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SAMPSON ESTATES BLK 3 LT 8
AOF f e\ 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 Eye 5/-/4g' ADE MAILING ADDRESS �_1 /- C -y LEGAL DESCRIPTION y' 4 ! 9 //( Set Y7 O 71 get- S 7'� Icctx LOCATION NO. OF BEDROOMS Y'Ua �sf Uy DISTANCE TO: Well pp 7t Absorption area �f / Dwelling / / PERMIT NO. 41 6 T '� s' LU Q Manufacturer Material S,�e No. of compartments, rn Liq. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth (6 00 y J U`Z DISTANCE TO: Well Dwelling PERMIT NO. 2 Z Manufacturer Material Liquid capacity in gallons Well Foundation - Nearest lot line PERMIT w= DISTANCE TO: 6D �- a j/E7 J LL z No. of lines Length of each line Total length of lines Trench width Distance betwe n lines � inches AO 't Top finish Material beneath tile Total effective absorption ayea cc l.- of tile to grade 7q inches _ [DC7 Length Width Depth PERMIT NO. Lu a Q I— Type of crib Crib diameter Crib depth Total effective absorption area as LU W In Well Building foundation Nearest lot line DISTANCE TO: J Class Depth Driller Distance to lot linePERMIT NO. J LU 3. DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER 7 PIPE MATERIALS Ast SOIL TEST RATING n INSTALLER G .,L 1�3'�L6i. REMARKS *:.49M ? aIX ,225' Q tk��®iVA� NOaI,TlJ3103d APPROVED 3t (3HaM7 dOLAWIDINAN (OIL— OIL6 C.,L c� o�P' S' slr�✓ �'%�; 72-013 (Rev. 3/78) I a I F=4 F=1 I I -r ff-e ID F= F: " C- " ID FR F:: lLi F= DEPARTMENT Cl�.HEALTH AND ENVIRONMENTAL PrrlTECTION 825 37REET.- ANCHORAGE: AK '99!_ 264-4720 C-1 " — _ I _v F=' PERMIT P-40: DATE ISSUED APPLICANT ADDRESS: CONTACT PHONE 840-795 05/29/84 SHASTA CONSTRUCTION BOX 7732 - EAGLE RIVER, AK 99577 694-4961 LEGAL DESCRIP: SUBDIVISION: SAMPSON ESTATES SECTION: 3 TOWNSHIP: 15N LOT SIZE: 43560 (SQ.FT. OR ACRES) MAX BEDROOMS: 3 LOT: 8 RANGE: IW �Al 1 V I BLOCK - 3 LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE. ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — I CERTIFY THAT: :1. 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE (NOR) AND THE`STATE OF ALASKA. 2. 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL NOR CODES AND REGULATIONS., AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. 3. 1 WILL ADHERE TO ALL NOR AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT. 4. 1 UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 BEDROOMS AND ANY ENLARGEMENT WILL REQUIRE AN ADD ITIOVAL PERMIT. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY NOR BUILDING CODES: THEN (1) AN ELECTRICAL PERMIT, AND INSPECTION MUST BE OBTAINED; (2) AS—BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT.; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. 5 1 GNED ----- =ZIL APPLICANT: SHASTA CONSTRUCTION I DATE: ISSUED BY DATE ------------------- —F FR E= 1'4 r=: E. FE E -'s PJ - C* F;Z F=f I rA DEPTH TO PIPE BOTTOM (FT.) 4.0 4.0 4.0 GRAVEL DEPTH (FT.) 6.0 O:5 3.5 TOTAL DEPTH (FT.) 10. 0 4.5 7. 5 GRAVEL WIDTH (FT. 2. 5 22.0 5.0 GRAVEL LENGTH (FT. 50.0 41.0 65.0 3RAVEL VOLUME j*.CU. YDS. :0. 0 2-3. 4 48.1 TANK SIZE (GALS) 1,000. 0 :1, 000. 0 :1, 000. 0 SOIL RATING (SQ.FT. /8R) 200 197 200 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — I CERTIFY THAT: :1. 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE (NOR) AND THE`STATE OF ALASKA. 2. 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL NOR CODES AND REGULATIONS., AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. 3. 