HomeMy WebLinkAboutBONNIE VIEW LT 5Bonnie View
Lot 5
#017-422-14
12/05/2012 23:52 9072430742 AWPS, INC. PAGE 01/
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.2, V
Marx Begich
Mayor
Y.
Well Drilling Permit Number. SW
Parcel Identification Number-
Bo/in l -e,, Vie,W
L - .;)r �
Pnrtsp Installation nate:
Pump Intake Depth Below Top of Well Casii
Pump Manufacturer's Name: %� — 4
Pump Model: ; --5
Pump Size )� hp
Pitless Adapter Burial Depth: / O feet
Pitless Adapter Manufacturer's Name: 62'e
Pitless i•c'apker 1aas.' i9 r: A) 4
ird;:nc- i_?h�"i"y iJ1415i4`fi
=:Til; 8r•eces• S r:e^ r
p Installation Log
Date of Issue:
ei8 Llsind'ect^ci 'i Myon EI No
Method o3 Ufisiafc:r,naa
Comments:
Pump Installer Name:
Pro��peeJg�'ty Owner Name & Addrt
P4CR F'rj � I S CJiE
Qfeet .
0
Anchorage Pump & Well Service
330 East 76th Avenue
Anchorage, Alaska 99518
Phone: 907-243-0740
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
GRED, . E.R ANCHORAGE AREA BORt JGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME __/JU Z_�IA'J MAILING ADDRESS_ 3's_ a �wA �PrPH0NE
LOCATION �_ N�"_-- LEGAL DESCRIPTION _�__�.� ���� Ui eC�l S.
SEPTIC TANK:
DISTANCE NUMBER OF
FROM WELL MANUFACTURER __ Ce ��� MATERIAL _S_T�V COMPARTMENTS
INSIDE LENGTH _ INSIDE WIDTH
-7-V
T11 I=r)RAIN F D:
LIQUID DEPTH LIQUID CAPACITY/(dEN GALLONS.
`� l TOTAL LENGTH
DISTANCE FROM WELL 1/4 FOUNDATION_ ' ___NEAREST LOT LINE/ OF LINES 4 �
NUMBER OF LINES DISTANCE BETWEEN LINES _ TRENCH WIDTH 3 IN. TOTAL EFFECTIVE
ABSORPTION AREAdy SQ. FT. LENGTH OF EACH LINE
DEPTH OF FILTER ��
DEPTH: TOP OF TILE TO FINISH GRADE MATERIAL BENEATH TILE -- IN. ABOVE TILE 4 IN.
WELL:: % �p
TYPE-.L��-- -(gid _`L�%IJ DEPTH /�
CONSTRUCTION _
BUILDING
FOUNDATION
CESSPOOL
APPROVED
NEAREST NEAREST r SEPTIC SEEPAGE
LOT LINE _� SEWER LINE TANK " SYSTEM_
OTHER SOURCES
DISAPPROVED-.-_--_- REMARKS
DISTANCES:.°!
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL: S& -T-1 - t- --
�r h
LOT SLOPE: 46
/ c f
REMARKS: 160 D� r
Form EQ -032
DIAGRAM OF SYSTEM
DISTANCE FROM:
/e l
DATE/� �4: F-7TYAPPROV
G.A.A. B.
SIGNED�__ _______________
H�P��CHNT BOB TROUTMH�
ISSUED BY __�M|�__��-___________^ ~~
i.
�'Jf3li1-TQk-
'ANT % INC. Q4E EAST 01 YT. AVE. ' MOX E087 ANCHORAGE, nK.966o2 R.H `3.7 2lH .49:3
August 5, 1976 R & M No. 656274
Mr. Bob Troutman
3509 Iowa Drive Apt 1
Anchorage, Alaska 99501
RE: Test Hole and Soil Log Report for Sanitary System
Lot 5 Block 1 Bonnie View Subdivision "A3'
Dear Mr. Troutman:
We are submitting herewith the test boring results and our comments
regarding soil conditions encountered at the subject site. This investigation
was performed in accordance with your request of July 23, 1976 and those
procedures outlined in a letter dated July 15, 1975, by Mr. Rolf Strickland
of the Greater Anchorage Area Borough Department of Environmental Quality.
A single test hole was put down within the subject site area for the
purpose of defining general subsurface soil conditions for the proposed
sanitary system. Excavation was accomplished with an auger type drilling
rig and the test hole was extended to a total depth of 17.5 feet below
ground surface. The final log prepared for the test hole has been
included in Drawing A-01.
Ground water was encountered in the test hole at 11 feet while drilling.
we appreciate being given this opportunity to be of service to you.
should you have any questions with regard to the above, please do not
hesitate to contact us.
