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Home My WebLink AboutCHESTER CROMWELL LT 78AChestee C omwell Lot 78A #05 ! - ! 03- 27 Municipality of Anchorage · Development Servlces Department ,'-*,' %' Building Safety Division ~,' , '.. On-Site Water & Wastewater Program, 4700 South Bragaw St. "~ I~11 P.O. Box 196650 Anchorage, AK 99519-6650 ~ www.ci.anchorage.ak.us (907) 343-7904 Page 1 of On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: SW010490 PID Number: 051 - 103-27 Name: TROY LEWIS Wastewater System: [] New · Upgrede P.O. BOX 211171 * ANCHORAGE, AK 99521 ABSORPTION FIELD (907) 351-5824 4 r'lOeep Trench · Shallow Trench O Bed mMound r'lOther LEGAL DESCRIPTION ~, ro~: 1.2 c.~o/s.., to,°, ~,,. ,,o~ w,~,2.67_5.96 - 78A CHESTER CROMWELL 0.67-3.96 .. 2 - - - SEE DWG. n. 70+ WELL: [] New [] Upgrade 5 n. 1 ~ n. n. 500+ so. ri. D 3034/ F-810 ~ *EXISTING TANK SEPARATION DISTANCES - Se~t~ r'l Hofdlng I-I S.?.IF.P. O Other Tank Field Station Tank s*..r u,-* ANCHORAGE TANK 1250 We, I00'+ I00'+ - - 25'+ STEEL 2 Su~fo~e Wo~e, 100'+ 100'* - - - LIFT STATION Curtain Drain NONE~ KNOWNI /~'mP ~*~.~: eecu~ca~ ~c~. e*,~e~s ~ Remarks: *THE EXISTING SEPTIC TANK WAS INSTALLED BENCH MARK IN 1994. THE TANK WAS FOUND TO BE OF GOOD BACK DOOR THRESHOLD CLOSE TO POINT "A" INTERGRITY ON 5/10/2002. 1 00.00 Inspections performed by: AWWC, INC. Dates: 1st 5/10/02 ~?.*.c_~..?;i ! (' ' '/~J ~' '''-'3~ Development Serviqe~ Department Approval u~, ... ~ ...' P...,....c.; AS BUILT DRAWING SWO10490 - 051 -103-27 ~EXISTINO SEPTIC SYSTEM~ / O~ [DETAIL [ ~ THAT S[RV[S LOT 788; / ~/ ~0 ~ // ~ CHESTER CROMWELL S/O~ ~Z -- ~150' WELL ~DIUS N N~N / ; ~EXISTING 1250 GALLON ' ~/ [ ~EPTIC TANK INTEGRI~ x% TEST H~LE ~1 ~ ~ ~ ~ ~-- ~-o~ ST~ ~ ~~x,~ LOCATION) ' ST2 ~4~ ~T:~ - ' '~ ~ ~ ~ DDL1 47.0 63.6 - ~x ~ SEE D~AIL A ~ I FO 47.7 64.2 - / ' x X ~ DBL2 48.7 64.8 - - ~X ........ ~'-'~ D~L3 47.4 63.6 - / x ~[XISTING ~[O TO ~[ D8L4 48.7 65.2 - USED AS A RESERVE SITE ~5 & S ENG. CO1 55.5 85.8 81.3 (APPROXIMATE LOCATION) Mil 54.6 84.2 81.2 C02 118.1 - 133.3 MI2 115.6 -- 131.7 ll~SI~ ~WI'ER & ~SI'E~WI'ER PREP~EO FOR: PHONE NUM~[R: PAGE NUMBCR: TROY LEWIS (907) 351-5824 2 OF 5 LOT 78A1 CHESTER CROMWELL SUBDIVISION AS-BUILT OF SEPTIC SYSTEM UPGRADE .E".,.NU..£.: AS BUILT DRAWING SWO10490 ' 051-10,3-27 FINAL GRADE - 96.92+ TOP OF.TANK AT---~ = INLET 92.92 ~ /--TOP OF TAI~cK AT _~ OLIILET 92.84 \ / INVERT Or BUN¢ INTERGRITY VERIFIED ~--INV[RT or BUN(;; AT AT INLET-92.34 lJ ON 5/10/02. OUTLET ,= 92.09 \/ MONITORING TUBE-~ j~LEANOUT FINAL GRADE /---ORIGINAL GRADE -- · - · / HIGH -- 95.00 / LOW -- 9=1.71. FILTER FABRIC--~ i [~~NV~RT 0¢ D~STR~BUT~ON : ~:~:~:~ LINE = 91.04 (AVG.) "--BO'FI'OM OF' TRENCH = 89.04 (AVERAGE) ................... CONSULTANTS. INC. ~ ...... 1" 'REP~ED FOR: mONE NUMBER: PAGE NUMBER: I~ q '*' TROY LEWIS (907) 351-5824 5 OF 3~,[ tie LOT 7aA; CHESTER CROMWELL SUBDIVISION q~p4~'.. PROFILE AS-BUILT OF SEPTIC SYSTEM UPGRADE AI.,ASI(A ~WATER & '~VASTI~YVAI~ER ~a~-~...' ISOIL LOG - PERCOLATION TESTI 'EDAL DESOR,PT,ON: LO. 78.: CHESTER CROM.E.L ./0 PERFORMED FOR: TROY tE~S DATE: 5/10/2002 'q~, '"...Xi ...... '"~,v~"~, DEPTH i .... (~e~t) :==:.- ORGANICS ITEST HOLE #1 [ -'?o% SOIL CLASSIFICATIONS 2- ~';' '°°° ~ .... °~"' ::~':'-'.'o :--' GW ~ ORG ? ,'.oo~ - · ,~: 0oo -.ff../ ~, ,-'-'"'-7. GP ~ I'lL e '.o°¢: GM " ~ CL 4-- ~ 'o"'~, GW/SW ~ Ge OL 5--' c: . ~% SP CH · o..-o,~ SH ,/,,,Y,; OH 6--' ~'"t°°°" ,~?"