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SAND LAKE #2 BLK 6 LT 11
l t f � '� ��1-X33-acs Municipality of Anchorage On -Site Water and Wastewater Section • (907) 34.3-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION DEPORT Permit Number: OSP201425 PID Number- 611-133-26 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New X Upgrade Name CLUFF MICHAEL LIGHTLE STEPHANIE ABSORPTION FIELD 0 Deep Trench ❑ Wide Trench ❑ Sed ❑ Mound Site Address 8341 Seaview St ❑ other Phone Number of Bedrooms Soil Rating Total depth from original grade 266-4360 3 GPD!SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft.Gravel depth beneath pipe Ft. Subdivision Flock Lot SAND LAKE 42 BLK 6 LT 11 FRI added above cripinal grade Ft IGravel length -1 Ft. Township Range Section Gravel vridth Ft.l Beds: Number of Lines - Distance between lines - Ft. SEPARATION DISTANCES Toi Septic Absorption Holdng Sewer Total absorption area I Number of trenches Dist. between trenches From Tank Feld lift Station Tank Line Ft= Ft. ,Jell ,, 100'+ ria tla� TANK 9 Septic ❑ S.T.E.P. ❑ Holdin © Other Manufacturer Greer Capacity 1000 GaI, Surface Water 1100'+ na na Material Plastic Number of ccrnpartments. 2 Lot Line 10'+ I n i na I NA l oundation 1 �}' {- na na LIFT STATION hlanufacluter Capacity Gal. Remarks Septic Tank Replacement Alarm location Electrical installed by PIPE MATERIAL House to tank D3034 drainfieldTank to 3034 Installer Dean Drainfield Mrff D3034 Inspector NorthRim Eng. BENCH MARK (Assumed elevation) 100 It Inspection 1'- 11/3,120 11/4/20 Location and description dales: 2f" I +v V �f Driveway 30 OSI -SITE WATER AND WASTEWATER SECTION APPROVAL s St�` p +++� OF Conditional Approval; Date Jor 49 TH •f c+ Steve Eng _ cE-szas "?Jr ♦ Septic System' Approv L_ t Date / 2- D ��e 11'/ 2 U/ 't Note: this nnnrovnl dr)PS not include well nermit renttirpm ents. rri (0 ° o Wb�ZZ (3) OD <rq �0 tD vcQ �y N�.NoQ a Q MK �: 44 El ro Z ro O CD. _ C+ \'� �� ro O P a "a ro O C Q aa44aaa++a�°+ _0D p C+ m O 37p c+ I p n :3-0 O (� Q z HT1 Q ° X-< Ol ro QQ —I ro ro :3 O n c m u`i m F9 rD Q M < 0 C+ � z o o�� Hro o ro° �� m-1,,.3 �o CA rD %bd D o 1-1 F— c iC7 z `ui a M n d td (� 7C ro ro drD FTI ro O ro ro o v� n r0 ro Ln _0 Q Q cn z- ro 90 ro '3 0:3 ro 1j n :3 :5- n w 5 m AS -BUILT MEASUREMENTS A B T1 19 17 T2 22 20 dco 24 22 NOR THRIM ENGINEERIN =' P'' s sm. SteveEng.co PO Box 77072 Eagle River, Alaska 99577 f4y c£-e2sap L 4 907.694.7028 11%2'0%2 ►� SAND LAKE #2 1 = 40' *44g' BLOCK 6 LET 11 RECORD LAYOUT a WASTEWATER UPGRADE kJ REPLACE SEPTIC TANK °atli2oi2o of 3 O O Flat Slope Flat Slope O ` 2 °3 cdrm Drivew y Flat Slope New 1000 Gall n Septic Tank w DCO's Decommi sioned ld Septic ank PER UP 011-4. c11 --- O NOR THRIM ENGINEERIN =' P'' s sm. SteveEng.co PO Box 77072 Eagle River, Alaska 99577 f4y c£-e2sap L 4 907.694.7028 11%2'0%2 ►� SAND LAKE #2 1 = 40' *44g' BLOCK 6 LET 11 RECORD LAYOUT a WASTEWATER UPGRADE kJ REPLACE SEPTIC TANK °atli2oi2o of 3 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201425 Work Type: SepticTank Upgrade Tax Code Number: 01113326000 Site Legal Address: SAND LAKE #2 BLK 6 LT 11 G:2224 Site Mailing Address: 8341 SEAVIEW ST, Anchorage Owner: CLUFF MICHAEL 50% & Design Engineer: NORTH RIM ENGINEERING This permit is for the construction of: - ❑- Disposal Field ✓❑ Septic Tank - ❑ Holding Tank [--]-Privy--- Effective -Privy Effective Date: Expiration Date CJ Department Lot Size in Sq Ft Total Bedrooms: 10/15/2020 10/15/2021 6750 EI -Private -Well ---❑-Water Storage All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: Locate the beginning of the field to confirm that the 5' separation between the tank and field will be met. Received By: Issued By: Date: Date: � Z0 3 1111111111111 111111!111 11111111liq 11111111liq 1111191,111,1111 " r 1 171", A� Development Services Department .