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HomeMy WebLinkAboutSHRYOCK LT 3l
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3
72-013 (Rev. 3/78)
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
& !'
� /G/9
AUPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
OT .iter� .
s/ '.o
LOCATION f' "ll g
f/
NO. OF BEDROOMS
U
DISTANCE TO:
Well [7
CJ z
Absorption area
a 1j 1
Dwelling
P
��.
Y
PZ Z
LU
Manufacturer (�'/�
Material _ }—
No. of comp5tments
y
Liq. capacity in gallons
�5��
IF HOMEMADE:
th
is id-deprt>_
OOz
DISTANCE TO:
Well
Dwelling
PERMIT NO.
02<
2N
Manufacturer
Material
Liquid capacity in gallons
O
Well
Foundation /
Nearest lot line f
PER Alfl�*")
�
w
DISTANCE TO:
�j
���(-`!l`�`J
J LL
No. of lines
Length of each line
r
Total length of lines
J
Trench width
is lines
P Z w
& �J inches
- -- -
p�.
Top of tile to finish grade
Material beneath tile
Total effective absorption area
o
inches
& c)
Length
Width
Depth
PERMIT NO.
ui
Q
Q F
Type of crib
Crib diameter
Crib depth
Total effective absorption
area
9.—
u!
w
U)
Well
Building foundation
Nearest lot line
DISTANCE TO:
Class
Depth
Driller
Distance to lot line
PERMIT NO.
a
W
Building foundation
Sewer line
Septic tank
Absorption areals)
DISTANCE T0:
OTHER
i !� i I
PIPE MATERIALS
PVC
SOIL TEST RATING
7�
INSTALLER
DE 6 /'' oO&) E C, C
3- 0/&
U '—
•ro c,H
RE=MARKS
r
6`
loll -
TcdI
`
nmn
X
_N
io'
19N
too
14
OCA
av,r�
LEGAL(o
ukto $ A,'A
APPROVED
DATE
C)jlkbei
83
akml�E
(LY -6
72-013 (Rev. 3/78)
Tli-;F,[ I..'F SOIL. ABSORPTION ,.7Yl-TEI-I P..`,: TREPACH
: , F,*:ATING (SO FT/BR)= J.50
t.-UtelBER OF BET-ROO11-5, 4
SIZE OF' '1*'F.IE 5-01L 11S:
r If -p
P-4 L— Co 11 F -
ME LFhIGTH I.X11,10-4,51019 IS THE (IJ -4 FEET) OF THE TRENCH OR DF'FlIhIF'IE*L.D
THE. DEPTH O' A
Ill":
T. F*=ll 0
F 11, _,fl q,,II jl-,-r Ffl" 3 E'�"
GRO1. NE -1 MAE) '['HE
DE: FFi F., T 1-- 1 EI, -,I
T
D EhI'ki.' C PA 1, 1 E. I` --I "I" A L. ,'OTE'CTI OtA
THERE IS PACI SET
I.-J'(E,.,TFI
For;:,
=,_+"-1
'I"HE CIPMVEL E:,F..'F:,Tl,.l
I'-::; 'THE
IlItAIP1,111
2 Ifs 4.-. r°-1
FlydD THE BOTT011
OF' THE
FEET,
F--! C—LI N -J 1 IIRu E.E.
F'ERI-111" I' -JO.
11-- 1.
C: 1 F9 Ir -4 I E-- :3— F5. Ic--` 030, F�-,fl P.— 0 PA #F:5,
APPI
SRA E:i*.i::.-' -:1-0:15.- 191,AV-1-1. Ak". I —J. 6
L 0 I. AT' Cit -4
LEGAL
L:.0 T S* I Z E FT:.ET
Tli-;F,[ I..'F SOIL. ABSORPTION ,.7Yl-TEI-I P..`,: TREPACH
: , F,*:ATING (SO FT/BR)= J.50
t.-UtelBER OF BET-ROO11-5, 4
SIZE OF' '1*'F.IE 5-01L 11S:
r If -p
P-4 L— Co 11 F -
ME LFhIGTH I.X11,10-4,51019 IS THE (IJ -4 FEET) OF THE TRENCH OR DF'FlIhIF'IE*L.D
THE. DEPTH O' A
TREVACH
OR
PIT 'THE DPE;1TINCE E:E*T14EEhI THE SURFAC.:E' OF THE:
GRO1. NE -1 MAE) '['HE
BOTTOM
OF
THE E:,::CAvATj.ot-,i (PA FEET).
