HomeMy WebLinkAboutLAKE HILL ACRES #1 LT 2, • a
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N 0Sl-Asa- oa
i
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 ?4t'917'9 PID Number: D 5/ - 057--,Oz
Name:
A�118m_l P vc. SqM�
Wastewater System: ❑ New KUpgrade
Address:
ABSORPTION FIELD
i
ZQL.
Phone:
6i - 3(/ jV 9
No. of Bedrooms:
13
❑Deep Trench hallow Trench [I Bed ❑Mound ❑Other
LEGAL DESCRIPTION
Soil Rating:
Or �
Total Depth from original grade:
GPD/Sq. . Ft.
Lot: Block: Subdivision:
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
_L, 6k(Mig IA/
Z..5- Ft.
5,r 0 Ft.
Township: /
Range:
Section:
Fill added above original grade:
Gravel length: ?0 0
/,0 Ft.
/ Ft.
WELL: El New to
Upgrade
Graveldepih kvi DTl1 3
Number of lines:
Distance between lines:
X 51/N
FL
Ft.
Classification (Private, A,B,C):
Total Depth: _ =
-Cased To:
Total absorption area:
Pipe material:
" RYe 3034
CW 1V4�C
–�--'�Ft.
Ft.
e UO SQ. Ft.
Driller: I�
bate Drilled:
Static Water Level:
Installer:
Date I tall d:
!�
Ft.
IZsISINUS N E
f/251L
yield:t w�
Pump Seat:
Casing Height Above Ground:
TANK
GPM
Ft.
Ft.
SEPARATION DISTANCES
(Septic 11 Holding ❑S.T.E.P.
To
Septic
Absorption
- Litt
Holding
PebUg/Private
Manufacturer:
Capacity In gallons:
From
Tank
Field
Station
Tank
Sewer Lines
R,
aft, !*�1
000
Well
!�Z
pZ�
/
/ylA
N1
l
i
�0
Material��`
Number of Compartments:
Surface
NIA
_�
LIFT STATIONa/'p
Water
Lot/d6)
�y
/ /
i
Size in gallons:
Manufacturer:
Line
Foundationzo
'
� �'
NlA
"Pump on" level at:
; p off' level at:
High water alarm at:
CurtainA//�
��
–
Pump Mek del
Electrical Inspections performed by:
Drain
/ •
BENCH MARK
Remarks: �X/ TiNG /EG _E / �1�
Location and Description:
,A , - -51-14E v45L41-7-0 NK /C44)
18OLL010 12r 5112/1`th;alvj
ar 9J' Grp r4 L 'v" kegr �
D �lavS
Assumed Elevation:
/00. o
Or-E�C1NE£p'9'*�S�L
'L�',f`/ ta'/';��'�i G aP 9�f.
a'ms 0n a44.4���
. °
�nl /�/'/°e� � c;� < 3 Irl L
/ 11115 ✓lG co ce—
1_) 0/ 9
b (.
9 oe oaesoota�q°oosoeaa.oasa.00e ,
Inspections performed by: Dates: 1st
,,;vo,a•aa••�bo • peBos;.•
2rld�9
5f
�, �:g 4�
Louis A. Eutera . r
Department of Heal.tti nd Huma rvices appr vat�o
aoras�"��4
Z ��
Reviewed and approved by: Date:
72-013 (1191) MOA 25
Permit No. SW940170 Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
I anal f)asr.rintinn: Lake Hill Acres #1, Lot 2 PID No.: 051-052-02
I
ELEVATI❑NS
(NOT TO SCALE)
BBOT -TO I
—M OF SIDING, SE CORNER OF HOUSE
AS�1 Si
ELEV = 100.00' r—
m
FIELD =
ORIGINAL �
+1' ADDED FILL GROUND rn
LEVEL @ 94.7' (SE)t94.7'
t2' 95.6' (NE)
2' 35PSI INSULATIONNO GWT
81.2'
TANK
93.5' 3.3' 93.1' 93.1'
SE TRENCH PIPE ELEV = 92.0' BOTH SIDES
72-013 A (Rev. 9:91) MOA 25
SWINGS
A-2 = 59.0'
B-2 = 22.6'
A-4 =
61.3'
B-4 =
29.2'
A-5 =
61.5'
B-5 =
30.1'
A-6 =
61.8'
B-6 =
30.6'
A-10
= 76.4'
B-10
= 44.5'
A-12
= 81.1'
B-12
= 53.8'
SLE 1"=60'
NEW TRENCH
EXISTING TRENCH
• - MONITOR TUBE
o - SEWER CLEANOUT
¢ - WELL
— - EASEMENT
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650��
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT��
PERMIT NUMBER:SW940170 DATE ISSUED: 6/09/94
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES EXPIRATION DATE: 6/09/95
OWNER NAME:KUBICKI PAUL P &
OWNER ADDRESS:22716 OLD GLENN HWY
CHUGIAK, ALASKA 99567
PARCEL ID:05105202
LEGAL DESCRIPTION: LAKE HILL ACRES #1 LT 2
LOT SIZE: 17000 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 (24 HOURS) .
