HomeMy WebLinkAboutSAND LAKE #2 BLK 6 LT 20ao �
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264.4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
NEW
UPGRADE
MAI ING ADDRESS
LEGAL DESCRIPTION
L�-tti
z
LOCATION
Lot C( n t) i? a r.1 D
NO. OF BEDROOMS
1_3
Uy
DISTANCE TO:
Well
�jpT (
Absorption area
Dwelling
�,5�(�
PERMITO.
a~. Q
UJ I.-
Manufacturer
Materi
No.'Jcompartments
0
Lie. capaci�y6 g6 ns
VV--
IF HOMEMADE:
Inside length .�_
Width
Ligyiid-depth
6
DISTANC
Well
Dwelling
PERMIT NO. `
C
2 F
Man turer
aterla
_ apacity in gallons
o
w=
' DISTANCE TO:
Well
ND Z (
Foundation
Z9.0
Nearest lot line r
- z
PERMIT NO.
J LL z
Z w
No. of lin eS
Long of each li e
t
Total length of lines
(�
Trench width
- inches
Distance bet on lines
1,,3
�-[[
cc F-
O
Top of the to finish grade ,
Material beneath tilep7-Total
-imehes
effective a sorption area
w
Length
Width
Depth
PERMIT NO.
U
Q I-
as
W
Type of crib
15rib de th
Total e e absor tion
area - -�
W
ISTANCE TO:
Buildin found
Nearest lot line
-
J
J
ss
Depth
Driller
Distance to lot line
PERMIT NO.
0
w
�
DISTANCE TO:
Building foundation
Sewer line -
Septic tank
Absorption area(s)
OTHER
I
PIPE MATERIALS
SOIL TEST RATING
�S
INSTALLERa
REMARKS
o -( ,Zm at I h b r/
D
o
f
l
L•
APPROVED
DATE LEGAL
'(/7 Lao 6 C
72-013 13/78)
DEPFIRTNEP•dT HEALTH AND EPd'v' I RCtP� MENTAL. OTECi' I CIPS li c eS-
:T)*:EET, AP,It-HORAISE, A4::. -='-'`='F-iJ_ Al' LY?CE1aS
pp yy ¢g p�,p Ir
q g''' �v ® m- _
264-4720
g-�• 14 @ @�-,_ q T_ _ g,,��, @ 'g' _
0.J4 C...... G_.... 9 ': I -J C., 1.3 L� -A -....... _E" 1 ...T- g-- v.«:e° C:. � 1 "•i! IL..._ ll'•_a 2 v � 9 ....' 2 °� .N_
PERMIT P-40. r: 810800
BXIO-1682 345-2."
APPLICANT E�:At-R-.•r 1- k -')O
LOCATION I.JILCO'r:; :_._P•dG:'
LEGAL L_ 0 B6 SAP DLAKE LOT IEE � afi=� t=tt-tAf::E FF' 'f
TYPE OF SOIL ABSORPTION sYsTEC'1 I S : TRENCH
C'1A;>;IP1i_thi NUMBER OF PEEFiCp'�- ._
-SOIL. RATING (SID FT/BR):=
THE REQUIRED S I2 E OF THE SOIL ABSORPTION -TEM IS:
t-
IF-_ _T, F-4 L__ EE P-1 r_i'T ie - %. _. L.- I -
THE. LENGTH DIMENSION I '['HE LENGTH (IP• -t FEET::' OF 'THE TREVICH OR E:tRAINFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWE'E N 'THE SURFACE OF 'THE
GROUND D AP•dD THE BOTTOM OF THE EXCAVATION ':!N FEET).
THERE IS NO SET [-lT 'TH FOE". TRENCHES.
THE GRAVEL DEPTH I THEE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTF't=TL.L. PIPE
FIND 'THE BOTTOM OF THE. E. --`CA .'AT I ON (IN FEET).
FE F"T-
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM M THIS DEPARTMENT NT DURII' G THE
INSTALLATION I P•d'S,F'EC:T I ON OF' AP -JY WELI.._'S, ADJACENT •TCI THIS PROPERTY AND THE
NUMBER OF RES. I DENCE: THAT 'THE WELL WILL 'SERVEE.
I P- F F=" EF_ C:- -g-. I CH r -1- iii �a F �, �_ � � � �W CIA
BACKFILLING OF' AP•d'r S•'r'STEI'1 WITHOUT FINAL INSPECTION AP';ID APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DI_;TANC:E BETWEEN A WELL AND ANY ON—SITE SEkIAGE DISPOSAL S4"STE7M IS
:100 FEET FOP' A PRIVATE WELL OR 150 'TO Cio FEET FROM A PUBLIC WELL. F-)EPE.P• D I P• G
UPON THE TYPE OF PUBLIC: WELL.
MINIMUM DISTANCE FROM A PRI'v'ATE kIELL. To A F'RIVFiTE SE14ER LINE IS•".'= FEET AND
fo A C:OP4P'1t_NITY _;EWER LINE I=; 75 FEET.
