HomeMy WebLinkAboutMUIRWOOD PARK BLK 4 LT 8Muirwood Park
Block 4
Lot 8
#011-422-85
'-.:;'" '~ Municipality of Anchorage Page ! of 3
Development Services Depadment
On-Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ct.anchorage,ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW020344 PID Number: 011-422-85
Crown Pointe, Inc. WastewaterSystem: New
AddreSs:
5400 Abbott Road Anch. AK 99507 ABSORPTION FIELD
345-6277 Five (5) Deep Trench
LEGAL DESCRIPTION 1.2 o,o~¢ 3.0
4 8 Muirwood Park 3 F,. 7
3. F,. 46 F~.
Well: Municipal Water System c~a,~,.~m: 3 Ft. mmb.~o.,.es:3. [[~st~ b~,..~,..:.
Ft. Ft.644 Ft' ASTM D3034 PVC
Ft. Sanders & Sanders 9/3.7/2002
yin.: ~PM [ Pump Se, at:Ft. [ c.~.g, ..g., Ado.,. ~.r.~:F, TANK
SEPARATION DISTANCES E3 Septic [-I Holding [-I S.T.E.P. [~ Other:
T.~'~...j_oI Septic Absorption Lift Holding ~ublic/Pfivate ManufaCturer; ~apac~t¥
Tank Field Station Tank S~,~rU~, Anchorage Tank 3.,500
w.,, >200' >200' N/A N/A >25' Steel Two (2)
~tu.,s"""~' w~t., >3.00'>5, >3.00'>3.0, N/AN/A N/AN/A ~/ ~,.~: LIFTc.,,.ISTATION~'~'~'"'~'~ - NONE ON LOT
F~,.~.,,o. >5' >3.0' N/A N/A /~ '"'""'~'~'~": I''~'""°''''~"'''': ~,.
cu~.o.~. None Noted PumpMake&Moael ElectnCallnSpecl~onspedormeclby:
.e.,~: BENCH MARK
Southwest Corner Deck at Front Door.
100.0 Ft.
Engineer's Stamp
?K~/' :,..~' ............
,.' ~.:.." A '"....~,',
Inspections performedby: MEA Dates: 1't 9/3.7/02 ff~.[ 49th. "~ ~'A:
2"~ 9/17/02 ,~.~.c~^r~r.,~:r,so~ ~.
Department of Health and Human Services approval *,~.O~.r..o', No c[-4381
*. ~'~'. ....... ~,~-
Reviewed and approved by: ~_~'_~? Zt/, ~t:~Tt~Date:_J'~-/Z//- O~ '.-~'o... ,~.; .~.... .................
Permit Number:. SW020344
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bmgaw Street Anchorage, AK. 99519-6655 - 343-7904
On-Site Wastewater Disposal System or Well Inspection Report
N 90'00'00"E 167.19'
Page 2 of 3
PID No. 011.425-85
00
0
S1
S2
C4
C5
M1
A B
22.3 23.2
15.3 24.7
55.2 16.5
70.6 61.1
59.1 21.5
FIVE BEDROOM
HOME
-91
S2
C4
aISlteltern°te
¢5
30'
Z
10' BUFFER LANDSCAPE ESMT.
N 90'O0'O0"E 146.50''
KINCAID ROAD ~.~.,c.~
PLAN AS-BUILT .........
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:SW020344
Page 3 of 3
PID No. 011-422-85
83.7/
171.;) :r;, BACKFILL
..... ~eotext~le F,b~ic
97.7j Br ,,inFie{,d Rock
'37.7
/ ,
90.7 80.5
46' T~en~h Length
PROFILE AS-BUILT
Scole: I" = 10'
MUNICIPALITY OF ANCHORA GE
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 PERMIT
Initial
Date Issued: Sep 13, 2002
Expiration Date: Sep 13, 2003
Permit Number: SW020344
Legal Description: Muirwood Park Block 4 Lot 8
Design Engineer: 0014 Anderson Engineering
Owner Name: Crown Pointe, Inc.
Owner Address: PO Box 112313
Anchorage, A 99511-
Parcel ID: 011-422-85
Site Address: nhn
Lot Size: 40001 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.
Date:
Date:
Parcel I.D.
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 SEWER/VVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Permit Number SW 0Z0~44~
Properly owner(s) Crown Pointe, Inc.
Mailing address (1) P.O. Box '112313 Anchorage, AK 99511
Mailing address (2) Zip Code
Legal description (Lot, Block & Sub'd.) Lot 8, Block 4, Muirwood Park Subdivision
Legal description (Section, Township & Range)
Lot Size 40~001 SF
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Acres/Sq.Ft.
