HomeMy WebLinkAboutSAND LAKE #2 BLK 6 LT 12
~i... ~' MUNICIPALITY OF ANCHORAGE /
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENI'AL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 2644720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME.__._ ~ , IPHONE ~;~NEW
MAI LING ADDRESS
LEGAL DESCRIPTION
~ DISTANCE TO: Well /~'~ Absorption areao~ Dwelling/~/[ ~ / PERMIT NO._~ff~/~5
D ~ Manufacturer ~ Material ~] 1 No. of compartments -~
~ Liq'7~gall°ns IF HOME.DE: Insidel~ Width ~ Liquiddepth.~
~ ~ DISTANCE TO: Well Dwelling ~ PERMIT NO.
O z ~ Manufacturer Material Liquid capacity in gallons
~ Well Foundat,o~ ~ .e~rest lot I,ne ~ .~MIT ~0
--~ Nc. of lines / Length ofe~ch line~7~. Total length oflines.¢~.._. Trench w,dth../Z,nches Distancebet~enlines/~
~ ~ ~ Top of tile to finish grade Material beneath til$ .... Total effective absorption area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO: ~ /
M Class Depth Driller Distance to lot line PERMIT NO.
Building foundation Sewer line Septic tank / Absorption area(s)
~ DISTANCE TO: ,/ / '
OTHER
PIPE MATERIALS : it'
'7 //' /z; i/
APPROVED DATE LEGAL
72-013 (Rev. 3/78}
F':'ER!"i ! T
FiF'PL :i CF!HT i"IFIR.k: T[3L~S[-:'.'i'-4 E;:[~d.',).:: 'T'ERR'T' PLF~C:E
[,_OCFiT :[ ON
L..EGRL. L &2 E: 6 SFIBIE:, LFIKE S,-.-'D '.S~;2 L. OT SIZE
T'¢F'E OF SOJiL RDS[)RPT]:OI'-,! Sb'S'TEH :ES: TRENCH
HRX:[P!UH F,iL!HE~ER OF:' BEE:,ROOHS :~: SO:iL. F:RTiNG (SQ F"i",--"E~i~:):-;;
THE F?E~UIF;E:[:, SZ2:E OF:' THE SOiL RBSORF'T:i:Oi'.4 S'.?STEH ~S:
FIND THE E:[:)TT[)H OF "r"4-'
[..
F:'E:RH]:T RPF:'I T'":Ri'-T ~-~'::I': THE !'~.~:..::,r U 4:,.'.-E .... t~
):i"J'Z;'T'F:: Fi"']'" "~ T '.,?:7, F'F'i":TTi'"ti'-,I':; i-![::' F:l~'.,!~,' t r: I :: Fl['
NLII"!BF:F;i OF RES I2[i:JNCES THF!T TFiE I'.I[:i'_L. HiLL
i"'I~Jf'4Zi'"ILi!"i DISTFtf',IE:E BE'TI,iE:EN F! HFLL. [aN[;:' RN'T' ON-SZ'TE SE!.'.tRGE [:'IE;POSF~I...
:i..EHZ, FEET FO[? ~ F'RiE'v'FTFE HELL OR J..E::.i6 TO 2E"Z~ F'E:ET F~'.OH Fi F:'L!E~LIC i4E::LL
LiF'ON THE T"?PE OF F't...IBL:[C HELL.
PIZN!FILIH E:'ZSTFti",ICE: F'I:~'.[:tH F! F'R]:VFI'i"E !.'.!EL.L TO R PF?.Z"/FITE SEi.,.iE:F: LINE
TO R E:Cff'!Ht_fN]:T'¢ SEI.'.IE!:;;: L.:[NE: IS 7~ FEET.
HELL LOGS ¢~[~:E RE~;¢.J:iI:~:ED Fff',!D HUST BE F~iE"f'LtF:!",IEb TO THE [:'EF'F~RTHiENT !,.!ZTH:[N :]N:E~ E:'i::i?S
OF THE !4ELL. CCIHF'LET]:ON.
