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HomeMy WebLinkAboutWOEBEGON LT 19A-1 MUNICIPALITY OF ANCHORAGE DEPARTMENT .EALTH AND HUMAN SE.WCES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT N..~a DISTANCES ".~' / ~ ~ ~ '~ Tn SEPTIC ABSORPTION AddressFROM~ TANK FIELD WELL Phone(st Permn NO NO. ~f ~ed~ooms WELL Lot ~ ~ Subdivision 8mock~/~ ~¢J~ ~ FOUNDATION Township, R~nge, Section AB-BUILT DIAGRAM IShow Iocaeon ol wen, septic system, prope~y lines, loundation, ~ /~--~ ~ /~ ~ ~ driveway, wmerbodmes, etc) TANKS ~ SEPTIC ~ HOLDING Manulacturer Capacity i~ gallons ~ ~oo80 FI ~/~ FT Number of lines J~on talin9 Pipe mater~al WELLS ~ PRIVATE ~ OTHER (Identify) REMARKS: I~~ x cedlly Ihal this Inspection was pedorm~d according Io all Municipal and Stale guidelines In ellecl on this dale: ~/ 72-013 (3/85) 115.oo' I 20' BLM Eosement ~ I 10' Utility Easement L t , ? Lo¢oO°n i ~ ~ m o I 134.34' ~levet~on~ _Septic System Asbuilf LEGAL: Woebegon Subdv, Lot 19A OWNER: Joel Bobb CONTRACTOR: Deon Construction ~ ~:':~,','' ' .... ~'~ ':' ~UALg --- EAOLE RIVER EN~ZNEERINO ~ERVICEN ~ P.O. Box 772294 ~.~, ~ EAGLE RIVER, AK. 99577 ' ' (907) 694-5195 FAX: (907) 694-8408 DOC CO, dba SUL]LIVAN WATER WELLS P.O. BOX 670272~ CHUGIAK, ALASXA 99567 · TELEPHONE 688.2759 OWNER OF LAND ' ~ 0 ~Z,, t=~ ~ ~ I}EI'Tt{ OF WELL .~ ,ed/ ADDRESS ~90 ~O~' ~7 ~ ~ ~ ~ ST.~TIC LEVELOFWATER FT. LEGALDESCRI~ION~Y {~ ~ ~ ~ ~_~ ~d'~)~WDOWNI:T, PE~IT NUMBER. KIND OF CASING ~ V O KIND OF FORMATION: From ('~ Ft. to c~ Ft. From ~ Ft. to II Ft. From Ft. to Ft. From / / ~t. to~ Ft. ~mm,~ Ft. to ~t, From ~Ft. t o.~ Ft. From Ft. to__Ft. From Ft. to Ft. From__Ft. to Ft. From Ft. to Ft From Ft. to..__Ft From Ft. to Ft. From Ft. to Ft.. From Ft. to__.Ft. From Ft. to__Ft.._ Frotn Ft. to Ft. From Ft. to__Ft. Froln Ft. to___ Fronl Ft. m [:1, From__ Fi. Fronl FI. lo .... Fl. MISCL. INFORMATION: DRILLER'S NAME [ -'~'~-. ~ DEPT. OF ENVIRONMENTAL CONSERVATION WALTER J. HICKEL, GOVERNOR ANCHORAGE DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, AK 99577 RECEIVED APR 2 6 19'31 563-6775 Mr. Louis Butera, P.E. Eagle River Engineering Services PO Box 773294 Eagle River, AK 99577 I'¢~u,~ c4~ahty of Anchorage Dept. Health &Hurnan Services April 24, 1991 Re: Certificate to Operate, Woebegon~ S/D, Lots 19A & 19B; 8721-FA-072, Class C Public Wa. ter System ID 217071 Dear Mr. Butera: This is in response to your submittal, received in this office on March 2, 1991, in which you requested a "Certificate to Operate" for a Class C public water system located on the referenced property. I have completed my review of the submitted information and this office's file on this project. The package has been discussed with the District Engineer and the following comments are offered. The Department takes exception to the amount of storage capacity provided. The fifth edition of "Community Water Systems Source Book" cites a need for eight gallons per minute per residence for twenty minutes to meet instantaneous demand requirements. In this case a total of 160 gallons of water is required. The well produces 120 gallons in 20 minutes leaving a difference of 40 gallons which should be in usable storage. These figures are for one single family residence. When the other lot is built upon the storage for the other home should be 160 total gallons. As there are no complaints in the Department files concerning the amount of water, the Certificate to Operate can be approved based upon historical sufficiency for the first property. Our recommendation for the storage is a recommendation and not a requirement. Based on the information provided by you and the data certified by your stamp, "Approval to Operate" can be granted. Any future expansion of the water system will require plan review in accordance with 18 Alaska Administrative Code 80.400. In accordance with 18 Administrative Code (AAC) 80.900 this system is a Class C Public Water System. It has been assigned a Public Water System Identification Number (PWSID#) of 217063. Bacterial and nitrate sample analyses were within acceptable limits set in 18 AAC 80.050 as reported by Chemical & Geological Labs of Alaska. This approval does not imply the granting of any additional authorizations nor' obligate any state, federal, or local regulatory body to grant required authorizations. Thank you for your cooperation with this Department. If you have any questions, please do not hesitate to contact Keven Kleweno. Sincerely, Environmental Engineer enclosures cc: John Smith, DHHS w/o eric. Tom Fink, Mayor January Iunicipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 10, 1991 Joel Babb PO Box 774233 Eagle River, Alaska 99577 Subject: Lot 1gA Woebegon Subdivision