HomeMy WebLinkAboutGRACE #1 LT 3Grace #1
Lot 3
#017-042-60
Municipality of Anchorage
Community Development Department Page of
On -Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP121162 PID Number: 017-042-60 ❑ New 0 Upgrade
Name:
DAVID & BREANA HARDIN
ABSORPTION FIELD
0 Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
12750 KILLEY STREET, ANCHORAGE, AK 99516
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
907-727-7291
3
0.8 GPD/SF
13.5 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3.5 Ft
Gravel depth beneath pipe
10Ft.
Subdivision Block Lot
GRACE #1 3
Fill added above original grade
var Ft
Gravel length
41 Ft.
Township Range Section
Gravel width
2Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
I
Dist. between trenches
From
Tank
Field
Tank
line
820 Ft'
1
NA Ft.
Well
TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
100'+
100'+
NA
NA
25'+
Manufacturer
EXISTING
EXISTING
Capacity
1000Gal.
Surface Water
100'+
NA
NA
Material
Number of compartments
Lot Line
5'+
10'+
NA
NA
Concrete
1
NA
Foundation
LIFT STATION
5'+
10'+
NA
NA
Manufacturer
Capacity
Curtain Drain
NA
"50'+
NA
NA
NA
cal.
Remarks *None known. Connected to existing system
Pump on level at
in.
Pump off level at
-
in.
High water alarm at
in.
with diverter.
Pump make and model
Electrical Inspections performed by
Installer
PIPE MATERIAL Housetotank D3034 Tankto
drainfield D3034
Michael N. Anderson
Drainfield D3034 Co/MT D3034
Inspector ArcTerra Consulting, Inc.
BENCH MARK (Assumed elevation) 100R
Inspection ection 1 � 7/10/12 7/10/12
Location and description
2"d
3 r 7/10/12 a"'
Concrete stoop / slab at bottom of stairs
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
OF A� ��t
Conditional Approval: Date
�•�p'��."'00 ••.:45 1)
M :
1] 00
AAN Kenneth M. Duffu W
♦� Jr :� CE 7116 •�
,`
Approved Date 7-/3- J Z
�ROFEssta
inspecnon Rep&R_i-r-iz.coc
AS -BUILT SYSTEM DETAILS/SITE PLAN
GRACE #1, LOT 3
AOR, LOC.WELL
A -C=132'
B -C=120' w
A -D=133' o
B -D=119' o
A -E=125' 0
B-E=106'EXISTIN(
0 SEPTIC
TANK
'dj-ft_`
� \lk
/ ��OF AL� �''
9 T _ *,0
Of
' KENNET D /
CE -7116 WA:
$W /
�l1�fr.
1 \ ssloo div
LOT 2
TH12-1
p55 0
Permit OSP121162
PID# 017-042-60
WELL
30.0
3 -BR \
HOUSE m \
LOT 3
6
10' UTIL S T8E ESMT
LOT 38 NBS° 10 02"W 305.42' WELL
1
ORIGINAL/FINAL GRADE
FILTEFFARRIC \
SEWER ROCK
U l
PREPARED FOR:
DAVID & BREANA HARDIN
12750 KILLEY STREET
ANCHORAGE, AK 99516
FIELD BOOKS
D PUTED:
BMDARY: BOUNDARY
STAKING STAKING
CHECKED:
AmuiLT: REJ
DAIS:
DM RLE:
GRID:
ADA[) RIE FILE
JOB No.:
41'
12-154
SCALE: 1" = 50'
SCALE: NTS
Grace #1 Lot 3
Private Well
High Nitrates
July 13, 2012
Approximately two years ago on June 24, 2010, the private drinking water well on Grace
#1 Lot 3 was found to have nitrates at 10.1 mg/L. A well log was not available, so the
well casing was required to be inspected using a down -hole camera. The well casing
was found to be in good condition, with no perforations to 40+ feet below grade. The
inspection was considered adequate to approve a COSA on July 13, 2010 for the
subject property.
Recently, during the process to acquire a new COSA, the same well was found to have
nitrates at 10.7 mg/L. Due to the well casing inspection that had been done within the
last two years, the question was raised as to whether a new well casing inspection
should be required.
The discussion focused on the well's history of continuously increasing nitrate levels,
and whether or not the well's annulus seal should be dye tested to find out if it had
leakage into its source aquifer. This would be to help determine if the well is the cause
of high nitrates in the aquifer or if it is only the recipient of high nitrates.
An On-site certified well driller and an On-site certified well pump installer were
consulted regarding the likelihood that the subject well could be the cause of high
nitrates in the source aquifer. They both indicated the well was very unlikely to be the
cause and that dye testing and grouting the well annulus would be expensive and not
solve the problem. On-site also believes the well is very unlikely to be the cause since
the aquifer is confined with a static water level that is approximately 32 feet above the
aquifer. It should be noted that during the course of researching this issue, another
property in the subdivision was found to have an unconfined high nitrate well. A well
such as this would be much more suspect than the subject well.
The conclusion of the department is to not require the private drinking water well on
Grace #1 Lot 3 to be tested again or have the annulus grouted.
On -Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number:
OSP121162
Tax Code Number:
01704260000
Work Type:
Septic Upgrade
Permit Effective Dates: June 29, 2012 to June 29, 2013
Design Engineer:
ARC TERRA CONSULTING INC
Subdivision:
GRACE #1
Site Legal Address: GRACE #1 LT 3G:2835
Owner/Address: HARDIN DAVID K & BREANA L
12750 KILLEY ST ANCHORAGE AK 995162862
Site Mailing Address: 12750 KILLEY ST, Anchorage Lot Size in Sq Ft: 53174
Total Bedrooms: 3
This permit is for the construction of:
Y Disposal Field N Septic Tank N Holding Tank N Privy N Private Well N 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Special Provisions: Per the engineer, the house is being converted to three (3) bedrooms.
The property will not be eligible for a COSA until the bedroom count has been verified by a current
appraisal.
Receiv(
Issued
MUNICIPALITY OF
Community Development Department
Development Services Division
ANCHORAGE
On -Site Water & Wastewater Program
Mayor Dan Sullivan
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Phone: 907-343-7904
Fax: 907-343-7997
Parcel I.D. D/'7 — 0YZ — (00
Property owner(s) A4v1,0 RREA ✓_I Hs4,eWAJ Day phone
Mailing address 12750 kILI EY ST. f}n/1e#aMK AA::� 99Sf(o
Site address
Legal description (Sub'd., Block & Lot) 6W.4GE */ LOT 3
Legal description (Township, Range & Section)
/C
Lot Size 17 Sq. Ft. Number of Bedrooms 3
THIS APPLICATION IS FOR:
THIS APPLICATION IS AN:
(0 all that apply)
Absorption Field
Initial ❑
Septic Tank
❑
Upgrade
Holding Tank
❑
Renewal ❑
Privy
❑
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
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.