THERE IS PACI SET
I.-J'(E,.,TFI
For;:,
TFIEP,1CHES.
'I"HE CIPMVEL E:,F..'F:,Tl,.l
I'-::; 'THE
IlItAIP1,111
DEPTH Of',' CIRFA IEL. BETWEPA THE OUTFALL. PIPE
FlydD THE BOTT011
OF' THE
FEET,
F--! C—LI N -J 1 IIRu E.E.
'S.5,- E=-" IF-`
11-- 1.
C: 1 F9 Ir -4 I E-- :3— F5. Ic--` 030, F�-,fl P.— 0 PA #F:5,
PER.1-11T APPLICAIAT HAS THE RE'-'--* PID 1-4S.F. BI L IT'i-I TCI I...'1EPARTHDIT DURP-4G THE.
THI::5 PROPERTY AND THE
OF MAY WELLS AD-TAF:ENT TCj
NlJt-IBE-'R OF THAT T[ --IE WELL klILL �ER1,iE.
"T...:5:: C-11 P-4 F-1 EE F-Rw E -HE G IF.' FEEC
FINC, FIPPROVAL. BY THIS
E: A C I FI L L. I hl G ("IF' AP. -h-1 WITI-IC'l-IT FINAL I p
C-lEPAF`Tmf-,-'t-4T BE' SUBJECT TO PRO EI
i-Ilt-11-VILIM F)ISTAt-4CE BETkIED-4 A 1-40-1. FIP-41:1 AtOr' Ohl --SITE SEIdAGE DISPO.5-AL IS
7 1 .1
:1.1210 FEET FC -F, Fi P RI I...' FITE I--IELL OR, lr�:O TO 20C., FEET F'P.01,1 FI PUBLIC". WELL C, E P E P. -I I.) I hl G
UPON THE TLr:F,E' CIF PUBLIC WELL.
I TF, I'l 1 ['11 IN C.-IS'TANCE, FF,Olvl A PRIl,/ATE WELL TO A PRI%,'A"I*F.'. :w -E l.-IER LI[ -,IE l: r', 225 FEET ANCI
TC.1 A (" '01,11-lUtAITY 5EkIER LIhIE 1'..; 75 FEET.
O"I'TIER, REGUIREMEhITS IlAli-' APDL.',.'. SPEi-IFIC:FITICINS i7jP-1D [iIAGR.AMS FIRE
W.,T'l I I TO IhISL.IRE PRFIPER ItISTALLATIC"IP.J.
"T... > F 7,, 1 B Ez- S Cm F." E:-- r-1 P"
I E ERTIFY THAT
J.: I AM P"AMILIAR WITH THE FOR SEkIERS AND
FORTH F:i-1 THE OF AhIL"Jil"'IRAGE.
2: 1 WILL Ii%isTALL. THE IN ACC:ORClANCE 14I TI -1 THE C':0DES.
m.
THE:Ot-4-SITE MAY REG'!UIRE ENLARGEI-0,11, IF THE
I MADERSTAf-AD 1"1111"r'
F.*ESIDENCE L'-:; RE'lli'DDELED TO 111C.I. UDE Ill' --IRE THFIN -4 BET,PM011s.
.5- 1 G N E`
L
ve-Cl
U E
MUNICIPALITY OF ANCHORAGE
Department f Health and Environmenta Protection
825 Street, Anchorage, AK. 99501
264-4720 /v)
HANDWRITTEN PERMIT
Permit #�6_� l l WSLL AND/OR ON-SITE SEWER PERMIT
Applicant:Mailing Address: J
Location: Phone Number:
Legal Description:�� Lot Size:
Type of Soil Absorption ystem Is:
Trench:_ Drainfield: _ Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: Lr' Soil Rating(sq.ft/br) (/S-0
The Required Size of the Soil Absorption System Is:
DEPTH - LENGTH J_S GRAVEL DEPTH WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(H6t-D� TANK SIZE GALLONS
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
# # TWO(Z) INSPECTIONS ARE REQUIRED #
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feel
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 u 3 * * #
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that theAn-site sewer system may require enlargement if
the X sidence is e d led to include more that bedrooms.
