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HomeMy WebLinkAboutROCKHILL BLK 3 LT 1Onsite File
#015-362-18
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191455 PID Number: 015-362-18
Dwelling: FEI Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New R Upgrade
Name
JOHN HIGGINS
ABSORPTION FIELD
❑ .Deep Trench ❑Wide Trench ❑Bedound
Site Address
6200 BARRY AVENUE, ANCHORAGE, AK 99507
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth original grade
-
4
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
ROCKHILL; BLOCK 3, LOT 1
Fill added above original gr
Ft.
Gravel length
Ft.
Township Range Section
-
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total orption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft?
Ft.
Well
1001+
TANK X Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER TANK
Capacity
1250 Gal.
Surface Water
100'+
Material
HDPE
Number of compartments
2
Lot Line
5'+
NA
Foundation
LIFT STATION
Manufacturer
Capacity
Gal.
110'+
Remarks OLD TANK DECOMMISSIONED PER UPC
PER CONTRACTOR
Alarm location
Electrical installed by
PIPE MATERIAL House to tank EXISTI Tank to EXIST6
6 drainfield
Installer
A+ HOME SERVICES
Drainfield DawaiExisnNG CO/MTD3034
Inspector TIM ECKLUND AND DAVID GARNESS
BENCH MARK (Assumed elevation) 97:26 ft
Inspection15` 10/11/2019 -
Location and description
TOP OF MH
3b - 4"' _
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's St p
oQQ600p �4
Conditional Approval: Date
o ..... 9 . ..:��QO
D D
Septic S stem
ss;' p
E—A79�'r
Approved 1 tom. Date %©'{
C 3
Note: this approval does not include well permit requirements.
p0 �0fess'°Q\
#AECC884 �000�o
(Rev 05/02/18)
PERMIT NUMBER:
OSP191455
RECORD DRAWING
BARRY AVENUE \ /
NEW 1250 GALLON HDPE GREER
TANK RATED FOR 10' BURIAL -
Y
DRIVEWAY
1 +.
1&2
&4
EXISTING TRENCH; NEW C/O INSTALLED
ON NORTHEAST END OF TRENCH
CSEPTIC
AR!n
PARCEL ID NUMBER:
015-362-18
GARNESS ENGINEERING GROUP, Ltd
- --- -- ENGINEERING'S SALES o CONSULTING ------------ -
3701 E. TUDOR ROAD, SUITE 101 *ANCHORAGE, AK 99507 • PHONE (907) 337-6179 • FAX (907) 33&3246 • WEBSITE: w gamessengineenng.com
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
JOHN HIGGINS - 2 OF 3
LEGAL DESCRIPTION: DRAWN BY:
ROCKHILL; BLOCK 3, LOT 1 D.J.G.
TYPE OF WORK: DATE:
SEPTIC TANK RECORD DRAWINGS 10/14/2019
W
1"=40'
OF
,.....::..................
... ..::.....;
r s
r...... .... • ................. ......0
♦♦ ��: J r A. Games s :'�=
♦♦% G C -7953 Ar
LICENSEeO4';:a;SS\Ok ••
#AECC884 /
PERMIT NUMBER: RECORD D RAW I N G PARCEL ID NUMBER:
OSP 1'9 1455 015-362-18
TOP OF MH = 97.26
FINAL GRADE = 95.74-96.73
MH ST2
TOP OF TANK AT INTLET = 90.40 TOP OF TANK AT OUTLET = 90.40
NEW 1250 GALLON
INVERT OF BUNG AT INLET = 89.84 H. D. P. E. G REER INVERT OF BUNG AT OUTLET = 89.56
SEPTIC TANK RATED
FOR 10' BURIAL
i\AV
GARNESS ENGINEERING 49 *•'•
G NG GROUP, Ltd ................................;
�- --- _ = ENGINEERING G SALES o CONSULTING 0
3701 E. TUDOR ROAD, SUITE 101 ' ANCHORAGE, AK 99507' PHONE (907) 3376179' FAX (907) 338-3246' WEBSITE: x gamessengineenng.00m . ,,,, ,,,„., ,
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
JOHN HIGGINS - 3 OF 3 �j �'• reyA.•••arnes. :�-Q=
LEGAL DESCRIPTION: DRAWN BY. / C -795 �=
1p 4W
ROCKHILL; BLOCK 3, LOT 1 D.J.G. I .