` On -Site Water & Wastewater Section ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel 1. D. 011-133-26 Property owner(s) CLUFF MICHAEL LIGHTLE STEPHANIE Mailing address 8341 SeayieW St Site address same Phone: 907-343-7904 Fax: 907-343-7997 Day phone 266-4350 Legal description (Sub'd., Block & Lot) SAND LAKE #2 BLK 6 LT 11 Legal description (Township, Range & Section) Lot Size 6,750- -Sq Ft. - Number of Bedrooms -3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) Q (w/wo ADU) Septic Tank ED Upgrade Duplex (D) ❑ Holding Tank ElRenewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with apppzable MuDic'I_pal Codes. (Sig'nffu'rc''of property owner or authorized agent) Permit/Rush Fees: � M'l5c Goat lb--1� Date of Payment: O1 13 p D 2 0 Receipt Number: O5I ? IJ Permit No. 0 S � © � D,5 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Sand Lake #2 Block 6 Lot 11 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: The current septic tank has failed- the seepage trench still functions. This lot is small with nearby wells drawn on plan sheet. No adverse impacts are expected from tank replacement. The easements are depicted on the lot. The slope is indicated in the area of the septic system. No conflicts to neighbor properties. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. New 2- compartment, 1000 gallon septic tank. Watertight couplings on inlet & outlet. 5 minimum between the tank and trench. 5 to property lines & 10 to house. 4 of cover or insulation is required for tank; an equivalent of 1 insulation for 1 foot soil cover. Tank & solid pipe must be set on well compacted, stable soil. No large rocks for tank bedding. Plastic/fiberglass tanks require special bedding per MOA- sand or pea gravel. 4 diameter cleanouts with airtight caps are required 1 to 4 from foundation wall, prior to any 90 degree bend in 4 inch line, in each tank compartment, and two adjacent opposing cleanouts between the tank and the absorption field, not more than 10 from the tank positioned to provide cleanout access towards the tank and towards the absorption field. All cleanouts must extend to at least ground level. In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron. Insulation must be placed over any pipe installed under driveways or parking areas. Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, Sewer Service Line is minimum 2% slope. Septic Tank to be pumped every two years or when required. Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201425, Deb Wockenfuss, 10/15/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201425, Deb Wockenfuss, 10/15/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201425, Deb Wockenfuss, 10/15/20 MUNICIPALITY OF ANCHORAGE i DEPARTMENT OF HEALTH & ENVIRONMENTAL- PROTECTION I ® ENVIRONMENTAL ENGINEERING DIVISION 87.5 L Street - Anchorage, Alaska 99501 Telephone 2.64-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME- - ,,�JJ��J- ---� - PHONE (ANEW T// / L G✓t S %Y't./ ❑ UPGRADE MAILING ADDRESS Sly f} r°S ver �v 3 6.4 LEGAL DESCRIPTION % S-o.1d LOCATION NO. OF BEDROOMS U Y DISTANCE TO: Wel,l/� J /"U(G. Absorption area Dwelling�3 41 PERMIT NO. _ wQ � Manufacturer67 fee Material` {_ / No. of compartments y Liq. cacit©n6allons IF HOMEMADE: Inside length Width Liquid depth Y J02 DISTANCE TO: Well Dwelling PERMIT NO. iz H Manufacturer Material Liquid capacity in gallons m= DISTANCE TO: Well Foundation Nearest lot Ile PERMIT NO. J LL z l= z tu No. of lines Length of each line .,3s Total length of lines __ Trench idth inches Distance between lines r f.. a Top of tale to finish grade j /� Material beneath the inches Total effective absorption area .300 Lu 0 Length Width Depth PERMIT NO. Q F wLU a Type of crib Crib diameter Crib depth Total effective absorption area N DISTANCE TO: Well Building foundation Nearest lot line J J Class Depth Driller Distance to lot line PERMIT NO. Lu DISTANCE T0: Building foundation Sewer line Septic tank Absorption area(s) OTHER O Ln PIPE MATERIALS �'Ies7<7c_ SOIL TEST RATING 00 INSTALLER ca/e� REMARKS/� -J 0 Jr., )/e o f %© 7(- r APPROVED DATE LEGAL `�—Z`f Vrd? S�?4laA 112 d ` 72-013 (Rev. 3/78) 04 1 311:����� CD! F=' ��4 i�� DEPHRTMENT\^/HEALTH HND Elk! VIRONME�TOTECTION 825 /L' STREET/ HNCHORHGE/ HK. 99501 264-4720 !S W WW FTC Fol is! FEE 0-11 7, PERMIT NO. ( 820192- ) HPPLICHNT T to T H ]452670 LOCHTION SEHYIEW LEGAL L11 B6 SHND LAKE S/D #2 LOT' SIZE 675"D SQUHRE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH. MHXIM[/M NUMBE-�'R OF BEDRGOM5 = ] SOIL RHTING (S0 FT/BR)= 100 THE REQUIRED