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HomeMy WebLinkAboutT15N R1W SEC 5 LT 105Tom Fink, Mayor MuniciPality of Anchorage ' Department of Health and Human Services 825 '%" Street December 2, 1993 Ann M. Martin PO Box 670538 Chugiak, Alaska P.O, Box 196650 Anchorage, Alaska 99519-6650 343-4744 99567 0538 Subject: T15N R1W Section 5 Lot 105 Permit #SW920401, PID #051-082-09 The subject permit, issued December 2, 1992 by this office single family well ahd/or on-site wastewater system, has expired as of December 2, 1993. A new permit must beiobtained from this office for a well and/or on-site wastewater system NOT installed by the expiration date. for a If you have drilled the well, a well log must be sent to this office for documentation of the installation and to close the permit. If a licensed Professional Engineer has inspected the installation of the On-site wastewater system, the original as-built inspection report must be sent to this office for review, approval andldocumentation. All inspection reports must be submitted within 30 days of construction completion. When applying for a new permit, the fees are: $320.00 for an on-site wastewater permit; $120.00 for a well permit and $440.00 for a combzngd on-site wastewater and well permit. If you have any questions, please call this office at 343-4744. Sin erely, i On-site Services enc: Copy of Permit PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT !OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW920401 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:MARTIN ANN M OWNER ADDRESS:PO BOX 670538 i, CHUGIAK, AK 99567 PARCEL ID:05108209 ~ LEGAL DESCRIPTION: T15N R1W SEC 5 LT 105 LOT SIZE: 108900 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED:12/02/92 EXPIRATION DATE:12/02/93 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) ANDiDRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. RECEIV~,D BY: ISSUED BY: SPECIAL PROVISIONS: EXISTING WELL TO BE ABANDONED PER CODE. DATE: DATE: AS-BUILT 1 hereby certify that I have surveyed the following described property: ~,.L.,/-.'/, L-o"t" I~b~- Anchorage Recording Precinct, Alaska, and that the improve- meats situated thereon are within the property lines and ~io not overlap or encroach on the property lying ad ,~cent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and tfiat there are no roadways, lransmission lines or other visible easements on said property except as indicated hereon..' Dated at Eagle River, Alaska · dc;~' . I9 g'~ · this za' '~ day of ROBEa~ C. JOHNSON -Rca~, SCAI F Rei~i~tored Land ~urvevo, Mo. 880-LS 1' ~ .~ ~ Box 77-0456, Eagle Riv~'r, Alaska 99.577 Phone (907) 694-2543 MAILING ADDRESS f LEGAL DESCRIPTION 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 PHONE ~W DISTANCE TO: Lengtb of No. of lines each line Top of tile to finish grade Type of crib DISTANCE TO: Class DISTANCE TO: Inside length Liquid de~pth ~ [~W//~ PERMIT NO. Material Liquid capacity in gallons Nearest lot llne PERMIT NO. ~gth of lines Trench width inches Distance between lines beneath tile Crib dept~.~ B u ,I di n g ~9~J~ t i/¢g~, 'Driller Sewer line Total effective absorption area inches PERMIT NO.~., ~, Nearest lot line //~,~ ~'4' ' Distance to lot line PERMIT NO. Septic tank ' Absorption area(s) \.~ OTHER P I ~Pj~A~T F.