Permit #900369, PID #051-032-38 The subject permit, issued by this office for a single family well and/or on-site wastewater system has expired as of December 31, 1990. A new permit must be obtained from this office for a well and/or on-site wastewater system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this office for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site wastewater system, the original as-built inspection report (three-part form) must be sent to this office for review, approval and documentation. All i~spection reports must be submitted within 30 days of construction completion. When applying for a new permit, the fees are: $90.00 for an on-site wastewater permit; $50.00 for a well permit; $140.00 a combined on-site wastewater and well permit. for If you have any questi~s, Joh}4/Smi t]~,//lZ. ~. ' [ Pr~.r.am _MarFager On-site Services please call this office at 343-4744. JW/ljm:200 enc: Copy of Permit "Kids Are Our Future" ALASKA EFIUIROIIlllEFITAL COFITROL SERUIC S, ~nqinccrir~q 6- [~nuironmcnrol $1udics (907) P. O. Box 240668 Anchorage, AK 99524-0668 279-5553 *** FAX (907) 276-8706 Municipality of Anchorage Department of Health & ltuman 825 L Street, Fifth Floor Anchorage, AK 99501 November 7, Services 1990 RE: Lot 19A, Woebegon Subdivision Enclosed are the design drawings and wastewater system for this lot. specifications for a This lot is a nearly flat lot. The drainage slope is less than one percent from the southwest to northeast. To the east and northeast are lots which have no development. Lot 19B is undeveloped. There are no streams within 100 feet of this lot. A Class "C" well serves (8721-FA-072). Lot llA, trailer The well Lot 19A. within 200 feet of Lot 20 is over 200 Lots 19A and 19B with water Maru Subdivision, has one occupied and one unoccupied and partially collapsed trailer. serving this lot ts 220 feet from tho testhole for The sewer system for Lot llA, is the proposed system. feet from the Maru Subdivision, The well for BLM proposed sewer system. Lot 19A, Woebegon Subdivision, contains 2.497 acres. Available are tile results of two soils 'tests on this lot. t 412 ~,/OSl/339b 3.venue s -&rtchoR&(~e.-&lA8ka~gf ~ (907) 279-5§5.3 Both show sands and gravels to a depth of 12 and 14 feet, No water was found in either test hole. There is sufficient space on these lots for systems to be replaced several tSmes without impacting the sewer systems of the surrounding lots, The lot is vegetated with small birch 'trees, 2-4 inches in diameter. There is little undergrowth to impede drainage. There were no wetland areas noted. Road drainage is parallel to lot lines so it will not impact the lot, The development of this lot as a sing]e family home should not adversely Impact surrounding lots, ALASKA IUI OI m nTAL COI1TI OL Inc. · ~n~in~riocI ~, [~nuironm~tal $1u~ics SPECIFICATIONS FOR A FIVE-WIDE WASTEWATER TREATMENT SYSTEM LEGAL DESCRIPTION: LOT 19A, WOEBEGON SUBDIVISION 1.0 GENERAL 1.1 The Drawings, sheets 1 thru 8, shall be a part of this specification. 1.2 All materials and workmanship shall meet the requirements of the Municipality of Anchorage. Department of Health & Human Services (DtlHS), the conditloes of the permit, and all applicable rules and regulations currently in effect. 1.3 All elevations and depths are advisory and are be verified or modified in the field by a DHtIS approved inspector. to 1.4 It is the responsibility of 'the property owner or installer to adhere to approved designs for installation, to maintain the specified separation distances, and to have the appropriate inspections, 1.5 It is the responsibility of the property owner or installer to report to the engineer any observed conditions which would put tile system in violation of state or Municipal regulations. 1.6 If the installation is not inspected by an AECS engineer, AECS will not be responsible for the installed system. An engineer at AECS should be consulted prior to construction, to determine the number of inspections that will be required and to explain what these inspections will involve. 2.0 SEPTIC SYSTEM 2.1 The existing septic tank may be used, if it meets the capacity requirements for the residence and the approval of DHHS. Older systems may need tank integrity verified, If not, then specifications 2.2 through 2.6 apply. 2,2 The septic tank shall be a UPC-approved two-compartment tank, constructed of 12 gauge steel with bitumastic coating, set level on undisturbed soil and insu]ated with overlying layer of 2 inch burial type polystyrene. 2.3 The septic tank shall be a minimum of 5 feet from 141 ~ .W6St, -331~b ~vsi'K~e · .&ncho~aqe~ ~.