HomeMy WebLinkAboutHALL LT 12BHall
Lot 12B
#051-092-66
Municipality of Anchorage ." ~..
Development Services Department :~
Building Safety Division
On-Site Water and Wastewater Program, 4700 S. Bragaw SL
P.O. Box 196650 Anchorage, AK gg519-6650 Page t of~
www.ct, anchorage.ak.us (907) 343-7904
O.-S~TE W^STEW^TE. D~SPOSAL SYSTEM ^.[~/O. WELL ~.SPECT~O. REPO.T
Permit Number, 5t001031~ PiE Number.
"" E.,~ l~11 W, stewatetSystem: DNew ~t~Upgrade
~'t~'~e~ ~ '7~ci'~'u¢' ~-R~4;A~,./~''' ~lj ~'~),~ ABSORPTION FIELD
~"~ 0.~.,,'~'~''~''= 1
LEGAL DESCRIPTION ~,.
Well: DNew DUpgrade I~,,. 3 I ~ ,,
'"'"'"-'"'"'.~;'~ '"~-~ -" '~'" 57O ""-' D~/F
,, ,
SEPARATION DISTANCES ~septic D HoMing D S.T.E.P. O Othe~
Septic Abso~tio~ L~ Holging Pu~ah
TankField Station Tank ,~,~, Pr~le~ c~ , I~0~.
"~' ~/~ 5~Tt~ ~d~ BENCHMARK
Inspections pedormed oy ........... uates:
Development Se~ices Depa~ment Approval
~:~i:~ed and approved by' Date: ~
P£R,~? ~0. SWO 10313
Municip. o~Li'l: oF Anchoro, ge
DEPARTHENT OF HEA~TH AND HUHAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
p.n. Box 196650 mAncho,,",',ge, Ate, sRo, 99519-6650®Tetephone~ 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LECAL LOT 12B~ HALL S/D
SEPTIC~
P.I.D. NO. 051--092--66
LOT 12A
MT2 ;01
MT1
)2
CE-8801
PERMIT IlO..SWO 1031 ..~
PAOE ~ or ~
MunicipaU~c oF' .A.n=c h.o F o g.e.
DEPARTMENT OF HEA~_TH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O, Box 196650 ·Amchom~ge, A~sk~ 99519-6650·Telephone~ 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
L£CAL LOT 12B, HALL S/D
P.I.D. NO. 051--092--66
~_ST1ST2 /- 98.9'
F,.A ORADEJ /-2"__ 2" .,NSU'AT700
~ NEW ~
..,-.-, / I 1000 GALLON I~ ,
~o,o- JPOLYETHYLENE J ~-95.$
fFINAL GRADE
flNSULATION ~
IGINAL
GRADE
A B
FCO 50.0' 10.0'
ST1 56.5' 55.0'
ST2 59.0' ,58.0'
DBL1 60.5' 40.0'
DBL2 61.0' 41.0'
C01 95.0' 89.5'
MT1 89.0' 82.0'
C02 116.0' 10,5.5'
MT2 120.5' 110.0'
·
WATER FOUND ® 89.7
85.7' B.O.H.
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage. Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
7'/5'~/ ~ t~ .C,-,. ;' Township. Range. Section: 7'/~- ~" ~'/~.' £-~ ~
4-
5
6
7.
8
9
10
11
12
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED)
IF YES, ATWHAT .e- ,
DEPTH~
A
IIII
.-,~..I I I
I I Ill
I Ill! Il
PERCOLATION RATE
(minutes/mCR! PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND
/'~---.,/.--.'~'-/ /--~' /1 ~
FT
PERFORMED 8Y: ~'/'E ~: ~' I ~....~.~,~,l..~ CERTIFY THAT THIS TEST WAS PERFCRMEO IN
ACCOflOANCEWITHALLSTAT~ANDMUNICIPALGUIDELINE~INEFFECTONTHISOAT~. OAT~ ~ ~ ~ ~
72~ (Rev 4,~
MUNICIPALITY OF ANCHORAGE
Development Sen/ices Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P,O. Box 196650, Anchorage, AK 99519*6650
(907) 343-7004
ON-SITE WASTEWATER DISPOSAL $YSTEM PERMIT
Upgrade
Date Issued: Aug 10. 2001
Expiration Date: Aug 10, 2002
Permit Number: SW010313
Legal Description: HALL LT 12B
Design Engineer: 0003 S & S Engineering
Owner Name: Ron Hall
Owner Address: PO Box 670955
Chugiak, AK 99567-
Parcel ID: 051-092-66
Site Address: 021024 SCENIC DR
Lot Size: 40039 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is fo~; 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. Ail 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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 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.
