HomeMy WebLinkAboutENGLE LT 1
Municipality of Anchorage Page I of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewate'r Disposal System and/or Well Inspection Report
Permit Number: .~j,~o[z~~..~ PID Number: ~3~r-~l
Name: ,
~ ~c~ ~. ~ ~~ ~. ~~ Wastewater System: Q New Upgrade
Address:
~~ ~c ~ ~ ~ ABSORPTION FIELD
Phone~ ~ ~No. of B~oms: ~Dee~nch ~ Shallow Trench ~Bed ~Mou~Other
LEGAL DESCRIPTION sci. Rating: ~GPD/Sq. Ft. Total Depth~fr~inal grade:
Lot: ] Block: Subdiv~io~: 3epth to pipe bo,om from orig~de: ~epth beneath pipe
~ ~ ~ ~ ~t., ~t.
Township: Range: I Section: Fill added above original grade:~ Gravel length:
~ Ft. ~ Ft.
WELL: ~ D NeW D Upgrade ~rave~width: ~ NumbS: Distance between lines:
... Ft. Ft.
Driller: ;. ' Date Drilled: Static Water LevekF,. Ins,~¢r: ~ ~¢. Date 'nstalled~l ~
SEPARATION DISTANCES ~ s,ptic ~o~ding ~ S.T.E.,.
To Septic Absorption Lift Holding )ublic/Private Manufacturer: / Capacity in gallons:~~
From Tank Field Station Tank Sewer Lines
WaIF ~ ~ ~ ~1 ~J~ Material: ~~ Number of Co,paYments:
Sudace
Water ~ ~ I~ -- LIFT STATION_~
Lot ~ ~ / siz. i. ,.,on.: ~ M...~.o~u,.,: ~~
Line ~ ~
Foundation ~ ~ ~ ~ / ~ "Pump on" lev~mp off" level at: High water alarm at:
Cu~ainDrain ~ ~ ~ ~[~ ~ Pump~Model ~Electrical Inspections pedormed by:
Remarks: ~ ~~ ~~ BENCH MARK
-
~' ~/~. Location and Description:
Assumed Elevation;
ENGINEER'S SEAL
17034 Eagle River Lo~ Road, NO~s. 1st ~ ~ ~ ~ .... '; :
Inspections performed by: ~agle River, Ala~a ~5~ ' ~1 I ~
Department of Healt~Hu ices approx~ ~ ~~~,,
~~~ ~ ~ Date:~ .......
Reviewed and approved by /~
72-013 (Rev, 9/91) MOA 25
2 2
Per,nit No, $W940098 Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
ENOLE SUBDIVISION, LOT 1 01701350
Legal Description: PID No.'
CO 6" CO ALARM ,
~ 89.1'
30 -- -AVE.
C01 34' 37.5'
6" CO 42.5' 44.5'
ALARM 48' 49
OT 1 3500 GALLON ~
HOLDING TANK~~t
I
~.x~s*. s.,.E.~ ~ ~
SCA~ t" = 40' AREA ABeD ;
~ 100' WE~
72-013 A (2/91) MOA 25
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM
PERMIT NUNBER:SW940098
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:THODEN MARK A & ELAINE M
OWNER ADDRESS:13000 MICHAEL RD
ANCHORAGE, ALASKA 99516
(UPGRADE) PERMIT
DATE ISSUED: 4/29/94
EXPIRATION DATE: 4/29/95
PARCEL ID:01701350
LEGAL DESCRIPTION: ENGLE LT 1
LOT SIZE: 71100 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
HOLDING TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS
RECEIVED BY:
ISSUED BY:
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
April 20, 1994
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTHAUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
MUNICIPALITY OF ANCHORAGE
Department of Health and Human S~rvices
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot I; Engle Subdivision
Request you issue a permit for a 3500 gallon holding tank to be
instated on the reference property. The tank capacity has been
oversized for a 3 bedroom house at the request of the owner.
Your attention is directed to the attached correspondence from Lou
Butera dated April 10, 1989. Apparently test holes excavated on the
property indicate a high water table (3 ft.) with soil layers above
the water table unuseable for septic effluent leaching.