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
I 14 Drop moItVDiemocyov
ISSUED BY:
DATE:-
4'
ATE:
' DATE: �,q — �— �
Louis Butera, P.E.
Registered Civil Engineer
May 18, 1994
Jim Cross, P.E.
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Lake Hill Acres #1, Lot 2
Narrative & Waiver Application
Dear Mr. Cross:
On behalf of our client, we request a 10' waiver of the 100' minimum separation distance of
well to field, and well to tank to 90'. Due to small lot size and existing well location, this 90'
distance is necessary to provide the required absorption area while retaining the existing field
and observing lot line setbacks. We feel it would be prudent to retain the existing field and
utilize a diversion valve to minimize future leachfield replacement problems.
While asbuilting the site, it was discovered that an existing tank cleanout, on Lot 3 is currently
98.8' from the well on Lot 2. The well on Lot 2 was drilled before Lot 3 was developed. We
also request that this separation distance be included in the waiver.
The proposed septic upgrade and waiver will have very limited impact on adjacent properties
for the following reasons:
1. The surrounding lots have sufficient room for their own septic sites. Although
reserve space is very limited by its own well radius, Lot 3 appears unaffected by
the proposed upgrade or waiver on Lot 2. Lot 1 has a specified, unused reserve
area located by previous permit.
2. Immediate neighboring septic systems are all +30' distant.
3. Drainage will not be affected and is not a major consideration in our design. The
site topography indicates that surface and groundwater flow would be to the
southeast, away from the well in question, supporting our waiver. Grade slopes
10-12% to the southeast in this area.
4. Attached are well logs for Lots 1, 2, and 3 indicating similar conditions. The
logs indicate several thick protective layers of clay and gravel, and one thick
layer of silt. Static water levels are above the water bearing layer, indicating a
\C: \WPWIN60\WPDO CS\ 1994\94-011 A. NAR
confined aquifer. Static levels for the wells on Lots 2 and 3 are 147', and 166'
for Lot 1.
5. Near surface soils consists of organics, silts and clay with gravel. A single layer
of GM type soils was encountered from the 2'-4' level. Percolation rates of the
receiving soils at 4-13.5' levels indicated 15-18.5 minutes per inch. Soils near
the bottom of the test hole excavations were very dense below 10' depths. No
water table was encountered to 13.5' deep.
6. The names and addresses of the adjoining land owners are as follows:
Lot 1, Block 1 Lake Hill Acres #1
Richard & Sandra Farmer
P.O. Box 771725, Eagle River, AK 99577
Lot 3, Block 1 Lake Hill Acres #1
Del & Darlene Wormus
22706 Old Glenn Hwy., Chugiak, AK 99567
7. Statement of positive and negative impacts:
• The waiver enables locating an adequately sized septic system on a small
lot that has a poor well location. An existing violation will also be
rectified.
• The cost of the waiver will significantly affect the project budget.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\C: \WPWIN60\WPDO CS\ 1994\94-011 A. NAR
SPECIFICATIONS FOR SEPTIC TANK REPLACEMENT
LEGAL: Lake Hill Acres #1, Lot 2
A. GENERAL
The drawings shall be a part of this specification.
2. All materials and workmanship shall meet the requirements of Anchorage
Department of Health and Environmental Protection Permit.
B. THE SEPTIC TANK
Location of tank may require repositioning of sewer pipe through the foundation
wall, with insulation as specified in #6 below. Pipe currently exits under footing.
2. Septic tank construction shall be a (minimum) 1,000 gallon steel, two
compartment tank, currently approved by the Municipality of Anchorage.
3. Septic tank is to be installed level, ±0.08', on compacted base material.
4. All connections are to be made with caulder couplings.
5. The existing tank shall be pumped, removed and properly disposed of. Hole is
to be backfilled with a base of pit run gravel to prevent settlement.
6. New tank to be provided with two cleanouts and "Bull Run" brand diversion
valve or engineer approved equivalent, after tank. Light-duty plastic valves with
a poor seal are not acceptable. A foundation cleanout 1-4' from home is to be
installed prior to tank.
7. Soil or a combination of soil and extruded board insulation to a depth of 4' or
equivalent shall be placed over tank.
Twenty-four (24) hours notice required on all inspections.
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: LOT 2, LAKE HILL ACRES fel
A. GENERAL
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health
requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the
field by the engineer.
5. All excavations and depths are advisory and are to be verified in the field by the
contractor to meet Municipality of Anchorage requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements
and to locate any adjacent multi -family wells.
7. The excavation is to be exactly in the area shown on the site plan, any deviation
requires engineer approval.
8. It is always recommended that a surveyor locate the nearest lot line position and
the location of any easements.
B. TRENCH
1. The trench is to follow the natural land contour to maintain uniform total depth
of the trench bottom.
