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Home My WebLink AboutKNIK HEIGHTS BLK K LT 4K nik Heights Block K Lot 4 #018-232-19 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201389 Work Type: SepticTank Upgrade Tax Code Number: 01823219000 Site Legal Address: Kn,`< He19ht Al k 11K Lof Site Mailing Address: 1:?7 jLtp 66kiAlbY6GgC RA Owner: MOON CLARISSA S Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date Expiration Date �1»enC s awl' :J h 1 Delrn•tIII ell t Lot Size in Sq Ft: Total Bedrooms: 9/16/2020 9/16/2021 ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: Date: Date: 6 M MUNICIPALITYOF ANCHORAGE R U.5 Development Services Department' =7 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 018-232-19 Property owner(s) MARK MOON Day phone Mailinq address 13340 BAINBRIDGE RD, ANCH AK Site address PO BOX 111295 ANCH AK Legal description (Sub'd., Block & Lot) KNIK HEIGHTS BILK K LT 4 Legal description (Township, Range & Section) Lot Size 41,600 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank El Upgrade ❑ x Duplex (D) ❑ Holding Tank ElRenewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 27y Coui 0 Date of Payment: Receipt Number: Permit No. 0S1020138c1 Waiver Fees: Date of Payment: Receipt Number: Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Sept. 15, 2020 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New septic tank permit Legal: KNIK HEIGHTS BLK K LT 4 To Whom it may concern: This is a request for a septic tank permit on the above referenced lot. The tank has collapsed and needs to be replaced ASAP. This tank replacement will not impact any of the neighbors or encroach on any wells, septic or open water issues. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201389, Deb Wockenfuss, 09/16/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201389, Deb Wockenfuss, 09/16/20 �� MUNICIPALITY OF ANCHORAGE �� 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 NEW _�� UPGRADE MAILINGADDRESS LEGAL ?ESCRIPT LOCATION NO. OF BEDROORIS ,kX t) Y E a W / Absorption area/t DISTANCE TO: rp.b �QO r(Q Manufacture /l1 eQ.,/ Dwelling . An Materiae^ — / PERMIT NO L, Qdy 9� No. of compartments 01- Liq. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth fj Y J�2 DISTAN Well Dwelling PERMIT I.%Man io-0 urer Material Li tl capacity in gallons w= DISTANCE TO: Well �(�� Fountlato Nearest lot Ime PERMIT NO. Q' J u- Z F Z w No. of lines Lengtho qqh line S-6 Total length li / Trench wide ,inches Distance bet yv/'�eyyn i s /LJ ' Is m t-- p Top of the to finisg ade ( , Material beneath tile inches inches effectivl(+�s r t area fJ W engtn Width Dept PEHh O. Q h wd Type of crib Crib diameter rib depth Total effective ab prion area y DISTANCE TO: shell Building foundation NZ, Nearest Io se J J Class Depth Driller Distance to lot line PERMIT NO. W r+ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER 9 0 s ' l 1$s PIPE MATER IALST SOIL TEST RATING INSTALLER nV GCJt-� REMARK I a s APPHO E ' I I DATEZEGAL / 72-013 1091,6178) \J MUN I C I Fant- I TV QF Ffr-ICHOFZFI(3IE: ' DEPARTMENTPF HEALTH AND ENVIRONMENTAL KROTECTION 825 '. 'STREET, ANCHORAGE, AK. 95 .1 11l2c 264-4720 v WELL F1N0 C01 r-4 I TE SEIJEFZ F: EFZM I -r PERMIT Ffu. C 800492 ) 6 : IS APPLICANT ROBERT RUNKEL 9021 GRANITE PLACE 344-7720 LOCATION RIDGEWOOD 11-s -L) LEGAL �L4 -BLOCK-K. -KNIK-HE16ATS LOT SIZE 50000 SQUARE FEFT TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS.= 4 SOIL RATING CSO FT/BR)= 210 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: E>EP'TH= S. 5 LENGTH= 1Q5 CiMFFl V I -EL- D•EF}TH= 4 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 CIN 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). FZEG!U I FZEE> TFINK 5I =E 1 25E9 GF=ILLQNS} 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 14ILL SERVE. --- TWO "< 2 ] I N�---F="ECT I QNs AFZE FZEGIU I FZEE7 --- 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 FET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM R PRIVATE WELL TO A PRIVATE_ SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL -LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER, REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABL''E TO INSURE PROPER INSTALLATION. f�'EFZM I T E}{F� I RES C7ECEMFIEFZ X1.1 1.5?OQ I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED: _ w _v R LICANT ROBERT RUNKEL ISSUED BY - 1- _ Q ------ DATE -------- VZK/ O V4. 