E OF WORK: DATE: LICENSE
Q
�O PROFESS\������
SEPTIC TANK PROFILE 10/14/2019 #AECC88a ,��►������
MUNICIPALITY OF ANCHORAGE
61*_j
Community Development Department Phone: 907-343-7904
Development Services Fax: 907- 343-7997
On -Site Water & Wastewater Program
Mayor Dan Sullivan
On -Site Sewer/Well Permit Application
For A Single Family Dwelling
Parcel I.D. 015-362-18
Property owner(s) JOHN HIGGINS Day phone
Mailing address 6200 BARRY AVENUE *ANCHORAGE, AK 99507
Site address 6200 BARRY AVENUE `ANCHORAGE, AK 99507
Legal description (Sub'd, Block & Lot) ROCKHILL; BLOCK 3, LOT 1
Legal description (Township, Section & Range)
Lot Size Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DEWELLING:
(Mall that apply)
Initial ❑ Single Family (SF)
Absorption Field ❑ Upgrade (w/wo ADU)
Septic Tank ® Duplex (D) ❑
Renewal EJ
Holding Tank ❑ Multiple Dwellings ❑
Privy ❑ .(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR:
N/A Distance: -
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd.
(Signature of property owner or authorized agent)
Permit/Rush Fees:d1 ai 5� Waiver Fees:
Date of Payment:y Q 6 i Date of Payment:
Receipt Number: 2a3 ( C-1 Receipt Number:
Permit No. QS Plq `y5_T Waiver No.
®I (j 01 P m (Rev. 01/11)
y,"PA"rr MUNICIPALITY OF ANCHORAGE
\, On-Site Water & Wastewater Program
.?; PO Box 196650 4700 Elmore Road �"°"� c
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 i
http://www.muni.org/onsite v
I)epartineiit
On-Site Wastewater Disposal System Permit
Permit Number: OSP191455 Effective Date: 10/10/2019
Work Type: SepticTank Upgrade Expiration Date: 10/9/2020
Tax Code Number: 01536218000
Site Legal Address: ROCK M I LL SLK 3 LT j
Site Mailing Address: (0a00 gc,-;rrcl �V�.rl fie, chplr e� (�I�� TV` >Oi
Owner: HIGGINS JOHN M & DEBORAH A Lot Size in Sq Ft:
Design Engineer: GARNESS ENGINEERING GROUP LTD Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received BN
Issued By:
Date: (V111 �q
Date:
GARNES.S ENGINEERING GROUP,
ENGINEERING -SALES -CONSULTING
October 10th, 2019
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Proposed Septic Tank Upgrade for Rockhill; Block 3, Lot 1
To whom it may concern:
The subject lot is served by a private well and septic system. Per MOA records, the existing
septic tank is approximately 36 years old. Per MOA memorandum, a septic tank of this age
must be physically inspected and/or replaced prior to COSA approval. Based upon this fact, we
are proposing to replace the septic tank. We are proposing to decommission the existing septic
tank per UPC and install a new 1250 -gallon HDPE Greer tank rated for 10' burial. See attached
design drawings for tank location and other MOA requirements.
We are unaware of any adverse impacts this installation would have on adjacent wells or septic
systems. If you have any questions, please contact us at 337-6179. Thank you for your
assistance.
.S.
3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259
Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com
■
1 o SEPTIC
ARE _
i
/
CREIWOD; LOT 1
❑ I zk'�p2
Ste/
ROCKHLIL; BLOCK
1, LOT 9
I \
- � - ----------------BARRY AVEN U
CRESTWOOD; OT 24 /
w I
SEPTIC I
/ AR�n \
-I
I ❑
CRESTWOOD; LOT 23
QSEPTIC
ARE�D
ROCKHLIL; BLOCK
1, LOT
O
(-SEPTIC
ARE
'Oo
o,G I
s
�! \V
ROCKHLIL; BLOCK
3 OT 2
\ / V
(:'SEPTIC
ARE
SEPTIC
ARHj
_ `
ROCKHLIL; BLOCK
3, LOT 3
/
ASSUMED LOCATION FIELD VERIFY
/
PRIOR TO CONSTRUCTION
I 100' WELL RADIUS
1
I
GARNESS ENGINEERING GROUP, Ltd
ENGINEERING oSALES %CONSULTING
3701 E. TUDOR ROAD, SUITE 101 ' ANCHORAGE, AK 99507' PH@g4E (907) 337-6179 • FAX (907) 338-3246 • WEBSITE: www. gamessengineedng.com
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
JOHN HIGGINS - 1 OF 2
PROJECT/LEGAL DESCRIPTION: DRAWN BY:
ROCKHILL; BLOCK 3, LOT 1 D.J.G.
TYPE OF WORK: DATE:
�,_ SEPTIC SYSTEM DESIGN UPGRADE 10/8/2019
GEG, Ltd. HAS AN 8 PAGE SPECIFICATION LETTER
THAT PERTAINS TO THIS DESIGN. BY PROCEEDING
FORWARD WITH THIS INSTALLATION, THE
ENGINEER, WELL DRILLER, CONTRACTOR AND
PROPERTY OWNER AGREE THAT THEY HAVE
READ THESE SPECIFICATIONS AND AGREE TO
ACCEPT THE TERMS AND CONDITIONS OUTLINED.