Very truly yours,
} & M CONSULTANTS, INC.
,Tames W. Rooney
h�
V i.ce President
,FWR/ddp
xc' I GAA13
BENJAMAN ROAD
T.H. 1 8/2/76
a
SILTY SAND
W/SOME GRAVEL
& SOME ORGANIC MATERIAL
SANDY SILT
W/SOME GRAVEL --^__6'
SILTY SAND
w/SOME GRAVEL
Sanitary Sewer Test Hole F B.
_._ ---- GRID
kp `,� ` J Bob Troutman
R&M C.. .... A .. INC.
Anchorage, Alaska PROJ.N0056274
B/2/7o __ t ,)W(-, NO 7liil -
GRAVELLY SAND
•..•�
W/TR SILT
•:. _
`OCCASIONAL COBBLES
W.D.
••t %'•
@ll'
:17.5' T.D.
This log represents
subsurface soil conditions
within Lot 5 Block 1
F,Mlni - Vi (W F,,,)?di Vision
Section 25 T12N R3W
Sanitary Sewer Test Hole F B.
_._ ---- GRID
kp `,� ` J Bob Troutman
R&M C.. .... A .. INC.
Anchorage, Alaska PROJ.N0056274
B/2/7o __ t ,)W(-, NO 7liil -
PERCOLATION TEST
BOB TROUTMAN
R & M NO. 656274
ELAPSED
DROP IN
TIME
TIME
INCHES
10:00
0
0
10:01
1
5
10:02
2
3
10:03
3
2
10:04
4
2
10:05
5
1
6
1.5
10:06
10:07
7
1
10:08
8
1
10:09
9
1
10
1.5
10:10
15
2.5
10:15
10:20
20
2
25
2.5
10:25
30
1.5
10:30
40
3.5
10:40
10:50
50
2
60
_Z.-5
11:00
35.5 Total Drop
60 Minutes
.y OF A
III% • p as °Q ••
i
� fito
car .Meyer
°® 353
PROFESSO
Location:
BESSE, EPPS & POTrS
2220 EAST 88 AVENUE
ANCHORAGE, AK 99507
(907) 349-6451
WATER WELL TEST
Date: � ---- --
Subdivision:
Subdivision: '
Lot:
Block: /
Client's Name:
Address:
Tester:�,���
Initial Reading cn Meter:
TIME
GPM
GALLONS
A VOLUME
GALLONS
TOTAL VOLUME
/41% raA
i, --A a 1 n/a
G
3
71
NOTES:
Pr -,Auction GPM 24—Hour Capacity Gallons
A, l l//l;' 1. 4--v/1, A
i
me s
moo
j
` F
TH
�V Gr'n�t say av°
of
o (n to'! l(1 � C:r�, •aq
NO, 32515 3
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""�.�,�_� Qt1IM Q1 of A6x n(littl(Ttl [tl
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t�� ��1r�4� t�,+t!
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7. hereby cer6fy that 1 Q,o r. lit`"Yed to RAN"$_ i
a
i'Telr♦_ � _ liirl]nt e fce c t aili Precilict, t!1 , flio 1
..��'"✓`� yl - fit , 1111�,[r,l �!!yE•nt ,itR;W d thereoll aro i "tf tlir 4');) r r
do nal 6vorlap or onclonch fig
It i i{ %djn(,erlt t)]etc tIl l h Ii, PI'S irY F 1 , 1 t Is c i i .rrr-
� e ry, "!"g nC3Jr-tlCrrl.l, ,7 we i'irr l�;
�:- rlu nit .ItP2 i�ittl lift !t E�1 r t I It;t e t _1z,•
61�' .,.........,. ytllr�ti m t ilii! \45
iti�.,l
100
1
G G f! L/!%C/a % /-
i it
Municipality of Anchorage
On -Site Water & Wastewater Program
(907) 343-7904gIll
c
F
t
RUSH! CERTIFICATE OF ON—SITE SYSTEMS APPROVAL'
Parcel I.D. 017-422-14 Expiration Date:
1. GENERAL INFORMATION �1 j
a i
Complete legal description BONNIE VIEW S/D; LOT 5
Location (site address) 12621 NEHER RIDGE, ANCHORAGE, AK, 99516 - '
Current Property owner(s) MARCELLA CORNELL Day phone C/O AGENT
Mailing address
Real Estate Agent
12621 NEHER RIDGE, ANCHORAGE, AK, 99516
SARAH HALTNESS W/ REMAX/DYNAMIC Day phone
2. TYPE OF DWELLING:
■ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4, TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
WaiverNariance request for:
Received by:..