0 �80C''A'. 48TH AVE. STE. IC CONSTF'�JCTION S >, TEST LAB ANCHuRA 248 1333A 99503 PERFORMED FOR: FttDYRI H / BOB R N FU DATE PERFORMED: 9/12/80 LEGAL DESCRIPTION: Lot 4 Block K Subdivision KNIK HEIGHTS THIS FORM REPORTS: O Visual Solls Examination b Percolation Test ACTL-80-1452 DEPTH SOIL NOTES FEET DESCRIPTION LIGHT BROWN SILT 3' BROWN SILTY GRAVEL W/ CLEAN GRAVEL POCKETS, COBBLES & BOULDERS -G X- 8.5#1 BRN. GRV-SA -G P- - 15' BRN. SILTY GRAVEL TO SILTY SANDY GRAVEL r�r� DEPTH TO H2O BOTTOM OF HOLE 9 10 80 9/10/80 WAS GROUND WATER ENCOUNTERED NO _ I0 a ••i••.•u.••�.,. IF YES, KHAT DEPTH r••�•.....� LEGEND ��-��+�-:-- Kinney R,Ala T - Perc zone �^ •. + .• 3656-E •'••••.. S S — Sample tckena�9Fpp a� 'PROFESS"' Q - Frozen zone l v - wnter table 9/10/80 GENERAL SITE SLOPE ,READING DATE GROSS TIME NET TIME DEPTH TO H2O NET DRAINAGE 9 10 80 9/10/80 11:30 2:30 -_ 27/32" 10 " 0" -- --- 0-- - 3.00-111!119/32" Z -1-19/32" 9/10/80 _- - a 11 5/17 1 18/32" -.--- a_ 0 — —V W - - �N Z r�- � GENERAL SITE SLOPE ,READING DATE GROSS TIME NET TIME DEPTH TO H2O NET DRAINAGE 9 10 80 9/10/80 11:30 2:30 0HRS1 3 HRS. 27/32" 10 " 0" -- �S/32" _ 9 7 10 80 3.00-111!119/32" -1-19/32" 9/10/80 3:30 4 0 HRS 11 5/17 1 18/32" -.--- PERCOLATION RATE: 19 min/in DRAINAGE REQUIREMENTS: 210 PROPOSED INSTALLATION: O SEEPAGE PIT IN DRAIN FIELD O OTHER COMMENTS: '.TEST PERFORMED BY: B.P. . L.S. DATA CERTIFIED BY:_ Kinney R. Baxter DATE:9/12J80 11 V- MD� Cl v-. C !Uo S c ) Y0 . A it3 s�� i , Y0 . A it3 s�� RETURN TO: Division of Geological and ( 'yslul Surveys (OCGS) • 7001 . Porcupine Drive (Trlep.s: 2116615) A Anchorage, Alaska 99501 \' E� W A T ESR+ WE L L R EC ORD Drilling Company Nnee Y 1rn's 1/rt'•1/10. tt L�H�r1ScS LOCATION OF WELL Please como lata (roar la, 16, or It. STATE OF ALASKA MUNICIPALITI ANCHORA S{PARTMENT OF NATURAL RESOU0.C[S DEPT. OF ENVIRONMENTAL I..:TCCTION A.O.L. Mo. 1A. Borough „" I, Subd l vial on kna( L(6i'ktt Lot Block Ib. Fraction / / / Section Np. R N/S E/V Meridian Ic. Distance and Direction from Road Intersections Street Address and Area of Well Location 9. OWNER OF WELL:r �'H COn s%/alc7fl0ny Zi.�. Address: 2. WELL LOG Feet 11a1oe Surface Material Type Top Bottom 6. WELL DEPTH: (completed) t` fc. Surface Elevation Date of Completion i µ 5. ® Cable tool ❑ Rotary ❑ Orlven ❑ Dug ❑Auger [3 Jetted ❑$orad ❑Other: ly 5-Z r We 6. USE: [RDomestic ❑ Public Supply ❑ Industry ❑ Irrigation ❑ Recharge ❑ Commercial ❑Test Wall ❑Other: fr er Is +L 3 PzjiZA✓el 234F AVO L 7. CASING: E] Threaded 29We l dad �I., to .21Lft. Depth Wight lbs/ft. in, to -Z&-ft14MrVTh.J`3I0 pYG B. FINISH OF WELL: Type:%inej Diameter: Slot/Mesh Size: Length: Set between ft. and ft. Fittings: 9. STATIC WATER LEVEL: 3 ft. ❑ Above lxBa1ow land surface Type of Measurement: 10. PUMPING LEVEL belom land surface ,� 3n ft. after 1/1z— hrs. pumping g.p.M. ft. after Mrs. pumping g•p•m. 11. WELL MEAD COMPLETION: ❑ In Approved Pit W Pitless Adapter Inches above grade I 12. GROUTING: Well Grouted: ❑ yes ONO Material: ❑Nut Cement 1:1 Other; 17. PUMP: (If available) MP Length of Drop Pipe 236 ft. capacity of 9•10. Type: R Subna rsibie ❑ Reciprocating ❑ Jet ❑Other: 11. REMARKS: 15, WATER WELL CONTRACTOR'S CERTIFICATION: This well pas drilled under my Jurisdiction and this report Is true to the best of my knowledge and belief: �ernra lir' C.ns FG�'nir.yLnrises �.E} 332.'