70,
I
I
I
I
BARRY AVENUE
4' / \
EXISTING 4 \
BEDROOM
• HOUSEci
w \ 1
Jw
ca I
� I
O I
I /
I \
I
I
PROPOSED 1250 GALLON HDPE GREER TANK \
RATED FOR 10' BURIAL; INSTALL DOUBLE
I O
CLEANOUTS BEFORE AND AFTER
I °
I
I
I
I
APPROXIMATE LOCATION OF EXISTING 1250
GALLON STEEP SEPTIC TANK TO BE
_ DECOMMISSIONED PER UPC
10' TELE g ELEC. EASMT — — — — — —
WELL FOR ROCKHILL; BLOCK 3, LOT 3 TO —
BE LOCATED PRIOR TO CONSTRUCTION
CSEPTIC
GARNESS ENGINEERING GROUP, Ltd
=---- ---—, ENGINEERING o SALES o CONSULTING —_— —
3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507' PHONE (907) 337-6179' FAX (907) 338-3246 • WEBSITE: w .gamessengineenng.com
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
-T
JOHN HIGGINS I - 2 OF 2
PROJECT/LEGAL DESCRIPTION:
ROCKHILL; BLOCK 3, LOT1
TYPE OF WORK:
DESIGN OF SEPTIC TANK UPGRADE
DRAWN BY:
D.J.G.
DATE:
10/8/2019
I
N
SCALE:
1"=40'
tilt
��••� OF,'4,
Ar
i * 4 • * •�0
.....:....................................0
0
o �....... ........................... 0
:, Je . Gar ss c Q i
0��%'. CE -795 ?i
AV
17.
LICENSE 1oFESS1
#AECC884 �""' /
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
1*0 ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
NEW
-Q
❑UPGRADE
MAILING ADDRES
9y�
S tl <i 'S
LEGAL DESCRIPTION
LOCATION
NO. OF BEDROOMS
U Y
DISTANCE TO:
Well
r
Absorption area
s
Dwelling
—,S-/
PERMIT NO.
a :
E' EPAF:TP`IEP,IT OF HEALTH
TF:EET:
PEF:P"I i l 1',I!=!.:Q14__':7
APPLI!-:Ai'•!T PHYLLIS Artl':I+_!P 'SIC -P•4
L01 -- :AT 10 P. -I
LEGAL I_1E=F:!=i!: l'%'Fj I L.I._
-u c a 1.' -1: u= "u' _ u a "_u=�
AP•!G' EP!' i F:i !Pdl IEP,iTt IL F'F:!-!TE!=:T 10 N
AI',I!_Hi RFi! E : Ak%'_ j•1
2G 4— 4 1' ;2;i_i
E-_ �-=-7 I)= F° E=" FE � " 11-4 1 -T_
_ F i FTIX 4—'4:---' 9'95!•:! _
LOT SIZE 999999
TYPE !::!F __lI I L FiE,Si IRPT I t_ N E'•r'E.TEI'I I _ :
1'Ih is; 1_' 1' ►C'1 Pdi_IP'1E EF: ± !F E.EG�F:!=!� IIS - 4= FI I L F:AT I I'•!! SC-'! FT/BR' = = 5
THE RE! -!I I I F:EC SIZE OF THE SOIL AE. _i-_ !F'PT I !_!P,l E.'• STEll I E : � 1C-
�_tt E-9 = _ B P-„ P:-3 1- 9-0 = -4 � 3 I--„ F=flLLE= r)_ ID REE_" _T_
('17-0 s - q -,a/� -?a
THE LEI' -4G T H D I NDIS I OP•! IS THE LEP-:I!3TH -:' I N. FEET) OF THE TF:EP•,IE:I-1 � iF: GRA I Y IF i ELD.Rnq,�
THE C EF'TH i !F A Tr==:EI' I! I -I OF. F' I T IS THE f_:- I C. T(=►I'
IC:E BET14EEP•`I THE '�I_IF:FA!_ E OF THE
GF:!=!111',ID AiNDI THE BOTTOM OF THE E -;i :A'.,'ATI0N -% IP•! FEET).
THERE I,=" P,IO SET IAI I LATH FOR TREI'•!!=:HE ^.
THE I__jF:A%'EL DEPTH I S THE l'l I l',I I I`il_1M DEPTH i �F !__3iF:A%'EL E,ETI.-.IEEN THE OUTFALL PIPE
AP -1D THE BOTTOM OF THE EX!_i=►VAT I OP•! :'P-4 FEET
T C—_ -i a=a g" -A fF =_ I =E_=-- a. = = J_ :2 !f _- H-!! Q a=a L L_11- I -4A
PERI"el I T ADPL I C :AI',IT !-IAS, THE TO I hIFORM TH I E, DEPAF:TME1'•4T DDR I kli-A THE
INSTALLATION 11'•!SPE!_T i i !i',I,� DF ANY WELLS AC: JA!_ENT TO THIS PRF_IPERTY AkID THE
1',1Li1''1E,EF: i �F RES! :E ~ THAT THE kIELL Ij.I I LL SERME.
