HomeMy WebLinkAboutAUTUMN RIDGE TR BAu 'umn Ridg
T act B
#015-054-$$
4~ ] ~
Municipality of Anchorage Page '1 of 3
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
P,O. Box lg6650 Anchorage, AK g951g-6650
www,cLanchorage.ak.us (907) 3437604
ON-SITE WASTE'WATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number:. SW020165 PID Number:. 015-054-33
.Northwood Homes Wastewater System: New
Address:
P.O. Box g2301 Anch, AK 99509 ABSORPTION FIELD
Pho~e. Number of Bedrooms
,694-5890 Five {5) Deep Trench
S<xl Re,rig Toial Dep~ fro~ o~g~nat
LEGAL DESCRIPTION 1.2 GP~e 10
Tract B Autumn Ridge 3 FI. 7
TownsJ~ip: Range: Settlor1: Fdl ad(ted at3ove ong~nat grade: Graw*l Length:
Well: Private 3 F,. 1 I'
Class~cah~l (Private, A, I~. C): To(al Depth: Cased to: Total ab r,o~phon erea. P,pe Mate~at
Private 360 Ft. 350 ~t 714 Fe ASTM D3034 PVC
Aloine Drilling 6/12/02 145 F, Sanders & Sanders 6/28102
SEPARATION DISTANCES [] Septic [] Holding [] S.T.E.P. I-'1 Other.
Septic Absorptior Lift Holding 'ubflc,~rlvate Anchorage Tank 1,500
Tank Field Station Tank Sewer Une
w,, >100' >100' NIA N/A >25' Steel Two (2)
s...~.water >100' >100' NIA N/A ~ / LIFT STATION - NONE ON LOT
c.~. ~... None Noted
Garage Floor Slab
100.0 FL
~ Engineer's ~tamp
Inspections performed by: MEA Dates: 1= 6/28/02 ' ·
Department of Health and Human Servicj~s approval
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage. AK. 99519-6655 - 343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number:. SVV020166
Page 2 of 3
PID No. 015-0,54-33
/
f AJtemate Site-
/,z ,
/ /%4,
C6 C5
/ c4
20' Trail Easement
S1
S2
C3
C6
M1
A
63.0
69.5
80.0
115,0
173,0
B
43.6
54.1
63.5
100.9
165.0
C3
S2
S1
1.500 Gallon
Septic Tank
Well
r~
<f
0
PLAN AS-BUILT
SCALE 1" = 50'
Municipality of Anchorage
Department of Health and Human Services
825 'L' Street
P.O. Box 196650 Anchorage. Alaska 99519-6650
Rk-.k Mysttomht~Jtwww.ct.a nchorage.ak.us
Mayor
Permit Number: #SW 020166 Date of Issue: 6-12-02 Parcel Identification Number: 015-0,f,4-33
Date Started: 12-1-02 DateCompleted:~ lswelllocatedatapprovedpermit location?[] Yes [] No
Legal Description: Aufumn Ridcle Tr B
Property. Owner Name &.addr~,.' Notthwood Homes PO Box 92301
_ .An~c. horage, A;aska 99509 .,,,
Method ofDrilllng [~] aitzotaxy [] cable tool
Borehole Data: Depth (trt)
Soil Type, Thickness & Water Swam From To
stick-up 0 2
fill matedal 2 34
gravelly silt 34 241
sandy sil~y gravel H20 241 256
silt 256 267
7ravel(y sift 267 339
silty water sand & gravel 339 360
You'v~ Just Given Me An Eg[~llll® Headach~
Caning type: steel
Wall Thielmess: .250 inches
Diameter:._6 inches Depth: 350 feet
Liner Type:
Dizme~er:. ~ inches Depth:
Casing sfickup above ground: 2 feet
fee[
Static water levd (from ground level): 145 feet
Primping levek_240 feet after
_2 hours pumping 15 gpm
Recovery Rate: 15 gpm
Method of Testing: aiF lift
Well Intake Opening Type:
I'-] Open End [] Open Hole
[] Screened Start feet Stopped feet
[] Perforations Start 245 feet Stopped 255 feet
Groat Type: ~entonite #8 Volnme: ] bg
Depth: Start 0 feet Stopped ~ feet
Pump: Intake Depth feet
Pump size , bp Brand Hame ~
Well Disinfected Upon Completion? [] Yes [] No
Method of Dislnfeetion: chlorinq..t..ablets
Commen~:
Well Driller. Alpine Drilling & Enterprises
PO Box 11O496
.Anchorage Alaska 99511
Attention: Thc well driller shall pmvi& a well log to the property owner within 30 days of completion and the pwperty
MUNIClPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT
Initial
Date Issued: Jun 12, 2002
Expiration Date: Jun 12, 2003
Permit Number: SW020166
Legal Description: AUTUMN RIDGE TR B
Design Engineer: 0014 Anderson Engineering
Owner Name: Northwood Homes
Owner Address: PO Box 92301
Anchorage. AK 99509-
Parcel ID: 015-054-33
Site Address: 009370 BIRCH RD
Lot Size: 116338 SQ. FT.