OTHER REQLI I FiiEi"'tENTS I"!Fi? FIF'F:'L.'?'. SPEC ! F' i C:F!T :[ ONS FiND CONSTFiLiE:T ): Oh! [::,1[ F:iGF~:FIP1S RRE
FI',,,'F~ ]: LRE~LE: TO Z !'.,!SIJ[~'.E PROPER i NSTFiL. LFFi' Z ON.
i C:EF. tTZ F':" THRT
:L: i Fill FF:IHZL_]:F!F: H'i'TH THE F;:Ei;:!LtIRE:!"IEI"4TS FOF.: ON--SITE SEHERS RND HELLS RS SE'T'
FOF-::TH B'T' THE: !'dt,,.li'.,! :[ C :! F'FIL .ii Tk' OF FiNC:t'!OFb:I,(:ii!E.
;::': Z H:[LL ZNL:;T,RLL THE S'¢STEH iN FiE:C:OF:[:-'i"4.?'~CE HZTH THF.~: C:O[:'E'..:.;.
Z: I I,.iNE:,EJF?STFii'-,ID THF!"F 'T'HE': Oh,!--.S:[TE :':T, EIqEF: :5'?'S'f'E:hl P!Fi',? RE[;¢JZF'.E: '-2:NLRF::(L:;EHE:HT :iF' TFIE
RESIDENCE IS.:; F:Ei','iOE:,ELE:E:, TO INCL[JDE i"10~:E 'THFI!'.J 3: E~EDF.:O(]HS.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
DATE PERFORMED:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
SLOPE
SITE PLAN
10
11
12
13
14-
15-
16-
17
18
19
2O
WAS GROUND WATER'
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
;/ Reading Date Gross Net Depth to Net
Time Time Water Drop
Jr.
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND -- FT
CERTIFIED BY:
DATE:~7Z',--'- ~.0 ~ 7-~
72-008 (6/79)
CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
PUBLIC WATER SYSTEM
APPROVAL TO CONSTRUCT
Plans for the construction of.
,public water system located
in
Alaska, submitted in accordance with 18 AAC 80.100
by
have been reviewed and are
[] approved.
[] conditionally approved (see attached conditions).
BY 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. Date
or descriptive reference)
Approved by
The "APPROVAL T° OPERATE" section must be completed before any water is made available to
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 c.omp et on date.
BY TITLE DATE
As-built plans submitted during the interim appr~)val 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.
BY TITLE DATE
Municipality of Anchorage
Development Services Department'
. Building Safety Division
,. ~ On-Site Water and Wastewater Program
.. !4700South BragawSt. '
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage.ak.us
: (907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. :011-133-25
1. GENERAL INFORMATION
C0mP!ete legal.deScription LoC
Location (site/addre§s or directions)
HAA# 0
Expiration Date: .(~'~i
12; Block 6; .Sandlake Subdivision #2
8349 Seaview
Current Property owner(s) Ted Whip
Mailing address
Len'ding agency
Mailing address
Day phone 360-303-8998'
Day phone
Real EstateAgent I(~[m p.~s]e¥ / JKP
Day phone
Mailing Address 11~ W_ Nnrth.rn T,'lEht-n
Unless otherwise requested, HAA will be held by •SD for pickup.
2. NUMBEROF BEDROOMS: -~
TYPE OF WATER SUPPLY: '
Individual Well []
Individual Water Storage []
Community Class A Well ~]
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual Omsite [~
Individual Holding tank I'-'1
Community On-site F']
Public Sewer Fi
l
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 homeowners. 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, sample results. (Certificates may be reissued for a pedod 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:
STATEMENT OF INSPECTION'BY*ENGINEER
As certified by my seal affixed hereto and as Of the validati~)n 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 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.
NameofFirm S &'S Engineering phOne 694-2979
Address 17034 N. Ea~le River Loom Ste. 204 Ea~le River, AK 99577
Engineer's Printed Name Robert C. cowan Date ,~"-/3-p/'O~
bedrogms.
DSD SIGNATURE
Approved for
Disapproved.
