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THOMAS L BOYLE BLK 2 LT 3B
Thomas L Boyle Block 2 Lot #015-282-10 /17-5S KI, Z *IZE JQo✓ / r 17- d k c/ Fs -.?5F- issue cl io1z1 �— rc JxV0_ as CO -,."d 77V6 E4 456!' %f/E/LE WEQG CG1Ni=� /C77a1� %.Pi41JE 19M4L_,✓SES WccN r//imr�CGS A614 -rd -17401, 4 -rd -17 401,11MOv 1,1-70/ flC�;C- 4-C4g, /9 MUST BF 79,60✓ 9*k 01CL/ E--- /)Nhz-'r Zj- 7t-7'1.S S}J',rl-2F4,7 Ce c/! i36 �// �uiY/rCJ� E'nCi-CoC�7in� Eyj �1rt?C �c>[n�r /-OVall 4.C1� Gyrt� !+N/Qinins //�.ur/l Jv Z7 Z� �� 0 0 7to-p� Municipality of Anchorage Page I of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: SW q s 0 338 PID Number: 10 Name: R Ll3 R.11 L. E Wastewater System: ❑ New VUpgrade Address: ABSORPTION FIELD 5"p Phone: No. of Bedrooms 3 ❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound YOther LEGAL DESCRIPTIOii Soo Rating' Total Depth from original grade: C.pr)lsq FI Lot: Block) Subdivision: Depth to pipe bottom from original grade Gravel depth beneath pipe O — B. Ft _ o.5 FI. Township: Range: Section: Fill added above ongmal grado t Gravel length: FI 0 FI. WELL: ❑ New ❑ Upgrade Gravel widen: Numberollines: OslaKeaelweenf ms: 6 120 FI let. Classification (Private. A.B.C): Total Depth: Cased To: Total absorption 8 Pipe Ft. Fl. � so Ft 11material. //�� 11 tt Sa.iaAd4.cL �{CPVL Driller: Date Drilled: Static water Level. Installer: ,At� A - Dale Insla ted: !e _/D A, Ft. e -to Zo Yield:Pump Set nt: Casing Height Above Ground TANK GPM Ft FI. SEPARATION DISTANCES ❑Septic ❑Holding VS.T.E.P. To Septic Abso,pllon Lul Notd.nqvbacNrnAte Manufacturer: 1, I� Capacity In ons: nll•,� 6 From Tana Field Suwon Tan. Sevv Llan, q,Ls, Well t Q, O b 2 O L� Material: S Number of Copanmenls: M % LIFT STATION WateSurfacr water Lot 7. 5 n^ �7 /' Size in gallons: Mawfacly er, /J -� L Line � (. b {) O !•1'k. Get, ( a ", Foundation t ^'f / I O t 'Pump on" level 'Pump of,"; ovLf Oel al: High water ala m at: Curtain N//O• Pump Mate t-MTodel Electrical bnspections performed by - Drain Drain 05 o ww 1-4 V Int Remarks: BENCH MARK rr 11 /� 1 Location and DasQr� to tion: p s t't a s+1 I S S Ot.�td' j'� lk'F Z' i U S-"'�Vji C O e_VLLe -01-'K ro I n 0 1. � d� IXArt of Assumed Elevation: a✓ t tNJ �— • / 2 EN%TtEENS SEAL ....�1.�. l�L-� ✓ qct `i'•'~' , / •tet �~'v~ Inspections performed by: , Dates: is ��` q r ""'•»' "� �" s ;+ 2nd { o J ,•. c. ........... .. a -n i !✓ I V ". T� ben?rvtG'ard j 1. Department of Health and Human Services approval �• ��'. CE -2226 ted' Reviewed and approved by: Date: 72-012 (AN. 9/91) MOA 25 I I III III Q W CLASS C 1 ' I I I I � A � I I I III I I I III 1 I I III I I I I I III III STABLE . : .. ... III �L MT ROTSAND CO ...... III BCNC RK �e7 III MT TOP OC SAND I I 20 X 10 SAND FILTER � I 3 -BED DOM RESIDENCE i I I I 1150 CAL STEP -1 III �------ 13 III I I I III III l l •��•'(� • OF»•'•�1� I I 49th°••• I I IN= Well MEN SU AND i C -2225 II ••p ........ �• III 25 0 25 50 75 100 125 150 SCALE. 1' = 50 FT. TOBBEN SPURKLAND P.E. LOT 3B BLOCK 2 BOYLE SID SEPTIC SYSTEM,AS BUILT 203 W 15TH. AVENUE DATE: OCT. 23, 1995 ANCH. AK. 99501 RANDY RANDALL 1,,,N 12140 CANOE STREET SHEET: 1/3 GRID: 2734 Fon J SIDE VIEW BOTTOM SIDING BENCHMARK SOOTH YEST CORNER OF STABLE I TOBBEN SPURKLAND P.E. I I 2Qg�0 SIND FILTER I I SEPTIC SYSTEM AS BUILT I 203 W 15TH. AVENUE LOl 38 BLOCK 2 BOYLE S/D DATE: OCT. 23, M ANCH. AK. 99501 ,,. 1 RANDY RANDALL SHEET: 313 GRID: p734 w• }f.�:;E•r.cT7ur. r.vr0}•r mit,i is t Al. rrY Ui ANCtIUBAt)C. i::1J IU.' ING `;AC;. CY 0 TV 10 WN ::..00 CA;cT Tlllrtlrt ROAD Cr1utJC• (907) `iG0-3464 ltlr'uR;IATIIIN: (')0%) 7^G-0?.11 06 E.• ....- CLEC DOC •--- ---- PCt"OCT d-: 95-0906 ADrWI:SS: 721=0 CAW71 S7 DATE: 101::!0/9`i r• OWE 12: 1.0T: :1D til.17C1:: 2 DOISE COtS WHTS: LTI'T STATION IN Till: AM __...----------------------------------------------- C'i!'C nr Cr!';r'CCTION: t:^.rN;FL'CTION: ): Electrical SeTvicF 2: C4( f!0 NONC:OMFLIANCF. 01^M'C•'VCD----- - -rC -] COFk:CCT]OtlS EII 6ft7lAt. A. EYF'LAltfElr N};T.OII r ] WILL 'tC^.XAttIflC AT NEXT INSE•CCT IUN C ] 00 NOT CONCAL UOT IL GlC CN PrCTur, COnr1CflTS: �_ l 2c7a,,(.4(- 1 r�Ct Iq�2i�(2 UUC' d rNSE'r:CTOE:�\ IiAT1, FIEt! C11r Y) ��iSrfL Ai;l� r f.Til:. Pi.E:A:cI: CAI I. Fr -11' 7t:t,)•YCT TCN lu1 trot rr,ra�lvr, r;1 r�; Nn•i Tct: a r Percmt Psuing by Weight ZR x x V Q 8 10/18/95 17:09 COMMERCIAL. TESTING » 9073434786 Q00'd 6Z91'ON XS/Xt 8S:91 S6/81/OT a r Percmt Psuing by Weight ZR x x V Q 8 s Po •!CORCCOQ�lIR Iv "7.tvu VISVIV, Nd L0:9 46 -BT -OT J PM P 01 1 Y � w 1 s Po •!CORCCOQ�lIR Iv "7.tvu VISVIV, Nd L0:9 46 -BT -OT J - ---- S,I /'t_/iA✓doi4 Acill - L�ICC�ut?io.J--YY',,tjcs- G✓177�__ u - — Jx po - �s 16/18/95 17:68 C"ERCIAL TESTING + 94373434786 ■ too -a agrox za/xt eS:sj 56/evoi Pa emt Pwi.a by Wtdht xxcl 8 is r 0 C r c _ P 9 P F r �d. §1 � I& •!enseaa!Ae 8V7d9&.L V1ISV'7! NQ We QE -BL -OT r �d. §1 � 8V7d9&.L V1ISV'7! NQ We QE -BL -OT f[�� <� rE' I PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE \Q m DEPARTMENT OF HEALTH AND HUMAN SERVICES 'Q As P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT NUMBER:SW950338 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:RANDALL BRUCE A & TINKA OWNER ADDRESS:12140 CANGE ST ANCHORAGE, AK 99516 PARCEL ID:01528210 LEGAL DESCRIPTION: BOYLE BLK 2 LT 3B LOT SIZE: 46200 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: Q11 Pptl6u.Y 01wn. (UPGRADE) PEP41T FIL7EQ bANp a Trym- 16hel'Er DATE ISSUED:10/12/95 EXPIRATION DATE:10/12/96 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: SEE 47714,C#t140 RECEIVED BY: V ISSUED BY CT&E Environmental Services'nc�=. L�Y4-E 95.4648 All 200 —-,m.-J07.562.2343 Anchorage. AK 99518.1605 Fax: 907-561-5301 VBGS .boas..aawSGS G� (Sm"G4.Ww4.aw.va,rc,) DATE: `D IZ QJ DATE: /0112-//5'� �(�Iills i:4S- SI7c ViS"r 'S•.W.4PAU.a• �> FIITEz iv1A7'(- —Loo Kt QuFS74C.IAA4 S.:N•PL.F 6) 7A*fry 3� SA Vlli�S Ti4i—r_-n1 awe g u1 7�n T� 1h(f F, kc M.A. CN /v�I9�r Special Provisions Bottomless Sand Filter 1. Attached material specifications and contruction guidelines (except for the filter size, perimeter framing and liner) must be adhered to. 2. Air compressor pump must be located in an area or enclosure such that cold ambient air is not injected into the filter. 3. Installation of the sand filter between October 15 and April 15, or any time ambient temperature is less than 400 F, must be started and completed on the same day or the site must be tented and heated to prevent freezing. IV. MATERIAL SPECIFICATIONS A. ISF Package The primary filter liner, pressure lines, flushing piping and valve, pump basin, pumps and associated timers, switches and alarms shall be obtained from OSI or a supplier of their products. For Anchorage, the basic 18' z 20' ISF with PVC liner is specified. In addition to the filter package, the OSI linear air diffuser is required, with a suitable air pump. 1. Liner - OSI Model 11 or equivalent. 30 mil PVC cut and fabricated to provide water tight enclosure of filter sand volume. Seams to be permanent as per Manufacturer's recommendations. All connections, such as boot flanges, through sand filter to be permanently bonded to the liner. 2. Manifold Assembly - OSI Model SFM 1036 or equivalent with orifice shields and flushing assembly. All drilled holes to be cleaned of burn and pipes flushed prior to assembly. 