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Home My WebLink AboutCAMPBELL HEIGHTS BLK 3 LT 13l_a�mP��Q wk - 060) a --, ug W �> 55,2 �.S i~ tin - uoWio'W� �u�W "J Q 1n ox "J 4 S• WY7= Hyl � I '1 Vli I � � Uaf. 1� JmOW l� G Ir w �• t W�sa =0W=W Wgrc=10 cz N WU~DO: 4 '~O;e ratlEw 2 Z ; j.(9 W WW h F' IJOUW p¢�¢N hl WZms a�o4o „J<r•p�- � � 1 A tll 2 3ouNz a<J�"O WN M<Ip02� / I GH=0-i W=VeJ W OZZUJ JQ iW I Q9UJWaZp W02 CZ -mix m'f j n 0 „1 ► a Q W v�rnM-y aeY& s. W 8as8sa8sRR$ ~t «p4&Res::2. m 4 A pVlt Nh \�aiMA�p4 s::bQseeRa&#A O ` ohhh hh hhhhh hhh d oI i oj2: C "Jr Wei N � � W. Jekn J. mummer Senior Administrative Officer AA" ASNesio tjer 4 $ewe r utilities ar Anchorage. Alaska 99$01 Dear Nr. Major: Anchorage - Campbell Heights L.I.D. 091 Plans (7)9 specifications and contract documents for the sub set !select were fonnrded to ppthis Department by your letClassr50 D.I. February on both muieHth will Aveprovide w land Snit 67th Avows Yetlaaing at etlating maakoln in the street for 2186' mad terminates is a Snakole. The sewn ea mast 67th Awawe extends east 2621' to a manhole in Ruth Street, then south 100' to a cleamout in Ruth Street. Tae si, clfleatieas contained soil Investigation borings, six L alsad spaced pyall oa both Aveaws concerned. will be In accordance with the M stleipality of AmcberagMort o Standard yegM atlons of may 1176. There is but as*w has with well along the proposed construction on Last Nth Avenue. which is not a problem Skeels a and 6 show most 67th Avenue which has pwrens hometo and volts. P1cue mote that while we mlmlamm •dparatloa et u ,ler w 60'. 66mrs1 gaiitOtt a dietnwe eetwem /rirato valla am eenowtrr bw6re are Aire fees than mmlalmua. ; cue mote thst err briaklm$ t�fsd set sa#�"tr�=0� �i6'i,a4iuits gt�t.. iwt . !�_ y 11 ae�rpaiiilai41 �ii ttsait�leiregwtred N�. 6 fiacorely You. IWrd X�'Xr1� Facility Construction i Operation ' Dl��arW rr or Frrexeawp aCrr niH • t..r a wnr u.... Parch 10, 1979 Mr, Richard H. Britt State of Alaska Departnent of Environmental Conservation facIiIt Construction t Operation Pouch •D' Juneau, Alaska 97911 Dear Mr. Britt: Attached find sheets 5 and 6 of Campbell Heights South L.I.D. 91 with Proposed rodifications to the design of the project. If you should find the rodifications acceptable we shall proceed to redraw the plans accord- Ing1y and resubmit a full set of plans and specifications for your review aid approval. An explanation of the design modifications to Campbell Heights South L.I.D. 91 is as follows: SHEET 5 1. Move sanitary sewer line 10' south of the center line of Sixty Seventh Awawe. This new alit+rsnt has the advantage of minimizing b the conflict with the 50 foot radius protective areas around water wells. We propose to encase In concrete any pipe ,points that atsy fall within the 50 foot radius protective area. 2. Move WI -11 44.52 feet in an easterly direction. This would optimize the wxiaum distance between the manhole and the water wells. The distance between manhole 10 and manhole 11 would be 400 linear feet. S. A11 arnholes shell be Constructed with RkM.IIEK flexible ttttertllht Gaskets. l SHEET 6 1. tivs seal4ry saver line 10' so th of s Center line of Sixty W"Wth Av"W. TMts allpment min(%it" re tonal lct with SO fast arae bran/ water wells. Pipe Joints w tMn the 50 feet radius protective areas shall be encased In concrete. i �1rt� US -36 111"? het fn a Wftwly direction. lits 1 ffcati-is would optimize the euxl" distant@ between manhole amd several water wells. 3. hove Mnholes it and 15 1n a westerly direction to maintain a maxirtur distance of 100 linear feet between ranholes. 6. All ranholes shall be constructed with RA -NEB. Flexible Watrr- tight Gaskets. 5. Y.annole lE shall be a sPecially constructed Aanhole with a 9 foot high fiberglass cone setting on a regular concrete manhole bash. RAO-nry flexible Watertight Gasket shall be used between the fiber. glass cone and the concrete base. This construction will Insure a watertirt manhole that would resist frost Jacking. ,ttiched find a detail drawing and pictures of Specially constructed fiberglass j manholes. As yoare aware most of the Lateral Improvement Districts In Anchorane nvotru e lnstalletton of sanitary sewer lines In estatllshed residential subdivisions. Typically. water wells and septic tanks were installed at random w -t thout recognizing the future need for sanitary Sewer lines and without foreseeing the constraint posed by Drink Water Pegulatlons. We find ourselves designing sanitary sewer pro,lects where It is Impossible to develop sewer Alignments that fully meet State Requlatlons. We are forced into a Position of having to do the best to aC(,r,'date the Spirit /I of the regulations. describedThe above design to do oPtinized the Aaxlmv,mdistancetbetween nanholesattempt that. and water wells, maintained the mrmimuw distance of loo linear feet between manholes. and made provisions to provide watertight manholes. Please AccePt the Proposed design modifications as a reasonable solution to the conflict with the State Regulations. Stnoereiy� (/.JE VICENTE.