COSA to be released to the engineer, unless
3
227-0599
requested by the engineer.
COSA Fee $ B q! `& 6
Date of Payment' Pl
Receipt Number
COSA #D3 -
Date: L
Waiver Fee $ _
Date of Payment
Receipt Number
Waiver #
Distance: -
TYPE OF WASTEWATER DISPOSAL:
®
Individual On-site
❑
Individual Holding tank
❑
❑
Community On-site
❑
❑
Public Sewer
❑
requested by the engineer.
COSA Fee $ B q! `& 6
Date of Payment' Pl
Receipt Number
COSA #D3 -
Date: L
Waiver Fee $ _
Date of Payment
Receipt Number
Waiver #
Distance: -
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 -
inve�sVgation, 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, l 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 al! applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 - ANCHORAGE, AK, 99507
Engineer's Printed Name
Engineers Comments:
JEFFREY A. GARNESS, P.E.
In conducting this evaluation, GEG, Up. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines 8 Regulations. The reported results described the performance ofthe
system under the conditions encountered at the time of the test, and separation
distances measured to readify identifiable features. The operational life ofall wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year. and the wafer usage of the family being served by the system.
These condons are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, not do they guarantee that
there are no hiddeir 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.
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
Phone
337-6179
Date 7i Z fs
bedrooms, with the following stipulations:
_t�ll�ittif!Itttr I rr1�7rr
L�QQ
�= ON-SITE TZ 0'
J
-� WATER AND
J0 WASTEWATER oz=
...noAAA 63m�
r Q
yA�yvl.lill)11!«��•
By_ Original Certificate Date: ,2 y -
The AQ fcip �r",t�,Offzs
rage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the reprgiven 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. ATTCHMENTS:
COSA Checklist Nitrate Advisory
Septic System Advisory Ar Advisory
Well Flow Advisory 6sOther
Rev. 10/12112)
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description:
BONNIE VIEW SID: LOT 5
A. WELL DATA 'TO BEDROCK
Parcel ID: 017-422-14
Well type PRIVATE If A, B, or C provide PWSID# NIA Well Log (YIN) YES
Date completed 4/11/1976 Sanitary seal (YIN) YES Wires properly protected (YIN) YES
Total depth 425 ft. Cased to `19 ft. Casing height (above ground) 12+ in.
Date of test
Static water level
Well production
FROM WELL LOG
4/11/1976
WATER SAMPLE RESULTS
AT INSPECTION
1/19/2015
16 ft,
0.46 g.p.m.
Coliform �0 colonies/100 ml. NitrateDmg./L. Collected by: GEG, Ltd.
o1
Arsenic: r JKDug./L. Date of sample: 1!22!2015
B. SEPTIC/HOLDING TANK DATA NOTE: TANK IS 39 YEARS OLD AND LIKELY APPROACHING THE END OF ITS USABLE LIFE.
Tank Type/Material SEPTIC/STEEL Date installed 10/15/1976
Tank size 1000 gal. Number of Compartments 2 Cleanouts (YIN) YES
Foundation cleanout (YIN) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping Pumper A+ HOME SERVICES
C. ABSORPTION FIELD DATA BELOW EXISTING GRADE TO BOTTOM OF SUMP
Date installed 10/15/1976 Soil rating (g.p.d./ft or /bdrm 100 System type TRENCH
Length 42 ft. Width 3 ft. Gravel below pipe 4 ft.
Total depth `6.4 ft. Eff. absorption area 336 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 1/1912015 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test -13 in. Water added 1110 gal. New depth +4 in.
Elapsed Time: 1110 min. Final fluid depth -11 in. Absorption rate >= 450+ (-1270) g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date -
MEASUREMENTS TO LIQUID LEVEL ARE RELATIVE TO THE INVERT OF THE DRAINPIPE. SEE ATTACHED LETTER
REGARDING ADEQUACY TEST.
__ 1
_. 0
D. LIFT STATION
Date installed
"Pump on" level at in.
Size in gallons Manhole/Access (Y/N)
"Pump off' level at we er alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot *100'+
Absorption field on
100'+
On adjacent lot:
On adjacent lots
100'+
100'+
Public sewer main N/A Public sewer manhole/cleanout NIA
Sewer /septic service line 25'+ Holding tank N/A
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 51+
Water main
N/A
Wells on adjacent lots 1004
Property line 5'+ Absorption field 51+
Water service line 10'+ Surface water 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main N/A
Water service line 104 Surface water 100'+ Driveway, parking/vehicle storage **0'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
*PER WALATKA SURVEY, 101.5' FROM WELL TO TANK CLEANOUT.