Conditionai approval for
bedrooms, with the following stipulatio'ns:'
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
(Rev, 01/02}
X
Maintenance Agreements
SupPlemental Engineer's Report
Othe~
Original Certificate Date: ~, .. '~- 0/-~
'~ Municipality of'Anchorage
Development SerVices Department
· Building Safety Division
OmSite Water & Wastewater Program
4700 South Bragaw St.
:P.O. Box 196650 Anch6rage, AK 99519-6650
: ,,,,w,,v.ci.anchorage.ak.us
(907) 343-7904
' ' HEALTH AUTHORITY'APPROVAL CHECKLIST
Leg~,l'De$cription: /~-; //~LOC..I,('~'=,," ,.,~l;;~/-z,zzo ~._,,q-.~t'.~'r" Parcel ID:
A. WELL DATA : '71~'2
Well. type .,/1~. If A, B, or C provide PWSID # gl5 ~,~. Well Log (Y/N) ,
D~te Completed ' Sa~ seal (Y/N) Wires properly protec~ (Y/N)
T?~ Idepth. ft. ' to--ft.' Casing height (a round)-
, ~tiC water level ' ~ fL ': / ft.
~',~ / , /
We I, producbon / : g.p.m. / g.p.m.
WATER SAMPLE ~SULTS: / .
Cohfqrm ~olonies/100 mi. · N~trate rog.II. / Other bacteria., coonies/1
Arsenic: Img.ll. ~ Date of sample: ~ Collected by:
B. SEpTICI~ TANK DATA '
~',~, . . . ,
Tanksize .~ OOO gal.. Numbe?ofCompadments ~ Cleanouts (Y/N).
· , : , ,.
~'~:: (YIN). Y D~pressionovertank(Y/N) ~
Foundation cleanout . High water alarm (Y/N)
D~ ~ O~'~ Pumper ~~.~ ~
c. A~SORPT~O~ F~ELD
D~"i&stalled 'S/~ Soil rating (g.p.d.lft'or~ I~ Systemtype ~,
; i i,i , ;
LenCh ~ ~. ' Widm ~ n ~r~v~ be~o,~ p
T~tl ~epthqft. Eft. absorpt! onitoringtube. V Depression over fi~,,
Flu ~ depth in absorption ~ield before:test ~ in. Water added~gal. New depth~z~ iht
E~ap~ed Time: 30 min. F~n,, fluid depth ~. Absorption rate >: ~
',~ ~;: .
r,ejuvenation treatment (past 12 mo.) (YIN & type) ,~,/--~ ,/-f"/,~¢~ ~ ,J
If yes, give date --'-"-
Date installed , · '"C'J J'~ ,Size in gallons i .,:' Manhole/Acc'es~ (Y/N) '·
~,.
"Pump on" level ai ' : in. "Pump off" level at __ in. ', High water a arm lev"e'l'at
Datum ~ ' Cycles tested i Meets alarm & circuit requ rements?
E. SEPARATION DISTANCES i - ' .....
SEPARAT ON DISTANCES FROM WELL ON LOT TO' ~ ~..r ,,,f-
.'Absorption field on lot i ; / ~' ,,,F ;..: i On adjacent lots ·
Publcsewermain~,~' ;'' ' /SJ//'~-_ ' : .Pubhcsewermanhole/cleanout
,Sewer /sept c service l ne ' ,//01(2 4-, .:~ - Uold,ngtank
. SEPARATION DISTANCES FROI~I ~EP~ICf~~ TANK ONLOTTO: .
.,,Buidngfoundation', i ~,~-2 ~- · Property line ~ ) Absorpdon[~e~a?, ~...~
Water main ~'I;C) ~ -')- Waterserwce hne I I~'.-)- Surface water
! SEPARATION.D:I'STANcE:FROM ABSORPTION FIELD ON LOT TO:
i". Pr°~ert¥1ine ';: i iO-l~-~v~!:Bu dingfouhdatioh i lt~ ~'+: Watermaifi '!
!:~ Curtain drain NtTto'E ~ t,4.,0 WellsonadjacenLIots,-~c~..:~ +' ~:' ' 'i il: .
,G. ENGINEER S CERTIFICATION. · :; , I' . . -~'/~ ,.i ",~'~' ·
I ce~ify that l have determined through field Inspect o ,' , ,~~"--;
review of Municipal records that the above systems.are in ;~ ; .