[&gk ~F995 o:~'~ (9o 7~2¢~" 5555' 2.4 2.5 2.6 2.7 the house foundation, and a minimum of 5 feet from the absorption area. The septic tank and drainfield shall be a minimum of 100 feet from any private well or body of water, 150 feet from Class "C" wells, and 200 feet from Class "A" or "B" wells, unless otherwise specified. Less than the required separation distance must have prior approval or waiver by Alaska Department of Environmental Conservation (ADEC). Piping shall be fitted with a mechanical watertight calder coupling of the inlet and outlet of the septic tank. Piping shall be 4 inch ASTM D-3034 or cast iron, sloped a minimum of 1/4 inch per foot from the house to the tank and 1/8 inch per foot from the tank to the trench. Cleanouts shall be installed as designated, capped with air-tight rain caps (Jim Caps or equivalent), and extend a minimum of 2 feet above ground level. If a lift station is required, it shall be a combination lift station septic tank per Anchorage Tank and Welding, Inc. using an ORENCO lift station design. Specifications and design drawings are on file with tile Municipality and with the engineer. 3.0 DRAINFIELD 8.1 The gravel for the dralnfleld shall be 0,5 to 2.5 Inch, screened rock with less than 3 percent passing the No, 200 sieve. Al/ substitates must have prior DHHS approval. 3.2 The bottom and side of the excavation shall be raked with the backhoe blade to ensure that it has not been compacted during excavation. The bottom elevation shall be level. 3.3 Monitor standpipes(s) shall be placed as shown tn the drawings, and shall be rlgld PVC ASTM D-3034, or 4 lnch cast iron. The section shown with holes may be drilled 0.5 inch holes on the 6 inch centers on opposite sides of the pipe, or a regular section of perforated sewer pipe, clamped to a solid section, with either a no-hub coupllng or a solvent joint. The perforated section of the monitor tube shall be located in gravel only. A 3,4 3,5 3.6 3.7 rubber rain cap (Jim Cap or equivalent shall be placed over the top of the pipe. The distribution pipe shall be 4 inch rxgid PVC with a minimum crush strength of 1500 pounds or equal. If the system is a pressure distribution system see Section 5.0. All distribution pipes shall be laid level. If the final grade of the drainfteld is less than 4 feet from the gravel, insulation is required using burial type polystyrene rigid board insulation. There shall be 1 inch of insulation for every foot of soil less than the required 4 feet of cover, but there must be at least 18 Inches of soil cover even though insulation is used. The solid pipe extending from the septic tank or lift station to the drainfield shall also have a minimum of 4 feet of cover or an equivalent layer of Insulation to prevent freezing of the line. Filter fabric is required on top of rock. It is recommended that tile area excavated and the area in the vicinity of the drainfieid shall be planted with a white clover, red fescue mix, or with Kentucky bluegrass, 4.0 INSPECTIONS 4.1 A minimum of three inspections are required for installation of the trench. The first inspection will be of the excavation to verify that the installation will be in the proper soil. 4.3 The second inspection will be after placement of the gravel, monitor standpipe(s) and distribution pipe to verify proper installation before backfill. 4.3 The third inspection will be after final backfill, grading and seeding to ensure that adequate soil cover has been proved over the drainfield, 4,4 The inspection of tacorporated with inspections, the septic tank can be any one of the above listed The lift station will require either an MOA electrical inspection or certification by a licensed electrician depending on whether the building code applies to this part of tile city. 5.0 PRESSURE DISTRIBUTION SYSTEM 5.1 The lateral and header pipes are to be Schedule 40 PVC or ABS Jn the sizes indicated on the drawings. The laterals are to be level within plus or minus 1 inch. 5.3 All joints are to be solvent welded. 5.4 There shall be 2 inches of rock over the top of the headers and laterals. 5.5 The holes in the pipe are to be properly sized and spaced. 5.6 The holes shall be clean with no cuttings still attached to the pipe or left free inside the pipe. 5.7 Holes may be reverse beveled if it does not increase the outside hole size. ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 12OO West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 CHECKED BY DATE SCALE. SHEET NO. ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 CHECKED BY DATE DATE N ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 CALCULATED BY ~ ~'~ Ig DATE CHECKED BY SC^LE / '/~- ~O! DATE ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 CHECKED BY OATE m .11 0 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST P~R~O~MED POR: ~/o ~ / LEGA, DESCRmT~ON: [~ /~?