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HomeMy WebLinkAboutVONS LT 4Vons Lot 4 015-081 -36 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: (¢~'~/ q~,¢ll~ PIDNumber: Name: Wastewater System: '~New Q Upgrade Address: ~Lt$ ~'7~1 ACe ABSORPTION FIELD Phone: No. of Bedr~s~ ~DeepTrench DShaflowTrench DBed DMound DOther LEGAL DESCRIPTION Soil Ratlng:,~[~.~ ~Sq, Ft. Total Depth from originalgrade: Lot: Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth beneath pipe Township: J Range: Section: Fill added above original grade: Gravel length: Number of lines: J D~stance between lines: WELL: ~New ~ Upgrade Gravel width: ~ Ft. / '~ Ft. Classification (Private. A.B.C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Dallied: Static Water Level: ~ ~ Date installed' Yield: Pump Set at: Casing Height Above Ground: 7-/O GPM i~ 0 ~ Ft. 7 J Ft. TAN K SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. To Septl~ Abso~p[ion Lgt Holding Public/Private Manufacturer: ~ CapaciW~n gallons: From Tank F,eld SJaUon Tank Sewer Lines ~[~ ~( '¢ ~ ~ / Material:~ Number of Compadments: su~.~ LIFT STATION LineL°t ~.~ I ~ I ~ ~.~ Sizein gallons: Manufacturer: CuHainDrain ~ ~ Pump Make & Model Electrical Inspections performed by: , Remarks: BENCH MARK ~ ~.~ Location and Description: .~ EN~INAER'S sEAg inspections performed by: ~ Dates: 1st ~ Department of Hea~ and Huma~ Services approval . Reviewed and approved by: Date: 72-013 (Rev. 9/91) MOA 25 N I £EAL£'; 1_'~ = 50 FT~ I I I I ~C 62 ~ANK CO [ ~ [ B~ 43. 5~ I AD 76 BD 5~ DO~BLE CO I ~E i Jo.5 I I OE i04,5 fRENCH CO AF lSi TRENCH ~ 4NO CO I ~ ~ id~ ~1, ~ptio lank I I ~F I19 ANCH. YANK I ~ TOBBEN SPURKLAND P.E. LOT 4 VONS ,~ SEPTIC SYSTEM AS BUILT 203 W 1 5TH. AVENUE ¢9~0 ~ROVER DelVE DATE: SEPT. 6, ANCH. AK. 99501 ~OXANN~ HERSCHEL SHEET: 2/~ GRID: 24Jg (907~ Z79-~916 Monitor Cleon Cleon Si. ondord Trenches; Eoundo '~ion Cleon lO00 ,c)ol Septic Double Cleon 64' Lon9 Deep Sey/er rock Cover SCALE IE 82.4 M/~o Fi 140 88~. 74.2 NB SCALE BENCH MA£tC m? BLOCK ASSUMED ELE~/ 18~00 TOBBEN SPURKLAND P.E E03 \415%h Ave Anchorcge Ak 99501 vo]vs ROXANNA HERSCHEL 9940 OROVER DRIVE SEPTIC SYSTEM AS BUILT D~'rE: SEPT. 6, i996 SHEET, GRID~ M-W DRILLING, Ine, Box 110378 · 10330 Old Soward Highway (907} 349.§535 ANCHORAGE, ALASKA r)~511 DRILLING LO~ Well Owner ROXAHNE HORSCHEL .._O~e of WellDOMESTIC Location (address of: Tow~Mp, ~ge, ~Uon, ff ~mwn; or distance math road _LOT ~ VONS ~IIB[)IVIRION: q940 nRnVER STREET _ _ ANCHORAG~ ALA~ Size of ca~Lug _6" Depth of Hole__204 feet Ca, ed to_ 2~)4.93 (eet Static water leveL96 ~t. ([~); ~ow) l~d s~iace. F~lsh ofwell (check one) o~n end ( X ) ~reen ( ); Pefforat~ ( .