Received By:
Issued By:.
Date:
Municipalily of Anchorage
Development Services Department
Building Safely Division
On-Site Water and Wastewaler Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ek.us
(907) 343-7904
ON-SITE SEWER/VVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. C'~'',/- E)~ ,,~-- {_~,G
Permit Number SW ~ IO '.~_.~
Properly owner(s)
Mailing address (1) PO Bo× ~'~0 q~ ~
Mailing address (2) ~/,3 t~ I~ ~1 ~ -- Zip
Legal description (Lot. Block & Sub'd.) Lo* t~ ~) ,~1/ ~/b
Legal description (Section, Township & Range)
Lot Size ~. ~ ~~ Number of Bedrooms
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Dayphone ~CO)-- q 71
Code
[] Well Only
Water Storage
Jacuzzi .
Waler Softening Un'it
I cerlify Ihat Ihe above Information Is correcl. I further certily Ihal this application Is being made for a
Single Famlly Dw~lllng and Is In accordance wilh applicable Municipal Codes.
17034 Eagle River Loop Roa, d No. 204
(Signature o! property owner or authorized agent)
Permil Fees:
Date o1' Payment:
Receipt Number:
(Rev. 12/00)
Waiver Fees:
Date o1' Payment:
Receipt Number:
ROBERT C. COWAN. P.E.
July 12, 2001
CML ENGINEERS
(907) 694-297B
FAX (907) 694-12 ! I
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 12B, Hall Subdivision
It is requested that you issue a permit to upgrade a septic system to serve the existing
three bedroom dwelling on the referenced property.
A test hole was excavated and a percolation test performed on 6/2/92. The approximate
location of the test hole is located on the attached site plan. Ground water was monitored
and after seven days water was found at 6.5 feet as shown on the attached soils logs.
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
areas or drainage patterns by the installation of the proposed septic system. The
construction of this system will not prevent any future development on any of the adjacent
properties.
If you require additional information, please contact us.
Sincerely,
RCC ij
Enclosure
17034 NORTH EAGLE RIVER LOOP · SUffE 204 ,, EAGLE RIVER. ALASKA 99577
9-
10-
11-
12.
13-
14-
15-
16-
17-
18-
19-
20-
Municipality of Anchorage
Development Services Department
Building Safety Divislo~
On-Site Water and Wastewater Program
4700 South Bragaw SL
P.O. Box 196850 Anchorage, AK 99519-6650
www.ct.e ncho~'aee ~k.ts~
(907} 343-7~O4
Soils Log - Percolation Test
Performed Fo,':. ~
COMMENTS
ENCOUNTERED? .
IF YES, AT WHAT DEPTH? i~/ Ls
Deplh Io Water A;ter 0
Date;~/
Reading D;lle Gross Time Nel Time Depth Io Waler Net Drop
(n~,~ es,~ ) PERC HOLE DIAMETER
PERFO. EO .y.' " ' '--/ //2
· ,, ,.~.. ..... ~, , 1/p'~.~ r--. l~' ~,,/',--,-' CERT FY THAT THIS TEST, WAS.
PERFORMED IN AI3~(~J~bl~ ~ .I~i~ClPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
Eagle Rb~', Alaeka 99577 ·
Municipality of ,~nchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage. Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: J~o~J ~f~ l/
4
5
6
7
8
9
10-
I1
14
15
16
18-
20
o 8
.IDe
WAS G
ENCO~
IF YES
DEPTH
PERCOI
Township, Range. Section:
SLOPE
GROUND WATER
OUNTERED~
. AT WHAT
COMMENTS.