~,~ 1 2 4- 5- 6- 8- 9- 10- 11 13- 14- 15- 16 17 18 19 20 COMMENTS SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? A, / s L IF YES, AT WHAT O DEPTR? p E Depth to Water AFter MonilarJflg? Z;, ,~, Date; Reading Date Gross Net Depth ~6~ Net Time Time Water(.~p) Drop PERCOLATION RATE z/ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ./. -.' FI AND f' ' FT PERFORMEDBY: L, /~:'~z~ , CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) Munlclpallly of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST pERFORMED fOR, LEGAL D~SCRIPTION; ~ ~-~-~- 3 4 5 6 7 8 9 10- 11 12 13 14 15 16 17- 18 19 2O DATE PERFOI Township, Range, Section:~'~¢ ~ 'T'J.5'/~_X~)' ~-/'¢~ SLOPE SITE PLAN WAS GROUND WATER Gross Net Depth to Net Reading Date Time Time Water Drop pERCOLATION RATE -~'/?/-- {minutes/inch) PERC HOLE DIAMETER -- TEST RUN BETWEEN -- FTAND -- FT pERFORMED BY: 9R(~ '~(~,O)~ ,., - ¢,,*4,..,, , ...... , ~L¢~8[ .... ~ I~ u~h~ ....... DATE. ~um&~F WITH AL ~'~ ~MUNICI~EGUIDELINES ACC ............ L.,~, ,,~J,~ 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: ,2 4- 5- 6 7 8 9 10 11 12 13 I6- 17- 18- 19- 20- DATE PERFORMED: Township, Range, Section:5¢¢ ~,, ¢"'"~¢-'~,/ SLOPE ~ITE PLAN IF YES, AT WHAT DEPTH? WAS GROUND WATER ~ ~) ENCOUNTERED? , E DepDi to Waler Afler ~donllerino? Dale: I Gross Net Depth to Net Reading Date Time Time Water Drop ! PERCOLATION RATE -~'~ (minutes/inch) PERC HOLE DIAMETER __ TEST RUN BETWEEN __FTAND FT COMME.TS e .=n;nnu~n Ry. t]R['~ t[]~)¢ (I / ~/ ~ t ~ CERTIFY THAT THIS TEST WAS PERFORMED IN kOOORDANOE WITH ALL ~'~'~NIOIPAL GUIDELINES IN EFFEOT ON THIS DATE. DATE: 72-008 (Rev. 4185) - DEWF. OF ENVIRONMENTAL CONSERVATION / ANCHORAGE/WESTERN DISTRICT OFFICE 437 'E' STREET, SUITE 303 ANCHORAGE, ALASKA 99501 STEVE COWPER, GOVERNOR 274-2533 December 11, 1986 Mr. Lou Butera, PE Eagle River Engineering Services, Inc. PO Box 773294 Eagle River, Alaska 99577 SUBJECT: Lots 19A & 19B, WOEBEGON SUBDIVISION Peters Creek, AK 8721-FA-072 Dear Lou: We have reviewed the plans ~nd specifications For the subject project and are hereby issuing this letter and a "Certi¢icate to Construct" which constitutes written approval required by A.S. 46.03.720(a) For construction oF the water system. Final approval will require the submission o¢ Engineered as-built plans. Inspection and sign oFF o¢ as-built plans shall be per¢ormed by a ProCessional Engineer registered in the State oF Alaska. Arrangements For this inspection work is the responsibility oF the developer. In addition, the owners signature, address and telephone number is required. The "CertiFicate to Operate" the water system will be issued when the Department has approved the applicant's as-built plans. Any Future expansion o¢ the subject project will require additional approval From this oFFice. All Cuture correspondence should include the above assigned project number, Sincerely, SWE:pkk ENCLOSURE ,.. STATE OF ALASKA "~-'-;;:,:' .":DbPARTMENT OF ENVIRONMENTAL CONSERVATION · ..'CONSTRUCTION 'AND OPERATION 'CERTIFICATE for ' ,' ' . , PUBLIC ~NATER SYSTEMS " ~APpROvAL TO CONSTRUCT Plans forth?construction'or modification of .~' ? public water System located ;' Alaska, submitted.in accordance with 18 AAC 80.100 -- · have been reviewed and are ';" ..... :--Bi conditionally approved (see attached conditions). ' BY ; * 4: ' ~,~ TITLE DATE ;,:,¢:.¢ -1-.-' ;.~". If constru~fioni~as ~ot ,~tar~ed within'two years of,,the.approval date, this certificate Is void and new plans and · - ,,,- ...... speclflce-tlons?mUst be submitted for review and approval before construction. 'APPROVED CHANGE ORDERS Approved by Date Change (co~(ract order no. or descriptive Ceference~ C. _.APPROVAL TO OPERATE : The '.'APPROVAL TO OPERATE".,section must be comoleted and signed by the Department before any water ~. ,r [s m~de ava[lable to the public, ?,:'.:~ ~ :~..:~, . '::.' ,i'-;':'*:.The ~0"~i'ructlon o~ the ' ,:~.?...';~? 2;.:,.-..:,:', '.::..