;I _d LL _ ,_ _ z 9-4 �_-" � ate_ -a- ,>_ �_o '-d e a�j F° 1= �° a_II I
DACE -.::F i LL I P•!!3 OF AP•!'.' E'r` -TEP ! 1.-.1 I THi !I -IT FII -,..IAL I NSPE!_T I i !P•! AP,ID APPROVAL E:',' THIS
C:-EPAFM IEi%IT WILL BE =,►—IE, ,IE!_T TE! PR !=,E!_ -IT I i iP,l.
� •! ON-SITE !EI''Ii!,1II' Yl DIST=,I�::E BETkIEEII A I!ELL ANE, AIr_EWAGE GI_PEHL -'r'' TEP'I IS
D,DiD FEET FOR FI PR i', ATE WELL OF, 150 Ti ! 201_D FEET FROM A PLIE.L I !_ I.,.IELL DEPEI'ID I P -M
UP OP•! THE TYPE i !F F'I_IF;LI!_ kIELL..
I'l i I',I 11,11 IP'1 C:- I _,TAP,K:E FROP 1 A PRIVATE I..!ELL T� � A PRI %,,ATE SEI.%IEF: LINE I FEET A!'•!G,
TO A !_OI%V111P,I I TY EEI.dER i_ I I',IE IS 5 FEET.
!=!THEE: RD -!I I I REI'lEP,ITS IlA',' APPLY. +PEi : I F I i :ATI !=!P•! _ AhID !_i !P•!= TF:I I!_T I &I DIAGRAMS AF:E
A!jAILAE,LE Ti! INSURE PROPER INSTALLATION.
F=" II-_ ° [F-11 L 9 F—`
I CERTIFY THAT
1: I All FAMILIAR kI I TH THE RE! -!I I I REP'1EP,IT_. FOR OP -1 -SITE -EI.4EF:S AND l. -JELLS AS 'SET
FORTH BY THE I* II Ii',! I i=: I PAL I T'i-` OF I=!I' III-IORAGE.
�iFI WILL INSTALL THE -r-TEPIN h_P.I I T! -I THE !_E!DE=,.
T THE !=!P•!-•-E� I TE SEI.-.IEF: E.'T` = TEf 1, FLAY RE! -!I I I F:E EI',ILAF:!_3EP'1E1'•!T I F THE
i U1',1L EF:r TAP!C:� THA
` F-HAI,C.)ED.-IC:E I = Cr,_G1rF,I �I E:EDF:Oi !I''1=.
S I G!'•!
APDL/'I'1!:AP,I T
1 _,= I -IEC:' E--'r'__-----C.q
F'!-I`�'LLI' AAP•!!=!P! F - IN -
r
f i
r
_ ff
T
SOILS LOG
f, \ MUNICIPALITY OF ANCHORAGE
/ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION
TEST
\\ 825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: P'K ;5 ASI an . n h DATE PERFORMED:
LEGAL DESCRIPTION: :Rod. �G J(-.) Y tyiS! UV-) Loi ��< 33 PtNK3w `i 5r S O?
SLOPE SITE PLAN
) Ot or�ani't Sa;l
t I
2 )
(#•1 L) -)-run sit t
s
i
5-
6-
7 67
i
8
r �
9
10-
13-
14-
15-
OF
013-
14-15
clean well gr dad J14ae I
no S; l �r
Layers o�=n�atl-Si�c q.-,tee\
-F.r--i-;�;c€ �•tt� 14yer5
fpbb\eS I b at a e� }
ail CtCar
cr M0.1t $P. ai'+'i$ O'Y GtUn, r�rxv Ct, f
WAS GROUND WATER ,., S
ENCOUNTERED?., t� o L
O
IF YES, AT WHAT E y++l� -EtrrSt�t Sa•� y ..
DEPTH?
jw
•+ 0
•
foe .*ia N• • pHi• `
w
mY C Reid, Jr,
�� d'1� ' • Ato. ?23 t •!: -
20 ®O .,.,
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
� 1
COMMENTS Sc>;� -rurn �( c�r\!y rs rdy s ,u11�, 85 C1`/ �d•m, .
PERFORMED BY: 5eve.n� _CERTIFIED BY: DATE:
72-008 (5/79)
Gross
Net
Depth to
Net
Reading
Date
Time
Time
Water
Drop
aaee
� 8
20 ®O .,.,
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
� 1
COMMENTS Sc>;� -rurn �( c�r\!y rs rdy s ,u11�, 85 C1`/ �d•m, .
