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Home My WebLink AboutTHUNDERBIRD HEIGHTS #1 BLK 4 LT 25Thunderbird 'D Heights #1 Block 4 Lot 25 #051-582-16 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 / � ) L .Qi/fl/ D/✓J / PHONE �a NEW ❑ GRADE M17AILINGADDRE * V LEGA;_ DESCRIPTION LOCATION NO. OF BEDROOMS v Y410W DISTANCE TO: Well /j (� Absorption area Dwelling PERWj NO. 1 wZQ Manufacturer Mate ' No. of co m rtments Liq. ca 3c�iSy jr gallons 2V IF HOMEMADE: Inside length Width Liquid depth O Y JAZ DISTANCE TO: Well Dwelling PERMIT NO. _ F Manufacturer Material Liquid capacity in gallons D w= DISTANCE TO: Well - 61Founds i n Nearest to lre PERMIT N0. 4i� / Q O .W.1 LL z No. of lines Leng o a9Ft line Total 1 ngijif Imes Trench wi Distance bet we I. s F 0 Top of tile to finish grade Material beneath the inches Total effective a sornn n area w c� Length Width Depth PERMIT NO. oQ. a w Type of crib Crib diameter Crib depth Total effective absorption area H DISTANCE TO: Well Building foundation Nearest lot line J J Class Depth Driller Distance to lot line PERMIT NO. 3 DISTANCE T0: Building foundation Sewer line Septic tank Absorption area (s) OTHER PIPE MIALS AA T , 20k) SOIL TEST RATING _ 1 IN ALL Rc .� ix) REMARKS I . i r I I 4 ff APPRO ED DATE LEGAL rc-u�o tnev.siro MUN I C I F>nL_ I TY 171F= nNCHOF�RGE f DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 'L' STREET, ANCHORAGE, AK. 99501 264-4720 TE '-EWEF c F"EF�M I T 1 MI. PERMIT 140. C 800109 )' l M(4- wn APPLICANT KLEIN CONSTRUCTION BOX 2524 PALMER AK ((31115 LOCATION THUNDERBIRD HTS LEGAL ;'L215 94THUNDERBIRD"HEIGHTS.' LOT SIZE 21000 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING CSO FT/BR)= 85 THE REQUIRED SIV OF THE SOIL ABSORPTION SYSTEM IS: 3 5' ,/ 37 E?Ef=�'TH= vS L__E:N13-rH 3:2 13 FR F1VE=_I_ C?EF}TH= -4- THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF R TRE14CH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BET14EEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION CIN FEET). FRaMU I F:;ZEL't s;EF=oT 10 -r F4 NK :S I ZE= 117101f3 0nL_L_C)r4 S} PERMIT APPLICANT HAS THE RESPONSIBILITY TO I14FOR11 THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. -- Tt•j(3 C !=-> > I h-a0-13F°'ECT I 17h75 1-4FZE F= E:(PU I FZEC.N --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION A14D APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET 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 IJELL TO A PRIVATE SEWER LINE IS 25 FEET A14D TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F}ERM I T EXF' I FZEc-::: E}FEE GEME3aM Q1_.. ,•.soCa I CERTIFY THAT 1: I APS FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE 0 -SITE SEWER. SYSTEM MAY REQUIRE ENLARGEMENT IF THE RES I DEbtCE I S R 7DELED TO I NCLU E MORE THAN 3 BEDROOMS./� W t SIGNED: --- ^AP CANT K CONSTRUCTION a C / I ISSUEDE+Y_l ,L_ �I _1 =�L�� - -`� DATE_ =G_� ZJ _e C-1- - V4. 0 .f MUN I C I F>nL_ I TY 171F= nNCHOF�RGE f DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 'L' STREET, ANCHORAGE, AK. 99501 264-4720 TE '-EWEF c F"EF�M I T 1 MI. PERMIT 140. C 800109 )' l M(4- wn APPLICANT KLEIN CONSTRUCTION BOX 2524 PALMER AK ((31115 LOCATION THUNDERBIRD HTS LEGAL ;'L215 94THUNDERBIRD"HEIGHTS.' LOT SIZE 21000 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING CSO FT/BR)= 85 THE REQUIRED SIV OF THE SOIL ABSORPTION SYSTEM IS: 3 5' ,/ 37 E?Ef=�'TH= vS L__E:N13-rH 3:2 13 FR F1VE=_I_ C?EF}TH= -4- THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF R TRE14CH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BET14EEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION CIN FEET). FRaMU I F:;ZEL't s;EF=oT 10 -r F4 NK :S I ZE= 117101f3 0nL_L_C)r4 S} PERMIT APPLICANT HAS THE RESPONSIBILITY TO I14FOR11 THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. -- Tt•j(3 C !