~,~-,, SC SEE AS-BUILT DRAWING : ~.',~oo~, 7-- ~' '~°°" DEPTH TO · ': o~° DATE :o .,',oo ~ GROUNDWATER ~ - ~ 10' 5/10/02 lo' 5/13/02 9-! ~ ItIIi 10' 5/17/02 it2H''H'~' DATE READING CLOCK NET TIHE WATER LEVEL NET DROP 11 ~ J~!J~ , - ,---- O~/SJ"d TildE (HINUTES) READING (INCHES) ~2-:~J Jt!J;~: 5/10/02 1 - - lJilI! _2 - 2 01 13- ,__ 3 - _ ~ 4 __- 2 o' ___6~ 14-, ~.o.u ........... 5 ..... _._~- __ .7_ ............... 6"_ ............... , 6 - _ ...... _2 ........... 0". ........... 6;' ...... 15-- 17--, I PERCOLATION RATE <1 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES) 19- TEST RUN BETWEEN 5.0 FT. AND 5.5 FT. 20-- ~ A FOUR HOUR PRESOAK WAS PERFORMED: D YES · NO SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORMED BY: JODY MAUS COMM~'~J~S.iNSITU SANDY SOILS FROM 8' - 10' WILL ACT AS A SAND FILTER. PERFORMED BY A.W.W.C., INC. I, JEFFREY A. GARNESS, CERTIFY THAT THIS VIAS/PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: DEPTH TO GROUNDWATER DATE 10' 5/10/02 10' 5/13/02 10' 5/17/02 MUNICIPALITY OF ANCHORAGE Developreent Sen/ices Depa~'tment On-Site Water & Waslewater Pregram 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (gO7) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Dec 19, 2001 Expiration Date: Dec 19, 2002 Permit Number: SW010490 ~Legal Description: CHESTER CROMWELL LT 78A' Design Engineer:. 0003 S & S Engineering Owner Name: R. C. Cromwell OwnerAddress: P O BOX67620222 CHUGIAK, AK 99567-0222 ParcellD: 051-103-27 Site Address: 020616 JEHOVAHJIREH ST Lot Size: 55692 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 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: 1. The attached approved design. 2, All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State cf 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 Apd115, 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 preven! freezing. 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 SEWEPJVVELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLI'NG Parcel I.D. ~)5~.o 'Ij, O~ - '~ Permit Number Property owner(s) Mailing address (1) Mailing address (2) Day phone Zip Code Legal description (Lot, Block & Sub'd.) Legal description (Section, Township & Range) Lot Size 5 ,~! (,0 ~,"~' -Ae~s~ THIS APPLICATION IS FOR: Sewer Only ~ Sewer and Well Sewer Upgrade ~ THIS PROPER~ CONTAINS: Hot Tub Swimming Pool Therapy Pool Number of Bedrooms Well Only [] Water Storage [] Jacuzzi Water Softening Unit 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) 17034 Eagle River Loop Road, No. Eagle River, Alaska Permit Fees: Date of Payment: Receipt Number: (Rev. 12/00) Waiver Fees: Date of Payment: Receipt Number: ROBERT C. COWAN. P.E. November 9, 2001 ClWL ENGINEEP. S (907) 694-2979 FAX (907) 694-1211 PEgCOLATION TEST MUNICIPALITY OF ANCtIORAGE Development Services Department P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 78a, Chester Cromwell S/D It is requested that you issue a permit to upgrade a septic system to serve the existing four bedroom dwelling on the referenced property. A test hole was excavated and a percolation test was performed. The approximate location ofthe test hole is located on the attached site plan. At the time of excavation on 10/4/01 no water was found. After seven days of ground water monitoring the test hole was still found to be dry. An additional test hole xvill be percolated at the time of excavation. We do not anticipate any adverse effects on neighboring xvells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system xvill not prevent any future development on any of the adjacent properties. If you require additional information, please contact us. Sincerely, RCC6hm Enclosure 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER. ALASKA 99577 A~ A~-I~UII.T SURVEY DRAW~ ~Y: ,~r~· SOI~ CPD/SQ 600/1.2 = 500 SQ }~. REQ'D. [7 IS TIlE RESPONSIBiLTY OF TIlE CONTRACTOR }, ~.