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Home My WebLink AboutT&T LT 2 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I ~ ENVIRONMENTAL ENGINEERING DIVISION ~ 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE NAME ".~ L~ ~ ~ UPGRADE MAILING ADD~ESS LEGAL DESCRIPTION iWelI ~ Absorption area Dwelling PERMIT N~ ~ ~ Manufacturer ~ ~6/' ~'~¢C I ~ P Liq. capacitv in gallons IF HOME.DE: inside length Width Liquid depth I ~ 5~ PERMIT NO. ~ ~ Material Liquid capacity in 9allons ~ Well Foundation ~ ~ l O+ ~ [ ~ No. of lines Length o~ each tine Total length of lines Trench Total effective absorption area Material beneath tile Length Width Depth PERMIT NO. ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ ~ Well Building foundation Nearest lot line ~ DISTANCE TO: Class Depth Driller Distance to lot llne ~ERMIT NO. ~ Septic tank Absorption area(s) ~ Building foundation ~ DISTANCE TO: OTHER PIPE MATERIALS ]~ ~,~ INSTALLER REMARKS ~ DATE LEGAL z2-013 (Rev. 3/78) [:,EF'FIRTMENT L_¢, HERLTH h,4[ .... '-"-=' "L" .:,TREE ~., Ri'.4CHORRGE, FtK. , F'EF:i"IiT NO. RF'PL. :,': CRNT Cf:IRL. ES:ON CONST LOCF:i 'F ~ ON LEC, F~L L2 T&T Th-:F'~ OF SOIL ABSORPTION S;YSTEt'i ~,IF~:~.C[Hf...iH NUMBER OF BEI>F.'.OOHS = 4. T I:;k E N C H S;OIL RRT~NG "':;K~ F'r,. ER.. ::L,~._ .Ih:-_ hLz..~I_IIREE '=,TZE OF THE '~OIL RE:SOF-,F'T.i:ON .=,Tz, FEtl '.'..iE LIENISTH DIMENSION IS THE LENGTH ,'ZN FEET:))) AF THE TRENCH OR DRFtlNF:IELE:,. Ti. iE [.EPTH OF FI TRENCH OR F'IT T,:, THE: [)'[E;TFII'.,IC:E BETP~EE:N THE S;URFRCE OF THE ...... ' ": '" i ,:: I N 3'.;")UN[:' Ffl'.,I[:, THE Eff3TTOM OF ]'HE E,.-,..H , ON FEET::'. ......... · - ~.IF~ '=FT 141 'TH FEF TRENCHES;. ".' :::' ']~:i;::¢,,'EL [)EF'TH tS ]"HE MINIMUH 1.:'~? ~I-! OF GRR',,,'EL 8ETI.4EEN THE OUTFRLL PIPE ~:~!":L) THE E, OTTOM OF THE E::.::C:F¢,/RTZON ,'iN FE'ET::'. ~ ~-- ~; ii_.g ~ ~:. E [:" .=. E ~: -~ :E ¢'Z: 'T IF:~ Il ¢-'E~.r'.z! RF'PLiCFINT HFIS THE F~,E,~F'rd'.,ISZE:ZLZTY TO INF'ORH THItF, [:,EF'RRTMENT L")JF.'IIq3 THE ~--"<' ....- - TH...:, F'ROPERTY Fli'.,l[:, THE ?.~'~TF-[ FTION !I'.,IL:;F'ECTICdq':5 3F R.i'.~'.r' HELLS FiC, JF!CENT TO T'- NUflEEF. OF RE=,I[.,ENL. E-, 'f'HRT THE HELl- t,.IILL -- .=='- F-" ES' ~%-~ LIt :E F-." F_ [-':, ....... p ,-,,,:' ,' I,]ITHOLIT FINRL tNSF'EC:TZON RND RF'PROVRL BY E:RCI<.FZI_LZN.~ OF FIN"r' B, EPRRTMENT I,.IIL. L BE S.IEJECT TO F'RO'SEC:UTION. HZNZHIjH E)ZSTFINCE BET~,4EEN R 14ELL FINE:, RNY ON-SITE :,Et.iHME D, ISPOSRL :,?_TEl1 ±00 FEET FOR R F'RI',,,'RTE I,.!ELL OR ±DO TO 200 FEET FROH R PUE:LZC: 14ELL E:,EPENDZNG .F'ON THE TYPE OF F'UBLZC I.,.tELL. ,_ , ., .,- MZNIMUM DI~TFINC:E FF.:Cd"t R F'F:[',,,'RTE F!ELL TO Ft pF.:T',/FITE :,EL!EF. LINE I:, '.25 FEET RND TO R COHMUNITY SEHER LINE IE, 75 FEET. !4ELL LOGS RF'.E RE';4.1IF:ED RNB, HIJST BE RETURNED TO THE DEPRRTMENT !4ITHZN Z::O DFIYS OF THE 14EU- COMF'LET'rON. OTHER REQUIREi',1ENTS l'"llElY RPPL"r'. SPEC:iFZC:RTIONS RND CONSTRUCTION DIRGF.:RHS FIRE FI',,,'FIILiFIE:LE TO ZNSURE FF_FEF. 'rNSTRLLRTION. ..... F_ E.:,, [:~ E C: EE If'"IE: E F-" pEEF-:~-lJ :E T E.