PERFORMED BY: 5eve.n� _CERTIFIED BY: DATE:
72-008 (5/79)
..
'A=T19t11 T;t: Dlvlstom � iMlogl aphyslgal Sssrwys c�ti
ari TargtrAus{sz 2"-66151
' 3fAT�'�.
OVA{tTtli{R ®/
SOOT perewtee
Anchora". Mashe I
WA`TEIt WILL Rttsgii
.
gr{Illnq Coayaaq Maar Vein $ �It
1 p� g�Nc .o..�.� "
Y.S.Q.t. LN+B1 Via.
Milling peomlt ft..
T100 OF WILL please ea,plete either la. 111. or 16.
A So+pUP Ssirivlslr Lot /10" Ib. Fraction Section No.
441"
TwnshIp Adage
J1l atawcm and o l rw t low from Rod Intersect)
). &An of %W" r ' ti
4-`'-:
P}"
1' Sub 5 W� n�T �,(!/ dcc, /�,
Ai1r...t k.'.C� ZJ•�
NsB-1 9 5 8 7.1941, R 3-661 6 goc��
G:
Street Address and Area of Well Location
. WELL. LOG Feat Below
4. WELL DEPTH: (cowls
34irface ilwrtisn ,
Surface
101
j
Material Type Top Bottom
ft.
'
ravel;[rave O 15
5. pCable tool 39Rotary pDrlrea
ltillpJotted
p Auger per. p
rn s t e sand
rave W s
6. USE:X�Domestic pp"lic Supply ©{
i
ou ers
jq
pIrrigation 13Rechargey
Ity rave
=
pTest Well C] Other:
ou eff
rn s sand7.
CASING: p Threaded 14ed �.
rave
6_1n. to 10 1 ft. Depth w140K
In. to ft. Depth
AM
e. FINISH OF WELL:
Typo: �nTA2e
n
Slot/Mash/Size: Leyth:
y'
Sat between ft. aM '
Fittings: '
4G
9. STATIC WATER LEVEL: ft.'
OF AN &
1 by OF H EGT10
r
pAtwva 0aelw laved s OMM
;i«\1
Type of Measurement:
10. PUMPING LEV[l below Aland surface
ft. after hrs. pglglag
g'�
9
C.
ft. after _ Ara. �{zBlgl ii
""':
11. YELL MEAD COMPLLT IOU t isl flgws-my
p pItI*sf Adapter 1sa11Re aj�jjt
12. GROVIMGz weII Gsstab"s (ry3 Too `
Ms tar i a 1 t ❑ Iluli CatlMt I.J :' *'F
I3 PW: (if eve118614
Larytle of &,no flawg ftp.
Water.4zst ,ptis,�."
IS. WATER WELL CONTRACTOR'S CERTIFICATION:
L� ��4���p `• s �'�
This well •.as drilled underurisdiction and this •thet
my J sport I s trw Z1
freak ��,
Alaska Now-Well-Vern' s Drilling & Ent
A1��g2� ` ' `° `M1
Aegistar siness
tmMe r{k
Address: qqr
SI fined:law
, J:
Form 02- 11�S ✓ 7� Coot 01stributlon: WHITE -"State DGGS, PINK - Miller, CAMAY - Customer -
H
Ll
1
DEPART -NT OF HEALTH AND ENV I RONM( `AL PROTECTION
_ 'L' STREET: ANCHORAGE, hn. 99501
264-4720
PERMIT NO. ( 830=:00
APPLICANT N'1AR V I N AAMONS hl SRA BOX 4242 ANCHORAGE RAGE 9954= 2 349-2812
LOCATION
LEGAL L183 ROCKH I LL -/ D LOT SIZE _?999__ 9 SQUARE FE
MINIMUM DISTAN CE BETWEEN H WELL AND AN',PT ON—SITE SEWAGE DISPOSAL _,Y _,TEM I
i4_ O FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DI -TAN CE FROM A PRIVATE WELL TO A PRIVATE _,EWER LINE I 25 FEET AND
TO i A COMMUNITY _EWER LINE I 75 FEET.
WELL LOG_ ARE REQUIRED AN'dG' MUST BE RETURNED TO THE DEPARTMENT WITHIN _ 0 D1=1Y
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE Ti � INSURE PROPER INSTALLATION.
F" E_ F' 9-•1 1 T F::- a E" -il_ 1 =: E_ E o E= C1 E_ tl EA E_ FR -T-1 = AL c3 ED
I CERTIFY THAT
:1.: I AN FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE -ITE _EWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY CSF ANCHORAGE.
RAGE.