Total Bedrooms: 5 Permit Bedrooms: 5
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. 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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By: ~~"--, v(v~ {~ ~- ~ ~, Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWEPJVVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O1~'"" '~,~'Z/-- ~,'~
Permit Number SWOZO/66
Properly owner(s). Northwood Homes
Mailing address (1) P.O. Box 92301 Anchoraqe, AK 99509
Mailing address (2) Zip Code
Legal description (Lot, Block & Sub'd.) Tract B, Autumn Ridqe Subdivision
Legal description (Section, Township & Range)
Size //b I ~O¢¢ Acre~ Number of Bedrooms Five
Lot
(5)
Day phone 694-5890
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
E] Well Only []
[] Water Storage []
[] Jacuzzi []
[] Water Softening Unit []
I cedify that the above information is correct. I fudher certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
II
Permit Fees: -L'jt'O O
Date of Payment:
Receipt Number: ~-- ~'~ "~
(Rev. 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
ANDERSON ENGINEERING'
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 ' ' 522-6779 (FAX)
June 4,2002
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject:
Tract B, Autumn Ridge Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Tract B, Autumn Ridge Subdivision intends to construct a new six-
bedroom home on the lot. We are therefore requesting a permit be issued for the'
constuction of a well and septic system to serve the new home. The attached Site Plan
and backup documentation identify the location and configuration of the new septic
system and the parameters used in the design. Also identified on the plans are the
location of the proposed 'well on the lot, test hole locations and the locations of existing
wells and septic systems in the area. Drainage contours are also shown and current
drainage patterns will be maintained after construction. The lot is composed primarily
of fill material, but the absorption trench will be placed in native ground at the base of
the fill slope.
The test holes placed near the location of the proposed absorption trench and alternate
site indicated poorly to well graded gravel with some silt and percolation rates of less
than 1 minute per inch. No groundwater was found during the placement of the test
holes and none was noted during the high water period. We are therefore proposing to
place a 3' wide by 45' long by 7' effective depth absorption trench on the property. The
total depth of the trench will be 10'. The distribution pipe will be placed at 3' below the
ground surface.
The ground surface on the lot slopes as shown on the attached Site Plan with a fairly
steep slope from the top of the fill to the location of the absorption trench. The new
absorption trench will be constructed in conformance with Municipal requirements and
parallel to ground contours where possible. All components of the new septic system
will be constructed a minimum of 100' from the well on the lot and those in the area and
10' from the service line from the well to the house.
If the system is constructed in accordance with our design the following statements
apply:
Tract B, Autumn Ridge
June 4, 2002
Page Two
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
o
The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
I1~ I~q.ft.
49th
T I
<ON
Z
AREA SYSTEM PLAN"
SCALE 1"-- 100' .- · -
TRACT B
AUTUMN RIDGE SUBDIVISION
· ...... .... !.. . ~:, ' . · -.,.-. .. : .. .. , . . ' :~__
NOTE: No Conflicts With Wells or Septic
Systems on Neighboring Lots.
SITE PLAN
SCALE 1" = 50'
TRACT B, AUTUMN RIDGE SUBDIVISION
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Six Bedroom Home
Perc. Rate: LT 1 Min./Inch
Avg. Application Rate: 1.2 GPD/SF
Deep Trench System
1,500 Gallon Septic Tank
7' Drain Field Rock
6 Bedrooms X 150 GPD 11.2 GPDISF = 625 SF of Absorption Area
625 SFI14 SF/LF = 44.6 LF Trench Length
Therefore: Construct an Absorption Trench 45' in Length by 3' Wide With 7' of Drainfleld
Rock Beneath the Distribution Lateral. Distribution Lateral to Be Placed 3' Below Existing
Ground. Total Depth of Trench to Be 10' Below Existing Surface. Cover Over Septic Tank
a Minimum of 4' or 2" of Insulation and 2' of Cover.
2.5'
.5'
Geotextile
Fabric
7.01
'4" Perforated. PVC
Schedule 40
Dra~nfie/d Rock
NOTE:
TYPICAL DEEP TRENCH SECTION
(NO SCALE)
Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 10' From Lot Line.
Minimum 4' Separation From Groundwater.
Minimum 100' Separation From Wells in the Area.