The original soil test performed on the property in June, 1982
apparently did not reveal the high water table conditions but did
indicate a percolation rate of the soil of 52 minutes per inch. It
appears that the permit was modified at the time of construction in
1983 to account for a high water table of approximately 7 feet. The
system installed is in a state of failure and an immediate upgrade is
required.
If yo~~dditio nal
Sin~.
/gk
information, please contact us.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
Z
MICHEAL ROAD
o
_J
N¥'ld 3lis
:I"lVO~
TUE 1 $ '- 25 T ]:
MUNICIPALITY OF ANCHORAGE
DtPARTMENT OF HEALTH AND ~NVIRONMENTAL PROTECTION
SOILS LOG- PERCOLATION TEST
TEST
1
4
9
;0
~UNO W~¥ER
11
~,. ,,.,..,~ .r.. ,~,,,,.~
'~3
G/O$S
1 4 O~e T;~e I
'
TEST RUN E~?WE-eN . FT AND ,---------- FT
I'IR R--, , -5--c34
RIVER ENGINEERING ERVICE$
Lo~ ~ul~ra. P.E.
Mr. Earl Malone
ASSOCiated
~05 W 4th Ave, Sut:e 08!
Anchorage,
Re: Lot
HUD
Dear Mr. Malone,
At your request, Z have
the above ..........
4/,'~/C~
A test hole w~$ firs: e>:oava~e~ into the ex£s~iDg septic leachbed
tc de,em!ne c~nd!tion of the bed. The exf. s~in~ ieachbe~ was
~ha~ the leach be~ ,:on$!s~ed of m . - ' recOpY
layer, under lain by 2' of fine.~and, which w~s placed ~i ~'
original groun~ surface within 2' o~ =he gr.oun~ wa:er :able level,
Monitor p~pes were Ins~a!!e~ ~o allow ~e~hoc~inc of the ground
!eve!, which i~ the critical factor ~or approval, From this ~e~t hole
it w~s de~erm~ne~ that the ,~ ~n~ ~eachbe~ w,~ .... ,
constru:ted, nor was i~
replacing =he be~ in another area. The bes~ Iocm~ion w~s d~,e.min, e~ and
:es:. The op:iOn~ for :his lo:, :heretore, are as follows:
I ~nes~ will--to ~e
on.q_q~, Once this a
proven by mcni:orlng. If the drain is effec~ive the wate~ table will
be lowered and e perc test can be accomplished ~ leach field designei.
Z woui~ est!mate the cost Of the curtain ~rain ms being $~,000.00-
$4,500.00 and the subsequent cos: of leach fiel~ a lif~ soak!on
$7,500.00 ~lus engineering costs. The our~ain ~rain would be
installed in as e~ec=ive a manner as possible ~u= ~here is no
water
guarantee of final results, d~e ~o unk~ow~ nature of un~er~roun~
~low pa~terns.
hol~in~ tank wi~ hi~h, wa:er alarm. The ca~i:al ecs: wo~id be :ow'
permit wcul~ have ~o ~e
recommended. From ~ne ~nforma:i~n :ha~ i havg, a f~un~a:i:n ~ra~n could
~.,~_~,. ~o~,.~ cost S125
S~ncere!y,
Louis Bu:era, ~.E,
<Permit ~: 820832
,January 31, 1983
TO: Permit Applicant
Subject: Lot 1 Engle Subdivision
A permit issued by this department for an individual well
and/or on-site sewer system has expired as of December 31,
1982.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log needs to be sent
to this department for documentation of the installation
date and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files and documentation.
If there are any further questions, please call this office
at 264-4720.
S incerel~
Robert C. Pratt, R.S.
Acting Program Manager
Sewer and Water Program
RCP/ljw
enc: Copy of Permit
SWP/057
PERMIT.NO.