SITE PLAN
.ATION RATE
TEST RUN BETWEEN
{mmutes, mcl~} PERC HOLE DIAMETER _.
FT AND FT
PERFORMED BY: . ~"~' ~ ~' I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DA TE.
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
ROBERT C. COWAN. P.E.
CMLENGINEERS
(907) 694-2979
FAX (907) 694-121!
SO4. TEST
REFERENCE: Lot 12B, Hall Subdivision
July 12, 2001
GENERAL:
The scope of this project includes the verification of the existing i 000 gallon
septic tank, installation of a 1000 gallon minimum septic tank if required,
installation of a 250 gallon minimum pump basin, and a pressurized absorption
bed to serve the existing three bedroom residence located on the referenced
property.
Construction shall be in accordance with the approved site plan and design
drawings; Municipal permit with any special provisions or conditions; and all
applicable State and Municipal Wastewater Disposal Regulations.
The contractor shall be responsible for obtaining any necessary underground
utility locates.
Unless specifically a~,eed otherwise, the propert~y owner shall be responsible
for final grading areas subsequently depressed from soil settling. On all
leachfield mound systems, the property owner shall be responsible for ensuring
a satisfactory vegetation growth over the mounded area.
Contractors installing wastewater disposal systems must be certified by the
Municipal Health Department for system installations. Owners installing their
own systems must also receive prior approval from the Municipal Health
Department.
SEPTIC TANK INSTALLATION:
A septic tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two cleanouts for pumping access.
..
The septic tank shall be sufficiently bedded to prevent settling or shifting of the
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE R~VER, ALASKA 99577
Page 2 o $ & S Englneerfng
Lot 12B, Hall S/D
July 12, 2001
All standpipes on the septic tank shall extend a minimum of 12 inches above final
grade.
Septic tanks installed with less than 4 ft. of cover shall be insulated.
A foundation cleanout shall be installed one to four feet from the building foundation.
In the line between the tank and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic tank). These cleanouts
shall be located on undisturbed soil not more than 10 ft. from the tank. The first
cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be
to clean toward the septic tank.
Final grading over the septic tank shall be such that a positive slope exists away from
the septic tank.
LEACHF1ELD BED INSTALLATION:
Excavate the proposed Bed Area to the depth shown on the design. The bottom of the
excavation shall be within 2 inches of level. If the bottom of the excavation becomes
smeared, it must be raked or scratched (ruffed-up) before gravel or sand placement.
If a sand layer is required, place sand over entire excavation to the required depth
shown on the design. The top ofthe sand layer must be within 2 inches of level.
Sewer rock shall be placed uniformly throughout the entire bed. The distribution
piping is to be ofPVC (ASTM D3034 or equal). AIl joints are to be solvent cemented.
Gravel depth below the distribution pipes shall be a minimum of six (6) inches.
Gravel depth above the perforated pipe shall bo a minimum oftwo (2) inches.
The distribution piping must be as shown on the design. The distance between the
outermost perforated distribution pipes and the sidewall of the absorption bed must be
no more than three feet.
Silt barrier material must be installed between the final gravel layer and the native soil
backfill, unless insulation is used, then the silt barrier should be installed over the
insulation. Ensure the silt barrier covers the entire gravel surface before placing
backfill.
Page 3. $ & S Englneerfng
Lot 12B, Hall S/D
July 12, 2001
Monitor tubes shall be of four (4) inch diameter, installed at the locations shown on the
design, and extend a minimum of 12 inches above final grade. The portion of the
monitoring tube extending through the gravel depth shall be perforated six (6) inches
below the bottom of the horizontal distribution lines. The monitoring tube should not
extend below the bottom of the gravel surface.
Backfill over the final gravel layer must not be less than twenty-four (24) inches.
