HomeMy WebLinkAboutDEBORA #2 BLK E LT 12ipso 041 2OR 0oa
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL
PROTECTION
ENVIRONMENTAL ENGINEERING
DIVISION
825 L Street - Anchorage, Alaska 99501
Telephone 264-4720
/
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE'11NCW
i z
—=m ,_ 0&br5�
❑UPGRADE
MAILING ADDRES Cle
Oy 25t le
LEGAL DESCRIPTION
Z
LOCATION
NO. OF BEDROOMS
F it—f
3
DISTANCE TO:
Well
Absorption Brea
G j'-
Dwelling /
�Z
PEH �u}
Manufacturer
Maters
No. of compartments
1
F�0�
L, D city itallons
!/C/IF
HOMEMADE:DISTANCE
Inside length
Width
Liquid depth
TO:
Well
Dwelling
PERMIT NO.
Material
Liquid in
Manufacturer
capacity gallons
O
Well /
Foundation / j•
ZS
Nearest lot line /
Z '�'
PEft�u� y�
1
W =
DISTANCE TO:
/as-
/
� u. W
No. of lines
Length of er.:I neta
Total lenyjlj 1+=s
Tren wvidtly
Distance between lines
F _ w
G ZZ..
inches
Top
erialpeneathj
Total effective an area
-P
of tile to inish gradei_Ma
5-/
{le
p
e% ��rt,
inches
e"e"
Length
Width
Depth
PERMIT NO.
W
QF-
Type of crib
Crib di er
Crib depth
Total effective absorption
area
Wa
W
y
Well
Building foundation
Nearest lot line
"
DISTANCE TO:
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
"iDISTANCE
T0:
Building f and i i
Sewer line
Septic tank
Absorption areas)
OTHER
PIPE MATERIALS
cT tovc
SOIL TEST RATING r c
INSTALLER
REMARKS
at
d
I
�
:..,.
••i �r
S
ass f. K�
-I.. -Sha
� v.'•• No. 1457•E .' .tom t
4 Op9C.......... .... 11
ori,
APPHO D DATE
cLEGAL
72-01Y(R�. 31781 /
hi u r-4 I C I Fr^'�L_ I T Y iQ F F -i r-4 c" '' F=i G E
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PNuIECTION
825 'L' STREET, ANCHORAGE, AY. 99501
264-4720
CAtJ—S} ITE no En L4 EFT F•EFZOl I T
PERMIT NO. C 790103 >
APPLICANT JOE SENTER CONTRACTING SR BOX 147A E.R. 694-9932
LOCATION ELENORA
LEGAL L12 B-E DEBORA #2 LOT SIZE 9768 SQUARE FEET
TYPE OF SOIL ABSORSTION SYSTEM IS: TRENCH
MAXIMUM NUMBER. OF BEDROOMS = 3 SOIL RATING (SO FT/BR,)= 85
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
E?EF='Tvi= fLCA L_Er4UTH= 2'2 C3FQA':rEL GtiEF'TH= .=
THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR, DR,AINFIELD.
THE DEPTH OF A TRENCH OR.. PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION CIH 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).
F:ECAu I Ft`EE?. SEPTIC TAtJF� S I �E= 1CnC_iEy GALLCA
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.
--- T44A 4 Z� ] I rA"aF'ECT I CAv4to ARE F= ECRL F I F= Eo E> ---
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.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F>E=FZP1 I T E}4 F' I FEE'S C�ECEIrl E:EFR 2�1r 1 E�+?S;l
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 IH ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT THE ON—SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE Qj ODELED TO INCLUDE MORE THAN 3 BEDROOMS.
SIGNED:--- — ----------------
AP'LICANT JOE SENTER CONTRACTING
ISSUED BY____�_
L_ ________—DATE__ _ 7� __ V3.2
/ ✓17�u< � �l�/c�t.ti`�f ���1 l �J ti /) `^'�'i � � �iL1--Q.:�
0 & E GEOr:CHNICAL & DEVEL MENT CO.
Box 90, Davis St., Eagle River, Alaska M77
694.2774 or 688-2280
Russell Oyster Earl E//is
6942774 SOIL LOG 688.2280
Sods Er Foundations Land Developmant
Performed for: Name: Tel. No.