~, A L8, INSTALLER REMARKS 72-013 (Rev. 3/78) LEGAL MUNICIPALITY OF ANCHORAGE '-iHealth and Environmenta? Department nrotection 825 !Street, Anchorage, AK. .9501 I 264-4720 * * * HANDWRITTEN PERMIT * * * Permit ~ WELL AND~ ON-SITE SEWER PERMIT J , Applicant: ~c,~ ¢ ~/--;~ Mailing Address: ~oo~t~on~ I ~hone ~e~: ._~.~ Type of Soil ~sorption System Is: Trench: Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: {~ Soil Rating(sq.ft/br) The Required Size of the Soil Absorption.~System Is: _ / ~'[~ENGTH $ GgAVEL DEPTH / WfDTH The length dimension is the length(in feet) of the trench or dr~i~field. The depth of a trench or pit is~the distance between the s~rface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minim~ depth of gravel between the outf~ll ~ipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~ GALLONS * * Permit applicant has the respgnsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will s~rve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this departmen will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee for a private well or ].50 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a conlmunity sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply.: Specifications and construction diagrams are avaJ. lable to insure proper installation. * * * PERMI$ EXPIRES DECEMBER 31, 1 9 * * I certify that: (1) I am f~miliar with the requirements for on-site sewers and wells as set forth by the Mu~.icipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if is include more t~ 3 bedrooms. ~he residen~/~ zemodeled to Signe~: .//~ ~,. ~.-'~.<"7 Issued b Appli~/~t '~ ~ Date: / SWP/024 (1/81) <TI.,.IO COFIF'I:tFCFf'IEI",FI' l'Flhll:::::' IE::,, 112E :~:7, % JC3i IqOTE :::,.i:~5 FT. I';i:E~:.:!L.I:I: RE';'~ TI40 IqOTIZ -' I'"ll:l"r' [;?.E[;!LIIF?.E I.., ]: [::'"l' ,:;TI40 COHPF:h';;:'T'FIIENT TFII",II':::,':' :1: cIEr;?.T ]:l::'.r' Tiff:IT: :1... :[ I::11'1 F'FIFI:I:I..:I:FII;?. I,.IITll 'THI!; I:;;:E:QI,,,IIRE:HENT':'i!; I':O1:;'. OI'.,I--,:5]:TE ::~;EI.,.IE[;?.E; I':ll'.dl::, I.,.IEL, I._.'.2; F:IS SET F:'OF?.TII EJ:~.~ TI. lEE f, ILIi'.,I :t: E: ]: F:'F'IL :I: T'.r' O1::' F'iI'.,ICIIEII';:I':IEiE FINE::, "I"HIi~: ~;']'i::i'I"E: Ell:::' ;2. :[ I.,.I:I:I...L ]:N~2;'f'F:ILL. TIlE fi',",-'E;TEH :1:1'.,I FIC:CCII;?.[::,F'INC:E: 1.,.I]:'1"1.'1 THE: CODEE; RI",ID I"IFI',,,'E F't OOP"¢ O1::' TIlE CODE: Sl.,li'"ll'"ll::lf;?."r' FIND [}' ]: l::'tG[:;:l::li*l F:I"FTI::ICI'II"IEN'I"S I.'.IH:[E:H F:'IEI'~:H :I: T. :% ]: UI",IDL::I';:~E',TI':II",ID THF:i"I" 'I"IIE; OI",I'"2;];TF :~E:I.'.IEF;! '.~,"~":'?f'lEl'"l i"lF:l'¢ I:?.E6¢J:[I:;~:E IENLF:IF?.EiEHE;I',IT :[]::' 'I"I'IIZ F~:E:2~;:CDIZI",IE:IE :[:~; i;%I"IOI::'IL::I....I!E:I3' '1"O :[NC:L.I.J[::,E: HOI';;:E! TI'II::II",I 4 E~E:E:'I:;?.CtOH'.~. F'E:I:;::H :[ 'I" I::IF'F1.,.:I:CJ:IIqT I'IFI'.E; 'FILE: I:~'.[iE:SF'Cdq~:';:[I:3]~L:[T"r[ TO :[I",II::'OIE:I'"I f:'E:I:;:)~OI",Ii",IEL. THE: ZI",I:iE;TJ:'IL.L. FIT:[OIq .]:N:E~F'E:CT:I:ON:!i; Eli:' I:::ff',l~r' I'.IEi:LL.2~, FID,.]'F:IC:IEI",IT TO 'f'H]:rE; I::'F~:OF'EI:;?.T]¥' I:::11",!1::' THE: I",ltJHIi3[ii:l::;: OF' [;?.E;:5:CI:::'IENCIZ'.E; TIIF:IT ?HIE P.IE:LL. P.IZLL :~IER","E:. ]:F I::'i L]:F:'T :i~;TI::IT:I:EII",I :[:ii; ZI",I:E;TFII..[..IZ[:.h, I':dl",l E:I..ECTf;~::[C:FIL. F'EF:'.I'I:[T I::'IND :[i",IE;F'E:CT]:Oi",I I'"IU:E',T E',IZ OEFFI::'I.'I.'[",IE:[::'. FI~;"[id.J:t:I....TE; C:F'II",II",ICFI"! E',E: 13F'i:::'RO',,,'EE:' I.,.I:[THOIJT F'IN EL.I!ZCTF?.]:CF:IL I';:LEF'OF;!T. THE: EL. EC:"FI;?.:CC:FIL. I.'