—PORTION OF DRAINFIELD IS UNDER DRIVEWAY. ACCEPTABLE PER CODE AT TIME OF INSTALLATION.
G. ENGINEER'S CERTIFICATION
l 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 Printedame JEFFREY A. GARNESS
Date 7-/l/1,r-
(Rev. 10/12112)
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MICHAEL ROAD (Not Built) m
Municipality of Anchorage pP E
Development Services Department '
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
Water Well Advisory
Certificate of On -Site Systems Approval (COSA) # 151037
During a recent COSA on-site inspection and test of the potable water
supply well on Block , Lot 5 of Bonnie View subdivision, the well's
productivity was determined to be 0.46 gallons per minute. The minimum
well productivity required by this Department (AMC 15.55) for a 3 -bedroom
residence is 0.31 gallons per minute. Although the subject well currently
exceeds this minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction of non-critical
water uses such as washing cars and watering lawns and gardens may be
required.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
GARNESS ENGINEERING GROUP, Ltd
CIVIL & ENVIRONMENTAL ENGINEERS
January 27, 2015
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Road,
Anchorage, Ak 99519-6650
REFERENCE: Bonnie View S/D; Lot 5: Adequacy Test.
To whom it may concern,
The drainfield on the subject property has a listed effective depth of 48 inches. According to the agent, the
house had been vacant for about 1 month prior to testing, but workers had been in the house during this
period. The 6" sump was used for testing on 1/19/2015. At the beginning of our test, the liquid level was
13 inches below the invert of the drainpipe. Over the course of 197 minutes, we introduced 1,110 gallons
into the drainfield through the sump, bringing the liquid level to 4 inches above the invert of the lateral line.
The liquid level initially rose very quickly to invert level, but took water almost 800 gallons without rising
further. The last 200 gallons caused the level to rise above the invert until the system was at 100% capacity.
During this time, the tank level and post tank cleanout were monitored closely and it was confirmed that no
water backflowed into the tank. After the water was shut off, the liquid level was monitored several times
over the course of 1110 minutes. At the end of the recovery period, the liquid level had dropped to 11
inches below the invert of the drainpipe (a total drop of 15 inches). This corresponds to an absorption rate
in excess of 1270 gallons per day, if the liquid level in the sump accurately reflects the liquid level in the
drainfield. At times, the liquid level in the trench may be lower than the actual liquid level in the sump, but
would not be higher. However, GEG, Ltd. would like to advise/disclaim the following items:
• It was communicated to us by the agent that the house was vacant for approximately 30 days prior
to the start of our test.
• We cannot confirm that this sump was perforated to accurately reflect the liquid level in the trench.
• The trench was filled to its absolute maximum capacity during this test. The typical drainfield
operating level might be within the top 10% of the system.
• The steel septic tank is 39 years old at this time and is likely approaching the end of its usable life.
If you have ani Westions, please contact us at 337-6179.
.E., M.S.
3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259
Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com
Municipality of Anchorage
On -Site Water & Wastewater
(907) 343-79C""Y�
CERTIFICATE OF ON-SITE
Parcel I.D. 017-422-14 Expiration Date: 3f7—/ 3
1. GENERAL INFORMATION
Complete legal description BONNIE VIEW LOT 5
Location (site address)
Current Property owner(s)
Mailing address
Real Estate Agent
12621 NEHER RIDGE DRIVE *ANCHORAGE AK
JACQUELINE SCHAKEL Day phone 354-0664
12621 NEHER RIDGE DRIVE *ANCHORAGE AK
2. TYPE OF DWELLING:
E Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual Well
0
Individual On-site
E
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Weli
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
Received by: Z Date: /z4/
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ no 2914-PI1AS�N
Date of Payment Na kQ 112. /CJVN
Receipt Number
COSA # CXD0A\ 5 fro
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by seal affixed hereto and `as'Ythe validation date shown below, ! verify that my
investigation; based on procedures `outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
r"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.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507.
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date l2 6 t i
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.
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms.
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
...
A. or
as
9
AfCE--J33
bedrooms, with the following stipulations:
Io
ON-SITE
WATER AND
WASTEWATER
PROGRAM
The Municipality or Anchorage Devetop,emt Services Division IDSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenetations 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. ATTCHMENTS: /
COSA Checklist c Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
By:f C9
(Rev. itl0.5)
Original Certificate Date: A ��—
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: BONNIE VIEW, LOT 5 Parcel ID: 017-422-14
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A
Date completed 4/11/76 Sanitary seal (Y/N) YES
Total depth 425 ft. Cased to 19 ft.
FROM WELL LOG
Date of test 4/11/76
Static water level 18 ft.
