Loading...
HomeMy WebLinkAboutSEACLIFF BLK 3 LT 14A�C�11-�1-�11 V" ILR / m1 m YV AV I HEALTH DEPARTMENT NO 657 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279.2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM 45l�_ MAILING G� c� NAME sc��/N�� //�%� GGd� 1�� PHONE /? —ADDRESS- LOCATION�� l ��t�� ���/��� LEGAL DESCRIPTION SEPTIC TANK: ski, NUMBER OF DISTANCE FROM WELL ��I% ���Q MATERIAL COMPARTMENTS LIQUID LIQUID CAPACITY /452GALLONS. INSIDE LENGTH ' INSIDE WIDTH �� DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS / OUTSIDE DIAMETER L— OR WIDTH / LENGTH `� DEPTH G` LINING MATERIAL Laic/ �'.��' ��./`��J . DISTANCE FROM WELL ��XX� f� `� BUILDING FOUNDATION��, NEAREST LOT LINE A�.�TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) TILE DRAIN FIELD: /VI,3�' DISTANCE FROM WELL NUMBER OF,01 ABSPTION A ISTANCE BETWEEN SQ. FT. LENGTH LINE NEAREST LOT LINE TRENCH 12 '��29 SQ. FT. TOTAL LENGTH OF LINES IN. TOT ECTIVE DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE DISTANCEFROMLs WATER Z— WELL: TYPE ��� ��`� DEPTH— BUILDING FOUNDATION. SAMPLE , NEAREST NEAREST SEPTIC ��� SEEPAGE c�OTHER _ LOT LINE L___SEWER LINE L� ,TANK , SYSTEM ,CESSPOOL �'— SOURCESl� DISTANCES: DIAGRAM OF SYSTEM DATE o y q I Q e DATE GAAB-HU-L l71'(L' A I hi Jl'IU 1"nAq_7r AnnA ' _Jn"UITII Gase Ivo. HEALTH DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 279-2511 SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT NAME OF APP LI CANT YOMIY-fr ---' C"_L-2 MAILING ADDRESS y`� �t ' ` ' ; PHONE N0, F RESIDENCE ADDRESS 52-1-2 LOCATION OF INSTALLATION 0,11' r? rte IV 61 IV l`t 15ZA 3 LEGAL DESCRIPTION `� " / f?, f /"'t % 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 SINGLE FAMILY DWELLING Parcel I.D. # O 11 - 1 I � y � " HAA # � ON L) .o 1. GENERAL INFORMATION Complete legal description ka ' 1# 4 a Lo c K 3 s z .4 cLI SID Location (site address or directions) 013 0 5 T q C L4 r R 0- E-AC, tlei.4Gj Property owner, S v C 14 a� rt ST r ^' U Day phone � y 3' S� o i 6 Mailing address 3 o t— Jg c� a, L4J'VC C40 -2d -G- c o ct S -i S— Lending agency Day phone Mailing address Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well X Public water 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 k 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#21 5. 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 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. S & S ENGINEERING p Name of Firm17034 Phone 6 `� " e River Loop Read No. 204 Address Eagle River, Alaska 99577 A l Engineer's signature 6. DHHS SIGNATURE V/ Approved forbedrooms. By: Disapproved. Conditional approval for Additional Comments C= auric Date / (17 OF A A� . KUbtKI C. COWAN f ! `4 -,•.� ce-gaol r ,� r, t�C�.•b.. .. � .,. bedrooms, with the following stipulations: Date IZ IT -9 _� 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 courtesyto 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.1/81) Back MOAA21 Municipality of Anchorage RECEIVED � DEPARTMENT OF HEALTH & HUMAN SERVICES }mac Environmental Services Division DEC 1 1. 