2. The bottom of the trench shall be level, plus or minus 1.5".
3. The total depth of the trench excavation is not to exceed 7.5' at any point.
4. The trench gravel is to be covered with typar fabric material.
5. Soil or combination of soil and extruded board insulation to a depth of 3' or
equivalent is to be placed over the leachfield.
6. The area over the trench is to be finish graded to prevent ponding of surface
water runoff.
7. The new septic tank and leachtrenches must not be closer than 90' to the on -lot
well. The septic tank and leachfield must not be closer than 100' to any off -lot
existing private wells, 150' to any Class "C" well, or 200 feet to any community
well.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH = 7.5' GRAVEL DEPTH = 5'
TRENCH LENGTH = 80'* TRENCH WIDTH = 3'
SOIL RATING = 0.6 GPD/ft2 BEDROOM CAPACITY = 3
SEPTIC TANK = 1,000 gallons minimum
NOTE: * 5' of the trench crosses the old tank location and is not considered a part of
effective net length, total trench length is for design purposes 75'. However, the
5' portion shall be constructed in a like manner..
Twenty-four (24) hours notice required for all inspections.
C:\WPWIN60\WPDOCS\1994\94-01 IB -SPC
EAGLE RIVER
ENGINEERING SERVICES
P. 0. Box 773294
EAGLE RIVER, ALASKA 99577
Phone 694-5195
Lake Hill Acres 46, Lot L /y4-vlla.cai
SHEET NO. -----
CALCULATED BY
CHECKED BY -
SCALE ---
00. 1
Y-
SCALE
CH
IN
OF
DATE --_ -
05/18/94
-
DATE_" 05/18/94
0.1
Louis A.
CE
N❑ SURFACE WATER
NO KNOWN CURTAIN DRAINS
SEPTBC SITE PLAN
LEGAL: LOT 2, LAKE HILL ACRES #1
OWNER: KUBICKI
CONTRACTOR: N A
JOB # 94-01 1 DATE: 05 18 94 SCALE 1" = 40'
EAGLE RIVER ENGINEERING SERVICES
P.O. Box 773294
EAGLE RIVER, AK. 99577
(907) 694-5195 FAX: (907) 694-3297
SLOPE
TEST HOLE
MONITOR TUBE
SEWER CLEANOUT
WELL
EASEMENT
OF /is
q
49TH*
i „
LOUIS A. BUTERA O�Of
,,�CE-6736
#4F" ��
(ENGINEERS SEAL)
Municipality of Anchorage
'�a�t DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: �Ctu(' 1: [/I//cDATE PERFORMED: 5-3-9y
LEGAL DESCRIPTION: Z-4kc f/,//f /'C/cS'.Z, LoT? Township, Range, Section: Trrv.
7l1 4 FE3'1" I
1 i I v z•/ / /�_
2
v.'
3
4 �• � 5,'l9Y SaH
C. /
(6M)
Gfoue/. ,f/o Co66�e
L •
w,7h
6 a
7
8
Date
Gross
Time
Net
Time
O
Net
Drop
9
5-1-1 q
Q
10
//
11.70
/S M:N
D.•
(/H/%
(ENGINEER'S SEAL)
Municipality of Anchorage
DEPARTMENT OF HEALTH R HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: Pf� k- "A' C -k DATE PERFORMED: 5-3-`!Y
LEGAL DESCRIPTION: 1,k, 11,115 �1� LaT Township, Range, Section: T/r t, R
TYQ DFiiT1!_ SLOPE SITE PLAN
1 (FEEi1_ /VON -/1/oT.
2
/✓ //
�% m C %Own L 0'.w/ �D(L�
14
C) Q,
3
a
0 At
5-
ti 6
)r; 07
6-
6J
'S
7
72, 1/6"
y 4@C y'OOLN Nbf
8
9 O
12
13
G
Net Depth to
Time Water
14
15
0 At
6
16-
ti 6
)r; 07
17
17
'S
r;23
72, 1/6"
y 4@C y'OOLN Nbf
19
J Ff
20
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
s
IF YES, AT WHAT L
O
DEPTH? P
E
Depth to Water After
Monitoring? �e7 Date: 6"11'514
5.
Reading
Date Gross
Time
Net Depth to
Time Water
Net
Drop
7/'%d '
ti 6
)r; 07
72
8
r;23
72, 1/6"
PERCOLATION RATE_ (minutes/inch) PERC HOLE DIAMETER
6
TEST RUN BETWEEN FT AND 6 FT
PERFORMED BY:�
CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:—/���i�'�'
72 008 )Rev. 4,85) ,
by
DOC Co. dba
SULLIVAN WATER FELLS
P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688.2759
OWNER OF .AND 4klz / Co w S i^ DEPTH OF WELL /
ADDRESS 1 7 7 STATIC LEVEL OF WATER FT. %
LEGAL DESCRIPTION L r� I J MLAO 46i,r DOWN FT.
DATE. - Started /�/ Fel Ended - /OZ,P 1)
PERMIT NUMBER
KIND OF FORMATION:
From Ft, to ci� Ft.
