HomeMy WebLinkAboutGLENN VIEW ESTATES WEST PH 2 BLK 2 LT 6Glenn View
Estates West
Ph 2
Block 2
Lot 6
#051-793-27
Municipality of Anchorage Page 1 of 3
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section 825 "L' Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us (907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW010050 PID Number 051-793-27
Name:
MM&M Construction
Wastewater System: New
Address:
P.O. Box 670495 Chugiak, AK 99567
ABSORPTION FIELD
Phone: Number of Bedrooms:
688-1236 Four (4)
Deep Trench
-
LEGAL DESCRIPTION
Soil Rating:
8 GPD/Ft
Total Depth from original grade:
11.5 Ft.
Block: Lot: Subdivision:
2 6 Glenn View Est. West Phase II
Depth to pipe bottom from original grade:
4.5 Ft.
Gravel depth beneath pipe:
7 R.
Township: Range: - Section:
Fill added above oiginal grade:
0 Ft.
Gravel Length:
55 Ft.
Well: Community Water
Gravel width:
3 Ft.
Number of lines:
1
Distance between lines:
N/A Ft.
Classification (Private, A, B, 0):
Class A
Total Depth:
Ft.
Cased to:
FL
Total absorption area:
770 Ft'
Pipe Material:
ASTM D3034 PVC
Driller:
Dale Drilled:
Static Water Level:
Ft.
Installer:
MM&M Construction
Date Installed:
6/26-30/01
Yield:
GPM
Pump Set at:
Ft.
Casing height
Above Ground:
Ft.
TANK
- SEPARATION DISTANCES
n Septic • Holding ❑ S.T.E.P. 0 Other:
To
From
Septic
Tank
Absorption
Field
Lift
Station
Holding
Tank
•ubliclPdvate
Sewer Line
Manufacturer'
Anchorage Tank
Capacity Gallons:
1,250
Wel
>200'
>200'
N/A
N/A
>25'
Material:
.Steel
Number of Compartments:
Two (2)
surface Water
>100'
>100'
N/A
N/A
LIFT STATION — NONE ON LOT
Lot One
>5'
>10'
N/A
N/A
Size:
Ga,
Manufacturer:
Foundation
>5'
>10'
N/A
N/A
'Pump on level at:
in.
'Pump off- level at:
in.
High water alarm at:
in.
Curtain Drain
None
Noted
Pump Make & Model
Electrical Inspections performed by'
'Remarks:
BENCH MARK
Location and Description:
Back Patio Door Stoop
-
Assumed Elevation:
100.0 Ft.
c, n7jfitfls1Stam p
Ot- Ai's:,
e.
48'A�•• .- ix
M
n
Inspections performed by: Mike Anderson Dates: 1a' 6/26/01'%`
(ijo 71:::;,V
40TH v� 2
4 �°°`°� '°'y9' '
4
2nd 6/30/010;
,.f�ykf f 4 it....,<,..
A, o MICHAEL E. ANDERSCN
Department of Health and Human Services approval
Reviewed and approved bG:iv [ Date: " /7-01
S 5,,:-. CE-4381
t4 aROFc5510 P .j'
(Rev. 70/99)
t7 W% ol. b.'
September 10, 2001
Municipality of Anchorage
Building Safety Division
On -Site Water and Wastewater Program
4700 S. Bragaw Street
Anchorage, AK 99507
Attention: Dan Roth
Subject: Lot 6, Block 2, Glenn View West Subdivision Phase 11
Septic System Design
Permit Number SW010050
Dear Dan:
The location of the absorption trench for the subject lot was moved toward the back of
the lot to allow more buffer between the front of the house and the roadway. A test hole
was placed at the location shown on the site plan for the as -built which revealed
identical soils to those shown on the test hole submitted with the design. A percolation
test was performed at the new test hole and the results are attached. In addition, water
monitoring at the new location revealed no groundwater. Placing the absorption system
at the location shown will not conflict with wells or septic systems in the area. We
therefore request the final location of the septic system be approved as submitted.
