HomeMy WebLinkAboutTHUNDERBIRD HEIGHTS #1 BLK 4 LT 30s,�;
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PID:051-582-21
FIRST WATER CONSULTING
THUNDERBIRD THS. #1 BLOCK 4, LOT 30
PERMIT:OSP231167
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP231167
Work Type: SepticTank Upgrade
Tax Code Number: 05158221000
Site Legal Address: THUNDERBIRD HEIGHTS #1 BLK 4 LT 30 G:1865
Site Mailing Address: 27947 RAVEN CT, Chugiak
Owner: DERKSEN JAY RICHARD &
Design Engineer: FIRST WATER CONSULTING
This permit is for the construction of:
Effective Date:
Expiration Date:
cnc
� r
J
Del)ai-tment
Lot Size in Sq Ft:
Total Bedrooms:
7/5/2023
7/4/2024
20044
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: IS' CA(- D P (,j C- Date.
Issued By: L Date: S 2
4
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051-582-21
Property owner(s) JAY & SHARON DEREKSEN Day phone
Mailing address 27947 RAVEN COURT, CHUGIAK, AK 99567
Site address 27947 RAVEN COURT, CHUGIAK, AK 99567
Legal description (Sub'd., Block & Lot) THUNDERBIRD HEIGHTS #1 B4, L30
Legal description (Township, Range & Section)
Lot Size Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption Field ❑ Initial ❑
Single Family (SF) El
(w/wo ADU)
Septic Tank El UpgradeX
❑
Duplex (D) ❑
Holding Tank El Renewal ❑
Multiple Dwellings ❑
Privy ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that
this is in accordance with
applicable Municipal .Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: Z ?-
r -
Date of Payment: It, / U 2 3
Receipt Number: _ ® 1(Z
Permit No. 6SPZ3
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / firstwaterAK@gmail.com
!
!!
June 19, 2023
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: THUNDERBIRD HEIGHTS #1 BLOCK 4, LOT 30
The owner has requested that we obtain a septic permit to upgrade the existing aged 1250-gallon
steel septic tank on the above referenced lot. For current functionality and future flexibility, we
propose to install a 1500-gallon HDPE tank per the attached design to serve the existing 4-
bedroom residence. No groundwater was noted in the MOA on-site file, but if groundwater is
encountered during installation an epoxy coated steel septic tank may be required. The lot and
area are served by public water. The design will not impact any of the neighboring properties.
Please contact us if you have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231167, Curtis Townsend, 07/05/23
FIRST WATER CONSULTING
NO WELLS WITHIN
200' OF PROPOSED
SEPTIC TANK
THUNDERBIRD HEIGHTS #1 BLOCK 4, LOT 30
DESIGN DETAILS:
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231167, Curtis Townsend, 07/05/23
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 2644720
' ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
�I O GJ SL�iL� S%-
P/NONE
Cf / ���
NEW
❑ UPGRADE
MAILING ADDRESS
a u IF A
LEGAL DESCRIPTION /
® G x=LG/
LOCATION
Jle
NO. OF BEDROOM
v Y
DISTANCE T0:
Wer
Absorption ar
Dwelling 3p
PERMIT N 40
LU-
H
Manufacturer q pin
Materials„„ f
No. of compar ments
,
Liq. a acity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth✓
DMZ
DISTANCE TO:
Well
Dwelling
PERMIT NO.
2? F
Manufacturer
Material
Liquid capacity in gallons
c
W =
J CL Z
F ¢
cc I..
a
Well
DISTANCE TO: «
No. of lines Length off ne •
o`
Top of tile to finish grade
Foundation G Nearest lot li
D f / f-
Total length of e 4, Trenc �dth
�j inches
Material beneath tile
inches
PERMIT
D
Distance bet;v i .s -
/r/
Total effective absorption area
W
t7
Length
Width
Depth
PERMIT NO.
CL F
Wa
Type of crib
Crib diameter
Crib depth
Total effective absorption area
rn
DISTANCE TO:
Well
Building foundation
Nearest lot line
-i
W
Class
Depth
Driller
Distance to lot line
PERMIT NO.
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIP MATERIALS
s -T" -f &C
SOIL TEST RATI NCi �_�
!lllXX
INSTALLER
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REM
KS
.on -r `Y) /vI iIJAME
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ROV DATE LEGAL
A
t�1 L� ttil I �G I P A L I _r ke cl F A t -a lz� H L-3 F_ F=1 G E
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
` 825 'L' STREET, ANCHORAGE, AK. 99501
264-4720
I T E _. E F}a E F.: Fes' E F:;' -'Ir -1 I - T; �[� ? ill . v
PERMIT NO. 790074 } c
APPLICANT JQHN KINSELLA/JA; CONST BOX 2511 EAGLE RVR i1�y�94 3181
LOCATION KvaV tJ CJ '
LEGAL L30 B4 THUNDERBIRD HTS LOT SIZE 2=+044 SQUARE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MAXIMSiM NUMBER OF BEDROOMS = 4 SOIL RATING {SO FTe'BR)= 85
THE REQUIRE[) SIZE OF THE SOIL ABSORPTION SYSTEM IS:
G■EF•TH= 1C1 L_Et-.Fi„TH= 2nP c�F=cR'•r'EL G■EF~TH= is
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 (IPJ 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).