O (.1 4i ' f13 41:' c, 0%1
From oZ Ft. to�_Ft.
C < H Y AV•C„PM✓c
From Ft. to F.. 4'Y�A:�'L
From ��.Sf Ft. to Ft.
'
L t rr' /
From Ft. to //J- Ft.
From Ft. to -Ft.
From
FromLL/ Ft. to -J —Z2 F,
Sq,U d
From
From FL to' Ft.
X ad
From /� Ft. to l Ft,,.ur/)
Ft. to
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C7
From Ft: to Ft.
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From I T Ft. to 9"�Ft.—_.�5
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Ft.
From Ft. to Ft.
Ft. to
Ft.
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o
Ft. to—Ft.----
Ft.—FromFt.
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to
Ft.
From Ft. to Ft.
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dISCL. INFORMATION:
GALS. PER HR
KIND OF CASING
From
Ft. to
Ft.
From
Ft, to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft,
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Ft. to
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Ft. (o ---Ft.
Front
-Ft. to__
Ft.
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Ft.
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o
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DRILLER'S NAMEf
Munic pality of Anchorage
Ti
Department of Health and Human Services
825 "L" Street
Tom Fink,
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
June 8, 1994
Lou Butera, P.E.
Eagle River Engineering Services
PO Box 773294
Eagle River, Alaska 99577
A
Subject: Waiver Request for Lot 2 Lake Hill Acres #1
Waiver Request #WR940026, PID #051-052-03 S'L&tLkov1c)
Dear Mr. Butera:
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 private well on Lot 2
to the septic tank on Lot 2 of 90 feet; a private well on Lot
2 to the absorption field on Lot 2 of 90 feet; and the well on
Lot 2 to the septic tank cleanout on Lot 3 of 98.8 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.
Sincerely,
Daniel J. Roth
Civil Engineer
On-site Services
DJR/ljm
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR# WR940026 PID# 051-052-03 HA#
Date Received: May 19, 1994
Legal Description: Lot 2 Lake Hill Acres #1
Permit #
Engineer: Lou Butera, P.E., Eagle River Engineering Services
PO Box 773294, Eagle river, Alaska 99577
Applicant: Paul/Jane Kubicki
Waiver Requested: Well to septic tank - 90 feet; well to absorption
field - 90 feet; well on Lot 2 to setpction tank cleanout of 9;3�.8 feet.
Criteria: 1. Geology: Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
3. Other:
Waiver is Granted: ✓< Waiver is NOT Granted:
List Conditions or Reasons for above: SrF��9�/��N/�✓>
Date: By/
viewer
Rec #: 25916/4354 Amount: $_920.00 Date Paid: May 19, 1994
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MUNICIPALITY OF ANCHORAGE
®
e DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING
DIVISION
825 LStreet -Anchorage, Alaska 99501
Telephone 2.64-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR
WELL INSPECTION
REPORT
NAME
P ON �^'77
NEW
`/t�—
�G�
UPGRADE
MAILING ADDRESS -
LEGAL DESCRIPTION
Z Z_a ke k1lA�s
LOCATION - (
NO. OF BEDROOMS 7
I
Well
C`
Absorption red ,
Dwelling
U
DISTANCE T0:
��
y
F_ Z
W F
Manufacturer
er 0`)
No. of compartments ^�
rn
Liq. apacit
j
IF HOMEMADE:
Inside length
Width
Liquid depth
z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
= z
_
Manufacturer
Material
Liquid capacity in gallons
W lam'
Found�tYUB
Neave tlot Ie _ f,
PEI,TiN
=
DISTANCE TO:
07
LL�r
Z
P W
No. of lines
Length o Fj'Iy(i L
(3
Total lei'
f ^24 4
�
Trench dth !
O inches
DistancLeti'&twe rLlj pes
/ ? L
~
Top of tile to finis6--rjtle�
Mat ria,
C �� be o til
��
P•., i/
Total effective absorption area
y -2
inches
Length
Width
Depth
PERMIT NO.
W
()
QF-
Type of crib
Crib diameter
depth
Total effective absorption
area
as
U1
W
y
Well
Building foundation
Nearest lot line
DISTANCE TO:
J
Class�, y
v
Dep tFp
Driller
Distance to lot line
PERMIT NO.
