HomeMy WebLinkAboutRIVERPARK VIEW BLK 1 LT 4Onsite Fife
\ 'MUNICIPALITY OF ANCHORAGE i
1 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-0720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
NEW
_
9y -576S
❑UPGRADE
MAILING DRESS
LEGAL DESCRIPTION
L
o erl s vlLf 311
LOCATION rllClE 9','Vlr d -
NO. OF BEDROOMS
Y
DISTANCE TO:
Well i
S . f-
Absorptio aJea
.�•
Dwey
./ —
PERT 0. /�
d Q Manufacturer
EE�
Material
Na. of com rtments
W H
C..
w
Uqcapacity in gallons
fl
IF HOMEMADE:
Inside length
Width
Liquid depth
aD2
DISTANCE TO:
Well
Dwelling
PERMIT NO.
0 F
Manufacturer
Material
Liquid capacity in gallons
O
W =
DISTANCE TO:
Well J, t.
�
Foundatt 5r, i
o��OOf� t
Nearest lot line, 7`
PE TJyO.
G
rL Z
ZW
No. of lines
3
Lengts of each line
Total length of lie
Trench witlth
Distance be[ en lines
F-
2 40
inches
m H
o
Topf the to finish grade f —
Material beneath the
t
Total effective abso on area
inches
03,2 J
Length
Width
Depth
PERMIT NO.
W
4 F
W 1
Type of crib
Crib diamete
1,14
Crib depth
Total effective absorption area
to
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS ^��
I!J
SOIL TEST RATING
2 �s
INSTALLER
94 P T U
It
REMARK .. _.'•'+
C
O
'`
17
.
•A.
•,o
1-17�
l
�.
Roan •.
,11 C7�'� fVo. ti,i�•r.
�
� �of .,,. , • .,
• L' T•
eras-�.^c'�'•
L�,
,:A
Yn
APPH DATE LEGAL
��]�
ZZ 11a4 OPO -11 .
-0f (Rev. 3/78)
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING, CSO FT/ER)= 285
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
C•EFl-r"= S4 L_Et4':3T"= E:r_ f3F?nVEZL C�EPTH= N_.
THE LENGTH DIMENSION
THE DEPTH OF A TRENCH
GROUND AND THE BOTTOM
THERE IS NO SET WIDTH
THE GRAVEL DEPTH IS T
AND THE BOTTOM OF THE
IS THE LENGTH (IN FEET) OF THE TRENCH OR DP,AINFIELD
OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
OF THE EXCAVATION (IN FEET).
FOP. TRENCHES.
-IE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
EXCAVATION (IN FEET).
F<:EG!iJ I Ft:ECSEPT I G TFit•aF� E I �E= 14_�r,r� �GFiLL�t-�E
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DUPING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
--- TL40 C_ `> I t4SF=EZ CT I 1-n r4- nME: F;�.*EGtIJ I RELY ---
BACKFILLING OF ANY SYSTEM 14ITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT !•JILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A 6JELL 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 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 THE DEPARTMENT WITHIN 30 DAYS
OF THE !-JELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER. INSTALLATION.
PEFl.M I T E};P I FRES C�ECEMF3EF?' 31s 154 2
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 THE CODES.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS.
SIGNED: ___ P==� =� --------------- A-kq"
APPLICANT PRESTON PEPPERS
ISSUED
V4. 0
I T'— RD F= H r -4F_' 1 h� F: F-1 C3 E
11
DEPARTMENT'
HEALTH AND ENVIRONMENTAL iOTECTION
Ij�
J
825 'L'
STREET, ANCHORAGE, AK. 99501
��VV
264-4720
L,FELL F:IrAC•
L}t F— ITE �EWEF= PERI 1
I T
PERMIT
NO. ( 820313 )
APPLICANT
PRESTON PEPPERS
PO BOX 1064 EAGLE RIVER
694-9681
LOCATION
CLEMSEN CIR
LEGAL
L1 THOMSON SID
LOT SIZE 40342
SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING, CSO FT/ER)= 285
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
C•EFl-r"= S4 L_Et4':3T"= E:r_ f3F?nVEZL C�EPTH= N_.