=-> > I h-a0-13F°'ECT I 17h75 1-4FZE F= E:(PU I FZEC.N --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION A14D APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET 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 IJELL TO A PRIVATE SEWER LINE IS 25 FEET A14D TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F}ERM I T EXF' I FZEc-::: E}FEE GEME3aM Q1_.. ,•.soCa I CERTIFY THAT 1: I APS FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE 0 -SITE SEWER. SYSTEM MAY REQUIRE ENLARGEMENT IF THE RES I DEbtCE I S R 7DELED TO I NCLU E MORE THAN 3 BEDROOMS./� W t SIGNED: --- ^AP CANT K CONSTRUCTION a C / I ISSUEDE+Y_l ,L_ �I _1 =�L�� - -`� DATE_ =G_� ZJ _e C-1- - V4. 0 • M.UM.,- -ENGINEERING SOILS LOG -.. pERC: YEgY soils IoQ {� percolation t; Performed for: 2,m -kl /lei date s le of die. G 31 4. 6, 8. 9� 104 Ground water . depSh._.A) A. perc. rate between erformed by: certified by 4372-E Parcel I.D. 051-582-16 Municipality of Anchorage On -Site Water and Wastewater Program a (907)343-7904 Certificate of On -Site Systems Approval Expiration Date: / -.2 _6- J-6- 1. GENERAL INFORMATION Complete legal description Thunderbird Height #1, Block 4, Lot 25 Location (site address) 27733 Raven Ct. Current Property owner(s) Margaret Rocafort Mailing address Real Estate Agent 27733 Raven Ct. 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class 'A' Well 0 Community ❑ Dnhlin WN f+ , c ... +o.., n WaiverNariance request for: Distance: r Received by: ' ` ',` ", Date. COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ qq6 Date of Payment b-0 Receipt Number o01 u6 COSA # Waiver Fee $ Date of Payment Receipt Number 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 Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Alk. 99510 Engineer's Printed Name Steven R Pannone 6. DSDSIGNATURE V System #1 Approved for , bedrooms System #2 Approved for _ bedrooms Disapproved Conditional approval for Date 7/31113 bedrooms, with the following stipulations: By Original Certificate Date: % co TheA y, e t ge Development Services Dvision (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upoentations given in paragraph 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 f 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: Thunderbird Heights #1, Block 4, Lot 25 Parcel ID: 051-582-16 A. WELL DATA Well type Class 'A' If A, B, or C provide PWSID # AWW U Well Lo Date completed Sanitary seal (YIN)_ Wires pro protected (Y/N) Total depth ft. Cased to ft. sing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test Static water level ft. ft. Well production g.p.m. g.p.m. WATER SAMPL SULTS: Colifo colonies/100 mL Nitrate mg/L ug/L Date of sample: B. SEPTIC/HOLDING TANK DATA Collected by: Tank Type/Material Septic/Concrete Date installed 7/1/80* Tank size 1,000 gal. Number of Compartments Y, dZ Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N)N�� High water alarm (YIN) N Date of pumping aC� (' l 3 s Pumper J /? , C. ABSORPTION FIELD DATA Date installed 7/1/80* Soil rating (g.p.d./ft2 or ft2/bdrm) 85 SF/BR System type Trench Length 39 ft. Width 3 ft. Gravel below pipe 4 ft. Total depth 6 ft. Eff. absorption area 255 ft2 Monitoring