: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
113NED : _—------------
APPLICANT
-----------
APPLIGAN•dT MARV I N AAMONd _C iN.d
--- 4___ _--- � ----DATE----y 4za
0
MUNICIPALITY OF ANCHORAGE
0
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. 0l0'- :7007 - JF
1. GENERAL INFORMATION
Complete legal description UGIC�
i
Location (site address)
Current property owner(s) / vl ✓1 'u,"
Mailing address / i
Real estate agent
Expiration Date: I — 122C72 0
'L 3 LoI-
?'nu-6
I�I�,1 ✓1S Day phone go' 0 - gs q
2. TYPE OF DWELLING:
�9Single Family (w/wo ADU)
Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for:
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ X60. 60
Date of Payment 90 AI Im
Receipt Number (, +163
COSA # ®Sct9 Nq I -
Waiver Fee $
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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm ��� Phone 3�S
Address %60
Engineer's Printed Name
h:� ,����.� � � ®pip•
Y -N pdW '•@ '@J Yl
Q'
A='�Lcr- ppC>b D D
6. DSD SIGNATURE -P�
L t, 1. Pf�•: , -. n r. � uY. \.7Ct:�2d�a1 FF! �
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
WATE'R A N U m
tt,
Original Certificate Date:_��
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 State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
)C� �cJ zOSA Checklist
Legal Description: c �ILtu`� )3)of , ZoL Parcel ID: ��� �3�0� �i✓ty
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
[Well log is filed with Onsite (or attached)
Date drilled
sJa1183
Total depth —L(—D1 ft
Cased to _I QLft
Sanitary seal is functioning correctly
0 Wires are properly protected
Casing height (above ground) J7 in.
Date of flow test for COSA'9 Zb
Static water level at beginning of test 6&2sft.
Comments
Well production at time of test 02 � gpm
Water storage tank volume gallons
Welpdisinfected for coliform test? ❑ Yes *0
Coliform bacteria is Negative
Nitrate �'� mg/L itrate less than MRL (ND)
WIn Arsenic 'uQ�/L48rsenic less than MRL (ND)
Collected by add 1f�Q%U v -
Date of Sample l wl l q
B. TANK DATA
Age of tank(s) L years - O
RE
Tank type/material �ov< - I�Sv (a10
Mea ured operating fluid level in septic tank
4A,(►W)
Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed)
*LL standpipes present per record drawing
Total measured depth from grade 1a+3 ft (max)
Measured depth to pipe invert from grade') 161 ft (min)
❑ N/A - pressurized field
Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance
Age of lift station
Lift station mater'
Comments!
Adequacy test date ZYJ( I
Results Pass For bedrooms
Fluid depth prior to test in JD4 1
Water added 6,,3?9al
New depth in D f&�
Elapsed time R 1- min
Final fluid depth in D(? -y
Absorption rate 4,00 gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
Jv
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot >_ 10p' Community Sewer Manhole/Cle/t>l(,es if No ft
Neighboring Tank > 100' N4es if No ft Private Sewer/Septic Line > 25' n,-,J*,yes i
Absorption Field on Lot > 100' NKes if No ft Holding Tank > 100' [jk<es i
Neighboring Absorption Fields >X Animal Containment > 50' Yes i
Yes if No ft
Manure/Animal Excreta Storage > 1 Pd
Community Sewer Main > 75' ❑ Yes if No ft 211yes i
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' NI Yes if No ft Surface Water > 100' n/Yes if No
Property Line > 5' []'Yes if No ft Wells on Adjacent Lots:
Absorption Field > 5' Lryes if No ft Private Wells > 100' b4s if No
Water Main > 10' 0/yes if No ft Community Wells > 200' P/Yes if No _
Water Service Line > 10' U 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'
LrYes
if No
0'
If absorption field is under driveway comment below
Property Line > 10'
[�Yes
if No
f No ft
Wells on Adjacent Lots:
Y
f No ft
Water Main > 10'
E s
if No
f No ft
Private Wells > 100' 'esif No
Water Service Line > 10'
�s
if No
f No ft
Community Wells > 200;res�if No
Surface Water > 100'
des
if No
ft
f No ft
Building Foundations > 10' NI Yes if No ft Surface Water > 100' n/Yes if No
Property Line > 5' []'Yes if No ft Wells on Adjacent Lots:
Absorption Field > 5' Lryes if No ft Private Wells > 100' b4s if No
Water Main > 10' 0/yes if No ft Community Wells > 200' P/Yes if No _
Water Service Line > 10' U 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'
LrYes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
[�Yes
if No
ft
Wells on Adjacent Lots:
Y
Water Main > 10'
E s
if No
ft
Private Wells > 100' 'esif No
Water Service Line > 10'
�s
if No
ft
Community Wells > 200;res�if No
Surface Water > 100'
des
if No
ft
F. ENGINEER'S COMMENTS
� Q1O -kld/ iy`gia,l Zd= 10 - lI,-l"1.
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 COSA guidelines in effect on this date.