WELL LOGS ARE REQUIRED
AND MUST BE RETURNED TO THE DEPARTMENT W I TH I P•d 4_i DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLIT SPEC I F I CAT I CaNS AP•dD C:C'Pd'=;"fR}_IC:T i CII'd DIAGRAMS ARE
AVAILABLE TCI I P•dSURE PROPER I P• STALLAT I Or 1.
F=" U F-- rl 1 ___ E-" ' E.. ,, E: -e E a u 1E ✓ ^: -:_ _: T _ _:L
I CERTIFY THA"f
SET
.1_ : I AM FAP'1 I L- I AR N I TE I THE REI !Lt I F:E'P'1E PdT S FOR ON—SITE -EEdC.F" : APANDL1EL.L ,ry: t IT;
FORTH BY THE C'1UPd:E C i PAL I TY OF ANCHORAGE.
: I WILL. INSTALL THE: SYSTEM IN ACCORDANCE WITH THE CODES.
I UNDERSTAND THAT THE OPd--SITE SEWER SYSTEM MAY REQUIRE
RESIDENCE IS REMODELED TO INCLUDE MORE: THAN ' BEDROOMS.
APF'L_ I CAP 1- ' C'AP•dP•dY CAROL—AND
<a t
ISSUED BYq;tZ=
ENLARGEMENT IF THE
}� SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION O PERCOLATION
• TEST
Pouch 6650, Anchorage, Alaska 99502 276.2221
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: l+'s�� D L > h!t2 /%%fZJ_=/15 %"-�/V T6 DATE PERFORMED: aL !9. f g �
LEGAL DESCRIPTION: /.r9% /C/ D �•�r /�/�Dal C��./�-1-(,�' �f�[�3�Aj _
SLOPE SITE PLAN l4)RJ)7'02'pw—
DEPTH
1 %® AP 5`` tO / L 0,6,+.47 i%t�&
3
v. .
i
Gross
4-
Depth to
Net
Reading
Date
Time
Time
Water
Drop
5 5
of
r,
0 p •:
6
` •
j ' A
7
0`�
i
8
9
10
•q+� e
tl •�
�e
12-1
13 O' •
��
14OF
r G15- 060004
16 fid. ,� � C%.• ••
7a
goo
17 ip.
FRe Earl R. Barnard
18 �Q ��•. 754E
19
���6�•pR0rESs�o��
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
S
Aldo I L
O
P
E
20 I I PERCOLATION RATE (minutes/inch)
u TEST RUN BETWE••ENN FT AND FT
COMMENT42
S '9 �/1 %�p ` ��a ! % AA A !� ��/QM IeAJ� l�l`L.AF X2
PERFORMED BY:
72-008 (7/76)
CERTIFIED BY:.
Gross
Net
Depth to
Net
Reading
Date
Time
Time
Water
Drop
i
20 I I PERCOLATION RATE (minutes/inch)
u TEST RUN BETWE••ENN FT AND FT
COMMENT42
S '9 �/1 %�p ` ��a ! % AA A !� ��/QM IeAJ� l�l`L.AF X2
PERFORMED BY:
72-008 (7/76)
CERTIFIED BY:.
Gross
Net
Depth to
Net
Reading
Date
Time
Time
Water
Drop
20 I I PERCOLATION RATE (minutes/inch)
u TEST RUN BETWE••ENN FT AND FT
COMMENT42
S '9 �/1 %�p ` ��a ! % AA A !� ��/QM IeAJ� l�l`L.AF X2
PERFORMED BY:
72-008 (7/76)
CERTIFIED BY:.
"Ju
41kKq
i
Ir W.
W • ®• MU NICIP DEPTLITY OF ANCHORAGE
�! ENVIRONMEOE
;;. Water Well Drilling TAI P'OT_CTION
Nv Phone 349-3809 1
Anchorage, AK. 2
Well Owner'.), ''I . �r '(=1 ;. T l �,.,_,•,,
Well Location (fx `A, "£
r f/
Size Casing Depth of Hole `
Static Water Levelo=•f. > feet Well Test `
Date,of Completion
WELL LOG
RECEIVED
Date /
Phone
Cased to
Gal per Minute for
AUTHORIZATION TO DRILL
I hereby authorize W.W.D. Drilling to proceed with the above work. Payment shall be made in the following manner:
Rig up Minimum (50% of anticipated depth) feet. @ per foot
Balance due upon completion.
In the event it is necessary to institute legal proceedings to collect any amounts due on this contract, I agree to pay an additional
sum of Ten percent (10%) of the original contract price as attorney's fees, plus costs, for legal proceedings.
Name
Date Address
feet
Hours
WSW.D.
i
Water Well Drilling
Phone 349-3809
Anchorage, AK.