9l dtlClS 825 L Street, Room 502 • Anchorage, Alaska 99501 • 0907) 343-4 4 unicipality of Anchorage Dept. Health & Human Services Health Authority Approval Checklist Legal Description: L o T J`/ Parcel I.D.: I 1 �I 3- 1 A. WELLDATA ctp s f is — c aN r,w�, r y a Ar22 Well type If A, B, or C, attach ADEC letter. ADEC water system number I 10 If ' Log present (Y/N) Date completed Total depth Cased to Casing height ove ground) Sanitary seal (Y/N) Wires perly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well production g.p.m. g.p.m. WATER SAMPLE RE TS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed (' I �� I Tank size / n 0 Number of Compartments 1 Cleanouts &N) y S Foundation cleanout (Y/0 IV 0 Depression (Y/& h' �' High water alarm (Y/&' ^ Date of Pumping Y / 't -7 Pumper /t 1-4 ) Y_ A AA s C. ABSORPTION FIELD DATA Date installed (' // 81 7 t Soil rating (g.p.d./ft2 ft2/bdr ) A System type Length f 0 Width jo Gravel thickness below pipe Total depth / , Effective absorption area r i Monitoring Tube present S Depression over field (YiQ Date of adequacy test I a ��� /`I 7 Results (Pass/Fail) P4 55 For -3 bedrooms Fluid depth in absorption field before test (in.); Immediately after`fti 'gal. water added (in.): Fluid depth 3 + (ins) Minutes later: Absorption rate = Y s-0 g.p.d. 7 VtAA�I s T ,Perexide treatment (past 12 months) "Y,N) YC "S If yes, give date " G"3 1 7 72-026 (Rev. 3/96)" D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at' Cycles E. SEPARATION DISTANCES Size in gallons "Pump on" level at' SEPARATION DISTANCES FROM WELL ON LOT TO Septic/holding tank on lot Absorption field on lot Public sewer main service line N1 _ On adjacent lots :10-n—ad­jacent lots ump off" level ate �-- - J114 Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation S' -- Property line 5 Absorption field v " Water main/service line /o + Surface water/drainage / 0) d Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line l o 4 Building foundation 10 Surface water Curtain drain N" ^` �- X'v0W,%/ F. ENGINEER'S CERTIFICATION Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots f certify that f have determined thru field inspections and review of Municipal in conformance with MOA HAA guidelings in effect on this date. Signature `✓� L7 ' jj� Engineer's Name ell J� J (; R �. ��' w'.v,✓ Date )x /// / a a� HAA Fee $ Date of Payment _ ' " G Receipt Number 0 5 72-026 (Rev. 3/96)' -5- Waiver Fee $ Date of Payment Receipt Number 4 a u c7 i stems are S3 t ROBERT C. ..........e... `^ s COWAN . CE-88ol i MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 C. Application Date 1. GENERAL INFORMATION j (a) Legal Description include lot, block, subdivision, section, township, range){ ( P I Location (address or directions) j (b) Applicant Name _, /M Telephone: Home v2�8�" 5 D`� _ Business Applicant Address gi S O '-I- (c) Applicant is (check one): Lending Institution ®;Owner/buildey Buyer D ; Other D (explain); 3 �iCcca Il1u�Ia (� (d) Lending Institution rl° ���in�- Telephone i Address ���r yv�C�r7 Cr }� 1.,✓i`I' (e) Real Estate Company and Agent Y�C9y�k Address , Telephone (f) Mail the HAA to the following address: x8 M, 1re 6? t 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 71 € i t F 3. WATER SUPPLY i Individual Well © Community Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. j 4, SEWAGE DISPOSAL Onsite Public D Community D Holding Tank D 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 (11/84) 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 ; e -s &4 C Telephone �� U Addre Date M=ONZ( :I Approved Approved 6ef f Terms of Conditional Approval I I l . OF A1,4%jt 46 C. Reld, Jr. . 