Sincerely,
Michael E. Anderson, P.E,
Attachment
Municipality of Anchorage
DEVELOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK 99519-6650 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number SW010050
PAULA SUE
CIRCLE
1
PID No. 051-793-27
Four Bedroom
Home
ilk
c4 5
S1 ® M7
Alternate Site
10Landscape Easement
15' Utility Easement
Page 2 of 3
81
S2
M1
C4
C5
38.1
30.2
40.9
25.5
40.4
PLAN AS-BUILT
it"e
....
e ,4=micHarti E. ANDERSON ,
"t-\ GE -43814 Co
SCALE 1" = 40'
8
29.6
37.3
96.4
42.8
95.9
Municipality of Anchorage
DEVELOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK 99519-6650 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number SW010050 PID No. 051-793-27
U
99.7
NMV
UUU
2"" rns
NMV•
UU
1,250
95.9 / Gallon
Se . Tank
99.2
Geotextile
N
x
E
1.
Fabric
95.7
Page 3 of 3
P8
81.2
55'
PROFILE AS -BUILT
1"=10'
95.35
87.7
SaVAz
OF 4/
4cTH
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C•` 9 . N;iCHAEL E. ANDERSON e 4,
. CE -4381
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PROFESS\O 44.
a
AP
se
Rock
cat
iDrainfield
4
81.2
55'
PROFILE AS -BUILT
1"=10'
95.35
87.7
SaVAz
OF 4/
4cTH
t�7J�%�°
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C•` 9 . N;iCHAEL E. ANDERSON e 4,
. CE -4381
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PROFESS\O 44.
a
Municipality of Anchorage
Department of Health & Human Services
825 L Street, Anchorage, AK 99502-0650
SOILS LOG - PERCOLATION TEST
A
O'r it
r.r: Lao \ -...
z.
�frc.PFO
Performed For: MM&M Contracting Date Performed: °fir,' 6OFESSO
Legal Description: Lot 6. Block 2 Glenn View West Estates Phase II
SLOPE
TESTHOLE NO. 2
GM/SM
Silty Gravel
6 with Sand
Bottom of
Test Hole
Was Groundwater
Encountered?
North
South
No
If Yes, What Depth?
Depth to Water
After Monitoring 713/01
Date:
None
S
L
0
P
E
SITE PLAN
See Site Plan
Reading
Date
Gross
Time
Net
Time
Depth To
Water
Net
Drop
1
26 -Jun
2:08
1.38"
2
2:38
3.5"
2.12"
3
3:08
5.75"
2.25"
4
3:09
1.5"
5
3:39
3.75"
2.25"
Perc. Rate: 13.3 Min./Inch Perc. Hole Diameter: 6"
Test Run Between 5 Ft. and 6 Ft.
Comments: Perc. Cavity Presoaked Prior to Test. Test Hole Placed During Construction
Performed By: Mike Anderson, I Michael E. Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 9/10/01
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Permit Number: SW010050
Legal Description:
Design Engineer: 0014 Anderson Engineering
Owner Name: MM & M CONTRACTING
Owner Address: P.O. BOX 670495
CHUGIAK , AK 99567 -
This permit is for the construction of:
Disposal Field ✓ Septic Tank
Holding Tank
(o/3o/&: fb:oom4
Date Issued: Apr 03, 2001
Expiration Date: Apr 03, 2002
Parcel ID: 051-793-27
Site Address: NI -IN PAULA SUE CIRCLE
Lot Size: 40035 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
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 ( 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.
6-/5-O/ SEF_ EN6/ naR`S Ra✓r:Ea PE 516,1/ pc, TEC 6-/4-G/
A ?T4cR6-D.
Received By:
Issued By:
Date: ' 3°'0
Date: 4 -3 -01
Parcel I.D.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
on -793 -2.7
Permit Number SW O/005'O
Property owner(s) MM&M Contracting Day phone 688.1236
Mailing address (1) P.O. Box 670495 Chugiak, AI( 99567
Mailing address (2)/V//A/ P99tjt19 5tE C /RCLE1 Zip Code 79517
Legal description (Lot, Block & Sub'd.) Lot 6, Block 2, Glenritiew Estates West Subdivision Phrw2
Legal description (Section, Township & Range)
Lot Size 40 037 Acre•/Sq.Ft.