THE LENGTH DIMENSION
THE DEPTH OF A TRENCH
GROUND AND THE BOTTOM
THERE IS NO SET WIDTH
THE GRAVEL DEPTH IS T
AND THE BOTTOM OF THE
IS THE LENGTH (IN FEET) OF THE TRENCH OR DP,AINFIELD
OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
OF THE EXCAVATION (IN FEET).
FOP. TRENCHES.
-IE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
EXCAVATION (IN FEET).
F<:EG!iJ I Ft:ECSEPT I G TFit•aF� E I �E= 14_�r,r� �GFiLL�t-�E
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DUPING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
--- TL40 C_ `> I t4SF=EZ CT I 1-n r4- nME: F;�.*EGtIJ I RELY ---
BACKFILLING OF ANY SYSTEM 14ITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT !•JILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A 6JELL 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 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 THE DEPARTMENT WITHIN 30 DAYS
OF THE !-JELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER. INSTALLATION.
PEFl.M I T E};P I FRES C�ECEMF3EF?' 31s 154 2
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 THE CODES.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS.
SIGNED: ___ P==� =� --------------- A-kq"
APPLICANT PRESTON PEPPERS
ISSUED
V4. 0
Russell Oyster
694-2774
O & E ENG VEERING & DEVELOI HENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
SOIL LOG
Earl Ellis
688-2280
Performedfor. Name: 5c n T T r EPPE 25 Tel. No � � - %(f /
Mailing Address: -A U • 130 x /OEA4L-F—�i!/f,P_ , AA
Legal Description: LOT / %fi�.�4Psoi✓ �yf3 p,
Depth (teeQ Soil Cheracledstics
0
1
2
—3
4
13n7-re,,4 SEASONAL
�i 5 --fl I< F/ZOS 7-
6-
7—
-
67 / F_2G, FST
8— e7/%7 51L7 -Y 54 A10
—9 Gla VEG / ✓�. i
10 — (TENSE
11- .2
12— Qp
13 />D 7'7-0 4j
14-
15
4-
15 —
16 —
Ground Water Encountered: Yes No � If yes, what depth
Proposed Installation: Seepage Pit_ Drain Field
Performed by:
mss,
PLOT PLAN
No Serpi-e
PERC.TEST
3/(1 10 1—,a—sr -.So
-,/0 n •cA,/01 ,2
At
Earl P. Ellis
_j � C�rx;iftr� ��tlltYt� mug
by
DOC Co. aoa
SULLIVAN WATER WELLS
P.O. BOX 272, CHUG IAK, ALASKA 98567 • TELEPHONE 6882759
OWNER OF LAND rf r'r'c.�I ("uyJ �f
ADDRESS /' 2
LEGAL DESCRIPTION
DATE • Started S /� "� Ended
PERMIT NUMBER
KIND OF FORMATION:
From n Ft. to 3 Ft.
f�"1
Ft.
From Ft. to I.lf Ft.
CL r1
Ft
From '1 Ft. to <5' Ft.
`�h+ ��
; ` el
From S Ft. to_?_Y__Ft.
S'/ / G %
Ft.
From L� Ft. to /422 Ft.
Ikof
From
From J L/ Ft.to—L /2 Ft.
Ft. to
Ft.
From Ft. to Ft.
Ft. to
From
Ft. to
Ft.
From
Ft. to
Ft
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to—Ft.