1 WILL ADHERE TO ALL NOR AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT. 4. 1 UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 BEDROOMS AND ANY ENLARGEMENT WILL REQUIRE AN ADD ITIOVAL PERMIT. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY NOR BUILDING CODES: THEN (1) AN ELECTRICAL PERMIT, AND INSPECTION MUST BE OBTAINED; (2) AS—BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT.; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. 5 1 GNED ----- =ZIL APPLICANT: SHASTA CONSTRUCTION I DATE: ISSUED BY DATE ------------------- /—', 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 PERFORMED FOR: 94, �ac `-U� S y- c-, DATE PERFORMED: 1114l % 6 1/5,PLl ll , LEGAL DESCRIPTION: Zt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 )� h✓t I 6r'.AZ f G,-4 ✓e, oe fere. MEN■ Ne■■ OHM NONE ■E■■ NE■■ NEVE MEMO ■E■■ ■■■E SITE PLAN L WAS GROUND WATER L ENCOUNTERED? . O �. _ .... P IF YES, AT WHAT DEPTH? Reading 20 1 Date Gross Time Net Time Depth to Water Net Drop r 41 S v Jz ;vs v •........- Vgoy / � ®AIAI ��� PERCOLATION RATE � (minutes/inch) �pO 1 014. 'n , TEST RUN BETWEEN FT AND .—L_ FT / COMMENTS�2a p /1�jU�P Ad le e4ir-rr.-�e1-e A / kcrP ST 11 O l ifhsk-t PERFORMED BY: 'eE: 1'.Y-��� CERTIFIED BY: -fJ a DATE: ! z - B 72-008 (6/79) t fu��..�•. ..n...'nln la nllhnr In- Ih nr IC.i WATER WELL REFORD STATE OF ALASKA DEPAR 'MENT OF NATURAL RESOURES ,r Divisiol of Geological & Geophysical Surveys Drilling Part, it No. A.D L. No. d t Borough Subdivision Lot ! Block -- Ib. 1/a gtre. Section No. Townshlp.NO Rt ng. EMerl0lon ;AncbSampson 8 ,3—of_af—af _ Sp W❑ DISTANCE AND DIRECTION FROM ROADINTERSECTIONS3. OWNER OF WEIL:� r, Ray- .Pelletier Well # 2 Address: Shasta Construction Anchorage, � Ak e Street Address and Area of Well Location 2. WELL LOG - -. _ - Feet Below surface 4. WEfL &EPTHI ) final) 5. D TE OF PLETI N .�. �� �6 84 ll UU f:. _ _ _ M ofarlol Type Top Bottom Soil an grave 8. ❑ Coble tool - ary ❑ Driven ❑Dap . 11 Auger '' Q Jet led ❑ Bored. ❑ other: s , It - Gravel, silt, water- 7. USE Domotllapublic Supply ❑Industry C] Irrlggrlon! 0 Recharge commerical p Toot Well. ❑ other: ' Gravel, silt, San Gravel, gray. sand 5 110 rave , sand. , 8111, , wat 9T—T1-0- � 0. CASING: Q Threaded e[de0 �. diem. V In. to 140 ff. Dopth :_ Weight 17lbs./ft. to ft.. Depth Stickup ft. rave if. San- ., Water 9. FINISH OF WELL: - Typo: Diameterr Slo1/Mash Slzo:Length: Sot between ft. and ft. Backfilling Gravel pack UCN -w\104' OC Vk ix,� EC(10 1'4.•Dq�ii:`.PdTt� i 10. STATIC WATER LEVEL:'—ft. Date W L,1: Above or � Below land surface Equipment used: II. PUMPING LEVEL below land surface and YIELD ft. after hrs. pumping 9-9.m• . ft, after his. pumping 9 -P.M. 12.GROUTING Well. Grouted: C] Yes 0 No - Material: 13 Noot Cement 0 Other: 13, PUMP: (if available) HP Length of Drop Pipe ft. capacity 9.p.m. C3 Subm. C] Jef [3 Cantrifical ,_D-Orh+ 141.REMARKS: Production C' S GPM 16. WATER. WELL CONTRACTORS CERTIFICATION: - 15. Mater Temperature _.—a ❑.F ❑ C This well was drtlled•under-my Jurisdiction end this report Is true to the best of my knowledge and belief; Magnuson:Drilling AA 5385 Registered. Business Nome Contract License Number , Address T''0'e. Box'. 70504'Eagle River-, Ak. 99577 une , Signed: Data: Authorized Ropresentotivo _ Form 02-WWR (11/8I) Copy Distribution: WHITE •$tote DGGS, PINK-Drillor, CANARY- Customer - 2. TYPE OF RESIDENCE Single -Family Cf Number of Bedrooms 3 3. WATER SUPPLY Individual Well Q Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite RX 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. Page 1 of 2 72-025 (Rev 8186) Front MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date Novembelt. 