Insulation must be installed when the backfill depth is less than thirty-six (36) inches.
The finished grade over the bed must be mounded to prevent the formation ora
depression a.qer settling.
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be constructed by a Municipally
approved septic tank manufacturer.
2. The following pipe materials are approved for use in septic system installations in the
o
Municipality of Anchorage:
T~5~e of Pipe Perforated Solid
Cast Iron
ASTM D3034 (PVC)
ASTM FSI0 (HDPE)
ASTM D2662 (ABS)
Yes Yes
Yes Yes
Yes No
Yes Yes
Use of a type of pipe other than listed above must be approved by the inspecting
engineer.
Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco,
or equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
All leachfield gravel (sewer rock) shall be 0.5'-2.5" screened gravel with less than 3%
passing the #200 sieve.
When sand is being used as a filter material, its gradation specifications must conform
to current M.O.A. or D.E.C. requirements, which ever specifications applies.
Page 4 - S & $ Englneerfng
Lot 12B, Hall
July 12, 2001
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the installation of
the wastewater disposal system. These inspections will occur as follows:
The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any gravel. A septic tank may be
set in place, but may not be backfilled before this inspection.
The second inspection must be conducted after the placement of the silt barrier,
gravel, distribution lines, standpipes, clean.uts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting
engineer is to be contacted at least 24 hours prior to the start of constxuction. If necessary, a
pre-construction meeting will take place on-site. The inspecting engineer will not coordinate,
direct or control in any way the contractors activities.
The owner shall contract with the contractor to perform the work outlined in these
specifications and plans and in accordance with the attached M.O.A. permit. There will be no
contractual arrangement existing between the contractor and S & S Engineering. S & S
Engineering shall be the owners representative and will inspect the work as stated above to
document the contractors activities. Final acceptance of the contractors work rests with the
owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor
to carry out the work in accordance with these construction documents. S & S Engineefing's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incident to this project.
CONTRACTOR/INSTALLER
~ Municipality of. Anchorage .
((, -~,~ DeveloPment Servi'~'. D~'~a~r~r~ ~ ht
,'~\~,,m~,,~,~4/I, ~ .., ,' ,, · ..~ ..... :~Bu~dingSafe~Dvision '.. :;. , ' .
· ,~ · · . ........ On-S~teWaterandWastewaterPr~ram..-
.... .:~ ,~:~.-, ~,..*.. ...... ; d,4700Sou~BragawSL. ' .... . ; "~'.~-':
. ' ~ -,.._ . ":'P.O, Boxl~6~50:~6mg~,'~,'99519~650' :' .;.:'..'. ,:,..':..'.' ..
' ' .','- ... ' ..,.. '. ,~... , . ':., ~::~.cLan~orage.a~.us: -, ,. .., ,,., .
~(97) ' ' ' ' ' ....
; ~ - "-, · : -: ~3-79~ . . ', '
CERTIFICATE OF H~LTH AUTHORI~ APPROVAL
SlNGgE-EAMI~M, D~ELLING
' FOR A' . .... ,:r ......... -: ~ '.,.,':
Parcell D' O~t
~)~'-~, ~piration Date:
1 .~ G ENE~L"IN FO RMATION '
,?. ~ .."Complete regal description Lot 1 ~ ~ST~~/'D,~ ;5,.~,:: ~.
..... :"Ub~ti0fi'({it6'~'d~ or directions) 21024 Sc enic
· .;. :Current Property owner(s)
': ~..."',;',.Malling a~ld~re§~
Lencl'ing agency
Mailing address
Real Estate Agent
Ron Hall Dayphone 688~7'9871-
PO Box 670955, Chugiak_,._..'J~ _99567,-...- "'-..,
Mailing Address
"Un/ess othe'rwise requested, HAA will be held by DSD lo'pickup.