SIZE OF' THE �OIL ADS ORF, TION SYSTEM IS� Eon ������ Q U EH: P�4 C� -T, 1-1= 19: IS W FT 1=1 %.A M U �ESE ���� � THE LENGTH DIMENSION IS THE LENGTH <l ;l'-4 FEET) OF THE TRENCH OR DRHINFIEL[> THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE BETWEEN THE SURFHCE OF THE GROUND HND THE BOTTOM OF THE EXCHVHTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCHVHTION (IN FEET). FQ M Kit U 1 FET 1=1 Elo ������ �M 148 S' ��:Z` -E---_ — ��I-2--il C3 fl=�u L_ HE_ Co 141� PERMIT HPPLICHNT HAS THE RESPON5IBILITY TO INFORM THIS DEPHRTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WEELLS ADJACENT TO THIS PROPERTY HND THE NUIBER OF RESIDEk-lC:E.S, THE WELL. WILL -SERVE. ��_ Y- Q M FEZ cis U 1 FEZ, I -E.: v: --n BHCKFILLING OF ANY SYSTEM WITHOUT FINAL AND HPPROVHLBY THIS DEPHRTMENT WILL BE SUB'JECT TO PROSECUTION. MINIMUM DISTANCE BETNEEN H WELL AND ANY OM~SITE SENHQE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTHHCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET HND TO H COMMUNITY SENER LINE IS 75 FEET. OTHER REQUIREMENTS MHY HPPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS HRE AVAILABLE TO INSURE PROPER INSTHLL�TION W �SN" 1 F EE.' -7-7. ���Q it! 10 FEE-- F-`.' �E.',;� I CERTIFY THAT 1: I HM FHMILIHR WITH THE REQUIREMENTS FOR 01N. -SITE �EWERS FIND NELLS AS SET FORTH BY THE OF ANCHORAGE. 2� I WILL INSTHLL THE SySTEM IN HCCORDHNCE NITH THE CODES. ]� IUNDERSTHND THAT THE 0N-_ ---ITE SEWER S9STEM 1119[Y REQUIRE ENLHRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS. SIGNED:____^_____~___`_~�~..~..�~~______~__~~~~ HPPLICHNT T & T CONSTRUCTION ISSUED BY ~ Y4 0 _ a €' iF At _#) _g- . -i _ � I <7E -t z_f• t.f;� _ � >_•_:•t s; {�'j s}�1� _.'°S `_:3�." •p_i�` ` t - : •e `..t ;? -. -n-t-_ `a. tF � _ �3 . � _ 5 t. as S' p:f '.`%`C'?� ! �'tt E} r �-?;.�} �'_-`'_' : _Is` .s _s.��i �S §f= 4' _ z .t� 1 �_ si i-3 � : "7�? i. •_ $r5 f_ Y , s };ts,2 CIA - ?_x-,45-:€": r?""' ??"_ sz}§ :`s is .e _'''.'z§�3t` s 1;"q ,`- _r f> s r ii? 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E3_._`tf§ §t2({ -r 5V : ��-- �X... �']*�!? _ st Ott -t iJ(f't )' . ! {{���i•ggi.tf= ''lxe}: .�' Yi _ i:1Z 3t'.§t#�fi`t'ir, t-`[ t_4— - f f }t)-}}). `F-1 Srq t}fit t"�- i:�i-7:- _ ... a i i}'tS { Y.S 1` e . _ _ _ - tea. •... ..,, r,'}, .' e .�.t#� Y-: Tr J_CJ_tl_,-r.Li� l �i WJ SOILS LOG MUNICIPALITY OF ANCHORAGE p •,ed DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: TJ��I `''yDATE PERFORMED: Lb EGAL DESCRIPTION: �� ' V 5,A IA K n�H1 / ` SLOPE SITE PLAN 1 --0 0 ® 5P 2 m Net 3 e Time 4 9 Drop a 6 7 � e G ° 8 � d C 9 10 A r e d d 12 ° 0 13 ° 14 C% ° S 15- 16- 17- 18'-t- 19 5 16 17 18' 19 P9 d 'S anal 3ePu�,;ls WAS GROUND WATER IV S ENCOUNTERED? Iy L 0 P IF YES, AT WHAT E DEPTH? 20� PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT / COMMENTS : f1 S` 1F.. CA C--f.l /•t_ OO ��/� rr -e PERFORMED BY: 'fqhtl J%(VvQ /�31 CERTIFIED BY: DATE: �z C�-76-- 72-008 (6/79) Gross Net Depth to Net Reading Date Time Time Water Drop •.. .g !c ov p • ° ..ea.a. .e.•ea•. i • ........... r tc �• Le y C. Reid Jr, 20� PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT / COMMENTS : f1 S` 1F.. CA C--f.l /•t_ OO ��/� rr -e PERFORMED BY: 'fqhtl J%(VvQ /�31 CERTIFIED BY: DATE: �z C�-76-- 72-008 (6/79) CONSTRUCTION AND OPERATION CERTIFICATE ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION PUBLIC WATER SYSTEM ell APPROVAL TO CONSTRUCT Plans for the construction off to �- i� � � ��� ,y..- "I'ri o cIA Lcj ; 1 `4 fq- J4 },J i_ E public water system located in Alaska, submitted in accordance with 18 AAC 80.100 by 14 L& ; JCc., 61 i i i 1 ' ` have been reviewed.and are approved. 