�E. SMwr wt/lily Emgfsrer Anchorage water I Sewer utilities JV:*" At tacheatatt r .. r •tr i; o+ 1•� 2 �.. lout the 4MID 1104 so 4MA �yy �r tabs o t��e! Bt2reeehat � _ 901newe�amt extend at least /• on all Sides of is the mower pipe. The well at the intersection of test Sixty Seventh Avenue and Ruth Street Is shown as sited In the now. It is too clop (451) to the manhole that was to have marked the east and of this mover run. The run must be terminated by manhole at least 100' from this well and on East Sixty Seventh Avenue. He are not acquainted with the 'fiberglass manhole* you proposed and would appreciate catalog data concerning it. We look forward to your reply. Sincerely yours, r)-1' , -4. 6 Richard 11. Britt Co Facility nstruction i Operation Aprl1 $0, 1970 RECEIVED MAY 3 )919 BT.' Joh BargbMaa Aeab orap�coma Wagater a Sswer Utilities Ambno � UeYmms, =6 Aretie Boulevard Aachorage, Alaska 99803 Dear Mr. Aarihmes: Asaborage - Campbell L.I.D. 091 This'projeat will provide sever lines on both Sixty Sixth and Sixty SsseKb A.eases in the area bounded by Sprece and Ruth Streets. Co9nectlon will be made to the existing sewerage srstem em $pangs Street. The proposal will use about $4360 of S" duatils•lroa pips. het ewregafONo9 tgelmrdw ear 1etNr of p0Or9as1 So, 1970 W ■web U. lffT7ff lir. Jdb9 Clinger'• letter of April li. 1070 Me fonarded plus and specifications whisk reflect the repuirseeats of dm� prewlASf.&sISM. -ted 01aae Bad ami!lesttm9e w approved by tbie Departmest for those items of our concern. Sisserely Ya,,AR'wls..q &L4_ �''C 4• `O 2101tard ■. $Vitt OD9�satl�l�ttee en :00e wtonto 'GAXad[D-2• GREATEL. ANCHORAGE AREA - OROUGH Case No. ' IIEALTII DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 279-2511 SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT rn tt NAME OF APPLICANT L • MAILING ADDRESS Soy �� PHONE NO: 77—/S� ;3 RESIDENCE ADDRESS 3a'l/7 G 7 LOCATION OF INSTALLATION a2z'CL-- f•6714 LEGAL DESCRIPTION /1 •�'a / 3 Jgt'k 3 APPLICATION TO INSTALL: SEPTIC TANK, SEEPAGE PIT DRAIN FIELD , OTHER TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH TO BE INSTALLED BY PERCOLATION TEST RESULTS ANTICIPATED DATE OF COMPLETION BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT THIS IS TO SERVE AS / AS DESCRIBED BELOW �%j Q,;Z& SEPTIC TANK SIZE DISTANCES: Health Authority , PERMIT TO INSTALL A SIZE OF UNIT TO BE SERVED TYPE I&CL& SEEPAGE AREA TYPE DIAGRAM OF SYSTEM I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the above described system is in accordance with said code. DATE APPLICANTS SIGNATURE Rus# I f!PLANS MUNICIPALITY OF ANCHORAGE Development Services Department "� ' Phone: 907-343-7904 On -Site Water & Wastewater Section - gLH Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 014 072 08 1. GENERAL INFORMATION Expiration Date: Fc�h 15 ) � 0�2 C Complete legal description CAMPBELL HEIGHTS BLOCK 3 LOT 13 Location (site address) 3847 E 67th Current property owner(s) Matthew Corinth Day phone Mailing address Real estate agent Nathan Jabaay Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic ❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ED Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Vzo Waiver Fee $ I Date of Payment % llgll9 Receipt Number t-I&117'D COSA# l310)C10 /5-q5 Date of Payment Receipt Number Waiver # 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, based on procedures outlined in the Certificate of On -Site 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 C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 11/10/2019 Awl OF ALgSI ii� Co. 6. DSD SIGNATURE i 49 System #1 Approved for 3 bedrooms CHARLES G BALZARINI System #2 Approved for bedrooms �+ �F� % CE -13854 •• ��)� Disapproved 0,11;F�PROfESS10�Pti Conditional approval for bedrooms, with the following stipulations: A,kk (((((((u1" =M WASTEWATER z_ J� PROGRAM ,� JJJ By: '�'� ` 6ma Original Certificate Date: f 1 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: CAMPBELL HEIGHTS BLOCK 3 LOT 13 Parcel ID: 014 072 08 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Well production at time of test +4.0 gpm Date drilled 1968* Water storage tank volume 0 gallons Total depth 85* ft Well disinfected for coliform test? ❑ Yes ❑ No Cased to +40 ft OR Coliform bacteria is Negative ❑ Sanitary seal is functioning correctly Nitrate 1.47 mg/L ❑ Nitrate less than MRL (ND) ❑ Wires are properly protected Arsenic ug/L ❑ Arsenic less than MRL (ND) Casing height (above ground) 12 in. Collected by C.BALZARINI Date of flow test for COSA 11/7/19 Date of Sample 10/31/19 Static water level at beginning of test 33 ft. Comments date drilled and total depth as reported on previous COSA / HAA Age of tank(s) s Tank type/material Measured operating fluid level in septic tank ❑ Standpipes/foundation cleanout per record drawing Date of pumping D. AB PTION FIELD DATA no absorption field Which