Minimum 10' Separation From Water Service Line.
· Performed Fo~ Bob Klein
Legal
.1
2
3
4
.
10
~12
14
16
17
18
19
Description: _Tract B. Autumn Ridge Subdivision
SLOPE
PTIOL
· ~-' ~'~. ........~.~
Depadment of Heal~ & Human Se~s ~~.~.f.~ ' ·
825 L S~t, ~chorage, AK ~502~650 ~ ~ ~,~.~ .. -
SOILS LOG- PERCO~TION ~EST ~* ~',,
' Date Ped~ [, ~1~/~ g- .
SITE P~
GP/GM
12% - 18%
Silt
Vas Grour~dwater .- ·
Encouhtered? -
· Ill Ye~,'What Depth?.
Depth to Water
After Monitoring
Date: -
No S · · '. : """
.L
'N<~h~-' ' P "·
1/22/00 E
Reading. D~te . Gross, Net Depth To Net
· '" Time "- Tir~e Water' Drop '.
-. I 11'Dec 11:39 [ '. .2". · .'
· 2 11:44. · 5 .10.5" .- 8.5"
· 3 , 11:45 - 2.25- .- .
: 4'.' 11:50 5 .10.75" ..'8.5" .
5 11:51 2" "'.
· :- 6 -' 11:56 5 10.5" ' 8.5'
Perc. Rate: LT 1 MinJInch :' Perc. Hole Diameter:
Test Run Between 5 Ft. and 6 Ft. '
Bottom of
Hole
Comments: Percolation Cavity Presoaked Prior to Testing. ' .... · ·. ' ' '
Performed By: A- Harala. ' I, MicJlAeLE_A3d~z~ :.Certif3; That This Test Was Perf0rme(J
In Accordance With All State and Municipal Guidelines In Effect On This Date: .t/20/00
· Municipality of Anchorage
Department of Health & Human Services
825 L street, ,~chorage, AK 99502-0650
SOILS LOG - PERCOLATION TEST
Performed For: [~ob Klein '
Legal Description: Tract B. Autumn Ridge Subdivision
SLOPE
PTIOL
GPIGM
12% - 18%
Silt
G~'0und
. Water
Bottom of
Hole
Was Groundwater .......
Encountered?. .Ye~; -- '
I If Yes, What Depth? · - 10'..'
Depth to Water ·.
After Monitoring . 10' ' '
Date: "I,'22/00 '.
S
L
'11
12
13
15
16
17
19
Rea. ding Date Gross Net · ' Depth To Net ..
Time . Tim(i':' Water ' Drop
'1 : 11-Dec 1:20 " 2'.. '
: 2 1:22 "2 10.5". "8.5 ....
· 3 .- 1'.23 2.25' '.
· '..' 4 1:25 2. 10.75" · 8.5"
5 ' 1:26 · 2".
~6 '1:28,· "' 2 -. 10.5". -'8.5'
Perc. Rate: LT 1 Min./Inch Perc..Hole Diamete'r: 6'
Test Run Between 5 Ft. and 6 Ft.
Comments: Percolation Cavity Pre,~oakod Prior to Testing. . - :.., · · "- :
Perform~:iBy:'A. Harala. .I,'~-/ I -..- ,.- :- Cedify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect on This Date: ' 1/20/00 '
· Performed For:. Bob Klein
Legal Description: Tract B_ Autumn Ridge Subdivision
SLOPE
1 PT/OL
3
Was Grouhdmter '
Enmuhter~? No S -
Gray 'Dop~toW~t&r ' . O ' : ..
Date: .. ' a~t00 fi .....
12
Reading Date Gross ·: Net ' Depth To.. Net ' ,.
· . Tir~"" Time · Water· · Drop . ''
1 7-Dec. 3:15 . .. · .. · .3.5, J ·
.2 3:17 .2 . . 9.5" 6' -
3 · 3:18 .:3.5'' , - ·...'
· . 4. .. 3:20 2 . 9.5'..- ' 6' .
5 .' '. 3:21 3.5" ' .'-'.
6 .' 3:23. .2 · ' . 9.5",. 6"'
.Bottom of ·. Perc. Rat~: LT 1 MinJInch ' Perc. Hole Diameter: 6" . -
Hole Test Run Between 4 Ft. ~nd 5 Ft. . ' "
Comments: Percolation Cavity Presoaked prior to Testing. : . . .
· Performed By:' A. Harala. I, - ' ;-: -. - ' certify That This Test Wa; Performed
· In Accordance With All State and Municipal Guidelines'In Effect On This Date: 1/20/00
.:13
' ...