�� �>
Signed �__G� .z ni Issued by :
A licant •��: _� �j
Date... j
SWP/024(1/81)
SOILS LOG
�= MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
—/ SOILS LOG — PERCOLATION TEST
PERFORMED FOR: ay is .I�l,.> ^ DATE PERFORMED:
LEGAL DESCRIPTION: l �7 '�-` •� �`\��``1�
2 w grcc� , 6VA (Uj-'e-
,, ro cpr�v�',tly .sc��
3 - r, ,v
f' �4
5 .�� qrC 11�Vtf
6/(��� �� try qrc
7
9
10
12
13
14
15
16
17
18
19
20
COMMENTS
IM
SLOPE
I
SITE PLAN
elm
'31 4iV qr� WAS GROUND WATER 1V� S
1 ENCOUNTERED? Iy L
T O
E
IF YES, AT WHAT E
DEPTH? _
Reading
Date
Gross
Time
Net
Time
Depth to
Water
0
r.
13
«t,Iq
1al a
/0
_ /3•-<l3
'5e
qcF
-} N2 c�
SIC
r�
k� : S I
•5 7
TL
I
"'XX
I
elm
'31 4iV qr� WAS GROUND WATER 1V� S
1 ENCOUNTERED? Iy L
T O
E
IF YES, AT WHAT E
DEPTH? _
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
+ilzc�
I
13
«t,Iq
1al a
/0
_ /3•-<l3
'5e
qcF
-} N2 c�
k� : S I
•5 7
PERCOLATION RATE (minutes/inch)
TEST RU BETWEEN— FT AND ���-- FTr
PERFORMED BY: CERTIFIED BZ
wyor) 5� Cly
72-008 (6/79)
DATE: C_) J(1-0
f
1
BILL SHEFFIELD, GOVERNOR
i
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501 274-2533
November 2, 1984
Alaska Enviornmental Control
Services, Inc.
1200 W. 33rd Avenue, Suite B
Anchorage, Alaska 99503
SUBJECT: Waiver Horizontal Separation between Well and Septic Tank,
Sofr_y"Gk Subdivision, Lot 10 (8521 -WA -056)
Dear Sir:
The Department has reivewed the subject waiver request and hereby waives
the horizontal separation between the well and septic tank to 86 feet
on the subject property for a single family residence only.
BEE/msm
0
Sincerely,
4Buce E. Eric son
District Engineer
//- 1 -?v
u;s®¢ Shry41�Sr�,�.
AWU
_
der OL
I
®CPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
November 2, 1984
Alaska Enviornmental Control
Services, Inc.
1200 W. 33rd Avenue, Suite B
Anchorage, Alaska 99503
BILL SHEFFIELD, GOVERNOR
274-2533
MUNICIPALITY OF ANCHORAGE
pEPr. OF HEALTH &
ENVIRONMIENTAL PROTECTION
NOV G i98i�
SUBJECT: Waiver Horizontal Separation between Well and Septic Tank,
Shryrock Subdivision, Le#—'�O (8521 -WA -056)
4,p3
Dear Sir:
The Department has reivewed the subject waiver request and hereby waives
the horizontal separation between the well and septic tank to 86 feet
on the subject property for a single family residence only.
Sincerely,
4Buc?-eef . Eric son
District Engineer
BEE/msm
ALASKA NUIROWnTAL COnTROL SCnUICeS, InC.
engineering & enuironmenlal Studies
A,'UNI CIP,%,LITY o FNCHOKAGE
November 5, 1984 I"UT O, HL«LTH &
ENVIFO d!vl::: lTi,,L P;?OTLC71ON
Mr. Robbie Robinson NOV Ig84
Department of Health &
Environmental Protection �$ L
825 L. Street ' �A V
Anchorage, Alaska 99501
Subject: Lot 3, Block 0 Shryrock Subdivision
Dear Robbie:
On August 1, 1983, Jim Roberts wrote a letter to Ms. Doris Davis
reference Lot 10, Shryrock Subdivision. This was in error to a
HAA. We became involved with it at 'that time. We have done
soils tests, inspected upgrade, absorption field, septic tank,
etc all under that legal description. Your office also issued a
sewer permit, 830808 for lot 10, Shryrock Subdivision. Since
that time, the lot has been carried by both us and your office as
Lot 10, Block 0, Shryrock Subdivision.
The legal description is wrong. The lot is a actually Lot 3,
Block 0, Shryrock Subdivision. All paper work done since the
original error was made has the wrong legal.