system tes date installed) ❑ ALL standpipes presen record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Com - no septic tank or lift station Adequacy test date Results []Pass For bedrooms Fluid depth prior to test in Water added gal New depth in sed time min Final flui th in Absorption rate gpd Any rejuvenation treatment t 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ❑ Yes Neighboring Tank > 100' ✓❑ Yes Absorption Field on Lot > 100' ❑ Yes Neighboring Absorption Fields > 100' ✓❑ Yes Community Sewer Main > 75' ❑ Yes if No na ft Community Sewer Manhole/Cleanout > 100' 85 if No ❑ Yes ❑ Yes if No ft if No ft Private Sewer/Septic Line > 25' 0 Yes if No ft if No na ft Holding Tank > 100' ❑✓ Yes if No ft Animal Containment > 50' ✓❑ Yes if No ft if No ft 44 Manure/Animal Excreta Storage > 100' —❑✓ if No ft Yes if No ft c/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > Property Line > 5' Absorption Field > 5' Water Main > 10' Water Service Line > 10' LJ -Yes if No ft ❑ Yes if No ❑ Yes if No ft El Yes if No ft ❑ Yes if No ft Surface Water > 100' ❑ Yes if No Wells on Adjacent Lots: Private _ 0' �efi Community Wells >200 If septic tank is under driveway comment below Ft�t bsorption Field on Lot to: (Please enter distances if less than required) Building Foundation > ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes i ft Wells on Adjacent Lots: Water Main > 10' ❑ Yes if No ft . to Wells > 100' ❑ Yes if No Water Service Line > 10' ❑ Yes if No ft Community Wells > ❑ Yes if No Surface Water > 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS property is served by a well only. NO Septic. Separation to Sewer main and Sewer manhole approved by ADEC and documented on previous COSAs & HAAs G. ENGINEER'S CERTIFICATION / certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet -ARM,-01. A •TH CHARLES G BALZARINI �' • CE 13854 • `� .� �PROFESSIONP ft ft rai ft ft 40.1Lot 13, Block 3 Campbell Heights 17,653 Sq. Ft. +/- 3847 E. 67th Avenue 1 Story Wood Frame House;;;;;;;;;;;;;;;;; ; E T E G W OHU OHU OHU OHU OHU OHUOHUOHUOHUOHUOHUOHUOHUOHUOHUOHUOHU OHUOHUOHU MBN00° 07' 00"W 140.00N90° 00' 00"E 126.10 N00° 07' 00"W 140.00N90° 00' 00"E 126.10 51.7 26.651.7 26.62.1 6.412.2 8.2100' WELL RADIUSSHED 10' UTILITY EASEMENT 17.7 52.7 LOT 9 LOT 12 LOT 14 ℄ E. 67th AVENUE PAVED DRIVEWAY Frederic W. Wagner NO. L.S.-9946 PROFESSIONAL SEAL Frontier Surveys, LLC Project No: 19-456 Date: 650 W. 58th Ave. Suite E Anchorage, Alaska 99518 As-Built Survey of: www.frontiersurveys.com Frontier Surveys, LLC I, Frederic Wagner, hereby certify that this Mortgage Inspection Survey was performed by me, or under my direct supervision on Plat:Grid:Ordered By: 907.460.1686 - info@frontiersurveys.com This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances should this document be used for construction or for establishing a boundary or fence line. November 5th, 2019. Legend: Scale 1" = 30' Gas Meter Electric Meter/Outside Power Deck Septic Telephone Pole Fence Mailbox STA T E O F ALA S K A49 TH ROYEVRUSDNALLANOISSEFORP DERE T S IGER 11/8/2019 S G E Metal Post Lot 13, Block 3 Campbell Heights General Notes: 1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws. 2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. 3. All measurements/setbacks are to the visual/apparent building footprint. 4. All dimensions to property lines are plus/minus 0.1ft. Charles Balzarini 11/5/2019 P-243B N/A Found Rebar E T W Found YPC Elec. PedestalWater Well Tel. Pedestal C*0 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water ti Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 q) U."G CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING /� , 1 Parcell.D. DILk-oaz-ng COSA# IJ�DUIzi 1. GENERAL INFORMATION Expiration Date: 7-/3-0(a— Complete -t/3-O(a— Complete legal description CAMPBELL HEIGHTS: LOT 13, BLOCK 3. Location (site address) 3847 EAST 67th AVENUE • ANCHORAGE. AK 99507 Current Property owner(s) ROBERT ABSTON Day phone (418) 665-4151 Mailing address Lending agency Mailing address Real Estate Agent Mailing address 3847 EAST 67th AVENUE • ANCHORAGE. AK 99507 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 2 Day phone Day phone 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Weil ❑ Community On-site ❑ Public Water System ❑ Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site 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 On -Site 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 samples. (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 engineers 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 Certificate of On -Site 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 riles 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineers Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LID. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines B Regulations. The reported results described the performance of the system undorthe conditions encountered at the time of the test, and separation distances measured to readily Idontitiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may tluctuato during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for o2 bedrooms. Disapproved. Conditional approval for Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Phone 337-6179 Date W t z A6 1 AM 441 I fit � 11 i 1 i —795 bedrooms, with the flowing stipulations: ,,�:tj 011llF, Arsenic Advisory Maintenance Agreements Supplemental Engineer's Reort Other AND CATER ' = �en,1 By: Original Certificate Date: —% 3— I: i Municipality of Anchorage !' Development Services Department J Building Safety Division " On-site Water & Wastewater Program 4700 Bregaw Street P.O. Box 196650 Anchorage, AK 99519.86.!0 www.muri.org/onsite (907) 3437904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: CAMPBELL HEIGHTS, LOT 13, BLOCK 3. Parcel ID: 01!4-07;L08 A. WELL DATA *PER 1972 HAA Well" PRIVATE If A, B, or C provide PWSIDN N/A Date completed • 1968 Sanitary seal (Y/N) YES Total depth •85 ft. Cased to 40+ ft. FROM WELL LOG Date of test Static water level ft. Well production g.p.m. WATER SAMPLE RESULTS: Well Log (YM) NO Wires property protected (Y/N) YES Casing height (above ground) 18+ in. AT INSPECTION 4/4/2006 35 ft. 3.9 g.p.m. Coliform 0 colonies/100 ml. Nitrate N DOther bacteria d colonies/100 ml. 4 /'t �o b Arsenic: -�Q_ ug./L. Date of sample: 4/4/ 006 Collected by: GEG Ltd. B. SEPTICIHOLDING TANK DATA Tank Type/Material Tank size gal. Foundation deanout (YM) C. ABSORPTION FIELD DATA PUBLIC SEWER Number of Compartments Pumper Date installed (YM) tank (Y/N) _ High water alarm (YIN) Date inata9ed Soil rating (g.p.d./ft'or ft%drm) _ System type Length ft. Width ft. Gravel be6 ft. Total depth ft. Eff. absorption area _ ft' Monitoring to Depression over field Date of adequacy test Results a0) For bedrooms Fluid depth In absorption field before _ In. Water added _ gal. New depth _in. Elapsed Time: Final fluid depth _ In. Absorption rate >= g.p.d. treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed 'Pump on" level at _in. Size in gallons High water alarm level at Cycles tested Meets alarm 6 circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAifi station on lot _N/A On adjacent kns N/A Absorption field on lot N/A On adjacent kits Public sewer main •44 Public sewer manhole/deanout '85' Sewer /septic service line 25'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Building foundation Property line Absorption field Water main Water service line Wells on ad SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water Water service linells w Drive Curta onSurface Weadjacent lots F. COMMENTS WAIVERS GRANTED G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are In conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date !� bi/06 COSA Fee S T� 140f Date of Payment 1- Receipt Number a (nev. 1 trod Waiver Fee $ Date of Payment Receipt Number water parldnglvehide storage VW411 MM Apr .13. 2006 8:16AM Garness Engineering Group, Ltd. No -2762 P - I Apr .r .. ...,,v ,,.. rAtest:....r.0.4. ..r.r.7215 7-75. ,.,,../002 r -M a U (�railC Drilre .�H't'l/ �. E .4 S f - /24. /O' fl /IvwSf� _1.f . sc� s /I- 3d' e•,srltrls .•t RL(Tt:t). unitk TrUN r -G >.? -,T, 71 2a iTu>sE Sf.OVIN ON THE RECORDED r. r . ._ . n-•rrr., es - VV147— �` C1Fj /T• •Corn t hereby certify that I have surveyed the toll, described property Zw— /a —j3L0GK,S C.4W PZJEYL. Anchorage Recording Fracinet, Alasicat and the improvemenu situated thereon are within the pre tines AM do net overlap or encroach on the pre lying adjacent thereto, that no impprevementr on etty lying adjacent thereto eneroactl On the premi Quos on and that there are no roadways, transm Lees or other visible easements on said property e as indicated hereon. Dated at Anchorage, Alaska III, 6 `7J gay of 4p.,%714 19 FRED WALATKA k ASSOCW. Engineers and Surveyors "e K �Srjr�lr -t VC Il'i•5 ._�� •.� ?� v 0 .tri W • «jl: N iM �7'Cb.QH. , 4rne /osep y« U ' (�railC Drilre .�H't'l/ �. E .4 S f - /24. /O' fl /IvwSf� _1.f . sc� s /I- 3d' e•,srltrls .•t RL(Tt:t). unitk TrUN r -G >.? -,T, 71 2a iTu>sE Sf.OVIN ON THE RECORDED r. r . ._ . n-•rrr., es - VV147— �` C1Fj /T• •Corn t hereby certify that I have surveyed the toll, described property Zw— /a —j3L0GK,S C.4W PZJEYL. Anchorage Recording Fracinet, Alasicat and the improvemenu situated thereon are within the pre tines AM do net overlap or encroach on the pre lying adjacent thereto, that no impprevementr on etty lying adjacent thereto eneroactl On the premi Quos on and that there are no roadways, transm Lees or other visible easements on said property e as indicated hereon. Dated at Anchorage, Alaska III, 6 `7J gay of 4p.,%714 19 FRED WALATKA k ASSOCW. Engineers and Surveyors R •'' SGS Ref. C 1061625 Client Name: Garness Engineering Group Project Name: Campbell His, 1-13, B3 Client Sample ID: Campbell His, L13, B3 Matrix: Drinking Water PWSID Remarks: SGS Environmental Services Inc 200 W. Potter Drive Anchorage, AK 99518 Tel: (907) 562-2343 Fax: (907) 561.5301 All dateshimes are Alaska Standard Time Printed DatoTme: 04/12/06 14:10 Collected Datefiime: 04/04/06 13:20 Received Date/Time: 04/04/0813:50 Technical Director. Stephen Edo/ Released Allowable Prep Analysis Parameter Results POL Units Method Limits Date Data . Init Nitrate NO 0.10 mpg EPA 300.0 10.00 04104/06 04/04/06 air Arsenic NO . 