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Home My WebLink AboutKIJIK LT 3Kijik Lot 3 #017-092-19 On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP151091 Tax Code Number: 01709219000 Work Type: Septic Upgrade Permit Effective Dates: May 01, 2015 to April 30, 2016 Design Engineer: PANNONE ENGINEERING SERVICE Subdivision: KIJIK Site Legal Address: KIJIK LT 3 G:3038 Owner/Address: HUGHES CHARLES & INA PO BOX 110693 ANCHORAGE AK 995110693 Site Mailing Address: 6201 E 142ND AVE, Anchorage This permit is for the construction of: Y Disposal Field Y Septic Tank N Holding Tank N Privy Lot Size in Sq Ft: 90000 Total Bedrooms: 3 N Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: US- Issued By: Lz:// Date: sillsol-S MITRAL APR 2 4 2015 MUNICIPALITY OF ANCHORAGE Gr®tch,, Stubir Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcell.D. 017-092-19 Property owner(s) Charles & Ina Hughes Day phone None Available Mailing address 6201 E 142nd Avenue, Anchorage, AK 99511 Site address 6201 E 142nd Avenue, Anchorage, AK 99511 Legal description (Sub'd., Block & Lot) K1JIK L3 Legal description (Township, Range & Section) Lot Size 90000 Sq. Ft. APPLICATION IS FOR: (N all that apply) Absorption Field ❑X Septic Tank ❑x Holding Tank ❑ Privy - ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms 3 APPLICATION IS AN: TYPE OF DWELLING: Initial ❑ Single Family (SF) ❑X (w/wo ADU) Upgrade 1ZDuplex (D) F1Renewal ElDuplex Dwellings ❑ (SF and/or D) THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number: Q�Y% Permit No. �sp�s�ix�r Permit App_::- ::'-.-Cl Waiver Fees: Date of Payment: Receipt Number: Waiver No. Pannone Engineering Services etc Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panenRak.com 22 April 2015 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road P. O. Box 196650 Anchorage, Alaska 99519 Subject: KUIK L3 Septic System Upgrade Permit Request Ladies and Gentlemen: am writing to request a permit to install an upgrade septic system be issued for this property. The proposed systems will serve an existing three (3) bedroom house. Currently the existing seepage pit is in failure. The existing 1250g septic tank will be verified and replaced if necessary. A new field will be installed and the existing seepage pit will be used in reserve. This lot is served by a private well. The surrounding lots are also served by private wells. There are no wells within 200' of this system, "W� CAAVA � Shd)N Soils. Pannone Engineering performed one test hole on this lot in April of 2015, and groundwater was monitored for at least seven days. The test hole monitor tube was dry after the seven day monitoring period. It is my opinion, based on the results of the soils tests and overall soils appearance; an application rate of 0.6 gallon/day/square feet should be used for a conventional wastewater system. 1. Soil Absorption System Design. a. - See Sheet 2 of the design package. 2. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain field. The proposed drain field upgrade will maintain at least 100 feet from all surface water and drainage ditches. 