J
/
G
W
Building foundation
Sewer line
Septic tank
Absorption areas)
DISTANCE TO:
OTHER
PIPE MATERIALS
s
SOIL TEST RATING
,S
-
INSTALLER
REMARKS
dV
�� �7-$0 ss acocca nary®;9 �E'
69 61 o a aosa "•
a
e
�
0 ao .m,pao o d
ee °ae
E
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vee a �a PNCkA0?,NC
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T F
F
APMED
//JJ - D_LE AL --
x
M U" I IZ-- I "L I -FavR C, F= n r-4 C. I-, FR n f3 El
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 `L' STREET, ANCHORAGE: AK. 9950:1
264-4720
WF=k-1 F=g " L -'*,u C-1 E: W l= F;'-" F="I= F__* M I _r
PERMIT NO. ( 8209833' )
APPLICANT EDWARD EVANS SR BOX :177 E. R. 99577 694-2637
LOCATION
LEGAL L2 LAKEHILL ACRES #1 LOT SIZE 999999 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SQ FT/BR)= 150
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
0 lDF;;?nVf=l E'w a F="
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
F? E= IC -9 L-9 I FZ E= L --a !---:; E-= F=l' _r T I=-- -r n r-4 K =-. I `E_ 0 El CZ -1 13 Fi I I I=N
.PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
-VWI=l < ao > I I nF.!I= FZEEOU I F-tE=E-u .---
BACKFILLING
--BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM Is
100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MST BE RETURNED TO THE DEPARTMENT WITHIN 30
UDAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
I -F F=XF=" I FREE-`- E'xE-=fi�F=til E.F=FR A � e=" `;R
I CERTIFY THAT
1: 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND I -JELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: 1 UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS.
SIGNED:_ --------------------
APPLICANT EDWARD EVAN
ISSUED ___GATE__-- /-: V4. 0
PERFORMED
LEGAL DESCRIPTI
1
2•
3•
4-
5
6
7
8
10.
11
12
13
14-
15.
16
17-
18.
19.
20
COMMENTS
xSOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION F-1 PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 _ 264-4720
SOILS LOG - PERCOLATION TEST
DATE PERFORMED: 7�-r<'�/
)N: Z_ Z ZaAe
fi(
6 o ry e( /2 L C
.TIL 7— eq �2
SLOPE
WAS GROUND WATER /jj
ENCOUNTERED? kl1o
IF YES, AT WHAT
DEPTH?
SITE PLAN
■■■■■■■■■■
Reading
Date
Gross -
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
PERFORMED BY:r..,,;� ` - ',til 3-iG�i ern �nerr CERTIFIED BYf`. /il'Gtl/ L ` tl4i;fes DA
0
PERFORMED
xSOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST �j/, �J
DATE PERFORMED:
DESCRIPTION:
Z, z .
DEPT
' d
6/sn-
a+ 2� s3`A /
SA
b !� f-7 '
4 /
d/
a Ay
6-
7
8
9
10
11
12
13
14
15
16 ,•tee �, "/z `Y
17
Date
Net
Time
Depth to
Water
9 g
18
s Rc rt �A• ainr
i
20$
..
t:
COMME
SITE PLAN
■■i■
NEEM
MEMS
NONE
■ 11■
MMIME
EVEN
M■ ■■
MEMO
■Ei■■
■91■■
MSI■■
x
WAS GROUND WATER S
ENCOUNTERED? L
O
/ P
IF YES, AT WHAT E
DEPTH? 4
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
i
t:
PERCOLATION RATE (minutes/inch)
EST RUN BETWEEN FT AND FT
��� „i &/ A� io?�f.l,
PERFORMED BY: S f---•L1�
�&1ee W AC- CERTIFIED BY �� DATE: OCTT (
MUNMWAUTY OF ANCHORAGE
Development Services Department = Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I. D. 051-052-02
1. GENERAL INFORMATION
Complete legal description LAKE HILL ACRES #1 LOT 2
Expiration Date: / 2 / Z / _
Location (site address) 22716 OLD GLENN HWY., CHUGIAK, AK 99567
Current property owner(s) DENNIS & MARCIA TOENNESSEN
Mailing address
Real estate agent
Day phone
22716 OLD GLENN HWY., CHUGIAK, AK 99567
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
®
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5 5 6 Waiver Fee $
Date of Payment ZzL / Date of Payment
Receipt Number 312/0-5- Receipt Number
COSA # 0 S C 2 113 a6,- Waiver #
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, 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 and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 7/712021
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to +�s111
these various and dynamic characteristics and are outside the control of the evaluator of the •�(�
well and septic system. Therefore, any estimate of how long a system will function satisfactory g�Q: • • • • • �,9 ���
for current or future occupants or guarantee that no unseen encroachments, deficiencies or JJ
discrepancies exist can be given by First Water Consulting & NES ' / * • 9 7H .... ,.;* I
6. DSD SIGNATURE Curtis Huffman /
System #1 Approved for bedrooms �+'�Fc��; •, CE 128991. rrW
System #2 Approved for bedrooms �i�1�PROFE`O ?�
Disapproved
Conditional approval for bedrooms, with the following stipulations:
VP
IAIA
� ONSITE
r
WAST, -AND M
Sao ROG� Alli o
.QLR�SO�\��
J
B Original Certificate Date: 77-2—/—Z/
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other 5 +�ee ( 71a*t,J1W5;C0Vy
A
Legal Description: LAKE HILL ACRES #1 LOT 2 Parcel ID: 051-052-02
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled 10/1982
Total depth 191 ft
Cased to 40+ ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 24+ in.
Date of flow test for COSA 6/29/2021
Static water level at beginning of test 157 ft.