Please convert all paperwork to reflect the proper legal, lot 3,
block 0, Shryrock. Lot 10, Block 0, Shryrock does not exist.
Sincerely,
Ron Godden
Environmental Engineer
1200 West 33rd Auenue, Suite B 9 Anchoraqe, Alaska 99503 a (907) 561-5040
J
r
PDC' c u�r �v� Th'Ar
m
hl
/oy. E.3 y
° b WELL
P
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6A? A,
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SE/'TSG C
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� • v
o.
SAS r /06.63
SURVEY TYPE !�
❑ AS- BUILT - NO CORNERS SET
❑ PLOT PLAN - AS -BUILT - LOT SURVEY -TOPOGRAPHY
❑ LOT SURVEY
® RECERTIFICATION AS -BUILT - NO CORNERS SET
33r
a
w
331
SYMBOLS �E
ASSUMED ELEV. aw>
DRAINAGE
�-�-e- wDOD FENCE .4 Cc5MCN7-
_R- CHAIN LINK FENCE.
NOTE= Fences are shown in their approximate
locations only.
It isthe responsibility of the builder or owner, prior to
to verify building grode relative
LEGEND hub a tock -found ❑ set
iron rebor -found O set •
construction, proposed
to finished grade and utility connections and to determine
iron pipe -found O et 0
brass cap -found ® set
the existence of any easements, covenants or restrictions
which do not appear on the recorded subdivision plat.
alum. cap -found a set Q
Lot Survey Certification
on® t
�y�� OF A4�vYr.
Prepar d by
BENCH IWAfK INC.
I hereby certify that I have
surveyed the property shown
described hereon, andLZ
i7��; •°°noo°ro"^^s� aqui
``�° % •<
professional Land Surveyors _®
Drawn by:
and
the improvements situated
o V
g (45T� j. a`Zr (ash
Scale= „ ,
1 = 40
WAH
Date Surveyed 1984
Oct. 8,
Checked b y` REJ
thereon within the property
lines and do not overlap or
�r ;
"^ °^O ° Q;
encroach on adjacent proper
and that no improvements q�° ° Boc"B °o Op 0 Dote Drawn: Grid; W.O.
odjaceMpropertyoverlapor / °°ROBERT OR R. Oct. 9, 1984 3034 84-280
encroach on the premises in �� 414) °° V
question and Ihot there ore ��� °o °°°, e`b�G47' Legal Description: Lot 3 5111 yOCk $Ubd1V1S10n
no roodways,utititylines o dti �pfj `°�°°°o ��Zj .
other vis I ble easements on
soid property exreptos ind C31+'10,f
Parcel I.D. 018-252-09
Municipality of Anchorage A
On -Site Water and Wastewater Program
(907) 343-7904 .
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Expiration Date: / / — / / — I
Complete legal description Shryock, Lot 3
Location (site address) 2946 Nugget Lane Anchorage, AK
Current Property owner(s) U.S. Bank National Trustee Day phone
Mailing address
Real Estate Agent
P.O. Box 8265 Wichita Falls, TX 76307
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: Three
4. TYPE OF WATER SUPPLY:
Individual Well
F]
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Waiver/Variance request for.
Received by: v
COSA to be released to Zengines. unless
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual
0
Holding Tank
❑
Community
❑
Public Sewer
❑
by the engineer.
COSA Fee $ °J Waiver Fee $
Date of Payment gi (01 15 J-"' Date of Payment
Receipt Number d �G Receipt Number
COSA# O�� St�tS Waiver#
S. 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 Anderson Engineering Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineers Printed Name Michael E. Anderson, P.E.
6. ATURE
DSD
System #1 Approved for —3—bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms,
Date 8/5/2015
® ��• OF 44 1140
o *; 49TH f 'r
r A," MICHAM tPKKURSON : � X
J : CE -4381
®9+'SPF•• f �S� f�.•����
®,®®�pROFESSIl1Na.p•►®
with the following stipulatillAu-%ivvii
By: di3Original Certificate Date: S — / I' /,7
The nl �O, evelopment Seryices Division (DSu) issues Certiricaies of Cn-Site Systems Approval (CvSA) based only
upon the representaparagraph 5 by an independent professional civil engineer registered In the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet r :.i c
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: Shryock, Lot 3
Parcel ID: 018-252-09
A. WELL DATA
Well type Private If A, B, or C provide PWSID #
Well Log (Y/N) N
Date completed Pre 1973* Sanitary seal (Y/N) Y
Wires properly protected (YIN) Y
*
Total depth 60 ft. Cased to 60*ft.
