The URL can be used to link to this page

Home My WebLink AboutEKLUTNA WEST LT 15Eklutna W st Lot 15 #051-062-42 Municipality of Anchorage Page I of ~- 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: ~'/~'~° ~3. PID Number: ~5'-/ ~ ~ ~ Name: ~~ ~ ~t'$~ ~~ Wastewater'~tem: ~New D Upgrade ~d~,: ABSORPTION FIELD Phone: INo, of Be~ooms: .~roeepTrench ~ShallowTrench ~Bed ~Mound ~Other LEGAL DESCRIPTION SoilRating: /. ~ GPD/Sq. Ft. TotalDepth~o~originalgrade: Lot~ Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth b~ea~ pipe Township: I Range: I S~tlon: Fill added above original grade: Gravel length: /, ~ Ft. ~ ' Ft. I I WELL: c"'~"~e~ C Upg~ Gravelwidth: ~' Number of lines: ~t. / ~ Ft. ~ion (Private, A.B.C): ~' Cased To: Total absorption area: P pe material: [ ~ / FL F~. ~ ~ ~ SQ. Ft. ~/~ t~ Y Driller: ~ Date Drilled: Static Water Level: Installer: ~/~¢~ Date installed: ~_ Pump Set at: Ft. ~ C~ing Height A~v~ound: ~ GPM Ft. TANK SEPARATION DISTANCES ~ptic D Ho,~g ~ S.T.S.P. To Septic A~o~tion Lift Holding Public/Private Man, lecturer: ~ Capac[W in gallons: From Tank Field Station Tank Sewer Lin~ ~,~, ~ / ~ Material: i Number of Compa~ments: Su,ace ~ ...... w~.~ ~ ~--- LIFT STATION Lot ~' i~' I ~ ' Size in gall°ns: I Manufacturer:~ Line Foundation ~/ ]~f ~/ "Pump on" level at:~~' level at:' ~- i CuAain Pump~odel ~ Electrical inspections pedormed by: Drain ~ ..... -~ '~ Remarks: ~~r ~ ~ ~'~ BENCH MARK Location and Description: Elevation: ENGIN~Ah:S SEAL Inspections pedormed by: ~ ~ ~ ~' Dates: let ~-Z~ ~? ,,~/49'"~,- ~ Depadment of Health a~d Human Sewices approval 't~'~.~% ~"~'c.~ Reviewed and approved by: Date:/~ -~-~ ~ 72-013 (Rev. 9/91} MOA 25 ,I Permit No. $W980382 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-665~ Telephone: 543-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: Eklutna West Lot 15 PID No.: 05106242 SWING TIES A-C =17.3' B-C =12.1' A-D =22.3' B-D =44.3' S89'26'49"E 178,40 PIT ABANDONED o TANK ABANDONED S89°26'49"E Approximete Keybox Location 255.28 ELEVATIONS (NOT TO SCALE) NE LOT COR REBAR ASSUMED ELEV = 100.00 1000 GAL SEPTIC TH1 o~ o ~ 1¸5' ALL SEPTICS +50' [] - TEST HOLE ALL WELLS +200' ° - MONITOR TUBE o - SEWER CLEANOUT + - WELL LEACHFIELD EASEMENT SCALE 1"-40' 10/5/98 ORIGINAL GROUND LEVEL AT: N89.6 MUNICIPALITY OF ANCHORAGE 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 PERMIT Upgrade Date Issued: Sep 24, 1998 Expiration Date: Sep 24, 1999 Permit Number: SW980382 Legal Description: EKLUTNA WEST LT 15 Design Engineer: 0024 Eagle River Engineering Services Owner Name: Norma Louise Sharon Owner Address: 204 Stan Key Road Castle Rock, WA 98611- Parcel ID: 051-062-42 Site Address: 021431 SETTLERS DR Lot Size: 27841 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] SepticTank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received B~ ~ ~ Issued By: :?¢~"/-~-"/~ ~ Date: Date: Eagle River Engineering Services Louis Butera, P.E. P.O. Box 773294 (907) 694-5195 tel Eagle River, AK 99577-3294 (907) 694-3297 fax September 21, 1998 Jim Cross, P.E. Manager, On-Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Eklutna West Lot 15 Narrative & Permit Application Dear Mr. Cross: We are applying for an upgrade permit for a dwelling where the old undocumented leachpit has collapsed and has to be replaced as soon as possible. We are applying in advance of the 7 day monitoring period with the intent of the permit being issued as soon as the ground water table is confirmed. The test hole is 18' deep with no water at this time and the system is designed at a total depth of 8'. The proposed septic upgrade will have very limited impact on adjacent properties for the following reasons: 1. The surrounding lots are large, allowing sufficient room for septic sites. 