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DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
82,51 'L" STREET, ANCHORAQEm AK. 99501
264-4720
LMIFEL-L.- F=IEFFRr-1 I _r
PERMIT NO. ( 790015,
APPLICANT HARTMANN)RUDOEF P, 0. BOX 3-4092 277-4729
LOCATION SCENIC DR.
I-EGAL T 5 RIW SEC5 LOT2 LOT SIZE 54000 SQUARE FEET
MINIMUM DISTANCE BETWEEN A WELL. AND ANY ON-SITE SEWAGE DISPOSAL, SYSTEM is
100 FEET FOR A PRIVATE WELL.; OR
150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL,
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLETO INSURE PROPER INSTALLATION.
I CERTIFY THAT
1: 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE,
2: 1 WILL. INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
SIGNED:
A Fl
PPLIC. T HARTM NN DOEF
14 4,
ISSUED
'
. GR��.�� �N����������� 8��� ���� ��W
' — ' ''''~,.~..^`=� ,`,.�r^ u��w` .v�^o
/
Department of Environmental Quality
/ 333OCStreet
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISP
OSAL STEM
1-1i-Rl- PHONE
LEGAL DESCRIPTION
SEPTIC TANK: py-
DISTANCE
NUMBER OF
|msmc LovGTH---- INSIDE
T4i=E DRAIN FIELD:
| D|sT»wcs FROM WELL -4- p0Umo*T|Om mc�qssT �0T �|mE ( TOTAL LENGTH�|
---------' --�-��_�_-_oF LINES
/NUMBER^
or �|mESDISTANCE BETWEEN L/mss TnEmco w|oT 3/- IN. TOTAL EprscT|vE
ABSORPTION AREA �7 Q SQ. FT. LENGTH Or EACH L|ms (
�
DEPTH OF FILTER
oEpT*. TOP OF TILE TO p|m|6* GRADE w�Tsn|�� �smc*T* TILEIN. *oOvs TILE |m.
WELL: `
TYpEc0wsT�UcT0m
,
DEPTH —DISTANCE
FROM:
uu|Lo|mo mE*nssT
NEAREST
SEPTIC 5ssnAas
FOUNDATION_, LOTL|mE_____-.
sEvvEn L|mE-_____.
T*m*_-___'. SYSTEM
CEssp0oL________. OTHER SOURCES
APPROVED ---- DISAPPROVED
*sM*nxs
DISTANCES:
DIAGRAM OFSYSTEM
INSTALLED BY:
�
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE:
nEKxanKS.
DATEU,
»u�x.*.o.
,_.
- � :._. ,.
��
�, ,: � ; .. � r>.
_.�. �:
_�. ,_. f � � -��
i �a r _
KSOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
'I Pouch 6-650, Anchorage, Alaska 99502 276-2221
SOILS LOG — PERCOLATION TEST
10-
WAS GROUND WATER S
11 ENCOUNTERED? L
or 0
12- P
IF YES, AT WHAT E
13 DEPTH?
COMMENTS
Reading
Date
Gross
Time
Net
Time
Depth to
Water
N " t
Drop
PERCOLATION RATE
PERFORMED CERTIFIED BY:
72-003 (7/76)
(minutes/inch)
FT AND - F
0
11-2-7-77
- ATE:
4"
cc
�? �� i2)c/1
ON
,4,a 1/1 5 -L
INSPECTION APPOINTMENTS
DATA RECEIVED
TIME
TIME
TIME
DATE
DATE
DATE
T TYPE OF RESIDENCE
NUMBER OF,BEDROOMS
XSINGLE FAMILY
INSPECTOR
INSPECTOR
INSPECTORP
j1a 4 -
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOITEPT. 01c
825 L Street - Anchorage, Alaska 99501 ENV IRONJ",4E. 1 -U -L "CTION
•
ENVIRONMENTAL SANITATION DIVISION APR 2, i� '1980
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE&fi UIN"
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER w
ml
PHONE
,2 7 7
MAILING ADDRESS
PROPERTY RESIDENT (if different from above)
PHONE
0 V22-c4rl lino' -7
XjOA,
2. BUYER
PHONE
— 17 Re y /2" z�R
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
Azz"o"141,1ve-, C'
MAILING ADDRESS
4. REALTOR/AGENT
PHONE
Af,fJ-
-
MAILING ADDRESS
5. LEGAL DESCRIPTION
-r ia 1 '=
'5- C"
STREET LOCATION
__OleIpve_ /
T TYPE OF RESIDENCE
NUMBER OF,BEDROOMS
XSINGLE FAMILY
F-1- One ED Four F-1 Other
X Two F-1 Five
F -I MULTIPLE FAMILY
F -I Three 0 Six
7. WATER SUPPLY
INDIVIDUAL*
ATTACH WELL LOG. A well log is required for all wells drilled
F-1 COMMUNITY
since June 1975. For wells drilled prior to that date, give well
E-1 PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
-k-
INDIVIDUAL/ON-SITE**
YEAR ON-SITE SYSTEM WAS INSTALLED.
ED PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
o'� A'�e 7-E
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
0 SINGLE FAMILY
ED MULTIPLE FAMILY
NUMBER OF BEDROOMS
F -I ONE
0 TWO
D THREE 0 FIVE D OTHER
El FOUR D SIX
2. WATER SUPPLY
0 INDIVIDUAL
El COMMUNITY
0 PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
EI INDIVIDUAL/ON -SITE
OPUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATEINSTALLED
INSTALLER
Size: 1000 If Tank is homemade
give dimensions:
SOILS RATING
Q
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES WELLTO:
Septic/Holding Tan I
Absorption Area
Sewer U7_7
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
d? -'APPROVED FOR BEDROOMS
0 CONDITIONAL APPROVAL (letter must accompany certificate)
EJ DISAPPROVED
DATE
BY
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