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Home My WebLink AboutSUNDI LAKE BLK 1 LT 1 ®evelopment Services ®epartment Building Safety ®ivision ®n 4 Sire Water A WasTewa Ter ProgramAIV 4700 Elmore Road r P.O. Box 196650 E T Y MarkBegieh Anchorage, AK 99507 s " Mayor www.muni.org/onsite (907)343-7904 Pump hstaft%on Log Well Drilling Permit Number: SW Date of Issue: Parcel Identification Number: 9 Legal Description Property Owner blame & Address: 834-7 Sand% D�,�e- SoZ Pump Installation Date: 3-14— Pump _l4_Pump Intake Depth ]Below Top of Well Casing: o 0 feet Pump Manufacturer's Name: Pump Model: S'o C- 3 11 - $ 512 Pump Size /'— hp Pitless Adapter Burial Depth: 7 feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Completion? X1 Yes ❑ No Method of Disinfection: -i I I +3 Comments: Pump Installer Name: ANCHORAGE WELL & PUMP SERV. 330 EAST 76 AVENUE ANCHORAGE, AK 99518 PHONE: 907-243-0740 AWPS.COM Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. Municipality of Anchorage Page 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: ECt,/,/~ ~(~ '~ PID Number: ~m~: ~_~; ~ Kt~¢'~ Wastewater System: D New ~Upgrade Address; ~'~ ~[~ ~ ~ ~ ~ ~-l~ ABSORPTION FIELD Phone: Nc. of Bedrooms: ~Deep Trench B Shallow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: Lot: Block: Subdiv~ion: Depth t0 pipe bottom from original grade: Gravel depth beneath pipe Township:II Range: Section: Fill added abovej ~~original grade: Ft. WELL: B New ~ Upgrade ~ravelwidth: ~ ~ ~ Ft. Number of lines:~ Distsncebe~eenli~es:.~ Ft. Classification (Private, A,B,C): ~tal Depth: Cased TO: Total absorption area: Pipe material: Yield: Casing Height Above Ground: ~EPARATION DISTANCES ~ Septic U Holding gS.T.E.P. To Septic Absorption Lift Holding =ubl[c/Pdvat~ Manuf8cturer: Capacityin gagons: From T~nk Field Station Tank Sewer Lines ~ ~ ~. ~ ~ ~ w.ir I¢ d ~ID ¢¢~ ~ Materi~l: % 'T ~ C~ Number of Com~ment,: Sudace Water ¢~0 y~ LIFT STATION "Pump on" level at: "Pump off" level at: P~mp Make & Model I Electrical Inspections pedormed by: Cu~ain ~ Remarks: BENCH MARK Location and Description: I A~umed Elevation: ENGINEER'S SEAL Inspections pedormed by: ( Dates: 1st ~ " Depa~ment of Health and Human Se~ices approval 72-013 (Rev. 9/91) MOA 25 ~ 1500 COVER SWING TIES: AC 70.5 FT 88 78.5 OF 26 E£ 22.5 TS TOTAL LENGTH 44 FT ABANDONED OLD TANK Ii PLACE, TOTAL DEPTH 11 FT EFFECTIVE ROCK G. 5 FT COVER 5.5 FT 100 125 150 BENCH t#ARK: GARAGE SLAB ASSUktED ELEVATION lO0. O0 FT TOBBEN SPURKLAND P.E. 205 W ISTH. AVENUE ANON. AK. 99501 (907) 279-5916 [ SUNDI LAKE BLOCK 1 8547 SUNDI DRIVE CEDRIC NORTH LOT i SEPTIC SYSTEM AS BUILT DATE: JUNE I1, 1999 sHEET: 2/5 GRID: 2224 PERMIT # 214990030 PID # 011 13! 01 SDLOIO1R, D~/5 PRIMARY TRENCH o I £tondord ?mench: £' Wide 4'I' Long 9,5' ,Beep 6.5' Sewer rock £' Cover INSULATED NB ££ALE Ploni~om £' Corem INSULATED I01~ 91.5 6,5 Et o£ Septic t~ocl< Effective NL7 ££ALE ol !500 5AL STEP TANK 91.5 1500 5AL ~TEP TANk' TI3BBEN SPURKLAN]3 P.E. I I BO3 W151:h Ave Anchor'o, ge Ak 99501 SUNDI LAKE S/D LOT I BLOCK i ~pfilC SEPTIC SYSTEH DESIGN DaTE~ JUNE 11, i~99 SHEET~ ~/3 GRID: ~4 SW990050 PARCEL ID // 011-131-01 SDLOIOiS. DWG MUNICIPALITY OF ANCHORAGE Deparfment of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box '196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Mar 10, 1999 Expiration Date: Mar 09, 2000 Permit Number: SW990030 Legal Description: SUNDI LAKE BLK 1 LT 1 Design Engineer: 0007 Tobben Spurkland, PE Owner Name: Cedric North Owner Address: 8347 SUNDI DRIVE ANCHORAGE , AK 99502-4148 Parcel ID: 011-131-01 Site Address: 008347 SUNDI DR Lot Size: 14100 SQ. FT. Total Bedrooms: 4 Permit Bedrooms; 4 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AACSO ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASIC4. 