F:E�-!�_� I F* EG• '= EF•T I C TnrAt<
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY 4JELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE (JELL (JILL SERVE.
--- TW�� C ] T t�IS�F=•ErT I Ot-a5� ARE on- I F=_EG■ ---
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 FEET FOR A PRIVATE I -JELL; OR
150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F•ERtrt I T E= F• I F?E:E: 21L 1:D.� •D
I CERTIFY THAT
1: •I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND 4JELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL I PJSTALL THE SYSTEM IPJ ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE M ,E TH814 4 BEDROOMS.
_zG•.Y-`
APPLICANT ,JOHN KINSELLA/JAK CONST.
ISSUED B� �'_` `----DATE�--- V3.'
r
0 & E GEOTL%.'FHNI CAL & DEVELOP MENT CO.
• Box 90, Davis St., Eagle River, Alaska 99577
• 694.2774 or 688.2280
Russell Oyster Ead Ellis
694-2771 SOIL LOG 6ee-2280
Soils & Foundations Land Development
Performed for: Name: P,Ei�M S Tel. No.
Mailing Address:
Legal Description: Zo 7—
Depth
Death (feet) Soil Characteristics
3
4
5
6
SgVpo - 4�r-Pe
8 W/L�e��iCES
Q ,r
9. ,CJOliLD�l1S e �8 �i
10
11
12
13
14 go r>z�.0 mf �r
15
16
Y's
Ground Water Encountered: Yes No - If yes, what depth
Proposed Installation: Seepage Pit .. Drain Field
Comments:
A/e Scy LE
Performed by: Date:_ /�7
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COSA Checklist.docx
COSA Checklist
Legal Description: THUNDERBIRD HEIGHTS #1 BLOCK 4 LOT 30 Parcel ID: 051-582-21
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA - PUBLIC &/OR CLASS “A” WATER
Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank NA
Date of pumping NA – NEW TANK
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 6/11/79
ALL standpipes present per record drawing
Total measured depth from grade 8.6 ft (max)
Measured depth to pipe invert from grade 3.7 ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective (ED).
If not, state depth into effective 4.9’
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 6/8/23
Results Pass
Fluid depth prior to test 16 in
Water added 600 gal
New fluid depth 30 in
Elapsed time 1440 min
Final fluid depth 15 in
Absorption rate 600 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 72 in (MOA 6’ ED)
Effective depth used 28 in (Missing ED + Final Fluid Depth)
Effective depth remaining 44 in
Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots &
appears approximate with 4.9’ ED per visual observations of lateral into sump. MOA permit and other COSA/HAA shows
6’ED.
COSA Checklist.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) - NA
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 5/8/2024
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
5/8/24
1 " = 40'
F'�AVEN
C:0URT
ANCHORAGE RLCO11DING DISTRICT, ALASKA
AS -BUILT OF:
THUNDERBIRD HEIGHTS ADD Nol
LOT 30 BLOCK 4 PLAT 78-19
SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a
physical survey of this property as shown on this drawing and that the
improvements situated hereon are within the property links and no
enchroachments exist other than noted. tinder no circumstance shoult
any information on this drawing be used for construction of fences,
structures, improvements, ox• for establishing boundary lizif-.s.
EXCLUSION NOTES: It is the owners responsibility to determine
the existence of any easements, covenants, or restrictions ,vhich
do not appear on the recorded subdivision plat.