. ; conformance with IMOA 'H~ guidelines in effect o~ this daler, : , ~,~. ROBER
:En ~ eersPn e ,N ....
Date of Payment ~:L~ ~1 ~r ' ,. Date of Payment.
Sent By: JKP;
..... 9072764309; May-26-04 4:56PM;
~uu~ E JOHNS JR
Page 2/2
PAGE ~2
30'
I
SURVZy C-,ER~lr-iCA ,'iON
L[----3.%='~. ."_'=.. , -'.. .,,,. .
'=. ,m' .'u~,~' SURVEy TYPE
PLOT PLANS & LOT SURVEYS
C ~s~'~,- ' UILDF..R OR OWNER PRIOR TO
"~ t'CI1ONo tO vERIr"Y PROP0~ BtJIU~INC ~R,,~D~
~0 .~/q~E~.ED O~xO£ AND UTIuTy CONNE:CTION~ AND TO D£T--r..~MI~IE
Robert'
Prepared by -
E. Johns, Jr. &
Profess;onul Lond Surveyors'
AN ~2 r_ ~2 ~v~.
"' -~ 0 ' Lot
4,2004 ~ P. EJ
24, 2004 ~.224
I, OI' !2, BLOCK 6,
ADDII'ION NO. 2
ASSOC.
S~3..'.D LAKE SUBDIVISIC
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
~)//-- //.~'.~ '-'~-5'~ HAA# Jc[iC~r
1. GENERAL INFORMATION
Complete legal description
Lot 12~' Block 6; Sand Lake Subdivision #2
Location (site address or directions)
8349 Seaview ~
Property owner
Mailing address
Mark Tovsan
6943 T&rry Place
Anchorage, AK
Anchorage,
Day phone
AK 99502
~43-55~4
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup..
NOTE:
Individual well
Community well ×XX
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
XXX
Individual on-site
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 MOA~2!
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
Ad dress
Engineer's signature
DHHS SIGNATURE
~'~ Approved for ~
/
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
/././
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 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 engineer's work.
72~25 (Rev. 1/91) Back MOA fY21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L-o?-/7-) ~L/< (~; ~%~,D L~.~ Parcel I.D.
A. WellData !~'d_- (_E.7-c~--'v~ of~ ~r--~/~/~c_/z/-/,~.jc~'- /.~ /~cc_~c..~.~o L..~-/-/
Well type G~_~..E'.5 //~
Log present (Y/N)
Total depth
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Sanitary seal (Y/N)
Cased to
FROM WELL LOG
Date of test
Septic/holding tank on lot
Absorption field on lot
Public sewer main
_ .Casing height
Wires properly pro~ ~
PECTION
Static water level
Well flow ~~
Pum__.~l
SEPARATION DISTANCES FROM WELL TO: ~-/__~ 5'.5' ~
ii0[ X
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Sewer service line
WATER SAMPLE RESULTS: ~E~T ~/C ~ ~ ~- ] O - ~.
Nitrate
Tanksize //(.-300 ~_¢¢4¢___
Foundation cleanout(~N)
Other bacteria
Compartments
~r'~' ~ Depression (Y~,~
Alarm tested (Y/N)
Pumper ,z~ _~1.-. //~D/vl ~
Coliform
/'~ ~:7~'7~Fo u nd at iD n ~'-E/
Water main/service line
Date of sample:
B. SEPTIC/,I,I~L--~I~TANK DATA
Date installed ~"/[ °~/
Cleanouts ~/N)
High water alarm (¥/~)
Date of pumping
SEPARATION DISTANCES FROM SEPTIC/HOL-DhN~ TANK TO:
Well(s) on lot ,//O r On adjacent lots
¥'
To property line Absorption field
Surface water/drainage /00 ~u
CONTINUED ON BACK PAGE
72-026 (3/93)° Front
C, LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
J ..--"P'd~p off" Level at
.~C~ycles tested
Manufacturer
Manhole/Access (Y/N) ~
High water alarm level
Meets MOA electrical codes (Y/N) ~
SEPARATIO~ROM LIFT STATION TO:
~.?~ On adjacent lots
D. ABSORPTION FIELD DATA
Surface water
O Z
Date installed
Length ~_~ r-~ / Width'
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soilrating(GPD/Ft2) /~-.~T~"~ Systemtype
~ / Gravel thickness ,~", 5 / Total depth ~ /
Oleanout present~N) "7'"E-S Depression over field (Y,~
Result,~ail) .~'~.~.-~',S for '~'-~.E-~-(3) Bedrooms
~ After test
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot //Y
To building foundation
On adjacent lots ~ ~
Surface water /~
Cu~ain drain ~(
E. ENGINEER'S CERTIFICATION
Signature / //
Engineers N~ ~-~
~, ~o~j~e ~ver Eoop Road
Date Ea~River, Alaska
On adjacent lots ,,~)~,xJ~ y'P/2a~S~z_Y--j Property line /-~
To existing or abandoned system on lot ~/-J
Cutbank ~(_~ r ~ Water main/service line /O
Driveway, parking/vehicle storage area ~
and HAA guidelines in inspection.
