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GRE...cR ANCHORAGE AREA BOA. ,JGH
Department of Environmental Quality
-" 3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME— yY\ �� MAILING ADDRESS Ro,� -1/7 FI?. PHONE 69
LOCATION JA. ,— LEGAL DESCRIPTION _t_oT a' `�I�- �• Z) S
SEPTIC TANK:
DISTANCE NUMBER NUMBER OF
FROM WELL It) d MANUFACTURER " MATERIAL COMPARTMENTS
az_
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPAC ITV °± O GALLONS.
TILE DRAIN FIELD:
TOTAL LENGTH
DISTANCE FROM WELL FOUNDATION �S NEAREST LOT LINE 77 OF LINES
NUMBER OF LINES DISTANCE BETWEEN LINES TRENCH WIDTHJC_ IN. TOTAL EFFECTIVE
ABSORPTION AREA �4_u SQ. FT. LENGTH OF EACH LINE
DEPTH OF FILTER ` r
DEPTH: TOP OF TILE TO FINISH GRADE MATERIAL BENEATH TILE l9
WELL:
TYPE CONSTRUCTION
BUILDING NEAREST NEAREST SEPTIC
FOUNDATION_, LOT LINE , SEWER LINE . TANK_
CESSPOOL . OTHER SOURCES
APPROVED DISAPPROVED REMARKS
DISTANCES:
INSTALLED BY.
SEWER LINE DEPTH
PIPE MATERIAL:
Pl y
g
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LOT SLOPE: —_
REMARKS:
Form EQ -032
IN. ABOVE TILE IN.
H DISTANCE FROM:
SEEPAGE
SYSTEM_
DIAGRAM OF SYSTEM
DATES -�h APPROVED _V_ C
G.A.A.B.
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F'FRHIT NO.
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Lt-EPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
:'25 'L' STREET, ANCHORAGE, AK.
279-2511
�_�r I—_• T_ 'T,F='=•EWER F= -E -A -1 I T
C 77544 )
7 a I-`17 �luuts.
QcP.
AFPLU=ANT I.IRYNF Kt_R4'Ilr•1 BOX 71.7 E. R. 694-2195
I_OF:RTION r'IERr_:'r' Ur-'1VE
I F'G!K- L24 BE DEBORAH SI IED #2 LOT SIZE 11250 SClUAF.'E FEET
TYPE OF SOIL AE:SORBTION SY'STEH IS: TRENCH
I'1 i;IPp-It1 NUMBER.' OF REDF:OOPIS = - SOIL RATING !SO FT/BR, 05
THE F.EOUIRE:' SIZE OF THE SOIL ABSORPTION SYSTEH IS:
F-, F- -r"== =-+ I_ 1= r -•I f- T F F = �� �_ F i'•r' E l_ C• E F� _f_ F r•
THF LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THF DEPTH OF A TRENCH OR FIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
CiT: UND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE PIINIHUq DEPTH OF GRAVEL BETWEEN THE OUTFALL FIFE
AND THE BOTTOM OF THE EXCA4'AT I ON i I N FEET).
I FZ-F-_C• 'E7EF�T I �� Tt tFFF�F< I E= Z4-y� y�=y ��FiLF_fJr J
FFFje1 _2L FiRT l HL Yom! E _ TT r — ---
H F'A.,IiAGE F'1_AtdT PIH'. �L''Er.PiIITE_• �T15Ti _LIE JECT TO THE
FOLLOWING CONDITIONS:
1. EITHER A CLASS I OF: II NSF APPROVED PLANT MAY BE INSTALLED.
2. A CONTINUOUS MAINTENANCE AGREEMENT IS REQUIRED. IF A PIAINTENANCE
AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED TO ENLARGE THE SOIL
ABSORPTION SYSTEPI ANEvOF' YOU NAY BE SUBJECT TO PROSECUTION.
-----------------------------------
--- T1Jr_e •__ :2 > I I ciFd=. t=iF=-E F_ FE G! L-1 I F-- EE C• ---
RRCF::FILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DFPArJMENT WILL BE SUBJECT TO PROSECUTION.
t9ItJIf91-101 DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL OR 2011 FEET FOR A PUBLIC. WELL.