Permit/Rush Fees:
Date of Payment: 12-k�/a
Receipt Number: (I SP/ a //(,o
Permit No. G35yqb
Waiver Fees:
Date of Payment:
Receipt Number:
G:1Build1ng%0n SiteTorms%Client FormsTermit App_010411.doo (Rev. 1/11)
June 27, 2012
ARC 1 ERRA
CONSULTING, INC
212 E. 51"Ave, Anchorage, AK. 99503
ffice (907) 868-3791, Fax (907) 868-3793
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Upgrade Sewer Permit — Grace #1, Lot 3
The owner has requested we proceed forward to obtain a septic permit to
upgrade the failed crib on the subject lot. The general slope of this lot is from east
to west at a grade of approximately 12-17% over the septic area.
On June 20, 2012 a testhole was performed to investigate soils and groundwater.
The results of this test are attached for your review. The proposed upgrade will
serve the existing 3 -bedroom house. We propose to install one deep trench as
shown on the proposed design. Groundwater was not encountered at excavation
or at monitoring.
The property and adjacent lots are served by private water. There is no surface
water within 100' of the proposed system and there are no known curtain drains
within 50'. We do not expect there to be any adverse effect on adjacent lots by the
development of this system. If you have any questions, please contact me at 868-
3792 / FAX 868-3793.
Respectfully submitted,
ArcTerra Consulting, Inc.
Kenneth M. Duffus, P. .
Attachments: On -Site Sewer Application
Wastewater Absorption System Details/ Site Plan
Soils Log/ Percolation Test
20441 PTARMIGAN BLVD • EAGLE RIVER, AK 99577-8736 • PH (907) 868-3791 • FAX (907) 868-3793
WELL & WASTEWATER DISPOSAL SYSTEM DETAILS/SITE PLAN
GRACE #1, LOT 3
PRIOR TO CONSTRUCTION
NO PUBLIC WELLS WITHIN M' OF
PROPOSED SYSTEM.
NO PRIVATE WELLS WITHIN M OF
PROPOSED SYSTEM EXCEPT AS NOTED,
PROPOSED WELL EXCEPT AS NOTED.
OF AZ
AW <' �
I * 9TH
KENNETH M. /
` CE -7116 W�
$i
Scale: 1 "= 100'
DESIGN DETAILS PAGE 1 OF 2
3 BDRM X 150 GPD = 450 GPD
450 GPD/0.6 GPD PER SQ. FT. (3 MIN/IN.)= 563 SQ. FT
(563 / 2 x (10' GRAVEL) = 29 FT. TRENCH
USE 1 TRENCH - 40'(L) X 2' (W) X 10' (D)
Total depth of system is 13.5' MAX from original grade.
Total depth of gravel below distribution pipe is 10' .
NOTES:
1.CONNECT TO EXISTING SEPTIC TANK W1 DIVERTER
2. INSULATE TRENCH WITH 2" HD BURIAL FOAM IF < Y OF FILL.
MIN. 2' FILL WITH INSULATION, >T COVER NO INSUL REQ.
3. CONTRACTOR WILL ENSURE MAXIMUM 2% SLOPE INTO SEPTIC TANK.
4. CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT
WELLS, SEPTICS EASEMENTS, PROPERTY LINES, ETC...
PREPARED FOR:
DAVID & BREANA HARDIN
12750 KILLEY STREET
ANCHORAGE, AK 99516
FIELD BOOKS
BOUNDARY: n, Islr
STARING CTALm
ASBUILT: REJ
on. PLE:
ACAD ALE` FILE
COMPUTED:
DRANK: BMW
OHERED: KMD
DATE: 6/27/1
GRID: 2835
JOB No.: 12-154
WASTEWATER DISPOSAL SYSTEM DETAILS
GRACE #1, LOT 3
h
CPZ
CONNECT TO EX
& ADD DIVERT[
& CLEAN OUTS
FLAG PROPERTY LINES
WELL RADII & EASEMENTS
PRIOR TO CONSTRUCTION
NO SLOPES >25% WITHIN 50'
DOWN SLOPE OF PROPOSED FIELD
Aw OFALq Wit'
/ * 9TH*
/ KENNETH M. D
CE -7118 04
Ar
" 'ESstO-t�� �w
PREPARED FOR:
DAVID & BREANA HARDIN
12750 KILLEY STREET
ANCHORAGE, AK 99516
FIELD BOOKS
cDNRui .
BOUNDARr. BOUNDARY
DRAM:
BMW
STARING. STAKING
amm;
KMD
Assu'Lr. REJ
DAIS.
6/27/12
DW RM
GRID:
2635
ACRD "m FILE
10B Nm:
12-154
off'
vvC"
Scale: 1 "= 30'
PAGE 2 OF 2
b LILTING
e'?' AK. 99577-0'5"
ARC 1 ERRA
CONSULTING, INC
212 E. 51"Ave, Anchorage, AK. 99503
office (907) 868-3791, Fax (907) 868-3793
SOILS PERCOLATION TEST
Performed for: David or Breana Harden Date Performed: 6 20 rt
Project: GRACE #1 LOT 3 TEST HOLE # TH 12-1
Depth
(Feet) SEE ATTACHED SITE PLAN
20-
Org/OL
SM/SP w/ gm/gp pockets
B.O.H.
HOLEPRESOAKED
PRIOR TO TEST
FOR HOLE LOCATION
Was Ground water encountered? NO What depth? NA
Depth to water after monitoring? NO Date? 6127/12
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
1
6/20/12
1:00
6"
—Drop
-
2
1:10
10 min
2 14/16"
3 2116"
3
*
1:11
G,
4
1:21
10 min
214116"
3 2116"
5
*
1:22
6"
-
6
1:32
10 min
215/16"
31/16"
7
*
1:33
-
6"
-
8
1:43
10 min
3"
3"
9
*
1:44
6"
10
1:54
10 mill
3"
3"
11
*
1:55
6"
-
12
2:05
10 min
3 1/16"
2 15/16"
*
Water
Added
Percolation Rate 3.4 (min/in) Pere Hole Diameter 6"
Test Run Between 4.5 feet and 5.5 feet
I, Kenneth M. Duffus, certify that this test was performed in accordance with all State
and Municipal guidelines in effect on this date.
GRE, ANCHORAGE AREA BOF" ' mH
~]~)~/]~ Department of Environmental (~uality
' "'~.' 3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOCATION
MAILING ADDRESS 3/Z//~ /~-'~'/---'~ PHONE tO
LEGAL DESCRIPTION ~'~---~ /Cz ~'~ '"/-/"¢/~'~¢/~'/ ~/~/~///
SEPTIC TANK:
DISTANCE 2¢//¢¢~/ NUMBER OF
FROM WELL /~:~ MANUFACTURER /~/ ~¢2~2 MATERIAL J~C-~g~ COMPARTMENTS
INSIDE LENGTH INSIDE WIDTH
LIQUID DEPTH ~ LIQUID CAPACITY ,/~:¢D~' GALLONS.