5.00 ugrL 200.8 10.00 04/04106 04106106 scl MUNICIPALITY OF ANCHORAGE O DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section 91 P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# a— 0� HAA# 1-E*)`%{r`LlS1 1. GENERAL INFORMATION Complete legal description Lot 13; 8toch 3; Campbef..E ftigW Location (site address or directions) 3847 E. 67th Avenue. Anchoaage., AK Property owner Ge_otge. Angus Day phone (503) 682-9286 Mailing address 8275 S.W. EtUgaen Road #59 w.it.sonv.EUe., OR 97070 Lending agency Mailing address Day phone Agent Le.e• Pe•hnuX/ Hoathwest Paopenties Day phone 278-3000 Address 3333 DenaU Staeet Suite. 220 Anehoaage. AK 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 2 '�, XXX NOTE: If community well system, provide written confirmation from State AVEC attest - Ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer XXX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72- )RN.1/Y1) F. MOA -21 S. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my invest'gation 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. S & 5 ENGINEERING Phone K - `I 7 Name of Firm 4 Eag • River loop Road No. 404 Address Eagle Rivor.Alaaka sgsn Engineer's signature 6. DHHS SIGNATURE 0 %y Approved for 2 bedrooms. Disapproved. Conditional approval for Additional Comments Date /0 / A y R09£RT G MA'AM fCif� CE•BaO 1to ' •, bedrooms, with the following stipulations: �i Gr f1 �Gr/`as Date // — / — %S ItITlr 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. rxms m.•. wo er. Mon m • r Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 82VV Street, Room 502 • Anchorage, Alaska 99501• (907) 343-4744 Static water level Well production WATER SAMPLE RESULTS: Coliform 0 VIK V�K g.p.m. aF RSI T•t...rw 3 J- Nitrate 0.1 Other bacteria 0 D,W of sample: /o / t1 /,r 4 /.I s / %S— Collected by: s & S ENGINEERING g1034 EIIIII RIM MP Kola No. 204 B. SEPTIC111OLDING TANK DATA P v,0 L / c St ti s,Z Eapl* Riwr, Alaska 99577 Date installed Tank sive Number of Comparlm eanouts (Y/l� Foundation cicaapgt (Y/N) It M) High water alarm (YM) DoofPPumper C. ABSORPTION FOLD DATA P V 6 L, t_ S E t✓ E A Date installed Length Width_ Eftecuve absorption area Date of adequacy test Soil rating (g.p.d.M' or ft'/bdrm) _ Gravel thickness below pipe _ Monitoring Tube present(Y/1� Results (Pass/Fai� Fluid depth in absorption field before System type over field (YIN) For bedrooms Immediately atter_ gal. water added (in.): Fluid depth erftvtinwes later: Absorption ram = a.p.d. WOON19 treatment (pan 12 months) (Y/N) If yes. give date Health Authority Approval Checklist ; 0 Legal Description: L o r' 13 d c k 7 Parcel I.D.: 01,y-076 Gp t' tcc rJ 4rFNtj f/O t'r7 N A. WELL DATA qpe A/R , v A r C If A. B, or C, attach ADEC letter. ADEC water system number nWeil Log pint (Y@ N O Date completed v /'► 4 Y _ Total depth Y 5- *- Cased to 4 0 + Casing height (above groin) Sanitary seal (f rN) Y t S Wires property protected (ON) Y f Jr M PtA ho w.t F,LE S FROM WELL LOG ATINSPECTION Date of test t! / K / o s- / a! 3— Static water level Well production WATER SAMPLE RESULTS: Coliform 0 VIK V�K g.p.m. aF RSI T•t...rw 3 J- Nitrate 0.1 Other bacteria 0 D,W of sample: /o / t1 /,r 4 /.I s / %S— Collected by: s & S ENGINEERING g1034 EIIIII RIM MP Kola No. 204 B. SEPTIC111OLDING TANK DATA P v,0 L / c St ti s,Z Eapl* Riwr, Alaska 99577 Date installed Tank sive Number of Comparlm eanouts (Y/l� Foundation cicaapgt (Y/N) It M) High water alarm (YM) DoofPPumper C. ABSORPTION FOLD DATA P V 6 L, t_ S E t✓ E A Date installed Length Width_ Eftecuve absorption area Date of adequacy test Soil rating (g.p.d.M' or ft'/bdrm) _ Gravel thickness below pipe _ Monitoring Tube present(Y/1� Results (Pass/Fai� Fluid depth in absorption field before System type over field (YIN) For bedrooms Immediately atter_ gal. water added (in.): Fluid depth erftvtinwes later: Absorption ram = a.p.d. WOON19 treatment (pan 12 months) (Y/N) If yes. give date D. LIFT STATION Date installed Manhole/Access (YM) High water alarm E. SEPARATION DISTANCES Sire in *Datum at* "Pump aft' level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Sepuc/hohling tank on lot t" 1.4 : On adjacent lots Absorption Geld on la Ai /4 ; On adjacent lots A,1.4 /n Public sewer main J1 y I * Public sewer manhoWcleanout $ S r i Sewer /septic service line So +" Lift station N I R Orr APrA4vtd Ay DBG AT TI.1e CF IivpTA{LArloly SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Water main/service line Surface water/drainage SEPARATION DISTANCE FROM ABSORFTION FIELD Building foundation Surface water F. ENGINEER'S CERTIFICATION Absorption Wells on mam/semce line Driveway, parking/vehicle storage area Wells on adjacent las Property line / certifv that I have determined thru field inspections and review ofMrmieipai records in cumfo/mance with rMOA R-1.4 guidelines i effect on this date. Signature J/��'►�J i*' Engineer's Name R6,9 # X 7-C • (0414^/ Date 10/2y/,15` HAA Fee S .nJ� Waiver Fee $ Date of Pa%mcm /n .