Loading...
HomeMy WebLinkAboutGLENN VIEW ESTATES LT 8 lenn Vie Estates Lot 8 #051-521-45 Municipality of Anchorage Page / of ~.~__ 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 Permit Number: __.SW_9'TobH G PID Number: O~t - ~ I'- ~ Name: Address~C¢¢~ ~/~¢[~ ,/~ Z C I ) [ ~G' WastewaterSystem: ~New D Upgrade Po~o~ ~7~0~2~ E~'~J~ A~ ABSORPTION FIELD _ Phone: ¢~. ~¢~ (INo. of Bedrooms:¢ a Deep Trench ~ShalDwTrench DBed BMound ~Other LE GAL D ESCR I PTI O N sci, Rating: Total Depth from original grade; Lot: ~ Block:~[8~11~¢ ~$~,Subdiv~i°n: , Depth to pipe~,~_bottom Irom~,~original grade: Ft. Gravel depth beneath pipe~,/ F(~ Township: Range: Section: Fill added above original grade: Gravel length: ~/, ~ Ft. Ft. WELL: ~New ~ Upgrade Grave~ width: Number of lines: Distance between lines: Classification (Private. A.B.C): To~al De,Ih: Cased To: To~al absorption area: Pipe material: ~/O . Driller: Date D~lled: Static Water Level: installer: Pump Set ~1: Casing HeigM Above Ground:i Yield: ~O GPM aO~ Ft. ~ r,. TANK SEPARATION DISTANCES ~ Septic U ~o~ding ~ To Septic Absorption Mil Holding ~ubllc/Privale Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines Ane~or~ ~ ~/~ ~ Well' /~+ /~+1 .~ ~ ~' Material: ~ Number of Compadments: su,~o. ' ' LIFT STATION Lot I I Size in gallons: Manufacturer: Foundation /~ ~ [~ t~ ~ ~ ~ "~ump on" ~1 ~':I "Pump oil' at: Ui~h water a~arm at: CurtainDrain /00 ~+/0014 ~ ~ ~ Pump Make~rical InsPections pedormed by: Remarks: ~¢ ~¢~ ~¢~ ~K~;~5 BENCH MARK Location and Description: ~0  Assumed Elevation: ENGINeErS SEAl. Inspections performed by: ~~/~/nd Dates: 1st~/7/¢7 ["~~ ~~ ..................... Department of Health and Human Services approvar ' "' Reviewed and approved by: ~ Date: 7-~~- ~ 1 ~ROFESSXB¢~~X~i* 72 013 (Rev 9/91) MOA 25 i AS-]BUTLT SYSTEM ]DETAILS/SlaTE PLAN LET 8, GLENN VIEW ESTATES S/g Per'mi~c~ SW970046 ;15' TELECOM ~ ELEC, EASEMENT / / SCALE, 1 = 5W ~ B~0=49,2' X~ /~ SEPTIC ~ ~94.82~ ~ ~ / ;~/ ~AN~ ~ SEVER ROCK : ,.,, I I SCALE~ NTS ~' ~.~. ~6~ LERBY ALDERMAN EAGLE RIVER, AI<~ 99577 P,B, BBX 670045 ~~ CHUGIAK, ALASKA 99567 BATE,7/a~/97 REV,7/~9/~7 D~aWING ~ SCALE' AS NBTED 97016-S[ f~D ENGINEERING 20441 PTARMIGAN BI.VD. EAGLE RIVER, AK 99577-8736 OFFICE (907)696-611 I FAX (907)696-8111 FAX TRANSMISSION DATE: TO: FROM: SUBJECT: (907) 696-8111 COMMENT~: " "'/: t:>/::: '"---' '~ .'7,::,,/:~'~ .:.' ~,. :4- /'" ///,: ' _, .. ~ ' , ::5'i ;, /:,:¥,::~ ...... -~ -,//: ,..~ ~:-,,, ~ , . , . ~_ .~ / ,~ /, . / TOTAL PAGES ( Including Cover Sheet )_ ';" Sent By: , :: ~ Phone # (907) 696-6111 Receiver: Please deliver this facsimile transmission to the above addressee. If you do not receive all of the pages in good condition, Please advise the sender at your earliest convenience. Thank you for your assistance. ( ertifie Drilling by SULLIVAN WATER WELLS P,O, IBOX 670272, cHUGIAK, ALASKA I]9567 ', TELEPHONE 689-2?69 OWNER OF LAND ADDRESS DATE · Started __ P~R~r~ NUU~ER STATIC LEVEL OF ~,%xTER F'I~. c,,~t.s. PER ,rt _ From Ft_ to,__Ft~ From Ft. to Fl From_ Ft. to ,Ft -From. ." , Ft~-to-~-~,_. Ft'' From_--.FLto .... Ft. From--Ft. to Et, __ From Ft, to _Ft. Fromm, Ft. to____FL From ,_Ft. to From Ft, to__ From,__ Ft. to.____ rom Ft. to,__ FI.. Ft. lo ~FI. to Ft. to From ~_Ft, ~o .... From.__.Ft, to~ From , ~F£. to ".From ~ ~-. ~o - From Ft. to From FI. to From Ft- From.~ FI. to From~Ft. to Ft F! Ft._ Ft. Ft. ,. Ft.._ Ft .Ft, MISCL !~FoRMATION: DRILLER'S NAME ~/.~.~_..~x~_ ...... MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW970046 DESIGN ENGINEER:KND ENGINEERING OWNER NAME:ARCTIC DEVCO INC OWNER ADDRESS:P.O. BOX 670045 CHUGIAK, ALASKA 99567 PARCEL ID:05152126 LEGAL DESCRIPTION: T15N R1W SEC 10 SW COR NW4 LOT SIZE: 48845 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: DATE ISSUED: 4/02/97 EXPIRATION DATE: 4/02/98 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: THE ATTACHED APPROVED DESIGN. 