3. Topography: The proposed drain field is located on the western portion of the lot. The surrounding topography generally slopes from east to west at approximately 12%. There are no steep slopes within 50 feet of the proposed drain field. 4. Drawing Markings: The Drawings are marked "For MoA Review Only". When written notification that the review is complete and that there are no further comments is received from MoA On -Site Department, the note will be removed and "Issued for Construction" drawings will be issued. Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 Physical: 332 East Manor, Anchorage, AK 99501 Telephone: (907) 272-8218 FAX: (907) 272-8211 Page 2 of 2 The proposed installation will not affect the future development of the surrounding or existing lots. If you have any questions or concerns, please contact me at 272-8218. Sincerely, Steven R. Pannone, P.E. Owner7Civil Engineer Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 Physical: 332 East Manor Ave, Anchorage, AK 99501 Telephone: (907) 272-8218 FAX: (907) 272-8211 E c 95 12509 TANK W/ DCO AND DV SEEPAGE PIT E TO BE REUSED AS RESERVE FII 59.2 � :os o\ DRAINFIELD P 62.5LF• 2.5W, 6'ED, NO WELLS W/1200' OF PROPOSED SEPTIC IJa-� I I I I I 1C0 --I I I o I I I I I I 0'TD. I 1C1 I I I I I rI % h I I I I I I I 10' Telecom & Elec Esmt�' I 6 115 N I o 10' 101 ----- I I 11 NOTES:PANNONE ENG SVC, LLC -�'OFq A� oi3a�,5 FOR CONSTRUCTION - P.O. BOX 100217 ANCHORAGE, AK 99510 r '��'•'"..... ((t PHONE (907) 272-8218 FAX (907) 272-8211 % �yt+ Scale "•' „" P.I.D. NO KIJIK 13 " ...... .R..Pane on e. 17 092 CHARLES & INA HUGHES / PERMIT NO. DRAWN JRL I�PCT CE 8149 �OSPXXXXXX 6201 E. 142ND AVE Sheet PLAN ANCHORAGE, AK 99511 ��1% S9oN` -T 1 OF 3 SPECIAL PROVISIONS TO SPECIFICATIONS 1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON—SITE WASTEWATER DISPOSAL SYSTEMS. 3. SCOPE OF WORK: VERIFY INTEGRITY OF EXISTING 1250g SEPTIC TANK, REPLACE IF NECESSARY AND INSTALL NEW DRAIN FIELD. 4. GROUNDWATER WAS NOT ENCOUNTERED AS EVIDENCED BY THE SOIL TEST HOLE. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 16.0 FEET BELOW EXISTING GRADE NOTIFY THE ENGINEER IMMEDIATELY. FILTER FABRIC 4" 0 DRAIN PIPE TH-1 ``DRAIN ROCK 6" ABOVE PIPE INV 4.0 GM -3.0 s.o SM 6.0 -16.0 1 SECTION DESIGN PARAMETERS PRIMARY/RESERVE SEPTIC SYSTEM NO. BEDROOM: 3 (450 gpd) TANK SIZE: 12508 PERC RATE = 19.5 MPI SOIL RATING: 0.6 GPD/SF AREA RQD: 750 SF SYS. TYPE: DEEP TRENCH 6.0' E.D. MIN LENGTH: 62.5 LF USE: 62.5 LF X 2.5' WIDE, 6' E.D., 10.0' TO TOTAL AREA: 750 SF PROFILE LEGEND ---- WATER LINE/ WELL RADIUS ---F— ----- NEW SEPTIC NOTES: PANNONE ENG SVC, LLC FOR CONSTRUCTION P.O. BOX 100217 ANCHORAGE, AK 99510. PHONE (907) 272-8218 FAX (907) 272-8211 KIJIK L3 DRAWN 1 JRL CHARLES & INA HUGHES 6201 E. 142ND AVE DESIGN NOTES ANCHORAGE, AK 99511 ABBREVIATIONS CU COPPER DIP DUCTILE IRON PIPE TH TEST HOLE FC FOUNDATION CLEAN OUT T# TANK CLEAN OUT NO. C# CLEAN OUT NO. M# MONITOR TUBE NO. R.I. RIGID INSULATION DCO DOUBLE CLEAN OUT DV DIVERTER VALVE FS FLOW SPLITTER BEG BELOW FINISH GRADE OG ORIGINAL GRADE FG FINISH GRADE TS&V TOPSOIL & VEGETATE E EXISTING P PROPOSED Date OF. AL�sl� 04/30/15 r.