~ -- plated on ,; ran'(ed I'n'terfm approval't'6 ~)pei'ate for 90 days following the completion date. public ^ (date). The system is hereby ' · "BY TITLE DATE =.':'~-- ~:.,. ,;As-built plans submitted durin~ the interim approval ~er[od, or an inspection by the Department, has confirmed '~t:' -;': ";' the system was constructed accord[n§ to the approved plans. The system is hereby granted final approval to \ TITLE DATE OISTRIBUTION: 1.'WHITE - ENGINEER (Complete Section C) 2. YELLOW - WATER SYSTEM FILE (Complete Secllon C) 3. PINK · ENGINEEPJMUNI.SOROUGH (Cornple[e Section C) 4, GOLDENROD · MUNI.SOROUGH (Complete Section A)  Munic, lpality of Anchorage REOUES? FOR VOUCHER CHECK FROM: TO: DATE: 1. Health and Human Services (DEPARTMENT) MUNICIPAL CONTROLLER CHECK NO.. November 20, 199~ REQUEST THAT A MUN C pALITY OF ANCHORAGE CHECK BE ISSUED TO: R 82262 I THIS SECTION FOR ACCOUNTS PAYABLE USE ONLY 1099 VOUCHER NO. PAYMENTDT.. V VENDOR NO. REFERENCE NO, E DATE INVOICE NO, OATE PREP APPR Name Eagle River Engineering Services Address PO Box 773294 Eagle River, Alaska 99577 THIS PAYMENTIS FOR THE FOLLOWING (SUBSTANTIATION ATTACHED): The engineering f~rm for this property called (11-20-97) and requested that the Health Authority Approval for this property be pulled f~om review. Please refund the fee of $300.00 to the above firm. Thank you. Lot 19A Woebegon Subdivision 3, DIsPOSmON OF CHECK: (1) x:~x MAIL TO PAYEE (2) [] MAILTO PAYEE WITH ATTACHMENT (3) [~ NOTIFY PAYEE TO PICK UP IN TREASURY Phone #: (0) © Name:. Org. #: · ~'UTHORIZED USE ONLY NOTIFY DEPARTMENT EMPLOYEE WHEN CHECK IS READY IN FINANCE Phone #: 4. ACCOUNTS TO BE CHARGED: DESCRIPTION ENTER ALL POSITIONS OF ACCOUNTING DISTRIBUTION Org/CC Acct/ObJ AMOUNT 300.00 $ 300.00 5. TOTAL AMOUNT OF CHECK 6. SIGNATURES ~'~_ . ~,, Cvs. ~ Employee Phone N o~' (~ 7. INSTRUCTIONS 40-001 (Rev. 11194)~ ARproving Authority To be used only when payment cannot be made by purchase order, travel expense report, travel authorization or petty cash. Mq~! be approved by depcrtment head unless approval authority is delegated in accordance with Policy and Procedure 24-7. Retain. carbon copy foil your file. DEPARTMENT Of HEALTH AND H.U, M, AN SERVICES E n v i r OTner~eepnl~oa In eS..e;~,i:~.e4s7 ~)~,v,sion ON-SITE SERVICES FEE DOCUMENTATION OS- 03368 Date Paid: ('-x~(.~ -, \o~ \.~I"} Permit Number: Name of Pay!ar,; (Name on Check) M,ai, ling/~ldress: (Off of check) Legal Description(s): Sewer & Well Permit: Well Permit: Sewer Permit: Copy Request: 72-034 (Rev. 10/87) Type of Payment: (Indicate Amount Paid) Health Authority: ~ Excavator Permit: Engineer Permit: Pumper Permit: Well Driller Permit: Tank Manufacturer: (Waste Treatment) DISTRIBUTION: WAIVERS: Lot Line: Well to Tank: Well to Field Field to Surface Water Tank to Surface Water WHITE--MASTER FILE CANARY--PROGRAM FILE STATE OF ALASKA DEPARTM: DF ENVIRONMENTAL OONSERVATION APPROVAL OF ON.glTE RESIDENTIAL WATER AND SEWER SYSTEMS PROPERTY DESCRIPTION This approval does not constitute a guarantee of any kind, expttoit or Implied, as to the performance of the water supply and waetawater disposal systems. WATER SUPPLY A resent water sample was tested and found to meat DapartmaJ~t of Environmental ConServation ~ ~' '? f~tle J Dam' j" I"?W .m . ..- ~. ~,~ ....... , ,, drink. WASTEWATER DISPOSAL The domestlo wastewater'eystam was: ', [] Inspeoted by the Department of Environmental'6?nservatlsn and'{,ound to b~' In tempi anco with aPi~llcabls requirements of lB AAC 72; , ,/ X / ' ~ Inspeoi~d by a Professional En'~lneer who oertlfla~hat tho system o~p'llea with a~plloable re. qulrameh~ of I~/AAC 72 Xx .~ '~ ,'- ~ Installed by'~.Certlfled Installer wh~[ertJfJe~ th~t'the ayst~ oompllo~ ~th a~lJog~le requlrement~ of lB AAO 7,~or x. /¢ % / ~ te~ted by'a Professional Engineer wg~b~.[tlfles that the performance of th~ system I~ ~atlofaotory ~nd th~lthe ~yst~ oornpJlea wltWthe m~lmum aeparaUon d~nces.'~peolflod In 18 AAO 72. Th~ lpprov~ ~va d~a ~.~nglef~mll nultlfamlly~itwl tel of bedroome,~ ~a.o4o4 (Riv, 818~i DISTRIBUTION[ WHITE--BANK/LENDING INSTITUTION; CANARY--APP[ ICANT; PINK--DEPARTMeNTS DEWT. OF ENVIRONMENTAl, CONSEI[VATION ANCHORAGE DISTRICT OFFICE 800 E. DIMOND BLVD,, SUITE 3-470 ANCHORAGE, ALASKA 99§03 (907) 349-7755 August17,1993 Mr. Joel J. Babb Joel J. Babb & Co., inc. P,O, Box 774233 Eagle River, Alaska 99,577 Subject: Lots 19A & 19B Woebegon Subdivision, Blrchwood, Alaska, Class C Public Water System, PWSID Number 216790 ADEO Project Number 9421-DW-228-031~ Review Dear Mr. Babb: This letter Is in response to your August 15, 1993 fax In which you requested that the April 13, 1993 "Boll Water Notice" be lifted and a current compliance certificate for the existing water system be issued, I have reviewed the submitted anal~ical results and find that the requirements noted in my April 13, 1993 letter have been met, Thus, the BOil Water Notice Is now Invalid, The Department is no longer requiring that all water be boiled prior tO use. With regards to the Issuance of a ourrent compliance certificate, I have reviewed the results of all the samples collected from the existing Class C Public Water System, Results from the recent water samples were satlsfaC[ory for total coliform bacteria and the results of r~y sampling event verify that the water is satisfactory for nitrate (as nitrogen), Therefore, for the concerns of this Department, this system Is in compliance with State of AlaSka Drinking Water Regulations (18 AAC 80). Attached is an "Approval of On. Site Residential Water and Sewer Systems" certificate verifying the existing Class C Public Water System compliance. Thank you for your cooperation and coordination with this Department, As noted In the Department's August 6, 1993 letter, If the proposed well is Installed, all items of the letter w{ll need to be met, If you have any questions, please do not hesitate to contact me. Sincerely, Keven K Kleweno, P,E, District Engineer EnClosure: As Stated KKK/cf -181?...