1•E _.' CAUTION Engineer's Seal ., 7 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 79-095 I7/fl41 "AUNI�)rr." - DEPT. Of- HEALTH & VIRONME� JTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 E C E 1V Legal Description: I -O' /4A 7-/'2- A) Yl 5e l A. WELL DATA Well Classification 6 Dmm u-nl `� ` I^ B, C, D.E.C. Approve Y/ 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 ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot _ ; 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 ter,. B. SEPTIC/HOLDING TANK DATA Date Installed` Size f d®Ci No. of Compartments StandpipesON) Air -tight Caps6N) Foundation Cleanout Y Depression over Tank (Y Date Last Pumped �✓ _ `� Pumping/Maintenance Contract on File (Y/N) for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply f�� pp y Well �r To Building Foundation To Property Line D To Disposal Field i To Water Main/Service Line `E Ile To Stream, Pond, Lake, or Major Drainage Course Comments �l Page 1 of 2 72-026(11/84) % ' !: •J ...J ate... �...-. C. ABSORPTION FIELD DATA 5 k 75' Soils Rating in Absorption Strata Type of System Design Date Installed b -6/2Z Length of Field /4 Y Width of Field �} Depth of Field n :tea , G�'/� Gravel Bed Thickness Square Feet of Abso (y' ��0 Standpipes Presen ON �1 Depression over Field (Y/N)/ Date of Last Adequacy Test __����— Results of Last Adequacy Test Separation Distance from Absorp ion Field: To Water -Supply Well -t MoD ! To Property Line / To Building Foundation `'— To Existing or Abandoned System on Lot ,N14- ; On Adjoining Lots 1 30 To Water Main/Service Line %� / ✓ To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course ,✓�✓/- To Driveway, Parking Area, or Vehicle Storage Area D /`'K` /J Comments �h'�G�Gvr�mc Ac 44:e_a ed des EJt��_C�Y D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N — Comme — Dimensions Manhole/Access (Y/N) "Pum evel 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 conformed to all MOA and HAA guidelines in effect on the date of this inspection Signed n I Date Company /r ��� _ MOA No. 5195 —o_,;Xta 4� OF �11 Receipt No .5 cC� v y�pa�,�A�.......��e•Q�� �8 Date of Payment G1 5 0qt .•'4�'(� Amount: $ Lf�c� rI�•••w•wi7J��� Page 2 of 2 72-026 (11/84) I(fI BILL SHEFOELD, GOVERNOR jA, L In _ J DEPT. OF ENVIRONMENTAL CONSERVATION Telephone: (907) Address: ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 274-2533 ANCHORAGE, ALASKA 99501 DATE: PWS I.D.# stn-1J}S To Whom it May Concern: According to records on file in this office the Water Regulations Water System is in compliance with the State Drinking Sincerely, G� APPLIC VT FILLS OUT UPPER HAL ONLY Phone Prot grty . HneS Douglas & Charles Lee wk 562-2831 Zip Code 243-6146, Mailvng Ad ress 99.502 uml Date Date Karen adiidJames Stone Date Address P.O.Box 3586 Anchorage, AK. Zip Code 99510 Inspector Phone Lending Institution Alaska Pacfic Mgt. CO. Inspect Address 101 W. Benson Blvd. P.O.Box 420 Anchorage, Akk Zip Code 99510 276-3110 Phone Realty Co. & Agent Jack White Co. Lew Weeks 3201 "Crr St. #100 Zip Code 277 i553 Address 9990-1 Legal Description Lot 14A Block 3 Seacliff CEIVE Street Location 9305 Jaclaire 'CONDITIONS OF APPROVAL ( ) DISAPPROVED Type of Residence - EL Single Family: DATE ET -Multiple Family No. of Bedrooms - BY: 11 Other Soils Rating Date Sewer Installed - Well To Absorption Area - Water Supply ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. ❑ Individual Community •.:_ V" l For wells drilled prior to that date, give well depth (attach log if available). LTJ Public