Well production ASSUMED 3 g,p.m,
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml.
Arsenic: nd ug./L.
B. SEPTIC/HOLDING TANK DATA
Nitrate 1.83 mg./L.
Well Log (Y/N) YES
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
*12/5/12
*14.3 ft.
*0.60 g.p.m.
*WELL TESTED BY AWPS (SEE ATTACHED)
Date of sample: 11 /29/12
Collected by: AWPS
Tank Type/Material SEPTIC/STEEL Date installed 10/15/76
Tank size 1000 gal. Number of Compartments E Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (YIN) N/A
Date of pumping 9/4/12 Pumper MCDONALDS PUMPING
C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE TO BOTTOM OF SUMP
Date installed 10/15/76 Soil rating (g.p.d./ft'or Ibdrm 100 System type TRENCH
Length 42 ft. Width 3 ft. Gravel below pipe 4 ft.
Total depth *8.41 ft. Eff. absorption area 300 ft2 Monitoring tube **YES Depression over field NO
Date of adequacy test 11 /30/12 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test ***�1 in. Water added 455 gal. New depth **71.5 in.
Elapsed Time:11 0 min. Final fluid depth ***�1 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE If yes, give date
**SUMP/MT APPEARS TO EXTEND 77" BELOW INVERT OF DRAINPIPE.
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YM
"Pump on" level at in. "Pump ofr level High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lot:
Absorption field on lot 100'+ On adjacent lots
Public sewer main N/A
Sewer/septic service line 25'+
Animal containment areas 50'+
100'
100'+
Public sewer manhole/cleanout N/A
Holding tank
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main_ N/A
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 0'
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
PORTION OF DRIVEWAY IS OVER DRAINFIELD. CONDITION HAS EXISTED FOR OVER 20 YEARS AND
APPROVED ON 1989 HAA.
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 COSH guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date 111.1b.11 z
(Rev. 11/05)
�.......................
e r ness:
y CE -71 53 �G
04��0ed
17 Z[ I �ovoo
_lof essio0\
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage. ak.us
(907)343-7904
Water Well Advisory
Certificate of On -Site Systems Approval (COSA) # 121560
During a recent COSA on-site inspection and test of the potable water
supply well on Block , Lot 5 of Bonnie View subdivision, the well's
productivity was determined to be 0.60 gallons per minute. The minimum
well productivity required by this Department (AMC. 15.55) for a 3 -bedroom
residence is 0.31 gallons per minute. Although the subject well currently
exceeds this minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction of non-critical
water uses such as washing cars and watering lawns and gardens may be
required.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
q
vy t
�,✓ .�' t'�y 'N i
* f Tt�A''9��• h
An[irrw' �.Pubs •. rp
A7``s''. Tin, 351A 5
SURVEYORS CERTIFICATION
I MISERY CERTIFY THAT I HAVE SURVEYED THE
PROPERTY DESCRIBED ON THIS PLAT AND THE
IMPSOVEMENTS SITUATED T149REON ARE LOCATED
AS SHOWN ON THIS PLAT..9
DATED THIS %� BAY OF 221 X
/) e /) .)/�)
CA
10'0/;/'il Er, 7.
LEGEND- t
O LOT CORNERS
FOUNDATION
--® DRAINAGE ARROWS
NOTES,
I. IT SHALL BE THE RESPONSIBILITY OF THE BUILDER OR OWNER TO VERIFY TNA
BUILDING LOCATION SHOWN M9ZTS ALL SUIDIVISION COVENAN T9 AND EDNING
ORDINANCES.
I. IT 19 THE RESPONSIBILITY OF THE BUILDER TO VERIFY ALL ELEVATIONS WITH
RESPECT TO ALL UTILITIES,5 DRAINAGE.
S. THIS PLAT RIPAEBENTS THE PARCEL OF PROPERTY DESCRIBED BELOW TAKEN
FROM THE RECORDED PLAT DESCRIBING THAT PARCEL. INBTROIIENTR RECORDRD
PRIOR TO OR AFTER THE FILING OF THE RECORDED PLAT ARE HOT SHOWN ON
THIS PLAT,
A. THE INFORMATION ON THIS PLAT IS FOR THE UBE OF LENDING INSTITUTIONS
SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES ANO
PLAYT£O LOT LINES 04 EASEMENTS , THE PLAT 18 NOT TO BE USED PON
POSITIONING ADDITIONAL STRUCTURES 00 FENCER.