~ ~ ~;crl~ scr~n or pez~[O~ . ] ~t~zO ..... Well p~p~g te~t a~ga~ ~ 100~ 0f ~awdo~ kom s~Qe ~1 ']& ~SK) (minuta) for~ou~ with ~ · . ~_4~__TO 18 Date of completion 04 JULY ~996 ~"( : -- ){i!; '. c ~omld surface Gi~ d~]ls Of iormationa panetrated, size of material, color ~d '~:' ~'~'i; ~ " ~~. aDAVELLY la ~ TO~ RECEIVED l0 1996 Mu icipality ot Anchoraqe · , ,,~, ~. ~dumGp Services --95~TO~ 142 TO 170 195 TO. 200 200 .TO_204 -__ ,C~LA'~: SILl GRAVEL: SI[Ty~' ·DAMP WATERBEARING GRAVEL: SILTY, COARSE 1--CUSTOMER MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519 6650 PAGE 1 OF ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW960116 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:BELLOTT ROBERT J & BARBARA A OWNER ADDRESS:243 87TH AVENUE ANCHORAGE, ALASKA 99515 DATE ISSUED: 6/13/96 EXPIRATION DATE: 6/13/97 PARCEL ID:01508136 LEGAL DESCRIPTION: VONS LT 4 LOT SIZE: 40552 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL 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 ) (NOT REQUIRED FOR WELL ONLY PERMIT) 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 ISSUED BY: ~©~/~ .~. 203 W 15th. Aveuue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 4, VONS S/D ROXANNA HERSCHEL No Ground Water or Impervious Layer to 17 fl. Use Standard Trench Soil Rating. 36 rain/in = 0.45 g~ Ipsfpd No. of Bedrooms 3 Required Area per Bedroom: 150/0.45 = 333.3 sq.ft.. Total area required: 3 x 333.3 = 1000 sq. ft. Finish Floor Elevation 635 Ground Elevation at Absorption Field 610 +- Testhole Total D~pth No bedrock or impervious layer. No water Bottom trench elevation 599 Rock depth 8 ft. Length of trench 1000 / 16 - 62.5 ft. SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 63 FT TOTAL WIDTH 2 FT TOTAL DEPTH 11 FT ROCK DEPTH 8 FT COVER 3 FT SEPTIC TANK 1000 GAL 17 Elev. of bottom 593 The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not chauge the general slope of the area. Ponding and/or concentration of surface runoff will not result fi'om this installation. MUNICIP^tI1Y OF ANCHC)~U~ ~t~II~OI, IMENTAL SERVICES DIVISION Municipality o! Anchorage DEPARTMENT OF HEAL'TH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST ': ~(ENGINEER'S SEp) PERFORMED ~OR: ~ILL, 10 11 12 13 14 15 16 17 18 19 2O COMMENTS Township, Range, Section: SLOPE WASGROUNDWATER ENCOUNTERED? IF YES, AT WHAT DEPTH7 SITE PLAN I S L O P E M0nil~rlno? ~ Vy 0ate: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~:) (minutes/inch) PERC HOLE DIAMETER TEST RUN EE~WEEN '~ FT ^~O '? ?z. ~T PERFORMED BY: ~' --~ I '~* ~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCEW[THALLSTATEANDMUNICIPALGUIDELiNESiNEFFECTONTHiSDATE, DATE: ~"~ /~1~'~ ~}'/a:~ 72-008 (Rev, 4/85) N LU?' 1 I , L~T 5 50 O 50 100 150 ~00 ~50 300 I XqALE~ 1" = ]00 FT. ~ I I EAXT ~gTM AVE I L~T ~ I I I I I I I I I I I TBAOT 4 ii ~ I UNPEVEL~PEP I .~ I ~ I ii I Vocon~ I I I ] I I I VAconf I I Co o ~ ~ LOT ~  Mo co n ~ TOBBEN SPURKLAND P.E. LO7' 4 lIONS &/~ SEPTIC SYSTEM DESIGN 205 W 15TH. AVENUE ANCH. AK. 99501 99~0 ~BOVEB DBIVE DATE: ~AY 15, 1996 [907) 27~-)~1~ ROXANNA HERSCHEL SHEET: 1/3 GRID: 2439 Elev. 599.6 Elev. 609.5 I I ~5 0 2~ 50 75 JOO Jc3 1~, X ~ ] I ~...,~.-~ ................. ~ ....... ~z~..J I ~ ~ ,~ ~ I ,.....~-...~,~.~.~,..~ /~ ~ ~,,~. ~.o ~ - ~ ~.