SEEPAGE PIT:
/
NUMBER OF PITS / DIAMETER /¢2 / ~,
OR WIDTH / /
LENGTH , DEPTH
/
LINING MATERIAL/~//¢/~/~ ~'zg~/~3RIB SIZE: DIAMETER~.¢F' DEPTH ~/ DISTANCE FROM: WELL
TOTAL EFFECTIVE
BUILDING FOUNDATION~ NEAREST LOT LINF~q~'~'/¢,'- ABSORPTION AREA (WALL AREA) ~ SQ. FT.
ADDITIONAL ABSORPTION ~'~
WELL:
//~ /
TYPE CONSTRUCTION ~ DEPTH
BUILDING NEAREST ~f NEAREST
FOUNDATION /z~/ LOT LINE [¢ SEWER LINE
CESSPOOL ~ OTHER SOURCES
DISTANCE FROM:
SEEPAGE ~..~-
SYSTEM Z'Z~
APPROVED DISAPPROVED REMARKS
DISTANCES:
INSTALLED BY: -¢¢/~//E
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form No. EQ-031
DIAGRAM OF SYSTEM
GREATER ANCHORAGE AREA BOROUGH ,~:
PERMIT NO.
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-456 !
SEWAGE DISPOSAL 'SYSTEM -- APPLICATION AND PERMIT
MAILING ADDRESS //~)'// )'~ ~-~:~'/~
INSTALLATION OF: SEPTIC TANK ~ SEEPAGE PIT ~ ,, D~N FIELD . OTHER
FINANCKD THROUGH TO BE INSTALLED BY
NOTE= THIS PER~IT IS NOT VALID WITHOUT SOIL
COMPLET,ON DATE ANTICIPATED ~~
FINAL INSPECTION: 24 HOUR NOT~CE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK sIZe ~ TYPE ~~''~g~' g ARea SIZE
MINIMUM DISTANCES, REQUIREMENTS /
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT '~ -- O/ DraIN field
SEPTIC TANK TO SEEPAGE PIT WALL ---
SEPTIC TANK ~ / ~-0 /
.. SEEPAGE Pit ., DRAIN FIELD
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK /~ ~ SEEPAGE PIT ~//<~
DRAIN FIELD /~ ALSO CONSIDER AREA WELLS.
WATER MAIN TO SEPTIC TANK //~2-- ~
SEEPAGE Pit ~ :,
DRAIN FIELD
SEPTIC TANK, /~ 0 . SEEPAGE PIT */~ ~/ · DRAIN FIELD/ TO RIVER, LAKE STREAM,
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION S FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE Pit
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
LICENSED DESIGNER
DIAGRAM OF SYSTEM
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. ~~
FORM NO, E(~-016
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite (907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 017-042-60 COSA #
Expiration Date: Q - l -1
1. GENERAL INFORMATION
Complete legal description GRACE #1 LOT 3
Location (site address) 12750 KILLEY STREET, ANCHORAGE, AK 99516
Current Property owner(s) DAVID & BREANA HARDIN Day phone
Mailing address 12750 KILLEY STREET, ANCHORAGE, AK 99516.
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well:
®
Individual On-site
Individual Water Storage
❑
Individual Holding Tank
Community Class Well
❑
Community On-site
Public Water System
❑
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures 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. 1 further verify that based,on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, tvq 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 ARCTERRA CONSULTING, INC. Phone .868-3792
Address 20441 PTARMIGAN BLVD. EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 0710/2012
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. 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,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
1i.
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
cwH GnecKllst A Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory
Other
By: Original Certificate Date: % -/_j -/
(Rev. 11/05) ;A1
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite (907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: GRACE #1 LOT 3 Parcel ID: 017-042-60
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID #
Date completed Unkn Sanitary seal (Y/N) Y
Total depth 118* ft. Cased to *50+ ft.
FROM WELL LOG
Date of test
Static water level ft.
Well production
WATER SAMPLE RESULTS:
Coliform NEG colonies/1OOmL
Well Log (Y/N) N
Wires properly protected (Y/N) Y
Casing height (above ground) 12+ in.
AT INSPECTION
6/18/12
ft.
g.p.m. 7+ g.p.m.
Nitrate 10.7 mg/L
Arsenic: ND mgA Date of sample: 6/26/12 Collected by: ArcTerra
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Concrete Date installed 7/5/1974 Tank size 1000 gal.
Number of Compartments 1 Cleanouts (Y/N) Y Foundation cleanout (YIN) Y Depression over tank (Y/N) N
High water alarm (YIN) N Date of pumping 6/26/12 Pumper A+
C. ABSORPTION FIELD DATA
Date installed 7/10/12 Soil rating (g.p.d./ftz or fe/bdrm) 0.8 System type Deep Trench
Length 41 ft. Width 2 ft. Gravel below pipe loft. Total depth 13.5 ft.
Eff. absorption area 820 ftz Monitoring tube Y Depression over field N
Date of adequacy test NA — New System Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test in. Water added_ gal. New depth in.
Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at _in. High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Absorption field on lot 1001+
Public sewer main
Sewer /septic service line
On adjacent lots 100'+
On adjacent lots 1001+
Public sewer manhole/cleanout 1001+
Holding tank
Animal containment areas 501+ Manure/animal excrete storage areas 1001+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 51+ Property line 51+ Absorption field 51+
Water main 101+ Water service line 101+ Surface water 100'+
Wells on adjacent lots 1001+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 301+ Building, foundation 10'+ Water main 101+
Water Service line 101+ Surface water 1001+ Driveway, parking/vehicle storage 101+
Curtain drain 50'+ (None Known) Wells on adjacent lots 1o0'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that l 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.
Engineer's Printed Name KENNETH M. DUFFUS
Date 7!10/2012
COSA Fee $250.00 7` / sn —
Date of Payment_
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Community Development Department
Development Services Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
Nitrate Advisory
Certificate of On -Site Systems Approval 4 121271
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
3 of Grace 41 subdivision. This inspection revealed a nitrate concentration
of 10.7 milligrams per liter (mg/L) was reported for the property's well
water sample. 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 Pact Sheet" for important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
SGSRef.#
1122562001
Client Name
ArcTerra Engineering and Surveying
Project Name/#
Grace #1 Lot 3
Client Sample ID
Spigot -Grace #1 L3
Matrix
Drinking Water
Sample Remarks:
Printed Date/Time
Collected Date/Time
Received Date/Time
Technical Director
Parameter Results LOQ Units Method
Metals by ICP/M5
Arsenic ND 5.00 ug/L EP200.8
07/02/2012 16:53
06/26/2012 13:00
06/26/2012 14:05
Stephen C. Ede
Allowable Prep Analysis
ContainerlD Limits Date Date htH
C (<10) 06/28/12 07/02/12 NRB
Waters Department
Total Nitrate/Nitrite-N
10.7 * 0.100
mg/I,
SM21 4500NO3-F B (<10)
Microbiology Laboratory
E. Coli
Negative 1
IOOmL
SM21 9223D A
Total Coliform
Negative 1
100mL
SM21 9223B A
06/28/12 CMA
06/26/12 MEM
06/26/12 MEM
PR9VOiFD rY151rt➢ RafR
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UNDER NO CIRCUMSTANCES SHOULD AN AS—BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES.
THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY
AND ASSUMES FINANCIAL LIABILITY ONLY FOR THE COST OF THE SURVEY.
USTED DISTANCES PREVAIL OVER SCALING, REPRODUCTION MAY CAUSE ERRORS IN SCALE.
LOT=SURVEY TYPE
SYMBOLS
fWNDA710N AS -BUILT
El FISTRUMRE AS -BUILT
SET REBARNAL 7= ;W DRAINAGE ASPHALT
❑ PLOT PIAN ... AB -BUILT ...LOT SURIEY ... TaPOCFAPMY
O FOUND REBAR 0 6 e. HOOD FENCE CONCRETE—
AS -BUILT ... Na C ERS T WMrB CATIM AS -BUILT ... NO CORNERS SET
ASSUMED ELEV.-X---X.-7F METAL FENCE ® WOOD DECK
PLOT PLANS & LOT SURVEYS
NOTE:
IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER. PRIOR TO
ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE
CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE
SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS,
TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE
ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW
THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS
MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED.
WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT.
ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED.
SURVEY CERTIFICATION
..,,.��trrrr
Prepared by
PLOT PLAN
.•�-�E o� q��+4+
Robert E. Johns, Jr. 8c Assoc.
M KK h0.,, 4M aws." Iw.u,. aM tlM I
••••
!_
Professional Land Surveyors
a n.�'pan` "a�dtl1o�u.�wewmY
A..........
'r VJ'• •�
1700ErA Drim
�
ALASKA
ANCHORAGE, ALASKA 99564
Scale: _
Rec. Lot S.F.
Rec. Plat file No.
FOUNDATION AS—BUILT
!• •••••• •••• ...
•'•
111
601
la o m AAi-Bui1 iwyhi epi.'
Ae�mBveall. '"
0
/ •••• uu.. . . •....•`
Date S°`''e'�d 7/10110
Drawn bY. REJ
Checked b
aIG Ffamalbn a I Iw.m
OBERT OHNS,•a
M K
�y WyW .'
'. �•.••
Ar
Date Drawn:
Grid:
W.O'
e
�.9f �' 121—S AF
7/10/10
2835
12-248
FINAL STRUCTURE AS—BUILT
I, a L A r., "w+er awry ewe I
'• i
f'i•�'
•��
Legal Desrlptian:
"ma dt a M
mxom
e
Oy
�
a a�ession
uwr
•w. _�.�.
4raa..�•
GRACE #1
Municipality of Anchorage
• Development Services Department s
Building Safety Division x, .• « _
On -Site Water and Wastewater Program 5E,T Y
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650 _.._..
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I. D. 0 COSA #J �� 1,� 1117
Expiration Date: i Q - % 3
1. GENERAL INFORMATION
Complete legal description /°,,eC Z o
Location '(site ,address) `,?50
Current Property owners) Day phone 90i-6 �- X126
Mailing address 2,o/ w-y-,
�GHI L�ysn�cy°�r
Lending agency �'rs T � °�����►� ,���� Day phone
Mailing address ��, box f®tea 7 Zo
Real Estate Agenty
(.�®dam
Day phone
lam?--yl�-o���
Mailing Address
���t '®®6NT
Su> r� �o® �� LGd
4k/%so3
-- . Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
[Y�.
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank ❑
Community On-site ❑
Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures 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 c:�>Ey",�•s
Address T �s,A AZ;
Engineer's Printed NameG�l
5. DSD SIGNATURE
Approved for 3 bedrooms.
Disapproved.
Phone 9®7`�/-� �,�►t.
Date � 7— — lU
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
e WASTEWATER e
PROGRAM `
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Z., d Original Certificate Date: —7 % 3 — ZQ
(Rev. 11105)
Municipality of Anchorage
• a,, 0 ' o
Development Services Department a Z
Building Safety Division t
On -Site Water & Wastewater Program 5 " T'Y
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650'
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: 6 Aft t ,z l o T 3 Lo T 3 6 8hc t 3 Parcel ID: O /7 -'0
A. WELL DATA
Weil,type Pr,r,4 Tc If A, B, or C provide PWSID # Well Log (Y/N) /l
Date completed uN**v 4-q Sanitary seal (Y/N) _.Les
Total depth lifft. Cased to f b eft.
FROM WELL LOG
Date of test IV,4
Static water level ft.
Well production g.p.m.
Wires properly protected.(Y/N) %-s
Casing height (above ground) IS-" in.
AT INSPECTION
>� g.p.m.
WATER SAMPLE RESULTS:
Coliform _colonies/100 mL Nitrate `D. r mg/L Other bacteriacolonies/100 mL
Arsenic: NA ug/L date of sample: 6- 2'1-"0
B. SEPTICIIOLDING TANK DATA
Tank Type/Material
CH.c.14-Tt *
Collected by: 1q A41g, N ,
Date installed 7- S ` 7/
Tank size 1000 gal. Number of Compartments .1v Cleanouts (Y/N) Ye -5
Foundatiotrcjaanou (Y/N) ,, Depression over tank (Y/N) 14/0e; High water alarm (Y/N)
Date of purno 0. Pumper
C. ABSORL'TIDN-F�.;D,�LTA�-
Date installed; 7 07," Soil rating (g.p.d./ftzft2/bdrm) j.7.r* System type Q
Length l y ft. Width I I" to AtO � ft;* Gravel below pipe
Total depth JJ_ft. Eff. absorption area 360 ft2 Monitoring tube Ye.% Depression over'field IVO
Date of adequacy test Results (Pass/Fail) ss For 3 bedrooms
Fluid depth in absorption field before test V y in. Water added r4Ogal. New depth rO in.
Elapsed Time: q37 min. Final fluid depth in. Absorption rate >= +- qSD g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) /lam/% If yes, give date X/4
D. LIFT .STATION NO f r,,� 7, e 7
Date;installed Size in gallons Manhole/Access (Y/N)
"Puat in. "Pump off' level at in. High water alarm level at in.