.IOF?.I( HLI:!.';T E:E I::'OI",IE: E:h" FI I._:[CIEI",I:E;EI::' IEI_I:]:E:'f'I'.;'. :r E: :[ FII'.,I. Permit #__ Applicant: Location: MUNICIPALITY OF ANCHORAGE oepartmen+ ff Health and Environment.' Protection 825 ~ Street, Anchorage, AK264_4720 ' ~9501~~J * * *]HANDWRITTEN PERMIT * * WELL~,ND/OR ON-SITE SEWER PERMIT ! Phone Nuraber: Legal Description-: / /~ ~-~ . ~'~/~ ~-- Lot Size: Type of Soil Absorption System Is: Trench: Drainfield: ! Seepage Bed: ~ Holding Tank: T Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br) ~.~S~ ] The R~equired Si~e/o~ t~e Soil A?sorption System Is: DEPTH LENGTH ~ . WIDTH The length dimension is the kength(in 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 excavationl(in 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 excavat~on](~n feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecutionI. Minimum distance between a wel.1 and any on-site sewage disposal system is 100 fee~ for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum dist!ance from a 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 this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMI EXPIRES DECEMBER 31, 1 9 8 3 * * * I certify that: (1) (2) (3) Signe~: I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. I will install the system in accordance with codes. I understand that the on-site sewer system may require enlargement if the residence is remodeled to include m°re 2~ 3~~ Issued by: SWP/024(1/81) MUNICIPALITY OF ANCHORAGE DEPARTMENT OE HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOLES LOG - PERCOLATION TEST 6 8 .. SOILS LOG [] PERCOLATION TEST DATE PERFORMED: ,,tO/V./ SLOPE SITE PLAN 10- 11 13 14 15 16 17 18 19 2O COMMENTS WAS GROUND WATER ENCOUNTERED? / IF YES, AT WHAT (.~,~'~ / E; DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) :FEST RUN BETWEEN FT AND FT /'2--/ CERTI FI ED BYe/' DATE: ,5:4- -:AGLE~ RIVER, ALASKA 338-5312 JoE GIIELAROWSKII DRILLING CO. LIFETIME ALASKAN SERVING ALASKA PO. BOX 772847, EAGLE RIVER, ALASKA 99577 DEPTH OF WELL .............. )..t~!i!~5ii .................................................... D OF FORMATION: FROM ......... [2 .......... FT. 'FO FROM ......... (.] .......... FT. TO FROM ......... :i,(:! ....... Ft. TO ....... ~..;.~ .......... ........ ~ ............ FT ......... ] .1..~ .,~ .............. FROM .......... :i ~,-". ....... FT. TO FROM ...................... FT. TO ...................... FT .................................... FROM ...................... FT. TO ...................... FT ............ ! ........................ ...................... FT. TO ...................... FT ............ i ........................ FROM FROM ...................... FT. TO ...................... FT ............ i ........................ FROM ...................... FT. TO ...................... FT ............ , ........................ FROM ........... : .......... FT. 'FO ...................... FT ............ , ........................ FROM ...................... FT. TO ...................... FT ............ ........................ FROM ...................... FY. 'FO ...................... FY ............ l ........................ FROM ....................... FT. TO ....................... FT ......................... FROM ....................... FT. TO ........................ FT ........................ FROM ....................... FT. TO ........................ FT ........................ FROM ....................... FT. TO ........................ FT ........................ FROM ....................... FT. TO ........................ FT ........................ FROM ....................... FT. TO ........................ FT ........................ FROM ....................... FT. TO ........................ FT. MUNiCIpALITY O~ ANCH~R'~ ................ FROM ....................... FT. TO .~.EPT OF HEALTF~t~ FROM ....................... FT. TO ........................ FT.. ....................... JUL 2 FROM ....................... FT. TO ........................ FT ........................ FROM ....................... FT. TO .................. FROM ....................... FT. TO ........................ FT ........................ ?L. INFORMATION: DRILLER'S NAME .................... "J.....]...i ........................................................................ / :- w ~ />'Z--/~_ TJ~ bv l '?-Ft i0 a- i Z. '~ ~,HNICAL '~'' 0 Et E GEO~ "" ' ~_, DEVEI..( MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 ,'lussel! Oyster F.'~rl Ellis !~oils ~t Foundations Land Development for: ,: ',, ,l;,,:er Encountered: Yes No ~i'" yes, M~at, depth_~ .... XnstMlati0n: Seo[~e ~it ...........[)rldn Fl~'id ......... Mu,, cilpality of Anchorage MEMORANDUM DAT I]: TO: FROMI SUBJECT: May 21, 19761 File Principal Environmental Control Officer T15N R1W Secitmon 5 Lot 105 At 2:00 p.m., I visilted the property above. Due to the two (2) soil tests Which were taken, the best of which places the water tabile at 63 inches, I can not see any way/~//~h~ch an on-sate sewer system could be installed. RoDert P. Neale Principal Environmental Control Officer RPN/ljh ~h~ ycau tt l~ q~lt~ po~ibl~ t~at {',~t~ water tabl~ eould ;,la~ ow~ ~.~th~ dnrt~ff th~ ext~:nMon 2~. MUNICIPALITY OF ANCHORAGE DEPARTMENT oF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF I~SPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 ' Application Date ® GENERAL INFORMATION (a) (h) (c) Legal Description, (include lot, blo(~k, subdivisi'0n, section, township, range) Location (address or directions) Applicant Name ~~L.~Telephono: Home ~- ¢~./~ Business Applicant is (check one): ~endin~ Institution ~ ' Ownor/builder Buyer ~ ' Other ~ (explain): (d) Lending Institution ~.~.~~_ Telephone Address _. / (e) .eal Estate Compaay and Agent : ~ff~-~¢/':~-~=¢7 Address (f)'--Me+Hhe HAA to the following address: TYPE OF RI-'SIDENCE Single-Family ,~ Multi-Family Number of Bedrooms Other 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. SEWAGE DISPOSAL Ousite PtJblic [] 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 2 ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION AS certilied by my seal affixed hereto and as of the validation date shown below, I varify that my investigation of this Health Authority Approval shows that the on-site Water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of Structure indicated herein, I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the or3-sita 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 i, i hOiNl:l=RIN0 Name of Firm SR-B--~96-X- + Address __ ~,~RiVERFAK_9~;577 Date Telephone Approved'~'r~~edrooms b~~ l*~'~'~r'~E' ~/~A Date ~'- ~;~ Approved ~ Disapprovec~ Conditional Terms ol Corrditional Approval · ; :, ! CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska, The DHEP does this as a coudesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the 'professional engineer's work. Page 2 of 2 72 825 (1~/841 WELL DATA Well Classification Well Log Present ~r,,~-. Total Depth _ '~ Static Water Level UNICIPALITY OF ANCHORAGE (MOA/ EAI..TH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITy OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAt, PROTECTION 264-4720 I¥1A¥ 0 ? 