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Home My WebLink AboutUNDERMOUNTAIN ESTATES LT 7 Municipality of Anchorage Page 1 of 3 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: _~W9802! 0 PID Number: 050-481 -09 Name: MM&M Contractin~ Wastewater System: E] New [] Upgrade Address: P.O. Box 670495 Chugiak, AK ABSORPTION FIELD ind. of Bedrooms: Phone: 688--1236 Four (4) ~geepTrench [] Shallow Trench E]Bed {2]Mound DOther LE GAL D ESCRIPTI O N so, Rating: Total Depth from original grade: · 4 5 GPD/Sq. Ft. 1 1 . 5 Lot: Block: Subdivision: Depth to pipe bottom from o¢iginal grade: Gravel depth beneath pipe 7 v Undermountain Est. 1 . 5 Ft 1 O Ft. Township: I Range: I Section: Fill added above original grade: Gravel length: 2,5 Ft. 6 7 Number of lines: 0islance between lines: WELL: E3 New [] Upgrade irave~width: 3 pt 1 - Classification (Private. A.B.C): Tolai Oeplt~: Cased TO: To(al absorption area: Pipe material: Private 200 F~. 38 P~. 1 f340 so.~. ASTM D3034 PVC Ormer: Sullivan 7/6/98 . 80 Ft. MM&M Contracting 8/1-5/98 Yield: 10 GPM Pump Set at: Ft. Casmg Heighl2 *bo,e Grou,,:F,. TAN K SEPARATION DISTANCES :~eptic [] Holding [] S.T.E.P. From TankI Field Station Tank Sewerl.ines Anc. Tank 1 , 250 Well >200 >200' N/A N/A N/A Steel Two Sudace >200 >200' N/A N/A N/A LIFT STATION Water LOt > 5 ' > 1 0 ' N/A N/A N/A Size in gallons: Manufacturer. Line Foundation > 5 ' > 10 ' N/A N/A N/A "Pump on" level at: "Pump off" level at: High water alarm at: Curtain None on Lo PumpMake& Model I Electrical Inspections pedormed by: Drain I Remarks: 2" Insulation over septic BENCH MARK tank per installer. Garage Floor Slab I Assumed ~:levation: Inspections performed by: ~4EA Dates: 1st R/ /98 ..Ct .___ 2nd 8~5~98 Department of Heal. and I-'Juman Semites approval ~.,t'I... ~'~ ..~ Reviewed and approved by' ,/~'/~//'~,~"¢----~// ~ Date:/2 ~/'-¢,¢;~ '1 ?~ · Municipality of Anchorage Page 2 of 3 ., , ,,., DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, AK 99519-6650 343-4744 On-Site Wastewater Disposal System or Well Inspection Report Permit Number SW980210 PID No. 050 ....... -481-09 Four Bedrm Home Sl S2 C3 C4 M1 A 82 86 90 148 148 1,250 Gallon Septic Tank B C 05.5 09.1 .7 14.5 .5 154.0 .0 153.5 PLAN AS-BUILT SCALE 1"= 30' ~7' Long X 3' Wide X 10' Effective Depth Trench ;2 ~1 C3 C4 T~{ 2 ~ TH 1 ! Reserve Area Municipality of Anchorage Page 3 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, AK 99519-6650 - 343-4744 On-Site Wastewater Disposal System or Well Inspection Report Permit Number SW980210 PID No. 050-481-09 5 MMM CONTRACTING PHONE NO, ; ~881258 Nov, 06 1998 11:13AM P1 "" "' - .ox:'~7o~ - .: ':'" ' "P.O' 'CHUOIAK ALASKA ggS~7 · TELEPHO~ 688 2769 ' '. :' ' :. ~WNBR OF LAND /*~//~ ./'~_.._! ADDRESS · · LEGAL DESCRIPTION , '...' ._d.~E~.,,.-p'/o,~ ~ · PERMIT NUMBER ~0~ Date of l~sue ~ -~- TAX INDgNTIFIOATION NUMBE" :0~'- 4,~L- .'0 Is ~well i~'cated.at approved permit Io~ation? ~s , ~ No Method of DHUIng: ' '~rota~ ~ cable tool D'ep~h of welh ~ ....... . DJ;meter A ,t inoh"s,, depth ' ~ .' ,.feet Liner Type:' ' ~3~'[ Caslng'Stlck'up Above ~mund:...' ~ ' ' rem Static Water Level (from ground level): ' . ~ feet Pumping level; .... feet after.· hrs. pumping ...... Recove~Rate: ~0' gpm' : Method of To,ting: ,,.._~1 ~ ' . Well ntake Opening T~pe: ~ ~pen End' [~ .'Screened: Start. [~ Perforations Stad. Grout Type: Depth; from . ~ Pump intake Depth: __' Pump Size.. hp 'Brand Name Well Disinfected Upon Completioh? ~ {~ NO Method of Disinfect{on' C Comments: ~'~ ' ~ ~/~/ . '' foot BORE HOLE DATA DEPTH RE.'C VE'D NOV 24 1998 ' Municipalitg~t Anchorage )rlller'a Name l~~'''~ ~ ,,' ATTENTION: It Is the responsibility of .the property owner to Submit a copy Of the well Icg to the' proper authority. Muhiolpality of. Anchorage: Department of Health & Human Se~v!ces end/or. Depertn~ent of Environmental Conservation, MatSu 'Borough: Department of Environmental Cbnservatioll. . . MUNICIPALITY OF ANCHORA GE Department 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 / WATER SUPPLY PERMIT Initial Date Issued: Jun 30, '1998 Expiration Date: Jun 30, 1999 Permit Number: SW980210 Legal Description: UNDERMOUNTAIN ESTATES LT 7 Design Engineer: Anderson Engineering Owner Name: MM&M Contracting Owner Address: PO Box 670495 Chugiak, AK 99567- Parcel ID: 050-481-09 Site Address: Lot Size: '102113 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 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: 2. The attached approved design. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska 3. Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling 4. (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 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: ~/~45~ (~ ~ Date: June 21, 1998 Municipality of Anchorage Department of Heath & Human Services 825 "L" Street Anchorage, AK 99502-0650 Subject: Lot 7, Undermountain Estates Subdivision Septic System Design Impacts to Adjacent Properties Dear Onsite Services Engineer: We are hereby applying for a permit to construct a new well and septic system on Lot 7, Undermountain Estates Subdivision. The lot is currently vacant with no development on any side except to the east. The attached site plan and backup documentation identify the size and location of the new septic tank and absorption trench to serve the home. It also shows the location of the proposed well and the 100' protective radius. Nowells on adjacent lots are within 200' of the new septic system. Two testholes were placed on the lot at the locations shown. Silty gravel was found in the holes nearly full depth with only a shallow layer of organic material found at the top. Both holes were nearly identical with percolation rates of 40 minutes per inch at the 4' to 5' level. No groundwater was noted during excavation nor was any found during the monitoring period. We are therefore proposing to construct a deep trench system with 10' effective depth. Total length will be 67' with the distribution piping at 1' below the existing ground surface. A new 1,250 gallon septic tank will be placed outside the 100' protective radius of the well. The surface of the lot slopes dramatically from north to south at rates approaching 25%. Some slope flattening may be required to achieve the 50' separation distance from the septic system to the break in grade. Substantial sitework will be required on the lot, however, to pride driveway access and a building site. Excess material will be used to flatten the slopes near the septic system. 'Lot 7, Undermountain Estates June 21, 1998 Page Two If the 1. 4. system is constructed as designed the following statements apply: 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 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. The system, if constructed as designed, will have no adverse impact on reserved space, either surface or subsurface, on any lots located in the area. 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, Michael E. Anderson, P.E. Attachments ROAD Proposed Well 7,250 Effect. NOTE: MAINTAIN 50' SEPARATION FROM ANY SLOPE NO WELLS IN THE AREA ARE WITHIN 150' SEPTIC SYSTEM AREAS. THAN 25%. PROPOSED SITE PLAN SCALE. 1" -- 50' LOT 7, UNDERMOUNTAIN ESTATES DESIGN FACTORS; SYSTEM REQUIREMENTS: Four Bedroom Home Deep Trench System Perc. Rate: 30 - 60 Min./Inch 1,250 Gallon Septic Tank Application Rate: .45 GPD/SF 10' Drainfield Rock 4 Bedrooms X 150 GPD / .45 GPD/SF = 1,334 SF of Absorption Area 1,334 SF/20 SF/ LF of Trench = 67 LF Trench Length Therefore: Construct a Deep Absorption Trench System With One Lateral 67' in Length with 10' of Drainfield Rock Beneath the Lateral. Distribution Pipe in Trench Placed at 1' Below the Original Ground Surface. Natural Backfill Geotextile Fabric 4" Perforated PVC (Slots Down) t0' Drainfield Rock 2' (Minimum) NOTE: TYPICAL DEEP TRENCH SECTION (NO SCALE) Grade Area Over Trench to Drain Away. Minimum 3' of Cover over Septic System. Maintain 50' Separation From 25% Slope. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: MM&M Contracting LEGAL OESCRIPTION: Lot 7r OL Estates 1 2 3 4 5 6 7 8 9- 10- 11 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS DATE PF..RI Undermountain Township, Range, Section: GM SLOPE Bottom of Hole 1 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? nepth to WaJ~.r Ajar MoAimnng? NQ~ n~,~ 6/1 7/9. SITE PLAN 3e~ S:Lte~PLa] '~/ ~/~/~6 ~ ~ ~ -- ~y~. ,, --- I I PERCOLATION RATE z~ (m:nutes/lnc~) PERC HOLE DIAMETER TEST RUN BETWEEN z./__ FT AND ~'-- FT Test Cavity Presoaked Prior to Test.. ACCORDANCE WITH ALL STATE AND MUNICIPAl. GUIDELINES IN EFFECT ON THIS DATE. DAT~' (~/~//~ ~ 72-008 (Rev. 4/~5) Muni~palib/of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502~550 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: MM&M Contracting LEGAL DESCRIPTION= 1 2 3 4 5 6 7 8 9 10 11 12 Lot 7 ~ Undermountain OL Estates GM TESTHOLE NQ, 2 Township. Range, Section: ....... SLOPE SITE FI.AN It WA~ GROUND WATER ENCOUNTERED? IF ¥E$o AT WHAT DEFrH? 13- 14- 15- 16- 17- 18- 19- 20- Bottom of Hole None Mm 6/17/9 Reading ~te Groa; Net Time .T;me ,~/. ;:$~ -- t Drop PERCOLATION RATE 4~ O (mmute~m~J~) PERC HOLE DIAMETER ~ /' T~T RUN B~W~N ~ ~ AND COMMENTS. Test Cavity Presoaked Prior t6 Test. PERFORM~ ,y: _ A. Harala I '~'~ ~~,FY ACCORDANCE WITH A~ STATE AND MUNICIPAL GUIO~NES IN EFFECT ON THIS DATE DA~ 72~ (R~, %4v Ir" cod , Municipality of Anchorage %Y40 zN On -Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 050-481-09 Expiration Date: 1. GENERAL INFORMATION Complete legal description Undermountain Est. Lot 7 Location (site address) 24707 O'Reindner Current Property owner(s) Sean Wagner Day phone 907-854-1155 Mailing address Real Estate Agent 24707 O'Reindner Eagle River, AK 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 4 TYPE OF WASTEWATER DISPOSAL: 4. TYPE OF WATER SUPPLY: Individual Individual Well ® Holding Tank ❑ Individual Water Storage ❑ Community ❑ Community Class _ Well ❑ Public Sewer ❑ Public Water System ❑ WaiverNariance request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 55-D Date of Payment 11-2.(o'lg1 Receipt Number 2V5-5�� COSA # 05C1 q 14%01 Date: Waiver Fee $ Date of Payment Receipt Number Waiver # 1-43114eNo; j 5. STATEMENT O ION 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. Name of Firm ARCTERRA CONSULTING, INC. Phone 696-6111 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date / as Engineers Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future �� ►\ occupants or can ArcTerra guarantee that no unseen i O Z4. encroachments, deficiencies or discrepancies exist. W CNV j4 S; 1 6. DSD SIGNATURE System #1 Approved for bedrooms. �1 „ j System #2 Approved for Disapproved. Conditional approval for bedrooms, with the following stipulations: Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet 10-10-12.doc �por'ed -12eI -�o✓ Wswhrl* c.a I :rr¢v OSA Checklist s Legal Description: Undermountain Est. Lot 7 Parcel ID: 050-481-09 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 7/6/98 Total depth 200 ft Cased to 38 ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 38 in. Date of flow test for COSA 11/8/19 Static water level at beginning of test 76 ft. Comments B. TANK DATA Age of tank(s) 21 years Tank type/material Septic/Steel 49" Measured operating fluid level in septic tank ® Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA Which system tested (date installed) _a�g ® ALL standpipes present per record drawing Total measured depth from grade 13.7 ft (max) Measured depth to pipe invert from grade 3.6 ft (min) ❑ N/A — pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective Structure served by this system 1 Well production at time of test 5.5 gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes 0 Nc ® Coliform bacteria is Negative Nitrate 234 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) Collected by Arcterra Consulting Date of Sample 11/8/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 11/8/19 Results ❑✓ Pass For 4 bedrooms Fluid depth prior to test 50 in Water added 600 gal New depth 63 in Elapsed time 10 min Fil fl ® Code -required soil cover over field nauid depth 50 in FJ System presoaked Absorption rate 600+gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet lf'� 0. " A 7;� E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ® Yes if No Community Sewer Manhole/Cleanout > 100' ® Yes if No ft 7 Yes if No ft Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' VI Yes if No ft Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ® Yes