0 conditionally approved ee attached conditions). v / L)._ X, 7 Efy TITLE DATE If construction has not started within two years of the approval date, this certificate is void and new plans and specifications must be submitted for review and approval before construction. APPROVED CHANGE ORDERS Change (contract order no.. or descriptive reference) Approved by Date The "APPROVAL TO OPERATE" section must be completed before any water is made available to I the public. APPROVAL TO OPERATE The construction of the public water system was completed on (date). The system is hereby granted interim approval to operate for 90 days following the completion date. BY - - TITLE - DATE As -built plans submitted during the interim approval period, or an inspection by the Department has confirmed the system was constructed according to the approved plans. The system is hereby granted final approval to operate. TITLE Parcel 1. D. 011-133-26 1 Certificate of On -Site Systems Approval Expiration Date: 3 r2- —2-0Z GENERAL INFORMATION Complete legal description SAND LAKE #2 BLK 6 LT 11 Location (site address) 8341 Seaview St Current property owner(s) CLUFF MICHAEL LIGHTLE STEPHANIE Mailing address Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 266-4350 Day phone 4. TYPE OF WATER SUPPLY: MUNICIPALITY OF ANCHORAGE FX I Private Septic El Water Storage ❑ Development Services Department ❑ Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel 1. D. 011-133-26 1 Certificate of On -Site Systems Approval Expiration Date: 3 r2- —2-0Z GENERAL INFORMATION Complete legal description SAND LAKE #2 BLK 6 LT 11 Location (site address) 8341 Seaview St Current property owner(s) CLUFF MICHAEL LIGHTLE STEPHANIE Mailing address Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 266-4350 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well FX I Private Septic El Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 660 (-,OVID Waiver Fee $ Date of Payment Receipt Number COSA # 03C 20 l.h 6 5 Date of Payment Receipt Number Waiver # 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, 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm NorthRim Eng. Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng ti. DSD SIGNATURE System #1 Approved for 3 bedrooms System #2 Approved for bedrooms Disapproved Date 11/20/20 OF eVq OM1 sir :49LH� *>f f♦ Steve Engya'k;fik f 41 A Ar CE 621% Conditional approval for bedrooms, with the following stipulations: vvni L.1\ n1YV 'i/1W)))) W) N) , 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 vrork. 7. ATTACHMENTS: CASA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory W=11 PInter ArhAenm (1tEicr COSA Checklist Legal Description: SAND LAKE #2 BLK 6 LT 11 Parcel ID: 011-133-26 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Well production at time of test gpm Date drilled Water storage tank volume gallons Total depth ft Well disinfected for coliform test? ❑ Yes ❑ No Cased to ft OR Coliform bacteria is Negative ❑ Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND) ❑ Wires are properly protected Arsenic 20.8 ug/L ❑ Arsenic less than MRL (ND) Casing height (above ground) in. Collected by NRimEng Date of flow test for COSA Date of Sample 10/22/20 Static water level at beginning of test ft. Comments Private Well On Lot 12- Regulated By State DEC B. TANK DATA Age of tank(s) new years Tank type/material 5ep""=" Measured operating fluid level in septic tank new ❑ Standpipes/foundation cleanout per record drawing Date of pumping new D. ABSORPTION FIELD DATA 4/82 Which system tested (date installed) same ❑ ALL standpipes present per record drawing Total measured depth from grade 10 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: New Monitor Tube installed COSA Checklist yellow sheet C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date ioiztizo Results ❑✓ Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 450 gal New depth 1 in Elapsed time 30 min Final fluid depth 0 in Absorption rate 450 gpd Any rejuvenation treatment (past 12 months) If yes, enter date no E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if cnrnmunitywell) Septic Ta nklLift Station on Lot > 100' (R] Yes if No Community Sewer Manhole/Cleanout > 100' [] Yes if No ft F1 Yes if No ft Neighboring Tank > 100' F1 Yes if No it Private Sewer/Septic Line > 25' 0 Yes if No ft Absorption Field on Lot > 100' C:] Yes if No ft Holding Tank > 100' El Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' El Yes if No ft El Yes if No it it If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' F-1 Yes if No it F-1 Yes if No it From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' (R] Yes if No ft Surface Water > 100' 21 Yes if No ft Property Line > 5' El Yes if No it Wells on Adjacent Lots-, Wells on