HomeMy WebLinkAboutROEHL LT 1Roehl
Lot
#020-092-75
,, Municipality of Anchorage Page / 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: ~.,.) ~O/~Z.- PID Number: 0~0- O?~-
Name: ~ ~0~/~/~ Wastewater System: ~ New ~ Upgrade
Address:
/ ?//J ~r~ ~:~ ~5/~ ABSORPTION FIELD
Phone:~ ~./~/ JNo. of~drooms: ~DeepTrench ~ Shallow Trench ~Bed ~Mound ~Other
Total Depth from original grade:
LEGAL DESCRIPTION so, Rating: O, ~5 GPD/Sq. Ft.
Lot: / BIock:~ ~Subdiv~i°n:~ Depth to pipe bo~om~, from~ original grade: Ft.Gravel depth beneath~ p~pe Ft.
Township: j Range: J Section: Fill added above original grade: Gravel length:
I
Number of lines: Distance ~n lia~:
WELL: ~New ~ Upgrade Gravel width: ~ Ft. ~ /~ Ft.
Classification~~(Private, A,B.C): Total~Depth: Ft. Cased~/To: Ft. Total absorption/~ares: SQ. Ft. Pipe mat~al:~
Driller: Date Drilled: St~ticWater Level: installer: Date installed:
Yield: ~ GPMI~ Pump Set/~/~at: Ft. C~ing Height A~ve~ Ground:Ft. TAN K
SEPARATION DISTANCES ~s.~tic ~ ~o~n~ ~ SX.E...
TO Septic Abso~tion Lift Holding ~b;~c~Private Manufacturer: Capacity in gallons:
Fro~ Tank Fie,d Station Tank Sewer Lines ~. ~ /
Wel~ / ~¢l / 75 / ~/~ ~M, / q ~' Material: S ~¢ ~ Number of Compa.ments:
Sudace ~
w=t~ ~/~ ~/~' r/~o ~/~ LIFT STATION
Uot ~ / Manufacturer:
Fou.datio. ?, /?/ ~/~ "Pump on" level at: ~at= I High water alarm at:
CaSein Orain ~/~ y ~ p~ J ~lectdca, ,nspections pedormed by:
Remarks: BENCH MARK
Location and Description:
J A~umed Elevation:
ENGINEER'S SEAL
Inspections pedormed by: ~ / ~ Dates: 1st 05~¢/9¢ ,~¢~ :'49~,4
eal~H ~~ ~' ............
Depadment of H um ices approva[ · ' ' .:
Reviewed and approved ~ o¢, ,
72-013 CRev. 9/911 MOA 25
Permit No. SW95-0102
Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 545-4744
On-Site Wast°water Disposal System and/or Well Inspection Report
Legal Description: ROEHL LOT 1
PtD No.: 020-092-75
300,00
GRAVEL DRIVEWAY
N 89°52'26
SPLITTER 3'X71'RES£RVE ~EA
300,00 N 89°52'2( W
WELL
SWING TIES
A-C = 42.1
B-C = 39,4
A-D = 29.9
B-D = 24.4
A-E = 15.4
B-E = 52.6
SCALE 1' = 60'
ELEVATIDNS
~ 'FOP OF REAR HOSE SPIOOT
(NOT TO SCALE) ~ ASSUMED ELEV = IO0,O0 ~
ORIGINAL ~
7~,~
- MONITOR TUBE
- SEWER CLEANOUT
- WELL
LEACHFIELD
EASEMENT
5/2:3/96
ENGINEER'S SEAL
.x5¢."'"
DEPA~T~MENT OF NATURAL RE$~URC~
WATER WELL
' ~S ~w
WELL O~ER: --
MIL~SUREO FROM:~casina top O~ro~ su~a~
Type and Color From To
................ .Muoic~
Dept. Health & Hu
WELL DEPTH: ,, - DATE dr' COmPLeTiON
Depth of casing:~---~~ . . .