>' —+1—iy scared duin tame ( on tract L came umosr Address: Signed: li ~v ,e - --CData: Rl �� Author,zed Pep resent. t)ve Form 02-WWR Copy Distribution: WHITE - State OGGS, PINK - Driller, CANARY - Customer Municipality of Anchorage r "" Development Services Department � Building Safety Division ; • �'°� Onsite Water and Wastewater Program „ , „ 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 995196650 / L/ www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 018-232-19 COSA# Don I 11 Expiration Date: 7— 4 —06 1. GENERAL INFORMATION Complete legal description Lot 4 Block K Knik Heights Location (site address) 13340 Bainbridge Anchorage AK 99516 Current Property owner(s) Tamara 6 Toby Gillespie Day phone 440-5192 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 13340 Bainbridge Anchorage AK 99516 Day phone Di HemdordHomes Unlimited Day phone 346-4111 517 West 1211, Ave.. Anchorage AK 99501 Unless otherwise requested, COSA will behold by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well El Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site 19 Individual Holding Tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of Onsite Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Onsite Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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 Certificate of Onsite Systems 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 Pannone Engineering Services LLC Phone 272-8218 Address P.O. Box 102954 Anchorage AK 99510 Engineer's Printed Name Steven R. Pannone P.E. Date 2120106 Engineers Comments: In conducting an adequacy test, l attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations.. Ile reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water �.�� QF aaa• levels that may fluctuate during the year, and the water usage of the family being served by the system .l�P •'""""``o�i� These conditions arc outside the control of the evaluator of this system. All guarsystems eventually fail and ; `� `+� • . satisfactory test results do not antee future pa fomran,w es ce of the system, nor do they guarantee that �` 4o....��'•�� there arc no hidden defects or encroachments. PES can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational report is for the sole benefit of the owner listed ♦ fA Steen f. one requirements of the MOA DSD. The content of this above. Any reliance upon or use of this report by any other person or party is not authorized nor will it �#c'`�\' 1�g49 »�= confer any legal right whatsoever. ea'F�"w.....-..•" ``5•' 5. DSD SIGNATURE �aa44 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: COSA Checklist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other. By: / li�. / 0-t Original Certificate Date: / (Rev. MS) Municipality of Anchorage e , • Development Services Department ° Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 34379W CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST A. WELL DATA Wed type E Total depth , j_ft. Date of test Static water level Well production If A, B, or C provide PWSID 0 _ Well Log (Y/N) Y Sanitary seal (YIN) Y Wires properly protected (YIN) _ Cased to -20—ft. FROM WELL LOG 231 ft. WATER SAMPLE RESULTS: Coliform _2_colonies/100 mL Arsenic: j(]mgA B. SEPTICIHOLDING TANK DATA Nitrate 2.12 mg/L Date of sample: I= Tank Type/Material Greer Steel Tank size 1250 gal. Number of Compartments Y Casing height (above ground) 12+ in. AT INSPECTION 24@006 230 ft. 3.0+ g.p.m. Other bacteria _L colonhWI00 mL Collected by: Laura Pannone Date installed 1141980 Cleanouts (Y/N) Y Foundation cieanout (Y/N) V Depression over tank (Y/N) H High water alarm (YIN) WA Date of pumping 2412008 Pumper Northland Pumolno C. ABSORPTION FIELD DATA Date installed 1141980 Soil rating (g.p.d./fe or fe/bdrm) 210 System type Daeo Trench Length 105 ft. Width 3 ft. Gravel below pipe 4 fL Total depth 11 fl. Eft. absorption area44Q fl= Monitoring tube Y Depression over field RQ Date of adequacy test 21812006 Results (Pass/Fail) Pass For 4 bedrooms Fluid depth in absorption field before test 2M in. Water addediff gal. New depth2a in. Elapsed Time: Q min. Final fluid depth 2a in. Absorption rate >= M g.p.d. Any rejuvenation treatment (past 12 moa (YIN & type) No If yes, give date D. LIFT STATION Date installed _ Size in gallons L 'Pump on' level at _ in. 