MUN I 0 I ~f~L I T'T' EmF ANC~.'nOE
DEPARTMENT L ~)ERLTH AND ENVIRONMENTAL , FECTION
825 ~L' 5TREET~ ANCHORAGE., AK. 995~i
264-4720
WELL RNC~ I3t4--5 I TF SEWER PERM I T
( 8288~2 )
APPLICANT
LOCATION
LEGAL
JEFF BONIN SENTRY BUILD
Li ENGLE
8Z29 STORMY PL 99502
LOT SIZE
144-9211
9~999 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = ~ SOIL RATING <SQ FT?BR)=
.~04
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DEPTH= 8 LEN6TH= 1--?-? 6RA'...'EI DFPTH= 4
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
I~:EI_--!.IJ I RED SEPT I C TA=If.II-( S I ZE":~'"". I 080 GALLONS
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
T&40 (2) I r4SPECTImDNS ARE REQUIRFD
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
i00 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF
THE
WELL
COMPLETION.
4I'CIERATMIFF~AMTIHIRITAR WITH THE REQUIREMENT' FOR ~T~E~~4~R~ W:!~~ SET
F~RTH BY THE MU~ICIPALIT'¢ ;F 'AN~.C~ORAGE. ' ~/
2: I WILL INSTALL THE SYSTEM I.~ ~CCORDANCE WITH ,T, HE CODES.
-~: I UNDERSTAND THR~THE ON-S~T~SEWER SYSTE~ MAY' REQUIRE ENLARGEMENT IF THE
RESIDENL. E IS REMOEKELI~, TO IN6LU~E MORE THAN _'.' BEDROOMS. .
...- I GNED: ........ ........... / ,
. ............
"SUED B~ ....... DATE, ........ V4.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG-- PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
DATE PERFORMED:
SITE PLAN
I0
11
12
13
14
15
16
17
18
19
20-
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
/~:]/ I~"~ '~7 , O~
~ERCOLATION RATE ! '~', cC*' ,J~-,~ ~- minutes/inc~)
PERFORMED BY: ~...~or~,~lcP~ I'''' /0' ~f'~l' '~-.~ CERTIFIED BY: ~~~ DATE:
72-008 (6/79)
Front M0A #21
i .As;'certified bY myseal affiXed heret0 ~ndas °f the~validatio~,date Shown bel°Wl I verif
investigation of this H~alth Auth0rltyrAisProv~l aPPlication showS'that'the on-site wate~ Su 3Pi'
.. ~ iYstem is*~afei:fb~bt ~dal and adequate~f°r the number of bedrooms
id dicated herein: furthers, er fythat based on,the Informat on obta nec
.... : i ENGINEERI
The MuniciPality of Anchorage Department of Health and Human S~rviCes (DHHs) issues Health Author ty
ApProval Certificates` based only Upon the represen[atlons given In paragraPh 5 above by an independent
prOfeSsional engineer registered in tho State of Alaska. The'DHHS does th s as a'courtesy to purchasers of homes
:~ii~;.~i!~ ~'~ and their lending ~nst~tutlons m order to satisfy, certain federal and state requirements. Employees of DHHS do not:
~}!;condfict:, inspections or. analyze ,data~;before,.a::;ce.rtlflcate,ls~lssued ~}~he~M.nlcipallty of Anchorage:Is :not:,~,,~
7~_4~.~.5~?ev. 'i/gl) B~ck MOA~
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~ / ~: C-~//8-~ Driller ~'~'F/J~/'--)
Cased to 3~/ ~'~j~-Z]~c~.~<:~) Casing height
A. Well Data
Well type /C>~
Log pre sent
Total depth
Sanitary seal<~N)
Wires properly protected (~1)
FROM WELL LOG AT INSPECTION
Date of test
Static water level ~ ~ ~ ~
Well flow ~ g.p.m. ~' ~
/SO
SEPARATION DISTANCES FROM WELL TO:
~olding tank on lot ~ ~ ~ ; On adjacent lots /~
Absorption field on lot ~¢ ~ ~ ; On adjacent lots /~
Public sewer main ~ r~ Public sewer manhole/cleanout
Sewer sewice line ~ ~ Petroleum tank ~ a ~
~ lC (-lA.)&
//,Jq,
WATER SAMPLE RESULTS:
Coliform ~"'~/[ o ~P....~ Nitrate
Date of sample: /__.iL/~(
B.~t~/HOLDING TANK DATA ~)~O ~
Date installed Z~c'/~_~/¢/-/- Tanksize "~'~'~ ~L.--- Compartments
Cleanouts ~N) y~7~ Foundation cleanou~l~) ~'~ ~ Depression
High water alar~lN) ~ Alarm ,este(~/N)
Date of pumping F/~ ~ /UECJ '~q/.J,P~ Pumper
SEPARATION DISTANCES FROM S[-PT-I~/HOLDING TANK TO:
Well(s) on lot ?~' ~ ~ On adjacent lots r~.~ ¢../_ Foundation
To property line Absorption field /~,JO/.Jc~/°~jE~VVater main/service line
Sudace water/drainage /OC) ~
¢'00 /~4~ Other bacteria
/
Collected by: ~-~~
! CONTINUED ON BACK PAGE
72-026 (3/93)* Front ;: ,' : , '.
