have determined through field inspec~ons and review of Municipal records that the above systems are/n conformance with MOA HAA guidelines in effect on this date. Engineer's Pdnted Name '-~ ~'/~,~. ~pu~v'~_.l~q.~'~ / HA~ Fee s Date of Payment Receipt Number (Ray. lZt01} Waiver Fee $ Date of Payment Receipt Number Absorp~on field - I0 Surface water Hto Water main '~'11' S ommway, i~lng/Vehlcle ~tomge. 710 T.SPURKLAND P.E. 20.1 WEST ISTtl. AVENUE SUITE 20.1 ANCIIORAGE. ALASKA 90501 (907) 279-3016 Fax (007)276-6013 September 24, 2002 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage AK. 995169-6650 Subject: HAA Lot 2 Block 2 Highland llills PID 050-382-33 Gentlemen; An inspection of this wastewater treatment system on September i I, 2002 showed that the accumulation of solids in the primary chamber was minimal and that removal ofthese solids was not warranted. Yours truly, Municipality of Anchorage Development gervfcff Deplrtment PROPERTY OWNER AGREEMENT FOR THE MAIN'I'I~NANCE OF AN ON-SITE WASTEWATER DISPOSAL SYSTEM This agreement, da[ed , is made b~twoen th-, Murdcipallv/of Anchorage Development Services Deparimcnt (ISSD) and the praperty owner(s) of: This agreement is made/'or thc purpose of malnialning an on-site wmcwater disposal system on the subject property. The properly owners agree to thc following: Submit to the Municipality of Anchorale, on an innuel b~ls, an i~pcct/on and operation statement/'rom n registered pmfeaslonei engineer. Th/s/nspection and opera[lan statcmcm shall vcri~ that the engineer has inspected all effluent t.~ a/r pumps, timers, and alarms, nnd that deficlcnclcghavc been repaired and that the system Is functiordng u designed. (Sign-mr,) ~ ' (Sisn~ture) (Printed N~me) (Printed Name) ,~.$BUILT I HEP. EEY C~'RTIF'Y .'tHAT I HAVE SURVEYED THE F.OLLOWING ~E$CEJBED PROPERTY, ~' ~D ~AT NO ~N~C~HMENTS EXIST ~C~ AS INDICA~D. IT IS THE RES~SIgILI~ OF THE ~'N~ ~ D~ERMIHE THE EXISTENCE OF ANY E~ENTS, COVENA~S~ OR ~tCTl~S WHI~ ~ NOT ~PEAR ~ THE R~ VISION P~T, UNDEA NO CI~CUMST~CE~: 8~ ~NY DATA H~N ~E USED FO~ ~NS~LI~ION ~ FENCE LIN~ OR FOR EST~LISHIN~ ~- ARY LINES. DRAWN~ /! .~t~' CT&E Environmental Services Inc. CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID Sample Rcmarks: 102603500 I Tobben Spurkland P.E. Hi~hland hills #2 L2, B2 Highland Hills #2 L2, B2 Drinking Water 0 All Dates/Times are Alaska Standard Time Printed Date/Time 09/16/2002 14:13 Collected Date/Time 09/I 1/2002 16:20 Received Date/Time 09/12/2002 17:15 Results PQL Units Mc~hod Allowable I~p Analysis Limits D~te Date Init Waters Department Nitratc-N 3.58 0.200 mg/L EPA 300.0 (<ul0) 09/13/02 JDT Mierobiolo~' I~borator~' Total Coliform I OB, No Coli col/lOOmL SMI$ 9222B (<=1) 09112/02 KAP CT&E Environmental Services Inc .... ,- ~. Drinking Water Analysis Report for Total Coliform Bacteria READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE 200 W. Potter Drive MUST BE COMPLETED BY WATER SUPPLIER [~ PUBLIC WATER SYSTEM ID# -- -- -- ~ PRIVATE WATER SYSTEM [] Send I~esults [.