Well Owner
Well Location
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL PT. OF HEALTH g
P,';OTECTION
2 2 �og2
s RECEIVED
Date �� -•%L i— 'f
Phone
Size Casing „ Depth of Hole a2 65 , Cased to �0 J ' feet
Static Water Level /aS feet Well Test Gal per Minute for % Hours
Date of Completion �D /�9_�
WELL LOG
.CLt-t.c..Q�-� • � teJ�t.�...r.-of+h� .de,ll�i .;,,e...'; ,
.2D ��•S �- 5 .o i cam► 2 �:
V :
AUTHORIZATION TO DRILL
I hereby authorize W.W.D. Drilling to proceed with the above work. Payment shall be made in the following manner:
Rig up Minimum (50% of anticipated depth) feet. @ per foot
Balance due upon completion.
In the event it is necessary to institute legal proceedings to collect any amounts due on this contract, I agree to pay an additional
sum of Ten percent (10°/a) of the original contract price as attorney's fees, plus costs, for legal proceedings,
Name
Date Address
a
i
r
AUTHORIZATION TO DRILL
I hereby authorize W.W.D. Drilling to proceed with the above work. Payment shall be made in the following manner:
Rig up Minimum (50% of anticipated depth) feet. @ per foot
Balance due upon completion.
In the event it is necessary to institute legal proceedings to collect any amounts due on this contract, I agree to pay an additional
sum of Ten percent (10°/a) of the original contract price as attorney's fees, plus costs, for legal proceedings,
Name
Date Address
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° Municipality of Anchorag
On -Site Water & Wastewater Program x
(907)343-7904
01 -f
nl0y o 2 2015
CERTIFICATE OF ON-SITE SYSTEMS
Parcel I.D. 011-133-17 Expiration Date:
1. GENERAL INFORMATION
Complete legal description SAND LAKE #2; BLOCK 6, LOT 20
Location (site address)
Current Property owner(s)
Mailing address
Real Estate Agent
8244 WILCOX STREET *ANCHORAGE, AK 99502
CURTIS WILLIAMS Day phone 245-1261
8244 WILCOX STREET *ANCHORAGE, AK 99502
' Day'phone
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
WaiverlVanance request for: N/A
Distance: —
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 521(0 -
Waiver Fee $
Date of Payment 1 1/7l* Date of Payment
Receipt Number CbJ5" GL Receipt Number
COSA # o5 151 % of 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.
Name of Firm
Address
GARNESS ENGINEERING GROUP, Ltd.
3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK, 99507
Engineer's Printed Name
Engineer's Comments:
JEFFREY A. GARNESS, P.E.
In conducting this evaluation, GEG provided an engmeenng evaluation of the well an&brseptic system in accordance with the
guidelines end regulations established by the Municipally a Anchorage and industrypractims. The reporfedres ifs describe the
condition of the systom/s on the canals of the evaluation. Separalkn distances were measured to roadpyidentifiable features.
Hidden defects or encroachments may exist that were not identified during the evaluation. The operationallife of all wefts and septic
systems depend on a variety of vadablesincluding, but not limited to, sal conditions, groundwater levels (that may fluctuate during
the year), quality of construction (materials and workmanship), and the water usage of the famiy utilizing the syslews. These
conditions can vary, and are outside the control of GEG. Satisfadwy lest results do riot guarantee futureperformance of the
sysfemis, therefore, GEG makes no womanly (express w implied) regarding the future performance onhe well aseptic system.
GEG makes no representation whether an alternative well or septic system can be insfalled on the propedyin the event odbarofthe
commit systems fad. The confenf stills report is for the sae benefit of the personviudy who retained GEG. Reliance now the
information provided in this report by any ofher person orparty, including but not limited to subsequent propedypurchasers is net
authorized. In shat, GEG disavows any legal duty to anyone other than the persoalpady, who paid for this report.
6. DSD SIGNATURE -)
System #1 Approved for bedrooms.
M
System #2 Approved for
Disapproved.
Conditional approval for
i
bedrooms.
Phone 337-6179
Date 11 7_ J_
bedrooms, with the following stipulations:
n h.....11 �.
?ROFESSI�
IA Ab 114 1110, 11 fA Aria kh.4m rf fA cf S fico I � 04 Art
Original Certficate Date:
The municipality or Anchorage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.
The MunicipalrYy of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTCHMENTS:
COSA Checklist I -- Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
(Rev. 10112/12)
/AW
If more than 1 septic system Is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description:
SAND LAKE #2; LOT 20,
BLOCK 6
Date of test
Parcel ID: 011-133-17
Static water level
its xqIs -_
A. WELL DATA
Well production
200
y,p,m,
*ORIGINALLY DRILLED TO
205' ON 10/21/1981,
DEEPENED ON 1/11/1982
Well type PRIVATE If A, B, or C provide PWSID# N ZA
Date completed *1/11/1982 Sanitary seal (Y/N) YES
Total depth 401 ft. Cased to 205+ ft,
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate
Well Log (Y/N) YES
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
10/8/2015
6.2 g.p.m.
Collected by: GEG. Ltd.