---.F ~ " I C. EF.T I F THRT ±: I RM FRMILIRR HITH THE REtS!UIREf'tENTS FCR ON-SITE SEP.tERS FINE:, P.IELL'E, FI'-, _,ET - ' LuE E--,. FL~TH BT THE MUF,!ICIF'FILITY OF HNCHUF..H-~E. _ .... <" I P.ttLL Ii,l:. HLL THE =,-r.=,TEfl IN FIC:C:L-IRC'RNC:E [,.IITH THE '~:: I I_N.r)E:RSTRND THRT THE uN-_-,ITE =,EI.4EF. _,,._,TEl1 MSY REC,!UIRE ENLHKJEMENT IF' THE RESIDENCE IS REf, IADELED TO ZNE:LUE:,E MORE THRN 4- BEE)ROOfd:=,. V4.. 0 ~.. , WATER WELL RECORD STATE OF ALASKA OEPARTMENT OF NATURAL RESOURES Oivision of Geological & GeophysicaISurveys Drilling Permit No. LOCATION OF WELL (Pleage complete either la, lb or lc.) A.D.L. NO. _o,_ot_o,_so wo ,. OWNE, OF WELL~ 8. CASIN~ 0 Threaded .~Welded 9. FINISH OF WELL; M=IeH=;: ONeet Cemenl 0 Other: iS. PUMP= (If =w;;oble) HP 15. Water Temperature o 0 F this reportis ,rue to the~ best of~/~my~ knowledgeon~ belief; Aut h~?ed ~eprasentafive Elevation Date grilled q-9-81 ~--aboratory Tests c~ ~ ~ ~: ~ ~ ~ ~ ~ ~ Minus #200 Sieve = 8.2% SA Minus #200 Sieve : 1.2% BROWN-GREEN MOSS & ORGANICS (Pt) BROWN SILT (ML) medium stiff, moist BROWN-GRAY SILTY SANDY GRAVEL (GP-GM) dense, moist no free water encountered LOG OF TEST PIT B Equipment Backhoe - Drott Hoe Elevation -- Date Drilled 4-9-81 BROWN-GREEN MOSS & ORGANICS (Pt) BROWN SILT (ML) medium stiff, moist SILTY GRAVEL (GM) medium dense, moist -- BROWN GRAY SANDY GRAVEL (GP) I dense, moist rounded particles to 6" diameter 'GRAY MEDIUM TO COARSE SAND (SP)' dense, moist · BROWN SANDY GRAVEL (GP) dense, moist HARDINg- LAW~ON Jot) No. 9675,001.08 A.=p.ppp_r~qgate 4/81 BROWN SANDY SILT (ML) stiff, moist GRAY-BROWN SILTY FINE SAND (SM) dense, moist-wet BROWN SANDY SILT (ML) stiff, moist no free water encountered LOG OF TEST PITS A & B HILL DRIVE IMPROVEMENTS Anchorage, Alaska PLATE l MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # _~-~- - ~[~'~-I~ HAA # 1. GENERAL INFORMATION Complete legal description Lot 2~ T ~ T Subdiv,~ion Location (site address or directions) 11561 H~ C,bl.c~e,, Anchora.q~, Alaska Property owner John and Barbara Wolf~ek Day phone 346-1481 Mailing address 11561 Hi~ ¢ir~.e., Anehorag6, AZ~ka Lending agency Mailing address Day phohe Agent Cha~ne. McK16an/ 2001 Rexc~ty Day phone Address_ 2600 Den~c¢~ S.f.~e.~. Su.C~¢ 400 Anehoraq~, AK 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 '~ TYPE OF WATER SUPPLYi NOTE: 276-2001 Individual well XX× 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: XXX Individual on-site 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. NOTE: 72-025(Rev. 1/91) Front MOA~2t 5. '~ STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address $ & $ ENGINEERING 17034 Eagle River Loop Road No, 20~.~. Engineer's signature Phone Date / 6. DHHS SIGNATURE .! ~ Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: 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~)25 (Rev. 1/91) Back MOA#21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAl. CHECKLIST Legal Description: ~-r~T ¢'~ ! T .