'Pump off" Datum E. SEPARATION DISTANCES Cycles SEPARATION DISTANCES FROM WELL ON LOT TO: r Septic tankilift station on lot lU U Absorption field on lot 100' -It - Public sewer main 100+ Sewer /septic service line 50+ Animal containment areas 100+ in. Manhole/Access (YIN) High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots 100+ On adjacent lots 100+ Public sewer manhole/cleanout 100+ Holding tank 100+ Manure/animal excrete storage areas 100+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10.03 Property line _+ Absorption field 8' Water main 100+ Water service fine 25+ Surface water 100+ Wells on adjacent lots 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 101 + Building foundation 10+ Water main 100+ Water Service line 25+ Surface water 100+ Driveway, parkinghrohide storage 20+ Curtain drain None Observed Wells on adjacent lots 1+_ F. COMMENTS 1 ..'•��eeeeee G.' ENGINEER'S CERTIFICATION f�„ ..... c`!.ee♦ I cer* that 1 have determined through field inspections and r��`� ss� review of Municipal records that the above Systems are in conformance with MOA COSA guidelines in effed on this date. Engineer's Printed Name Steven R Pennons. P.E.�..,CC� e3/31l0b �8143 Date .,,��:E�. COSA Fee E t7 Waiver Fee $ ,3/ 6 Date of Payment v Date of Payment t� y Receipt Number 1 $ 1 Receipt Number (Rev. 11105) 4 l ` O0. ° o C septic Vent J Lot 3 S ,�• septic �922p " vem deck 32.7 ry 114. 2.0 OH 4.7 li OPower Pole = 4. ev Lot 5 LOT 4 O Well HeJ' w SCALE: 1"= 50' ghb°rs0� HOPE: ASPHALT LOCATION IS APPROXIMATE DUE TO SNOW E ICE `� 10' Utility Easement —C�N. O�•�V Ci: A a: ?p44ti M0. 22"G•: v ..�•-•. EASEMENTS OF RECORD. OTHER THAN 5-K O THOSE SHOWN ON THE RECORDED pb 06 -21,05 S PLAT ARE NOT SHOWN HEREON. •if 8297Y rn o� N 0 I / UI O t I / W 0 Ito .0D o •� � / So D � �c �r AS -BUILT NO CORNERS SET THIS DATE I hereby certify that I have performed a Mortgagee's inspection of the following described property: LOT 41 JgLoe-k K , kalK i•IEI61475 SH&O. Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within the property Ines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on property lying acqacent thereto encroach on the premises in question and that there are no roadways, transmission Ines or other visible easements On said property except as indicated hereon. Dated at Anchorage, Alaska this 2VA dayot A4ARG11 -20— FRED WALATKA & ASSOCIATES (907) 248.1666 Engineers and Surveyors \ Municipality of Anchorage • Development Services Department °•%^' °` Building Safety Division b, •'; On -Site Water and Wastewater Program ° 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ek.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 018-232-19 Parcel I.D. HAA # N A Q 10 32, Expiration Date: I." GENERAL INFORMATION Complete legal description Lot 4, Block 'K', Knik Heights s/D Location (site address or directions) 13340 Bainbridge Road Current Propertyowner(s) Goerlich Dayphone 345-1925 Mailing address 13340 Bainbridge.Road, Anchorage, AK 99516 Lending agency Residential/Yohyan •Pharr Dayphone 222-8800 Mailing address Real Estate Agent Mailing Address 1400 W. Benson Blvd., 2nd floor, Anchorage, AK -99503 Unless otherwise requested, NAA will be held by DSD !or pickup. Day phone 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑X Individual On-site El 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 5 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 less than 30 days old. (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 welts 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 seat 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 S b S ENGINEERING 17034 Eagle River Loop Road No. 204 Address Eagle River, ei k- 94577 Engineer's Printed Name Robert C. Cowan, P. F,. 