" · ' ' ~ ~o~H ,:,.~;~ =~' ~
Muni~pal~ of ~chomge ,~ .~.~ '~'~'~ ~'
·. . ~'~ . ~. ~ H~RSON ' ~
Depaffment of H~Ith & Human Se~es ~, ~,.?o~ =t~ t. ~_. : ~,
825 L Strut, ~chomge, AK 99502~ ¢~ ~... Cc .-';~ ~
- SOILS LOG - PERCO~TION TEST (~. ~;rp · ...... _~:~ ~- .
Peffo~ F~: ~b ~ein · Date P~m~: 1~/99- .
L~ Description: T~ct B. Autumn Ridge SuEdivision
SLOPE ' SI~ P~'
- ':. Was Gr(~ndwater .... .
9 .... Encounte['ed~'. :' :.No.' -. S ' - ·
" If Yes, What Depth? L
- '. Depth to Water O ' '
^fferMonitoring '': Rone" P ' " .... '
" Date: - ll2Zt00 - _~= ' ' : '"
Reading Date ' Gross Net. Depth To- Net ·
Time" Time' Water . Drop
1. 7-Dec 2:14 3.13" ~ . '
2 : .2:16 2 .10" 6.87"-
3 .., 2:17 3.25' · ...
4 2:19 2 .10t · 6.75" '
5 ' : 2:20 3.25"
· . 6 .... 2:22 , 2 .. 10" 6,75',
GWIGP
19 Bottom of: Perc. Rail: LT 1 Min./Inch Perc. Hole Diameter:. 6" '
Hole - Te.~t Run Between 4 Ft. and 5 Ft ....
Comments: Percolatio.n Cavity Presoaked Pri6r to TeSting. - "
Performed By:,/~: Harala. I, i · : -- .- . Cedify That'This Test. Was Performed
In Accordanc~ With Ail State and Municipal Guidelines In Effect On This Date: 1/20/00" ~
Performed For: Bob Klein
' "~ (o..' ~-" "~' "
." ' .,.'r~ · ,,ttQTH.
Municipality of Anchorage '~ ........................
Department of Health & Human Services
825 L Street, Anchorage, AK 99502-0650 ~,~,'.. CE - 43
. ,~.~ . ..¢~
· SOILS LOG - PERCOLATION TEST c,. ¢.' .. . ,.-~ ,
· Date Performed: 12/'5199,
Legal Description: ]'Fact B. Autumn Ridge Subdivision
SLOPE
I PTIOL
4
5
6
./'7
Trace
ML'-
.-
'9
10
.11
'12
-.
.13
Was Groundwater ,. ,.
' Encountered? No
· If Yes,.What Depth? ·
DePth to W~ter
After. Monitoring . None
Date:
'lP_?J00
Bottom of ....
:. '... :- "...· ..'Hole
.16
17
18" .: ·'. :... .
19
S
'L
O .'."
Reading Date Gross Net'. Depth To Net
'Qme Time Water D~op .....
Perc: Rate: No Pe~;c.
· .'Comments: No Percolation Test Perfo~'med ' "' '"
· 'Pe~'c. Hole Diammcier. '"
Performed By:..A. Harala. "' ' I, i ~, -. -' ' Cedify That This Test Wa~ ib6rform~d:'
· In Accordance With gll §tare and Municipal Guidelines In Elfeet On lhis Date: - '1/20/00'
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: TRACT B, AUTUMN RIDGE SUBDIVISION
GENERAL:
The scope of this project includes the procurement and placement of a
new 1,500 gallon septic tank at the location shown on the Site Plan.
The project also includes the construction of a new 45' long X 3' wide
X 7' effective depth absorption trench at the location also shown on
the Site Plan and at the configuration shown. The distribution line in
the trench will be placed at 3' below the existing ground surface. Total
depth of the trench will be 10' below the existing ground surface. The
new absorption trench and septic tank must be placed a minimum of
100' from the well on the lot and the wells on adjacent lots and 10'
from the water service line between the well and the house.
Intef~[-~ediate cleanouts will be required between the septic tank and
absorption trench as the distance exceeds 100' and traverses a fairly
steep slope.
Construction shall be in accordance with the .approved site plan,
design drawings, Municipal Permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater
Disposal Regulations.
The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the
location of all lot lines.
o
Unless specifically agreed otherwise, the contractor shall be
responsible l'or final grading areas subsequently dopress~d from soil
settling. Property owner shall be responsible for revegetation of
affected areas unless specifically agreed otherwise.
o
Contractors installing wastewater disposal systems must be certified
by the Municipal Department of Health and Human Services for
system installations. Owners installing their own systems must receive
prior approval from D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
1. The newl,500-gallon septic tank must be procured from an approved
source and installed at the location shown.