Mailing Address:
Legal Description:
Depth (feet) Soil Characteristics
0
1
z
3
4
5
6
7
8
9
10
11
12
13
Ground Water Encountered: Yes No If yes# what depth
Proposed Installation: Seepage Pit Drain Field
Comments
Performed by: �% -' Date:
HORAGr
C�� fifirdBrilling �i N JTI_ I .A`S L710N
by
A & L DRILLING COMPANY h`"AY 3 1 1979
BOX 97, EAGLE RIVER, ALASKA 99577 • TELEPHONE 694-2569 RECEIVED
OWNER OF LAND .SEN r t -C
ADDRESS
LEGAL DESCRIPTION Z /,-� 174K E D LE6,<o,? Sj4
DATE -Started i = 0Ended a
PERMIT NUMBER 7 40 O / of
KIND OF FORMATION:
From /l Ft. to I Ft. O u6p Ru An r N From Ft. to Ft
From I Ft. to -j Ft. �n c & r .F#4.y oo From Ft. to Ft
From t Ft. to ^? S Ft. S"ANO ( IC IQ Jc < J/5- 14 %From Ft, to Ft
From 2 S Ft. to 32 Ft. c�G 0'9 ' +F �49✓E4- From Ft. to Ft
From `D Ff. tof—Ff. fA'yJV %Rpf< ?'4/4TFoniFLto Ft
From
f !/
DEPTH OF WELL
4 S
Ft. to
Ft
STATIC LEVEL OF
WATER FT. =75
FI
/
DRAW DOWN FT.
7
From
Ft. to
GALS. PER HR
From
Ft. to
Ft.
KIND OF CASING
H
From /l Ft. to I Ft. O u6p Ru An r N From Ft. to Ft
From I Ft. to -j Ft. �n c & r .F#4.y oo From Ft. to Ft
From t Ft. to ^? S Ft. S"ANO ( IC IQ Jc < J/5- 14 %From Ft, to Ft
From 2 S Ft. to 32 Ft. c�G 0'9 ' +F �49✓E4- From Ft. to Ft
From `D Ff. tof—Ff. fA'yJV %Rpf< ?'4/4TFoniFLto Ft
From
Ft. to
Ft
From.
Ft. to
Ft
From
Ft. to
FI
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
FI. to
Ft.
From
Ft. to
Ft.
From Ft. to Ft.
MISCL. INFORMATION:
From
Fl. to
Ft.
From
Fl. 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'SNAMC
MU" I C I PAL_ I TY OF ArJCHnRAGE
4% .. DEPARTMENT O-"'EALTH AND ENVIRONMENTAL F ~TECTION
825 'C• STREET, ANCHORAGE, At'. 99501
264-4720
LJELL_ PERMIT
PERMIT NO. < 790012 )
APPLICAtIT SULLIVAN LEE BOY, 197 EAGLE RIVER 628 2543
LOCATION ELLENNOR ST
LEGAL L 12 B E DEBRA SUB LOT SIZE 9801 SQUARE FEET
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.
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.
PERMIT EXP I RES DECEME3EFZ 31, 1S?7'9
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 WILLnINSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
SIGN
ICAt4,T SULLIVAN LEE
ISSUED BY�I`__n^_1__�Lc���``____DRTE_1,���� V3. 2
e
(00041,
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date (O — "Z
I. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lo -r /z BLX 6E ) DG-P.�,e_A
Location (address of directions)
(b) Applicant Name Pihr»01-17H Jur' -Telephone: Home till' -2z3 L Business
Applicant Address r . U. t5 OX ' 1' I t ' t V &_4 1 'Lf±g t4! 'n
(c) Applicant is (check one): Lending Institution ❑ ; Owner/buildey$%Buyer ❑ ; Other ❑ (explain); -
(d) Lending Institution Telephone
Address
(e) Real Estate Company andAgent
Address C� L-6— r'�
Telephone
(f) MaTtthrVtAA to the following address:
2. TYPE OF RESIDENCE
Single -Family Multi -Family ❑ Other
Number of Bedrooms
3. WATER SUPPLY
Individual Well 0- Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite c�_ Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the Stale Department of Environmental Conservation
attesting to the legality and status.