~f~BDIdlSZdl'J Parcel I.D. A. WELL DATA Well type ~lO~'~[ Log present (~N) Totaldepth Sanitary seal C/N) Date of test Static water level Well flow ADEC water system number If A, B, or C, attach ADEC letter. ~Z~'~' Date completed ~-/(~-~>-~ Driller L~-~ Cased to /'~ ;~ Casing height YE--~ Wires properly protected I~N) FROM WELL LOG Pump level ,~ · SEPARATION DISTANCES FR~) Septic/holding tank on lot Absorption field on lot g.p.m. Public sewer main Sewer service line AT INSPECTION %5'+ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank /'~_. ~_/~o~ WATER SAMPLE RESULTS: Coliform (~ Nitrate Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed ~ - -~- 8~ /////////M'/' Tank size Cleanouts ~)/N) '~' water alarm (Y/~ High Date of pumping ¢'~,~'~g ~'/,~. Other bacteri.a Collected by: :~'dia R var, Alaska 99577 , / I~.,~) ~ Compartments ~- Foundation cleanout ~1) ~ E.Z. Depression (Y/~ /'J//d~ Alarm tested (Y/I~) Pumper SEPARATION/~ ~T~ ~S* FRO I C/141~-q~)4-N6 TANK TO: Well(s) on lot L ~(~ ~ ~/On adjacent lots ~r+ To property line ~0 Absorption field ~ Surface water/drainage IO(~ ~' T 7034 l+;a~le River Loop Roac~ N'IJ, 20~J Foundation ~,O Water main/service line. CONTINUED ON BACK PAGE C. LIFT STATION Size in gallons __~'~"'---.__ Manhole/Access Vent (Y/N) '~ ~-///~"Pu~p off" level at High water alarm level ~ Cycles tested Meets MOA electrical codes (Y/~ SEPARAT~M LIFT STATION TO: ,~p~6t On adjacent lots D. ABSORPTION FIELD DATA Date installed Length /~-' Soil rating /~-,~ ~?/~,-:~ System type k//' Gravel thickness ~ r :"~/~Total depth /Width Total absorption area Depression over field (Y/~ Results (pass/fail) Peroxide treatment (past 12 months) (Y~ Cleanouts present (~N) Date of adequacy test ~, for ~1 bedroom,,; Ef--~O~ ~.~ If yes, give date_ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /0,,~ /'/ On adjacent lots /00 '¢ .Property line /(~ / To building foundation /~. r To existing or abandoned system on lot /'~J//,~ On adjacent lots Surface water Curtain drain _ Cutbank /v~ ' Water main/serviceline Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I'ha¢e checked, verified, or conformed to all MOA and HAA guidelines in effect on th~ Signature . Engineer's Name Date HAA Fee $ /7~] C~' ~'¢~ Date °f Payment O'~ '~-~ -- F~{~ ~C~~ Receipt Number ¢¢~/ _ 72026(Rev 3/91) Back MQA21 Waiver Fee: $ Date of Payment __ Receipt Number Tom Fink, Mayor un ;3ipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 February 25, 1993 Roger Shafer, P.E. S & S Engineering 17034 Eagle River Loop Road Suite 204 Eagle River, Alaska 99577 Subject: Waiver Request for Lot 2 T & T Subdivision Waiver Request 9WR930008, PID 9015-163-65, HA930086 Dear Mr. Shafer: Your request for waiver(s) of the required 100 foot horizontal separation of a septic system to a private well has been approved. The approved separation distance(s) are a well to the septic tank on property of 90 feet. This waiver approval applies to the existing septic system to well separation only. Any future upgrade to either will require all. separation distances be met or another approval from this department. Robert W. Robinson Civil Engineer On-site Services Co~ur:/~ //? / ljm:#6 ~/ MUNICIPALITY OF