OTHER REOUIREHENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAr9S ARE
h',)AILAFLE TO IN'=URE PROPER INSTALLATION.
F EF< -1 1 I EXE-' I F, --F_ _ G'F-1=:F_r-IE:EF- —::I-
-r
I CERTIFY THAT
I.: I Arg FAPIILIAR WITH THE RE !UIRENENTS FOR ON-SITE SEWERS
FORTH BY THE HUNICIPALITY OF ANCHORAGE.
I WILL IPJSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
_ . I UNDERSTAND THAT THE ON- ,ITE SEWER SYSTEt'1 t1A'i F.'EGiI IIF,'E
PFSIDFNCE IS REHODELED TO IN_.LUDE PIORE THAN - BEDROOML
S I GNFD : ---Cd--- ---- ' ---- ----------------
APPLICAN WAYP t L'..LAYI
27
ISSUED BY -
AND WELLS AS SET
ENLARGEMENT IF THE
V-3. c+
0 Ef E GEO�'-CHNI CAL & DEVEL PMENT CO.
Russell Oyster
6942774
Soils Et Foundations
Box 90, Davis St., Eagle River, Alaska 99577
6942774 or 6882280
SOIL LOG
Earl Ellis
6882280
Land Development
Performed for: Name: VA/AYIlF i<I,AVUPt Tel. No.
Mailing Address: Ve,Y -717 En,I,T- tvrc_ ,lir.. 99`_:77
Legal Description: (" L► E , Lor q , -I-, Er; c `." ue. D.
`2
Depth (feet) Soil Characteristics
z
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5
6
7 GP CL tr4Al ' S171VP Cir It' c
8 G`� LLL S'dtaDF_/ZS '1'd
9 /6 ' r
10
11
12--
13
14
Ground Water Encountered: Yes No If yes, what depth
Proposed Installation: Seepage Pit Drain Field
Comments:
Performed by: Date:
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MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
(e) Leg// - e7 ri;1? J= lu ' r3e))CAlock, suSPj
Application Date
.ision, section, township, range)
Location (address or directions
_ 1
61
(b) Applicants Name!/:/ II��K�G Tele hone — Ho�m-e
Applicants Address
(c) Applicant is (check one) Lending Institution ; Owner/bcilder ;
Buyer [_:j ; Other [_:] (explain);
(d) Lending Institution
Address
S 7
•� ---Jus
(e) Real Estate Co. d Agent
(f)
Address
Telephone
LO
4tsi-i. the HAA to the following address:
s' S-
On I /a ��1� I
2. Type of Residence
Single—Family I.K�l Multi—Family Other (describe)
Number of Bedrooms
3. Water Supply
Individual Well � 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 Public Community Holding Tank
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
(Page 1 of 21
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 oo-ait*'.
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 regula-
tions in effect on the date of this inspection.
Name of Firm $ F. p Telephone
Address Ox•'aLERIVER AE1,LA�K•, 2^S7t zPE 44 I%to
Date
(ENGINEER SEAL) 6L<('..lS
4� A A. Shefiv
/ ;f ••, No. 1457E
6. DHEP Approval ��yPp�'•••.....''�
1 `� �QFES3td.:
O
Approved for bedrooms B l �tA_P.
Approved Disapproved Conditional
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS 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 HONES AND
E
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATREQUIRE
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHO,1AGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
2 of 2] 7-19-84
WE
A. WELL DATA
n
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1994
h, L:NICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIROhI.MENTAL PROTECTION
OCT 2 91084
RECEIVED.
Well Classificati ll % 2 If A, B, cc C, D.E.C. Approved(Y/N)
Well Log Present/ d Date Completed �O f fi/B Y Yiel, s
Total Depth Cased to ell / Depth of Grouting.
Water level /6u� Pump Set At k
Casing Height Above Ground .30 Sanitary Seal on Casi
Electrical Wiring in Condui (rte) Depression Around Wellhea OF
Separation Distances fran
To Ssptic/HeldintQ Tank on Lot 14�0 />< On Adjoining Lots AOo --A
To Nearest Edge of Absorption Field on Lot I/O ; On Adjoining Lots A:�)O
To Nearest Public Sewer Lire /-j /7:4 To Nearest Public Sewer
Cleanout/Manhole
W To Nearest Sewer Service Lire on Lot
'Water Sample Collected By ro -i lheelle, late /o '- 2 S1--bl V
Water Sample Test Results
C" nts bLU eve// 9Vj6 *4" o nes 41 w t..+c 7 -,O's A"0 /a !ems 4
Q L v 2 ti `-Peel
B. SEPTIC/HOLDING TANK ARTA
Date Install -7 7 Size
Standpipes (Y Air -tight Cape.