Utility Septic Tank Size /cot) Sewer Disposal r Year Individual Installed: Individual When Connected to Public Utility: 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 L VS Inspector Inspector Inspector Inspect Field Notes: Yb MUNIGIPAUTY ,9T AWCHiC� A FEAT. a,( 4 Jz; e CEIVE ( APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE BY: Soils Rating Date Sewer Installed - Well To Absorption Area - Well Log Received . / p � 7 Well to Tank Septic Tank Size /cot) 0 72023 (3182) m ALASKA OAROnm WL CONROL SCIbVS, InC. engineering & 6nuironmental Studies CHARLES LEE 8210 HUCKLEBERRY ANCHORAGE AK 99502 SELLER — BUYER — SUBDIVISION — SEACLIFF JANUARY 10 1984 BLOCK — 3 LOT — 14A ADEQUACY TEST FOR SEWER SYSTEM MUNICIPALITY OF ANCHORAGE DEPT. OF 11`ALTH r: ENVIRONIMIENTAL PROTECTION THE TYPE OF ABSORPTION SYSTEM IS A PIT WITH AN UNKNOWN AREA. THE SYSTEM IS CAPABLE OF ACCEPTING 675 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 675 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 3 BEDROOM HOME. THE SEPTIC TANK WAS PUMPED ON 1/11/84 . SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1000 IS ADEQUATE FOR THIS 3 BEDROOM HOUSE. ADDITIONAL COMMENTS : NOTE — THERE IS A 4 INCH CLEAN OUT TO THE LEACH FIELD OF AQ I, r.r��nl see eeeoeaeae� 5� tij�. a Y D' fiu est '+ea' ecees ay/e/Q Y"9a �oo .ve. eeee• £dv. U eo� . L oy C. Reid, Jr. a�cP�."^„ No. 2251E 1200 West 33rd Auenue, Suite B • Anchorage, Alaska 99503 • (907) 276-1361 ocmqlas and Lee 11 11 2 10 iluc1cYt e r r y Aflc�ior,'IYJO, AK 99510 Subject* Lot l4h,BIOCk 3, Seaclikt I.Approval for the ix)cliVidlIal Sf-'W,9r al"ll watel, tacilltie-E3 carmot ho grant(A until the following iteols hawe been cofilpleted: pj-je s(,,V.tic taink ml.wmpad with a roceipt '3ub'mi I.. trio to th-IS d a r i e n t aciec-Allacy te5O_- nec-Is tc) l3e pertorniod on the exi,-_miny 1 I IS leaching area. ThiS OF St: Will ed'Ote"Iine if t1�e syst(�'OR ad ec ur Iluate "'Iccor(Aing to �4ational ��taadi 0--i. r listing ot private firmg performing ring thO to t:_ i - r t noe�ds t() ,:w-t�-I�jz3 c.)f fife for ovir review. I _ �;j to A our (ij) il-1,Ctj cleanout neo ­k to be inst,-I'Led to tbt� loacbing tarea. pleasG notity tnis rje")t_ _nt-, Irt'qe -,r re ) a inspection whon the I 4 have been coxrecte?lg It there are any turthur que-stions, please call this office at ;)64-4720. since r--ly? ti i tn. o n e r t �s .M . i'_ 17/a/El k.11closure cc, jac-" wilitel Co. I�Iaska Pacitic Hgt. Co. B60LZV-4-0 L561: 3313109N1114Itld 1NMRS3A09 'S 'N {i 61 ` uoilDadsui }o aluQ Act panadsul '.(IiJoglny glluaH leDol ❑ •AiunoD ❑ -alelS ❑ :Aq @pew uonDadsul -Aue;i `sl:g:gxa panoldde grim AldwoD lou saop E)saop E]uopullelsul uopdwnsuoD uewnq Jo; Ajo»e;siles lou si ❑ sl ❑ Jalum;o Algena 61 alep aA:B „`saA„ s: Jamsue;l 'ON Cl sz),, ❑ �apuw uaaq Jalem;o uopeu:wexa teDrdoloualnq seH •suolle8 `6luuduD -10TAeILD ❑ •amssaJd ❑ :a8elws;o adhi .ON ❑ •sak ❑ :IgBpJalem 8wpunow dwnd 'ON ❑ -saA ❑ :paweip Apadoid wooldwnd 'lid dwnd ❑ 'punoJB anoge asnoydwnd ❑ 'luawaseq jjo wooldwnd ❑ luawasug ❑ :w paleDOl -alnuiw lad suollu8 'dl:Dedu3 dwnd •laa} `@did dolp }o gl8ua-I -Ilam daaQ ❑ 'gam mollegS ❑ :dwnd .ON ❑ -sat ❑ ag8plalem JanoD Ilam ui s8wuado -lulayq ❑ -pooA\ ❑ 'alalauOD ❑ :JDAOD 113m IIU'Dv9 tiuu!pJo ❑ 'AEP PIPPIld ❑ 'moJ3 luawaD ❑ :gJim paleas ifuim punoJe @Duds roilaaxg waj }o yldap w Ig21pl3lem paleas alnww Jad suolled 'ppTA aluwixolddy •laa; 'Ilam u: Ja)em }o 