Casing height (above ground) >12 in.
FROM WELL LOG
AT INSPECTION
Date of test
7/17/15
„Static water level ft.
35.2 ft.
Well production g,p,m.
3.0 9-
p.m-WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate 18 mg/L
Arsenic ND ug/L Date of sample: 5/29/15
Collected by: Anderson Engrg.
*Information Taken from Municipal Files.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Date installed <1973/10/6/83*
600/1250 1/2*
Tank size gal. Number of Compartments
Cleanouts (Y/N) Y
N**
Foundation cleanout (YIN) _ Depression over tank (YIN) N
High water alarm (Y/N) N
Date of pumping 5/31/15 Pumper A Pius Home Services
Two Septic Tanks On Site. 600 Gallon and 1,250 Gallon.
**Clean Out in Crawlspace.
C. ABSORPTION FIELD DATA
Date installed 10/6/83 Soil rating (g.p.d./ft2 or ft2/bdrm) 150 SF/BDRM System type Deep Trench
Length 78* ft. Width 5* ft.
Gravel below pipe 2.5* ft.
Total depth 10* ft. Eff. absorption area 936 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 7/17/15 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 0 in. Water added
650 gal. New depth 12 in.
Elapsed Time: 1,440 min. Final fluid depth 0 in.
Absorption rate >= 600 g p d
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
If yes, give date
*Information Taken from Municipal Files.
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at in.
"Pump off' level at
in. High water alarm level at in.
Datum
Cycles tested
Meets alarm &-circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot
$ 86
On adjacent lots >1 00
Absorption field on lot
>100'
On adjacent lots >100'
Public sewer main
>75
Public sewer manhole/cleanout >100
Sewer /septic service line
>25'
Holding tank >75'
Animal containment areas >50'
Manurelanimal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >51
Property line
>51
Absorption field >5
Water main >10'
Water service line
>10 Surface water >100
Wells on adjacent lots >100'
ABSORPTION FIELD ON LOT
TO:
Property line >10
Building foundation
>10 Water main >10
Water Service line >
Surface water > Driveway, parking/vehicle storage >10'
Curtain drain None Noted
Wells on adjacent lots >100'
F. COMMENTS
"Waiver Issued.
G. ENGINEER'S CERTIFICATION14
m�E OF.A t
i certify that t have determined through field inspections and ®Q�,"• 4.4
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date. e �'40- W
Michael E,°�""° ...
. Anderson, P.E."._
Engineer's Printed Name ,,,,,,,,;,,,,,,,,,,,
Date 8/5/15 MICHArL E. AAN81ERSON
COSA brown sheet 10-10-12.doc
0
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION,),, D /
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL,
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, towns iprange)
�Ss¢,tY©C/e'�'..•�C'•,u,�
Location (kddress or directions)
(b) Applicant Name /f//Y - .. cAiP�i� Telephone: Home 3s�S-7GGS Business
Applicant Address
(c) Applicant is. (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution,'(/7AAnd Telephone
Address
(e) Real Estate Company and Agent 7&-1 6VAO-7 8/c honk/l
Address
Telephone 276 " 777LT
(f) M
2. TYPE OF RESIDENCE
Single -Family Multi -Family ❑ Other
Number of Bedrooms
3. WATER SUPPLY
Individual WeIIU 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{( 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 (11,84)
G 3 s/�[Iro ez .