2. Immediate neighboring septic systems are all +30' distance. 3. Drainage will not be affected and is not a major consideration in our design, 4. The entire surrounding area utilizes a community waster system which results in sufficient reserve area for all lots, soil is excellent. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. \ 1998\98-068-NAR PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORMED: '~-- /oc~-- ~'~ LEGAL DESCRIPTION: ~'"k//~7-~/~: J4,~-,57'- /_.~,-/- /..C-- Township, Range, Section: SLOPE SITE PLAN 1 2 3 4 ;,,'r ~,-~ 5 6 7 8 9 10 - WAS GROUND WATER ENCOUNTERED? 11 IF YES, AT WHAT 1 2 DEPTH? kth to Waler Alter 13 - Monitoring? /~ gate: ,tV'o S E 14- 15 16 17 18 19 20 Gross Net Depth to Net Reading Date Time Time Water I ~/- ~/-,/~ I~-.'~? ~I ~'I~ t Io,.,.., ~ i I~.'o/ ~ 7 ~l/~ PERCOLATION RATE __ TEST RUN BETWEEN __ ~o 5'"' (m~nutes,'inch) PERC HOLE DIAMETER Z2/ FT AND ~- FT COMMENTS PERFORMED BY: -"~,'~ Z:~ J'" I .~_~---~ ~z~'-~--~'~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; ~;7~ ~ ,~---~.-~-,oc, 72-008 (Rev. 4/85) PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street. Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED: LEGAL DESCRIPTION: ~C"/</~, 7-~.~ /,~-~7" Z~?- /~'- ToWnship. Range. Section: 1 2 3 4 5 6 7 8 9 10 '11 12 13 14 15 16 17 18 19 2O COMMENTS T SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? ,~/'(3 S IF YES. AT WHAT ~.,'~A (~ DEPTH?. p E Depth to Water After Monitoring? . Dote:. Gross Net Depth to Net Reading Date Time Time Water Drop ~'~.~ PERCOLATION RATE ~° '?' (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN Z/' FTAND -~- FT PERFORMED BY; ~'"~' ~ -'f'' I -~'~"~ ' CERTIFY THAT THIS TEST WAS PEI~FORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; ~- Eagle River Engineering Services Louis Butera, P.E. P.O. Box 773294 (907) 694-5195 tel Eagle River, AK 99577-3294 (907) 694-3297 fax LEGAL: A. 1. 2. 3. SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM Eklutna West Lot 15 9/21/98 GENERAL The septic plan is for a single family residence only. The drawing and or site plan shall be a part of this specification. All materials and workmanship shall meet the Anchorage Department of Health and State Department of Environmental Conservation requirements. 4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. 5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage, Department of Environmental Conservation requirements. 6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi-family wells. 7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. 8. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. 9. Any remaining open test hole excavations shall be filled. B. SEPTIC TANK 1. Septic tank shall have a minimum capacity of 1000 gallons and shall be of MOA approved design. 