( S Date of Payment Receipt Number _ l�3-�� Receipt Number Rev. 8195 OSS: haa.wk.doc Faq aotusr C. COWAN W CE - 8801 ALME Environmental Services Iqc. Laboratory Division C:6E Refs 95•+616.1 Laboratory Analysis Report Est. Anal Ms. rix NATER Limits Date Date Init Client Sample ID L13 SLIU CAMPBELL NTS 30/06/95 CMR Client Name S i s ENGINEERING WORK Order I8637 Ordered By R. COWAN Printed Date 10/11/95 61 10:16 bre. Project Name Collected Date 10/05/95 m 09:00 Are. Project# Received Date 10/OS/95 a 11:30 bre. PNSID UA Technical Director STEPHEN C. EDE Released Sample Remarks: SAMPLE COLLECTED BY: C.K.M. oC Allowable Est. Anal Parameter Results Qual Dnits Method Limits Date Date Init -------------------------------------------------------------------------------------------------------------------- Nitrats-N 0.10 D ey/L SPA 3S3.1 10. 30/06/95 CMR .............................................................. .......................... a ......... a................. • See Special Instructions Above DA . Unavailable •• See Sample Ramarks Above NA - Not Analyzed C'. Undetected, Reported value is the practical quantification limit. LT . Lau Than D;- Secondary dilution. OT . Greater Than C 200 W. Potter Drive. Anchorage, AK 89518.1606 — Tel: (907) 562.2343 Fax: (907) 561.5301 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA. FLORIDA. ILLINOIS, MARYLAND. MICHIGAN, MISSOURI. NEW JERSEY. OHIO. WEST VIRGINIA 200 p89'DN ITZIP69LOG « ENIIS31 1d1x1344M 170:11 56/11/01 MUNICIPALITY OF ANCHORAGE �. Department of Health 8 Human Services 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. k y — O7 — OQ HAA 4 14-0-1 C o So 9, 1. GENERAL INFORMATION (Must be completed prior to submittal) ENYIF�NMEWAI. SERVICES DIVISION (a) Legal Description (include lot, block, subdivision, section, township, range) NOV 26 L990, Location (address or directions) 3A47 E.L7 tt (b) Property owner nIM ITRI BADER Telephone: (home) 345-2160 Business Mailing Address 13341 CANYON QD arfCH_ 99-516 (c) Lending Institution 14oRTHLAAh P10ieTAA6E Telephone '274- W50 Mailing Address 9UM' DENALI ANC1I, 89503 (d) Real Estate Company and Agent FORTyrtE PROPERTIES R f LL DAIiLS Address 3000 "A ST ANON 99503 Telephone 562- 7653 "= �'�'• (e) Mail the HAA to the following address: (or check here ¢Y if hold for pick up.) I `P List contact person and day phone number below: i- I - TED Mocer Pfs-- 13 S`S 2. TYPE OF RESIDENCE Single -Family Number of bedrooms 2- 3. 3. WATER SUPPLY 1 Individual Well Community O Public 0 Note: It 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 ❑ PublicV Community ❑ Holding Tank O Note: If community well system, must have written confirmation from the State Department of,Environmental• Conservation attesting to the legality and status.14. 72-M In«. veal Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by myseal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system Is safe,p 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. NameofFirm FLATTOP TECH SVCS Telephone 314S- 13S,5 - Date Afc,✓ 20 1990 � -� aF'A4q�A �Y.r.�.••.••••.•••••••.•.•••a J.F:;;?pl�,c,; •��,,,,,,,• gineer'sSeal •^ �TH2000.;£ F. MOORE � 2� J..> •. CE -3539 ; a 6. DHHS APPROVAL:.•, Approved for' 2 bedroomsby JO1+1y �'� Date 11�Z9�90 Approved K Disapproved Conditional Terms of Conditional Approval ,•y The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 omisslons In the professional engineer's work. 72-M (RW. UN) On% Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) • Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: i.vf 13, Q/acfr 3 Cana bell H& A. WELL DATA Well Classification Pr'I bcx iLe If A. B. C. D.E.C. Approved (Y/N) Nal. Well Log Present (Y/N) H—Date Completed = 1968 Yield _'::,6 1:o///90 Total Depth 8S' Cased to :;, Ho' Depth of Grouting __ N,,4• Static Water Level 2-S' Pump Set At > 'VO' Casing Height Above Ground l2 ° Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N) N SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot N.A. i CZhy ; On Adjoining Lots - N- �• To Nearest Edge of Absorption Field on Lot M.A• <C'Ay Sewe'L ; On Adjoining Lots To Nearest Public Sewer Line y'1' To Nearest Public Sewer Cleanout/Manhole 6S' To Nearest Sewer Service Line on Lot 7 2SF Water Sample Collected by FIc7 f 7.ech Svc ; Date 11 / 16 /90 Water Sample Test Results-SafuiaCA0!rn - 0C01'Jo..,/4'001a•e. 40.1njl-e n7/mAe-N Comments Ivelf fh From 1972 /h4R. Durpnc well Tlacu tod on /11/6/90 s�e.r/k. B. SEPTIC/HOLDING TANK DA% ,m[ Date Installed Size`` A) ?EG ojqwnsc of cve[f-xewer s�sa�a/r.., o4t f ai Sewer hAf War IAxAc tt ece. No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Foundation