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HomeMy WebLinkAboutCHRISTOPHER HEIGHTS #1 BLK 1 LT 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES Address'A / I [(~ 'J (' I~_ ~'/~ ~' ~0 SEPTIC ABSORPTION WELL --~ TANK FIELD Pdo~e(s, ...... IPerm,~ No ' JNo ~f B~:ooms WELL LEGAL DESCRIPTION Lot I B~ock Subd?s,on . Townsh~p,[ Range,~ Section ' ' "~ / d: ~/ ~ ¢ ~_,"! ~'" S,' ~- dr,veway,AS-BUILTwalerDIAGRAMbod,es, etc)(Sh°~ Iocat,or, of well, sept,c system, property hnes, foundat,on, TANKS ~a~uiaotur~r Capacity m gallons TYPE OF SYSTEM ~ TRENCH .~BED ~ W. DRAIN ~ OTHER Depth to p~pe bottom from ~ Total depth from original grade F'I[ added above o,,9,nal grade Gravel ~e ,t G .... I length~ / Gravel width/F> lotal absor~uon area ~ D,stance Oelweer hnes Numb o h J Pipe material WELLS ~" PRIVATE ~ OTHER fldentifv) Classdlcatlon~~. (A,B,CI, i ~ r '' }otal Depth FI Cased to FI ~[. Instal~ Date Installed: -[ ] o / REMARKS: ' ; j¢ Scale: I :2 -- cedil that's inspection was pedormed according Io all ~, 7,.~ Mealt epa men pprova .... / . [ . .,, ,'. , . 72-013 (3185) iiii2.,5 i .... Gt r' eet, Pw~c:hc~ r'. (aqe, f..:~ 1 .a.ii~ i.::a 9V5'.-i) ]. 0 l'.,i ....b '.il I ~::;i !..s L.E W E R F" iE R H ]. i:L r'~ g i ne,:..'.:.: ~" ,'.) e, s ~. g F,. e d i.).~,~i"~ ,.i.:,r" !qam,..:~,: At....I.,.. I AtqCIE BANI.::: Own~:.:.!r' ¢.:~ddr'e)ss: I::'0 ~(]X A Iq C H [)R A G IE, A ~::: 9 9 5 C; F:'a ~* c: e }. I d: 0 1 5-.;2::S 1 .... 9 1 I..c,t. Leg a J.: Sui:'; d :i. ¥ i s i c:,n ~CHR f S'I'OI:::'HER H"I' S .t.1. i Lc.d.. ,", 1 Sec t. :L c)r",.: ;:::",:3 '~ C)Wl"i sh i p: 12N F,.'ange: :3W I....,.::~ {. ~.~ i ;..'. e: "' ....... ~ ..... ( s c:l. f (::) e.~ S .) Max Bedpc:,oms: 'f't"~is F:'epmi'L: 3 'fot. at Cat:)acit. y: 3 B 1 (oc k: 1 :!!!~EI:::"t :t: C '1 ¢-.qql<: td ]. I'"~ :i. mLtm 't.o'l:. a .I. SCl::) t ]. c: 't..ar'~ k (:::ap) ac: i t y: J., OOC; ga I i ohs, E:ac:h sep't:. :i. c: 'Larik mus'L have aC !eas'L 2 c:c, ml:)ar.t, mer'~'Ls,, Depth 'Lc) top o~ septic 't. arlk ,-:s) .::: 4,,0 · l'(.':~eL r. equ].r.E,S ir"isu].atic)r"~ (::,var' t. arll.:: (si . :i: i'qSi, t'P4_I .... I::'IEF( E.I",iG I NE:EF:i:S A'f' f'P~E;I..EiiJ.} OiES ]: GI",t ~, lqLi I liii. CUR f [:~ I i'4 DR~:'~ I hi [3LJ 'f'.'-' F: ¢:q...I i',tC] T' [ I::: Y DHI'-tS I:::'R I OIR l Ci I:!i. ACH :1: I'..I~iSF:qEC; i I 01,.i ,, I H J. ~i; l'::'E!':d¥11 T ! S :[S;SLHZD !::C.ff:,: 'l"Hlii':. iiL×]:Si"lhiL~} 3 BI:.~;);}RI.3LJP'I OWEt....I....i:NC-) LiNt_'f AIq[.) E:XF:.'l!:,:ti!i:'.:i.:; 0I",1 :!. 2 ./:3 :i / (}il 9. .I: C:IEI::,,"I ]: I'::Y iF.ir-'.~I: :1., .I. am .,' ami .I. ].a'.~r' wit. h 't..l"'~0:;, r'-C:.,C:!L~].F'I,?.~FII(-:-:.:,r"~t.~.-".-:- t c',r' (.], r'i ..... !s .i. 'lL (-:.:e !i~:..:.:..~W6;~I"Ei and wel .l.s a~ s~+.'f ',or't.h l:)y the:, Mur'iJc:ii::,a].J. ty (:)[ Ar-~c:hc~r. ag(.--.-) r, MC)A) ar'~d 'Lhe State ol Alaska, ;~'::., :[ ~,.~i ]. :t. :i nst. aJ. ]. t. hr..:~ '.