Datu Cycles tes Meets alarm &circuit requireZnts?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot !� %���� On adjacent lots lDo
Absorption field on lot 4-1490 ' On adjacent lots/DO
Public sewer main 1444 ¢!Oe Public sewer manhole/cleanout A,/4 — -4 tea
Sewer /septic service line 3 S Holding tank Ae/ 4
Animal containment areas /✓f1 4'/ay Manure/animal excrete storage areas AO tip
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 6S-� Property line _)-0 Absorption field
Water main +/oa Water service line +/dp Surface water *I've
Wells on adjacent lots t-100
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line t'l0 Building foundation g� Water main
Water Service line Surface water �1 p4 Driveway, parking/vehide storage
Curtain drain 4l Wells on adjacent lots
F. COMMENTS T%
�`=T'�0... RGce/iI +�d%.•.O//may
G. ENGINEER'S CERTIFICATION ,�•OF ,%" +
I certify that I have determined through field inspections and P49 m •• *,��
review of Municipal records that the above systems are in *.
conformance with MOA COSA guidelines in effect on this date. ....:« ••i
;SAW
Engineer's Printed Name/vl49rTlic.� �.r�®►!a, �I�^��•,. (.1{ ; ��
Date l' l0 +44 OP aE"�o��.•
COSA Fee $ "T O Waiver Fee $
Date of Payment :2 r -O Date of Payment
Receipt Number 3 3 Receipt Number
(Rev. 11/05)
Municipality of Anchorage s�
• ''� Development Services Department r °w
Building Safety Division
SA ETY
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
Nitrate Advisory
Certificate of On -Site Systems Approval # 101117
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
3 of Grace #1 subdivision. This inspection revealed a nitrate concentration
of 10.1 milligrams per liter (mg/L) was reported for the property's well
water sample. 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.
Matthew J. Nardini, P.E.
2000 E. Village Loop
Wasilla AK 99654
July 13, 2010
Jeff Poet
Onsite Services
Municipality of Anchorage
Re: Grace Subdivision #1 Lot 3
Mr. Poet,
1.11rl- W
email: matt@olympusengineering.com
Phone: 907-373-6289
Fax: 815-642-0719
Upon water testing on the above property, SGS Environmental reported that the Nitrate levels in
the water taken from the well were at a level of 10.1 mg/L. This exceeds the maximum allowable
level of 10.0 mg/L. Upon receiving this result, Jim Sullivan of Arctic Pump and Well was
contracted to use a camera to go down the well to examine the casing and pitless for any holes,
breaks, or places where any contamination from surface sources could enter the well.
This was performed to determine if any surface contamination could be the cause of the high
Nitrate levels found in the well. On July 10, 2010, Arctic Pump and Well did perform this
inspection, and found no irregularities or places that would allow surface contamination to enter
into the well.
There are no animal containment areas near the well, and the surface drainage and topography of
the ground near the well provide for good drainage away from the well. There is also a good seal
from the well cap, providing protection from contamination.
Based on these observations and the inspection performed of the well casing and pitless adapter, it
is the conclusion of Olympus Engineering that this well is not a source for surface contamination
into the aquifer. It can also be assumed that the level of Nitrate in the water is reflective of the
levels of the aquifer that is tapped by this well, and that no further repair is required for this well at
this time. It is not necessary to grout the well to a depth of 40' to maintain aquifer integrity.
Thank You for your time and effort.
Sincerely;
W
Matthew J. N rdin', P.E.
Owner/Princip ngineer
Olympus Engi eering
7/13/2010
5615301 SGS North America Inc.
SGS Ref.#
1103036001
Client Name
Olympus Engineering
Project Name/#
Grace #1 Lot 3
Client Sample ID
Grace #1 Lot 3
Matrix
Drinking Water
PWSID
0
09:11:58 a.m. 07-01-2010
Printed Date/Time 06/30/2010 8:24
Collected Date/Time 06/24/2010 15:00
Received Daterfime 06/24/2010 16:01
Technical Director Stephen C. Ede
215
Sample Remarks:
Allowable
Prep Analysis
Parameter
Results
LOQ
Units
Method Container ID
Limits
Date Date
Init
Metals by ICP/MS
Hardness as CaCO3
305
5.00
mg/L
SM20 23403
C
06/25/10 06/28/10
KDC
Waters Department
Total Nitrate/Nitrite-N
10.1
0.100
mg/L
SM20450ONO3-F
B
06/27/10
AYC
Microbiology Laboratory
Colony Count
0
col/100mL
SM20 9222B
A
(<200)
06/24/10
DLC
Fecal Coliform
0
col/100mL
SM209222B
A
(<I)
06/24/10
DLC
Total Coliform
0
col/100rnL
SM20 9222B
A
(<1)
06/24/10
DLC
Private Individual Analysis
Alkalinity
212
10.0
mg/L
SM20 2320B
D
06/25/10
LP
Aluminum
ND
20.0
ug/L
EP200.8
C
06/25/10 06/28/10
KDC
Antimony
0.761J
1.00
ug/L
EP200.8
C
(<6)
06/25/10 06/28/10
KDC
Arsenic
ND
5.00
ug/L
EP200.8
C
(<10)
06/25/10 06/28/10
KDC
Barium
11.4
3.00
ug/L
EP200.8
C
(<2000)
06/25/10 06/28/10
KDC
Cadmium
ND
0.500
ug/L
EP200.8
C
(<5)
06/25/10 06/28/10
KDC
Calcium
91500
500
ug/L
EP200.8
C
06/25/10 06/28/10
KDC
Chloride
44.1
0.500
mg/L
EPA 300.0
D
(<250)
06/27/10 06/28/10
SDP
Chromium
1.82J
2.00
ug/L
EP200.8
C
(<100)
06/25/10 06/28/10
KDC
CO3 Alkalinity
ND
10.0
mg/L
SM20 2320B
D
06/25/10
LP
Conductivity
652
1.00
umhos/cm
SM20 251013
D
06/25/10
LP
Copper
17.9
1.00
ug/L
EP200.8
C
(<1300)
06/25/10 06/28/10
KDC
Fluoride
0.0450)
0.100
mg/L
EPA 300.0
D
(<2)
06/27/10 06/28/10
SDP
HCO3 Alkalinity
212
10.0
mg/L
SM20 2320E
D
06/25/10
LP
5615301 SGS North America Inc.
EEI
09:12:18 a.m. 07-01-2010 315
SGS Ref.#
Client Name
Project Name/#
Client Sample ID
P
Matrix
PWSID
1103036001
Olympus Engineering
Grace #1 Lot 3
Grace # 1 Lot 3
Drinking Water
0
Printed Date/Time
Collected Date/Time
Received Date/Time
Technical Director
06/30/2010 8:24
06/24/2010 15:00
06/24/2010 16:01
Stephen C. Ede
Parameter
Results
LOQ
Units
Method
Container ID
Allowable Prep Analysis
Limits Date Date
[nit
Private Individual Analysis
Iron
174J
250
ug/L
EP200.8
C
(<300)
06/25/10 06/28/10
KDC
Lead
5.33
0.200
ug/L
EP200.8
C
(<15)
06/25/10 06/28/10
KDC
Magnesium
18500
50.0
ug/L
EP200.8
C
06125110 06/28110
KDC
Manganese
3.07
1.00
ug/L
EP200.8
C
(<50)
06/25/10 06/28/10
KDC
Nickel
3.14
2.00
ug/L
EP200.8
C
(<100)
06/25/10 06/28/10
KDC
OH Alkalinity
ND
10.0
mg/L
SM20 2320B
D
06/25/10
LP
PH
7.70
0.100
PH units
SM20 4500-H B
D
(6.5-8.5)
06/25/10
LP
Selenium
ND
5.00
ug/L
EP200.8
C
(<50)
06/25/10 06/28/10
KDC
Silver
ND
1.00
ug/L
g
EP200.8
C
(<100)
06/25110 06!28/] 0
KDC
Sodium
5880
500
ug/L
EP200.8
C
(<250000) 06/25/10 06/28/10
KDC
Sulfate
16.5
0.I00
mg/L
EPA 300.0
D
(<250)
06/27/10 06/28/10
SDP
Thallium
ND
1.00
ug/L
EP200.8
C
(<2)
06/25/10 06/28/10
KDC
Total Dissolved Solids
426
10.0
mg/L
SM20 2540C
D
(<500)
06/25/10
AYC
Zinc
90.2
5.00
ug/L
EP200.8
C
(<5000)
06/25/10 06/28/10
KDC
i � _ • � Vim;}�� ` �� `� �' , � � � � e
9 .8 wy 3 �' '„fir ' . ' =.ti D,ee `•:l�{amo�. '•.