:.2. NUMBER OF BEDROOMS: 3
3', TYPE OF WATER SUPPLY:,
· ,., In~lMdual Water Storage []
community Class ~ Well []
Public Water System []
Dayph6ne
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
[]
[]
[]
[]
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of AJaska. Cedificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal end/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority 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 less than 30 days old. (Cediflcates 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 inyestigation,
based on procedures outlined in th& Health'Authority 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 t~e time of installation.
Name of Firm S & $ E~GINEERING
I lu,,~ ~:.agla klver Lo~p KOA~ ~o, -;~
Address Eaqle Rlverf Alaska ~9577
Engineer's Printed Name Robert C. Covan, ?.~;,
5. DSD SIGNATURE _ .
[,//' Approved for ~ bedrooms.
Disapproved,
Conditional approval for
Phone
Date ~/~. 3/o I
,,~.4,~7.:..~ ":-...;.',~.¢.%
..... ,
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(007) 343-79O4
HEALTH AUTHORITY APPROVAL CHECKLIST
LegelOescriptlon: LOT" 13. I.~ /-/'~b~.. ,..~/~ ParcellD:O.,,
WELL DATA
Well type ~0/~
Date oompleted
To,-, d,~t~ ~! ..
If A, B, or C provide PWSID # -
Casedto ~0-/- It.
FROM WELL LOG
Date of test t ~-/~ z
Static water level 3 _~ It.
Well Production ) O g.p.m.
weil Lo~/N) Ye *~
wres ~e~y prot.c~d~N)
Casing height (above ground)
AT INSPECTION
7/:~/o ~
¥- ~' g.p.m.
y~ J
13-~ in.
WATER SAMPLE RESULTS:
Coliform 0 colorjies/100 mi.
Date of sample: ~ [~-}//0 I
Nitrate ;t. ~o mg./I.
Coilecmd by:
B. SEPTIC/HOLDING TANK DATA
Other bacteria O colonies/100 mi.
S & S ENGINEERING
17~4 Fagle River Loop Romd Ho. 204
Tank~l;yge/Materia! ..~,.Pr~¢- / ).t.,I).P,E.
:T'a~k '~'~.~ / 0oO' .gal. Number of Comparlments '~-
' Fot~nd~flon cteaoout~/N'). ¥~J Depression overtank
.,Date of pumping ),,d/~ .. ~v~t.~J Pumper
C. ~BSORPTION FIELD OATA
Eagle River, Alaska 99577
Date installed
Cleanouts~/N)
High water alarm
Date'inStalled ?/' VJO'I' Soil rating ~o~ ~/bdrm) O, f System type B ~' O
Lengtl~ * ~ ~' It. Width J ~ It. Gravel below pipe 0.5-- It.
Total depth ~ ff. Eft. absorption area ,~-'/..~_~0 .it= Monitoring tube ~--f Depression over field N 0
Date of adequacy test ~/A - *~,~' Results (PassJFail) ~ For ~ bedrooms
Fluid depth in absorption field before tast ~atar added__ gal. New depth
in.
Elapsed Time: rm~,,,,,,,,,~ tiuid depth in. Absorption rate >= g.p.d.
Any~nt (past 12 mo.) (Y/N & type) If yes, give date
D. UFT STATION
Date installed Size in gallons Ma~
'Pump on' level at in, 'Pu~p o~ ~~ water alarm level at
Datum Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot ] O oJ
Absorption field on lot J '~ ~ /
Public sewer main ~//A
Sewer/septic service line ~-.~ ~
On adjacent lots
On adjacent lots ,/
Public sewer manhole/cleenout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ,3 I Property line ~ I
Water main N/,~ Water service line
Wells on adjacent lots ,/O 0 J-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ) ~' Building foundation *"7
Water Service line ] 0 /¥"
Sun'ace water.
Cudaindrain ~'~- /¢,,,O~W' Walls on adJacent lots /00 '~'
F. COMMENTS ',,. : :
Absorption field
Surface water
Water main ~///A
D~veway, panV. ing/vehicle storage
~n~an~ ~ MOA H~ guidelines ~ eff~ ~ ~is date. ~_~ ....~
Date of Payment
Receipt Number
(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number