DEPTH TO STATIC WATER L~EL:
USE OF W~L: ~ dom~T~
WELL INTAKE OPTING 3YPE:
~ pedorat~ ~ open hmo
- Dept~s of oOe~nBs: ..... Io 'It
~REEN TYPE: ......
S~t/Mesb ~ze: ft
GRO~ T~E: __. Volume: ~ ..... L ............
Depth: from ~
Duration:~~~
PUMPING ~ ANO YIE. LD~
~ ~_ttafter_.~_
PUMP INTAKE DEPTH: ~_~._
REMARKS:
PLEASE MAIL WHITE COPY (~ F LOG TO:
DNI~JDIVIStON OF MINING' & WA
~chorage, Ak 9950J~5~35
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF 1
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW950102
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAME:DOWLING JAMES K
OWNER ADDRESS:iTlll BETTIJEAN ST
ANCHORAGE, ALASKA 99516
DATE ISSUED: 6/05/95
EXPIRATION DATE: 6/05/96
PARCEL ID:02009275
LEGAL DESCRIPTION:
ROEHL LT 1
LOT SIZE: 49500 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
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 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
TO ENSURE A MORE EVEN SPLIT OF THE FLOW OF EFFLUENT FROM THE
SEPTIC TANK TO THE TWO ABSORPTION TRENCHS, A ZABEL Z200 FLOW
DIVIDER OR EQUIVALENT SHALL BE USED.
~,-
Louis Butera, P.E.
Registered Civil Engineer
May 25, 1995
Jim Cross, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Roehl Subdivision, Lot 1
Narrative & Permit Application
Dear Mr. Cross:
The proposed well and septic system 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. Reserve space is adequate, due to lot size.
4. Drainage will not be affected and is not a major consideration in our design.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\C:\WPWIN60\WPDOC$\1995\95-038A.NAR
Zabel Z200Flow Divider° Zabel Z200 D Flow Director
BRAND NEW FOR 94 - The Zabel Flow Divider replaces old fashioned distribution boxes and pipe manifolds
and The Zabel Flow Director replaces expensive, old fashioned Y-valves. They are also more effective and easier
to install. All Zabel products are manufactured from high quality injection molded PVC and carry Zabel's
Lifetime Warranty if parts fail due to manufacturer's defect in material or workmanship. The warranty does not
include replacement parts not sold by Zabel and does not include labor for removal or reinstallation.
1. The Flow Divide distributes effluent leaving the
septic tank by means of a patented central weir
design that insures the flow is evenly divided even
if the Flow Divider is not perfectly level.
2. The inlet pipe of the Flow Divider is constructed
so that effluent will flow from it and down into the
effluent into two equal portions.
3. Distributes flow better than D-boxes and mani-
folds that are subject to frost heave or ground
settling.
4. Testing shows that even with a level discrepancy
of 1/8" or more between the right and left port, the
division of the flow was almost 50/50. A standard
D-box or manifold distorts the flow under these
same conditions.
1. The Flow Director is a Flow Divider with a pat-
ented sleeve valve installed to distribute the efflu-
ent flow to a primary field of your choice and
allows the secondary field to rest until needed:
2. The Flow Divider automatically back flows from
the primary to the secondary field and does not
depend on the homeowner to change the sleeve
valve in the Flow Director. A standard Y-valve is
dependent on the homeowner to change the flow
direction at the proper time. Unfortunately, this
usually does not happen and a problem develops
such as an effluent break out resulting in ground
water contamination.
3. At the time the septic tank is normally serviced,
the septic tank service company can redirect the
flow allowing the primary field the opportunity to
rest.
· Manufactured from injection molded PVC.
· Always insures an even flow.
· Doesn't create solids build up.
· Will not clog.
· Lifetime Warranty.