Cleanout (Y/N) Date Last Pumped ;for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) _ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well To Property Line To Water Main/Service Line _ To Building Foundation To Disposal Field To Stream, Pond, Lake or Major Drainage Course Comments -Ret idtncev S rvect i'y i}1"W4C Sewe o - 72-M (R". VN) Front Page 1 of 2 C. ABSORPTION FIELD DATA C. A.) Soils Rating in Absorption Strata Date Installed _Type of System Design Length of Field Width of Field � Depth of Field Gravel Bed Thickness Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well To Building Foundation To Existing or Abandoned System on Lot ; On Adjoining Lots ' To Water Main/Service Line To Cutback (if present) _ Statndpipes Present(Y/N) Date of Last Adequacy Test To Property Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Residence served by Awwu ,ecaylic Sewer D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level'at "Pump Oft" Level at High Water Alarm'Levetat Vent'(Y/N) Tested for ' ' Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) " Comments "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 of this I 4��0 A4 Signed . Svcf � .•,......,.gv�Od --� �:;�� Company-Tech vGj•• Date Now ?=! 1990 ........................ Engineer's Seal ..... 90 -O 19 MOA No. ...... TAEODO.iE F. A)OORE j l: C t � E-35s� Receipt No. as 57 4 (!gln Date of Payment Amount: $ t -r L. -r_ ' Receipt No. _ Waiver Fee: $ Date of Payment 72-M (Ft". ?/W) Beck Page 2 of 2 GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 DATE RECEIVED: ,/,�2 S'/7.a INSPECT• TIME• REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES FOR 1. APPROVAL REQUESTED BY: .. in(lI /'-.;�.i--r/� �i'��• ADDRESS: PHONE: It%✓�i^"1. 2. PROPERTY OWNER:_PHONE: 1� 3. LEGAL DESCRIPTION: '�•t /� /?%l-/ .? . �it�y, �/ l��i�% �J_.r�• 4. TYPE FACILITY TO BE INSPECTED:../? ;,IY�/STREET -,Yll NUMBER OF BEDROOMS: 2 l4117 5. WELL DATA: A. TYPE B. DEPTH F.� ` /%L C. SIZE D. CONSTRUCTION 0Af E. BACTERIAL ANALYSIS 6. SEWAGE DISPOSAL SYSTEM: A. SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM ON BACK) i 1. SIZE /CGG iilll--ori 2. AGE %l % r•: l/i�� : «� 3. - MANUFACTURER /�^ fi i%l� ! /�� ,•� �£� /1�� 4. INSTALLER f. APPROVAL REQUEST. bR SEWER & WATER FACILITIL. ' PAGE TWO B. SEEPAGE PIT 1. SIZE 2. LINING C. DISPOSAL FIELD 1. NUMBER OF LINES 2. TOTAL LENGTH 7. REQUIRED MEASUREMENTS A. WELL TO SEPTIC TANK B. WELL TO SEEPAGE PIT /� S C. WELL TO SEWER LINE /n D. WELL TO PROPERTY LINES f S E. WELL TO OTHER POSSIBLE CONTAMINATION i 1 F. FOUNDATION TO SEPTIC TANK 7 i / G. FOUNDATION TO SEEPAGE PIT H. SEEPAGE PIT TO PROPERTY LINE / h 8. COMMENTS: APPROVED: _ lig. 5 DISAPPROVED: DATE: 13 17 Z_ DATE: APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED. GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY C,Kcb APPROVED: _ lig. 5 DISAPPROVED: DATE: 13 17 Z_ DATE: APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED. GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY �•1 � / n �,� Y ^ 037 REQUEST FOR APPROVAL OF 712- - INL, VIDUAL SEWAGE AND WATER FACILIM ./�� " (Fill out in Triplicate)` Q f .2 .of person requesting approval0.//,1w4//-^ t 2. �!�nq of property i owner I&Ilzzz 3. rlal .escriprinn ,/<7 �' 4. II%iml.ea ..f J,edt,wms in house S. Water Analysis: / a. Eacter•i a 1 / -��r C9 b. Deterpentt c.. w-1-1 data: a. b. Leptis C. Casing Siz: d. Distance from well to closest existing or proposed: 1. Sewer lira 2. Septic tank �/— 3. Seepage Areas 4. Cesspool, ' 5. Property Line.- 6. ine-6. Other sources of possible contamination, i.e., creeks, lakes, houses, barn, drainage ditch, etc. 7. Sewdee dispocal system. f o -n P -A a. Age of system > C a s b. Septic tank capacity in gallons_/ejne:� C. Name of septic tank manufacturgr 1. If "home made" show diagram on reverse side of this form. d: Disposal field or seepage pit size and type 1. Distance to property line to house fw:ndation-��±�� a., Percolation Test -results f. Percolation Test performed by a- Use the reverse.side of this form to show diagram. Diagram should include `the following inforr.ation: property lines; -well location, house location, n. -O is tank location, disposal area location, location of percolation test, al•d direction of Around slope. 