Arsenic[,"_Lqlug./L. Date of sample: l0/7/2015
B. SEPTIC/HOLDING TANK DATA ISTEEL SEPTIC TANK IS APPROACHING THE END OF ITS USEFUL LIFE
TankType/Material SEPTIC/STEEL Date installed 10/7/1981
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (YM) YES Depression over tank (Y/N) NO High water alarm (YM) N/A
Date of pumping 9/22/2015 pumperMCDONALD'S PUMPING SERVICE
C. ABSORPTION FIELD DATA*BELOW EXISTING GRADE TO BOTTOM OF SU P
Date installed 10/7/1981 Soil rating (g.p.d./ieo /bd 85 System type
TRENCH
Length 30 . ft. Width 4-8 ft. Gravel below pipe 5 ft.
Total depth *7.6+ ft. Eff. absorption area 300 fe Monitoring tube**YES Depression over field NO
Datsofadequacytest 10/14/2015 Results(Pass/Fall) PASS For 3 bedrooms
Fluid depth in absorption field before test **0 in. Water addedl,193 gal. New depth **0 in.
Elapsed Time: 0' min. Final fluid depth **0 in. Absorption rate >= 450+ g,p,d,
Any rejuvenation treatment (past 12 mo.) (YM & type) NONE If yes, give date
**SUMP ONLY EXTENDS 42 INCHES BELOW INVERT OF LATERAL.
FROM WELL -LOG
Date of test
1/11/1982
Static water level
its xqIs -_
8. Wgj�o
Well production
200
y,p,m,
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate
Well Log (Y/N) YES
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
10/8/2015
6.2 g.p.m.
Collected by: GEG. Ltd.
Arsenic[,"_Lqlug./L. Date of sample: l0/7/2015
B. SEPTIC/HOLDING TANK DATA ISTEEL SEPTIC TANK IS APPROACHING THE END OF ITS USEFUL LIFE
TankType/Material SEPTIC/STEEL Date installed 10/7/1981
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (YM) YES Depression over tank (Y/N) NO High water alarm (YM) N/A
Date of pumping 9/22/2015 pumperMCDONALD'S PUMPING SERVICE
C. ABSORPTION FIELD DATA*BELOW EXISTING GRADE TO BOTTOM OF SU P
Date installed 10/7/1981 Soil rating (g.p.d./ieo /bd 85 System type
TRENCH
Length 30 . ft. Width 4-8 ft. Gravel below pipe 5 ft.
Total depth *7.6+ ft. Eff. absorption area 300 fe Monitoring tube**YES Depression over field NO
Datsofadequacytest 10/14/2015 Results(Pass/Fall) PASS For 3 bedrooms
Fluid depth in absorption field before test **0 in. Water addedl,193 gal. New depth **0 in.
Elapsed Time: 0' min. Final fluid depth **0 in. Absorption rate >= 450+ g,p,d,
Any rejuvenation treatment (past 12 mo.) (YM & type) NONE If yes, give date
**SUMP ONLY EXTENDS 42 INCHES BELOW INVERT OF LATERAL.
D. LIFT STATION
Date installed Size in gallons Manhole/Access (W/N
"Pump:on" level at in. "Pump off" High water alarm level at
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots *90'+ .�w &VgAe-�
Absorption field on lot 100'+On adjacent lots 100'+ V3W
Public sewer main
Sewer /septic service line
Public sewer manhole/cleanout
Holding tank N/A
100'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building,foundation 5'+
Property line 5'+
Absorption field
**5
Water main 10'+
Water service line 10'+
Surface water
100'+
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line **4'+ Building foundation 10'+ Water main 10'+
Water service line
10'+
Surface water 100'+
Driveway, parking/vehicle storage 2'+
Curtain drain NONE
KNOWN
Wells on adjacent lots
100'+
F. COMMENTS
*WR0300061
**PER 10/7/1981 MOA INSPECTION REPORT
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 COSH guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date I I I j
(Rev. 11105)
... . ...........
y Ga ness,:
CE 3 ,•'.
4�napro f es sioro�c
Municipality of Anchorage
Development Services Department
Building Safety Division
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 # OSC151609
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 20 of
Sand Lake #2 Subdivision. This. inspection revealed an arsenic concentration
of 28.9 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.
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ALASKA WATER AND WASTEWATER CONSULTANTS, INC.
6901 DEBARR ROAD. SUITE. 28. ANCHORAGE, AK, 99004
PHONE (907) 337-6179/FAX: (907) 336-3246
3AL DESCRIPTION:
SAND LAKE SUBDIVISION (F2; LOTS 18 & 19, BLOCK 6
DE OF WORK:
SITE PLAN FOR WAIVER REQUESTS
EPAREO FOR: PHONE NUMBER:
GERALDINE AUSTERMUHL (907) 344-0506
D': DRAWN BY: PACE
12/20/99 K.T.W./J.L.M. 1 1 = 100' 1 OF 2
A.
Mtmicipality of Anchorage
Department of Health and Human Services WAR
825 "L" Street
Rick Mystrom. P.O. Box 196650 Anchorage, Alaska 99519-6650
Mayor
htip://www.ci.anchorage.ak. us
343-4744
January 6, 2000
Jeffrey A. Garness, PE
Alaska Water & Wastewater Consultants, Inc.