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 1 BLOCK 1 SUNDI LAKE S/D CEDRIC NORTH Municipality of Anchorage Department of Health and Social Services 820 1 Street Anchorage, Alaska 99501 January 5, 1999 We are submitting an application for the upgrade of the septic system for this lot. The submittal consists of ttu'ee (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the septic system is subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following: No Ground Water or Impervious Layer to 24 ft. Use Standard Trench with STEP tank Soil Rating. From Testhole 11/10/98 <1 min/in = 1.2 gal pet' sq.ft/day No. of Bedrooms 4 Required Area per Bedroom: 150/1.2 = 125 sq.ft. Total area required: 125 x 4 = 500 sqft Testhole depth 17 feet Bottom Rock At 11 feet Top Rock At 4 feet Rock Depth 7 feet TotalTrench Lengtb 500 / 14 - 35.7 ft. USE 40 LF SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 40 FT TOTAL WIDTH 2 FT TOTAL DEPTH 11 FT ROCK DEPTH 7 FT COVER 4 FT SEPTIC TANK 1500 GAL STEP The installation of this septic system will not prevent wells from being installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on tl~is or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Munlcll;,alJty el Anchorage DEPARTMENT OF '~EALTH & HUMAN SERVICES 825 '~L" Street, Ao~:horage, Alaska 99502-0650 SOILS LOG- PERCOLATION TEST LEGAL " (ENGI~E£R'S SEAL ~,, DATE E ORMEO: "l,o/q Township, Range, Section: SLOPE SITE PLAN W~%GROUNDWATER E' COUNTERED? IF 'r'ES, AT WHAT Peading Date Gross Net Depth to Net Time Time Water Drop E !;~COLATION RATE ~. (m~tl~ eshnch) PERC HOLE DIAMETER TIL~TRUNE~ETWEEN FTAND FT ~"~ ~ /~ DISCLAIMFR: Grn~ndwater (~f~ndition~ indicate,~ are for the dates ~hown only. Past and future presence aod/or depth of groundwater can not be predicted ' ~rom these ooser~a~lons. PERFORMED BY: I ~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANC~WITHALLSTAT~ANDMUNICIPALGUJEELINESINEFFECTONTHiSDATE. DATE: J ~/~0/~ ~ ~ LL~T CLASS 'A~ I,/ELL NZ7 WELL N 50 100 151) 200 ££ALE: I' = 1.00 FT, Lfl __ 50 100 150 000 SCALE: 1' = !00 FL JTOBBEN SPURI(LAND P.E. 205 W ISTH. AVENUE ANCH. AK. 99501 (907) 279-$916 PERMIT # S~/9900XX [ SUND1 LAK£ BLOCI( I LOT 8547 SUNDI DRIVE CEDERIC NORTH SEPTIC SYSTEM DESIGN DATE: DEC. 30, 1998 SHEET,' I/5 GRID: 2224 PID # 011-13i-0I SDLOlOll, Db/6 1500 STANDARD TOTAL LEN6TH 40 TOTAL DEPTH 11 FT EFFECTIVE £OCK 7 FT COVER $,5 FT 25 0 25 50 75 100 125 150 SCALE; U = SO FL TOBBEN SPURKLAND P.E. 203 W 15TN. AVENUE ANCH. Al(. 9950! (907) 279-,3916 SUNDI LAKE BLOCIf 1 8547 SUNO/ DRIVE £EDRIC NORTH LOT 1 SEPTIC SYSTEM DESIGN DATE: DEC. 30, 1998 SHEEL' 2/5 GRID: 2224 PEt~iVlT # S~/9900XX PID # Oll 131 Oi £DLOIOI~.D~/G o I Standard Trench; ~' Wide 40' L on9 11' Deep ZO' Server mac/< 3,,~' Cover NB ££ALE 1,500 GAL STEP TANK ?,0 Pt of' Septic Effective ND SCALE ]500 GAL STEP TANK T~BBEN SPURKLAND P,E, 203 \415th Ave Anchorage Ak 99501 SUN])/ £AI(E S/D LOT I BLOCK i DATE: JAN, 5, 1999 SHEET, GRID, ~2~4 PERMIT ff SW9900XX PARCEL ID ff 011-131-01 SDLOIOI$.DWC Rick Mystrom. Mayor Municipality of Anchorage Department of Health and Human Services 825 "L" Street