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). THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED A_ND CLOSED ON THE SAME DAY B. COVERED, SEALED AMD HEATED TO PREVENT FREEZING THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ~~ ISSUED BY: ~"~ ~ '"', DATE: ~/~/~7 DATE: ~ '-2 "f7 20441 PTARMIGAN BLVD. EAGLE RIVER, AK 99577-8736 (907)696-6111/FAX (907)696-8111 March 15, 1.997 Municipality of Anchorage Dept. of Health & Human Services On-Site Services Section P. O. Box 196650 Anchorage, Alaska 99519-6650 RECEIVED Mu ~ cipality o~ Ancno~ age. Dept. Health & Human Ser~'icos Subject: Lot 8, Glenn View Estates S/D - New sewer/well permit Gentlemen: On March 10, 1997, we excavated a new testhole for the subject property. There is one previous testhole which was dug during the preliminary plat process, however it was not suitably located for the four bedroom house which is proposed for this lot. A copy of this soil log is attached for your reference. There was no water observed in the testhole at the time of excavation and we monitored the existing testhole on March 16, and found no water, which is consistent with the previous report. The results of these tests and previous water monitoring are attached. We propose to install single 5' wide shallow trench. If required, additional fill will be placed over the system to provide a minimum of 3' of cover when complete, however, this is not anticipated at this time. There are no public or private wells within 200' of our proposed system location except as noted. There is neither surface water within 100' nor any known curtain drain within 50'. We do not expect that there will be any adverse effect on adjacent lots by the development of this system. If you have any questions, please contact me at 696-6111/FAX 696-8111. Respectfully submitted, IICISt !D Engineering Kenneth M. Du'ffu , P~.E. attachments: On-Site Well and Sewer Application Wastewater Absorption System Details/Site Plan Soils Log/Percolation Test /ASTBWATER LST VACANT VACANT SYSTEH DETAILS/SITE P 8, GLENN VIEW ESTATES S/D VACANT PROPOSED P PROPOSED 15' TELEEDH & ELEC VACANT ' WELL VACANT DESIGN DETAILS 4 DDRN X 150 GPO = 600 GPO 600 GPO/i,2 GPO PER SQ. FT, 500 SQ, FT 500/5' X .50 R.F. (4.0' GRAVEL) - 50 FT. TRENCH ToteL dep'th oP system ~s 4.0' Prom original grade, To-teL depth oF grovel is 4,0' , NOTES', 1, USE 1250 GALLON SEPTIC TANK. INSULATE TANK IF <4' COVER. 2. INSULATE TRENCHES WITH 2' HI] DURIAL FOAM.. 3. CONTRACTOR WILL ENSURE MAXIMUM aY. SLOPE INTO SEPTIC TANK. 4, ADDITIONAL FILL WILL BE ADDED OVER SYSTEM TB ACHIEVE MIN, 3' CUVER IF REQUIRED. PREPARED FBR: LERDY ALDERMAN M2CI INC, P.O. BOX 670045 CHUGIAK, ALASKA 99567 KND ENGINEERING 20441 PTARMIGAN BLVD EAGLE RIVER, AK, 99577 <907)696-6111/Fax <907)696 8113 SCALE, 1' = 100'1 97016-S1 Municipalily of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Slreet, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST I 2 3 4 5 6 7 8 9 10 '11 12 13- 14 15 16 17 18 19 2O COMMENTS SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT ~/',,4 oL DEPTH? p E Depth Io Water Alter /I / M0nilorin9/ 'D~,',/ Date: _~ G, ~'.7 Gross Net Depth to Net Reading Date Time Time Water Drop ,~ ~ ~/~-77 //.'o I -- 5- %¢ ', _ II .' o z I ~ i n ~ '~CT" ~/'~ " _ I i: o ~ ,, & ~/./" .-/~" " - 9' - _. /'/.'_o 7 " & " _¢2" / /.' o,~ " & 7'z " v/~ ,' //:e~ " 7" PERCOLATION RATE 2-, tm,nules/mchl PEFIG HOLE DIAME [E~ ~ 12-OO8 (Rev 4/85) THA1 THIS TES1 WAS PERFORMED IN Municipality of DEPARTMENT OF H~LTH & HUMAN SERVICES ~z~ L ~treet, ~ncnorage, Alaska 99502-0650 SOILS LOG -- PERCO~TIC)N TEST LEGAL DESCRIPTION: ~U~ ~J~ ~(~(~5 Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 COMMENTS SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? s IF YES, AT WHAT (~ DEPTH? p E o,,,, ,0 w,,. ~onitoring? , O~tm . Reading Date Gross Net Depth to Net Time Time Water Drop t , 06,//u1¢~ I/.'o? ¢- ~' I;P¢ 0" -?" 