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Number of Bedrooms Three (3)
Well Only
Water Storage
n
C
❑ Jacuzzi ❑
❑ Water Softening Unit (l
n
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit Fees: t ClIXJ
Date of Payment:
Receipt Number:
(Rev. 12/00)
Gal °0t
Waiver Fees:
Date of Payment:
Receipt Number:
MEMORANDUM
DATE: June 16, 2001
TO: Dan Roth l ,�
FROM: Mike Anderson, P.E!' cAs4—
SUBJECT: Lot 6, Block 2, Glennview Estates West Subdivision Phase II
Septic System Design Revision
Permit No. SW010050
We have revised the design for the septic system for Lot 6, Block 2, Glennview Estates
West Subdivision Phase II to include a four-bedroom system as opposed to the original
design which was for a three-bedroom home. The new design includes a 1,250 gallon
septic tank and a 54' long x 3' wide x 7' effective depth absorption trench. The attached
Site Plan shows the location and dimensions of the new system. As with the original
design the new system will not conflict with wells or septic systems on neighboring lots.
Please review the attached design revision and modify the permit to allow the new
septic system design. Thank you for your assistance with this modification.
March 21, 2001
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 6, Block 2, Glenn View Estates West Subdivision Phase II
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 6, Block 2, Glennview Estates West Subdivision Phase II intends to
construct a new four-bedroom home on the lot. The lot is currently vacant and all
adjacent lots in the new subdivision are also currently vacant. We are hereby applying
for a permit to construct a new septic system on the lot to serve the new home. The
attached Site Plan and backup documentation identify the location and configuration of
the new septic system and the parameters used in the design. It also shows the
location of the alternate site and the water service line proposed for the lot. Existing
drainage patterns are also shown and will not be altered by the development of the lot.
Several test holes have been placed in the subdivision over the past years. All of these
holes reveal well to poorly graded gravels with sands with percolation rates between 3
and 21 minutes per inch. A test hole at the proposed location for the new absorption
trench revealed silty gravel with varying degrees of sand. No groundwater was noted in
the test hole during excavation and none was noted during the monitoring period. We
are therefore proposing to place a 3' wide by 54' long absorption by 7' effective depth
absorption trench to treat the septic effluent. The pipe will be placed at 3' below the
existing ground surface and the total depth of the trench will be 10'. A minimum of 3'
of cover will be placed over the bed to prevent frost penetration and possible freezing.
The ground surface on the lot slopes as shown on the attached Site Plan with a slight
grade from east to west. The area for the new absorption trench, however, is fairly flat.
The new trench will be constructed parallel to the contours of the surface in
conformance with Municipal requirements. Grading will be accomplished to assure
surface drainage is away from the new trench. The existing drainage pattern on the lot
will not be affected during development.
If the system is constructed in accordance with our design the following statements
apply:
1. The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future. The subdivision is currently
Lot 6, Block 2, Glennview Estates West
March 21, 2001
Page Two
served by a community water system.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
ciliaLAL
Michael E. Anderson, P.E.
Attachments
c
nWs_
-7,`0 miGIR n E. ANDERSON
#4,%fP ^
CE 4381
PROFESSION
PAULA SUE
CIRCLE
cI
n
m
1
\P\
Four
Bedroom
House
01,250 Gallon
Septic Tank
Alternate
Site
454' Long X 3' Wide
X 7' Effecti e Depth
Absorption Tr-nch
do
LOT 6, BLOCK 2, GLENN VIEW
ESTATES SUBDIVISION
PHASE 2
SITE PLAN
SCALE 1" = 40'
",F OF f
;* 49IEt4,4
4 A 0 MfCHAfL E. ANDERSCN -:
CE - 4381
t s
lat®� ®tea
•
LOT 6, BLOCK 2, GLENNVIEW ESTATES WEST
SUBDIVISION PHASE II
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Four Bedroom Home
Perc, Rate: 6-15 Min./Inch
Application Rate: .8 GPD/SF
Deep Trench System
1,250 Gallon Septic Tank
7' Drain Field Rock
4 Bedrooms X 150 GPD / .8 GPD/SF = 750 SF of Absorption Area
750 SF/14SF/LF = 53.6 LF Trench Length
Therefore: Construct an Absorption Trench 54' in Length by 3' Wide With 7' of Drainfield
Rock Beneath the Distribution Lateral. Distribution Lateral to Be Placed 3' Below Existing
Ground. Total Depth of Trench to Be 10' from Existing Surface. Mound Over Trench if
Necessary to Provide Minimum Cover of 3'.