Well production at time of test 4.5+ gpm
Comments
B. TANK DATA
Age of tank(s) 27 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 48"
® Standpipes/foundation cleanout per record drawing
Date of pumping 6/29/2021
Structure served by this system
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® Nc
® Coliform bacteria is Negative
Nitrate mg/L ® Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
F�
'
Collected by FWH
Date of Sample 6/29/2021
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _ years
Lift station material
Comments: SEE ATTACHED MOA TANK ADVISORY
D. ABSORPTION FIELD DATA UPPER / LOWER TRENCHES
Which system tested (date installed) 7/5/1994
® ALL standpipes present per record drawing
Total measured depth from grade 8.7' / 8.8 ft (max)
Measured depth to pipe invert from grade 3.3' / 3.7 ft
(min)
❑ N/A — pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective 5.4'/ 5.1' OF THE 6' ED
® Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
Adequacy test date 6/29/2021
Results M Pass For 3 bedrooms
Fluid depth prior to test 28" / 16 in
Water added 500 gal
New depth 38" / 20 in
Elapsed time 1420 min
Final fluid depth 28" / 15 in
Absorption rate 450 god
Any rejuvenation treatment (past 12 months) N
If yes, enter date
FWC;
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
® Yes if No ft
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No *90+ ft
® Yes
if No
Neighboring Tank > 100' ❑ Yes
if No *98+ ft
Private Sewer/Septic Line > 25' ® Yes
if No
Absorption Field on Lot > 100' ❑ Yes
if No *90+ ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
® Yes
Animal Containment > 50' ® Yes
if No
® Yes
if No ft
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No ft
® Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
® Yes if No ft
Property Line > 5'
® Yes if No ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes if No ft
Private Wells > 100' ® Yes if No
Water Main > 10'
® Yes if No ft
Community Wells > 200' ® Yes if No _
Water Service Line > 10'
® Yes if No ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No
—ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No —ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
*MOA WAIVERS
G. ENGINEER'S CERTIFICATION
l certify that l 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.
OF Ak
.. .... ....�....... ►.
Curtis Huffman >�
CE 1289917/7/21
,•���.��
ft
ft
Septic 'Tank Advisory
Certificate of On -Site Systems Approval #OSC 211386
Subdivision: Lake Hill Acres #1 Lot 2
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this property is years old. Typical replacement costs range from $8,000 to $11,000
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of what the metal of a 20 -year-old steel tank MAY look like.
Mailing Address p O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org E
., :..a dK � ,.�,x. �„-.,�a., . :�, .,. . b s�..r�✓ _as_.....u.., e.� .x: � cs k�" sr tia�. . rh... � ; s r� a`r..,. ,'.�i ,7�,ww , �.ry
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH b HUMAN SERVICES AEMM
Division of Environmental Services
Ori -Site Services Section EMS
P.O. Box 196650 - Anchorage, Alaska 99519-6650 •
343-4744 .
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel l.D.#. 051-052-02 HpA#.
1. GENERAL INFORMATION
Complete legal description Lot 2; .Lake Hills''.Acres Subdivision #1
Location (site address or directions) 22716 Old Glenn Hwy:
Chugiak,.._AN .;.
Keno Mari Property`owner�-•Day phone
+tom+r•..•; .`.-:....,. - ,�:.-. �
'Mailing addres.s C/O Remax•of Eagle River,"'Eag1e�_River, .AK
is..._.....-,..,Y r:• .., .. - ,,- _ , .
Lending agency' Day phone
Mailing address
..Joe Perrozzi/ Remax of Eagle River 694-4200
Agent Day phone
Address -16600 Centerfield Dr. Eagle River, AN 99577
Unless otherwise requested, HAA will bye held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE_ OF WATER SUPPLY:. _
Individual well XX -
Community well
Public water
..il.
NOTE: If community well_ system, provide written confirmation from State ADEC attest -
Ing to the legalityand status of system.
4. TYPE OF WASTEWATER DISPOSAL:-
Individual
ISPOSAL:
Individual on-site XX
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-M(n•..1/91) Fn MOAI21
S. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, l 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 furtherverify 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 effecl4i��aSU � &kffl is inspection.
Name of Firm "' // / Cota fis, Phone '3_77-6179'
Address 99
Engineer's signatureL;. jit
Date
Wastewater Consultants, Mc.,^
Shall be PAID '$ `�'
-or prior to, closing for the ti
Engineering Services Provided. ,•j
6. DHHS SIGNATURE
Approved for
Disapproved.
THREE bedrooms.
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
By: / Gd • �°"' ( 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 orderto 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.
rsars m.+" uv+) e.ck Mw m
RECEIVED
Municipality Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICMG 26 1999
Environmental Services Division r chorage
825 L Street, Room 502 • Anchorage, Alaska 99501 A Services
Legal Description:
A. WELL DATA
Well type PRIVATE
Log present (YM)
Total depth 191'
Sanitary seal (Y/N)
Health Authority Approval Checklist
LOT 2, LAKE HILLS ACRES #1 Parcel I.D.:
051-052-02
If A, B, or C, attach ADEC letter. ADEC water system number N/A
YES Date completed 10/82
Cased to 40'+ Casing height (above ground) 2'+
VES Wires properly protected (Y/N) YES
FROM WELL LOG AT INSPECTION
Date of test 10/82 8/13/99
Static water level 147' 162'
Well production 10 g.p.m. 6.0 +/— g.p.m.