ANCHORAGETM Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR~ WR930008 PID# 015-163-65 HA# ~A930086 Permit Date Received: February 22, 1993 Legal Description: Lot 2 T & T Subdivision Engineer: Roger Shafer, P. E., S & S Engineerinq 17034 Eagle River Loop Road, Suite 204, Eagle River, Alaska 99577 Applicant: John/Barbara wolflick Waiver Requested: Well to septic tank on lot - 90 feet Criteria: 1. Geology: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: Points: 3. Other: Waiver is Granted: / Waiver is NOT Granted: List Conditions or Reasons for above: ~}~u~,c/ ~-v~/~~ ~>14 ~' ~ ~/~ ~/~ ¥ ! I Name of Reviewer Rec #: 24481/6561 Amount: $ 410.00 Date Paid: Feb 22, 1993 4- ROBERT SHAFER, P E ROGER SHAFER. P.E. February 19, 1993 CIVIL ENGINEERS (907) 694-2979 FAX 694 !211 HEALTH AUTHORITY 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 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 MU,%IC'?A' ITY r'"F ~,NCHORAGE ENVIkONMENTAL &ER'vlC,~$ DIVISION FEB 2 2 199;~ RECEIVED REFERENCE: Lot 2, T & T Subdivision This letter is to request a waiver for the horizontal separation distance between the private well and the septic tank serving the referenced property at 90 ft. The septic system serving the referenced property was installed by Newton's Excavating, and inspected and approved by the Municipality in August 1983. In April 1984 a Health Authority Approval was issued on the referenced property. In September 1983 the private well was erroneously drilled less than the required 100 ft. from the septic tank serving the referenced ~roperty. For the following reasons we feel the separation distance prescribed in 18ACC.72 may be waived to 90 feet in this case. 1. The encroachment is upon the septic tank only. Generally speaking, a septic tank does not serve as a continous source of contamination as would a leachfield. Although the septic tank is not considerably lower in elevation than the well, surfacing effluent from the septic tank would never drain towards the well due to the drainage patterns on the property (See Site Plan). Topography in the area suggests the subsurface migration of effluent would be away from the well as opposed to towards it. ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 Page Two Lot 2, T & T Subdivision February 19, 1993 The septic tank is located in the front yard near the driveway's edge, the front yard is a well groomed grassy yard which is seperated from the driveway by a 10"xl0" timber serving as a protective curb (See Attached Photo). If the system were to fail to the point of daylighting, the surfacing effluent should be easily detected in sufficient time to prevent wide spread contamination of the surrounding surfaces. From a well flow test performed on the well serving the referenced property in February 1993, we found that after continuously pumping the well for four hours at 4.8 gallons per minute, the static water level drawdown was only 5 ft. This reasonably high well flow rate suggests that use of this well would create a minimal hydraulic gradient. Therefor, use of the well would