Natural
Backfill
Geotexti.le
-Fabric
4" Perforated
PVC (Slots Down)
NOTE:
7'_0"
Drainfield
Rock
TYPICAL DEEP TRENCH SECTION
(NO SCALE)
Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 10' Separation From Lot Line.
Minimum 4' Separation From Groundwater.
Minimum 10' Separation From Water Service Line.
Minimum 50' Separation From Break in Grade >25%
l iH
E>
v.Te6.s8Fe7i las 1.yG1(/f}!d� +f
C:• �'C MiCHAEL E. ANDERSON f ^'
CE -4381
Municipality of Anchorage
Department of Health & Human Services
825 L Street, Anchorage, AK 99502-0650
SOILS LOG - PERCOLATION TEST
Performed For: MM&M Contracting Date Performed:
Legal Description: Lot 6. Black 2. Glenn View West Estates Phase II
SLOPE
OG/OL
TESTHOLE NO. 1
GM/SM
Silty Gravel
with Sand
Bottom of
Test Hole
Was Groundwater
Encountered?
If Yes, What Depth?
North
South
No
Depth to Water
After Monitoring 3/10/01
Date:
None
S
L
0
P
E
eco!
cs
cc,
0 P, oMiCHAEL E. gt�DERSG`i•151
#6' CE -4381
$ffy`D •
10/41£411t,‘"»
SITE PLAN
k PROFESS \N
See Site Plan
Reading
Date
Gross
Time
Net
Time
Depth To
Water
Net
Drop
1
19 -Oct
10:15
2.13"
2
10:45
4.5"
2.37"
3
11:15
6.75"
2.25"
4
11:16
2"
5
11:46
4.25"
2.25"
Perc. Rate: 13.3 Min./Inch Pere. Hole Diameter: 6"
Test Run Between 5 Ft. and 6 Ft.
Comments: Perc. Cavity Presoaked Prior to Test. Test Hole Deepened During Construction
Performed By: Mike Anderson, I Michael E. Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 3/21/01
Municipality of Anchorage
Department of Health & Human Services
825 L Street, Anchorage, AK 99502-0650
SOILS LOG - PERCOLATION TEST
Performed For: MM&M Contracting
Legal Description: )mot 6. Block 2. Glenn View West Estates Phase II
SLOPE
tltiS °" Jg
to 49TH %iv 01
070 MICHAEL E. ANDERSCN =�
®® Jl°°° CE -4381 C4
F9F°•. °' kms®
jp
4444PROFESSI % *
1 MMe
Date Performed:
OG/OL
TESTHOLE NO. 1
GM/SM
Silty Gravel
with Sand
Bottom of
Test Hole
Was Groundwater
Encountered?
If Yes, What Depth?
Depth to Water
North
South
No
After Monitoring 3/10/01
Date:
None
S
L
0
P
E
SITE PLAN
See Site Plan
Reading
Date
Gross
Time
Net
Time
Depth To
Water
Net
Drop
1
19 -Oct
10:15
2.13"
2
10:45
4.5"
2.37"
3
11:15
6.75"
2.25"
4
11:16
2"
5
11:46
4.25"
2.25"
Perc. Rate: 13.3 Min./Inch Perc. Hole Diameter: 6"
Test Run Between 5 Ft. and 6 Ft.
Comments: Perc. Cavity Presoaked Prior to Test. Test Hole Deepened During Construction
Performed By: Mike Anderson, 1 Michael E. Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 3/21/01
Try.
1N D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
a 10i392FEE 31999
Performed for:
SOILS PERCOLATION TEST
1*j.9TH
,p
S. CE 7776��
'"
`....
o % �(ennein K Dull • I
Gregory Strong Date Performed:
iklatROFESsk001'
10/2/ nIaNsy
Project: SE1/4, SE1/4, SEC 4, T15N, R1W, SM TEST HOLE # 98-3
ORG -SM - reddish brown
soft, loose
SM/GM — brownish
medium dense to dense
S.O.H.