3. Pump Basin, if required - Sand filter pump basin is to be OSI Model PBSF1561FI with flow inducer and matching 15 inch diameter riser sections as needed to extend 12 inches above finish grade maintaining a water tight seal through the full length of conduit riser. PVC splice box to be installed with a conduit seal kit. 4. Filter Secondary Pump (if required) - OSI Model 20 OSI 05 FIIiF' with appropriate float assembly and high pressure discharge assembly. 5. Linear Air Diffuser - Available at OSI, no model number available. B. Electrical Required timing and control devices shall be those supplied by OSI for use with their sand filter package. All necessary conduits, buried electrical wires, connections, and switches shall meet National Electrical Code specifications and be listed by Underwriters Laboratories or a similar agency. Connections to existing electrical service must be designed and fabricated by a licensed electrician. C. Air Pump The air compressor and pump shall be a Thomas Industries, Inc. model No. 5070 linear air pump, or equal product Fittings must be air tight and capable of withstanding a 20 psi maximum. Operating pressure is three to five prig delivering 2.4-1.6 cubic feet per minute. A port for measuring line pressure utilizing a'standard low range air gauge is recommended. D. Piping Gravity drain pipe shall be four inch (40) diameter ASTM 3034 PVC or MOA approved equal product. Pressure piping shall be schedule 40 PVC conforming to ASTM D-2241 or polyethylene pipe shall conform to ASTM D-2239-74 at 160 psi. Air diffuser line shall be three quarter inch 11 (3/4") HDPE as supplied by OSI. Arctic air line, external to the filter shall consist of minimum R-4 dual wall HDPE constructed with urethane foam, three quarter inch (3/4") HDPE with one inch (1") foam pipe insulation jackets and four inch (4") PVC outer shell, or an approved alternate. All pipe shall have two inch (2") insulation, two feet (2') wide over areas which have less than four feet (4') of soil cover. Additional insulation may be warranted under driving surfaces or snow -cleared areas. Fittings for all piping shall conform to industry standards and manufacturer's recommendations. E. Bedding Materials Materials used for bedding below the spring line of pipes shall be MASS Class "B" material or equivalent. This material need not meet the stringent standards of the filter sand. Material used for fill over the springline shall be free of large stones or large inorganic materials, and shall be placed in a thawed condition. F. Pea Gravel Locally available, washed three eighths inch (3/8") round pea gravel is suitable for use in the ISF. Material must have 100% passing the three eighths inch (3/8") sieve, and must have less than 20 percent (20 %) passing the one quarter inch (1/4") sieve, and less than one percent (1 %) passing the #8 sieve. One quarter inch (1/40) pea gravel with round particles and less than one percent. (1 %) passing the #8 sieve is an approved substitute, if available. `G ISF Sand Currently, the only approved source of ISF filter sand is Central Paving Product's "Winter Road Sand" available at the Palmer yard. Substitutes must have less than two percent (2 %) passing the 4100 sieve, less than one percent (1%) passing the #200, and have 100 percent (100%) passing the #4 sieve. A coefficient of uniformity Cus4 is recommended. H. Round Rock Washed, three quarter inch (3/40) to one and one half inch (1-1/21) septic rock with no fines present will be adequate. This material is utilized to segregate the pea gravel from the one quarter inch (1/4") slots in the four inch (4") underdrain. Rock is piled around and two inches (2") over the four inch (4") pipe. •L Insulation Two inch (2") thick extruded polystyrene foam with a +35 psi direct burial rating. 12 J. Filter Fabric OSI product LIFF or an alternate product meeting the following specifications: Minimum 80 pound tensile strength (ASTM -D-4632) and minimum 2.5 per second permittivity rating (ASTM - D -4491). IC. Tank for Lift Systems 1. Septic tank should be a two compartment steel tank specifically for the use of OSI for their patented lift station assembly Model 4200. 2. The tanks shall be designed for soil loading conditions as required by Municipal and State regulations. The design or analysis shall be in accordance with accepted engineering practice and local regulatory agencies. 3. All welding shall be in accordance with applicable codes and standards. 4. An additional second compartment outlet riser shall be 12 gauge sheet steel, and shall extend 12 inches (120) minimum, above surface grade, shall have a minimum nominal diameter of 24 inches (24"), and shall be capable of being equipped with the following: a. A junction (Nema 4x) box or equal, bonded and attached to the riser. b. UL listed electrical cord grips, installed in the 1 -box. 5. A lid shall be furnished with the riser. It shall be constructed of fiberglass or equivalent aggregate finish. Meet H-10 loading requirements and have a secure latching mechanism. 6. Riser installation - each riser shall be sealed or welded to the top of the tank in such a manner as to prevent infiltration of groundwater. 7. Insulation - four inches (4") of rigid extruded polystyrene shall be placed in the riser directly below and attached to the lid. 8. Insulation - two inches (2') sprayed shop applied urethane on circumference of riser with 46465 Tnemec coating. L. Effluent Pumping Assembly 1. Effluent pumping assembly shall be OSI Model 20-OSI-05-HHF series consisting of the following: a. 1/2 HP 110 volt or equal UL listed effluent pump. b. Screened pump vault (US patent No.4439323) 59 inches (59") deep, three sixteenths inch (3/16") thick high density PVC cylinder houses the pump, level controls and screen and serves as a baffle to prevent the screen from clogging. C. All piping shall be PVC or other non -corroding material. 2. Pump controls and alarm system - control shall be OSI SICTETMRO or SSFICTETMROIRO, as appropriate, 110 volt with the following options: a. Event counter. b. Elapsed time meter. 13 C. Program timer. d. 10 watt heater. C. Remote alarm panel option with a minimum of 80 DB sound pressure at 24 inches (24"), operating temperature -30AC to 65AC, continuous sound to be located in the home. f. Oil tight visual alarm with push -to -silence feature. Automatic audio alarm reset. g. 15 amp motor rated toggle switch, double pole, double throw with three positions; manual (man), automatic (auto), and center (off) (HOA). h. Nema 4x rated, fiberglass, or equal, enclosure with hinged cover. M. Substitutions The Department will consider substitute materials if adequate product information is supplied to the On -Site Services program manager. 14 V. CONSTRUCTION GUIDELINES A. Lift Station 1. Excavate to proper depth to allow gravity flow from residence and drainback from the sand filter, install tank level, tolerance 0.01 foot (0.01'), on undisturbed earth or classified NFS fill material compacted to 95 percent (95 %). Line tank excavation walls with two inches (2') +35 psi burial foam full depth of tank. Backfill between tank and foam insulation with sand material and compact, in a manner to prevent damage -to the .tank surface coating. 2. After inspection, create a level sand surface over the tank and add two inches (2') burial foam +35 psi directly over the tank Mound unclassified soil over tank location to a depth of two feet (2') above finish grade to allow positive drainage away from the tank and counteract buoyancy, if applicable. 