not create a large hydraulic gradient so there would be little tendency for the septic effluent to be "drawn" toward the well. Water samples were taken from the private well serving the referenced by our firm on January 11, 1993 and tested for coliform bacteria and nitrates by the Alaska Chemical and Geological Laboratory. The results were satisfactory (See attached). The results show a relatively low nitrate level of 2.26 mg/1. Since septic tank effluent is very high in nitrates and nitrates travel through soils often unaltered, it appears that after more than 8 years of septic system use, the well is still not affected by septic effluent. We do not anticipate any adverse effects on the well serving the referenced property by waiving the separation distance down to 90 ft. Page Three Lot 2, T & T Subdivision February 19, 1993 If you require any additional information please feel free to call. j~E&~Spcerely~ civil Engineer ROGER J. SHAFER, P.E. for your review, 17034 Eagle River Loop Road ROBERT A.SHAFER ~~ CIVIL ENGINEER "" ~tELL/_FLOI~ lEST DATA SHEET '"~' LOOATIONOFWELL(LegalDescdption): /~~~ [ ~ ~ T STATIC WATER LEVEL (Top Of C~sing): ~' FL DATE: CLOCK ELAPSED TiME SINCE DEPTH TO DRAWDOWNI PUMPING PUMPING STARTED/ WATER, FT. RECOVERY RATE, GPM REMARKS TIME STOPPED, MIN. I.~: 0 .~ 0 ~:,9.~' ' (swl) 0 0 Start '"/"//(2~/~J~ D - ~'~ ~5 30 35 40 45 55 ~ 60 (1 hour) 9o ~:O% 12o(2 hours) 180 (3 hours) 210 RECOVERY t 0 0 5 10 15 20 25 30 35 Flow is not Guarant~ecl Subsequent Variations Can Occur. -% ,0 ./ 3.70 N 000-04" 44" E 165.19 _> --~ ~-E~ MUNICIPALITY OF ANCHORAGE Di-qISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEAL%Si AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date ~O n~zA~_ ~3z~ (a) Legal Description (include lot, block, subdivision, section, township, range) Location (add~ess o~ directions) (b) Applicants Name (c) Telephone Applicants Add,es s Applicant is (check one) Lending Institution ~-] ; Owner/builder ~; (d) Lending Institution _ ~%~ (e) Real Estate Co. &'Agent Address Te le phone 2. Type. of Residence $ingl~-Family Number of Bedrooms 3. Wate~ Supply Individual ~11 ~ ~lt i-Family E~ 4- Othe~ (describe Cc~munity ~--~. Public ~ Note: If ccr~munity well system, must have written confirmation from the State Department of Enviror~ental Conservation attesting to the legality and status. Is the well adequate fo= the number of bedroz~s specified in this HAA (Y/N) 4. Sewc~e Disposal Onsite ~ Public ~-~ Community ~--] Holding Tank ~-~ · Is the vmstewater dis_Dosal system adequate fc~ the r~mtbe..r of b~drocms (Y/N) [Page 1 of 2] 2-15-84 5. Engineerin~ Firm P~ovidin_g Inspections, %%sts, Data and Inforraation I certify that I have checked, verified, c~ confc~med to all MOA HAA Guidelines in effect on the date of this inspection. Nan~ of Firm __~'~_~ Add~ess Sigr d Date Date Telephone (ENGINEER SEAL) 6. DH?~__~prova 1 Approve d fo~ Approved [~ Disapproved !