SEE ATTACHED SITE PLAN
FOR HOLE LOCATION
Was Ground water encountered? NO What depth? NA
Depth to water after monitoring? DRY Date? 10/9/98
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
1
10/9/98
9:47
-
6"
-
2
10:17
30 min
2"
4"
3
*
10:18
-
6"
-
4
10:48
30 min
2 3/4"
3 1/4"
5
*
10:49
-
6"
-
6
11:19
30 min
2 3/4"
3 1/4"
7
8
9
10
11
12
*
WATER
ADDED
Percolation Rate 9.2 (grin/in) Perc Hole Diameter 6"
Test Run Between 3 feet and 4 feet
I, Kenneth M. Duffus, certify that this test was performed in accordance with all State and Municipal guidelines in
effect on this date.
Municipality of Anchorage
On -Site Water & Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 051-793-27
1. GENERAL INFORMATION
Complete legal description
Location (site address) 21200 PAULA SUE CIRCLE, CHUGIAK, AK 99567
Current Property owner(s) RACHEL POTTER
Mailing address 21200 PAULA SUE CIRCLE, CHUGIAK, AK 99567
Real Estate Agent BOB RINK Day phone 261-7619
Expiration Date: 4-19-17
eha
GLENN VIEW ESTATES WEST PHASE II; BLOCK 2, LOT 6
Day phone 529-1091
2. TYPE OF DWELLING:
▪ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
4
TYPE OF WASTEWATER DISPOSAL:
❑ Individual On-site
❑ Individual Holding tank
❑ Community On-site
1111 Public Sewer
WaiverNariance request for: N/A
•
Distance: -
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date: /f����
COSA Fee $ '52.4
Date of Payment
Receipt Number 61lS'16
COSA# 05°157/51
Klni<S c -
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
S. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. 1 further verify that based on the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK, 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the
guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the
condition of the system/s on the dates of the evaluation. Separation distances were measured to readily identifiable features.
Hidden defects or encroachments may exist that were not identified during the evaluation.The operational life of all wells and septic
systems depend on a variety of variables including, but not limited to, soil conditions, groundwater levels (that may fluctuate during
the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system's. These
conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the
system's; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system.
GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the
current systems fail The content of this report is for the sole benefit of the person/party who retained GEG. Reliance upon the
information provided in this report by any other person or party, including but not limited to subsequent property purchasers, is not
authorized. In short, GEG disavows any legal duty to anyone other than the person/party who paid for this repot.
6. DSD SIGNATURE
VSystem #1 Approved for
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms.
Date
gArk
3 •"��
�,Sillisl;
\QL��V OF hyo/
IS ON-SITE 2-
WATER AND
bedrooms, with the following stipulations: t n WASTEWATER fl
PROGRAM
By:
L(! . r
Original Certificate Date: ( C1 1
The frlur4p= ity ar nchorage Develop, emt 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. ATTCHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
(Rnv 10x19119,
Nitrate Advisory
Arsenic Advisory
Other
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
PA 2—
Legal Description: GLENN VIEW ESTATES WEST PHASE II; BLOCK 2, LOT 6 Parcel ID: 051-793-27
A. WELL DATA
PUBLIC WATER
If A, B, or C provide PWSID# _ Well Log (Y/N)
Date completed Sanitary seal (Y/N) Wires properly pr. - -d (Y/N)
Total depth ft. a -, o ft. g height (above ground) in
FROM WELL LOG AT INSPECTION
Date of test
Static water leve ft.
roduction g. p. m.
WATER SAMPLE RESULTS:
Coliform
gpm
PUBLIC WATER
cotoniesI400-m1 Nitrate mg./L
B. SEPTIC/HOLDING TANK DATA
Date of sample:
Tank Type/Material SEPTIC/STEEL
Date installed 6/26-30/2001
Tank size 1250 gal Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping 4/10/2015 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA
Date installed 6/26-30/2001 Soil rating (.
Length 55 ft. Width
I`BELOW EXISTING GRADE
ft2/bdrm) 0.8 System type DEEP TRENCH
3 ft. Gravel below pipe 7 ft.