Laboratory Test Results using
1000 ml samples @ 3 gpm
Level
Right Port
Left Port
1/16" Tilt
Right Port
Left Port
1/8" Tilt
Average
Distribution
50.03%
49.97%
50.2%
49.8%
Right Port 51.3%
Left Port 48.7%
Questions concerning Z200 Flow Divider * Zabel Z2OO-D Flow Director please call
1-800-221-5742 or Fax (502) 267-8801 for further information.
Z200-01-ll/94
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: Roehl Subdivision, Lot 1
GE~RAL
1. The well and septic plan is for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health
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 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.
Bo
1. The trench is to follow the natural land contour to maintain uniform total depth of
the trench bottom.
2. The bottom of the trench shall be level, plus or minus 1.5".
3. The total depth of the trench excavation is not to exceed 10' at any point.
4. The sewer line is to replace the existing sewer line that leads to the existing pit.
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 = 10' GRAVEL DEPTH = 7' under pipe, 2" over pipe
TRENCH LENGTH = 71' TRENCH WIDTH = 3'
SOIL RATING = 0.45 GPD/ft2 BEDROOM CAPACITY -- 3
SEPTIC TANK = 1,000 gallon minimum
Twenty-four (24) hours notice required for all inspections.
C:\WPWIN60\WPDOCS\1995\95-038A.SPC
~ ~..~ ~ RANSE}M RIDGE
300,00
N 8'~°sa'as'' w
..... ~ ~ .... , I
~ X ~' -~-
~ ~ ,~ ~ELL
TH ~OT ~ 300,00 N 89~52'2~"~
/ X ~ - TEST HOLE
~ X · - MONITOR TUBE
/ X o - SEWER CLEANOUT
X + - WELL
~ELL ~ PROPOSED LEACHFIELD
NO SURFACE WATER EASEMENT
NO KNOWN CURTAIN DRAINS
WELL ~ SEPTIC SITE PLAN
LEGAL: ROEHL SUBD. LOT 1 ~....'-
ow [R:
CONTRACTOR: N/A ~.~~'~[
JOB ¢ 95-038AI DATE: 05/24/951 SCALE 1" = 60'
~.~ '. uou~s A. ~UT~A
A EAGLE RIVER ENGZNEERING SER WC~S
EAGLE RIVER, AK. 99577 694 3297 I~?°~ss~°~
(~07) S~4-S~S FAX: (SO7) -
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box 773294
Eagle River, Alaska 99577
(907) 694-5195
ERES Project No:: 95-038
Calculated By: LB
Date: 5/18/95
Single Family 3 Bedroom Dwelling
Deep Trench Subsurface Wastewater Disposal Field
Water use at 150 gallons per bedroom = 450 gallons
Percolation rate = 48 minutes perinch
Wastewater application rate = 0.45 gallons per day per square foot
Required absorption area = 1000 square feet
Trench width (W) = 2 feet
Gravel depth (D) = 7 feet
Required length = Required absorption area / 2 / D
Required length = 1000 /
Required length = 71 feet
Total Excavation Depth = 10 feet
2 / 7
SINGLE FAMILY ON-SITE WORKSHEET
ERES PROJECT NUMBER: 95-038
LEGAL DESCRIPTION: Roehl subdv. Lot 1
NUMBER OF BEDROOMS;
WATER USE PER BEDROOM:
PERCOLATION RATE:
DEPTH TO GROUNDWATER:
DEPTH TO IMPERMEABLE LAYER:
ANTICIPATED DEPTH OF COVER:
MOUND OR BED SYSTEM
WASTEWATER APPLICATION RATE:
ABSORPTION AREA REQUIREMENT:
MINIMUM BED LENGTH
12 FEET WIDE BED
15 FEETWIDE BED
TRENCH SYSTEM
WASTEWATER APPLICATION RATE:
ABSORPTION AREA REQUIREMENT:
SHALLOW TRENCH OPTIONS
5 FEET WIDE TRENCH
CALCULATED BY: LB
3
150 GALLONS
48 MINUTES PER INCH
16 FEET
16 FEET
3 FEET
0.3
1500
USABLE SOIL STRATA
TOTAL USABLE DEPTH: 1 0
USABLE SOIL STRATA DEPTH: 7
GAL/SQ.FT
SQ.FT
125 FEET
100 FEET
0.45
1000
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)
1 175 4 125
2 140 4.5 111
2.5 127 5 100
3 117 5.5 91
3.5 108 6 83
4 100 7 71
8 NA
9 NA
DESIGN SPECIFICS
FIELD SYSTEM:
GRAVEL DEPTH:
TRENCH OR BED WIDTH:
LENGTH:
TOTAL
EXCAVATION
DEPTH:
D
7
2
71
10
(B=BED, S=SHALLOWTRENCH & D=DEEP TRENCH)
FEET
FEET
FEET
FEET
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
2
3
4
7
tO
12
t 4 l"
15 -
16
17-
18-
19-
20-
COMMENTS
DATE PERFORMED: 5----/o/--
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Deplh to Water AIt~r ,,
/~' Date:
Monitoring?