6901 DeBarr Road, Suite 2B
Anchorage, Alaska 99594
Re: Waiver Request For Lots 18/19 Block 6 Sand Lake #2 Subdivision, Waiver
Request Number WR990101, P.I.D. 011-133-49
Dear Mr. Garness:
Your request for waiver of the required 100 feet horizontal separation from a
private well to an on-site wastewater disposal system has been approved. The
approved separations are as follows:
1. The on -lot well to septic tanks on Lots 6, 7, 18 & 20 Block 6 Sand
Lake #2 Subd. of 92, 78, 65 & 90 feet respectively;
2. The on -lot well to wastewater absorption fields on Lots 18/19 Block 6
and Lots 6 & 7 Block 7 Sand Lake #2 Subd. of 90, 95 & 93 feet
respectively.
This waiver approval applies to the existing on -lot water well to septic systems
separations only. Any upgrades to any of these items will require all separations
be met or another waiver approval from this office.
Sincerely,
C/ / ;
Daniel J. Rob
Civil Engineer
On -Site Services Program
a
MUNICIPALI`.CY OF ANCHORAGE
Department of Health and Human Services
on-site services Section
Waiver Review Worksheet
WR# Rg99ntn1 PIU# A11�133_�i9 _ HA# 11A990j_a _.. Permit #_! ,
Date Received: December 27,_19999
Legal Description: Sand --
Engineer: Alaska Water &,Wastewater Conenlranrs —__
6901 Debarr Road, Suite 2A An_aharage, AK gg504 --- �
Applicant: Geraldine Ay`ermub�^ — --
Waiver Requested: A blanket 65. feet frnm rhe ura11 tQ
all ennrnnnhj ig-4ap4;;L„- b: a 0!1 feta. *&u to all eReE eaeh+ng'draitfields.
Criteria: 1. Geology: Points:
A: Water Table —
B. Soil Sorption _—
C. Permeability --
D. Water Table Gradient --
E. Horizontal Separation —
TOTAL:
2. Special Conditions:
3. Other:
Waiver is Granted: -..>< Waiver is NOT Granted:
List Conditions. or Reasons for. above: �JE4 I¢TA i/ -f, V —
Date : I -
By:
Rec #: 05490 — Amount: $_gg0.nn ^ Date Paid: ,a.��T--
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Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904476,
C
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 011-133-17 HAA# D2 J 15�
1. GENERAL INFORMATION Expiration Date:
Complete legal description SAND
LAKE SUBDIVISION #2:
LOT 20, BLOCK
6
❑
Individual Holding tank
Location (site address or directions)
8244 WILCOX DRIVE
* ANCHORAGE.
AK 99502
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
WENDY WHITE Day phone 248-5546
8244 WILCOX DRIVE * ANCHORAGE, AK 99502
Day phone
Day phone
Unless otherwise requested, 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
3
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 private 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
watei 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.
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 homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of issue for properties served by a private 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
watei 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 $ at, or prior
to closing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 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.
Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone
Address 3701. E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described 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 during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator 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. AKW WC, inc. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements 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 report by any
other person or party is not authorized, nor will It confer any legal right whatsoever.
S. DSD SIGNATURE
Approved for 3 bedrooms.
Disapproved.
337-6179
Date Z 6 d
Conditional approval for bedrooms, with the fllowing stipulations:
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Manitenance Agreements
Supplemental Engineers Reort
Other
By: Original Certificate Date: O 03
(Rev. 12111)
Municipality of Anchorage *."
• Development Services Department
Building Safety Division
Onsite Water & Wastewater Program
4700 South Sragaw St.
P.O. Box 196650 Anchorage, AK 995196650
www.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: SAND LAKE SUBDIVISION #2: LOT 20, BLOCK 6 Parcel ID: 011-133-17
A. WELL DATA
Well type PRUATE If A, B, or C provide PWSID# N A
Date completed 1/11/1982 Sanitary seal (Y/N) YES
Total depth 401 ft. Cased to 401 ft.
FROM WELL LOG
Date of test 1/1111982
Static water level 125 ft.
Well production 200 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml.
Arsenic: N/A mgR..
B. SEPTIC/HOLDING TANK DATA
Nitrate 0.1 mg./L.
Well Log (YM) YES
Wires properly protected (YM) YES
Casing height (above ground) 18+ in.
AT INSPECTION
5/28/2003
151 ft.
8.1 g.p.m.
Other bacteria 0 colonies/100 mi.
Date of sample: 5Z28/2003 Collected by: AKWWC
Tank Type/Material STEEL Date installed 10/181
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation deanout (Y/N) —YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping 7/21/03 Pumper A+ HOME SERVICES
C. ABSORPTION FIELD DATA Fes: 'OR—AD-El
Date installed 10/7/61 Soil rating (g.p.dJftibrtj@rm85 System type TRENCH
Length 30 ft. Width 4'-8 ft. Gravel below pipe 5 ft.