A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts for pumping
access.
3. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
4. All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
Tract B, Autumn Ridge
June 4, 2002
Page 2 of 3
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct
burial insulation.
o
A foundation cleanout shall be installed one to four feet from the
building foundation. Two cleanouts are required between the tank and
the drainfield.
7. Final grading over the tank shall be such that a positive slope exists
away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown on the
design. The bottom of the trench shall be within 2" of level.
Distribution piping must be placed level with perforations down atop a
level bed of drainfield rock. Rock should then be placed over the pipe
to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between the drainfield
rock and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated.
o
Contractor shall redly the septic tank and drainfield are a minimum
100' away from any private water wells in the area, 150' from a Class
"C" Well or 200' from any community well.
o
Direct bury insulation must be placed over the distribution system if
less than 3' of backfill depth is available. Finish grade over the trench
must be mounded to prevent ~"'
s~,,,e,,,e,,, or depressions.
7. Grade area surrounding the absorption trench to drain away.
A minimum 2' of accepting soil is required below the drainfield rock for
a 5' wide trench. Contractor shall vedfy this condition pdor to
placement of the rock. All pockets of unacceptable materials must be
removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a municipally approved septic
tank manufacturer,
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated
and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and
ASTM D2662 or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
Tract B, Autumn Ridge
June 4, 2002
Page 3 of 3
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Femco, or equal).
5. A permeable geotextile fabdc (Typar, Mirafi or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing
the #200 sieve.
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These
inspections must be conducted under the supervision of a professional
engineer registered in the State of Alaska. The first inspection must be
conducted after the excavation of trenches, beds or pits and before the
installation of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement of the
geotextile fabdc, gravel, distribution piping, standpipes, cleanouts and
insulation. No backfill should be in place at the time of inspection.
Contractor shall provide a copy of all field survey layout and construction
notes for use in preparing the certified as-built of the completed system.
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-054-33
Legal description AUTUMN RIDGE TR B
Site address 9370 BIRCH RD Anchorage AK 99507
Expiration Date: C/ 1-/* -2D Z 3
Current property owner(s) DAM REVOCABLE TRUST 2019 50% &MWM REVOCABLE TRUST 2019 50%
X The On-site system(s) is/are approved for 5 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
Original Certificate Date: 7/7/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory X Arsenic Advisory
Other
COSA Approval_June 2022
MUNICIPALITY OF ANCHORAGE
tEry"
Development Services Department
On -Site Water & Wastewater Section
Phone: 907-343-7904
Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERALNF��k
I ORMATION
Parcel I.D. 015-054-33
Complete legal description AUTUMN RIDGE TRACT B
Location (site address) 9370 BIRCH ROAD, ANCHORAGE, AK 99507
Current property owner(s) MEEKER REV. TRUST... Day phone
2. ON-SITE SYSTEMS SIZED FOR 5 BEDROOMS
3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ® Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 21 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ® Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ SYD p Waiver Fee $
Date of Payment (o 2 /Zo 2- Date of Payment
COSA # oS c Z3 121 Waiver #
P/ o '(?--Vs V- r -,r -Y_ / S � 20 2 3
COSA Applicalion.doc
COSA Checklist
Legal Description: Autumn Ridge Tract B Parcel ID: 015-054-33
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled 5-12-02 Total depth 360 ft
Cased to 350 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) > 24 in.
Date of flow test for COSA 6-14-23
Static water level at beginning of test 216.7 ft.
Comments
B. TANK DATA
Measured operating fluid level in septic tank 48"
Date of pumping 6-16-2023
❑ Required maintenance completed, if AWWTS
Comments: No AWWTS
D. ABSORPTION FIELD DATA
Which system tested (date installed) 2002
® ALL standpipes present per record drawing
Total measured depth from grade 11 ft (max)
Measured depth to pipe invert from grade4!fft (min) ❑
N/A — pressurized field. q --P
❑ Per record drawings, field is insulated.
® Monitor tubes (MT) go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) None
If yes, enter date
Well production at time of test > 7 qpm
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® No
® Coliform bacteria is Negative
Nitrate 3.28 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
Collected by Tim Ecklund Date 6-14-2023
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments: No Lift Station
Adequacy test date 6-14-2023
Results f g Pass
Fluid depth prior to test 0 in
Water added 1050 gal
New fluid depth 6 in
Elapsed time 20 min
Final fluid depth 0 in
Absorption rate >750 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 84 in
Effective depth used 0 in
Effective depth remaining 84 in
Comments/Deficiencies: Approximate total measured depths from existing grade.