Gross
Time
SITE PLAN
TI'/ I ·
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE --
TEST RUN BETWEEN __
(minutes/inch) PERC HOLE DIAMETER __
FTAND ~ FT
PERFORMED BY; ~"~/~ ~-,,,.~- , ,~'~'~'~'~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: '~z/xJ~,'//~'~'c'
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
FERFORMED FOR: '~'"/,'"?
LEGAL DESCRIPTION: t~ m {;,, ~ t/
DATE PERFORMED:
Township, Range, Section:
1
2
3
4
6-
7
8
9
10
11
12
13
14
15
16
17
18
19
20
SLOPE
WASGROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH7 p
E
Depth to Water After
Monitoring? ,~1~-2 /~//Date: ~'73~/'~"
SITE PLAN
,,
,;
Gross Net Depth to Net
Reading Date Time Time Water Drop
I ~--t~/r- ~.,~-o ~ ~ ~ ~11~
PERCOLATION RATE ~'-~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~' FT AND ~ FT
COMMENTS
PERFORMED BY: ~'~'~"/~/'~ ~ I '"'/~/-~--~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; ~'~--/'-~_/~$-
Municipality of Anchorage
Development ServiCe~ Department
. . , . :. Building Safety Division
On-site Water and WasteWater Pr0gJ'am '
.. 4700South Brag~wSt." ~ .'
- P.O. Box 196650 Anchorage, AK 99519-6650.
www.ci.anchorage.a~.us .'. '.
· . (907) 343-7904
CERTIFICATE OF HF_ALTH AUTHORITY APPROVAL FOR A S NGLE FAM LY D ,WELL NG' "'~'."
Parcel I.D.'O~O ~. (,-)C~ _-'/~ . . HAA #
' ·Expiration Date: ~
1. GENERAL INFORMATION
Comp. lete legal de~ription' "-~O.gJl.(..: [ M I
' ' " ' ,3/Tp.t.
Location (site address or directions) f~,e~ e 1~ .~a.~ ~'t~-'~'d ~
Cu~r~nt Property owner(s)~.Jl~t. %OpJ~.t~.~. Day phone
' Mailing address ,- ~.~--~ ~,.--
Lending agency ,~'~.A .~, ~" Day phone
Mailing address
Real Estate Agent
· ? Mailing Address
Un/ess otherwi$~ ~eqUes/ed, 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 []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
[]
[]
[]
[]
The Municipality of Anchorage Development Services Depadment (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 Io homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for propedies served by a private or Class C well and may be reissued with
n..e.w 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 ere valid for one year for propedies 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.
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 tTpe 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 end State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm
Address
Engineer's Printed Name [ tOLl i.S
DSD SIGNATURE
._L_~ Approved for ~
Disapproved.