1986 Legal Description: ~ ~"~ If A, B, C, D.E.C. Approved (Y/N) /_ ¢, I~ate Completed /- / [- ¢'¢' Yield Cased to ~ ~¢ ~ Depth of Grouting -~ ~¢~ / ~ Pump Set At ~0 Casing Height Above Ground Electrical Wiring in Conduit Separation Distances from Well: To Septic/Holding Tank on Lot Sanitary Seal on Casing (~/N) Depression Around Wellhead (~'J~' /~9 / ~- ; On Adjoining Lots /¢,0 ( ~- To Nearest Edge of Absorption Field ~)n LOt __ /,¢~o /'~ ; On Adjoining Lots To Nearest Public Sewer Line . ?'J'/~- To Nearest Public Sewer Cleanout/Manhole -~- To Nearest Sewer Service Line on Lot Water Sample Collected by · ~i ~"q ~ I ~-4 ~/~.¢'/,,4' 6 ; Date Water Sample Test Results .~,:~p-~,/~ ~./4~---*'T-O ~ y Comments B. SEPTIC/HOLDING 'rANK DATA Date Installed~'-' ~'~¢:~¢ ~c4' Size Standpipes ,~/N) Air-tight Caps ~N~ Depression over Tank (.~ Pumping/Maintenance Contract on Fi'le (Y/N) Holding Tank High-Water Alarm (Y/N) ~ Separation Distances from Septic/Hol!ding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course Comments Page 1 of 2 72-026(11/84) -7__ No. of Compartments Foundation Cleenout Date Last Pumped ~"--~"%~--- ;for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ,.~ ~ ~ Width of Field Square Feet of Absorption Area ~?O Depression over Field Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well /0 0 I ,'- To Building Foundation Lot To Water Mafn¢Service Line //'~' ~ '(/"/~'~' Type of System Design ~E~/~/~ Length of Field ~'~--" Depth of Field /~¢2~,,,t./~ ._S /~'_r ~'~,4.4 / Gravel Bed Thickness / ! Standpipes Presen~4N')' Date of Last Adequacy Test To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots -'-'-'-'-'-'-'-'-'~ To Cutbank (if present) Comments D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments "Pump Off" Level at Vent (Y/N) //_ Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all M CA and HAA guidelines in effect on the date of this inspection. S & S ENGINEERING Signed Date SRB 196X Company E I E f ¢vlOANo. Receipt No. ~ ~'~Cl 0(~ Date of Payment ~-'7~'~ Amount: $ (¢ t~'°'~ Page 2 of 2 1986 72-026 (11/84) .MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRON~,N~I"A~, HEAL%~ DEPART~3Brf OF H~kLTH AND ENVIRONMENTAJ~, PROTECTION APPLICATION POR HEAL~.I~ AUTHORITY APPROVAl, CERTIFICATE ! Application Date .. r 1. General Information ~ ..... (a) I~gal Desc~iRtion Jxinclu~de~.lot, block, subd~vision, ~ection, tc~nship, range ) Location (address o~ di~e~ction~?r)~ /, x /.z~ - 7.,, .... ...... (c) Applicant is (check on~), Lending Institution (d) l'~nding Inatitution Address ~]; &mer/builder~_'~; Te ].e_phone (e) I~al Estate Coo & Agent Address Multi-Family t----~-' Other (d~scribe) Individual Well ~ Co~nunity L--~ Public [~'-~.. Note: If cc~munity w~ll system, must have v~;itten ccnfi~m:nticn f~c~a ~Jqe State Depa~:trm~nt of Enw. ron~ntal Conservation attesting to t}~ legality arid status° Is the ~911 adequate fo~. the number of becl~cc~s specified in this HAA .