tube N Depression over field N Date of adequacy test 7/25/13 Results ( Pass/Fail)Pass _ � For 3 bedrooms Fluid depth in absorption field before test 38 in. Water added 483 gal. New depth 38 in. Elapsed Time: 110 min. Final fluid depth 38 in. Absorption rate , 450+ g,p,d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date D. LIFT STATION Date installed Size in gallons_ "Pump on" level at in. "Pump off' level at Datum Cycles tested _ E. SEPARATION DISTANCES WELL ON LOT TO: Manhole/Access (YIN) _ in. High water alarm level at Meets alarm & circuit requirements? Septic tank/lift station on lot On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer /septic service line Holding tank Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Water main 10+ Water service line 10+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water Service line 10+ Surface water 100+ Curtain drain 50+ Wells on adjacent lots 100+ Absorption Feld 5+ Surface water 100+ Water main 10+ Driveway, parking/vehicle storage11 0+ in. F. COMMENTS * No clear date on instalation * I61-DtA 2 1 Ci Q m4mcrlt'D t C Lb frGVO 638`is or. 2y" ei elnGv" FieLo) l^/cI.U�1 V6 G. ENGINEER'S CERTIFICATION % I certify that I have determined through field inspections and review of Municipal records that the above systems are in 49tH '•.�}, conformance with MOA COSA guidelines in effect on this date. / • .. -. Engineers Printed Name Steven R. Pannone •. 9 $1even IVIS • Date 7/31/13 COSA brown sheet 10-10-12.doc euim+e �� DEY. (ASAA®) xallw oslNCT eullalra sLTaac rnaer soE autnrro xlTBAf% pxAatR eual,ro ¢ISAoc 30' 24 N89' 59' 00"W I 199.30' C.O.s o I vi oa $ 68.0' 27.0' io, c_B EXISTING b 2fiO ZX HOUS O 68.0' 0 0 b Q 0 wn 16l < N 90? 10' UTIL ESMT O 179.57' 889" 59'00"E RAVEN COURT co --------------------------- UNDER NO CIRCUMSTANCES SHOULD AN AS-BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE ONES. THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL LIABILITY ONLY FOR THE COST OF THE SURVEY. LISTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE. LJ Lor s wy SURVEY TYPE SYMBOLS ❑ FOUNOATON AS-BUILT ❑ FINAL STRUCTURE A EIUILT .-: • SET REBAR 7 � DRAINAGE 0 ASPHALT ❑ PLOT PLAN ... As-BUILT LOT SURVEY ... TOPI0N O FOUND REBAR 0 e e W� FENCE ....... CONCRETE SE AS-B LT .. NO CORNEAS SET pECFRTFlCATON AS-B I T ... N DIiNFFS SET A UIL OO ASSUMED ELEV. .p--.N )E METAL FENCE ® WOOD DECK PLOT PLANS & LOT SURVEYS NOTE: IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS, TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED. SURVEY CERTIFICATION •.•r\\\% , ,,44 Prepared by Robert E. Johns, Jr. & Assoc. PLOT PLAN IhwyDor" tnaw My+err r,wyr �•••�E. • •�P,.• "" Professional Land Surveyors row irvna s rmlww a d e,• �::' p 1700 Brink Driw. yw.n m vw Nm ma r m. ert er mr 6nreuw low 'versa I y, • ANCHORAGE. ALASKA 99504 mw1e' Www aria' AF ^I• '. +• '._=Yr'rt• Scala:1 to 40r Rec. Lot S.F. Rae. Plot Fila No. FOUNDA71ON AS-BUILT 4 fl N E Jfm, d.. M•Ly ulkr aot •• •• V Date Surveyed: 13 Drawn b p R EJ Checked byA AK JIVI n.w nakanaa m Aa-Bult rray w bwY rmMaam m �. wt a s a an Yw r •••• ..�:.• .. ..... .... r08108/ a„avn. ata nam,wtlr r aw.n r.sw aas...wmNYr,a,b re•t _ U • ' RO OHNS r Drawn: 08/09/13 Grid: W.O. 13-383 .-,�. -'j ; - a ...Date •`9P 4121 i• NW1865 FINAL STRUCTURE AS-BUILT I, pWrl c xaw x.. I+.er away me, "`.w` aw Aar �. �e • •'•.yac �\` Legal Description: ww°'"".° m adTe .w.we m tlar lot ra awt Nt w ••••.••� ad d • P '••••••,••' ,� . ca\\\\� ` Lot 25 BLOCK 4 aM.ma. ata nN,maum au alwr naam lot '• �h .