Adjacent Lots: Absorption Field > 5' 21 Yes if No ft Private Wells > 100' nl Yes if No ft Water Main > 10' El Yes if No ft Community Wells > 200' P1 Yes if No ft Water Service Line > 10' Q Yes if No it If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances it less than required) Building Foundation > 10' Yes if No ft If absorption field is under driveway comment below Property Line > 10' Yes if No 5 it 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 / certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance wyith MOA COSH guidelines in effect an this date. .49 a* Steve Eng AV *-Q-AJ NOTES: THE RECORD PLAT DOES NOT SHOW ANY BEARINGS. NORTH AND EAST WERE HELD, THE DRIVEWAY LOCATION IS APPROXIMATE DUE TO SNOW COVER. I 0 LO 44.6' r " SEPTICPIPES o SEPTIC MANHOLE Z ASPHALT ' PAVEMENT'' . II I 30.00' { I & RAIL FENCE Lot 10 WOODEN FENCE EAST 135' 1 STORY RESIDENCE 46.3' Lot 12 Lot 15 WOODEN WALKWAY Lot 11 a 6.750 S.f. 'n N Lot 14 44.1' o .•\ N T I Lot 13 I I i PLOT PLAN AS BUILT X SCALE 1" = 30' GRID _ SW 2224 Project No. 20-726/R3 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & A S S a C i a t e S, inc. (907) 522-6476 Phone ao�o�0� 522-4625 Professional Land S u ry eY ors ken*langsurvey comax 015 "4 O F A jonathonOlongsurvey.earn S Q I hereby certify that I have surveyed the following described property: LOT 11, BLOCK 6, SAND LAKE SUBDIVISION (Plot No. P-176) Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on sold property except as indicated hereon. Dated this the ` Day of I;,Ao� &,-tANpc -- , 2.02 , at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. 49TH y*l ............r .............. KENNET G LAN it (°t9 QCs DO •••.LS -5202.••• yJ_pfl I�OQRO SSIONAL �pQo �400o�"d AECC963 Municipality of Anchorage .4 Development Services Department Building Safety Division kz�r ^ On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Arsenic Advisory Certificate of On -Site Systems Approval # OSC201665 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 6, Lot 11 of Sand Lake #2 Subdivision. This inspection revealed an arsenic concentration of 20.8 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING L Parcel I.D. # HAA # 1. GENERAL INFORMATION - Complete legal description Lot 11 • BEoch 6 Sand Labe Subdivision ',Q Location (site address or directions) 8341 Seavtiew Drive Anchonaae AK Property owner won Cho ' Day phone Mailing address 8341 Seav,i,ew 99502 Lending agency Day"phone Mailing address Agent Roc Y VISTA REAL ESTATE Day phone 273-7255 Address 3000 "C" StAeet, Suite 101 Anchonaae AK 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well XXX Public water L =6-0 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX 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. 72-025(Rev.1/91) Front MOAN21 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 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 Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm 17034 Eagle River Loop Address f_ Engineer's signature 6. DHHS SIGNATURE X Approved for bedrooms. Disapproved. Conditional approval for Additional Comments 4 Phone 21�17 9 Date 6 1 'i'I tai., Y�1titY1' :. fQih. hi�•f.'. bedrooms, with the following stipulations: Date - 2 / - %r�' 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 orderto 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 (Rev. 1/91) Back MOA M21 Municipality of Anchorage O Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L,7 // /SLK % !44✓Q LA {arcel I.D. 90 A. Well Data Well type If A, B, or C, attach ADEC letter. ADEC water system number Z /.S46 Log present(Y/N) Date Total depth Sanitary seal (Y/N) Date of test Static water Well flow Pump I ell SEPARATION DIST Septic/het€#g..tank on lot Absorption field on lot WELL LOG FROM WELL TO: /Z? ( --)I- to Driller Casi Wires p7A_T rly prot d (Y/N) INSPECTION On adjacent lots ; On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer service line Petroleum tank * W1A6✓&-kTUV.1_774N-Fn FKDp-i phJ WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/1*60IN6 TANK DATA by: Date installed �Z Tank size I U( -,A L— Compartments Z - Cleanout Y/ ) Foundation cleanout(�Y�% 1) (L-6 S Depression (Y/N) \ � High water alarm (Y�q f