( s • • pTGS e4 Municipality of Anchorage On-Site Water and Wastewater Program oil (907) 343-7904 s. F ETY Certificate of On-Site Systems Approval Parcel I.D. 051-032-44 Expiration Date: l - l S 1. GENERAL INFORMATION Complete legal description Woebegon Lot 19A-1 Location (site address) 22533 Davidson Circle Current Property owner(s) US Bank Day phone Mailing address 6200 Park Ave, DeMoines, IA 50321 Real Estate Agent Day phone 2. TYPE OF DWELLING: Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Q Individual El Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received is " , �� Date: ll COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ ace;, --1-4316 Waiver Fee $ Date of Payment (0 � - Date of Payment Receipt Number C `S4D(p Receipt Number COSA# O C-\ t 212- Waiver# 4 1 .M'., ;.......W 5. STATEMENT OF INSPECTS BY ENGINEER 1 .' `. As certified by my seal affixed hereto and di the v lidation date sown below, I rify 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. In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations.The reported results describe 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 soil condition,ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system.The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone, P.E. Date 6/14/2018 �� OF AL,�sl�a� Ta r*. - • TM i\ •* / 6. DSD SIGNATURE % 1 -\e 4. System #1 Approved for ��.a.bedrooms j .S}even R. .-----j"•nnone: / -V.% CE-8149 ••,,��� System #2 Approved for bedrooms 9� 4, �r Disapproved 1 vNNNI Conditional approval for bedrooms, with the following stipulations: � _- I .eatrS 01—b ` �� {4 .P 1)t q S- I S E-p-�s �� k N 2_0-yr 0Lb .�•. Ot- Aix., t?"`,- 'r --.,-• 's \NPS G" ,M Ce..----( Original Certificate Date: to -1 S .-I c 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' \ amk COSA blue sheet r '- c If more than 1 septic system is on the lot: COSA Checklist# 1 of 1 Structure served by this system 1 Certificate of On-Site Systems Approval Checklist Legal Description: Woebegon Lot 19A-1 Parcel ID:051-03244 A. WELL DATA Well type P(Old Class C) If A, B, or C provide PWSID# Well Log (Y/N) Date completed Sanitary seal (Y/N) Y Wires properly protected (Y/N) Total depth ft. Cased to ft. Casing height(above ground) 12 in. FROM WELL LOG AT INSPECTION Date of test N/A Static water level ft. ft. Well production g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 2.7 mg/L Arsenic NDug/L Date of sample: 6/7/18&6/11/18 Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 12/1/90 Tank size 1250gal. Number of Compartments 2 Cleanouts(Y/N) Y Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 6/6/18/ Pumper ir'S — C. ABSORPTION FIELD DATA Date installed 12/1/90 Soil rating (g.p.d./ft2 or ft2/bdrm) 1 .2 System type W-trench Length 54 ft. Width 5 ft. Gravel below pipe 3.5 ft. Total depth 6.8 ft. Eff. absorption area 500 ft2 Monitoring tube Y Depression over field N Date of adequacy test 6/7/18 Results(Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 3 in. Water added 450 gal. New depth 10 in. Elapsed Time: 360 min. Final fluid depth 3 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment(past 12 mo.) (Y/N &type) n If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100+ On adjacent lots 100+ Absorption field on lot 100+ On adjacent lots 100+ Public sewer main 75+ Public sewer manhole/cleanout 100+ Sewer/septic service line 25+ Holding tank 100+ Animal containment areas 50+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10+ Property line 5+ Absorption field 5+ Water main 10+ Water service line 10+ Surface water 100+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water main 10+ Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS Field was presoaked IAW code. G. ENGINEER'S CERTIFICATION 4,- OF �. 1 •,Q )4 I certify that I have determined through field inspections and j g'�.•• � .y��� review of Municipal records that the above systems are in *; • 4.