3. Excavate to level of tank inlet and outlet installing inlet and outlet piping properly bedded on undisturbed or compacted fill material. Pressure effluent line is recommended to be one and one quarter inch (1-1/4') ID pipe installed with positive dminback to tank. Material for the line may be HDPE or Schedule 40 PVC. 4. All connections to be as per MOA-DHHS and UPC requirements, PVC 3034 piping with caulder or equivalent couplings for inlet riser pipes. All tank connections are to be completely water tight. B. Sand Filter A 19 feet by 21 fees (19' x 21') arra is staked out utilizing reference stakes around the perimeter of the excavation: 1. Verifya necessary for gravity flow to the leachfield portion if not utilizing a pump basin. Determine the elevation of the sand filter bottom and reference to a bench mark. 2. Excavate sand filter area to proper depth, plus two inches (2"). Place two inches (2") of leveling material in bottom of sand filter) If a pump basin will be included, excavate the depression. Hand level to a uniform surface, level ± one half inch (1/2"). Smooth transition from floor to pump basin depression and radius basin edges with tamped, wet sand. The sand provides a smooth, stone free surface for the liner to contact 3. Construct and install perimeter framing support walls to specified dimensions. If the filter is buried, the support frame is constructed of untreated two by four inch (2' x 4') dimensional lumber and one half inch (12") plywood. Strength requirement is dependent on filter size and soil backfill characteristics. Temporary bracing is recommended until backfill is completed. Ensure no nails or staple points can contact the PVC liner. Install two inches (2") of 35 psi rigid polystyrene insulation over interior plywood perimeter walls, fastening to wood with construction adhesive. 4. The 30 mil PVC liner is unfolded from the anter of the excavation and stretched over the top edges of the support flame. Ensure that the liner is in full contact with the bottom and sides and that no bridging occurs. Note: Installation of remainder of sand filter interior materials should be accomplished during warin ambient temperature (+400), and should is be completed within one day. If this is not possible, the excavation must be covered to prevent the intrusion of leaves or other contaminants. If temperatures are below 400, the excavation should be tented and heated at night. Stockpiled materials must be kept covered. Under no circumstances should frozen soil materials be placed within the filter. Remove all debris such as leaves and sticks from the filter. 5. Place underdrain and pump basin in prepared area if required (pressure system). Basin must be placed with a bottom cap installed to prevent damage to liner. Install boot flange and seal to underdrain pipe, if underdrain penetrates perimeter (gravity system). Use manufacturer's recommended method for bonding PVC liner and sealing to four inch (4") underdrain. Underdrain is installed with slots facing up. Provide and cover stub -out for later connection to leachfield, if a gravity system. 6. Install additional boot flanges and pipe stub -ins to interior of filter at correct elevation. Install boot flanges for pressure inlet, air line, and any other required transitions. Relieve perimeter insulation at pipe transition areas. 7. Place layer of washed three quarter to one and one half inch (3/4" to 1-1/2") septic round rock around and two inches (2") over the underdrain to prevent pea gravel and finer material from entering slots. Remaining sand and gravel elevations are now marked on interior walls of the liner before adding materials. 8. Place six inches (6") of pea gravel. Level ± one half inch (0.5"). Place fill around outside perimeter of framing as necessary to avoid 'blow-out" of the framing sidewalls. 9. Place six inches (6") filter sand. Level to ± one half inch (0.5'). Place fill around, outside perimeter of filter as necessary. 10. Place air diffuser line. Penetrate and seal to previously installed boot flange. Lay air diffuser line in a concentric spiral with approximately one foot (1') separation between passes. Use sand piles to hold the position of the air line. Seal end of the air line with a brass compression fitting. 11. Place remainder of twenty-four inch (24") total filter sand layer. Sand is placed damp to allow for compaction. Wet sand if necessary and place in six inch (6") lifts, do not mechanically compact. Level sand surface with six foot (6') carpenters level and a straight edge. Place monitor tubes on sand surface. Place fill around perimeter framing during filling to help support the frame shape. 12. Place two inches (2') of pea gravel over top of sand to support distribution system. Install pressure lines, manifold, and flush valves. Connect to pressure effluent line from septic tank through boot flange. 13. Fill septic tank with clean water and conduct pressure test. Verify minimum squirt height of four feet (4') and check for leaks in pressure piping. Verify trickle hole in tank end of pressure line allows drain back of pressure line 14. Install snap on orifice shields, and cover piping with remaining three inches (3") of pea gravel. Level to one half inch (0S"). 15. Extend six inch (6") monitor tubes, latmal cleanouts and valve boxes, and add pump basin riser, if necessary. All risen shall extend above finished grade. Install two inch (2') 35 psi burial foam insulation and standpipe coven before placing fill. Cover insulation with approved filter fabric material, relieved to fit monitors and standpipes. Hand fit gaskets made of filter fabric around standpipe penetrations to provide an effective silt barrier. 16 Install two inch (2") 35 psi burial foam in sump riser lid. Attach with construction adhesive. 16. Place unclassified fill over sand filter utilizing excavator. Do not drive on or over filter bed with machinery or vehicles. Establish rough grading. Install gravity or pressure line to leachfield, if applicable. Complete connection and pressure test line before backfilling. 17. Install three inches (3') topsoil and establish finish grade. Fertilize and seed. C. Leachfield Install leachfield using the same materials, techniques and tolerances required for conventional leaching systems. Reference AMC Code 15.65. D. Electrical The electrical portion must be installed and inspected by a locally licensed electrician. It is recommended that electrical service work be coordinated in advance to allow testing of the controls and electrical panel during the squirt test. The electrician shall be responsible for obtaining the proper inspections and a copy of the inspection report shall be submitted to the MOA with the system asbuilts. 