Alarm tested (Y/N) / ZIA Date of pumping `t Pumper A -r &✓Li l SoL�UIceS te SEPARATION DISTANCES FROM SEPTIC/148EW &TANK TO: Well(s) on lot /JuN� rcC'-SOn adjacent lots 2 Foundation o To property line Z-2- / Absorption field S r Water main/service line Surface water/drainage /66 1-t- 72-026 (3/93)* Front t 72.026(3/93)•Front CONTINUED ON BACK PAGE z ;o n m LU L � W 9-13 LLt ° v < LLI O 3 Cie 6 W Date installed �Z Tank size I U( -,A L— Compartments Z - Cleanout Y/ ) Foundation cleanout(�Y�% 1) (L-6 S Depression (Y/N) \ � High water alarm (Y�q f Alarm tested (Y/N) / ZIA Date of pumping `t Pumper A -r &✓Li l SoL�UIceS te SEPARATION DISTANCES FROM SEPTIC/148EW &TANK TO: Well(s) on lot /JuN� rcC'-SOn adjacent lots 2 Foundation o To property line Z-2- / Absorption field S r Water main/service line Surface water/drainage /66 1-t- 72-026 (3/93)* Front t 72.026(3/93)•Front CONTINUED ON BACK PAGE C. LIFT STATION NvL SL Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DIST. Well D. ABSORPTION FIELD DATA LIFT STATION TO: On adjacent lots Manhole/Access (Y/N) Cycles tested off" Level at Surface water Date installed 4182- Soil rating (GPD/Ft2) d ///L System type �' /Jcp Length Z S Width S r Gravel thickness t� ( Total depth Total absorption area Cleanout presentY/) lis Depression over field (YO Date of adequacy test—LW i4 Results (pass/fail) PA SS for12L—�E� Bedrooms 7/ i Water level in absorption field before test After test Peroxide treatment (past 12 months) (Y/N) A)Ai If yes, give date ,AJ�r1 SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /v O^J 6- r/212_)6S1_On adjacent lots Z3 Z -Property line o r p/ �� a To building foundation /9 To existing or abandoned system on lot On adjacent lots Z o /,/— Cutbank S6 /_/_ Water main/service line /h Surface water /0 y r->/- Driveway, parking/vehicle storage area S (4 -- Curtain drain E. ENGINEER'S CERTIFICATION I certify that / have checked, Signature Engineer's NamE G Each Date Eastle Rive HAA Fee $ J DO ` ao NEERING e River Loop Read No. Date of Payment — %/- Receipt Number 72-026 (3/93)' Back VZY Waiver Fee Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE % DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION D 3 �J DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 22SS O 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) 6 Location (address or d' ections) / (b) Applicant Name Telephone: Telephone: Home Business Applicant Address (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent 20/OG !� Address Telephone % �z (f) Mail the HAA to the following address: S & S ENGINEERING 17034 Eagle River Loop Road No. 204 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well ❑ Community ❑ PubliA Note: If community well system, must have written confirmation from t \State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite,tSJ Public ❑ Community ❑ Holding Tank ❑ Note: if community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 c1 1/84) Page 1 of 2 5. ENGINEERING FIRM PROVIDING SPECTIONS, TESTS, FILE SEARCH, DA'. .AND INFORMATION 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 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 Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. S & S ENGINEERING Name of Firm 17034 Eaglep Koad No 22O4 Telephone Address Eagle River, Alaska 99577 Date )'j U 6. DHEP APPROVAL Approved for �2 bedrooms by Date ZKLg�ff Approved Z_ — Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 (11/84( ppUNICIPAtiTy OF ANCHORAGE ENVIRONMENTAL SERVICESPALITY OF ANCHORAGE HEALTH ( AUTHORITY APPROVAL AL(HAA) CHECKLIST - FEBRUARY 1984 r• r ' ' ^1 1 1�aa 264-4744 RE 1. Legal Description: A. WELL DATA /� Well Classification ks If A, B, C, D.E.C. Approved W— 1) Well Log Present (Y/N) Date Completed Yield Total Depth Cased to Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot �2� ; On Adjoining Lots To Nearest Edge of Absorption Field on Lo 132 ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ; Date Water Sample Test Results Comments 4_V"/b'1 V)&4� V 'f � C— — ( o B. SEPTIC/AOL-1 TANK DATA Date Installed -4-62- Size(( c2� No. of Compartments -2— Stand Stand pipesdL�;N) — --- Air -tight Caps(ON) X Foundation Cleanout49N) Depression over