~ RO3ERT Q COWAN /~ ~ I)lb-rihcgs. lAD PROPERTY ~NgS PRIOR TO J} ~ .~ r~' ~ I 20 Uhl [sml I INSIALL DIVERIER VALVE ~°~X [XlSItNG 1250 GALLO ~X X SEPIIC lANK (VERIFY INIEGRIIY & ~[PLAC[ IF NECESSARY) EXISTING 20' TR[NC~' I ALL PORIIONS OF SYSI[M WITH LESS IHAN 5.5' OF COVER REOU~[ INSUL~IION. Municipality of Anchorage Development Services Department ,,~ ~.~, ~ , Building Safety Divlsion '* P.O. Box 196650 Anchorage, AK 99519-6650 www~d.anchoraae.ak.us (9o7) 343-?~04 Soils Log - Percolation Test 1- 2. 3. 4- 7- 10- 14- 15- 16- 17- 18- 19- 20- COMMENTS WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water After Monitoring? Reading Date Gross Time Net Time Depth to Water Net Drop - / /0 /O /B" (~,, Io 1o I~;" 4," /o Io /~ ?z~ ~'~ lO tO 14 Y~." 5'yz' IO ~o 147~,, ~',~.,. TEST RUN BET~NEEN a~- FT AND ~' FT PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ¢,% %5 \¢j5 Municipality of Anchorage Page / of DEPARTMENT OF HEALTH AND HUMAN SERVICES ~~' ~' ~&j t~)~~'1~.' ' ENVIRONMENTAL SERVICES DIVISION ~ .O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater DisPosal System and/or Well Inspection Report Permit Number: ~VO~¢~ PlDNumber: ~- Name~/~C~ ~'d~ C ~Z WastewaterSystem: O New ~pgrade Address~o. ~OX ~Z O~Jt ~U¢/~, ~, ~ ABSORPTION FIELD Phone: ~ '~ ~o.o~edrooms: ~OeepTrench ~ Shallow Trench ~Bed ~Mound ~Other i / Soil Rating: Total Depth from original grade: LEGAL DESCRIPTION GP~sq. ~. Lot: Block: Subdiv~ion: Depth to pi~ bottom from original grade: Gravel depth beneath pipe Township:~[ ~'~~ Ra~ ~ ~ Section:~ ~ Fill added above original grade: Ft. Gravel length: Ft. Gravel width: Number of lines: I Distance be~een lines: WELL: New ~/~ ~ Upg rede Ft.m Ft. Classification (Private, A,B,C): / Total Depth: Cased To: Total absorption area: Pipe material: Ft. Ft. SQ. Ft. Driller: Date Drilled: Static Water Level: Installer: Date installed: Ft. Yield: GPM IPump Set at: Ft. ICasing Height Ab°ye Gr°und:Ft. TANK SEPARATION DISTANCES ~e,tic ~ Ho~Uing ~ S.T.E.,. To Septic Absorption Lift Holding Public/Private Manufacturer: Capaci~ in gallons: From Tank Field Station Tank Sewer Lines ~5~ ~r ~ ~ ~ ~ Well- /~/ /0~ ~ ~ ~ Material: ~ Number °f C°mpa~ments: ~ Sudace LIFT STATION Water /~ ~ 1~4 ~ ) ( , Lot~ Size in gallons:[ Manufacturer: Cu~ainDrain ~ ~ . ,~ ~ Pump Make & Model,I Em~trical Inspections pe~ormed by: Remarks: ~. ~//~ ~ ~. /~2~ BENCH MARK Location and Description: · m Assumed Elevation: ~.....- ~....~1.. · Inspectionspedormedb /~ Dates: 1st ~(,/~/ ~'~9~ % *~' Department of Heal,and HHman Se~ices approval ',~:h.~.,_~ .... ;.......~;~ Reviewed and approved by: ~~~' ~ Date: ~-~- ~ ,,. ~0~ESSt~ 72-013 (Rev, 9/91) MOA 25 Permit No. Page Municipality of Anchorage 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 Legal Description: 6o/" ? ~ /~ 0 PID No.: ENGI No. CE-5325 72-013 A (Rev. 9/91) MOA 25 Anchorage, Alaska 99519-6650 Date: To: From: Subject: September 5, 1995 File, Lot 48A Chester Cromwell Subdivision Daniel J. Roth, Civil Engineer, On-Site Services ~ On-Site Wastewater Disposal System Inspection Report, Permit Number SW940292 The approval signature on the subject document dated August 25, 1995 is for the septic tank installation only. In no way does this give approval to the non-as-builted drainfield. At the time of Health Authority Approval request, the drainfield may be subject to further documentation. 