°zIef-
ie
,.,ro res
V -C -V k s
s^t'gr+,w:°ti�,a�L.•�±�°.i�.. �• 1wr;�"�4� t "'s • '- a;.-�`._`.. t 3'. �.. _ _
i
OF .4
®,= 49L
Ll
•AsUBUIN ww;,y
�i a•, �,•a •a••••••• •eww.••e
•
•• a •Ir/ . •a• .••w..
It is the responsibility of the owner to determine�/•'�=•l'`1µ- , °, Ka4 oa.r'®;
the existence of any easements, covenants, or re- �l 0 ter•., }�ca , ,
strictions which do not appear on the recorded sub- r�FSF "�..` ,••'"s�,p
division plat. Under no circumstances should any OTE
` data hereon be used for construction or for esta-
T$ OF RECORD, OTHER THAN T"OSE
fishing boundary,or fence lines. -The surveyor takes SHOWN ON THE RECOROEO PLAT, ARE Nor
responsibility for the initial transaction only. ° SHOWN Mrom.
LOT 36 BLOCK 5LEN
OEQ
g+ & IMARS EAP MONUMENT
—_tt.�'iCA4A !-1 e 1.1 .Ze 4�a�E, � PLAT NO. I 'tom InOAX►wofEae. o
ANCHORAGE RECORDING DISTRICT 13 HUN A TACK
REPAR CY BY: I)OWLJNG-
a A SSOCIATES.
1426 NYDER STREET
ANCHORAGE ALASKA 99501 N
sTE� ;-q 9 BY, SCAL E': ,> ` ✓ WORK R.' FIELD WOK: GRID:
INVOICE #
Block Lot
10/08120 gallons, I standpipeg, I hogies
Tank located 751 from front of house
T®TA
REMARKS
/0�06 Gallons Septic _ Leach Area Holding Tank
El PROBLEM AREA — CALL FOR MOREI FO ATION
C] NEEDS TO BE DONE AGAIN IN 6 MONTHS
❑ Good Shape [1 Sludge buildup on bottom
Jim cap missing or El Out standpipe to 1' above ground
needs replacing
Standpipesl?�1-6Time
Floater on top
Needs Septictrine
· ~ 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 S NGLE FAMILY DWE. LLING
1. 'GENERAL INFORMATION
Location (site address or directions)
Property owner'
· Ma.ili~g address
Lending agency'~
Mailing address
Day phone
Day phone
Agent' f~'?2. '~e.~J~: '~AT~5~
Address· "'-~lll '0_' ~"-t--r2~_-~_-T-,/
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
.~'..~ .:-' : ::;
Public water
NOTE:
lng to the legality and status of system.
4, 'i"YPE OF wAsTEwATER DISPOSAL:
"If community well system, provide written confirmation from State ADEC attest-
'Individual on-site ' ._.
HOdingtank ' :" '-'
Community on-site
· - Public sewer
if.community wastewater system, provide Written confirmation from State AD£C
attesting to the legalitYand status o~ system.
NOTE:
72-025 (Rev, 1/91) Fron_t_ 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 Munici pality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in corn pliance with all Municipal and State codes,
ordinan cas, and regulations in effect on the date of this inspection.
Name of
Address
Engineer's
Phone 2~"~
DHHS SIGNATURE
3
~' Approved for
Disapproved.
bedrooms.
Conditional approval for bedrooms, with the following stipulations:
Note: The well for this property meets existing State and Municipal Codes.
There ~r~ n~rm~m present. It is suggested that periodic testing be
performed to insure the wells continued suitability. Current nitrate
concentration i2 ~ /,~ ~/~ ~A ~n~m,~m ~nn~n~r~t~on i~ 10,0 mg/1
More information on nitrates is available from the On-site Services Program,
DHHS,
Additional Comments
The Municipality of Anchorage Department of Health and Human services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requ rements. 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(Re¥.1/91) BaCk MOACY21
Municipality of Anchorage P~ E, C E IV E D
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division DIG 29 1997
825 L Street, Room 502 · Anchorage, Alaska 99501 · ( 34 -47
~v(~)t~r~ic, p a~ ,t y 7o~.chorage
Dept. Health & Human Services
Health Authority Approval Checklist
Legal Description: ~.'~,;~.'~
Parcel I.D.:
A. WELL DATA
Well type~;:;~{~- t\) J~'r-~
Log present (Y/N) ~
Total depth /l ~
Sanitary seal (Y/N) '
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to .b~-P'+
FROM WELL LOG
g.p.m.
Casing height (above ground). /,~_tr
Wires properly protected (Y/N) ~'
AT INSPECTION
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform '-- C~ ~
Nitrate
g.p.m.
Other bacteria D
Date of sample: /'~ [~{q~
COllected by:
B. SEPTIC/HOLDING TANK DATA
Date installed '~ /,.,~ / ~ z~ Tank size
Number of Compartments / Cleanouts (Y/N).__
Foundation cleanout (Y/N)
Date of Pumping t' ~1'7_.~'! ~?-
Depression (Y/N)
Pumper i~.-''''F' ~..~/.~-
High water alarm (Y/N).
C. ABSORPTION FIELD DATA
Date installed "~//5-[~ q Soil rating (g.p.d./ft o~.?~!bd~ ,/'~,5~ System type ~-I~ ~
Length ? //4 ~ Width 1'7_-'2o ' Gravel thickness below pipe ~, ' Total depth /'~-
Effective absorption area '~' ~,¢::~ ~ Monitoring Tube present (Y/N) ~' Depression over field (Y/N)
Date of adequacy test I '~/~ ~/ff"-~ Results (Pass/Fail) ~)A ~ For ~.~ bedrooms
Fluid depth in absorption field before test (in.); .?~.4( Immediately afterZ-'/',.~"-~ gal. water added (in.):
Fluid depth ~,~-¢~ (ins) Minutes later: /~C) Absorption rate = ~ .g.p.d.