\ * r conformance with MOA COSA guidelines in effect on this date. / Engineer's Printed Name Steven R. Pannone, P.E. -#••:Sieveri i. Pannone:••# Date 6/14/18 04:-.. CE-8149 ' COSA canary sheet_2-6-15.doc M 8473Y oo ORIGINAL AVENUE — o o M 0..) ``' N89°59'48"E 20.06 0 Q-///3D 10' T & E Easement "� °o;f r \ Gravel driveway 0 40.0 80.1 - 30 \ a; ro - - - > vt \` Gara9e o O .._ — -m — — 40,0 c', -4' 1 o 1111111- Z4 128.7 28.0 Lot 19A-1 co (I) aa) w Same °'House o /CO `,\\�$ L.11Q N with \ N ca W Basement { shed I -Septic vent M 0 o 28.0 1 Ow co o ors oo Lot 18 T0 O ~ hed U) Z o 10' x 10' Well Easement c ((Book 02296 pg 055) 30 lass C Well - 30.24 1 ° 1 I S89°51'47"W 299.92 Lot 19B 1 AS-BUILT NO CORNERS SET THIS DATE �1/4.XNN.,4,1 t I hereby certify that I have performed a Mortgagee's inspection OF /� ' of the following described property: LOT 19A-1, i�P,,:„ • • ' ' '; �;q�,>n, WOEBEGON SUBDIVISION • ov49th %N 4.,I Anchorage Recording District,Alaska,and that the � ' �.. .,. improvements situated thereon are within the property lines /N' A ... . and do not overlap or encroach on the property tying j adjacent thereto,that no improvements on the property lying c •Brett A. ilmot ,, / adjacent thereto encroach on the premises in question and SCALE: 1 40' s .,:t-l',..,... that there are no roadways,transmission lines or other - r 112392 LS �, ��F•' • .• hvisible easements on said property except as indicated 1 Opp ' • • • ' •�10 hereon. I 1 °FE-ssio k- Dated at Anchorage,Alaska EASEMENTS OF RECORD, OTHER THAN 1\%XN.N. this 6th day of JUNE ,2018. THOSE SHOWN ON THE RECORDED /•,..'. �f" FRED WALATKA&ASSOCIATES,L.L.C. PLAT ARE NOT SHOWN HEREON. Le.. Engineers and Surveyors UNLESS OTHERWISE NOTED FB 18-2, pg 72 BE 907-248-1666 MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT i • eft�"rl 907-343-7904 On-Site Water and Wastewater Section Fax:Fax: 343-7997 www.muni.org/onsite Septic Tank Advisory Certificate of On-Site Systems Approval # OSC181272 Subdivision: Woebegon, Lot: 19A-1 The septic tank for this property is 28 years old. The average life for a steel septic tank is 20 years. Typical replacement costs range from $6,000 to $9,000. This advisory must be attached to all copies of the subject Certificate of On-Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. 0 f ' , . .. , J t.,,,...,-,..F,$ �5f"� ' 41'4,, _,.• �3 * 1~ , te ` su.wR :� � )- ; *,,ak . Sultat ' '4 .tirir.'..:*''''i.14?': -,..1:''''.1-24.1.'' '''''' ' ,.;;;I'''-'-'•••.::;- . LIIPICA--4....454!.. 'ili. ^:::*tl'-'71.-.%. z-.'_%,-. - < I .:4,..' S s ''i s . .#h+ns ,gam e., ,c 0' 0. 4 `� .fix: .y :" �fi..t, .'k� 1�. '' p '£di•777RRR a. �'� ii,.."; �� ate'' x a 'A.',. 2018e. 4 D ,N6 Y o'er Mailing Address: P. O. Box 196650* Anchorage,Alaska 99519-6650 *www.muni.org MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services SectiOn P.O. Box 196650 AnchOrage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ParcelI.D.#_os1 ~32 3R -v 1. GENERAL INFORMATION Complete legal description WOEBEGON, LOT 19A Location (site address or dimctions) 22533 DAVIDSON DRIVE Property owner Mailing address Lending agency Mailing address Agent Address JOEL J. BABB P.O. BOX 774233 LES BAILEY Dayphone 689-6464 EAGLE RIVER, AK 99577 Day phone _ Day phone 2, 3. Unless otherwise requested, HAA will be held for pickup. , _ Community well Public water fl~ ~"~-' ~ NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site 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. 72-025 (Rev. 1/91) Front MOA~I 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 inves_ti_gation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ]~a~]e ];~d. ver En~Jneer~]l~ Sez'vJces Phone 694-5195 P.O. Box 773294~, Eagle River, AK 99577-3294 Address Engineer's signature Date 11-18-97 DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. with the following stipulations: Additional Comments By: Date The Munic )rage Department of Health and Human Services (DHHS) issues Health Authority Approval 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, Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division NOV 1 8 1997 825 L Street, Room 502. Anchorage, Alaska 99501. (9~-,~'~i~7~4Ancho,'age Dept. Health & Haman Services Health Authority Approval Checklist Legal Description: ~,¢ ~/2',,'¢ /-'¢'/'¢¢~ ~,.F d.'-,/ Parcel I.D.: ~.~' ,/-. dj .~.- - %¢ A. WELL DATA Well type ~__.~.r'..,' ~' Sanitary seal (Y/N) ~ Date of tk Static water !~l Well production If A, B, or C, attach ADEC letter. ADEC water system number WATER SAMPLE RESULTS: Coliform ~ / Date of sample: Date completed Cased to FROM WELL LOG g.p.m. Nitrate AT INSPECTION \ ¢1,, / ~./_/4. Other bacteria Collected by: ~,,~¢; J- g,p.m, B. SEPTIC/HOLDING TANK DATA Date installed /;t/¢',¢ Tank size Foundation cleanout (Y/N) Date of Pumping 11/1~17/~ C. ABSORPTION FIELD DATA Date installed /A/5' c~ Length ~4~¢ ' Width Depression (Y/N) A/ High water alarm (Y/N) Pumper (,T-/~,~ Number of Compartments '-~ Cleanouts (Y/N)__ Soil rating (g.p.d./fF or fF/bdrm) /, .2 o"/~,X/' System type 5-/ Effective absorption area Gravel thickness below pipe ~,--¢- ' Total depth 0'".5- / Monitoring Tube present (Y/N) ~ Depression over field (Y/N) //"/ Date of adequacy test //-/-~- - ? 