~J. _Se__wa__ge__ Di sp~qs a__l Onsite ~_-_~[. Public r~-~, Community ~Z~-] Nolding Tank Is the!wastewater disposal System adequate for the ~t~ber of [Page 1 of 2] 2-15-84 5. ~erinq Firm Pr_ovid:i_n~_i_qn~jp~ctions, 1t~sts Data and Information o~ confound to all I, DA HAA C~i¢t~lirms in . Te, ].eRJmne__~' Adc~ess S igr~,~d ~f Date (ENGINEER SEAL) 6,pHEP A_j2prova 1 Approved fo~_~? bect~c~ m ap ow EL-j[ Terms of Conditional Approval ~ne Municipality of AnchoFage Depa~:tment of l~alth and Environmental Protection dc~.s not .guarantee the continued satisfactory pmrformanee of t~m water supply and/or the wastewater disposal system. %~nis approval indicates that, as of th~ validation date shcva~ above, ba~d on the data and information furnished ~%; an engil~,~er registered in the State of Alaska, the wa~er supply and wastewater disposal system is safe and func- tional for the numkx,~r of bedroc~s and type of st~uctua:e indicated. ( DHEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] 2-15-84 MUNICIPALITY OF ANCHORAGE (MOA) H~TH .hD'THOPG. TY32::~PROVAL (H/~.) CHECKLIST - FEBRUARY 1984 Well Classification ~'~/'~ . _ If A, B, o~ C, D.E.C. Approved.(Y-/N~-- Total Depth ~'7 i%a~d -- ! ' '~ - ' Z . .~-- to ~ -- ~ ~pth of G=outzng ' -/' ~ Static Water ~1 ~/~. ~ ~t At ~ o /~ Casing Height Above Ground i ~? ~ Electrical Wiring in Condu{t Separation Distances f~cm ~11: To ~ptic/H~%~i~ank on Lot /~ ¢-- Sanitary Seal o~ Casing((Y~__ .Delm~ession Around Wellhead-(__~___ ; On Adjoining nots__/~~C) f To Nearest Edge of Abso~pt%on Fiel f _; On Adjoining Lots /~© . i To Nearest Public Sewer Line To Nearest Public Sewer l~ ~,^'; L ' Cleancut/Manhole~ /~i/f~- To Nearest Sewer Service. ine on .Lot WateF Sample Collected By~' ,( ~-'f~//~¢~/~; Date ~_9~/~//~ Kf Water Sample Test ~sults i ~/~-/.~/r/c) c~-'?--~ ~,// ' Comn~nts ~ B. SEPTIC/H~ TANK DATA Date Installed ~.-3t9 '-~/~ Si?~ /. ~3(~ NO. of Compa~tr~nts ~ Standpims~) ~Ai~-tight CaperS) _ Foundation Cleanout~) ~p=ession.'o~ Ta~ (Ye ~ ~te ~st ~d ~/~ ~ P~)ing~alntenan~ ~n~a~ on File (Y~) ; fo= Holding Tank High-Wate~ Ala~ (Y~) __ ~a~y Holdi~ Tank ~rmit (Y~) ~pa=ation Distance f~ ~ptic~ Tank: To Water-Supply ~11_ /f~ / To ~lfllng Foundation .¢. TO ~ter Main/Se=vi~ Li~ ~ __ To S~e~, Pond, ~e, ~ Majo~ ~aina~ Corauents [Page 1 of 2] 2-15-84 Ce ABSORPTION FIELD DATA Soils Rating in Absorption St~ata./ "~,~._'~'/~.. _ , Type Date Installed ~---~3--~q~ Length of Field Width of Field Square Feet of Absorption A~ea Dep~ession ove~ Field Results of Last Adequacy Test Depth of Field Gr~vel Bed Thickness ///standpipes P~esent /D~te of Lest Adequacy Test Separation Distance f~m Absorption Field: To Water-Supply W~ll .//~ /2~ To P~ope~ty Line /~) To Buildin~ F~ation /~/~ To Existing ~ ~ndo~d System Lot ~/~ ; ~ Adjoining ~ts 3~) /'~ TO Wate~ Main/~vi~ Line ~ To ~tba~(if p~nt) To St~e~ond~ke/~ ~jo~ ~aina~ C~se /j~ F~ . To ~iveway, Pa~ki~ ~ea, ~ Vehicle Sto~a~ ~ea ~ Commsnts D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at Dimensions Manhole/Access (Y/N) "Pum~ Off" Level at High Wate~ Alarm Level at Tested fo~ Electrical Codes(Y/N) Comments ~ // /Vent' (Y/N) Pumpin~Cple~lng Adequacy Test. Meets MOA certify tha/~.ave checked, o? the d~~~/ction. · _ ~"~L~' fl~v~, ALAS'(A ~:~ [Page 2 of 2] Check Permitted Bedroom RatinG Against HAA Request verified, o= conformed to all MOA HAA Guidelines in effect MOA / 2-15-84