- F '+ Scale yam' '9 �II NTS " V'y")"' P.LD. 2 �\ /�\/ � 17-092-1! �F•. CE 8149 ,I11��OFESSIONP�-� 'ERMIT NO. 2 OF TEST HOLE 1 SOILS LOG - PERCOLATION TEST SLOPE TEST HOLE - WAS GROUND WA ENCOUNTERED? IF YES, AT WHAT DEPTH? DEPTH TO WATER MONITORING? - DATE: 0 READING DATE CLOCK NET TIME WATER LEVEL READING 2 MPIE GM ORANGESAND 5.185" &GRAVEL 3 WMIN 7811" 2636" 4 3 1103 5.185" 5 4 1133 30MIN 6 1.825" 16.44 5 1134 7 5.185" 6 8 30MIN 6.725" t549' 19.48 9 12:05 SM SILTY SAND 10 8 12:35 1 30 MIN 6.725" 11 19.48 12 13 14 15 16 BOH NO GROUND WATER DATE PERFORMED: 04/14/2015 SOILS LOG - PERCOLATION TEST SLOPE TEST HOLE - WAS GROUND WA ENCOUNTERED? IF YES, AT WHAT DEPTH? DEPTH TO WATER MONITORING? - DATE: 0 READING DATE CLOCK NET TIME WATER LEVEL READING NET DROP MPIE 1 N114115 1031 5.185" 2 1101 WMIN 7811" 2636" 1138 3 1103 5.185" 4 1133 30MIN 7010" 1.825" 16.44 5 1134 5.185" 6 12:N 30MIN 6.725" t549' 19.48 7 12:05 5.185" 8 12:35 1 30 MIN 6.725" 1.540" 19.48 PEROLATION RATE 19.5 (min/inch) PERC HOLE DIAMETER 6 inches TEST RUN BETWEEN 4 FT AND 5 FT COMMENTS: Test hole excavated by Pannone Enaineerina Svc. Test Hole was Dresoaked'before Derc test PERFORMED BY: Steven R. Pannone, P.E. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. NOTES: PANNONE ENG SVC, LLC of a� �>>t Date 04/30/1 -OR CONSTRUCTION. - - P.O. BOX 102954 ANCHORAGE, AK 99510 �Q'�� '•'9S�( PHONE (907) 272-8218 FAX (907) 272-8211 iCb." —# Scale DRAWN I JRL SOILS LOG KIJIK L3 CHARLES & INA HUGHES 6201 E. 142ND AVE ANCHORAGE, AK 99511 *. •*f� NTS ..... ..:.. . . ..P.I.O. NO ... 017-092-1 Steven f2. an / PERMIT NO. 1�19Fc� CE 8149, OSPXXXXXX `tli'g OFFS`==�' Sheet 3eOF 3 GREY' R ANCHORAGE AREA BOR"FIGH / Department of Environmental Quality UNN 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME MAILING ADDRESS/PHONE LOCATION LEGAL DESCRIPTION SEPTIC TANK: DISTANCE�j NUMBER OF I FROM WELL M l MANUFACTURER f ;% MATERIAL COMPARTMENTS INSIDE LENGTH INSIDE WIDTH J LIQUID DEPTH — LIQUID CAPACITY / 'l' GALLONS. SEEPAGE PIT: NUMBER OF PITS DIAMETER - OR WIDTH 17LENGTH'Z6 DEPTH Z� LINING MATERIAL,40 44"L CRIB SIZE: DIAMETER _DEPTH DISTANCE FROM: WELL f. Gjf TOTAL EFFECTIVE BUILDING FOUNDATION, NEAREST LOT LINE aABSORPTION AREA (WALL AREA) SQ. FT. ADDITIONAL ABSORPTION WELL: J �� T CONSTRUCTION l�/L//�O DEPTH / f/�A�dY�/� TYPE DISTANCE FROM: BUILDING / NEAREST NEAREST SEPTIC y SEEPAGE FOUNDATION l s LOT LINE "2 I t SEWER LIN//E /Q I� TANK /GtP/ SYSTEM /Od CESSPOOL OTHER SOURCES APPROVED — DISAPPROVED REMARKS DISTANCES: Shdt�l/rr INSTALLED BY: PIPE MATERIAL: LOT SLOPE: TG .SJUT� Q REMARKS: DIAGRAM OF SYSTEM ��E.d�fl OCl ,ZS' S'IV �nC� f0 vslt� a ,lli�ue�ln%9 / /j l 0Y«� a DATE /gZf APPROVED G.A.A.B. Form No. EQ -031 LwcxvLLVL 3� �r �W¢Lo N+`�D• .F. L GREATER ANCHORAGE AREA BOROUGH PERMIT NO. DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT p NAME OF APPLICANT 0.,;t V(Vr MAILING ADDRESS � �' _ / f f'PHO E 66 �v INSTALLATION LOCATION LEGAL DESCRIPTION INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH r7 SEEPAGE PIT n !1 DRAIN FIELD. , OTHER , L_/TO BE INSTALLED Y an_ I _ SOIL TEST RE LTs lD - �a , //`✓y / ��` NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE / l v r TYPE EEPAGE AREA SIZE �ry MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK 5 FOUNDATION TO SEEPAGE PIT L/ -L) L DRAIN FIELD /!