~ Conditional~-~ Terms of Conditional Approval ~he Municipality of Anchorage Department of Health and Envirou~rental P~otection dces not guarantee the continued satisfactory ~erformance of the water supply and/or t~he wastewate~ disposal system. This approval indicates that, as of the validation date shown above, based on the data and information furnished by an er~ineer registeDad in the State of Alaska, the water supply and wastewater disposal system is safe and fun,c-, tional for the number of bed~coms and type of structure indicated. ( DHEP SEAL) 7. Mail the HAA to the following add~ess: KB2/d5/s [Page 2 of 2] 2-15-84 L_~A z_ LoT A. WELL DATA' ' MUNICIPALITY OF ANCHORAGE (MOA) HEALT[~ ~/3'I~ORITY APPROVAL (BAA) CHECKLIST - FEBRUARY 1984 TZ3- '7- Su~b, ui~ozd MUNICIPALITY OF DF. PT. OF HEALff~ & ~NVJRONM~NTAL PROTECTION' APR ~.'. Well Log P=esent (Y/N) ~ ")'"~ri ' Date Complet/ed 9// ~/~-~ __ Total Depth ~_. / 'Cased to ~LZ! / Depth of S, outing~/~//~ Static Water Level .~c?~/ Casing Height ,A~ove dround ~-, 5/ Elect3ical Wiring in Conduit Separation Distances f~cm Wall: To Septic/Holding Tank On Lot ~.~ ! ; On Adjoining Lots ~ To Nearest Edge of Absorption Field on Lot JO ~ ~ ; On. Adjoining Lots To Nearest Public Sewer Line . ~J/A To Nearest Public Hewer Cleancut/Manhole ;4/~ To Nearest Sewer Service Line on LOt Water Sample Collected By ~ ~hJ~a%Lr~u~ ; Date ~ ~Z Water Sample Test P~sults Ccmrents '/-~L~74~ ,)~ A~> ~-~ /Jo&. Sanitary Seal on Casing (Y/N) ~_~ Depression Around Wallhead (Y/N) /%40 Bo SEPTIC/HOLDING TANK DATA Dete Installed ~_~ .~ ~ f~ Size i2 .~0 NO. of Compartments Standpipes (Y/N) ~5 Air-t~ght Caps (Y/N). ~5 Foun~tion Clean~t (Y~) ~.~ ~pression o~ Ta.~ (Y~) ~O I -- ~te ~st P~d _~ ~ ) ~ lA p~ihg~intenan~ ~n~a~ ~ ~ile (Y~)~.; fo~_ ~ S~( ~'~ Holding Ta~ High-Wate~ A!a~ (Y~) ~ ,/~ ~e~a~y Holding Tank ~t (Y~) ~/-~ Sep~ation Distan~s ~ ~ptic~olding Tank: To Water-Supply ~11 ~ / TO ~ilding Foundation To P~operty Line J~ ! TO Water Main/Service Line ~/~ course AfC/F APP~-i~-~m-~ TO Disposal Field..ICDF~<~ ~_ '~_,O',O/ To Stream, Pond, Take, c~ Major Drainage [Page 1 of 2] 2~15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~3 - ~ '- ~Jz~ Width of Field .~" ~f-'£lB~ Type of System Design Length of Field 4 ~ ! Depth of Field ./O Gravel Bed Thickness Square Feet of Absorption A~ea ~ Standpipes P~esent (Y/N) Depression over Field (Y~),~~ ~te of ~st A~a~ ~st Results of ~st Ade~a~ ~st mp~ .sq.~;-~ ~/~ Separation Distan~ f~om ~sorption Field: To ~te~-Supply ~11 ~O~ I To ~o~rty Li~ To Building Foundation ~ ~' To Existing Lot ~/~ ; ~ Adjoining ~ts To Wate~ Main/~=vi~ Line ~,/A~ To ~t~(if pre~nt) To St=e~ond~ke/~ Majo= ~aina~ Co~se ~j~ . To ~iveway, Pa=king ~ea, o~ Vehicle Sto~a~ ~ea Co~nt~ ~ ..c/~ .~ P~.~.~ ~ ~.~ ~d.~t (=7% De LIFT STATION Date Installed Siz~ in Gallons "Pump O~" Level at High Wate~ Alarm Level at Tested fo~ Electrical Codes(Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Confronts ** Check Permitted Bedroom Rating Against HAA Request certify that I have checked, verified, or confo~r~d to all MOA HAA Guidelines in eff.=ct on the date of this inspection. Signe~J~.~ ~ ~,~ ~ Date Company ~/~g~ .~ i~A/~l,l)~r~.~/Al-~OA NO. KB1/d5/s [Page 2 of 2] 2-15-84