19, 1987 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 8; Mock 3; Sampson. Subdivision f12sdO^, Location (address or directions) Sampson D&i.ve (b) Property Owner AHFC - Fonbe�s Telephone: Home Business 276-5599 Mailing Address 235 East 8th Avenue, Anehoxage, Alaska. (c) Lending Institution CommonweQ h Mottgage Telephone Mailing Address Anchorage, Alaska (d) Real Estate Company and Agent JACK WHITE COMPANY/Lynda BanneA Address P.O., Box 771699, Eagte RiveA. Alaska 99577 Telephone 694-5500 (e) Mail the HAA to the following address: or: Check here K7, if hold for pick up. List contact person and day phone number below. S 9 S ENGINEERING1694 2979 17034 EaaPe Rive(. Loa.p Road, Suite 204 mage Riv +L, AJ"ka 99577 2. TYPE OF RESIDENCE Single -Family Cf Number of Bedrooms 3 3. WATER SUPPLY Individual Well Q Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite RX 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. Page 1 of 2 72-025 (Rev 8186) Front 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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. Name of Firm SSn3ENGINEERING 6 9�- Telephone EagferRivertOOP-Road No. 204 Address — Eagle River, Alaska 99577 Date 7 '"A4jt�.�� :iii •W-:::<.�.,r= ;*\„`':ia n >F 6. DHHS APPROVAL Approved for / v bedrooms by / r Date�P2y��l Approved �Disapproved Conditional Terms of Conditional Approval CAUTION 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. Page 2 of 2 72-025 (Rev 8/86) Back A. WELL DATA Well Classification �NtCVpALCCY OF(3r�F��`�Y OF ANCHORAGE (MOA) pNUENZA-SG4EALTH AUTHORITY APPROVAL (HAA) ©1g�9HECKLIST - FEBRUARY 1984 264-4744 .> . r— Legal Descriptio � e> If A, B, C, D.E.C. Approved (Y/N) Well Log Present&N) Date Completed — bZ� E-.194- Yield2A— �'F0 -V- Total rTotal Depth I A'C21 Cased to p Depth of Grouting Static Water Level ( Pump Set At u Casing Height Above Ground '� Sanitary Seal on Casing �G I) Electrical Wiring in ConduitON) Depression Around Wellhead (Y, 1O Separation Distances from Well: I To Septic/Il@idirrg Tank on Lot �� �a' ; On Adjoining Lots A - To Nearest Edge of Absorption Field,o Lot ��ol�' ; On Adjoining Lots '4 - To To Nearest Public Sewer Line To Nearest Public Sewer I Cleanout/Manholed` To Nearest Sewer Service Line on Lot Water Sample Collected by �7 S �'�� I f� ; Date Water Sample Test Results Comments B. SEPTIC/#U)MMFIG TANK DATA Date Installed (O-' 12.'i?A Size t� C No. of Compartments StandpipespY N) Air -tight Caps (ON) Foundation Cleanoutrgl) Depression over Tank (Y/9 Date Last Pumped Pumping/Maintenance Contract on File (Y/N) t�T; for Holding Tank High -Water Alarm (Y/N) r-) P Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/44Qk "Tank: / To Water -Supply Well L> To Building Foundation �Z To Property Line L::> j'F To Disposal Field To Water Main/Service Line Course �'C� `�_ To Stream, Pond, Lake, or Major Drainage i Comments ;1" 'OcjOF,��erI OZ1� Page 1 of 2 72-026 (Rev. 8/861 Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design i{j��T SLFI Date Installed — 2 44 v Length of Field S� u � Width of Field 2 Depth of Field IZ' Gravel Bed Thickness Square Feet of Absorption Area Standpipes Present (!N) Depression over Field (Y/j? Date of Last Adequacy Test Results of Last Adequacy Test / yS�7 " !22 - Separation Distance from Absorption Field: I To Water -Supply Well ',' To Property Line o ) To Building Foundation Lot To Water Main/Service Line 1� To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Iled Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments To Existing or Abandoned System on On Adjoining Lots 3fl I� To Cutbank (if present) E>t:�> I -i - 1101k Dimensions Manhole/Access (Y/N) "Pump Off" Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) ng Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed S & S ENGINEERING �` /� /X 17034 E.918 v / Compangagl@ RI*ar, Alaska 99571 MOA No. �- 6G�-Oo/ Receipt No �= •, ,;, Date of Payment 3 / Amount: $ Page 2 of 2 72-026 (Rev 8,86) BaCk CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, EVC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER IQAhA01 TO BECOMPLETED BY LABORATORY PUBLIC WATER SYSTEM I.D.# E t b PRIVATE WATER SYSTEM Name Phone No. S & S ENGINEERING Mailing ALZO4 Eagle River Loop Road No. 204 Eagle Riverj Alaska 9957?; City FO -1-1 Zip Code SAMPLE DATE: m I 1 I l ��I Mo. Day Year SAMPLE TYPE: Routine Check Sample {for routine sample with lab ref. no. ) ❑ Treated Water ElSpecial Purpose LJUntreated Water SAMPLE NO. LOCATION � 2 ��� 3 4 5 Time Collected Collected By Analysis shows this Water o e. Satisfactory ❑ Unsatisfactory ❑ Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received / /— E), - C Time Received I/ IZZ '� F Analytical Method: Membrane Filter No. of colonies/100 ml. Lab Ref. No. Result` Analyst U m U m U m U m BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS Membrane Filter: Direct Count RGC(1L2G Verification: L COLLECTING SAMPLE D Coilform/100ml BG Final Membrane F' t sults Coilform1100m1 Reported By p.m. TNTC = Too Numberous To Count OR = Other Bacteria PART I OF 2 REMAINDER TO FOLLOW H£MICAL & GEOLOGICAL LABORATORIES OFALASKA, INC ,Bene! ANCHORAGE, a�99 aaewo,E79� «< ANALY010 a! %lets :VERNAL Peg it: Elet ISMp lRe8Ae'lE�',q.uat87 Saiple Rlecld:MOV ze UldCrOfl @;K prfa Pep>« zB To; ;&§ A7w ;za . !«2wLOOP RD. KIN a w .R. 2 %m£ !kms C chomla >! 5 A; G' i ! SIR! UMe e t3�l G!«1 Account fp + »mm NOV a 8?wm3 Released » «brl2 $vmMa: eANAUSIS gTUTED: kyr? ME ES ;c g �» . .�, ii Sor; cial Above N o Nntncted w g!R : Abovp U lAu,` n,G 4e' , gleam u»G !§ MUNICIPALITY OF ANCHORAGE • ` DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date Nov 9, 1984 (a) Legal Description (include lot, block, subdivision, section, township, range) 1-6 1, 8- R //f 3 Setn s 61.. �e'r 1 -c - r j / s' iv /2 3 it S ec 3 Location (address or directions) (b) Applicants Name Shasta Construction Telephone - Home Business Applicants Address (c) Applicant is (check one) Lending Institution Owner/builder ; Buyer = ; Other [� (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single -Family Multi -Family Number of Bedrooms 3 3. Water Supply Individual Well � Community Other (describe) Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite Public E—i Community E=1 Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. Engineering Firm Providing Inspections, Tests, File Search, Data 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 regula- tions in effect on the date of this inspection. Name of Firm T Sw' .-1h /a. a( rpm; Telephone 0 75S 35i1G Address 03 Date //q/ 19 l>r/ J S e4g (ENGINEER SEAL) et C, -e .rsr .55751-o 6. DHEP Approval 1 +;`•,"�� 71), `), 2 10/1 ',•� ,� Approved for-j,/lye bedrooms By Approved Disapproved Conditional Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. 