17 o PROPERTY OWNER AGREEMENT FOR THE MAINTENANCE OF AN ON-SITE WASTENVATER DISPOSAL SYSTEM This agreement, dated (�) G 7' / 199 S , is made between the Municipality of Anchorage Dc .t tment of Health and Fluman Seoices (DHHS) and the pro erty owner(s) of: /:./4GdatP 1'i'L / i3�%y U:6 LZi,r)7ei• Cir This agreement is made for the purpose of maintaining an on-site wastewater disposal system on the subject property. The pruperty owners agree to the fullowing: Allow the Municipality of Anchorage the perpetual right �f entry to the property during normal working hours, to allow for effluent sampling or evaluating the general state of repair or function of the system. Submit to the ,Municipality of Anchorage, on an annual basis, an inspection and operation statement from a registered professional engineer. This inspection and operation statement shall verify that the engineer has inspected all effluent and air pumps, timers, and alarms, and that any deficiencies have been repaired and that the system is functioning as designed. (Signature) (Printed Name) STATE OF ALA g )tarize -lere) I�t4 h INOTARY PU IN I BETTY J. (Signature) (Printed Name) �. P-StJacC. Qpayed p��ere_ &i u t JJ� Sys Q k- �.rrnm. T.SPURKLAND P.E. 203 W. 15th. AVE. SUITE 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 Municipality of Anchorage Division of Environmental Health Department of Health and Social Services 820 I Street Anchorage, Alaska 99501 Subject: Up grade permit Lot 3B Block 2 Boyle 12140 Cange Street Randy Randall Gentlemen; October 1, 1995 During an HAA inspection the septic system on this lot was tested and failed. A thorough soil investigation showed that a conventional system could not be installed without encroaching on protective well radii. A holding tank or a "Orenco" type intermittent sand filter were the only practical options. A sandfilter can be installed as shown on the siteplan. It is possible that the existing leach field will be encroached during the excavation of the filter. If so, all "contaminated" soil will be replaced with Lake Otis Gravel and buried on site. Tobben urkland P.E. z yo m W N LU d uz LLJ 8 tY 1T.S PURR LAM P.E. 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907)279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN Groundwater at 12 ft Percolation rate more than 60 minutes per inch in two of four testholes Use bottomless sandfilter in vicinity of testholcs 2 and 4 ercolation rate 1 minute per inc Use 4 gallons per sq. Ft. per day Required Area per Bedroom: 150/4 = 37.5 sq.ft.. No. Of Bedrooms 3 Total area required: 37.5 x 3 = 112.5 sq. ft. Sandfilter bottom area: 15 x 25 = 375 sq. Ft The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. pg• 1 7 ••�S i 49th n BEI! SPURKLAND Nn [F -?PAS . 50 0 50 100 150 200 250 300 SCALE: P = 100 FT, ITOBBEN SPURKLAND P.E. I I LOT 3B BLOCK 2 BOYLE SID I I SEPTIC SYSTEM DESIGN I 203 W 15TH. AVENUE DATE: SEPT. 30, 1995 ANCH. AK. 99501 RANDY RANDALL 1,,,,.1 12140 CANDf STREET SHEET: 1/3 GRID: 2734 I' I , I I III I I I Q W CLASS C I I I I I 411 411 III I I 12 411 W I I I S 5tS DOWN I I STABLE DOOR / I I I INSTALL 15 X 25 SANOFILIfR I I FAILED TRENCH 411 ®l/ 411 14 I I I I I I RfAlOVf 1000 GAL TANK INSTALL 1250 GAL STEP III —© III I I I I 1 V '••• OF T081) N SPURKLAND I I SIC -,;p% No. CE -2225 ll 4, I I I d ••♦������FESS.����' I I I I I 25 0 25 50 75 100 125 SCALE; 1' = 50 FT. I I I I I I I : — — -... 3- TOBBEN SPURKLAND P.E. SEPTIC SYSTEM DESIGN 203 W 15TH. AVENUE LOT 3B BLOCK 2 f10YLE SID ANCH. AK. 99501 RANDY RANDALL DATE: SEPT. 30, 1995 --- .— 12140 CANGE STREET SHEET: 213 GRID: 2734 From STEP 1/8' holes every 2 feet top and bottom of airline 1/8' holes at all to. points of airline 6' Hollpipe 83034, 6' Long ��--J/4' PVC, Holes Pointing Up TOP VIEW Laterol and Ortifite Shield Air Supply + 6 in7Th,s I 3 FEET OF COVER SIDE VIEW 4' MONITOR Mirofl Texti T 15 {c 49th IP SPURKLAND No. EE -2225 PR FESS 3/4' Washed Rock 6 inches CENTRAL PAVING ROAD SAND 24 inches BENCH MARK TOBBEN SPURKLAND P.E. 15x25 SAND FILTER SEPTIC SYSTEM DESIGN 203 W 15TH. AVENUEDATE: SEPT. 30, 1995 ANCH. AK. 99501 LOT JB BLOCK 2 BOYLE SID _. RANOYRANDALL SHEET: 313 GRID: 2734 Municipality ofAnchora9 e • v PalitY ....... DEPARTMENT OF HEALTH 8 HUMAN SERVICES �, ..... ..... 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST ! °`: To' :cn $pvrk'ond �• CE -2225 PERFORMED FOR: t�OtM_ dE-tn 1�CL," •eE[.Ci( DATE PERFORM&. 1 `-cC�Cs LEGAL DESCRIPTION: Lo�3 B �.2 �C_�//L._ Township, Range, Section: 1 2 3 4 5 6 7 a 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS ;able 1: 7 PLAN WAS GROUND WATER ENCOUNTERED? b S IF YES, AT WHAT L O DEPTH? P E Depth to Water Alter Monitoring? Date: ���-7 Mwmm } ,zV PERCOLATION RATE (minutesnnch) PERC HOLE DIAMETER TEST RUN BETWEEN FTAND FT PERFORMED BY: I 7 I r -17 t> CERTIFY THAT THIS /TESTWAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE - `'''n r ` A-, r �}' I J 72-008 (Rev. 4185) 5 (t. PERFORMED LEGAL DESCRIPTION: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, At chorage, Alaska 99502-0650 SOILS LOG —• PERCOLATION TEST (-{- s . (J 2 3- 4 4 ML 5 1 ailT 6- 78 7- a .. 9 16 1)v� 17 Sat 18- 19 20 COMMENTS Township, WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth a water After e Monitoring? ( Q 0, - A yid (ENGINEER'S SEAL)'vf7 ' „iP+:• CL -2225 • ,'�.y l,w Pq ^-rrvtll��•�-`� _DATE PERFORMED: q %•J Section: SITE PLAN ■■■■■■■■■■ • ■■■■■■■■■■ Reading Date Gross Not h Time Time Depth to Water AL Y1s4�4; ,g3 7t 12 12q \ y V lip • 3n o ✓ � � 14t 13- 3 s Yo o s' 14 14 s / 3 / 15 16 1)v� 17 Sat 18- 19 20 COMMENTS Township, WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth a water After e Monitoring? ( Q 0, - A yid (ENGINEER'S SEAL)'vf7 ' „iP+:• CL -2225 • ,'�.y l,w Pq ^-rrvtll��•�-`� _DATE PERFORMED: q %•J Section: SITE PLAN ■■■■■■■■■■ • ■■■■■■■■■■ Reading Date Gross Not h Time Time Depth to Water Net Drop ,g3 7t • 3n ' v CEO s Yo o s' -3 V / 3 / PERCOLATION RATE (m:nutevmch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT PERFORMED BY: �_ J 1 7 —, _�, CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: �J If vs - 72 -008 (Rev. 4/115) L Ate; •(ENGINEER'S SEAL) Municipality of Anchorage a' ; i DEPARTMENT OF HEALTH & HUMAN SERVICES..� f .. A 825 "L" Street, Anchorage. Alaska 99502-0650 4 v� 1 • °' `, o,k!ond \ N •• CE -2225 �• SOILS LOG — PERCOLATION TEST 4rel) . ........•'�b�' . j% PERFORMED FOR:. /1LQ GATE PERFORMED: T� J LEGAL DESCRIPTION:_ LA 3 O �ieIe. Township, Range, Section: r SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS pCt d. t4 }{L WASGROUND WATER ENCOUNTERED] IF YES, AT WHAT DErTH7 0ept11 lo Water Atter Monitoring] Reading I Of PERCOLATION RATE TES' RUN.BETWEEN mu ■■■■■■■■■IN Gross Time (minutevmch) PERC HOLE DIAMETER FT AND FT PERFORMED BY: r, S I r i CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: - �l ox - 72 -008 (Rev. 4/85) 0 T44 14y �E °F..�'.L�]r'!� Munlcl;,allty of Anchorage ►; DEPARTMENT OF HEALTH & HUMAN SERVICES !i'� a Toot Spvrkland ••� 825 •L" Street, Anchorage, Alaska 99502-0650 d SOILS LOG — PERCOLATION TEST �Qt f`n •.. cEsns . ••�`!% PERFORMED FOR: E LEGAL DESCRIPTION: ko, so fJoy / /so,. F; iII 9; 2Sq.4. y 3 i-( L 4- 5- 5 s • ,• /f h i K4 6 ' S? 7- 8- K K DATE PERFORMED: I� ?, Range, Section: SLOPE SITE PLAN / � r 10 30 +•wr O�IY Ok WASGROUNDWATER ENCOUNTERED? 11 S IF YES, AT WHAT L DEPTH? 0 12 P E 13 DepthMonit toWarr AAe� Monitorinp7 —ty4— Date: ALY9+_ 14- 15- 16- 17- 18- 19- 20- COMMENTS a151s17181920 COMMENTS PERCOLATION RATE (mmutevinM) P RC HOLE DIAMETER [4STAUN BETWEEN F1 AND FT 6'14 ALL a ciraiNtQ�tt7 LjuZ" 30. ec- 8x PERFORMED BY: - 7 S _ I _ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE:+ l99 72-008 (Rev. 4/85) T.SPURKLAND P.E. 203 W15TIL AVE. SUITE 203 ANCHORAGE, ALASKA 99501 SPECIFICATIONS FOR SEPTIC SYSTEM INSTALLATION LOT 3B BLOCK 2 BOYLE S/D RANDY RANDALL 1.0 GENERAL 1.1 Owner is B.A. (Randy) Randall, 3340 Arctic Blvd. N 201, Anchorage, Alaska 99503 1.2 Engineer is the person or entity hired by the Owner to inspect this project. The Engineer must be recognized by the Municipality of Anchorage, Department of Health and Human Services. 