+:~ystem'~ ir'~ ac:c:or, clar~c:e w.~il:.h a.t. }. I-'IOA c:cx::le.iF, and ~ ~.~':?._t.l. at :i.(::)r'~s~ ar"~c! J.r'~ c:¢::,mp].ial"iC:6.:, k:JJt, l-i 'l:.he des:i, gr't c:r'.it,:!er, ia c::,.~ 'Lhis pel'm:Lt., .S,, I :-.~:i.].t aclher'e to ali P'iC~F~ ar'~,::l ',St. at.e:, (::)~- Alaska r. eci,'..~.ir'em,:.:.:.:,r-~t.s ~'(::,r t. he:, !_:; ,:.:-':! t !:::, a(::: l-:: (::t :i. ~.;; I:.. a(I'"~C:E?S i.r' (:;)al a.f]";/' (E,;.; :~. !E-t. :i. r]~i.:.! ~.:,.~67 ]. ] r.- W,.::~'iStK....)k',.h~').'I:.(E,P ('J. :i. ~[)C..H.-.h..*.' ...... .~: '":~ / "=~ ,..(:m ~ ' '" OF [],; .~['" ]. j..r.:: Eh-::~b~(-E,r' ...7..'~(~16.e '~VvEFL.(.~..'[I.'. (::.~r"~ kh i s (::)r' ar"~'.¥' 'q.,, :[ L.~I"iCJE.)I"'.'-'.S't..:~.I"IC4, t. ha't:, this l::,er'rnJt :i.s vaJ.:[d al. scl und(-:-z,r'.s't:ar"~ct t. hat. t. he:, c:apac:it'..v ,:::~i t, he t..c)t, aJ. syst. em :i.s 3 [:)e,:::!r. cx::mi!i~ ar'.,cl 6), F'I y ~:L~ I'i ], a. 1" ,:.. "' '~ t. I/g i ,[ J. [' E~' CI :. ............. ........................... ......... .... ( Ii! w r"~ (.):.~ r'. ~ ..... "' ': "' ~:' '.:' .... ~.-,t...l_ ~. ~--q 4t. ...... B Al;q,... ' / _ ~ .................................................... ,OA'Tiii!'. LEGAL DESCR,PT,ON: L_o-i~ //-~ /~C-t~ J Township, Range, Section: "Z-/z. ~.! ? ~ ~.) ~ z~ ~ ~_~ H ~-.] ~'To I~ H~_.-I~ /-~ ~ T-~. SLOPE SITE PLAN DEPTH (FEET) 1 2- 3 4- 5- 8- '12- 14- 113- 17- 18- 20- WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? p E 0e,th to Ware, A.~r -~ /Z~ n-- ~ '~ Monitoring7 ~ ~' ./4' Date: , , Gross Net Depth to Net Reading Date Time Time Water Drop IO: ~' / lo 40 /O,,,,., .07 /o '~ ~.~ / 1: O / /0 ~., ,~ . O~ I/ PERCOLATION RATE ~----~--~'.~ [ (minutes/tach) PERC HOLE DIAMETER TESt RUN BETWEEN ~T AND __ FT COMMENTS 72-~8 (Rev. 4i85) PERFORMED IN SEWER. SYSTEM "LOCATION PLAN. '~t:~. DRAWN BY, SYSTEMS INDICATED IS NOT EXACT. ,,,' ,~, ,~ PROPERTY C~NERS, WELLS, AND ~PTIC ~/~~2 ~. NORTH ~¢~q ~ DIMENSIONS INDICATED HAVE BEEN PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street. Anchorage, Alaska 99502-0650 SOILS LOG m PERCOLATION TEST //4 /g//<: / O,,vt .,~,~- (,~NG II~'~.t~'~ SEA L) Township. Range, Section: SLOPE SITE PLAN / / / / / 10 11 12 13 14 15 16 17 18 19 20 WAS GROUND WATER ENCOUNTERED? S L IF YES. AT WHAT O DEPTH? p E Monitoring? ~ Oale: ~1.-1/ o-! Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FTAND __FT ACCOROANCEWITHALLSTATE.AND MUNICIPAL GUIOELINESIN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) SYSTEM 'LOCATION PLAN. ~ LOT J BLOCK SUaOlVl~ L~ SION PROPERTY CORNERS~ WELLS~ AND SEPTIC D~AWN BY' SYSTEMS INDICATED IS NOT EXACT. a DETERMINED BY USE OF CLOTH TAPE AND . ~ ~ ~ ~r ~ , . I~' Ifil I . SEWER SYSTEM 'LOCATION PLAN ~ P ~ ;~',~ ~'r~ ~ ~ ' LOT I BL~K ~ SUBDIVISION I I * ' .... . ',~; j SECTION/TOWNSHIP/RANGE :" ~'~C~ t~; ; *'~ SCALE' NOTE, ACCURACY OF LOCATION OF EXISTING ~'~,'~:t~ ;~<~:''~,~ //?