Total depth 7.5 ft. Eff. absorption area 300 ft' Monitoring tube **YES Depression over field NO
Date of adequacy test 7/29/03 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 110 in. Water added gal. New dep945.5 in
Elapsed Time: 60 min. Final fluid depth 42.5 in. Absorption rate >= 450 g,p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) SEPTICLEAR If yes, give date 6/18/03
**M.T. ONLY EXTENDS 47' BELOW INVERT
***135 GALLONS WAS INTRODUCED IN 17 MINUTEST
D. LIFT STATION
i
Date installed
"Pump on" level at in.
Datum
E. SEPARATION DISTANCES
Size in gallons
High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
100'+
Absorption field on lot
1008+
Public sewer main
N/A
Sewer /septic service line
25'+
*WAIVER REQUESTED
On adjacent lots *90'+
On adjacent lots 1001+
Public sewer manhole/deanout N/A
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5' Property line 5'+ Absorption field 5'
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 4' Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehide storage 1'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
DRAINFIELD IS ONLY OPERATING IN THE TOP 14% OF THE SYSTEM.
G. ENGINEER'S CERTIFICATION
1 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.
of a Go as:
Engineers nn1e.NamA_ JEFFREY A GARNESS79 4-
s,a•.......••.Dateoprofeeaw�a
HAA Fee $ Waiver Fee $
Date of Payment Date of Payment
Receipt Number Receipt Number
(Rev. 12101)
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: SAND LAKE SUBDIVISION #2; LOT 20 BLOCK 6 Parcel ID: 011-133-17
A. WELL DATA
Well type PRIVAn if A, B, or C provide PWSID# NIA Well Log (Y/N) YES
Date completed 10/21 /81 Sanitary seat (YM) YES Wires properly protected (YM) YES
Total depth 205 ft. Cased to 205 ft. Casing height (above ground) 18+ in.
FROM WELL LOG AT INSPECTION
Date of test 10/21/81 5128/2003
Static water level 125 ft, 151 ft.
Well production 1.8 g.p.m. 8.1 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi. Nitrate 0.1 mgA. Other bacteria 0 colonies/100 ml.
Arsenic: N/A mgJL. Date of sample: 5/28/2003 Collected by: AKWWC
B. SEPTICIHOLDING TANK DATA
Tank TypelMaterlat STEEL Date installed 10/7/81
Tank size 1000 gal. Number of Compartments _ 2 Cleanouts (YM) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) _ O High water alarm (Y/N) N/A
Date of pumping 7/21 /03 Pumper A+ HOME SERVICES
C. ABSORPTION FIELD DATA
Date installed Ioh181 Soil rating (g.p.dJftbr bdrm 85 System type TRENCH
Length , ** 30 ft. Width 4-8 ft. Gravel below pipe 5 ft.
Total depth 7.5 it Eif. absorption area 300 ft Monitoring tube **YES Depression over field NO
Date of adequacy test 7/21 /03 Results (Pass/Fall) PAS For 3 bedrooms
Fluid depth in absorption field before test _ 35 in. Water added*135 � gal. New dept►*43'5 in.
Elapsed Time: 153 min. Final fluid depth 40.5 in. Absorption rate >= 450 g,p.d,
Any rejuvenation treatment (past 12 mo.) (Y/N & type) SEPTICLEAR If yes, give date 6/18/03
**M.T. ONLY EXTENDS 43.5" BELOW INVERT
***135 GALLONS WAS INTRODUCED IN 17 MINUTESI
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at in.
E. SEPARATION DISTANCES
High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
100'+
j Absorption field on lot
100'+
Public sewer main
N/A
Sewer /septic service line
25'+
'WAIVER REQUESTED
On adjacent lots +901+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5' Property line 5'+ Absorption field 5'
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 4' Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 1'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
DRAINFIELD IS ONLY OPERATING IN THE TOP 14% OF THE SYSTEM.
G. ENGINEER'S CERTIFICATIONco
I certify that 1 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.
QQ fr A. Go ness.:
Engineers Printed ame JEFFREY A GARNESS 'V a —7953 �Fe�
Date 7�L0
4's^sd Professlc�a �c4
HAA Fee $ 375 + 150 `RLxSh
Date of Payment :2=.2-9-0.3
Receipt Number 3 Cl z z
(Rev. 12101)
Waiver Fee $ 1 OCID
Date of Payment 7-2 9 — 0 3
Receipt Number 3 9 ;- 5%z
WRO3006
JUL-28-2003 MON 1200 Ph FAX NO. P. 02
N
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BLK 6 1
4 i 21 i 30' I
,
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•
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Recertified JULY 23, 2003
,, I� o om raawe wyW of ft labwn PREPARED FOR:
'�•'•"• Kerwin & Wendelon White
��';,••• •., �+�� LOT 20. BLOCK 6, _
rGj�• �/ SAND LAKE SUBDIVISION NO.2
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11 «.••.••''• ��� a tdNah�ir�.«ewnw an wa P�aw'N doePt 2309 Notes 2339
KARABELNlKOFF
Annw.oaMttta,vat25thdava-!Yj)�.20 23 SURVEYING w)3r•3at
8/4/2003
Municipality of Anchorage o ,�E•.
a
Mark Bcyich, Mayor
Sir [Tr
Building Safety Division
P.O. Box 196650 • 4700 Braga«• Street
Anchorage, Alaska 99519-6650 • (907) 343.8301 • Fax (907) 343-8'300
littp://i%i%-w.nittiii.org
Jeffrey A. Garness, PE
Alaska Water & Wastewater Consultants, Inc.