1.3 Contractor is the person or entity hired by the Owner to install this project. The Contractor must be recognized by the Municipality of Anchorage, Department of Health and human Services. 1.4 The Drawings, sheets 1 through 3, shall be pan of this specification. 1.5 All materials and workmanship shall meet the requirements of the Municipality of Anchorage, Department of Flealth and Human Services, the conditions of the permit, and all applicable rules and regulations currently in effect. 1.6 All excavation depths are advisory, and are to be verified and may be modified in the field by the Engineer. 1.7 It is the responsibility of the Owner or the Contractor to adhere to the approved design, to verify that the specified separation distances are met, and that the required inspections are performed. The Department of Health and Human Services shall be notified at least two (2) hours in advance of each inspection. Notify DIISS by calling 3434744. 1.8 The Contractor or the Owner shall report to the Engineer any observed condition which would put the septic system in violation of State or Municipal regulations. 2.0 SEPTIC TANK 2.1 If there is an existing septic tank, it may be used if it meets the capacity requirement for the residence. The tank shall be inspected by the Engineer, and its water tightness and structural integrity shall be verified. 2.2 A new septic tank shall be one fabricated by either Anchorage Tank and Welding or by Greer Tank The septic tank shall be a UPC -approved two-compartment tank, constructed of 12 gauge, or better, steel with bitu- mastic coating. The tank shall be set level on undisturbed soil. The tank shall be covered with the equivalent of four feet of soil. 2.3 The septic tank shall be installed a minimum of five feet from the house foundation and a minimum of five feet from the absorption area. Specifications for septic system installation Lot 3B, Block 2, Boyle SID p6 t ce; 100 feet rom 2.4 l be a um Of 100 feet from any any body f water, creeks orldrainage ditches with flowing water, 150 feet from ClasssC" wets rand 200 feetfrom Class A or Class B wells. 2.5 All pipe connections to the tank shall be mechanical watertight couplings. Cleanouts shall be installed as designated and capped with air -tight rain caps. Cleanouts shall extend a minimum of 12 inches above final ground elevation. Provisions shall be made for landscaping and importation if topsoil. 2.6 Lift station shall be as manufactured by Anchorage Tank and Welding Effluent Pump shall be OSI Model 20 -OSI -05-1111F Control Panel shall be OSI Simplex control panel with Elapsed Time Meter, Counter, Programmable Timer, and Intrinsically Safe Control Relay. Air Compressor shall be Thomas Industries Linear Compressor Model 5070. Air line shall be IIDPE coiled conduit. 3.0 SAND FILTER 3.1 Gravel shall be 3/8" washed pea gravel. 3.2 Sand shall be Central Paving Road sand with less than 4 % passing the # 100 sieve, and less than 2 % passing the #200 sieve. 3.3 Pressure distribution pipe shall be Schedule 40 PVC or ABS. 3.4 Solid 4 -inch pipe shall be ASTM D3034. 3.5 Monitor standpipes shall be installed as shown. That section of the pipe penetrating the gravel shall be perforated, either by drilling 0.5" holes on 6 -inch centers or by joining a section of F810 perforated pile to a solid section of pipe. 3.6 Geotextile shall be Miraft 140. 3.7 Insulation shall be extruded direct burial polystyrene. Dow Chemical Styrofoam 11140. 3.8 Topsoil shall be a mixture of 40-60% organic matter, 20.30% sand and more that 20% silt. All quantities are measured by volume. 3.9 Grass seed shall be Kentucky bluegrass. 4.0 INSTALLATION 4.1 Locate all underground utilities, property lines, future driveways, existing or proposed water wells, water ways, surface and sub surface drainage facilities, lakes, ponds, and all other facilities requiring separation distances from the proposed septic system. Notify Owner or Engineer of any observed possible conflict. 4.2 Stake alignment of system with markers showing the protective distances from wells and water bodies. Specifications for septic system Installation Lot 3B, Block 2, Boyle 5/D pg.2 4.3 Establish an elevation benchmark. This BM shall be easily identifiable, stable and permanent. An arbitrary elevation of 100 can be assigned. 4.4 Install the tank as shown on the drawings. Record the inlet and outlet elevations of the tank. Tank shall be placed on undisturbed native soil. 4.5 Excavate the absorption field. Bottom of excavation shall be level and scarified.. Record elevation of each comer and center point of bed. Construction equipment shall not operate on the floor of the excavation. Any material compacted by the operation of the construction equipment shall removed and replaced with uncompacted materials. Any material contaminated by the existing drainfield shall be removed and replaced with "Lake Otis Gravel" 4.6 Place the sand to the depth specified. Do not contaminate sand with native materials or spoils from the excavation. Level the sand surface (+_ 1") before placing the pea gravel. Level the pea gravel before installing the perforated pipe. 4.7 Solvent weld the joints. 4.8 Cover the distribution pipe with pea gravel , and cover the excavation with geotextile before backfilling and placing insulation, if required. 4.9 Record the finish ground elevation at each comer and at the midpoint of the bed. 4.10 Furnish a copy of all survey notes to the Engineer. 5.0 INSPECTIONS 5.1 A minimum of five inspections are required. The first inspection will be to lay out the installation with the proper separation distances from the adjoining well$. The second inspection will be of the open excavation. At this time the soil conditions will be observed and compared to the design assumptions. Ground water conditions or presence of bedrock will �e verified. The third inspection will be after the placement of the air distribution piping, the fourth inspection after placement of pea gravel and effluent distribution piping, standpipes, tank(s) and other components as specified. A final inspection will be conducted after placement of topsoil and cleanup. Any deficiencies will be noted and the Contractor notified. Such deficiencies shall be egrrected within ten days. 5.2 All electrical work requires either an MOA electrical inspection or certification by an licensed electrician. Submit proof of inspection or certification to the Engineer. 5.3 Submit catalog data of all mechanical equipment. 5.4 Notify Engineer at least 24 hours in advance of beginning any work. Sr,cJr,- ti.ms for KN" r+-re^e �nsr:Yr.4r., La 73. P!,4 _', Fio.tc $.'17 3 it.3 \ (^I MUNICIPALITY OF ANCHORAGE 77 ^ 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 VSNEW c ' („ C�,•,Cj p%i[._��5� (� I -ET E_.