•• THUNDERBIRD HEIGHTS#1 MUNICIPALITY OFANCHORAGE ' • �' 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 A SINGLE FAMILY DWELLING Parcel I.D. # O 51—SP Z— / G �4 1.. GENERAL INFORMATION Complete legal description Le -r 2s11 211-5)5-k 'q -�Ir�,va��z�r� th-S, '01 ) Location (site address or directions) Property owner Zrvv-Sm. sW* Individual well Day phone &ES -35•29.- _ .. _.Community well 01`• \` Dl b •• Mailing address 22233 SAv&A) G-rr eNvc,rA)e-, Ar, 1)9,9&7 Lending agency Mailing address Day phone Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well _ .. _.Community well 01`• \` Dl b •• Public water , NOTE: If community well system, provide written confirmation froth State A6E , attest-�? ;- Ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: �;•-` . ,r�,',. Individual on-site ".. Holding tank Community on-site -. Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-M(Rm.1r81) Front MOA121 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify 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 ZmaryP� TZ- AiVNOA e- I -G? g- Phone Zf4—C30i5 Address ouzo-zT, ANc4-o2Ac,g, A.K 1:VCD<S-7y Engineer's signatur - Date FF — zo- 4 S- 6.'- 6.` DHHS SIGNATURE Approved for bedrooms. Disapproved. Steven R. Pannone �•. 10, CE -8149 •✓•• ~•r n r .'' Conditional approval for bedrooms, with the following stipulations: t , 421ditional Coi'nments i -t By: . W, 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 theirlending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct Inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-M ma+. /91) Bark MOA#21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: (..b'r ZS V3 Loc ICN TM,'NbaoNQ1irza Parcel I.D.: O SI - .G-$Fz / 6 Vk-rle' %lb A. �VELL DATA Well type rsMK AAs rM If A. B, or C. attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static %eater level Well production WATER SAMPLE RESULTS: Coliform Date of sample: Date completed Cased to FROM WELL LOG B. SEPTIC/IIOLDING TANK DATA Nitrate 9— p.m- RECEIVED AUG 211995 Casing height (above gr n!cipalny of Anchorage � (.tteatttI & hhrmart Services Wires properly protected (YIN) Collected by: AT INSPECTION Other bacteria g.p.m. Date installed .s - rc) Tank size (000 4 Number of Compartments Z Cleanouts (Y/N)_ '� Zcs,a Foundation cleanout (Y/N) V* z G?A Depression (Y/N) No High water alarm (Y/N) w(A Date of Pumping BfiBl9s- Pumper C. ABSORPTION FTELD DATA Date installed —S -5f) Soil rating (g.p.d./ft`o t`/bd ) S.S System type -T-VLa,vct4- Length 2q r Width 3' Gravel thickness below pipe 4' Total depth G Effective absorption area Monitoring Tube present(Y/N) V Depression over field (Y/1) N Date of adequacy test o0l /R (ss Results (Pass/Fail) 'plass For 3 bedrooms Fluid depth in absorption field before test (in.); — o — Immediately afters gal. water added (in.): 6 " Fluid depth -T Minutes Minutes later: — o -- (in.) Absorption rate = g.p.d. Peroxide treatment (past 12 months) (Y/1) N o If yes, give date D. LIFT STATION Date installed Manhole/Access (Y/N) I "Pump on" level at* "Pump off' level at* Nigh water alar at* *Datum cs tcstcd E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /VIA : On adjacent lots Absorption field on lot Public sewer main Server /septic service line On adjacent lots Public sc%ver manhole/cicanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation G` Property line Zo Absorption field Water main/service line 7 t Surface water/drainage �•w� Wells on adjacent