Number of Bedrooms Five (5)
Day phone 727-8167
I certify that the above information is correct. I further 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)
Permit Fees:
Date of Payment:
Receipt Number:
(Rev. 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
[] Jacuzzi [--I
[] Water Softening Unit []
[] Well Only []
[] Water Storage []
t, ; !
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 .. 522-6779 (FAX) .
September 3, 2002
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject:
Lot 8, Block 4, Muirwood Park Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Propedies
Dear Onsite Services Engineer:
The owner of Lot 8, Block 4, Muirwood Park Subdivision intends to construct a five-
bedroom home on the lot. We are therefore requesting a permit be issued for the
construction of a new septic system to serve the home. The lot is currently served by
the Municipal water system. 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 water service location, test hole locations
and the locations of the existing wells and systems on adjacent lots. Drainage arrows
are also shown and current drainage patterns will be maintained after construction.
The test holes placed near the location of the proposed and alternate absorption
trenches indicated fairly clean well graded to poorly graded sand varying amounts of silt
and a percolation rate of 2 to 5 minutes per inch in the accepting layer. We are
therefore proposing to construct a deep absorption system with a 3' wide by 45' long
trench with a 7' effective depth. The distribution piping depth will be 3' below the
surface. Total depth of the trench will be 10'.
The ground surface on the lot slopes as shown on the attached Site Plan with 2% to 3%
slopes from west to east. The new septic tank and absorption trench will be
constructed parallel with the slope in conformance with Municipal requirements. All
components of the new septic system will be constructed a minimum of 10' from the
water service line on the lot. The system will also be constructed a minimum of 100'
from any surface water in the area.
If the system is constructed in accordance with our design the following statements
apply:
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 subdivision is currently
served by the Municipal water system.
Lot 8, Block 4, Muirwood Park
September 3, 2002
Page Two
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.
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
SCALE 1" = 100'
49th
This
VACANT
7
I
I
I
!
-' 32.18'.:
":VACANT "' '.'
". N90'00'00"£
...... , 238.5(" i
/ '" NOO'OO'OO"W 485.01'""(R&~M) ' ". k 'x~ .,~,,~.,.C,'.,;'.'C.:.,:::
\...,0o. ..... =: .......... KINCAII~ 'R~3A~D
'" O
--~. ', FROM ASSUMED DATUM (TfP)
RELATIVE
ELEVATION
N gO°OO'OO"E 167.19'
[ZIS~ING & PROPOSED
DRAINAGE PATI£RN
.I
I
.I
TH2 /
5.0' /
45.0'
/
iX 101'
FIN. FLR.
EL. = 103' A.C. DRIVE
Five
Bedroom .
]~ome .,'z.~.
.~ £NTRY
32.0'
10'
1,500 ,Gallon
Septic Tank
45' Long x 3' Wide
x 7' Effective Depth
10' BUFFER LANDSCAPE £SMT.
· ~o' u~u'~s~.
L~
i3o' E! ·
N gO°OO'OO"E
146.50'
'SITE PLAN
SCALE 1" = 30'
KINCAID ROAD
arnate
'' ~ Alt
Sit
Absorption Trench
LOT 8, BLOCK 4, MUIRWOOD PARK
SUBDIVISION
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Five Bedroom Home Deep Trench System
Perc. Rate: 2 -4 Min./Inch 1,500 Gallon Septic Tank
Avg. Application Rate: 1.2 GPD/SF 7' Drain Field Rock
5 Bedrooms X 150 GPD 1 1.2 GPDISF = 625 SF of Absorption Area
625 SFI14 SFILF -- 44.6 LF Trench Length
Therefore: Construct an Absorption Trench 45' in Length by 3' Wide With 7' of Drainfield
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
NOTE:
TYPICAL DEEP TRENCH SECTION
(NO SCALE)
Minimum 6' Separation From Bedrock.
Minimum 10' From Lot Line.
Minimum 4' Separation From Groundwater.
Minimum 100' Separation From Wells in the Area.
Minimum t0' Separation From Water Se~ice Line.