� ❑ UPGRADE MAILING ADDRESS t 3$6.0 0 M ooPl TLoAD LEGAL DESCRIPTION Z d LOCATION NO. OF BEDROOMS Qtq = 3 Well DISTANCE TO: 0 Absorption area Dwelling NOT PERMIT NO. p U Y IN �,PQ, �6 P Q Manufacturera a Maters a _ No. of compartment O W F Liq. capac is o ns IF HOMEMADE: Inside length Width Liquid depth 6Y DISTANCE TO: Well Dwelling PERMIT NO. 02 2? F Manufacturer Material Liquid capacity in gallons O DISTANCE TO: Well n 12 y Foundation (/V101 Nearest lot linePERMIT NO. E3:20/65 W = OT � M E No. of lines Length of each line Total length I lines Trench width Distance between lines F ? ui �� �j P inches H Top tile to finish Material beneath tileTotal of grade effective a so sign area Length Width Depth PERMIT NO. W l7 Q F Type of crib Crib diameter Crib depth Total effective absorption area Wd w DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. J W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS CAST Fir- 2 F SOIL TEST RATING INSTALLER REMARKS YoLb E&A�.l� _ r �- I .D Q i tin I t � OF A ••.. .. �G9� .............. . .... e; 2225-E NE -42 1971 X41 APPROVED DATE LEGAL fair -se, svQ, 73oyL.� 72-0131Rev. 3178) , rl Ul r -a I c I F=• F1 L_ I T Y I -D F Fi r -a C H r7l F- FI C3 E_ DEPARTMENT r, HEALTH AND ENVIRONMENTAL '30TECTION 825 STREET, ANCHORAGE, AY,. 95.j1 f• 264-4720 .tklE=LL F rAn C r4—SITE S= EIJEF? F'EFKPl I T PERMIT NO. ( 820165 ) APPLICANT MICHELSOHN & DAUGHTER C 3360 OLD MULDOON RD 333-4264 LOCATION CANGE LEGAL L36 B2 BOYLE LOT SIZE 44400 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING CSO FT/ER)= 245 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: G�EPTH= 11 LEr•aGTH= Ci F= F14'EL LIEF TH= r THE LENGTH DIMENSION IS THE LENGTH CIN 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 CIM 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 CIN FEET). Ft E=CALJ I F?EE> SEF?T I CT TFir4F< S I ZIE= 1C+C+Ci C3FIILLCDt45 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. --- IFL4Ci K :12 ? I r4 coF"EC IF I C3r45 FiF?E F?EG!lJ I FZEOE> --- 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 WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO R 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 WELL COMPLETION. OTHER, REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F1EFQ?l I T E=XF' I FREnno E>EnC E=tlE E=F2 wl1L r 15?E323 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. I UNDERSTAND THAT VE ON-� SELJER SYSTEM MAY REQUIRE ENLARGEMENT IF THE PESIDY P.EMODELED TO IN UDE MOPE THAN 3 BEDROOMS. SIGNED:-- - - - ------------ R PLICAFJT IICHELSOHN _jHTER CONST ((� ISSUED BY_ l.t/1�4� ____ •_DATE__1��3� Z V4.0 SOILS LOG � MUNICIPALITY OF ANCHORAGE �, • .r I DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION K PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST p PERFORMED FOR: BRUCE �RfaN DA LL S DATE PERFORMED: �' �' Z LEGAL DESCRI PTION: Lo 1T3IF� BLoc,K 2 'BOYL L= SlD r-1 _ SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9 10 it 12 13 14 15 16 17 ML SIL:1 ,49w IPmAS GROUND WATER S •••e• • ••• •.ENCOUNTERED? C) L O ••••.••••••••.. P 0. 2225-E �,�,,IF YES,ATWHAT E JUNE 25, 1971 'DEPTH? NU 25 3971E 20'1 . , . _.:% •V� PERFORMED 4o LE Reading Date Grost Time Net Time Depth to Water Net Drop 1.3•tL 1 u 30 lb C)' Rtvo be 30 �Z'/ / t i9 D 0 O 3. I'Lo So /04 e r 41: so 211) 3o Iq 1 5:0C 9 -yo 3d 20 1 1 - PERCOLATION RATE 5 D (minutes/inch) TEST UN BE EEN h FT D 7 FT I CERTIFIED BY: DATE: 3' 3' if 2— O to O R to 3 b O m n 9 O O 7 R W n 0 H r r m A H r tp co N W i•v W :d T ;z O t+ r pY a :? G :r r :N 7 p n i > 7 -.7 T "f '+1 't7 T 41 ^1 A A A A A A A A A A A A Z n o O O o O O 3 O $ $ p 3 3 K r V[ N; t� , � O i QS : N i J= O OiW t Ot = Oi i W i t = i i i i .ai ?••ss11 i ;�t7 i^� i•� i i••+i�� i i��t7•� ;•r� ii O O O O O O O O O O O O S : i i 04 t ::lm: N:to + J" W: (7,: n:J N i r i E of aim i i i i i ? i t 1 i s i int + its i i•rrf1 41 iei.�� �te1� �•�t ty / µ Rt Ri m :a i a: a;R ;n s i i t to N: N w: w: 1Cn i ri Yo to in p. i i i i e n: n t n i L1 i t n t • t i s w: t (: wt d' n M: (D t d+ w t (D 0 r r so r r m 0 n b —• •tf A -s �t A A -n m A A n �+ n A A A �n •n A A A 'n A 0 00 3 3 3 S 3 si _ t i °•r� i : t •e� •� y •+� O O O O O O O O O O O O i i i • � Is i t s + i i Q �� � y y �•1 � '•t y �•1 �� i i i i i it • is �i ,= i Is Is Is Is •y0 "N*Nd ; � t •. i s t 1 3 t i s 1 + t + i = i Iti- _ _ i t r tp co N W i•v W :d T ;z O t+ r pY a :? G :r r :N 7 p n i > > K r � z t = y Municipality of Anchorage -- Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel l.D. O ts- B2- Ib 1. GENERAL INFORMATION HAA# O__� OZ�� Expiration Date: 9- !' - O 3 Complete legal description t-oT 3B BoYLE BK 21 Location (site address or directions) 12.140 c -q N G E Current Property owner(s) G. -c g Varr. l: Day phone 3Y5 -4.7z7 Mailing address Mao c-«- Je Lending agency Day phone Mailing address Real Estate Agent My.tia t3a-ow„ tom. V. Day phone 2L411- gel 77 , Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 'z _ 3. TYPE OF WATER SUPPLY:, TYPE OF WASTEWATER DISPOSAL: Individual Well Q Individual On-site 1z Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 Health Authority 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 __ 6be.� Address aO3 U2/ Engineer's Printed Name 't obboK 3pJKbclo<.�o� S. DSD SIGNATURE _J� Approved for �3_ bedrooms. Disapproved. Phone o't74-341h Conditional approval for bedrooms, with the following stipulations: Additional Comments Municipal Codes. Note: The well for this property meets existing State and There are nitrates present. It is suggested that periodic testing be per orme ,to insure the wells continued su-Eability. Current nitrate concentration is 6.07 mg/1. EPA maximum concentration is 10.0 mg/1. More infor— mation on nitrates is available from the On—Site Services Program, at 343-7904. Attachments: HAA Checklist X Septic System Advisory X_ Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: - ZA1v Original Certificate Date:_ (Rom. oim) Municipality of Anchorage •� • "' Development Services Department ° Building Safety Division ' On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT 38 8k:- aC->qLE S6-> Parcel ID: 015~ 28;.- to A. WELL DATA well" R If A, B, or C provide PWSID d Well Log (Y/N) �Ic tj Date completed14 g Sanitary seal (YIN) Total depth _? 74 ft. Cased to lift. FROM WELL LOG Date of test 3/Z 4/i 1 Static water level 3? R Well production 1,!!:, 9•P•m• Wires properly protected (Y/N) Casing height (above ground) aLl n. AT INSPECTION S- 2.1-'t73 39 ft. g.p.m. WATER SAM������////P,,,,LE RESULTS: Coliform colonies/100 ml. Nitrate 6.01 mg.A. Other bacteria _ colonies/100 ml. Arsenic: _ mg.A. Date of sample: APA Collected by: urV B. SEPTIC/HOLDING TANK DATA Tank Type/MaterialS 1 E t� S f^ LL Date installed t b �4� 4S Tank size 12 3o gal. Number of Compartments Cleanouts (YIN) ?� Foundation cleanout (Y/N) Depression over tank (Y/N) N_ High water alarm (Y/N)_ Dateoft umping 5��b�03 Pumper Aut b _ �es5_ p/ C. ABS�fljMON FIELD DATA Date instiItCd tc I - Soil rating (g.p.d.Alz oaA!Mdrm) _Y_ System type a cJ Length iZ o R Width '2a R Gravel below pipe 5 ft. Total depth �_ ft. Eff. absorption area Ilfy6 ft= Monitoring tube Depression over field Date of adequacy test / ? r o D Results (Pass/Fail) � For ,L bedrooms Fluid depth in absorption field before test-- in. Water added 500 gal. New depth in. Elapsed Time: -min. Final fluid depth i . Absorption rate >= 4160 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N &type) 1�'I If yes, give date '� D. LIFT STATION Date installed to I m't I 4.S Sae in gallons 12 So Manhole/Access (YIN) _ Y 'Pump on' level at 3&, in. 'Pump off" level at Vii. in. High water alarm level at in. Datum Bm, t' . nA 3" ke.