/ ' SEPTIC TANK TO SEEPAGE PIT WALL /✓ SEPTIC TANK `� SEEPAGE PIT �?o DRAIN FIELD TO NEAREST LOT LINE. � y WELL TO SEPTIC TANK /C!U SEEPAGE PIT 019 DRAIN FIELD lf) , ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK T SEEPAGE PIT /0 DRAIN FIELD I ./0-- ,, �n7 //ll � 1 /��) 1 0 SEPTIC TANK, . SEEPAGE PIT ('UV DRAIN FIELD . TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. jjo,,/(3 &-j I �_v G.A.A.B. OR LICENSED DESIG DIAGRAM OF SYSTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE - / APPLICANT'S SIGNATURE cL�eu vn F_(]-016 _ ( 7 ' k I I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE - / APPLICANT'S SIGNATURE cL�eu vn F_(]-016 Performed for_, Legal Description: _/,71- This form reports: Soils Depth Feet UI\"HILI\ nl\VIIVf\MUL MINLM UVnVUV 'Department of Environmental Qua -f -,Ay 3330 IIC11 Street Anchorage, Alaska 99503 SOILS LOG - PEROLATION TEST 2_ 3 4 - SaN'JS 5- 6 -. ^ 7- 9- 10 - S/,o Date Performed 91—cy-° i V rcolation test 12 - 13 - 14 •- 4as ground water encountered? �}1L3 _ _ If yes, at what depth? Reading Date Gross Time Net Time Depth to Water Net Drop Percolation rate minute. Proposed installation: Seepage Pit Drain Field _ Depth of Inlet _ _ ^ _ _ _ Depth to bottom of pit or trench _ WITIENTS : ---- -- ----- -- Performed Qy:C�h�tR__Certified EQ-040 (6/74) to-- - - -- --- _ �-�� `"`' `�` '`j� �� `�--� MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) l,o f 3J t y ) •k s lb Location (address or directions) K201 C Ig2 nd Ac"e CSF 601del7tl(ecv (b) Applicant Name C6arkf 4u 4 --r Telephone: Home 3 Y,5--- 13Y 7 Business Applicant Address G� 1' y ! nct /ua , Glipi care /'} k W' 70� (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder"; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution First Interstate Bank Telephone 264-5565 Address 3230 110 St 2nd Floor Anchorage AK 99503 (e) Real Estate Company and Agent _n/a Address Telephone (f) Mail the HAA to the following address: Please call either owner or Dawn @ First Interstate for pick—up. 3,q9 3��a x 4S 1 C` � \ �� 6 M K cx d"a l 2. TYPE OF RESIDENCE Single -Family R Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well JR Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite Public ❑ Community ❑ Holding Tank ❑ *At'G Note: If community Wl system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 1.1 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 shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate fort he 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 (=lcc/�or-Fechnr cat Sery'tcd1 Telephone Sys Address Pi_6-3G Ccho .Sid 0 AnC%?a 2 %t'C Date o c,NV At �¢L� •••� /Ari `. ��t 4carH cif •"•�..?:.....:.. THEODORE F. fA00RE 01 Engineer's Seal i �•. ; ••,• CE - 3589 DHEP APPROVAL Approved for bedrooms by ate 1 �� Approved Disapproved Conditional Terms of Conditional Approval dhep CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations 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 requirements. 