From
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
MISCL. INFORMATION:
n
DEPTH OF WELL / is
STATIC LEVEL OF WATER FT. Ir
DRAW DOWN FT
GALS. PER HR ?v00
KIND OF CASING l s o0
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
From
Ft. to
Ft
Ft. to
From
Ft. to
Ft
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From
Ft. to
Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft
DRILLER'S NAME `"`
_ PIIS $0-L
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 A SINGLE FAMILY DWELLING
Parcel I.D. N �In'1 — DLII -CSI HAAtt IAh1O1L1i)O°1%
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner OrWvfAJ �� �or`'�- Day phone i96 -3oy�
Mailing address
Lending agency
Mailing address.
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 2 \
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
Day phone
Day phone
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
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-MCRw.1/91) FWt MOAR1
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 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 ��`14A4,�AJ15y Phone 2'z16 - "° Z -
Address
Engineer's signature
6. DHHS SIGNATURE
Approved for ,3 bedrooms.
M
Disapproved.
Conditional approval for
Additional Comments
Date 62
OF A It 3'
}las T. Kcnivy
CE -5176
bedrooms, with the following stipulations:
I CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending Institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct Inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
rxmta«.wil SWk MOWm
® Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lnr / 7::; M rr ^J 4-,.-A1 Parcel I.D.
A. Well Data
Well type r.9- If A. B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Vr-
Date complet!$ yi9B=- Driller 5.-Z-1rZ + A 7
Total depth i i z L
Cased to
' 2 6 Casing height
2.6
Sanitary seal (YM) yEs
Wires properly protected (Y/N) yEs
FROM WELL LOG
AT INSPECTION
Date of test
Static water level
1�4'
Well flow
6-2
g.p.m. g.p.m.
o
Pump levell
c/u�uo� 1 ✓
�%✓�uo�c, J
'C
rn
SEPARATION DISTANCES FROM WELL TO:
H
Om
Septictholding tank on lot
47116- /
; On adjacent lots oo +
z
Absorption field on lot �2
13 0'
; On adjacent lots oo
Public sewer main
'-/� —Public
sewer manhole/cleanout
Sewer service line
'J114
Petroleum tank
WATER SAMPLE RESULTS:
Coliform d Nitrate 0'" Other bacteria
Z
Date of sample: 412 Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed 9-Z' i49 2 Tank size /040 X-4- Compartments z
Cleanouts (Y/N) Y6s Foundation cleanout (YM) 'yO • Depression (Y/N)
High water alar (YIN) Alarm tested (YM) 10114
Date of pumping Pumper _I25 Pvw.piria
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot > / ,r On adjacent lots Foundation
To property line > 6 Absorption field6 Water main/service line
Surface water/drainage All
`),�
6' "
rt-ozeC.ux+l•Fm
u CONTINUED ON BACK PAGE
C. LIFT STATION
Date Installed Manufacturer
Size in gallons Manhole/Access (YM)
Vent (Y/N) 'Pump on' level at 'Purnp off" Level
High water alarm levelnCycles cam/
Meets MOA electrical codes (YM)
SEPARATION DISTANCE -PROM LIFT STATION TO:
on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed Z4 9B: Soil rating (GPD/Ft=) System typeell
.
Length2 9,-7 ----L —�' Width 30 Gravel thickness 6 � Total depth
,c�.IllfH
Total absorption area � � Cleanout present (Y/N) Y Depression over field (Y/N) 411
Date of adequacy test s�z�9� Resufts (pass/fafl) for .3 Bedrooms
Water level lr 'absorption field before test Sod ' IV After test
Peroxide treatment (past 12 months) (Y/N) Al K yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot > ' 3 0 On adjacent lots] Property line i 6 9
To building foundation LTo existing or abandoned system on lot J�^'
On adjacent lots > Cutbank Water main/service line
Surfacewater Ve Je Driveway, parking/vehicle storage area
Curtain drain ')114
E. ENGINEERS CERTIFICATION
I cer* Drat I have checked, verified, or conformed to all MOA and HAA
HAA Fee $ 80o "Jo
Date of Payment G —/S—%
Receipt Number lod0o// M? �3 )
72-026 t -W)' sack
Waiver Fee $
Date of Payment
Receipt Number
••.........• N, -
?4OFESStOt:'4
J MIs inspection.