~ Send Invoice Anchorage. AK 99518-1605 Tel: (907) 562-2343 561 5301 A~alysts shows his Water SAMPLE to be: U~%s~actor/ [] Sample over 30 hours old. Results may be unreliable. [] Sample too ~ in transit. Sample should not be over lears old fo~ analysis to indicate reliable results. se send a new sample via special deliver~ mail. [] Treated Water ) ,,~_Untreated Water Date Received: Time Received: / ""~ / ~5'"" Analysis Began: [] Send Results [] Bend Invoice SAMPLE DATE: SAMPLE TYPE: ~J~outine [] Repeat Sample (refer to lab no. [] Special Purpose TIme Collected [] Location Collected from: Collected: by 0nltlal): ~ BACTERIOLOGICAL WATER ANAYSIS RECORD Analytical Method: [~Mombrane Filter Sent to ADEC: ANC FBK JUN Date: 'Time: [] Fax Client notified of unsatisfactory results: MMO-MUG Result: Total Colifon'r Membrane Filter: DireCt Count Verification: LTB Fecal Colltorm Confirmation: Final Membrane Filter ResultS: Reported By: Comments: [ (~"~ ~ ~iColl Co,onles/100m, BGB COLIFORM ,C~ c~.~ ~--r.~ (,., ~,~1~ Collform/100ml , ~ ~'-~k.~.. Date:~ ~/(,~k Time: /~'~ { ~' Member of the SGS Group (Soci~t~ G~n~rale de ~rveillanca) -' Property owner ~: ....' ' "" ' ? -- ~Mailing address · ~ : ~ ...~ ~,~.~-" . . ~ Lend. lng age. ncy Da~, phone ' ~Z~,~'-:L,'7~.~ .! '~.~: ............. 'A.14 qq,~7?'/: :~": .... ...... '" Day phon..e - -- ...... '.: ~ .- ..,. : : Address . .- ~' ' -. ' - '" ' ' '" ise req ~st~l, HAA Will be Id fo pick - '" ' ;'" .... ' ' Unless otherw u he r,. up.. , ........ ~ .. ,:; ..' ,,::.'.: .... . , . . :: "N E '- UMB-R .... .., . · ' 2..'. OFBEDROOMS.' " .. ~ .~..,.. -:.. ' 3." :TYPE OF. WATER SUPPLY'.: ' _ ' ' '."-*;..-: ' : Individual ~;_~.weh'~. < ,.. Commun tywell Public water ....................... 'NOTE:- If community wel~ ~YSte~'provide written confirmation'from State ADE~ atte~t2 .: :' ' ' ..lng tO the legali~y-a'n'd status of s~stem.'*-~-,* ' · , . · - · ~,:* - ~ .... . 4. TYPE OF WASTEWATER DISPOSAL~ ~ ' ~ , .... '~' ' ' ,. Individual on-site .:. :.... __. Holding tank Community on-site ~ Public sewer : '" ~'. NOTE:' If community wastewater system, provide written confirmatio~I from S~"ADE~ ~ '.: "-'"' attesting to the legality and status of system. ' ~' -: ' - :'"~: "': ' - . :,. As ce~ by m~ ~1 a~x~ ~o ~d ~ of the validation date sho~ ~..I ven~ that my inv~a~on' of~is H~lth Au~ofi~ Appr6v~ ~pli~tion hbo~ that ~e o~ite w~ersupply - ~ -an~or~aterd~l ~ s~fe, fun~ional and ad~uate for~ num~r~ ~r~ms and W~ ~f ~m~um indim~ heroin. I fu~her ~ri~ that ~ on ~e info~flon ob~in~ from .: . ~he Mumc~!~ of Ancho~ge fil~ ~d from my ~nv~t~gation and ins~on, ~ o~ite ~ter ~ - supply an~orw~d~s~l s~em is in compli~ with all Munici~ and S~te c~, o~inan~, ~d ~ulafio~ in ~ on the date of this ins~ion. ~ - - -. . ~ *Date. . ....