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HomeMy WebLinkAboutSKYLINE VIEW BLK 1 LT 10 MUNICIPALITY OF ANCHORAGE DEPT. OF ' L' i~C' ION DEPARTMEN'r OF HEALTH & ENVIRONMENTAL PROTECTIOI~NvhqON ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264,4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REr.~BT pHr~l~ ~ J~ ! ~ ~I~w ~/~-~ --,2~J~ / [~ UPGRADE" MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO, QF BEDROOMS / Absorption area DISTANCE TO: IWe'l /~E'~ I .,~'~' ' Dwelling Matej2i~l-~ Manufacturer ~,,~Z~_ .~,~_ Liq, capacity in gallons Well Inside length / ~ I F HOME.DE: Dwellin9 Width DISTANCE TO: PERMIT NO,~ Materiai 2- "N~ea'rest lot Ii e Foundation Total length of lines Trench Material beneath tile '¢ ~ inches Liquid depth PERMIT NO. Manufacturer Liquid capacity in gallons Depth Dist a nc e ,~7.~n lines Total effective absorption area 2'7z'. PERMIT NO. DISTANCE TO: Well /~ ! Length of each line , ¢-'¢: / Top of tile to finish grade Length Width Type of crib Crib diameter Well DISTANCE TO: Class Depth Building foundation Crib depth Total effective absorption area Building foundation Nearest lot line Driller Distance to lot line PERMIT NO, DISTANCE TO; Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TFST RATING INSTALLER REMARKS DATE 72-013 IRev, 3/78) LEGAL PERMIT NO. DEF'RRTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 025 q.." STREET, ANCHORAGE., APPLICANT LOCfiTI ON LEGAL R.L. PELL. ISSIER LIO B'i. SKYLINE VIEW PO BOX i,~6 CHLIGIflK LOT SIZE 688 290G ~.9000 SQlJRRE FEET TYPE OF SOIL fiBSORBTION SYSTEH IS: TRENCH NA,~-;INUN NUMBER OF BEDROOMS = 2: SOIl_ RFITING (S~ PT/BP>= ({:5 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYS'I"EH IS: THE LENGTH DIHENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRfiINFIEI.~D. THE DEPTH OF FI TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF TWE GROUND AND TWE BOTTOM OF THE EXCfiVfiTION (IN FEET). THERE IS NO SET WIDTH FOIR TRENCHES. TWE GRAVEL DEPTH IS THE HINIMUM DEPTH OF GRAVEL BETWEEN THE OLITFRLL. PIPE fiND THE BOTTOM OF TWE EMC:flVfiTION (IN PEET). PERMII' APPLICANT HAS THE RESPONSIBILITY 'FO INFORM THIS DE. PfiRTMENT DURING TFIE] INSTFILL. fiTION INSPECTIONS OF tiNY I.qELLS fiDJfiCENT TO THIS PROPERTY fiND THE NUMBER OF RESII)ENCES THfiT THE NELL WILL SERVE. BF:ICKFILLING OF tiNY S"r'STEtl WITHOUT FINflflL INSPECTIOI'.t fiND fiPPROVflL. BY TillS DEPfiRTt'IENT WILl.. BE SUBJECT TO PRO':.;EC.'UTION. HINIHUN DISTANCE BE'rWEEN fl WELL AND FINY ON-SITE SE"WAGE DISF'OSRL SYSTEH IS :~00 FEET FOR fl PRIVATE NELL.: OR 150 TO 200 FEET FROH fl PUBLIC WELL DE. PENDING UPON THE T~PE OF F'LIBLIC NELL. OTHER RE~UIREHENTS.f.lfiY flPPI_Y. SPECIF'ICRTIONS fiND CONSTRI.ICTION DIfiGRRHS PRE RVRILRBL. E TO INSURE PROPER INSTALLATION. I CER. TIFM THAT t: I fl/'1 FflMll-IfiR WITH TFIE RE(qLJIREHENTS FOR ON-SITE SEWERS fiND NEI..LS tis SET FORTH BY TltE NONICIPflLITY OF ANCHORAGE. Z~: I NIL. L INSTALL THE SYSTEM IW ACCORDANCE NITW THE N:: I UNDERSTAND TI'IRT THE ON-SI'F~ SEWER SVSTEN MAY REQUIRE ENLRRGEHENT IF THE RESIDENCE IS REMODELED TO INCL.I.IDE MORIE THAN 3 BEDROOMS. ......................... I ~SIJED BY ............................. : O & E ENC.NEFRING & DEVEL©, ,dENT CO. Box 90, Davis St., Fagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Performed for: Legal Description: _/~ 07- /~ / Earl EIII~ SOIL LOG 6[]8-2280 Name:_ ~'~,'~ · Mailing Address: Depth (feet) Soil Characteristics 0 5__ 6__ 7__ 8__ 9__ 10___ PLOT PLAN 13__ 14__ 15___ 16__ PERC. TEST Ground Water Encountered: Yes _ No ~'/~'_ If yes, what depth__ Proposed Installation: Seepage Pit Drain Field Comments: : Q 0 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Se~¥ices Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description ~ i%. ,~,~ /, ~'~'/~l~J ~.Z.