~ D~AWN BY, PROPERTY CORNERS, WELLS~ AND SEPTIC ~ NORTH ~/ ~ DIMENSIONS INDICATED NAVE BEEN '* DETERMINED BY USE OF CLOTH TAPE AND ~,:~r: f~ ~,,:~1 : ,L,;;~ .......................................... :.':.:' ...................................................................... :~ ...-.- . ................ :.;...:~.'.:,:. :.:.:.-:-'-:~:"~ ?; ....... :.;~.x~?.' -.;~;-'.'..--'., NOT ~Y 8UHVEYING TEOHNIQU[~. [i ~;~ .~;~: :~ : : : ::: :: ..~ PREPARED FOR, :::.....~:~:: .. ....... r' '] ri [1'[ ii ii i'll OWNER ACCEPTANCE & WARNING ~s my agent, Acreage Systems, Inc., is authorized to furnish op~procure ~aterials, labor, inspection and permits required to complete the work in the above proposal. I/we acknowledge the right of Acreage Systems, [nc., to claim a lien to secure payment. Lien will cover'the cost of · abor, materials, equipment or legal fees furnished for the repair or mprovements on the above described property under wn~er's signature · location. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES MEMORANDUM DATE: TO: FROM: March 30, 1989 File, Lot iA Blk. 1 Christopher Hts. D.N. Bolles, On-site Services ~ SUBJECT: On-site inspection of septic system. In the afternoon of 3/28/89, I inspected the installation of an absorption bed on the subject lot. The bed area had been excavated, lateral pipes laid and backfill of gravel had begun. The bed had been turned to parallel the slope of the hill. Depth of the bed to the north was -2.5' to -3.0' and depth at the southern extremity was -1.0' to -1.5' The monitoring tube adjacent to the bed was probed and found to be dry, a depth 10' below the bottom of the bed. The bed installation and workmanship were of good quality with no deficiencies observed. I also observed three test pit locations; and two monitoring tubes, which were installed years earlier. The two monitoring tubes were installed on the slope just east of the garage, note locations on sketch. Water was encountered at -12' in the first MT (#1), and at -7' in the second MT (#2), there appears to be a 5' drop between MT#1 and MT#2. The three test pits revealed that the area surrounding the bed is comprised of gray silts with cobbles and occasional boulders. The silts were frozen and appeared to have a high moisture content. The silts from the third TP appeared to have been in a near liquid state at the_~ time the pit was dug. ~b~_~~~,'~~/ This lot may have at one time been, and could s~t~r~functio~~L~ a drainage for the area west of Rockridge Dr.