~-... -~..._~: / 7 ~ i i TOBBEN SPURKLAND P.E. ~07' 4 VON~ ,~/D SEPTIC SYSTEM DESIGN 205 W 15TH. AVENUE ANCH. AK. 99501 9940 GROVER DRIVE DATE: MAY l& 1996 (907~ g79-~916 ~OXANNA HERSCHEL SHEET: 2/~ GRID: 24~9 /~oundo t. lon £1eon out JO00 9ol Septic ton/< 53 Monitor Cleon Ou Cleon Out Standard ?renches: ~3' Lan9 l l' Deep 15 8' Sewem rock 3' Cover NO SCALE ~ 3' Cover' Toni< Pfiro f,i 140 of' .Smp i;i~ 1000 gal, sepf,'c rani< BENCH MAr?t< uoNuumvr ASSUMED ELE~/ 63Z00 TBgSEN SPURKLAN~ P.E 203 WLSth Ave Anchorage Ak 99501 LOT <l VOWS ROXAHHA HERSCHEL 9940 OROVER DRIVE SEPTIC SYS'rEM DESIGN DarE: WAY 15, 1996 SHEET: G~iD: ~439 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 EImore Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. GENERAL INFORMATION Complete legal description' Location (site address) Current Property owner(s) Mailing address Expiration Date: ~'~ "J'~/-/- / / Von Lo - N Lending agency Day phone Mailing address Real Estate Agent Mailing Addres]s, ~ Unlegs otherwise reque$ied, GOSA will be held by DSD for pickup. 2. NbNi B.ER,,O Fi~ E,~RO0~ S: TYPE OF WATER SUPPLY: Individ'u'al 'Well Individual Water Storage Community Class, Public Water System Day phone Well TYPE OF WASTEWATER DISPOSAL: ~. Individual On-site [] Individual Holding Tank [] Community On-site [] Public Sewer The Municipality of Anchorage Development Services Depadment (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site System's Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my 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. Name ofFirm ~,pu~\~.~ ~.n~;, ,'~(:~,c4, A/.~ Phone Address ~_.O~ 'vd. -.I,~'{~ Av'¢.~ 5,'J-e. 2o7_;/qncJ~c~r~z, AK' CLC/,5OI Engineer's Printed Name. L~.~_$ ,.-qpu~,~.v~ "J / I DSD SIGNATURE ~,~ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X By: (Rev. 11/05) Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: ~/)~' ¢~ Y" / / Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: VO ns Parcel ID: OI5- A. WELL DATA Well type Pmu~r~ Date completed~l~/c/(~ Total depth '~.oq ft. If A, B, or C provide PWSID # __ Sanitary seal (Y/N) "/ Cased to '2-05/ ft. Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) -F ~ in. FROM WELL LOG Date of test Static water level <~ (o ft. Well production ~- IO g.p.m. AT INSPECTION g.p.m. WATER SAMPLE RESULTS: Coliform A/~- colonies/100 mL Nitrate /VD mg/L Arsenic: ~,Z~t ug/L date of sample: 5/5/Zoi B. SEPTIC/HOLDING TANK DATA Tank Type/Material / Tank size" [000 gal. Number of Compartments Foundation cleanout (Y/N) Date of pumping 5/~l/ C. ABSORPTION FIELD DATA Date installed "~3[~q~t~ Soil rating (g.p.d./fl~ o~ '~ Length (o~ Total depth ,l[i~ ft. Date of adequacy test Collected by: Date installed Cleanouts (Y/N) Depression over tank (Y/N) ,/~ High water alarm (Y/N) Pumper ,4' ft. Width ~ ft. Eft. absorption area 1~7-~ ft2 Monitoring tube 5/~I/Zo~I Results (Pass/Fail) Fluid depth in absorption field before test (o<~ in. Elapsed Time: r-<g5 min. Final fluid depth ~,~ Any rejuvenation treatment (past 12 mo.) (YIN & type) System type Gravel below pipe ~ ft. "/ Depression overfield /V' For ~ bedrooms We~r ~dded {~00 gal. New depth ~(~,5 in. . in. Absorption rate >= ~50 g.p.d. V'¢> If yes, give date "-' D. LIFT STATION Date installed "PumPDatum on" I~ E. SEPARATION DISTANCES Size in gallons "Pump ofl" level at~. Cycles tested.,. Manhole/Access (Y/N) ~ High water alarm level at ,,,- . Meets alarm & circuit r~rnents? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot JCO Public sewer main Sewer/septic service line Animal containment areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~ ~' Property line -~ + Absorption field Water main A//A , water service line lC) ~+ surface water Wells on adjacent lots ICOI'{' On adjacent lots IOO ~'(' On adjacent lots (OO ~4 Public sewer manhole/cleanout ~V'/~ Holding tank ,4/'//4, Manure/animal excrete storage areas SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Water Service line I0 t-t- Curtain drain 50 F. COMMENTS Building foundation JO ~- Su ace water Wells on adjacent lots ~{~Z) ~- Water main . ,/V//d~ Driveway, parking/vehicle storage G. ENGINEER S CERTIRCATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Pdnted Name Lr.~ 4Ug.~.~~ COSA Fee $ Date of Payment Receipt Number /-/qO '- $ Date of Payment Receipt Number (Rev. 4/10) I.of 2A EAST 99th S 89'55'56"E 115.¢2' AVENUE R=20.O0' Lot 4 40,553 s.f. SHED 15.0' x 4.~.1' WITH PATIO N~tD STORAGE BELOW x 5.2' ..: PORCU 10' TELECOM. &:.-.~ lOO' ELECT. EASEMENT~ a __ N ' Lot I I GOLDENN HILLS SUBD. I = 50.00' NOTE: THERE IS AN UNDEFINED DRIVEWAY ENCROACHMENT EASEMENT FOR AN EXIST1NG DRIVEWAY AT THE NORTHWEST CORNER OF THE PROPER3¥ FOR THE BENEFIT OF LOT 5, VONS SUBDIVISION, GRANTED IN BOOK 2915 AT PAGE 601 ON APRIL 25, 1996. PLOT PLAN AS BUILT X SCALE 1' = 40' GRID SW 2459 Project No. 11-022 Lang & Associates, inc. 11500 Da~ A,,on.s. *,chorogs. (907) 522-6476 Phons Registered Land Surveyors (907) 522-4625 Fax kglanglsOalaska.nef / JclanglsOalaska.nef I hereby certify that I hays surveyed the following dsscribed properly: I. of 4, VONS SUBD. (Plat No. 85-545) Anchorage Recording DIMHct, Alaska, and that the Improvements sltuafed thereon are within fha properly lines and do not encroach onto the property adjacent thereto, that no Improvements on the properly lying adjacent thereto encroach on fha surveyed premises and that there are no roadways, transmission lines or other vlslble eassmenl= on said properly except as Indlaafed hereon. Dated this the \~-v Day of ~J~kCL~J~ , ~ !.\ , af Anchorags, Alaska If ls the msponslbiltly of the career to detemllne the exlsfenco of any easements, covenants, or restrictions which do not appear' on fha recorded subdivlslon plat. Alaska 99515--3049 ~'4~- ........... ~ ~- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 015- 0 ~,1 - ~, HAA# 1, GENERAL INFORMATION Complete legal description Location (site address or di'~ections) (~q HD ~ P-oV~P-. 'D ¢~1 V~-.- Property owner Mailing address Day phone Lending agency Mailing address Day phone Address Day phone ~:;L7~¢ '~'7~ -/ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: Individual well P'/ Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest~ lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community waetewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025{Rev. 1/91) Fronl MOA#2~ STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. NameofFirm '-~o~be,.