P,O. Box 196650 Anchorage, Alaska 99519-6650 ht~p://www.ci.anchorage,ak.us Tobben Spur~and, PE 203West 15thAvenue, Suite 203 Anchorage, AK 99501-0000 July 22, 1999 Subject: Waiver Request for SUNDI LAKE BLK 1 LT 1 Waiver # WR990041 Lot Line Request for Parcel ID 011-131-01 Dear Engineer: Your request for a waiver of the required 10 feet horizontal separation of the on-site wastewater disposal system to the lot line has been approved. The approved separation distance is 3 feet. This waiver approval applies to the current on-site wastewater disposal system and lot line separation only. Any future upgrade to the on-site wastewater disposal system and lot line will require all separation distances to be met or another waiver approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely'6~2~~ ,[eft'Poet Engineering Technician III On-Site Water Quality Program MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet Date Received: July 9, 1999 HA~ Permit ~ SW990030 Legal Description: Lot 1 Block 1 Sundi Lake Subdivision Engineer: Tobben Spurkland, PE 203 West 15th Avenue~ Suite 203~ Anchorage. Alaska 99501 Applicant: Cedric North Waiver Requested: Lot line waiver from the on-site septic tank and dratnfield to the north property line. . ) Criteria: 2. 1. Geology: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: Special Conditions: Points: 3. Other: Waiver is Granted: Waiver List Conditions or Reasons for above: is NOT Granted: Date: Rec ~: 05060/649i Amount: By: 115.00 Name of Reviewer Date Paid: July 9. 1999 T.SPURKLAND P.E. 203 W. 15th. AVE. SUITE 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 Municipality of Anchorage Department of Health and Social Services 825 L Street Anchorage, Alaska 99501 Subject: Lot Line Waiver Request Sundi Lake S/D 011~131-01 Gentlemen; July 9, 1999 RECEIVED JUL 9 1999 Mumoq)ahty ct Anchorage Oept. Health & Human Services Due to space restrictions we request a lot line waiver for both the tank and the drain field installed on this lot on May 21, 1999. A check in the amount of$115.00 is enclosed. Yours i~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF FIEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ' PHONE NAME ~;...,ERMIT APPLICANT: C & J EXCAVATING ~'NEW MAILING ADDRESS LEGAL D~SC~I~TION LOCATION NO. OF BEDROOMS ~ DISTANCE TO: /~/ / ~/ PERMIT'NO. Manufacturer Ma~ / No. of compartments ~ Liq, capacity in gallons Inside length Width Liquid depth /Z ~/2 IF HOMEMADE: ~ ~ DISTANOE TO: We~ Dwelling~ PERMIT NO. O ~ ~ Manufaoturer ~ Material Liquid oap~city in gallons ~ Well Found~o~ Nearest lot ~ine PERMIT NO. -- No. of lines / ~O~ ,~' ~ )riches OTHER MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage. A~aska 99501 264-4720 SOILS LOG- PERCOLATION TEST {~ SOILS LOG [] PERCOLATION TEST SLOPE SITE PLAN 11 15 16- 17- 18- 19- 20- COMMENTS IF YES, AT WHAT (~ ~/' ""/2.~ OEPTH? WAS GROUND WATER ~S ENCOUNTERED? ~.)_ ~ E Reading Date Gross Net Depth to Net Time Time Water Drop PERFORMED BY: 72-008 (6/79) 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 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Day phone Lending agency Mailin. g address Agent ~ 12./x Address" Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: NOTE: Day phone Day phone Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. NOTE: 72-025 (Rev, 1/91) Front MOAt¢21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation 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. Name of Firm '"~ ~b-,~ ~t Address o¢0_~ Engineer's signature Phone Date DHHS SIGNATURE V'~ Approved for Disapproved. bedrooms. __ Conditional approval for bedrooms, with th-e following stipulations: Additional Comments 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 DH HS 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. CEIVI:L, Municipality of AnchorageJUL DEPARTMENT OF HEALTH & HUMAN SERVICES .... MUNICIP/S, LIIY OF ANCHO~ Environmental Services IJIVlelon 825 L Street, Room 502. Anchorage, Alaska 99501.