. : ·
Municipality of Anchorage
Development Services DepartmentJOn-Site Water and Wastewater Program
4700 South Bragaw Street. Anchorage, AK 99516-6650
SOILS LOG - PERCOLATION TEST
Performed For: White Raven Development
Legal Description: Lot 8. Kincaid Park Subdivision
SLOPE
7
8
9
10
11
12
13
14
15
16
17
1S
OG/PT
SPISM
15% Silt
North
Date Performed:
Was Groundwater
Encountered? S
If Yes, What Depth?. L
Depth to Water
After Monitoring None P
Date: 5/15102 E
SPISM
Some
GP
Bottom of
Hole
South
No
SITE PLAN
· 50,00'
· N90'O0'O0
r't311N~ 1" IRON PIPE
Reading Date Gross Net Depth To Net
Time Time Water Drop
I 22-Jan 3:15 2.75"
3:25 10 5.375" 2.625"
3:26 2.5"
3:36 10 5.125' 2.625"
3:37 2.5"
3:47 10 5.125" 2.625"
Perc. Rate: 3.8 Min./Inch Perc. Hole Diameter: 8"
Test Run Between 5 Ft. and 6 Ft.
Comments: Test Cavity was Presoaked Prior to Test. SW/SM Layer From 7' to 19'
Percolates Less Than 5 Minutes Per Inch.
Performed By: Alan Harala. I, J~ac~E~3~[~ Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Datei 8/6/02
Municipality of Anchorage
Development Services Department/On-Site Water and Wastewater Program
4700 South Bragaw Street, Anchorage, AK 99516-6650
SOILS LOG - PERCOLATION TEST
Performed For: White Raven Development
Legal Description: tot 8. Kincaid Park Subdivision
SLOPE
8
9
10
11
12
13
14
15
16
18
OG/PTIOL
SMISP
Was Groundwater
Encountered?
If Yes, What Depth?
Depth to Water
After Monitoring
Date:
North
South
No
None
2/28102
Bottom of
Hole '
Date Pcrformed:
S
L
O
P
E
SITE PLAN
;
.~ : [--31.42'
... /14G.50' R--20.00
:o, / 50.00
· g"~/ ' N90'O0'O0
FOUND 1" IRON PIPE
0.6' BELOW PAVEMENT
Reading Date Gross Net Depth To Net
Time Time Water Drop
22-Jan 2:02 4.5"
2:12 10 7.75" 3.5"
2:14 4.5"
2:24 10 7,25" 2.75"
2:25 4.5'
2:35 10 7.19" 2.69"
2:36 4.5"
2:46 10 7.19" 2.69'
Perc. Rate: 4 MinJInch Perc. Hole Diameter. 8"
Test Run Between 5 Ft. and 6 Ft....
Comments: T([st Cavity was Presoaked Prior to Test. :
Pedormed By: ~ I. M~?~L~:II~r~I Certify That This Test Was Per[ormed
In Accordance With All State and Municipal Guidelines In Effect On This Date~ .~.: 3/2/02
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 8, BLOCK 4, MUIRWOOD SUBDIVISION
GENERAL:
The scope of this project includes the procurement an~l placement of a
new 1,500-gallon septic tank at the location shown on the site plan
and the construction of a 45' long by 3' wide by 7' effective depth
absorption trench also shown on the Site Plan. The total depth of the
trench will be 10' below existing ground and the distribution pipe will be
placed at 3' below the surface. All components of the septic tank and
absorption trenches must be constructed a minimum of 10' from the
water service line on the lot. A minimum of 4' of fill must be placed
atop the septic tank and 3' of fill above the absorption trench. In lieu of
fill 2" of direct bury insulation may be placed with 2' of fill atop the
insulation.
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.
Unless specifically agreed otherwise, the contractor shall be
responsible for final grading areas subsequently depressed from soil
settling. Property owner shall be responsible for revegetation of
affected areas unless specifically agreed otherwise.
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 1,500-gallon septic tank must be procured from an approved
septic tank manufacturer 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.
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct
budal insulation.
Lot 8, Block 4, Muirwood
September 3, 2002
Page 2 of 2
6. 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.
2. 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.
o
e
Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated.
Contractor shall verify 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.
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 settlement or depressions.
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.
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).
Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Femco, or equal).
Lot 8, Block 4, Muirwood
September 3, 2002
Page 3 of 3
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 fabric, 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 cedifled as-built of the completed system.
I.D. 011-422.85
GENERAL INFORMATION
Co ,replete legal description Lot 8, Block 4, Muirw0od Park Subdivision
I'ocatron (sire'address or directiofis) Parkwest Circle at Kincaid Road
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
HAA# /~ ~
Expiration Date:
I O
:'-" ..... (~u~;-e'n~ ~Sr6~erty owner(s) Crown Pointe, Inc. Day phone 727-8167
·. ' · . v ......-., Mailing address . 5400 Abbott Road Anchora.qe AK 99507. -'.. -'~- ...'.:'
,'~..'~..',' -', ,' l.ending.~ -ac]encv: ·: , , .. '.: '. '..-~.. :. :. '.-.Dav,--ohone ' .-' .........