COSA Checklist.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
® Yes if No ft ® Yes if No
Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No
Iii
ft
Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' ® Yes if No ft
® Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ®Yes if No ft
— ®Yes if No ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No
Tank to Property Line > 5' ® Yes if No ft Wells on Adjacent Lots:
Field to Property Line > 10' ® Yes if No ft
Water Main > 10' ® Yes if No ft
Water Service Line > 10' ® Yes if No ft
F. ENGINEER'S COMMENTS
Private Wells > 100' ® Yes if No
Community Wells > 200' ® Yes if No
If tank or field is under driveway comment below
Well production is very good. Absorption Field is very good Septic Tank is 21 years old
I
6
ft
ft
G. CERTIFICATION & 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 Certificate of On -Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING
Phone 907-350-9566
Engineer's Printed Name CURTIS HUFFMAN, PE
Date 6/26/23
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the in land
,,�".
�° • • ' • •
surface, changes use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
• . .
�•� ••
construction (workmanship & materials), the water usage of the family being served by the
/�
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the..
, , , , , • • • ,
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting & (It S
Curtis Huffman
�'c�'••. CE 128991 .4`y
. Am
cl`��F •
. 6/26/23. AP , ®
FD pROFESSI4�A�'.�®
COSA Checklist.docx
www.muni.org/onsite
Septic Wank Advisory
Certificate of On -Site Systems Approval # OSC231213
Subdivision: Autumn Ridge . 7"'ract B
The septic tank for this property is 21 years old. The average life of an asphalt
coated steel septic tank is 20 years. Typical replacement costs are $10,000 or more,
not including engineering, surveying or MOA permitting fees.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
This is an example of what the metal of a 30 year old steel tank MAY look like.
MailiriJg Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muri org
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904 5 .: r C T .
Certificate of On -Site Systems Approval
Parcel I.D. 015-054-33 Expiration Date: "! l9 "Z�% �-
1. GENERAL INFORMATION:
Complete legal description Autumn Ridge: Tract B
Location (site address) 9370 Birch Road *Anchorage, AK 99507
Current Property owner(s) Rock & Johnna Reber Day phone 907-748-3500
Mailing address 9370 Birch Road *Anchorage, AK 99507
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community (]
Public Water System ❑ Public Sewer []
Waiver/Variance request for:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ $412.50 (COVID-19) Waiver Fee $
Date of Payment/Z/,-�z,-)
Receipt Number 05ZCt 2 Cr
COSA # OSC201676
Date of Payment
Receipt Number
Waiver #
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,
based on procedures outlined in the Certificate of On -Site Systems 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 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: Garness Engineering Group Ltd (GEG)
Address: 3701 East Tudor Road Suite 101- Anchorage Alaska 99507 _
Engineer's Printed Name: Jeffrev A. Garness
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system
in accordance with the guidelines and regulations established by the Municipality of Anchorage and
industry practices. The reported results describe the condition of the system/s on the dates of the
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or
encroachments may exist that were not identified during the evaluation. The operational life of all wells
and septic systems depend upon a variety of variables, including but not limited to, soil conditions,
groundwater levels (that may fluctuate during the year), quality of construction (materials and
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of
the well or septic system. GEG makes no representation whether an alternative well or septic system
can be installed on the property in the event either of the current systems fail to perform adequately in
the future. The content of this report is for the sole benefit of the person/party that retained GEG to
perform the evaluation. Reliance upon the information provided in this report by any other person or
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
6. DSD SIGNATURE
System #1 Approved for 5� bedrooms
System #2 Approved for
Disapproved
Conditional approval for
bedrooms
bedrooms, with the
Phone: 907-337-6179
Date: !t) � _ C
f'�^y "arnrr.
cy
a;
#AECC884
P�\Iy OF(,gr�,
ON-SITE
WATER AND m ^_
r tpIS`V•'ATER z^
PROGRAM
l
B � Original Certificate Date: 2'
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given In paragraph 5 by an independent professional civil engineer registered in the Stale of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist_ Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet70.70.12.doc
COSH Checklist
Legal Description: Autumn Ridge; Tract B Parcel ID: 015-054-33
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
0 Well log is filed with Onsite (or attached)
Date drilled 9112102
Total depth 360 ft
Cased to 350 ft
n Sanitary seal is functioning correctly
0 Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 9/1/20
Static water level at beginning of test 218.1 ft.