Total depth 10.9 ft. Eff. absorption area 770 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 4/14/2015 Results (Pass/Fail) PASS
For 4 bedrooms
Fluid depth in absorption field before test 60 in. Water added 1026 gal. New depth *80 in.
215/ 81.5/
Elapsed Time: 1150 min. Final fluid depth 73.5 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date
*1/2" OF WATER IN CO NEXT TO MONITORING TUBE. CO ON OPPOSITE END WAS DRY.
D. LIFT STATION
Date installed
"Pump on" level at in. "Pump of level at
Cycles tested
Size in gallons Manhole/Access (Y/N)
alarm level at in
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
ift station on lot
Absorption field on lot
Public sewer main
PUBLIC WATER
On adjacent lots
On adjacent Tots
Sewer /septic service 0
containment areas
c sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 1004
Wells on adjacent Tots 100'+ PVT. & 200'+ PUBLIC
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 10'+ Water main 101+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+ PVT. & 2001+ PUBLIC
F. COMMENTS
AS -BUILT SURVEY IS ON FILE AT MOA.
A +" ueb Purr ibJ(r izezeler
G. ENGINEER'S CERTIFICATION
1 certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this .
date. �•
Engineer's Printed Nagre JEFFREY A. GARNESS �•
•�
Date
fC/.(
(Rev. 10/12/12)
0
••
Gor-essf i
CE -• �PROF.-ES (Oise
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. C °13 _a2
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
COSA# 0°103 7 -
Expiration Date: / U -- / 6 / 0
GLENN VIEW ESTATES WEST, PHASE 2; BLOCK 2, LOT 6
21200 PAULA SUE CIRCLE * CHUGIAK, AK *
99567
FORECLOSURE Day phone
Day phone
BOB RINK W/ DYNAMIC PROPERTIES Day phone 261—'7619
3111 C STREET * ANCHORAGE, AK * 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
4
TYPE OF WASTEWATER DISPOSAL:
l♦ Individual On-site
❑ Individual Holding tank
❑ Community On-site
❑ Public Sewer
•
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues COSAs upon request to homeowners. Certificates of'On-Site Systems
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Name of Firm
3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AI< 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Address
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. Theoperational
levels thfe at all wells
is and
septic systems depend on the local soils condition, groundwater
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 the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
Approved for 1 bedrooms.
Disapproved.
Conditional approval for
Date
13114ID�a
D
OI
e /0/t ►.ccw�
��eCr o
,2: ON-SITE G-
`' WATER AND .. m
WASTEWATER :
PROGRAM :
v-0 r NTSENC�0)
bedrooms, with the fllowing stipulations:
t'rofessio� buil,,.
�°o.. OF qNr .
. •T, •ltttll�,
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
By:
1/7,
(Rev. 11/05)
)
/o
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
0/6-09
A.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:
WELL DATA
Well type
Date completed
Total depth
GLENN VIEW ESTATES
WEST, PHASE 2; BLOCK 2, LOT 6
ft.
If A, B, or C provide PWSID#
Sanitary seal (Y/N)
Cased to ft.
FROM WELL LOG
Date of test
Static water level ft
Well production
WATER SAMPLE RES
g.p.m.
Parcel ID: OS/ 7 1 3 - "27
PUBLIC WATER
Well Log (Y/N)
Wires properly protected (Y/N
Casing height (ab
ATI CTION
ound)
ft.
Coliform colonies/100 ml. Nitrate mg./L. Other bacteria
g.p.m.
in.
colonies/100 ml.
epic: ug./L. Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Date installed 6/26-30/2001
Tank size 1250 gal. Number of Compartments E Cleanouts (YIN) YES
Foundation cleanout (Y/N) YES
Date of pumping 1 U/' / v el
Depression over tank (Y/N) NO High�water alarm (Y/N)
Pumper San; k�t I'uvt,c trS
C. ABSORPTION FIELD DATA ]•BELOW EXISTING GRADE]
Date installed 6/26-30/2001 Soil ratingq(�.p.d.2 or ft2/bdrm) 0.8
Length 55 ft.
Width 3 ft.