WORK ORDER NUMBER: DATE: SCALE. E -MA]Lj
MAY 8, 2024 1 "=40' schullerakOgmail.com
24-024 DRAWN BY: CHECKED BY WD NUMBER: BOOK PAGE:
JLS NW1865 240132
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1831 Talkeetna. Street
Anchorage, Alaska 99508
(907) 227--1455 office
(907) 274-49'92 fax
I .1UNICIPALITY OF ANCHORAGE '
' DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
`f CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date 10/21/85
1. ! GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 30 Block 4 Thunder Bird Heights' T16 NR1W Sec25
Location (address or directions)
Raven Loop
(b)' Applicant Name Jay R. Derksen Telephone: Home 688-9034 Business276-5418
Applicant Address SR2 Box 415 Raven Ct. Chuiziak,
AK 99567
'
! (c) Applicant is (check one): Lending Institution ® ; Owner/builder ❑ ; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution Alaska Pacific Bank Telephone
'i
Address Anchorage AK
(e)' Real Estate Company and Agent N/A
Address
Telephone
(I) Mail the HAA to the following address:
Pick-up by applicant
2. TYPE OF RESIDENCE
Single-FamilyEF Multi -Family❑ Other
Number of Bedrooms 4
3. WATER SUPPLY
Individual Well ❑ Communityflt 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 Ox 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 72-02501,84)
5. ENGINEERING FIRM PROVIDING iNSPECTIONS, TESTS, FILE SEARCH, DAT.. AND INFORMATION
• t
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 adequWe
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 F RIVER EWINPIEE 6,mtb. Telephone
Address EAGLE RIVER, AK 99577
/d%a 1 fbS P. O. g4 5:195
BOX 294
Date _�
0 :¢
0 c : Louis A. Dutera ; W,
,f�JJ••° CE -6736 °J NZ
�` •
"ROFESStt)NP�+ro
6. DHEP APPROVAL n
Approved for bedrooms by
Approved Disapproved Conditional _
Terms of Conditional Approval
CAUTION
Date
Engineer's Seal
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
72-025 (11/84)
Ir MUNICIPAL17y OP ANCHOUC`
MUNICIPALITY OF ANCHORAGE (MOA)
ENYI ONMENT LDEPT. FEALTH P OTEC71Off
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: Jot 30 ,-'/�4e(�"^ E VF D
7A'4-o(e" h^,:�I 1 -IP, 5'1,+.1 T/6N/eJ& s; Dr
A. WELL DATA
Well Classification PZ -f'4 Z / � If A. B. C, D.E.C. Approved (Y/N) �4 IJ
Well Log Present (Y/N) Date Completed
Total Depth
Static Water Level
Cased to
Casing Height Above Ground _
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole _
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Depth of Grouting _
Pump Set At
Yield
Sanitary Seal on Casing (Y/N) _
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
_ To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
Date Installed /7 79 Size la5-0 No. of Compartments _
Standpipes (Y/N) --%' Air -tight Caps (Y/N)
}' Foundation Cleanout (Y/N)
Depression over Tank (Y/N) AJ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) N�/, ; for
Holding Tank High -Water Alarm (Y/N) /2-114 Temporary Holding Tank Permit (Y/N) N�
Separation Distances from Septic/Holding Tank:
To Water -Supply Well ")Do t To Building Foundation
To Property Line / O * To Disposal Field S
To Water Main/Service Line / + To Stream, Pond, Lake, or Major Drainage
Course /✓oTc
Comments
Pagel of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ES` 4ble 2 Type of System Design
Date Installed E `! Length of Field -2-21
Width of Field Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area
1Standpipes Present (Y/N) Y
Depression over Field (Y/N) /V Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well Dov t To Property Line �C
To Building Foundation 20/ To Existing or Abandoned System on
Lot /Vu --X- ; On Adjoining Lots — 3
To Water Main/Service Line ly To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION ^^,,
/v�
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N) —
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
'• Check Permitted Bedroom Rating Against HAA Request ••
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed r'�'���5�'�Date /Uf a/JJ3'
Company MOA No. 17-
Receipt
7
Receipt No. a
Date of Payment
Amount: $ �' ✓`�
Page 2 of 2
72.026 (11,84)
as
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it
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Louis A. Butera
CE -6736
?ROFESSO-:4
Engineer's Seal
..........
!� MUNICIPALITY OF ANCHORAGE ✓�4f Fi
«. r ,
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
(*D
825 L Street • Anchorage, Alaska 99501��UG 13 i979
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264.4720 R E C E 1. -V- E D.
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DI RECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNER PHONE
s / (/O
MAILING ADDRESS
PROPERTY RESIDENT Ilf different from above PHONE
`S
2. BUYER a C?
PHO
N
-S
MAILING ADDRESS
.=LENDING INSTITUTION PHONE
1 e
MAILING ADDRESS
..'I
4. REALTOR/AGENT PHONE
MAILING ADDRESS
b. LEGAL DESCRIPTION
i
STREET LOCATION
117
6. T PE OF RESIDE CE
NUMBER OF BEDROOMS
K SINGLE FAMILY
❑ One ❑ Four ❑ Other
❑ MULTIPLE FAMILY '
❑ Two ❑ Five
Three ❑ Six
7. WATER SUPPLY
❑ INDIVIDUAL'
*ATTACH WELL LOG. A well log is required for all wells drilled
COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
5� INDIVIDUAL/ON-SITE"
*'If individual/on-site, give installation date
❑ PUBLIC UTILITY
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-01013/781
n
i
%/
THIS SIDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑.. FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified_LOG
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
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
6, APPROVED FOR — BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
S — � — � 7
BY (Title)
1 L(
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
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AS -BUILT SURVEY
I hereby certify that I have surveyed
the following described property:
LOT 30, BLOCK 4, THUNDERBIRD HEIGHTS/
SUBDIVISION ADDITION NO. l. -Plat No. 78-19
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Anchorage
Anchorage Recording District, Alaska, and that tt& ro<'e'ntssituated thereon are within the property lines and. do -not -overlap or encroach on the property lying adjace:thereto, that the improvements located on the propertyadjacent thereto do not encroach on the premises in ques
and that there are no roadways, transmission lines or other
visible easements on said property except as indicated hereon.
Dated at Palmer, Alaska this 25t
WARREN FISCUS LAND SURVEYING
P.O. BOX 290
PALMER, ALASKA 99645
3
1986. R