13Aal duidwnd w gldap alewxolddV 'laa; '8uise3 }o gldaQ `JwseD;o addd, 'laa; 'gldap teloy -sacpui 'JalaweiQ mollanjisuoo Ilem 'laa} 'uopnllod alq:ssod }o saD.wos Jaglo aaa; 'loodssaD aaa} `lid adedaas '.laa; `play lesodsip 13a} -,duel Dndas aaa} `lamas ale aaa; `Jamas Doli ]SVD '13a; 'Jeal ❑ '@pis ❑ 'Ino]} ❑ W Dull lot Isaieau aaa; 'uouepuno; 8ulpling :WOAD Ilem l,o 83UDISIO 'Ilam palog ❑ 'Ilam 8nQ ❑ 'Ilam uaA:JQ ❑ -Ilam pallpQ ❑ :woJ; /lddns slum tenpiAipul 'laa} 'auq /WadoJd IuoJ} woJ; Ipuq las 8uglamQ •daap laa} `apw laa} :anis 30-1 -swals6s lesodsip-a8emas pue Alddns-Jalem lenp:A:pw gloq grim padolanap 8umq lou Diu ❑ air ❑ poogJoggWiau w sapladOJd Jalem }o Alddns alenb@pe gsiwn} of AI:wD:A ale:paww: w sham }o aml:e;;o pJODaJ IUDDaJ ISow aATq -pooglogqd:au ui AJewolsnD lou ale ❑ ale ❑ sllam lenp:Alpul ,sagaui 'wuw }o aziS paa;--'wear Jalem Dllgnd lsaleau of aauelslQ W31SJLS Aiddns-2131dM ivnalAI4Nl—N011:)3dSNl JO 1210d3b 61 uopDadsui;o aluQ palDadsul Aluoglny ylteaH IV3O'l ❑ %unoD ❑ •@IDIS ❑ :Aq epow uolpedsul 'laa; `Jeal ❑ 'apls ❑ 'luoJ} ❑ lu awl 101 Isaieau aaa} 'uouepuno; 8uiptmq aaa} `Ilam :woJ} aDuelsiQ leu@luw 8uwll laa; `gldaQ -laa} 'Jalawmp aplslno slid ;o JagwnN :911d e6odeeS 'sagaui lain Jano le:Jalew J3119;o gldaQ sagaui ''alp gleauaq lepaluw JaJlg;o cpdaQ Jaglo 'auols ma olg ❑ 'laneJo ❑ :pJDluw J31lg;o ad6,l, sagDw 'apeJB gswg of alp }o dol 'yldaQ laa} awl gDea }o gigual 'Jaa; aJenbs 'saLiDuaJl }o wolloq Of uaJu uondlosge aAUDD;}@ leJod, -sagDui `glp:m gDuaJI 'laa} `sawl uaamlaq aDuels:Q 'sang }o JagwnN 'laa} 'saug alp ;o gl8ual lelgl, •Jaa} 'Jeal ❑ 'aps ❑ 'luoJ} ❑ le auy lol Isamu aaa} 'uouepuno; aaa} `llama :woJ} aDueJs:Q laa; :pleld losodsld elll Jaglo 'slyd agudaaS ❑ •plag lesodsip DPI ❑ }o slsisuOD 1NWWRI1 AIMMOD35 lu:Jalew 8uluf7 •suolle8 '6l:DedeD pnb:l paa} 'gldoQ 'laa; 'Jalaweip apisul 'Jeal ❑ `ap:s ❑ 'luoJ; ❑ le auq lot Isamu aaa; 'uouupuno} :woJ} aDumsiCl :loodsse:) 'laa; 'gldap pinbil •laa; 'glp1m apisul 7aa} 'gl9ual apisul •suog138 luawlledwo3 aalu: , aueduD 'suolle8 '/glDedeD p:nbg triol sluawlJedwoD }o JagwnN 'lepaleysr 103j-, [lam woJ} xmuls:Q nJluol al;deg loodssaD ❑ 'stuul DpdaS ❑ }o slsisuOD 1N3W1V3M1 AHVWI8d W31SAS iVS0dSI®-30VM3S 1t a lAIGNi-®NOW)USNI dO 1110M 'BEATER A"dMORA.GE AREA BOROUGH; MALTH DEPARDENT 327 EAGLE STREET ANCHORAGE, ALASKA 99501 279-2511 DATE, RECEIVED:;.__'. INSPECT: MIT_: '7- 1,,-)-7/ REQUEST FOR APPROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES FOR 1. Approval Requested- -1��-awl Address Phone 2 . Property Owner ?. 1 F(/t c ,Ph one ,�/(.`' T 3. Legal Description In 4. Type of Facility to be Inspected, STREET: Number of Bedrooms S. Well Data: A. Type B. Depth C. Size D. Construction E. Bacterial Analysis 6. Sewage Disposal System: A. Septic Tank (If homemade, show diagram on back) 1. Size 2. Age__ Z,ZF6(1 3. "Manufacturer 4. Installer. Approval Request for Sew $ Water Facilities Page Two , B. Seepage Pit 1. Size 2. Lining C. _Disposal Field 1. Number of Lines 2. Total Length 7. Required Measurements A. Well to Septic Tank B. Well to Seepage Pit C. Well to Sewer Line D. Well to Property Line E. Well to Other Possible Contamination F. Foundation to Septic Tank G. Foundation to Seepage Pit H. Seepage Pit to Property Line 8. COMMENTS: APPROVED: DISAPPROVED: DATE:_ ,✓.c::< �� �� DATE: APPROVAL VALID FOR ONF YEAR FROM DATE SIGNED. GREATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT ED1170