Peroxide treatment (past 12 months) (Y/N) ~
If yes, give date
72-026 (Rev. 3/96)* --::~: : ' ::-. :': ·
¢w~ted
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot / ¢'~- ~ -to c,¢~.
LIFT STATION
Date installed ¢//~,/,-./ ~
Manhole/Access (Y/N) ~" level at* "Pump off" level at*
I fl~L
}, ir *Datum '
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation d¢¢, ,~-t Property line
Water main/service line / ~ Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Surface water
Curtain drain
F. ENGINEER'S CERTIFICATION
Building foundation
Absorption field
Wells on adjacent lots
Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots /
I cerhfy that I have determined thru field Inspections and review of Mun/c/pal records tha.~¢~lZ~b ~fe~s are
/n conformance w/th MOA HAA gu~defines in effect on this date. ~',,; ~ :,,,~ ....... -'"(,:-. ~
Engineer's Name ~~ ~~~~ ~~ ~
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev, 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
Steven R. Pannone, P.E.
Consulting Engineer
P.O. Box 142025
Anchorage, Alaska 99514
(907) 272-8218
Legal:
Owner:
Residence:
Septic System:
(from Municipal records)
SEPTIC SYSTEM ADEQUACY TEST
Lot~& Block ~/xna~A b~O a]
Ta~Size: /~ gallons. Abso~tionSystemT~e: ~etB
Absorption System Size: t~
Mstallation Date: ~/~¢
Date of Pumping: r~[~
Date of Test:
By: A't~
Test Procedure: System was inspected and meassured Tank was found with q t Feet of cover.
Liquid depth was measured to be ,~-15'" Inches. The drain field was found to have 6' Feet of cover and
a total depth of/~ . There was ~.g- Inches of liquid measured in the field's monitor tube.
Water was added to the system at a constant rate of ~,'t- G.P.M. The water levels in the tank and drain-
field monitor tube were monitored. A total of q, Sx> Gallons of water was added. During the test the level
rose / ! Inches in the field. No rise was noted in the tank.
The infiltration rate was monitored for/¢t¢o Minutes. During this period, a total of ~Gallons were
absorbed. By extending the observed infiltration rate, a total absorbption rate ct6-~ Gallons per day was
arrived at.
TESTS RESULTS: This system meets~m~a~t the code requirements of the Municipality of
Anchorage.
The operational life of all septic systems depend on the local soil condition, ground water levels that may
fluctuate during the year, and the water usage of the family being served by the system. These conditions are
outside the control of the evaluator of this system. We can therefore not give any estimate of how long the
system will continue to meet the operational requirements of the Municipality and State.
CTs. el.# 977705001
Cllem i ~me Pannone Eng Sty.
i~o~ect ]~ame/# L ~6~ B3 MeMnon No_ 1
Client S~ple
Matrix Drinking Water
Order~
Sarnnle Remake:
Printed Date/Time 01/05/98 11:26
Collected Date/Time 12/;18/97 12:00
Received Date/Time 12/29/97 1 ! :45
Technical Director: Stephen C, Ede
R~le~t~ec~ B~' _~--~ ~f'
Ni~rmtm-~ 6.~6 0,10o n~J/L E~A ~00.0
T~;al ~otiform 0.00 cotl~OOr~ ~M~s
~ GT~;~ nv!ronmentalServlces Inn.
L~:TT 8661-90-NU£
I_aDora~ol.y, [.hv~lon
Water Analysis Report for Total Colifom Bacteria x~
Anchorage, AK 9951 ~-160~
TO BE, CO~PL~ F~D P-Y LAi~Oi~.ATOR¥'
~fla~is 51aows this Water SAMPLE tO be:
.~atis .f~c.tory
Sample ovee 30 houra old, ruutk~ m=y
be unreliable
Sample coo Iofl~ in transit: sample should
~o~ be over 48 hou~ old ~ e~in~ion
Dale Reeeiv~ , , .
~me Received
Ansl~cnl Metb~ ~b~e P;Itcr
]3mr.
Clrtnt flosifled of UMlttlfnetm'f results;
T~mf~
BACTERIOLOGICAL WATER A~ALYSIS I~ECORD
Cnloniel[llXl mi
Coliform/lO0 mi
.N, INII~.,'.,IUC IZ,nluiI', Tdtil
Membrane filt~n Direel Count
YeHflcstiot: LTfl , BGB. ....
~nai ,',,femb~M ~lt~ tmlu
4S:TT ~66T-90-NU£
~ CT~I~ Environmahtal Servicog Inc,
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
$43-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description LoT ;~6, gL~ 3 McM/~HoN s/B, /}Db'N ~' [
Location (site address or directions)
Property owner STE ~E /~ ~TH
Mailing address ~0.~ox tlozsG , A~cH.
Day phone 786-3~80
Lending agency S£R'TTLE ~O~T6A~E - Le~y E~II,~ Day phone
Mailing address ,¢¢'o ¢ ~ /'F~,~/ ,~c~¢ /F~.
Agent N, A-. ( R~ ~c~nc~,~c'~ o,~ fy ) Day phone
Ad dress
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well ¢
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site v/
Holding tank
Community on-site
Public sewer
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 verifythat 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.
NameofFirm ~'/_ATTOP T£cFt ~I,'CS Phone 3ff5'- 13.S',5'
Address Iq~3o ~cRo S'r, /~ rqC~. Ak 995-/6
Engineer's signature '~7"~ ~. "~'/¢,0.¢-,x_ Date
DHHS SIGNATURE
~ Approved for
/
Disapproved.
Conditional approval for
/
bedrooms, with the following stipulations:
Additional Comments
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.
72~025 (Rev. 1/91) Back MOA it21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ).- 3~,.. ~ $, I~c~/tHON G! Parcel I.D.
A. WELL DATA
Well type [='Eli~ATE
Log present (Y/N) ~
Total depth ( I ~' /
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed l~7¥ Driller
Cased to ~. ~-o ' Casing height I
Wires properly protected (Y/N)
FROM WELL LOG
g.p.m.
; On adjacent mots
; On adjacent lots
Public sewer manhole/cleanout
To C.D.
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main '~' Ioo
Sewer service line ~ 2 5
WATER SAMPLE RESULTS:
Coliform ~ cC'(/lO0 r~-~ Nitrate
Date of sample:
Petroleum tank NONE
/'~7//'''~' Other bacteria
Collected by: FJ..~7-'TOP '['Ect./
B. SEPTIC/HOLDING TANK DATA
Date installed 7/3/7~ Tank size )000 ($,z)L Compartments !
Cleanouts (Y/N) "/ Foundation cleanout (Y/N) ~/' Depression (Y/N)
High water alarm (Y/N) N. A, Alarm tested (Y/N)
Date of pumping ! I ./ 'T / ? ~ Pumper ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot Jo'/~ pRo~ C.O, On adjacent lots ~ /00 '
To property line Jo~ AbsOrptiOn field 2.0~
Surface water/drainage ~/oo '
Foundation
Water main/service line ~2~'
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
._ "Pump on" level at
Manufacturer.