COSA Checklist yellow sheet
1k • ��j'I!41�i: S '
Evan J. Griffith lilt
�•• CE 10003
ft
ft
ft
ft
ft
SGS Ref.#
1195494001
Client Name
Residential Testing - Cash Account
Project Name/#
Chad Weiler
Client Sample ID
6200 Berry St.
Matrix
Drinking Water
Printed Date/Time
10/04/2019 16:36
Collected Date/Time
09/20/2019 12:15
Received Date/Time
09/20/2019 12:30
Technical Director
Stephen C. Ede
Sample Remarks:
Allowable Analysis
Parameter Results Limits Units Container ID Method Date
Metals by ICP/MS
Arsenic
ND
Waters Department
Total Nitrate/Nitrite-N
8.64
Microbiology Laboratory
E. Coli
Negative
Total Coliform
Negative
(<10) ug/L B EP200.8 10/03/19
(<10) mg/L C SM214500NO3-F 09/25/19
100mL A SM219223B 09/20/19
100mL A SM219223B 09/20/19
2
CT
r
•
O *-----
qsJ
9; 49 LH 0��x,20
04 LS -6914 500
P •.
SAT
C DISH
------------------
AS BUIL
NO CORNERS SET THIS DATE
`sT�'EET
" = 30'
�p4a ....... �a o
I HEREBY CERTIFY THAT -I HAVE PERFORMED A SURVEY
�Ofessional�o OF THE FOLLOWING DESCRIBED PROPERTY
O�DODDo�� LOT 1, BLOCK$ ROCK1-JILL 5UB.
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY 'ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELiNES. THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOWN EXIST OTHER THAN NOTED.
HEREON ( UNLESS INDICATED) DATED AT ANCHORAGE,ALASKA THIS 12 TH DAY OF.
NOTE: FEN ELI NES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE OCTOBER , 2019
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE.
HOLT LAND SURVEYING
9309 GROVER _DRIVE
ANCHORAGE,AK 99507
345-5513
14408, FB 200-10,199-72
BARRY
�-
N 89 5744 E 100.02
L = 66.21 R = 265.6
71
a
m
D
OM'fLL
a
SHED
?�
2c Z,
SHED
ti(D
O 4V'
p W
qy i
4i
DECK
CT
r
•
O *-----
qsJ
9; 49 LH 0��x,20
04 LS -6914 500
P •.
SAT
C DISH
------------------
AS BUIL
NO CORNERS SET THIS DATE
`sT�'EET
" = 30'
�p4a ....... �a o
I HEREBY CERTIFY THAT -I HAVE PERFORMED A SURVEY
�Ofessional�o OF THE FOLLOWING DESCRIBED PROPERTY
O�DODDo�� LOT 1, BLOCK$ ROCK1-JILL 5UB.
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY 'ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELiNES. THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOWN EXIST OTHER THAN NOTED.
HEREON ( UNLESS INDICATED) DATED AT ANCHORAGE,ALASKA THIS 12 TH DAY OF.
NOTE: FEN ELI NES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE OCTOBER , 2019
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE.
HOLT LAND SURVEYING
9309 GROVER _DRIVE
ANCHORAGE,AK 99507
345-5513
14408, FB 200-10,199-72
a
DEVELOPMENT SERVICES DEPARTMENT It j
On -Site water and wastewater Section l
www.muni.org/onsite \�
Nitrate Advisory
Certificate of On -Site Systems Approval # osc191492
Subdivision: Rockhill, Block: 3, Lot:
1A water sample revealed a nitrate concentration of 8.64
milligrams per liter
(mg/Q. The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Please see the attached "Nitrate Fact Sheet" for important
information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
�8t tCt arel4, 0"W0E) ���$ 11C K3 8 OWN%21
0 ',,990
90" CiiUX1I OC a
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
Mailing address ; f p`� U " "'� itxc�r� o v
yc 7�✓'!
A
Lending agency Day
phone
Mailing address - -
-
':
v aUF ti
Ax f, i k#
gentDay phone ¥
xJ,
Unless` otherwise requested, HAA willbe held for pickup
2 rr,t* NUMBER OF BEDROOMS:`� � --
u r
3 'TYPE OF WATER SUPPLY
Individual well__.....'..
*fr3 Y3 i 4
Community wesnll
Public water..",
NOTE: if community well system, provide written confirmation from State ADEE`attest-'. h
ing to the legality and status of system.
c C.: ' 1
4 .-'TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
APprovedTfor bedrooms.,
ry ,
Disapproved
i
_m
, r
u
bedrooms, with the following astipu
By:
CAUTION
ons:
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-M (Rev.1/91) Back MOA #21
O MUNICIPALITY OF ANCHORAGE
® DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. #Z— /8
HAA #
1. GENERAL INFORMATION
Complete legal description Loi
Location (site address or directions)
G/c.ti /"'ciliac/fo/.