~ ~g~n~s ~gnatum · * I O: I ,, ........................ ~. .,. .......... ......... ._.:..__' ...... ~._.. : '..', ~':"DHH~ SIGNORE "" ~ifio~ ~pro~l for ~ms, with ~ foll~' . , .. _. .. ... -* . · ,;; * ~ .... .; : ~*. Add~onN ~m~ ' . ~ Mu~i~i~ of ~'~t'o~*'H~ ~ Hu~ ~i~ (DHHS) ~ ~1~ A~o~ 'Appel ~t~'~ on~ u~'~ ~t~ gi~n In ~g~h 5 ~ ~ ~ i~t p~ ~gl~~ ~ ~S~ ~ ~ ~ DENS d~ ~ ~ a ~u ~d ~r ~i~ !~[~ in ~ ~ ~in ~1 ~d ~ ~ui~ ~ of DHHS do not ~ndu~'J~s ~ ~e.~Om a ~ is ~. ~ Muni~li~ ~ ~c~m~ b not RECEIVED ~fin~i'~ii.ty ~rAfl~fib~§~ OCT 2 S DEPA~E~ OF H~L~ & HUMAN SERVICE~uNIcmAul~ ,ut ~~ En~mnme~l Se~s D~ion ~~ 825 L Street, Room 502 · Anchorage, Ala, s.ka. ggs01 · (907) 343-4744 Health Authority Approval Checklist Parcel I.D.: I A. WELL DATA we, ~ ~. Log present (Y/N) y Total depth I ~ If A, B, or C, attach ADEC letter. ADEC water system number Date completed q['7 / ~'_T, Cased to ~..~.. ~.,~ I Casing height (above ground) D~te of test Static water level 7 FROM WELL LOG Wires properly protected (Y/N) AT INSPECTION Well production g.p.m. ~ g.p.m. WATER SAMPLE RESULTS: Date of sample: B. SEi:ri'IC/I'IOI fliNG TANK DATA Dateinstelled 'O///t/'/'~ Tank$1ze I~o~ Number of Compartmente /=~ Cleanouts(Y/N) . Foundation cleanout (Y/N) y Depression (Y/N) ~ High water ala~n (Y/N) O=,~ P.~no h~ P.,~e~ ~/~ Y C. ABSORPTION FIELD DATA Length ~-,~. v~th E~tecUve .t=o~m area '.,'ZG C~ Fluid depth in absoq~on field before test (In.); Fluid depth r,/- (ins) Minutes later:. PemxMe tma~nent (past 12 mo~ths) (Y/N) rating (g.p.d.flta.e~E~/l~) ~-,,,0 Gravel thickness below pipe ~'" Total depth MonltodngTubepresem(y/N) ~' Dep_m~_~onoverfleld(Y/N) Resu~s (Pa.~.~Fs,) L/ For Immediately after..__~gaL water added (in.): Absorption rate = ..g.p.d. D. UFT STATION Date Installed Manh~e/Accese (Y/N) ~/ High water alarm level at"~-~' ~/~.. Cycles tested '~ e-~)'"' E. SEPARATION DISTANCES Size in gallons 'Pump on" level at* ~. ~ '~ 'Pump off' level at' SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic sen.ice line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation .2..<~ Prol~rty line ,,~ Abson~on field Water maln/sewice line ~'f~O Su~mce water/drainage '/o Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line I Surface water Curtain dmJn ID Building foundation I:~ Water maln/sewice line Driveway, parking/vehicle storage ama Wells on adja~em lots '~ HA~FSe $ Date of Pm~nsm Receipt Number 72026 (Rev. Waiver Fee $ Date of Payment Recal~ Number OC?-22-gg 0~:13 I:RO~,~-¢TE a~l~_- CT&E Environmenta! Services Inc. T°lg3 CT&E Client Name Project Name/# Client Sample ID Matrix Ordered By PWSI~ 995671001 Tobbcn Spuddaad 2:2 Highland HLlls 2/2 Highland Hdla Drinking WaTer 0 Client pO~ Pre-?a~d Colts/.NO3 Primed DatelTime 10/21/99 15:03 Coll~ Date~ime 10/14/99 ~4:45 R~eiv~ ~ateffime 10114/99 17:15 T~al Dire~or: Stephm C. Ed~ TO:aL Cot;tor~ C COL/IOOf. S818 92Z28 ~.