2. Existing septic tank and leachpit to be pumped and filled with native earth, abandoned in place. C. TRENCH 1. The trench is to be located as shown on the site plan. 2. The bottom of the trench excavation shall be level, plus or minus 1.5". 3. The total depth of the trench excavation is not to exceed 8' at any point. 4. The sewer line is to replace the existing sewer line that leads to the existing pit with plumbing routed under the trailer to exit the front of the building. The effluent line within the trench shall be laid level within 0.03'. 5. The trench gravel is to be covered with typar fabric material. 6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed over the leachfield. 7. The area over the trench is to be finish graded to prevent ponding of surface water runoff. 8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS: TOTAL DEPTH = 7' min. or 8' max TRENCH LENGTH = 38' SOIL RATING = 1.2 GPD/fi2 SEPTIC TANK = 1000 gallons GRAVEL DEPTH = 4' under pipe, 2" over pipe TRENCH WIDTH = 5' BEDROOM CAPACITY = 3 Bdrm Twenty-four (24) hours notice required for all inspections. \1998\98-068-spc EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294 Eagle River, Alaska 99577 (907) 694-5195 ERES Project No.: 98-000 Calculated By: LB Date: 9/22/98 Legal: Elkutna West Lot 15 Single Family 3 Bedroom Dwelling TEST HOLE Shallow Trench Subsurface Wastewater Disposal Field Water use at 150 gallons per bedroom = Percolation rate = Wastewater application rate = Required absorption area = Trench width (W) = Grovel depth (D) = 450 gallons 1.5 minutes per inch 1.2 gallons per day per square foot 375 square feet 5 feet 4 feet Required length = Shallow trench factor * Required absorption area / W Shallow trench factor = (W + 2) / (W + 1 +2 D) Shallow trench factor = 0.50 Total Excavation Depth = 7.0 feet Required length = 38 feet EKLUTNA.xls 8:38 AM9/22/98 SINGLE FAMILY ON-SITE WORKSHEET ERES PROJECT NUMBER: 98-000 LEGAL DESCRIPTION: Elkutna West Lot 15 NUMBER OF BEDROOMS: 3 WATER USE PER BEDROOM: 150 PERCOLATION RATE: 1.5 DEPTH TO GROUNDWATER: 18 DEPTH TO IMPERMEABLE LAYER: 18 ANTICIPATED DEPTH OF COVER: 3 MOUND OR BED SYSTEM CALCULATED BY: LB WASTEWATER APPLICATION RATE: ABSORPTION AREA REQUIREMENT: MINIMUM BED LENGTH 12 FEET WIDE BED 15 FEET WIDE BED TRENCH SYSTEM WASTEWATER APPLICATION RATE: ABSORPTION AREA REQUIREMENT: SHALLOW TRENCH OPTIONS 5 FEET WIDE TRENCH GALLONS MINUTES PER INCH FEET FEET USABLE SOIL STRATA FEET TOTAL USABLE DEPTH: USABLE SOIL STRATA DEPTH: 0.8 GAL/SQ.FT 563 SQ.FT 12 9 47 FEET 38 FEET 1.2 375 GAL/SQ.FT SQ.FT DEEP TRENCH OPTIONS 3 FEET WIDE TRENCH EFFECTIVE REQUIRED TRENCH EFFECTIVE REQUIRED TRENCH DEPTH (FT) LENGTH (FT) DEPTH (FT) LENGTH (FT) 1 66 4 47 2 53 4.5 42 2.5 48 5 38 3 44 5.5 34 3.5 40 6 31 4 38 7 27 8 23 9 21 10 NA DESIGN SPECIFICS FIELD SYSTEM: S GRAVEL DEPTH: 4 TRENCH OR BED WIDTH: 5 LENGTH: TOTAL EXCAVATION DEPTH: 7.0 (B=BED, S=SHALLOWTRENCH & D=DEEP TRENCH) FEET FEET FEET FEET EKLUTNA.xls 8:38 AM9/22/98 ,J S89'26'49"E 178.40 ' O .,,4.% ~qS/ ABANDON EXISTING oTANK !~--n ~ % ] % /~-~ . ' S89'26'49"E ~ 5'X58' TRENCH kEYBOX 235.28 ALL SE?TICS +30' LOCATION ALL WELLS +200' [] - TEST HOLE ALL SURROUNDING LOTS · - MONITOR TUBE ON COMMUNITY WATER o - SEWER CLEANOUT '4,- - WELL EASEMENT NO SURFACE WATER PROPOSED LEAOHFIELB NO KNOWN CURTAIN DRAINS I...i.