~ A natural slope~W~~A exists to the center of the lot from both the east and west, and c~ there is a well defined depression running from south to north through the length of the lot. This depression runs through a portion of the calculated reserve area indicated by the engineer. It is possible that this is the original stream location, the water from which was diverted into a French drain constructed on the east side of Rockridge Dr. ~,O. S~.,X 5650 ANGHOPqAGE, ,._AoKA 99502-0650 (907) 264-=11 i TQ ~,,' ',' k',', © :~?L DEPARTMENT OF HEALTH & HUMAN SERVICES January 10, 1986 TO: Permit Applicant Subject: Permit # 850724 Lot 1 Block 1 Christopher Heights Subdivision #1 A permit issued by this Department for an individual well and/or on-site sewer system h~s expired as of December 31, 1985. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installatidn of the on-site sewer system the original as-built inspection report(three part form) must be sent to this office for review and approval,and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/ljw enc: Copy of Permit PE:].;.:H Il "i i'..iO :: IEi ]: E:; S Li E: 'O :: ANC;I"'IEiI::;.:AE')E!; ,, Al'q 995 1 ~ :];49..--80 :I. I BLOCK: .1. ....~ ,,x,:d. em , .I ,, ,~.,'::,,=.¢ t,- ........... e ,.-'1-) ~ ...... i r'.,,-'~ + hat best .;. :L t s voui" ,= i t e f , ·, 1 ., :::- :;:," .,. ..' · :' -'r' i -' ) ('~ i U i i--.u ..... L. l=.¢' ~ r"J* ~'" ~" / ~V C) .......... 7 ':":"'"" "::' I ::' ",l r=~ 'r H cJ::] "' 'I '=' r'~ .~..~. 4 ' C} ~ C')?;, C') · /-~ u-' ,'----'--~' ~¢-'~i~ ¢-". · ': ! ~. ' '~.'¢:~f"~ "') -~E.-~E. , a,,,J .... ;:, .L .,= F: ,,:,~..-,L..;:::, ~ J., ,2~:~;;),. ~ .. ..... ~.~ ................... Z ,, :::~E,O., u .~.-~- ............ ' ' ' I 15 (~ '='" J. .... ,..¢' L,"" ... '"'"'""'"" ... , ~,E:.L,L .!.!,1:.. ) I "(:': ~ ,'~ -' "r '-'- ~., '~"~' .(~J::.r-' ir-I 'l'J'l F:'J;F'E;,=q..~""'""w'""~ ~ dui ::~ :]; 5 I:::'T, ......... ' .......... I,l,:,t ....... ~--~f .,U,,I ....... ...... t':,UI ~.~, ::; 4 r'~ F::'T J'h-ii' Id: .............. I:. A IF=T S'I'ATZON · ~"~:'? DIE]::'"J'H iU =, T :::.~:: .............. ,",".,,-* ........ ' ........ ",' .... r"~l ' r", L -,' ,,, ~ ...... r',, .... , .=..~=;. , ..... H~..,,' .... '~'~ v' ....... "':""') '~'rq '"~::' I::'T EACH; · ii~' t=,l'"..~.~ .... t .... t....,=.~..f(~ th > ,',..~ i::iEE,~U ]; RES MUI...'r'tl:::'LE: ..,~ .,~ ~Nu~ E;,,.E.,E:.~..L ].1.4 ..... / · t~: 4¢, ~ f"lt~t'',, t'JLJc~ J ..... "~-~ v :. i;.'~T L..l:::.~--'l~ F TWO COMI='AF:RTMENTS ...... I .L i ~ "::.,' Lh'~'~'.:::,. ,... ~ [. Z[. am -,': am :~. ]. i a i"- t-~ J. 'L j..~ t h 6] r' c-') qL.t i r' 6'.:m(.:ar'J .1:. ,..B £ c.) r' (]r"~ ....-s :J. t e E-;6.)WEe P S and ~,.,.le ]..l. '-.5 8'.El ::::.e~. ,.. .............. ' " ' ..... ~- ...... ~:,-L¢.~,...e of' Al~=,.~::.~-:.a, [','.:::,i"L,~ l:)'y' the cl_t~:i.c::',.pa]ity c::,f ~.~r~c.,~(..¢~.ac:je (MOA) and the c ............ 2. ]. ~,,,.,:i. ]. ]. ic, sta].l the system :Ln ac(:::c)u-dar'~ce w:i. tl"~ a].l I"'IC)A c: (:] d (.~ .F:; and · - . I- ' per'm:L t, a r"., ,::.! :L J'i (:: ,::::, Ci'~j:::, .~ :i. ;='.',.i"~ (::: E? i,',~ :L 't:. l"~ t h E' d [.:.) s :i. g ri c: r'. J. t 6) P :i. a o ~' '~ ri :). ?.:. . . 3, ]' ~..,,J:i.]:L a(::!l~e!'e '~'..