. T4s- /3U/Li
.Lor s
V/,E lel 5 URI,
PIP
Owner Information
Intake Depth:
Static Water Level:
Max Drawdown:
Air Line Depth:
Average Discharge:
PUMP ON
PUMP OFF
WATERWELL - TEST PUMP REPORT
330 E 76th Avenue, Anchorage AX 99518-2840
Ph: (907) 243-0740 Fax: (907) 243-0742
I d pl.71�21 rA
A —
a IV5 - -
glenxvmc
Time. 1.'13 Date: —/—,M,!:4,z2
Time: oe.'50 Date:
Well Information
Total Depth:
Depth of Casing:
Static Water Levelk
Casing Size:
Screen Diameter:
Screen Slot;
Screened From:
Screened To;
Remarks:
Elapsed
Water Level
Flowmeter
Flow GPM
Comments
Time
Feet
Meters
4AC 441d' &91-
6W
iW 9f/ 641
4'y3
3aTf
Xf q16
av
12.
6Y
...
.... ......
-57ft — QAA- -!PL1.41Pe,0X-66qG.41
..........
T
GALLONS PUMPED=
TIME PUMPED=
TEST AFTER EVACUATION=
WELL TEST YIELD=
Tnr4i ?Ws�rL j-ff
A WA
5he A"acwnw
I
2?40 A*0M"16W a96ow
MUNICIPALITY OF ANCHORAGE
• Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # c, c� -- L� Q r-) - � �-A HAA # _tel`a�9 cl Lj,
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range) I 1
Location (address or directions)
Al e � e r Ro�9 d
(b) Property owner lobi"t T ov7'��-✓ Telephone : (home)-3y-e3LZSBusiness ,272-907/
Mailing Address /;Z 621 N, -Lig'— /4704d
(c) Lending Institution
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
Telephone
L; Ad / To'dr:r�)'e_'; t�n ti
(e) Mail the HAA to the following address: (or check here if hold for pick up.)
List contact person and day phone number below:
/�o 6c.;-' -%,'c./r�.4^. o-
2. TYPE OF RESIDENCE
Single-Family'x
3. WATER SUPPLY
Number of bedrooms 3
Individual WelIX Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site, Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
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 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 com fiance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection. �S�C /�A g c h:,� 0_r
Name of Firm J3(15S,z 40s V= O Telephone
Address Svc A/<. %95'a-7
Date S, o7� 7�l'is d,# TP - 7-,F'7
6. DHHS APPROVAL
.Approved for __? bedrooms by
Approved—. Disapproved
D. rAoore, h.
/ 4n, ' Date _
Conditional
Terms of Conditional Approval
;77, �c,l�l1�"TiJzd�1-r- �'t°s ilV7 7'4c- sTUv tG>'�� d✓ %�%�''�
l�f U4? Lr tat, 11&et_ 7_4.� -Ili, 41s'c> 1rO�2 LE i�r'�. Q : i �:S ia? j�� /'� 3'L; �T �• Z / 2't'li•�
�•-L {���'�� �li2 �ii0� �l� �Z. i i' L S.
,i CAUTIOI
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
frr�
D. rAoore, h.
/ 4n, ' Date _
Conditional
Terms of Conditional Approval
;77, �c,l�l1�"TiJzd�1-r- �'t°s ilV7 7'4c- sTUv tG>'�� d✓ %�%�''�
l�f U4? Lr tat, 11&et_ 7_4.� -Ili, 41s'c> 1rO�2 LE i�r'�. Q : i �:S ia? j�� /'� 3'L; �T �• Z / 2't'li•�
�•-L {���'�� �li2 �ii0� �l� �Z. i i' L S.