- EXISTING LEACHFIELO S E PTI C S IT E P LA N LEGAL: EKLUTNA WEST LOT 15 ~. CONTRACTOR: N A ~ ~ ,~-~ --~'~ · .. A EAGLE RIVER ENGINEERING SERVICES ,~.g .,,GU,SA. BUT~RA,* EAGLE RIVER, AK. 99577 "0;~"¢ ' .... (907) 694-5195 FAX.. (907) 694-3297 Municipality of Anchorage Development Services Department Buitding Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.a k.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 05'1- 0~2- q-2 1. GENERAL INFORMATION Complete legal description ~gk ~ a ~'na [V'~ 5 ~ . ]- 0 ~ Location (site address or directions) .~1'~'31 .~e~ef'5 Dr,,. ~d~ial~ Current Property owner(s) ~e~ ~ IH~en~ T ma. ~ Day phone Mailing address ~0. ~0A 102 17~/ ~,r4~e ~ ~K qq~lO Lending agen~ ~ I/x F~ ,, ~ ~-~r~r~ Day phone Mailing address ~t~ ~ ~¢Z.~.~ Real EstateAgent V;~a Xe~( Esf,~e Dayphone Mailing Address ~A~I ~ ~free f Unless ethe~ise requested, H~ will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class /4 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 H4As 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 o!d. (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 appIication, 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 sb'ucture indicated here{n. I further verify that based on the information obtained from the Municipality of Anchorage flies 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. Address n0, E,~,~ Engineer's Printed Name DSD SIGNATURE p'"' Approved for Disapproved. Conditional approval for Phone Date bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Adviso~ Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other (Rev. Original Certificate Date: M-nicipality 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 w~vw.ci.anch(xage.ak.u s (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST AD Legal Description: E~: ]~! ~'n a ff A. B, or C pr~e ~SID OM WELl. LOG Date of test Static water level Wall pr~uction ~ g.p.m. WATER S~PLE RESULTS: ~:,te~f~ample~ Coll~ by~~ Percel ID:0S/- Well Log (Y/N) Wires properly protecled (Y/N) Casing height (above ground) AT INSPECTION in. ft. g.p.m. Other bacteria colonies/100 mi. B. SEPTIC/HOLDtNG TANK DATA Tank Type/Material 5 t~ I Tanksize /000 gal. Number of Compertments Foundation cteanout (Y/N) Y~5 Depression over tank (Y/N) Date of' pumping ~:~ -' ! - ¢~ Date installed I/2 Cleanouts (Y/N) Y~.5 High water alarm (Y/N) Pumper ~ ~,~ ~,~ ,:A C. ABSORPTION FIELD DATA Date installed ~/~ ~/~ ~ Soil rating (g.p.d./~ or ft=/bdrm) ]. ~ Length ..I~'/ ft. Width .5-/ fl. Total depth ~' ' ft. Eft. absorption area $ 0 ¥ ft2 Monitoring tube Date of adequacy teat ~'/.21/o,?, Results (Pass/Fail) Fluid depth in absorption field before test I,C, .,c in. Wale~ added~[~'0 gal. Elapsed Time:/_//.._min. Final fluid depth ISrff in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (YIN & type) System type 5J~.llO~ 7ra.cJ Gravel below pipe ,~- ' ft. __ Depression over field )V,) For .~ bedrooms New depth 1(.5- in. /.-/5'0 g.p.d. If yes, give date D. LIFT STATION Da"~t~stalled "Pump ~ in. Datum E. SEPARATION DISTANCES ~o~wm~,/;31.~, h/~'e~' SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot /~//~q Public sewer main ~ Sewer/septic service line Size in gallons 'Pump off' level at Cycles tested Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank in. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ,~' Water main Wells on adjacent lois Property line + I._._~".