3 " t:1o ¢" ~ -' /.'o~ ~" ~" PERCOLATION RATE____ '~' . [mmutesy~nchl PERC HOLE DIAMETER TEST RUN BETWEEN X'5 FTAND ~', S_FT PERFORMED BY: /~ ~' ~---"~ I ~ CERTIFY THAT THIS TEST WAS PERFORMEO IN Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 47'00 Brsga,~ Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 ,,,,, / - CERTIFICATE OF ON-SITE SYSTEHS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-521-45 1. GENERAL INFORMATION COSA# Expiration Date: Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address GLENN VIEW ESTATES S/D; LOT 8 25415 GLENN HILL CIRCLE * CHUGIAK, AK * 99567 CHRISTY BRADFORD Day phone 398-8515 23415 GLENN HILL CIRCLE * CHUGIAK~ AK * 99567 Day phone CECELIA NIMS W/ PRUDENTIAL Day phone 250-0099 5801 CENTERPOINT DRIVEr #200 * ANCHORAGE, AK * 99505 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 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 samples. (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. STATEMENT OF ~NSPECT~ON BY ENGINEER d by ~:llli7~eo /lei ~lj c~llLI a,.b Oi ~11~ V~IIUa[IUIi u~ OIJUYVII ~I~VV~ V~ ~ tglOc ~/ As oeRifie my sea/ ..... '- ....... ~ ~ ~ "~ .... ':~':~ ~ ~'~ ~ ..... ~ .... I .... :;" +~+ investigation, based on procedures outlined in the CeNficate of Qn-Site Systems Approval Guidelines for t,ffis appfication, 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 fuRher verify that based on the information obtained ~'cm the Municipafity of Anchorage Nes end f~m 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. NameofFirm GARNESS ENGINEERING GROUP, Ltd. Phone 557-6179 Address 5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater 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 the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for / Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: ~,~a,.hments: COSA Checklist Septic System Advisory Well Flow Advisory (Rev. 11/05) Arsenic Advisow Maintenance Agreements Supplemental Engineer's Report utner Original Certificate Date: · MUnicipality of Anchorage Development Se ices Department Building Safety Division On-Site Water & Wastewater Program _ 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Legal Description: WELL DATA Well type PRIVATE Date completed Total depth 243 GLENN VIEW ESTATES S/D;. LOT 8 4/1997 ff. IfA, B, or C provide PWSID# N/A Sanitary seal (Y/N) YES Cased to 241 ft. FROM WELL LOG 4/1997 149 ff. g.p.m. Nitrate I, I ~J mg./L. Date of sample: 9/7/2010 Date of test Static water level Well production 30 WATER SAMPLE RESULTS: Coliform · C) colonies/lOO mi. Arsenic: ~i~ ug./L. SEPTIC/HOLDING TANK DATA 2 Depression over tank (Y/N) NO Pumper. ~*BELOW EXISTING GRADEI Soil rating ~or ft2/bdrm) 1.2 Width 5 ft. Tank Type/Material SEPTIC/STEEL Tank size 1250 gal. Number of Compartments Foundation cleanout (Y/N) YES Date of pumping ~ :9/7/2010 ABSORPTION FIELD DATA Date installed 4/7/1997 Length 51.5 ft. Total depth *7.4 .ft. Eft. absorption area 515 ft2 Monitoring tube YES Date of adequacy test 9/7/2010 Results (Pass/Fail) PASS Fluid depth in absorption field before test 0 in. Elapsed Time: - min. Final fluid depth 0 Any rejuvenation treatment (past 12 mo.) (Y/N & type) CHECKLIST Parcel ID: 0 Well Log (Y/N) YES Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 9/7/2010 148 .ff. YES 18+ in. System type SHALLOW TRENCH Gravel below pipe 4 ~ ft. Depression over field NO For 4 bedrooms Water added 658 gal. New depth 0 in. in. Absorption rate >= 600+ g.p.d. NONE KNOWN If yes, give date - Date installed 4/7/1997 Cleanouts (Y/N) YES High water alarm (Y/N) N/A JR'S PUMPING Other bacteria (~) Collected by: 6.38 g.p.m. __ colonies/100 mi. GEG Ltd. D. LIFT STATION Date installed "Pump on" level at in. Size in gallons Manh~ ~ "Pump off" level--water alarm level at Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot 100'+ Public sewer main N/A Sewer/septic service line 25'+ Animal containment areas 50'+ .in. 100'+ Meets alarm & circuit requirementS? On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout Holding tank N/A Manure/animal excrete storage areas N/A 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Water main N/A Water service line.. 10'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Absorption field 5'+ Surface water 100'+ Property line 10'+ Building foundation 10'+ Water service line 10'+ Surface water 100'+ Curtain drain NONE KNOWN Wells on adjacent lots. 100'+ COMMENTS Water main N/A Driveway, parking/vehicle storage 10'+ G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date COSA Fee $ Date of Payment Receipt Number 0,~.