~-~¢~ Location (site address or directions Property owner Mailing address Day phone/'¢ Lending agency Mailin. g address Day phone Agent Day phone Address Un/ess otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~¢ ,. TYPE OF WATER SUPPLY: Individual welt 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: If community wastewater system, provide written confirmation from State ADF:,C attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #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. ~'~- ¢-*' ~,~T-,~'L--~/-_J ~/ Phone[¢~ ~ ~'///-/~// Address Engineer's signa[ure DHHS SIGNATURE ~ Approved for -/"'/LC ~'~ bedrooms. Date ~). I~). ~c:~ Disapproved. Conditional approval for bedrooms, with t~e following stipulations: Note: The well for this property meets existing State and Municipal Codes. There are nJtrate~ present. It is suggested that oeriodic testin~ be performed to insure the wells continued suitability. Current nitrate concentration is 5.58 mg/!. EPA mz×imnm concentr~tio* is ~.~ mg/!. More information on nitrates is available from the On-site Services Program, 343-~,~. DHHS, ~ntt 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 courtesyto 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. Municipality of Anchorage JUN DEPARTMENT OF HEALTH & HUMAN Enwronmental Services Division [~NVIRONMENfALSERV~C~S DIVISl 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Che(;klist A. WELL DATA Well type Log present (Y/N) Total depth _ / Sanitary seal (Y/N) Parcel I,D.:. If A, B, or C, attacl~ ADEC letter. ADEC water system number Date completed Cased to /~'/ Casing height (above ground) Y' Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well production WATER SAMPLE! RESULTS: Coliform Date of sam01e:_ B. SFPTIC/HOLDING TANK DATA Date installed //~"/2' Foundation cleanoul (Y/N) Date of Pumping C. AI=~SORPTION FIELD DATA Date installed Length -~/'// Width Nitrate ~ 4,-_W Other bacteria Collected by: /'~,~¢/~-¢' /~' ~'~-~2 Tank size /'¢~'¢' Number of Compartments. _,Z, Cleanouts (Y/N). '-/ Depression (Y/N) ~ High water alarm (Y/N) Pumper ~/-'~'~' ,/~,',~-/.-~/,'J,~' Soil rating (g.p.a./fF or fF/bdrm_) O~ System type ,t ' Gravel thickness below pipe 4/" Total depth Effective absorption area ,¢' ¢"~ ,z~/z Monitoring Tube present (Y/N) Date of adequacy test ~,/~/"¢'? Results (Pass/Fail) Fluid depth in absorption field before test (In.l: ,'¢/~ '" Fluid depth ,d/'" (ins) Minutes later: ,¢, Peroxide treatment (past 12 months) (Y/N} Depression over field (Y/N) /2. For ~ bedrooms immediately a~ter~;¢~' gal. water added (in.): Absorption rate = 4"~'~ g.p.d. If yes, give date 72-026 (Rev. 3/96)* F. D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles-testa-cT~/ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line Size in gallons "Pump on" level at* On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station "~/'/¢ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ,~z~/:'/ Property line / ~ ,'-/z:~/- Absorption field Water' main/service line ,Z~"t'~'~ Sudace water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /~ ://' Building foundation Wells on adjacent lots Water main/service line ..~,....~- Sudace water '~//"¢ Driveway, parking/vehicle storage area Curtain drain .,~.,,o~-- ,~,~ ~ ~x,~ Wells on adjacent lots /~ ENGINEER'S CERTIFICATION ~' ~. I ce~ify that l have determined thru field inspections and review of Municipal rec~'t~' ~, }~ are in conformance with MOA HAA muidelines in effect on this date ~" ~ ~ "~1 Signature ~ ~~ ~.,: ~:.,~t~ ~:. Bate ¢ ..... ..' HAA Fee $ ." ,Date of Payment / '/--//' CU~ Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number JUN'O~t-99 12:15 FROL~-CT£ ~NVIRONM~NTAL Zt~m, C T&E£nvironm~r,,alService~ln¢. CT&E Clien~ Name Proj~ Name/# Client' Sample rD Matrix Ordered By PWS~ 992419OO1 Douglas Keniey P,E, Lot i0 Bk i Skyline View Lo[ 10 Bk I Sk~liae View Drinking Wa~ee 0 Clien[ Printed Date/Time 06/08/99 12:11 Collated Date/Time 06/01/99 19:30 R~eiv~te/Time 06/02/99 t4:25 Tec~eal Dir~tor: Stephen C. Ede 5.58 0.500 t~O/L ~PA ~00.0 10 max cot/100m~ SHla 9~8 06/02199 0~/(}~199 SC~ 06/0~/9~ ~P 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 Eot 10; Block 1; Skyline View Subdivision Location (site address or directions) ]r9357 Lupine S~ree_t_ Property owner Mailing address Groha]] (owner) Day phone 688-6514 (occu, L)ant) Lending agency Mailing address Day phone Virginia Kohfield - ~3/MAX OF EAGLE RIVER Day phone Agent Address 16600 Centerfield Drive, Suite 201, Eagle River, Alaska Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: NOTE: 694-4200 99577 Individual well XXX Community well Public water If community well system, provide written confirmation from State ADEC attest-. lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site .