> Water service line Absorption field '~' I 0 / Surface water +100 / SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 'J' Water Service line Curtain drain Building foundation -~ 10' Surface water '~ 160~ I Wells on adjacent lots ')' dQ Water main 1' ~,$" Driveway, parking/vehicle storage F. COMMENTS ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name ~/0/4~$ Date _~/,~ I/~) 2 HAA Fee $ Date of Payment Receipt Number (Rev. 12/00) 75, o,e Waiver Fee $ Date of Payment Receipt Number, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section ,, P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Day phone NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Agent ~C~.~ Address Unless otherwise requested, HAA will be held for pickup. Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 'NOTE: 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. NOTE: 72-025 (Rev. 1/91) Front MOA#21 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 Munici 3al and State codes, ordinances, and regulations in effect on the date of this inspection. - Phone Name of Firm ~-,a~]e ~{~.vez' ~ngJzzeez~ Address P.O. ~,~ ~_~_a29~:' ~., ..... Engineer's signature ':"~:7,~; .-:~:-~.7-" Date DHHS SIGNATURE ~' Approved for .~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval CerUficates 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 enginee¢s work. 72-O25(Rev. 1/91) Back MOA~21 Well-type ~',~ s~ ,,~ IfA, B, crC, attachADEC letter:~ADEC Water system number:-~9;~::~v~'~'~,:'.~ · :-- 'Log present(Y/N) '/~/~ · Date completed, · . ~' - - - Total depth - CaSed'to :'. , · . Casinghelght (above,ground) · · ~'. ' :: · / '~' ~ ~ Wires properly prOtected (Y/N) *' Sanitary seal (Y/N) - . ' · . 'FROMWELELOG ..... · . 'AT .INSPECTION - · - ' . ; ' Date of~est.-? -... , ; : - '-' ~ ': · ~ . -~ Static wate~ level~.~ ..... · ,, .~- ,. _ :-. - : Well production:. - ; . ' g,p.m.- * - ' '' - , . ' g:P'~1:~ r~ ~:~.i- wATER 8AMP~E-~IE~uLTB: ., .:.. - Date of sample: , Collected y. ' , , Date i , present (Y/N) ~' - DepressiOn over field (Y/N) Fluid depth/n absorphonfield before test (in.); -. . Immediately after,..-~ gal. water added· (in.).- , , :~_-. - . · · ~ ~ · - . _ ' . ~ ~-~ F u d de th (ins) M nutes later:. :Absorption rote = . ' - ,,, , . ,g~p.d.- 72;"026:(Rev. 3/96)* · · '- : ,-'-- -' '-~'-~' :'~' -': :' ';-"'~' '~-: ~" '"" · " " ' ' · .. ' . - : - ·" - ". . LIFT STATIO~ Date Installed '~ Manhole/Access (Y/N) Size In gallons "Pump on" level at* *Datum "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septio/holdlng tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~ / Property line /-'//~' Water main/service line 7~/a / Surface water/drainage ~'/a~ ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Absorption field Wells on adjacent lots Property line '/5' / Surface water "~/'~ / Curtain drain /~/~ Building foundation Y,f' · Water main/service line Driveway, parking/vehicle storage area /5' / · We Is on adjacent lots ~- D.~ ,, · R ENGINEER'S CERTIFICATION in conformance w/~ MOA HAA guidelines In effect on this date. Signa~m ~ . ~ EnglneereName ~,~-~ , ~~ ~ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* ~3-~7-L::~2 ~:221:~ FROrl E.R. EnBtneer~n~ ~cs. 249'?84? p.l~t ASBUILT-NO CORNER~; SET THI~ DATE. .. I HEREBY CERTIFY .THA~ I HAVE S~D THE ~ :" .'" FOLLOWING DESCRIBED~ PROPER~ ' '." //'~' ' ' / · ARY TOl'(qL P.~I