~ a9 '~ (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number SGS Ref.# 1104684001 Client Name Gamess Engineering Group, Ltd Printed Date/Time 09/17/2010 10:32 Project Name/# Glenn View Estates~ Lot 8 Collected Date/Time 09/07/2010 13:15 Client Sample ID Glenn View Estates; Lot 8 Received Date/Time 09/08/2010 12:03 Matrix Drinking Water Technical Director Stephen C. Ede PWSID 0 Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Hardness as CaCO3 97.3 5.00 mg/L SM20 2340B C 09/08/I0 09/09/10 NRB Waters Department Total Nitrate/Nitrite-N 1.19 0. I00 mg/L SM20 4500NO3-F B 09/14/10 AYC Microbiology Laboratory E. Coli Negative 1 100mL SM20 9223B A 09/08/10 DLC Total Coliform Negative I 100mL SM20 9223B A 09/08/10 DLC Private Individual Analysis Alkalinity 123 10.0 mg/L SM20 2320B D 09/08/10 LP Aluminum ND 20.0 ug/L EP200.8 C 09/08/10 09/09/10 NTB Antimony ND 1.00 ug/L EP200.8 C (<6) 09/08/10 09/09/10 NRB Arsenic ND 5.00 ug/L EP200.8 C (<10) 09/08/I0 09/09/10 NRB Barium 3.50 3.00 ug/L EP200.8 C (<2000) 09/08/10 09/09/I0 NRB Cadmium ND 0.500 ug/L EP200.8 C (<5) 09/08/10 09/09/10 NRB Calcium 17700 500 ug/L EP200.8 C 09/08/10 09/09/10 NRB Chloride 3.16 0.100 mg/L EPA300,0 D (<250) 09/08/10 09/09/10 SDP Chromium ND 2.00 ug/L EP200,8 C (<100) 09/08/10 09/09/10 NRB CO3 Alkalinity ND 10.0 mg/L SM20 2320B D 09/08/10 LP Conductivity 299 1.00 umhos/cm SM20 2510B D 09/08/10 LP Copper 255 1.00 ug/L EP200.8 C (<1300) 09/08/10 09/09/10 NRB Fluoride ND 0.100 mg/L EPA 300.0 D (<2) 09/08/10 09/09/10 SDP HCO3 Alkalinity 123 10.0 mg/L SM20 2320B D 09/08/10 LP Iron ND 250 ug/Lt EP200.8 C (<300) 09/08/10 09/09/10 NRB t PLOT PLAN ASBUILT ~ SCALE ~"= 50' GRID h~, JSq. o Project No, mm ~ ~ 1~ ~ LcIrl~ ~1~ ~ffioc~a~ ~c, 11500 Dali Avenue, Anchorage, Alaska gg515 (907) 522-6476 Phone ~~~~ Reglsfered Land Su eyors (907) 522-4625 Fax ~ OF ~ ~ ~cho~g, Recording Olatflct. Alaaka, and that fha Improvement,-,Itu:ted ~.."' 49~ ~ '..~v~. thereon a~ within the propa~ lina~ and do not eno~ach onto the p~pe~ easement, ce~enanta, or re=fHaflon= which do not appear on the recorded =ubdi~lalon pl~. ~~ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw S~reet ~J P,O, Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEHS , ,PPROVAL FOR ,b, SINGLE FAHILY DWELLING 1. GENERAL INFORMATION cos Expiration Date: ~ -//O - ~ ~ Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address _GLENN VIEW ESTATES; LOT 8, _2,3415 GLENN HILL CIRCLE * CHUGIAK~ AK 99567 _ MICHAEL &: LAUREL LINDQUIST Day phone 688-2529 _P.O. BOX 770606 * CHUGIAK~ AK 99567 Day phone Real Estate Agent Mailing address . ANNE ROBERTS w/ PRUDENTIAL Day phone_.244-3392 16635 CENTERRELD DRIVE * E.R., AK 99577 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: _ 4 3. TYPE OF WATER SUPPLY: Individual Well Individua~ Water Storage Community Class_ Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer The MunicipaIity 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 lhe State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of lille (except between spouses) for properties served by a single-family on-site wastewatar 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 samples. (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 seat affixed hereto and as of the validation date shown be/ow, 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 end State codes, ordinances, and regulations in effect at the time of installation. Name of Firm CARNESS ENGINEERING CROUP. Ltd. _ Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE. AK 99,507 Engineer's Printed Name JEFFREY A. CARNESS, P.E. Phone_ 337-6179 Date Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analys~s of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The repealed results described the performance of the system under tho