lots N l� SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation / 4 t Water main/service line s Sol Surface water- too I Driveway, parking/vehicle storage area So 1 Curtain drain � too' Wells on adjacent lots � /0.D t F. ENGINEER'S CERTIFICATION 1 certify that 1 have determined thru freld inspections and review ofA1p in conformance with A/OA 1114 guidelines in effect on this date. Signatuf� Engineer's Name ST�31E3NRNNONt� Date 8—Z1 -4S HAA Fce $ 3 are iey Date of Paymcnt �— Receipt Number Rev. 8/95 OSS: Ilaa.wk.doc meipalrecords 1/rd{the n . Finowni Waiver Fee $ Date of Payment Receipt Number _ above systems are i ...... . .._.. r"� W ) 5. LEGAyL OE$CRIPzIONJIWA �fc�J DATE RECEIVED i INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE DEPT. OF H=ALTH &. NMENTAL PF.OTECTION DEPARTMENT OF HEALTH & ENVIRONMENTAL PROT&W& 825 L Street • Anchorage, Alaska 99501 OCT 2 J ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTYOWNER Cyt PHONE '7 �- 73 MAILING ADDF'I, f PROPERTY ESI DENT (If different ri b ve)PHONE � r 2. BU ER PHONE MAILI ,ADboXDRES$r� /' gg0t) 1 K 3. LENp;NG INS�11{Tx/UJ1T pyo MAILING A S W • 4. REALTOR/A 2NT Wj i ✓ ,yt / 1 A��1 MAILING �Q E S F. ) 5. LEGAyL OE$CRIPzIONJIWA �fc�J _/ STREETi/— LOCATION 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS E3 One C3 Four ❑ Other SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY Three ❑ Six 7. WATER SUPPLY INDIVIDUAL` ' ATTACH WELL LOG. A well log is required for all wells drilled `❑ Qf ' COMMUNITY since June 1975. For wells drilled prior to that date, give well /❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM 46 'D YEAR ON-SITE SYSTEM WAS INSTALLED. INDIVIDUAL/ON-SITE" ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLICUTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON-SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED INSTALLER SOILS RATING ❑Septic Tank or ❑ Holding Tank Size: If Tank is homemade give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS APPROVED FOR -3 BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE lam- 0 / 9C) BY IL 72-010 (Rev. 6/79) APPLI*" INT FILLS OUT UPPER HA'�- ONLY Property Owner Bruce and Guadalupe Johnson e SR 2 Box 401 F688 'Mailing Address Chu iak AK Zip Code ( -1062 Buyer Joe E. and Jessie W. Barnett '; 3 3309 Baxter Address Anchorage. AK Zip Coda o4 333-7377 Lending Institution Alaski USA Feder+l Credit Union Phone 777 Juneau Date .Address Anchorf a AK Zip Code 276-5100 Realty Co. 6 Agent NONE Phone Address Zip Code Inspector Legal Description Lot 25 Block 4 Thunderbird Heights Subd. Addn. No. 1 Corner of Riven Loop and Riven Ct. (Dark brown tri level Street Location on corner, next to blue house Type of Residence X Single Family 1 ❑ Multiple Family No. of Bedrooms-_ .❑ Other Water Supply ❑ Individual ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975. ❑ Community For wells drilled prior to that date, give well depth (attach log If available). IC Public Utility Sewer Disposal 19130 * Individual Year Individual Installed: ❑ Public Utility When Comected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 00 Time Time Time Time Q��cn Date Date Date Date 4-?�C�- Inspector Inspector Inspector Inspector irGJkc.4, ha)btfMCIPALITY z Field Notes: OF ANCHORAGE DEP?, OF WALTH V ENVIRO-;M-2NTAL PROTECTION yi, MAK 2 5 3�8� RECEIVED (4,rrPPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL - �d DATE BY Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Septic Tank Size ' Well to Tank 72,023 (=I