Page I of 2 r2-025(11.84)
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH. DATA AND INFORMATION
As certified by my seal affixed hereto and as of thevalidation date shown below, I verily that myinvestigation of this Heafth
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 Telephone
SRO 94GX
Address "' K r:ttr"t, At AEKA—Z-=
PH. 694-297J
Date
6. DHEP APPRO� '
Approved for bedrooms by
Approved DisapprovConditions k�-
Terms of Conditional Approval
CAUTION
b,wi A. Sher
tw. lu7-e
Date jl l
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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVUI( kW Ty OF AN04011 iE
CHECKLIST - FEBRUARY 1984 DEPT. OF HEALTH &
264-4720 ENVIRONMENTAL PROTECTION
Legal Description: __L::0Nknl
A. WELL DATA RECEIVED
Q
Well Classification �� If A, B, C, D.E.C. Approved (Y/N) ~TN
Well Log Present&) Date Completed (��1i %� Yield •
Total Depth Ai 15 r Cased to 1 41 5 Depth of Grouting
Static Water Level ? — Pump Set At 01K
ti
Casing Height Above Ground Sanitary Seal on CasingCftN)
Electrical Wiring in ConduitON)
Depression Around Wellhead (YO
Separation Distances from Well:
r 1
To Septic/Holding Tank on Lot On Adjoining Lots ( nC> At—
To Nearest Edge of Absorption Field on Lot Ito : On Adjoining Lots
To Nearest Public Sewer Line a A To Nearest Public Sewer f
Cleanout/Manhole To Nearest Sewer Service Line on Lot
Water Sample Collected by s 5 ��" t� E-ILI^L ; Date (c'^
Water Sample Test Results`>��`
Comments sjgL
QP-pt7Jc.g,� I►.3 CSC_f✓�s oJ' - 5 CyPAA
SEPTIC/M6LDINGIANK DATA
Date Installed (0-5-29 Size ) Cnf21� No. of Compartments Z
StandpipeC5 N) Air -tight Caps (SN) 1 Foundation Cleanout (Y
Depression over Tank (1p Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) —;for
for
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from SepticLWek4o@-Yank:
, r
To Water -Supply Well (pa To Building Foundation (Z
r �
To Property Line ('� '� To Disposal Field S
To Water Mem/ServiFe Line To Stream, Pond, Lake, or Major Drainage
Course N ��
Comments
Page 1 of 2
722026(111r84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata I56L� Type of System Design TRFa+ X_,Il
Date Installed 901
Length of Field 2-Z'
Width of Field �� 4 Depth of Field 4�r
Gravel Bed Thickness
Square Feet of Absorption Area �"�� Standpipes Present)
Depression over Field (YINP Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well 477 IF To Property Line 1'ta
To Building Foundation
Lot
To Water falai"/Service Line
To Existing or Abandoned System on
On Adjoining Lots ez; '14
t� To Cutbank (if present) rJ P
To Stream/Pond/Lake/or Major Drainage Course /P
To Driveway, Parking Area, or Vehicle Storage Area 5-bI d,
Comments
D. LIFT STATION
Date Installed -
Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Ofl" Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
•• Check Permitted Bedroom Rating Against HAA Request ••
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date J-
0 06 C
s
Comparyt1 SRU 196X MOA No. 0O
Receipt No. PH. 674-2370 r34�q
Date of Payment 25::>
Amount: $
Page 2 of 2
72-026 (11,84/
- APPLIC"NT FILLS OUT UPPER HAL',ONLY
Time
Property Ownar FO.0 ke57—�/ 711;le6 //vbr/ &-00
Phone
Ma ling Address j fl.c.%T L( C( A' C /%/7_ —. P� Zip Code
``�
Buyer /J�-1 N D04-F0ff /%% `/ ///dL+ �JJON'tXr"
Address -:2 I7 U/ 0 L: 1-112 Z/ /Oc, /f 4 ` Zip Code
Lending Instltutlonw�//� /i5 `I C_ / I -/L �
Phone
Address . /l/l�. -f7NE/Iy LTS 1/ e /I Z I p Coda
Date
Realty Co. d Agent Epe) /tool/ Ae6WZ-ry - /-//(.t
Phone
LLt /J-A-7
Address , UJ O / /�_ Zip Code /�� f
Legal Description i9 13024 /,z 1V .2 .L 07 4Z 0 L -
Street Location E/. F qJ /% _ - it
Type of Residence
0-19�ingle
Family
❑ Multiple Family No. of Bedroom
Inspector
❑ Other
Inspector
Water Supply
CL-W5v1dual
ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975.
❑ Community -
For wells drilled prior to that date, glve well depth (attach log
If available).
❑ Public Utility
RAGE
Sewer Disposal
Cl-�dlvidual Year Individual Installed:
❑ Public Utility When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
G
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector ((��
RAGE
Field Notes:
DFeT C` 1.n".T T.
y
::.ri 2 G`e:�83
RECEIVED
( L4 -APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
DATE
BY:
Solis Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
a
Well to Tank f Ili-
Septic Tank Size
"W3 nM
5. LEGAL DESCRIPTION
4
DATE RECEIVED
s INSPECTION APPOINTMENTS
4�
�_ >✓6 r
TIME
TIME
TIME
DATE
DATE
DATE
❑ One ❑ Four ❑ Other
n
1 -
INSPECTOR
INSPECTOR
INSPECT
7. WATER SU LY
INDIVIDUAL'
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT"ICIPALITY OF ANCHORAGE
825 LStreet- Anchorage, Alaska 99501 DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
1
ENVIRONMENTAL SANITATION DIVISION
\ AUG 2 8 1981
Telephone 2644720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEW REMITTED
DIRECTIONS: Complete all parts on page t. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER
PHONE
G
MAI LING ADDRESS QQ''
�Ul54 9, Qt
PROPE TY RESIDENT Ilf different from bove)/�
HONE
v E P C uC --
2. SU ER
(O
MAILING ADDRESS
'/gII/�U U /uP✓
3. LE ING INSTITUTION
PHONE
MAILING ADDRESS
4. RE O /AGENT
PHONE
_
01 -es- i
MAILINGADDR S
Ix r
5. LEGAL DESCRIPTION
4
.y./ '1
+Y
4�
�_ >✓6 r
STREE LOCATION
6. TYPE OF RESIDENCE
NUMBER OF+BEDROOMS
❑ One ❑ Four ❑ Other
rw SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
Three ❑ Six
7. WATER SU LY
INDIVIDUAL'
*ATTACH WELL LOG. A well tog 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
r/
Ai
INDIVIDUAL/ON-SITE"
%J YEAR ON-SITE SYSTEM WAS INSTALLED.-
❑ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
710(R". 6/79)
1.
_ THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
0' SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
PINDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
7
INSTALLER
,..o
peptic Tank or ❑ Holding Tank
/Size: IO a O If Tank is homemade
dimensions:
SOILS RATING -
TYPEgive
TYPE OF TAN
G
MANUFACTURER
TOTAL ABSORPTION AREA ¢
ti
MATERIAL
4. DISTANCESSeplic/Holding
W ELL T0:
Tank
Absorption Area
w
Seer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
A!5 DISAPPROVED
DATE/ 0— t. _
i0- 6 -EZ
BY
tetAl
72010 (Rev. 6/79)
� r
' Municipality
of
Anchorage
n (11G.V6C)-i-7-&/
825 "L" STREET Obb
ANCHORAGE, ALASKA 99501 /)(
(907) 2644111 �y �yJLows
GLOfiGE hl. SULLIVAN.
MAYOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
September 1, 1981
Brian Baldwin
8 Cheryl L. Curtis
Realty Center
8301 Arctic Boulevard
Anchorage, Alaska 99502
Subject: Lot 12 Block E Debora Subdivision #2
Approval for the individual sewer and water facilities
cannot be granted until the following items have been
completed:
( )� A well log needs to be submitted to this office
for our files and review.
(2) The water analysis report needs to be submitted to
J��this office from the Chem Lab, 5633 B Street, for
Our review,
.(3) The well seal on the well needs to be tightened so
thatit is water tight.
(4) sed electrical wires to the well head are in
iolation of the Municipality of Anchorage codes and
must be encased in conduit.
(5) The septic tank pumped with a receipt submitted to
is office.
please this office for a re -inspection when the
noted descrepancies have been corrected. If there are
any further questions, please call this office at 264-4720.
Sincerely,
James S. Roberts
Associate Environmental Specialist
JSR/ljW
-eL';
nnr-noel ITV
i
5. LEGAL PESCRIPTION
MUNICIPALITY OF ANCHORAGE
DEPT. Ui 1..`� •�
ENy130NV.ENTAL U-3;[CTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
826 L Street • Anchorage, Alaska 99601
J U N 211979
C(*))
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 2644720
RECEIVED
❑ One ❑ Four ❑ Other
❑ Two ❑ Five
REQUEST
FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Plane allow ten (101 Ueys for proeeseirg.
I. PROP
INDIVIDUAL'
*ATTACH WELL LOG. A well log is required for all wells drilled
/1�(
❑ COMMUNITY
HONE
❑ PUBLIC UTILITY
e
IL SEWAGE DISPOSAL SYSTEM
"
7
z -
MAILING ADDRESS
If system is over two (2) years old an adequacy test is required
If
PROPERTY RESIDENT (If different from above)
by this Department.
PHONE
2. BU
PHONE
MAILING ADDRESS
3. LENDING JPSTITUTION
PHONE
MAILING RESS
/
eNS6N
!3/✓ ii
4. LT
'PHONE
7 l5 - eA",
ING ADDRESS
r ✓ n`
i
5. LEGAL PESCRIPTION
ZA /
STREET
/CATION
w
6. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
SINGLE FAMILY
❑ One ❑ Four ❑ Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
Three ❑ Six
7. WAT'ZUPPLY
INDIVIDUAL'
*ATTACH WELL LOG. A well log is required for all wells drilled
/1�(
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
IL SEWAGE DISPOSAL SYSTEM
"
7
1n INDIVIDUAL/ON-SITE"
self individual/on-site, give installation date—//
If system is over two (2) years old an adequacy test is required
If
❑ PUBLIC UTILITY
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
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
PERMITNUMBER
DEPTH OF WELL
DATE DRILLED -
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATEINSTALLED
INSTALLER
SOILS RATING
❑Septic Tank or .01 -folding Tank
Size: /0610 If Tank is homemade
give dimensions:
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELLTO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
b— APPROVED FOR 73 BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
-fl:t-r -� 3 �1
BY (Title)
rQc
LEGAL DESCRIPTION
R-010 !Rev. 3/70