~ .~,p¢-r"'[<:/~,¢2 "~.F_. Phone_ Address ~t2"~ ~ /,5-,LJ~ ~ ,,~c~ Engineer's signature ~ Date DHHS SIGNATURE ', Approved for /)t~- Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: 7; [Lt/ ;~, The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements, Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-O25 {Rev. 1/91) B~¢k MOA ~1 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division ~0~,' 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority ApProval Checklist Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth ~ O 14 f Sanitary seal (Y/N) LO'[" 1'4} VON ~.~ '%1~ Parcel I.D.: Date of test Static water level Well production IfA. B. or C, attach ADEC letter. ADEC water system oumbcr Date completed O 7,tgtf/~ ~ ~ Cased to ~t,~O q, q ~ Casing height (above ground) y Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION o'7. o¥.qt.. q6 ~. / g.p.m Nitrate ~%/D Other bacteria Collected by: Tamk size / Ogr~ Number of Compartn]eats Depression (Y/N) I'q High water alarm (Y/N) Pumper N//.~_ ~,~ (~,~) ~/r~tv,,r,e~}_~, WATER SAMPLE RESULTS: Coliform Date of sample: I ~ 6,. B. SEPTIC/HOLDING TANK DATA Date installed Foundation clcanout (Y/N) Date of Pumpiag C. ABSORPTION FIELD DATA Date iustallcd 7/~dtql,, I g.p.m. · Cleaaouts (Y/N))/ Peroxide treatmeut (past 12 months) (Y/N) ~ ~ Total depth I I ~ Depression over field (Y/N) I~l For ..~ bedrooms hnmediately a£ter_~gal, water added (in3: t~ Absorption rate = ~'~ g.p.d. lf yes, give (late ~ Fluid depth in absorption fickl before test (in.); Fhfid depth ~ (ins.) Minutes later: Length ~ ~ t Width ~ t Gravel thickness below pipe Effective absorption area } 0~14 H Mmfitoring Tube present(Y/N) y Date of adequacy test N ] I~ Results (PassfFail) "l> Soil rating , '03,t~,-, orft2/bdrm) D. LIItT STATION N ~>1',1 L~ Date iastallcd Size in gallons Manhole/Access (Y/N) "Pump oil" level at* "Pump off' level at* High water alarm level at* *Dattlm Cycles tested E. SEPARATION DISTANCES Septic/holding tai~k oil lot Absorption field on lot Public sewer main Sewer/septic smwice line SEPARATION DISTANCES FROM WELL ON LOT TO: ] I ~ On adjacent lots I ~ ~ ~ Oil adjacent lots H/~ Poblic sewer maahole/cleaaout ) ,~t ~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 1-/~. ,~ · Property line "~ .~ / Absorption field Watcrmain/serviceline ~¢,,>,2 Surfacowater/drainage Iq]o Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: I0 q-. ~ Water mait#servico line Driveway, parking/vehicle storage area / Wells oil adjacent lots ~, t~'t9 ' Property line F. ENGINEER'S CERTIFICATION ........ :- :7', I certify that I have determ ~ed thru field iaspecttons and review of Mumctpal rocor ds that the &bdve spMeJns are in conformance with MOA H,,Ld guidelines in effect oa this date. Signature ~ ~ E lgmeer s Nanlc Date ~o~ 7t ]~L HAA Fee $ ~ .. ~ Waiver Fee $ Date of Payment Receipt Number Date o£ Payment J///~ ,~/f,~,~ Receipt Number ~ Rev. 8/95 OSS: haa.wk.doc