if No ft ® Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: ® Yes Absorption Field > 5' ® Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' ® Yes if No ft Community Wells > 200' Yes if No ft Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS 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 COSA guidelines in effect on this date. COSA Checklist yellow sheet 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. Cf CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING .050-481-09 V HAA# , 1. GENERAL INFORMATION Complete legal description Lot 7, Undermounta±n Estates Location (site address or directions) Riedner Road Property owner Mailing address Lending agency Mailing address Agent Address ': ~&M Contracting Dayphone P.O. Box 670495 Chugiak, AK 99567 688-1236 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: Four (4) TYPE OF WATER SUPPLY: Individual well XZX 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 ××x Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~925 (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 0f structure indicated herein. ~ further verifythat 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 Anderson' Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's signature · Date 11/12/98 DHHS SIGNATURE ~ Approved for ¢ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date 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. 72-025 (Ray. 1/91) Beck MOA #21 Municipality of Anchorage J~ E C E I V E,~ DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division NOV 2. 4 199I 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907~)r~/~i~a~y of Anchorage oept. Health & Human Services Health Authority Approval Checklist Lot 7, Undermountain Est. Parcel D.: 050-481-09 If A, B. or C, attach ADEC letter. ADEC water system number Legal Description: A. WELL DATA Well type Pr±vate Log present (Y/N) Total depth ;200 ' Sanitary seal (Y/N) Date of test Static water level ¥ Date completed 7 / 6 / 98 Cased to 38 ' ¥ FROM WELL LOG 7/6/98 80' g.p.m. Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Well production I 0 WATER SAMPLE RESULTS: Coliform 0 Date of sample: 11 / 1 0 / 98 B. SEPTIC/HOLDING TANK DATA Date installed 8/5/98 Foundation cleanout (y/N) Date of Pumping New C. ABSORPTION FIELD DATA Date installed 8 / 1 - 5 / 98 Length 67 ' Width Nitrate Non Detect Collected by: Other bacteria 0 MEA g.p.m. Tank size 1,250 Number of Compartments __ Y Depression (Y/N) N - Pumper 2 Cleanouts (Y/N) Y High water alarm (Y/N) N Soilrating (g.p.d./ft2orft2/bdrm .45 Systemtype Dee Tren h 3 ' Gravel thickness below pipe 1 0 ' Total depth 1 4 ' Effective absorption area 1,340s~F~.3Monitodng Tube present (Y/N)__ Date of adequacy test New Const. Results (Pass/Fail) Pa.~.~ Fluid depth in absorption field before test (in.); Fluid depth (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) N immediately after bedrooms Depression over field (Y/N) __ For 4 gal. water added (in.): Absorption rate = g.p.d. If yes, give date 72-026 (Rev. 3/96)* Eo LIFT STATION - Date installed None on Lot Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line Manhole/Access (Y/N) High water alarm level at* *Datum Cycles tested SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: >100' >100' N/A >25' Size in gallons "Pump on" level at* On adjacent lots > 1 f~ 0 ' >100' On adjacent lots Public sewer manhole/cleanout Lift station N/A "Pump off" level at* >100' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation > 5 ' Propertyline > 5 ' Absorption field. Surface water > 1 0 0 ' Curtain drain None on Lot F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections in conformance with MOA HAA guidelines in effect on this date. Signature Engineer's Name Michael E. Anderson, P,E. Date 11/12/98 Water main/service line > 2 5 ' .Sudace water/drainage > 1 0 0 ' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line > 1 O ' Building foundation > 1 0 ' Driveway, parking/vehicle storage area Wells on adjacent lots > 1 f) ¢) ' N/A Water main/service line systems are HAA Fee $ ~C') Date of Payment ~ Receipt Number z/ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number