Tank (Y/6 Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) PI/61 Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/fia Wjug, Tank: To Water -Supply Well Z% To Building Foundation r i To Property Line ZZ To Disposal Field° S To Water Main/Service Line c--> I"- To Stream, Pond, Lake, or Major Drainage Course I4- � p� Comments Page 1 of 2 72-026 (Rev. 8/86) Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata t o /tea- - Type of System Design i Date Installed .4Z4::7 Length of Field 7�S t J Width of Field S Depth of Field /d Gravel Bed Thickness �O J Square Feet of Absorption Area ���� Standpipes Present49N) - Depression over Field (YO Date of Last Adequacy Test Results of Last Adequacy Test�5�-� k� Y��-• Separation Distance from Absorption Field: To Water -Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course _ To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments To Property Line To Existing or Abandoned System on On Adjoining Lots To Cutbank (if present) gD 1 Dimensions Manhole/Access (Y/N) "Pump Off" Level at ::�� Vent (Y/N) Pumping-15ystsduring Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed 5 & S ENGINEERING Date Com an 19034 Eagle River Loop Road NM lAd o� P YE��H�. Receipt No. Date of Payment CJ Amount: /7� y v e` !s ell � � dd s r 3 Page 2 of 2 ' K y 72-026 (Rev 8BM Back i DEPT. OF ENV iRONMEI TAIL CONSIEliliVNI"O"Y ANCHORAGE/WESTERN DISTRICT OFFICE. 3601 "C" STREET. SUITE 1334 ANCHORAGE. ALASKA 99503 DATE: _3-9-88 ----------- PWSID #: _215469______-----_ To Whom It May Concern: STEVE COWPER, GOVERNOR 563--6775 According to the records on file in this office, the --Lois 6,-7, 8-125 _Block 6, SAND -LAKE -#2Y ------ Water System is in compliance with the State of Alaska Drinking Water Regulations. Sincerely. Ronald S. Klein Environmental Field Officer MUNICIPALITY OF ANCHORAGE ' DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) (b) Applicants NanE Applicants Addr�-SZn m (c) Applicant is (check one) Lending Institution Buyer ; Other (explain); ^ (d) Lending Institution Address (e) Real Estate Co. & Agent Address Telephone 2. Tvpe of Residenm Single -Family _ Multi -Family Number of Bedroom �. 3, Water Supply individual Fell Crxrmaanity� I Owner/builder Other (describe)- Public Note: If comffunity wall system, must have vrritten confirmation. frcm the State Department of Environmental Conservation attesting to the legality and status. Is the well adequate for the number of bedrooms specified In this HAA Y, 1)___ 4. Sewage Disposal Onsite mf Public C Community Holding Tank r f jr i Is the wastewater disposal system adequate for the rur&Der of bedrocans dby ) [Page 1 of 21 2-15-84 F � r 1 , 5. Engineering Firm Providing Inspections, 'Tests, Data and Information I certify that I have checked, verified, or conformed to all NADA mAA Guidelines in effect on the date of this inspection. Signed Date Name of tE}irm Tele hone Address �f�( ����i21 - �J Signed by�r.r (r�fG�c�iec7 ! i n"� ®r Date J /Z/ % ��o=,..JP 4an Fx The Municipality of Anchorage Department of health and Envirommntal Protection dons not guarantee the continued satisfactory performances of the water supply and/or the wastewater disposal system. This approval indicates that, as of the validation date shown above, based on the data and information furnished by an engineer registered in the State of.Alaskao the water supply and wastewater disposal system is safe and func- tional for the number of bedrooms and type of structure indicated. (MEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s (Page 2 of 21 2-15-84 Fl a —1<..