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. (DHEP SEAL) RR4/ej/D18 [Page 2 of 21 7-19-84 MUNICIPALITY OF ANCHORAGE �! DEPT. OF HEALTH & ENVIRONIMIENTAL PROTECTION NOV ? i9b4 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) RECEIVED CHECKLIST - FEBRUARY 1984 B. SEPTIC/HOLDING TANK DATA Date Installed v� � L Size /o,00 Ga ( No. of Compartments Q - Standpipes (Y/N) y _Air -tight Caps (Y/N) Foundation Cleanout (Y/N)' Depression over Tank (Y/N) A/ Date Last Pumped lVe w Pumping/Maintenance Contract on File (Y/N) *'14 ; for Holding Tank High -Water Alarm (Y/N) /y/moi Temporary Holding Tank Permit (Y/N) A`w Separation Distances from Septic/Holding Tank: To' Water -Supply 'Voll /DU �` To Building Foundation /a To Property Lire 8o / To Disposal Field F" To Water Main/Service Line r o?o To Stream, Pond, Lake, cr Major Drainage Course A/bn-2_ — Comments C [Page 1 of 21 LAS ,ply 2-15-84 Legal Description: 1071-9 moi'%jl A. WELL ARTA Serr„�s�• Esfe� �`�� N ��� Ste 3 Well Classification If A, B. or C, D.E.C. Approved(Y/N) Well Log Present (Y/N) /V Date Completed G�� Y Yield /f C urs, Total Depth /4/4,- r Cased to /2/0/ Depth of Grouting Static Water Level Pump Set At %-a S ' Casing Height Above Ground a/ Sanitary Seal on Casing (YM) E=lectrical Wiring in Conduit (Y/14) % Depression Around Wellhead (Y/N) Separation Distances from 1r7911: To Septic/Holding Tank on Lot /Oa f On Adjoining Lots /ad To Nearest Edge of Absorption Field on Lot `aD ; On Adjoining Lots /o6 To Nearest Public Sewer Lire /1-144.e._ To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Lire on Lot OS -1 - Water Sample Collected By EA4 r„ee - ; Date Water Sample Test Results S" c44t,, 1- 4,.jaar- Ccm rants B. SEPTIC/HOLDING TANK DATA Date Installed v� � L Size /o,00 Ga ( No. of Compartments Q - Standpipes (Y/N) y _Air -tight Caps (Y/N) Foundation Cleanout (Y/N)' Depression over Tank (Y/N) A/ Date Last Pumped lVe w Pumping/Maintenance Contract on File (Y/N) *'14 ; for Holding Tank High -Water Alarm (Y/N) /y/moi Temporary Holding Tank Permit (Y/N) A`w Separation Distances from Septic/Holding Tank: To' Water -Supply 'Voll /DU �` To Building Foundation /a To Property Lire 8o / To Disposal Field F" To Water Main/Service Line r o?o To Stream, Pond, Lake, cr Major Drainage Course A/bn-2_ — Comments C [Page 1 of 21 LAS ,ply 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Q00 0 Type of System Design %erg Date Installed";_y Length of Field � D Width of Field 3e " Depth of Field 10, /o ' Gravel Bed Thickness Square Feet of Absorption Area coo Standpipes Present (Y/N) f Depression over Field (Y/N) A) Date of Last Adequacy Test Illew Results of Last Adequacy Test %Uew ce-O's') Separation Distance from Absorption Field: To Water -Supply 'Abll /l) D f To Property Line S8 To Building Foundation 30 ' To Existing or Abandoned System on Lot /l/o? On Adjoining Lots 3o' To Water Main/Service Line /O'er To Cutbank(if present) To Stream/Pond/Lake/or Major Drainage Course /L en L e 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(YM) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedrocm Rating Against HAA Request ** I certify that I have checkedr verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. Signed =� �— ,, Date l� 41 _ Company %o de Sd214rf7 /<,aa( C'i= MOA No. fry-sTu/i KB1/d5/s (Page 2 of 21 "Y",�o o cyto r. `,"" -r `e 2-15-84