C. LIFT STATION ~
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer ~
Manhole/Access (Y/N) ~
..--~P~p off" Level at
~ested
Meets MOA electrical codes (Y/N) ~
SEPAR~~LIFI' STATION TO:
~t On adjacent lots
Sudace water
D. ABSORPTION FIELD DATA
Date installed
Soil rating (GPD/FF)
Length Width Gravel thickness
Total absorption area
Date of adequacy test
Water ievel in absorption field before test J
Peroxide treatment (past 12 months) (Y/N) J
SEPARATION DISTANCE FROM A D TO:
Well on lot ,.~ On adjacent lots
To building foundation J
On adjacent lots J
Surfa~ w~e~__
/~afn drainE. ENGINEER,S ~ATiON
Cleanout present (Y/N)
Results (pass/fail)
Syste~
e.~pression over field (Y/N)
for Bedrooms
After test
If yes, give date
Property line
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
I cer#fy that I have checked, verified, or conformed to all
Signature
Engineer's Name
Date
Ne.
Date of Payment ,.5'-.._~ -~-P ~
Receipt Number ,~5-~?~/
?2-o~s (~)' ack
and HAA guidelines in effect on the date of this inspec~on.
Waiver Fee $.
Date of Payment
Receipt Number
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~~-~'~',~'~',~'~'~',~',~'~',~',~',~',~'a
LABORATORY ANALYSIS REPORT
CT&E Ref.# 94.1786-5
Client Sample ID L1 ENGLE S/D
Matrix WATER -- ~x,
ClientName S & S ENGINEERING WORK Order 77695
Ordered By R.J.S. Printed Date 04/25/94 ~ 16:11 hrs.
Project Name Collected Date 04/21/94 @ 18:00 hrs.
Project# Received Date 04/22/94 ~ 10:30 hrs.
PWSID UA
.TechnicalDirector
ReleasedBy:
STEPHEN C. EDE
Sample Remarks: ROU'I1NE SAMPLE COLLECTED BY: S.S.
Parameter
QC Allowable Ext. Anal
Results Qual Units Method Limits Date Date Init
Nitrate-N
6.00 mg/L EPA 353.2/300.0 10
04/24/94 LLH
* See Special Instructions Above
** See Sample Remarks Above
U = Undetected, Rep orted value is the practical quantification limit.
D = Secondary dilution.
UA = Unavailable
NA = Not Analyzed
LT= Less 3ban
GT = Greater lhan
5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF H~LTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR .HEALTH AUTHORITY APPROVAL CERTIFICATE
1, General Information Application Date ~x~ ~i~ I~,
(a) Legal Description (include lot, block~ subdivision, section, township, range)
Location (address or directions)
(b) Applicants Name
Applicants Address
(c) Applicant is~check one) Lending Institution
Buyer ~i 0ther ~-~ <explain); ,
<d> Lenaing nstitution
Business
~--~; Owner/builder
Telephone
Address
(e) Real Estate Co. & Agent
Address /
Telephone
(f) Mail the HAA to the following address:
e
Type of Residence
Single-Family ~~ilti-Family
Number of Bedrooms
Other (describe)
Water Supply
Individual Well ~~Community ~--~ Public ~-~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Sewage Disposal
0nsite~~u;lic~-]
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.