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 S Telephone /�
Address 1,2."A) .33 rcl /�W- _ u iy- _,8lbtle4/ y �� 3
Date
®l,.►ulALewi
14 ""llit
�••� •••��•di��.*fib
DHEP APPROVAL
Approved for bedrooms by Date
Approved � / ' Disapproved Conditional
Terms of Conditional Approval
�� �i11�1►aTl'
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Pnge 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MOAr
MUNICIPALITY OF ANCHORAGIHEALTH AUTHORITY APPROVAL (HAA)
ENVIRONMENTAL SERVICES DIVISION CHECKLIST- FEBRUARY 1984
284-4720
AUG 71907 Legal Description: 40`7-3
�z� /L3tJ ��G- 33
A. WELL DATAR���IV�D
Well Classification _k/If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Ye—Date Completed RRC /973 Yield
Total Depth (0/ 60 r C sed to V a A Depth of Grouting .JIA
Static Water LevelPump Set At
r
Casing Height Above Ground — � Sanitary Seal on Casing)
Electrical Wiring in Conduit (Y N) Depression Around Wellhead (Y�
Separation Distances from Well:
f /
To Septic/Holding Tank on Lot ��' �� i� On Adjoining Lots O
To Nearest Edge of Absorption Field on Lot On Adjoining Lots
To Nearest Public Sewer Line A/1" To Nearest Public Sewer ,
Cleanout/Manhole I To Nearest Sewer Service Line on Lot 7, t
Water Sample Collected by /�ereS A W/ErA) ; Date
Water Sample Test Results SSS ) f'177F� 22
Comments® piez, cc.) 7z'sr 7-7-?- -x'7• nsaw !w'ehw Dtluw?,S RE?Ae7
Co
B. SEPTIC/HOLDING TANK DATA
PRE'/973 c
Date Installed /0"(9-0 Size /moo No. of Compartments _ a
Standpipes6N) Air -tight Caps) Foundation Cleanout (Ye
Depression over Tank (Ye Date Last Pumped __ZA947
Pumping/Maintenance Contract on File (Y/N) ��%} ; for ,d/4
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/'N) // /� —
Separation Distances from Septic/Holding Tank:
To Water -Supply Well �Z �� To Building Foundation /
To broperty;Ljn, �S To Disposal Field
r
To Water Main/ Service Line /V 't To Stream, Pond, Lake, or Major Drainage
Course
Comments1 �k PSE /97,� A -4f . f S 71ih' Wd>ti!✓�,@�
1 .
Page 1 of 2
72-026(11/84)
3 S/*,1eeK
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata %>U Type of System Design %jf'/0ic1Fj�GG�
Date Installed /O'1o��3 Length of Field
Width of Field Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area O 9 Standpipes PresentON)
Depression over Field (Y® Date of Last Adequacy Test 7.. z -z -X7
Results of Last Adequacy Test vef-v —
Separation Distance from Absorption Field:
To Water -Supply Well /4< To Property Line
To Building Foundations To Existing or Abandoned System on
r
On Adjoining Lots
To Cutbank (if present)
Lot
44AUI
r
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course /_0 f
To Driveway, Parking Area, or Vehicle Storage Area /e :e -
Comments Comments
D. LIFT STATION
Date Ins -
Size in Gallon
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhnla/Ar:r:P.CC !Y/Nl
"Pump Off" Level at
Vent(Y/N)
�pings during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I ha hec d, ve ified, or conformed to all �MOA and HAA guidelines in effect on the date of this inspection.
Signed �l/ti e'�"" Date a 7-8l +'���
Company c`f MOA No. ®d'SF _ ,��..y°•"••.''Q�
J Lam' ���' •' '•
Receipt No./ d / pCr�;• _ �;���
Date of Payment lJ �%8110®0
0
'° •ei°
Amount: $�
o Y e. RED, 9R. � �)
EJe �R/GGRS �Gdi'iRT °o . CE - 2251
Page 2 of 2
72-026 (viae)
Ze A�rV
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HEMIC
5633 6 STREET ANChIORAGE, ALASKA 99518 TELEPHONE (907) 562.2343
FEI7ERAL TAX ID li 92-0040440
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MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date '2 $ oa410
(a) Legal Descr.iFtion (include lot, block, subdivision, section, to
Location (address
� or directions)
-- —Q�4 I J�IuGGET
(b) Applicants Name 4L\)-jo pnJas Telephone - Ho_eyy A?30SBusiness
Applicants Address oZGU(a1yuG66T LANe= 4ACkona6-6 41Z '799-l%
e)
(c) Applicant is (check one) Lending Institution ; Owner/-bcri-1-der ;
Buyer ; Other (explain); T�
(d) Lending Institution Telephone �-
Address
(e) Real Estate Co. & Agent IJJ; Wf_ -, Mc)KR`Csc=/+k i eD C4fz'Pr - �-
Address c�9'CY9 Aac-�rL `J)W'te AO) �Y,CL'0 itSc��k �/g5'Q3
'Telephone 5('I- 55 Y
(f) Mail the HAA to the following address:
2. Type of Residence
Single -Family, Multi -Family
Number of Bedrooms
3. [dater Supply
Individual Edell � CommunityEl
Other (describe
Public =
Note: If community well system, must have written confirmation from (:he State
Department of Environmental Conservation attesting to the legality and status.