5. DSD SIGNATURE _P/ Approved for _q� bedrooms. Disapproved. Phone 6 `% y , �-`f -7 9 Date r%/7/0 / F OF �•. RCZrRT C. COVIAN •••r,C ! V Conditional aooroval for bedrooms, with the following stipulations: Attachments: HAA Checklist x Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: S 0 L (Rev. 1ZtQ Municipality of Anchorage Development Services Department Building Safety Division Or -Site Water S Wastewater Program 4700 South Bragaw Sl. P.O. Box 196650 Anchorage, AK 995198850 www.ci.andwrage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST r , Legal Description: L D T 1/ /3 i o C K IS iCivi K N 4' rF NT J Parcel ID: 01 $— d 3 a—/ `I A. WELL DATA Well type Lit v*r t If A, B, or C provide PWSID 4 = Well Log (yid) 7 t f Date completed 43/t 1 Sanitary Zeal o(6�N tis I Wires properly protected (!?IN) YE J Total depth4L ft. Cased too— —ft. Casing height (above ground) 1 4 in. Date of test Static water level Well production FROM WELL LOG / /aJ/ r/ WATER SAMPLE RESULTS: 7 Coliform colonies/1o0 ml. Date of sample: S 11 ` O f B. SEPTIC/HOLDING TANK DATA 9— P.m- Nitrate 1.'Q mg.n. AT INSPECTION s-//(,/@ / ft. g.p.m. Other bectede O colonies/100 mi. Collected by: E i 5 DICINEERWO 7034 Eagle River Loop Read No. Mi& Rlvw, Alaska 49517 Tank Type/Material SO A: I�(' ST t 4 L Date installed Jd b l Y o Tank size 0 -SO gal. Number of Compartments Z Cleanouts&) Foundation cleanout aN) L1 -±A -1L Depression over tank (Y6) ^'J Date of pumping S Flo/ e o Pumper 3 146" 'i C. ABSORPTION FIELD DATA Date installed 116/10 Length /03r Torir, ft. Soil rating (g.p.dJft2 or ft° rtn A10 Width 3 ft. vE Jr High water alarm (Ye ^' O SiXt,IGJJ System type T R t—G H Gravel below pipe 'Y ft. Total depth tf r/i ft. Eff. absorption area Q40 ft2 Monitoring tube Yc J Depression over field JV o Date of adequacy test ��/e�o 1 Results 6a au) P#3 S For y bedrooms Fluid depth In absorption field before test 1AV In. Water added gal. New depth i L in. Elapsed Time:N/A min. Final fluid depth' A in. Absorption rate >= 6 0 0 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N 8 type) ^r ° "I K ..o r If yes, give date D. LIFT STATION Date installed Size in gallons 'Pump on" level at _ In. TWPQfflLW Datum / Cycles tested _ in. Mertli6rAccess (Y/N) — High water alarm level at Meets alarm 3 circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankfilft station on lot J I On adjacent lots Absorption field on lot 0 .i On adjacent lots r 100 f In. Public sewer main �A Public sewer manhole/deanout �q Sewer /septic service line S r+ Holding tank J0r 14 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: i Building foundation 7 Property line S y` Absorption field f Water main pr / A Water service line /0 I "f" Surface water °Q r; Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: r Property line / D + Building foundation /0 { Water main JJ 14 Water Service line / D i Surface water / t) Driveway, parldrrp/vehicle storage 7u � Curtain drain h c,t k rok++ : Wells onadjacent lots /'00 F. COMMENTS G. ENGINEER'S CERTIFICATION � ��; �r �`qs 1 certify that I have determined through field krspedons and � � r '• 2 in review of Municipal records that the above systems are conformance with MOA HAA guidelines in effed on this date. $.._. Engineer's Printed Name Ra�e.4� �. Caws -k• Pf % ROBERT C. COWANOWAN 4 / :f�� S_// 7 01 c, y CE .8801 ,r fj Y• Date t. " '• ` �' r HAA Fee $ 3 oo.Waiver Fee $ Date of Payment s— / r >' /a / Date of Payment Receipt Number O 0 4 S 17, Receipt Number (Rev. 12100) IAAY-13-01 09:45 FROAI- LCUE Environmental Services Inc. 1a'rrrrlrrrrrrirliir� T-950 P.02/03 F-353 Cr&E Ref.N 1012673001 Client PON Client Name S & S Engineering Printed Date/time 05/22/2001 11:28 Project Name/N fat 4 B ik Heights Collected Date/time 05/162001 14:00 Client Sample ID fat 4 BikK Knit Heights Received Date rime 05/162001 14:40 Matrix Drinking Water Technical Dlreetor Stephen. . Ede Ordered By PWSID 0 Released B Sample Ra=ks: Allowable Prep Analysis ppymetet Resale PQL Units Melbod Limits Date Datc Init Waters Department Nitrate -N 1.42 0.500 mg/L EPA 300.0 (<10) 05/16/01 SCL Microbiology Laboratory Total Coliform 0 0 col/100mL SM18 9222D 05/16/01 KAP J4 MUNICIPALITYOF MCHORAGE - _bEPARTMENTIOF HEALTH HUMAN SERV I ICES Division of Environmental Services Q9 7 I -'- on -sit Sirvicessection 1�,- T I - P.6. Box 196650 v -Anchorage, Alaska'-, 99519-6650 CERTIFICATE OF. HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING -3 r) Parcel I.D. # ;L ni_ 1. GENERAL INFORMATION opt 66mplete le441'descriptlonkmo K ki/ay)--r. -3 -'13.4 1 7 cition (site address or directions) 133 RaA,0 -Lo, ns) 4i C -1/d of 4 a Propertyownee, o 9 Day phone - Mailing addrim1 -3 3`'1 -0 Day ph �;#T! W;4 agency.Lending one 7 7 Mailing can iddriis- Day phone Address Unlessotherwise requi�iti�i,!HAA will he hold for OF -WATER INOTE: If community well system, provide written confirmation from ing to the legality and status of system s $V 4,; ',TYPE OF WASTEWATER DISPOSAL.; 4 Individual on-site: Holding tank :,-',%"i C;on-site* lot ommunity, Public sewer,..