~A 0.500 f~J/L EPA ]O0.O 107~3/99 K.Ap lo n~ax 10119/99 101%5199 SCL PROPERTY OWNER AGREEMENT FOR THE IVIAI1NTEN~CE OF AN ON-SITE WASTEWATER DISPOSAL SYSTEM This agreement, dated.~_0 I -0 5- 14'f~, is made between the Muakipality of Anchorage Depxrtment of Heal,h alld Hugl3n Services ~H~) ~d ~c prope~ This agreement is made for the purpose of maintzining aa on-site w~tcwater disposal .......... " system on the subject property. The property owners a~Ixee to th, e folio'Mag: Submit to the Municipality of Anchorage. on an annual basis, an inspection and operation statement from a registered professional engt,,eer. This inspection and operation statement shall verify ,hat thc engineer has inspected all effluent m~d ak pumps, timers, md alarm.s, and that any deficiencies have been repaired md that thc system is functioning as designed. (S,g.amrO ~ (P~bated Name) (Printed Name) ' . ............................. I~:~arize Mere pe'sonall¥ appeared before me, Y whese identity I proved on the bas.~.a of _ whose ldentl'.'t I proved on the bath/affirmation , a credible witness co be the signer of the aboy~ document, and he/she acknowledged that he/sh~ signnd ~otary' Public Ny commission ~xptres MUNICIPALITY OF ANCHOttAGE DIVISION OF ENVIRONMEN~fAL HEALTH DEPAR~I]qEb~F OF fW_ALTH AN[) ENVIRONMENTAL PROTECTION APPLICATION bTDR [~AL!7{ AU'I~4ORITX APPROVAl., CERTIFIOXTE 1, General Inforrmation Application Date (a) Legal Description (include lot, block,, subdivis%o~,~, section, township, range) Location (~dd~ess o~ directions) (b) Applicants Na,m - L-/..5' ~/~{-/t('l~ T~le~hcr~ Applicants Addre~S___ZL(3. ~OX IZ ~:~''~- '~% ~V'! (c)Applicant. is (check one)~.ndin.q Institution ~]i~; Buyer ~; Otl~er L--~j~ (explain); (d) I~nding Institution 'relepho~Te Address (e) I~al Estate Co. & Agent Address Telephone 2o _TyJ2~ of l%asidenc~ S ingle-Famil~i~ Numbe~ of Bedroonm 3. Wate~ Su~ Other (des~'ibe) Note: If cc~mnity %~1.]. system, must have. Ya.~itten confirmaticn frcm tJ~e State Department of Envirop~]~ental Conservation attesting to the [Legality and status: Is the ~11 adequate fez, the numl~r of ~dr~ms s~cified in this [~ ~%~N) 4. ~2~posa~ Onsite~ mblic ~;]] ~mnity [~i Holding Ta~ [[][[1' Is the wastewater dis~sal system adequate for the numkmr of ~dr~ ~) [Page 1 of 2] 2-15-84 5. j~r_~uineerin9 Firm Provid_in_q_~I..nspec____~tions, Tests, Data and Information I certify ti]at I~]e~d~cked, verified~ or confound to all MOA HAA Guidelir~s in effect on the d~..e . _ Address (ENGINEER Signed by [)ate 6. DHEP Approval. Appr ow. d for Appr ov~.d ~ Conditional Terms of Conditional Approval. ~he Municipality of Anchorage Deparbrent of [-balth and Environmental Protection does not guarantee the continued satisfactory perfornmncm of t]~ water supply and/or the wastewater dis~3sal system. %~%is approval indicates that~ as of tim validation date shcvnn a~ov~, based cn t~m data and information furnished by an engineer registered in the State cf Alaska~ the ~.