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed '7/~]'7q
Length ~.O/ 4. ~2/ Width )~4t
Total absorption area ~J(oC) ~
Depression over field (Y/N) ~
Results (pass/fail) Pc¢-~_f
Peroxide treatment (past 12 months) (Y/N)
Soil rating 125 ~'/6b~'/~ System type 5£EPA6E
Gravel thickness (~ Total depth
Cleanouts present (Y/N) ¥
Date of adequacy test Io/3o/9z
for ~
NONE Kl'Ce~'f',l If yes, give date N ,/~ ·
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot 115
To building foundation
On adjacent lots ~$0'
Surface water
Curtain drain
On adjacent lots ~,/oo' Property line 10 ~
F~eo~ C,O. To existing or abandoned system on lot N.,~,
Cutbank N./~. Water main/service line ~25"
Driveway, parking/vehicle storage area ~,/e ~
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
Date It(
HAA Fee $ ~'/'?~ -2 , :¢ ¢.':
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA99518 T~EPHONE (907) 562-2343 FAX:(907) 561-5301
ANALYSIS RESULTS £or INVOICE $ 60177
Chemlab Rei,~ 92.6074 Sample ~ 1 ldatrJx: WATER
Client Samol~ ID
?WSIO
Collected
Rcceived
Preserved with
L36 ~3 MCR~HON ~ SOUTH HOSE EI~ Client Name :FLATTOP TECHNICAL SRV
UA Client Aect :FLATTOT
10/30/92 ~ 13:45 ?~s. BPO$ : ?0~ :NONE RECEIVED
10/30/92 @ 16:30 ks, Req$ :
AS ~EQUIEED Ordered By :
~na].ysis Comp!~ed 11/02/92
Laboratory Superviso~ : S~EP~EN C. EDE
Send ~eporrs
i)EL~TTOP TECHNICM, SRV
Pa~amet ez Result~ Units ~[~t hod ~l].owable Limits
NITRATEq~ i~" ' '~/ mR/1 gPA 3,53.2/300.0
Smaple ROUTINE SAI~LE COLLECTED BY: CI)~IS.
~emarks:
i Te~ts ?erformad ' See Special Inctruction~ Abow Uk~Unavailable
ND~ None Detected "' Sea Sample Remarks Above:
NA~ Not M%alyzed LT-Less Than, GT-Great~z Yhau
Member of t.e SGS Group (Soci~tb G~nbrale de Surveillance)
Drinking'Water Analysis Report for Total Coliform Babteria·
TO BE COMPLETED BY WATER SUPPLIER
FI PUBJ. lC WATER SYSTEM I.D.
~i[/PRIVATE WATER SYSTEM
Name
Phone No.
MeJling Address
A lc 4.
C~ly
Mo. Day
SAMPLE TYPE:
'~(. Routine
[] Check Sample {for routine sample
with lab ref. no.
[] Special Purpose
SAMPLE
No.
1
2
3
4
5
Year
[] Treated Water
~ Untreated Water
Time Collected
Collected By
TO BE CbMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
~SatisfactOry
[] Unsatisfa~ory
1
[] Sample ldo long in transit; sample should
not be ovi~r 30 hours old at examination
to ~nd~cate rehable results. Please send
new sample via special delivery mail.
Date Received
Time Received
Analytical Method: Membrane Filter
* No. of colonies/100 mL
Lab Ref. No. Result*
A.D.E.C.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Membrane Filler: Direct Count I~) Coliform/100 mi
Verification: LSB BGB
Fecal coliform confirmation
Final Membrane Filter Results ,-2 Coliform/100 mi
TNTC = Too Numerous To Count
OB = Other Bacteria
PART ONE OF TWO
REMAINDER TO FOLLOW
porn.
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # .~ [~'~.\~ - (7..L~ ~ - ,-~. ~ .HAA# ~-\ {~ Q
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
(b)
(c)
(d)
Location (address or directions)
I ~6' CO
Property owner ~'&t~ ~-,ba'o~
Mailing Address I
Lending Institution
Mailing Address
Real Estate Company and Agent
Address y O07 ~(~
Telephone ~ f - 7~
Telephone: (home) 5' ~f,.¢-¥7~ Business
Telephone ~-6" ~. - ~,~'0"~'
(e)
Mail the HAA to the following address: (or check here r~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
3. WATER SUPPLY
Individual Well ~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 Of 2
~ ~.o ~ e6ed
I~UO!~!puoo
le^oJddv leUO!l!puoo ~o SLUJe/
peAoJddes!a pe^oJddV
Aq SLLlOOJpeq ~ JOe peAoJddv
'qVAOI:IddV SHHa '9
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description:
Well Classification lc' ~'~
Well Log Present (Y/N) /~ Date Completed
Total Depth It8 Cased to ~ 'fo' Depth of Grouting
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot I o'7'
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
If A, B, C, D.E.C. Approved (Y/N)
Yield ~
Pump Set At '~- ~'o0't
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
~ c.o, ; on Adjoining Lots ';~ too '
; On Adjoining Lots ~' ~oo,
To Nearest Public Sewer Cleanout/Manhole
I
Foundation Cleanout (Y/N) Y'
Water Sample Collected by ~'lM-/~/, "/~,,~,,! .Cvcr ; Date ~,/1~/~
Water Sample Test Results ~ f~r .,L~ c~"° ~'/Y
Comments D~4~';~.~ b~,¢II /vteto( ~-~'½ a,~
SEPTIC/HOLDING TANK DATA
Date Installed ?/5'/'/'f Size I oo~ No. of Compartments
Standpipes (Y/N) ~' Air-tight Caps (Y/N)
Date Last Pumped ~/'~-/8'~
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N) N.,4.
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well ~'O'~ t
To Property Line I0~
To Water Main/Ser~vice Line ,~
,4.
To Stream, Pond, Lake or .Major Drainage Course
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ? [,~'/7 ~'
Width of Field f ~
I 8,5'
Square Feet of Absortion Area '~'O
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field I
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot N, A,
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line lo r
To Existing or Abandoned System on
; On Adjoining Lots '~ ~ '
To Cutback (if present) t,/,&.
~> ¢0/
D. LIFT STATION Al,/~.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guid_.eJ~;ICc&~p, effect on the date of this
inspection. ~(~ ~- - -~ ~.
Signed ¢~
Company ~[~f~ ~c ,;(~[ ~ v~C~ ~"4~TH'~
Date ~¢ ~, /e~¢ p .......................... cEng~neersSeal
MOA No. ¢¢ - ¢~ 8 ~ * ~HEODORE F' MOORE .
' F2~'~ . ,~Y' ReceiptNo.
Date of Payment ¢~d~o/ Waiver Fee: $
Amount:$ ,/~,-- -- CE~ Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2