3701 East Tudor Road, Suite 101
Anchorage, Alaska 99507
Subject: Waiver Request for Sand Lake #2 Subdivision Block 6 Lot 20
Waiver Request #WR0300061
Parcel ID #011-133-17
Health Authority Approval Certificate Number HA030368
Dear Mr. Gayness:
Your request for a waiver of the required 100 feet horizontal separation from the
septic tank to private well has been approved. The approved separation distance is 90.0
feet. This approved separation distance is the well on the subject lot to the septic tank on
the adjoining Lot 21 Block 6 Sand Lake #2 Subdivision.
This waiver approval applies to the existing septic tank to private well separation only.
Any future upgrade to the on-site wastewater disposal system will require all separation
distances be met or another approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-7904.
Sincerely,
5 ;V) (-/ —
Daniel J. Roth
Civil Engineer
On -Site Water & Wastewater Program
Municipality of Anchorage
Development Services Department
• ++ Building Safety Division =
On -Site Water and Wastewater Program * "
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
Waiver Review Worksheet
WR#: WR030061 PID#: 011-133-17 HAM HA030368 Permitil:
Date Received: 9/ 03
Legal Description: SAND LAKE #2 SUBDIVISION BLOCK 6 LOT 20
Engineer: ALASKA WATER & WASTEWATER CONSULTANTS. INC.
Lr-1,271:px[�lri'P,IIt
Criteria:
Geology
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
Total:
Points:
...............................................................................
Waiver Is Granted: X
Waiver Is not Granted.
List Conditions or Reasons for above: Y EE A MN 0014 E 4
Date: By:
Name of Reviewer
...............................................................................
Rec#: 39252 Amount: $800.00 Date Paid: 7/29/2003
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ALASKA. WATER F- WASTEWATER
nu,.:,.vNxwx»nnr.a...n. CONSULTANTS, INC. *►.�xx.....^>w,�.,.:..a •n.x::.r ,. a,�n.M�w.,.�,..,x•.,
July 29, 2003
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On -Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Waiver Request and Health Authority Approval for
Sand lake Subdivision 92; Lot 20, Block 6
The existing 3 -bedroom house is served by a private well and septic system. During evaluation,
we noted that the well on the subject property is only 95.9 feet from the first compartment clean-
out for the septic tank, which serves Sand Lake Subdivision #2, Lot 21, Block 6. To be
conservative, we are requesting that you grant a 90 feet separation distance waiver between the
subject %yell and septic tank. Justification for this waiver is summarized as follows:
• The lots are generally flat. The wells for both properties are located on the west one-half of
the lot. The septic systems are located on the east one-half of the properties, near Wilcox
Drive. Structures lie between the well and the septic system. If the septic system on Lot 21
were to overflow it would have to run over the ground and cross the driveways for both
properties in order to migrate towards the wellhead. This could not occur without getting the
attention of both parties. Furthermore, based upon our evaluation of the topography, it
appears that overflowing effluent Nvould not run towards the wellhead.
• The location of the septic system is in a very visible area so that if any effluent was to
surface, it would be noticed and the problem corrected.
The only feasible path of contamination is subsurface migration of wastewater when the steel
septic tank corrodes to such an extent that it begins to leak. Attached are well logs for a number
of nearby properties. The wells are a minimum of 200 feet deep, with some being over 500 feet
deep. The aquifer is very deep and protected by geological stratums of clay and sand that has
served to protect restrict the flow of contaminants into the aquifer. This encroachment has for
approximately 22 years, and recent water samples (from the well on Lot 20, Bk 6) indicated non-
detectable nitrate levels and no bacteria. Based upon the aforementioned facts, it appears that
there is minimal risk associated with granting the requested waiver.
The septic system on Lot 21 was installed on 10/01/81, and the well that serves Lot 20 was
drilled on 10/21/81. In short, the septic tank was in place prior to the well, so the owners of Lot
20 are liable for the waiver fees.
3701 E. Tudor Road, Suite 101 *Anchorage, AK 99507
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akw%vc.com
1NVe are requesting that this waiver and the HAA be expedited so that an established closing date
can be met.T OA rush fee was submitted with this package. If you have any questions,
please contact a 337-6179. Thank you for your assistance.
.E., M.S.