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 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW940292 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:CROMWELL RUFUS C JR OWNER ADDRESS:P.O. BOX 670222 CHUGIAK, AK 99567 DATE ISSUED: 8/15/94 EXPIRATION DATE: 8/15/95 PARCEL ID:05110327 LEGAL DESCRIPTION: CHESTER CROMWELL LT 78A LOT SIZE: 55692 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: THIS PERMIT IS FOR THE CONTRUCTION OF: SEPTIC TANK 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) 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: DATE: DATE:~~/~ July 25, 1994 Municipality of Anchorage Environmental Services Division P.O. Box 196650 Anchorage, AK 99519 Re: .Sewer Upgrade Permit for BLM Lot 78A Chester Cromwell ,Sub. Dear Sirs: On May 22, 1994 an adequacy test was performed at the subject lot with a four bedroom house an a septic system that was reported to be installed in 1960. The system passed the test, however, requires the seepage crib to be replaced with a 1250 gallon septic tank. The crib shall be abandoned and a test hole dug to 14' depth to verify that na groundwater is located in this area. Other pertinent information is as follows: The septic system is located in an area with less than a three percent slope and has adequate room for a replacement drainfield. The ground slopes away fram the well site and na drainage courses are within the area. There are no apparent impacts to adjacent properties with this proposed upgrade and its location meets ali current separation distance requirements. The attached site plan shows the proposed location of the septic tank replacement for issuing the permit. The permit fee has been paid. If there are any questions concerning this matter, please contact me at 696-3437. Thank you. Sincerely, r, P.E. CE5325 -I Municipality of Anchorage Development Services Department Buitding 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' Parcel I.D. 051-103-27 1. GENERAL'INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Expiration Date: ~/'-- LOT 78A; CHESTER CROMWELL S/D Location (site address or directions) ' Current Property owner(s) Mailing' address Lending agency Mailing address Real Estate Agent Mailing address 20616 JEHOVAH JIREI~ STREET * CHUGIAK, AK TROY LEWIS Dayphone 351-5824- P.O. BOX 211171 * ANCHORAGE, AK 99521 Day phone Day phone Un/ess otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 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 Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 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 homeownem. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a pdvate 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. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ to closing for the engineering services provided. at, or pdor 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 out#ned 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 Anchorege fi/es and from my investigation and inspection, the on-site water supply and/or was/ewe/er disposal system is(am) in compliance with all applic, ab/e Municipal end State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER &: WASTE'WATER CONSULTANTS. INC. Phone Address 6901 DEBARR ROAD. SUITE 2B "ANCHORAGE. AK 99504 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 337- 6179 Engineer's Comments: In conducting this evaluation, AWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results desc.