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. Page 2 of 2 ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) „f�K i tflaO HEALTH AUTHORITY APPROVAL (HAA) �V 7 CHECKLIST - FEBRUARY 984 RECEIVED 264-4720 Legal Description: i -o 1L 3 S/0 A. WELL DATA Well Classification P riyicer'(: If A, B, C, D.E.C. Approved (Y/N) N,A • Well Log Present (Y/N) Y Date Completed ��`% 7y Yield�P �✓��e'�'� Total Depth 1 �� Cased to 0 'Az Depth of Grouting Nei • Static Water Level 16!� Pump Set At Casing Height Above Ground — Electrical Wiring in Conduit (Y/N) Separation Distances from Well: Sanitary Seal on Casing (Y/N) — Depression Around Wellhead (Y/N) To Septic/Holding Tank on Lot 1 IO ` le7 C-0, ; On Adjoining Lots > &l)o f To Nearest Edge of Absorption Field on Lot r ; On Adjoining Lots 7 too To Nearest Public Sewer Line NeA• To Nearest Public Sewer Cleanout/Manhole MWN• To Nearest Sewer Service Line on Lot Ne 7}• Water Sample Collected by %=M ; Date Water Sample Test Results _$ cc c-ole1®rm ✓jam[%/ r'clr Comments B. SEPTIC/HOLDING TANK DATA Date Installed 9124_17y SizeI y e? I No. of Compartments Standpipes (Y/N) r Air -tight Caps (Y/N) }r Foundation Cleanout (Y/N) Depression over Tank (Y/N) N Date Last Pumped 412-8 /8e Pumping/Maintenance Contract on File (Y/N) Ne it. ; for /Vr/f Holding Tank High -Water Alarm (Y/N) NA Temporary Holding Tank Permit (Y/N) At, 4 Separation Distances from Septic/Holding Tank: To Water -Supply Well I I Or9in C• C'• To Building Foundation To Property Line 5—d' To Disposal Field — To Water Main/Service Line Course �> 100' Comments Page 1 of 2 72-026(11/84) yqe 16-1 To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 1 2,5.0'63 dr -r" Type of System Design -been Date Installed 2 18,5`1 % y Length of Field 2 0 Width of Field f .' Depth of Field Gravel Bed Thickness Square Feet of Absorption Area 3 to 0' Standpipes Present (Y/N) Y Depression over Field (Y/N) N Date of Last Adequacy Test -a/ 2l /�� Results of Last Adequacy Test Met V Jaetfi cele feecee%P _4�pr -3 be? cerooml Separation Distance from Absorption Field: To Water -Supply Well 1.36' To Property Line S To Building Foundations To Existing or Abandoned System on Lot N,µ. ; On Adjoining Lots > 36 e To Water Main/Service Line NeA. To Cutbank (if present) Iv, it To Stream/Pond/Lake/or Major Drainage Course 2' l�G' To Driveway, Parking Area, or Vehicle Storage Area ^ 1��'' Comments .50- -e Waee is 1530 c alluAw An sure ccecetes -Rut'd later c lT eelo '11) s kw 1:c err I?-ee r nMy �elld v f I i Fe D. LIFT STATION NA Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Date2�C21186, Company F&Mr_ c4reieul Sum MOA No. Receipt No. i c) % 5 `3 FIN Date of Payment �%� ...., r Amount: $�� .0 Co a\y�� '• e!� ®4 Engineer's Seal O........... Page 2 of 2 A a 1.......1 I •. THEODORE F. MOORE ,• rj > CE - 3589 w+ AV 72-026 (1vsa)