Comments
B. TANK DATA
Age of tank(s) 18 years
Tank type/material
Measured operating fluid level in septic tank 48"
Standpipes/foundation cleanout per record drawing
Date of pumping 5/4/20
D. ABSORPTION FIELD DATA
Which system tested (date installed) 2002
M ALL standpipes present per record drawing
Total measured depth from grade 10.6E ft (max)
Measured depth to pipe invert from grade 4.16+ ft (mut)
❑ N/A — pressurized field
I� Monitor tubes go to bottom of effective. If not, state
depth into effective
F Code -required soil cover over field
A System presoaked
(Required if vacant for greater than 30 days prior to
date of test) "2043
Gallons introduced gallons
Comments/Deficiencies: 'Pre-soaked on 911/20
COSA Checklist yellow sheet
Well, production at time of test 7.0+ gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes A No
R Coliform bacteria is Negative
Nitrate 1.43 mg/L ❑ Nitrate less than MRI. (ND)
Arsenic ug/L ®❑ Arsenic less than MRL (ND)
Collected by GEG, LTD.
Date of Sample 7/7/20
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments.
Adequacy test date "9r2no
Results F,/ -]Pass For 5 bedrooms
Fluid depth prior to test 0 in
Water added 758 gal
New depth 8 in
Elapsed time 30 min
Final fluid depth 0 in
Absorption rate 750+ gpd
Any rejuvenation treatment (past 12 months) 110
If yes, enter date n/a
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if fess than required or if community well)
Septic Tank/Lift Station on Lot > 100'
®
Yes
Community Sewer Manhole/Cleanout > 100'
❑✓ Yes
if No
ft
❑✓ Yes
if No ft
Neighboring Tank > 100' M✓ Yes
if No
ft
Private Sewer/Septic Line > 25' 1771 Yes
if No ft
Absorption Field on Lot > 100' P� Yes
if No
ft
Holding Tank > 100` ❑✓ Yes
if No ft
Neighboring Absorption Fields > 100'
Q Yes if No ft
Water Main > 10'
Animal Containment > 50' F�' Yes
if No ft
[771 Yes
if No
ft
0 Yes. if No ft
Water Service Line > 10'
F/�
Yes
if No
Manure/Animal Excreta storage > 100'
if septic tank is under driveway comment below
Community Sewer Main > 75' 17, Yes
if No
ft
E] Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
®
Yes
if No
ft
Surface Water> '100'fes]✓
Yes if No ft
Property Line > 5'
1771
Yes
if No
ft
Wells on Adjacent Lots:
0
Absorption Field > 5'
Fv
Yes
if No
ft
Private Wells > 100'
Q Yes if No ft
Water Main > 10'
i/✓
Yes
if No
ft
Community Wells > 200'
0 Yes. if No ft
Water Service Line > 10'
F/�
Yes
if No
ft
if septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
U
Yes
if No
ft
if absorption field is under driveway comment below
Property Line > 10'
F71
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
0
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
Q✓
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100'
Q
Yes
if No
ft
F. ENGINEER'S COMMENTS
*Met code at time of installation
G. ENGINEER'S CERTIFICATION
I certify that 1 have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
COSA Checklist yellow sheet
Orr !x
......�.
,Ja�f.,r// cy A. Gcrriess,
79,53
e ssiC�t��. .
MECC884
£i55-54£
L0566 )IV'39VHOHDNV
3AI110 )AA01 0 60£6
9NIAMWIS ONVI 110H
95-50? 9J 66961
0Z0Z f7n1
30 AVO HI El SIHl V)ISVIV`3E)WOH7NV 1V O31V(l
'O310N NVH1 N3H10 1SIX3
SiN3WH3VONDN3 31SISIA ON ONV S3NIl Ala3dOVd 3Hi
NIHIIM HV NOR3H1 O31Vf11Is S1N3W3AOUdWI 319ISIA
3H1 1VH1 ONV `V)ISVIV `1JIdiSIO 9NION0D3H 39V'dOHDNV
(E6l-IOOZ1V7d) 9nS3DGIYAtWn1l7V 8L7Vb1
Ala3dONd O3SIN3S3O 9NIM01101 3H1 d0
A3Avns V 03WN032l3d 3AVH I 1VH1 A3I12l3J A93a3H I
MVU SIH113S Sa3NHO3 ON
A3Ac/ns17117GSV
Isuoissal o��0
1"lOH "V 3NVHS
301 HO/ONVMON53A/5S30X3013/]031VW/XONddV3GA NW NO3H3HAIM OHS JN/AVdAAW
51N31Y3110NdHl 7VN011/OOV NO/11SOd LO S3Nf7,UU3d02/d
3N1Yt1313001035173BO1.LON3tlV.'JNIMVt/OS/Kl N01/V3ddV,SViY1VFLL 53N1730N3d .310N
(Oat VO1ON/SS37Nn) NO3H3H
AMOHS 10N3UV. L V"7d QN0032 /3H1 MO.ONR/63ddV380H1 AWU F13H10 bN003F1d0sW.7n3SV3
53An30N3)HO S1N3iY3A0YdNl "53F1R10nHL, 7VNOLUOOV!7N/NOLUSM2/OdO3Sn3B0110N
SIONV 'S1,V31Y35V3t10/ONVS3Nr7107 031LV7d ONV53Nn1JnF1LSJNl[5/X3N33ML3BS10IZdN00
.iNVMOH501,(77VJ/dL03dS5NOLUl1/1SNLJN/ON37d035n3H1 LOjS/N032/3HNO11MN2/OdN/3H1
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A ,SINGLE FAMILY DWELLING
Parcel I.D. 015-054-33
GENERAL INFORMATION
Expiration Date:
Complete legal description Tract B, Autumn Ridge Subdivision
Location (site address or directions) Birch Road near Abbott Road
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Northwood Homes
P.O. Box 92301 Anchorage, AK 99509
Day phone 694-5890
Day phone
Day phone
Un/ess otherwise requested, HAA will be held by DSD for pickup.