~ter supply and wastewater disposal system is safe and func t ional for the ntun~ez~ of ~edrooms and type of structure indicated. (D~EP SEAL) 7. Mail the HAA to the follcming address: KB2/d5/s [Page 2 of 2] 2--15-84 MUNICIPALITY OF ANCHORAGE (MOA) HFALTH AU%~HORITY APPROVAL (HAA) C[~CKLIST - FEBRUARY 1984 aJ Well Classification ~_~'; ~, Well Log P~esent ~) Total Depth /,~CC) t . Cased to Static Water Level , /'7~- / Casing Height Above Ground - ElectJzical Wiring in Conduit ~,~N) Separation Distances from Well: If A, B, o~ C, D.E.C. Approved(Y/N} /,.~]; __ '~%/~ /~/ ~pth of GroUting Sanit~y ~al on Casing ~) ~pression ~ound ~l~ead (Y~ To Septic/~l~ Tank on Lot ~;~P + ~ ; On Adjoining Lots,, /~ /~ TO Nearest Edge of Absorption Field 79 Lot //~'~; On Adjoining Lots__~_~) [¥ _ To Nearest Public Sewer Li~e ~////~To C leanout/Manhole ~ Nearest :°w~rNe~Z~ %'~%t ~//L wate~ Sample Collected By 5 ~!,~' ~--~ ;"~/'~!;'~ ; Date -~%~--~-~--~ '-~-~/~ Water Sample Test Results SE~IC~ T~ ~TA Date Installed ~'~'~/%~-~.'~ Size 3/d~P(JP ~///~No. of CQ,~nts 'F~ Standpipe ~) Ai~-tight Caps ~) Foundation Cleanout (Y~ ___ ~p~ession o~ Ta~ JY~) Date ~st P~d ~~ P~ing~aintenan~ ~n~act ~ File (Y~) l~; for " - HOlding Ta~ High-Wate~ A].a~ (Y~) ~ ~ra~y Holdi~ Tank ~r~t (,Y~)~ ~paration Distance fr~ ~ptic~ Tank: To Water-Supply Well To Property Line To Water Main/Se~ Course . ! CO, ii,tits To Building Foundation_____~_~__~ To Disposal Field ~5~- / ' To Stream, Pond, lake, o~ Major Drainage [Page t of 2] C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field '~ f ~' ~:~ / Square Feet of Absorption A~ea Depression over Field (Y_~ Results of Last Adequacy Test Separation Distance from Absorption Field: To ter-Supply //3-- To /S'--~ ~' Type of System Design Length of Field ~ co f/ ~-~ Depth of Field ~ / /~ Standpipes P~esent ~) /~/~te of Last. Adequacy Test /~/~.:~u TOLotBUilding F~tion ~-~ /~ ; On Adjoining To Water Main/Service Line ~'//~ To Stream/Pond/Lake/o~ Major D~ainage Course To D~iveway, Parking A~ea, o~ Vehicle Sto~age A~ea Coran~nts To Existing or Abandoned System cn Lots 9~ /~ , To Cutbank ~ i,f~ present) D. LIFT STATION Date Installed Size in Gallons "Pump On"Level at High Water Ala~mLevel at Tested for Electrical Codes(Y/N) Dimensions ///~m~ Off" LeveI at /ff~ Vent (Y/N)' Pumping Cycles du~ing Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request I certify that/I~h.a-~e checked, verified, or conformed to all MOA HAA _Gu~kg~j;~s in effect on the date~of th~ Sj~De~ction, , Signed; Date ~- KB1/d5/s ~,. 'f.~.. ,,,, o. ,..~- '.~" [?age 2 of 2] 2-15-84