Property owner a 6e Lc c Day phone _2 77",2S//
Mailing address
Lending agency v
Day phone
Mailing address
Agent
Day phone
Address
Unless otherwise requested, HAA will be held for pickup. MUNICIPALITY OF ANCHOkt GE
2. NUMBER OF BEDROOMS: ENVIRONMENTAL SERVICES DIVISION
3. TYPE OF WATER SUPPLY: ! '' t3 'IQ
b
Individual well E%C E I V E
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site_
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm KIND Engineering Phone
ZL.
Address Eacgie FI;vor, AK 99577-8736
Engineer's signature
6. DHHS SIGNATURE
0
Approved for bedrooms.
X
Disapproved.
�X Conditional approval for `f' bedrooms, with the following stipulations:
SFE E,V61-1gPA.5 /97TACHEp L ETTER PUC14)Tj/n16 T1 -1E U, 0R t FO BE i�fCO�rPLlSH�EI'
70 FuLLF/LL TI -IS
'&A"'01 1—__A'9 PRROVAL ' 'M' SHALL Of FtCROU EV TO
COMPLETE w01PK '9AV-L-0911- LOT 6g kELS 6D 4PPROy144 15
Additional Comments G1vfv Y 7_1-0.s OFFICE CO'yDlTica,' sY,911- 0',E RE7PA4PR'542pr
No L 1�7-?-�R T'1lRAl T t A,,F- l5 /�fyd
NL1TIC
Date 2 — 22 —1Z
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72.025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage MUNICIPALi7 "uF AI,,CHuk,AGC_
DEPARTMENT OF HEALTH & HUMAN S"&fflt.SERVICES DIVISION
Environmental Services Division
825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 314-31474'41 M6
ry I '
/'Health Authority Approval Checklist
Legal Description: Le� Q/aLK �CK�/i6� Parcel I.D.: O/S — 36 2 — A8
A. WELL DATA
Well type /RJD If A, B. or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Y Date completed 5 f 21 L 3
Total depth /U/ Cased to /U/ Casing height (above ground) 33'
Sanitary seal (Y/N) Wires properly protected (YIN)
FROM WELL LOG AT INSPECTION
Date of test S�vP3_/g 3
Static water level
Well production 3U 9.13.111. 7 . /R.D.M.
WATER SAMPLE RESULTS
Coliform Q Nitrate 3, Y /)V// Other bacteria Q
Date of sample: /�07�/9� Collected by: /1//
B. SEPTIC/HOLDING TANK DATA
Date installed 63 Tank size /Z `J 0 Number of Compartments p >i Cleanouts (Y/N)
Foundation cleanout (Y/N) �_ Depression (YIN) /A/ High water alarm (Y/N) A1,4
Date of Pumping 112'511f6 Pumper A/D/ �J Cl`I C� / e
YE 4as onl j oh.'c CO. 4L05 e"Vo Co . ar, 7;V e.
C. ABSORPTION FIELD DATA
Date installed S 3 A9 3 Soil rating (g.p.d./ft' or ft'/bdrm) g5 System type iDE6P %2ENCf1
Length _�16_ Width Gravel thickness below pipe 5 Total depth /Z S/
Effective absorption area 350 Monitoring Tube present(Y/l)—L— Depression
/over field (Y/N) /V
Date of adequacy test / Results (Pass/Fail) A1SS For 7 bedrooms
Fluid depth in absorption field before test (in.); 112 Z Immediately after gal. water added (in.):
Fluid depth 37 (ins.) Minutes later: /o2oo Absorption rate = 706 fi g.p.d.
Peroxide treatment (past 12 months) (Y/N) /V If yes, give date AIA
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump ori" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
"Pump off' level at*
Septic/holding tank on lot /oo ,.7 : On adjacent lots /00 1 +
Absorption field on lot /oo ; On adjacent lots
loo
Public sewer main/✓f /� Public sewer manhole/cleanout
Sewer /septic service line S 1 -f Lift station /V
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation lP 0 f Property line /0 1 + Absorption field lv
Water main/service line /D Surface water/drainage /60 + Wells on adjacent lots /60 f
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation 76 + Water main/service line ZS 1 4 -
Surface water /00 + Driveway, parking/vehicle storage area
Curtain drain 160 -�Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
-f-
Property line /D '4
I certify that I have determined thru field inspections and review ofNlunicipal records x tl@Fhgqq%QhVFs are
in con armance with AvIOA H.1.41 uidelines in effect on this date.
J g ff
� .* �o�'"'°'aa `'r=
., s, Fater
SignatureCV
J'3
s
�� ®ca6�e"socca:.aee�:oa „s
Engineer's Name
��'�*G�
Date Z- 19Z
c+F;�-..;:f:�i.i•�,A�',`,';,>
�
HAA Fee S • 41t)
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number