,i CAUTIOI
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA) �fii\
Health Authority Approval (HAA)
r 1013HECKLIST - FEBRUARY 1984 i
343-4744
RECEIVED
A. WELL DATA j
Well Classification
Legal Description:
If A, B, C, D.E.C. Approved (Y/N) _/yA
Well Log Present (Y/N) Date Completed,- 7 Yield O • SgOm T ;_,
I
Total Depth,�25 Cased t 'd� ` c Depth of Grouting
Static Water Level -2 %' Ty,, � F. -7 —,. s � Pump Set At * 3-5/ r
Casing Height Above Ground
2 / `f _
Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) — % Depression Around Wellhead (Y/N) IV
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot /00711 ; On Adjoining Lots
To Nearest Edge of Absorption Field onnLot % el) p 71" ; On Adjoining Lots
To Nearest Public Sewer Line 4(.14 To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot ?0 '
Water Sample Collected by A lvd Pt, A -S ; Date 7�
Water Sample Test Results �� l�%J 1.1"4C A r
Comments i 01 -IHS ee_. r
B. SEPTIC/HOLDING TANK DATA
Date Installed /S Size* 4_20 No. of Compartments A--" :2
Standpipes (Y/N) i Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N)
Depression over Tank (Y/N) /V Date Last Pumped
Pumping/Maintenance Contact on File (Y/N)
;for
Holding Tank High -Water Alarm (Y/N) &4 Temporary Holding Tank Permit (Y/N) N14
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well 7h To Building Foundation
To Property Line �00 .1 To Disposal Field *-
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course /VoN
Comments X41111J'�
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata0 Type of System Design*72'1''4"-'
Date Installed 76 Length of Field
Width Lof Field ' Depth of Field t 7
• = ' Gravel Bed Thickness
Square Feet of Absortion Area* �' Statndpipes Present (Y/N)
Depression over Field (Y/N) % Date of Last Adequacy Test
Results of Last Adequacy Test ,
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well _ Z00 "7 To Property Line /S
To Building Foundation To Existing or Abandoned System on
Lot U V ; On Adjoining Lots / 06
To Water Main/Service Lined ® To Cutback (if present) /VOA`
To Stream, Pond, Lake, or Major Drainage Course `,/
To Driveway, Parking Area, or Vehicle Storage Area U
Comments
F0 H HS RC rC 6 r ,U
D. LIT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
L/fGi"de, -5ff<,40
6 / d ,I e < eA,
Q 7( Areeipr^t i'.
Dimensions
Manhole/Access (Y/N) .
"Pump Off" Level at
Vent (Y/N) _
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request"
I certify that I have checked, ve 'f r conformed to all MOA and HAA gu(de4irles m e'ff .qt on the date of this
inspection.
s, G4r
Signed
Company ,'L D 7/ -�
Date —1 "' % 6gineer's Seal
MOA No.X��c�
�f
Receipt No. J
Date of Payment
Amount: $
Receipt No
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
BE.SSE, EPPS & POTTS
2220 EAST 88 AVENUE
ANORAGE, AR 99507
(907) 349-6451
WATER WELL TEST
Date:.- 1
LOCATION: n
Subdivision:
Lot: S
Block:
Client's Name:
Address: / .2 /D z % Me e r- /o /}
/
TESTER: �, d ,�' `� r a
Initial Reading on Meter: .-5 3 7 -- J
NOTES: f �I� i 5 �i,-,J�-. A
- - ..- . J . . ,
Z41A
r A
Production Rate: 0• S G?`1 24_-riour Capacity -ZO--(-2 Gallons
DRAW
/o,r
GALLONS
GALLONS
FIELD
METER
DOWN
TIME
GPM
A VOLUME
TOTAL
MONITOR LEVEL
READING
✓ 7
<.
s
v
-33 7)
!
/1?,
3
6Z
612—
/ice "'
o:aa
10"20
,2,/
237
?3
! 22
9.'Y4
21.5
s
2 e 7
o
610
2---
3;.3 0
ss
v. 7s
y o 7p
-239
IJ "112
I -Z S
l NC-r5'r
,j 13'yy
3/-5
I ," a s
S,
.5 7
r�N
�IO w
27
/s'an
I" '<e,
�
.y ,,
NOTES: f �I� i 5 �i,-,J�-. A
- - ..- . J . . ,
Z41A
r A
Production Rate: 0• S G?`1 24_-riour Capacity -ZO--(-2 Gallons
NORTHERN
TESTING
LABORATORIES,
Time
INC.
6N' UNIVERSiTY PLAZA ✓.'ES'
SUITE A
Sampled:
05/17/89
0 7 P-3115
-,505 FAIRBANKS STREET
A
-�.;rit=
Completed:
90T'8379
Bess, Epps & Potts'
2220 E. 88th Avenue
Anchorage, AK. 99507
Attn: Andy Potts
Source: Bonnie View 51BV
Sample ID#: A051789-6
Date
Arrived:
05/17/89
Time
Arrived:
1135
Date
Sampled:
05/17/89
Time
Sampled:
1030
Date
Completed:
05/17/89
Parameter Unit Result ADEC MCC*
Nitrate -N mg/1 2.0 10
Reported By: Date: 05;18/89
Francois Rodigari, Anchorage Operations Manager
* MCC = Maximum Contaminant Concentration
�'HE�
07'r 1 �AIS,
7:_4LGORA
INC.
FA,RPA'I•(I. ,'TRFET
r,
_„ 277, _M,
Quality Control Report
Client: BEP
ID#. A051789-6
Listed below are quality control assurance reference samples with a known
concentration prior to analysis. The acceptable limits represent
a 95% confidence interval established by the Environmental Protection
Agency or by our laboratory through repetitive analyses of the
reference sample. The reference samples indicated below were analyzed
at the same time as your sample, ensuring the accuracy of your results.