".;c ' :~',!
HAAFee$ ~DO,
Date of Payment
Receipt Number
waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)' Back
"~ ': WALTER J. HICKEL, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 995'15
(907) 349-7755
July 26, 1994
Mark Tovsen
8349 Seaview
Anchorage, AK 99502
SUBJECT: Lot 12, Block 6, Sand Lake #2 (8349 Seaview St.)
Class "A" Public Water System, PWSlD #215469
Dear Mr. Tovsen:
I have completed a review of this office's files concerning the monitoring status of the
above-referenced Class "A" Public Water System and found the following:
The last satisfactory Total Coliform Bacteria Sample results was submitted
to this Department on June 22, 1994. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last inorganic Chemical Contaminants Sample results were submitted
to this Department on October 26, 1993. This does meet the provisions of
18 AAC 80.200(a), of the State Drinking Water Regulations.
The last Radioactive Contaminants Sample results were submitted to the
Department on October 26, 1993. This does meet the provisions of 18 AAC
80.200(a), State Drinking Water Regulations.
The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC)
were submitted :o this Department on July 6, 1993. Based on analysis of
the previous VOC samples results have been satisfactory. This does meet
the provisions of 18 AAC 80.200(a), State Drinking Water Regulations.
Issuance of this letter does not imply that the above-referenced Class "A" Public Water
System is in compliance with other provisions of the State Drinking Regulations. Unless
otherwise noted, this letter is.valid for 30 days and is for the specified legal description
noted above only.
Mark Tovsen 2 July 26, 1994
If you have any questions on the above information, please do not hesitate to contact this
office at 349-7755.
Sincerely,
Michael Lu
Environmental Eng. Asst. II
APPLI( iNT FILLS out UPPER HA[..~. ONLY
Pr~gerty O'~i~r, ~'~ ~---- ~'~(~/? ,j~ '~, Phone
Address ~ ~ '~/~ ,~ ~c'~ Zip Code
Address ~.~/~/~ ~ ,~< ...... ~ Zip Code
Realty Co. & A~nt Phone
Address /~ Zip Code
Street Locati~ . ~"~ ~ ~/~/ ~ /
Type of Resi~nce
SingleFamily
Multiple Family No. of Bedroo~
~ Other
~lndividual ~ ~ )~ ~ ~ ~]~ ~ . A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975.
~ ~ CommunitYPublic Utility For wells drilled prior to that date, give well depth (attach log if available)~
~ ~,uivi~u~ q .~ ~ L~q ~- ] ~ ~3 Y~ ~nUiviaua~ ~,~ta,,d: /
~ ~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time ~'
Date Date Date Date
Inspector Inspector Inspector Inspect~
Field Notes: q.~ ~ ~ cm~,.~ L.,..),~.~C2 ~ ~,~ ,j, aJ-~ ,~ MUNICIPALITY OF ANCHORAGE
DFPT 0'- ','~'LT:~ 'q'
( ~,~ovE~ ~D~OO~S 3 ~ . '~O~D~T~O.S O~ ~OVAL
Soils Rating Date ~wer Installed Well To Absorption Area ~ ~ ~ Well Log Received
d--~ Well to Tank l~ Septic T~k Size IO0~
72-023 (3182)