(::) ali. M[]A ar"~cl State c)f' Alaska r'-equ'ir'emer"~ts .Fop the se'l:, bac:k (::J :[ :liE.';:'. :'::;i"i,[::~::eE.:. [ t" (:3d~ a'~,i']'y ~.Zi,;..'. J. st ing t,,,~e 1 i, wa. stee,~a.'l:.eP id 'i..st::)c)sa ]. s'ys'l.:.cem c:,P I::' ...d:) s,:.:,.:,',,....uer, acje syst(.:.?m c:u'"~ th :i. ~ of a -~',,..' ad.j a c:: (:.a r] t c) P r'iE, ar'b'y ]. c'~t ,, ,:i. ,,]i J..~.i'"~ ,:::i E, F' s ~:..~'..'¢L ii (:i t h a '!'.. t J"~ :i. Eii. j:::, e F. rd ~. t :i. s 'v' a ]. i (::1I: (::~ r'- a rr~ a ;.:: :i. Fr~ L.t ~"r~ C] '[' 4 b 63 (':1 r'. (3,'3 fi'~ ?:; a r"~ d ...... .. . .- ' ....... ~ I'-: ~'::' I I ~ ' t :'~\ r'y ~:'.", J'", ]. ~:'~ "(:] EE, rrJE:-? r"., '~.'.. ~./..] :i. ]. 'J. p (.::.:' (::j u :L r'. ,':-.~ a r'~ .d. d ,...~ :[. t J. (:::,ri a .i. .... ' ..... "' :l. 11600 CANOE RD. ,4NCHOR.4GE , ~4ff. ~§1~ (907) 545-7'008 SOILS LOG PERCOLATION TEST SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCR,PT'ON: SLOPE SITE PLAN I ,~ "7' r I .I WAS GROUND WATER ~ o , tF YES, AT WHAT OEPTH? i Z 8 X ' 17- 18- 20- Water I Drop t 1 R 'in I Date Gross INet P.%". CE- 6793 %~,.'-......' Ii'~, ' ..... '. ~**~ ' j ~ ~~ ~ ~RCOLA'r~oN RATE TEST RUN BETWEEN FT AND ~ FT -t irmnutes/inch) COMMENTS 0 ?.o*c~~ LOT k £ ° S0~EY CERTIFICATION: ' hereby certify that I have ,urveyed the property ahown end j~~j~nj ~ Iscribed hereon end that the 'mprOYement~ Situated thereon ere within the property 'ln~ endencrOechment~ exist other then noted. PLEASE NOTE: ,, ,, ~. contract LEGEND: SET FOUND ENGINEERS · P~NNERB- SURVEYORS ~r's responsibility to ch~k top 5/8" REBAR ~ 0 Of foundation In relation ~ HUB ~ TACK ~OWEST BENSON BLVD. 272-9231 finish grade and building ~t- MONUMENT becks in elation to lot Ilna AL-CAP ~ ~ CHKO.: ANCHORAGE, ALASKA 99503 ~2-5291 and easements. PK NAIL X IRON PIPE LEGAL DE~IPTION: lot / 8LOc~ / '~'~':/''=3o' DATE 0 0 Parcel I.D. # 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 1. GENERAL INFORMATION Complete legal description Location (site address or directions) E,E'I( t-.~ ~r.z.s~-c'F-~ "~uf_-~ Property owner Mailing address Lending agency Mailing address Agent Address Day phone A,oc Il- Afc Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 : TYPE OF WATER SUPPLY: Individual well Y- Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE.OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If commun, ity wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 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~---"~,'o,¢~ ~a~c~. .5 "~C. Address '=~[:~. ~,~'~ ,'c~ '~?