Conditional approval for
Phone
Date'
~., L~'
~. ......'~? ·
bedrooms. ..
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: (¢ - /~'- 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
vnew.ct.anchorage.ak.us
(S07) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription: ,~f' / /L~Orf',,~ /
Parcel ID: ,~,~o
WELL DATA
Well ty~e
Date completed ~-:
Total depth ' '~'q ff.
If A. B, er C provide PWSID # ,v,~
Sanitmy seal (Y/N) Y
Cased to ?¥ lt.
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
Date of test
Static water level 4"7
FROM WELL LOG AT INSPECTION
~- '~-~-
ft. ~? It.
Well production
g.p.m, o~. o"'g.., g.p.m.
WATER SAMPLE RESULTS:
Coliform r~ colonies/100 mi.
Data of sample: (~ -~ '~ ~
B. SEPTIC/HOLDING TANK DATA
Nitrate 4,5' mgJI. Otherbactaria ~ colonies/100ml.
Collected by:.
D~te installed
Cleanouts (Y/N)
High water alarm
Tank Type/Material · S 7'='e /
· Tank size 13..c'c' gal. Number of Compartments
FoUndation ctaanout (Y/N) ,Y Depression ova' tank (Y/N)
Date of pumping [.~/L.~ot ~ Pumper A ~' /"/o,-r/kC
C. ABSORPTION FIELD DATA
Date installed ,,,~'-D& Soil rating (g.p.d./lt= or ~/bdrm) o,
Length 7,;7. ft. Width ..T ft.
Total depth J O ft. Eft. absorption area I ~ ft= Monitoring tube __
Date of adequacy test ~- 5'- 4 ~ Results (Pass/Fail)
f l~l /TaT~.
Fluid depth in absoq~tion field before test~_~.q'n. Water added 7~'~ gal.
Elapsed Time:/~- min. Final fluid depth /3 in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
System type .d~-?
Gravel below pipe '7 ft.
Depression over field /%/
For ~ bedrooms
ew depth /in.
~--/.r-z) g.p.d.
If yes, give date
D. LIFT STATION
Date ins~d
'Pump on" I~at
Datum ~,
Size in gallons
in. "Pump off' level at in.
E. SEPARATION DISTANCES
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & c~rcuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot. f'toe /
Absorption field on lot v-,/,~ ,~ '
Public sewer main ,'~/~
Sewer Isepfle service line ~' /~'~ ~
On adjacent lots
On adjacent lots
Public sewer manhole/eleanout
Holding tank
SEPARATION DISTANCES FROM SEPT3C/NOLDING TANK ON LOT TO:
Building foundation 7 / Property line /& /
Water main Y-/% r' Water sen, ice line ~,~ r /
Wells on adjacent lots ~/=4 /
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~ ~' /
Water Service line /*,~/
Curtain drain ,~'~
Absorption field
SurPace water
Building foundation
Surface water 2~/~
Wells on adjacent lots
Water main /v'/~
D~iveway, parking/vehicle storage
F. COMMENTS
G, ENGINEER'S CERTIFICATION
I ced:fly that I have determined through field inspections end
review of Municipal records that the above systems are
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name
Date ~'-- /
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number
JU~l-I;'.-Ol ID:l? FR~K~-
ai~sT~- CT&E Env.onmenta, Ser~lce~ 'nc.
[-633 P.0~/O3 F-333
CT&£ Ref. W 1013222001
I'r~lttt Name'm Lot I ~ehl
Client Sa~e W ~t I
~e~ By
~'SID 0
PQL
Nitmte-N 0. S00 U 0.500 n',g/I. EPA 300.0 (<10)
O6/0S/O1 SCL
Mlc~ob~o~ocJ~' LaboratorY'
· ~mlColi~rm 0
0 =ol/10itmL SM Ig 922213 ('ct]
1~6/O8,Ot
. PRELIMINARY '