() L' l 4t'f I CPQ° L$r C. P ) 1 , � No. 2251dG .I r. ! t, c/ ��vVcc.l 6.DHEP Approval P �tp" �, ROFE,SK�,.. J L� 7Zl+i',l Wiz' z"f r� iF``fl /fit,>zr.Y ✓;: .v l Date Approved for_ bedrooms By — Approved Disapproved f::� Conditional Terms of Conditional Approval The Municipality of Anchorage Department of health and Envirommntal Protection dons not guarantee the continued satisfactory performances of the water supply and/or the wastewater disposal system. This approval indicates that, as of the validation date shown above, based on the data and information furnished by an engineer registered in the State of.Alaskao the water supply and wastewater disposal system is safe and func- tional for the number of bedrooms and type of structure indicated. (MEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s (Page 2 of 21 2-15-84 MUNICIPALITY OF ANCHORAGE E t DEPT. OF HEALTH & MCNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL ( HAA) r j l) {_ 1 n iom CHECKLIST - FEBRUARY 1984 Legal Description: �� �XED � A. WELL DNTA Well Classification Cpm Ife; B, or C, D.E.C. Approve /N) Well Log Present (Y/N) Date Completed Yield Total Depth Cased to Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) Separation Distances from W-bll: To Septic/Holding Tank on Lot 07 _.4 on Adjoining Lots A)101- � To Nearest Edge of Absorption Field on Lot,/i On Adjoining Lcts To Nearest Public Sewer Line � &4- To Nearest Public Sewer Cleanout/Manhole )V . To Nearest Sewer Service Line on Lot Water Sample Collected By Water Sample Test Results Com-ents B. SEPTIC/HOLDING TANK DATA Date Date Installed -5 Size /©dC No. of Compartments Z_ Standpipes (0) Air -tight Caps Y ) Foundation Cleanout (Y11Q____ Depression over Tank(Y Date Last Pumped n r4il T p Pumping/Mainterance Contract on File (Y/N) N ; for Holding Tank High -Water Alarm (Y/N) AILq Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding �Tank: To Water -Supply Troll �� To Building Foundation j0 �e To Property Line tom/ To Disposal Field 6-"8 To Water Main/Service Line /Q To Stream, Pond, Lake, or Major Drainage ,(or_ Ft q -1'i � ( (Page 1 of 21 2®15m84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata lee X!r Type of System Design Date Installed Length of Field / D Width of Field �/ Depth of Field `p'm Gravel Bed Thickness 6149 Square Feet of Absorption Area j Standpipes Present (Y ) Depression over Field (Y ) Date of Last Adequacy Test Results of Last Adequacy Zest _( f, �2 W=nom 4 Separation Distance from Absorption Field: To Water -Supply Wall f 3� � LV To Property Line To Building Foundation fg,r d) To Existing or Abandoned System cn Lot_ lyl,4- ; On Adjoining Lots _-,- �{ 0, To Water Main/Service Line To Cutbank(if resent) 301,45 To Stream/Pond/Lake/or Major Drainage Course A)14 - To Driveway, Parking Area, or Vehicle Storage Area $� Ccm,ents _�e7 �cdi `nuj4 Av yc D. LIFT STATION Date Installed Size in Gallons "Pump cm" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Comments Dinensions Manhole/Access (YM) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or, conformd to all MOA HAA Guidelines in effect on the da. of this inspection. Signed p\ Date �( Company MOA No. 5Ti53 -Oal� KB1/d5/s [Page 2 of 21 � NROFESSO 2-15-84 s 6 O BILL SHEFFIELD, GOVERNOR DEPT. OF ENVIRONMENTAL CONSERVATION Telephone: (907) Address: SOUTHCENTRAL REGIONAL OFFICE 437 "E" STREET, SUITE 200 ANCHORAGE, ALASKA 99501 DATE:- PWS ATE:PWS T.D. # ��7t e CL d of To Whom It May Concern: 274-2533 According to records on file in this office the Water System is in compliance with the State Drinking Water Regulations. Sincerely, APPLIC SIT FILLS OUT UPPER HAL, . ONLY Time Property Owner _r I t.J Date - Phone Mailing Address jk/i 12 o1 1-03s='4 Zip Code j'St7 Z 3G/S �6 7U Buyer (�( Address f Zip Code Lending Institution Phone Address Zip Code MUNICIPALITYTC` Realty Co. & Agent " rz. -1-TION Phone Address Zip Code JJ Legal Description�- d Street Location a �^ 'CONDITIONS OF APPROVAL Type of Residence >N�ingle Family ❑ Multiple Family No. of Bedrooms ❑ Other Water Supply Soils Rating ❑ Individual Well To Absorption Area ATTACH WELL LOG. A well log is required .for all wells drilled since June 1975. 'WCommunity 14-21-4^ IP `l— For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility wer Disposal �-- U -"°.n ✓� Y Individual Year Individual Installed: t _ ❑ Public Utility When Connected to Public Utility: - ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date - Date Date Date 0 Inspector Inspector Inspector - Inspector (� s"SQ �, MUNICIPALITYTC` Field Notes: " rz. -1-TION ENVIRJ;I'- r„?.- :..0 RECEIVED ( L -4 -APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' � e' -'?'—� �- DATE BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received 14-21-4^ IP `l— Well to Tank - Septic Tank Size 0 U 72023 (3182)