G. Sewage Disposal
Onsite Public Community Holding Tank r
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 21
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 Telephone%pi�S
Address 12 C)( -)UJ 3 � �WC '4MQ Lt0/Z 4CrC- f'C
Date__4e� Z
6. DHEP Approval
Approved for
Approved
Terms of Conditional
(ENGINEER SEAL)
V, 4P %
461
Qg� �
bedrooms B ' L
Disapproved Conditional
Approval
CAUTION
tF
b
►0.�.�/0 .u:i.n 0
�a s��. <. .iraZr .• fi
AA' x'.44 -
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 2] 7--19-84
MUNICIPALITY OF M,!CHORAG;:
DEPT. OF iJU,,[iiI
MUNICIPALITY OF ANCHORAGE (MOA) LNv1PONMLNr:\L Ha_ -CTION
HEALTH AUTHORITY APPROVAL (HAA) NOV 1984
CHECKLIST - FEBRUARY 1984
A. WELL DATA Legal Description: `SCJ 5ht?_!e -0ek
Well Classification ;1ytp If A, B. or C, D.E.C. Approved(Y/N) Ai,
Well Log Present (Y -WO Date Completed pve /G73 Yield �p,U'{
Total Depth GT I„o' Cased to �'o' ,4 Depth of Grouting
Static Water Level 32,-2..b Pump Set At --�— - _
Casing Height Above Ground _1,_(4' Sanitary Seal on Casing ((jDI) -t�
Electrical Wiring in Conduit (Y/N) *,y4 Depression Around tbllhead (Y N
Separation Distances from Well:
To Septic/Holding Tank on Lot 1A R�' ; On Adjoining Lots 6•r IOU'
To Nearest Edge of Absorption Field on Lot flj,'Z' On Adjoining Lots_6-LL
To Nearest Public Sewer Line N a To Nearest Public Sewer
Cleancut/Manhole N4- To Nearest Sewer Service Line on Lot oj,�4- _
Water Sample Collected By Q_ G000erl Date.—
Water Sample Test Results
Commnts "— W1e,_P uopy2Grtca.tNO No W -Lee ¢bJJF avm"o 'iF,i- ?ve- 1913
B. SEPTIC/HOLDING TANK DATA
Date Installed Xce"9� 1g83 Size 4 &000 1060 No. of Ccmpartments * 4
Standpipes QN) _W Air -tight Caps (Y/N) Fo ndation Cleanout (Y
Depression over Tank (Y nZ Date Last Pumped / IL2
Pumping/Maintenance Contract on File (YM) N0,- ; for _V�_
Holding Tank High -Water Alarm (Y/N)pjl, Temporary Holding Tank Permit (Y/N)►V4-
Separation Distances from Septic/H� Tank:
To Water -Supply I RG To Building Foundation 1�!
To Property Line c15 I To Disposal Field X-2 31
To Water Main/Service Line Ali To Stream, Pond, Lake, or Major Drainage
Course &-i 1 UO,
Comments ov rAtnL QyOem / - (Ap(ir?apry (b Fvuwi As_bNP f -
Receipt #k
Date Paid:
Amount: 0.0
(Page 1of2]
2-•15-84
(T /(.) Sh24fCL)cK-
C. ABSORPTION FIELD ARTA
Soils Rating in Absorption Strata 15-0 Q'/6n-Type of System Design .-irZcs%
Date Installed IV (0 "33 Length of Field
Width of Field 3 6,0 Depth of Field Y G�
Gravel Bed Thickness Ve3(jl/
Square Feet of Absorption Area &Uy CJ Standpipes Present 6/N) L/„es
Depression over Field (Y/I9 rlam Date of Last Adequacy Test tv9-
Results of Last Adequacy Test __ 4 -
Separation Distance from Absorption. Field:
To Water -Supply i,b11 IIC-, -L-, To Property Lire 1- I-]
To Building Foundation * S� To Existing or Abandoned System on
Lot UN Y, _ ; On Adjoining Lots (r/ iU U
i
To Water Main/Service Line N A- To Cutbank(if present) G T 2S
To Stream/Pond/Lake/or Major Drainage Course G'1(G u/
To Driveway, Parking Area, or Vehicle Storage Area `4�t
Continents
D. LIFT STATION
Date InstD I
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(
Comments
Dimensions
Manhole/Access (YM)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles u Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verif_iedr or conformed to all MOA HAA Guidelines in effect
on the date of this inspection,.