[Page 1 of 2]
5: En$ineerin$ Firm Providiz~ Inspections~ Tests~ File Search~ Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority ApprovaI 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 regula-
tions in effect on the date of this inspection.
Name of Firm ~<~ .5 ~.AJ~AJ(L~_=~--.~ /A JO . Telephone
- - d~ Condltton~ /
Approved ~ Disapprove ...... -- -- /
Terns of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHOPdkGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO pURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP 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.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
A.- T~ELL DATA
Well Classification ~
Well Log P=esent (Y/N)
Total Depth Jamb [ ~ ~--Caced to
Static Water Level
Casing Height Above Ground
Electzical Wiring in Conduit (Y/N)
MU~CIPALITY OF ~CHO~AGE (MOA) ~----~'
HEALTH AUTHO~TY APPROVAL (H AA)
Legal Description: ~O-~
If A, B, c~ C, O.E.C. Approved(Y/N)
Date Ccmpleted Yield
Depth of Grouting
Pump Set At
Separation Distances f~cm Well:
To Septic/Holding Tank on Lot JOO! ; On Adjoining Lots ~ ~/
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ~./~ To Nea=est Public Sewer
Water Sample Collected By ~ ~ ; Date ~ /7__~/~
I
Water San~le Test Results
~$anitary Seal on Casing (Y/N)~.~
Depression A~ound Wellhead (Y/N)k) ~ :?
Be
S~.PTIC/HOLD~G TA~ ~T?
Date~ Installed'
Standpipes (Y/N), ~.'.~__
si~ /O~O ~ r .. No: ~f Cu,~nts ~
Air-tight Caps (Y/N) u/w'% Foundation Cleanout (Y/N)~=-~
Dep=ession over Tank (Y/N) ~0 Date Last Pumped ~/~
Pumping/Maintenance Contmact on File (Y/N) ,,/~ ; fc~ A//~
Holding Tank High-Water Alarm. (Y/N) ~/~ '-~x~aRy Holdirg Tank Permit (y/N)
separation Distances f~cm septic/Holding Tank:
To water-Supply Well /O~/ ~ To Buil~ding F(~undation ~/
To P=operty Line ~ $ / To D~sposal Field ~'~ /
TO water Main/service Line ~/~ To Stream, Pond, Lake, c~ Major D=ainage
Cou~{~-nts
[Page 1 of 2] ~.~_,~,
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed .~3t~
Width of Field ~ ~!
~/Grave 1 Bed
~ession ~= Field (Y~) ~D ~ of ~st A~a~ ~st ~/~
Rmsults of ~st ~a~ ~st
Separation Distan~ f=~ ~s~pti~ Field:
To Building Foun~tion ' ~ / To Existing
Lot ~//~ ;
To ~ter ~in/~=vi~ Line ~ /~ To ~t~(if ~e~nt)
/
TO St=e~ond~ke/~ Majo= ~ai~
To ~t~way, Pa=ki~ ~ea, ~ Vehicle St~a~ ~ea
C~f.~nts
Type of System Design
th of Field 2_~-/
Depth of Field ~,~)! ~//~l~gv~.~fm~UL.
D. LIFT STATION
Date Installed ~0 L-~. ~ ~
Size in Gallons lO00 ~
HiGh ~ate~ Ala~?m Level at
Tested fo~ KJ/~
Dimsnsions ~,O~0 ~Z,O
Manhole/Access (Y/N)
"Pump Off" Level at d)~ '
Pumping Cycles do~ing Adequacy Test.
Meets MOA
Electrical Codes(Y/N)
Ccmmsnts
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, c~ eonfom~d to all MOA HAA C~i~d~nes in effect
on the date of this inspection. --~_~m~
KB1/d5/s
[Page 2 of 2]
2-15-84