~,,~,,D,~,,~,, ~c~ Health Authority Approval Checklist LegalDescription: L0'TI~ ~,l,r'...~{ ~u.~.~_~ J..~//~.~J~ Parce D.: ~l/- 1'%1- 4) 1 A. WELL DATA Well type ~'~ Log present (Y/N) Total depth Sanitary seal (Y/N', If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to /~O [ Casing height (above ground) ~/ Wires properly protected (Y/N) "'/ / FROM WELL LOG AT INSPECTION Date of test Static water level Well production WATER SAMPLE RESULTS: Co,farm Date of sample: Nitrate ~ ~ Other bacteria Collected by: J B. SEPTIC/HOLDING TANK DATA Date installed ~ Tanksize /~'~D Number of Compartments ~ Cleanouts (Y/N) . Foundation cleanout (Y/N) ~'/Y~,,;'4'/~ Depression (Y/N) ~ High water alarm (Y/N) Y Date of Pumping ~"///~ Pumper I'~./~. Y C. ABSORPTION FIELD DATA Date installed //~,~ Soilrating (g.p.d./ft~orft~/bdrm) / ~ Systemtype /~ Length J/~Y Width ,-~ Gravel thickness below pipe ~.-~ Total depth Effective absorption area ~ Monitoring Tube present (Y/N).__~//__ Depression over field (Y/N) Date of adequacy test '-//,A Results (Pass/Pail) '-~ For J'-/ bedrooms ( Fluid depth in absorption field before test (in.); ' /~ Immediately after ~gal. water added (in.): Fluid depth t./ (ins) Minutes later:. ~ Absorption rate = ~ g.p.d. Peroxide treatment (past 12 months) (Y/N) L.~ if yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) ~'"/ High water alarm level at* Cycles tested Size in gallons / "Pump on" level at* ,~//O "Pump off" level at* *Datum ~/~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /~) Absorption field on tot Public sewer main On adjacent lots On adjacent lots Public sewer manhole/cleanout Sewer/septic service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: FOundation ,.f:'~ Property line ~ Absorption field Water main/service line ~- Surface water/drainage ),,~-~ ~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Surface water Curtain drain Building foundation /~ ~ Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots ~' ENGINEER'S CERTIFICATION -,~ '~ .'" ' ~', I certify that I have determined thru field tnspections and revtew of Muntctpal rec~/dg~t~at the ~ovo ~j/~tcms are Signature Engineer s Name Date Date of Payment ~ ~/'~'~ Receipt Number , 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number '3 Trented '?, ater (:ii/, 4'; rto[ifl',,"~l o, MUNICIPALfTY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date ,~) //~',' GENERAL INFORMATION (a) Legal Description (ir~clu~!~t, block, subdivision, section, town. ship, range) Location (address or directi.on~s) ;~ -: - (b) Applicantf~m~e _~.-~, ,* . . Telephone: Home ~ ' /7~. Business Applicant Address. ;~ ;~ ~ ,~/~'~f ~' ~- (c) Apphcapt' '~s (checff o~ :,:'E~8~ng Institutio,~, Owner/builder~; Buyer ~; Other ~ (explain); · .