~ Engineer's signatur~ DHHS SIGNATURE Approved for \ ~ ~£~- bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: 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 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 13 DEPARTMENT OF HEALTH & HUMAN SERVICEI~ E ~' E ! V E D Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) Municipality of Anchorage Health Authority Approval Checklis{;)ePt- Health & Human Services Legal Description: Parcel I.D.: A. WELL DATA Well type~--~~J Log present (Y/N) Total depth __ Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number /~J(~ Date completed '=~¢' ~ Cased to -~ (.,, ' ¢4 Casing height (above ground) ' ~'~ Wires properly protected (Y/N) AT INSPECTION Date of test Static water level Well production FROM WELL LOG g.p.m. WATER SAMPLE RESULTS: Coliform -~- ~ ~ Date of sample: ~//~[ ~'~' Nitrate ¢,{C)0 r,.) Other bacteda '"-~;~ '"'- Collected by: //2~ B. SEPTIC/HOLDING TANK DATA Date installed ~ / ~ n / ~ 1'Tank size Foundation cleanout (Y/N) '~ Date of Pumping 'z/~./~ ~ C. ABSORPTION *FIELD DATA Date insta, ed W Length (~ ~ Width /C, cPO Number of Compartments ~ Cleanouts (Y/N) . Depression (Y/N) ~ High water alarm (Y/N) ~ {'/¢~ Pumper /~ -'c · Soil rating (g.p.d./fF ~~_'z~'- System type ~ / ~ Gravel thickness below pipe C) .~_~- Total depth Effective absorption area / ! '-~ q Date of adequacy test ~--~/¢~/?' ~ Fluid depth in absorption field before test (in.); Fluid depth"~--~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) Monitoring Tube present (Y/N), ~' Depression over field (Y/N) Results (Pass/Fail) %~c~¢k~-% For ~ Immediately after ~rb) gal. water added (in.): Absorption rate = ~.~'O .g.p.d. If yes, give date bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION Date installed /'[,~.._,~~/ Size in gallons ~ Manhole/Access (Y/N) "P m~JL~ at* "Pump off" level at* High water alarm level at* .....~~ ~Datu~ Cycles~e.sted~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main ~4~'[~ On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station Sewer/septic service line SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~' ~ Property line /C>'f- Absorption field Water main/service line ~,¢'~ Surface water/drainage /cz2'-r Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /¢'"f" Building foundation Water main/service line '~(~ Surface water ! c~c~'~ Driveway, parking/vehicle storage area Curtain drain ! c:'c:::,'''~ Wells on adjacent lots / c~"'1- ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipa'lrec~ms are inconformancewithMOAHAAguidelinesineffectonthisdate.r~ " Signatu Engineer's Name ~~ ~~~t~' ~' * ............ Date ~ ~ ~ ~ R HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number T-?TO P.02/05 CT&Ir Ref.~ Client Name Pr~m Nnme/# Cli~ Sample :ID Ord~ By PW~ Sample Ren~rl~: Client ~ l~a~t~'~] Da~e/Ti~e 02/I1/99 13:53 Col]ect~l Date/Time 02/08/99 13:02 [baeelved D~te/1'ime 02/09/99 08:45 Technical XMrcctor: Stephon C. Ede Rel~s~d B~ POL units Tota~ Co&~form 0 co t/1001111. EPA lO0.0 10 max o~gG/~ 02/D9199 SCL -4A I~t(] 39(]l~lNOOa / 0~0£ -- _.2 .90,ZOoO N 0t, '~0£ O~'gO£ el '" 0 ,,~ O0 C~ · ~(~7-- (~(i) oo 099 ~ -O/~ ~'Z'099--~ ~ \--3 90,LOoO0 ~Y_ F':, "' (Z/(I) O0 099 3/~ lZ099 ~ ,90000 N I) O0'OE£ ~ (I) O0 0~:~ 8 >'F- O/iN Iz' me; b