Sample # Parameter Unit Result Acceptable Limit
----------------------------------------------------------------------
----------------------------------------------------------------------
EPA WP284-3 Nitrate -N mg/l 0.10 0.10 - 0.18
Reported By: Date: 05/1.8/89
Francois Rodigari, Anchorage Operation Manager
-----------------------------------------------------------------------
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
1. GENERAL INFORMATION
(a) Lel.-taescriptign (include lot, bl
ii�l- .� ✓2fl � l�
Application Date
subdivisio section, township, range)
Location (address or directions)
I/�1__'=/ A
/":r
(b) Applicant Name�'-? Telephone: Home '«��usiness
Applicant Address
(c) Applicant is (check one): Lending Institution D ; Owner/builder'g1; Buyer ❑ ; Other D (explain); -
(d) Lending Institution '-f l Sym -- Telephone
(e) Real Estate Company and Agent
A AAr-.nn
Telephone
(f) Mail the HAA to 1pe following address:
2. TYPE OF RESIDENCE
Single -Family Multi -Family D Other
Number of Bedrooms
3. WATER SUPPLY
Individual Well Community D 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 D Community D Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11/84)
Page 1 of 2
5. ENGINEERING FIRM PROVIDIN%x INSPECTIONS, TESTS, FILE S ?ARCH, D.,, A AND INFORMATION
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
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 compliancewithicipal and State codes, ordinances, and regulations in effect on
the dahis-i-nsion. J
Name of Firm%s.—�f'r'��f Telephone :0
Address-�,�—
Date
_t;%�o�@�
•
AV
•°
�• • °'°'°°""°' •0"""'0'" *gineer's Seal
�4. C S. Me a
®� n� 6353goes
�$e,PRQFESSI�N�`'a
6. DHEP APPROVAL
Approved for � bedrooms by Li� DateZ
Approved Disapproved Conditi f
Terms of Conditional Approval
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
72-025 (11/84)
C. ABSORPTION FIELD DATA
D.
Soils Rating in Absorption Strata le 2Z Type of System Design
Date Installed f Length of Field �f2 / ✓
Width of Fielder Depth of Field j
Gravel Bed Thickness
Square Feet of Absorption Area 3 3--
Depression
zDepression over Field (No -A/
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well
Standpipes Presen Y, I)
Date of Last Adequacy Test
To Property Lined /
To Building Fo ndatio .SO To Existing or Abandoned System on
Lot 7� ; On Adjoining Lots iao
To W�/Service Line -d To Cutbank nt)
To Stream/Pond/Lake/or Major Drainage Course
Date Installed Dimensions
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N) _
Comments
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
certify that I ha ech cked erified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date 4S 1?9<:�,
Company, A No
Receipt No. 90735
Date of Payment 6 a7' EZ,
Amount: $
Page 2 of 2
72-026 (11/84)
.00*
1-4
ys • '•�'� ®� Engineer's Seal
••••• • • • • •• •w ••
®l mfr s Ca Meyer i S
m
%
53
[ ,•• • toy®
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE (MOA, ENVIRONMENTAL PROTECTION
HEALTH AUTHORITY APPROVAL (HAA) np�
CHECKLIST - FEBRUARY 1984
264-47on
Legal Description: "ZS
A. WELL DATA
Well Classification If A, B, C, D.E.C. Approved (Y/N)
Well Log Present 1) Date Completed Yield 2• e-) ✓
Total Depth ��� Cased took Depth of Grouting —
Static Water Level ? Pump Set'At
Casing Height Above Ground Sanitary Seal on Casing(ON
Electrical Wiring in Condui&) Depression Around Wellhead ( -�
Separation Distances from Well:
To Septic/Holding Tank on Lot ; On Adjoining Lots _122a
To Nearest Edge of Absorption Field on/Lot ja0 / ; On Adjoining Lots Z4 �—
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by L
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
To Nearest Public Sewer /
o Nearest Sewer Service Line on Lot
Date c /—,55 '
Date Installed, ✓-S ;- Size ,/� ✓ No. of Compartments Z
Standpipe/ J)eLe-, Air -tight aps(!DJ) Foundation Cleanouq!nk)400
�
Depression over Tank ( ,-�``� Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ; for
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)/4
Separation Distances from Septic/Holding Tank:
/ v -
To Water -Supply Well To Building Foundation
To Property Line Zo To Disposal Field /e
To Waier r/Service Line.%' ���61
Course
Comments
Page 1 of 2
72-026(11/84)
To Stream, Pond, Lake, or Major Drainage
5