N/A
System type DEEP TRENCH
Gravel below pipe
Total depth 10.8 ft. Eff. absorption area 770 ft2 Monitoring tube YES
Date of adequacy test **10/2/2009 Results (Pass/Fail) PASS
Fluid depth in absorption field before test 30 in. Water added 1260ga1.
Elapsed Time: 240
7 ft.
Depression over field NO
For 4 bedrooms
New depth
65 in.
min. Final fluid depth 61 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date
**HOUSE WAS VACANT AT TIME OF TEST. PRESOAKED ON 9/30/09 WITH 2000 GALLONS OF WATER.
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at in "Pump off level
Datu
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
containment areas
Manhole/Access (Y/N
High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
PUBLIC WATER
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+
Property line 5'+ Absorption field
Water main 10'+ Water service line 10'+
Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
5'+
Surface water 1 00'+
Property line 10'+ Building foundation 10'+ Water main
Water service line 10'+
Curtain drain NONE KNOWN
F. COMMENTS
Surface water 100'+
10'+
Driveway, parking/vehicle storage 10'+
Wells on adjacent lots 200'+
G. ENGINEER'S CERTIFICATION
1 certify that t have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's PrintedlName JEFFREY A. GARNESS
Date IOf4 04
4p
rness:
C%mp0
fe
�e E
aprofeselo,.00�
�D00000��
COSA Fee
Date of Payment
Receipt Number 0
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FORA SINGLE FAMILY DWELLING
Parcel I.D. 051-793-27
1.
GENERAL INFORMATION
HAA# /74-Mmala
Expiration Date: -J9 - = 02
Complete legal description Lot 6, Block 2, Glennview Estates West Subdivision Phase II
Location (site address or directions) 21200 Paula Sue Circle
Current Property owner(s) Mark and Carol Woods Day phone 688-7512
Mailing address 21299 Paula Sue Circle Chugiak, AK 99567
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
Four (4)
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
n
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 Alaska. Certificates 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 and/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. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage Is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the 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 the time of installation.
Name of Firm Anderson Engineering
Address P.O. Box 240773 Anchorage, AK 99524
Phone 522-7773
Engineer's Printed Name Michael E. Anderson, P.E. Date 6121/2002
5. DSD SIGNATURE
Approved for L74- bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
LoV
J2•' ON-SITE •�-
WATERANLL: m
WASTEWATER
PROGRAM `
JIO.f� • e .O~\\\
JJJJ� ENT SEMS
Attachments:
HAA Checklist
Septic System Advisory
Weil Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
BY
77/7/2._7 t K / cC" Original Certificate Date: to
Rev. 12100)
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
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 6, Block 2, Glenn View Estates West Phase II Parcel ID: 051-793-27
A. WELL DATA
Well type AWWU If A, B, or C provide PWSID # Well Log (Y/N)
Date completed Sanitary seal (Y/N) Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate mg./I. Other bacteria colonies/100 ml.
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 612612001
Tank size 1,250 gal. Number of Compartments 2 Cleanouts (YIN) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping Pumper Recent Construction
C. ABSORPTION FIELD DATA
Date installed 6130!2001 Soil rating (g.p.d./f2 or ft2/bdrm) .8 GPD/SF System type Deep Trench
Length 55 ft. Width 3 ft. Gravel below pipe 7 ft.
Total depth 11.5 ft. Eff. absorption area 770 ft2 Monitoring tube Y Depression over field N
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test in. Water added gal. New depth in.
Elapsed Time: min. Final fluid depth in. Absorption rate
>=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
g.p.d.
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
"Pump on" level at in. "Pump off" level at _ in, in.
Datum Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer /septic service line Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5' Property line >5'
Water main N/A Water service line >10'
Wells on adjacent lots >100'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 5'
Absorption field >5'
Surface water >100'
Building foundation >10' Water main >10'
Water Service line >10' Surface water >100'
Curtain drain None Noted Wells on adjacent lots >200'
F. COMMENTS
S
Health Authority was issued on this property in October of 2001. House
year ago.
Driveway, parking/vehicle storage >10'
has been occupied only 8 months. Constructed less than 1
sswike II 4.
. 91: . t '
�,k�4#9
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Michael E. Anderson, P.E.