conditions encountered at the time of the test, and separation ' distances measured to readily identifiable features. The operatioual life of all wells and septic systems depend on the local soils condition, groundwater levels that may t~uctuate durfng the year, and the water usage of the fatuity being served by the system. Those conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future perfocnance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long tho system will cent/hue to meet the eperetionat requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reh'ance upon o¢ use of this roPor~ by any other person or parD/is not authorized, nor will it confer any legal right whatsoever. 5. D~D SIGNATURE ~ Approved for ~ bedrooms. Disapproved. Conditional approval for _ Attachments: CaSA Checklist bedrooms, with the fllowing stipulations: .,,6'.~o?"' o -' ...... ~',,;,'~ '. PROGRAM Arsenic Advisory Septic System Advisory Well Flow Advisory Nitrate Advisory Maintenance Agreements Supplemental Engineer's Reort Other Original Certificate Date: ,~"'-/0- ~) ~ Legal Desaiption:, A. WELL DATA Municipality of Anchorage Development Services Department Building Safety D~ O~-Site Warm & Wastewatsr Program 4700 Bragaw Slmel P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.o~/onsite (~07) 343-7O4 CERTIFICATE OF ON-SITE SYSTEPIS -~PPROVAL CHECKLIST GLENN VIEW ESTATES SUBDMSION; LOT 8r Parce 05'1 I - ¥.;" Well type PRfVA/E IfA, B, or C provide PWSID# .N,/A Date Completad, 4/1997 Sanitary seal (Y/N) .YES Total depth 243 ft. Cased to. 24.1 ft. FROM WELL LOG Date of test 4,/1997 Static water level 149 fl. Well production 50 g.p.m. WATER SAMPLE RESULTS: Well Log (Y/N). YES Wires properly protected (Y/N) - YES Casing height (above ground) 18+ in. AT INSPECTION _._.__~_~2006 146 ft. 6.9 g.p.m. Col~orm 0 A~senic: . ND B. SEPTIC/HOLDING TANK DATA Tank Type/Material. SEPTIC/STEEL Tank size 1250 gal. Number of Compa~ments. Co colonies/100 mi. . ug./L. Nltrata . 0.91 mg./L. Other bacteda 0 Date of sample: ~9/2006 Collected by: colonies/1 O0 mi. GEG Ltd. Date installed. 4.,/7/I 997 Cleanouta (Y/N) _ YES High water alarm (Y/N), JR'-, PUMPING 2 Foundation ctaanout (Y/N) .YES Depression over tank (Y/N). N.O Date of pumping ~ Pumper_ ABSORPTION FIELD DATA F~J~F"~i;~;~'~ Date installed 4,/7/1997 Soil rating (g,p.d./ff~or~). 1.2 Length, 51.5 ft. Width 5 ff. Totaldepth -7.17 ft. Eff. apsoq3fionaroa..Sr15 ft2 Moflitoringtuhe YES Date of adequacy test 2/9/2006 Results (Pass/Fail) _PASS Fioid depth in absoq3flon field before test DRY in. Water added ! .208gal Elapsed Time: .1. 76 min. Final fluid depth DRY in. Absorption rate >= Any rejuvenation treatment (,past 12 mo.) (Y/N & type) NONE KNOWN~ If yes, give date. System type SHALLOW TRENCH Gravel below pipe 4.1 ft. Depression over field. NO For 4 bedrooms New depth DRY in. 600+ g,p.d. D. LIFT STATION Date installed Size in gallons E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: 100'+ Septic tank/lilt station on lot 100'+ Absorption flelcl on tot 100'+ Public sewer main Sewer/septic sewice line . 25'+ On adjacent lots _ 100'+ 100'+ On adjacent lots Public sewer manholeJdeenout 100'+ Holding tank N/A Animal containment areas 50'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ pmparty line 5'+ Absorption field N/A _ Water service line 10'+ Surface water_ Water main Wells on adjacent lots 100'+ _ Manure/animal excrete storage areas _ 100'+ 5'+ 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Water seneca line Curtain drain _ 10'+ Building foundation 10'+ Water main_ N//A 10'+ Surface water 100'+ .Driveway, parking/vehicta storage _ 10'+ . ~ ~ ~L Wells on adjacent lots 100'+ , F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through ~eld inspec~ons a. nd review of Municipal recorde that the above systems sm Jn conformance vv~t MOA COSA guidelines in effect on this date. Engineetas Printed Name JEFFREY A. GARNESS Date '2../"z., Waiver Fee $ Date of Payment Receipt Number SGS Ref.