Signed L�� � s Date `.LVSae W.
Company /kECS MOA No. -02 �'�pENG4
KBl/d5/s
ay C. Reid, Jr.
No. 2251 •E _.-
Vent
:
(Page 2 of 21 _"°,��,.�•°' �`
i
Sewer Disposal
Individual
Public Utility Year individual Installed:
Holding 'rank When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
APPLW�NT FILLS OUT UPPER HA' ONLY
Property Owner
Phone
Mailing Address
CT S2
rBuyer
Zip Code
7
Address
Lending Institution
Zip Code
Phone
Address
ReallyZip
Co. & Agent
— — — — Code
Phone
Address
Legal Description
9
Zip Code
Street Location
Type of sidence
P"Single Family
0 Multiple Family
No. of Bedrooms
El Other
TT
Water Supply
Individual
ATTACH
Community
D Public Utility
WELL LOG. A well log is required for all wells drilled since June 1975.
Foorr wwells drilled prior to that date,
give well depth (attach log if available).
Sewer Disposal
Individual
Public Utility Year individual Installed:
Holding 'rank When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
August 1, 1983
JiOri , I?dvi.:
it. Rt. %\ 1°'ox 11019
Anchorage, AK 99`107
3ubject.s Lot 1.0 Skyr.oc�k Subdivision
Approval for the i.ndividua_l, set7o-r and water faci.l.itic!s cannot
be grarateci until the following items ilc"ave been romp.letedl
° `file septic tank pur�rped with a receipt submitted to this
department. `1'he total number of gsaliom; pumped needs tolx:
on the receipt and verified by a registered erigineer as to
the ac.:tual number of gallons pumped. This is tQ ver. ii y the
tai"l.e Of i:.}le :9e}_)tic tank.
° Lxpose the ,_septic tank manhole to v(-,r;.l y its cxistence.
° 21le top of the well. casing ,hot.;ld be ,y)aled so that ii-- is
water. tight.
° An adequacy test needs to
be por_formed on
the existing
leaching
area. t'hi s te;t
trill determinc
if the system is;
adequate
accor_cli.nq to Nat
-L fitanc3arcls.
A 11st:islh of
pri.vat-.e
firms performing
the test is aracloseci.
hi report
necsdss to
be submitted to
this office for
our review.
The sstarldpi.t)e to the Sewer :system need caps ora them and
stiarlClpipe8 raised. abovo ground.
Please notify this Department for a rein:;pecti.on when the
noted discrepancies have been corrected. If there are any
further questions, please call this Office at 264-4720.
Sincerely,
Jira Roberts
. stmciate Environmental -Sp('_cia-Ust:
J;t6 B/p/E
Pnclosure
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ALASKA C3WIROWnTAL COnTROL SRUS, InC.
engineering & enuironmental Studies
AUGUST 10 1983
DORIS DAVIS
SRA BOX 4019
ANCHORAGE AK 99507
SELLER — DORIS DAVIS BUYER
SUBDIVISION — SKYROCK BLOCK — 0 LOT — 10`
ADEQUACY TEST FOR SEWER SYSTEM
THE TYPE OF ABSORPTION SYSTEM IS A CRIB WITH AN UNKNOWN AREA.
THE SYSTEM IS CAPABLE OF ACCEPTING 260 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 192 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IS NOT ACCEPTABLE FOR A
HOME OF 4 BEDROOMS.
THE SEPTIC TANK WAS PUMPED ON 8/10/83 .
SEPTIC TANK ADEQUACY
DUE TO THE THICK SLUDGE ONLY 600 GALLONS COULD BE
PUMPED OUT OF THE EXISTING SEPTIC TANK. THE SEPTIC
TANK WILL HAVE TO BE VERIFIED AT TIME OF UPGRADE.
ff O p"p,�•((//, ® aa
qr,.�p� n
�497M' l
• 77 q u
Leroy _. Reid, Jr.
N 2251-E
1200 West 33rd Auenue, Suite 3 • Anchorage, Alaska 99503 9 (907) 276-1361
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64A 84 B
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