WATER SAMPLE RESULTS:
Colitorm Nitrate • to %(o m 9 ! G Other bacteria
Date of sample: 8/16/99 Collected by: A.W.W.C.. INC.
B. SEPTIC4HOLDINO TANK DATA
Date installed 7/5/94 Tank size 1000 Number of Compartrnents 2 Cleanouts (YM) YES
Foundation cleanout (YM) YES Depression (Y/N) NO High water alarm (YIN) NO
Date of Pumping 8/13/99 Pumper SANITARY PUMPERS
C. ABSORPTION FIELD DATA 1 -UPPER TRENCH (CLOSEST TO HOUSE)
2 -LOWER TRENCH (CLOSER TO ROAD)
Date installed 7/5/94 Soil rating (g.p.dift' or fP/bdnn) 0.6 System type TRENCHES
Length 80' Width 5' Gravel thickness below pipe 5' Total depth 8.5'+
Effective absorption area 800 FT SO Monitoring Tube present (Y/N)—YM Depression over field (Y/N) NO
Date of adequacy test 8/13/99 Results (Pass/Faiq PASS For 3 bedrooms
1-18.75" 1-474 1=44"
Fluid depth In absorption field before test on.); 2-23. Immediately after2_S6%al. water added On.): 2=34.5'
1-32" 1-1020
Fluid depth 2-28.75" (Ins) Minutes tater. 2-942 Absorption rate : 450+ g.p.d.
Pemodde treatrnent (past 12 months) (Y/N) NONE KNOWN If yes," data —
72-026 (Rev. 3196)•
9
D. LIFT STATION
Date installed N/4 Size in
Manhole/Access (Y/N) 'Pu rt 1"evel at'
High water alarm level a *Datum
Cwt sed
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
'Pump off" level at*
Septic/holding tank on lot nn'+ On adjacent lots 98.8'
Absorption field on lot 90_'+ On adjacent lots t nn'+
Public sewer main N/A Public sewer manholetcleanout N/A
Sewer /septic service line 25'+ Litt station N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation 5'+ Property fine 5'+ Absorption field 5'+
Water mairdservice line --J&±—Surface water/drainage 300,.1. Wells on adjacent lots 1 On'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line •10'+ Building foundation tq'.L Water main/service line
Surface water t 00'+ Driveway, parking/vehicle storage area
Curtain draln NnNF KNnWN Wells on adjacent lots 100'+
*PER INSPErZON REPORT
F. ENGINEER'S CERTIFlCATION
I cerw that I a" Veld inspections and review of Munidpal
in con A gJldelines in effect on tlrls date.
Signature < \ '7`
Engineer's N 4T
�� / `' JEFFREY A GARNFCC
Date
HAA Fee $
Date of Payment
Receipt Number
72-028 (Rev. 3196)•
10'+
tn,+
Waterer Fee $
Date of Payment
Receipt Number
f7,--1
Sent By: RE11"AY. OF EAME FIVER, M.; 90789B02!4; Aug -14•99 12:17PIa;
El!'it-lti-8b I& 101b I(! lhhA Vh kHSLE kib'tk; �F1t7{ NU. yUIF-' U214
ASBUILT-NO CORNERS SET THIS DATE.
I HEREBY CERTIFY THAT 1 HAVE SURVEYED THE
FOLLOWING DESCRIBED, PROPERTY•
ANC THAT NO ENMKIACHMENTS EXIST EXCEPT AS
INDICATED. IT It THE RU12MIOILITY OF TML
OWNER TD DETERMINE TMC EXISTENCE OF ANY
EASE£Mcmm COVENANTS OR REiTRICTIONS
WHICH DO NOT APPEAR E;l THE M= MIM Ml -
VISION PLAT. UNDER NO CIRCUMSTANCLS SHOULD
ANY DATA HERMN BE USED FOR CONSTRUCTION
09 FENCE LINES, OR FOR ESTABLISHING DOl1ND-
ARY LINES. '
0
Page 1!1
P. 02/0'2
EbliA.RD & ASSCCIATFS LAND SiLMI?IC 694-0829
SPALE:
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.., 3 TYPE OF WATER SUPPL rn A
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:.. Individual well
rt s Community well = «C
_ attesting "to. the legality and status of system. ,
72-025 (Rev. 1/91) Front MOA #21
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1.
72.025 (Aay. 7/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: 681"-6 f/lLL %%65 # Parcel I.D. DrJ/ Q 54 —Oz—
A.