� Cycles tested 10 "t Meets alarm & circuit requirements? _ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 12 t) On adjacent lots Absorption field on lot %X& On adjacent lots 1004 JM >+ Public sewer main NIA Public sewer manhole/cleanout N/A Sewer /septic service line &25+ Holding tank rf/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation I-1 Property line 7 a Absorption field i b Water main N /A Water service line 25 Surface water N D Wells on adjacent lots '71" SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 20 Building foundation 1-0 Water main N/A Water Service line A-5 t Surface water N 10 Driveway, parkingrvelude storage `10 t Curtain drain N 1 o F. COMMENTS G. ENGINEER'S CERTIFICATION Wells on adjacent lots 1Bo '{ I cert/fy that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. �I Engineer's Printed Name l o b 6,L,4 S a u +k a K aC Date Ma.,,'a_I 1003 r HAA Fee $ [_ Waiver Fee $ Date of Payment 6 3 Date of Payment Receipt Number 36, y d Receipt Number (Rev. 12/01) George P. IVuerch, Mayor Anchorage Municipality of Anchorage All -America City Buiklitlg Safety DiN ision 111110, IIII' 2002 From: Jeffrey W. Poet On-site Water and Wastewater Program 4700 South Bragaw Street Anchorage, Alaska 99519 Date June 9, 2003 To: (The buyer) of Boyle Lot 3B Block 2 Re: Septic System Advisory At the time of construction, municipal inspectors discovered "Conflicting Sieve Analyses" regarding the sand used in the system. They questioned the backfill And compacting around the septic tank and also stated that the required 2" was Replaced by 1 %i' insulation. This septic system does not have final construction Approved by the municipality. Due to these issues, municipal inspectors did not sign the final engineering as -built For the septic system; however, since the system has been in operation since 1995 And a professional engineer has tested and approved the system; it is receiving a Health Authority Approval. JefTrcy W. Poet Engineer Technician P.O. Box 196050 • Anchorage, Alaska 99519-GG50 • Telephone: (907) 343-8301 • Fax: M7) 343.8200 4700 South Bragaw Strcet • Anchorage, Alaska 99.507 1ittp://i%�%�v.ci.nncliorngc.alc.us Jun me.:42a e . 0 s & 7 � «,4;9. 3 CO.2C.CO. .------------- ——----—--------- � �(§\ !@ : \\ \ ! ° I r > }; 2 / o g r m r @ j B $ )�r > ) e ! © } § k | §;— } | r& I [At ; I | 1 /tt >I ! !i- - | .syr ,.30.00. } |� |L t e / f "•|| 15. ® . C&N E STREET �\7� �■ �� JUN -03-2003 TUE 11:13 AN FAX N0. P. 03 p. 2 .ti ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT MEMORANDUM OF UNDERSTANDING BETWEEN MUNICIPALITY OF ANCHORAGE ANDj21CL&avn ,,1 c r THIS t MEMORANDUM Op UNDERSTANDING made and entered into as of this —Thcy °f—i.1(dL�Q� 2003 , by and between I�Q(C F 8►q�yQ� �'� a„ C t7, herein the S� "OWNER," and the Municipality of Anchorage, herein the ,MUNICIPALITY.,, In consideration of the mutual covenants contained herein, the parties to this Memorandum of Understanding agree as follows: I. ADVANCED WASTEWATER TREATMENT SYSTEMS. Municipality grants permission to Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as I t=.s located at Lo j $k2 BoyL�= Anchorage, Alaska. 2. Definition$. A. Alteration. Any change to the design or function of an AWWTS that includes the installation or removal of any parts, components or pieces not included in the original construction permit and design. Prior to performing any alterations to on AWWTS the owner must obtain a Wastewater Disposal System Construction Permit from the Municipality pursuant to Anchorage Municipal Code (hereinafter, `•AMC") 15.65 13. Certificate of Ott-Stte Systems Approval. An approval by the Municipality of existing water and wastewater disposal systems given at the time of property sale and title transfer in accordance with AMC Page 1 of 5 10 '.4 2109 94Z L04 0mv1xvn4s 1 NV £[CTT rear-re-Nnr JUN -03-2003 TUE 11:13 AM "�" "`' �� • a a moa FAX N0. P. 04 p.3 15.65. These approvals certify that the Systcros are adequate for the homes that they Support and meet the codes that were in place at the time of system construction. C. Damage. Any man-made or natural change in a system that would inhibit the system from performing as designed. D. Maioteaance and Repair. The scheduled and as needed replacement of existing parts, components and pieces of an AWWTS that were included in the original design which would allow the AWWTS to continue to perform as designed. E. Permit (Construction). An On -Site Wastewater Disposal System Construction Permit as defined by AMC 15.65. F. Permit (Operating). An Advanced Wastewater Treatment System Operating Permit. An annual permit, issued by the Municipality, that allows the Owner to operate an AWWTS, upon meeting all requirements of this agreement, the conditions of the Operating Permit, the requirements of the On -Site Wastewater System Construction Permit and all relevant provisions of AMC 15.65. 3. Fee. Owner shall pay to Municipality an annual fee of (5.00), payable on or before the issuance of the operating permit and annually thereafter. The annual fee is due on or before the anniversary date of the approval by the Municipality of Installed system. page 2 of 5 £B •d £T09 922 106 QNtf'7MMrldS 1 W" 0t•:01 , £00Z—E0—Nfll' a 5 JU_N-03-2003 TUE 11:13 AM FAX N0, P. 05 w •• .� -a i 1 :90A JUN70E-200$ 1014T AM T SPURKLAND r � 907 276 601'S4 r .Pum 4. Term. The term of this Memorandum of Understanding shall be for the life of the AWWTS. The term begins on the date of approval by the Municipality of the installed system and shall continue while the AWWTS system is in use or operational or until the property is sold or title is transferred by owner and a new certificate of on site approval is issued to the new owner or transferee of the property. S. Alterations, Installation and Removal of Additional Equipment. Owner agrees not to make any alterations, removal of parts or additions to the AWWTS without a Construction Permit from the Municipality. 6. Maintenance and Repairs. A. Throughout the term of this Memorandum of Understanding, the Owner shall maintain AWWTS in good repair. In addition, it shall be the responsibility of the Owner during the term of this Memorandum of Understanding, and any extensions or renewals thereof, at the owner's sole expense, to pay for any and all: (1) repair(s), (2) maintenance, (3) adjustment(s), (4) replacement costs, and (5) inspection costs. Further, owner agrees to. comply with all applicable ordinances, laws, regulations, rules and orders for the AWWTS. B. Owner agrees to provide the Municipality a written schedule of routine maintenance and repairs which have been performed on the system pursuant to the terms and conditions contained in the Owner's AWWTS Operating Permit. This schedule shall be submitted to the Municipality annually upon the renewal of the permit. The schedule of maintenance and repair contained in the Owner's AWWTS Operating Permit is: Page 3 of 5 JUN -03-2003 TUE 11:13 AM . FAX N0. P. 06 ... V. vo t t : eaa C. Owner acknowledges that the fine schedule for failing to maintain and repair an AWWTS are codified in AMC 14.60. D. Owner agrees that only maintenance, repair personnel certified by the Municipality will inspect and make any necessary maintenance, repairs or permitted alterations to the systems. E. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS upon 24 hours written notice. F. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. G. Owner agrees that the relevant provisions of the standard specification guidebook for AWWTS is the governing professional guidelines for the construction, maintenance and repair of the Owner's AWWTS. 7. Nonwalver. The failure of either parry at any time to enforce a provision of this Memorandum of Understanding shall in no way constitute a waiver of the provisions, nor in any way affect the validity of this Memorandum of Understanding or any part hereof, or the right of such party thereafter to enforce each and every provision hereof. S. Amendment. A. This Memorandum of Understanding shall only be amended, modified or changed by a writing, executed by authorized representatives of the parties, with the same formality as this Memorandum of Understanding was executed and such writing shall be attached to this Memorandum of Understanding as an amendment. Ze-d 2709 94Z d06 Paee 4 of 5 P•S a N"iAbnds 1 Ntl 6P.:0T Veez-re-Nnr JUN -03-2003 TUE 11:14 AM vaa FAX N0. p 07 a•••. e... zea aa: JUH-0S-2003 10147 AM T SPURK4ANDG • i 907 276 Sala P ye 8. For the purposes of any amendment modification or change to the terms and conditions of this contract, the only authorized representatives of the parties are: Owner Ma rr F. &a"Sasa"I er BrR ✓d Anchorage: Purchasing Officer C• Any attempt to amend, modify, or change this contract by either an unauthorized representative or unauthorized means shall be void. 9. Jurisdiction: Choice of Law. Any civil action arising from this Memorandum of Understanding shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Memorandum of Understanding. 10. Stverablllty. Any provisions of this Memorandum of Understanding decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Memorandum of Understanding. OWNER: By: Date lltIL%?/7 -3 STATE OF ALASKA THIRD JUDICIAL DISTRICT MUNICIPALITY: By: Title: Date: ss. The foregoing instrument was acknowledged before me thisday of Mnrc a�n heS rte+oHIci iA Municipality of Anchorage. Page $ of s by JUN -03-2003 TUE 11:14 AM FAX N0. P. 08 :run us uj S S : 49a p.7 My Commission expires: 7S',, n \O '»cj 0.teMM1ASSIGNM ENrAAACode Addmdom AMC 15.6! Ven oe ndoc Pagc 6 of S 10'd 2101 94Z 406 G"WIlllnde 1 W!f 61:01 £00Z-^s0-Nnf MUNICIPALITY OF ANCHORAGE ' DEPARTMENT OF HEALTH d HUMAN SERVICES Division of Environmental Services On Site Services Section go P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 1. GENERAL INFORMATION HAA A A Af\ L1 -1 Q Complete legal description L O i 313 Bi4 2 I -)-/LC SIC> Location (site address or directions) IQ 4 D Cly K U E S Property owner 7R0_t't0 -a0t � r v C me_ Day phone -4Z 2 - 00 / l Mailing address (ot-1 L1 t) CO- H-cl Lending agency Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water -3,q 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 1 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. 724250t*v. 1/71 F, MOA 011 I= IJ W W tY 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 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 �' �O "1 S R V f `4-X F Phone �-_7q Address ;fin .2, 'Z" Engineer's signature j Date. 6. DHHS SIGNATURE K Approved for bedrooms. Disapproved. Conditional approval for Additional Commei State and Mun .; suggested tha continued sui maximum cnnce 10/2319 5 bedrooms, with the following stipulations: Note: The well for this property meets t(JQ1 <.Vl1cJ• 11.c1c v •• •. ... .. .. t.r a periodic testing be performed to i bili,tnv. Nitrate concentration is 7. Date *1 z7/ 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. Tian M.. M) 9.0. ..wa 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: I.o4 3Q, gia�i T3e�lo S%a Parcel 1.D.: O I J — Z8 ,'( -1 L A. WELL DATA Well type F_ If A. B. or C. attach ADEC letter. ADEC water system number K/A Log present (YM) N Date completed _ 1961 11 Total depth � � � Cased to i 7 t-'` Casing height (above ground) Sanitary seal (Y/ Wires properly protected (YM) _ FROM WELL LOG Date of Test Static water level Well production WATER SAMPLE RESULTS: g.p.m. AT INSPECTION 9¢/1314 z a Coliform Nitrate ' Other bacteria 9 l2r4"L..l b 'b/9+' Date of sample: 9I 3�g5 Collected by: ! -s . a W a > N W I.- V (_) W C, gx IL SEPTIC/HOLDING TANK DATA Date installed _ 1 0/ I 14 Tank size I.Z. 50 Number of Compartments _- Cleanouts (YM) _-�/_ Foundation cleanout (YIN) Depression (Y/N) _� High water alarm (YM) V Date of Pumping _ n2A Pumper K1f A C. ABSORMON FIELD DATA 't� fJ(( 1 0 Wt I., ffs S Date installed 10118-11- Soil rating SAN10 FI L- E2 (g.p.d./fl' or e/bdrm) _ LA System type R. S I— t 1 Length Width _UI Gravel thickness below pipe (ol l Total depth & 1 Effective absorption area �tlt�O Monitoring Tube present(Y/N)* Depression over field (YIN) N Date of adequacy test N1A Results (Pass/Fail) For3 bedrooms / Fluid depth in absorption field before test (in.):r, /mmediately ager_ 0. wat (in.): v /er added Fluid depth V (ins.) Minutes later: ✓ Absorption rate = _ v g.p.d. Peroxide treatment (past 12 months) (Y" NO if yes, give date tl D. LIFT STATION Date installed Manhole/Access (Y/N) 11 Sire in gallons /;_ 6 0 "Pump on- level at" q2- "Pomp off• level at- Ll 0 I High water alarm level at' 1 � .*Datum 14 ter+ Cycles tested 77 E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot I .2 O 1 On adjacent lou iso Absorption field on lot On adjacent las t610 Public sewer main ��iQr Public sewer manholdcleanout '�//A / 1 Sewer /septic service line Lift station j OZO SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation / 7 Property line 1. 5 Absorption field 5 Water main/scrvice line t Surf= water/drainage N O Wells on adjacent lou '�!J t SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: I t Building foundation Water mam/service line i 0 Jf01 Surface water 1`I � 0 Driveway, parking/vehicle storage area "7 ,t 1 / Curtain drain N 117 Wells on adjacent lou (] Property line _ F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal reeorxft that thr above systems pre in conformance with A104 R14 guidelines in effect on this date. iy Signature r . Engmeer s Name I ob H �p u r K `� K tiX �- t� '•;Lp Se 14kre; Date Otr1 �.Ji IR t `�.:; CL. •gid •`r 1 HAA Fee S 3W Waiver Fee S _ Date of Pavaxm 3— 9s Date of Payment Receipt Number 11. 3% Receipt Number Rev. 9195 OSS: haa.wk.doc • APPLK�VT FILLS OUT UPPER HAI 'ONLY" Property Owner �2r �C�/�f.��� •� K(�1—T1`d,&A7-- Phone Mailing Address Zip Code - 7cP_ $S Byerlg, A )e/9A-)D/9/-L Date Address 1 lei/ Zip Code ,5 C- 7 a — S S,31 - Lending Institution r 3 A Inspector Phone Address "Tc' Zip Code Realty Co. d Agent Phone Address Zip Code (x) APPROVED BEDROOMS .3 Legal Descrfpfl. ,-3,8 a6 D t/ p *CONDITIONS OF APPROVAL ( ) DISAPPROVED Street Location (1,,,� ( ) CONDITIONAL APPROVAL' Type of Residence DA C�S`ingle Family t BYe ❑ Multiple Family No. of Bedrooms Soils Rating ❑ Other Well To Absorption Area Water Supply CiLffidlvldual 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 fog If available). ❑ Public Utility Sewer Disposal individual Year Individual Installed: ❑ Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Dile Date Date Inspector Inspector ZDate Inspector Field Notes: �"`. /) /f - • - _ „ n a,,., /1 3 (x) APPROVED BEDROOMS .3 *CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DA t BYe Soils Rating Data Sewer Installed Well To Absorption Area Well Log Received Septic Tank Size 7 —gZ Well to Tank nm1 a"