~x-- 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. 72~25(Rev, 1/91) Front MOA #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 s Address 17034 Eagle River Loop Road Eagle River, Alaska Engineer's signature DHHS SIGNATURE Approved for Disapproved. Conditional approval for Phone ~.~bedrooms. bedrooms, with the following stipulations: By: Additional Comments Note: The we]_]_ £or this property meets e×istinq State and Municipal Codes. There are nitrates present. It is suq~ ~h~ ~ p~r~ ~n? b~ performe~ to insur~ the we]is continued sui%ability. Nitrate concentration is 4.7 mg/1. EPA ..~ .......... ~=~4~ ' -~.0, m~/1. 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. 72K)25(Rev, 1/91) Back MOA~21 Municipality of Anchorage .~ Department of Health & Human Services HEAt. TH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type ~2¢-~V ~d' P~ Log present ~YN) __ ~/ Total depth /1~ ~ Sanitary seal ~N) Date of test Static water level Well flow Pump level If A, B, or C, attach ADEC letter. Date completed Cased to ~. c~ t FROM WELL LOG SEPARATION DISTANCES FROM WELL. TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ADEC water system number /~- ~"1°~ Driller Casing height Wires properly protected~¥N) y g.p.m. AT INSPECTION ~/ L~' '~,~' ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform __L-~2 ~'~"~ /~¢¢ '~'~ Nitrate _ Date of sample: ~ -- L,,, ~ ~,, '?.~ Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~,~ - Cleanouts~/N) High water alarm Date of pumping Tank size_ [oOO ~' Foundation cleanout ~:~/N) _ Other bacteria S & S ENGINI'"ERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Compartments 'Z. - y ~ Depression (Y~ Alarm tested (Y/N) /J~- Pumper ;~'¢-- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \ c,o '~ ¥' On adjacent lots To property line \ o ~'v- Absorption field _ Surface water/drainage ~ O~ ~ ~ Foundation _Water main/service line t o ~"~ 72 026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Manufacturer "Pump on" level at Meets MOA electrical cod~ ~ SEPARAT~ FROM LIFT STATION TO: Well o~a4d~ On adjacent lots Manhole/Access (Y/N) ~ ~' level at ~'"~""~Cyc les tested Surface water D. ABSORPTION FIELD DATA Date installed \\_ Length '~'¢~ Width Total absorption area Depression over field (Y~.~ Results 4~'fail) Peroxide treatment (past 12 months) (Y~) Soil rating ~:~' ~ System type Gravel thickness '¢~'~ Total depth ~,t Cleanouts present Q/N) ~ Date of adequacy test ~.- for "~'"~4¢.¢--¢~.. ~.) . bedrooms /,,(~J¢-- ~N'~ ~J/v' If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot ~P~ To building foundation To existing or abandoned system on lot On adjacent lots Cutbank Water main/service line Surface water Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date S & S ENGINEERING Eagle River, Alaska 9957? HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91) 8ack MOA 21 / 70 --13 Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY _ 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANALYSIS NEEULTS for INVOICE I 50948 C}m~ah Refit 92.0491 Sample t I }~attix: WATER Client Eemple ID PNSID Collected Received ?reserved with LiO B1 SKYLINE VIEW S/D Client Name :3 ~ S ENGINEERING UA Client Acer :SNSENGP FEB 6 92 ~ 16:00 h~. BPO! : FEB ? 