OZA. Well Data
Well type /�1e�Vr6 If A, B, or C, attach ADEC letter. ADEC water system number. N%1
Log present (Y/N) 1,5.5 Date completed 101EZ, Driller SULL/!/f)JN
I � �
Total depth � 9� Cased to �97i - Casing height 7i I
I
m
Sanitary seal (Y/N) / `/ 65 Wires properly protected (Y/N)
oz
FROM WELL LOG AT INSPECTION z n
z
Q�//�%5 ire ai
Date of test /Q A Z � � <
Static water level % �} % / / �j(� e1 V o
Well flow �Q g.p.m. g•p•n�" u N c
o
Pump levell
Z
SEPARATION DISTANCES FROM WELL TO:
Septic/he-tank on lot %%i ; On adjacent lots /HJT 0711E,C5 t/UO
Absorption field on lot 9Z� ; On adjacent lots/00
Public sewer main Public sewer manhole/cleanout N/A
Sewer service line f o5 Petroleum tank IVM9 NP/'RCQ J %/
WATER SAMPLE RESULTS:
Coliform Nitrate D. / ML IL- Other bacteria
Date of sample: 0ql/// ./9s Collected by: /lly/MCS
B. SEPTIC/G TANK DATA
Date installed 09 Z9'� Tank size _00(9 Compartments
Cleanouts (Y/N) y6 -S Foundation cleanout (Y/N) YES Depression (Y/N) /X0
High water alarm (Y/N) NIA- Alarm tested (Y/N) 11114
Date of pumping NSA C 011E Y619,e OQ Pumper 1,111A
SEPARATION DISTANCES FROM SEPTIC/HSG TANK TO:
Well(s) on lot % Z On adjacent lots Foundation ZO /
o I l
To property line Absorption field 41D0 Water r;/service line fl0
Surface water/drainage d/A
CONTINUED ON BACK PAGE
72-026 (3/93)' Front - -
C. LIFT STATION '/'4
Date installed Manufacturer
Size in gallons 57anhole/Acce
/N)
Vent (Y/N) "Pump on" level at "Pump off" Level at
High water alarm level Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DIST ROM LIFT STATION TO:
W of On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed 0.7 L94 Soil rating (GPD/Ftz) 01b System type a6,66 CN
Length Width Gravel thickness 5/ Total depth /, S
Total absorption area Cleanout present (Y/N) YC5 Depression over field (Y/N) _No
Date of adequacy test NJAI < /Y2 01,D Results (plass/fail) Pl/ SS for �� Bedrooms
Water level in absorption field before test IWA After test 14
Peroxide treatment (past 12 months) (Y/N) H14 If yes, give date N�/)
Z" 35PS/ /N5UA197101/ JAI 4PLf'145 OF / 3' S01L Cov�f-12.
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 9 ?_ On adjacent lots tloo Property line
To building foundation �i % I To existing or abandoned system on lot /a
On adjacent lots 71-3o .Cutbank N/,I Water mai service line t 2O
Surface water //1/i Driveway, parking/vehicle storage area fi/O J
Curtain drain NOMI- /�PP6k&kl
E. ENGINEER'S CERTIFICATION
-)�Wnlvaa Dlsingees 0b/08/9y
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on. the date of this inspection.
Signature
fJ �cn""na an�fi t �'fi s�
Engineers Name /iaU/5 AUJ-El24 �-�• .: �- .?
t.,ru +.)
Date O y �/ i/ 9
HAA Fee $ v Waiver Fee $ j
Date of Payment Date of Payment
Receipt Number as Receipt Number
-H
APPLIC "NT FILLS OUT UPPER HAI `� ' ONLY
Property Owner,, L IDIVAA ��t , (:_- ii/Cj r'�.5 - Phone
Mailing Address/ -2'7 L ) C G - l Zip Code
r7
Buyer PAUL L C4 F') (- kC-
z /�
Address 79oo OL -1312-126 7 f n 1 J i cticgl % Zip Code
Phone
Lending Institution
Address Zip Code
Really Co. & Agent o
Phone
Zip Code
Address �'Ir/ (C / V x�i
!<<• l - 3 - %�� `=�
Legal Description 2,
/Aj�1
Street Location ^ �.%i (. Lt ✓iJ f (/ L
Type of esidence
Single Family
❑ Multiple Family No. of Bedrooms
❑ Other
Water Supply
0 --individual
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
❑ Community
For wells drilled prior to that date, give well depth (attach log if available).
❑ Public Utility
✓'/ 45.
Sewe ,Dlsposal ! (,,,.
D' Individual Year Individual Installed:
❑ Public Utility When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
7—
Time
Time
Time
Time
Date
Date
Date
MDe
_/
Inspector
Inspector
Inspector
Inspector
✓'/ 45.
Fiend/ Notes:
4
(]�.) APPROVED BEDROOMS
-
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL AP VAL'
I j
DATE ,
BY:
Soils Rating
Date Sewer Installed
Well To Absorption Area /-= 6
Well Log Received - .-
Septic Tank Size q--a�
fJ�- A - r,' '
Well to Tank
,-