-, NOTE.,— If community wastewater system, provide written cohfirmat %'attesting to the legality a' andstatusof systern.-,%; ;tote ADIEC.attest- I b fl -1 )h from State ADEC 7 STATEMENT OF INSPECTION BY ENGINEER certified by my sea[ affixed hereto and as of the validation date shown below. Iverify that my r r 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._Ifurtheive4ythat based o n the information obtained from -site water 7 the Municipality of Anchorage files from my Invest!qation and Inspection, the on supply and/or wastewater disposal system is in complia ce with all Municipal and State codes, .-iordinances, and regulations In effect on the date of this Inspection. --SASIENGINEERfWA Name of Firm Phone C/ • TW -100P 1104C1 140. 2W Address RI"rAlaska M77;- 7;- A, Engineers signature Date'' ,Jt 3 .7 7, ..... . ... .. OF L4 .7A . ......... ROEERT t. COWAN X i�DHHIS SIGNATURE:!---, . .... .... Approved for... ro Disaooved ..conditional approval. for ,;.:bedlrooms.'vilth'thefollowing 'stipulations:, _7 ? x t r4 Date • The Mdnlclpaifit'y'of Anchorage Department ! Of Health and Human (DHHS)"r as Health Authority Approval Certificates based only upon the represW6ti6ns'gi"n-in, paTgraph b, above by an.independent, prolessione' engineer registered in the State of Alaska The DHHS does this as a courtesy to y .,and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not , inspections or analyze data beforo'a certificate'is issued TheiMunicipality of Anchorage is not •=- ponsible for errors or omissions in the professional engineers work Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES J Environmental Services Division 825"L" Street, Room 502 • Anchorage, Alaska 995010 (907) 3434744 Health Authority Approval Checklist Legal Description: A-0 T y A � K IK KN 1 r( M t 1 r' w f Parcel (.p.; O/ S— 7 1 I 'I r 11 c< A. WELL DATA tT o Welt type PA I V* T! If A. B. or C, attach ADEC letter. ADEC water system number �C Log present &N) Y t S Date completed r 64 IQ;131 't # Total depth a.4 0 Cased to At 2#10 casing height (above ground) ) Sanitary seal (ON) YtS Wires properly protected d>`() Yt 3 FROM WELL LOG AT INSPECTION Date of lest 1 /a -1/ 1 / // / -.;if. / 9 S - Static water level 1 -3 / D Zi - ' Well production '7. 0 g.p.m. y 0 -! g.p.m. ;t Aa1Tt.Lrt4 By .`Lye, degN (r WATER SAMPLE RESULTS: Coliform O Nitrate I -A- Other bacteria O Date of sample: / t a/ q s Collected b•; S a S ENGINEERING B. EPTI OLDING TANK DATA E"%River' Alaska 99577 Date installed h /4( /!0 Tank size ) ;L Sy Number of Compartments a- Cleanouts (®/N) iE J Foundation cleanout (Ye A ° s Depression (Yo /' 0 High water alarm (Yd e DateofPumping Pump" tft r1AVG4j �. eOv Pia(, IA GA�w1 $1*4(t NAJ 4t4N v(td F.A C-Lldr Cr P.*Ay([ $. C. ABSORP770N FIELD DATA Date insatied 4 f 6. / kO Soil rating (g.p.d.W o System type 044i4 sAf C#4 Length / o Width / Gravel thickness below pipe '1 � Total depth T • S Wective absorption area Ty 0 Monitoring Tube pmsmt&/N) `/s i Depression over field (YO A' 0 Date of adequacy test 11 / 1 i / 9 S Results (Pass/Fail) P4 S S For bedrooms Fluid depth in absorption field before test (in.): 0 Immediately after77 44igai. water added (in.): O Fluid depth O (ins.) Minutes later:'' 0 Absorption rate = G 0 0 + e.p.d. Peroxide treatment (past 12 months) (YM) WON IL K n o wW If yes, give date _ D. LIFE STATION Date installed Manhole/A(Y/N) High water alarm level at* Cycles E. SEPARATION DISTANCES 1. Pump Sire in gallons *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Se�i holding lank on W 10 0 r { ; On adjacent lots Absorption field on Int / 0 e f ; On adjacent lots N �A -Pump off' level at" lot) �4 Public sewer main Public sewer manhole/cleanout Sewer /septic service line Litt station w 14 SEPARATION DISTANCES FROM OLDING TANK ON LOT TO: t�� r �t Building foundation Irt property line S Absorption field Water main/service line rO 1f' Surface wateddtamage /'Oe 1'1' Wells on 4acem lots /O J SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: t Building foundation to t Water mainlservice line f 0 { Surface water / ° J r Driveway, parking/vehicle storage area 'a Curtain drain NO,'L Wells on adjacent lots / 00 Propem• line F. ENGINEER'S CERTIFICATION I certtfv that I have determined thru jletd inspections and revtew ofUumcfpal records that the��a in Conformancewit MPA l guiZZ ect on this date. Signature / C F Al,q 96,61t47- y Engineer's Noce l� 6 8 ER ,7— t Date ! n 30 /1 S— % . — ......! y n ` ROalRr C. COWAN CE -8801 HAA Fee S 047e`� Waiver Fee ltt il>,�' Date of Payment Date of Payment -- Receipt Number/ S ? c Z Receipt Number Rev. 8/95 OSS: haa.wk.doc are MUNICIPALITY OF ANCHORAGE O Department of Health &Human Services a� DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # (-)\ `t_ _Q - 1 C1 HAA # VILC (1C-(_�.S 9 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) LOT 4; BLOCK "K" KNIK HEIGHTS Location (address or directions) 13300 Sainbnidge (b) Property owner Patni.c.i.aA•CanteA Telephone: (home) 345-0091 Business Mailing Address 13300`13inbnidge (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent FORTUNE PROPERTIES ATTN: Kau EtUson Address 3000 A S#.ea 0101 Anchorage. Ak. 99503 Telephone 562-7653 (e) Mail the HAA to the following address: (or check here 5�(if hold for pick up.) List contact person and day phone number below: 5 & 5 ENGINEERING 17034 Eagle River Loop RoadNo. 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family P( Number of bedrooms 4 3. WATER SUPPLY Individual Well IBX Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site IRX 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. 72a25IR".7ne) Pagel of 2 Z jo Z abed %*IS(SVZ' W)MIL ,Njom s,jaau!6ue Isuo!ssoloid ayl ui suo!ss!woiosialajoppsuodsai lou si a6ejoyouV joAl!led!o!unN ayl •panss! si aleo!j!jjaoeajo;aq elep azAleueio suolloodsui lonpuoolou op SHHO;OsaaAoldw3 •sluawailnboi alels pue lejapal uiuvaoAjsllesoljapio u! suo!lnl!lsu! 6u!pual rayl pue sawoy;o siaseyoind of AsaUnoo a se s!yl S80p SHHO ayl'UNSPIV;o OMS 041 u! paials!6ai jaau!6ua!euo!ssalad luopuadopu! ue Aq anoge S 4dei6eied u! UOA16 suolleluasaidai ayl uodn Aluo paseq pajeoiltiao IenaddyAluoylny y)leaH sanss! (SHHO) sao!Ajag uewnH pue yl!eaHtoluawliedaO e6eioyouV;o Al!led!o!unlnl ayl N011f)VO .11 le"add� leuo!l!puoO;o swlal Ieuo!1!puoO panaddes!O—�—panadd;+ 0 _ eleO w� Aq swoapaqJoj panaddy IVAOUddV SHHC '9 /49- r, 5. '5�..✓av: euoydalal ZLS66 931" V ""I aleO "Z *ON peob dool je"Ia e16e3 4LOLL ON1833NION3 5 73 SSa1ppV wJ!j;o aweN •uolloodsui s!yl;o elep ayl uo loa;;a u! suolleln6ai pue 'saoumpio'sopoo alelS pue ledlownyq Ile yl!m eoue!Idwoo ui si walsAs iesods!p jalemalsem jo/pue Alddns Salem ells-uo ayl'uo!loadsu! Pur uo!le61lsa"ul Aw wog; pue salt' e6ejoyouV ;o I4!led!o!unV4 ay) woij pou!elgo uollewjojul ayl uo paseq ley) IyuaA jaLivn; I Malay paleolpu! ainlonils;o adAj pue swoojpaq;o jagwnu ayl jo; olenbape pue Ieuollounj 'ales sl walsAs lesods!p jalemalsem jo/pue Alddns jalem ells-uo et') ley) smogs lenaddV Al!joylnV WIVaH s!yl jo u01je6ljsaAui Aw Imp ApJOA I'molaq umoys alep uo!lep!le"ayl;o se pue 0101ay pax!lle leas Aw Aq pa!;lliao sV 'NOUVWHOdNI CNV V1VC'HOEMS 311:0S.M.L'SNOLLOUSNl °JNIOIAOHd WHIR ON1833NION3 'S /r� • y MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) Rq CHECKLIST - FEBRUARY 1984 sEp'4�Ccyp' 343-4744 Fsoivrso Legal Description: ?SLK- �K- RF 19'go N A. WELL DATA CF��/c Well Classification C Q * r-� O\y 1 �J� t� If A, B, C, D.E.C. Approved (Y/N) A Well Log Present CON) _Date Completed 6I Yield Ar 4?V1 '} Total Depth �� Cased to 231 Depth of Grouting 3 S 9 C>) Static Water Level 'Z'r'O % Pump Set At Off'• �t Casing Height Above Ground \Z A- Sanitary Seal on Casing (VN) Electrical Wiring in Conduit¢P/N) `/ Depression Around Wellhead (YANp a SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot t cp.t-i- ; On Adjoining Lots I oo 1.4- To �To Nearest Edge of Absorption Field n Lot bei ; On Adjoining Lots t To Nearest Public Sewer Line G To Nearest Public Sewer Cleanout/Manhole N A To Nearest Sewer Service Line on Lot 25, 4 - Water Water Sample Collected by �7 S �'1 tr�rY ;Date _22' Water Sample Test Results '�1St � — �[ G,� tom+`1T P Comments B. SEPTIC/HOLDING TANK DATA Date Installed 0' O- 80 Size (7 Si7 No. of Compartments -2— Standpipes Standpipes CYN) 4 Air -tight CapsdE�?N) _Foundation Cleanoutc°/N) Depression over Tank (Yds >J Date Last Pumped Pumping/Maintenance Contact on File (Y/N) ; for rJa Holding Tank High -Water Alarm (Y/N) P Temporary Holding Tank Permit (Y/N) A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well I C. -:)o k To Building Foundation I M To Property Line _ % d 1 -Ii— To Disposal Field to t t To Water Main/Service Line o A -- To Stream, Pond; Laky or Major Drainage Course Comments p` �'JS �roM�. !2624 ' 72.C26 (A". 7/ft) Foot Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 2l ::� Type of System Design el PIF6r�A Date Installed I k — ko- gc> Length of Field Width of Field 3 Depth of Field S �S Square Feet of Absortion Area Gravel Bed Thickness `r Statndpipes Present4Y/N) S1 Depression over Field (YtM rJ Date of Last Adequacy Test Results of Last Adequacy Test1SP SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well To Property Line S , To Building Foundatio` To Existing or Abandoned System on Lot ra fP ; On Adjoining Lots 3ct�4 To Water Main/Service Line t To Cutback (if present) P To Stream, Pond, Lake, or Major Drainage Course (fit 1" To Driveway, Parking Area, or Vehicle Storage Area G4' It Comments D. LIFT STATION Date Installed SizeSn,Pahoris "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at during Adequacy Test. "Check Permitted Bedroom Rating Against HAA Request" certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date af:this.�,� Inspection. _ ��t `;,-A Signed Company cRING 17034 E". = iver oop oa o. u4 Date -aaka 99577 E3�' r. MOA No. C c �O -CSO Receipt No. - 17 5-0 /G ss Date of Payment Amount: $ �7U-fir% 72-M (R.. 7/81) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 19 5. LEGAL DESCRIPTION DATE HECEIVED INSPECTION APPOINTMENTS —'— L STREET LOCATION TIME TIME TIME 6. TYPE OF RESIDENCE DATE DATE DATE SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 5 INSPECTOR INSPECTOR INSPECT ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) pF ANCHORAGE DEPT. Of h- MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL CJic_Cf10N DEPARTMEN T OF HEALTH & ENVIRONMENTAL PROTECTION `30 YEAR ON-SITE SYSTEM WAS INSTALLED. 825 L Street • Anchorage, Alaska 99501 *�w 6 �ar� 2 ENVIRONMENTAL SANITATION DIVISION Telephone 264.4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts at page 1. Incomplete requests will not be processed. Please allow ten 001 days for processing. 1. P OPERTYOWNER PHONE f MAILING ADDRESS yB I Is1.�� Wc, �4rc flk G C)L PROPERTY RESIDENT (11 tliftere t from above) PHONE Z. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION PHONE MAILING ADDRESS 4. REALTOR/AGENT PHONE MAI`NG ADDRESS 19 5. LEGAL DESCRIPTION G STREET LOCATION d i 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS 25 1:1 One 10 Four C3 Other SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY INDIVIDUAL' *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) B. SEWAGE DISPOSAL SYSTEM ® INDIVIDUAL/ON-SITE" `30 YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72010 (A". 6/79) p'—w THIS SIDE FOR OFFICIAL USE ONLY.. - 1. TYPE OF RESIDENCE ❑ SINGLEFAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLICUTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL GATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLICUTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑Holding Tank Size:OS-0 If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL - 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area w Seer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS Lei—APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED GATE BY 72010 (Rev. 6/79)