~fbed the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate dudng the year, and the water usage of the family being served by the system. These conditions ara outside the control of the eva/ua/or 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, AW1NC, Inc. can therefore no/provide any warranty or future estimate of how long the system will continue to meet the operational roquiroments 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 repod by any other person or porly is not au/ho#zed, nor will it confer any legal #ght whatsoever. DSD SIGNATURE Approved for ~ Disapproved. Conditional approval for __ bedrooms. bedrooms, with the fllowing stipulations: Attachments: HAA Checklist Septic System Advisory Well Flow Advisory ~_ · WASTEWA]I:~, : : ....... Manitenance Agreements '"~,;.~ ~¢~;'*' Supplemental Engineers Reo~ ~Jjjjj))))})))))l Other (Rev. 12~I) Original Certificate Date: ~ - I ,~ - O.~--- Legal Descdption: A. WELL DATA Well type PRIVATI~ Municipality of Anchorage Development Sewices Department Building Safety Division On-Site Water & Wastewater Program 4700 ,South Bragaw St, P.O. Box 196650 An(tim'age. AK 99519-6650 www.ci.anct~orage.ak.us (g07) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST LOT 78A; CHESTER CROMWELL S/D Parcel ID: 051-105-27 If A, B, or C provide PVVSID# N/A Well Log (Y/N), NO Date completed UNKNOWN Sanitary seal (Y/N) YES Totaldepth 125'+ It. Casedto 40'+ fi. FROM WELL LOG Date of test Static water level Well I:m:Muction .,Y g.p.m. WATER SAMPLE RESULTS: Coliform ~ colonies/100 mi. Nttrate0o'~hlg.A.. Arsenic: N/A mg./L. Date of sample: 5/17/02 B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Tank size 1250 gal, Number of Compartments 2 Foundation cteanout (Y/N) *YES Date of pumping 5/17/2002 C. ABSORPTION FIELD DATA Date ~stefled 5/10-11/02 Length 70+ .It. Depression over tank (Y/N) No Pumper. soil rating ~:l.:~lc~r lt~edrm) 1.2 Width 5.0 .lt. Wires pmpedy protected (Y/N) Casing height (above ground) AT INSPECTION 5/10/2002 115' lt. 5.16 g.p.m. Other bacteria Collected by: *INSIDE: FOUNDATION Date installed Cleanouts (Y/N) High water alarm (Y/N) dR'S PUMPING YES Total depth .5.e-e,4 It. Eft. absorption area 500+ It~ Monitoring tube YES Date of adequacy test NEW Results (Pass, Fail) - Fluid depth in absorption field before test - in. Water added - gal. Elapsed Time: - min. Final fluid depth - in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) - 18+ in. colonies/100 mi. AKWWC, INC, /1994 YES System M~e 5-WIDE Gravel below pipe 2,0 fi. Depression over field NO For 4 bedrooms Now depth - in. - g.p.d. If yes. give date - O. LIFT STAr)ON Date installed Size in gallons Me~.~~__ _ "Pump on" le~gh~ wa rte alam~ level at ~ in. ~ Cycles tested. Meets alarm & circuit requirements?. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanldlllt station on lot100'+ Absorption field on lot 100'+ Public sewer main N/A Sewer/septic service line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/deanout Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Water main N/A Water sen/ice line 10'+ Wells on adjacent lots * 100'-t- SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Properly line 10'+ Water service line 10'+ Curtain drain NONE KNOWN Building foundaMon 10'+ Surface water 100'+ Wells on adjacent lots '100'+ Absorption field 5'+ Surface water. 100'+ · 150'+ TO WELL ON LOT 78B Water main N/A Driveway, parking/vehicle storage 25'+ F. COMMENTS 7953 ." 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 Illame D.te JEFFREY A. GARNESS HAA Fee $ Date of Payment Receipt Number (Rmv. Waiver Fee $ Date of Payment Receipt Number