7 Fluid depth in absorption field before test (in.); Fluid depth. ~ //(ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) Results (Pass/Fail) /~.r.r For /7" bedrooms Immediately after-~'~¢ gal. water added (in.): .CZ)/~ Absorption rate = ~'- /¢,.¢-0 g.p.d. If yes, give date 72-026 (Rev. 3/96)* D. LIFT STA'~N Date installed',~ Manhole/A~ High water alarm Cycles tested E, SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot On adjacent lots On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer/septic service line ¢' ~'s- / Lift station /./ /.4 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation .5'~' / Water main/service line ~'¢ ' Property line 5-¢ / Surface water/drainage Absorption field Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Properly line _~c~ / Building foundation '7,¢ ' Water main/service line Surface water ¢/,¢~ ' Driveway, parking/vehicle storage area 7~' / Curtain drain H I^ Wells on adjacent lots ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections in conformance with MOA HAA guidelines in effect on this date. Signature ~ Engineer's Name Date 2/- /~ - 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 C~RTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ~"')~ \ - f~) '~3 ~- ~ .'% ~ HAA# ~'~ ~0~, ~"~ ('~ -~ ~L~ 1. GENERALINFORMATION Completelegaldescription Woebegon, LOtL19A Location (site address or directions) NHN Davidson Drive, Chugiak Property owner Joel Babb Mailing address ~le R±ver, AK Lending agency N/A Mailing address Day phone 694-6685 99577 Day phone Agent N/A Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well Community well × Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: x If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev 1/91) Front MOA~21 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. Eagle River Engineering Services Phone 694-5195 Box 773294, Eagle River, AK 99577 Name of Firm Address P.O. Engineer's signature DHHS SIGNATURE 4 /~'/" Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: 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. Em ployees 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. /2-025 (Rev. 4/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~.,/¢b;&E.~o/'.-/ /0'7-/(~ Parcel I,D, A. WELL DATA Well type C~ If A, B, or C, attach ADEC letter. ADEC water system number ~/~ ¢ ¢~ Log present (Y/N) Date completed Driller Total depth__Cased to .~.~g.h el~h~ Sanitary seal (Y/N) Wires proper~/-p~tected (Y/N) FROM WELL I. OG~ AT INSPECTION i!i!~ii!~tr lev el ~/~,,....- SEPARATION DISTANCES FROM WELL TO: g,p,m. Septic/he~d:i~g tank on lot ; On adjacent lots Absorption field on lot Public sewer main Public sewer service line WATER SAMPLE RES Coliform Nitrate Date of ~ B. SEPTIC/HOL-DiNG TANK DATA Date installed /.Z/¢O Cleanouts (YIN) Tank size Petroleum tank ; On adj~jccef~ots'~ Pu blic..seW~er man hole/clean out Other bacteria Collected by: ./?.~ Foundation cleanout (Y/N) Alarm tested (Y/N) High water alarm (Y/N) ¢// ' Date of pumping E) ¢.~ ~'~ SEPARATION DISTANCES FROM SEPTIC/~G TANK TO: Compartments Depression (Y/N) Well(s) on lot / 5~' ! On adjacent lots To property line ¢~/~ Absorption field Surface wate r/d raj n age ./Y'/~i Foundation ~ ~ / Water mafnCservice line ¢~/ 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N)~~ SEPARATION DIST~JM4~E FROM LIFT STATION TO: Well on_~t~ On adjacent lots "Pump on" level at ~ Cycles tested D. ABSORPTION FIELD DATA Date installed ,/ Length ~' Width ~' / Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Manufacturer Manhole/Access (Y~ · ----"~"'~"Pu mp off" level at Surface water Soil rating /' ~' (~?/,2./~ System type Gravel thickness --~, ~ ' Total depth Cleanouts present (Y/N) Date ofadequacy test ¢~'/.~//¢"~ ~,a~o~ -i' ~/zy' ,, f,~ ztt-~5 ',.t-ct for if yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / To building foundation On adjacent lots Surface water /'.//..4 Curtain drain /~/~ On adjacent lots /' /DO / Property line .~O / "~(..3 ' To existing or abandoned system on lot ~//~ _Cutbank /"//.4 Water mamlservice line //D / 75/ Driveway, parldng/vehicle storage area bedrooms E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect ~2~8,d,a~e of this inspection. ,, Signature -' ~~ ~ t49~ ~*~ Engineer's Name DOO/5 ~0¢~. A~, ~ ~~ · ~ HAA Fee $ ~ ' ~ Waiver Fee: $ Date of Payment ~-' / ~ ~ ~ Oato of ~aymont Receipt Number ~ r/O ~ F? ~¢~) Receipt Number