3701 E. Tudor Road, Suite 101 • Anchorage, AK 99507
Ph: (907) 337-6179 * Fax: (907) 338-3246 ' Website: ak%mc.com
SAND LAKE S/D /2 1
LOT 2, BLACK 6 SAND LAKE S/D j2
1
' LOT 23, BLOCK 6 I
I
\I
SAND LAKE S/D 12 I \ SAND LAKE S/D t2
/LOT 3, BLOCK 6 I \ LOT 22, BLACK 6 '
/ \
4SAND LAKE S/O #2SAND LAKE S/D 2 T 21, BLOCK 6
LOT 4, BLOCK 6 \ ^ /
��
/ 100 — —
/ ' 86 WPNER pn51S
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SAND NE S/D 2 1� VLDL V
/
LOT 5, BLOCK \ \ T 20, BLOCK LAKE CK 6
1-01/
SAND LAKE S/D /2 SANLOT 199. BLOCK LAKE S/D 62
I LOT S. BLOCK 6
v
I
X
\ SAND LAKE 5/D J2, — /'kgD LAKE O / \
/ \ LOT 7, BLOCK LOT 16, BLOCK 6 6
7/29/2003 pF qq
DRAWN BY: p C!......... 4
ALASKA WATER & WASTE`VATL'R A.J.G./J.W.M. -�
CONSULTANTS, INC. 1 — 40, „poo
3701 E. TUDOR ROOD. SUITE 101 • ANCHORAGE. AK 99507 • PHONE (907)337.6179 ' FAX (907U38 -32L6
PREPARED FOR: PHONE NUMBER: PACE NUMBER:
WENDY WHITE 248-7586 1 OF 1 QO y
LEGAL DESCRIPTION: Q op, C 79 •'��e`QQ
SAND LAKE #2 LOT 20, BLOCK 6
TYPE OF WORK: uvgedP�ofesslo°°����
SITE PLAN FOR WAIVER REQUEST 4�DOfessW o
` 07/30/2003 00:01 907-348-8931
v� /offale
ALASKA. WATER WASTEWA
CONSULTANTS, INC.
SEPTIC ADEQUACY TEST DATA
LEGAL DESCRIPTION: 4Z 2V � � � �L
STUET ADDRESS:
CLIENT: O
"4 �GL7
NUMBER OF BEDROOM: a GALLONS PER DA NEEDED:
PAGE 01
SEPTIC: *SEE H.A.A. SITE VISIT CHECKLIST* DATE OF TEST:
FIELD MEASURE NTS:
TOP OF MT/SUMP TO BOTTOM-----------� (MT,) /
TOP OF MT/SUMP TO DISTRIBUTION LINE-- (MTI) / (MT2) %
STICK-UP OF MT/SUMP--.---'------------'-----'------ (MTl) / (MT2)
TOP OF MT/SUMP TO LIQUID LEVEL--------- � (MTI _ (MU) '
Sr z
4j,0
RESULTS:
PASSED ABSORBED GALLO SIN X00 _ MINUTES (� _GPD)
FAILED - SEE ATTACHED LETTER �,//off-- 3'r x 2-7 �Ig,�
rnmments- Pte. _ � :YA1 4&44.' .4�te�— :
T z• ,
Signature: l �Date ' Ala -'9
6901 Debw Rud, Suite 2-8 - Anchomp. Aluks 99504 - Ph: (907) 337-6179 • Fuc: (907) 338-3246 • aww@(RaWOA.net
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@a tro 01.47
taIt y
ow WAN
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4j,0
RESULTS:
PASSED ABSORBED GALLO SIN X00 _ MINUTES (� _GPD)
FAILED - SEE ATTACHED LETTER �,//off-- 3'r x 2-7 �Ig,�
rnmments- Pte. _ � :YA1 4&44.' .4�te�— :
T z• ,
Signature: l �Date ' Ala -'9
6901 Debw Rud, Suite 2-8 - Anchomp. Aluks 99504 - Ph: (907) 337-6179 • Fuc: (907) 338-3246 • aww@(RaWOA.net
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Time
ne
N
y
c7C,c�� StR°tA
Date
Date
Date
-a
t- \'2--)-- '�6'a U'D
Inspectur
Inspector
Inspector
Comments
Conditional Approval
MUNICIPALITY OF ANCHORAGE
U^
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
-
„AN 8 IaO�
RECEIVED
Date Sewer Installed
Permit No.
Septic Tank Size ° 3
p_
Holding Tank Size
Soils Rating
Well To Absorption Area
Well Log Received
Well to Tank
PLO
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner D,4NN V C A VO
Phone
Mailing Address 15'0 Avy� �� �� ANCAv�
/'
Buyer
Address
Lending Institution-J(/���pw'l
Phone
Address ._'&) e- 14N4 o / f 4-
VZ,` 4300
Realty Co. & Agent
Phone
Address
Legal Description o HCl dZ&6 -5^VcZ
Street Location $�� l/��Yrr�
TypeoResidence
N�Single Family
❑ Multiple Family No. of Bedrooms
❑ Other
Water Sypply
Lf Individual
ATTACH WELL LOG. A well log is required for all wells drilled since June
❑ Community
1975. For wells drilled prior to that date, give well depth (attach log if
❑ Public Utility
available.
Sewe!gpeDisposal
I
/
ri Individual
Year Individual Installed:
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.