2.. NUMBER OF BEDROOMS: Five {5)
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] . Indivi.~.u~l On-site []
[] Individqal Holding tank []
[] CommunityOn-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 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 pdvate or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reis.~ued 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
Se
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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. I further vedfy 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 cemp~iance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm Anderson Engineednq
Address P.O. Box 240773 Anchoraqe, AK 99524
Engineer's Pdnted Name Michael E. Anderson. P.E.
Phone 522.7T/3
Date 2/12/2003
DSD SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Attachments: HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreeme.~..~
Supplemental Enging~r's Report
Other · .i
Original Certificate Date: 2 ///-/-/~" ~
! /
(Rev. 1 ?JO0)
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
~w~w.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:. Tract B, Autumn Rid,qe Subdivision
A. WELL DATA
Well type Private
Date completed 6/12/2002
Total depth .360 ft.
If A, B, or C provide PWSID # ~
Sanitary seal (Y/N) Y
Casedto 350 lt.
FROM WELL LOG
Data of tast 6/12r2002
Static water level t45
Well production 15
WATER SAMPLE RESULTS:
Coliform /-> colonies/lO0 mi.
Date of sample: '~-/,/z~ ~
B. SEPTIC/HOLDING TANK DATA
Tank Type/Matarial SeptldSteel
Tank size t,500 gal.
Foundation cleanout (Y/N) Y
Date of pumping
C. ABSORPTION FIELD DATA
Date installed 6/28/2002
Length 5t
Total depth tt It.
fL
g.p.m.
Nitrate /, %7 mg./I.
Collected by:
Parcel ID:
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground). >.2
AT INSPECTION
g.p.m.
Other bacteria 0 colonies/lO0 mi.
Number of Compartments _2
Depression o~,er tank (Y/N) _N
Pumpei' N/A
Date installed 6/28/2002
Cleanouts (Y/N) Y
High water alarm (Y/N) N
If yes, give date
Date of adequacy test Results (Pass/Fail)
Fluid depth in absorption field before test ~ in. Water added
Elapsed Time: ~ min. Final fluid depth in.
Any rejuvenation treatment (pest 12 mo.) (YIN & type) N
Soil rating (g.p.d./ft= or ~/bdrm) t2 GPD/SF
ff. Width .3 ft.
Eft. absorption area 714 ~ Monitoring tube Y
System type .. Deep Trench
'Gravel below pipe. 7 fL
Depression over field N
For bedrooms
gal. New depth in.
Absorption rate >= g.p.d.
LIFT STATION
Date installed Size in gallons
'Pump on' level at in. 'Pump off' level at in.
Datum Cycles tested
E. SEPARATION DISTANCES
Fe
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lilt's',~tion on lot >100'
Absorption field on lot >100`
Public sewer main H/A
Sewer/septic service line_..J~t/A~ )' 7~' /
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
On adjacent lots >t00'
On adjacent lots >t00'
Public sewer manhole/cleanout N/A
Holding tank
Absorption field >5.
Surface water >t00'
Property line >5'
Water service line >10`
Building foundation >5.
Water main >t0`
Wells on adjacent lots >100'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Water main >t0.
Driveway, parking/vehicle storage >25'
Property line >10'
Water Sewice line >10'
Curtain drain None Noted
COMMENTS
Building foundation >fO'
Surface water >100'
Wells on adjacent lots >t0~
in.
G. ENGINEER'S CERTIRCATION
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 Michael E, Ander~on, P.F-
Date 2/12/2003
HAA Fee $ ..~ 7-5-"o ~ ~
Da= of P ment / o
Receipt Number '-~ / '~ '~...~"'
(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number