Date 6121/2002
HAA Fee $
375 tfri—
�• s�oA
g*: 49=w � I#
"" ••M!CHA _E 1',� ERSC,N • •. 2. °
;c. !40 1 "`„�'
V. S .1/
47 a Li
f<qF •" �\a' i>
°`C .4
@4 "frESSI0I °w'
Date of Payment
Receipt Number
(Rev. 12/00)
6—t1 -oz
2144-2,
Waiver Fee $
Date of Payment
Receipt Number
ROM : CeUNT.Y RERLTY
PHONE NO. : 9076881238
5vr?. " ...
Sep. 10 2001 08:44RM P1
-1 GPA s,.
r•
le Wyo., ,"
3<�a Rye •'•-« 400
Y .:.o z3a ..4
h7 ✓44..5
Vis.` .a....'::.�.:
Received Time Sep•10• 9:O1AM
Ihereby entity that FJ ave aegyed ihe.£onQvmg des:.
t,
At::ltaragrc. rding, RecoPie. Alaska and that. the improve,,,
amts st ammo thter.
maroon are wiitthin. the propertylines and do iot
ovllapot a nap$tjj an the property lye adjacent theteto'';fhab'.
no improvemerds on property tying adjacent thereto.enctoach
on the premises in question and that -there are no roadways,?,'
transmission Tinea or other ale* easements on said property
except as iztdirated hereon.
Dated at Eagle Riva: Aknaka
this 7-5^Th• Oaf TO lY zoJ •
SCALEROBERT C. JOHNSON -R
:
I„
SCALE: SurroyortJo.880-L5BOX 77-0456, `'
River„ Alaska :99571
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
HAA # /1/4ofb1/6/3
Parcel I.D. 051-793-27
Expiration Date: C% — I % -
1. GENERAL INFORMATION
Complete legal description Lot 6, Block 2, Glenn View Estates West Subdivision Phase II
Location (site address or directions) Paula Sue Circle
Current Property owner(s) MM&M Construction Day phone 688-1236
Mailing address P.O. Box 670495 Chugiak, AK 99567
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: Four(4)
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class A Well
Public Water System
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 Alaska. Certificates 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 and/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. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the 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 the time of installation.
Name of Firm Anderson Engineering
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
5. DSD SIGNATURE
1/ Approved for ¥ bedrooms.
Disapproved.
Phone 522-7773
Date 9110/01
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
il
WATER AND
•
WASTEWATER
°. PROGRAM
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
BY: So/ G✓. i" cret
(Rev. 12100)
Original Certificate Date: 9 — / 7- 0 /
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
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 6, Block 2, Glenn View Estates West Phase II Parcel ID: 051-793-27
A. WELL DATA
Well type A If A, B, or C provide PWSID # Well Log (Y/N)
Date completed Sanitary seal (Y/N) Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate mg.A. Other bacteria colonies/100 ml.
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 612612001
Tank size 1.250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (Y/N) N
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed 6130/2001 Soil rating (g.p.d./ft2 or ft2/bdrm) .8 GPD/SF System type Deep Trench
Length 55
ft. Width 3 ft. Gravel below pipe 7 ft.
Total depth 11.5 ft. Eff. absorption area 770 ft2 Monitoring tube Y Depression over field N
Date of adequacy test
Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test in. Water added gal. New depth in.
Elapsed Time: min. Final fluid depth in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
g.p.d.
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at _ in. "Pump off' level at in.
Datum Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer /septic service line Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Manhole/Access (YIN)
High water alarm level at in.
Meets alarm & circuit requirements?
Building foundation >5' Property line >5'
Water main NIA
Wells on adjacent lots >100'
Absorption field >5'
Water service line >10' Surface water >100'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line >10' Building foundation >10'
Water Service line >10'
Water main >10'
Surface water >100' Driveway, parking/vehicle storage >10'
Curtain drain None Noted Wells on adjacent lots >100'
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that t have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Michael E. Anderson, P.E.
Date 911012001
APV
t
RP'
•AS
F F
..Mt ICH E L thts .a
FC. , CE 'MVP
#m00 :k6FESS10 s;c;—'
HAA Fee $ ")1 `3
Date of Payment q ti; o5
Receipt Number
(Rev. 12/00)
t_UDOH
Waiver Fee $
Date of Payment
Receipt Number