':':" ''-' 'MfiiJing:~'dd~-e~'": ':''" ': ' ........ : ' . '
"-' ..'.' Real'E§{at~:Agi~nt - -" ...................... Day phone ...................
. ·- Unles~ othe[Wise requested, HAA will be held by DSD forpickup.
' ' 2;:';NUMB'ER I~F BEDROOMS: Five (5)
· '~ ""',~:: 'TYPE'OF WATER sUpPLY: -'-
TYPE Ola WASTEWATER DISPOSAL:
Individual On-site []
' · .... :,.-~: Individual Well ... :.. :; I-'1
' '.-',...:' -';', '-'tnd v dual Water Storage ............... ~' [] .................. Individual Holding tank' - ' []
-' x ...... ;i~0,.,m..mu_n!ty.C a.S.S Well [] . Community On-site []
'P~l~li(~ Wa't~r System [] Public Sewer []
The .... Municipality of Anchorage Development Services Depadment (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 H. AAs upon request to hc~meowners. 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 oId. (Certificates may be reissued for a period of up lo one year with
valid water samples.) Cedificates 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 a.ffi~ed hereto and as of the validation date shown below, I verify that my investigation, .
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further veri~ 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 Anderson Enqineering
· ~ "- ' ' . Address P.O. Box 240773 Anchora.qe, AK 99524
"' Engineer,s Printed Name Michael E. Anderson, P.E.
'L.C. 7. , -;-:: ', - , .';;
": ""5. DSD SIGNATURE
Phone 522-7773
Date 411112003
'::L,,, ....... ' Ap ovedfor
?::"?;' - Disapproved.
}:;.: L',<L:, .,:, :: ,, ,:. i', ',-:-,.: :COnditional approval for
.~,.:..:, ,.:',.,-? .:,' .-'.'.' i, , ...
bedrooms, with the following stipulations:
Additional Comments
.......... Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Ivlaintenance Agreements
Supplemental Engineer's Repod
Other
Original Cedi,qcate, Date:
(Rev. 12/00)
Municipality of Anchorage
.. -. Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cLanchorage.ak.us
(907) 343-7904
Legal Description:
A. WELL DATA
Well type .Pubflc Water
Date completed
Tntal.depth.. fL
HEALTH AUTHORITY APPROVAL CHECKLIST
Lot 8~ Block 4~ Mubwood Park Subdivision
If A, B, or C provide PWSID #
Sanitary seal (YIN)
FROM WELL LOG
g.p.m.
Nitrate ~. mg./I.
Collected by:
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform colonies J100 mi.
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Tank size 1~500 gal.
Foundation cteanout (YIN) Y
Date of pumping
C. ABSORPTION FIELD DATA
Length 46
Total depth 11 fl.
Date of adequacy test
Number af Compartments _2
Depression over tank (YIN) N_
Pumper New Construction
Date installed 9/17/2002 Soil rating (g.p.d./fF or ~/bdrm) t,2 GPDISF
ff. Width 3 fl.
Eft. absorption area _644 ~ Monitoring tube Y
Results (Pass/Fail)
Fluid depth in absorption field before test __ in. Water added
Elapsed Time: __ min. Final fluid depth in.
Any rejuvenation treatment (past. 12 mo,} (YIN & type) N ~ --
Parcel ID: 011-422-85
Well Log (Y/N)
Wires properly protected (Y/N)
...... CasingJ~eight (above ground)
AT INSPECTION
ft,
g.p.m.
Other bacteria
Jrt.
Date installed 9/17/2002
Cleanouts (YIN) Y
High water alarm (YIN) N
System type DeepTrench
Gravel below pipe 7
Depres_~ion over field N
colonies/100 mi.
gal.
Absorption rate >=
If yes, give date
ft.
For bedrooms
New depth in.
g.p.d.
D. LIFT STATION
Date installed
"Pump on" level at in.
Datum
E. SEPARATION DISTANCES
Size in gallons
"Pump off" level at __ in.
Cycles tesled
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
Manhole/Access (Y/N)
High waler alarm level at
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5' Property line >5'
Water main NIA Water service line >10,
Wells on adjacent lots >200'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation >10'
Surface water >100'
Wells on adjacent lots >200'
Absorption field >5'
Surface water >100'
Water main
Driveway, parking/vehicle storage
Property line >10,
Water Service line >10,
Curtain drain None Noted
F. COMMENTS
in.
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 Michael E. Anderson, P.E.
Date 4/1'112003
HAA Fee $ 3'7~"
Date of Payment
Receipt Number
(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number