D�
�d
Signature
Engineers Name
Date c
HAA Fee $ 80o "Jo
Date of Payment G —/S—%
Receipt Number lod0o// M? �3 )
72-026 t -W)' sack
Waiver Fee $
Date of Payment
Receipt Number
••.........• N, -
?4OFESStOt:'4
J MIs inspection.
D�
�d
MUNICIPALITY ANCHORAGE
Department of Healthth 8 Human Services
O DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 1; Thompson Subdivt.a.ion; (�-hnmsn, ' ,O)
Location (address or directions)
NNN Ctemons C.iKeee
(b) Property owner Robeat 9 Vickie (famne Telephone; (home)694-4200 Business
kfailing Address do PePar-,t�Rive)t—E
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent RQ Alan nA Fergle, Rivo2 ATfN- Andnoy Aleyann
Telephone 694-4200 --
(e) Mail the HAA to the following address: (or check here if hold for pick up.)
List contact person and day phone number below: '
5 8 5 ENGINEERING
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family I!�x Number of bedrooms ^;-
3. WATER SUPPLY
Individual Well Lox Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site V Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72m5JA".71N) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
Inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Date
Alaska 99577
Telephone 697LZ-1279
0
6. DHHS APPROVAL q
Approved for bedrooms by Date /2 -21 —gJ
ApprovedDisapproved Conditional
Terms of Conditional Approval
ref
CAUTION
The Municipalityof Anchorage Department of Health and Human Services (DHHS) Issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above byan independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in orderto satisfy certain federal and state requirements. Employeesof DHHS do not conduct Inspections
or analyze data before acertificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (R".7/88) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
WNWN• Health Authority Approval (HAA)
. , ,CITY Of ANCHECKLIST - FEBRUARY 1984
EWIRON,gtNTAL SCFVICSS DIVISION 343-4744
Legal Description: Lit � i��.5na S. 6.
A. WELL DATA 'RECEIVED
Well Classification INC I-Arrnt / u If A, B, C, D.E.C. Approved (Y/N) "4th
Well Log Present (Y/N) Date Completed s 8 Yielder. 9 g B
�I
Total Depth 11.2�Cased to 11a1r Depth of Grouting
Static Water Level ( t3 Pump Set At
Casing Height Above Ground f r(t Sanitary Seal on Casing (Y/N) Y
Electrical Wiring in Conduit (Y/N) L Depression Around Wellhead (Y/N) hi
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot 106"l- ; On Adjoining Lots y 00 "*1
To Nearest Edge of Absorption Field on Lot ( OD , t ; On Adjoining Lots -/001+
To Nearest Public Sewer Line 641R To Nearest Public Sewer Cleanout/Manhole 06
To Nearest Sewer Service Line on Lot ,2 -I -
Water Sample Collected by 'S -4 S �b�tla rI ; Date 1;X I—T-199
Water Sample Test Results o�'`A�� ��A �-tO (/y '� 19Ac-t�.riy4 hNa tM-kMte s
Comments
B. SEPTIC/HOLDING TANK DATA
Date InstalledS��'8f Sizet'dl No. of Compartments Z
Standpipes (Y/N) j✓ Air -tight Caps (Y/N) _Foundation Cleanout (Y/N)
Depression over Tank (Y/N) 0 Date Last Pumped /.;2 — -4 — 8 R
Pumping/Maintenance Contact on File (Y/N.) ri A ; for _AJJA
Holding Tank High -Water Alarm (Y/N)ti f9—Temporary Holding Tank Permit (Y/N)46
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well OS f To Building Foundation _
,
To Property Line 10 t To Disposal Field (a r
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course (C0 t
Comments6eprtic iRA)V poempP_d 64 ���s Ces'SOool P)ffA 1r'J5
724M (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating In Absorption Strata �5 �8� Type of System Design / EW.(A
Date Installed 4--.22 -139 Length of Field 21� 40�
Width of Field 3 Depth of Field /0
Gravel Bed Thickness 11
Square Feet of Absortion Area / 03 a Statndpipes Present (Y/N) I
Depression over Field (Y/N) Date of Last Adequacy Test
Results of Last Adequacy Test 5�jf[s f�}c+nsu — 3 Rnc%sobow,
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well r ns t To Property Line /0 �t
To Building Foundation .2;? "- To Existing or Abandoned System on
Lot On Adjoining Lots 30 t
To Water Main/Service Line 10 / To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course /00 f'
To Driveway; Parking Area, or Vehicle Storage Area .20 �t
Comments
D. LIFT STATION
Date Installed
Size in Gallons '
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Check Permitted Bedroom Rating Against HAA Request"
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
Inspection.