Depression ;;T
TankDate La
Pump' ing/Maintenanee Con act on File (Y
Holding Tank High -Water Alarm (Y `'r -V-
U No. cf Compartments Z
'4Rf FCurdation learout
lurped ��� y P
�; far
Temporary Holding Tank Permit (Y/N o -
Separation Distances fram Septic/Holdirg Tar -k:
To Water -Supply Wall /0,�) "-4— To Building Foundation 1(,5'
To Property Lina 11/071- To Disposal Field %b /
To Water Main/Service Line 30 �f To Stream, Pord, Lake, or Major Drainage
No J—
Course
Cont, nts
[Page 1 of 21
Pu, VF- 3beo5e
kQNQ. poi., ko I as 11111
C�JMouv} � q 5.06,
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorp ion Strata Type of System Design
Date Installed ? 2-11-77 Length of Field Z 2
Width of Field 3E Depth of Field
Gravel Bed Thickness 2 -
Square
Square Feet of Absorption •eaStandpipes Present (YA�ry
Depression over Field ( Date of Last Adequacy Test /0 2 S W
Results of Last Adequacy "bst S X
Separation Distance from Absorption Field:
To Water -Supply Well zl� To Property Line
To Building Foundation Z � To Existing or Abardotaed System rn
Lot N Ol^T)z On Adjoining Lots /c"n -71r_
To Water Mair,/Service Line Zir -�Z To Cutbark(if present) /C.0 r-/�
To Streaam/Po d/Lake% Major Drainage Couzse AJ 0 r'1 li
To Driveway, Parking Area, cc Vehicle Storage Area ,Sz ( F
Comments o4i J a
tz-
D. LIFT STATICN
Date Installed
Size in Gallons
"j unp Cn" Leve l at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Comments
Dimensions
Manhole/Acs (Y/N)
"Pump off"' C vel at
Pumping Cycles
** Check Permitted Bedroom Rating Against HAA Request **
Test. Meets MOA,
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed 8 & .n Date A)
CompaY•-am RiVE�TI MOA No. �.y I •••4•r I y
RBl/d5/s
N A. Sherr
+ p :•' Ne. 11.57 ! S%�
[Page 2 of 21
84
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- �.- �., Via• .•.1 •��L...r•�i�
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__ � CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907)562 2343 ANCHORAGE INDUSTRIAL'CENTER
T ` : ✓ 5633 8 Street .*,.
Drinking Water -Analysis Report for Total Coliform Bacteria a
TO BE COMPLETED
WATER SYSTEM: Q
Water system Name
Mailing Address
WATER SUPPLIER
(*).Sao h on back
LD. q0.
7
- i Snn - - • . zip Cade
t7tY
SAMPLE DATE:
trio ow Year . ..
SAMPLETYPE:. i,_ �', :- c ;
,tRoutine
❑ Check Sample (for routine sample t ❑Treated Water
with lab rot. no. ,p�ntreated Water
❑ Special Purpose { OR
SAMPLE
NO. LOCATION
2..-
3 I 7 j{ lei
S
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
V
t
Time Collected
Collected ; By ..
TO BE COMPLETED BY LABORATORY
Analysts shows this WaterSAMPLE be:
)S?atisfactory
❑Unsatisfactory.,,' '•... •.' 'i
❑'Sample too long in transit; sample should
Inot be over 30 hours old at examination to
tindicate reliable results. Please send new
jsample via special delivery mail.
Collformlt00rnt
Date Received
t I5�00
Time Received
Analytical Method:'
❑Fermentation Tube ,
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b. Ref No.7 Result' _ Analyst,
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oetaaa" BACTER IOLOG ICAL WATER
a«. tao
Membrane Filler. Direct Count
Verification: LTB
Final Membrane Filter Results T
' Reported By
TNTC = Too Numerous To Coun
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NALYSIS RECORD -
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