# Client ,Name Projecl ,Name/# Client Sample ID Matrix PWSID $amvlc Remarks: 106067000 I Garness Engineering Group, Lid. Glenn View Esl Lot 8 Glenn View Est Lol 8 DHnking Water All Dates/Times are Alaska Standard Time Printed Date/Time 02/17/2006 14:52 Collecled Date/Time 02/10./2006 7:20 Recek'ed Date/Time 02/10/2006 9:25 Technical Director Stephen C. Ede Nitrate-N Allowable Prep Analysis Results PQL Units Method Conlainer ID Limits Date Date 0.911 0.100 mg/L EPA 353.2 Init B (<=10) 02/10/06 JC ~t:als b~' ZCP/I,~ Arsenic 1~ cr°b.iol oc.~ :,abora t;or~, Total Coliform ND $.00 ug/L EP200.8 col/100mL SM20 9222B C (<=10) 02/13/06 02/15/06 TK A {<=1) 02/10~6 TLF PAGE 02 JRs Pump[ag PO Box 773415 Eagle River, AK 99577 (907) 694-6454, Service Agreement Gamese Engineering Gmu~ Jt~ Desc. dplfon: 1030g 3701 E Tudor Road P.O. Number. Sutte 101 AncOt-age. AK g~07 Terms: Net 30 (907)337.6179 Sales;eD: Kadia JobType Repeat Meagan & Chris Map Book: Map G~d: 29 Number:. 019214 Order Date: 13-Feb-200~ Ser~ce Date: 21.Feb-2006 12:00 am Tec~nidan: Dave 23415Bernie Glen HUl Job Comments: JLa~-~e~'--'~"~'~'0:~-- :1000~ ............... . Pt-lea Each x 2 Men Tax $130.00 NO No IBla~ ~udge from Tank to L// REC; line lo be Jetted in s~o;fng Tax percent. B/F 3 x'$ - Due to amount of solids Extension Actual $130.00 Planned; 1000 Gall~e Actual: _ Hose Lang.: Double Tank: ~ _ Pump System: []. Baffles Irdat: r_"~. Baffles Outle~: ~ __ Eagle River, AK ~g567 (907) 337-6179 Service Type Qty Septic Sen~ce 15K 1 AddlUonel Local~ou Comments; · '$ are on gray home w/dark blue Irlm. NO Doge. Chain link fendng If1 beck, Aeeose fi.om Paters C~eek Chr~sl~an Center. STEEP OW, Pipes In bac~ ar~l ~4 stole NonTaxable Total Taeable Total Tau[ Total Grand Total Estimated Charges: S130.00 S0.00 &0.00 $130.00 q Actual Cherges: ~ Cua~mar agrees ~o the'terms and coadlt~ens of this sauce agreement. THIS I$ A BINDING AGREEMENT. $1gna~ura and TIUe of Cuslomer RePresentativ~ Aaeeptad by JRa Pumping Data Accepted ro~ your added ¢onven~enea w~ accept; Amedoan Ex~e~, Dicover, Visa and Master Card payments over em phone. After 30 Day~ accounts wlli be turned Ove~ to collectJous. $25.00 For NSF Checks Returned. Municipality of Ancilorage Development Services Department Building Safety Division On-Site Water and W,3stewater Program ZlTOO SoUth Bragaw St. P.O. Box 'i96650 Anchorage, AK 995~g-6650 www.ci,anchorage.ak. Us (g07) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ParcelI.D, 051-521-45 ¸1. GENERAL INFORMATION ,Complete legaldescripiion I, ot 8; 'Location (site address or directions) HAA# I-t/:) 0 3 0 2-1 Expiration Date:> - - O Glenn View Estates 23415 Glenn Hill Cir. ::CUrrent Properly owner(S) Mailing address Ann & Guy Soper. Day phone 688-4819 Lending agency Day phone Mailing address RealEstateAgent Sharon Minsch / Remax MailingAddmss 16600 Centerfield Dr. Ste Un~ssothe~iserequeste~ HAA wi/l~ he~ DSO~rpick~, NUMBER OFBEDROOMS: 4 Day phone 694-4200 201 Eag-le River, AK 99577 3~ TYPE OF WATER SUPPLY: Individual Well Individual Wa[er Storage Community Class__ Public Water System Well 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 Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal ahd/or water supply system. DSD also issues HAAs upon request to homeowners. Cedificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid i'or 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. STATEMENT OF INSPECTION BY ENGi~jEER As cedified by my seal affixed hereto and as o{~ the validation da{e shown below, I verify that my InvesUgation, based on procedures outlined in the Health Authority Approval Guidelines for Mis 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 0n 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 S & S Engineering Address 17034 N. Eagle River Loop Ste. 204 Engineer's Printed Name Robert C. Cowan bedrooms. DSD SIGNATURE Approved fot Disapproved. Phone 694-2979 . Eagle River, AK 99577 Date 5-/~/~ ~ '"~"',.'"' ".,Y4- Condi[J0nai approval f0F bedfb0ms, With the f°llowing Stipula{i0n~i Additional Comments WATER AND PROGRAM Attachments: HAA Checklist Septic Sys{.em Advisory . Well Flow Advisory Maintenance Agreements S~ppiemental Engineer's Report Other Date Well; On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. BOx 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907] 343-7904 HEALTH AUTHORITY APPROVAL provide PWSID # Sanitary seal (~N) Date of sample: _~.