92 @ 13:55 h~s. Req# : AS REQUIRED Ordozed By tR. DIFFER PO{ :HONE RECEIVED Analysis Completed : FEB tO 92 Laboratoxy Eups~vl~or : S~EPIIEN C. EDE Released By : ~* '~. ~/ Send Reports to~ lis & E ENGINEERING 2) Parameter Results Units Hethod Allowable Limits NITRATE-N 4,7 mg/l EPA 353.2 10 Sample ROUYINE SABLE COLLECYED BY: RAY. Renm{k~: i Tests Performed Soo Special Instructions Above UA-Unavailable ND- None Detected *' Dee Sample Remarks Above HA- Wot Analyzed LT-Less ~han, GT-Oreatsr Than ~,~-~ Member of the SOS Group (Socibt6 G~n6rale de Surveillance) MUNICIPALITY OF ANCHORA(.~ DIVISION OF ENVIRONMENTAL tIEALTH DEPARTMENT OF ttEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date_ ~/V 4_¢' (a) Legal Description (include lot, ~lpck, subd.i~visioB, section, township, range) Location (address or directions) (b) Applicants Name__~_~_~/_L./.~.----fC_ Telephone '- Home Business Applleants Address (c) Applicant is (check One) Leadln~ Institution Buyer ~--t ; Other ~-~ (explain); (d) Lending Institution / '~-~- Address (e) Real Estate Co. & Agent ~ ~ -- (f) Mail the ~ ~o the following sddress: ~_~; Owner/builder~~ Telephone 2. T_y.p_~__of Residence Singls-Family~ Number of Bedrooms 3. W__at_e__r S~p!.y Individual Multi-Family Commuaity ~ Other (describe) Public ~_~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservatiou attesting to the legality and status. 4..S. pwase Disposal Onsite.~ Public C~ Community ~ Holding Tank~ ~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. E__ngineerin8 Firm Providin~ 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 ,~ investigation of this Health Authority Approval shows that the om-sits water ~upply and/or wastewater disposal system is safe, function~[ and adequate for the number of bedrooms and type of structure i~Micated herein° I further verify that, based on the information obtained from the M~nicipality 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 ragula- tiona in effect on the date of this inspection. Name of Firm Address DHEP Approval Approved for~/~{hbedrooms Approved _~__ Disapproved Telephone Conditional Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEA~LTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASEl) SOLELY UPON TKE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFES'SIONAL 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 REQUIRE- MENTS. ]']MPLOYEES 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. (DHEP SEAL) RR4/eJ/D18 [Page 2 of 2] 7-19-84 ae k~UNICtPALF[Y OF ANCHORAQI~ DEP'[, OF HEAL'III [NVIF, ONMENTAL PkO fL'C¥1OU M[~ICIPALITY OF ANCHORAGE (MOA) Legal Description: Total ~p~ /D ~ / ~d to ~D / ~pth of G~outzng --- Static Water ~1 ~ O ~ ~ ~t At ~ ~ Casing Height ~ G~nd ~. ~ '~ Sanit~ ~al on ~sinG Elec~ieal Wi~ing in ~nduit~) ~]~ession ~ound ~l~ead ; ~ ~joining Lots /~ To ~amst ~ge of ~s~t:Lon Field on ~t //O ~ ; ~ Adjoinin~ ~ts . ])ate Instal:l~d 11/~ Siz~ _~/~,~3.~ No. ~ CQ,~nts . ~ - - __ . ~ ~ - ~ess~.on 0~ Ta~ ~ ~te ~st P~d /~/~ ~ P~ing~inte~n~ ~a~ ~ Fil9 (Y~/~' ; for Holding Ta~ Hi~h-Watelt ~a~ (Y~/~ ~)~y Holdi~ Tank ~t Separation Distan~s ~ ~ptic~lolding Tank: To Wate -Supplz TO Property Line -- /dD t~ To Water ~b~r/Servioe Line Course To 5uilding Foundation 2C~- To Dis[x)sal Field_ %$~' / To Stream, Pond, Lake, c~ Major D~.ainage Coranents Receipt ~ Date Paid: Amount: . [Page t of 2] 2-15-84 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date ·Installed ///'~ ~ Width of Field 3 6 ~ ~ngth of Field Depth of Field Gravel Bed Thickness Square Feet of Absorption A~ea Z 7 ~.- Standpipes P~esent ~/~ ~p~ession ove~ Field (~ ~te of ~st ~a~ Test Sep~ation Distan~ f~ ~s~ption Field: To Building Foun~tion 3 ~ ~ To Existing or ~ndo~d System To ~i~way, Pa~ki~ ~ea, ~ Vehicle St~a~ ~ea ~ Counts ~ ~ ~ ~ D. LIFT STATION Date Installed Size in Gallons "Pu~ O~" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions · ~nholo/Access (Y/N) //J /P~f" Level at ~ / /~/ Vent (Y/N) Pumpin$ Cycles du~ing Adequacy Test. Meets MOA Counts ** Check Permitted Bed~cc~ Rating A~ainst HAA R~quest ** I certify that I have checked, verified, or. oonfo~d to all MOA on the date of this inspection. KB1/d5/s [Page 2 of 2] Date MOA No. 2-15-84