~, ., .. ;~f (d) Lendino Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address; TYPE OF RESIDENCE Single-FamilyJ~ Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual WelI,Ei~ Community [] Public [] Note: If corn m unity well system, must have written confirmation frorn the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL OnsiteJ~ Public [] Community [] Holding Tank [] Note: If corn munity well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status, 72-025 {11/84) Page I of 2 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 compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Approved for ~J'/~' ~_ bedrooms Approved ~ Disapproved 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 [ending 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 ,'2-025 (11/84) WELL DATA MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF AN~'/~i~I~----- AUTHORITY APPROVAL (HAA) DEPT. OF HEALTF¢'&' ENVJRONMt~NTAL PROTECTI~t~IECKLIST - FEBRUARY 1984 264-4720 MAY 1 g 1986 Legal Description: /,o~' / ,.~.~.~,~-~/~,' ~_..-..~,~--~_~-~,,~.,~'..c~,.'~. RECEIVED Well Classification ,2C::~T~*'"~ Well Log Present (Y/N) Y' Total Depth ./.~/~ .~X'. Cased to Static Water Level ~,~/ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B. C, D.E.C. Approved (Y/N) Date Completed /'~ ~ ) -" ~'~ Yield Depth of Grouting ~ Pump Set At //~ ~ ~~ ~ ~ ~ Sanitary Seal on Casing (Y/N) ~ Depression Around Wellhead (Y/N) To Nearest Edge of Absorption Field on Lot / ~ ? / To Nearest Public Sewer Line /'V"~;,,,~'_ To Nearest Public Sewer Cleanout/Manhole /,/.~.,~-~ To Nearest Sewer Service Line on Lot Water Sample Collected by ~ -, ~, ,,~=', .o,~,.~--2~ ; Date Water Sample Test Results ..~'~:~/'~'~ Comments ; On Adjoining Lots ,'J V,-'~;" /'~-/-3/ ; On Adjoining Lots /9 ;,/~-~,,~ /:¢,'~-.~" B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well / .~ ~::72 TO Property Line ~--- ,*,~ To Water Main/Service Line Course ,//~,/ CommenJs;,~,.~ ~ ze / '~, ~,~/No. of Compartments Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) Y Date Last Pumped .~ /~ ;for Temporary Holding Tank Permit (Y/N) To Building Foundation //¢ ~1/ To Disposal Field '~ · To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Separation Distance from Absorption Field: TO Water-Supply Well ./..~ .~ / To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Standpipes Present (Y/N) Date of Last Adequacy Test To ~r, ty-- Line '~:~ To Existing or Abandoned System on ; On Adjoining Lots /'~'V. To Cutbank (if present) ' Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test, Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request I certify that Ihave checked~, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Company/~.~ ~~MOA No. Receipt NO, ~¢ Date of Payment Amount: $ (¢~ Addreas Lending Institution /~,,/' ~ Address Realty Co. & Agent APPL' NT FILLS OUT UPPER H/ ONLY Zip Code Zip Code "'-,~. Zip Code Phone Phone Street Locatic~ Type of Residence Single Family ~Multiple Family [] Other , Water Supply ~.' Individual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. [] Community For wells drilled prior to that date, give web depth (attach log if available). [] Public Utility Year Individual installed: / g/'~C~ 2__. When Connected to Public Utility: Sewer Disposal [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time ,Time ~ Date Date D~_~./ ~_ ~._~) Date Inspector Inspector Inspector Inspector Field Notes: N(~ '~']( A ~l~- ( I ) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED CONDITIONAL APP OVAL' DATE BY: Soils Rating Date Sewer Installed Well TO Absorption Area Well Log Received Well to Tank Septic Tank Size 72-023 (3/~2}