~/°,~'~ Tank size /D%0 gal. Foundatfon cleanoutCN) ~$ Date'Of'pumping ~- / ~./.~ z... C, ABSORPTION FIELD DATA Dateinstal!~d ~;//,~,/~ Soilrating~0rff2/bdrm) Length ,~"/. ~"- ft. Width ,~"'- Numbei~ ~f Compartments Depression over tank (Y~ /d0 Pumper ~7~'- ~' Collected by.S & S ENGINEERING 17034 Eagle River L~p Road No. 204 Eagle River, Alaska 99577 High water alarm (Y(~) · Eft. abs'orption area ..%'/~"-ff2 Monitoring Resultsl~'Fa ) Fluid depth in absorption field before test 10/~'~' in. Water added -~ l~al. ElapSed Time: ~0 min. Final fluid depthJ)~:~'in. Absorption rate Any rejuvenation treatment (past al Manhole/Access (Y/N) Date installed . i Ions . "Pure p on" level at in. "Pump o~ m. High water alarm level at uit requirements? Datum Cycles tested SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100 ~' Absorption field on lot 100 r- Public sewer main ~J Sewer/septic service line , ~- I¢ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT Building foundation 10 ~ Property line Water main JlJ/l~j~ Water service line Wells on adjacent lots IC~~' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ¢0 '(- Building founc ation / Water Service line l0 t' Surface water (0,5 Curtain drain- ~)~¢~ ~ lr~,.~,J Wells on adjacent lots On adjacent lots On adjacent lots Public sewer manhole/cteanout Holding tank Absorption field Surface water Driveway. parking/vehicle storage in, G, ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in e~fect~on ~his date. Engineers-' Printed Name /~'8~"~'7-C, Co ~,~ Date ~"'/~,.~ / 0 ~ HA,& Fee $ Date of PaymeDt Receipt Number (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number 05-21-03 04:IFPM FROm~-CT&E ENVIRON~NTAL SR¥ §075B15301 T-B55 P.04/05 F-621 ~t~ CT&E Environmental Services Laboratory Division ~~~~/~~' :ZOO W. Potter Drive Drinking Water Analysis_ _ Report for Total Coliform Bacteria Te,:Anch°rage'(907) 562-2343AK 99518-1606 READ INSTRUCTIONS ON REV~R,¢:E ?:lrtE B£FORE COL ,LECTING SAMPLE Fax:. :i907) 561-5301. MUST BB COMPLETBD BY WATER SUPPLIER ITO BE COMPL~fI'I~D BY LABORATORY [ Analysis Showa this Water SAMPLE to be: J~' PRIVATE WATER SYSTEM ICl ' Unsatisfa~ory Send Invoice Name ~l Send h~vo~ce Month Day Year SAMPLE TYPE: ' o Roqtine [] Repeat Sample (.for routine sample wtth'lab:reL no. I o$9~obo 0 ~ ) Treated Water Untreated Water 0 Special Purpose Time Collected SAMPLE LOCATION Collected B~ [] Sample over 30 hours old, zesults may be unreliable Sample too long in tranail; sample should not be over~lOhours old at exantinafion to indicate reliable r~sults. Please send new sample via special delivery,mail. Date Received ~--/b ' O ~ Time Received ( ~/.Z~ Analytical Method: '~-~[cmbrane Filter /o MMO-MUG * Numbm' of colonies/lO0 tnl. 1 032680 ~h Fbks Jun [] Foxed Date: That: . Client notified of unsatisfactory resalts: Phoned ' Spoke With Date: Tirac: BACTERIOLOGICAL WATER ANALYSIS RECORD M~O-MUG Result:. Total C611form E. Call ,.. Colonies/lO0 mi Membrane l~lter. Direct Count Verification: LTB BGB COLII~IRM. Cerumen,m: Fecal Coliform Confirmation Final' M embraa e Filter Results Time hfs Foxed Member of the SGS Group (Soci~t~ G6n~rale de Surveillance) cmwmnM&ili:NT&l ¢ACILITIES IN A~S~. ~LIFORNIA. FLORIDA, ILLINOIS, MARY~ND, MICHIGAN. MISSOURI. NEW .JERSEY, OHIO, ~T V~RGINIA 05-12-03 01:43PM FRO~CT&E ENVIRON~NTAL SR¥ 9075615301 T-504 P.02/03 F-376 SGS Ref.# Client Name Project Name/# Client Sample ID Matrix 1032506001 S & S Engineering LB, Glenn View Estates L8, Glenn View Estates Drinking Water Sample Remarks: All Dates/Times are Alaska Standard Time Printed Date/Time 05/12/2003 7:19 Collected Date/Time 05/07/2003 14:30 Received Date/Time 05/08/2003 9:30 Allowable Prep Analysis Parameter Results PQL Units Method Limits Date Date Init Waters Department Nitrate-N 0.869 0,100 mg/L EPA 300.0 (<=10) 05/08/03 M~ crobiology Laboratory Tot~ Coliform .