Signed S&SEPIGINGERING
Company 17034 Eagte RiverLoopRoad No. 204
Date 42-
Eaglee%/3%8 9
MOA No. C G R9-Oo3
Receipt No. ( 1J91 1 /,9/�/
Date of Payment 2 —13-09
Amount: $ f %61.00
Receipt No:
Waiver Fee: $
Date of Payment
72-026(Rev. 7/88( Beck Page 2 of 2
lite of this%
Lwt &
R . r►�. tv7i r.,
le -`I Pd C'n'uI_
'
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME
TIME
TIME
6. TYPE OF RESIDENCE
C
DATE
DATE
DATE
❑ Two ❑ Five
❑ MULTIPLE FAMILY
in--)-qsL,
INSPECTOR -
INSPECTOR
INSPECTOR
*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
MUNICIPALITY OF ANCHORAGE W�{7tN CIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH6 ENVIRONMENTAL PROTECTION --T
t--
825 L Street • Anchorage, Alaska 99601 ENVG ., U 1 •. A .
ENVIRONMENTAL SANITATION DIVISION
C u i '_ 1952
*Dw
Telephone 2644720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEft€IJCIL'
DIRECTIONS: Complete all parts at page 1. Incomplete "units will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNER
PHONE
Preston Peppers
694-9681
MAILING ADDRESS
PROPERTY RESIDENT Ilf tlllferent Irom above)
PHONE
1345-2150
2. BUYER
PHONE
Robert C. and Vicki F. Hamre
MAILING ADDRESS
P.O. Box 262, Girdwood, Alaska 99587
3. LENDING INSTITUTION
PHONE
Alaska Mutual Bank
694-9571
MAILING ADDRESS
Parkgate Bldg., Eagle River, Alaska 99577
4. REALTOR/AGENT
PHONE
Fonda Deans Totem RealtV, Inc.
694-9494
MAILINGADDRESS '
P.O. Box 911, Eagle River, Ak. 99577
5. LEGAL DESCRIPTION
,Lot 1, Thomson Subdivision
STREET LOCATION
NHN Clemens Circle
6. TYPE OF RESIDENCE
NUMBER OF+BEDROOMS
EX SINGLE FAMILY
❑ One ❑ Four ❑ Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
0< Three ❑ Six
7. WATER SUPPLY
70 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.)
S. SEWAGE DISPOSAL SYSTEM
LAX INDIVIDUAL/ON-SITE"
1982 YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLICUTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72010 (Rev. 6/79) 1 to u,
/ /1 Y&r
_ THIS SIDE FOR OFFICIAL USE ONLY ,
1. TYPE OF RESIDENCE
❑ SINGLEFAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAUON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septiic�Taannik,or ❑Holding Tank
Size.= If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL u
4. DISTANCES
W ELL TO:
Septic/Holding Tankr
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
0 APPROVED FOR BEDROOMS
CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
U A.
BY
72 010 (Rev. 6/79)