9. The i„t•.,,.,ri�n .on this form is true and correct to the best of my knowledge. S,gnature of Applicant Date Signed TO BE FILLED OUT BY HEALTH DEPAETME,T PEPSOHNEL OS-. ae above described sanitary "”— nitary facilities are hereby approved, subject to the .ollowi nsconditions: Conditions: F7 The above described sanitary facilities are disapproved for the following reasons,. Signat e o ici ' Date - • }o s. Approval is valid for one year following the date of approval. CI'J:cw ' . REQUEST FOR APPROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Trioll-rate) 1-0 L.. Name of person requesting approval 2. Name of property, owner 3. LePa1 description i. 4, Number -o£ -bedrooms in house C_ l S. Waten_P.nalysis: -4 j a. Bacteria-,/- � 3J- b. Detergent (a 3�7 E.67" j1\110% 6. Well data: a. Type \` b. Depth %3 n c. Casing Size__ �o , d, Distance from well to closest existing or r000sed: 1. Sewer line 2. Septic tank 3. Seepage Area 4, Cesspool�---Z.L 5. Property Line 6. Other sources of possible contamination, i.e., creeks, lakes, houses, barn, drainage ditch, etc. 7. Sewage disposal system. a. Age of system b. Septic tank capacity ons c. Name of septic tank manufacturer 1. If "home made" show diagram on reverse side of this form. d; Disl field or seepage pit size and type a- — A h 6 1. Distance to property line 7_to house foundation. e. Percolation. Test 'results— , f. Percolation Test performed by Use the reverse side of this form to show diarram. Diarram should include ,the foilowing information: tPoperty lines; -well location, house location, %,grtic tank location, disposal area location, location of percolation test, and direction of ground slope. 9. The Information on this form is true and correct to the best of my knowledge. S rnature of Applicant Date Signed TO BE FILLED OUT BY HEALTH DEPAP.T14ENT PEPSONNEL �__ e above described sanitary facilities are 'hereby approved, subject to the '.'-ollowinv ennrlitinni. - Conditions M A -t a 1'e "": M The above described sanitary facilities are disapproved for the following reasons: Signa�jre re or 12ppicra;j., " Mate 4 J%p %',(..J Approval is valid for one year followin£ the date of approval. CPJ:cw . Cf 11,4 REQUEST FOR APPROVAL OF ✓/ At m • INDIVIDUAL SEWAGE AND WATER. FACILITIES / �f 3 0 n• (Fill out in Triplicate) ac•K q/ I0. a -3 ':,. Vane of person requesting approval 2, 11ame of property owner 3. Legal description /L 3" 4. Number'of bedrooms in house 5. Water Analysis: a. Bacterial jj b. Detergent 6. Well data: a. Type b. Depth c. Casing Size d. Distance from well to closest existing or proposed: 1. Sewer line 2. Septic tank 3. Seepage Area 4. Cesspool' 5. Property Line 6. Other sources of possible contamination, i.e., creeks, lakes, houses, barn, drainaZe ditch, etc. 7. Sewage disposal system. a. Age of system b. Septic tank capacity in gallons �1 c. Name of septic tank manufactur@r 1. If "home made" show diagram on reverse side of th s form. d: Disposal field or seepage pit size and type - 1. Distance to property line to house foundation e. Percolatiou. Test 1esults f. Percolation Test performed by a. Use the reverse side of this form to show diagram. Diagram should include the fogylowing information: property lines; -well location, house location, "ptic tank location, disposal area location, location of percolation test, and direction of ground slope. 9. The Information on this form is true and correct to the best of my knowledge. Signature of Applicant Date Signed TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL C:I�he above described sanitary facilities are hereby approved, subject to the -fo'llowinp conditions: Conditior.s: M The above described sanitary facilities are disapproved for the following reasons: Signature of Ff_ icial.; t. Date ri.; Approval is valid for one year following the date of approval. CPJ:cw r .. t -a .#.: - I. -t a_ �•. ...�. -.•. .. .� .. 1 ;;\r,n n.'L'..'u.n additional bedroemp - - ?- _�jj - y t_�-: . ( ryt —I -1 T- + i vuTSM SUvecY l!'. %rSTIM FOR L� I-tl_� ,J,-., I'la!.. tT- t i1v AGI CI rOS�t lf: j`rf PIRT II.—TO BE COMPLETED BY HEALTH DEPARTMENT of p,SPt CTJ.5 .y t. T_r�_I t_ .. t -a .#.: - I. -t a_ �•. .a .t Y-. 1� . ♦`. 7-T-1 1 - - ?- _�jj - y t_�-: . ( ryt { -1 T- + tT- �-4 - 7T--} 4 �t � - -t.. �t � r� - �-r- Y7 - t -4+ t+- ..4 1 ..r.l- , r 1-14- -11�-t.. y y( t 1. 1 y. tl r -4 4- -♦y_ rT-�1 -a-iL .i -E 1 t + t f- Y - 1 -� 1 ♦•- t a" rt -t' "; 1 f.1--1" .i ;' -� t 44 - It is the opinion of the 1:1 State E3 Count ® UKdl Department of Health that this individual warer-supply system i ® is is nor satisfactory as a domr.nc water supply for the subject property. It is the opinion of the Cj State [] Count} XX Local Department of Health that this individual sewage -disposal sys. tem with pngocr maintenance: ® Can be expected to function satisfactorily, and Cannot be expected pectrd to function satisfactorily is not likely to create an insanitary condition I DATE SIGNAPJRET TITIF 4/4/72, / .' Sanitarian NOTE: The health authority should Complete Jho opprop•lote opinion statement above and sTx date, signature end title In the Spot** pre.ided. 11 Use of the above gdd for health Deportment Inspetter's Chatch as well as ase of the back of this form Is of the option of the health o.therity. PART Ill.—FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: 1 have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that the Individual water -supply system be considered ElAcceptable n Not Acceptable Srwage disposal Iv considered 11 Acceptable n Not Acceptable. DATE 'SIGNATURE I HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM ❑ CHIEF ARCHITECT DEIUtY FOR CHIEF ARCHITECT ENA Form 737: R.. ria, 1958