-']~C ~ col/100mL SMI8 9222B (<=1) 05/08/03 KAP Ma~ 19 03 03:57p Sharon Hin~ch 6963858 p.1 Lan~ ~ A~e~,l~40m !~ 115~0 D~I Avenue, Anchorage, Alaska 99515 .aglsterea Lane =u~eyors {9o7) 522'4625 Fax ~=nomg~ ~e=e~ng DI~H~. Nas~a, and that the Impr~ament= attualea , thereon are within the p~pe~ ifnes and do net encroach ante the pmpe~ ~. ~,; ~.~a~.~ ..... ~.~.~ ~dlaaanf the~=. ~f no Impr~amenfa on the pmpe~ ~[ng adjacent them~ ~'~ .... IIn*a ~r ~her vlalble eazemen~ on zQld ,prQpe~ except ~ Indicted he.on. ~'~'~ ..... ~;'["' '~'"~'~'~ Oared this th, ~b" Day of I%~W -~. at ~n=h~r=g,. Alaa~a ~".. LS-SZO~ .'"~ ~ ia the ~onslblll~ of fha e~nur ~ de~ine ~e uxls~nae of any mazemen~, eovenant~, or rem~lons ~hlch de not appear Dn the reco~ed 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 E2~L~ -~- CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner ~ 2~./: ,/~¢ Mailing address ~© '(~ ¢. Lending agency Day phone Mailing address Agent Day phone_ Address Unless otherwise requested, HAA will be held for pickup. NUI~IBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well 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 community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 IRev. 1/gl) Fronl MOA ~121 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. Phone {~{~--/~/! / Name of Firm KND Engineering 2b~N1 Ra~migan Blvd. Address Eagle River, AK 99577-8_7~ Engineer's signature -~: DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms, 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 engineers work. 72~25 fRe¥. 1/911 Back MOA fY21 MUNICIPALITY OF ANCHORAGE I~NVIRONMENTAL SERVICES DIVISION Municipality of AnChorage JUL 24 1997 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 3~.4f~J VE 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) Legal Description: A. WELL DATA Well type Leg present (Y/N) Total depth Sanitary seal (Y/N) Health Authority Approval Checklist ~¢'/x)~'~SZ. ~/.,~¢'(~ Parcel I.D.: If A, B, or C, attach ADEC letter. ADEC water system number Date completed z///~ Cased to ;7--/--//// Casing height (above ground) ~,z// '/ Wires properly protected (Y/N) _ AT INSPECTION Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ,.~ Date °f sample: B. SEPTIC/HOLDING TANK DATA Date installed z¢/~/'7 _ Foundation cleanout (Y/N) y Date of Pumping ,N/.,Cr· FROM WELL LOG / g.p.m. / g.p.m. / Nitrate , (~ 3 Other bacteria Tank size Number of Compartments ~- Cleanouts (Y/N) Y _ Depression (Y/N) /4/ High water alarm (Y/N) Pumper C. ABSORPTION FIELD DATA Date installed Length :~' I. ;~ [ Width ~'- Effective absorption area 500 Date of adequacy test Soil rating (g.p.d./ft2 or ft2/bdrm) /,,~_ Gravel thickness below pipe Monitoring Tube present (Y/N) ~/ Results (Pass/Fail) ------- _ System type ~. /-/. / ' Total depth __ Depression over field For '---"-- Fluid depth in abaton field before test (in,); /Immediately after gal, water ad~n,): Fluid depth~ ..~/~./ (ins) Minutes later:// Absorption rate = // g.p,d. Peroxidy.,,~,.tment (past 12 months)(Y/N) / If yes, give date 72-026 (Rev. 3/96)* bedrooms LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested Size in gallons ~ ,,~ump on" level at* "/~u m~off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 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 / O '.,c Property line / O ~ -F Absorption field / O Water main/service line /~) ~ ' Surface water/drainage /4~O -A Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /~ -/- Building foundation /~) '¢' Water main/service line /OO + Surlace water ! C~ C> '~ Driveway, parking/vehicle storage area SD- ~-~ Curtain drain ~o~ ,~'~oco~ Wells on adjacent lots I/,~(~) ~ ENGINEER'S CERTIFICATION I certify that l have determined thru field inspections and review of Municipal rc, L~"~"~a*~ove systems are in conformance with MOA HAA guidelines in effect on this date. / Date Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)*